"RGiSZ^ 
 
 e<^^ 
 
 (Enlumhta ilnittfratty 
 \i\ thp (Etty of Nm fork 
 
 l^tUvtntt Stfarary 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/practiceofobstetOOedga 
 
THE 
 PRACTICE OF OBSTETRICS 
 
 EDGAR 
 
THE 
 
 PRACTICE OF OBSTETRICS 
 
 DESIGNED FOR THE USE OF STUDENTS 
 
 AND PRACTITIONERS OF 
 
 MEDICINE 
 
 J. CLIFTON EDGAR 
 
 PROFESSOR OF OESTETKICS AND CLINICAL MIDWIFERY IN THE CORNELL UNIVERSITY MEDICAL COLLEGE; VISITING 
 
 OBSTETRICIAN TO THE EMERGENCY HOSPITAL OF BELLEVUE HOSPITAL, NEW YORK CITY; 
 
 SURGEON TO THE MANHATTAN MATERNITY AND DISPENSARY; CONSULTING 
 
 OBSTETRICIAN TO THE NEW YORK MATERNITY HOSPITAL 
 
 THIRD EDITION, REVISED 
 
 TWENTY-THIRD THOUSAND 
 
 mitb 1279 flUustrations, incluMno tiv>e colored 
 plates ant) 38 figures printed in Colors 
 
 PHILADELPHIA 
 
 P. BLAK ISTON'S SON & CO 
 
 IOI2 WALNUT STREET 
 I9IO 
 
Copyright, 1903, by P. Blakiston's Son & Co. 
 
 Copyright, 1904, by P. Blakiston's Son & Co. 
 
 Copyright, iqo6, by P. Blakiston's Son & Co. 
 
 Reprinted, 1910 
 
 PP.ESS or 
 
 F. FELL COMPANY 
 PHILADELPHIA 
 
TO THE 
 
 STUDENTS OF OBSTETRICS 
 
 OF THE PAST DECADE AND A HALF, WHOM IT HAS BEEN MY 
 PRIVILEGE TO INSTRUCT, THIS BOOK IS 
 DEDICATED BY THE AUTHOR 
 
PREFACE TO THE THIRD EDITION. 
 
 When the first edition of this book appeared three years ago, the author 
 stated in the preface that "the aim of the present Practice of Obstetrics is to 
 . present the subject of midwifery from a practical and clinical standpoint, so 
 that it will best facilitate the requirements of the student of medicine and of 
 the active obstetrician." "To this end the simplest classification has I believe 
 been adopted." This object the author has kept constantly before him in the 
 revisions for the new editions, and how far success has attended his efforts is at- 
 tested to by the demand for ii,ooo copies of the work in less than three years 
 from its publication. 
 
 The classification adopted in the first edition has been adhered to in the 
 subsequent ones, as from the experience of other teachers and that of the 
 author it has been found generally satisfactory. 
 
 It has been the author's purpose in the third edition to weigh carefully 
 such criticisms as have appeared, and when possible to meet them. 
 
 The principal criticism, that the book was too large, has been answered by 
 reducing its size in the present edition by about one hundred pages, although 
 much new matter and 140 new illustrations have been added. This has been 
 accomplished by rewriting, condensing, the omission of some now obsolete 
 matter, and reducing the size of some of the illustrations. 
 
 Again, it will be noted that the classification is rendered more graphic by 
 the addition of page numbers to the ten part headings throughout the book. 
 
 It will be noted in comparing the second and third editions that the follow- 
 ing new subjects have been added to the latter, namely: i. Appendicitis Com- 
 plicating Pregnancy. 2. Tapeworm Complicating Pregnancy. 3. Fibroma Mol- 
 luscum Gravidarum (Illustration). 4. Hematoma of the Vulva (Illustration). 
 5. Lactation Atrophy of the Uterus and Breasts. 6. Brachial Birth Paralysis. 
 
 7. Vaginal Incision and Drainage (Illustration). 8. New History Charts for 
 Institution Work. 
 
 It will be still further noted that the following subjects have been rewritten 
 in whole ..or in part: i. The Development of the Ovum, Embryo, Fetus, Fetal 
 Membranes, and Fetal Structures. 2. Chorio-epithelioma Malignum. 3. The 
 Treatment of Placenta Prsevia. 4. The Toxemia of Pregnancy. 5. The Eti- 
 ology of Eclampsia. 6. Ectopic Gestation. 7. Treatment of Pelvic Deformity. 
 
 8. Morbidity in the Puerperium. 9. Indications for the Induction of Abortion 
 and Premature Labor. 10. The Forceps. 11. Caesarean Section. 12. Vaginal 
 Csesarean Section. 13. Porro-Caesarean Section. 14. Complete and Incom- 
 plete Abdominal Hysterectomy. 
 
 From the foregoing changes it will appear that much time and work have 
 been expended in the present edition in bringing the embryology and pathology 
 of the subject up to date, and that the section on Obstetric Surgery has been 
 largely rewritten and added to. 
 
viii PREFACE TO, THE THIRD EDITION. 
 
 The author still believes it is inadvisable in a text-book designed for stu- 
 dents to burden the text with extensive bibliography and history of the various 
 subjects treated; hence he has introduced this matter only where he has 
 deemed it advisable. 
 
 The clinical material and experience found in this book were obtained by 
 the author as Attending Obstetric Surgeon during the past eighteen years in 
 The Bellevue Emergency Hospital; The New York Maternity Hospital; The 
 Midwifery Dispensary; The Society of the Lying-in Hospital; The Mothers' 
 and Babies' Hospital; and The Manhattan Maternity and Dispensary. 
 
 During the above period at least 20,000 cases of confinement have come 
 more or less under the personal observation of the author. With two of the 
 foregoing institutions named, The Bellevue Emergency Hospital and The Man- 
 hattan Maternity and Dispensary, the author is still actively connected as at- 
 tending surgeon. 
 
 ['$1 For the third time the author desires to express his thanks to the publishers 
 for their continued generosity and courtesy, 
 
 J. Clifton Edgar. 
 
 50 East 34TH Street, New York City. 
 October 15, igo6. 
 
PREFACE TO THE SECOND EDITION. 
 
 The exhaustion of the first edition of this Practice of Obstetrics within four 
 months of the date of its publication, and the many compUmentary reviews 
 which have appeared and personal letters received by the author, have been 
 most gratifying, and I desire to express my appreciation of the fact that my 
 efforts to present the subject of obstetrics from the practical and clinical stand- 
 point have not been entirely unsuccessful. 
 
 Too short a time has elapsed since the appearance of the first edition to 
 make necessary a complete revision of the work. 
 
 1. Under Pathological Pregnancy will be found a section on "The Toxemia 
 of Pregnancy," and under this latter subject I have placed, (i) Nausea and 
 Vomiting, (2) Icterus, (3) Convulsions and Coma, (4) Eclampsia. 
 
 2. The section on Fever in the Puerperium in Part VIII of the first edition 
 which included Puerperal Sepsis, has been entirely rewritten and brought up 
 to date under the heading of Morbidity in the Puerperium. 
 
 3. All the colored plates of the first edition have been remade, and three 
 new ones have been added to the second edition, namely, two of the Toxemia 
 of Pregnancy, and one of the Stools of Healthy Breast-fed Infants. 
 
 4. It will be noticed that many of the illustrations of the first edition have 
 been redrawn, and that forty-five new illustrations have been added to the 
 second edition. Some typographical errors have been corrected and a number 
 of minor changes made throughout the text. 
 
 5. I find it necessary in the present edition to restate my position regarding 
 the indications for Embryotomy and Caesarean section, which from the stand 
 point of laboratory and theoretical obstetrics were apparently misunderstood 
 and therefore criticized 
 
 I find it unnecessary, however, in the second edition to change the relative 
 amount of space devoted to Embryotomy and Cassarean section, namely, eighteen 
 pages to the former and eight to the latter; because Embryotomy comprises 
 eight distinct operations, many of them complicated, and some of them fre- 
 quently performed upon the dead fetus, while Cassarean section, on the other 
 hand, is a single and simple operation, and not so frequently made use of. 
 
 It is a far cry in obstetrics from the theoretical deductions of the library 
 and the laboratory to the clinical conditions we find at the bedside. 
 
 The amount of space devoted in the present edition to the Toxemia of Preg- 
 nancy does not imply that the existence of a universal toxic pregnant state is 
 
X PREFACE TO^ THE SECOND EDITION. 
 
 yet established or even fully believed in. The subject is daily assuming in- 
 creasing importance and interest, and it is to be hoped that the physician will 
 study his cases of pregnancy with this possibility in mind, will record and report 
 his observations, and will especially give his patients the benefit of any doubts 
 which may arise when the question of a toxic state is in any way suggested. 
 
 I desire to express my indebtedness to James Ewing, M.D., Professor of 
 Pathology in the Cornell Medical College, for much valuable help in the prepara- 
 tion of the section upon The Toxemia of Pregnancy. 
 
 Again I wish to thank the publishers for their continued generosity and 
 
 courtesy. 
 
 J. Clifton Edgar. 
 50 East 34TH Street, New York City. 
 June I, I go 4. 
 
PREFACE TO THE FIRST EDITION. 
 
 This Practice of Obstetrics is founded upon fifteen years' work in maternity 
 hospitals and in bedside and didactic teaching. 
 
 The cHnical and theoretical material collected from these sources has 
 been rearranged, rewritten, and as far as possible compared with modern 
 authorities. The aim of the present Practice of Obstetrics is to present the 
 subject of midwifery from a practical and clinical standpoint, so that it will best 
 facilitate the requirements of the student of medicine and of the active obstet- 
 rician. To this end the simplest classification has, I believe, been adopted. I 
 have omitted as unnecessary in such a work the elaborate section upon the 
 anatomy of the female genital organs usually found in the works upon obstetrics, 
 and have entered directly upon the physiology of these organs. The omission 
 of the separate section upon anatomy is to avoid repetition, since the anatomy, 
 histological and topographical, of the pelvis and its contents will be found 
 in its appropriate place under the Parts on the Physiology of Pregnancy and 
 Labor. I have divided the work into ten Parts, namely: I. The Physiology of 
 the Female Genital Organs. II. Physiological Pregnancy. III. Pathological 
 Pregnancy. IV, Physiological Labor. V. Pathological Labor. VI. Physio- 
 logical Puerperium. VII. Pathological Puerperium. VIII. The Physiology of 
 the Newly Born. IX. The Pathology of the Newly Born. X. Obstetric 
 Surgery. 
 
 This classification, elaborated and broadened from year to year, is practi- 
 cally the same that I have followed during the above period in the two depart- 
 ments of teaching. Several innovations will be found in this book. 
 
 1. At the beginning of each Part the table of the contents of the part in 
 question has been placed, and to further insure ease of reference each Part is 
 subdivided into sections, each section in turn headed with a sub-table of its 
 subject-matter. 
 
 2. The subjects of asepsis and of pelvimetry, including cephalometry, are 
 treated under The Examination of Pregnancy. I believe that this is the proper 
 time and place for the student to be drilled in these subjects. 
 
 3. The subject of Deformities and Monstrosities of the Fetus has been entered 
 into more fully than usual under Antenatal Pathology, with 144 illustrations, 
 including all of the common and most of the rarer monstrosities. 
 
 4. The illustrations of the mechanism of labor and moulding of the fetal 
 skull in vertex, bregma, brow, face, and pelvic presentation are mostly new, 
 and are arranged as it has been my custom to teach these subjects. The illus- 
 trations of cervical engagement of the presenting part were obtained by palpating 
 with two fingers of the left hand, and at the same time sketching with a soft 
 pencil in the right hand. Inspection of the cervical engagement by the aid 
 of a perineal retractor and reflected light was also used, but this method was 
 less satisfactory than palpation except in the case of face presentation. The 
 illustrations of vulval engagement of the presenting parts are from flash-light 
 
xii PREFACE. 
 
 photographs. Most of this work was done at the Emergency Hospital of 
 Bellevue Hospital. The photographs of fetal skulls showing the result of 
 head moulding are from skulls in the author's collection, which now numbers 
 over one hundred. 
 
 5. Short sections upon the medico-legal aspects of obstetrics, together with 
 a brief study of Rape, the latter including an analysis of six hundred con- 
 secutive examinations for evidences of the same, are placed under their appro- 
 priate Part headings. 
 
 6. I would especially call attention to the following subjects: (i) The relation 
 of tuberculosis to pregnancy. (2) The teeth in pregnancy. (3) Antenatal path- 
 ology. (4) Monstrosities, and deformities of the fetus. (5) Labor in elderly 
 primiparse. (6) Prophylactic diet in fetal dystocia. (7) Prematurity and asphyxia 
 of the newly born. (8) The diseases of the newly born. (9) Posture in ob- 
 stetrics, and Obstetric Surgery. (10) The complete presentation of the subject 
 of cephalometry. (11) New method for illustrating the mechanism of labor. 
 (12) Pelvic Deformity. (13) Morbidity in the Puerperium. (14) An appendix 
 on obstetric history keeping. 
 
 Radiography in obstetrical practice is still in its infancy and the results as 
 to fetography have been disappointing. On the other hand, Rontgen pho- 
 tography of the maternal pelvis is a highly promising field, but as yet offers no 
 practical advantages. 
 
 As far as possible the subject of Embryology has been considered from the 
 practical and clinical standpoint, and detail has been omitted as not suited to 
 a work on practical obstetrics. Anatomical descriptions, except as necessary 
 for the subjects of pregnancy and labor, have also been omitted. 
 
 Much work had been expended upon the section on antenatal diseases of 
 the fetus, before the appearance of Dr. Ballantyne's pioneer book upon Ante- 
 natal Pathology. This work I have freely consulted in the revision of my 
 manuscript. 
 
 The 2200 confinement cases from which many of my statistics are drawn 
 comprise 1000 cases from the New York Maternity Hospital and 1200 from the 
 Mothers' and Babies' Hospital; 800 of the latter being dispensary or outdoor 
 cases. The bound histories of these cases have been presented to the New 
 York Academy of Medicine, and are there available for inspection. 
 
 All unnecessary division into chapters has been discarded, and as far as 
 possible italicizing has also been avoided. To replace the latter a system of 
 paragraphing by means of display type in four series has been uniformly adopted 
 throughout, supplemented by numerical divisions. It will be observed that as 
 far as possible full-page illustrations have been avoided. My aim has been to 
 insert the illustrations in the midst of the text itself so as to more readily catch 
 the eye of the reader. To this end a rather wider page of printed matter than 
 usual has been made use of and the illustrations are of moderate size. Many 
 of the illustrations are new, collected during fifteen years of clinical work, and 
 most of those taken from other sources have been redrawn. 
 
 The illustrations, as will be noted, are not reproduced to a given scale, as I 
 have found that clearness of detail is best obtained by the use of different scales 
 of reproduction. All weights and measurements are given in English, with the 
 metric system equivalents in parenthesis. 
 
 To Simon Henry Gage, B.S., Professor of Histology and Embryology in the 
 Cornell University, I am indebted for his critical revision of my manuscript on 
 "The Phenomena Produced by Pregnancy within the Uterus." Also to Drs. 
 Edward Preble and Emma E. Walker for much valuable assistance in the search 
 
PREFACE. xiii 
 
 through recent foreign obstetric literature and in the preparation of the index. 
 The drawings for the illustrations were executed by Frank Stout, Howard J. 
 Shannon, Frederick A. Fulton, and H. C. Lehmann. 
 
 The author desires to thank most cordially the successive members of the 
 House Staffs of the New York Maternity Hospital, and Emergency Hospitals, 
 for valuable assistance in the preparation of the histories and records of 
 obstetric cases; also Mr. Kenneth M. Blakiston, of the pubhshing firm of 
 Messrs. P. Blakiston's Son & Co., for his unfailing courtesy in the many 
 details of the preparation of the illustrations and the publication of the work. 
 
 J. Clifton Edgar. 
 50 East 34TH Street, New York City, 
 yune 15, I go 3. 
 
TABLE OF CONTENTS. 
 
 PART I. 
 
 PAGE 
 
 THE PHYSIOLOGY OF THE FEMALE GENITAL ORGANS, i6 
 This Part Contains 37 Illustrations. 
 
 SECTION 
 
 I. Ovulation, 1 7-19 
 
 II. Menstruation, 20-26 
 
 III. Insemination, 26 
 
 IV. Impregnation, . 27-29 
 
 V. Rape, 29-34 
 
 VI. Hygiene of the Sexual Functions, 35-39 
 
 PART IL 
 PHYSIOLOGICAL PREGNANCY, 41 
 
 This Part Contains 192 Illustrations. 
 
 I. Phenomena Produced by Pregnancy within the Uterus 41- 88 
 
 II. Phenomena Produced by Pregnancy in the Maternal Organism, 89-118 
 
 III. The Diagnosis of Pregnancy 1 19-132 
 
 IV. The Differential Diagnosis of Pregnancy, 132-138 
 
 V. Feigned Pregnancy — Pseudocyesis, 138-139 
 
 VI. Unconscious Pregnancy 139 
 
 VII. Multiple Pregnancy 140-144 
 
 VIII. The Duration op Pregnancy 144-145 
 
 IX. Calculating the Date of Confinement 146-14S 
 
 X. The Examination of Pregnancy, 14S-184 
 
 XL The Hygiene and Management of Pregnancy, 184-188 
 
 PART III. 
 PATHOLOGICAL PREGNANCY, 1S9 
 
 This Part Contains 276 Illustrations. 
 
 I. Diseases of the Decidu^, 101-198 
 
 II. Diseases of the Chorion, 198-201 
 
 III. Anomalies of the Amnion and Liquor Amnii, 201 -208 
 
 XV 
 
xvi TABLE OF CONTENTS. 
 
 SECTION PAGE 
 
 IV. Anomalies and Diseases of the Placenta, 208-237 
 
 V. Anomalies of the Umbilical Cord 237-242 
 
 VI. Deformities and Monstrosities of the Fetus, 244-254 
 
 VII. Antenatal Diseases of the Fetus .255-271 
 
 VIII. Death of the Fetus, 272-274 
 
 IX. Diseases of the Genital Organs, 274-291 
 
 X. Toxemia of Pregnancy, 291-314 
 
 XI. Diseases of the Urinary Tract 315-321 
 
 XII. Diseases of the Alimentary Tract, 321-325 
 
 XIII. Diseases of the Circulatory System, 325-328 
 
 XIV. Diseases of the Respiratory System, 329-332 
 
 XV. Diseases of the Nervous System 332-33S 
 
 XVI. Infectious Diseases :i3^-337 
 
 XVII. Skin Diseases 337-34° 
 
 XVIII. Diseases of the Osseous System : 340-342 
 
 XIX. The Premature Interruption of Pregnancy 342-361 
 
 XX. Ectopic Gestation, 361-367 
 
 XXI. Pregnancy in One Horn of a Uterus; Unicornis or Bicornis 367-368 
 
 XXII- Missed Labor, 3^8 
 
 XXIII. Sudden Death During Pregnancy, 369 
 
 XXIV. Injuries and Operations upon Pregnant Women, 369-37° 
 
 XXV. Pregnancy after Operations Involving the Genitals 370 
 
 XXVI. The Fever of Pregnancy, 370 
 
 XXVII. The Metrorrhagia of Pregnancy 3 7^-372 
 
 PART IV. 
 PHYSIOLOGICAL LABOR, 373 
 
 This Part Contains 132 Illustrations. 
 
 I. The Passages, 375-408 
 
 II. The Fetus 408-427 
 
 III. Expelling Forces, 428-431 
 
 IV. Etiology of Labor, 431 
 
 V. The Stages of Labor 432-440 
 
 VI. The Mechanism of Labor, 440-448 
 
 VII. The Duration of Labor 448 
 
 VIII. Live Birth 448 
 
 IX. Feigned Delivery, 449 
 
 X. Unconscious Delivery, , 449-450 
 
 XI. Vertex Presentation, 450-463 
 
 XII. Management of Labor 463-496 
 
 PART V. 
 
 * 
 
 PATHOLOGICAL LABOR, 499 
 
 This Part Contains 269 Illustrations. 
 
 DUE TO ABNORMAL CONDITIONS OF THE FETUS: FETAL DYSTOCIA, 499 
 
 Fetal Dystocia from Faulty Attitude, 499 
 
 I. Excessive Flexion of the Head, Roederer's Obliquity, 499-500 
 
TABLE OF CONTENTS. xvii 
 
 SECTION PAGE 
 
 II. Bregma Presentation. . Incomplete Flexion 500-503 
 
 III. Brow Presentation, 503-508 
 
 IV. Face Presentation, 508-5 1 8 
 
 V. Presentation of Anterior Parietal Bone or Ear. Naegele's Obli- 
 quity 518 
 
 VI. Presentation of Posterior Parietal Bone or Ear. Litzmann's 
 
 Obliquity, 5 ig 
 
 VII. Prolapse of the Arms. Dorsal Displacement of the Arm 520-522 
 
 VIII. Prolapse of the Legs 522 
 
 IX. Prolapse of the Cord, 522-527 
 
 Fetal Dystocia from Faulty Presentation, 527 
 
 X. Pelvic Presentation 527-538 
 
 XI. Shoulder Presentation, 538-544 
 
 Fetal Dystocia from Faulty Position, 545 
 
 XII. Persistent Occipito-posterior Position 545-550 
 
 XIII. Persistent Mento-posterior Position 550-553 
 
 XIV. Transverse Position of Head at Outlet, 553-554 
 
 Fetal Dystocia from General Fetal Conditions, 554 
 
 XV. Multiple Birth 554-557 
 
 XVI. Multiple or Compound Presentations, 558-559 
 
 XVII. Excessively Long Cord 559 
 
 XVIII. Short Cord 559-560 
 
 XIX. Rupture of the Cord 560 
 
 XX. Decapitation of the Fetus 560 
 
 XXI. Avulsion of Fetal Extremities 560 
 
 XXII. Malformations, Deformities, and Anomalies Producing Dystocia,. . .560-565 
 XXIII. Fetal Rigor Mortis 565 
 
 DUE TO ABNORMAL CONDITIONS OF THE MOTHER. MATERNAL DYS- 
 TOCIA, 566 
 
 Maternal Dystocia from the Forces, 567 
 
 I. Precipitate ' Labor, 567-568 
 
 II. Protracted OR Retarded Labor: Uterine and Abdominal Inertia, .568-574 
 Maternal Dystocia in the Parturient Tract and Adnexa, 574 
 
 III. Retention of Placenta and Membranes 574-577 
 
 IV. PosT-PARTUM Hemorrhage 577-584 
 
 V. Rupture of the Uterus, 584-590 
 
 VI. Inversion of the Uterus, 590-592 
 
 VII. Excessive Right Lateral Obliquity of the Uterus 592 
 
 VIII. Rupture of Cervix, Vagina, Rectum, Perineum 592-600 
 
 IX. Labor After Anterior Fixation or Suspension of the Uterus, 600-602 
 
 Maternal Dystocia from Obstructed Labor, 602 
 
 X. Uterine, Ovarian, Renal, Peritoneal Tumors, 602-605 
 
 XI. Anomalies of the Membranes 605 
 
 XII. Rigidity of the External and Internal Os. Trismus Uteri 606-608 
 
 XIII. Deviation or Malposition of the Os, 608-609 
 
 XIV. Occlusion of the External Os 609 
 
 XV. Cancer of the Uterus, 610 
 
 XVI. Rigidity and Atresia of the Vagina and Vulva, 610-612 
 
 XVII. Vaginal and Vulval Thrombosis and CEdema, 613 
 
 XVIII. Distended Bladder and Rectum, Cystocele, Rectocele, Vesical 
 
 Calculus, 613-615 
 
 XIX. Fractures of the Pelvis 615 
 
 XX. Diastasis of the Pelvic Joints, 615 
 
 XXI. Pelvic Deformity 616-665 
 
xviii TABLE OF CONTENTS. 
 
 SECTION PAGE 
 
 Maternal Dystocia from General Maternal Conditions, 665 
 
 XXII. Labor in Elderly Primipar^ 665-667 
 
 XXIII. Intestinal Hernia 667 
 
 XXIV. Cardiac and Pulmonary Disease, 668 
 
 XXV. Cerebral and Spinal Disease 668 
 
 XXVI. Digestive Disturbances 669 
 
 XXVII. Sudden Death, 669 
 
 XXVIII. Postmortem Delivery, 669-670 
 
 XXIX. The Metrorrhagia of Labor, 671 
 
 PART VI. 
 PHYSIOLOGICAL PUERPERIUM. THE PUERPERAL WOMAN, 672 
 
 This Part Contains 18 Illustrations. 
 
 I. General Phenomena, 672-677 
 
 II. Local Phenomena, 677-687 
 
 III. Diagnosis of the Puerperium, 687-688 
 
 IV. Management of the Puerperium, 688-698 
 
 PART VII. 
 PATHOLOGICAL PUERPERIUM, 700 
 
 This Part Contains 54 Illustrations. 
 
 I. Puerperal Hemorrhages 701-705 
 
 II. Intestinal Anomalies 705 
 
 III. Urinary Anomalies, ' 705-707 
 
 IV. Anomalies of the Genital Tract, 708-7 10 
 
 V. Anomalies of the Pelvic Articulations 710 
 
 VI. Diastasis of the Abdominal Muscles 711 
 
 VII. Fever in the Puerperium, 71 1-758 
 
 VIII. Anomalies of the Breasts, 759-760 
 
 IX. Anomalies of the Milk Secretion, 760-761 
 
 X. Diseases of the Breasts 761-768 
 
 XI. Blood Conditions, 768-769 
 
 XII. Diseases of the Nervous System, 769-773 
 
 XIII. Skin Diseases, 773 
 
 XIV. General Diseases, 773 
 
 XV. Sudden Death, 773-776 
 
 PART VIII. 
 THE PHYSIOLOGY OF THE NEWLY BORN, 778 
 
 This Part Contains 19 Illustrations. 
 
 I. General Phenomena 779-7S5 
 
 II. Hygiene and Management of the Newly Born, 785-796 
 
TABLE OF CONTENTS. xix 
 
 PART IX. 
 
 PAGE 
 
 THE PATHOLOGY OF THE NEWLY BORN, 798 
 
 This Part Contains 37 Illustrations. 
 
 SECTION 
 
 I. Pathology due to Interrupted Pregnancy. Prematurity, 800-807 
 
 II. Affections of Antenatal Origin which Extend into Extrauterine 
 
 Life, 807-812 
 
 III. Affections which Originate Intra partum, 812-837 
 
 IV. Diseases Incident to Change of Environment 837-840 
 
 V. Diseases due to Bacteria and Fungi, 840-847 
 
 VI. Diseases of Unknown Nature, 847-S51 
 
 VII. General Post-partum Conditions, •. 852-856 
 
 PART X. 
 OBSTETRIC SURGERY, 858 
 
 This Part Contains 239 Illustrations. 
 
 (A) INTRODUCTION, S59 
 
 I. Preparations for Operation, 860-86 1 
 
 II. Decinormal Saline Solution Injections, 86 1-S65 
 
 III. Anesthesia in Obstetrics, S65-S68 
 
 IV. Posture in Obstetrics, 868-879 
 
 V. Vaginal Examination 879 
 
 VI. Digital Exploration of the Uterus, S80 
 
 VII. Vulval Douche, S81 
 
 VIII. Vaginal Douche, S81-882 
 
 IX. Intrauterine Douche 882-S84 
 
 X. Vaginal Tampon S84-S85 
 
 XI. Uterine Tampon, 885-887 
 
 XII. Passing the Catheter 887 
 
 (B) OPERATIONS PREPARATORY TO DELIVERY, 887 
 
 I. Artificial Rupture of the Membranes, 887-888 
 
 II. Induction of Abortion and Premature Labor, 888-895 
 
 III. Manual Dilatation of the Cervix, 895-901 
 
 IV. Instrumental Dilatation of the Cervix 902-906 
 
 V. Manual and Instrumental Dilatation of the Vagina and Vulva, 906-907 
 
 VI. Incisions of the Cervix, Vagina, and Vulva 907-91 1 
 
 VII. Correction of Faulty Postures, Malpositions, and Malpresenta- 
 
 TioNS 911-914 
 
 VIII. Vectis 915 
 
 IX. Fillet, 915-916 
 
 X. Reposition of Prolapsed Small Parts, Foot, and Cord, 916-9 19 
 
 XI. Version 919-936 
 
 XII. Pelviotomy, 936 
 
 XIII. Symphyseotomy, 937-942 
 
 XIV. Embryotomy in General, ^- 942-944 
 
 XV. Perforation 944-946 
 
 XVI. Rachidotomy, 946 
 
 XVII. Cranioclasm, 947-951 
 
 XVIII. Cephalotripsy 951-955 
 
XX TABLE OF CONTENTS. 
 
 SECTION PAGE 
 
 XIX. Decapitation 955-960 
 
 XX, Evisceration, 960-961 
 
 XXI, Amputation of Extremities 961 
 
 XXII. Cleidotomy 961-962 
 
 XXIII. Spondylotomy 963 
 
 (C) OPERATIONS FOR DELIVERY, 963 
 
 I. Expression of the Fetus, Expressio Fcetus, 963-964 
 
 II. Forcible Delivery, Accouchement Force, 964-965 
 
 III. Manual Extraction of the Fore-coming Head, 965 
 
 IV. Shoulder Extraction in Head-first Labors, 966-968 
 
 V. Breech Extraction, 968-973 
 
 VI, Extraction of the After-coming Head 974-982 
 
 VII. Forceps 982-1007 
 
 VIII. Sling or Soft Fillet 1007-1009 
 
 IX. Blunt Hook, 1009-1010 
 
 X. Crochet, 10 10 
 
 XI. Extraction of the Fetus Mutilated by Embryotomy, loii 
 
 XII. CjESarean Section 1011-1016 
 
 XIII. Abdominal Hysterectomy, 1016-1020 
 
 XIV. Porro-C.«;sarean Section 1020-1022 
 
 XV, Vaginal Cesarean Section, 1022-1025 
 
 XVI. Post-mortem Cesarean Section, 1025 
 
 XVII. Delivery of Placenta and Membranes 102 5-103 1 
 
 (D) OPERATIONS FOR THE CORRECTION OF INJURIES, 103 1 
 
 I. Celiotomy for Rupture of the Uterus, 1032 
 
 II. Celiotomy for Sepsis of the Uterus, 1032 
 
 III. Repair of Injuries to Cervix, Vagina, Rectum, Perineum, 1032-1037 
 
 APPENDIX. 
 
 This Contains 10 Illustrations. 
 
 Private History Records 1039-1042 
 
 Institutional Records 1043-1046 
 
 INDEX ' I047 
 
\ 
 
PART ONE. 
 
 The Physiology of the Female Genital Organs* 
 
 I. OVULATION. (Page 17.) Definition ; Origin of the Ova ; Causes of Rup- 
 ture of the Graafian Follicle ; Mechanism of the Conveyance of the Ovum to 
 the Tubes and Uterus ; Corpus Luteum ; Retrograde Changes in the Corpus 
 Luteum ; Obliteration of Follicles which do not Rupture. 
 
 II. MENSTRUATION. (Page 20.) Synonyms; Definition; Puberty; Pheno- 
 mena ; Changes in the Endometrium during Menstruation ; Time of Occur- 
 rence; Conditions Influencing Menstruation; The Menstrual Cycle; Men- 
 struation — Temporary, Intermittent, and Periodic; Duration; Quantity of 
 Blood Lost ; Composition of the Menstrual Blood ; Modifications and Ano- 
 malies ; Relation between Menstruation and Ovulation ; The Menopause. 
 
 III. INSEMINATION. (Page 27.) Definition; Phenomena. 
 
 IV. IMPREGNATION. (Page 27.) Synonyms; Definition; The Semen; The 
 
 Spermatozoa ; Ascent of the Spermatozoa ; Place of Meeting of Spermatozoa 
 and Ovum; Relation between Impregnation and Menstruation; Unconscious 
 Impregnation. 
 
 V. RAPE. (Page 29.) Definition ; Law of Rape ; Rape on Females after Pub- 
 erty; Conditions Simulating Defloration; Rape upon Children and Infants; 
 Rape by Boys and Children ; Rape on the Dead ; Statistics of 600 Consecu- 
 tive Examinations for Evidences of Rape. 
 
 VI. HYGIENE OF THE SEXUAL FUNCTIONS. (Page 35.) Heredity; Educa- 
 tion ; Mode of Life ; Dress ; Sexual Life ; Prevention of Conception ; Child- 
 birth ; Climacteric ; Cancer ; Family Physician. 
 
I. OVULATION. 
 
 Definition. — -This term includes the formation, growth, and expulsion of the 
 mature ovum from the ovary. The chief function of the ovary is accomplished in 
 this process. It takes place spontaneously in all viviparous animals. 
 
 Origin of the Ova. — The ova originate from certain cells which are derived 
 from the ingrowth of the germinal epithelium that surrounds the young ovary, 
 and which are gradually differentiated into the female generative elements. 
 This occurs very early; in fact, the formation of the Graafian follicles is nearly 
 completed during the antenatal period. After birth the formation of new cells 
 is much restricted, and at the end of the second year is supposed to cease entirely. 
 The ovaries of a child of two years are estimated to contain about 70,000 Graafian 
 follicles. The greater number of ova never arrive at maturity. Before puberty 
 some of these immature ova undoubtedly develop to a certain point, but it is not 
 until the establishment of menstruation that the normally complete maturation 
 of the follicles with their ova takes place. With the advent of puberty the sur- 
 face of the ovary becomes covered with small projections. These prominences 
 are the Graafian follicles, which are distended by the liquid within them. They 
 approach the ovarian periphery, cause a thinning of the tunica albuginea, and 
 give rise to the vesicles before mentioned. Gradually the blood-vessels and 
 lymphatics disappear, and at a certain point the covering of the follicles becomes 
 thin and translucent, usually at the place called the macula, or stigma folliculi. 
 When the follicle reaches maturity it bursts, discharging its contents, which 
 consist of an ovum, the liquor folliculi, and a few cells of the discus proligerus. 
 This change takes place periodically, now in one, now in more than one follicle, 
 during the entire child-bearing period. Several follicles in different stages of 
 development may be found at the same time. The particular follicle that is 
 nearing maturity becomes congested and some of the enlarged blood-vessels 
 burst into its cavity, thus increasing the distention and the tendency to rupture. 
 When mature, the follicle is, on account of the escaped blood, of a bright red 
 color. As to the time of rupture of the follicle, whether it occurs before or after 
 menstruation, is a question not yet definitely settled. In order that the ovule 
 may escape, not only must the layers of the follicle be lacerated but also all of 
 the structures covering it. 
 
 Causes of Rupture of the Graafian Follicle. — Follicular rupture is produced by 
 a combination of several factors: (i) By the pressure of the liquor folliculi, which 
 causes thinning and absorption of the theca folliculi, the follicular wall having 
 been weakened by fatty degeneration of the tissues. (2) B}^ the proliferation of 
 the lutein cells, causing the tension of the liquor to be raised. (3) By the swell- 
 ing of the ovary at every menstrual period. (4) By the contraction of the 
 ovarian muscular fibers. (5) Ovulation is a periodic process, and in nearly all 
 mammals, except man, it occurs only at certain seasons of the year, so that 
 the young are born at a time when food suitable for the parent is most abundant. 
 (6) Sexual congress may influence the discharge of the ovum, probably only 
 hastening the normal process. (7) The sympathetic nervous S3'-stem also in 
 some way affects the process. 
 
 2 17 
 
IS PHYSIOLOGY OF THE FEMALE GENITAL ORGANS. 
 
 Mechanism of the Conveyance of the Ovum to the Tubes and Uterus. — The 
 
 oldest theory of this conveyance, that held by Rouget, was that the fimbriated 
 extremity of the tube became erectile and, aided by muscular contraction, 
 grasped the ovary. The existence of a peculiar erectility in the Fallopian 
 tubes has, however, been disproved, as experiments show that it possesses none 
 of the characteristics of erectile tissue. Galvanization of the tubes shortly after 
 death produces only a vermicular action which has no effect on the position of 
 the fimbriae. Kehrer's theory was that the ova were ejaculated from the follicle 
 into the tube, a view that has been upheld by few. The most probable theory is 
 that of Henle, that the ova are carried along in the serum by currents generated 
 by the ciliated epithelium which covers the fimbriae of the tubes. This ciliary 
 motion causes a current in Douglas' cul-de-sac. This action has been demon- 
 strated by Pinner, who injected powdered insoluble coloring-matter into the 
 abdominal cavity of a rabbit. Particles were found after death in the uterus and 
 vagina. The same phenomenon was observed by Jani (W^igert's laboratory) in 
 regard to tubercle bacilli. Lodi injected the eggs of a tapeworm into the peri- 
 toneal cavity of rabbits and recovered them in the tubes and uterus. In the 
 lower animals the majority of the ova pass into the tube, but in man it would 
 seem that the greater part are thrown into the abdominal cavity. It is usually 
 stated that it takes eight days for the ova to reach the uterus. In a certain 
 number of cases there is a migration of ova, which pass across the abdominal 
 cavity and come down the opposite tube. This is called external migration. 
 Pathological conditions afford proof of this fact. There are two classes of such 
 cases: (i) With normal tubes. If we find a corpus luteum in the right ovary 
 and the right tube converted into a hydrosalpinx, the inference of external migra- 
 tion may be drawn. Also in tubal pregnancy: given an occluded right tube 
 with a corpus luteum in the right ovary, and a pregnancy in the left tube with no 
 •corpus luteum in the left ovary, and we must draw the same inference. (2) In 
 the case of bicornate uterus a corpus luteum may be found in one ovary and 
 pregnancy in the other side of the uterus. Kussmaul was the first to advocate 
 this view of external migration. Leopold and others have experimented by 
 removing in an animal a tube and the opposite ovary. Later, if the animal 
 became pregnant the proof of external migration was positive. I have re- 
 peatedly demonstrated this external migration of the ovum by operating upon 
 rabbits in the Loomis Laboratory. Older writers declared that there was internal 
 migration causing tubal pregnancy in the opposite tube, the ovum having passed 
 through the uterus. This statement cannot be denied, neither can it be proved. 
 Hence we see that external migration does take place, whereas the occurrence 
 of internal, though possible, has not been proved. 
 
 Corpus Luteum. — After the follicle has ruptured and the ovum has been cast 
 off, the corpus luteum is formed. As has been said, previous to rupture there has 
 occurred a fatt}^ degeneration of the cells of the membrana granulosa and of the 
 discus proligerus. There is a certain amount of hemorrhage within the follicle, the 
 walls collapse, and this is the first stage of the corpus luteum. The hematin of the 
 extravasated blood gives rise to the "yellow" color. The cells of the internal 
 layer of the theca folliculi rapidly proliferate, forming festoons which project into 
 the blood-clot contained in the cavity of the folHcle (Fig. i). This yellow layer is 
 quite thick, being about one-half the thickness of the whole corpus, which meas- 
 ures half an inch (1.25 cm.). These cells are lutein cells. The stroma of the ovary 
 also sends ingrowths into this mass. The blood-clot organizes, the walls contract, 
 and finally a small, irregular cavity is left. This is at last obliterated by the 
 meeting of the walls, and merely a cleft remains. A corpus luteum is formed 
 
OVULATION. 
 
 19 
 
 with every bursting of a follicle. When fertilization of the ovum occurs, the 
 corpus luteum becomes larger. ■ The old terminology recognizes a corpus luteum 
 verum and a corpus luteum spurium. The corpus luteum of pregnancy meas- 
 ures from about four-fifths to one inch (2 to 2.5 cm.) in diameter, while the 
 ordinary corpus luteum measures about three- fifths inch (1.5 cm.). For some 
 time the idea obtained that there was a marked difference between the corpus 
 luteum verum and the corpus luteum spurium; it has, however, been shown that 
 the only difference is that of size, due to the greater blood-supply during preg- 
 nancy. There has been endless discussion about the corpus luteum, the principal 
 point of dispute being the hyaline change. 
 
 Retrograde Changes in the Corpus Luteum. — After the formation of the corpus 
 luteum the yellow layer is converted into a hyaline mass which is penetrated by a 
 
 Tunica externa 
 Tunica interna 
 
 Stratum granulo- 
 sum (follicular 
 epithelium) 
 
 Cumulus ovigerus 
 
 Ovum with zona 
 pellucida, germi- 
 nal vesicle, and 
 germinal spot 
 
 Fig. I. — Section of a Large Graafian Follicle of a Child Eight Years Old. X 9°- 
 The clear space within the follicle contains the liquor follictdi. — (Stohr.) 
 
 few bands of ovarian stroma. Finally a thin layer of connective tissue is the only 
 representative of the blood-clot, and this stage is known as the corpus fibrosum 
 or corpus albicans. But still further changes must go on, for only a few of these 
 bodies are to be found in an ovary. The minor details of these changes are not 
 well known. The ovarian stroma prolongations increase, while the hyahne 
 material diminishes and assumes bizarre forms. At last there may be only a 
 trace of connective tissue remaining. Only twenty or thirty folhcles rupture in 
 a year and many ova disappear. Many folhcles never rupture at all. 
 
 Obliteration of Follicles which do not Rupture. — The ovum may assume signs 
 of maturity, fatty degeneration takes place in the membrana granulosa, the 
 whole mass dissolves in the hquor follicuH, and the fluid finally disappears and 
 the walls collapse. There is absence of blood-clot. The foUicle is surrounded by 
 a thin hyaline stratum formed from the inner layer of the theca foUiculi. 
 
20 
 
 PHYSIOLOGY OF THE FEMALE GENITAL ORGANS. 
 
 II. MENSTRUATION. 
 
 Synonyms. — Menses; Menstrual flow; Menstrual flux; Flow; Catamenia. 
 
 Definition. — By menstruation is meant the monthly hemorrhage which takes 
 place in the uterus during the child-bearing period of the normal woman, except 
 during pregnancy and lactation, when it is nearly always suspended. 
 
 Puberty. — The first occurrence of menstruation with the accompanying 
 changes marks the stage of sexual maturity at which, in the female, fecundation 
 becomes possible. The signs are: The growth of hair on the pubes and on other 
 parts of the body; the enlargement of the breasts; the increased grace of the 
 general contour of the body ; the establishment of ovulation and menstruation ; 
 the full development of the pelvis; the growth of the sexual sense; alteration in. 
 
 Fig. 2. — Uterus and Adnexa showing Coincident Menstruation and Ovulation. 
 Suicidal death from morphine on second day of menstruation. — (Author's specimen.) 
 
 the mental qualities, the girl becoming more retiring. The menstrual function 
 is not generally established at once, but for the first few months there may be only 
 premonitory symptoms of a vague and uncomfortable nature. There may soon 
 occur a slight discharge of mucus tinged with blood, and later the regular menses 
 will be established. 
 
 Phenomena. — (i) The General Phenomena consist of pains in various parts 
 of the body, chilliness, heat flashes, and hysterical symptoms. The reflex 
 nervous system is always at its maximum point of irritability and there is often 
 depression with drowsiness. There are general discomfort, weariness, and a 
 marked distaste for active exercise. Dark circles appear under the eyes, the 
 breasts swell and become painful, and a sense of fulness and oppression is felt in 
 the head (Fig. 6). There are often considerable changes in the general nutritive 
 processes and the excretion of urea by the kidneys is lessened. (2) The Local 
 Phenomena are those of pelvic congestion. Rupture of an ovisac occurs, the 
 
MENSTRUATION. 
 
 21 
 
 - Epithelium 
 
 Gland tubule 
 
 Mucosa 
 
 uterus becomes much congested, the cervix softens and is of a bluish color with 
 relaxation of the external and of the internal os. The uterine mucous membrane 
 is also swollen, congested, and raised into folds which give the surface an irregular 
 appearance (Fig. 2); abundant secretion pours from the glands, and, at least in 
 some cases, the epithelium desquamates, and the capillaries losing their support, 
 their walls undergo fatty degeneration, burst, and discharge the blood (Fig. 4). 
 The tubes are also congested and thickened, and blood sometimes escapes into 
 them. The vagina becomes darker in color, gland secretion is abundant, and the 
 temperature is slightly elevated, often by 1° F. (0.5° C.) (Fig. 7). The whole 
 vulva is swollen and tense and pruritus may occur (herpes menstrualis). 
 
 Changes in the Endometrium during Menstruation. — Various views have been 
 held as to the changes in the uterus at this time. The prevailing view is that 
 a certain amount of the mu- 
 cosa, though small, is cast 
 off; that there is fatty de- 
 generation of the walls of 
 the blood-vessels which per- 
 mits the outflow of blood, 
 and this is the primary 
 change during menstrua- 
 tion. The flow arises from 
 diapedesis of the blood-cor- 
 puscles. The amount of 
 blood is comparatively small 
 and does not really consti- 
 tute a true hemorrhage. The 
 flow is preceded by altera- 
 tions in the glands, which 
 become hypertrophied and 
 present a zigzag appearance 
 on cross-section, while the 
 cells in the lower part of 
 the glandular structure may 
 become larger and resemble 
 epithelial cells. The con- 
 nective-tissue cells also un- 
 dergo hypertrophy (Figs. 4 
 and 3). 
 
 Time of Occurrence. — 
 As has been stated, the 
 
 establishment of puberty ushers in the process of menstruation. The accompany- 
 ing physical changes give evidence of the capacity for conception and child- 
 bearing now assumed by the woman. In temperate climates the average age for 
 the beginning of menstruation is the fifteenth year. There are, however, many 
 exceptions to this rule within normal limits, as it is not so very uncommon to 
 observe the beginning of this process at the tenth or eleventh year, or its delay 
 to the eighteenth or twentieth. The average age in India is said to be the ninth 
 year, while in Iceland it is given as the sixteenth year. There are recorded 
 curiously abnormal cases of menstruation, pregnancy, and childbirth in early 
 childhood, also of childbirth years after the menopause, which normally occurs 
 about the forty-fifth year. 
 
 Conditions Influencing Menstruation. — Menstruation is influenced by (i) 
 
 Fig. 3. — Mucous Membrane of the Resting Uterus 
 OF A Young Woman. X 35. — (Afier Bohm and von 
 Davidojj.) 
 
22 
 
 PHYSIOLOGY OF THE FEMALE GENITAL ORGANS. 
 
 race; (2) mode of life; (3) climate; (4) heredity; and (5) genital sense. Some 
 authors lay considerable stress on the influence of race. It is said that English girls 
 in Calcutta menstruate no earlier than in England, although subjected to the same 
 climatic influences as the Hindoos, i or 2 per cent, of whom menstruate as early 
 as the ninth year, while 25 per cent, menstruate at twelve years of age. The 
 children of the superior classes, being of a higher nervous organization, are apt to 
 menstruate earlier. Their manner of life is more luxurious and mental stimulation 
 is premature, as shown in the earlier period of menstruation. As to the influence 
 
 Disintegrated surface ":T..pji^~,Jy'.->f'^. 
 Blood-vessels ■ - '.' j?x>^s^V fe^: 
 
 Excretory duct 
 
 ._J:?Mv'S^I 
 
 
 Superficial epithelium 
 Disintegrated surface 
 
 Glandular lumen 
 
 ^■^C'- ;{■■.U/^'^ — ^P'Kit" J — Depression in mucosa 
 
 '^^y^\-^^,':^lf?^'':J.':l l':M ■S^-^^'^'^-^A%''^-^^^ — Excretory duct 
 
 •- Gland-tubule 
 
 Blood-vessel 
 
 Blood-vessel 
 
 >-- Muscularis 
 
 Fig. 4. — Mucous Membrane of a Virgin Uterus during the First Day of Menstrua- 
 tion. X 30. — (Schafer.) 
 
 of climate, it has no doubt been exaggerated, although the general rule holds that 
 menstruation occurs somewhat earlier in the tropical than in the arctic regions. 
 Premature or late sexual development is often noticed as a family trait. Sexual 
 excitement is thought to influence the advent of menstruation, and Clay * has 
 noted this excitement among the hard-working factory girls of Manchester, 
 where, in the nature of the work, there is a promiscuous mixing of sexes. In the 
 case of pregnancy, menstruation is nearly always suspended during the whole 
 period of gestation, recurring from six to eight weeks after the birth of the 
 
 * "Brit. Record of Obstet. Med.," vol. i. 
 
MENSTRUATION. 23 
 
 child. Exceptions to the rule of suspended menstruation in pregnancy 
 occur now and then during the early months, and are explained by the fact that 
 the uterine cavity is not obliterated by the junction of the decidua reflexa and 
 the mucous membrane of the uterus, or the decidua vera, till the close of the fifth 
 month. In case the menses continue throughout pregnancy, — a very rare con- 
 dition indeed, — there is probably an abnormal and incomplete fusion of the 
 deciduag. Naegele * held that menstruation regenerates the capacity for con- 
 ception which had failed by degrees during the intermenstrual period. The 
 relation between menstruation and the "heat" of lower animals is a very 
 interesting study. The most satisfactory theory appears to be that menstru- 
 ation is caused by a central nervous influence reflected through the sympathetic 
 nervous system to the ovaries and uterus. 
 
 The Menstrual Cycle. — The entire menstrual cycle comprises four stages 
 (Marshall), and extends, as a rule, over twenty-eight days: (i) The preparatory 
 or constructive stage consists in making ready for the reception of the ovum. 
 This preparation, according to Marshall, is probably made for the ovum which is 
 discharged at the preceding period, for it is probable that a week is consumed in 
 the migration of the ovum from the ovary to the uterus. When pregnancy does 
 not occur, this stage is followed by degenerative changes. (2) The destructive 
 stage comprises all the ordinary phenomena of menstruation. It lasts about five 
 days, varying, however, according to individual peculiarities. (3) The re- 
 parative stage is occupied with the regeneration of the destroyed parts of the 
 uterine tissue — the focus of new growth being the unharmed deeper tissues still 
 existing. This process takes place in from three to four days. (4) The quies- 
 cent stage comprises the remaining twelve or fourteen days of the whole cycle 
 and just precedes the beginning of the next period. 
 
 Menstruation is Temporary, Intermittent, and Periodic. — It is temporary be- 
 cause it exists only during the sexual life of the woman, asserting itself at puberty 
 and declining at the menopause till it ceases altogether. It is intermittent 
 because it comes and goes, and periodic because the series of phenomena repre- 
 senting this physiological process reproduce themselves at intervals of usually 
 one month, being the result of the hyperemia which occurs in the whole genital 
 system of the woman — ovary, tubes, uterus, and broad ligaments. Periodicity 
 is variable, but twenty-eight days is considered the normal period. Two sisters 
 are mentioned in whom menstruation occurred only two or three times a year 
 (Joulin). 
 
 Duration. — The duration of menstruation averages five days, but varies from 
 three to seven. Some cases are known in which menstruation lasts only a few 
 hours, others in which it lasts many days. 
 
 Quantity of Blood Lost. — The total amount lost varies normally from five to 
 ten ounces. The amount, even if rather large, need not be considered abnormal 
 unless the general health suffers. High living, rich diet, and, indeed, anything 
 that abnormally stimulates mind and body, will tend to increase the flow. Con- 
 sequently city-lDred girls and those of the higher classes have a greater flow than 
 the hard-worked women of the laboring classes. It is also greater in warm 
 climates than in cold, and English women in India menstruate profusely, while 
 on their return to England there is marked decrease of the flow. The same fact 
 has been noted in American women moving from the Southern States to the Lake 
 region. It appears that women sometimes menstruate more profusely in summer 
 than in winter. The daily loss is not the same during the period. It is shght at 
 first, as a rule, reaches the maximum on the third day, and then gradually de- 
 * "Erfahrungen und Abhandlungen," Mannheim, 1S12. 
 
24 PHYSIOLOGY OF THE FEMALE GENITAL ORGANS. 
 
 creases. At the last it often ceases for a few hours and then returns. Emotion 
 or excitement of any kind is very apt to bring it on. 
 
 Composition of the Menstrual Blood. — The discharge is made up of water, red 
 and white blood-corpuscles, mucus-corpuscles, abundant epithelial cells from the 
 uterus and vagina, and rarely strips of uterine mucosa. Virchow believes that 
 some of the epithelium comes from the interior of the uterine glands. The direct 
 discharge from the uterus consists of pure blood, and if it is collected by the 
 speculum it will coagulate. The fact that ordinary menstrual blood does not 
 coagulate has caused much speculation. Mandl has given the true explanation 
 by showing that small quantities of mucus or pus will keep fibrin in solution, and 
 that the former is always found in the secretions from the cervix and vagina and 
 mingles with the blood in its passage from the uterus to the external world. 
 However, in case of excessive flow there will not be sufficient mucus to act on all 
 the fibrin. The color is generally dark at first, while later it becomes paler. 
 Women in poor health often have a very pale discharge. The amount of inter- 
 mingled mucus doubtless has much to do with the differences in color. The reac- 
 tion is alkaline. There is always a faint odor to menstrual blood which is char- 
 acteristic. It has been likened to that of marigolds. It is probabty due either to 
 decomposing mucus or to the mixture of the secretions of the vulvar sebaceous 
 glands. This peculiarity has been noted from the earliest times, and even now 
 in England on many farms the old prejudice of the deleterious effects of menstrual 
 blood is seen in the custom of not allowing menstruating women to attend to the 
 making of butter, preserves, cheese, etc. The influence of menstruation on the 
 general health is very apparent. It is quite common to observe symptoms of 
 marked toxemia occurring a day or two before the flow, such as headache, nausea 
 and vomiting, jaundice, vertigo, and high blood-pressure, which subside upon 
 the establishment of the hemorrhage. 
 
 Modifications and Anomalies of Menstruation. — At times menstruation occurs 
 through the skin of the mammae. This is probably due to their intimate sympa- 
 thetic connection with the generative organs. Bleeding may also take place from 
 the surface of an ulcer or from hemorrhoids. All of these locations are such as to 
 give easy external escape to the blood. In other cases the bleeding occurs from the 
 nose ; or there may be vomiting of blood or bleeding from the lungs. Cutaneous 
 hemorrhage may take place. Vicarious menstruation is generally a sign of ill 
 health and is usually seen in young women of highly nervous organization. It 
 may begin at puberty and continue throughout the entire sexual life. Its occur- 
 rence is periodic, corresponding with the menstrual nisus, although the amount 
 of blood is generally considerably less than that lost in normal menses. AVe find 
 also such abnormalities as menorrhagia, dysmenorrhea, and retention of menses 
 from obliteration of the neck of the uterus or the vaginal orifice. Other modi- 
 fications are in the suppression of menstruation from pregnancy, from lactation, 
 or from emotion. 
 
 Relation between Menstruation and Ovulation. — This relation is not entirely 
 clear. Menstruation is not necessary to child-bearing, but there is a marked 
 connection between ovulation and menstruation. Various theories are ad- 
 vanced: by Pfliiger, that the presence of the ripe follicle causes a reflex action 
 which brings on menstruation; by Strassmann, that menstruation is due to 
 pressure changes in the ovary. To prove this he injected a sterile fluid into the 
 ovary and found the animal went in "heat" as a result. It has also been 
 observed that on the second or third day after ovariotomy the patient often 
 undergoes a pseudo-menstruation, probably caused by the pressure of the 
 Hgatures; also that menstruation may continue after ovariotomy. Some have 
 
MENSTRUATION. 25 
 
 tried to explain this by saying that a portion of the ovary had been left behind 
 or that the discharge was. due to some pathological condition not noticed at 
 the time. These cases, however, are too numerous to be explained on the sup- 
 position of a mistake. Leopold showed that ova mature at all times, both before 
 puberty and after the menopause, and this was observed by others. Lowenthal 
 thought that menstruation depended upon non-fertilization of the ovum; that 
 is, was a primitive abortion. Variations of three weeks have been noticed in the 
 time of delivery corresponding to fertilization just before or just after menstru- 
 ation. Young girls have also become pregnant before menstruation began, 
 and ruptured follicles have sometimes been found in the ovary in the inter- 
 menstrual period. Pregnancy seldom occurs during lactation, though men- 
 struation begins much sooner than the end of lactation. Lawson Tait 
 believed that there are nerves from the tubes to the sympathetic system, and 
 these he called menstruating nerves. All of these facts make the relationship 
 of menstruation to ovulation somewhat obscure. The following conclusions, 
 however, may safely be drawn: Ovulation and menstruation occur about the 
 same time, although ovulation often follows menstruation and may occur be- 
 tween the menses. The ovarian changes which precede ovulation, by producing 
 ovarian tension, refiexly excite the uterus and cause menstruation. These 
 changes are nearly or quite complete before the bursting of the Graafian follicle. 
 The time of labor cannot be accurately estimated, and rules for avoiding concep- 
 tion are very uncertain. Both ovulation and menstruation are under some ner- 
 vous control, yet either process may occur independently. Conception is more 
 apt to result from a coitus just after a menstrual flow than at any other time. 
 Three theories have been advanced as to these relations: (i) Ovulation deter- 
 mines menstruation; (2) menstrual congestion favors ovulation, since there occur 
 simultaneously congestion of the ovary and uterus; (3) menstruation and ovu- 
 lation are interdependent. 
 
 The Menopause. — The climacteric or change of life varies as widely as does 
 the establishment of menstruation, although the average age is between forty and 
 fifty years. Cases of women menstruating till the eightieth or ninetieth year, 
 which have been reported, must be regarded as exceptional and as having no 
 bearing on the general rule. The great majority of women cease to menstruate 
 in the forty-sixth year; most cases of prolonged menstruation are dependent on 
 pathological conditions — organic disease of some kind, malignant or otherwise. 
 Cases in which menstruation ceased between the ages of thirty and forty years 
 are noted, certain instances being recorded as early as the twenty-fifth year. 
 It is the generally received opinion that women who begin to menstruate early 
 cease to do so at a correspondingly early period, so that the average duration of 
 the function is about the same in all women. But Cazeaux and Raciborski 
 think differently, and they are upheld by the opinion of Guy, which he formed 
 from the observation of 1500 cases. These authors think that the earlier a 
 woman begins to menstruate, the longer she will continue; believing that early 
 menstruation indicates extreme vital energy, and that this continues during the 
 entire child-bearing epoch. Thirty years of sexual activity are considered the 
 normal duration. Climate and other accidental factors do not seem to have so 
 much influence on the cessation of menstruation as on its establishment. The 
 menopause is generally ushered in b}^ gradual changes in the amount of discharge. 
 There are irregularities in its occurrence, and a diminution in amount, or even at 
 times an increase, till finally it ceases altogether. The genitalia all undergo an 
 atrophic change and nervous phenomena appear (Fig. 5). Flashes of heat are 
 very characteristic, and both the physical and mental being may undergo altera- 
 
26 
 
 PHYSIOLOGY OF THE FEMALE GENITAL ORGANS. 
 
 tions. There is a more or less constant tendency to obesity at the time. The 
 notions among the laity as to the great dangers of the menopause are, without 
 doubt, greatly exaggerated. It is not uncommon to see a woman who for years 
 has suffered from uterine and other complaints seem to enjoy robust health after 
 this trying period has been passed. Statistics conclusively prove that mortality 
 at this time is no greater than at any other period. Some have noted that in 
 certain cases, especially of unmarried women, there is a loss of feminine traits 
 
 LINE OF'SECTION 
 
 Crural nerve 
 
 Psoas muscle 
 
 Iliac muscle 
 
 ' al artery ( injected) 
 
 undibiilo-pelvic liga- 
 
 m.ent 
 
 >)emng of right tube 
 
 Obturator artery 
 
 ngin of uterine and 
 
 vesicular arteries 
 
 Broad ligarnent 
 
 Right ovary 
 
 Mesenterium tubts 
 
 fiddle hemorrhoidal 
 
 artery j?7;g-Ai' ureter 
 
 Right tube 
 
 Co7n»wn pudic art. 
 
 Transverse sec. of round lig- 
 
 Gluteal miiscle 
 
 Transverse sec. of rectum 
 
 Fig. 5. — Atrophy and Prolapse of 
 
 Rectum 
 Crural nerve 
 Crural artery {injec 
 Med. and small glut, 
 
 m.uscle 
 Obturator nerve 
 Obturator artery 
 Origin of uterine ar 
 vesicular arteries 
 Ligament, latum cov 
 Left ureter. [left < 
 
 Left broadjigameni 
 Ischialjierve 
 
 Middle hemorrhoidi 
 
 artery 
 
 ~ Left t,^be 
 
 Ant. border of pyriform. muscle 
 
 Transverse sec. of round lig. 
 
 Common pudic art. 
 Retroverted uterine body 
 
 Douglas^ pouch 
 
 Uterus and Adnexa following the Menopause. — 
 
 and the assumption of certain anatomical male characteristics — a more an- 
 gular form, a harsher voice, or even the development of an imperfect beard or 
 moustache. 
 
 III. INSEMINATION. 
 
 Definition. — By insemination is meant the deposition of the seminal fluid 
 within the genital tract of the female during sexual intercourse. 
 
 Phenomena. — Before conception can take place there must be a meeting and 
 fusion of the vital elements of the two sexes. This is brought about by coitus or 
 copulation, by means of which the semen of the male is deposited in the vagina of 
 the female. This act is called insemination, although fecundation does not follow 
 unless the ovum and spermatozoon come together and amalgamate. When this 
 occurs, the woman conceives and enters upon the period of pregnancy or gesta- 
 tion. The orgasm is the climax of the sexual act. Its normal occurrence is 
 simultaneous in the male and female, and makes conception more probable. 
 When it is not simultaneous, the cervical alkaline mucus protects the spermatozoa 
 
Fig. 6. — Breast of a Nulli parous, Married Woman a Few Days Before a Menstrual 
 Period, Showing Changes Identical with Those Produced by Pregnancy. 
 
 * S» irf to -<• " fjsk 
 
 Fig. 7. — Vaginal ^^[urous -Memhrane of .v Nulliiwrous \\'oman the First Day of 
 
 ]\fENSTKUAL PEk lOU. S llOWING CHANGES ANALOGOUS TO I'lUiSE PkoDUCEI) T.V PkEGNANCV. 
 
IMPREGNATION. 
 
 27 
 
 from the acid secretion of the vagina. The collection of semen covering the 
 cervix permits the spermatozoa, by virtue of their inherent power of locomo- 
 tion, to enter the uterus. This explains the occurrence of conception in cases 
 in which the woman has been apathetic during sexual intercourse, having no 
 orgasm, or when she was unconscious from any cause. The time at which insemi- 
 nation is least likely to be followed by fertilization is from the seventeenth to the 
 twenty-third day after menstruation has ceased. It is most apt to occur on the 
 first day after menstruation. 
 
 IV. IMPREGNATION. 
 
 Synonyms. — Fertilization; Incarnation; Fecundation. 
 
 Definition. — By impregnation is meant the union of the ovum and the sperma- 
 tozoon. A woman who has never given birth to a child is called nulliparous, or a 
 nullipara, and her condition is termed nulliparity. The 
 state of capacity for having children is called parity. 
 When a woman is pregnant for the first time she is said 
 to be a primipara, or a primigravida, or a primigravidous 
 woman, or in the condition of primigravidity. In suc- 
 ceeding pregnancies she is a multipara, or a multigravida, 
 a multigravidous woman, or in the state of multiparity. 
 
 The Semen. — The medium by which the spermatozoa 
 reach the female generative organs is the semen. The 
 semen is a thick, viscid, albuminous fluid, whitish, yel- 
 lowish, or opalescent in color, with a peculiar odor that 
 has been likened to lime or to the filings of bone. It 
 consists of the secretion of the testicles together with that 
 of the prostate and Cowper's glands. It is composed of 
 the liquor seminis, in which are found microscopically 
 the seminal granules and numerous minute anatomical 
 elements termed spermatozoa, which are the vital ele- 
 ments. The liquor seminis, which on chemical exam- 
 ination yields 82 per cent, of water, holds in solution a 
 mucilaginous, odoriferous body called spermatin, as well 
 as protein matter, fats, phosphates, chlorides, and other 
 inorganic materials. 
 
 The Spermatozoa. — Each spermatozoid (Fig. 8) consists of a flat oval head, 
 which measures about -g-oVo iiich (3-5-0 mm.) in width, and represents the nucleus 
 of an epithelial cell; a small body, and a very long fiHform tail, or flagellum, 
 which in the living spermatozoon is in constant motion. The general appearance 
 of a spermatozoid is that of a tadpole. These little bodies come from the special- 
 ized sperm cells of the epithelium of the seminal tubules in the testicles. The 
 profile of the spermatozoid is pyriform in shape, and its entire length is -g-J-g- to 
 j|-Q- inch (0.05 to 0.06 mm.). The spermatozoa, the most important elements, 
 are not passive constituents of the liquor seminis, simply floating in this medium ; 
 they are endowed with motility, and seem to dart hither and thither as though 
 endowed with volition. It is difficult to realize, in watching the curious move- 
 ments of these minute organisms, as they advance now en masse, now singly, at 
 times diving down, then coming to the surface again, then in their gyrations 
 skilfully avoiding obstacles many times their size, that they are not to a certain 
 
 Fig. 8. — Human Sper- 
 matozoa. X 360. I. 
 Viewed from the sur- 
 face. 2. Viewed in pro- 
 file. 3. Coiled seminal 
 filament. 4. Sperma- 
 tozoon of bull: a, head; 
 h, middle-piece; c, 
 main-piece. The end- 
 piece and the demar- 
 cation of these parts 
 cannot be perceived 
 with this magnifica- 
 tion. — (Stdhr.) 
 
28 PHYSIOLOGY OF THE FEMALE GENITAL ORGANS. 
 
 extent possessed of the power of voluntary motion. However, these motions 
 are doubtless due to the undulatory vibrations of the tail, which depend purely 
 upon molecular tissue changes like those which give rise to the movements of 
 ciliated epithelium, or to the ameboid movements of protoplasm. The rate of 
 motion of the spermatozoa has been variously estimated; Henle states that they 
 travel an inch in seven to twelve minutes, or from the hymen to the cervix in 
 three hours (Sims). They have been found within the female genital .organs, 
 with their power of motion unimpaired, eight to ten days after they were deposited 
 there. As soon as the spermatozoa are deprived of this motility their vitalizing 
 power is lost. Environment has much to do with the retention of this power. 
 Extreme heat or cold or excessively acid or alkaline secretions will destroy them. 
 Mercuric chloride has a most untoward effect upon them, as have also the mineral 
 poisons and lack of water. They may be dead when ejaculated, as the result of 
 disease or catarrh of the seminal vesicles or alcoholic or sexual excess; or they 
 may be absent from the seminal fluid in consequence of anatomical defect, or 
 inflammation and obliteration of the seminal ducts. The seminal granule, or 
 accessory corpuscle, is that part of the cell which is extruded in the development 
 of the spermatozoon, and is analogous to the polar globule in the maturation of 
 the ovum. The fifteenth or sixteenth year marks the first appearance of the 
 spermatic particles in the sexual discharge ; although there is frequently a seminal 
 discharge several years earlier, it seldom contains these elements. Very often 
 spermatozoa disappear from the seminal fluid of old men, sixty-five years being 
 the average age, though many exceptions to this rule are on record. The amount 
 of spermatic fluid ejaculated in sexual congress averages about i dram (3.7 c.c.) 
 and the number of spermatozoa, as estimated by Lode, is 226,257,900. If much 
 in excess of this, the condition is termed polyspermism; while if much less, the 
 condition is pathological, and is designated as oligospermism. 
 
 Ascent of the Spermatozoa, — Many theories have been suggested as to the 
 method by which the spermatozoa reach the uterus. Litzmann, Wernicke, and 
 Beck proposed the aspiration theory, according to which the hood-like layer of the 
 uterus contracts, forcing the cervix down into the lake of spermatic fluid, then, re- 
 laxation following, the semen is aspirated into the canal. Marion Sims' view has 
 been received with the greatest favor. It is that the semen forms a lake in the 
 posterior cul-de-sac, and, the cervix dipping in, the fluid passes up into the uterus. 
 A proof of the truth of this theory is offered by the observation of the great 
 infrequency of pregnancy in cases in which uteri, after operation, cannot dip into 
 the spermatic fluid. It was formerly thought that the current produced by the 
 cilia of the uterus carried the spermatozoa along their upward path, while the 
 tubal cilia wafted the ovum toward the uterus; but Hofmeier, several years ago, 
 showed that the ciliary motion was all in the same direction, toward the outlet 
 of the uterus. Tubal pregnancy shows that the spermatozoa must get into the 
 tube by their own inherent motion. Occasional cases of pregnancy in which 
 conception occurs through a minute opening and an almost imperforate hymen 
 prove the extreme motility inherent in the spermatozoa. 
 
 Place of Meeting of Spermatozoon and Ovum. — Various authorities have 
 located the point of fecundation in the uterus, tubes, and ovary, and isolated 
 observations are on record showing that fecundation may take place in any one 
 of these organs, as the spermatozoa reach the uterus by reason of their own 
 motility, aided by other mechanism, whence they pass to the tube and wait for 
 the ovum, which may or may not be fertilized. 
 
 Relation between Impregnation and Menstruation. — It has been practically 
 proved from observations on the wives of sailors and from artificial impregna- 
 
IMPREGNATION. 29 
 
 tion* that the most favorable time for impregnation is immediately after men- 
 struation ; and also that the spermatozoa may retain their vitality in the vagina for 
 at least seventeen days, even through a menstrual period. Instances are known in 
 which insemination, occurring just before a menstrual period, was followed by 
 pregnancy and delivery at term.f Menstruation under such circumstances may be 
 perfectly normal, and the downward current of blood does not interfere with the 
 upward passage of the spermatozoa to the Fallopian tubes. Hist examined 
 sixteen embryos with the utmost care. He found that in twelve the stage of 
 development proved that impregnation had occurred, not at the time of the last, 
 but at what would have been the next, menstrual (first missed) epoch, had not 
 the woman become pregnant. The remaining four embryos in their develop- 
 ment corresponded to impregnation occurring at the last menstrual period. 
 Duncan says, in this connection, that when a fertilizing insemination takes place 
 just before the period is due, the latter frequently "does not take place at all, or 
 only very scantily; the uterine system, as it were, anticipating the conception 
 and preventing the failure which might result from a free discharge of blood." 
 It is quite evident that such cases, occurring in married women, would be very 
 liable to be considered "cases of gestation protracted a. month." 
 
 Unconscious Impregnation. — A woman may become pregnant in a state of 
 partial or complete unconsciousness. In cases of rape young girls have been 
 impregnated while unconscious as the result of fright, a blow, drugs, or alcohol. 
 Impregnation during unconsciousness as the result of anesthetics, chloroform, 
 ether, or nitrous oxide is also possible. Artificial impregnation, the seminal fluid 
 having, with suitable instruments, been injected directly into the uterus, has 
 also been successfully performed. Brouardel,^ who has studied and written 
 upon this subject, states that copulation and impregnation can occur in a woman 
 without her knowledge during hypnotic sleep. "That a woman should be un- 
 conscious both of the fact of sexual intercourse, and also continue unconscious of 
 the resulting pregnancy up to the birth of the child, we decline to believe, unless 
 she was feeble-minded or idiotic." (Reese.) 
 
 V. RAPE.II 
 
 Definition. — Rape, derived from raptus mulierum, signifies carnal knowledge 
 of a female by a man, forcibly and unlawfully, without her consent. It may, 
 however, be committed by fraud or by intimidation. 
 
 Law of Rape. — Common law declares a female under thirteen years of age 
 incapable of giving consent. Carnal knowledge between thirteen and sixteen is 
 regarded as a misdemeanor ; it is not a crime if the age is over sixteen and there is 
 consent. The testimony of the prosecutrix alone is considered legally com- 
 petent, since she and the offender are generally without other witnesses. As 
 false accusations of rape are common, the corroborative testimony of medical 
 evidence is generally required. In 600 accusations I could find evidences 
 of penetration in but 386 instances. In 212 there was no evidence what- 
 
 * Bossi: " Nouvelles Archives d'0bst6trique et de Gyn^cologie," Paris, April, 1S91. 
 
 t Milne Murray: "Edinburgh Med. Jour.," Sept., 1S92. 
 
 t "Anatomie menschl. Embryonen," Abth. I. V., II., Leipzig, 1SS2. 
 
 § " Gaz. des Hopitaux," 1S77. 
 
 II See more exhaustive article, "Medico-legal Consideration of Rape," by Edgar and 
 Johnston, "Medical Jurisprudence, Forensic Medicine and Toxicology.'," Witthaiis and 
 Becker, vol. 11. 
 
30 PHYSIOLOGY OF THE FEMALE GENITAL ORGANS. 
 
 ever of penetration of the genital organs and in two cases menstruation and 
 chancroids rendered the diagnosis uncertain. The examination should be made 
 as soon as possible after the assault, and the physician should carefully note the 
 time of his examination and try to obtain by inquiry the exact time of assault. 
 The female should be allowed no time to prepare for the examination. Several 
 points should be kept in mind and noted by the physician: (i) Signs of violence 
 on the genitals of the female; (2) signs of violence on her body or that of the 
 defendant; (3) evidence of blood or semen on the body or clothes of either; (4) 
 the existence of venereal disease, syphilis, chancroid, or gonorrhea, in one or both 
 of the individuals concerned. The evidence of masturbation and criminal 
 assault may be present in the same instance, and in the majority of cases the 
 medical expert can swear only to the "penetration of some blunt instrument." 
 The subject may be treated in four parts: (i) Rape on females after puberty; 
 (2) rape on children and infants; (3) rape by boys and women; (4) rape on 
 the dead (necrophilia). False accusations are considered throughout the text. 
 
 I. Rape on Females after Puberty. — The fourchette and posterior commissure 
 are often destroyed by the first delivery, but they are seldom injured by sexual 
 intercourse. In 386 penetrations the fourchette was lacerated in but 17 of the 
 cases observed by me. The hymen is the most convincing sign of virginity. It is 
 a membranous structure guarding the entrance to the vagina and making a line of 
 demarcation between it and the external genitals. There are four chief forms, 
 with many variations. These are: (i) A form with a central, antero-posterior 
 opening; (2) the semilunar; (3) the annular; and (4) the diaphragmatic. 
 (Figs. 9 to 33.) * The first and third are the most common varieties. The imper- 
 forate hymen is a pathological condition. Is the presence of an intact hymen 
 evidence of virginity? Although the presence of the hymen is not absolutely 
 invariable, still it is unquestionably the most valuable physical sign. However, 
 even when it rem.ains uninjured, it does not offer positive proof that rape has not 
 been committed. This is especially true in the case of young children, in whom 
 it is deeply placed, and the organs are undeveloped; for it must be remembered 
 that the slightest penetration is a crime. Authentic cases in which prostitutes 
 have had perfectly preserved hymens are on record. f It may even persist after 
 delivery, remaining as a loose ring. J Does the absence of the integrity of the 
 hymen, on the contrary, indicate defloration? The greatest care must be exer- 
 cised in deciding this question. The hymen may be injured manually, as in one 
 of my cases by a midwife; or it may be destroyed by accident, as by falling 
 astride of an object; again, violent exercise may rupture it — e. g., horseback- 
 riding. Congenital absence of the hymen is known (Fig. 35). Surgical opera- 
 tions or vaginal examinations, roughly conducted, not infrequently cause rup- 
 ture. The breasts are only slightly affected by handling and sexual indulgence. 
 One sign alone cannot afford positive proof of virginity, but all taken together 
 give assurance of it. It is well known that the use of vaginal astringents may 
 tone up and narrow the vagina and even restore the hymen to a great degree. In 
 complete recent defloration the hymen will furnish the most convincing proof, 
 but the external genitals may also be inflamed to a greater or less extent ; and if 
 the inflammation is extreme the patient's movements will be interfered with and 
 she will evince a great dread of opening the thighs. These signs are most im- 
 portant and are seldom simulated. There may also be signs of violence on the 
 
 *Figs. 9 to 33 inclusive, and Fig. 35, are from E. Von Hofmann's "Atlas of iLegal 
 Medicine." 
 
 t Grey's " Forensic Medicine," p. 49. 
 
 J Stolz: "Annales d'Hygi^ne," 1873, t. 2, p 148. 
 
RAPE. 
 
 31 
 
 Fig. 9. — Circular Hymen 
 WITH Wide Opening and 
 Circular Smooth-edged 
 Margin of Equable 
 Height Throughout, 
 
 Fig. 10. — Semilunar 
 Hymen. 
 
 Fig. II. — Semilunar 
 Hymen. 
 
 ,. if^^' 
 
 Fig. 12. — Hymen of Newly Fig. 13. — Circular Hymen Fig. 14. — Deep Irregular 
 
 Born Child with Deep with Deep Congenital Notch of the Hymen of 
 
 Notches to the Right Notches. Edges Smooth a Newly Born Infant. 
 
 AND Left. and Rounded. 
 
 Fig. 15. — Congenital Deep 
 Irregular Notch of Hy- 
 men. 
 
 Fig. 16. — Fimbriated Hy- 
 men in a Virgin. 
 
 Fig. 17. — Serrated or Fim- 
 briated Hymen in a Vir- 
 gin. 
 
32 
 
 PHYSIOLOGY OF THE FEMALE GENITAL ORGANS. 
 
 Fig. i8. — Hymen Bipartus 
 OR Septus or Divided Hy- 
 men. 
 
 Fig. 19. — Hymen Bipartus 
 orSeptus or Divided Hy- 
 men. 
 
 Fig. 20. — Hymen Septus in 
 AN Unmarried Woman 
 Twenty-four Years Old. 
 Strong and Thick Sep- 
 tum. 
 
 P^^. 
 
 T^l'Cf 
 
 Fig. 21. — Large and Small 
 Openings in a Divided 
 Circular Hymen. 
 
 Fig. 22.— Circular Hymen Fig. 23. — Circular Hymen 
 OF AN Adult Parous of Virgin, Age Twenty 
 Woman. Years. Hymen Partim 
 
 Septus. 
 
 Fig. 24. — Circular Hymen 
 with Congenital Trans- 
 verse Septum in Girl of 
 Seventeen 
 
 Fig. 25. — Divided Hymen Fig. 26. — Circular Hymen 
 of Infant with Thick of Child, Age Twelve, 
 Transverse Septum. Ruptured by Rape. 
 
 Death in Ten Days from 
 Peritonitis. 
 
RAPE. 
 
 33 
 
 Fig. 27.— Circular Hymen 
 WITH Old Healed Lac- 
 eration TO Left and 
 Right. 
 
 Fig. 28. — Remains of Hy- Fig. 29. — Hymen after Sev- 
 
 MEN Six Months after eral Labors. Shape Or- 
 
 Delivery at Term. Car- iginally Circular. 
 
 UNCULiE MyRTIFORMES. 
 
 Fig. 30. — Divided Hymen 
 OF A Prostitute Eigh- 
 teen Years Old. Coitus 
 Took Place through the 
 Left Opening. 
 
 Fig. 31. — Remains of a Di- 
 vided Hymen after De- 
 floration AND Parturi- 
 tion. 
 
 Fig. 32. — Hymen from a 
 Woman, Age Twenty- 
 nine, Who Died in Sixth 
 Month of First Preg- 
 nancy. Originally a Di- 
 vided Circular Hymen. 
 
 .^^i^.y-*- 
 
 FiG. 33. — Hymen from El- 
 derly Multiparous 
 Woman. 
 
 Fig. 34. — Parental Rape 
 ON Infant Eight Months 
 Old. Complete Lacera- 
 tion OF Pelvic Floor. — 
 (New York Children's So- 
 ciety.) 
 
 -# 
 
 r~ 
 
 --•>* 
 
 Fig. 35. — Congenital Ab- 
 sence OF Hymen. Mas- 
 culine PSEUDOHERMAPH- 
 
 rodism. Female Infant 
 WITH Normal Internal 
 AND Hermaphroditic Ex- 
 ternal Organs. 
 
34 PHYSIOLOGY OF THE FEMALE GENITAL ORGANS. 
 
 genitals, thighs, abdomen, or perineum. The hymeneal tear itself may be 
 attended with pain and difficulty in walking. Attention should be paid to the 
 manner in which the hymen is torn, as well as to the appearance of the edges of 
 the segments. As a rule, healing takes place in from eight to twelve, or at most 
 twenty, days. Rarely the tears of the hymen unite; if they do, a cicatrix may 
 remain. Incomplete recent defloration is usually seen in young children. Non- 
 recent defloration may be told chiefly from the absence of a complete hymen, its 
 remnants only remaining. The vulval canal is likely to be dilated. 
 
 Conditions Simulating Defloration. — Traumatism, all ulcerative and gangren- 
 ous affections of the pudendum, chancre, chancroid, mucous patches, and herpes 
 progenitalis may each cause such destruction that the results may simulate 
 those caused by intromission. An extreme degree of leucorrhea or an excessive 
 menstrual discharge may cause dilatation of the vagina and superficial ulceration 
 of the mucous membrane, like that produced by coitus. Again, marks of vio- 
 lence must be considered. Stains of blood and semen should be carefully exam- 
 ined. Vaginal discharges must be scientifically considered. Leucorrhea must 
 be differentiated from gonorrhea. 
 
 Can a woman be violated against her will? The best authorities believe fully 
 that a mature woman, in full possession of her faculties, cannot be raped by a 
 single man against her will. In the case of a child or an old woman, or when 
 there are two or more assailants, the conditions are very different. Terror may 
 in certain instances cause paralysis. Can rape be accomplished during natural 
 sleep? This is probably unlikely, indeed impossible, in the case of a virgin. 
 Rape by fraud, unfortunately, is widely prevalent, as in the impersonation of a 
 husband. Rape on psychopathic individuals, in the hypnotic state, and during 
 unconsciousness from narcotism, alcoholism, and anesthesia has occurred. 
 
 2. Rape upon Children and Infants. — This is far more common than the 
 crime on adults, for it is easier to perpetrate, and there is a wide-spread super- 
 stition among some nationalities that intercourse with a virgin is a sure cure 
 for venereal disease. On account of the disproportion between the organs, the 
 crime usually consists in placing the head of the penis between the labia majora 
 or the thighs of the child. There are great differences between the genital organs 
 of the child and the adult. The whole vulval canal is relatively much longer in 
 youth than after puberty. It is important to examine the fourchette and com- 
 missure for evidence of rape in children, since, on account of the very small open- 
 ing, injury is more common in their case than in that of mature women. The 
 hymen is very deeply situated in the child and there is almost no possibility of 
 intromission. The pubic arch, as well as the vagina and its entrance, are very 
 narrow. One of my 600 cases was rape by a father upon his daughter eight 
 months old, causing complete laceration of the perineum from vagina to rectum. 
 The hemorrhage was controlled and the perineum repaired with sutures (Case 
 No. 70,542) (Fig. 34). 
 
 G. P.; bom in United States; aged eight months; seen February 17, 1893, soon after 
 assault. The external genital organs were found to be greatly swollen, contused, and oedema- 
 tous. Complete laceration was foiuid to have occurred at the vaginal and rectal orifices, 
 ■causing loss of tissue between these two orifices and for some distance up on the recto-vaginal 
 ■septum, so that the vaginal and anal orifices appeared as one, surrounded by a bleeding 
 ■mass of lacerations. The child was removed to a hospital and an operation requiring the 
 introduction of several sutures was necessary to control the bleeding and partially to repair 
 the torn parts and restore them to their original condition. Defendant in this case was 
 ■charged with attempt at rape, pleaded not guilty, was adjudged insane, and committed 
 to tiie State Asylum for Insane Criminals at Matteawan. 
 
 3. Rape by Boys and Women. — Erections are known to be possible at four 
 
HYGIENE OF THE SEXUAL FUNCTIONS. 35 
 
 years of age, although both in this country and in England a boy under seven 
 years cannot legally commit a' felony. Rape by women, or rape by females on 
 males, is not uncommon. It is generally committed by an adult woman to gratify 
 a perverted sexual instinct, or while in a state of nymphomania. There is a super- 
 stition among the ignorant that the act will cure venereal disease. 
 
 4. Rape on the Dead, or Necrophilia. — This subject must not be confused with 
 that which deals with the evidence of rape found on the dead body, the crime 
 having been committed before death. The history of this revolting deed extends 
 back through the ages. In the State of New York this crime is punishable by 
 the maximum penalty of twenty years of imprisonment.* Physical evidence of 
 it would be difficult if it were not seen. Several instances of this crime occurred 
 in the old New York city morgue. 
 
 Statistics. — In my study of 600 consecutive examinations for evidence of rape made in 
 New York, for the Society for the Prevention of Cruelty to Children, I obtained the following 
 statistics: Age: The' yoiongest child was eight months, the oldest eighteen years, and the 
 average age was eleven years. Nativity: 405, or 67.50 per cent., were native bom; 65, or 
 10.83 per cent., were Italians; 36, or 6 per cent., were Germans; 23, or 3.83 per cent., 
 Russians; 13, or 2.16 per cent., Enghsh; 10, or 1.66 per cent., Austrians; 8, or 1.33 per 
 cent., Irish; 4, or 0.66 per cent., Scotch; 4, or 0.66 per cent., Swiss; 4, or 0.66 per 
 cent., Hvmgarians; 3, or 0.50 per cent., French; 3, or 0.50 per cent., Belgian; and 2, or 
 0.33 per cent., Bohemian. Marks oj a struggle: I found marks of a struggle in only 
 15 cases, or 2.50 per cent. These included abrasions, contusions of the thighs, groins, 
 buttocks, shoulder, and arm, 11 cases, or 1.83 per cent.; scratches of the hand and face, 3 
 cases, or 0.50 per cent.; and black eye in i case, or 0.17 per cent. Condition oj the external 
 genitals: Contusions, abrasions, or lacerations were present in 21 cases, or 3.60 per cent.; 
 vulvo- vaginal abscess in i case, or 0.17 per cent.; chancres or chancroids in 18 cases, or 
 3.01 per cent.; the fourchette was lacerated in 17 cases, or 2.83 per cent. The hymen was 
 found to have been ruptured in 338, or 57.46 per cent, of cases; inflamed in 7 cases, or 1.19 
 per cent.; stretched in 11 cases, or 1.83 per cent.; contused in i case, or 0.17 per cent.; 
 and abraded in 2, pr 0.33 per cent, of cases. Secretions: A muco-purulent or purulent 
 discharge was found in 67 cases, or 11. 16 per cent.; the gonococcus was found in 16 cases, 
 or 2.66 per cent.; and spermatozoa in 2, or 0.33 percent. Impregnation, as far as the 
 cases could be followed, was known to have occurred in 22, or 4 per cent. Undoubtedly 
 this is a low percentage, as many cases passed from observation. Penetration of the 
 genital organs by a blunt instrument was considered to have been recent in character in 
 201, or ^7, per cent.; non-recent, in 180, or 30 per cent., and both recent and non-recent 
 in 5 cases. Penetration was thus determined in 386 cases, or 65 per cent. In 2 cases, 
 because of menstruation and venereal sores, it was impossible to determine whether pene- 
 tration had occurred or not. This leaves 212 cases, or 35 per cent., in which there was no 
 evidence whatever of penetration of the genital organs. 
 
 VI. HYGIENE OF THE SEXUAL FUNCTIONS. 
 
 The health of the young girl should be most carefully guarded with a view of 
 preserving the integrity and vitality of the sexual functions. The difference in 
 vigor between the American women and their English and Continental sisters 
 points strongly to the superiority of the habits of hfe of the latter. The vulnera- 
 bility of the female pelvic organs is well known, and most of the dangers attend- 
 ing their treatment in former times have been done away with by modern aseptic 
 technique. The causes of gynecological disease are (i) predisposing and (2) 
 exciting. Chronologically considered, the first predisposing cause is heredity. 
 
 Heredity. — The untoward results of this factor are seen either in the direct 
 transmission from mother to daughter of specific physical defects, or in general 
 ill health as the heritage of ill-conditioned parents. It is generally accepted that 
 
 * Rust's "New York Penal Code and Criminal Procedure," 1891, chap, v, p 63, sec 
 303. clause 4 
 
36 PHYSIOLOGY OF THE FEMALE GENITAL ORGANS. 
 
 the children of parents of advanced years are apt to be less vigorous than those of 
 younger progenitors. 
 
 Education. — This has a powerful influence on the genital functions. Great 
 concentration in study uses up the nerve energy of the body and leaves the uterus 
 and ovaries without their legitimate share. Especially does close application to 
 music have a deleterious effect on these functions, by its emotional influences and 
 the expenditure of nervous energy which it demands. Hyperemia of the pelvis, 
 however caused, tends to produce disease of its contained organs. Sexual excite- 
 ment produced either through mental or physical influences — e. g., the observa- 
 tion of obscene sights or pictures, or masturbation — is also a cause. 
 
 Mode of Life. — Lack of exercise and of outdoor air is a fruitful cause of disease 
 and poor pelvic circulation. In the last few years attention has been called to 
 these defects in the life of the average American girl, and athletic sports, com- 
 paring favorably with those of men, have been instituted. Neglect of the skin 
 as the medium for so much of the vitiated excretions of the body is particularly 
 noted among the poorer class of foreigners. The amount and kind of food exer- 
 cises an important influence on the young girl's health. A common habit, which 
 grows stronger with every repetition, is the omission of breakfast. Soda-water, 
 ice-cream, and candy are most harmful if taken to excess, as they very often are. 
 Indigestible and non-nutritious foods should be avoided. All these factors tend 
 to produce anemia and general ill health. Neglect of the excretions is a very 
 common fault in young girls, as well as in women, and especially those with 
 gynecological troubles. The bowels, instead of moving once or twice a day, as 
 they should normally, are evacuated perhaps once a week. The poisons of the 
 waste matter are absorbed and sapremia results. The circulating impurities 
 show themselves in the anemic appearance, lack of energy, headache, and 
 neuralgic pains.- Then, again, the bladder is often not emptied when it should 
 be; consequently distention and displacement of the uterus by the enlarged 
 bladder, or paralysis of that organ, or cystitis may result. Disregard of the 
 menstrual periods causes much trouble. Girls during these periods are very apt 
 to make no difference in their manner of life from that at any other time. 
 Oftentimes violent exercise and exposure at these periods bring on serious con- 
 sequences. 
 
 Dress. — The manner of dressing has much to do with health or disease ; it is 
 especially faulty amongst women. Tight garments for any part are most inju- 
 rious. The disproportionate arrangement of clothes as to the warmth they 
 afford is injurious; for instance, when the lower abdomen is not sufficiently pro- 
 tected. Incorrect corsets exert a most baneful effect on the female organism. 
 The old-fashioned garment, even when worn loose, exerts a pressure of thirty 
 pounds (Fig. 36). The abdomen suffers from this more than the thorax. There 
 is a thinning and weakening of the abdominal wall, which becomes relaxed and 
 pushed forward, in the upright position, by the liver and intestines. In the sitting 
 posture, the pressure exerted by the abdominal wall, which should be backward 
 against the spine, is exerted downward toward the pelvis, and causes bulging of 
 the vulva even to the extent of half an inch (1.27 cm.). Corsets made to sup- 
 port the lower abdomen have not these objections (Fig. 37). High heels should 
 be avoided, for when they are worn, especially by the young, whose bones and 
 articulations are soft and pliable, they not only distort the foot but often en- 
 gender other troubles, such as neuralgic pains in the legs, alterations in the shape 
 of the pelvis, and curvature of the spine. Ordinary social pleasures entailing 
 late hours have a very bad effect on a girl's nervous organization. 
 
 Sexual Life. — Normal sexual intercourse, even when frequent, is not apt to 
 
HYGIENE OF THE SEXUAL FUNCTIONS. 
 
 37 
 
 injure a healthy woman. But irregularities indulged in will bring in their train 
 many complaints. Marriage, if pelvic disease exists, is often attended with dire 
 results, and causes much misery to both husband and wife. The growth of fibro- 
 mata seems especially active in the uteri of unmarried women and in those who 
 have never borne children. It would seem that the energies of that organ, which 
 are normally applied to the formation of a child, being deprived of that object, 
 • are free to take part in the production of a new growth. 
 
 The Prevention of Reproduction. — The act of reproduction may be set at 
 naught in a twofold manner: (i) By conditions which prevent the union of the 
 
 Fig. 36. — Corset Improperly Titted, so 
 THAT Abdominal Contents are Pushed 
 Downward and Backward, thus Fa- 
 voring Posterior Uterine Displace- 
 ments. Note the unnatural pressure 
 upon the breasts. — (Photographed from 
 life.) 
 
 Fig. 37. — Properly Fitting Corset. Hy- 
 pogastrium Supported from Below 
 Upward. Breasts Free and only 
 their Lower Portions Supported. — 
 
 (Photographed from life.) 
 
 reproductive units, and (2) by death of the embryo which results from the union 
 of these units. 
 
 I. Non-impregnation. — When non-impregnation comes about solely through 
 conscious efforts of the participants, we have a condition of affairs known as 
 artificial sterility, a subject which has a distinct obstetrical significance, because 
 in order to save the Hves of certain women, and at the same time to avoid feticide, 
 it is justifiable to prohibit impregnation. Unless either the life or the health of 
 the woman is certain to be wrecked by bearing a child, or unless she is incapable 
 of giving birth to a normal living child, the prevention of impregnation is justly 
 regarded as a violation of the moral law, an injury to the State, and to a certain 
 extent a detriment to the health of the participants. Technically, at least, it is a 
 
38 PHYSIOLOGY OF THE FEMALE GENITAL ORGANS. 
 
 violation of the criminal code, the various contrivances used for the prevention 
 of conception being regarded as contraband. A sharp distinction should there- 
 fore be made between artificial sterility which is practised to save the more ' 
 valuable life, and that which simply seeks to prevent reproduction in itself. 
 
 Therapeutic Prevention. — This expression signifies the prevention of impreg- 
 nation in cases in which the reproduction of a healthy, living child is quite impos- 
 sible, or if possible would mean either the death or permanent invalidism of the^ 
 mother. 
 
 Indications. — These comprise: (i) General conditions in the mother which 
 are likely to be transmitted to the child — syphilis, the tuberculous dyscrasia, 
 insanity, epilepsy. (2) General conditions in the mother which would be aggra- 
 vated to such an extent by reproduction that her death would be determined, or, 
 if inevitable in any case, greatly accelerated — heart disease, tuberculosis, cancer, 
 nephritis, diabetes, etc. (3) Conditions in the mother which, by producing 
 extreme dystocia, would make Caesarean section the only route by which the 
 child could be born — high degrees of contracted pelvis, obstruction of the birth 
 tract by inoperable tumors. 
 
 Management. — In the case of a woman who furnishes any of the indications 
 just enumerated, it is the duty of the physician to inform the patient and her 
 husband of all the consequences of impregnation under the circumstances. If 
 the matter is left to him to decide, he must insist that conception shall not occur. 
 Much further than this he can hardly go. Realizing that cohabitation without 
 intercourse is a condition difficult to realize, he may suggest a separation, tem- 
 porary or not. If this is refused, coitus might be permitted during the so-called 
 agenetic period of the intermenstrual cycle (from the seventeenth to the twenty- 
 fourth day after cessation of a period). The married pair should be informed 
 that this precaution simply diminishes the risk, and that if the lS,tter is assumed, 
 impregnation, if it occur, will necessitate interruption of the pregnancy, which 
 will submit the mother to more or less danger, hardship, expense, etc. If the 
 matter is left to the physician, he can hardly sanction coitus under any circum- 
 stances. Sooner or later the question will arise as to the use of so-called illegiti- 
 mate measures of preventing conception. If asked the objections to these, he 
 must take the stand that every one of these preventive measures constitutes an 
 abuse of a normal function. The coitus interruptus, coitus reservatus, simple or 
 antiseptic douching after coitus, wearing of coverings for the penis or obturators 
 for the uterus, etc., are all unphysiological and many of them untrustworthy. A 
 physician can never sanction anything which is frankly unphysiological, and 
 should explain to his patients that the act. of intercourse consists in three distinct 
 stages: (i) The male organ becomes completely rigid, passing from a state of 
 flaccidity into erection. (2) The second stage comprises intromission, friction, 
 and the orgasm or crisis. (3) The act of copulation is not concluded by the 
 orgasm. The penis, therefore, should not be withdrawn at once, but allowed to 
 remain until the gradual subsidence of the erection leaves it in its original flaccid 
 state. This final stage of copulation undoubtedly plays an important role in 
 impregnation, and if it is shortened or omitted, the consequences appear to be 
 unpleasantly felt by both sexes. In other words, withdraw^al of the penis 
 immediately after the orgasm is virtually a coitus interruptus. It is character- 
 istic of the various illegitimate measures for preventing conception that all of 
 them interfere with the second or third stage of coitus. The consequences to 
 the woman of these illegitimate practices are in part: (i) An unnatural local 
 congestion which leads to oophoritis, endometritis, leucorrhea, dysmenorrhea, 
 sterility, metrorrhagia, and cancer of the uterus; (2) neuroses of various kinds, 
 
HYGIENE OF THE SEXUAL FUNCTIONS. 39 
 
 spinal irritation, neurasthenia, etc. In the man the consequences are similar in 
 character, with the addition of dissatisfaction with imperfect coitus with his 
 wife, which often foments dislike, unfaithfulness, marital infelicity, and divorce. 
 If impregnation is actually contraindicated in a given case, the practitioner can- 
 not recommend any of the illegitimate modes of prevention of conception 
 because they are either harmful, or untrustworthy, or both. There is, however, 
 one course possible, which may be recommended as both safe and efficacious, 
 and one which can hardly be abused. That is, obhteration of the Fallopian 
 tubes for a short extent by the vaginal route. 
 
 This course is unobjectionable in theory from any standpoint; yet I fear it 
 hardly constitutes a solution to the problem. 
 
 2. Interruption op Pregnancy. — After pregnancy has begun it may be in- 
 terrupted by the natural death of the fetus from disease, trauma, etc. This is con- 
 sidered under the heads of death of the fetus, abortion, etc. (Part III). Preg- 
 nancy intentionally ended is feticide. Criminal feticide is the destruction of fetal 
 life for no other reason than to avoid child-birth. This is considered under the 
 head of criminal abortion (Part III). Therapeutic feticide, on the contrary, con- 
 sists in taking the fetal life when non-interference with pregnancy would result 
 in the death or permanent invalidism of the mother, or the birth of an abnormal 
 unit of society. The subject of therapeutic feticide is considered under " Ob- 
 stetric Operations " (Part X). 
 
 Child-birth. — Child-birth not infrequently is the origin of disease of the pelvic 
 organs, which hinders or prevents their normal functions. These troubles may or 
 may not result from improper medicinal or surgical treatment. Abortion is a 
 fruitful cause of pelvic trouble. Puerperse should receive the most careful 
 attention, and should be kept in bed till the uterus has contracted back into the 
 pelvis. In order to avoid the perils of gonorrheal and syphilitic infection, these 
 subjects are now receiving like attention with tuberculosis. The application of 
 the general principles of aseptic midwifery and early operative measures in case 
 of delayed labor, with immediate surgical attention given to lesions of the soft 
 parts, are doing much to prevent the frequent pelvic troubles so common in 
 former years. . 
 
 Climacteric. — The climacteric, although a physiological process, is a period 
 during which various diseases may show themselves. Nervous phenomena are 
 among the most common disturbances. The most serious occurrence is the 
 appearance of carcinoma, either in the uterus or in the breast. During this 
 period the bowels should be kept open. Cold bathing followed by brisk rubbing, 
 and lukewarm baths taken at intervals of a few days, tend to calm the nerves. 
 The diet should be carefully supervised. The patient should be supported men- 
 tally and encouraged by a favorable prognosis. In case of hemorrhage, it 
 should be checked just as in ordinary cases. 
 
 Cancer. — There is little possible prophylaxis at present for malignant disease 
 of the pelvic organs, but there is hope for the future. As. soon as the true cause 
 of cancer is discovered, some method of preventing or at least arresting its 
 progress will present itself. 
 
 Family Physician. — The family physician should be the guide of the child 
 from infancy through the various stages of life up to womanhood. He should 
 instruct not only the girl, but her mother also, in regard to the importance of the 
 sexual organs, their functions, and their proper care. The generative organs are 
 the last to develop, and when the girl is deficient in vitality these organs are the 
 first to suffer, for when undeveloped they are most prone to disease. 
 
PART TWO, 
 Physiological Pregnancy* 
 
 PHENOMENA PRODUCED BY PREGNANCY WITHIN THE UTERUS. 
 (Page 41.)— The Ovum; Maturation; Fertilization; Primitive Chorion; 
 Deciduse; Segmentation; Qerm=layers; Primitive Organs; Origin of Mem- 
 branes; Amnion; Allantois; Chorion; Placenta; Umbilical Cord; Nutrition 
 and Metabolism of the Ovum, Embryo, and Fetus ; Characteristics during 
 the Several Lunar Months ; Evolution and Determination of Sex. 
 
 II. PHENOMENA PRODUCED BY PREGNANCY IN THE MATERNAL OR- 
 
 GANISM. (Page 89.) — Local Phenomena in the Genital Tract, Adnexa, 
 Pelvis, and Breasts; General Phenomena in the Digestive System, Heart, 
 Lungs, Liver, Nervous System, Blood, Urine, Skin, etc. 
 
 III. THE DIAGNOSIS OF PREGNANCY. (Page 119.) 
 
 IV. THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY. (Page 132.) 
 V. FEIGNED PREGNANCY— PSEUDOCYESIS. (Page 138.) 
 
 VI. UNCONSCIOUS PREGNANCY. (Page 139.) 
 
 VII. MULTIPLE PREGNANCY. (Page 140.) 
 
 VIII. THE DURATION OF PREGNANCY. (Page 144.) 
 
 IX. CALCULATING THE DATE OF CONFINEMENT. (Page 146.) 
 
 X. THE EXAMINATION OF PREGNANCY. (Page 148.)— Obstetric Asepsis of 
 Patient and Physician ; Objects, External or Abdominal ; External Pelvi- 
 metry; Internal or Vaginal; Internal Pelvimetry; Rontgen Pelvimetry; 
 Pelvigraphy; Indirect Pelvimetry; Cliseometry; Cephalometry. 
 
 XI. THE HYGIENE AND MANAGEMENT OF PREGNANCY. (Page 184.) — 
 Prophylaxis; Exercise; Diet; Drink; Bowels; Fresh Air; Care of Skin, 
 Clothing, Breasts ; Mental Condition ; Examination of Urine ; Sexual 
 Intercourse. 
 
I. THE PHENOMENA PRODUCED BY PREGNANCY IN THE 
 
 UTERUS. THE DEVELOPMENT OF THE OVUM, 
 
 EMBRYO, FETUS, FETAL MEMBRANES, 
 
 AND FETAL STRUCTURES. 
 
 Introduction. — Pregnancy begins with conception and normally ends with 
 labor at the fortieth week. If no complications arise during this time, we have 
 a physiological pregnancy (Part II). On the other hand, various accidents may 
 bring about a pathological pregnancy (Part III). 
 
 A nulliparous woman, or a nullipara, is one who has never borne a child, 
 and the condition is one of nulliparity; 
 
 A primigravidous woman, or a primigravida (or primipara), is one who is 
 pregnant for the first time, and in subsequent pregnancies she is known as a 
 multigravidous woman or a midtigravida (or multipara). Different degrees 
 of gravidity or parity are usually designated by the Roman numerals, thus: 
 Ipara, a woman in her first pregnancy; Ilpara, one in her second pregnancy; 
 Illpara, IVpara, Vpara, etc. 
 
 In the following review of the subject of embryology, emphasis is placed upon the 
 growth of the embryo, fetal membranes, and fetal circulation — facts which bear most directly 
 upon the subject of obstetrics. For a full consideration of the subject special works on 
 embryology should be consulted. Among these, Minot's discussions of difficult points are 
 valuable, while the most recent book with an almost exclusive bearing upon human embry- 
 ology is KoUmann's " Entwickelungsgeschichte der Menschen." The embryological part of 
 Quain's "Anatomy" and Hertwig-Mark's "Embryology" also give excellent accounts of 
 the subject. For the latest information one must refer to the monographs which are appear- 
 ing in scientific periodicals. His's monumental work* is 
 the source of the greater portion of the accurate informa- 
 tion on the sub j ect of human embryology. The phenomena 
 of the development of the human being in its earliest stages 
 have not been adequately worked out; hence the gaps in 
 knowledge are usually filled in by statements from com- 
 parative embryology. We shall endeavor to differentiate 
 what is known of human development from that which is ■ y,-^ 
 
 inferential. \\|x 
 
 The Ovum. — At birth the ovary of a child is ''^'^^-, ua 
 
 believed to contain the maximum number of ova, "^ ~ -or~ "-' 
 
 estimated as high as 70,000. These primordial ova Fig. 38. — Primitive Folli- 
 
 are typical, spherical cells containing a nucleus ^^ ^^^^l. "^"^ ^^J^'^V^^^t 
 . , •'^ ' ^ . ,*',,. .„. Woman Thirty-two Years 
 
 with a membrane and one or several nucleoli (rig. Qld. th, Connective-tissue 
 38). They are arranged in so-called egg-tubes of layer; theca folliculi ; /, epi- 
 Pfluger and egg-nests (Fig. 39), which extend for t^f^^i', '^^^S. 
 some distance into the body of the ovary. By or germinative vesicle. — 
 the gradual ingrowth of vascular connective- tissue {Ajter W. Nagel.) 
 between the individuals of the tubes and nests the 
 
 ova are separated and become entirely surrounded by a connective-tissue sheath 
 the theca folliculi. Thus are formed the primitive follicles which at a later stage 
 
 * "Anatomie menschlicher Embryonen," 18S0-18S5. 
 41 
 
 
 ^^ 
 
 ^^f^ 
 
 ■^ 
 
 ■J-V^ 
 
 v^ 
 
 
 
 
 
 
 t 
 
 
 
 
 
 'Ov 
 
42 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 of development are known as Graafian follicles (Fig. i). As the ova develop 
 they increase in size until at maturity they are about y-^ inch (0.2 mm.) in 
 diameter, surrounded by a porous membrane, the zona pellucida or radiata; this 
 in turn is surrounded by a several-layered follicular epithelium known as the 
 corona radiata. A cell membrane limits the ovum proper, between which and 
 the zona pellucida there exists a narrow fissure known as the perivitelline space 
 The cell body, or vitellus, is protoplasmic and contains a few granules of food- 
 yolk similar to that which forms so marked a feature of the hen's egg. On 
 account of this small amount of food-yolk, or deutoplasm, the mammalian egg 
 is said to be alecithal (without yolk), in contradistinction to telolecithal eggs, 
 as best exemplified by Amphibia and birds, where the nutritive yolk is massed 
 
 J^S KE PS 
 
 Fig. 40. — Full-grown Human Ovum before 
 Maturation. A spherical cell with nucleus, 
 nucleolus, and yolk granules, z.p.. Zona pel- 
 lucida; y. ox v., yolk or vitellus; g.v., germinal 
 vesicle with nucleolus; cr., corona radiata; pz., 
 protoplasmic zone of ovum; p.s., perivitelline 
 space. — (After Nagel.) 
 
 Fig. 39. — Development of Graafian 
 Follicle of Mammals. D, Cumulus 
 oophorus; Ei, ripe egg with its germ i- 
 native vesicle and germinative spot 
 (K); Ke, germinal epithelium; Lf, 
 liquor folliculi; Mg, stratum granu- 
 losum; Mp, membrana pellucida ; Ps, 
 Pfluger's tubes; 5, fissure between 
 follicular cells {G) and cumulus oopho- 
 rus; 5o, connective-tissue stroma with 
 blood-vessels (g); Tf, theca folliculi; 
 V, V, primitive follicles. — {After Wie- 
 dersheim.) 
 
 at one pole; and centrolecithal eggs, as exemplified by Arthropods, where the 
 deutoplasm has a central position. 
 
 The nucleus becomes somewhat eccentrically placed and contains a conspi- 
 cuous nucleolus (Figs, i and 40). The whole ovum is encapsuled by the Graaf- 
 ian follicle. The follicles are scattered at different levels throughout the stroma 
 of the ovary (compare Ovulation, page 17). 
 
 Maturation of the Ovum and Zoosperm. — In many of the lower animals 
 a process called maturation of the ovum has been observed, whereby the nucleus 
 migrates toward the surface and by an active process of division throws off 
 a part of its substance in the form of polar globules, the part remaining in the 
 cell being called the female pronucleus or egg nucleus. 
 
PHYSIOLOGICAL PREGNANCY, 
 
 43 
 
 Polar bodies in different stages of development have been found in the eggs 
 of mammals (Figs. 41 and 42), and we may reasonably infer that a similar pro- 
 cess transpires in the human ovum. As the result of a somewhat analogous 
 process of maturation and division, the zoosperm or mature male element (Fig. 
 
 Fig. 41. — Formation of Polar Globules, 
 Mouse. Showing the nucleus of the 
 ovum dividing to form the first polar 
 globule, p.g., and at the right a zoo- 
 sperm, s, which has entered at the pro- 
 jecting portion. — (After Sobotta.) 
 
 Fro. 42. — Fertilization in the Mouse 
 Showing an ovum with two polar globules 
 and the male and female pronuclei about 
 to unite; g. s., achromatic spindle.^ 
 (Ajier Sohotta.) 
 
 'y^ 
 
 
 Fig. 43. — Ovum of White 
 Mouse. First segmen- 
 tation spindle with the 
 chromosomes of the pro- 
 nuclei still forming two 
 distinct groups. X 1500 
 diams. — {After Sohotta.) 
 
 Fig. 44. — Ovum of White 
 Mouse. First segmenta- 
 tion spindle with equa- 
 torial plate of chromo- 
 somes. X 1500 diams. — 
 {After Sobotta.) 
 
 Fig. 45. — Ovum of White 
 Mouse. First segmenta- 
 tion spindle. The chro- 
 mosomes have divided 
 and migrated toward the 
 poles of the spindle, form- 
 ing two groups. X 1500 
 diams. — {After Sobotta.) 
 
 8) contains a nucleus, — the male pronucleus, or sperm nucleus, — which repre- 
 sents only a part of the original nucleus from which it was derived. 
 
 Fertilization or Impregnation. — When the two sexual elements come in 
 contact in the upper part of the Fallopian tube, the zoosperm enters the ovum, 
 where its body becomes indistinguishable (Fig. 42), and a union of the two 
 
44 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 pronuclei takes place. This is considered the essential step in fertiHzation, 
 the union giving rise to a new nucleus called the segmentation nucleus. In the 
 ovum of the white mouse, according to Sobotta, the pronuclei never actually fuse 
 to form a membranate segmentation nucleus. Here the pronuclei lie first in close 
 apposition and are then separated by the formation of the achromatic spindle 
 (Fig. 42). 
 
 The pronuclei now break up into chromosomes and arrange themselves first 
 into two groups about the spindle (Fig. 43) and then into an equatorial plate (Fig. 
 44). At this stage there occurs a longitudinal splitting of the chromosomes and a 
 consequent doubling of their original number. The chromosomes next draw apart 
 
 toward the two poles of the spindle 
 (Fig. 45), where, after the completion 
 of the first segmentation, they give rise 
 to the nuclei of the resulting cells. It 
 is now believed that a similar process 
 of fertilization takes place in all mam- 
 malian ova. Facts of this sort have 
 great bearing upon theories of heredity, 
 
 
 ■)•■■■ 
 
 
 
 Fig. 46. — Transverse Section of the 
 Uterus from a Six-months' Fetus 
 AT THE Level of the Internal Os. 
 I, Cylindrical ciliated epithelium; 2, 
 connective-tissue stroma of mucous 
 membrane containing blood-vessels; 
 3, muscular layer with arteries; 4, sub- 
 serous connective tissue; 5, peritoneal 
 endothelium; 6, intraligamentary 
 connective tissue, containing main 
 branches of uterine artery. — {Schaej- 
 jer.) 
 
 Fig. 47. — Uterus and Ovum at Seventh or 
 Eighth Day. Section through Fig. 48. 
 o, Decidua vera; b, d, decidua reflexa; c, 
 ovum; o.i., internal os. — {Leopold.) 
 
 because it is evident that the actual sub- 
 stance derived from both parents goes 
 to form the new individual and appar- 
 ently is distributed by subsequent nuclear 
 division to every portion of the body (see 
 Impregnation, page 29). 
 Primitive Chorion. — During its passage through the Fallopian tube the ovum 
 derives more or less nourishment from the parts by which it is surrounded. 
 This is accomplished at a very early period by the formation upon all of the 
 extra-embryonic somatopleure of a growth of delicate villi which give to the 
 ovum even at this time a shaggy appearance. This is the primitive chorion, 
 and the whole ovum at this time is called the chorionic vesicle. 
 
 The Deciduae. — The uterus prepares for the reception of the fertilized ovum 
 by the premenstrual swelling of its mucosa which forms a pulpy nidus for its 
 new occupant. If the fertilized ovum does not then appear, menstruation 
 takes place. If the fertilized ovum remains in the genital tract, then the uterine 
 
PHYSIOLOGICAL PREGNANCY. 
 
 45 
 
 mucosa undergoes changes by which it is converted into decidua. That formed 
 in pregnancy is called decidua gravidilaiis. The normal uterine mucosa is thin, 
 averaging from 0.039 to 0.117 inch (i to 3 mm.) in thickness. Its most marked 
 change in pregnancy is the increase in this dimension, for in this condition it 
 often attains -g- inch (i cm.) in thickness. It is very vascular, soft and velvety 
 in consistence, and its surface is wavy or undulating, studded with depressions 
 which correspond to the openings of glands. With the beginning of pregnancy 
 the decidua comprises three parts : ( i ) Decidua vera is the hypertrophied mucous 
 membrane of the entire uterus (Figs. 47, 48, and 49). It atrophies in the 
 last third of pregnancy and is cast off in part with the membranes at labor and 
 in part with the lochia. (2) Decidua serotina, placental serotina or decidua 
 basilis, is that part of the decidua vera upon which the ovum is embedded 
 and which subsequently takes part in the formation of the placenta (Fig. 47). 
 (3) Decidua reflexa, circumfiexa or capsularis, or epichorial decidua, is not, as 
 its original name indicates, reflected, but is formed by growth of the uterine 
 tissues over the ovum till they meet above its surface (Figs. 47 and 49). This 
 
 Fig. 48. — Uterus and Ovum at Seventh or Eighth Day, showing Decidua Vera. 
 o.i, Internal os; a, uterine wall. — (Leopold.) 
 
 process of reflexion is nearly completed in the youngest human ovum, Peters 's 
 (Fig. 51), and is quite finished in from eight to twelve days after the migration 
 of the ovum into the uterus. The capsule grows with the increase of the ovum 
 until the second month, when it begins to degenerate, disappearing entirely by 
 the seventh month (Fig. 53). 
 
 Theories of the Origin of the Decidua. — There have been various theories 
 concerning the decidua. In 1840 Weber and Sharpy demonstrated glands 
 within it and showed it to be a hypertrophied mucosa. Friedlander's ideas 
 concerning the structure of the decidua are, in general, correct. He found 
 therein glands lined by high, columnar, ciliated epit;helium. The decidua vera 
 comprises two layers; the upper layer, or stratum compactum, consisting of 
 decidual cells with gland ducts here and there, while the attached layer, or 
 stratum spongiosum, is of spongy consistency, and made up of a few decidual 
 
46 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 cells, blood-vessels, and dilated glands or cavities.. Friedlander believed that 
 at the end of pregnancy the compact layer is thrown off; while there is left the 
 
 / 
 
 '..'^Si^ V5:>;/T(V 
 
 Cih:: 
 
 ■ y^'^.'-z'r-^-^--^M^^^. 
 
 Fig. 49. — Microscopic Section through an Ovum in Situ at the Seventh or Eighth 
 Day, showing Uterine Wall, Decidua Vera and Reflexa. — (Leopold.) 
 
 Fig 50. — Uterus and Ovu.m at Two Weeks, o, Ovum; d, decidua vera; o.i., internal 
 
 os; 5, external os. — (Leopold.) 
 
 spongy layer, which is the dilated, irregular surface usually seen. It is now 
 known that the line of demarcation is somewhat deeper than Friedlander be- 
 lieved. His work has been verified by Leopold and Meinert. 
 
PHYSIOLOGICAL PREGNANCY. 
 
 47 
 
 ""'" %^'0^^^^^S&iSi:f<if^^ . : .^ : ■.,';;... :.i-'/'^ 
 
 
 j^ .V~^'^j^.r\-"VJ. -i-.r^- '■ 
 
 Fig. 51. — Section OF Peters's Ovum IN Situ. y4m.c, Amniotic cavity; WJac, blood lacuna; 
 clol, blood-clot on surface of the uterus; Cce, extra-embryonic ccelom; Conn, connective 
 tissue of uterus; Ec, ectoderm of chorion; Ep, epithelium of uterus; Mes, mesoderm of 
 chorion; Sh, embryonic shield; Tro, trophoblast; Yi, mesodermic core of chorionic villus; 
 Yk, cavity of yolk-sac. — {After H. Peters.) 
 
 . nnagl. 
 
 'mr' 
 
 
 • ■ ^^^-Z 
 
 ^mp' 
 
 m 
 
 jSMSSk 
 
 ii 
 
 
 d' W' 
 
 '^&% 
 
 
 
 
 FiG. 52. — Uterus One Month Pregnant; Portion of the Compact Layer of the 
 Decidua seen in Vertical Section, coagl, Coagtilum upon the surface; d. d' , decidual 
 cells. X 445 diams. — (Minot.) 
 
48 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 The Decidual Cell. — The origin of the decidual cell, discovered by Hegar 
 and Maier about i860, though variously explained, is now known to be the 
 connective-tissue cell. It is much larger than the cell of the interglandular 
 substance and is often very irregular in shape. The hypertrophied decidual 
 cell (Fig. 52) resembles the epithelioid cell of tuberculosis and the lutein cell. 
 It also resembles the large sarcoma cell, and, according to Ruge, is the physio- 
 logical type of this pathological unit. The hypertrophied decidua, the spongy 
 layer in the early months of pregnancy, may look like malignant adenoma. 
 
 Formation. — The formation of the decidua is not dependent on the presence 
 of the fertilized ovum, for we find it in the extrauterine pregnancy. This 
 condition is not absolutely pathognomonic of pregnancy, for the decidual cell 
 is found in endometritis and membranous dysmenorrhea, in which latter affec- 
 tion a cast of the uterus is thrown off. The development of the decidual cell 
 
 Fig. 53. — Diagram showing the Relations of the Uterus, Embryo, and Embryonic 
 ^Structures at the Second Month of Gestation. — (After Allen Thompson.) 
 
 from the connective tissue of the stroma of the uterus, and that of the lutein 
 cell from the connective tissue surrounding the ovum, are analogous processes. 
 In the ovary they tide over the reconstruction period, while in the uterus they 
 help to form the placenta, and after the birth of the child they are cast off. 
 
 Disappearance. — The decidua vera is thickest at the third month of preg- 
 nancy, after which it steadily becomes thinner (Figs. 105 and 137). In early 
 pregnancy the ovum does not completely fill the uterine cavity, but when this 
 comes about the decidua vera is compressed and begins to atrophy, while the 
 decidua reflexa comes into closer and closer contact with it, until about the 
 sixth month, at which time the two deciduse cannot be distinguished. At term 
 the vera is not much thicker than the original mucous membr,ane. Until the 
 period of fusion of these two parts of the decidua, the interval between them 
 is filled with hydroperione, a mucous liquid much like the liquor amnii. During 
 
SEGMENTATION. 
 
 49 
 
 the later months of pregnancy the decid.ua undergoes a fatty degeneration that 
 assists in loosening its attachment to the uterus, and, as already stated, the 
 greater part of this membrane is cast off during labor. Its remains are dis- 
 charged with the lochia, save a very little that stays behind to assist in the 
 production of a new uterine -mucosa (compare Physiologic Puerperium) 
 
 Is. - 
 
 z.p. 
 
 ~i P-b- 
 
 Fig. 54. — Segmentation of a Mammal, Bat. Two-celled Stage. Two segmentation 
 spheres each having a nucleus. The dark bodies are yolk granules, s.s., Smaller 
 segmentation sphere; l.s., larger segmentation sphere; z.p., zona pellucida; p.b., polar 
 globule. — {After E. van Beneden.) 
 
 Fig. 55. — Segmentation of the Ovum, 
 Rabbit. Four-celled Stage. — {After 
 van Beneden.) 
 
 Fig. 56. — Segmentation of the Ovum, Rab- 
 bit. Many-celled or Morula Stage. 
 Numerous spermatozoa lie in the thick- 
 ened egg membrane. — {After Bischoff.) 
 
 Segmentation. — In the human ovum nothing is known of the process by 
 which a single cell subdivides into many. In lower vertebrates and several 
 mammals the process has been carefully followed. In the latter, the segmenta- 
 tion-nucleus divides, thus forming two cells which again divide. These four again 
 divide, and the process of subdivision is continued until a soHd ball of cells is 
 4 
 
50 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 formed, the early blastula or morula, so called rom its resemblance to a mulberry 
 (Figs. 54, 55, and 56). In Amphioxus and some other lower forms the morula 
 
 Fig. 57. — Segmentation of the Ovum. Sections of the Ovum of the Rabbit During 
 THE Later Stages of Segmentation, showing the Formation of the Blastodermic 
 Vesicle, a, Showing the outer layer and the inner cell mass before the formation of a 
 cavity; also the so-called blastopore * ; b, showing the cavity formed by the absorption 
 of liquid; c, enlarged cavity; d, showing the cell mass forming a layer at one side of the 
 thinned outer or Rauber's layer; ent., inner mass of cells; ect., outer or subzonal layer. 
 When the ovum attaches itself to the uterine wall, this laj^er becomes the trophoblast; 
 z.p., zona pellucida. — {After van Beneden.) 
 
 sec.c- 
 
 Ky l.TTL 
 
 Fig. 58. — Formation of the Blastodermic Layers in the Mole in Three Successive 
 Stages, z, Zona pellucida; ex., subzonal epithelium (ectoderm); sec.c, segmentation 
 cavity; hy., hypoblast; i.m., inner mass of cells. — (Minot.) 
 
 by further division of its cells is converted into a blastula, which by the process 
 of invagination at the vegetative pole becomes a gastrula (Fig. 59). 
 
 * Minot thinks that van Beneden erred in his interpretation of the interruption in the outer 
 or subzonal layer, and believes that it is really a continuous layer of cells. 
 
SEGMENTATION. 
 
 51 
 
 Such a total division of cells is called holoblastic, to distinguish it from mero- 
 blastic division, or such as takes place in a chick, in which a partial division of 
 the egg occurs, forming a disc-like layer of cells on the surface of a large, undivided 
 yolk. 
 
 Holoblastic or total division occurs in all but the two most primitive mam- 
 mals, the ornithorhynchus and echidna, in which there is a large polar yolk mass 
 which does not divide completely into cells. The discovery of the latter fact 
 affords a key to the apparently anomalous condition of the higher vertebrates, 
 in which the embryo in its early stages of development resembles very closely 
 that of reptiles and birds; and the fetal membranes show strict correspondence 
 in form and function to those of the latter. The method of development and the 
 form of fetal appendages peculiar to reptiles and birds is consequent upon the 
 large mass of nutritive yolk contained in their eggs. The fact that the ova of 
 higher mammals, while containing little or no yolk, yet in their development fol- 
 low along the lines of yolk-containing 
 eggs, is explained by the hypothesis that 
 they have descended from oviparous an- 
 cestors whose eggs were rich in yolk. 
 
 -■iT^X 
 
 ■<,^^:^^c. 
 
 
 dg. 
 
 '^■^%sj 
 
 Fig. 59. — Formation of Gastrula, Amphiox- 
 us. The entoderm, en., has begun to in- 
 vaginate, making the segmentation cavity, 
 S.C., smaller; e.c, ectoderm. — {After Hat- 
 schek.) 
 
 ^'yoo] 
 
 Fig. 60. — Formation of Gastrula in Am- 
 PHioxus. The segmentation cavity has 
 almost disappeared between the ecto- 
 derm, ec, and the invaginated entoderm, 
 en., which lines the digestive cavity, d.g., 
 or enteron. The opening of the latter is 
 the original oral opening or blastopore, 
 0.0. A single mesodermic cell, m.c, at 
 the left at the union of the ectoderm 
 and entoderm. — {After Hatschek.) 
 
 According to this hypothesis, Mono- 
 tremes and Marsupials are the connect- 
 ing links between birds and mammals. 
 In the evolution of viviparous mammals 
 
 the membranes which were formerly of service in development within egg capsules 
 and in the presence of nutritive yolk now become adapted for intra-uterine devel- 
 opment where nourishment is received direct from the maternal organism. In 
 some of the forms observed, the cells of the morula are not uniform in appear- 
 ance, larger clear cells being massed at one pole, smaller dark cells at the other. 
 The clearer cells grow and divide more rapidly, finally forming a complete en- 
 velope except at one point (as recorded by van Beneden) (Fig. 57), surrounding 
 the smaller cells. As the morula passes by the action of the ciliated epithelium 
 through the Fallopian tubes a liquid is formed between the two kinds of cells 
 which increases in amount until there is produced a much enlarged, hollow sphere 
 of flattened cells, within which and attached to one point is a group of smaller 
 elements (Fig. 57). The former cells compose the subzonal layer, later, some- 
 times known as Rauber's layer; the latter are known as the inner cell mass and 
 
52 
 
 PH YSIOLOGICA L PREGNA NC Y. 
 
 eventually give rise to the major part of the ectoderm and the entire 
 entoderm. 
 
 Formation of Germ-layers. — By reason of the control of conditions, which 
 
 Fig. 6i. — Germ-disc of an Embryo Rab- 
 bit. — (After E. van Beneden.) pr, Primi- 
 tive streak; kf, head process; hk, Hen- 
 sen's node; en, canalis neurentericus. 
 — {Hertwig-Mark.) 
 
 fh 
 
 Fig. 62. — Longitudinal (Sagittal) Sec- 
 tion THROUGH AN EgG OF TriTON AT 
 
 THE Beginning of Gastrulation. ak 
 Outer germ-layer; ik, inner germ -layer; 
 jh, cleavage-cavity; vd, coelenteron; w, 
 blastopore; ci2, yolk-cells; dl and vl, dor- 
 sal and ventral lips of the blastopore. — 
 {Hertwig-Mark . ) 
 
 JVC CH 
 
 BH L'M 
 
 PJV 
 
 \.5i=- 
 
 Fig. 63. — Sagittal Section of Frog Embryo showing the Three Layers. The blasto- 
 pore now becomes the proctodeal opening and the neurenteric canal joining enteron 
 with neural canal. — {After Gotte.) 
 
 BF, Fore-brain; BH, hind-brain; BM, mid-brain; CH, notochord; M, mesoblast; NC, 
 cavity of neural tube; NT, neurenteric canal; PN, pineal body; PT, point where 
 future mouth arises; TI, intestinal region of mesenteron; TP, pharyngeal region of 
 mesenteron; J/, proctodeal aperture ; VK, liver; Y", yolk-cells. 
 
 is possible in that animal, the formation of germ-layers has been more fully 
 and frequently studied in the chick than in any other species. The following 
 changes, however, have been taken from the embryology of the rabbit, which 
 is tolerably well understood, because this mammal naturally has more resem- 
 
FORMATION OF GERM-LAYERS. 
 
 53 
 
 blance to man. The concentrated mass of cells above described at the pole 
 of the ovum flattens out into a disc called the blastoderm, which is seen to 
 
 y.s. 
 
 a.s. 
 I.e. 
 
 Fig. 64. — Section THROUGH Early Human Ovum. X 24. c?.^., Embryonic disc; e(;., ecto- 
 derm; m., mesoderm; y.s., yolk-sac; c, chorion; ,am., amnion; a.s., allantoic stalk; 
 a.c, allantoic canal. — {After Graf Spee.) 
 
 consist of two kinds of elements (Fig. 58, c), with two layers next to the outer 
 
 sphere of flattened cells; and more or less continuous with it, which together 
 
 are regarded as the ectoderm. The cells 
 
 which complete the sphere are called, 
 
 from their discoverer, Rauber's layer, 
 
 and in the rabbit they disappear (see 
 
 Membranes). 
 
 There are also cells lying next to the 
 cavity which form the entoderm,. This 
 two-layered germ, though arising in a 
 much modified manner, is properly com- 
 parable with the two-layered or gastrula 
 stage of the amphioxus (Fig. 60), and 
 the cavity is also called the segm-entation 
 cavity.* The blastoderm of the rabbit, 
 as seen from above, soon takes the form 
 of a shield, in the mid-line of which is 
 seen the primitive streak (Fig. 61). In 
 section this is found to be a thickened 
 cord of cells in which ectoderm and en- 
 toderm fuse, and from the junction of 
 which a third layer, called the mesoderm, 
 
 m.g. 
 
 P-g- 
 
 ■^ ' 
 
 J^lpf^-^ _P'*.s^ 
 
 extends out on either side. At the an- 
 terior limit of the primitive streak is 
 located Hensen's knot; here the three 
 primary germ layers are in intimate 
 union; from this point grows forward the 
 so-called head process from which the 
 future body arises. The primitive streak 
 in higher vertebrates is an elongated rep- 
 resentative of the blastopore of the am- 
 phibia (Fig. 62), which in its turn repre- 
 
 * Some investigators, notably O. Hertwig, dissent from this interpretation. Hertwig 
 considers a stage like that of d, Fig. 57, as a single-layered blastula, and believes that here, 
 as in other vertebrates, a two-layered gastrula arises by invagination or ingression of cells. 
 
 Fig. 65. — Dorsal View of a Human Em- 
 bryo. 1.54 mm. long. X30. The am- 
 nion, am., is nearly all removed. The 
 yolk-sac, y.s., shows blood islands. The 
 elongated embryo shows a medullary 
 groove, m.g., the neurenteric canal, n.c, 
 and the primitive streak. The abdom- 
 inal stalk, a. 5., connects it to the chorion, 
 c, with its branched villi, p.g.. Primi- 
 tive groove. From a wax reconstruc- 
 tion. — {After Graf Spee.) 
 
54 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 sents a modified gastrula mouth of the still earlier forms (Fig. 60). The blasto- 
 pore of amphibia becomes covered by an unequal growth of cells, its last trace 
 being in the neurenteric canal which connects the primitive enteron with the 
 caudal end of the neural canal (Fig. 63). A neurenteric canal with the same 
 essential relations is found in higher vertebrates at the cephalic end of the primi- 
 tive streak. Finally blastopore, primitive streak, and neurenteric canal dis- 
 appear, leaving no trace, but they are of profound interest, since they form a 
 
 ^fe^' m. 
 
 Fig. 66. — Sagittal Section of Fig. 65. Showing in addi- 
 tion the allantoic process, the complete amnion, am., with 
 a slight extension toward the chorion, c, and the thickening 
 of the mesoderm, m., where the heart will develop, m.p., 
 Medullary plate; h.f., heart fold; c.v., chorionic viUi; a.s., 
 allantois stalk; p.s., primitive streak; a.c, allantoic canal; 
 y.s., yolk sac; en., entoderm; v., vessels; p.s., primitive 
 streak. 
 
 Fig. 67. — Cross-section of 
 Fig. 65. Shows the ecto- 
 derm forming the medul- 
 lary folds and groove and 
 at the right thinning to 
 form the amnion, am., 
 Amnion; ek., ectoderm; 
 ct., amniotic mesoderm; 
 g., meeting point of soma- 
 topleure and splanchno- 
 pleure; df., mesoderm of 
 yolk sac; b, b, b, blood- 
 vessels; en., entoderm; n, 
 blastopore; d, cavity of 
 yolk-sac, — (After Graf 
 Spee.) 
 
 common landmark in early development throughout 
 
 the vertebrate series, marking the point from which 
 
 the mesoderm takes its origin. The neurenteric canal 
 
 is seen in a very early human ovum described by Graf 
 
 Spee (Fig. 65). According to Mall, its last remnant is 
 
 distinct until adult structures are sufficiently developed 
 
 to determine its relative location, it being at the level of the first rib. This one 
 
 fact shows that the structures derived from the head and neck are the earliest to 
 
 be laid down, the whole of the trunk and limbs being of later formation. 
 
 Formation of Primitive Organs. — The early embryology of organs has also 
 been much more completely studied in the lower animals, though the differences 
 that have been observed between the latter and man do not appear to be so 
 radical in the organs as in the original layers. If the rabbit be taken as the 
 
FORMATION OF PRIMITIVE ORGANS. 
 
 55 
 
 type, after the three layers — ectoderm, entoderm, and mesoderm — are differen- 
 tiated, the ectoderm at some Httle distance in front of the primitive streak 
 by a process of unequal growth becomes folded in, and in a similar way at the 
 caudal end, while at either side folds are also formed, until by this means the 
 embryo is outlined and somewhat 
 raised above the general level of 
 the embryonic shield. At the 
 same time other folds affecting the 
 ectoderm appear at either side of 
 the axis and gradually extend 
 caudally. These are the medul- 
 lary folds, between which lies the 
 medullary groove. The folds arise 
 above the general level (Figs. 65, 
 66, and 67), and as they grow up- 
 ward, fold over toward each other 
 until they unite to form a tube. 
 This is the neural tube, and is at 
 first in connection with the ecto- 
 derm of the general surface of the 
 body, which is now called the epi- 
 dermis. The first closure of the 
 
 tube is in the neck region, the closure extending both forward and back As 
 the closure proceeds the tube is separated from the epidermis (Figs. 68 and 
 69). At either side, just at the junction of the part of the ectoderm which 
 
 Fig. 68. — Transverse Section of a Mole Em- 
 bryo. (Heape's Stage H.) am., Amnion; Md., 
 medullary grove; My., primitive segment; Ccb., 
 coelom; En., entoderm; nch., notochord; ao., 
 aorta; vt.a., vitelline artery; Som., somatic meso- 
 derm; Spl., splanchnic mesoderm. — {After W. 
 Heape.) 
 
 Fig. 69. — Cross-section through the Rump of a Rabbit Embryo of Eight Days and 
 Three Hours. The medullary or neural tube, Md., is closed and completely .separated 
 from the epidermis, which is continuous with the epithelial layer of the amnion and chor- 
 ion. At this level amnion and chorion have not separated and the folds forming them 
 have not yet quite united. The notochord {Ch) is separated from the entoderm {Ent) . 
 The primitive segments {Seg) are hollow. The body-cavity, Coe., is continuous with the 
 extraembryonic cavity. There are still two aortae, Ao.; Cho., chorion; Am., amnion; 
 Som., somatopleure ; Spl., splanchnopleure, — {After Minot.) 
 
 is to form skin with that which is to form the neural tube, there is a thicken- 
 ing of ectoderm which, in the form of a cord, becomes free from its attachment 
 to the former. These cords come to lie on both sides of the neural tube and 
 
56 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 give rise to the nervous ganglia and to the sensory roots of the nerves, and 
 also finally to the sympathetic system. Before the closure of the tube is com- 
 plete two pockets arise from it on the two sides near the cephalic end. These 
 
 h.c. 
 nt.c. 
 
 ;^ t.c.r. 
 
 Fig. 70. — Sagittal Section of a Rabbit 
 WITH 8 TO 12 Myotomes. Shows the 
 neural tube hollow and beveled to form 
 the fore-brain, f.b.; the chorda, c, bent 
 and touching the hypophysis, h.c; the 
 bUnd end of the entoderm, en., coming 
 in contact with the ectoderm to form the 
 oral plate ; the continuation of the ecto- 
 derm to form the amnion, ant.; the heart, 
 h., prominent and just below the mouth- 
 cavity, m.c. t.c.r., Trabeculse cranii of 
 Rathke; f.g., foregut. — {After Keibel.) 
 
 Fig. 71. — Section of a Model of a Three 
 Weeks' Human Embryo, showing the 
 Optic Vesicles as Outpocketings from 
 THE Brain. — (Stisanna Phelps Gage.) 
 V .fug. Jugular vein; inf, inf undibultim ; 
 Dien, diencephalon ; Mesen, mesen- 
 cephalon; O.V., optic vesicle; the notch 
 at the tip is the beginning of the optic 
 cup. 
 
 -~:^^<\-^!'0\ \^ 
 
 are the first indications of the eyes. As the tube closes the pockets extend 
 farther and farther outward, becoming partly constricted off from the tube (Fig. 
 
 71). The outer surface of the pocket be- 
 comes pushed inward against the inner 
 surface until a double- walled cup (Fig. 72) 
 is formed, which ultimately becomes the 
 many-layered retina, connected with the 
 brain by the stalk which elongates and in 
 which are developed the fibers of the optic 
 nerve. The optic cup gives rise to few other 
 parts of the eye, but the larger portion of 
 them is produced from the mesoderm, 
 which pushes in and around these funda- 
 mental parts (Fig. 72). At the same time 
 that the optic cup is forming the ectoderm 
 which covers it is producing an ingrowing 
 pocket, which by a similar process is con- 
 stricted and finally wholly separated from 
 the ectoderm to form the lens of the eye, 
 which fits into the opening of the optic cup 
 (Fig. 72). The ectoderm also gives rise 
 to the internal ear, which is completely constricted off, and to the external ear 
 and the nasal epithelium, which form deep pockets but are never separated from 
 
 CO. 
 
 e. 
 
 Fig. 72. — Section through the De- 
 veloping Eye of a Human Embryo 
 (10.2 MM. Long). Shows the open 
 stalk connected with the mid-brain; 
 the double-walled optic cup ; the vesi- 
 cle of the lens cut off from the ecto- 
 derm, ec; and mesoderm growing in 
 to form the cornea, c, vitreous humor 
 (v.h.), etc. w., Mesoderm; r.L, retinal 
 layer; p. I., pigment layer; s. and c, 
 sclera and chorioidea; t., thalamen- 
 cephalon; co., conus opticus ; e., epen- 
 dyma. — (After Kallmann.) 
 
FORMATION OF PRIMITIVE ORGANS. 
 
 57 
 
 the exterior. At the same time that the neural tube is forming, the entoderm 
 along the middle line and just below the neural tube is by evagination and sub- 
 sequent constriction forming a much smaller tube, which soon becomes soHd and 
 forms the notochord (Figs. '68, 69), the first trace of a body-axis. The notochord 
 does not extend to the cephalic tip of the neural tube, but stops at the hypophysis 
 (Fig. 70); that is, near the level of the sella turcica of the adult skull. The 
 chorda and its cephalic end forms landmarks throughout the vertebrate series 
 and from very early stages of development. In 
 mammals it becomes insignificant, as it is enclosed 
 in the vertebral column. The entoderm at first 
 lines a simple, unconstricted yolk-sac (Figs. 64 and 
 66), but as the embryo grows out over the almost 
 stationary sac the upper portion of the latter be- 
 comes separated by a constriction on all sides, 
 more pronounced anteriorly and laterally, to give 
 origin to a continuous tube blind at both its ceph- 
 
 vagfus Tierce 
 
 external 
 carotid, 
 
 'internal 
 carotiet 
 
 recurrent 
 laryn^ea. 
 nerve 
 
 riffht^ 
 'Siwclaviarv 
 
 inrumtiruzte 
 artery 
 
 yertebral 
 
 arch of 
 aorta 
 
 Jlepa, 
 
 ascending 
 
 aortcv 
 
 \.iefe . 
 
 sabclaruiny 
 arteriosus 
 
 pidmonari/ 
 trunk 
 
 aorta^ 
 
 Mn 
 
 Fig. 73. — Diagram showing the Destination of the 
 Arterial Arches in Man and Mammals. — {Modified 
 from, Rathke.) 
 
 Fig. 74. — Scheme of the De- 
 velopment OF THE Chief 
 Veins of the Body. — (Quain.) 
 
 alio (Fig. 70) and caudal ends, the alimentary canal. The union with the yolk-sac 
 from which it was constricted becomes relatively smaller until there is a mere stalk, 
 vitelline stalk (Figs. 65 and 75), at the extremity of which is the yolk vesicle. In 
 mammals the yolk-sac grows for a time, and though it contains but a trace of nu- 
 tritive yolk, it possesses a rich network of blood-vessels, known as the omphalo- 
 mesenteric vessels. The sac loses all functional importance and soon begins to 
 atrophy, but persists as a very small vesicle until birth, when it may be found 
 
58 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 o.pt.v. 
 
 among the decidual tissues. Each of the bHnd tubes of the entoderm above men- 
 tioned comes in contact with an ingrowing pouch of ectoderm. The double layer 
 so formed of ectoderm and entoderm (Fig. 70) breaks down, thus forming the 
 openings from the alimentary canal to the exterior, the mouth (Fig. 75) and the 
 anus. By a process of formation of pouches, modified sometimes into soHd out- 
 growths or tubes, the ento- 
 "^^- derm of the alimentary canal 
 
 gives rise to the lungs, Hver 
 (Fig. 75), pancreas, and the 
 special glands of the enteron. 
 The mesodermic sheet or 
 layer arises at the primitive 
 streak and first pushes for- 
 ward at either side of the 
 middle line but not crossing 
 it. The portion lying next 
 the notochord becomes seg- 
 mented. Each of these seg- 
 ments at some stage is hol- 
 low and is called a somite 
 (Fig. 69). That portion of 
 the somite which lies next 
 to the ectoderm and is 
 known as the dermatome or 
 cutis plate fuses with it to 
 form a portion of the skin. 
 The remaining part under- 
 goes very extensive growth 
 and modification to form the 
 muscles of the body and 
 limbs, and an important part 
 of the mesenchyma from 
 which the supporting and 
 bony framework of the body 
 is developed; that portion of 
 the mesodermic somite from 
 which the former arises is 
 known as the myotome or 
 muscle plate; that from 
 which the latter structures 
 arise the scelerotome. That 
 portion of the mesoderm 
 which does not take part in 
 the formation of somites, 
 and which lies at the sides 
 of the latter, becomes early 
 divided into two layers, one of which unites with the ectoderm to form the 
 somatopleuric or parietal layer, — which gives rise to the body-wall, the amnion 
 and chorion, — while the other, uniting with the entoderm, forms the splanchno- 
 pleuric or visceral layer, which gives rise to the alimentary canal and its deriva- 
 tives (Figs. 67 and 68). It is the mesodermic portion of the latter which gives 
 rise to the muscles and connective tissue of the alimentary canal. 
 
 Fig. 75. — Human Embryo at Third Week. The left 
 body-wall or side has been removed, so that the neural 
 canal and gut are exposed. The left wall of the anterior 
 end of the gut and the still very broad vitelline duct 
 have also been removed, th., Thalamencephalon; o.v., 
 optic vesicle; c.h., cerebral hemisphere; b.c, branchial 
 clefts; t a., truncus arteriosus; Z., lung; a., auricle; li., 
 liver; o.m.v., omphalo-mesenteric vein; v.d., vitelline 
 duct; ^,tail; u.a., umbilical artery; mi., midbrain or 
 mesencephalon; m., medulla; d.a., descending aorta; 
 c, chorda; e., esophagus; 5., stomach; V., intestine. — 
 {After His's model.) 
 
Fig. 76. 
 
 12th day 
 
 (nat. size). 
 
 Fig. 77. 
 2ist day 
 (nat. size). 
 
 Fig. 78. 
 
 30th day 
 
 (nat. size). 
 
 Fig. 79. 
 
 34th day 
 
 (nat. size). 
 
 Fig. 80. 
 
 6i week 
 
 (nat. size). 
 
 Fig. 81. — End of 2d month (62d 
 day) (nat. size). 
 
 j^^f^^-^j^ 
 
 Fig. 82. — End of 3d month 
 (nat. size). 
 
 Fig. 83. — End of 4th month (nat. size). 
 
 Figs. 76 to 83. — Natural size and Development of the Human Embryo in the First 
 
 Four Months of Pregnancy. 
 
 (Figs. 76 to Si are from His, and Figs. 82 and 83 are from Bumm's fresh fetuses.) 
 
 59 
 
60 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 The space formed by the separation of these two layers of mesoderm is the 
 body-cavity or ccelom. At first, in man, it seems to be separate from the extra- 
 embryonic coelom (Fig. 67)^ but soon becomes continuous with it, as in the rabbit 
 (Fig. 69). Later this connection is lost by the growth of the body-walls to unite 
 around the umbiHcal cord. The body-cavity proper is divided by the gradual 
 growth of the diaphragm into abdominal and thoracic cavities. The thoracic 
 cavity is further divided into the pericardial and the two pleural cavities. All 
 the supporting and connective tissues, as bone, cartilage, and the muscles and 
 
 Figs. 84, 85, 86, 87. — Fetal Skulls of the First Third of Pregnancy (Two-thirds 
 Natural Size). — {Author's collection.) 
 
 blood-vessels, take their origin from the mesoderm; but while the problems 
 involved in a full consideration of the mesoderm and ccelom are fundamental 
 in character, they are very complex and, moreover, have not been satisfactorily 
 worked out in their finer details. (For the heart and vascular system, see sec- 
 tions on Nutrition and Circulation.) 
 
 The urogenital system is derived from a cord of tissue lying between the 
 somites and the coelom (Fig. 69). This early forms the Wolffian or pronephric 
 duct, which gives rise to tubules forming the primitive excretory apparatus, 
 the mesonephros or Wolffian body In lower vertebrate forms a fetal kidney, 
 
 Figs. 88, 89, 90. — Fetal Skulls of the Middle Third of Pregnancy (Two-thirds 
 Natural Size). — {Author's collection.)' 
 
 called the pronephros, precedes the mesonephros. It exists in a very rudi- 
 mentary condition in the human embryo. With the exception of its duct it 
 entirely disappears to make way for the mesonephros. This structure projects 
 far into the coelom and its mesothelial covering cells which give rise to the 
 Mullerian duct, and to the ova or zoospores, the essential parts of the ovary 
 or testis. The mesonephros disappears, gradually giving place to the definite 
 kidney or metanephros, but its duct at the caudal end gives rise to the duct 
 and tubules of the true kidney. In the male it produces the vas deferens. 
 
GERM-LAYER. 61 
 
 In the female the Miillerian ducts are transformed into the Fallopian tubes 
 and caudally, by their union, into the uterus and vagina. The limbs arise as 
 mere pads of indifferent mesodermic tissue covered by ectoderm. Into them 
 gradually extend outgrowths of the myotomes producing muscles and carrying 
 with them the vessels and nerves which have already joined them. A part 
 of the mesoderm is condensed in rod-like forms. The connective-tissue cells 
 are transformed into cartilage in those portions of the rods which are to form 
 the bones. Where the joints are to be, the condensed connective tissue persists, 
 forming amphi-arthrodial joints. The true synovial joints are developed later 
 by a solution of the connective tissue between the ends of the cartilages. The 
 hands are formed gradually from mere pads and the fingers are at first webbed. 
 In the main outlines human differentiation of organs is like that of the rabbit, 
 as shown by the fact that the selected illustrations are mostly human; but in 
 one important particular the distinctively human development differs from 
 that of the rabbit, the body being outlined from outlying portions at a later 
 
 Figs. 91 and 92. — Fetal Skulls of the Ninth and Tenth Months of Gestation 
 (Two-thirds Natural Size). — {Author's collection.) 
 
 stage relatively than in that animal. In this respect it more nearly resembles 
 the mouse (see Membranes, page 61). 
 
 Tissues or Organs Derived from Each Germ-layer. — Ectoderm: (i) Ectodermic 
 layer of chorion and amnion. (2) Epidermis with appendages (hair and nails); 
 the epithelium of (a) all skin glands including the mammary ; (6) the stomodeal 
 portion of the mouth, including the salivary glands and the enamel of the teeth; 
 {c) the nasal passages, upper part of the pharynx, and the hypophysis; {d) the 
 proctodeal portion of the alimentary canal; {e) the crystalline lens and the ex- 
 ternal ear. (3) The whole of the nervous system, brain, spinal cord, nerves, 
 ganglia, and epithelial portions of the organs of sense (retina, internal ear, olfac- 
 tory, taste and tactile organs). Mesoderm: (i) The urinary and genital organs, 
 except the lining of the bladder and urethra. (2) The skeleton and all support- 
 ing connective tissue. (3) All muscles, both striated and unstriated. (4) (a) 
 The epithelium of the vascular and lymphatic systems and of serous cavities 
 derived from the coelom or arising in joints; (6) blood and lymph. Entoderm: 
 The epithelium of the alimentary canal (exclusive of the stomodeum and proc- 
 todeum) with that of its derivatives. Eustachian tube, thymus, thyroid, lungs, 
 liver, pancreas, bladder, urethra, urogenital sinus, and all the small glands and 
 
62 
 
 PHYSIOLOGICAL PREGNANCY. 
 
ORIGIN OF MEMBRANES. 63 
 
 tubules, together with the rudimentary allantois and the yolk-sac belonging to 
 the membranes. 
 
 Origin of Membranes. — The membranes are the extra-embryonic portions 
 of the ovum which serve to aid in its protection and nutrition. Because of the 
 ease and frequency of the study,, the most familiar type of membrane formation 
 has come to be that of birds. In these animals the folds of united mesoderm 
 and ectoderm or the somatopleure (see above), which have been tucked in all 
 around to outline the embryo, rise up outside the embryonic region until, like 
 the medullary folds, they unite over the back of the embryo to form a closed 
 sac. Synchronous with the upward growth a still more peripheral portion 
 of the splanchnopleure continues around the ventral portion until a union takes 
 place. This results in the formation of a continuous sac enclosing both embryo 
 and yolk-sac. The portion of the membranous sac dorsal to the embryo is now 
 composed of two layers connected in the middle line. The line of junction 
 breaks down, and there results an inner closed sac, the amnion, covering in the 
 dorsal part of the embryo and formed by an extension of its body-wall; and 
 an outer closed sac, the chorion, which encloses not only the amnion with the 
 embryo, but the yolk which depends from the ventral side of the latter. It 
 also includes the white of the egg and lies next the shell From the caudal end 
 of the entoderm grows out a sac, the allantois, covered with the splanchnopleuric 
 layer of mesoderm and carrying with it blood-vessels from the heart. The 
 allantois expands until it comes in contact with the chorion, where it brings 
 its blood-vessels close to the exterior, thus serving as an organ of respiration. 
 In some mammals, as the rabbit, horse, pig, and cow, a modification of the 
 above method of membrane formation occurs which is in the nature of an abbre- 
 viation of the process. As stated above, in such forms the ovum consists at 
 the end of segmentation of an outer Rauber's layer, with a nodule of cells at 
 one pole (Fig. 57). The cells at the pole multiply and spread out in the form 
 
 Fig. 93. — Five Schematic Figures Illustrating the Fetal Membranes; all these, 
 
 WITH THE Exception of the Last Embryo, are Represented in Longitudinal 
 
 Section. — {After Koelliker.) 
 
 1, Blastodermic vesicle with zona pellucida, segmentation cavity, germinal area, and 
 site of the embryo. 2, Blastodermic vesicle wj^h developing yolk-sac and amnion. 3, 
 Blastodermic vesicle with closing amnion and protrusion (or budding) of the allantois. 
 4, Blastodermic vesicle with chorionic villi, larger allantois, and embryo with oral and anal 
 orifices. 5, Blastodermic vesicle showing vascular allantois in contact with the chorion 
 and penetrating the villi of the same; an umbilical cord is indicated; the yolk-sac is atrophic 
 and the amniotic cavity is increasing in size. The ectoblast is represented in yellow, the 
 visceral mesoblast and the vascular layer of the allantois and yolk-sac are red, the ento- 
 blast green. The zona pellucida in Figs, i to 3 is represented in black, as are also: Fig. i, 
 the entire middle germinal layer; Figs. 2, 3, and 4, the parietal mesoblast of the amnion; 
 Figs. 2 to 5, the mesoblast in the neighborhood of the embryo, with the exception of the 
 splanchnopleure and heart. 
 
 a. Place at the origin of the embryo showing thickening of the wall of the germinal 
 vesicle; ac, amniotic cavity; al, allantois; am, amnion; ar, commissure of the amnion; as, 
 amniotic fold of the umbilical cord; vs, vascular layer of the allantois; vv, vascularized 
 chorionic villi; d, zona pellucida; dd, site of the gut lined with entoblast; this site originates 
 from a portion of the inner layer of the blastodermic vesicle (later the epithelium of the 
 yolk-sac); vd, vitelline duct; e, embryo; h, region of the heart; gc, segmentation cavity 
 which later becomes Ys, the cavity of yolk-sac; cs, head-fold of the amnion; nt, thickening 
 of the middle layer of the blastodermic vesicle which is a part of the site of the embryo 
 m' , at first extending no further than the germinal area; ex, original space between amnion 
 and chorion (exocoelom) ; ch, chorion, as yet without villi (serous covering) ; cs', tail-fold 
 of the amnion; st, region of the sinus terminalis; u, urachus (allantoic stalk); vl, anterior 
 body-wall in the region of the heart. 
 
 In figures 2 and 3 the amniotic cavity has, for the sake of clearness, been drawn too 
 large. The cavity of the heart has everywhere been represented too small and many 
 details, more particularly the body of the embryo, have, with the exception of figure 5, 
 simply been shown schematically. 
 
64 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 of a plate which gives rise to the three layers, the ectoderm becoming continuous 
 with Rauber's layer. The entoderm grows around inside the ectodermal layer 
 and forms the hollow yolk-sac The splanchnopleure never completely invests 
 the yolk, as it does in the chick; the somatopleure forms the amnion outside 
 the embryo and a chorion which separates from the amnion (Fig. 69); the 
 principal modification consisting in the fact that as the mesoderm does not 
 extend to the ventral limit, the chorion, composed of ectoderm and mesoderm, 
 
 CAorion /70/if/osf/m 
 
 Jfeadof 
 £7nAryo 
 
 f/z/iht/rmlVesLclc (Af/vp/iruvijrJ 
 
 Amnionic 
 farify" 
 
 J/i/esiinal' 
 ^^^^^^ Caruil'. 
 
 C/u>rioni^eye 
 
 Fig. 94. — Schematic Representation of Early Embryonic Structures. 
 
 is not completed on the ventral side. This interval is completed by the simple 
 layer of ectoderm forming Rauber's layer. The modification is still further 
 emphasized by the atrophy and disappearance of the cells of this layer. The 
 facts just stated have given rise to many ill-founded theories with regard to 
 human development; thus, Rauber's layer was supposed to have no relation 
 to the true ectoderm, and as the entoderm seemed to come to the surface, it was 
 supposed that there was a so-called "inversion of the germ-layers." 
 
 Fig. 95. — Human Ovum Twelfth to Thirteenth Day. — {Reichert.) 
 
 Another modification of the membrane-formation which has been used to 
 explain the condition in man is well illustrated in the mouse and some other 
 rodents. The heap of cells at the pole first differentiates off a few entodermal 
 cells which multiply and form a layer. A cavity then appears in the ectodermic 
 portion of the mass of cells which enlarges so greatly as to form a sac nearly 
 covered by the ectodermic layer, the whole extending far into the interior of 
 
THE MEMBRANES AT TERM. 65 
 
 the outer or Rauber's layer of the ovum. The embryo is formed at the deepest 
 portion of this invagination. The amnion is produced by the growing together 
 in an hour-glass-Uke formation of the invagination over the back of the 
 embryo; the remaining portion next the original implantation of the heap of 
 cells becoming the chorion and finally a part of the placenta. Here, too, the 
 remaining portion of the ectoderm in Rauber's layer does not apparently become 
 a part of the chorion. Contrary to the condition in the chick, rabbit, and many 
 other mammals, the allantois of the mouse does not form a large pouch of ento- 
 derm, but is a small tubular invagination of the yolk-sac. It is, however, covered 
 by mesoderm, which continues as a sheet over the chorion and carries the blood- 
 vessels of the embryo to the placenta, where the blood is aerated. 
 
 In Peters 's embryo, the youngest human specimen studied, it is seen that 
 the conditions are not as in the chick, with early formation of embryo and sub- 
 sequent differentiation of membranes; nor as in the rabbit, nor even quite as in 
 the mouse. The membranes in Peters's embryo have been developed preco- 
 ciously (Fig. 51). The chorion is a completely closed sac with amesodermic lining, 
 such as occurs quite late in the chick. There is no sign of the disintegration 
 of the outer ectodermic layer, as in the Rauber's layer of the rabbit, but later 
 stages (according to Mall) indicate that it becomes transformed into the syncy- 
 tial layer of the chorion {q. v.). The amnion is also a closed sac with the un- 
 differentiated embryo, a simple thickened plate of cells, lying in its deepest 
 portion, thus having a strong resemblance to the early condition in the mouse. 
 The yolk-sac is also closed and is larger than the amnion, but is not constricted 
 with any indication of an alimentary tract, as would be the case in the chick 
 at a similar stage of development with reference to the mesoderm. The latter 
 has, indeed, attained a remarkable development. It has entirely invested the 
 yolk-sac forming the splanchnopleure, while the somatopleure is represented 
 by the amnion and the chorion completely invested by the mesoderm before 
 there is an indication of the formation of somites. Whether the amniotic sac 
 becomes hollowed out of a solid mass of cells, as seems to be the case in the 
 mouse, or whether there is only a division of the amnion from the chorion, such 
 as occurs in the rabbit (as surmised by His and Nagel), although taking place 
 relatively earlier, cannot be determined without further investigation. In Graf 
 Spec's embryo (Figs. 65 and 66), and in an ape examined by Selenka, an appear- 
 ance is found which points to the latter conclusion ; since the amnion in these speci- 
 mens has a diverticulum pointing toward the chorion, as though just constricted 
 off therefrom. The important point in this connection is that the amniotic sac 
 never separates completely from the chorion as with the rabbit, but remains 
 connected with it by a broad band of mesoderm. In the next later stages of 
 human embryos it is found that a small diverticulum of the yolk-sac extends 
 into this mass of mesoderm, which has become relatively smaller, forming the 
 stalk which with further development becomes the umbilical cord. Although 
 a true allantois — in the sense that it occurs in the chick and many mammals — 
 is not present, the mesodermic layer of that organ may be said to exist; since the 
 blood-vessels, when they arise, pass by way of this allantoic rudiment through the 
 abdominal stalk to the chorion. To sum up, but that this earliest human ovum, 
 before an embryo has even been outlined, has membranes of a stage of develop- 
 ment corresponding to a much later stage in the chick, a closed chorion, a closed 
 amnion, a closed yolk-sac. The essential difference is that there is no free allan- 
 tois containing an extensive entodermic cavity, and that the mesoderm con 
 nects the embryo with the chorion from the earliest stages and not secondarily. 
 
 The Membranes at Term. — At term the fetus is surrounded by three mem- 
 5 
 
66 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 branes, two of which are of fetal and one of maternal origin. Their order, from 
 within outward, is: amnion, chorion of fetal origin, and decidua refiexa and 
 vera of maternal origin. 
 
 The Amnion. — As seen above, the amnion is the innermost of the fetal mem- 
 branes. At first it encloses only the dorsal part of the embryo, but with growth 
 and closure of the body- wall around the umbilicus, it completely invests the 
 embryo except that the cord passes through it. It is continuous with the fetal 
 epidermis at the umbilicus (Figs. 65, 66, 67, 93, and 94). It consists of two 
 layers, one of flattened cells derived from the ectoderm and continuous with 
 the epidermis, the other of connective-tissue cells and fibers, mesoblastic in 
 origin. The enclosed space constitutes the true amniotic cavity or sac, and 
 its chief function is the secretion of liquor amnii. At first the amnion, as com- 
 pared with the embryo, is quite large. Then the embryo grows more rapidly 
 and the amnion closely invests it ; and finally at the second month a more rapid 
 
 growth of the amnion takes 
 place, which ultimately re- 
 sults in a close relationship 
 between it and the chorion. 
 As long as a cavity exists be- 
 tween amnion and chorion it 
 is sometimes called the false 
 amniotic cavity and is filled 
 with a liquid somewhat sim- 
 ilar to the amniotic fluid. At 
 birth the bag of waters con- 
 sists of the amnion and part 
 of the chorion. Sometimes 
 this is not ruptured until after 
 the head is born. 
 
 Liquor Amnii. — The am- 
 niotic fluid contained in the 
 amniotic sac is somewhat 
 variable in quantity, the aver- 
 age being about a liter, or 
 quart. Of this, nearly one- 
 half is formed during the last 
 three lunar months. At times 
 this fluid is very scanty, so that it interferes with the growth of the fetus, and 
 causes its premature expulsion. There is on record a case in which, in the 
 absence of a normal supply of liquid, ulcers were formed on the knees and 
 ankles of a fetus, due possibly to friction. Many other deformities have been 
 found to be correlated with the same condition. When its amount is exces- 
 sive, the condition is called hydramnios, in which many quarts of fluid may 
 be present. The amniotic fluid is alkaline in reaction. Its greatest bulk 
 — nearly 99 per cent. — consists of water, in which are found albumin; creatin; 
 epithelial cells from the fetal skin, bladder, and kidneys; sebaceous material; 
 urea and several inorganic salts (phosphates, chlorides); as well as many other 
 constituents. Its specific gravity varies between 1.0005 and 1.0082. It is 
 generally opaque, white in color, although this may change from the presence of 
 unusual ingredients, meconium giving it a dark brown tinge, while a macerated 
 fetus colors it red. It has a heavy and characteristic odor. Keim has found 
 that the freezing-point of this fluid is higher at term than that of the maternal 
 
 p.m. 
 
 y.s. 
 
 Fig. 96. — Ruptured Human Ovum Fifteenth to 
 Eighteenth Day. Amnion has been opened, a.s., 
 AUantois stalk; p.m., parietal mesoblast; y.s., yolk- 
 sac; a., amnion; h., heart. — {Coste.) 
 
THE LIQUOR AM NIL 
 
 67 
 
 or fetal blood-serum. This indicates an intrinsic tendency to absorption. Its 
 origin is a moot question. The theory that it consists chiefly of fetal urine is 
 disproved by chemical analysis, only a small part arising from this source. The 
 fetal tissues contribute a small portion by exudation. The greater part is of 
 maternal origin and the result of transudation through the placenta. The 
 investigations in regard to the two sources of the amniotic fluid have been as 
 varied as they are interesting. As to the excretion of urine by the fetus, there 
 seems to be undeniable evidence, more than three pints of this excretion having 
 been found in the fetal bladder. After the communication between the bladder 
 and the exterior of the body is completed through the agency of the urethra, 
 there is from time to time a passage of the renal secretion from the fetus into 
 the amniotic fluid. At just what stage of fetal development this occurs has 
 not yet been decided. This prenatal urine is very poor in coloring-matters, 
 as may be seen from the specimens collected soon after birth. Another theory 
 
 Fig. 97. — Isolated Terminal Branch of Fig. 
 Villus from the Chorion of an 
 Embryo of Twelve Weeks. — (Minot.) 
 
 : .<y 
 
 -Chorionic Villi at Five Months 
 — {Minot.) 
 
 supposes that the fetal skin is the source of this fluid, and there has, indeed, 
 been noted in several cases a connection between affections of the fetal skin 
 — in one instance extensive nevi — and hydramnios. The view that much of 
 the liquor amnii has a maternal source is substantiated by the results of numerous 
 experiments. Tuntz, after the injection of sulphindigotate into the veins of 
 pregnant rabbits, recognized the reagent in the liquor amnii by its blue coloring- 
 matter, while there was no trace of it in the fetal kidneys. Experiments with 
 other substances — e. g., iodin, salicylic acid, and potassium ferrocyanid — have 
 been made. Chloroform administered to the mother in labor has been demon- 
 strated later in the umbilical circulation, so that it probably exerts an an- 
 esthetic influence on the fetus. However, the endeavor to introduce such 
 substances as fat, vermilion, and india ink into the fetal circulation by admin- 
 istering them to the mother has had doubtful success, positive results being 
 undoubtedly dependent on injury to the blood-vessels. 
 
68 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 There has been much discussion as to the passage of formed elements, such 
 as pathogenic bacteria, from the mother to the fetus; and various opinions 
 are held on the subject. Certain substances taken by the mother are found 
 later in the liquor amnii, even when the fetus is dead — showing that the latter 
 took no part in the process. Also cases in which the product of conception is 
 early destroyed exhibit an amount of amniotic fluid corresponding to the age 
 of the ovum, and not to the development of the embryo. 
 
 Functions. — The functions of the liquor amnii are varied, being chiefly, 
 however, protection for mother and child. It saves the uterus from the in- 
 jurious effects of fetal movements. It distends that organ, and thus allows 
 a certain freedom of movement to the fetus, and by the prevention of adhesions 
 between the amnion and child it lessens the chance of development of mon- 
 strosities as well as intrauterine amputations and other abnormalities, and 
 prevents any harmful pressure by the uterine walls. The amniotic fluid has 
 a specific gravity near enough to that of the fetus to lessen greatly the muscular 
 efforts in its movements. It protects the fetus from external violence and 
 maintains for it an equable temperature. It receives and dilutes the fetal 
 secretions and, according to some authorities, serves as a source of nourishment 
 
 to the fetus. This last sug- 
 gestion has little foundation, 
 although the presence of 
 lanugo and epithelial cells in 
 the meconium shows that the 
 amniotic fluid has been swal- 
 lowed. It is quite probable, 
 however, that it- supplies to 
 the fetal tissues a large pro- 
 portion of the water which 
 they possess before birth, in 
 order, according to Preyer, 
 that they may be able to ab- 
 sorb from the blood of the 
 umbilical vein the albumin 
 and salts which it contains. Finally, the hydraulic action of the amniotic fluid 
 is most valuable in labor. It forms a veritable water- wedge, and serves by its 
 downward pressure to dilate the circular muscle bands of the os uteri ; and after 
 being released from the amniotic sac it acts as a lubricant to the birth canal. 
 
 The Allantois. — The allantois in many mammals is a diverticulum of the 
 caudal part of the alimentary canal, which carries with it the splanchnic layer 
 of the mesoderm until contact is made with the chorion, thus forming a 
 large sac containing fluid. But in man the entodermic diverticulum is a mere 
 rudiment (Fig. 66) which can be traced along the umbilical cord for some distance 
 but does not form a free sac. A mesodermic layer, however, perfectly analogous 
 to that of other mammals, does connect the caudal end of the embryo with the 
 chorion and serves to carry the blood-vessels from the embryo to the chorionic 
 villi. This mesodermic layer, as seen above, is precociously formed. As in 
 other mammals, the proximal portion of the allantoic rudiment forms the urinary 
 bladder and the urachus which becomes one of the ligaments of the latter. 
 
 The Chorion. — There is probably no organ in the human fetus which has 
 been the subject of such false conceptions as the chorion. It is defined by Minot 
 as follows: "The whole of that portion of the extra-embryonic somatopleure 
 which is not concerned in the formation of the amnion." As shown above, 
 
 Fig. 99. — Chorionic Villi at Full Term. — {Minot.) 
 
THE CHORION. 
 
 69 
 
 the young human ovum already has a chorion with a mesodermic lining (Figs. 64 
 and 51). It is covered by villi, solid outgrowths of the epithelial layer, which 
 show slight cavities at their bases into which the mesoderm protrudes. The 
 villi extend into the uterine mucous membrane in such a way as to indicate 
 that epithelium, glands, and walls of blood-vessels in their path have been dis- 
 integrated and not merely pushed aside; that is, they protrude freely into the 
 maternal blood. In the somewhat later stage shown in Reichert's ovum (Fig. 
 95) the villi are grouped in a band, leaving the two flattened poles of the ovum 
 bare. Still later the villi become hollow with two distinct layers of epithelium, 
 and soon are penetrated by blood-vessels which have entered the mesoderm 
 of the chorion. The simple club-shaped villi of the early ovum soon begin to 
 degenerate on the side next to the decidua refiexa until in this part the chorion 
 is smooth, chorion Icsve (Figs. 53 and 104). On the smaller area next the decidua 
 serotina, the villi become greatly enlarged and complexly branched, the blood- 
 
 FiG. 100. — Unruptured Human Ovum of about Third We£k, showing Chorion. 
 
 X 2\. — {Author's case.) 
 
 vessels of the embryo following the ramification. This part of the chorion is 
 called the chorion frondosum, and becomes the fetal portion of the placenta 
 (Figs. 53 and 100). 
 
 The outer layer of the epithelium of the villi undergoes a peculiar modifica- 
 tion. The cells, rapidly developing, do not entirely separate, but form a syn- 
 cytium * with numerous nuclei. As seen from the first, this has a destructive 
 effect on the uterine mucosa and blood-vessels (Fig. 64). On account of the 
 theoretical objections to the idea of contact of fetal epithelium and maternal 
 blood with no intervening maternal structures, the syncytium has been considered 
 by many as an altered maternal structure covering the blood sinuses. All 
 the evidence now accumulating seems to point in the direction above stated, 
 
 * Syncytium: (i) A single cell having many nuclei; (2) a structure composed of epi- 
 thelial cells, forming the outermost fetal layer of the placenta and lying between the decidua 
 and chorionic villi over the layer of Langhans. 
 
70 PHYSIOLOGICAL PREGNANCY. 
 
 that it is a fetal structure; and the chorionic villi, although bathed in maternal 
 blood, separate the latter from the embryonic blood. The vilH assume different 
 characteristics at different stages of development. At the stage of formation of 
 the placenta at the third month they are irregular, short, and thickset (Fig. 97). 
 Later they are more regular and the angle formed by the junction of their 
 branches with the parent stem is more obtuse (Fig. 98). At the close of preg- 
 nancy their arrangement is more regular, while the branches are less densely 
 crowded and far more slender (Fig. 99). Knowledge of the appearance of 
 the villi is most important, since the existence of pregnancy is positively con- 
 firmed by their microscopic detection in suspicious discharges from the vagina. 
 The embedding of the villi in the decidua is never very intimate, and through- 
 out their course of development they can be extricated with very little difficulty. 
 
 Fig. ioi. — Ovum of Fig. 100 Cut Open, showing Embryo and Amnion. X 2J. — 
 
 {Author's case.) 
 
 A large number of the villi do not penetrate the decidua to any depth; those 
 which are intimately joined to it are called the anchoring or fastening villi. 
 
 The Placenta. — The placenta is the essential nutritive and respiratory organ 
 of the fetus. It results from the union of the chorion frondosum, q. v. (placenta 
 foetalis), and the decidua serotina (placenta matemalis). Formation: In addi- 
 tion to the growth of the chorionic villi, q. v., there are extensive changes in 
 the placental region of the decidua, which also proliferates and forms septa; 
 these, growing down between the chorionic villi, sometimes reach the surface 
 of the chorion. It is only at the margins of the placenta that the decidual septa 
 are well marked. Interesting and important formations in the placenta are 
 the intervillous spaces. The decidua vera is abundantly supplied with a net- 
 work of blood-vessels which, as we have already seen, are entered by the grow- 
 ing villi of the chorion. With continued growth these open capillaries become 
 the intervillous spaces, which are really large sinuses or lacunas of maternal 
 blood, the endothelial cells of which have disappeared. As a result of this 
 change the branched chorionic villi extend freely into an almost continuous 
 
THE UMBILICAL CORD. 
 
 71 
 
 sinus of maternal blood which is bridged by villi (anchoring villi) the tips of 
 which are embedded in the decidua. The little curling arteries, so called, which 
 are derived from the maternal blood-vessels, run along the decidual septa and 
 empty into the sinuses near the chorion. The maternal veins start from the 
 bases of the septa, and thus the circulation is maintained through the sinuses. 
 Structure: The mature placenta is a flat, round or oval, sponge-like body 
 which measures from 6 to 8 inches (15 to 20 cm.) in diameter and 0.8 to 
 1.2 inches (2 to 3 cm.) in thickness at the central point, while the margin is 
 about 0.2 inch (0.5 cm.) in thickness. Its weight is about a pound (500 
 grams). After expulsion the uterine or maternal surface is dark red and 
 granular, invested by a grayish, transparent membrane consisting of the super- 
 ficial layer of the cells of the decidua serotina, and is marked by numerous 
 ridges and lines which divide it into irregular lobes called cotyledons. These 
 number from sixteen to twenty. On this surface of the separated placenta 
 are tags of tissue corresponding to the decidual layer. The placenta, when 
 detached from its bed, shows the line of demarcation in the spongy layer 
 {q. V.) of the decidua. The fetal surface, 
 smooth and shining, is covered by the 
 amnion, and the umbilical cord is attached 
 to its center. The bulk of the organ is 
 spongy in character and consists of the 
 tufts of chorionic villi and the intervillous 
 spaces which are divided into cotyledons, 
 above mentioned, by septa of connective 
 tissue. After the separation of the pla- 
 centa from its maternal site tags of de- 
 cidua and chorion hang from the latter. 
 Around the peripheral margin of the pla- 
 centa is sometimes seen a circular vein, 
 the "circular vein of the placenta." 
 Site: * The placental site, as has already 
 been described, is at the junction of the 
 chorion frondosum and decidua serotina, 
 which generally takes place near one of 
 the tubal orifices, although the organ 
 may be found attached to any point in 
 the cavity of the uterus. As a rule, it faces the ventral surface of the fetus. 
 
 The Umbilical Cord. — The umbilical cord is a means of communication 
 between the fetal and maternal organisms. It is also called the funis, 
 funicle, or navel string. Origin and development: In the human ovum the 
 mesodermic connection of the amnion with the chorion, including the rudi- 
 mentary allantois, is called the abdominal stalk (Figs. 64 and 65). With 
 the growth of the body-wall and the extension of the amnion this stalk, 
 together with the stalk of the umbiHcal vesicle, and the blood-vessels which 
 unite the embryo with the chorion, become invested by a continuation of the 
 somatopleure, this whole forming the umbilical cord (Fig. 96). The umbilical 
 vesicle itself is never included within this cord (Fig. 96), but extends freely 
 beyond it, and by the fourth week becomes inconspicuous. Structure and 
 vessels: The epithelium of the cord consists not of a single layer but of several 
 layers of stratified epithelium, continuous at the proximal end with the epi- 
 
 * For the exact location of the placenta, see Diagnosis of Pregnancy, and Cassarean 
 Section. 
 
 Fig. 102. — Human Ovum and Embryo 
 AT Four Weeks. X 2 and reduced. — 
 {Schultze.) 
 
72 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 
 Chorionic Tu/if^ 
 
 Fig. 103. — Complete Ovum and Decidua Vera of about the Sixth Week. Shows 
 smooth and rough sirrfaces of decidua vera and chorion. Photographed under water 
 X 2. — {Author's case.) 
 
THE UMBILICAL CORD. 
 
 73 
 
 dermis and at the distal end with the amniotic epitheUum • covering the 
 placenta. The cord is not covered by the amnion throughout its entire 
 
 ..^iJMi.'iL 
 
 Fig. 104. — Ovum of Fig. ioi Opened; shows Chorion Removed Except at Site of Rudi- 
 mentary Placenta above and to the Right; Amnion, Liquor amnii, and Embryo 
 with Rudimentary Umbilical Cord. X i^- — (Author's case.) 
 
 Fig. 105. — Ruptured Human Ovum at Eight Weeks. X 2. c, Chorion; a, amnion; 
 U.C., umbilical cord. — {Schtdtze.) 
 
 extent, for this latter structure is always separate from the cord proper. A 
 gelatinous substance, Wharton's jelly, protects the cord vessels perfectly from 
 
74 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 Fig. io6. — Amnion, Liquor Amnii, Embryo, and Umbilical Cord, about the Tenth 
 
 Week. X i^. — {Author's case.) 
 
 ,./ 
 
 Fig 107. — Amniotic Cavity Inflated, showing Maternal Surfaces of Placenta 
 and Amnion and Umbilical Cord Emerging from Cavity of Amnion. Full 
 Term. — {From a photograph of a fresh specimen.) 
 
THE UMBILICAL CORD. 
 
 75 
 
 Fig. io8. — Placenta and Unruptured Membranes at the Thirty-eighth Week 
 (One-third natural size.) — {Author's collection.') 
 
 Fig. 109. — Membranes of Fig. 108, Cut Open to show Fetus. Specimen hardened in 
 formaldehyde before rupturing. (One-third natural size.) — {Author's collection.) 
 
Fig. 
 
 -Fetal Surface of Placenta 
 AT Term. — (Minot.) 
 
 Fig. III. — Section of Human Placenta 
 OF Seven Months in situ. Am., Am- 
 nion; Cho., chorion; Vi, trunk of villus; 
 vi, sections of villi in the substance of 
 the placenta; D, decidua basalis; Mc, 
 muscularis; D',' compact layer of decidua; 
 Ve., uterine artery opening into the 
 placenta. The fetal blood-vessels are 
 drawn black; the maternal blood-spaces 
 are left white; the chorionic tissue is 
 stippled except the canalized fibrin, 
 which is shaded by lines; the remnants 
 of the gland-cavities in D^^ are stippled 
 black. — {Minot.') 
 
 Fig. 112. — Connective Tissue of the Um- 
 bilical Cord of a Human Embryo of 
 about Three Months. X 511 diam- 
 eters and reduced. Stained with alum 
 cochineal and eosin. — {Minot.) 
 
 Fig. 113. — Cross-section of Umbilical 
 Cord at Term. X about 12 diameters, 
 y, Remnant of the allantois; V, umbilical 
 cord; A, A, umbilical arteries. — {Minot.) 
 
 Fig. 114. — Transverse Section through 
 the Umbilical Stalk of an Embryo of 
 2.10 MM. — Am., Amnion; m.d., medtdlary 
 groove; V,V., umbilical veins; A. A., um- 
 bilical arteries; All., allantois; coe, coelom. 
 {His.) 
 
 76 
 
THE UMBILICAL CORD. 
 
 77 
 
 harmful pressure. It is derived from the mesodermic layer of the abdominal 
 stalk. The gelatin has an irregular distribution, being thicker in some parts, 
 where it forms the so-called false knots in the cord. This peculiar substance 
 consists in great part of embryonic connective tissue, and is abundantly 
 supplied with branching cells-, the protoplasmic processes of which freely anas- 
 tomose. The vessels of the -funis are originally two arteries and two veins. 
 The two veins fuse early, leaving only one (Figs, no and 113), which comes to lie 
 between the arteries, so that the funic pulse can be easily felt. The vessels are 
 coiled from right to left, there being ten to twelve such turns. The spiral aspect 
 thus given to the cord has been variously explained. One cause assigned is the fetal 
 
 Fig. 115. — Section of Injected Full-term Placenta, c.s.. Cotyledon septum; a., 
 amnion; c, chorion; d.s., decidua serotina; m.i.v., muscle with injected vessels. — 
 (Leopold.) 
 
 movements; another, the fact that the growth of the blood-vessels in length is 
 more rapid than that of the connective tissue. The walls of both arteries and vein 
 are of about equal thickness. The calibre of the vein is in excess of that of 
 the arteries; and while the vein has semilunar valves, the arteries have circular 
 valves. The length of the cord averages about 22 inches (50 to 60 cm.), though 
 when very long it may measure 64 inches (160 cm.), while the shortest on record 
 is 4.8 inches (12 cm.). Its diameter is from -| to f of an inch (i.i to 1.5 cm.). 
 The strength of the cord varies; its tensile power at term ranging from 5 to 
 12 pounds (2 to 5 kilograms). Its function is twofold: It carries nourishment 
 from the mother to the fetus as well as waste matter from the fetus to the pla- 
 centa. 
 
78 PHYSIOLOGICAL PREGNANCY. 
 
 Nutrition and Metabolism of the Ovum, Embryo, and Fetus.* 
 
 Ovum. — The primordial human ovum in the ovary derives the nourishment 
 by which it grows from the general blood and lymph supply of the ovary, and 
 in so doing lays up a small amount of nutriment in comparison with that of the 
 germ-yolk or deutoplasm or food-yolk (Fig. 96). It is still an open question 
 whether the follicle-cells surrounding the ovum contribute directly to its 
 nourishment. As the ovum passes through the oviduct, as already stated, it in- 
 creases in size by absorption of liquid, which separates the primitive chorion 
 from the germ mass (Fig. 57). Later, and until it possesses vessels and circu- 
 lation, it derives its nourishment from the intimate relations of the chorionic 
 villi with the maternal blood (Fig. 49). The decidua vera, by reason of its 
 increased cell-formation, indicates the presence of active metabolism favorable 
 for the production of nutritive substances available for the growing embryo. 
 There has been endless discussion concerning the intervillous spaces. One theory 
 regards them as dilated uterine glands which secrete "uterine milk" for nourish- 
 ing the ovum. It is now known that the glands become practically closed and 
 that their ducts degenerate before the growing villi. 
 
 During the third week the vitelline or earliest embryonic circulation develops, 
 beginning in the mesodermic layer of the yolk-sac in the form of blood islands 
 (Figs. 65 and 66). In the mean time the original sparse food-yolk has increased 
 in amount within the yolk-sac, and the blood islands unite to form vessels 
 which again combine to form the omphalomesenteric or vitelline veins by which 
 the contents of the umbilical vesicle are carried to the embryo proper for its 
 nourishment. At the same time the heart and systemic vessels arise (Figs. 
 65 and 70) and blood passes through the vitelline veins into the sinus venosus. 
 Then, mixing with blood returned by the systemic vessels from the body of the 
 embryo, it passes into the single auricular segment or caudal end of the tubular 
 heart The blood is conveyed from the anterior or arterial extremity of the 
 heart through the truncus arteriosus to the aortic arches (Fig. 73); from the 
 latter it flows into the two primitive aortas. The smaller quantity is carried 
 into vessels which nourish the embryo, while the greater portion reaches again 
 the vascular area by the vitelline arteries. Thus a complete circulation in 
 closed vessels is formed for the nourishment of the embryo. 
 
 True Chorion. — The development of this organ has already been described. 
 The villi, hollow at first, are invaded, soon after their appearance, by mesoderm 
 and then by blood-vessels derived from others which grow out along the abdom- 
 inal stalk. With the development of these vessels the primitive chorionic circu- 
 lation is established, which rapidly supersedes the vitelline. With the distinct 
 localization of the placenta this becomes the placental circulation. After the 
 earlier stages of development, all the returning placental blood passes through 
 the liver on its way to the heart, but when the placental circulation becomes 
 more extensive the extra work is assumed by the development of the ductus 
 venosus, through which a considerable amount of blood passes directly into 
 the inferior vena cava without traversing the liver (Figs. 100, loi, 102, and 103). 
 
 Functions of the Placenta. — The placental functions are varied, and it may 
 be stated in general that it assumes the role of several other organs, the lung 
 or gill, the alimentary tract, liver, and kidney. It aerates the fetal blood, 
 
 * The term ovum, as here used, indicates not only the unfertilized egg, but also the 
 fertilized egg and the early stages of its development; it therefore includes not only the 
 embryo but the membranes. The term fetus is used to designate somewhat loosely the 
 later stages of the developing organism. 
 
NUTRITION OF THE OVUM, EMBRYO, AND FETUS. 79 
 
 supplying it with oxygen so that it is the respiratory organ of the fetus. It 
 absorbs nutriment from the maternal blood, thus playing the part of the 
 mature alimentary tract. It has been shown, according to Bernard, to possess 
 a glycogenic function analogous to that of the liver. It also serves the pur- 
 pose of an excretory organ, eliminating not only the carbon dioxid but other 
 abundant waste products of .the fetal metabolism. Interesting work has been 
 done, showing the peculiar selective power possessed by the epithelial cells of 
 the chorionic villi. They eliminate the carbon dioxid of the fetus, and if the 
 interchange of gases were reversed, the villi absorbing carbon dioxid from the 
 maternal blood, this would prove fatal to the fetus. 
 
 Fetal Blood. — In the early months of gestation the fetal blood contains 
 nucleated red blood-corpuscles, sharply distinguishable from those of the mother. 
 At first these are few in number, but increase very rapidly; so that in well- 
 preserved specimens the vessels are large, conspicuous objects and are crowded 
 with corpuscles. At about the third month the majority of these cells have 
 been replaced by non-nucleated corpuscles similar to those of the adult. The 
 relative quantity of blood in the fetus and placenta undergoes considerable 
 variation, the placenta at first having the larger amount; later the fetus and 
 placenta contain about equal amounts, while still later the quantity in the fetus 
 exceeds that in the placenta. The fetal arterial blood-pressure is about half 
 that of the newly born child, while the venous pressure is much higher. The 
 velocity of the blood in the umbilical arteries is far slower than in adult arteries 
 of similar calibre. The fetus eliminates about the same volume of carbon 
 dioxid as it absorbs of oxygen. This latter amount is about one-fourth that 
 used by the maternal organism, and the amount of gas concerned in the pla- 
 cental system is about one-half that which is used in the lung during respiration. 
 In this way the slight metabolism of the fetus is explained; consequently when 
 the communication with the mother is severed, the possibility of survival is 
 longer, and is not followed by immediate suffocation, while it also accounts 
 for the slight difference in temperature of mother and child. 
 
 Kidney Excretion. — The kidneys begin to assume functional form at the 
 seventh week. At first their ducts communicate with the rudimentary allan- 
 tois, but since the bladder is derived from this organ, the ureters finally empty 
 into that viscus. In the course of development urine is excreted by the fetus 
 from time to time, as can be proved by the presence of urea in the amniotic 
 fluid. There is always a certain amount of albumin in the fetal urine. There 
 is a specially important medico-legal point in connection with the appearance 
 of the kidneys: it is the formation of dark yellow infarcts, which are invariably 
 present even if the infant has breathed but for a very short time before death. 
 Their causation is not known. 
 
 Bowel Excretion. — The bowels are normally inactive in intrauterine life, 
 although in pathological conditions — e. g., apoplexy, coiled cord, compressed 
 cord, etc. — there may be a discharge of meconium. This should be a danger- 
 signal when occurring in labor, unless there is a breech presentation. 
 
 The Fetal Circulation. — As stated in the section on nutrition, the first signs 
 of the blood and blood-vessels in the embryo are the blood islands in the um- 
 bilical vesicle. The heart in reptiles, birds, and mammals, so far as has been 
 sufficiently determined, has been found to develop as two independent tubes 
 in the visceral layer of the splanchnopleure of the neck region. As the two 
 visceral layers fold over the ventral side of the embryo and fuse, the double 
 heart also fuses to form a single tubular heart. The separation into auricles 
 and ventricles of a right and a left heart is due to the growth of valves and par- 
 
80 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 Fig. ii6. — The Fetal Circulation, ao, Aorta; a.pu, pulmonary artery; au, umbilical 
 artery; da, ductus arteriosus; dv, ductus venosus; int, intestine; vci and vcs, inferior 
 and superior vena cava; vh, hepatic vein; vp, vena portae; v.pu, pulmonary vein; vu, 
 umbilical vein. — (From Kollmann.) 
 
NUTRITION OF THE OVUM, EMBRYO, AND FETUS. 81 
 
 titions in this single tubular heart. From the cephalic end of the primitive 
 tubular heart extend two primitive aortas, and from the caudal or venous end 
 extend the two vitelline veins. All of the subsequently developed arteries 
 and veins are likewise in pairs except the posterior cava (inferior vena cava). 
 The adult condition of the vascular system is attained by two processes: viz., 
 suppression and fusion. The suppressions and fusions are shown in part in 
 Figs. 73 and 74. Advancing from the primitive embryonic condition, the vessels 
 of the allantois and placental circulation soon cause the development of a 
 more complicated system, in which the heart and liver play important rdles. 
 In the later months of pregnancy the blood, laden with nutriment for the 
 developing fetus, collects from the ultimate venous rootlets in the chorionic villi 
 and ultimately finds its way to the (i) umbilical vein. At first there are two 
 umbilical veins, but soon the right fuses with the umbilical cord and only the 
 left persists. This enters by way of the umbilical cord, passes first to the navel, 
 and thence upward along the free suspensory ligament of the (2) liver to the 
 under surface of this organ, where it subdivides into several branches. Two 
 of these go to the left lobe and the others to the lobus quadratus and the lobus 
 Spigelii. The vein again subdivides at the transverse fissure into two branches, 
 the larger of which, joining with the portal vein, penetrates the right lobe. The 
 smaller, as the (3) ductus venosus, or duct of Arantius, passes on across the 
 inferior hepatic surface until it meets the (4) left hepatic vein just at that point 
 where the latter vessel joins the (5) inferior vena cava. The blood which circu- 
 lates through the liver undoubtedly undergoes certain changes in metabolism, 
 and finally collects again in the hepatic vein, through which it flows to the 
 ascending vena cava. Thus there are two avenues through which the blood, 
 flowing through the umbilical vein, reaches the inferior vena cava; the greater 
 part, together with the portal venous blood, circulating through the liver, pre- 
 vious to entering the vena cava by the hepatic vein. The remainder goes 
 directly to the vena cava by the union of the ductus venosus and the left hepatic 
 vein. The blood coming from the ductus venosus and hepatic veins mingles 
 in the inferior vena cava with that from the lower extremities and the abdominal 
 viscera. It flows into the (6) right auricle, and, directed by the (7) Eustachian 
 valve, it courses through the (8) foramen ovale into the (9) left auricle. Here 
 it joins a little blood that has come from the lungs by the pulmonary veins. 
 It then flows from the left auricle to the (10) left ventricle, and thence into the 
 (11) aorta, by which it is in great part taken to the (12) upper extremities and 
 (13) head. A little passes down by the (14) descending aorta. The blood from 
 the head and upper extremities is collected by the (15) venous radicles and finally 
 reaches the branches of the (16) superior vena cava, known in earlier stages of 
 development as the right duct of Cuvier. This is formed by the junction of a 
 superior vein (the primitive jugular) and an inferior cardinal vein, the corre- 
 sponding left duct disappearing in the process of development. The superior 
 vena cava empties into the (17) right auricle, where it mingles with a small 
 quantity from the inferior vena cava; it then passes over the Eustachian valve 
 into the (18) right ventricle, and thence into the (19) pulmonary artery. Since 
 the fetal lungs are solid and almost impervious, but a small portion of the blood 
 from the pulmonary arteries passes to them and is then returned by the pul- 
 monary veins to the left auricle. The greater quantity flows through the (20) 
 ductus arteriosus, rediClung by this channel the (21) descending aorta (see 14), 
 where it joins the small part of the blood from the left ventricle which has also 
 passed into this artery. It now descends to supply the (22) abdo^ninal and 
 pelvic viscera and the (23) lower extremities, although its greater part flows 
 6 
 
82 PHYSIOLOGICAL PREGNANCY. 
 
 through the (24) hypogastric arteries to the (25) umbilical arteries and the 
 (26) placenta. 
 
 Peculiarities of the Fetal Circulation. — Several facts stand out with 
 special clearness in this process of fetal circulation: (i) The duplex function 
 of the placenta — respiration and nutrition. In this organ the venous or impure 
 blood is oxygenated and surcharged with nutriment, and returns to nourish 
 the fetus. (2) By far the greater part of the blood of the umbilical vein circu- 
 lates through the fetal Hver, which fact accounts for the very large size of that 
 organ, especially in early fetal existence. (3) The right auricle is the meeting- 
 place for a dual current, that from the inferior vena cava being guided by the 
 Eustachian valve into the left auricle, while the blood coming from the upper 
 extremities and the head descends from the right auricle into the right ventricle. 
 In early stages the entrance of the ascending vena cava is almost directly into 
 the left auricle, so that there is probably little or no mingling of the two streams, 
 but later the two auricles are more definitely separated and a certain mixing of 
 the two currents occurs. The blood from the placenta, together with that 
 from the ascending cava, is carried through the left heart almost directly to the 
 aortic arch, whence it proceeds by means of the large aortic branches which 
 are given off near the heart to the head and upper extremities, thus accounting 
 for the extremely well-developed condition of these parts; while the blood that 
 has already circulated in the upper parts, being thereby deprived of most of 
 its nutriment, is carried, together with a small part from the left ventricle, to 
 the viscera and lower extremities; and this fact consequently accounts for the 
 small size and poor state of development of the latter. 
 
 Characteristic Features. — The characteristic features of the fetal cir- 
 culation are (i) the ductus venosus, (2) the ductus arteriosus, (3) the foramen 
 ovale, (4) the hypogastric arteries, and (5) the umbilical vein. After birth 
 circulation and respiration take place as in the adult, although the changes 
 leading to the complete functional development of the systems and the atrophy 
 of the fetal structures take a considerable period of time. 
 
 The Earliest Human Ovum. — The earliest ovum in an apparently normal con- 
 dition is that described and figured by Peters in 1899 (Fig. 51). It was sectioned 
 with a portion of the uterine wall in which it was partially embedded. The 
 extreme limits of the ovum are about 0.12 X 0.06 X 0.06 inch (3 X 1.5 X 
 1.5 mm.), in the form of a flattened sphere. The outer surface or chorion is 
 covered by villi, and it is found that it is a hollow sac, the cavity of which 
 measures 0.064 X 0.032 X 0.036 inch (1.6 X 0.8 X 0.9 mm.). Within the sac 
 of the chorion and attached to one side is a cellular mass about 0.008 inch (0.2 
 mm.) in diameter and containing two cavities. The cavity lying nearer the 
 chorion is the amnion ; the other cavity is the yolk or umbilical sac. The amnion 
 is formed as a closed sac of a single layer of cells which are elongated on the 
 side away from the chorion ; i. e., in that part where from later stages it is known 
 the embryo will be formed. The yolk-sac is lined by entodermal cells, and 
 between it and the above-mentioned thickened ectodermal cells is a layer of 
 mesoderm which not only lies between ectoderm and entoderm, but completely 
 envelops the yolk-sac and the amniotic sac and forms a connection between 
 these and the chorion and then forms a complete lining for the chorion. Thus 
 it is seen that in this early human embryo, in which the body is represented 
 by a flat or concave disc of ectoderm, a layer of mesoderm, and a sac of ento- 
 derm, the relative rate of development of parts has been quite different from 
 that described above for the rabbit. This difference becomes more apparent 
 when the membranes are discussed. But it is seen that there is essential unity 
 
CHARACTERISTICS OF THE OVUM, EMBRYO, AND FETUS. 83 
 
 in the fact that the three germ-layers exist. Just how they arise in man must 
 await solution until still younger human embryos are as carefully preserved and 
 studied as was Peters 's specimen. 
 
 Characteristics of the Ovum, Embryo, and Fetus in the Several Lunar Months 
 of Gestation. — These are of value to enable us to determine the exact period 
 of gestation, the cause of the premature interruption of pregnancy, the clew 
 to many congenital deformities and intrauterine diseases and accidents, and 
 tests of maturity. 
 
 Embryos of the First Month. — The size of the ovum described bv 
 Peters is 0.12 X 0.06 X 0.06 inch (3 X 1.5 X 1.5 mm.); and of the em- 
 bryonic area about 0.0076 inch (0.19 mm.). The chorion is hollow with a 
 mesodermic lining and solid epithelial villi. The amniotic sac is formed and 
 the embryonic area is merely a thickened portion of this sac. The yolk-sac 
 is larger than that of the amnion. The embryonic mass is attached to the 
 chorion by a wide mesodermic connection which completely separates the 
 latter from the amniotic epithelium. Spec's specimen (Fig. 64) measures 0.28 
 X 0.22 inch (7 X 5.5 mm.), and the embryo 0.0148 inch (0.37 mm.). The meso- 
 dermic connection of embryonic mass with the chorion is narrower and blood 
 islands have appeared on the yolk-sac. In Etemod's specimen the chorion 
 measures 0.432 X 0.328 X 0.24 inch (10.8 X 8.2 X 6 mm.) and the embryo 
 0.052 inch (1.3 mm.). The embryonic area is somewhat elongated and shows 
 a neural groove and neurenteric canal. The heart is at the extreme cephalic 
 end of the embryonic area. Vascular connections are established between 
 yolk and embryo and also with the chorion. In Spee's specimen (Fig. 65), 
 measuring 0.072 X 0.06 inch (1.8 X 1.5 mm.) with embryo 0.0616 inch (1.54 
 mm.), the chorionic villi are already branched with mesoderm penetrating 
 them. The allantoic rudiment extends into the abdominal stalk, but heart and 
 blood-vessels do not seem to be so far advanced as in Eternod's smaller specimen. 
 At the end of the third week (Figs. 100 and loi) the ovum measures about 
 I X 0.8 inch (25 X 20 mm.) and the embryo 0.16 to 0.2 inch (4 to 5 mm.). 
 The villi are distinctly branched. The embryo is well outlined; head, trunk, 
 tail, and limbs are recognizable. The neural tube is completely closed and dif- 
 ferentiation into brain and eye vesicles has begun. The internal ear is a closed 
 vesicle. The nasal epithelium is a thickened disc. The mouth connects with 
 the pharynx, in which are four branchial clefts. The alimentary canal is a 
 straight tube except for the wide connection with the yolk-sac and its ap- 
 pendages; thyroid, thymus, lungs, and liver are recognizable. The heart tube 
 has assumed the characteristic S-shaped twist, and though divided into auricular 
 and ventricular portions, is not separated into right and left halves. The 
 mesonephros (primitive kidney) is prominent. The somites are numerous and 
 distinct. The limbs form bud-like projections. In other words, during the third 
 week the majority of the organs take on recognizable features (Figs. 75, 76, 77, 
 and 78). 
 
 End of First Month or Fourth Week. — Characteristics of ovum: Waldeyer's 
 classical description of an ovum four weeks old gives its size as that of a pigeon's 
 egg; in length f inch by f inch broad (20 X 16 mm.). (Mall gives 1.12 X 0.8 
 inch — 28 X 20 mm. — for an embryo of twenty-seven days.) Its weight was 34.5 
 grains (2.3 grams). The chorion is a flattened vesicle containing fluid and is 
 made up of two walls. The inner wall is smooth while the outer one bears the 
 branching villi. It is not firmly embedded in the uterine tissue and its separa- 
 tion can easily take place. The yolk-sac is larger than the cephalic extremity 
 of the embryo and its stalk is enclosed in the umbilical cord. A clear space 
 
84 PHYSIOLOGICAL PREGNANCY. 
 
 separates the chorion from the amnion, which remains close to the embryo. 
 The embryo and chorion are connected by blood-vessels which do not penetrate 
 the villi (Fig. 102). 
 
 Characteristics of the embryo: At this period the human embryo can be dis- 
 tinguished from that of any other mammal only with great care. It is much 
 curved, head and tail being close together, and is \ inch long (7 to 8 mm.); or, 
 taking the vertex-coccygeal length, i inch (20 mm.). Weight, 20 grains (1.30 
 grams). The cerebral vessels are present, and the brain and spinal cord are 
 enclosed. The eye and ear vesicles can both be distinguished and the nasal 
 epithelium forms a slight pit. Only three branchial clefts are clearly seen. 
 The tongue is a mere rudiment and the mouth is perforate. The liver shows 
 marked growth and the kidneys appear about this time, with the beginnings 
 of the pancreas. The heart is very prominent and its division into four cavities 
 has begun. It has probably assumed its function by the third week. It is 
 covered by the pericardium. The rudimentary extremities are still bud-like 
 (Figs. 78 and 79). 
 
 End of Second Month or Eighth Week. — Characteristics of ovum: The 
 ovum at the end of the second month is as large as a hen's egg. It is about 
 2 inches (5 cin.) long by if inches (4 cm.) wide. Its weight is from 330 to 
 375 grains (22 to 25 grams). About the middle of this month there is a more 
 luxuriant growth of the villi at one part on the chorion marking the origin of 
 the placenta. Instead of obtaining nourishment from the umbilical vesicle, 
 the fetus now depends wholly on the maternal blood for its food. The um- 
 bilical vesicle is much smaller proportionally and is attached to the embryo 
 by a slight pedicle. The amnion is distended with fluid but is not yet in con- 
 tact with the chorion (Figs. 103 and 105). 
 
 Characteristics of the embryo: The vertex-coccygeal length is about an inch 
 (2.5 cm.), the total length being about the same. Its weight is nearly 60 grains 
 (4 grams). The head is about as large as the trunk. The neck is formed. All 
 the visceral clefts except the first are closed. This latter forms the external 
 auditory meatus, tympanum, and Eustachian tube. The superior and inferior 
 maxillary processes are formed. Bone nuclei appear in the clavicles and lower 
 jaw. The salivary glands and dental groove are formed. There is decrease 
 in the size of the wide oral opening. According to His, the embryo is trans- 
 formed into the fetus when it has reached a length of about 0.6 to 0.64 inch 
 (15 to 16 mm.); for at this stage the shape of the head and the articulation of 
 the extremities are distinctly of the human type, and the tail has nearly dis- 
 appeared. The hands and feet are webbed at first. The eyes, ears, and nose 
 can be clearly made out. The brain vesicles, although exhibiting large cavities, 
 are developing and increasing the size of the head. The body begins to straighten 
 a little from the growth of the viscera. The cord is somewhat longer, and 
 although the umbilical ring is contracted to some extent, there are still a few 
 loops of intestine in it. The AVolffian bodies are smaller, but the kidneys and 
 suprarenal bodies are developed. Although the external genitals are now 
 apparent, the sex cannot be distinguished, for the elements of both sexes are 
 equally present (Fig. 81). 
 
 End of the Third Month or Twelfth Week. — Characteristics of ovum: 
 The ovum is about the size of a goose-egg. It averages 4|- inches (11 cm.) in 
 length. The placenta, though small, is now complete, and the chorion loses its 
 villi except at this point. The amnion is in contact with the chorion. 
 
 Characteristics of the fetus: The vertex-coccygeal length of the fetus is 3.2 
 inches (7 to 8 cm.), while the total length is 4 inches (10 cm.). It weighs about 
 
CHARACTERISTICS OF THE OVUM, EMBRYO, AND FETUS. 85 
 
 450 grains (30 grains). The cord, as it lengthens out, begins to make spiral 
 turns, while the umbilical ring narrows and the intestines are now wholly within 
 the abdomen. The sex can be distinguished by the appearance or absence 
 of a uterus. The scrotum -and labia majora are composed of skin folds and 
 the penis and clitoris are equal in length. The nails are fine membranes, and 
 the webbed appearance of the fingers and toes disappears. Nearly all the 
 bones present points of ossification. The neck is longer, while the ribs mark 
 the line of division between the abdomen and chest. The palate is formed 
 between the oral and nasal cavities. Teeth are forming and lips close the 
 mouth. The eyes are relatively nearer together and become covered by the 
 lids. The proctodeal or anal opening is perforate (Fig. 82). 
 
 End of the Fourth Month or Sixteenth Week. — Characteristics of the 
 fetus: The fetus is 3 inches long (7.62 cm.) from coccyx to vertex, the entire 
 length being 5 inches (12.7 cm.). The weight is 1800 grains (120 grams). The 
 placenta continues to grow and the cord becomes more spiral in form. The 
 sex is clearly defined. Lanugo develops. There is meconium in the intestines. 
 The umbilical cord is thicker on account of the beginning formation of Wharton's 
 jelly (Fig. 83). 
 
 Vitality: There may be feeble movements of the limbs, and if the child is 
 bom it may live some hours, endeavoring during this time to breathe. 
 
 End of the Fifth Month orTwentiethWeek. — Characteristics : TheYertex- 
 coccygeal length is 4.5 inches (10.16 cm.), the total length 8 inches (20.32 cm.). 
 The weight is 4095 grains (273 grams). The cord is about 12 inches (30 cm.) 
 long. Here and there are patches of vernix caseosa. The face is wrinkled 
 and has a senile appearance. The eyelids are opening. The head is huge, 
 comparatively. There is more fat on the body (Fig. 134). 
 , Vitality: It is, as a rule, during the fifth month that the mother feels quicken- 
 ing. The fetal heart sounds are audible. If born at this time, the fetus gener- 
 ally dies at once, though it may live a few hours. It may breathe and cry 
 (Figs. 83 and 130). 
 
 End of the Sixth Month or Twenty-fourth Week. — Characteristics: The 
 ■fetus is 6.15 inches (15.87 cm.) long from vertex to coccyx, with a total length 
 of 12.20 inches (31. 11 cm.). It weighs i^ pounds (680 grams). The skin is 
 richer in fat, the hair on the head grows. There are distinct brows and lashes. 
 The head is large. The cord is midway between the symphysis and the xiphoid 
 cartilage. The testicles approach the inguinal rings. 
 
 Vitality: A fetus born at this time might live for fifteen days, but it would 
 finally die from insufficient air-supply, for the finer air-passages are yet un- 
 developed. There would also be imperfect assimilation of food and rapid loss 
 of heat. 
 
 End of Seventh Month or Twenty-eighth Week. — Characteristics: The 
 vertex-coccygeal length is now about 8 inches (20.32 cm.), the total length 
 14.4 inches (36.19 cm.), and the weight has reached 2^ pounds (iioo grams). 
 The pupillary membrane disappears. There is considerable meconium in the 
 large intestine. Lanugo covers the body except the palms of the hands and 
 the soles of the feet. 
 
 Vitality: ' A child born about this time very seldom survives. However, 
 no effort should be spared to save life, for, according to Lusk, it may be owing 
 to the skepticism of the physician in regard to the viability of these infants 
 that so many have died. 
 
Shape of Uterus. 
 
 Marked antero-posterior 
 growth. Pyriform shape. 
 
 Pyriform shape still pre- 
 served but almost cylin- 
 drical. 
 
 Pyriform shape disappear- 
 ing. Shape now nearly 
 spherical. 
 
 Marked ovoid. Anterior 
 surface rounded like a 
 ball. Posterior surface 
 flattened. Tubes below 
 horns. 
 
 Shape same as at end of 
 fovu"th month. 
 
 Ovoid of 4 and 5 months 
 gradually becoming egg- 
 shaped. Posterior wall 
 flattened by spinal col- 
 umn. Tubes well below 
 horns. 
 
 Size of Uterus. 
 
 ix ' gJC ' i^ ' g'X 
 
 x^-^ xx-j ^ ^H^ 
 
 x.2"^ X2y X-- ' x:?o 
 
 CO 1 ■* 1 "^ ! ^ 
 
 ■;:? -"^ 
 
 XX? ^xg 
 
 vo m ^ c '^ 
 
 • vo • w 
 
 X M oi X J;; 
 
 J o . 
 
 
 
 
 
 
 
 oi 
 
 H 
 U 
 
 b 
 
 H 
 
 X 
 
 o 
 
 3 
 
 s 
 
 r»-. 
 
 77.16 to 308.64 gr. 
 (5 to 20 grams) 
 
 1.94 to 4.23 oz. (55 
 to 120 grams) 
 
 "In 
 
 i 
 
 
 
 00 
 
 <s 
 
 N 
 
 
 
 00 
 
 dv 
 
 vo 
 
 B 
 
 Total Length of 
 Fetus. 
 
 ■ 
 
 ■ 
 
 
 2-75 to 3.54 in. (7 
 to 9 cm.) 
 
 3.94 to 6.69 in. (10 
 to 17 cm.) 
 
 7.08 to 10.62 in. (18 
 to 27 cm.) 
 
 00? 
 ^ 
 
 ^^ 
 
 
 
 00 
 
 H 
 
 Vertex-coccygeal 
 Length of Fetus. 
 
 ^_^00 
 
 B^ 
 
 d'^s 
 
 •2 o 2 
 
 d d 
 
 0.33 to 0.5 in. (0.85 
 
 to 1.28 cm.) 
 0.51 to 0.67 in. (1.3 
 
 to 1.7 cm.) 
 0.63 to 0.82 in. (1.6 
 
 to 2.1 cm.) 
 
 0.82 to 2.68 in. (2.1 
 to 6.8 cm.) 
 
 2.71 to 3.54 in. (6.9 
 to 9.0 cm.) 
 
 3.82 to 5.79 in. (9.7 
 to 14.7 cm.) 
 
 5.9 to 7.36 in. (15.0 
 to 18.7 cm.) 
 
 Pregnancy. 
 
 3d week 
 4th week 
 
 5 th week 
 
 6th week 
 
 7th and 
 8th weeks 
 
 12 th week 
 1 6th week 
 
 20th week 
 24th week 
 
 
 Q 
 
 
 5 
 u 
 
 Oh 
 
 ist 
 month 
 
 2d 
 month 
 
 3d 
 month 
 
 4th 
 month 
 
 -^B 
 
 6th 
 month 
 
 ■SNOi.i.'aoav 
 
 86 
 
 ■(saovi'aavDSiPM) s^oavn a^inxvivHi 
 
Distinctly egg-shaped. 
 Broadest portion just be- 
 low ftmdus. Longitudinal 
 axis predominates. Pos- 
 terior surface flattened 
 by spinal column. Tubes 
 well below horns. 
 
 Shape same as at end of 
 seventh month. 
 
 Ovoid shape. Longitudinal 
 axis predominates. Ftm- 
 dus broad. Posterior de- 
 pression caused by lum- 
 bo-sacral angle. 
 
 Ovoid shape. Fundus 
 rarely regular and de- 
 pends on posttire of 
 fetus. Fetal head causes 
 increased development of 
 anterior part of lower 
 portion of uterus, causing 
 sacciform dilatation of 
 lower uterine segment. 
 
 VO '^ N 
 
 x-^ 
 
 IN 
 
 '♦'NO X 
 t^ IN ^ 
 
 x^lC- 
 
 M 
 
 XxS 
 
 HM IT) 
 
 00 10 • 
 
 ^00 
 
 -^X 
 
 w 
 
 to 10 
 
 CO (J 
 XX-r: 
 Hn • 
 
 ONUp« 
 
 X " 
 
 
 2f in. (6.98 
 
 cm.) 
 
 00 
 
 ON 
 
 - no' 
 
 <N 
 
 01 10 
 
 NO M 
 
 t^ 00' 
 
 •si-^? 
 
 fO fO 
 
 0\ M 
 00 10 
 
 00' On 
 ro CO 
 
 
 
 w 
 
 H 
 
 m' 
 
 ;ri C t-- CO 
 
 ".ON ! ^ &) 
 
 J^O 
 . lONO 
 
 +^0 "^ 
 
 NO +J 
 
 ro 1 ro 
 
 to' 
 
 '0 
 
 -tJ 
 
 
 0° 
 
 NOW 
 
 NO 
 
 NO B 
 On 
 
 4oo 
 '^ fO 
 
 
 
 00 ro 
 00 V-' 
 
 .B ^ 
 
 i NO On-'-v 
 
 NO 00 
 
 ON^ irjO 
 
 -t NO 
 
 M 1 M 
 
 00 
 
 .s 
 
 00 1 
 
 
 
 06 
 
 li • 
 
 od°° 
 
 00 C 
 
 -^ 
 
 P) 
 
 ■^B 
 00 
 
 On 
 
 M 
 
 .s 
 
 H 
 OOO 
 
 M 
 
 ^ fO 
 
 '^ ^ 
 
 NO 
 
 ■ -IJ 
 
 
 M 
 
 .B 
 2° ( 
 
 H 
 00^ 
 
 M 
 
 H 
 
 28th week 
 
 29th week 
 32d week 
 
 34th week 
 36th week 
 
 i :S ^ 
 t^ 
 
 1 CO I* 
 
 -1 
 -1 
 
 00 
 
 
 
 
 •saoevT synxvKa^d 
 
 87 
 
88 PHYSIOLOGICAL PREGNANCY. 
 
 End of the Eighth Month or Thirty-second Week. — Characteristics: The 
 vertex-coccygeal length is 10.20 inches (26.03 cm.), the entire length 15.80 
 inches (40 cm.), the weight is 3^ pounds (1571 grams). The lanugo on the 
 face is becoming more scanty, but the hair on the scalp is thicker. One testicle, 
 generally the left, has descended into the scrotum. In the lower epiphysis of 
 the femur ossification begins. The nails do not yet project beyond the finger- 
 tips, although they are firmer in consistency. The cord is relatively a little 
 lower in its insertion than it was the previous month. 
 
 Vitality: With very watchful care a child born at this time may survive. 
 
 End of the Ninth Month or Thirty-sixth Week. — Characteristics: The 
 vertex-coccygeal length is 11. 10 inches (27.94 cm.), the total length 17.25 inches 
 (44 cm.), and the weight is 5^ pounds (2640 grams). There is a further 
 increase in the subcutaneous fat. The development of the nails is not yet 
 complete. The cranial bones are compressible and very susceptible to moulding. 
 T'he diameters of the head are about 0.4 to 0.6 inch (i to 1.5 cm.) less than 
 those of the average fetus at full term (Fig. 109). 
 
 Vitality: With ordinary care the fetus almost invariably survives. 
 
 End of the Tenth Month or Fortieth Week. — Characteristics: The vertex- 
 coccygeal length is 14.8 inches (37 cm.), the total length 19.84 inches (50 cm.), 
 and the weight 7 pounds (3200 grams). The skin is pink, but paler, more 
 abundantly supplied with fat, and has less lanugo. The nails are perfectly 
 developed and project beyond the finger-tips. The eyes are opened. The 
 ossification center in the lower epiphysis of the femur is 0.2 inch (5 mm.) in 
 diameter, and that of the cuboid bone is just making its appearance. The 
 diameters of the skull are normal (Fig. 138). (See Physiologv of Labor, Part 
 IV.) 
 
 Embryo, Fetus, and Uterus in the Several Months of Gestation. — Although it 
 is customary to measure embryos from vertex to sole, measurement of the trunk 
 (or, in youngest embryos, the two extreme points) is doubtless more exact. 
 During the first and second months only the trunk can be measured, and in the 
 third and fourth months the legs cannot readily be extended. The notable dif- 
 ferences of various authorities may be explained in part by the fact that em- 
 bryos preserved in alcohol diminish in weight from 3 to 5 per cent, on an average 
 (i to 14 per cent, extremes) according to the strength of the fluid; and in part 
 by fluctuations in the estimation of the age. Exact data upon these points 
 are entirely wanting. It is best to be guided in judging the age by certain 
 developmental signs, such as growth of lanugo in each month, etc. In the 
 table on pages 86 and 87 the vertex-coccygeal lengths of the embryo and 
 fetus are from Schultze's figures.* The weights are those of Droysen and 
 Gottengen and the size and shape of the uterus are the author's estimates. 
 The last measurements, it must be remembered, are influenced by the 
 presentation, size, and number of the fetus, by the size and position of the 
 placenta, by the amount of liquor amnii, and by pathological conditions. 
 
 * Schultze: " Gnindriss der Entwickltmgsgeschichte des Menschen und der Sauge- 
 thiere," Leipzig, 1897, p. 137. 
 
CHANGES IN EXTERNAL GENITALS, VAGINA, AND CERVIX. 89 
 
 II. THE PHENOMENA PRODUCED IN THE MATERNAL 
 ORGANISM BY PREGNANCY. 
 
 LOCAL PHENOMENA IN THE GENITAL TRACT, ADNEXA, PELVIS, 
 
 AND BREASTS. 
 
 1. External Genitals. — The vulva takes part in the general hyperemia of 
 the generative system, though these changes are rarely apparent until the third 
 month. The labia majora and minora are both increased in size, are more 
 elastic and resisting, and there is a deeper pigmentation than normal, which 
 is particularly marked in the external labia. The functional activity of the 
 sebaceous follicles and sweat glands of the labia is increased, and the external 
 genitals are later often bathed with a glairy mucous secretion. Somewhat 
 later still in pregnancy the veins and venous plexuses are much engorged, while 
 distinct varicosities are not uncommon. 
 
 2. Vagina. — The muscular and mucous walls of the vagina are thickened 
 and lengthened. This hypertrophy is particularly well marked at the upper 
 portion. The walls are consequently strengthened, so as better to accommodate 
 the passage of the fetus at term. The mucous membrane becomes darkened 
 by pigmentation. The attachment of the mucous coat to the tissues beneath 
 becomes loosened, so that its displacement is easy, and it is not infrequently 
 torn off in labor, thus originating vaginal prolapse. The rugag are distinctly 
 defined; the lymphatics, as well as the blood-vessels, are unusually developed; 
 the tissues become softened and infiltrated, and the submucous fat decreases. 
 On account of the increased quantity of blood in the loose tissues, as well as 
 the venous stagnation which occurs, the vaginal surface looks violet, blue, or 
 purple, instead of red as normally (Fig. 7). The mucous glands produce 
 an abundant secretion, the papillae of the vagina hypertrophy, and it is not 
 uncommon about the seventh or eighth month to find the surface covered 
 throughout its whole extent with myriads of these little pinhead prominences, 
 which have given rise to the term " granular vaginitis of the pregnant woman." 
 The temperature of the vagina is slightly increased, and the augmented supply 
 of blood to the part causes a distinct throbbing of the vaginal arteries, readily 
 detected by the examining finger, the so-called "vaginal pulse." The apparent 
 length of the vaginal canal varies according to the period of pregnancy at which 
 the examination takes place. In the early weeks, before the uterus rises above 
 the pelvic brim, the vagina is shortened; afterward it increases in length till 
 the middle of the eighth month (as a result of the sinking of the uterus at this 
 time), when it again becomes shortened. 
 
 3. Cervix. — (i) Consistency: The tissue of the non-gravid uterus is firm, 
 hard, and non-elastic. With the occurrence of conception, softening begins 
 at the external os, and gradually extends upward till the whole cervix is in- 
 volved. It is caused by serous infiltration, with which passive dilatation of 
 the blood-vessels is associated. At the end of the fourth month the lips of the 
 OS are entirely changed in consistence, being soft and velvety on palpation. 
 By the sixth month one-half of the cervix has participated in this change, and 
 by the eighth the entire cervix is involved. 
 
 2. Volume. — The cervix takes part in the hypertrophy of the entire uterus, 
 its volume changing somewhat as pregnancy advances. This increase, how- 
 ever, does not compare in extent with that of the body of the uterus. 
 
 3 Situation and Direction. — In the first three months the cervix is 
 
90 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 lower in the pelvis and a trifle to the left. This position results from the in- 
 creased weight and the pressure upon the fundus toward the right by the dis- 
 tended rectum. After the third month the cervix rises higher in the pelvis 
 
 MESO-SIGMOID 
 UTERUS \ 
 
 RECTO-VAGINAL POUCH 
 
 RECTUM \ 
 
 LEFT COMMON ILIAC V 
 
 RIGHT COMMON ILIAC A 
 
 ROUND LIGAMENT OF UTERUS 
 
 UMBILICUS 
 
 DEEP EPIGASTRIC A 
 FALLOPIAN TUBE 
 OVARY 
 
 UTERO VESICAL POUCH 
 BLADDER 
 
 RAPHE OF LEVATOR ANi M 
 
 EXTERNAL SPHINCTER ANI M 
 
 DORSAL VEIN OF CLITORIS 
 
 VESICAL PLEXUS OF VEINS 
 \ URETHRA 
 
 INTERNAL SPHINCTER ANI M 
 
 PERINEAL BODY 
 
 Fig. 
 
 117- — Sagittal Section of Normal Adult Pelvis. — {Deaver.) 
 
 till the last two or three weeks of gestation, when it sinks again. Sometimes 
 toward the end of pregnancy, if the head is the presenting part, it pushes forward 
 the lower anterior wall of the uterus, causing the cervix to point backward. 
 
CHANGES IN THE UTERUS. 
 
 91 
 
 or even a little upward.* The cervix changes in direction according to the 
 movements of the uterine body. 
 
 4. Cervical Canal. — Coincident with the cervical softening, the cavity 
 becomes broader, and the external os patulous. The time of this change varies 
 according as the patient is a primigravida or a multigravida. Sometimes, in 
 the former case, the external os remains closed till the end of pregnancy; but 
 even under these circumstances it generally becomes patulous after the seventh 
 month. In multigravidae this change is more pronounced, so that in the last 
 months of gestation it is often possible to feel the membranes through the 
 
 URETER (behind PERITONEUM) 
 LOOP OF SMALL INTESTINE 
 
 VERMIFORM APPENDIX 
 
 CECUM (displaced UPWARd) 
 
 DEEP EPIGASTRIC A 
 
 FUNDUS OF UTERUS 
 
 FIMBRIATED EXTREMITY OF FALLOPIAN TUBE 
 
 SIGMOID FLEXURE (DISPLACED UPWARD) 
 
 LOOP OF SMALL INTESTINE 
 
 ROUND LIGAMEMT 
 
 ODLITCRATED HYPOGASTRIC A 
 EXTERNAL ILIAC a(dEHIND PERITONEUM) 
 
 BLADDER (olSTENDEo) 
 FALLOPIAN TUBES 
 URACHUS 
 
 Fig. 118. — Pelvic Contents seen from Above. — [Deaver.) 
 
 APPENDICULO-OVARIAN LIGAMENT 
 
 patulous OS. The alleged shortening of the cervix, as taught by old authorities, 
 has been shown to be non-existent; but during the two weeks just preceding 
 labor some shortening does begin to take place, proceeding from above down- 
 ward till the cervical canal is merged into the uterine cavity; this shortening 
 is owing to the incipient contractions of the uterus which are preparing the 
 cervix for labor. 
 
 4. Uterus. — The most important changes in the whole organism during 
 pregnancy take place in the uterus. The alterations which the latter undergoes 
 
 * Sacciform dilatation of the lower uterine segment. 
 
92 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 as the result of each menstrual period must be regarded as an introduction 
 to that series of changes which end only with the return of the organ to its 
 normal condition after the expulsion of the product of conception (see Men- 
 struation, page 20). 
 
 I. Volume and Size. — The volume or size of the small, inflexible virgin 
 uterus is expressed by 2f inches (7 cm.) in length, i| inches (4.5 cm.) in breadth, 
 
 s.u.a. t.s.a. t.c 
 
 t.s.p' 
 h.a. 
 
 u.s.l. 
 o. 
 
 u. 
 
 t.s.p. 
 
 U.S.L 
 
 t.ur.a. 
 
 ■:'.i.»e^'^ 
 
 v.p.c. 
 
 ui. 
 
 u.a. 
 o.l. 
 
 Fig. 119. — The Pelvic Inlet and Female Pelvic Organs in a Woman Forty Years 
 Old, Who has borne Children. The bladder is partially filled with urine. (J natural 
 size.) i.s.a., Internal spermatic artery; s.u.a., superior ureteric artery; c.i.v., common 
 iliac vein; i.s.p., internal spermatic plexus; h.a., hypogastric artery; u., ureter; u.s.l., 
 utero-sacral ligament; 0., o., ovary; e.i.a., external iliac artery; e.i.v., external iliac vein; 
 r.l., round ligament; e.a., epigastric artery; f.t.. Fallopian tube; v.p.c, vaginal portion 
 of cervix; i.e., inferior cava; a., aorta; nt.s.a., median sacral artery; c.i.v., common 
 iliac vein; s.f., sigmoid flexure; u., ureter; M.5.Z., .utero-sacral ligament; u.a., uterine 
 artery; o.l., ovarian ligament; ut., uterus; b., bladder; i.ur.a., inferior ureteric 
 artery. — (Tandler and Halban.) 
 
 and I inch (2.5 cm.) in thickness. The hypertrophy of the uterus is concerned 
 not only with the muscle-fibers, but with the connective tissue and all the 
 vessels. These changes are reflex in character, and begin with impregnation. 
 Indeed, the uterus increases up to the fourth month, even in tubal or any form 
 of extrauterine pregnancy. The growth of the ovum may act at first as a 
 physiological cause of these changes, but not as a mechanical one. Uterine 
 enlargement is not directly dependent upon the presence of the ovum, for the 
 
SIZE OF THE UTERUS. 
 
 93 
 
 latter does not entirely fill the cavity of the organ at the end of the fifth month; 
 consequently it is not until this time that mechanical distention can be reckoned 
 as an influential factor. At first this hypertrophic process affects all parts 
 
 Fallopian 
 tube 
 
 !Pfr~-' 
 
 Round 
 Ligament 
 
 Body of Uterws 
 . — Isthmus' -^_ 
 
 Extroy Vaaincd 
 , portion on Cervix, 
 
 External os 
 
 Posterior Wall of 
 Vo^inciy- 
 
 Fig. 120. — The A.vter[or Surfaces of the Nuli.iparols axu Multiparous Uterus 
 
 COiMPARED. 
 
 " EtLndiis 
 ' FcdlopimiTiibe 
 
 CaviiyofBody 
 
 ^,,--- Isthmus -- -._ 
 
 Internal os 
 
 .--- Cerncal Canal 
 j\fQch 
 
 - Lateral Ti(/7inal 
 
 CiLideSac. 
 External os 
 
 ZateralTiiffinalWall 
 PosteriorVa^malMilt 
 
 Fig. 12 1. — Sagittal Sections of the Nulliparous and Multiparous Uterus. 
 
 of the organ ahke, but later the cervix grows more slowly than do the fundus 
 and the body. At one period the walls attain the thickness of five-eighths of an 
 inch (1.5 cm.). The thickness, however, decreases in the latter part of gesta- 
 
94 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 tion, on account of extreme distention, to three-sixteenths of an inch (0.5 
 cm.). The capacity of the "virgin uterus, which is almost imaginary, may be 
 
 Fig. 122. — Virgin Cervix and Os with 
 Oval Opening. 
 
 Fig. 123. — Virgin Cervix and Os with 
 Transverse Fissure. 
 
 Fig. 124. — Virgin Cervix and Os with Oval Opening. 
 
 Fig. 12 i;. — Multiparous Cervix with 
 Gaping Fissured Os. 
 
 Fig. 126. — Cervix and Os of Ad- 
 vanced Age with Small Round 
 Opening. 
 
 increased as much as 5 19-fold at term (Krause, Levret). The outer surface 
 of the virgin uterus measures six square inches, while at term it amounts to 
 
SIZE OF THE UTERUS. 
 
 95 
 
 339 square inches. The unimpregnated uterus weighs about i\ ounces (35.43 
 gm.), while the pregnant organ at term weighs about two pounds (900 gm.). 
 
 Fig. 127. — Sagittal Section of Uterus and Pelvic Contents at the Second Month 
 OF Pregnancy. Retroversion. {\ natural size.) — {Schaeffer.) 
 
 Fig. 128. — Sagittal Section of Uterus and Pelvic Contents at the Third Month 
 OF Pregnancy. Unusual vertical position of the gravid uterus. (J natural size.) — 
 (Schaeffer.) 
 
I/iff^r/tf// o.s 
 
 Fig. 129. — Frozen' Section of a Uterus at the Third Month. Uterus resting normally 
 on the bladder. Placenta and membranes in the uterus. — (Freimd.) 
 
 Fig. 130. — Sagittal Section of Uterus 
 AND Pelvic Contents at the Fourth 
 Month of Pregnancy. Primigravida. 
 Breech presentation. Normal position of 
 the uterus. (J natural size.) — (Schaeffer.) 
 
 Fig. 131. — Frozen Section of a Uterus 
 at the Fourth Month of Pregnancy. 
 Placenta and membranes are retained. 
 
 — (Freund.) 
 
 96 
 
Fig. 132. — Pregnant Uterus at the Fifth Month, showing Anterior Surface and 
 Prominent Right Horn (Unicornate Uterus). — (Author's case.) 
 
 Fig. 133. — Uterus of Fig. 132 Opened Posteriorly, showing Unruptured Amnion 
 with Contained Fetus, Thickness of the Uterine Walls, and Length of Uterine 
 Canal. — {Author's case.) 
 
 7 97 
 
98 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 Fig. 134. — Amnion and Fetus from Fig. 133 after Entire Specimen was Hardened in 
 Formaldehyde. Shows posture of fetus and shape of the fetal ovoid. — (Author's case.) 
 
 Crest 
 
 Ilium 
 
 Internal os. ^''^*K^ 
 
 V(/ffinaI fornix ^ 
 External os. ^ 
 
 ' ' i-{ '*"*^^^Ti? — Ischudluberosify 
 
 ^^^- 135. — Frozen Transverse Section of a Uterus from a Multigravida at the 
 Thirty-sixth Week. No uterine contractions have occurred. The cervix is closed 
 and the canal unshortened. Death from eclampsia. {\ natural size.) — {Leopold.) 
 
' Irdernal os 
 
 Erigrmil OS. 
 
 Fig 136. — Frozen Section of a Uterus at the Seventh Month, with Retained 
 Placenta and Membranes. — (Freund.) 
 
 99 
 
100 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 For the size of the uterus at the end of each calendar month see table, pages 
 86 and 87. 
 
 2. Shape. — The virgin uterus is pyriform or pear-shaped, flattened from 
 before backward (Fig. 120). Its upper end or fundus, the broad extremity of 
 the organ, is directed upward and forward (Fig. 119). Its lower end, or apex, 
 looks downward and backward. Consequently it forms an angle with the 
 vagina. During the first six or eight weeks of gestation the organ loses its 
 
 «^^^ 
 
 Fig. 137.— Pregnant Uterus at Thirty-eighth Week seen from the Front. Ante- 
 rior walls are held back to show the maternal surface of the placenta, the tinruptured 
 amnion, thickness of the uterine walls, and the length of the cervical canal. — {Author's 
 case.) 
 
 flattened pear shape and bulges out over the cervix, in all the transverse diam- 
 eters, but more particularly antero-posteriorly ; so that now the uterus resembles 
 very much an old-fashioned jug inverted (Fig. 169). Later it expands more 
 in the lower segment, and by the fifth month its form is midway between spherical 
 and pyriform, the vertical diameter being longest (Fig. 132). Its antero- 
 posterior measurement is greatest just below the middle of the body. During 
 the last of pregnancy it becomes egg-shaped, ovoid, or cylindrical (Fig. 137). 
 These changes in shape occur in the normal uterus, but may be influenced by 
 
SHAPE OF THE UTERUS. 
 
 101 
 
 multiple pregnancies, by anomalies of the liquor amnii, and by pathological 
 conditions. Asymmetry of the corpus uteri often exists even at a very early 
 period of pregnancy (Figs. 13.2, 139 to 143). Fig. 132 of the author's collection 
 shows this condition. The bulging portion is often marked bff from the rest 
 of the corpus by a furrow (Fig. 163) (compare Diagnosis of Pregnancy). 
 
 The shape of the uterus at the end of each calendar month is as follows: 
 End of first month, pyriform, by reason of marked antero-posterior growth, 
 changing to cylindrical; second month, exaggeration of first month, spherical 
 form suggested; third month, almost spherical; fourth month, marked ovoid 
 
 Fig. 138. — Frozen Section of Uterus from a Primipara at the Fortieth Week. 
 Uterine contractions have just commenced. Death from eclampsia. Note the un- 
 shortened cervical canal and the lateral flexion of the bodyyand head of the fetus. 
 (J natural size.) — {Leopold.) 
 
 with round anterior and flattened posterior surfaces; fifth month, exaggeration 
 of fourth month; sixth month, ovoid changing to egg-shape with posterior wall 
 flattened by spinal column; seventh month, egg-shaped, broadest just below 
 fundus; eighth month, exaggeration of seventh month, lower portion widening 
 out; ninth month or full term, ovoid shape with predominance of longitudinal 
 axis; anterior surface more convex, with marked bulging of anterior part of 
 lower uterine segment, caused by fetal head. A posterior depression caused 
 by the lumbo-sacral angle and fundus may be due to irregular posture of the 
 fetus. 
 
102 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 3. Situation or Position. — On account of increased weight, the uterus, 
 in the early months of pregnancy, sinks down into the pelvic cavity. After 
 the third month it rises gradually, till it almost touches the diaphragm, and 
 before term it sinks again by reason of the engagement of the lower part of the 
 uterus in the pelvic cavity, and the relaxation of soft parts preceding delivery. 
 This is called the "lightening" before labor. The virgin uterus is normally 
 anteflexed (Fig. 117). This condition becomes much accentuated in pregnancy, 
 especially when the abdominal walls are lax, as after the patient has borne a 
 number of children, when anteflexion is much exaggerated. Not only does 
 
 /■/ -"^'^ 
 
 
 Fig. 
 
 i3g. — Egg-shaped 
 Uterus. 
 
 Fig. 140. — Cylindrical- 
 shaped Uterus. 
 
 Fig. 
 
 141.- 
 
 -Unicornate-shaped 
 Uterus. 
 
 \ 
 
 Fig. 
 
 142. — Bicornate-shaped 
 Uterus Arcuatus. 
 
 Uterus, 
 
 Fig. 143. — Oblique Cylindrical-shaped 
 Uterus in Shoulder Presentation. 
 
 the sinking of the organ depend upon its increase in weight, but also on the 
 greater surface of the fundus exposed to the downward pressure of the intestines. 
 Before the pregnant uterus has risen out of the pelvis, the abdomen is not in- 
 creased in size In fact, it is often said to be flatter, on account of the partial 
 descent of the uterus into the pelvis. About the middle of the third or begin- 
 ning of the fourth month, however, the fundus slowly rises above the pelvic 
 brim, and it may then be felt as a smooth, rounded tumor. 
 
 4. Axis. — While the uterus is in the pelvic cavity its longitudinal axis changes 
 from time to time, like that of the nonpregnant organ. These alterations in 
 
MUSCULAR TISSUE OF THE UTERUS. 
 
 103 
 
 direction probably depend on the condition of the bladder. Later on in preg- 
 nancy, when the uterus has extended up into the abdomen, it tends to tilt for- 
 ward against the abdominal wall, and its axis corresponds more nearly with that 
 of the pelvic brim, the angle formed with the horizon being 30 degrees. At term, 
 the position and relations of the uterus vary with the posture of the woman. 
 While upright, the heavy fundus inclines forward against the abdominal parietes, 
 as far as the consistency of the latter will permit. In the recumbent position, 
 the uterus rests against the spinal column in the lumbar region, while the fundus 
 approaches the diaphragm., and the intestines are massed around the organ in 
 front and at the sides, particularly 
 the left side (Fig. 160). In either 
 lateral position the uterus natur- 
 ally inclines to the corresponding 
 side. In women with very lax ab- 
 dominal parietes the fundus may 
 even hang downward, there not 
 being sufficient support from the 
 flaccid muscles of the abdomen 
 (Fig. 151). Besides the anterior 
 obliquity, there is also a right 
 lateral obliquity, to explain which 
 many theories have been ad- 
 vanced (Fig. 160). Rotation 
 (torsion) on its longitudinal axis 
 is often noticed, so that the 
 ovaries are displaced, the left gen- 
 erally lying toward the middle 
 line and forward, while the right 
 is directed backward (Fig. i6o). 
 The cervix naturally follows in 
 the wake of the larger body. In 
 extreme anteflexion it cannot 
 always be felt. 
 
 5. Consistency. — The con- 
 sistency of the pregnant uterus 
 changes from the rigid, firm, in- 
 elastic condition of the non-preg- 
 nant organ to the soft, elastic 
 consistency which increases with 
 the advance of pregnancy An 
 obscure sense of fluctuation is 
 often perceived. This consistency 
 differs from that of metritis, which 
 
 causes a hard and non-elastic uterus; from that of subinvolution, which gives 
 a soft but inelastic consistency to the organ; and from that of fibroid, which is 
 also hard and inelastic. So, at term, the full-grown fetus is contained within 
 a flexible-walled cavity. 
 
 6. Mucous Membrane. — (See Decidua, page 45.) 
 
 7. Muscular Layers. — In the non-pregnant uterus the muscle-fibers have 
 a very irregular distribution. Roebger has done very important work on this 
 subject, and says that we do not find definite layers of muscles. Much dis- 
 cussion has taken place as to the musculature of the pregnant uterus. Luschka 
 
 Fig. 144. — Height of the Fundus and Posi- 
 tion OF THE Cervix in the Several Weeks 
 OF Gestation. 
 
104 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 and Henle's work is as good, as any. They believe the pregnant uterus to con- 
 sist of three layers: (i) An external or hood-like, longitudinal layer, passing 
 over from the fundus of the uterus and continuing into the ligaments (Fig. 152). 
 (2) A median layer, where the network of fibers attains its greatest thickness 
 (Fig. 154). (3) An internal layer, which forms the sphincters about the uterine 
 orifices — tubes and os uteri (Fig. 153). These chief layers are connected by 
 communicating groups, so that when they are separated the intervening spaces 
 are rhomboidal in shape. The connective tissue between the muscle-fibers 
 
 ife-, 
 
 IZ'^-WEEK 
 
 20™WEEK 
 
 32"" WEEK 
 
 40"WEEK 
 
 Fig. 146. 
 
 Fig. 147. 
 
 -Shape of the Abdomen in a Primigravida.- 
 photographs.) 
 
 Fig. 148. 
 -{Redrawn from. Hirst's 
 
 soon becomes increased, and toward the last of pregnancy exhibits distinct 
 ftbrillas (Ruge, Hofmeier). By hypertrophy and hyperplasia the three muscular 
 layers are defined. The hypertrophy of the single muscle-fibers is perhaps 
 the most striking change in the whole organism, the increase being eleven times 
 in length and five times in width. The new muscular elements rapidly grow 
 as well. 
 
 8. Fibrous Tissue. — The fibrous tissue is increased, chiefly by absorption 
 of fluid and consequent increase in bulk, and it sends in its newly developed 
 
Fig. 149. — Shape of the Abdomen in a Young Primigravida at Full Term after 
 THE Falling of the Uterus and in the Dorsal Posture. 
 
 Fig. 150. — Shape of the Abdomen in a Young Prumigravida at Full Term after 
 THE Falling of the Uterus and in the Standing Posture. 
 
 105 
 
106 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 fibers between the muscle bundles, thus adding its influence to the other factors 
 which change the consistency of the uterus in the gravid state. 
 
 9. Arteries and Veins. — The arteries increase in calibre and length. Their 
 tortuosity is not lost. The veins enlarge into wide channels, the sinus uteri. 
 These penetrate between the muscle bundles and are especially well developed 
 at the placental site. The walls of these channels do not collapse when injured, 
 
 Fig. 151. — Shape of the Abdomen in a Multigravida with a Moderate Generally 
 Contracted Pelvis at the Thirty-eighth Week and in the Standing Posture. 
 
 on account of the close connection between them and the surrounding connective 
 tissue. They are obliterated after labor by the contraction of the uterine 
 muscle, which surrounds them. These blood-vessels penetrate the minutest 
 divisions of the chorion frondosum, and consist of the end ramifications of the 
 umbilical arteries and veins. The arteries and veins pursue their course side 
 by side, a distinguishing characteristic of the latter being their thin walls and 
 
ARTERIES AND VEINS OF THE UTERUS. 
 
 107 
 
 large calibre. Only capillaries occupy the terminal villi. They are, as a rule, 
 just under the epithelium, and are connected by free anastomoses. They are 
 so abundant that this area has the appearance of a saturated sponge. Their 
 
 Fig. 152. — External Muscular Layer of 
 THE Pregnant Uterus. Anterior Sur- 
 face. I, Fallopian tube. 2, Round liga- 
 ment. 3, Ovarian ligament. 4, Trans- 
 verse fibers. 5, Longitudinal fibers. 6, 
 Z-shaped arrangement of fibers. 7, Orifice 
 of external os. — (Henle.) 
 
 Fig. 153. — Internal Muscular Layer 
 OF the Pregnant Uterus after 
 Removal of the Two Outer Layers. 
 I, Section of the external layer. 2, 
 Section of the middle layer. 3, Fal- 
 lopian tubes. 4, Circular fibers of 
 the horns. 5, Circular fibers of the 
 isthmus. 6, Circular fibers of the 
 cervix. 7, Orifice of the external os. 
 — (Henle.) 
 
 diameter is large enough to accommodate five or six red corpuscles side by side. 
 They have a delicate endothelial wall, which, together with the chorionic epi- 
 
 FiG. 154. — Middle Muscular Layer of the Pregnant Uterus, i, Left tube. 2, Right 
 tube. 3, Fundus uteri. 4, Superficial muscular layer incised and turned back. - 5. 
 Flexiform fasciculse of the middle layer. 6, EUiptical openings occupied by the uterine 
 sinuses. — (Henle.) 
 
 thelium, alone separates the fetal from the maternal blood in the intervillous 
 spaces. The uterine artery is much enlarged during pregnancy, but relatively 
 less so than the ovarian. As pregnancy advances it becomes more tortuous 
 
108 PHYSIOLOGICAL PREGNANCY. 
 
 its course being less direct, and its attachment to the uterine wall loosened.* 
 Its level in the pelvis will depend on the upward growth of the uterus, as well 
 as on its attachment to the pelvic wall, and its relation to the outer border of the 
 broad ligament is lost in the latter part of pregnancy. Its relation to the ureter 
 is the same in pregnant and non-pregnant uteri (Fig. 156). The ovarian artery 
 is greatly enlarged in pregnancy. Its course from the point where it reaches 
 the pelvic brim at the bifurcation of the common iliac artery is upward and 
 forward, accompanying the infundibulo-pelvic hgament, lying close to the 
 
 I s. and i.g. 
 
 ^^ \spe.p. 
 
 Fig. 155. — Nerve-Supply of the Female Genital Organs, p-n.. Phrenic nerve; s.n., 
 splanchnic nerve; l.g-s., lumbar ganglion of the sympathetic; g.u.p., great uterine 
 plexus; r.p.h., right hypogastric plexus; s.p., sacral plexus; r.c.g., right cervical gan- 
 glion; 7;.M., vagus nerve; s.n., splanchnic nerve; 5.g., solar ganglion; 5.r.g., suprarenal 
 ganglion; 'i.r.g., infrarenal ganglion; s. and i.g., superior and inferior genital ganglia; 
 spe.p., spermatic plexus (ovarian nerves). — (Frankenhduser.) 
 
 ovary, overshadowing the Fallopian tubes, and finally reaching the comu of 
 the uterus (Polk) (Figs. 156 and 157). 
 
 10. Nerves. — The logical view seems to be that these organs of sensation 
 participate in the general increase of the other parts of the uterus. 
 
 11. Lymphatics. — The lymphatics increase greatly, both by hypertrophy 
 and hyperplasia. The lymph spaces just below the mucous membrane are 
 much increased in size, and the lymph channels which run from them through 
 the muscles of the uterus reach the size of a goose-quill. Underneath the peri- 
 toneum these lymph vessels form a plexus continuous with the general lymphatic 
 system. On this arrangement of these absorbent vessels depends that striking 
 
 * Tandler und Halban: "Topographie d. weibl. Uterus," 1901. 
 
PERITONEUM. 
 
 109 
 
 characteristic of the uterus after labor, its readiness to take up and assimilate 
 infecting material, peritonitis frequently presenting the first symptom of this 
 process. 
 
 12. Peritoneum. — The connective tissue found in the uterus between its 
 peritoneal covering and the muscular walls becomes less dense and more cellular, 
 so that while the peritoneum in the non-gravid state was closely bound to the 
 organ, allowing very little if any motion between the two, in the pregnant 
 condition, especially at term, it is freely movable on the muscular coat, thus 
 diminishing the risk of laceration during labor. The peritoneum at the end 
 
 c t. 
 
 ut. 
 
 •\ ut. 
 p.b.w. 
 
 Fig. 156. — Relations of the Ureters, Uterine Arteries, and Cervix in the Non- 
 pregnant State, u., u., Ureter; h.a., hypogastric artery; s.L, suspensory ligament; 
 e.i.a., external iliac artery; u.a., uterine artery; p.b.w., posterior bladder wall; r., retro- 
 uterine fold; c, cervical canal; u.a., uterine artery; c.t., cellular tissue; ut., uterus. 
 — (Tandler and Halban.) 
 
 of pregnancy, before the sinking of the uterus, shows a shallowing of the anterior 
 fossa, and the pouch of Douglas is almost obliterated. The retro-ovarian 
 shelves are now on a level with the pelvic brim, instead of on a level with a line 
 drawn from the middle of the symphysis to the third or fourth piece of the sacrum. 
 The pouch of Douglas is raised. There is backward displacement of the broad 
 ligaments, from the growth of the uterus, causing the almost complete oblitera- 
 tion of the posterior fossa, (a) Broad ligaments: During pregnancy the broad 
 ligaments are drawn upward, so that at full term the bases of the ligaments lie 
 on a level with the pelvic brim, and extend from the pectineal eminence ante- 
 
no 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 riorly, to the synchondrosis posteriorly, these Umits being determined by the 
 round Hgaments anteriorly and the ovarian artery posteriorly. Separation of the 
 laminae of the broad ligaments during pregnancy causes the triangular form at 
 
 C.1.V 
 
 u.Ll. 
 
 p.c.l 
 
 Fig. 157. — Topography of the Uterine Artery and Ureters in Pregnancy at Thirty- 
 sixth Week, p.. Placenta; c.i.a., common iliac artery; c.i.v., common iliac vein; 
 u., ureter; d.p., Douglas' pouch; ii./., vaginal fornix; ^.c.Z., posterior cervical lip; i.o., in- 
 ternal os; e.o., external os; r., rectum; a.l., anterior lip; v., vagina; i.v., internal iliac 
 vein; u.l.l., umbilical lateral ligament; u.a., uterine artery; b., bladder; ur., urethra. — 
 (Tandler and Halban.) 
 
 full term, the base of the triangle corresponding to the pectineal line, and its 
 apex to the horn of the uterus (Fig. 159). After delivery the ligaments slowly 
 regain their position in the pelvis. Hence the ureters have no fixed relation 
 to the broad ligaments in the latter part of pregnancy, because the ureters do 
 
PROPERTIES OF THE UTERUS. 
 
 Ill 
 
 not undergo the same displacement during gestation, (b) The utero-sacral 
 ligaments are attached, in the latter part of pregnancy, to the first, instead of 
 to the third or fourth, sacral vertebra, (c) The round ligaments by the growth 
 of the uterus are drawn up. above the pelvic outlet. 
 
 13. Properties. — (a) Sensibility: The sensibility of the uterus undergoes 
 very little change. The cervix in the non-pregnant state may sometimes even 
 be cauterized without much discomfort to the patient. But the sensibility varies 
 
 =^ri\ 
 
 Fig. 158. — Topography of the Uterine Artery and Ureters in Pregnancy at the 
 Thirty-sixth Week. — Same as Fig. 157 with upper portion of left uterine wall and 
 a portion of the peritoneum removed, d.p., Douglas' pouch; l.s.u., lower segment of 
 uterus; v.f., vaginal fornix; c.c, cervical canal; v., vagina; h.a., hypogastric artery; ur., 
 ureter; i.s.a., internal spermatic artery; i.s.p., internal spermatic plexus; e.i.a., exter- 
 nal iliac artery; u.a., uterine artery; e.i.v., external iliac vein; u.l.l., umbilical lateral 
 ligament; v.h.a., vesical branch of uterine arterv; b., bladder; u., urethra. — {Tandler 
 and Halban.) 
 
 in accordance with its cause; e. g., forced dilatation of the cervix is quite painful. 
 The body, although somewhat less sensitive than the cervix, is not entirely insen- 
 sible, for pain is caused by the contractions of labor, or by the introduction of a 
 sound or hand. Even fetal movements are painful to some women, {b) Irrita- 
 bility: This property also differs in various subjects. Irritability of the uterus, 
 when excessive, is probably of pathological origin The slightest cause in some 
 women — a misstep, for example — may cause abortion; while others may ride to 
 hounds with no injurious results, [c) Contractility: The muscle-fibers exhibit 
 
112 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 contractility, which consists in a shortening of the fibers followed by relaxation. 
 Contractions occur throughout pregnancy, and are usually painless; they promote 
 the uterine circulation and help to fix the position of the child. 
 
 14. Thickness of the Walls. — The great increase in the size of the uterine 
 cavity is not due to the mechanical pressure of the growing ovum, but to the 
 hypertrophy of the walls themselves. If the former cause obtained, the pregnant 
 uterine walls would be much thinner than those in the non-gravid state. In the 
 first three months the walls increase a little in thickness, owing to the rapid 
 development of the muscular and vascular systems; at the fifth month they 
 are about normal in thickness (Fig. 133), and at term they are of a thickness 
 about equal to that of the non-pregnant parietes, although a trifle thicker at the 
 placental site; and much thinner in the lower uterine segment, the thickness thus 
 
 varying at different points 
 (Fig. 137)- 
 
 15. Topographical Rela- 
 tions AT Term (Fig. 160). — 
 The topographical relations of 
 the intestines are worthy of 
 note. They are always above, 
 behind, and at the sides of the 
 uterus, thus giving no reson- 
 ance over the anterior abdom- 
 inal wall. In front of the uter- 
 us are the vagina, the posterior 
 surface of the bladder, and the 
 internal surface of the anterior 
 abdominal wall. Now and 
 then, as an exception to the 
 statement previously made, 
 one or more coils of intestine 
 intervene between the uterus 
 and the abdominal wall. Be- 
 hind, the uterus is in relation 
 with the rectum, the sacro- 
 vertebral articulation, the ver- 
 tebral column, the mesentery, 
 and a mass of intestines ; on the 
 right, with the corresponding 
 side of the pelvic excavation, the iliac vessels, the psoas muscle, caecum, and right 
 abdominal wall; on the left, with the corresponding part of the pelvis, the iliac 
 vessels, the aorta, the sigmoid flexure, the psoas muscle, and a mass of intestines 
 which separate the uterus from the left lateral abdominal wall. The fundus is 
 in relation with the transverse colon, a part of the stomach, the anterior margin 
 of the liver, the ensiform cartilage for a time, and the lower floating ribs. The 
 ovaries and Fallopian tubes are close to the sides of the uterus, at a point cor- 
 responding to the junction of the upper and middle segments. When pregnancy 
 is drawing to a close, a large part of the anterior uterine surface is in contact 
 with the abdominal wall, while its lower surface rests against the posterior part 
 of the symphysis pubis. The posterior surface leans against the spinal column; 
 the large intestines cover the fundus, while the small intestines are forced to 
 both sides. 
 
 5, Bladder, — In early pregnancy the bladder is not so capable of expanding 
 
 Fig. 159. — Broad Ligaments of the Pregnant 
 State. Pregnant uterus at the thirty-sixth week. 
 —{Polk.) 
 
BLADDER. 
 
 113 
 
 in an antero-posterior direction, and so the distention takes place laterally. 
 In the displacements of the uterus, which are so frequently seen in preg- 
 nancy, the bladder follows the uterus. As the uterus a^icends in its growth, 
 
 Fig. i6o. — Topography of the Uterus at the Fortieth Week. Right lateral obliquity 
 and axial torsion from left to right of the uterus are present. — (From nature.) 
 
 therefore, the urethra elongates, and in certain uterine displacements may 
 become partially or completely occluded, thus leading to overdistention of the 
 bladder, paralysis of its musculature, decomposition of the retained urine, and 
 
114 PHYSIOLOGICAL PREGNANCY. 
 
 cystitis. If the uterine displacement is not corrected, there may result dis- 
 astrous vesical troubles, the lining membrane may be cast off in shreds, or a 
 cast may be thrown off; even the muscle-layer may contribute to the general 
 disturbance. As the bladder accompanies the uterus in its upward growth, 
 the orifice or bulb of the urethra is elevated and hidden behind the symphysis 
 pubis, and it is consequently more difficult to introduce a catheter. The canal 
 also becomes more curved, so that a curved male catheter is used with more 
 facility than the straight female instrument. The dragging upon the bladder 
 by the initial prolapse of the uterus, together with the subsequent (third month) 
 pressure of the latter when anteverted, diminish the size of the bladder, causing 
 frequency of micturition. At times, when the bladder is full, a simple sneeze 
 or cough will cause involuntary discharge of urine. Vesical tenesmus may 
 also annoy the patient, particularly during the first three months, before the 
 uterus rises; and also during the last fortnight of pregnancy, after it has fallen. 
 
 6. Ureters. — In the latter part of pregnancy the ureters do not, as in the 
 non-pregnant state, follow the pelvic wall to the ischial spines; but, having 
 crossed the brim near the bifurcation of the common iliac artery, they accom- 
 pany the internal iliac artery. They leave the pelvic wall about on a level with 
 the brim, pass beneath the broad ligament on the same level, and downward, 
 forward, and somewhat inward, about midway between the pelvic wall and 
 the utero-vaginal junction ; and approach closely the anterior wall of the vagina, 
 entering the base of the bladder about one inch below the cervix, and about 
 two inches below the spine of the pubis (Polk) (Tandler and Halban) (Figs 
 156, 157, and 158). 
 
 7. Rectum. — The rectum is apt to be loaded during pregnancy. This 
 constipation is not so much due to the local uterine pressure, as to diminished 
 peristalsis of the intestinal tract. During the early part and the last two weeks 
 of gestation, constipation may alternate with diarrhea, from the irritation caused 
 by the descent of the uterus. From interference with the blood-supply, hemor- 
 rhoids may develop in the anus and rectum. 
 
 8. Lower Extremities. — In the later months of pregnancy, oedema and vari- 
 cose venous enlargements are often found, due to the obstruction to the return 
 circulation (Part III). Numbness, neuralgia, pains, cramps, and difficulty 
 in walking may all result from the pressure of the uterus upon the sacral plexus. 
 
 9. Pelvic Joints. — The inter-articular cartilages, especially that of the sym- 
 physis, become softened and hyperemic, and more movable. The pelvic liga- 
 ments also participate in the swelling and softening, and the synovial mem- 
 branes are increased in size and said to be distended with fluid. Thus the com- 
 ponent parts of the joints are pushed apart. Occasionally a case is so extreme 
 that it is some time before the normal power of walking returns. The move- 
 ment of the coccyx on the sacrum is important. This permits a bending back 
 of the coccyx during labor, thus lending an efficient aid to the process, for the 
 antero-posterior diameter of the pelvic outlet is materially increased (see Physio- 
 logical Labor). 
 
 10. Breasts, — Intimate sympathetic relations exist at all times between the 
 breasts and the pelvic organs. Very early in pregnancy, usually about the 
 second month, the mammae increase in size and become tender. This growth 
 continues during pregnancy, and consists in the increase of connective and 
 glandular tissues and fat. Blue veins become prominent and course over the 
 breasts. Permanent strics appear at any time after the sixth month, due to 
 stretching of the cutis vera, which permits the subcutaneous fibrous tissue to 
 glisten through (Fig. 161). The nipples also enlarge and become sensitive. 
 
GENERAL PHENOMENA. 115 
 
 Their power of erectility is also increased. They are often covered with small 
 branny scales. The areolce become much enlarged, and darker in color from 
 a deposit of pigment. This varies in degree with the complexion of the patient. 
 In blondes it is sometimes scarcely perceptible, while in brunettes a great part 
 of the breast may be involved. The areola, in addition to becoming dark, grows 
 moist and swollen, while the series of tubercles increase in size in it around the" 
 nipple. Montgomery believes them to be closely connected with the lactiferous 
 ducts, which can sometimes be traced to their summits where they open. These 
 also increase in size and number with the progress of pregnancy. Outside the 
 primary areola, in the later months of pregnancy, a secondary circle appears, 
 called the secondary areola. This is composed of light spots scattered all 
 around the periphery of the areola, which has shaded off from the deeper tones 
 near the center. This change, too, is more marked in brunettes. Even as 
 early as the third month, pressure on the breasts may force out a drop of 
 serous-looking liquid. On microscopic examination milk and colostrum glob- 
 ules will be detected, the latter being desquamated epithelial cells of the glands 
 filled with oil-globules (Fig. 6). 
 
 GENERAL PHENOMENA. 
 
 1. Digestive System. — Nausea and vomiting are common disturbances in 
 pregnancy. They are of all grades, from one simple attack at the time the 
 woman first raises her head from the pillow, to repeated and severe vomiting 
 spells, which occur from time to time during the day, and even in the night. 
 These attacks sometimes begin with conception; more commonly, however, 
 about the sixth week, lasting, as a rule, until the fourth month. The assump- 
 tion of the erect position seems to cause this nausea, probably on account of the 
 extra congestion brought on in the uterus by this position, thus increasing 
 its irritability. These symptoms may result from various conditions of the 
 stomach or uterus, though the common and probably correct explanation 
 of the milder variety is that the uterine fibers are stretched, and the 
 nerves consequently irritated. (See Toxemia of Pregnancy.) Gastric in- 
 digestion may also occur, causing acidity, flatulence, heartburn, eructations, 
 etc. The intestines seem to lack their normal peristaltic power, and that, 
 together with the pressure of the growing uterus, renders constipation a 
 common ailment of pregnancy, and one which should be relieved in order to 
 prevent overburdening the kidneys. Diarrhea and excessive flatulence are 
 at times not uncommon. The former may be of nervous origin, due to the 
 mechanical irritation of the intestines by the growing uterus. Intestinal in- 
 digestion is also very common, and may give rise to severe cramps. The ap- 
 petite is apt to be capricious in early pregnancy, though it may change and 
 become ravenous. There may be curious morbid cravings for various sub- 
 stances, such as clay, chalk, slate-pencils, certain vegetable acids, etc.; even dis- 
 gusting articles may come into the category. 
 
 2. Heart. — The existence of hypertrophy of the left ventricle has usually 
 been taught as a physiological change in pregnancy to meet the extra demands 
 made on the organism by the complex vascular arrangement of the pregnant 
 uterus. The right ventricle and the two auricles were not believed to participate 
 in this hypertrophy. Alfred Stengel and W. B. Stanton, of Philadelphia, how- 
 ever, controvert the old French notion that the heart becomes hypertrophied 
 during pregnancy. By a series of carefully made tracings and readings of instni- 
 ments^devised for the measurement of blood-pressure, they show the correctness 
 
116 PHYSIOLOGICAL PREGNANCY. 
 
 of Gerhardt's idea that the growth of the fetus, by pressing up the diaphragm, 
 forces the apex of the heart upward and outward, and that this dislocation 
 has been misinterpreted as a sign of hypertrophy. The tracings in twenty- 
 six cases with careful measurements show this dislocation, which disappears 
 after parturition. There is, however, a shght irregularity in the contour of 
 the upper right margin of the heart, indicative of a slight hypertrophy of the 
 right conus arteriosus. The murmurs which are heard in primigravidse are 
 probably the result of a slight overaction of the right heart. No constant 
 changes in blood-pressure could be demonstrated. 
 
 3. Lungs. — The mother has to provide for the nourishment of her child 
 and herself during pregnancy, therefore an extra quantity of blood must not 
 only be circulated but purified. In this process the elimination of carbonic 
 acid gas must be increased. By mechanical pressure of the growing uterus 
 the diaphragm is forced upward, lessening the longitudinal diameter of the 
 respiratory space, although the lower thorax is somewhat broadened. This 
 decrease in breathing space causes a certain amount of dyspnea, from the time 
 of the beginning till the last weeks of pregnancy, when the uterus sinks again, 
 and respiration and circulation are carried on with greater ease. In the early 
 months cough and dyspnea, from sympathy, may cause a derangement of the 
 respiratory organs, while the same is later caused by the growing uterus. These 
 phenomena are most common in twin pregnancies, or in dropsy of the amnion. 
 
 4. Liver. — Tiny fatty globules occur in the cells of this organ, varying in 
 size from a pin's head to a millet-seed. De Sinety believes this change to be 
 particularly associated with lactation, and to disappear after that period. The 
 liver is also enlarged, as are the spleen and lymphatic glands, both the latter 
 showing the same fatty changes. The enlargement of the spleen is due to the 
 important relation existing between it and the quantitative change in the 
 circulating blood. (See Toxemia of Pregnancy.) 
 
 5. Nervous System. — The changes are purely junctional, and disappear 
 quickly after delivery. The nervous system becomes more impressionable. 
 The changes in the special senses are chiefly characterized by increased ex- 
 citability. The list of reflex nervous phenomena is manifold, and they are even 
 seen, in a relatively slight degree, in young women at the time of ovulation and 
 the beginning of menstruation. Much more will they be excited by the great 
 changes taking place in the maternal, organism in pregnancy. 
 
 Psychical Changes. — The disposition is in some cases entirely altered 
 for the time being. Women previously amiable become peevish, fretful, irritable, 
 and overanxious about their health and the condition of the offspring; and 
 look forward with great dread to the pangs of labor. Others are affected in 
 the opposite way, and become buoyant- in spirits and unusually cheerful. This 
 difference seems to depend largely on the intensity of the desire on the part of 
 the mother for a child. The state of despondency which is so common, espe- 
 cially in the first part of pregnancy, may lead to extreme melancholia and even 
 develop into mania or dementia. This condition is seen particularly in patients 
 of an intensely neurotic organization, in those with an hereditary taint of in- 
 sanity, or with a history of hysteria or alcoholism. It may also follow severe 
 mental shock in pregnancy. Unhappy marriages are also a fruitful cause of 
 mania in gestation. Hysteria in pregnancy offers an excellent illustration of 
 the fact that the gravid state accentuates any defect, either physical or mental, 
 in the patient. It was formerly thought that pregnancy exerted a beneficial 
 effect on a hysterical woman, but this is erroneous. However, after its occur- 
 rence the patient should be carefully watched and guarded. The physician' 
 
BLOOD; URINE; SKIN. 117 
 
 should encourage her, and as is the case with the insane, special attention should 
 be paid to the nutrition of the sufferer, and if necessary forced feeding should 
 be instituted. Again, the patient should be treated with perfect frankness, 
 and no deceit attempted. -A careful physical examination before labor often 
 gives the patient a feeling of confidence in her adviser. 
 
 6. Blood. — Many conflicting views concerning the blood changes in preg- 
 nancy have existed. The whole quantity is increased. It is generally agreed 
 that there is a slight leucocytosis, but as to the increase or decrease in the number 
 of red blood-corpuscles, there is still a dispute. Many authors believe their 
 proportion to be decreased, but Ahlfeld, quoting the work of Reinl, Schroder, 
 Ingerslev, Fehling, Mayer, Wild, Mochnatscheff, and Frommel, declares that they 
 are increased, as is the liquid element of the blood. The number of white cor- 
 puscles, as has been indicated, are also slightly increased. The blood is deficient 
 in albumin, but increased decidedly as to its fibrin element, as well as extractive 
 matters. This fact explains the frequency of thrombotic affections in connection 
 with pregnancy and delivery. This hyperinosis is increased also after labor, 
 by the great quantity of effete matter thrown out into the circulation of the 
 mother, to be disposed of by her emunctories. The blood of the pregnant woman 
 is generally in a state more like that in anemia than plethora, and treat- 
 ment should be applied accordingly. Objections to the anemia theory have 
 been raised, on the ground that pregnancy is a physiological, and not a patho- 
 logical condition. This is ideally true, but owing to the influence of many 
 factors, such as civilization, climate, diet, and others, it must be admitted that 
 the pregnant woman is seldom in a state of perfect health ; that her condition 
 leans toward anemia and poverty of blood, and must be considered and treated 
 accordingly. 
 
 7. Urine. — As to the frequency of albuminuria in pregnancy, authorities 
 differ, as well as to the amount of albumin commonly present; some declaring 
 the percentage to reach 20 or 30. In physiological albuminuria there are no 
 tube casts, nor any morbid symptoms. Albuminuria is far more common in 
 labor than in pregnancy, and its existence is explained by the theory of renal 
 anemia caused by the reflex vasomotor spasm of the renal arteries, resulting 
 from the uterine contractions. It may occur early, before there is any possi- 
 bility of renal venous stagnation from pressure, and it is then the result purely 
 of reflex irritation. The intimate relation between the nerve ganglia of the 
 pelvis and the venous supply of the kidney would explain this. The urine 
 exhibits both quantitative and qualitative changes. The amount excreted in 
 twenty-four hours is increased in quantity and decreased in specific gravity, 
 due to the hydremic condition and the high arterial tension. There is an in- 
 crease in the chlorides, and the phosphates and sulphates are decreased, on 
 account of their use in the development of the fetus. Chalvet and Barlemont 
 found a decrease also in the urea, uric acid, creatin, and creatinin; these may 
 also pass over to the fetus (Lehmann and Donne). (For Albuminuria and 
 Pregnancy-kidney see Part III.) 
 
 8. Skin. — The functions of the glands of the skin — sebaceous, sweat, and hair 
 follicles — are increased in gestation. Pigmentary spots over the body are com- 
 mon. Patches of yellowish-brown color over the face are known as chloasma 
 or the "mask of pregnancy." The abdomen and breasts are also darkly pig- 
 mented in areas. The lineae albicantiae are very marked. Many women will 
 have on the abdomen a brown area of about two fingers' breadth, extending 
 from the mons veneris to the umbilicus, which it sometimes surrounds, and 
 beyond to the xiphoid cartilage. This band is more distinct below than above 
 
118 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 -3?<i|| 
 
 the navel (Fig. i6i). The circle around the latter is known as the "umbilical 
 areola" (Fig. i6i). The mammary areolae, both primary and secondary, have 
 been described. These pigmentations undergo many variations in extent and 
 degree in different patients. Brunettes show them more plainly than blondes. 
 The pigmentation of the vulva, as a sign of early pregnancy, has also been 
 referred to. These deposits seldom disappear entirely, but they are less after 
 labor. Abdominal striae, or silvery streaks or white lines, are seen on the abdom- 
 inal wall as the result of the first pregnancy ; and it is not uncommon to observe 
 the formation of new ones in subsequent pregnancies (Fig. i6i). They may 
 
 also be seen on the hips, thighs, and 
 breasts (Fig. i6i). These markings 
 are at first of a pinkish or bluish-red 
 tint, but after parturition they be- 
 come white or pearl-colored. They 
 are due to the partial] rupture and 
 atrophy of the connective tissue of 
 the deep layers of the distended skin. 
 They are not peculiar to pregnancy, 
 but occur even on men after the skin 
 has been subjected to much stretch- 
 ing, as in ascites, etc. The skin -cover- 
 ing the umbilical depression, in the 
 first three months of intrauterine ges- 
 tation, is drawn inward and down- 
 ward, by the traction on the urachus, 
 the ligament following the descent of 
 the bladder occasioned by the early 
 sinking of the uterus. The navel now 
 presents a pit or depression. This 
 causes a dragging sensation ; when the 
 uterus begins to rise out of the pelvis, 
 the navel resumes its former appear- 
 ance. During the fourth, fifth, and 
 sixth months the depression becomes 
 progressively shallower, till at the 
 seventh it is on a level with the skin, 
 the ring being at the same time dilated 
 so as to admit the end of the finger. 
 During the last two months the um- 
 bilicus may actually form a protuber- 
 ance, and this condition is known as 
 "pouting of the navel." Not in- 
 frequently, if the woman overexert herself, an umbilical hernia will be formed. 
 9. Gait. — The gait of a pregnant woman undergoes change, for in order to 
 preserve the center of gravity, the head and shoulders must be thrown back- 
 ward. Short women show this change most markedly. 
 
 10. Delay of Bony Repair. — On account of the drain by the fetus on the 
 mother's osseous elements, fractured bones unite slowly. 
 
 11. Temperature. — The temperature in pregnancy remains unchanged. 
 Some authorities, however, believe it to be lower in the morning than later 
 in the day. 
 
 !> 
 
 Fig. i6i.^Pregnancy at the Thirty-eighth 
 Week showing Stride and Pigmentation 
 OF Thighs, Abdomen, and Breasts, and 
 Right Lateral Obliquity of the Uter- 
 us. — (From author's photograph at the Emer- 
 gency Hospital.) 
 
THE DIAGNOSIS OF PREGNANCY. 119 
 
 111. THE DIAGNOSIS OF PREGNANCY. 
 
 Importance. — The importance of expert diagnosis in cases of suspected 
 pregnancy is very apparent. There are no mistakes in a physician's experience 
 so hard to hve down as those made in this department of medicine, and none 
 that excite harsher criticism, or greater ridicule for the diagnostician. Apart from 
 these less important considerations, it must be remembered that the knowledge 
 of the existence of pregnancy is often of the greatest importance to the life of 
 the patient, both in the field of medicine and that of surgery. A physician can 
 sometimes render incalculable service by being able skilfully and honestly to ex- 
 clude the possibility of pregnancy; and, on the contrary, he can do great harm 
 
 "fw^lj^^'ljiy" 
 
 Fig. 162. — Position of the Fingers for Vaginal Examinations and Manipulatioms. 
 
 — (Photograph.) 
 
 and cause much misery by expressing the opposite opinion in a case innocent 
 of this condition, the opinion being based on a careless or ignorant interpreta- 
 tion of the signs presented. The medico-legal value attaching to this question 
 is often important. 
 
 A number of symptoms and signs taken together give certain evidence of 
 the presence of pregnancy; and single signs, especialty in the latter part of preg- 
 nancy, render the diagnosis probable or even positive. The physician, how- 
 ever, will always do well to be reserved in the expression of his opinion, if there 
 is any doubt as to the condition. The diagnosis depends upon the physician's 
 ability to group the symptoms in the order of their importance, and upon his 
 familiarity with all the methods of examination. The difficulties of diagnosis 
 
120 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 will be considered later, under the head of differential diagnosis. Mistakes 
 should be avoided by the greatest care in the details of the examination. With 
 all these precautions, there are on record numerous cases which exemplify the 
 striking errors of eminent specialists. 
 
 The physical signs are of far more importance and value than the symptoms, 
 and are obtained by means of sight, touch, and hearing. There is much room 
 for deception in the patient's account of herself, for she may intentionally or 
 unintentionally misrepresent one or all of her symptoms. But the informa- 
 tion which is obtained by inspection, palpation, percussion, and auscultation, 
 lacks the uncertain element always present in the personal history, and gives 
 data that can be relied upon. Upon the period of the pregnancy will depend 
 to a certain extent the satisfactory results of the examination. For the prepara- 
 tion and posture of the patient for the examination see Obstetric Examina- 
 tion. 
 
 Classification. — The symptoms and physical signs of pregnancy may be 
 
 Fig. i63.^Right and Left Halves of a Frozen Section of a Uterus at Two and a 
 Half Months, showing Changes in Shape and Density of the Uterine Walls 
 AND Thick Decidua. — (After Pinard.) 
 
 conveniently classified as: (i) Uterine; (2) vaginal; (3) abdominal; (4) mam- 
 mary; (5) fetal; (6) sympathetic and reflex; (7) due to pressure and congestion; 
 (8) cutaneous; (9) individual and subjective. 
 
 I. Uterine. — (i) Cessation of Menstruation. — This, as a general rule, 
 is the first warning of pregnancy to women who have been exposed to impregna- 
 tion. It is not a perfectly trustworthy symptom, for it may occur in various 
 diseases and conditions. However, when occurring in healthy women who 
 have previously menstruated regularly, it is strongly presumptive of pregnancy, 
 and it is of great practical value, as it probably offers the most reliable datum 
 for predicting the date of confinement. Nevertheless, certain errors must 
 be guarded against in relation to this symptom, for various chronic diseases, 
 such as tuberculosis, anemia, syphilis, and some acute affections, such as diph- 
 theria, pneumonia, and dysentery, may cause a cessation of the menstrual flow, 
 either permanently or temporarily. Change of climate ; exposure to cold; mental 
 emotions; general debility; excessive desire to become pregnant, as in the newly 
 
THE DIAGNOSIS OF PREGNANCY. 
 
 121 
 
 married; or a fear of becoming so in the unmarried who have exposed them- 
 selves to impregnation — all these causes may be instrumental in bringing about 
 a cessation of the menses. Pregnancy may occur in cases in which menstruation 
 is absent, as in women during lactation; while it has been known to occur in 
 young girls before this function was estab- • 
 lished. A few authentic cases are recorded 
 of the occurrence of conception after the 
 climacteric; and, again, of the continuance 
 of the menstrual periods during pregnancy, 
 or of what is thought to be menstruation by 
 the patient. At the same time there may 
 be hemorrhages due to pathological condi- 
 tions of the internal genital tract, as from 
 the vagina, mucous membrane of the cer- 
 vix, decidua, chorion, polypi, or placenta 
 praevia. If menstruation pure and simple 
 does occur during pregnancy, it may easily 
 be explained by the anatomical condition 
 of the growing uterus with its contents. 
 (See Development of the Ovum, page 46.) 
 (2) Changes in Volume, Shape, and 
 Position. — In palpating the uterus in 
 search of the signs of pregnancy, the bi- 
 manual or conjoined method is preferable to simple palpation with one hand, or 
 vaginal touch, as it is called ; and of the bimanual methods, the abdomino-vaginal 
 is most useful, and most often used, but the abdomino-rectal is occasionally of 
 value, especially in primigravidas. The physical signs arising from the progres- 
 sive growth of the uterus, causing alterations in volume, shape, and position 
 
 Fig. 164. — First Method of Elicit- 
 ing Hegar's Sign of Pregnancy. — 
 (Sonntag.) 
 
 Fig. 165. — Second Method of Eliciting 
 Hegar's Sign of Pregnancy. — {Sonntag.) 
 
 Fig. 166. — Third Method of Eliciting 
 Hegar's Sign of Pregnancy. — (Sonn- 
 tag.) 
 
 of the organ, have already been described under "The Local Changes Produced 
 by Pregnancy," page 91, and famiHarity with these changes should be acquired 
 by the student. At the same time, other causes of uterine enlargement may 
 simulate pregnancy, as subinvolution, inflammation of the uterus and peri-uterine 
 
122 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 Fig. 167. — Position of the Two Hands in the Bimanual Examination for the Diag- 
 nosis OF Pregnancy. 
 
 Fig. 168. — Bimanual Examination with 
 THE Hand on the Fundus and One 
 Finger in the Left Lateral Vaginal 
 Fornix. 
 
 Fig. i6q. — Bimanual Examination with 
 the Hand on the Fundus and a 
 Finger in Each Vaginal Fornix. 
 
THE DIAGNOSIS OF PREGNANCY. 123 
 
 tissues, and intramural tumors of the organ. (See Differential Diagnosis of 
 Pregnancy.) 
 
 (3) Changes in Consistency. — (a) Progressive softening of the cervix, which 
 begins at the external os,-and gradually extends, until by the end of pregnancy 
 the whole cervix is included in a velvety softness due to serous infiltration. 
 Beginning softening can often be detected as early as the second or third week; 
 on this change Goodell founded the rule that, when the cervix is as hard as the 
 tip of one's nose, pregnancy presumably does not exist; but if it be as soft as 
 one's lips, pregnancy is probable. (6) Softening and compressibility of the lower 
 uterine third constitute Hegar's sign. This is of great value, and has been ob- 
 served by the sixth or eighth week. It consists in alteration in the consist- 
 ency and shape of the region of the uterus situated just above the cervix — a 
 change that is most striking in the middle division of the lower uterine third. 
 This part of the uterus seems at times hardly thicker than ordinary cardboard, 
 and it would appear almost as if the fundus and the cervix were separate tumors. 
 The shape is also changed, the lower uterine third widening abruptly above 
 the cervix, and not gradually, as in the normal pear-shaped uterus. These 
 alterations are far more difficult to recognize in women who have already borne 
 one or more children, but when well marked are absolutely indicative of a 
 pregnant uterus. The detection of these changes requires a certain degree of 
 skill in the performance of the bimanual examination, and also of familiarity 
 with the sensations communicated to the finger by the non-pregnant uterus 
 of women who have never borne children, by the non-pregnant uterus of women 
 who have borne several children, and also by the uterus altered by certain 
 pathological conditions. Method of examination: (a) In a patient whose abdom- 
 inal walls are lax and thin and whose vagina is roomy, the two fingers are intro- 
 duced into the vagina, and passed high up behind the cervix, w^hile the other 
 hand presses down into the abdomen from above and behind the pubes (Fig. 
 167). (b) But if the fundus should be decidedly antefiexed, the vaginal finger 
 should be passed up in front of the cervix, while the external hand presses down 
 the fundus (Fig. 167). (c) Where the favorable conditions of lax abdominal 
 parietes and capacious vagina are not present, the index-finger is passed into the 
 rectum, while the thumb is inserted into the vagina in front of the cervix. The 
 other hand, in the meanwhile, exerts pressure on the abdomen behind the 
 pubes. (d) Still another method is feasible: with the internal hand in the same 
 position as in the last method, the external hand presses the fundus uteri down- 
 ward. Sometimes the cervix is pulled down by a tenaculum. Between the 
 second and fifth months of pregnancy 30 per cent, of the cases may be recognized 
 by this sign. Anesthesia is rarely required in order to conduct these examina- 
 tions. There are diseased conditions of the wall of the uterus in which this sign 
 cannot be obtained, even though pregnancy exists, (c) Consistency of body of 
 uterus. Pregnancy changes the rigid, firm, inelastic condition of the non-pregnant 
 uterus, to an elastic, resilient state which increases with the advance of preg- 
 nancy, until the fetus is contained in a flexible, elastic-walled cavity. The 
 peculiar sensation imparted by a uterus enlarging from pregnancy is most char- 
 acteristic (Fig. 163). (See Local Changes Produced by Pregnane}'.) 
 
 (4) Intermittent Contractions — Braxton Hicks's Sign. — These may be 
 detected by palpation as early as the fourth month. If the hand is placed 
 in full contact with the abdominal contour of the uterus, friction and pressure 
 being absent, and retained there for from five to twenty minutes or less, the 
 gradual relaxation or contraction of the uterine musculature will be felt. These 
 contractions as a rule occur every five or six minutes, while the duration of each 
 
124 PHYSIOLOGICAL PREGNANCY. 
 
 contraction is from two to five minutes. Braxton Hicks says that "if an abdom- 
 inal tumor thus changes in density and hardness we may be sure that the tumor 
 is the uterus." But Lanier has shown that the same sensations of intermittent 
 contractions may be obtained from a distended bladder. Soft fibroids of the 
 uterus also give these sensations, as well as do the uterine efforts to expel blood- 
 clots, polypi, or retained menses. However, when taken in connection with 
 the other signs of pregnancy, this sign is of great value. 
 
 (5) Uterine Murmur, Souffle, or Bruit. — This sound was also wrongly 
 called the " placental souffle " or " murmur," or bruit placentaire, by those who 
 regarded it as due to blood rushing through the placental sinuses. Again, it 
 has been called abdominal souffle by others, who think it due to pressure of 
 the pregnant uterus upon the large abdominal vessels. The sound is a single 
 murmur, synchronous with the first sound of the maternal heart. Its quality 
 varies, sometimes being gentle, murmuring, blowing or musical, resembling 
 very much the sound produced by pronouncing "voo" in a low tone. At other 
 times it is harsh, loud, and scraping; while again it may be sibilant, or sonorous. 
 Its rhythm may be continuous and regular, corresponding with the mother's 
 pulse, or it may be distinctly irregular. After once being heard, it may dis- 
 appear for a few minutes or for several days, and its position is very apt to shift. 
 Sometimes it will persist in a circumscribed spot; again in two spots, one on 
 either side of the uterus; or, again, it will be diffused over the whole anterior 
 abdominal region. The weight of authority is to the effect that this sound 
 originates in the uterine blood channels. The murmur has been observed several 
 days after the birth of the placenta, and no legitimate proof of its origin in 
 the abdominal vessels has been offered. Aside from its variation in position, 
 it frequently varies in duration, intensity, tone, and pitch. It is most frequently 
 detected at the lower part of the abdomen, and this would of necessity be the 
 case in the early part of gestation. Feebleness or death of the fetus has no 
 effect upon it. Only an expert can recognize it before the sixteenth week. 
 It is not a positive sign of pregnancy, for similar sounds may be heard in ovarian 
 or uterine tumors of large size. In labor it is stronger at the beginning of a 
 pain, ceasing altogether at its height, and returning again as the pain declines. 
 
 (6) Uterine Fluctuation — Rasch's Sign — may be detected as early 
 as the second month of pregnancy. As in ballottement, two fingers of the 
 left hand are introduced into the anterior vaginal fornix, while the right hand 
 firmly grasps the fundus. Tapping by the fingers of the external hand will 
 transmit an impulse to the internal fingers, the wave being transmitted through 
 the liquor amnii. This sign, considered by many to be of diagnostic value, must 
 not be confounded with Hegar's. 
 
 (7) Asymmetry of the Corpus Uteri. — The fact has often been noted that 
 at a very early period of pregnancy the corpus uteri is asymmetrical, one side 
 being thicker than the opposite; while the bulging portion is marked off from 
 the rest of the corpus by a furrow (Fig. 163). This bulge may appear upon any 
 portion of the body of the organ. There is also a difference in the density of the 
 two portions, the prominence being dense and firm, while the rest of the corpus 
 feels elastic (Fig. 163). Braun-Fernwald, who has studied this sign with great 
 care, believes that this asymmetry of the uterus is a necessary result of the 
 implantation of the ovum upon one side of the uterine cavity.* Many authori- 
 ties believe that this is the earliest and most constant uterine sign of pregnancy. 
 
 (8) Uterine Pulse. — The claim has been made that the pulse of the 
 uterine artery, which is ordinarily impalpable, may be recognized early in preg- 
 
 *"Wien. klin. Woch.," 1899, No. 10. 
 
THE DIAGNOSIS OF PREGNANCY. 125 
 
 nancy. To elicit this sign the organ should be depressed and the artery felt 
 for high up in the lateral cul-de-sac. 
 
 2. Vaginal. — (i) Purplish Discoloration of the Vaginal and Vulval 
 Mucous Membranes — Jacquemier's Sign: Congestion of the vulval and 
 vaginal blood-vessels causes, as early as the sixth, but frequently not until 
 the twelfth week, first a violet or light blue, and, as pregnancy advances, a 
 purplish or deep blue tint of the mucous membrane (Fig. 7). In the vulval 
 canal the sign is most intense just below the urethral orifice. This is one of 
 the probable signs of gestation. It is true that pelvic inflammation and tumors 
 may produce the sign, but rarely to the degree caused by pregnancy. (2) 
 Increased Secretion: The vaginal discharges are normally increased during 
 pregnancy, coincident with the hypertrophy of the mucous membrane, and a 
 condition may arise in the perfectly healthy pregnant woman which would be 
 known in the non-gravid subject as catarrhal vaginitis. This is especially 
 common in the latter half of gestation. The discharge is whitish and may be 
 profuse enough to alarm the patient. Endotrachelitis may also be the cause 
 of a vaginal discharge during pregnancy. (3) Temperature: The sensation 
 of increased heat in the genitalia is an important sign. It is due to the augmented 
 blood supply to those parts, to the pathological condition of vaginitis, or to 
 congestive diseases of the pelvic viscera. (4) Vaginal Pulse — Osiander's 
 Sign: During and after the middle third of gestation a distinct pulsation of 
 the vaginal arteries, due to local high arterial tension, may be made out; while 
 not a positive sign of pregnancy, this is a probable one, and is of value in con- 
 junction with others. Non-pregnant conditions, as fibroids and pelvic inflam- 
 mations, may give rise to the same sign. 
 
 3. Abdominal. — (i) Progressive Enlargement: In the beginning of 
 pregnancy there is hypogastric flattening, due to the sinking of the uterus from 
 its increased weight. Later the abdomen enlarges, becoming the shape of a 
 pear, with the smaller end downward. The enlargement first becomes notice- 
 able at the fourth month. The tumor is then in the median line, but later tends 
 to the right. The uterus rises about two fingers' breadth every four weeks. 
 At the end of the third month the fundus uteri is about on a level with the top 
 of the symphysis. During the fourth month it occupies the hypogastrium ; 
 at the fifth it is half-way between the symphysis and umbilicus; b}^ the sixth 
 it is at the umbilicus or just above; by the seventh it is half-way between the 
 umbilicus and ensiform cartilage. It reaches the ensiform by the eighth month, 
 where it remains for about two weeks, then sinks a trifle in the last two weeks 
 of pregnancy. It is hardly necessary to state that this is merely a doubtful 
 sign, as abdominal enlargement closely simulating pregnancy may be due to 
 many pathological conditions, such as uterine fibroids, excessive deposition of 
 fat in the abdominal walls, tympanites, ovarian cysts, and other abdominal 
 tumors. (2) Pigmentation (Fig. 161): This, as I have repeatedly demonstrated 
 in the clinic, is in some women entirely absent, thus giving us only a doubtful 
 sign of pregnancy. It has also been observed in cases of ovarian irritation, 
 at the menstrual periods, and in myomata of the uterus. (3) Stri^ (Fig. i6t ) : 
 They give us only an uncertain sign of pregnancy, as they may result from 
 excessive non-pregnant enlargement of the abdomen. They are found even 
 in the male. (4) Abdominal Ballottement: During the middle third of preg- 
 nancy, by placing the hands upon both sides of the abdomen, where the muscles 
 are not too tense, the fetus may be passed back and forth between the two 
 hands by a series of gentle but decided pushes or taps. This is known as " ab- 
 dominal ballottement." A tense, resisting abdominal wall, or one loaded with 
 
126 PHYSIOLOGICAL PREGNANCY. 
 
 fat, will obscure all the signs of pregnancy obtainable by palpation. (5) Fluc- 
 tuation: In the last third of pregnancy, if the palm of one hand be placed upon 
 one side of the abdomen, while the opposite side is lightly tapped, distinct 
 fluctuation may in some cases be elicited. This is naturally an uncertain sign. 
 
 (6) Changes in the Percussion-note and Umbilicus: Percussion should 
 not be neglected in the examination for pregnancy. This method will yield 
 only negative signs before the end of the third month. In practising percussion 
 in early pregnancy, care should be taken not to mistake the flatness produced 
 by a distended bladder for a pathological tumor of the pelvis or abdomen. 
 Generally the dullness of the uterine body can be detected, surrounded on three 
 sides by the tympanitic intestines. Now and then, however, a few intestinal 
 coils will interpose themselves between the uterus and the, anterior abdominal 
 wall, and give a tympanitic resonance in response to tapping. (For changes 
 in the umbilicus, see page 118.) 
 
 4. Mammary. — The physical signs include (i) general enlargement; (2) 
 prominence of the veins; (3) pigmentation, forming primary and secondary 
 areolae; (4) enlargement of the tubercles of Montgomery; (5) prominence, erec- 
 tion, turgescence, and bran-like scales of the nipple; (6) formation of striae; 
 
 (7) secretion of colostrum. The presence of secretion is the most valuable of 
 the foregoing signs, and in primigravidous women it is a probable sign of gesta- 
 tion. In multigravidse it becomes uncertain, though the suppression of milk 
 in a nursing woman has considerable importance in corroborating other signs. 
 Taken alone, these signs are not trustworthy; their absence does not prove 
 the non-existence of pregnancy; they should be supplemented by more positive 
 signs. Uterine or ovarian diseases may be accompanied by many of them, or 
 they may persist a long while after delivery. (See Local Changes Produced 
 by Pregnancy, page 89.) The advantage of mammary changes over other 
 objective signs consists in their early and almost inevitable occurrence, and 
 in the possibility of examining the patient's breasts without rousing her sus- 
 picion. 
 
 5. Fetal. — (i) Quickening: This term arose from the former erroneous 
 notion that at the time when the mother became conscious of the spontaneous 
 movements of the fetus, life was imparted to the fetus. The active fetal move- 
 ments are generally first felt by the mother at the end of the sixteenth week. 
 Although perceived by the patient at such a comparatively late period, they 
 really occur very early in embryonal existence, i. e., as soon as the muscular 
 tissue is sufficiently developed to contract. The commonly accepted idea is that 
 they are first perceived by the mother when the uterus has expanded suffi- 
 ciently to come in contact with the anterior abdominal wall, and thus the fetal 
 movements are transmitted to her sensory nerves. They have been compared, 
 when first felt, to the fluttering of a bird imprisoned in the hand. With ad- 
 vancing gestation these movements increase in vigor, and may even become 
 painful, consisting of sharp, short strokes, or kicks. They greatly increase after 
 fasting, and just before fetal death by asphyxia. They may cease entirely, 
 and the fetus still remain in perfect condition, although their sudden and com- 
 plete cessation is often coincident with the death of the child. In some cases 
 these movements have never been detected by either mother or physician, and 
 yet at term a perfectly healthy child has been delivered. Pathological conditions, 
 such as hydramnios and ascites, may either partly or wholly obscure these motions. 
 This sign, considered as a subjective symptom, is open to many errors, for 
 irregular muscular contractions of the abdominal muscles, the peristalsis of the 
 intestines, especially when the latter are full of gas, or a wandering kidne3^ 
 
THE DIAGNOSIS OF PREGNANCY. 127 
 
 may cause similar sensations. However, some little value attaches to it from 
 the fact that its first occurrence furnishes a certain datum for the calculation 
 of the time of confinement. . When the physician himself feels, or sees, or hears 
 these movements, they constitute a sure sign of the existence of pregnancy, 
 and of the viability of the child. No other movement, normal or abnormal, 
 occurring in the abdomen can ever give a like sensation to the hand of the 
 examiner. After their first detection by the physician, and as gestation ad- 
 vances, they may not only be felt but also seen or heard. Prior to the fourth 
 month, the methods of bimanual palpation, or vaginal stethoscopy, may elicit 
 them occasionally, but after that time abdominal palpation is used. Among 
 these movements should be included fetal hiccough. 
 
 (2) Palpation of the Fetus. — About the middle of pregnancy the 
 uterus will have become so elastic, thinned, and compressible that we are able 
 upon palpation to make out the fetus, which is now large enough to be recognized 
 by the abdominal touch. At the end of pregnancy this is of great value in 
 detecting the various positions of the child. Movements of the fetus may be 
 seen by the eye or felt with the hand. In examining for fetal movements, the 
 palm of the hand is placed upon the abdomen, and steady downward pressure is 
 kept up for some moments. Should the movements not be felt, pressure, or a 
 series of gentle raps with the other hand about the first, will generally suffice to 
 produce them. 
 
 (3) Heart Sounds. — Mayor, of Geneva, in 1818, discovered that upon 
 applying the ear to the abdomen of the pregnant woman the fetal heart sounds 
 could be heard, and thus the most important sign of pregnancy was brought 
 to light. Kergaradec, of Lausanne, ignorant of the discovery of Mayor, an- 
 nounced the same fact three years later, in 1821. The discovery was accidental 
 in each case. Auscultation in obstetrics furnishes the only sign of pregnancy 
 which, in itself, and in the absence of all others, is perfectly reliable; namely, the 
 heart sounds of the fetus. These sounds are first heard about the middle of the 
 fourth month. They consist of two sounds or beats, — a first sound and a second 
 sound. These two are separated by a slight interval, the first sound being the 
 louder, longer, and more distinct; the second often being almost inaudible. 
 The usual simile used in illustration is the ticking of a watch heard through a 
 pillow. While the rapidity of this sound continues the same throughout preg- 
 nancy, the intensity and strength steadily increase. The rapidity and intensity of 
 the fetal heart sounds may temporarily be increased or diminished; thus, the 
 movements of the child may accelerate the pulse several beats per minute, and 
 at the same time increase its intensity. On the other hand, during labor and 
 after the escape of the liquor amnii, the contractions of the uterine walls ma}^ 
 greatly depress the heart, and this fact is one indication for interference in pro- 
 longed or retarded labors. The position, or point of the greatest intensity, of the 
 fetal heart sounds will vary with the position of the child in the uterus. In head 
 presentations the fetal heart is most frequently heard at a point half-way between 
 the umbilicus and the left anterior superior spine of the ilium, the reason for 
 this being that the most frequent position of the fetus is with its back anterior 
 and directed a little to the left side of the mother. The next most frequent 
 site will be on the same level, but upon the right side. In breech cases, on the 
 other hand, the fetal heart is best heard above the umbilicus, on either side 
 of the median line, according to the position of the child, the sound of the heart 
 being naturally heard with greatest intensity at that point where the back of 
 the child touches the uterine wall. Like all vascular sounds, it is transmitted 
 better through solid than fluid media. When the fetal heart sounds are heard 
 
12S 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 distinctly, they furnish an absolute and certain physical sign of pregnancy. It 
 is the surest sign, and is readily recognized after the fourth month. It is entirely 
 beyond the control of the patient. The only other sign of equal value is 
 recognition of the fetus by abdominal or vaginal palpation. The sound of 
 the fetal heart not only makes it positive that pregnancy is present, but also 
 that the child is living. The fact that it is not heard, however, does not nega- 
 tive pregnancy, for the fetus may be dead, or the sounds for a time inaudible; 
 the maternal abdominal walls may be very thick and fat; the fetal back may 
 be posterior; the intestines may be full of gas; hydramnios may be present. The 
 rate of the fetal heart sounds and that of the mother's do not correspond. The 
 fetal heart beats from 130 to 150 times a minute. It is slightly more frequent 
 
 Fig. 170. 
 
 -Internal Ballotement at the Sixth Month. 
 
 Posture. 
 
 Patient is in the Reclining 
 
 in small than in large children. Attempts have been made from this to pre- 
 dict the sex of the child, since males are usually larger than females. When 
 the sounds are distinctly heard, but the uterus is too small to contain a fetus 
 old enough to make them, there is a strong indication of extrauterine pregnancy. 
 (4) Ballottement. — In the latter part of the fourth month, or the first 
 part of the fifth, ballottement may be practised. The preferable position for 
 the patient is reclining, midway between standing and sitting, although either 
 of the latter positions may be assumed (Fig. 170). Ballottement is the earliest 
 of the positive signs, as it may be obtained from the fourteenth or fifteenth 
 week till within six or eight weeks of delivery. In practising ballottement 
 the examining finger is introduced into the vagina and suddenly pushed up 
 
THE DIAGNOSIS OF PREGNANCY. 129 
 
 against the lower portion of the uterus. The impulse thus generated is trans- 
 mitted to the fetus, which bounds upward and then falls back upon the ex- 
 amining finger (Fig. 170). This is a physical sign of pregnancy which, when 
 clearly made out, is infallible; for although an antefiexed fundus, or a calculus 
 in the bladder, or some other pathological conditions, may give rise to very 
 similar sensations, still, in such cases, no other signs of pregnancy will be present. 
 Before the end of the fourth month the fetus is too small to respond to the 
 digital impulse, and after the seventh month the child is relatively too large, 
 so nearly filling the uterine cavity that it cannot be moved about as freely as 
 formerlv. In multiple pregnancies, and in deficiency of the liquor amnii, the 
 
 »-:«»(' 
 
 %k \ 
 
 Fig. 171. — Auscultation op the Fetal Heart with the Phonendoscope. Method of 
 raising the fundus of the uterus upward and forward so as to bring the uterine walls 
 close to the abdominal parietes and thus intensify the fetal heart-sounds. — {From a 
 
 photograph at the Emergency Hospital.) 
 
 sign will be absent for the same reason. Neither shoulder nor breech presenta- 
 tions, as a rule, respond to this test. 
 
 (5) Umbilical Murmur, or Souffle, consists of a slight blowing murmur, 
 synchronous with the fetal heart sounds, and most distinctly heard in their 
 vicinity. The sound can be detected in about 15 per cent, of all the cases of 
 pregnancy, and is thought to be due to pressure upon the umbilical cord, from 
 its coiling, or from some form of compression. Its position varies with the 
 presentation of the child. Its practical value is nil. 
 
 6. Sympathetic and Reflex. — (i) Nausea and Vomiting; Morning Sick- 
 ness. (See Digestive System, page 115.) (2) Sympathetic Disturbances 
 OF THE Nervous System, such as changes in disposition and taste, have no 
 9 
 
130 PHYSIOLOGICAL PREGNANCY. 
 
 value in the diagnosis of pregnancy and have been described under The Phe- 
 nomena of Pregnancy. 
 
 7. Pressure and Congestion. — The neighboring organs are disturbed by the 
 growth and development of the uterus, these disorders depending partly upon 
 hyperemia and partly on mechanical pressure, (i) Bladder: The bladder 
 becomes irritable; during early pregnancy frequerit micturition, incontinence, 
 and vesical tenesmus are common symptoms. In a woman previously free 
 from vesical irritation, this symptom, in conjunction with cessation of men- 
 struation, we have frequently found most valuable, and we would class it as 
 a probable sign. In our experience, persistent vesical irritation is the most 
 valuable of the very early symptoms. (See Bladder, page 112.) (2) Rectum: 
 In the latter months fecal accumulations in the lower bowel cause much irrita- 
 tion and discomfort. (3) Lower Extremities: Sciatica, oedema, and varicosi- 
 ties are frequently observed as the result of pressure. 
 
 8. Cutaneous. — Pigmentation of the forehead and cheeks, in the form of dark 
 brown patches termed chloasmata, or blotches, is found in some pregnant women, 
 especially brunettes. These patches, as well as the dark circles about the eyes, 
 are most uncertain signs, and are found occasionally during menstruation and 
 in ovarian and uterine disease. Pigmentation and striae of the breasts and 
 abdomen have already been classified under Mammary and Abdominal Signs. 
 
 9. Individual and Subjective. — A woman who has borne many children 
 is often better able to tell when she has conceived than is the most skilful diag- 
 nostician. Under these circumstances the truth is reached by individual or 
 idiosyncratic phenomena. Dismissing as entirely untrustworthy the existence 
 of peculiar sensations during the impregnating coitus, there can be no doubt 
 that individual signs may appear within a few days after conception. One 
 woman under these circumstances experiences a characteristic vertigo, another 
 nose-bleed, a third pruritus vulvas, a fourth swelling and tenderness in the veins 
 of the lower extremities (in cases of past puerperal phlebitis). The various 
 sensations experienced have an individuality which is never noticed on any 
 other occasion. 
 
 SUMMARY OF THE DIAGNOSTIC SIGNS OF PREGNANCY. 
 
 The symptoms and signs of pregnancy may be divided into three classes: 
 (I) Doubtful; (II) probable; (III) certain. The first may occur in the male. 
 The second have to do only with the genitals of the woman. The third are 
 produced only by the presence of the fetus. (I) To this class belong all those 
 signs dependent partly on pressure, and partly on blood changes, or alterations 
 in nervous activity. These are nausea, vomiting, fainting, varicosities, oedema, 
 headache, toothache, and backache, also pigmentation of the skin, frequent 
 micturition, and "longings" or "cravings." These signs are almost valueless; 
 save in cases of multiparas, who, never having suffered otherwise from any of 
 these symptoms, have noted a certain syndrome in every pregnancy. In some 
 instances nausea, vomiting, and depressed spirits have occurred almost im- 
 mediately after a fruitful coitus, so that the patient was aware of her condition 
 before the cessation of the menses. (II) The next group proceeding from the 
 female genitalia is of more importance and comprises: (a) cessation of the menses. 
 (b) The changes in the color of the vulva, vagina, and uterus; the palpable 
 pulsation in the vaginal fomices ; the increasing size of the uterus ; the rounding 
 of the external os; and the softening, elasticity, and thinning of the uterus just 
 above the insertion of the sacro-uterine ligaments, (c) The uterine souffle. 
 
THE DIAGNOSIS OF PREGNANCY. 131 
 
 (d) Breast changes, (e) The striae and umbiHcal changes. (Ill) The certain 
 signs are: (a) Mapping out of the fetus. (6) Fetal heart sounds, (c) Move- 
 ment of the child as felt by -the examiner, (d) Umbilical murmur. 
 To recapitulate: 
 
 I. The Positive or Certain Signs are : (i) Mapping out the whole or parts of 
 the fetus by palpation. (2) The fetal heart sounds. (3) Movements of the 
 fetus, active or passive; to be regarded only when confirmed by an experienced 
 observer. (4) Vaginal and abdominal ballottement. (5) The umbilical or funic 
 murmur, in the 10 or 15 per cent, of cases in which it is present, is also a certain 
 sign. 
 
 II. The Probable Signs are: (i) The progressive enlargement of the uterus 
 and its characteristic alterations in shape. (2) The compressibility of the 
 lower uterine segment — Hegar's sign. (3) Intermittent uterine contractions — 
 Braxton Hicks's sign. (4) Changes in consistency of enlarging uterus. (5) 
 Changes in consistency and color of vagina and cervix. (6) Uterine murmur. 
 (7) Cessation of menstruation. (8) Mammary signs —enlargement of breasts 
 and Montgomery's tubercles. (9) Pigmentation and secretion. 
 
 III. The Uncertain or Doubtful Signs are: (i) Changes in size and shape 
 of abdomen as well as pigmentation, strias, fluctuation and changes in the per- 
 cussion note. (2) Sympathetic and reflex disturbances — nausea, vomiting, alter- 
 ations in taste and disposition. (3) Pressure and congestive signs — irritable 
 bladder or rectum, pain, and oedema in lower extremities. (4) Cutaneous signs — 
 chloasmata on the forehead and cheeks and dark circles under the eyes. Pigmen- 
 tation and striae of the abdomen and breasts have already been classified. 
 
 The signs of pregnancy may be classified, finally, according to the time at 
 which they appear. First month : The abdominal changes begin to appear. 
 There is cessation of menstruation. It is early for the manifestation of morning 
 sickness, and for changes in the breasts, though they may take place. The 
 cervix begins to soften from the very first. Second month : Hegar's sign may 
 now be obtained. There is pulsation in the vaginal vault. This month is 
 the ordinary time for the beginning of mammary and gastric changes. Depres- 
 sion of the umbilicus persists, and the uterus sinks, while the abdomen is flat. 
 Third month : The umbilicus is still depressed, and the uterus sunken till the end 
 of this month, when it begins to rise. The softening of the cervix increases 
 in extent. Gastric ^nd mammary changes continue. Fourth month : The 
 uterus begins to rise, consequently the depression at the navel commences to 
 fill out, and the abdomen to become prominent. The breast changes increase, 
 but as a rule the gastric disturbances cease. At the end of the month 
 the heart sounds may rarely be heard. The uterine murmur is present. The 
 patient sometimes feels quickening, and the examiner may detect fetal move- 
 ments, as well as uterine contractions. Fifth month : Normally at this time 
 the gastric disturbances have entirely ceased, and the appetite and digestion 
 are excellent. The abdomen is plainly increased in size, and frequently quick- 
 ening is felt. The mammary changes continue, with the appearance of the 
 secondary areola. Ballottement readily reveals the presence of the fetus and 
 heart sounds are plainly audible. Sixth month : The sounds and motions of 
 pregnancy are all evident. In multigravidae the external os is patulous, ad- 
 mitting a finger-tip. The fundus is about at the level of the navel. Cutaneous 
 striae develop. Seventh month : The external os may now, even in primiparag, 
 admit the finger-tip. The cervix is more elevated in the vagina. The fundus 
 is two inches above the umbilicus. Ballottement is still obtainable. The vaginal 
 part of the cervix is apparently shortened one-half. Cutaneous striae continue 
 
132 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 to develop. Eighth month-: Ballottement is hardly obtainable. The fundus 
 is halfway between the umbilicus and the ensiforai cartilage. The abdomen 
 is much enlarged, and is pear-shaped. The umbilicus may begin to pout at the 
 end of this month, and in multigravidae milk may be secreted. Fetal parts are 
 easily palpable. Ninth month : Ballottement is no longer obtainable, although 
 the other physical signs are all more marked. The fundus, at the end of 
 this month, is almost at the ensiform cartilage. The cervix still seems shorter. 
 The OS is very patulous, especially in multigravidae. The umbilicus protrudes. 
 Tenth month : The physical signs are distinct. At the middle of this month 
 the fundus is at its greatest height. It settles down in the last two weeks, 
 thereby lessening the pressure symptoms, while the os also sinks and the um- 
 bilical prominence decreases. The patient feels lighter and more comfortable. 
 There may, however, be difficulty in locomotion and oedema of the genitals 
 and legs. The vertex is usually engaged in the pelvis in primigravidae and at 
 the inlet in multigravidae. The cervical canal in primigravidae shortens and 
 disappears just before or at term, and in multigravidae several days or even 
 weeks before labor. 
 
 IV. THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 
 
 I. Non-pregnant Enlargements of the Uterus. — (i) Hematometra, usually 
 due to retained menses, is a rare condition; non-appearance of menstruation 
 occurs with imperforate hymen, or obstruction in the cervical canal, and the 
 
 Fig. 172. — -Hematometra. A Non-preg- 
 nant Enlargement of the Uterus. — 
 (Montgomery.) 
 
 Fig. 173. — Hematocolpometra. A Non- 
 pregnant Enlargement of the Uterus. 
 — {MoTitgomery.) 
 
 tumor develops slowly with periodic increase in size (Figs. 172 and 173). (2) 
 Hydrometra may be due to the closure of the external or internal os, or both, 
 with catarrhal discharge from the mucous membrane, which by its accumulation 
 causes enlargement of the uterus. At times a watery fluid accumulates in the 
 
THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 
 
 133 
 
 Fig. 174. — Diffuse Interstitial Myomata. 
 A Non-pregnant Enlargement of the 
 Uterus. — (Alontgomery.) 
 
 uterus; this condition is rare, and is very seldom seen before the menopause. 
 
 (3) Physometra is due to the generation and retention of gas in the uterus. This 
 is, indeed, a tympanites of the letter. When the uterus has reached such a size 
 that it may be percussed, resonance is 
 
 obtained. Sometimes foul-smelHng 
 gas escapes per vaginam, and when 
 the uterus is raised its weight does 
 not correspond with its size, the 
 organ being much hghter than would 
 be supposed from its appearance. 
 
 (4) Pyometra consists in the accumula- 
 tion of pus in the uterine cavity. 
 Hematometra, hydrometra, physo- 
 metra, and pyometra are very rare 
 conditions, while pregnancy is very 
 common. The first three conditions 
 consist in the distention of the uterus 
 by blood or other liquid, or by gas 
 of some sort. The atresia which pro- 
 duces these conditions may be con- 
 genital or acquired. There is no his- 
 tory of exposure to impregnation, as 
 there is in pregnancy ; the menses are 
 absent, as a result of imperforate hy- 
 men, or of traumatic or inflammatory 
 
 occlusion of the cervix. In pregnancy there is the normal history of menstru- 
 ation with the sudden cessation of its appearance. In these abnormal conditions 
 
 there is a history of a slowly 
 developing tumor, with sud- 
 den and periodic enlarge- 
 ment, followed by slight de- 
 crease in size. These periods 
 correspond to the menstrual 
 epochs and are characterized 
 by great pain. The duration 
 greatly exceeds that of preg- 
 nancy. By physical exam- 
 ination in pregnancy the 
 vagina is found congested 
 and softened, while in these 
 diseased conditions it is gen- 
 erally discovered to be ab- 
 normal in some respect. 
 The mammary changes in 
 pregnancy are suggestive. 
 (5) Chronic Metritis gives 
 the uterus a firmer resist- 
 ance than is imparted by 
 pregnancy; Hegar's sign is 
 not present, nor is the characteristic " pot-bellied " shape of the uterus of preg- 
 nancy. Amenorrhea is often present, and a purulent secretion frequently co- 
 exists. (6) Subinvolution is generally accompanied by pain in the dorsal or 
 
 Fig. 175. — Large Myomata op Anterior and Pos- 
 terior Uterine Walls. A Nonpregnant Enlarge- 
 ment of the Uterus. — {Montgomery.) 
 
134 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 ovarian regions, with tenderness of the uterus itself. There is a history of very- 
 abnormal menstruation, together with a bloody, muco-purulent leucorrhea. 
 There is no increase in the size of the uterus, nor are there any signs of pregnancy. 
 Locomotion is difficult, and the patient may have amenorrhea from anemia or 
 lactation. (7) Myoma and Fibroma: These tumors are usually irregular, firm, 
 dense, and not necessarily in the median line. Menstruation is irregular and pro- 
 fuse, and the uterine evidences of pregnancy are mostly absent, especially the 
 Hegar and Braxton Hicks signs; on the other hand, asymmetry and the uterine 
 souffle are sometimes demonstrable. There is, further, a history of slow and 
 protracted growth, which may extend over months or even years (Figs. 174, 
 175, 176, and 177). (8) Congestive 
 Hypertrophy of the Uteriis: This 
 
 affection is not infrequently mis- -=-— ._ v . \ 
 
 taken for pregnancy, especially 
 when accompanied by amenorrhea. / 
 
 However, in this condition the 
 
 Fig. 176. — Local Interstitial Myo- 
 MATA. A Non-pregnant Enlarge- 
 ment OF the Uterus. — (Montgomery.) 
 
 Fig. 177. — Myoma of the Body and Can- 
 cer OF THE Cervix. A Non-pregnant 
 Enlargement of the Uterus. — {Mont- 
 gomery.) 
 
 uterus is apt to be tender and the seat of considerable pain. Time will give 
 the correct diagnosis. 
 
 2. Uterus Normal in Size with Extrauterine Enlargements. — (i) Abdominal 
 Fat: This condition becomes more common as age increases. It usually simu- 
 lates pregnancy in the very young and anemic. Menstruation in the obese is often 
 irregular and scanty. The cervix is neither enlarged nor softened. A uterus 
 of normal size may be recognized by the vaginal or rectal touch, and if the 
 abdominal fat can be pushed aside a tympanitic resonance may be obtained 
 over the umbilical region. (2) Distended Bladder: The duration of this 
 condition is relatively brief. There are external discomfort and dribbling|^of 
 urine. The position, shape, and resistance resemble those of the pregnant uterus. 
 In retroflexion of the uterus the distended bladder is often mistaken for the 
 uterus. Catheterization of the bladder will at once clear up the diagnosis. 
 
THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 
 
 135 
 
 (3) Fecal Accumulation sometimes produces enlargement of the abdomen. 
 Catharsis and enemata will remove this condition. (4) Ovarian Tumor (Cys- 
 toma) (Fig. 178): In this condition most of the probable signs of pregnancy 
 are absent. The abdominal tumor is soft, fluctuating, and usually unilateral. 
 A normal uterus should be made out by direct examination. There is also a 
 history of a slowly growing unilateral tumor, with the presence of the cachexia 
 and facies which accompany ovarian tumors. There may, however, be co- 
 existence of the two conditions, which makes the diagnosis difficult. The two 
 tumors will then be of different consistence, and may have a groove between 
 them. Vaginal examination will reveal enlargement of the uterus, while 
 there are also present the signs of ovarian cyst. There should be further evi- 
 dences of pregnancy. Aspiration of the ovarian tumor is no longer practised, 
 as in this procedure there is nothing to be gained in making the diagnosis. 
 
 (5) Ascites: In this condition the certain and probable signs of pregnancy are 
 all absent and the cervix and body of the uterus possess normal characters. 
 The abdomen, flattened in front and bulging at the sides, exhibits fluctuation. 
 By changing the woman's position the horizontal limits of percussion-reso- 
 nance change. In the dorsal 
 
 position there is dullness in 
 the flanks on percussion. The 
 condition upon which the as- 
 cites depends may be in evi- 
 dence (cirrhosis of the liver, 
 tuberculous peritonitis, etc.). 
 
 (6) Pelvic Hematocele : This 
 condition, which usually oc- 
 curs in the broad ligament, 
 could hardly be mistaken for 
 pregnancy. (7) Pelvic Exu- 
 dations: The uterus may be 
 surrounded by pelvic exudate, 
 the whole representing an ap- 
 parently homogeneous swell- 
 ing. (8) Retroversion and Re- 
 troflexion: These conditions have been mistaken for pregnancy at times, since 
 they frequently cause hypertrophy of the uterus, and irregularities or cessation 
 of the menses. The history must be carefully investigated. Vaginal examina- 
 tion generally discloses an anteposed cervix of firm consistence. The tumor will 
 also be found situated in Douglas's cul-de-sac. Very careful examinations, re- 
 peated at short intervals, will reveal the true nature of the case. Sometimes 
 several months will be required to make the diagnosis certain. The greatest diffi- 
 culty will be found in those cases in which the fundus has reached the superior 
 margin of the symphysis, or a little higher, before the convincing signs of preg- 
 nancy are present, and when the fetus is dead. Time is often required for clearing 
 up this diagnosis. Large tumors should generally offer little difficulty, but the 
 possibility of the coexistence of pregnancy and a tumor should always be remem- 
 bered. (9) Tympanites : In this condition the whole abdominal surface will 
 give a clear note of percussion; the signs of pregnancy, both subjective and 
 objective, are all wanting. Tympanites and pregnancy may coexist, however. 
 Tympanites may be excluded by feeling the spinal column through the abdomi- 
 nal wall. This may be accomplished by firmly pressing the hands, one on the 
 other, against the abdomen, while the patient draws deep breaths. The pres- 
 
 FiG. 178. — Intraligamentous Myoma. Uterus Nor- 
 mal IN Size with a Pelvic Tvmor.— (Montgomery.) 
 
136 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 sure should be especially firm during expiration. In this way the absence of a 
 gravid uterus may be proved. The enlargement also varies in the two condi- 
 tions: in pregnancy it is chiefly antero-posterior in the first months, while in 
 tympanites it is uniform in all directions. There should be no resonance over 
 the uterus, since the intestines, as a rule, are above and behind the organ. As 
 before noted, however, the intestines may be forced over the anterior face of 
 the uterus from gaseous distention. (lo) Distended Tubes, perhaps adherent 
 to the uterus, might possibly simulate pregnancy. In this case they will 
 move with the cervix, (ii) Encysted Peritonitis and (12) Ectopic Gestation 
 may sometimes cause confusion. (13) Enlarged Abdominal Organs may suggest 
 
 pregnancy; they, however, increase 
 from above downward. In case of 
 wandering spleen or kidney, the or- 
 gan can be pushed upward. Reso- 
 nance may be obtained below the 
 limit of dullness and will show the 
 cause of enlargement. Encysted 
 dropsy may be met with, but very 
 infrequently. In malignant growths 
 of the omentum and mesentery there 
 are irregularity and fixation. If the 
 growths are extensive and have ex- 
 isted for some time, there is apt to be 
 cachexia. 
 
 3. Pregnancy with Extrauterine 
 Enlargements. — The physician must 
 be on his guard against a combination 
 of these conditions; for example, in- 
 trauterine pregnancy and ectopic ges- 
 tation may exist together; or one of 
 these conditions with an ovarian 
 tumor; also in intrauterine pregnancy 
 the uterus, from retroflexion, or re- 
 troversion, or both, may give the ap- 
 pearance of a tumor in Douglas's cul- 
 de-sac. Abdominal enlargement from 
 pathogenic conditions sometimes oc- 
 curs in combination with pregnancy. 
 In these cases the latter condition is 
 very apt to be overlooked, while the 
 former is the only one recognized. 
 In certain cases the pathological conditions may be removed, and then the 
 pregnancy will become apparent. The abdominal walls also may contain an 
 undue amount of fat, which will tend to obscure the gestation, (i) Ascites may 
 coexist with pregnancy and in various clinical forms, due respectively to (a) 
 tuberculous peritonitis, which may develop slowly side by side with gestation; 
 (6) some obstruction of the portal circulation (cirrhosis of the liver, pylephlebitis) ; 
 (c) obstruction of the circulation of lymph; and, finally, {d) pregnancy itself, 
 which may produce ascites as a result of a pathological condition which affects 
 the maternal peritoneum and fetal amnion. (2) Ectopic pregnancy may be 
 associated with normal uterine gestation, and the presence of the latter furnishes 
 a contraindication to the operative treatment of the former, although in cases 
 
 I- \ 
 
 Fig. 179. — An Ovarian Cyst Behind and 
 TO One- Side of a Pregnant Uterus. 
 Pregnancy with a Pelvic Tumor. — 
 {Montgomery.) 
 
THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 
 
 137 
 
 of this description both fetuses have been dehvered ahve by laparotomy. As a 
 rule, the embryos have the same degree of development. Normal pregnancy 
 may also be associated with a past extrauterine gestation. (3) There may also 
 be coexistence of uterine and cornual pregnancy ; this latter condition often so 
 nearly resembles ectopic gestation that it cannot always be differentiated from 
 it. (4) Persistent distention of the bladder may sometimes obscure beginning 
 pregnancy. It would be almost impossible to confuse the (5) tumor of appen- 
 dicitis with beginning gestation. (6) Ovarian tumors not infrequently com- 
 plicate pregnancy; this combination may give rise to much danger to the 
 mother, for it will be almost impossible for the abdomen to accommodate both 
 of these tumors, growing simultaneously (Fig. 179). Sometimes the tumor is 
 subjected to such pressure that it may burst and discharge its contents into 
 the peritoneal cavity; or it may give rise to a slow inflammatory process, causing 
 much exhaustion, and finally terminating fatally. Several lines of treatment 
 are suggested — ovariotomy, or induced labor. (7) At times small tumors 
 develop, which may gradu- 
 ally rise above the brim. In 
 this case, if the tumor is not 
 behind the uterus, it may be 
 distinguished from that or- 
 gan. On the other hand, 
 the abdomen may be so dis- 
 tended by the presence of 
 the gravid uterus and the 
 tumor that hydramnios or 
 twins may be suspected. 
 (8) Pyosalpinx or hydro- 
 salpinx may also complicate 
 pregnancy. (9) Other tu- 
 mors of the soft parts have 
 at times to be considered; 
 e. g., those of the broad liga- 
 ments, tubal and other swell- 
 ings. (10) Ventral hernia 
 and pendulous abdomen 
 must be distinguished. (11) 
 A large floating kidney, or 
 
 displaced spleen or liver, or tumors of any of the abdominal viscera, such as 
 hydatids of the liver, or carcinomatous tumors, may be found in conjunction 
 with pregnancy, as has been stated. 
 
 In some conditions it is possible to remove the trouble which obscures the 
 pregnancy, and then the latter stands out clearly. However, the best way of 
 making a true and positive diagnosis of the pregnant state is to make several 
 examinations, and to wait until undeniable proofs of gestation are present. 
 There is one differential point of great value in the diagnosis of pregnancy : after 
 the sixth month it is the only abdominal tumor which presents the condition of 
 a movable solid mass in a liquid. 
 
 From a medico-legal standpoint the diagnosis between a muciparous and 
 puerperal uterus, and between a primigravida and multigravida, sometimes 
 becomes important. Multiparous Uterus: Cavity 2^ inches (6.5 cm.), trian- 
 gular; cervix small, cartilaginous, and same length as body; external os trans- 
 verse, and edges smooth; uterus anteflexed; external os closed. Puerperal 
 
 Fig. 180. — Pregnancy Complicated by Myoma of the 
 Anterior Uterine Wall. Pregnancy with a Pel- 
 vic Tumor. — {Montgomery.) 
 
138 PHYSIOLOGICAL PREGNANCY. 
 
 Uterus: Cavity 3 inches (7.5 cm.), or over, oval; cervix large, soft, larger than 
 body; irregular external os, with roughened edges; axis of uterus straight, 
 retrodisplaced; external os patulous. Primi gravida: Fourchette present; peri- 
 neum intact; labia in apposition; granular condition of vagina present; cervix 
 long, conical, or closed; abdomen tense; pinkish strias, late in pregnancy; breasts 
 full, firm, sensitive; nipples undeveloped; strias usually absent from breasts. 
 MuUigravida: Fourchette absent; perineum relaxed or torn; labia frequently 
 patulous; granular condition of vagina absent; cervix short and open; abdomen 
 relaxed; white striae, from beginning of pregnancy; breasts relaxed; nipples 
 large and developed; striae frequently present on breasts. 
 
 V. FEIGNED PREGNANCY, PSEUDOCYESIS. 
 
 Pregnancy, for various reasons, may be feigned or simulated. Suits are 
 frequently brought for damages, or to compel marriage, and it then becomes 
 the duty of the physician to render a decision in the case. The pregnancy 
 may be purposely feigned or simulated, or the woman in question may really 
 
 J 
 
 Fig. iSr. — Author's Case of Feigned or False Pregnancy (Pseudocyesis) at the 
 Thirty-sixth Week (?). A bimanual exartiination revealed a uterus normal in size 
 and position. — {From a tracing.) 
 
 believe herself to be pregnant. The latter condition is one well recognized 
 in obstetric medicine; and constitutes what authorities variously term false, 
 spurious, or nervous pregnancy, or pseudocyesis. In cases of feigned or simu- 
 lated pregnancy, a physical examination removes all doubt; for although the 
 woman may simulate many of the doubtful signs of pregnancy in her attempt 
 
UNCONSCIOUS PREGNANCY. 139 
 
 to deceive, yet an examination reveals none of the probable or sure signs, and 
 the uterus is found of normal size (Fig. i8i). Pseudocyesis is observed in 
 women who are advanced .in .years; in those who have an intense desire to 
 become pregnant; in women who marry late in life, and are anxious to prove 
 their power of reproduction. Most frequently we observe the condition in a 
 woman who is approaching the menopause, when her menstrual flow has become 
 scanty, or has ceased outright for a time; a deposit of fat takes place in her 
 anterior abdominal walls, and her intestines become distended by flatulence. 
 In such a case many of the doubtful and some of the probable signs of pregnancy 
 are present. For example, menstruation may cease; the mammary signs of 
 gestation appear, even to the secretion of colostrum or milk; the abdomen 
 becomes progressively more prominent; the woman assures her physician that 
 fetal movements (quickening) are present; and this may end in what is termed 
 spurious labor. (See Part IV.) The diagnosis of the condition is not difflcult. 
 Above all, the physician should be on his guard against accepting any statements 
 the patient may offer in regard to her condition; and in expressing an opinion, 
 he should rely upon the exclusion of the probable and certain signs of gestation, 
 which he does by a careful physical examination of the woman, preferably 
 with the aid of anesthesia. 
 
 In the Robert Ray Hamilton case, which occurred in New York in the latter part of 
 1888, Mr. Hamilton's mistress represented to him that she was pregnant by him. He be- 
 lieved this to be the case, and gave her considerable sums of money to enable her to go into 
 the country to be confined. She went away, remained a few months, and upon her retiim 
 produced a child which she stated was the child bom at her alleged confinement. He fully 
 believed her story and accepted the child as his own. It appears from the police memoranda 
 that several children were bought from midwives for sums of from ten to fifteen dollars, and 
 that two of these died while acting their parts as supposititious children. Owing to a quar- 
 rel between nurses, the fraud was finally discovered, and the woman and her accomplices 
 were indicted for obtaining money under false pretenses. The indictment never came to 
 trial.* 
 
 VI. UNCONSCIOUS PREGNANCY. 
 
 It is not only possible, but quite common, for women to become pregnant 
 and remain so for some time before they become aware of their condition. This 
 applies more particularly, if not exclusively, to those who are married. In the 
 unmarried, in spite of their serious protestations of entire ignorance of everything 
 concerning the matter in question, unconscious impregnation and pregnancy 
 is a rare condition. Many cases may be furnished of married women, espe- 
 cially those childless for a number of years, who finally really do become preg- 
 nant, and then refuse to believe the medical attendant when assured that such 
 is the case, believing their altered condition to be due to some disease. "When 
 a woman is impregnated in a lethargic state, it is unlikely that she should go 
 beyond the sixth month without being fully aware of her pregnancy ; and if her 
 motives were innocent, she would undoubtedly make some communication 
 to her friends" (Taylor). It must be borne in mind, however, that it is possible 
 for a woman to carry her child to full term and be unconscious of the fact of 
 pregnancy, t 
 
 * For illustrative cases of feigned pregnancy, see author's article, "Pregnancy, Labor, 
 and the Puerperal State," "Medical Jurisprudence, Forensic Medicine," Witthaus and 
 Becker, vol. 11, p. 336. 
 
 t Turner, "London Obstet. Trans.," vol. iv, p. 113; also "London Lancet," 1861, i, pp. 
 609-643. For illustrative cases of unconscious pregnancy, see author's article on the sub- 
 ject in Witthaus and Becker, "Forensic Medicine," vol. 11, pp. 362-364. 
 
140 PHYSIOLOGICAL PREGNANCY. 
 
 VII. MULTIPLE PREGNANCY; SUPERFETATION. 
 
 Definition. — If more than one ovum becomes impregnated at the same or 
 different dates, the result is multiple pregnancy; as twins, triplets, quadruplets, 
 quintuplets, sextuplets. Fecundation of an ovum with a double yolk may 
 occur. Several cases of six children at a birth have been reported. 
 
 Frequency. — Twins occur once in ninety cases; triplets once in eight thou- 
 sand; quadruplets once in four hundred thousand. Multiple pregnancies are 
 more frequent in certain countries than others; for example, Bavaria, Ireland, 
 and Russia. In 2200 labors I found twins in 31 cases, or once in 70 cases, or 
 1.40 per cent. 
 
 Etiology. — The most important factor in the causation of multiple pregnancy 
 is heredity, and it shows itself on the maternal side especially. In women who 
 have once given birth to twins, an increasing tendency seems to be present for 
 multiple pregnancy in subsequent gestations. Multiple pregnancy may arise 
 (i) from one or more ova in a single uterus; (2) from two or more ova im- 
 pregnated in a double uterus; (3) from one ovum or more in the uterus, and 
 one extrauterine. In this connection two analogous conditions, termed super- 
 fecundation and superfetation respectively, must be considered. 
 
 Superimpregnation; Superfecundation; Superfetation.— The term 
 superimpregnation indicates the impregnation of two or more ova at the same 
 coitus; simultaneous fecundation. By the term superfecundation is meant the 
 impregnation of one oviile or more after one has been already impregnated; or 
 the fertilization of one ovum or more of the same ovulation, at a second coitus, 
 after one has been already fecundated — successive instead of simultaneous 
 fecundation. The result of superfecundation is simply multiple pregnancy, but 
 the children may or may not differ, according as they possess the same father 
 or different fathers. By the term superfetation is meant impregnation when an 
 embryo already occupies the uterus, or the fertilization of a second ovum after 
 the development of the first ovum has been going on in the uterus for a month or 
 more. Two results may follow: (i) Two children are born at the same time, but 
 different in development; or (2) two children are born at different times, 
 equally developed. 
 
 If all of the above conditions are possible, we may have as the result of super- 
 fecundation: (i) The birth of twins or triplets, with certain physical pecu- 
 liarities, proving that they have had different fathers. And as the result of 
 superfetation: (2) The birth of children at the same time, differing in the degree 
 of their development; or, (3) after the birth of a mature child, a second one 
 equally developed may be born, after the lapse of several weeks or months. 
 That superfecundation may occur in both women and the lower animals is now 
 a matter of certainty. A mare is covered by a stallion, and after an interval 
 of several days, is covered by an ass; the result is twins, — one a horse, the other 
 a mule (Mende). A setter bitch during the same ovulation (heat) is covered 
 successively by a pointer and a mastiff ; her puppies plainly indicate the different 
 fathers. Medical literature supplies abundant cases to illustrate superfecunda- 
 tion in woman. 
 
 For superfetation to be possible, the occurrence of ovulation is required 
 several weeks or months after the fertilization of the first ovum. The physio- 
 logical law in woman is for ovulation to cease as soon as impregnation takes 
 place. Nature seemingly intended woman to be uniparous, although we see 
 the exceptions in multiple pregnancy. The believers in superfetation lay stress 
 
MULTIPLE PREGNANCY ; SUPERFETATION. 
 
 141 
 
 Mcmbrana 
 granulosa 
 
 
 
 Fig. 182. — Graafian Follicle with 
 Three Ova. — (Von Franque.*) 
 
 upon the fact that because women apparently menstruate for one or more periods 
 during pregnancy, therefore ovulation occurs at the same time. Playfair cites 
 the presence of menstruation, as a proof of ovulation. As has already been 
 pointed out, the presence -of menstruation is no proof that ovulation is also 
 present. (See Duration of Pregnancy.) 
 
 Conclusions.— (i) Superfetation has, in many instances, been assumed to 
 exist without sufficient evidence. (2) There 
 are on record cases that we are unable to ex- 
 plain on any other ground than that of super- 
 fetation. (3) Whether in all cases of apparent 
 superfetation the uterus was normal, is not 
 definitely known. The result of all the ob- 
 servations made upon this subject is, that the 
 majority of the alleged cases of superfetation 
 may be explained (i) upon the theory of twin 
 pregnancies, in which one fetus has grown at 
 the expense of the other and is first expelled, 
 the other remaining until it has acquired the 
 proper maturity; (2) by the existence of a 
 double uterus (Fig. 457). Nevertheless there 
 are a few other cases which do not admit of 
 either of these explanations, and which can- 
 not be accounted for except on the theory of 
 two successive conceptions (Reese). 
 
 Explanation of Multiple Pregnancy.: — 
 There are various causes for the occurrence of 
 multiple pregnancies. The most frequent is 
 
 probably the coincident, or almost coincident, rupture of simultaneously matured 
 Graafian follicles, whose ova are iinpregnated at the same, or very nearly the 
 same, time. As a general rule, twins develop from two distinct ova, which are 
 derived from the same or different Graafian folHcles. They may be situated in 
 different ovaries, as proved by the presence and position of the corpora lutea. 
 
 So twins may be derived (a) from one ovum from each 
 ovary; (6) from two ova from one ovary; (c) from a 
 double ovum, both nuclei being fertilized (Fig. 183); 
 {d) from a division which takes place in the blasto- 
 derm, giving rise usually to monsters, but sometimes 
 to twins (Fig. 93). The presence of a double nucleus 
 may be assumed when twins are derived from a single 
 ovum, but, as emphasized by Ahlfeld in his researches 
 on the production of double monsters, the possibility 
 must be entertained that the twins may have resulted 
 from complete fission of a single germ. The twins are 
 then termed "homologous," and their mental and 
 physical similarity is striking. Twins originating 
 from a single ovum are always of the same sex, while 
 those from two ova may be of the same sex or of different sexes. Triplets may 
 be derived from one, two, or three ova. A common method is for one child to 
 originate from one ovum, while the other two are derived from another single 
 ovum. The arrangement of the placentae and membranes will depend upon the 
 
 * "Zeitschrift f. Gebvirts. u. Gynakol.," Bd. xxxix. 
 t " Zeitschrift f, Geburts. u. Gynakol.," Bd. xxxix. 
 
 Fig. 183. — Two Primor- 
 dial Follicles in One 
 OF Which is an Ovum 
 with Two Germinal 
 Vesicles. — {Von Fran- 
 que.'t) 
 
142 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 DECIDUA 
 SEROTIW, 
 
 ECIDUA 
 
 EROTINA 
 
 method of their origin. Quadruplets may consist of double twins, or of triplets 
 together with a single child. 
 
 Membranes. — As to the arrangement of the fetal membranes, the decidua 
 
 vera is invariably single ; the decidua refiexa 
 is double when the ova are attached to parts 
 of the uterine wall widely separated. The 
 chorion, since it takes its origin primarily 
 from the zona pellucida, is single when the 
 twins are derived from two nuclei within 
 a single ovum, but double when they 
 originate from separate ova. Originally 
 the amnion is always double, for it is 
 elaborated as an outgrowth extending from 
 the embryo itself. When twins are in one 
 common membrane, there has been, as 
 noted before, an absorption of the septum 
 which, for a time, served as a barrier (Figs. 
 184, 185, and 186). 
 
 Placenta. — Primarily the placenta is 
 double, for each fetus produces its own 
 allantois and the placental region result- 
 ing therefrom. In the case of twins com- 
 ing from different ova, the placenta may 
 remain separate, but even in this case 
 fusion of the placental areas finally occurs. There is almost without excep- 
 tion an anastomosis of the vessels of the placentae of single-egged twins, 
 consequently the placentae are fused to a certain extent, and there results 
 a common area of nutrition for both fetuses; while there are two other 
 
 Fig. 184. — Twin Pregnancy Result- 
 ing FROM Two Ova from the Same 
 OR Different Graafian Follicles 
 
 AND FROM THE SaME OR OPPOSITE 
 
 Ovaries. First arrangement of fetal 
 structures. A.M., Amnion. The 
 heavy black portion indicates the 
 chorion. — (Dakin.) 
 
 DECIDUA SEROTINA 
 
 - DECIDUA 
 SEROTI 
 
 DECIDUA 
 SEROTINA 
 
 DECIDUA 
 VERA 
 
 DECIDUA 
 
 VERA 
 
 'DECIDUA 
 REFLEXA ^ 
 
 Fig. 185. — Twin Pregnancy from One 
 Ovum with Two Germinal Spots. 
 Second arrangement of fetal structures. 
 A.M., Amnion. The heavy black por- 
 tion indicates the chorion. — (Dakin.) 
 
 DECIDUA 
 VERA 
 
 DECIDUA 
 VERA 
 DECIDUA 
 REFLEXA 
 
 Fig. 186. — Twin Pregnancy from One 
 Ovum with One Germinal Spot. Third 
 arrangement of fetal structures. A.M., 
 Amnion. The heavy black portion in- 
 dicates the chorion. — (Dakin.) 
 
 areas, one for the special use of each fetus (Hyrtl). Hence, if there 
 are two distinct ova, there may be expected two sets of membranes, 
 while in the case of one ovum with two nuclei, a double amnion but a single 
 
MULTIPLE PREGNANCY; SUPERFETATION. 143 
 
 chorion, and a single placenta will probably develop. Sometimes only- 
 one amnion is found, in which case the partition between the two has 
 probably been dissolved. Veit found in 429 cases, that 383 were from 
 two distinct ova, 46 from a single ovum, and two had a single amnion. 
 Ahlfeld found a single amnion in 456 cases, or half as frequently as Veit. 
 In a twin pregnancy with one placenta it is very necessary to tie the cord 
 of the infant first born, for the second may bleed to death from the cord 
 of the first. 
 
 Abnormal Conditions. — The circulation of one child may be more fully 
 developed than that of the other, so that the second becomes a monster. There 
 may be a marked amount of fluid in one sac and very little in the other (Ahl- 
 feld). The anastomoses of the vessels of the placenta may exert a very strong 
 influence on the development of the twins. Circulation from the weaker may 
 be directed almost entirely to the stronger, and there will result, in the case of 
 the first, fetal atrophy, or acardia. In case of the death of one fetus, the living 
 child will, in its growth, compress the dead child more and more till it becomes 
 a flattened mass pressed against one side of the uterine wall, and known as the 
 "fostus papyraceus"^ (Fig- 445)- There may be a striking difference between the 
 infants at birth, the one being large and vigorous, the other small and puny. 
 Now and then it happens that the larger child is born at term, and the 
 immature fetus is retained till it has become more like its fellow, when 
 it is likewise expelled. Cases of double uteri have been recorded in which 
 two children of the same mother have been born a month or more apart 
 (Barker, Generali). 
 
 Symptoms and Diagnosis. — Often there are no subjective symptoms to point 
 to this interesting condition. Usually all the symptoms of pressure and con- 
 gestion, and sometimes the reflex and sympathetic disturbances, are exag- 
 gerated. As a rule, the duration of pregnancy is shortened by about two weeks, 
 by reason of the overdistention. The uncertain signs are: (i) exaggerated 
 pressure, and congestive symptoms; (2) excessive size and irregularity of the 
 uterine tumor, with (3) increased tension of the uterine walls, and (4) diminished 
 fetal mobility. The certain signs are: (i)the palpation of similar parts of the 
 fetus, as two heads, two breeches, a number of fetal extremities, or after dilatation 
 of the OS, two bags of membranes. (2) The detection of two or three fetal heart 
 sounds at different points of the abdomen, of the same degree or of different 
 degrees of intensity, and separated by areas over which the sounds are absent or 
 indistinctly heard. Errors in diagnosis are the result of depending too much on 
 this sign; in the case of a uterus containing a large fetus, with little liquor amnii, 
 and covered by thin maternal abdominal walls, the fetal heart may be heard 
 more or less distinctly over the entire uterine surface, and unless two observers 
 auscultate and count at the same time, differences in heart rate and intensity 
 may appear to be present. I made this mistake early in my private prac- 
 tice; the child, a male, weighed 9 J pounds. (3) The detection, by bimanual 
 palpation, of two fetal poles in the uterus. Thus, with two fingers in the vagina 
 upon the presenting fetus, upon pushing this fetal pole upward, the hand upon 
 the fundus will perceive an absence of motion in one fetal pole, and the conveyed 
 impulse of the vaginal palpation in the other. This, in my experience, is the 
 most reliable sign, as I have frequently demonstrated to students in the 
 clinic. 
 
 Prognosis. — The dangers for the mother are: (i) greater liability to toxemia of 
 pregnancy and eclampsia, on account of the increased metabolism of the two or 
 
 * See Amorphus anideus, Fig. 391. 
 
144 PHYSIOLOGICAL PREGNANCY. 
 
 more fetuses, and the greater pressure on the kidneys and ureters. My study 
 of 31 cases of twins shows albuminuria almost constantly present. (2) Uterine 
 inertia, prolonged labor, and post-partum hemorrhage are liable to occur as a 
 result of the extreme uterine distention. (3) Abnormal presentations may be 
 present as the result of irregularity in the shape of the uterine cavity. (4) Pre- 
 mature expulsion of the fetuses occurs in about 25 per cent., with greater ten- 
 dency to placental retention. The fetal prognosis is affected by: (i) Deficient 
 development of one or both twins; the stronger and better-developed twin 
 attracts more nourishment, and crowds and perhaps kills its fellow (fcetus papy- 
 raceus) ; or lack of fetal movement results in poor muscular development of 
 the extremities and bodies of both twins. (2) In unioval twins anastomosis 
 between fetal and placental vessels is apt to produce monsters. (3) Hydramnios 
 is frequent. (4) Complications of malpresentation and position may occur at 
 the time of birth. Thus, (a) compound presentations, as double head, double 
 breech, and head with breech, or breech with extremities; (6) malpresentations, 
 as shoulder presentation of second child (10 per cent.); (c) coiling and twisting 
 of the cords after the onset of labor; {d) locking and welding, an engagement 
 and interlocking of both heads, locking of a head or breech with a shoulder 
 presentation, interlocking of chins, interlocking of occiputs.* 
 Phenomena of Labor. See Part V. 
 
 VIII. THE DURATION OF PREGNANCY. PROTRACTED 
 
 GESTATION. 
 
 Definition. — By the actual duration of pregnancy we understand the time 
 that elapses between impregnation and labor. The duration we are unable to 
 obtain in any case with exactness, since the date of conception is always un- 
 known. The uncertainty is due to two facts: First, there may exist an interval 
 of from one to fourteen days between the time of insemination and fertilization 
 of the ovum; and, second, it is impossible to know in a given case whether the 
 ovum which is fertilized is the product (i) of the last menstrual epoch, (2) of 
 the intermenstrual period, (3) of, or the date corresponding with, the first sup- 
 pressed period. The real duration of' pregnancy, therefore, in the human 
 female is an unknown quantity. 
 
 The Average Duration. — We learn from experience that the average apparent 
 duration of pregnancy is ten lunar or nine calendar months, or forty weeks, 
 or two hundred and eighty days from the beginning of the last menstrual period, 
 or two hundred and seventy-two days from the date of conception. Schlichtingf 
 investigated 456 cases, and made the average to be 269.5 days; and yet the time 
 varied from two hundred and forty to three hundred and thirty-four days. 
 Winckel,J in his 5010 cases examined, found 70 in which the duration of gestation 
 was more than three hundred days, and in 6.8 per cent, of those cases in which 
 the exact date of impregnation was considered known, the duration was more 
 than three hundred days; in one case the duration was three hundred and 
 
 * In 31 twin labors in hospital practice I fotind the maternal mortality o per cent. 
 Both children lived in 24 cases, or 77.41 per cent., and one lived and one was still-bom in 
 6, or 19.35 psr cent. Labor was natural m 20 cases, or 64.51 per cent.; the forceps was re- 
 quired in 4 instances (once in eight cases) ; version in 4 and breech extraction in i. 
 
 t "Arch. f. Gynak.," Bd. xvi, 210. 
 
 X "Text-book of Midwifery," 1890, p. 94. 
 
DURATION OF PREGNANCY ; PROTRACTED GESTATION. 145 
 
 fourteen, and in another three hundred and eighteen days. Lowenhardt,* 
 from 518 cases in which the women could give the date of the fruitful coitus, 
 found that the average duration of pregnancy from the date of conception was 
 272.2 days. Leuckardt, from an analysis of 67 cases found upon the marriage 
 and birth register of a church, in which labor occurred within ten months after 
 the marriage night, computed the average duration of pregnancy to be 272.5 
 days. Hasler,t from a large number of cases in which the date of the impreg- 
 nating coitus was known, estimated the average duration of pregnancy to be 
 272.24 days from the dateof conception, and 280.5 days from the beginning of 
 the last menstrual epoch. Issmer,| in an exhaustive paper upon the duration 
 of pregnancy, based on a careful analysis of 464 cases, has given the following 
 interesting conclusions: (i) Conceptions occurring in the first half of the inter- 
 menstrual period are to those in the second half as 72 to 27. (2) Pregnancies 
 dated from the first half of the intermenstrual period are shorter in duration 
 than those dated from the second half. (3) When impregnation occurs in the 
 first half, the ovum fertilized is that which was discharged at the last men- 
 struation (ovulation); while when it occurs in the second half, the ovum im- 
 pregnated is one that escapes at or near the next menstrual period. (4) The 
 average duration of pregnancy is two hundred and sixty-eight days from con- 
 ception, or two hundred and seventy-eight days from the completion of the last 
 menstruation. The maximum duration is three hundred and four days. 
 
 Authorities differ somewhat in giving the average duration of gestation in the human 
 subject. Thus (calculated from the first day of the last menstruation) : Schlichting § (440 
 cases) gives 273.1 days; Matthew Duncan || gives 278 days; Lowenhardt-Ahlfeld ^ (166 
 cases) gives 281.6 days; Hasler (large number) , 280.5 days. And, calculating from concep- 
 tion, Schlichting,** 456 cases, gives 269.5 days; Lowenhardt, ft S18 cases, gives 272.5 days; 
 Leuckardt, tt 67 cases, gives 272.5 days; Hasler, §§ large number, gives 272.24 days. 
 
 Protracted Gestation. — A case is reported by Thomson |||| in which gestation lasted 317 
 days from the last menstrual period, or 301 from the last sexual intercourse. Kriiche^^ re- 
 ported a case in which he believed the duration of pregnancy was 330 days. The latest period 
 to which pregnancy may be protracted is stated by various authors as follows: Depaul, 300 
 days (high limit) ; Robert Barnes, 300 days (improbable) ; Issmer,*** 304 days; Winckel,ttt 
 320 days; Schr6der,ttJ 320 days; Schlichting, §§ § 334 days; Runge,|||||| 320 days. 
 
 Reese TflfTf states that it is possible for pregnancy to be prolonged beyond the usual 
 period accepted as the average, but he gives no limit. 
 
 As to the legitimacy of offspring according to the duration of pregnancy, different coun- 
 tries possess different laws. In Austria**** the law recognizes the legitimacy of the child 
 bom within 240 to 307 days after the death of the father. In France tftf "the legitimacy 
 of the infant bom 300 days after the dis.solution of the marriage is liable to be contested." 
 In England and America "the light of the courts in this matter is reflected light. Physicians 
 must determine the matter; and if the space between the minimum and maximum periods 
 hitherto allowed is shown to be too long or too short, the courts will readily follow the truth 
 as it is made manifest." In Wharton "On Evidence" (sec. i, 300) we find no absolute 
 limit laid down. Each case is determined upon its merits. A liberal view is taken, and the 
 legitimacy of births at the completion of 313 and 317 days respectively has been judicially 
 decided. This limit of 317 days is, according to most medical authorities on the subject, an 
 extreme one. 
 
 * "Arch. f. Gynak.," in, 1782. 
 
 t "Ueber die Dauer der Schwangerschaft," Zvirich, 1876. 
 
 t "Arch. f. Gynak.," xxxv, 1889, p. 310. § "Arch. f. Gynak.," Bd. xvi, 210. 
 
 II Ibid., Bd. Ill, 456. t "Monat. f. Geburtsh.," xxxiv, 180, S. 266 
 
 ** Loc. cit. tt Loc. cit. Jt Loc. cit. §§ Loc. cit. 
 
 III! "Trans. London Obstet. Soc," vol. xxvii. 
 ^1f "Deutsche med. Zeitung," von Grosser, 1883, 370. 
 
 *** "Arch. f. Gynak.," Bd. xvi, 210. ttt "Text-book of Midwifery," 1890, p. 94 
 
 ttt "Lehrb. der Geburtsh.," 9te. Aufl., Bonn, 18S6', p. 109. 
 
 §§§ "Arch. f. Gynak.," Bd. xvi, 210. |||||| "Lehrb. d. Geburtsh iilfe," Berlin, 1891 
 
 lift "Text-book of Med. Jur. and Tox.," Phila., 1889. 
 
 **** "Das k. k. Oesterreichische burgerliche Gesetzbuch," "Amer. Sys. Obstet.,' vol. i. 
 tttt L'article 315 du code civil. 
 10 
 
146 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 IX. CALCULATING THE DATE OF CONFINEMENT. 
 
 1. When the Date of a Single Cohabitation is Known. — Add 280 days, or 
 (Naegele's rule) count back three months from the date of cohabitation, and add 
 seven days for impregnation. In leap years, after February 6th, the number of 
 da^'-s to be added varies according to the month; e. g., in February, four days; 
 in December and January, five days; in April and September, six days, 
 
 2. When the Date of the Last Menstruation is Depended Upon. — (i) Count 
 back three months from the appearance of the last menstruation, and add ten 
 days, three for menstruation and seven for impregnation. The first day of the 
 last menstruation is a date far more readily obtained than the date of cessation, 
 and is the best time to count from. (2) Duncan's rule: Add to the last day 
 of the last menstruation, nine months, which should be counted as 275 days, 
 unless February be one of the months, in which case the period will be 273 days. 
 To the date thus obtained, add three days in the former case, and five in the 
 latter, which will make 278 days. This two hundred and seventy-eighth day 
 will be the middle of the fortnight in which labor will be apt to take place. (3) 
 Lowenhardt's method: Reckoning is made of the number of days between the 
 last menstrual epoch and the one preceding that. This result, multiplied by 
 10, will represent ten menstrual periods, and will be very accurate. 
 
 3. When the Date of the Last Menstruation is Unknown. — If a woman becomes 
 pregnant when she is not menstruating, — in lactation, for example, — or when 
 from any other reason the date of the last menstruation cannot be ascertained, 
 some method must be employed which does not take this into account ; such as 
 (i) counting from the date of quickening; (2) height of the fundus; (3) men- 
 suration of the fetus in utero; (4) time of lightening; (5) changes in the cervix, 
 (i) From date of quickening: Count from the first appearance of the "quick- 
 ening," which, on the average, appears at the seventeenth week. To this date 
 is added four and one-half months, in order to estimate roughly the' date of 
 confinement. (2) From the height of the fundus an approximate idea may be 
 obtained; fourth month, the fundus occupies the hypogastrium ; fifth month, 
 midway between symphysis and umbilicus; sixth month, on a level with the 
 umbilicus or just above; seventh month, midway between the umbilicus and 
 xiphoid cartilage; eighth month, at xiphoid cartilage; ninth month, descends 
 almost to depth at which it was in seventh month, the presenting part having 
 entered the pelvic brim in primigravidas. On account of the variations in the 
 position of the umbilicus, Spiegelberg estimated the height of the fundus above 
 the symphysis in the different weeks of pregnancy. His results are appended: 
 
 From 22d to 26th week ftuidus of uterus 8.56 inches (20.0 cm.) above symphysis. 
 At the 28th 
 
 " 32d-33d 
 
 " 34th 
 
 " 35th-36th 
 
 " 37th-38th 
 
 " 39th-4oth 
 
 10.43 
 
 (25.0 cm.) " " 
 
 " 11.02 ' 
 
 (27.5 cm.) 
 
 II. 81 
 
 (29.0 cm.) " " 
 
 " 12.00 ' 
 
 (30.0 cm.) 
 
 12.50 ' 
 
 (31. S cm.) 
 
 12.99 
 
 (33.0 cm.) 
 
 " 13-39 ' 
 
 (34.5 cm.) 
 
 (3) By measurement of the fetal ellipse: On account of the variations in individual 
 pelves, and the importance in contracted pelves of the size of the fetus, Ahlfeld 
 has paid much attention to the measurement of the child in utero. The fetal 
 ellipse in the last months of pregnancy is nearly half the length of the fetus; 
 i. e., the length of the long axis of the fetus, as it lies flexed in the uterus, is about 
 
CALCULATING THE DATE OF CONFINEMENT. 
 
 147 
 
 half the length of the extended fetus (Fig. 187). These measurements are taken by- 
 means of calipers, one end of which is rested against the presenting part in the 
 vagina, and the other against that part of the fetus in the fundus of the uterus. 
 Thus, whenever a measurement is taken of the fetal ellipse, it will represent half 
 the length of the fetus at that particular date. The table below gives the corre- 
 sponding length of the fetal 
 ellipse, of the extended 
 fetus, and its weight at va- 
 rious weeks of its growth. 
 This method is used when 
 the fetus presents longitu- 
 dinally. When the pres- 
 entation is transverse, the 
 measurement is purely ab- 
 dominal. (4) The phe- 
 nomenon of lightening at 
 the beginning of the pre- 
 paratory stage to labor, al- 
 though its value in fore- 
 telling the day of delivery- 
 is not great . ( 5 ) Changes in 
 the portio vaginalis and cer- 
 vical canal \x\.\aiq,\c^\Xqx'^zx\, Fig. 187. — Calculating the Date of the Expected 
 of pregnancy, especially in Confinement by Measuring the Fetal Ovoid with 
 
 __:^-~-ro^ri'/^':o ^\^^^^AA Vvo O^^ PoiNT OF THE PELVIMETER ON THE FeTAL HeAD IN 
 
 primigraviaas, snouia oe ^^^ Vagina, and the Other on the Breech through 
 taken into consideration. the Anterior Abdominal Wall. 
 
 Period of Preg- 
 nancy. 
 
 Axis of Fetal Ellipse. 
 
 Total Length of F 
 
 STUS. 
 
 Weight of Fetus. 
 
 At the 20th week 
 
 3.82 to 5.79 in. (9.7 to 
 14.7 cm.) 
 
 7.08 to 10.62 in. 
 to 27 cm.) 
 
 (18 
 
 9.8 oz. (280 grams) 
 
 " 24th " 
 
 5.90 to 7.36 in. (15.0 to 
 18.7 cm.) 
 
 11.02 to 13.48 in. 
 to 34 cm.) 
 
 (28 
 
 1.39s lbs. (634 grams) 
 
 28th " 
 
 7.08 to 8.97 in. (18.0 to 
 22.8 cm.) 
 
 13.88 to 14.96 in. 
 to 38 cm.) 
 
 (35 
 
 2.64 lbs. (1200 grams) 
 
 32d " 
 
 9.45 to 10.82 in. (24.0 to 
 
 14.96 to 16.93 i^' 
 
 (38 
 
 3.52 to 4.18 lbs. (1600 
 
 
 27.5 cm.) 
 
 to 43 cm.) 
 
 
 to 1900 grams) 
 
 36th " 
 
 10.63 to II. 81 in. (27.0 
 
 16.52 to 18.90 in. 
 
 (42 
 
 3.74 to 5.72 lbs. (1700 
 
 
 to 30.9 cm.) 
 
 to 48 cm.) 
 
 
 to 2600 grams) 
 
 " 40th " 
 
 II. 81 to 14.56 in. (30.0 
 
 18.90 to 20.47 i^' 
 
 (48 
 
 6.60 to 7.92 lbs. (3000 
 
 
 to 37.0 cm.) 
 
 to 52 cm.) 
 
 
 to 3600 grams) 
 
 The exact day of delivery probably depends on small details, either mental 
 or physical. Impregnation has been observed to occur at any time in the men- 
 strual month, although considered to take place more frequently in the few 
 days just preceding, and those immediately following, menstruation. Some 
 women always seem to exceed the normal limits of pregnancy, and in such cases 
 the child is usually a large-sized male. In other cases the duration of pregnancy 
 is shorter than usual; it is said to be so, early and late in the reproductive age, 
 and in single women, while it is long in the middle part of the child-bearing 
 period. It is quite likely that the gestation period corresponds with the length 
 of the individual's menstrual cycle. If fecundation takes place a few days 
 after the close of a menstrual period, the next menstrual period is almost 
 invariably suppressed. If, however, it occurs a few days before a menstrual 
 
148 PHYSIOLOGICAL PREGNANCY. 
 
 epoch, then there may be an irregular or atypical menstruation succeeding. 
 In the case of a woman with an irregular menstrual history the difficulties of 
 calculation increase. 
 
 X. THE EXAMINATION OF PREGNANCY. 
 
 No better time than that of the examination of pregnancy can be selected 
 for inculcating in the student the principles of obstetrical cleanliness, mechanical 
 and chemical. The principles of personal cleanliness and disinfection, if not 
 learned now, are less likely to be acquired afterwards. While it cannot be stated 
 that the same danger attends vaginal examinations in pregnancy as in labor, 
 still, in the latter part of pregnancy, the examining finger often enters the cer- 
 vical canal, and in the one or more weeks of the preparatory stage of labor the 
 conditions are often quite analogous to active labor. Moreover, the possibility 
 of a low placental attachment, or even of actual labor, must always be granted. 
 For these reasons obstetric asepsis demands that the same rigid cleansing of the 
 hands and forearms, and precautions in separation of the sides of vulva, be ap- 
 plied to the examination of pregnancy, as to that of labor and the puerperium. 
 
 Obstetric Asepsis. — In Vienna, in 1847, the foundation of aseptic midwifery 
 was laid by Semmelweis, and perfected by others along the lines laid down 
 by Pasteur and Lister. Semmelweis, in 1847, discovered the septic nature of 
 puerperal fever, and by means of chlorine solutions instituted an antiseptic pro- 
 phylaxis against the scourge. In brief, puerperal fever was, according to Sem- 
 melweis, no new specific disease, but a variety of pyemia. 
 
 At the beginning of the present century the consensus of opinion was that 
 the pregnant vagina and gravid and puerperal uterine cavity were quite sterile 
 under normal conditions, and that autoinfection from these sources was quite 
 impossible except in rare instances. In other words, septicemia was in the 
 vast majority of cases a disease introduced from without. The evidence upon 
 which this view rested, including the result of the labors of Bumm, Kronig, 
 and others, was thought to be irrefutable. Of course, theories were not wanting 
 to explain this supposed sterility of the birth-tract, and the chief of them had 
 reference to the bactericidal power oi the vaginal secretion and lochia,* each 
 of which was pronounced to be not only a poor culture-medium, but, moreover, 
 endowed with powers of self -purification, even after the introduction of an 
 abundance of germ-life. This theory was in excellent accord with practice, 
 for it inculcated the greatest thoroughness in obstetric asepsis and made 
 the practitioner practically responsible for the occurrence of an aseptic puer- 
 perium. From this point of view I trust the profession will never recede, but 
 as a matter of fact the views thus held as a scientific gospel have within the 
 past few years been completely undermined by new discoveries. An increasing 
 number of observers have found that the healthy vagina of the pregnant woman 
 is by no means always sterile; and that streptococci pathogenic to animals 
 may be recovered from not a small proportion of cases. Two of the most 
 recent authorities, von Rosthorn t and Lenhartz.J accept the view that the 
 vagina is not sterile, and possesses no inherent bactericidal power. At the 
 
 * As will be seen later, the lochia does possess such powers, although they are hardly in 
 force directly after delivery. 
 
 fvon Winckel: " Handbuch d. Geburtshulfe," Bd. i, 1903. 
 J " Die septische Erkrankungen," 1903. 
 
THE EXAMINATION OF PREGNANCY. 149 
 
 same time, Franz,* Schauenstein.t Wormser,| and others have shown that 
 ordinary saprophytes and streptococci invade the uterine cavity immediately 
 after labor in a very large number of cases. Walthard ^ claims that vaginal 
 germs at times readily pass-into the non-pregnant uterus, where they may set 
 up endometritis and toxemia. The locomotive powers of virulent streptococci 
 in cultures is of course well known; for example, according to Bumm,|| these 
 germs, after having inoculated birth-traumas in the vulval region, can migrate 
 into and infect the endometrium in twenty-four hours, while the rapid decom- 
 position of retained decidual and placental structures shows that saprophytes, 
 whatever their source, have ready access to the puerperal uterus. Sepsis of 
 grave character occurs not rarely in women who have never been submitted 
 to the examination of pregnancy and in those who have been examined with 
 sterilized gloves. 
 
 According to the older views, the external genitals alone abounded in germ 
 life, and much of the puerperal morbidity could be attributed to the accidental 
 transportation of these germs into the vagina by the examining finger, and by 
 manipulation on the part of the patient. 
 
 I found that the secretion in the vulval canal, in twenty-eight pregnant 
 and two parturient women in the Emergency and Maternity Hospitals, showed 
 pyogenic bacteria in forty per cent, of the cases : Staphylococcus pyogenes albus 
 in 8 cases. Staphylococcus pyogenes aureus in 3 cases, and Streptococcus pyogenes 
 in one case. In all but two of the cases the external genitals were washed with 
 soap and water just previous to the taking of the cultures. T[ 
 
 Vaginal Examinations and Manipulations. — We may accept the following 
 statement as probable: The microbes which are known to cause puerperal 
 morbidity may or may not be present in the healthy vagina. From the very 
 large proportion of cases in which they invade the uterus immediately after 
 labor "the chances are that the majority of vaginas contain germs. These, 
 while comprising even Streptococcus pyogenes in a goodly proportion of cases, 
 must not straightway be regarded as pathogenic; they may or may not be 
 so. The question must arise, "If we believe that the vagina in a very large 
 proportion of cases contains germs which are almost certain to pass into the 
 uterus after delivery, and which while not necessarily or ordinarily pathogenic 
 may still be the cause of severe and even fatal sepsis under certain circum- 
 stances, should we return to the old custom of antiseptic douching of the vagina 
 as a routine practice?" At present this question, it must be confessed, is by 
 no means easy to answer offhand. Such antisepsis is still practised as a pro- 
 cedure of necessity in selected cases, as in suspected gonorrhea, before manual 
 or operative delivery, etc. (See Part X.) We have no means of differentiating 
 between sterile and non-sterile vaginal secretions, for Doderlein's distinction 
 between normal and pathological secretions — the latter having an alkaline 
 reaction and excess of formed elements — has little practical value. We know 
 in advance that the majority of cases in the absence of vaginal antisepsis will go 
 through the puerperium without morbidity. We may also feel fairly positive 
 that a certain proportion of women will in the long run undergo more or less 
 severe sepsis, with secondary morbidity, and perhaps some fatalities. But 
 
 * Franz; " Hegar's Beitrage z. Geburtshulfe , " 1902, vi. f Cited by Franz, v. supra. 
 
 J Ibid. ^Walthard: " Zeitschr. f. Geburts. u. Gyn.," 1902, xlvii. 
 
 II" Grundriss zum Studium des Geburtshulfe," 1902, p. 655. 
 
 If See author's experiments on 13 primigravidas and 17 multigravidas at Emergency and 
 New York Maternity Hospitals. " Asepsis in Obstetrics," " New York Medical Record," 
 Feb. II, 1899, vol. Lv, p. 193. 
 
150 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 should douching really reduce morbidity? When vaginal antisepsis was prac- 
 tised as a routine procedure, it was asserted that the upper vagina could not 
 be rendered sterile. I can at present see but one way in which this question 
 can be answered. If some of the experimenters who have developed the tech- 
 nique for obtaining the lochial secretion from the puerperal uterus will submit 
 a large series of cases to antiseptic vaginal douching before delivery, and will 
 then investigate the bacteriology of the uterine cavity on the various puerperal 
 days, we might gather some notion of the efficacy of vaginal antisepsis. 
 
 Another method of some value might be the taking of rectal temperature, 
 as is Bumm's * custom, with a view of detecting febriculas from slight saprasmia, 
 the woman having previously been subjected to vaginal antisepsis. If thirty per 
 cent, to sixty per cent, of the cases showing elevation of temperature (100.4° F- 
 in the rectum) should show a marked reduction, we might well conclude that 
 vaginal douching should be practised. 
 
 Hofmeier (Wurzburg) t has repeatedly asserted the value of routine prophy- 
 lactic antepartum douching, and credit must certainly 
 be given him for securing the smallest morbidity and 
 mortality of any maternity in Germany. This ob- 
 stetrician has had but four deaths in his last 6000 
 deliveries — a mortality of but 0.06 per cent. It should 
 be added that the general hygienic conditions at H of- 
 meier's clinic are by no means favorable, and that his 
 cases are examined by a very large number of stu- 
 dents, candidates for state examinations and by mid- 
 wives. Sublimate is used as an antiseptic. 
 
 Lenhartz J states that of forty deaths from puer- 
 peral infection at the Eppendorfer Krankenhaus, 
 Hamburg, no less than twenty-two occurred after 
 normal spontaneous labor. It seems a reasonable 
 supposition that antepartum douching would have 
 saved many of these women. Lenhartz recommends 
 prophylactic douching with sublimate (i : 4000) or 
 lysol (two per cent.). 
 
 Preparation of the Patient. — When feasible the 
 bladder and rectum should be emptied, the external 
 genitals scrubbed with soap and water with a soft 
 brush or cotton, the whole, including the vulval canal, 
 rinsed with plain water, and then cleansed or irrigated 
 with I : 2000 or i : 4000 sublimate solution, from 
 above downward. 
 Preparation of Physician. — Care of the Finger-nails. — Ragged, unclean, 
 badly groomed finger-nails are inexcusable in the obstetrician, and certainly pre- 
 dispose to sepsis, since they cannot readily be rendered aseptic (Fig. 188). With 
 a few minutes' attention each morning, one can keep his finger-nails in good con- 
 dition. The shape of the nail is largely a matter of individual taste, but for 
 aseptic purposes a nail with rounded point will best serve the obstetrician's 
 purpose, provided that at the rounded point the nail is not more than yg- inch 
 (0.15 cm.) in length. 
 
 Disinfection of the Hands. — The foundation of the aseptic method in 
 
 *Bumm: " Zeitschr. f. Medizinal-beamte," April i, 1903. 
 t Hofmeier: "Munch, med. Wochen.," 1902, Nos. 18, 19. 
 J Lenhartz: "Die septiscH. Erkrankungen," Wien, 1903. 
 
 Fig. 188. — The Left-hand 
 Finger shows an Ex- 
 aggeration OF A Badly 
 Groomed Finger-nail 
 and Cuticle which 
 Would Favor Sepsis 
 FROM the Lodgment of 
 Septic Material. The 
 Right-hand Finger 
 shows a Properly Kept 
 Nail and Cuticle. 
 
THE EXAMINATION OF PREGNANCY. 
 
 151 
 
 obstetrics rests upon sterilization of the hands, which may be accomphshed 
 
 in one of several ways. It must be remembered that when we refer to the hand 
 
 we include as well the forearm to the elbow, which in all cases, especially in 
 
 labor and operative obstetrics, should receive the same conscientious cleansing 
 
 as the hand and fingers. To this end 
 
 the coat should be removed and the 
 
 sleeves rolled up before the cleansing 
 
 process begins. Women physicians 
 
 should have the sleeves of both arms 
 
 so made as readily to permit of being 
 
 rolled back to the elbow. All methods 
 
 of disinfection should be preceded by 
 
 thorough and prolonged scrubbing 
 
 with a hand-brush in soap and hot 
 
 Fig. 189. — Flattened End of an Orange 
 Stick Used to Push Back the Cuticle 
 FROM THE Nail. 
 
 Fig. 190. — Edge of a Towel Used for 
 Cleaning and Polishing the Inner 
 Surface of the Finger-nail. 
 
 water, particular attention being given to the spaces under and around the 
 nails, which are to be kept short and smooth. About five minutes should be 
 employed in the scrubbing process, which is to be followed by some form of 
 chemical antiseptic treatment. 
 
 Rubber Gloves. — I cannot too strongly urge the use of sterile rubber gloves, 
 as a routine measure in confinement 
 cases. No ordinary obstetrician, 
 namely, the so-called general prac- 
 titioner, and no physician, surgeon 
 or obstetrician, who is at all doubtful 
 concerning his personal asepsis, is 
 justified in attending women in con- 
 finement without utilizing this simple 
 and effective precaution. 
 
 Chemical Antiseptics. — The 
 most generally employed chemical 
 
 antiseptics are carbolic acid and bichloride or biniodide of mercury. A very 
 large number of other chemicals have been suggested and used more or less, 
 but few of them have any qualities which will enable them to displace the sub- 
 
 FiG. 191. — Hand Enclosed in Rubber 
 Glove. 
 
152 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 stances first mentioned. Among those which have from time to time proved 
 useful may be enumerated permanganate of potash, oxaUc acid, chlorinated lime 
 and carbonate of soda, alcohol, creolin, lysol, and hydrogen peroxide. Creolin 
 is not often used at present, but lysol, in a two per cent, solution, is employed 
 to some extent as a vaginal douche before labor, when there is reason to believe 
 that there is infection present in the vagina, and also as a solution for instru- 
 ments. It is objectionable for the latter use because it makes the instruments 
 slippery, while this lubricating quality is somewhat useful when employed in the 
 vagina. Bichloride of mercury is used in solution for various purposes in strengths 
 of I : 500 to I : 10,000, and the same is true of the biniodide. The tablets which 
 are extensively sold are very convenient and accurate in making solutions of these 
 
 chemicals, and they have the addi- 
 tional advantage that substances 
 are combined with them which pre- 
 vent the solutions becoming inert 
 as a result of the affinity of the 
 mercuric salt for albuminous 
 bodies. Carbolic acid is used in 
 watery solutions, to which a little 
 glycerin has been added. The 
 strength varies from 1 : 20 to 
 I : 100. After the preliminary 
 scrubbing one of the following anti- 
 septic methods should be em- 
 ployed: 
 
 1. The scrubbed hands and fore- 
 arms are ( i ) rinsed in sterile water ; 
 (2) immersed for half a minute in 
 alcohol of at least 80 per cent, 
 strength; and (3) then in a i : 1000 
 or I : 2000 solution of bichloride or 
 biniodide of mercury, for from 
 three to five minutes. A scrub- 
 bing-brush may also be used with 
 advantage in these solutions, to 
 assist in causing the antiseptic to 
 penetrate. 
 
 2. After scrubbing, the hands 
 and forearms are (i) immersed in 
 a saturated solution of potassium 
 permanganate until they are 
 stained a deep mahogany brown; 
 
 (2) they are then transferred to a saturated solution of oxalic acid, and kept 
 immersed until decolorized. (3) After this they are rinsed in sterile water or 
 salt solution. This method is very efficient. Some writers advise washing for 
 three minutes in a i : 500 bichloride of mercury solution, as an additional pre- 
 caution after the oxalic acid is washed off (Halsted, 1899). 
 
 3. (i) A paste is made by mixing water with chlorinated lime ; the hands are 
 rubbed thoroughly with this, and (2) meanwhile a lump of sodium carbonate 
 is picked up and rubbed in with the mixture, until a sensation of coolness is felt. 
 
 (3) A hand-brush is now used with the solution for several minutes, and 
 
 (4) the hands washed in sterile water and then in (5) alcohol or weak ammonia 
 
 Fig. 192. — Opened Vulva in a Primigravida, 
 Aged Twenty-two; Thirtieth Week of 
 Pregnancy; Deep Vulval Canal. — (From a 
 photograph at the New York Maternity}) 
 
THE EXAMINATION OF PREGNANCY. 
 
 153 
 
 water. The last two methods are very efficient and are commonly used by 
 surgeons in operating, but even after these precautions cultures from the deeper 
 layers of the skin will sometirnes grow. After the sterilization of the hands is 
 complete, the obstetrician niust see to it that they are not again contaminated 
 by coming in contact with anything which has not been sterilized, between the 
 antiseptic solution and the vagina. 
 
 Sterilized rubber gloves will be found useful in obstetrical practice for making 
 examinations, especially when the hands have recently had to do with septic 
 cases, or when the means for a chemical sterilization are not at hand. The 
 rubber gloves can be sterilized by boiling (Fig. 191). If a lubricant is necessary, 
 and it rarely is, it should be vaseline 
 or glycerin which has been heated for 
 five or ten minutes to 212° F. and 
 kept afterward in a sterilized vessel. 
 
 Objects of the Examination. — In 
 the examination of pregnancy (i) 
 the actual existence of pregnancy 
 should be determined, as well as (2) 
 the period of gestation; (3) the prob- 
 able date of labor; (4) the viability 
 of the fetus; (5) the diagnosis of the 
 presentation, position, and engage- 
 ment of the head; (6) the condition 
 of the patient's genital organs, in- 
 cluding the breasts; (7) the size of 
 her pelvis ; and (8) the obstetric prog- 
 nosis. It is advisable also at this 
 time to inquire and record (see chart, 
 Appendix) (i) the date and type of 
 the last menstruation ; (2) her family 
 and personal history, including de- 
 gree of parity; (3) the character of 
 her previous pregnancies, labors, and 
 puerperiums. Her nurse or nurses 
 should also be arranged for, and 
 directions given regarding the hy- 
 giene of pregnancy and the procur- 
 ing of the mother's, baby's, and ob- 
 stetric outfit. (See Part IV.) Primi- 
 gravidae should have their pelves 
 measured before the twenty-eighth 
 week; the spines, crests, trochanters, 
 
 external and internal conjugates, being measured as matters of routine. Should 
 pelvic deformity exist, more exhaustive measurements should be taken, and if 
 necessary we should not hesitate to make an internal examination under nitrous 
 oxide, chloroform, or ether. A comparison should be made between these measure- 
 ments and the weight and height of the patient, and her husband, and their ages. 
 The patient's skeleton should be considered as to its character; one composed 
 of light bones has generally a relatively large pelvic girth, while the converse 
 also holds true. If the patient be a multigravida, all of these careful measure- 
 ments are not necessary in private practice, if the previous children have been 
 of usual size and the labors uneventful. However, the size of the fetal head 
 
 Fig. 193. — Opened Vulva in a Primigravida; 
 Thirty-eighth Week; Shallow Vulval 
 Canal. — {From a photograph at the New York 
 Maternity.) 
 
154 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 should be estimated two weeks before labor is expected, in order to detect any 
 overgrowth of the fetus. (See Cephalometry.) The examination of pregnancy 
 can conveniently be divided into (i) external or abdominal, and (2) internal or 
 vaginal. 
 
 EXTERNAL OR ABDOMINAL EXAMINATION. DIAGNOSIS OF FETAL 
 PRESENTATION, POSITION, AND ENGAGEMENT OF PRE- 
 SENTING PART. EXTERNAL PELVIMETRY. 
 
 The patient should lie upon her back upon the side of the bed or couch, 
 with the clothing loosened and the abdomen bare, or covered only with one 
 thickness of a bed-sheet, through which it is possible to make a satisfactory 
 examination. The examiner should see that his hands are warm, since the 
 
 Fig. 194. — Location of the Fetal Back and Small Parts by External Palpation. 
 The left hand displaces the fetus to the left for locating the dorsal plane. — {From 
 a photograph taken at the Emergency Hospital.) 
 
 contact of a cold hand with the abdominal wall is apt to excite reflex contractions 
 of the abdominal muscles, and even in the uterus. Moderate flexion of the 
 thighs will often assist in relaxing the abdominal muscles, and this position 
 can often be used to advantage. The bladder and rectum should have been 
 emptied recently. We should ascertain as much as possible at the first exam- 
 ination, and, in order that nothing be overlooked, we ought to follow some 
 definite routine order of examination, as in the case of the internal examination 
 
THE EXAMINATION OF PREGNANCY. 
 
 155 
 
 of pregnancy (see page 167) and labor (see Labor). We should also accustom 
 ourselves to palpate with the left as well as the right hand. The order of 
 examination here recommended is: (i) Determination of general conditions. 
 (2) Location of fetal back, and small parts. (3) Palpation of the lower fetal 
 pole. (4) Palpation of the upper fetal pole. (5) Location of the cephalic 
 prominence. (6) Deep pelvic palpation. (7) Locating anterior shoulder. (8) 
 Palpation in breech presentation. (9) Palpation in shoulder presentation. 
 (10) Location of the fetal heart. (11) External pelvimetry. Most of the 
 methods of abdominal palpation can be carried out while the examiner sits 
 at the bedside, facing the patient's abdomen. 
 
 Fig. 195. — Palpating the Lower Fetal Pole by External Palpation. — (Front a 
 photograph taken at the Emergency Hospital.) 
 
 I. General Conditions. — (i) The general condition of the patient should 
 first be observed, and evidences of blood changes, pulmonary, cardiac, renal, 
 syphilitic, or tuberculous disease noted; (2) the breasts and nipples are to be 
 inspected for lacteal capacity and evidences of previous inflammation in the 
 former, and for flatness, inversion, fissure, or erosion of the latter. We pass 
 next to the abdomen and determine (3) the direction of the uterine axis, detecting 
 any excessive right or left lateral obliquity or other displacement, the result of 
 previous inflammations or operation, and (4) the thickness and pendulous 
 condition of the abdominal walls. We should then determine by abdominal 
 palpation the general shape and size of the uterus; the relation of the fundus 
 to the umbilicus and ensiform cartilage; the size of the fetus, and its relation 
 
156 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 to the amount of liquor amnii, and whether the fetus lies vertically, trans- 
 versely, or obliquely in the uterus. This is accomplished by placing the palms 
 of the hands one on each side of the abdomen, and sliding them evenly and 
 gently upward and downward over the entire pregnant uterus, from the fundus 
 to the pubis and back again to the fundus, at the same time, gently and without 
 much pressure, palpating the whole maternal abdomen with the finger-tips 
 (Figs. 195 to 201). 
 
 2. Location of Fetal Back and Small Parts. — The next point to be made 
 out is the location of the child's back; this can usually be done by palpating 
 the whole maternal abdomen with the tips of the fingers, gently and without 
 
 Fig. 196.— Palpating the Upper Fetal Pole by External Palpation. — (From a 
 photograph taken at the Emergency Hospital.) 
 
 much pressure. Stronger pressure may be necessary to ascertain the amount 
 of resistance, mobility, etc., but it should be remembered that strong pressure 
 blunts the tactile sensibility of the ends of the fingers. The small parts by 
 this method will be felt as small rounded knobs, more or less movable. If the 
 examiner will steady the fetus in its long axis, and exert some pressure upon 
 the upper pole, the dorsal convexity will be considerably increased, and therefore 
 more easily palpated. Another method is to apply moderate deep pressure 
 with the palm of the hand on the middle of the abdomen. This displaces the 
 fetus toward the side to which its back is turned, and while the pressure is main- 
 tained with one hand the examination may be made satisfactorily with the 
 other (Fig. 195). In order to make out whether the back of the fetus is turned 
 
THE EXAMINATION OF PREGNANCY. 
 
 157 
 
 toward the back or front of the mother, it is to be remembered that the fetal 
 back offers a broad, smooth convex surface from end to end, while the lateral 
 aspect is not convex from end to end, is narrower, and has a deep sulcus be- 
 tween head and pelvis. T-he small parts on one side indicate that the back 
 is on the other, except in the case of twins. If small parts can be felt beyond 
 either end of the fetus, the presentation is pretty certainly a breech. Certain 
 conditions may, when present, make this part of the examination difficult or 
 uncertain. A large amount of abdominal fat, hydramnios, and a rigidly con- 
 tracted uterus, are some of these conditions. 
 
 3. Palpation of the Lower Fetal Pole. — The hands of the examiner are placed 
 
 Fig. 197. — Locating the Cephalic Prominence. in Vertex Presentation by External 
 Palpation. — (Front a photograph taken at the Emergency Hospital.) 
 
 flat upon the sides of the abdomen, with the palms toward each other, and 
 the fingers toward the feet of the patient, and resting a little above Poupart's 
 ligament (Fig. 195). When the hands are passed toward each other and also 
 toward the cavity of the maternal pelvis, it is usually possible to catch quickly 
 the fetal pole, and to manipulate it. The first point to determine, when the 
 pole is found, is whether it is head or breech. The head is large, hard, and 
 globular, and separated from the trunk by the constriction of the neck; and it 
 is, furthermore, the only part of the fetus which sinks into the maternal pelvis 
 before labor. The breech always lies above the excavation of the pelvis until 
 labor begins. When either fetal pole is found in an iliac fossa, the presentation 
 will be transverse. 
 
158 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 4. Palpation of the Upper Fetal Pole. — To accomplish this satisfactorily, 
 the position of the hands is in the opposite direction from that just described, the 
 palms being placed facing each other on the upper part of the abdomen, with 
 the fingers toward the patient's head (Fig. 196). The head when found in the 
 upper segment of the uterus can be subjected to ballottement, and otherwise 
 has the characteristics which have been mentioned (Fig. 200). The breech 
 in the upper segment is less mobile, more voluminous, and softer than the 
 head (Fig. 196). 
 
 5. Location of the Cephalic Prominence. — (i) The hand is pressed trans- 
 versely across the maternal abdomen, just above the symphysis, and the head 
 
 Fig. 198. — Deep Pelvic Palpation to Determine the Amount of Engagement op 
 THE Presenting Part by External Palpation. — {From a photograph taken at the 
 Emergency Hospital.) 
 
 thus grasped and palpated (Fig. 197). The occipital side is that at which 
 the hand sinks deepest into the pelvis; since the occiput itself is the part of 
 the head which, as a rule, is deepest in this cavity. The greatest prominence 
 at the brim is, therefore, the forehead, most marked in the occipito-posterior 
 position. (2) The right or left hand, with thumb and fingers separated as far 
 as possible, grasps the fetal head just above the pelvic inlet (Fig. 197). Since 
 the head in primigravidae is usually partially engaged in the pelvic inlet, it is 
 advisable to direct the thumb and finger-tips downward toward the pelvic 
 cavity. In multigravidse, by reason of the rather high situation of the head 
 the thumb and finger-tips are held more horizontally. In the latter case we 
 
THE EXAMINATION OF PREGNANCY, 
 
 159 
 
 can assist in the manoeuver by steadying the fundus with the disengaged hand. 
 The head feels hard and ball-Hke and can usually be moved from side to side. 
 The breech appears soft and irregular. In pelvic presentation the same method 
 can be applied to the head lying in the fundus (Fig. 197). In shoulder presenta- 
 tion, no definite presenting part being found at the pelvic inlet, the head is 
 sought for by gently palpating with short finger-strokes in one or the other side 
 of the uterus (Fig. 201 ). It can then be grasped in the same manner as above, 
 and the manoeuver assisted by steadying the breech with the disengaged hand. 
 6. Deep Pelvic Palpation. — In primigravidae when the head is engaged in 
 the pelvis, and in both primiparae and multiparas when the same condition 
 
 Fig. 199, — Locating the Anterior Shoulder by External Palpation. Right hand 
 depresses and raises fundus, while the left palpates for the shoulder. — {From a photo- 
 graph taken at the Emergency Hospital.) 
 
 obtains, the method of palpating the cephalic extremity shown in Fig. 198 is 
 most useful, especially during labor. Moderate flexion of the thighs, approxi- 
 mation of the heels, and separation of the knees greatly assists in relaxing the 
 anterior abdominal walls. As pictured in Fig. 198, the examiner stands at 
 the side of the bed, facing the patient's feet. The palms of the hands are 
 placed on both sides of the lower uterine segment, and the finger-tips of 
 both hands are made to enter the pelvic cavity slowly and gently, alongside 
 of the head, between it and the pelvic walls. As in Fig. 197, but more satis- 
 factorily, the head when engaged in the pelvis can be felt as a hard, oval body 
 occupying the latter; the more prominent forehead, on one side, being readily 
 
160 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 distinguished from the less prominent occiput, or nape of the neck, on the 
 other. The forehead is especially prominent in occiput posterior positions 
 (Fig. 198). We have no more valuable method of determining bregma, 
 brow, and face presentations before dilatation of the os, than that by deep pelvic 
 palpation. In bregma presentation incomplete flexions of the occiput and 
 forehead are about equally prominent; in brow presentations the occiput is 
 more in evidence, while in face presentations it is the most prominent part 
 of the fetal head to be palpated. 
 
 7. Location of the Anterior Shoulder. — One hand is placed above the uterus 
 upon the fundus, so as to steady the organ and press it into the pelvis. A¥ith 
 
 Fig. 200. ^Locating the Cephalic Extremity of the Fetus in Breech Presentation 
 BY External Palpation. — (From a photograph taken at the Emergency Hospital.) 
 
 the other hand the anterior shoulder can be recognized as a rounded prominence, 
 which when on the left of the median line, indicates a left fetal position, and 
 when on the right, a right fetal position. When the shoulder is less than two 
 inches from the median line, the fetal position will be anterior; when more 
 than two inches away, posterior (Fig. 199). 
 
 8. Palpation in Breech Presentation (Fig. 200). — The flexed band is pressed 
 transversely across the maternal abdomen just at or above the umbilicus and the 
 head grasped and palpated (Fig. 200). Or we can proceed as in palpation of the 
 upper fetal pole (Fig. 196). The anterior shoulder (Fig. 199), the dorsal plane, 
 and small parts (Fig. 195) are palpated practically as in head presentations. 
 
THE EXAMINATION OF PREGNANCY. 
 
 161 
 
 9. Palpation in Shoulder Presentation (Fig. 201). — The same general prin- 
 ciples apply here as in head and pelvic presentations. 
 
 10. Location of the Fetal Heart (Fig. 171). — This may be accomplished 
 with the stethoscope, with the phonendoscope, or by the ear alone. The abdom- 
 inal wall should be pressed against the uterine tumor, since sound is best trans- 
 mitted through a homogeneous soHd. This is best accomplished by pressing 
 the fundus with one hand, and directing the uterus downward and forward 
 (Fig. 171). It is advisable to direct this pressure in such a manner as to bring 
 simultaneously the dorsal surface of the fetus as nearly as possible under the 
 
 
 '•/ 
 
 Fig. 201.— Locating the Cephalic and Podalic Extremities of the Fetus in Shoulder 
 Presentation by External Palpation. The left hand grasps the head and the 
 right the breech. — (From a photograph taken at the Emergency Hospital.) 
 
 stethoscope. The sounds resemble the ticking of a watch under a pillow, and 
 vary from 130 to 140 per minute, being about twice as frequent as those of the 
 healthy adult heart. Active movement on the part of the fetus increases the 
 fetal heart-rate. If the organ is located on the left, — that is, if the point of 
 greatest intensity of the heart sounds is on the left of the median line, — the 
 presentation is left; if on the right, the presentation corresponds. If the heart 
 is located above the umbilicus, the presentation is pelvic; if below, the head 
 will present. Twins show naturally two hearts of different rates, and the sex 
 can sometimes be guessed at by remembering that a persistent fetal heart rate 
 under 120 indieates a boy; and over that a girl. In certain dorso-posterior 
 11 
 
162 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 positions, and in some cases of hydramnios, it is occasionally impossible to 
 hear the fetal heart. 
 
 EXTERNAL PELVIMETRY. 
 In taking the external pelvic measurements the pelvimeter and tape-measure 
 are necessary. Two very good instruments in common use are the pelvimeters of 
 Baudelocque (Fig. 203) and of Schultze (Fig. 202). The former must be used with 
 caution on account of the spring of the metallic arms. The modification of the 
 Baudelocque pelvimeter, elliptical in shape, occasionally seen at the instrument- 
 makers, has even greater spring than the original, and should be avoided if accur- 
 ate results are desired. The Schultze pelvimeter is of a shape which gives great 
 firmness, and is convenient to carry in the pocket or obstetric bag. In use the arms 
 of the pelvimeter are separated, a rod being taken in each hand, with an index- 
 finger on each knob. The knobs are then placed on the two selected points, 
 
 fixed in position, the screw near the handle is 
 tightened by an assistant, and the distance 
 between the two points is read off on the scale 
 attached to the instrument (Fig. 203). The 
 patient should be dressed as for bed, and placed 
 first in the dorsal position, upon the side of the 
 bed or lounge. The physician standing at her 
 right side, and holding an arm of the instru- 
 ment with the thumb and fingers of each hand 
 near the points, applies the latter to the outer 
 edge of the anterior superior iliac spines, and 
 notes the diameter thus gained (Fig. 203). He 
 then pushes the points backward and forward 
 along the outer edge of the iliac crest, and notes 
 the greatest diameter which can in this way be 
 obtained. The woman then turns on her side, 
 or abdomen, and the points of the pelvimeter 
 are placed on the posterior superior iliac spines, 
 which are marked by well-defined dimples, 
 and the distance between these is noted. The 
 oblique diameter is obtained by placing one of 
 the points upon the posterior superior iliac 
 spine, and the other upon the anterior superior 
 iliac spine of the opposite side. The external 
 conjugate is obtained while the patient lies on her left side or stands in the 
 erect position. One point is placed in the depression just below the spine of 
 the last lumbar vertebra, while the other is placed upon the middle of the 
 upper anterior border of the symphysis pubis. The distance between the 
 femoral trochanters may be obtained by placing each point as nearly as 
 possible upon the most projecting part of each greater trochanter. This last 
 is an unimportant diameter. In external pelvimetry we rely upon the fol- 
 lowing twelve measurements; the first four of which are most commonly 
 used: (i) Interspinous. (2) Intercristal. (3) Between the great trochanters. 
 (4) The external conjugate, or Baudelocque's diameter. (5) Right oblique 
 diameter. (6) Left obUque diameter. (7) Between the posterior superior 
 iliac spines. (8) Between the tub era ischii. (9) Transverse diameter of outlet. 
 (10) Antero-posterior diameter of outlet. (11) Length of the symphysis. 
 (12) Circumference of the pelvis. (13) True conjugate measured externally. 
 
 Fig. 202. — Schultze's 
 
 METER. 
 
 Pelvi- 
 
THE EXAMINATION OF PREGNANCY. 
 
 163 
 
 1. Interspinous Diameter (Fig. 203). — This is the widest distance between 
 the anterior superior ihac spines, and is measured by placing the points of the 
 pelvimeter upon the external surfaces of the spines, at the insertion of the sar- 
 torius muscles (Fig. 203). In normal pelves this measurement varies from 
 9^ to 10^ inches (24.1 to 26.7 cm.). 
 
 2. Intercristal Diameter (Figs. 203 and 204). — This is the widest interval 
 
 A/f/erior 
 
 Fig. 203. — Measuring the Interspinal Diameter with the Baudelocqub Pelvimeter. 
 
 between the iliac crests, and is measured between the most prominent portions 
 (Fig. 204). In normal pelves this diameter varies from 10^ to 11^ inches (26.7 
 to 29.1 cm.). 
 
 3. Between the Great Trochanters (Fig. 209). — This diameter is the greatest 
 distance between the external surfaces of the great trochanters of the femora. 
 In normal conditions it measures 12.4 inches (31 cm.), but may even be ii^ 
 
164 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 inches (29.1 cm.), without indicating pelvic contraction. Because of variations 
 in the size of the femoral head, this diameter is the most unreliable one of those 
 
 here mentioned. 
 
 4. The External Con- 
 ,,: jugate; Baudelocque's Di- 
 
 n; i ameter(Figs.2o6 and 207). 
 
 — This is measured from 
 the depression just below 
 the spine of the last lum- 
 bar vertebra, which is 
 about one inch above the 
 posterior interspinous di- 
 ameter, to the point on 
 the skin of the mons ven- 
 eris in front of the upper 
 external edge of the sym- 
 physis pubis. In normal 
 cases it measures 8 inches 
 (20.3 cm.). As a clinical 
 index of contracted pelvis 
 this diameter is unreliable. 
 According to Jewett, how- 
 ever, when the external 
 conjugate is at or below 6 
 inches (15.2 cm.), or even 
 below 6^ inches (15.8 cm.), 
 the pelvis is invariably 
 contracted; between 6^ 
 inches (15.8 cm.) and 8 
 inches (20.3 cm.) the amount of contraction is very uncertain, and must be 
 settled by internal measurements; at or above 8 inches (20.3 cm.) the pelvis is 
 almost sure to have ample room. A certain relationship is said to exist between 
 the lengths of the ex- 
 ternal and internal 
 conjugates ; such 
 
 marked variations, 
 however, occur be- 
 tween the two that 
 the external can 
 never be relied upon 
 as an exact clinical 
 index of the internal. 
 Litzmann measured 
 the external conju- 
 gate during Hfe, and 
 the internal or true 
 conjugate post mor- 
 tem in 30 cases, and 
 
 found that there was an average difference between the two of 3! inches (9.5 cm.). 
 In the entire 30 cases, there were variations from 2f inches (7 cm.) to 4^f inches 
 (12.5 cm.). 
 
 5 and 6. Right and Left External Obliques (Fig. 205). — The right external 
 
 Fig. 204. — Position of the Points of the Pelvimeter 
 FOR Measuring the Intercristal and Bitrochanteric 
 Diameters of the Pelvis. 
 
 Sapfr/or 
 Spwe 
 
 
 Fig. 205. — Position of the Points of the Pelvimeter for 
 Measuring the Right External Oblique Diameter of the 
 Pelvis. 
 
THE EXAMINATION OF PREGNANCY. 
 
 165 
 
 oblique is measured from the right posterior superior spine of the iHum to the 
 left anterior superior spine, and measures 8| inches (22 cm.). The left external 
 oblique is the distance from' the left posterior superior spine of the ilium to the 
 right anterior superior spine, and measures also 8| inches (22 cm.). These 
 right and left oblique diameters should be equal or nearly so. In obliquely 
 contracted pelves, as the 
 single oblique pelvis of 
 Naegele, a considerable 
 difference may be present. 
 In such pelves several 
 other oblique measure- 
 ments are of value, in order 
 to determine differences 
 between the two lateral 
 halves of the pelvis, al- 
 though in these cases, 
 more than in any other, an 
 external examination is 
 necessary to detect the ex- 
 act degree of deformit3^ 
 Three additional measure- 
 ments are: (i) From the 
 posterior superior spine of 
 one side to the tuber ischii 
 of the other. (2) From the 
 spine of the last lumbar 
 vertebra to the anterior 
 superior iliac spines of both 
 sides. (3) From the pos- 
 terior superior spine of one 
 side to the great trochanter 
 of the opposite side. (4) 
 From the lower margin of 
 the symphysis to the pos- 
 terior superior iliac spines. 
 (5) From the middle line 
 of the back to both pos- 
 terior superior iliac spines. 
 
 7. Between the Poste- 
 rior Superior Iliac Spines. — 
 This is measured from the 
 outer surfaces of these 
 spines, and equals norm- 
 ally 3|- inches (9.8 cm.). 
 
 9. Transverse Diameter 
 of the Outlet (Fig. 210). — 
 
 This diameter is rarely referred to, and less often taken, but it is of great 
 value in showing contraction at the pelvic outlet in kyphotic and funnel- 
 shaped pelves. With the patient in the lithotomy position, the palmar sur- 
 faces of the index-fingers are pressed firmly against the inner borders of the 
 tuber ischii, and an assistant then measures the diameter with the points of the 
 pelvimeter placed on the index-fingers, close to the ischial bones (Fig. 209). 
 
 Fig. 206. — Measuring the. External Conjugate Diam- 
 eter OF the Pelvic Inlet. Diameter of Baude- 
 locque. Baudelocque Pelvimeter. 
 
166 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 Normally this diameter is 4^ inches (11 cm.). The transverse diameter of 
 the outlet may be measured with equal facility by determining the distance 
 between the ischial tuberosities. The site of the latter is located by the 
 points at which a horizontal line touching the anterior margin of the anus 
 comes in contact with the folds of the thigh. The knobs of the pelvimeter 
 are applied at these points, the shanks of the instrument having previously 
 been overlapped, and pressed firmly against the subjacent bones. The meas- 
 urement thus obtained is normally 4^ inches (11.43 cm.). There should be 
 allowed for the soft parts about \ inch (0.635 cm.), varying with the thickness of 
 the nates. The true transverse diameter of the outlet is therefore 4^ inches 
 (11 cm.). 
 
 10. Antero-posterior Diameter of the Outlet. — The woman is placed on her 
 
 side and the examiner introduces his 
 index-finger into the vagina, with 
 the thumb over the region, of the 
 coccyx. By moving the latter bone 
 back and forth, the location of the 
 sacro-coccygeal joint is determined, 
 and a pencil mark is made upon the 
 superjacent skin. One button of 
 the pelvimeter is applied over this 
 mark, while the other rests within 
 the vulva, and upon the lower bor- 
 der of the symphysis. The straight 
 or antero-posterior diameter of the 
 outlet is thus determined, and is 
 normally 5 inches (12.5 cm.) . About 
 ^ inch (1.5 cm.) must be subtracted 
 from the thickness of the coccyx and 
 soft parts to obtain the actual or 
 net measurement. The preceding 
 method is known as Breisky's, and 
 is endorsed by Skutsch. This diam- 
 eter can usually more readily be 
 measured directly with the fingers 
 internally (Fig. 208). 
 
 II. Length of the Symphysis (Fig. 
 213). — This is important in determ- 
 ining the depth of the true pelvis, 
 and in assisting in the estimation of 
 the true from the diagonal conjugate. It is measured with a pelvimeter by press- 
 ing one point closely down upon the center of the upper border of the symphysis, 
 and the other point against the center of the subpubic ligament. It can also 
 be estimated with the fingers (Fig. 213). 
 
 12. External Circumference of the Pelvis. — This is measured with the tape- 
 measure over the middle of the symphysis, just below the iliac crests, and across 
 the middle of the sacrum, and is usually about 35^ inches (88.75 cm.). 
 
 13. The True Conjugate Measured Externally. — In thin, non-pregnant women, 
 and in the early months of gestation, the true conjugate may occasionally be 
 estimated directly from without, by placing the palmar surface of the hand 
 upon the hypogastrium, and pressing backward until the tips of the fingers reach 
 the promontory. The hand is then marked over the pubes with a finger-nail 
 
 Fig. 207. — Point (x) Below the Spine of the 
 Last Lumbar Vertebra used to Indicate 
 the Posterior Extremity of the Exter- 
 nal Conjugate of the Pelvic Inlet. 
 
THE EXAMINATION OF PREGNANCY. 167 
 
 of the disengaged hand, and after allowing for the thickness of the abdominal 
 walls and pubes, the estimate is made. The method is of little practical value. 
 A graduated rod with a blunt surface for pressing against the sacral promontory 
 may be substituted for the- hand. 
 
 These external measurements are not trustworthy, since errors of as much 
 as two inches may occur. They rather point out the general shape of the 
 pelvis and not the exact pelvic capacity. Baudelocque's conclusion that the 
 external conjugate minus from 2| to 5 inches (7 to 12.5 cm.) equals the internal 
 true conjugate is now known to be untrustworthy. Of the above the diam- 
 eters of the most practical importance are the (i) interspinal, (2) intercristal, 
 (3) external conjugate, (4) transverse of outlet, and (5) antero-posterior of 
 outlet. A marked diminution in the interspinal and the intercristal diameters 
 leads to the suspicion of a transversely contracted pelvis. If the intercristal 
 diameter is no greater than the interspinal, or if it is less, the pelvis is probably 
 rachitic. A difEerence in the lateral halves of the pelvis is shown by a difference 
 in the oblique diameters; while a notable diminution in the external conjugate 
 shows that we have to deal with a flattened pelvis. Unlike the case of the 
 true conjugate, it is not safe to make inferences as to the length of the internal 
 transverse diameter of the lesser pelvis, from these external measurements, 
 because there are too many opportunities for disparities in the shape and size 
 of the ilia. The nearest approximation to a rule, which, however, holds good 
 in not more than fifty per cent, of cases, is that the interspinous line is twice 
 as long as the transverse diameter of the lesser pelvis. These external meas- 
 urements, however, have some value in other directions. Thus, if the spine 
 and crest measurements exhibit little or no difference, the pelvis in question 
 is probably rachitic. The external measurements should always be compared, 
 for if each has the normal length, the lesser pelvis should be regarded as nor- 
 mal. But if the interspinous line is as long as the intercristal, or longer, the 
 external conjugate is unnaturally short, and these disparities indicate the exist- 
 ence of a fiat, rachitic pelvis. Again, if the three external measurements are 
 in the normal proportion to one another, but are all unnaturally short, they 
 indicate the existence of a generally contracted pelvis, the most common 
 variety in the United States. 
 
 INTERNAL OR VAGINAL EXAMINATION. INTERNAL PELVIMETRY. 
 
 An internal pelvic examination is imperative in all primigravidse, and in 
 others upon whom the least suspicion of pelvic deformity rests. The same 
 care in the preparation of the patient and of the physician's hands should be 
 taken at this time as in internal examinations during labor. 
 
 Objects of the Examination. — In the internal or vaginal examinations we 
 strive (i) to confirm the findings of the external examination in regard to (a) 
 the actual existence of pregnancy; (6) the period of gestation; {c) the probable 
 date of labor; (d) the viability of the fetus; {e) the presentation, position, 
 and engagement of the head. (2) In addition, we seek information as to the 
 conditions of the soft parts, as to congenital defects, pathological growths which 
 may obstruct or complicate labor, or injuries resulting from previous deliveries. 
 (3) The possibility of a placenta praevia should always be kept in mind. (4) 
 The size of the pelvis should be estimated, and (5) the obstetric diagnosis con- 
 firmed and completed. 
 
168 PHYSIOLOGICAL PREGNANCY. 
 
 INTERNAL PELVIMETRY. 
 
 For internal pelvimetry many instruments have been devised, but the best 
 of all is the educated hand. AVe have, therefore, manual and instrumental 
 pelvimetry. After the usual disinfection of the vulva, and of the hands and 
 arms of the physician, the patient is placed in the lithotomy position, with 
 the hips projecting well over the edge of the bed or table. The first and second 
 fingers are then introduced into the vagina and passed well upward toward 
 the promontory of the sacrum. With these two fingers the general conforma- 
 tion and capacity of the pelvis, the pelvic inclination, the depth, inclination, 
 and thickness of the symphysis pubis, the shape and curve of the sacrum, the 
 flexibility of the coccyx, and, with the assistance of the external pressure upon 
 the fundus, any marked disproportion between the fetal head and pelvis, can 
 be determined (Fig. 226). Several internal pelvic diameters will demand 
 measurement in cases of suspected deformity, although usually the diagonal 
 and true conjugates are a sufficient clinical index of the pelvic capacity. These 
 diameters are: (i) the sacro-pubic; (2) the pubo-coccygeal ; (3) the transverse 
 diameter of the outlet; (4) the diagonal conjugate; (5) the true conjugate; 
 (6) the transverse diameter of the inlet. 
 
 1. The Sacro-pubic Diameter (Fig. 208). — With two fingers in the vagina, the 
 tip of the second finger seeks and presses firmly against the sacro-coccygeal 
 joint, and the radial edge of the hand is brought up firmly against the subpubic 
 ligament. A finger-nail of the other hand then marks the point of junction 
 at the apex of the pubic arch (Fig. 208). The vaginal fingers are now with- 
 drawn, and the distance between the two points of contact is measured with 
 a pelvimeter or tape-measure. Normally this diameter measures 4^ inches 
 (11. 5 cm.). 
 
 2. The Pubo-coccygeal Diameter. — This is measured in the same manner as the 
 above, but from the subpubic ligament to the tip of the coccyx. In anterior 
 positions of the coccyx this diameter is about 4-2- inches (11. 5 cm.), but recession 
 during expulsion of the head may readily increase the diameter to 5^ inches 
 (14 cm.). 
 
 3. Transverse Diameter of the Outlet. — This has been described under 
 external pelvimetry (page 162, Fig. 210). During labor, or under partial 
 anesthesia, this diameter can be estimated by pushing the half-fist between 
 the ischial tuberosities and partly into the vaginal orifice. The width of the 
 four fingers or knuckles is then compared with the bisischial space. (Compare 
 Manual Pelvimetry.) 
 
 4. The Diagonal Conjugate (Fig. 209). — This is the distance from the center 
 of the sacral promontory to the subpubic ligament. To measure it manually, 
 the first and second fingers of either hand are introduced into the vagina, and 
 the sacral promontory is sought for. Some experience is necessary to be able 
 to recognize the promontory, and care should be taken not to mistake a " false 
 promontory" for the true one. Unless the deformity is extreme it will be 
 the second finger which touches the promontory. Keeping the finger in contact 
 with the latter, the radial side of the first finger or hand is held firmly against 
 the subpubic ligament, while the exact point of contact is marked by the finger- 
 nail of the first finger of the other hand (Fig. 209). The fingers are then with- 
 drawn, and the distance is measured with the pelvimeter (Fig. 211) or tape, 
 the examining hand being held in the same relative position. This diameter in 
 normal pelves measures 5^ inches (13.5 cm.). 
 
 5. The True Conjugate. — The true conjugate can be estimated from the 
 
THE EXAMINATION OF PREGNANCY. 
 
 169 
 
 r*h 
 
 Fig. 208. — Digital Method of Measuring the Antero-posterior Diameter of the 
 Pelvic Outlet. — (From a photograph.) 
 
 \ 
 
 .^i ttJ auiiitaiimM tti.- 
 
 FiG. 209. — Digital Method of Measuring the Diagonal Conjugate of the Pelvic 
 
 Inlet. — (From a photograph.) 
 
170 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 diagonal conjugate, by constructing a triangle formed by the two conjugates 
 and the symphysis pubis, of which the diagonal conjugate corresponds 
 nearly to the hypothenuse, and the true conjugate to the base. The diagonal 
 conjugate, the known quantity, is the longest of the three sides, and the true 
 conjugate, the unknown quantity, can be obtained from it by subtracting on 
 an average i inch (2.5 cm.). The amount to be deducted, however, will vary 
 with the height, thickness, and inclination of the symphysis and the height of 
 the sacral promontory. When the symphysis is i-| inches (3.75 cm.) or over, 
 f inch (1.905 cm.) should be subtracted from the diagonal conjugate; and when 
 it is less than 1^ inches (3.75 cm.), a little less is to be subtracted. The esti- 
 
 FiG. 210, — Method of Measuring the Transverse Diameter of the Pelvic Outlet. 
 The points of the pelvimeter are placed on the palmar surfaces of the tips of the index- 
 fingers. See diagram, upper left of illustration. — {From a photograph.) 
 
 mation of the true conjugate by this plan can only be approximated, since it 
 depends upon so many variable quantities. The method of taking the height 
 of the symphysis is described on page 166. For determining the thickness of 
 the symphysis the pelvimeter of Skutsch, or one of its modifications, may be 
 used (Fig. 215). It can be roughly estimated, of course, by the thumb and 
 finger of the accoucheur (Fig. 213). The normal angle between the true conju- 
 gate and the symphysis has been estimated at 105 degrees. After the physi- 
 cian has made it a rule to combine internal pelvimetry with vaginal examina- 
 tion, he will soon learn to recognize and appreciate departures from the normal 
 type. An important point, commonly misunderstood, is that the obstetric con- 
 
THE EXAMINATION OF PREGNANCY. 
 
 171 
 
 jugate is the smallest amount of available intrapelvic space in the antero- 
 posterior diameter, whether measured from the true promontory or some other 
 point, as a false promontory or' displaced lumbar vertebra. 
 
 True Conjugate with Pelvimeters (Skutsch). — Many pelvimeters have been 
 devised for measuring the true conjugate. 
 These instruments, as a rule, do not take 
 cognizance of other internal diameters. 
 Two instrumental methods for measuring 
 the true conjugate give practical results: 
 viz., those of Skutsch and Farabeuf re- 
 spectively. The measurement which the 
 former gives is known as the interno- 
 external, and is not so accurate as that 
 obtained by the direct method with the 
 latter or Farabeuf's instrument. (See 
 page 172 and Fig. 214.) Eight years' ex- 
 perience with this instrument has satis- 
 fied the author that it is the most accur- 
 ate instrument for the purpose at present 
 in existence. 
 
 The Skutsch pelvimeter is about the 
 shape of a pair of calipers (Fig. 215). Its 
 internal arm is of steel, with a spatula- 
 like tip, while its fellow is of pure lead 
 covered with india-rubber tubing. To de- 
 termine the true conjugate, the woman is 
 placed in the dorsal position, with knees 
 elevated and thighs separated. The sac- 
 ral promontory is first located, and then 
 the projecting point on the internal aspect 
 
 of the symphysis. A point is then selected upon the mons veneris correspond- 
 ing to an imaginary continuation of the true conjugate, and indicated by a 
 crayon mark. The internal or steel arm is then introduced into the vagina, 
 with the finger as a guide, and its spatula-like tip applied firmly to the pro- 
 montory and there maintained, 
 while with the other hand the 
 lead arm is given such a contour 
 that its terminal knob is placed 
 near the marked spot upon the 
 mons. The external hand then 
 gives the pelvimeter a slight 
 twist upon its axis, after which 
 the knob of the external arm 
 may be pressed accurately upon 
 the marked spot. The pelvim- 
 eter is then locked and with- 
 drawn. The distance is meas- 
 ured by the scale accompanying 
 the instrument. The internal arm of the pelvimeter is then applied to the 
 internal aspect of the symphysis, and its distance from the marked point upon 
 the mons veneris is determined, in the same manner as was the first measure- 
 ment. Subtraction of the small from the large measurement gives the length 
 
 Fig, 211. — Measuring the Distance 
 FROM THE End of the Second Fin- 
 ger TO the Mark Made upon the 
 Radial Bqrder of the Hand. 
 
 Fig. 212. — Stein's Pelvimeter for Measuring 
 Directly the True Conjugate. 
 
172 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 \ 
 
 of the true conjugate. The Skutsch pelvimeter is in Hke manner used to measure 
 the transverse diameter of the pelvic inlet. (See Fig. 216.) 
 
 True Conjugate with the Farabeuf Pelvimeter. — This resource was intro- 
 duced into pelvimetry by Farabeuf * for the purpose of lengthening the index- 
 finger, in case the accoucheur should be unable to reach the promontory, either 
 by reason of the shortness of his finger, or because of unusual dimensions of 
 the pelvis. While fingers of average length are sufficient for pelvimetry in 
 contracted pelves, this is by no means necessarily the case in general pelvim- 
 etry, and therefore the device of Farabeuf is excellent in routine obstetrical 
 practice. The custom of reinforcing the finger with a vesical sound is open 
 to criticism, from the fact that it may be given a wrong direction; and a further 
 disadvantage is the absence of a device to indicate the exact position of the 
 
 symphysis. The thimble-like 
 pelvimeter consists of two deli- 
 cate steel arms, which are par- 
 li-'-^sc^^- ^ allel for a short distance, but 
 
 which then diverge, and after- 
 ward roughly assume the con- 
 tour of a tapering forefinger. 
 This frame is provided, on its 
 inferior surface, with two in- 
 complete rings, designed to fit 
 the first and second phalanges 
 of the exploring finger. The 
 elasticity of the steel arms per- 
 mits the rings to slip over a finger 
 of any normal dimensions. At- 
 tached near the extremity of this 
 steel frame is a delicate horse- 
 shoe-shaped piece of steel, which 
 turns in either direction, up or 
 down, and which constitutes the 
 extension to the exploring finger 
 (Fig. 214). The parallel portion 
 of the steel arms also constitutes 
 a groove, along which slides the 
 measuring rod, which is bent at 
 its terminal end into a right 
 angle. This bent portion is in- 
 tended to enter the urethra in order to touch the internal aspect of the sym- 
 physis. The proximal end is provided with a ring, while the upper surface of 
 the rod has a graduated index (Fig. 214). With this pelvimeter the obstetrical 
 conjugate can be measured directly. The steel arms are introduced against 
 the promontory, followed by the passing of the measuring rod into the bladder 
 (Fig. 214). 
 
 6. Transverse Diameter of the Inlet (Fig. 216). — Exact measurements of the 
 transverse diameter of the brim are as yet hardly practicable. The pelvimeter of 
 Skutsch is an example of what has been done in this direction (Fig. 216). 
 To obtain the transverse diameter at the pelvic inlet with this instrument, the 
 woman is placed in the dorsal position with her extremities in leg-holders. 
 The fingers of the left hand are introduced within the vagina and along the 
 * " Gaz. Hebdom. de Med. et Chir.," June, 1889 
 
 Fig. 213. — Measuring the Height and Thick- 
 ness OF THE Symphysis with the Fingers. 
 This procedure is also useful to determine the 
 amount of engagement of the presenting part 
 or the effect of the uterine contractions in causing 
 descent of the head or breech. 
 
THE EXAMINATION OF PREGNANCY. 
 
 173 
 
 Fig. 214. — Direct Instrumental Method of Measuring the True Conjugate op 
 THE Pelvic Inlet with the Farabeuf Pelvimeter. — {From a photograph.) 
 
 Fig. 215.— Measuring the True Conju- 
 gate OP THE Pelvic Inlet with the 
 Skutsch Pelvimeter. 
 
 Fig. 2^6. — Measuring the Tra.ms- 
 verse Diameter of the Pelvic 
 Inlet with the Skutsch Pelvim- 
 eter. 
 
174 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 Fig. 217. — Direct Internal Manual Pelvimetry in a Normal Pelvis. The width 
 of the hand is 3^ inches (9 cm.). Note the free space between the promontory and 
 small finger. — (From a photograph.) 
 
 Fig. 218. — Direct Internal Manual Pelvimetry in a Normal Pelvis. The long 
 diameter of the closed fist is 4 inches (10 cm.). Note the tmoccupied room to the 
 front and sides of the fist. — (From a photograph.) 
 
THE EXAMINATION OF PREGNANCY. 
 
 175 
 
 linea arcuata, while the right hand locates the point at which an imaginary- 
 continuation of the transverse diameter would transfix the skin in the region 
 of the hip. This point is indicated by a crayon mark. The error in the deter- 
 mination of this point is said to be very slight. The internal arm of the pel- 
 vimeter is now introduced within the vagina, and its tip is applied to the left 
 extremity of the transverse diameter, while the knob of the lead arm is similarly 
 applied o•^er the hip and the short measurement taken. The steel arm within 
 the vagina is now reversed, so that its convexity faces about; the opposite 
 extremity of the transverse diameter is then located, and the long measure- 
 ment made. The difference between the two gives the diameter sought. An 
 internal measurement sometimes taken in order to estimate the transverse 
 
 Fig. 219. — Direct Internal Manual Pelvimetry in a Normal Pelvis. The long 
 diameter of the fist as thus placed in the pelvis measures 4 inches (10 cm.). Note 
 the space between the promontory and the knuckle of the small finger. — (From a photo- 
 graph.) 
 
 diameter of the pelvic brim is that of Lohlein. With two fingers in the vagina, 
 the distance from the center of the ligamentum arcuatum to the upper anterior 
 angle of the great sacro-sciatic notch is taken. According to Lohlein, this is 
 f inch (2 cm.) less than the transverse diameter of the inlet. The practised 
 hand will soon learn to appreciate any notable transverse contraction in pal- 
 pating the lateral pelvic walls. 
 
 Internal Manual Pelvimetry. — Internal manual pelvimetry comprises pal- 
 pation of the pelvic canal by the fingers introduced within the vagina, and 
 measurement of the pelvic diameters by the aid of the entire hand. Palpation 
 of the pelvic canal serves to detect the presence of objects which obstruct the 
 lumen of the pelvic canal, such as abnormally long bony prominences. But 
 unless favored by circumstances which render possible the introduction of the 
 
176 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 entire hand into the vagina, such as large size and great distensibility of the 
 latter, the value of mere palpation of the pelvic canal is not great. 
 
 For a number of years the author has practised a variety of manual pel- 
 vimetry shown in figures 217 to 221. The originator of this method was Dr. 
 Robert Wallace Johnson, of England. It necessitates the introduction of the 
 whole hand into the pelvis, a distensible vagina, and narcosis of the patient. 
 It is inapplicable in nulliparous patients, and in many primigravidas before 
 labor sets in, but can be used to advantage in most multigravidae, and in all 
 parturients. In all primiparse and many multiparae considerable care and 
 time must be used in the dilatation of the vagina, so as to avoid rupture of 
 that organ or of varicose veins so often present. Troublesome venous hemor- 
 
 FiG. 220. — Direct Internal Manual Pelvimetry in a Generally Contracted Pelvis. 
 Note that the long diameter of the fist reaches from promontory to symphysis. Also 
 that the circumference of the fist almost blocks the pelvic inlet. — {From a photograph.) 
 
 rhage from the latter source once occurred in my practice from a too rapid 
 dilatation. As the illustrations indicate, the measurements of the pelvic inlet 
 are compared with the known circumference and diameters of the tightly 
 closed fist. When applicable, the method is the most positive and satisfactory 
 of the internal means for determining the available space at the inlet. 
 
 It should not be forgotten that pelvic contraction is usually relative, not 
 absolute, and that the size of the fetal head is just as important as the size 
 of the pelvis. The size and compressibility of the head, and whether it can 
 be made to enter the pelvic brim, are factors that should never be neglected. 
 (See Cephalometry.) Finally, the importance in doubtful cases of a thorough 
 examination under full anesthesia, and by an experienced accoucheur, cannot 
 be overestimated. It is hardly necessary to point out all the refinements of 
 
THE EXAMINATION OF PREGNANCY. 
 
 177 
 
 diagnosis in the various forms of pelvic deformity. The educated hand will 
 recognize the difference in the respective lateral pelvic walls, which accom- 
 panies the obliquely contracted pelvis (Naegele); the converging walls and 
 approximated ischial tuberosities, which characterize the funnel-shaped pelvis 
 (Roberts) ; the presence of bony tumors, etc. The student who has mastered the 
 principles of pelvimetry, and the descriptive classification of pelvic deformity, 
 will not need exact instruction for every possible case. 
 
 RONTGEN PELVIMETRY. 
 
 The :r-rays are able to detect anomalies of the bony pelvis, including narrow- 
 ing of the inlet. We therefore possess a new resource in pelvimetry. Accord- 
 ing to Bouchacourt, the rays give us three species of information: (i) As to 
 
 Fig. 22 1. — Internal Direct Manual Pelvimetry in a Flattened and Generally 
 Contracted Pelvis. Note that the fist almost fills the pelvic inlet. — {From a photo- 
 graph.) 
 
 the presence or absence of deformity in general. (2) As to whether the deformity 
 is symmetrical or asymmetrical. (3) As to the nature of the deformity.* 
 To practise Rontgen pelvimetry, the woman is placed upon the plate in a some- 
 * "L'0bst6trique," 1900, v, pp. 20-34. 
 
 12 
 
178 PHYSIOLOGICAL PREGNANCY. 
 
 what reclining position, the tube being above and in front of her; or she may- 
 lie in the lithotomy position, with the plate under the ischial tuberosities, if 
 possible at a right angle with the pelvic axis, the tube being above the woman 
 in a line with the said axis. Freund speaks of a third position — namely, the 
 Trendelenburg — as specially adapted for pelvic photography. Finally, if a 
 picture of the rear of the pelvis is desirable, the patient must lie prone with 
 the plate beneath and the tube above her. Williams * gives a method of his 
 own devising, for measuring the transverse diameter of the pelvis at the inlet. 
 
 PELVIGRAPHY. 
 
 Attempts have been made to depict the entire pelvic cavity during life 
 by some method of graphic representation. As far as I know, but two such 
 methods have ever been proposed; these are skiagraphy of the pelvis, and the 
 geometrical method of Neumann and Ehrenfest, assistants of Professor Schauta 
 (Vienna). Skiagraphy of the pelvis is described under the sections on Rontgen 
 Pelvimetry (page 177) and Rontgen Cephalometry (page 184). 
 
 The geometrical method consists in taking a series of measurements of certain 
 pelvic diameters, and plotting the size and outline of various pelvic planes. 
 The two transverse diameters and the sagittal plane are sufficient to give a com- 
 plete notion as to the individuality of the pelvis. The authors just mentioned 
 employ for this purpose an instrument termed by them a pelvigraph. The 
 principle involved in the construction and application of the pelvigraph is 
 that of the parallel rulers, one number representing a palpator for the localiza- 
 tion of points within the pelvis, while the other is provided with a water-level 
 and a dial index. There are several palpating arms, the peripheral portions 
 of which are bent in various curves or angles, to reach different parts of the 
 pelvis; but the proximal portion and the terminal button are always in the 
 same axis. The various measurements, angles, etc., are plotted upon drawing- 
 paper as soon as they are determined, and in this manner the entire sagittal 
 plane is reproduced on paper. The transverse diameters should then be 
 measured. This method may be found fully described and illustrated in the 
 " Monatsschrift fur Geburtshiilfe und Gynakologie," 1900. 
 
 Fabre's Method. — In 1900, Fabre, of Lyons, described before the Interna- 
 tional Medical Congress at Paris a method devised by him for measuring the 
 superior strait, which he termed metric radiography. Exact mensuration 
 with radiography is of course impossible, as the image varies with the distance 
 between the ampulla and the various positions of the pelvis. But it is possible 
 to measure the dimensions approximately by the method about to be described. 
 Four rulers of metal, each provided with a certain number of saw-like teeth, 
 form a square about the pelvis. The posterior ruler is opposite the posterior 
 superior ischial spines, the anterior lies horizontally in front of the upper por- 
 tion of the pubis, etc. A skiagram is then made, and the shadows of the teeth, 
 which should be exactly opposite to one another, may be joined by straight 
 lines, dividing the area of the pelvic shadow into minute squares, whereby the 
 dimensions desired may be measured approximately. 
 
 CLISEOMETRY. 
 
 Cliseometry is the art of measuring the size of the angle of inclination of the 
 planes of the pelvic inlet and outlet. For many years obstetricians have sought a 
 practical and trustworthy method for determining these angles. Some authorities 
 * ' The Rontgen Rays in Medicine and Surgery," 1901, p. 378. 
 
THE EXAMINATION OF PREGNANCY. 
 
 179 
 
 have seen in cliseometry a valuable prospective resource in the differential diag- 
 nosis of pelvic deformities, while others believe that the subject of forceps-traction 
 should benefit most from increased study of the inclination. Cliseometers have 
 been devised by Naegele, Rit-gen, Prochownik, and others, but no one apparatus 
 has ever attained any considerable degree of recognition. Sources of error, cum- 
 brousness, and general impracticability have thus far attended all attempts to 
 systematize and popularize cliseometry. Neumann and Ehrenfest * have intro- 
 duced a device for measuring the pelvic inclination, which they term a cliseometer 
 (Fig. 222). It consists of a rigid curve (A), which carries at one end a hollow 
 cylinder rod (B), so disposed that it lies directly in the axis of the free extremity of 
 the curve, which is armed with a knob (C); the hollow cylinder contains a solid 
 
 Fig. 222. — Method of Measuring the Degree of Pelvic Inclination. 
 (Instrument of Neumann and Ehrenfest.) 
 
 Cliseometry. 
 
 rod (D), which sUdes up and down, and is armed with a second knob (F). The 
 two knobs are naturally in the same axis. The upper extremity of the moving 
 rod contains a disc (G), which rotates in the direction of the length of the rod. 
 The periphery of the disc is divided into degrees. Above and below are zero 
 marks, and the numbering is so arranged that there are four quadrants^ of 90 
 degrees each. The disc is also provided with a water-level and an index. When 
 the cliseometer is so placed that the axis in which the knobs lie is horizontal, 
 the index points to o. If the knobs are apphed to the points used in measuring 
 the external conjugate with a pelvimeter, and the disc is then rotated until 
 the water-level is horizontal, the zero points are also horizontal. The angle 
 
 * " Monatsschrift f. Geburts. und Gynakol.," 1900, vol. xi. 
 
180 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 made by the cylindrical rod and knobs with the horizontal plane, or diameters 
 between the zero marks, represents the inclination of the plane of the inlet.* 
 
 CEPHALOMETRY. 
 
 Various procedures have been devised for the determination of the diameters 
 of the fetal skull, especially the biparietal and the bitemporal. Attempts 
 have been made to measure the skull directly — that is, through the intervening 
 soft parts ; to estimate the size of the skull through measurements of more 
 accessible fetal structures; and, finally, to estimate the cranial dimensions by 
 the duration of pregnancy. 
 
 I. From the Period of Gestation. — Dubois's Method. — From numerous meas- 
 
 
 rz^ 
 
 Fig. 223. — Ferret's Method of Cephalometry and Instrument. 
 
 urements of the fetal skulls after premature deliveries, controlled by the supposed 
 duration of pregnancy, Dubois arrived at the following relationship between 
 the month of gestation and the biparietal diameter: seven months, 2^ inches 
 (7 cm.); eight months, 33- inches (8 cm.); eight and a half months, T^i^ inches 
 (8.5 cm.); term, 4 inches (9 cm.). Unfortunately for this relationship, we 
 cannot usually determine the duration of pregnancy, and therefore but little 
 practical benefit is derived from the application of such a method to fetometry. 
 2. Direct Abdominal Cephalometry. — Ferret's Method (Fig. 223). — Perret was 
 the first to practise the measurement of the fetal head through the abdominal 
 wall. The foundation of this method was laid in the results of craniometry of the 
 newly bom. Numerous measurements had shown Perret that whatever the length 
 of the biparietal diameter, the occipito-frontal measurement is approximately i 
 
 * The instrument of Neumann and Ehrenfest is made by M. Schurr, Vienna, IV Schaum- 
 btirgerstrasse, No. 7a. I obtained my instrument through the Kny-Scheerer Co., New York. 
 
THE EXAMINATION OF PREGNANCY. 
 
 181 
 
 inch (2.54 cm.) longer; so that if it were possible to measure the occipito-frontal 
 diameter in utero, the shorter measurement could be calculated with ease. 
 For the practice of external- cephalometry, or the measurement of the occipito- 
 frontal diameter of the fet-us through the abdominal wall, the cephalometer 
 devised by Perret is employed. This apparatus is simply a spherical compass, 
 such as is sometimes used in external pelvimetry, but the knobs which arm the 
 branches of a pelvimeter are replaced by a special device for overcoming the 
 difficulties which are incident to mensuration through the thick abdominal wall 
 (Fig. 223). Ferret's description of this device is as follows*: "At the extremity 
 of each branch is a flattened blade, so shaped as to be held readily between the 
 fingers. These httle blades revolve on their axes in slots which exist in the tips 
 of the branches of the compass. On account of this mobility, the fingers of the 
 operator enjoy a corresponding freedom of movement. With the fingers in posi- 
 tion, that end of the blade which corresponds to the palmar surface and projects 
 beyond is furnished with a convex button." 
 
 Ferret's method of using his cephalometer is as follows: The woman is placed 
 on her back, and the operator ap- 
 plies his hands to each side of the 
 abdomen, just as when seeking to 
 determine whether or not the head 
 is engaged (Fig. 223). If engage- 
 ment has occurred, the procedure 
 must be abandoned. Otherwise the 
 operator begins to palpate with the 
 short movable blades (which fur- 
 nish the tips of the branches of the 
 cephalometer) the head between 
 the terminal phalanges of the mid- 
 dle and ring fingers of both hands. 
 As the palpating finger-tips locate 
 the head, an attempt is made to 
 press the cephalometer buttons 
 against the forehead and occiput of 
 the child. When this has been ac- 
 complished, the distance is read 
 off on the scale of the apparatus. 
 
 The thickness of the abdominal wall is next measured directly, by pinching 
 up a fold of the latter, and is deducted from the fetal measurement (Fig. 
 224). The result should be the occipito-frontal diameter of the child's 
 head. If now we subtract i inch (2.54 cm.), we obtain the biparietal 
 diameter. The cephalometer has been in constant use in the Tamier clinic in 
 Paris for a number of years. In the hands of Ferret and others the results are 
 surprisingly good, the error between the intrauterine and extrauterine measure- 
 ments being insignificant in the majority of cases; so that in the hands of one 
 specially trained, cephalometry may be termed a practical success. On the con- 
 trary, others have published series of cases in which the error was so great as to 
 invalidate the results of the method for ordinary practice. What has thus far 
 been said of Ferret's cephalometry refers only to labor at term, the mensuration 
 having for its immediate object the determination of disparities between the 
 measurement of the head and pelvis. There is, however, a second and equally 
 important indication for cephalometry in connection with artificial premature 
 
 * "L'Obst^trique," Nov., 1899. 
 
 Fig. 224. — Measuring the Thickness of the 
 Anterior Abdominal Wall. 
 
182 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 delivery. Given the dimensions of a contracted pelvis, ceplialometry should 
 determine the maximum size of the head compatible with natural delivery, and 
 indicate the period at which pregnancy should be terminated. 
 
 The ratio between the two cranial diameters of the fetus holds good for 
 the seventh, eighth, and ninth months, the difference, i inch (2.54 cm.), being 
 in reality the average difference of all skulls having a biparietal diameter of 
 from 3 to 3^ inches (7.62 to 8.89 cm.). Labor must be interrupted, of course, 
 before the biparietal diameter becomes longer than the true conjugate. The 
 results of Perret and others, in this department of obstetrics, appear to show 
 that his method is of undoubted value in aiding in the choice of that moment 
 for the interruption of pregnancy which shall be most advantageous for the 
 interests of mother and child alike. 
 
 3. Stone's Method of Cephalometry (Fig. 225). — This is a modification of 
 
 Fig. 225. — Stone's Method of Cephalo- 
 metry. 
 
 Fig. 226. — Determining the Capability of 
 THE Head to Descend into the Pelvis. 
 Muller's Method of Cephalometry. — 
 {Bumnt.) 
 
 Ferret's method. An ordinary pelvimeter is used, and no deduction is made for 
 the thickness of the abdominal and uterine walls. The patient is in the ordinary 
 dorsal posture, and the examiner standing on one side, facing the patient's feet, 
 carefully palpates and makes out the position of the fetal head. If it is already 
 engaged in the pelvis, it will not only be impracticable, but also unnecessary to 
 measure it. The occipital and frontal poles are now grasped between the two 
 hands, and an assistant places from below the ends of the pelvimeter between 
 the terminal phalanges of the middle and ring fingers of the examiner, pushing 
 them firmly inward as the examiner directs. An assistant or nurse is necessary 
 to obtain the best results, in order that the examiner's fingers may be entirely 
 free accurately to locate the fetal head (Fig. 225). From this measurement 
 obtained, namely, the occipito-frontal diameter, is subtracted one inch (2.5 cm.), 
 which is the average difference at the seventh, eighth, and ninth months between 
 the occipito-frontal and biparietal diameters. Stone found the average difference 
 
THE EXAMINATION OF PREGNANCY. 
 
 183 
 
 to be 2.33 cm. in one hundred measurements, and he subtracts 2 cm. for heads 
 with an occipito-frontal diameter of less than 4.2 inches (11 cm.) and one inch 
 (2.5 cm.) for those above this .measurement. Thus fairly accurate results will 
 be obtained and sufficient amount will be allowed for the moulding.* 
 
 4. Manual Engagement of the Head. — Miiller's Method (Fig. 226). — The 
 relations which exist between the head and pelvis may often be determined 
 by various manual procedures. The so-called method of Miiller has been 
 brought into regular and systematic use by prominent obstetricians of Paris, 
 
 •■-mHI^ 
 
 Fig. 227. 
 
 -Determining any Disproportion between the Fetal Head and the Pelvic 
 ' Inlet. 
 
 under the name of '' palper-mensurateur ," given it by Pinard. According to 
 Budin, it is sufficient to make an attempt to engage the head in the pelvis, by 
 pressure exerted through the abdominal wall, as in Hofmeier's method for 
 securing the engagement of the head during labor. (See Labor.) After the 
 bladder and rectum have been emptied, the accoucheur places a hand on 
 each side of the hypogastrium (Fig. 227), the head being in relation with the 
 inlet. Pressure is then made in the axis of the superior strait, so that the head 
 is forced into the pelvic cavity. If this engagement can be brought about, 
 
 *W. S. Stone, "Antepartum Measurement of the Fetal Head," " N. Y. Medical 
 Record," November 4, 1905, p. 725. 
 
184 PHYSIOLOGICAL PREGNANCY. 
 
 it is evident that labor should be normal. The head enters the pelvis more 
 readily if the patient is so placed that the long axis of the uterus is vertical and 
 at right angles to the plane of the inlet. The manceuver is disagreeable to 
 many women, and is also difficult of execution if the abdominal walls are thick 
 and resistant, but it renders real service, giving valuable information to the 
 physician. I have found it more reliable to introduce the whole hand into the 
 vagina, and with the fingers spread over the head to have an assistant exert 
 pressure on the hypogastrium to secure engagement of the head (Fig. 227). 
 The internal hand then estimates the relation between the size of the head 
 and the inlet. Perret, in comparing his method of cephalometry with the 
 "palper-jnejisurateur," states that it cannot be applied in nervous women, in 
 cases of vicious insertion of the placenta, hydramnios, thick abdominal walls, 
 or in any case after labor has begun. It is, of course, applicable in head 
 presentations only. The "palper-mensuratetir" also gives false information at 
 times. Thus, it appears to indicate that delivery is impossible in cases in which 
 the pelvis is normal, and failure to engage is due to trouble higher up (false 
 lumbar promontory, tumors, etc.). 
 
 5. Internal Manual Cephalometry. — A fairly accurate estimate of the size 
 of the fetal head may be obtained by introducing the whole hand into the vagina 
 after full dilatation of the cervix, and grasping the head with the extended fingers, 
 then with firm suprapubic pressure with the other hand attempting to engage 
 head and fingers together (Fig. 227); or one can simply grasp the head as in 
 Fig. 226, and estimate its size by palpation. 
 
 6. Rontgen Cephalometry. — As will be seen by referring to the section on 
 Rontgen pelvimetry, recognition of pelvic anomalies is relatively simple. The 
 great problem to overcome is the photography of the fetus. If a combined 
 shadow of both the head and pelvis could be obtained, much light would be 
 thrown upon the relations existing between these structures in individual 
 cases. In 1898, Gocht * announced that photography of the fetal skeleton 
 was impracticable. Varnier, however,t succeeded, after more than three years 
 of effort, in obtaining a clear view of the contour of the fetal head in a woman 
 seven months pregnant, so that he regards it as practicable to determine the size 
 of the head, its position, degree of flexion, and manner of engagement, in the 
 latter months of pregnancy. No shadow can be obtained of the spine and 
 limbs, however. Varnier's J complete studies have not yet appeared, and although 
 he has demonstrated to me personally in Paris the minute technique of his 
 method, I do not feel at liberty to publish it. 
 
 XI. THE HYGIENE AND MANAGEMENT OF PREGNANCY. 
 
 Prophylaxis. — A large proportion of the women who apply to the gynecologist 
 for relief of crippled pelvic organs owe their invalid conditions to mismanagement 
 or avoidable accidents of the pregnant, parturient, and lying-in states. This 
 large class of invalids, who owe their condition to careless and unclean obstetrics, 
 can be greatly reduced, if not practically done away with, and the remedy is 
 to be found not in the preaching, but in the practice of clean and conservative 
 obstetrics. A careful attention to prophylaxis, on the part of the obstetrician, 
 
 * " Lehrbuch d. Rontgen-Untersuchung." 
 
 t "Ann. de Gyn6col. et d'0bst6triqiie," April, 1889. 
 
 t Professor Varnier died in 1903. 
 
THE HYGIENE AND MANAGEMENT OF PREGNANCY. 185 
 
 is of value not only in anticipating and warding off many of the dangers of 
 pregnancy, labor, and the puerperium, but also in preventing many subsequent 
 disabilities of a gynecological nature. Nowhere more than here does the old 
 maxim, that prevention is -better than cure, find truer application. There 
 is relatively little that we can do during pregnancy, which will have a direct 
 influence in the prevention of subsequent uterine and pelvic trouble. Attention 
 to the general health, however, — e. g., the prevention of constipation, the 
 proper treatment of coexisting anemia, moderate exercise in the open air, 
 suitable clothing, especially the avoidance of constriction about the waist, in 
 a word, a good hygiene of pregnancy, — is undoubtedly of prophylactic impor- 
 tance in two ways: (i) By providing the patient with healthy blood, one of 
 the best of germicides, and thus, perhaps, forestalling or minimizing the effects 
 of septic infection; (2) by increasing the muscular and general nutrition, factors 
 of undoubted importance in the prevention of -subsequent subinvolution of 
 the uterus and adnexa. Every pregnant woman should be impressed with 
 the importance of placing herself under the care of the physician who is to 
 attend her, as soon as she shall become aware of her condition. It would be 
 wise to give such a patient, early in gestation, some simple directions, either 
 verbal or printed, embracing advice regarding exercise, clothing, diet, care of 
 bowels, skin, kidneys, breasts, teeth, and the danger-signals of approaching 
 complications. (See Appendix.) There can be little doubt that not only patients 
 but their advisers are too prone to consider this a period of invalidism, and 
 to forget that it is a physiological process. One of the important results of the 
 former view is the neglect of muscular exercise, especially in the higher ranks 
 of life, where the desire to escape observation, and the fears inspired by false 
 ideas, lead to the neglect of even the little exercise — i. e., walking — to which 
 the patient is accustomed, and the consequent weakening of the whole muscular 
 system. Now, just the opposite should be the case. The strain imposed upon 
 the muscular system by the requirements of labor is a severe one, and should 
 be forestalled by the cultivation, as far as possible, of muscular strength. In 
 the effort, however, to secure a proper hygiene of pregnancy, we should not 
 forget the danger of overexertion; and this brings us to the consideration of 
 one point which I believe to be of especial and direct prophylactic importance. 
 I refer to the avoidance of everything which increases intrapelvic pressure 
 and resulting pelvic congestion. 
 
 No one who has had an extensive obstetric experience can jail to observe that 
 a large number of pregnancies are, when carefully studied, really pathological in 
 their nature. Witness the frequency of the toxemia of pregnancy as we understand 
 the condition to-day, and the probable dependence of most cases of vomiting of 
 pregnancy upon this state. (See Part III.) 
 
 Our present knowledge of the pregnant state demands that women at this time 
 shall be constantly under the observation of a competent physician. 
 
 Pregnancy cannot be treated through the m.ails or over the telephone. 
 
 It is not enough that a monthly or bi-monthly examination of the urine be made 
 for symptoms of hepatic or renal insufficiency, as such urinary analysis often 
 fails completely to indicate the presence of toxemia. 
 
 Pregnant women should be frequently seen by their physician, and watched for 
 general symptoms of the over-charging of the blood with toxic material — as nausea 
 and vomiting, headache, physical and mental lassitude, high arterial tension, 
 alterations in character and disposition. 
 
 Thus, and thus only, shall the physician do his whole duty by his patient. 
 
 Exercise. — The pregnant woman is often almost unfitted for exercise in 
 
186 PHYSIOLOGICAL PREGNANCY. 
 
 the early part of pregnancy, on account of the usual discomfort of "morning 
 sickness," and in the last part by her great increase in size, at which latter 
 time she generally lies down frequently and is disinclined to any exertion. The 
 nausea of the early months often plays a protective role in pregnancy, as it 
 demands rest on the part of the patient, who might otherwise overexert herself. 
 Nevertheless, a moderate amount of exercise is very beneficial during the period 
 of gestation; walking offers the most favorable form, since more violent exercise 
 may cause much harm. Carried to the point of slight fatigue every day, exercise, 
 especially walking, will put the woman herself, as well as her child, into the 
 best physical condition for her approaching labor. If the patient is unable 
 to take this kind of exercise, then the passive form obtained 'in carriage-driving 
 will be found next in order of efficiency; but if this causes backache and a 
 feeling of weight in the lumbar region it should be forbidden. 
 
 Diet. — A mixed diet, sufficient in quantity to meet the often increased appetite 
 of the patient, is probably the best. Important modifications of diet are, of course, 
 imperative in threatened albuminuria, vomiting of pregnancy, and other morbid 
 conditions. (See Pathological Pregnancy.) Usually early in pregnancy there 
 are certain digestive disturbances which, with the less active life they entail, 
 cause a decrease in desire for food. In many cases morning sickness has been 
 avoided, or at least lessened, by giving an early morning breakfast to the patient, 
 after which she sleeps for an hour or two before rising. A generous, wholesome, 
 and simple diet is demanded by the patient. Meats, vegetables, and fruits should 
 be included. By the fourth month the gastric disorders disappear, as a rule, and 
 appetite returns. It is well, during the last of gestation, for the patient to take 
 several extra lunches daily, and on account of the encroachment of the enlarging 
 uterus on the gastric space, the amount of food taken at one time should be 
 smaller, but the intervals between meals should be shorter. 
 
 Drink. — The drink should be water, milk, or chocolate; tea and coffee may 
 be taken in moderation, but should not be strong. Alcoholic beverages should 
 be avoided, for the pregnant woman is especially prone to contract the alcoholic 
 habit. 
 
 Bowels. — The bowels should be carefully looked after, and constipation 
 is to be especially avoided. Plenty of water should be taken and the diet 
 should look toward the alleviation of constipation. Coarse cereals, fruit, etc., 
 encourage free movements. Enemata or mild laxatives may be added to the 
 regime. Glycerin, soap, gluten, and cocoa-butter suppositories are useful; 
 one or two teaspoonfuls of aromatic cascara at bedtime ; tasteless fluid extract 
 of cascara and fluid extract of licorice each a half-teaspoonful at bedtime; 
 tablet triturates with varying combinations of aloin, cascarin, belladonna, and 
 strychnine. The habitual use of suppositories and enemata should be avoided, 
 as well as the sulphate of soda, mineral waters, or, in fact, the constant use of 
 any drug, as our object should be to secure proper action of the bowels by 
 attention to the diet and the free use of water. Most pregnant women are 
 benefited by an occasional dose of a mercurial at bedtime, followed by a saline 
 or sulphur water in the morning. (Compare Constipation, under "Pathological 
 Pregnancy.") 
 
 Fresh Air. — Plenty of outdoor air is essential to the patient. The gravid 
 woman is eliminating an increased amount of carbonic acid, as she is breathing 
 for two. Crowded rooms should be sedulously avoided, and all impure air, 
 sewer-gas, etc., excluded. There must be thorough ventilation of the rooms occu- 
 pied both by night and day. 
 
 Care of the Skin. — The skin should play its full part as an eliminating organ. 
 
THE HYGIENE AND MANAGEMENT OF PREGNANCY. 
 
 187 
 
 especially in the last part of pregnancy, as the kidneys must be relieved as far 
 as possible of extra work. Bathing should be continued according to the patient's 
 habits before pregnancy. Reaction may be secured by friction with a coarse 
 towel. Hot and cold baths, -however, or any shock, — for example, that incident 
 to sea-bathing, — should be avoided. Tepid 
 vaginal douches are often a source of great 
 comfort. 
 
 Clothing. — Clothing should be well adapted 
 to the condition. Corsets are to be laid aside; 
 low-heeled shoes are to be preferred; it is well 
 to suspend the weight of the garments from the 
 shoulder-straps. The clothes should weigh as 
 little as possible and be loosely fitted. Circular 
 garters ought to be replaced by side supporters. 
 It is well to recommend warm drawers as soon as 
 the enlarging abdomen lifts the skirts from the 
 thighs. If the abdomen is very lax and pendu- 
 lous, a suitable binder may well be applied for 
 support. It should aim to lift the weight from 
 below and exert no pressure. One of the best 
 abdominal supporters is a French maternity cor- 
 set (Figs. 228 and 229), which combines support 
 of the lower abdomen with that of the breasts. 
 I had this corset imported several years ago, 
 and have used it in my practice, with much 
 satisfaction to my patients.* 
 
 Leucorrhea. — In the case of leucorrheal dis- 
 charge, vaginal douches may be necessary, and 
 bathing and care of the external genitals are ab- 
 solutely demanded for the comfort of the mother. 
 Local treatment, if demanded, can be applied 
 without harm, with proper precautions, (See 
 Part III.) 
 
 Breasts. — There must be no pressure on the 
 mammary glands, and they must be warmly 
 covered. The nipples particularly must be kept 
 scrupulously clean. The physician should make 
 an examination of these organs a month before 
 labor, when any abnormalities, such as abrasions, 
 fissures, milk scabs, etc., can be treated. If the 
 nipples are retracted, they may be drawn out 
 gently every day by the patient herself. Some 
 believe in the daily exposure of the nipples to 
 the air, in order to render more active the 
 epidermic secretion. To prevent sore nipples 
 during lactation, I am accustomed to instruct 
 
 my patients to carefully draw out each nipple daily, in the last few weeks of 
 gestation, with absorbent cotton moistened with an oily astringent, such as com- 
 pound tincture of lavender, two ounces, and glycerin, half a drachm. (For breast 
 supporters, see Pathological Puerperium, Part VII.) 
 
 * This maternity corset is now made in this country for me by Mrs. Leighton, 3 East 
 41st Street, New York city. 
 
 Fig. 228. — Ax Improved Ma- 
 ternity Corset for Sup- 
 port OF THE Lower Abdomen 
 AND Breasts in the Latter 
 Weeks of Gestation. An- 
 terior View. — (From a pho- 
 tograph taken at the Emergency 
 Hospital.) 
 
188 
 
 PHYSIOLOGICAL PREGNANCY. 
 
 Mental Condition. — Mental depression and excitement should be guarded 
 against. Anxiety shoiild be quieted, kind assurances and encouragement should 
 not be spared. The patient should be guarded from all petty worries and troubles, 
 as well as from shocks or surprises. Judicious amusement should be provided, 
 
 and she should be surrounded by cheerful and 
 agreeable companions, while her mind should 
 be occupied by some pleasant and congenial 
 occupation. The influence, moral, mental, phy- 
 sical, of the mother on the fetus in titer o is a 
 subject so vast and complex that its depths 
 have never yet been sounded. Great allow- 
 ance should be made for the whims and irri- 
 tability of the pregnant woman, as she is 
 often not responsible for her altered temper. 
 Many changes in her are probably due to the 
 alterations, both quantitative and qualitative, 
 in her blood at this time, as well as to the 
 changes taking place in her sexual organs. So 
 she should be humored and shielded, and her 
 idiosyncrasies should be gently overlooked. 
 
 Examination of the Urine. — From the third 
 to the seventh month, monthly examinations of 
 the urine should be made; from the seventh 
 to the ninth month, every two weeks, and then 
 once a week till labor begins. The patient should 
 be warned to make an immediate report of any 
 decrease in the amount of urine excreted in the 
 twenty-four hours. The examination should 
 take account of the twenty-four hours' amount, 
 / . / ' '''*.''^^c^^ ^^® specific gravity, the quantity of urea and 
 
 r °""'7rl;:.: / j£^. \:^)r^ its variation, intestinal or hepatic toxemia, and 
 
 the presence of albumin and casts. Through 
 this constant watch for symptoms of toxemia 
 many cases of eclampsia may be avoided. (See 
 Toxemia of Pregnancy.) 
 
 Sexual Intercourse. — The subject of marital 
 intercourse during pregnancy has received much 
 attention. Many and diverse opinions have 
 been expressed, but it is generally considered 
 that during the first months of pregnancy, and 
 at the last, sexual intercourse should be forbid- 
 den. To most pregnant women it is distasteful, 
 although in others the sexual appetite is in- 
 creased. It often causes great pelvic discom- 
 fort. It should in any case be forbidden at 
 those times which correspond with the menstrual 
 epochs, as then pelvic congestion and a special 
 tendency to abortion exist. Sexual intercourse is held to be one of the most 
 influential factors in producing abortion and systemic disturbances. 
 
 The possibility of infection of the uterus during coitus from germs beneath 
 the foreskin cannot be denied. This is especially liable to occur in a case of 
 placenta prsevia. 
 
 Fig. 229. — An Improved Ma- 
 ternity Corset for Support 
 OF THE Lower Abdomen and 
 Breasts in the Latter 
 Weeks of Gestation. Pos- 
 terior View. — (From a photo- 
 graph taken at the Emergency 
 Hospital.) 
 
PART THREE. 
 Pathological Pregnancy* 
 
 I. DISEASES OF THE DECIDU/E. (Page 191.) 1. Acute Infectious or Ex= 
 anthematous Deciduitis. 2. Acute Hemorrhagic Deciduitis. 3. Acute Puru- 
 lent Deciduitis. 4. Chronic Catarrhal Deciduitis, Endometritis Gravidarum 
 Catarrhalis, Endometritis Deciduae Catarrhalis. 5. Chronic Diffuse Hyper- 
 plastic Deciduitis, Endometritis Deciduae Chronica Diffusa, Endometritis 
 Gravidarum Hyperplastica. 6. Chronic Tuberous or Polypoid Deciduitis. 
 
 7. Chronic Cystic Deciduitis. 8. Apoplexy of the Decidua. 9. Atrophy 
 of the Decidua. 10. Deciduoma. 11. Chorio-epithelioma Malignum. 
 
 II. DISEASES OF THE CHORION. (Page 198.) 1. Cystic Degeneration of the 
 Chorionic Villi; Hydatidiform or Vesicular Mole ; 2. Flbromyxomatous De- 
 generation of the Chorion. 3. Chronic Choriitis. 
 
 III. ANOMALIES OF THE AMNION AND LIQUOR AMNII. (Page 201.) 1. 
 
 Plastic Exudation, Amniotitis. 2. Abnormal Tenuity. 3. Cysts and Der- 
 moids. 4. Premature Rupture, Amniotic Hydrorrhea. 5. Anomalies in 
 Color and Composition of Liquor Amnii. 6. Oligohydramnios. 7. Hy= 
 dramnios. 
 
 IV. ANOMALIES AND DISEASES OF THE PLACENTA. (Page 208.) 1. Ano- 
 
 malies. — (1) Size: (a) Atrophy; (b) Hypertrophy; (c) Placenta Membra- 
 nacea. (2) Form. (3) Number, (4) Relation. (5) Insertion : Placenta 
 Praevia. 2. Injuries. — Premature Detachment. Accidental Hemorrhage. 
 3. Stasis and CEdema. 4. Interstitial Hemorrhage. — Apoplexy. Infarc- 
 tion. Thrombosis. 5. Placentitis. — (1) Acute Septic, (2) Gonorrheal, (^3) 
 Emanuel's Disease. (4) Specific; (5) Chronic Interstitial and (6) Albumm- 
 uric. 6. Infectious Qranulomata. — Tuberculous and Syphilitic. 7. Sec- 
 ondary Metamorphoses. — (1) Progressive. Hyperplastic and Sclerotic. 
 Adherent Placenta. (2) Regressive. Results of Fetal Death. White In- 
 farcts. Cystic, Calcareous, Fatty, and Miscellaneous Degenerations. 8. 
 Tumors. — -Placentomata. Polypi. 
 
 V. ANOMALIES OF THE UMBILICAL CORD. (Page 237.) 1. Length. 2. 
 Thickness. 3. Insertion. 4. Coils. 5. Knots. 6. Tangling. 7. Torsion. 
 
 8. Stenosis of the Vessels. 9. Cysts. 10. Calcareous Deposits. 11. Hernia. 
 
 12. Syphilis. 13. Obstruction of the Vessels. 14. Dilatation of the Um- 
 bilical Vein. 15. Hypertrophy of the Valves. 16. Congenital Tumors. 
 
 VI. DEFORMITIES AND MONSTROSITIES OF THE FETUS. (Page 244.) 
 
 VII. ANTENATAL DISEASES OF THE FETUS. (Page 255.) I. Infectious Dis- 
 eases. 2. Acute Poisoning. 3. Chronic Poisoning. 4. Dyscrasic Condi- 
 tions. 5. Cardiac Diseases. 6. Diseases of the Alimentary Tract. 7. Dis- 
 eases of the Nervous System. 8. Diseases of the Urogenital Apparatus. 
 
 9. Skin Diseases. 10. Bone Disease. 11. Traumatisms. 12. Neoplasms. 
 
 13. General CEdema. 14. Maternal Traumatisms. 15. Maternal t Uterine 
 Disease Affecting the Fetus. 16. Fever in the Mother Affecting the Fetus. 
 17. Death of the Mother Affecting the Fetus. 
 
 VIII. DEATH OF THE FETUS. (Page 272.) 1. Maceration. 2. Mummification. 
 3. Absorption. 4. Putrefaction. 5. Saponification. 6. Calcification. 
 
 IX. DISEASES OF THE GENITAL ORGANS. (Page 274.) 1. Anteflexion and 
 Anteversion. 2. Retroflexion, Retroversion, and Incarceration. 3. Latero- 
 flexion and Lateroversion. 4. Prolapse of the Pregnant Uterus. 5. Tor- 
 sion. 6. Hernial Protrusion of the Pregnant Uterus. 7. Periuterine In- 
 flammation and Adhesion. 8. Rheumatism of the Uterine Muscle. 9. 
 Metritis. 10. New Growths of the Uterus. 11. Spontaneous Rupture. 
 12. Malformations. 13. Leucorrhea. 14. Cystic Vaginitis. 15. Specific 
 Vaginitis. 16. Prolapse of the Vagina. 17. Pruritus Vulvae. 18. Vari- 
 cosities of Vagina and Vulva. 19. Vegetations. 20. CEdema of the Vulva. 
 
21. Eczema of the Nipple. 22. Mammary Abscesses. 23. Hemorrhage 
 from the Genitals during Pregnancy. 24. Hematoma of the Vulva. 
 
 X. THE TOXEMIA OF PREGNANCY. AUTO=TOXEMIA OF PREG- 
 NANCY. HEPATIC INSUFFICIENCY. PREGNANCY LIVER. PRE- 
 ECLAMPTIC STATE. (Page 291.) 1. Toxemia of Pregnancy. 2. Nausea 
 and Vomiting. 3. Icterus. 4. Convulsions and Coma. 5. Eclampsia. 
 
 XI. DISEASES OF THE URINARY TRACT. (Page 315.) 1. Passive Con= 
 gestion of the Kidney. 2. Acute Nephritis. 3. Chronic Nephritis. 4. 
 Floating Kidney; Tumors of the Kidney. 5. Pyelonephritis. 6. Hydro= 
 nephrosis. 7. Renal Calculi. 8. Renal Insufficiency and Toxemia. 9. 
 Vesical Irritation. 10. Cystitis. 1 1. Incontinence of Urine. 12. Urinary 
 Retention. 13. Vesical Hemorrhoids. 14. Vesical Calculi. 15. Cystocele. 
 16. Vesical Neoplasms and Traumatism. 17. Albuminuria. 18. Polyuria. 
 19. Peptonuria. 20. Hematuria. 21. Glycosuria. 22. Lipuria and Chy- 
 luria. 23. Acetonuria. 24. Urinary Sediments of Pregnancy. 
 
 XII. DISEASES OF THE ALIMENTARY TRACT. (Page 321.) 1. Gingivitis. 
 2. Dental Caries. 3. Oral Sepsis. 4. Salivation or Ptyalism. 5. Anorexia. 
 6. Nausea and Vomiting. 7. Persistent Vomiting, Hyperemesis Gravi- 
 darum. 8. Malacia, Longings. 9. Gastric and Intestinal Indigestion. 10. 
 Consumption. 11. Diarrhea. 12. Hemorrhoids. 13. Jaundice, Icterus 
 Gravidarum. 14. Appendicitis. 15. Tapeworm. 
 
 XIII. DISEASES OF THE CIRCULATORY SYSTEM. (Page 325.) 1. Acute 
 Endocarditis. 2. Chronic Endocarditis. 3. Affections of the Heart Mus= 
 cle. 4. Graves's Disease. 5. Varicosities. 6. Aneurysm. 7. Palpita- 
 tion. 8. Syncope. 9. Hydremia. 10. Pernicious Anemia. 11. Exoph- 
 thalmic Goiter. 
 
 XIV. DISEASES OF THE RESPIRATORY SYSTEM. (Page 329.) 1. Hyper- 
 osmia. 2. Bronchitis. 3. Pneumonia. 4. Emphysema. 5. Pleurisy. 
 6. Hemoptysis. 7. Pulmonary Tuberculosis. 8. Acute Miliary Tuber- 
 culosis. 9. Dyspnea of Pregnancy. 10. Neuroses and Spasmodic Cough. 
 11. Asthma. 
 
 XV. DISEASES OF THE NERVOUS SYSTEM. (Page 332.) 1. Cerebral Dis- 
 ease. 2. Gestational Melancholia, Mania, and Dementia. 3. Vertigo and 
 Syncope. 4. Insomnia. 5. Gestational Paralysis. 6. Gestational Neu- 
 ralgias. 7. Neuroses. 
 
 XVI. INFECTIOUS DISEASES. (Page 336.) 1. Variola. 2. Scarlatina. 3. 
 Measles. 4. Typhoid. 5. Typhus. 6. Erysipelas. 7. Malaria. 8. Pneu- 
 monia. 9. Syphilis. 
 
 XVII. SKIN DISEASES. (Page 337.) 1. Pruritus. 2. Pigmentation. 3. Herpes 
 Gestationis. 4. Impetigo Herpetiformis. 5. Alopecia. 6. Fibroma Mol- 
 luscum Gravidarum. 
 
 XVIII. DISEASES OF THE OSSEOUS SYSTEM. (Page 340.) 1. Relaxation of 
 the Pelvic Joints. 2. Inflammation of the Joints. 3. Osteomalacia. 4. 
 Rachitis. 
 
 XIX. THE PREMATURE INTERRUPTION OF PREGNANCY. (Page 342.) 
 
 XX. ECTOPIC GESTATION. (Page 361.) 
 
 XXI. PREGNANCY IN ONE HORN OF A UTERUS UNICORNIS OR BI- 
 CORNIS. (Page 367.) 
 
 XXII. MISSED LABOR. (Page 368.) 
 
 XXIII. SUDDEN DEATH DURING PREGNANCY. (Page 369.) 
 
 |XXIV. INJURIES AND OPERATIONS UPON PREGNANT WOMEN. (Page 369.) 
 
 XXV. PREGNANCY AFTER OPERATIONS INVOLVING THE GENITALS. 
 (Page 370.) Pregnancy after Ventro=fixation and Ventro=suspension. 
 (See Pathological Labor, page 600.) 
 
 XXVI. THE FEVER OF PREGNANCY. (Page 370.) 
 
 XXVII. THE METRORRHAGIA OF PREGNANCY. (Page 371.) 
 
Pathological or abnormal pregnancy is one in which some departure from a 
 physiological pregnancy occurs in mother, ovum, embryo, or fetus. Although 
 the vast majority of pregnancies are normal, still it must be remembered that 
 in all classes of mankind the departures from the normal standard in ances- 
 tors and parents, with their accompanying physical imperfections, latent or 
 obscure though they may be, will show themselves in even more pronounced 
 and dangerous forms in the pregnant womail and the fetus in utero. The 
 influences upon the present and subsequent generations of years of improper 
 hygienic environment and nutrition, with their resulting faulty development 
 of muscle and bone, and reflex neuroses must never be lost sight of in the 
 examination of pregnancy. 
 
 I. DISEASES OF THE DECIDU/E. 
 
 ;•. Acute Infectious or Exanthematous Deciduitis. 2. Acute Hemorrhagic Deciduitis, j. 
 Acute Purulent Deciduitis. 4. Chronic Catarrhal Deciduitis, Endometritis Gravidarum 
 Catarrhalis, Endometritis Deciduce Catarrhalis. 5. Chronic Diffuse Hyperplastic 
 Deciduitis, Endometritis Deciduce Chronica Diffusa, Endometritis Gravidarum Hyper- 
 plastica. 6. Chrome Tuberous or Polypoid Deciduitis. 7. Chronic Cystic Deciduitis. 
 8. Apoplexy of the Decidua. g. Atrophy of the Decidua. 10. Deciduoma. 11. Chorio- 
 epiihelioma Malignum. 
 
 Introduction. — The decidua is the transformed endometrium, and it is sub- 
 ject to any of the diseases that may attack the non-gravid uterine mucous 
 membrane; but in the case of pregnancy these affections are apt to assume 
 a severe grade, owing to the great hypertrophy of the tissue concerned. The 
 results are apt, also, to be more serious, on account of the relation to the fetus. 
 Endometritis, so called, is generally not inflammatory, so the term, as often 
 applied, is a misnomer. These diseases are of several forms. 
 
 I. Acute Infectious or Exanthematous Deciduitis. — As its name impHes, this 
 is generally a result of the acute infectious diseases, although it may be an 
 extension of an inflammation from the endometrium before pregnancy. Ahlfeld 
 declares that the cervix is nearly always infected first, and this can be clearly seen 
 if the decidua serotina lies near the cervix, as in placenta prasvia. Of great 
 interest are the eleven cases of Klotz, which show the effect of measles[on preg- 
 nancy. Nine of these suffered from abortion, at a time which seemed to show a 
 direct connection between the expulsive efforts of the uterus and the breaking- 
 out of the eruption on the skin. Klotz believes that the uterine contractions 
 are caused by the irritation of the exanthem as it occurs on the mucous mem- 
 brane of the uterus. This disturbance is analogous to the photophobia, coryza, 
 bronchitis, and vesical tenesmus, which are the expression of the effect of the 
 same irritating cause upon other mucous membranes. The same explanation 
 would probably hold good for abortions occurring in any of the eruptive fevers. 
 This condition consists in active inflammatory changes, which may involve only 
 small foci or the entire decidua. 
 
 191 
 
192 PATHOLOGICAL PREGNANCY. 
 
 2. Acute Hemorrhagic Deciduitis. — In deciduse may often be found old and 
 fresh extravasations of blood between the villi. In one variety tuberosities 
 form, much like those seen in the tuberous decidua. If the extravasation con- 
 tinues after the death of the fetus, there is finally formed what is known as a 
 "fleshy mole." This structure conforms to the shape of the uterine cavity, 
 and consists of various layers of blood of different hemorrhages, held together 
 by means of the atrophied villi. In the center of this mass we usually find the 
 empty amniotic cavity, but at times the macerated fetus is present. (Compare 
 Pathology of Interrupted Pregnancy.) 
 
 3. Acute Purulent Deciduitis. — This condition is very rare. The case de- 
 scribed by Donat shows the state of the structures concerned. This patient 
 expelled at term a placenta which was surrounded by a margin of decidual 
 tissue infiltrated with pus. Between the amnion and chorion, which were both 
 thickened and -opaque, was a mass of purulent liquid. This condition probably 
 resulted from an unsuccessful abortion attempted by the woman herself. Various 
 explanations have been offered to clear up the nature of the case. Donat him- 
 self thinks that the pus made its way from the decidua through the chorion, 
 collecting between the latter membrane and the amnion. Careful macroscopic 
 and microscopic examinations were made, dispelling all doubt about the case. 
 Hirst suggests that the pus might have been originally expressed from a dis- 
 tended tube. Thence it may have forced its way through the ovular decidua, 
 or, if ealrlier in pregnancy, through the layers of the membranes. This last 
 theory seems quite plausible, in consideration of the recent work done on hydror- 
 rhoea ovarialis intermittens, in which affection there is a periodic discharge 
 from the tube into the uterus. 
 
 4. Chronic Catarrhal Deciduitis; Endometritis Gravidarum Catarrhalis; En- 
 dometritis Deciduae Catarrhalis; Hydrorrhoea Gravidarum. — Definition. — This is 
 a chronic inflammation of the decidual endometrium, probably arising from 
 some obscure morbid condition of the mucous membrane. 
 
 Pathology. — Many theories have been advanced to explain this rare condi- 
 tion. It may arise from a hypertrophy of the glands, whose openings are not 
 obliterated; and, as a result of this state of chronic glandular inflammation, a 
 clear viscid liquid is poured out between the decidua and chorion, whence it 
 makes its escape to the os uteri. The secretion varies greatly in quantity; in 
 one reported case, from one-half to three-quarters of a liter was lost each 
 time. Some believe that the secretion comes from the bursting of a cyst which 
 is formed between the ovum and the uterine walls; others, that it is a transu- 
 dation of the liquor amnii through the membranes. Another suggestion is that 
 the liquid escapes from an opening in the membranes at a distance from the 
 OS uteri ; still another, that the liquid comes from a sac between the amnion and 
 chorion. In these last cases there may be only one gush of the liquid contents ; 
 but if the discharge is a continuous one, or repeated intermittently, none of 
 these theories will hold good. This affection occurs in the first part of preg- 
 nancy, before the refiexa joins the vera; if, however, this union does not take 
 place, the discharge may continue throughout pregnancy. 
 
 Symptoms. — The fluid, which is of a pale yellowish color and transparent, 
 may escape from the vagina by dribbling, or by one sudden gush. It may 
 escape from time to time for weeks, and in such quantity as to soak the 
 clothing of the patient. 
 
 Diagnosis. — If a physician is called to such a case, and is told that there 
 has been an escape of waters, he is apt to think that the membranes have been 
 ruptured. In hydrorrhea there are no pains, the cervix is not dilated, and 
 
DISEASES OF THE DEC I BUM. 
 
 193 
 
 Fig. 230. — Decidual Endometritis, i, Decidual 
 tissue; 2, fetal villi; 3, layer of pus. (X 250 
 diameters ) — {From a specimen in the Pathologi- 
 cal Laboratory of the Cornell University Medical 
 College.) 
 
 ballottement can be obtained. If after the watery discharge pregnancy con- 
 tinues as before, the diagnosis of hydrorrhea may be estabhshed. Pregnancy 
 often continues to term with no 'untoward phenomena. 
 
 Differential Diagnosis. — Hydrorrhoea gravidarum is distinguished from incon- 
 tinence of urine also by the na- 
 ture of the secretion, and by the 
 absence of urea and of acid re- 
 action. Endotrachelitis and col- 
 pitis are excluded by inspection, 
 and by the absence of pus. Pus 
 may occur, however, if the dis- 
 ease is accompanied by an endo- 
 metritis. 
 
 Prognosis. — In general, the 
 prognosis is good for both 
 mother and child, as the preg- 
 nancy is not compromised by 
 the disease. The child should 
 be born at term and in good 
 condition. If other causes of 
 abortion are operative, the ges- 
 tation may of course be inter- 
 rupted. When the discharge is 
 continuous and of a dark hue, 
 the case may not go on to term. 
 Treatment. — The manage- 
 ment is comprised in the pro- 
 phylaxis of abortion. The woman should be kept recumbent, even in cases 
 of moderate degree. Opiates should be administered if uterine contractions are 
 present. 
 
 5. Chronic Diffuse Hyperplastic Deciduitis; Endometritis Deciduae Chronica 
 
 Diffusa; Endometritis Gravi- 
 darum Hyperplastica. — Defi- 
 nition. — Instead of the atro- 
 •phy of the uterine mucous 
 membrane that normally 
 takes place in the latter part 
 of pregnancy, the condition of 
 hyperplasia that existed in 
 the first part continues to 
 increase (Fig. 230). 
 
 Pathology. — This steady 
 progression, which aflfects 
 both layers of the decidua, 
 results in a membrane |- or 
 ^ inch (3 or 4 mm.) in thick- 
 ness. The cells increase in 
 size, and have larger, more vesicular nuclei. The tissue looks like that of a 
 sarcoma, and has been described as such. If the disease makes rapid strides, 
 abortion will generally occur as a result of hemorrhages into the mucous mem- 
 brane, which separate it from the wall of the uterus. Or it may occur from the 
 death of the fetus, whose nourishment has all been diverted to the increase of 
 13 
 
 Fig. 
 
 231- 
 
 -Decidua Tuberosa from an Abortion. - 
 {Ahljeld.) 
 
194 
 
 PATHOLOGICAL PREGNANCY. 
 
 the decidua. The embryo may be absorbed, and the decidual membranes after- 
 ward discharged as an empty sac with very thick walls, in which case it consti- 
 tutes one variety of the fleshy moles, (See Abortion.) Or the embryo may be 
 destroyed by hemorrhages into the abnormally developed decidua, the blood 
 forcing its way through all obstructions into the cavity of the ovum. In this 
 condition only microscopic examination will reveal the true character of the 
 tissues. New-formed muscle-fibers have been seen in the hypertrophic tissues. 
 The etiology of this affection is generally an antecedent morbid condition of the 
 mucous membrane, which the presence of the fecundated ovum excites to ab- 
 normal proliferative activity. The morbid condition is actually a chronic endo- 
 metritis, either simple, syphilitic, or gonorrheal. Similarly, the death of the em- 
 bryo, or some disease of the latter, may ex- 
 cite the previously healthy mucous mem- 
 brane to overgrowth. 
 
 Prognosis. — The danger to the mother 
 lies in the frequent retention in utero of rem- 
 nants of the placenta, which are not expelled 
 with the rest of the ovum. Frequently the 
 
 i-b 
 
 Fig. 232. — Polypoid Degeneration of the De- 
 cidua Vera. The upper figure is a section of one 
 of the polypoid growths enlarged, showing blood- 
 vessels at a and decidual cells at b. — {Veil.) 
 
 Fig. 233. — Tuberous Subchorial 
 Hematomata of the Decidua. — 
 {Walther.) 
 
 decidua over the placental site is retained, giving rise to hemorrhages or septi- 
 cemia. This condition has been described under various names by different 
 authorities. 
 
 6. Chronic Tuberous or Polypoid Deciduitis. — This disease of the decidua 
 was first described by Virchow, who thought it syphilitic in origin, since his case 
 exhibited a syphilitic history (Figs. 231, 232, and 233). Later work, however, 
 shows no evidence that the disease is due to syphilis, and no assignable cause 
 has thus far been discovered. 
 
 Pathology. — This is a hyperplastic affection, and corresponds to hyperplasia 
 in the non-pregnant condition, so that the etiology of this form of deciduitis 
 must be traced to a pre-existing chronic endometritis. The disease belongs 
 to early ova, and quite often the chorionic villi are seen to have undergone 
 myxomatous degeneration. Schroeder states that in all the cases so far de- 
 scribed, abortion has occurred between the end of the second month and the 
 beginning of the fourth. Ahlfeld says that this condition is frequently seen in 
 aborted ova. The internal surface of the decidua is studded with villus-like 
 
DISEASES OF THE DECIDUM. 195 
 
 projections, which measure half an inch (1.25 cm.) or more in height (Fig. 232). 
 They are polypoid nodules or cones, very vascular, and possess a smooth sur- 
 face. Between these nodes may be seen the openings of the glands, which do 
 not appear at all upon the projections. The entire membrane is much thickened, 
 and consists of proliferated connective tissue, and hypertrophy of the decidual 
 cells, with enlargement of the nuclei. Although the surface is by some described 
 as smooth, others characterize it as rough and covered with coagulated blood. 
 Bulius, of Freiburg, has done much work in this field. Sections show decidual 
 cells with a little glandular tissue. The fibrous bundles of connective tissue 
 constrict the gland openings and blood-vessels. Yet, in spite of this, the entire 
 decidua is extremely vascular. 
 
 7. Chronic Cystic Deciduitis, or Endometritis Deciduae Cystica (Fig. 234). — 
 This affection is rare, but has been observed by Hegar and Breus. It resem- 
 bles the last form, endometritis polyposa, except that the fibrous elevations 
 are not masses of decidual cells, but consist of cystic gland cavities which con- 
 tain liquid. They are retention-cysts, formed by occlusion of the glands of the 
 uterine ducts. This condition is found only in very 
 
 young ova. It might occur in the first stages of 
 
 chronic hyperplastic decidual endometritis, in which y^ , «. V rt''^ 
 the advancing disease destroys and later obliterates CI^ \'^ J< -. ^ k^^ 
 the glands. About the retention-cysts the connec- 
 tive tissue is hypertrophied, and embryonal elements _ , 
 are also found, together with an increase in decidual ^^^"' 
 
 '^^^^'- . . L^ 
 
 Treatment of Decidual Infian-ifnations . — In preg- ^^ 
 
 nancy the treatment of these chronic forms of endo- 
 metritis is impossible, the only resource being to use 
 prophylaxis, by treating the antecedent chronic endo- 
 metritis that is almost invariably present. <X 
 
 8. Apoplexy of the Decidua. — We have alluded to 
 this subject under hemorrhagic endometritis. The 
 great vascularity of the deciduse and the delicacy of 
 
 the walls of the vessels predispose these tissues, under p n 
 
 the influence of mild traumatism, to effusion of blood, eration op the Decidua 
 with resulting abortion. Apoplexy of the decidua Vera. — {Breus.*) 
 occurs most frequently during the first two months 
 
 of pregnancy. The blood collects both within and between the membranes. 
 The effusion of blood may extend through the entire thickness of the deciduae 
 (Fig. 235). _ 
 
 If abortion occurs directly after the effusion of blood, the whole mass dis- 
 charged is known as a "blood " or "sanguineous " mole (mola sangiiinea). But if 
 this expulsion occur at a later period, there is time for the organization of blood- 
 clot, which gives a curious raw-beef appearance to the mass, which is then called 
 a " carneous " or " fleshy" mole {mola carnosa). (See Abortion.) If a deposi- 
 tion of lime salts take place in the clots, as it rarely does, there is formed a 
 "calcareous" or "stone" mole. Pregnancy coming to an end in this manner 
 is called a false or molar pregnancy, and the product is known as a "blighted" 
 ovum. 
 
 The etiology of apoplexy of the decidua consists in traumatisms of various 
 kinds: injuries, blows, repeated congestions from too frequent coitus; also 
 
 * "Arch, fur Gyn.," Bd. XIX, S. 486. 
 
196 
 
 PA THOLOGICAL PREGNANC Y. 
 
 Bright 's disease, the decidiiae sharing in the general tendency to congestion 
 characteristic of this disease. 
 
 The treatment is simply that of abortion. 
 
 9. Atrophy of the Decidua. — In rare instances the deciduae atrophy instead 
 of undergoing hypertrophy and hyperplasia (Fig. 236). Hegar, Matthews Duncan, 
 Spiegelberg, and Priestley have described this condition. The uterine, ovular, 
 or placental decidua may participate in this change either singly or together. 
 If the uterine mucosa is affected, the ovum does not find a sufficient resting 
 place in the uterine fundus. It stays in its normal site until it becomes too 
 heavy for the decidual attachments. These.it gradually pulls into a long, 
 slender pedicle, which lodges in the cervix. It increases in size till it causes 
 reflex contractions of the cervix, being in this manner expelled from the uterus. 
 This is the cervical pregnancy of Rokitansky. 
 If the ovular decidua is affected, there is 
 lacking the outermost membrane of the 
 ovum, which consequently may rupture and 
 its contents be expelled from the uterus. 
 
 10. Deciduoma. — Neoplasms of the de- 
 cidua are very rare. Two varieties have 
 been described, one of which is non-malig- 
 nant and the other malignant. Deciduoma 
 consists of the remains of decidua which 
 
 Fig. 235.— Fleshy Mole (Mola Carnosa). — 
 (Ahlfeld.) 
 
 Fig. 236. — Atrophy of the Decidu.a. 
 Y ERA.— (Ahlfeld.) 
 
 have undergone hyperplasia. The chief symptoms are hemorrhage, a leucorrheal 
 discharge which is fetid and profuse, with now and then fragments of decidual 
 tissue. There are elevated temperature, chilly sensations, and prostration, 
 showing a certain amount of toxemic disturbance. There is only an insecure 
 attachment between the tumor and the uterine wall. The growth should be 
 thoroughly removed by the curette. Quinine, ergot, and stimulants are indi- 
 cated internally. 
 
 II. Chorio -epithelioma Malignum. — Definition. — A malignant uterine neo- 
 plasm originating from the decidual tissues, but manifesting itself only after 
 the termination of pregnancy, whether by mole-formation, abortion, or full- 
 term delivery, and including ectopic pregnancy. 
 
 Pathology. — These growths have been regarded respectively as deciduomata 
 and syncytial growths of malignant nature, sarcomata, epitheliomata, and car- 
 
DISEASES OF THE DECIDUJE. 
 
 197 
 
 cinomata, but at present the consensus of opinion is that they represent an epi- 
 thelioma of the chorionic tissue. The destructive vesicular mole, while at times 
 resembling chorio-epithelioma, is held to be a different condition, but transition 
 forms occur in which differentiation is impossible.* In cases in which the de- 
 structive mole has completely invaded the uterus, the veins of the latter may be 
 occluded, and bits of villi entering the circulation may cause metastases in the 
 lungs. In chorio-epithelioma, on the other hand, the metastases are numerous 
 and varied in site; not only the lungs, but the brain and viscera may be affected. 
 Local metastases in the vagina and vulva also occur. As already stated, how- 
 ever, transition forms are encountered which render hard and fast distinctions 
 difficult or impossible. 
 
 A striking feature of true chorio-epithelioma is that it may consist of meta- 
 stases alone, i. e., a primary focus in the uterus may not be demonstrable. 
 Another not less remarkable fact 
 is an analogous condition in the 
 male, in which embryonal tu- 
 mors in the testicle not only re- 
 semble deciduoma in the partu- 
 rient female as to structure, but 
 are attended with similar meta- 
 stases. This fact has led to the 
 belief that the process must be 
 something more than an acci- 
 dent of maternity. 
 
 The elements of the chorio- 
 epithelioma are derived from 
 the epithelium of the chorionic 
 villi alone, or from both the epi- 
 thelium and stroma. In typical 
 forms the original arrangement 
 of the chorionic elements is pre- 
 sented, while in atypical forms 
 it is lost. All transitions be- 
 tween the two forms may occur. 
 In the typical form, the morbid 
 process is expressed by a distinct 
 tumor-formation, while in atypi- 
 cal forms we see rather a diffuse 
 
 infiltration of the neighboring tissues by the chorionic elements. In both forms 
 the proliferating cells have the property of causing the formation of fibrin — a 
 phenomenon also to be seen in the normal placenta and in vesicular mole. 
 
 Symptomatology. — Chorio-epithelioma, when typical, usually begins as a 
 small tumor in the uterine cavity, save in those cases in which a primary lesion 
 cannot be demonstrated. In such cases the process is probably atypical, the 
 infiltrating chorionic cells passing into the circulation without the formation of 
 a nodule. Under such circumstances, the first lesion noted may be a secondary 
 vaginal nodule. Naturally, we find no symptoms during pregnancy, and unless 
 we are dealing with a uterine mole, we do not find any clinical association of 
 the disease with the post-gestational period. The local metastases, i. e., those 
 connected with the birth tract, should appear first, in the form of nodular growths 
 in the vagina or vulva; but these appear so long after the termination of preg- 
 * Risel, " Ueber das maligne Chorio-epitheliotn," Leipzig, 1903. 
 
 Fig. 237. — Syncytioma Malignum. This photo- 
 graph shows the tip of a fetal villus covered with 
 strands and masses of neoplastic syncytium. 
 (X 200 diameters). (From a specimen in the 
 Pathological Laboratory of the Cornell University 
 Medical College). 
 
198 PATHOLOGICAL PREGNANCY. 
 
 nancy that they hardly belong to obstetric practice. Symptoms of visceral meta- 
 stases depend upon the vital organs chiefly attacked (lungs, brain, etc.). In 
 case of numerous metastases death occurs under the usual picture of general 
 malignancy, as seen in the metastatic sarcoma and cancer. 
 
 Diagnosis. — This is based on microscopic study of the vaginal and vulval 
 tumors; in their absence, the expulsion of a mole or an atypical uterine hemor- 
 rhage should be regarded with suspicion, and the uterus should be curetted and 
 its scrapings examined. 
 
 A differential diagnosis between chorio-epithelioma and destructive vesicular 
 mole is hardly demanded. 
 
 Treatment. — Since the metastases are often limited to the lower genital pass- 
 ages, these growths should always be extirpated at once. If the uterus appears 
 healthy and yields no scrapings suggestive of malignancy, hysterectomy may 
 not be indicated, as a primary uterine tumor has probably failed to form. But 
 while recovery has often occurred under these circumstances, hysterectomy done 
 upon exact indications usually fails to save life. Hence, there must be transi- 
 tion cases in which the indications for hysterectomy cannot be laid down. 
 Spontaneous recovery from chorio-epithelioma has been recorded a number of 
 times. 
 
 II. DISEASES OF THE CHORION. 
 
 /. Cystic Degeneration of the Chorionic Villi. Hydatidijorm or Vesicular Mole. 2. Fibro- 
 myxomatous Degeneration of the Chorion, j. Chronic Choriitis. 
 
 I. Cystic Diseases of the Chorion. — Synonyms. — Hydatidiform, Hydatiform, 
 Hydatoid, Placental, Vesicular, or Cystic Mole; Uterine Hydatids; Cystic disease 
 of the ovum ; Hydatidiform or myxomatous degeneration of the chorionic villi ; 
 Cystic degeneration of the villi of the chorion ; Dropsy of the villi of the chorion ; 
 Molar pregnancy. 
 
 Definition. — This disease consists in a cystic formation at the ends of the 
 villi, giving them the appearance of berries or grapes (Fig. 240). 
 
 Frequency. — The disease is very rare; Madam Boivin, of Paris, found it but 
 once in 20,000 cases. I have seen it four times in 15,000 cases of labor observed 
 in hospital and private practice. It is oftenest found in multiparae, especially 
 between the ages of twenty-five and forty. It is characterized by the tendency 
 to recur in the same patient in subsequent pregnancies. Mayer has reported 
 eleven cases of this disease in one patient. Hydatidiform mole develops usually 
 in the first few months of pregnancy, and very rarely after the fourth month. 
 When occurririg within the first four weeks, death of the fetus rapidly follows ^ 
 in some cases with complete absorption. If the development is later, in the 
 second or third month, the fetus, although it may die, may be saved, if too 
 much of the membranes and placenta is not involved. If the death of the 
 fetus does occur at this period, there is rarely complete absorption. As has 
 been stated, the disease is far more common in the latter part of the woman's 
 sexual life; according to some authorities, 22 per cent, are found between the 
 ages of forty and sixty. 
 
 Pathology. — In the formation of this growth, the syncytium and Langhans*^ 
 layer of cells play a most important role, and appear to give the first 
 impulse toward the changes in the villus. Large masses of syncytium and 
 chorionic epithelium bore their way into the uterine walls, suggesting a 
 
DISEASES OF THE CHORION. 
 
 199 
 
 malignant growth (see Chorio-epithelioma Malignum). Not only do the epi- 
 thelial cells proliferate, but also the connective tissue with its vessels. The 
 resultant translucent vesicles contain a fluid closely resembling the liquor 
 amnii, and in size they range 'from that of a millet-seed to a walnut. The mass 
 in toto may grow as large as a man's head, absorbing the nourishment intended 
 for the fetus, which usually dies, while the mole develops over the whole surface 
 of the chorion (Fig. 240). The arteries of the degenerated villi become obliter- 
 ated, with destruction of the decidua. Uterine pains begin, as a rule, in the fourth 
 or fifth month. At times the mass is so intimately connected with the uterus 
 that its expulsion is very difficult. Sometimes the growth erodes the great 
 blood-vessels, causing fatal hemorrhage. The vesicles possess the same form as 
 do the elements of the original chorion of the first two months, and this accounts 
 for the peculiar grape- or berry-like appearance of the tumor-mass. Either the 
 whole surface of the chorion is covered with 
 these cysts, which replace the villi, or only 
 the placental region is affected. The former 
 happens when the mole forms in early preg- 
 nancy, before the development of the pla- 
 centa; and the latter if the mole does not 
 develop till after the placenta. In the first 
 case the fetus naturally perishes; in the 
 second, it may come to maturity. 
 
 Diagnosis. — This can be made to a cer- 
 tainty only by palpating the cysts. They 
 may be felt during hemorrhage when the 
 cervix dilates somewhat. There is no reason 
 to doubt the invariable association of this 
 disease with pregnancy. Mistakes have 
 sometimes been made by confusing true hy- 
 datid cysts which have been discharged from 
 the uterus, with the little bladder-like 
 growths of the mole. Hewitt has reported 
 a case in which hydatids, which were origin- 
 ally in the liver, had extended to the peri- 
 toneum, and were just at the point of burst- 
 ing through the vagina at the time of the 
 patient's death. It must also be remem- 
 bered that hydatids may be retained in the 
 
 uterus for a long time, and then be discharged; or a few are left behind that 
 may give rise to a new set of growths, and these be extruded long after im- 
 pregnation. When true hydatids obscure the diagnosis, it can always be cleared 
 up by microscopic revelation of the characteristic heads and hooklets of the 
 echinococcus. 
 
 Etiology. — The essential cause is not yet determined. Marchand thinks 
 it most probable that the condition is due primarily to a change in the ovum, 
 an argument being the coexistence of a normal ovum and a mole. In cases of 
 twins, one may be perfectly healthy, while the other is affected (Fig. 238). Some 
 ascribe the cause to disease of the mother; the arguments for this theory being 
 the occurrence of a mole several times in the same woman, and its frequent 
 association with uterine fibroids, cancer, or syphilis. Virchow believed it to be 
 due to endometritis. As already stated, it seems most prone to affect older 
 women. Other causes assigned are pre-existing metritis, chronic deciduitis. 
 
 Fig. 238. — Cystic Chorion in Twin 
 Pregnancy. Hemorrhage During 
 Labor. — (Bensinger.) 
 
200 
 
 PATHOLOGICAL PREGNANCY. 
 
 uterine fibroids, maternal syphilis or carcinoma, absence or deficiency of 
 allantoic vessels, fetal syphilis or other disease, fetal death (Gierse, and Grailly 
 Hewitt). 
 
 Symptoms and Clinical History. — At first there is nothing to call attention to 
 the existing disease, and it is only with the advancement of pregnancy that the 
 characteristic symptoms appear. Three symptoms are most characteristic of 
 this peculiar disease: (i) The uterus enlarges far more rapidly than in preg- 
 nancy. (2) Hemorrhage occurs, small in amount, or diffuse, irregular, varying 
 in duration from several hours to as many weeks. These hemorrhages become 
 more severe as the vesicles grow into the decidua, and consist of watery and 
 sanguineous discharges, which have been hkened to currant-juice in appearance. 
 
 
 Fig. 239. — Cystic Chorion 
 Perforating the Walls 
 OF Uterus. — (Spiegel- 
 •) 
 
 Fig. 240. — Cystic Disease of the Chorion. Hydatidi- 
 FOR.M Mole. — {Photograph of the author's specimen.) 
 
 They are probably caused by the breaking-down of the cysts, which result from 
 painless uterine contractions. The great increase in size of the uterus is not 
 apparent till the third or fourth month. (3) There is a cystic or doughy feel 
 on palpation, while the outlines of the fetal tumor are very obscure, and no 
 fetal heart sounds can be heard. The hemorrhages may be frequent and profuse, 
 or one attack may prove quickly fatal. When the cysts are found in the vaginal 
 discharge the diagnosis is certain. They are whitish, sago-like bodies, generally 
 surrounded by small blood-clots. There are numerous reflex symptoms result- 
 ing from the enlarged abdomen; viz., excessive nausea, vomiting, faintness, even 
 syncope, and abdominal, lumbar, or sacral pains. Extreme exhaustion may 
 develop. The abdominal pains may possibly be caused by the growth of the 
 vesicle into the uterine substance (Fig. 239). Renal insufficiency and albu- 
 
DISEASES OF THE CHORION. 201 
 
 minuria are not uncommon. When the cystic change extends to involve the 
 uterine wall, the disease assumes a semi-malignant character, and, septic peri- 
 tonitis and death may result from perforation of the uterus. The lower third 
 of the uterus is tense. Ballotte'ment is obscure. 
 
 Prognosis. — The patient rarely goes to term, and the fetus" is generally 
 destroyed, often completely absorbed. The maternal mortality is 13 per cent. 
 The causes of maternal death are hemorrhage, septic infection, and uterine 
 perforation with peritonitis. Generally the fourth or fifth month of pregnancy 
 sees the expulsion of the ovum, which is favored by the unusual growth and 
 consequent overdistention of the uterus, as well as by the irritation caused 
 by the penetration of the uterine substance. Rarely, a group of cysts may 
 be extruded without interrupting the course of pregnancy. Cancer of the uterus 
 may result. (See Chorio-epithelioma Malignum.) 
 
 Treatment. — After the condition is discovered the uterus should be emptied 
 in order to prevent infiltration of the uterine wall by the syncytium. The 
 cervix may be dilated if necessary by any of the approved methods and the 
 growth removed by the fingers or curette. The latter should be carefully used 
 on account of the danger of uterine perforation. After evacuation of the 
 uterine contents, the woman should be treated as a puerperal patient. Full 
 doses of ergot should be given for some days after the removal of the mole. 
 
 2. Fibre myxomatous Degeneration of the Chorion, or Myxoma Fibrosum. — • 
 This disease is even more rare than the preceding. It is limited, as a rule, to 
 the placental area, and occurs during the latter part of pregnancy. It has 
 been described by Virchow and Hildebrandt, and is characterized by fibroid 
 degeneration of the connective tissue of the chorion at the placental site. Small 
 tumors are formed that eventually undergo myxomatous degeneration. After 
 this change has taken place the parts concerned have ' a soft, gelatinous feel. 
 The fetus may not be destroyed, on account of the tardy development of the 
 disease. The symptomatology is not clear, and labor may take place before 
 the diagnosis is made. The treatment can only be symptomatic. 
 
 3. Chronic Choriitis, or Inflammation of the Chorion. — The chorion shares 
 the characteristics of other vascular tissues, in being subject to low grades of 
 inflammation. From this cause dense adhesions are formed between the 
 chorion and the amnion and the decidua. Syphilis may often account for this 
 condition. Or, an endometritis may be the forerunner of inflammation of the 
 decidua, in which the chorion takes part. Abortion will probably result. The 
 treatment is symptomatic. 
 
 III. ANOMALIES OF THE AMNION AND LIQUOR AMNII. 
 
 I. Plastic Exudation, Amniotitis. 2. Abnormal Tenuity, j. Cysts and Dermoids. 4. 
 Prem^ature Rupture, Amniotic Hydrorrhea. 5. Anomalies in Color and Composition of 
 Liquor Amnii. 6. Oligohydramnios. 7. Hydranmios. 
 
 Introduction. — As might logically be expected, the similarity between the 
 pathology of this fetal membrane and that of other serous structures is 
 very striking. There is the same chance for the occurrence of changes of secre- 
 tion, inflammations, exudations, serous and plastic, and bands of adhesions. 
 
 I. Plastic Exudation, Amniotitis or Amnitis. — This affection generally occurs 
 in embryonal life, when the amnion lies against the developing skin of the 
 child, and it is due to the scarcity of liquid, and its failure,' consequently. 
 
202 
 
 PATHOLOGICAL PREGNANCY. 
 
 to lift the fetal membrane from the child's body. When this condition is exten- 
 sive, two results may follow: First, the decidua becomes detached, and this is 
 naturally followed by death of the fetus 
 and severe hemorrhage from the ma- i 
 
 ternal vessels. Second, a great many 
 fetal malformations may occur, for 
 
 Fig. 241. — An Amniotic Adhesion Ex- 
 tending FROM THE Scalp to the Edge 
 OP THE Placenta, and Twisted Around 
 THE Umbilical Cord. The Fetus Has 
 A Double Hare-lip. — (Winckel.) 
 
 Fig. 242. — Normal and Pathological 
 Amnion Epithelia. I, Normal amnion 
 epithelia; II, amnion epithelia in hy- 
 dramnios; III, the same with giant cell. 
 —{Ahlfeld.) 
 
 bands of plastic exudation are formed, which connect the fetus and amnion. 
 As the amniotic cavity grows, these bands are stretched, and they m^ay connect 
 
 different parts of the 
 fetus , or one or both ends- 
 may freely float in the 
 surrounding liquid. 
 There are no blood- 
 vessels in these bands. 
 At times they prevent 
 the normal arching over 
 of the body-cavities, and 
 eventration, anenceph- 
 alus, or some other ano- 
 maly of non-union re- 
 sults. Spontaneous or 
 intrauterine amputa- 
 tions not infrequently 
 follow amniotitis ; the 
 bands may wrap around 
 a limb, and so constrict its blood-supply that its further development is impossi- 
 ble; and there is either perfect separation, or the part, hindered in its growth^ 
 
 Fig. 243. — -Amputation of Arm by Amniotic Adhesions. 
 
ANOMALIES OF THE AMNION AND LIQUOR AM Nil. 
 
 2oa 
 
 atrophies. If the Hmb is completely amputated, and this has happened before 
 the third month of pregnancy, there will probably be entire absorption of the 
 member before birth. If later than this period, the amputated part may be 
 extruded in labor after the birth of the child. The idea that the umbilical cord 
 produces amputations is erroneous, for the cord itself would be so compressed 
 in such a case that its circulation would be interfered with, and the child 
 would die of asphyxia. 
 
 2. Abnormal Tenuity. — In the latter part of gestation, on account of abnormal 
 
 tenuity or thinness, the amnion may 
 rupture and become separated from 
 the chorion. The latter remains in- 
 tact, while the amnion is rolled on it- 
 self, forming cords or bands, which 
 may wind around the fetus, or be- 
 come so entangled with the umbilical 
 cord as, by constriction, to cut off its 
 blood-supply, thus causing the death 
 of the fetus. 
 
 3. Cysts, Dermoids. — The forma- 
 tion of cysts in the substance of the 
 amnion has been described; they are 
 
 Fig. 244. — Deformities of the Face and 
 Skull Caused by Amniotic Adhesions. 
 —{Lepage.) 
 
 Fig. 245. — Dermoids of the Amnion. I, 
 Multiple dermoids (i) ; II, one of the der- 
 moids with daughter-cyst. — (Ahlfeld.) 
 
 small and of no clinical importance. Dermoids have also been described. One 
 has been observed that was attached by a pedicle to the amnion of an aborted 
 fetus. Besides cysts, caruncles and tuft-like growths have been noted in con- 
 nection with the amnion. In the case of fetal death, certain changes take place 
 in the amnion, which result in the loss of its glistening appearance, and in a con- 
 siderable thickening of its substance. The histology of this condition is not 
 understood (Fig. 245). 
 
 4. Amniotic Hydrorrhea. — Rupture of the amnion may be followed by abor- 
 tion. Occasionally, however, the amnion and chorion are ruptured at a point 
 
204 
 
 PATHOLOGICAL PREGNANCY. 
 
 remote from the internal os, and the amniotic Hquid drips away for weeks before 
 labor. This is called amniotic hydrorrhea (Fig. 247). 
 
 5. Anomalies in Color and Composition of the Liquor Amnii. — The color, 
 which in the latter part of gestation is normally an opaque white, may become 
 reddish from the presence of a macerated fetus, or it may be green or brown, 
 from the escape of fetal meconium. When the amount of liquid is extremely 
 small, its consistency may resemble that of molasses or mucus. If the mother 
 has diabetes mellitus, it may contain sugar. Sometimes the liquor amnii is 
 decomposed. This is generally coincident with the death and putrefaction 
 of the fetus, in which case a true physometra (gaseous products of putrefaction) 
 is present to a certain degree. However, instances in which, with this condi- 
 tion, the fetus was born alive are on 
 
 record. For such cases no explana- 
 tion has yet been given. 
 
 6. Oligohydramnios consists of a 
 deficiency of the amniotic liquid. 
 This is a rather rare condition, oc- 
 
 \ 
 
 Fig. 246. — Compression of the Fetus 
 IN Oligohydramnios. — (Ahlfeld.) 
 
 Fig. 247. — Diagrammatic Representation 
 OF THE Different Varieties of "False" 
 Amniotic Cavities and Waters, a, Am- 
 nio-chorionic water; d, decidual water; t, 
 true amniotic cavity and liquor amnii 
 proper. — (Bumm.) 
 
 curring only once in three or four 
 thousand cases. The great disad- 
 vantages of this affection are seen in 
 
 the early part of pregnancy; for the uterine walls are not sufficiently separated, 
 and consequently fetal deformities occur, such as talipes, bowing of the limbs, 
 ulcers on the prominent parts of the body from the constant friction, adhesions 
 between the amnion and fetal surfaces, and intrauterine amputations. In some 
 cases abortion occurs, as the growth of the fetus is seriously interfered with. 
 When this condition continues into advanced pregnancy, the uterus is strikingly 
 small and hard. The movements of the fetus being limited, the mother becomes 
 so conscious of them as actually to suffer discomfort or pain therefrom. Labor 
 is generally difficult and abnormally prolonged. No treatment is available, 
 even though the condition is diagnosticated before birth. 
 
 7. Hydramnios, Polyhydramnios, Hydrops Amnii, or Dropsy of the Amnion. — 
 Definition. — This condition consists in the excessive accumulation of amniotic 
 fluid in the amnion, or of a deficient absorption of the same. 
 
ANOMALIES OF THE AMNION AND LIQUOR AMNII. 205 
 
 Pathology. — It is difficult to estimate exactly the normal amount of liquor 
 amnii, for in labor it dribbles away and is mixed with blood; but approximately 
 it measures from one to two pints. If there is much more than this quantity, 
 hydramnios exists. The condition is not pathological until about five pints 
 accumulate. In general, the liquid collects gradually but persistently, giving 
 a chronic form to the affection, till at term it may reach six gallons and more. 
 There is a condition known as actite hydramnios, in which the increase is very 
 rapid, and from the resulting distention of the uterus grave symptoms super- 
 vene. It may develop within a few days, or, as in a case reported by Sentex, 
 in a single night. This affection usually occurs in early pregnancy, and at the 
 fifth or sixth month the abdomen is as large as it would normally be at the 
 ninth or tenth month, or even larger. Schneider observed thirty liters at six 
 months. The character of the liquid is generally like that of the normal liquor 
 amnii. Prochownik states that it contains more urea than is normally present, 
 owing to excessive secretion of the fetal kidneys. This condition is frequently 
 associated with monsters; hydrocephalus, hemicephalus, spina bifida, cleft palate, 
 harelip, club-foot, or some other deformity is present in lo per cent, of cases. 
 
 Frequency. — Hydramnios occurs once in 250 or 300 cases. It is more frequent 
 in multigravidae than in primigravidas (23 to 5); more frequent in twin preg- 
 nancies of the same sex than in single pregnancies. There are some cases of 
 twins in which one sac contains more liquid than normal, while the other contains 
 less. This condition has been observed in extrauterine pregnancy. 
 
 Etiology. — Three general causes are accepted in the etiology of this affection: 
 (i) Fetal, (2) maternal, (3) amniotic. In abnormal states, in which the liquor 
 amnii comes in contact with the floor of the fourth ventricle, fetal diabetes 
 mellitus is caused, and, in consequence, an excess of fetal urine in the amniotic 
 fluid. Changes or obstructions in the umbilical vein, such as phlebitis and 
 thrombosis, also torsion of the cord, will cause damming back of the blood, 
 and resulting transudation of serum. A large fetal bladder, by pressure on 
 the vein, will force the blood back into the placenta. Lesions of the liver, 
 the heart, the blood-vessels, or the kidneys of the mother, by interfering with 
 circulation, may cause this trouble. Albuminuria, diabetes, and syphilis have 
 been claimed as sources of the affection, as well as leukemia and anemia. The 
 amount and degree of transudation through the amnion has been proved by 
 Sallinger to depend upon the strength of the blood-pressure in the umbilical 
 vein, and upon the size of the cord. Tumors of the placenta, causing an increased 
 blood-pressure, will cause transudation, as will also fetal tumors that obstruct 
 the circulation. The fetal skin may be the source of hydramnios. An abnor- 
 mal blood-supply, sent by a hypertrophied heart, may excite the skin to 
 extra activity. Other cases of extensive nsevi, thickened skin, and elephan- 
 tiasis congenita cystica, have been reported in association with hydramnios. 
 The amnion itself may be productive of hydramnios. The condition of acute 
 inflammation, amniotitis, may be followed by extreme serous exudation. This 
 etiological factor would explain cases of hydramnios which follow traumatism 
 of the abdomen of a pregnant woman. Adhesions between amnion and fetus 
 have been developed in such cases. Acute hydramnios has also been ascribed 
 to this cause. McClintock reports- that in about 75 per cent, of the cases he 
 has studied the fetus has been of the female sex. Hydramnios is at times ob- 
 served in association with serous effusions in other parts of the maternal organ- 
 ism. It would therefore be of value in this trouble to make a blood examina- 
 tion of the mother, in order to ascertain if the hydremia so commonly found 
 in pregnane}^ is increased. Certain cases of dropsy of mother and child. 
 
206 PATHOLOGICAL PREGNANCY. 
 
 associated with this affection and syphiHtic in origin, have been reported. As 
 to the theory of deficient absorption of liquor amnii, those cases of hydramnios 
 coincident with nephritis and serous effusions in the mother could be explained 
 in this way. In this affection the fetus is often born dead and shriveled, and 
 the placenta is enlarged and oedematous. Maternal mortality after labor is also 
 high, probably dependent upon the debilitated state of the patients. The large 
 majority of cases which admit of any explanation — for, according to Bar, 44 per 
 cent, of all cases have no demonstrable cause — can be traced to a fetal origin. 
 
 Symptoms. — In the acute form the symptoms are sudden, often intense, 
 pain; fever, from the acute inflammation of the amnion; a great and rapid 
 abdominal distention; inability of the patient to lie down; irregularity of pulse 
 and respiration; dyspnea; and lividity of the face. The symptoms may be 
 slight or pronounced. In the. chronic form, the undue pressure of the uterus 
 on the abdominal contents causes impeded respiration and palpitation of the 
 heart from the upward displacement of the diaphragm. But in this form 
 the accumulation of the liquid is gradual, and is consequently not followed 
 by the severe symptoms of the acute form. The distention becomes notice- 
 able about the third or fourth month. It gradually and slowly increases, 
 causing little discomfort to the mother. The patient is often somewhat de- 
 pressed, but suffers little disturbance in general health. Sometimes insomnia 
 is present, caused by the sensation of weight in the pelvis, which does not 
 amount to real pain. Neuralgia of the abdominal walls, pelvis, and lower 
 extremities results from pressure on the pelvic and sacral plexuses ; and oedema 
 of the abdomen, genitalia, and limbs, from obstructed pelvic circulation. There 
 are excretion of scanty and albuminous urine, from interference with the renal 
 circulation; digestive disturbances, as a reflex result of great uterine distention, 
 or from the direct pressure on the abdominal viscera, and at times ascites, 
 caused by pressure upon the portal vein. As a rule, the symptoms of preg- 
 nancy are increased in severity. The abnormally rapid increase in size of the 
 uterus is the most striking symptom of this condition. Relief is often afforded 
 by the occurrence of premature labor, the first stage generally being tedious, 
 from the overdistention of the uterus. From this same cause there is a greater 
 tendency than normal to post-partum hemorrhage, just as in the case of twins. 
 
 Physical Signs. — On inspection, we find abnormal distention of the abdo- 
 men. Palpation shows an enormous uterus, with tense and rather elastic 
 parietes, and vague fluctuation. The fetus may easily be moved from one 
 point to another, or even inverted. Auscultation reveals either a total absence 
 of fetal heart sounds, or a mufffed tone. Vaginal examination will show the 
 elevation of the os, with a partial obliteration of the cervical canal. The lower 
 uterine segment is elastic and tense, and the presenting part of the fetus cannot 
 readily be palpated. 
 
 Diagnosis. — As a rule, the diagnosis is not difficult. If there exists a larger 
 uterus than normal, the diagnosis of hydramnios is justifiable. There is, too, 
 the history of pregnancy to add its weight of evidence. However, difficulties 
 not uncommonly arise when there is a large collection of fluid, and when the 
 fetus is small, or dead, so that there is an absence of fetal heart sounds and 
 movexnents. It often occurs that, even though the enlarged uterus will give 
 a liquid wave as distinct as that felt in an ovarian cyst, still by dipping deeply 
 on palpation, the solid body of the fetus can be detected. The fetus will be 
 abnormally movable. Differential diagnosis between hydramnios and ovarian 
 cyst may be made by observing the following point: the development of hy- 
 dramnios is far more rapid. If there exist (i) the fetal heart sounds, (2) if 
 
ANOMALIES OF THE AMNION AND LIQUOR AMNIL 207 
 
 the fetal body can be mapped out, (3) if the hypertrophied round Hgaments 
 can be traced, ovarian cyst can be excluded. The normal position of the 
 uterus, whether pregnant or riot,' is low down in the pelvis in ovarian dropsy, 
 while in hydramnios it is drawn high up, and felt per vaginam with difficulty 
 (Kidd). The facies of ovarian trouble is characteristic in advanced cases. 
 Finally, emaciation occurs. A most valuable distinction is the presence of 
 Braxton-Hicks's sign, which always exists in pregnancy, — the occasional rhyth- 
 mic contractions of the uterus, especially when excited by manipulation. If 
 it can be proved that the hardening of the uterine wall thus produced extends 
 over the whole surface of the tumor, then it is positive that the whole mass 
 is uterus. When from its great distention the uterus resembles a large ovarian 
 cyst, the cervix will generally yield more than it normally does at the fifth 
 or sixth month of pregnancy, so much so that the finger can be inserted within 
 it till it reaches the membranes. Hydramnios may be confused with preg- 
 nancy complicated with ascites, though it may be distinguished, before it has 
 proceeded too far, by mapping out the uterine parietes, and by the detection 
 of resonance along the flanks, in the dorsal decubitus; or with a cystic tumor 
 of the broad ligament, or with a normal twin pregnancy. This diagnosis may 
 be difficult or even impossible, but usually in hydramnios the uterine enlarge- 
 ment is more tense or fluctuating. The fetal membranes may be palpated, 
 and the lower uterine segrnent, felt by vaginal examination, is generally dis- 
 tended, and the presenting part not palpable. This condition has been mis- 
 taken for distended bladder, with retroversion of the uterus. When the uterus 
 is extended to its extreme limit, and a certain diagnosis cannot be made, the 
 advisability of an abdominal exploratory operation should suggest itself, since 
 but slight danger attends such a procedure. Abdominal ascites pure and simple 
 must also be distinguished by the superficial position of the fluid, the difficulty 
 of mapping out the uterus, and the physical signs, which show that the fluid 
 exists free in the peritoneal cavity, and by the presence of dropsical effusions 
 in other parts of the body. The area of dulness is variable, depending upon 
 change of position of the patient. There is decrease in the quantity of urine 
 and it is whitish and turbid. Extreme and constant thirst is present. There 
 is a great distention of the hypochondria. In an extreme degree of ascites 
 there is marked protuberance of the umbilicus. 
 
 Prognosis. — Authorities differ as to the gravity of the prognosis. It cer- 
 tainly is not very good for the mother, though naturally it depends on the 
 cause of the existing condition. McClintock, out of thirty-three patients with 
 hydramnios, lost four by rupture of the uterus, two by exhaustion, and one 
 by infection. Winckel lost one by pre-existing pneumonia, while another had 
 an attack of paracolpitis and parametritis, although she recovered. The preg- 
 nancy has a decided tendency to terminate early, from the extreme uterine 
 distention, from the death of the fetus, or from the untimel}'- detachment of the 
 placenta; thus subjecting the patient to the risks of premature labor. Post- 
 partum hemorrhage is very apt to occur on account of the uterine inertia, 
 caused by extreme distention, and consequent weak labor pains and protrac- 
 tion of labor. Involution is prolonged, or not fully completed. Death may 
 be a sequela, due to exhaustion, particularly in the acute variety. Fetal prog- 
 nosis is unquestionably bad. Fully 25 per cent, of the children die. This 
 high degree of mortality follows from fetal malformations, dropsical troubles, 
 prematurity, and the frequency of abnormal presentations. Charpentier col- 
 lected 113 cases,' in which 20 presented by the shoulder, 21 by the breech, and 
 2 by the face. Many fetuses are in a diseased condition, and after birth show a 
 
208 PATHOLOGICAL PREGNANCY. 
 
 variety of pathological coajditions : viz., syphilis, hydrocephalus, or elephantiasis. 
 The common occurrence of prolapsed cord also adds to the fetal mortality. 
 
 Treatment. — The treatment should generally be expectant. The acute 
 cases, however, demand immediate evacuation of the contents of the uterus. 
 The OS should be dilated and the membranes then punctured. The method 
 of aspiration of the fluid through the walls of the uterus should not be counte- 
 nanced. The precipitate discharge of the fluid should be avoided ; the hand or 
 gauze may be used as a plug. Serious cardiac disturbances on the part of the 
 mother, or extreme discomfort, should indicate premature delivery. Especially 
 if there is danger of death of mother, labor should be immediately induced. It 
 has been suggested that a minute aspirating needle be inserted through the os, 
 and a part of the amniotic liquid thus removed, in order to relieve the distressing 
 symptoms, but not to bring on labor. This should, of course, be delayed as 
 long as is consistent with the safety of the mother, although the great possibility 
 of a monstrosity, or at least of a poorly developed child, diminishes the danger 
 of prematurely induced labor. In such cases, measures to prevent hemorrhage 
 should be instituted. The malposition of the fetus should also be guarded against. 
 
 Chronic hydramnios should be treated by the application of- an abdominal 
 binder (Fig. 228) and enforced rest on the part of the mother, in order to give 
 the fetus the best opportunity to survive. In mild cases, interference is 
 not necessary; but if severe respiratory or cardiac symptoms, great exhaustion, 
 etc., are present, the pregnancy should be terminated, as in the acute form. 
 The liquor amnii should be allowed to escape slowly, in order to avoid syncope, 
 prolapse of the cord, and hemorrhage from premature detachment of the pla- 
 centa. The precautions against hemorrhage should be observed, and every 
 endeavor made to secure firm uterine contractions. If the expulsion of the 
 fetus is too slow, it must be assisted in some way; although too early appli- 
 cation of the forceps should be avoided, for fear of the later hemorrhage. After 
 delivery by whatever method, there should be careful observation of the uterus 
 for some time, and besides giving ergot, we should stimulate its contractions 
 by the firm grasping of the uterus and by hot injections. 
 
 IV. ANOMALIES AND DISEASES OF THE PLACENTA. 
 
 I. Anomalies. — (7) Size: (a) Atrophy, (b) Hypertrophy, (c) Placenta Memhranacea; (2) 
 Form; (j) Num.ber; (4) Relation; (5) Insertion — Placenta Prcsvia. 2. Injuries. — Prema- 
 ture Detachment; Accidental Hemorrhage, j. Stasis and CEdema. 4. Interstitial Hemor- 
 rhage — Apoplexy; Infarction; Thrombosis. 5. Placentitis. — (/) Acute Septic, (2) Gonorrheal, 
 (_j) Emanuel's Disease, (4) Specific, (5) Chronic Interstitial and (6) Albutninuric. 6. In- 
 fectious GranuLomata. Tuberculous and Syphilitic. 7. Secondary Metamorphosis. — (i) Pro- 
 gressive Hyperplastic and Sclerotic, Adherent Placenta; (2) Regressive, Results of Fetal 
 Death; White Infarcts; Cystic, Calcareous, Fatty, and Miscellaneous Degenerations. 
 8. Tumors. — Placentomata, Polypi. 
 
 General Remarks. — -A perfectly satisfactory account of affections of the placenta cannot 
 be written because of our ignorance of the histology and development of this organ. No 
 distinction can be made between the fetal and maternal placenta from the standpoint of 
 pathology, because affections appear in both simultaneously, or pass from one to the other. 
 
 Etiology. — Diseases of the placenta originate as follows: (i) From certain pathological 
 conditions in the maternal organism, and especially endometritis which antedates concep- 
 tion. (2) From general diseases affecting the mother, as syphilis, tuberculosis, acute infec- 
 tious diseases, nephritis, leukemia, exophthalmic goitre. In this class, too, lesion of the 
 endometrium is the connecting-link between the maternal and placental diseases. The 
 endometritis, however, does not necessarily antedate conception, but may develop during 
 pregnancy, the fetal portion of the placenta being the first to suffer. (3) From primary 
 disease of the fetus, especially disturbances of the circulation including the umbilical vessels. 
 
ANOMALIES AND DISEASES OF THE PLACENTA. 209 
 
 When the fetus dies from whatever cause, certain alterations are regularly produced in the 
 placenta, such as obliteration of the vessels and fibrous degeneration of the cells. The con- 
 verse, of course, is true, so that disease of the fetal and maternal placenta may cause defective 
 nourishment and development of the fetus as well as the death of the latter, not only during 
 pregnancy but in the course of an. otherwise normal labor. This termination of pregnancy 
 may occur repeatedly in the same woman. If the fetus with a diseased placenta survives, 
 the increased resistance encountered by the placental circulation may have produced disease 
 of the heart or of some of the other viscera. Again, the fetus may not die in utero as a result of 
 the placental disease, but the pregnancy may terminate in missed labor, premature labor, 
 or premature separation of the normally situated placenta. Placental disease is also respon- 
 sible for some cases of hydramnios. We are unable to state whether placental affections 
 can affect the health of the mother (nephritis of pregnancy, eclampsia, etc.). They play a 
 very prominent role, however, in connection with labor (accidental and unavoidable 
 hemorrhage, adhesions, retention, etc.). 
 
 Diagnosis. — There are no known methods by which placental diseases, with the excep- 
 tion of placenta prasvia and accidental hemorrhage, may be recognized in utero. 
 
 Treatment. — With the exception of syphilis of the placenta we know of no affection of 
 the latter organ which can be 'affected by treatment. 
 
 I. Anomalies. — (i) Size. — (a) Atrophy: By this term is meant simple 
 qualitative atrophy, and not the diminution in size which is secondary to in- 
 flammatory affections. There is a tolerably definite relationship between the 
 fetal and placental weights under normal conditions which is expressed by 
 5.5 : I. When an otherwise normal placenta is of smaller size than this ratio 
 requires, a condition of arrested development is present. Nothing whatever 
 is known of the causes of primary atrophy, which is seen alike in the ill-nourished 
 and the robust. (6) Hypertrophy: Simple hypertrophy is the opposite to the 
 condition just described, the placenta being increased in area and thickness 
 although of normal quality. It should not be confounded with an oedematous 
 or hyperplastic placenta. As this condition is encountered only with very large 
 fetuses, and preserves the habitual ratio, it is hardly to be ranked among ano- 
 malies, (c) Placenta Membranacea: This rare anomaly represents a placenta which 
 extends over the greater portion or even the whole of the chorionic surface 
 (Figs. 256 and 269). The expanded structure is correspondingly thin and mem- 
 branous in texture. In this anomaly there is an evident failure on the part of 
 the decidua serotina to develop into the normal placenta, with persistence of 
 the chorionic villi. Clinically this anomaly generally constitutes a prsevia (Fig. 
 269), and also complicates the third stage of labor by retention or actual adhesion 
 and resulting hemorrhage. Fortunately, it is very rarely encountered in practice. 
 
 (2) Anomalies of Form. — These are best considered collectively. The prin- 
 cipal aberrations in the shape of the placenta are as follows: (i) Lobate placenta, 
 in which the organ is divided into two or more lobes (Figs. 249, 250, 251, 254, 
 and 255). (2) Horseshoe placenta (placenta reniformis) (Fig. 257). (3) Fenes- 
 trated placenta, characterized by one or more solutions of continuity in the sub- 
 stance of the organ through which the chorion is visible (Fig. 253). Anmdar 
 placenta, which extends about the uterine cavity like a belt (Fig. 253). Von 
 Franque explains these anomalies by the supposition of abnormal development 
 which results from endometritis. Some of the chorionic villi failing to develop, 
 the placenta exhibits corresponding defects through which fantastic forms are 
 assumed. Clinically, all of the preceding placentae may cause disturbance of the 
 third stage of labor through partial detachment and retention. They are less to 
 be feared in this respect, however, than the subsequent class. 
 
 (3) Anomalies of Number. — These represent apparently a higher degree of 
 the process involved in the genesis of the preceding class. Generally speaking, 
 they are included under the term supernumerary or accessory placentas. If 
 these subsidiary structures contribute to the nourishment of the fetus, they are 
 termed placentcz succenturiat(£ ; otherwise they are known as false placentae (pla- 
 
 14 
 
Fig. 
 
 . — Irregularly Formed Pla- 
 centa. — (Auvard.) 
 
 Fig. 249. — Placenta with Several 
 Irregular Lobes. — (Auvard.) 
 
 Fig. 
 
 250. — Placenta with Two Equal 
 Lobes. — (Ribemont-Lepage.) 
 
 Fig. 251. — Placenta with Two Un- 
 equal Lobes. — (Auvard.) 
 
 Fig. 252. — Placenta Succen- 
 turiata. — (Ribemont-Lepage.) 
 
 Fig. 253. — Fenestrated Twin Placenta at 
 Seventh Month. — (Hyrtl.) 
 
 210 
 
«^tw "^ 
 
 iSt-^'' ' • 
 
 
 Fig. 254. — Trilobed Placenta, 
 Two Lobes Equal in Size. 
 
 Fig. 255. — Placenta with Two Unequal 
 Lobes and Velamentous Cord Insertion. 
 — (Ribemont-Lepage.) 
 
 Fig. 256. — Placenta Membranacea. 
 (Ahlfeld.) 
 
 Fig. 257. — Bilobed Placenta. 
 "Horseshoe" Placenta. 
 
 ~..^' 
 
 Fig. 258. — Placenta in Triplets. Three Dis- 
 tinct Masses of Placenta, with an Isolated 
 Cotyledon. — (Ribemont.) 
 
 Fig. 259. — Small Accessory 
 Placenta. — (Ribemont-Le- 
 page.) 
 
 211 
 
212 
 
 PATHOLOGICAL PREGNANCY. 
 
 centae spuriae). As many as half a dozen of these accessory organs have been 
 found in a single uterus. 
 
 These anomalies probably originate in one of two ways: (i) Endometritic 
 
 ^\ 
 
 Fig. 260. — Battledore Oval Placenta. 
 {Auvard.) 
 
 Fig. 261. — Placenta with Velamentgus 
 Cord Attachment. — (Ribemont-Lepage.) 
 
 proliferation during the developm.ent of the placenta may divide the latter 
 into two or more segments, some of which may be small — mere single 
 
 cotyledons, in fact. (2) An 
 ovum may be implanted 
 over a uterine angle, where 
 a complete placenta would 
 not form; as a result pla- 
 cental tissue develops on 
 either side of the angle. 
 This particular type is 
 known as the duplex or bi- 
 partite placenta. Multiple 
 placenta as a class are said 
 to occur in one labor out of 
 about 352 (Ribemont-Des- 
 saignes). The most common 
 type of multiple placenta is 
 the placenta duplex, or bi- 
 lobed placenta, which was 
 encountered by Ahlfeld 5 
 times in- 3000 cases (Figs. 
 249 to 251). These ano- 
 malies may cause serious 
 complications of the third 
 stage of labor. The practi- 
 tioner should always ex- 
 amine a placenta carefully 
 to make sure that there is no 
 apparent loss of substance. 
 
 (4) Anomalies of Re- 
 lation. — By this term is 
 meant the anomalous rela- 
 tions which may exist between the placenta and the other fetal appendages 
 (membranes, cord). Battledore Placenta: This term is applied to a placenta in 
 
 Fig. 262. — Placenta Succenturiata. — {Author's case.) 
 
ANOMALIES AND DISEASES OF THE PLACENTA. 
 
 213 
 
 which the cord has a lateral implantation (Fig. 260). It is considered under 
 Anomalies of the Cord. Placenta Marginata; Placenta Circumvallata: When the 
 chorion lasve begins within instead 
 of at the border of the placenta the 
 latter necessarily exhibits a free 
 margin and is known as a pla- 
 centa marginata. When the 
 chorion forms a rigid annular fold 
 at the inner limit of the margin, 
 we have a so-called placenta cir- 
 cumvallata. These conditions have 
 their inception before the placenta 
 has arrived at its normal super- 
 ficial growth. The outermost villi 
 penetrate into the substance of the 
 decidua vera, so that the latter is 
 split, its upper segment becoming 
 a part of the refiexa. Through 
 
 some inflammatory process in the latter with resulting fibroid induration, 
 the lateral expansion of the placenta is accomplished in an abortive fashion, 
 the outer portion being without its normal chorionic investment. During the 
 
 Fig. 263. — Placenta Dimidiata. — (Ahlfeld.) 
 
 Fig. 264. — Diagram Representing the 
 Formation of Marginal Placenta 
 Previa. The ovum becomes fixed to 
 one side of the internal os ; the chorion 
 and placenta form, and a marginal pla- 
 centa pr3via results. — (Ahlfeld.) 
 
 Fig. 265. — Diagram Representing thh 
 Formation of a Central Placenta 
 Previa. The ovum becomes fixed just 
 over the internal os; the chorion and 
 placenta form, and a central placenta 
 praevia results. — (Ahlfeld.) 
 
 sclerotic contraction of the inflammatory zone in the reflexa, the chorion is forced 
 into a sharp fold at its junction with the surface of the placenta (placenta 
 circumvallata). As in the case of most of these placental anomalies, the 
 
214 
 
 PATHOLOGICAL PREGNANCY. 
 
 essential cause of the marginate and circumvallate forms is to be found in a 
 diseased endometrium, which is responsible for the pathological condition of 
 the refiexa. A higher degree of the process which causes the placenta mar- 
 ginata should, in theory at least, interfere with the growth of the placenta 
 to such an extent as to cause the death of the fetus. The clinical significance 
 of these placental anomalies is twofold : ( i ) The amnion and chorion are often 
 intimately adherent, so that during expulsion of the after-birth the chorion 
 may be torn from the placenta and left behind. (2) The complications pro- 
 
 ^xTlSLD^r 
 
 Fig. 266. — Diagrams to Represent the Varieties of Placenta Pr.«via According 
 TO THE Definitions Set Forth in this Work. — {Author's classification.) 
 
 duced by other placental anomalies, such as incomplete detachment, retention, 
 and atonic hemorrhages, are frequently encountered here. 
 
 (5) Anomalies of Insertion; Placenta Previa. — Definition. — The 
 placenta is said to be prsevia when it is attached to any portion of the lower 
 uterine segment, and since dilatation of the segment is necessarily followed 
 by hemorrhage from separation of the placenta, the condition is sometimes 
 called unavoidable hemorrhage. Hemorrhages of pregnancy in the first months 
 are usually due to abortion, menstruation, or lesions of the cervix, and are 
 
ANOMALIES AND DISEASES OF THE PLACENTA. 215 
 
 not profuse. In the last three months they are almost always due to a pre- 
 mature detachment of a normally or abnormally inserted placenta. The former 
 is considered under Accidental Hemorrhage. Placenta praevia has also been 
 defined as a localization of the placenta over the internal os when the latter 
 is dilated (Fig. 266). 
 
 Frequency. — In estimating the frequency of this anomaly as of others in 
 obstetrics, account must be taken of the hospital service or private practice 
 from which the conclusions are drawn. Thus, we find the proportion given 
 as high as i in 250 and as low as i in 1000. In an indoor and outdoor hospital 
 service, and in a private practice in which no emergencies and consultation 
 cases are seen, the latter figure is not far from correct; while where einergency 
 and consultation cases are counted, the proportion may easily approach the 
 former figures. Statistics exhibit great irregularities. In some years the 
 condition is so frequent as almost to simulate an epidemic. In 2200 preg- 
 nancies I found that the diagnosis of placenta prasvia was made in 9 cases, 
 or 0.40 per cent., or i in 244 cases. Three, or 33.33 per cent., were in primiparae, 
 and 6, or 66.66 per cent., were in multiparae. One thousand of these patients were 
 confined at the New York Maternity, where no emergency cases are received, 
 and 1200 at the Mothers' and Babies' Hospital at a time when few cases out- 
 side the regular hospital service were cared for. 
 
 Varieties. — In placenta prcevia centralis the placenta completely covers the 
 lumen of the os after dilatation is complete. This form is very rare, and the 
 placenta is placed to a great extent to one side of the uterus — especially the 
 right side (Fig. 266). In placenta prcevia partialis the placenta partially covers 
 the lumen of the os after complete dilatation, and there is more placental sub- 
 stance on one side of the os than on the other (Fig. 266). In placenta prcevia 
 lateralis or marginalis the placenta does not reach beyond the margin of the 
 internal OS. This is the most common form (Fig. 266). In the lateral variety 
 the placenta is situated on the lateral surface of the lower part of the uterus, 
 not quite reaching the edge of the internal os. On dilatation of this lower 
 uterine segment the placenta may be separated with very little loss of blood. 
 In the marginal variety the placenta stretches down to, but not over, the internal 
 OS. These several varieties can be arranged again in two groups — complete 
 and incomplete. The complete variety comprises the placenta praevia cen- 
 tralis, while the three varieties remaining are embraced under the term in- 
 complete. 
 
 Etiology. — Placenta previa is much more common in multigravidse than in 
 primigravidffi, the proportion being about six to one. Among the various 
 causes which may result in faulty attachment of the ovum are conditions lead- 
 ing to enlargement and relaxation of the uterus and to changes of shape ; e. g., 
 multiparity, multiple pregnancy, and uterine malformations; also conditions 
 leading to changes in the uterine mucosa, as endometritis, abortions, and tumors. 
 It seems more common in the poorer classes; owing probably to hard work and 
 subinvolution of the uterus. Abnormally low position of the Fallopian tubes 
 and abnormal size of the uterus are etiological factors. A diseased endome- 
 trium is probably the fundamental cause. It is believed by some that in a 
 threatened abortion the ovum may be arrested in its descent and become at- 
 tached near or at the cervix. Hofmeier and Kaltenbach propose another 
 theory, — that the placenta is developed -both in the decidua basalis and the 
 decidua reflexa; adhesion occurs between the refiexa and vera, and therefore the 
 placenta may be over the internal os. 
 
 Cause of the Hemorrhage. — It is necessary to understand thoroughlv the 
 
216 PATHOLOGICAL PREGNANCY. 
 
 anatomy of the parts concerned in order to form a true idea of their mechanism, 
 both normal and abnormal. 
 
 According to our present understanding of its morphology, the pregnant 
 uterus consists of three parts which are distinct both anatomically and physio- 
 logically. The upper part or body is divided into two sections by Bandl's 
 ring, while the cervix forms the third part (see Part IV). The physiological 
 function of the cervix is active only during labor itself. 
 
 The normal arrest of the ovum is a little below the uterine opening of 
 the tubes and above Bandl's ring. This statement is upheld by the fact 
 that the placenta is nearly always attached to the side of the uterus. The 
 fundal implantation is very rare. The area of attachment is very small in 
 early pregnancy and the development of the placenta will conform to the growth 
 of that part of the uterus to which it has attached itself. Above, the wall of 
 the uterus becomes thicker and ready for its function — contraction; below, it 
 becomes thinner and expands. In case the placenta is low down it will for a 
 time conform to the uterine changes. First it will enlarge at the point of at- 
 tachment, then it will expand to a certain degree; but when the limit is reached, 
 then hemorrhage will occur. If the attachment is very extensive or particu- 
 larly firm, there will occur partial rupture of the placental substance, or the 
 placenta will separate from its base. During labor, as dilatation continues, 
 the breech between the uterine wall and the placenta becomes gradually 
 greater and greater: with each contraction of the uterus new placental tissue 
 is lacerated. The retraction of the uterus from the placenta is most clearly 
 seen in those cases in which only a small edge of placenta can be felt when 
 the cervix begins to dilate, but in which nearly the whole placenta is lowered 
 when dilatation is completed. But this changed position is not so much 
 affected by the descent of the placenta as by the ascent of the lower part of 
 the uterus. 
 
 The parturient uterus is characterized by three properties : contractility and 
 retractility of the upper segment, dilatability of the lower segment. These ex- 
 plain the entire mechanism. This theory seems to be the most satisfactory of 
 those advanced, and is founded upon the supposition that the lower segment 
 of the uterus belongs to the body and not to the cervix. The idea is generally 
 current that true decidua is never found on the mucous membrane of the cer- 
 vix, so that the placenta cannot primarily be implanted there. This has not 
 yet been positively proved. 
 
 The low implantation of the placenta undoubtedly renders it more liable 
 to detachment from mechanical causes — such as shocks, jars, etc. — than when 
 it is normally situated. In the upright position of the woman, moreover, the 
 blood-pressure is greater in the placenta when it is praevia. The decidua refiexa 
 may grow downward and become attached over the internal os. 
 
 Pathology. — The placenta is generally the subject of malformation; its form 
 is irregular; it is thinner and covers a larger surface than the normally situated 
 placenta; the decidual part is unevenly developed, being very thick above 
 and thin below; the upper part is also very firmly attached to its bed, while 
 the attachment of the lower part is very slender. The placenta may be bilobed 
 or there may be a placenta succenturiata, causing errors in diagnosis. The 
 forms which it may assume are varied. The adhesions between the pla- 
 centa and the uterine wall are often abnormal, causing complications in its 
 delivery. The insertion of the cord is also abnormal, and it is not often found 
 centrally attached, but is apt to be nearer one side than the other. Prolapse 
 of the cord is consequently not uncommon. 
 
ANOMALIES AND DISEASES OF THE PLACENTA. 
 
 217 
 
 Symptoms. — The principal symptom is hemorrhage. It occurs without 
 warning and varies from a few drops to an amount sufficient to produce 
 grave anemia; the attacks, however, are usually slight at first and increase in 
 severity; and the time of the hemorrhage often corresponds to a menstrual 
 epoch. It occurs at any time of pregnancy, from the beginning of the third 
 month to delivery; it is most frequent in the last month, though it may be 
 looked for soon after the sixth month. The more nearly central the placenta, 
 the earlier will be the occurrence of hemorrhage. Most cases of so-called 
 menstruation in pregnancy are due to the low implantation of the placenta. 
 There is usually no show of blood in the marginal variety till the beginning of 
 labor. 
 
 During pregnancy the amount of blood lost is not so apt to be dangerous, 
 but at the completion of gestation or during the commencement of labor the 
 loss of blood may be tremendous, the 
 constitutional symptoms of hemor- 
 rhage supervening, and within a few 
 minutes the patient's life may be 
 placed in great danger, death occur- 
 ring within a few moments of the be- 
 ginning of the hemorrhage. The hem- 
 orrhage ceases when (i) the separa- 
 tion of the placenta is completed; also 
 generally after (2) the rupture of the 
 membranes, for then (3) the present- 
 ing part, of the placenta itself is forced 
 down upon the bleeding uterine sin- 
 uses, closing their openings. 
 
 When labor has commenced, each 
 contraction of the uterus causes fresh 
 portions of the placenta to become 
 detached, and consequently fresh ves- 
 sels are torn and left open. The ten- 
 dency of these contractions, however, 
 in all forms of hemorrhage is to con- 
 strict the open mouths of the uterine 
 sinuses and so to control the hemor- 
 rhages. The apparent increase of the 
 bleeding in placenta praevia during a 
 uterus forcing out from the organ blood which had already escaped during the 
 interval. In one way, up to a certain point, contractions do favor hemorrhage 
 by detaching fresh portions of the placental tissue, but the actual loss of blood 
 comes from the uterine sinuses during the interval and not during the contrac- 
 tion. ;<,yi 
 
 Course of Labor. — The first stage is liable to be delayed, since the pres- 
 ence of the placenta interferes with the cervical dilatation; unless the 
 patient is exhausted by hemorrhage, however, the labor may progress rapidly 
 after the presenting part has entered the cervix, since the latter is usually 
 soft and elastic. Rigidity of the cervix is sometimes present (12 per cent, 
 of the cases, Muller). 
 
 Diagnosis. — Early in pregnancy the diagnosis is impossible unless the pla- 
 centa is actually palpated, but in the last third of gestation, the character 
 of the hemorrhage and, after dilatation has been secured, the palpation of the 
 
 \ 
 
 Fig. 267. — Placenta Previa in Twin Preg- 
 nancy. — (Hojmeier.) 
 
 pain" is due to the contractions of the 
 
218 PATHOLOGICAL PREGNANCY. 
 
 placenta, determine the diagnosis. Inspection and auscultation have no part 
 in the diagnosis of placenta praevia. Little or nothing is to be gained by 
 abdominal palpation, but vaginal exploration is most valuable. The only- 
 positive evidence of the condition is obtained by palpating the placenta with 
 the fingers passed through the os. During labor this is best performed in 
 the intervals between the pains, and, fortunately, in the last months of the 
 pregnancy the cervical canal is usually yielding and patulous and offers little 
 resistance to the finger in the class of patients most often suffering from this 
 anomaly — namely, multigravidae. Before dilatation of the os, by palpating 
 the lower uterine segment through one of the vaginal fornices, the placenta 
 may be made out through the uterine wall between the fingers and the pre- 
 senting fetal part. Ballottement will be obscure or absent altogether, and 
 the large placental vessels and those of the lower segment may be distinctly 
 felt pulsating under the finger. The cervix and vaginal fornices are softer 
 than normal and have a boggy feel, due to the increased blood-supply, and 
 the presenting part is with difficulty made out through the placental substance. 
 These signs are often more marked on one side of the cervix than the other. 
 After dilatation of the cervix, if the placenta is centrally attached, the whole 
 internal os will be covered over by a thick, boggy mass, soft and granular, 
 distinguished from coagulum by its consistency and its resistance to pressure 
 of the finger (Fig. 266). Through this placental mass the presenting fetal 
 part may be felt, but far less distinctly than in the normal condition. If 
 the placental attachment is only partial, the bag of waters will be felt, and 
 above it the head, occupying one part of the internal os, while the rest of the 
 aperture will be covered by the placental mass (Fig. 266). If the attachment 
 is marginal, only the thick edge of the placenta will be made out near the 
 rim of the internal os (Fig. 266). 
 
 Differential Diagnosis. — The condition is to be distinguished from acci- 
 dental hemorrhage and from rupture of the uterus. (See Accidental Hemor- 
 rhage.) 
 
 Prognosis. — Death of the mother is due to hemorrhage and sepsis. The 
 nearer to the time of labor the hemorrhage occurs, the better the prognosis, 
 as dilatation and emptying of the uterus can more readily be accomplished. 
 For the same reason the prognosis is better in multigravids than in primi- 
 gravidffi, and during labor than in pregnancy. Again, the danger is greater 
 for both mother and fetus the more centrally the placenta is placed, for when 
 centrally located a greater number of uterine vessels will be exposed before 
 labor can terminate. There is danger also of hemorrhage after birth, as 
 the lower segment, flabby and inert from the muscular atrophy which 
 follows the distention caused by the abnormal placenta, does not completely 
 occlude the vessels left gaping after detachment of the latter. The cervix 
 and lower segment should be very carefully guarded, as mechanical manipu- 
 lations — especially in rapid dilatations and extractions — may fatally tear these 
 parts. (See Part V.) Death may supervene suddenly after the bleeding has 
 entirely ceased, from the great constitutional depression which follows the loss 
 of blood. 
 
 The increased risk of septic infection is due (i) partly to the greater ten- 
 dency which the vessels have for absorption as a consequence of their emptiness 
 following the hemorrhage; (2) partly to the low position of the placental site, 
 it thus being more exposed to external influences; and (3) lastly to the manual 
 or instrumental interference at the placental site that may have been found 
 necessary during delivery. 
 
ANOMALIES AND DISEASES OF THE PLACENTA. 
 
 219 
 
 The less the bleeding is accompanied by uterine contractions, the graver 
 is the prognosis, since labor pains always tend to close the mouths of the blood- 
 vessels. Lastly, the greater -th© anemia that is brought about before actual 
 labor, the greater the risk; since some operation may be demanded to hasten 
 delivery which the woman in her weakened condition is little able to bear. 
 There is more hope of saving the child than many authors admit, and this fact 
 should be kept constantly in mind. In early gestation the cause of fetal death 
 is placental apoplexy followed by painless abortion. In these cases the ovum is 
 usually expelled entire (Fig. 268). Later on, after the child has become viable, 
 the chief danger is as- 
 phyxia from the loss of ma- 
 ternal blood as a conse- 
 quence of separation of the 
 placenta. Other causes of 
 fetal mortality are ( i ) mal- 
 position, the placenta in 
 the lower uterine segment 
 not allowing the head to 
 .present, the shape of the 
 uterus also being distorted ; 
 (2) premature delivery 
 found necessary to save the 
 mother's life, and (3) ver- 
 sion, which in many cases 
 is performed to control 
 hemorrhage or to effect 
 speedy delivery. Hemor- 
 rhage and inanition may 
 also be causes of fetal 
 death. Malpresentation 
 frequently occurs owing to 
 the relaxed condition of the 
 uterus and the softening 
 and stretching of the lower 
 uterine segment, and to 
 the fact that the placenta 
 usually occupies the space 
 filled by the presenting 
 part. Miiller found in 1 1 48 
 cases 272 transverse pres- 
 entations and 107 breech 
 presentations. Premature 
 
 labor and premature rupture of the membranes are common in this condition. 
 In our 9 cases of placenta prsevia already cited, there was one maternal death, 
 due to rupture of the uterus from rapid manual dilatation of the cervix. The 
 maternal mortality was 11. 11 per cent.; the fetal mortality, 22.23 percent. Of 
 the 9 cases, 4 were treated by manual dilatation of the cervix followed by im- 
 mediate version and extraction; 2 by podalic version; i by manual dilatation 
 and forceps, and i by spontaneous delivery. 
 
 Summary of Prognosis: The causes of the great maternal mortality are (i) 
 hemorrhage; (2) septicemia; (3) inflammations — metritis, peritonitis, phle- 
 bitis; (4) shock of version, which operation is generally indicated, and is, in 
 
 Fig. 268. — Partial Placenta Pr.-evia at Four and a 
 Half Months. Spontaneous exptilsion of an unrup- 
 tured ovum with moderate hemorrhage. — (Author's col- 
 lection.) 
 
220 
 
 PATHOLOGICAL PREGNANCY. 
 
 many cases, performed when the woman is in an exhausted state from the 
 loss of blood or previous attempts at delivery through an imperfectly dilated 
 OS. The causes of fetal tnortality are (i) asphyxia; (2) prematurity; (3) version; 
 (4) malpresentations ; (5) inspiration pneumonia. 
 
 Treatment. — There is no preventive treatment of this condition. When the 
 diagnosis of placenta praevia is assured, the broad rule is to empty the uterus at 
 once. This is at least the theoretical aspect of the question. In practice, how- 
 
 FiG. 2 69. — Central Placenta Previa at the Sixteenth Week. Sudden and spontaneous 
 hemorrhage and death within six hours from acute anemia. Blood loss estimated at 
 several pints. Placenta membranacea is also present. The membranes are unruptvured. 
 (^ natural size.) — (Author's collection.) 
 
 ever, numerous conditions assert themselves which constitute exceptions. A 
 certain number, probably constantly decreasing, of practitioners regard inter- 
 vention before the seventh month as meddlesome. Statistics show that fatal 
 hemorrhage before this period is rare. Fig. 269 is a specimen in my collection 
 from a woman pregnant at the sixteenth week, with placenta praevia, who died 
 of uterine hemorrhage and acute anemia within six hours after the appearance 
 of the first bleeding. The blood loss was estimated at several pints. The 
 
ANOMALIES AND DISEASES OF THE PLACENTA. 
 
 221 
 
 minority, who dissent from the routine practice of emptying the uterus at all 
 times, hold that the interruption of pregnancy before viability is unnecessary, 
 unless for special indication, such as profuse hemorrhage. They claim also 
 that if the mother is in no danger, the fetus should be given a chance of sur- 
 vival. The majority, on the 
 other hand, maintain that the 
 mother is always liable to a fatal 
 hemorrhage; that moderate loss 
 of blood up to the time of viabil- 
 ity produces a weakening effect 
 on the mother; and, finally, that 
 the chances of the fetus for sur- 
 vival are so slight that they 
 should be disregarded. To the 
 dissent of a portion of the pro- 
 fession must be added the scru- 
 ples of the prospective mother 
 and her relatives. The idea of 
 terminating the pregnancy with- 
 out regard to the right of the 
 fetus may be repugnant, and an 
 heir may be greatly desired for 
 more reasons than one. The 
 mother, too, may be willing to 
 accept the risk. In such a case 
 the most the practitioner can do 
 is to explain the dangers as fully 
 as possible, and perhaps to call 
 a consultation; the joint opinion 
 of two practitioners should go 
 far toward persuading the 
 woman to choose the wise 
 course. 
 
 If the condition is recognized 
 before the seventh month, and 
 the aim is to continue the preg- 
 nancy, the woman must be 
 made to lead a quiet life, men- 
 tally and physically. She should, 
 as far as possible, avoid all mus- 
 cular effort, such as straining at 
 stool. Coitus should be inter- 
 dicted. The diet should be light. 
 If moderate hemorrhage is pres- 
 ent, she should lie in bed till all 
 bleeding ceases. For uterine con- 
 tractions opiates should be 
 
 given. If the symptoms are more severe, the patient should be placed 
 upon the full regimen for threatened abortion. The foot of the bed 
 should be raised and cold applications made to the pelvis. The ex- 
 pectant method requires the constant presence of an attendant who is 
 
 'nUrnal Os 
 
 External Os 
 
 Fig 
 
 270. 
 
 Frozen Section of a Case of Central 
 Placenta Previa in which One Leg Has Been 
 Brought Down According to Braxton-Hicks's 
 Method and the Half-breech Used as a Tam- 
 pon TO Plug the Lower Uterine Segment and 
 the Cervical Canal. — (Leopold.) 
 
 requires 
 able to deal with a profuse hemorrhage should such occur. 
 
 Only in the most 
 
222 
 
 PATHOLOGICAL PREGNANCY. 
 
 exceptional circumstances should expectancy in placenta prasvia be con- 
 sidered either in pregnancy or labor. To be sure, I have observed several 
 spontaneous safe confinements in placenta prasvia of the lateral or marginal 
 variety, and been able to demonstrate the condition to hospital staffs, and spon- 
 taneous delivery in premature cases may exceptionally occur, without dangerous 
 blood loss in the central variety, by the placenta being born before or with the 
 fetus (Fig. 268). However, because of the danger of an unexpected, profuse, 
 and possibly fatal hemorrhage, in either pregnancy or labor, always present in 
 placenta prasvia, the uterus should be emptied as soon as possible after the 
 diagnosis of the condition is positively made. 
 
 Fig. 271. — Vaginal and Cervical Tampon in Central Placenta Previa. Foiir-inch 
 sterile gauze used for the tampon and a T-bandage applied. 
 
 In either pregnancy or labor there are three indications that must be met : 
 (i) The first stage of labor must be rendered as short as possible by artificial 
 dilatation of the cervix. (2) Hemostasis must be as complete as possible. (3) 
 The second stage should be abbreviated. 
 
 In pregnancy labor should first be induced, and as soon as the cervix has 
 been effaced, the indications for management, as just stated, carried out. In 
 the absence of hemorrhage, and in lateral placenta prsevia, labor can be brought 
 on by the introduction of one of the smaller modifications of the Champetier de 
 Ribes bags. For the introduction of the bag sufficient dilatation can be secured 
 by dilating the cervix with one finger or with the Goodell type of instrument. 
 In the presence of hemorrhage and in primigravidous women with rigid cervices 
 
ANOMALIES AND DISEASES OF THE PLACENTA. 223 
 
 it is better to tampon the cervical canal and vagina tightly with sterile gauze. 
 This procedure temporarily checks the bleeding, and rarely fails to cause a draw- 
 ing up of the vaginal cervix, if not to induce active labor (Fig. 271). At all 
 events, sufficient softening and dilatation are produced to permit a further rapid 
 dilatation and delivery, or other manoeuvre determined upon. 
 
 1. Rapid Dilatation. — In pregnancy or labor the cervix being in a readily 
 dilatable condition, the best results for mother and child will be obtained by 
 rendering the first stage as short as possible, thus minimizing the amount of 
 blood loss. This is accomplished by instrumental dilatation with a dilator of 
 the Bossi type or by manual dilatation. For the latter, I firmly beheve the 
 bimanual method is far superior to the one-handed method, because by it the 
 fingers cause no unnecessary separation of the placenta, which the fingers of one 
 hand passed into the os are bound to accomplish in complete placenta praevia. 
 Dilators of the Bossi type are particularly well adapted to cases of rigid cervix, 
 fortunately rarely encountered in placenta praevia. The Champetier de Ribes 
 bag or its modifications rarely have a place here in accelerating the first stage 
 or in controlling hemorrhage, and never in central implantation of the placenta, 
 as separation of the placenta and concealed hemorrhage will result from their 
 use. 
 
 2. Hemostasis. — At any time after the os is sufficiently dilated to admit two 
 fingers, we always have a sure method of controlling hemorrhage in the Braxton- 
 Hicks manoeuvre of combined version. (See Operations.) (Fig. 270.) If in the 
 midst of an instrumental or manual cervical dilatation bleeding becomes too 
 free, one leg of the fetus should be brought down by the Hicks method, and the 
 breech of the fetus used as a tampon to control further bleeding. It is my cus- 
 tom after the leg is brought out of the vagina, to attach a sling to it, and have 
 an assistant make traction on the latter. I then proceed to complete the cervi- 
 cal dilatation by the bimanual method (Part X) and empty the uterus. It is 
 under such circumstances, namely, when the thigh of the fetus plugs the cervix, 
 that the bimanual method of dilatation is the only one feasible (Part X). Should 
 the bleeding become alarming after almost complete cervical dilatation, it is 
 usually best to perform the ordinary direct podalic version, and proceed with 
 the breech extraction forthwith. Rupture of the membranes as a means to con- 
 trol hemorrhage is uncertain, and should be deferred until late in the first stage. 
 My experience does not lead me to recommend its use. 
 
 3. Shortening of the Second Stage. — I believe the best results for both mother 
 and child are secured by rendering the second stage as short as is consistent with 
 the integrity of the mother's soft parts. This should apply even to those cases 
 in which bleeding has been controlled by Hicks 's bipolar version method, because 
 the danger of internal concealed hemorrhage is always present. One should 
 therefore elect forceps, podaHc version, or breech extraction, according to the 
 indications for each present. After profuse hemorrhage a patient will, when first 
 seen, often be found to be suffering from acute anemia or collapse, and possibly 
 she is at the moment losing little or no blood. It is advisable, in such cases, to 
 tightly tampon the lower uterine segment, cervix, and vagina with sterile gauze, 
 and wait until reaction has been secured by infusion, stimulants, and nutrient 
 enema before completing dilatation or dehvery (Fig. 271). In the case of a 
 dilated or dilatable os and a collapsed patient it is justifiable partially to detach 
 the placenta from the zone of dangerous attachment, or even entirely to detach 
 and dehver it, tightly to tampon the lower segment and vagina, and to rally 
 the patient before proceeding to the delivery of the child. 
 
 CcBsarean Section. — Eclampsia and placenta praevia have occasionally been 
 
224 PATHOLOGICAL PREGNANCY. 
 
 looked upon as indications for Caesarean section, by reason of the high maternal 
 and fetal mortality in both" these conditions. I admit that the operation, or its 
 substitute, vaginal Cassarean section, is occasionally indicated in eclampsia, for 
 the reason that eclampsia is more common in primigravidae than in multigravidae, 
 and hence the cervix is more often persistently rigid in eclampsia than in placenta 
 praevia, but, I believe, it is safe to state that placenta praevia will rarely demand 
 Caesarean section. 
 
 Management of the Third Stage. — Manual removal of the placenta is necessary 
 only when after delivery the hemorrhage still persists. Sometimes bleeding 
 continues after the placenta is born, and even when the uterus is well con- 
 tracted. In this variety of post-partum hemorrhage the management does 
 not differ from that of the ordinary forms. (See Post-partum Hemorrhage.) 
 It should be remembered that the low situation of the placental site predisposes 
 post partum to hemorrhage and sepsis. As a prophylaxis against the former, 
 especially after much blood loss prior to and during labor, the application 
 of the uterine and vaginal gauze tampon is of great service. 
 
 After-treatment. — All danger is not over after expulsion of the placenta. 
 The patient may be threatened with fatal syncope and must be kept recumbent 
 with head low. If the indications arise, she should be given alcoholic stimu- 
 lants by the mouth, and ether or caffeine hypodermically, with saline infusion. 
 Vomiting, which is common after placenta previa, should be met with cracked 
 ice, and, if necessary, nutrient enemata. 
 
 2. Injuries. — Premature Detachment of a Normally Situated Pla- 
 centa. Accidental Hemorrhage. — Definition. — Accidental hemorrhage is 
 generally understood to mean one which occurs from the separation of a nor- 
 mally situated placenta, in contradistinction to the unavoidable hemorrhage 
 of placenta praevia. These terms may be considered misnomers, as not infre- 
 quently the etiology is almost the same. The separation may be partial or 
 complete, the former variety being far more common. It is one of the gravest 
 conditions met with in obstetrics. Clinically there are two classes, those in 
 which contractions of the uterus are present, and those in which they are absent. 
 Quite recently Holmes, of Chicago, has published a thesis * based upon the 
 analysis of 200 cases from literature. He advocates the use of a new name 
 for this condition: viz., ablatio placentce. He claims that the latter occurs 
 much more frequently than has been believed. 
 
 Frequency. — According to Holmes, the ratio of ablatio placentae to normal 
 labor must be re-stated. In clinics where some effort has been made to recog- 
 nize and record the existence of this complication something like i : 200 appears 
 to be the prevailing proportion. 
 
 Varieties. — There are two ways in which this hemorrhage may declare itself: 
 it may be frank or open, or hidden or concealed (Fig. 272) ; the former being the 
 more usual, while now and then the two forms are present in the same case. 
 The point of separation of the placenta in the first instance is generally at its 
 lower part and the blood then easily trickles down between the chorion and the 
 deciduas and finds its way out through the vulvar orifice. In the concealed 
 variety the detachment may take place at the center of the placenta, its con- 
 nection around the entire periphery being at first perfect. In this case there 
 would be formed a large clot behind the placenta. Or the separation may 
 take place at the top of the placenta, in which case, as well as in the last, 
 the hemorrhage would be to a certain extent limited. Then, again, the mem- 
 branes may have ruptured and the orifice of escape may be blocked by the 
 * "American Journal of Obstetrics," vol. xliv, 1900. 
 
ANOMALIES AND DISEASES OF THE PLACENTA. 
 
 225 
 
 presenting part or by some of the appendages of the fetus or by a large 
 blood-clot. 
 
 Among the predisposing causey are profound anemia, general ill health with 
 great debility, persistent pelvic congestion from any cause, prolonged gesta- 
 tion, multiparity, and the loose attachment of the placenta which is normal 
 in the last two months of gestation and depends upon the fatty changes going 
 on as preparatory to labor. Thus, we rarely see accidental hemorrhage until 
 the last few weeks or at the onset of labor, and seldom in primigravidae. It 
 is questionable whether this hemorrhage can ever occur with a healthy pla- 
 centa and uterus; some dis- 
 eased condition, as syphilis, 
 uterine or peri-uterine inflam- 
 mation, or nephritis, is neces- 
 sary as a predisposing cause. 
 The observations of many 
 point to a close connection 
 between nephritis and this 
 hemorrhage, the apoplexies 
 and degenerative changes of 
 the decidua and placenta 
 favoring the hemorrhage.* 
 
 The most important cause 
 of this complication is disease 
 of the deciduae. 
 
 Among the exciting causes 
 is traumatism ;0f various 
 kinds, direct and indirect, re- 
 ceived either externally or 
 from violent muscular efforts 
 on the part of the patient. 
 This cause cannot be denied, 
 although it is ignored by some 
 authorities. Underbill reports 
 a case due to direct trauma- 
 tism, and I observed a case in 
 which a woman pregnant at 
 the eighth month, while hang- 
 ing clothes from the fire- 
 escape of a tenement-house, 
 leaned heavily with her ab- 
 domen against the iron rail- 
 ing. Faintness and profuse 
 uterine hemorrhage occurred 
 
 immediately, followed shortly by labor and the delivery of a dead fetus and 
 several large blood-clots. The placenta was situated above the lower segment. 
 
 Hemorrhage from traumatism does not always follow the shock. In a 
 case of mine it was delayed several days. This is in accordance with the 
 observations of Kiwisch, who states that hours or days may elapse between 
 the two events. Again, hemorrhage may occur when the patient is in repose 
 or even when she is asleep. This accident has also followed indirect trauma- 
 tism, as slipping on ice, lifting heavy weights, vomiting, coughing, concussion, 
 
 * O. Von Weis: "Archiv f. Gynak.," Bd. xlvi, H. 2, 1893. 
 15 
 
 Fig. 272. — Internal Concealed Hemorrhage from 
 Entire Separation of a Normally Situated Pla- 
 centa. Internal Concealed "Accidental" Hem- 
 orrhage. — {Modified from Winter.) 
 
226 PATHOLOGICAL PREGNANCY. 
 
 jolting, etc., by which probably some of the placental attachments were lacer- 
 ated. Profound emotion has been given as an exciting cause by Barnes,* by 
 causing sudden alteration in the equilibrium of the utero-placental circulation. 
 A marked predisposition is undoubtedly present in these cases. A very short 
 cord has sometimes proved to be the cause of this accident, especially if the 
 fetus be vigorous. In hydramnios, in which the volume of the uterus is 
 quickly diminished by the escape of a large bulk of liquid; or in twin deliv- 
 eries, after the birth of one child, the subsequent contraction may cause 
 placental detachment with fatal hemorrhage. Sligh's case t illustrates both 
 of these conditions, as well as the necessity for instantaneous action in com- 
 plications of this kind. 
 
 Certain cases have been reported in which the uterus was abnormal; in one 
 case there was present vagina duplex, and the uterus also shared in the abnor- 
 mality. Other cases have shown a condition of uterus bicornis with one 
 horn rudimentary. If the placenta is attached to the latter, and should 
 this horn contract while the rest of the uterus remains passive, the placenta 
 may become prematurely separated. That this phenomenon does take place 
 has been clearly proved. 
 
 Symptoms and Diagnosis. — In the external form, the escape of blood 
 is noticed, and at once points to the existing condition. The problem in the 
 case of the concealed variety is often obscure. In certain cases marginal 
 separation does not occur, and the escaping blood is collected between the 
 uterus and placenta, where it forms clots which are retained in this situation 
 (Fig. 279). More commonly, however, separation of the placental margin 
 does occur, and there forms a collection of blood between the wall of the uterus 
 and the membranes. This may be either in the region of the fundus or near 
 the cervix. In the latter situation the blood may be prevented from escaping 
 by the pressure of the presenting fetal part. In this case the coagula are 
 prone to cause much pain from the distention and stretching of the uterine 
 muscle. Besides the appearance of blood in the frank variety, there is generally 
 pain, which is at times persistent and of a tearing, piercing character or 
 cramp-like, colicky, and bearing-down. The suffering varies greatly in dif- 
 ferent cases. Pain may be localized at the placental region or at the lower 
 uterine segment, due to stretching from retained clots. Instead of a sudden 
 gush of blood, there may be a more" or less continuous dripping, part escaping 
 and part coagulating. This condition may continue for weeks. 
 
 The symptoms of the concealed form are chiefly extreme collapse and ex- 
 haustion with no apparent cause. In case of extreme internal hemorrhage 
 with slight external escape, the diagnosis may be made by the fact that the 
 constitutional symptoms are so much more severe than the amount of blood 
 visible would be likely to account for. Shock may exist even when there is 
 no great loss of blood; it is then due to enormous distention of the uterus. 
 Besides the pain already referred to, which may be agonizing, there may 
 be observed an irregularity in the form of the uterus, caused by the massed 
 coagula. This is not easy to make out, except, perhaps, in the case of a patient 
 who is thin and who has very lax abdominal walls. A rapid increase in the 
 size of the uterus may be noticed. There miay be a complete absence of labor 
 pains, and if they are present they are usually slight and insufficient. Escape 
 of blood-serum by the vagina is a symptom of great significance as indicating 
 the persistence of clots within the uterus. 
 
 Differential Diagnosis. — Placenta prcevia can be differentiated from acci- 
 * "System of Obstetrics." page 582. f "American Journal of Obstetrics," 1S92. 
 
ANOMALIES AND DISEASES OF THE PLACENTA. 227 
 
 dental hemorrhage only by actually palpating the placenta in the former, 
 although the latter condition is apt to occur in the first stage of labor, to be 
 attended by sharp pains, and to. persist until the uterus is evacuated or the 
 patient dies. No deviations- from the conditions of normal pregnancy are 
 revealed by vaginal examination in accidental hemorrhage. This statement 
 must be slightly modified, as in the concealed variety vaginal examination 
 may show a prominence of the vaginal part of the uterus. It is as if it were 
 being pressed down into the vagina from above, while the presenting part is 
 often well above the pelvic brim. Rupture of the uterus follows a protracted 
 or obstructed labor or operation. There are previous thinning of the lower 
 uterine segment shown above the pubis, recession of the presenting part, and 
 diminution of the uterine tumor; the membranes have usually ruptured; escape 
 of the fetus into the abdominal cavity may be observed, giving two abdominal 
 tumors. It is easy to exclude lacerations of the cervix by palpation and 
 inspection. A ruptured extrauterine pregnancy must also be taken into con- 
 sideration. The history of the case should be investigated. Abnormal pains, 
 changes in the fetal heart sounds, alterations in the outlines of the uterus, 
 symptoms of the hemorrhage, and the condition of the vaginal part of the 
 uterus afford the chief differential points. 
 
 Prognosis. — When there is an external flow of blood, the prognosis for the 
 mother is not very unfavorable, since the condition may be readily recognized 
 and treated. Speedy termination of pregnancy will check the bleeding and 
 save the patient's life. The shock is not so great, for the uterus is not so dis- 
 tended; and the separation of the placenta is frequently incomplete. About 
 85 per cent, of the children are born dead. In the concealed form, however, 
 there is far more danger, and here the mortality is great, for often the diagnosis 
 is not made until the patient is nearly moribund. Of Goodell's 106 cases, 
 54 mothers died — 51 per cent. 
 
 Other factors influencing this great mortality are the constitution of the 
 patient, which is generally feeble and diseased, and the shock from overdis- 
 tention. The very fact, too, of overdistention indicates loss of contractility 
 of the uterine musculature. The nearer the completion of the second stage, 
 and the more readily the cervix is dilated naturally or artificially, the 
 better the outlook. In pregnancy the chances for fetus and mother are better 
 in multiparas than in primiparae, on account of the ease with which the os can 
 be dilated in the former. 
 
 For the child, the prognosis is even worse. Of 107 children, of Goodell's 
 cases, 6 only were born alive — 94 per cent, mortality. This is probably ex- 
 plained by the fact that when blood collects between the placenta and the uterus, 
 the fetal part of the former is probably torn and the child dies from hemor- 
 rhage. Other causes of fetal death are prematurity and asphyxiation from 
 interference with the function of the placenta. The maternal mortality 
 in Holmes's series of cases is considerably lower than that commonly admitted — 
 32.2 percent.; his child mortality (85.8 per cent.) is slightly better than that here- 
 tofore taught. The death-rates (maternal) for concealed and open hemorrhages 
 were 23 and 34.6 per cent, respectively. It is difficult to formulate special 
 prognostic indications. 
 
 Treatment. — If the hemorrhage takes place during pregnancy and is not 
 severe, the treatment should be parallel with that of threatened miscarriage. 
 Or, even if the hemorrhage has been large but has entirely ceased, the uterus 
 need not be interfered with. The treatment should then be preventive and 
 
228 PATHOLOGICAL PREGNANCY. 
 
 protective. These patients-^ should always be carefully watched. It may be 
 that a living child will be bom at term. 
 
 In the presence of severe hemorrhage the two indications are (i) to secure 
 tonic and continuous uterine contraction and (2) the emptying of the uterus 
 as rapidly as is consistent with the safety of the mother. I believe the first 
 indication is most surely obtained by (i) artificial rupture of the membranes, (2) 
 massage and manual compression of the uterus, and (3) the repeated hypo- 
 dermatic injections of ergot (ttvxxx of the tincture every fifteen minutes for 
 three or four doses). The speedy delivery can be accomplished by rapid instru- 
 mental and digital dilatation of the cervix and the use of forceps, version, or 
 perforation according to indication. Deep incisions of the cervix are occa- 
 tionally useful. 
 
 The most efficient check to hemorrhage is uterine contraction, which must 
 be brought about if possible. By rupture of the membranes, the liquor amnii 
 will escape and the uterine contraction will take place. If the loss of blood is 
 very small, it may be that rupture of the membranes will be the only artificial 
 step necessary, and the rest will be looked after by nature, though early rupture 
 of the membranes delays labor. In severe cases the mother's safety alone 
 should be considered, for the death of the child is reasonably certain. 
 
 In the milder forms, vaginal plugging, massaging the uterus, with general 
 stimulation, should be used till the cervix is sufficiently dilated to allow of 
 delivery. Tampons must not be used after rupture of the membranes, but the 
 method of tightly tamponing the vagina when the membranes are intact, as prac- 
 tised at the Dublin Rotunda, has given good results. A modified Champetier de 
 Ribes bag under the same conditions can be tried until dilatation is obtained. 
 A firm abdominal binder should be applied to prevent any internal collection 
 of blood from forming. Uterine compression and the administration of ergot 
 will further contractions, as will the application of an ice-bag over the sus- 
 pected place of hemorrhage. Cold may be applied by atomizing ether over 
 the abdomen. If the hemorrhage does not cease, or if concealed hemorrhage 
 is suspected, the uterus must be emptied. During the progress of labor and 
 delivery the uterus should be carefully followed down by an assistant, and 
 after delivery every effort should be made to secure and maintain uterine con- 
 traction. (See Expression of Fetus, Part X.) 
 
 Perforation may be indicated if the child is dead or non-viable, or if the fetal 
 head is large or the maternal pelvis very small, or the hemorrhage so severe 
 as to endanger the mother's life. Cassarean section should be considered in ex- 
 treme cases. If the patient is in collapse, it may be best to revive her by 
 warmth and stimulants before operative proceedings are begun. The after- 
 treatment consists in the prevention, if possible, of post-partum hemorrhage. 
 When much blood has been lost, the resulting anemia must be promptly 
 treated by hypodermoclysis of decinormal saline solution, with rectal and intra- 
 venous injection as well. There have been no recent advances made in the 
 therapeutics of this affection, which is still unsatisfactory. 
 
 3. Stasis, Passive Congestion, and CEdema. — Obstruction of the return cir- 
 culation of the placenta gives rise to a characteristic state of that organ. 
 Through the resulting oedematous saturation, the size of the latter may undergo 
 a fourfold increase. It becomes pale and friable, and hence easily disintegrated 
 during expulsion, with retention of certain portions. As in the case of oedema 
 elsewhere, stasis may not be the sole efficient cause, for a hydremic quality of 
 the blood incidental to the underlying state of the patient may co-operate. 
 Stasis and oedema of the placenta have been encountered in cardiac disease 
 
ANOMALIES AND DISEASES OF THE PLACENTA. 
 
 229 
 
 (so-called cardiac placenta), renal disease, and other maternal conditions. 
 More commonly, however, the causes are to be sought in hydramnios or some 
 obstruction in the circulation -of -the fetus. The latter class includes syphilitic 
 obstruction of the umbilical vein (Fig. 277), and disease of the fetal heart, liver, 
 and kidneys. Finally, in general fetal anasarca the placenta may be oedematous. 
 When the fetus is responsible for the oedema, the fetal portion of the placenta 
 is chiefly involved. 
 
 4. Interstitial Hemorrhage (Apoplexy, Infarction, Hematoma, Thrombosis). — 
 The effusion of blood is not necessarily interstitial, for it may be between the 
 chorion and placenta, in the form of a large clot, over the whole external 
 chorionic surface; or it may represent a utero-placental hemorrhage (Fig. 279), 
 The first occurs during the first three months of pregnancy, before complete union 
 of the chorion and decidua; after the third month, this union prevents effusion 
 beyond the limits of the placenta. 
 Hence during the greater portion of 
 pregnancy the hemorrhage is apo- 
 plectic and sharp!}' distinguishable 
 from accidental and inevitable pla- 
 cental hemorrhages (Figs. 273, 274, 
 275, and 276). 
 
 Pathology. — It is in the early 
 months that hemorrhage more com- 
 monly occurs from true apoplexy, 
 which consists in the rupture of the 
 fragile maternal capillaries surround- 
 ing the villi. Later on in pregnane}', 
 the cause is more often thrombosis in 
 the sinuses, or rupture of the fine 
 blood-vessels which enter the placen- 
 tal sinuses after penetrating the upper 
 layer of the decidua serotina. These 
 masses of coagulated blood, in their 
 several stages of degeneration, con- 
 stitute placental hematomata. These 
 formations undergo the usual retro- 
 gressive metamorphoses. (i) The 
 form of the fresh clot is most com- 
 mon when abortion has resulted from 
 the hemorrhage. (2) The extrav- 
 
 asated blood may be walled ofE by a fibrous envelope, more or less thick, 
 and may consist of reddish or brownish liquid, or even clear serum, while the 
 blood coloring-matter is collected upon the cyst-wall or the neighboring villi. 
 (3) The liquid may contain numerous white blood-corpuscles, giving it the 
 appearance of pus, and such collections have been described as "placental 
 abscesses" by various writers. (4) In other cases the fibrin element may be 
 in the ascendency. This condition is found particularly in certain cases of 
 thrombosis of the placental sinuses ; as in an aneurysm in the course of obliteration 
 the slow coagulation of blood results in the deposition of layers of fibrin. (5) 
 The serum may rapidly disappear, leaving the red blood-corpuscles in a mass, 
 while the leucocytes are either distributed through the latter or collected in 
 one place. (6) Still another change is the organization of the clot, by which 
 a distinct neoplasm is formed, while the adjacent villi go through a fibro-fatty 
 
 Fig. 273. — Hemorrhages into the Pla- 
 centa Caused by Albuminuria. — {Ribe- 
 mont-Lepage.) 
 
230 
 
 PATHOLOGICAL PREGNANCY. 
 
 degeneration. The utero-placental hemorrhage may be recognized, after the 
 expulsion of the ovum, by the characteristic appearance of the latter. It is 
 fleshy in consistency, dark bluish-black in color, and has a very smooth sur- 
 face. On examination the amnion and chorion are found to be uninjured. The 
 fetus may be absorbed, if sufficient time has elapsed between its death and the 
 expulsion of the ovum. If the period of time is shorter, the fetus will be seen 
 floating in the liquor amnii. If, as the ovum is discharged, the decidua becomes 
 detached, the former looks much like a blood-clot. It is to the hemorrhage into 
 the placental site, after the third or fourth month, that Cruveilhier has applied 
 the term placental apoplexy. If the extravasation of blood takes place into the' 
 
 
 Fig. 274. — Early Placental Infarct showing Coagulation Necrosis of Villi and 
 Portions of Blood-vessels. The Dark Homogeneous Areas are Necrotic. 
 X 35. — {From a specimen in the Pathological Laboratory of the Cornell University Medi- 
 cal College.) 
 
 I. Group of villi completely necrotic, fibrinoid homogeneous, staining deeply with eosin; 
 2. large vessels, the peripheral portions of whose walls are fibrinoid and necrotic. 
 
 uterine sinuses, thrombosis of the placental sinuses is said to have taken place 
 (Slavjansky). 
 
 Etiology. — The blood-current in the sinuses of the placenta moves very slowly 
 in its course; this sluggishness, with the predominance of fibrin in the blood of 
 pregnant women, causes a tendency to thrombosis. The placental villi may be 
 diseased. The heart from some cause may be stimulated to sudden and excessive 
 action, which produces apoplexy not only of the placenta, but also of the brain. 
 Syncope also gives rise to a tendency to thrombosis. The more common locality 
 of the rupture is in the maternal part of the placenta ; its cause is some patho- 
 logical condition of the mother which leads to great arterial tension and venous 
 congestion; e. g., chronic nephritis. In this state any additional strain on the 
 
ANOMALIES AND DISEASES OF THE PLACENTA. 
 
 231 
 
 already overtaxed venous walls makes them rupture, with the consequent apo- 
 plexy or extravasation. Traumatism also may produce this condition; for ex- 
 ample, a blow upon the abdomen. If the cause be of fetal origin, death may 
 result from the arrested blood-supply. 
 
 Symptoms. — There are no clinical symptoms characteristic of this condition. 
 The condition terminates in abortion. When the discharged ovum is examined, 
 the cause will be apparent. 
 
 Prognosis. — The danger increases with the advance of pregnancy, and in 
 the latter months it is considerable. 
 
 Treatment. — The treatment is that of abortion and premature labor. 
 
 5. Placentitis. — To-day it is admitted that inflammation of the placenta 
 may occur, even if very infrequently. The best argument for the existence 
 of placentitis as a disease is the great 
 
 number of progressive and retrogres- ^-.-—-^ 
 
 sive lesions, encountered in the organ, 
 which are known to follow inflamma- 
 tion in other portions of the body. The 
 principal objection to the recognition 
 
 Fig. 275. — Fresh Hemorrhagic Infarct 
 OF THE Placenta. — {Schilling.) 
 
 Fig. 276. — Placental Infarct in Eclamp- 
 sia. Subamniotic Necrotic Area. — 
 (Schaeffer.) 
 
 of the existence of placental inflammation lies in the absence of capillaries and 
 nerves in the maternal portion. Placentitis may be divided into acute and 
 chronic forms, (i) Acute septic placentitis: This affection is mentioned by 
 authors as having been caused by direct infection either from attempts at 
 criminal abortion or from rupture of a pyosalpinx into the uterus. Pus 
 forms in situ, and with the phenomena of general sepsis, abortion results. 
 (2) Gonorrheal placentitis: According to Donat, the gonococcus is able to 
 cause an acute purulent inflammation which extends from the decidua sero- 
 tina into the fetal placenta and produces interruption of pregnancy". Von 
 Franque is skeptical as to the existence of this type of disease. (3) Eman- 
 uel's disease: This author has described a necrotic and purulent inflammation 
 of the placenta in the lesions of which he found certain non-specific micro- 
 
232 
 
 PATHOLOGICAL PREGNANCY. 
 
 organisms. The affection first involved the decidua and thence extended into the 
 maternal placenta, causing abortion. In this connection it may be stated 
 that placentas which exhibit many of the phenomena that commonly follow 
 acute inflammation elsewhere (white infarcts, necrotic foci, thrombosis, etc.) 
 may well have been aft'ected by some form of bacillary disease. (4) Specific 
 placentitis: Authors speak by implication of placental alterations in the acute 
 specific infectious diseases. We have been unable to obtain any satisfactory 
 account of these lesions. (5) Interstitial placentitis: This condition, which 
 doubtless corresponds to the decidual and diffuse placentitis of some authors, 
 is an interstitial inflammation of the maternal portion of the placenta which 
 begins in the vascular trabeculse. Through the changes which accompany 
 chronic inflammation in general, the villi are subjected to compression and 
 arrest of blood-supply. Secondary degenerative changes then ensue in the 
 
 parenchyma of the organ, which becomes 
 diminished in size. Firm adhesions may 
 form between the placenta and the wall of 
 the uterus. Endometritis, either primary 
 or secondary, is doubtless the cause of a 
 majority of these affections. Hegar and 
 Maier once described a form of interstitial 
 placentitis which was essentially a peri- 
 arteritis. (6) Renal or albmninuric pla- 
 centitis: There are no constant changes in 
 the placentce of women who are suffering 
 from albuminuria, but such individuals 
 very commonly exhibit such alterations as 
 whits infarcts, round-cell infiltration, var- 
 ious degenerations, hemorrhages, fibrous 
 hypertrophy of villi, endarteritis and peri- 
 arteritis, etc. These lesions in turn cause 
 defective development or death of the fetus, 
 premature delivery, premature separation 
 of a normally seated placenta, and, much 
 more rarely, adhesions. All these changes 
 may occur without nephritis, the latter 
 being only a contributory cause, acting 
 perhaps indirectly through the presence of 
 endometritis of renal origin. 
 6. Infectious Granulomata. — The placental changes in tuberculosis and 
 syphilis are tolerably well known. 
 
 (i) Tuberctdosis. — LocaHzation of this affection in the placenta is extremely 
 rare, and is known to occur only under the following conditions : In acute miliary 
 tuberculosis, as well as in the chronic form of the same disease which follows pul- 
 monary phthisis, we sometimes encounter small grayish-yellow tubercles in the 
 organ. They are but sparsely present. The placenta is almost immune to attack 
 from Koch's bacillus. The tubercles, which are usually caseous, are scattered 
 in the intervillous space — decidua, villi, stroma, etc. The blood-vessels of the 
 villi exhibit obliteration as a result of endothelial proliferation. In this manner 
 the fetus might be protected to a certain extent from placental infection. The 
 diagnosis of tuberculosis of the placenta has been verified by the demonstration 
 of the bacillus and also by animal experiment. 
 
 (2) Syphilis. — This affection is perhaps the most prolific cause of death 
 
 Fig. 277. — Syphilitic Placental Vil- 
 li. Marked proliferation of the con- 
 nective-tissue and rotind-cell infiltra- 
 tion (5), especially in the neighbor- 
 hood of the thickened blood-vessels 
 (i) ; a few of the villi have lost their 
 protoplasmic investment and are in 
 process of conversion into intervillous 
 
 1 thrombi (3) ; 6, normal protoplasm 
 containing nuclei; 7, villous blood- 
 vessels — healthy, belonging to the 
 fetus — (original microscopic draw- 
 ing) . — (Scheie ffer.) 
 
ANOMALIES AND DISEASES OF THE PLACENTA. 233 
 
 of the fetus. The syphiUtic placenta is larger, thicker, and lighter in color 
 than normal. Its appearance suggests that it has been soaked in water 
 While the normal placenta is. from one-sixth to one-eighth the weight of the 
 child, the syphilitic placenta- weighs about one-third or one-fourth as much 
 as the child. The fact must of course be considered that the syphilitic child 
 is less developed; syphilitic fetuses being generally smaller than normal. Macro- 
 scopically these placentae may differ in appearance. If the fetus has been dead 
 some time, the placenta will be very pale in color, soft or slippery, and greasy 
 to the touch. If the child lives till term, the organ is commonly unusually 
 large and pinkish in color, due to the hypertrophied decidua, which hides the 
 true color. Normal villi possess only a few cells but many blood-vessels; the 
 syphilitic villi are filled with round cells which have undergone fatty degenera- 
 tion and resemble embryonic cells. In syphilitic villi the blood-vessels are 
 scarce; the stroma is increased, and is represented by granulation tissue; the 
 blood-vessels show endarteritis, and in hardened specimens the villi are seen to 
 be thickened. Parts of healthy tissue of the placenta, which intervene between 
 the diseased areas, may exhibit extravasations. However, these character- 
 istics do not give absolute proof, but probability, of syphilis. Corroboration 
 may be furnished from the condition of the child. When gummata are found 
 as in cases in which maternal syphilis antedates conception, they vary in size 
 from a hempseed to an olive, and possess the characteristic structure of gum- 
 mata in other situations. These formations have a central core of soft yel- 
 lowish or reddish cheesy degeneration, surrounded by concentric lamellae, or 
 a true abscess cavity, with fatty walls which secrete pus. They often undergo 
 fatty and calcareous changes. Diagnosis: It is impossible to make an accurate 
 diagnosis during pregnancy. Prognosis: The fetus generally dies rapidly of 
 malnutrition, owing to obliteration of the nourishing blood-vessels. Placental 
 syphilis is one of the commonest causes of abortion. The greatest maternal 
 risk occurs at the time of labor, from adherent placenta and subsequent sepsis. 
 The treatment of fetal syphilis will generally be prophylactic. If both parents 
 of the future embryo be affected with the disease, then antisyphilitic treat- 
 ment should be instituted in both individuals. If only one be syphilitic, it 
 would be useless to treat the healthy one. 
 
 7. Secondary Alterations in the Placenta. — Under the head of secondary 
 progressive alterations we shall consider hyperplastic and sclerotic changes, 
 together with adherent placenta. Degenerations comprise the results _of fetal 
 death, white infarction, cystic, fatty and calcareous degeneration, etc. 
 
 (i) Hyperplastic and Sclerotic Changes. — Proliferation of fixed connective- 
 tissue cells with an immediate tendency to hyperplasia and an ultimate dis- 
 position toward sclerotic and atrophic metamorphosis is a sequel to a number 
 of primary placental affections. These changes are due in most cases to 
 chronic placentitis, whether the latter be owing to simple endometritis, renal 
 disease, or syphilis. Fibrous metamorphosis has received various terms: 
 viz.-, interstitial placentitis; sclerosis of the placenta; scirrhous, tuberculous, 
 or cartilaginous degeneration, etc. Of special clinical interest are the adhesions 
 which form as a result of the organization of hyperplastic tissue between the 
 placenta and the uterine wall; and the white infarcts, so called, which are due in 
 part to the constriction of certain areas of placental tissue by the same sclerotic 
 process. 
 
 (2) Adhesions. — Adhesions between the placenta and the uterine wall are of 
 rare occurrence, for the majority of cases thus characterized are only instances 
 of simple retention. True adhesion, however, occurs at times, and the two 
 
234 PATHOLOGICAL PREGNANCY. 
 
 structures are then consolidated to such a degree that any natural separation 
 is impossible. Adhesions may also be the result of imperfect development (ab- 
 sence of glandular zone, of entire serotina, etc.; see Part II), through which the 
 villi become deeply imbedded in the muscular wall of the uterus. (See Part V.) 
 
 (3) Degenerations which Follow Fetal Death. — After death of the fetus 
 in utero the circulation persists for a while in the intervillous space, the 
 placental tissue remaining intact. The fetal vessels gradually become oblit- 
 erated by endothelial proliferation. The stroma becomes changed into fibroid 
 tissue. The fixed connective-tissue cells of the pedicles of the villi, chorion, 
 and amnion begin to proliferate, with resulting thickening of these structures. 
 Langhans's layer and the syncytium also show irregular proliferation. In 
 the course of time the syncytium disappears, and the villi become transformed 
 into a hyaline substance devoid of nuclei. The circulation in the intervillous 
 space ceases as a result of thrombosis. Fatty degeneration, calcification, 
 and other degenerative processes are in evidence. The placenta as a whole 
 undergoes marked shriveling, becoming small, thin, and of a hardness sug- 
 gesting leather or cartilage. Upon section it is white and almost homogeneous. 
 
 (4) White Infarcts. — White infarcts constitute graAdsh-red, yellowish, or 
 pure white areas of the placenta which replace the spong}^, highly vascular 
 tissue of the latter. At first only moderately firm, they increase in hardness 
 progressively from the deposition of lime-salts. In certain cases, however, 
 there is a secondary softening of the infarcts, which may terminate in cyst 
 formation. Microscopic infarcts occur in all placenta and fully 50 per cent, 
 of the latter exhibit infarcts which are visible to the naked eye; hence these 
 small formations are physiological. But infarcts of considerable size, also, 
 are frequently encoxuitered. The large or pathological infarcts, some of which 
 may involve half the placenta, have a various extent and distribution. They 
 may be scattered here and there as rounded or stellate areas without any regular 
 arrangement, and are then termed insular. Wedge-shaped infarcts have 
 their bases in the serotina and their apices among the masses of villi. Annular 
 infarcts are sometimes seen, and may involve the free border of the placenta 
 or be seated within the peripher^^ Finally, there is a type of infarcts known 
 from its location as the subchorial. The nature and pathology of white infarcts 
 have given rise to much discussion. The simplest and most plausible expla- 
 nation is as follows: In the hyperplastic and sclerotic changes which have 
 just been described, beginning as an endarteritis in the chorionic villi, com- 
 pression of placental tissue must necessarily occur at times in certain areas 
 which ultimately have their blood-supply cut off and undergo the transforma- 
 tion known as coagulation-necrosis. This lifeless tissue becomes changed 
 to a homogeneous mass of hyaline appearance, which undergoes various retro- 
 grade changes, such as softening, canalization (so-called canalized fibrin), 
 cyst formation, calcification, etc. Secondary hemorrhages may occur about 
 these infarcts. As these formations are deprived of blood-vessels, the area 
 of the normal placental tissue is diminished to a greater or less extent, so that 
 the nutrition of the fetus may suffer, even to the extent of abortion. The 
 danger to the mother lies in the possibility of the formation of adhesions between 
 the infarcts and the uterine wall, with resulting irregular detachment and reten- 
 tion of the placenta. 
 
 Williams* examined 500 consecutive placenta for infarcts, including 
 both white and red varieties. He found 185 of these specimens free from 
 all appearance of such lesions except to an almost microscopic degree. But 
 
 * Prof. Welch's Festschrift, 1900. 
 
ANOMALIES AND DISEASES OF THE PLACENTA. 
 
 235 
 
 15 were the seat of the red or hemorrhagic variety. The remaining 300 
 placentae all contained white infarcts, distributed as follows: on the surface, 
 223, or 44.6 per cent.; purely marginal location, 77, or 15.4 per cent. As 
 implied above, microscopic infarcts are invariably present. The mere act 
 of infarct formation is physiological, and, at best, a normal senile degeneration of 
 the placenta. When present in a high degree, it is the result of some disease, and 
 more especially albuminuria, in the mother. We are quite unable to explain the 
 pathogeny of morbid infarct formation, but it seems certain that bacteria play 
 no part therein. The inherent independence of albuminuria and eclampsia is 
 shown by the fact that we do not necessarily find high degrees of infarction in 
 the latter disease. 
 
 (5) Cystic Degeneration. — The great majority of placental cysts result from 
 softening. In some cases the latter 
 
 process is primary and results from 
 liquefaction of the original myxo- 
 matous tissue of the placenta. There 
 is some analogy between these for- 
 mations and vesicular moles. The 
 largest and most familiar placental 
 cysts, however, result from the 
 softening of infarcts. These may 
 attain such dimensions as to simu- 
 late a second bag of waters. This 
 type of cyst is largely subchorional 
 in location. The cystic fluid is usu- 
 ally cloudy and contains albumin. 
 Placental cysts may rupture during 
 labor (Fig. 278). 
 
 (6) Calcareo^is Degeneration. — 
 This is by no means uncommon; as 
 a rule, it is not of clinical import- 
 ance, and lime concretions are some- 
 times found in large numbers. Its 
 occurrence in syphilis has already 
 been mentioned. Placental calculi, 
 ossiform concretions, placental ossi- 
 fication, stone placenta, have already 
 been noted under the subject of in- 
 farcts. These deposits are almost 
 always found on the uterine placen- 
 tal surface, in the decidua serotina, 
 
 whence they may extend to the fetal part of the placenta. When the degener- 
 ation begins in the fetal structures, it is confined to them, and implicates the 
 small blood-vessels of the villi, extending from their tiny extremities to their 
 trunks. These concretions are in the form of grains, needles, or scales. They 
 consist of amorphous carbonates and phosphates of lime and magnesia ; as 
 many as five hundred have been found in one placenta (Chambord). Stony 
 scales or laminse or even larger formations may be found in placentae that 
 have been left in titero weeks or months after the occurrence of fetal death. 
 In the common form, during the life of the fetus, the placental function is not 
 disturbed. 
 
 (7) Fatty Degeneration. — This frequently occurs, and modern investigation 
 
 Fig. 27S. — Multiple Cysts on the Fetal 
 Surface of the Placenta. — {Ribentoni- 
 Lepage.) 
 
236 
 
 PATHOLOGICAL PREGNANCY. 
 
 tends to show that fatty change is usually consecutive to the fibrous metamor- 
 phosis (Robin-Ercolani). It sometimes occurs in the decidua serotina. Here, 
 however, it is part of a chronic endometritis, the placenta being involved 
 secondarily (interstitial endometritis of Hegar). A fibrous change may occur 
 in the vilH themselves, or in the interspaces; the usual contraction, obliteration 
 of vessels, and fatty change following. This fatty tissue is friable and greasy to 
 the touch. It greases any substance with which it comes in contact, and is 
 rather firm in consistency. 
 
 (8) Miscellaneous Degenerations. — So-called hyaline degeneration is a pheno- 
 menon which accompanies white infarction. Pigment deposits consist of hemo- 
 globin or its derivatives and result from extravasations of blood. They are 
 usually small and disseminate, and are devoid of pathological significance. 
 Mucous degeneration such as attacks the chorionic villi may occur at times in 
 the placenta. 
 
 8. Placental Tumors. — (i) Placentomata: Excluding cysts, which are prob- 
 ably better regarded as an expres- 
 sion of degenerative change, and 
 vesicular moles and deciduoma ma- 
 lignum which belong to the pathol- 
 ogy of the deciduse, a number of 
 placental neoplasms — about fifty in 
 
 Fig. 279. — Separation of the Placenta by a Retro-placental Hemorrhage. The 
 figure to the right is the blood-clot removed from the center of the placenta. — (Tarnier.) 
 
 round numbers — have been placed upon record, all of which appear to be of the 
 same fundamental type. The favorite locality is the fetal surface of the placenta 
 near the cord. Much more rarely they occur upon the maternal surface or in 
 the substance of the organ. They are of a firmer texture than the placenta, from 
 which their outlines and color are well defined, and are also isolated from the 
 placental tissues proper by a well-marked capsule. Histologically these tumors 
 are examples of myxoma fibrosum, although some authors prefer the name an- 
 gioma, because of the great number of blood-vessels present. In a few cases of 
 placental tumor the structure of sarcoma was approximated. None of the 
 reported cases had any tendency to malignancy. Coagulation-necrosis often 
 develops in these tumors. (2) Placental Polypi: These formations are not 
 usually included under placental tumors proper, as they represent a disease 
 
ANOMALIES OF THE UMBILICAL CORD. 237 
 
 of the uterine cavity which was due originally to the persistence of placental 
 residues. They may, however, be described in this connection. Placental 
 polypi may be benign or malignant. The formation of the former has been 
 described by Pilliet as follows : The fragments that are left behind after abortion 
 may either assume new growth, by drawing their nourishment from the uterine 
 vessels, or they may have deposited on them blood-clots, which become 
 organized and constitute large polypoid tumors. These tumors give origin 
 to abundant hemorrhages, muco-sanguinolent leucorrhea which is commonly 
 very offensive, together with attacks of uterine colic. The uterus is boggy 
 in consistency, large, and subinvoluted. Treatment should include thorough 
 uterine curettage. The malignant or destructive placental polyp consists of 
 a malignant growth of one villus or of several villi, which are apt to penetrate 
 the uterine walls, even as far as the abdominal cavity. Death follows from 
 exhaustion, hemorrhage, or peritonitis. 
 
 V. ANOMALIES OF THE UMBILICAL CORD. 
 
 /. Length. 2. Thickness, j. Insertion. 4. Coils. 5. Knots. 6. Tangling. 7. Torsion. 
 8. Stenosis of the Vessels, p. Cysts. 10. Calcareous Deposits. 11. Hernia. 12. Syphilis. 
 ij. Obstruction of the Vessels. 14. Dilatation of the Umbilical Vein. 15. Hyper- 
 trophy of the Valves. 16. Congenital Tumors. 
 
 1. Length. — The cord at term is usually about twenty inches (50 cm.) in 
 length; but great variations occur. It is sometimes almost absent, and cases 
 have been recorded in which it was four or five feet (122 to 152 cm.) in length. 
 There is one case recorded in which the cord attained the length of nine 
 feet (2.75 m.); others in which it was only two-fifths of an inch (i cm.) long. 
 Deviations from the normal length are sometimes of clinical importance. 
 (See Pathological Labor, Part V.) Abnormal shortness may come from natural 
 or artificial causes; as, for instance, when adhesive inflammations of the 
 amnion result in the gluing together of the coils of the cord, or when the latter 
 become attached to the fetal skin or to the amnion. When it is ^tremely 
 short, it prevents the descent of the fetus, or causes hemorrhage from premature 
 placental separation, or even mal-presentation. When very long, it may form 
 dangerous coils or knots (Fig. 280). 
 
 2. Thickness. — The cord may develop to the thickness of the adult thumb. 
 In this case the vessels are normal, there being simply an increase in the density 
 of the tissue of the cord (Figs. 288 to 290). 
 
 3. Insertion. — This may be central, lateral (battledore), or velamentous 
 (Figs. 248 to 263). In the latter case the vessels of the cord pass between the 
 membranes, for a greater or less distance, before reaching the placenta. This 
 is due to the fact that during the development of the cord adhesions form 
 between the cord and either the amnion or the chorion, thus interfering 
 with the formation of the sheath, which normally binds them together. 
 The eccentric position is by far the most frequent. Hyrtl's table includes 
 many abnormal placentae, and is, therefore, not absolutely correct. It is as 
 follows: Eccentric, 54 per cent.; central, 16 per cent.; marginal, 19 per cent.; 
 velamentous, 11 per cent. The last percentage is too great, as it is usually 
 only 2 or 3 per cent. The velamentous cord is important from a practical 
 standpoint, for rupture of the membranes may cause a rupture of the cord 
 and the death of the fetus from hemorrhage. This form of insertion is a source 
 
238 
 
 PATHOLOGICAL PREGNANCY. 
 
 of considerable danger to the fetus, for the vessels, in their abnormal position, 
 are exposed to traumatism, and their rupture may result in serious or even 
 fatal hemorrhage, before the delivery of the fetus can be brought about. There 
 is an analogous condition in that form called meso-cord, from its resemblance 
 to the suspensory structures of the kidney, rectum, or colon. Here the cord, 
 instead of having its normal insertion, is received into an amniotic fold which it 
 first traverses. The well-being of the fetus is not at all interfered with by this 
 anomaly. 
 
 4. Coils. — The cord frequently becomes wound around the fetus. I had a 
 case in my own practice, in which the cord was coiled seven times around the 
 child's neck, the result being the death of the fetus (Fig. 288). Another case is 
 recorded, in which it was in nine coils about the neck. In 2200 labors I found 
 
 the cord about the neck in 514 cases, or 23.36 per 
 cent. The cord was coiled once about the neck in 
 19.77 P6^ cent.; twice in 3.18 per cent.; three times 
 in 0.40 per cent. Coiling was called by the earlier 
 writers "suicidium foetus in utero" (Figs. 283 to 287). 
 5. Knots (Figs. 288 to 290). — These form in con- 
 sequence of the fetal movements ; the fetus may pass 
 through a loop in the cord, thus producing a knot; 
 
 Fig. 280. — Short Umbilical 
 Cord. 
 
 Fig. 281. — Tangling of the Umbilical Cords in a Case 
 OP Twins Contained in One Amniotic Cavity, a, Com- 
 plicated knot of both umbilical cords; A, the same knot 
 enlarged. — (Ahlfeld.) 
 
 these are of the most varied appearance. They are also due, at times, to uterine 
 contractions during labor, before rupture of the membranes, and form a possible 
 complication of version. Knots are usually harmless, since the constrictions 
 are rarely tight enough completely to obliterate the lumen of the vessels. The 
 pulsations of the cord favor the loosening of the knots, on account of the in- 
 cessant repetition of the shock of pulsation. Rarely a true knot forms; false 
 knots are the result of local increase of Wharton's jelly (Figs. 291 and 290). The 
 obstruction of the umbilical vessels causes a more or less complete arrest of the 
 circulation, which decidedly hinders the development of the fetus and may 
 even cause its death. 
 
 6. Tangling. — In multiple pregnancies the cords sometimes become tan- 
 
ANOMALIES OF -THE UMBILICAL CORD. 
 
 239 
 
 gled, and this accident results nearly always in asphyxiation of both fetuses, 
 
 with their expulsion (Figs. 281 and 282). 
 
 7. Torsion. — This is a twisting of the cord on its long axis. It occurs 
 
 most commonly about the seventh 
 month. It was formerly supposed to 
 be due to active movements on the 
 part of the fetus, but it has recently 
 been shown that, while a certain 
 amount of torsion may be produced 
 by fetal movements, it is never cap- 
 able of occluding the vessels, and that 
 the higher degrees of torsion occur 
 after the death of the fetus (Schauta), 
 
 Fig. 282. — Coiling of Both Umbilical Cords 
 OF Twins, about Each Other and about 
 A Leg. Also Two True Knots. — (Winc- 
 kel.) 
 
 Fig. 283. — Coiling of the Umbilical 
 Cord about the Fetus and Its Ex- 
 tremities. — (McGtll-i cuddy.) 
 
 Fig. 284. — Coil 
 iNG about a Leg. 
 
 Fig. 285. — Coiling 
 about a Leg and 
 AN .\rm. 
 
 Fig. 286. — Coil- 
 ing about the 
 Neck and Leg. 
 
 Fig. 287. — Coil- 
 ing about a 
 Shoulder. 
 
 and as a result of the movements of the mother. Torsion occurs more frequently 
 in the case of male children, in multiparas, and with long cords. It usually occurs 
 near the umbilicus, and the cord is frequently oedematous and the seat of thrombi 
 
240 
 
 PATHOLOGICAL PREGNANCY. 
 
 and cysts. A certain amount of twisting of the arteries around the vein is 
 generally seen, commonly ten to twelve twists. 
 
 8. Stenosis of the Vessels. — The umbilical vein is sometimes narrowed by 
 a local periphlebitis. This occurs at the placental insertion and usually does 
 no harm. Thrombi sometimes form in the umbilical arteries, as the result 
 of atheromatous changes, and partially occlude the vessels. If these pro- 
 cesses are extensive, corresponding injury to the fetus of course results. This 
 stenosis may be congenital. If the involvement concerns only the vein, 
 hypertrophy follows, with congestion and oedema of the placenta. If, however, 
 the arteries are also affected, the circulation of the fetus will be obstructed 
 and the fetus will become oedematous. 
 
 9. Cysts. — Serous and mucous cysts are sometimes found in the cord. This 
 may result froni cystic degeneration which follows some obstruction to its 
 
 circulation, and as a result a collection of serum 
 formed in the spaces beneath the amniotic cover- 
 ing and in the tissues of the allantois. Possibly 
 it is a result of the liquefaction of Wharton's jelly, 
 
 Fig. 288. — Coiling of the Um- 
 bilical Cord Seven Times 
 
 ABOUT THE NeCK OF THE 
 
 Fetus. Death op the 
 Fetus and Miscarriage. — 
 (Author's case.) 
 
 Fig. 289. — Syphilis of the Umbilical Cord. Transverse 
 section showing inflammatory changes of the media and 
 adventitia. i. Vein with thin wall; 2, thickened artery; 
 3, rotmd-ceU infiltration; 4, stroma of normal myxoma- 
 tous connective tissue; 5, external layer of cuboidal cells 
 investing the umbiHcal cord. — (Schaeffer.) 
 
 the fluid collecting in the sacs that are formed ; it may follow apoplexies of the 
 cord. It is not clinically important. 
 
 10. Calcareous deposits are sometimes seen, and are supposed to be the 
 result of syphilis. They are found in the mucous tissue or in the blood-vessels, 
 but are of no importance. 
 
 11. Hernia. — This is the protrusion of some of the abdominal contents at 
 the umbilicus, the result of faulty development. The intestines, in the fetus, 
 are at first outside the abdominal cavity, and in case of hernia they have "either 
 failed to enter the abdomen, or, having entered, they are permitted to escape 
 through a defect in the abdominal wall. In some cases nearly all the abdominal 
 viscera escape. Sometimes the traction exerted by the escaped viscera pro- 
 duces deformities of other fetal parts, such as strictures of the rectum, or de- 
 formities of the legs. The dilated sheath of the cord envelops the protruded 
 viscera. Often the infant is still-bom. If the child is bom alive, the displaced 
 
ANOMALIES OF THE UMBILICAL CORD. 
 
 241 
 
 organs must be protected by proper bandages till operation can be performed. 
 This affection is really eventration rather than hernia. 
 
 12. Syphilitic Lesions. — Macroscopic lesions are induration of the cord, 
 thickening of the vascular coats, disconnection of the funicular vessels, owing 
 to the disappearance of mucous tissue. Histological lesions are endophlebitis 
 and periphlebitis, endarteritis and periarteritis (Fig. 291). 
 
 13. Obstruction of the Vessels. — The disconnection of the funicular vessels, 
 by the disappearance of mucous tissue (Wharton's jelly), is a very rare condi- 
 tion; it is known to have been due to syphilis, and is accompanied by vascular 
 
 lesions, such as gumma of the 
 external coat of the vein, endo- 
 phlebitis and periphlebitis. 
 ^^ ^j 14. Dilatation of the Umbili- 
 
 cal Vein. — The vein may be the 
 seat of abnormal dilatations, of 
 
 Fig. 290. — True Knot of the Umbilical Cord. 
 The true knot is the center of the three in the 
 left-hand figure, the ones above and below are 
 false knots. The right-hand figure is the same 
 cord with the knot untied. — (Author's case.) 
 
 Fig. 291. — ^False Knot of the Um- 
 bilical Cord. 
 
 varicosities perhaps as large as a 
 pigeon's egg, and injurious to 
 the development of the fetus, on 
 account of the embarrassment to the circulation. This condition, however, is 
 generally unimportant, though sometimes one of the varicose veins will rupture. 
 As a rule, this takes place close to the placenta, and a large hematoma is formed 
 At times the hemorrhage is so extensive as to cause fetal death. 
 
 15. Hypertrophy of the Valves. — This also rarely occurs. The etiology is 
 probably syphilis; the lumen of the vessel is obstructed, and the situation of 
 the valves may be indicated by large nodules. 
 
 16. Congenital Tumors. — Congenital tumors of the umbilicus are of very 
 infrequent occurrence. They comprise atheromata and dermoids and so-called 
 entero-teratomata. Atheromata and dervioids: In 1892 Pernice was able to 
 
 10 
 
242 PATHOLOGICAL PREGNANCY. 
 
 find reports of but three cases of these tumors in literature.* He describes 
 these formations as benign epithelial tumors. Pernice believes that dermoids 
 alone originate in the scar of the cord because the latter should contain no seba- 
 ceous glands. Atheromata doubtless originate in the skin around the umbilical 
 scar. It is quite likely that the dermoid alone is congenital. Enter o-teratomata: 
 These growths, also known as adenomata, bear a marked resemblance to ordinary 
 granulomata. 
 
 ANTENATAL PATHOLOGY. 
 
 Embryonal and Fetal Pathology in General. — Ballantyne and others make a 
 sharp distinction between fetal and embryonal pathology. During the period 
 of embryonal life, which is computed by various authors at from six to twelve 
 weeks, what is known as organogenesis occurs. In other words, the future 
 organs of the body are rapidly differentiated from the primordial embryonal 
 tissue, so that at the termination of this cycle they have attained almost com- 
 plete development. During the remainder of intrauterine existence there is 
 little more than an increase in size, just as in extrauterine life. It seems most 
 natural to suppose that disease in the embryo must be manifested rather by 
 arrested or perverted development of organs than by ordinary pathological 
 alterations. A slight malformation of an embryonal organ must increase in 
 size with the growth of the latter; in no other way could the occurrence of ex- 
 tensive malformations be explained. But there is a close association between 
 deformities and diseases ; this causes the surmise that certain conditions which 
 appear to be diseases of the fetal period have in reality an earlier or embryonal 
 origin, and are themselves, therefore, malformations. On the other hand, a 
 few true deformities may arise during the fetal period because organogenesis, 
 while nearly completed in the earlier weeks of gestation, goes on, to a certain 
 extent, throughout intrauterine life, and, indeed, through many years of indi- 
 vidual existence. Those structures in^ which complete development is delayed 
 include the bones, teeth, genitals, etc. The pathology of the embryonal period, 
 then, is currently believed to be co-equal with the subject of teratology, or mon- 
 strosities, including malformations. We are still deeply ignorant as to the manner 
 in which such conditions are produced. Studies of very early embryos which 
 have perished either from intrinsic causes or from affections of the membranes 
 throw hardly any light on the genesis of monstrosities. There can be little 
 doubt that abnormal development of the amnion, with or without the forma- 
 tion of adhesions and constricting bands, would work havoc with the embryo 
 and probably the fetus as well, but the solution of the problem is hardly 
 advanced by this theory. On account of the absence of facts in regard to 
 teratogeny, I have omitted this subject, and after a statement of the little that 
 is known of embryonal pathology, and illustrations of most of the (i) monstrosi- 
 ties, I shall consider (2) the diseases of the fetal period of intrauterine life, and 
 (3) death of the fetus. 
 
 Pathology of the Early Human Embryo. — Professor Mall, of Johns Hopkins 
 University, t has examined over fifty pathological embryos at very early 
 stages of development. He states that after the second week pathological con- 
 ditions are readily recognizable. Diseases of the very young ovum are of two 
 kinds: primarily embryonal and primarily chorial. In the first group the 
 * "Die Nabelgeschwulste," Halle a. S. t Professor Welch's Festschrift, 1900. 
 
ANTENATAL PATHOLOGY. 243 
 
 embryo is affected while the development of the chorion is unchanged. In the 
 second group the chorionic disease results in the strangulation of the embryo. 
 Roughly speaking, these affections- may be represented pathologically as con- 
 sisting in three degrees: viz.,"(i) simple arrest of development, (2) partial 
 destruction of embryo, (3) total destruction of the same. About twenty-three 
 cases studied by Mall were examples of arrested development, while in five 
 the embryo was partly, and in eight completely, destroyed. Eight cases were 
 also noted in which the disease appeared to originate in the umbilical vesicle. 
 It would appear that in the majority of cases the pathological process began 
 in the embryo. The chorion is endowed with great vitality and is able to 
 exist independently and undergo normal development for a considerable time 
 after the death of the embryo, but finally its independent existence comes to a 
 standstill, and it either persists as a cystic formation or collapses to form a 
 fleshy mole. On the other hand, the embryo undergoes rapid destruction if 
 the chorion becomes affected. In computing the period at which abortions 
 occur we must naturally be guided by the degree of development of the chorion, 
 not by that of the embryo. In simple arrest of development we may note the 
 coincidence, for example, of a two weeks' embryo in a four weeks' ovum. 
 
VI. DEFORMITIES AND MONSTROSITIES OF THE FETUS. 
 
 CLASSIFICATION* 
 
 (A) SINGLE 
 MONSTERS 
 
 (IncludiriK 
 I ncidental 
 M onste rs 
 or Anomal- 
 ous Indi- 
 viduals). 
 
 (B) DOU- 
 BLE MON- 
 STERS. 
 
 Heterotaxy. Splanchnic Inversion. 
 
 Complete. 
 
 ncomplete. Androgynoides. Gynandroides. 
 
 . Hermaphro- 
 
 DISM. 
 
 Anomalous 
 Individuals. 
 
 Essential 
 Monstrosi- 
 ties. 
 
 I. Separate 
 Twins. 
 
 II. United 
 Twins. 
 
 Hemiterata. (Anomalies of : 
 
 /(i) Growth. 
 
 (2) Non-union. 
 
 /(3) Cleavage. 
 J(4) Structure. 
 '(5) Persistence. 
 
 ({a 
 1 i 
 
 ) Excess. (4) 
 Defect. 
 
 /Subdivided accord] 
 ( ing to locality. 
 
 f (a) Redundancy. 
 I [b) Defect. 
 
 Microscopic. 
 
 (a) Intrinsic. 
 Extrinsic. 
 
 I. Terato- 
 
 MELUS. 
 
 I 2. Teratocor- 
 
 MUS. 
 
 |3. Teratoce- 
 phalus. 
 
 4. Teratopro- 
 
 SOPUS. 
 
 Non-disappearance 
 of fetal structures 
 
 ,,, ^ r .• , f (a) Intrinsic. {b) 
 
 (6) Conformation.! <^ ' ^ ' 
 
 f(a) Hemimelus. 
 
 ( \b) Phocomelus, etc. 
 
 {a) Dipus. 
 
 (b) Monopus. 
 
 (c) Apus. 
 
 Celocormus. 
 f (a) Teratothorus. 
 ( {b) Teratosoma. 
 
 (i) Ectromelus. 
 
 {2) Symelus. 
 
 I (i) Complete. 
 [ (2) Partial. 
 
 ( (a) Iniencephalus. 
 
 (i) Involving spine-; (d) Exencephalus. 
 
 ((c) Anencephalus. 
 
 (2) Local. 
 
 (1) Aprosopus. 
 
 (2) Paraprosopus. 
 
 Homologous Normal Twins. 
 
 . Omphalo- 
 sites. 
 
 Paracephalus. 
 
 Acephalus. 
 Amorphus. 
 
 I. Dicephalus 
 (epischistos). 
 
 . Dipygus 
 (hyposchistos). 
 
 \3. Amphischistos. 
 
 I. Helerotypus. 
 
 \2. Heteralius. 
 
 \3. Endocynia. 
 
 f fa) Hemicephalus. 
 \ [b) Encephalocele. 
 
 , Schistoprosopus. 
 J Ectroprosopus. 
 j Cyclopia. 
 ^ Synotia. 
 
 1. Anceps. 
 
 2. Dipus. 
 
 3. Apus. 
 
 4. Acormus. 
 
 Thorus, Athorus, Acormus. 
 
 f Mylacephalus. 
 1 Anideus. 
 
 (i) Sympygus. 
 
 (2) Monopygus. 
 
 (i) Syncephalus. 
 
 f Lecanopagus. 
 J Ischiopagus. 
 j Pygopagus. 
 ^Somatopagus. 
 
 fMonolecanus. 
 J^ Monosomus (dipro- 
 sopus). 
 
 
 Craniopagus. 
 
 Hemipagus. 
 
 Janiceps. 
 
 , , ,, , , f(a) Dibrachius. 
 
 (2) Monocephalus. 1^^^' Deradelphus. 
 
 ({a) Sternopagus. 
 (i) Thoracopagus. < (6) Xiphopagus, 
 ( etc. 
 
 (2) Rachipagus. 
 
 (a) Thoracopagus parasiticus. 
 
 (b) Dicephalus parasiticus. 
 ic) Acephalus. 
 
 (d) Athorus. 
 
 (e) Apygus. 
 
 (a) Craniopagus parasiticus. 
 lb) Ischiopagus parasiticus. 
 
 (c) Dipygus parasiticus or polymelus 
 (nolomelus, pygomelus, etc.). 
 
 ({a) Polygnathus (epiguathus, etc.). 
 < (b) Sacrococcygeal tumors. 
 ((c) Fetal inclusion. 
 
 j Tricephalus. 
 
 (C) TRIPLE 
 MONSTERS 
 
 The illustrations of deformities and monstrosities are taken mostly from Ahlfeld's Atlas. A few are from 
 Hirst and Piersol's Atlas and from photographs and drawings of the author's cases. 
 
 244 
 
50ME OF THE MONSTROSITIES AND DEFORMITIES 
 OF THE FETUS INCLUDINO SIMPLE ANOMALIES 
 A. SINGLE MONSTERS 
 
 INCIDENTAL 
 I.HETEROTAXY 
 
 '■■;•■ <+ 
 
 COMPLETE TRANSPOSITION OF VISCERA 
 FIG. 292 
 
 Minovici and Juvara: "Archives des Sciences Medicales," iii, 1898 
 
 245 
 
FXTERNAL MAI F GENITALS SIMULATING FEMALE ORGANS 
 
 mAl thiJMAL iv^t ^^'^^^ ilMUL^^i UN^ur t^^^ EXTERNAL FEMALE GENITALS SIMULATING MALE ORGANS 
 
 2 HERMAPHRODISM 
 EXTERNAL 
 
 FIG, 29S 
 
 INTERNAL 
 
 FIG. 296 
 
 FIG. 297 
 
 COMPLETE ( BILATERAL ) 
 
 HERMAPHRODISM 
 
 FIG 298 
 
 UTERUS MASnnjNOS 
 FIG". SOO 
 
 5.HEiMITERATA 
 
 FIG. 299 HERMAPHRODISM 
 
 FIG/ SOI 
 
 ( 1 ) ANOMALIES OF GROWTH 
 
 OVERGROWTH OF FFNGERS 
 FIG. 802 
 
 OVERGROWTH OF ONE HALF OF TONGUE 
 FIG SOS 
 
 OVERGROA/VTH OF HAND DEFECT OF RADIUS 
 FIG. ?S04 FIG. 311 
 
 OVERGROWTH OF FEET 
 Fia SOS 
 
 OVERGROWTH OF LEG 
 FIG a06 
 
 OVERGROWTH OF ONE HALF OF FACE 
 FIGJ S07 
 DEFECT OF HIP JOINT 
 FKJJ ais 
 
 L_ 
 
 L'46 
 
(2) ANOMALIES OFNON UNION 
 
 DOUBLE HARELIP 
 FIO. 316 
 
 SINGLE HARELIP 
 FIG. 814 
 
 PERSISTENT 
 
 HARELIP AND CLEFT PALATE BRANaiL^^ CLEF.X 
 FIG. 81S 
 
 TRACHEAL FISTULA 
 FIG. 818 
 
 BUCCAL FISTULA 
 
 FIG. 317 CONGENITAL UMBILICAL HEBNLA. 
 
 FIO. 820 
 
 SPLIT PELVIS 
 FIO. 821 
 
 H\T>OSPADIAS 
 EXSTROPHY OF THE BLADDER EPISPADIAS FIG. 824 
 
 FIO. 822 FIG. 328 
 
 247 
 
(5 ) ANOMALIES OF CLEAVAGE 
 
 DOUBLE FALLOPtAN TUBE 
 FIG. SS9 
 
 DOUBLE TOUMB DOUBLE URETER AND 
 
 f-K--- S82 KIDNn- PELVIS 
 
 FIG 338 
 
 HORSESHOE KIDNE\ p,Q ■ „ , o 
 
 FIG. 342 
 
 POLYMAi^TIA 
 FIG. 336 
 
 DOUBLE GALLBLADDER 
 FIG. 337 
 
 SUPERNUMERARY VERTEBRAE (TAIU 
 FIC>- 840 
 
 (6) VICES OF CONFORMATION 
 
 VULVOVAGIA"VL ANUS 
 FIG. S4B 
 
 ATRESIA ANI FT RECTI 
 FIG. 351 
 
 ATRESIA RECTI 
 FIO. 352 
 
 ATRESIA ANt 
 FIG 3BO 
 
 248 
 
ESSENTIAL IVIONSTERS 
 
 1 . TERATOMELUS or umb monstrosity. 
 
 ,o6C:'\.^: 
 
 
 PHOCOMELDS 
 ™- 333 
 
 SIFJENOjMELUS 
 FIG 356 
 
 2 .TERATOCORMUS or trunk monstrosit\'. 
 
 PLEUROSOMA 
 FIG. 361 
 
 FISSURE OF DTAPHRAGIvr 
 FIG. 362 
 
 CELOSOMA 
 FIG. ye>0 
 
 249 
 
5.TERATOCEPHALUS ob head monstrosity 
 
 PODENCEPHALUS 
 "* FIO. 871 
 
 HYPERENCEPHALUS 
 FIQ. 372 
 
 EXENCEPHALUS 
 FIG. S70 
 
 4-.TERATOPROSOPUS or face monstrosity. 
 
 FIO SSO 
 
 RHINOCEPHAL.US 
 
 FIG. 379 
 
 CEBOCEPHALUS 
 FIG. 878 
 
 OTOCEPHALUS 
 FIG. 384 
 
 (Tl'CLOCEPHAL U S 
 FIG. 882 
 
 250 
 
t^^^wjy-'" "^ 
 
 B. DOUBLE MONSTERS 
 
 I. SEPARATE TWINS 
 
 (1. HOMOLOGOUS NORMAL TWINS) 
 
 2 . OMPHALOSITES or placental parasites. 
 
 PARACEPHALUS DIPUS 
 FIG. 386 
 
 PARACEPHALUS ACORMUS 
 PIG. S87 
 
 AMORPHUS ANIDEUS 
 
 no. yyi 
 
 ACEPHALUS ATHORUS 
 FIG. 889 
 
 MYLACEPHALUS 
 FIG 890 
 
 ACEPHALUS THORUS 
 FIG. 888 
 
 Etymological Key. — Prefixes: a- or an-, "absence of"; syn- or sym-, "fusion," or 
 "blending of two symmetrical structures"; mono^, "single," "undivided"; di-, "two"; tri-, 
 "three"; anti-, "opposed" or "opposite"; i^ira-, " four " ; epi-, "above"; hypo-, "below"; 
 ectro-, "abortive," "defective," "rudimentary "; 5c/jz5to-, "cleft"; micro-, "small"; hemi-, 
 "half." Suffixes: -pagM5, "united," "connected"; -sc/iV5i05, "cleft." Parts ofBody 
 -cephalus, "head"; -cormus, "trunk"; -pygus, "breech"; -melus, "limb" ("extremity") 
 -thorus, "chest"; -notos, "back"; -prosopos, "face"; -crania, "skull "; -rachis, "spine" 
 -lecanus, "pelvis"; ischio, "seat-bone"; -pus, "foot," "leg"; -hrachius, " arm" ; -ophthal- 
 tnos. -opos, "eye"; -otos, "ear." 
 
 251 
 
1 1 UNITED TWINS 
 AUTOSITES 
 
 1. EPISCHISTOI (CLOVEN ABOVE) 
 
 MONOSOMUS TETROPHTHALMUS 
 FIG, 402 
 
 MONOSOMUS TRIOPHfHALMUS 
 FIG. 401 
 
 MONOSOMUS TRIOTUS 
 FIG- 4.03 
 
 252 
 
2. HYPOSCHISTOI (CLOVEN below) 
 
 CRANIOPAGUS FRONTALIS 
 FIG. 405 
 
 CRANIOPAGUS PARIETAI.IS 
 FIG. 406 
 
 CRANIOPAGUS OCrrPITALlS 
 FIG. 407 
 
 MONOCEPHALUS DIBRACHIUS DIPUS 
 
 FIG 412 _ 
 
 MONOCEPHALUS DIBRACHIUS TETRAPUS M0N0CEPHALU5 DIBRACHIUS TRIPUS 
 FIG. 414 FIG. 413 
 
 5. AMPHISCHISTOI (cloven above and BELOW) 
 
 3TERNOPAGUS 
 
 ^DEROTHOPAf-npAGUS 
 
 XIPHOPAGUS ^^' ^'^ "^"^ ~ PROSOPOTHORACOPAGUS 
 
 FTG. 4.1P, THOR.\COPAGUS TRIBRAClilUS '^'^- 4-'^ 
 
 FIG. 417 
 
 253 
 
X)]PYGU5 CEPIIALOMELUS J5IFYGUS THORACOMELUS DIPYGUS GASTPOMELUS DIPYGUS Py001^rEr.US 
 
 FIG. 426 
 
 FIG. 428 
 
 mo. 429 
 C TRIPLE MONSTERS' 
 
 TRICEPHALUS. 
 
 EPIGNATHUS 
 FIG 4SO 
 
 fEXAL INCLUSION 
 
 FIG. 4S3 
 
 SACROCOCCYGEAE TUMOR 
 
 254 
 
ANTENATAL DISEASES OF THE FETUS. 255 
 
 VII. ANTENATAL DISEASES OF THE FETUS. 
 
 /, Injections Diseases. 2. Acute Poisoning, j. Chronic Poisoning. 4. Dyscrasic Condi- 
 tions. 5. Cardiac Diseases. 6. Diseases of the Alimentary Tract. 7. Diseases oj the 
 Nervous System. 8. Diseases oj the Urogenital Apparatus, g. Skin Diseases. 10. Fetal 
 Bone Disease, il. Fetal Traumatisms. 12. Fetal Neoplasms, ij. General Fetal CEdem.a. 
 14. Maternal Traumatisms. 15. Maternal Uterine Disease Ajjecting the Fetus, 16. 
 Fever in the Mother Ajjecting the Fetus. 77. Death oj the Mother Ajjecting the Fetus. 
 
 I. Infectious Diseases. — i. Variola. — When a pregnant woman contracts 
 this disease, one of three conditions may result: (i) Pregnancy is inter- 
 rupted at the moment of the eruptive period and the woman is delivered of a 
 dead or moribund child that has not been contaminated by the disease. Appar- 
 ently there has not been time for the latter to develop. This is the commonest 
 termination of pregnancy in a variolous woman. As a variety of the preceding 
 there is occasionally noted a termination in which the child survives. This 
 occurs when labor sets in during the first onset of the disease and also when the 
 type of maternal disease is very mild (varioloid). (2) Pregnancy is not inter- 
 rupted by the disease. There is a simple coincidence of labor and the mother's 
 disease which supervenes shortly before term, or the pregnancy is continued 
 during and after the subsidence of the disease until term arrives. The children 
 which result from these pregnancies are born intact and it is possible to vaccinate 
 them successfully. The type of maternal disease in this category must be very 
 mild. (3) Pregnancy is interrupted and the child is born with a full variolous 
 ■eruption. These cases are rare, but many have been placed on record. In a 
 few the eruption did not appear until a few days after delivery. The most 
 remarkable of all cases of intrauterine variola are seen in twin pregnancies in which 
 •one twin is born intact while the other has variola. Kaltenbach has even reported 
 a case of triplets in which two of the children were born with smallpox while the 
 third was healthy. Vinay regards this as open to a very simple explanation. 
 A healthy placenta, he states, does not allow disease germs to pass through it. 
 When, however, this organ is the seat of infarcts or other lesions, the natural 
 "barrier is overcome. (4) To the preceding categories a fourth may be added; 
 here, while the mother is not known to have had variola, although there may be 
 a history of exposure, her pregnancy is interrupted and the fetus is found to have 
 smallpox. In one such case the mother had had intercourse with a variolous 
 convalescent who was probably the father of the child. This woman was doubt- 
 less protected from the disease by vaccination. Vinay is inclined to believe that 
 the maternal immunity in these latter cases is more apparent than real ; for in all 
 the recorded instances of variolous pregnancies in healthy women the latter have 
 •exhibited headache and backache at the time when the fetus should have been 
 contracting the disease. The mother therefore suffers from the rare form of the 
 latter known as variola sine exanthema, in which the entire eruption may be 
 absent, escape observation, or consist only of a few pustules. Symptoms: 
 There is absolutely no method by which we can determine the incubation 
 period of fetal variola. The localization of the disease differs considerably from 
 that in the adult, for the face is often spared while the trunk is likely to bear the 
 brunt of the eruption. The eruption may be discrete or confluent, and the 
 disease may actually run its course in liter o, so that the child is born with cica- 
 trices only. The lesions are umbilicated, but do not, of course, form crusts in a 
 moist medium. When the fetus is first attacked in utero, it betrays its distress 
 by violent movement. Prognosis: Intrauterine variola is fatal in the great 
 majority of instances. Examples under which recovery occurs have already 
 
256 PATHOLOGICAL PREGNANCY. 
 
 been cited. The child is not necessarily still-born, for it may survive for 
 some days. Surviving children are sometimes susceptible to vaccination, but 
 in other cases are refractory. Treatment: There is no indication for thera- 
 peutic abortion and no management which can be directed especially to the 
 fetus. All pregnant women should be vaccinated when smallpox is prevalent. 
 For treatment of the mother, see Section XV. 
 
 2. Vaccinia. — The child borne by a woman who had smallpox during 
 her pregnancy may or may not be susceptible to vaccination. Those who are 
 immune give no evidence of having had fetal variola. Vaccinia can be 
 transmitted to the fetus. Many women are vaccinated during pregnancy and 
 their infants have the same experience soon after birth. The results of different 
 authorities vary somewhat, but, according to Ballantyne, about 33 per cent, of 
 infants are in this way rendered immune. Individual observers place the per- 
 centage of immunity as high as 60 per cent, and even 80 per cent. This in- 
 herited refractoriness to vaccination is short-lived, so that such infants should 
 by all means be vaccinated as soon as a positive result is obtainable. The 
 claim has been made that unsuccessful vaccination of the mother often confers 
 some immunity on the fetus. 
 
 3. Measles. — When a pregnant woman contracts measles, gestation is 
 usually interrupted (in about 75 per cent, of cases, according to limited figures). 
 Children thus bom may present a morbillous rash and coryza. Ballantyne, 
 who has seen an undoubted instance of intrauterine measles, cites some twenty 
 others from literature. In each of these the mother herself presented the symp- 
 toms of the disease. 
 
 4. Scarlatina. — Pregnant women often contract this disease, and may 
 or may not abort. Ballantyne has reported an undoubted case in which 
 the premature infant of a scarlatinous mother was seen to have a rash and en- 
 larged glands on the first day post partum. According to this author, there are 
 about a score of such cases recorded. Vinay also states that healthy children 
 have been born of scarlatinous mothers who have afterward infected the off- 
 spring by lactation. In my own case in private practice, scarlatina in the 
 mother resulted, immediately upon the appearance of the eruption, in a 
 seventh-month miscarriage of a dead fetus, the latter showing no evidence of 
 the disease. 
 
 5. Erysipelas. — The possibility "of the occurrence of fetal erysipelas 
 having been established by certain obstetricians (Kaltenbach, Runge, Stratz), 
 Lebedjeff succeeded in demonstrating the presence of Streptococcus erysipe- 
 latis in the chorion. Erysipelas in the mother is not often transmitted to the 
 fetus, and causes abortion in about 50 per cent, of all pregnancies. According 
 to Hofmeier, the fetus exhibits tachycardia when the mother is attacked by the 
 disease, the pulse-rate varying directly with the mother's temperature. 
 
 6. Diphtheria. — Nothing is known of intrauterine diphtheria. While newly 
 born children have doubtless been contaminated by diphtheritic mothers, it is 
 doubtful if a genuine case of congenital transmission has ever been recorded. 
 
 7. Typhoid Fever. — Fetal typhoid is a well-established example of ante- 
 natal disease, and has been known since 1840. While the older cases were 
 recognized by the characteristic intestinal lesions, the fetus, as a rule, does not 
 present this localization. After the discovery of Eberth's bacillus diagnosis 
 of fetal typhoid became easier, and still another impetus has been received from 
 the Widal reaction. Pregnant women who contract typhoid fever exhibit a 
 high percentage of interruption of pregnancy, statistics giving the frequency 
 as from 58 to 83 per cent. (Vinay). The study of typhoid fetuses since 
 
ANTENATAL DISEASES OF THE FETUS. 257 
 
 the discovery of Eberth's bacillus does not appear to show that the latter 
 causes many lesions, although it is found very widely distributed. In other 
 words, the fetus is the seat of a pure typhoidal sepsis in the majority of cases 
 Widal's test applied to the "fetal blood has given positive results, showing 
 that the antitoxic as well as the toxic principle passes through the placenta. 
 Aside from the occasional occurrence of true typhoid lesions in the fetus, and 
 the common occurrence of a bacillemia or pure sepsis, it is believed by recent ob- 
 servers that the toxins of the disease cause slight but important structural alter- 
 ations in the fetal viscera, and also retard metabolism and reduce the body- 
 temperature, so that the child, if it grow up, will exhibit dystrophic stigmata, 
 mental peculiarities, deafness, etc. Since the high temperature of typhoid is 
 responsible in part for the frequency with which pregnancy is interrupted, it has 
 been supposed that the Brand method of treatment would reduce this rate. 
 Statistics, however, show very little improvement in this respect. 
 
 8. Cholera. — According to Vinay, this disease exerts a more disastrous 
 influence upon pregnancy than any other, variola not excepted. Analysis of 
 many cases shows 53 per cent, of interruptions in which the children are in- 
 variably still-born. According to Slavjansky, the placenta exhibits character- 
 istic alterations, due in turn to a specific metritis. Tizzoni and Catani found the 
 comma bacillus in the fetal tissues. The child is invariably expelled shortly 
 after its death, apparently because of the oxytocic action of the cholera virus. 
 Many mothers, however, must die undelivered. Those who survive and whose 
 pregnancies are not interrupted have borne healthy children. Ballantyne 
 cites several instances in which newly born infants were already infected 
 with cholera, although Tarnier taught that intrauterine transmission did not 
 occur. 
 
 9. Malaria. — The possibility of fetal paludism has been extensively ques- 
 tioned, but is now generally admitted. Children with enlarged spleens and 
 other evidences of paludism have been born to malarial mothers. The most 
 recent authorities dispute the claim that plasmodium malariae has ever been 
 found in the fetal tissues. Evidence afforded of intermittent fever in the 
 newly born is open to criticism, because such infants may have been bitten by 
 infected mosquitos soon after birth. Practically, therefore, the diagnosis must 
 be based upon the presence of congenital hypertrophy of the spleen, associated 
 perhaps with dropsical accumulations, extravasated blood, discolored skin, and 
 pigmented white blood-corpuscles. Such children exhibit, in addition, sub- 
 standard weight, debility, wrinkled skin, pallor, etc. It has been claimed that 
 children bom of malarious mothers exhibit almost constant defects in length 
 and weight in comparison with those born of healthy mothers. There is also a 
 very high percentage of interruptions of pregnancy in malarious women, though 
 abortion is not common. Vinay has collected notes of 158 pregnancies with 120 
 interruptions (about 76 per cent.); but of this number there were but 20 abor- 
 tions, the remainder representing premature deliveries. Hence, statements 
 which relate to small size and debility of the newly born may be explained largely 
 by prematurity. Malaria has, per se, a marked tendency to bring on delivery 
 ahead of time, and since quinine is a specific for the disease, the good it may do 
 will greatly outweigh the prospect of an occasional assertion of an oxytocic action. 
 
 10. Influenza. — Epidemic influenza is responsible for many premature 
 births ; failure of such children to survive should not be attributed to congenital 
 transmission when we bear in mind the high mortality of prematurity in general. 
 In regard to the possibility of actual transmission of the disease, Ballantyne 
 states that he has had several personal cases of influenza contracted in iitero. 
 
 17 
 
258 PATHOLOGICAL PREGNANCY. 
 
 11. Fetal Sepsis. — If the mother is iil a state of sepsis from pneumo- 
 cocci, streptococci, staphylococci, or Bacillus coli, and the placenta allows them 
 to pass into the fetal circulation, a condition of intrauterine sepsis necessarily 
 results, and some of the fetal organs will probably be attacked. Pneumococcus 
 sepsis, fetal pneumonia: Pregnant women with pneumonia frequently abort, and, 
 according to Vinay, 60 per cent, of their infants born alive die shortly after 
 birth, presenting at autopsy evidences of pulmonary hepatization. The sooner 
 delivery can occur after the mother is attacked, the more likely are the children 
 to survive. The claim that these alterations in the lung are pneumonic has been 
 disputed in the belief that the fetus undergoing air-hunger from the maternal 
 pneumonia attempts inspiration and aspirates amniotic fluid, as a result of which 
 the lung presents a characteristic appearance at autopsy. Admitting the proba- 
 bility of this claim, it is still certain that fetal pneumonia may occur as a feature 
 of pneumococcus sepsis. Streptococcus sepsis: Streptococcus pyogenes has been 
 found in the blood and tissues of the fetus in connection with various fetal 
 diseases of the mother. Most recorded cases appear to be examples of pure 
 sepsis without lesions. The streptococcus of erysipelas appears to have caused 
 fetal endocarditis and other lesions, and Moncorvo thinks that congenital ele- 
 phantiasis may originate in this way. Staphylococcus sepsis: The staphylococ- 
 cus has been found in fetal tissues in a case of typhoid fever. If acute articular 
 rheumatism, as has been claimed, is due to the staphylococcus, the few recorded 
 cases of fetal rheumatism may be cited in this connection. Bacillus coli sepsis: 
 Ballantyne states, without references, that Bacillus coli has been found in the 
 fetus. 
 
 12. Miscellaneous. — Anthrax has been transmitted from the mother to 
 the fetus in a few instances, the bacillus of the disease being recognized in 
 the fetal tissues. Hydrophobia is transmissible by animal experiment, but 
 fetal hydrophobia in mankind has never been described. Tetanus: We know 
 of no case of association of tetanus in the mother with trismus in the newly 
 born. Naturally, in the vast majority of recorded cases of the latter the fetus 
 was not exposed to infection from the mother. Yellow fever: Pregnant women 
 with this affection often abort. When they recover without miscarriage, the chil- 
 dren afterward born are said to be immune to the disease. This statement, made 
 upon the authority of individual observers, is not generally credited. Relapsing 
 fever is known to be transmissible to the fetus. According to Klein wachter, 
 there is a fetal typhus. Ballantyne mentions a fetal varicella. Kleinwachter 
 mentions fetal epidemic parotitis. Fetal pertussis is mentioned by Ballantyne. 
 Of epidemic cerebrospinal meningitis a single case is on record (Ballantyne). 
 
 13. Tuberculosis. — When a consumptive woman becomes pregnant, she 
 tends to abort in proportion as the disease is advanced. Thus, it has been 
 computed that about 15 per cent, of abortions occur in the first, and 2,2 per 
 cent, in the second, stage of phthisis. When the pregnancy is not interrupted, 
 the offspring of these women are usually delicate and undersized, and after 
 developing the so-called strumous or tuberculous diathesis, they tend to fall a 
 prey to the disease. Before the discovery of the infectious character of tuber- 
 culous matter and the specific germ of the disease, it was generally beheved that 
 the phthisical individual practically acquired the disease in utero. The apparent 
 relative immunity of the fetal and placental tissues toward direct implication in 
 the tuberculous processes has, however, led to the conviction that antenatal 
 infection is a mere curiosity in pathology, and that the mother transmits to her 
 fetus nothing more than a lack of resistance to disease. There is a species of 
 fetal tuberculosis that may be of common occurrence. The toxic products of the 
 
ANTENATAL DISEASES OF THE FETUS. 259 
 
 disease, circulating in the maternal blood, should certainly be able to enter the 
 fetal vessels, and there give rise to a train of symptoms similar to those which 
 follow injections of tuberculin in large doses. It can hardly be doubted that 
 exposure to this influence often causes fetal death, especially in the later months 
 of pregnancy; while those children who do not die in utero exhibit at birth the 
 delicacy and undersize already mentioned. The fact that bacilli are seldom 
 found in the blood of tuberculous individuals, and then, as a rule, only in miliary 
 tuberculosis, furnishes a strong argument against the existence of bacillary 
 emigration from the mother to the fetus even if the placenta were permeable. 
 
 Actual Fetal Tuberculosis. — This condition has been recognized a very few 
 times only (between twenty and thirty). There are two distinct types: viz., 
 simple bacillosis without lesions, and tuberculosis proper. In the former the 
 fetal tissues are shown to contain bacilli by the microscope, by culture, or 
 by animal inoculation. In the latter tubercles are recognizable. Accord- 
 ing to some authors, the lesions are almost necessarily located in the organs 
 first traversed by the placental blood, especially the liver and spleen. This 
 claim remains to be proved, as a great variety of organs may be attacked 
 by the disease. In some of the cases the placenta or endometrium was also 
 tuberculous, but there is no necessary relationship in this particular. 
 
 The great infrequency of fetal tuberculosis is to be explained as follows: 
 Cases are undoubtedly overlooked, and some pediatrists — Holt, for example — 
 are inclined to look upon cases of tuberculosis in extremely young children as of 
 fetal origin. But even with this concession the disease is notably rare, because 
 two conditions are doubtless indispensable factors in its production: (i) The 
 mother must be suffering from general miliary tuberculosis, otherwise her blood 
 will contain no bacilli; and (2) the placenta must be the seat of some lesion 
 whereby the bacilli are suffered to enter the fetal blood. 
 
 The possibility that fetal tuberculosis may be derived from a tuberculous 
 ovum, or even infected spermatozoa, has been subjected to experimental testing 
 in animals. Paternal infection has been deemed impossible, but contamination 
 through the ovum is regarded as a possibility. Tuberculosis of the ovary is now 
 known to occur frequently, and in some cases the disease has even appeared to 
 attack the Graafian follicles by preference. As to the fate of an ovum proceed- 
 ing from such a follicle we can only make conjectures. Statistics appear to 
 show that early abortion occurs very rarely in tuberculous women, but these 
 figures are based on pulmonary tuberculosis only. Genital tuberculosis is, of 
 course, a different type of disease. 
 
 14. Syphilis. — Fetal syphilis — i. e., syphilis which asserts itself during 
 the fetal period for the first time — must be distinguished from syphilis 
 which is contracted perhaps during fetal life, but on account of the prolonged 
 incubation period does not assert itself until after delivery — usually not until 
 the second month of extrauterine life. We know little of germinal and embry- 
 onal syphilis. Antenatal syphilis, then, is to-day synonymous with fetal 
 syphilis. The effects of the syphilitic poison or poisons upon the fetus are, 
 speaking broadly, the same as those seen in adult life: viz., specific and non- 
 specific, or, in other words, syphilitic and parasyphilitic. The latter changes in 
 the fetus are essentially dystrophic, and comprise a long series of modifications 
 of development in various organs and tissues. All the structures which make 
 up the ovum may be attacked by the disease — fetus, liquor amnii, membranes, 
 cord, and placenta. The specific alterations induced by fetal syphilis are, in 
 brief, as follows: Liver: While this may escape injury, it is very commonly 
 affected, being enlarged and hardened and strewn with whitish dots. These 
 
260 PATHOLOGICAL PREGNANCY. 
 
 changes are the results of a diffuse interstitial cirrhosis, the white granules con- 
 sisting of miliary gummata. Larger gummy nodules are seldom seen in the fetal 
 liver. Lungs: These are often the seat of interstitial pneumonia and miliary 
 gummata, the changes being analogous to those found in the liver. The so-called 
 white pneumonia which is sometimes encountered consists of patches of air-cells 
 filled with epitheHal debris in a state of fatty degeneration. Heart and Vessels: 
 The heart is seldom attacked beyond the deposition of a few mihary gummata, 
 but the vessels are usually the seat of generalized periarteritis and endarteritis 
 with resulting obstruction of the lumina of the vessels attacked. Thymus: The 
 lesions of this organ, largely cystic, do not appear to be specific in character. 
 Kidneys: These organs are not usually implicated by the disease. Intestines: Fetal 
 peritonitis is largely of syphilitic origin. Osseous System: The diaphyses and epi- 
 physes of the long bones are separated by a peculiar linear tract which is of vary- 
 ing breadth, yellow, and irregular (Wegner's line). This formation represents 
 the occurrence of syphilitic osteochondritis. The peculiar color is due to the fatty 
 or cheesy metamorphosis of the products of inflammation. Integument: The 
 bullae of pemphigus of the newly born may develop in utero as a part of the fetal 
 evolution of the disease. This is also true to a limited extent of moist papules, 
 condylomata, etc. A pseudo-ichthyotic condition of the skin representing 
 extensive desquamation is sometimes seen. The changes which occur in the 
 fetal appendages are described under the disease of the latter. 
 
 Transmission. — There is no necessary connection between the date upon 
 which the germ first attacks the fetal tissues and the period of an explosion of 
 symptoms. The fetus may contract the disease, but it may be the newly bom 
 or older infant that first exhibits the specific lesions. Or the ovum may contract 
 the disease and the fetus suffer from it. In describing fetal syphilis we must 
 confine ourselves largely to the outbreak itself. We must also bear in mind the 
 non-specific lesions from which the fetus may suffer, (i) To take the most 
 familiar conditions conceivable in this connection, let us suppose that a woman 
 some months pregnant undergoes an explosion of secondary syphilis of a severe 
 type. The placenta is attacked along with most of the other tissues of the body, 
 and the. fetus dies before it has time to share the maternal disease. This is 
 the most common type of the relations which subsist between syphilis and the 
 fetus, and corresponds to the great frequency of abortion and miscarriage in 
 syphilitic women. Children born under these circumstances should have nothing 
 peculiar in their appearance. (2) If the fetus is not killed outright, it is almost 
 certain that the germs of the disease will traverse the placenta and set up some 
 of the visceral changes which have already been indicated. Unless this infec- 
 tion occurs near term, a fetus thus rendered profoundly syphilitic is very 
 likely to die in utero from the disease itself; and when expelled, it will present 
 a typical picture of fetal syphilis, including maceration. If such a child is born 
 alive but hopelessly diseased, we have the so-called syphilis neonatorum, which 
 should not be confounded with infantile syphilis proper, which represents the 
 outbreak of an infection received in utero. (3) If the germs of the disease do 
 not traverse the placenta, at least at the outset, the fetus is exposed to the toxic 
 principle of the disease as it circulates through the maternal blood, and, even 
 aside from this, it must perhaps suffer to some extent from the anemia and mal- 
 nutrition of the mother which are due to the action of this poison. Directly 
 and indirectly, then, the fetal development is more or less interrupted, just as it 
 would be in tuberculosis, alcoholism, etc. The fetus may be bom in this condi- 
 tion alone, or, as is much more likely, — at least early in the maternal disease, — 
 some of the maternal germs finally penetrate the placenta. The fetus when 
 
ANTENATAL DISEASES OF THE FETUS. 261 
 
 born is found to be small and feeble, with certain evidences of prematurity, not 
 yet syphilitic perhaps, but containing the germs of the disease. After several 
 weeks of extrauterine life the -disease becomes active, and the usual pheno- 
 mena of secondary syphilis -develop. This is the familiar type of congenital, 
 hereditary, or infantile syphilis. In some cases the activity does not occur 
 until late in childhood or even until adolescence (tardy hereditary syphilis) ; such 
 individuals are peculiarly afflicted with the evidences of dystrophy of syphilitic 
 origin. (4) As intimated, it is possible for a fetus to escape bacillary infection 
 in utero, and develop no syphilitic lesions in after years, although the child may 
 present evidences of dystrophy. (5) Finally, it is possible for an infant to escape 
 syphilis in utero altogether — not only its specific but non-specific influence. All 
 the preceding types may occur in the pregnancies of one woman. It is impos- 
 sible in a work of this sort to enter into the discussion of such subjects as direct 
 paternal infection, syphilis of the unimpregnated ovum, infection of the mother 
 from the fetus, immunity, Colles's and Profeta's laws, etc. Syphilis contracted 
 before or near the time of conception is said to be more generally fatal to the fetus 
 than when the mother is infected some weeks or months after impregnation has 
 occurred; that is, the proportion of abortions and of fetal syphilis will be higher 
 in the former case. 
 
 Treatment. — The mother of course requires treatment for syphilis, and there 
 is no special indication for the treatment of the fetus. Mercury and potassium 
 iodide should be given as early as possible and continued throughout pregnancy. 
 Very recently an attempt has been made to treat the fetus locally by the use of 
 medicated tampons introduced into the vaginal vault. The mercury was used in 
 the form of ointment, mixed with an equal or a double quantity of cocoa-butter 
 (Riehl). In theory a special indication should exist for the fetus when a syphilitic 
 husband has impregnated his wife. In these cases the fetus is supposed to infect 
 its mother, and proper local medication might prevent this catastrophe if it really 
 ever occurs. Riehl's method would be applicable here, but a more rational 
 treatment would be to empty the uterus at once. In regard to the routine prac- 
 tice of abortion in syphilis, the chance of curing the fetus is so considerable that 
 it is contraindicated as a general resource and is indicated only under special 
 contingencies. 
 
 2. Acute Poisoning. — Chloroform: There is no longer any doubt that chloro- 
 form used as an anesthetic in labor tends to cause fetal asphyxia. This is demon- 
 strated by the results of Csesarean section, and is, in fact, something of a con- 
 traindication to the use of anesthesia in labor. Chloroform has never been 
 recovered from the fetal blood. Fehling believes that it can determine the 
 presence of fetal icterus and albuminuria. Ether: What has been said of chloro- 
 form applies equally well to ether. (See Anesthesia in Obstetrics, Part X.) 
 Coal-gas: The pregnant woman sometimes inhales this gas with or without 
 suicidal intent. In cases in which the mothers escaped death they sooner or 
 later were delivered of dead or macerated children. This gas is extremely poi- 
 sonous to the fetus. Nevertheless there is no evidence that the gas enters the 
 fetal circulation to any extent. Alcohol: Cases are upon record in which the 
 ingestion by pregnant women of an inordinate amount of alcohol has apparently 
 caused fetal death. Mineral Asids: In cases of acute poisoning with sul- 
 phuric acid the fetus appears to have shown some of the dehydrating action of 
 this substance, but only in its skin, which is hard and brown. Metalloids: 
 In phosphorus-poisoning the fetus shows very much the same lesions as the 
 mother, it being certain that this substance passes through the placenta. In 
 
262 PATHOLOGICAL PREGNANCY. 
 
 acute arsenical poisoning, bowever, the ovum gives no evidence that this drug 
 reaches the fetal tissues. 
 
 3. Chronic Poisoning. — Plumbism: In pregnant women suffering from 
 chronic lead-poisoning abortion occurs in no less than 60 per cent, of cases, and 
 children born alive have a high secondary mortality and exhibit a marked ten- 
 dency to convulsions and hydrocephaloid or rachitiform malformations of the 
 head. The latter inheritance may even proceed from the father alone. When 
 both parents are affected, the child morbidity is increased. It is not known to 
 a certainty whether the lead kills the fetus outright or simply excites labor. The 
 metal has been found in the fetal viscera, where it has apparently set up inflam- 
 matory disturbances. On the other hand, preparations of lead have a notorious 
 tendency to produce abortion, and are much used with this criminal intent. 
 Mercurialism: In pregnant women who are subject to chronic mercurialism the 
 tendency to abortion and premature delivery is high, although the exact ratio 
 is unknown. When syphilis is present, large medicinal doses of mercury are 
 known to prevent abortion. The metal has been found in the fetal tissues. A 
 curious fact repeatedly noted is the improvement in health which follows preg- 
 nancy in these cases. Thus, a worker in a mirror or barometer factory may have 
 her salivation, tremor, etc., disappear after conception, to return when abor- 
 tion has occurred. This apparent protecting action of the embryo suggests 
 Colles's law of maternal immunity in syphilis. The action of mercury upon 
 pregnancy seems to be less severe than that of lead. Phosphorism: De Caulbry, 
 Borri, and others state that pregnant workers in match factories undergo abor- 
 tion very frequently. But few data are available regarding chronic phosphorus- 
 poisoning. Arsenicism: We know even less of arsenic than of phosphorus in 
 regard to the effects of chronic maternal poisoning upon the fetus. Alcoholism: 
 It was not until 1900 that Nicloux* was able to demonstrate that the drug in 
 question enters the fetal circulation. He gave a woman milk-punches after she 
 was well along toward delivery, and was able to distil some of the alcohol from 
 the blood of the umbilical vein. In regard to the effects of alcoholism on preg- 
 nancy, as studied in a series of chronic drunkards,! there is no evidence of any 
 strong tendency to abortion. Still-birth is quite common, but the principal 
 effect of alcohol upon the fetus is shown in the extraordinary tendency to ner- 
 vous and cerebral disease, malformation, and degeneracy exhibited by these 
 children as they grow up. Alcohol in the fetal circulation tends to arrest the 
 highest development. Morphinism: In pregnant morphinomaniacs no especial 
 tendency to abortion or premature delivery has been noted. The children born 
 to such women often appear healthy in every respect. Morphin, however, 
 has been recovered from the fetal tissues. There is considerable evidence 
 that such fetuses are more likely than others to require resuscitation at birth. 
 I have observed that attempts at withdrawal of the morphin during gestation 
 have been followed by excessive fetal movements, which subsided when the use 
 of the drug was renewed. This phenomenon suggests that the fetus has acquired 
 a tolerance to the narcotic. Nicotinism: The pregnancies in many tobacco fac- 
 tories, etc., are not interrupted, although there is a very high mortality among 
 the children of these women. 
 
 4. Dyscrasic Conditions. — Diabetes: Fetal diabetes is not actually known to 
 exist, but the sugar in the maternal blood may be able to pass into the circula- 
 tion of the fetus and give rise to various disturbances. Sugar has been found 
 in the amniotic fluid in cases of diabetes, and also in the urine of the new-born. 
 Artificial (phloridzin) glycosuria in the mother causes sugar to appear in the 
 
 *" L'0bst6trique," 1900, t. v. t Sullivan : "Jour. Mental Science," 1899 
 
ANTENATAL DISEASES OF THE FETUS. 263 
 
 fetal urine. According to Vinay, pregnancy in diabetic women is interrupted 
 in over a third of the cases, while about one-half of the children born alive do not 
 survive; but this need not be .due to the sugar directly, because diabetes often 
 leads to disease of the endometrium. A Ihuminuria, Renal Disease, Toxemia of 
 Pregnancy, Eclampsia of the Mother: The children are often still-born or die 
 soon after birth. All in all, the chance of survival of these children is very 
 small. They are undersized and below weight, even when fully matured. 
 They are very prone to be seized with convulsions after birth, and,' according 
 to some, even in utero. Autopsies upon many of these fetuses have revealed no 
 constant pathological changes. In fact, the obscurity which attaches to the 
 entire problem of eclampsia, etc., in the mother, extends to the fetus. (Compare 
 Section X, Part III.) Leukemia: Women with this affection seldom become 
 pregnant. In the few recorded cases the infant was sound. Cancerous Ca- 
 chexia: Still-births are very common, while children born alive are very weakly 
 and in many cases succumb soon after birth. The toxins which must be present 
 in the maternal blood appear to exert an influence on the fetus which is similar 
 to that observed in tuberculosis. 
 
 5. Cardiac Diseases. — Endocarditis : Its presence is revealed by changes anal- 
 ogous to those of the same disease in extrauterine life: viz., thickening of the 
 endocardium, contraction of the orifices, and valvular lesions. The causes are 
 very obscure. The clinical features of this affection are as interesting as its 
 pathogeny is obscure. It has been diagnosticated a number of times during 
 intrauterine life through auscultation of the fetal heart, systolic murmurs having 
 been readily apparent. Auscultation after delivery gave the same sounds in 
 living children, while autopsy confirmed the diagnosis in the case of non-survival. 
 The presence of a uterine souffle under these circumstances might readily pro- 
 duce an illusion. As with so many other presumably fetal diseases, it appears 
 quite probable that what is called fetal endocarditis represents an embryonal 
 anomaly. Fetuses with this affection are very prone to exhibit one or more 
 malformations of other tissues (hare-lip, cleft palate, imperforate anus, horseshoe 
 kidney. Mongoloid idiocy, etc.). Atheroma: At least one case of atheroma of 
 the aorta and pulmonary artery is known. The fetus was premature and sur- 
 vived about two weeks. It is hardly possible for such a condition to develop 
 in so short a time after birth. 
 
 6. Diseases of the Alimentary Tract. — Ascites: As a rule, this condition is due 
 to fetal peritonitis, and is thus a result of disease. It is considered to some 
 extent under " Dystocia of Fetal Origin." Peritonitis: This disease is usually, 
 but not necessarily, accompanied by effusion (see Ascites). The adhesions which 
 form may cause various late malformations in the abdominal cavity. Fetal 
 peritonitis may be due to hydramnios or syphilis, but in very many cases appears 
 to have arisen idiopathically or from unknown maternal causes. Congenital 
 Obliteration of the Bile-ducts: This interesting affection is one of the best exam- 
 ples of the diseases of the fetal period. It appears to be analogous to biliary 
 cirrhosis of the liver in adult life. The initial process, the nature of which is 
 unknown, leads to obstruction of the biliary passages,- which is accompanied or 
 followed by cirrhosis of the liver and jaundice. The fetus is born with icterus, 
 and the condition is thus one of icterus neonatorum, under which name it is fully 
 described (Part IX). Congenital Hypertrophic Stenosis of the Pylorus: This 
 belongs clinically under the diseases of the newly born, but undoubtedly develops 
 in utero. It possesses a nervous or spasmodic element which precedes or is asso- 
 ciated with hypertrophy of the pylorus and the wall of the stomach. Something 
 analogous to this union of nervous spasm and hypertrophy is seen in the urethra 
 
264 PATHOLOGICAL PREGNANCY. 
 
 and bladder, also the colon. Adiscellaneous: Ballantyne, in addition to the con- 
 genital hypertrophy of the colon, speaks of a " congenital volvulus." 
 
 7. Diseases of the Nervous System. — Congenital Hydrocephalus (Figs. 435 and 
 436). — Definition: An excessive accumulation of cerebrospinal fluid within the 
 brain or its membranes, causing enlargement of the skull. The serous effusion is 
 generally confined to the ventricles, although it may be found in the interstices 
 of the pia mater, in the parenchyma of the cerebrum, or between the arachnoid 
 and the dura mater. (See also " Dystocia of Fetal Origin," Part V.) Frequency: 
 This affection is rare, occurring once in about 3000 deliveries. Pathology: The 
 skull becomes enlarged, sometimes enormously so, by the pressure of the in- 
 creasing quantity of the fluid, and the edges of the sutures are separated 
 more or less widely; the bones become very thin, sometimes like parchment; 
 the skull is much larger proportionately than the face, the forehead being 
 especially prominent. The head may even reach the size of that of an adult; 
 the body, as a rule, is normally developed, and is of the size which corresponds 
 to the period of pregnancy, but is often wrinkled and emaciated. Other mal- 
 formations, as meningocele, frequently coexist, and hydramnios is a common 
 
 Figs. 435 and 436. — Hydrocephalus. Two Views of the Same Skull. (J natural size.) 
 
 — {Author's collection.) 
 
 accompaniment. The quantity of liquid in the ventricles may reach several 
 pints. The head is shaped like a wedge, with the base upward; the charac- 
 teristic deformity produced by the normal size of the face and lower part of 
 the skull, surmounted by the enormously distended upper part, is very 
 striking. The eyes are very deeply set, and their axes point obliquely inward, 
 so that they look crossed, and the deformity is often hideous, from the promi- 
 nence of the eyes and the overhanging forehead (Fig. 435). With this affection 
 polyhydramnios is commonly present, but rarely will hydrorrhachis be found. 
 There is a decided tendency, on the part of the mother, to rupture of the 
 uterus. Etiology: This is not positively settled. It has been observed to occur 
 several times in children of the same mother: in one case six (Gohlis) ; in another 
 seven (Peter Frank). Very rarely have abnormal conditions been found in the 
 mother. Frequent anomalies are present in the fetus itself and its surrounding 
 parts; namely, spina bifida, club-foot, large quantities of liquor amnii, anasarca 
 and ascites, and congenital rickets. Most of these defects are due to the same 
 cause as the hydrocephalus. Then, too, may occur diaphragmatic hernia, absence 
 of one kidney, etc. (Winckel). Diagnosis: The condition is seldom recognized 
 during pregnancy. In a small proportion of cases hydramnios coexists. Vicious 
 
ANTENATAL DISEASES OF THE FETUS. 265 
 
 presentations are often present. Exceptionally certain phenomena have led to 
 the making of a diagnosis, such as the absence of ballottement and parchment- 
 like crepitation and fluctuation. in the fetal head. (See Fetal Dystocia, Part V.) 
 
 Meningocele; Encephalocele; Hydrencephalocele. — Meningocele (Fig. 328) con- 
 sists in hernia or tumor in which there is a protrusion of the cerebral mem- 
 branes through an opening in the skull. These form a sac, which may or 
 may not contain cerebrospinal fluid. In encephalocele (Fig. 330) there is a pro- 
 trusion of the brain substance which is connected with the bulk of the brain 
 by a constricted neck or pedicle. In this tumor there may or may not be 
 fluid. In hydrencephalocele (Fig. 329) there is a protrusion of a portion of the 
 brain substance, as in encephalocele, but this contains within its center a cavity 
 filled with cerebrospinal fluid and communicating with the distended lateral 
 ventricles of the brain. 
 
 Meningocele is rarer than meningo-encephalocele. The occipital and fronto- 
 nasal regions form the most frequent seat of these tumors. The size varies 
 from that of an olive to an egg-plant. The tumor is always congenital; 
 generally it is round and elastic, soft and fluctuating. Its reducibility varies. 
 It is always in or near the median line. There is pulsation synchronous with 
 that of the heart. Convulsions or even coma may be caused by compression. 
 These deformities probably result from an arrest of development of the cranial 
 bones. They may be due to arrested or defective development, or they may 
 result from an intracranial inflammation, terminating in bands of adhe- 
 sion, or to a thinning of the bones of the skull from internal hydrocephalus. 
 The head itself may be normal or hydrocephalic. Coincident with these tumors 
 is a softening of the cranial bones, which renders expression of the head easier 
 in labor. They do not often offer an obstruction to delivery, for, on account 
 of their position, they are expelled either before or after the head itself. The 
 maximum degree of obstruction will obtain when the tumor is of large 
 size, with short pedicle and a lateral position. Prognosis for both mother 
 and child is much better than in cases of congenital hydrocephalus. All diffi- 
 culty in the expulsion of the fetus is, as a rule, obviated by puncture of the sac. 
 After birth the tumor should be carefully guarded from any friction or injury. 
 (See Fetal Dystocia, Part V.) 
 
 Spina Bifida (Figs. 335, 336, 337). — This is a defect in the vertebral canal, 
 which consists of a fluid tumor formed by the protrusion of some part of the 
 contents of the canal. It is found at any point of the spinal column, but most 
 frequently at the cervical or near the end of the dorsal region. Among the con- 
 genital deformities it is one of the most frequent. Spina bifida is thought to be 
 due to early arrested development, taking place generally before the segmentation 
 of the cord. Since the dorsal vertebral arches fuse more rapidly than the 
 cervical or lumbar, there is more opportunity for the defect to occur in the 
 two latter regions. There are two degrees of this malformation: («) Hydror- 
 rhachis externa — in which the liquid is between the cord and its envelopes or 
 in the midst of the cord in the ependymal cavity; (/J) Hydrorrhachis interna 
 constitutes a meningocele. In hydrorrhachis interna the tumor contains not only 
 the cord but also the spinal nerves arising from it. The tumor is, as a rule, 
 associated with spina bifida, though this is not always the case. It ma}^ be sessile 
 or pedunculated, depending upon the extent of the fissure. The latter may 
 be in the vertebral bodies or the tumor may protrude through the intervertebral 
 notch or foramen, and point anteriorly — spina bifida occtilta. Although the 
 tumor is most often single, it may be multiple or it may exist in two 
 regions of the canal at the same time. It may be formed before the closure 
 
266 PATHOLOGICAL PREGNANCY. 
 
 of the central canal, or even later, the accumulated fluid causing it to open 
 again. Its size varies considerably, though it is often about the size of a nut. 
 Any effort at crying or standing distends the tumor. Prognosis: Early death is 
 frequent, although the victims of this infirmity have been known to reach 
 fifty years of age. The prognosis is greatly influenced by the anatomical 
 variety and by the complications. The simple meningocele when covered by 
 skin is the most favorable form. Indeed, complete recovery may be hoped 
 for. In some cases hydrocephalus has been known to develop after cure of 
 the original deformity has been obtained by operation. The diagnosis is 
 not difficult as to recognition of the general condition. It is not so easy to 
 distinguish the different varieties. Treatment: If the malformation is not 
 extreme, the treatment should be expectant. Inflammation often follows 
 injections into the sac or excision of the sac. The tumor should always be 
 protected from pressure, and if it is not covered by integument the surface 
 must be kept aseptic. For details of the operation a work on operative surgery 
 should be consulted. 
 
 Cerebral Diplegia: While congenital spastic rigidity, or Little's disease, is 
 usually held to have an intra-partum origin, it is by no means certain that there 
 is not in some cases an antenatal element. Chorea: This affection can some- 
 times be diagnosticated ante partum through the choreic movements of the 
 fetus. In such cases we often find a history which might in part account for 
 the affection, such as history of maternal fright or fall, alcoholic or epileptic 
 inheritance. But chorea is sometimes hereditary, and even a distinctly family 
 malady, which peculiarity has been remarked in some of these intrauterine 
 cases. A distinctly hereditar}^ affection has nothing to do with the fetal stage 
 of intrauterine life, hence chorea from this standpoint could not be placed 
 among fetal diseases. The same is true of such affections as Friedreich's 
 ataxia, Thomsen's disease, etc. Maternal Impressions: The nervous system of 
 the mother is easily excited, a very slight irritation being capable of arousing 
 contractions of the uterus. The effects on the fetus of disturbances of the 
 maternal nervous system are probably most common in the case of women 
 with highly developed nervous organizations. The modus operandi of these 
 phenomena is not yet clearly understood. Although there is no apparent 
 nervous connection between mother and child, there may be an alteration in the 
 blood caused by profound nervous disturbance analogous to the decomposing 
 effect of an electrical current on a chemical solution. This view would be some- 
 what supported by the well-known fact sometimes observed in women whose milk, 
 as a result of strong emotion, becomes a rank poison to the child. Maternal impres- 
 sion is as yet a mooted question, and reliable literature on it is deplorably defi- 
 cient. However, much has been written on both sides, and arguments and exam- 
 ples have been brought forward which, in their turn, would seem to almost prove 
 the opposed views. The affirmative side of the subject has been espoused from the 
 earliest historical period. Instances pointing to the connection between or the 
 dependence of congenital deformities, both physical and mental, upon maternal 
 impressions are too numerous to be completely dismissed as coincidences. On 
 the other hand, two of the strongest arguments opposing this view have been 
 advanced as : ( i ) the lack of nervous connection between mother and fetus and 
 (2) the alleged cause of the anomaly generally takes place at a period not coinci- 
 dent with that of the embryonic evolution of the part affected. The whole 
 subject is at present in an uncertain state. Hereditary Predispositions of the 
 Fetus: Syphilis with its effects on the fetus has already been noticed. There 
 are certain deformities which belong to certain families as an inheritance ("recur- 
 
ANTENATAL DISEASES OF THE FETUS. 267 
 
 rent deformities"). These may be serious enough to cause death. One strange 
 affection that has been noted is the thickening of the fibrous and muscular tissue 
 of the umbiHcal vein, which diminishes the cahbre to such an extent that several 
 fetuses affected in this way were born dead. They belonged to the same mother 
 (Leopold). 
 
 8. Diseases of the Urogenital Apparatus. — Nephritis: In dropsy, anuria, etc., 
 of the newly born the question of the existence of intrauterine nephritis naturally 
 arises. Cases in which the children thus affected are born alive have thus far 
 been inadequate for the solution of the problem. Thus, in an observation cited 
 by Ballantyne the child did not become dropsical until the second day after 
 birth. It survived three weeks. The existence of fetal nephritis must be 
 determined largely from a study of unborn or still-born children. Vesical Dis- 
 tention: This is also considered among the causes of dystocia of fetal origin 
 (Part V). In any case it is hardly a fetal disease nor due to a disease, but 
 rather a condition associated with various malformations, some of which are 
 responsible for its existence. Ballantyne makes a special variety of the type 
 which is due to obstruction within the urethra and which causes extreme thick- 
 ening of the bladder walls and the ureters. In some 
 
 of these hypertrophic cases, however, no obstruction 
 can be found, so that the existence of a spasmodic 
 stenosis must be assumed, and it is this factor which 
 permits us to place the affection among true diseases. 
 Hydronephrosis : This condition, the result of em- 
 bryonal malformations, is considered under " Dys- 
 tocia of Fetal Origin " (Part IX). Cystic Degener- 
 ation of the Kidneys: The nature of this condition is 
 obscure. If due to a sclerogenous inflammation of 
 the urinary tubules, it would be a disease, otherwise 
 it would have to be placed with fetal neoplasms of 
 embryonal origin. It is considered under " Dystocia 
 of Fetal Origin." Diseases of the Genitals: These 
 organs, representing a persistence of embryonal struc- 
 ture during the fetal period, are subject to malforma- 
 tions rather than diseases. A congenital prolapse of Fig. 437. — Fetal Ichthyo- 
 the uterus is known to occur, almost always in asso- ^^^- (Kyoer s case.) 
 
 ciation with spina bifida, and is described in great 
 detail by Ballantyne. A red mass is seen to project from the vulva at birth. 
 
 9. Antenatal Cutaneous Diseases. — There may be a failure of development 
 in any one or all of the specialized structures of the skin, evident at birth, as 
 happens in the case of other organs. When the lack is total {e. g., atrichia), it 
 is apt to be accompanied by other deformities. More or less localized aberrant 
 growth is shown in the formation of naevi of various sorts — vascular, pilary, pig- 
 mented, papillomatous, verrucous. Aside from these tumors, the commonest 
 misdirection of the great embryonic cellular activity is in an increase of the 
 surface layers of the epidermis, the stratum corneum particularly, which is called 
 ichthyosis. There are two varieties, one which is congenital and one which 
 develops after a few years have passed. 
 
 (i) Ichthyosis Congenita (Hyperkeratosis C on genitalis , Harlequin Fetus, 
 Universal Congenital Keratoma) (Fig. 437). — The children are usually premature 
 and immature. They rarely survive more than a few da^^s, but Sherwell has 
 seen one child live as long as five months. The skin is covered with polygonal 
 homy plates, one-sixteenth of an inch or less in thickness, closely adherent and 
 
268 
 
 PATHOLOGICAL PREGNANCY. 
 
 separated from each other by deep furrows, which in the neighborhood of the 
 orifices may extend into the cutis and consequently bleed. Prognosis, of course, 
 is unfavorable. 
 
 (2) Keratolysis Exfoliativa is a congenital affection described by 
 Sangster. In it a condition obtains in which the loosened horny stratum 
 comes away in large thin flakes, and leaves a reddened prickle-cell layer, 
 indicating a lack of the normal adhesive quality between the epidermic 
 cells. The affection is excessively rare, and is not very remotely related to 
 ichthyosis, at least so far as the histology goes. 
 
 (3) General Cystic Elephantiasis. — This affection is thought to possess 
 a close relationship with general fetal dropsy, although it may also be allied 
 
 to localized forms of elephantiasis 
 (Fig. 438). 
 
 10. Fetal Bone Diseases. — The 
 skeleton diseases of the fetus repre- 
 sent but a single basic condition: 
 viz., irregular or imperfect ossification 
 (Fig. 43q). In virtue of the great 
 mass of names which have accumu- 
 lated in the literature of this condi- 
 tion, Ballantyne proposes to abolish 
 them all and describe a single affec- 
 tion which occurs in four types. 
 Thus, Type A consists essentially of 
 a softening of the bones, betrayed by 
 the presence of craniotabes and curva- 
 ture of the long bones. Type A re- 
 sembles extrauterine rickets more 
 than any other fetal bone disease. 
 Type B exhibits a great fragility of 
 osseous tissue, as well as curvature 
 and shortening of the long bones. 
 The latter fracture from simple ma- 
 nipulations. While these two types 
 have more or less resemblance. Type 
 C is radically different, being charac- 
 terized by extreme overgrowth of the 
 epiphyses of the long bones. The 
 diaphyses appear correspondingly 
 short. This hyperplasia of the car- 
 tilaginous epiphyses of fetal hfe must be related in some manner to the enlarge- 
 ment of these portions of the skeleton in extrauterine rickets. This type of fetal 
 bone diseases has been known as chondrodystrophia foetalis. Type D is in some 
 respects the converse of the preceding, and is usually known as achondroplasia. 
 It is seated chiefly in the limbs and trunk, the head being approximately normal. 
 The disorder is essentially defective endochondral ossification. The diaphyses 
 of the long bones are reduced in length from a half to a third, the epiphyses being 
 normal. This is the most striking feature of the disease. The individual has 
 very short limbs, the brevity of the lower extremities conferring upon him a 
 dwarfish stature. The achondroplasic dwarf differs from the phocomelus monster 
 largely because in the latter the affection dates from the embryonal period, 
 while in the former it develops in the course of fetal life. 
 
 Fig. 438. — General Cystic Elephantiasis. 
 — (Ballantyne.) 
 
ANTENATAL DISEASES OF THE FETUS. 
 
 269 
 
 II. Fetal Traumatisms. — Injuries occurring during fetal life must be dis- 
 tinguished from traumatisms of intra-partum origin, on the one hand, and certain 
 accidents which probably date' from the embryonal period, on the other. This 
 is by no means a simple matter. Fetal traumatisms may be divided into wounds 
 of soft parts, fractures, dislocations, and amputations. 
 
 Wounds. — Scars and circular defects of the skin have been found at times. 
 When the former occur over what appear to be badly united fractures of the 
 long bones, it is possible that the osseous injury was complicated at the time by 
 a cutaneous wound. The circular defects which are usually encountered on the 
 
 Fig. 439. — Four Skulls showing Lack of Development of the Parietal Bones (" False 
 
 FONTANELLES") AND CONGENITAL FiSSURES OF THE PaRIETAL AND OCCIPITAL BoNES 
 
 ("False Sutures"). — (Author's collection.) 
 
 scalp are due, it is thought, to the tearing away by amniotic adhesions of portions 
 of the integument (see Congenital Defects of the Skin, Section VI). 
 
 Fractures. — Clinically we understand by this condition various malforma- 
 tions which indicate more or less imperfect bony union of a past fracture. Thus, 
 observers have noted imitations of all the terminations of fractures in extra- 
 uterine life, such as nodular swellings from excess of callus, angular union, false 
 joint, etc. In some cases scars of the soft parts over the fractures appeared to 
 indicate that the latter had been complicated by a cutaneous wound. As to 
 causes of fetal bone fractures, it is difficult to conceive of their occurrence save 
 in brittle bones (see Fetal Bone Diseases, page 268). We know that fractures 
 occur intra partum under these circumstances (see Fetal Birth Traumatisms, 
 Part IX). It is generally admitted that these results of fetal injuries are very 
 
270 PATHOLOGICAL PREGNANCY. 
 
 commonly associated with true malformations, in which case they must be re- 
 garded as received during the embryonal period. When it seems clear that the 
 injury occurred during advanced fetal life, we must explain it by a peculiar 
 combination of causes, such as brittleness of bone, scanty amniotic fluid, and 
 excessively strong fetal movements or external violence. 
 
 Dislocations. — What has been said of the nature of fetal fractures will hold 
 good for dislocations. Thus, if recent, they suggest an intra-partum origin. If 
 evidently due, as in some congenital dislocations of the hip, to defective develop- 
 ment of structures forming the joint, the possibility of a teratological origin must 
 be borne in mind. This conception of dislocations leaves little to be said of their 
 occurrence during fetal life proper. The joint most frequently involved is the 
 hip, while the shoulder is sometimes affected. These affections are probably 
 considered to best advantage under the head of birth traumatisms. (Part IX.) 
 
 Amputations. — In the condition known as spontaneous intrauterine or con- 
 genital amputation the defect must be of a character to show that a limb once 
 existed, or, in other words, an amputation stump must be present. The ampu- 
 tated limb, more or less macerated, etc., may be found in the amniotic fluid and 
 be expelled with the fetus. The amputation may afifect any portion of the ex- 
 tremities, from a single finger to an entire limb. The occasional presence of what 
 appear to be rudimentary digits upon the end of the stump serves to throw added 
 doubt upon the actual nature of these amputations. Until recently these injuries 
 were thought to be due to constriction by amniotic bands, this explanation being 
 found in most text-books on obstetrics. Dermatologists sought to do away with 
 a traumatic element, and regard the amputation as having been caused by a sort 
 of sclerodermatous constriction of the skin itself. Ballantyne is in favor of doing 
 away with all our present views, believing that the mutilation takes place in the 
 embryonal period. 
 
 12. Fetal Neoplasms. — Affections of this class are embryonal in origin, and 
 hence to be ranked with anomalies and monstrosities. The fetal tissues may be 
 the seat of cysts, fibromata, chondromata, lymphangiomata, exostoses, rhabdo- 
 myomata, sarcomata, etc. 
 
 13. General Fetal (Edema. — Anasarca. — This is a total dropsical condition 
 of the fetus, including complete anasarca and effusion into all the serous sacs, 
 the placenta being often oedematous (Fig. 440). This affection is extremely 
 rare. Ballantyne could find but 60 cases recorded in literature. This number, 
 however, does not include cases of dropsical double monsters. There is sufficient 
 evidence in some cases to connect the fetal oedema with developmental anomalies 
 of the fetal circulation, or perhaps with certain visceral inflammations in the fetus. 
 The behavior of the fetus during gestation presents no peculiarities. Diagnosis 
 during labor is likewise difficult. Dystocia after birth of the head might suggest 
 dropsy of the trunk, but delay at this period of labor might be due to many other 
 causes, which would have to be excluded in diagnosis, A fetus has never yet sur- 
 vived the disease. 
 
 General Fetal (Edema in Twin Monstrosities. — There are, according to 
 Ballantyne, no cases on record in which both twin fetuses, whether normal or 
 monstrous, were afflicted with general dropsy; and but two cases are known to 
 have existed in which one of the normal twins has thus suffered (Fig. 441). 
 
 14. Maternal Traumatisms. — The fetus may be seriously or fatally injured by 
 external violence. This has already been noted in the section on injuries of the 
 fetus due to external violence (page 269). 
 
 15. Maternal Uterine Disease Affecting the Fetus. — Chronic metritis and 
 endometritis have been noted as causes of fetal death. Hirst reports two cases 
 
ANTENATAL DISEASES OF THE FETUS. 
 
 271 
 
 in which non-development of the uterus was apparently the cause of repeated 
 premature deliveries. Prolapse of the gravid uterus may exist. This is not 
 often primary in pregnancy, and if the organ does not rise in the pelvis it will, 
 especially if the pelvis is smalt, become jammed in by the bony parietes and abor- 
 tion occur. Anteversion of the pregnant uterus is not often attended with serious 
 symptoms, but retrodisplacement of the gravid uterus is very productive of 
 abortions. The influential causes are metritis and endometritis, hyperemia, and 
 hemorrhage into the decidua which result from the venous stasis caused by the 
 retro-displacement. 
 
 i6. Fever in the Mother Affecting the Fetus.— This is a common cause of 
 
 abortion and premature deHvery, especially 
 when fever is suddenly developed. Many ex- 
 periments have been made on animals in order 
 to arrive at the definite effects that high tem- 
 perature of maternal origin produces in the 
 fetus. Views on the subject have changed to a 
 great degree accordingly. It has been shown in 
 the guinea-pig, for example, that the fetus can 
 endure a much higher temperature than had 
 \ formerly been supposed. In one case, the ani- 
 
 FiG. 440. — General CEdema of 
 THE Fetus. — (BaUantyne.) 
 
 Fig. 441. — General CEdema in a Twin Fetus. — (Bal- 
 lantyne.) 
 
 mal after attaining a temperature of 111.2° F. (44° C), lived nine mmutes.* 
 Danger to the fetus must be feared only when the maternal temperature rises 
 suddenly or reaches a point over 105° F. (40.5° C). In the latter case energetic 
 antipyretic measures would be indicated. In case of maternal death, post- 
 mortem Csesarean section or accouchement forc6 would be useless if the patient s 
 temperature had reached 109^ F. (43° C.), or if it had risen with great rapidity. 
 17. Death of the Mother Affecting the Fetus.— The effect of the maternal 
 death upon the fetus in utero is considered in the section on post-mortem delivery 
 (Part V). 
 
 * Preyer: " Physiologic des Embryo," Leipzig, 1S84. 
 
272 
 
 PATHOLOGICAL PREGNANCY. 
 
 VIII. DEATH OF THE FETUS. 
 
 I. Maceration. 2. Mummification, j. Absorption. 4. Putrefaction. 5. Saponification. 
 
 6. Calcification. 
 
 Etiology. — Successive pregnancies in the same mother may result in still- 
 births, or in the birth of children who live but a short time. Syphilis in one of 
 the parents is thus suggested, and, according to Ruge, it occurs in 83 per cent. 
 
 of the cases. Other condi- 
 tions, however, may pro- 
 duce a like result. Apo- 
 plexy of the placenta, 
 membranes, or ovum itself, 
 resulting from an inflam- 
 mation of these tissues, is a 
 frequent cause of fetal 
 death. Systemic poisoning 
 of the mother with lead, 
 mercury, or tobacco may 
 result fatally to the fetus. 
 Not only maternal influences are to be considered in fetal death, but paternal 
 conditions as well such as old age, extreme youth, alcoholism, chronic disease, 
 etc. Sometimes no apparent cause can be discovered, and 
 the mother seems to abort simply from habit, and at about 
 the same period in her pregnancies. The essential cause of 
 this catastrophe may be in the fetus itself, from diseases, 
 injuries, or deformities. The effect of the death of the 
 fetus on the mother may be really nil unless the germs of 
 putrefaction in some way reach the body. 
 
 Fig. 442. — Macerated Fetus. — {M anhalian Maternity.) 
 
 Fig. 443. — Mummified Fetus and Necrotic Decidua. The fetus 
 died at the third month, but the entire ovum was retained for 
 seven months more. The decidua and chorion are filled with 
 coagulated hematomata. The fetus measured 3-^ inches (8 cm.) , 
 was much deformed, and the left foot was adherent to the right 
 leg. — (Schaeffer.) 
 
 Fig. 444. — Mummi- 
 fication OF THE 
 Fetus. — (Galabin.) 
 
 Diagnosis of Fetal Death. — ( i ) The uterus ceases to grow or diminishes in size. 
 (2) Subjective symptoms of pregnancy gradually disappear. (3) The milk 
 secretion appears. (4) The fetal heart-sounds and movements disappear. (5) 
 
DEATH OF THE FETUS. 
 
 273 
 
 There are loss of resiliency and crepitation of the fetal skull. This latter occurs 
 only when the fetus has been dead for some time, and the head has become 
 quite macerated, so that the bones are loosely joined together. (6) Peptonuria 
 and disturbance of renal function occur. (7) Diminution of cervical temperature 
 is noted. (8) There is absence of pulsation in the umbilical cord, or in the fetal 
 precordium, which may be learned by introducing the hand within the uterus. (9) 
 Stoltz's sign is not positive, but is supposed by him to consist in a slight mur- 
 mur or rustle, which is caused by decomposition of the amniotic fluid. (10) 
 Certain changes in the health or the condition of the mother have been supposed 
 to point to the existence within her uterus of a dead fetus, such as depression of 
 
 spirits, pallor of the face, a feeling of weight 
 .'^ in the lower part of the abdomen; but 
 
 ^ ^ these signs are uncertain. The health of 
 
 the mother is not affected, so long as the 
 
 membranes remain unruptured. \ 
 
 Changes in the Fetal Structures. — The 
 
 kind of change that will take place in the 
 
 Fig. 445. — Foetus Papyraceus. 
 {Author's case.) 
 
 Fig. 446. 
 
 -LiTHOPEDiON ("Stone Fetus"). 
 {Ahlfeld.) 
 
 fetus depends on the time of its death, the length of time from that event until 
 expulsion, and whether or not there will be access of air to the amniotic sac. (i) 
 Maceration (Fig. 442) : This is the most common change in the fetus after death. 
 The skin loses its physiological activity, and, as a result, the vemix caseosa is no 
 longer secreted for the protection of the fetus, and the liquor amnii produces 
 maceration. A fetus in this condition is known as a jcctus sanguinolentus. The 
 surface is likened in appearance to a washerwoman's hand, wrinkled and softened. 
 Here and there the epithelium has desquamated, leaving glistening red spots. 
 All of the tissues, even to the internal organs, are, as it were, water-logged. The 
 cord lacks the normal spiral aspect, being round, soft, and smooth. The amniotic 
 fluid, as noted under that heading, is much discolored from the absorption of the 
 18 
 
274 PATHOLOGICAL PREGNANCY. 
 
 blood coloring-matter and the products of decomposition. It may be reddish, 
 greenish, or brownish, and it may possess an offensive odor. (2) Mummification 
 (Figs. 443, 444, 44S): This change sometimes occurs after a missed labor. It 
 may be regarded as typical in a dead fetus which has attained the age of several 
 months, but can occur only when the membranes have remained unruptured. 
 If the fetus has for some time been subjected to pressure, as in the case of twins 
 when the live embryo by its growth gradually compresses the dead one, the latter 
 will finally become very fiat, and is then known as foetus papyraceus (Fig. 445)- 
 This process of mummification has been rightly named, for such a fetus is dry 
 and shriveled in appearance. The color is grayish-yellow, and the consistency 
 is leathery. The amniotic fluid, which is lacking, has either been absorbed by 
 the chorion or drained off, consequently the fetal appendages are likewise dried 
 and tough, and show some fatty degeneration. This condition is frequently 
 caused by the twisting of the cord around the neck of the fetus. (3) Absorption : 
 Total absorption can occur only in the first ten or twelve weeks of pregnancy. 
 It has occurred in intrauterine pregnancy, and is* a favorable termination in ex- 
 trauterine pregnancy. The first step in this process is maceration of the fetus, 
 followed by a complete absorption. The striking characteristic is the thick and 
 mucilaginous condition of the liquor amnii. (4) Putrefaction : So long as the 
 membranes remain intact, putrefaction is impossible. Physometra and tym- 
 panites uteri may subsequently occur as the result of this transformation. In 
 this process the soft parts are disintegrated, leaving the bones to be disposed of. 
 either by ulcerating their way through the overlying structures, or by surgical 
 removal. It is not uncommon to find suppuration coincident with putrefaction. 
 (5) Saponification : Saponification and adipoceration are parts of some chemical 
 change, by which the fetus becomes fatty or soapy, through the deposit within 
 its tissues of margarates of calcium, potassium, cholesterin, and sodium. After 
 this transformation it has a characteristic greasy feel. (6) Calcification (Fig. 
 446) : This change may occur as an intrauterine or extrauterine termination of 
 pregnancy, when a lithopedion is formed. The process consists of the deposition 
 of lime salts in the fetal tissues, the result being what is known also as a " stone 
 child." There are recorded cases in which this condition has been shown to exist 
 for years, the petrified fetus being retained in utero. 
 
 IX. DISEASES OF THE GENITAL ORGANS. 
 
 /. Anteflexion and Anteversion. 2. Retroflexion, Retroversion, and Incarceration. 5. Latero- 
 flexion and Later aversion. 4. Prolapse of the Pregnant Uterus. 5. Torsion. 6. Hernial 
 Protrusion of the Pregnant Uterus. 7. Periuterine Inflammation and Adhesion. 8. Rheu- 
 matism of the Uterine Muscle, g. Metritis. 10. New Growths in the Uterus. 11. Spon- 
 taneous Rupture. 12. Malformations, ij. Leucorrhea. 14. Cystic Vaginitis. 15. Specific 
 Vaginitis. 16. Prolapse of the Vagina, ly. Pruritus Vulvae. 18. Varicosities of Vagina 
 and Vulva, ig. Vegetations. 20. CEdema of the Vulva. 21. Eczema of the Nipple. 22. 
 Mammary Abscess. 2j. Hemorrhage from the Genitals during Pregnancy. 
 
 I. Anteflexion and Anteversion (Fig. 151). — In the later months of pregnancy, 
 owing, in multigravidae, to the lax condition of the abdominal walls, or to the sepa- 
 ration of the recti, or to the giving way of an old cicatrix, anteflexion and ante- 
 version may occur, giving rise to the condition known as pendulous abdomen, 
 or " hanging belly." This condition is also a frequent accompaniment of pelvic 
 deformities, due to the fact that the uterus cannot descend, as in normal preg- 
 nancy. The fundus, under such circumstances, may be lower than the cervix, 
 
DISEASES OF THE GENITAL ORGANS. 
 
 275 
 
 the latter being carried upward and backward into the hollow of the sacrum; 
 thus labor may be greatly complicated, and the presenting part be directed 
 away from the axis of the pelvic outlet. Incarceration of an antefiexed, pregnant 
 uterus, although rare, has been known to occur, as the result of an inflammatory 
 adhesion, or after the operation of anterior fixation or suspensio uteri. In these 
 cases there are usually severe vesical symptoms, and interruption of pregnancy, 
 or the uterus goes to term and operative procedures are necessary to deliver the 
 fetus from the uterus, which has, so to speak, buckled upon itself. (See Maternal 
 Dystocia, Part V.) As a general rule, the uterus replaces itself spontaneously 
 bv its own growth. In may be bound down by adhesive bands, resulting from 
 inflammation, in which case pain and difficult micturition supervene. The organ 
 then either forces itself upward into the abdomen or expels its contents. If 
 there are no pelvic tumor, no exudate, and no previous anterior displacement to 
 account for the pathological position, then its cause will probably be found in a 
 contracted pelvis, or in retraction of the utero-sacral ligaments. This condition is 
 also accentuated by the intra-abdominal pressure brought to bear on the posterior 
 uterine wall. In rare cases traumatism may cause acute anterior displacement. 
 
 An/, aid. tfolt — 
 
 Anl.Per./kt. — 
 
 Pariefal PerUoneum 
 
 Vessels ofClilirrts ' - 
 l/relhra — 
 Lfficujih minus 
 Triifon efBladdei — 
 Voffina — 
 Perineumr 
 jpkincter am. exlernus 
 Jphiitiler cuu inlerruis 
 
 UmhilLcus 
 
 Left Com.ii.tui. 
 
 ^Left Com.il:yein 
 I/orn of ///eras 
 , (/ferine porf of rf.ful/e 
 _ C'feruie yes. pouch 
 _ Uterin£ yessels 
 Peu^fas pouch 
 ^^U fffero satral 
 fi^ameni 
 
 Fig. 447. 
 
 -Enormous Distention of the Bladder, Rectum, and Sigmoid Flexure, 
 CAUSING Posterior Displacement of the Uterus. 
 
 A few believe in the causal relationship of anterior displacements to the per- 
 nicious vomiting of pregnancy, but this I have failed to confirm. This malpo- 
 sition often causes sterility, but seldom has any relation to abortion. Symp- 
 toms: In extreme cases of this condition, shoulder presentations of the fetus must 
 be looked for, and there will be pain in the distended skin, oedema of the lower 
 abdomen, vesical and rectal disorders, while locomotion will often be accom- 
 plished with great difficulty. Treatment: In the simple and non-adherent cases, 
 which occur in the early months of pregnancy, it will usually be sufficient to 
 regulate the bowels and to keep the patient in the recumbent posture for the 
 greater portion of the time. In case of pendulous abdomen the uterus should be 
 replaced and retained by a moderately firm bandage (Figs. 228 and 229). In 
 the adherent or incarcerated cases an effort should be made, under etherization, 
 with careful manipulation, to break down the bands of adhesion; if this fails and 
 no marked symptoms are present, the case may be allowed to proceed as far 
 toward term as possible. I delivered one child by version at term from such 
 an adherent uterus, the result of anterior fixation for retroflexion. 
 
 2. Retroversion and Retroflexion (Figs. 447 to 451). — Retroversion is the 
 
276 
 
 PATHOLOGICAL PREGNANCY. 
 
 / 
 
 Fig. 448. — Retroflexion and Prolapse of the Preg- 
 nant Uterus. Danger of sloughing into the poster- 
 ior vaginal wall, the anterior rectal wall, or through 
 the perineum. 
 
 most important of the uterine displacements, on account of the serious re- 
 sults which sometimes follow it. It is a cause of sterility, and if conception 
 
 does take place, the malposi- 
 tion generally corrects itself 
 "^^-..^J by the end of the third or 
 
 fourth month. At times 
 abortion occurs. In multi- 
 gravidas retroflexion is one 
 of the commonest displace- 
 ments, but it rarely causes 
 sterility. 
 
 Etiology. — Backward dis- 
 placements may be caused by 
 previous uterine disease; e. g., 
 adhesions between the uterus 
 and posterior wall of the pel- 
 vis, or by relaxation of the 
 round ligaments. It may also 
 be produced by falls or violent 
 jars; distention of the blad- 
 der may be regarded as a pre- 
 disposing cause. It is more 
 likely to occur in cases of flat- 
 tened pelvis. 
 
 Symptoms. — Vesical irri- 
 tation from pressure of the 
 cervix upon the bladder, constipation and pain in the back from pressure of the 
 fundus, sensations of pressure and weight in the pelvis, are the prominent symp- 
 toms, which generally come 
 on gradually, rarely sud- 
 denly. Locomotion is some- 
 times very difficult ; there are 
 frequent reflex phenomena, 
 vomiting holding a promi- 
 nent place. On examina- 
 tion, the cervix is found ele- 
 vated, the body of the uterus 
 is in the cul-de-sac of Doug- 
 las, the anterior vaginal for- 
 nix is empty, and the blad- 
 der is displaced downward 
 and backward. 
 
 Terminations. — By the 
 end of the third month, re- 
 troversion usually disap- 
 pears with the upward 
 growth incident to preg- 
 nancy, by (i) spontaneous 
 reposition. When this does 
 
 not occur, however, and when the ftmdus remains posterior, the increase in size 
 
 of the uterus causes an aggravation of all the symptoms, and if the upward 
 
 * "Arch. f. Gyn.," Bd. xli, Taf. viii. Fig. i 
 
 Fig. 449. — Sagittal Section of a Retroflexed In- 
 carcerated Pregnant Uterus at Five and a Half 
 Months. Necrosis of the Bladder and Death Re- 
 sulted. — {Schwryzer. *) 
 
DISEASES OF THE GENITAL ORGANS. 
 
 277 
 
 growth and ascent of the uterus are prevented by the promontory of the sacrum, 
 the condition is known as (2) incarceration. (3) Spontaneous abortion or mis- 
 carriage is another termination, Caused by uterine congestion and interference 
 with the growth of the fetus. 
 
 Incarceration (Figs. 449, 450, 451). — By incarceration is meant the reten- 
 tion of the uterus below the promontory of the sacrum and in the true pelvis. 
 If the retroflexed or retroverted uterus is not replaced, or if spontaneous 
 reposition or abortion does not occur, the increasing size of the uterus results 
 in its farm impaction in the pelvis. The symptoms are vesical irritation and pain 
 in the back, retention of urine from pressure upon the bladder and obstinate 
 constipation, or even obstipation, from pressure of the fundus. The genitals 
 and thighs may become swollen and oedematous, and grave symptoms, the re- 
 sult of peritonitis, due to rupture of the bladder or to sloughing of the uterus or 
 to severe metritis or parametritis, may ensue. Abdominal palpation fails to 
 disclose the fundus, while vaginal ex- 
 amination shows that the latter is im- ^^ ^^_^ 
 
 prisoned in the cul-de-sac of Douglas. 
 The latter fact may be made plainer by 
 examination per rectum. The cervix 
 may be found behind the symphysis, 
 or it may be difficult or impossible to 
 reach it. There maybe great disten- 
 tion of the bladder, and the perineum 
 may even be distended by the pressure 
 of the fundus. 
 
 Diagnosis. — Incarceration , especi- 
 ally in its early stages, may be con- 
 founded with extrauterine pregnancy. 
 In the latter condition, however, though 
 the uterus may be somewhat enlarged, 
 the normal relations of the cervix and 
 fundus are still preserved; distention 
 of the bladder does not usually occur, 
 nor is there oedema of the vulva, or 
 perineal distention, or severe symptoms 
 of pelvic congestion. The rupture of 
 the sac in extrauterine pregnancy usu- 
 ally occurs near the end of the second month, while incarceration usually develops 
 during the fourth month. In cases of incarceration uterine contractions may be 
 recognized in the tumor. In doubtful cases examination under anesthesia, with the 
 bladder empty, will be necessary. There is often dribbling of urine at the third or 
 fourth month. Menorrhagia would differentiate this condition from intrauterine 
 polyp. As to the terminations, if the incarceration is not relieved, there may be 
 rupture of the posterior vaginal wall and perineum, with extrusion of the uterus ; 
 very rarely pregnancy has continued to term, the anterior wall of the uterus 
 becoming enormously stretched, and the head of the fetus remaining in the hollow 
 of the sacrum. Sloughing of the uterus may occur, with the discharge of its 
 contents into the vagina or rectum. 
 
 Prognosis. — In the lesser forms of displacement, occurring early in pregnancy 
 the prognosis is good, since spontaneous replacement usually occurs. Even in 
 cases of incarceration the prognosis is good if the condition is promptly and 
 properly treated. In neglected cases, however, it is very bad, since the patient 
 
 Fig. 450. — Partial Retroflexion. The 
 posterior uterine wall is fixed in the pelvic 
 cavity. The anterior wall dilates and the 
 dotted lines show the progressive dilatation 
 of the anterior uterine wall. — (Bumm.) 
 
278 
 
 PATHOLOGICAL PREGNANCY. 
 
 is exposed to many dangers, including rupture of the bladder, sloughing of the 
 uterus, septic peritonitis, shock, and exhaustion. 
 
 Treatment. — The bladder and bowels being emptied, in the simpler forms of 
 displacement an effort may be made to replace the uterus by pressure with the 
 fingers while the patient is in the lithotomy position ; but reduction will be more 
 easily effected if the patient is in the knee-chest position. (See Operations 
 Part X.) A repositor may be used if failure attends the attempt with the fingers, 
 and pressure should be made in the upward direction and to one side, in order to 
 avoid the promontory. The reduction will be more easily accomplished if the 
 cervix is at the same time drawn downward by a volsellum forceps (Fig. 463). 
 After replacement, the newly acquired position of the uterus should be main- 
 tained by a pessary or tampon, large enough to be efficient. If the uterus is 
 strongly bound down by adhesions, steady and long-continued pressure should 
 be kept up, by thoroughly tamponing the posterior cul-de-sac through a Sims 
 speculum, with the patient in the knee-chest position, the boro-glyceride tam- 
 pons being renewed daily; if this fails 
 abortion should be induced before incar- 
 ceration takes place. I have seen the 
 insertion into the vagina of a rubber bag, 
 filled with water and kept in place with 
 a T-bandage, act well in cases not of long 
 standing. This gentle, continuous pres- 
 sure is very efficacious. After reduction, 
 it will be well to apply a large-sized 
 Hodge pessary. When reposition is 
 once well effected, there is not much 
 danger of a relapse. 
 
 Treatment after Incarceration Has Oc- 
 curred. — Strict asepsis should be ob- 
 served, and the bowels and bladder 
 emptied. Considerable difficulty may be 
 experienced in passing a catheter, owing 
 to the height of the bladder and the com- 
 pression of its lower part ; a prostatic or 
 gum-elastic catheter should be tried. By 
 drawing down the cervix by a vulsellum 
 forceps, the passage of the catheter will 
 be facilitated. If skilful and careful 
 efforts to pass the catheter are not successful, the bladder must be aspirated with 
 rigid asepsis, about two inches above the symphysis. Efforts at reduction are 
 then instituted under anesthesia, and, if not successful, the induction of abortion 
 will be the last resort. If the cervix cannot be reached by drawing it down with 
 vulsellum forceps, it will be necessary to aspirate the uterus through the posterior 
 vaginal cul-de-sac. The most prominent part should be selected, and as soon as 
 the bulk of the uterus has been sufficiently reduced by the discharge of the liquor 
 amnii, the organ should be replaced, the cervix seized, the os dilated, and the 
 uterus emptied in the usual manner. In rare cases the induction of abortion 
 may be impossible, and vaginal hysterectomy will be necessary, especially if 
 sloughing of the uterus have occurred. 
 
 3. Latero-version and Latero-flexion. — These are not very frequent, and are 
 usually due to some malformation. A moderate deviation to the right is a 
 normal condition, constituting the right lateral obliquity of the pregnant uterus. 
 
 Fig. 451. — -Reduction of an Incarcer- 
 ated Retroflexed Pregnant Uterus 
 BY Means of Fundal Pressure, Trac- 
 tion ON the Cervix, and the Knee- 
 chest Posture. — {Bumm.) 
 
DISEASES OF THE GENITAL ORGANS. 
 
 279 
 
 In rare cases the uterus is deviated laterally, owing to a congenital shortening of 
 one of the broad ligaments. Again, there may be a defective development of 
 one side of the uterus, causing 
 
 latero-fiexion. Excessive lat- 
 
 eral deviation sometimes oc- 
 curs in cases of pelvic deform- 
 ity. (See Pelvic Deformity, 
 Part V.) The effects of these 
 malpositions are more striking 
 in labor than in pregnancy. 
 (See Maternal Dystocia.) 
 
 4. Prolapse oif the Pregnant 
 Uterus (Fig. 452). — This is an 
 uncommon occurrence, and in 
 most cases the prolapse ante- 
 dates the conception. It may, 
 however, occur during preg- 
 nancy, either as a result of a 
 severe shock or fall, or from a 
 lax condition of the pelvic floor, 
 due to an old laceration of the 
 perineum. It may be caused 
 by retroversion, and it is al- 
 most without exception found 
 in multigravidas. There is 
 probably no case on record in 
 
 which pregnancy continued till term in a uterus outside the vagina. In the cases 
 reported the condition was probably one of hypertrophic elongation of the infra- 
 
 FiG. 452. — Total Prolapse of a Retroflexed 
 Pregnant Uterus, Due to Pressure of a Large 
 Pedunculated Ovarian Cyst on the Left Side, 
 Completely Filling in the True Pelvis, and 
 Reaching to the Umbilicus. Rectocele and 
 Ischuria. — (Schaeffer.) 
 
 H 
 
 Fig. 453. — Labial Hernia of the Pregnant Horn of a Uterus Bicornis. — (Winckel- 
 
 Eisenhart.) 
 
 vaginal portion of the cervix, the fundus of the uterus being in the pelvis. Hy- 
 pertrophy of the supravaginal or infravaginal portion of the cervix simulates 
 
280 
 
 PATHOLOGICAL PREGNANCY. 
 
 procidentia, and if amputation of the hypertrophied cervix is performed during 
 the third month, pregnancy may continue without disturbance; in aggravated 
 cases this treatment is indicated. Terminations: Spontaneous reduction usually 
 takes place, in consequence of the upward uterine growth incident to pregnancy; 
 in rare cases incarceration may occur, producing pain, pressure symptoms, con- 
 gestion, and, if not reheved abortion. Diagnosis: It has been confounded with 
 cervical hypertrophy, and this mistake should be avoided, lest it lead to efforts 
 at reposition, which may result in abortion. A careful bimanual examination, 
 with the recognition of the body of the uterus in its normal position, should pre- 
 vent this mistake. Treatment: The bladder and bowels should be watched, and 
 the patient should spend much of her time in the recumbent position with the 
 hips elevated, and standing, walking, and lifting should be avoided. When the 
 prolapse is considerable, the uterus should be replaced and kept in position bv 
 
 
 Fig. 454. — Hernia of the Pregnant Uterus. — {Adams.) 
 
 an air or water pessary and a vulvar napkin if required. When incarceration has 
 occurred, the attempt at replacement should be made with the bowels and bladder 
 empty. As a preliminary, the patient should be placed upon the back with the 
 hips elevated, and the congestion of the uterus diminished by scarification. The 
 knee-chest position may be of service, and anesthesia will be necessary. If 
 replacement cannot be effected, the induction of abortion is indicated. After 
 labor prolonged rest should be enjoined, with the hope that involution of the 
 organ may result in cure of the prolapse. There is always a possibility that 
 pregnancy, labor, and the puerperium will be followed by the cure of old dis- 
 placements. 
 
 5. Torsion. — In some cases the shght normal twisting of the uterus on its 
 long axis from left to right is much exaggerated, or it may be reversed and the 
 uterus twisted to the left. This condition is usually due to adhesions, the 
 result of inflammatory processes, and in these an ovary being brought forward, 
 
DISEASES OF THE GENITAL ORGANS. 
 
 281 
 
 may be injured by attempts to express the placenta or by manipulation. I have 
 never observed a malpresentation or malposition caused by excessive torsion. 
 
 6. Hernial Protrusion of the Pregnant Uterus (Figs. 453, 454). — A uterine pro- 
 trusion may complicate inguinal, umbilical, or ventral hernia, and when it occurs 
 in ventral hernia it is usually due to separation of the recti. It is sometimes seen, 
 however, on the side of the abdomen, and may be due to congenital defects or to 
 an operation cicatrix. Cases of inguinal protrusion sometimes occur, in cases of 
 pregnancy, in one horn of a bicornate uterus. The protrusion of the pregnant 
 uterus in femoral hernia is denied by some writers, but its existence has been 
 asserted by others; e. g., Spiegelberg. Sometimes adhesions between the uterus 
 and intestine cause the former to be drawn into the hernial sac. There may be 
 hernia of the ovary, followed by hernia of the uterus. The symptoms in case of 
 the ventral variety are not import- 
 ant, and they are easily mitigated. .^-- 
 
 Not so in the inguinal variety, for 
 then incarceration and strangulation 
 rapidly develop. The prognosis is 
 good in the ventral form, but grave 
 in the inguinal. The diagnosis of a 
 ventral hernia will be readily appre- 
 ciated, and an inguinal or a femoral 
 hernia will present the symptoms of 
 hernia, with the absence of the uter- 
 us from its normal position, and de- 
 viation of the vagina toward the side 
 on which the hernia is situated. 
 Treatment: In the case of a ventral 
 or umbilical hernia the treatment 
 consists in reduction and an ab- 
 dominal supporter; in the other 
 varieties reduction should be effected 
 if possible, and maintained by a 
 truss, by the recumbent position, 
 and by the avoidance of standing, 
 walking, and heavy lifting. In ad- 
 vanced cases reduction may not be 
 possible, even with herniotomy, and 
 the induction of abortion or hyster- 
 ectomy may be necessary as a last 
 resort. 
 
 7. Peri-uterine Inflammation and Adhesion. — These affections are often alle- 
 viated by appropriate treatment, which should be employed during the intervals 
 between pregnancies (Fig. 455). Sudden rupture of adhesions of the omentum 
 and its contained blood-vessels during the onset of labor may cause fatal hemor- 
 rhage into the peritoneal cavity. 
 
 8. Rheumatism of the Uterine Muscle. — This is a rare condition. There is 
 pain of a neuralgic or a myalgic character, much aggravated by the intermittent 
 uterine contractions which normally occur during pregnancy. It is observed in 
 patients of the rheumatic diathesis, but may be due to exposure to cold and 
 perhaps to violent coughing or straining efforts. Treatment consists in anodyne 
 local applications, with anodynes and salicylates internally. 
 
 9. Metritis. — When this occurs it is usually an aggravation of a previously 
 
 Fig. 455.— Periuterine Inflammation and 
 Adhesion; Tubal Pregnancy; Rupture of 
 THE Sac; Internal Hemorrhage; Numer- 
 ous Cord-like Adhesions between the 
 Uterus, Left Tube, and Intestines. — 
 {Hojmann.) 
 
282 PATHOLOGICAL PREGNANCY. 
 
 existing condition, and thus the symptoms of the pre-existing disease are all inten- 
 l^ified by the physiological hypertrophy of pregnancy. It is one of the causes of 
 the pernicious vomiting of pregnancy. Severe pain and the feeling of weight and 
 pressure or "bearing-down feelings " in the pelvis are common; abortion often 
 results. Treatment: Boro-glyceride tampons may be used, but if long con- 
 tinued are, of course, likely to induce abortion; anodynes are indicated; ex- 
 treme danger for the mother, especially from vomiting, may require the induc- 
 tion of abortion. 
 
 io. New Growths. — Pregnancy may be complicated by the presence of various 
 neoplasms of the uterus, especially fibroid or fibro-cystic tumors. These do little 
 harm during pregnancy, as 'a rule, but symptoms of pelvic congestion are marked^ 
 often with pain, and their growth is rapid by reason of the increased vascularity 
 of pregnancy. In rare cases operative interference may be necessary, on account 
 of hemorrhage or excessive distention. As a complication in labor, the situation 
 above or below the pelvic outlet, and the mobility of the tumor, will be important 
 factors. Malignant growths have been mentioned in connection with deciduoma 
 malignum; cancer of the cervix has frequently been mistaken for placenta 
 previa; cystic tumors of the ovary grow very rapidly during pregnancy. New 
 growths are far more important as a. complication of labor than of pregnancy. 
 (See Part V.) The most frequent form is the fibroid, which grows rapidly from 
 the increased supply of blood to the genitalia. The cervix is often the seat of 
 small polypoid growths which are the source of severe hemorrhage. Operations 
 for the removal of new growths do not necessarily interfere with pregnancy. 
 (See Operations on Pregnant Women, Part X.) 
 
 11. Spontaneous Rupture of the Uterus. — This is a rare complication, when 
 occurring in pregnancy independent of direct traumatism. It may occur from 
 excessive distention; from multiple pregnancy; from hydramnios in a uterine 
 wall already weakened by previous prolonged uterine disease, as endometritis 
 and metritis, malignant disease, a previous hysterectomy, as Caesarean section, 
 or myomectomxy for fibroids. It has occurred in the interstitial variety of 
 ectopic gestation, and I have seen a case of partial spontaneous rupture, follow- 
 ing missed labor, in a case of pregnancy in one side of a uterus septus. The 
 symptoms are the same as those of rupture during labor; e. g., concealed hem- 
 orrhage and shock. The prognosis could hardly be worse, and the treatment is 
 the same as for a ruptured ectopic sac; hysterectomy probably gives the best 
 prognosis, although suture of the wound may be employed. 
 
 12. Malformations of the Genital Organs. — (i) Uterus. — These are caused, 
 for the most part, by the preservation, to a greater or less extent, of the' septa 
 between the ducts of Muller. The student will remember that from the upper 
 portions of these ducts, as they converge, are formed the Fallopian tubes, and 
 that by their juxtaposition and the absorption of their inner walls the uterus 
 and vagina are formed (Fig. 460). If the absorption of the inner walls of the 
 tubes does not take place, the uterus and vagina are divided into two lateral 
 halves. Should a partial union take place, a corresponding degree of malforma- 
 tion results. The organ resulting from this faulty development may present 
 the appearance of one body separated into two parts by a partition, indicating 
 that the two Mullerian ducts have become joined, but that the partition between 
 them has persisted, its absorption not taking place. Or there may be two more or 
 less separate bodies, owing to the non-union of the ducts. There are many degrees 
 of these deformities, each having its own designation, and the arbitrary limits 
 which have been assigned them are numerous. However, the most convenient 
 nomenclature would seem to be as follows : the uterus which retains its original 
 
DISEASES OF THE GENITAL ORGANS. ,283 
 
 partition is known as uterus septus duplex. The partition may exist in approxi- ■, 
 mately five degrees. The. first and shghtest degree results in the uterus incudi-i^ 
 formis (Fig. 142) (anvil-shaped uterus), the organ being flattened from above 
 downward, and its transverse diameter being longer than the longitudinal. 
 Another slight deformity of this variety is the uterus cordiformis (arcuate, 
 cordate, or heart-shaped uterus) (Fig. 456); here the original embryonic shape 
 of the uterus is suggested by a depression in the median line of the fundus. 
 This condition is not often discovered during life, although digital examination 
 of the uterine cavity would reveal its existence. In the second degree the 
 septum extends the length of the body to the internal os. This form also may 
 escape detection, but may be discovered after an abortion or delivery, and it 
 may even be destroyed by pregnancy. In the third degree the septum extends 
 not only through the uterine body, but also through the cervix. This con- 
 dition could easily be recognized by careful cervical examination. In the 
 fourth degree the septum runs down into the vagina, but does not completely 
 divide it. In the fifth degree the septum divides the vagina completely, causing 
 the condition known as vagina septa, or double vagina. It will be readily 
 seen that different degrees of persistence of the septum will produce correspond- 
 ing kinds of malformation. In this bifid condition, as well as in the double 
 uterus, the two sides may be equal or unequal. 
 
 Double Uterus (Figs. 457, 460). — In this class the organ is more or less com- 
 pletely divided into two distinct parts. In the first degree the fundus consists 
 of two parts, due to the non-union of the upper parts of Muller's ducts. The 
 external surface of the fundus presents a depression or groove, and the resulting 
 form is called the uterus bilocularis, or uterus bicornis arcuatus. 
 
 Double Uterus Bicornis, Uterus Duplex Bicornis (Fig. 458). — When the ducts 
 fail to unite till they have descended for some distance below the normal point 
 of junction, the uterus bicornis, bicornate or bifid uterus, is produced. There are 
 two diverging uterine cavities, each communicating with the cervix at one ex- 
 tremity, and with a Fallopian tube at the other. The cervix in this form may 
 be single or double. When there are two vaginae, one of them may have a blind 
 ending above or below. 
 
 Uterus Duplex Separatus cum Vagina Separata- (Fig. 460). — In the uterus 
 didelphys, or double uterus, we have a rare condition, in which the ducts do not 
 unite at all, and consequently there are two separate uterine cavities and two 
 vaginae; each body has its tube and ovary. This is a retrograde form corre- 
 sponding to that of the lowest mammalia. The short broad ligament connects 
 the diverging bodies. The uterus unicornis results from the faulty development 
 of one of Muller's ducts. In a case of this kind one tube and one ovary are gen- 
 erally lacking. There are in this form also varying degrees of development. 
 There may be a rudimentary horn, or it may be sufficiently developed to allow 
 of menstruation, and even of a few months' pregnancy. In cases in which 
 the one horn is entirely lacking, there is sometimes discovered the absence of the 
 kidney and ureter on the malformed side. The uterus unicornis may possess a 
 double cervix, uterus biforis. 
 
 Absent Uterus. — Diagnosis of this extremely rare condition, even under 
 narcosis, is never positive. Its existence is nearly always coincident with the 
 absence of the entire genital system, pre-eminently the vagina. In searching for 
 the uterus, which is not palpable by the ordinary methods, the rectum and 
 bladder may be explored at the same time, the former by the index-finger and 
 the latter by the catheter. Failure to outline the uterus in this way does not 
 offer positive evidence of its absence, since it may be placed in one side of the 
 
284 
 
 PATHOLOGICAL PREGNANCY. 
 
 pelvis, or it may be in such a rudimentary condition as to defy discovery. Celi- 
 otomy or necropsy alone will prove the presence or absence of the organ. 
 
 Fig. 4=;6. — Pregnant Uterus Arcuatus, 
 Transverse Section. — (Bumm.) 
 
 Fig. 457. — Uterus Biseptus. 
 
 Rudimentary Uterus. — The organ may be represented by a transverse 
 bit of connective tissue attached to the bladder, and divided into two parts, to 
 each 'Of which is attached a tiny ovary. 
 The palpation of these organs is rarely 
 possible. In these cases the vagina is 
 
 
 Fig. 458. — Bicornate or Bifid Uterus. 
 
 Fig. 459. — Uterus Bipartitus or 
 Duplex. 
 
 either absent, or exists in such a stunted condition, with a hymen so very 
 small, that the internal genitalia are often thought to be entirely absent. Some- 
 
DISEASES OF THE GENITAL ORGANS. 285 
 
 times the vagina is represented by a small cul-de-sac which is continuous with 
 
 Fig. 460. — Uterus Didelphys or Double 
 Uterus. C, Uterine cavity; V, vagina. 
 — (Dak in.) 
 
 Fig. 461. — Uterus with Two Horns, 
 One Developed and the Other Ru- 
 dimentary. — (Dakin.) 
 
 the urethra; although so slightly developed, it may become enlarged on 
 
 attempted sexual intercourse. Men- 
 struation is rarely present in these 
 cases. When it is, it may be so 
 painful as to indicate castration. 
 Hematometra sometimes occurs. 
 Ovulation may take place without 
 menstruation. Ordinary bimanual 
 palpation, or the method mentioned 
 
 Fig. 462. — Atresia of a Rudimentary 
 Horn of a Double Uterus with an 
 Accumulation of Menstrual Blood. 
 
 Fig. 463. — Uterus Septus. C, C, Uter- 
 ine cavities. — {Dakin.) 
 
 Fig. 464. — Uterus Unicornis. 
 
 Fig. 465. — Uterus with Complete 
 Absence OF One Horn. C, Uter- 
 ine cavity; V, vagina. — {Dakin.) 
 
 under absent uterus, may detect the condition; however, with a well- 
 
286 PATHOLOGICAL PREGNANCY. 
 
 developed vagina and established menstruation it may not be recognized. The 
 breasts and pubes are generally well formed. When Miiller's ducts are in a very 
 rudimentary state, the ovaries are often in a condition of cystic degeneration. 
 
 Fetal and Infantile Uterus; Pubescent Uterus. — Hypoplasia uteri is not an 
 atrophic uterus but results from faulty development. The fetal uterus presents 
 the characteristics of the organ as found in the fetus — a very small, thin-walled, 
 bullet-shaped body, with a cervix several times its length. The vagina is, as a 
 rule, short and narrow. The patient generally suffers from extreme chlorosis, 
 amenorrhea which defies treatment, and attendant troubles. The infantile 
 form presents the normal organ in miniature. The arbor vitas folds do not reach 
 to the fundus in this form as they do in the fetal form. The patient is troubled 
 with amenorrhea, dysmenorrhea, sterility, and nervous symptoms. Such cases 
 should receive systematic treatment, not only general but also local. The 
 cervix ought to be dilated and the body subjected to intrauterine faradism, 
 as well as medicinal applications. In these cases the vagina, pubes, and mammae 
 are generally perfectly formed, although the opposite condition may obtain. 
 Menstruation is not often present, nor is sexual desire. 
 
 Imperforate fetal uterus is of very rare occurrence. The body especially lacks 
 a cavity. Uterus fetalis hicornis is an organ which presents the fetal character- 
 istics in both form and size, and is possessed of the cornua. 
 
 Accessory uteri have been noted. In one case a somewhat smaller uterus, in 
 sagittal position, lay in front of the normal organ. The origin of this anomaly is 
 not clear. Precocious development of the uterus, with that of the other genitalia, 
 is not infrequently observed in small children. Unusual cases have been de- 
 scribed in which the mucous membrane of the cervix lies in transverse folds. 
 Transverse septa have been found in the cervix. Cases are noted in which 
 these septa had to be removed before labor could be completed. Several con- 
 genital anomalies of position of the uterus have been noted. The oblique posi- 
 tion of the organ, in which the body is bent to one side or the other by the shorten- 
 ing of one of the lateral ligaments, also occurs. 
 
 Congenital retroflexion exists in some cases, as well as anteflexion with its 
 attendant symptoms, dysmenorrhea, nervous disturbances, etc. 
 
 Congenital prolapsus uteri is rarely met with, and is generally only one of 
 several associated stigmata of faulty development. 
 
 Not alone the uterus is subject to malformations, but the adnexa and external 
 genitalia as well. One or both tubes may be absent or rudimentary. In the 
 former instance the ovaries and uterus are apt to be lacking also. In certain 
 cases there are several openings to the tube which may vary in their position. 
 The tubes may also present abnormalities in length or calibre. 
 
 (2) Ovaries. — Absent ovaries constitutes also a very rare condition, which 
 it is impossible to recognize without direct inspection. These organs may be 
 rudimentary, or one alone may be lacking, as in uterus unicornis. The absence 
 may be only apparent, as when the ovary is attached to one of the other abdom- 
 inal organs. Supernumerary, as well as accessory, ovaries have been reported, 
 the former being far more rare than the latter. Malposition of the ovaries is not 
 very uncommon, and often gives rise to much trouble. In case of the presence 
 of a hernia, the prolapsed ovary may slip into the hernial sac, and cause extreme 
 pain, while the diagnosis of the condition will be very difficult to make. 
 
 (3) Ligaments. — The uterine ligaments may be defective or absent. This 
 condition, especially of the round ligament, is generally associated with faulty 
 development of the uterus. 
 
 (4) Vagina. — The vagina may be absent or rudimentary. When absent, the 
 
DISEASES OF THE GENITAL ORGANS. 287 
 
 ■uterus will also generally be absent, or, if present, it will be slightly developed. 
 If only a part of the vagina is present, it will usually be the lower part. At 
 times the whole vulva may' be' absent or ill-formed. There are all sorts and de- 
 grees of deformities of the vagina, associated with a variety of changes of physio- 
 logical function of the internal genital organs. Indications for operative treat- 
 ment will depend greatly on the conditions of the whole genital system. Atresia 
 may exist at any place in the genital canal, between the vulval opening and the 
 internal os. It may be congenital or acquired. Congenital atresia is found, as 
 a rule, at the lower end of the vagina. Atresia of the cervix is seldom complete, 
 and is the result of cicatricial formation. This may result from laceration in 
 labor, or rarely there may be a condition of cervical endometritis, followed by 
 agglutination of the lips of the cervix. Complete atresia of the vagina is always 
 associated with malformation of the other genitalia. Atresia of the vulva is not 
 infrequently seen. The vulva may be absent, and this condition is usually only 
 one feature of a general genital deformity. It may also be infantile in its devel- 
 opment, as is sometimes seen in feeble women, especially those who have been in 
 wretched health before puberty. The nymphae may be absent, very small, or 
 hypertrophied. 
 
 (5) Clitoris. — Defects in the clitoris are often of great clinical significance. 
 Its absence is a rare condition, but it is not so infrequently hypertrophied, in 
 some cases to such an extent that it is difficult or impossible to differentiate the 
 ■sex of the individual. It is sometimes rudimentary or even bifid, as when the 
 symphysis is absent, or in exstrophy of the bladder (see Deformities and Mon- 
 strosities, page 247). 
 
 (6) Hymen. — The hymen may also present deformities. It may be imper- 
 forate, or there may be atresia. The supernumerary hymen that has been re- 
 ported is probably, as a rule, a vaginal bridle. The congenital absence of this 
 membrane is open to grave doubt, although instances of the anomaly have been 
 reported from time to time. In 600 cases of children under sixteen years, exam- 
 ined by the writer for evidences of rape, in no instance was the hymen absent 
 (see Rape, page 29). 
 
 Malformations of the urethra and bladder are various. The urethra may be 
 ■entirely absent, or only partly defective. Atresia urethra sometimes exists, but 
 generally ends fatally. 
 
 Clinical Significance of Deformities. — Malformation of the uterus rnay 
 affect the course of pregnancy and labor in various ways. In uterus septus duplex 
 there are a few cases in which the placenta has been located upon a persisting 
 septum, post-partum hemorrhage occurring from deficient retraction. The empty 
 half of the uterus may of itself become an obstruction to labor, especially if it 
 be hypertrophied and retroverted. During labor it is very apt to sink into the 
 sacral hollow, and contract synchronously with the musculature of the pregnant 
 part. The pregnant side of the uterus turns toward the median line of the body. 
 The clinical significance of this malformed organ is similar to that of the uterus 
 duplex bicornis. In uterus arcuatus brow and face presentations are favored 
 when the breech is in that segment of the fundus which corresponds to the back 
 of the fetus. When pregnancy occurs in the anvil-shaped uterus (uterus in- 
 €udiformis) the fetus is forced to assume the transverse position, on account of 
 the shape of the uterus, which is flattened, having the transverse at its greatest 
 ■diameter. In the cordate uterus, the cavity being only slightly smaller than 
 normal, a two-chambered organ is merely suggested. When the utero-vaginal 
 septum is complete, sexual intercourse may take place in either canal. In labor 
 the septum itself may offer an obstruction. Laceration of the septum often 
 
288 PATHOLOGICAL PREGNANCY. 
 
 takes place. In uterus duplex bicornis with pregnancy in one horn, the uterine 
 obliquity necessarily present may be a cause of faulty presentation, position, and 
 attitude. When pregnancy occurs in one horn, confusion in the diagnosis with 
 the condition of tubal pregnancy can scarcely be avoided. Menstruation may 
 take place from one horn, while pregnancy exists in the other. Different periods 
 of pregnancy may exist simultaneously in the two horns ; labor is sometimes 
 obstructed by the vesico-rectal ligament which connects the two horns in a 
 bicornate uterus. Associated with this malformation are apt to be atony, weak 
 labor pains, and faulty involution. In the uterus unicornis with pregnancy in 
 that part of the uterus which has become developed, labor is usually normal. 
 If, however, pregnancy occurs in the rudimentary horn, the course and termina- 
 tion of the case will be similar to that of extrauterine pregnancy (see page 361). 
 The rudimentary horn is not suited for the normal course of gestation, and if this 
 occurs it results in rupture before the sixth month. The danger of this condition 
 is as great as that of tubal pregnancy, from which it cannot be differentiated 
 before operation. In the event of atresia of the stunted horn, hematometra will 
 develop, the diagnosis of which it may be impossible to determine without opera- 
 tion. This may develop into pyometra. When the true nature of this condi- 
 tion is known, it is important to open this retention cyst and allow the contents 
 to flow slowly out, in order to avoid a sudden change of pressure, which might 
 result in the bursting of this thin-walled sac into the abdominal cavity. This 
 would put the patient in great danger of infection and septicemia. Especially 
 is this caution necessary when hematosalpinx exists as a complication. Should 
 the tumor rupture of itself, the tear may be so high up that a part of the sac will 
 be left too far out of reach to be properly drained, and this condition will also be 
 followed by infection and septicemia. In uterus hiforis (one-homed uterus with 
 double cervix) there may be considerable trouble during labor. If the septum is 
 found, it may be pushed to one side and so kept out of the way, or it may be cut 
 between two lines of sutures. Severe hemorrhage has followed its rupture. It 
 is plain to see how any of the foregoing deformities may cause trouble of various 
 sorts and degrees. There may be trouble with the placenta, as it is not infre- 
 quently retained. This may be due to the weak force of expulsion, or to its 
 attachment to both cavities of the uterus. This retention may be the cause of 
 septicemia. When labor is proceeding,^ the physician may examine the two open- 
 ings alternately, finding now a dilated os, then a contracted os. Or the wrong 
 side may be examined, and no internal signs of pregnancy be found. In the case 
 of one individual with a double uterus, succeeding pregnancies occurred regu- 
 larly on the alternate sides. 
 
 13. Leucorrhea. — One often observes excessive leucorrhea as the result of 
 the congestion of pregnancy, and following or accompanying acute or chronic 
 inflammation, non-specific in character. Much annoyance is caused by the dis- 
 charge itself, and the swelling, heat, and general discomfort. The profuse serous 
 discharge becomes later purulent and contains various fungi. In the treatment 
 care should be exercised not to excite uterine contractions. The author is 
 accustomed to rely mainly upon suppositories of hydrochlorate of hydrastis, 
 gr. i; borate of zinc, gr. \; extract of belladonna, gr. \; cocoa-butter, or boro- 
 glyceride and cocoa-butter, q.s. After careful irrigation of the vagina at bedtime 
 with an alum douche, a teaspoonful of alum to the quart of warm water, care being 
 taken that there is no obstruction to the return flow, and that the douche bag is 
 not more than two feet above the pelvis, one of the above suppositories is inserted 
 into the vagina, and a napkin applied for the night. In the morning the alum 
 douche is repeated. Other combinations in suppositories are useful. When the 
 
DISEASES OF THE GENITAL ORGANS. 289 
 
 uterus is irritable, or the vagina painful or sensitive, suppositories of extract 
 of belladonna gr. -J, and tannic acid gr. 5-10, are used; and the douche is omitted 
 entirely; or a solution of subacetate of lead two teaspoonfuls, and laudanum two 
 teaspoonfuls, to the quart of warm water, is used. Care must be taken during 
 pregnancy in the employment of any form of tampon with the various prepara- 
 tions of boro-glyceride, tannin, zinc, and hydrastis. 
 
 14. Cystic Vaginitis. — This is an inflammation of the vagina, usually limited 
 to the upper two-thirds, and accompanied by the development of small cysts, 
 from which, when punctured, air and serum exude; it is attended by a profuse 
 frothy discharge, and the symptoms are more acute than those of simple catar- 
 rhal vaginitis. The treatment is the same as for leucorrhea. 
 
 15. Specific Vaginitis. — The infection takes place as the result of sexual 
 intercourse, but in rare cases it may possibly be caused by the use of infected 
 towels, or by other' contact with infected surfaces. All the symptoms of simple 
 vaginitis are aggravated ; there are urethritis and vesical irritation ; the discharge 
 is profuse and purulent, and contains the gonococcus (diplococcus of Neisser); 
 smarting pain accompanying urination is especially prominent ; abscesses of the 
 vulvo-vaginal gland sometimes occur, and redness and excoriation of the external 
 genitals are common. There is always considerable danger of septic infection 
 during labor, and the fetus is likely to develop specific ophthalmia. Treatment: 
 The vagina should be irrigated with an antiseptic solution, sublimate solution 
 (i : 4000), or permanganate of potash, and excoriated surfaces cauterized with a 
 2 per cent, solution of nitrate of silver; loose tampons of boro-glyceride and 
 tannin, or of iodoform and tannic acid, may be used; suppositories of iodoform, 
 tannic acid, and cocoa-butter, or hydrastin and boro-glyceride used at bedtime. 
 The introduction of the suppository should be preceded and followed by a warm, 
 carefully administered lysol or creolin douche (i per cent.). Since the vaginal 
 secretions are alkaline in this affection, Doderlein has suggested the topical appli- 
 cation of a I per cent, solution of lactic acid to the vaginal walls. Antiseptic 
 vaginal douches during labor are advisable, and after delivery the child's eyes 
 should be washed with a saturated solution of boric acid, and nitrate of silver be 
 instilled into each eye, after the method of Cred^ (see Part IX). 
 
 16. Prolapse of the Vagina. — In multigravidas, and occasionally in primi- 
 gravidae, — in the former from a previously existing condition, and in both as 
 the result of the changes produced by gestation, such as congestion, increased 
 pressure, hypertrophy and loosening of the vaginal walls, — a certain amount 
 of prolapse of the anterior wall, associated with perhaps some cystocele, is com- 
 mon in the later months of pregnancy. Prolapse of the posterior wall with 
 cystocele we not infrequently see in multigravidae, and occasionally in primi- 
 gravidcB, from habitual constipation with overloaded rectum and neglect. I once 
 saw a prolapse of the posterior wall with rectocele, in a primigravida, due to 
 persistent constipation, in which the rectocele presented in the ostium vaginse; 
 I was summoned in the night, the patient mistaking the condition for a possible 
 miscarriage. The symptoms are those of vesical and rectal irritation, dysuria, 
 frequent micturition, and perhaps aggravation of existing hemorrhoids; the 
 physical signs are plain on examination. The treatment consists in careful atten- 
 tion to the bowels, the avoidance of tight clothing, the manual reposition of the 
 prolapse, and in fitting a proper abdominal support to the patient, to lessen the 
 weight of the uterus (Figs. 228 and 229). The abdominal binder described for 
 use after the puerperium can be employed to advantage, since it supports the 
 lower part of the uterus and the pelvic floor as well (see Part VI). A pneumatic, 
 water, or celluloid pessary may possibly be required, held in place by the above, 
 
 19 
 
290 
 
 PATHOLOGICAL PREGNANCY. 
 
 Fig. 466. — Varicose Veins of the Vulva. 
 — {Case of Dr. Wihner Krusen) 
 
 or an ordinary T-bandage. During labor prolapse may prove an obstruction 
 (see Part V). 
 
 17. Pruritus Vulvae. — This is always a source of great annoyance, and occa- 
 sionally of miscarriage. It is due to irritating discharges or to local conditions; 
 it often occurs in diabetes. It may have a reflex origin, as rectal worms, 
 and some have asserted that it is frequently a neurosis. Treatment: The 
 
 general health should be attended 
 to and the cause should be ascer 
 tained, and treated if possible; the 
 urine being always carefully ex- 
 amined for sources of irritation, 
 as sugar and uric acid. I have 
 found, after correcting the irri- 
 tating discharges and attending to 
 the urine and bowels, that sublimate 
 solution (i: 1000) is of great value 
 in subduing the itching; carbolic 
 acid, either in ointment or solution, 
 is of value; a drachm of carbolic 
 acid to four ounces of ointment of 
 rose, or to eight ounces of water 
 or oil, may be used. Ointments of 
 cocain, ichthyol, resorcin, menthol, 
 opium and belladonna, and salicylic 
 acid are recommended. 
 
 18. Varicosities (Fig. 466). — Va- 
 ricose veins about the vulva and lower part of the vagina, the result of the 
 general pelvic congestion, frequently occur. Constipation should be avoided, 
 and in bad cases the vulval region should be supported by a T-bandage, and 
 the patient should spend a good deal of time in the recumbent position. The 
 compound ointment of gall, and ointments of carbolic acid, ' cocain, and 
 witch-hazel I have found useful. 
 \ ■ 19. Vegetations. — These often 
 follow gonorrhea, especially when 
 the rules of cleanliness are not 
 observed; they are confined to the 
 vulva. Cleanliness and the fre- 
 quent application of an astringent 
 powder, as oxide of zinc, or bis- 
 muth and salicylic acid, boro- 
 glyceride and tannin, will be suffi- 
 cient for treatment; bad cases may * ' ' ,,^«j,.'/ 
 be touched with chromic acid, but 
 operative treatment should be 
 avoided during pregnancy. 
 
 20. (Edema of the Vulva (Fig. 
 467). — (Edema here may be uni- 
 lateral or bilateral; it may be due to renal insufficiency, in which case it is always 
 bilateral, or to mechanical pressure of the enlarging uterus and fetus upon the 
 pelvic veins. It may also be due to general anasarca, or to local inflamma- 
 tion, as specific vaginitis. When excessive, ulcerative sloughing of the labia 
 may occur, and labor be obstructed (see Part V). In the treatment the cause 
 
 Fig. 467. — CEdema of the Vulva. 
 
TOXEMIA OF PREGNANCY. 291 
 
 is to be sought out and treated : diuretics for the renal insufficiency ; an abdomi- 
 nal support for pressure; proper treatment for local inflammation. Hot fomen- 
 tations and multiple puncture of the tense skin are palliative; the latter should 
 be avoided when possible, for fear of local infection. 
 
 21. Eczema of the Nipple. — This, when occurring during gestation, is apt to 
 be a very obstinate affection. For treatment the general health should receive 
 attention. Locally the parts affected should be kept clean, frequent washing 
 being avoided; antiseptic, astringent, and desiccating applications should be used; 
 powdered oxide of zinc and salicylic acid make a good application. The nipples 
 are to be guarded from irritation and exposure to the air by a protective dress- 
 ing, which, however, should not press upon them. The condition is apt to resist 
 treatment. I have been most successful with the use of Unna's ointment mull, 
 hydrarg. carbolic, (hydrarg., 20 per cent.; carbolic acid, 5 per cent.), cutting a 
 piece of the plaster to fit accurately over the affected part, and renewing it daily, 
 using only a little sterile vaseline in the removal of the plaster. 
 
 22. Mammary Abscess. — This may occur during pregnancy, but is not 
 common. I had in my service at the New York Maternity a case of double 
 mammary abscess at the eighth month of gestation, which was twelve months 
 from the birth of the last child. Both breasts were incised, and drainage was 
 employed without interrupting the pregnancy. It frequently occurs during 
 the puerperium,' and is discussed in connection with the pathology of that 
 period (see Part VII). 
 
 23. Hemorrhage from the Vagina During Pregnancy. — (See Metrorrhagia of 
 Pregnancy.) 
 
 24. Hematoma of the Vulva. — The veins of the vestibular bulbs, lying be- 
 neath the mucous membrane of the vestibule on either side, are liable to rupture 
 during pregnancy, giving rise to hematoma of the vulva, and possibly profuse 
 external hemorrhage. The condition is found more frequently during parturi- 
 tion and the puerperium. (See Pathology of Labor and Puerperium.) 
 
 X. THE TOXEMIA OF PREGNANCY. AUTOTOXEMIA OF 
 PREGNANCY. HEPATIC INSUFFICIENCY. PREG- 
 NANCY LIVER. PRE-ECLAMPTIC STATE. 
 
 I. Toxerma of Pregnancy. 2. Nausea and Vomiting. 3. Icterus 4. Convulsions and Coma. 
 
 5. Eclampsia. 
 
 I. Toxemia of Pregnancy. — Introduction. — The conception of a special 
 toxemia of pregnancy has grown from small and vague beginnings to a well- 
 developed and harmonious theory which challenges the attention of every 
 medical man. That such a condition exists is no longer a matter of doubt; 
 but the extent to which it prevails will unquestionably be a subject of debate 
 in obstetrics for many years to come. 
 
 It is unnecessary to refer in detail to the various discoveries which have cul- 
 minated in the modern theory of the toxemia of pregnancy, which is sufficiently 
 well established to admit of a statement of the etiology, pathology, symptoma- 
 tology, clinical varieties, course and termination, diagnosis, prognosis, prophylaxis, 
 and treatment. As far as is known, the subject in question has thus far never 
 been dealt with in this systematic fashion, and I am under obligation to Ewing for 
 filling out certain gaps in my attempts in this direction. 
 
292 PATHOLOGICAL PREGNANCY. 
 
 Definition. — The toxemia of pregnancy may be defined as a state of the 
 blood and metabohsm, possibly arising from the hepatic insufficiency, to which 
 the pregnant woman is strongly predisposed ; expressed most commonly by trivial 
 ailments (petty morbidity of pregnancy), but exceptionally by serious, severe, 
 and even pernicious affections, such as acute yellow atrophy of the liver, per- 
 nicious vomiting, eclampsia, — conditions which, while once thought to have- 
 nothing in common, are now seen to be closely related. 
 
 Pathological Anatomy. — The anatomical alterations chiefly affect the 
 liver, kidneys, and spleen. Exceptionally other organs may be involved, as 
 peripheral nerves, thyroid, etc. The blood state in fatal cases resembles that 
 of severe sepsis. Liver: Lesions of this organ are constantly present, but exhibit 
 great irregularity in extent and severity. They are either degenerative or 
 necrotic, the latter succeeding the former. We may encoiinter extensive areas 
 of degeneration without necrosis, and, conversely, may see necrosis result from 
 isolated foci of degeneration, A certain degree of fatty metamorphosis (stea- 
 tosis) is said to be the rule in pregnancy; and from these minimal changes there 
 may occur a steady increase in intensity until acute parenchymatous hepatitis 
 is reached, this condition consisting of an acute fatty degeneration, plus a 
 proliferation of the interlobular connective tissue (Fig. 468). In like manner 
 necrosis may develop in foci of fatty degeneration, and may occur in in- 
 creasing severity until it culminates in acute yellow atrophy of the liver (Fig. 
 469). Whenever necrosis reaches a certain stage the blood-vessels become in- 
 volved, and hemorrhages and thrombosis may result ( Fig. 469). The most severe 
 lesions of the liver are partly degenerative and partly necrotic; for this reason 
 the size and appearance of the liver in the acute toxemia of pregnancy may vary 
 greatly. In one instance the organ may be the seat of acute parenchymatous 
 hepatitis with no diminution in size, while in another, the necrotic element is 
 so marked that the size may be reduced to a third of the normal. Even in the 
 midst of the extensive destruction, there is evidence of attempted regeneration 
 of biliary canaliculi. Ewing, regarding necrosis of the hepatic cell as almost 
 inseparable from the acute toxemia of pregnancy, gives the following degrees of 
 intensity : Necrosis may be limited to individual isolated cells throughout a lobule ; 
 or it may involve the zone of cells between the central vein and the periphery; or, 
 finally, it may involve the entire lobule, save a slight peripheric rim of cells 
 (Figs. 468, 469). Kidney: The appearances of the kidney are very irregular. 
 Not only does the specific pregnancy-kidney occur under a variety of forms, but 
 it may be complicated with nephritis, which affection may also occur de novo. 
 Although some pathologists deny the existence of a specific kidney of pregnancy, 
 the characteristics laid down by von Leyden appear to demonstrate the existence 
 of a condition sui generis. From this point of view the pregnancy-kidney is an 
 acute fatty infiltration of the kidney which does not compromise the integrity 
 of the organ, and which tends to disappear after delivery. In rare instances 
 acute toxemia of pregnancy is found to be associated with an acute parenchy- 
 matous nephritis, terminating in atrophy. The connection of such a lesion 
 with the specific kidney of pregnancy is a matter of speculation. Spleen: In 
 acute toxemia of pregnancy, associated with hepatitis and necrosis of the liver, 
 the spleen may be similarly involved. The damage thus inflicted upon this organ 
 is held by some to account for the mysterious examples of anemia and leukemia 
 which develop after the puerperium. Nerves: Polyneuritis occurs in the gravida 
 to a greater extent than may be explained by chance. In some cases the phrenic 
 nerve has been involved. Korsakoff's psychosis (mania with polyneuritis) has 
 also been seen in the gravida. Thyroid: The normal enlargement of this organ 
 

 
 
 
 ? ^ 
 
 
 t 
 
 
 » • 
 
 
 
 Normal liver 
 cells. 
 
 Zone of intense 
 granular and 
 fatty degener- 
 ation. 
 
 Zone of necro- 
 sis about cen- 
 tral vein. 
 
 Fig. 468. — Toxemia of Pregnancy. Portion of an hepatic lobule from a case of the toxemia 
 of pregnancy. Specimen shows intense granular and fatty degeneration, and also zone of 
 necrosis about the central vein, x 75 diameters. — (From a specimen in the Pathological 
 Laboratory of the Cornell Uni"c'crsity Medical College.) 
 
TOXEMIA OF PREGNANCY. 293 
 
 in the gravida has been found wanting in certain cases of eclampsia. Blood: 
 In high degrees of toxemia of pregnancy the blood shows characteristic changes 
 which resemble those of sepsis. Thrombosis and embolism may occur, begin- 
 ning in the hepatic veins. Another feature of this state is the acute hemor- 
 rhagic diathesis, which leads to surface hemorrhages (petechiae or extravasa- 
 tions). Finally icterus may be enumerated among the symptoms of the acute 
 dyscrasia of the blood. 
 
 Etiology. — There are three sets of etiological factors which must be con- 
 sidered in connection with the toxemia of pregnancy: i. Conditions which 
 predispose to hepatic insufficiency, comprising pregnancy itself, heredity and 
 a previous history of toxemia. 2. Accessory factors which tend to modify the 
 disease and cause it to assume special clinical types, and to influence the time 
 of its appearance; these comprising nervous instability, the menstrual epoch, 
 and mechanical factors. 3. Actual toxic substances in the blood, or toxic 
 states of that fluid. The exact relation of this class of factors to the hepatic 
 insufficiency is problematical, because a vicious circle is involved. Thus a 
 toxic blood-state may by throwing additional work upon the liver cause a 
 partial paralysis of its functions, which in turn causes the accumulation of more 
 toxic matter in the blood. Each individual factor will now receive separate 
 discussion. 
 
 1 . Pregnancy. — This is the sine qua non among etiological factors ; for while 
 many of the phenomena of the toxemia of pregnancy may occur in the non- 
 pregnant, some of the lesions of the liver and kidney appear to occur only in 
 gravidity, while clinically the course of the malady is intimately bound up with 
 gestation. The frequent — yet by no means universal — cessation or great 
 amelioration of the symptoms after death of the fetus or emptying of the uterus 
 is alone sufficient evidence of the specificity of this affection. The relationship 
 of pregnancy to the autotoxic state is considered more fully under pathogeny. 
 Hereditary, Congenital and Acquired Tendency to Hepatic Insufficiency: For the 
 great influence of heredity in this connection see page 2 98. We may also infer that 
 hepatic insufficiency may be acquired in various ways. Previous History of Toxe- 
 mia of Pregnancy: In a large proportion of cases one attack appears to predispose 
 to another at a consecutive pregnancy. This is especially likely to happen if the 
 first attack was of sufficient severity to produce structural alterations of the vis- 
 cera. Even in the absence of a history of toxemia, the mere fact that children of a 
 given woman are bom in rapid succession may furnish a very strong predisposi- 
 tion ; for the toxemia, however slight or latent, may become cumulative. If the 
 toxemic symptoms are not resolved after delivery and persist into the lacta- 
 tion period, conception would likely be followed by toxemia in an aggravated 
 form. In this connection we may cite the statement by Ewing that in some 
 cases of dysmenorrhea antedating conception the women exhibit evidences 
 of a toxic condition resulting apparently from suppression of the menses. 
 A woman of this sort is notably predisposed to toxemia in case of con- 
 ception. 
 
 2. Accessory Factors. — Numerous factors help to shape the course of the 
 toxemia. The nervous instability which, according to von Herff, is almost 
 inseparable from pregnancy, and which perhaps is itself evidence of an autotoxic 
 state, undoubtedly plays a very prominent role — in proportion to its degree — 
 in the causation of paroxysms of vomiting and eclamptic convulsions. If reflex 
 irritation is the factor in the morbidity of pregnancy which many assume, it 
 can be such only through the accession of nervous instability. An important 
 factor for determining the onset and exacerbation of symptoms is the time of 
 
294 PATHOLOGICAL PREGNANCY. 
 
 the menses. Thus hyperemesis may first set in or become much aggravated or 
 develop terminal symptoms, at the end of the various months of pregnancy. 
 When the increase of the ovum and uterus is of such extent as to raise the intra- 
 abdominal pressure, compress important organs, and interfere with circulation 
 and respiration, this mechanical factor often becomes of great significance in the 
 development of pregnancy-kidney, and other conditions — constipation, for 
 example — which may increase the severity of the autotoxic state. 
 
 3. Toxic Substances and Influences. — (i) Nitrogenous substances derived 
 either from katabolic activity or from the ingesta are most commonly suspected 
 of participating in the toxemia of pregnancy. The failure of the liver to syn- 
 thetize the lower nitrogenous products of katabolism to urea and uric acid is 
 held to be responsible for the accumulation of these substances in the blood. 
 There are included here amino-acids, ammonia, xanthin bases, etc. However, 
 but one of these — carbaminic acid — is a known chemical poison; and this has 
 not yet been found in the blood in toxic quantities. If the toxic state already 
 exists, a nitrogenous diet appears to favor greatly the development of convul- 
 sions; this fact arguing that the peptones and peptoids of digestion normally 
 require disintoxication by the liver before they are fit for assimilation. Finally, 
 nitrogenous products of putrefaction, ordinarily rendered harmless by the liver, 
 may be pathogenic in the gravida. (2) Bile: From the frequent use of 
 the term cholemia as a synonym for toxemia of pregnancy, it might be 
 thought that the condition represents an absorption or suppression of the 
 bile. This is not the case, however. Bile when injected into animals 
 possesses narcotic properties, but there is not much evidence that bile per se 
 or the substances from which it is produced plays any important role in the 
 genesis of the autotoxic state of the gravida. At the same time it is by no 
 means impossible that such is the case. The subject is considered more fully 
 under pathogeny. (3) Changes in the normal alkalescence or concentration of 
 the blood may be responsible for the toxic phenomena. Thus the same dimi- 
 nution of the alkalescence which is known to exist in diabetic coma (so-called 
 acid-intoxication) may be noted in the acute toxemia of pregnancy. This is 
 held to be due to the presence of "acetone bodies " (acetone, aceto-acetic acid), 
 of lactic acid and the higher fatty acids, and probably represents imperfect 
 oxidation of carbohydrates. In this condition the urine gives an intense acid 
 reaction. The opposite state of increased alkalescence is seen under experi- 
 mental conditions (Eck's fistula) and perhaps clinically as well — as in cases in 
 which the breath, urine, etc., are ammoniacal. (4) Occasional or Chance Poisons: 
 Since the liver of the gravida is in a state of exhaustion, it is well to bear in mind 
 that it may not be able to fix and neutralize ordinary poisons of alien source which 
 have a special tendency to injure it. These comprise phosphorus, arsenic and 
 antimony, alcohol when taken habitually, and perhaps other substances of a 
 similar nature. Bacterial toxins must also be borne in mind as chance factors. 
 
 Pathogeny. — Pregnancy itself is doubtless the efficient cause of the hepatic 
 overwork, for the liver presides over anabolism and must be largely concerned 
 in the upbuilding of the fetus. The importance of the hepatic tissue to the 
 growing organism is best seen in the disproportionally large size of the liver in 
 the fetus and infant. It is often stated that the maternal liver should not be 
 overtaxed in the early months of pregnancy; and this may be true in the sense 
 that the products of embryonal katabolism must be insignificant; we must 
 bear in mind, however, that during the embryonal period a rapid organogenesis 
 occurs; and that the various tissues and organs are all rapidly evolved from a 
 relatively undifferentiated matrix. It is commonly affirmed that this rapid 
 

 &"^i)^^ 
 
 / 
 
 '&'k^^ ^y ; 
 
 Per i p Ii era I 
 row of in- 
 tact cells. 
 
 Narrozv zone 
 of very fat- 
 tv cells. 
 
 Edge of area 
 of necrotic 
 and disin- 
 tegrated 
 cclls.zi'Iiicli 
 occupy in- 
 }i c r t tv 0- 
 th irds of 
 lobu'e. 
 
 Fig. 469.— Toxemia of Pregnancy. Portion of an hepatic lobnlo from a case of pornicimis 
 vomiting of pregnancy. Specimen siiows fatty degeneration and necmsis.— (/■';•<»//; a 
 spccniini iu flic Pathological Laboratorv of ihc Cornell University Medical Collate.) 
 
TOXEMIA OF PREGNANCY. 295 
 
 differentiation is accomplished by the aid of enzyme-like bodies, which are 
 generated, do their work, and g-ive way to others. While it is often said that 
 the maternal blood contains all these potentialities for fetal development, 
 it would be more nearly correct to state that this responsibility is invested in 
 the chief hematopoietic organ — the liver. 
 
 To this drain upon the liver must be added the influence of suppressed men- 
 struation in the gravida, which is said to entail congestion of the liver, and per- 
 haps also retention of toxic substances in the circulation. If, now, the various 
 predisposing causes are borne in mind, as heredity, previous toxemia of preg- 
 nancy, etc., we may readily conceive of causal factors which may explain the 
 "failure of the liver " even when it occurs, as in rare cases, early in pregnancy. 
 
 As pregnancy advances the risk increases. Thus the gravida after subsidence 
 of preliminary nausea, etc., may develop a voracious appetite, and may take 
 large quantities of nitrogenous food. The steady growth of the uterus and 
 ovum must add in time to the katabolic work of the liver. The increase of intra- 
 abdominal pressure must be prejudicial to the work of that organ; and the 
 obstinate locking-up of the bowels which frequently occurs must favor the 
 absorption of putrefactive products. The woman cannot exercise, and her 
 respiratory activity is prejudiced. To all these contingencies must be added 
 the possibility of some bacterial infection, an addiction to alcohol, or some form 
 of drug-poisoning, as from arsenical wall-paper, "complexion wafers," etc. 
 
 Toxemia in pregnancy has been noted in connection with ectopic gestation 
 and even with hydatidiform mole. The latter fact appears to disprove the 
 likelihood of a fetal source of toxemia. 
 
 Symptomatology. — Some of the more important and constant symptoms 
 require special attention. These may be grouped under the following heads: 
 viz., gastro-hepatic, urinary, nervous, and cutaneous. G astro-hepatic: While by 
 no means constant, pain and tenderness over the epigastrium and right hypo- 
 chondrium are not infrequent. The area of hepatic dulness may be increased. 
 This class of symptoms may be due to a variety of causes — hepatic congestion, 
 perihepatitis, soreness of muscles from vomiting, and in some cases actual in- 
 flammation of the liver. Urinary: In high degrees of toxemia unsynthetized 
 nitrogen compounds appear in the urine at the expense of the urea (ammonia 
 compounds, amino-acids, purin bodies). In some cases leucin may be present as 
 a result of destruction of liver tissue. Generally speaking, the urinary findings 
 in the toxemia of pregnancy are sufficiently numerous and varied to discourage 
 classification. They tend to show that various phases of hepatic insufficiency 
 may occur irrespective of other changes. Nervous: This class of symptoms 
 is characteristic of the toxic state. Alteration of character may be of the same 
 nature as the moody, peevish, and irascible "spells" which result from bilious 
 crises. An increase in reflex excitability may account for some of the mor- 
 bidity of the gravida. In higher types of toxemia an increase of cortical activity 
 is shown by intense restlessness, agitation, insomnia, convulsions, delirium, etc. 
 This class of symptoms may be followed or replaced by the opposite group — 
 apathy, hebetude, somnolence, stupor and coma. Headache may be mentioned 
 in this connection. In some cases the nerves are directly attacked by a circulat- 
 ing poison (polyneuritis). Cutaneous: Several cutaneous symptoms of pre- 
 sumably toxic origin — pigmentation, pruritus, etc. — are discussed in the section 
 on Skin Diseases in Pregnancy (page 337). The relationship of the pernicious 
 impetigo herpetiformis to the toxemia of pregnancy has not been determined. 
 Ewing regards it as belonging here. Although heretofore looked upon as a 
 septic condition with metastases to the skin, — death occurring usually from 
 
296 PATHOLOGICAL PREGNANCY. 
 
 pneumonic deposits, — the prominence of vomiting as a symptom is worthy of 
 mention, as suggestive of the autotoxic state. Jaundice in the gravida is a 
 subject of unusual interest. Despite the frequency of hepatic insufficiency in 
 the gravida, icterus appears to be quite rare, and when present due in some 
 cases to mere coincidence, as simple obstruction, etc. 
 
 Clinical Types. — The clinical picture of the toxemia of pregnancy varies 
 greatly with the intensity of the intoxication; but whatever its degree, it resem- 
 bles markedly the various symptoms of hepatic insufficiency in the non-pregnant. 
 The mild, self-limited form, comprising the so-called petty morbidity of the first 
 half of pregnancy, as seen especially in primigravidae, agrees in a measure with 
 so-called " biliousness " or " hepatism." The gastro-intestinal symptoms com- 
 prise nausea, vomiting, various forms of indigestion, anorexia, constipation, etc.; 
 the nervous and cerebral symptoms comprise nervous irritability, apathy, de- 
 pression, alterations of character, hysteria, headache, vertigo, etc. Chloasma 
 and pruritus are common. 
 
 The highest or most intense degree, constituting the so-called acute (including 
 fulminant) toxemia of pregnancy, agrees closely with the profound toxemia which 
 accompanies acute parenchymatous hepatitis and acute yellow or red atrophy 
 of the liver. Vomiting is severe and incessant, and " black vomit " is often 
 present. The cerebrum is profoundly affected. Intense headache occurs. At 
 the outset we usually find increased motor activity manifested by restlessness, 
 anxiety, insomnia, which symptoms pass readily into delirium, maniacal excite- 
 ment, and convulsions. This stage of excitation passes in turn into somnolence, 
 stupor, and coma. In exceptionally severe cases there is no stage of excite- 
 ment, the patient developing stupor and coma at the outset. Excitation and 
 depression appear to alternate in some cases. In acute toxemia the urine almost 
 always shows evidence of greatly disturbed metabolism, nitrogen retention, albu- 
 minuria, presence of leucin and tyrosin, etc., etc., and often of actual renal 
 lesions. The patient nearly always succumbs, and quickly — usually in a few 
 days, and often within forty-eight hours or even less. 
 
 Betw^een the acute and mild forms we find every degree of intensity. The 
 so-called pre-eclamptic state represents a severe but not necessarily pernicious 
 form of toxemia, which very often yields to timely treatment. Similar states 
 occur early in pregnancy and without any connection with eclampsia, and while 
 alarming, may still respond to treatment. A moderately severe toxemia appears 
 prone to attack some one group of organs and set up a peculiar train of symp- 
 toms. Hence we encounter such well-marked clinical syndromes as pernicious 
 vomiting, eclampsia, psychoses, polyneuritis, etc., all of which are considered 
 by themselves. 
 
 Course, Termination, and Sequels. — The acute toxemia is probably in- 
 variably fatal, although recovery seems to have occurred from analogous condi- 
 tions in the non-pregnant. While it tends to destroy the patient rapidly, it has 
 been known exceptionally to persist for months. Death usually occurs within 
 a week after the supervention of the nervous stage, and may result in a few days 
 or even hours. 
 
 Fetal death or emptying the uterus appears to exert no salutary effect; nor 
 is the condition amenable to disintoxicating methods, or to any treatment what- 
 ever. Persistence through and beyond the puerperal state could only occur as 
 a rare exception, death being none the less inevitable. 
 
 The course and termination of subacute toxemia are discussed under Nausea 
 and Vomiting of Pregnancy, Polyneuritis and Eclampsia. 
 
 Mild or benign toxic symptoms often cease spontaneously in the course of 
 
TOXEMIA OF PREGNANCY. 297 
 
 pregnancy itself, and in any case they usually disappear after delivery. Ewing 
 states that in some cases hepatic insufficiency persists after delivery. The 
 commonest actual sequelae -consist of blood changes; paralysis following neuritis ; 
 and occasional nephritis developed from pregnancy-kidney. Ewing believes that 
 puerperal sepsis may often be practically a sequela of the toxemia of pregnancy, 
 through furnishing a strong predisposition to infection. 
 
 Diagnosis. — Here are comprised the recognition of the various degrees of 
 hepatic insufficiency, beginning with the mild or benign types and ending with 
 complete paralysis; the recognition of the various associated blood-states; 
 and, finally, the characterization of the particular clinical type. It is therefore 
 requisite in all suspected cases to make a physical examination of the liver and 
 spleen, and to have the urine analyzed by an expert, with special reference to 
 the detection of unsynthetized nitrogenous bodies, and organic acids. The 
 patient may be tested on alimentary glycosuria. It is, of course, highly im- 
 portant to measure the work of the kidneys. In theory, a blood examination 
 should be valuable, but the simpler tests would not yield much information, 
 while a quantitative or physico-chemical analysis would not be possible in 
 routine work. The nervous system should be examined, because the degree of 
 nervous instability is a factor of importance, and the disposition of the toxemia 
 to attack the higher nerve-centers must be borne in mind. Further, it is im- 
 portant to recognize the evidence of a hysterical element when this is present; 
 also mechanical factors and chance complications. 
 
 Whenever a pregnant woman is taken violently ill, we must always bear in 
 mind the possibility of a fulminant type of the toxemia of pregnancy. It 
 is here that the condition is usually misunderstood; and mysterious cases 
 of sudden death, alleged suicides or accidental poisonings, supposed instances 
 of acute meningitis or of fulminant infectious disease, may perhaps have been 
 examples of the most intense degree of toxemia of pregnancy. To make an 
 exact diagnosis in these cases may not be possible. 
 
 In an ordinary case of the acute type a diagnosis should be made from a 
 physical examination of the liver, and the results of the urinary analyses, together 
 with the rational signs. 
 
 In the rare cases in which the liver appears normal or the urinary examina- 
 tion is negative the diagnosis is of course difficult. In these anomalous cases the 
 patient may appear to suffer from some profound infection or intracranial disease. 
 
 The diagnosis of the subacute types of toxemia will be considered under 
 Hyperemesis, Eclampsia, Polyneuritis, etc. 
 
 Recognition of the milder degrees of toxemia demands no special considera- 
 tion. Whenever a woman vomits persistently her urine should be examined 
 for evidences of faulty metabolism, as shown by the percentages of total nitro- 
 gen excreted as urea nitrogen, ammonia nitrogen, kreatinin nitrogen, uric acid 
 nitrogen, and tmdetermined nitrogen. A toxemic state is often first indicated 
 by departures from the normal standard, as high ammonia nitrogen percentage 
 or undetermined nitrogen percentage of the total nitrogen. 
 
 Mere diminution of the percentage of urea does not signify nitrogenous re- 
 tention, for the total nitrogen is distributed among the urea, ammonia, kre- 
 atinin, uric acid, amino-acid, etc. ; and while under normal conditions over 80 
 per cent, of the nitrogen occurs in the form of lirea, certain urines often con- 
 tain very large percentages of ammonia-nitrogen and correspondingly low ones 
 of urea. Diet and elimination of nitrogen by the bowel must always be con- 
 sidered in this connection. Increased percentage of ammonia-nitrogen is not 
 pathognomonic of toxemia of pregnancy, but may be viewed with suspicion. 
 
298 PATHOLOGICAL PREGNANCY. 
 
 My experience embraces 62 urinalyses for the nitrogen partition in 24 
 patients, and does not permit me to formulate rules for a guide to the diag- 
 nosis of an impending or existing pregnancy toxemia. However, in most of 
 my cases examined, faulty metabolism, as determined from urinalyses of 
 twenty-four hour specimens of urine for total nitrogen and its coefhcients, 
 coexisted with clinical symptoms of toxemia. 
 
 Prognosis. — This is good in the benign forms of toxemia. In the acute 
 and fulminant types the prognosis is nearly hopeless, since the mortality has been 
 almost universal. For the prognosis of eclampsia, hyperemesis, etc., see subse- 
 quent sections. Richard C. Norris* -is inclined to regard some cases of sudden 
 death in the puerperium as due to cardiac failure induced by the direct action 
 of the autotoxic blood-state upon the cardio-vascular system. 
 
 Treatment. — As for prophylaxis, a woman who seems to suffer much con- 
 stitutional reaction during menstruation should be carefully watched during 
 gestation. Charcot states that a functionally incompetent liver is very likely 
 to be inherited ; therefore a woman whose ancestors and kindred show a marked 
 tendency to "hepatism" would run more risk in becoming pregnant than one 
 without this ancestry. Finally, a woman in whom symptoms of toxemia appear 
 to persist during the period of lactation should by all means avoid a second con- 
 ception until complete recovery has occurred. For other resources read sec- 
 tion on Etiology. 
 
 The curative treatment demands a careful study of the symptoms in all cases, 
 and prompt action in most. Mild toxemia, so called, requires only expectant 
 management. 
 
 Despite the apparently hopeless outlook in acute toxemia, I strongly recom- 
 mend in all cases the same general line of treatment as that I set down for the 
 Preventive Treatment of Eclampsia. (See pages 308 and 309.) In addition 
 to the exclusive milk diet, and the stimulation of the action of the liver, 
 bowels, kidneys, skin, and lungs, I have found repeated colonic irrigation and 
 infusion, and intravenous infusion of the decinormal saline fluid, valuable. 
 On account of the diminished alkalescence of the blood, alkalies are indicated 
 in theory, as they are in diabetic coma, in which state they have produced some 
 benefit. Bearing in mind that the hepatic lesion may in a given case be due in 
 part to a bacillus, methylene-blue, which is eliminated by the bile, should be 
 of value as an antiseptic. 
 
 My views upon the evacuation of the uterine contents are the same here as 
 in the Preventive Treatment of Eclampsia. 
 
 Conclusion. — It will be asked, no doubt, "Why devote so much space in a 
 text-book to a condition like the acute toxemia of pregnancy, which apparently 
 is rare, and can seldom be foreseen, and, thus far, has almost resisted treatment? " 
 My answer is, that it represents a phase of our knowledge which is in its infancy, 
 and a subject which will, in my belief, come in time to throw light on many 
 dark places in obstetrics. Acute toxemia of pregnancy is not as rare by any 
 means as is generally believed, and is a most insidious affection when it does 
 occur, masking itself, as it does, under various clinical pictures. 
 
 If unrecognized, it may lead to a suspicion of poisoning, suicide, or some other 
 type of preventable death. We might, in a general way, compare the recog- 
 nition of this state with the 'discovery of ptomaines and ptomaine poisoning, 
 in regard to practical significance. Again, it may some time be possible to fore- 
 see, prevent, and cure this condition when not of the fulminant type. Recovery 
 
 * " Effects of the Toxemia of Pregnancy upon the Cardio-vascular System," "Amer. 
 Jour. Obstet.," July, 1903, pp. 31, 104. 
 
NAUSEA AND VOMITING IN THE PREGNANT WOMAN. 299 
 
 is not uncommon after acute phosphorus-poisoning, thereby showing the regener- 
 ative power of the liver. 
 
 2. Nausea and Vomiting in the Pregnant Woman. — This subject is considered 
 under the toxemia of pregnancy largely because in fatal cases hepatic lesions 
 of the same character as those which occur in eclampsia and acute yellow 
 atrophy of the liver may usually be found; also because severe vomiting is a 
 prominent symptom of many toxemias. If vomiting in the pregnant is fre- 
 quently spoken of as hysterical in character, it must be borne in mind that 
 this refers only to the clinical expression of the condition. 
 
 (i) Simple (So-called Physiological) Vomiting. — Slight nausea, with 
 or without vomiting, occurs in about one-half of all pregnancies, and in the 
 vast majority of primiparas; the symptom appears about the end of the first 
 month, and is usually associated with perversions of taste. There may be 
 general anorexia, repugnance to certain articles of diet, and unnatural cravings 
 for others not usually appetizing. Considered in their totality, symptoms refer- 
 able to the digestive tract are almost universally present in pregnancy; those 
 who escape nausea or perversions of taste and anorexia may suffer from hyper- 
 orexia or bulimia. These symptoms usually persist until the middle of the 
 fifth month, when they subside spontaneously, and appetite and normal tastes 
 return. 
 
 In their simplest expression the nausea and vomiting of pregnancy bear a 
 notable resemblance to the morning-vomiting of the alcoholic subject, appearing 
 as a rule upon rising from the recumbent position. Retching may be the only 
 active symptom, or actual vomiting of mucus, gastric juice, or biliary matter 
 may occur. The woman is usually able to eat breakfast, and has no further 
 gastric disturbance during the day. In rare instances the nausea and vomit- 
 ing occur in the latter part of the day or during the night. In the next higher 
 degree the woman vomits during or after the meal. She is, however, usually 
 able to continue eating and to retain the food ; so that there is no real interfer- 
 ence with nutrition. 
 
 In a still higher degree nausea is more than a momentary affair, and persists 
 for several hours, often accompanied by ptyalism and distress in the epigastric 
 region; vomiting is then slow to occur, and is much more distressing than usual. 
 In all degrees up to this point there is no necessary interference with nutrition, 
 and no absolute refractoriness to treatment. " 
 
 (2) Hyperemesis. — When vomiting is sufficiently persistent or distressing 
 to demand active treatment, the term hyperemesis is employed to distinguish 
 it. In a woman suffering from this degree of vomiting there is a tendency to 
 aggravation of the symptoms and interference with nutrition. 
 
 Vomiting of pregnancy sometimes pursues an anomalous course, without 
 regard to its severity. Thus, it may begin immediately after conception, as if 
 it were an expression of suppressed menstruation. The ordinary appearance of 
 vomiting coincides with the period of the second (suppressed) menstrual period. 
 The usual time of cessation of vomiting corresponds to "quickening" of the 
 fetus. In a few cases the disappearance of vomiting may be succeeded by 
 diarrhea. It has also been noted that a strong mental impression about this 
 time will cause the sudden cessation of vomiting. In a small proportion of 
 cases the latter symptom is prolonged to term, and in another series of cases 
 the gastric disturbances set in about the middle of pregnancy. This relation 
 to suppressed menstruation, with the occasional resemblance to the morning 
 vomiting of alcoholic subjects, suggests the presence of a toxic element, even 
 in so-called physiological and benign degrees of vomiting; as does also the 
 
300 PATHOLOGICAL PREGNANCY. 
 
 coexistence of numerous symptoms mentioned under Mild Toxemia of 
 Pregnancy. (See page 296.) 
 
 Most standard authorities, including gastro-intestinal specialists, continue to 
 refer benign vomiting of pregnancy to uterine irritation, due to compression of 
 the uterine nerves by the growing uterus in general, added to abnormal uterine 
 distention, malpositions, cervicitis, etc., in particular. Reflex vomiting some- 
 times occurs in pelvic affections of the non-pregnant. But it is generally ad- 
 mitted that an increased nervous excitability furnishes a predisposition ; and we 
 must not forget that this exalted sensibility, wherever found, is itself attributed 
 by many to an autotoxic state of the same nature as that which is produced 
 by nervous exhaustion. Quite recently Dr. M. Knapp, of New York, has denied 
 the existence of reflex vomiting. 
 
 Treatment. — Benign vomiting may be relieved by simple measures, such as 
 breakfast in bed before assuming the erect posture; the use of concentrated 
 liquid food; anesthesia of the stomach by a few drops of laudanum; readily 
 digestible solid food; sparkling wines, or alkaline effervescent waters; aromatics; 
 cracked ice, etc. After eating, recumbency should be maintained. Recent 
 clinical experience has caused me to look with suspicion upon even benign 
 vomiting, as the expression of a mild toxemia of pregnancy, and to treat it 
 accordingly, namely, by a restricted diet; stimulating the action of the liver, 
 bowels, skin, and lungs, and by colonic irrigation and infusion. 
 
 (3) Incoercible or Pernicious Vomiting. — These terms are applied re- 
 spectively to vomiting which is rebellious to all treatment, and that which is in 
 any way a menace to life or which has a grave prognostic significance. Several 
 entirely different conditions may be included here. Thus, in the gravida, as in 
 the non-gravida, vomiting may be purely symptomatic in character, although 
 doubtless aggravated and given a peculiar character through the gravid state, 
 which predisposes the woman to nausea and vomiting. Thus, these symptoms 
 may be due to intercurrent gastritis and other severe organic diseases of the 
 stomach; the passage of gall-stones, intestinal obstruction, peritonitis, menin- 
 gitis, etc., etc. Symptomatic vomiting will be referred to again under " Diag- 
 nosis." 
 
 Essential vomiting of pregnancy is of two distinct types : 
 
 (a) Autotoxic Type is a manifestation of the toxemia of pregnancy and is 
 accompanied by other severe symptoms of that condition, chiefly headache 
 motor cortical excitement (agitation, restlessness, insomnia, convulsions, deli- 
 rium), or apathy, stupor, and coma. Vomiting in this condition is violent, 
 incessant, and characterized in its later stages by hematemesis, the vomited 
 matter having a coffee-grounds appearance (black vomit). The patient does 
 not perish of vomiting, however, — i.e., as a result of inanition or exhaustion, — 
 but of the profound toxemia as affecting the blood and higher nerve-centers. 
 The vomiting, however, may be termed pernicious, because of its grave prog- 
 nostic significance, especially when " black vomit " is present. In this type, 
 unless recovery can be brought about, death usually occurs within two or three 
 weeks at the most, and often within a few days. Exceptionally, the condition 
 may persist for many weeks, so that transitions occur between this and the 
 following type, and in a certain number of cases the two are indistinguishable, 
 save when in case of death an autopsy clears up the situation. The toxic 
 nature of a case is then shown by evidences of the hepatic lesions of the 
 toxemia of pregnancy. 
 
 (b) Non-toxic Type. — The other type of essential vomiting of pregnancy is 
 known as the non-toxic or inanition type. Death occurs here purely from star- 
 
NAUSEA AND VOMITING IN THE PREGNANT WOMAN. 301 
 
 vation, the patient living for a number of weeks, during which period the prog- 
 nosis depends greatly on the ability of the medical attendant to control the 
 vomiting. 
 
 The inanition type of vomiting, including certain cases in which the toxemia 
 of pregnancy cannot be fully excluded, is so well known as to present certain 
 classical features. 
 
 Etiology. — A hysterical or neurotic substratum is often in evidence through 
 the numerous spontaneous and induced stigmata and symptoms of these condi- 
 tions. Reflex excitability is also a powerful factor in determining the 
 paroxysms of vomiting, and we therefore sometimes find evidences of a causal 
 connection between various lesions and malpositions of the uterus and the 
 emesis. 
 
 Symptoms. — For convenience, these are usually divided into three stages. 
 First stage: A condition beginning as hyperemesis — usually in the first two 
 months, but exceptionally during the sixth or seventh month — soon becomes 
 incoercible by ordinary medical measures, and the complete rejection of the 
 ingesta brings about more or less emaciation. During this stage the symptoms 
 may often be controlled by special treatment, or may even cease spontaneously. 
 Second stage: The pulse becomes small and feeble, the skin hot and dry, con- 
 stipation is extreme, and albuminuria appears with casts. There are progress- 
 ive emaciation and weakness. This stage may be prolonged for weeks, and at 
 any time during this period induction of labor or fetal death may save the 
 patient's life, although in a certain proportion of cases emptying the uterus is 
 without effect. Third stage: This period indicates that the patient has become 
 too weak to rally, even if vomiting ceases, which event often occurs. Pre- 
 monitions of death are numerous, and to these are superadded cerebral symp- 
 toms — headache, delirium, stupor, etc. Death usually results from coma. 
 These cerebral symptoms have no connection with the toxemia of pregnancy, 
 but are connected with progressive inanition and possibly with the constant 
 waste of gastric juice, which in animals is known to produce death amid similar 
 symptoms. 
 
 Diagnosis. — We must be certain that the woman is actually pregnant, 
 bearing in mind that pernicious vomiting may begin almost as soon as concep- 
 tion itself; and also that the emesis is not the result of an organic disease of 
 the stomach, brain, kidneys, pancreas, intestines, peritoneum, etc. We must 
 then exclude the toxemia of pregnancy, which is by no means easy in the milder 
 forms of the latter, and is doubtless often impossible at the outset. Hyper- 
 emesis, associated with the so-called benign or petty manifestations of toxemia 
 (see p. 296), need not be toxic itself. As a general rule, toxic vomiting is 
 associated with other severe symptoms of toxemia. 
 
 Prognosis. — This is good rather than bad if proper treatment is instituted 
 sufficiently early. If a toxic element is present, the prognosis depends in a 
 large degree upon the early termination of pregnancy. Under other circum- 
 stances artificial abortion is practised only as a last resort. A severe first 
 stage, passing rapidly into the second stage, is a rather unfavorable prognostic; 
 and after the second stage is reached a marked daily loss of weight — over 10 
 ounces (300 c.c.) — and the presence of the diazo-reaction have a serious prog- 
 nostic value. The prognosis for the fetus at or near term is relatively good. 
 
 Treatment. — Although I am not convinced that all cases of pernicious vomit- 
 ing of pregnancy have an autotoxic origin, still I believe that a large proportion 
 of these cases are due to hepatic insufficiency and toxemia, and that the best 
 results will be obtained by treatment directed to this cause. Hence while 
 
302 PATHOLOGICAL PREGNANCY. 
 
 not ignoring entirely the Value of hygienic, dietetic, medicinal, and even local 
 treatment, I advise that treatment be promptly directed to the correction of 
 an hepatic insufficiency and toxic blood-state, whether the clinical picture of 
 the toxemia of pregnancy is present or not. Regulate the diet, and if neces- 
 sary, nourish by rectal feeding; stimulate the liver and bowels by a full dose 
 of calomel, and secure the action of the drug by high enemata of sulphate of 
 magnesia; secure free action of the kidneys by diuretics, the free ingestion of 
 plain water or colonic infusion of decinormal saline solution; cause the skin to 
 act with hot packs and use oxygen freely for the lungs. Frequently repeated 
 colonic irrigation and infusion are most valuable to relieve the toxemia or hepatic 
 insufficiency and the intense thirst so often present. Likewise in severe cases 
 intravenous infusion of the saline solution will prove valuable, and it should 
 be resorted to early and repeated if necessary. My views upon the evacuation 
 of the uterine contents are the same here as in the Preventive Treatment of 
 Eclampsia. 
 
 The hygiene of the patient should be carefully regulated; kind treatment and 
 pleasant surroundings are of the greatest value; sexual intercourse is to be pro- 
 hibited; in grave cases the patient should remain in bed and perfect quiet and rest 
 be enjoined. Many cases can be improved if the patients can be made unconscious 
 of the fact of swallowing, either by spraying the fauces with a solution of cocain or 
 bv the use of the esophageal tube. Liqmd food, such as milk and lime-water, eggs, 
 beef -juice, koumyss, or clam-broth, should be tried; and if moderate quantities 
 are rejected, the food should be given in teaspoonful doses at short intervals; 
 at times it is most acceptable if given with cracked ice, in other cases very hot 
 milk or broths are retained. Somatose and panopepton are of value. 
 
 Medicinal. — Among the medicines that are useful are the oxalate of cerium, 
 in doses of from five to ten grains (0.3 to 0.6 gm.), with or without the subnitrate 
 of bismuth; iodine (Churchill's tincture), one or two drops well diluted; menthol 
 and cocain, either as a spray or internally, in small doses ; carbonic-acid water, 
 in small quantities or ad libitum; the same with the addition to each siphon of a 
 drachm (4 gm.) of the bromide of potassium; tincture of nux vomica in ten-drop 
 doses for gastric catarrh, and pepsin with diluted muriatic acid after food. Klein- 
 wachter uses creosote, 15 minims (i gm.) three times a day, combined with citrate 
 of caffein and gentian, as an intestinal antiseptic. The inhalation of oxygen 
 is serviceable even early in the disease. Nerve sedatives are sometimes very 
 useful; the bromide of potassium or of sodium, with or without chloral, may be 
 given in full doses per rectum. Codein may be given by the mouth or morphin 
 hypodermatically; the latter may be given en dermatic ally over the epigastrium 
 when local tenderness exists. Other remedial agents are counter-irritation 
 or the ether spray over the epigastrium, or the appHcation of ice to the cervical 
 vertebrae. Cases of success by the use of the electric current have been reported, 
 the faradic current being passed through the stomach. Believers in the hysteri- 
 cal theory apply the measures which are most efficacious in the treatment of 
 that affection. Thus, the woman may be separated from her friends and relatives 
 and placed in a sanitarium. Sometimes the mere threat of isolation has pro- 
 duced a cure. 
 
 Local. — Malpositions of the uterus, and engorgement or hypertrophy of the 
 cervix", should be corrected; erosions may be touched with a 10 per cent, solu- 
 tion of silver nitrate or with pure carboHc acid ; the apphcation of cocain to the 
 cervix and the vault of the vagina has been reported to be successful in some 
 cases. I have never found it of value. Dilatation of the internal os with a 
 glove-stretcher dilator, so as thoroughly to rupture the circular fibers at this 
 
ICTERUS. 303 
 
 point, is occasionally a successful procedure. At the same time any endo- 
 trachelitis, or erosions of the portio vaginalis, should be attended to. I 
 have found that attention' to these matters has apparently effected a cure. 
 I have dilated the internal os in primigravidas, curetted the cervical canal, 
 scraped the cervix itself free from erosions, applied pure carbolic acid to the 
 cervix and canal, and relieved the symptoms, without interrupting pregnancy, 
 in a number of cases given up as hopeless and sent to the hospital to have labor 
 induced. The finger will occasionally serve as a dilator, and in every case the 
 greatest care must be used not to rupture the membranes. 
 
 Induction of Labor. — This will become " necessary when there appears no 
 other way of saving the mother, but we must never wait too long before resort- 
 ing to this means, for although the vomiting always stops with the evacuation 
 of the uterus, the woman may die from exhaustion. 
 
 Rectal Feeding. — This may become necessary, and should not be delayed too 
 long. The physician must ever bear in mind that rectal alimentation has its 
 time limit, that it cannot be continued for weeks, as some suppose; for during 
 this time the patient grows progressively weaker, and the induction of labor is 
 finally resorted to, too late to save the mother's life. Rectal feeding has been 
 attended with variable results in the vomiting of pregnancy. Most commonly 
 the injections have consisted of beef -tea, albumin water, defibrinated blood, 
 brandy, milk, and peptones. A few drops of laudanum are sometimes added. 
 Rectal injections must be given in small quantities, not more than five or six 
 ounces, for fear of causing local irritation. At times the mere efforts of vomiting 
 are so great as to cause the expulsion of the enema. The rectum should first be 
 cleansed by the injection of a quart of water containing a teaspoonful of salt. 
 One hour after the resulting evacuation the first rectal feeding should be 
 given. Any kind of a syringe may be connected with a soft-rubber rectal tube 
 and 'the nutriment thrown slowly into the bowel. The tube is then withdrawn 
 and the patient instructed to lie quietly, in order that the enema may be retained. 
 Three to five nutrient injections of from five to ten ounces may be given daily. The 
 following substances are recommended for feeding: (i) Commercial peptones and 
 propeptones, two or three ounces in each injection. Commercial beef-juices. (2) 
 Milk and egg, a sort of eggnog, containing six or seven ounces of milk and one 
 or two raw eggs, a teaspoonful of powdered sugar, a large pinch of salt, and a 
 tube of Fairchild's pancreatin. (3) Pancreatized meat, five ounces of minced 
 raw beef, one or two of fresh pancreas, an ounce of butter, and six ounces of water, 
 all well compounded. These enemata should be given in rotation. In addition, 
 the body receives a supply of water by daily rectal injection of saline infusion.* 
 Pancreatized milk made with Fairchild's pancreatin may be used, also defibrin- 
 ated blood. Flint's formula — milk 2 ounces (60 c.c), whisky half an ounce 
 (15 c.c), with one half of an egg — may be used. Leube's pancreatic meat 
 emulsion is a good preparation: 3 to 10 ounces (90 to 300 c.c.) of very finely 
 chopped beef, one-third the quantity of minced pancreas (pig or ox), with the 
 addition of lukewarm water and mixed in a mortar to the consistency of a thick 
 soup. After each rectal injection the patient should retain the recumbent posi- 
 tion on the left side with hips raised, for a time, while the nurse supports the 
 anal region with a towel. Posenheim's formula is: glucose half an ounce; 2 
 €ggs; peptone i to 2 drachms, and half an ounce of emulsion of cod-liver oil. 
 Six per cent, solution of cocain should be applied to painful hemorrhoids. 
 
 3. Icterus. — Icterus being but a symptom and very infrequent as a com- 
 plication of the toxemia of pregnancy, I do not give it special consideration. 
 * Einhom: "Post-Graduate," New York, July, 1900. 
 
304 PATHOLOGICAL PREGNANCY. 
 
 Frequent references to the subject will be found under " The Toxemia of 
 Pregnancy." 
 
 4. Eclampsia. — See a'so Toxemia of Pregnancy. — Definition. — By the terms 
 eclampsia, puerperal eclampsia, and puerperal convulsions, is meant, in modern 
 medicine, an acute morbid condition, making its advent during pregnancy, labor, 
 or the puerperal state, which is characterized by a series of tonic and clonic con- 
 vulsions, affecting first the voluntary and then the involuntary muscles, accom- 
 panied by complete loss of consciousness, and ending in coma or sleep. The 
 disease may eventuate in death or recovery (Charpentier). Eclampsia may be 
 gestational, intra-partum, and post-partum, or puerperal eclampsia proper. 
 
 Frequency. — Eclampsia occurs most often in the latter part of gestation, 
 less often in labor, and least of all in the puerperium. The estimation of 
 its frequency has been variously tabulated as i in 500 pregnancies, i in 250 
 to 300, I in 350 to 500 — a variation of from 2 per cent, to 4 per cent. The com- 
 plication is stated to appear in i per cent, of all cases of albuminuria of preg- 
 nancy. Schauta believes it to occur in 25 per cent, of all pregnancies. I found 
 in 1200 cases of confinement, 800 of which were out-patient cases, that eclampsia 
 occurred in 7 cases, or 0.58 per cent., or i in 171 cases. In another series of 
 1000 hospital cases it occurred in 3 cases, or 0.30 per cent., or once in 333 cases. 
 Of the 10 cases, 8 occurred at the tenth month, i at the sixth, and i at the fifth. 
 
 Etiology and Pathology. — Eclampsia may be regarded as due to the auto- 
 toxic state of pregnancy as manifested chiefly in the latter months. For some 
 reason, at present unknown, the autotoxic state has a special tendency at that 
 period to attack the renal organs, and lead to the so-called kidney of pregnancy, 
 which in its essential form is a temporary fatty infiltration of the parenchyma 
 of that organ that disappears after delivery. In higher degrees of toxemia the 
 kidneys undergo changes analogous to those of the liver in acute parenchymatous 
 hepatitis and acute yellow atrophy. (See Toxemia of Pregnancy, p. 292.) In 
 rare instances pregnant women who are suffering from antecedent Bright 's 
 disease develop uremia before delivery, this naturally simulating ordinary 
 eclampsia' (see "Diagnosis"); but this is the exception. Authorities who are 
 only familiar with autopsy findings deny the existence of an essential pregnancy 
 kidney, for in fatal cases we see the more severe lesions — acute parenchymatous 
 nephritis with epithelial necrosis, renal atrophy, chronic nephritis in various 
 degrees, etc. But the existence of an essential pregnancy kidney is shown by 
 the fact that something like 75 per cent, of all cases of eclampsia recover, the 
 urine, shortly after delivery, showing no abnormalities. 
 
 The autotoxic state when manifested late in pregnancy, as the forerunner 
 of eclampsia, is not, as a rule, of the higher degrees; but the alterations present 
 in the pregnancy kidney, while not destructive, are sufficient to impair the renal 
 functions, so that a vicious circle is established in which the condition of the 
 blood and metabolism, by their action upon the kidney, lead to a reaction on 
 the part of the latter upon the former. Hence, ordinary eclampsia may be 
 regarded as a complicated affair — a moderately severe toxemia plus renal in- 
 adequacy. When the toxemia is of such severity as to cause marked destruc- 
 tive lesions of the kidney, death rapidly supervenes — not from the urinary 
 suppression, but from the intense basic toxemia through its immediate action 
 upon the blood-state and the cerebral cortex. The conditions are not essentially 
 different from those in which the patient dies of fulminant toxemia without 
 renal complications of any sort. 
 
 In the majority of cases of eclampsia, in which we feel sure of the existence 
 of the pregnancy kidney, it is stated that hepatic lesions are almost invariably 
 
ECLAMPSIA. 305 
 
 present, although these may be minimal and demonstrable only with the micro- 
 scope. (See Toxemia of Pregnancy, p. 291.) However, the majority of these 
 cases do not come to autopsy. In higher and usually fatal degrees of toxemia, 
 when the renal lesions are presumably severe and destructive, the hepatic 
 lesions may or may not be in proportion to the toxemia. In rare instances the 
 kidneys may be practically destroyed with little or no evidence of hepatic 
 lesions. 
 
 To sum up, the pathological findings of eclampsia necessarily embrace those 
 of the basic autotoxic state, plus the alterations incidental to the pregnancy 
 kidney. The cerebral lesions — hyperemia, oedema, thrombosis, hemorrhages — 
 are doubtless aggravated by the repeated convulsions and perhaps by the heroic 
 remedies demanded by therapeutic indications. This may also be true of the 
 myocardial degeneration and bronchopneumonia, which some pathologists 
 include among the autopsy findings. 
 
 Diihrssen and others describe a mild type of eclampsia, without any evidences 
 of toxemia or urinary abnormalities. They term this reflex eclampsia. 
 
 The predisposing and exciting causes of eclampsia enumerated in the older 
 text-books have little force to-day. We are in complete ignorance concerning 
 the tendency of the disease to develop late in pregnancy, in connection with 
 primiparity, prematurity, twin gestation, and the like; and are equally ignor- 
 ant as to reasons for the frequency of post-partum eclampsia (18 per cent.), 
 and for the persistence of convulsions after emptying the uterus in something 
 like 40 per cent, of cases. In regard to exciting causes they do not differ from 
 those in convulsive disorders in general, where reflex excitability is necessarily 
 present in high degree. 
 
 Symptomatology . — The symptoms of eclampsia may be considered under 
 the prodromal period, or pre-eclamptic state, and those occurring during the 
 attack. In the latter there are three stages: (i) invasion; (2) tonic and clonic 
 convulsions; (3) coma. Prodromal period, or pre-eclamptic state: The symp- 
 toms of this stage are very important, for they offer a certain warning of an 
 impending attack. There may be, as in epilepsy, a well-defined aura. After 
 this, or even without it, there may be headache, tinnitus aurium, visceral dis- 
 turbances, such as dizziness, amblyopia, amaurosis, epigastric pain, digestive 
 and nervous disturbances, and a feeling of general debility. These are fairly 
 constant in about one-fourth of all cases of eclampsia. At times there may 
 be symptoms of involvement of the brain, stupor or insomnia, vertigo, vomiting, 
 mental excitement, or despondency. These may all disappear, in which case 
 there is a return of appetite, a more abundant perspiration and diuresis, and 
 the patient falls into a refreshing sleep. Generally, however, the result is 
 not so favorable, and the premonitory signs, or pre-eclamptic state, after last- 
 ing for several hours or days, give place to those of the stage of invasion. There 
 is convulsive twitching of the lids, the eyes stare, and the pupils, which were 
 at first contracted to a pin-point, are widely dilated. During the attack there 
 is total insensibility to light. The face is cyanotic, and there is rapid and 
 convulsive jerking of the muscles about the alae of the nose and the mouth. 
 The mouth is contracted to one side, there are rotation of the head and rolling 
 up of the eyeballs. This is followed by the stage of tonic and clonic convul- 
 sions. The movements, which at first concerned only the head, now extend 
 to the neck, trunk, and extremities, very infrequently, however, passing to 
 the lower extremities. The neck is bent backward, and at last, together with 
 the back, forms an opisthotonic curve; there are extension and rigidity of 
 the arms, clenching of the hands, with the thumbs in the palms, and flexing 
 20 
 
306 
 
 PATHOLOGICAL PREGNANCY. 
 
 of the knees on the abdomen. The respiratory muscles, including the dia- 
 phragm, are involved by the tonic convulsions. Although the muscles of the 
 chest are firmly contracted, there may be one or two spasmodic respirations 
 at the height of the paroxysm. The tongue partly protrudes and, since it 
 is often bitten, the saliva, which is frothy, is colored with blood. There is 
 complete loss of sensation and of consciousness. The duration of the tonic con- 
 vulsions is from ten to twenty seconds, and they are followed by clonic spasms. 
 The clonic convulsions, as in the first of the attack, begin in the face, which 
 becomes horribly distorted, and then extend over the body. Irregular and 
 noisy respiration takes place, there are rapid opening and closing of the jaws, 
 and the tongue may be again bitten. The patient may have to be held in 
 bed, but generally the body retains its previous position. Eclampsia closely 
 follows epilepsy in many clinical features. Thus, there are overlapping (sub- 
 intrant) convulsions, a status convulsivus or continuous paroxysmal state (status 
 epilepticus, status eclampticus), and an exhaustion-paralysis or temporary loss 
 
 Fig. 470. — Segment of Liver showing TTemorrhagic Hepatitis in Eclampsia (Actual 
 Size). — (From a specimen in the Pathological Laboratory of the Cornell University Medi- 
 cal College.) 
 
 of motor power in the convulsed muscles in both diseases. At the end of the 
 attack full, labored, and stertorous respiration occurs. In one or two minutes 
 follows the stage of coma. The duration of this period is about half an hour. 
 Consciousness and sensation are slow to return. If a favorable issue is to take 
 place, the patient falls into a deep sleep, and awakes to ask confusedly what 
 has happened. After this stage mothers have denied their offspring born dur- 
 ing eclampsia. Rarely there is but a single attack, and as a rule a number 
 occur at varying intervals. If the seizures cannot be controlled, and death 
 is inevitable, there are a progressive rise of temperature to 104° F. (40° C.) 
 or more, and a small, rapid, wiry pulse. A semi-unconscious state follows, 
 and death may occur during this period, or in the course of an attack, from 
 pulmonary oedema, cerebral congestion, hemorrhage, or exhaustion. Patients 
 who have survived the disease proper may die during the puerperium of some 
 intercurrent affection. 
 
 The Effect upon the Fetus and Labor. — One attack is often sufficient to kill the 
 
ECLAMPSIA. 307 
 
 child. In twin pregnancy the death of one or both children may occur. How- 
 ever, the child may survive several attacks. Winckel notes an interesting fact, 
 that if the fetus is killed- and pregnancy not interrupted immediately, labor 
 both in its onset and course may be free from convulsions. In view of the 
 shock, nervous disturbance, and uterine contractions, there is apt to be an 
 abrupt termination of pregnancy. If the attack takes place in labor, there 
 is increase of the pains from general muscular excitement, so that the child 
 may be born while the physician is engrossed with the care of the mother. 
 There is involvement of the kidneys in about two-thirds of the cases of eclamp- 
 sia. In 84 per cent, the urine contains albumin, varying in quantity even 
 to 2.5 per cent., or higher. There are an increase of albuminuria with each 
 attack, and a rapid decrease after its subsidence. As a prodrome this is im- 
 portant. The urine generally contains sugar and formed elements, red and 
 white corpuscles, as well as casts; that is, there are present symptoms of 
 acute congestion of the kidney. 
 
 Diagnosis. — Convulsive affections other than typical eclampsia may occur 
 during pregnancy. Some of these stand in some near relationship to eclampsia, 
 while others do not. Thus, acute toxemia of pregnancy may be associated with 
 incidental or terminal convulsions, which may or may not resemble those of 
 typical eclampsia. When the resemblance is marked, yet without evidences of 
 renal disorder, the condition is termed cholemic eclampsia, because accompanied 
 by the picture of acute hepatic insufficiency. Atypical convulsions may or 
 may not accompany the most acute type of acute toxemia of pregnancy (p. 296). 
 Finally, in women with nephritis who become pregnant, true uremic convulsions 
 may occur, although the reverse is usually the case. Typical eclampsia, due to 
 secondary renal lesion, is readily distinguished from the other forms enumerated 
 by the pre-eclamptic stage, the progressive character of the convulsions with 
 increasing temperature, the evidences of renal impairment, the response to 
 proper treatment, etc., etc. There is probably no guide, nor is there any great 
 necessity for differentiation between atypical eclampsia and the convulsions due 
 essentially to the toxic state of pregnancy, for the conditions are closely alHed. 
 Uremia is distinguished from eclampsia chiefly by the absence of fever, and also 
 by a history of Bright 's disease; but the distinction is not of great importance, 
 for the treatment of the two conditions is practically the same. It must be 
 borne in mind that eclampsia without convulsions may occur, i. e., evidences of 
 pregnancy-kidney, pre-eclamptic state, oedema, retinitis, etc., may not be fol- 
 lowed by convulsions, but instead pass directly into stupor. Such a condition 
 is extremely rare, but not difficult to understand when we bear in mind that in 
 some cases of atypical eclampsia very few convulsions occur. 
 
 Of convulsive states which may simulate eclampsia without being allied to 
 it, are epilepsy and hysteria major, on the one hand, and the convulsions of 
 acute intercurrent diseases {meningitis, for example) on the other. Epilepsy 
 and hysteria should not be accompanied by toxemic phenomena, and the dis- 
 tinction ought to be readily made. The status epilepticus and status hysteri- 
 cus might, by reason of their continuous convulsions, stupor, high temperature, 
 etc., readily simulate eclampsia, although the history of the case should clear 
 up the obscurity. The convulsions of meningitis are local, while those of 
 eclampsia are general. Apoplexy rarely occurs in pregnancy. There are no 
 prodromes. Coma quickly follows. 
 
 Prognosis. — In 10 cases of eclampsia occurring among 2200 cases of labor I 
 found the maternal mortality was 2 cases, or 20 per cent. Of the viable chil- 
 dren, all lived. Puerperal eclampsia is still a very grave affection. Many statis- 
 
308 PATHOLOGICAL PREGNANCY. 
 
 tics show, even at the present time, a. maternal mortality of 30 per cent., while 
 that of the child reaches 50 per cent. There is imminent danger of a seizure 
 in the pregnant woman who shows marked symptoms of toxemia, albuminuria, 
 and the quantity of whose urine is gradually decreasing. The danger becomes 
 more pronounced in proportion to the increase of the albumin, the decrease of 
 the water excreted in the twenty-four hours, and the departure of the nitrogen 
 compounds of the urine from their normal standard indicates faulty metabolism. 
 As these conditions are reversed, to a corresponding extent the peril becomes 
 more remote. The amount of urea excreted is a more important factor in prog- 
 nosis than that of albumin, as has been clearly shown by Bouchard and Davis. 
 Davis discovered that the symptoms of toxemia decrease with the increase of 
 urea. The gravity of the prognosis increases in proportion to the early stage of 
 pregnancy at which the convulsion occurs. It has been demonstrated by Schauta 
 many times that all derangements, ev^en those of renal origin, subside after the 
 child's death; thus the prognosis will improve in repeated attacks in proportion to 
 the early occurrence of its death. Profuse sweating, especially of early occur- 
 rence, is a favorable sign. The prognosis becomes most unfavorable when 
 the seizures take place in pregnancy, when they follow one another rapidly^ 
 when they become gradually more pronounced, and when they have existed 
 for an extended period before assistance can be obtained. Mortality has been 
 decreased by chloroform treatment in these cases. Briefly, the prognosis is 
 favorable when: (i) The attacks are far apart and not severe. (2) The child 
 perishes. (3) The patient has conscious intervals between the attacks. (4) The 
 quantity of albumin is small. (5) Decrease of temperature occurs. (6) The 
 seizures take place in advanced labor or during the puerperium.. Prognosis 
 is not favorable when opposite conditions exist. 
 
 The vitality of a child born of an eclamptic mother is below normal, and it 
 often dies in the first twenty-four hours. The mother may succumb from ex- 
 haustion; cerebral apoplexy due to forcible rupture of the vessels; asphyxia 
 caused by spasm of the glottic and respiratory muscles ; oedema of the lungs 
 or of the brain, following a serous effusion from overcharged capillaries; con- 
 gestion of the brain, in which coma is the chief symptom; or cardiac paralysis. 
 The last, when taking place during the general convulsion, is followed by instant 
 death. The child's death may be due to maternal convulsions and the pres- 
 sure resulting therefrom; asphyxia, caused by compression or oedema of the 
 placenta, or an extreme amount of carbon dioxide in the blood; or it may 
 be by direct poisoning by the toxins in the maternal circulation. 
 
 Treatment. — The best etiological theory of the present day, although it may 
 not be correct in all details, is that eclampsia is due to toxemia. Taking this 
 for granted, then, the prophylactic treatment of eclampsia is far more im- 
 portant than the curative, since it is usually possible to prevent the attack. 
 Many prominent American as well as foreign obstetricians hold this opinion. 
 
 The Preventive Treatment. — The pre-eclamptic symptoms comprise a rapid 
 pulse, generally accompanied by high arterial tension; anorexia, gastrointestinal 
 derangements; mental and physical lassitude; headache; decrease of all the 
 excretions, both solid and hquid, either gradual or rapid; that is, just those 
 disturbances that might be expected from the introduction or retention in 
 the circulation of some toxin. The quantity of urine excreted in twenty- 
 four hours is not always to be depended upon as an exact guide to renal 
 failure. As has been stated, albuminuria may be wanting before, during, 
 and even after an eclamptic convulsion. (See Toxemia of Pregnancy.) 
 The eclamptic tendency increases proportionately with the advance of 
 
ECLAMPSIA. 309 
 
 pregnancy and the consequent increased fetal metabolism. Besides, it is 
 well known that the mortality of the mother decreases gradually from the 
 ante-partum to the postrpartum condition; that is, it is maximum when 
 the onset of eclampsia occurs during pregnancy, diminished during labor, and 
 is minimum when the seizure takes place for the first time after the child is 
 born. Thus statistics tabulated by Green * show the maternal mortality in 
 ante-partum eclampsia to be 46 per cent.; fetal mortality, 69 per cent.; 
 in intra-partum eclampsia, maternal mortality, 25 per cent.; fetal mor- 
 tality, 25 per cent.; in post-partum eclampsia, mortality of mother 7 per cent. 
 There is offered, from the present knowledge of the etiology of puerperal eclamp- 
 sia, at least a working hypothesis — namely, the early recognition of the pre- 
 eclamptic stage. In addition to the monthly or bi-monthly examination of 
 the urine for the detection of albumin, something more is needed, since non- 
 albuminuric eclampsia exists in from 9 to 16 per cent, of cases, and it seems 
 quite as fatal as albuminuric eclampsia, sometimes more so. In addition to the 
 physical signs of decided kidney inadequacy, as an index of impending eclamptic 
 seizure, we should watch for the general symptoms of a circulation overcharged 
 with poisonous material — high arterial tension, headache, dizziness, gastric dis- 
 orders, mental and physical lassitude; and for disturbances of the bowels, liver, 
 skin, and lungs, and their failure properly to perform their functions, in order that 
 the patient may be intelligently treated. Under these conditions only is the whole 
 duty of the physician to the patient accomplished. The following is the line 
 of treatment suggested by me for this state: (i) The amount of nitrogenous 
 food should be diminished to a minimum. (2) The production and absorption 
 of poisonous materials, in the intestines and body-tissues, should be limited and 
 their elimination should be aided by improving the action of (a) the bowels, (b) 
 the kidneys, (c) the liver, (d) the skin, and (e) the lungs. (3) The source of the 
 fetal metabolic products, and the peripheral irritation in the uterus should, if neces- 
 sary, be removed by evacuating that organ. The first indication, reduction of the 
 quantity of nitrogenous food, can be best met by an exclusive milk diet, to 
 which, as- the symptoms improve, fish and white meats may be added. It is 
 more agreeable to the patient, and a safer course to pursue, to begin at once 
 with an absolute milk diet, than to compromise, and later to institute a strict 
 milk diet. An abundant supply of pure air and water must be offered for the 
 second indication, that of elimination. To this maybe added gentle exercise or 
 light calisthenics, or even massage, in some instances. In treating the bowels 
 the writer advises the use of daily doses of colocynth and aloes at bedtime, fol- 
 lowed by a saline the next morning. For the liver, I find efficacious an occa- 
 sional dose of calomel and soda at bedtime, followed in the morning by one of 
 the stronger sulphur waters, as Rubinat, Villacabras, or Birmensdorf. Large 
 doses of glonoin are excellent to increase diuresis. To encourage the function 
 of the skin, the body should be clothed in wool or flannel, massage may be 
 used, and, according to the severity of the case, the warm bath, hot bath, 
 hot pack, or hot-air bath may be resorted to. A definite diaphoretic-diuretic 
 action, together with the additional prompt effect upon the liver and intes- 
 tines, is obtained by the following treatment: A tablet composed of calomel, 
 digitalis, and squill, each i gr. (0.06 gm.), and muriate of pilocarpin, -5^-g- gr. 
 (0.003 mg.), is given. The next morning a full dose of Villacabras water is 
 administered. Thus four of the five eliminative processes are urged to per- 
 form their functions more energetically. I approve of the use of jaborandi 
 
 * Green: "Puerperal Eclampsia; Experience of the Boston Lying-in Hospital in the 
 Last Eight Years," " Amer. Jour, of Obstet.," 1893, 28, 18-44. 
 
310 PATHOLOGICAL PREGNANCY. 
 
 in the pre-eclamptic state, provided there is no pronounced cardiac disease, 
 although it has been generally abandoned as a diaphoretic during the eclamptic 
 seizure. Inhalations of oxygen are beneficial when a sufficient supply of fresh 
 air is wanting, and in cases in which exercise cannot be taken. Some prepara- 
 tion of iron is indicated, as Basham's mixture, or the tincture of the chloride. 
 Each case must be treated individually; no absolutely definite rules can be 
 followed; but the preceding suggestions comprise the general hygienic and 
 medicinal treatment of the pre-eclamptic state. In certain cases a restricted 
 diet and gentle stimulation of the functions of the kidney and intestines are 
 sufficient, and the patient may be allowed a certain freedom, even exercise 
 in the open air, the skin being protected by wool or flannel. In more severe 
 cases of eliminative insufficiency the patient must be kept perfectly quiet 
 in bed, allowed only a strict milk diet, while all of the eliminative organs must 
 be stimulated in order to remove the symptoms of impending eclampsia. 
 However, it should be thoroughly understood that the milk diet is the corner- 
 stone of the preventive treatment of puerperal eclampsia, the hygienic and 
 medicinal treatment being only of secondary importance. In a case in which, 
 despite an exclusive milk diet and the energetic stimulation of the five elimi- 
 native processes, the symptoms and signs of the pre-eclamptic state still per- 
 sist, or at any time become urgent, abortion or artificial premature labor is 
 indicated. The ideas of those authorities (especially of the British school 
 of midwifery) who do not, in the presence of urgent symptoms, approve of 
 inducing labor in the pre-eclamptic state are difficult to understand. How- 
 ever, attention must be paid to the arguments that labor induced by the usual 
 methods increases reflex excitability and precipitates convulsions ; that by 
 such methods the patient's fate is sealed before delivery, on account of the 
 time necessary to eliminate the barrier of the cervix; and, lastly, that the 
 patient's danger is increased by the onset of labor. In reply, it may be stated 
 that the methods of terminating the pregnancy advised here need not neces- 
 sarily increase reflex excitability, and, should they do so, it is easy to control 
 the excitability for the time necessary to attain our ends; that the necessary 
 time is generally very short; and, indeed, that at the present time the onset 
 of labor and the termination of pregnancy may be practically synchronous, 
 and that there is consequently no extended or tedious labor to exert its un- 
 favorable reactions upon the patient. Byers * made the objection that, on 
 account of the necessary manipulation, induced labor increases the risk of 
 sepsis. This, however, should not prevent the modem obstetrician from under- 
 taking the operation when he is assured of being surgically clean. Charles, 
 of the Li6ge Maternity, gave statistics at the International Congress of Ob- 
 stetrics and Gynecology in 1896 which were greatly in favor of this procedure, 
 of induced labor, when prophylaxis fails or the pre-eclamptic symptoms become 
 urgent. His table demonstrates that every mother recovered and 75 per cent, 
 of the children lived. I strongly advise a quick manual dilatation of the os in 
 these cases ; only, however, after the cervical canal is in a condition suitable for 
 its safe performance. I would also insist upon a complete dilatation of the os, 
 before the operator undertakes to deliver the patient. 
 
 The Curative Treatment. — An eclamptic seizure presents a desperate con- 
 dition. From various parts of the world the most recent statistics continue 
 to estimate the maternal mortality at from 25 to 35 per cent. Rational curative 
 treatment of this affection will remain impossible as long as its pathology 
 continues obscure. From experience no one treatment can be recommended 
 *Intemat. Congress of Obstet. and Gynecology, Geneva, Sept., 1896. 
 
ECLAMPSIA. 311 
 
 for all cases. No matter what treatment may be pursued, many women recover, 
 many die in spite of treatment, while others do well with no treatment at all. 
 No one treatment, then, can be advised; each case must be attacked in accord- 
 ance with the existing indications. A combined treatment gives better promise 
 than a single, for preserving the lives of mother and child, in the event of an 
 eclamptic attack. For this combined treatment the three following indications 
 are offered: (i) Control the convulsions; (2) eliminate the poison or poisons 
 which we presume cause the convulsions; (3) empty the uterus under deep 
 anesthesia, by some method that is rapid and that will cause as little injury 
 to the patient as possible. These indications, though stated in the order of 
 their importance, still may be carried out synchronously. In another class 
 of cases the first and second indications should be fulfilled, while the physician 
 waits for a suitable moment to undertake the third. The second indication, 
 elimination, logically accompanies the first and third, and should be under- 
 taken at the same time with them. 
 
 1. Control of the convulsions. The most effective as well as the safest 
 medicinal anti-eclamptics are chloroform, morphin (hypodermatically), vera- 
 trum viride, and chloral hydrate, the latter being used alone or in com- 
 bination with the bromide of sodium. I prefer chloroform, veratrum viride 
 and chloral, in the order stated. For the last three years I have abandoned 
 almost entirely the use of morphin, since it seems to prolong the post-eclamptic 
 stupor, while it increases the tendency to death during coma, by its interference 
 with the eliminative processes. The most reliable of all agents for immediate 
 control of the convulsive attacks is chloroform. Veratrum viride in efficiency 
 stands second only to chloroform. With the pulse strong as well as rapid, 
 it offers the most certain means at our command for temporarily, and even 
 permanently, controlling the spasms. With a weak pulse, morphin hypo- 
 dermatically, inhalations of chloroform, and chloral administered per rectum, 
 together with stimulation, if necessary, may be used instead. The pulse-iate 
 is diminished by veratrum viride, and convulsions are almost unknown when 
 the pulse-rate is 60 or under; the temperature also is reduced, and the rigidity 
 of the cervical rings is relaxed; diaphoresis and diuresis are promptly effected, 
 so that, by the use of this drug, our first indication, the control of the convul- 
 sions, is fulfilled as well as the third, the elimination of an unknown toxin. The 
 initial dose of the tincture of veratrum viride, given subcutaneously, should 
 be generally from 10 to 20 minims (0.6 to 1.2 gm.); an additional 10 minims 
 (0.6 gm.) may be administered by the same method every succeeding half- 
 hour, till the pulse continues below 60 to the minute. While under the influence 
 of the veratrum, the patient should be kept in a recumbent position. Tumul- 
 tuous heart-action will probably supervene when the erect position is assumed. 
 Whiskey or morphin will easily control vomiting and collapse, if they occur. 
 Rapid evacuation of the uterus is the final resort for the control of the con- 
 vulsions. However, it might be stated that ice-bags to the back of the head 
 and neck have a decided effect in controlling and in preventing convulsive 
 seizures. 
 
 2. Elimination of the poison or poisons which are presumed to cause the con- 
 vulsions. The following means may be advised to eliminate the poisonous 
 material from the blood and tissues. Not only one, but all of the eliminative 
 organs of the body should be brought into play, and- the following indication 
 in eclamptic treatment should be carried out along with the two previously 
 described methods. As early and prompt catharsis as possible should be ob- 
 tained, by means of croton oil, compound jalap powder, or calomel followed 
 
312 PATHOLOGICAL PREGNANCY. 
 
 by salines, and high enemata of magnesium sulphate. The writer prefers 
 to treat the comatose condition, or post-eclamptic stupor of the affection, by 
 repeated doses of concentrated solutions of magnesium sulphate or Villacabras 
 water, administered by means of a long rectal tube, high up in the descending 
 colon. Hypodermatic injections of the sulphate of magnesium have been 
 demonstrated to be too slow and ineffective to accomplish any good. Dry 
 or wet cups over the kidneys, followed by hot fomentations, is an excellent 
 method of causing diuresis. Glonoin is invaluable as a diuretic and anti- 
 eclamptic, the latter indication being fulfilled by diminished arterial tension. 
 Veratrum viride stands next in order of efficiency. The objects of its admin- 
 istration, at this time, are similar to those in the pre-eclamptic condition. The 
 hot-air bath or the hot pack encourages diaphoresis, the writer preferring the 
 former. On account of the danger of pulmonary and glottis oedema, incident to 
 the use of pilocarpin as a diaphoretic, in the existence of an eclamptic seizure, 
 its use should not be countenanced. I have seen improvement result from vene- 
 section-followed by intravenous saline infusion, thus securing a cleansing and 
 disintoxication of the blood and tissues. Care must be taken that no great dis- 
 turbance of the blood-pressure is produced. Thus, in cases of high arterial 
 pressure the amount of saline should not exceed and may even be less than the 
 amount of blood withdrawn. I have also obtained satisfactory results by ex- 
 tended irrigation of the lower bowel, using either decinormal saline solution or 
 sterile water, by means of a long, single or return-flow tube. Collapse attended 
 by a small compressible pulse, as in the same conditions under other circum- 
 stances, is effectively treated by the introduction into the blood of a decinormal 
 saline solution. Some authorities advocate the hourly subcutaneous injections 
 of ether as a diuretic. Abundant administration of oxygen is invaluable as a 
 general stimulant, to assist the eliminative function of the lungs, and to sustain 
 life in post-eclamptic stupor or coma. Alcohol is often a necessary stimulant, 
 both during and after an eclamptic seizure, and strychnin has proved effective 
 in the post-partum condition, and with impending collapse; although, reasoning 
 from a physiological standpoint, it would seem to be contraindicated. 
 
 3. Emptying the uterus under deep anesthesia, by some method that is rapid and 
 that will cause as little injury to the woman as possible. Careful observations seem 
 to show that danger is essentially passed, in some 90 per cent, of cases, immedi- 
 ately after the uterus has been emptied, if this is accomplished early in the seizure. 
 The convulsions do not always cease by this method, but they become less dan- 
 gerous, and the case is converted to one of post-partum eclampsia, in which, as 
 has been stated, the mortality is only 7 per cent. It seems from the reports of 
 the International Congress at Geneva, September, 1896, and from the literature 
 of the last ten years, that the best authorities are in favor of emptying the 
 uterus as quickly as possible, in cases of eclampsia, whether the attack takes 
 place before or during labor, although the opinion as to the method to be 
 employed varies widely. Nevertheless, in the second stage of labor, after securing 
 dilatation, all are agreed that there is indication for the immediate emptying of 
 the uterus, and this operation should be promptly performed. This is accom- 
 plished with no additional danger to mother or child. In pregnancy and the 
 first stage of labor, the barrier offered to rapid delivery is the undilated cervix, 
 and it is just here that obstetricians hold such different opinions as to the best 
 plan of procedure. Expectant or palliative treatment will almost surely be fol- 
 lowed by death of the child, and about one-third of the mothers succumb. But 
 if the uterus is promptly evacuated by suitable surgical means, the child's life is 
 preserved and the mother is practically subjected to no danger. During preg- 
 
ECLAMPSIA. 
 
 313 
 
 nancy and early labor four methods are suggested for quickly emptying the uterus : 
 (i) Csesarean section (suprapubic and vaginal); (2) mechanical dilatation of the 
 cervix (various methods); _(3) deep incisions, which at once completely remove 
 the barrier of the cervix; (4) combined mechanical dilatation and deep cervical 
 incisions. A high mortality (36.26 per cent., according to the figures of Char- 
 pentier) attends the first method — Csesarean section — for the relief of eclampsia. 
 The popular method of the present day seems to be mechanical dilatation of the 
 cervix, and the prompt extraction of the fetus. This method is safe and effec- 
 tive when properly performed. 
 However, the safe performance of 
 this method will demand from 
 forty minutes to an hour and a 
 half before dilatation is well ad- 
 vanced. Certain cervical condi- 
 tions, even with this allowance of 
 time, will not yield to manual dila- 
 tation, or else entail lacerations of 
 the lower uterine segment. By 
 the third method of delivery, that 
 of deep incision of the cervix, is 
 presented a surgical means for 
 emptying the uterus in from five 
 to ten minutes, on condition that 
 the supravaginal portion of the 
 cervix has disappeared, either of 
 itself or by the application of ap- 
 propriate measures. The fourth 
 method comprises a combination 
 of the second and third, and is 
 suitable for cases in which the 
 supravaginal portion of the cer- 
 vix has not disappeared, and 
 prompt emptying of the uterus is 
 indicated. In this method the os 
 is mechanically dilated until the 
 internal os has disappeared, when 
 the dilatation is at once com- 
 pleted by means of the incisions. 
 There are few statistics to offer 
 concerning the results of the third 
 method and its modification, the 
 fourth, on account of their com- 
 paratively recent introduction. 
 In general, the indications will 
 
 be fulfilled by a prompt manual dilatation of the os, followed by extraction of 
 the fetus; however, unless this can be expertly carried out, with an intelligent 
 understanding of the mechanism of dilatation, particularly in primiparas, more 
 favorable results will be attained by a strictly expectant treatment. Although the 
 mortality is greater in multiparae, nevertheless, puerperal eclampsia is unfortu- 
 nately four times more frequent in primiparae. The cervix uteri consists of 
 muscle-fibers, both constricting and dilating, and while it is known that labor is 
 generally induced by the first convulsions, nevertheless the supervening asphyxia 
 
 /niernalos 
 
 £x€er/ia! as. 
 
 /ila^ider 
 
 fb^in/z. 
 
 Itectu 
 
 Fig. 471. — Frozen Section of the Uterus of 
 A Multigravida at the Thirty-fourth 
 Week. Who Died before Any Labor Pains 
 Occurred. Note the length of the cervical 
 canal and the closed condition of the internal 
 OS. — {Leopold.) 
 
314 PATHOLOGICAL PREGNANCY. 
 
 has a decided constricting influence upon the body of the uterus and the cervix, 
 which is most defi^iitely exemplified at the internal os. Consequently, there will 
 be imminent danger of uterine rupture in any method of rapid manual dilata- 
 tion of the OS undertaken before the internal os has at least partly disappeared. 
 This fact particularly concerns primiparse, in whom the supravaginal portion of 
 the cervix persists late in pregnancy, and even up to the beginning of labor. 
 Uterine rupture and death have not infrequently followed the careless perform- 
 ance of rapid manual dilatation of the os, especially in eclampsia; and undue 
 shock has been caused by dragging a fetus through an imperfectly dilated os, 
 not to speak of the death of the child. Hence the greatest care in this manipula- 
 tion is demanded. In case of placenta praevia, the lower uterine segment and 
 the cervix are made more easily dilatable by the hemorrhage and supervening 
 anemia. The reverse is true in eclampsia, as has been before suggested. Great 
 care should be taken not to extract the fetus prematurely, before full dilatation 
 has been attained and the external os paralyzed. I have seen cases of premature 
 extraction, under these circumstances, which have been followed by many unnec- 
 essary and dangerous lacerations of the lower uterine segment, and by an in- 
 creased mortality of both mother and child. 
 
 Although I have the strongest faith in the efficiency of an immediate removal 
 of fetal metabolism and irritation, in order not only to control but to cure the 
 eclamptic attack, I must protest, first, against the careless use of the term accouche- 
 ment force as applied to the rapid, scientific, and intelligent evacuation of the 
 uterus; and, secondly, against the thoughtless recommendation of this method 
 as being the best, if not the only one at our command, for controUing 
 eclamptic convulsions, without giving due consideration to the condition of 
 the cervical barrier. 
 
 Accouchement force comprises to-day three operations — namely, (i) the com- 
 plete instrumental or manual dilatation of the cervical canal, followed by (2) 
 either combined or direct version, or the application of the forceps, and (3) the 
 immediate extraction of the child. It is well for the patient suffering from an 
 eclamptic seizure that the frequency of the convulsions increases proportionately 
 with the progress of pregnancy. As already stated, it is unfortunate that the 
 eclamptic seizure is four times more frequent in primiparae than in multiparse, and 
 in primiparse the persistence of the supravaginal part of the cervix, even to late 
 gestation, and of a rigid and unrelaxing os, necessitates the use of preliminary and 
 temporizing methods before a rapid dilatation of the os and subsequent extraction 
 of the fetus can be safely performed. In these cases which are so critical, after 
 the institution of measures preparatory to a rapid dilatation and evacuation of 
 the uterus and waiting for them to culminate, so that at least the cervical canal 
 may have been rendered somewhat relaxed, even if the internal os has not 
 partly disappeared, my experience has proved veratrum viride invaluable, for 
 the preservation of life, on account of the various characteristics of the drug, 
 before described. Vaginal Csesarean section should also be considered in such 
 cases as a substitute for mechanical dilatation. 
 
DISEASES OF THE URINARY TRACT. 315 
 
 XI. DISEASES OF THE URINARY TRACT. 
 
 /. Passive Congestion of the Kidney. 2. Acute Nephritis, j. Chronic Nephritis. 4. Floating 
 Kidney, Tumors of the Kidney. 5. Pyelonephritis. 6. Hydronephrosis. 7 Renal 
 Calculi. 8. Renal Insufficiency, and Toxemia, g. Vesical Irritation. 10. Cystitis. 
 II. Incontinence of Urine. 12. Urinary Retention, ij. Vesical Hemorrhoids. 14. Vesi- 
 cal Calculi. 75. Cystocele. 16. Vesical Neoplasms and Traumatism. ly . Albumin- 
 uria. 18. Polyuria, ig. Peptonuria. 20. Hematuria. 21. Glycosuria. 22. Lipuria 
 and Chyluria. 23. Acetonuria. 24. Urinary Sediments of Pregnancy. 
 
 1. Passive Congestion of the Kidney. — This condition, when due to any 
 obstruction of the return flow of venous blood, may, of course, complicate 
 pregnancy; but the term is usually applied to a supposed consequence of the 
 pressure of the gravid uterus itself. Anemia of the kidney: But since the in- 
 creased intra-abdominal pressure of pregnancy aifects the renal arteries as well 
 as the veins, the tendency is naturally toward an anemic rather than a passively 
 congested kidney. This anemia is assumed to be the forerunner of albuminuria 
 and fatty degeneration; or, in other words, is the first step in the formation 
 of the so-called kidney of pregnancy. Its existence is naturally associated with 
 the latter part of pregnancy, after the gravid uterus has attained a certain 
 size; but some see in anemia of the kidney a reflex element, believing that 
 compression of the nerves in the uterus causes a lowering of blood-pressure in 
 the kidney. Pregnancy-kidney: This important condition is considered under 
 toxemia of pregnancy, eclampsia, and albuminuria. It is enough to state here 
 that it is essentially a fatty degeneration or infiltration of the renal epithelia 
 which varies much in degree, but which with very few exceptions undergoes 
 complete resolution after delivery. There is more or less tendency toward 
 recurrence at subsequent pregnancies. 
 
 2. Acute Nephritis. — Acute nephritis may develop during pregnancy as a 
 purely accidental complication, differing in nowise as to etiology, symptoms, 
 etc., from the same affection as it occurs in the non-gravid. The fact that such 
 a condition is to be construed for practical purposes as a severe form of preg- 
 nancy-kidney — with which, however, it has no known relationship — makes it 
 necessary to state but little under a separate heading. Acute nephritis is 
 attended with greater local and general disturbance, and its prognosis as a dis- 
 ease per se is less favorable. It tends to cause uremia, while in pregnancy- 
 kidney the toxic state is believed to precede the renal lesion. In cases in which 
 a differential diagnosis cannot be made between acute intercurrent nephritis and 
 pregnancy-kidney, it will be difficult to decide whether the toxic state is uremic 
 or eclamptic. Recent studies in cryoscopy show a difference in the blood in 
 these conditions; so that the differentiation should be rendered absolute. 
 Finally, acute nephritis, although it might possibly end in resolution in time, 
 would have no necessary tendency to terminate with delivery, and would in 
 most cases result in chronic nephritis, a termination unusual — and according 
 to some, unknown — in pregnancy-kidney. 
 
 3. Chronic Nephritis. — Chronic nephritis sometimes becomes apparent after 
 conception in the absence of any previous suspicion of the disease. If a woman 
 show the evidences of renal lesion very soon after impregnation, the inference is 
 that the affection is of considerable duration. It happens occasionally that a 
 woman with chronic nephritis becomes pregnant when fully aware of her condi- 
 tion. The influence of gravidity is usually serious, and becomes more marked for 
 each successive pregnancy. The mother may be variously affected. She may 
 die as the result of labor if the latter is severe in character or complicated by 
 
316 PATHOLOGICAL PREGNANCY. 
 
 operative intervention. Or the confinement may be uneventful, but the disease 
 may undergo a severe, perhaps fatal, exacerbation during the puerperium. It 
 is known that these patients readily become septic, and that very slight trauma- 
 tisms may become infected. While opinion is divided as to the advisability of 
 interrupting pregnancy in pregnancy-kidney and in acute nephritis, authors agree 
 that intervention of this sort is more justifiable in chronic nephritis. The remark- 
 able infrequency of eclampsia in chronic nephritis of pregnancy is an argument in 
 favor of the distinction between uremia and the toxemia of pregnancy. 
 
 4. Floating Kidney ; Tumors of the Kidney. — These conditions very seldom 
 complicate pregnancy and labor. The pressure of the gravid uterus, as a rule, 
 suffices to keep a floating kidney in place for the time being, and the chief danger 
 from this abnormality is during and after the puerperium, when it may become 
 aggravated. If the displacement is congenital, or if it occurs suddenly during 
 labor, the kidney may enter the pelvis and become incarcerated. The pedicle of 
 an ordinary floating kidney may become twisted. 
 
 5. Pyelonephritis. — This condition was formerly unrecognized, having been 
 confounded with cystitis. In 1889 Kruse * first called the attention of ob- 
 stetricians to this complication, and in 1892 Reblaud published a monographic 
 study of the subject. Frequency: Pyelonephritis of pregnancy is far from rare. 
 According to Vinay, at least one case occurs annually, on an average, in the 
 Hotel-Dieu Maternity, Paris. Etiology: This is entirely obscure. Compression 
 of the ureters, especially the right, by the gravid uterus will not accoimt for the 
 lesion. Vinay f and Reblaud both accuse Bacillus coli of active responsibility, the 
 latter even holding that it gains access to the urinary tract by direct propagation 
 through the intestine. In support of this contention Bue claims that purgation 
 aborts pyelonephritis. Symptoms : The disease may make its appearance at any 
 period after the fourth month. The symptoms, while obscure, are usually those 
 which characterize a severe acute disease, including a chill, high temperature, 
 malaise, etc. Pyuria is present, associated with albuminuria. Diagnosis: This 
 is made by exclusion of cystitis. There is induced tenderness over the kidneys. 
 Prognosis: The disease persists until pregnancy is terminated. It may recur 
 with successive pregnancies. Statistics are rare. Treatment: The indications 
 are rest in bed; sedation (hypodermatics of morphin), milk diet and intestinal 
 antisepsis. Vinay recommends benzo-naphthol for this purpose. The disease 
 does not appear to be severe enough to reqmre the induction of abortion. 
 
 Pyelitis is very rare during pregnancy, being far more common in the puer- 
 perium. (See Part VII.) 
 
 6. Hydronephrosis. — This affection may occur as a result of pressure on the 
 ureters by a uterus bound down by adhesions or by twisting of the pedicle of a 
 dislocated kidney. The uterus or kidney should be replaced and held in position 
 if possible. Interruption of pregnancy usually occurs. 
 
 7. Renal Calculi. — Renal colic is rare in pregnant women because of its in- 
 frequent occurrence in the female sex in general. The few published cases are 
 probably simply coincidences and the sole interest in considering the subject in 
 this connection is the simulation of labor pains by the colic. The treatment of 
 the affection differs in nowise from that in the non-pregnant. 
 
 8. Renal Insufficiency. — See Toxemia of Pregnancy. 
 
 9. Vesical Irritation. — This must not be confounded with cystitis, incon- 
 tinence, or retention, although some of these conditions may occur side by side. 
 It may be described as an almost physiological reaction on the part of the 
 bladder toward the irritation of the pregnant uterus. The organ is compressed 
 
 * Inaug Dissert., Wurzburg. t " L'0bst6trique," May 15, iSqq. 
 
DISEASES OF THE URINARY TRACT. 317 
 
 between the symphysis in front and the gravid uterus behind. It is an affection 
 most complained of in the fiarly months of pregnancy and in primigra vidae , and 
 tends to disappear about the fourth month of pregnancy, but often returns in the 
 last fortnight. 
 
 Symptoms. — The affection is a dysuria. There is a frequent desire to 
 urinate, with pain and scalding. The symptoms resemble those of cystitis but 
 are less severe. The distress is removed if the patient takes the recumbent pos- 
 ture for the time being. The bladder is usually hypersensitive. In case of 
 malposition of the uterus the pressure is usually directed against the neck of the 
 bladder, and vesical tenesmus results. If the vesical neck be forced against the 
 upper border of the symphysis pubis, there may be retention of urine (page 318). 
 This may cause incontinence or the urine may be completely retained and the 
 bladder will be overdistended. In this condition, if labor supervenes, rupture of 
 the bladder may take place, on account of the decrease of abdominal space 
 caused by the retraction of the walls. Cystitis commonly follows overdistention. 
 Abnormal presentations and positions of the fetus cause irritability of the 
 bladder in the latter months of pregnancy. There is either extreme pressure on 
 the bladder or this organ is pushed out of place. The fetus should be replaced 
 in normal position, which can be accomplished only by external manipulation. 
 
 Treatment. — The measures for relief are those employed in vesical irritation 
 in the non-pregnant, or as in cystitis, to be mentioned later (rest, dorsal decu- 
 bitus, baths, anodynes, etc.). Catheterization should be avoided unless abso- 
 lutely demanded. A normal presentation of the fetus should be secured if 
 possible by external manipulation, and an abdominal binder (Figs. 228 and 
 229) used, which will relieve the bladder of fetal pressure. I have iound the 
 modified knee-chest posture (Part X), used twice daily, of great benefit in 
 obtaining relief. 
 
 ID. Cystitis. — C\'stitis of pregnancy is not a rare disease. 
 
 Etiology. — It may originate from some of the minor urinary troubles develop- 
 ing early in pregnancy, such as retention due to retroversion. The actual deter- 
 mining cause is bacterial, and a number of germs are known to give rise to the 
 disease, including Bacillus coli and Staphylococcus pyogenes. These germs appear 
 to be unable to infect the normal bladder. Gonococcus cystitis is rarely seen in 
 pregnancy. Cystitis arises either through importation of germs by the catheter 
 or by their spontaneous migration from the vestibule along the urethra. 
 
 Symptoms. — These consist chiefly in increased frequency of micturition and 
 more or less scalding with tenesmus at the close of the act, at which time a blood- 
 clot may be expelled. Such a urine, upon standing, deposits a heavy sediment con- 
 sisting of pus-corpuscles. The type of cystitis which follows upon the irritable 
 bladder of early pregnancy is always mild; it may be readily overlooked and 
 mistaken for simple urinary irritation unless the urine is carefully tested. On 
 the other hand, the cystitis of retention is severe and aggravates the already 
 existing state of affairs. The retained urine may readily decompose, the pus 
 being transformed thereby into a ropy mass. The combination of retention 
 with cystitis has been known to produce abortion. The disease tends to improve 
 after delivery, but sometimes persists. In some women cystitis tends to recur 
 with each pregnancy. 
 
 Treatment. — Rest and avoidance of exposure are the first considerations. 
 Hence, in winter patients had better be confined to bed. The diet should be 
 extremely simple, consisting chiefly of clear soups, green vegetables, and farina- 
 ceous articles. Alkaline mineral waters should be taken freely. Any diuretic 
 infusion may be prescribed, with the additions of sandal-wood in capsules or 
 
318 PATHOLOGICAL PREGNANCY, 
 
 salol. Poultices should be placed over the hypogastrium and anodyne supposi- 
 tories may be necessary in severe cases. Urotropin is also of value. 
 
 11. Incontinence of Urine. — True incontinence is rare in pregnancy, although 
 it is by no means unknown in the later months. It should not be confounded 
 with the ordinary vesical irritability, which is almost inevitable, nor with the 
 dribbling which accompanies retention. The principal cause is the encroachment 
 on the bladder of the more dependent portions of the fetus during the last weeks 
 of pregnancy. If the fetus press fairly upon it, any sudden movement of the 
 diaphragm, as in laughing, coughing, etc., could readily cause the emptying of 
 the viscus. The constant escape of urine may give rise to excoriations of the 
 vulva and thighs. An abdominal bandage will usually relieve this condition 
 (Figs. 228 and 229). 
 
 12. Urinary Retention. — This is conceded to be the most prevalent of all the 
 urinary anomaUes of pregnancy, owing, perhaps, to the number of types which 
 the condition assumes. These are as follows: (i) Retention at the onset of preg- 
 nancy. The rationale of this is obscure. This is attributed to reflex spasm of 
 the vesical neck. (2) Retention in the course of pregnancy. This is due almost 
 exclusively to retroversion of the pregnant uterus, and begins at the third or 
 fourth month. (3) Retention toward the close of pregnancy. This is the result 
 of the direct compression of the urethra and bladder by the fetal head. 
 
 Symptoms. — These are self-evident — the urinary tumor and the failure to 
 pass water beyond a mere, dribbling. This dribbling saves the patient in most 
 cases from the accidents of complete retention. If dribbling does not occur 
 spontaneously, the patient is still able to get relief by efforts at bearing-do#n. 
 There is naturally much dysuria and reflected pain, while in some instances there 
 is a systemic reaction, including fever, anxiety, restlessness, and anasarca. If the 
 case is left to itself the bladder gradually distends until it assumes a prodigious 
 volume. The use of the catheter is quite likely to lead to infection and cystitis. 
 The diagnosis is readily established by palpation and the catheter. The drib- 
 bling of retention .should not be confounded with true incontinence. The 
 prognosis depends upon the character of the relief afforded by the use of the 
 catheter and by attempts to remove the cause. Treatment: The prompt and 
 repeated use of the catheter will insure the patient against the immediate un- 
 favorable results of retention. This is offset somewhat by the dangers of 
 catheterization. It may be necessary to introduce the instrument in the genu- 
 pectoral position. Glass is the best material for the catheter (Part X). 
 
 13. Vesical Hemorrhoids. — These, like other local pelvic varicosities occur- 
 ring during pregnancy, are the result of the general pelvic congestion, and 
 usually first draw attention to the condition on the occurrence of rupture and 
 consequent hematuria. The condition can only be suspected until cystoscopic 
 examination be made. 
 
 14. Vesical Calculi. — Vesical calculi have caused vesico-vaginal fistula dur- 
 ing labor and a case is recorded in which a stone was found large enough to 
 obstruct delivery.* The induction of labor during the last month of pregnancy 
 may be demanded; this late date being chosen in order that the prognosis for 
 the child may be rendered as favorable as possible. 
 
 15. Cystocele. — This may cause a pouching of the anterior vaginal wall, the 
 tumor even passing through the vulva. It has been mistaken for the amniotic 
 sac and punctured. For diagnosis a catheter may be passed into the cystocele 
 and palpated by vaginal touch. For treatment, after the bladder is evacuated, 
 the anterior vaginal wall should be pushed up in order that pressure by the head 
 may be avoided. 
 
 * Dakin: "Handbook of Midwifery," page 460. 
 
DISEASES OF THE URINARY TRACT. 319 
 
 1 6. Vesical Neoplasms and Traumatisms. — Carcinoma may occur and be 
 secondary to carcinoma of the cervix. Vesical irritation and hematuria are 
 among the symptoms. 
 
 17. Albuminuria. — The subject of albuminuria in the gravid is an extensive 
 one, which is considered under toxemia of pregnancy, eclampsia, etc. It 
 merits some independent consideration as well. Occurring in the first half of 
 pregnancy it must be regarded as of toxic origin, or as suggestive of hepatic 
 insufficiency or renal disease. The so-called functional albuminuria — which 
 is now believed to depend largely upon gastric insufficiency — may be present 
 before conception; but von Rosthom (Winckel's "Handbuch," 1903) assures 
 us that this condition never becomes aggravated by pregnancy, and that it is 
 not necessary to dissuade women with this anomaly from marriage and con- 
 ception. 
 
 True albuminuria of pregnancy begins, as a rule, not earlier than the 
 twenty- fifth week; and it is of such common occurrence that some regard 
 it as practically the rule. Once believed to be much more common in primi- 
 gravidas, it is now thought to, occur irrespective of parity. It is probable that 
 a small amount of albumin in the urine may be accounted for by circulatory 
 disturbances alone, and that to be considered evidence of a toxic state, album- 
 inuria must be associated with other phenomena. When the amount is con- 
 siderable, or when it steadily increases from small beginnings, it naturally sug- 
 gests both a toxic state and a renal lesion. It by no means follows that the trace 
 of albumin so often found comes directly from the blood, for it may simply be 
 derived from the epithelia and leucocytes which make their appearance in the 
 urine in increasing numbers late in pregnancy. Naturally only traces could be 
 accounted for in this manner. 
 
 The fact should be emphasized that waste of albumin is not without signi- 
 ficance in pregnancy. Albuminuric women show a distinct tendency to abortion 
 and premature delivery ; and while the fetus shows subdevelopment the placenta 
 is increased in size and shows such peculiarities as to be termed the " albuminuric 
 placenta." This subject needs to be studied anew, for it is possible that a 
 certain phase of endometritis gravidarum may account for the entire condition. 
 
 18. Polyuria. — Owing to increased tissue change, a moderate increase of the 
 urinary secretion always occurs during pregnancy. Occasionally the increase 
 is excessive. Cases are recorded in which 200 or more ounces (6 liters) in a 
 day were passed. The urine is usually normal in character except for a low 
 specific gravity. The patient suffers from thirst and the annoyance caused by 
 frequent urination. Treatment adapted to cause decrease in the flow of urine is 
 not advisable. 
 
 19. Peptonuria. — This is sometimes caused by fetal death and the absorption 
 of proteids (page 272). In other cases no assignable cause can be found. 
 
 20. Hematuria. — This is usually due to vesical hemorrhoids, but may occur 
 from other affections of the bladder and kidneys, as acute nephritis or cystitis, 
 calculi, neoplasms, or traumatisms of the bladder. For treatment the pelvic 
 congestion should be relieved by avoiding constipation and tight clothing. In- 
 jections of astringent solutions may be tried in bad cases if the symptoms point 
 to the bladder as the seat of the trouble. 
 
 21. Glycosuria. — The existence of glycosuria in pregnancy and the puer- 
 perium has been known for many years, and in 1877 it was ascertained that 
 puerperal glycosuria was a lactosuria, and thereby related in some manner to 
 the secretion of milk. The glucose which may sometimes appear to indicate a 
 toxemia should not be regarded as necessarily pathological, for if the tests are 
 
320 PATHOLOGICAL PREGNANCY. 
 
 of sufficient delicacy this substance may be found in nearly all urine, and 
 must, under these circumstances, be regarded as purely dietetic. This fact 
 was made the basis of Schenck's method of controlling sex of the offspring; 
 since if the normal trace of sugar cannot be made to disappear by diet, the 
 infant will probably be a female. Regarding the high degrees of glycosuria 
 and true diabetes, since these conditions may develop during pregnancy or 
 be present throughout it, the outlook is much the same as in operative 
 surgery, and the greater the degree of glycosuria, the worse the prognosis. 
 Statistics appear to show that labors in these women are quite apt to end unfavor- 
 ably in one or another way.* The fact that diabetes has been known to set in 
 during pregnancy and disappear spontaneously after delivery would seem to 
 connect such a phenomenon with the special toxemia of pregnancy. Women 
 who have thus recovered have gone through subsequent pregnancies without 
 reappearance of the disease. Other records indicate that a diabetes lighted up 
 in pregnancy may remain permanent. When a diabetic woman becomes 
 pregnant, her disease usually takes a turn for the worse, with a tendency to 
 improve temporarily after confinement. According to Lecorche, true diabetics 
 who become pregnant usually succumb to the disease within a short time after 
 delivery. 
 
 22. Lipuria and Chyluria. — These conditions are occasionally noticed. The 
 former is due to the general increase in adipose tissue throughout the body. 
 They are of no special clinical importance. 
 
 23. Acetonuria. — The metabolic changes incident to pregnancy would 
 naturally direct one's attention to the index of metabolism, the urine. The 
 significance of acetonuria in general not being well understood, such an investi- 
 gation as that undertaken by Max Stoltz.t in "Acetonuria in Pregnancy, Child- 
 birth, and Puerperium," is highly welcome. He finds that a slight acetonuria 
 which is physiologically found in pregnant women is not constant but is quite 
 variable. Increased acetonuria is frequently found in ' the course of preg- 
 nancy, lasting for one, two, or three days, without any symptoms of patho- 
 logical causes. In the majority of cases during child-birth there is increased 
 acetonuria. The longer the labor lasts, the more frequently does acetonuria 
 occur and the more abundant it is. In primiparae it is more constant and greater 
 than in multiparae. During the first thiree days of the puerperium, occasionally 
 during the first four days, it is considerably increased. Less often it appears 
 greatly increased later in the puerperium. The increased acetonuria of the puer- 
 perium is, as a rule, closely connected with the same condition during parturi- 
 tion. The influence of the establishment and the continuance of lactation upon 
 this condition requires further investigation. Increased acetonuria in pregnancy 
 and parturition is worthless as an index of the death of the fetus. It is a phy- 
 siological manifestation, without any pathological significance or cause. It 
 is explained by the alteration in fat metabolism during pregnancy and the suc- 
 ceeding states, and, corresponding to it, is of irregular and transitory duration. 
 
 24. Urinary Sediments of Pregnancy. — It is now known that abnormal 
 deposits occur in the urine of the gravida in the latter half of pregnancy in not 
 less than 97 per cent, of all cases. (Fischer, "Arch. f. Gynekol.," xliv.) This 
 appears to result largely from circulatory . disturbances which are inseparable 
 from direct and indirect pressure from the enlarging uterus. There is more 
 or less desquamation along the entire urinary tract, as shown by catherisation 
 of the ureters. In the renal epithelia fat droplets may sometimes be seen. 
 
 * Matthews Duncan: "Trans. Obstet. Soc. London," 1882. 
 t "Archiv f. Gyn.," Feb., 1902. 
 
DISEASES OF THE ALIMENTARY TRACT. 321 
 
 There is always a leucocytosis in the urine of the gravid, and the corpuscles 
 may proceed from the bladder or kidney; in the latter case being accompanied 
 by albuminuria. Erythrocytes and hematoidin crystals are sometimes encoun- 
 tered; and are thought to proceed almost wholly from the ureters unless, of 
 course, nephritis is present. Finally it is not uncommon to find hyaline casts 
 (25 per cent., Fischer), which are by no means necessarily associated with al- 
 buminuria. These cylinders are sometimes covered in part by renal epithelial 
 leucocytes, or erythrocytes. Granular casts are present but rarely and are 
 always accompanied by albuminuria. 
 
 These sediments are present at first but sparsely, but increase- regularly 
 toward term. During labor they attain a maximum, and erythrocytes are 
 then invariably present in large numbers. 
 
 XII. DISEASES OF THE ALIMENTARY TRACT. 
 
 I. Gingivitis. 2. Dental Caries, j. Oral Sepsis. 4. Salivation or Ptyalism. 5. Anorexia. 
 6. Nausea and Vomiting 7. Persistent Vomiting; Hyperemesis Gravidarum. 8. Mal- 
 acia; Longings. g. Gastric and Intestinal Indigestion. 10. Consumption. 11. Diar- 
 rhea. 12. Hemorrhoids, ij. Jaundice; Icterus Gravidarum. 14. Appendicitis. 75. 
 Tapeworm. 
 
 1. Gingivitis. — An inflammation of the gums due to the blood-changes of 
 pregnancy not infrequently occurs during gestation. It usually subsides after the 
 birth of the child, though it may continue throughout lactation. This affec- 
 tion is generally coincident with salivation, although it may occur alone, 
 and is more frequently seen in multigravidas than in primigravidae. The gums 
 are swollen and tender and bleed at the slightest touch; they are retracted, 
 leaving the necks of the teeth exposed to all the secretions of the mouth, and as 
 these are frequently very acid, their effect upon the teeth is deleterious. The 
 latter are apt to become loosened, making mastication difficult as well as painful; 
 the rest of the mouth may be involved and the process extend to the pharynx 
 and even to the stomach; the breath has an unpleasant odor. Treatment: The 
 teeth should receive the careful attention of a dentist. A good remedy is pre- 
 cipitated chalk pressed between the teeth at bedtime. During the day milk of 
 magnesia may be used repeatedly as a mouth-wash. 
 
 2. Dental Caries. — The rapid decay of the teeth seen in many women during 
 pregnancy is not due to the deficiency of lime salts in the blood, as it has never 
 been shown that there is such a deficiency; but it. is undoubtedly caused by the 
 acid eructations, vomiting, and secretions, the result of acid dyspepsia of the 
 early months of gestation. I have frequently noted in my private practice that 
 the number of teeth attacked and the rapidity of dental caries were directly pro- 
 portionate to the frequency, intensity, and persistency of acid dyspepsia with 
 eructations and vomiting. Biro * has shown that mere pregnancy, aside from 
 causing acid dyspepsia, has no effect on the teeth. One of the first duties of 
 the obstetrician toward his patient in pregnancy is to inquire into the condition 
 of the teeth and mouth, and, if necessary, to send the patient to her dentist. 
 Dental caries lapping over into or originating during pregnancy should receive 
 immediate attention. The carious substance should be partly or completely re- 
 moved, the cavity touched with pure carbolic acid (an alkali), and a temporary 
 gutta-percha filling put in. Severe and painful dental procedures, however, with- 
 out the use of cocain or nitrous oxide, should be avoided, since they may lead 
 
 * " Wien. med. Blatter." 1S98. 
 21 
 
322 PATHOLOGICAL PREGNANCY. 
 
 to abortion. For prevention we have nothing so efficacious as the free use locally 
 of alkalies, such as milk of magnesia, lime-water, or bicarbonate of soda, my 
 preference being for the first. This should be used as a mouth-wash after each 
 meal and at bedtime, care being taken to draw the fluid between the teeth. 
 It may be used oftener when the vomiting of pregnancy is persistent. Small 
 doses of milk of magnesia taken internally will often correct acidity, relieve vom- 
 iting, and thus prevent dental caries. In all cases attention must be given to 
 the dyspepsia present. 
 
 3. Oral Sepsis. — The mouth should be examined in all cases of fever or 
 septic symptoms occurring during pregnancy or the puerperium, and particu- 
 larly in instances of persistent nausea and vomiting of pregnancy. Many 
 pregnant women, consciously or unconsciously, have ulceration from caries 
 going on at the root of an old molar, which intermittently discharges a foul pus 
 at the edge of the gums (pyorrhoea alveolaris). Again, the rapid increase in the 
 use of bridges and gold caps over old broken-down fangs is, I am sure, an 
 important factor in oral sepsis. Often we find bone necroses under these caps 
 and bridges, and pus organisms from this source are most virulent. Not only is 
 this local septic condition a cause of stomatitis, but it is, the author feels sure, an 
 important and prevalent cause of gastric disturbances and systemic infection. 
 In one of my cases a second molar, decaying and ulcerating at the roots, was 
 removed under nitrous oxide by Dr. Hasbrouck, of New York, in the middle of 
 gestation; this was followed by a distinct improvement in pronounced gastric 
 disturbances present, and a cessation of symptoms which resembled an atypical 
 form of malarial infection, and which were attributed at the time to imperfect 
 plumbing. In my belief these general phenomena were septic in character. 
 Treatment: The source of the pus should be removed, with the use of nitrous 
 oxide if necessary; especially should necrosed and useless fangs be extracted, and 
 proper drainage effected. More attention should be given to oral antisepsis 
 than has hitherto been the custom; caps and bridges should be avoided; all 
 removable mouth plates should be sterilized daily; in cases in which, for any 
 reason, removal of necrosed teeth is not advisable, or the patient refuses 
 to have it done, the stump should be thoroughly touched daily with carbolic 
 acid (i : 20), and several times a day an antiseptic mouth- wash, such as per- 
 oxide of hydrogen (i 14), should be used. 
 
 4. Salivation or Ptyalism. — This occurs most commonly in the early months of 
 pregnancy, and consists in a profuse secretion of saliva; the patient suffers from a 
 continual dribbling which is very annoying; the condition is due to a neurosis or 
 toxemia. Sometimes the amount of saliva expectorated in twenty-four hours will 
 reach two or more quarts. The general health may even be impaired by this 
 trouble; and in certain instances the affection continues to term, and, very excep- 
 tionally, for some months after labor. The danger to the patient lies in the 
 inanition which results from this drain on the system. In Schramm's case the 
 ptyalin was absent, so that the saliva had no digestive properties left. The 
 mucous membrane of the mouth becomes red and swollen ; there is no fetor, and 
 this distinguishes the affection from mercurial ptyalism. Treatment: Astringent 
 tablets, such as troches of tannic acid, and counterirritation over the parotids are 
 useful; the bromides are most often of service; atropin or belladonna may be 
 tried; careful attention to the general health is necessary. 
 
 5. Anorexia. — Complete anorexia sometimes occurs; more commonly there 
 is a disgust for particular kinds of food, rather than absolute anorexia. This 
 condition is apt to mianifest itself at either extreme of pregnancy, when the 
 neurotic features are most predominant. Sometimes the patient will not be able 
 
• DISEASES OF THE ALIMENTARY TRACT. 323 
 
 to bear the thought of meat of any kind; again, she can take nothing else but 
 meat. Treatment: Tonics .and vegetable bitters are useful; the liver and 
 bowels should be carefully regulated, and the patient should be humored as 
 much as possible in the choice of food. 
 
 6. Nausea and Vomiting. — (See Toxemia of Pregnancy, page 291.) 
 
 7. Pernicious Vomiting ; Hyperemesis Gravidarum. — (See Toxemia of Preg- 
 nancy, page 291.) 
 
 8. Malacia ; Longings. — Patients will occasionally show a perverted appetite 
 for unnatural and unheard-of articles of diet. This affection is also designated 
 as pica, or more popularly as pining. In very rare cases it may be exaggerated 
 to true insanity. Gentle treatment may have some effect ; the mind should be 
 diverted; hygiene, particularly of the alimentary tract, should be carefully 
 looked after, and, if necessary, moral suasion should be tried. Labor terminates 
 these symptoms. 
 
 9. Gastric and Intestinal Indigestion. — These affections often occur in preg- 
 nancy, especially in primigravidse. Pyrosis or heartburn is particularly trouble- 
 some in the gastric form, enteralgia being most striking in the intestinal dis- 
 turbance. These discomforts are manifest most often in late pregnancy. 
 Treatment: Attention to diet and' the relief of constipation may be all that will 
 be necessary. Alkalies are frequently useful in pyrosis. Pepsin, pancreatin, 
 diastase, powdered calumba, the alkaline mineral waters, and an occasional 
 dose of calomel may be symptomatically indicated. In the intestinal 
 indigestion of pregnancy I have obtained good results from a mixture 
 of hydrastis, bicarbonate of potassium, and pancreatin or essence of pepsin 
 (Fairchild). 
 
 10. Constipation. — This is a common accompaniment of pregnancy, and is 
 due partly to pressure, but mostly to deficient innervation of the muscular 
 coat of the bowel, causing an exaggeration of the normal intestinal torpidity of 
 women. Women sometimes pass a week or more without defecation, and 
 then copraemic symptoms, such as mental dulness, dizziness, distended veins, and 
 headache, are apt to supervene. The direct mechanical pressure of the enlarging 
 uterus on the intestines has been shown by frozen sections to be almost insignifi- 
 cant. However, the distended anterior abdominal wall is deprived of much of 
 its power as a factor in defecation. Constipation has a tendency to cause 
 hemorrhoids, and may even, by accumulations in the colon, predispose to 
 abortion. 
 
 Treatment should be prophylactic, as far as possible; the trouble should be 
 anticipated early in pregnancy by a laxative diet, including fruits, and an 
 abundant quantity of plain water, drunk at bedtime and on rising in the morning. 
 In the curative treatment violent cathartics must be avoided, as they usually 
 exaggerate the condition subsequently, and have been known to interrupt 
 pregnancy. In neglected cases of several days' standing repeated enemata of 
 sweet oil and ox-gall may be necessary to unload the impacted rectum, or even 
 the mechanical use of the spoon, followed by enemata. Ordinarily the best 
 results will be obtained by the use at bedtime of pills containing varying quanti- 
 ties of aloin, cascarin or extract of cascara, extract of belladonna, strychnin, 
 podophyllin, and capsicum. These pills or tablets may be obtained the world 
 over. Experience has taught me that one formula will not be suitable for 
 all; I am, therefore, accustomed to use as many as six different combinations, 
 according to the nature of the case. It will sometimes be necessary to try three 
 or four different formulas, until a suitable one is found. Extract of cascara sagrada, 
 ^ gr. (0.03); cascara sagrada cordial, one or more teaspoonfuls (4 to 8); fluid 
 
324 PATHOLOGICAL PREGNANCY. 
 
 extract of cascara, in increasing doses, after meals or at bedtime; compound 
 licorice powder, capsules, tablets, or pills of inspissated ox-gall, 2 grains (0.12); 
 extractum pancreatis, 2 grains (0.12); and extract nux vomica, ^ grain (0.015); 
 after meals and at bedtime; small doses of Apenta, Birmenstarff, Marien- 
 bad, Hunyadi, Friedrichshalle, Villacabras, or Rubinat-Condal waters, an hour 
 before breakfast, are all reliable remedies; but a suitable one for each individual 
 case must be chosen. For years I have been in the habit of using combinations 
 of these waters, as Marienbad and Birmenstarff, equal parts; Birmenstarff half a 
 tumblerful and Villacabras one or two tablespoonfuls ; Friedrichshalle half a glass, 
 and one or two tablespoonfuls of Villacabras, or four tablespoonfuls of Rubinat 
 water. Combinations of Apenta and the stronger purgative waters can be made 
 in the same way. I have found Friedrichshalle water, one-third of a tumblerful, 
 and Saratoga Hawthorne water two-thirds, a pleasant and valuable laxative 
 and a marked diuretic. 
 
 Enemata of plain soapsuds, and of oil, glycerin, and ox-gall, as well as laxa- 
 tive suppositories of glycerin and gluten, are occasionally useful, but should 
 not be used continuously for fear of irritating the rectum. Various pastes con- 
 taining figs are often useful. A good laxative fig paste is made from one pound 
 of figs, two ounces of senna, one ounce of coriander seed, and sugar enough to 
 make a paste. Small quantities of this paste may be taken at bedtime, or even 
 after meals. 
 
 11. Diarrhea. — This is not common, but occasionally occurs as the result of 
 irritation from pressure, and from errors in diet. If severe, it may cause an 
 interruption of pregnancy, hence it is more serious than constipation, and when 
 it amounts to dysentery it is most unfavorable. The treatment consists in the 
 use of astringents, such as tannin or aromatic sulphuric acid, combinations of 
 opium, bismuth, chalk, and zinc, and, in neurotic subjects, the administration 
 of nerve sedatives and bromides. 
 
 12. Hemorrhoids are common, on account of the general pelvic congestion 
 incident to pregnancy, and the direct effect upon the circulation of the uterine 
 pressure. They are often due to constipation and straining. Very rarely are 
 the hemorrhoids of pregnancy the cause of severe hemorrhage, anal fissures, 
 and fistulse; nevertheless they cause intense discomfort and even suffering. 
 Treatment: Operations are to be avoided, as likely to induce premature labor. 
 The recumbent position, and the frequent assumption of the knee-chest position, 
 will be useful; constipation should be avoided; benefit may be derived from the 
 use of astringent and anodyne ointments and suppositories; e. g., unguentum 
 gallae, unguentum stramonii, equal parts; opium suppositories; compound oint- 
 ment of galls. The application of fluid extract of witch-hazel upon a compress, 
 and this in turn covered with an ice-bladder, will often afford relief. For the 
 constipation, sulphur, alone or in combination with aloin and extract of bella- 
 donna, is valuable. 
 
 13. Jaundice ; Icterus Gravidarum. — (See Toxemia of Pregnancy, page 291.) 
 
 14. Appendicitis. — While this condition is at present regarded as rare in 
 pregnancy, it is probable that its frequency will become much greater, since 
 the disease itself seems to be on the increase and should certainly be favored 
 by the fact that pregnancy itself appears to be passing more and more into an 
 autotoxic state or states. 
 
 One aspect of the autointoxication of pregnancy is intestinal torpor, fecal 
 stagnation, stercoremia, etc. — conditions which tend to involve the appendix 
 directly. An inflamed appendix occurring in pregnancy may set up a salping- 
 itis, and thereby pave the way for certain forms of sep":is following labor. 
 
DISEASES OF THE CIRCULATORY SYSTEM. 325 
 
 Appendicitis in the pregnant woman when of mild degree might readily be 
 overlooked by confounding it with some other local affection. In a suspected 
 case the history of a prior attack is of great value, and with such a history some 
 obstetricians do not hesitate to operate at once ; others choose an interval oper- 
 ation after delivery. 
 
 Aside from the few preceding considerations, appendicitis in the pregnant 
 presents no differences from the same affection in the non-pregnant. 
 
 15. Tapeworm. — Much distress and possibly interruption of pregnancy may 
 be caused by tapeworm during pregnancy. I have been confronted with 
 the problem of treatment in cases of intense abdominal distress and insomnia, 
 as anthelmintics followed by the usual castor-oil may interrupt pregnancy. I 
 have observed decided symptoms of threatened miscarriage from their use. 
 Broadly speaking, we should wait until the thirty-sixth week before resorting to 
 treatment. Should the health of the patient be seriously compromised by the 
 presence of the tapeworm, we may be compelled to resort to anthelmintic treat- 
 ment earlier, in spite of the risk of miscarriage. 
 
 XIII. DISEASES OF THE CIRCULATORY SYSTEM. 
 
 I. Acute Endocarditis. 2. Chronic Endocarditis. j. Affections of the Heart Muscle. 4. 
 Varicosities. 5. Aneurism. 6. Palpitation. 7. Syncope. 8. Hydrcemia. g. Perni- 
 cious Anemia. lo. Exophthalmic Goiter. 
 
 1. Acute Endocarditis. — This affection not only has an injurious influence upon 
 pregnancy, but it is also apt itself to become extremely grave. Pulmonary 
 congestion is sure to exist from the impeded action of the heart. (Edema of the 
 lungs causes the blood to be dammed back on the heart, and there result cardiac 
 failure and fatal syncope. The most usual time for the occurrence of this acci- 
 dent is during or just after the birth of the child, and it is caused by the extra 
 strain on the heart, coincident with the circulatory changes due to the lessened 
 intra-abdominal pressure. Regarding treatment, induced labor will be demanded 
 with the rapid emptying of the uterus after dilatation, nitrous oxide or ether 
 being used if compensation is absent. Digitalis is often useful in the first stage 
 of labor, and forceps always in the second. Moderate hemorrhage in the third 
 stage, or just after it, relieves the symptoms of cardiac embarrassment. Nitrite 
 of amyl has proved useful after labor. 
 
 2. Chronic Endocarditis. — This is often followed by a fatal termination, due 
 to the fact that the hypartrophy which already exists, and has been sufficient to 
 make up for the strain of pre-existing valvular lesions, is no longer able to meet 
 the extra demands of pregnancy. One great danger in all cardiac cases, especially 
 those with acute symptoms, is embolism. Pulmonary troubles are also apt to 
 supervene in the last half of pregnancy, from exposure to cold or exertion. 
 Pulmonary congestion and oedema may occur with fatal result. Valvular 
 disease may prove a very unfavorable complication, and this is largely due to 
 the same reasons which render the prognosis so unfavorable in pneumonia, and 
 also to increased pressure in the blood-vessels, which is incident to pregnancy and 
 labor. Death is often the result in severe mitral disease, the heart showing its 
 weakness especially after expulsion of the child or placenta. The prognosis is 
 unfavorable for both mother and child, although with proper care many cases 
 will terminate favorably ; placental apoplexy and abortion are common. Mitral 
 lesions, especially mitral stenosis, are particularly to be dreaded. 
 
326 
 
 PATHOLOGICAL PREGNANCY. 
 
 \ 
 
 The treatment is symptomatic as regards the cardiac affection.' The avoid- 
 ance of overexertion and excitement is of the highest importance, and the 
 hygiene and nutrition of the patient should be carefully guarded. The induction 
 of labor must be considered if the symptoms become very grave. Inhalations 
 of nitrite of amyl may be of service in cases of dyspnea and extreme high ten- 
 sion; stimulants are to be given only if indicated. In cases of great embarrass- 
 ment of the right heart, allowing the uterus to relax and bleed during the third 
 stage will be beneficial. Anesthetics should be used with caution, ether being 
 preferred. For obvious reasons the use of ergot is not advisable in cases with a 
 tendency to contraction of the arterioles. Syncope should be guarded against 
 by the application of the abdominal binder before delivery, which is gradually 
 tightened during the emptying of the uterus. I have found careful attention tO' 
 
 nutrition and the secretions, enforced rest 
 with massage, and the prolonged and free 
 use of strychnin of great help in bringing a 
 case of chronic valvular disease to the period 
 of viability, or even to full term. During 
 labor I use ether, and hasten the dilatation 
 as much as possible by bimanual stretch- 
 ing, giving digitalis if indicated, strychnin 
 always, and I always shorten the second 
 stage with forceps. Venesection is often 
 useful. 
 
 3. Affections of the Heart Muscle. — There 
 can be no doubt that in cases of valvular 
 lesions the hypertrophy, which before preg- 
 nancy was sufficient for compensation, may 
 become insufficient in view of the increased 
 demand, and thus may lead to serious symp- 
 toms. Fatty degeneration may occur as the 
 result of the toxemia of renal disease, or of 
 septic infection ; brown atrophy has been ob- 
 served in a few instances. The existence of 
 myocarditis should cause grave apprehen- 
 sions, because the heart is hindered from 
 adequately developing to meet the demands 
 made on it by the valvular lesions added to 
 pregnancy, 
 
 4. Varicosities. — Varicose veins, especi- 
 ally of the thighs and lower gluteal region, are 
 
 very common (Fig. 472). Those of the vulva, vagina, and rectum have already 
 been noted (Fig. 466). Varicosities also occur within the pelvis, especially in the 
 broad ligaments, and by their rupture may cause pelvic hematocele; the occur- 
 rence of hematuria from the rupture of varicosities of the bladder has been 
 noted. The chief caiise is the obstruction to the return circulation, by the pres- 
 sure of the gravid uterus. Predisposing causes are the increased amount of blood 
 in the circulation, and changes in the walls of the vessels, such changes being 
 favored by renal disease and hydrsemia. Multigravidse are more often subject 
 to this trouble than arfe primigravidae. The saphenous vein is always the first 
 vessel affected. Pain, especially upon standing or walking, and with an itching 
 sensation over the dilated vein, are common symptoms ; sensations of intrapelvic 
 weight and pressure may occur. The prognosis is good with proper treatment,. 
 
 Fig. 472. — Varicose Enlargement 
 OF THE Left Saphenous Vein in a 
 Pregnant Woman. 
 
DISEASES OF THE CIRCULATORY SYSTEM. 327 
 
 but the possible occurrence of rupture should not be forgotten; such an accident 
 may be followed by most alarming hemorrhage. Thrombosis and phlebitis are 
 possible complications. 
 
 Treatment. — The patient and friends should be warned of the possibility of 
 rupture, and should be furnished with a compress and bandage, instructed in their 
 use, and how, in case of hemorrhage, the limb should be elevated. Constipation 
 should be avoided, and the patient should spend a good deal of the time in the 
 recumbent position, with hips and legs elevated. Varicosities of the lower 
 extremities should be treated by the use of properly fitting elastic stockings, or 
 carefully applied bandages. Varicosities of the vulva should be supported by 
 a pad and a T-bandage. In all cases, too much standing or walking should be 
 avoided, and there should be no constriction about the waist. An abdominal 
 supporter may help to prevent excessive uterine pressure (Fig. 228). 
 
 5. Aneurism. — This is not common during pregnancy, but is of clinical 
 importance, because of the danger of rupture from the straining efforts of the 
 second stage. The careful administration of an anesthetic, and the termination 
 of labor as soon as is consistent with due regard to the interest of the mother, are 
 advisable. 
 
 6. Palpitation. — This is a frequent occurrence. It may be of neurotic origin 
 or reflex, from upward pressure of the uterus on the diaphragm; in many cases, 
 no doubt, both elements contribute to the causation; in the absence of organic 
 disease it is not usually of great importance. Treatment: Nerve sedatives may 
 at times be indicated, but as a rule it is better to attend to the general hygiene of 
 the patient and the removal of reflex causes — e. g., constipation. Moderate exercise 
 in the open air is beneficial; causes of excitement and worry should be removed 
 if possible. Should the condition of high arterial tension exist, profuse watery 
 stools produced by the use of calomel and salines may be required, and rest with 
 careful diet insisted upon. If the trouble is the result of mechanical difficulties 
 in the last part of pregnancy, hygienic measures, together with antispasmodics, 
 may give some relief, but only when the uterus begins to sink will permanent 
 relief occur. 
 
 7. Syncope. — A special syncope of pregnancy is mentioned by some writers 
 as a manifestation of hysteria. Its consideration belongs under the latter head. 
 
 8. Hydraemia ; Serous Cachexia; Serous Plethora. — An increased fluidity of the 
 blood was formerly supposed to exist during the whole of pregnancy. Recent inves- 
 tigations have tended to show that in the latter months the proportion of hemo- 
 globin and the number of red corpuscles are increased. There is no doubt, how- 
 ever, that hydremia does exist in a large proportion of cases, especially in 
 ill-nourished subjects, in consequence of the increased demands upon the 
 maternal circulation. Not uncommonly in hydraemia there is swelling of the 
 lower extremities extending upward even to the lower segment of the uterus. 
 If there are no kidney complications, danger need not be anticipated, but the 
 discomfort caused is excessive. Nervous manifestations are common; there is a 
 sense of fulness in the vessels, with disagreeable pulsation of the arteries; flashes 
 of heat, imperfect vision, and dyspnea are present; dull aching in the sacral 
 region, and a diminution of the fetal movements, and even toxic symptoms may 
 occur. The diagnosis is clear from the history of the case and from the blood- 
 examination. The latter reveals an abnormal amount of serum, a decreased 
 number of red blood-cells, less albumin and iron, and increased fibrin. The blood, 
 after being taken from the vessels, forms a clot with abundant serum floating 
 about it, closely resembling that of chlorosis. The whole amount of fluid is often 
 much more than normal. The prognosis is generally good. The symptoms 
 
328 PATHOLOGICAL PREGNANCY. 
 
 quickly subside after the child is bom, and prematurely induced labor is rarely 
 necessary. The treatment consists in careful attention to the secretions; the 
 persistent administration of some readily assimilated preparation of iron, as the 
 peptomanganate or albuminate of iron, with cod-liver oil; careful attention to the 
 diet ; forced feeding if necessary ; massage, with a change of air and environment. 
 
 9. Pernicious Anemia. — This condition is also known as progressive anemia; 
 it is of rare occurrence, and its etiology is obscure. It may be due to a previous 
 anemia or chlorosis, from whatever cause; and when once established, there is a 
 continuous progression till death either threatens or occurs; no serous plethora, 
 as in hydraemia, takes place, and there is only a slight oedema. Examination of the 
 blood shows slight hydraemia, and a diminution of albumin and of the number of 
 red blood-corpuscles. There are progressive pallor and emaciation, with exhaus- 
 tion; the symptoms resembling those of a severe attack of chlorosis. Loss of 
 appetite, hemorrhages from mucous surfaces, and attacks of vertigo and faint- 
 ness are common. The nervous system is not well balanced; profound inanition 
 may ensue, and the patient may die comatose. The ovum may or may not 
 be prematurely expelled. The diagnosis is simple and the prognosis bad. 
 Everything possible should be done to improve nutrition; tonics, especially iron, 
 should be used, a reliable preparation of the peptonate or albuminate being 
 usually preferable ; arsenic is usually valuable ; change of air and scene may be 
 of great service; the inhalation of oxygen is highly recommended; correction of 
 the gastro-intestinal catarrh which frequently coexists is most important; the 
 induction of abortion may become necessary, 
 
 10. Exophthalmic Goitre. — In 1895 Theilhaber* collected the reported 
 material on the relationship of Basedow's disease and pregnancy, and the con- 
 nection between the same affection and the puerperium and lactation. In 
 pregnancy a minority of cases of coincidence of the two conditions shows that the 
 disease was cured or improved by gestation, while in an excessive majority the 
 disease was made worse. Theilhaber sees in the relationship between Basedow's 
 disease and pregnancy a parallel to the frequent occurrence of neuroses during 
 the same condition (neuralgia, epilepsy, chorea, etc.). The relation between 
 Basedow's disease and the puerperium is as inconstant as the above. It has 
 frequently been observed that the disease developed during the puerperium and 
 then subsided, to reappear at a subsequent puerperium; and something of the 
 same nature has been observed in connection with lactation. Kleinwachter 
 claimed that the atrophy of the uterus often associated with Basedow's disease 
 was of a nature to exclude the possibility of gestation; but in a patient of Theil- 
 haber the woman conceived after years of uterine atrophy and amenorrhea. It 
 is best to dissuade girls with Basedow's disease from marriage. Those already 
 married should be forbidden to conceive, for the good reason that both gravidity 
 and the puerperium frequently aggravate the disease greatly, and that the off- 
 spring of such women are often highly neuropathic. On the other hand, if 
 pregnancy is already established, the prognosis is not sufficiently grave to indicate 
 its interruption unless the cardiac musculature is seriously compromised. In 
 cases of child-birth in these goitre subjects prolonged lactation is contraindicated. 
 
 * "Arch. f. Gynakol.," 1895. 
 
DISEASES OF THE RESPIRATORY SYSTEM. 329 
 
 XIV. DISEASES .OF THE RESPIRATORY SYSTEM. 
 
 /. Hyperosniia. 2. Broncliitis. j. Pneumonia. 4. Emphysema. 5. Pleurisy. 6. 
 Hemoptysis. 7. Pulmonary Tuberculosis. 8. Acute Miliary Tuberculosis, g. Dyspnea 
 of Pregnancy. 10. Nervous and Spasmodic Cough. 11. Asthma. 
 
 1. Hyperosmia. — Pregnant women of nervous temperament are sometimes 
 annoyed by an abnormal development of the sense of smell. Unpleasant odors 
 should be avoided as far as possible, and pleasing ones substituted, as the condi- 
 tion may predispose to nausea and vomiting, and even be an important factor in 
 the production of the pernicious vomiting of pregnancy. 
 
 2. Bronchitis.- — During pregnancy this is of no special significance, except 
 that violent coughing may induce abortion. In all respiratory diseases, however, 
 it should be remembered that the hydraemia of pregnancy predisposes to pul- 
 monary oedema. 
 
 3. Pneumonia. — (See Infectious Diseases.) 
 
 4. Emphysema. — This frequently occurs in an aggravated form, and may 
 cause abortion, from the retention of carbonic acid gas in the blood; the influ- 
 ence of this gas in causing uterine contractions is noted in connection with the 
 etiology of abortion. Symptomatic treatment, with counterirritation of the 
 chest, is indicated. It is possible that the inhalation of oxygen, from the relief 
 it affords, may tend to prevent abortion. Careful watch must be kept for 
 symptoms of weakening heart, and should they ensue artificial labor may be 
 demanded. 
 
 5. Pleurisy with effusion, owing to the diminished breathing space, and the 
 additional work thrown upon the heart, is a dangerous complication of pregnancy. 
 If the effusion becomes purulent (empyema), the danger is manifestly increased. 
 If the condition can be relieved by the evacuation of fluid, by aspiration or other- 
 wise, the procedure is imperatively indicated; otherwise the treatment is symp- 
 tomatic. 
 
 6. Hemoptysis may occur, in connection with overaction of the heart, 
 during the last few months of pregnancy, without organic pulmonary disease, 
 and is most common in women of highly nervous temperament. The treatment 
 should include absolute rest and quiet, and the use of sedatives, particularly the 
 bromides. 
 
 7. Tuberculosis and Pregnancy. — The subject of the relationship between 
 tuberculosis and pregnancy has recently attained an increased degree of impor- 
 tance, through the agitation in favor of the justification of abortion in the tubercu- 
 lous pregnant woman. A sort of traditional view still exists in the minds of 
 some medical men and laymen, that pregnancy may sometimes arrest the devel- 
 opment of consumption. 
 
 Pregnancy a Predisposing Cause of Tuberculosis. — Statistics appear to 
 show, according to Lancereaux, that a considerable number of cases of tubercu- 
 losis develop solely as a result of pregnancy. The morbific action of the bacillus 
 is not discredited by this statement, which simply means that the woman who 
 became tuberculous, had no family history of the disease, was not of the scrofulous 
 or tuberculous habit, had never been exposed to the hazard of contagion, and 
 was living at the time of the infection in a good sanitary environment. Assum- 
 ing, as Lancereaux does, that the bacillus is omnipresent, we must conclude that 
 pregnancy by itself can render a healthy individual " tuberculizable. " If preg- 
 nancy can thus affect the healthy, how much more likely would it be for the 
 disease to assert itself in a woman who is a fit subject for it, or in one who is 
 
330 PATHOLOGICAL PREGNANCY. 
 
 actually consumptive? In the former class are so-called " candidates for tuber- 
 culosis," who have a family history of the disease, of much significance under 
 these circumstances ; one should strongly dissuade girls with tuberculous history 
 and antecedents from early marriage, fearing that rapid child-bearing will infalli- 
 bly light up the dreaded malady. What has been said of the "candidates for 
 tuberculosis " applies with the same or greater force in the case of so-called latent 
 tuberculosis, and of apparent recovery from the disease. It must not be under- 
 stood that exceptions may not occur, and that tuberculous suspects necessarily 
 become phthisical after pregnancy. The influence of pregnancy, whether single 
 or repeated, upon such women represents a tendency rather than a law, but the 
 physician's responsibility is not lessened by this fact, and he must necessarily be 
 something of an alarmist, in order to advise his patients upon the safe side. The 
 circumstances and environment of the woman, and the general prognosis of preg- 
 nancy, aside from the question of tuberculosis, should have great significance in 
 the matter of forbidding or interrupting a pregnancy. In a case of uncontrollable 
 vomiting, for example, the fact that the woman is a tuberculous suspect would 
 have much weight in influencing the physician to interrupt the pregnancy. 
 Future generations must decide as to whether pregnancy in the tuberculous 
 woman should be interrupted as a routine procedure. Present sentiment is be- 
 ginning to dissuade such women from marriage, not less for their own benefit 
 than for the sake of posterity, and all organized movements which are seeking to 
 eradicate tuberculosis from the world lay much stress .on discouraging marriage 
 in tuberculous suspects. As long as this view prevails, there will necessarily be 
 some justification for interrupting pregnancy already under way. 
 
 On the other hand, it is claimed that incipient phthisis is no longer a fatal 
 affection, and that two-thirds or more of such cases may be cured, or at least 
 brought to a standstill. If this view be accepted, we have no statistical evidence 
 to show that consumption which develops during pregnancy may be cured or 
 arrested. If the disease develops early in pregnancy, the woman must go on for 
 a number of months before she can become a fit subject for treatment, and this 
 delay would of course militate greatly against her chances of recovery. Sana- 
 toria for consumptives do not care to admit pregnant women, and this prohibi- 
 tion is equivalent to ranking them as incurable. It cannot be denied that such a 
 custom as the induction of abortion, in mere tuberculous suspects, might readily 
 become a source of abuse, by furnishing a pretext for malpractice; but, at the 
 same time, the fact that a candidate for tuberculosis runs a very great risk of 
 becoming a consumptive through child-birth is a most stubborn one, and when, 
 in addition to becoming a consumptive herself, she also brings into the world an 
 individual who is likely to become tuberculous, it readily becomes apparent that 
 the question of the propriety of therapeutic abortion is bound to become an issue 
 in the future, in the practice of obstetrics. 
 
 Pregnancy and Actual Tuberculosis. — As a general rule, gestation 
 exerts a distinctly unfavorable influence upon the disease. The presence 
 of the gravid uterus interferes with respiration and the aeration of the 
 blood, while the nausea and vomiting of pregnancy tend to interfere with assim- 
 ilation. Despite the fact that a pregnancy is often sufficient to bring about 
 tuberculosis, it cannot be said that an incipient case of the latter is much acceler- 
 ated by one parturition. As a general rule, it may be stated that the more 
 advanced the pulmonary mischief, the greater the untoward effects of child- 
 birth. Generally speaking, the ill effects of pregnancy are not apparent during 
 the very first months, and some observers regard the fifth month as the period at 
 which the course of the disease is seen to be modified by the woman's condition. 
 
DISEASES OF THE RESPIRATORY SYSTEM. 331 
 
 However, the danger to the woman is present not alone through the course of 
 the pregnancy, but in the puerperium as well. A tuberculous woman may go 
 through gestation with no undue acceleration of her malady, only to succumb, 
 after delivery, to acute general tuberculosis or acute tuberculous pneumonia. 
 
 Some forms of pulmonary tuberculosis are much less influenced by pregnancy 
 than others, and it is generally held that the so-called fibroid phthisis is hardly 
 modified at all, either during gestation or after delivery. This important fact 
 should be borne in mind in practice, because a woman with fibroid phthisis is 
 probably capable of child-bearing. In sharply localized tuberculosis the effect of 
 pregnancy by itself does not appear to be unfavorable, and it is even claimed that 
 the woman with such a lesion is better during gestation. The efforts of the lungs, 
 cramped as they are by the gravid uterus, to obtain oxygen constitute a species of 
 pulmonary gymnastics, and, as a result, the tuberculous focus does not increase 
 in size. But the situation may change immediately after delivery. The great 
 strain of labor appears to mobilize the bacillus. The loss of blood, and the 
 shock and fatigue, lower the resistance. The stimulus to forced inspiration is 
 no longer present. Under all these circumstances the local process may suddenly 
 increase, and an acute infection of the lung tissue, or generalization of the tuber- 
 culous disease, may occur. The claims made by Pinard and other observers, 
 that phthisis may undergo spontaneous resolution during pregnancy, may pos- 
 sibly rest upon an erroneous interpretation of facts, and in any case such a 
 sequence must be very rare. If spontaneous recovery does occur, it is prob- 
 ably in cases of single and sharply circumscribed foci of disease. 
 
 Obstetric treatment has now come to be regarded as the proper course, theo- 
 retically at least, but meets with considerable opposition and even condemnation 
 from conservative sources. Bossi, who has practised this form of intervention for 
 ten years, has had only about twenty cases to his credit ; whence it is to be inferred 
 that the necessity for intervention does not arise so often as one would naturally 
 suppose. Results appear to show that when done under favorable circumstances 
 — general condition fairly good, pregnancy not very far advanced — intervention 
 holds the disease in check to a decided extent. While these women often bear 
 healthy and well-nourished children, a comparison of the issue of phthisical indi- 
 viduals with those of healthy stock will show, on the part of the former, an in- 
 feriority in size and weight, and a greater vulnerability and mortality early in 
 life; and all this irrespective of the prospect of developing some tuberculous 
 disease. Tuberculous pregnant women, also, show no little tendency to abort. 
 
 8. Acute miliary tuberculosis occurring during pregnancy is a rapidly fatal 
 disease and is frequently mistaken for septic infection. 
 
 9. Dyspnea of Pregnancy. — This condition is marked by paroxysms resem- 
 bling those of spasmodic asthma, and occurs most frequently in patients of ner- 
 vous temperament. Dyspnea from purely mechanical causes, such as upward 
 pressure upon the diaphragm, frequently occurs in the later months of pregnancy, 
 and can best be relieved by loose clothing and the avoidance of constipation. It 
 usually disappears spontaneously with the descent of the uterus, which takes 
 place at the onset of the preparatory stage of labor about two weeks before term. 
 Antispasmodics and nerve sedatives, and in severe cases the inhalation of 
 oxygen, are useful. 
 
 10. Nervous and Spasmodic Cough. — Coughing of reflex origin and without 
 organic change in the respiratory tract sometimes occurs in pregnant women, 
 especially those of nervous temperament. The paroxysms maybe so severe as to 
 induce abortion. It is best treated by nerve sedatives, such as the bromides, 
 chloral, valerian, and asafetida, and by the removal of the reflex causes; i. e.. 
 
332 PATHOLOGICAL PREGNANCY. 
 
 constipation, granulations or erosions of the cervix. In a severe case which 
 resisted all other treatment, I obtained a cure at the sixth month by curetting 
 away granulations from the vaginal portion of the cervix and cervical canal, and 
 touching all raw surfaces thus produced with pure carbolic acid. Pregnancy 
 was not in any way interfered with. 
 
 II. Asthma. — In asthmatic subjects the paroxysms are exceptionally severe 
 during pregnancy, and demand the same treatment as in the non-pregnant state, 
 oxygen being of great value. Certain women have asthma only in pregnancy, 
 and the appearance of a paroxysm then becomes evidence of the patient's condi- 
 tion. The general prognosis is somewhat unfavorable for mother and child. 
 Fetal and maternal death have occurred as a direct result of asthma, and thera- 
 peutic abortion is sometimes required.* 
 
 XV. DISEASES OF THE NERVOUS SYSTEM. 
 
 Z. Cerebral Disease. 2. Gestational Melancholia, Mania, and Dementia, j. Vertigo and 
 Syncope. 4. Insomnia. 5. Gestational Paralysis. 6. Gestational Neuralgias. 7. Neu- 
 roses. 
 
 1. Cerebral Disease. — Apoplexy has little influence upon the course of either 
 gestation or labor. Inflammatory diseases are rare and accidental, and their 
 influence upon the course of pregnancy is slight, except in the case of cerebro- 
 spinal meningitis; since this latter is infectious, it has an effect upon pregnancy 
 similar to other infectious fevers. 
 
 2. Gestational Melancholia, Mania, and Dementia. — Insanity rarely has its 
 origin during pregnancy, but may occur and present the types of mel- 
 ancholia, mania, or dementia, the most common type being melancholia with 
 a tendency to self-destruction. This rarely appears until the second third of 
 gestation, and is most common in elderly primigravidce, especially the unmarried. 
 The causes are pre-existence or predisposition, excessive fright, and prolonged 
 anxiety. 
 
 Maternity Insanity in General. — The term puerperal insanity has been generally used 
 in such a sense as to comprise any psychical disturbances which antedate or follow the 
 puerperium, within certain limits. This notion, according to the alienists, is loose and un- 
 scientific. The term puerperal insanity should be restricted to manifestations which develop 
 within from four to six weeks after labor, or, in other words, during the period of the lochia! 
 discharge. The complete relationship between child-bearing and insanity should be re- 
 garded as follows: (i) Course of pregnancy, etc., in the known insane. (2) Insanity of 
 pregnancy. (3) Insanity of the puerperium. (4) Insanity following the puerperium 
 (lactation insanity) . (5) To these might be added a fifth type occurring during the act of 
 labor, from the high degree of suffering — insanity (delirium) during labor. In regard to the 
 frequency of these types of insanity, it is claimed by alienists that some 10 per cent, or 15 per 
 cent, of all the female insane who require asylum treatment derive their condition in some 
 way from maternity. According to Abt, if 15 per cent, of insanity is due to maternity, the 
 individual frequency would be as follows: insanity of pregnancy, 2 per cent.; insanity of 
 puerperium, 9 per cent.; insanity of lactation, 4 per cent. These figures, however, have a 
 limited value, for many cases of maternity insanity are so mild and transient that no incar- 
 ceration is required. It appears safe to say that puerperal insanity, in the narrower sense, is 
 the prevalent form, a fact not without significance in connection with the theory that there 
 is some relationship between this type of psychosis and sepsis. 
 
 General Etiology of Maternity Insanity.— 'R.ega.rd.ed. independently of the particular phase 
 of these psychoses, the chief etiological element is doubtless heredity; the proportion of such 
 cases amounting to not less than one-half. In this connection, acquired insanity must also 
 be mentioned as a factor. This condition may develop in those of sound heredity, as a result 
 of acute infectious diseases, violent mental emotions, acute physical overstrain, etc. 
 
 General Symptomatology. — This subject should likewise be considered without regard to 
 
 * Audebert: Paris Intemat. Congress, iqoo. 
 
DISEASES OF THE NERVOUS SYSTEM. 333 
 
 any individual phase of maternity insanity. The symptoms are present in great variety, 
 and all the familiar types of insanity are found within the domain of our present 
 subject. Insanity of the depressive type, including melancholia, hypochondria, and 
 imaginary fears, is sufficiently well represented. The melancholic type frequently 
 exhibits a religious color, expressed by self-reproach, etc. The opposite type of mania 
 is also common, with its exaltation, and increased bodily and mental activity. The 
 expression of the latter may be harmless, consisting in mere pronounced eccentricity 
 of various kinds; but it is also often violent, so that restraint becomes necessary. 
 Formerly comprised under mania, but now placed in a special category, is the hallucinatory 
 type. Here there is neither exaltation nor depression, but the patient is simply deceived by 
 her perceptive faculties. The state is therefore one of extreme confusion. Unrecognized or 
 improperly treated, this type of insanity might become coequal in its results with mania. 
 The impulses of the victim of maternity insanity to destroy herself, her children, or others, 
 are now placed under the head of imperative conceptions, not necessarily connected or asso- 
 ciated with any of the basic types of insanity. These phenomena are said to be noted par- 
 ticularly when an inherited taint is present, and often they are the first expression of such 
 inheritance. The further discussion of these insanities is continued under the special forms, 
 and they are once more brought together under the head of treatment. 
 
 Etiology. — Gestation may either awaken a hereditary taint of insanity, or the 
 psychosis may develop de novo. In the latter case the resulting mental state may 
 be regarded as an exaggeration of the disturbances of psychical equilibrium, 
 so common in pregnancy, and in connection with menstruation, especially at the 
 time of the establishment of that function. This type of pregnancy psychosis 
 then, is the least removed from the physiological status. The disturbed psychi- 
 cal and nervous equilibrium so common in pregnancy would, in itself, occurring 
 apart from that condition, constitute a mild type of psychopathy and neuropathy. 
 We have only to call attention to the unnatural cravings, the blunting and per- 
 version of taste and smell, the pretematurally acute sight and hearing, the re- 
 markable changes in disposition, amounting almost to a reversal of temperament 
 and transformation of character, etc. This type of insanity often appears to 
 have a physical basis, and to stand in close relationship with anomalies of circu- 
 lation, as shown by the very commonly encountered attacks of vertigo and 
 fainting. Aside from the general causal factors already enumerated, a special 
 factor is found, in the case of pregnancy insanity, in the shock and perturbation 
 induced by the realization of the fact that conception has occurred. This factor 
 obtains chiefly in the unmarried, and in married women who, from any reason, 
 can ill afford to submit to pregnancy. Death of a near relative during preg- 
 nancy may have a similar effect. 
 
 Symptoms. — Since the eccentricities of pregnant women are commonly 
 understood, the borderland of insanity is frequently overlooked, and opportuni- 
 ties for arresting the condition are consequently forfeited. An act of violence of 
 some sort is the first intimation of the true state of the woman's mind. Many of 
 the milder cases are so slight in degree, and of so short a duration, that they pass 
 unrecognized, and thus help to invalidate the statistics of frequency and severity. 
 As a rule, the character of the psychoses of the early months of pregnancy is of 
 the depressive type; and, generally speaking, psychoses which supervene early 
 in pregnancy tend to become worse with the aggravation of the physical condi- 
 tions. Further, the numerous severe physical disturbances and diseases which 
 may develop as pregnancy advances have a distinct tendency to aggravate the 
 psychosis, causing it to pass into a more severe and pernicious type. Psychoses 
 of pregnancy are prone to be continued after delivery ; a tendency which illustrates 
 the futility of bringing on abortion under the circumstances. Imperative con- 
 ceptions are prone to supervene during pregnancy, and they should be sharply 
 watched for, in all pregnant women of psychopathic or degenerate stock. These 
 conceptions, held under control by the will before pregnancy, begin at this 
 period to be irresistible. Many of the morbid " phobias," so common in neuras- 
 
334 PATHOLOGICAL PREGNANCY. 
 
 thenia, are also encountered under these circumstances for the first time. This 
 sudden impairment of mental equilibrium appears to be due in many cases to the 
 presence of vomiting, vertigo, and the like. The impulses to homicidal or 
 suicidal violence, in the case of these women, often comes from the sight of a 
 knife or other lethal weapon; or of an open window, etc. In some cases the 
 women themselves confess to the presence of these impulses, while they are still 
 able to master them. 
 
 Treatment. — The keynote of successful treatment lies in early recognition of 
 the psychosis. Prophylactic and general regimen comprises sufficient feeding, 
 together with proper attention to all existing physical disorders. When the 
 diagnosis is made, an alienist should be summoned in consultation. Hypnotics 
 should be promptly administered, in the hope of procuring sleep and of control- 
 ling the attack. When the general practitioner is obliged to depend upon him- 
 self, no alienist or asylum being available, he can but carry out three general 
 principles, without reference to the considerations which attend a nice diagno- 
 sis. The patient must be (i) nourished, she must be made to (2) sleep, and 
 finally she must be (3) prevented from inflicting injury upon herself, her child, 
 or others. She should be kept upon the ground floor of the house, and all 
 lethal weapons, drugs, chemicals, etc., kept out of reach. She should be kept 
 in bed, and the bedding searched twice daily for secreted articles, which 
 might be used with suicidal intent. The services of a good nurse are all- 
 important. To restrain motor excitement, and thereby limit the danger of 
 suicide, opiates are indicated, and in high degrees, morphin and hyoscin 
 hypodermically. To secure sleep all external conditions must be made as 
 favorable as possible, after which any good hypnotic, such as trional or chloral- 
 amid, is indicated. If the patient will eat, she should be fed freely with simple, 
 nutritious articles and weighed frequently. If food is refused, the stomach-tube 
 must be employed. 
 
 Various important questions arise in connection with the management of this 
 affection, (i) Asylum treatment: While indicated in theory, this resource is 
 directly contraindicated in practice, for the chances are that the patient will 
 quickly recover and will never forgive her medical attendant for the stigma 
 brought upon her (as she believes) by incarceration in an institution. The 
 patient should instead have a trained attendant, and convalescence maybe has- 
 tened by travel. (2) Interruption of pregnancy: This is never indicated, for 
 the very good reason that it does not restore the patient's mind to the natural 
 state. (3) Lactation: The patient should never nurse her child and the secretion 
 of milk should be suppressed as soon as possible. (4) The element oj sepsis: The 
 possibility that puerperal mania may have a septic element should be utilized in 
 every possible way in the management of a case. The patient should have her 
 parturient tract thoroughly examined. 
 
 3. Vertigo. — We often observe a dizziness in highly nervous and hysterical 
 women, independent of the toxemia of pregnancy. It must be remembered 
 that an exaggeration of the usual hydraemia and anemia of gestation is often the 
 real underlying cause, and can be relieved by attention to the blood conditions 
 present. 
 
 4. Insomnia. — Insomnia may occur with circulatory changes, or independent 
 of them, due to the toxemia of pregnancy. When the former is the cause, the 
 treatment consists in cathartics, diuretics, and diaphoretics. In other cases it is 
 necessary carefully to regulate the diet, and to use nerve sedatives or anti- 
 spasmodics, such as the bromides, sulphonal, camphor, valerian, and asafetida, 
 care being taken to prevent a drug habit. 
 
DISEASES OF THE NERVOUS SYSTEM. 335 
 
 5. Gestational Paralyses. — Paralyses in pregnancy are sometimes incorrectly 
 termed puerperal paralyses. The nerves of special sense, or the facial nerves, 
 may be affected, or hemiplegia or paraplegia may occur. Paralyses of the nerves 
 of special sense may result in amaurosis or deafness, partial or complete. In the 
 case of amaurosis, kidney insufficiency should always be suspected. Anemia of 
 the retina may be the cause, and if injury to the latter has not occurred, the pre- 
 mature interruption of pregnancy will result in a cure. Deafness is a rare and 
 temporary condition, and may be either unilateral or bilateral; it may or may not 
 be due to renal insufficiency. Facial paralysis is extremely rare, and is usually 
 the result of profound anemia. Hemiplegia is not uncommon in pregnancy; it 
 may be caused by cerebral hemorrhage or anemia, and does not necessarily inter- 
 fere with pregnancy or parturition. Paraplegia may be the result of a spinal 
 disease, or of pressure upon the pelvic nerves by the fetal head; the loss of volun- 
 tary motion thus produced does not necessarily interfere with pregnancy or 
 labor. Both these conditions may demand the premature interruption of preg- 
 nancy, in addition to the use of strychnin, faradization of the affected limbs, 
 and iron. Both hemiplegia and paraplegia are apt to disappear in the puer- 
 perium. 
 
 6. Gestational Neuralgias. — Neuralgic pains in various parts of the body, the 
 uterus not excepted, are common. Toothache is often met with, and may be of 
 functional or organic origin (see page 321). Neuralgias of the lumbar and recti 
 muscles are also common, the latter being due to excessive stretching; sciatica 
 often occurs in the latter part of gestation, as a result of pressure. Headache, 
 when present, should always make us suspicious of renal insufficiency, as should 
 localized neuralgic pains in the head, face, or breast, which are often symptoms 
 of advanced renal disease in pregnancy. 
 
 The treatment consists in careful attention to the excretions, especially 
 those of the bowels and kidneys, and in the use of external and internal pallia- 
 tive measures, such as sedative applications, nerve sedatives, and antispasmodics. 
 
 7. Neuroses. — Hysteria is more or less common in all pregnant women. The 
 existence of pregnancy renders the mental balance of the woman unstable, and 
 an hysterical attack may be precipitated on the slightest occasion. True insanity 
 has developed as a sequela. Syncopal attacks and hyperemesis are both regarded 
 as of hysterical origin in many cases. The treatment is that of hysteria in 
 general. Moral suasion is far more effective than are drugs. 
 
 Epilepsy is a rare complication, because epileptics are usually sterile, and if 
 gestation does occur, are often free from an attack during pregnancy, the disease 
 returning in the lying-in state. It may be confounded with an eclamptic attack 
 (see Eclampsia). Children born of epileptics usually die of congenital epilepsy 
 when quite young. 
 
 Chorea in its milder grades is not uncommon; the causes being chlorosis, 
 rheumatism, and heredity. Sixty per cent, of the cases occur in primigravidse. 
 It usually appears in the first third of gestation, and shows a tendency to persist; 
 it is observed only during the waking hours, but if it is severe and persistent, inter- 
 ruption of pregnancy occurs. The maternal mortality is as high as 30 per cent. 
 Gestational insanity is often a sequela. The causes of death are muscular exhaus- 
 tion, heart failure, insanity, or the sequelae of an interrupted pregnancy. The 
 treatment in the milder cases consists of arsenic, given to the physiological point, 
 iron, good hygiene, and carefully regulated diet. Severe cases, with tetany as a 
 complication, may require anesthesia. The induction of premature labor 
 usually results in a spontaneous cure. 
 
336 PATHOLOGICAL PREGNANCY. 
 
 XVI. INFECTIOUS DISEASES. 
 
 /. Variola. 2. Scarlatina. j. Measles. 4. Typhoid. 5. Typhus. 6 Erysipelas. 
 7. Malaria. 8. Pneumonia. g. Syphilis. 
 
 These affections are also considered fully under the pathology of the fetus 
 (page 255). In the present connection they are briefly treated from the maternal 
 side. 
 
 1. Variola. — This tends to run a severe course in the pregnant woman, cases 
 of the confluent and hemorrhagic types being specially common. But mild 
 cases, of course, occur in mild epidemics and in individuals protected in part by 
 vaccination. Metrorrhagia occurs at times, and not necessarily in hemorrhagic 
 cases. The frequency with which abortion occurs is directly proportional to the 
 intensity of the disease. It is inevitable in the hemorrhagic type, almost inevit- 
 able in the confluent type, but occurs only in a minority of cases when the 
 disease is benign. Prophylaxis and treatment call for no special mention here. 
 Pregnant women should invariably be vaccinated under the same conditions as 
 other indviduals. 
 
 2. Scarlatina. — This is considered elsewhere as a puerperal disease (Part VII). 
 As a complication of pregnancy alone it is of rare occurrence, the gravid woman 
 enjoying a relative immunity in comparison with the puerpera. Certain obstetri- 
 cians hold that the disease may be latent during pregnancy, to assert itself after 
 delivery. This is a mere opinion at present. Another view is that the exposed 
 pregnant woman may transmit the disease to the fetus without herself becoming 
 infected. Scarlatina which breaks out during pregnancy runs its course as in the 
 non-pregnant. If the degree of infection is intense, abortion results. 
 
 3. Measles. — This is rarely described as a complication of pregnancy. The 
 gravid have no special immunity toward measles, but are chiefly protected by 
 having had the disease in childhood. The course of the disease appears to be 
 identical in the pregnant and the non-pregnant. Abortion is favored by the high 
 temperature and cough paroxysms. The relative frequency of abortion is hard 
 to ascertain, but in certain small series of cases it is high (3 out of 4 times, 5 out 
 of 7, etc.). Complications of measles are rare, and there is on record but a 
 single case of death from bronchopneurnonia. It is claimed that the tendency 
 to post-partum sepsis and hemorrhage is increased, so that unusual precautions 
 should be taken to ward off these accidents. 
 
 4. Typhoid Fever. — The severity of this affection in pregnancy is neither 
 necessarily increased nor diminished. Statistics may give either a high or a very 
 low mortality. The proportion of abortion and premature delivery is high, 
 ranging, according to statistics, from 58 to 83 per cent. As a rule, all depends on 
 the gravity of the case, although sometimes pregnancy will not be interrupted 
 even in the most severe examples. Toxemia is doubtless the chief agent in 
 bringing about abortion. Sepsis is said to be a common sequel of labor during 
 typhoid fever, so that the patient becomes a victim of associate infection with 
 two formidable maladies. 
 
 5. Typhus. — The few data upon record do not admit of the drawing of 
 any conclusions upon the course of the disease in pregnancy or the frequency with 
 which abortion is produced. 
 
 6. Erysipelas. — There is neither special disposition to nor immunity from this 
 affection in pregnancy, nor is its course modified by the latter condition. Fatali- 
 ties do not appear to have been recorded, and while abortion occurs with fre- 
 quency, there are no statistics by which this may be determined. 
 
SKIN DISEASES. 337 
 
 7. Malaria. — There is less than the normal susceptibility to malarial attacks. 
 It is sometimes developed during the puerperium; it is, however, probable that 
 many cases reported as malarial have been cases of unrecognized sepsis. When 
 malarial fever occurs in pregnancy, it may pursue an atypical course; abortion 
 seldom occurs. The fetus may suffer from this disease, being born with evidence 
 of it; e. g., enlarged spleen. Quinin should be administered, as in the non- 
 pregnant state. 
 
 8. Pneumonia. — In this disease the prognosis is grave in late pregnancy, 
 owing to the diminished breathing space, the hydraemia, and the extra work 
 which the heart has to perform. Interruption of pregnancy frequently occurs. 
 The gravity of the disease and the tendency to miscarriage increase progres- 
 sively during pregnancy, and are greatest in the later months. All the symp- 
 toms are aggravated by labor, hence the induction of labor is not indicated. 
 Premature labor or abortion should be prevented, if possible. However, if labor 
 begins, it should be hastened within safe limits. The heart should be sustained, 
 and the same general treatment be pursued as in the non-pregnant state; cupping 
 and full doses of strychnin are of great service. 
 
 9. Syphilis. — This is one of the most common causes of abortion (compare 
 Placental Syphilis and Abortion). The virulence of the disease proper, however, 
 does not seem to be increased, except that the initial lesion is apt to be very 
 severe, owing, perhaps, to the genital hyperemia and the hypertrophy incident 
 to pregnancy. 
 
 The prognosis will depend, to a great degree, on the resistant power of the 
 patient, as well as on the septic micro-organisms which are associated with the 
 micro-organisms of syphilis. Fournier has said that " a syphilitic woman who 
 becomes pregnant is more likely to abort than is a pregnant woman who 
 becomes syphilitic." Treatment should begin as soon as the infection is dis- 
 covered, and be pushed just short of salivation, being in general the same as 
 that of the non-pregnant state. For the local lesions, antiseptic, sedative, 
 and drying powders should be used. Besides medicinal measures, tonics and 
 systemic nutritious feeding are demanded.- 
 
 XVII. SKIN DISEASES. 
 
 /. Pruritus. 2. Pigmentation, j. Herpes Gestationis, 4. Impetigo Herpetiformis. 5. Alopecia. 
 
 6. Fibroma M olluscum Gravidarum. 
 
 Besides the ordinary affections of the skin, to which she is as liable as the non- 
 pregnant, a pregnant woman may at times show eruptions which are intimately 
 connected with her state. As a general rule, acne, psoriasis, and eczema are very 
 much worse during the pregnant state. Not infrequently it happens that after 
 its termination those of internal origin, eczema and psoriasis, disappear of them- 
 selves. The exanthems of eruptive fevers are not modified by a pregnancy they 
 complicate. 
 
 I. Pruritus. — Itching is a symptom, not a disease. The term pruritus is 
 limited in its use to conditions in which there are no evidences on the skin except 
 those which result from scratching. 
 
 When the diagnosis of pruritus is established, it remains to determine 
 
 the causative factor. Parasites, pediculi, and the itch mite must first be 
 
 excluded. Various excitants, such as jaundice, intestinal intoxication, the 
 
 toxemia of pregnancy proper, and nephritis, may operate in pregnant women. 
 22 
 
338 PATHOLOGICAL PREGNANCY. 
 
 There may be localized pruritus of the genitals from diabetes or leucorrhea; 
 of the anal region from rectal ulcers or hemorrhoids. In this climate there is a 
 pruritus (pruritus hiemalis) which comes on at the approach of winter, affects 
 chiefly the wrists and legs, and is probably due to feebleness of circulation. After 
 these factors are excluded, there remains a pruritus of pregnancy. Its causation 
 is doubtful, but it is probably due to irritation of the peripheral nerves by circu- 
 lating toxins. There is no eruption when pruritus begins, but when the patient 
 is seen, secondary ones due to scratching are present. They are blood-crusted 
 excoriations, generally linear, which may show various infections. The char- 
 acter of the latter are impetiginous or ecthymatous (see page 339). If the 
 disease has lasted for any length of time, the skin is thickened, pigmented, 
 and its lines are deepened. There is often an indolent enlargement of the 
 lymph-nodes. In all cases of general pruritus pregnancy toxemia should be 
 suspected, and the urine examined for the total nitrogen and its compounds. 
 
 Treatment. — When pruritus is local, the cause should be removed at once. In 
 general itching, the eliminative functions of bowels, skin, and kidneys should be 
 stimulated. (See Toxemia of Pregnancy.) Copious draughts of water are recom- 
 mended as a routine measure. Internally, the opium derivatives are not to be 
 thought of. The patient usually demands relief at once, so local measures are of 
 first importance. Practically all anti-parasitics are antipruritics — sulphur, naph- 
 thol, salol, menthol, thymol, camphor, and carbolic acid. They are used in lotion, . 
 alcoholic or watery, if the skin is not dry; if it is, ointments are preferable. 
 It is better to use the latter in any case until pus infection disappears. In local 
 pruritus, cleanliness is a necessity. Pledgets soaked in carbolic acid or Labar- 
 raque's solution may be placed between the labia or in the anus. Silver nitrate 
 (5 to 10 per cent, solution) painted over the parts is helpful. Antipruritics, 
 as a rule, are best combined with diachylon ointment. 
 
 2. Pigmentation. — The specific pigmentation of pregnancy has sites of elec- 
 tion — the face and chest, especially the breasts. Pigmentation of the areola and 
 nipple can hardly be regarded as pathological. Clinically, the color varies from a 
 golden yellow to a dark brown. The spots vary in size up to a universal involve- 
 ment. They are formed by coalescence or peripheral extension. The borders are 
 sharply defined and rounded. Involution begins, as a rule, in the oldest por- 
 tions. There is no disease for which pigmentation may be mistaken except 
 tinea versicolor. In the latter affection the scales may be readily scraped off, 
 and always show threads and spores of its fungus. Metabolic pigmentation 
 of any origin is pretty difficult to remove. That of pregnancy has more ten- 
 dency to disappear spontaneously than is the case in other states, and when 
 it occasions no distress to the patient's mind, it is qtiite as well to let it alone. 
 If it is disfiguring, its involution can be hastened on unexposed parts by strong 
 exfoliative applications, such as a 20 per cent, resorcin ointment or a 10 per 
 cent, salicylic acid collodion or plaster. The inflammation set up has a distinct 
 effect in promoting absorption. On the face, these things are likely to do 
 more harm than good. Peroxide of hydrogen or pyrozone (the weaker solution) 
 has sometimes a good effect. It must be applied five or six times a day. A 
 favorite formula is bismuth suboxid, ammoniated mercury, aa ,5j; lanolin, 5j. 
 The application is to be stopped temporarily when scaling appears. 
 
 3. Herpes Gestationis {Dennatitis Herpetiformis). — Its lesions have nothing 
 distinctive about them. They consist of erythematous patches, not of great ex- 
 tent, sharply defined, without scales or infiltration; of papules which are tiny and 
 pale, capped with blood crusts, like those of prurigo, or larger elements, red, 
 pointed, and hard. On the patches of erythema or on the papules, vesicles may 
 
SKIN DISEASES. 
 
 339 
 
 appear which can be found on parts not readily reached by the nails. Lastly, 
 bullae may arise on a reddened base. The sites of predilection are the buttocks, 
 backs of the thighs, flanks, and forearms, but in exceptional cases the eruption 
 may spread over the whole surface. The mucous membranes are never attacked. 
 The lesions all have a tendency to herpetiform grouping in clusters without 
 coalescence, itch furiously, appear in successive crops, and leave deep pigmen- 
 tation. The patient may get into a bad nervous condition with insomnia from 
 the irritation. 
 
 The disease is due to faulty metabolism or toxemia. It follows shock and 
 depressing conditions generally. It is a very rare complication of pregnancy. 
 
 Treatment. — Termination of pregnancy generally, but not always, brings 
 an attack to a close. There are three things which are useful in the treatment 
 of dermatitis herpetiformis. The first is rest, the second is arsenic, and the 
 third is sulphur. Prognosis is good 
 as regards life, bad as to recurrence. 
 
 4. Impetigo Herpetiformis. — It 
 was formerly thought that this dis- 
 ease appeared only in pregnant 
 women, but cases have occurred in 
 the non-pregnant and in males. 
 There appear about the ano-genital 
 region, the umbilicus, axillae, and in- 
 side of the thighs, groups of pustules 
 which spread peripherally until a 
 large part of the surface is covered. 
 The mucous membranes are affected 
 in the same way as is the skin. The 
 disease may terminate with preg- 
 nancy, but usually it does not. The 
 cases reported have all terminated 
 fatally except two, either from an 
 intercurrent pulmonary affection or 
 in a typhoid state. Internal medi- 
 cation is useless except in the form 
 of tonics and maintenance of nutri- 
 tion. 
 
 5. Alopecia. — Loss of hair is not 
 a common phenomenon in the preg- 
 nant state or immediately following 
 it. Of the two periods, it is oftener developed post partum than in the course 
 of pregnancy. There is a possibility, however, that the fall is noticed only when 
 the hair has become thin. The fall is general, but the temporal regions are 
 usually chiefly affected. It is rare that any part is completely denuded. 
 
 It would seem probable that this affection is to be classed with the alopecias 
 of prolonged fevers. If so, it is a nutritional disturbance in the hair papillae, 
 doubtless toxemic in origin. 
 
 Treatment. — The women usually require iron and strychnin, hydrotherapy 
 and forced feeding. Locally, something can be done in the way of prevention 
 by careful attention to the scalp hygiene during pregnancy. Shampooing 
 with tincture of green soap every fortnight and application of a 5 per cent, 
 resorcin lotion are sufficient. After full development, as regards the shampoo, 
 it is well to warn the patient that she may see a considerable loss at first. I 
 
 Fig. 473. — Fibroma Molluscu.m Gravidarum. 
 
340 PATHOLOGICAL PREGNANCY. 
 
 there is any scaling, the resorcin lotion should be used two or three times a 
 week. A serviceable wash is salicylic acid gr. xx, resorcin one-half drachm, 
 oleum ricini one-half drachm, oleum lavandulse ten drops, alcohol one ounce. 
 When there is no dandruff, pilocarpin is incomparably the best remedy. It 
 cannot very well be used in injection on account of its depressant action, but it 
 may be applied to the scalp every day in a one or two per cent, alcoholic lotion. 
 The hair should be parted and the wash well rubbed into the roots. If the ex- 
 pense is too great, undiluted fluid extract of jaborandi may be substituted, 
 but is not nearly so efficacious. Prognosis is always good. 
 
 6. Fibroma Molluscum Gravidarum. — Under the name of fibroma molluscum 
 gravidarum, Brickner * has described a hyperplastic process which differs from 
 the ordinary condition recognized by the same name only in its connection with 
 pregnancy. The growths begin to appear about the fourth to the sixth month 
 in the form of a number of small sessile or pedunculated elevations about the 
 neck, breasts, and submammary region (Fig. 473)- They may increase slowly 
 in number and become pigmented to a degree varying with individuals. As a 
 rule, they are smooth, soft, and polypoid in appearance, but owing to secondary 
 growths may digitate, or if the subdivision is less marked, show a mulberry- 
 appearance. The pigment is melanin, a non-ferruginous, metabolic material 
 deposited in the lowermost layers of the epidermis chiefly. Histologically, the 
 growths consist of an increase of a rather acellular collagen, accompanied by a 
 corresponding hyperplasia of the prickle-cells. Treatment is unnecessary, as 
 the fibromas di; appear spontaneously post-partum when other regenerative 
 processes are complete. 
 
 XVIII. DISEASES OF -THE OSSEOUS SYSTEM. 
 
 /. Relaxation of the Pelvic Joints. 2. Inflammation of the Pelvic Joints. j. Osteomalacia. 
 
 4. Rachitis. 
 
 1. Relaxation of the pelvic joints is an exaggerated degree of the normal 
 process by which the pelvis is prepared for labor (see page 114). On the other 
 hand, it may be caused by a pathological state of the joints, such as inflammation. 
 The sequelae of this condition may be suppuration, fluid in the joints, and other 
 abnormal conditions. Locomotion may be effectually hindered, and as a rule 
 there are pains in these joints, as well as in the thighs and in the lumbar region. 
 A firm binder gives great relief and is often a sufficient support for comfortable 
 locomotion (Figs. 228 and 229). Rest in bed must occasionally be enjoined; 
 the binder should be worn after delivery until the parts have returned to their 
 normal condition. I am accustomed to make use of the same type of binder in 
 these cases as after the early days of the puerperium (Part .VI); a plaster-of- 
 Paris bandage is, perhaps, necessary in the more severe cases. 
 
 2. Inflammation of the Pelvic Joints. — In rare instances an inflammatory 
 process occurs in connection with the relaxation just mentioned. The symp- 
 toms are aggravated, the pain may be severe, and there is swelling over the 
 affected joints, with tenderness on pressure. The treatment is the same as for 
 simple relaxation, with the addition of anodynes and anodyne applications. 
 Cold applications may be of service. 
 
 3. Osteomalacia. — This affection is rare in America, but endemic in Italy,. 
 
 *•' American Journal Obstetrics," vol. Liii, No. 2. 1906. 
 
DISEASES OF THE OSSEOUS SYSTEM. 341 
 
 Austria, Switzerland, and other portions of Europe. The subjoined account 
 is taken largely from Schuchardt's * work on diseases of the bones and joints. 
 
 The affected bones are of a lively red hue, and are either soft and flexible 
 or show a high degree of porotic atrophy, a saw cutting through them as if 
 they were rotten wood. In the very highest degree the periosteum is trans- 
 formed into a sac containing a white, puffy mass which represents the original 
 osseous tissue. As a rule, the marrow is unusually reddened, and commonly 
 consists of lymph-marrow; in rare instances fat-marrow may be present, the 
 color then being yellow. Cystic degeneration often occurs, and is thought to 
 be salutary and to denote the resolution of the morbid process. 
 
 The naked-eye deformities in osteomalacia are numerous and characteristic. 
 At first, while the patient is able to walk about, the changes are those produced 
 by the weight of the body. There is a stronger bend to the neck of the femur. 
 The pelvis takes on the characteristic clover-leaf form, the pubic bone becomes 
 beak-like, the sacrum is bent toward the pelvic axis, the lumbar vertebrae are 
 shortened and compressed and biconcave, suggesting the vertebrae of fish, etc. 
 The base of the skull is elevated. The origins of large muscles, tendons, and 
 ligaments often become unduly prominent because of the softness of the bones 
 (osteomalacic enlargement of bones). 
 
 The long bones are, at the outset, almost non-participating, but eventually 
 exhibit flexure and curvature. In the worst cases these bones become simply 
 amorphous masses of flesh. 
 
 If recovery sets in in these cases, new osseous tissue is formed, the centers 
 of the bones being occupied by osseous tubercula or enostoses. 
 
 With regard to the course pursued by puerperal osteomalacia, the disease 
 seldom attacks women who live under hygienic requirements. Miserable, 
 overworked, and underfed peasants, living in damp and unhealthful surround- 
 ings, are the principal victims. Even here certain endemic influences obtain, 
 so that Italy and Switzerland take the lead over other countries in morbidity. 
 
 As a rule, multigravidse are attacked by preference. The pelvic bones 
 are first affected, and under the influence of the warmth of the bed, rheumatoid 
 pains set in. Tenderness over one or both ischial tuberosities is an early symp- 
 tom, interfering with sitting. The pains appear wherever softening is in prog- 
 ress. The patient loses rapidly in height, even to the extent of a foot or more. 
 The joints appear to be involved in a sort of arthritis deformans, and fever 
 is occasionally present. Changes in the muscles, not unlike those of progres- 
 sive muscular atrophy, often occur. A peculiarity of gait is thought to be due 
 to paresis of the ileopsoas muscle. Later on it is found impossible to abduct 
 the thigh and eventually, of course, all locomotive efforts become impossible. 
 The condition may last for years, with exacerbations and remissions. Par- 
 ticular deformities may result from various positions assumed while the patient 
 is bed-ridden. In diagnosis this affection has not infrequently been confounded 
 with various diseases of the spinal cord. Symptoms of great value in early 
 diagnosis are isolated iliopsoas paresis, the diminution in height, and the altera- 
 tion in the measurement of the conjugate. With regard to treatment and prog- 
 nosis, Winckel has seen spontaneous recovery. Tonic and hygienic measures 
 of all sorts are prescribed, and prolonged treatment with phosphorus appears 
 to give excellent results. Cod-liver oil is usually given as a synergist. The fact 
 that the pelvic bones have undergone softening and extensibility, despite the 
 pelvic narrowing, does not favor the expulsion of the child. According to Litz- 
 mann, there occurred in 72 osteomalacic women only 21 natural labors. In 16 
 * In vol. XXVIII of the "Deutsche Chirurgie." 
 
342 PATHOLOGICAL PREGNANCY. 
 
 cases the fetal head was perforated; in 40, Caesarean section was performed, 
 artificial premature delivery was the management in 2 cases and symphyseotomy 
 in one. Seven women had rupture of the uterus, and four died undelivered. 
 Porro employed his utero-ovarian amputation in these cases with much success. 
 Fochier, of Lyons, and Levy, of Copenhagen, who have done many Porro opera- 
 tions in osteomalacic labors, came to the conclusion that the castration incidental 
 to this form of intervention has a salutary effect upon the disease. In 1886 
 Fehling began to test this theory by the performance of simple castration in 
 these cases, with an astonishing degree of success, and the practice has become 
 general. Even after the first day from the time of operation the pains abate and 
 the tenderness becomes less marked. In a small number of cases no benefit is 
 received from the operation, which should not be performed until all other 
 measures have failed. (See Section on Osteomalacic Pelvis, Part V.) 
 4. Rachitis. — (See Pelvic Deformity, Part V.) 
 
 XIX. THE PREMATURE INTERRUPTION OF PREGNANCY; 
 
 ABORTION; IMMATURE LABOR OR MISCARRIAGE; 
 
 PREMATURE LABOR. 
 
 Classification and Definitions. — An abortion is a termination of pregnancy 
 before the placenta is formed; namely, in the first twelve weeks or three months. 
 A miscarriage, or "partus immaturus," is the termination of gestation at any 
 time from the end of the twelfth week, or third month, to the end of the twenty- 
 seventh week, or six and three-fourths lunar months. A premature labor, or 
 ''partus prematurus," is the premature interruption of pregnancy, occurring 
 at and after the twenty-eighth week, or seventh lunar month, and before the 
 thirty-eighth week, or nine and a half lunar months. I look upon the classi- 
 fication which groups under the term abortion all cases occurring within the 
 first twenty-seven weeks of gestation as also justifiable, because before this 
 time practically no regard need be paid to the life of the fetus, which may 
 be regarded as lost. I would, then, speak of early abortions in the first 
 twelve weeks, and late abortions from the end of the twelfth week to the end 
 of twenty-seven and a half weeks. Most of the German text-books on ob- 
 stetrics look upon the separation of abortion and immature labor as unjustifiable^ 
 and consider the period of viability, at the end of the seventh month, to be the 
 only admissible point of division. Most of the French text -books understand 
 the term "avortement" to extend to the end of the seventh lunar month of 
 gestation. According to this classification, abortions are pregnancies ter- 
 minated in the first six and three-fourths months, or the first twenty-seven 
 weeks; a further division is made into early abortions in the first twelve 
 weeks, and late abortions, falling within the period from the beginning of 
 the fourth to the end of the seventh lunar month; the term premature labor 
 covers the remaining cases from the twenty-eighth to the thirty-eighth week. 
 For fear of confusion of terms already generally accepted in this country, I 
 hesitate to adopt this latter classification here. The period of viabiUty is the 
 time when the fetus can live apart from its mother, the turning-point between 
 partus immaturus and prematurus ; and this limit is generally placed at the 
 end of the seventh lunar month, or twenty-eighth week, from conception. 
 We must not lose sight of the facts, however, that, on the one hand, fetuses 
 may not be viable until after this estimated date, because the calculation of 
 
ABORTION, IMMATURE AND PREMATURE LABOR. 
 
 343 
 
 the duration of pregnancy is uncertain; and, on the other hand, that, excep- 
 tionally, children bom previous to the calculated twenty-eighth week may 
 live. There is to-day no_ doubt * that many children born before the end 
 of the seventh lunar month may be saved by the use of the couveuse and of 
 gavage, and that a certain proportion of the children bom at the twenty-seventh, 
 twenty-sixth, twenty-fifth, or even twenty-fourth week of gestation can be 
 preserved. Budin claims to have saved 30 per cent, at the twenty-fourth week. 
 
 A complete abortion is one in which the 
 fetus and membranes are cast off intact ; 
 an incomplete abortion is one in which the 
 fetus is born, and the embryonic mem- 
 
 FiG. 474.— First Type of Abortion. 
 Retention of remnants of decidua only. 
 So-called "complete abortion." 
 
 Chorion. 
 Amnion. 
 Liquor amiiii. 
 Embryo. 
 
 Fig. 475. — Second Type of Abortion. 
 Retention of deciduae. Incomplete abor- 
 tion. 
 
 branes, all or in part, remain in the uterus; an abortion is inevitable when such 
 hemorrhage occurs, and the ovum descends into the lower part of the uterus, or 
 when part of the chorion or liquor amnii escapes ; a concealed abortion is one in 
 which the embryo perishes, but is not expelled; in missed abortion the embryo 
 dies, symptoms of threatened abortion occur and subside, and the ovum remains 
 in the uterus for a varying length of time; spontaneoiis abortions are those which 
 occur naturally, not being caused by artificial interference of any kind; indticed 
 abortion is one which is caused intentionally and artificially, for strictly medical 
 *Ahlfeld: "Arch. f. Gynak.," viii, p. 194. 
 
344 
 
 PATHOLOGICAL PREGNANCY. 
 
 reasons; criminal abortion, "or feticide, signifies the act of attempting to procure 
 an emptying of the uterus for other than strictly medical reasons, and the term 
 holds good, whether the attempt proves successful or fails. The terms slow and 
 retarded abortions explain themselves. Therapeutic abortion is one which is per- 
 formed for strictly medical reasons. 
 
 Pathology. — The Ovum: In only exceptional instances does the entire ovum 
 intact, with the vera, pass out in the first months. One can repeatedly, in curet- 
 ting cases of apparently complete abortion, obtain pieces of tissue which the 
 microscope proves to be decidua (Fig. 52). It is common for the refiexa to be 
 
 Placenla. 
 
 SeroHna, 
 
 Cord. ■ V. I 
 
 Amnion. 
 Liguor amnii. 
 Embryo, 
 
 Fig. 476. — Third Type of Abortion. 
 Retention of deciduse and chorion. 
 Incomplete abortion. 
 
 Fig. 477. — Fourth Type of Abortion. 
 Retention of deciduse, chorion, rudi- 
 mentary placenta and amnion. In- 
 complete abortion. 
 
 ruptured by the descent of the ovum, leaving the former, with the vera and sero- 
 tina, to pass away during the puerperium, or to be removed by operation. Again, 
 we infrequently see the chorion as well as the reflexa ruptured, the cord being 
 torn from the placenta, and the fetus, enclosed in the amnion, with hquor 
 amnii, alone expelled (Fig. 106). I have several specimens of this variety of abor- 
 tion, and it has been observed as late as the sixteenth week (Fig. 106). A rare 
 modification of this last process is shown when decidua vera, reflexa, and chorion 
 are torn away, leaving the placenta (serotina) fitted like a cap on the amnion 
 (Fig. 478). The further gestation has advanced bevond the twelfth week, the 
 
ABORTION, IMMATURE AND PREMATURE LABOR. 
 
 345 
 
 more closely does the interrupted pregnancy resemble labor at term. Moles: 
 In many cases the embryo dies early, but abortion does not occur at once; the 
 result is a uterine mole. This formation consists of a sac with thick walls which 
 are at first red, but which later become of a lighter hue (Fig. 479). The cavity 
 is irregular and corresponds to the amnion; the entire space between the amnion 
 and the external surface is bound by chorion within and decidua without, 
 and is filled with blood, thus forming "blood moles" and "flesh moles" 
 (Fig. 479). In many cases the fetus entirely disappears. If the fetus has not 
 disappeared, it may retain a fresh appearance, despite the fact that it may 
 have been dead many days; or maceration may take place, the mass becom- 
 ing soft, flabby, and dark red; the fetal surface is covered with blebs; all the 
 parenchymatous organs degenerate; the brain is fluid and the skull collapses. 
 Such fetuses are not infected, and are sometimes spoken of as jcetus sangui- 
 nolentus. In other cases the fetus becomes dry or mummified, and may remain 
 in the uterus for years (Figs. 444 and 
 445). In rare cases a second preg- 
 nancy may take place; in other in- ■ '•\^it^l^'' 
 stances the mummified fetus becomes 
 
 Fig. 47S. — Incomplete Miscarriage at 
 THE Fifteenth Week. The amnion, 
 covered by shreds of chorion and deci- 
 dua, was expelled unruptured. Most of 
 the chorion and decidua, and the entire 
 placenta, were retained in the uterine 
 cavity. (| natural size). — (Author's 
 case.) 
 
 Fig. 479. — Blood Mole Changing into a 
 Flesh Mole, w, White area in the blood 
 mass; b, blood extravasation into rudi- 
 mentary placenta; rs, outer rough surface 
 of mole; o, ovum cavity with amnion cut 
 open. — (Bumm.) 
 
 calcified, and is then termed fcetus lithopcedion (Fig. 446). Periovular Hemorrhage; 
 Placental Apoplexy : Up to the end of the second month there is a marked ten- 
 dency for the blood to spread out and form a thin layer ^ to li inches (4 to 
 30 mm.) in thickness, upon the surface of the chorion, causing the ovum to re- 
 semble a piece of flesh, bluish or blackish in color. The enveloping mem- 
 branes are seldom ruptured, and since this collection of blood is often larger 
 than the ovum itself, it goes to show that the ovum is not the source of this 
 hemorrhage. But later, in the third and fourth months, this tendency 
 decreases, and the blood is apt to collect in a limited space in the placenta, 
 forming placental apoplexies. This latter tendency increases with the advance 
 of pregnancy (Figs. 482 and 483). 
 
 Frequency. — For many reasons exact figures as to the frequency of pre- 
 maturely interrupted pregnancies are difficult to obtain. During the first 
 eight weeks, undoubtedly, many interruptions of pregnancy pass unnoticed, 
 and later in pregnancy very few such patients enter maternities, and many do not 
 
346 
 
 PATHOLOGICAL PREGNANCY. 
 
 come to the notice of private physicians or of dispensary hospital services. 
 I have recently made an exhaustive study of the premature interruption 
 of pregnancy occurring among ten thousand cases of labor treated in a dispen- 
 sary or outdoor service, in New York city. In favor of a greater accuracy 
 of these statistics is the fact that all of the 635 cases of interrupted pregnancy 
 were outdoor or dispensary cases, and patients under such circumstances are 
 more likely to seek aid under their own roof than to apply for admission to a 
 general or maternity hospital. Among 10,000 cases of labor I found 635 pre- 
 mature interruptions; namely, 242 abortions, 175 miscarriages or immature 
 
 Fig. 480. — Abortion at the Eighth 
 Week. Separation of the (dv) decidua 
 vera and (5) serotina from the uterine 
 wall. Partial descent of the entire 
 ovum; hemorrhage into the decidua re- 
 flexa; beginning dilatation of the (i) in- 
 ternal OS. e, External os; lo, lower end 
 of ovum. 
 
 Fig. 481. — Abortion at the Eighth 
 Week. The ovum, entirely separated 
 from the uterine wall, rests in the dilated 
 cervical canal, the (e) external os alone 
 preventing its escape into the vagina (v) 
 — so-called "cervical abortion." u, 
 Uterine cavity; 1, internal os; r, rudi- 
 mentary placenta; dr, decidua reflexa; 
 d, decidua vera; e, external os;t;, vagina; 
 i, internal os. 
 
 labors, and 218 premature labors. The relative frequency, therefore, was one 
 abortion in every 41.3 labors; one miscarriage or immature labor in every 57,1 
 labors; and one premature labor in every 45,8 labors. In other words, there was 
 either an abortion, a miscarriage, or a premature labor once in every 15.7 labors. 
 Age of Patients. — In making out the percentages of the frequency of inter- 
 rupted pregnancy, in different five-year groups or ages, I obtained the following 
 results, namely: nineteen years and under, the percentage of interruption was 
 3,52 per cent.; twenty to twenty-four years, 5.01 per cent.; twenty-five to 
 twenty-nine years, 6.02 per cent.; thirty to thirty-four years, 7.33 per cent.; 
 thirty-five to thirty-nine years, 10.48 per cent.; forty to forty-four years, 18.94 
 
ABORTION, IMMATURE AND PREMATURE LABOR. 
 
 347 
 
 per cent. From these studies I draw the conclusion that the smallest probability 
 of an untimely interruption, of pregnancy is before the twenty-fifth year, and that 
 the greatest probability is after the fortieth year. 
 
 Parity. — In the table on page 348 has been arranged the relative frequency of 
 cases according to the number of preceding labors (-para), added to the number 
 of mature labors, under primiparae, pluriparae (pluriparas II, III, IV, and Vparae), 
 and multiparae. 
 
 The table shows that in primigravidae, gestation is least endangered in the first 
 months of pregnancy, and that the frequency of interruption in primigravidae in- 
 creases with the further advance of pregnancy. The table also shows that in 
 
 Fig. 482. — Abortion at the Twelfth 
 Week. First stage. Beginning separa- 
 tion of the placenta and dilatation of the 
 cervix, d, Decidua vera; w, uterine cav- 
 ity; dc, dilated upper portion of cervix; 
 e, external os; p, attached portion of 
 placenta; ds, decidua serotina; ps, area 
 of placental separation; o, cavity of 
 ovum; i, internal os; r, origin of reflexa. 
 
 Fig. 483. — Abortion at the Twelfth 
 Week. Second stage, p. Separation 
 of the placenta except at its upper por- 
 tion; b, beginning separation of the de- 
 cidua vera, cervix dilated and contains 
 the lower pole of the ovum; u, uterine 
 cavity; c, cavity of ovum; a, attached 
 portion of placenta; i, internal os; br, 
 blood-injected reflexa; e, external os. 
 
 pluriparse and multiparas the relation is reversed; the majority of interruptions 
 among these occurring in the first months of pregnancy, and that the frequency 
 of interruption now decreases with the further advance of gestation. The greater 
 frequency of uterine disease in multiparae, and the large number of preceding 
 labors, some of them undoubtedly anomalous, are a sufficient explanation of the 
 greater frequency of abortion than of premature labor in multiparas. With every 
 additional interruption of pregnancy the length of gestation recedes, so that after 
 the occurrence of a premature labor there ensue first miscarriages and finally 
 abortions. The uterus, therefore, in the presence of uterine disease, becomes ever 
 less tolerant of subsequent pregnancies, and expels its contents earlier, in pro- 
 portion to the number of preceding interruptions of pregnancy, thus emphasiz- 
 ing Winckel's statement that " the longer existence of uterine disease leads to 
 ever earlier interruption of pregnancy." 
 
348 
 
 PATHOLOGICAL PREGNANCY. 
 .■' TABLE OF PARA. 
 
 Primiparae 2q 
 
 Pluriparas* 120 
 
 Multi|)aras 79 
 
 Unknown 14 
 
 Total 242 
 
 Mis- 
 carriages. 
 
 Prhmature 
 Labors. 
 
 terrupted 
 Pregnan- 
 cies. 
 
 Total Full 
 Term. 
 
 TERRUPTED 
 
 AND Full 
 Term. 
 
 22 
 94 
 49 
 
 10 
 
 71 
 
 97 
 
 46 
 
 4 
 
 122 
 
 311 
 
 174 
 28 
 
 2,009 
 5,202 
 
 2,047 
 107 
 
 2,131 
 5.513 
 2,221 
 
 135 
 
 175 
 
 i 218 ■ 
 
 1 
 
 635 
 
 9.36s 
 
 10,000 
 
 Month of Gestation. — I found in the 635 cases, as will be seen in the table 
 on page 348, that there is a marked tendency for gestation to terminate in the 
 
 third month, 23.91 per cent, occurring at 
 that time; in the fourth month, 11. 18 
 per ceiit.; in the fifth month,' 6.93 per 
 cent. ; in the sixth month only the slight 
 liability of 6.15 per cent.; a slight in- 
 crease in the seventh month to 9.60 per 
 cent. ; and in the eighth and ninth 
 months the frequency again goes up to 
 12.63 psr cent, and 12.25 per cent, re- 
 spectively. 
 
 Etiology. — The causes of interrupted 
 pregnancy may be placed in three 
 classes, and named in the order of their 
 frequency (i) maternal causes; (2)causes 
 in the ovum, embryo, and fetus; (3) 
 paternal causes. 
 
 I. The maternal causes are divisible 
 into the systemic and the local. The 
 systemic causes include obesity, mar- 
 riages of consanguinity, pregnancies in 
 rapid succession, very hot climates, and 
 very high altitudes. Poisons, such as 
 syphilis, which holds the first place, are a 
 frequent cause; e.g., malaria; large doses 
 of arsenic in skin diseases ; lead and mer- 
 cury in factories; the abuse of drugs 
 known as oxytocics (ergot, cottonroot, 
 quinin, aloes, juniper, black hellebore, 
 tansy, pennyroyal, cantharides, any of 
 these rarely disturb a healthy ovum in a 
 healthy uterus) ; and the toxemia of kid- 
 ney insufficiency. The effects of mater- 
 nal toxemia on the fetus depend not on 
 the intensity of the poison, but on the 
 power it has to excite uterine irritability. 
 In some cases this irritability is so easily 
 aroused that a slight degree of toxemia 
 will be sufficient to excite it, entailing the 
 expulsion of the fetus before sufficient time has elapsed for it to perish from 
 
 * Pluriparae in II, III, IV, Vpars. 
 
 Fig. 484. — Abortion at the Twelfth 
 Week. Third stage. The ovum, sepa- 
 rated and expelled from the uterine 
 cavity (uc), lies partly in the cervical 
 canal and partly in the upper third of 
 the vagina. A portion of the decidua 
 vera (d ) still remains behind in the uter- 
 ine cavity above the internal os (t). 
 c. Cavity of ovum; o, lower pole of 
 ovum: p, placenta; e, external os; v, va- 
 ginal wall; b, blood-clots in the cavity 
 or ovum. 
 
ABORTION, IMMATURE AND PREMATURE LABOR. 
 
 349 
 
 toxemia; while in others the fetus will suffer only from the prolonged effect of 
 the poison, the uterus having so great a resistant power against the toxin. In 
 the latter condition the irritability of the uterus has a mechanical, and not a toxic 
 origin. The non-elimination of carbonic acid gas, in diseases of the heart, lungs, 
 and liver; or violent mental shock or excitement, may interrupt pregnancy; but 
 how this latter acts is not known. Anemia, tuberculosis, infectious diseases with 
 high temperature, especially when the latter is suddenly developed, are also causes. 
 The local causes include all causes of acute or chronic pelvic congestion, such as 
 malformations and malpositions of the uterus, especially retro-displacements; 
 metritis, endometritis, salpingitis, tumors, malignant disease; excesses in sexual 
 intercourse in the newly married; traumatisms, as a blow or a fall; criminal use o 
 instruments; all causes of obstructed venous return. Perhaps the most impor- 
 tant is previous uterine disease, such as endometritis, which is quite common. 
 
 
 Week. 
 
 Month. 
 
 Number ok 
 Casus. 
 
 Percentage of 
 Interruption. 
 
 
 
 4 
 
 I. 
 
 
 
 
 
 6 
 
 i§ 
 
 
 
 10 Not Noted. 
 
 
 8 
 
 II. 
 
 61 
 
 9.61% ) 
 
 
 
 lO 
 
 2i 
 
 40 
 
 6.29% l 
 
 232 Abortions. 
 
 
 12 
 
 III. 
 
 131 
 
 20.63% ) 
 
 
 
 14 
 
 3^ 
 
 21 
 
 3-31% \ 
 
 
 
 i6 
 
 IV. 
 
 62 
 
 9.76% 
 
 
 
 i8 
 
 4h 
 
 9 
 
 1.42% f 
 
 
 
 20 
 
 V. 
 
 35 
 
 5-5 1 f« 
 
 175 Miscarriages. 
 
 
 22 
 
 5* 
 
 9 
 
 1.42% \ 
 
 
 
 24 
 
 VI. 
 
 28 
 
 4.42% ) 
 
 
 
 26 
 
 6i 
 
 1 1 
 
 1-73%^ 
 
 
 
 28 
 
 VII. 
 
 47 
 
 7.40% \ 
 
 
 
 30 
 
 7i 
 
 14 
 
 2.20% 1 
 
 
 
 32 
 
 VIII. 
 
 8^ 
 
 65 
 
 10.26% 
 2.37% ( 
 
 218 Premature Labors. 
 
 
 34 
 
 15 
 
 
 
 3^^ 
 
 IX. 
 
 50 
 
 7.99% \ 
 
 
 
 3« 
 
 9i 
 
 27 
 
 4.26% / 
 Total 
 
 
 
 635 Interrupted Pregnancies. 
 
 2, The causes in the ovum, and embryo are many of them secondary to morbid 
 conditions in the mother, but at the same time are direct causes of interrupted 
 pregnancy. The most frequent are those which interfere with the nutrition 
 or cause the death of the embryo or fetus, and include decidual and placental 
 syphilis, inflammations, and low situations of the placenta. Less frequent 
 causes are other diseases and anomalies of the decidua, chorion, amnion, liquor 
 amnii, placenta, umbilical cord, and the fetus itself, which produce the same 
 result (see pages 191 to 243). As a rule, the fetus after death acts like a foreign 
 body in the uterus, although now and then it is retained for some time, but 
 rarely over two weeks. 
 
 3. Chief among the paternal causes is syphilis, resulting in syphilitic sper- 
 matozoa, syphilitic changes in the placenta and fetus, occurring in some instances 
 with no sign of the disease in th'e mother; tuberculosis; extreme youth or old 
 age; great constitutional depression, or exhaustion from any cause. 
 
 Relative Frequency. — The principal causes in the order of their frequency 
 are (i) diseased endometrium; (2) retro-displacements of the uterus, with 
 or without adhesions; (3) syphilis; (4) kidney insufficiency, toxemia; (5) 
 criminal interference; (6) low insertion of the placenta. 
 
350 
 
 PATHOLOGICAL PREGNANCY. 
 
 Recurrent Interruptions._ — The most frequent causes of instances of repeated 
 interruptions in the same individual are (i) disease of the endometrium; (2) 
 retro-displacements; (3) syphilis; (4) toxemia. In some instances the cause 
 is so pronounced and permanent, especially in cases Of chronic pelvic inflam- 
 mations, that a tendency to abort at the same period in successive pregnancies 
 exists, thus giving rise to the term "the abortion habit." Some abortions 
 occur without any assignable cause, or from such slight cause that the accident 
 has been ascribed to an " irritable uterus." As has been frequently pointed out 
 by different observers (Winckel), a striking feature in the study of the etiology is 
 the number of preceding premature interruptions of pregnancy. 
 
 In 407 abortions and miscarriages I found 38 women, or 9.1 per cent., 
 who had experienced previous abortions or miscarriages; 103, or 24.7 per 
 cent., who had experienced previous premature spontaneous labors; and 
 141, or 34 per cent., who had experienced previous interrupted pregnan- 
 cies. Among 218 spontaneous 
 premature labors, there were 
 15 women, or 6.9 per cent., 
 who had experienced previous 
 abortions or miscarriages; 44, 
 or 20.2 per cent., who had ex- 
 perienced previous premature 
 labors; and 59, or 26 percent., 
 who had experienced previous 
 interrupted pregnancies. The 
 most striking fact shown in 
 the foregoing figures is the 
 large number of previous un- 
 timely interruptions of preg- 
 nancy; for, as the figures 
 prove, among 407 women who 
 aborted and miscarried, 141, 
 or 34 per cent., suffered from 
 previous premature interrup- 
 tions of pregnancy; and 
 among the 218 cases of pre- 
 mature labor, 59, or 26 per 
 cent., had experienced pre- 
 vious untimely interruptions 
 of pregnancy. 
 Symptoms. — The symptoms of interrupted pregnancy vary with the different 
 months of gestation; but usually premonitory symptoms of pelvic congestion 
 occur, and the characteristic symptoms follow — namely, hemorrhage, pain, 
 dilatation of the os, descent and discharge of the ovum, embryo, or fetus. 
 Great variations in symptoms occur between the first and thirty-eighth weeks 
 of gestation. In the early weeks the clinical phenomena often resemble merely 
 an exaggerated menstrual epoch, while at the eighth month all the phenomena 
 of labor at term are present. A marked prodrome of spontaneous abortion and 
 miscarriage is a tendency to syncope, and it should be remembered that abortions 
 or miscarriages occurring suddenly are rarely accidental or spontaneous. 
 
 Clinical Phenomena. — i. Abortion: In abortion — namely, before the be- 
 ginning of the fourth month — ^the clinical picture presented by the emptying 
 of the uterus is usually altogether different from that of an interrupted preg- 
 
 FiG. 485. — Flesh Mole. — {Atithor's Case.) 
 
ABORTION, IMMATURE AND PREMATURE LABOR. 
 
 351 
 
 nancy occurring subsequently. During the first three months the ovum is 
 expelled as a whole, or broken up, with more or less profuse hemorrhage; hence 
 it is that usually but a single stage of labor can be recognized ; while after the 
 third month the course of labor corresponds more and more with parturition 
 at term, and in most instances three stages of labor can be distinctly differen- 
 tiated. In the first six weeks we most frequently have "ovular abortions," 
 so called because the embryo is still indistinguishable, the ovum being dis- 
 charged intact (see Pathology) and unruptured, with marked hemorrhage 
 but with little or no pain; the time of occurrence is apt to correspond with 
 the menstrual epoch, and the little pain and backache present are attributed 
 to menstruation and to the discharge of clots through a contracted cervix, the 
 ovum passing away unnoticed. 
 From the sixth to the twelfth week, 
 "embryonal abortions" are more 
 common, so called because the 
 human form has not yet been fully 
 assumed. In these we observe pro- 
 dromal symptoms of pelvic conges- 
 tion; the pain and hemorrhage are 
 more severe ; there is first an escape 
 of the embryo, followed after a 
 varying period, which resembles 
 somewhat the prolonged third stage 
 at term, by the retained decidua, 
 chorion, amnion, and rudimentary 
 placenta. The occurrence of abor- 
 tion at this time is often preceded 
 and accompanied by active symp- 
 toms, such as syncope, nausea, 
 slight rigors, backache, increased 
 vaginal secretion, frequency of 
 micturition, thirst, pallor, and, in 
 some cases, nervous symptoms. 
 Later the pain in the back in- 
 creases, and is perhaps attended 
 with a feeling of intrapelvic pres- 
 sure; free hemorrhage occurs, large 
 clots are passed from time to time, 
 and finally the ovum is expelled 
 intact or in portions. For the 
 symptoms of threatened, inevit- 
 able, complete, incomplete, neglected, concealed, missed, and criminal abortions, 
 see Diagnosis. 
 
 2. Miscarriage or immature labor: As gestation advances through the fourth, 
 fifth, sixth, and seventh months, we find the clinical phenomena of interruptions 
 becoming more and more like labor at term. Three stages of labor can now 
 be differentiated; the uterine contractions are more marked; severe voluntary 
 bearing-down efforts appear; there is less and less hemorrhage in the first 
 stage, and more at the end of the second and during the third; there is rupture 
 of the membranes and a gush of liquor amnii; occasionally the ovum is dis- 
 charged intact in the fourth, fifth, and even sixth months — fetus, liquor amnii, 
 membranes, and placenta being discharged in one mass. The distinguishing 
 
 Fig. 4S6. — Incomplete Abortion. Cervix 
 Readily Dilatable, p, Retained placenta; 
 b, blood-clot; s, separated vera; d, decidua 
 vera; h, hemorrhagic decidua vera. 
 
352 PATHOLOGICAL PREGNANCY. 
 
 clinical characteristics of interrupted pregnancy, at this period, are retention 
 of the placenta, which is completely or partially adherent, and profuse hemor- 
 rhage in the third stage. 
 
 3. Premature labor: In comparing the course of the process in immature and 
 premature labors, we find that, clinically, the most important distinguishing 
 feature between the two is the length of the third stage of labor. After the 
 end of the twenty-eighth week the third stage of labor may differ in no way 
 from the third stage at full term, while before the seventh month the third 
 stage may continue days and weeks, unless its course is artificially terminated. 
 
 Duration. — The duration of interrupted pregnancy varies. The process 
 may be quite rapid, or days or weeks may elapse. The average duration of 
 abortions may be stated as between twenty-four and thirty-six hours. Abortion 
 may be instantaneous. This is rare, and may result from a fall, which causes 
 the immediate expulsion of the ovum, with hemorrhage. The time may 
 equal that of labor, as more frequently happens, and hemorrhage and uterine 
 contractions are the two essential features, either one or the other predomi- 
 nating, or both being of about equal importance. Slow abortion is yet more 
 frequent than the two above types. The causes are weak uterine contractions 
 and undue resistance of the cervix, or more often retention of the placenta with 
 slow detachment. The latter feature depends on the extent of surface oc- 
 cupied by the chorionic villi. Placental retention occurs about fifteen times 
 in a hundred cases. Retarded abortion is occasionally caused by the reten- 
 tion of the ovum in the cavity of the cervix, the " cervical abortion" of 
 Schroeder (Fig. 481). 
 
 Diagnosis, — The diagnosis of any variety of interrupted pregnancy, abor- 
 tion, miscarriage, or premature labor depends upon five prominent factors: 
 namely, (i) the diagnosis of pregnancy; (2) pain (uterine contractions); (3) 
 hemorrhage; (4) dilatation of the cervix; (5) descent of the ovum, embryo, 
 or fetus into the os. 
 
 1. Abortion. — The same difficulty often attends the diagnosis of an abortion 
 in the early weeks, as the positive diagnosis of pregnancy during the same 
 time. If the ovum has entered the internal os and can be recognized by the 
 examining finger, no doubt will exist;, indeed, in most cases the evidence of 
 profuse hemorrhage and dilatation of the cervix will be sufficient. The ovum, 
 if intact, can be distinguished by the fact that it becomes tense and is pressed 
 downward during a pain. Clots should be carefully washed in water, in 
 order that portions of deciduae or fringe-like chorionic tissue may be recog- 
 nized. The possible existence of extrauterine pregnancy should not be for- 
 gotten, however, for in this condition the expulsion of decidua may occur. 
 The possibility of hemorrhage from cancer of the cervix or other morbid con- 
 ditions, already described, should also be remembered. The physical signs 
 do not differ materially in ovular and embryonic abortions. At first, on vaginal 
 and bimanual examination, we find the cervix softer than would be expected; 
 rather profuse hemorrhage from the os; the body of the uterus either hard 
 from tetanic contraction or alternately hard and soft. Later, after several 
 hours perhaps, dilatation of the os is observed; the ovum descends and may 
 be palpated through the os with the examining finger, and perhaps there is 
 effacement of the angle of anteflexion which exists early in pregnancy between 
 the cervix and body (Tamier's sign). This sign of inevitable abortion, de- 
 scribed by Tamier, is by no means constantly present. It is most important, 
 at this time, to be able to distinguish with the examining finger between the 
 ovum and a blood-clot situated just within the os. In threatened abortion 
 
ABORTION, IMMATURE AND PREMATURE LABOR. 353 
 
 the clinical picture shows a hemorrhage bright in color, free from clots, inter- 
 mittent in character, fairly- persistent, and moderate in amount; there is 
 little pain or none at all; the os is somewhat dilated, but does not allow 
 the passage of the finger; the uterus is soft, anteflexed, and intermittent con- 
 tractions are infrequent. The symptoms may subside, or persist and result 
 in a complete or an incomplete abortion. As long as a chance of the subsidence 
 of the symptoms exists, the abortion is said to be threatened. In inevitable 
 abortion the hemorrhage is persistent, increasing in amount, and contains clots 
 and fragments of the ovum and liquor amnii; pain and uterine contractions 
 are present and increase in severity ; the os is dilated and admits the examining 
 finger, which palpates the ovum within the os; the uterus is alternately soft 
 and hard, or is tetanically contracted. The ovum perishes and is expelled, 
 or occasionally is retained, as in missed abortion. In complete abortion there 
 is practically no hemorrhage; pain is absent; a slight discharge resembling 
 lochia and containing small shreds of decidua is present; the os is closed; the 
 uterus is hard and well contracted, and involution is progressing normally; 
 there is a rapid subsidence of all the probable signs of pregnancy. The exami- 
 nation of the mass that has been expelled, which should always be made, will 
 give the best results if the clots and blood are removed by washing in clean 
 water. In the case of complete abortion the deciduae will be seen closely em- 
 bracing the mass, since the line of separation is in the spongy part. In order 
 to detect any imperfection in the membranes, it is well to float them upon 
 the surface of the water, when their structure will be clearly seen. In incom- 
 plete abortion hemorrhage is persistent, but varies in amount; it is at first bright 
 in color, later dark brown, thick, and offensive; attacks of intermittent uterine 
 pain, resembling "after-pains," are present; the lochia may contain shreds 
 of decidua, amnion, or rudimentary placenta; the os readily admits the finger, 
 and decidua, membrane, pieces of placenta, and blood-clots are found in the 
 uterine cavity; the uterus remains persistently large and soft; involution is 
 absent, and, with the exception of the enlargement of the uterus, the probable 
 signs of pregnancy disappear. To sum up : if the pain and discharge continue 
 from time to time, if the uterus is soft and boggy, if the os remains patulous, 
 and if the examining finger detects retained portions of the ovum, the abortion 
 is incomplete. In neglected abortion the clinical picture is the same as in incom- 
 plete abortion, with the addition of the symptoms of local and general septic 
 processes (see Fever). In concealed abortion — namely, in cases in which the 
 embryo perishes but is not expelled — the clinical phenomena are absence 
 of hemorrhage and of pain; no discharge; the cervix is soft; the os is closed, 
 but may admit the finger with firm pressure; the uterus, soft, flabby, has lost 
 the usual resiliency of pregnancy, and fails to increase in size, rather diminishing; 
 the signs of pregnancy, aside from the enlarged uterus, subside. In missed 
 abortion there are all the clinical signs of threatened abortion, with a subsidence 
 of the same, followed by those of either concealed or neglected abortion. In 
 induced or criminal abortions the clinical phenomena may not differ from those 
 of spontaneous, complete, or incomplete abortions. 
 
 2. Miscarriage. — In the second third of gestation the diagnosis of either 
 pregnancy or a threatened interruption becomes much easier, because the 
 signs of pregnancy are all more marked, the symptoms of miscarriage are of 
 greater severity than those of abortion, fetal parts and uterine contractions 
 are readily recognized, and there are the formation of a bag of membranes and 
 the escape of liquor amnii. 
 
354 PATHOLOGICAL PREGNANCY. 
 
 3. Premature Labor. — The diagnosis of premature labor becomes practi- 
 cally the diagnosis of labor at term. (See Part IV.) 
 
 Differential Diagnosis. — Abortion and miscarriage are to be differentiated 
 from menorrhagia, metrorrhagia, dysmenorrhea, and ectopic gestation. Differ- 
 entiation is also called for between threatened and inevitable, complete and 
 incomplete abortion, and between an ovum and a blood-clot. It is a matter 
 of importance to distinguish between threatened and inevitable abortion, since 
 the treatment of the latter condition is radically different from that of the 
 former. In threatened abortion the discharge is usually of a bright red color 
 and free from clots, whereas in inevitable abortion large clots and perhaps por- 
 tions of ovum may be present. In threatened abortion there is little or no pain, 
 while in inevitable abortion, especially after the first month, the pain may be con- 
 siderable. Instances have been recorded in which the os has admitted two fin- 
 gers, but has subsequently closed and the symptoms have disappeared ; in which 
 fragments of decidua have been expelled from the uterus and yet the case has 
 gone on to term; but in general it may be said that if there are much pain and 
 profuse hemorrhage, if the cervix admits the finger, and if the ovum can be felt, 
 there is little doubt as to the result. Tamier's sign has already been mentioned 
 (page 352). To distinguish between a complete and an incomplete abortion is also 
 important, with reference to treatment, in order to determine whether the uterine 
 contents have been wholly or only partly expelled. The discharge of an intact 
 ovum will, of course, settle the question. If the hemorrhage and pain cease, if 
 the OS is closed, and if the uterus, although still large, is firmly contracted, and 
 there is a disappearance of the signs of pregnancy, especially the milk secretion, 
 the abortion is probably complete. In order to differentiate an ovum from a 
 blood-clot by the palpating finger, Holl's sign may be of service, (a) During 
 a pain, caused by uterine contraction, the ovum, increased in size, smooth 
 and tense, advances, while a blood-clot does not become tense, nor does it 
 advance. (6) The ovum presents a tense, resilient, and convex surface, while 
 the blood-clot is cone-shaped, apex downward, and non-elastic, (c) If pressure 
 is exerted on the fundus, in case the mass is an ovum, motion is not transmitted 
 to it as a whole, on account of its resiliency, while the blood-clot would be 
 moved en masse, on account of its solidity. 
 
 Prognosis. — Mortality: Among the 242 cases of abortion studied there were 
 no deaths from any cause; among the 175 cases of miscarriage, one death from 
 placenta prsevia and ruptured uterus occurred; and in 175 spontaneous pre- 
 mature labors there were four deaths, — one from placenta prasvia and hemor- 
 rhage, one from sepsis and bronchopneumonia, two from nephritis and eclamp- 
 sia. These cases were all cared for in their own homes. The prognosis of 
 spontaneous interruptions is good, under intelligent treatment, and when the 
 cause of the interruption is not in itself a menace to life; such as high tempera- 
 ture from an acute general disease, placenta praevia, nephritis, or eclampsia. In 
 criminal interruptions, on the other hand, the prognosis is bad, by reason of 
 the unskilfulness of the procedure admitting air and septic matter into the 
 uterus, the secrecy surrounding the affair, and the accompanying moral shock. 
 In neglected or improperly treated cases the mother is exposed to the dangers 
 of immediate and late septic infection, of hemorrhage, of endometritis, and 
 to a long train of remote evils, including the liability to subsequent abortions. 
 
 The irnmediate dangers of interrupted pregnancy are: (i) hemorrhage; (2) 
 retention of an adherent placenta; (3) sepsis; (4) tetanus; (5) perforation of 
 the uterus with a curette. 
 
 I. Hemorrhage. This complication causes alarm only when it is present 
 
ABORTION, IMMATURE AND PREMATURE LABOR. 
 
 355 
 
 in an extreme degree. It is the general symptoms resulting which are especially 
 to be feared; namely, the tendency to syncope, disturbances of the special 
 senses, etc. Hemorrhage predisposes to septicemia, but in itself is not often 
 fatal. Persistent hemorrhage, though slight, induces a condition of weakness, 
 strongly predisposing to infection later. Hemorrhage in abortion, as a promi- 
 nent symptom in the early stages of the 242 cases studied, occurred in 85.57 
 per cent., thus agreeing with what has already been stated regarding the fre- 
 quency of hemorrhage at the outset of abortion cases proper. Of these 242 
 cases, 214 were subjected to curettage, shortly after being seen, and in only 
 one case was there subsequent hemorrhage. In the 175 miscarriage cases, 
 hemorrhage as a prominent symptom before or during labor occurred in 66.29 
 per cent, of cases; iii of these 175 cases were subjected to curettage shortly 
 after being seen, and subsequent hemorrhage took place in five cases. In 
 the 218 cases of spontaneous premature labor, hemorrhage before or during 
 labor occurred in 6.42 per cent., and after delivery in four cases. Eight of 
 these hemorrhage cases were the 
 subject of placenta praevia. 
 
 2. Retention of adherent placen- 
 ta, which demands an expression, 
 a digital or manual removal, or a 
 curettage after removal, is com- 
 mon in the fourth and fifth months, 
 and becomes less so as full term is 
 approached (Fig. 486). 
 
 2,. Septic infection. This may be 
 due to decomposition of retained 
 placenta, or to faulty asepsis and 
 antisepsis in the technique of the 
 treatment . The pulse usually gives 
 the first signal, which is followed by 
 fever, rigors, suppression or putrid- 
 ity of the lochia, etc. Death may 
 come quickly or slowly, or by care 
 it may be warded off, though there 
 may be left behind lesions of the 
 uterus and its adnexa. I found 
 that fever as a complication occur- 
 red, among 242 abortions, in 11.57 
 
 per cent., two-thirds of this only being due to sepsis; in 1 75 miscarriages fever as 
 a complication took place in 21.71 per cent., three-fourths of this being caused 
 by septic infection; and in 218 spontaneous premature labors fever occurred in 
 19.27 per cent., one-half only of this amount being due to uterine sepsis. Pyemia 
 is especially common after abortion, infection taking place usually at the 
 placental site. 
 
 4. Tetanus. This is frequently reported as a sequel to abortion and mis- 
 carriage, but is most often an accident in the course of a general septicemia. 
 In the 242 abortions, 175 miscarriages, and 218 spontaneous premature labors 
 already referred to, no case of tetanus occurred. Although a rare condition, it 
 was observed twenty-one times by Bennington, who collected 41 cases of puer- 
 peral tetanus. 
 
 5 . Perforation of the uterine wall. Numerous cases of perforation of the uter- 
 ine wall, during curettage after abortions and miscarriages, have occurred. The 
 
 Fig. 487. — ^Placental Polyp in Situ. Drawn 
 from a specimen, u, Utero-placental arter- 
 ies; i, internal os; /, lower portion of polyp 
 hanging in vagina; h, blood-injected placen- 
 tal remnants; e, external. os. — (Bumm.) 
 
356 PATHOLOGICAL PREGNANCY. 
 
 danger of perforation is reduced to a minimum if the curette, when introduced 
 into the uterus, is passed cautiously to the fundus, and then, with a firm down- 
 ward stroke, is used to clear the uterine walls, especially at the horns. 
 
 The remote dangers of interrupted pregnancy are: (i) subinvolution and dis- 
 placements; (2) septic sequelae ; (3) endometritis; (4) polypi; malignant disease; 
 (5) sterility; (6) anemia; (7) recurrence; (8) neuroses. 
 
 1. Subinvolution and displacements. Involution takes place more quickly 
 than after labor at term, unless the abortion is incomplete; its progress being 
 delayed by septicemia and retention of the membranes. Subinvolution is 
 not uncommon after interrupted pregnancy; and often causes displacements. 
 Subinvolution is at times accompanied by a tendency to metrorrhagia, which 
 leads to anemia and debility. 
 
 2. Septic sequelcB. Local or general sepsis, which sometimes follows abortion, 
 may each induce a train of serious sequelae. The former is responsible for 
 endometritis, metritis, perimetritis, parametritis and pelvic abscess, salpingitis, 
 oophoritis, and sterility. Remote infections may develop as sequelae, as shown 
 in the occasional supervention of suppurative arthritis and other pyaemic 
 processes at a distance from the pelvis. 
 
 3. Endometritis. As regards endometritis, diametrically opposite opinions 
 are maintained. Stumpf, Winter, and Puppe say that it is not the result 
 of abortion and retention of membranes, and point to Veit's curetted cases, 
 in which the endometritis had to be treated after the puerperium was ended. 
 They neglect to suggest the possibility of a prior abortion, expectantly treated, 
 being at the bottom of the trouble. Reference to the figures given below shows 
 a 15.3 greater percentage of subsequent pregnancies when the secun dines 
 were instrumentally removed, which is tolerably fair evidence that these 
 cases were free from endometritis. 
 
 4. Polypi; Malignant disease. The non-septic residue of the embryo, 
 persisting within the uterus, may become nourished and develop into decidual 
 and placental polypi, and even into that rare and peculiar formation known 
 as deciduoma malignum, although this is seen more commonly after molar 
 pregnancy (Fig. 487)- 
 
 5. Sterility. Many authorities hold to the opinion that a uterine mucous 
 membrane, completely renewed after an abortion, by reason of a curettage, 
 is less capable of playing the part of a decidua of pregnancy than one that 
 has done so before in whole or in part.* 
 
 Certainly, my figures lead one to a far different conclusion from Puppe 's. 
 Of 119 cases treated by instrumental curettage, 38, or 31.9 per cent., had expe- 
 rienced one or more previous interrupted pregnancies; 5, or 4.2 per cent., 
 suffered subsequently in the same way; 48, or 40.3 percent., gave birth to 
 living children at term; and 21, or 17.6 per cent., were found to be pregnant 
 from the fourth to the eighth month when visited. These observations were 
 made at the patients' homes and the children were seen. Of 28 cases of abortion 
 expectantly treated, 10, or 35.7 per cent., had had similar previous experiences. 
 None suffered from subsequent interrupted pregnancies; 7 gave birth to living 
 children at term afterward (25 per cent.); 5, or 17.8 per cent., were found 
 to be pregnant from the fourth to the eighth month when visited. 
 
 6. Anemia. The hemorrhage which accompanies the act of abortion may 
 be so profuse, especially if the pregnancy is well advanced, that a condition 
 
 * Puppe: " Untersuchungen iiber die Folgezustande nach Abortus." Inaug. Dissert., 
 Berlin, 1890. 
 
ABORTION, IMMATURE AND PREMATURE LABOR. 357 
 
 of acute anemia, with all its sequelas, may be established. Hemorrhage due 
 to subinvolution has been mentioned (page 354). 
 
 7. Recurrence. The tendency to a recurrence of abortion, and to the estab- 
 lishment of habitual abortion, may be set down, with justice, as a sequela of 
 interrupted pregnancy, which is highly important by reason of its frequency. 
 
 8. Netiroses. Finally, American authorities enumerate a tendency to 
 functional neuroses, and even to psychoses, as one of the sequelae of the inter- 
 ruption of gestation. The pathogeny of these affections is obscure. 
 
 Treatment. — i. Prophylaxis: In habitual premature interruption the cause 
 or causes should first be sought. The various conditions which are known 
 to favor miscarriage should be considered, one after the other; the uterus 
 itself should first be examined; if conception has not taken place, any anomaly 
 which is apparent, such as malposition, endometritis, laceration of the cervix, 
 etc., should receive suitable treatment. If syphilis exists in either parent, 
 a thorough course of antisyphilitic treatment for several months should be in- 
 sisted upon, irrespective of previous medication; uterine displacements should 
 be corrected, and the uterus may, if necessary, be kept in position by a suitable 
 pessary for the first three months, care being taken, however, that the pessary 
 causes no irritation ; endometritis or other intrapelvic disease should be suitably 
 treated. For the various morbid conditions causing sterility, and their appro- 
 priate treatment, the student is referred to works on gynecology. If the woman 
 is already pregnant, the uterus is beyond the reach of treatment, save that a 
 pessary may be worn for retroversion, during the first three or four months. 
 Coitus should be forbidden during pregnancy, and rest in bed for a few days 
 before and after the dates corresponding to the usual menstrual epochs is 
 advisable; the use at this time of the fluid extract of viburnum prunifolium, 
 and the uterine sedatives — hydrastis canadensis, Jamaica dogwood, and Pul- 
 satilla — is also advised. Everything that causes mental or physical shock or 
 fatigue — excitement or worry ; exercises, walking, standing, prolonged physical 
 exertion ; improper diet ; the use of violent purgatives ; railway journeys or auto- 
 mobile riding over rough roads — must be avoided. Conditions which predispose 
 to abortion, such as severe coughing, vomiting, and intercurrent diseases of 
 pregnancy, should receive prompt attention. Another method of dealing with 
 habitual abortion is to forbid pregnancy until a given interval has elapsed. 
 This is probably the best means for meeting the indication, for the tendency 
 to abortion is not inborn but acquired, and physiological rest will enable the 
 uterus to outlive this faulty condition. 
 
 2. Threatened interruption: Abortion becomes inevitable when the ovum 
 is dead; this condition, however, in the early months can only be inferred. 
 The criteria upon which to base an assumption of this event are two: the 
 amount of hemorrhage, which when extensive argues for the existence of a 
 corresponding degree of separation of the ovum, and the degree of dilatation of 
 the OS. We should not act upon the supposition that death of the ovum has 
 occurred, for the patient should be given the benefit of the doubt, but wait 
 until a certain period has expired, during which the hemorrhage may subside 
 and the os close. After the sixth month we can tell whether the fetus is dead, 
 and in every case an attempt should be made to save the life of the child. The 
 patient should be kept in bed in a quiet, darkened room; the rectum and bladder 
 attended to; simple liquid diet used, and physical and mental rest secured 
 by sedatives. If marked symptoms are present, i of a grain (0.016 gm.) of 
 morphin may be given subcutaneously, and the bromides, with viburnum 
 prunifolium and hyoscyamus, administered by mouth; the patient remaining 
 
358 PATHOLOGICAL PREGNANCY. 
 
 in bed for several days after all symptoms have disappeared. A useful pre- 
 scription in these cases is: Sodium bromide, half an ounce (i6 gm.); simple 
 eUxir, three ounces (96 gm.); tincture of hyoscyamus and extract of viburnum 
 prunifolium, of each half an ounce (16 gm.). Take two teaspoonfuls, in a 
 sherry glass of water, every three hours. It may be necessary to continue this 
 line of treatment several weeks, and it is justifiable when we observe an 
 increase in the size of the uterus and other signs that the fetus is alive. The 
 management should be the same, whether the chances are in favor of or against 
 saving the ovum, and the general principles of treatment are the same as in 
 the prophylaxis of abortion. The best sedative is opium, which may also be 
 required as an anodyne if pain is present. If the loss of blood is excessive, some 
 hemostasis must be effected, but ice-bags and tampons are alike contraindicated,. 
 since either might have an oxytocic action. Our only resources are postural, 
 viz., elevation of the pelvis and, possibly, cold compresses to the vulva. If, 
 after several hours, it becomes evident, from the extent of hemorrhage, uterine 
 contraction, and dilatation of the os, that abortion is inevitable, the treatment 
 for that condition should be instituted. If, on the other hand, the symptoms 
 improve, the treatment should be continued until hemorrhage and pain have 
 subsided, and in any case for at least forty-eight hours. After this, the patient 
 should be regarded as on probation for a week longer, if there is any recurrence 
 of pain or metrorrhagia. 
 
 3. Inevitable interruptions; early abortions: Authorities are at variance as 
 to the indications. Shall the emptying of the uterus be left to nature, or is 
 it the physician's duty to evacuate this organ at once? Is it possible that each 
 of these plans has its legitimate field? Or, is it possible to combine the two 
 plans, by a compromise, without treatment? All methods. for the management 
 of inevitable abortion may be systematically classified as follows: (i) Purely 
 conservative or expectant treatment. Interference is altogether interdicted,, 
 and sole reliance placed upon the tampon, vaginal irrigation, and ergot. (2)- 
 Early artificial removal of the decidua or placenta, active treatment so called, 
 in which curettage is the routine plan. (3) An intermediate or eclectic method, 
 in which intervention is resorted to only in order to control hemorrhage or 
 sepsis. The indications for treatment, in all cases of inevitable abortion, are 
 the same: namely, first, to control the hemorrhage; and, second, to secure 
 complete evacuation of the uterine contents. Both are best fulfilled by instru- 
 mental curettage of the uterus, and as a temporary measure, to control hemor- 
 rhage while preparations for curettage are in progress, the vaginal tampon 
 is most valuable. The latest observations tend to show that in abortions, 
 contrary to the generally received opinion, the separation of the decidua vera 
 from the uterine wall takes place from above downward, ai:id that consequently 
 the complete removal of the decidua by the finger seldom, if ever, takes place. 
 Moreover, the removal of small fragments of decidua is easily accomplished 
 by the curette, while it is difficult, if not impossible, by the finger. Other 
 advantages of the curette are that less dilatation of the cervix is necessary, 
 the operation is less painful, and anesthesia is not always required. I advise, 
 in all cases of inevitable abortion and in those in which the accident has already 
 occurred (incomplete), that the patient be plainly told that a curettage is 
 necessary, leaving entirely out of consideration the amount of hemorrhage 
 as an indication for interference ; and if, upon explaining the danger of retained 
 secundines to her, consent for curettage cannot be secured, then only should 
 the first method of purely conservative or expectant treatment be followed — 
 namely, relying upon the vaginal tampon, irrigation, and ergot. The patient's 
 
ABORTION, IMMATURE AND PREMATURE LABOR. 
 
 359 
 
 consent having been obtained, curettage is performed in as short a time as 
 possible. The vaginal tampon is useful in all cases in which hemorrhage is 
 severe and the curettage cannot immediately be performed; it effectually 
 controls hemorrhage, aids in the separation of the decidua, and in the dilatation 
 of the OS. (For curettage, instrumental and digital, and vaginal tamponade, 
 see Operations, Part X.) 
 
 I advocate the active treatment of abortion, inevitable or incomplete, 
 by reason of the analyses of the records of many hundreds of cases, treated 
 
 
 Jl 
 
 F. 
 
 M 
 
 F. 
 
 M 
 
 F. 
 
 M 
 
 F. 
 
 M 
 
 E 
 
 M 
 
 E 
 
 M 
 
 F. 
 
 M 
 
 E 
 
 M 
 
 E 
 
 M 
 
 E 
 
 M 
 
 E 
 
 M 
 
 E 
 
 or'To'^MtNTS 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 o.il/S'Jo^nt 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 F. 
 
 107° 
 
 10C° 
 < 
 1 105° 
 
 i 104° 
 
 z 
 
 103° 
 102° 
 101° 
 100° 
 99° 
 
 Z 
 
 i 98° 
 I 97° 
 
 DAV OF DIS. 
 
 PULSE 
 
 ^RESP. 
 
 DATE 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 A 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 f^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 / 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ' 
 
 ' 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 -s 
 
 
 
 
 1 
 
 
 
 
 i^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 
 c 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 
 ^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 =; 
 
 
 
 
 ' 
 
 
 
 ^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ^ 
 
 
 
 
 
 
 
 O 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 -■s,. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 < 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 -l 
 
 
 
 
 
 
 / 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ■■=- 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 - 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ^ 
 
 
 
 
 
 
 
 
 
 
 V 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ^ 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 
 
 
 / 
 
 '■\ 
 
 
 
 
 
 
 
 
 Cl_ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 / 
 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 s 
 
 
 
 
 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 s. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 N 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 
 
 ^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ' ' 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Labor 
 
 1 
 
 2 
 
 3 
 
 4 
 
 5 
 
 G 
 
 7 
 
 s 
 
 u 
 
 10 
 
 11 
 
 120' 
 .''115, 
 
 lis,' 
 
 .•-120 
 
 115-' 
 ,'115 
 
 100,'' 
 ,'110 
 
 100.'' 
 
 05,' 
 .-'90 
 
 00,'' 
 ,'90 
 
 100.' 
 ,'100 
 
 95,'' 
 ,,'90 
 
 80,'' 
 .'80, 
 
 80,.- 
 ,'80 
 
 30,' 
 ,' 80 
 
 ^'' 
 
 
 ,''■ 
 
 ,'-' 
 
 ,' 
 
 ,,'' 
 
 ,- 
 
 ,,'' 
 
 ,,'' 
 
 ,,'-' 
 
 ,'-' 
 
 ,,' 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 >I 
 
 E 
 
 M 
 
 E 
 
 M 
 
 E 
 
 M 
 
 E 
 
 M 
 
 E 
 
 M 
 
 E 
 
 M 
 
 E 
 
 Op'TAfMtNTS 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 D.a,"".'Mgu«r 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 F. 
 
 107° 
 
 106° 
 i 105° 
 
 2 ■ > 
 
 -1 
 
 f 104° 
 103° 
 102° 
 101° 
 100° 
 99° 
 
 1 98° 
 '- — ^ 
 
 \ 97° 
 
 DAY OF DIS. 
 PULSE 
 RESP. 
 
 DATE 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 , 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 i 
 
 
 
 
 
 
 
 
 
 
 
 
 / 
 
 
 
 
 
 
 
 
 
 
 
 
 
 -•.J 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 — 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 , 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1/ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Ir 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ,51 
 
 
 
 
 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 \^ 
 
 
 
 
 
 
 
 
 
 
 
 
 ''■s. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 V 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ^ 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 1 
 
 2 
 
 i 
 
 4 
 
 5 
 
 G 
 
 90 .' 
 ,'^76 
 
 ,','90 
 
 76,' 
 ,-'90 
 
 .' 35 
 
 30,.' 
 ,'80 
 
 *'-80 
 
 .^'83 
 
 /•' 
 
 y' 
 
 ,'-' 
 
 y 
 
 ,'"" 
 
 
 y 
 
 
 
 
 
 
 
 
 Fig. 48S. — Miscarriage at Five and a Half 
 Months; Manual Extraction of the Pla- 
 centa; Septic Intoxication; Curettage on 
 the Fourth Day. 
 
 Fig. 489. — Incomplete Early 
 Abortion. Septic Intoxica- 
 tion; Curettage 
 
 by various methods, and especially from an exhaustive study of the pathology, 
 bacteriology, duration, complications, sequelae, and treatment of 242 cases; 
 166 of which were treated by instrumental curettage; 45 by combined instru- 
 mental and digital curettage; 3 by digital curettage only, and 28 by a purely 
 expectant treatment. Contrasting the expectant and active plans of treatment 
 of abortion, I believe the latter is less dangerous than the abortion and its 
 sequelae in cases of retention, and curettage makes sure that everything is 
 removed; involution and time are necessarv for convalescence after abortion; 
 
360 PATHOLOGICAL PREGNANCY. 
 
 the one is hastened, the other cut short, after curetting; this is, of course, a 
 boon to the working classes; the expectant plan requires two weeks for itself 
 alone; after instrumentation the patient may leave her bed on the fifth day; 
 pain and physical discomfort, as well as mental perturbation, are less than 
 in the expectant method; moreover, a large proportion of so-called complete 
 abortion cases are followed by hemorrhages, subinvolution, acute and chronic 
 sepsis; hemorrhage is always greater with expectant treatment; not more 
 than half an ounce is lost by instrumentation, before the fourth month. In 
 the first two months and a half, emptying of the uterus can be accomplished 
 with curettage alone, the canal admitting the finger with difficulty and pain 
 if anesthesia is not used. Uterine atony is controlled by irrigation and uterine 
 tamponade with gauze; ergot is rarely called for, the placental forceps only 
 occasionally. If curettage for any reason cannot be accomplished at once, 
 the vagina may be tamponed with sterile gauze until the operation can 
 be carried out. This course may also be pursued when curettage is refused, 
 and the gauze packing may be left in for twenty-four hours. Again, if the 
 accoucheur is a beginner, who dreads assuming the responsibility of forced 
 dilatation and curettage, he is justified in adopting the conservative plan, 
 and in temporizing with a gauze pack until dilatation occurs. Inevitable 
 abortion may terminate, in a small number of cases, in expulsion of the ovum 
 almost entire in which case it is arrested in the cervical canal. Under these 
 circumstances curettage may not be necessary, as hemorrhage may cease after 
 simple extraction with the finger or forceps. In case the ovum is too large 
 to pass through the os, the latter may be dilated. 
 
 Late abortions. In the management of late abortions the treatment which 
 has been advised for early abortions is preferable during the early portion 
 of the second third of gestation; since clinically we are unable to draw the 
 line so sharply between early and late abortion as some authorities would 
 have us do. With the advance of pregnancy the treatment should become 
 less and less aggressive, until it gradually merges into that of premature labor 
 and labor at term. The real criterion of late abortions is the marked pro- 
 longation of the third stage of labor, which is due to the facts that placental 
 development has occurred, and that the placenta is frequently adherent to 
 the uterus. In the removal of an adherent placenta the manual method, as 
 stated, is usually preferable, while for the removal of the decidua the curette 
 is to be preferred. It is best not to use the curette to remove the placenta 
 after the twelfth week. It is not consistent or safe to do so, and as a greater 
 number of abortions occur at the third month, the method of treatment must 
 be a combined one. The separation of the placenta is readily accomplished 
 by digital curettage; the curette remioves the decidua vera. Bimanual com- 
 pression of the fundus uteri by tv/o fingers internally and the other hand exter- 
 nally upon the abdomen, as a method of placental expression, is quite painful, 
 frequently ineffectual, and is not to be recommended. 
 
 4. Incomplete and septic abortions: If the fetus has been expelled from the 
 uterus, the membranes and placenta remaining behind, the indication is to 
 curette at once, even if forcible dilatation is required. In suspected and estab- 
 lished sepsis the greatest care must be used in all examinations and operative 
 procedures not to open up new areas for infection. Sepsis may not be recog- 
 nized as such, but we may assume that it is present if a high pulse exists, with 
 or without fever. In this class of cases, as in infection after labor at term, I 
 use the gentlest means to clear the uterus of retained material. Usually the 
 finger and irrigation are sufficient. In exceptional cases I still resort to the 
 
ECTOPIC GESTATION. 361 
 
 dull curette where the size of the uterine cavity or the nature of the retained 
 matter do not allow of the efficient use of digital curettage. The uterus is then 
 irrigated with several quarts of a saline or antiseptic solution, and further intra- 
 uterine treatment is contraindicated, with the possible exception of an occasional 
 irrigation, most carefully administered. The remaining treatment of septic 
 abortion does not differ from that of puerperal sepsis in general. 
 
 Premature labor. This is the same as the management of labor at full term. 
 (See page 463-) 
 
 After-treatment. — The after-treatment of abortions, miscarriages, and pre- 
 mature labors should approach as nearly as possible to that of the puerperium 
 at term. (See Part VI.) Unfortunately, after early interruptions of pregnancies 
 patients insist upon making light of the condition, leave the recumbent position 
 too early, and generally abandon treatment so essential for the attaining of proper 
 involution. Involution is relatively slower after abortions and miscarriages than 
 during the normal puerperium; hence the dangers of subinvolution, uterine dis- 
 placements, and pelvic inflammations should always be explained to the patient, 
 and the importance of the same attention to the condition as after labor at term. 
 The combined and persistent use of ergot and strychnin I have found of the 
 greatest value in hastening involution and in preserving the tone of the uterine 
 ligaments. I use one or two grains (0.06 to o.i 2 gm.) of ergotin, and one-thirtieth 
 (0.002) of a grain of the sulphate of strychnin, three times a day, in capsules 
 or tablets. As lactation is absent, this function does not constitute an objection 
 to the use of these drugs. Vaginal and uterine irrigation is unnecessary, except 
 after incomplete or neglected abortion, or miscarriage with symptoms of uterine 
 sepsis. Late in the puerperium very hot vaginal irrigations are of benefit in 
 assisting involution. Ergot and its derivatives must not be given until the 
 uterus is free from the products of conception. It is just as necessary for a 
 physician to know how to treat abortion as it is to treat normal labor, and the 
 matter should receive adequate attention in the schools. 
 
 XX. ECTOPIC GESTATION. 
 
 Definition. — Ectopic gestation or extrauterine pregnancy consists in the 
 development of the fertilized ovum outside of the uterine cavity. 
 
 Varieties; Site. — Despite the occasional alleged development of the ovum in 
 some one of a variety of atypical localizations — ovary (Fig. 490), angle of uterus 
 (Fig. 491), abdominal cavity, etc. — the vast majority of cases occur within some 
 portion of the Fallopian tube ; usually toward the ovary (Fig. 493). This variety 
 is known as the ampullar. Development of the ovum midway in the tube or at 
 its uterine extremity is very infrequent. Hence for practical purposes ectopic 
 gestation may mean an ampullar gestation — in other words, a phenomenon be- 
 ginning at some distance from the birth-tract, and in a region which is the seat 
 of many of the most important gynecological affections (ovarian diseases and 
 tumors, pus-tubes, hematomata, etc., etc.). Gestation in one born of a bicor- 
 nate uterus, included by some under ectopic pregnancy, is considered elsewhere 
 (page 500). Tubal gestation occurs very rarely as a bilateral affection. 
 
 A further division as to its site is primary and secondary. In the former 
 the original implantation of the ovum remains unchanged, while in the latter 
 the ovum, through rupture of the tubes, or other accidents of development, may 
 assume a new location. 
 
362 
 
 PATHOLOGICAL PREGNANCY. 
 
 
 •-p^ 
 
 Fig. 490. — Ovarian Pregnancy. — (Martin*) 
 
 Etiology. — A great number of conditions have been held responsible for tubal 
 gestation, through their theoretical ability to obstruct the tube from within or 
 compress it from without and thus cause the arrest of the ovum in situ. Gyne- 
 cologists enumerate among' 
 intrauterine causes, chronic 
 salpingitis, chiefly of gonor- 
 rheal origin, neoplasms, dis- 
 locations, and congenital mal- 
 formations, especially the so- 
 called persistence of the fetal 
 type of tube. Conditions 
 which compress the tube from 
 without include pelvic adhe- 
 sions and tumors. But while 
 there is no doubt that in indi- 
 vidual cases the presence of 
 some one or more of these fac- 
 tors may be recognizable, the 
 great majority can hardly be 
 thus explained away. The 
 very conditions which prevent the descent of the ovum only too often cause 
 sterility by preventing impregnation. One author, after a careful study of the 
 causation, can see no essential factor to explain the great majority of cases» 
 unless it be the infantile tube which per- 
 mits of impregnation but favors the 
 arrest of the ovum. 
 
 Pathology. — This includes changes 
 in the ovum, fetus, and uterus. The ges- 
 tation sac is formed from the coats of the 
 tube- wall. The muscular tissue, instead 
 of undergoing hypertrophy, often tends 
 to disappear. The sac then eventually 
 consists of connective tissue. Slight 
 peritonitis often coexists and adhesions 
 may form. The attachment of the 
 ovum does not differ radically from that 
 in normal uterine pregnancy. A pla- 
 centa forms, but the decidual structures 
 are rudimentary; so that the chorionic 
 vilH penetrate readily into the gesta- 
 tional sac as far as the peritoneum. 
 This phenomenon, by favoring hemor- 
 rhage, tends to favor both abortion and 
 rupture. In regard to the history of the 
 ovum in tubal pregnancy, it may under- 
 go early death in the tube and form a 
 mole; if rupture of the tube occurs, the 
 ovum, expelled into the abdominal cav- 
 ity, usually perishes, and if very young may be absorbed. In very exceptional 
 cases it may thrive (secondary abdominal pregnancy) ; if the ovum escapes into 
 the broad ligament (Figs. 492 and 494), death with molar formation results. It is 
 * "Ueber Ektop Schwangerschaft," Fig. i. 
 
 Fig. 491. — Interstitial Pregnancy. 
 Right Wall of the Uterus. Fourth 
 Month. — {Bumm.) 
 
ECTOPIC GESTATION. 
 
 363 
 
 Fig. 492. — Intraligamentous Pregnancy. 
 Broad Ligament. — {Bumm.) 
 
 Left 
 
 commonly stated that in any of these cases death of the ovum may be followed 
 by suppuration, but it is difficult to understand how this could result under the 
 normal sterile conditions which should obtain. If the fetus dies only after 
 reaching an advanced stage of development, some one of various changes noted 
 exceptionally after intrauterine fetal death should develop — calcification, adipo- 
 ceration, mummification, etc. 
 (page 272). The sac in these 
 conditions may remain quiet 
 for years, perhaps eventually 
 to undergo rupture into any 
 neighboring viscus or cavity. 
 If the fetus does not die 
 its tendency is toward poor 
 development, and the vari- 
 ous deformities and diseases 
 noted in intrauterine fetuses. 
 If it reaches a " viable " 
 stage, it usually dies during 
 its extraction or soon after. 
 Exceptionally survival occurs 
 and the child may be well 
 developed. 
 
 The collateral changes in the uterus during ectopic pregnancy are of much 
 interest and are considered under symptoms and diagnosis. They are the same 
 to a certain point as those found in normal pregnancy, even to the formation 
 of a decidua vera (Fig. 495). If the ovum dies these changes are arrested; 
 
 otherwise they progress, al- 
 though at a much slower 
 ,/'' rate than in intrauterine 
 
 pregnancy. The decidua, 
 however, do not keep pace 
 with the uterus and are 
 usually thrown off at an 
 early period in bits or en 
 masse, simulating abortion. 
 Exceptionally they are re- 
 tained to term, when so- 
 called false labor occurs. 
 
 Symptoms. — Three well- 
 marked phases of tubal 
 pregnancy may be noted 
 clinically. These are: (i) 
 the relatively latent period 
 of early gestation when rup- 
 ture or abortion does not 
 supervene; (2) the manifes- 
 tations of ruoture and abortion; (3) the period of late gestation in cases which 
 have escaped rupture. 
 
 /. Early Quiescent Period. — The quiescence refers to the ovum only, for the 
 patient may present the general and genital symptoms of normal pregnancy. 
 Expulsion of decidual fragments accompanied by hemorrhage internally sug- 
 gests abortion. Colicky pains in the lower part of the abdomen, and uncon- 
 
 \ 
 
 Fig. 493. — Tubal Pregnancy. Rupture of the Isth- 
 mus OF THE Left Tube and Escape of the Ovum 
 AND Blood-clots into the Abdominal Cavity. — 
 (Bumm.) 
 
364 
 
 PATHOLOGICAL PREGNANCY. 
 
 nected with expulsion of decidual fragments, are explained by tubal or uterine 
 contractions. Such pains constitute about the only local symptom proceeding 
 from the ovum and its vicinity and are said to be quite common. 
 
 //. Interruption of Pregnancy by Rupture or Abortion. — Rupture occurs 
 practically without warning, for any premonitory symptoms are vague in char- 
 acter. The phenomena are those of shock or collapse, marked peritoneal reac- 
 tion, -and at times acute anemia from hemorrhage. The intensity of these 
 symptoms varies with the seat and extent of rupture and the degree of hemor- 
 rhage. If the hemorrhage is copious enough, death usually soon supervenes 
 unless laparatomy can be performed; but even after profuse bleeding death is 
 not inevitable, for, as in other similar conditions, spontaneous arrest may occur, 
 although secondary hemorrhage may supervene. A special type of rupture is 
 that which takes place between the folds of the broad ligament. Danger of 
 
 L^'IIJfcc 
 
 Fig. 494. 
 
 -Broad Ligament Pregnancy.- 
 {Zweifel.) 
 
 Fig. 495. — Uterine Decidua from a 
 Case of Extrauterine Pregnancy. 
 — {Zweifel.) 
 
 fatal hemorrhage or collapse is here minimized, and the resulting hematoma 
 causes extreme pain from distention. 
 
 When tubal abortion (Fig. 496) occurs the accompanying hemorrhage into 
 the fetal sac may give rise to subjective symptoms which resemble those of rup- 
 ture but in a much milder degree. Abortion is now believed to be the common 
 termination of tubal pregnancy, and as the escape of blood may extend over a 
 long period, a large hematosalpinx forms and blood also drains into the peri- 
 toneal cavity with formation of a pelvic hematocele. 
 
 In tubal abortion and in mild degrees of rupture with fetal death, the con- 
 stitutional symptoms of impregnation naturally disappear. 
 
 Rupture usually occurs during the second and third months. 
 
 III. Latter Half of Gestation. — There is not much to be said here. The 
 phenomena chiefly resemble those of normal pregnancy, false labor so called 
 setting in at term or before; exceptionally a little later. Left to itself, the 
 fetus perishes during false labor. The uterus in ectopic pregnancy often con- 
 tinues to be the source of apparent menstruation, expulsion of decidual frag- 
 ments, etc. This with the asymmetric appearance of the abdomen, and the 
 
ECTOPIC GESTATION. 
 
 365 
 
 superficial position of the fetus, constitute the leading symptoms of the later 
 months in tubal pregnancy. 
 
 Diagnosis. — The subjective and constitutional phenomena of the different 
 stages of tubal gestation have been outlined in the preceding section. There 
 remains to be considered the objective and induced symptoms upon which the 
 diagnosis must chiefly be based. 
 
 During the early quiescent period when there are no pathognomonic symp- 
 toms for differentiating ordinary pregnancy, an enlarged Fallopian tube may be 
 made out by careful bimanual examination ; and the decidual character of the 
 fragments which escape from the uterus in some cases may be recognized by 
 the microscope. Naturally the fear of disturbing a normal pregnancy and of 
 rupturing an impregnated tube militates against a vigorous physical examina- 
 tion. As a matter of fact, a diagnosis is seldom made during the early months; 
 only after an early termination of pregnancy by rupture or abortion, or after 
 the cumulation of symptoms of an atypical gestation, is the condition usually 
 
 ( mfm^"\ 
 
 '^> 
 
 Fig. 496. — Tubal Abortion, Ovum being Extruded through the Fimbriated Ex- 
 tremity OF THE Tube. — {Kelly.) X i. 
 
 recognized. In a suspected case a history of prolonged sterility is of some 
 collateral value. 
 
 When rupture or abortion has evidently occurred, bimanual examination 
 reveals the presence of blood in Douglas's sac, in addition to the enlarged preg- 
 nant tube, the size of which may be abnormally increased by the supervention 
 of a hematosalpinx. Naturally in profuse hemorrhage with impending death 
 the diagnosis is established by the resulting laparotomy. In hemorrhage into 
 the folds of the broad ligament the peculiar character and seat of the tumor 
 are recognized by palpation through the vagina and rectum and from without. 
 
 In the latter half of gestation diagnosis is made by mapping out the sac and 
 the uterus itself, which while enlarged seldom exceeds even at term the size of 
 the normal impregnated organ at four months. The abnormal location of the 
 fetus is made out by auscultation of heart-sounds, ballottement, and in general 
 the measures in use for determining the fetal position in normal pregnancy. 
 (For the complications of normal with ectopic pregnancy see page 136.) 
 
 Treatment. — There is no medical treatment for ectopic pregnancy, nor any 
 palliative or temporizing management; for the right of the child to be born 
 
366 PATHOLOGICAL PREGNANCY. 
 
 alive does not enter into the question. During the early quiescent period when 
 the condition is strongly suspected, or when, during laparotomy, etc., the con- 
 dition is accidentally discovered, the tube should be extirpated. The ovary may 
 be let alone, treated conservatively, or extirpated along with the tube, accord- 
 ing to its condition. 
 
 After the diagnosis of rupture or abortion is made, a radical operation is at 
 once indicated, irrespective of the severity of the hemorrhage. When great 
 loss of blood has occurred, or is still taking place, saline infusion (intravenous) 
 is begun with the operation and continued during and after. In certain cases 
 in which hemorrhage appears to have ceased, it is of some advantage to allow 
 the patient to recover from slow collapse before anesthetizing. It is well to 
 postpone saline infusion, however, until the moment of operating. If the 
 patient has naturally rallied from the hemorrhage and shock to such an extent 
 that she is out of immediate danger, it is still best to interpose at once lest 
 secondary hemorrhage occur. 
 
 Tubal Abortion. — Laparotomy is performed in the Trendelenburg position. 
 The tube is first clamped and then ligated and both ends are removed. Escaped 
 blood, clots, fetal tissue, etc., in the peritoneal cavity should be removed by 
 sponging. In hematoma of the broad ligament the latter must be incised and 
 evacuated, the wound being closed with buried sutures. 
 
 After gestation has progressed beyond the period of rupture and abortion, 
 diagnosis must be followed by extirpation of the sac as a whole, or of its con- 
 tents. The first is practicable only up to a certain period, viz., before the 
 establishment of the placental condition, or prior to the end of the fourth 
 month. This is essentially readily accomplished by the ordinary operation of 
 salpingectomy with additional precaution as to hemostasis. 
 
 After this period the danger of hemorrhage is too great to permit of attempt- 
 ing the removal of the sac en masse and a modified operation is recommended. 
 The sac is incised and the fetus removed, the cord being afterward ligated close 
 to the placenta. The incision is then sutured to the external wound and packed 
 with aseptic gauze, after careful cleansing with the saline solution. A glass 
 drain replaces the packing at the end of forty-eight hours, and remains until the 
 complete obliteration of the sac. During this period the placental circulation 
 is slowly arrested and the placenta itself generally comes away in fragments. 
 If the fetus is dead, either recently or after a long interval, this precaution is 
 not necessary, as the entire contents of the sac may be removed, including all 
 fetal tissue. 
 
CORNUAL PREGNANCY. 
 
 367 
 
 XXI. PREGNANCY IN ONE HORN OF A UTERUS BICORNIS 
 OR UNICORNIS; CORNUAL PREGNANCY. 
 
 Cornual pregnancy is the development of an ovum in one horn of a two- 
 homed uterus or in one side of a double uterus (Figs. 497 and 498)- Fortun- 
 ately the condition is rare, for women with malformations of the uterus are 
 
 Fig. 497. — Pregnancy in the Rudimentary Horn of a Uterus Unicornis. The rudi- 
 mentary horn is shut off from the uterine cavity. The corpus luteum was found in 
 the ovary of the opposite side; hence intraperitoneal transmigration of the ovum oc- 
 curred. — (Howard Kelly.) 
 
 Fig. 4q8. — Uterus Duplex Bicornis, with 
 A Vagina Septa. The right uterus con- 
 tained the product of conception and was 
 6| inches (17 cm.) long; the left uterus was 
 filled with decidua alone and was 4f inches 
 (12 cm.) long, r. Right uterus ; v, right 
 vagina; i, intervaginal septum. — (Nagel.*) 
 
 Fig. 499. — Pregnancy with a Uterus 
 Duplex. t The unimpregnated part 
 caused an obstruction to labor. 
 
 * Veit's "Handbuch d. Gyn.," Bd. i, Fig. 119. 
 t "Zeitsch. f. Geb. u. Gyn.," Bd. xiv, S. 169. 
 
368 
 
 PATHOLOGICAL PREGNANCY. 
 
 subject to more complications during both pregnancy and labor than when 
 the uterus is normal; they are more easily infected and fatal terminations are 
 common. If the horn is well developed, delivery may be normal; but if the 
 horn is rudimentary and there is no normal communication with the lower 
 genital tract, the condition resulting is markedly like ectopic pregnancy (Figs. 
 501 and 502). The symptoms, course, and treatment are then practically the 
 same as in ectopic pregnancy. Kehrer, who collected and analvzed 82 cases 
 
 Fig. 500. — Pregnancy in an Undeveloped 
 Horn of a Uterus Bicornis. — (Werth.*) 
 
 Rd.Liyame> 
 
 Fig. 501. — Pregnancy in a Rudi- 
 mentary Horn of a Uterus, 
 SHOWING the Relation of the 
 Round Ligament to the Gesta- 
 tion Sac. The Sac is Inside of 
 THE Round Ligament. — {Dakin.) 
 
 Fig. 502. — Relations op the Sac of 
 A Tubal Pregnancy to the Round 
 Ligament. The Sac is Outside of 
 THE Round Ligament. — {Dakin.) 
 
 from literature in 1900, states that expectancy is never indicated. Intervention 
 should always be by Caesarean section after the thirty-second week. In Kehrer's 
 study all the cases of labor in uterus duplex (Fig. 499) are recorded. The great 
 majority are divided about equally between uterus unicornis bicollis and 
 uterus bicornis unicollis (Fig. 497). A few cases occurred in uterus bicornis 
 duplex (Fig. 499) and uterus septus bilocularis, but none whatever in any 
 other varieties. 
 
 XXII. MISSED LABOR. 
 
 At full term ineffectual labor sets in, subsides, and the uterus remains un- 
 emptied for months or even years; occasionally simple prolongation of preg- 
 nancy, without any onset of labor occurs. A like condition is that of 
 "missed abortion," when the fetus dies in the early months of gestation and 
 remains in the uterus for weeks or months. 
 
 Etiology. — This is obscure ; some variety of obstructed labor is usually present 
 such as tumors of the soft parts, exostoses or tumors of the bony pelvis, con- 
 
 * "Arch. f. Gvn.," Bd. xvii, S. 281. 
 
SUDDEN DEATH IN PREGNANCY. 369 
 
 tractfid pelvis, cancer of the uterus, cicatricial bands of the cervix or vagina. 
 The possibility of ectopic gestation, or of pregnancy in one horn of a bicornu- 
 ate or unicornuate uterus, must be remembered (see pages 361, 367). 
 
 Terminations. — The fetus always dies, and one of the following changes 
 occurs: (i) maceration of soft parts and prolonged discharge from the cervix, 
 with retention of the bones (page 305); (2) ulceration through the uterine wall 
 into the vagina, rectum, or abdominal cavity; (3) septic metritis and fatal 
 septicemia; (4) mummification; (5) calcification; (6) adipoceration ; (7) putre- 
 faction. (Compare Death of the Fetus, page 272.) 
 
 Treatment.— No pregnancy should be allowed to continue more than two 
 weeks past the normal period of gestation, without a thorough examination 
 as to the cause, with the aid of an anesthetic, if necessary. The treatment 
 will depend upon the findings in this examination. If pregnancy be normal, 
 labor should be at once induced; if ectopic or cornual, treatment should be 
 along the lines laid down for those conditions. In cases in which weeks or months 
 have elapsed and maceration or putrefaction of the fetus has occurred, in 
 intrauterine pregnancy, the uterus should be emptied with all antiseptic pre- 
 cautions, and in cases of uterine sepsis or perforation, hysterectomy is advisable. 
 
 XXIII. SUDDEN DEATH IN PREGNANCY. 
 
 Sudden death, directly attributable to pregnancy, appears, with few excep- 
 tions, to be an impossibility; although the state of gestation is naturally able 
 to influence unfavorably the prognosis of many serious affections, and thus to 
 bring about sudden death indirectly, as in the case of cardiac valvular disease. 
 Further, there are sudden affections which, while not peculiar to pregnancy, 
 appear to be determined by the latter and may lead up to sudden death (acute 
 yellow atrophy of the liver, impetigo herpetiformis). Finally, pregnancy does 
 not appear to afford any immunity to sudden deaths from common causes, 
 and the pregnant woman succumbs to apoplexy and the like, just as does the 
 non-pregnant. Sudden death, absolutely referable to the pregnant state, 
 could come only from eclampsia before delivery; from some mechanical result 
 of the crowding of the viscera by the enlarged uterus (internal intestinal strangu- 
 lation, etc.); from attempts at abortion, including the use of poisons; and, 
 finally, from operative intervention. 
 
 XXIV. INJURIES TO AND OPERATIONS UPON PREGNANT 
 
 WOMEN. 
 
 Injuries and Accidents. — Severe injuries do not necessarily result in a pre- 
 mature interruption of pregnancy. The more common are those which cause 
 a rupture of an enlarged blood-vessel of the external genitals or of the lower 
 extremities. In a distended and varicose condition of the vessels of the 
 vulva, the rupture of these vessels, owing to a fall from a bicycle, has resulted 
 in almost fatal hemorrhage. In a case in private practice, I almost lost a 
 patient from this cause; pregnancy was not disturbed. Many instances are 
 recorded of the mother sustaining severe injuries by blows and falls, without 
 pregnancy being interrupted. The abdomen itself has been torn open, and 
 the fetus has even sustained fractures and traumata, and pregnancy has con- 
 24 
 
370 PATHOLOGICAL PREGNANCY. 
 
 tinued. Extensive general bums, and severe local bruises and injuries of 
 the vulva and pelvic floor, have not interfered with pregnancy. Spontaneous 
 rupture of the uterus is one of the rarest accidents, and may be due to trau- 
 matism, overdistention, a previous Caesarean section, or chronic inflammation. 
 Again, traumatism may be an exciting cause of rupture, in the presence of 
 hydramnios, chronic inflammation of the uterus, or weakening of the uterine 
 walls by a previous hysterectomy. 
 
 Penetrating Wounds of the Gravid Uterus. — This lesion is of very rare occur- 
 rence. In 1899 * Estor and Pruech could find notes of but 40 cases in literature. 
 The wounds were inflicted by cutting or pointed instruments, projectiles, the 
 horns of animals, etc., and could be divided into incomplete, complete, and 
 complicated. In the first-named the uterine wall was not completely pene- 
 trated. Complete penetration has been extensive enough to permit the escape 
 of the cord or even the fetus itself. In the complicated type other abdominal 
 viscera were also wounded. The symptoms are those of shock and hemor- 
 rhage with pain, escape of amniotic fluid, and prolapse of some of the contents 
 of the uterus. Peritonitis resulted in a certain proportion of cases. About 
 25 per cent, of the cases were fatal from shock, hemorrhage, or peritonitis. 
 The complicated • wounds have necessarily a graver prognosis. Laparotomy 
 may be necessary for diagnosis, and certainly will be required for rational 
 treatment with or without hysterectomy. 
 
 Operations. — Surgical operations upon pregnant women are not only justi- 
 fiable, but demanded, when delay until after confinement would seriously 
 jeopardize the health or life of the patient. Under ordinary circumstances there 
 is little danger of interrupting the pregnancy. Women of great nervous irrita- 
 bility will sometimes prove the exception to the rule. The irritation produced 
 by ulceration at the root of a tooth is usually more liable to interrupt a preg- 
 nancy than the administration of nitrous oxide gas and the removal of the tooth, 
 or the establishment of free drainage. The author has repeatedly had gas 
 administered to patients for this purpose, and has never seen any bad results. 
 Fibroid tumors, ovarian cysts, and the appendix are now frequently removed, 
 without interrupting pregnancy, and for numerous other causes the abdomen 
 has been opened and pregnancy has continued. Operations should not be per- 
 formed at a period corresponding with the menstrual epoch, as abortion is then 
 more apt to occur. For the same reason, it will be well to avoid the third, fourth, 
 and eighth months. My opinion is that anesthetics in pregnancy are rather 
 favorable than otherwise in their influence, when thev decrease reflex irritation. 
 
 XXV. PREGNANCY AFTER OPERATIONS INVOLVING THE 
 GENITALS; PREGNANCY AFTER VENTROFIXATION AND 
 
 VENTROSUSPENSION. 
 
 See Pathology of Labor, Part V. 
 
 XXVI. FEVER OF PREGNANCY. 
 
 This peculiar affection has been described by a number of authorities, 
 including Tarnier and Ahlfeld. It occurs in two types, acute and subacute 
 
 * " Rev. de gynecol.," Nov., Dec, 1899, 
 
METRORRHAGIA OF PREGNANCY. 
 
 371 
 
 or chronic, which differ radically, and are held to be entirely separate condi- 
 tions. Acute fever of pregnancy resembles such conditions as typhoid fever, 
 septicemia, and acute miliary tuberculosis. Chronic fever of pregnancy appears 
 to be a neurosis, with participation of the heat-center. Clinically it has been 
 likened to a confirmed phthisis. From the facts that these febrile affections 
 supervene without the least apparent cause, and subside immediately after 
 the uterus is evacuated, they have received the designation "fever of preg- 
 nancy." On account of the serious character of the symptoms, abortion has 
 been performed a number of times. Had the correct diagnosis been made, 
 no intervention would have resulted. Kleinwachter is opposed to the use 
 of the term "fever of pregnancy," or including the condition among the 
 indications for terminating pregnancy. 
 
 XXVI I. THE METRORRHAGIA OF PREGNANCY; ANTE-PARTUM 
 
 HEMORRHAGE. 
 
 A discharge of blood from the vagina during pregnancy naturally suggests 
 threatened or inevitable abortion (Fig. 504), or placenta prasvia, and should 
 
 Fig. 503. — The Metrorrhagia of Preg- 
 nancy. Menstruation Occurring in 
 THE Early Weeks. 
 
 Fig. 504. — The Metrorrhagia of Preg- 
 nancy. Hemorrhage caused by the sep- 
 aration of the decidua vera from the uter- 
 ine wall in threatened or inevitable early 
 abortion. 
 
 always receive careful attention. There are various other causes of hemorrhage, 
 however, which should not be forgotten. They will be discussed here chiefly 
 with reference to the diagnosis; the treatment, when of obstetric importance, 
 being considered elsewhere, (i) In cervical endometritis, or cervical catarrh, the 
 vaginal mucus may be stained with blood, but the amount is usually slight; the 
 cervix will be found larger than normal, with perhaps pouting of the lips, erosions 
 of the mucous membrane, and follicular degeneration ; the outer lips of the ex- 
 
372 
 
 PATHOLOGICAL PREGNANCY. 
 
 temal os having a velvety feeling. There is follicular degeneration, and little 
 nodules, like shot, can be felt by the examining finger. (2) In eroded cervix, 
 or cervical erosions so called, there are patches of bright red, granular mucous 
 membrane, which were formerly erroneously supposed to be ulcers ; they readily 
 bleed upon pressure. (3) With lacerated and eroded cervix, the infection of a 
 cervical tear is a common cause of cervical endometritis. In these cases there 
 will be considerable cervical hypertrophy, with the other evidences of cervical 
 inflammation. (4) Persistence of menstruation is a rare condition. In many 
 
 of the recorded cases, the hemorrhage 
 has been probably due to placenta 
 praevia or other causes. The diagnosis 
 must rest on the monthly occurrence 
 of the flow and upon the exclusion of 
 other sources of hemorrhage (Fig. 
 5°3)- (5) Hemorrhoids of the vagina, 
 ostium vaginae, or vulva have already 
 been discussed. In rare instances, and 
 usually as the result of traumatism, 
 rupture may occur, giving rise to 
 severe hemorrhage, which requires 
 suture. The diagnosis is made by in- 
 spection. ( 6) Hemorrhage may be due 
 to separation of a placenta prcevia, or 
 of a normally situated placenta (see 
 pages 214 and 224) (Fig. 505). (7) An 
 iniracervical polyp sometimes occurs 
 as a complication of gestation, and 
 causes persistent hemorrhage; the 
 diagnosis is made by inspection. If 
 there is much protrusion of the poly- 
 pus the diagnosis will not be difficult. 
 In some cases, however, it is very likely 
 to be confounded with abortion, the 
 polypus being mistaken for the intact 
 ovum. The history of the case before 
 pregnancy may be of assistance. (8) 
 Cancer of the cervix may be a cause of 
 hemorrhage during pregnancy, and 
 has been mistaken for placenta prae- 
 via. The diagnosis will rest upon the 
 characteristic cauliflower appearance, 
 when it is present ; upon the fetid dis- 
 charge; and upon the exclusion of other sources of hemorrhage, such as placenta 
 praevia, cervical erosions, and cervical polypus. The diagnosis must, of course, be 
 confirmed by microscopic examination. ( 9) Malignant disease of the vagina is not 
 common, and when it does occur is usually secondary to cancer of the cervix. 
 Hemorrhage and a foul-smelling discharge are common symptoms. There may 
 be a papillary swelling of the posterior wall, or the vaginal walls may be generally 
 infiltrated and the vagina constricted. The inguinal glands are usually infil- 
 trated. (10) Apoplexy of the placenta has already been discussed; if slight 
 hemorrhage occurs and placental apoplexy is suspected, the treatment is, of 
 course, that of threatened abortion (see page 357). 
 
 Fig. 505. — The Metrorrhagia of Preg- 
 nancy. Internal concealed hemorrhage 
 from the separation of a normally situated 
 placenta, and also hemorrhage from the 
 separation of a central placenta praevia. 
 
PART FOUR. 
 Physiological Labor* 
 
 I. THE PASSAGES. I. The Bony Pelvis. (Page 375.) (I) The Bones. 
 
 (2) The Pelvic Joints. (3) Internal Surface of Pelvis. (4) The False Pelvis. 
 (5) The True Pelvis. (6) The Pelvic Inlet. (7) The Pelvic Cavity. (8) 
 Pelvic Outlet. (9) Table of Pelvic Measurements, (a) External; (b) In- 
 ternal. (10) Pelvic Planes, (a) Inlet ; (b) Cavity ; (c) Outlet. (11) Pelvic 
 Axes, (a) Inlet; (b) Cavity; (c) Outlet. (12) Comparison of Different 
 Pelvic Diameters, Circumferences, Planes and Angles. (13) Factors In- 
 fluencing Size and Shape of Pelvis: (1) Individual; (2) Sex; (3) Age, Infan- 
 tile and Antepubic. (14) Functions. 2. The SOFT Tissues OF THE Pelvis. 
 (Page 393.) Soft Parts. (1) Muscles. Psoas Majus, Psoas Parvus, Uia- 
 cus, Levator Ani, Pyriformis, Coccygeus, Obturator Internus, Bulbo- 
 cavernosus. (2) Ligaments, (a) Great Sacro-sciatic ; (b) Small Sacro- 
 sciatic. (3) Pelvic Cellular Tissue. (4) Blood-vessels and Lymphatics. 
 
 (5) Nerves. 3. The Parturient Tract. (Page 400.) 
 
 II. THE FETUS. 1. The Fetal Head. (Page 408.) (1) Introduction. (2) 
 Regions and Protuberances. (3) Bones. (4) Sutures. (5) Fontanelles. 
 
 (6) Movements upon Spinal Column. (7) Complete Flexion. (8) Incom- 
 plete Flexion. (9) Complete Extension. (10) Incomplete Extension. (11) 
 Rotation. (12) Moulding. (13) Diameters. (14) Planes and Circum- 
 ferences. 2. The Fetal Trunk. (Page 417.) (1) Shape. (2) Measure= 
 ments. 3. Attitude or Posture. (Page 420.) Fetal Ovoid or Ellipse. 
 4. Presentation. (Page 421.) (I) Shape of Uterine Cavity. (2) Shape 
 of Fetal Ellipse. (3) Uterine Contractions. (4) Mobility of Head. (5) 
 Direction of Uterine Force. (6) Gravity. (7) Reflexion. 5. Position. 
 (Page 425.) (1) Flattened Shape of Fetal Ovoid. (2) Shape of Uterine 
 Cavity. (3) Axial=torsion of Uterus. (4) Shortening of Left Oblique Di- 
 ameter of Pelvis by Sigmoid and Rectum. (5) Diminution of Transverse 
 Diameter by Muscles. (6) Greater Roominess of Right Oblique Diameter. 
 
 III. EXPELLING FORCES. (Page 428.) 1. Voluntary or Auxiliary Forces. 
 
 2. Involuntary Forces or Uterine Contractions. 3. Strength of 
 Uterine Contractions. 
 
 IV. ETIOLOGY OF LABOR. (Page 431.) 
 
 V. THE STAGES OF LABOR. (Page 432.) 1. Preparatory Stage. (I) 
 Sinking of Uterus. (2) Gradual Shortening of Cervix and Dilatation. (3) 
 False or Spurious Labor Pains. 2. First Stage or Stage of Dilatation 
 or DiLATABiLiTY. (1) True Uterine Contractions. (2) Muco-sanguineous 
 Discharge. (3) Mechanism of Cervical Dilatation. (4) Formation of Caput 
 Succedaneum. 3, Second Stage or Stage of Expulsion. (I) Charac- 
 teristic Uterine Contractions. (2) Use of Voluntary Forces. (3) Descent 
 of Presenting Part. (4) Dilatation of Vagina. (5) Dilatation of Vulva. 
 (6) Expulsion of Fetus. 4. Third Stage or Stage of Placental Delivery. 
 (1) Characteristic Uterine Contractions. (2) Control of Hemorrhage. (3) 
 Separation of Placenta. (4) Expulsion of Placenta. 
 
 VI. THE MECHANISM OF LABOR. (Page 440.) 1. Definition. 2. Import^ 
 ance. 3. Six Stages. (1) Moulding. (2) Engagement and Descent. 
 
 (3) Rotation of the First Part of the Fetal Ellipse. (4) Expulsion of the 
 First Part of the Fetal Ellipse. (5) Rotation of the Second Part of the 
 Fetal Ellipse. (6) Expulsion of the Second Part of the Fetal Ellipse. 
 
 VII. THE DURATION OF LABOR. (Page 448.) 
 
 VIII. LIVE BIRTH. (Page 448.) 
 
 IX. FEIGNED DELIVERY. (Page 449.) 
 
X. UNCONSCIOUS DELIVERY. (Page 449.) 
 
 XI. VERTEX PRESENTATIONS. (Page 450.) I. Definition. 2. Frequency. 
 3. Etiology. 4. Positions and Relative Frequency. 5. Mechanism. 
 (1) Flexion and Moulding. Caput Succedaneum. (2) Engagement and 
 Descent. (3) Anterior Rotation of Occiput. (4) Extension and Expulsion 
 of the Head. (5) Rotation of the Trunk and Restitution of the Head. 
 (6) Expulsion of the Trunk. 6. Diagnosis. 7. Prognosis. 
 
 XII. MANAGEMENT OF LABOR. (Page 463.) 1. Introduction. Prophylaxis 
 in Obstetrics. Hygiene of Pregnancy. Response to Summons. 2. Pre- 
 liminary Preparations. (1) The Obstetric Outfit. (2) Mother's Outfit. 
 (3) Baby's Outfit. (4) Physician's Obstetric Bag. (5) The Obstetric Nurse. 
 Rules. (6) The Lying=in Room. (7) The Labor Bed. (a) Permanent Bed ; 
 (b) Temporary Bed ; (c) Arrangement of Double Bed. 3. Preparation 
 OF THE Physician, (l) Previous Septic Contact. Gloves. (2) Personal 
 Cleanliness. (3) Obstetric Asepsis. (4) Operating Suit. (5) Hand Lubri- 
 cants. 4. Preparation of Patient. (1) Enema. (2) Pubic Hair. (3) 
 Antepartum Bath. Local Antisepsis. (4) Antepartum Douche. (5) Vulvar 
 Dressing. 5. The Examination of Labor. (1) Posture of Patient. (2) 
 Obstetric Prognosis. 6. Management of the First Stage. (1) Posture 
 of Patient. (2) Presence of Physician. (3) Attention to Bladder and Rec- 
 tum. (4) Food, Drink, Sleep. (5) Use of Voluntary Forces. (6) Care of 
 Membranes. (7) Anesthesia. (8) Repetition of Vaginal Examinations. 
 7. Management of Second Stage. (1) Posture of Patient. (2) Presence 
 of Physician. (3) Attention to Bladder and Rectum. (4) Food, Drink, 
 Sleep. (5) Use of Voluntary Forces. (6) Care of Membranes. (7) Anes- 
 thesia. (8) Repetition of Vaginal Examinations, (9) Perineal Protection. 
 (10) Cleansing of Eyes and Mouth. (11) Care of Cord about Neck. (12) 
 Shoulder Delivery. (13) Delivery of Trunk. (14) Following down Fundus. 
 (15) Posture of Child in Bed. (16) Establishment of Respiration. (17) 
 Ligation of Cord. (18) Care of Cord. (19) Silver Solution for Eyes. (20) 
 Handling Child. (21) Protection of Child from Cold. (22) Prevention of 
 Hemorrhage. (23) Inspection and Repair of Perineum. 9. Management 
 OF Third Stage. (1) Prevention of Hemorrhage. (2) Temporary Vulvar 
 Dressing. (3) Delivery of the Placenta. (4) Postpartum Douche. (5) 
 Ergot. (6) Inspection and Repair of Perineum. (7) Cleansing of Patient 
 and Bed. (8) Abdominal Binder. (9) Permanent Vulvar Dressing. (10) 
 Nourishment. Rest. Sleep. (11) The Physician's Hour. 
 
Labor is the physiological end of pregnancy, and may be defined as the pro- 
 cess by which the fetus and its appendages are separated from the mother. 
 All labors are classified as either normal or abnormal, or, as they are here desig- 
 nated, physiological and pathological labors. Normal or physiological labor 
 is the delivery of a living child with the vertex presenting, by the natural forces, 
 .and without complication in any of the three stages. Should the fetus be 
 still-born, its death having occurred either just previous to or during the labor, 
 but not being directly due to the labor, the labor would still be within the limits 
 of normal. Vertex presentation is the most frequent, it gives the lowest mor- 
 tality rate, and labor is more easily and quickly terminated by this than by 
 any other presentation. The three factors concerned in any variety of labor 
 are: (i) the passages; (2) the fetus; (3) the forces. 
 
 I. THE PASSAGES. 
 
 I. THE BONY PELVIS. 
 
 Introduction and Definitions. — A knowledge of the female bony pelvis 
 is the very alphabet of obstetric science and the foundation of obstetric art. 
 This structure is most important, since it is from the disproportion between 
 its size and that of the fetus or from its abnormal shape that many of the diffi- 
 culties during labor arise. The derivation of the term is from the Greek word 
 T^sU'^, "a bowl," from its fancied resemblance to that ancient utensil once 
 used by barbers; or it may be because it plays the part of a reservoir for certain 
 temporary secretions. It is that part of the trunk which forms the lower 
 abdom'inal boundary, and in the adult it is situated near the middle of the 
 body. It transmits to the lower extremities the weight which it receives from 
 the head and the rest of the trunk; it is supported anteriorly by the femora; 
 it is open above and below and is a bony, irregular, roomy, and conoidal shaped 
 cavity or canal. The anatomical pelvis is composed of four bones: the two 
 ossa innominata, the sacrum, and the coccyx. The obstetric pelvis includes, 
 besides these bones just mentioned, the last lumbar vertebra. This description 
 designates the static pelvis, but there are other parts to be considered in 
 the dynamic pelvis — that seen in the living subject and in labor. These are 
 the soft parts which form its floor and extend the parturient canal. It will be 
 seen from this statement that the obstetrician must recognize and be familiar 
 with two pelves, the one bony and stable, the other soft and pliable. The 
 former is passive, the latter active. The most important parts of the pelvis, 
 obstetrically, are the inlet and the outlet. 
 
 The Bones (Ossa Innominata, Sacrum, Coccyx). — The anterior and lateral 
 walls of the pelvis are formed by the ossa innominata. Each os innominatumor 
 hip-bone is shaped like a stretched-out quadrangle, constricted and twisted 
 in the middle, by which means the two parts of the bone are brought into differ- 
 ent planes (Fig. 506). The hip-bone is composed of: (i) the ilium; (2) the 
 
 375 
 
376 
 
 PHYSIOLOGICAL LABOR. 
 
 ischium; (3) the pubis. It is not till the eighteenth or twentieth year that 
 the several parts of the acetabulum are firmly joined. A faint white line marks 
 the junctions. The sacrum forms the larger part of the posterior pelvic wall. 
 It is shaped like a pyramid with the base at the upper part, and is composed 
 of four vertebras. The term is derived from sacer, "sacred," because it helps 
 protect the genitals, which were held to be sacred, or because it was offered 
 in sacrifice. The coccyx — so named because it was thought to look like the 
 cuckoo's beak — comprises five rudimentary vertebrae. It is shaped like a 
 triangle and has its base pointing upward. If a bony union is established 
 between the sacrum and coccyx, it may offer an obstacle to labor; normally 
 
 Fig. 506. — Female Bony Pelvis. 
 
 the coccyx remains movable until middle life. It represents the tail appendage 
 in vertebrates. 
 
 The Pelvic Joints. — By their existence the pelvis is possessed of a certain 
 amount of mobility between its several parts. These articulations number 
 seven — one pubic, two sacro-iliac, three sacro-lumbar, and one sacro-coccygeal. 
 Five of these articulations are amphiarthrodial, much like those between the 
 bodies of the vertebra. 
 
 Pubic Joint or Symphysis Pubis. — The pubic joint or "symphysis" pos- 
 sesses fibro-cartilages similar to the intervertebral discs, each of which is firmly 
 attached to the corresponding pubic bone. This cartilage is soft in the center 
 and firmer at the outside; thicker in front than behind, and thicker in females 
 than in males. Many assert the presence of a synovial membrane,* though 
 Morris, Depaul, and French authorities generally deny its existence save in 
 
 * Allen. 
 
THE PELVIC JOINTS. 
 
 377 
 
 exceptional cases. There are, besides, four ligaments — a posterior, a superior, 
 an anterior, and an inferior sub-pubic or ligamentum arcuatum. By the last 
 the pubic arch is filled out and made smooth and rounded (Fig. 510). In the 
 pregnant woman the symphysis together with the other joints becomes more 
 movable. The softening of pregnancy gives rise to a slight gliding movement. 
 The connected surtaces are practically not separated, as, indeed, this separation 
 would have to be considerable to increase the antero-posterior diameters to any 
 extent. 
 
 Following the investigations of Budin, I have made examinations of several 
 hundreds of pregnant women in three maternity services, over a period of 
 ten years, in order to ascertain if there were movements in the pubic articu- 
 lation. The ball of the finger was placed directly against the lower margin of 
 
 Fig. 507. — Male Bony Pelvis. 
 
 the symphysis pubis, and then the woman was asked to walk or stand first on 
 one and then the other leg. The side of the pubis corresponding to the free leg 
 was found to descend, while the bone on the other side remained fixed. I con- 
 cluded that there is invariably present in this joint a certain amount of mobility 
 which increases with the advance of pregnancy and with the number of preg- 
 nancies, and when present to a considerable degree the subjects have no difficulty 
 in walking; the mobility is very slight in primigravidas. (See page 114.) 
 
 Sacro-iliac Joints. — The sacro-iliac articulation joins the lateral surfaces of 
 the sacrum and ilium. Some anatomists, among whom is Luschka, believe that 
 there is a synovial membrane, especially marked in pregnancy. Morris does not 
 hold this view; at least he does not believe the synovial membrane to be constant, 
 although it is more apt to be present in the female than in the male. There are. 
 
378 
 
 PHYSIOLOGICAL LABOR. 
 
 besides, six ligaments to make the joint firm. In normal labor the only move- 
 ment worthy of mention in these joints is a gliding one, and by it the antero- 
 posterior diameter of the pelvic outlet is somewhat increased. In five sym- 
 physeotomies I obtained from two to two and a half inches separation at the 
 pubis, and subsequent strong fibrous union in each case without apparent injury 
 to the ligaments of the sacro-iliac joints. This proves the existence of a certain 
 amount of motion at these joints, and also of considerable stretching of the 
 anterior ligaments. 
 
 I believe that the movements taking place in the sacro-iliac joints during 
 labor are important to its progress. There is an elevation and depression of 
 the pubis, or diminution and increase of pelvic inclination; or, from another 
 point of view, if the sacrum is considered as the bone that moves, it oscillates 
 in an imaginary transverse axis which passes through the lower part of the 
 second sacral vertebra, so as to increase the pelvic inlet or outlet. j 
 
 Fig. 508. — Posterior View of Female Bony Pelvis. 
 
 Sacro-vertehral Articulation. — The union between the sacrum and the last 
 lower lumbar vertebra is like that between the other vertebrae. The pecu- 
 liarity of this joint is that the interarticular disc of cartilage is just twice as 
 thick in front as behind, thus forming what is termed the " sacro-vertebral 
 angle" (Fig. 511). The "pelvic inclination," while it depends in a great 
 measure upon the angle thus formed, yet is produced in part also by the 
 obliquity of the innominate bones to the sacrum. The union between the 
 vertebral bodies is amphiarthrodial, while that between the apophyses is 
 arthrodial. 
 
 Sacro-coccygeal Joint. — The most movable joint is the sacro-coccygeal joint, 
 and is considered a part of the pelvic floor. It has two articular surfaces, an 
 interosseous fibro-cartilage, and four peripheral ligaments. Firm union between 
 the coccyx and sacrum occasionally occurs even in young subjects, but is most 
 often found in elderly primiparas. Generally, however, during the exit of the 
 
INTERNAL SURFACE OF THE PELVIS. 
 
 379 
 
 head the coccyx is pushed back, and by this means the antero-posterior diameter 
 of the outlet is increased to the extent of one inch. 
 
 Functions of the Pelvic Joints. — In an obstetric sense the pelvic joints are 
 designed by nature not so much to increase the diameters of the pelvis by 
 
 N 
 
 Acetabulum. 
 Ischial Sp, 
 
 Linea ferifiinahs 
 Supra- spinous pkne 
 Ischial angle 
 Infraspi'nal plane 
 
 Ischial taierosi 
 
 Fig. 509. — Transverse Section through the Acetabula and Ischial Tuberosities, 
 SHOWING Posterior Portion of the Internal Surfaces of the False and True 
 Pelvis. 
 
 Superior l^ament 
 
 ParfofliTiea alda 
 
 Jtiffht rectus muscle 
 
 Posterior hgamcn t 
 
 
 the swelling they undergo in pregnancy and by the slight movements occurring 
 in them as they are to act as cushions to lessen jars and shocks that might 
 be transmitted to the spinal cord, uterus, or fetus, from blows, falls, and trau- 
 matisms in general. The greatest mobility is exerted at the sacro-coccygeal 
 joint, less at the pubic, and 
 least at the sacro-iliac. The 
 sacrum can move in an 
 antero-posterior diameter, 
 making a swing of i cm. for 
 the promontory. This is 
 most marked when the 
 woman is on her back with 
 her legs hanging over the 
 edge of the table, the atti- 
 tude known as "Walcher's 
 hanging position." (See Part 
 X, Posture in Obstetrics.) 
 
 Internal Surface of the 
 Pelvis. — The bony pelvis 
 may be regarded as a cylin- 
 der, contracted near its mid- 
 dle by the circumference of 
 
 the pelvic inlet, which divides it into a false pelvis above and a true pelvis below. 
 In contrast to the rough and irregular external surface, the internal surface of the 
 pelvis is smooth and symmetrical, and is clearly divided into the two parts men- 
 tioned above. The cavity of the pelvis may be considered to be an inverted, 
 
 Fig. 510. — Anterior Portion of the Internal Sur- 
 face OF the Pelvis. 
 
380 
 
 PHYSIOLOGICAL LABOR. 
 
 truncated cone. The dividing-line consists of the ilio-pectineal line, supple- 
 mented by the superior anterior margin of the sacrum and its alae, or the 
 boundar>^-line is the circumference of the pelvic inlet (Fig. 509). 
 
 The False Pelvis. — The false, superior, or large pelvis is bounded behind 
 by the last lumbar vertebra and the ilio-lumbar ligaments; on the sides by 
 the iliac bones; in front there is a gap filled up in the recent state by the elastic 
 lower abdominal wall. If the convergence of the bony walls of the false pelvis 
 were continued downward, they would meet at a point corresponding with 
 the fourth sacral vertebra. It is from this fact that the false pelvis has often 
 been compared to a funnel. The false pelvis really belongs to the abdominal 
 cavity, and to its contents it offers protection and support; it has no marked ob- 
 stetric value. In multigravidous women the iliac fossa serves to support the 
 fetal head. It forms an inclined plane which serves as a guide to the fetus and 
 
 Fig. 511. — Sagittal Section through the Middle of the Sacrum and Pubic Joint 
 SHOWING the Internal Lateral Surfaces of the False and True Pelvis. — 
 (From the author's aluminium- cast of a female pelvis.) 
 
 directs it downward when impelled by contractions of the uterus, and thus aids 
 its engagement in the pelvic inlet ; and not unless it be very much deformed will 
 it obstruct the passage of the child. 
 
 False Pelvis and External Measurements. — (See Pelvimetry, page 163.) 
 The True Pelvis. — The true, inferior, or small pelvis is that part below the 
 ilio-pectineal line, and it forms the true obstetric pelvis (Fig. 509). The true 
 pelvis in the female is much larger than that in the male. It is bounded poste- 
 riorly by the concavity of the sacrum ; on the sides by the sacro-sciatic liga- 
 ments and the internal surfaces of the acetabula and obturator membranes ; 
 anteriorly, by the pubic bones and obturator membranes. If any horizontal 
 plane of this curved cylinder — the true pelvis — is taken at a level, the bony 
 wall is incomplete. In any plane that may be selected there will be a foramen 
 covered by membrane or by distensible and elastic muscular or fibrous tissue ; 
 
PELVIC INLET. 
 
 381 
 
 or a movable joint such as the coccyx directly opposite the solid mass of the 
 pubic bones ; or some elastic tissue that will permit of considerable compression 
 without injury. The conclusion to be drawn from this fact is that although 
 the fetus must pass through this bony cylinder to reach the external world, 
 yet by the peculiar formation of the pelvis both the fetus and the mother's 
 soft parts are protected against too great or too prolonged pressure; while if con- 
 cussions should occur, their effect would be 
 much alleviated. 
 
 The Pelvic Inlet. — The pelvic inlet, supe- 
 rior strait, brim, margin, isthmus, linea ter- 
 minale, linea ilio-pectinea, is the entrance to 
 the cavity of the true pelvis. The superior 
 strait and the inferior strait received their 
 names because they were thought to be more 
 contracted than the space which lies between 
 them. I prefer the term pelvic inlet. The 
 anatomical inlet is the entrance of the small 
 or true pelvis, and corresponds to the upper 
 margin of the symphysis pubis, and to the 
 edges of the bones extending backward to 
 the sacral promontory (Fig. 513). The ob- 
 stetric inlet is the least available space at 
 the upper portion of the pelvic canal; it is 
 bounded by a line passing f inch (i cm.) be- 
 low the upper margin of the symphysis pubis, 
 along the posterior margin of the oblique 
 rami and body of the pubis, past the ilio- 
 pectineal eminences, the anterior margin of 
 the sacral alas, and the summit of the sacral 
 promontory. 
 
 Shape. — The shape of the inlet in the 
 bony pelvis is that of a curvilinear triangle 
 with the base behind and the apex in front, 
 the chief irregularity being found in the sac- 
 ral promontory. It is here that pelvic de- 
 formities cause by far the greatest trouble, 
 and hence an intimate knowledge of the pel- 
 vic inlet is necessary (Fig. 513). 
 
 Pelvic Inlet Measurements. — (See Pelvi- 
 metry, page 167.) The circumference of the 
 pelvic inlet is 16 inches (40.5 cm.). 
 
 Obstetric Landmarks of the Inlet. — (i) The 
 symphysis pubis in front; (2) just posterior 
 on either side, situated upon the pubic bone, 
 
 close to the iho-pubic junction, is found a rough eminence — the ilio-pectineal 
 eminence; (3) the boundary-line of the inlet on either side, known as the linea 
 terminalis; or more commonly, from its source of origin, as the ilio-pectineal 
 line; (4) the points on the sacro-iHac joints at which the linea pectinea joins 
 them; (5) the promontory of the sacrum or the sacro-vertebral angle. The 
 intervertebral cartilage between the sacrum and last lumbar, being wedge-shaped 
 and thicker in front, forms an angle between the sacrum and vertebral column 
 and causes the inclination of the pelvis. 
 
 Fig. 512. — Vertical Mesial Section 
 OF "a Female Pelvis showing the 
 
 LUMBO-SACRO-COCCYGEAL CuRVE, 
 
 THE Inclination and Shape of the 
 Symphysis, the Relations of the 
 Anatomical, Obstetric, and Diag- 
 onal Diameters of the Pelvic In- 
 let, and the Sacro-pubic and Coc- 
 cygo-pubic Diameters of the Pel- 
 vic Outlet. The Lower Figure 
 shows the Pubic Arch. — (Front the 
 author's lead-tape tracings.) 
 
382 
 
 PHYSIOLOGICAL LABOR. 
 
 The Pelvic Cavity. — The pelvic cavity, pelvic canal, excavation, small or 
 true pelvis, is the portion bounded by the inlet above, the outlet below, in 
 front by the symphysis pubis, at the sides by the innominate bones, and behind 
 by the hollow of the sacrum and the coccyx. The pelvic cavity is irregularly 
 barrel-shaped or cylindrical. It must never be forgotten that the pelvis offers 
 a curved and not a straight cylinder to deal with — a cylinder bent upon itself, 
 so to speak. If this fact be overlooked, the most important factor in deter- 
 mining the mechanism of delivery is ignored. This cavity may be conveniently 
 separated into four regions: anterior, posterior, and two lateral (Figs. 509 
 to 511). The anterior region has a marked notch in the pubic arch. The 
 surface is convex from above downward, and concave from side to side. In 
 the middle of this region the posterior part of the articulation of the symphysis 
 
 Fig. 513. — The Superior Surface of the Pelvis showing the Shape and Diameters 
 
 OF THE Pelvic Inlet. 
 
 pubis projects vertically and makes a prominence of from i to | of an inch 
 (0.63 to I cm.). Toward the sides the surface is smooth, and then come the 
 internal obturator or sub-pubic fossas. The posterior region consists of the 
 surfaces of the sacrum and coccyx. This part is concave from above down- 
 ward, the curve being deepest at the junction of the second and third sacral 
 vertebrae. Down to this point the curve is very fiat; which makes the axis 
 of the cavity straight above this level. The lateral regions consist of two 
 well-defined parts; the anterior being entirely bony and corresponding to the 
 posterior part of the acetabula and to the ischial body and tuberosity; and 
 its direction is from above downward, from without inward, and from behind 
 forward. The posterior part consists for the most part of the internal 
 face of the sacro-sciatic ligaments and foramina. The direction of this part is 
 
PELVIC OUTLET. 
 
 383 
 
 the converse of the anterior, it being from above downward, from without 
 inward, and from before backward. 
 
 Pelvic Cavity Measurements. — (See Pelvimetry, page 167.) 
 
 The depth of the pelvis at the symphysis is if inches (4 cm.). The depth of 
 the lateral wall over the smooth surface of the ischial bones is 32 inches (9 cm.). 
 The depth of the posterior wall, following the course of the sacrum and coccyx 
 from promontory to tip of coccyx, is 4^ to 5 inches (11. 5 to 12.5 cm.). 
 
 The obstetric landmarks of the cavity are as follows: (i) The pubic joint 
 in front; (2) the obturator foramen; (3) the spine of the ischium; (4) the 
 great sacro-sciatic ligament and foramen; (5) the small sacro-sciatic ligament 
 and foramen; (6) the sacrum and coccyx. 
 
 The Pelvic Outlet. — The pelvic outlet or inferior strait is the lower opening 
 of the cavity of the true pelvis (Fig. 515). While there is at the pelvic inlet 
 
 Fig. 514. — Transverse Section through the True Pelvis Just below the Pelvic 
 Inlet and Parallel to it. — {Author's collection.) 
 
 a continuous ring of bone, the circumference of the pelvic outlet is partly bony 
 and partly ligamentous, and there are, besides, certain projections not found 
 at the inlet; namely, the spines and tuberosities of the ischia separated by 
 notches, and certain indentations also, the most important being the pubic 
 arch. The anatomical outlet is the real outlet of the true pelvis and is bounded 
 behind by the coccyx; in front by the sub-pubic ligament; on the sides by 
 the ischio-pubic rami, the ischial tuberosities, and the greater and lesser sciatic 
 ligaments. The obstetric outlet is just above this, and is the circumference 
 of greatest bony resistance of the true pelvis as well as the smallest in size. 
 It is bounded by the posterior surface of the symphysis pubis about \ inch 
 (0.625 cm.) above the lower margin; the upper portions of the ischial tuber- 
 osities and the lower border of the sacrum. 
 
 Shape. — Its shape is that of a diamond or of two triangles having a common 
 
384 
 
 PHYSIOLOGICAL LABOR. 
 
 base, and varies with the mobility of the coccyx, and in labor it becomes almost 
 circular, thus being more changeable than the pelvic inlet. In the sitting 
 posture the weight of the body rests entirely on the ischial tuberosities, since 
 they are on a lower plane than the tip of the coccyx; and this explains why 
 transverse pelvic contractions are so much more frequent at this strait than 
 are the antero-posterior ones. Although the two lateral notches are so deeply 
 marked in the bony pelvis, they are made very superficial by the sacro-sciatic 
 ligaments The anterior notch is known as the arch of the pubis. The col- 
 umns of this arch are twisted outward, — this being more marked in the female, — 
 and so assist in the passage of the head in labor. By the yielding of the sciatic 
 ligaments the oblique diameters may be somewhat increased; this is not 
 
 cjSWiPHy^/^ 
 
 Fig. 515. — The Inferior Surface of the Pelvis, showing the Shape and Diameters 
 
 OF THE Pelvic Outlet. 
 
 important. However, there is an important increase in the antero-posterior 
 diameter, resulting from recession of the coccyx, so that although this 
 diameter is the shortest one of the irilet, it becomes the longest of the outlet. 
 
 Pelvic Outlet Measurements. — (See Pelvimetry, page 168.) The circumference 
 of the pelvic outlet is 18 inches (45 cm.). 
 
 Obstetric Landmarks of the Outlet. — Taking them from before backward, 
 we have: (i) The pubic arch, and at its apex the sub-pubic ligament. (2) 
 Passing backward, we have the descending ramus of the pubis and ascending 
 ramus of the ischium which assist in bounding the obturator foramen and in 
 forming the pubic arch. (3) At the junction of the two ischial rami is a thick- 
 ened projection, the tuberosity of the ischium. (4) Upon the posterior border 
 of the descending ischial ramus, and projecting forward, is a sharp spine, — 
 the spine of the ischium, — which when well marked plays an important part 
 
PELVIC PLANES 
 
 385 
 
 in the mechanism of labor. (5) The great and small sacro-sciatic ligaments. 
 (6) The coccyx. 
 
 Pelvic Planes. — The planes of the pelvis are imaginary levels at different 
 portions of the cavity; thus, we have a plane of the inlet, planes of the cavity, 
 and a plane of the outlet. By a pelvic plane we mean simply a mathematical 
 surface without depth or thickness. The short, slightly curved, cylindrical 
 cavity of the true pelvis, bounded by the bony walls already described, 
 varies in shape and size at various levels. For convenience in describing 
 these variations and pelvic inclination and angles, we erect imaginary levels 
 at different parts of the cavity of the true pelvis. If we accurately fit a piece 
 of cardboard into the inlet of the pelvis, the level surface thus produced would 
 
 Fig. 516. — Planes of the Bony Pelvis and Parturient Tract. Plane of the parturient 
 inlet; plane of the bony inlet; pubo-sacral plane of the outlet; pubo-coccygeal plane 
 of the outlet; plane of the parturient outlet 
 
 represent the plane of the pelvic inlet (Fig. 516). In like manner we have a 
 plane of the outlet, and planes of the cavity. It is in studying these pelvic 
 planes that we observe that the planes of the inlet and outlet are not parallel 
 with each other, are not at right angles with the axis of the body, nor are they 
 parallel with the horizon. (See Pelvic Angles.) Moreover, it is upon changes 
 in the shape and size of these pelvic planes that the presence of pelvic deformity 
 depends. 
 
 Plane of the Pelvic Inlet (Fig. 516). — As the obstetric conjugate is the avail- 
 able antero-posterior space at the inlet, so the obstetric plane of the inlet is 
 the space available at the inlet for the passage of the fetal head and body. 
 It does not coincide with the anatomical conjugate nor with the anatomical 
 25 
 
386 
 
 PHYSIOLOGICAL LABOR. 
 
 inlet. The plane of the obstetric inlet would be represented by a piece of 
 cardboard that so fitted the entrance of the pelvis that its margins corre- 
 sponded to the base of the sacrum, the ilio-pectineal line, and the posterior 
 surface of the symphysis along a transverse line f inch (i cm.) below its upper 
 margin. 
 
 Planes of the Pelvic Cavity (Fig. 516). — Hodge constructed a series of planes 
 parallel to the plane of the inlet. These planes are obsolete, and we now speak 
 of the plane of greatest pelvic dimensions or middle plane.* It extends from 
 the middle of the posterior surface of the symphysis pubis, over the central 
 points of the internal surfaces of the acetabular cavities, to the upper margin 
 
 Fig. 517. — Planes of the Bony Pelvis and Parturient Tract, and Axes of the Par- 
 turient Inlet and of the Bony and Parturient Outlets. 
 
 of the third piece of the sacrum. This is the largest plane of the pelvis; the 
 next in size is that of the inlet, and that of the outlet is the smallest. 
 
 Plane of the Pelvic Outlet (Fig. 516). — As at the inlet, so here we have an 
 anatomical plane of the outlet and an obstetric plane. The latter is somewhat 
 above the former and is the plane of greatest bony resistance at the outlet. 
 It is also the smallest transverse plane of the entire pelvis, and we also term 
 it the plane of least pelvic dimensions.! 
 
 * German, Beckenweite. 
 
 t Beckenenge. It touches the posterior surface of the symphysis pubis about -J of an 
 inch above its lower margin, just above the ischial tuberosities, and the lower border of 
 the sacrum. While this is the smallest transverse plane of the pelvis, it must be remem- 
 bered that the yielding character of the sciatic ligaments allows of marked expansion in 
 the posterior segment during the expulsion of the fetus. 
 
PELVIC INCLINATION AND PELVIC ANGLES. 387 
 
 Plane of the Parturient Outlet (Figs. 516 and 517). — At the moment that 
 the presenting part is expelled, the plane of the parturient outlet, or, to be 
 more exact, of the vulvo-vaginal ring, is nearly parallel with the long axis of 
 the mother's body, and, with the woman in the dorsal posture, looks almost 
 directly upward. 
 
 Pelvic Axes. — The axes of the pelvis are imaginary lines passing through 
 the centers of the planes of the pelvis, and at right angles to them (Fig. 517). 
 The axis of the inlet is represented by a line drawn perpendicular to the center 
 of the plane of the pelvic inlet. This line, prolonged upward, strikes the anterior 
 abdominal wall near the umbilicus; and projected downward, ends at the 
 fourth piece of the sacrum (Fig. 517). The axis of the cavity is represented 
 by a curved line joining the centers of a series of planes extending from the 
 pelvic inlet to the outlet, and including these latter planes. It should be stated 
 that the axis of the true pelvis is an axis of a curved and not a straight cylinder, 
 and hence is a curved line, and practically is dependent upon the curves of 
 the sacrum and coccyx, and thus of necessity differs according to the indi- 
 vidual. The axis of the parturient tract, as will be shown later (Fig. 517), is 
 a continuation of the axis of the cavity beyond the bony outlet, by the dis- 
 tention of the tissues which go to form the pelvic floor. (See page 408.) The 
 axis of the bony outlet is a perpendicular line passing through the center of the 
 plane of the outlet, and when there is no recession of the coccyx, this line, 
 prolonged upward, strikes the promontory; when the coccyx is pushed back- 
 ward, the axis of the outlet strikes the lower border of the first sacral vertebra. 
 The axis of the parturient outlet is a perpendicular line passing through the 
 center of the plane of the parturient outlet. This line is nearly at right angles 
 with the long axis of the mother's body, and is nearly perpendicular. If extended 
 backward and downward, it passes some distance below and in front of the 
 end of the coccyx. 
 
 Pelvic Inclination and Angles. — In the upright posture of the body the 
 plane of the pelvic inlet is inclined obliquely downward. The angle between 
 the conjugate and horizon measures 55 to 60 degrees, while the same 
 angle at the outlet is 11 degrees (Fig. 517). The inclination exhibits a good 
 deal of variability. Not only are there differences in the same measurement 
 in different individuals, but the angle is essentially altered by the position 
 of the limbs. Thus, it is increased by extreme flexion of the legs and by extreme 
 abduction and outward rotation of the thighs. The angle is smaller when 
 the thighs are moderately abducted and in slight inward rotation. The size 
 of the angle of inclination may be of diagnostic importance, since it calls our 
 attention to certain anomalies of the pelvis. As a rule, a change in the direction 
 of the plane of the inlet means a corresponding alteration in the axes of the 
 uterus and fetus, so that the influence of the inclination up on labor is much less 
 than was formerly supposed. On the other hand, the variation of the plane 
 of the inlet and axis of the uterus in the different postures of the body is a 
 matter of importance to the obstetrician, (i) If the woman lie flat on her 
 back with extended limbs, the plane of the inlet sinks backward until it forms 
 an angle of 25 degrees, open in front, with the horizon. (2) If she assume 
 the knee-chest position, this plane forms with the horizon an angle of 15 or 
 20 degrees, open behind. (3) If the pelvis and spinal column are approximated, 
 the size of the angle is increased. (4) If the woman lie upon her back across 
 the bed in such manner that her thighs hang over the side of the latter, the 
 pelvic inlet is expanded. This is the so-called Walcher position, to be con- 
 sidered from another point of view. (See Posture in Obstetrics, Part X.) 
 
388 
 
 PHYSIOLOGICAL LABOR. 
 
 Fig. 518. — Early Antenatal 
 Pelves. (Natural size.) — 
 {Author's collection.) 
 
 In this connection it is only necessary to state that 
 while the angle between the inlet plane and horizon 
 is less than in the fiat dorsal position, the angle be- 
 tween the conjugate and lumbar spine is notably 
 increased. (5) If the woman, lying upon her back, 
 flexes her legs at both the hip and knee, and at the 
 same time approximates them moderately, form- 
 ing the lithotomy position, the pelvis rotates a 
 little upon its transverse axis so that the angle of 
 the fiat dorsal position is increased from 25 to 30 
 degrees or over. (See Part X.) If now the thighs 
 and legs are flexed to the utmost so that the thighs 
 are pressed tightly against the abdomen, — the 
 exaggerated lithotomy position, — the pelvis con- 
 tinues to rotate upon its transverse axis until the 
 angle reaches 60 degrees. There is a corresponding 
 diminution in the angle between the spine and 
 conjugate. (See Part X.) (7) If with the woman 
 in the fiat dorsal position the trunk is raised so 
 that a reclining posture is assumed, the original 
 angle of 25 degrees is reduced to 20 degrees. In 
 the squatting or crouching posture the plane of 
 the inlet is almost horizontal, and hence hardly 
 any angle is present. Variations in the angle be- 
 tween the spine and pelvis are made possible by 
 the slight mobility of the sacro-iliac joints and of 
 the vertebras with each other and with the sacrum. 
 As has already been stated, the Walcher position 
 causes an expansion of the pelvic inlet. The oppo- 
 site eflect of contraction is produced by the exag- 
 gerated lithotomy posture. For a statement of 
 these phenomena and their practical application 
 to the mechanism of delivery see Posture in Ob- 
 stetrics, Part X. If a perpendicular falls at the 
 middle of the pelvic inlet, it should pass through 
 the coccyx below and the umbilicus above, pro- 
 vided that the angle between the vertebral column 
 and conjugate is normal (125 degrees). If the per- 
 pendicular passes through the center of the outlet, 
 it would pass through the promontory above. The 
 symphysis makes an angle with the inlet of from 
 90 to 100 degrees. See also section on Cliseometry, 
 page 178. 
 
 Comparison of Different Pelvic Diameters. — 
 The most important facts to be remembered here 
 are the diameters of inlet and outlet. As has been 
 already noted, the shortest diameter of the inlet 
 (antero-posterior, 4^ in. — 11.25 cm.) corresponds 
 when the coccyx has receded with the longest 
 diameter of the outlet; and, conversely, with the 
 longest diameter at the inlet (transverse, 51- in. — 
 13.12 cm.) to the shortest at the outlet (4! in. — 
 
FACTORS INFLUENCING DEVELOPMENT OF THE PELVIS. 389 
 
 II cm.). In considering the mechanism of labor and the slow progress of the 
 head as it gradually descends through the pelvic canal, a general rule will be ob- 
 served concerning the relationship existing between the fetal head and these 
 several diameters of the bony pelvis — namely, the long diameter of the fetal 
 head corresponds to the longest diameter of the true pelvis. 
 
 Factors Influencing Size and Shape of the Pelvis. — i. Individuality. — The pel- 
 vis presents great individual variations. No two pelves are exactly alike. This 
 is due to the varying influences of infancy and childhood, and shows itself in the 
 thickness and shape of the bones, and the resulting influence upon the cavity of 
 the true pelvis and the measurements in general. So great is the variation in the 
 flaring of the ilia that we are accustomed to ignore the measurements between 
 these bones in external pelvimetry. 
 
 2. Sex. — Just as in the other bones of the body, those of the pelvis are 
 stronger, thicker, and rougher in the male than they are in the female (Fig. 
 507). The chief differences concern the cavity, and these are dependent in 
 the female on the presence of the uterus. The male pelvis is far more angular 
 and markedly cordate than the female, its structure is heavier, and it is less 
 delicately curved. The female pelvis is broader and its cavity is rounder 
 (Fig. 506). The dimensions of the internal iliac fossa are less in the female 
 except the line drawn between the anterior superior iliac spine and the sacro- 
 iliac joint; the iliac fossa is shallower in the female; the pelvis of the male 
 is, as compared with that of the female, small, deep, steep, and funnel-shaped; 
 the tuberosities of the ilium are, in the male, more developed and extend 
 farther back; the pubic spines as well as the ischial tuberosities are more 
 widely separated in the female. The sacrum presents two curves, concave 
 from above downward and from side to side; this is more marked in the female 
 than in the male, the bone being shorter and its direction downward and back- 
 ward; in rachitis the lateral concavity becomes straight or even convex; the 
 vertical concavity is not an arc of a circle but is bent; this bending point is 
 known as the niche, and is found in the third sacral vertebra. The inlet is 
 rounder in the female, and all the dimensions are greater, especially the trans- 
 verse, which is not only longer but is placed farther forward than in the male 
 pelvis. The outlet in the female is much larger on account of the recession 
 of the ends of the sacrum and coccyx and the greater distance between the 
 tuberosities. The acetabula are relatively farther apart and their surfaces 
 look forward rather obliquely; this arrangement is not made to assist the 
 function of the hip-joints in walking, and it accounts for the proximity of the 
 knees of the female and for the peculiarity of gait. The sciatic notch is shal- 
 lower and more open in the female. The pubic arch in the male is more acute, 
 or about 70 to 80 degrees; in the female it is more rounded, 80 to 105 degrees; 
 the distance between the symphysis and the tuberosities, the anterior pelvic 
 wall, is longer than that of the female; in the female the ischio-pubic tubercle 
 is turned more outward and the ischio-pubic ramus is concave in the middle. 
 In the female there is marked pelvic inclination, while in the male it is slight. 
 In the male the sacrum and coccyx are higher and more curved than in the 
 female. The ischio-pubic foramen in the female is relatively larger and is more 
 oblique externally and inferiorly ; the common error that there is a difference in 
 its shape in man and woman has been disproved. The ischia are more widely 
 separated in the female; all the vertical diameters of the pelvis are greater 
 in the male. Just as in other bones of the body, these characteristic differences 
 in some pelves are marked, while in others they are slight, so as to make the 
 distinction between male and female pelves difficult. 
 
390 PHYSIOLOGICAL LABOR. 
 
 3. Age. — Infantile and juvenile pelvis. The pelvis is very small in the 
 newly bom child and is far less developed than the upper part of the body, and 
 to this cause is due the greater prominence of the abdomen (Figs. 518 to 523). 
 The larger part of the rectum and the bladder are almost wholly in the abdominal 
 cavity, and it is not till puberty that their permanent position is assumed. 
 Delivery is naturally made easier from the small size of the pelvis. At the time 
 of birth there is a greater development of the false than of the true pelvis, the 
 latter being straight and cylindrical in shape. It was not till recently that the 
 infantile pelvis has been supposed to possess any special form. It is in great 
 measure cartilaginous with points of ossification. The characteristics of the in- 
 fantile pelvis, as compared with the adult, are: (i) The os innominatum is com- 
 posed of ilium, ischium, and pubis ; the ascending and descending rami are entirely 
 cartilaginous; (2) the infant's pelvis is relatively more contracted; (3) the iliac 
 bones stand more perpendicularly; (4) the sub-pubic angle is less; (5) the pro- 
 montory of the sacrum is much higher and the sacrum is almost entirely straight ; 
 (6) the promontory of the sacrum forms a much more obtuse angle with the spinal 
 
 f^^^ 
 
 ^"\\ 
 
 Fig. 519. — Antenatal Pelvis of about Fig. 520. — Antenatal Pelvis of about 
 
 THE Seventh Month. (Natural size.) the Eighth Month. (Natural size.) — 
 
 {Author's collection.) {Author's collection.) 
 
 column than is found in the adult pelvis (Figs. 518 to 521). The sacrum has 
 twenty-one centers of ossification; each vertebral body, five; each vertebral arch, 
 ten ; and three on each side of the sacrum, making six for the alas. This condi- 
 tion persists for some time, and it is not till late that the centers join. According 
 to Litzmann, they unite from below upward; at three years the three lower bones 
 are ossified; at seven years the sacrum is ossified; the three bones of the os in- 
 nominatum join at puberty; at twenty, the pelvis assumes its normal shape. 
 The sacrum in the newly born child is more or less wedge-shaped, but does not 
 possess the antero-posterior curve of the adult sacrum and has little or no curve 
 from side to side; the diminution is due to pressure causing the bodies of the 
 vertebrae to press forward (Fig. 521). The alae are poorly developed; the pro- 
 montory of the sacrum is farther above the symphysis pubis ; this distance is so 
 great that Fehling, in considering the genesis of the pelvis, does not use the con- 
 jugata vera, but what he terms the conjugata vera inferior. The transverse width 
 is less in the infant and the shape is more like a funnel, the pelvic walls being 
 more markedly inclined. 
 
 Forces Leading to the Production of the Adult Pelvis. — These are important 
 
FACTORS INFLUENCING DEVELOPMENT OF THE PELVIS. 391 
 
 'd 
 
 '\ 
 
 '^, 
 
 / 
 
 ,^ 
 
 Fig. 
 
 521. — Fetal Pelvis at the Fortieth Week. 
 (Natural size.) — (Author's collection.) 
 
 because they somet'imes lead to deformed pelves. There are two sets of factors 
 to be considered, (i ) Congenital predisposition or tendency oj the pelvis to assume 
 a certain form. This is evident when the differences between male and female 
 pelves are noted, as both are subjected to the same forces. At birth the alae of 
 the first sacral vertebra are 
 only one-half as long as the 
 vertebral body itself. In the 
 adult woman the alae are 0.76 
 as long as the body. In the 
 adult man they are 0.56 as 
 long, making a difference of 
 twenty per cent. The body of 
 the second vertebra is three 
 times as broad as in the child; 
 the alse are five times longer in 
 woman and three times in 
 man. (2) Mechanical influ- 
 ences. These are very impor- 
 tant. They are the normal 
 growth of the pelvic bones , the 
 traction which ligaments and 
 muscles exert upon the devel- 
 oping bones, the body-weight, 
 the upward and inward pres- 
 sure of the heads of the femora, and the cohesive force offered at the symphysis 
 pubis. The excess or deficiency of any of these forces will modify the shape of 
 the pelvis. If the pelvic bones do not develop normally before birth, a deformity 
 
 will result which will be a form of 
 the congenitally contracted pelvis; 
 of this, the Naegele or Roberts pel- 
 vis is an example. The body-ii'cight 
 begins to exert its influence only 
 after the child begins to sit up. 
 Then the weight is exerted through 
 the spinal column down through 
 the sacrum. The first change con- 
 sists in the tilting forward of the 
 upper part of the sacrum and the 
 pushing outward of the pelvic brim. 
 The sacral promontory is lowered 
 and approaches the symphysis 
 pubis. Resistance is offered by the 
 sacro-iliac ligaments, so that the 
 degree of depression of the sacrum 
 is limited. The pelvis then tends to 
 rotate around a certain point back- 
 ward, but the sacro-sciatic liga- 
 ments which fasten the tip of the 
 sacrum to the ischii and ischiac spines resist this force, so that from the influence 
 of all these forces there results the curve or bend at about the middle of the third 
 sacral vertebra. This concavity distinguishes the adult pelvis from that of the 
 child (Figs. 511 to 523). If there were nothing to oppose this rotation, the same 
 
 Fig. 522. — Bony Pelvis of a Female Child of 
 Two Years. {\ natural size.) — (Author's col- 
 lection.) 
 
392 
 
 PHYSIOLOGICAL LABOR. 
 
 shaped pelvis would be found in both child and adult. The lateral concavity is 
 much greater in the infant. The adult pelvis is comparatively widened, since the 
 antero-posterior diameter is lessened. As long as the child is on its back the body- 
 weight exerts no influence. If it were not for the posterior ilio-sacral ligaments, 
 the promontory of the sacrum would press against the posterior surface of the 
 symphysis pubis. But the posterior part of the innominate bone extends beyond 
 the spinal column. The ilio-sacral ligaments act as a hinge and tend to spread 
 out the innominate bones, but this influence is resisted by the heads of the 
 femora, which press upward and inward. The innominate bones act like a 
 two-armed lever, with the sacrum as a fulcrum and the two forces — body- 
 
 F*G. S^Z-- 
 
 -BoNY Pelvis of a Female Child of Five Years. 
 
 collection.) 
 
 (f natural size.) — {Author's 
 
 weight and counter-pressure — exerted through the heads of the femora. So 
 the iliac bone is bent just in front of the sacrum, thus producing the transverse 
 widening of the superior strait. Another force is the cohesive force offered by 
 the symphysis pubis, which counteracts the tendency of the ilia to flare out. 
 Certain reported cases illustrate the effects of the various influences noted 
 above. Gurlt found a hydrocephalic woman who had always lain in bed. She 
 was thirty-one years old when she died. Her pelvis was a model of the infantile 
 type, though larger in size. The force exerted through the femoral heads 
 cannot act without the other forces, so that it never exists alone. Neither 
 could cohesion offered by the symphysis pubis act alone. Clinically an ex- 
 ample of body-weight acting alone has never been observed. Theoretically 
 
THE MUSCLES OF THE PELVIS. 393 
 
 it would indicate a split symphysis pubis and undeveloped legs. Freund, 
 of Strasburg, experimented with a cadaver, which he suspended by the tips 
 of the ilia. He cut apart the symphysis pubis; the ilia spread out while the 
 symphysis gaped widely. Litzmann observed a case of split pelvis in which 
 there was no union at the symphysis pubis, so only the two forces acted — 
 body-weight and counter-pressure of the femora. The resulting pelvis was 
 very wide posteriorly, while the counter-pressure of the femora caused the 
 anterior portions of the innominate bones to become nearly parallel. The 
 transverse width was marked. Hoist saw a case, that of Eva Lank, who was 
 born without lower extremities ; thus the counter-pressure through the femora 
 was lacking. The patient could sit up, consequently the forces — body- weight 
 and cohesion of symphysis — were exerted. There was a marked flattening of the 
 pelvis and a widening of the transverse diameter. The absence of the counter- 
 pressure of the femora and the long-continued pressure upon the ischial tuber- 
 osities caused the innominate bones to so rotate as to turn their crests inward 
 and the ischial tuberosities outward, thus producing an excessive widening of 
 the pelvic outlet. Somewhat similar changes are found in congenital dislocation 
 of the hip, where the children have never walked. It is plain to see that any 
 change from the normal in the action of the forces, or in the condition of the 
 parts concerned, will result in a deformity of the pelvis which may vary from a 
 slight to an extreme degree. All these facts are very important, and especially 
 practical in relation to deformed pelves. The inferior races seem to be charac- 
 terized by an inlet having a lessened transverse and increased conjugate diam- 
 eter. Whenever a fair-sized average has been made, there has never yet been a 
 people discovered in which the conjugate measured more than the transverse 
 diameter. The consensus of opinion seems to point to the fact that favorable 
 conditions of nutrition and activity lay the corner-stone for a well-formed pelvis. 
 Functions. — The functions of the pelvis are to form: (i) A ring by means of 
 which the body-weight is transmitted to the lower extremities; (2) an axis which 
 permits the movements of the lower extremities upon the trunk; (3) an attach- 
 ment and lever for powerful muscles; (4) a cavity to contain the delicate pelvic 
 organs; (5) a bony canal for the escape of the fetus from the abdominal cavity 
 during parturition; (6) and to assist in the performance, through the pelvic floor, 
 of the rectal and vesical functions. 
 
 2. THE SOFT TISSUES OF THE PELVIS. SOFT PARTS. 
 
 Familiarity with the bony pelvis alone is not sufficient for the obstetrician, 
 but he must study the pelvis together with the soft tissues, muscles, ligaments, 
 and cellular tissue which encroach upon the pelvic space and close in the openings 
 of the latter, which is thereby converted into a basin-like body. The blood- 
 vessels, the lymphatics, and the nerves also demand attention, and, finally, we 
 must go back to our pregnant uterus, already studied under pregnancy, place 
 it in position at the pelvic inlet, and carefully consider the pregnant and par- 
 turient tract or canal, extending, as it does, from the fundus of the uterus above 
 the umbilicus, to the edge of the perineum, which latter in the second stage 
 of labor may be distended five inches below the coccyx. 
 
 I. Muscles. — By the presence of the muscles of the pelvis, especially the 
 ilio-psoas (Fig. 524), the transverse diameter of the inlet is made smaller than 
 the oblique. This is one cause for the prevalence of the oblique position of 
 the fetal head in cephalic presentations. The function of the musculature of 
 the pelvic canal, ilio-psoas, obturator, levator, and other muscles, is mechanical 
 
394 
 
 PHYSIOLOGICAL LABOR. 
 
 during parturition. They protect the bony pelvis and guide the presenting fetal 
 part in a line which favors its expulsion ; they also serve as cushions on which the 
 fetus may rest and avoid injury from pressure. The muscles of the pelvic floor, 
 especially the levator ani and coccygeus, during parturition are, to an extent, 
 
 RiGHT CRUS OF DIAPHRAGM 
 \ 
 
 INTcRTRANSVERSALIS M 
 
 OUADRATUS LUMBORUM M 
 
 LEFT CRUS OF DIAPHHAOfc 
 
 PSOAS PARVUS M 
 
 SACRO-LUMBAR LIGAMENT 
 SUPERIOR SACRO-ILIAC 
 LIGAMENT 
 
 PSOAS MAGNUS M 
 
 RIGINS OF PSOAS MAGNUS M 
 FTiOM THS TRANSVERSE 
 PROCESSES OF THE 
 LUMBAR VERTEBR/E 
 
 PSOAS MAGNUS M 
 / 
 '^C CREST OF ILIUM 
 
 '*'m>\ PYRIFORMIS M 
 
 GRE*T TROCHANTER OF FEMUR \ 
 
 LESSER TROCHANTER OF FEMUR / 
 OBTURATOR EXTERNUS M 
 
 OBTURATOR MEMBRANE 
 
 QUADRATUS FEMORIS M 
 
 PECTINEO-FEMORAL BAND OF THE CAPSULAR 
 LIGAMENT OF THE HIP-JOINT 
 
 Fig. 524. — The Pelvic Inlet Seen from Above, showing the Psoas and Iliacus 
 
 Muscles. — {Deaver.) 
 
 passive. Their yielding is out and back, and they are often lacerated from their 
 resistance to the presenting part. However, the direction of the resistance turns 
 the head out and up under the symphysis. The functions of these latter muscles 
 are to give support to the viscera of the pelvis, complete the lower end of the 
 parturient canal, and to direct the presenting part to the orifice of the vulva. 
 
THE MUSCLES OF THE PELVIS. 
 
 396 
 
 Psoas Magnus (Fig. 524). — The psoas magnus is long and fusiform and is 
 situated on the side of the lunibar region of the spine and the pelvic brim. It 
 takes its origin from the bodies, transverse processes, and intervertebral sub- 
 stances of the last dorsal and all the lumbar vertebrae, and is inserted into the 
 lesser trochanter of the femur by a common tendon with the iliacus. Its action 
 is to flex and rotate the femur outward, also to flex the trunk and pelvis on 
 the thigh. Obstetrically it acts as a "bumper" or protection between the fetus 
 and the margin of the pelvic inlet; it diminishes the transverse diameter of 
 the inlet, so that in the recent state the oblique diameters become the longest, 
 and this partly explains the oblique position of the head in cephalic presenta- 
 tions. 
 
 Psoas Parvus (Fig. 524). — The psoas parvus is long and slender and is 
 situated in front of the psoas magnus. It takes its origin from the bodies of the 
 last dorsal and first lumbar vertebrae and the intervertebral substance, and 
 
 URATOR FASCIA 
 
 OBTURATOa CANAL 
 
 iEVATOR ANI M 
 
 FIBROUS RAPHE 
 
 OR RECTO- 
 COCCYGEAL LIQ 
 
 PYRIFORMI8 M 
 
 Fig. 525. — Muscles of the Female Pelvic Floor — Superior View. — (Deaver.) 
 
 is inserted into the ilio-pectineal eminence and the iliac fascia. Its action is 
 to make tense the iliac fascia. 
 
 Iliacus (Fig. 524). — The iliacus is a flat muscle filling up the entire internal 
 iliac fossa. It takes its origin from the iliac fossa, the inner surface of the 
 iliac crest, ilio-lumbar ligament, base of the sacrum, anterior spinous processes 
 of the ilium as well as the notch included between them, and from the capsule 
 of the hip-joint. It is inserted into the external surface of the tendon of the 
 psoas magnus. Its action is the same as that of the psoas magnus. The psoas 
 and iliacus flex the thigh upon the pelvis while the}^ rotate the femur out ward : 
 these functions are performed when they act from above. From below, with the 
 femur fixed, the lumbar part of the spine and the pelvis are bent forward by the 
 action of the muscles of both sides. By them also the erect position is main- 
 tained, since they support the spine and pelvis upon the femur, and help to- 
 raise the trunk when the bodv is recumbent. 
 
396 
 
 PHYSIOLOGICAL LABOR. 
 
 Levator Ani (Fig. 525). — This muscle takes its origin from the body and ramus 
 of the pubis posteriorly, the pelvic fascia, and the spine of the ischium, and is 
 inserted into the tendinous center of the perineum, the sides of the rectum and 
 vagina, the apex of the coccyx, and a fibrous raph^ extending from the coccyx 
 to the anus. There has been much contradictory discussion concerning the 
 comphcated form and functions of the levator ani muscle. The shape of the 
 muscle is that of a horseshoe. It acts like a sling which is anteriorly attached 
 to the pubes, and, passing backward in a horizontal plane, encircles the rectum 
 and vagina (Dickinson) Luschka describes it as the diaphragm of the pelvis, 
 but states that in many non-pregnant women it is almost membranous; we 
 must remember, however, that there is always a hypertrophied condition of 
 the muscle present during pregnancy. Its arrangement consists of flat bundles 
 
 Fig. 526. — The Parturient Pelvic Inlet Seen from above, showing the Narrowing 
 OF the Transverse Diameter Caused by the Psoas Muscles. 
 
 of muscle-fibers loosely connected, between which here and there are open- 
 ings filled up with connective tissue and fat. The good use to which such a 
 structure lends itself in the great distention of delivery can easily be seen. 
 The depth of the levator in woman is less than that in man, corresponding 
 with her shallower pelvis; while, as has already been shown, the horizontal 
 measurements are greater. According to Henle, the longitudinal muscle-fibers 
 of the lateral vaginal walls are intertwined with the fibers of the levator ani — 
 an arrangement analogous to that about the rectum. The division of the 
 levator which reaches to the front of the rectum is a very narrow band. In 
 shape it resembles a bow, with its most inferior extremity about one-half 
 inch above the anus. This band arises at the outer side of the pubic origin, 
 crossing over the larger bundle in its course. This part of the muscle in women 
 
THE MUSCLES OF THE PELVIS. 397 
 
 is very small and is "collected together in the recto-vaginal septum." This 
 fact can be proved, as a rule, by palpation. The connection between the levator 
 and the walls of the rectum is very intimate, although none of the muscle- 
 fibers end in the walls. There is the same intimate intermingling with the 
 longitudinal muscle-fibers as was noted about the vagina. The functions of 
 this muscle are numerous and important: (i) During the internal rotation 
 of the second stage of labor the levator, together with the coccygeus, internal ob- 
 turator, and trans versus perinei, are the chief causes in determining the anterior 
 rotation of the lowest portion of the presenting part. (2) The most character- 
 istic action of the levator is to draw forward toward the symphysis the anus 
 and perineal body, thus directing the head or presenting part out under the 
 symphysis, and relieving the strain on the perineum. (3) In the female the 
 pubo-coccygeal part of the levator ani serves the purpose of a sphincter muscle 
 of the vagina, and perhaps of the urethra after the collapse of the vagina. (4) 
 It antagonizes the diaphragm in its action on the pelvic contents, as it rises 
 and falls with it in deep respiration. When the abdominal muscles are acting 
 energetically, this muscle yields, enabling the pelvis to endure a greater strain 
 than if it were more resistant. When the tension is removed, the muscle restores 
 the perineum to its original condition. (5) It assists in the formation of the 
 pelvic floor and supports the lower end of the rectum, vagina, and bladder. 
 According to Studdiford,* the levator ani does not form a sling, but is more 
 like a narrow V with sides slightly convex toward the median line A band 
 of involuntary muscular fibers seated between the rectum and vagina serves 
 to connect the two portions of the levator. This is the muscular band which 
 may be felt behind the posterior vaginal wall. By its action the two segments 
 of the levator ani are approximated, so that the vagina is forced upward behind 
 the pubis while the rectum and coccyx, and probably the external sphincters, 
 are drawn forward. Studdiford attaches great importance to this band of 
 smooth muscle, and believes that by its automatic action the levator is enabled 
 to furnish continuous support to the pelvic viscera. 
 
 Obturator Internus (Fig. 525). — It takes its origin from the inner surface 
 of the obturator membrane and the posterior osseous edge of the obturator 
 foramen, as far as the ilio-pectineal line above and the sacro-sciatic notch behind; 
 its fibers converge and form a tendon which passes through the small sacro- 
 sciatic foramen, and then is directed downward and backward to be inserted 
 into the digital cavity of the great trochanter. Its action is to rotate the thigh 
 outward; to assist in increasing the resistance of the posterior segment of 
 the pelvic floor; to act as a bumper and protection to the fetus. Owing 
 to its thinness, this muscle does not materially affect the dimensions of the 
 pelvic cavity. 
 
 Pyriformis (Fig. 525). — The pyriformis arises by three digitations from the 
 front of the second, third, and fourth sacral segments, from the border of the 
 great sacro-sciatic foramen and the great sacro-sciatic ligament, and is inserted 
 into the upper border of the great trochanter after having passed through 
 the great sacro-sciatic foramen. Its action is to rotate the thigh externally; 
 it helps to form the posterior and outer wall of the pelvic cavity; in fact, its 
 action is the same as that of the obturator internus. 
 
 Coccygetts (Fig. 525). — This is a small, triangular muscle, by many included 
 
 in the description of the levator ani. It is situated in front of the small sciatic 
 
 ligament, between the levator ani and the pyriformis. This muscle takes its 
 
 origin from the spine of the ischium and radiates its fibers in the form of a 
 
 * " New York Medical Journal," April 12, 1902. 
 
398 PHYSIOLOGICAL LABOR. 
 
 fan and is inserted from the tip of the coccyx to the lateral surface of the two 
 lower sacral vertebras, filling up the open space behind the levator. Its action 
 is to support the coccyx and to close the pelvic outlet behind. The pelvic 
 surface helps to support the rectum, while externally it is closely connected 
 with the lesser sacro-sciatic ligament. This muscle assists in restoring the 
 coccyx to its original position after the strain of parturition or defecation is 
 passed. In caudate animals it is strongly developed and causes lateral move- 
 ments of the tail. 
 
 B ulbo-cavernosus (Fig. 525). — This muscle, which is sometimes misnamed 
 the sphincter vaginas or constrictor cunni, is analogous to the lateral half of 
 the male accelerator urinse muscle. Analogous to the role of the coccygeus, 
 which completes the muscular diaphragm back of the levator, is that of the 
 bulbo-cavernosus, which aids in closing the space between the ends of the 
 horseshoe, although it is a thin, weak muscle. Each bundle takes its origin 
 from the fascia of the perineum about half-way between the anal sphincter 
 and the ischia, only a small band being connected with the sphincter (Luschka). 
 Anteriorly the ends as they converge divide into three bands. One part goes 
 to the inferior surface of the corpus cavernosum of the clitoris, another passes 
 to the posterior surface of the bulb, and the third mingles with the mucous mem- 
 brane between the clitoris and the orifice of the urethra (Henle). The action 
 of this muscle is chiefly seen in its function of compressing the veins of the 
 clitoris, and thus increasing the turgidity of the erectile tissue and so main- 
 taining as well as creating erection of the clitoris. It is not a sphincter, although 
 by means of its pressure inward on the turgid bulbs the vestibule of the vagina 
 may be made smaller. Unless hypertrophied it cannot be discovered by pal- 
 pation. 
 
 Transversus Perinei, or Ischio-bulbosus (Fig. 525). — This muscle arises from 
 the ascending ischial ramus and is inserted into the base of the perineal body, 
 the fibers of the two muscles intermingling at this point. Its action is to make 
 the central tendon of the perineum tense, so that the other muscles attached 
 in that vicinity may have a fixed point from which to act; it also antagonizes 
 the action of the levator ani. In deep perineal laceration the two muscles 
 tend to produce gaping of the wound-, and interfere with union. 
 
 External Sphincter Ani. — From each side of the ano-coccygeal ligament, 
 just beneath the superficial fascia, thin sheets of striated muscle-fibers arise, 
 and passing forward blend with the other muscle-fibers ending in the perineal 
 body, thus surrounding the anus elliptically. Its fibers are interwoven with 
 those of the bulbo-cavernosus muscle. Its action is to contract the skin about 
 the anus; to assist the levator ani in supporting the opening during the strain 
 of defecation; and to close the anus. 
 
 2. Ligaments (Fig. 515). — The sacro-sciatic ligaments number four: two 
 posterior and two anterior. The great sacro-sciatic ligament arises from the 
 posterior inferior iliac spine and the posterior aspects and borders of the sacrum 
 and coccyx, and is inserted on the internal border of the tuberosity and the 
 ascending ischial ramus. The small sacro-sciatic ligament arises from the 
 borders of the sacrum and coccyx, and is inserted into the ischial spine. The 
 sacro-sciatic ligaments close the wall of the pelvis and offer protection to 
 and direct the presenting part. The obturator membrane closes the foramen 
 and acts as a cushion for protection of the presenting part. Besides the four 
 sacro-sciatic ligaments there are the anterior, posterior, and lateral sacro- 
 coccygeal ligaments, which connect the sacrum and the coccyx; the anterior, 
 posterior, and superior pubic ligaments, connecting the two pubic bones. 
 
LIGAMENTS, CELLULAR TISSUE, VESSELS AND NERVES. 399 
 
 These ligaments help to modify the shape of the pelvis and the direction of 
 its axis, as well as to act as buffers for the presenting part. 
 
 3, The Pelvic Cellular Tissiie. — It is only by the additional support afforded 
 by layers of fascia or by a mixture of fibrous tissue that even the strongest 
 muscle can resist strain that is prolonged. The pelvic cavity may be considered 
 to be divided into two spaces — peritoneal and subperitoneal — by an imaginary 
 plane which passes from the central point of the inner surface of the pubis to 
 that point where the third and fourth sacral bones unite. With the exception 
 of a part of Douglas's pouch the whole pelvic peritoneum should lie above 
 this plane. It is beneath the plane in the intervals between the pelvic viscera 
 where are the blood-vessels^ lymphatics, and nerves, as well as fibrous and mus- 
 cular tissue, and fibre-elastic elements, all of which comprise the cellular tissue 
 of the pelvis. The proportions of these different elements vary according 
 to the function to be performed. The function depends to a certain extent 
 upon the situation of the tissue. When investing blood-vessels, it assists in 
 the erectile functions of the venous system of the pelvis. When used as an 
 attachment for organs, it becomes more ligamentous in character and helps 
 to preserve the mutual relations of the organs which it helps to connect as 
 well as their normal position. Some parts of it act as lines of traction upon 
 different parts of the uterus. Parts of it keep in contact the vaginal walls, 
 since that organ is not only drawn backward but also toward the side of the 
 pelvis. This tissue also forms part of the uterine system. During pregnancy 
 this tissue is greatly hypertrophied in order to fill the space that is left vacant 
 when the uterus with its broad ligaments ascends. After delivery the excess 
 of tissue is gradually absorbed, and the uterus and its ligaments by degrees 
 return to their normal position. This tissue surrounds the cervix, and from 
 this point reaches out between the layers of the broad ligaments to the wall 
 of the pelvis.* The recto- vaginal process extends between these two organs 
 down to the pelvic floor, and permits of the changing degrees of distensibility of 
 these tubes. The vagino-vesical process is found between the superior part of 
 the anterior wall of the vagina and the posterior vesical surface. There is no 
 such deposit of connective tissue between these organs in the lower two-thirds 
 of the vagina. Since the amount of tissue in this process is so small the pelvic 
 peritoneum and the upper part of the anterior wall of the vagina come very 
 close together when the bladder is empty — a point of value for the surgeon. 
 The rectum and the sacrum are separated by a little connective tissue. 
 
 4. Blood-vessels and Lymphatics. — The blood-vessels of the pelvic floor 
 consist of the branches directly or indirectly derived from the anterior divi- 
 sion of the internal iliac, together with the veins which accompany them; 
 besides these there are numerous plexuses which are in close proximity to 
 the vesico-vaginal walls. The branches of the inferior pudic, the smaller of 
 the terminal branches of the anterior trunk of the internal iliac, are: inferior 
 hemorrhoidal, superficial perineal, transverse perineal, artery of the bulb, 
 artery of the corpus cavernosum, and dorsal artery of the clitoris. The sciatic 
 with its branches supplies the muscles on the back of the pelvis. Besides 
 these the inferior vesical and vaginal arteries with small branches from the 
 external pudic form a part of the pelvic blood-supply. The inferior hemor- 
 rhoidal and the superficial perineal arteries supply particularly the musculature 
 
 ♦Much work has been done of late years on the arrangement of this pelvic cellular 
 tissue, by various methods: (i) By frozen sections and pelves hardened in spirit; (2) by 
 injections beneath the peritoneum in various places and later tracing the ramifications; (3) 
 by water injections; (4) by plaster-of- Paris injections. 
 
400 PHYSIOLOGICAL LABOR. 
 
 of the pelvic floor. The superficial perineal artery passes through the super- 
 ficial fascia to the superficial perineal space and supplies the neighboring struc- 
 tures, giving off the transverse perineal branch. The continuation of the internal 
 pudic artery lies deeper, being between the two layers of the triangular ligament. 
 Here the arteries of the vestibular bulbs and of the crura of the clitoris branch 
 off. The internal pudic artery ends, having penetrated the anterior layer 
 of the triangular ligament, as the dorsal artery of the clitoris, from which small 
 branches reach the corpus cavernosum, the glans, and the prepuce. The ovarian 
 arteries from the abdominal aorta pass to either side of the pelvis, and, running 
 between the laminae of the broad ligament, supply the ovaries and tubes, one 
 branch passing to the fundus, another traversing the uterus and there anasto- 
 mosing with a branch of the uterine artery. The latter artery passes down 
 from the anterior trunk of the internal iliac to the uterine neck. Ascending 
 the sides of the uterus one branch meets the ovarian, and one, the circular 
 artery of the cervix. Incision of this artery or rupture causes marked 
 hemorrhage. The most important veins are the tributaries of the pudic 
 vein and those ha^ang an independent course forming a part of the ves- 
 ico-vaginal and hemorrhoidal plexuses. This venous supply is abundant. 
 The lymphatics owe their chief importance to their relation to septic ab- 
 sorption. The uterine lymph-spaces lie between bundles of connective tissue 
 and are covered with endothelial cells. These finally lead to the thoracic duct. 
 The glands of most importance are the sacral, lumbar, hypogastric, obturator, 
 inguinal, and uterine. 
 
 5. Nerves (Fig. 155). — These are derived principally from the sym.pathetic 
 system. From the uterine plexus are given off two hypogastric plexuses from 
 which twigs pass to the uterus and ovaries. To the perineum are distributed 
 branches of the internal pudic nerve and the inferior pudendal branch of the 
 small sciatic. The pudic, inferior hemorrhoidal, superficial perineal, deep 
 perineal, muscular filaments of the pudic, and dorsal nerve of the clitoris are 
 described as the nerves of the female perineum. 
 
 3. THE PARTURIENT CANAL. 
 
 Definition. — This term is applied to the cavity of the uterus, cervix, vagina, 
 and vulva, regarded as a single structure. Many obstetricians, however, restrict 
 the term to the parts which lie below the internal os, and define the birth 
 canal as the dilated passage or route by which the fetus must reach the external 
 world through the action of the expulsive forces exerted in the abdominal 
 region. The present conception of the birth canal as embracing the entire 
 genital tract is regarded as the most expedient. The term parturient canal, 
 however, does not apply to the genital passages in a state of quiescence. It 
 is present then, of course, in a potential sense only. The actual canal exists 
 only during labor, when the onward progress of the fetus, together with the 
 active dilatation and resistance offered to its passage, transform the distensible 
 structures into an anatomo-physiological entity which has its own individuality 
 and which demands a careful description. A knowledge of the bony pelvis, 
 the soft parts, and the changes which the uterus and other genitals undergo 
 during pregnancy is requisite before proceeding to the study of the parturient 
 canal. 
 
 Formation. — At the end of pregnancy the uterine cavity is distended by 
 the mature ovum which is closely united to the external membranes, decidua, 
 and uterine wall (Fig. 137). The internal os is tightly closed and the cervical 
 
THE PARTURIENT CANAL. 
 
 401 
 
 canal as well (Fig. 138). In. the primigravida the external os is likewise closed 
 and but slightly patulous in the multigravida. (See page 138.) A similar 
 condition of stenosis is present in the vagina and vulva. The potential cavity 
 now consists of two sections, the upper of which is represented by the uterine 
 cavity, while the lower comprises all the parts below the latter. The upper 
 section, already distended to the utmost, will dilate no more, but tends, on 
 the contrary, to contract upon and expel its contents, thereafter resuming 
 
 a i 
 
 'PEBlTONrrM 
 
 "-^"^ PERITONEUM 
 
 Fig. 527. — Frozen Section after Sudden Death from Cerebral Abscess during 
 THE First Stage of Labor. Age of patient thirty-seven years; 7-para; fiindus uteri 
 3 inches above the umbiHcus; internal os dilated to admit two fingers. The section 
 shows the interior of the left half of the uterine cavity with placenta and membranes 
 in situ. Note that the internal os has not been drawn up into the walls of the uterus; 
 the beginning formation of the contraction ring just above the plane of the pelvic 
 inlet, and that the rectum is impacted with feces. — {William C. Lusk's case.) 
 
 its original and natural state of closure. The lower section, on the other hand, 
 heretofore in a state of natural occlusion, must now be subjected to the utmost 
 degree of distention. The transformation of the potential into the actual 
 cavity, then, affects only those parts which have no active function of con- 
 traction. The precise line of demarcation between the two segments of the 
 uterus — i. e., the functionally active and the functionally passive — is a matter 
 of dispute. It was formerly assumed that the internal os marked the boundary 
 26 
 
402 
 
 ^PHYSIOLOGICAL LABOR. 
 
 between the segments, for in the state of quiescence this structure appears 
 to indicate that the first act of labor must be to overcome the resistance at 
 this point. 
 
 Contraction Ring. — According to modern teaching, the very first step 
 in the estabHshment of the parturient canal is the formation of the 
 so-called contraction ring, in the uterine wall at a point somewhat higher 
 up than the anatomical internal os, which latter, it is claimed, is of no 
 assistance whatever in the parturient canal (Figs. 527, 530). This contrac- 
 tion I'ing, which often goes by the name of Bandl's ring, is seated at a point 
 
 Fig. 528. — Frozen Section of the Uterus and Fetus from a Primipara, Aged Twenty- 
 four, WHO Died Suddenly from an Unknown Cause Two Hours after Admis- 
 sion to the Emergency Hospital. Labor had continued twenty-four hours, and 
 at time of death secondary inertia was present. The cadaver was frozen within 
 twenty-four hours, and the section made forty-eight hours from death. The caput 
 succedaneum is distending the parturient outlet, and the head Hes upon the pelvic 
 floor in the left occipito-anterior position before anterior rotation of the occiput' 
 (Compare Figs. 529 and 530.) — {Dr. W. E. Studdijord's case at the Emergency Hospital.) 
 
 in the uterus opposite a large coronary vein, and at which the serous coat of 
 the organ adheres intimately to the subjacent muscle (Figs. 529, 530, and 531). 
 It constitutes a wall-like ridge along the uterine cavity and divides the latter 
 into two segments, known as the upper and lower uterine segments, which 
 are peculiar to the parturient canal, having no existence save during the act 
 of labor (Fig. 530). The transitory existence of this ring gives it a problematic 
 character. We do not know whether it is always the same in different uteri 
 or even in the same uterus at different periods. That it undoubtedly exists 
 has been shown by frozen sections of women dying in labor (Figs. 531 and 532) 
 
THE PARTURIENT CANAL. 
 
 403 
 
 and by digital exploration during labor, while its existence is often implied 
 by various phenomena during parturition, such as special types of dystocia 
 and peculiar forms of rupture of the uterus. It is by no means certain that 
 those uterine fibers which lie between Bandl's ring and the site of the internal 
 OS do not contract to some extent. Another dubious point refers to the possi- 
 bility of independent contraction of the ring, most obstetricians holding that 
 this contraction is necessarily a part of the general action of the uterine muscle. 
 The consensus of opinion is that the ring is non-existent save during a labor 
 pain. Veit,* who has recently written at length upon the contraction ring, 
 claims that with the beginning of dilatation that part of the uterus which is 
 
 LOVER BORDER 
 OF PERITONEUM 
 
 CONTRACTION 
 RINQ 
 
 LUK 
 
 Fig. 529. — Outline of Fig. 528 with Explanatory Titles. 
 
 to form the future inferior uterine segment is distinctly thinner than the upper 
 or functionally active segment. 
 
 Cervical Dilatation. — The labor pains acting upon the amniotic fluid 
 which invests the fetus make uniform pressure within the uterine cavity. 
 The potential cavity of the cervix is naturally the locality which must give 
 way by a process of dilatation, and the amniotic sac with its fluid is forced 
 into this cavity in a wedge shape. With the inception of the pains the mem- 
 branes begin to separate from the contractile portion of the uterus, remaining 
 adherent, however, below the site of the actual or hypothetical contraction 
 ring. This separation varies in kind. Usually it occurs between the layers 
 of the decidua, although in some cases the detachment occurs between the 
 chorion and amnion. Next in sequence to the formation of the contraction 
 * " Monatschrift f. Geburts. u. Gynakol.," Feb., 1900. 
 
404 
 
 PHYSIOLOGICAL LABOR. 
 
 ring and dilatation of the cervix there occur certain changes throughout the 
 uterine walls. 
 
 Uterine Walls. — As the cavity of the uterus begins to discharge its 
 contents the muscular bundles which constitute the uterine wall undergo a 
 process of readjustment. Lamellae of muscle which were formerly superimposed 
 in strata now come to lie side by side, with resulting thinning of the uterine 
 wall. (Compare Figs. 530 and 531.) At the same time there ensue changes 
 in the position of the uterus. The latter begins to move backward and at 
 the same time to ascend. During the formation of the birth canal the fundus 
 gradually ascends until it reaches the costal arches, and synchronously with 
 this ascent there is also a slight lateral deviation, usually to the side which 
 
 Fig. 530. — Frozen Section seen in Fig. 528 with Fetus Removed. Note the contrac- 
 tion ring; the unruptured membranes; the shape of the parturient tract, including 
 uterus and vagina, and the thinness of the lower and the thickness of the upper uterine 
 segments. — {Dr. W. E. Studdiford' s case at the Emergency Hospital.) 
 
 is opposite to the fetal back. As the uterus rises the contraction ring also 
 ascends, and when the birth canal is fully formed the ring should be nearly 
 midway between the symphysis and navel (Figs. 527 and 529). This traction 
 which affects the upper segment and ring must affect the lower segment 
 as well; but as the cervix is held fast below, the lower segment must undergo 
 a process of stretching. In the primipara the dilatation of the cervix is a much 
 more laborious process than in the multipara, for in the latter much less resist- 
 ance is encountered owing to the semi-patulous condition of the external os 
 and cervical canal. In other words, the multiparous uterus has to oppose 
 chiefly the resistance of the internal os. The lax walls of the vagina, abun- 
 dantly moistened by the natural secretions, offer but little resistance to the 
 
THE PARTURIENT CANAL. 405 
 
 fetal head, by which they are readily separated. In primiparae, however, 
 the degree of resistance is considerable. The maximum of opposition is found 
 at the ostium vagincB, where "the distensibility is much less marked, and where, 
 moreover, additional resistance proceeds from the active contractions of the 
 levator ani muscle. This resistance is gradually overcome by the advancing 
 head, and is always much greater in the primipara, causing prolongation of 
 the period of expulsion. 
 
 The completed canal or tract through which the process of expulsion takes 
 place is irregular, with a curved axis (Fig. 516); the successive cross-sections 
 vary in shape in a definite manner, and the walls of the canal vary in rigidity 
 at the various segments. This canal, when completed under the combined 
 influence of the active uterine contractions and the passive dilatation of the 
 parts below the contraction ring, may be divided into three portions: viz., 
 (i) suprapelvic, (2) pelvic, and (3) infrapelvic. 
 
 Suprapelvic Portion. — The suprapelvic portion consists of the uterus, and 
 although it is a part of the parturient canal mechanically considered, it is more 
 especially the force which urges the fetus on than a part of the passageway 
 through which it travels. 
 
 Pelvic Portion. — The pelvic portion contains the cervico-vaginal portion 
 of the birth tract. During the elongation of the uterus and dilatation of the 
 OS the cervix lies within the pelvic excavation. The custom of describing the 
 bony pelvis as a portion of the birth tract does not appear to me to be advisable 
 (Fig. 516). 
 
 Infrapelvic Portion. — This consists of the distended and thinned sacral 
 segment of the pelvic floor (Fig. 516). When the utero-vaginal portion of 
 the birth tract has been formed by the act of labor, another step is required 
 for the completion of this structure, viz., elongation of the pelvic floor. When 
 the head of the child is upon the pelvic floor, the latter must necessarily go 
 through some form of violent alteration in shape before the passage of the fetus. 
 The capacity of the floor for distention is limited. But these changes in the 
 pelvic floor are not wholly effected in the single act of expulsion. A study 
 of this structure in frozen sections and otherwise shows that there are natural 
 differences between its relation in the non-pregnant and that in the pregnant at 
 term. While in the former the pelvic floor projects but slightly below a line 
 which passes from the tip of the coccyx to the lower border of the symphysis, 
 in the woman at term the perineum is already relaxed as well as thickened 
 by oedema, so that it bulges considerably beneath the natural level. The 
 ascent of the uterus, already described in connection with the formation of 
 the utero-vaginal portion of the birth tract, tends to draw upward the parts 
 anterior to the vagina; so that the fetal head does not force them below the 
 symphysis (Fig. 573). The distensible portion of the pelvic floor is therefore 
 the portion posterior to the vagina known as the sacral segment of the pelvic 
 floor. This segment appears at first sight to be thrust forward, and at the 
 same time elongated by the advancing head. But a study of lead-tape tracings 
 upon the pelvic floor during labor shows that the soft parts are really forced 
 backward, and at the same time excessively thinned. The anus is moved 
 backward. The pelvic floor projects but one inch in the non-pregnant. At 
 term its projection is 2f inches (7 cm.), and during labor an additional inch 
 is added. The normal perineum is i\ inches (3.17 cm.) long, while during 
 complete dilatation it measures 2^ inches (6.35 cm.). This increased projection 
 of the floor with its backward displacement and elongation appears to be due 
 entirely to the thinning of the sacral segment in response to the distention 
 
406 
 
 PHYSIOLOGICAL LABOR. 
 
 Fig. 531. — Uterus and Vagina from a Case of Sudden Death from Eclampsia near 
 THE End of the Second Stage of Labor. Note the retraction ring; the external 
 OS, the thickness of the uterine walls of the upper and lower uterine segments, and 
 the region of the internal os. — {Author's case at the Emergency Hospital.) 
 
THE PARTURIENT CANAL. 
 
 407 
 
 of the fetal head. While the perineum is almost three inches in thickness 
 at term, it is but an eighth of. an inch thick at the moment of expulsion. 
 
 LEFT 
 UTERINE, 
 BLOOD 
 VESSELS 
 
 Pig 532.— Outline of Fig. 531 with Explanatory Titles 
 
 Parturient Canal as a Whole.— This structure consists of an actively con- 
 tracting uterus in the shape and position which it assumes in virtue of its ascent 
 
408 PHYSIOLOGICAL LABOR. 
 
 in the abdominal cavity; and the passive portions, namely, vaginal and vulval, 
 which complete the canal and form a pronounced curve with a short anterior 
 and long posterior aspect (Fig. 516). The former is equii^alent to the anterior 
 uterine wall and the posterior surface of the symphysis plus the soft parts 
 which lie in front of the pubic bone, and the latter to the concavity of the pos- 
 terior uterine wall, the sacrum and coccyx plus the stretched and elongated 
 perineum. If each of these surfaces, the shorter anterior convex and the long 
 posterior concave, is divided into a given number of equivalent segments, 
 and the points which correspond on each surface are cut through by planes, 
 an imaginary line passing through the center of each of these planes will describe 
 a certain curve which is not the arc of a circle (Fig. 517). This curve represents 
 the axis of the birth canal, and must be described or followed by the center 
 of any solid mass which is forced through this passage. Numerous attempts 
 have been made to represent the various angles of inclination, axes, and curves 
 of the birth tract, but a total lack of agreement exists in the views of obstetri- 
 cians on this geometrical problem. In 1828 Carus attempted to show that 
 the parturient axis should be regarded, for practical purposes, as the arc of 
 a circle, the center of which was represented by the center of the posterior 
 surface of the symphysis. In this sense Carus's curve was understood by 
 Meigs, Tarnier, and others. But Carus states himself that the actual curve 
 is not the arc of a circle, but a so-called curve of the higher order, such as form 
 the subject-matter of Cartesian or analytic geometry. He intimates that he 
 has determined the formula for such a curve, and refers the reader to an in- 
 accessible work upon the skeleton. The arc of a circle appears to represent 
 the curve to the parturient canal in the drawings attributed to Krause, and 
 Moreau and Jacquemier, as cited in Varnier's analytic study of labor.* In 
 addition to difference of opinion as to the parturient curve, authors do not agree 
 as to the axis of the parturient uterus and superior strait. While many speak 
 of these axes as one and the same, Faraboeuf and Varnier regard them as dis- 
 tinct. With this last view I am in accord. 
 
 II. THE FETUS. 
 
 Although it is now well known that during parttirition the child is entirely 
 inactive, and so offers itself as a passive factor only, nevertheless certain parts 
 of the child do indirectly exert a modifying influence on child-birth. Obstetri- 
 cally considered, the fetus is made up of a head and a trunk, and constant 
 reference is made to the vertex, occiput, bregma, brow, and chin of the head, 
 and to the shoulders and pelvis or breech of the trunk (Figs 533 to 550). While 
 the bulkiest part of the fetus in its normal attitude or posture is the trunk 
 (see Attitude), still the head is least compressible, and so, obstetrically, is 
 larger than the trunk during the passage of the fetus through the pelvis, because 
 it offers the principal resistance. The head is much larger in proportion to 
 the trunk in the fetus than in the adult (Fig. 545). 
 
 The Fetal Head. — Because it is least compressible, it is the most important 
 factor in the mechanism of labor. Still, it is yielding to a certain degree, as is- 
 shown by the change in shape, which varies according to the diameters in which 
 the compressing force is applied. (See Moulding.) The fetal brain will endure 
 with impunity much compression and change in shape and volume, particularly as 
 
 * " Obst^trique Journali^re," iqoo. 
 
THE FETAL HEAD. 
 
 409 
 
 regards the hemispheres. The solidity of the bones at the base of the skuH protects 
 the gangha in that region. At term the shape of the fetal head is oval; the two 
 parts of the frontal bone are not closely united at birth and the incompressible 
 base and the compressible vault can be most clearly compared by making a section 
 through the skull parallel with the coronal suture just a little posterior to it 
 and passing through the parietal eminences and the mastoid processes The 
 bones of the base are solid and compactly ankylosed; the compressible vault 
 consists of flexible, semi-cartilaginous laminae, which are, except the frontal 
 bone, united to the base and to each other by membrane alone The face 
 of the child as compared with that of the adult is remarkably small in propor- 
 
 roj^rA/^£LL£ 
 
 Fig. 533. — Diameters and Landmarks of the Fetal Skull. Lateral Surface. 
 
 tion to the cranium. The lower jaw particularly differs from that of the adult ; 
 there are no teeth, and, the ramus being short and oblique, the lower maxilla 
 approaches closely to the upper, bringing the angle of the chin very near to the 
 center of the forehead, and rendering the distance from the tip of the chin 
 to the root of the nose not more than i J to i^ inches (3.17 to 3.75 cm.). 
 
 Regions and Protuberances. — The occiput is the region of the fetal 
 head behind the posterior fontanelle including and surrounding the external 
 occipital protuberances (Fig. 533). The vertex is the region between the an- 
 terior and posterior fontanelles and is bounded laterally by the parietal pro- 
 tuberances. The bregma is the anterior fontanelle. The sinciput, or brow, 
 is the region immediately in front of the bregma and including the anterior 
 portions of the two primitive halves of the frontal bones (Fig. 533). We find 
 
410 
 
 PHYSIOLOGICAL LABOR. 
 
 five protuberances upon the fetal head which are important as obstetric bony 
 landmarks. The occipital protuberance is situated at about the middle of the 
 occipital bone and an inch posterior to the posterior fontanelle (Fig. 535). 
 The parietal protuberances are situated at the center of the parietal bones (Fig. 
 533). The frontal protuberances are situated at the center of the frontal bones 
 
 (Fig- 536). 
 
 Bones. — The bones composing the vault of the head are the two frontal, two 
 
 oca PUT. 
 
 
 J^^/Mf'S'.i'CA 
 
 c?.' 
 
 p^. 
 
 N^i-. 
 
 
 \ ' 
 BITEMPORAL f ^: 
 
 3y^tN.(e.25c. 
 
 Fig. 534. — Diameters and Landmarks of the Fetal Skull. Upper Surface. 
 
 temporal, two parietal, and the occipital. The squamous portions of the fetal 
 skull form such small parts of this vault that they need not be considered (Fig. 
 533). From the standpoint of obstetrics, the base consists of an incompressible 
 bony mass comprising the face and inferior maxilla, ossification being further 
 advanced here. The compressible vault is attached behind and above. Occa- 
 sionally one finds supernumerary bones in the interparietal space ; they are caused 
 by irregular ossification, and are termed Wormian bones. 
 
 Sutures. — The membranous portions between the bones constitute the 
 
THE FETAL HEAD. 
 
 411 
 
 sutures, which are named according to the bones which they join and the posi- 
 tions which they occupy. The sutures are not dovetailed, but are separated 
 one from another. The frontal suture unites the two frontal bones ; the coronal 
 or fronto-parietal sutures join the two frontal with the two parietal bones; the 
 great, sagittal, or biparietal suture unites the two parietal bones; and the lamb- 
 doid (deriving its name from the likeness of its shape to the Greek letter A), 
 or occipito-parietal, joins the occipital and the two parietal bones. Besides 
 these there are two others : the temporal or squamous sutures, which are not 
 factors in the mechanism of labor, and cannot usually be palpated during the 
 process of the same (Figs. 534 and 536). 
 
 FoNTANELLES. — The point where two or more sutures meet is termed a 
 
 BREGMA 
 
 
 EXTERNAL 
 OCCIPITAL PffOTUBEf^ANCf 
 
 Fig. 535- — Diameters and Landmarks of the Fetal Skull. Posterior Surface. 
 
 fontanelle. There are two principal ones, namely: (i) The anterior or great, 
 also called the bregma and sometimes the sinciput; this space is diamond- or 
 kite-shaped, and is found at the point of junction of the frontal, coronal, and 
 sagittal sutures. It persists during labor, notwithstanding its somewhat de- 
 creased extent caused by the approach of the cranial bones. Four sutures 
 run into it ; it averages one inch in diameter and varies widely in size in different 
 fetal heads. (2) The posterior or small fontanelle, triangular in shape, is found 
 at the point of junction of the lambdoidal and sagittal sutures. This space 
 does not persist during labor, being then merely a depression or obliterated by the 
 overlapping.of the occiput by the parietal bones. Three lines of sutures run into 
 it. Not infrequently by reason of advanced ossification this fontanelle is absent. 
 
412 
 
 PHYSIOLOGICAL LABOR. 
 
 (3) The temporal joiUanellcs are found at the anterior and posterior extremities of 
 the inferior border of each parietal bone (Fig. 533). They are irregular in shape 
 and resemble somewhat the occipital fontanelle, and may possibly be mistaken 
 for it during labor in cases of lateral obliquity of the fetal head (see Part V). 
 
 (4) False jontanelles are occasionally seen either along the line of a suture or in 
 the body of a bone, and are due to imperfect or irregular ossification. They rpay 
 be mistaken for the principal fontanelles. In my collection of 34 full-term skulls 
 well-marked false fontanelles appear in 4 instances, or ii.i per cent.; in 2)Z pre- 
 mature skulls in 5 instances, or 15.1 per cent. (Fig. 439). 
 
 Movements of the Fetal Head Upon the Spinal Column. — Complete 
 Flexion. — The head may so bend upon the child's chest that the chin and sternum 
 
 Fig. 536. — Diameters and Landmarks of the Fetal Skull. Anterior Surface. 
 
 touch each other, giving the condition of complete flexion. The movement of 
 flexion is really rotation of the head on a transverse axis. 
 
 Incom,plete Flexion. — In certain cases when the head is at the pelvic brim 
 and in the third or fourth vertex position, flexion is either partly or entirely 
 wanting. Sometimes this condition results from the usual forces not exerting 
 their normal degree of action. Imperfect vertical flexion in a flat pelvis will 
 be referred to again (Fig. 539). 
 
 Com.plete Extension. — Again, the head may be bent backward so that the 
 occipital protuberance touches the cervical spines without doing any injury 
 to the vessels or ligaments of the neck and giving the condition of complete 
 extension (Fig. 539). These movements are believed to take place principally 
 in the cervical vertebras, the occipito-atlantoid articulation taking little or no 
 part in them. Antero-posterior motion in some instances certainly amounts 
 to as much as 115 degrees. The term incomplete extension explains itself. 
 
THE FETAL HEAD. 
 
 413 
 
 Rotation. — The occipito-atlantoid articulation furnishes the mechanism for 
 a very important movement' — that of rotation ; rotation that allows the vertex 
 to move from one point in 'the pelvis to another, and yet not necessarily re- 
 quiring the shoulders to follow this movement. The question as to how great 
 a degree of rotation of the head upon the spinal column may take place with 
 safety to the child has been the subject of much dispute among obstetricians. 
 Most of them agree that rotation in the arc of a circle consisting of 90 degrees 
 may occur without any injury to the child (Fig. 539), and Tarnier even goes so far 
 
 i 
 
 
 »s 
 
 #. 
 
 EXTERNAL 
 
 OCCIPITAL 
 
 PROTUBERANCE 
 
 Pjq_ 237. — Diameters and Landmarks of the Fetal Skull. Inferior Surface. 
 
 as to say that rotation in the arc of a semicircle may be made to occur without 
 injury. In this case the child's face would look directly backward over its 
 spinal column. From experiments with fetal cadavers I find that this rotation 
 or torsion is not confined to any single point or joint, but is distributed along 
 the upper spinal vertebra. Ninety-degree rotation of the fetal head durmg 
 labor often occurs without injury to the neck. Fig. 539 is one of several pho- 
 tographs of living children I have taken within an hour of delivery to prove 
 the harmlessness of ninety-degree rotation of the fetal head. In the present 
 case a hundred degrees was easily obtained. 
 
414 
 
 PHYSIOLOGICAL LABOR. 
 
 Lever Action of the Fetal Head. — The head is not, evenly balanced upon 
 the spinal column. It forms a lever, the chin end of which is the longer, the 
 occipital end the shorter, so that this anterior or chin arm tends to fall when 
 the head is balanced upon the condyles. The importance of this fact will be 
 more manifest when the mechanism of labor is discussed (Fig. 578). 
 
 Moulding. — The result of the pressure of the birth canal upon the fetal 
 skull is to diminish the capacity of the whole cranium. This is brought about 
 by: (i) The approximation and overlapping of the bones of the vertex. The 
 bones of the calvarium are not merely joined by membrane, as was stated before, 
 but there is considerable opportunity for overlapping under pressure, since (a) 
 they ossify late; {b) they are separated by sutures and fontanelles which permit 
 
 of overlapping; (c) and they are so 
 thin as to admit of bending and 
 moulding. Overlapping in the pro- 
 cess of labor always takes place in 
 a systematic manner. The parietal 
 bones overlap the frontal and the 
 occipital bones, and the parietal 
 bone which is submitted to the 
 greater pressure — that is, always 
 the one which lies posterior in the 
 pelvis — slidesunder its fellow. (2) 
 The cerebrospinal fluid is squeezed 
 out of the head into the spinal 
 canal. (3) The blood is also forced 
 out of the cerebral vessels, to a cer- 
 tain extent. (4) Then, too, the 
 brain substance itself in the fetus 
 is but slightly developed, and is 
 therefore capable of being com- 
 pressed and moulded to a consider- 
 able degree without any permanent 
 damage to the fetus. As the fetal 
 head descends lower and lower into 
 the pelvis it becomes subjected to 
 an increasing degree of compres- 
 sion and moulding. Moulding is 
 further assisted by the hinge pro- 
 duced by the non-ossification of the 
 triangular portion of the occipital 
 bone with the basilar portion. 
 Diameters of the Fetal Head (Figs. 533 to 537)- — For the purpose of 
 judging of the changes of shape in the head, and of comparing the head with 
 the pelvic dimensions, there are numerical measurements of certain diameters 
 of the fetal skull. Problems in the mechanism of labor concern not only the 
 size but the shape of the fetal head, and these are best understood, studied, 
 and described by the aid of diameters and circumferences taken at different 
 planes. The most important diameters in case of pelvic deformity are those 
 of the base, since they are incompressible. But those to be dealt with in the 
 usual case of labor are those having at least one extremity on the vault of the 
 skull, and therefore capable of being shortened. The incompressible diameters 
 are (i) the bimastoid; (2) the bimalar; (3) the bitemporal. The fetal head 
 
 Fig. 538. — Antero-posterior Movements op 
 THE Fetal Head upon the Body. Complete 
 flexion; incomplete flexion, incomplete exten- 
 sion; complete extension. 
 
THE FETAL HEAD. 
 
 415 
 
 diameters include (i) the occipito-mental ; (2) the occipito-frontal ; (3) the sub- 
 occipito-frontal; (4) the s'ub6ccipito-bregmatic; (5) the biparietal; (6) the 
 bitemporal; (7) the bimalar; (8) the bimastoid; (9) the f ronto-mental ; (10) 
 the cervico- or trachelo-bregmatic. 
 
 I. The occipito-mental diameter, O. M., 5-^ inches (14 cm.), is the greatest 
 distance from the center of the lower margin of the chin to a point on the pos- 
 terior extremity of the sagittal suture. 
 
 '^'^s**^.. 
 
 Fig. 539. — Rotation of the Fetal Head upon the Body. The illustration is from one 
 of several photographs taken of living children within an hour after delivery to prove 
 the harmlessness of 90 degrees or even greater rotation of the fetal head upon the 
 body. This photograph shows no degrees rotation. — {Photograph taken by the author 
 at ike Emergency Hospital.) 
 
 2. The occipito-frontal diameter, 0. F., 4^ inches (11.5 cm.), is measured 
 from the apex of the occipital protuberance to the root of the nose. 
 
 3. The suboccipito-frontal diameter, S. 0. F., 4f inches (11 cm.), extends 
 from the junction of the neck and occiput to the root of the nose. 
 
 4. The suhoccipito-bregmatic diameter, S. 0. B., 3|- inches (9.5 cm.), is meas- 
 ured from the junction of the nucha and the occipital bone to the center of 
 the anterior fontanelle. 
 
416 PHYSIOLOGICAL LABOR. 
 
 5. The hiparietal diameter, BI P., 3I inches (9.5 cm.), is the widest distance 
 between the parietal protuberances. 
 
 6. The bitemporal diameter, T. T., 3^ inches (8.25 cm.), is the distance be- 
 tween the anterior ends of the coronal sutures. 
 
 7. The bimalar diameter, M. M., 3 inches (7.5 cm.), is the greatest distance 
 between the malar tuberosities. 
 
 8. The bimastoid diameter, 3 inches (7.5 cm.), is the widest distance between 
 the mastoid apophyses. 
 
 9. The fronto-mental diameter, F. M., 3^ inches (8.25 cm.), is measured 
 from the summit of the forehead to the center of the lower margin of the chin. 
 
 The mento-frontal diameter cannot be estimated, as the frontal bone offers 
 no fixed point which would serve as one extremity. However, an approximate 
 measurement might be stated to be about 3 inches (7.5 cm.), one-half of w^hich 
 would span the distance between the glabella * and chin. 
 
 10. The cervico- or trachelo-bregmatic diam,eter, 3f inches (9.5 cm.), extends 
 from the junction of the neck and chin to the center of the anterior fontanelle. 
 
 These are average measurements taken from many thousand heads, elim- 
 inating as far as possible alterations in shape due to mouldmg of the head in 
 its journey through the pelvis, for even after easy labors, with perfectly normal 
 vertex presentations, the diameters of the child's head after delivery will 
 be decidedly different in relative length from those which have just been men- 
 .tioned. While these changes in length are usually only relative, yet they 
 may at the same time be absolute, chiefly affecting the occipito-mental and 
 occipito-frontal diameters. These are increased while all the others are dimin- 
 ished, especially the suboccipito-bregmatic and the biparietal. The diameters 
 are of value in that they indicate the circumference of the plane of the skull 
 in which they are taken. As has been stated, the general shape of the head 
 is roughly ovoid, or spheroidal, so that a reasonable idea may be obtained of 
 the mass under comparison. The approximate measurements of the more 
 important diameters of the fetal head for ease in memorizing and for practical 
 purposes may be stated as follows: 
 
 Occipito-mental, 5^ inches (14 cm.) Fronto-mental, ... 3 J inches ( 9 cm.) 
 
 Occipito-frontal, 4^ inches (11 cm.) Biparietal, 3^ inches ( 9 cm.) 
 
 Sub-occipito-bregmatic .3^ inches ( 9 cm.) Bitemporal 3^ inches (8.25 cm.) 
 
 Planes and Circumferences of the Fetal Head. — Again, we study 
 the shape and size of the fetal head by means of planes or cross-sections cor- 
 responding to its diameters, in the same way as we study the pelvis by means 
 of horizontal planes at different levels. 
 
 1. The occipito-mental plane (Fig. 541). This section passes through the 
 occipito-mental and biparietal diameters; its shape is irregular and oval; its 
 circumference is the greatest circumference of the fetal head and equals 15 
 inches (38 cm.). 
 
 2. The occip no- frontal plane (Fig. 543). This section passes through the 
 biparietal and the occipito-frontal diameters; it is irregularly oval in shape; 
 its circumference is 13I inches (35 cm.). 
 
 3. The sitboccipito-frontal plane (Fig. 542). This plane passes through the 
 bitemporal and suboccipito-frontal diameters; it is also oval and irregular in 
 shape; its circumference is 12 inches (30 cm.). 
 
 4. The suboccipito-bregmatic plane (Fig. 540). This section passes through 
 the biparietal and suboccipito-bregmatic diameters. This plane is the smallest 
 
 * Glabella, " the space between the eyebrows." 
 
THE FETAL HEAD. 
 
 417 
 
 of all the head planes; is nearly circular in shape, and is the plane which, in 
 normal vertex presentations and complete flexion of the head, is successively 
 in relation with all the pelvic planes from the inlet to the outlet of the parturient 
 canal. Its circumference, after moulding of the head, is ii inches (28 cm.)- 
 A study of these cephalic planes and circumferences shows that the circum- 
 ference of the suboccipito-bregmatic plane is the smallest, and that of the 
 occipito-mental is the greatest of the fetal head circumferences; that any 
 
 OCCI PUT 
 
 Fig. 540. — Line of Section and Shape 
 OP Suboccipito-bregmatic Plane. 
 — (Author's lead-tape tracing.) 
 
 Fig. 541. — Line of Section and Shape of 
 Occipito-mental Plane. — {Author's Lead-tape 
 tracing.) 
 
 departure from the normal attitude of complete flexion of the head, whereby 
 the head is partly extended, increases the circumference of the presenting 
 part anywhere from 11 to 15 inches, according to the degree of head extension; 
 thus making all the difference between an easy, normal labor and complete 
 obstruction due to a too great fetal head circumference presenting. 
 
 Trunk Measurements. — The measurements of the trunk are unimpor- 
 tant in average-sized fetuses, because all the diameters are compressible and 
 offer little obstacle to delivery (Figs. 544 to 550). 
 27 
 
418 
 
 .PHYSIOLOGICAL LABOR. 
 
 1. The hisacromial diameter, A. A., 4I inches (12 cm.), is the greatest distance 
 between the acromial processes. It is readily compressible an inch. 
 
 2. The bitrockanteric diameter, T. T., 3^ inches (9 cm.) is the widest distance 
 between the trochanters. 
 
 3. The dorso-sternal diameter, D. S., 3I inches (9.5 cm.), is an antero-posterior 
 diameter at the level of the shoulders. 
 
 4. The sacro-pubic diameter, 2^ inches (5.5 cm.), is the antero-posterior 
 
 OCCI PUT 
 
 OCCI PUT 
 
 SINCI PUT 
 
 Fig. 542. — Line of Section and Shape 
 OF SuBocciPiTO-FRONTAL Plane. — {Au- 
 thor's lead-tape tracing.) 
 
 Fig. 543. — Line of Section and Shape 
 OF Occipito-frontal Plane. — Author's 
 lead- tape tracing.) 
 
 diameter of the fetal pelvis. Flexion of the thighs upon the abdomen doubles this 
 diameter, making it 4^ inches (11 cm.); it is then compressible an inch or more. 
 
 5. The vertico-podalic diameter, V. P., 9^ to 10 inches (24.13-25.4 cm.), is the 
 length of the fetal ellipse, and is the greatest distance from the vertex to the 
 breech. 
 
 6. The bisacromial circumference — namely, a circumference corresponding 
 to the bisacromial diameter— is 13 inches {zz cm.) (Fig. 547)- This is compres- 
 sible several inches. > 
 
THE FETAL TRUNK. 
 
 419 
 
 Planes and Circumferences of the Fetal Trunk. — The bisacromial plane 
 is oval with its long axis transverse (Fig. 547). The midplane of the fetal ellipse 
 is an important one, and but rarely, if ever, referred to in works on obstetrics (Fig. 
 544). It is a plane passing through the center of the fetal body and including in 
 its circumference the knees, elbows, and umbilical cord. Its shape is generally 
 oval, and its long axis antero-posterior as regards the fetal body. The bitro- 
 chanteric with extended thighs is oval with a longer transverse diameter (Fig. 550). 
 When the thighs are flexed on the body a more round shape obtains (Fig. 549)- 
 
 Fig. 544. — Lateral Surface of the Nor- 
 mal Fetal Ovoid, or Ellipse, showing 
 ALSO the Line of Section (i, 2) and the 
 Shape of the Midplane of the Fetal 
 Ellipse. — {Author's lead-tape tracing.) 
 
 Fig. 545. — Anterior View of the Nor- 
 mal Fetal Ovoid or Ellipse. 
 
 Length and Weight of the Fully Developed Fetus. — At the for- 
 tieth week, or full term, the total length from heels to vertex varies from 18.9 
 to 20.47 inches (48 to 52 cm.); the vertex-coccygeal length being about one- 
 half of this. The average weight is 6.60 to 7.92 pounds (3000 to 3600 grams); 
 males weighing somewhat more than females and the first child less than sub- 
 sequent children, this progressive gain in weight, however, being true only 
 
420 
 
 PHYSIOLOGICAL LABOR. 
 
 till the fourth or fifth child. It must be remembered that variations in the 
 weight of the mature fetus occur from 6 to 12 pounds (2700 to 5400 grams); 
 in very rare instances 12 pounds (5400 grams) has been exceeded, and weights 
 up to 20 pounds (9000 grams) have been observed. 
 
 Attitude or Posture. — A practical point in connection with the part the 
 child plays in the process of labor has to do with (i) the manner in which the 
 
 Fig. 546. 
 
 Fig. 548. 
 
 Fig. 549. 
 
 Figs. 546-549. — Fig. 546 Shows the Relation of the Long Head Diameter to the 
 Long Shoulder Diameter, They being at Right Angles to Each Other. Fig. 
 547 Shows the Shape of the Bisacromial Plane. — {Author's lead-tape tracing.) 
 Fig. 548 Gives the Posterior View of the Fetal Ovoid or Ellipse, showing 
 Lines of Section of Bisacromial Plane (3, 4) and Bitrochanteric Plane When 
 THE Thighs are Flexed (5, 6). Fig. 549 Gives the Shape of the Bitrochanteric 
 Plane, when the Thighs are Flexed. — {Author's lead-tape tracing.) 
 
 child is placed in the uterus as regards the relationship existing between its 
 own parts, and (2) the relationship existing between it and the uterus and pelvis. 
 Attitude or posture designates the relation which the different parts of 
 the fetus bear to each other. In the normal attitude the body is flexed upon 
 itself, rendering the back arched so as to form a convexity backward (Fig. 545). 
 It has been shown that from the earliest period the embryo tends to curve 
 upon itself, and this flexion persists throughout intra-uterine life (Fig. 134). 
 The head is bent upon the sternum; the forearms are crossed or are near one 
 another upon the chest ; the thighs and legs are flexed so as to bring the knees 
 
ATTITUDE AND PRESENTATION OF THE FETUS. 
 
 421 
 
 near the elbows and the feet near the buttocks or breech; the dorsum of the 
 foot being somewhat flexed on the leg and the soles of the feet turned a little 
 mward; the umbilical cord is generally found in the space between the arms 
 and legs, although it may be wound about the neck or body of the child from 
 one to several times (Fig. 134). This is the attitude of the later months, but 
 in the earlier months, when there is a relatively greater amount of liquor amnii, 
 the fetus is not in such a compact mass, nor 
 are the extremities so near one another. 
 
 The Fetal Ovoid, or Ellipse. — In consider- 
 ing the whole body of the fetus, it may be 
 regarded as presenting roughly an ovoid mass 
 which is made up of two parts, head and 
 trunk, both of the same general shape — 
 ovoid. In normal mechanism the long axis 
 of the whole mass is almost parallel with the 
 axis of the birth canal, and the two axes of 
 the two masses respectively, head and body, 
 are nearly parallel, one to the other. The 
 trunk and breech of this fetal ovoid, or ellipse, 
 are bulkier and require more room than does 
 the head, which latter, after moulding, is com- 
 paratively pointed (Fig. 544). It must also 
 be rememlDcred that the fetal ovoid is flat- 
 tened from side to side; that its greatest 
 transverse diameter is an antero-posterior 
 one at about its center or midplane, and 
 measured from the spine to the region of 
 the flexed arms, legs, thighs, and the coiled- 
 up cord (Fig.' 544). Attitude is caused chiefly 
 by the tonic action of the flexor muscles, for 
 they, being the stronger, predominate over 
 the extensors, and the primitive attitude of 
 the embryo persists. The shape of the uterus 
 also offers an etiological factor. According 
 to Pajot's law of accommodation: " When a 
 solid body is contained in another, if the 
 container is the seat of alternate movement 
 and rest, if the surfaces are slippery and not 
 angular, the contained constantly tends to 
 accommodate its form and dimensions to the 
 form and capacity of the container." After 
 delivery a child will be seen to assume natu- 
 rally the prenatal attitude and yet it is free 
 to move in any direction. Faulty attitude 
 during labor may cause many complications, 
 such as incomplete flexion or bregma presen- 
 tation; brow and face presentations; lateral 
 flexion of the head and prolapse of arms, legs, and cord. 
 Part V.) 
 
 Presentation. — The term presentation is used to designate that portion of 
 the child showing itself most prominently at the os uteri, in the vagina, or 
 at the vulva, or it is the relationship of the long axis of the child to the long 
 axis of the uterus. 
 
 Fig. 550. — Anterior View of Fetus 
 WITH Extended Arms and Legs. 
 Shows line of section (3, 4) and 
 shape of bitrochanteric plane when 
 thighs are extended. — {Author's 
 lead-tape tracing.) 
 
 (See P'etal Dystocia, 
 
422 
 
 PHYSIOLOGICAL LABOR. 
 
 Table of Pelvic and Fetal Measurements, 
 internal measurements of the bony pelvis. 
 
 
 Antero-posterior 
 Diameters. 
 
 Oblique 
 Diameters. 
 
 Transverse 
 Diameters. 
 
 Circumferences. 
 
 Inlet 
 
 Middle plane 
 
 cavity, . . 
 
 Outlet, .... 
 
 of 
 
 4j in. (ii cm.). 
 
 5 in. (12.S cm.), 
 3f-4i in. (9.5- 
 12 cm.). 
 
 5 in. (12.5 cm.). 
 4 J in. (12 cm.). 
 
 si in. (13.5 cm.). 
 
 4f in. (12 cm.). 
 4-J in. (11 cm.). 
 
 16 in. (40.5 cm,). 
 18 in. (45 cm.). 
 
 Depth of the true pelvis in front is if in. (4 cm.) ; posteriorly 4^ to 5 in. (11.5 to 12,5 
 cm.); lateral walls 3^ in. (9 cm.). These measurements of the bony pelvis are lessened 
 by the muscles and tissue of the soft parts i to J inch (0.635 to 1.27 cm.). 
 
 CLINICAL MEASUREMENTS OF THE PELVIS. 
 
 Interspinal diameter , (Fig, 203) 10 inches (25.5 cm.) . 
 
 Intercristal diameter, (Fig. 204) 11 inches (28 cm.) . 
 
 Bitrochanteric diameter, (Fig. 204) 12 J inches (31 cm.). 
 
 External conjugate diameter (Fig. 206) 8 inches (20.25 cm.). 
 
 Right and left external obhque diameters, (Fig. 205) 8 J inches (22 cm.). 
 
 Diagonal conjugate diameter (Fig. 209) 5 inches (12.5 
 
 True conjugate diameter, (Fig. 214) 4^ inches (11.5 
 
 Transverse of inlet diameter (Fig, 216) 5J inches (13.5 
 
 Sacropubic conjugate of outlet diameter (Fig, 208) 4! inches (12 
 
 Bisischial diameter (Fig, 210) 4^ inches (11 
 
 External circumference of pelvis 35i inches (88,75 cm,). 
 
 cm.), 
 cm.), 
 cm.), 
 cm.), 
 cm,). 
 
 FETAL HEAD MEASUREMENTS (Figs, 533 to 537). 
 Occipito-mental diameter 5i inches (14 
 
 cm,), 
 cm,), 
 cm,), 
 cm.). 
 
 Occipito-frontal diameter, 4i inches (11,5 
 
 Suboccipito-bregmatic diameter zi inches ( 9,5 
 
 Biparietal diameter, 3I inches ( 9.5 
 
 Bitemporal diameter - 3i inches ( 8.25 cm.). 
 
 Bimastoid diameter, 3 inches ( 7.5 cm.). 
 
 Pronto-mental diameter, .'3i inches ( 8.25 cm.). 
 
 Cervico-bregmatic diameter, 3f inches ( 9.5 cm.). 
 
 Occipito-mental circumference, (Fig- 54^) ^5 inches (38 cm.). 
 
 Occipito-frontal circumference, (Fig. 543) 13! inches (35 cm.). 
 
 Suboccipito-f rental circumference, (Fig- 542) 12 inches (30 cm.). 
 
 Suboccipito-bregmatic circumference, (Fig, 540) 1 1 inches (28 cm.), 
 
 Biparietal circumference (Fig, 540) 12 inches (30 cm.). 
 
 FETAL TRUNK MEASUREMENTS. 
 
 Bisacromial diameter 4f inches (12 cm.). 
 
 Bitrochanteric diameter 3^ inches ( 9 cm.), 
 
 Dorso-stemal diameter, . . .' 3f inches ( 9.5 cm.), 
 
 Sacro-pubic diameter, 2 J to 4^ inches (5.5 to 1 1. cm.) , 
 
 Vertico-podalic diameter, 9^ to 10 inches (24,13 to 25.4 cm.), 
 
 Bisacromial circumference, 13 inches {^z cm.). 
 
PRESENTATION OF THE FETUS. 423 
 
 f Vertex, Bregma. Brow, Face. 
 I Cephalic ■ \ ■^'t^rior Parietal Bone, Posterior Parietal 
 
 " I Bone. 
 
 t Excessive flexion. 
 Classification 1 U. Pelvic { Breech. 
 
 °^ \ III. Trunk I Shoulder. 
 
 Presentations. I ..-„,. , ( t. ■, , , 
 
 IV. Complicated | Prolapse of cord; one or more arms or legs. 
 
 f Head and breech. 
 
 V. Multiple \ Two heads, two breeches. 
 
 [ Head or breech and shoulder or abdomen. 
 
 Relative Frequency. — The frequency of vertex presentations is 96 per cent. 
 of all presentations; the pelvis or breech presents in from 3 per cent, to 4 
 per cent, of all cases; face presentations occur in 0.5 per cent.; shoulder pres- 
 entations in 0.5 per cent.; and brow presentations in 0.25 per cent, of all cases. 
 
 We have no reliable figures to offer for the relative frequency of complicated 
 and multiple presentations. 
 
 Causes of Frequency of Vertex Presentations. — The etiology of the usual 
 presentation, — the vertex, — considered the normal since it is present in 96 per 
 cent, of all cases at full term, is readily understood. It is well established 
 that the head is generally lower than the breech, even from the very first 
 formation of the liquor amnii. It has been shown that in the early months 
 frequent changes occur in the position of the fetus in utero, that these changes 
 become less and less marked as full term approaches, until at that period the 
 proportion of head presentations far exceeds in frequency any other. According 
 to Churchill's statistics, head presentations occur in 83 per cent, of living and 
 only 53 per cent, of dead fetuses at seven months. Changes from other pre- 
 sentations to the vertex are more frequent than the converse, and a shoulder 
 is more often changed than a breech, the causes being the shape of the fetus 
 and uterus and uterine contractions. 
 
 In 175 miscarriages (third to seventh month) I found the proportion of 
 cephalic and podalic presentations equally divided. In 238 premature children 
 including living, still-born, twins, and still-bom and macerated, I found the 
 following : 
 
 Cases. 
 
 Cephalic (vertex) presentation, 129 or 54.20 per cent. 
 
 Podalic (breech) presentation SS or 23-12 per cent. 
 
 Shoulder presentation, 7 or 2.95 per cent. 
 
 Not noted on history, 47 or 19.23 per cent. 
 
 Total 238 
 
 In the total number of 238 premature children, including the twenty twin 
 cases : 
 
 Cases. 
 
 Fetus was bom living, 114 or 47.89 per cent. 
 
 Fetus was still-bom, 47 or 19.75 P^r cent. 
 
 Fetus was still-bom and macerated 43 or 18.07 P^r cent. 
 
 Condition not noted on histories, 34 or 14.29 per cent. 
 
 Total 238 
 
 Vertex. Breech. Shoulder. 
 
 Living children 3i-5o per cent. 9.24 per cent, 0.84 per cent. 
 
 Still-bom, 9-24 per cent. 5. 88 per cent. 1.26 per cent. 
 
 Still-bom and macerated, 8.82 per cent. (5.30 per cent. o per cent. 
 
 This last table shows markedly the predominance of vertex presentations 
 in fetuses bom alive (31.50 per cent, vertex, and 9.24 per cent, breech, in living 
 
424 PHYSIOLOGICAL LABOR. 
 
 fetuses; moreover, the sharp decHne in the excess of vertex presentations over 
 breech when a still-born or still-born and macerated fetus obtains (9.24 per 
 cent, vertex and 5.88 per cent, breech in the former, and 8.82 per cent, vertex 
 and 6.30 per cent, breech in the latter). 
 
 As pregnancy approaches term the presentation becomes progressively more 
 and more stable, and particularly so in primigravidae, because the head descends 
 lower in the pelvis, and the abdominal walls, being more rigid, prevent move- 
 ments to any extent.* 
 
 Gravity is an important factor in determinmg the position of the head at 
 the cervix. The fetus is immersed m a fluid not much lighter than itself (liquor 
 amnii, specific gravity i.oi). With these conditions the effect of gravity 
 will depend not upon the position of the center of gravity of the child when 
 suspended in air, but upon the relative specific gravity of the different parts. 
 Matthews Duncan proved that the specific gravity of the head is greater than 
 that of the headless trunk. 
 
 Other causes of head presentation exist, and one is the shape of the uterine 
 cavity and the law of accommodation, for the fetus in vertex presentation 
 takes up less room than in any other position. Although in the middle third 
 of pregnancy the pregnant uterus is nearly round, yet in the last third it becomes 
 more and more pear-shaped or pyriform, with the broad part directed upward 
 and the tapering extremity downward. In the study of the fetal ellipse it 
 has been seen that it consists of a bioad extremity, the breech, and the narrowed 
 part, the head. In the adaptation of the fetus' body to the uterine cavity, 
 a head or vertex presentation results. Since the uterus is so elastic and con- 
 tractile, when the long axis of the child lies transverse or oblique, uterine action 
 tends to make it parallel with the long axis of the uterus, accommodating the 
 bulky breech to the roomy fundus and the smaller pointed head and vertex 
 to the narrowed and less roomy lower uterine segment. 
 
 Reflex action on the part of the child plays its part in causing the head 
 to lie lowest. In the case of breech presentation the sensitive buttocks and 
 feet are constantly exposed to the jars caused by movements of the mother, 
 as well as to the augmented uterine contractions of the lower part of the uterus 
 caused by the extreme stretching to which it is subjected by a breech in the 
 latter part of gestation. 
 
 The intermittent uterine contractions, which increase in force and fre- 
 quency as gestation advances, help in securing a head presentation, assisted 
 liy the shape and attitude of the fetus and the bulk and mobility of the 
 fetal head. The sum of the force of intra-uterine pressure is toward the 
 lower uterine segment, and hence the head, being mobile, is forced down in 
 that direction. 
 
 Summary. — The following are the causes of vertex presentation, enumerated 
 in the order of their importance: (i) The shape of the uterine cavity; (2) 
 the shape of the fetal ellipse; (3) the intermittent uterine contractions; (4) 
 the mobility of the fetal head; (5) the direction of intra-uterine force; (6) 
 gravity; (7) reflex action. Alterations in the normal action of any one of 
 these important causes may result in departures from a normal vertex pres- 
 entation The shape of the uterine cavity may be changed by tumors, pelvic 
 deformity, low implantation of the placenta, hydramnios, and multiple preg- 
 nancy. The normal shape of the fetal ellipse may be changed by hydrocephalus, 
 
 * Schroeder, however, from observations made in 214 primigravidae, including four 
 cases of contracted pelvis, found during the last three weeks of pregnancy changes of pres- 
 entation occurring in 36.4 per cent. 
 
POSITION OF THE FETUS. 425 
 
 and by tumors of the neck and trunk. Gravity and reflex action are affected 
 by the death of the fetus. 
 
 Position. — The term position is used to define the relationship existing 
 between a certain point on the presenting part, and certain other points on 
 the pelvis of the mother. The points on the presenting parts are the occiput 
 in vertex presentations; the sacrum in breech presentations; the chin in face 
 presentations; the frontal bone in brow presentations, and a scapula in shoulder 
 presentations respectively. The four fixed cardinal points on the mother's 
 pelvis are the two acetabula in front and the two sacro-iliac synchondroses 
 posteriorly (Figs. 513 and 514). The positions in all presentations are named 
 numerically, beginning at the left acetabulum and passing to the right, and 
 thus around the pelvis; as the first, second, third, and fourth. There are, 
 therefore, four positions for each presentation, according as the single point 
 on the presenting part corresponds to one of the four cardinal points on the 
 motlier's pelvis. For example: in the right mento-posterior position the chin is 
 the point on the presenting part, and the right sacro-iliac synchondrosis is the 
 point on the pelvis of the mother. This is the third position in face presentation. 
 
 POSITIONS OF THE FETUS. 
 VERTEX POSITIONS. 
 L Left Occipito-anterior — Occipito Lasva Anterior, L. 0. A.. 70 per cent. 
 II. Right Occipito-anterior — Occipito Dextra Anterior, R. 0. A., 10 per cent. 
 
 III. Right Occipito-posterior — Occipito Dextra Posterior, R. O. P., 17 per 
 cent. 
 
 IV. Left Occipito-posteiior — Occipito Lasva Posterior, L. 0. P., 3 per cent. 
 
 FACE POSITIONS. 
 
 I. Left Mento-anterior — Mento Lseva Anterior, L. M. A., second in fre- 
 quency. 
 
 II. Right Mento-anterior — Mento Dextra Anterior, R. M. A., third in 
 frequency. 
 
 III. Right Mento-posterior — Mento Dextra Posterior, R. M. P., most common. 
 
 IV. Left Mento-posterior — Mento Laeva Posterior, L. M. P.. fourth in fre- 
 quency. 
 
 BROW POSITIONS. 
 I. Left Fronto-anterior — Fronto Lseva Anterior, L. F A. 
 II. Right Fronto-anterior — Fronto Dextra Anterior, R. F.. A. 
 III. Right Fronto-posterior — Fronto Dextra Posterior, R. F. P. 
 1 V. Left Fronto-posterior — Fronto Laeva Posterior, L. F. P. 
 
 PELVIC POSITIONS. 
 T. Left Sacro-anterior — Sacro Lseva Anterior, L. S. A., most frequent. 
 II. Right Sacro-anterior — Sacro Dextra Anterior, R S. A. 
 
 III. Right Sacro -posterior — Sacro Dextra Posterior, R. S. P., second in 
 frequency. 
 
 IV. Left Sacro-posterior — Sacro Lseva Posterior, L. S. P. 
 
 SHOULDER POSITIONS. 
 I. Left Scapula Anterior — Scapula Laeva Anterior, L. Scap. A., most 
 frequent. 
 
 II. Right Scapula Anterior — Scapula Dextra Anterior, R. Scap. A. 
 
 III. Right Scapula Posterior — Scapula Dextra Posterior, R. Scap. P. 
 
 IV. Left Scapula Posterior — Scapula Lseva Posterior, L. Scap. P. 
 
426 
 
 PHYSIOLOGICAL LABOR. 
 
 In Germany two positions of the vertex are described: The first vertex position (I 
 Schadellage) is when the occiput lies to the left side of the pelvis, and the second vertex posi- 
 tion (II Schadellage) is when it lies to the 
 right. The Germans consider our third 
 and fourth positions to be variations of 
 the first and second. In France four posi- 
 tions are described, as with us, and, in ad- 
 dition, right and left transverse positions, 
 making six in all. In England, as in Amer- 
 • ica, four positions are described. On the 
 
 Continent of Europe — namely, in France 
 and Germany — and also in America the 
 right oblique diameter of the pelvic inlet 
 starts from the right sacro-iliac synchon- 
 drosis and the left from the left. In Eng- 
 land, on the contrary, the reverse obtains; 
 namely, the right oblique diameter ends 
 ^^^-—, S't the right ilio-pectineal eminence, and 
 
 C^t**,^ ''. ''-jj^^^^f ^^^ 1^^^ ^^ that. which ends at the left emi- 
 
 *' '"^/^ ^^^1^ nence. 
 
 These are facts which must be remem- 
 bered in reading German, French, and 
 English works on obstetrics. 
 
 Relative Frequency. — In all pre- 
 sentations, with the exception of the 
 shoulder, the first and third posi- 
 tions most frequently obtain. In 
 other words, at the pelvic inlet the 
 long diameter of the presenting part 
 lies in a diameter of the uterus which 
 corresponds to the right oblique di- 
 ameter of the pelvic inlet, with the 
 dorsum of the fetus directed to the 
 left and anterior or to the right and 
 posterior. In vertex presentations 
 the first position obtains in 70 per 
 cent, of cases, the second in 10 per 
 cent., the third in 17 per cent., and the fourth in 3 per cent. In face presenta- 
 tions the first position is second in frequency; the second position, third in fre- 
 quency; the third most common, 
 and the fourth position is fourth in 
 frequency. In shoulder presenta- 
 tions the first position is most com- 
 mon. In pelvic or breech presenta- 
 tions the first is the most frequent 
 and the third is second in frequency. 
 Explanation of the Frequency of 
 the First Vertex Position. — The an- 
 terior part of the cavity of the uterus 
 is better adapted to accommodate 
 the posterior plane of the fetus, while 
 the posterior part, which is en- 
 croached upon by the prominent 
 lumbar vertebras, is more fitted to 
 receive the anterior part of the fetal 
 
 ellipse. This is why the child's back most usually presents anteriorly. But 
 if for any reason the uterus should be uniformly pear-shaped, and not be pos- 
 
 FiG. 551. — Axial Torsion of the Pregnant 
 Uterus and Shape of the Uterine Cavity. 
 Note that the long transverse diameter of the 
 uterus corresponds to the right oblique pelvic 
 diameter, thus bringing the left border of the 
 uterus and the fetal back (in L. O. A.) toward 
 the anterior abdominal wall. (Compare Figs. 
 160 and 545-) 
 
 Fig. 552. — Axial Torsion of the Uterus and 
 Shape of the Uterine Cavity. 
 
POSITIONS OF THE FETUS. 427 
 
 sessed of those peculiarities just mentioned, then the back of the fetus may look 
 to the back, front, or either side (Fig. 551). 
 
 We know that the longest horizontal axis of the uterus is a transverse one; 
 in other words, that the uterine cavity in the latter part of pregnancy is flattened 
 from before back (Fig. 137). In this connection also the torsion of the uterus 
 on its longitudinal axis, whereby the left lateral aspect inclines toward the 
 front, must be taken into account (Fig. 551).* The result of axial torsion is 
 to bring the roomy transverse diameter of the uterus into coincidence with 
 the right oblique diameter of the pelvic inlet. A glance at the fetus in its 
 normal posture (Figs. 544 and 545) will show that its greatest horizontal diam- 
 eter is an antero-posterior one; namely, from a point on about the center of 
 the curved back to the anterior plane formed by the legs, arms, and umbilical 
 cord. In other words, as frozen sections prove, the fetal ellipse is flattened 
 laterally (Fig. 545). This is true for all presentations with the possible excep- 
 tion of the shoulder. From this it will be readily seen that accommodation 
 or adaptation will cause the largest transverse diameter of the fetal ellipse 
 to correspond to the roomiest horizontal diameter of the uterus. Hence the 
 antero-posterior diameter of the fetal ellipse must correspond to the transverse 
 diameter of the uterus, and torsion of the uterus causes this latter to coincide 
 practically with the right oblique of the pelvic inlet. The presence of the two 
 parts of the bowel, the sigmoid flexure and the rectum, through which the 
 feces so often pass, is sufflcient to account for the oblique position of the pre- 
 senting part, whether the back lies anterior or posterior, and so to explain the 
 usual positions — left anterior or right posterior. 
 
 Although the transverse diameter of the bony inlet is by actual measure- 
 ment the longest, still this long diameter passes just in front of the promontory 
 of the sacrum, and the head enters the plane of the inlet half-way between 
 the symphysis and sacrum, and here the diameter is less than 5^ inches (Fig. 
 514). These facts account for the head lying in one or the other of the oblique 
 diameters. Another factor is also present, and that is the encroachment of 
 the muscles, the ilio-psoas in particular, on the inlet of the pelvis (Fig. 546). 
 This makes the transverse diameter of the superior strait less capacious than 
 the oblique. This, too, then accounts for the predominance of oblique fetal 
 positions regardless of the presentation. It has been determined that these 
 muscles decrease the transverse diameter by about 1.5 cm. (0.5906 inch) and 
 the conjugate by i cm. (0.3937 inch). The most frequent positions of the 
 fetus therefore are the first and third, the former being most frequent for reasons 
 stated above. 
 
 We may sum up the causes of the greater frequency of the first and third 
 positions as follows: (i) The flattened shape of the fetal ovoid; (2) the shape 
 of the uterine cavity; (3) the axial torsion of the uterus; (4) the shortening 
 of the left oblique diameter of the pelvis by the sigmoid and rectum; (5) the 
 diminution of the transverse diameter of the pelvis by muscles and sacral prom- 
 ontory; (6) the greater roominess of the right oblique diameter. 
 
 ♦Various causes for this axial rotation have been suggested: (i) the position of the 
 descending colon and the sigmoid flexure, which are often distended with fecal matter; 
 (2) the embryological development of the uterus; (3) the fact that the right round liga- 
 ment is shorter and more highly developed than its fellow; (4) the greater frequency of 
 the right lateral position of the patient. 
 
428 PHYSIOLOGICAL LABOR. 
 
 III. THE EXPELLING FORCES. 
 
 The expelling forces consist, first, of the voluntary or auxiliary forces, which 
 include the anterior and lateral abdominal muscles, diaphragm, and pelvic 
 floor; and, second, of the involuntary forces, which consist of the contractions 
 of the uterus and of the, round and broad ligaments. 
 
 1. The Voluntary or Auxiliary Forces. — (i) Abdominal Muscles and Dia- 
 phragm. — The abdominal muscles and diaphragm in contracting increase the 
 intra-abdominal pressure and give efficient assistance to the efforts of the uterus. 
 These forces come into play with the second stage of labor, and are at first 
 almost purely voluntary, but later on, toward the end of the second stage, 
 they are reflex by nature.* This increased abdominal pressure tends to force 
 the uterus with its contents downward, in a line whose direction is that of the 
 axis of the pelvic inlet. Action: Their action is as follows: In the process 
 of labor the patient draws a deep inspiration, thus flattening the diaphragm; 
 the glottis is closed and the diaphragm becomes fixed and contraction of the 
 abdominal muscles takes place. As a result of the descent of the diaphragm 
 the fundus is pressed forward so that the uterine axis is practically in line with 
 that of the pelvic inlet. In the last part of the expulsive period, when the 
 pains continue for several seconds, the patient is forced to open the glottis 
 for breath; the abdominal pressure is by this action relieved until closure 
 of the glottis once more takes place. At times, when the pain becomes unen- 
 durable and the patient is forced to cry out, the glottis is again opened, so 
 it may happen that in the course of one uterine pain there are several abdominal 
 contractions. Harvey, experimenting on dogs, and de Graaf on rabbits, in 
 order to show that the fetus is expelled by the "vis uteri propria,'' opened 
 the abdomen at term; nevertheless the animals expelled their young without, 
 of course, the aid of the abdominal muscles. Haller has seen spontaneous 
 expulsion of young in the case of pregnant females a short time after death. 
 (See Post-mortem Delivery.) Harvey, Smellie, and others have reported cases 
 of spontaneous labor in paraplegic women. Although the voluntary and reflex 
 contractions of the abdominal muscles are not an indispensable factor in labor, 
 nevertheless they accelerate the expulsion. It is undoubtedly true that the 
 application of forceps is often necessary on account of the feebleness of the 
 effort which is expended — for instance, in women with hernia. 
 
 I have repeatedly observed and demonstrated to students the second stage 
 of labor terminated without the co-operation of the abdominal muscles at all; 
 still, the action of these muscles is most important in the expulsion of the pla- 
 centa, especially after it has left the uterus. It can be clearly seen of what assist- 
 ance also the abdominal contractions are in completing the birth of the child in 
 breech cases, when the after-coming head has passed below the retracted fundus. 
 
 (2) The Vagina and Pelvic Muscles. — At term the musculature of the vagina 
 is hypertrophied to a considerable extent and is important in the expulsion of 
 parts of the ovum that can be acted on by peristalsis. The period when its action 
 is most valuable is during the expulsion of the placenta. The only pelvic mus- 
 cles of the pelvic floor concerned in expulsion are the levator ani, the transversi, 
 the sphincters of the vagina and of the anus. Their action is imperfectly peri- 
 staltic and assists the muscle of the vagina. 
 
 2. The Involuntary Forces, or Uterine Contractions. — The uterus, during the 
 
 * It was at one time held that the abdominal wall was the sole cause of the birth of 
 the child; later it was taught that it played no part, but Schroeder showed that both uterine 
 and abdominal contractions were conceme'd in the expulsion of the fetus. 
 
THE EXPELLING FORCES. 
 
 429 
 
 Fig. 553. — Shape of the Uterus during the 
 Period of Relaxation. 
 
 contractions of the second stage, is retained in its position by means of the round 
 ligaments, which are composed chiefly of involuntary muscle-fibers, assisted by 
 the muscular part of the broad ligaments. In contracting, the round ligaments 
 tend to force the fundus downward and forward, and by their action on the 
 upper part of the uterus they are one factor in the increase of intrauterine 
 pressure. After the uterus has been raised by the round ligaments, however, 
 abdominal pressure can act to better 
 advantage. 
 
 (i) Involuntary. — Although the 
 uterine contractions have no depend- 
 ence on the will, — i. e., they are in- 
 voluntary, — they may be consider- 
 ably influenced by the brain, as may 
 be seen by the effect of mental emo- 
 tions. 
 
 (2) Peristaltic. — Like other organs 
 composed of non-striated muscle, the 
 contractions are assumed to be peris- 
 taltic in nature, probably passing from 
 the Fallopian tubes down to the cer- 
 vix. The waves succeed each other so 
 
 quickly that the whole uterus is in action at the same time. From observations 
 on the lower animals it is believed that the direction is from above downward, 
 and the uteri of rabbits for example, being of a long, tubal form, act just like 
 a length of intestine. It is the general belief that the contraction of the human 
 uterus is not peristaltic. I have repeatedly attempted to determine this point in 
 Csesarean section cases, but the contractile segment was so instantaneously 
 involved that no peristaltic wave could be demonstrated. 
 
 (3) Intermittent. — The contrac- 
 tions are intermittent ; each contrac- 
 tion begins, reaches its acme, and then 
 subsides, the length of time occupied 
 by one "pain" depending upon the 
 stage of labor in which it occurs, the 
 average duration being about a min- 
 ute; the variations being between 
 thirty and sixty seconds. The inter- 
 val between contractions is about 
 thirty minutes at first, but decreases 
 to between two and three minutes at 
 the end of labor. The contractions 
 are rhythmical in their intermission — 
 there is an approximate regularity 
 about them, In this respect there is 
 a variation in the same ratio as the 
 During labor the contractions gradually increase in 
 At the beginning of labor the duration of the 
 
 Fig. 554. — Shape of the Uterus during a 
 Uterine Contraction. 
 
 length of the single pains. 
 
 severity, duration, and frequency. 
 
 contractions is about twenty seconds. Toward the end of the second stage the 
 
 duration is a minute or more. In some cases, after the uterine contractions have 
 
 continued for some hours, they cease for a corresponding period, after which they 
 
 once more become vigorous. 
 
 {4) The normal intermittence in the course of the contractions is a most 
 
430 PHYSIOLOGICAL LABOR. 
 
 necessary feature for the welfare of both mother and fetus. The latter would 
 succumb to asphyxiation were the contractions continuous, and the mother would 
 not be able to endure the long agony were it not alleviated by periods of rest. 
 She would also be subject to much injury of her tissues, and rupture of the uterus 
 would almost surely occur. The musculature of the uterus also would not receive 
 its nourishment and it would lose its irritability. This alteration of work and 
 rest in the uterus has its analogue in the action of many other organs, — e. g., the 
 heart, intestines, and brain, — these conditions seeming to be one of the essential 
 characteristics of living organs. 
 
 (5) The Uterus Changes in Form and Position. — Changes in form and posi- 
 tion of the uterus are also associated with its contractions. Its shape becomes 
 cylindrical during a contraction; the longitudinal and the antero-posterior 
 diameters are increased to a slight degree, while the transverse is distinctly 
 decreased. This latter, shortening somewhat, extends the fetus; its curvature 
 is lessened and thus causes an increase in the longitudinal diameter, causing 
 partial extension of the fetal ellipse. The effect of the contraction of the round 
 and broad ligaments on the uterus has been noted on page 429 (Figs. 553 and 
 
 554). 
 
 (6) Proportionate to the Resistance. — The force of contractions increases 
 with the advancement of labor; the length of the contractions increasing as 
 the length of the interval decreases. The pain caused by contraction against 
 resistance is generally proportionate to the resistance, though not invariably 
 so, for in primiparae in whom there is great resistance this state is usually coun- 
 terbalanced by the superior quality of the uterine musculature. The opposite 
 conditions are present in multiparse. In the second or third labor conditions 
 bear a more favorable relation to each other than at any other time. 
 
 (7) Vary with the Presentation. — The character of the contraction varies 
 with the presentation. In vertex presentations the contractions possess more 
 regularity and efficiency, and may even be termed characteristic of normal 
 labor; in face, brow, breech, and shoulder presentations irregularities are usually 
 manifest, so that the physiognomy of labor is well worth a careful study. For 
 in order to obtain normal characteristics there must be uniform pressure on 
 the lower uterine segment and the os, and this is not exerted in breech, face, 
 brow, or shoulder presentations; hence the facies in labor will often give the 
 keynote to the presentation. 
 
 (8) The Pain of Uterine Contractions. — The contractions are painful, this 
 being their most striking characteristic. It has given rise to the term "labor 
 pain." It is a well-known fact that in the majority of cases the first pain occurs 
 between ten and twelve o'clock at night. The cause is not known. As to 
 the character of the pains, it differs with the stage of labor in which the pain 
 occurs. They are at first quick, sharp, and colicky, and are due chiefly to the 
 dilatation of the cervix, and are felt usually in the sacral region, where pain 
 originating in the cervix is almost invariably referred. After the os has been 
 dilated they become "bearing down" in quality, and are then efficient in ex- 
 pelling the fetus. As to the intensity of the pains, that will depend on the 
 nervous constitution of the patient. They are generally more severe in prim- 
 iparae, especially during the stretching of the vagina and vulva. Pain is also 
 caused by resistance of the brim, and by the strain to which the attachments 
 of the uterus are subjected. To this is added the pressure by the heavy uterus 
 on the nerve plexuses in the pelvis, and that on the nerves of the vagina by 
 the presenting part. The abdominal muscles also are the seat of pain on account 
 of their contractions, which are cramp-like. Pain is also probably caused 
 
THE ETIOLOGY OF LABOR. 431 
 
 by compression of the ends of the nerves which He between the contracting 
 fibers. Werth advances the' suggestion that another cause is spinal neuralgia 
 resulting from the anemic condition of the lower cord and meninges. 
 
 (9) False Contractions or Pains. — These are contractions, sometimes pain- 
 less, at others very painful, which are generally localized in the abdomen, and 
 as a rule take place in multiparas. They occur a short time before labor begins 
 and generally in the early hours of the night. They have no effect in causing 
 dilatation nor are they accompanied by the " show." 
 
 (10) Pulse and Arterial Tension. — There is an increase in pulse-rate during 
 a uterine contraction, but it gradually decreases at the close. Arterial tension 
 is increased on account of the amount of blood that is driven from the uterus 
 to the general circulation. Respiration grows less frequent during a pain, 
 but increases in the intervals. The temperature of both uterus and body is 
 a little increased during a contraction. 
 
 Strength 0} Uterine Contractions. — Schatz * found that the pressure on the dynamometer 
 was 20 mm. mercury, while 15 mm. of this are due to the weight of the fluid. At the 
 height of the contraction it ranged to 100 mm. Considerable resistance has to be over- 
 come by the uterine contractions. If we measure the amount of force necessary to rupture 
 the membranes outside the body, we will have an approximate estimate of the force of 
 the contractions. Matthews Duncan's work was carried on with a piece of membrane 
 about 4 inches in diameter placed over a cylinder connected with an anemometer. His- 
 results varied from 5 to 37 pounds (2100 to 17,000 grams). In some cases a force equal 
 to the mere weight of the fetus accomplished the rupture ; in others considerable force 
 was reqtdred. Polaillon's tneihod: In this the surface of the membranes was estimated 
 as 217 square inches (1400 sq. cm.). Pressure exerted by the uterus amounts to 338.8 
 pounds (154 kilos), 88 of which are due to uterine contractions and the rest to the weight 
 of the fetus. Another method gave him the force of each pain as 19.8 pounds (9 kilos), 
 and for the whole labor 965.8 pounds (439 kilos). Duncan estimated that the force 
 in a whole labor was 40 or 50 pounds (18 to 22 kilos), and the effort which must be made 
 to hold back the head gives these figures. He also estimated the amount of force which a 
 child can endure, and found that there was no change till 90 or 100 pounds was reached. 
 After this the cervical vertebrae are dislocated and 30 pounds (about 14 kilos) more will 
 sever the head. Hence the force in labor must be less than this figure. In his estimations 
 Poullet made use of the tocograph, and Dr. Henry Leaman, of Philadelphia, invented an 
 instrument which he called the parturiometer, for measuring the force of uterine con- 
 tractions. This last instrument I experimented with for two years, but was never able 
 to arrive at any satisfactory conclusions. 
 
 IV. THE ETIOLOGY OF LABOR. 
 
 There is a fatty degeneration on the surface of the placenta which supervenes 
 near the end of gestation in many cases, but this is not constant. Eventually the 
 ovum becomes a foreign body. This theory was advanced by Naegele and others, 
 and the view appears to be a rational one. Eden regards all the changes in the 
 placenta as senile which finally cause it to become a foreign body. Leopold found 
 marked thrombosis of the vessels in the decidua. He considered that this finally 
 causes an increase in carbonic acid which soon causes contractions. Some believe 
 that when the uterine musculature is completely developed labor begins, but we 
 see uterine contractions in abortion and premature labor. Still another view is 
 that after the uterus has been distended to a certain extent there comes a reaction, 
 and the process of retraction begins and the fetus is expelled. But this does not 
 clear up the matter, since the thickness of the uterus varies in different subjects 
 and in the same subject in different pregnancies. Then, too, the uterus is 
 distended by hydramnios and multiple pregnancies far more than in normal 
 
 * The instrument used by Schatz was called the tocodynamometer. 
 
432 PHYSIOLOGICAL LABOR 
 
 pregnancy, and still the general rule holds good that the fetus is bom when 
 it becomes mature — not before, not afterward. Spiegelberg advances the 
 explanation that certain substances in the maternal blood which in the early 
 part of pregnancy the fetus has made use of, accumulate, since the nearer the 
 fetus comes to maturity, the less use it has for these same substances. As 
 it reaches the point of maturity and needs other forms of nutrition which it 
 is now unable to obtain, this fact, as well as the accumulated material in the 
 mother's blood which acts upon the motor centers of the uterus, militates for 
 its speedy expulsion. Since Braxton Hicks published his observations on the 
 constant contractions of the uterus, these various theories have been less con- 
 vincing. He claimed that the contractions take place after the uterus appears 
 above the symphysis pubis, and during labor these contractions are accentuated. 
 The function of these contractions in pregnancy is not known, but at the end 
 of pregnancy they expel the fetus from the uterus. Pohlman held that as 
 long as the fetus was immature and attached to the uterus it forms a part of 
 the maternal organism, at least in effect; but when full maturity is attained 
 it becomes a foreign body and is expressed by uterine contractions. The causa- 
 tion of labor is a very complicated question, and we are to-day ignorant of 
 the actual determining factor, through the operation of which a uterus, after 
 remaining comparatively quiescent for thirty odd weeks, suddenly and perhaps 
 unexpectedly takes it upon itself to get rid of a burden it has carried so long 
 without rebellion. 
 
 It is probable that there are several predisposing causes, and that the real 
 direct or exciting cause is some slight circulatory or nervous disturbance brought 
 on by overexertion, an overdose of cathartic, a misstep, straining at stool or 
 micturition, or mental excitement. 
 
 V. THE STAGES OF LABOR. 
 
 It is customary to divide labor into three periods or stages: namely, first, 
 second, and third, and designated respectively, stage of dilatation, of expulsion, 
 and last of placental delivery and uterine contraction and retraction. To 
 these we add, without assigning it a number, another; namely, the preparatory 
 stage. 
 
 The preparatory stage of labor extends from subsidence or sinking of the 
 uterus until true labor sets in, and begins about two weeks before true labor 
 in primigravidce and ten days before in multigravidaj. Its phenomena consist 
 in (i) sinking of the uterus, the so-called "lightening"; (2) gradual shortening 
 of the cervix and dilatation of the internal os, and (3) false or spurious labor 
 pains. 
 
 I. In the sinking of the uterus the organ sinks lower in the pelvis, the fundus 
 drops forward, and the head either engages or sinks down to the pelvic floor. 
 Deep engagement of the head is more marked and more constant in primi- 
 gravidse by reason of the tense abdominal muscles, strong uterine muscles, 
 and greater intraabdominal pressure. In both primigravidae and multigravidas 
 we often observe the head distending and pushing down into the pelvis the 
 thinned anterior wall of the lower segment, with resulting posterior displace- 
 ment of the cervix, so that the os looks backward and upward. This is the 
 so-called sacciform dilatation of the anterior part of the lower uterine segment 
 
THE STAGES OF LABOR. 433 
 
 (Fig. 790). This change affords great relief to the woman; her respiration 
 is less embarrassed, her clothes are looser, and her digestion is improved. The 
 irritability of the bladder and rectum becomes more marked; mucus pours 
 from the vaginal and cervical glands and is generally a very good indication 
 of the progress of the dilatation of the cervix. 
 
 2. The gradual shortening of the cervix and dilatation of the internal os. The 
 cervix, as a rule, retains its entirety until the thirty-sixth or thirty-eighth week 
 of gestation; up to this time the cervical canal is one inch long, the external 
 and the internal openings are closed, the supra- vaginal and infra- vaginal por- 
 tions are present very much as in the non-pregnant state. The greater intra- 
 uterine pressure and distention of the lower uterine segment in primigravidae 
 causes a gradual expansion and unfolding of the supra-vaginal cervix at about 
 the thirty-sixth week; but in multigravidae, because of the previous distention 
 of the lower uterine segment, pressure is not so readily communicated to the 
 margin of the internal os, and dilatation here does not commence until about 
 the thirty-eighth or thirty-ninth week. At the end of gestation in primigravidae 
 the internal os has usually expanded and disappeared for the reception of the 
 ovum; this is much less often the case in multigravidae. In pathological in- 
 stances of overdistention, such as hydramnios and multiple pregnancy, the un- 
 folding and complete disappearance of the internal os is most clearly shown, 
 and is, in some instances, nearly complete. (See the Parturient Canal, page 400.) 
 
 3. The false or spurious labor pains are the normal intermittent uterine 
 contractions of gestation occurring more frequently than usual, with greater 
 intensity and accompanied by pain. They are often caused by a temporary 
 indigestion or rectal distention, and hence are often relieved by a laxative 
 or enema. They are distinguished from true uterine pains by their temporary 
 character, irregularity, being felt generally over the abdomen instead of in the 
 lumbo-sacral region or just above the pubes; by not progressing in frequency 
 and severity and in not causing any hardening or dilatation of the os. The 
 most definite symptom of the commencement of labor is the presence of uterine 
 contractions or pains, recurring at intervals which gradua,lly decrease in length, 
 while the force of the contractions increases, and causing a gradual thinning 
 and dilatation of the cervix. 
 
 I. The first stage of labor, or stage of dilatation, extends from the onset of 
 true labor pains to the complete dilatation or dilatability of the os. The dura- 
 tion of this stage is variable; it may be as short as two hours or it may continue 
 several days. The length is influenced by the age of the patient and by the 
 number of children she has borne, it being longest in elderly women, especially 
 primiparas. The average duration for primiparse is often stated to be sixteen 
 hours, though it may be much longer; while for multiparae an average of nine 
 hours may be quoted. The phenomena of this stage are (i) true uterine con- 
 tractions or labor pains; (2) a muco-sanguineous discharge; (3) the mech- 
 anism of cervical dilatation; (4) the formation of the caput succedaneum. 
 
 I. The true labor pains cause the patient to assume different attitudes; 
 she is restless, often walking about from place to place and emitting cries on 
 the occurrence of a "pain," very different in character from those of the later 
 stages. The contractions or "pains," which at first are not very annoying, 
 occur about every half hour, and are accompanied generally by pressure sen- 
 sations. At first the pain is apt to be felt in the region of the sacrum, which 
 is the common location for pain originating from any cervical trouble, and 
 it may radiate to the lower abdomen or down the legs. Generally the first 
 pains come on in the early part of the night, and in character thev closelv re- 
 28 
 
434 
 
 PHYSIOLOGICAL LABOR. 
 
 semble the false pains which are often felt in the last weeks of pregnancy. The 
 woman is frequently more impatient of the pains of dilatation than she is of the 
 later ones, because she fails to see that any progress is being made, although 
 the passage of the head over the exquisitely sensitive perineum causes the 
 most excruciating agony experienced during all the course of labor. The 
 patient often vomits or shivers at this stage; there is an abundant secretion 
 of urine; the cervix grows gradually more patulous till its edges become con- 
 
 FiG. 555. — Frozen Section after Sudden Death from Cerebral Abscess, during 
 THE First Stage of Labor. Age of patient thirty-seven years; 7-para; fundus 
 uteri 3 inches above the umbihcus; internal os dilated to admit two fingers. The 
 section is a vertical mesial one with the frozen fetal parts of the opposite side placed 
 in exact superposition. Note the posture of the fetus and moulding of the head, 
 the latter being well above the pelvic floor; also the lower borders of the peritoneum 
 anteriorly and posteriorly; the beginning formation of the "bag of waters," ' 
 the contraction ring; and the distended rectum. — {William C. Lusk's case.) 
 
 and 
 
 tinuous with the walls of the vagina. When the diameter of the openmg reaches 
 about three inches, the descending "bag of waters" ruptures, allowing a little 
 of the liquid to escape, while the remainder is kept back by the ball valve-Hke 
 action of the head. The temperature rises slightly and the pulse of the patient 
 increases during a uterine contraction, but the fetal heart-beat is slowed at the 
 height of a pain. 
 
 2. The muco-sanguineous discharge. All of the secretions, both vaginal 
 
THE STAGES OF LABOR. 435 
 
 and cervical, are increased with the progress of labor, and they serve as a lubri- 
 cant to the passages. As the lower uterine segment and the cervix expand 
 the lower part of the menibranes is separated from the wall of the uterus, giving 
 rise to a slight hemorrhage which streaks the mucous discharge, and early 
 in labor the bloody mucus is known as the " show." 
 
 3. The mechanism of cervical dilatation (Figs. 556 to 564). According to well- 
 known hydrostatic laws, the pressure of the uterine walls in the state of contrac- 
 tion is communicated to the fluid in the bag of waters in a generally uniform man- 
 ner, barring the variations which occur at different levels, and which are due to 
 the weight of the liquid (Fig. 565). There is no propulsion till the cervix begins 
 to be dilated, and then the bag of waters is forced, to a certain degree, out 
 of the OS, the fetus in itself not being acted upon, but the force is expended 
 on the entire ovum (Fig. 566). The direction of the force is in the central 
 axis of the os and in a line perpendicular to its plane. The uterus acts in 
 two ways: (i) when it contracts its internal area is diminished, and the result 
 is intrauterine fluid pressure caused by the force exerted on the fluid within 
 the ovum; (2) after rupture of the membranes, and the consequent escape 
 of fluid, there occurs direct contact between the fundus and the breech, and, 
 indeed, this may very occasionally occur before the membranes are ruptured. 
 The abdominal muscles assist the uterus in both these forms of action; they 
 add their part to the force exerted by the uterus before the membranes are 
 ruptured as well as after this event takes place. The os may be said to be 
 dilated normally by the protruding bag of waters; this being the case when 
 the fluid is abundant and the membranes are unruptured. When these con- 
 ditions are present, the intrauterine fluid pressure has no effect on the fetus; 
 this can be inferred from the law in hydrostatics that fluid pressures, whatever 
 the cause, are always equal and opposite in all directions; hence the fetus is 
 not affected by contractions of the uterine musculature. Although the lower 
 uterine segment makes an effort at contraction, it is forced open at the os by 
 the power of the upper strong part. It is well known that the lower uterine 
 segment is by far the weakest part of the uterus, and so, during contraction, 
 its tendency is to expand; this being the effect of the intrauterine fluid pres- 
 sure. That part of the area of the uterus which is opposite the vagina is not 
 supported by the intra-abdominal pressure nor by the abdominal muscles, 
 both of which factors hold sway above. In this way not only is the centri- 
 fugal force increased, but the centripetal force is diminished. Another 
 feature which adds to the weakness of this part of the organ is the os — an 
 opening in the uterine wall much weaker than the Fallopian tube open- 
 ings. So that, indeed, the very first effect of uterine contractions is 
 seen in the expansion of the lower uterine segment. While the internal 
 OS and upper cervix and supravaginal portion are dilating, the bag of 
 waters begins to bulge through the os, and the fluid pressure can then act 
 directly on its edges. This process gradually proceeds till the internal os 
 disappears, the cervix shortens till it also is abolished, and then the mem- 
 branes act directly on the external os. The force exerted by the membranes 
 is directly proportional to their convexity. This can be explained by the 
 law in physics that the fluid pressure is opposite and equal in all points, and 
 is exerted at right angles to any surface against which it acts. Consequently 
 the rapidity of dilatation will correspond with the degree of bulging of the 
 membranes through the os. After the membranes are ruptured these laws are 
 applicable to the force exerted by the head in causing dilatation. These facts, 
 together with that of the successively increasing force of uterine contractions, 
 
436 
 
 PHYSIOLOGICAL LABOR. 
 
 Fig. 556. — Primiparous 
 Cervix at the Begin- 
 ning OF Uterine Con- 
 tractions. 
 
 Fig. 557. — Primiparous 
 Cervix Early in Labor. 
 
 Fig. 558. — Cervix in Mul- 
 tipara AT Beginning 
 of Uterine Contrac- 
 tions. 
 
 Fig. 559. — MuLTiPARous 
 Cervix Early in Labor. 
 
 Fig. 560. — Primiparous 
 and Multiparous Cer- 
 vix. Dilatation for 
 Two OR Three Fin- 
 gers. 
 
 Fig. 561. — "False Wa- 
 ters." Fluid between 
 Chorion and Uterine 
 Wall above and be- 
 tween Chorion and 
 Amnion Below. 
 
 Fig. 562. — Primiparous or 
 Multiparous Cervix. 
 Os One-half Dilated. 
 Internal Os drawn up 
 into Lower Uterine 
 Segment. 
 
 Fig. 563. — Rupture of 
 THE Membranes. i, 
 Usual site; 2, just inside 
 the os; 3, within the 
 uterus. 
 
 Fig. 564. — Formation of 
 A Second Bag of 
 Waters. 
 
THE STAGES OF LABOR. 
 
 437 
 
 explain why the last stages of dilatation are nearly always more rapid than 
 the first. To refer back to what was called the normal mechanism of the 
 first stage, — the membranes being unruptured, — the progress of the first stage 
 of labor is chiefly due to the first form of uterine force, the intrauterine fluid 
 pressure, while the membranes act only as dilators. The second form has not 
 yet been called into play, — direct pressure of the walls on the child, — neither 
 is the voluntary action of the abdominal muscles often present, so the intra- 
 uterine fluid pressure due to the general intra-abdominal pressure always 
 exerted by the tonicity of these muscles is to be looked upon as the important 
 factor in causing the progress of labor at this stage. 
 
 4. Caput succedaneum. If this stage is prolonged, a scalp tumor forms 
 
 J I I 
 
 Fig. 565. — General In- 
 trauterine Pressure 
 DURING A Uterine Con- 
 traction, before Rup- 
 
 ' ture of the mem- 
 BRANES. The X and — 
 signs indicate the results 
 of general intrauterine 
 pressure. 
 
 A — 
 
 Fig. 566. — Further Result 
 OF General Intrauter- 
 ine Pressure. The lower 
 segment is weakened, 
 thinned, and dilated. 
 A, A, and B indicate the 
 directions of the remain- 
 ing pressures. 
 
 Fig. 567. — Still Further 
 Result of the General 
 Intrauterine Pressure. 
 The fetus is partially ex- 
 pelled from the cervix, 
 and the uterus in conse- 
 quence shortens and be- 
 comes thicker in its upper 
 part. A, A, Lateral uter- 
 ine pressure; B, direct 
 pressure of the thickened 
 fundus upon the fetal axis. 
 
 on that portion of the head least subjected to pressure, due to venous conges- 
 tion and oedema. (Compare Part IX.) 
 
 2. The second stage of labor, or stage of expulsion, extends from the com- 
 plete dilatation or dilatability of the os to the complete expulsion of the fetus. 
 The duration of this stage varies from a few minutes to six hours or more. Its 
 average duration in primiparae is from two to three hours, and in multiparas from 
 one to two hours. The pheno.mena of this stage consist in: (i) Characteristic 
 uterine contractions; (2) the use of voluntary forces; (3) the descent of the 
 presenting part ; (4) the dilatation of the vagina; (5) the dilatation of the vulva; 
 (6) the expulsion of the fetus. 
 
 I and 2. Uterine contractions and the use of voluntary forces. The nature of 
 the contractions is entirely changed; they are far more severe than in the first 
 stage, and are bearing-down in character; the voluntary forces are now utilized; 
 
438 
 
 PHYSIOLOGICAL LABOR. 
 
 the patient makes use of the diaphragm and the abdominal muscles; she braces 
 herself for every paroxysm and holds tightly to whatever support may be at 
 hand. The cry differs also from the earher one, the patient often taking a quick 
 inspiration in the midst of a pain in order to be able to resume the expulsive 
 effort, this being accompanied by a characteristic grunt or the whole ended by a 
 moan. The pams are now efficient, and as the fetus is driven out through the 
 dilated cervix the vagina relaxes to receive it. When the perineum is reached, 
 
 Fig. 568. — Central Separation of the 
 Placenta from the Uterine Wall, 
 WITH the Formation of a Retropla- 
 cental Blood-mass. (Schultze's mech- 
 anism.) 
 
 Fig. 569. — Descent of the Placenta 
 Doubled upon Itself, with the Center 
 OF THE Fetal Surface Presenting. 
 (Schultze's mechanism..) 
 
 Fig. 570. — Descent of the Placenta with 
 THE Lower Border First, through the 
 Cervix and Vagina. (Duncan's mech- 
 anism.) 
 
 Fig. 571. — Complete Separation of the 
 Placenta. The placenta is expelled flat 
 with the lower margin first presenting. 
 (Duncan's mechanism.) 
 
 its firm but elastic structures bulge with every uterine contraction and recede 
 with its subsidence. The pelvic floor directs the presenting part upward and 
 forward toward the orifice of the vulva. Mucus lubricates both the passages 
 and fetus, and thus the vagina more easily allows the onward movement of the 
 fetus. Between the pains the soft parts press back the fetus till the presenting 
 part is so firmly fastened under the symphysis pubis that this cannot recur. 
 Finally the vulva gapes ; the presenting part is seen ; the anus relaxes and the 
 
THE STAGES OF LABOR. 439 
 
 rectal wall appears; there is an uncontrollable desire to micturate and defecate, 
 due to pressure on bladder and rectum; there comes the crowning effort, and the 
 head passes through the external opening (Fig. 590). The fundus uteri now quickly 
 subsides and the uterine muscle is in close contact with the parts of the fetus 
 still contained within it. At this stage there generally occurs a slight pause, 
 varying in duration. There is sometimes a cry at the expulsion of the 
 head and sometimes the patient makes no sound; when present, this has been 
 known as the physiological cry. 
 
 3. The third stage of labor, or stage of placental delivery and uterine con- 
 traction and retraction, extends from complete expulsion of the fetus to com- 
 plete expulsion of the placenta and membranes. The average duration of this 
 stage is, when spontaneously completed, about one hour. Immediately after 
 birth the patient feels calm and comfortable. Now and then there is a feeling 
 of faintness caused by the sudden evacuation of the uterus. The phenomena 
 of the third stage are: (i) characteristic uterine contractions; (2) the control 
 of hemorrhage; (3) the separation of the placenta; (4) the expulsion of the 
 placenta; (5) the physiological chill. 
 
 1. Uterine contractions. After the completion of the second stage the uterus 
 may be palpated in the hypogastrium, and should resemble a firm, round, ball- 
 shaped body, and more or less tonic as well as rhythmic contractions should 
 be present, although the latter are not necessarily felt by the woman as " pains." 
 The hardness of the uterus varies at this time and after the expulsion of the 
 placenta, but the risk of hemorrhage is not necessarily great unless there is 
 much relaxation between the intermittent contractions, or sudden gushes of 
 blood occur during or between the contractions. 
 
 2. The control of hemorrhage at this time is primarily due to the constriction 
 of the vessels by the firm and tonic uterine contractions, and secondarily to 
 coagulation of the blood in the mouths of the vessels. 
 
 3. Placental detachment. At or just before the expulsion of the fetus, the 
 placenta is partially detached from the uterus. Shrinkage of the placental 
 site and the forcing downward of the whole placental mass by uterine con- 
 tractions account for this separation. The usual and I believe normal manner 
 of placental delivery is for it to be folded on itself by the contracting uterus, 
 so that the long axis of the placenta corresponds to the long axis of the uterus, 
 and the margin that presents at the cervix, vagina, and vulva is the lower 
 margin, showing perhaps a little of its fetal surface (Duncan's method) (Figs. 
 57O1 571)- Occasionally, especially when traction has been made upon the cord, 
 the center of the fetal surface with the attached cord presents first, like an 
 inverted umbrella (Schultze's method) (Figs. 568, 569). It makes very little 
 difference, from a practical standpoint, how the placenta is bom. 
 
 4. Placental expulsion occasionally occurs with or just after the birth of 
 the fetus; usually, however, in purely spontaneous placental delivery, an hour 
 or even more intervenes between the fetal and the placental delivery. During 
 this time the uterus should be moderately hard as the result of tonic contraction, 
 and intermittent or rhythmic contractions, though not strongly marked, should 
 be present, thus causing the uterus to vary in hardness. The intermittent 
 contractions after a short time become stronger, nearer together, and finally 
 are felt as " pains " by the patient, and a little blood is expelled by them from 
 the vagina. In spontaneous expulsion these contractions finally complete pla- 
 cental separation and force the placenta down so that it lies partly in the 
 flaccid, relaxed cervix and partly in the vagina. In the absence of inter- 
 ference its expulsion from the vulva is accomplished by the voluntary forces, 
 aided by the contractions of the uterus and vagina. 
 
440 PHYSIOLOGICAL LABOR. 
 
 ■J 
 5. Physiological chill. Not uncommonly some slight shivering, in some cases, 
 — about 15 percent., — even passing into a decided chill, takes place shortly after 
 the placental delivery. It is more often observed after rapid deliveries, and 
 may continue from a few minutes to a quarter of an hour, and is unattended 
 by any alterations in the pulse or temperature. Its best explanation is that 
 the organism, or rather the abdomen, loses a large mass to which it had been 
 previously accustomed, the result being that the internal viscera are no longer 
 compressed, and we have a rapid rush of blood from the exterior to fill the 
 space left in these organs. Consequently a more or less severe chill results, 
 which is entirely physiological and is not a signal of danger. 
 
 VI. THE MECHANISM OF LABOR. 
 
 Definition. — The mechanism of labor is the manner in which the fetus passes 
 through the parturient canal; and it has to deal with the hard and the soft 
 parts which compose the latter and with the fetus and the expelling forces. 
 It treats of the movements of the fetus through and out of the parturient canal, 
 and the causation and character of these movements. 
 
 Importance. — Familiarity with the three factors of labor — namely, the 
 passages, the passenger, and the forces — is essential in order to appreciate 
 the combination of movements known as the mechanism of labor by which 
 nature guides the fetus from the uterine cavity through the pelvis into the 
 external world. With equal success might we hope to appreciate and treat 
 certain cardiac diseases without an understanding of the anatomy and physi- 
 ology of the heart, as to attempt the management of labor cases without a clear 
 knowledge of the mechanism of parturition. It is true that one ignorant of 
 the mechanism of labor may successfully care for cases of normal confinement ; 
 it is equally true, in other instances, that this want of knowledge results in 
 disaster to mother and fetus. 
 
 But one mechanism, of labor. From a mechanical standpoint all labors are 
 subject to the same physical laws and follow these laws, provided only that 
 expulsion occurs, spontaneously and at term, of a normal-sized fetus, and 
 through a normal pelvis: in premature labors and in cases of monstrosities 
 and deformed pelves many departures from the usual mechanism occur. It 
 may be stated, then, that there is but one mechanism of labor for all. The 
 mechanism of the first vertex position (L. O. A.) may be looked upon as the 
 standard; and the mechanism of the other three positions of the vertex, and 
 the several positions of the breech, face, and brow, as following the same general 
 standard. 
 
 Six Stages. — Six clearly defined stages of mechanism in all presentations 
 and positions, with the exception of shoulder presentation, can usually be 
 demonstrated. These stages are: (i) Moulding; (2) engagement and descent; 
 (3) rotation of the first part of the fetal ellipse; (4) expulsion of the first part 
 of the fetal ellipse; (5) rotation of the second part of the fetal ellipse; (6) expul- 
 sion of the second part of the fetal ellipse. 
 
 I. Moulding. — In the first stage the fetus, pressed upon and influenced 
 by the general intrauterine pressure, and perhaps also to a slight extent by 
 the voluntary efforts of the mother, tends to accommodate, to mould the shape 
 of its presenting part to suit the canal through which it has to pass. This 
 moulding in vertex presentation is accomplished by overriding of the bones 
 
THE MECHANISM OF LABOR. 
 
 441 
 
 of the vault of the skull and by actual change of the shape of the brain; in brow 
 presentations the same causes operate; in face presentations, the bones of 
 the face proper change very little, although a characteristic moulding of the 
 frontal, parietal, and occipital bones occurs, and swelling and oedema of the 
 facial tissue assists in the acquired general shape of the head; in breech pres- 
 entation moulding is entirely due to compression of the soft tissues. 
 
 II. Engagement and Descent. — Engagement of the head in the pelvis in vertex 
 presentations, especially in primigravid^-e, often occurs before labor sets in. En- 
 
 FiG. 573. — The Mechanism of Labor. The Head in the Left Occipito-anterior 
 Position on the Pelvic Floor before Anterior Rotation and Dilatation of 
 THE Vulval Orifice. 
 
 gagemenl and descent occur more readily and promptly in anterior positions of 
 the vertex and with moderate-sized fetuses. Dela5^ed engagement and descent we 
 observe in posterior positions of the vertex ; in primary or secondary inertia of the 
 uterus; in excessive uterine obliquity and torsion; in brow presentations, since a 
 greater circumference presents; in face and breech presentations because these 
 parts are irregular, are poor dilators, and are subject to oedematous swelling. 
 Naturally engagement and descent in any presentation or position are favored by 
 undersized fetuses and roomy pelvic inlets. 
 
 III. Rotation of the First Part of the Fetal Ellipse. — All explanations cf in- 
 
442 
 
 PHYSIOLOGICAL LABOR. 
 
 ternal rotation apart from the fetus may be classed as (i) uterine and (2) pelvic. 
 The uterine theory attributes a rotation force to the uterus itself. The pelvic 
 explanation takes into account the shape of the pelvis — as determined by the 
 ischial spines and planes and varying lengths of the pelvic diameters — and the 
 shape, resistance, and actions of the structures going to make up the perineal 
 floor. The anatomical investigations of J. Veit * and H. Varnier f deny to the 
 shape of the pelvis — namely, the varying lengths of the various planes — and even 
 to the bones of the pelvic outlet any influence on the internal rotation of the 
 head. The latter explains the rotation of the head as due exclusively to the 
 arrangement of the muscles of the pelvic floor and the perineum. 
 
 Fig. 573. — The Mechanism of Labor. The Head in the Left Occipito-anterior 
 Position on the Pelvic Floor. A caput succedaneum has formed, anterior rotation 
 has just begun, and partial dilatation of the parturient outlet has taken place. — 
 (Studd-i ford's frozen section at the Emergency Hospital.) 
 
 Desiring to test for myself experimentally the part the pelvic floor plays on anterior 
 rotation of the presenting part, I undertook the following experiments: I screwed a swivel 
 into the head of a fetal cadaver half an inch behind the small fontanelle, attaching a yard 
 of cord to the ring of the swivel. I repeatedly dragged the head through the pelvis of 
 a woman dead after recent delivery. The occiput invariably rotated to the front, even 
 when the head entered the pelvis in the posterior positions, so long as the pelvic floor re- 
 tained its integrity. When the tonicity of the floor became impaired by overstretching, 
 the head traversed the pelvis in very nearly the same position at it had entered. J In 
 making use of the term complete rotation of either head or shoulders in these observations, 
 it was not meant that mathematically complete rotation resulted, but only such as pal- 
 pation or inspection determined, unaided by more exact means of measurement. Leish- 
 man's researches with a cord stretched from symphysis to coccyx showed that exact co- 
 incidence of the sagittal suture and the antero-posterior diameter of the pelvic outlet 
 failed in many instances. The well-known experiments of Paul Dubois consisted in push- 
 
 * "Die Anatomic des Beckens im Hinblick auf den Mech. d. Geb.," 1887. 
 t "Du Detroit Inferieur musculaire du Basin obstetrical," Paris, 1888. 
 X Edgar: "The Mechanism of Labor," loc. cit. 
 
THE MECHANISM OF LABOR. 
 
 443 
 
 ing fetal cadavers of various sizes through the birth canal of a puerpera recently dead. 
 He found that the occiput turned forward, provided the pelvic floor was not injured by 
 rupture or overstretching. Repetition of his experiments overstretched the floor, and 
 then rotation failed. 
 
 Rotation was complete and readily accomplished in the first of my experiments; then, 
 as the muscles and tissues became more and more stretched and relaxed as the result of 
 repeated pressure upon them, I found rotation first incomplete and finally failing to occur 
 altogether. Given the normal attitude of the fetus (extreme flexion of the head) and 
 good expulsive powers, and the most important remaining condition for forward rotation 
 and a normal mechanism is a firm pelvic floor. 
 
 Fig. 574 — The Mechanism of Labor. The Vertex is Dilating the Parturient 
 Outlet after Anterior' Rotation of the Occiput — "Crowning." 
 
 A clear mental picture of the shape of the fetal ellipse and of the parturient 
 canal is absolutely essential to the further understanding of the mechanism 
 of parturition. One should always recollect: (i) The fetal ellipse is made 
 up of two parts, a bulkier but more compressible body, and a relatively smaller 
 but less compressible head; these parts are readily movable in their relation 
 to each other so as to produce degrees of flexion and extension and of torsion 
 and rotation (Fig. 544). (2) The antero-posterior diameters of the head are 
 the largest diameters (Fig. 545)- (3) While it is true that the greatest diameter 
 of the non-compressed fetal bod}?- is the antero-posterior one at the level of 
 the umbilicus, still the greatest diameter of the shoulders is the bisacromial, 
 4f inches (12 cm.) (Fig. 547); and at the breech, the bitrochanteric, 3+ inches 
 
444 
 
 PHYSIOLOGICAL LABOR. 
 
 (g cm.) (Fig. 550). (4) The most dependent portion in a vertex presentation 
 is the occiput; in a face presentation, the chin; in a brow presentation, the 
 brow; in a breech presentation, the buttock which lies in the anterior segment 
 of the pelvic cavity;, and of two shoulders, the one in the anterior pelvic seg- 
 ment. (5) The greatest resistance of the pelvic floor is found in the posterior 
 segment; the levator ani muscle with other muscles and tissues of the pelvic 
 floor enter into the formation of a scoop-like body with the greatest resistance 
 behind a line joining the spines of the ischii ; the tendency and function of which 
 by resistance and contraction are to guide and direct whatever comes in contact 
 
 Fig. 5 75. — The Mechanism of Labor. Extension of the Head through the Par- 
 turient Outlet. 
 
 with it anteriorly toward and into the vulval slit, the weakest and least resistant 
 portion of the pelvic floor. (6) The parturient canal possesses an irregular, 
 corkscrew-like shape, (a) The fetal ellipse rests with its greatest (antero- 
 posterior) diameter in the greatest (transverse) diameter of the uterus. Torsion 
 of the uterus swings the left side of the latter forward so that the fetal back 
 points midway between the left and front (Fig. 551). (b) The roomiest diam- 
 eter of the parturient pelvic inlet is the oblique (Fig. 552); into this the pre- 
 senting part enters, (c) The roomiest diameter of the parturient pelvic cavity 
 is still the oblique; through this the presenting part travels, (d) The roomiest 
 
THE MECHANISM OF LABOR. 
 
 445 
 
 diameter of the bony and parturient outlet is the antero-posterior diameter 
 (Fig. 515); this, the long diameter of the presenting part seeks, assisted by 
 the greater resistance of the posterior segment of the pelvic floor and the shape 
 of the entire segment. (7) From the foregoing it follows: (a) that the 
 longest horizontal diameter of the uterus is the transverse diameter, ren- 
 dered oblique in its relation to the pelvic inlet by the torsion of the 
 uterus on its vertical axis; (b) the long diameter of the parturient pelvic 
 outlet does not correspond with that of the inlet, hence a torsion, a rota- 
 
 / 
 
 \ N 
 
 Fig. 576. — The Mechanism of Labor. Internal Rotation 
 External Rotation of the Head, or ''Restitution." 
 permits the birth of the anterior shoulder first. 
 
 OF the Shoulders and 
 The unsupported head 
 
 tion of the portion of the fetal ellipse passing from one to the other in 
 order to obey the law of physics and travel in the direction of least re- 
 sistance occurs ; {c) whatever portion of the presenting portion of the fetal 
 ellipse first strikes the pelvic floor, whether it encounters this structure in front 
 of or behind a median transverse diameter, will be directed forward under the 
 symphysis pubis and into the vulval slit; {d) it is undoubtedly the fact that 
 it is not one factor alone, but several, that determine this rotation. Accommo- 
 dation, adaptation, the great principle that runs through all the mechanism 
 
446 PHYSIOLOGICAL LABOR. 
 
 of labor, whereby the long diameter of the presenting part adapts itself to 
 the long diameter of that part of the pelvis in which it may find itself; the 
 corkscrew-like arrangement of the pelvis; the lessened resistance caused by 
 the urethral and vaginal orifices in front ; the greater resistance of the thicker 
 and heavier tissues in the posterior half of the pelvis; the inclination of the 
 pelvis; the shape of the child's head; the inclination of the uterus causing 
 the anterior part of the presenting portion to reach the pelvic floor first — all 
 play their part in the causation of anterior rotation. 
 
 Deep Transverse Position. — Not uncommonly in elderly multiparas with lax 
 soft parts one observes a deep transverse position of the sagittal suture or 
 bitrochanteric diameter; namely, the head or breech advances through the 
 lower part of the pelvis, and even up to the orifice of the vulva, in a transverse 
 or oblique position, and internal rotation occurs only at the very last moment 
 in the vulval orifice. This possibility must ever be kept in mind in medium 
 and low forceps operations upon the head in vertex, face, and brow presenta- 
 tions; for the lateral pelvic walls are 3^ inches (9 cm.) deep, and the distance 
 from shoulders to occiput in vertex presentations, from shoulders to chin in 
 face, and to forehead in brow, does not exceed three inches, and so further 
 descent in transverse positions without rotation and escape of the presenting 
 part would draw the chest into the pelvis with the head, and the dorso-sternal 
 diameter, 3! inches (12 cm.), added to the presenting head diameter, would 
 result in impaction, and traction with the forceps would greatly endanger 
 the life of the fetus and the soft parts of the mother. 
 
 rV. Expulsion of the First Part of the Fetal Ellipse. (See Pathological 
 Labor.) — This is the head in cephalic presentations and the trunk in breech 
 presentations. The manner of expulsion of the head will depend upon the pre- 
 sentation and position. In occipito-anterior positions the head is expelled by a 
 movement of extension in front of the pubis; in permanent occipito-posterior 
 positions, by a movement of extension over the edge of the perineum; in mento- 
 anterior positions of face presentation, the head flexes in front of the pubis; in 
 permanent mento-posterior positions impaction occurs and no expulsion results. 
 In brow presentations the same general mechanism as in occipital presentations 
 obtains. In breech presentations the sacro-perineal curve and the drawing for- 
 ward of the presenting part by the levator ani muscle cause a lateral flexion of 
 the trunk during its expulsion (compare Fig. 138). 
 
 V. Rotation of the Second Part of the Fetal Ellipse. — This occurs (i) in the 
 trunk in cephalic presentations, and (2) in the head in breech presentations. 
 
 I. The internal rotation of the trunk in cephalic presentations, vertex, face, 
 and brow, naturally causes an external rotation of the expelled head. Internal 
 rotation of the head in breech presentation does not so constantly cause external 
 rotation of the trunk by reason of the greater weight and bulk of the latter. 
 In cephalic presentation — namely, vertex, face, and brow — when the trunk is the 
 second part to be expelled, the shoulders, we have every reason to believe, enter 
 the pelvic inlet in the oblique diameter opposite to the one in which the head 
 entered ; or, if the head entered in a transverse diameter, it is possible, in a roomy 
 pelvis and with a child that is not too large, for the shoulders to enter in the 
 opposite diameter or in the antero-posterior diameter of the inlet. At all 
 events, we usually find the shoulders first in an oblique diameter, and the anterior 
 portion of the presenting part, because of the direction of the axis of the superior 
 strait, is lower than is the posterior; consequently it is this part that first reaches, 
 and is influenced by the resistance at, the floor of the pelvis and is deflected 
 anteriorly to the pubic arch. If both shoulders came to the pelvic floor at one 
 
THE MECHANISM OF LABOR. 447 
 
 and the same time, we have every reason to beheve that they would both be 
 equally influenced by the factors which cause anterior rotation, and consequently 
 the bisacromial diameter would remain in the same diameter in which it entered 
 the pelvic inlet. Observation has taught me that while complete anterior 
 rotation of the head is the rule, yet complete rotation of the shoulders is not 
 by any means so constant as is that of the head. I made observations * upon 
 sixty-seven primiparae and seventy multiparas as regards the internal rotation 
 of the bisacromial diameter, and found that complete rotation occurred once 
 in 1.3 cases in primiparae, and once in 1.2 cases m multiparas. It will be seen 
 from the above that complete rotation occurs with about equal frequency 
 in primiparae and multiparas. Even before the shoulders begin to rotate inter- 
 nally we see an unwinding, as it were, of the muscles of the neck that have 
 been twisted in the internal rotation of the fetal head, and as a consequence 
 the head makes a partial movement of external rotation, and this first partial 
 movement of rotation is termed "restitution." When the shoulders rotate 
 within the pelvis, there must, in consequence, be a decided rotation on the 
 part of the head which is already delivered, and this further and more marked 
 rotation of the head is termed external rotation of the head, whereby in vertex 
 L. O. A. position the face of the child looks almost directly to the inner surface 
 of the right thigh of its mother. 
 
 2. Head rotation in breech cases. In breech presentations when the head is 
 the second part to be expelled, the long diameter of the head enters the pelvis in 
 the opposite diameter to that in which the bitrochanteric of the breech engaged. 
 Provided the head continues flexed upon the sternum, when the pelvic floor 
 is reached, rotation of the occiput to the pubis and of the face to the hollow of 
 the sacrum occurs, in all but about 1.5 per cent, of cases, no matter what the 
 original direction of the occiput at the inlet. What is the explanation of 
 this rotation? I believe it is to be found at the occipital end of the head, 
 which is the most prominent and consequently the most positively influenced 
 by the pelvic floor. A glance at a cast of a fetus in its normal attitude will 
 demonstrate the prominence of the occiput (Fig. 544). If the forehead were 
 most in evidence, then the opposite rotation would occur. 
 
 VI. Expulsion of the Second Part of the Fetal Ellipse. — This is the delivery 
 (i) of the trunk in cephalic presentations, and (2) of the head in breech presen- 
 tations. 
 
 I. First, as to the delivery of the trunk in trunk-last cases, R. Lefour be- 
 lieves the posterior shoulder, as a rule, is born first. Auvard found that in 
 29 cases the posterior shoulder came first in 16 and the anterior in 9 cases. 
 He recommends in all cases support of the head in order to prevent its own 
 weight interfering with the natural progress of the expulsion of the body. Leonet 
 asserts that the anterior shoulder first disengages in 90 out of 100 cases if the 
 fetal head be not supported; that the posterior shoulder first emerges in 90 
 out of 100 cases if the head be supported. He states that the danger to the 
 perineum first begins upon the disengagement of the posterior shoulder. Re- 
 garding shoulder delivery, I made observations on 69 primiparae and 68 mul- 
 tiparas, and found that the posterior shoulder was born three times as often 
 as the anterior in primiparae and two and a half times as often in multiparae. 
 In almost every one of the above cases, however, the head upon delivery was 
 lightly supported by the hand; this support results in favoring the birth of 
 the posterior shoulder first. The posture of the woman does not appear to 
 affect the mechanism of shoulder delivery, as my observations upon 15 cases 
 * "The Mechanism of Labor." loc. cit. 
 
448 
 
 PHYSIOLOGICAL LABOR. 
 
 of spontaneous delivery in primiparae and 28 in multiparas in dorsal and lateral 
 postures seemed to prove. 
 
 2. Head expulsion in head-last cases. (See page 531.) 
 
 VII. THE DURATION OF NORMAL LABOR. 
 
 The duration of the several stages, as well as the total duration, varies within 
 wide limits in different individuals. Labor is generally one-third shorter in multi- 
 parse than in primiparae, on account of the soft parts offering less resistance after 
 previous labors. The duration of the spontaneous first stage may be approxi- 
 mately stated as ten to fourteen hours in primiparae, and six to ten hours in mul- 
 tipara; of the second stage, two hours for the former and one hour for the latter. 
 The duration of the third stage varies from a few minutes to two hours; the 
 average being about half an hour. It is rarely spontaneously completed in this 
 country. An obstetric tradition holds that labor is especially prolonged in elderly 
 primiparae (thirty to forty years). The statistics of Courtade of the Tarnier Clinic 
 (1900) and the author's show that labor in elderly primiparse is but slightly 
 longer on the average than in primiparae in general. (See Maternal Dystocia.) 
 
 The following table gives the average duration of spontaneous labor in 
 544 primiparae and 910 multiparas, and the average duration in 47 elderly primi- 
 parae from among the lower and laboring classes of New York. 
 
 Of the primiparae, the longest duration of the first stage was fifty-four hours; 
 the shortest, forty-five minutes. Of the 544 labors, the second and third stages 
 took place practically together in two cases. Of the multiparas, the longest 
 duration of the first stage was forty-four hours; the shortest, thirty minutes. 
 The second and third stages took place practically together in three cases. 
 Of the elderly primiparse, the longest duration of the first stage was fifty-three 
 hours twenty minutes; the shortest, fifty minutes. The longest total duration 
 of labor was fifty-three hours thirty-five minutes; the shortest, two hours 
 ten minutes. Of the 47 cases, in no instance did the placenta follow imme- 
 diately the birth of the child (see Maternal Dystocia). 
 
 VIII. LIVE BIRTH. 
 
 By live birth is meant simply that the fetus was born alive, and the defi- 
 nition of the term is entirely independent of the viability of the child, which 
 latter term indicates the capability the child possesses of continuing to live. 
 
FEIGNED DELIVERY— UNCONSCIOUS DELIVERY. 449 
 
 A strict medico-legal rendering of the term live birth ignores entirely the imma- 
 turity, viability, and mat-urity of the child, and requires an answer only to 
 the question, Was the fetus at the moment of expulsion alive? The test of 
 a live birth differs in various countries; in Germany, crying "attested by 
 unimpeachable witnesses"; in France, respiration; in Scotland, crying; in 
 England and the United States neither breathing nor crying is essential to 
 establish a live birth; the pulsation of the child's heart, or of one of its arteries, 
 or the slightest voluntary movement is regarded as sufficient for this purpose 
 (Reese). In regard to crying as a test of live birth. Coke remarks: "If it be 
 born alive it is sufficient, though it be not heard to cry, for peradventure it 
 may be born dumb." Legally, all we require for a live birth is anything to 
 prove that the child was alive at the time when it entered the world. 
 
 IX. FEIGNED DELIVERY. 
 
 From a variety of motives, as for extorting damages or charity, compelling 
 marriage, disinheritance, obtaining admission to some charitable mstitution, 
 or for no assignable reason, women may simulate or feign delivery of a child. 
 A careful examination of these cases if the simulated delivery is said to be 
 recent, and if the various doubtful, probable, and certain signs of recent delivery 
 are excluded, will clear away all doubt.* (See Signs of Recent Delivery, Part 
 VI.) This condition in the lower animals is quite common, and has been repeat- 
 edly observed by dog-breeders. I have observed the phenomenon in the breed- 
 ing of Scotch terriers. Years ago Harvey, in writing upon conception, stated 
 that overfed bitches, which admit the dog without fecundation following, are 
 nevertheless observed to be sluggish about the time they should have whelped, 
 and to bark as they do when their time is at hand, also to steal away the whelps 
 of another bitch, to tend and lick them, and also to fight fiercely for them. 
 Others have milk or colostrum in their teats, and are, moreover, subject to 
 the diseases of those which have actually whelped. 
 
 X. UNCONSCIOUS DELIVERY. 
 
 The possibility of a woman giving birth to a child even at full term, and 
 remaining, for a time at least, unconscious of the fact, must be granted. The 
 possibility of unconscious delivery is especially important in regard to the 
 subject of infanticide; the defense in these cases often being that the woman 
 was unconscious of the act of parturition. Unconscious delivery during the 
 action of narcotic drugs and anesthetics, and in women in convulsions, stupor, 
 coma, or moribund condition, is common, and women have been delivered 
 unconsciously during profound sleep. f Unconscious delivery during hysteria 
 is possible, but here as well as during sleep it is more than likely that the pains 
 
 * Compare Kost: "Text-Book of Medical Jurisprudence," Cincinnati, 18S5, p. 1S9 
 Goodell, W.: "Medical News," Phila., 1890, lviii, pp. 409-411. "Henke's Zeitschrift," 
 vol. XLiv, p. 172. Fischer, C.: "Zeitschr. f. Wundartze u. Geburtsh.," Hegnach, 1887, 
 XXXVIII, pp. 264-268. "Ein forensicher Pseudo-Geburtsfall." 
 
 t For cases of unconscious delivery during sleep compare Weill: "Gaz. M6d. de 
 Strasbourg," 18S1, i, x, p. 103; Case, M. W.: "American Journal Med. Sciences," Phila., 
 1886, Lv, p. 270; Samuelson, A.: "Brit. Med. Jour.," London, 1865, 11, p. 550; Tamier: 
 "Journal des Sages-Femmes," Juillet 10, 1891. 
 29 
 
450 PHYSIOLOGICAL LABOR. 
 
 of the expulsive stage of labor would arouse the woman ; this is especially 
 true of primiparae, but every obstetrician is aware that in some women, par- 
 ticularly multiparae with roomy pelves and relaxed soft parts, a very few and 
 almost painless contractions of the uterus are sufficient to empty the uterus 
 rapidly and easily. Perhaps the most frequent diseased condition in which 
 a woman may be unconsciously delivered is the stupor, convulsions, or coma 
 of puerperal eclampsia; as is well known, puerperal mania often follows this 
 condition. 
 
 Under the preceding conditions it is quite possible for a woman to be confined, 
 to injure or even to kill her child, subsequently to be restored to consciousness, 
 and to be perfectly truthful in her assertion of her entire ignorance of what had 
 happened, and the clinical picture of puerperal albuminuria or eclampsia would 
 sustain her statements. Again, the expulsion of the child has been mistaken 
 for a strong desire on the part of the woman to empty her bowels ; this is a 
 common defense set up for the charge of child murder. An intense desire to 
 empty the lower bowel accompanies the expulsive stage of labor, and from 
 our present knowledge of the subject, gleaned from many cases reported by 
 competent observers, and from personal cases, a woman may be seized with 
 this intense desire to defecate, hurriedly enter a water-closet or privy, and 
 be absolutely ignorant of the act of parturition until too late to save the expelled 
 child from injury. Such accidents are possible and have happened. Before 
 the claim of such an occurrence is accepted in a given case, a thorough inves- 
 tigation should be made by the medical witness, including a vaginal examina- 
 tion of the woman in question.* 
 
 In addition, we must bear in mind that while the woman may in a given 
 case be unconscious of the expulsion of her child at the moment of delivery, 
 yet she cannot remain ignorant of the fact that she has been delivered, if she 
 be at the time conscious. 
 
 XL VERTEX PRESENTATION. 
 
 Definition. — A vertex presentation is, strictly speaking, an occiput presenta- 
 tion, the occiput being the region of the fetal- head behind the posterior fontanelle 
 including and surrounding the external occipital protuberances (Fig. 541). 
 When this region forms the presenting part, there exists an occipital or so-called 
 vertex presentation. This presentation affords the most natural posture for 
 the fetus, the best opportunities for its favorable development, and at labor 
 the best prognosis for both mother and child. 
 
 Frequency. — The frequency of vertex presentations is 96 per cent, of all 
 cases. Compare Presentations, page 423. 
 
 * I was hurriedly summoned one night to a case of this character, in which a servant in 
 the family, a primipara, out of wedlock, and at or near term, mistook a nearly painless labor 
 for a difficult defecation, and the child was born in the pan of the water-closet. The patient 
 complained of lumbo-sacral pains and rectal pressure and denied any knowledge of the 
 escape of liquor amnii. Attempted infanticide was of course suspected, but an investiga- 
 tion satisfied all that there was no premeditated infanticide. The child lived, and it and 
 its mother were removed the same night to a hospital. 
 
 In another case I was asked to see a woman in a New York tenement in which the patient, 
 a multipara, was delivered precipitately on a fire-escape, in the act of leaning over the rail- 
 ing and exerting a good deal of strength in drawing a clothes-line loaded with clothes toward 
 her; she was unaware of labor until the child, near term, struck the iron floor of the fire- 
 escape. The child sustained contusions of the scalp and a depression of one parietal bone, 
 but sur\ived. 
 
VERTEX PRESENTATION. 451 
 
 Etiology. — See Presentations, page 423. 
 Positions and Relative Frequency. — 
 
 I. Left occipito-ahterior, Occipito-laeva anterior, L. 0. A., 70 per cent. 
 II. Right occipito-anterior, Occipito-dextra anterior, R. 0. A., 10 percent. 
 
 III. Right occipito-posterior, Occipito-dextra posterior, R. O. P., 17 per cent. 
 
 IV. Left occipito-posterior, Occipito-lasva posterior, L. 0. P., 3 per cent. 
 In vertex presentations the first position obtains in 70 per cent, of cases; 
 
 the second in 10 per cent.; the third in 17 percent.; and the fourth in 3 per 
 cent. For the explanation of this relative frequency, compare Relative Frequency 
 of Positions, page 424 (Fig. 577) 
 
 Mechanism. — I. Left Occipito-anterior Position, L. 0. A. (Fig. 586). — 
 I . Flexion and Moulding oj the Head. — The sagittal suture in this position cor- 
 responds to the right oblique of the pelvic inlet, or possibly to a diameter 
 between this and the transverse. If head flexion is complete, the suboccipito- 
 bregmatic circumference, 11 inches (28 cm), is in relation with the circumference 
 of the parturient inlet — the most favorable presentation (Fig. 586) 
 
 Flexion. — Most authorities associate flexion of the head upon the body 
 with this stage. Possibly flexion is rendered more complete at this time, but 
 a study of frozen sections of pregnancy and elective versions before labor has 
 convinced the author that flexion is complete, or nearly so, before the onset 
 of labor. The normal attitude of the fetal ellipse during pregnancy is one of 
 flexion of all its parts (page 420). The causes of flexion prior and subsequent 
 to labor are: (i) The normal attitude of the fetal ellipse during pregnancy is one 
 of flexion of all its parts. (2) This flexion of pregnancy is increased or completed 
 during moulding and entrance of the head into the inlet, because the sincipital pole 
 of the head-lever is longer than the occipital pole; so that when the head en- 
 counters the resistance of the parturient inlet, the sincipital or long pole of the 
 lever meets with greater resistance and ascends, forcing the chin nearer the ster- 
 num, and thus emphasizing or completing primary or gestational flexion (see page 
 422) (Fig. 577). If for any reason flexion be not complete, then possibly a circum- 
 ference as great as the occipito-frontal (13^ inches — 34.5 cm.) will be in relation 
 with the circle of resistance of the parturient inlet. Complete antero-posterior 
 flexion of the head is normally present at this time, and opinions differ as to the 
 occurrence of lateral flexion or inclination. A lateral inclination of the fetal 
 head toward the maternal sacrum bringing the sagittal suture nearer to the pro- 
 montory than to the symphysis is termed Naegele's obliquity, or asynclitism 
 (page 523). When the head descends with its planes parallel with the pelvic 
 planes, a synclitic condition of the head is present. With normal pelves and 
 fetuses the synclitic engagement of the head exists (Kuneke); in labor with 
 deformed pelves, especially with flattened pelves, Naegele's obliquity is some- 
 times found (see Pelvic Deformity, pages 604 and 605). By Solayres's obliquity 
 (Fig. 586) is understood the entrance of the sagittal suture into the pelvic inlet 
 in an oblique diameter. Roederer's obliquity is extreme flexion of the chin on 
 the sternum (page 499). 
 
 Moulding. — In most labors adaptation of the skull to the pelvis is brought 
 about by certain movements of the bones of the cranial vault upon one another. 
 Moulding is an important and possibly an essential factor in the mechanism 
 of labor, since it prepares the head for a ready engagement and descent, and 
 the change in the shape of the head lowers the dip of the occipital pole of the 
 head lever in the pelvis, thus favoring and rendering more positive anterior rota- 
 tion of the occiput later on. Post-partum measurements show that the greatest 
 reductions in the diameters take place in the transverse ones, which are often 
 
452 
 
 PHYSIOLOGICAL LABOR. 
 
 lessened by twice the width of the sagittal and frontal sutures. The fontanelles 
 also assist in the compression of the head, so that the transverse diameters are 
 often diminished from |- to |- inch (1.5 to 2 cm.), and a corresponding elongation 
 occurs in the sagittal diameters, but it can be shown by a study of many fetal 
 skulls that the changes in shape of the skull in vertex presentations due to mould- 
 ing consist not so much in actual measurable changes in the length of the head as 
 in the flattening of the region about the brow and anterior fontanelle, an arching 
 and greater prominence of the presenting part of the parietal bone, and, in pro- 
 longed labors, a more vertical position of the squamous portion of the occipital 
 bone. A summary of the disposition of the bones of the skull due to moulding 
 in vertex presentation is as follows: (i) The anterior or presenting parietal bone 
 is the lowest presenting part, and it overlaps not only its fellow but also the frontal 
 and occipital bones. Thus, in the two left positions of the vertex the left or pos- 
 terior parietal bone is over- 
 a-4% ridden by the right; and in 
 
 the two right positions the 
 right or posterior parietal 
 bone is overlapped by the 
 left (Figs. 582 to 585). {2) 
 The half of the frontal bone 
 which is posterior and to- 
 ward the sacrum is overlap- 
 ped by its neighboring bones 
 and is slightly flattened by 
 the pressure of the promon- 
 tory. (3) Again the anterior 
 or lowest parietal bone bul- 
 ges more and becomes more 
 prominent, while the poste- 
 rior or higher parietal bone, 
 which is against the sacrum, 
 is forced toward the frontal 
 bone and relatively flat- 
 tened. Thus the halves of 
 the skull are somewhat 
 asymmetrical (Figs. 582 to 
 585). (4) The portion of the head which is lowest and constitutes the presenting 
 part is often forced out into a point and forms the apex of a cone, the base of 
 which corresponds to that plane which passes through the parturient canal first. 
 Thus, in the L. 0. A. position the suboccipito-bregmatic circumference or plane 
 forms the base of a cone, the apex of which is the posterior superior angle of the 
 right parietal bone. This explains the situation of the caput succedaneum and 
 of a cephalhematoma. In ordinary cases deformity from moulding disappears in 
 one or two days, and in the more pronounced cases in two to four days. In cases 
 of contracted pelves with excessive moulding of the head, permanent deformity 
 may result which perhaps can be positively determined only by taking a cast of 
 the head, as measurements are misleading and unreliable. 
 
 The Capitt Succedaneum. — The change in the shape of the head produced by 
 moulding is still further modified by a swelling on that portion of the presenting 
 part which is least subjected to pressure from the canal, due to venous hyperemia 
 and oedema, and termed the caput succedaneum. (See Part IX.) In the L. O. A. 
 position the caput forms upon the posterior superior angle of the right parietal 
 
 (96-9a?i) 
 
 Fig. 577. — Diagram showing the Relative Frequency 
 OF THE Positions of Vertex Presentation. 
 
VERTEX PRESENTATION. 
 
 453 
 
 bone, encroaching somewhat upon the small fontanelle and occipital bone (Fig. 
 587). Wrinkling of the scalp usually precedes the formation of the tumor, and 
 is indicative of commencing pressure. The scalp tumor may form within the bag 
 of membranes before their rupture ; after rupture of the membranes while the cer- 
 vix is only partly dilated; and, thirdly, at the vaginal outlet after the head reaches 
 the pelvic brim. In the first two instances the caput is usually small and of little 
 practical importance, but at the vaginal outlet, where it usually forms, it may 
 attain considerable size, and may enable one after delivery to diagnose the posi- 
 tion the head occupied within the birth canal. While it is true that in normal 
 labor the caput most often forms 
 within the birth canal, still in con- 
 tracted pelves, by reason of the re- 
 sistance of the pelvic inlet, an enor- 
 mous scalp tumor may form before 
 the head enters the bony pelvis. 
 Upon the sinciput the caput is usu- 
 ally larger than when situated upon 
 the occiput, partly by reason of the 
 greater laxity of the tissues in the 
 former situation, and partly be- 
 cause of the longer duration of 
 labor when the sinciput is directed 
 to the front. In size the diameter 
 may vary from one to two inches 
 (2.5 to 5 cm.) or more. In left occi- 
 pito-anterior positions the caput 
 forms upon the superior posterior 
 angle of the right parietal bone, 
 overlapping somewhat the small 
 fontanelle and occipital bone; in 
 right occipito-anterior positions, 
 upon the corresponding point of the 
 left parietal bone ; in right occipito- 
 posterior positions the tumor de- 
 velops upon the anterior superior 
 angle of the left parietal bone, 
 sometimes overlapping the frontal 
 suture; in left occipito-posterior 
 positions we find the caput upon 
 the anterior superior angle of the 
 right parietal bone, also often over- 
 lapping the frontal suture. In in- 
 stances of a moderately rapid labor up to the time the head reaches the pelvic 
 floor, and in instances in which the internal rotation of the head has been com- 
 plete and the head is detained for a long period at the vaginal outlet, a large caput 
 succedaneum often forms directly in the median line over the sagittal suture, and 
 thus possibly obscures the diagnosis. 
 
 2. Engagement and Descent of the Head (Fig. 586). — It must be remembered 
 that flexion, engagement, and descent of the head are often completed before 
 labor actually sets in, this being specially true of primigravidae (see Engagement 
 and Descent, page 441 ). In these cases of ante-partum engagement and descent, 
 head-flexion is completed or emphasized in the transit of the head through the 
 
 Fio. 578. — Diagram showing the Relation of 
 THE Lever-like Action of the Head to the 
 'Fetal Axis. 
 
454 
 
 PHYSIOLOGICAL LABOR. 
 
 MOULDING IN VERTEX PRESENTATION. 
 ANTERIOR POSITIONS 
 
 Fig. 579. — Before Moulding. 
 
 Fig. 580. — ^Moderate ^Ioui.ding. 
 
 Excessive ^vIoulding. 
 
 cervix. Exceptionally because of a 
 small head, or a softened and com- 
 pletely dilated cervix, — the latter in 
 multiparae, — the ring of the cervix 
 does not enter as a factor into the 
 causation of flexion. In exceptional 
 cases only is Naegele's obliquity pres- 
 ent, and usually the head enters the 
 pelvis in the axis of the inlet with the 
 biparietal diameter parallel with the 
 plane of the inlet, and this relation of 
 the head to the successive planes of 
 the pelvis is maintained until the pel- 
 vic floor is reached. Engagement and 
 descent go hand-in-hand, and the ease 
 and promptness with which the latter 
 is accomplished will depend upon 
 the resistance encountered at the 
 barrier of the cervix and in the walls 
 of the pelvis and vagina. 
 
 3. Anterior Rotation of the Occiput 
 (Figs. 588 and 589). — Descent con- 
 tinues until the most dependent por- 
 tion of the presenting part — the occi- 
 put — reaches the pelvic floor. For 
 reasons already set forth (page 442), 
 anterior rotation of the occiput occurs 
 so that it turns forward under the 
 pubic arch, and the sagittal suture oc- 
 cupies very nearly the antero-poste- 
 rior diameter of the bony pelvic outlet 
 (Fig. 590). Excessive rotation: We 
 occasionally see excessive internal ro- 
 tation of the head, by which is meant 
 that the sagittal suture rotates from 
 one oblique pelvic diameter past the 
 conjugate and into the opposite ob- 
 lique. This is probably in conse- 
 quence of excessive rotation of the 
 trunk, due to strong uterine contrac- 
 tions compressing the fetal back and 
 turning it toward the front and oppo- 
 site side. In my sixty-nine observa- 
 tions in primiparse, and seventy-one 
 in multiparae, excessive rotation of 
 the head from one oblique diameter 
 to the other occurred in but one in- 
 stance — a primipara.* 
 
 4. Extension and Expulsion of the 
 Head (Figs. 574 and 575). — Rotation 
 
 ♦Edgar: "The Mechanism of Labor; Some Experimental and Clinical Observations," 
 "Amer. Joum. Obstet.," vol. xxviii, No. 4, 1893. 
 
VERTEX PRESENTATION. 
 
 455 
 
 being complete, there comes a time 
 when, the occiput having passed 
 under the subpubic ligament and 
 being partially born, the shoulders 
 attempt to enter the pelvis with the 
 head; and as under ordinary cir- 
 cumstances there is not sufficient 
 room for both, the head escapes 
 from the vulva by a movement of 
 extension. This is not strictly true, 
 for repeated observations show 
 that part of the head, including the 
 occiput, is bom before the chin 
 leaves the sternum, a fact we must 
 always remember in our attempts 
 at perineal protection and forceps 
 delivery (Fig. 573). This escape 
 of the head is caused by the force 
 of uterine contraction acting 
 through the spinal column and 
 by the contraction of the muscles 
 that go to make up the pelvic 
 floor ; and we see the beautiful pro- 
 vision of nature that has caused 
 only the smallest circumference — 
 namely, the suboccipito-bregmatic, 
 13 inches (33 cm.) — to be passed 
 through the birth canal; and even 
 at the vulva, the occiput having 
 been born first, all the circumfer- 
 ences of the fetal head that pass 
 in succession through the vulval 
 opening are measured not from the 
 occipital protuberance, which is al- 
 ready born, but from a point mid- 
 way between it and the foramen 
 magnum, and are consequently the 
 smallest or the suboccipital circum- 
 ference (Fig. 574). 
 
 5. Rotation of the Trunk and 
 Restitution of the Head. — The right 
 or lower shoulder rotates to the 
 pubis and the face looks toward 
 the right thigh of the mother. (See 
 Mechanism, page 447.) 
 
 6. Expulsion of the Trunk. — We 
 have now followed the bisacromial 
 diameter into the antero-posterior 
 diameter of the pelvic outlet. The 
 involuntary and voluntary forces 
 direct the shoulders into the par- 
 turient outlet. Shoulder delivery: 
 
 MOULDING IN VERTEX PRESENTATION. 
 (AUTHOR'S COLLECTION OF SKULLS.) 
 
 Fig. 582.— Left 
 
 Posterior View 
 
 Fig. 5S3. — Left Position. Anterior View. 
 
 Fig, 584. — Right Position. Posterior View, 
 
 Fig. 585. — Right Position. Anterior View. 
 
456 
 
 PHYSIOLOGICAL LABOR. 
 
 VERTEX PRESENTATION. 
 
 FIRST VERTEX POSITION. 
 
 LEFT OCCIPITO-ANTERIOR, L. O. A. 
 
 Fig. 586. — At Pelvic Inlet. 
 
 Fig. 587. — Right Parietal Bone in the 
 Cervix. 
 
 Fig. 588. — Head at Pelvic Floor be- 
 fore Rotation. 
 
 The right or anterior shoulder, whether 
 it does or does not appear first under 
 the arch of the pubis, is usually de- 
 tained at this point, and the posterior 
 or left or perineal shoulder, with arm 
 and forearm, are propelled over the edge 
 of the perineum and born, their escape 
 being followed by the delivery of the 
 right or pubic shoulder and arm (Fig. 
 620). With the birth of the shoul- 
 ders the arms, forearms, and hands are 
 usually found flexed upon the child's 
 chest, as they are found in the normal 
 attitude (see page 420). The shoulders 
 having been delivered, the body usu- 
 ally follows immediately after. Some 
 obstetricians would speak of a stage of 
 rotation of the buttocks, but there is 
 every reason to believe that when the 
 shoulders rotate the buttocks rotate 
 with them, in ordinary cases, and con- 
 sequently there is little or no torsion 
 of the body, but the buttocks come 
 down and are expelled in the antero- 
 posterior diameter of the outlet in 
 practically the same way as are the 
 shoulders. 
 
 IL Right Occipito-anterior Posi- 
 tion, R. 0. A. (Fig. 591). — (i) Flexion 
 and moulding of the head: This stage in 
 the mechanism is the same as in the L. 
 0. A. position, except that the caput 
 forms upon the posterior superior angle 
 of the left parietal bone and the shape 
 of the head and the overlapping of the 
 bones differ (Fig. 592). (2) Engagement 
 and descent: The sagittal suture enters 
 the left oblique diameter of the pelvic 
 inlet and descent occurs as before until 
 the pelvic floor is reached (Fig. 593). 
 
 Fig. 
 
 . — Head at Pelvic Floor after 
 Anterior Rotation. 
 
 Fig. 590. — In the Vulva, with Incomplete 
 Anterior Rotation. — {From a photograph.) 
 
VERTEX PRESENTATION. 
 
 457 
 
 SECOND VERTEX POSITION. 
 RIGHT OCCIPITO-ANTERIOR, R. O. A. 
 
 Fig. 591. — At Pelvic Inlet. 
 
 Pig. 592. — -Left Parietal Bone in the 
 Cervix. 
 
 Fig. 
 
 593. — Head at the Pelvic Floor 
 BEFORE Anterior Rotation. 
 
 (3) Anterior rotation of the occiput: This 
 occurs, for reasons already stated, from 
 right to left instead of from left to right 
 as in the L. 0. A. position (Fig. 593). 
 
 (4) Extension and expulsion of the head 
 are the same as in the L. 0. A. position. 
 
 (5) Rotation of the trunk: The bisacro- 
 mial diameter of the shoulders enters the 
 right oblique diameter of the pelvic inlet 
 and the rotation of the trunk causes the 
 left shoulder to come under the pubic 
 arch. (6) Expulsion of the trunk is the 
 same as in the L. 0. A. position, as 
 regards anterior and posterior shoulder 
 delivery (Fig. 620). 
 
 III. Right Occipito-posterior 
 Position, R. 0. P. (Fig. 596). — i. Flex- 
 ion and Moulding of the Head. — This 
 stage is the same as in the R. O. A. 
 position, except that the flexion is liable 
 to be imperfect. The caput succedaneum 
 develops upon the anterior superior 
 angle of the left parietal bone, some- 
 times overlapping the frontal suture 
 (Fig. 597), and the shape of the head 
 and the overlapping of the bones differ 
 (Figs. 584 and 585). 
 
 2. Engagement and Descent of the 
 Head. — The suboccipito-bregmatic di- 
 ameter in this position enters the inlet 
 in its right oblique diameter. Following 
 engagement we have descent, in some 
 cases until the pelvic floor is reached, 
 and in others anterior rotation of the 
 vertex occurs before the pelvic floor 
 is reached. In these latter instances 
 there is every reason to believe that 
 it is the resistance of the posterior 
 
 Fig. 594. — Heae) at the Pelvic Floor 
 before Anterior Rotation. 
 
 Fig. 595. — Head Expulsion after Anterior 
 Rotation. — (From a photograph.) 
 
458 
 
 PHYSIOLOGICAL LABOR. 
 
 THIRD VERTEX POSITION. 
 
 Right Occipito-Posterior, R. O. 
 
 P. 
 
 Fig. 596. — At the Pelvic Inlet. 
 
 wall of the uterus or of the recto-vaginal septum that determines this early 
 rotation (Fig. 530). 
 
 3. Rotation of the Occiput. — When once the vertex has reached the pelvic 
 floor, the case may terminate in one of four ways, and, in order of frequency, 
 they are as follows: First, complete anterior rotation of the occiput about the 
 
 right half of the pelvis until the pubis 
 is reached; second, posterior rotation of 
 the vertex into the hollow of the sacrum 
 and birth of the head with the occiput 
 to the rear by extension over the peri- 
 neum; third, posterior rotation and im- 
 paction; and, fourth, the conversion of 
 the vertex presentation into one of face 
 presentation; and although this latter 
 termination is extremely rare, some in- 
 stances of it are on record, and we are 
 compelled to recognize its possibility 
 (Fig. 538). (1) Anterior rotation: It is 
 unnecessary to describe the first method 
 of termination ; the same principles apply 
 heie as in the first and second positions. 
 The greater resistance of the posterior 
 segment of the pelvic floor causes the 
 occiput to be deflected in the direction 
 of least resistance — namely, to the vul- 
 val orifice (Fig. 599). (2) Posterior rota- 
 tion and birth of the occiput over the peri- 
 neum: Instances occur, however, in 
 which from some cause, as roominess of 
 the pelvis, smallness of the child, want 
 of rigidity of pelvic floor from numerous 
 labors, or other causes, — distention of 
 the floor by the passage of the first twin, 
 incomplete flexion of the head, permit- 
 ting the sinciput to be as low as or lower 
 than the occiput, — anterior rotation 
 fails. Most authorities state this to 
 be a rare condition, yet according to 
 Naegele's statistics it occurred once in 
 73 cases of labor. In 2200 labors I 
 found persistent occipito-posterior posi- 
 tion to occur in 89 cases of labor, or 
 4.04 per cent. Should anterior rotation 
 fail and the occiput remain in the pos- 
 terior half of the pelvis, it is possible 
 under certain conditions for the occiput 
 to follow the posterior wall of the par- 
 turient canal and to be born by extension over the edge of the perineum. 
 Labor then is almost always prolonged, and in some instances impossible as the 
 result of impaction (Fig. 601 ). The cause of the prolongation of the labor under 
 such circumstances was first pointed out by P. Dubois, and is readily understood. 
 The back of a child's neck (Fig. 544) is not much over 3 inches (7.5 cm.) in 
 
 Fig 597. 
 
 -Left Parietal Bone in the 
 Cervix. 
 
 Fig. 
 
 598. — Vertex at the Pelvic Floor 
 BEFORE Anterior Rotation. 
 
VER TEX PRESENT A TION. 
 
 459 
 
 THIRD VERTEX POSITION.— (Cont.) 
 
 Fig. 599. — Vertex at the Pelvic Floor 
 BEFORE Anterior Rotation. 
 
 i?^'>-' 
 
 length; the posterior wall of the parturient canal, from the promontory of the 
 sacrum to the edge of the perineum (Fig. 516), is in the neighborhood of ten 
 inches (25 cm.), counting five inches from the promontory to the tip of the 
 coccyx and five more from this point to the edge of the distended pelvic floor. 
 If an anterior position of the vertex obtains, the birth of the head is readily 
 and easily accomplished; for the two 
 inches of the back of the neck without 
 any difficulty pass over the if inches 
 (4 cm.) of the anterior pelvic wall meas- 
 ured at the symphysis, and the head is 
 born before the shoulders necessarily 
 enter the pelvic inlet. For the head to 
 be born in an occipito-posterior posi- 
 tion we may hope for no break in the 
 straight and rigid mass that the fetus 
 represents, until the head together with 
 the neck has traversed the ten inches 
 of the posterior pelvic and perineal walls, 
 and the head is finally permitted to be 
 born over the perineum. Delivery under 
 such circumstances is certainly possible 
 by the natural forces, for after an exceed- 
 ingly tedious labor and extreme flexion 
 of the head on the sternum, and the occi- 
 put distending the pelvic floor for several 
 hours, finally with tremendous bearing- 
 down efforts on the part of the parturient 
 woman, the occiput is enabled to climb 
 up, as it were, over the edge of the peri- 
 neum, the forehead and face appear at 
 the pubes, and the perineum slipping by 
 the occiput and along the neck, extension 
 completes the birth of the head. (3) Pos- 
 terior rotation and impaction: Unfortun- 
 ately we occasionally meet with instances 
 in which anterior rotation of the occiput 
 or spontaneous delivery of 'the occiput 
 to the rear both fail to occur. And if we 
 have added an impaction and swelling of 
 the shoulders that have partially entered 
 the pelvic cavity, we have one of the 
 tragedies of midwifery practice. Given 
 a normal-sized fetus, a pelvis of ordinary 
 dimensions, perhaps a primipara with 
 rigid soft parts, and the cause of impac- 
 tion of those cases of occipito-posterior 
 
 position that have been improperly treated in the early second stage of labor is 
 easily understood. The occiput passes into the hollow of the sacrum, reaches 
 the coccyx perhaps, but still is several inches (5 inches) from the edge of the 
 perineum. Under the circumstances the body of the child must enter the pelvic 
 cavity with the head in order to allow of the occiput's reaching the edge of the 
 perineum. We have impaction then because the dorso-sternal diameter, 3! inches 
 
 }i 
 
 Fig. 600. — Restitution of t 
 after Anterior Rotation 
 
 PULSION. 
 
 iE He/\d 
 
 AND Kx- 
 
 FiG. 601. — Delivery of the Head after 
 Posterior Rotation of the Occiput. 
 
460 
 
 PHYSIOLOGICAL LABOR. 
 
 FOURTH VERTEX POSITION. 
 LEFT OCCIPITO-POSTERIOR, L. O. P. 
 
 / 
 
 Fig. 602. — At Pelvic Inlet. 
 
 (9.5 cm.) (Fig. 544), is added to the fronto-mental diameter, 3^ inches (8.25 cm.) 
 (Fig. 533), giving an antero-posterior diameter of the presenting fetal mass of 7 
 inches (17.78 cm.) that the uterine forces are attempting to drive through a pelvis 
 the average diameter of which is usually not more than 4! inches (12 cm ) (Fig. 
 
 509). And this is not all; the length of 
 the fetal ellipse when the child is in nor- 
 mal attitude is half the length of the 
 entire fetus — namely, about 11 inches 
 (27.5 cm.); consequently when the occi- 
 put has come to the edge of the peri- 
 neum the breech of the child has practi- 
 cally entered the inlet of the pelvis, and 
 the uterus under such circumstances can- 
 not but act at a disadvantage. We can 
 readily see, then, what either spontane- 
 ous or artificial birth of the fetus means 
 to the mother — almost invariably a par- 
 tial or complete loss of her perineal struc- 
 tures, or uterine inertia and exhaustion 
 (Fig. 601 ). (4) Conversion into a face pre- 
 sentation: The fourth manner in which 
 this posterior position may terminate is 
 for the occiput in some way to become 
 arrested in its course, and then, the chin 
 leaving the sternum, rotation on a bi- 
 parietal diameter takes place, the head, 
 as it were, turns a somersault, becomes 
 extended within the pelvic cavity, and 
 we have resulting a face presentation of 
 the mento-anterior variety. This is of 
 rare occurrence spontaneously. A few 
 manual conversions of an occipito-pos- 
 terior position into a face presentation 
 within the pelvis have been reported. 
 
 4 Expulsion of the Head. — If, as hap- 
 pens in all but 1.5 per cent of cases, an- 
 terior rotation of the occiput about the 
 right half of the pelvis to the pubis 
 occurs, the head delivery is the same as 
 in the R. O. A. position (Fig. 606). 
 
 5. Rotation of the Trunk. — The shoul- 
 ders enter the pelvis with the bisacromial 
 diameter in the left oblique pelvic diam- 
 eter, and the left anterior or lowest shoul- 
 der naturally rotates to the pubis. 
 
 6. Expulsion of the Trunk. — After 
 shoulder rotation this is the same as in 
 the R. 0. A. position. 
 
 IV. Left Occipito-posterior Position, L. O. P. (Fig. 602). — (i) Flexion 
 and moulding of the head: This stage is the same as in the L. 0. A. position, 
 except that the flexion is liable to be imperfect, the caput succedaneum develops 
 upon the anterior superior angle of the right parietal bone, often overlapping the 
 
 Fig. 
 
 603. — Right Parietal Bone in the 
 Cervix. 
 
 Fig. 604. — Vertex at the Pelvic Floor 
 BEFORE Anterior Rotation of the 
 Occiput. 
 
VERTEX PRESENTATION. 
 
 461 
 
 FOURTH VERTEX POSIT10N.-(Cont.) 
 
 frontal suture (Fig. 603), and the shape of the head and overlapping of the 
 bones differ somewhat (Figs. -582 and 583). (2) Engagement and descent of the 
 head: The suboccipito-bregmatic diameter in this position enters the left oblique 
 diameter of the inlet (Fig. 602). Descent now occurs as in the L. 0. A. position 
 (page 453). (3) Rotation of the occiput: The same general principles govern the 
 further progress as in the R. O. P. posi- 
 tion, except that backward rotation in 
 the 1.5 percent, would occur from left to 
 right, and the anterior rotation which 
 usually occurs takes place around the left 
 side of the pelvis to the pubis (Figs. 604 
 and 605 ) . Delivery or impaction in occi- 
 pito-posterior cases is the same as in the 
 R. 0. P. position (page 458). (4) Expul- 
 sion of the head: If, as happens in all but 
 1.5 per cent, of cases, anterior rotation of 
 the occiput about the left half of the pel- 
 vis to the pubis occurs, the head delivery 
 is the same as in the L. 0. A. position 
 (Fig. 590). (5) Rotation of the trunk: The 
 bisacromial diameter enters the right ob- 
 lique diameter of the inlet, and the right 
 or anterior or lowest shoulder naturally 
 rotates to the pubis (Fig. 576). (6) Ex- 
 pulsion of the trunk: After shoulder rota- 
 tion this is the same as in the L. A. 
 position (Figs. 620 and 621). 
 
 Diagnosis. — One may be required to 
 make the diagnosis of vertex presenta- 
 tion (i) during pregnancy, (2) during 
 labor, (3) after labor has been com- 
 pleted. 
 
 Fig. 605. — -Vertex at the Pelvic Floor 
 BEFORE Anterior Rotation of 'the 
 Occiput. 
 
 r 
 
 Fig. 606. — Expulsion of thb'Head after 
 Anterior Rotation of the- Occiput. 
 
 1. During Pregnancy (see table on 
 page 463). — The diagnosis of vertex pre- 
 sentation during pregnancy before the os 
 is sufficiently dilated to permit of distin- 
 guishing sutures or fontanelles, or the 
 character of the presenting part, is made 
 by external or abdominal palpation (see 
 page 463). 
 
 2. During Labor. — Abdominal pal- 
 pation may be carried out as well during 
 labor between the pains. When labor 
 has advanced far enough for us to pal- 
 pate the vault of the skull, the diagnosis 
 of vertex positions is made from the posi- 
 tion and character of the fontanelles and sutures which we can palpate. Vertex 
 presentations are recognized by the characteristic sensation of a hard and globular 
 head, which soon becomes familiar to the student. The diagnosis of the position 
 must be made by mapping out the sutures and fontanelles. This is apt to puzzle 
 the beginner, and is sometimes difficult for the experienced obstetrician, and can 
 be learned only by practice upon the manikin and at the bedside (see Figs. 587 and 
 
 Fig. 607. — Restitution of the Head. 
 
462 
 
 PHYSIOLOGICAL LABOR. 
 
 592). On entering the os uteri the finger usually finds first the anterior parietal 
 bone, and behind this the sagittal suture. Taking this suture as the chief land- 
 mark, and remembering that it has a fontanelle at each end, the examining finger 
 undertakes to find these fontanelles or one of them. Following the sagittal suture 
 downward -and forward, the small (occipital) fontanelle is found toward the 
 mother's left if the position be an L. 0. A., or toward her right if it be an R. O. 
 A. The beginner should not forget that the small fontanelle, as soon as the 
 uterine contractions commence to force the head into the pelvic brim, is not an 
 opening, but only an angle formed by the posterior borders of the parietal 
 bones and the anterior edge of the occipital. Following the sagittal suture 
 back from the posterior fontanelle, the finger may reach the large, soft 
 anterior fontanelle, and the student should not be satisfied with his diagnosis 
 unless he has recognized both fontanelles. If the head is well flexed, the pos- 
 terior fontanelle may be the first thing encountered by the finger, and the ante- 
 rior fontanelle may be so far back that to reach it is difficult. Important points 
 
 for the student to remember are 
 that from the posterior fonta- 
 nelle run three sutures, from the 
 anterior fontanelle, four; that 
 a posterior fontanelle easily 
 reached denotes good flexion of 
 the head, and that an anterior 
 fontanelle easily reached denotes 
 small size of head, incomplete 
 flexion, bregma presentation, or 
 a posterior position of the occi- 
 put. An exact diagnosis by su- 
 tures and fontanelles is by no 
 means essential in every appar- 
 ently normal case before rupture 
 of the membranes, and to insist 
 upon it is to expose the patient 
 to the danger of premature rup- 
 ture of the membranes and sep- 
 tic infection. Palpation of the 
 anterior or lower ear is a valu- 
 able diagnostic sign (Fig. 608). 
 3. After Labor. — After labor is completed we are sometimes called upon, for 
 medico-legal purposes, to express an opinion regarding the presentation in which 
 the child was born We usually rely on two points in making the diagnosis of 
 presentation at this time. First, the shape of the child's head; and, second, the 
 position of the caput succedaneum. When labor has been rapid, when there has 
 been no caput, and when little or no moulding has occurred, there is nothing by 
 which we may be enabled to express a positive opinion, and there is nothing in 
 the genital canal of the woman to aid us in making our diagnosis. 
 
 Prognosis. — Vertex presentation offers the best prognosis for both mother 
 and child, but it varies slightly with the position, — the anterior being more favor- 
 able than the posterior, since in the latter cases the labors are generally longer and 
 more difficult, while the forceps is necessary about once in seven cases. The soft 
 parts are more frequently torn. The maternal mortality is less than i per cent, 
 when the case is intelligently managed. The fetal mortality is 5 per cent, in ante- 
 rior vertex positions, and is increased to over 9 per cent, in posterior positions. 
 
 Fig. 608. — The Palpation of the Anterior or 
 Lowest Ear of the Fetus as a Means of Posi- 
 tive Diagnosis of the Position. 
 
THE MANAGEMENT OF LABOR. 
 DIAGNOSIS OF VERTEX POSITIONS. 
 
 463 
 
 Position of Fetus. 
 
 Position of Fetal 
 Hhart-sounds. 
 
 Left occipito-anterior, Occiput to left acetabulum, forehead to Below and to the left of 
 L. O. A. right sacro-iliac joint; back to left; umbilicus. 
 
 extremities to right, above. 
 
 Right occipito-ante- ^ Occiput to right acetabulum, forehead Near median line, below 
 rior, R. O. A. to left sacro-iliac joint; back to right; umbilicus, 
 
 extremities to left, above. i 
 
 Right occipito-poste- 
 rior, R. O. P. 
 
 Left occipito-poste- 
 rior, L. O. P. 
 
 Occiput to right sacro-iliac joint, fore- 
 head to left acetabulum ; back in right 
 flank; extremities to left, anteriorly. 
 
 In right flank, below a 
 transverse line through 
 umbilicus. 
 
 Occiput to left sacro-iliac joint, forehead I In left flank, below a 
 
 to right acetabulum; back in left transverse line through 
 flank; extremities to right, anteriorly. umbilicus. 
 
 XII. THE MANAGEMENT OF LABOR. 
 
 Imitation of nature is the key to the management of normal labor. By 
 management is not meant interference, but watchful observation. A proper 
 understanding of this fundamental principle will serve to do away with 
 much meddlesome and injurious practice. In fact, it is not to® much to say 
 that in normal cases the object of the accoucheur is to find out, not how much, 
 but how little interference is justifiable. The desire of the student to see and 
 to study abnormal cases should be restrained until he has become thoroughly 
 familiar with the phenomena and natural course of normal labor. It is scarcely 
 an exaggeration to state that the greater proportion of the morbidity if not 
 the mortality of child-birth is due to the careless and unskilful management 
 of normal labor. Meddlesome midwifery, sins of commission, may be dangerous ; 
 it is equally so in obstetrics to adhere too closely to the modem dictum, that 
 there shall be no interference without a positive indication. Let him or her 
 beware who adopts the latter course and follows it without a thorough famil- 
 iarity with the physiological processes of normal labor and the many and varied 
 dangers which may suddenly and unexpectedly arise during child-birth. Imita- 
 tion and a watchful expectancy, not a blind, unreasoning trust in the processes 
 and powers of nature, should guide us in the management of labor. What 
 apparently begin as the simplest labors will often subsequently demand active 
 interference on the part of the attendant. The whole process of labor, properly 
 considered, is a conservative process the tendency of which is to prevent sepsis, 
 and it should be our aim not to thwart this process or supplant it by methods 
 of art, but to follow and aid it, interfering only when, for one reason or another, 
 the resources of nature prove insufficient. Nature's processes in labor are 
 from within outward. The fetus starts on its journey through the parturient 
 canal from the sterile uterine cavity, passes through the aseptic cervix, continues 
 on its way through the vagina, a tube which while often containing bacteria. 
 
464 PHYSIOLOGICAL LABOR. 
 
 even of those species which are sometimes pathogenic, may still be regarded as 
 sterile in the majority of cases, and only at the point of final expulsion comes 
 in contact with a surely septic surface, at a time when such contact can do no 
 harm. In other words, the fetus passes from the clean to the relatively clean, 
 and finally to the unclean. Moreover, during and after the journey of the fetus 
 through the birth-canal nature has provided additional safeguards against 
 infection, notably the physiological increase of the vaginal mucus, which while 
 its germicidal power has doubtless been greatly overestimated may at least be 
 regarded as in most cases unfavorable to the multiplication of bacteria, and 
 which attends the normal progress of the first and second stages of labor; the 
 flushing of the canal from within outward by the aseptic, saline liquor amnii 
 at the end of the first stage; by a second flushing of the canal by a rush of aseptic 
 saline blood and liquor amnii at the termination of the second stage ; at the 
 termination of the third stage the cleansing process is completed by the out- 
 ward passage of the placental mass and the subsequent flow of blood. Then 
 follow quickly the reparative processes of nature to close the open blood-vessels 
 and lymphatics. While, as we thus see, all nature's processes are from within 
 outward and conservative, — from the sterile toward the septic, — manipula- , 
 tions on the part of the obstetrician must necessarily be from without inward — 
 from the unclean toward the clean. It is also probable that the microorganisms 
 of the external genitals have an intrinsic tendency to migrate to the vagina, 
 and to invade the puerperal uterus, and even the uterus in labor; and that they 
 are able to prevail at times even in the face of the conservative forces just 
 enumerated. Hence the importance of non-interference except in the presence 
 of a positive indication. 
 
 Prophylaxis. — While in the management of pregnancy we can, as a rule, 
 act only indirectlv as far as gynecological prophylaxis is concerned, we can in 
 the management of labor do a great deal which is of positive and immeasurable 
 benefit to the patient in preventing subsequent serious and perhaps lifelong 
 disability. 
 
 Limiting the Duration of Labor. — That a labor prolonged beyond the limits 
 of safety is of itself the cause of subsequent local trouble is well known. This 
 statement is applicable to all kinds of abnormal labor, but finds its best appli- 
 cation in cases in which local sloughing of the maternal parts (leading sometimes 
 to vesico-vaginal fistula) is caused by prolonged pressure of the fetal head. Mater- 
 nal lesions may be the result not only of the premature or unskilful use of the 
 forceps, but also of undue delay in its use. To lay down exact rules, as some 
 have attempted to do, as to the time which should be allowed to elapse before 
 the application of the forceps without reference to the individual case, is wrong. 
 Many other circumstances must guide us here. But it is safe to say that when 
 with good uterine contractions the head remains stationary, the danger of 
 injury to the maternal soft parts becomes an important factor. A similar 
 danger also arises from too prolonged efforts to retard the passage of the head 
 through the vaginal outlet in order to prevent laceration of the perineum. 
 I refer here not only to the dangers arising from prolonged pressure, but also 
 to permanent relaxation of the muscular structures of the pelvic floor, with 
 resulting disability. 
 
 Prompt Surgical Treatment of Traumatism. — It should be the aim of the 
 obstetrician to leave his patient in at least as good condition as that in which 
 he finds her, and no man should attempt the care of the lying-in patient who 
 does not understand the ultimate results of the more common lesions of the 
 genital tract which may accompany the parturient act, and the methods 
 
THE MANAGEMENT OF LABOR. 465 
 
 of their repair. Not long ago, when trachelorrhaphy was a very common 
 operation, and when the importance of cervical lacerations with reference not 
 only to the etiology of cancer but of various lesser troubles was overrated, 
 the immediate suture of cervical lacerations was advocated in many quarters. 
 With the advent of more correct views, however, the majority of obstetricians 
 do not favor the immediate repair of cervical lacerations unless required by 
 severe hemorrhage. The danger of sepsis is by no means inconsiderable. 
 The importance of the immediate repair of all lacerations which endanger 
 the muscular structure of the pelvic floor is now generally recognized. 
 
 Asepsis. — Most important of all in connection with prophylaxis during labor 
 is rigid attention to asepsis and antisepsis. The importance of septic infection 
 as a factor in the production of uterine and pelvic disease is too evident to need 
 comment. One fact, however, I desire to emphasize: viz., that what is called 
 antiseptic midwifery, while it has enormously decreased the mortality from 
 puerperal infection, has by no means had a corresponding effect upon the mor- 
 bidity. We are too prone to consider only mortality in our results and to 
 pass over entirely the question of morbidity. Even to-day the influences upon 
 morbidity, the ultimate consequences of a mild puerperal process, are too 
 apt to pass unrecognized by the obstetrician, and the case passes into the hands 
 of the gynecologist for the cure of chronic uterine and peri-uterine inflammation, 
 which had its origin in an unnecessary, if not careless, vaginal examination. 
 We hear much of a lowered mortality, and little or nothing of a reduced mor- 
 bidity. 
 
 Preliminary Preparations. — (i) The obstetric outfit. (2) Mother's outfit. 
 (3) Baby's outfit. (4) Physician's obstetric bag. (5) The obstetric nurse. (6) 
 The lying-in room. (7) The labor bed. (8) Articles to be in readiness at time 
 of labor. 
 
 I. The Obstetric Outfit. — Shall the obstetric outfit be prepared by the 
 patient or nurse, or shall it be procured already prepared from some dealer 
 in surgical dressings? A further question naturally suggests itself — namely. 
 Of what does the obstetric outfit to-day consist? Aside from the mother's 
 outfit, meaning the clothes she will need during her lying-in period, and the 
 "baby's outfit," including, if possible, a "baby's basket," the obstetric outfit 
 should include at least the following articles: (i) A douche pan, preferably 
 square and of enamel or agate-ware. (2) Two ordinary rubber blankets, or 
 two pieces of rubber sheeting, one one yard square and the other two yards 
 square. (3) Three or four dozen soft napkins for vulval dressings, or the same 
 number of vulval pads from a surgical-dressing dealer. (4) One or two pounds 
 of sterilized absorbent cotton, or twenty-five yards of cheese-cloth or sterilized 
 gauze, for sponging. (5) Six abdominal binders of soft muslin or mull, eighteen 
 inches wide and preferably made to fit the figure at the sixth month of gestation. 
 (6) Two hand-brushes. (7) Some old linen for the baby's eyes and mouth. 
 (8) Four ounces of tincture of green soap. (9) Bottle of sublimate tablets. 
 (10) Seven ounces of chloroform. (11) Four ounces of boric acid, pow^dered. 
 (12) One tube of sterile white vaseline (for the baby). (13) Small and large 
 safety-pins and bank-pins. 
 
 If there is no nurse available before labor sets in, and it is necessary for the patient to 
 see to the cleansing of the above articles, she may be instructed to pin the douche pan, rub- 
 ber sheeting, and hand-brushes separately in coarse kitchen towels and boil them for half 
 an hour in an ordinary wash-boiler. The articles so boiled are then dried without removing 
 the towels, put away, and not opened until the time of labor. The soft napkins, if these are 
 to be used for vulval dressings, should, freshly laundered, be pinned, half a dozen in a 
 package, in coarse kitchen towels, and put away until the onset of labor. The nurse is then 
 30 
 
466 PHYSIOLOGICAL LABOR. 
 
 instructed to sterilize one package at a time by placing it in the oven until the outer covering 
 is scorched. For sterilizing instruments and dressings in the oven of the kitchen range, one 
 only requires a thermometer graduated to 200° C, so as to prevent the temperature rising 
 too high, and to make sure that 140° C. is obtained. The absorbent cotton, the old linen 
 for the baby's eyes, and the cheese-cloth are treated in the same way, the two latter being 
 cut up into convenient pieces and sterilized as needed. It is sufficient that the abdominal 
 binders be thoroughly laundered and pinned separately in freshly laundered towels until 
 needed. It will be noted that the time-honored douche bag and tube have not been referred 
 to, and this is because I do not employ douches except for positive indication; and, further, 
 because I believe these articles should be part of the physician's outfit, sterilized and cared 
 for under his direct supervision. 
 
 Most or all of the articles contained in the above list of the " obstetric outfit " can to-day 
 be obtained, sterilized in their final wrappers and ready for use, from many of the dealers 
 in surgical dressings (notably. Van Horn & Co., New York; Kalish, New York; Johnson & 
 Johnson, New York; Fraser & Co., New York), at prices for the outfit varying from four 
 to thirty dollars. These obstetric outfits, cleansed and sterilized, are usually packed and 
 sealed in a neat box, thus allowing the contents to be kept intact until needed. The con- 
 tents of these outfits vary somewhat in detail, but the following list contains the essentials: 
 (i) Agate-ware (square) douche pan. (2) Sterilized bed pads. (3) Sterilized vulval 
 pads. (4) Sterilized absorbent cotton. (5) Sterilized absorbent gauze. (6) Two pieces 
 of rubber sheeting or two ordinary rubber lalankets, one for permanent labor bed and the 
 second for the draw-sheet. (7) Abdominal binders. (8) Glass and rubber catheters, {g) 
 Scrub- and hand-brushes. (10) Sterilized tape for cord. (11) Sublimate tablets; boric 
 acid powdered; chloroform; ergot; borated talcum powder; soap; tube of sterile vase- 
 line; safety-pins. 
 
 2. Mother's Outfit. — -(i) A number of merino or flannel undervests to be changed night 
 and morning, to secure free skin action and prevent chilling. (2) Long night-dresses to be 
 changed once a day. (3) Warm flannel wrap or dressing sacque. (4) Abdominal binders 
 of soft muslin, half a yard wide and made to fit the figure at the sixth month of gestation. 
 (5) Breast binders for large and pendulous breasts, plain muslin or ordinary corset-covers 
 (see Part VI) . An abundance of old linen sheets and a generous supply of towels. 
 
 3. Baby's Outfit. — Should be plain, so as to withstand frequent washing; with long 
 sleeves and high neck to secure warmth, since cold is so injurious to the newly bom, and 
 loose and light in weight, so as not to impede any organ in the body, (i) Soft flannel under- 
 shirts with high neck and long sleeves, open in front so as to be easily removed or adjusted. 
 
 (2) Four-inch, soft flannel binders to go round the abdomen and lap one-third, which should 
 not be hemraed but overstitched, and should be secured to the child with tapes or sewed. 
 
 (3) Cotton or linen diapers, which should not be of canton-flannel. When folded once, the 
 diaper is half a yard square (to fasten with safety-pins). A second napkin is sometimes 
 necessary. (4) Heavy or light, according to season, flannel slip to act as bath petticoat 
 and dress, open and fastened in front. (5) Knit woolen socks reaching nearly to the knee. 
 Cold feet are often an exciting cause of colic. White muslin slip may, if desired, be worn 
 over flannel slip. When there is little hair on the head, a plain cambric or light flannel cap 
 will prevent nasal catarrh. Bahy basket: The ordinary contents are: (i) Bobbin. (2) 
 Scissors. (3) Safety-pins. (4) Soft linen (4^ by 4) in boracic acid solution for cleansing 
 cord, eyes, and mouth. (5) Soft hair-brush. (6) Powder box of lycopodium or fine starch 
 powder. (7) Tube of sterilized white vaseline. (8) Soft towels. (9) Complete change of 
 clothing. (10) Woolen shawl, blanket, or wrap. 
 
 4. The Physician's Obstetric Bag. — For several years I have experi- 
 mented with different patterns of bags and cases in order to fulfil the 
 requirements of private practice. I have always looked on leather obstetric 
 bags with suspicion and fear, because of the difficulty of cleansing them, and 
 because articles to be used in the lying-in room cannot be safely carried in 
 them unless such articles and instruments are boiled immediately before use; 
 further, I believe that the ordinary obstetric leather bag which has been from 
 one case to another, in cabs and street-cars, which of necessity has had its 
 interior soiled by bloody fingers and instruments, green soap, ergot, or other 
 drugs, has no place in the lying-in room in the present age of aseptic surgery. 
 Leather obstetric bags can, therefore, not be recommended, because of the 
 difficulty, if not impossibility, of cleansing them. Linen obstetric bags which 
 can be boiled or sterilized by steam have been used in Germany. Diihrssen 
 has an asbestos bag which can be sterilized by dry heat with the instruments 
 in situ. Aluminium I have found unsuitable by reason of the uncertain com- 
 position of the metal. The ideal obstetric case is one made entirely of metal 
 
THE MANAGEMENT OF LABOR. 467 
 
 which will permit of cleansing by dry heat, steam, or boiling. Such a case 
 ' may be contained for transportation in a suitable holder or bag. The bag- 
 shaped cover is preferable because more convenient and conventional. The 
 great disadvantage of a metal case, aside from its greater cost, is its additional 
 weight. The aseptic metal obstetric case, which is here recommended, is the 
 result of much experimenting, and weighs but six pounds more, including 
 leather holder, than an ordinary leather obstetric bag. The weight of the 
 case complete with glassware filled, and including a Tarnier forceps, is twenty- 
 five pounds. This increased weight can be further reduced some two pounds 
 by the use of lighter metal in the manufacture of the case. From actual expe- 
 rience extending over a period of several years I believe that the inconvenience 
 of the additional five or six pounds is more than overbalanced by the many 
 advantages of such a case, not the least of which is cleanliness. 
 
 The case practically consists of two trays, male and female, made of sheet-iron and 
 enameled in white at a temperature of several hundred degrees (Fig. 609). The male or 
 larger tray measures 17X8X6 inches, partially fits into a shallower female tray (17 X 8 
 X si inches), leaving a space of two inches, in which space is contained a third tray 
 made of canvas, with loops and compartments to contain the glassware of the case. A 
 leather holder or case covers both trays when fitted together, and strong straps hold all 
 firmly together. My objects in having the case thus made of two trays, one large and the 
 other small, and both enameled at a high temperature, with an inner canvas tray to contain 
 the glassware, are as follows: 
 
 1. The case is aseptic. The case proper can always be rendered sterile before being 
 taken to a confinement by boiling, by baking in an ordinary kitchen oven, or by steam 
 under pressure, as the size of the case permits its being sterilized in the medium-sized steam 
 sterilizer of the market. No matter what the character of the complication attended, be it 
 ever so septic, or instruments, douche bag, catheter, gown, etc., ever so soiled with pus or 
 blood when thrown into the case to be carried away, the entire outfit can be placed in a 
 wash-boiler and rendered sterile in a short period of time by boiling. 
 
 2. Such a case furnishes us at the bedside, after the canvas tray is removed from the 
 smaller tray and the contents from the larger, with two sterile receptacles which may be put 
 to a number of uses and will often prove most valuable and convenient. For example: 
 aside from a supply of hot water in an emergency, nothing more need be required to conduct 
 a confinement than the case and its contents; as the larger tray, which holds, when half- 
 full, six quarts, may be used to wash the hands and forearms in soap and water, and the 
 smaller female tray, which holds, when half- full, three quarts, to disinfect the hand and 
 forearm in sublimate solution. 
 
 3. The length of this tray (seventeen inches) permits of the entire forearm being sub- 
 merged in the sublimate solution, an advantage that will quickly be appreciated by the 
 surgeon (Fig. 609). 
 
 4. I am in the habit of using the smaller, female tray as a sterilizer. When in the 
 course of labor indications point to the use of forceps, the instrument, still secured in its 
 labeled canvas case, is placed in the smaller tray of the case and sent to the kitchen to be 
 boiled for an hour. The boiling water is poured off in the kitchen, and, the forceps still in 
 its case, is brought in the tray to the bedside, and the case is opened only after the patient 
 and the operator's hands have been prepared for operation. 
 
 5. The larger tray, again, by reason of its size, makes an excellent bath in which to 
 plunge an asphyxiated child, and one has always at hand a convenient bath-tub in which a 
 modified Byrd's method of artificial respiration can be carried on, the child being meanwhile 
 submerged in very hot water (Fig. 609) . 
 
 6. The advantages of the inner canvas tray, which rests in the space between the 
 two metal trays, will be readily appreciated. This tray is practically a canvas case 
 measuring 17X8X2 inches, with a lid, and canvas handles at either end to lift it out of the 
 smaller metal tray (Fig. 609). My object in using canvas here, with a separate loop or 
 compartment for each piece of glassware or instrument, was to secure a noiseless tray for 
 this part of the physician's obstetric outfit, one in which the articles are all in plain sight, 
 so as to be selected at an instant's notice, and one, moreover, that can be repeatedly cleansed 
 by boiling whenever soiled by bloody fingers, soap, vaseline, or ergot. 
 
 7. The case as a whole is readily converted into an obstetric operating case by the 
 addition of the desired instruments pinned in towels and placed in the larger of the two 
 trays, for which purpose sufficient room has been provided. The length of the large tray 
 permits of Tamier's forceps, a cranioclast, and a cephalotribe being carried in it. 
 
 Contents of the Case. — (a) In large male tray: (i) Clean apron. (2) Kelly pad. (3) 
 Canvas lithotomy sling. (4) Four-quart sterile douche bag in canvas case. (5) MetaJ 
 receptacle containing sterile vaginal and douche tubes and glass catheter. (6) Volsella, 
 
Fig. 609. — The Author's Obstetric Case. — (From a photograph.) 
 
 468 
 
THE MANAGEMENT OF LABOR. 469 
 
 dressing, needle and tongue forceps, and scissors in canvas case. (7) Obstetric forceps in 
 canvas case. (8) Sterile cotton and plain gauze. (9) Five per cent, iodoform gauze. (10) 
 Two sterile nail-brushes. -(11) Rubber gloves. 
 
 The two metal and the one canvas tray having been cleansed by boiling or by dry 
 or moist heat, as already described, each of the various articles contained in the above 
 list is cleansed in a different manner in order to secure surgical cleanliness, (i) The 
 apron or canvas suit is simply freshly laundered. (2) The Kelly pad is cleansed with laun- 
 dry soap, hot water and a brush, and finally with a i : 20 carbolic acid solution; shoiold the 
 pad be used about a case in which a suspicion of sepsis exists, it is boiled for half an hour. 
 (3) The Kelly canvas lithotomy sling is made of canvas, galvanized iron rings, and brass 
 buckles, and is boiled for half an hour after use. (4) The four-quart douche bag and tubing 
 are, after use, scrubbed with hot water, soap, and a brush, rinsed in clean hot water, placed 
 in its canvas case, and boiled for half an hour. The towel and bags are then allowed to dry 
 in an enamel-ware vessel over the kitchen range, and when dry are placed in the case. (5) 
 The metal receptacle containing the glass douche tubes and catheter is boiled together with 
 the lithotomy sling and douche bag. Both metal receptacle and glass tubes are first, how- 
 ever, scrubbed in a hot soda solution with soap and a brush. (6) The volsella, dressing, 
 needle and tongue forceps, and scissors are, before being placed in the canvas case, simply 
 scrubbed in hot soda solution with soap and a brush and then dried, as they are intended to 
 be sterilized at the residence of the patient. (7) The obstetric forceps is treated in the same 
 manner as the foregoing. (8) The sterile cotton, plain gauze, and iodoform gauze can be 
 procured already sterilized from a dealer in surgical dressings. 
 
 (6) In the canvas tray contained in the small female tray are: (i) Green soap (sterile). 
 (2) Vaseline (sterile). (3) Gauze eye sponges (sterile). (4) Gauze cord dressing (sterile). 
 (5) Chloroform. (6) Ergot. (7) Strong acetic acid (99.5 per cent.). (8) Sublimate 
 tablets. (9) Fine boric acid (sterile). (10) Normal saline powders. (11) Silver nitrate 
 solution (2 per cent.). (12) Tape for cord (sterile). (13) Silk and gut ligatures and 
 needles (sterile). (14) Soft-rubber catheter (sterile). (15) Umbilical scissors. (16) 
 Medicine-dropper. (17) Nail-cleaner. (18) Safety razor. (19) English catheter (No, 
 16) with stylet. (20) Safety-pins. (21) Sterile gauze bandage for sling. (22) No. 8 
 soft braided catheter opening at end. (23) Spring scales. 
 
 Obstetric Operating Case. — For an operating set, add to the labor case the following: (i) 
 Braun's cranioclast. (2) Dubois's scissors. (3) Smellie's perforator. (4) Three artery 
 clamps. (5) Perineal retractor. (6) Tamier forceps. The above six in canvas cases. (7) 
 Scalpel and blunt bistouuy. (8) Ether. (9) Rubber apron. (10) Sterile gauze bandages 
 for slings. 
 
 Use oj the Case at the Bedside.* — It is recommended in the use of this obstetric 
 case at the bedside that the leather cover be removed in another room or the 
 hall, and only the enamel-ware trays carried into the lying-in room. A small 
 table is selected, placed at the head of the bed on the side selected for vaginal 
 examination and delivery. This table is covered with two or three freshly 
 laundered towels. The large male case is lifted out of the smaller female 
 tray and placed, with its contents undisturbed, at the distal end of the table 
 (Fig. 610). The canvas tray is then lifted out of the small female tray and 
 placed, with its lid thrown back, next to the large tray, and lastly and nearest 
 the physician is placed the small female tray ready for the sublimate solution. 
 If it is desirable to use the larger tray for hand washing, the articles contained 
 in it may be arranged conveniently upon another portion of the table. Ordi- 
 narily I do not disturb the contents of the larger tray until needed, and use 
 running tap-water for hand cleansing with soap and water. 
 
 The nail-cleaner, green soap, and one of the hand-brushes are now taken to 
 the nearest tap of hot and cold water or to a basin of hot water, the coat is re- 
 moved, the sleeves are rolled to the elbow, the nails are cleaned, and the hands 
 and forearms are scrubbed and rinsed free of soap. Returning to the bedside, 
 the clean gown is put on, the remaining hand-brush is dropped into a solution of 
 I : 2000 sublimate in the smaller tray, and the hands and forearms are scrubbed 
 in this. Sterile rubber gloves are now drawn on. The patient having been pre- 
 pared for vaginal examination and confinement, these are carried out forthwith. 
 As labor goes on, the various articles are taken from the canvas and large tray as 
 
 * My obstetric case is made for me by the Kny-Scheerer Co., 225 Fourth Avenue, New 
 York. 
 
470 
 
 PHYSIOLOGICAL LABOR. 
 
 TOP OF 
 
 
 
 \^ 
 
 > 
 
 to! 
 
 > 
 -< 
 
 
 
 z 
 
 s 
 
 STAND 
 
 needed. Sterile cotton and plain gauze are at hand as needed for sponges in any 
 of the three stages ; the Kelly pad for the rupture of the membranes or the second 
 and third stages, or vaginal douches; the sterile douche bag and glass tubes for 
 irrigation; the sterile vaseline for lubricating the fingers, if one desires to use it; 
 chloroform for administration in the second stage ; sterile gauze sponges to wipe 
 the baby's eyes and mouth on the expulsion of the head; sterile tape to tie the 
 cord; sterile dressing for the same; clean scissors to cut the same; nitrate of silver 
 for the eyes; ergot for the end of the third stage or hemorrhage, as well as acetic 
 acid for the latter, and a soft catheter to aspirate the baby's larynx. Should 
 complications occur, we have the sterile lithotomy sling and the Kelly pad for 
 
 drainage at the side of the 
 bed ; a safety razor to shave 
 the vulva; a catheter to 
 empty the bladder; a vol- 
 sella and dressing forceps 
 and iodoform gauze to 
 pack the uterus; needle 
 forceps, needles, scissors, 
 silkworm-gut and catgut 
 for lacerations of cervix or 
 perineum; an English cath- 
 eter to replace a prolapsed 
 cord ; a tube to give intra- 
 uterine irrigations, and 
 sterile bandages to use as 
 slings for versions. 
 
 If major obstetric op- 
 erations are demanded, we 
 add to the above case the 
 list of instruments already 
 enumerated. If at any time 
 in the course of labor the 
 forceps, perineorrhaphy, or 
 uterine packing set appears 
 indicated, it is, in its orig- 
 inal wrappings, placed in 
 either the larger or smaller 
 tray and sent to the kitchen 
 to be baked or boiled. 
 
 5. The Obstetric 
 Nurse. — She should be 
 free from cutaneous, suppurative disease or purulent coryza, nor should she re- 
 cently have attended cases of infectious diseases, especially erysipelas, scarlatina, 
 diphtheria, or typhoid. Oral sepsis on the part of the obstetric nurse has hereto- 
 fore received no attention, and may possibly account for otherwise inexplicable 
 cases of puerperal infection. Two nurses, one for the mother and one for the 
 infant, for at least the confinement and the first week of the puerperium, will 
 generally secure a smoother and more rapid convalescence, and are strongly to be 
 recommended. The obstetric nurse should early in the case learn the attending 
 obstetrician's routine management of mother and infant, and should not depart 
 from it unless serious emergency demand it. An excellent plan is for the 
 physician to provide a printed resum^ of his general treatment of the pregnant, 
 
 Fig. 610.- 
 
 -Plan showing Arrangement of Lying-in 
 Room. 
 
THE MANAGEMENT OF LABOR. 
 
 471 
 
 parturient, and puerperal woman, and have the nurse familiarize herself with 
 the same. 
 
 6. The Lying-in Room. — The lying-in room should not have been used 
 by any one suffering from infectious disease, and it should be of good 
 size, well ventilated, and with as much sunlight as possible. Care should be 
 taken as to the plumbing of the house, and the room should be as far removed 
 from drains and water-closets as possible. It should be thoroughly cleaned and 
 all unnecessary draperies and upholstered furniture removed. The tempera- 
 ture should range from 66° to 72° F. A bare floor is preferred to a carpeted one, 
 but in case of the latter, the carpet may be protected by an oil-cloth or a rug 
 at the side of the bed. 
 
 7. The Labor Bed. — The bed and bedding should be perfectly clean. 
 The bed should be accessible from both sides and out of all draughts. It should 
 not be too low. Soft beds should be avoided, a hair mattress being preferable. 
 In all cases requiring operative interference it is much better to deliver the 
 patient upon a table. Over the middle third of the mattress a piece of rubber 
 sheeting, oil-cloth, or tarred paper, a yard or more in breadth, is placed and 
 pinned firmly with safety-pins. A clean bed-sheet is then placed over the 
 entire mattress and pinned down This is the permanent bed (Fig. 611). Over 
 
 PERMANENT LABOR BED{^SBBER''aHEETiKG' 
 
 Fig. 611. — Plan of Arrangement of the Permanent and the Temporary Labor 
 
 Beds. 
 
 the site of the permanent rubber sheeting, a second rubber sheet of the same 
 size is placed. This is the foundation of the temporary bed, and is of the nature 
 of a draw-sheet (Fig. 611). Upon this second rubber sheet may be placed one of 
 the absorbent obstetric pads now commonly sold, or several sheets folded to retain 
 the discharges from the vagina. During labor the absorbent pad may be renewed 
 as necessary, and the last one, together with the upper rubber sheet, ma}^ be re- 
 moved at the completion of labor. The permanent rubber sheeting remains for 
 several days of the puerperium, to protect the mattress. A piece of oil-cloth or 
 waxed cloth or a freshly laundei-ed bath blanket should be placed at the bedside 
 to protect the floor. 
 
 8. Articles to be in Readiness at Time of Labor. — (Obtainable in every 
 household.) (i) Arrangement for an abundant supply of hot water. (2) A bowl 
 for vomited matter. (3) Two clean earthen-, agate-, enamel,- or paper- ware 
 bowls for hand cleansing. (4) A clean bowl for the placenta. (5) Three 
 pitchers: one for boiling water, one for cold boiled water, and one for mixing 
 antiseptic solutions. (6) A clean cup or tumbler with boric acid solution and 
 gauze or old linen wipes for the baby's eyes. (7) A half-dozen freshly laundered 
 old linen sheets to serve as bed pads or pilches. (8) An abundant supply of freshly 
 laundered sheets and towels. (9) A change of night-clothing, warmed, for the 
 
472 
 
 PHYSIOLOGICAL LABOR. 
 
 mother. (lo) A warm blanket to receive the baby. Of these articles, the four 
 
 bowls, the cup, and the three pitchers should be scrubbed with soap and water 
 
 and boiled in a wash-boiler or at least scalded out. It is 
 
 j sufficient that the old sheets to be used as bed pads and the 
 
 usual bed-sheets and towels be freshly laundered. For special 
 cases, however, — for example, breech presentations, — it is 
 desirable that half a dozen towels are sterilized by boiling or 
 by dry heat in an oven, as described above. 
 
 Response to Summons. — A physician engaged to attend 
 a case of confinement should, when summoned, respond as 
 promptly as possible, since by the rigid observation of this 
 rule it is frequently the case that complications which may 
 easily be remedied at an early stage may present the gravest 
 difficulties if not treated till a later period. Examples are 
 malpresentation, malposition, faulty attitude, prolapse of the 
 small parts, severe perineal laceration, postpartum hemor- 
 rhage, and fetal asphyxia. 
 
 Preparation of the Physician. — (See Asepsis in Obstetrics, 
 page 148.) 
 
 Preparation of the Patient. — The pubic hair, especially 
 when long or thick, should be clipped moderately short ; then, 
 whether the bowels have recently moved spontaneously or 
 not, a full enema of soapsuds (Oij) and glycerin (one ounce) 
 should be administered. After the onset of labor the use of 
 the toilet by the patient should be forbidden in order to 
 lessen the dangers of infection, and the commode or vessel 
 must then be substituted. At this time and subsequently 
 the patient should be encouraged to empty the bladder 
 frequently and completely. 
 
 The Ante-partum Bath. — The traditional ante-partum 
 tub bath has recently * been the subject of severe criticism 
 from the standpoint of asepsis. Not only is the parturient 
 woman at the end of such a bath immersed in a dilution of 
 her own dirt, but, as has been shown experiinentally, the in- 
 fected water often enters the 
 
 vagina of both primiparas and 
 
 multiparae. Moreover, under 
 such conditions the danger of 
 nipple infection is always pre- 
 sent. The ideal ante-partum 
 bath, then, would be for the patient to stand or sit 
 under a running stream of boiled water, thus elimin- 
 ^.ting another possible source of septic infection of 
 the parturient woman. This can, in maternity 
 hospitals, readily be accomplished under a warm 
 shower-bath and in some dwellings in private prac- 
 tice. When a shower of boiled water is not available, 
 
 the author instructs the nurse to place the patient in a bath-tub and to 
 pour several gallons of boiled water, allowed to cool to the proper temperature, 
 over the shoulders of the patient, the patient at the same time being instructed 
 
 Fig. 612. — White 
 Linen Suit 
 FOR Obstetric 
 Work. 
 
 SIKPJLE 
 
 OBSTETRIC or-T:RATfXG SUIT 
 
 IN LINEN CASE 
 
 Fig. 613. — Case Containing 
 Linen Suit for Obstetric 
 Work. 
 
 * Sticher: " Centralblatt f. Gjmakologie," Mar. 
 Gynakologie," Feb. 9, 1901. 
 
 2, 1901; and Strogan: "Centralblatt f. 
 
THE MANAGEMENT OF LABOR. 473 
 
 thoroughly to scrub the external genitals and body generally with a coarse, clean 
 wash-cloth and green soap, the nurse using the soap on the back and shoulders. 
 All soap is finally washed off and the bath completed with several quarts of 
 sublimate solution (i : 5000*). The patient's external genitals are finally 
 thoroughly cleansed by the nurse with absorbent cotton and a i : 2000 solution 
 of sublimate. The surface of the body is now dried with brisk friction. A 
 sterile vulval pad as a temporary occlusion dressing is then applied and pinned 
 to a waist-band made from a clean gauze bandage (Fig. 633). If a bath-tub 
 is not available, the following procedure is recommended: (i) Have the patient 
 take a sponge-bath of hot water and soap, using not a sponge but a clean wash- 
 cloth. (2) The nurse is instructed to cut the pubic hair short, if it is long or 
 thick, with scissors. (3) The nurse now with a soft hand-brush or absorbent 
 cotton scrubs with soap and hot water the external genitals, pubes. and inner 
 sides of the thighs, and cleanses the vulval canal from above downward with 
 absorbent cotton and soap and water. (4) The parts are now rinsed off with 
 clean water. (5) The same parts are then with absorbent cotton and i : 2000 
 sublimate solution given a final cleansing, always toward the anus, care being 
 taken to include the vulval canal with the sublimate solution. A sterile vulval 
 pad or gauze is now applied to the external genitals as a temporary occlusion 
 dressing, and fastened by a T-bandage. In every method of cleansing the 
 vulval canal and external genitals the greatest care must be used to avoid 
 the production of erosions by stiff brushes or rough handling, as these lesions 
 may subsequently become infected. 
 
 Ante-partum Vaginal Irrigation. — It now appears that the consensus of 
 opinion of a few years ago as to the sterility and germicidal qualities of the vaginal 
 mucus was somewhat premature. It is certain that the vagina in the healthy 
 pregnant woman very often contains bacteria, often streptococci, and that in a 
 majority of cases the germs enter the uterus immediately after delivery. 
 
 It is nowhere maintained that this phenomenon is inherently pathological ; but 
 it cannot be doubted that sometimes this is the case, and it is more than likely 
 that these bacteria are responsible for the residual morbidity with occasional 
 death which cannot be made to vanish with the strictest asepsis. This source of 
 morbidity, if reached at all, may be reached only with ante-partum antisepsis. 
 
 The Examination of Labor. — The Obstetric Examination. — On enter- 
 ing the lying-in chamber the physician should note in a general way the physical 
 and mental condition of the patient, and should she be, as is naturally in most 
 instances the case, the victim of anxiety and nervousness, he should endeavor 
 by his words and demeanor to reassure her and to quiet her apprehension. He 
 should then take the pulse and temperature, not forgetting that the former 
 is often increased by nervous influences, and, if time permits, a brief but careful 
 examination of the heart and lungs is advisable, if this has not already been 
 attended to (see page 148). In the obstetric examination it is advisable for 
 the physician to follow some routine in order to avoid needless repetition and 
 to secure thoroughness, (i) The patient has been prepared for labor as de- 
 scribed on page 472. She is placed on a couch or bed in the dorsal posture, 
 with the head but slightly raised, clothed only in her night-dress and covered by a 
 sheet. (2) Unless such information has already been obtained at the exami- 
 nation during pregnancy, it is well at this point to record the age, parity, 
 former health, especially children's diseases of the individual and at what 
 
 * Statistical proof from the Imperial Maternity Asylum of St. Petersburg shows a fall 
 of 7.4 per cent, in fever in the puerperal woman by the substitution of the shower for the 
 old-fashioned tub bath. 
 
474 PHYSIOLOGICAL LABOR. 
 
 age she first walked; the type and date of her last menstruation; the history 
 of her present pregnancy, and the character of her former pregnancies, labors, 
 and puerperiums. The patient should be exposed as little as possible, hence 
 for the external examination two sheets may be used, one to cover the body 
 and one the lower extremities from the pubes down, the upper sheet being 
 raised to expose the abdomen (Fig. 194). For the external examination in the 
 dorsal posture, the patient may be covered with a sheet, as shown in Fig. 194. 
 (4) The physician renders aseptic his hands and forearms as described on page 
 150, not forgetting that his coat should be removed and his forearm bared 
 to the elbow. The woman physician should see to it that her sleeves are made 
 so as to allow of their being rolled up. The use of sterile rubber gloves is to- 
 day the best means for the prevention of infection. 
 
 External Examination. — Having attended to the foregoing prelimin- 
 aries, it is now in order to make the external examination, and this should 
 always, except in case of emergency, precede the internal, because: (i) It 
 enables one to make the latter more intelligently; and (2) it helps one to gain 
 the confidence of the patient and prepare her for the internal examination. 
 This part of the examination, often neglected and usually undervalued, is 
 of the highest importance. By many authorities it is considered almost equal 
 in value to vaginal examination, while others who have made a careful study 
 of this method claim that by its frequent use they can dispense altogether 
 with the internal examination in a large proportion of cases. In the first stage 
 of labor this examination will not differ greatly from the external examination 
 already described under the " Examination of Pregnancy," page 150. Exami- 
 nations should be made between the pains, since the action of the fetal heart 
 is more rapid during a pain, and the uterine contractions render satisfactory 
 palpation difficult. Although the diagnosis by external manipulation is some- 
 what more difficult at this time than before labor, it is usually possible to obtain 
 a satisfactory idea of the position and presentation. Important facts to be 
 noted are: (i) The position and presentation (see page 154); (2) the rate 
 and character of the fetal heart-sounds (see page 129); (3) the condition of 
 the bladder as to distention; (4) the size-of the fetal head and whether or not 
 it has entered or can be made to enter the pelvic cavity; (5) and the strength, 
 duration, and frequency of the uterine contractions. The occurrence of the 
 pains at regular intervals and the contraction of the uterus during a pain, 
 which may be appreciated by a hand placed on the abdomen, are of importance 
 in distinguishing the onset of true labor. The sinking of the uterus, referred 
 to in the section on the symptoms and signs of pregnancy, which occurs during 
 the last two weeks of pregnancy, is also of some significance. The characteristic 
 shape of the abdomen when the membranes have ruptured and the head is 
 low in the vagina soon becomes familiar to the observer and denotes that the 
 patient is far advanced in labor. 
 
 Pelvimetry. — Should the patient be a primipara who has not been sub- 
 jected to the exaniination of pregnancy (see page 150), the routine external 
 pelvic measurements — namely, the crests, spines, trochanters, obliques, and 
 external conjugate — should be taken, and if pelvic deformity exist, as further 
 indicated by the internal examination, we should not hesitate to make a thor- 
 ough internal examination under nitrous oxid or ether, passing the whole hand, 
 if necessary, into the pelvis to secure accurate data of the available space at 
 the pelvic inlet (see page 174). If the patient be a multipara, all these careful 
 measurements in private practice are not necessary if the previous children 
 have been of usual size and the labors uneventful. 
 
THE MANAGEMENT OF LABOR. 
 
 475 
 
 Internal Examination. — After the external examination, the patient 
 having already been prepared as described on page 472, the nurse should place 
 
 -..'-"V„ 
 
 SHEET 
 
 ! 
 
 Fig. 614. — Vaginal Examinations during Labor. Position of the Patient and 
 Separation of the Vulva; Introduction of the Fingers with the External 
 Genitals Exposed to View. (Method recommended.) 
 
 her in the dorsal posture, with thighs flexed, parallel with the edge of the bed 
 (Fig. 914). The external genitals and vulval canal are again cleansed from 
 before backward by the nurse with i : 2000 sublimate solution by means of 
 
476 
 
 PHYSIOLOGICAL LABOR. 
 
 absorbent cotton. No unsterilized object, hand, instrument, dressing, or cloth- 
 ing, should touch the genitals, which during the course of labor are covered 
 with a sterile vulval pad. The physicians 's hands and forearms are re-sterilized 
 (see page 150) and the ostium vaginae is exposed by separating the labia with 
 the sterile thumb and finger of the left hand (Fig. 614). The sterile first and 
 second fingers of the right hand are now passed directly into the vagina, having 
 
 come in contact with nothing from 
 ^„ . the sublimate solution to the va- 
 
 ginal entrance (Fig. 614). No towel 
 or vaseline should be used, the ex- 
 amination being made while the 
 hand is still moist with the bichlo- 
 ride solution. 
 
 The First Vaginal Examina- 
 tion. — It is desirable to make a 
 careful vaginal examintion as early 
 as possible in the first stage in order 
 to verify the information, as to the 
 fetal position and presentation, 
 which may have been obtained by 
 external palpation, and to deter- 
 mine the existence or nonexistence 
 of conditions in the pelvis or soft 
 parts which would prove obstacles 
 to delivery, unless the information 
 has already been obtained at the 
 examination during pregnancy 
 (page 150). In the first vaginal 
 examination during labor we 
 should strive to determine: (i) The 
 condition of the vulva and vagina 
 as to dilatability and the presence 
 of lubricating mucus ; (2) the con- 
 dition of the bladder and rectum ; 
 (3) the condition of the cervix as 
 to dilatability and degree of dilata- 
 tion; (4) is pregnancy present ? (5) 
 is the woman in labor? (6) what is 
 the stage of labor? (7) the presence 
 of the "bag of waters" and whether 
 it becomes tense during a pain, an 
 important point in distinguishing 
 true from false labor pains ; (8) the 
 presentation and position; (9) the 
 internal conjugate diameter; (10) 
 any apparent disproportion be- 
 tween the presenting part and the capacity of the pelvis; (11) the effectiveness 
 of the pains on the os, membranes, and presenting part. (12) This examination 
 should also carefully confirm the results of the examination during pregnancy as 
 to the presence of pelvic deformity or obstruction in the soft parts and as to the 
 fetal position and presentation. If any suspicion of pelvic deformity exist, the 
 true conjugate should be estimated, the height of the symphysis noted, the lateral 
 
 Fig. 615. — Vaginal Examinations during 
 Labor. The External Genitals are not 
 Exposed to View. (This method is not re- 
 ccmmended.) 
 
THE MANAGEMENT OF LABOR. A:TJ 
 
 surfaces of the pelvis palpated, and the methods of determining the actual degree 
 of pelvic deformity applied ; t)iese have already been described under the " Exam- 
 ination of Pregnancy," page 1 50. If the vertex presents and descends regularly 
 with the pains, and if the patient's general and local condition is satisfactory, in- 
 terference, and especially the passing of the finger through the os uteri, owing 
 to increased danger of sepsis, is to be scrupulously avoided. Noticeable delay, 
 however, in the progress of labor should be carefully investigated, and, if 
 necessary, under anesthesia, as will be described in the section on delayed 
 labor. 
 
 Repetition of Vaginal Examinations. — It was formerly the custom to 
 make frequent examinations during the whole course of normal labor, and this 
 is still taught in some text-books, but the consensus of modern teaching is to the 
 effect that such a course is unnecessary and dangerous (see page 149)- It is true 
 that, with proper care as to asepsis, the danger of infection is limited, but it never- 
 theless exists, since even with the greatest care it is impossible to exclude all 
 sources of contamination. Examinations are also annoying to the sensibilities of 
 the patient, and when frequently repeated they sometimes become extremely pain- 
 ful. They tend to remove the vaginal mucus which nature has provided for lubri- 
 cating the parts and to cause erosions of the mucous membranes which may serve 
 as starting-points for septic infection. Their frequent repetition has in many 
 cases a bad effect on the nervous system, and undoubtedly contributes at times 
 reflexly to delay the progress of labor. It is nevertheless true that it is the 
 duty of the attendant to keep himself informed of the progress of his patient, 
 and that this may, at least in the case of beginners, require two or three 
 vaginal examinations. Increasing experience diminishes the necessity for 
 vaginal examinations, and it should be the effort of the physician to acquire 
 such familiarity with abdominal palpation and the clinical history of labor that 
 the necessity for frequent examinations may not exist. 
 
 Having made the first examination, the attendant should endeavor as far as 
 possible to determine the further progress of labor by external palpation and by 
 observation of the patient, but if in doubt, he should repeat the examination often 
 enough to satisfy himself as to the non-existence of a delayed first stage. Exact 
 rules as to the frequency of examination cannot be given, but modem investi- 
 gation tends to the conclusion that in normal cases one careful examination early 
 in the first stage and another after the rupture of the membranes should be 
 sufficient for the experienced accoucheur. Examination after rupture of the 
 membranes may guard one against the neglect of face presentation, which some- 
 times occurs at this time, and of prolapse of small parts of the fetus or of the 
 cord; it determines also the exact position of the head. It cannot be too em- 
 phatically stated that pregnant, parturient, and puerperal women can be fatally 
 infected by a single careless internal examination. Some danger of infection is 
 always present, therefore internal examinations should be as infrequent as 
 possible. 
 
 In many instances it is possible to conduct a labor without any internal 
 examination, since the chief information gained through the vagina is the stage 
 of dilatation of the cervix, and this is often not specially important to know. 
 Leopold and Sporling * and Leopold and Orb f believe that it is possible to 
 conduct safely 90 per cent, of all labors without any other than external methods 
 of examination. Among the first 1000 cases of these observers there were only 
 6.5 per cent, of errors of diagnosis, while in the second thousand the percentage 
 was only 1.77 per cent, 
 
 * " Arch, fur Gyn.," XLV, 339-371. t " Arch, fur Gyn.," xlviii, 304-323. 
 
478 PHYSIOLOGICAL LABOR. 
 
 MANAGEMENT OF THE FIRST STAGE. 
 
 This stage commences with the onset of true labor pains and ends with the 
 full dilatation or dilatability of the os uteri. The conduct of the obstetrician 
 during this stage is usually passive, provided no evidences of maternal or fetal 
 dystocia have been discovered at the examination either during pregnancy or 
 during labor. 
 
 Posture of the Patient. — In the absence of any abnormal conditions, such as 
 hemorrhage, placenta praevia, or prolapse of the funis, the patient may follow 
 pretty much her own inclinations as regards sitting up, walking about, or lying 
 down. In prolonged labor, especially in primiparse, sitting erect or walking 
 about the room is of advantage in assisting dilatation of the os and fixation of 
 the head. As soon, however, as the os is nearly dilated or dilatable, and the 
 membranes are about to rupture, the patient must be placed in the dorsal or 
 lateral recumbent position, until the membranes rupture or are ruptured arti- 
 ficially. Should rupture occur when the patient is in the erect posture, there is 
 danger of prolapse of the cord or of one of the fetal extremities. 
 
 Presence of the Physician. — His presence in the lying-in room is not usually 
 advisable at this time, but in multiparas and in rapidly progressing labors in 
 primiparse it is best that he be within call. 
 
 Vaginal Examination. — Repetition of the examination during labor (page 
 149) is usually not necessar}^ although many advise an immediate examination 
 when the membranes rupture so as to exclude prolapse of the funis. Frequent 
 abdominal palpation will generally suffice for following the progress of labor (see 
 page 154). 
 
 Food, Drink, Sleep, Attention to Bladder and Rectum. — In prolonged labors 
 the patient should be encouraged to take at intervals during the first stage small 
 quantities of liquid nourishment, such as plain milk or milk and carbonic water, 
 or simple broths or soups, such as chicken, clam, or beef. I am accus- 
 tomed to forbid the use of solid food, in view of the fact that ether or 
 chloroform narcosis may subsequently be demanded. No restriction should be' 
 placed on the amount of water desired by the patient. When there is nausea 
 or vomiting, very hot clear tea or black" coffee can advantageously replace the 
 water. In the absence of a positive indication alcohol should be avoided. The 
 patient should be induced and aided to sleep, if possible, between the pains, 
 especially if labor commences at night, since a sleepless night is a bad prepara- 
 tion for labor. The patient should empty the bladder at frequent intervals, 
 since its distention is a common cause of delay at this time. The catheter 
 should be avoided. If the rectum has not already been emptied, or if it refills 
 again, a copious enema should be given. 
 
 Use of the Voluntary Forces. — In any but exceptional cases voluntary 
 bearing-down efforts on the part of the patient, either with or without the aid of 
 bandages of bed-sheets used as traction straps for the hands, should be dis- 
 couraged. Such proceedings only fatigue the patient and usually do not aid 
 the progress of labor. 
 
 Care of Membranes. — Every precaution should be taken against the acci- 
 dental rupture of the membranes, either by vaginal examination or by sudden 
 movements of the patient, in order to avoid a dry labor and its consequences 
 (see Part V). 
 
 Anesthesia. — (See Operations, Part X.) 
 
THE MANAGEMENT OF LABOR. 479 
 
 MANAGEMENT OF THE SECOND STAGE. 
 
 This stage commences with full dilatation or full dilatability of the os, and 
 ends with the complete expulsion of the fetus or fetuses. 
 
 Posture of the Patient. — At or near the end of the first stage the patient 
 should be placed in bed, and, as a rule, must remain there until the completion 
 of the second stage, the bed-pan being used for evacuations of the bladder and 
 bowels. As the period of fetal expulsion approaches, the patient is placed in 
 the position, dorsal or lateral, preferred by the physician, and the nurse is 
 instructed to draw up and pin at the shoulders the night-clothing to pro- 
 tect it from soiling. An ordinary bed-sheet may be pinned about the waist 
 like a skirt to cover the lower part of the body and as a further protection 
 against soiling. 
 
 Presence of the Physician. — Usually he should not absent himself during 
 this time. 
 
 Vaginal Examination. — In the absence of dystocia, abdominal palpation 
 may be relied upon for determining the course of labor (page 154). 
 
 Food, Drink, Sleep, Attention to Bladder and Rectum. — The same principles 
 apply here as in the first stage, with the exception of sleep (page 478). The 
 second stage is usually so short that it is rarely necessary to feed the patient. 
 Care should be taken, however, that both bladder and rectum are empty at this 
 time. The presence of a distended bladder can be determined by external 
 examination. 
 
 Use of Voluntary Forces. — In the second stage, and especially when it is 
 protracted, the patient should be encouraged to bear down during the pains. 
 Much can be accomplished by instructing the woman to hold her breath and bear 
 down as a contraction reaches its height. If the contractions are severe and 
 painful and the patient does not bear them well, she may be induced to bear 
 down by being allowed to inhale a few drops of ether or chloroform at the begin- 
 ning of each pain. Other legitimate and simple measures to overcome inefficient 
 contractions at this time are having the patient repeatedly assume a sitting 
 posture on the edge of the bed, or even on a chair; pulling upon the hands of the 
 nurse ; bracing the feet against the foot of the bed ; pulling with both hands upon 
 slings made of stout roller "bandages fastened to the bed below the feet. (See 
 Prolonged Labor.) For a too rapid expulsion anesthesia is our sheet-anchor; 
 instructing the patient not to bear down is also useful. 
 
 Artificial Rupture of the Membranes. — The membranes usually rupture 
 spontaneously at or near the completion of the first stage after their purpose 
 has been accomplished. Earlier rupture is not uncommon. A common and 
 pernicious practice is the early artificial rupture of the membranes to accelerate 
 labor. As a rule, they should not be interfered with, even though they distend 
 the vulva. Indications may arise which demand their artificial rupture. (See 
 Operations, Part X.) 
 
 Anesthesia. — (See Operations, Part X.) 
 
 Perineal Protection.* — When the presenting part approaches the pelvic 
 floor and vulva, preparations are to be raade to protect the perineum from 
 rupture. The most important part of the management of the second stage is 
 the prevention of perineal tears. Lacerations of the fourchette in primiparae 
 and superficial tears about the vulval orifice often occur, but these readily heal 
 
 * For the varieties, frequency, etiology, mechanism, symptoms, diagnosis, prognosis, 
 and prophylaxis of perineal injuries, see Pathological Labor, Part V. For the treatment of 
 the same, consult the section on Obstetric Surgery, Part X. 
 
480 PHYSIOLOGICAL LABOR. 
 
 with simple asepsis. Deep tears, however, are avoidable in normal cases. The 
 great importance of avoiding rupture of the perineum cannot be overestimated. 
 It is scarcely an exaggeration to state that one-half of the gynecological cases 
 owe their condition directly or indirectly to rupture of the muscles of the pelvic 
 floor during labor. The causes of perineal laceration are three in number, 
 namely: (i) Relative disproportion in size between the presenting part and the 
 pelvic outlet; (2) too rapid expulsion, so that tearing instead of stretching re- 
 sults; (3) and faulty mechanism of labor whereby a larger circumference of the 
 presenting part than necessary passes through the outlet. 
 
 Prophylaxis depends upon the cause.* If there is great disproportion in 
 size or abnormal rigidity of the outlet, abundance of time must be given to the 
 muscles of the pelvic floor to stretch sufficiently without tearing to permit of 
 the passage of the fetus. Preliminary digital stretching as well as the use of 
 chloroform will assist in the relaxation of these muscles, and if all attempts fail 
 and conditions do not permit of further delay, episiotomy, properly performed 
 and repaired, is preferable to deep perineal rupture (see Obstetric Operations, 
 Part X). The chief ends in view are (i) to prevent too rapid expulsion; (2) to 
 preserve the normal mechanism of delivery, and, if possible, (3) to effect delivery 
 of the head between the pains. 
 
 1. The too rapid advance of the head can be prevented by inducing the patient 
 to refrain from bearing-down efforts, to breathe rapidly during the pains, and to 
 cry out during the emergence of the head ; by the manual retardation of the pre- 
 senting part and by the administration of chloroform or ether. Partial anesthesia 
 is an invaluable resource, aiding relaxation of the tissues, preventing too rapid 
 expulsion, and allowing of complete control of the case. The advance of the 
 head should be retarded by pressure applied not to the perineum but to the 
 presenting part. No attempt should ever be made to support the perineum 
 directly, and all methods of perineal protection which depend upon intrarectal 
 manipulations of any character should be carefully avoided, as liable to injure 
 the rectum, produce spasm of the pelvic floor muscles, and favor subsequent 
 infection of the genital tract or the eyes or umbilicus of the child. 
 
 2. The normal mechanism of delivery should be aimed at so as to secure the 
 smallest possible diameters of the presenting part to pass through the parturient 
 outlet. A valuable point in vertex anterior positions is so to retard extension 
 of the head, until the external occipital protuberance has passed the subpubic 
 ligament, that the smallest or suboccipito-bregmatic circumference (Fig. 574) 
 may be the one to engage and pass through the outlet. 
 
 3. Delivery of the head between the uterine contractions has a distinct advantage 
 in that we have a relaxed instead of a rigidly contracted pelvic floor to deal with. 
 Method second or third will accomplish this end. 
 
 Methods of Perineal Protection. — Any of the various postures of the patient 
 may be selected, but I advise the left lateral prone posture for left positions of 
 the presenting part, and the right lateral prone posture for right positions. It 
 is generally admitted that the lateral position is most favorable to perineal 
 preservation. In this position the force of violent pains is diminished, since 
 the expulsive power here is actually a resultant of two divergent forces. In the 
 lateral and latero-prone positions the intra-abdominal pressure is also weakened, 
 and the perineum is always under ocular control. Further, disinfection may be 
 carried out more completely in the lateral decubitus. In the dorsal posture the 
 weight of the head carries the latter away from the pubic arch and against the 
 perineum; this condition is not favorable to the latter. While this disadvantage 
 
 * Compare Pathological Labor, Part V. 
 
THE MANAGEMENT OF LABOR. 
 
 481 
 
 may be oflfset by the upward pressure of the posterior segment of the perineum 
 toward the symphysis, the former thereby becomes ischemic, thin, and more prone 
 
 second. third. 
 
 Fig. 6i6. — Perineal Protectio:^, showing Three Methods. 
 
 to rupture. The thighs, however, should not be too energetically flexed, other- 
 wise the perineum will be put upon a dangerous stretch. After delivery the lateral 
 posture must be quickly changed to the dorsal, lest air embolus result. Among 
 31 
 
482 
 
 PHYSIOLOGICAL LABOR 
 
 Fig. 617. — Cleansing the Eyelids Immediately 
 
 AFTER THE BiRTH OF THE HeAD. 
 
 primitive people a squatting or kneeling position is often instinctively adopted 
 during delivery, but it cannot be claimed that such postures favor the perineum, 
 as labor under these circumstances has a precipitate character. While labor may 
 be shortened and facilitated by these attitudes, the safety of the perineum would 
 seem to demand that the lateral position should be assumed during the moment 
 of expulsion. Any of the following methods may be utilized, as all are subservient 
 to the principles already laid down. The principle in all methods of direct manual 
 
 protection of the perineum is to 
 delay expulsion of the presenting 
 part in such manner as to realize 
 all the advantages of the elas- 
 ticity of the perineum. The de- 
 gree of latent elasticity of this 
 structure may be determined by 
 inspection. The fetal head, or 
 other presenting part, should be 
 supported rather than the peri- 
 neum. In fact, the attempt to 
 support the latter is attended by 
 danger. 
 
 Method one: The patient is 
 placed in the lateral prone pos- 
 ture. In the left lateral prone 
 posture the physician, seated at 
 the bedside behind the patient, 
 passes the left hand and forearm over the right thigh of the patient and uses the 
 fingers of this hand to retard the exit of the presenting part, and also to assist, 
 to a small extent, the normal mechanism of labor until the pelvic floor is suffi- 
 ciently stretched to allow the passage of the fetus without laceration (Fig. 616). At 
 the same time, with two or three fingers of the right hand placed upon the protrud- 
 ing head, and without touching any part of the maternal tissues, control of the 
 expulsion and regulation of the head movements can readily be carried out (Fig. 
 616). In this method both hands are 
 used to control a too rapid advance and '-—--._ 
 conjointly to regulate the head move- 
 ments, so as to secure the most favorable 
 mechanism of head delivery. Chloro- 
 form or ether will greatly assist our en- 
 deavors . 
 
 Method two: The posture of the pa- 
 tient and the position of the physician 
 are the same as in Method One. Chloro- 
 form or ether is invaluable. The position 
 and functions of the left hand are the 
 same as above. At the same time, with 
 
 the fingers of the right hand (Fig. 616) placed on each side of the coccyx, over the 
 extremities of the bitemporal diameter of the fetal head, the presenting part is 
 pushed up as close to the subpubic ligament as possible, thus making use of all 
 the available space of the pubic arch. The use of chloroform or ether to the 
 obstetric degree, and the delivery of the presenting part during perineal relaxa- 
 tion between the pains, by pressure with the fingers on either side of the coccyx, 
 or by expressio jcrtus (Part X) , will greatly lessen the chances of rupture. Exten- 
 
 FiG. 618. — Little Finger Wrapped with 
 Gauze for Removing Mucus from the 
 Child's Mouth. 
 
THE MANAGEMENT OF LABOR. 
 
 483 
 
 sion and delivery of the head should never be permitted until the external occi- 
 pital protuberance has beefi bom be- 
 yond the arch of the pubes. 
 
 Method three: Lateral posture and 
 chloroform or ether, as above. In the 
 left lateral posture the right, and in 
 the right posture the left, hand is used 
 for perineal protection. In the dorsal 
 posture of the patient either hand is 
 available. By the natural forces or 
 by pressure upon the fundus the head 
 is made to distend the vulva suffi- 
 ciently to enable the middle finger of 
 the perineal hand to obtain a point 
 of pressure upon the forehead of the 
 fetus by reaching behind the anus but 
 without entering the rectum (Fig. 
 6i6). The thumb of the hand is then 
 placed upon one labium majus and the 
 index-finger upon the other over the parietal protuberances of the advancing 
 
 Fig. 619. — Method of Loosening and Car- 
 rying THE Cord over the Head when 
 THE Former is Tightly Coiled about thb 
 Child's Neck. 
 
 
 \N 
 
 \:o >CERV!Qb5\CR^IALD, 
 
 \>. I 
 \^ I 
 
 Fig 620. — Method of Shoulder Delivery. The Head is Raised to Bring thb 
 Neck Close to the Pubes, and the Anterior Shoulder well behind the 
 Symphysis, thus Encouraging Delivery of the Posterior Shoulder First, 
 
 WITH THE CeRVICO-ACROMIAL DiAMETER ENGAGING. 
 
484 
 
 PHY BIOLOGICAL LABOR. 
 
 head (Fig. 6i6), and serve to draw the labia inward and backward and prevent 
 undue strain upon the posterior commissure, which Hes in plain sight above the 
 
 Fig. 621. — Method of Shoulder Delivery. The Anterior Shoulder is here Born 
 First, and the Head is Raised to Encourage Expulsion of the Posterior 
 Shoulder. 
 
 S«U«*'ifJ«-'-""'<»i"1«>— • 
 
 Fig. 622. — Supporting the Child during the Expulsion of the Trunk and Legs. 
 Note that the trunk is grasped at the pelvis, leaving the chest and abdomen free from 
 pressure. 
 
THE MANAGEMENT OF LABOR. 
 
 485 
 
 web between the thumb and forefinger. Pressure of the fingers upon the parietal 
 eminences prevents the too sudden advance of the head, while the middle finger 
 
 Fig. 623. — Proper Position of the Child Immediately after Delivery. It lies on 
 its right side and the buttocks are raised to favor the flow of mucus and foreign sub- 
 stances from the mouth. — (From a photograph taken at the Emergency Hospital.) 
 
 reaching behind the anus and protected by a sterile towel exerts pressure upon 
 the forehead, and . at the proper 
 moment during the relaxation be / 
 
 tween the pains increases head ex- 
 tension and slowly shells it out 
 through the vulval opening. Mod- 
 erate fundal pressure with the free / / 
 hand may assist in the manoeuver. ; 
 
 Cleansing of Eyes and Mouth. — 
 After the delivery of the head, the 
 eyelids should be carefully cleaned 
 by means of a soft linen cloth and 
 
 sterile water, or boric acid solution ; ' ■^- 
 
 a separate wipe being used for each 
 eye and the lids washed, from the 
 
 nose outward, free from all mucus, 
 
 ii^^j ^^ .^ ^ :..^„ A+ +-u;^ +'-„^ Fig. 624.— Method of "Stripping" the Um- 
 
 blood, or mecomum. At this time ^^^^^^^ ^^^^ ^^ Remove the Excess of 
 
 also the lips and nose are in like Wharton's Jelly. 
 
486 
 
 PHYSIOLOGICAL LABOR. 
 
 Fig. 625. — Method of Tightening the Liga- 
 ture ABOUT THE Umbilical Cord. Note the 
 position of the thumbs to prevent injury to 
 the ring from cutting or breaking of the liga- 
 ture. 
 
 manner wiped free of mucus, and the little finger, wrapped with a piece of moist 
 linen, is passed into the child's mouth and any accumulated mucus removed by 
 an outward sweep of the finger (Fig. 618). 
 
 Care of the Cord about Neck. — Search should be made to discover whether the 
 cord encircles the neck, and if it does a loop should be enlarged and drawn over 
 
 the head; but if this cannot be 
 done, the funis should be cut be- 
 tween a double ligature, or, if time 
 is lacking, without the application 
 of ligatures (Fig. 619). 
 
 Delivery of the Shoulders. — 
 After the head is bom, in the ab- 
 sence of any indication for immedi- 
 ate delivery, it is better to wait for 
 natural expulsion of the shoulders 
 and body, the head in the mean 
 time being supported in the flat of 
 the hand (Fig. 620). 
 
 Preservation of Perineum dur- 
 ing Delivery of Shoulders. — This is 
 best attained by preserving the 
 normal mechanism of shoulder de- 
 livery (see page 447). Delivery of 
 the shoulders should be delayed if 
 possible until nearly complete rotation of the bisacromial diameter has taken 
 place. The head should be held in the hand and gently raised so as to bring the 
 anterior shoulder well up behind the symphysis, thus securing the cervico-acromial 
 diameter of the fetus at the outlet instead of the bisacromial (Fig. 620). The 
 posterior shoulder is thus permitted to be delivered first, contrary to the common 
 custom, and should be 
 
 carefully guided in its /' 
 
 passage over the peri- 
 neum. Shoulder delivery 
 should be accomplished 
 whenever possible by 
 the natural forces, since 
 I have found that man- 
 ual extraction increases 
 the number of perineal 
 lacerations. Care should 
 be taken lest during the 
 delivery of the shoul- 
 ders an existing lacer- 
 ation caused by the head 
 be increased in size. 
 During the detentionof 
 
 the anterior shoulder behind the pubis the fetal hand of the opposite arm lying 
 across the child's chest will usually soon appear in the vulva. Delivery, we have 
 found, is assisted by slowly flexing this forearm and arm out through the vulva and 
 thus delivering the posterior shoulder by slight traction on the posterior arm. 
 Should there be delay in the expulsion of the posterior shoulder, traction upward 
 upon the head, the fingers encircling the neck, is to be preferred to traction with a 
 
 \ 
 
 \ 
 
 Fig. 626. — Method of Cutting the Umbilical Cord after 
 THE Application of the Two Ligatures. 
 
THE MANAGEMENT OF LABOR. 
 
 487 
 
 finger in the axilla. (See Part X.) Should there be delay in the delivery of the 
 anterior shoulder, it is best remedied by making traction directly downward 
 
 Fig. 627. — Method of Inspecting the 
 Stump of the Umbilical Cord for 
 Hemorrhage. 
 
 Fig. 628. — Method of Instilling Drops 
 OF Nitrate of Silver Solution into 
 THE Eye of the Newly Born Child. 
 
 £^': 
 
 Fig. 629. — Method of Lifting the Newly Born Child with One Hand. — {From a 
 photograph taken at the Emergency Hospital.) 
 
488 PHYSIOLOGICAL LABOR. 
 
 with the hands placed on the sides of the head, taking care not to injure the peri- 
 neum. If this does not succeed, traction may be made by a finger in the axilla. 
 (See Part X.) 
 
 Delivery of Body, Pressure on Fundus. — After delivery of the shoulders the 
 body is, as a rule, rapidly expelled. Should there be delay, however, the thorax 
 may be grasped with the hands and gentle traction made, or, better, the fetus 
 expelled by pressure upon the fundus. In the delivery of the shoulders and 
 body of the fetus the general principle — namely, to make use of all the available 
 space of the pubic arch — is followed. To accomplish this, the shoulders and body 
 are not permitted to press too closely against the perineum, but are rather pushed 
 carefully into the pubic arch. During the expulsion of the fetus the fundus is 
 followed down by the hand of the physician or assistant, and must be watched 
 for at least an hour. This dutv mav be releg^ated to an assistant or a nurse. 
 
 \ 
 
 Fig. 630. — Method of Lifting the Newly Born Child with Two Hands. — {From a 
 photograph taken at the Emergency Hospital.) 
 
 Care and Posture of the Child in Bed. — If the child cries vigorously, measures 
 for establishing respiration are unnecessary, and all rough handling should be 
 avoided. It should be wrapped in a warm blanket previously prepared and 
 allowed to rest between the mother's thighs until after ligation of the cord (Fig. 
 623). It should be placed upon the right side, since this posture tends to aid the 
 physiological changes in the fetal circulation, and with head low to prevent cere- 
 bral anemia. 
 
 Establishment of Respiration. — Should the child cry out feebly, or should there 
 be any delay in the establishment of respiration, it should be smartly slapped upon 
 the buttocks or a few drops of cold water should be dashed upon the face and 
 chest. In feeble or premature children, however, all rough handling should be 
 avoided. (See Asphyxia Neonatorum, Part IX.) 
 
 Ligation of the Cord. — Respiration being fully established, the ligation of 
 
THE MANAGEMENT OF LABOR. 
 
 489 
 
 the cord should be delayed until pulsations cease, unless there is some positive 
 indication to the contrary. Immediate ligation deprives the fetus of about 
 three ounces of blood. 
 Before ligation it is a 
 good plan to grasp the 
 cord with the thumb and 
 first finger of one hand 
 close to the navel, care 
 being taken not to make 
 traction, and with the 
 fingers of the free hand 
 to strip away the gelatin 
 of Wharton from the 
 fetus for a distance of 
 two or three inches (Fig. 
 624). This gives a thin 
 stump for subsequent 
 separation. The cord is 
 now ligated with sterile 
 bobbin or floss silk, 
 about li inches from the 
 umbilicus, it being first 
 determined that no les- 
 ion of the cord exists. A 
 second ligature is then 
 placed about two inches 
 from the first in order to 
 prevent hemorrhage in 
 case of twins, but chiefly 
 
 to retain blood in the placenta that the uterus may more readily expel it 
 Division of the cord with scissors is now performed close to the first ligature, 
 
 ^ 
 
 W 
 
 Fig. 631. — Method of Inspecting the Lower Vagina and 
 Perineum for Lacerations at the Completion of Labor. 
 
 Fig. 632. — Testing the Amount of Injury to the Perineum. 
 
 This is best done in the hollow of the hand, the scissors being passed between 
 the second and third fingers to avoid injury to the actively moving extremities and 
 unnecessary spurting of blood (Fig. 626). Some amputate the cord close to the 
 
490 
 
 PHYSIOLOGICAL LABOR. 
 
 umbilicus and bring the edges together with fine sutures (Dickinson). I have 
 been unable to determine that this procedure possesses any advantages over the 
 ordinary method. The stump of the cord is now touched with sublimate solu- 
 tion ( I : 2000) and a dry occlusion dressing of absorbent cotton or gauze is ap- 
 plied (Fig. 627). 
 
 Care of Child. — The child, wrapped in some warm material, is placed upon its 
 right side with its head lower than its body in some safe spot where it will not be 
 liable to fall to the floor or be sat upon. In lifting a naked, slippery child from 
 the bed to wrap it in a blanket one may grasp it as in Fig. 629 by one hand, or 
 with two hands, as in Fig. 630. In both instances the head in a state of flexion 
 should be allowed to hang lower than the body. Either of these methods is recom- 
 mended for physiological reasons. 
 
 Prevention of Ophthalmia. — As soon after birth as convenient the eyes and 
 lids are again wiped clear of mucus and 2 drops of a i per cent, solution of nitrate 
 
 of silver are dropped into each eye (Fig. 628). 
 This is strongly advised both in private and hos- 
 pital practice. 
 
 Inspection of Perineum (Fig. 631). — Immedi- 
 ately after the completion of the second stage the 
 patient should be carefully turned over from the 
 lateral to the dorsal posture to avoid air embolus. 
 I am accustomed to inspect the perineum at this 
 time instead of waiting for the completion of the 
 third stage. My reason for this is that it can be 
 more readily done now on accotmt of the partial 
 anesthesia of the second stage. The perineum 
 and vagina should be carefully examined, as many 
 severe lacerations are not visible externally. The 
 labia are separated by the fingers wrapped in ster- 
 ile gauze or cotton, both hands being used, and 
 the parts thoroughly inspected. Here as else- 
 where, however, intra-rectal manipulations are to 
 be avoided if possible. The occurrence of rather 
 free hemorrhage during the latter part of the 
 second stage may indicate a vaginal laceration. 
 Preliminary Vulval Dressing (Fig. 633). — Immediately after the expulsion 
 of the child, I am accustomed to place over the gaping vulva an antiseptic 
 dressing, either several folds of aseptic gauze or one of the aseptic vulval pads in 
 common use. This dressing is allowed to remain in situ until the placenta 
 displaces it on the delivery of the latter. This dressing I use with two objects 
 in view: first, to prevent, as far as possible, the entrance of air into the gap- 
 ing vagina; and, second, to indicate the amount of hemorrhage going on at 
 this period. 
 
 Fig. 633. — Temporary Vulval 
 Dressing of Sterile Gauze 
 DURING the Third Stage of 
 Labor. 
 
 MANAGEMENT OF THE THIRD STAGE OF LABOR. 
 
 The third stage of labor commences at the complete expulsion of the fetus 01 
 fetuses and ends at the complete expulsion of the placenta and membranes. The 
 patient having been carefully assisted in turning from the lateral to the dorsal 
 posture, the physician or nurse continues by gentle pressure, not kneading, of the 
 fundus to Keep up and encourage firm tonic uterine contractions in order to pre- 
 vent hemorrhage and the formation of an intrauterine clot. When the uterus does 
 
THE MANAGEMENT OF LABOR. . 491 
 
 not seem to be doing its work properly, it may be necessary to use gentle friction 
 by a circular motion with the hand until contractions are resumed, or it may 
 even be necessary to grasp the fundus vigorously and subject it to active manipu- 
 lation in order to get a prompt response. There is generally a tendency to 
 hasten the completion of the third stage. This should be avoided, and the 
 temporary suspension of strong uterine contractions after the expulsion of the 
 child should be looked upon as a physiological condition. Common mistakes 
 at this time are: (i) Undue haste and rough manipulation in the completion of 
 the third stage. This is a common cause of retained placenta. (2) Premature 
 attempts at expulsion. It should be delayed at least until about half an hour 
 after the birth of the fetus unless previous separation occurs. (3) The neglect 
 to assure one's self that the bladder is empty. (4) To press the uterus forward 
 against the pubis instead of downward and backward, more in the axis of the 
 pelvic outlet. (5) To excite contractions instead of waiting for the natural 
 ones. The former method should be practised only in cases of hemorrhage or 
 dangerous uterine inertia. (6) It is not necessary to twist the membranes into a 
 rope, and sometimes they are torn in this way. If the membranes should tear, 
 a piece of sterilized thread may be tied to the part projecting from the cervix. 
 Traction upon the membranes should not be made. 
 
 With the onset of the third stage of labor care as to asepsis should be re- 
 doubled. Untold harm has been done by unnecessary interference at this time, 
 and sepsis is often caused by irrational attempts at its prevention. After the 
 second stage the vagina and cervix are full of abrasions and trifling lacerations 
 which are of no consequence if let alone, but which offer a tempting field for the 
 propagation of septic germs. In normal cases all manipulations within the 
 vagina, and especially the introduction of the fingers, should be scrupulously 
 avoided during and after the third stage of labor. 
 
 Prevention of Hemorrhage and Delivery of Placenta and Membranes. — The 
 chief objects at this time are (i) to secure good uterine contraction, (2) to pre- 
 vent hemorrhage and to deliver the placenta and membranes intact. If, as fre- 
 quently happens, the placenta follows the child into the vagina, it may be ex- 
 pressed at any time. Usually, however, placental separation takes at least half 
 an hour. For this period after the child is delivered the uterus should be kept 
 under manual observation, and if the placenta and membranes are not expelled 
 in that time, the Crede method may be resorted to (Figs. 634 and 635). 
 
 Crede's Method of Placental Expression. — To practise this the fundus is 
 grasped with one hand, fingers behind and thumb in front, and a contraction 
 awaited (Fig. 636). At the height of the pain the uterus is firmly compressed 
 and forced downward and backward into the pelvis. If the first attempt fail, 
 another may be made in the same manner at the next contraction. It maybe 
 necessary to repeat this procedure during several contractions. When the placenta 
 appears at the vulva, little or no traction must be made upon it, but the mem- 
 branes loosened and expelled by compression of the fundus of the uterus, at the 
 same time pushing the uterus backward as nearly into the axis of the vagina as 
 possible ; the placenta meanwhile is allowed to rest in the palm of the other hand so 
 that no unnecessary traction shall be made on the membranes (Fig. 635). The 
 last string of membrane should be rather squeezed out than drawn out. After 
 delivery of the placenta and membranes the physician continues to hold the 
 fundus in the hand; this should be done for an hour after deHvery (Fig. 334)- 
 An assistant or a nurse may relieve the physician of this duty. (See Operations, 
 Part X.) 
 
 Examination of the Placenta and Membranes (Fig. 637). — The physician now 
 
492 
 
 PHYSIOLOGICAL LABOR. 
 
 takes the placenta, turns the membranes back, and places the fetal surface down 
 on the palm of his hand. The cotyledons should lie in close apposition; there 
 should be no defect on the uterine surface at the furrows limiting the cotyledons, 
 or at the margin of the placenta; the grayish-white coating of the decidua sero- 
 tina should cover the cotyledons and no red placental villous tissue should be 
 seen. He examines the margin of the placenta for torn vessels pointing to the 
 
 retention of the secondary 
 placenta or placenta succen- 
 turiata. Then he passes the 
 hand intq the cavity of the 
 membranes, distends them, 
 and, taking into account the 
 
 Fig. 634. — Delivery of the Placenta. The Left Hand follows down the Fundus of 
 THE Uterus and the Right Hand Receives the Placenta, the Latter Preventing 
 any Sudden Tension upon the After-coming Membranes. The placenta is here ex- 
 pelled by Schultze's mechanism. — {From a photograph taken at the Emergency Hospital.) 
 
 size of the child and the amount of liquor amnii, estimates as nearly as possible 
 whether the entire bag of membranes be present. 
 
 Retention of Secundines, — Retained fragments of placenta are best removed 
 immediately by passing two fingers into the vagina and os uteri, and with the 
 external hand pressing the fundus down over the internal fingers which grasp and 
 remove the fragments. Dangers of subsequent hemorrhage and sapremic in- 
 fection are thus avoided. When uncertainty exists regarding the retention of 
 
THE MANAGEMENT OF LABOR. 
 
 493 
 
 small pieces of membrane, one can safely adopt an expectant plan of treatment, 
 as in this case it is safer than intrauterine manipulations. The proposed routine 
 uterine and vaginal examinations of the genital tract at this time to determine 
 the condition of the parts and the retention of secundines cannot be too vigor- 
 ously condemned. Nothing is to be gained by this course save in very excep- 
 tional cases, and as its routine practice involves a distinct element of risk, its 
 adoption cannot be recommended. 
 
 Fig. 635. — Delivery of the Placenta. The Delivered Placenta is Supported in 
 THE Right Hand and the Left Hand Makes Moderate Pressure upon the Fundus 
 OF THE Uterus until the Membranes are Loosened and Expelled. — {From a 
 photograph taken at the Emergency Hospital.) 
 
 Repair of the Perineum. — Lacerations of the vagina and perineum should 
 now be carefully closed with appropriate sutures. (See Part X.) 
 
 Ergot. — If the retraction of the uterus should not be entirely satisfactory after 
 it is emptied, and manipulations and the Cred6 method have not induced contrac- 
 tions, fluid extract of ergot may be given by the mouth or subcutaneously. The 
 usual dose is one-half to one drachm by the mouth and twenty minims hypo- 
 dermically; it may be repeated if required. This drug is especially useful after 
 chloroform anesthesia, since the uterus sometimes does not contract quite 
 promptly after its employment. Ergot used after the uterus is empty is useful 
 as a preventive not only of hemorrhage, especially in multiparae and atonic cases, 
 
494 
 
 PHYSIOLOGICAL LABOR. 
 
 but of sepsis, and as an aid to involution and in the prevention of after-pains. 
 The contraction of the uterine muscle keeps the sinuses closed, preventing the 
 
 Fig. 636. — Crede's Method of Placental Expression. — {The upper illustration is from 
 a photograph taken at the Emergency Hospital.) 
 
 formation of clots and the entrance of sepsis, and also hastens involution by 
 curtailing the blood-supply to the uterine muscular tissue. On the one hand, I 
 
THE MANAGEMENT OF LABOR. 
 
 495 
 
 know of no valid objection to the use of one or two doses of ergot after confine- 
 ment; and, on the other, the drug thus used adds materially to the safety and 
 comfort of the patient. 
 
 Post-partum Douche. — There is at present some controversy as to the advis- 
 ability of giving a vaginal douche after delivery of the placenta. The analogy 
 between the indications for the ante-partum and the post-partum douche is not, 
 as some have supposed, perfect. Before delivery the vaginal mucous membrane 
 is intact and bathed in the acid bactericidal mucus of the vagina. Hence, as 
 Kronig has shown experimentally, ante-partum douches, by diluting and washing 
 away this mucus, actually delay the 
 destruction of pathogenic germs pre- 
 viously introduced into the vagina. 
 After delivery the conditions are quite 
 different and all conditions for the pro- 
 pagation of sepsis are present. Hence 
 it seems proper that one thorough vag- 
 inal douche should be given. Nothing 
 but a glass tube should be used, and 
 this should be perforated at the sides, 
 the perforations looking a little back- 
 ward, that the fluid may not enter the 
 uterus. As the tube is introduced the 
 labia should be carefully separated 
 (See Part X) and the tube carried 
 as far as possible into the vagina with- 
 out touching the surrounding tissues. 
 When few or no vaginal examinations 
 have been made, the post-partum 
 douche should be omitted. It may be 
 said to carry a risk of infection with 
 it, but not to the same extent as the 
 digital vaginal examination (Figs. 192 
 and 1 9 3 ) . In intelligent hands the irri- 
 gation is practically free from danger. 
 It certainly, in my experience, adds to 
 the comfort and safety of the patient : 
 (i) by causing the uterus and vagina 
 to expel retained clots; (2) by setting 
 up firm uterine contraction which pre- 
 vents hemorrhage and after-pains; (3) 
 the warmth lessens the pain of the 
 laceration and stretching to which the 
 
 vagina has been subjected. An intrauterine douche is given only when the hand 
 or instruments have been introduced into the uterus, or when there is other 
 reason to suspect the possibility of intrauterine sepsis. 
 
 Cleansing of the Patient and Bed. — At the completion of the third stage the 
 external genitals should be carefully cleansed with boiled water and with bichlo- 
 ride solution (i : 4000); the cleansing should include the thighs, buttocks, and 
 lower surface of the abdomen, since these are usually soiled by blood, perhaps 
 by urine and feces. The temporary bedding should be removed and its place 
 supplied by that which is perfectly clean, and the patient should be given, if 
 necessary, a clean night-dress. 
 
 Fig. 637. — InspectiOxV of Placenta and 
 Membranes immediately after the 
 Third Stage. Hand is Passed into Am- 
 niotic Cavity and same Distended while 
 Inspecting the Cotyledons of the Pla- 
 centa. — {From a fresh specimen.) 
 
496 PHYSIOLOGICAL LABOR. 
 
 Vulval Dressing. — A sterile napkin, preferably an antiseptic pad of some 
 absorbent material, should be applied to the vulva and held in position by a 
 band carried between the thighs and fastened anteriorly and posteriorly to the 
 abdominal binder by safety-pins. This vulval dressing should be changed as 
 often as it becomes soiled. Deodorizing chemicals or those with any odor 
 should not be used on the vulval dressing, as these mask the fetor of decompos- 
 ing lochia, a valuable sign of early septic infection. 
 
 Abdominal Binder. — This contributes to the comfort of the patient and is 
 usually desirable. It should be of unbleached muslin and wide enough to reach 
 from below the trochanters to the lower ribs. The attendant should stand on 
 the patient's right and the binder should be fastened from below upward. This 
 should be done by taking the part of the binder next to the abdomen in the left 
 hand and the part which is to be external in the right and holding them together 
 with one hand while the pins are inserted from below upward with the right 
 hand. A moderately tight abdominal binder promotes involution of the uterus. 
 After a few days it may be applied more loosely, but may be discarded when 
 the patient leaves her bed. (See Part VI.) 
 
 Presence of the Physician. — The physician should be within call for at least 
 an hour after the completion of the third stage, and should not leave his patient 
 until good uterine contraction has been secured and her pulse has become nor- 
 mal, or is at least below loo. 
 
 Nourishment, Rest, and Sleep. — When the third stage has been completed 
 and the patient made comfortable, she should receive some light nourishment, 
 as a cup of milk, weak tea, chocolate, cocoa, or soup. All visitors should be 
 banished from the lying-in chamber; the curtains should be drawn, the room 
 well ventilated, and the patient allowed to secure as much sleep as possible, 
 undisturbed by the washing, dressing, or crying of the child. 
 
32 
 
PART FIVE, 
 
 Pathological Labor* 
 
 DUE TO ABNORMAL CONDITIONS OF THE FETUS: FETAL 
 
 DYSTOCIA, 
 
 FETAL DYSTOCIA FROM FAULTY ATTITUDE. (Page 499.) I. Excessive 
 Flexion of Head. Roederer's Obliquity. II. Bregma Presentation. In- 
 complete Flexion. III. Brow Presentation. IV. Face Presentation. V. 
 Presentation of Anterior Parietal Bone or Ear. Naegele's Obliquity. VI. 
 Presentation of Posterior Parietal Bone or Ear. Litzmann's Obliquity. VII. 
 Prolapse of the Arms. Dorsal Displacement of the Arm. VIII. Prolapse 
 of the Leg. IX. Prolapse of the Cord. 
 
 FETAL DYSTOCIA FROM FAULTY PRESENTATION. 
 Presentation. XI. Shoulder Presentation. 
 
 (Page 527.) X. Pelvic 
 
 FETAL DYSTOCIA FROM FAULTY POSITION. (Page 545.) XII. Persistent 
 Occipito-Posterior Position. XIII. Persistent Mento-posterior Position. 
 XIV. Transverse Position of Head at Outlet. 
 
 FETAL DYSTOCIA FROM GENERAL FETAL CONDITIONS. (Page 554.) XV. 
 Multiple Birth. XVI. Multiple or Compound Presentations. XVII. Ex- 
 cessively Long Cord. XVIII. Short Cord. XIX. Rupture of the Cord. 
 XX. Decapitation of the Fetus. XXI. Avulsion of Fetal Extremities. 
 
 XXII. Malformations, Deformities, and Anomalies Producing Dystocia. 
 
 XXIII. Fetal Rigor Mortis. 
 
 DUE TO ABNORMAL CONDITIONS IN THE MOTHER: MA- 
 TERNAL DYSTOCLA.. 
 
 MATERNAL DYSTOCIA FROM THE FORCES. (Page 567.) I. Precipitate Labor. 
 II. Protracted or Retarded Labor. Uterine and Abdominal Inertia. 
 
 MATERNAL DYSTOCIA IN THE PARTURIENT TRACT AND ADNEXA. (Page 
 574.) III. Retention of Placenta and Membranes. IV. Post=partum Hemor- 
 rhage. V. Rupture of the Uterus. VI. Inversion of the Uterus. VII. Ex= 
 cessive Right Lateral Obliquity of Uterus. VIII. Rupture of Cervix, Vagina, 
 Rectum, Perineum. IX. Labor after Anterior Fixation or Suspension of 
 Uterus. 
 
 MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. (Page 602.) X. Uter- 
 ine, Ovarian, Renal, Peritoneal Tumors. XI. Anomalies of the Membranes. 
 XII. Rigidity of the External and the Internal Os. Trismus Uteri. XIII. 
 Deviation or Malposition of the Os. XIV. Occlusion of the External Os. 
 XV. Cancer of the Uterus. XVI. Rigidity and Atresia of the Vagina and 
 Vulva. XVII. Vaginal and Vulval Thrombosis and (Edema. XVIII. Dis- 
 tended Bladder and Rectum. Cystocele, Rectocele, Vesical Calculus. XIX. 
 Fractures of the Pelvis. XX. Diastasis of Pelvic Joints. XXI. Pelvic 
 Deformity. 
 
 MATERNAL DYSTOCIA FROM GENERAL MATERNAL CONDITIONS. (Page 
 665.) XXII. Labor in Elderly Primiparae. XXIII. Intestinal Hernias. 
 XXIV. Cardiac and Pulmonary Disease. XXV. Cerebral and Spinal 
 Disease. XXVI. Digestive Disturbances. XXVII. Sudden Death. XXVIII. 
 Post-mortem Delivery. XXIX. The Metrorrhagia of Labor. 
 
Pathological labor or dystocia — the latter term from two Greek words 
 meaning difficult or painful labor — is one which departs from the conditions of 
 physiological labor, as set forth on page 375. A multitude of variations, acci- 
 dental and pathological, may arise on the part of the mother or the fetus to 
 cause this variety of labor. Originating in the latter they cause fetal dystocia, 
 and in the former maternal dystocia. 
 
 According to my classification I shall describe fetal dystocia as due to: 
 (i) faulty attitude; (2) faulty presentation; (3) faulty position; and (4) general 
 fetal conditions. Maternal dystocia I divide into dystocia from (i) the 
 forces; (2) the parturient tract and adnexa; (3) obstructed labor; (4) general 
 maternal conditions. 
 
 DUE TO ABNORMAL CONDITIONS OF THE FETUS: 
 
 FETAL DYSTOCIA. 
 
 FETAL DYSTOCIA FROM FAULTY ATTITUDE. 
 
 Faulty attitude or posture of the fetus may be caused by anything which 
 alters the normal shape of the fetal ovoid (see page 421). Thus, dystocia may 
 be due to a faulty attitude caused by any deviation of the fetal head from the 
 normal position of flexion. According to the degree of extension present will 
 be the variety of the malpresentation which will result. (i) Thus, occa- 
 sionally excessive flexion (Fig. 638), or Roederer's obliquity, under certain 
 conditions may act as a cause of fetal dystocia. (2) If the flexion is incomplete 
 to a slight degree only, so that the chin departs only a short distance from the 
 sternum, the bregma will present instead of the vertex and a bregma presentation 
 results. (3) If a greater degree of extension occurs and the head occupies a 
 position upon its transverse axis, midway between flexion and extension, the 
 brow or the region immediately in front of the bregma will present, giving a 
 brow presentation. (4) And if complete extension take place and the chin is 
 the presenting part, a face presentation results. (5) Further, should lateral 
 flexion of the head occur so as to cause the anterior parietal bone or the ear to 
 present, the condition known as Naegele's obliquity occurs. (6) Should the 
 lateral flexion result in presentation of the posterior parietal bone or the ear, 
 the obliquity is called Litzmann's. Faulty attitude may also result in prolapse 
 of the (7) arms, (8) legs, (9) umbilical cord. 
 
 I. EXCESSIVE FLEXION OF THE HEAD; ROEDERER'S OBLIQUITY. 
 
 Excessive flexion of the head upon the trunk has been termed Roederer's 
 obliquity (Fig. 638). This is nothing more than an exaggeration of the normal 
 head flexion of labor whereby the occiput enters the inlet perpendicularly, the 
 
 499 
 
500 
 
 PATHOLOGICAL LABOR. 
 
 EXCESSIVE FLEXION OF HEAD. 
 ROEDERER'S OBLIQUITY. 
 
 Fig. 
 
 head moulding being more to the posterior part of the head, with the apex well 
 back on the occipital bone, thus positively providing for the engagement of the 
 suboccipito-bregmatic circumference, ii inches (28 cm.), in the circumference 
 of the inlet, 16 inches (40.5 cm.), and is to be looked upon as a favorable condi- 
 tion. The causes are excessive rigidity of the cervix or vagina, generally con- 
 tracted pelvic inlets, or excessively large 
 fetal heads, especially in dead or macer- 
 ated fetuses. The diagnosis is simple. In 
 left positions of the head the small fon- 
 tanelle is more to the right and very little 
 of the sagittal suture can be felt ; the large 
 fontanelle is unusually high. The prognosis 
 is not necessarily favorable at the pelvic 
 inlet, although after the engagement of the 
 head the conditions never cause dystocia. 
 Because of the obstruction sometimes pro- 
 duced at the inlet by excessive flexion of a 
 large head of a dead or macerated fetus, 
 causing the shoulders and head to attempt 
 to enter at the same time, I have classed 
 this condition among the causes of fetal 
 dystocia. Many authorities refer to the 
 condition only \mder normal labor. Treat- 
 ment may be demanded at the inlet to 
 assist in the engagement of the head, since 
 the tonicity of the neck has been lost in 
 macerated fetuses. After engagement no 
 treatment is required. 
 
 II. BREGMA PRESENTATION.* IN- 
 COMPLETE FLEXION. 
 
 Definition. — By this condition is meant ' 
 a partial extension of the head whereby 
 the large fontanelle is brought upon the 
 same plane as the small (Fig. 641). 
 
 Frequency. — Authorities generally state 
 that incomplete flexion resulting in a 
 bregma presentation is rare. My experi- 
 ence is that dystocia from this source is 
 most common. I believe it to be one of 
 the most important factors in the produc- 
 tion of prolonged and tedious labors, either 
 from tardiness in the rotation from a pos- 
 terior to an anterior position due to the 
 incomplete flexion, or because the occipto- 
 frontal circumference (13! inches — 35 cm.) 
 instead of the suboccipito-bregmatic (11 inches — 28 cm.) is brought in rela- 
 tion to the periphery of the birth canal. 
 
 Temporary and Persistent Varieties. — A close observer cannot fail to detect 
 instances in which incomplete flexion of the head or bregma presentation has 
 
 * The bregma is the anterior fontanelle. 
 
 638. — Occiput at the Pelvic 
 
 Inlet. 
 
 Fig 
 
 639. — Occiput at the Pelvic 
 Inlet. 
 
 Fig. 640. — Occipital Bone in the 
 Cervix. 
 
FETAL DYSTOCIA FROM FAULTY ATTITUDE. 
 
 501 
 
 BREGMA PRESENTATION OR IN- 
 COMPLETE FLEXION OF 
 THE HEAD. 
 
 Vertex to the Left. 
 
 (f 
 
 f 
 
 occurred both as a temporary and as a persistent condition. Temporary descent 
 of the large fontanelle is frequently observed in all the four positions of the vertex 
 in normal labors during the engagement of the head in the inlet, but more fre- 
 quently in roomy pelves after the head has 
 passed the psoas muscles and entered the 
 roomier part of the pelvis, also in slightly 
 and decidedly flattened pelves in conjunc- 
 tion with Naegele's lateral flexion and 
 presentation of the anterior parietal bone. 
 In the case of flattened pelves the biparie- 
 tal diameter becomes arrested at the con- 
 tracted inlet, the narrower bitemporal 
 diameter of the sinciput descends, engages, 
 and passes the inlet, followed, after a 
 period of moulding, by the biparietal and 
 restitution of the head to its normal state 
 of complete flexion. In the persistent 
 variety, although the same etiological fac- 
 tors may obtain, still for some reason the 
 condition becomes permanent. 
 
 Etiology. — This is the same as in brow 
 and face presentations, although in some 
 instances dolichocephalic conditions of the 
 fetal head play an important part (pages 
 503 and 509). 
 
 Positions ' and Relative Frequency. — 
 The positions and their relative frequency 
 are the same as in vertex presentations, 
 as the anatomical conditions differ very 
 little from those of normal labor. 
 
 Mechanism. — While some authorities 
 consider that bregma presentation demands 
 a description of a special mechanism, I am 
 accustomed to describe the condition as 
 merely a departure from the mechanism of 
 vertex presentation due to moderately 
 incomplete flexion of the head. The me- 
 chanism differs from that of normal vertex 
 presentation in that departure from the 
 normal occurs by reason of the increased 
 circumference of the presenting part, and, 
 further, the imperfect flexion brings the 
 forehead down as far as the vertex, thus 
 interfering with internal anterior rotation. 
 It must be remembered that labor is not 
 impossible in all cases of this condition, 
 and that the several steps in the mechanism 
 can be recognized as in other presenta- 
 tions. Should the partial extension be 
 follows: Moulding is extensive by reason 
 frontal diameter (4.5 inches — 11.50 cm.) 
 
 ^FlG. 641. 
 
 -Bregma at 
 Inlet. 
 
 THE Pelvic 
 
 Fig. 
 
 -Bregma at 
 Inlet. 
 
 THE Pelvic 
 
 Fig. 643. — In the Cervix.- Right 
 Parietal Bone and Halp^ of 
 Frontal Presenting. 
 
 uncorrected, the mechanism is as 
 
 of the delay. Since the occipito- 
 
 and circumference (13! inches — 35 
 
 cm.), and not the suboccipito-bregmatic diameter (3f inches — 9.5 cm.) and 
 
502 
 
 PATHOLOGICAL LABOR. 
 
 BREGMA PRESENTATION OR INCOM- 
 PLETE FLEXION OF THE HEAD, 
 
 VERTEX TO THE RIGHT. 
 
 I i 
 
 Fig. 644. — Bregma at the Pelvic Inlet. 
 
 Fig. 645. — Bregma at the Pelvic Inlet. 
 
 Fig. 646. — In the Cervix: Left Parie- 
 tal Bone and Half of Frontal Pre- 
 senting. 
 
 Fig. 647. — At the Pelvic Floor, 
 
 circumference (11 inches — 28 cm.), are 
 brought in relation with the diameters 
 and circumference of the pelvic inlet, 
 persistent bregma presentations undergo 
 prolonged and characteristic moulding 
 (Fig. 649). Engagement and descent are 
 slow by reason of the greater circumfer- 
 ence involved ; rotation of the head fails 
 altogether because the vertex and fore- 
 head are equally influenced by the factors 
 causing rotation, or is accomplished only 
 with the greatest difficulty and much 
 damage to the maternal soft parts. 
 Labor often comes to a standstill by 
 reason of the transverse position of the 
 occipito-frontal diameter on the pelvic 
 floor. The perineum begins to tear even 
 before the head has reached it, on 
 account of the great dilatation of the 
 upper vagina by the large cephalic 
 diameters. The laceration becomes ex- 
 tensive, extending through the sphincter 
 ani and even up the recto-vaginal sep- 
 tum. In expulsion of the head the 
 latter is bom by propulsion and partial 
 extension. Rotation and delivery of 
 the trunk occur as in normal labor. 
 
 Diagnosis. — This is not difficult. 
 Whenever on vaginal examination the 
 large fontanelle is readily made out as 
 occupying a prominent place in the cir- 
 cumference of the parturient canal with 
 the sagittal, frontal, and coronal sutures 
 radiating therefrom, the condition may 
 be looked upon as one of bregma presen- 
 tation or incomplete flexion of the head. 
 This presentation in its clinical features 
 resembles a brow, as the supraorbital 
 ridges may often be palpated well up 
 anteriorly, posteriorly, or laterally. 
 (Figs. 646 and 642.) 
 
 Prognosis. — This is usually good, as 
 the condition is readily recognized and 
 remedied. When overlooked, all the 
 dangers of tedious labor and secondary 
 inertia are to be feared. 
 
 Treatment. — Immediate correction of 
 the incomplete flexion should be made 
 either (i) by pushing' the forehead 
 up during uterine contraction with 
 two fingers in the vagina, at the same 
 time making pressure upon the fundus; 
 
FETAL DYSTOCIA FROM FAULTY ATTITUDE. 
 
 603 
 
 MOULDING OF HEAD IN 
 PRESENTATION. 
 
 BREGMA 
 
 Fig. 648. — Before Moulding. 
 
 or (3) the whole hand may be introduced into the vagina and either the occiput 
 drawn down or the forehead pushed up, counterpressure being at the same time 
 made upon the podalic extremity of the 
 fetus through the fundus, or upon the 
 occiput through the lower uterine seg- 
 ment. (See Correction of Bregma, 
 Brow, and Face Presentations, Part X.) 
 
 III. BROW PRESENTATION. 
 
 Definition. — A partial extension of 
 the head whereby the brow instead of 
 the vertex becomes the presenting part. 
 The head is so extended in this presen- 
 tation as to occupy a position midway 
 between complete flexion and complete 
 extension (Fig. 650). 
 
 Frequency. — This is the rarest of all 
 cephalic presentations and occurs in 
 one-fourth of one per cent, of all cases. 
 As brow presentation is a transition 
 stage in the development of face pre- 
 sentation, it is, considered temporarily, 
 as frequent as the latter. But as 
 generally estimated — those which re- 
 main brow till artificially altered — they 
 are far less common than the face. In 
 a series of 2200 consecutive confine- 
 ments I found brow presentation in 3 
 cases, or 0.13 per cent., or i in 733 cases. 
 Face presentation occurred in 5 cases, or 
 0.22 per cent., in the same series. 
 
 Etiology. — Any cause which favors 
 incomplete flexion or partial extension 
 of the head may cause a brow presenta- 
 tion; the causes are, therefore, the same 
 as those for face presentation. (See page 
 509.) If the brow is not converted by 
 natural means into a face presentation, 
 the inference must be drawn that there 
 is a greater obstacle present than in 
 cases in which face presentation de- 
 velops. The forces exerted on the two 
 arms of the head-lever in brow presenta- 
 tion are almost equal, the posterior arm 
 being just a little longer than the ante- 
 rior (Fig. 648). 
 
 Positions and Relative Frequency. — There are four cardinal positions of the 
 brow, as in other presentations: 
 
 Fig. 649. — After Moulding. 
 
 I. Left fronto-anterior — Fronto Lasva Anterior — L. F. A. (Fig. 650). 
 II. Right fronto-anterior — Fronto Dextra Anterior — R. F. A. 
 
504 
 
 PATHOLOGICAL LABOR. 
 
 FIRST BROW POSITION. 
 LEFT FRONTO-ANTERIOR, L. F. A. 
 
 III. Right fronto-posterior — Fronto 
 Dextra Posterior — R. F. P. 
 
 IV. Left fronto-posterior — Fronto 
 Laeva Posterior — L. F. P. (Fig. 654). 
 
 Fig. 650. — Brow at Pelvic Inlet. 
 
 Fig. 651. — Brow in the Cervix. 
 
 As in vertex presentation, the third 
 and first positions are the most frequent, 
 and in the order named. 
 
 Mechanism. — (i) Brow presentation, 
 being often a transitional condition 
 between vertex and face presentation, 
 may at any stage in the mechanism of 
 labor be converted into one of these 
 spontaneously. (2) Again, with a roomy 
 pelvis and a small fetus, the latter 
 in brow presentation may be pushed 
 through the pelvis without any special 
 mechanism. (3) In exceptional cases 
 in "^hich the fetal head is relatively 
 small, special mechanisms of brow pres- 
 entation can be recognized, as follows: 
 
 III. Right Fronto-posterior, R. 
 F. P. — (i) Moulding: This process is 
 so slow that sometimes labor pains 
 continue for hours — twenty-four to 
 thirty-six — before engagement of the 
 brow takes place. In the unusual cases 
 in which a brow presentation enters the 
 pelvis, there has been an extreme mould- 
 ing of the head, the latter being rather 
 small; the caput succedaneum occupies 
 the space from the root of the nose to 
 the anterior fontanelle. A side view of 
 the head shows it to be rather triangu- 
 lar in shape. (See Figs. 659 and 660.) 
 Fig. 652. — At _Pelvic Floor before The occipito-mental diameter has de- 
 creased, but this has been compensated 
 for by an increase of the occipito-fron- 
 tal. The shape of the head is now 
 characteristic of this presentation. The 
 slope of the parietal and occipital bones 
 is downward and backward, while the 
 forehead is almost perpendicular. (2) 
 Engagement and Descent: Because of the 
 altered shape of the head the forehead 
 sinks into the pelvis more deeply than 
 any other part of the head and the 
 head is somewhat extended as it passes 
 through the pelvic inlet. The course 
 of the brow to the pelvic floor is 
 due to energetic contractions of the 
 
 Anterior Rotation of Brow. 
 
 Fig. 653. — In the Vulva after Ante- 
 rior Rotation of the Brow. 
 
 uterus, causing the mother much pain. 
 
FETAL DYSTOCIA FROM FAULTY ATTITUDE. 
 
 505 
 
 Labor usually comes -to a standstill 
 at this stage of engagement and de- 
 scent by reason of obstruction. (3) 
 Anterior Rotation of the Forehead (Fig. 
 656): If the presentation remains un- 
 changed until expulsion, the forehead 
 finally reaches the pelvic floor and 
 rotates anteriorly for the same reasons 
 as the occiput does in vertex presenta- 
 tion. At the same time the vertex ro- 
 tates posteriorly into the hollow of the 
 sacrum. The brow lies opposite the 
 vulva, the face just back of the pubis 
 with the chin at its upper margin, and 
 the superior maxilla against the sym- 
 physis. Anterior rotation of the brow 
 at the pelvic floor may, in exceptional 
 cases, possibly occur, but more often 
 labor comes to a standstill with a 
 deep transverse position of the head. 
 (4) Expulsion of the Head (Fig. 657): 
 Before the head has appeared outside 
 the vulval orifice, the neck and the 
 body of the child have descended some- 
 what into the pelvis. The flexion of 
 the head is increased as the forehead 
 appears in the vulva; the perineum 
 then retracting. Expulsion is accom- 
 plished by the cranial vault first sweep- 
 ing forward over the perineum ; then the 
 eyes, nose, superior maxilla, mouth, and 
 chin successively make their appearance 
 under the symphysis pubis, and are 
 bom. (5) Rotation of the Trunk and 
 Restitution of the Head (Figs. 653 and 
 657): After delivery of the head, shoulder 
 rotation and restitution of the head 
 occur as in vertex presentation. In 
 the right fronto-posterior position the 
 left shoulder rotates to the symphysis 
 and restitution of the child's face to the 
 left thigh occurs. (6) Expulsion of the 
 Trunk: This is the same as in vertex 
 and face presentations (page 447)- 
 
 I, II, and IV. Left Fronto-ante- 
 RiOR, L. F. A.; Right Fronto-ante- 
 RioR, R. F. A.: AND Left Fronto- 
 posterior, L. F. P. (Fig. 654), follow 
 the same general principles as the 
 above. 
 
 Persistent Posterior Rotation of the 
 Brow. — As in permanent occipito-pos- 
 
 FOURTH BROW POSITION. 
 LEFT FRONTO-POSTERIOR, L. F. P. 
 
 Fig. 654. — Brow at Pelvic Inlet. 
 
 Fig. 655. — Forehead in the Cervix. 
 
 ?5>^x 
 
 : l^- ^ 
 
 •j^ 
 
 Fig. 656. — Brow at the Pelvic Floor 
 BEFORE Anterior Rotation of- thb 
 Forehead. 
 
 ^ ^ ,. O 
 
 Fig. 657. — Delivery of the Head after 
 Anterior Rotation of the Brow. 
 
506 
 
 PATHOLOGICAL LABOR. 
 
 tenor and mento-posterior positions, arrest may occur at- the pelvic inlet, or 
 after engagement of the brow. As in face presentation with the chin posteriorly, 
 the difficulties of spontaneous delivery are so great that birth may be said to be 
 impossible unless anterior rotation of the brow occurs. 
 
 Position of Fetus. 
 
 Position of Fetal Heart 
 Sounds. 
 
 Left fronto-ante- 
 rior. L. F. A. 
 
 Brow to left acetabulum; back to right; ex- 
 tremities to left, above. 
 
 Right fronto-an- 
 terior. R. F. A. 
 
 Right fronto-pos- 
 terior. R. F. P. 
 
 Left fronto-pos- 
 terior. L. F. P. 
 
 Brow to right acetabulum; back to left; ex- 
 tremities to right, above. 
 
 Right side of abdomen, 
 below umbilicus. 
 
 Left side of afedomen, 
 bel«w umbilicus. 
 
 Brow to right sacro-iliac joint; back to left; 
 extremities to right, above. 
 
 Brow to left sacro-iliac joint; back to right; 
 extremities to left, above. 
 
 Left side of abdomen, 
 below umbilicus. 
 
 Right side of abdomen, 
 below umbilicus. 
 
 Diagnosis. — By abdominal examination the two ends of the head may be 
 discovered to be at about the same level (Fig. 654). Unless the subject is readily 
 palpated, the diagnosis of a brow presentation by external palpation is very 
 
 difficult. By vaginal ex- 
 amination the small fon- 
 tanelle and the orbital 
 ridges are felt at opposite 
 points in the available 
 space, while the large f on- 
 tan elle and the coronal, 
 frontal, and sagittal sutures 
 are between (Figs. 651 and 
 
 655)- 
 
 Prognosis. — This is un- 
 certain for the mother and 
 very bad for the fetus. 
 Maternal mortality is as 
 high as 10 per cent.; fetal 
 mortality has reached 30 
 per cent. The dangers to 
 the mother are exhaustion 
 from prolonged labor due 
 to obstruction, severe laceration of the parturient canal, sepsis, and shock. The 
 dangers to the child are excessive moulding and compression of the skull, causing 
 apoplexy or asphyxia; prolapse of the cord is a common complication, as in 
 deformed pelves, because the brow imperfectly fits the pelvic inlet. The family 
 must be warned that the child's face will be swollen and hideous as in face pres- 
 entation. It is quite possible for spontaneous rectification of a brow presenta- 
 tion to occur at any stage of the mechanism of labor. This, however, cannot be 
 relied upon any more than in shoulder presentation.* Sometimes, though 
 
 * Ahlfeld ("Die Entstehung Steiss- und Gesichtslagen ") furnishes twenty-six cases in 
 which the result to both mother and child is given. Fritsch (" Klinik der alltaglichen 
 geburtshulflichen Operationen," p. 46) gives the histories of seven cases, and Budin ("Tete 
 du Foetus," p. 53) the history of one case. In the thirty-four deliveries there were two 
 maternal deaths; in one of the fatal cases a coxalgic oblique pelvis existed as a complica- 
 tion. In the other the brow spontaneously changed into a face presentation. There were 
 ten spontaneous deliveries, the brow presenting with four dead children, but one died 
 previous to labor. There were ten cases of spontaneous delivery in which the brow during 
 
 Fig. 658. — Persistent Posterior Position of the 
 Brow. 
 
FETAL DYSTOCIA FROM FAULTY ATTITUDE. 
 
 507 
 
 rarely, if the fetus is very small, or 
 the pelvis very large, the fetus may 
 be delivered without any mechanism 
 or danger. In reality the prognosis 
 will depend on the operation which is 
 chosen for delivery of the child. An 
 unchanged brow position with normal 
 head will require so much time for 
 spontaneous delivery that the ob- 
 stetrician cannot conscientiously wait 
 for nature to complete the birth. 
 
 Treatment. — One must never trust 
 to spontaneous rectification; manual 
 correction of the faulty attitude into 
 a vertex presentation, or even into a 
 breech by podalic version, gives better 
 results than waiting for spontaneous 
 delivery with the brow presenting. 
 Correction of a brow presentation by 
 changing the posture of the woman, 
 and also, I may add, by external 
 manipulation alone, as in Schatz's 
 method (Part X), are refinements of 
 obstetric procedure which rarely suc- 
 ceed and unnecessarily disturb the 
 patient. Further, in this as in other 
 faulty attitudes, presentations, or 
 positions of the head when the fetus is 
 positively determined to be dead. 
 
 MOULDING IN BROW PRESENTATION. 
 
 Fig. 660. — Fetal Skull showing Mould- 
 ing IN Brow Presentation. — (Author's 
 collection.) 
 
 Fig. 659. — Before Moulding. 
 
 Fig. 66r. 
 
 -After Moulding in Fronto- 
 Anterior Position. 
 
 delivery became converted into either a face or a vertex presentation. Of these one child 
 died. Fourteen children were extracted with forceps, nine with the brow presenting, of 
 which two were dead, one from prolapsed funis, and one which had died before labor; five 
 after conversion into face or vertex presentations, with no deaths. Thus among the thirty- 
 four children there were seven deaths, but of these, four only could be attributed to the 
 presentation. 
 
508 PATHOLOGICAL LABOR. 
 
 perforation of the skull and extraction with the cranioclast or cephalotribe should 
 always be performed when by so doing the prognosis for the mother is improved. 
 Arguments from the standpoint of sentiment alone should never deter us from 
 mutilating the head of a dead fetus in order to lessen the dangers of extracting 
 an unmutilated head through the birth canal. 
 
 1. Before Engagement of the Brow. — (i) Placing the parturient on the side 
 toward which the dorsal plane of the fetus points, or an attempt at manual 
 correction by external manipulation by Schatz's method (see Part X), may 
 be tried, but it offers little hope of success. (2) Manual conversion of the 
 brow into a vertex by combined internal and external methods is the best 
 treatment. Digital upward pressure on the brow ; lifting up the brow with the 
 whole hand; drawing down upon the occiput with the whole hand, or one of 
 these methods combined with Schatz's method, and all combined with external 
 manipulation, as described in Part X, should be tried, and in the order named. 
 Flexion, once obtained, must be maintained until engagement takes place, other- 
 wise the brow presentation will recur. These indications obtain at the pelvic 
 inlet, in both fronto-anterior and fronto -posterior positions of the brow. Of 
 course, the conversion of the former into a vertex presentation results in an 
 occipito-posterior position at the inlet, but even this position of the vertex offers 
 a better prognosis than a brow presentation. To extend the head manually 
 in fronto-anterior positions and convert the brow presentation into a mento- 
 anterior position of the face, is a most questionable procedure; and in view of 
 the serious prognosis in face presentations, I would be unwilling to recommend 
 it. Salowieff,* however, in 18 brow cases occurring in the Moscow Maternity 
 Hospital during a period of ten years, found that 10 were terminated by version 
 and expression, i by forceps, i spontaneously, i in a vertex presentation, and 
 5 in face presentations. The last five were treated by introducing a finger into 
 the child's mouth, drawing the chin toward the brow, and retaining the finger 
 in the mouth until the uterine contractions fixed the head in the converted face 
 presentation. Simplicity and safety are claimed for this procedure. The un- 
 favorable prognosis of face presentation has, however, still to be met. (3) The 
 forceps in a true brow presentation should never be resorted to before at least 
 partial rectification of the faulty attitude, for the unusually large circumference 
 of the presenting part results disastrously for the fetus and mother. (4) Fail- 
 ing in manual rectification, one of the methods of version, followed promptly 
 by extraction, offers the best prognosis, always provided the necessary con- 
 ditions for version are present or can be secured. (See Part X.) 
 
 2. After Engagement of the Head. — (i) An attempt at manual rectification 
 as described above should be made. (2) The use of the forceps is dangerous 
 and difficult, and must only be tentatively attempted. (3) Symphyseotomy, 
 undoubtedly, in the presence of a living fetus, offers the only hope after manual 
 rectification fails, and should be seriously considered. (4) In all instances in 
 which the fetus is known to be dead, perforation of the head should be per- 
 formed. 
 
 IV. FACE PRESENTATION. 
 
 Definition. — ^A face presentation may be defined as a cephalic presentation 
 in which the head is in extreme extension, with the occiput in contact with the 
 neck. The face engages in the pelvis with the chin as the most dependent por- 
 tion. Face positions are therefore classified, in accordance with the location of 
 the chin, as right and left mento-anterior and posterior (Figs. 663, 667, 671, 675). 
 * " Centralbl. f. Gynak.," Leipzig, 1898, No. 30. 
 
FETAL DYSTOCIA FROM FAULTY ATTITUDE. 
 
 509 
 
 Frequency. — About .i labor in 250 is a face presentation (0.5 per cent.). 
 This represents an average, as individual statistics show considerable variations. 
 In 2200 cases of labor I found that face presentation occurred in 5 cases, or 0.22 
 per cent., or i in 440 cases (Fig. 662). (Compare Pelvic Deformity.) 
 
 Etiology. — At first sight face presentation appears to be a simple anomaly 
 of the mechanism of labor, the result of some obstruction in the parturient tract 
 which unflexes and extends the head. Regarded from this simple point of view, 
 a face presentation would be looked upon as a consequence of pelvic contraction, 
 and perhaps of rigid os, prominent ischial spine, and the like. But this assump- 
 tion is by no means easy of demonstration, nor is there any necessary ratio 
 between the frequency of particular types of obstruction of the birth tract and 
 deflexion anomalies. Some other factors must contribute to its production. 
 Both observation and theory point to the possibility that anomalies in the fetal 
 head or neck are often concerned in the production of this presentation. Some 
 of the conditions which reside in the fetus and interfere with normal flexion are: 
 congenital goitre, spastic 
 contraction of the muscles 
 of the neck, coiling of the 
 cord about the neck, etc. 
 But conditions of this sort 
 occur with too great infre- 
 quency to account for the 
 production of face presen- 
 tation. Moreover, the fac- 
 tors thus far enumerated 
 do not account for all the 
 face births encountered in 
 practice, or even, accord- 
 ing to some authorities, for 
 the majority of them. We 
 have to look upon face 
 presentation as something 
 more than an anomaly of 
 the mechanism of labor ; or, 
 in other words, it must be 
 placed in the same cate- 
 gory with breech and shoul- 
 der presentations. From this point of view we are able to add to our etiological 
 factors the causes of malposition in general ; including prematurity, contracted 
 pelvis, hydramnios, multiple pregnancy, monstrosities, etc. These, however, 
 cannot be brought into direct relationship with the effects produced, and 
 the connection between the two is a matter of statistics rather than of 
 actual demonstration. It is evident that we must look still more deeply 
 into the matter before we can exhaust all possible etiological factors. Only 
 one element remains for consideration, viz., the uterus itself. Matthews Duncan 
 was able to trace a relation between lateral deviation of the uterus and certain 
 face births; and other authorities have similarly held the triangular and 
 saddle-shaped types of uterus responsible for the latter in certain cases. The 
 individual causal elements which are at present recognized by most authorities 
 may be divided as follows: (i) Causes of malposition in general, such as pre- 
 maturity, contracted pelves, hydramnios, twin pregnancy, monstrosities, etc., 
 and the conditions covered by Schatz's hypothesis. (2) Causes residing 
 
 Fig. 662. 
 
 Diagram shqwing the Frequency of Face 
 Positions. 
 
510 
 
 PATHOLOGICAL LABOR. 
 
 FIRST FACE POSITION. 
 LEFT MENTO-ANTERIOR, L. M. A. 
 
 Fig. 663. — Face at Pelvic Inlet. 
 
 Fig. 664. — Chin and Left Cheek in 
 THE Cervix. 
 
 r< 
 
 \ 
 
 Fig. 665. — Face at Pelvic Floor 
 before Anterior Rotation of the 
 Chin. 
 
 ^a'J-y-''^^? 
 
 Fig. 666. — Face in the Vulva after 
 Anterior Rotation of the Chin. — 
 {Author's photograph.) 
 
 in the uterus, such as lateral obliquity, tri- 
 angular and saddle-shaped uteri, pendulous 
 abdomen (Fig. 151), etc. (3) Causes resid- 
 ing in the fetus which interfere with flexion 
 or favor extension. These are numerous 
 and varied and include: large head from 
 any cause; long head; tumor of occiput; 
 spastic rigidity of neck muscles — all of 
 which produce extension; and congenital 
 goitre, coils of cord under the chin; obesity 
 and dropsical condition; muscular hypo- 
 tonus of the asphyxiated and dead child — 
 all of which prevent flexion. (4) Causes 
 residing in the parturient canal: narrow 
 pelvis, especially short transverse diameter; 
 rigid os; the projecting rim of a placenta 
 prsevia ; prominent ischial spine ; distended 
 maternal bladder. 
 
 Ahlfeld regards all causes resident in 
 the uterus or fetus as primary, and all 
 causes which obtain in the birth passages 
 as secondary. In Winckel's cases, 30 
 per cent, had hydramnios; 22 per cent, 
 had coiling of the cord about the child; 30 
 per cent, had contracted pelves, etc. The 
 most frequent association in these cases, 
 in Winckel's experience, is contracted pel- 
 vis, large child, and pendulous abdomen. 
 
 Position and Relative Frequency (Fig. 
 662). 
 
 i. Left mento-anterior, mento lasva 
 
 anterior, L. M. A. (Fig. 663), 
 
 second in frequency. 
 
 II. Right mento-anterior, mento dex- 
 
 tra anterior, R. M. A. (Fig. 667). 
 
 III. Right mento-posterior, mento dex- 
 tra posterior, R^^M. P. (Fig. 
 671), most frequent. 
 
 IV. Left mento-posterior, mento laeva 
 posterior, L. M. P. (Fig. 675). 
 
 The relative frequency of the several 
 positions is, first, right mento-posterior; 
 and, second, left mento-anterior. Right 
 mento-anterior and left mento-posterior 
 are very rarely seen. (Compare Presenta- 
 tion, page 423, and Fig. 662.) 
 
 Mechanism. — I. Left Mento-ante- 
 rior, L. M. A. (Fig. 663).— The part 
 played by the occiput in vertex presen- 
 tation is simulated by the chin in face 
 presentation. Face presentation, how- 
 ever, differs somewhat in the mechanism 
 
FETAL DYSTOCIA FROM FAULTY ATTITUDE. 
 
 511 
 
 of labor from vertex, although the same 
 general principles obtain. The forces act 
 at a disadvantage in face presentation, 
 (i) The direction of uterine contraction 
 is not in direct line with the lowest por- 
 tion of the presenting part as in vertex 
 presentation (Fig. 684). (2) The cervical 
 vertebras, owing to extension of the head, 
 are bent almost at right angles, hence the 
 head is dragged rather than pushed through 
 the pelvis, with a resulting tremendous 
 friction, loss of power, prolonged labor, 
 and dangerous compression of the vessels 
 of the neck. (3) Again, in the internal 
 rotation of the face another difficulty in 
 the ordinary mechanism of labor presents 
 itself. Anterior rotation of the chin does 
 not occur so readily as anterior rotation of 
 the vertex because the distance from the 
 trunk to the chin is less than from the 
 trunk to the occiput. The depth of the 
 sides of the pelvis is 3I inches (8.75 cm.) 
 and the distance from the trunk to the 
 chin in face presentations is about 2 inches 
 (5 cm.), hence, either the neck must be 
 elongated in order to allow the chin to 
 reach the resistance of the pelvic floor or 
 the shoulders and thorax must enter the 
 pelvis with the face. The second is im- 
 possible without causing impaction, and 
 the first results in prolonged labor and 
 danger to the fetus, hence interference is 
 often called for in face presentations at 
 the time of rotation of the chin anteriorly. 
 Further, when the chin finally reaches the 
 pelvic floor, the irregular, soft, often oede- 
 matous chin is not acted upon so positively 
 by the factors which produce anterior rota- 
 tion as is the regular, hard vertex, and 
 hence the tardy rotation of the face and 
 greater necessity for instrumental inter- 
 ference in this stage of the mechanism of 
 labor in face presentation, (i) Extension 
 and moulding of the head: The head passes 
 through several stages of inclination before 
 complete extension is reached, and the 
 occiput lies close to the dorsum. During 
 this process moulding takes place to a 
 certain extent, though it is difficult of 
 accomplishment and requires a long time. 
 This is due to the mature ossification of 
 the bones and sutures of the face. The 
 
 SECOND FACE POSITION. 
 Right Mento-anterior, R. m. a 
 
 /> 
 
 Fig. 667. — Face at Pelvic Inlet. 
 
 Fig. 668. — Chin and Right Cheek in 
 THE Cervix. — (From author's draw- 
 ing.) 
 
 Fig. 669. — Face at the Pelvic Floor 
 . Before Anterior Rotation of the 
 Chin. 
 
 Fig. 670. — Delivery op the Face 
 AFTER Anterior Rotation of the 
 Chin. — (Autlior's photograph.) 
 
512 
 
 PATHOLOGICAL LABOR. 
 
 THIRD FACE POSITION. 
 
 Right mento-Posterior, R. M. P. 
 
 V ^'"<^ / 
 
 Fig. 671. — Face at Pelvic Inlet. 
 
 Fig. 672. — Chin and Right Cheek in 
 THE Cervix. — {From author's draw- 
 ing.) 
 
 ^ 
 
 Fig. 673. — Face at the Pelvic Floor 
 before Anterior Chin Rotation. 
 
 Fig. 674. — Delivery of the Head 
 AFTER Anterior Rotation of the 
 Chin. — {Author's photograph.) 
 
 shape of the head after an ordinary face 
 delivery is that of a flattened arch, while 
 the frontal bones are increased in their 
 convexity and the supra-occipital is pressed 
 back. (Figs, 680 and 681.) The diameter 
 of the face occupying the right oblique 
 diameter of the inlet is the cervico-breg- 
 matic, and this is so long (3! inches — 9.5 
 cm.) that it necessitates quite extensive 
 moulding of the head, especially if the 
 adaptation is inclined to be close. The 
 entire back of the head must be bent 
 downward and pressed against the neck. 
 (Fig. 680.) The anterior or left cheek is 
 on a lower level than the posterior (Fig. 
 664). In face presentations the cheek 
 which comes first, or the anterior one, is 
 the seat of the caput, and the size of the 
 latter will be in accordance with the amount 
 of time which elapses before anterior rota- 
 tion of the chin occurs. Delay after rota- 
 tion involves the entire face in the forma- 
 tion of a caput. If there is no unusual 
 delay in extension, the lower part of the 
 face is exposed, while in case of delay the 
 caput is formed at the upper portion of 
 the face. (2) Engagement and descent of 
 the face (Fig. 665): The chin is the main 
 point of the mechanism, and it is so far 
 ahead of the cervico-bregmatic diameter 
 that it is deep in the pelvis by the time 
 this diameter has passed the pelvic inlet. 
 Here sometimes occurs a temporary stand- 
 still for a time, for if the region of the 
 sagittal suture remains in the sacro-iliac 
 notch, the sacral promontory will prevent 
 the head from turning backward, while all 
 this time the lower part of the anterior 
 sulcus is imparting continually a forward 
 impetus to the chin. The contractions of 
 the uterus as well as extension of the neck 
 of the fetus bring the fetal face to the floor 
 of the pelvis. The extension of the fetal 
 neck sometimes amounts to 2 inches (5 
 cm.) before the chin and the pelvic floor 
 are brought into contact. (3) Anterior 
 rotation of the chin (Fig. 665): In order 
 that anterior rotation of the chin may 
 take place, the force of propulsion must 
 be strong enough to press the chin 
 down to the lowest point possible in 
 the pelvis. After the occiput passes the 
 
FETAL DYSTOCIA FROM FAULTY ATTITUDE. 
 
 513 
 
 sacral promontory the chin rotates ante- 
 riorly under the symphysis pubis, while 
 the bregma sinks into the hollow of 
 the sacrum. (4) Flexion and expulsion 
 of the head (Figs. 666, 670, 674, 678): In- 
 ternal rotation being partially or entirely 
 complete, the force of uterine contrac- 
 tion causes the expulsion of the head by 
 flexion; the chin, mouth, nose, eyes, and 
 forehead appearing successively in the 
 vulva. (5) Rotation of the trnnk and 
 restitution of the head: Following the 
 same law as in vertex presentation (page 
 447), the lower or left shoulder or ante- 
 rior shoulder rotates to the symphysis, 
 causing the child's face to turn to the 
 mother's left thigh (restitution) (Fig. 678). 
 (6) Expulsion of the trunk: This is the 
 same as in vertex presentation (page 447, 
 Fig. 675). 
 
 II. Right Mento-anterior Position, 
 R. M. A. (Fig. 667). — Here the same general 
 principles obtain as regards (i) extension 
 and moulding of the head and (2) engage- 
 ment and descent, these being the same as 
 in the left-mento anterior (Fig. 667). (3) 
 Rotation of the chin is from right to left 
 (Fig. 669). (4) Flexion and expulsion of 
 the head are the same as in the L. M. A. 
 (Fig. 670). (5) In rotation of the trunk 
 and restitution of the head the right ante- 
 rior or lower shoulder rotates anteriorly 
 to the symphysis, and the consequent res- 
 titution of the child's face is toward the 
 right thigh of the mother (Fig. 674). (6) 
 Expulsion of the body follows. 
 
 III. Right Mentq-posterior Posi- 
 tion, R. M. P. (Fig. 671). — Extension 
 and moulding of the head and (2) engage- 
 ment and descent are the same as in the 
 anterior positions, except that they are 
 apt to be tardy, as in posterior vertex 
 positions (page 459, Fig. 673). (3) Ante- 
 rior rotation of the chin from right to left 
 about the right half of the pelvis to 
 the symphysis is the normal mechanism. 
 Should anterior rotation fail, we have re- 
 sulting a persistent mento- posterior posi- 
 tion (Fig. 756). (Compare page 551.) (4) 
 Flexion and expulsion of the head are the 
 same as in the anterior pesitions (Fig. 674). 
 (S) In rotation of the trunk and restitu- 
 
 33 
 
 FOURTH FACE POSITION. 
 Left Mento-Posterior, L. m. p 
 
 'T 
 
 Fig. 675. — Face at Pelvic Inlet. 
 
 Fig. 676. — -Chin and Left Cheek in 
 THE Cervix. 
 
 Fig. 677. — Face at the Pelvic Floor 
 before Anterior Chin Rotation. 
 
 Fig. 67S. — Restitution of the Head 
 after Anterior Rotation of the 
 Chin and Expulsion. 
 
514 
 
 PATHOLOGICAL LABOR. 
 
 MOULDING IN FACE PRESENTATION. 
 
 \ 
 
 Fig. 679. — Before Moulding. 
 
 Fig. 680. — After Moulding. — (Author's case.) 
 
 Fig. 681. — Fetal Skull showing Moulding in 
 Face Presentation. — (Author's collection.) 
 
 tion of the head the right anterior 
 or lower shoulder rotates to the 
 symphysis. (6) Expulsion of the 
 body follows. 
 
 IV. Left Mento-posterior 
 Position, L. M. P. (Fig. 675). — 
 The cervico-bregmatic diameter en- 
 ters the pelvis in the left oblique 
 diameter, the chin pointing to the 
 left sacro-iliac synchondrosis, (i) 
 Extension and moulding of the 
 head and (2) engagement and de- 
 scent occur as in the R. M. P. posi- 
 tion (Fig. 677). (3) Anterior rota- 
 tion of the chin from left to right 
 about the left half of the pelvis 
 to the symphysis is the normal 
 mechanism. Should anterior rota- 
 tion fail, we have resulting a per- 
 sistent mento-posterior position 
 (comparepagessi) (Fig. 756). (4) 
 Flexion and expulsion of the head 
 are the same as in anterior posi- 
 tions (Fig. 674). (5) In rotation 
 of the trunk and restitution of the 
 head the left anterior or lower 
 shoulder rotates to the symphysis 
 (Fig. 675). (6) Expulsion of the 
 body follows. 
 
 Diagnosis. — The recognition of 
 facial positions by external ex- 
 amination has been pronounced 
 impracticable by many diagnos- 
 ticians. Ahlfeld, however, states 
 that this type of faulty attitude 
 may be recognized occasionally, 
 while, according to Schatz, great 
 pains and experience make such 
 recognition practicable in routine 
 diagnosis. Facial positions may 
 be made out by external manipu- 
 lation alone, before dilatation of 
 the cervix, as follows: Pressure 
 above the pelvic inlet reveals the 
 presence of a prominent head 
 (occiput). Having located the 
 occiput in this manner, the small 
 parts and fetal heart-sounds should 
 be recognized on the opposite side 
 of the uterus. The method re- 
 commended by Schatz depends for 
 success upon mapping out the con- 
 
FETAL DYSTOCIA FROM FAULTY ATTITUDE. 
 
 515 
 
 vexity of the abdominal aspect of the fetus, and upon the demonstration that 
 this convexity could not represent the normal dorsal arch of the vertex presen- 
 tation (Fig. 684) and is as follows: If the fetus is in the cephalic position with 
 breech in the fundus, the spinal convexity will be made more pronounced in a ver- 
 
 ts*, 
 
 J' 
 
 Fig. 682. — Face Presentation. Originally in the right mento-posterior position, 
 thor's case at the Emergency Hospital. — {From a photograph.) 
 
 Au- 
 
 tex presentation, by pressing upon the breech in the direction of the pelvic inlet, 
 and the other hand will be able to trace the curvature from the breech down- 
 ward. But in a facial presentation a convexity is also present, and an abdominal 
 curvature which may simulate the dorsal arch. In palpating this convexity from 
 the breech downward, the hand would locate the legs at the outset. Again, if the 
 
516 
 
 PATHOLOGICAL LABOR. 
 
 height of the convexity really represents the child's chest, pressure made^by the 
 hand upon the breech may be transmitted to the hand upon the chest. In facial 
 presentation, in comparison with the normal vertex presentation, the fetus appears 
 to have a short back, and limbs may be felt on both sides of the uterus, the 
 legs above and at one side, the arms below and upon the other side. This 
 peculiarity makes it expedient to exclude the probability of a twin pregnancy 
 
 '^ 
 
 Fig. 683. — Face Presentation. Originally in the right mento-posterior position, 
 thor's case at the Emergency Hospital. — {From a photograph.) 
 
 Au- 
 
 before making a diagnosis of a face presentation. In regard to internal recog- 
 nition of face presentation, the usual method consists in mapping out the facial 
 line, from the root of the nose to the chin. 
 
 Prognosis. — In primiparous labors the prognosis for mother and child is 
 considerably more unfavorable than in vertex cases. The prolongation of labor 
 is an element which is naturally unfavorable to mother and child alike. The 
 
FETAL DYSTOCIA FROM FAULTY ATTITUDE. 
 
 517 
 
 mother's condition is also prejudiced by her great efforts to expel the child, 
 while the special danger to the latter is found in the hyperextension of the head. 
 The danger of birth trauma, with or without subsequent infection, is present here 
 as in all labor in abnormal positions. In multi- 
 parous labors the prognosis for mother and 
 child is said to be but little if at all worse 
 than in vertex presentations. The great im- 
 provement in this respect in comparison with 
 the fatality of the remote past is to be ascribed 
 to the recognition of the fact that face presen- 
 tation can take care of itself and that patience 
 and expectancy are valuable traits in the ob- 
 stetrician, if the labor is too far advanced to 
 permit of correction of the faulty position. In 
 2 1 face cases occurring in the Moscow Mater- 
 nity Hospital during a period of ten years,* 17 
 terminated without assistance, 2 by forceps, 
 and 2 by craniotomy. All the mothers recov- 
 ered. An element in the prognosis is found in 
 the position of the chin, since, a much higher 
 mortality is found in posterior positions. In 
 the latter the mother is exposed to the danger 
 of severe laceration of the perineum, while the 
 child has a relatively small prospect of sur- 
 vival. The maternal mortality has been 
 placed at 6 percent.; the fetal at 15 percent. 
 The dangers for the mother are (i) those of 
 
 protracted labor, or (2) of deformed pelvis, which latter so often complicates a 
 face presentation. The dangers to the child are (i) those of prolonged labor; 
 (2) cerebral congestion and apoplexy; (3) asphyxia from pressure on the vessels 
 of the neck; (4) injury to the eyes during vaginal examination. 
 
 Fig. 684. — Direction of Forces 
 IN THE Conversion of a Face 
 Presentation into a Vertex. — 
 (Ahlfeld.) 
 
 Position of Fetus. 
 
 Left mento-ante- 
 rior. L. M. A. 
 
 Left mento-ante- 
 rior. R. M. A. 
 
 Right mento-pos- 
 terior. R. M. P. 
 
 Chin to left acetabulum, forehead to right 
 sacro-iliac joint; back to right; extremities 
 to left. 
 
 Chin to right acetabulum, forehead to left 
 sacro-iliac joint; back to left; extremities 
 to right. 
 
 Left mento-pos- 
 terior. L. M. P. 
 
 Chin to right sacro-iliac joint, forehead to left 
 acetabulum; back to left; extremities to 
 right. 
 
 Chin to left sacro-iliac joint, forehead to right 
 acetabulum; back to right; extremities to 
 left. 
 
 Fetal Heart-sounds. 
 
 Left side of abdomen, 
 below umbilicus. 
 
 Right side of abdomen, 
 below umbilicus. 
 
 Right side of abdomen, 
 below umbilicus. 
 
 Left side of abdomen, 
 below umbilicus. 
 
 Treatment. — In this presentation more than in any other, successful treat- 
 ment depends upon a thorough acquaintance with the mechanism of labor. 
 The membranes should be preserved as long as possible, since the face is a 
 poor dilator and the fore-water protects it from injury. The friends should 
 
 *Solowieff: " Centralbl. f. Gynak.," Leipzig, 1S9S, No. 30. 
 
518 
 
 PATHOLOGICAL LABOR. 
 
 PRESENTATION OF THE ANTE 
 RIOR PARIETAL BONE OR 
 EAR; NAEGELE'S OB- 
 LIQUITY. 
 
 be informed that the face, when born, will be very much distorted. One should 
 recollect that in a very large proportion of cases a face presentation does not 
 require intervention until the face reaches the pelvic floor, and this holds good 
 in both anterior and posterior positions of the chin. Fortunately, moreover, 
 a persistent posterior position of the chin is of rare occurrence, not more than 
 
 in one per cent, of all face positions, and 
 in spite of the fact that the right mento- 
 posterior position is first in frequency. 
 In the absence of other factors of maternal 
 or fetal dystocia expectancy is the key-note 
 in the treatment. 
 
 1. At the Pelvic Inlet. — In both anterior 
 and posterior positions the case should be 
 allowed to proceed without intervention, so 
 long as labor progresses satisfactorily. The 
 membranes must be preserved, however, 
 and complete extension secured by upward 
 pressure on the forehead. Failure of en- 
 gagement of the face at the inlet calls for 
 conversion into a vertex, followed by high 
 forceps or spontaneous labor in posterior 
 chin positions, and podalic version and ex- 
 traction in anterior chin positions, or con- 
 version and high forceps in both. 
 
 2. In the Pelvic Cavity. — Delay in an- 
 terior rotation of the chin often occurs for 
 physical reasons, hence it must be favored 
 by securing complete extension, by drawing 
 forward the chin, by pushing back the fore- 
 head; or by putting the fingers or a blade 
 
 y JQIV* 'Xlk^W. °^ ^^^ forceps under and behind the chin, 
 
 >^^>Jl^^^^l^fi^^^ *° ^^^^ *^^ latter some hard substance to 
 
 "y^V^A ^^^^^ /JMt ■] act upon. (See Operations, Part X.) For 
 
 the treatment of persistent mento-posterior 
 cases see page 552. 
 
 Fig. 686.-AT the Pelvic Inlet. y. PRESENTATION OF THE ANTE- 
 
 RIOR PARIETAL BONE OR EAR. 
 NAEGELE'S OBLIQUITY. rPig 
 685.) 
 
 Normally the anterior parietal bone in 
 vertex and bregma presentations is lowest 
 and most prominent in the cervix and va- 
 gina. When, however, excessive lateral 
 flexion of the head occurs, to the extent, 
 perhaps, of the presentation of the anterior 
 ear, Naegele's obliquity of the head is said to be present. Naturally the sagittal 
 suture approaches the sacral promontory and the posterior parietal bone is carried 
 upward and backward. The latter is often found flattened after delivery and 
 even depressed or fractured, and is overlapped by the anterior. An exaggerated 
 bregma presentation is usually present. The etiology of this complication is to 
 
 Fig. 685. — At the Pelvic Inlet. 
 
 Fig. 6S7. — Anterior Parietal 
 AND Ear in the Cervix. 
 
FETAL DYSTOCIA FROM FAULTY ATTITUDE. 
 
 519 
 
 PRESENTATION OF THE POSTE- 
 RIOR PARIETAL BONE OR EAR. 
 LITZMANN'S OBLIQUITY. 
 
 be found in a pendulous abdomen, flattened or generally contracted pelvis, or 
 other obstruction permitting of the lateral flexion of the fetal head. The diag- 
 nosis is not difficult by ordinary vaginal palpation ; but should doubt exist, the 
 introduction of the whole hand into the vagina will remove any uncertainty. In 
 left positions of the vertex the right parietal 
 bone and perhaps the right ear will be found 
 presenting; the small fontanelle high and 
 to the left and the greater toward the right. 
 Should the obstruction not be too great, the 
 head may reach the pelvic floor in this way. 
 The prognosis depends entirely upon the 
 cause of the condition. In the lesser forms 
 of pelvic contraction the prognosis is favor- 
 able, also when the anomaly occurs as a 
 transient condition, which it does in about 
 one-third of all cases. The treatment con- 
 sists in relief of the pendulous abdomen 
 or anteverted uterus with an abdominal 
 support or bandage in pregnancy (Fig. 
 228), and the manual correction of the 
 condition in labor if necessary. Nearly one- 
 half of the cases rectify themselves spon- 
 taneously. Of course, special treatment of 
 the case is often demanded. 
 
 PRESENTATION OF THE POSTE- 
 RIOR PARIETAL BONE OR EAR. 
 LITZMANN'S OBLIQUITY. (Fig. 
 
 ) 
 
 Fig. 688. — At the Pelvic Inlet. 
 
 ^J^^^^if 
 
 qr~" 
 
 Fig. 689. — At the Pelvic Inlet. 
 
 Here the sagittal suture approaches the 
 symphysis, with the resulting presentation 
 of the posterior parietal bone or ear. In- 
 complete flexion with the sinciput lower 
 than the occiput will often be present. The 
 condition usually occurs in markedly flat- 
 tened pelves, the latter obstruction result- 
 ing in a lateral flexion of the fetal body and 
 head, the reverse of the Naegele obliquity. 
 Only rarely does Litzmann's obliquity oc- 
 cur in normal pelves. The highest degree 
 of this, as of Naegele 's obliquity, is the pre- 
 sentation of an ear. The diagnosis may 
 cause some uncertainty unless the whole 
 hand is introduced into the vagina, when 
 the conditions above described will be 
 readily recognized. The prognosis will 
 
 usually depend on the amount and variety of the pelvic contraction; it is favor- 
 able in the so-called spontaneous cases and in moderate degrees of contraction. 
 It is unfavorable in a moderate degree of general contraction should the brow 
 enter the pelvis. The treatment in spontaneous cases consists in manual correc- 
 tion; and in pelvic contraction, in appropriate treatment of the obstruction. 
 
 Fig. 690. — Posterior Parietal Bone 
 AND Ear in the Cervix. 
 
520 
 
 PATHOLOGICAL LABOR. 
 
 VII. PROLAPSE OF THE ARMS. DORSAL DISPLACEMENT OF THE 
 
 ARM. 
 
 In an obstetric sense prolapse of the arms is important only in connection 
 with cephalic presentations, — vertex, brow, face, — as prolapse of the upper ex- 
 tremities in breech and shoulder presentations has little if any effect upon the 
 course of labor, and is rather favorable than otherwise. Presentation of a hand 
 frequently occurs before rupture of the membranes, and after rupture either dis- 
 appears by recession or the presentation is con- 
 verted into a prolapse; the arm then usually 
 occupies the hollow of the sacrum and is often 
 combined with prolapse of the cord. If the arm 
 is far in advance, there is a chance of the head 
 being deflected into the iliac fossa while the 
 shoulder descends and a shoulder presentation 
 occurs. If, however, the hand can just be pal- 
 pated by the side of the head, it is likely that 
 the latter will be bom first while the hand 
 stays behind. Also the hand when at the side 
 of the pelvis — namely, at one end of the trans- 
 verse diameter — is not so apt to be an impedi- 
 ment as when it lies in front, for in this latter 
 position it encroaches on the conjugate diam- 
 eter. The position of the prolapsed hand is 
 generally at one end of the bitemporal diam- 
 eter. Sometimes rotation is interfered with. 
 If, however, the hand lies against the occiput, 
 it may prevent its descent at least for a time, 
 and cause head extension at the pelvic inlet 
 (Figs. 693, 695, and 696). 
 
 Etiology. — The causes are found in any- 
 thing that disturbs the natural relationship of 
 the presenting part with the pelvic inlet. Thus 
 malpresentations, such as shoulder, brow, or 
 face, are causes, since they do not properly 
 engage at the inlet; or anomalies in the shape 
 of the uterus which have developed during 
 pregnancy from some cause or are due to 
 tumor, hydramnios, or twins; or displacement 
 due to a pendulous abdomen. Pelvic contrac- 
 tion, as in the prolapse of the cord, is a com- 
 mon cause, as it prevents a proper adjustment 
 of the presenting part to the inlet. For the 
 same reason multiple presentation, as in twins, 
 Rupture of the membranes in the sitting or 
 standing posture, especially in multiparae, and sudden exertion on the part of 
 the mother during or even after engagement of the presenting part, must be 
 recognized as etiological factors. Death of the fetus with loss of its muscular 
 tonicity must also be included. 
 
 Diagnosis. — This is a simple matter, and the possibility of this accident 
 should always be one of the mental queries at all first and subsequent internal 
 examinations of labor. 
 
 OF 
 
 Fig. 691. — Lateral Obliquity 
 THE Head in Vertex Presenta 
 
 TION. 
 
 and a premature fetus are causes. 
 
FETAL DYSTOCIA FROM FAULTY ATTITUDE. 521 
 
 Prognosis. — In shoulder and breech presentations prolapse of one or both 
 arms is rather a favorable condition, and affects the prognosis accordingly. 
 For this reason I am never accustomed to replace the prolapsed arm or arms 
 under such circumstances. The advantage lies in the fact that we can usually 
 apply a sling or soft fillet to the arm or arms, keep them prolapsed, and thus the 
 subsequent danger of the arm or arms becoming extended and causing impaction 
 of the after-coming head is obviated. Prolapse of an arm in vertex presentation 
 is often a serious condition. The arm occupying the inlet with the vertex may 
 result in a lateral deviation of the head, and a vertex presentation may thus be 
 converted into a bregma, brow, or face, or, if the head is freely movable, even 
 into a shoulder. Or, a less serious condition, an arm prolapsed behind the sym- 
 physis may cause lateral flexion and presentation of the anterior parietal bone 
 (Naegele's obliquity) or of the posterior (Litzmann's obliquity). The cause of 
 the prolapse — whether it originates in the bony pelvis, the maternal soft parts, 
 or the fetus — must not be lost sight of as affecting the prognosis. 
 
 Treatment. — (i) In shoulder and breech presentations no treatment, in my 
 opinion, is required, other than to secure the prolapsed arm or arms with a sling 
 in order to prevent subsequent extension alongside or above the after-coming 
 head. (2) In instances of prolapse of an arm or arms with the head when the 
 latter is well engaged, an expectant treatment should be followed; and if delayed 
 labor occurs, endangering fetus or mother, the forceps should be applied to the 
 head, care being taken not to include the prolapsed arm, and the fetus extracted 
 as in medium or low forceps operations. It will facilitate extraction if moderate 
 traction is also made with a sling to the prolapsed arm. Impaction in the case 
 of a dead fetus of course demands perforation. (3) Manual reposition of the 
 arm may be preceded, as a matter of duty, by an attempt at postural reposi- 
 tion — namely, placing the patient in the exaggerated semi-prone, knee-chest 
 or Trendelenburg posture. Postural reposition alone rarely succeeds. (4) 
 When the head is movable at the inlet or is extra-medial b3v reason of the pro- 
 lapsed arm filling in one side of the pelvis, and the arm thus constitutes an 
 actual obstruction, manual reposition should be performed. This is the same 
 as in the case of a prolapsed leg, (See page 522.) (5) Version and extraction 
 may be required if reposition fails and indications of delayed labor demand 
 intervention. 
 
 Dorsal Displacement of the Arm (Figs. 692, 694). — In cephalic and breech 
 presentations it occasionally happens that an arm is not only prolapsed, but is so 
 displaced that the forearm lies transversely across the back of the neck behind 
 the occiput and forms a ridge or elevation in the generally uniform fetal ellipse 
 which may catch upon the pelvic inlet or a rigid cervix and constitute a serious 
 obstruction to labor. Diagnosis : The condition is the more dangerous because, 
 as no appreciable change occurs in the presentation, it naturally escapes diagnosis 
 unless the hand of the attendant is passed above the head to explore for the cause 
 of delay. Such an exploration under ether is always called for when forceps- 
 indication with no marked disproportion between the head and fetus is evident 
 and traction fails to bring down the head. Treatment : (i) In Cephalic Presen- 
 tation. — In spite of the obstruction the fetus can sometimes (a) be delivered by 
 moderate traction with the forceps. Strong traction must not be employed for 
 fear of injury to the fetal neck. (6) The forceps failing, an attempt should be 
 made with the hand passed between the shoulder and the pelvic wall to flex the 
 forearm back into its proper place over the scapula, and the lateral and anterior 
 thoracic walls. Fracture of the arm is occasionally unavoidable, (c) The forceps 
 and manual rectification having failed, combined or internal podalic version under 
 
522 PATHOLOGICAL LABOR. 
 
 proper conditions of fetus and uterus must be performed. (2) In Breech Pres- 
 entation AND Breech Extraction. — Delay here from dorsal displacement of 
 the arm is more important than in cephalic presentation, since shorter time is 
 allowed for removing the obstruction and fetal asphyxia in the mean time is liable 
 to occur, (a) A conservative as well as effective plan of procedure is to bring 
 down the non-displaced arm, to put a sling upon it, and, by using this arm as a 
 tractor as well as by grasping the trunk, to rotate the latter in the direction that 
 will disengage the displaced arm. (b) The replacement thus accomplished will 
 usually be only partial, and it will be necessary, after rotating the displaced 
 arm into the posterior part of the pelvis, to pass the whole or half hand into the 
 pelvis and sweep the now partially displaced arm over the face and chest. It 
 may possibly be necessary deliberately to fracture the arm in order to liberate the 
 fetus in time to prevent its death by asphyxia. (Compare Part X.) 
 
 Vlll. PROLAPSE OF THE LEGS. 
 
 Prolapse of the lower extremities is unusual in any presentation. It is rather 
 favorable than otherwise in breech and shoulder presentations, and occurs, as a 
 rule, only when the fetus is dead, immature, or macerated. In certain breech 
 presentations there is extension of one or both thighs from vigorous movements 
 on the part of the fetus or from sudden outflow of liquor amnii. Thus one or 
 both feet or one or both knees or a knee and a foot present. An influencing 
 factor in this condition is the fact that the breech does not fully occupy the 
 lower uterine segment, especially when there is much liquor amnii. Frequency : 
 Footling presentations are said to occur once in 92 cases, or in a little over i per 
 cent, of all breech cases. Knee presentations are very rare, occurring once in 
 3000 cases. The simultaneous presentation of hand and foot is extremely rare. 
 Treatment: (i) In shoulder and breech presentations no treatment is required 
 other than to secure the prolapsed leg with a sling. In the rare instances in 
 which prolapse of the leg occurs with cephalic presentation (vertex, brow, or 
 face) the treatment will vary according to circumstances (Figs. 696, 697). 
 (See Part X.^ 
 
 IX. PROLAPSE OF THE UMBILICAL CORD. 
 
 Synonyms: Prolapsus Funis; Chorda Prae via; Funicular Presentation. 
 
 Definition. — In this condition a loop of the umbilical cord descends into the 
 pelvis in advance of the presenting part. If the membranes remain unruptured, 
 the condition is known as presentation of the cord, but after rupture, when the 
 cord descends into the vagina, it is called prolapse of the cord. Before rupture, 
 the loop of cord may be felt through the membranes moving in the liquor amnii, 
 and from the very beginning of labor it presents at the pelvic inlet. It may be 
 carried down by the sudden outflow of liquor amnii when the membranes rupture, 
 or the loop may be forced down by muscular action by the side of the engaged 
 head, and thus escape from the vulva. Sometimes both arms of the loop are 
 seen side by side; in other cases the two parts are separated by a fetal part. 
 The most common position in which the loop is found is in front of one of the 
 sacro-iliac joints or of the cotyloid cavity. It is seldom directly in front of the 
 sacrum or behind the pubic arch. The last-named positions are most dangerous, 
 as they give most chance for compression of the cord by the fetal parts (Figs. 
 700 and 701). 
 
 Frequency. — The frequency of this complication varies, in different countries 
 
<^ CO 
 
 .,-'-'-"T;^:r?^s>^^ 
 
 523 
 
524 
 
 PATHOLOGICAL LABOR. 
 
 and in different institutions, with the frequency of pelvic deformity and the 
 posture of the parturient woman during labor. On the whole, it is not very infre- 
 quent. One estimate gives it as occurring once in from 200 to 300 cases of labor, 
 but the limits according to various authors, range between one in 65 and one in 
 500 cases. In 2200 confinements in New York city I found the cord was pro- 
 lapsed in 26 cases, or in 1.18 per cent., or once in 84.6 cases. 
 
 Etiology. — The cause of this condition is found in a lack of accommodation 
 between the presenting part and the lower uterine segment and the pelvic inlet. 
 Malpresentations, malpositions, deformities of the head, and contractions of the 
 pelvis act as predisposing causes. In 26 cases of prolapse of the cord I found 14 
 vertex presentations, i brow, 3 shoulder, and 8 breech, one of the last being a 
 prolapsed foot as well. In 9 of the 26 cases some form of pelvic contraction was 
 present. Eight of the cases were in primiparae and 18 in multiparse. Excessive 
 right lateral obliquity of the uterus, uterine fibromata or myomata, hydramnios, 
 
 too long cord, marginal insertion of the 
 cord, placenta praevia, plural pregnancy, 
 multiparity, pendulous abdomen, a male 
 fetus, complex presentation, or the pres- 
 ence of a very small fetus in premature 
 labor, predispose to prolapse of the cord. 
 Cases have been reported in which this 
 complication has occurred in successive 
 pregnancies, and in the absence of an ob- 
 vious cause, predisposition has been said to 
 be the etiological factor. The upright posi- 
 tion on the part of the mother at the time 
 of rupture of the membranes, and a sudden 
 escape of the liquor amnii, may act as excit- 
 ing causes, as may also violent movements, 
 or efforts at bearing-down, particularly if 
 ergot has been used prematurely in the last 
 instance. 
 
 Diagnosis. — The diagnosis differs some- 
 what whether made before or after the 
 rupture of the membranes. It should 
 be simple enough after the rupture of the 
 membranes, especially if the loop of cord 
 has fallen into the vagina or outside the 
 vulva. It may be distinguished from a prolapsed intestine by the absence of 
 a mesentery, and by the characteristic twists of the umbilical cord which can be 
 felt, and, if the child still lives, by the presence of pulsation in the cord. In 
 some cases, however, pulsation in the cord ceases a short time before the death 
 of the child, so that the heart should be auscultated before death is decided to 
 have occurred. If the membranes are still unruptured and the pulsation is ab- 
 sent, the diagnosis is not quite so clear. Pulsations which occur in the vaginal 
 or uterine arteries may be distinguished from those of the cord by being syn- 
 chronous with the pulse of the mother. Before the escape of the liquor amnii, 
 the cord, being non-resisting, is pushed ahead of the examining finger until it is 
 really beyond palpation. Prolapsed cord has also to be differentiated from the 
 presence of a foot or a hand in the vagina, an ectopia of the fetal intestines, and 
 an oedematous and lacerated lip of the cervix. 
 
 Prognosis. — The mortality among children in this condition amounts to 50 
 
 Fig. 
 
 700. — Prolapse of the Cord in 
 Vertex Presentation. 
 
FETAL DYSTOCIA FROM FAULTY ATTITUDE. 
 
 525 
 
 per cent. The prognosis for the child depends on the time of labor at which the 
 prolapse occurs, the presentation and position of the fetus, the condition of the 
 membranes, the condition of the cervix, the amount of cord prolapsed, and the 
 gravity of the abnormality causing the accident. The great danger for the child 
 is from asphyxia due to compression of the cord. Head presentation carries the 
 greatest danger with it. The danger is less in proportion to the greater length of 
 time that the membranes remain intact, and, after their rupture, in proportion to 
 the rapidity of delivery. The amount of the cord prolapsed and the region of the 
 pelvis into which it descends also influence the prognosis. The fetal mortality 
 is higher in primiparae and in oversize of the fetus. 
 
 The prognosis for the mother depends upon the gravity of the abnormality 
 which causes the accident, and of the operation demanded. Mental disturbance 
 and breast complications subsequent to the death of the fetus may have some 
 effect on the mother. Cases do occur in which, from various causes, the cord is 
 tightly stretched, and is thus so shortened that the placenta is prematurely de- 
 tached, with resulting hemorrhage. In my 
 26 collected cases, one mother died on the 
 fifth day, undoubtedly as the result of the 
 operation to save the child, and 5 of the 
 26 children were still-bom. 
 
 Treatment. — The treatment of this 
 condition is most important because of 
 the high mortality among children. 
 Whatever measures are instituted should 
 be promptly applied. 
 
 1. Preventive Treatment consists 
 in posture of the parturient, preservation 
 of the membranes, and immediate correc- 
 tion of lateral displacement of the present- 
 ing part. Many cases are due to improper 
 management of labor. The membranes 
 should never be ruptured prematurely 
 without a positive indication, and the 
 waters should never be allowed to gush 
 from the uterus when the woman is in 
 the erect or sitting posture. With an ex- 
 cess of the liquor amnii, a gradual escape of the waters should be aimed at by 
 partially occluding the vaginal outlet with gauze or cotton. In conditions favor- 
 ing prolapse the woman should be kept in the dorsal posture during the first 
 as well as the second stage. 
 
 2. Curative Treatment. — If the child is dead, the presentation or prolapse 
 of the cord does not, of course, constitute a special indication, for the interests 
 of the mother do not require that the fetus shall be extracted at once. 
 
 In the curative treatment of presentation of the funis before dilatation of the 
 cervix has taken place, or rupture of the membranes, active interference is not in- 
 dicated. Every effort should be made to prevent the premature rupture of the 
 membranes. For this purpose a Barnes bag may be introduced, or the vagina may 
 be tamponed. The patient should be cautioned against straining, and should 
 assume the exaggerated latero-prone position (Part X) on the side opposite to that 
 on which the cord lies, in order that gravity may favor the return of the displaced 
 cord. The knee-chest position is also frequently useful in causing the return of 
 the cord. If the fetal heart-sounds begin to fail, the cord should be pushed up be- 
 
 FiG. 701. — Prolapse of the Cord in a 
 Doubled Fetus, the Anterior Fetal 
 Plane Presenting. 
 
526 PATHOLOGICAL LABOR. 
 
 tween the pains, care being taken not to rupture the membranes. This should be 
 done while the patient is in the knee-chest position. If the cord does not return, 
 the membranes should be ruptured, and sufficient descent of the head secured to 
 retain the cord, by expression of the fetus or by using forceps. After the cord 
 has been replaced, the patient should lie upon the side, as above described, and 
 with the hips elevated by a pillow. If the accoucheur possesses the requisite 
 experience and skill, and if the mother's condition permits, he may perform 
 version by thq combined method, but without bringing down the foot into the 
 vagina. The foot should be secured by a fillet. 
 
 In the treatment of presentation of the funis after dilatation of the cervix, if 
 the head remains above the brim and cannot be made to engage, there are 
 two alternatives: manual or instrumental reposition and version. Too much 
 handling of the cord, however, is dangerous to the fetus. If reasonable efforts 
 at reposition fail, version should be performed, unless it is so dangerous to the 
 mother as to be considered unjustifiable. 
 
 Manual reposition is best done while the patient is in the exaggerated latero- 
 prone or knee-chest position. While counter-pressure is made over the fundus, 
 the hand should be passed into the cervix, the head pushed a little to one side, 
 and the cord carried up beyond the head, and, if possible, to a position behind the 
 neck. During this manipulation the cord should be balanced on the tips of as 
 many fingers as possible and not grasped in the hollow of the hand. This act 
 of reposition should be done as rapidly as possible. Manipulations should be 
 suspended during uterine contractions. The hand should be gradually with- 
 drawn, and the descent of the head into the cervical canal aided by pressure 
 over the fundus, or the application of the forceps. After reposition the 
 woman should be placed on the side opposite to that at which the prolapse 
 developed. 
 
 Instrumental reposition will become necessary if rupture of the membranes 
 takes place before dilatation of the cervix, since the time occupied in securing 
 dilatation would very likely prove fatal to the child. The best repositor is an 
 ordinary English catheter (See Part X). The stylet is made to pass out from the 
 eye of the catheter, a loop of disinfected bobbin is passed loosely around the 
 cord, and is attached to the stylet, which is then withdrawn into the catheter 
 and pushed to the tip, in order to hold the tape in position. The catheter and 
 cord are then carried up as far as possible, the stylet is withdrawn to avoid 
 possible compression, and the catheter is left in position. Every effort should 
 then be made to induce engagement as described above. If efforts at reposition 
 are not promptly successful, manual dilatation, followed by version or forceps, 
 according to the indications, should be performed. Another method of slinging 
 the cord is shown in Part X. 
 
 In face presentations version should be performed, unless there are contra- 
 indications, since the face does not completely fill the cervical canal, and the 
 replaced loop is likely to re-prolapse. In prolapse of the foot in breech pres- 
 entations the cord is not in danger until the breech enters the cervix. In 
 breech presentations pressure upon the cord may be relieved by bringing down 
 a foot, but if the fetal heart-sounds begin to fail, extraction should be as rapid 
 as is consistent with the safety of the mother. In shoulder presentations no 
 modification of the usual management is indicated. In the very rare cases in 
 which the head is impacted, or has passed the inlet, and the cord pulsates, the 
 use of the forceps is indicated. After the child is dead the condition does not 
 call for interference. If there are still other complications, such as placenta 
 praevia or shoulder presentation, the same treatment is indicated as at first 
 
FETAL DYSTOCIA FROM FAULTY PRESENTATION. 527 
 
 described. When prolapsed cord offers the only complication, it should be 
 restored as quickly as possible. Throughout the management of the case the 
 operator or an assistant should listen at intervals for the fetal heart. If 
 asphyxia appears to be impending before dilatation of the cervix is com- 
 plete, the Braxton-Hicks method of version may be performed, although the 
 foot should not be brought below the level of the os, where it may be held 
 by a sling until dilatation is complete. If fetal asphyxia is impending after 
 dilatation is complete, podalic version should be performed if the head is 
 movable at the inlet; otherwise forceps must be applied. In my series of 26 
 cases, above quoted, with a fetal mortality of 19.2 per cent., 8 children were 
 delivered by forceps, 9 by version, 4 by manual extraction in breech cases, and 
 5 spontaneously. Records are wanting in 2 cases. 
 
 FETAL DYSTOCIA FROM FAULTY PRESENTATION. 
 
 X. PELVIC PRESENTATION. 
 
 Definition. — Pelvic or breech presentation represents positions of the fetus 
 in which the inferior pole of the fetal ellipse is found at the pelvic inlet, in the 
 vagina, or at the vulva. It is classed as a longitudinal presentation, and therefore 
 is amenable to the conditions of that class. The positions are named in accord- 
 ance with the location of the fetal sacrum (page 529), It is unnecessarily com- 
 plicating to describe in this connection a foot and knee presentation. Prolapse 
 of the feet and legs is merely a complication of a pelvic presentation as prolapse 
 of the cord and hands is in other presentations — vertex, bregma, brow, face, 
 or shoulders. It is useful, however, to distinguish between a simple pelvic pres- 
 entation and a mixed one. In a simple breech presentation the lower extrem- 
 ities are flexed on the anterior surface of the body. Flexion is limited to the 
 hip-joint, the knee being in extension. The breech alone presents at the inlet. 
 (Figs. 703, 704). In a mixed breech presentation the lower extremities maintain 
 the physiological attitude throughout, hips, knees, and ankles alike exhibiting 
 some degree of flexion ; so that the feet are found in some relationship with the 
 breech at the pelvic inlet — perhaps above, perhaps below (Fig. 707). 
 
 Frequency. — Statistics covering a vast number of child-births show that about 
 one labor in thirty-two is a breech presentation, the percentage being 3.2. A 
 large proportion of breech cases is found in premature deliveries, multiple preg- 
 nancies, and anomalous labors (page 423). Simple breech occurs in about 60 per 
 cent, of cases. In 2200 labors I found pelvic presentation occurred in 82 cases 
 or 3.72 per cent., or once in 26 labors. 
 
 Etiology. — The etiology of breech cases is complex, so that the theoretical 
 causal factors cannot always be brought into relationship with this anomalous 
 presentation. In general it may be stated that anything which interferes with 
 the normal shape of the fetal ellipse or changes the shape of the ovoid uterine 
 cavity after the thirty-second week may result in a malpresentation, such as 
 pelvic ; in other words, there is failure of one or more factors governing the deter- 
 mination of vertex presentation (compare page 424). Certain conditions predis- 
 pose to breech presentations: (i) First, the causes of faulty attitude in general, 
 including pelvic, shoulder, and possibly face presentation. These include, on the 
 part of the mother, relaxation of the uterine and abdominal walls, abnormal 
 mobility of the uterus (conditions found in women who have borne many chil- 
 
528 
 
 PATHOLOGICAL LABOR. 
 
 dren); distention of the uterus (hydramnios), deformity of the uterus, whether 
 due to malformation (uterus arcuatus, bicomis, etc.) or to fibroids; contracted 
 
 pelvis; placenta praevia. (2) 
 On the part of the fetus the 
 corresponding factors are pre- 
 maturity (we must expect 
 breech presentation in every 
 second case of labor before 
 the eighth month, page 423); 
 multiple pregnancy; mon- 
 strosities; fetal diseases, dead 
 and macerated fetuses. We 
 frequently see the coincidence 
 of several of these factors in a 
 given case. 
 
 Positions and Relative Fre- 
 quency. — 
 
 I. Left sacro- anterior, 
 Sacro laeva anter- 
 ior, L. S. A. (Fig. 
 706), most fre- 
 quent. 
 II. Right sacro-anterior, 
 Sacro dextra an- 
 terior, R. S. A. 
 
 ,... (Fig. 715)- 
 
 / ^' III. Right sacro-poster- 
 
 \ / ' ior, Sacro dextra 
 
 posterior, R. S. P. 
 
 -Mixed Breech Presentation. Compare ^^^S- 7I9). second 
 
 Fig. 707, in frequency. 
 
 ^^ 
 
 Fig. 
 
 702. 
 
 Fig. 703. — Simple Breech Presen- 
 tation. 
 
 ^.. 
 
 Fig. 704. — Simple Breech Presentation. 
 
FETAL DYSTOCIA FROM FAULTY PRESENTATION. 
 
 529 
 
 IV. Left sacro-posterior, Sacro lasva posterior, L. S. P. (Fig. 723). 
 
 The left sacro-anterior is the most frequent, and the right sacro-posterior the 
 next. In 163 pelvic presentations, Naegele found 120 left sacro-anterior and 40 
 right sacro-posterior. The same factors determine the relative frequency of the 
 several breech positions as those of the vertex (page 426). To understand this 
 one must keep in mind the shape of the fetal ellipse; the shape of the uterine 
 cavity; the torsion of the uterus upon its long axis, and the fact that in pelvic 
 as in vertex presentation the longest horizontal diameter of the fetal ellipse is 
 an antero-posterior and not a transverse diameter (Figs. 702, 704). This is 
 brought about by the flexion of the thighs, legs, arms, and head upon the 
 anterior fetal plane in the normal attitude or posture (page 420). 
 
 Mechanism. — I. Left Sacro-anterior, L. S. A. (Fig. 706). — The same stages 
 obtain here as in the mechanism of vertex presentation. The bitrochanteric 
 diameter (Fig. 707) approaches the pelvic inlet in the latter's left oblique diam- 
 eter, the fetal back looking to the left and front (Fig. 706). (i) Moulding 
 of the breech: Increased intra- 
 uterine pressure results, in ad- 
 dition to moulding, in more 
 perfect flexion of the limbs 
 and head. No movement an- 
 alogous to flexion in vertex or 
 extension in face presentation 
 occurs, nor does a typical 
 tumor like the caput succed- 
 aneum form. This process is 
 also one of adaptation The 
 breech is swollen either from 
 simple oedema or the condi- 
 tion may be more severe and 
 present a much enlarged, dark 
 surf ac e. Itismorec ommonly 
 seen over the anterior hip, 
 though it may reach the geni- 
 tal regions, especially the scro- 
 tum in males. If the knees or 
 feet present, they may become 
 oedematous. (2) Engagement 
 
 and descent: By reason of the irregular shape of the breech this stage is often 
 prolonged. The left anterior or lower hip first enters the inlet and cervix (Figs. 
 707 and 708) and slowly the uterus forces the breech onward into the pelvic cavity 
 until the left hip meets with the resistance of the pelvic floor. (3) Anterior rota- 
 tion of the left hip: Rotation of the buttocks occurs when the pelvic floor is reached. 
 It must be clearly understood that while the greatest horizontal diameter of the 
 fetal ellipse is the antero-posterior, yet the greatest diameter of the presenting 
 part or breech is the transverse diameter, the bitrochanteric, 3^ inches (8.75 cm.) 
 (Fig. 704). One must also remember that in the stage of descent that buttock or 
 trochanter which lies in the anterior segment of the pelvis is the lowest, and hence 
 the first to be influenced by the trough-like shape of the pelvic floor and deflected 
 to the front at the pelvic outlet, thus bringing the long diameter of the presenting 
 part .(jDitrochanteric) into the long diameter of the pelvic outlet (antero-posterior), 
 and fulfilling the great principle in the mechanism of labor, namely, accommoda- 
 tion (Figs. 708, 709). The left, lower, or anterior buttock is thus brought to the 
 34 
 
 Fig. 
 
 93-99 J^ 
 
 705. — Relative Frequency of the Breech 
 Positions, 
 
530 
 
 PATHOLOGICAL LABOR. 
 
 FIRST BREECH POSITION. 
 Left Sacro-Anterior, L. S. a. 
 
 Fig. 706. — Breech at the Pelvic 
 
 Inlet. 
 
 Fig. 707. — Breech at the Pelvic 
 
 Inlet. 
 
 Fig. 708. — Left Buttock in the 
 Cervix. 
 
 Fig. 709. — Left Buttock, in the 
 Vulva. — (From a photograph.) 
 
 symphysis pubis by the rotation of the 
 breech in its entirety. (4) Expulsion of the 
 breech and lateral flexion of the body: When 
 the anterior hip has reached the pubis, and 
 the posterior the posterior portion of the 
 pelvic floor, the impetus given the fetus by 
 the posterior segment bends forward the 
 breech in its entirety and a lateral curva- 
 ture of the trunk occurs (Fig. 138). The 
 lateral curvature soon becomes decided and 
 the buttock may be seen at the vulval open- 
 ing. The trunk is propelled into the pelvic 
 cavity and the anterior hip becomes fixed 
 beneath the pubic arch. Next the posterior 
 hip makes onward progress until the poste- 
 rior buttock appears overthe fourchette, fol- 
 lowed by the trochanter. With the birth of 
 the posterior part of the breech the peri- 
 neum withdraws from the pelvis of the 
 fetus, and on account of the posterior sur- 
 face of the breech being relieved entirely of 
 pressure there is decreased curvature and 
 the fetal trunk straightens out, freeing the 
 anterior hip from its forced position against 
 the arch of the pubis (Fig. 718). Expulsion 
 of the trunk now readily follows. The 
 thighs are always flexed when no prolapse 
 occurs and the legs are often extended (Fig. 
 703). Extension of the legs I do not con- 
 sider an abnormal condition, as it is due to 
 the tight birth canal "peeling" them up, so 
 to speak, along the fetal body. Normally 
 the arms preserve their original position 
 upon the chest of the fetus and are thus ex- 
 pelled. An unfortunate complication arises 
 should one or both arms become extended 
 along the sides of the head within the pelvis. 
 The hips, the legs, and the trunk appear in 
 quick succession, and the child is delivered 
 up to its waist. Almost simultaneously the 
 shoulders enter the inlet and the umbilicus 
 appears at the vulva. The bisacromial di- 
 ameter of the shoulder engages in the left 
 oblique diameter of the pelvic inlet and the 
 shoulders descend until the left, lower, or 
 anterior shoulder reaches the pelvic floor. 
 The left shoulder then rotates anteriorly 
 from right to left, causing the bisacromial 
 diameter to correspond to the antero-pos- 
 terior diameter of the pelvic outlet. The 
 anterior shoulder becomes fixed under the 
 pubic arch. The arms, flexed on the chest. 
 
FETAL DYSTOCIA FROM FAULTY PRESENTATION. 
 
 531 
 
 and the shoulders, first the right or 
 posterior, and later the left or ante- 
 rior, are delivered. (5) Rotation of the 
 head and restitution of the trunk: The 
 head, regarded as a lever, is pressed 
 upon at its longer arm by the uterus, 
 and this serves to keep it flexed or to 
 increase existing flexion. The head 
 engages and descends. The occipito- 
 frontal diameter of the head enters the 
 pelvis in its right oblique diameter. In 
 perfect flexion of the head and normal 
 posture of the child the vertex or occi- 
 put is the only prominent or project- 
 ing portion. Consequently at the pel- 
 vic floor it is this pole of the head 
 which alone meets with any resistance 
 and, following the usual law, is de- 
 flected anteriorly, bringing the long 
 diameter of the head into that of the 
 outlet. Anterior rotation of the occi- 
 put we know clinically rarely fails, and 
 then because of an extended head or 
 some anomaly either in the shape of 
 the head or in the parturient tract. 
 Coincident with head rotation, slight 
 restitution of the trunk, bringing the 
 fetal dorsum to the front, is sometimes 
 observed. (6) Expulsion of the head: 
 Although acting at a disadvantage by 
 reason of the relatively small size of 
 the head, the uterus by contracting 
 acts upon the vault of the cranium. 
 The occiput still being the projecting 
 and prominent portion of the head. 
 
 Fig. 710. — Delivery of the 
 Head with the Occiput 
 
 After-coming 
 Anterior. 
 
 Fig. 711. — Delivery of the 
 Head with the Occiput 
 
 After-coming 
 Anterior. 
 
 Fig. 712. — Delivery of the After-coming 
 Head with the Occiput Anterior. 
 
 Fig. 713. — Delivery of the After-com- 
 ing Head with the Occiput Poste- 
 rior. First Method. 
 
 Fig. 714. — Delivery of the After-com- 
 ing Head with the Occiput Posterior. 
 Second Method. 
 
532 
 
 PATHOLOGICAL LABOR. 
 
 SECOND BREECH POSITION. 
 RIGHT SACRO-ANTERIOR, R. S. A. 
 
 Fig. 715. — Breech at Pelvic Inlet. 
 
 Fig. 716. — Breech at Pelvic Inlet 
 
 •/ 
 
 Fig. 717. — Right Buttock 
 Cervix. 
 
 Fig. 718. — Breech in the Vulva. 
 Expulsion of both Buttocks. 
 
 and in the anterior segment of the pelvic 
 outlet, is naturally caught and held by the 
 bony fork of the pubic arch, leaving the long 
 or sinciput extremity of the cephalic lever 
 to be influenced by the contraction of the 
 uterus and pelvic floor and to be driven 
 down into the vulval opening, causing the 
 head to be bom by a movement of flexion; 
 the chin, mouth, nose, eyes, forehead, an- 
 terior fontanelle, and lastly the occiput 
 passing over the perineum in the order 
 named (Figs. 710, 711, 712). 
 
 Posterior Rotation of the Occiput. — In 
 rare cases, not more than 2 per cent., ante- 
 rior rotation of the occiput fails, the sinciput 
 end of the cephalic lever rotates to the pu- 
 bic arch and the occiput to the coccyx. 
 This complication results from incomplete 
 flexion of the head, whereby the sinciput of 
 the after-coming head becomes as promi- 
 nent as the occiput or more so, and hence is 
 equally or to a great extent influenced by 
 the greater resistance of the posterior part 
 of the pelvic floor, and is rotated anteriorly. 
 Two terminations of a persistent occipito- 
 posterior position of the after-coming head 
 are possible: (i) Uterine contractions force 
 the sinciput, or long end of the head lever, 
 under the pubic arch and flex the head 
 through the vulval orifice; the chin, mouth, 
 nose, eyes, forehead, and occiput appearing 
 in the order named under the pubis (Fig. 
 714). (2) Occasionally extension of the 
 head takes place at the pelvic inlet and the 
 occipito-mental diameter (5^ inches — 13.97 
 cm.) is brought in coincidence with the an- 
 tero-posterior diameter of the inlet, thus 
 presenting a mechanical impossibility. In 
 these cases contraction of the uterus forces 
 the chin over and upon the upper portion of 
 the symphysis and thus fixes the face end of 
 the cephalic lever. The occipital or short 
 end of the head lever alone being free, is 
 forced by uterine contraction down to the 
 pelvic floor and the head is bom through 
 the vulval orifice by a movement of con- . 
 tinued extension; the occipital protuber- 
 ance, the small and large fontanelles, fore- 
 head, nose, mouth, and lastly the chin being 
 bom in the order named (Fig. 713). 
 
 II. Right Sacro-anterior Position, 
 R. S. A. (Fig. 7x5). — The bitrochanteric 
 
FETAL DYSTOCIA FROM FAULTY PRESENTATION. 
 
 633 
 
 diameter approaches the pelvic inlet in the 
 latter's right oblique diameter, the fetal 
 back looking to the right and front, (i) 
 Moulding of the breech: Same as in Position 
 I (page 529). (2) Engagement and descent. 
 Same as in Position I (page 529). (3) An- 
 terior rotation of the right hip: This occurs for 
 the same reason as in Position I (page 530), 
 
 (4) Expulsion of the breech and lateral flexion 
 of the body: Compare Position I (page 530). 
 
 (5) Rotation of the head and restitution of the 
 trunk: The occipito-frontal diameter enters 
 the left oblique pelvic diameter and the 
 occiput rotates to the pubis from right to 
 left (Fig. 715). Restitution occurs as in 
 Position I. (6) Expulsion of the head (Fig. 
 710): See Position I (page 531). 
 
 III. Right Sacro-posterior Position, 
 R. S. P. (Fig. 719). — The bitrochanteric 
 fetal diameter approaches the left oblique 
 pelvic diameter; the fetal back looks to the 
 right and rear (Fig. 720). (i) Moulding of 
 the breech and (2) Engagement and descent 
 occur as in Positions I and II. (3) Anterior 
 rotation of the right hip now occurs (Fig. 
 721). (4) Expulsion of the breech and lateral 
 flexion of the body follow (see pages 582 and 
 531) (Fig. 722). (5) Rotation of the head and 
 restitution of the trunk: The occipito-frontal 
 fetal diameter enters the right oblique pel- 
 vic diameter, the occiput pointing to the 
 right sacro-iliac synchondrosis. Rotation 
 of the occiput follows from this latter point 
 around the right pelvic wall and to the sym- 
 physis, for reasons already stated, in all but 
 less than 2 per cent, of cases (Fig. 719). (6) 
 Expulsion of the head now occurs as in Posi- 
 tions I and II (Fig. 710). 
 
 IV. Left Sacro-posterior Position, 
 L. P. S. (Fig. 723). — The bitroch^.nteric 
 fetal diameter approaches the left" (Oblique 
 pelvic inlet diameter; the fetal back looks 
 to the left and rear (Fig. 724). (i) Moulding 
 of the breech and (2) Engagement and descent 
 occur as in Positions I and II (Fig. 725). 
 (3) Anterior rotation of the left hip: This oc- 
 curs from left to right to the median line 
 (Fig. 725). (4) Expulsion of the breech and 
 lateral flexion of the body: As in I, II, and 
 III (Fig. 710). (5) Rotation of the head and 
 restitution of the trunk: The occipito-frontal 
 fetal diameter enters the left oblique pelvic 
 
 THIRD BREECH POSITION. 
 RIGHT SACRO-POSTERIOR, R. S. P. 
 
 Fig. 719. — Breech at Pelvic Inlet. 
 
 Fig. 720.— Breech at Pelvic Inlet. 
 
 C 
 
 Fig. 721. — Right Buttock in thb 
 Cervix. 
 
 Fig. 722. — In the Vulva. Escape 
 OF THE Anterior or Right Leg. 
 
534 
 
 PATHOLOGICAL LABOR. 
 
 .1 
 
 FOURTH BREECH POSITION. 
 LEFT SACRO-POSTERIOR, L. S. P. 
 
 diameter, the occiput pointing to the left sacro-iliac synchondrosis. Rotation 
 of the occiput around the left side of the pelvis to the symphysis occurs at the 
 floor of the pelvis (Fig. 723). (6) Expulsion of the head follows (Fig. 710). 
 
 Prognosis. — For the mother: The prognosis in respect to the mother's survival 
 corresponds with that of occipital presentations in all cases which terminate 
 spontaneously, although intervention is required much more frequently in breech 
 cases. The likelihood of perineal rupture is also greater. For the child: The prog- 
 nosis for the fetus is much more unfavorable than in occipital presentations ; the 
 average mortality being 20 per cent. The chief danger is from asphyxia, which 
 often occurs as the after-coming head passes the pelvic inlet coincident with the 
 birth of the navel. An additional peril is compression of the cord between the 
 fetal parts and the pelvic bones. Complete compression for five to ten minutes is 
 sufficient to kill a strong, healthy child. Third, premature detachment of the pla- 
 centa may cause death of the child. Par- 
 tial detachment often results irrespective of 
 the fetal position when the uterus is par- 
 tially emptied; but while this has no special 
 significance in head presentations, it is 
 otherwise when the head is still in the uterus 
 and respiration impossible. Under these 
 circumstances the prognosis is not neces- 
 sarily ominous because it may be improved 
 by treatment. In regard to the prognosis 
 of particular types of pelvic presentations, 
 the best outlook occurs in mixed breech 
 cases, because the entire circumference of 
 the trunk and lower extremities serves to 
 dilate the birth tract. Conversely, if the 
 feet constitute the presenting part, the 
 prognosis is unfavorable because a complete 
 foot presentation cannot dilate the birth 
 tract sufficiently for delivery of the after- 
 
 FiG. 723. — Breech at Pelvic Inlet. 
 
 Fig. 724. 
 
 jREECH AT Pelvic Inlet. 
 
 Fig. 725. — Left Buttock in Cervix 
 
 Fig. 726. 
 
 -Escape of the Trunk through 
 the Vulva. 
 
FETAL DYSTOCIA FROM FAULTY PRESENTATION. 
 
 535 
 
 coming head. The first risk of the child, death from asphyxia, irrespective of com- 
 pression of the cord or detachment of the placenta, is due to premature inspiration, 
 produced by the contact of the bom portions of the body with the cooler outside 
 air. Respiration causes aspiration of mucus with obstruction of air-passages. Ex- 
 tension of one or both arms is an unfortunate complication, which still further pro- 
 longs the expulsion of the head ; because the uterus cannot grasp the breech so 
 firmly as it can the head, and thus while the fore-waters still have communication 
 with the rest of the liquor amnii, there is premature rupture of the membranes 
 from this unusual force of uterine contractions. Dry labor may ensue. Frac- 
 tures and dislocations often occur when interference is necessary. Hematoma of 
 the stemo-mastoid and torticollis have also been noted in connection with breech 
 delivery. 
 
 Diagnosis. — 
 
 Position of Fetus. 
 
 Left sacro-ante- | Sacrum to left acetabulum; back to left ante- 
 rior. L. S. A. ! rior; abdomen to right posterior. 
 
 Right sacro-ante- i Sacrum to right acetabulum; back to right 
 rior. R. S. A. anterior; abdomen to left posterior. 
 
 Right sacro-pos- j Sacrum to right sacro-iliac joint; back to 
 terior. R. S. P. j right posterior; abdomen to left anterior. 
 
 Left sacro-poste- j Sacrum to left sacro-ihac joint; back to left 
 rior. L. S. P. j posterior; abdomen to right anterior. 
 
 Position of Fetal Heart- 
 sounds. 
 
 Left side of abdomen, 
 opposite umbilicus. 
 
 Right side of abdomen, 
 opposite umbilicus. 
 
 Right side of abdomen, 
 opposite umbilicus 
 and toward the back. 
 
 Left side of abdomen, 
 opposite umbilicus 
 and toward the back. 
 
 External Examination. — If the fundus uteri is palpated the head may be 
 recognized in that locality in the first position on the right side and in the second 
 position to the left (Figs. 706 and 715). The back is recognized by its uniform 
 resistance. On the opposite side of the uterus, occupied chiefly by liquor 
 amnii, the resistance is much less marked. In palpating over the pelvic inlet we 
 encounter not the head but a less resistant structure. The lower extremities 
 may be made out in the inferior uterine segment. The fetal heart should be 
 heard, in the first position, just to the left of the median line and at the height 
 of or a little above the umbilicus. In the second position the heart should be 
 heard on the right side at some distance from the median line and somewhat 
 further back, the level being the same as in the first position. 
 
 Internal Examination. — As a rule, the breech is higher up at the beginning of 
 labor than is the head in vertex presentation. The bag of waters projects to quite 
 an extent into the vagina, sometimes forming an elongated tumor. Now and then 
 the tension is so great that rupture occurs with a loud report, on the same principle 
 as the bursting of a paper bag full of air. As the cervix does not perfectly grasp 
 the presenting part, nearly all of the amniotic fluid is lost after the membranes 
 are ruptured. When this discharge is very rapid, the pains often decrease or 
 cease entirely for the time being. Meconium is often mixed with the fluid. In 
 palpating the presenting part we encounter a soft, smooth, somewhat conical sur- 
 face. If we assume this to be the head, we are unable to recognize sutures, fon- 
 tanelles, or hair. If we assume that we have a breech presentation, we may be 
 able to recognize the anus, the ischial tuberosities, and the tip of the coccyx, above 
 which is the triangular sacrum. As labor advances the genitals may be recognized, 
 but even then an attempt to distinguish the sex is by no means easy. The anus will 
 feel like a dimple between two skin-covered elevations. The buttock will feel like 
 
536 
 
 PATHOLOGICAL LABOR. 
 
 HEAD MOULDING IN BREECH PRESEN- 
 TATION. 
 
 Fig. 727. — Before Moulding. 
 
 Fig. 728. — After Moulding. — {Author's case.) 
 
 a soft, round tumor, through which 
 the great trochanter will offer its re- 
 sistance. If the tip of the coccyx be 
 felt, the examining finger can trace 
 back its connection with the sac- 
 rum. The ischial tuberosities and 
 the external genitals also present 
 other important landmarks. The 
 tip of the coccyx always points 
 away from the back of the fetus. 
 The heels and toes also, when the 
 two feet present, will indicate the 
 position of the fetus. 
 
 Dififerential Diagnosis. — Face 
 and Breech: Great care must be ex- 
 ercised in distinguishing a face from 
 a breech presentation, for to the 
 touch the similarity of the mouth 
 and the anus may readily lead to 
 an erroneous diagnosis. The anus 
 lies in a fossa, while the mouth is 
 more superficially placed. If the 
 finger is gently introduced into the 
 cavity, the contraction and resist- 
 ance of the sphincter ani give cer- 
 tain evidence of a breech presenta- 
 tion. Foot and hand: The foot is 
 recognized by the presence of the 
 heel and the absence of the adduci- 
 ble thumb and by the toes being 
 nearly in a straight line. If the 
 child is alive, the kicking move- 
 ments also distinguish between feet 
 and hands. Knee and elhow: The 
 patella in the knee can usually be 
 distinguished from the olecranon in 
 the elbow. In doubtful cases due 
 to oedema, the part should be fol- 
 lowed up to the trunk. The groin 
 may be differentiated from the ax- 
 illa bv the absence of the ribs. 
 
 Fig. 
 
 729. — Moulding of Skull.- 
 collection.) 
 
 ■{Author's 
 
 Fig. 730. — Moulding of Skull. - 
 thor's collection.) 
 
 -(Au- 
 
FETAL DYSTOCIA FROM FAULTY PRESENTATION. 537 
 
 Treatment. — During pregnancy we can often convert the breech into a vertex 
 presentation by external version. It will not always be found easy, however, 
 to maintain the latter presentation. A common method of accomplishing this is 
 to apply two long cylindrical compresses of gauze to the sides of the uterus and to 
 hold them in place with a firm abdominal binder. I gave this method a thorough 
 trial in the case of a physician's wife, and each removal of the binder resulted in 
 a return to a breech presentation. External version, however, is more often 
 successful in the beginning of the first stage, the fetus then being manually held 
 in the vertex presentation until engagement occurs. I have succeeded with 
 this method in several instances after labor has begun. 
 
 Successful treatment can be obtained only by a careful study and appreciation 
 in each case of the particular mechanism of labor and of the conditions under 
 which the life of the fetus is placed in danger. It should be remembered (i) that 
 labor is tedious, because the buttocks constitute a slow dilator of the cervix, vagina, 
 and vulva; (2) that the compressible trunk imperfectly dilates the passages, leav- 
 ing much for the after-coming hard, incompressible, and relatively large head to 
 accomplish in the way of dilatation ; (3) that the real dangers begin when the um- 
 bilicus enters the pelvis, and are increased manifold when the umbilical cord and 
 head occupy the pelvis at one and the same time. The principles in the treat- 
 ment of pelvic presentation are : ( i ) To prolong the first stage of labor. This is to 
 secure full dilatation of the passages. We accomplish this by discouraging the 
 use of the voluntary forces and by the use of chloroform if necessary. (2) To pre- 
 serve the membranes as long as possible. This also has for its object the securing 
 of a full dilatation. To accomplish this, we make few examinations and keep 
 the patient as quiet as possible in the recumbent position. The Germans 
 recommend hydrostatic bags or tampons in the upper part of the vagina, but 
 I have failed to appreciate their utility. The preservation of the membranes 
 is' of especial value in breech presentations, because the breech cannot 
 well dilate the cervix, for the later passage of the firmer and harder head. 
 The soft parts are frequently lacerated by the after-coming head when the 
 breech has borne the brunt of dilating the cervix. (3) Carefully to watch the 
 fetal heart-sounds after the rupture of membrane and to prepare for a rapid 
 second stage. To have everything ready for the resuscitation of an asphyxiated 
 child and to keep the position of the fetus, the mechanism of head expulsion, 
 and the dangers clearly in mind. (4) Always to follow down the fundus. This 
 preserves head flexion and keeps the uterus closely applied to the head, thus pre- 
 venting extension of the arms. (5) To protect the perineum as in vertex cases. 
 (6) When the umbilicus appears, to draw down the cord a few inches, to place it 
 to the rear, if possible opposite a sacro-iliac joint, to watch its pulsations and to 
 protect it from longitudinal stretching. (7) To wrap the child in a hot towel 
 (100° F.) to prevent respiration from contact with the air of the lying-in room 
 (70° F.) and to support it well to prevent pressure on the neck. (8) As the 
 chin appears, to elevate the trunk and to assist in the expulsion of the head 
 if necessary by suprapubic pressure {expressio foetus). Much can be done at 
 this time by urging the woman to use her voluntary muscles in bearing-down. 
 If there is much delay, one should not hesitate to employ some form of manual 
 extraction of the head. (See Obstetric Surgery, Part X.) Should the arms be- 
 come extended along the side of the head or above it, they must be immediately 
 brought down. (See Operations, Part X.) Should the head remain transverse 
 at the pelvic outlet, two fingers should be placed on the occiput and two fingers 
 on the malar bones, or one finger in the mouth, and, the trunk being supported 
 between the forearms, the chin shoiild be rotated to the posterior pelvic wall. 
 
538 
 
 PATHOLOGICAL LABOR. 
 
 FIRST SHOULDER POSITION. 
 LEFT SCAPULA ANTERIOR, L. SCAP. A. 
 
 Fig. 731. — At the Pelvic Inlet. 
 
 (See Part X.) The trunk should not be twisted under any circumstances, in the 
 hope of causing internal rotation of the head. Should the head remain in a 
 transverse position in the upper portion of the pelvis, the head should be 
 brought to the pelvic floor by suprapubic pressure and then the above proce- 
 dure followed. That the life of the child may be saved the head must be born 
 within five to ten minutes after the appearance of the umbilicus. Sometimes 
 
 the placenta is detached too easily, like- 
 wise endangering the life of the child. 
 Hence it is necessary to aid the birth of 
 the head. If head flexion is not pre- 
 served, the chin will catch somewhere in 
 the pelvis. The flexion should be main- 
 tained by firm continuous pressure on 
 the fundus of the uterus. In case there 
 is prolapse of the cord, the rapid delivery 
 of the child is indicated. If the heart- 
 beat is rapid or slow, speedy birth is im- 
 perative. If the leg or foot presents , it is 
 easy to hurry the labor ; but if the breech 
 presents, the acceleration is more diffi- 
 cult. It can be done by passing the finger 
 over the groin and making traction. 
 Some claim that as soon as the diagnosis 
 is made one should pull down one or both 
 legs. One advantage of not doing so is 
 that the breech is a better dilator of the 
 cervix than is the body with the legs ex- 
 tended, and, generally speaking, it is 
 better to leave the presentation as it is, 
 for fear that leg traction might extend 
 head and arms. The first stage of labor 
 should be entirely finished before the 
 second stage begins. We should not in- 
 terfere without some positive indication. 
 The forceps is seldom, if ever, required to 
 deliver the after-coming head in breech 
 presentation. (See Operations, Part X.) 
 
 XI. SHOULDER PRESENTATION. 
 
 Synonyms: Trunk Presentation; 
 Transverse Position; Cross-birth. 
 
 Definition. — Shoulder presentation is 
 so named from the shoulder being the 
 presenting part. An absolute transverse 
 position exists when the long axis of the fetus forms a right angle with the long 
 axis of the uterus, and is of rare occurrence. It is never present during labor. Any 
 position of the fetus in which an angle exists between the fetal and uterine long 
 axes is technically a transverse position, therefore obHque is really the proper term 
 to designate the anomaly. Unless the obHquity is so slight that the ordinary head 
 and breech positions are assumed spontaneously or through artificial aid during 
 labor, a transverse or oblique position is virtually one in which the shoulder pre- 
 
 FiG. 732. — At the Pelvic Inlet. 
 
 Fig. 733. — Right Shoulder in the Cer 
 vix. 
 
FETAL DYSTOCIA FROM FAULTY PRESENTATION. 
 
 539 
 
 SECOND SHOULDER POSITION. 
 RIGHT SCAPULA ANTERIOR, R, SCAP. A. 
 
 sents. These positions are, therefore, usually classified with respect to the special 
 attitude of the shoulder. In shoulder presentation the shoulder almost invariably 
 becomes anterior, and presents in the cervix or vagina at an early stage of the 
 labor, since it is the most prominent and resistant part of the trunk. This is due 
 to the contractions of the uterus at the beginning of labor, although it is conceiv- 
 able, and even likely, that any of the numerous so-called trunk presentations 
 should persist. Under the term shoulder presentation, then, we include all exist- 
 ing trunk presentations, such as dorsum, 
 lateral plane, abdomen, thorax, neck, 
 arm, elbow, or hand. The commonest 
 form of shoulder presentation is the dor- 
 so-anterior, with the head to the left. 
 Occasionally in this connection we have 
 a compound presentation, such as hands 
 and feet or feet and head. In all cases of 
 shoulder presentation a wedge is formed, 
 its base pointing upward, made of one of 
 the long diameters of the head (4^ to 5^ 
 inches — 11.43 to 13.97 cm.), and an ob- 
 lique diameter of the trunk (4I inches — 
 12 cm.) occupying the lower uterine seg- 
 ment (Fig. 731). Labor consequently 
 with a full-term child and a pelvis of 
 average dimensions becomes impossible 
 without either spontaneous or artificial 
 correction of the malpresentation. 
 
 Frequency. — The proportion of 
 shoulder presentations as given by dif- 
 ferent statistics varies considerably. At 
 one maternity the ratio may be i to 125 
 normal births, while at another it may 
 not exceed i in 300. The proportion of 
 primiparae to multiparae also varies, the 
 former comprising 6 to 27 per cent, of 
 the total. In 2200 cases of confinement 
 I found shoulder presentation occurring 
 in 12 cases, 0.54 per cent., or i in 183 
 cases. 
 
 Etiology. — This differs entirely with 
 the parity of the woman. In primigra- 
 vidae the pelvis in shoulder presentations 
 is usually contracted. As occasional con- 
 tributory factors may be mentioned vari- 
 ous conditions which predispose to faulty 
 positions in general — hydramnios, mon- 
 strosities, malformation of the uterus, twins. In multigravidse shoulder pre- 
 sentations often come about through relaxation of the abdominal walls, and 
 especially in pendulous abdomen. The causes mentioned as obtaining in primi- 
 gravidae are also operative here to some extent. Unusual mobility of the fetus 
 is another condition believed to favor the persistence of the oblique position 
 In the fetus immaturity — by reason of the weak muscles, the relatively large 
 amount of liquor amnii, and the shape of the fetal ellipse in the premature fetus — 
 
 Fig. 734. — At the Pelvic Inlet. 
 
 Fig. 735. — At the Pelvic Ixlet. 
 
 Fig. 736. — Left Shoulder in the Cer- 
 vix. 
 
540 
 
 PATHOLOGICAL LABOR. 
 
 THIRD SHOULDER POSITION. 
 
 Right Scapula posterior, R. Scap. p. 
 
 is the great cause of shoulder presentation. (Page 423.) Death and maceration 
 of the fetus and multiple pregnancy for like reasons are causes. (Page 423.) In 
 the parturient tract pelvic deformity, excessive pelvic obliquity, and excessive 
 right lateral obliquity of the uterus are causes by interfering either with the proper 
 attitude of the child or the ready engagement of the head in the pelvic inlet. For 
 the same reason placenta prasvia, lax abdominal walls, as in hanging belly, and 
 an excessive amount of liquor amnii may result in shoulder presentation. This 
 
 malpresentation is seven times more fre- 
 quent in multigravidag than in primi- 
 gravidae. Hydrocephalus or enlarge- 
 ment of the fetal head from any cause, 
 since then it cannot engage in the pelvic 
 inlet; fetal monstrosities and extreme 
 mobility of the fetus from any cause; 
 tumors of the pelvis or uterus, kyphotic 
 spine and exostoses of the pelvic bones ; 
 tight lacing during pregnancy, which de- 
 creases the depth of the uterus while in- 
 creasing the width ; jars or traumatism of 
 any kind — any one of these may offer 
 cause for this faulty presentation. 
 
 Positions and Relative Frequency. — 
 Shoulder positions are named from the 
 relation which a scapula — part of the 
 fetus — bears to one of the four cardinal 
 points of the pelvis. It should be re- 
 membered that right and left never refer 
 to the scapulae, but always to the right 
 and left side of the pelvis; thus in the 
 right scapula anterior we mean that the 
 scapula is to the mother's right and an- 
 terior, no consideration being taken of 
 the fact that the left scapula of the fetus 
 presents. 
 
 I. Left scapula anterior, Scapula 
 laeva anterior, L. Scap. A. (Fig. 731). 
 
 II. Right scapula anterior. Scapula 
 dextra anterior, R. Scap. A. (Fig. 734). 
 
 III. Right scapula posterior. Scapula 
 dextra posterior, R. Scap. P. (Fig. 737). 
 
 IV. Left scapula posterior, Scapula 
 laeva posterior, L. Scap. P. (Fig. 740). 
 
 Left scapula anterior is the most fre- 
 quent position. 
 
 Mechanism and Course of Labor. — 
 We may say there is practically no mech- 
 anism of labor in shoulder presentation. It is safer to look upon labor as im- 
 possible without artificial aid than to trust to a spontaneous termination of the 
 complication. The usual steps in unaided cases are impaction of the shoulder; 
 ascension of the contraction ring; fetal death from prolonged pressure and 
 maternal death from rupture of the uterus or exhaustion. While this is true, 
 still under certain conditions a shoulder presentation has been known to terminate 
 
 F-iG. 737. — At the Pelvic Inlet. 
 
 Fig. 738. — At the Pelvic Inlet. 
 
 fi 
 
 Fig. 739.- 
 
 -RiGHT Shoulder in the Cer- 
 vix. 
 
FETAL DYSTOCIA FROM FAULTY PRESENTATION. 
 
 541 
 
 FOURTH SHOULDER POSITION. 
 LEFT SCAPULA POSTERIOR, L. SCAP. P. 
 
 Fig. 740. — -At the Pelvic Inlet. 
 
 spontaneously, in three ways, viz.: (i) Spontaneous rectification or spon- 
 taneous version; (2) spontaneous evolution; (3) doubled fetus, partus condu- 
 plicato cor pore. 
 
 1. Spontaneous Rectification and Verston. — The term spontaneous rectifica- 
 tion is usually confined to instances in which the cephalic extremity of the fetus 
 is brought into the lower uterine segment, and the term spontaneous version 
 to those cases in which the breech is 
 
 brought to the pelvic inlet. Spontaneous 
 rectification is of frequent occurrence, 
 and is often observed in the latter part 
 of gestation or in the preparatory or first 
 stage of labor. Spontaneous version is of 
 less frequent occurrence, as the breech 
 is not so frequently substituted for the 
 shoulders at the pelvic inlet as is the 
 head. The requirements for spontaneous 
 version are a rigid fetus, viz., living and 
 strong; irregular and strong uterine con- 
 tractions, confined to the fundus, where- 
 by the breech is driven down into the 
 lower uterine segment. Spontaneous 
 version is most apt to take place in mul- 
 tiparse whose tissues are lax. After the 
 bag of waters has ruptured, spontaneous 
 version is seldom encountered, although 
 the phenomenon is sometimes seen im- 
 mediately after rupture before the am- 
 niotic fluid has escaped to any great ex- 
 tent. When the waters have mostly 
 escaped, the tendency of the uterus is to 
 grasp the fetus firmly, so that the shoul- 
 der presentation becomes confirmed. The 
 opposite phenomenon is sometimes seen, 
 in which a normal position of the child 
 becomes transformed by uterine contrac- 
 tions into a shoulder presentation. These 
 so-called secondary shoulder positions 
 are of very infrequent occurrence. Spon- 
 taneous rectification and version are 
 both probably due to uterine contrac- 
 tions, but another factor assists, such as 
 the antero-lateral pressure of the pa- 
 tient's thighs as she sits or throws her- 
 self into certain postures, e. g., kneeling 
 or sitting. After spontaneous version or 
 rectification has occurred, the mechanism is that of a head or breech presentation. 
 
 2. Spontaneous Evolution (Fig. 543). — When a shoulder presentation be- 
 comes confirmed, a favorable termination of labor is still possible if the pelvis is 
 ample, the pains are strong, and the fetus is small. In these cases the shoulder, 
 forced into the pelvic inlet, follows the general law of rotation and turns forward. 
 It then comes to lie beneath the symphysis, the two fetal poles being closely 
 approximated. The shoulder is followed by the subjoined half of the thorax, the 
 
 At 
 
 Fig. 741. — At the Pelvic Ixlet. 
 
 Fig. 742. — Left 
 
 Shoulder 
 vix. 
 
 IN THE Cer- 
 
542 
 
 PATHOLOGICAL LABOR. 
 
 Fig. 746. 
 Figs. 743 to 746. — The Four Stages of Spon- 
 taneous Evolution. 
 
 buttocks, the opposite shoulder, 
 and finahy the head. This pro- 
 cess may require but very Httle 
 time, and even a soHtary con- 
 traction is known to have been 
 sufficient. This spontaneous ter- 
 mination of shoulder presenta- 
 tion occurs in about 8 per cent, 
 of all cases if unusually small 
 children, second twins, prema- 
 ture births, etc., are included. 
 In a series of immature living 
 children the proportion is still 
 higher, and some authors do not 
 even class these deliveries as 
 pathological. The stages, then, 
 in the accomplishment of spon- 
 taneous evolution are: (i) com- 
 pression of the fetus; (2) descent 
 (Fig. 743) ; (3) engagement of the 
 anterior shoulder under the pu- 
 bic arch (Fig. 744); (4) driving 
 out of the podalic extremity of 
 the fetus over the posterior wall 
 of the parturient tract (Fig. 745) i 
 
 (5) delivery of the posterior 
 shoulder and arm (Fig. 745); 
 
 (6) delivery of the after-coming 
 head (Fig. 746). Excessive lat- 
 eral flexion of the fetus is neces- 
 sary for the accomplishment of 
 spontaneous evolution. Unless 
 all conditions are most favorable 
 for birth, the case will end in fetal 
 impaction and death of the fetus. 
 
 3. Doubled Fetus {Partus 
 Condnplicato Cor pore) . — When 
 spontaneous evolution occurs in 
 very small yielding fetuses, the 
 approximated head and but- 
 tocks may pass through the pel- 
 vis side by side, rotation failing 
 to occur. This so-called partus 
 condnplicato cor pore is extremely 
 rare. The fetus's head and body 
 together enter the pelvis with 
 the prolapsed shoulder in ad- 
 vance. There should be rotation 
 of this shoulder to the pubic 
 arch, but the mechanism of this 
 process is scarcely noticeable, 
 since if it is possible for it to take 
 
FETAL DYSTOCIA FROM FAULTY PRESENTATION. 
 
 543 
 
 Fig. 747.— Frozen Section of a Neglected Shoulder 
 Presentation. Woman died in the second stage of 
 labor. Shows first stage of spontaneous evolution. — 
 {Chiara.) 
 
 place at all, the fetus must be very soft and small. In this process the head and 
 body are delivered together, followed by buttocks and legs, the second arm lying 
 between the head and breech. The conditions necessary for delivery by a doubled 
 fetus are a roomy pelvis and a small, macerated, dead or premature fetus. It is 
 an extremely rare termination. 
 
 The preceding terminations of shoulder presentation are exceptional, and in 
 the great majority of cases 
 nature is unequal to the task 
 of expelling the fetus. If 
 labor in a shoulder presenta- 
 tion begins with weak pains 
 and early rupture of the mem- 
 branes, the contractions re- 
 maining feeble after the latter 
 event, such a state of affairs 
 may persist for days until the 
 cervix is fully dilated. Or we 
 may sometimes see rupture of 
 the membranes followed by 
 violent contractions which 
 cause rupture of the lower 
 segment of the uterus within 
 a few hours. Under any cir- 
 cumstances the long sojourn 
 of the fetus in the maternal 
 passages, often inevitable in 
 
 shoulder presentation, is frequently followed by maceration, especially when 
 death has occurred early in labor. Maceration, by rendering the child more 
 compressible, is sometimes the occasion of spontaneous ending of labor. 
 
 Diagnosis. — Before labor abdominal palpation usually renders the diagnosis 
 simple. During labor we find the cervix high up in the pelvis and irregular 
 formation of the bag of membranes. When uncertainty exists, one must admin- 
 ister chloroform and pass the whole 
 hand into the vagina to make a 
 positive diagnosis. The shoulder 
 is to be differentiated from the 
 breech (page 536); the elbow from 
 the knee (page 536) ; the hand from 
 the foot (page 536). Inspection 
 alone will often reveal the nature 
 of the case, as the transverse diam- 
 eter of the uterus exceeds the longi- 
 tudinal and the outline is not sym- 
 metrical. As a rule, the fetal back 
 lies anterior. Then the round, hard 
 head can be felt in one iliac fossa 
 and the soft, irregular breech in the 
 opposite side of the mother's abdomen high up (Fig. 201). The hne of the back 
 may be traced between the two. These points may be observed before labor or 
 in its early stage. But at a more advanced stage, as lateral flexion of the child 
 increases, the head would almost appear to join the breech at a right angle. 
 When the resisting back lies posterior, it cannot be felt by palpation. By vaginal 
 
 Fig. 748. — Neglected Shoulder Presenta- 
 tion. Left Scapulo-anterior Position. 
 Death of fetus and oedema and excoriation of 
 the right shoulder. — (Schaeffer.) 
 
544 
 
 PATHOLOGICAL LABOR. 
 
 examination the dependent part of the bag of waters gives a sensation often 
 likened to that of a glove-finger; the head cannot be felt; if the shoulder presents, 
 its rounded contour may be felt as well as the axillary fossa; the ribs may be 
 traced near at hand and also the acromion, clavicle, and scapular spine. 
 
 Position of Fetus. 
 
 PosiTioK OF Fhtal Heart- 
 sounds. 
 
 Left Scap. -ante- 
 rior. L.Scap.A. 
 
 Right Scap. -ante- 
 rior. R. Scap. 
 A. 
 
 Right Scap. -pos- 
 terior. R. Scap. 
 P. 
 
 Left Scap. -poste- 
 rior. L. Scap. 
 P. 
 
 Head in left ihac fossa, back anterior; extremi- 
 ties on right side, in upper part of abdomen. 
 
 Head in right iUac fossa, back anterior; ex- 
 tremities on left side, in upper part of abdo- 
 men. 
 
 Head in right iliac fossa, back posterior; ex- 
 tremities on left side, in upper part of abdo- 
 men. 
 
 Head in left iliac fossa, back posterior; extremi- 
 ties on right side, in upper part of abdomen. 
 
 Left side of abdomen, 
 below umbilicus. 
 
 Right side of abdomen, 
 below umbilicus. 
 
 Right side of abdomen, 
 below umbilicus to- 
 ward the rear. 
 
 Frequently cannot be 
 heard. Left side to 
 the rear. 
 
 Prognosis. — In cases left to themselves the prognosis is grave for both mother 
 and child. With intervention, the outlook varies with the stage of labor and 
 other factors. If the case is seen early, the position may be transformed from 
 the oblique to the vertical, especially if the bag of waters is intact; while if the 
 latter can be preserved until the cervix is fully dilated, there is a good chance of 
 extracting the child alive. The outlook for the mother is prejudiced only by the 
 added danger from atonia, hemorrhage, and infection from manipulations. It 
 must be remembered, however, that rupture of the uterus may occur during 
 the performance of embryotpmy. The prognosis will depend on the operation 
 undertaken, since natural termination of shoulder presentation is not the rule. 
 When the presentation is rectified early, there is a good outlook for mother and 
 child. Neglected cases will result in death of both. Dangers to the child come 
 from compression of the brain centers, vessels of the neck, or umbilical cord. 
 Injury of the child is liable to occur during operation. The mother may die of 
 sepsis, exhaustion, rupture of the uterus, or hemorrhage. Conclusions: The 
 prognosis depends upon: (i) the stage of labor at which the complication is 
 recognized; (2) the time that elapses before the correction of the mal- 
 presentation ; (3) the time that has elapsed since the membranes ruptured, and 
 the quantity of liquor amnii still remaining in the uterus ; (4) the condition 
 of the uterus and cervix, especially as regards thinning of the lower uterine 
 segment, and ascent of the contraction ring; (5) prolapse of the cord as a com- 
 plication. A neglected shoulder presentation results in a gradual escape of all 
 the liquor amnii, contraction and retraction, a tetanic or inert condition of 
 the uterus with or without uterine rupture, exhaustion and death of both mother 
 and fetus. 
 
 Treatment. — All delay is dangerous, and the sooner the malpresentation is 
 corrected by external, combined, or internal version, the better the prog- 
 nosis. If the shoulder is already impacted, decapitation of the fetus must be 
 performed or some other method of removing the child should be undertaken at 
 once. Laparotomy, with the Caesarean or Porro operation, is certainly safer in 
 many neglected cases than a difficult decapitation. (See Part X.) 
 
FETAL DYSTOCIA FROM FAULTY POSITION. 545 
 
 FETAL DYSTOCIA FROM FAULTY POSITION. 
 
 XI!. PERSISTENT OCCIPITO-POSTERIOR POSITION. 
 
 Definition. — The vertex presentation in which backward rotation of the 
 occiput occurs in the first and second positions or in which a permanent occipito- 
 jjosterior position obtains in the third and fourth positions. As a rule, labor is 
 prolonged in these cases, partly because the head does not flex as it ought to on 
 its entrance into the pelvis, and consequently does not readily descend, and 
 partly on account of the protracted internal rotation (Fig. 750). 
 
 Frequency. — This is variously stated as from i to 4 per cent. In 2200 labors 
 I found that persistent occipito-posterior position occurred in 89 cases, or 4.04 
 per cent.; 46, or 51.68 per cent., were in primiparae; 2>3' or 37.07 per cent., in 
 multipar.Te ; and 10, or 11.23 P^r cent., were of unknown para. 
 
 Etiology. — The most common cause is incomplete flexion of the head whereby 
 some other part of the head, such as the forehead, first meets the resistance of 
 the pelvic floor, and is deflected anteriorly. This throws the occiput into the 
 hollow of the sacrum. In other cases the cause may be found in a defect in the 
 resistance of the pelvic floor, as in the birth of the second twin w^hen the pelvic 
 floor has been stretched by the birth of the first ; in old and extensive lacerations 
 of the pelvic floor ; in disproportion between the head and floor, as in very roomy 
 pelves, or in undersized heads; in uterine and abdominal inertia; in obstruction 
 to forward rotation of the vertex, as in prolapse of the hand or foot anteriorly; 
 in pelvic deformity, as in justo-minor or k^-^photic pelves; or in hydrocephalus of 
 the fetal head. In these cases accommodation or adaptation results in a pos- 
 terior position of the vertex. Sometimes in cases in which there is a slight 
 disturbance of flexion and the occiput first touches the floor, there is rotation 
 backward of the occiput because the fronto-occipital diameter engages and it is 
 impossible for the head to rotate from one oblique diameter through the shorter 
 transverse to the other oblique. 
 
 Mechanism. — (Compare Vertex Presentation, Part IV.) To understand 
 the mechanism of labor, careful comparison must be made between the lower an- 
 terior and posterior wall of the parturient tract. The anterior wall of the pelvis, 
 namely, the symphysis, is i§ inches (3.81 cm.) to 2 inches (5.08 cm.). The dis- 
 tance from the junction of the neck with the trunk to the vertex is about 3 inches 
 (7.62 cm.), hence in occipito-anterior position the head reaches the pelvic floor 
 and extends through the vulval orifice without the trunk necessarily entering the 
 pelvis until the head is completely delivered. The posterior wall of the pelvis, 
 from promontory of sacrum to coccyx, is 5 inches (12.7 cm.), and the pelvic floor, 
 when distended, from coccyx to edge of perineum is also 5 inches (12.7 cm.), raak- 
 ing 10 inches (25.4 cm.) from promontory to perineum. Hence for the vertex to 
 reach the pelvicTloor in the posterior position the neck must be greatly elongated 
 or the trunk must enter the pelvis with the head. If the latter occurs, subsequent 
 impaction is liable to take place, for we will then have at the pelvic outlet a pre- 
 senting part whose antero-posterior diameter is made up of the fronto-mental 
 diameter of the fetal head (3 J inches — 8.25 cm.) and the dorso-stemal diameter 
 of the fetal trunk (3! inches — 9.5 cm.), making together 7 inches (17.78 cm.) to 
 pass through the lower part of the pelvis (Fig. 750). In spite of the foregoing, 
 spontaneous termination sometimes occurs. The brow engages under the sym- 
 physis; the perineum, tremendously distended, retracts over the occiput; the 
 latter, in an extreme state of flexion, sometimes with an entire loss of perineum 
 35 
 
546 
 
 PATHOLOGICAL LABOR. 
 
 Fig. 749. — Diagram Explanatory of the Mechanism 
 OF Persistent Occipito-posterior Position of the 
 Vertex. 
 
 and anterior rectal wall, extends and is bom. The nape of the neck then rests 
 upon the retracted and lacerated perineum and the supraorbital ridges, eyes, nose, 
 and mouth appear under the symphysis and the head is born by extension. Per- 
 sistent occipito-posterior position is also known as "face to pubis." When natural 
 
 expulsion takes place, as 
 has been said, the face 
 passes under the symphysis 
 and the occiput makes its 
 way over the perineum. 
 This process is not an easy 
 one and necessitates vigor- 
 ous contractions, lax ma- 
 ternal soft parts, and head 
 of ordinary size. The head 
 moulding results in very 
 much shorter occipito -fron- 
 tal and occipito-mental di- 
 ameters with correspond- 
 ing lengthening of the 
 suboccipi to -bregma tic 
 (Fig. 752). Before passing 
 through the outlet the head 
 becomes well flexed. After 
 the head is bom external 
 rotation (internal rotation 
 of the shoulders) occurs, 
 after which the body is 
 bom. If flexion be prevented, the head may rarely come down into the pelvis in 
 a state of extension and there exists a brow or face presentation. Or, again, the 
 head only partially flexed may enter the pelvis, and after reaching the floor there 
 may be partial rotation and the head become fixed in the transverse diameter of 
 the cavity of the pelvis (Deep Transverse 
 Position of the Head, page 553.) 
 
 Diagnosis. — In palpation of the mater- 
 nal abdomen at the beginning of labor the 
 fetal limbs but not the back may be felt, 
 especially if the parietes are lax and thin, 
 and the head may be perceptible above the 
 brim. The heart-sounds are heard between 
 the ribs and the crest of the ilium. By vag- 
 inal examination the head may be felt 
 through the fomices, and later on, when 
 the cervix is sufficiently dilated, the pos- 
 terior fontanelle is in the posterior part of 
 the pelvic cavity, while the sagittal suture 
 is in the line of an oblique diameter. In the 
 first stage the pains are not infrequently 
 irregular and abnormal. 
 
 Prognosis. — The dangers to the mother are prolonged labor, exhaustion, and 
 even death. Severe lacerations of the pelvic floor are the rule. In impaction 
 pressure necrosis, sepsis, and shock of operation may occur. The mortality for 
 the child is about 10 per cent. The dangers are: asphyxia from prolonged com- 
 
 FiG. 750. — Persistent Occipito-pos- 
 terior Position. 
 
FETAL DYSTOCIA FROM FAULTY POSITION. 
 
 547 
 
 HEAD MOULDING IN PERSISTENT OC- 
 CIPITO-POSTERIOR POSITION. 
 
 pression or premature separation of the placenta; cerebral compression, and 
 pressure on the cord. 
 
 In my 89 cases already referred to, the maternal mortality was 3 cases, or 
 3.38 percent. Regarding the fetal prognosis, 79, or 88.76 per cent., lived; 7, or 
 7.86 percent., were still-bom; and the 
 result for 3, or 3.38 per cent., was not 
 recorded. In the 89 cases referred to 
 above, the method of delivery was by 
 natural forces in 43 cases; forceps in 
 41 ; version in 2 ; craniotomy in i case, 
 and symphyseotomy in i case. 
 
 Treatment. — Prophylactic : The 
 preventive treatment of this quite 
 common and serious complication of 
 labor promises very little indeed, be- 
 cause we are unable to remedy the 
 anatomical cause of the condition 
 found in the fetus, pelvis, or maternal 
 soft parts. When the diagnosis of oc- 
 cipito-posterior position is made in 
 pregnancy, it has been proposed that 
 the more favorable anterior position 
 shall be obtained by external manipu- 
 lation through the anterior abdominal 
 wall. This is a refinement of abdom- 
 inal palpation which I believe to be 
 theoretical in the hands of most, if not 
 all, obstetricians. Postural prophyl- 
 axis, on the other hand, I believe 
 offers some hope in cases in which the 
 anatomical influences in fetus, pelvis, 
 or maternal soft parts are not too 
 strong. In instances in which there 
 is reason to suspect this complication 
 the patient may be instructed to as- 
 sume the knee-elbow position for five 
 or six minutes morning and evening 
 for a fortnight or even longer preced- 
 ing labor.* This to be followed by the 
 lateral posture. I have found in pri- 
 vate practice that it is often a physical 
 impossibility for patients to remain 
 more than a minute or two in the 
 knee-chest position by reason of the 
 intense cerebral congestion and dis- 
 comfort produced. In such a case in 
 the latter part of pregnancy and dur- 
 ing the first and second stages of labor I have the woman placed in an exaggerated 
 lateral prone position with a pillow or several sheets under the lower buttock in 
 order, as far as possible, to reverse the condition of the dorsal position. The choice 
 of side for the patient to lie upon is the one toward which the occiput points. (See 
 * Reynolds: "Practical Midwifery," page 211, 1892. 
 
 Fig. 751. — Before Moulding. 
 
 Fig. 752. — After Moulding. Note depres- 
 sion at anterior fontanelle caused by the 
 pubic arch. 
 
548 
 
 PATHOLOGICAL LABOR. 
 
 Operations, Part X.) Operative: It should be clearly understood that operative 
 interference in occipito-posterior position is not to be undertaken until labor has 
 advanced to a point at which the interests of fetus or mother demand interven- 
 tion. It must be remembered that operation is applicable only to persistent 
 cases of this kind; that most of the originally occipito-posterior positions ter- 
 minate anteriorly spontaneously, and that only between one and four per cent, of 
 all vertex positions result in persistent posterior positions, the remaining being 
 either originally anterior positions or terminating spontaneously as such. Before 
 deciding upon interference in all cases of delayed labor at the pelvic inlet I always 
 make a thorough examination under chloroform, introducing the whole hand if 
 necessary to ascertain the presentation and position, and secure flexion or exten- 
 sion as the case may be. For con- 
 venience' sake I am accustomed to 
 divide all of these cases into three 
 classes: (i) High cases, in which the 
 vertex is still above the pelvic inlet 
 and not engaged; (2) medium, in 
 which the vertex is fully engaged but 
 occupies the upper part of the pelvis 
 and has not reached the pelvic floor; 
 (3) low cases, in which the occiput 
 rests on the pelvic floor and possibly 
 distends the perineum. 
 
 I. High Cases. — This is the most 
 infrequent of the three classes, for in 
 the majority of cases the natural 
 powers possess strength enough to 
 engage the head, and only subse- 
 quently, by reason of the malposi- 
 tion and excessive force required, do 
 the powers fail. Fortunate it is that 
 this is the case, since this class car- 
 ries with it the worst prognosis under 
 operative treatment. No serious 
 disproportion existing between the 
 fetus and pelvis, we have at our com- 
 mand four procedures for the man- 
 agement of these cases: (i) Rotation 
 of the back of the fetal ellipse to the 
 front by external manipulation, fol- 
 lowed by the application of the forceps; (2) rotation of the vertex from the pos- 
 terior to the anterior position by internal manual means, followed by the use of 
 the forceps; (3) the application of the forceps without previous attempts at 
 anterior rotation of the occiput; (4) internal podalic version followed by breech 
 extraction, (i) External manual rotation: The possibility under favorable con- 
 ditions — namely, intact membranes and thin abdominal walls — of rotation of 
 the occiput forward by external manipulation must be granted, but such a 
 theoretical refinement of obstetrical palpation can scarcely be of much practical 
 value. (2) Internal manual rotation: Anterior rotation of the occiput by means 
 of the hand passed into the uterus and grasping the head or shoulders and 
 allowing the anterior position to terminate spontaneously, or delivering imme- 
 diately with the forceps, is the favorite treatment with many operators in 
 
 Fig. 753. — Persistent Occipito-posterior 
 Position of the Head. R. O. P. Pro- 
 longed labor; secondary inertia; rest; strych- 
 nia; spontaneous delivery with anterior ro- 
 tation of the occiput. — {From a tracing. 
 Emergency Hospital, October 7, 1892.) 
 
FETAL DYSTOCIA FROM FAULTY POSITION. 549 
 
 America, and by some used to the exclusion of other methods of treatment. 
 I have been more successful with other methods, and I am convinced after 
 repeated trials that the mortality with this method equals that of internal 
 podalic version, for the reason that successfully to carry out the anterior rotation 
 the hand must be used not only to rotate the head, else it will immediately 
 return to its malposition, but it must be passed up to rotate the shoulders 
 as well. This grasping of the fetal body I have foxmd disturbs the circulatory 
 equilibrium of the fetus, favors intrauterine asphyxia, and, unless the fetus 
 is immediately extracted, intrauterine death ensues. Should this method of 
 correction be selected, it should always be performed bimanually, one hand 
 upon the anterior abdominal wall assisting in the work of the internal hand. 
 The operation can often be more readily performed with the patient in the 
 exaggerated left lateral prone posture, and lying upon that side of the 
 pelvis around the segment of which we desire the occiput to rotate. (See 
 Part X.) If the fetal back and occiput are directly to the rear, and there 
 is thus no choice of sides for the patient to lie on, the exaggerated left lateral 
 prone posture will be found the most convenient for permitting the use of 
 the right hand internally. (3) Forceps: The application of the forceps without 
 previous attempts at antenor rotation of the occiput. Both theoretically 
 and practically . I believe this method will give better results as far as fetal 
 mortality and morbidity are concerned, and equally as good results for the 
 mother as version. The difficulties and dangers of a high forceps operation 
 in this as in other presentations and positions must ever be kept in mind, and 
 so great are these dangers that I would recommend this method of treatment 
 only to those thoroughly familiar with the technique of a high forceps operation. 
 For those of limited experience in high forceps operations version will prove 
 the safer operation for the mother, although carrying with it a high fetal mor- 
 tality. Of course, the usual contraindications for version always hold good — 
 namely, escape of the liquor amnii, tetanic uterine contractions, and dangerous 
 thinning of the lower uterine segment. It is in these cases particularly that 
 no aesthetic reason should prevent our perforating the head of a dead fetus. 
 Usually it is not wise to attempt an adaptation of the forceps under such 
 conditions to the sides of the fetal head, — namely, the cephalic application, — 
 but to apply the instrument at the sides of the pelvis — namely, the pelvic 
 application. My object in the use of the forceps in these cases is to change 
 a high occipito-posterior position into a medium or low one, then to remove 
 the forceps, which has perhaps grasped the head obliquely, adapt it over the 
 fetal ears, use the instrument as a rotator, and instrumentally rotate the 
 vertex to the front as in medium and low cases. (See Operations, Part X.) 
 (4) Version: Manual anterior rotation or forceps without manual rotation failing 
 and. the fetus being still alive, version remains as the only alternative. I 
 place version last because I believe the forceps alone or combined with manual 
 rotation offers the best prognosis in the hands of the experienced operator. 
 If by reason of uterine retraction version is forbidden, perforation and possibly 
 symphyseotomy should be considered. 
 
 2. Medium Cases. — As in high cases of persistent occipito-posterior posi- 
 tions, the first step in the treatment is to insure complete flexion of the head. 
 Anterior rotation may be promoted by pressure upon the forehead applied 
 during a pain. This pressure should be applied as far forward as possible. 
 If the head becomes extended, it may be flexed by pushing up the forehead 
 or pulling down the occiput. For the latter purpose a vectis or blade of the 
 forceps may be used if there is no room for the hand. If the expulsive force is at 
 
550 PATHOLOGICAL LABOR. 
 
 fault, the judicious use of remedies for delay in the second stage may be employed 
 (page 573). If all efforts at rotation fail and immediate delivery is demanded, 
 the application of the forceps is the only resource, short of perforation. (For 
 the use of the forceps in occiput posterior positions see Operations, Part X.) 
 
 3, Low Cases. — This I have found to be the most frequent variety of occipito- 
 posterior cases met with. The forces are able to push the fetal head to the 
 pelvic floor, and then delayed labor ensues by reason of the fact that the forceps 
 is unable either to rotate the occiput anteriorly or to deliver the head of the 
 occiput remaining at the rear. Whether the case be a left or right sacro-position, 
 two methods of delivery in the case of a living fetus are open to us. These 
 are (i) forceps delivery with the occiput still posterior; and (2) rotation of the 
 occiput anteriorly with the forceps and delivery as in anterior positions of the 
 vertex. In all cases with the exception of a few multiparas with lacerated and 
 relaxed pelvic floors in which little resistance to delivery is offered 1 would 
 advise the second plan of procedure, — namely, anterior rotation of the occiput 
 with the forceps, — for the reasons that less laceration of the pelvic floor occurs, 
 and the fetal morbidity and mortality are less in mechanical anterior rotation 
 and delivery. Much bitter opposition to instrumental rotation of the present- 
 ing part has been expressed by English and American obstetric writers, notably 
 Playfair,* Lusk,t Hirst, f and Reynolds^; the French and German writers 
 taking a more liberal view of the question. Since the early nineties I have 
 been teaching and using instrumental rotation in these cases in both hospital 
 and private work, and, with certain limitations, have never had occasion to 
 regret it. A paper by Brodhead, || of New York, read before the New York 
 Obstetrical Society, brought out in the discussion that the method, in New York 
 at least, was coming into general favor; Cragin, Tucker, Marx, Von Ramdohr, 
 and I indorsing the operation. (See Operations, Part X.) 
 
 XIII. PERSISTENT MENTO-POSTERIOR POSITION. 
 
 Definition. — A face presentation in which backward rotation of the chin 
 occurs in the first and second positions, or in which a persistent mento-posterior 
 position obtains in the third and fourth positions (Fig. 756). 
 
 Frequency. — Face positions in the pelvic cavity with the chin persistently 
 behind are rare ; their existence has even been denied. They make up less than 
 one per cent, of all face positions. 
 
 Etiology. — ( I ) The face may engage at the inlet with the chin behind and an- 
 terior rotation may not take place; (2) or, with the chin in front, posterior rota- 
 tion occurs. In the first case the failure of anterior rotation is due to the relative 
 disproportion between the depth of the excavation at the side and the length of 
 the fetal neck, so that the chin does not meet with sufficient resistance to produce 
 anterior rotation. Certain pelvic deformities or obstructive conditions of the soft 
 parts might produce the same results. The prominence of the bregmatic region 
 in consideration of the distance it must travel in rotation renders necessary the 
 presence of strong, persistent uterine contractions and capacity of the head for 
 moulding. The second variety can occur only with a very large pelvis or small 
 head; the head is imperfectly extended, the sinciput meets with the pelvic-floor 
 resistance before the chin and is turned forward, carrying the chin backward. In 
 
 * " Science and Practice of Midwifery," 1S98. 
 
 t "The Science and Art of Midwifery," 1S92. 
 
 J " Text-book of Obstetrics," i8q8. § " Practice of Midwifery," 1896. 
 
 II "American Journal of Obstetrics," vol. xlii, No. 6, 1900. 
 
FETAL DYSTOCIA FROM FAULTY POSITION. 
 
 551 
 
 
 the case of a very small fetal head or justo-major pelvis the face may be forced 
 into the pelvis with extension incomplete. The sinciput strikes the pelvic floor 
 in advance of the chin. If the chin is behind in the inlet, it remains behind; if 
 in front, the sinciput strikes the sacral segment of the pelvic floor and rotates for- 
 ward, carrying the chin backward. 
 
 Mechanism. — To understand these unreduced mento-posterior positions we 
 must bear in mind the mechanism of normal posterior face positions. These 
 presuppose the existence of complete head extension by virtue of which the chin 
 is first to strike the pelvic floor and be rotated beneath the pubis. When 
 the etiological elements already enumerated come into play so that the chin 
 finds its way to the hollow of the sacrum, the head, neck, and thorax constitute 
 a wedge which with further progress of labor 
 becomes impacted. The almost unanimous 
 testimony of obstetricians is that birth of 
 living mature children in mento-posterior 
 positions is necessarily impossible. Ahlfeld 
 states that a few cases of undoubted authen- 
 ticity are on record, but does not state how 
 such births were made possible. The 
 mechanism of this position in relation to 
 its essential fatality may be summarized as 
 follows : Spontaneous expulsion is impossible 
 without partial or complete rotation of the 
 chin forward; the length of the fetal neck 
 from the trunk to the chin is about 2 inches 
 (5.08 cm.) ; the posterior wall of the partur- 
 ient canal from the promontory to the edge 
 of the perineum is 10 inches (25.4 cm.); the 
 chin cannot reach the perineum without en- 
 trance of the thorax into the pelvis; impac- 
 tion results because the trachelo-bregmatic 
 diameter of the head, and dorso-sternal di- 
 ameter of the thorax, each of which measures 
 3^ inches (8.89 cm.), or 7 inches (17.78 cm.) 
 in all, attempt to pass into the pelvis at 
 once. Naturally all the phenomena of ob- 
 structed labor result, including tetanoid con- 
 tractions of the uterus. The fetus perishes 
 from asphyxia as a consequence of compres- 
 sion of its head and chest. These unreduced 
 
 mento-posterior positions are often compared with those in which the occiput 
 does not undergo anterior rotation. In the occipito-posterior variety the occiput 
 clears the perineum and frees the head ; but in the mento-posterior the large fon- 
 tanelle is pressed against the pubis, and for the chin to clear the perineum a 
 degree of extension would be required which is impossible for a living, full-sized 
 fetus (Fig. 756). 
 
 Diagnosis. — In a mento-posterior position the occiput is found more toward 
 the front in the anterior and lower part of the uterus, palpable and visible from 
 the outside. Internally the vaginal vault appears flat and the chin stands high 
 and is difficult to reach posteriorly. The fetal cardiac sounds are heard with 
 difficulty. With the entire hand in the vagina the diagnosis is not difficult. 
 
 Prognosis. — This position is universally recognized as forming the most 
 
 Fig. 754. — Moulding of the Head in 
 Face Presentation. Primipara; 
 R. M. P.; first stage of labor three 
 days; membranes ruptured two 
 days; uterine inertia; manual dila- 
 tation of cervix; adaptation of 
 forceps. Fronto-mental diameter 
 transverse in the pelvis; rotation 
 with the forceps; delivery of a living 
 child. — {Author's case at Emergency 
 Hospital. December 8, igo2. From 
 a tracing.) 
 
552 
 
 PATHOLOGICAL LABOR. 
 
 Fig. 755. — Moulding from Persistent Mento-poste- 
 RiOR Position. R. M P.; prolonged labor; secondary 
 inertia; strychnia; spontaneous delivery with anterior 
 rotation of the chin. — {Author's case at the Emergency 
 Hospital, April, 1902.) 
 
 serious mechanical complication of labor arising from the fetus. The child mor- 
 tality is about 50 per cent. C. B. Reed* collected 75 of these cases from 
 literature and found the maternal mortality 11.6 per cent, or about the maternal 
 mortality of placenta previa. The fetal mortality in the 75 collected cases was 
 40.6 per cent. This series includes both persistent cases at the inlet and outlet 
 
 and several small children. 
 Persistent cases with the 
 chin embedded in the pelvic 
 floor with a full-sized child 
 give a fetal mortality of 
 practically 100 per cent. 
 The mother is exposed to 
 great danger and the mor- 
 tality is high. 
 
 Treatment. — i. At the 
 Pelvic Inlet. — We must re- 
 member that less than i per 
 cent, of all face presenta- 
 tions are persistent mento- 
 posterior, hence the value 
 of expectancy within safe 
 limits. Defective extension 
 should be corrected by the 
 fingers or hand. Failure of engagement of the face at the inlet calls for conver- 
 sion into a vertex by Baudelocque's, Thom's, or Schatz-Thom's methods, fol- 
 lowed by high forceps or spontaneous labor in posterior chin positions, and 
 podalic version and extraction in anterior chin positions, or conversion and high 
 forceps in both. In multiparae I prefer podalic version and extraction to the 
 exclusion of other com- 
 bined methods. 
 
 2. In the Pelvic Cav- ~" 
 
 ity. — Application of the 
 hand or forceps blade 
 beneath the chin will 
 give the latter a point of 
 support which will favor 
 anterior rotation. Trac- 
 tion with forceps will 
 bring the chin upon the 
 pelvic floor and slight 
 rotation will enable it to 
 rotate forward. No at- 
 tempt should ever be 
 made to deliver the 
 'chin over the perineum. 
 When the face is im- 
 pacted, the indication 
 
 must lie between forceps for rotation, symphyseotomy, Cassarean section, and em- 
 bryotomy. The original teaching of Scanzoni and others that forceps might be 
 used to turn the chin forward is now almost universally condemned. Popescule f 
 
 *" Amer. Jour. Obstet.," vol. li. No. 5, 1905. 
 t " Centralbl. f. Gynakol.," Aug. 4, 1900. 
 
 Fig. 756. — -Persistent Mento-Posterior Position. 
 
FETAL DYSTOCIA FROM FAULTY POSITION. 
 
 553 
 
 followed this advice and lost the mother. He states that he would never use the 
 forceps in another case. Von Braun states that the use of the forceps for this 
 complication means death for mother and child. Doderlein appears to think that 
 great technical skill might accomplish something with the forceps. I have re- 
 peatedly used the forceps successfully as rotators of the chin anteriorly when the 
 chin had not become embedded in the pelvic fioor, and when it did not point 
 directly posteriorly. Popescule first brought the face into the transverse posi- 
 tion. He then detached the blades, reapplied them, turned the chin under the 
 symphysis, and extracted the child. In the past most authorities agreed that 
 perforation is the indication of necessity, even in the living child. Symphyseo- 
 tomy has been suggested as applicable to this complication. It has been once 
 performed.* 
 
 XIV. TRANSVERSE POSITION OF THE HEAD AT THE PELVIC 
 
 OUTLET. 
 
 Definition and Etiology. — Descent of the head occurs without anterior rotation 
 in consequence of certain anomalies of the pelvis or fetus. This is the "deep 
 transverse position" of the head. This position is primary or secondary. The 
 primary position is found in 
 the simple fiat pelvis, in the 
 generally contracted fiat pel- 
 vis, and in the masculine or 
 funnel-shaped pelvis, and 
 even in the larger pelves 
 when the head is very small 
 and the liquor amnii sud- 
 denly lost with precipitate 
 descent of the head. It is 
 also found in congenital 
 double hip dislocation. In 
 the simple flat pelvis the 
 bregma is lower, while in the 
 generally contracted flat pel- 
 vis the posterior fontanelle is 
 lower. Nearly all of these 
 
 cases when analyzed show themselves to be occipito-anterior presentations. The 
 secondary position is found when the head is large and the occiput is broad, as in 
 dolichocephalus. The occiput continues posterior from the first till the head 
 reaches the floor of the pelvis. At this point there may occur a partial rotation of 
 the occiput into the transverse diameter of the outlet. The bregma is generally 
 lower than the occiput. Incomplete head flexion is a common cause. Again, this 
 position may occur in case of a flat pelvis which is large enough to let the head pass 
 the inlet in an oblique diameter, the occiput being posterior, but which is so con- 
 tracted below that anterior rotation cannot completely take place as in the mas- 
 culine pelvis. Reed found 32 deep transverse arrests of the head in 3600 labors 
 at the Chicago Lying-in Hospital, or 0.9 per cent.; 18 cases occurred in multi- 
 paras and 14 in primiparse (Fig. 757). 
 
 Symptoms. — If the head remains in this position, pressure necrosis, fistula, 
 and death of the fetus and mother may occur. The head may be bom trans- 
 versely, causing extensive laceration, or anterior or posterior rotation may take 
 * Montgomery: "Trans. 111. Med. Soc," 1904. 
 
 Fig. 757. — Transverse Position of the Head at thb 
 Pelvic Outlet, Deep Transverse Position of thb 
 Head. 
 
554 PATHOLOGICAL LABOR. 
 
 place. In some cases the pains may entirely cease owing to the obstruction to 
 labor. In others, the head may be forced through the bony outlet by the excessive 
 strength of the pains, and the perineal tissue then suffers. Spontaneous trans- 
 verse delivery may rarely occur in the case of a large pelvis, a small head, and 
 an old perineal laceration. Cases are known in which the head if it continues in 
 extreme flexion is bom transversely in a fiat and contracted pelvis. 
 
 Prognosis. — For the mother, delayed labor, exhaustion, and sepsis; for 
 the fetus, asphyxia or death from compression of the brain or placenta. 
 
 Treatment. — Postural treatment offers very little. Anterior rotation may 
 be favored by the lateral decubitus, the patient lying on the side toward which 
 the occiput faces. (See Posture in Obstetrics, Part X.) Stimulants, such as 
 strychnin, quinin, and alcohol, may be administered to increase the expulsive 
 forces. Digital rotation with the hope of bringing the occiput forward may be 
 tried, but will hardly succeed in contracted pelves: (i) With two fingers in the 
 vagina we may attempt to push the sinciput posteriorly; (2) with two fingers 
 or the whole hand in the vagina we may lift up the head slightly and with two 
 fingers of the other hand in the rectum attempt to push the brow backward; 
 (3) with the whole hand in the vagina grasping the vault of the head, we may 
 attempt both to raise the head from between the tubera ischii and at the same 
 time rotate the occiput anteriorly. Failing with manual correction, the forceps 
 may be applied over the parietal bones; and failing in this, in an oblique pelvic 
 diameter and rotation combined with traction used. Symphyseotomy has its 
 place in firm impaction and a living fetus. In all cases of impaction with a 
 dead fetus the head should be perforated. 
 
 FETAL DYSTOCIA FROM GENERAL FETAL CONDITIONS. 
 
 XV. MULTIPLE BIRTH. 
 
 Definition. — The birth of two, three, or more normal fetuses. Monsters 
 are not included under this head. 
 
 Frequency. — The proportion of multiple to single births varies considerably 
 in different countries. The ratio of triple, twin, and ordinary labors in Ger- 
 many is given by Strassmann as i : 89 : 7921. It is of interest to note that in 
 this series the number of twin pregnancies is exactly the square root of the 
 number of single births. For the etiology see page 140. 
 
 Symptoms. — The course of multiple delivery is often short. After one 
 fetus is expelled the uterus is quiescent for a certain period; upon an average, 
 for half an hour. Instead of this physiological repose, however, prolonged 
 inertia may develop. In such cases the second child may be in a transverse 
 position, and in any case the second membranous sac should be ruptured at 
 the expiration of half an hour. The cervix being fully dilated and the cord 
 of the first fetus still connected with the placenta, the chances for intrauterine 
 infection are considerable. The fetal presentations run as follows in twin labors : 
 the commonest form is the double vertex (Fig. 762); next, the fetus to be 
 bom first presents by the head, the other by the breech (Fig. 764); third, the 
 first fetus presents by the breech, the second by the head; fourth, a head and a 
 shoulder presentation are associated, the first child usually presenting by the head. 
 Two shoulder presentations occur infrequently (Fig. 761), while two pelvic pre- 
 sentations are very exceptional. Averaging a large number of presenting parts in 
 multiple births it is found that about 54 per cent, are cephalic, about 32 per cent. 
 
Figs 758 to 764. — Presentations 
 IN Twin Deliveries. — {After 
 Dickinson.) 
 
 Fig. 764. 
 
 5.55 
 
556 PATHOLOGICAL LABOR. 
 
 pelvic, while the remainder are shoulder. About three-fifths of the heads are in 
 the first, the remainder in the second cranial positions. It very seldom occurs 
 that both heads are in the same positions. As a rule, the fetuses are face to face, 
 and the one on the left side is bom first, the right coming after in the second 
 cranial position. If the fetuses are placed one behind the other, the heads 
 should be in the same position. In regard to abnormal presentation in twin 
 pregnancy, bregma, brow, and face positions occur more frequently than with 
 single births, comprising not less than lo per cent, of cephalic births. Bregma 
 presentation is probably increased because of the diminished prominence of the 
 frontal region in twins, which reduces the resistance encountered at the pelvic 
 inlet. As a rule, brow and face presentations run a more favorable course than 
 in single labors. (For diagnosis and prognosis see page 143.) 
 
 Management of Twin Labors. — In the case of abortion of one twin it was 
 once the practice to attempt retention of the second, and successes have been 
 reported. To-day it is the uniform practice to bring away the sound fetus 
 with its dead fellow, for the chance of saving life does not compensate for the 
 danger of infection. In women with contracted pelves the occurrence of multiple 
 pregnancy is in some respects an actual advantage. It occasionally happens 
 that such a woman, after losing a series of normal single children through 
 dystocia due to contracted pelvis, has given birth to living twins (I have my- 
 self had such a case), and even in cases in which the latter were both in shoulder 
 presentation (Strassmann). For this reason it is highly important, before 
 inducing premature delivery for contracted pelvis, to obtain the assurance 
 of the non-existence of twin pregnancy. Symphyseotomy must never be 
 performed unless assurance of a single pregnancy exists. If the diagnosis 
 of twins has been made at any period, the woman should never be informed 
 of the fact; she should be told the truth only after the first birth. The leading 
 indications for intervention in twin labors vary with the two children. The 
 presence of inertia, so common in these births, renders it necessary at times 
 to hasten the delivery of the first twin by artificial measures. With its fellow 
 it may be necessary to hasten birth by reason of hemorrhage or failure of the 
 fetal heart. The necessity for narcosis which often arises during extraction 
 of the first child adds to the likelihood of such indications. As the great ma- 
 jority of twin births terminate spontaneously, non-intervention should be the 
 rule, especially in vertex presentations. If the inertia is unduly prolonged, 
 the membranes should be ruptured at a period somewhat earlier than in single 
 births. The first step after the first child has been delivered and the cord 
 ligated is to make a vaginal and abdominal examination. If the second fetus 
 be found in any but a shoulder presentation, there should be no immediate 
 intervention save for causes to be described later, since in most cases delivery 
 is easy owing to the dilatation of the birth canal by the first child, and because, 
 owing to the danger of post-partum hemorrhage, the rapid emptying of the 
 uterus is inadvisable. The uterus should be followed down by the hand during 
 the stage of expulsion, and every precaution should be taken against the occur- 
 rence of hemorrhage. If the second fetus is found in a shoulder presentation, 
 cephalic or podalic version should be performed and extraction effected imme- 
 diately unless the version can be accomplished by the external or combined 
 methods alone. Post-partum hemorrhage after the first labor is a complication 
 to be reckoned with. It must be remembered that tears of the cervix, vagina, 
 and perineum are very rare in twin labors, and that the appearance of hemor- 
 rhage after the first birth points almost certainly to a placental origin. If 
 the placenta is single, the escaping blood is a menace to the child coming after; 
 
FETAL DYSTOCIA FROM GENERAL FETAL CONDITIONS. 557 
 
 if double, the second child is not compromised. In any case of uncertain 
 diagnosis the second fetus must be given the benefit of the doubt and delivered 
 at once. Failure of the fetal heart is an indication for intervention. In the 
 case of hemorrhage or other source of danger to the mother or the second infant, 
 the latter should be rapidly delivered by forceps or complete version. If 
 after an hour or thereabouts from the birth of the first child the uterus does 
 not contract, the condition of atony usually demands intervention. Some 
 authorities see no harm in waiting as long as three hours if the condition of 
 the mother and fetus is favorable. Many cases are on record in which the second 
 fetus has remained in utero for several weeks and been delivered in a vigorous 
 condition. Hence, if the first child is premature and is followed by its placenta, 
 it may be wise to leave the second child in utero, that its chance of ultimate 
 survival may be improved. When it is decided to interfere, the membranes 
 should be ruptured and massage of the fundus begun. As a rule, all the secun- 
 dines are expelled at once after the birth of the second child. Owing to its 
 large size, it is often difficult to bring away the placenta by Credo's method. 
 There is after twin labors a marked tendency to atony of the uterus which 
 demands an extra large dose of ergot and prolongation of the usual interval 
 of medical supervision. The likelihood of hemorrhage is naturally increased 
 if the twins are expelled in quick succession, as this amounts to precipitate 
 labor. In rare cases both placentse are expelled before the birth of the second 
 child, which must then be delivered at once to avoid suffocation. In the case 
 of unioval twins (with but one placenta) a twisting and entanglement of the 
 cords sufficient to retard delivery may occur. In this case it is well to cut 
 the cord between two ligatures and deliver at once; or the division of both 
 cords may be required. In rare cases the first fetus may be transverse while 
 the second is astride of it (Fig. 758). This possibility should be remembered, 
 since in such a case traction on the legs of the second would be disastrous. 
 
 Management of Triple Labor. — Labor here is generally easy because of the 
 small size of the fetuses. As in twin births, dilatation occurs slowly by reason 
 of the inertia of the distended uterus. When expulsion begins, however, 
 the labor may be precipitate, each fetus being small and the last two requiring 
 no delay for dilatation. Each bag of waters presents and ruptures in turn, 
 but the placentas and cords show much variation. Each placenta may 
 follow its fetus as in single births; the first two placentas may come away 
 after the second child, or all three may follow the third fetus. The interval 
 between the labors varies greatly. In a precipitate delivery there is no interval 
 and the children may all be expelled in fifteen or twenty minutes. In other 
 cases there may be a short interval between the births of the first and second 
 fetuses and a much longer one between the second and third, or this may be 
 reversed. Apparently the complete uterine repose which occurs between 
 labors in a twin pregnancy is less common in triple births, but may extend 
 over hours and even days. The principal presentation is the cephalic — about 
 60 per cent. The tendency to abnormal presentations is usuall}'- seen in the 
 last child. The prognosis for the mother is less favorable than in single births. 
 Notwithstanding what has been said of precipitate labors and short intervals, 
 there are many protracted confinements which with the frequency of abnormal 
 presentations contribute to the morbidity. Puerperal complications are fre- 
 quent. The fetal mortality is very heavy, no less than 31 per cent, being 
 still-bom. 
 
558 PATHOLOGICAL LABOR. 
 
 XVI. MULTIPLE OR COMPOUND PRESENTATION. 
 
 Owing to the small size of the fetus in multiple labors the element of dystocia, 
 whether maternal or fetal, is essentially out of the question under ordinary 
 conditions. Indeed, multiple pregnancy is an actual advantage to a woman 
 with contracted pelvis. The situation is very different when the two children 
 tend to engage in the pelvis at the same time, and especially when, by reason 
 of the unusually small size of the heads, they succeed in so doing. Two types 
 of complication thus arise, termed respectively (i) multiple presentation and 
 
 (2) interlocking of fetal heads. These will be described separately. 
 
 1. Multiple Presentation. — In multiple presentation we find parts from both 
 fetuses at the pelvic inlet, and while engagement of both presenting parts 
 may be possible, labor may be retarded by the fact that neither part is able 
 to pass the brim. The presenting parts may be two heads, head and breech, 
 head and limbs, or all the lower extremities (Figs. 695, 696, 697, 762, 763, 764). 
 Treatment: In the case of two heads or a head and breech, the hand introduced 
 into the vagina should endeavor to push one of the presenting parts, preferably 
 that which is higher up, upward and out of the way. While this manipula- 
 tion might suffice, some authors advocate engagement of the lower head with 
 forceps to prevent a return of the complication. If a head and limb present 
 together, the latter may be pushed up and the head engaged with the forceps. 
 If the lower extremities descend into the pelvis, those which belong to the second 
 fetus should be pushed up while the first fetus should be extracted by its feet. A 
 complication of somewhat similar nature occurs when both bags of waters 
 project into the dilating cervix and delay labor. It is necessary to wait 
 until the os is fully opened, after which the most advanced bag should be 
 punctured. The question of multiple presentation has a medico-legal aspect, 
 for the subject of the right of priority of birth sometimes arises. One fetus 
 could present first by an extremity, for example, while the other might be 
 bom before it. 
 
 2. Interlocking of Fetal Heads. — Interlocking of the fetal heads occurs in 
 several ways, (i) When the heads are unusually small, a double cephalic pres- 
 entation may result in the engagement of both, the second entering the pelvic 
 cavity closely after the first, and becoming impacted against the neck or thorax 
 of the first child (Fig. 699). Treatment: In the first form of interlocking the 
 management usually advised is to deliver the first fetus with the forceps and 
 then to extract the second. If the locking cannot be overcome, it may be necessary 
 to perforate and dismember the first fetus, as otherwise both may be lost. The 
 second child has the advantage over the first in that its cord is in less danger 
 of compression. Some authorities appear to regard the prospect of unlocking 
 these heads as practically hopeless, and proceed at once to perform craniotomy 
 on the first fetus. (2) If the first twin has presented by the breech and has 
 entered the pelvis with the exception of the head, the second head may slip past 
 it into the excavation. If the fetuses are face to face, which is the usual rela- 
 tion, the two chins may become locked together; if back to back, the occiputs; 
 and if the back of one is to the face of the other, the locking occurs between the 
 chin and occiput (Fig. 698). Treatment: The first step is an attempt to push 
 the head of the second fetus up out of the pelvis. Failing in this, expectancy 
 may be tried; but if there is no advance, the forceps should be applied. 
 If delivery is still impossible, the head of the fetus which dies first (usually the 
 first one) should be perforated and extracted in an attempt to save its fellow. 
 
 (3) A. second fetus in shoulder presentation may engage during the birth of the 
 
FETAL DYSTOCIA- FROM GENERAL FETAL CONDITIONS. 559 
 
 first fetus, so that the latter is arrested before some part of the trunk has entered 
 the pelvis. Treatment: The engaged portion of the second fetus must be re- 
 placed and traction made upon the other by the forceps or hands, according to 
 the presenting part. If the first fetus is dead, it should be decapitated and 
 an attempt made to extract the other by version. 
 
 XVII. EXCESSIVELY LONG CORD. 
 
 The cord is frequently increased in length; instances being recorded in 
 which it was from six to nine feet long. A long cord may become entangled 
 in knots or it may become coiled about the fetus till so little is left that the 
 symptoms of short funis are produced, causing delay in delivery. (Seepage 559.) 
 It predisposes to prolapse of the funis. When the cord is coiled several times 
 about the fetus, compression is liable to cause serious or fatal asphyxia. 
 
 XVIII. SHORT CORD. 
 
 Definition. — Measurements of many thousands of umbilical cords show 
 that the great majority have a length of from 17 to 24 inches (43.18 to 60.96 
 cm.). An absolutely short cord is one which is too short to permit of delivery 
 of the fetus before the separation of the placenta (Fig. 280). At the moment 
 of expulsion the distance between the fundus uteri and the vulva is about 8 
 inches (20.32 cm.). The cord must therefore be at least of that length 
 to permit of the birth of a child. But the distance between the umbilicus 
 and anus of the latter must be added if expulsion is to occur easily, so that the 
 minimum normal length of the cord should be one foot (30.48 cm.) for head 
 presentations, and by a like calculation 15 inches (38.1 cm.) in breech cases. 
 An absolutely short cord must therefore be less than 15 inches (38.1 cm.). This 
 calculation was made by Tamier and Leroy in 1893, who state that the ex- 
 tensibility of the cord makes the above figures slightly too small (about 10 per 
 cent.). The same effect of shortening may be produced in connection with 
 coiling of the cord about the neck or limbs. This is termed the accidentally 
 short cord, and is elsewhere considered. (Page 237.) 
 
 Etiology. — The naturally short cord is purely an anomaly of development. 
 It has been noted in successive labors in the same woman. In a portion of 
 the cases reported the amniotic fluid has been scanty. 
 
 Symptoms and Diagnosis. — There is no method by which a short cord re- 
 veals itself during pregnancy, for even if the position of the child were affected, 
 as has been claimed, no distinction could be made between natural and artifi- 
 cial shortening. During labor, symptoms, while pronounced, are equivocal. 
 With everything favorable for timely expulsion of the child, labor does not 
 advance properly. The traction upon the cord during each pain is followed by 
 a recoil of the presenting part, which is due to the elasticity of the funis. 
 In individual cases the condition has been recognized by a combination of 
 rational symptoms, such as tugging and unusual distress at the placental site. 
 It doubtless happens that the conditions become manifest only when the 
 placenta gives way with hemorrhage, or when the uterus becomes inverted. 
 It would seem, at first sight, that after labor was well advanced the in- 
 troduction of the hand might lead to a recognition of the condition, but 
 practically nothing can be learned in this way. Little distinction is made 
 in practice between a naturally and an artificially short cord. Brickner 
 gives the symptomatology of short cord as follows*: (i) Recession of the head 
 * "Am. Journ. Med. Sciences," Nov., 1899. 
 
560 PATHOLOGICAL LABOR. 
 
 between pains; (2) arterial hemorrhage during and between pains; (3) urina- 
 tion between pains during expulsive stage; (4) pain over the placental site, 
 worse during the expulsive period; (5) desire to sit up and lean forward; 
 (6) uterine inertia. 
 
 Prognosis. — The mother is endangered by the possibility of hemorrhage and 
 inversion of the uterus. A considerable proportion of infants are still-born. 
 
 Treatment. — If there are reasons for suspecting the presence of a short 
 cord, the membranes should be ruptured, manual expression begun, and the 
 forceps applied. According to Budin, attempts to uncoil the cord or to perform 
 podalic version are strictly contraindicated. If brevity of the cord is not 
 suggested till the head is arrested in the excavation, there are no resources 
 beyond the same combination of manual expression and forceps. The cord 
 may rupture under traction, and in that case labor must be terminated rapidly 
 and the funicular hemorrhage checked. After extraction of the head a coiling 
 of the cord about the neck may be discovered. It is then better to cut and 
 ligate the cord than to try to loosen the coils. The artificially short cord must 
 not be confounded with the cord simply coiled about the neck or limbs, produc- 
 ing no dystocia. Some of these coils may be detached incidentally during in- 
 ternal version. 
 
 XIX. RUPTURE OF THE UMBILICAL CORD. 
 
 Rupture of the umbilical cord is an accident of rare occurrence. This acci- 
 dent may arise from shortness of the cord, which may be congenital, or from 
 the cord becoming wound about the fetus. It may also be due to abnormal 
 insertion of the cord, or to precipitate labor. The child usually dies from shock 
 or asphyxiation, or rarely from hemorrhage; since the ruptured vessels are pro- 
 tected by the retraction of their tissues and by the covering of Wharton's jelly. 
 When this complication takes place before the child's birth, either immediate 
 version or the use of the forceps is indicated. 
 
 XX. DECAPITATION OF THE FETUS. 
 
 This complication is also very rare, but sometimes occurs when too much 
 force has been applied to the after-coming head, either in a normal breech 
 presentation or after version. The forceps or the craniotractor must be used to 
 extract the fetal head, external pressure at the same time being employed to 
 hold the latter in place. Danger of maternal laceration from bony spicules 
 should be carefully avoided. (See Operations, Part X.) 
 
 XXI. AVULSION OF THE FETAL EXTREMITIES. 
 
 This can take place only when the fetus is premature or partially macerated. 
 After its occurrence the rest of the body should at once be extracted. It will 
 be well to follow extraction by an antiseptic douche. 
 
 XXII. FETAL MALFORMATIONS, DEFORMITIES, AND ANOMALIES 
 PRODUCING DYSTOCIA. 
 
 Double Monsters. — The malformations which give rise to dystocia are 
 limited practically to the double monsters. Single fetuses with malformations 
 do not, as a rule, produce obstructed labors. Double monsters as causes of 
 
FETAL DYSTOCIA FROM GENERAL FETAL CONDITIONS. 561 
 
 dystocia are best divided, as proposed by Veit, into: (i) Those with slight sep- 
 aration; (2) those with moderate, and (3) monsters having a great degree of 
 separation. 
 
 We may state that the greater the separation the greater the HkeHhood of 
 dystocia (Figs. 385 to 435). The general principle of treatment which I fol- 
 low in these cases is: (i) Determine the character of the obstruction by pass- 
 ing the hand into the uterus. (2) If an extraction with the aid of decapitation 
 and possibly eventration seems feasible deliver in this way. (3) If a prolonged 
 
 Fig. 765. 
 
 Fig. 766. 
 
 Fig. 767. 
 
 Fig. 768. Fig. 769. 
 
 Figs. 765 to 769. — Fetal Deformities Producing Dystocia. Fig. 765, Congenital 
 hydrocephalus. Fig. 766, Anencephalus, Fig. 767, Distention of bladder and ureters. 
 Fig. 768, Dicephalus dibrachius. Fig. 769, Thoracopagus. 
 
 mutilating and difficult extraction is required, it is better to at once perform 
 Caesarean section. (4) Should the Csesarean section be undertaken after pro- 
 longed attempts at delivery, and sepsis is suspected, either an incomplete or 
 complete hysterectomy should follow the Caesarean section. 
 
 Oversize of the Fetus. — There is no standard of oversize, though infants 
 weighing over 13 pounds (about 6000 gm.) at birth are very rarely encountered. 
 A few cases of giant fetuses weighing 20 pounds (9000 gm.) and upward have 
 been recorded. Excess of weight, however, does not necessarily involve a 
 dystocic labor, for the head of such a child may have a good capacity for 
 36 
 
562 PATHOLOGICAL LABOR. 
 
 moulding. A representative case of an overdeveloped fetus causing d5''stocia is 
 one described by A. Martin.* The child weighed over i6 pounds (7500 gm.), 
 and could not be delivered until craniotomy had been performed. Dystocia 
 from overdeveloped children is common. Etiology: Overdevelopment has but 
 two known causes: (i) Heredity; the children of giants, especially the male 
 children of a giant father, having a tendency to overdevelopment even in utero. 
 (2) Prolongation of pregnancy. Post-mature fetuses naturally continue to in- 
 crease in size until the deferred labor sets in. Symptoms and Diagnosis : A 
 very large child in utero may simulate a twin pregnancy or other conditions 
 of distention. Careful palpation and cephalometry (page 180) will show that 
 there is but a single large child. Gestation with a very large fetus is accom- 
 panied by the same phenomena as is multiple pregnancy. The distention is 
 partly accounted for in the first case by the increased volume of the placenta 
 and amniotic fluid. Labor with overlarge fetus is naturally slow and numer- 
 ous accidents may arise. During dilatation the cervix may give way with a 
 prolonged tear involving the body of the uterus. There is a similar danger 
 of rupture of the lower part of the birth tract, especially the perineum. Diag- 
 nosis must be made between a normal large head and hydrocephalus, short 
 funis, and other causes of dystocia. Treatment: If labor cannot end spontane- 
 ously without danger to mother and child, the indication is clear to apply the 
 forceps. Version is not to be attempted. If the child succumbs during expul- 
 sion, embryotomy should be performed. 
 
 Oversize of the Head. — A perfectly normal fetus may have an abnormally 
 large head, associated often with a tendency to premature ossification, with 
 resulting diminution in the size of the fontanelles. These heads resist mould- 
 ing, and this fact, in addition to their size, renders them apt to produce 
 dystocia. Treatment: The indications are the same as in the preceding class ; 
 viz., expectancy at first followed later by the forceps if necessary, or perfor- 
 ation in the case of death of the child. 
 
 Premature Ossification of Fetal Skull. — The symptoms, results, and treat- 
 ment are the same as the preceding. 
 
 Congenital Hydrocephalus. — Diagnosis: Abdominal palpation may dis- 
 cover a large, hard, round tumor situated above the pubes, while the cardiac 
 sounds will proceed from a point above the umbilicus. Naturally the abdo- 
 men is greatly distended. Failing to recognize the usual evidences of a head 
 presentation, the practitioner may believe that a breech presentation exists. 
 Examination with the entire hand is necessary for diagnosis. In breech pre- 
 sentations the presence of a large mass in the uterus during expulsion of the 
 trunk might lead to belief in the presence of a second fetus, uterine 
 fibroid, etc. The presence of spina bifida in breech cases has sometimes 
 led to a suspicion of hydrocephalus. Prognosis: The outlook is grave. 
 Very few labors terminate spontaneously. In cases in which an early diag- 
 nosis is not made the mortality is high. When the complication is foreseen, 
 the outlook for the mother is good. For the mother in undetected cases the out- 
 look is bad, although it has been recently improved by superior antisepsis. The 
 mortality to the mother averages about 2 5 per cent. (Poulet and Spiegelberg). 
 Rupture of the uterus is not uncommon, either near the cervix or at the 
 fundus. Vesico -vaginal fistula may result from the pressure of the fetal head. 
 If the nature of the complication is unsuspected, matters may be made worse 
 by attempts at version or forceps delivery. Treatment: The prophylaxis 
 of hydrocephalus hardly exists, despite certain efforts in this direction. If 
 
 * Cited by Tamier and Budin, edition 1900, Paris. 
 
FETAL DYSTOCIA FROM GENERAL FETAL CONDITIONS. 563 
 
 the condition is recognized during the latter months of pregnancy, the fetus 
 may be placed in a pelvic presentation, as there is less danger then of rupture 
 of the uterus. When labor is much delayed by this complication, puncture of 
 the head and withdrawal of the accumulated fluid are demanded. The cranial 
 bones then collapse. If the aspirator is used, it will withdraw the fluid 
 effectually, and give the child a chance of life. Even a short period of extra- 
 uterine existence may sometimes be of great medico-legal importance. After 
 perforation, turning has been advised, but this is usually superfluous, for the 
 pains are generally sufficient to complete the birth. If there is difficulty in 
 the descent of the head, application of the cephalotribe is in order. This will 
 crush the head, so that it will be readily extracted. The forceps should not be 
 used, for the blades are too short, and the cephalic curve is not large enough. 
 The head, too, is so distended that its form changes with pressure to such a 
 degree that the forceps cannot secure a firm grasp. It is only when the head is 
 closely and deeply wedged in the pelvis, and its capsule is unyielding, that any 
 success with the forceps may be hoped for. In breech cases the skull may be 
 perforated from beneath. The French claim that the simplest manner of 
 withdrawing the fluid is by puncturing the spine. This procedure, adopted by 
 Tarnier in 1868, has been employed by all of his pupils. I always perforate 
 through the floor and roof of the mouth. Cases of shoulder presentation should 
 be treated by preliminary podalic version and afterward as in the management of 
 breech cases. If version is contraindicated, decapitation should be practised. 
 
 Encephalocele; Hydrencephalocele (Figs. 329, 330). — This condition is rarely 
 a cause of dystocia. The tumor which projects from the skull consists only of 
 fluid in a membranous sac. If large enough to obstruct labor, it could readily be 
 tapped. Epignathi (Fig. 430) : These parasitic tumors, growing as they do from 
 the mouth, are able, if they are large, to cause more or less dystocia. They are 
 freely movable on the fetus and extraction can usually be effected by version. If 
 this fails, the epignathus must be reduced in size. Anencephalus (Fig. 367) : In 
 this monstrosity dystocia arises from the fact that the rudimentary skull is in- 
 sufficient to pave the way for the shoulders. The condition is therefore one of 
 shoulder dystocia, for which see page 538. Cystic Hygroma: These cystic for- 
 mations grow from the neck or the front of the chest, and may equal the fetal 
 head in size. They are retention cysts which arise after occlusion of the 
 lymphatics. Congenital Cystic Goitre: This may be classed with the foregoing 
 in relation to dystocia. Winckel gives considerable attention to these cysts 
 of the neck, as do also Tarnier and Budin. The cysts are not diagnosticated 
 until labor has begun, and then are made out only with several fingers in the 
 vagina, and sometimes not until after delivery. If moderate traction will not 
 bring away the child, the tumor should be punctured with a curved trocar. 
 The greatest care should be taken, since these cysts do not jeopardize the 
 child. 
 
 Unusual "Width of the Shoulders and Chest. — The shoulders and thorax of 
 a very large child do not appear to cause d3^stocia. Unusual development 
 of these parts in an ordinary child, as well as the absolute and relative width 
 of the shoulders in pseudo-encephali and anencephali, constitutes the state 
 which produces dystocia. Similar in dystocic effect is congenital hydrothorax. 
 Labor in such cases might be arrested with the shoulders in the inlet, and the 
 efforts of the uterus to expel the child might asphyxiate it as a result of com- 
 pression of the chest. Diagnosis: These conditions cannot be recognized 
 till after the birth of the head or the breech, when, with the entire hand 
 in the vagina, the diagnosis may be made. Treatment: This should not be 
 
564 PATHOLOGICAL LABOR. 
 
 confounded with the management of deficient rotation of the shoulders. To 
 overcome the impaction present in actual dystocia it will probably be neces- 
 sary to perform cleidotomy. (See Operation, Part X.) 
 
 Ascites. — (See Trunk Dystocia.) (Fig. 767.) 
 
 Tumors which Originate in the Urinary Apparatus. — These comprise ac- 
 cumulations of fluid in the bladder or kidneys due to imperforate urethra 
 or some other malformation, and also the condition known as congenital cystic 
 degeneration of the kidney. Both distended bladder and hydronephrosis 
 may attain an enormous size in comparison with the fetus (Fig. 767). While 
 the average quantity of urine which thus accumulates is not over a pint, 
 there are cases upon record in which the retention amounted to seven quarts. 
 The kidneys in cystic degeneration form a large, solid tumor which is made 
 up of innumerable retention cysts developed from the urinary canaliculi. 
 These cysts are filled with urine, and when the process is extensive a large 
 abdominal tumor results. It is supposed that the retention is due originally 
 to a sclerotic process in the renal papillas. An analogous affection of the liver 
 sometimes coexists. 
 
 Dystocia Due to Affections of the Fetal Trunk. — Symptoms : During labor in 
 cephalic presentations after the head is born, the process of delivery is arrested. 
 If an inexperienced practitioner attempts to extract the child forcibly, he will 
 be likely to disrupt it. If the case is a breech, the conditions are analogous. 
 A fetus with retention of urine almost always presents by the head. Naturally 
 there is a scantiness of the amniotic fluid. Diagnosis : If there is obstruction due 
 to something above the shoulders, the entire hand should be inserted into the 
 birth tract, when the nature of the obstacle will become apparent. An attempt 
 should be made to determine whether the tumor is solid or fluid. An analogous 
 course should be pursued in breech cases. Prognosis: The outlook is naturally 
 grave for the fetus. For the mother, all depends upon the management of the 
 case. If the cause of dystocia is not recognized and removed, she will be ex- 
 posed to extensive rupture of the genital tract by the futile attempt at delivery. 
 If the correct diagnosis is made, the mother's chances are vastly improved. 
 Treatment: In head presentations with the head arrested in the excavation, 
 the forceps should be applied to deliver it. Any coils of cord about the fetal 
 neck should be unwound. Traction should be resumed gently until no further 
 advance is possible, after which the hand in the vagina will complete the diag- 
 nosis as to the nature of the tumor. If the latter contains fluid and the infant 
 is dead, the abdomen should be opened by a perforator. Labor may then 
 be readily completed. If the child is living, puncture should be made at the 
 umbilicus with a fine trocar. If the tumor is solid, the child must be eviscer- 
 ated whether dead or alive. In breech cases an analogous course must be 
 pursued. It must be remembered that the placenta is very large in some cases 
 of ascites; if this is forgotten, the uterine tumor might suggest a second fetus. 
 
 Sacro-coccygeal Tumors. — (Figs. 432 and 770.) They are seldom recog- 
 nized during pregnancy. Hydramnios is present in the vast majority of 
 cases. Symptoms: Labor is almost always premature. The head usually 
 presents. Delivery occurs spontaneously in the vast majority of cases. 
 This implies that the majority of tumors are too small to affect labor. 
 More or less dystocia must occur with growths the size of the fetal head. 
 The degree of dystocia is not in proportion to the size of the tumor, for the 
 latter may be partially cystic, and hence easily reducible in size. In head 
 presentations with a large solid tumor the latter will probably be expelled spon- 
 taneously after a period of moulding. In pelvic presentations a high degree 
 
FETAL DYSTOCIA FROM GENERAL FETAL CONDITIONS. 565 
 
 of dystocia may result, the trunk and tumor seeking to engage at the same 
 time. If the feet are down, efforts at traction might disrupt the fetus. Diag- 
 nosis: This can be made only with the entire hand in the vagina, chloroform 
 having been given. A tumor of this sort might well be confounded with a 
 number of conditions, fetal or maternal. Budin states that the commonest 
 error is the assumption of the presence of a double monster united at the breech. 
 Prognosis: In dystocia the maternal prognosis depends, as in all similar con- 
 ditions, upon the time at which the diagnosis is made. The outlook for the 
 child is very poor, there being but a small 
 proportion of survivors. Treatment: The 
 dystocia is less than in the case of abdom- 
 inal tumors. In head presentations traction 
 should be made with forceps until it becomes 
 evident that delivery is impossible. Punc- 
 ture should be practised in several places in 
 the hope that the tumor is partly fluid. If 
 this fail, the child must be eventrated, after 
 which the legs may be extracted and the 
 tumor treated by morcellation, while in a 
 breech case the tumor must be made to pre- 
 sent first with the same intent. 
 
 XXIII. FETAL RIGOR MORTIS. 
 
 Although death of the fetus is of such 
 common occurrence, rigor mortis has been 
 noted so rarely that the possibility of such 
 a phenomenon has been denied. Ballantyne, 
 who has seen one case, gives references to 
 about twenty-five others in literature, several 
 of the latter having been described in connec- 
 tion with Caesarean section. Cadaveric rigi- 
 dity in the fetus is believed to be feeble and 
 transitory, and to escape observation unless 
 death occurs just before labor begins. In 
 some cases, however, the condition is well 
 marked, and may last for hours, proving a 
 source of fetal dystocia. Wolff * analyzed 
 34 recorded cases of this phenomenon. The 
 claim which has often been made that 
 eclampsia plays a prominent part in its 
 
 genesis is not borne out by statistics, for maternal convulsions occurred in but 8 
 pf these 34 cases. This coincidence is evidently due to the fact that the fetus 
 often perishes during an eclamptic delivery. For similar reasons we find the 
 coincidence of protracted and obstructed labor, prolapsed cord, placenta praevia, 
 premature detached placenta, etc., on one hand, and antenatal rigor mortis on 
 the other. 
 
 Of the 34 cases detailed by Wolff, no less than 30 were associated with the 
 conditions just enumerated. 
 
 These, however, were not sufficient in themselves to determine rigor mortis 
 in the fetus. In a large proportion of cases, the latter may be brought in re- 
 
 * *' Arch. f. Gynakol.," lxviii, IQ03. 
 
 Fig. 770. — Sacro-coccygeal Tumor 
 IN A Female Fetus Born at the 
 Sixth Month. — (Author's collec- 
 tion.) 
 
566 PATHOLOGICAL LABOR. 
 
 lation with death of the mother during labor, and it is not uncommon for the 
 rigid state of the fetus to be recognized in connection with Caesarean section on 
 the dead or dying. 
 
 On June 12, 1904, a primipara, age 30, already fourteen hours in labor was admitted 
 into my service at the Bellevue Emergency Hospital. Csesarean section was required, and 
 performed by my assistant, Dr. Moore. Two hours before the operation the fetal heart 
 sounds were heard by several observers. A dead nine pound child was extracted with rigor 
 mortis present to a marked degree. The extremities were flexed upon the body and were 
 so rigid as to raake it practically impossible to extend them. The fetal body and neck 
 were also in complete rigor mortis. This case was of rapid development, as the fetal heart 
 sounds had been heard up to two hours of operation. The patient died suddenly eighteen 
 hours post-partum. No autopsy could be obtained. 
 
 DUE TO ABNORMAL CONDITIONS IN THE MOTHER: 
 MATERNAL DYSTOCIA. 
 
 Physical Phenomena of Maternal Dystocia. — Much confusion exists in regard 
 to the results of difficult labor upon the maternal organism, and the terms " prim- 
 ary inertia," "uterine exhaustion," "secondary inertia," "tetanic state of the 
 uterus," "delayed labor," "obstructed labor," are applied somewhat indis- 
 criminately to designate various phases of such conditions. An attempt is made 
 to submit these conditions to a brief analysis. 
 
 Primary Inertia. — Here the sluggish action of the uterus is not due to ex- 
 haustion. The causes lie in the uterine muscle itself, which is unable to contract 
 forcibly. We see this in the very young and in the elderly; in invalids and in 
 distention of the uterus by hydramnios, multiple pregnancy, etc. The pains 
 are weak and occur at long intervals. There is no constitutional reaction beyond 
 fatigue. The subject of inertia is considered in detail under Protracted Labor. 
 
 Secondary Inertia, Exhaustion of the Uterus. — ^This appears to be the result 
 of inertia of the uterus plus slight obstruction ; although the latter is not always 
 in evidence. . The pains, feeble at the start, ultimately cease. The uterus seeks 
 rest. This temporary suspension of the pains has been termed secondary inertia 
 in contradistinction to obstructed labor with original absence of inertia. Exhaus- 
 tion of the uterus betrays itself by flabbiness, which enables the obstetrician 
 to recognize the outlines of the child. There is no tenderness on pressure. 
 A-side from fatigue, constitutional reaction is absent. After rest, food, and sleep 
 the uterine contractions reappear. 
 
 Tetanic State of the Uterus. — This anomalous action of the uterine muscle 
 develops when an obstruction is present. The original pains become vigorous 
 when the obstruction is first felt, but if the impediment cannot be overcome, the 
 intervals between the pains become shorter and shorter until the tetanoid state 
 develops. The fetus is closely embraced by the uterus and the constant pressure 
 tends to interfere with the placental circulation. The constitutional reaction 
 is marked, as the tetanic contraction rapidly exhausts the mother. Her pulse 
 and respiration increase and her face shows anxiety. The uterus is hard and 
 perhaps tender. It holds the fetus firmly, so that the presenting part cannot 
 be pushed up. If the head has reached the true pelvis, it shows a marked caput 
 succedaneum, while the lower part of the birth tract is swollen. In this condi- 
 tion immediate delivery is the indication. 
 
 Prolonged Labor. — Primary inertia, exhaustion, and obstruction all tend to 
 lengthen the duration of labor. What is meant by prolonged labor in the nar- 
 
MATERNAL DYSTOCIA FROM THE FORCES. 567 
 
 rower sense of the term is the result of a moderate disproportion between the force 
 and the resistance. Let us suppose that the pains are strong and that the resist- 
 ance does not amount to obstruction. Tetanus uteri does not develop. The 
 woman is simply in the position of one who makes great and long-continued mus- 
 cular exertion, and the results are those which follow such efforts. The pulse 
 rises to loo or 120 and there is rise of temperature. The patient becomes anxious, 
 distressed, and restless ; vomiting of reflex origin may occur ; the tongue is coated, 
 the vaginal and cervical secretions are arrested, and the parts are hot and dry. 
 Such a clinical picture may be seen in breech presentations. 
 
 Obstructed Labor. — Tetanic contractions indicate that there is an obstruction 
 to labor. There is only a difference in degree between a protracted labor as de- 
 scribed and an obstructed labor. The term should be restricted to cases in which 
 delivery by natural passages is impossible. At the outset the symptoms are 
 those of protracted labor. Finally exhaustion of the mother begins ; the pulse 
 becomes weak and thready; jactitation indicates the high degree of nervous 
 prostration; the tongue becomes black and dry, and the patient passes into a 
 typhoid or adynamic state as a result of the profound exhaustion. 
 
 MATERNAL DYSTOCIA FROM THE FORCES. 
 
 I. PRECIPITATE LABOR. 
 
 Definition. — Labor terminating so rapidly as to interfere with the physio- 
 logical processes of the several stages. Its occurrence is comparatively infre- 
 quent. A narrower definition is labor of such rapid and unforeseen character 
 that the parturient is confined in an entirely unusual position, as standing, 
 squatting, kneeling, or sitting 
 
 Etiology. — Excessive expulsive powers, either voluntary or involuntary, and 
 deficiency in the resistance in the parturient canal or bony pelvis are the main 
 etiological features. The physical condition of the patient seems to have 
 little or nothing to do with the excessive contraction. Deficiency in the resist- 
 ance may result from a number of causes. For example, there may be an under- 
 sized child at full term or as the result of premature labor. The parturient 
 canal itself may be oversized and roomy and relaxed as the result of the general 
 physical condition or nervous influences independent of an increase in the size 
 of the pelvis. The justo-major or giant pelvis and the split or inverted pelvis 
 are the two conditions in the hard parts predisposing to precipitate labor. It 
 may be that in a previous confinement there have been lacerations of the cervix 
 or perineum, or both, allowing the fetus to be precipitated through an orifice, 
 instead of being forced along, as is normally the case. 
 
 Symptoms. — The symptoms are those of a rapidly terminating labor. The 
 pains appear suddenly and increase very rapidly in intensity. They are usually 
 of a bearing-down character from the beginning. Labor may be over in a few 
 minutes when the pelvis is large or the fetus small, even without any excruciating 
 pains. However, the converse may prove true. The child may even be bom 
 while the mother is asleep. 
 
 Diagnosis.— One or two contractions sometimes expel the fetus. In other 
 cases palpation shows a rapidly advancing presenting part, almost continuous 
 tetanic action of the uterus, and forcible contraction of the abdominal walls. 
 The latter may be absent. In cases in which there are only one or two severe con- 
 
568 PATHOLOGICAL LABOR. 
 
 tractions the patient is probably of a sluggish, apathetic temperament and does 
 not really feel much pain. In other cases which are not so rapid the suffering may 
 be intense. If the child dies from rupture of the cord as a result of precipitate 
 labor, the mother may be subjected to judicial inquiry by reason of the fact 
 that infanticide is sometimes committed through neglect to ligate the cord. 
 Similarly, a fall of the child in connection with precipitate labor may lead to 
 injtiries of the cranium, limbs, viscera, etc., and hence the suspicion of attempt 
 at infanticide may be aroused. In cases of this sort in which the mother is 
 accused but denies all intent of injuring the child, corroboration of her word may 
 be supplied by study of the pelvis and soft parts and of the fetus. If the pelvis 
 is over-large and there are old lacerations which have diminished the resistance, 
 etc., or if the child is unusually small, we have conditions which favor precipi- 
 tate labor. If we find the uterus inverted, extensive fresh lacerations of the 
 soft parts, with a history of post-partum hemorrhage, etc., we have conditions 
 which may have been caused by precipitate labor. In regard to the child dead 
 of hemorrhage from the cord, it will be necessary to exclude the existence of 
 patent umbilical arteries, anomalies of the cord and vessels, and hemophilia. 
 Much may be learned from cross-examination of the mother. 
 
 Prognosis. — The dangers to the mother are hemorrhage from premature de- 
 tachment of the placenta, lacerations of the parturient tract, post-partum hem- 
 orrhage, inversion of the uterus, serious or fatal syncope from sudden diminution 
 of intra-abdominal pressure, and uterine inertia. The dangers to the fetus are 
 ante-partum asphyxia from premature detachment or compression of the placenta 
 or from rupture of the cord, and injury from a fall to the floor, to the street, or 
 into the basin of a water-closet. I had a case in practice of a child being born 
 by precipitate labor into the bowl of a water-closet. I was asked once to see 
 a depression in a parietal bone in a newly born infant, the restdt of precipitate 
 labor on the fire-escape of a tenement-house. The mother at the time was 
 leaning over the railing and drawing the clothes-line toward her. Both these 
 children survived. I have also witnessed a precipitate labor in a patient ascend- 
 ing a staircase in a maternity hospital, the child's fall in this case being 
 broken by being suspended by the cord. No complications resulted to the 
 mothers in these three cases. 
 
 Treatment. — When precipitate labor has once occurred, it is likely to take 
 place again, and in such a case, preventive treatment is in order during preg- 
 nancy. During the last few weeks of pregnancy the patient should not go far 
 from home and should secure fresh air by driving rather than walking. A com- 
 petent nurse, who can take entire charge of labor if necessary, should during this 
 time be in attendance. A well-fitting abdominal binder (Fig. 228) will some- 
 times act as a preventive measure. All mental reflex irritation must be guarded 
 against. Repeated small doses of the bromids or of opium are of use to quiet 
 the irritable state of the uterine muscle-fibers, as in the case of treatment of 
 abortion. During labor the early use of chloroform or the subcutaneous use of 
 morphin is most valuable, and all bearing-down efforts on the part of the patient 
 must be discouraged. She should be placed in the lateral posture or, better 
 still, in the exaggerated semi-prone (see Posture, Part X), and manual retarda- 
 tion of the head at the pelvic outlet practised if necessary. 
 
 II. PROTRACTED LABOR. UTERINE INERTIA. 
 
 Definition. — Labor prolonged beyond the average length (page 448) to such 
 an extent as to be dangerous to mother or fetus ; or a degree of uterine contrac- 
 
MATERNAL- DYSTOCIA FROM THE FORCES. 569 
 
 tion insufficient to overcome the normal resistance or that produced by some 
 abnormality. Uterine inertia is that condition in which the uterine contractions 
 by reason of their weakness or irregularity are insufficient to dilate the os in the 
 first stage, or expel the fetus in the second. The insufficiency may pertain only 
 to a certain portion of the uterus; so that we may speak of partial and total 
 inertia. Thus the defective action may be confined to the cervix. Abdominal 
 inertia is a weak or inefficient condition of the abdominal walls which renders 
 the patient unable to aid the uterine contractions of the second stage by her 
 voluntary forces or bearing-down efforts. Three degrees of abdominal inertia 
 are recognized; namely, simple inertia, exhaustion, and paresis. From the date 
 of the beginning of uterine inertia, whether from the onset of labor or after a 
 period of normal pains, a division is made of primary and secondary. Primary 
 or true uterine inertia is that condition of weak pains in which the uterine con- 
 tractions have been inefficient from the beginning of labor. It is an unusual 
 variety of prolonged labor. Neither mother nor fetus need necessarily suffer. 
 Secondary inertia or uterine exhaustion is a gradual or sudden cessation of strong 
 uterine contraction, generally in the second stage. Contractions may subse- 
 quently recommence spontaneously. 
 
 Etiology. — The causes of primary inertia do not coincide with those of the 
 secondary type. The former might arise from a great variety of conditions, as 
 follows: (i) Defective innervation (paralysis of the nerve-centers which preside 
 over uterine contractions); (2) defective development of the uterine muscle; 
 (3) abnormal shape of the uterus, as in uterus bicornis; (4) abnormal position 
 of the uterus, as in the anteversion which accompanies a pendulous abdomen, 
 and in prolapse; (5) abnormal distention of the uterus, as in hydramnios or 
 twins; (6) diseases and tumors of the uterine wall; (7) too intimate adhesions 
 between the embryonal sac and the cavum uteri. Numerous contributory 
 factors are also known to exist. Uterine inertia is thought to be hered- 
 itary. It is common in elderly primiparae and in mvdtiparas who have gone 
 many years without becoming pregnant. On the other hand, we see inertia 
 frequently in the opposite condition of too frequent labors. As a rule, we find 
 weak pains in the obese, in delicate women, in invalids, in convalescents from 
 acute infectious diseases, and in those who are poorly nourished from any cause, 
 especially in victims of hyperemesis gravidarum. Remediable factors are found 
 in distended bladder and rectum, tympanites, and overloaded stomach; all of 
 which have been known to impede the healthy action of the uterus. Secondary 
 inertia occurs more frequently than primary. It is common in primiparae 
 whose soft parts are rigid, and, generally speaking, it is found in any condition, 
 whether maternal or fetal in nature, which heightens the resistance to the normal 
 passage of the child. The conditions which make up the etiology of the 
 obstructive inertia need not be detailed in this connection. Partial inertia is 
 due usually to the presence of some local lesion or tumor of the uterus. Abdom- 
 inal inertia occurs in the presence of grave diseases, such as typhoid fever or 
 tuberculosis ; in inanition from any cause, and as a result of the inhibitory in- 
 fluence of pain and profound mental emotion. 
 
 It is readily apparent that primary and secondary inertia are not closely 
 related, the latter being due to obstructive conditions which at times must exhaust 
 the most vigorous uterus. For this reason primary inertia is sometimes spoken of 
 as true or essential inertia, while the secondary form is characterized rather as an 
 exhaustion or paresis. Still the two forms do possess some features in common. 
 Thus, vigorous contractions often readily overcome slight degrees of obstruction 
 which could determine secondary inertia in a sluggish uterus. 
 
570 PATHOLOGICAL LABOR. 
 
 Symptoms. — In the First Stage. — One of the first symptoms is the failure of 
 the uterine contractions to cause progressive dilatation of the cervix. Soon the 
 contractions become of short duration with longer intervals; they are accom- 
 panied by excessive suffering, giving rise to the expression "painful pains"; 
 they become cramp-like and irregular, and finally during each painful contraction 
 no thinning of the cervical lip or protrusion of the bag of membranes occurs. 
 Examination of a primipara will usually reveal a firm cervical ring and no ap- 
 parent obstacle to the completion of the first stage, provided only strong uterine 
 contractions were present. In the case of a multipara the contractions present 
 will usually be less painful, with long intervals, and a soft, flabby cervical ring 
 will usually be found, with vaginal walls so soft and readily dilatable that it 
 appears that only a few contractions accompanied by some abdominal efforts 
 woiild suffice to expel the fetus. In either case at this period the patient may 
 fall asleep and efficient contractions may not recur for twelve or twenty-four 
 hours. For a long period there are, as a rule, no symptoms beyond the mere 
 delay of labor. If the membranes are intact, this stage may persist for several 
 days without serious effects upon mother or child. Some fatigue and loss of sleep 
 necessarily result. If, however, the difficulty is found to be due to some condition 
 of the cervix, such as rigid os, exhaustion will ultimately be substituted for simple 
 inertia. (Exhaustion is considered under the head of prolonged labor in the second 
 stage of labor.) In case of premature rupture of the membranes the symptoms 
 become more serious, though less so than in the second stage. The liquor amnii 
 escapes slowly and the futile efforts to open the cervix will lead to exhaustion at a 
 much earlier period than will inertia with bag of waters intact. A tetanic contrac- 
 tion of the uterus may be present during the first and second stages of labor, but 
 this is not the rtde, as the contractions may be simply weak, irregular, or painful 
 in type. Should partial or complete escape of the liquor amnii ensue, a dangerous 
 complication results ; for even should the head for a time act as a ball- valve and 
 keep back some of the water, ''dry labor'' is always to be feared, with its tendency 
 to retraction of the uterus, ascent of the'contraction ring, dangerous thinning of 
 the lower uterine segment, and disturbance of the utero-placental circulation. 
 What contractions now remain tend not to cause dilatation and expulsion but 
 a further thinning of the lower uterine segment and finally its rupture. 
 
 In the Second Stage. — In simple protraction of the second stage of labor the 
 symptoms at the outset are not unlike those of the first stage. The uterine 
 contractions may be weak and irregular or tetanic — usually the latter. Inves- 
 tigation may show that the auxiliary forces are not co-operating with the uterus. 
 There may be no bearing-down, especially in cases in which for any reason the 
 patient is unable to fix her diaphragm (cardiac or pulmonary disease) ; or when 
 the abdominal wall is the seat of any structural or functional disease (oedema, 
 corpulence) ; or when fear exerts an inhibitory effect upon labor. The extreme 
 pain may cause the woman to cry out unceasingly, so that bearing-down is im- 
 possible. Finally, inertia may depend upon some simple local condition (an 
 unemptied bladder or rectum), or upon some psychical cause easily remedied, 
 as the presence of an obnoxious individual. If inertia persists during the second 
 stage, the most important symptoms may have reference to the child, who will 
 be almost certain to become asphyxiated. The pressure of the fetal head upon 
 the soft parts, which will cause sloughing if continued, does not betray itself by 
 any special train of symptoms. A general characteristic of inertia in the second* 
 stage is the dry condition of the maternal passages from the failure of the natural 
 secretions of the cervix and vagina. 
 
 Exhaustion. — This should be separately considered, for while primary inertia 
 
MATERNAL' DYSTOCIA FROM THE FORCES. 571 
 
 may end in exhaustion if the patient is not relieved, this abortive ending of labor is 
 more commonly a result of obstruction to the passage of the child in the presence 
 of contractions of the uterus originally normal. It is especially in these obstruc- 
 tive labors that a peculiar condition of the uterus is prone to develop which is 
 known as "continuous action." The continuous or tetanic action of the uterus is 
 brought about as follows : The abortive contractions, if regular, succeed each other 
 with progressively diminishing intervals until they finally merge into a state of 
 tonic contraction. Experience shows that in simple inertia the tetanic state super- 
 venes rapidly ; while in obstructive conditions with strong pains it is deferred. It 
 is important to distinguish between this tetanic state and simple passivity of the 
 uterus, as there is no doubt that they have been and still are confounded. Practi- 
 cally the tetanic uterus is an affair of the second stage of labor, though exceptions 
 may occur. This distinction is highly important in practice, as oxytocics are ab- 
 solutely contraindicated in the tetanic uterus. The symptoms of the latter are 
 revealed by abdominal palpation, the permanent rigidity of the womb contrast- 
 ing strongly with the soft, lax structures felt when the uterus is merely relaxed. 
 Another result of the abortive labor pains is retraction of the uterus in ob- 
 structive cases, which is brought about as follows: The strong contractions of 
 the uterus iiltimately determine a stretching of the lower segment, which gives 
 way under the pressure of the fetus. As the cervix stretches the body undergoes 
 a corresponding thickening, and the retraction ring or Bandl's ring shifts its 
 position upward. This ring sometimes becomes recognizable by external palpa- 
 tion, and is then regarded as indicating intervention, but not version. Retrac- 
 tion of the upper segment as just described is said to occur most commonly after 
 early rupture of the membranes. Inertia, either primary or secondary, should 
 not be confounded with non-advance of labor from undue obliquity of the uterine 
 axis. The phenomena of exhaustion, when the latter is once established, do not 
 differ from those of adynamia in general. 
 
 Diagnosis. — Statements of the woman to the effect that the pains are weak 
 have little value. Diagnosis is readily made, as a rule, by palpation, which 
 reveals the absence of a natural uterine action, and by the arrest of labor. If 
 the presenting part advances slightly, it is only to recede again. Upon timing 
 the pains they are found to be very short, with long intermissions. The fetus 
 exerts active movements during the interval. The diagnostic featiores of tetanic 
 uterus have been enumerated. 
 
 Prognosis. — In primary inertia the prognosis for the time being is good if the 
 bag of waters does not rupture. Before rupture of the membranes the first stage 
 of labor may be much prolonged, even several days, without serious result to 
 mother or child, although this favorable ending cannot always be looked for. Ner- 
 vous exhaustion which follows the suffering, anxiety, loss of sleep, insufficient 
 food, etc., must always be guarded against, for extreme exhaustion predisposes to 
 subsequent accidents in labor and the puerperium. If the waters break before the 
 dilatation of the cervix, an additional cause of inertia is supplied. The chief 
 danger to the fetus is found in the prolonged compression of the skull and pla- 
 centa, which favors the development of asphyxia. The mother is threatened with 
 the formation of a passive oedema of the parts in advance of the fetus, which in 
 turn predisposes to necrosis and the eventual development of fisttdas, to say 
 nothing of the added dangers of infection. It must not be forgotten that inertia 
 has been known to terminate in precipitate delivery. This can hardly be due to 
 sudden return of uterine vigor, but to the fact that labor has progressed more 
 rapidly than the physician supposed. Excessive delay in the second stage is 
 always dangerous for both fetus and mother: for the former because of asphyxia 
 
572 PATHOLOGICAL LABOR. 
 
 from compression of the head and placenta; for the latter from exhaustion, 
 pressure necrosis and fistulas, rupture of the uterus, septic conditions, and 
 post-partum hemorrhage from uterine atony. 
 
 Treatment in the First Stage. — In the great majority of cases of delayed labor 
 in the first stage there is no real obstruction in the cervix. The latter will almost 
 always dilate readily enough if the expulsive powers are sufficiently strong. The 
 first principle of treatment is to ascertain the cause of inertia and to remove it. 
 This may be a distended bladder or rectum, or the excessive pains of uterine 
 contraction, especially when spasmodic in character. As the invariable indica- 
 tion is to accelerate the first stage of labor, any legitimate means at our disposal 
 may prove of service, and our resources may be divided into two groups: (i) 
 Those applied outside the parturient canal, and (2) those which we make use 
 of within the passages. As a general principle, we should avoid recourse to the 
 second group as far as possible. 
 
 (i) Means for Accelerating the Ftrst Stage of Labor, which are Applied without 
 the Passages. — All our resources should be set in operation, even those of the 
 simplest character. Rest, a short sleep, feeding, and stimulation are all of benefit. 
 Exercise in the form of walking is often of value. It not only strengthens 
 feeble contractions, but when the latter have ceased for a time, — which often 
 happens after early rupture of the membranes, — it brings about their reappear- 
 ance, doubtless through reflex excitation by the weight of the presenting part 
 on the lower uterine segment. Other postural resources, such as the squatting 
 position, cannot be recommended because of the danger of prolapse of the cord. 
 The physician must not overlook the possibility that the cause of inertia may 
 be found in a distended bladder or rectum, and must guard against such a 
 contingency. Heat is a valuable stimulant to the sluggish uterus, and may 
 be administered in the form of a general shower or douche bath or hot com- 
 presses applied over the sacriim and hypogastrium. In the latter form the action 
 of the heat is reinforced by alternation with cold. A large number of oxytocic 
 drugs have been used, some for stimulant, others for sedative action. Ergot 
 should never be used in the first stage of labor; it should be given only after the 
 expulsion of the placenta. Quinine is largely used at the present day, and acts 
 probably as a purely nervous stimulant. When the stomach is irritable, I employ 
 large doses of the bisiilphate of quinine (grs. xx to xxx) in rectal suppositories. A 
 group of sedative drugs comprises chloral, tincture of gelsemium, and the coal-tar 
 products.- These are indicated in irregular and painfiil contractions. Chloral is 
 now in almost general use. Opium appears to act as a sedative in irritable con- 
 ditions and as a stimulant in sluggishness. General anesthesia is contraindicated 
 during the first stage of labor, but the inhalation of a few drops of ether or chloro- 
 form is often employed for sedative effect in irregular and painful contractions. 
 If too much chloroform is inhaled, the action is too pronounced and the contrac- 
 tions may be arrested entirely. On this account, if anesthetics are employed 
 at all, ether or the A. C. E. mixture should be preferred. In instances in which 
 the severe pain and cramp-like action of the contractions appear to interfere 
 with the progress of cervical dilatation, I have found that pouring a small quan- 
 tity of ether into an Allis inhaler, and allowing the patient to inhale it, controls 
 the suffering quite as well as does chloroform, and there is much less danger of 
 producing inertia uteri. Cocaine applied directly to the cervix has been used as a 
 local anesthetic. Manual friction of the fundus uteri, manual expression (Part X), 
 and the like are hardly indicated in inertia of the first stage unless dilatation of the 
 cervix is over half completed. Voluntary efforts at bearing-down are likewise of 
 little service, save when the cervix is partly dilated, especially in multiparas, and 
 
MATERNAL DYSTOCIA FROM THE FORCES. 573 
 
 when rupture of the membranes has occurred. I have abandoned the use of elec- 
 tricity as dangerous to the fetus in the first stage of labor. A unique resource, 
 since it is applicable during pregnancy rather than in the midst of labor, is the 
 continuous use of strychnine for some weeks before delivery. This is more than 
 a mere oxytocic, for it is also a prophylactic against a flabby uterus after delivery. 
 Its special field appears to be in debilitated women. It should be given at first 
 in doses of g-^ grain three times daily, beginning at not less than four or more 
 than eight weeks before the expected confinement. One week before the date 
 of the latter the dose may be increased to jg- or even -^^ grain. I have 
 used the drug in this manner in many multiparse with a history of feeble, irreg- 
 ular, and faulty uterine contractions, post-partum hemorrhage, or severe after- 
 pains, and with most excellent results. Strychnine is also of use during the first 
 stage of labor as an oxytocic, but then should be given hypodermatically. The 
 amount given is -g-^^- grain every fifteen minutes until -2V grain has been taken. 
 
 (2) Means for Shortening the First Stage of Labor that are Used within the 
 Passages. — It may be that the uterus responds to the various stimuli but the 
 woman has become exhausted from the delay, so that more radical intervention 
 is called for. We must have made sure that there is no mechanical defect; 
 this necessitates a careful internal exploration. The simplest internal resource 
 is the hot vaginal douche, especially indicated in cases in which the lower uterine 
 segment has been forced downward into the pelvis with resulting incarceration 
 between the fetal head and the bony pelvis, causing oedema of the os. If the 
 cervix is partially open and contractions are present which do not cause any pro- 
 trusion of the bag of waters, we may suspect the presence of adhesions between 
 the membranes and the uterine wall. This condition is remedied by the finger 
 introduced into the cervix to the extent of two joints, and swept around 
 within the ring of the os. In primiparse this is difficiilt of execution, and it 
 may first be necessary to push the fundus downward and backward. Care must 
 be taken, while detaching these adhesions, to avoid rupturing the membranes, 
 which is not so likely to happen if the finger is used rather than a catheter with sty- 
 let. If these measures are unsuccessful, intrauterine irritation in some form must 
 be employed. Bougies introduced between the membranes and the uterine 
 wall and allowed to remain in situ are attended by slow and uncertain results. 
 A resource attended by a prompt response is the principle which underlies 
 the bags of Barnes and Champetier de Ribes; these devices not only excite 
 uterine contractions, but dilate the cervix as well (see Part X). As far as 
 the simple indication of accelerating labor is concerned, it need only be said 
 that the principle of these hydraulic dilators may usually be dispensed with, 
 and certainly should be when possible. Some authorities regard manual 
 dilatation of the cervix for simple inertia as nothing less than malpractice. 
 However, very gentle dilatation intended simply to stimulate the uterus 
 is a rational procedure and may safely be done with the fingers. (See 
 Manual Dilatation of the Cervix, Part X.) It is especially applicable when 
 the OS is partly dilated, soft, and pushed low down into the pelvis. Incisions 
 are as little indicated as is instrumental dilatation. If an emergency arises so 
 that the indication is to extract the child at once, one or both of these last- 
 mentioned procedures may be required. 
 
 In the Second Stage. — After cervical dilatation, the treatment of delayed 
 labor usually becomes a simple matter in the absence of maternal or fetal ob- 
 struction, and resolves itself usually into the application of the forceps, when 
 the positive indication shows itself either on the part of the fetus or on that 
 of the mother. (Part X.) Occasionally in non-engagement of the head the 
 
574 PATHOLOGICAL LABOR. 
 
 choice will be between forceps and version. (Part X.) Strychnine, friction, and 
 compression of the fundus, encouraging and educating the patient to use her 
 voluntary muscles in bearing-down, will in many instances bring the head 
 into digital control in the vulva. It is at this time that supplying the patient 
 with traction straps to pull on, thereby assisting in her bearing-down efforts, 
 will often be of assistance. 
 
 MATERNAL DYSTOCIA IN THE PARTURIENT TRACT AND 
 
 ADNEXA. 
 
 ill. RETENTION OF PLACENTA AND MEMBRANES. 
 
 Definition. — The placenta as a whole with its membranes is said to be retained 
 when these structures have not been expelled one hour after the birth of the 
 child. After apparently successful termination of the third stage of labor 
 placental and membranous tissues may remain behind, especially when accessory 
 formations, as secondary placentee, are present. 
 
 Etiology. — The causes of retained placenta and membranes are as follows: 
 (i) Adhesion of the placenta (so-called placenta accreta), which is due to a 
 previous endometritis deciduae. (See page 191.) This adhesion, which is seldom 
 universal, prevents the loosening and detachment which occur naturally in the 
 third stage of labor. (Figs. 568 to 571.) It often happens that the supposition 
 of an adhesion of the placenta is incorrect, the delay being purely natural 
 and due to atony, powerless contraction, etc. Such a conclusion may be arrived 
 at when too precipitate efforts at manual expression are not rewarded. True 
 adhesion is very rare (Fig. 771). (2) Atony of the uterus. A condition of inertia 
 of the uterus in the third stage of labor may be the cause of retention (Fig. 772). 
 This state may be surmised if timely efforts, to expel the placenta by Credo's 
 method are unavailing. (3) Hour-glass contraction. By this expression is meant 
 a contraction of Bandl's ring, which incarcerates the placenta, the fundus uteri 
 remaining in a lax condition (Figs. 773 and 774). Schauta regards this condition as 
 one of atony of the uterus despite the contraction of the ring. (4) Contraction 
 of the external os (Fig. 775). (5) Tetanic contractions of the entire uterus. 
 This condition, which has been seen after the abuse of ergot, incarcerates the 
 placenta for the time being (Fig. 776). (6) Actual incarceration of the placenta 
 without regard to the uterine contractions is seen in certain malformations of 
 the uterus (Figs. 456 to 465). (7) The foregoing causes refer to the entire pla- 
 centa, but it is also possible, as already stated, for a portion of the placenta or 
 membranes to be left behind through unskilful management of the after-birth 
 period, and also despite all precautions. 
 
 Symptoms and Diagnosis. — The principal symptom is naturally the non- 
 expulsion of the placenta. If complete adhesion is present, there will be no 
 hemorrhage. Examination of the fundus by palpation enables us to recognize 
 the presence of uterine atony; and the association of vigorous contractions 
 with the non-appearance of the placenta will cause us to suspect the presence 
 of adhesion. More or less hemorrhage may accompany either atony or partial 
 adhesion. In hour-glass contraction the fundus feels elastic, like an inflated 
 balloon. After apparent expulsion of the entire ovum, the persistence of fragments 
 of the decidual structures or the presence of a placenta succenturiata might be 
 indicated by a persistent hemorrhage, expulsion of bits of tissue, after-pains, etc. 
 
MATERNAL DYSTOCIA IN THE PARTURIENT TRACT. 575 
 
 Treatment. — Prophylaxis: This complication can usually be prevented by 
 the proper management of the second and third stages of labor, but especially 
 the latter. If the uterus is followed down with the hand on the fundus during 
 the second stage and no traction is made upon the child to assist delivery; if 
 the fundus is carefully held during the third stage and compression exerted 
 
 Fig. 771. — Retained Placenta 
 FROM Adhesion to the Uterine 
 Wall. 
 
 Fig. 772. — Retained Placenta from Atony of 
 the Uterus. 
 
 \ 
 
 Fig. 773. — Retained Placenta from Tightening of the Contraction Ring. 
 Form of "Hour-glass Contraction." 
 
 Onb 
 
 only after the lapse of half an hour, and then only during uterine contraction; 
 if no traction is made upon the cord and ergot administered only after the 
 complete emptying of the uterus, retention of the whole or a portion of the 
 placenta will rarely occur. Curative treatment: This will depend upon the 
 amount of hemorrhage present. In the presence of profuse hemorrhage with 
 
576 
 
 PATHOLOGICAL LABOR. 
 
 retained placenta the indication is to empty the uterus completely by the 
 quickest possible means ; for complete uterine contraction is the surest means 
 
 Fig. 774. — Retained Placenta from 
 Irregular Contractions of One 
 Horn. One Form of "Hour-glass 
 Contraction." 
 
 Fig. 775. — Retained Placenta from Tighten- 
 ing OF THE External Os. Follows the abuse 
 of ergot. A common cause of the complica- 
 tion. 
 
 Fig. 776. — Retained Placenta from Tet- 
 anic Contractions of the Entire Uterus. 
 
 Fig. 777. — Retention of Mem- 
 branes. 
 
MATERNAL DYSTOCIA IN THE PARTURIENT TRACT. 577 
 
 to close the vessels and so to control the hemorrhage. Should Crede's method 
 of placental expression fail, recourse must be had to digital or manual extrac- 
 tion of the placenta. (See Operations, Part X.) 
 
 IV. POST-PARTUM HEMORRHAGE. 
 
 Definition. — Post-partum hemorrhage is hemorrhage from any portion of 
 the parturient canal after delivery of the fetus. Post-partum hemorrhage 
 proper is only from the placental site (Fig. 778). It is primary or immediate 
 when it occurs within twenty-four hours after the expulsion of the child. It 
 is secondary or remote when it occurs at any time during the puerperium subse- 
 quent to the first twenty-four hours. Post-partum hemorrhage is also internal 
 
 Fig. 778. — Diagram showing the Four Varieties of Post-partum Hemorrhage. 
 
 or concealed, and external or open. It may occur from the cervix, vagina, or the 
 pelvic floor (Fig. 778). The typical form is commonly known as "flooding." 
 Frequency. — Severe cases of hemorrhage are not common, to judge from 
 hospital statistics; but it must be remembered that proper facilities for treat- 
 ment are there always at hand. This is by no means always the case in private 
 practice. It may be stated in general that the complication occurs in a mild 
 form once in fifty labors; is severe, once in 1000; and fatal, once in 5000. I 
 found in 2200 cases of confinement, — 800 of which were outdoor, and the re- 
 mainder hospital cases, — that post-partum hemorrhage occurred in 104 cases, 
 or 4.72 per cent. This includes mild, severe, and fatal cases. The frequency 
 37 
 
578 PATHOLOGICAL LABOR. 
 
 of the accident in hospital and dispensary practice was about the same. Of 
 these cases, 33.65 per cent, were in primiparas; 60.57 in multiparse, and 5.76 per 
 cent, had no record of parity. Of the hemorrhages, 25.96 per cent, occurred 
 before placental delivery; 62.50 per cent, after the completion of the third 
 stage, and in 11.53 per cent, the hemorrhage took place both before and after 
 delivery of the placenta. Of the foregoing, mild cases occurred once in 22 
 labors; severe cases once in 550; and fatal cases once in 7333 labors. The 
 great frequency of the complication in the foregoing cases is due undoubtedly 
 to the common use of the forceps (see Part X) and to the mismanagement 
 of the third stage. (Page 490.) It is strange that this accident does not occur 
 more frequently, especially in consideration of the characteristic structure 
 of the uterine walls, and the alterations which have taken place in the pelvic 
 blood-vessels and tissues during pregnancy. The conservatism of Nature is 
 to be thanked for the escape of so many puerperal women. 
 
 Mechanism. — The three processes which prevent post-partum hemorrhage 
 from occurring more frequently than it does are (i) changes in the vessel walls, 
 (2) changes in the muscle-fibers of the uterus, and (3) changes in the blood. 
 In pregnancy the blood-vessels of the uterine walls and of the broad ligaments 
 and pelvic fascia are enormously dilated. In the uterus the vessel-walls grow 
 very thin, and the external coats are gradually absorbed, until at the end of 
 pregnancy the intima alone is left, which is surrounded by the hypertrophied 
 muscle-fibers. The muscular fibers as pregnancy advances arrange themselves 
 longitudinally in rows so as to form canals, in which the vessels run to join 
 with the placental vessels. Besides the longitudinal arrangement of the fibers 
 parallel with the vessels, the fibers in the latter months of gestation arrange 
 themselves so as to form strong circular bands or sphincters encircling the 
 vascular trunks. Thus each vessel runs in a muscular canal made up of con- 
 tractile smooth muscle-fibers, and, in addition, falciform, sphincter-like bands 
 of the same contractile fibers encircle several vascular trunks. This is well rep- 
 resented by a package of cigarettes. There each individual cigarette is surrounded 
 by its paper cover and the whole pack by its strong cover. This arrangement 
 permits perfect obliteration of the blood-channels by uterine contraction. 
 Besides, the intima is very elastic, which gives the vessel -wall the property 
 of contractility, by which the ragged edges of the sinuses retract into the sub- 
 stance of the uterus which covers them and stops up the apertures. The third 
 process in Nature's conservatism is the increased coagulability of the blood. 
 The blood-current is slowed in the great sinuses, and, owing to this and the 
 extreme thinness of the vessel-walls, there is a marked tendency to diapedesis 
 of white blood-corpuscles which proliferate in the connective tissue around 
 the vessels and add their part to the obstruction of the lumina. When, there- 
 fore, the decidua separates, this process hinders hemorrhage. On the other 
 hand, there are (i) cases in which the uterus will remain comparatively large 
 and flaccid and still no flooding result. (2) In many cases alternate contraction 
 and relaxation of the uterus will take place after labor, and still no hemorrhage 
 occur. This leads to the consideration of another preventive factor — thrombosis. 
 In these cases of incomplete or partial contraction of the uterus the organ 
 has sufficiently contracted to allow of the formation of coagula in the mouths 
 of the uterine sinuses, so that when the uterus again relaxes, these openings 
 are plugged by coagulated blood. 
 
 Etiology. — Predisposing Causes. — Among these is the hemorrhagic diathesis. 
 Some women are by nature "bleeders," and all through their pregnancy, par- 
 turition, and puerperium they are subject to hemorrhage. Certain conditions of 
 
MATERNAL DYSTOCIA IN THE PARTURIENT TRACT. 579 
 
 the mother's blood, as albuminuria, extreme malarial poisoning, leucocythemia, 
 and alcoholism, strongly predispose to hemorrhage. Certain conditions of the 
 liver, heart, and lungs which retard or obstruct the return circulation are also pre- 
 disposing causes. It is more common in multiparae than in primiparae; in 2200 
 confinements, I found this hemorrhage twice as frequent in the former (60.57 per 
 cent.) as in the latter (33.65 per cent.). It is apt to occur in those in whom men- 
 struation is generally profuse — in women of a delicate constitution. Thus it is ' 
 seen among the rich rather than among the hard-working classes; in delicately 
 nurtured women who have cultivated the emotional at the expense of the phy- 
 sical. It also occurs in women of the temperate zones who have taken up their 
 residence in the tropics and have become debilitated by the warm climate. Irregu- 
 larities in the maternal forces, such as precipitate or protracted labor, also lead 
 to post-partum hemorrhage; so does overdistention of the uterus, as in multiple 
 pregnancies and hydramnios. Certain conditions of the muscular walls of the 
 uterus, degenerations, tumors; or malposition of the organ, partial or com- 
 plete inversion, also favor post-partum hemorrhage. 
 
 Exciting Causes. — Foremost among these is the improper treatment of 
 the second and third stages of labor. This complication is, almost without 
 exception, the attendant's fault, and applies to the too rapid emptying of 
 the uterus, as in extraction in breech presentations, and the use of forceps, 
 cranioclasts, or cephalotribe, or by too rapid extraction after turning, and 
 the excessive use of anesthetics — chloroform or ether. Here also belong efforts 
 on the part of the attendant to hurry delivery by uterine compression, and 
 injudicious voluntary efforts on the part of the patient during the second stage; 
 as, for example, too forcible bearing-down during the hard pains. Mental 
 emotions, such as anger, fright, anxiety, and such disturbances as coughing, 
 laughing, vomiting, defecation, etc., have been known to give rise to post-partum 
 hemorrhage. A distended bladder or rectum often constitutes an exciting cause. 
 The retention of the placenta, membranes, or blood-clots, or new growths 
 in the uterus, may hinder its contraction. A uterus completely and perma- 
 nently contracted cannot give rise to a severe hemorrhage. Other factors are: 
 uterine apathy; imperfect development of the organ or a deficient nerve- 
 • -supply to it; adherent placental tissue; a large pyosalpinx, h3'-drosalpinx, 
 pelvic exudate, old adhesions of the peritoneal surface of the uterus, or any 
 mechanical obstruction to uterine contraction. Placenta prsevia may be the 
 cause of post-partum hemorrhage, for the lower uterine segment has not the 
 power to contract that the upper part of the organ has, hence when the placenta 
 is attached here the open mouths of the vessels do not close so quickly. 
 
 Symptoms. — The symptoms in many cases come insidiously — all may 
 apparently have gone well, and the placenta expelled naturally, but soon after, 
 the first symptom perhaps will be a complaint from the patient that she "feels 
 faint," and that "something is flowing away from her." This warning should 
 never be disregarded, and an immediate examination should be made. There 
 may be only a slight discharge or the blood may be escaping in torrents. On 
 palpating the uterus it is found to be soft, flaccid, and flabby, rising to and 
 perhaps above the umbilicus, and presenting hard, irregular prominences which 
 shift their position under a firm grasp. These are blood-clots within the uterus. 
 In the more severe cases in which uterine inertia is complete, external pal- 
 pation will not discover any uterus at all. Alternate contractions and re- 
 laxations of the uterus, together with pain and tenderness when the fundus 
 is firmly grasped, are certain signs of hemorrhage from atony of the muscular 
 fibers. There may be slight open or external hemorrhages taking place for 
 
580 PATHOLOGICAL LABOR. 
 
 some time before any general symptoms are produced, and the patient not 
 complaining, the physical signs will be overlooked. In extreme cases, however, 
 of the concealed or the open variety, the general symptoms of shock and col- 
 lapse set in, and it seems impossible to cause the uterus to contract immediately. 
 In sudden profuse hemorrhages death may occur within two or three minutes. 
 Frequency of the pulse-rate and decreased force are valuable danger-signals 
 of the condition, and when observed should demand a careful examination of 
 the uterus and the discharge. 
 
 Diagnosis. — The diagnosis is generally plain, especially when the bleeding 
 is external. It is different when the blood accumulates within the uterine 
 cavity, which constitutes the concealed variety, for although there are then 
 the symptoms of syncope and collapse and a more or less rapidly enlarging 
 abdomen, yet these symptoms and signs may be present without internal 
 hemorrhage, (i) Syncope occurring after labor does not always depend upon 
 loss of blood. It is often observed after precipitate and very rapid labors, 
 for in these cases the uterus is so quickly emptied that the pressure to which 
 the abdominal vessels has been subjected in the last two months of pregnancy 
 is suddenly removed; the circulation in them becomes free and unobstructed 
 and there is a rapid determination of blood from the upper part of the body, 
 giving rise to cerebral anemia and fainting. When this occurs, raising the 
 foot of the bed and the application of a moderately tight abdominal bandage 
 will usually relieve the condition. (2) Enlargement of the abdomen may be 
 owing to the fact that the intestines, being suddenly relieved of pressure and 
 distended by gas, cause the abdominal wall to swell up nearly to its previous 
 size. But in this case careful physical examination by palpation, percus- 
 sion, and vaginal touch will readily determine the true state of affairs. (3) 
 An hysterical attack coming on immediately after labor may be mistaken for 
 the general symptoms of hemorrhage; but physical examination will again 
 distingmsh the well-contracted uterus in the hypogastrium. (4) Lacerations 
 of the cervix causing rupture of the circular artery or lacerations of the genital 
 tract below the cervix may be mistaken for post-partum hemorrhage. In these 
 cases there will be a firmly contracted uterus. If any doubt exists, a speculum 
 can be passed and the bleeding point treated. If the hemorrhage does not 
 occur within ten or fifteen minutes of the birth of the child, it is not usually 
 due to cervical or vaginal tears. Engel (1840), Schraeder, Virchow, Valenta, 
 and Olshausen have described a dangerous variety of hemorrhage: viz., in 
 cases in which, although the rest of the uterus is firmly contracted, the place 
 of placental insertion does not participate, and there results what might be 
 termed paralysis of the placental site. The part involved is driven down 
 into the uterine cavity by the uterine parenchyma which is contracted about 
 it like a ring, and thus a sort of tumor is formed which projects into the uterine 
 cavity, and at a corresponding point upon its external surface a depression 
 may be made out by careful palpation. This variety is particularly danger- 
 ous, because, the greater part of the uterine globe being firmly contracted, 
 this small relaxed part may escape observation. Rarely an uncontrollable 
 post-partum hemorrhage occurs from a firmly contracted and uninjured uterus. 
 One case is on record in which it occurred from an aneurysmal vessel; another 
 from a rupture hematoma of the cervix; and a third from a lacerated varicose 
 cervical vein. These complications are said to be more common in high than 
 in low altitudes on account of lessened atmospheric pressure (Hirst). 
 
 Prognosis. — The prognosis is doubtful, as it depends on several factors. It 
 is the graver, the earlier the hemorrhage takes place. There is great danger in 
 
MATERNAL DYSTOCIA IN THE PARTURIENT TRACT. 581 
 
 that variety in which by the formation of a vaginal or cervical clot or the intro- 
 duction of a tampon it becomes hidden. If the blood is like serum, not clotting, 
 there is immediate danger of death. Pain in the back is taken as an encouraging 
 sign indicating uterine activity. Other things being equal, the prognosis is 
 more dangerous in the internal variety than in the external, for in the former 
 the flow is apt to escape detection. There, again, the prognosis will vary 
 depending on the completeness of the uterine inertia, and whether the patient 
 is to have immediate and skilful treatment, for a very few moments may decide 
 
 Fig. 779. — Compression of the Fundus for the Emptying of the Uterus and thb 
 Control of Post-partum Hemorrhage. 
 
 the patient's fate. The late results of the hemorrhage are the same as those 
 from any severe hemorrhage. 
 
 ■ Treatment. — Preventive. — In case the pregnant woman is suffering from 
 albuminuria, leucocythemia, or alcoholism, the condition should be treated, 
 so that when the time of delivery draws near, the nervous, muscular, and cir- 
 culatory systems of the patient may be in as good a condition as possible. 
 All causes of obstructed venous return should be sought out, whether resident 
 in the liver, heart, or lungs, and remedied as far as possible. Women worn 
 out with frequent child-bearing and the attendant nursing and anxiety should 
 
582 
 
 PATHOLOGICAL LABOR. 
 
 be strengthened by iron» fresh air, nourishing food, and moderate exercise. 
 When there is reason to fear precipitate labor, the patient should not go about 
 without a nurse properly qualified to manage the delivery. In attending 
 such a case before the child's birth, delay should rather be encouraged so that 
 the uterus may not be emptied too rapidly and the danger of uterine inertia, 
 increased. In cases of protracted labor the physician should not delay till 
 the patient is exhausted before he renders assistance. A case of hydramnios 
 should not run too far; rather should the membranes be ruptured when labor 
 appears about to progress smoothly. The most important part of the pre- 
 
 Fig. 780. — Bimanual Compression of the Uterus for the Control of Post-partui* 
 Hemorrhage. The fingers of the left hand can, at the same time, compress the 
 abdominal aorta. 
 
 ventive treatment is the proper management of the second and third stages- 
 of labor. The hand should not leave the fundus after the birth of the child 
 till the placenta is expelled, and uterine contractions should be watched care- 
 fully afterward for at least an hour. Any disturbance of the patient during 
 this time should be avoided, and the administration of a drachm of the fluid 
 extract of ergot after complete emptying of the uterus adds to the safety and 
 comfort of the woman. The placenta and membranes should be carefully 
 examined after their expulsion. An abdominal binder should be applied im- 
 mediately and the child placed to the breast within three hours of the com- 
 pletion of labor. 
 
MATERNAL DYSTOCIA IN THE PARTURIENT TRACT. 583 
 
 Curative Treatment. — The curative treatment is more satisfactory than 
 that of any other obstetrical complication. The mechanism by which the 
 condition occurs must be carefully borne in mind; whence it will appear that 
 successful management must fulfill three indications: viz., (i) The uterus 
 must be evacuated, (2) it must be made to contract completely; (3) the loss 
 of blood and its consequences must be made good by measures directed to 
 the relief of the acute anemia, (i) Evacuation of the uterus: The uterus in these 
 
 Fig. 781. — Bimanual Compression of the Uterus. The Left Hand, in the Shape 
 OF A Fist, is Introduced into the Uterine Cavity, and This is Grasped'by 
 THE Right Hand through the Anterior Abdominal Wall. 
 
 cases usually contains fragments of placenta, membranes, or blood-clots which 
 must be brought away. Credo's movements (See Operations) are therefore 
 instituted in the same manner as in the expulsion of the placenta (Fig. 779). 
 In kneading the uterus the fundus is at the same time compressed, while the 
 ulnar border of the operator's hand makes pressure on the abdominal aorta. 
 The hand is introduced into the uterine cavity only when the Cred^ method 
 fails in its purpose. (2) Permanent contraction of the ^lter us: The rules for bring- 
 
584 PATHOLOGICAL LABOR. 
 
 ing this about are in part a continuation of the preceding. Compression of 
 the fundus uteri and of the aorta is maintained, or Breisky's method of bimanual 
 compression of the uterus may be employed alternately (Fig. 780). The uterine 
 cavity should be douched with hot water, either plain or with the addition of 
 I per cent, acetic acid. About one quart of water should be injected at a tem- 
 perature of 120° F. (49° C). In an emergency hot or cold vinegar may be used 
 in place of the acidulated water. The alternate use of hot and cold water or ice 
 has been advocated in these cases, but cold in the uterus is a depressant and adds 
 to the shock of the hemorrhage. There is no objection, however, to the applica- 
 tion of cold to the vulva. Another method of bimanual compression (Gooch's) is 
 also recommended (Fig. 781). It consists in compressing the fundus with one h^nd 
 while the other, tightly closed, occupies the uterine cavity. When for, any reason 
 the hand is introduced within the uterus, it should be withdrawn only during a 
 contraction lest air entering a sinus cause fatal pulmonary embolism. The man- 
 agement thus far given should be sufficient in most cases to arrest all hemorrhage. 
 It is eminently natural management, since it aids and imitates Nature's methods. 
 However, it is not invariably successful, for a degree of atony sometimes exists 
 which cannot be made to yield to mechanical excitation. If the styptic douche 
 and Gooch's method are ineffectual, the uterine cavity and the vagina must be 
 tamponed with gauze. (See Tamponade of Uterus, Operations, Part X.) The 
 tampons should be removed in about six hours. As an adjuvant to the measures 
 just described, ergotin may be injected subcutaneously. Styptics to the uterine 
 cavity are contraindicated with the exception of those enumerated. (3) Treat- 
 ment of anemia and shock: This is directed especially to the acute anemia and 
 tendency to heart failure which are produced by loss of blood. If the severity 
 of the symptoms is such as to warrant the most active treatment, the pillows 
 are removed from the bed, the foot of the bedstead is elevated, and the patient's 
 arms and legs are bandaged (autotransfusion). Warm saline infusion is then 
 introduced into the rectum and subcutaneously beneath the breasts. (See 
 Operations, Part X.) Stimulants must be used with care owing to their tend- 
 ency to cramp the heart under these circumstances. Ammonia may be injected 
 into a vein, and camphorated oil subcutaneously. Absolute quiet is demanded. 
 Feeding must not be neglected in these cases. At first it may require limitation 
 to sips of brandy and coffee every fifteen minutes; after some reaction has set 
 in, beef -juice, panopeptone, mutton broth, etc., may be substituted. In case 
 of vomiting the patient may be nourished by the rectum with enemata of hot 
 water containing whisky and pancreatinized milk or panopeptone. 
 
 V. RUPTURE OF THE UTERUS. 
 
 Definition. — A partial or complete rupture of some part of the uterine wall 
 occurring during pregnancy, labor, or the puerperium. So-called spontaneous 
 rupture may occur during pregnancy from rapid stretching of the uterine walls 
 or from cystic degeneration of the chorion. These latter ruptures are very 
 rare and result almost invariably from traumatism. Intra-partum rupture is 
 rupture of the uterus proper. Rupture may also occur during the puerperium 
 from a dissecting metritis in septic conditions, or from sloughing following 
 prolonged pressure of the fetal head during labor. This is also very rare and 
 is nearly always traumatic, e. g., from post-partum curettage. 
 
 Frequency. — It occurs about once in 1000 cases of confinement. A case 
 might not be met with in a decade, while, again, one observer might see two 
 in the same day. However, this accident is far more frequent than is generally 
 
MATERNAL DYSTOCIA IN THE PARTURIENT TRACT. 585 
 
 stated. A great proportion of those in private practice which end fatally 
 are reported as post-partum hemorrhage or as septic peritonitis. It is only 
 in maternity hospitals that anything like correct statistics can be compiled. 
 
 Pathology. — On account of the general right obliquity of the uterus, the 
 retraction is greater on the left side than on the right. In shoulder presenta- 
 tion, also, the head is most often on the left. These facts probably explain 
 the general direction of the ruptures and their greater frequency on the left 
 side. The cause for the frequency of rupture on the posterior wall is the direc- 
 tion of the force of uterine contractions. When the rupture is in the lateral 
 wall, the peritoneum is generally felt intact, for its attachment in this situation 
 is loose and the folds of the broad ligament near the uterus are separated to 
 a certain degree by the growth of that organ during pregnancy. As a rule 
 the edges of the rupture are not clean-cut, but are rough and jagged, and the 
 direction is often oblique (Fig. 783). The prevailing low situation of the rupture 
 depends on the greater distention and thinning of this part of the uterus during 
 labor (Figs. 530 and 531). The degree of the tear varies from the size of a 
 finger-tip to an opening large enough for the fetus to pass through. A trans- 
 verse rupture sometimes embraces all or nearly all of the circumference of 
 the organ (Fig. 783); a longitudinal or oblique tear may extend downward 
 into the vagina or upward into the fundus of the uterus (Fig. 782). If the 
 rupture is quite large and the uterine contents are evacuated, the upper part 
 of the organ firmly contracts, while it is forced out of its normal position by 
 the fetal body, which lies in the abdominal cavity. The manner of escape 
 of the fetus varies in different cases. In a large tear it, together with the pla- 
 centa, may be extruded into the cavity; or, again, if its head is impacted in 
 the pelvis, it may be only the trunk and extremities which lie outside the uterus. 
 In some cases the placenta remains in the uterus and is delivered through the 
 vagina. Incomplete rupture consists of partial or almost complete rupture of the 
 muscular coat. Complete rupture involves muscle and peritoneum. From the 
 former may result extrauterine and extraperitoneal hematocele. Very rarely 
 rupture of the peritoneum alone occurs. The complete rupture consists in 
 a communication between the cavities of the uterus and peritoneum. The 
 rupture is called complicated when there is associated an injury of a neighbor- 
 ing organ; for example, an opening into the bladder or intestines. 
 
 Etiology. — Among the predisposing causes are disproportionate size of the 
 head and pelvis, stretching of one side of the lower uterine segment from lateral 
 displacement, and any force which tends to twist the organ upon its longitudinal 
 axis. Schuchard (1884) found among 73 cases of hydrocephalus, 14 cases 
 of rupture of the uterus. A shoulder presentation is responsible for a large 
 proportion of cases of rupture of the uterus, and it is possible for the cervix 
 to be so rigid that rupture occurs before the cervix yields. Contributory 
 causes of rupture are anything which narrows and makes rigid the cervical 
 or vaginal canals (healed fistulas or lacerations, new growths, etc.); pathological 
 change in the uterine tissue (syphilis, soft myoma, carcinoma). Placenta 
 prasvia may also act as a cause. The scar of a previous Cesarean section 
 has been known to be a cause. Rupture occurs seven times as often among 
 multiparas as among primiparae. Among 19 cases Bandl found 2 primiparae, 
 and others have given the percentage of primiparag as 12 or less. 
 
 The exciting causes include the unintelligent use of ergot. A number of 
 cases of rupture have occurred from intrauterine manipulation, curettage, 
 version, extraction of placenta, etc., criminal abortion. Rupture occurring 
 during pregnancy is due to some pathological change in the uterine wall or 
 
586 
 
 PATHOLOGICAL LABOR. 
 
 to a new growth. Wittrow (1891) reported a case of rupture from external 
 violence. The peritoneum and the muscular coats were torn but not the mucosa. 
 Cases of rupture have been reported which occurred after the placenta was 
 removed, from clumsy and violent manipulations by the accoucheur or mid- 
 wife. The site of the rupture is usually lateral and on the left side, correspond- 
 ing to the position of the vertex. The body of the organ is seldom torn. There 
 are two methods in the mechanism of spontaneous rupture: (i) Rupture by 
 
 OVAR/AN 
 VESSELS 
 
 f^TERIOR 
 URFACE 
 
 NTERNAL OS 
 
 UTERINE yH^ 
 
 vesseTs 
 
 \^ 
 
 EXTERNAL OS ' '^ 
 
 Fig. 782. — Longitudinal Rupture of the Uterus, Following Manual Dilatation 
 OF the Os in Placenta Pr^evia. Tearing of the main branches of the uterine artery 
 and death from internal hemorrhage. Note that the cervical canal and the limit 
 of the internal os are still present. — (Author's case.) 
 
 thinning of the lower segment. In proportion to the variation between the 
 expelling power and the resistance, thinning of the lower segment takes place 
 while it closely hugs the enclosed fetus until rupture occurs. (2) Rupture by 
 compression of the uterine wall. The wall sometimes ruptures from the com- 
 pression to which it IS subjected between the bony pelvis and the presenting 
 part. 
 
 Symptoms. — Impending: The most characteristic symptoms are the ascent 
 
MATERNAL DYSTOCIA IN THE PARTURIENT TRACT. 587 
 
 of the contraction ring and the tension and tenderness of the round Hgaments. 
 Pulse and temperature may not be changed, but the patient may develop 
 great anxiety and restlessness. Thickening of the upper portion of the uterus, 
 and a transverse groove across the lower portion, can often be recognized through 
 the abdominal wall, the latter just above the pubis. The uterine contractions 
 will be strong or even tetanic, in either case accompanied by intense pain. 
 There is often a history of previous prolonged, obstructed labor due to pelvic 
 
 \Round ligament. 
 \Main branch of uterine 
 artery dra'wn uy. _._: 
 
 ^a«.. 
 
 Fig. 783. — Transverse or Oblique Rupture of the Uterus and Tearing of a Main 
 Branch of the Left Uterine Artery. Death from internal hemorrhage and shock 
 a short time after being received into the Emergency Hospital. Case had been treated 
 for inertia with ergot by a midwife. — {Author's case.) 
 
 deformity, with entire escape of the liquor amnii causing dry labor. The 
 symptoms of rupture are very characteristic, especially when complete. There 
 is a sharp, acute pain; a sudden cry from the patient; sometimes a sound of 
 tearing tissue ; followed by immediate collapse and symptoms of internal 
 hemorrhage. External hemorrhage, recession of the presenting part, prolapse 
 of the intestines, and subperitoneal . emphysema are sometimes present. Col- 
 lapse is soon marked, the pain severe, the pulse small and rapid, the patient 
 
588 
 
 PATHOLOGICAL LABOR. 
 
 usually vomits and the uterine contractions cease, though the latter is not an 
 invariable occurrence. In the case of a head presentation the head often recedes 
 from the pelvis even if it is alread}'' engaged. In shoulder presentation the 
 head may sometimes be felt through the tear, and it will be noted that the 
 form of the uterus has suddenly altered. In some cases the fetus may leave 
 the uterus entirely and may be palpable through the abdominal walls. Even 
 in rupture of considerable extent the hemorrhage may be slight or even absent, 
 and there may be no external evidence of it, especially when the head is firmly 
 engaged. The claim that collapse after delivery means rupture of the uterus 
 
 is sound, but there are cases in which there is 
 extensive rupture without collapse, and such 
 conditions are readily unrecognized. Patients 
 have often experienced a sensation of tearing, 
 and in several instances have described it to 
 me as of "something giving way." The 
 hemorrhage which nearly always occurs may 
 be external or internal. In proportion to the 
 severity of the hemorrhage will the symptoms 
 be grave. Symptoms of peritonitis come on 
 very quickly. Terminations are: (i) cicatri- 
 zation and healing; (2) rapid death from 
 hemorrhage and collapse; (3) retarded death 
 from peritonitis and septicemia. 
 
 Diagnosis. — When the foregoing symp- 
 toms have made their appearance, physical 
 exploration will confirm the diagnosis, (i) 
 Auscultation shows cessation of fetal heart- 
 sounds, as the fetus generally dies. (2) Vag- 
 inal palpation is normal as long as the fetus is 
 still within the uterus, but if it has passed 
 partly or completely into the abdominal 
 cavity, the presenting part is out of reach. 
 (3) Abdominal palpation: The uterus pre- 
 serves its form if the fetus remains in it. Pres- 
 sure increases the pain at the point of rupture. 
 The painful region may be emphysematous. 
 If the fetus has escaped partly or completely 
 into the abdomen, there will be two tumors — 
 one the fetus, and the other the retracted 
 uterus. (4) Direct examination of the uterine 
 cavity. The location and extent of the rup- 
 ture may be discovered in this manner. Some- 
 times there is hernia of the intestine which be- 
 comes strangulated in the uterine wound. There are cases of uterine rupture 
 which would have been overlooked if the physician had not been obliged to deliver 
 artificially. The condition may be confounded with placenta praevia and acci- 
 dental hemorrhage. (Pages 214 and 224.) 
 
 Prognosis. — This is the most serious complication in obstetrics ; the maternal 
 mortality may be placed, in complete rupture, at 90 per cent.; the fetal mor- 
 tality at 95 per cent. Maternal death is due to shock, primary or secondary 
 hemorrhage, peritonitis or septicemia; fetal death is due to asphyxia from inter- 
 ference with the placental circulation. The foregoing maternal mortality is esti- 
 
 FiG. 784. — Complete Rupture of 
 THE Uterus Involving Left Lat- 
 eral AND Posterior Walls and 
 Extending from the Contrac- 
 tion Ring almost to the Ex- 
 ternal Os, Which Latter is In- 
 tact. Also complete rupture of 
 posterior vaginal wall just below 
 external ring, opening into Doug- 
 las's pouch. — {After a specimen in 
 the Museum of the Munich Frauen- 
 klinik.) 
 
MATERNAL DYSTOCIA IN THE PARTURIENT TRACT. 589 
 
 mated from the unrelieved cases. This is diminished under modem methods of 
 treatment, being placed at from 55 to 60 per cent. One reason for the very un- 
 favorable course of most cases is that the patients are already seriously weakened 
 and usually infected before the accident occurs. In incomplete ruptures in which 
 the peritoneal coat is not torn the prognosis is naturally much more favorable 
 than in the complete, and they occur more frequently than is generally supposed. 
 Rupture may occur also down to the mucosa from the peritoneal side. Anterior 
 ruptures may also involve the bladder, and are therefore more serious. The 
 gravity of the case is increased by complications. If the rectum or bladder is 
 lacerated, there will be an escape of the contents into the surrounding tissues. 
 There may be hernia or incarceration of the intestine with subsequent gangrene. 
 There may be rupture of an hematocele, and death from hemorrhage or septic 
 peritonitis may follow the suppuration of this mass. 
 
 Treatment. — Prophylactic Treatment. — This is most important. All cases 
 having obstructed or prolonged labor from any cause must be watched for 
 tetanic or cramp-like action of the uterus, retraction, or dangerous thinning 
 of the lower uterine segment, in order that artificial aid may be given before rup- 
 ture actually occurs. When rupture is threatening, the strength of the labor 
 pains must be diminished by chloroform or morphin and any malposition 
 of the uterus or fetus must be corrected. All obstetrical work must be carried 
 out with the greatest caution, especially the application of the forceps. Some 
 cases will demand perforation; some in which the presentation is a shoulder, 
 may require decapitation, invariably or only when the child is dead. Version 
 is usually attempted when the child is alive. Csesarean section may be required 
 when rupture is threatening and delivery does not seem practicable by other 
 means. In nervous patients with a tendency to tetanic contraction of the 
 uterus the wise use of anesthetics will often result in a favorable course. When 
 slight pelvic contraction has been diagnosticated, the state of the uterus during 
 its contractions must be carefully watched ; and as soon as the contraction ring 
 rises, labor should be quickly terminated by forceps or craniotomy. Decapita- 
 tion is the only allowable method in neglected shoulder presentation. In all 
 cases where rupture is impending, labor must be ended by the method safest to 
 the mother, regardless of the fetus. If the head is immovable, the use of the 
 forceps is in order. But if the head is movable and version contraindicated, 
 the forceps will most likely injure both mother and child. All violent manipu- 
 lations should be avoided. In threatened rupture, embryotomy is preferable to 
 version, for the introduction of the hand as well as the turning of the child is 
 very dangerous when the uterus is in this condition. In cases of hydrocephalus 
 perforation is indicated. The chief complications which are followed by danger 
 of rupture are contracted pelvis, hydrocephalus, and shoulder presentation. If 
 in neglected shoulder presentation version is suggested, it should be ascertained 
 whether the fetus is still living. In order to make "this certain the hand, if pos- 
 sible, should be passed up almost to the shoulder and the cord palpated for pul- 
 sations. Version is not performed in case of a dead fetus. 
 
 Curative Treatment. — If rupture has already occurred, no disinfecting douche 
 is to be used, and the rupture must not be allowed to increase. Version must 
 not be attempted in the presence of a rupture with the fetus still in the uterus. 
 The rupture might be made larger and the perhaps untom peritoneum torn 
 through. If the fetus is partly protruding into the abdominal cavity, delivery 
 is still possible through the vagina, but it is an uncertain operation. Most 
 authorities agree that laparatomy is the best treatment for the majority of cases, 
 though Braun thinks that some can be treated by uterine tamponade, when the 
 
590 PATHOLOGICAL LABOR. 
 
 tear is not too great, when the placenta remains in the uterus, and when there 
 is no sepsis. I regard the prognosis as almost always justifying laparotomy in 
 uterine rupture. I believe laparotomy to be indicated in all cases of complete 
 rupture and when there is serious hemorrhage from an incomplete one. Sepsis 
 is always an indication for laparotomy. 
 
 When celiotomy is done for a septic indication, the peritoneum must be pro- 
 tected at all hazards from the septic contents of the uterus. The operator is 
 next confronted with the alternative: Shall he save the uterus or extirpate it? 
 The indications for extirpation, are : (i) Evidences of infection; (2) presence of 
 extensive contusions and extravasations in the uterine wall; (3) presence of ex- 
 tensive laceration of the uterine supports, especially the broad ligaments. If 
 these conditions are absent, the rent in the uterus should be sutured. Suture 
 of the uterus must be done with extreme care, and if the lips of the wound are 
 Tagged, contused, or necrotic, they should be resected. The sutures should in- 
 volve only the serous and muscular coats (see Technique of Caesarean Section, 
 Part X.) Many successful cases of suture have been reported. The uterine 
 tissue may be so friable that suture of any kind is out of the question. Under 
 these circumstances the organ should be extirpated. The after-treatment is like 
 that of an ordinary hysterectomy. Various statistics give a mortality rate for 
 the operative treatment of uterine rupture at from 25 to 50 per cent. Abdominal 
 hysterectomy, if the patient is in fair condition, in these days of antiseptic sur- 
 gery is attended by very good results. 
 
 Incomplete ruptures treated by tampon must also be treated by external ab- 
 dominal pressure. This method of tamponade is said by some to make possible 
 a subperitoneal hematoma, and pressure assists in preventing this. Ruptures 
 extending upward into the supravaginal portion of the uterus are especially liable 
 to be accompanied by serious hemorrhage, from which placenta prsevia is to be 
 differentiated. The hemorrhage from such lacerations may be very troublesome 
 and dangerous, and it may be necessary to open the posterior vaginal fornix and 
 clamp the broad ligaments in much the same way as in a vaginal hysterectomy. 
 
 Summary of Treatment. — (i) Curative treatment should always be prompt 
 and active; expectant treatment is usually fatal to the mother and always 
 to the fetus; the fetus must be delivered by some method — podalic version, 
 forceps, or craniotomy if dead — that will cause as little shock as possible. (2) 
 A careful examination of the position and extent of rupture must be made. 
 (3) If the latter is small, low down, posterior, and meconium and clots have 
 not escaped into the peritoneal cavity, the uterine cavity must be freely irrigated 
 with warm sterilized water, and a good-sized strip of sterile gauze passed to the 
 fundus, a firm abdominal binder applied, full doses of ergot administered, and 
 the case treated expectantly. One should be prepared for laparotomy on the 
 first indication of peritonitis. (4) Large ruptures with escape of the fetus into 
 abdominal cavity, and ruptures high up in the uterine wall, are best treated by 
 removing the child by the natural passages if possible and immediately perform- 
 ing laparotomy and hysterectomy, or, instead of the latter, Sanger's operation. 
 
 After-treatment. — The after-treatment is upon general principles. If re- 
 covery follows and subsequent pregnancy occurs, it should be terminated at the 
 thirty-sixth week to avoid spontaneous rupture. 
 
 VI. INVERSION OF THE UTERUS. 
 
 Definition. — By inversion of the uterus we mean a complete or partial 
 turning of the uterus inside out. It may occur before or after the delivery 
 
MATERNAL DYSTOCIA IN THE PARTURIENT TRACT. 
 
 591 
 
 of the placenta. It is the rarest of all complications of labor, occurring once 
 in 200,000 cases, and may be partial or complete. It generally begins by 
 a slight depression of the fundus. In a hospital experience of many thousand 
 cases of confinement one case of complete inversion has occurred. I have seen 
 in consultation practice several cases of partial inversion. 
 
 Etiology. — It is most common in primiparae and is due to the so-called 
 paralysis of the placental site, too vigorous compression of the fundus, or traction 
 on the cord. Mismanagement is generally responsible for this complication. 
 Other causes are sudden delivery, especially when the patient is standing 
 and the uterus relaxed; exertion after delivery, such as coughing or straining; 
 heavy pressure on the fundus from above; or a short cord, from whatever cause. 
 The uterus must be relaxed, for inversion of a well- 
 contracted uterus is almost inconceivable. This 
 accident generally takes place during the third stage 
 
 Fig. 785. — Beginning Inversion of the Uterus. 
 
 Fig. 786. — Inversion of thb 
 Uterus. 
 
 of labor, although rarely it may happen days after delivery. In very rare cases 
 it may occur without reproach to the physician. 
 
 Symptoms. — These are acute pain, hemorrhage, and shock; imperceptibility 
 of the fundus through the abdominal wall and a cup-like body in the vagina or 
 protruding through the vulva (Figs. 785, 786). The hemorrhage may be slight 
 or profuse according to whether the uterine sinuses are closed or open. There is 
 a rapid, thready pulse, the skin is clammy and pale, and nausea, vomiting, and 
 even syncope may occur. Reflex cardiac paralysis and cerebral anemia may 
 result. Most rarely this complication may occur with no apparent symptoms. 
 
 Diagnosis. — Inversion may be confounded with uterine polyp. The latter 
 is insensible and does not contract on examination, and its pedicle may be 
 traced upward through the os uteri into the cavity and demonstrated with 
 •a sound. The patient should be catheterized to set aside the possibility of 
 
592 PATHOLOGICAL LABOR. 
 
 a distended bladder. If the physician is present when the accident occurs, 
 and if the placenta is wholly or partially attached to the uterus, the diagnosis 
 is clear. The opening of the tubes may be seen on the lower part of the tumor. 
 The uterus is generally particularly sensitive and contractile. An inverted 
 uterus can alwaj^-s be half reduced; polyps cannot. Rectal examination will 
 detect absence of the uterus from its normal position. 
 
 Prognosis. — Mortality is as high as 50 per cent. Death, due to either hemor- 
 rhage or shock, often occurs soon after the accident (within half an hour). It may 
 also be caused by incarceration of an intestinal loop in the inverted uterus, by 
 peritonitis, by puerperal infection, or by gangrene. Cases are on record in which 
 recovery has taken place after the uterus has sloughed. A few cases in which 
 manual reposition was not accomplished were spontaneously restored. The 
 prognosis depends largely upon prompt reduction of the organ, as delay increases 
 the danger and difficulty. Prognosis should always be guarded. 
 
 Treatment. — The accident can usually be avoided; hence the prophylactic 
 treatment is most important. Precipitate expulsion of the fetus should be 
 prevented and unnecessary force in Crede's method and in traction upon the 
 cord avoided. Curative treatment consists in the immediate reduction of the 
 tumor with the aid of anesthesia. The bladder and rectum should be emptied 
 and reduction accomplished by taxis, followed by intrauterine irrigation and tight 
 intrauterine tamponade. The more quickly treatment is instituted, the more 
 successful the result. When the placenta is completely adherent or nearly so, 
 an attempt should be made to replace it with the uterus, although this is a dis- 
 puted point. The fist should be placed against the inverted fundus while the 
 other hand makes counter-pressure over the abdomen. If the placenta is almost 
 separated or if it interferes with reduction, it must be entirely detached. When 
 the body of the uterus has become swollen and congested, it is compressed either 
 manually or by bandaging before it is reduced. If this is impossible on account 
 of spasmodic constriction of the os, anesthesia may relax the spasm. Pressure 
 firmly continued gives the best results. After reduction has been accomplished 
 the uterus must contract before the hand is withdrawn, and if the placenta 
 is still attached it should be separated. Some authorities advise, in replacing 
 the uterus, to begin with that part which was last inverted. In cases in which 
 the uterus cannot be restored without great shock to the patient, especially 
 if she is not seen until several days have elapsed, the operation should be delayed 
 temporarily. If the uterus cannot be returned, hemorrhage can be controlled 
 by ergot and the local application of astringents, such as acetic acid, and stimu- 
 lating contractions by putting the child to the breast. 
 
 VII. EXCESSIVE RIGHT LATERAL OBLIQUITY OF THE UTERUS. 
 
 Although it is a physiological fact that the uterus leans as a rule to the 
 right side in pregnancy, this position is sometimes exaggerated so that much 
 of the expulsive power is wasted by driving the presenting part against the 
 lateral pelvic wall, resulting in delayed labor, malpresentations and malpositions, 
 and even in uterine rupture (Fig. 783). Postural treatment by placing the 
 patient on the left side is usually sufficient to relieve the condition. 
 
 VIII. LACERATIONS AND CONTUSIONS OF THE CERVIX, VAGINA, 
 
 RECTUM, AND PERINEUM.* 
 I. Lacerations and Contusions of the Cervix. — The cervix is ruptured very 
 frequently during labor, this accident invariably occurring in primiparae. The 
 
 * Compare Operations, Part X. 
 
MATERNAL DYSTOCIA IN THE PARTURIENT TRACT. 
 
 593 
 
 scars resulting from lacerations of the cervix constitute one of the essential 
 evidences of previous pregnancy (Fig. 123). 
 
 Etiology. — The mere act of labor itself is the cause of the milder degrees of 
 
 Fig. 7S7. 
 
 Fig. 7SS. 
 
 Figs. 787 and 7S8. — Author's Cases of Annular Detachment of the Cervix. The 
 left-hand figure was in the case of a generally contracted pelvis, and the other was 
 due to incarceration of the anterior lip of the cervix between the advancing head 
 and the symphysis. 
 
 laceration, the injury occurring during the expulsion of the head, shoulders, etc. 
 Deeper tears have a different cause. There is usually a predisposition in the 
 shape of organic rigidity. Precipitate or premature expulsion of the fetus before 
 dilatation is complete and operative extraction under the same condition both 
 produce extensive injuries. Many 
 lacerations are due to forceps de- 
 liveries and version, but especially 
 to the unskilful use of instruments. 
 Symptoms. — The vast majority 
 of tears are longitudinal, involving 
 the OS, but circular lacerations have 
 been described (Fig. 789). In one 
 of the author's cases of anatomical 
 rigidity the entire portio was torn 
 from the rest of the uterus (Fig. 
 787). Ordinary longitudinal tears 
 may be single, bilateral, or multiple, 
 the latter being rare. Deep lacera- 
 tions of the cervix may extend into 
 the vaginal culs-de-sac (extraperito- 
 neal rupture of the uterus). Finally, 
 there is a submucous rupture, which 
 is manifested by a patulousness of 
 the OS. Clinically the principal 
 
 symptom of ruptured cervix is hemorrhage. In the deeper varieties some of the 
 large branches of the uterine artery may be torn. Cervical lacerations often heal 
 spontaneously during the puerperium. The diagnosis is made b}^ careful inspec- 
 tion and palpation. As regards prognosis, after the cessation of hemorrhage 
 38 
 
 Fig. 789. — Laceration of the Cervix dur- 
 ing Labor. 
 
594 
 
 PATHOLOGICAL LABOR. 
 
 m*, 
 
 Fig. 790. — Utero-vesical Rupture Due to Secon- 
 dary Inertia in Persistent Occipito-posterior 
 Position. B, B' , Bladder ; R, rupture. 
 
 there is still danger of infection, and of the development of cervical catarrh, 
 with resulting tendency to abortion. 
 
 Treatment. — The prophylaxis consists in the utmost care in all operative 
 procedures which involve either forcing or drawing the fetus through an imper- 
 fectly dilated os. In regard to treatment proper, hemorrhage must be arrested 
 if profuse, and the best method is by immediate suture of the tear. 
 
 2. Lacerations and Contu- 
 sions of the Vagina. (See Repair 
 of Injuries, Part X.) — These in- 
 juries may be either spontan- 
 eous or artificial in origin. The 
 lower third is implicated much 
 more commonly than the rest of 
 the passage. Next in order 
 comes the upper third (culs-de- 
 sac), and lastly the middle third. 
 Etiology. — Lacerations of the 
 lower and middle thirds are due, 
 as a rule, to the marked trans- 
 verse distention of the vagina by 
 the presenting part. These vag- 
 inal tears are usually longitu- 
 dinal at the junction of the pos- 
 terior with one of the lateral 
 walls. Lacerations of the upper 
 third are due to causes practi- 
 cally the same as those for rup- 
 ture of the uterus, with which 
 they are also clinically related. 
 Submucous rupture is usually 
 due to the sudden descent of 
 the head in precipitate labors 
 and forceps extractions. Many 
 lacerations occur from operative 
 delivery. A special form of in- 
 jury to the vagina — a contusion 
 rather than a laceration — is seen 
 in the upper third in certain de- 
 formities of the pelvis in which 
 bony projections encroach upon 
 the excavation. Thus the ischial 
 spines project into the funnel- 
 shaped pelvis and the crest of 
 the OS pubis in exostosis pelvis. 
 The vagina then becomes incar- 
 cerated between the fetal head 
 and the bony prominence. Similar contusions are seen when the fetal head is 
 arrested in a narrow pelvis, and if the bladder is incarcerated between the fetal 
 head and the symphysis a vesico -vaginal fistula may result. (Figs. 790, 791.) 
 Ruptures in the upper third of the vagina may originate from mere extension 
 of cervical lacerations into the culs-de-sac, or they may begin in the vagina itself, 
 usually the posterior fornix. These injuries, unlike those of the lower and middle 
 
 m 
 
 Fig. 791. — Utero-vesical Rupture. 
 Degree of Fig. 790. 
 
 Advanced 
 
MATERNAL DYSTOCIA IN THE PARTURIENT TRACT. 595 
 
 thirds, run chiefly in a transverse direction. In the most serious types the vagina 
 may be torn across — the so-called "colporrhexis." The vagina may also be 
 separated from the uterus as a result of longitudinal stretching, which results 
 when the uterus with the cervix is drawn upward over the presenting part. This 
 condition is seen at times in certain presentations, such as shoulder or head in 
 narrow pelves. Spontaneous rupture of the posterior cul-de-sac has been seen in 
 connection with pendulous abdomen, congenital shortening and various acquired 
 alterations in the vagina. Introduction of the hand into the vagina in the per- 
 formance of version is a very common cause of rupture. The same may be said 
 of the application of the forceps. Injuries of the anterior fornix are also almost 
 always artificial. 
 
 Symptoms. — A peculiar form of laceration sometimes occurs in which the 
 mucosa of the inferior vaginal segment tears slightly while the submucous tissue 
 is extensively ruptured. Under these conditions a pocket is formed in which the 
 lochial secretions may collect, with the formation of abscess and fistula. Lacera- 
 tions of the middle and lower third are accompanied by hemorrhage and may be 
 followed by infection or by the formation of urinary or fecal fistulas. Hemorrhage 
 is seldom profuse unless the tears extend into the paravaginal tissue. Lacerations 
 of the ostium vaginae extending upward by the side of the clitoris may provoke 
 hemorrhages which threaten life. In extensive injuries, especially in the "pocket " 
 ruptures already described, there may be high fever, stagnation and putrefaction 
 of lochia, pelvic cellulitis, and general infection. Extensive injuries give rise to 
 cicatricial stricture of the vagina. 
 
 Diagnosis. — Lacerations of the lower third which are continuous with vulval 
 or perineal tears are diagnosticated by stretching the ostium vaginae with the 
 fingers, when the course and extent of the injury may be determined (Figs. 631 
 and 632). If, with vulva and perineum intact and uterus well contracted, 
 arterial blood escapes from the vagina, it' is evident that a laceration exists either 
 in the cervix or in the upper third of the vagina. The uterus should be pushed 
 into the lesser pelvis and drawn down with volsella forceps. It is common under 
 these circumstances to see a deep laceration from the cervix into the fornix 
 vaginas. Transverse lacerations of the posterior cul-de-sac, which sometimes 
 extend through the peritoneum, may be almost as grave in their consequences 
 as rupture of the uterus. The clinical picture is much like that of the latter, and 
 the diagnosis should be made with the hand in the vagina. 
 
 Treatment. — Deep lacerations recognized soon after delivery should be su- 
 tured. If the rupture forms a pocket in the submucous tissue it must be irri- 
 gated with antiseptics and packed with gauze. In severe contusions the vagina 
 must frequently be irrigated in such a manner that the affected surface is kept 
 clear of the lochial discharge. If fistula form, they sometimes close spontane- 
 ously under daily touching with nitrate of silver. 
 
 3. Lacerations of the Pelvic Floor. — These injuries comprise ruptures of the 
 fourchette, posterior vulval commissure, perineum, lower third of the posterior and 
 lateral vaginal walls, and the recto-vaginal septum. The tissues involved may 
 include the integument from the anal orifice to the posterior vulval commissure, 
 the mucous membrane of the vulva, vagina, and rectum, the cellular tissue, 
 the sphincter ani and levatores ani muscles. 
 
 Varieties. — These lacerations exhibit many varieties and may be classified 
 in various ways. The arrangement which is taught in most text-books is, how- 
 ever, only partially correct. It presents these injuries as occurring in three 
 degrees, as follows: The mildest grade of rupture extends from the posterior 
 vulval commissure for a variable distance into the perineal body; the second 
 
596 
 
 PATHOLOGICAL LABOR. 
 
 degree extends as far as the sphincter ani, while in the highest degree the rupture 
 involves the sphincter and the recto-vaginal septum. This mode of grouping 
 takes no cognizance of lacerations of the vaginal sulci, which are the most fre- 
 
 \ 
 
 Fig. 792. — Abrasions and Superficial 
 Tears of the Vestibule and Vulva. — 
 {Redrawn after Bar.) 
 
 Fig. 793. — Abrasions and Superficial 
 Lacerations of the Vestibule and 
 Vulva. — {Redrawn after Bar.) 
 
 I 
 
 Fig. 794. — Lateral Vagino-perineal 
 Ruptures with Abrasions of -Sthe 
 Vulva. — {Redrawn after Bar.) 
 
 Fig. 795. — Perforations and Lacera- 
 tions of the Labia Minora and Vagi- 
 nal Inlet. — {Redrawn after Bar.) 
 
MATERNAL DZSTOCIA IN THE PARTURIENT TRACT. 597 
 
 quently occurring and the most important of all the accidents, owing to the 
 participation in the rupture of the levator ani muscle. Central rupture of the 
 perineum is described by most authors as an injury sui generis, as if it had no 
 connection with the common varieties. It seems to me that the only way of 
 classifying and naming these lacerations is that which takes Cognizance of the 
 precise tissues involved. Thus, ruptures of the pelvic floor are (i) lacerations, 
 (2) submucous or muscular ruptures. 
 
 (i) Lacerations are (a) vulval (fourchette, posterior commissure); (6) vulvo- 
 perineal; (c) vaginal (described under that head); (d) intraperineal (so-called 
 central rupture) (vagina also involved); (e) lateral vagino-perineal (vulva in- 
 volved), unilateral, bilateral; (f) postero-lateral vagino-perineal; (g) vagino-peri- 
 neo-anal or rectal; (h) perineo-rectal (extension of central rupture into rectum). 
 (a) Vulval: Abrasions and superficial tears of the vulva occur in most labors. 
 (Fig. 792.) In 100 consecutive cases Auvard found 81 such lesions. In 49 
 cases there were accompanying lacerations of the perineum. In 32 the anterior 
 and lateral parts of the vulva alone were involved. Tabs are frequently seen 
 at the sides of the vulva after a difficult second stage. Buttonhole tears have 
 been observed in the labia minora. In rare instances — only three or four are 
 oa record — the urethra has been involved. Most vulval lacerations are super- 
 ficial and heal readily under antiseptic treatment. Lacerations at the side of 
 the clitoris may bleed profusely. The chief danger, however, is from sepsis, 
 smce the vulva, unlike the vagina, is the habitat of the streptococcus and other 
 pathogenic germs. Fourchette: This ruptures in primiparae as a continuation 
 of rupture of the base of the hymen. Posterior commissure: This is torn by 
 extension of the hymen-fourchette laceration. Ruptures of the base of the 
 hymen and fourchette occur practically in all first labors and are not included 
 in the statistics of ruptured perineum. (6) Vulvo-perineal: In actual rupture 
 of the perineum the mildest degree must involve the posterior commissure and 
 extend for a variable distance into the perineal body. (See Part X.) (c) Vag- 
 inal: Rupture limited to the lower third of the posterior vaginal wall is de- 
 scribed under the head of lacerations of the vagina {q. v.). (Fig. 799.) {d) 
 Intraperineal: This is the so-called central rupture or perforation of the peri- 
 neum. (Figs. 796 and 797.) The posterior wall of the vagina is extensively 
 involved. Very rarely the entire fetus passes through such an opening. (Fig. 
 797.) It is a rare accident, but 75 cases being mentioned in literature. These 
 ruptures may readily unite, but cases have occurred in which a permanent opening 
 has resulted, {e) Lateral vagino-perineal: These represent a continuation of 
 vulvo-perineal ruptures which extend into the vaginal sulci on one or both 
 sides. (Fig. 794.) They are very common and produce serious results because 
 the fibers of the levator ani may be included in the rent. When both sulci are 
 involved a Y-shaped lesion is produced. (/) Postero-lateral vagino-perineal: This 
 is the " perineal rupture of the second degree " of most authors. It extends to 
 the border of the anus without involving the latter. (Fig. 794-) ig) Vagino- 
 perineo-rectal: This is the " rupture of the third degree," or complete rupture — 
 a rare accident. (See Part X.) As it extends through the anus and recto- 
 vaginal septum, it produces fecal incontinence. There is little or no attempt 
 at spontaneous repair, (h) Perineo-rectal: A very few cases of intra-perineal 
 or central rupture have extended into the rectum. 
 
 (2) Submticous or muscular ruptures were first described by Schatz. They 
 occur in patients with unusual elasticity of the skin of the perineum. When 
 the latter is distended by the advancing fetus, the elastic integument readily 
 yields, while the more rigid muscle is ruptured. (Figs. 798 and 799.) 
 
598 
 
 PATHOLOGICAL LABOR. 
 
 Frequency. — It is usually asserted that some injury to the perineum results 
 in 30 per cent, of labors in primiparae and 10 per cent, in multiparae. Such 
 figures refer to maternities, where the prophylaxis of these injuries is intelli- 
 gently managed. Doubtless in miscellaneous midwifery practice, in which the 
 attendants include numerous midwives and untrained physicians, the figures 
 would be considerably higher. Perineal lacerations are generally admitted 
 to be the most frequent of all maternal birth traumatisms. In 1200 confine- 
 ments at the Mothers' and Babies' Hospital, I found that perineal lacerations, 
 requiring suture, occurred in 88 cases, or 7.33 per cent.; and in 1000 cases 
 at the New York Maternity, in 211 cases, or 21.10 per cent. It is worthy of 
 
 ',W 
 
 Fig. 
 
 796. — Central or Intra-perineal 
 Rupture. — {Lepage.) 
 
 Fig. 797. — Central or Intra-perineal 
 Rupture. — {Lepage.) 
 
 note that in the first series, with a frequency of 7.33 per cent., nearly all the 
 1200 cases were used for clinical demonstration, students delivering the patients 
 under the supervision of a hospital interne, while in the second series, with 
 21.10 per cent., no clinics 'or demonstrations were held, nor were students 
 permitted to deliver the cases. 
 
 Etiology and Mechanism.. — The predisposing causes of perineal rupture include 
 unusual rigidity of the tissues, seen especially in elderly primiparae, corpulence, 
 oedema, and the peculiar friability of tissue seen in certain women. Exciting 
 causes comprise rapid expulsion in normal labors, whether delivery is spontan- 
 eotis or artificial. The birth of the suboccipito-frontal circumference of the 
 
MATERNAL DYSTOCIA IN THE PARTURIENT TRACT. 
 
 599 
 
 head is always a menace to the integrity of the perineum in cranial and breech 
 positions, as is the occipito-mental in face presentation. The perineum is also 
 menaced by the abrupt expulsion of the posterior shoulder in head presen- 
 tations. The mechanism of traumatisms of the pelvic floor, I believe, is as 
 follows: (i) When the remains of the hymen give way to the presenting part 
 the laceration may extend to the fourchette, or, in a multipara, may begin in 
 the latter. According to the circumstances in each case, the injury may stop 
 at the fourchette or extend to a variable degree into the pelvic floor. (2) 
 The rupture of the floor is simply a continuation of the vaginal laceration. (3) 
 The mucous membrane is the first to yield, the tear extending into the sub- 
 jacent tissue. Intraperineal or central rupture occurs, according to Budin, 
 in primiparae the residue of whose hymens is extraordinarily unyielding. In 
 
 Fig. 798. — Lacerations of the Vaginal 
 Sulci and Submucous or Muscular 
 Rupture of the Perineum. The in- 
 tegument over the perineum remains in- 
 tact. — (Redrawn after Bar.) 
 
 Fig. 799. — Submucous or Muscular Rup- 
 ture of the Perineum. The integu- 
 ment over the perineum remains intact. 
 
 these cases the distended posterior vaginal wall ruptures, involving the entire 
 perineum in the injury. 
 
 Diagnosis. — This is made by inspection and palpation, the parts being 
 put on the stretch (Figs. 631 and 632). 
 
 Prognosis. — Rupture of the pelvic floor is a serious accident, especially 
 when the muscles are involved. The bad results may be immediate or remote. 
 The former include the possibility of septic infection, which can occur if the 
 recent wound is not successfully repaired. An infected lochial discharge may 
 interfere with union by second intention. The ultimate results of perineal tears 
 when extensive and unrepaired are as follows: The anterior wall of the vagina 
 which rests upon the intact perineum sags down, dragging the uterus with it. 
 The ostium vaginse becomes more patulous and allows the posterior wall of the 
 vagina to prolapse. Rupture of the levator muscle also causes sagging of the 
 pelvic floor. Incontinence of feces results from rupture into the rectum. 
 
600 PATHOLOGICAL LABOR. 
 
 Treatment. — Prophylaxis: Preservation of the perineum has been placed 
 by some authorities as second in importance only to preservation of the lives 
 of the mother and child. From this standpoint it is possible to discuss the 
 entire mechanism and conduct of labor with the one aim in mind of favoring 
 the perineum under all circumstances when the more weighty conditions 
 do not assert themselves. This has actually been done by Krantz.* The 
 factors which bear directly and indirectly upon the state of the perineum are 
 numerous, but for convenience we may make three major classes: (i) Anomalies 
 of the expiilsive forces; (2) anomalies of the soft parts, — vagina and perineum; 
 (3) faulty presentations and positions of the child. 
 
 Curative treatment. (See Operations, Part X.) 
 
 IX. LABOR AFTER OPERATIONS INVOLVING THE GENITALS. 
 
 Pregnancy and Labor after Ventrofixation and Ventrosuspension. — These 
 operations have now been performed many hundred times. Up to 1896 at 
 least 808 had been done in America alone. f In this series of cases at least 
 one ovary was left, and pregnancy followed in 56 (nearly 7 per cent.) of the 
 patients. The mortality in the fifty-six pregnancies was less than 5 per cent., 
 and but one of the three deaths could be attributed to the operation. The 
 percentage of pregnancies terminating in abortion was 7. In a series of foreign 
 operations J comprising the results of 175 pregnancies, there were 10 per cent, 
 of abortions and 2.25 of deaths. It is a matter for regret that in these joint 
 statistics of 231 pregnancies no distinction is made between the older and 
 more dangerous operation of fixation and the more recent and safer ventro- 
 suspension. In the American series of 56 cases there were three forceps deliv- 
 eries, two retained placentae, and one induced labor, for uncontrollable vomiting. 
 Hence, over 11 per cent, of the pregnancies (the abortions having been sub- 
 tracted from the total) were dystocic. In the series of foreign cases the 
 percentage of dystocic labors was exactly 14. These percentages are of coiurse 
 unfavorable in comparison with the results of labor under ordinary circum- 
 stances, and therefore some authorities § advise a careful forecast of the chances 
 of dystocic births, and if such are imminent they cotmsel induction of labor 
 at the eighth month. During the sixth month a series of examinations shotild 
 be begun for the purpose of controlling the position of the cervix, which may 
 be found to be drawn up out of the pelvis despite the apparently natural 
 relations of the fundus. If the cervix is thus displaced, its anterior wall is 
 said to constitute a tumor at the brim of the pelvis. According to Dickinson, || 
 it is by no means easy to estimate the dimensions of this tumor. Bidone ** 
 once forestalled the results of ventrofixation, when delivery seemed to be im- 
 possible, by performing laparotomy and dividing the adhesions which crippled 
 the uterus. Judging from the favorable termination of the majority of cases 
 of pregnancy following these operations, this resource of Bidone's is indicated 
 only under very exceptional circumstances. As in cases of obstructive dystocia 
 in general, the issue most to be dreaded in theory is rupture of the uterus. 
 
 * '' Die Aetiologie d. geb. Dammverletzung, " Wiesbaden, 1900. 
 t Gordon: "Transactions of the American Gynecological Society," 1896. 
 X Noble: "Transactions of the American Gynecological Society," 1896, . 
 § "Amer. Jour, of Obstetrics," 1901, xliv, 40. 
 II Borland and Noble: "Amer. Jour, of Obstetrics," 1897, p. 121. 
 ** "Amer. Jour, of Obstetrics," 1901, xliv, 40. 
 
MATERNAL DYSTOCIA IN THE PARTURIENT TRACT. 601 
 
 Dickinson,* who has had one fatality from this accident and who performed 
 Caesarean section in a subsequent case (of twin pregnancy), with a second 
 fatal result, assures us that rupture of the uterus is a rare termination of these 
 labors, and that but eight Caesarean sections are on record in this connection. 
 In both of Dickinson's fatal cases fixation of the uterus was present, although 
 
 Fig. 800. — Maternal Dystocia following Anterior Fixation of the Uterus. Shoulder 
 presentation, in the left scapulo-anterior position; buckling of the uterus upon itself; 
 elongation of the cervical canal ; manual dilatation of the cervix followed by a difficult 
 version and extraction, and delivery of a dead fetus. — (Case seen by tlie author in 
 consultation with Dr. Nathan G. Bozentan, of New York.) 
 
 in the first example the operator had attempted to perform suspension. 
 Ventral fixation as pregnancy advances may possibly result in what is practically 
 a ventral suspension, by the constant dragging of the ever-enlarging uterus. 
 A more serious termination, however, is the occurrence of marked expansion of 
 the comua, and an exaggerated anteflexion of the anterior uterine wall. The 
 * "Amer. Jour, of Obstetrics," 1901, xliv, 34. 
 
602 PATHOLOGICAL LABOR. 
 
 cervix is drawn upward and backward, even to the sacral promontory, and 
 an elongation or supravaginal hypertrophy of the cervical canal results (Fig. 
 800). The internal os, then, may be found as high as the second or third lumbar 
 vertebra. I saw a case of this character in consultation with Dr. Nathan G. Boze- 
 man, of New York. The patient was at term, suffering from secondary inertia 
 and exhaustion, with a dead fetus in the left scapulo-anterior position. After 
 a difficult dilatation of the elongated cervical canal, I was able to seize the 
 upper leg and gradually extract the child around the obstruction formed by 
 the hypertrophied cervix and thickened fundus (Fig. 800). 
 
 Labor after Vaginofixation. — Ruhl * states that severe interference with 
 labor may result from the fixation of the uterus at the anterior vaginal wall. 
 Nevertheless, among hundreds of cases in which this operation has been 
 performed, but 9 are on record in which labor had to be terminated by 
 Caesarean section; most of the labors having been uneventful. Ruhl was able 
 to supply notes of 71 cases of vaginofixation followed by pregnancy. In 3 
 cases it was necessary to incise the anterior utero-vaginal wall, but in the others 
 there were no difficulties attributable to the operation. Even in numerous 
 cases in which the fundus was attached to the vagina, and in which trouble 
 might have been expected, there were no complications of labor except in 
 the three cases just mentioned. When the fundus is sutiu-ed to the vagina 
 the former is deeply placed, the cervix has a high position and is retrodisplaced, 
 the posterior uterine wall is upon the stretch, and the anterior wall is doubled 
 upon itself. The fundus lies close above the symphysis. Labor under these 
 circumstances pursues a peculiar course. Slight uterine contractions are 
 noted days and even weeks before labor sets in, and finally the os slowly dilates. 
 In these cases mechanical dilatation, as by the use of the colpeurynter, is of 
 little benefit because of the unnattiral position of the cervix. After prolonged 
 waiting the os is sufficiently dilated for the introduction of the hand, but the 
 latter can enter only in a cramped position, so that version, forceps, etc., are 
 hardly practicable. Ruhl on two occasions inserted his entire hand and grasped 
 a foot, but could not deliver the child. In a case in which Cesarean section 
 was performed the uterus was found strongly anteflexed, literally standing on 
 its head, and the posterior wall was stretched almost to the thinness of paper. 
 
 MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 
 
 X. UTERINE, OVARIAN, RENAL, AND PERITONEAL TUMORS. 
 
 General Considerations. — Tumors may produce either relative or absolute 
 obstruction of the birth canal. In the former case the birth of a living child 
 may be possible, either unassisted or with the aid of forceps or version. If 
 the presence of the tumor is recognized during the course of gestation, extir- 
 pation may be possible; or if not, the pregnancy may be interrupted or ar- 
 tificial premature delivery performed. If the obstruction to delivery is 
 absolute at term Csesarean section or perforation must be the indication. 
 While numerous forms of benign neoplasms may be present in the pelvis, 
 the vast majority are either uterine myomata or ovarian tumors. 
 
 Uterine Myomata. — The association of these growths with pregnancy is 
 not of frequent occurrence, perhaps because women thus afflicted are very 
 * " Monat. f. Geburts. und Gynak.," xiv, p. 477. 
 
MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 
 
 603 
 
 often sterile. Hofmeier (1900) shows that the greatest fecundity occurs before 
 the age of thirty-five, while myomata tend to appear after that period. When 
 a woman with myoma becomes gravid, the tumor begins, as a rule, to increase 
 in size. If it is located within the lesser pelvis, an incarceration of the mass 
 may occur, which tends to produce a benign form of degeneration under which 
 complete disappearance may result. On the other hand, the myoma may be 
 displaced upward with the enlargement of the uterus, a fact which the physician 
 should turn to account by a careful examination from time to time. This dis- 
 placement may occur very late in pregnancy, after the operation of Cassarean 
 section had been decided upon. Exceptionally the presence of these growths 
 may set up peritonitis, thereby adding to the difficulties already present. As a 
 rule, the presence of myoma 
 uteri interferes little with the 
 course of gestation. Again, 
 if the tumors affect the cervix 
 rather than the body of the 
 uterus, mechanical disturb- 
 ances of several kinds may 
 occur, and it is this form 
 which tends to produce the 
 higher grades of obstructive 
 dystocia. Although, as al- 
 ready stated, tumors in the 
 bony pelvis often ascend and 
 cease to obstruct labor, even 
 after the latter is under way, 
 this mobility appears to be 
 made possible by a softening 
 which they sometimes under- 
 go during gestation. After 
 delivery these tumors tend 
 to diminish in size, corre- 
 sponding to the increase 
 noted after conception. They 
 may undergo a process of 
 complete involution, running 
 parallel with that of the 
 uterus itself. The presence 
 of myomata during the third 
 stage of labor interferes with 
 the detachment and expul- 
 sion of the placenta, thereby favoring the occurrence of post-partum hemor- 
 rhage. Uterine myomata may undergo suppuration during the puerperal period, 
 becoming foci of local sepsis. 
 
 Diagnosis. — The condition may lead to several difficulties of diagnosis. 
 Thus, the metrorrhagia from the presence of the tumor masks the amenorrhea 
 of gestation; the enlargement of the uterus occurs as the result of either con- 
 dition. As pregnancy advances the tumor may soften to a remarkable degree 
 and thus be overlooked; if a diagnosis of myoma has already been suggested, 
 this seeming disappearance may lead to a change of opinion. 
 
 Prognosis. — This depends entirely upon the size and seat of the tumor. 
 Small subserous or interstitial tumors may be ignored in prognosis and treat- 
 
 FlG. 801. 
 
 Myoma of the Lower Segment and Cer- 
 vix. 
 
604 
 
 PATHOLOGICAL LABOR. 
 
 ment. Others ma}^ or may not require extirpation during pregnancy. As a 
 rule, gestation itself is undisturbed by the presence of the growths. Labor and 
 the puerperium may not be interfered with. 
 
 Treatment. — During pregnancy the management is as follows: If the size and 
 seat of the tumor occasion apprehension for the welfare of the mother and child, 
 it is better to perform myomectomy, than to interrupt pregnancy, for this inter- 
 ruption destroys the child, is dangerous to the mother, and is without effect upon 
 the tumor. The danger of accidentally inducing abortion through the oper- 
 ation of myomectomy is slight. If this operation is impracticable, supra- vaginal 
 amputation of the pregnant uterus should be performed. Growths which 
 are dangerous chiefly from their position in the lesser pelvis should be watched 
 carefully in the hope that they may ascend. We should even refuse to inter- 
 fere at term, since this ascent often occurs after labor has begun. Then, if ascent 
 has not occurred spontaneously, the patient should be anesthetized and placed 
 
 in the lateral, abdominal, or 
 knee-elbow position, when 
 it will often be possible to 
 press the mass into the ab- 
 dominal cavity, even when 
 it appears to be incarcerated 
 in the pelvis. If the tumor 
 is irreducible, it is better to 
 perform Caesarean section, 
 even if the child is dead, 
 because of the great diffi- 
 culty in perforating and ex- 
 tracting in the presence of 
 the growth in the pelvis. 
 
 Ovarian Tumors. — T h e 
 presence of these neoplasms 
 in the abdominal cavity 
 adds to the pressure symp- 
 toms caused by the pregnant 
 uterus, and during labor in- 
 terferes with the force of the 
 uterine contractions. In 
 cases in which they remain 
 in the pelvis they may cause either partial or complete obstruction of the 
 birth tract. Diagnosis: The under surface of the tumor may be made 
 out by the vaginal touch. If fluctuation cannot be recognized, an explora- 
 tory puncture may be made. As a rule, the cervix is placed very high, and 
 the presenting part of the child does not descend. Course and Prognosis: The 
 complication of ovarian tumor with pregnancy is always serious. The cyst is 
 liable to rupture, which event might be regarded as desirable except for the 
 danger of peritonitis, hemorrhage, and gangrene of the cyst. Treatment: Such 
 cases should never be left to Nature. If the tumor is recognized during preg- 
 nancy, it must be extirpated unless very small. The same course is advised 
 even during labor, whenever practicable. Thus, in a typical case the indication 
 would be to perform laparotomy, extirpate the growth, and terminate the labor 
 by Caesarean section. This course cannot be pursued as a matter of routine, 
 and in the majority of cases the operator has to be content with the attempt 
 to push the tumor from the pelvis into the abdominal cavity. He must be 
 
 V, 
 
 Fig. 802. — Myoma of the Cervix which Has Been 
 Pushed Down into the Vagina by the Advancing 
 Head. Face Presentation, Left Mento-anterior. 
 
MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 605 
 
 prepared in these cases for the accidental rupture of the cyst ; and if the attempts 
 at reposition fail, he should seek to diminish the size of the mass by tapping. 
 If this resource also fails, and if the exigency of the case forbids extirpation of 
 the growth, Cassarean section alone must be performed. 
 
 Miscellaneous New Formations. — Other benign tumors which may cause ma- 
 ternal dystocia are of rare occurrence. They comprise dermoids of the pelvic 
 connective tissue; echinococci in the same location and also in the peritoneal 
 cavity; floating kidney and spleen, etc. As a rule, the various cystic formations 
 should be treated like ovarian tumors. Displaced organs should be replaced 
 before delivery, or if they complicate labor they should be thrust out of the 
 way. Hernias — umbilical, inguinal, femoral — may form an obstacle to labor 
 by interfering with the proper force of intra-abdominal pressure. They should 
 be reduced or held in position until after the delivery has been effected, when, 
 if necessary, they may receive attention. 
 
 XI. ANOMALIES OF THE MEMBRANES. 
 
 The dystocic element in force here is connected principally with the period 
 of rupture, and hence we may consider the entire subject under the following 
 classification: (i) Dystocia from premature rupture; (2) dystocia from tardy 
 rupture; (3) dystocia from adherent membranes. 
 
 1. Premature Rupture. — Premature rupture is not necessarily due to any 
 intrinsic peculiarity of the membranes, but to anomalous conditions elsewhere; 
 i. e. , contracted pelvis, or shoulder presentation. A certain proportion is thought 
 to be of endometritic origin. Early rupture of the membranes is of frequent 
 occurrence, but the condition is not invariably dystocic because the amniotic 
 fluid does not necessarily all escape. When such is the case, however, the 
 dystocic condition known as "dry labor " develops. (Page 570.) The loss of 
 the water wedge before the completion of dilatation brings the head of the 
 fetus in direct contact with the cervix; this tends to induce a tetanic action 
 of the uterus and work injury to the cervix. The latter becomes greatly 
 elongated and its anterior lip often oedematous; laceration is very common. 
 Compression of the fetal head causes a tendency to asphyxia and intracranial 
 hemorrhage. The tetanic action of the uterus combined with the oedematous 
 cervix retards the first stage of labor and exhausts the mother. Premature 
 rupture is greatly dreaded in anomalous presentations and contracted pelves, 
 conditions under which it is especially prone to occur. In such cases it con- 
 tributes a further element of dystocia. The form of irregular uterine action 
 caused by dry birth is described under anomalies of the expulsive forces (page 
 570); the injuries of the cervix are given on page 592, and the treatment comes 
 tinder the head of protracted first stage. (Page 572.) 
 
 2. Tardy Rupture. — Dystocia connected with tardy rupture of membranes 
 originates in anomalies of the membranes themselves, such as increased density 
 or elasticity. After full dilatation there is no tendency to spontaneous rupture, 
 engagement goes on, and rupture may occur in the vagina or the fetus may 
 be bom with its membranes intact ("bom with a caul ") (Fig. 1009). Dystocia 
 in these cases comes from the additional work thrown upon the uterus by 
 having to expel the unyielding amniotic fluid along with the fetus. This con- 
 dition is remedied by simply puncturing the membranes as soon as dilatation 
 is complete. 
 
 3. Adhesions. — Another form of dvstocia of membranous origin is due to 
 
606 PATHOLOGICAL LABOR. 
 
 adhesions between the membranes and the lower segment of the uterus. The 
 cause is endometritis. When labor begins, the cervix fails to dilate and the 
 condition may be confounded with agglutination, inertia, rigid os, etc. The 
 cervix is pervious to the finger and the adhesions may be plainly felt. Although 
 the uterine body may be contracting readily, the cervix remains passive. After 
 a variable period the chorion gives way and dilatation begins with the amnion 
 as the sole membrane of the bag of waters. In some cases the chorion does 
 not give way of itself; it must then be detached by sweeping the finger around 
 the inner os. (Page 573.) If this attempt fails, it is justifiable to puncture 
 the bag of waters even if dilatation has not occurred, as the os will then 
 dilate. 
 
 XII. RIGIDITY OF THE INTERNAL AND EXTERNAL OS. TRISMUS 
 
 UTERI. 
 
 Numerous states of the cervix may be responsible for its failure to dilate 
 during the first stage of labor. The various conditions which determine dystocia 
 of cervical origin should be considered together, even at the risk of repetition, 
 especially in regard to differential diagnosis, although some of them are not 
 entitled to the designation of rigid os or cervix. The causes of cervical dys- 
 tocia may be divided into (i) functional, (2) organic. 
 
 1. Functional or Spastic Rigidity. Trismus Uteri. — Dystocia of functional 
 origin is due principally to a spastic rigidity of ike external os; much more rarely, 
 and usually in premature births, we observe a corresponding condition in the 
 internal os, more pronounced in induced than in spontaneous delivery. The 
 extreme type of spastic rigidity is known as "trismus uteri." Dystocia of func- 
 tional character is very common, its frequency being due to the great variety of 
 conditions under which it occurs. Etiology: The most pronounced type is the 
 reflex. Some conditions on which this depends are (i) the immediate pressure of 
 the fetal head on the cervix in premature rupture of the membranes with evacu- 
 ation of the amniotic fluid; (2) the presence of a malposition of the fetus with 
 failure of the presenting part to adapt itself to the cervix, the membranes having 
 prematurely ruptured; (3) pre-existent inflammatory conditions of the lower seg- 
 ment; (4) ill-advised attempts at operative interference; (5) any condition of the 
 upper segment which can induce painful contractions ; (6) distended bladder and 
 rectum. Spasm of the internal os is a condition evidently little understood. Recent 
 experience has taught me that functional rigidity is often present at the internal 
 OS in late abortions and premature labors. Often both internal and external rings, 
 as well as the lower part of the uterus are involved. In addition to essential 
 functional rigidity, it is highly probable that in the organic forms about to be 
 described more or less functional spasm coexists. A species of rigidity which 
 appears to be sui generis is that which occurs in elderly primiparae. It has been 
 termed "organic," "fimctional," and both combined. It has been proposed to 
 distinguish this form by the names "constitutional" or "anatomical." 
 
 2. Organic Rigidity. — The numerous conditions which have been comprised 
 under this head are divisible into two classes, (i) congenital and (2) acquired, 
 (i) Congenital: Complete imperforation would prevent all chance of conception. 
 Congenital elongation of the portio is practically the only known congenital mal- 
 formation of the OS from the standpoint of cervical dystocia. This condition has 
 been known to delay the first stage of labor and to require mechanical dilatation. 
 (2) Acquired: These may be divided into four classes : (i) Conditions which alter 
 the consistency of the cervix; (2) conditions which efface the os; (3) deviations of 
 
MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 607 
 
 the cervix ; and (4) adhesions between the cervix and membranes. The three last 
 named have all been described elsewhere (pages 603, 608, 605). There remains for 
 consideration acquired organic rigidity in the narrower sense of the term. Of this 
 there are six varieties: (i) Traumatic or cicatricial. These are caused by opera- 
 tion or the use of the cautery. Authorities differ as to the ability of the ordinary 
 tears of childbirth to produce this condition. Sloughing of the cervix should be 
 followed by changes of this character. The parts are the seat of more or less 
 scar tissue, while the cervical canal may contain bridles of the same. (2) 
 The hypertrophic conical elongation of the cervix as seen in prolapse of the 
 genitals. Such a cervix dilates slowly, but there is no further abnormality. 
 (3) Inflammatory. More or less rigidity may result from cervical endometritis 
 and metritis if severe or protracted. (4) Specific. Tamier devotes consider- 
 able attention to syphilitic rigidity of the cervix which may occur in a variety 
 of forms — the induration of a primary sore, the sclerosis which follows upon 
 the unnatural development of the mucous patches in connection with that 
 of the pregnant uterus; gummata; tertiary ulcers; cicatrization, and, finally, 
 a peculiar type of sclerosis comparable to syphilitic stricture of the rectum, 
 in which, as is well known, the lesions are non-specific, although the cause 
 is clearly syphilitic (parasyphilitic sclerosis). (5) Neoplastic. Benign tumors 
 of the cervix have been considered elsewhere. (6) Malignant. (See Cancer 
 of the Uterus, page 610.) 
 
 The symptoms, diagnosis, and management of the foregoing may be con- 
 sidered in common. 
 
 Symptoms. — The os dilates slightly or not at all, so that labor cannot advance. 
 If dilatation is possible, the process is very slow. The condition becomes one 
 of obstructed labor in the first stage and the subject is treated under that head 
 (page 570). Individual symptoms will be mentioned under diagnosis. 
 
 Diagnosis. — Spasmodic rigidity theoretically should readily be distinguished 
 from any other form, but as a matter of fact spasm may be associated with organic 
 rigidity, so that the presence of the latter is not excluded. Some authorities 
 recognize the presence of spasm in slow dilatation, by the absence of tension in the 
 bag of waters, and of the normal mucus of the cervix (Galabin), by its tender- 
 ness and heat, and by the hard, thin, unyielding edge of the cervix (Tamier). 
 When a physician is confronted by non-dilatation, he should exclude all possi- 
 bility of such conditions as deviation and occlusion and of adhesions between cer- 
 vix and membranes. He then has to distinguish between (i) functional, and (2) 
 organic rigidity. Owing to differences in the conception of these conditions by 
 different authorities, it is hardly possible to lay down rules for diagnosis which 
 will be in harmony with the teachings of all. I believe it is of vital importance 
 to distinguish between mere slowness of dilatation and organic rigidity, etc. ; in 
 other words, between cases for intervention and for non-intervention. 
 
 Treatment. — Spastic rigidity: The tendency of this condition is gradually to 
 disappear; dilatation being finally established. Serious accidents are rare. A 
 certain amount of expectancy is indicated in conjunction with antispasmodics, 
 including warm vaginal irrigations, chloral or opiates by the rectum, and, if 
 the preceding fail, the inhalation of chloroform. Finally, if everything has 
 failed, spasmodic ridigity must be treated like other forms by hydrostatic manual 
 or instrumental dilatation and multiple incisions. The preceding summary of 
 treatment does not include any causal indications; it is, of course, understood 
 that causal elements, if amenable to removal, will be so dealt with before other 
 treatment is instituted. If the causes cannot be reached, the symptom must 
 be treated directly as above. Congenital organic rigidity: After a due interval of 
 
608 
 
 PATHOLOGICAL LABOR. 
 
 expectancy, say four or five hours, artificial dilatation should be begun with the 
 finger or instrumental dilators and finished with the use of the hydrostatic bag 
 or by bimanual dilatation. (See Operations, Part X.) Acquired organic rigidity. 
 There is a likelihood that all these forms of organic rigidity will be accompanied by 
 a certain amount of functional spasm, hence some good might be accomplished 
 
 by applying the treatment already 
 indicated for spastic rigidity while 
 awaiting dilatation. When inter- 
 vention is proved to be necessary, 
 dilatation should be attempted; 
 Ervix. and if this fails, incisions are indi- 
 cated. (See Operations, Part X.) 
 
 XIII. DEVIATION OR MALPO- 
 SITION OF THE CERVIX. 
 
 In this condition the cervix may 
 occupy either the anterior or poste- 
 rior fornix or may be displaced 
 laterally after the same fashion 
 (Figs. 803 and 804). Etiology: 
 The common but not sole cause of 
 this condition is obliquity of the 
 entire uterus. The same effect is 
 produced, however, by overdevel- 
 opment of some portion of the 
 inferior segment during the latter 
 part of pregnancy. These may 
 both coexist in the same uterus. 
 Backward deviation is the more 
 frequent clinical variety (Fig. 803). 
 It is due either to anteversion or to 
 overdevelopment of the anterior 
 portion of the lower segment.* 
 This form of deviation is very 
 common (Fig. 803). Anterior and 
 lateral deviations are produced in 
 a similar manner, but are of -much 
 more rare occurrence (Fig. 804). 
 Symptoms : As in all dystocic 
 anomalies of the cervix, most of 
 our information is obtained from 
 touch, confirmed in certain cases 
 by the result of palpation of the 
 uterus through the abdominal wall. 
 ^The vaginal touch, which should 
 always take account of the culs-de-sac, finds one effaced and the other of undue 
 depth. In backward deviation the fetal head is often found engaged and almost 
 upon the pelvic floor. The cervix looks directly backward upon the sacrum, at 
 a height which varies in individual cases, and which may attain the promontory. 
 
 * Sacciform dilatation of the. anterior portion of the lower uterine segment. 
 
 Fig. 803. — Backward Deviation or Malposi- 
 tion OF THE Os. Sacciform dilatation of the 
 anterior portion of the lower uterine segment. 
 Of frequent occurrence. 
 
 CetvIk 
 
 Fig. 804. — Anterior Deviation or Malposi 
 TiON of the Os. a Rare Anomaly. 
 
MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 609 
 
 It may be difficult in the latter case to feel the os at all (Fig. 803). In anterior 
 deviation the conditions are reversed. The os looks toward the upper part of the 
 symphysis, and it may be impossible to reach it with the finger, unless the 
 patient is first placed in the genupectoral position. (See Posture, Part X.) 
 Analogous symptoms are present in lateral deviation. Diagnosis : If the prac- 
 titioner cannot locate the os, he may conclude erroneously that he is dealing 
 with imperforation of the cervix, or that the latter has become completely 
 effaced by dilatation. It has happened that the inexperienced have sought to 
 apply forceps under the latter misapprehension. In order to make a differential 
 diagnosis it is sometimes justifiable to rupture the membranes. I urge that the 
 patient be chloroformed and a manual exploration made. Prognosis : Generally 
 deviations give an unfavorable prognosis, which varies with the degree of the 
 complication. In the milder cases spontaneous restitution may occur as labor 
 advances. In the more severe types all the phenomena of obstructed labor may 
 be developed. Treatment : After a period of waiting for nature to correct the 
 deviation, an attempt should be made to tilt the cervix into its proper axis by 
 the finger in the vagina and hooked into the os, choosing the time when a 
 pain is present. If this succeeds, the position of the cervix should be tested 
 during subsequent pains. If it fails, as is frequently the case in anterior devia- 
 tion, it may be necessary to open the os mechanically and to extract the child, 
 alive or dead. 
 
 XIV. OCCLUSION OF THE EXTERNAL OS. 
 
 This condition — also known as conglutination, agglutination, or obliteration 
 of the external os — can occur only after impregnation has taken place. How- 
 ever, there is probably an incomplete degree of this condition which might 
 permit the entrance of spermatozoids into the uterus. Etiology : Occlusion of 
 the OS comprises several types. In the simplest form the os is agglutinated 
 with inspissated mucus. A more complex variety represents obliteration from 
 fibrous adhesions. The actual cause of occlusion, or at least of the type of 
 fibrous adhesion, is traumatism, the healing of old lacerations, the results of cau- 
 terization or inflammation. A predisposition may be present, such as congenital 
 narrowing of the cervix. Occlusion occurs more frequently in multigravidae. 
 Symptoms and Diagnosis : There are hardly any symptoms in the ordinary sense 
 of the word. The imperforate condition is recognized at the onset of labor, 
 and has then been mistaken for complete dilatation. The closed os is some- 
 times recognized and located by the presence of a slight prominence or depression. 
 A valuable symptom is the dryness of the vagina from the absence of cervical 
 secretion. Diagnosis can be made only after rigidl}^ excluding other dystocic 
 anomalies of the cervix. It is often impossible to distinguish between the two 
 principal forms of obliteration. Prognosis : The os may open spontaneously, 
 especially in the mucus agglutination; otherwise we may look forward to the 
 various phenomena of obstructed labor. Treatment : The closed os must be 
 reopened, if possible, by the finger, using the nail. This is eas}^ with mucus agglu- 
 tination or incomplete fibrous occlusion. In two cases of complete occlusion 
 I have reopened the os with blunt scissors during labor. In one case it was 
 necessary to dilate the opening manually. In the higher degrees of the fibrous 
 type it may be necessary to perform vaginal Csesarean section. (See Operations, 
 Part X.) In intermediate grades it may suffice to incise the site of the os in 
 different directions with the scissors or bistoury and to apply the forceps. 
 
 39 
 
610 PATHOLOGICAL LABOR. 
 
 XV. CANCER OF THE UTERUS. 
 
 As a general rule, if a woman with uterine cancer becomes pregnant, the 
 disease is aggravated. In some 15 per cent, of cases the pregnancies are inter- 
 rupted, and in the remainder at least a third of the children are still-born even 
 at term, the proportion being much larger in premature delivery. Prolonged 
 pregnancy is not uncommon in women with uterine cancer. Spontaneous 
 delivery is possible when much of the cervix remains intact, and even when it 
 is largely replaced by cancerous tissue, provided the latter is yielding. The 
 softening of the affected tissue, however pernicious in itself, may enable the 
 uterus to expel its contents. If the fetus cannot pass the obstruction a delayed 
 labor results, and cases are on record in which the women thus afflicted have 
 been in labor for over a week. Under these circumstances maternal death from 
 exhaustion, or death and putrefaction of the fetus, or general maternal septi- 
 cemia may occur. Another possibility is rupture of the uterus. If delivery 
 results without the occurrence of these accidents, the patient is doomed to pass 
 into the cancerous cachexia. The recognition of cancer of the uterus should 
 not be difficult. If some doubt exists, a piece of the cervix should be excised 
 and examined microscopically. The presence of cancer sometimes obscures 
 the diagnosis of early pregnancy. Treatment : If the patient is seen during the 
 course of the pregnancy, an attempt may be made to let the case go on to term, 
 and treat the woman with anodynes, hemostatics, tonics, etc. Such a course 
 should be elected only at the request of the patient and under peculiar circum- 
 stances, such as the desire for an heir. To extend this line of treatment it would 
 also be rational to perform a palliative operation upon the cancer. In the 
 majority of cases the natural course to pursue would be to interrupt the preg- 
 nancy after the child becomes viable, or to perform a Caesarean or Porro-Caesarean 
 operation, or hysterectomy. Therapeutic abortion is strictly contraindicated 
 in these cases. (See Part X.) These radical measures, however, are not always 
 indicated or applicable, and if the obstetrician finds himself in the presence of 
 a case of labor in a woman with uterine cancer, when the immediate indication 
 is to oppose the rigidity of the os, the proper course to pursue is mechanical 
 dilatation or incision, the latter being full of danger to the patient. As these 
 measures may be insufficient, it is permitted to perform a rapid ablation of the 
 cancerous cervix and to deliver the child with the aid of the forceps or ver- 
 sion ; or in case of death of the fetus, some form of embryotomy is the indication. 
 Caesarean section alone is the indication of necessity when the cancer has ex- 
 tended from the uterus to the vagina or has become inoperable. A total 
 hysterectomy should be performed when the cancer is technically operable. 
 
 XVI. RIGIDITY AND ATRESIA OF VAGINA AND VULVA. 
 
 Obstruction to labor arising within the vagina may be either (i) functional 
 or (2) structural. The former consists in the spasmodic condition known as 
 vaginismus. 
 
 I. Vaginismus. — Vaginismus is almost peculiar to first labors. If it is of 
 high degree, the first indication is to resort to chloroform narcosis. If by this 
 means the spasm is not overcome, then manual dilatation or deep incision should 
 be practised, with subsequent application of the forceps in obstinate cases. The 
 spasmodic condition of the pelvic floor may attain such a high degree that 
 delivery of a living child is impossible. 
 
MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 611 
 
 2. There are a number of structural alterations of the vagina which cause 
 dystocia. They may be divided into (i) congenital and (2) acquired. 
 
 (i) Congenital Affections comprise (a) simple narrowness or smallness of 
 the passage, (b) atresia, (c) septa, and (d) abnormal terminations. (a) Small 
 vagina: This is not described by most authors. In Tamier and Budin 's great work* 
 considerable space is given to it. Every gynecologist and obstetrician knows that 
 some vaginas are unnaturally small, and while the pregnant state softens the 
 tissue and makes it more distensible, such vaginae have a special tendency to 
 laceration during labor, (b) Atresia (Fig. 805); This term should be used to 
 denote congenital imperforation which may be complete or partial. It is of 
 rare occurrence in comparison with cicatricial stricture — a condition which 
 it resembles. It exhibits every variation in regard to the length of the 
 constricted portion and the degree of imperforation. From the standpoint 
 of dystocia, atresia and cicatricial stricture may be considered together (see 
 the latter), (c) Septa: The vagina may be divided into compartments by 
 septa, longitudinal and transverse. Longitudinal septa represent the abortive 
 vagina duplex. They form large "bridles" between the anterior and posterior 
 walls and almost inevitably obstruct labor and bring about their own rupture. 
 The fetus has sometimes been strangled 
 by one of these "bridles " getting about 
 its neck. Transverse septa may be 
 multiple. They should not be con- 
 founded with atresia in which the 
 narrowed area has length as well as 
 breadth, for the transverse septa are 
 mere diaphragms containing openings 
 of various sizes. The opening in one 
 of these high up in the vagina may be 
 taken for a partially open os. Such 
 a mistake could hardly occur if the 
 physician always feels for the culs- 
 
 de-sac. Transverse septa offer more Fig. 805.— Atresia of the Vagin.\. 
 
 or less resistance to labor. For con- 
 venience of description the septa will be considered in their dystocic aspects 
 with atresia and cicatricial stenosis. Abnormal terminations: In the absence 
 of external genitals the vagina has been known to empty into the urethra 
 or rectum. Impregnation has actually occurred in both abnormal openings. 
 Children have been bom through the anus, and have even been delivered 
 through the latter with forceps. f 
 
 (2) Acquired Affections maybe grouped under the title cicatricial stric- 
 ture, a term which fits them and which agrees with the nomenclattire of other 
 organs of tubular structure (rectum, esophagus). It is a mistake to use the 
 word atresia in this connection. Cicatricial stricture of the vagina: This is due 
 either to the results of traumatism or to local infection. In either case loss of sub- 
 stance occurs by sloughing, ulceration, or healing by second intention. The re- 
 sulting scar produces a constriction in some portion of the organ. The com- 
 monest source of traumatic stricture is child-birth, which may operate in several 
 ways; thus, impaction of the fetal head in the vagina may end in sloughing, so 
 that a vesico-vaginal or recto-vaginal fistula may develop with the stricture. 
 Again, extensive laceration of the vagina, such as results from improper use 
 of the forceps, may lead to similar results. Stricture is also due to infective 
 disease. 
 
 * Paris, igoo. t Tamier and Budin, Edition 1900, Paris. 
 
612 PATHOLOGICAL LABOR. 
 
 General Consideration of Vaginal Atresia, Transverse Septa, and Cicatricial 
 Stricture. — These three conditions — the two former congenital, the last ac- 
 quired — represent collectively the atresia of text-books, and as far as obstetrical 
 practice is concerned they may be considered together. Such a study has 
 been made by Maher,* who found records of over 200 labors with such com- 
 plications. He found the most common form to be a thin transverse septum 
 situated midway in the vagina, having openings of varying sizes. In one-half 
 of all the cases the obstruction was in the middle of the vagina, while the 
 remainder were divided equally between the upper and lower thirds. The ob- 
 structions may exhibit very different behavior during labor according to their 
 size and consistency. They may stretch and allow the fetus to pass, may 
 lacerate, or oppose such resistance to the passage of the fetus that something 
 above the obstruction yields. Thus, ruptures of the uterus and of the recto- 
 vaginal walls have occurred under these circumstances. The mortality in labor 
 with vaginal obstruction is high for the child and considerable for the mother; 
 Maher's figures are 41 and 13 per cent, respectively (Fig. 805). 
 
 Treatment. — In the majority of cases spontaneous delivery is possible. 
 Each case must be managed in accordance with the character of the obstruction. 
 Attempts at dilatation will probably induce labor, hence they should not be 
 employed before term unless premature delivery is desired. The use of hydro- 
 static bags, digital dilatation, and shallow radiating incisions is justifiable 
 to assist nature. Dilatation must be complete before the forceps is applied. 
 After delivery the constricted point should not be allowed to close again; daily 
 irrigation and dilatation should be practised. When the obstruction is un- 
 yielding or when vesico-vaginal fistula coexists, Cassarean section is indicated ; 
 but if the obstruction is such that the lochia could not escape by the vagina, 
 the Porro operation is to be preferred. 
 
 Rigidity of the Vulva ; Persistent Hymen. — The vulva may exhibit a narrow- 
 ness or rigidity as a whole which is either overcome in time by the act of labor 
 or leads to multiple lacerations. Unnatural rigidity of the perineum is con- 
 sidered under the head of the management of this structure during labor. (Page 
 480.) Aside from the vulva proper, resistance may be encountered from the 
 hymen, naturally in primiparas and only when some anomaly of formation 
 is present. As a rule, the various types of persistent hymen give way under 
 the pressure of the child's head, but exceptions occur in which labor has actually 
 been obstructed by this structure, such a state of affairs having been confounded 
 with vaginismus. Such resistance has been offered in these cases that a central 
 laceration of the perineum has occurred through which the child was born. 
 The treatment of resistant hymen is simple, consisting in gradual digital dilata- 
 tion or in multiple incisions. 
 
 Obstructed Labor due to the Levator Ani. — (i) Occasionally instances occur in 
 which a well-flexed head rotates at the pelvic floor, bringing the sagittal suture 
 into the antero-posterior diameter of the outlet. Then, in spite of strong 
 uterine contractions and an elastic pelvic floor, no advance occurs. In these 
 cases the contraction of the levator ani simultaneously with the abdominal 
 muscles (voluntary forces) offers just enough resistance to hold back the head. 
 Moderate traction of a few pounds with the forceps will be sufficient to 
 exhaust and overdistend the fibers of the muscle and overcome the obstruction. 
 (2) There are certain cases in which dangerous obstruction occurs in cases of 
 permanent hypertrophy and shortening of the levator sufficient to necessitate 
 craniotomy. 
 
 * "Virginia Medical Semi-monthly," 1897, 11, 176. 
 
MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 
 
 613 
 
 XVII. VAGINAL AND VULVAL THROMBOSIS. 
 
 OEDEMA. 
 
 HEMATOMA AND 
 
 The conditions known as puerperal hematoma and thrombosis are occa- 
 sionally present before the birth of the child, and under these circumstances, 
 if sufficiently large, may constitute an obstruction to the presenting part (Fig. 
 807). This accident has a special significance in twin pregnancies, for while it 
 may not occur sufficiently early to obstruct the first child, it may interfere with 
 the birth of the second. Treatment: If the birth of the child is actually obstructed 
 
 or if rupture of the tumor is threat- 
 ened, the usual practice is to per- 
 '^ ' ~'- form incision and extract the child 
 
 / ) as soon as possible, after which hemo- 
 
 " - ■" ~ .-'" stasis is indicated. (See Puerperal 
 
 Hemorrhages.) CEdema of the vulva 
 
 Fio. 806. — Pedunculated Superficial 
 Thrombus of the Vagina. A, 
 Tumor drawn to left. 
 
 Fig. 807. — Fibroid Tumor of the Right 
 Labium Majus Resembling a Throm- 
 bus. 
 
 and vagina may precede labor, in which case it is due to renal or cardiac disease; 
 or it may be the result of labor itself in conditions of impaction of the head in the 
 vagina. (Fig. 467.) The oedematous tissues are very vulnerable and prone to 
 gangrene. The indication would ordinarily be incision, but the liability to septic 
 accidents is a contraindication save when intervention is absolutely necessary. 
 When a rupture at the vulval outlet is threatened, episiotomy may be performed 
 under strict asepsis. 
 
 XVllI. DISTENDED BLADDER AND RECTUM. CYSTOCELE, RECTO- 
 CELE, VESICAL CALCULUS. 
 
 Distended Bladder. — The subject of retention during pregnancy is considered 
 on page 318. The condition is often encountered during labor, because the 
 presenting part may, during its descent, press upon the neck of the bladder. 
 As the cervix dilates, the summit of the bladder ascends into the abdomen. 
 Abdominal palpation will therefore readily reveal the presence of the fluctuating 
 mass in front of the uterus. The urine collects in the upper part of the bladder 
 
614 
 
 PATHOLOGICAL LABOR, 
 
 and impairs the efficacy of uterine contractions. An elastic male catheter 
 will probably be required to reach the urine. Owing to the displacement of 
 the meatus and urethra, considerable difficulty may be encountered in entering 
 
 Fig. 808. — Distended Bladder During 
 Labor. 
 
 Fig. 809. — Abdomen Seen in Fig. 808, 
 after the Use of the Catheter. 
 
 the bladder. It may even be necessary to push back the advancing head in 
 order to make way for the passage of the instrument (Figs. 808 and 809). 
 
 Fecal Accumulations. — The extreme type of retention of feces known as 
 coprostasis, in which ordinary resources are insufficient for the evacuation 
 
 of the bowel, constitutes a serious mechanical obstacle 
 to delivery and may lead to grave consequences (Fig. 
 810). Such a condition is of very rare occurrence, for 
 Tarnier* saw but one case. One would expect copro- 
 stasis to depend, in these cases, upon some malforma- 
 tion of the rectum, and such a coincidence is known 
 to have occurred. These fecal accumulations obstruct- 
 ing a portion of the pelvic cavity must have the same 
 dystocic effect upon labor as a contracted pelvis; they 
 prevent engagement of the head and lead to faulty 
 positions. Owing to the degree of hardness of the 
 feces, removal dan hardly be effected save by extract- 
 ing them piecemeal with the finger or a scoop. 
 
 Cystocele. — A large cystocele which produces in- 
 version of the vagina necessarily causes a variety of 
 stenosis of that portion of the birth tract. Such a 
 condition may be due to vesical calculus (page 615). 
 An ordinary cystocele may be remedied for the time 
 being by evacuating the bladder with a catheter so 
 bent as to reach the interior of the pouch. In cases of obstructed labor 
 the prolonged compression of the vagina against the symphysis may result 
 in necrosis and fistula. 
 
 Rectocele. — This condition, due to prolapse of the vaginal wall, is very 
 rarely encountered during labor. When present, the tumor may contain either 
 the rectum or a portion of the intestines (vaginal enterocele). The diagnosis is 
 * Tarnier and Budin, vol. iii, p. 488 
 
 Fig. 810. — Distended Rec- 
 tum Obstructing Labor. 
 — {From W. C. Lusk's 
 frozen section.) 
 
MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 615 
 
 made by digital exploration of the rectum. Rectocele is not a formidable com- 
 plication of labor and the danger of impaction and pressure accidents is not 
 great. An enema should be given, after which the prolapsed vaginal wall 
 should be replaced until the presenting part has passed the obstruction. (For 
 consideration of enterocele, see page 614.) 
 
 Vesical Calculus. — Stone in the bladder very rarely complicates pregnancy. 
 Cases have, however, been recorded in which calculi have obstructed labor 
 either by causing vaginal cystocele or through impaction at the pubis. In any 
 case of obstruction of the vagina the possibility of calculus should be excluded 
 by passing a vesical sound. The stone must be removed from the region of 
 the birth tract by placing the woman in the modified latero-prone or knee- 
 elbow position. (See Part X.) If this is impossible, vaginal lithotomy must be 
 performed; the wound cannot be closed, however, until after delivery. If 
 a small calculus could become impacted in such a way as to impede labor, it 
 should be possible to extract it through the urethra after previous dilatation. 
 
 XIX. FRACTURES OF THE PELVIS. 
 
 In a pelvis which is greatly contracted the innominate bones may sometimes 
 be fractured by instrumental delivery. This is inexcusable, for with such a 
 pelvis forcible instrumental delivery is contraindicated, a safer treatment 
 being some major operative procedure. On the other hand, rachitis or some 
 other pathological process may render the bone so fragile that it will break 
 during an instrumental delivery through no fault of the obstetrician. In certain 
 cases, especially of elderly primipars, the coccyx is broken by the passage 
 of the fetal head. The condition of coccygodynia follows. This is most painful, 
 and often demands subsequent removal of the broken piece (Figs. 852, 853, 
 854). 
 
 XX. DIASTASIS OF THE PELVIC JOINTS. 
 
 Etiology: This condition is the result of the natural traumatism of labor 
 and may affect the symphysis or one of the sacro-iliac joints. All three of 
 the interpelvic articulations may be involved at the same time. A general 
 predisposition to this is furnished by the relaxation which the pelvic joints 
 undergo during pregnancy. Multiparae are predisposed by reason of relaxation 
 from repeated pregnancies. Pelvic deformity constitutes a strong predis- 
 position; so do unusual size of the fetus, disease of the joints, etc. A special 
 class of cases is due to the use of the forceps. In some cases the mechanism 
 of the injury is obscure, none of the preceding factors having aided in its pro- 
 duction. This accident occurs with considerable frequency, especially in 
 osteomalacic, generally contracted, and funnel-shaped pelves. The joint most 
 frequently ruptured is the symphysis. Symptoms : Unless the patient happens 
 to be under the influence of an anesthetic, she usually feels " something give 
 way " at the time of the accident. The limbs are seen to be rotated outward 
 and are immovable. Pain, both spontaneous and induced, is usually present 
 over the affected joint. When the symphysis ruptures, the vagina is usually 
 lacerated, and the finger can recognize the injury by palpation. The prognosis 
 is good as a rule. The treatment of ruptured symphysis corresponds to the 
 after-treatment of symphyseotomy. The pelvis should be immobilized by 
 strips of adhesive plaster or plaster-of-Paris and the patient should remain 
 in bed four or five weeks before attempting to walk. 
 
616 PATHOLOGICAL LABOR. 
 
 XXI. PELVIC DEFORMITY. 
 
 Definition, — A deviation in size, shape, or mobility from the normal type, 
 sufficient to cause unfavorable symptoms during pregnancy and labor. The 
 larger part of these abnormal forms are contractions full of danger for both 
 mother and child, and often demand instrumental delivery. The deformity 
 may exist in any one or all of the diameters, the most frequent and most serious 
 being those which affect the pelvic inlet. Besides mechanical obstruction in 
 pelvic deformity, the physician often has to deal with unfavorable mechanisms 
 of labor caused by abnormal posture, position, or presentation. 
 
 Frequency. — The frequency of pelvic contraction in native-born American 
 women has been estimated at 2 per cent., and among foreign-born women 
 at 6 per cent.* It is, however, probable that its frequency in American 
 women, especially among the poorer classes and in the large cities, has 
 been underestimated. According to Winckel, pelvic contraction occurs in from 10 
 to 15 percent, of women, but it is sufficiently marked to cause symptoms in only 
 5 per cent. Contracted pelves are believed to be rarer in America than abroad. 
 However, Williams states that they are nearly as common in Baltimore as on 
 the continent of Europe. He found that from 12 to 15 per cent, of women show 
 them, but most of these were not marked enough to impede labor. Reliable 
 statistics, however, are generally wanting; and it must happen that the 
 lesser degrees of pelvic deformity pass unnoticed, particularly when no syste- 
 matic measurements are made, and when the attention of the accoucheur is 
 directed to the measurements of the various pelvic deformities only by some 
 actual obstruction to the passage of the child. It has been only in recent years 
 that the subject of pelvimetry has been given the place it deserves in conserva- 
 tive obstetrics. The regular and routine adoption of the examination of preg- 
 nancy (seepage 148), including pelvimetry, will prove to any one the frequency 
 of contracted pelves. Then, and only then, will the real cause of many anomalies 
 in labor be apparent, such as malpresentations and malpositions, prolonged 
 labor and uterine inertia; and the prematiure induction of labor, the use of the 
 forceps, of version, symphyseotomy, and cranioclast will not be empirical, but 
 will be employed for a rational and sufficient cause. In the last ten years the 
 statement has frequently been made to the author by graduates attending his 
 lectures and clinics, that in several years' practice they have never observed a 
 single case of deformed pelvis, but their ratio of difficult forceps, versions, 
 perforations, and even vesico-vaginal fistulas was ftdly up to the average. 
 
 My conclusions from a critical study of 1200 consecutive hospital cases are 
 as follows f: (i) Of 1200 consecutive cases measured, 499, or 41.58 per cent., 
 were American-born women; 215, or 17.91 per cent., Irish; 130, or 10.83 per 
 cent., Russian; 105, or 8.75 per cent., German; 30, or 2.50 per cent., black, 
 etc. (2) Contracted pelves occurred in 44 cases, once in 27.27 cases, or in 
 3.66 per cent. Generally contracted pelves occurred in 30 cases, once in 40 
 cases, or 2.50 per cent. Flattened pelves occirrred in 14 cases, once in 85.71 
 cases, or 1.16 per cent. No irregiilar forms of contraction were observed. (3) 
 Twenty, or 45.45 per cent., of my cases of pelvic contraction were among Amer- 
 ican-born women, and deformity occurred once in 24.95 of these cases, or in 4 
 per cent. (4) Three, or 6.81 per cent., of the contracted pelves were among 
 black women, and deformit}'- occurred once in 10 of these cases, or in 10 per cent. 
 (5) My material gives a frequency of contracted pelves (1200 cases, 3.66 per 
 
 * "Trans. Amer. Gyn. Soc ," 1890. 
 
 t "Pelvic Deformity in New York City," "Trans. Amer. Gyn. Soc," 1Q02. 
 
MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 617 
 
 cent.) midway between the conclusions of Williams (Baltimore, looo cases, 
 13. 1 per cent.); Crossen (St. Louis, 800 cases, 7 per cent.); Reynolds (Boston, 
 2127 cases, 1. 13 per cent.); and Flint (New York, 10,223 cases, 1.42 per cent.). 
 (6) My statistics — 3.66 per cent, of contractions in 1200 cases — differ from those 
 of England (F. Barnes,* of London, 38,065 cases, 0.5 per cent.); of France, 5 to 
 2 1. 1 1 per cent.t; Germany, { 9 to 9 per cent.; Switzerland, 8 to 16 per cent.; 
 Austria-Hungary,^ 2.44 to 7.8 per cent.; Russia, || 1.2 to 5.1 per cent.; Italy,** 
 18.13 psJ^ cent.; Holland, ft 3.51 per cent. (7) Special or irregular forms of pel- 
 vic contraction, such as osteomalacia, obliquely contracted, coxalgic, double cox- 
 algic, spondylolisthetic and kyphotic, or fractured pelvis, are uncommon in this 
 country. (8) The generally contracted pelvis is the deformity most frequently 
 met with in New York. I found twice as many generally contracted as flat- 
 tened pelves in my material (30.14). Williams found practically the same 
 condition in Baltimore (79.45). (9) Records kept of private and consultation 
 cases in New York over a period of ten years show a somewhat higher percentage 
 than the results obtained from the 1200 hospital cases — namely, about 5 per 
 cent, for all deformities, the generally contracted pelvis being twice as frequent 
 as the flattened. The frequency seems to vary in different countries. The 
 Saxon pelves are most often contracted, which explains why Zweifel has per- 
 formed ninety Caesarean sections. They are common enough to explain why 
 the second stage often lasts four or five hours, why face presentations and other 
 anomalies are numerous. Deformed pelves are frequent enough anywhere 
 to demand that the physician be familiar with the different varieties, and also 
 that he be versed in the art of pelvimetry. Schauta's estimate is twenty per 
 cent, in Austria. There are numerous geographical variations which do not 
 yet admit of a definite explanation. Among the native American women to- 
 day the rachitic pelvis is very infrequent, the most common types being the 
 generally contracted and those following spinal deformity. 
 
 General Etiology and Development. — The etiological factors which may be 
 considered as producing deformed pelves are: (i) Defective development; (2) 
 disease of the pelvic bones; (3) irregularities in the junction of the pelvic bones; 
 (4) disease of those parts of the skeleton which are carried by the pelvis; (5) 
 disease of those parts of the skeleton which carry the body-weight. (See Classi- 
 fication, page 617.) The normal adult pelvis is the complicated outcome of a 
 combination of various factors. (See The Passages, page 391, Part IV.) 
 
 Classification and Description of Different Varieties. — Classification has been 
 many times attempted, but with most unsatisfactory results. Different bases 
 of classification have been taken, — e. g., the causes or effects, — but the variations 
 are so numerous that the simplest and most scientific arrangement is based 
 on the location and character of the deformity. The classification I adopt 
 is practically Schauta's. 
 
 {A) Anomalies of the Pelvis as a Result of Defective Development. — I. Generally 
 symmetrically contracted, non-rachitic pelvis, justo-minor or small round 
 pelvis: (i) The infantile type; (2) the masculine or strong type; (3) the dwarf 
 type. II. Simple flat, non-rachitic pelvis. III. Generally contracted flat, 
 non-rachitic pelvis. IV. Narrow, funnel-shaped pelvis. Fetal or "lying- 
 down" pelvis. V. Imperfect development of one sacral ala (Naegele pelvis). 
 
 * International Gynecological Congress at Geneva, 1S96 (reported in "Centralbl. f. 
 Gynak."). 
 
 t Fochier, Pinard: Loc. cit. J Loc. cit. § Pawlik: Loc. cit. 
 
 I| Hugenberger: "Petersburg, med. Wochen.," 1872, in. 
 ** Pestalozza : Geneva Congress. 1896. tt Treub: Geneva Congress, 1896. 
 
618 
 
 PATHOLOGICAL LABOR. 
 
 VI. Imperfect development of both sacral alae (Robert pelvis). VII. Gener- 
 ally equally enlarged pelvis, justo-major pelvis. VIII. Split pelvis. 
 
 {B) Anomalies of the Pelvis as a Result of Disease of the Pelvic Bones. — I. 
 Rachitis. II. Osteomalacia. III. New growths. IV. Fracture. V. Atrophy, 
 caries, necrosis. 
 
 (C) Anomalies in the Junction of the Pelvic Bones. — I. Synostosis at the 
 symphysis. II. Synostosis at one or both sacro-iliac joints. III. Synostosis 
 at the sacro-coccygeal joint. IV. Exaggerated motion or separation of the 
 pelvic joints. 
 
 {D) Anomalies of the Pelvis due to Disease of those Parts of the Skeleton which 
 
 are Carried by the Pelvis. — I. Spondylolis- 
 thesis. II. Kyphosis. III. Skoliosis. IV. 
 Kypho-skoliosis. V. Assimilation. VI. Lor- 
 dosis. 
 
 (E) Anom.alies of the Pelvis due to Disease 
 of the W eight-hearing Parts of the Skeleton. — 
 I. Coxitis. II. Luxation of the head of one 
 femur. III. Luxation of the heads of both 
 femora. IV. Unilateral or bilateral club-foot. 
 V. The absence or deformity of one or both 
 lower extremities. 
 
 A. ANOMALIES OF THE PELVIS THE RESULT 
 OF FAULTY DEVELOPMENT. 
 
 I. Generally Symmetrically Contracted, 
 Non-rachitic Pelvis. Pelvis .^quabiliter Justo- 
 minor, or Small Round Pelvis (Figs. 8ii , 814). 
 — In _the generally contracted pelvis the fe- 
 male shape is preserved but the size is dimin- 
 ished. Under this heading are grouped three 
 sub- varieties, (i) The infantile or juvenile 
 type, the bones of which are delicate and small ; 
 (2) the masculine type, strong pelvis, the 
 bones of which are strong and large; (3) 
 the dwarf type, which is extremely small, 
 and whose bones, like those of the infant 
 pelvis, are connected by cartilaginous instead 
 of bony union (Fig. 813). 
 
 The divisions between the innominate 
 
 bones are distinct, as well as those between 
 
 the vertebras of the sacrum. In this form of 
 
 pelvis all of the diameters have their normal 
 
 relations, but the measurements of the entire 
 
 pelvis are less than normal. This pelvis merges very gradually into other forms, 
 
 as the generally contracted flat, the simple flat, and the transversely contracted 
 
 pelvis. 
 
 Frequency and Etiology. — This type of deformity is often found, particularly 
 in the class frequenting the free hospitals and dispensaries. It is the most 
 frequent type in America. I found it in 2.50 per cent, of my cases. These 
 women have been born to hard work and unhealthful environment. However, 
 this malformation is sometimes met with in those who are otherwise well formed. 
 
 Pig. 811.— Generally Symmetri- 
 cally, Non-rachitic, Contrac- 
 ted Pelvis. Justo-minor or 
 Small Round Pelvis. 
 
MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 619 
 
 Clinical Characteristics. — The transverse concavity of the sacrum is increased; 
 the sacral promontory is pushed upward, but is not prominent. While the 
 posterior superior iliac spines are further apart than normal, the iliac crests 
 and spines are closer together. The transverse diameters are decreased; the 
 conjugate of the superior strait is shorter than normal; the side walls of the 
 pelvis can be so easily felt that it is not uncommon for the finger to be able to 
 follow the iliopectineal line. This form of pelvis is not, strictly speaking, a 
 copy of the normal adult pelvis in small dimensions, for it has some of the 
 characteristics of the infantile pelvis. As a rule, women with the generally 
 contracted pelvis are short in stature and slender, but there are exceptions. 
 
 In the forms of the generally contracted pelvis 
 most commonly seen the contraction is usually 
 slight. In certain instances the pelvic outlet 
 is contracted transversely. The dwarf variety 
 is most unusual, and is found only in dwarfs. 
 Diagnosis. — The generally contracted pel- 
 vis can be easily differentiated from any other 
 deformed type — the rachitic, for example — 
 when it is remembered that the measure- 
 ments, although less than normal, are sym- 
 // ■-' "• -^i^ metrically so. There is one possible exception 
 
 only — the external conjugate diameter; this, 
 
 Fig. 8i2. — Achondroplasic Dwarf. 
 — (Depaul.) 
 
 Fig. S13. — Dwarf Pelvis. 
 
 on account of the peculiarities of the sacrum, which is not situated so anteriorly 
 as the normal, may be longer than usual. Another important measurement 
 is that of the pelvic circumference, which is always much less than normal. 
 The internal examination should be carefully made, especially the estimation 
 of the transverse diameters. 
 
 Prognosis. — Difficulty begins with the onset of labor and increases with 
 its progress. The head is overflexed with a consequent prominence of 
 the posterior fontanelle, while the sagittal suture lies commonly in an oblique 
 diameter (Fig. 639). Descent is slow, but there is rarely the lateral obliquity 
 which is seen in flat pelves. Breech presentations are especially to be dreaded 
 
620 
 
 PATHOLOGICAL LABOR. 
 
 in this form of pelvis, for it is very difficult to free the legs and arms, and to 
 bring the head down through the contracted canal. Although the mother 
 does not suffer from injuries to the soft parts which are incident to labor in 
 some forms of contracted pelvis, still the pelvic joints are liable to be ruptured 
 and eclampsia is very common. As for the child, the caput succedaneum is of 
 unusual size and is just over the smaller fontanelle. The cranial bones greatly 
 overlap (Fig. 582). 
 
 II. Simple Flat, Non-rachitic Pelvis (Fig. 894). — A frequent form of de- 
 formed pelvis consists in the shortening of the antero-posterior diameter. This 
 
 variety is common and was the first 
 contracted pelvis to be recognized. 
 It was not till later that the distinc- 
 tion between it and the rachitic fiat 
 pelvis was made clear. 
 
 Frequency and Etiology. — The etiol- 
 ogy is obscure, although, as a rule, this 
 type of pelvis is probably congenital. 
 It is a very common type and is found 
 as often among the upper classes as 
 among the lower; and it is also as 
 common in the otherwise well-formed 
 woman as in the stunted. Various 
 predisposing causes of this deformity 
 have been suggested, such as over- 
 exertion in youth; excessive burden- 
 bearing; the combination of weak 
 pelvic ligaments and a heavy trunk; 
 arrested rachitis. It is probable that 
 heredity is an important factor, for 
 it has been noted frequently in newly 
 born children and fetuses. 
 
 Clinical Characteristics. — It is only 
 the antero-posterior diameter in this 
 pelvis which departs from the normal, 
 the other pelvic diameters being as 
 a rule undisturbed. The degree of 
 distortion is never great. The sacrum 
 is displaced forward to a slight degree 
 and the cartilage between the second 
 and third sacral vertebrse is unusually 
 prominent, often making a double 
 promontory. The mutual relations 
 between the iliac crests and spines are almost nil. Contrary to the condition 
 in the generally contracted pelvis, vaginal palpation will reveal the lateral 
 pelvic walls only with difficulty. The pelvis is perfectly symmetrical. 
 
 Diagnosis. — Unless there has been difficulty in previous labors there will be 
 nothing but the measurements to call attention to the condition, which is easily 
 overlooked. In the presence of a double promontory the one nearest the 
 symphysis must be used in measuring the conjugate. 
 
 Prognosis. — Pendulous abdomen is often present in this form of pelvis. 
 Labor need not be seriously interfered with, although instrumental delivery 
 maybe necessary under certain conditions, such as feebleness of the uterine con- 
 
 FiG. 814. — Symmetrically Contracted Pel- 
 vis FROM Complete Assimilation of the 
 Fifth Lumbar Vertebra with the Sa- 
 crum. 
 
 Fig. 815. — Diagram of Pelvic Inlet of 
 Fig. 814. 
 
MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 621 
 
 tractions or oversize of the fetal head. The first stage is generally protracted, 
 for the head is longer than usual in engaging. After engagement has taken 
 place, the course of labor runs smoothly, although the maternal strength may have 
 been much exhausted by the demands made upon it before engagement took 
 place. This condition of affairs will, of course, naturally protract the course of 
 labor. The head accommodates itself to the shape of the pelvis; this accounts 
 for its transverse position and slight extension as it enters the pelvis; which 
 allows the palpation of the bregma (Fig. 645). The anterior parietal position 
 is assumed, since the sagittal suture is brought near the sacral promontory 
 (Figs. 685 and 686). Very infrequently the head assumes the posterior parietal 
 position, so that the sagittal suture approaches the symphysis (Figs. 688 and 
 689). This is generally confined to primiparas. Early rupture of the mem- 
 branes is frequent. It is probable that in the majority of cases labor termin- 
 ates spontaneously. Faulty presentations and prolapse of the cord or extremities 
 frequently occur. Necrosis of the maternal soft parts may be expected from the 
 long pressure to which they are subjected. As to the child, although the caput 
 succedaneum is not extreme, there are often depressions or grooves on the head 
 varying with the position of the pressure to which it has been subjected. 
 
 III. Generally Contracted Flat, Non-rachitic Pelvis (Fig. 895). — As the name 
 indicates, this pelvis is characterized by the peculiarities of both the generally 
 contracted and the flat pelvis. 
 
 Frequency and Etiology. — This pelvis results from congenital defect but not 
 from rachitis, and is rather common. Some authorities believe that it can be 
 caused by too early walking or long standing on the feet in the first years of life. 
 
 Clinical Characteristics. — With the exception of the diagonal conjugate, 
 which may be increased on account of the elevation of the sacrum, all of the 
 diameters are decreased, particularly the conjugate of the inlet. The sacrum 
 is small, its promontory is much elevated but not prominent, while its position 
 is considerably posterior in comparison with the normal. The alee as well as 
 the innominate bones are not fully developed. Two points should serve to 
 differentiate this type from the rachitic pelvis — the abnormally posterior posi- 
 tion of the sacrum and the fact that the anterior half of the pelvic circumference 
 is only slightly broadened. Otherwise there are various points of resemblance 
 between this and the rachitic pelvis. The entire pelvis is smaller than normal. 
 The mechanism of labor is similar to that in flat pelves. 
 
 Diagnosis. — An absolute diagnosis can be made only by the direct measure- 
 ment of the various diameters, and is even then difficult. Although these 
 diameters throughout bear a resemblance to those of the generally equally con- 
 tracted pelvis, the diagonal diameter is an exception, being longer in the last- 
 named. This factor, together with the ease with which the side walls of the 
 pelvis can be reached by the internal finger, will help in the diagnosis. 
 
 Prognosis. — More difficulty in labor is experienced in this pelvis than in the 
 simple flat variety, for the oblique diameters do not afford extra room for the 
 head of the fetus, the whole pelvis being undersized. 
 
 IV. The Narrow, Male, Funnel-shaped Pelvis ; Fetal or Lying-down or Un- 
 developed Pelvis (Fig. 816). — The name suggests both the shape and the etiology 
 of this type of pelvis. The subject of funnel-shaped pelvis has been much 
 neglected. 
 
 Frequency. — This has been considered an exceedingly rare variety, but is 
 often found when the pelvis is systematically measured. Schauta estimated 
 5.90 per cent, of funnel pelves in 5000 cases. 
 
 Etiology. — It is due to the absence of the forces upon which the evolution of 
 
622 
 
 PATHOLOGICAL LABOR. 
 
 the normal pelvis depends. (Page 391.) Those unfortunates who, owing to 
 infantile paralysis or for other reasons, have never walked are the ones in 
 whom it is most markedly found. A suggestion of this type is also sometimes 
 found in ver;^'- young girls. Schauta pointed out the fact that this pelvis is 
 generally due to maldevelopment by which the walls of the pelvis are lengthened 
 and the body-weight is thrown backward on the sacrum. 
 
 Clinical Characteristics. — The characteristics of the fetal pelvis persist — 
 usually length and narrowness of the sacrum and elevation of the promontory 
 which gives a longer diagonal conjugate than usual. The whole pelvis is very 
 narrow and deep and there is not the normal width at the hips. The sacrum is 
 unusually straight. The transverse diameter of the outlet is contracted, and 
 Schauta showed that contraction in the pelvic outlet may be in any diameter. 
 The sacrum is far back between the iliac bones. The spinal column is normal. 
 
 Another Form of Funnel Pelvis. — 
 A kyphosis in the upper vertebras 
 gives a lordosis in the lower part. 
 If the kyphosis is lower, the influ- 
 ence on the pelvis is marked. Sup- 
 pose the kyphosis is in the lumbar 
 region, there is no compensatory 
 lordosis, but in order to enable the 
 patient to stand upright there are 
 changes in the pelvis causing an 
 enlargement at the superior strait. 
 Rotation of the sacrum backward 
 causes an increase in the superior 
 and a decrease in the inferior strait. 
 The pelvis assumes more or less the 
 horizontal position. The iliac bones 
 are spread apart by the sacrum, 
 causing the distance between the 
 spines and crests to be increased. 
 Great tension is put on the ilio- 
 sacral ligaments, causing a drag on 
 the ischia, tending to spread the 
 bones above -and causing a con- 
 traction below from side to side. 
 Hence the pelvic outlet is dimin- 
 ished both transversely and antero-posteriorly. The tension is on the ilio- 
 femoral ligaments, and this throws the ilia outward and the ischia inward. A 
 kyphosis, in order to produce this, must take place in early life. Later, the 
 pelvis is tilted but no such change takes place. 
 
 Diagnosis. — The diagnosis may be easy if measurements are taken. Usually 
 the deformity is overlooked. The kyphosis itself should give the clue. The 
 measurements of the inlet and outlet must be compared. (See Pelvimetry.) 
 The diameters of the outlet are less than normal, while those of the inlet are 
 normal or even greater. When this deformity exists in an extreme degree, so 
 that the inlet and the pelvic cavity are contracted, there is a still greater degree 
 of contraction, comparatively speaking, in the outlet. The internal examination 
 of the pelvic canal is of great service in making the diagnosis, for it will clearly 
 reveal the shelving walls converging toward the outlet, the contraction of the 
 pelvic arch, and the close relation of the ischiac tuberosities and spines. 
 
 Fig. 816. — Narrow, Male, Funnel-shaped 
 Fetal or Lying-down Pelvis. — (Ahlfeld.) 
 
MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 623 
 
 Prognosis. — In more than one-half of the cases labor has terminated 
 fatally. It may be possible to deliver with forceps, since spontaneous 
 delivery takes place only in the slightest degree of this deformity. If the 
 transverse diameter is less than three inches (7.62 cm.) and the antero-pos- 
 terior diameter is also contracted, symphyseotomy is indicated, while still 
 greater contraction will demand Caesarean section. Hence in these forms the 
 ordinary means of pelvimetry are not sufficient for making the diagnosis. If 
 the diagnosis is not made, the child will be dragged out through the contracted 
 outlet. Faulty positions of the head at the outlet are common. The power 
 of expulsion is generally weak. Lacerations and necrosis of the soft parts are 
 most frequent, and on account of the convergence of the pubic rami there is 
 great danger of perineal laceration. 
 
 V. Imperfect Development of One Lateral Mass of Sacrum. Naegele's Pelvis. 
 Obliquely Deformed or Contracted Pelvis. Obliquely Ovate Pelvis. Single 
 Oblique Pelvis (Figs. 817, 818, 819, 820). — Naegele first described this in 1806, 
 and published a work in 1839 in which he had collected some thirty cases. 
 
 Frequency and Etiology. — By many obstetricians this pelvis is considered 
 extremely rare, but careful observation will result in the discovery of one or 
 two in the course of the average practice in obstetrics. There are two theories 
 as to etiology: (i) Failure of development of the alas of the sacrum on one 
 side from absence of bony nuclei; (2) inflammatory changes in the same place 
 causing synostosis. Reasons for the congenital view are: (i) Such deformities 
 have been observed in intrauterine life; (2.) if it were due to inflammation, 
 traces of this trouble would be left behind — but these are not found. The 
 direction of distortion of the innominate bones is upward and backward on 
 the sacrum. This condition would not be possible in the presence of primary 
 ankylosis. The atrophy of the part embraces the whole length of the sacrum. 
 It is to-day accepted that the first theory is the correct one. The ossification 
 of the bones is secondary. Even children having this deformity before ankylosis 
 takes place have the oval pelvis, because the well side in developing draws 
 over the affected side. As soon as the patient begins to walk, the body-weight 
 is applied more to the leg of the diseased side, causing an adhesive inflammation 
 leading to synostosis. Sometimes this union does not take place, but the 
 pelvis is deformed notwithstanding. 
 
 Clinical Characteristics. — The sacral ala on the deformed side is atrophied 
 or entirely wanting, -while there exists a synostosis between the sacrum and 
 the iliac bone. The asymmetrical narrow sacrum faces the deformed side, 
 the promontory being actually twisted over toward the contracted side. The 
 pelvic inlet is oval in shape, with the tapering end on the deformed side (Fig. 
 819). The crests of the pelvis are markedly asymmetrical. The symphysis 
 is deflected from the middle line to the unaffected side, while the pubic arch is 
 contracted and deflected (Figs. 819 and 902). The external surface of the sym- 
 physis faces toward the diseased side instead of directly forward. The ilio- 
 pectineal line of the affected side is almost a straight line, while the ilium on 
 the sound side has a greater curve in its anterior part than normal, but in 
 every other particular is practically unchanged. The posterior superior spine 
 of the ilium approaches the sacral spines. The oblique diameter drawn from 
 the superior posterior spine of the ilium of the deformed side to the anterior 
 superior spine of the normal side is increased (Fig. 820). Careful internal 
 pelvimetry will detect considerable decrease in the oblique diameter drawn 
 from the point just above the center of the obturator foramen on the con- 
 tracted side to the opposite sacro-iliac synchondrosis. Pressure of the femur 
 
624 
 
 PATHOLOGICAL LABOR. 
 
 on the diseased side is exerted in an upward direction, so that the innominate 
 
 bone is pressed upward and 
 inward, while on the sound 
 side femoral pressure is di- 
 rected upward and outward. 
 Thus the sound side is en- 
 larged. This fact is of im- 
 portance because in the 
 mechanism of labor there is 
 only one side of the pelvis 
 for the fetus. The normal 
 true conjugate plays no 
 part. The diameter to be 
 considered skirts the poste- 
 rior wall at the sacro-iliac 
 synchondrosis. There is no 
 shortening of the true con- 
 jugate, and therefore these 
 pelves are often unrecog- 
 nized. 
 
 Diagnosis. — This is read- 
 ily made in routine pelvic 
 examinations, although 
 without careful measure- 
 ments the deformity may 
 be easily overlooked. In the 
 ' internal examination the 
 
 asymmetry ought to be rec- 
 ognized by the ischial spines. 
 The contracted pubic arch 
 and distorted promontor}' 
 would also be noticed. 
 
 Fig. 817. — Oval Oblique Pelvis 
 
 {Budin.) 
 
 u 
 
 Fig. 818. — Oval Oblique Pelvis of Naegele. 
 VIC Inlet. — {Author's collection.) 
 
 The distance is measured 
 from the spine of the last lum- 
 OF Naegele. bar vertebra to the anterior 
 
 superior spines of the iha, and 
 from the last lumbar spine to 
 the posterior superior spine. 
 Then the measure is taken from 
 the anterior superior spine of 
 one side to the posterior supe- 
 rior spine of the opposite side; 
 from the posterior superior spine 
 of the ilium on one side to the 
 tuber ischii on the other; from 
 the posterior superior spines of 
 the ilia to the inferior edge of 
 the symphysis pubis; from the 
 inferior edge of the pubis to the 
 spines of the ischium, and again 
 from the spines to the nearest 
 sacral borders. The longest 
 measurement between the ischial 
 spines and the inferior border of 
 the pubis is on the decreased 
 side, while the reverse is true 
 Pel- of the distance between these 
 spines and the sacrum. . 
 
MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 
 
 {J2t 
 
 The majority of these cases have been diagnosed after death. 
 Ueves the diagnosis to be 
 free from difficulty when 
 there is a great difference 
 between the sides. The 
 patient may exhibit no limp 
 in her gait, but a careful 
 history of her early life 
 should be obtained. Phy- 
 sical examination may also 
 reveal healed sinuses. A 
 rectal examination is valu- 
 able for detecting an anky- 
 losed joint. Externally the 
 most valuable measurement 
 is that from the trochanter 
 major of one side to the iliac 
 crest of the other, and vice 
 versa. 
 
 Prognosis. — The results 
 are usually fatal. Probably 
 two-thirds of the cases pass- 
 ing into labor have ended 
 in death. If the deformity 
 is great, the child must 
 pass through the healthy 
 side of the pelvis, as the 
 contracted side is not large 
 enough to admit any part 
 of the fetus. The mechan- 
 ism is similar to that of the 
 generally contracted pelvis. 
 The occiput descends first, 
 as the head is extremely 
 flexed. If the breech pre- 
 sents, the prognosis is more 
 unfavorable, for it may be 
 impossible for the head to 
 pass. The mortality of the 
 mothers is 80 per cent., ac- 
 cording to Litzmann. The 
 prognosis in respect to the 
 mother will necessarily de- 
 pend upon several factors. 
 Eighty per cent, as quoted 
 is thought to be too high 
 for maternal mortalit}', and 
 it is to be accounted for 
 by the use of inappropriate 
 treatment, and also by the 
 fact that often the condi- 
 tion was not recognized 
 40 
 
 Zweifel be- 
 
 FiG. 819. — Oval 
 
 Oblique Pelvis 
 0udin.) 
 
 OF Naegele. 
 
 Fig. S20. 
 
 —Oval Oblique Pelvis of Naegele. 
 VIC Outlet. — (Aiiihor's collection.) 
 
 Pel- 
 
626 
 
 PATHOLOGICAL LABOR. 
 
 early enough for the use of suitable therapeutic measures. Various accidents 
 are apt to take place during labor, such as ruptures, fistulas, fractures, etc. 
 
 Treatment. — This differs according to the extent of the deformity. If the 
 inferior strait is contracted, Caesarean section should be performed. Farabeuf 
 recommends ischio-pubotomy. (See Operations, Part X.) If the attendant is in 
 doubt, Caesarean section should be performed, since unless the degree of deformity 
 is slight, forceps and version are not generally attended by good results. 
 
 VI. Imperfect Development of both Lateral Masses of the Sacrum, Robert's 
 
 Pelvis. The Ankylotic Pelvis. 
 Transversely Contracted Pel- 
 vis (Figs. 821, 822). — Robert 
 was the first to describe this 
 pelvis in 1842. It is closely 
 related to the Naegele pelvis. 
 Frequency and etiology: This 
 is the rarest of contracted 
 pelves, only eight cases hav- 
 ing been reported. It is 
 due to failure of develop- 
 ment of the sacral alae on 
 both sides. There is gener- 
 ally synostosis on both sides, 
 and the sacro-iliac synchon- 
 drosis is absent. Clinical 
 characteristics: The sacral 
 alas are either absent or 
 poorly developed. The nar- 
 row sacrum has an extremely 
 elevated promontory, felt on 
 internal examination. The 
 spines and tuberosities of 
 the ischium are more closely 
 approximated than norm- • 
 ally. The transverse pelvic 
 diameters are much de- 
 creased, while on account of 
 the slight anterior displace- 
 ment of the sacrum the 
 conjugate of the superior 
 strait is diminished. The 
 transverse diameter of the 
 inlet is particularly short- 
 ened, varying, according to 
 Kleinwachter, from 2.76 to 3.94 inches (7 to 10 cm.), while that of the out- 
 let is from 0.88 to 2.76 inches (2.25 to 6 cm.). The pubic angle is diminished. 
 Asymmetry of the Robert pelvis sometimes exists. Diagnosis is based upon 
 the above condition. Prognosis: Caesarean section with its attendant dangers 
 is nearly always indicated. Treatment: Perforation and extraction may be 
 performed within certain limits, a case in which the transverse diameter of the 
 pelvic inlet measures 3.1 inches (7.8 cm.) and that of the outlet 2 inches (5 
 cm.) is supposed to represent the extreme limit of its applicability. Caesarean 
 section has been performed in the majority of the cases. 
 
 Fig. 821. — Double Oblique Pelvis of Robert. 
 
 Fig. 822. 
 
 -Double Oblique Pelvis of Robert. 
 gram of pelvic inlet of Fig. 821. 
 
 Dia- 
 
MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 
 
 627 
 
 Fig. 823. — Generally Equally Enlarged Pelvis. 
 JusTO-MAjOR Pelvis. Pelvic Inlet. — {Author's 
 collection.) 
 
 VII. Generally Equally Enlarged Pelvis. Pelvis ^quabiliter Justo-major. 
 Giant Pelvis. Justo-major Pelvis (Figs. 823 and 824). — This pelvis is occa- 
 sionally observed in women of medium height, although it also sometimes 
 accompanies a gigantic stature. Frequency and etiology: This condition is often 
 merely congenital, with no other particular explanation. Clinical characteristics : 
 In this pelvis all the diameters, 
 
 although preserving normal 
 proportions, are increased. 
 The condition is seldom no- 
 ticed, especially if not present 
 in an extreme degree. During 
 pregnancy the woman is liable 
 to have increased pressure 
 symptoms. This is due to 
 the low position of the uterus 
 in the roomy pelvis. Consti- 
 pation, urinary symptoms, 
 oedema of the vulva, varicose 
 veins, and difficult locomotion 
 are common in pregnancy. 
 Diagnosis: This is rarely made, 
 but if measurements show a 
 general and symmetrical in- 
 crease, diagnosis of a justomajor pelvis is justifiable. The promontory cannot 
 be reached by internal examination, nor are the side walls of the pelvis 
 easily accessible. Prognosis: Labor is usually not disturbed by this anomaly, 
 although the majority of obstetricians consider that delivery is apt to be 
 precipitate on account of the large size of the birth canal. 
 
 VIII. Split Pelvis. Inverted Pelvis (Fig. 825). — The name and illustration 
 
 indicate the deformity. Frequency 
 and etiology: This condition repre- 
 sents an anomaly of non-union, 
 comparable and usually associated 
 with such malformations as ex- 
 strophy of the bladder, myelomen- 
 ingocele, etc. As a complication of 
 labor it is one of the rarest of pelvic 
 anomalies. Clinical characteristics: 
 Although the deformity of this t3'-pe 
 most frequently concerns the sym- 
 physis pubis, still in some cases the 
 sacrum as well as the lower part of the 
 vertebral column is fissured at birth. 
 In the separation of the pubic bones 
 the heads of the femora, pressing 
 upward, force the innominate bones 
 outward and backward, resulting in 
 the approach of the posterior superior spines of the ilium behind the sacrum, 
 which is pushed inward. Thus there is created a groove posterior to the 
 sacrum, from which circumstance this variety of pelvis receives the name- 
 of "inverted" pelvis. The space where the bones fail to meet is usually 
 filled with" fibrous tissue. Exstrophy of the bladder usually accompanies this 
 
 Fig. S24. — Generally Equally Enlarged 
 Pelvis. Justo-major Pelvis. Pelvic 
 Outlet. — {Author's collection.) 
 
628 
 
 PATHOLOGICAL LABOR. 
 
 Fig. S25. — Split or Inverted Pelvis. 
 
 Fig. 827.— Pelvic Inlet of Fig. 826. 
 
 Fig. 826. — Pelvis Deformed from In- 
 fantile Paralysis of the Right Side 
 WITH Atrophy of the Corresponding 
 Femur. , 
 
 Fig. 828. — Pelvis Deformed from 
 Faulty Development of the Sa- 
 cral Vertebra. 
 
 /^ 
 
 
 Fig. 829. — Deformed Pelvis from Faulty 
 Development of the Sacrum. 
 
 Fig. 830. — Pelvis Deformed from Faulty 
 Development of the Sacral Vertebra. 
 
MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 
 
 629 
 
 deformity. Not infrequently there are other congenital defects. It is not 
 often that this pelvis is observed in a woman who bears children, though there 
 are several recorded cases. The diagnosis is perfectly clear. Prognosis: No 
 obstacle to labor is presented by the deformity, and it may be compared 
 with the justo-major pelvis. There is no indication for obstetric treatment 
 during labor. There is almost invariably prolapsus uteri after labor. In the 
 case of cleavage of the sacrum there is often present a meningocele projecting 
 into the pelvis which may offer a serious obstruction to the passage of the child . 
 
 B. ANOMALIES DUE TO DISEASE OF THE PELVIC BONES. 
 
 I. Rachitis or Rickets. Rachitic Pelvis. — This deformity has doubtless 
 always existed. Hippocrates and Galen knew of it, but Glisson (1650) first 
 
 "■nffMSimmM 
 
 Fig. S3 1. — Zone of Ossification in a 
 Normal Epiphysis (Microscopic): i, 
 Hyaline cartilage; 2, zone of beginning 
 proliferation of the cartilage; 3, columns 
 of cartilage-cells arranged in rows; 4, 
 columns of enlarged cartilage-cells; 5, 
 first zone of calcification; 6, layer of 
 osteoblasts in first zone of ossification; 
 7, fully developed cancellous tissue 
 (spongiosa) ; 8 and 9, blood-vessels in 
 transverse and longitudinal section. 
 
 
 "B^is 
 
 Fig. 832. — Zone of Ossification in a 
 Rachitic Epiphysis (Microscopic): i, 
 Transition of normal hyaline cartilage 
 to proliferating cells; 2, zone of carti- 
 lage-cells arranged in rows; 3, cellule- 
 fibrous medullary spaces containing 
 blood-vessels in the region of the pro- 
 liferated and enlarged cartilage-cells; 4, 
 island of calcified cartilaginous tissue; 
 5, columns of osteoid and fully devel- 
 oped calcified bone-tissue; 6, columns of 
 osteoid tissue not containing lime-salts; 
 7, like 3, with the blood-vessel in trans- 
 verse section. 
 
 described the disease. Rickets of the newly born child may be one of two 
 varieties — fetal or congenital. It was the former that was familiar to the 
 ancients, as the latter has been recognized only of late years. Both types of 
 
630 
 
 PATHOLOGICAL LABOR. 
 
 this disease begin in intrauterine life, but while in the fetal form the stigmata 
 of the disease are fully developed at birth, in the congenital form the evidences 
 of the disease continue their development after birth. Fetal rachitis has been 
 called a disease of the periosteal cartilage. There is an exuberance of growth 
 of this part while the process of calcification is faulty. In rachitis the growth 
 of the cartilage and subperiosteal tissue is defective as well as the process of 
 ca,lcification. 
 
 Frequency and Etiology of Rachitis. — From fifty to seventy per cent, of 
 dispensary patients in Glasgow and Vienna exhibit traces of this affection. -In 
 America it is especially seen in the colored race. In the lower animals there 
 occurs a disease similar to rickets. Malnutrition of the mother and deficiency 
 in lime salts seem to be the most important etiological factors. 
 
 Pathology of Rachitis. — Bone is normally formed (i) under the periosteum, 
 
 (2) from cartilage, (3) from the med- 
 ullary canal. All of these may be 
 affected by the disease. The essen- 
 
 FiG. 833. — Sagittal Section of a Rachi- 
 tic Pelvis. Note the false sacral pro- 
 montories and the disappearance of the 
 vertical concavity of sacrum. 
 
 Fig. 834. — Sagittal Section of a Rachi- 
 tic Pelvis. Contraction at the pelvic 
 inlet with exaggeration of the vertical 
 concavity of the sacrum. 
 
 tial fact is that there is excessive bone-formation while calcification is limited. 
 Hence it is a primary disease — never caused by solution of pre-formed calcified 
 bone. Roloff noted that in zoological gardens lions fed on meat without bones 
 develop a similar condition (lahme) on account of the lack of calcium (Figs. 831, 
 832). _ 
 
 Clinical Characteristics of Rachitis. — Rachitis is a disease of children occurring 
 during the first three years of life. If the child has already learned to walk, it 
 ceases to do so. Hence, one should always ask "When did the patient learn to 
 walk?" The disease gives rise to soft bones, with their resulting deformities. 
 The epiphyses of the long bones are enlarged ("knock-knee, rachitic rosary"). 
 This is more marked on the pleural than on the pectoral side of the ribs. Pigeon - 
 breast often results, especially if adenoids are associated. The head is more or less 
 square or blunt. The bones of the skull have flat areas, which are thinned, and 
 spoken of as craniotabes. Gastro-intestinal symptoms are marked and marasmus 
 
MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 
 
 631 
 
 may result. The various parts of the body are disproportionate, the abdomen being 
 very large. Hydrocephalus and enlarged thyroid are often present. The pelvis 
 and spinal column are subject to deformities. In certain cases the head is 
 inclined laterally upon the axis of the spine. The long bones are often curved, 
 while their spontaneous fracture is not uncommon. Diagnosis from recog- 
 nition of the clinical characteristics as given above should be simple (Figs. 833, 
 834,835). 
 
 Varieties of Rachitic Pelves. — There are several varieties of deformed pelvis 
 resulting from the inroads of this disease. The most frequent is (i) flat rachitic 
 pelvis, in which, although all of the diameters are shortened, the antero-posterior 
 is most affected. (2) The simple fiat, rachitic pelvis, in which the transverse 
 diameters suffer no change. (3) The gener- 
 ally equally contracted' rachitic pelvis. (4) 
 The pseudo-osteomalacic pelvis, which comes 
 to resemble the pelvis of osteomalacia from 
 the effect of pressure on the soft rachitic 
 bones. (5) Very rare forms of distorted pelves, 
 in addition to the foregoing, result from 
 rachitic affections of the spinal column. 
 
 Clinical Characteristics of Rachitic Pelves. — 
 Three influences serve to modify the pelvis 
 in rachitis: (i) Arrest of development occa- 
 sioned by the progress of the disease; (2) 
 the pressure exerted both by the superim- 
 posed and the subjacent skeleton; and lastly 
 (3) the "pull" of the ligaments and muscles 
 attached to the pelvic bones. The pelvis 
 as a whole is undersized, having a dis- 
 torted inlet which is often kidney-shaped 
 or rarely like the figure 8. The pelvic cavity 
 is very shallow. The pull of the obturator 
 muscles upon the soft bones widens the 
 pubic arch, and if great flattening is pres- 
 ent, there will result the figure 8 pelvis. 
 The promontory of the sacrum is abnormally 
 prominent. The obliquity of the pelvis is 
 greatly increased. The epiphyses are pecu- 
 liarly altered, while the presence of other 
 characteristics of rachitis adds to the cer- 
 tainty of the diagnosis. As a rule, the bones 
 of a rachitic pelvis are abnormally fragile 
 
 and small; rarely they are coarser and heavier than normal, (i) and (2) Rachitic 
 flat pelvis: As a result of softening of the bones the child learns to walk late, 
 or if it has walked ceases to do so for a time (Figs. 836, 837, 838, 839). The 
 bones are soft and the child does not walk, but sits up; hence the pressure of 
 the body-weight is not counteracted by the upward pressure of the femora. 
 The broadening becomes marked and the transverse diameter is shorter than 
 normal. The iliac bones are flared out so that the iliac spines are farther 
 apart than the crests. The sacrum tends to rotate, imparting a backward 
 impulse to the lower part, but this is offset by the firm grasp of the ligaments, 
 and a curve is the result. Hence the antero-posterior diameter of the inferior 
 strait is shortened. The bodies of the sacral vertebrae are pushed forward at 
 
 Fig. 835. — Rachitic Dwarf. De- 
 livered by C.-ESAREAN Section. — 
 (Author's case.) 
 
632 
 
 PATHOLOGICAL LABOR. 
 
 r^^: 
 
 Fig. 836. — Rachitic Pelvis. Diminution of 
 all diameters, especially of the antero-pos- 
 terior. 
 
 Fig. 837. — Pelvic Inlet of Fig. 836. 
 
 Fig. 838. — Simple Flat Rachitic Pelvis. Note the Fig. 83Q. — Pelvic Inlet of Fig. 83$ 
 false sacral promontories. 
 
 Fig. 840.— Generally Equally Contracted Fig. 841.— Pelvic Inlet of Fig. 840. 
 Rachitic Pelvis. 
 
MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 
 
 633 
 
 the expense of the alae, making the anterior surface of the sacrum straight or 
 convex. The child sits on the tubera ischii without the upward pressure of 
 the femora to counteract, and the transverse diameter of the inferior strait 
 becomes broadened, and there is also a flaring outward of the ischiac bones. 
 The area of the superior strait remains about the same, but the relations are 
 distorted. Owing to the backward movement of the sacrum, there is more 
 room in the pelvis, although the ex- 
 ternal antero-posterior diameter of 
 Baudelocque is less than normal. 
 The interference with labor ends 
 when the head has passed the supe- 
 rior strait. The effect of the deform- 
 ity varies according to the extent. 
 As to the measurements of the pelvis, 
 a true conjugate, one less than 2}. 
 inches (5.5 cm.), is absolutely con- 
 tracted; 2^ inches (6.35 cm.) to 3 
 inches (7.62 cm.) is a deformity of 
 the third degree; 3 inches (7.62 cm.) 
 to 3^ inches (8.89 cm.) is a deformity 
 of the second degree, and the child 
 may be born spontaneously or with the 
 aid of the forceps; 3Hnches (8.89 cm.) 
 t0 4i inches (10.795 cm.) is a deformity 
 of the first degree, and the first child 
 is usually born spontaneously. Con- 
 tractions of the first degree are of 
 little importance. The child's head 
 is 3 1 inches (9.5 cm.) for the biparie- 
 tal diameter, but this is capable of 
 considerable shortening. In a flat 
 rachitic pelvis the head is less flexed, 
 being semi-extended. The two fon- 
 tanelles are on the same level. The 
 head becomes tilted in normal cases 
 so that the sagittal suture lies nearer 
 the promontory of the sacrum. This 
 is called Naegele's obliquity. (Pages 
 518.) In flat rachitic pelves this is 
 accentuated and the sagittal suture 
 lies in front of the sacrum and the 
 parietal bone presents — anterior par- 
 ietal presentation. This increases till 
 finally the ear is left behind the sym- 
 physis pubis. Then rotation takes 
 
 place, causing the sagittal suture to leave the sacrum. In a few cases 
 the sagittal suture is anterior. The complication is then more serious, as 
 the head becomes wedged above the symphysis pubis. Whenever the two 
 fontanelles are felt equally, a flat rachitic pelvis may be suspected. After 
 the head has passed the superior strait the mechanism of labor is normal. 
 Presentation by the posterior parietal bone is serious because the head is 
 wedged on the symphysis pubis. The child cannot be bom spontaneously. 
 
 Fig. 842.^Pseudo-osteomal.a.cic Rachitic 
 Pelvis. — (.4 ntlior's collection.) 
 
634 
 
 PATHOLOGICAL LABOR. 
 
 Great pressure is exerted on the posterior parietal bone by the sacrum, causing a 
 depression in the bone. Sometimes this depression is spoon-shaped. It is quite 
 likely that the brain has been injured. By palpation only a vague idea of the 
 size of the head can be obtained. (3) The generally equally contracted rachitic 
 pelvis: It is chiefly characterized by arrested development (Figs. 840, 
 841). It entails contraction of the transverse diameter such as is seen in 
 the fetal pelvis. This form is very rare and it leaves the shape of the 
 pelvic brim little changed from normal, since the ravages of the disease 
 have done their work at such an early age that the child did not sit up 
 or walk till recovery had taken place. Consequently the processes which 
 serve to change the shape of the pelvis when disease offers them in a favorable 
 condition, have not had a chance to exert their influences. (4) The pseudo-osteo- 
 malacic pelvis: This is the result of several conditions the opposite of those 
 considered in the last section (Fig. 842). The deformity of this type is 
 striking, for the disease progresses while the child is walking and perchance 
 carrying heavy weights (Fig. 842). From the action of the two forces, 
 superimposed and subjacent, the pelvis is distorted to an extreme degree. 
 The acetabula are pushed inward so that they encroach on the pelvic space. 
 
 The innominate bones yield 
 to the pressure exerted upon 
 them and are bent laterally, 
 while the sacrum is pressed 
 downward and bent also in 
 the same direction. The de- 
 formities are far advanced be- 
 fore the disease has exhausted 
 itself, and the pelvis is fixed in 
 its distorted form. 
 
 Diagnosis of Rachitic Pel- 
 ves. — Signs of rachitis in other 
 parts of the body will make 
 the diagnosis more clear. The 
 history of infantile rachitis 
 can also generally be elicited. 
 The relative position of the crests and spines of the ilia is of important diagnostic 
 significance (Fig. 843). The history and personal appearance must also be taken 
 into consideration. After rachitis in childhood the woman is generally observed 
 to be short with thick, curved limbs, enlarged joints, square head, and chicken- 
 breast. The abdomen is short, and on this account, and because of the failure 
 of engagement of the presenting part, when pregnancy occurs it hangs far for- 
 ward and downward in a characteristic manner. Besides walking late, the ra- 
 chitic child is late in teething. Not infrequently a double sacral promontory is 
 observed in these patients. In some cases the lumbar vertebras are curved inward 
 so far that they offer an obstruction above the brim. This results from rachitis 
 of the spine. In measuring the effective conjugate from the symph^^sis the outer 
 point must be taken above the sacrum. To differentiate this pelvis from that of 
 osteomalacia is not difficult, for there are characteristics belonging to the latter 
 which clearly distinguish it, and, besides, the other rachitic signs come into play — 
 those found elsewhere in the body and the direction of the crests of the ilia. 
 After the disease has run its course the consistency of the bones is farm and hard. 
 II. Osteomalacia. Osteomalacic Pelvis (Figs. 844 to 848). — In English works 
 the disease is called " malacosteon." The pelvis in a patient suffering from 
 
 Fig. 843. — -Diameters of the Iliac Spines and 
 Crests in a Rachitic Pelvis Compared. D.M., 
 Intercristal diameter; D.A., interspinal diameter. 
 
MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 
 
 635 
 
 this disease is called the "osteomalacic," "malacosteon," or " Y-shaped pelvis." 
 It is also known as the "beak-shaped " or "rostrate pelvis." Frequency and 
 etiology: It is rare in America but very common around the head-waters of 
 the Rhine. Litzmann's statistics (1892) show that of 131 cases 11 were in 
 males, 85 in pregnant or puerperal women, and 35 in non-pregnant women. It 
 is essentially a disease of women, being in them about five times more fre- 
 quent than in men. It occurs during pregnancy or during the puerperium. 
 This disease is caused by the production of soft bone in the adult through the 
 absorption of lime salts (Fig. 844). This bone is unable to resist pressure 
 without being distorted into bizarre forms. It usually occurs between thirty 
 and fifty years of age, in pregnant women or in those who have had children, 
 
 and especially in those who have had many 
 children. It is observed in animals kept in 
 zoological gardens, where it is usually 
 thought to differ from the similar condi- 
 tion in human beings. Varieties of osteo- 
 malacic pelves: The relative deformity from 
 malacosteon may be expressed by several 
 forms of pelves: (i) Oblong, in which the 
 antero-posterior diameter is increased (Fig. 
 845); (2) oblong rostrated, dhlong m shsL-pe 
 
 Fig. 844. — Microscopic Section 
 through an osteomalacic bone. 
 I , Remains of calcified bone-sub- 
 stance; 2, decalcified bone-substance; 
 3, large medullary spaces due to the 
 disappearance of bone-substance; 4, 
 Haversian canals. 
 
 Fig. 845. — Osteomalacic Pelvis. Oblong In- 
 let BEFORE Much Deformity Has Occurred. 
 Weight of this pelvis fifteen ounces. Weight 
 of healthy bony pelvis about thirty ounces. — 
 {Author's collection.) 
 
 with anterior beak (Figs. 846, 847, 848); (3) rostrated, with beak in front; (4) 
 cordiform, heart-shaped. This last form is very rare. Pathology: The old idea 
 was that bones affected with this disease contain far less calcium than the normal 
 bone. In 1895 Curatulo and Turelli made animal experiments. They estimated 
 the total excretion of carbonic acid, lime, and phosphoric acid. Then they cut 
 out the ovaries and found certain changes. The animals did not breathe so 
 rapidly and excreted less lime and phosphoric acid. Hence it was shown the 
 ovaries increase the excretion of these products. In 1896 Denecke estimated 
 the amount of lime and phosphorus excreted by osteomalacic women ; the ovaries 
 were then removed. In a few weeks there was a marked decrease in the excre- 
 
636 
 
 PATHOLOGICAL LABOR. 
 
 Fig. 846. — Osteomalacic Pelvis. Oblong Ros 
 TRATED. Pelvic Inlet. 
 
 tion of these substances. In 1897 Senator recorded a case of osteomalacia. 
 
 Excretion estimates were made and the diet carefully regulated, while thyroid 
 
 extract was administered. It 
 was found that the excretion 
 of lime and phosphorus was 
 increased. Ovarian extract 
 caused an increase of nearly 
 double that noted under the 
 thyroid treatment. Clinical 
 characteristics: The patient 
 suffers from rheumatoid 
 pains, inability to walk, and 
 difficult labors. The pelvic 
 bones become very soft so 
 that in extreme cases they can 
 actually be bent by the hand ; 
 they are also very painful. 
 The pelvis naturally becomes 
 much distorted and the sym- 
 physis pubis comes to resem- 
 ble a beak, because the heads 
 of the femora drive the in- 
 nominate bones inward, while 
 the symphysis is held in place 
 by its muscular attachments. 
 On internal examination the 
 finger may be laid in the hol- 
 low of this deformity (Fig. 
 848) . The pubic arch is much 
 narrowed and the true con- 
 jugate is very short. The 
 promontory of the sacrum is 
 very prominent, being forced 
 downward and forward, while 
 the tip of this bone and the 
 coccyx bend so sharply for- 
 ward that the outlet of the 
 pelvis is almost completely 
 obstructed. The tubera ischii 
 are displaced outward so that 
 the transverse diameter of the 
 outlet is increased. The pa- 
 tient suffers from dyspnea 
 and cough. The bones be- 
 come very porous and light, 
 containing much cancellous 
 tissue. This tissue contains 
 large cavities, which may be 
 froin two to four millimeters 
 in length. The pelvis actually 
 
 collapses and the sufferer always loses markedly in height, — even as much as a 
 
 foot in some cases, — while, unable even to stand, she is confined to her bed. It 
 
 Fig. 847. — Diagram of Pelvic Ixlet of Fig. 
 
 Fig. 848. — Osteomalacic Pelvis. Oblong Ros- 
 trated. Pelvic Outlet. 
 
MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 
 
 637 
 
 occurs during pregnancy, 
 diagnosed as rheumatism, 
 woman is somewhat lame 
 difficult labor follows. 
 The second child will 
 probably be born dead 
 while the following will be 
 delivered by craniotomy 
 or abdominal section. 
 (See Osteomalacia in 
 Diseases of Pregnancy.) 
 Diagnosis: The length of 
 the true conjugate is not 
 a criterion of the capacity 
 of the pelvis, but the diag- 
 nosis can be made by a re- 
 view of the clinical symp- 
 toms together with care- 
 ful internal and external 
 examinations. The pecu- 
 liar pains attendant upon 
 this disease, the peculiar- 
 ity of the gait, and finally 
 the total inability to 
 walk, the characteristic 
 beak-like pelvis, with al- 
 most complete obstruc- 
 tion of the outlet, the loss 
 of height, all make a 
 striking clinical picture. 
 Other types to be thought 
 of in making the diag- 
 nosis are: the pseudo- 
 osteomalacic, the Robert, 
 the kyphotic, or a pelvis 
 which has been fractured 
 or invaded by malignant 
 disease. Prognosis: It is 
 not in itself a fatal dis- 
 ease. The patients usu- 
 ally die of inanition. 
 The obstruction is very 
 marked even though the 
 bones are so flexible. Out 
 of 85 cases reported by 
 Litzmann, 47 were fatal. 
 Treatment: If taken in 
 the beginning, an im- 
 provement in surround- 
 ings is indicated, as are 
 oleum morrhuae and ton- 
 ics. Phosphorus has been 
 
 its first signal being rheumatoid pains, and it may be 
 
 This continues till the child is born, after which the 
 
 , and the trouble returns at the next pregnancy and 
 
 Fig. 849. — Large Exostosis of the Pubis. 
 
 Fig. 850. — Exostosis of the Sacral Promontory. 
 
 V. ■• 
 
 Fig. 851. — Osteosarcoma of the Pelvic Cavity. — (Bar.) 
 
638 
 
 PATHOLOGICAL LABOR. 
 
 used. Ovariotomy ought to be done, especially as these women are usually very 
 fertile. Hysterectomy gives the best result. Sometimes the suppression of the 
 sexual functions may even cure the disease. 
 
 III. New Growths. — The presence of exostoses or other kinds of tumors of the 
 pelvic bones is very infrequent. But such growths may be the cause of a high 
 degree of dystocia. The pelvis with bony exostoses (Figs. 849 and 850) is known 
 as acanthopelys, acanthopelvis, pelvis spinosa, spiny or thorny pelvis, and Hau- 
 der's pelvis. It is believed that exostoses are found, as a rule, in pelves other- 
 wise deformed, and they are generally situated over one of the pelvic joints. In 
 their original state they are composed of cartilage, afterward becoming bony. 
 Most of them are small — about the size of a small bean or olive, though now and 
 then they may attain the dimensions of a pigeon's egg. In some cases spicules of 
 bone develop at certain points in the pelvis, projecting into its cavity. They are 
 very apt to injure the uterus or the descending head. Perforation of the uterus 
 is common under these circumstances. After fracture of the bones irregular 
 callus may also form projections. Other pelvic tumors are osteosarcomata (Fig. 
 851), enchondromata, sarcomata, fibromata, cysts, and carcinomata. Their size 
 will form the criterion for the difficulty offered in labor. The cysts may be hyda- 
 
 FiG. 852. — Pelvis Deformed by Mul- 
 tiple Fractures. — {Von Martz.) 
 
 Fig. 853. — Pelvis Deformed by Multi- 
 ple Fractures. — {Paparoine and Tar- 
 nier.) 
 
 tid or may be formed in enchondromata or sarcomata. Cancer is never primary. 
 It may be an extension from the original focus or it may be metastatic. The 
 growth may infiltrate the bones, making them porous and soft, as in osteo- 
 malacia. Prognosis: According to Winckel, in 49 cases of pelvic tumor ob- 
 structing labor, the maternal mortality was 50 per cent, while the fetal was 90 
 per cent. Treatment: Caesarean section" is generally performed, although the 
 posterior vaginal wall has been excised and the growth removed by this route. 
 IV. Fractures. — Out of 13,200 fractures from the statistics of nine hospitals 
 in England and America, only | of i per cent, were fractures of the pelvis (Hirst). 
 Contracted pelves may result from fractures and dislocations, whether con- 
 genital or occurring later. These pelves are not symmetrical, and when the 
 traumatism has taken place very early are sometimes undeveloped, and are 
 always accompanied by grave deformity. The contraction is found on the side 
 of the fracture. Nearly all cases of serious pelvic fracture end fatally. The 
 resulting deformity may be of various forms, depending upon the nature and 
 seat of the fracture (Figs. 852 and 853). If the horizontal pubic ramus is 
 broken, it is impossible to keep the broken ends together during repair, and 
 thus great deformity may result. In unilateral dislocations the resulting pelvis 
 
MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 
 
 639 
 
 is obliquely contracted. A similar deformity is seen in the pelvis resulting 
 from the early loss of one leg (Sitz pelvis, page 622, Fig. 816). 
 
 V. Atrophy, Caries, and Necrosis. — An oblique contraction occurs sometimes 
 in the rare event of tuberculosis of the sacro-iliac joint. In affections of this 
 joint there will develop the same result as that in a true Naegele pelvis from 
 imperfect development of an ala of the sacrum. If the trouble takes place in 
 early life, there will be loss of substance, arrested development of the part 
 affected, and an anchylosed joint, all of which result in atrophy of the pelvis. 
 
 SACRO-COCCY.ART 
 
 C. ANOMALIES IN THE JUNCTION OF THE PELVIC BONES. 
 
 I. Synostosis at the Symphysis. — The development of synostosis in this joint 
 is quite common and occurs most often during early childhood. This condition 
 would present a difficulty in the operation for symphyseotomy, but although 
 it would limit the expansion of this joint which normally takes place during 
 labor, it is not a serious complication in other- 
 wise unobstructed labor. 
 
 II. Synostosis at One or Both of the Sacro- 
 iliac Joints. — Synostosis of this joint occur- 
 ring in early life is succeeded by badly de- 
 veloped sacral alee on the abnormal side; the 
 part of the innominate bone concerned in 
 this joint suffers also in its development, so 
 that there results an obliquely contracted 
 Naegele type. Arrested development of the 
 alae of the sacrum as a primary occurrence 
 is far more frequently seen than this latter 
 affection. If, instead of taking place in early 
 childhood, the synostosis does not occur till 
 after puberty, the untoward effects may be 
 considered of no consequence. In case this 
 affection takes place on both sides, there 
 results a pelvis much like the Robert. This 
 is still less frequent than the transversely 
 contracted pelvis, owing to faulty develop- 
 ment of the sacral alse. 
 
 III. Synostosis at the Sacro-coccygeal 
 Joint. — The joint between the sacrum and 
 the coccyx is anchylosed, as a rule, between 
 
 the thirtieth and fortieth years, but since the joint between the first and second 
 coccygeal vertebras does not take part in this process the effect on labor is scarcely 
 worth considering. There is now and then a case in which anchylosis takes place 
 in all the joints of the coccyx as well as in the sacro-coccj^geal joint, especially in 
 elderly primiparas (Fig. 854). If labor occurs in such a patient, it will be necessary 
 to fracture the coccyx or to break up the anchylosed sacro-coccygeal joint. The 
 fracture sometimes takes place during the natural passage of the head down 
 through the pelvic outlet, but it occurs more commonly in instrumental delivery. 
 
 IV. Exaggerated Motion or Separation of the Pelvic Joints. — This may be just 
 an exaggeration of the normal condition of the joints during labor. However, 
 it will more probably have a pathological foundation, such as inflammation 
 of the joints, succeeded by suppuration, fluid in the joint, new growths, caries, 
 or osteomalacia. During labor there is sometimes a predisposition of the joints 
 to rupture on account of the relaxation incident to pregnancy and labor. Some- 
 
 FiG. S54. — Anchylosis of the Coc- 
 cyx. — (Author's colleciion.) 
 
640 PATHOLOGICAL LABOR. 
 
 times locomotion during pregnancy is made difficult by the relaxation of the 
 joints. (See Part II.) The coccyx has been known to become dislocated 
 during labor. This condition is productive of much pain, and often demands 
 excision of the bone. 
 
 U. ANOMALIES OF THE PELVIS DUE TO DISEASE OF THOSE PARTS OF THE 
 SKELETON WHICH ARE CARRIED BY THE PELVIS. 
 
 I. Spondylolisthesis. Spondylolisthetic Pelvis, Kilian's Pelvis, Rokitansky's 
 Pelvis, Prague Pelvis (Figs. 855 to 860). — The term originated with Kilian, 1853, 
 and is derived from spondylos {cr-o'^du'/Mc) ^ veri;ebra, and olisthesis {oMtjOeatq)^ " a 
 slipping out "or " down." Rokitansky, Kiwisch, and Seyfert; had described the 
 deformity, but Kilian gave the first accurate description. Neugebauer and Lane 
 also did much work on the subject. To cause pelvic obstruction spondylolisthesis 
 must take place in the lumbosacral region, and in obstetrics we understand the 
 term to indicate a dislocation of the last lumbar vertebra in front of the base of the 
 sacrum, so that the inferior surface, or possibly the anterior surface of the former, 
 comes in contact with and is united by bony union with the anterior surface of the 
 first piece of the sacrum. As a result a marked lordosis occurs in the lumbar ver- 
 tebras, and the fourth, third, and possibly the second lumbar vertebra may drop 
 into the pelvic inlet, causing an obstruction in the antero-posterior diameter. 
 Backward and downward displacement of the base of the sacrum and the poste- 
 rior portion of the pelvic inlet results. Compensatory elevation of the anterior 
 portion of the pelvis follows. The height of the symphysis is increased. Thus 
 pelvic inclination is markedly lessened, and the vulval orifice is raised and 
 directed more anteriorly. The amount of obstruction at the inlet will naturally 
 depend upon the distance the last lumbar vertebra descends and the degree of 
 lordosis. Frequency and etiology: It is not a common condition. Up to 1892 
 Schlesier collected fifty-three cases in skeletons, and many more clinically. It 
 is a disease essentially of women, only three cases having been observed in men. 
 The etiology is obscure. It is caused by violence, such as blows, excessive body- 
 weight, the patients being commonly obese, and by the faults of development or 
 ossification in the articular portions of the spinal column. The bones are often 
 found to be healthy. Clinical characteristics: In most of the cases the anterior 
 half of the fifth lumbar vertebra is pushed forward at the same time that the 
 posterior part persists in its normal position at the lumbo-sacral joint (Figs. 
 ^55' 856, 857, 858). Now and then a case presents in which the whole ver- 
 tebra is pushed forward. There are some cases in which an increased length 
 of the vertebra is caused by a separation of the two extremities of the spon- 
 dylolytic interarticular part and the space is filled in with fibrous tissue. The 
 lordosis is marked (Fig. 857). The diminished pelvic inclination causes an 
 undue strain on the ilio-femoral ligaments. In this way the ischial tuberosi- 
 ties are brought closer together than normal, while the crests of the ilia flare. 
 Naturally the posterior superior spines of these bones flare also. The ribs 
 and the brim of the pelvis become approximated and the height of the 
 patient is decreased. The transverse diameter of the outlet is diminished 
 while that of the inlet is increased. On internal examination the conju- 
 gate diameter of the inlet may be observed to be shortened. Diagnosis: 
 This is seldom difficult. The patient has a deformity causing the distance 
 from the costal margin to the pelvic inlet to be diminished. There is marked 
 lordosis in the lumbar region. The spine of the last lumbar vertebra is more 
 easily felt than normally. The transverse diameter of the pelvis is increased 
 owing to the flaring of the iliac bones. There is a contraction of the pelvic 
 
MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 641 
 
 Fig. 855. — Spondylolisthesis. Poste- 
 rior View. — {Budin.) 
 
 Fig. 856. — Spondylolisthesis. Anterior 
 View. — {Budin.) 
 
 Fig. 857. — Sagittal Section of A' Spon- 
 dylolisthesic Pelvis. — {Neugebauer.) 
 41 
 
 Fig. 858. — Sagittal Section of a Spon- 
 DYLOLiSTHESic Pelvis. — (Netigebouer.) 
 
642 
 
 PATHOLOGICAL LABOR. 
 
 outlet. The contraction of the true conjugate is due not to the sacrum but 
 to the lumbar vertebrae. The external conjugate is markedly diminished. The 
 patient is rather short, having lost in stature. Neugebauer, in 1895, published 
 
 Fig. 859. — Lumbar Vertebra of Nor- 
 mal Shape. 
 
 Fig. 
 
 860. — Lumbar Vertebra Elongated 
 BY Spondylolisthesis. 
 
 an article on "Ichnograms" or pictures of foot -tracks. In spondylolisthesis 
 the steps are very short, and the legs, being converged, are put forward one in 
 
 front of the other. The patient's 
 appearance and history are very 
 important. There may be the 
 history of a fall or other acci- 
 dent, or the bearing of heavy 
 weights. The buttocks, taken 
 together, are curiously heart- 
 shaped, being flattened and end- 
 ing below in a point. The abdo- 
 men is pendulous and deeply 
 creased above the symphysis. 
 Looked at from behind, the pa- 
 tient presents a saddle-shaped 
 back. Her gait is peculiar; she 
 may feel top-heavy. There is 
 sometimes crepitus in lumbar 
 region (Fig. 855). Prognosis: 
 The extent of the obstruction to 
 labor depends upon the degree 
 to which the pelvic cavity is en- 
 croached upon by the lumbar 
 vertebras. The effect of this pel- 
 vis on labor is similar to that of 
 the fiat pelvis. Lacerations, 
 fistulae, and tears are frequent. 
 As the presenting part descends 
 it strikes the middle part of the 
 pelvic floor instead of sliding for- 
 ward to the orifice of the vulva. 
 Treatment: A large proportion 
 of the women die in labor. If 
 the deformity is diagnosed and 
 the distance from the nearest 
 lumbar vertebra to the symphysis — the false or effective conjugate — is 2>\ inches 
 (7.93 cm.), the forceps can deliver the child. If less, a suprapubic operation must 
 be done. 
 
 Fig. 861 AND Fig. 862. — Dorso-lumbar Kyphosis. 
 — (Tarmer.) 
 
MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 
 
 643 
 
 Spondylolizema. — The condition known as spondylolizema is analogous to 
 the one just described, although it is not congenital but results from caries of 
 
 the last lumbar veri;ebra. The name pelvis obtecta is 
 applied to this deformity as well as to the extreme 
 rachitic pelvis. 
 
 II. Kyphosis,* Kyphotic Pelvis (Figs. 863 to 866). 
 — Breisky gave the first complete description of this 
 pelvis in 1865, although the condition had been pre- 
 viously recognized by Litzmann and Neugebauer. 
 Frequency and etiology: Although this form of pelvis is 
 comparatively rare, still an accurate observer in the 
 course of his practice will undoubtedly meet with ex- 
 amples. The deformity results from kyphosis or from 
 
 "%P 
 
 Fig. 863. — Sacro-lumbar Fig. 864. — Kyphotic Pelvis showing the Iliac Foss^ and 
 Kyphosis. Pelvic Inlet. 
 
 Fig. 865, — Diagram of the Pel- 
 vic Inlet op Fig. 864. 
 
 Fig. 866.- 
 
 -Kyphotic Pelvis showing the Pelvic 
 Outlet. 
 
 Pott's disease, which affects the spine at such a low point that the usual lordosis 
 which is present as a compensatory factor cannot overcome the faulty direction 
 
 * Kyphosis. Hump-backed. Angular curvature and dorsal prominence of the spine. 
 Backward curvature of the spinal column. 
 
644 
 
 PATHOLOGICAL LABOR. 
 
 Fig. 
 
 867. — Pregnancy with a Kyphotic Pelvis. 
 Hanging Belly. — (Tarnier.) 
 
 Fig. 868. — Oval Oblique Kyphotic Pelvis. 
 {Guichard.) 
 
 of the force of the body- 
 weight. Clinical characteris- 
 tics: Naturally the extent of 
 the deformity will depend on 
 the position of the spinal 
 protuberance (Figs. 862, 863, 
 867). The lower this is, the 
 worse will be the resulting de- 
 formity. The most common 
 position for the kyphosis is at 
 the junction of the dorsal and 
 lumbar vertebrae. As the re- 
 sult of the insufficient com- 
 pensation of the lordosis of 
 the lumbar spine, the rotation 
 of the sacrum on its trans- 
 verse axis is downward and 
 backward, just opposite to 
 that seen in rachitis. The 
 body is bent forward, and the 
 pelvic inclination diminished 
 (Fig. 867). The sacrum is 
 higher, straighter, longer; its 
 lateral concavity is increased 
 so that its width is lessened 
 (Fig. 870). The conjugate of 
 the inlet is increased. The an- 
 terior spines of the iliac bones 
 are pushed further apart, 
 while the posterior spines are 
 more closely approximated, 
 this latter effect being the re- 
 sult partly of the pull exerted 
 by the sacro-iliac ligaments 
 and partly of the narrowness 
 of the sacrum. The width 
 of the pelvis is decreased 
 through its whole depth, most 
 markedly so at the outlet on 
 account of the approximation 
 of the spines of the ischia. 
 The coccyx and the end of the 
 sacrum are pushed forward, 
 thus decreasing the pelvic 
 outlet. The narrower this 
 outlet becomes, the wider the 
 inlet, for the outward force 
 exerted on the iliac crests is 
 increased, this effect being 
 heightened by the extra 
 strain on the ilio-f emoral liga- 
 ments which pull the anterior 
 inferior spines downward and 
 
MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 
 
 645 
 
 Fig. 869. — Escape of the 
 Head under the Pubic 
 Arch in a Kyphotic 
 Pelvis. — -{Tarnier.) 
 
 outward. In order that the body may not fall forward, there occurs a slight 
 flexion of the knees and thighs, while there is scarcely any pelvic inclination (Fig. 
 862). When the deformity is lumbo-sacral there may 
 be involvement of the superior part of the sacrum in 
 the pathological process and its tissues ma^ be de- 
 stroyed (Fig. 863). The promontory of the sacrum is 
 palpated with difficulty per vaginam. Diagnosis: The 
 history of the case is generally plain, and the deformity 
 very evident. As in all cases of pelvic deformity, the 
 measurements are most valuable. They show that the 
 anterior spines and crests of the ilia are more widely 
 separated, while the posterior spines as well as the 
 ischial tuberosities are approximated. The conjugate 
 of the outlet is to some extent decreased. Complica- 
 tions such as asymmetry, general contraction from 
 arrested development, and lateral contraction at the 
 inlet should always be guarded against, as they often 
 make spontaneous labor impossible. Prognosis: Winckel states that in a series 
 of twenty-one cases of this kind the maternal mortality was 66 per cent., while 
 
 that of the children was 7 5 
 per cent. Labor is much 
 obstructed by the promi- 
 nence of the lumbar spine 
 in all cases except in those 
 with the least marked lum- 
 bo-sacral kyphosis. The 
 untoward effects are not 
 generally pronounced until 
 the presenting part has 
 reached the pelvic floor 
 (Fig. 869), The tendency 
 to shoulder presentation on 
 account of the decreased 
 perpendicular diameter of 
 the abdominal acvity is 
 generally corrected by the 
 first few labor pains. The 
 labor may be more precipi- 
 tate than normal, but when 
 the presenting part reaches 
 the outlet the obstruction 
 may be so great that there 
 can be no spontaneous ad- 
 vance, though now and 
 then labor is terminated 
 spontaneously on account 
 of the great mobilit}'- of the 
 pelvic joints. Occipito- 
 posterior positions are 
 quite common in these pel- 
 ves, since on account of the posterior deformity of the sacrum more room is 
 offered for the fetal back. Treatment: As a rule, labor is not difficult to manage. 
 
 Fig. 870. — Diagram showing the Forces Concerned 
 IN the Production of a Kyphotic Pelvis. — {Tarnier.) 
 
646 
 
 PATHOLOGICAL LABOR. 
 
 The forceps may afford sufficient aid for delivery; should the case be of a grave 
 order, symphyseotomy will nearly always suffice. If, however, there is present an 
 
 ^' 
 
 Fig, 871. — Scoliosis. Poste- 
 rior View. 
 
 Fig. 872. — Scoliotic Pelvis, with Encroachment 
 OF the Left Cotyloid Region upon the Pelvic 
 Cavity. 
 
 Fig. 873. — Scoliotic Pelvis. Posterior View. Fig. 874. — Diagram of the Pelvic 
 
 Inlet of Fig. 872. 
 
 asymmetrical or extreme contraction, it may be necessary to resort to Caesarean 
 section. In case of a dead fetus, craniotomy may easily be performed, since the 
 head on the pelvic floor is quite accessible. 
 
MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 
 
 647 
 
 III. Scoliosis/'^ Scoliotic Pelvis (Figs. 871-874). — This term includes all the 
 lateral deformities of the spinal column having a pathological origin. Frequency 
 and etiology: This is a rare form of pelvic deformity. The most frequent cause 
 is rachitis, consequently the pelvis may be contracted as well as asymmetrical. 
 The origin, however, may be non-rachitic. The deformity, as a rule, begins dur- 
 ing the development of the pelvis, the result depending on whether this is before 
 or after ossification of the pelvic bones. Clinical characteristics : The deformity 
 of the pelvis is marked and the degree of scoliosis is quite perceptible. The two 
 sacrocotyloid diameters are not of equal length, while the internal conjugate does 
 not come up to the nor- 
 mal. Deformities of the 
 pelvis are not so marked 
 as they would be, if every 
 convexity did not usually 
 have its compensatory 
 concavity. In the pelvis 
 with this deformity there 
 is a certain amount of 
 oblique contraction. The 
 lumbar vertebrae are the 
 ones generally affected. 
 The superior articulating 
 sacral surface, on the side 
 toward which the bending 
 of the spine takes place, 
 receives the greatest 
 weight. The center of 
 gravity is displaced. The 
 head of the femur exerts 
 a greater pressure up- 
 ward, inward, and back- 
 ward against the innom- 
 inate bone of the de- 
 formed side. There is 
 also an anterior upward 
 displacement of the 
 acetabulum on this side, 
 while the symphysis is 
 forced to the opposite 
 side. The pelvis on the 
 deformed side is dimin- 
 ished in size (Figs. 872, 
 
 873, 874). In case of the limitation of the scoliosis to the dorsal vertebrae, a 
 compensatory bending of the lumbar vertebrae may hinder any change in the 
 form of the pelvis from taking place. Diagnosis: The deformity may be detected 
 by observation and pelvimetry. Prognosis: The asymmetry is seldom so marked 
 as to cause serious obstruction to labor, the mechanism corresponding with that 
 in the generally contracted pelvis. If delivery is possible, the forceps is indicated 
 after the head has become well moulded. 
 
 IV. Kyphoscoliosis. t Kyphoscoliotic Pelvis (Fig. 878). — This deformity 
 
 * Scoliosis: Lateral curvature of the spinal column. 
 
 ^Kyphoscoliosis: Backward and lateral curvature of the spinal column. 
 
 Fig. 875. — ScoLio-RACHiTic Pelvis, with Reniform 
 Inlet. Encroachment of the right cotyloid region 
 upon the pelvic cavity. 
 
 Fig. 876. — Diagram of the Pelvic Inlet of Fig. 875. 
 
648 
 
 PATHOLOGICAL LABOR. 
 
 includes a combination of the malformations of kyphosis and scoliosis. It is 
 an obliquely contracted pelvis of lesser degree, being mostly deformed in the 
 transverse diameters. Frequency and etiology: The etiology is naturally that 
 of the two types which make this combination. Clinical characteristics: The 
 most common example of this type is the lumbo-dorsal kyphoscoliosis. The 
 kyphotic deformity is primary in point of 
 time, and, combined with the scoliosis, a 
 combination of both sets of deformities re- 
 
 Sc.prdr 
 
 Sc.o. 
 
 Fig. 877. — ScoLio-RACHiTic Skeleton. Sc.pr.dr., 
 Primary dorsal scoliosis; Sc.o.l.g., compensatory 
 lumbar scoliosis. — (Clamart.) 
 
 Fig. 
 
 878. — Kyphoscoliotic Skele- 
 ton. — (Leopold.) 
 
 suits with a trace of the original funnel-shape. The pelvis is decidedly asym- 
 metrical, though its lateral contraction is not so great as in a pure kyphosis. As 
 the kyphosis is etiologically rachitic and not carious, it will not be angular, but 
 it will be superior dorsal in position and will run the chance of being compensated 
 for by lordosis of the lumbar region. The joints are all rachitic. The symphysis 
 is inclined to the side opposite the direction of the lumbar curve. The spinal 
 
MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 
 
 649 
 
 bones present the combined deformities of rachitis and kyphosis. Vaginal exam- 
 ination yields the same results as in kyphosis. The true conjugate is increased 
 and the pelvis is transversely flattened and represents a lesser degree of obliquely 
 contracted pelvis. Diagnosis : This will be made from observation of the deformity 
 and from pelvic measurements. Prognosis: This will depend 
 upon the degree of deformity. 
 
 V. Assimilation Pelvis. — This pelvis resembles the ky- 
 photic type and is slightly funnel-shaped. The deformity 
 depends upon the symmetrical blending of the five vertebrae 
 of the coccyx with the lower sacral vertebra or of the upper 
 sacral vertebra with the lower lumbar vertebra (Fig. 879). 
 Single-sided asymmetry may depend upon scoliosis of the 
 vertebras of the coccyx. The deformity then resembles 
 scoliosis and is more pronounced in the presence of rachitis. 
 When the deformity is symmetrical, the promontory is high, 
 the angle being but slightly developed, and the pelvic curve 
 diminished by the slight forward bending of the trunk. 
 
 VI. Lordosis Pelvis.* — Neugebauer refers to some cases 
 of primary lordosis independent of spinal disease or pelvic 
 deformity, and in this country the only case described is that 
 of Hirst (Fig. 880). It can readily be seen how a marked 
 anterior spinal curvature would greatly increase the pelvic 
 inclination, and thus interfere with the engagement of the 
 presenting part. 
 
 Fig. 879. — Assimilation of the First Coccygeal Vertebra with 
 THE Sacrum, i, Blending of the horns of the coccyx and sa- 
 crum; 2, blending of the bodies of the fifth sacral and first 
 coccygeal; 3, movable intercoccygeal articulation; 4, assimilation 
 of first coccygeal vertebra; 5, coccyx. 
 
 Fig. 880. — Lordo- 
 sis FROM Pa- 
 ralysis OF the 
 Spinal Muscles. 
 —{Hirst.) 
 
 E. ANOMALIES OF THE PELVIS DUE TO DISEASE OF THE WEIGHT-BEARING 
 
 PARTS OF THE SKELETON. 
 
 I. Coxitis. Coxalgic Pelvis (Fig. 883). — This deformity may be described as 
 an oblique pelvis dependent upon hip disease. The coxalgic pelvis is subject 
 to several modifications which depend upon the time at which the affection 
 originates and the mobility of the diseased part as well as upon the presence of 
 dislocation. The earlier this trouble begins and the more the leg is used, the 
 greater will be the deformity. If the disease does not appear till after the pelvis 
 * Lordosis: Anterior curvature of the spinal column. 
 
650 
 
 PATHOLOGICAL LABOR. 
 
 is developed, there may be an absence of obliquity. Frequency and etiology: The 
 deformity is not infrequent. Other causes besides hip-disease are infantile par- 
 alysis, dislocation of the hip-joint, and amputation of a lower extremity. Clini- 
 cal characteristics: There are two types of this pelvis, although there is obliquity 
 in each case: (i) In the first type the innominate bone on the unaffected side is 
 pushed upward, inward, and backward, since the sound leg carries the main body- 
 weight (Fig. 88i). Thus the sound side is contracted while the diseased side, 
 lacking the normal developing forces, persists in its infantile form or the form it 
 had when the disease manifested itself. The location of the deformity is just 
 the reverse of that in the Naegele pelvis. (2) In the other type the deformity 
 is on the diseased side, the innominate bone of this side being forced in upon the 
 pelvis, the deformity depending upon the arrested development of this side (Fig. 
 882). There is probably a co-existent atrophy of the sacral ala with anchylosis 
 of the sacro-iliac joint. There will be observed, therefore, an asymmetrical pelvis ; 
 rotation of the pelvis upon the spinal 
 column; anchylosis of the hip and 
 decided shortening of the conjugate. 
 
 Fig. 881. — CoxALGic Pelvis showing De- 
 formity ON THE Healthy Side. 
 
 Fig. 882. — CoxALGic Pelvis showing De- 
 formity ON the Diseased Side. 
 
 Diagnosis: These patients are recognized by their limp. Pelvimetry as well as 
 palpation, both external and internal, will reveal the state of affairs in the pelvis. 
 Prognosis: The degree of deformity is seldom so great as to interfere seriously 
 with labor. In such a case the method of procedure would correspond with that 
 advised for the Naegele pelvis. In the first type there is seldom any serious 
 obstruction to labor unless rachitis is also a complication. It is in the second 
 type that difficulty is experienced, and it may be as great as in the Naegele 
 form. 
 
 II. Luxation of the Head of One Femur (Figs. 885, 886). — If this deformity 
 is congenital or if it take place in early years, the pelvis is somewhat affected, 
 but not, as a rule, to such an extent as to affect labor seriously. The resulting 
 shape of the pelvis will depend upon the direction in which the luxation takes 
 place. An oblique contraction may be produced by a one-sided dislocation. 
 
 III. Luxation of the Heads of Both Femora (Figs. 887,888, 889, 890). — The 
 general statements made in the last paragraph will also apply to this case. If 
 
MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR, 651 
 
 both thigh-bones are dislocated backward upon the ilia, the sacrum is rotated 
 
 forward to an extreme degree, 
 and the canal of the pelvis be- 
 comes shallow with a very wide 
 outlet. The line between the 
 lower border of the symphysis 
 and the inner femoral condyle 
 is diminished. 
 
 Fig. 883. — CoxALGic Pelvis with Adduction of 
 THE Diseased Femur (Left Side). 
 
 Fig. 884. — Enlargement of the 
 Cotyloid Region due to Cox- 
 algia. 
 
 IV. Unilateral or Bilateral Club-foot (Fig. 891). — These deformities produce 
 changes of little importance. The inclination of the 
 pelvis is increased, the arch of the pubis is narrowed, 
 the tuberosities of the ischia and the acetabula are 
 brought closer together. 
 
 V. Absence or Deformity of One or Both Lower 
 Extremities. — In the first case there results the "Sitz 
 pelvis," the characteristics of which have already been 
 noted (page 622). Generally there is rotation of the 
 
 
 Fig. 885. — Dislocation of Fig. 8S6. — Deformed Pelvis from Congenital Disloca- 
 THE Right Femur. tion of One Femur (Left Side). 
 
652 
 
 PATHOLOGICAL LABOR. 
 
 innominate bones on an anteroposterior axis, so that the iliac crests approach 
 each other, while the ischial tuberosities are separated. Any deformity occurring 
 in consequence of the bowing of the extremities is scarcely worth the mention 
 from a practical standpoint. 
 
 GENERAL SYMPTOMATOLOGY. 
 
 Subjective Symptoms. — In pregnancy: The effects of deformed pelves are 
 various. They may alter the position of the pregnant uterus ; e.g., in contraction 
 
 Fig. 887. — Congenital Dislocation of 
 Both Femurs. 
 
 Fig. 
 
 -Congenital Dislocation of 
 Both Femurs. 
 
 of the pelvic inlet in the early months, the uterus may become retroverted, and 
 even finally incarcerated in the pelvis. Later the uterus is higher than in normal 
 gestation, since the head of the fetus cannot descend into the pelvis. In the 
 later months of pregnancy the uterus is far more mobile than normal on account 
 of the narrowing of the pelvis. Its obliquity is also increased. The patient is 
 frequently unable to empty the bladder owing to the pressure to which it is 
 
MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 
 
 G53 
 
 subjected. Quickening is felt early, generally by the fourth month. Pendulous 
 abdomen is very common in contracted pelvis from the position of the long axis 
 of the uterus, which looks either forward or to the right, and is especially marked 
 in patients whose abdominal walls are flaccid. It is more frequently found in 
 
 multigravidae than in primigra- 
 vidae. If pendulous abdomen is 
 not a complication, the fundus 
 will be much higher in position 
 than normal. In labor: The pains 
 are very irregular and their nature 
 depends upon the abnormal fac- 
 
 FiG. 889. — Pelvis from a Case of Congenital 
 Dislocation of Both Femurs. 
 
 Fig. 
 
 890. — Diagram of the Pelvic 
 Inlet of Fig. 889. 
 
 tors producing them. They are sometimes violent, at other times spasmodic, and 
 again they are feeble. Labor is prolonged. When labor is beginning, the pre- 
 senting part is abnormally high and does not adapt itself well to the lower uterine 
 segment. The head is very slow in engaging, consequently in pregnancy lightening 
 does not occur, and these conditions 
 give rise to painful dyspnea. Some- 
 times the presenting part fails to 
 engage at all. The caput succeda- 
 neum is generally very large and its 
 gradual development is sometimes 
 thought to indicate progress of the 
 descending part. The presentation 
 and position of the fetus also often 
 suffer from contracted pelves, the 
 abnormal varieties being about three 
 times as common as normal. For 
 example, a vertex presentation may 
 be turned into a brow, face, or shoul- 
 der. In breech presentation there is 
 frequently a prolapse of foot or knee. 
 Prolapse of the cord is also frequent. 
 Multiparity, as in the normal pelvis, 
 
 only adds to the likelihood of faulty presentations, for the walls of both uterus 
 and abdomen became gradually more relaxed with each successive pregnancy. 
 If the uterus together with the cervix is either at or above the pelvic inlet, the 
 bag of waters is forced downward into the cervix as a conical body 
 
 Fig. 
 
 Deformed Pelvis from Double 
 Club-foot. 
 
 Not infre- 
 
Fig. S92. 
 
 Fig. S93. 
 
 Fig. 894. 
 
 Fig. 895. 
 
 Fig. 896. 
 
 Fig. 897. 
 
 Fig. 898. 
 
 Figs. 892 to 898. — Shape of the Pelvic Inlet in the More Common Types of 
 Pelvic Deformity, Compared with the Normal. 
 
 654 
 
MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 655 
 
 quently the membranes rupture early with escape of the liquor amnii. The lower 
 uterine segment may become so stretched and thin that it bursts, while the rup- 
 ture may involve the cervix and vagina or there may occur a forcible separation 
 
 Fig. 899.— Congenital Fig. 900.— Osteo- Fig. 901.— Rachitis. Rela- Fig. 902. — Oval Oblique 
 
 Dislocation OF Both malacia. tively Contracted. Pelvis. 
 
 Femurs. 
 
 Figs. 899 to 902. — The Author's Lead-tape Tracings of Various Types of Pelvic 
 Deformity, showing Sagittal Sections and Shapes of the Pubic Arches of Each. 
 
 of the uterus from the vagina. In any case the maternal soft parts are apt to be 
 bruised and lacerated; so much so, indeed, that sloughing will often follow. 
 
 Fig. 903.— Double Oblique Fig. 904.— Spontaneous Fig. 905.— Rachitis. Abso- Fig. 906. — Oval 
 Pelvis Dislocation of One lutely Contracted. Oblique kypho- 
 
 Femur. tic Pelvis. 
 
 Figs. 903 to 906. — The Author's Lead-tape Tracings of Various Types of Pelvic 
 Deformity, showing Sagittal Sections and Shapes of the Pubic Arches of Each. 
 
 (Edema is also a complication. The articulations are in certain cases separated 
 by the force exerted for the delivery of the child. 
 
 Objective Symptoms. — (See General Diagnosis, below.) (Figs. 892 to 906.) 
 
656 PATHOLOGICAL LABOR. 
 
 GENERAL DIAGNOSIS. 
 
 Previous History. — The previous history will often furnish essential infor- 
 mation concerning the present condition of the pelvis. If traces of rachitis, 
 for example, are seen in other parts of the body, there will be strong presumptive 
 evidence as to the presence of a rachitic pelvis. The history of previous labors 
 will offer a probable prognosis as to the termination of pregnancy. The char- 
 acteristic influences of the various diseases have been enumerated. 
 
 Inspection. — Account should be taken of the posture of the woman, of spinal 
 curvature, and of any lameness. 
 
 Palpation. — The position of the hips, the size of the iliac bones, the depths 
 of the iliac fossse, the width and curve of the sacrum, and the depth, thick- 
 ness, and inclination of the symphysis should be noted (Figs. 892 to 906). 
 
 Mensuration. Pelvimetry. — The physician should measure the pelvis as a 
 routine in the examination of pregnancy (see page 148) and in cases of suspected 
 maternal or fetal obstruction, for the same reason that he uses percussion 
 and auscultation in the diagnosis of cardiac and pulmonary disease. Al- 
 though the science of pelvimetry is most important, still the child's birth de- 
 pends partly on the size of its head, the degree of its adaptability, the char- 
 acter of the uterine contractions, and the resistance of the maternal perineum 
 and soft parts. It also happens that in two patients with the same size pelves one 
 can be delivered spontaneously while the other cannot. However, these facts 
 do not lessen the obstetrician's duty in respect to pelvimetry; they merely indi- 
 cate its limitations. (Compare clinical characteristics of various forms of pelvic 
 deformity, pages 619 to 653.) 
 
 Prognosis, — (See Individual Varieties and Treatment.) 
 
 PROPHYLACTIC TREATMENT. 
 
 Prophylaxis may be instituted at various stages in the history of the mother. 
 
 In case of the grosser pelvic deformities, seen before marriage, in which birth 
 by the natural passages would be impossible, one would be justified in advising 
 celibacy. 
 
 If a woman with a pelvis which will not permit the birth of a viable child is 
 already married, or if the pelvis of a newly married woman is contracted to a 
 questionable degree and the husband is of another race, or much larger than his 
 wife, or has head measurements unlike hers, it may be advisable to avoid concep- 
 tion. In any case the choice must lie between foregoing offspring altogether and 
 conception with some expedient for avoiding labor at full term. If the woman 
 conceives deliberately, much care should be used in determining as accurately as 
 possible the date of the fecundating coitus. The subject of avoidance of concep- 
 tion has been considered on page 37. kr. Is- ^-m--\ 
 
 In cases of absolute contraction seen after conception has occurred, much 
 would depend upon the month of gestation at which the advice of the physician 
 is sought. If the pregnancy is recent and the pelvis such that natural delivery 
 would be impossible, the alternative is between artificial abortion and Caesarean 
 section at term. In this situation the burden of choice should be placed on the 
 woman and her relatives. If Caesarean section is absolutely refused, pregnancy 
 may be interrupted — the sooner the better. In anything short of absolute pelvic 
 contraction, artificial abortion would not be justifiable. If the pregnancy were 
 far advanced in absolute pelvic stenosis, little or nothing would be gained by 
 the induction of premature labor in comparison with Caesarean section. In 
 instances of relative contraction, the patient, whatever the stage of pregnancy, 
 
MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 657 
 
 may look forward to a twofold alternative: (i) Artificial premature delivery; 
 (2) delivery at full term with dependence upon Prochownik's diet to keep down 
 the size of the fetal head, (i) Artificial premature labor: This is a preventive of 
 dystocia, the only objection being the danger of fetal death from immaturity. 
 As to the mother, the danger is undoubtedly greater in dystocic delivery than in 
 induced labor. (2) Diet: The principle of regulating the diet of the pregnant 
 woman for the purpose of preventing overgrowth or retarding full development 
 on the part of the fetus, and thereby favoring eutocia, has been carried out in a 
 limited way for a number of generations; yet this topic is hardly mentioned in 
 the great majority of text-books. 
 
 Prochownik's attention was called to the subject by the mortality among 
 children bom before term, especially in connection with induced labor for 
 contracted pelvis; and by his special experience in dieting pregnant women 
 who were obese, anemic, etc., with the sole aim of improving the mother. In 
 this connection he found that the nutrition of the fetus was modified in a twofold 
 manner: first the embryo was enough of a true parasite to obtain nutriment to 
 fulfil all the practical ends of healthy metabolism, growth, and vitality; second, 
 the restriction in the mother's diet could manifest itself in the child in such par- 
 ticulars as a lessened accumulation of adipose tissue, and a slower rate of precipita- 
 tion of the earthy matter required for ossification. Observations of this char- 
 acter have been reduced to a common truth in biology and the application of the 
 diet to women with contracted pelves as a substitute procedure for artificially 
 induced premature labor was a consistent and logical advance in the management 
 of obstructive maternal dystocia. One of the- first problems in imposing this 
 diet upon the pregnant woman is to cut down the amount of fluids without the 
 collateral provocation of constant thirst. To this end fats and carbohydrates 
 are eliminated as far as possible and such articles are allowed as contain a large 
 quantity of water, especially green vegetables. The diet * as originally published 
 appears to have stood the test of experience without the necessity of subsequent 
 modification. It is as follows : 
 
 Breakfast. — A small cup of black coffee, 3.38 oz. (100 c.c); zwieback, or 
 bread with a little butter, 4 or 5 oz. (25 grams). 
 
 Luncheon. — Any kind of meat or fish, eggs, green vegetables, salad, cheese. 
 
 Dinner. — Same as luncheon, with the addition of bread and butter i to ij 
 oz. (40 to 50 grams). 
 
 Absolutely Forbidden. — Water, soup, potatoes, farinaceous food, sugar, beer. 
 Fluids allowed: 10 to 14 oz. (300 to 400 c.c.) red or Moselle wine or water per diem. 
 
 Prochownik has now employed this diet for the past twelve years, the total 
 number of births aggregating 26, while other obstetricians, especially in the 
 Netherlands, have brought the total up to 62. 
 
 An analysis of the material which is tabulated by Prochownik in the " Therapeutische 
 Monatschrift," August and September, 1901, appears to establish the truth of the following: 
 (i) All the mothers bore the diet well after slight initial hardships, principally thirst (espe- 
 cially in the corpulent) , and repugnance to so much animal food. Both these difficulties 
 were mitigated by increasing the allowance of green vegetables. The weight of the woman, 
 allowance being made for the growth of the embryo and uterus, remained practically at a 
 standstill. (2) All the confinements were relatively easy in comparison with previous labors, 
 even in those exceptional cases in which despite the diet the fetus was large and fat at 
 birth. (3) All the children were bom alive, although the mothers, as a class, had expe- 
 rienced still-births. The few cases of asphyxia neonatorum were easily reanimated. As 
 far as known, all the children survived the accidents which produce secondary mortahty. 
 (4) The great majority of the children were lean at birth, there being a notable subdevelop- 
 ment of the panniculus adiposus. The skin of the head was noticeably lax and the cranial 
 bones exhibited a notable degree of mobility upon one another. (5) The children exhibited 
 
 * "Centralbl. f. Gynak.," 1SS9, No. 2>i- 
 42 
 
658 PATHOLOGICAL LABOR. 
 
 the essential insignia of maturity (normal length, head measurements, etc.). (6) The nor- 
 mal gain in weight took place in the majority of the children. (7) The diet of the mother 
 exerted no unfavorable influence upon lactation. 
 
 Naturally, as soon as delivery occurs the special diet is discontinued and 
 the substitute regimen is rich in non-nitrogenous articles. In all attempts 
 at imposing an antidystocic diet upon a pregnant woman the regimen is not to 
 be begun until the latter months of pregnancy. The Prochownik regimen is 
 intended for the last six weeks of gestation only. It is believed that no extra 
 advantage would accrue from lengthening the dietetic period. The large propor- 
 tion of nitrogenous food and the small quantities of fluid of Prochownik's diet 
 undoubtedly favor the toxemia of pregnancy. I was confronted with this difh- 
 culty in a relative generally contracted pelvis, and in spite of the free exhibition 
 of calomel and colon irrigation was compelled to abandon the diet, and to induce 
 labor at the thirty-eighth week. 
 
 CURATIVE TREATMENT. 
 
 The problem of the proper management of labor in contracted pelves is one 
 of the most difficult in midwifery. The subject itself is a vast one, for it con 
 cerns not only those cases in which the pelvis has been measured and the pelvic 
 anomaly diagnosticated, but that greater contingent in which no exact pelvic 
 diagnosis is made and which simply represents obstructive dystocia from some 
 cephalo-pelvic disproportion which is generally of maternal origin. Broadly 
 speaking, these labors can be managed in three ways: (i) Pregnancy may be 
 interrupted before the fetus has attained a certain size (Part X). (2) Labor 
 at term may be managed along normal lines; i. e., may be left to nature until 
 some complication arises which threatens the lives of mother and fetus. (3) 
 Some form of active intervention, undertaken for the purpose of protecting the 
 mother and child from the risks of dystocia, may be practised at or before the 
 onset of labor — or forceps, symphyseotomy, embryotomy, or Cassarean section. 
 
 It is a singular fact that precedent and local prejudice play highly important 
 roles in the choice of methods. Thus, in one obstetrical center perforation of 
 the fetal cranium appears to be the commonest termination of these labors; in a 
 second, the ideal is symphyseotomy; in a third, expectancy predominates; in a 
 fourth, induction of premature labor. Those obstetricians who follow the national 
 or local custom in the management of these cases naturally offer reasons for their 
 conduct which appear sufficient for its justification. In many localities adherence 
 to routine and precedent is responsible for unnecessary mortality and morbidity, 
 either fetal or instrumental. 
 
 Some authorities who are not under the influence of custom are actuated 
 largely by theoretical considerations in the management of these labors. Their 
 theories may be the outgrowth of personal experience. Thus, an obstetrician who 
 has seen spontaneous labor occur repeatedly in moderately contracted pelves 
 without undue prolongation of the act of parturition comes to believe that such 
 pelves up to a certain limit are not pathological at all. He therefore adopts a let- 
 alone policy in the management of these cases. Another practitioner may have 
 seen some accident — a rupture of the uterus, perhaps — occur in a pelvis with but 
 a slight degree of narrowing. Thenceforth pelvic contraction is always something 
 to be feared, and he forms a rule of terminating such pregnancies by the induction 
 of premature labor or Csesarean section. 
 
 Many obstetricians try to formulate indications for treatment based upon the 
 length of the trite conjugate as a clinical index of pelvic contraction and the par- 
 ticular species of pelvic deformity. But even if a uniform scale were agreed upon, 
 
MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 
 
 659 
 
 this method of fixing indications is trustworthy only to a certain extent; viz., in 
 determining absolute pelvic contraction, or the degree which is prohibitive of 
 delivery by natural passage at term. This * is represented in a flat pelvis by a 
 true conjugate of less than 2.76 inches (7 cm.), and in a generally contracted pelvis 
 by a true conjugate of less than 2. 95 inches (7. 5 cm.). Other obstetricians make the 
 degree of absolute contraction slightly lower or higher, but the statistics of Kronig t 
 show conclusively that a goodly proportion of labors may be spontaneous through- 
 out, in any degree of pelvic narrowing which is outside the limit of absolute pelvic 
 contraction. The same statistics show that interference may sometimes be indicated 
 in the very mild degree of contraction. There is no criterion by which the obstet- 
 rican may foretell the outcome of a case. In something like 6 per cent, of cases of 
 labor in contracted pelves, irrespective of the pelvic measurements, labor could 
 not be completed without resort to Csesarean section, symphyseotomy, or embryo- 
 tomy. It is fair to assume that in this minority of cases there was either absence 
 of proper pains or defective head moulding, and that these elements rather than 
 a particular degree of pelvic contraction were chiefly responsible for the dystocia. 
 In other words, given sufficient plasticity of the head and strong uterine contrac- 
 tions, relative contraction of the pelvis does not necessarily mean dystocia. In 
 other words, the difference in the length of the true conjugate, up to a certain 
 point, does not furnish a basis for special indications. Other factors are present in 
 sufficient force to invalidate any system of procedure based upon several degrees 
 of pelvic narrowing. A division into two degrees is well and good, for the indi- 
 cations in absolute and relative contraction differ widely; and although the sub- 
 division of the relative contractions in two classes is not always satisfactory, 
 it is most convenient and the best method we have for purposes of classification 
 and clinical study. 
 
 CLASSIFICATION OF PELVIC CONTRACTION. 
 
 Absolute Pelvic 
 Contraction. 
 
 Relative Pelvic 
 Contraction. 
 
 Simple flat pelvis with a true conjugate of less than 2.76 inches 
 
 (7 cm.) 
 Generally contracted pelvis with a true conjugate less than 2.95 
 
 inches (7.5 cm.) 
 
 (Class One. — First Degree Coniraciion 
 — Simple flat pelvis with a true 
 conjugate from 3.74 inches (9.5 
 cm.) to 3.35 inches (8.5 cm.) 
 Generally contracted pelvis with a 
 true conjugate from 4 inches (10 
 cm.) to 3.60 inches (9 cm.) 
 Class Two. — Second Degree Contrac- 
 tion. — Simple flat pelvis with a true 
 conjugate of from 3.35 inches (8.5 
 cm.) to 2.75 inches (7 cm.) 
 Generally contracted pelvis with a 
 true conjugate of from 3.50 inches 
 (8.9 cm.) to 2.95 inches (7.5 cm.) 
 
 i Simple flat pelvis with a 
 true conjugate of 2.76 
 inches (7 cm.) or more. 
 ' Generally contracted pelvis 
 with a true conjugate of 
 2.95 inches (7.5 cm.) or 
 more. 
 
 I. ABSOLUTE PELVIC CONTRACTION. 
 
 An absolutely contracted pelvis is represented in a simple flat pelvis by a 
 true conjugate of less than 2 76 inches (7cm.), and in a generally contracted' 
 pelvis by a true conjugate of less than 2.95 inches (7.5 cm.). If a woman with 
 absolute pelvic contraction becomes pregnant, and is seen in season, she should 
 be allowed to choose between therapeutic abortion and Cassarean section at 
 
 * Kronig: " Die Therapie beim engen Becken," Leipzig, 1901. t Loc. cit. 
 
660 PATHOLOGICAL LABOR. 
 
 term. If she be seen before the end of the seventh month it may be possible 
 to induce labor and perform craniotomy. 
 
 In this situation, the burden of choice should be placed on the patient and 
 her family; of other alternatives, it is not worth while to speak. 
 
 My experience with symphyseotomy would cause me to emphatically reject 
 the claim of the Italian school that this operation has a place either in induced 
 premature labor at or after the seventh month, or at the fortieth week in ab- 
 solutely contracted pelves. 
 
 Again perforation and embryotomy are possible at term in the above cases, 
 but I am satisfied that the mortality is greater than in Caesarean section. 
 
 Some English authorities and J. W. Williams advise that if the true con- 
 jugate be above two inches (5 cm.) (absolute indication for Caesarean section 
 of some authorities), craniotomy should be the operation of choice when the 
 fetus is dead or dying. 
 
 From this I strongly dissent, as my experience with craniotomy in these low 
 grades of pelvic deformity has taught me that they carry with them a high 
 degree of mortality to the mother. Moreover, unsuccessful attempts at cranio - 
 clast extraction and at embryotomy in pelves whose clinical index is between 
 2 and 2^ inches, will greatly militate against the chances of the patient's recov- 
 ery from a Csesarean section that is subsequently necessary to deliver her. 
 
 2. RELATIVELY CONTRACTED PELVES. 
 
 A relatively contracted pelvis is represented in a simple flat pelvis by a 
 true conjugate of 2.76 inches (7 cm.) or more and in a generally contracted 
 pelvis by a true conjugate of 2,95 inches (7.5 cm.) or more. 
 
 Relative contraction of the pelvis does not necessarily cause dystocia. Thus, 
 statistics show that a great majority of labors in all degrees of relatively 
 contracted pelves may be termed physiological.* 
 
 * The Kronig statistics of the latter (loc. cit.) show that of 504 cases of labor in flattened 
 pelves with a true conjugate between 3.74 and 2.76 inches (9.5 and 7 cm.) , intervention for the 
 pelvic complication alone was required in less than 9 per cent. (Below 2.76 inches — 7 cm. — 
 the percentage of intervention for the pelvic element was, of course, 100 per cent.) In the 
 so-called second degree of contraction, 3.35 and 2.76 inches (8.5 and 7 cm.), the percentage 
 of intervention for primipars was but 16, although much higher for multiparas. For the 
 so-called first degree of contraction, 3.74 and 3.35 inches (9.5 and 8.5 cm.), the percentage 
 of intervention was but 2.7 per cent. In 222 cases of generally contracted pelvis with a 
 true conjugate of from 3.94 to 2.95 inches (10 to 7.5 cm.) intervention for the pelvic element 
 alone amounted to but 9 per cent. Below the measxirement of 2.95 inches (7.5 cm.) (abso- 
 lute contraction) the percentage of intervention was, of course, 100. In the second degree 
 of contraction alone the percentage of intervention was 16 per cent., and in the first degree, 
 zero In other words, in 91 per cent, of these relatively contracted pelves labor was of the 
 normal type. In the great majority of cases no intervention whatever was required. In a 
 small minority — 14 per cent. — complications arose which menaced the life of the mother or 
 child and necessitated the use of the forceps. These complications, however, had no connec- 
 tion with the pelvic deformity, at least so far as the mother was concerned, but arose from 
 such conditions as fever, eclampsia, placenta praevia, etc. Indications to terminate labor 
 proceeding from the state of the fetus may or may not have been due to the pelvic contrac- 
 tion. Doubtless there was a greater proportion of prolapse of the funis and intrauterine 
 asphyxia than in labor in normal pelves, but the average duration of labor in these cases was 
 less than fifteen hours, which is within normal limits. In the absence of good control 
 material it is difficult to prove that the size of the pelvis is responsible for the fetal indica- 
 tions for forceps in KJronig's cases. The children were, as a rule, of large size in these forceps 
 cases. Of the 64 cases in which it became advisable to interfere, 25 children were saved 
 and 39 lost, the latter number including cases of fetal death in utero. The combined fetal 
 mortality of the labors of "normal type" was 44, or about 10 per cent. This figure, how- 
 ever, is believed to represent the normal fetal death-rate including primary and secondary 
 
MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 661 
 
 In order to appreciate the fact that every case of labor in a pelvis relatively 
 contracted is a law unto itself, and must be managed accordingly, one must 
 study the phenomena and results of labors in which there has been no inter- 
 ference, namely, in which expectancy has been the main treatment. This has 
 been done in recent years at the obstetrical clinics of Paris, Vienna, and 
 especially Leipzig, where the work of Zweifel and Kronig is of great practical 
 value. 
 
 They also demonstrate that even in the first degree of relative contraction 
 spontaneous labor may beimpossible. The outcome of a particular case isdifficult 
 to foretell. This is because of the difficulty of proving with accuracy the com- 
 parative size of the fetal head, and of predicting whether sufficient plasticity of 
 the head and strong uterine contractions will be present in a given case. Both 
 pelvimetry and cephalometry have, however, in the past few years made great 
 strides toward accuracy, and we can to-day draw very definite conclusions by 
 our different methods of examination concerning the relative size of a given 
 pelvis and fetal head. (See Pelvimetry and Cephalometry, pages 162 to 180.) 
 
 Class One. First-degree Contraction. — Simple flat pelvis with a true conjugate 
 of from 3.74 inches (9.5 cm.) to 3.35 inches (8.5 cm.). 
 
 Generally contracted pelves with a true conjugate of from 4 inches (10 cm.) to 
 3.60 inches (9 cm.). 
 
 Spontaneous labor is the rule in this class. 
 
 Kronig* in several hundred flattened pelves of this class found that the percent- 
 age of intervention was but 2.7 per cent. 
 
 Should there be an absence of proper uterine contractions or should defective 
 head moulding or a large head be present, dystocia may ensue and failure of 
 the head to engage in the pelvic inlet occur. 
 
 In Pregnancy. — If a case of first -degree contraction is seen in pregnancy 
 before term, a careful estimate of the available space at the pelvic inlet should 
 be made. For this purpose, I prefer internal manual pelvimetry and the use 
 of the Farabeuf pelvimeter. 
 
 The fetal biparietal diameter at this time is also estimated by Ferret's and 
 Muller's methods. 
 
 Unless some special contraindication exists, the case may be allowed to go 
 to full term. Prochownik's diet in the last six weeks will favor eutocia. 
 
 From week to week the relation between the size of the head and the inlet 
 should be determined by Ferret's method of cephalometry. If the head 
 deeply engages in pregnancy, of course, all anxiety ceases. 
 
 The borderland cases of this class, with short conjugate, will render it dif- 
 ficult to predict the outcome of labor at term. Should cephalometr}^ determine 
 a disproportion between the biparietal and true conjugate diameters, then the 
 indication of premature labor, according to the rules laid down for that opera- 
 tion in contracted pelves, should be considered. 
 
 In Labor. — Since spontaneous labor is the rule in these pelves of the first- 
 degree contraction, labor should be allowed to proceed undisturbed as long as 
 possible, and interfered with only for a positive indication. 
 
 Moulding engagement and descent usually occur after a reasonable period 
 
 mortality. Kronig and others who incline to the belief that labor in contracted pelves is 
 physiological up to a certain point, admit that the size of the pelvis contributes to the death 
 of the fetus in certain cases. But no control statistics of labor in normal pelves are pub- 
 lished, and as the average duration of these labors is not beyond the normal, it is possible 
 that this concession is not warranted by the facts. The proportion of forceps cases is not 
 greater than in many miscellaneous series. 
 * Loc. cit. 
 
662 PATHOLOGICAL LABOR. 
 
 of second-stage pains, provided sufficient plasticity of the head and strong 
 uterine contractions are present. 
 
 The membranes should be undisturbed, and in delayed cervical dilatation, 
 a careful bimanual stretching of the ring of the os I have found a valuable 
 procedure. 
 
 Our aim is to secure engagement of the head, so as to avoid the resort to 
 high forceps or version, if possible. To this end the Walcher position (Part X), 
 used from time to time, will increase the pelvic inlet conjugate and assist in 
 cephalic engagement. 
 
 The forceps, high, medium, or low, may be required in cases of prolonged 
 second stage, and under the same conditions as in delayed second stage in 
 general. The advice to perform version at the completion of the first stage, 
 the prophylactic version of many German authorities, in all cases of moderately 
 contracted pelves, I believe is rarely, if ever, called for, and by reason of the 
 rapid extraction thus made necessary, is almost always fatal to the fetus. 
 
 The management of labor with relative contraction of the pelvis may be 
 summed up as follows : Labor should be allowed to proceed and the character 
 of the pains and the moulding of the head noted. In vicious presentations and 
 positions it may be necessary, of course, to perform prophylactic version. If 
 labor progresses satisfactorily, the case may be left to nature unless an indica- 
 tion arise to terminate it rapidly. If it becomes evident that labor is making 
 no progress, the obstetrician must choose between forceps and version, symphy- 
 seotomy. Cesarean section, and perforation. 
 
 Class Two. Second-degree Contraction. — Simple fiat pelvis with a true conjugate 
 of from ;^.;^^inches (8.5 cm.) ^02.75 i'^ches{'j cm.). Generally contracted pelvis with a 
 true conjugate of from 3.50 inches (8.g cm.) to 2.95 inches (7.5 cm.). 
 
 When the true conjugate is over 2.76 inches (7 cm.) in flat and 2.95 inches 
 (7.5 cm.) in generally contracted pelves, the possibility of the spontaneous 
 birth of a full-term child of average size must be remembered. Although it is 
 true that the larger sized pelves of this second-degree contraction may and 
 do permit of spontaneous labor, still one must remember that the proportion 
 of spontaneous births sharply diminishes as we recede from the limits of this 
 degree and approach those of absolute pelvic contraction. (Less than 2.76 
 inches (7 cm.) in flat and 2.96 inches (7.5 cm.) in generally contracted pelves.) 
 
 Thus Kronig found that in 504 cases of labor in flattened pelves with a true 
 conjugate between 3.74 and 2.76 inches (9.5 and 7 cm.), relatively contracted 
 pelves, intervention for the pelvic complication alone was required in less than 
 9 per cent., and below 2.76 inches (7 cm.) the percentage of intervention for 
 the pelvic element was 100 per cent. 
 
 Kronig also found that in 222 cases of generally contracted pelves with a true 
 conjugate of 3.94 to 2.95 inches (10 to 7.5 cm.), relatively contracted generally 
 contracted pelves, intervention for the pelvic element alone amounted to but 9 
 percent. Below 2.95 inches (7.5 cm.) intervention was necessary in 100 per cent. 
 
 On the other hand,* the statistics of Ludwig and Savar show that 
 intervention was necessary with a true conjugate of 
 
 2.76 inches 
 
 (7 cm.) in 100 per ce 
 
 2.96 
 
 (7.5 cm.) " 85 " ' 
 
 3.12 
 
 (8 cm.) " 75 " ' 
 
 3-35 " 
 
 (8.5 cm.) " 50.3 " ' 
 
 3-5° " 
 
 (9 cm.) " 41-3 " 
 
 3-75 " 
 
 (9.5 cm.) " 24-4 " 
 
 * ' Klin. Bericht liber die Geburten beim Engen Becken, Bericht aus der II Geburt. 
 Gynecol. Klinik in Wien," Wien, 1897, 120-353. 
 
MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 663 
 
 The treatment of this class must necessarily vary as the case is first seen in 
 pregnancy or labor. 
 
 In Pregnancy. — The same general principles are in force here as in Class 
 One. Careful watch for disproportion between the head and pelvic inlet should 
 be kept with the aid of Ferret's and Mtiller's methods, assisted by nitrous oxide 
 anesthesia, if necessary. 
 
 With the lesser degrees of contraction of this class, in the absence of marked 
 disproportion, pregnancy may be permitted to proceed to full term, with the 
 assistance in the last six weeks of Prochownik's diet. Should it appear at 
 any time from the estimate of the size of the fetal head that serious dystosia 
 is likely to ensue, the case should be treated as in the more marked degrees of 
 this class. 
 
 In the greater degrees of contraction of this class we should never trust to 
 spontaneous labor at term except in the case of twins or an exceptionally 
 small fetus. Thechoice in these cases lies between induction of labor and Caesarean 
 section at or near term. 
 
 Excellent results in my cases have been obtained by inducing labor at the 
 thirty-sixth week, and my fetal mortality from this procedure has been little 
 if any greater than in spontaneous labor at term in normal pelves. 
 
 In balancing the choice between induction of premature labor and Caesarean 
 section, it must not be forgotten that although a small premature child does 
 readily pass through a contracted pelvis when at full term decided dystocia 
 would occur, still the premature fetus in less able to stand punishment either 
 from birth, forceps, or other pressure. 
 
 For example, as I have frequently observed, an easy forceps or breech 
 extraction at the thirty-fourth week is likely to be more dangerous to the 
 child than a somewhat more difficult operation at full term. 
 
 At the thirty-sixth week the biparietal diameter is Si inches (8.25 cm.), and 
 although this does not correspond to the clinical index of all pelves of this 
 class, still the greater plasticity of the fetal head at the thirty-sixth week per- 
 mits of more ready moulding than at term. 
 
 The fetal mortality so progressively increases as we induce labor earlier 
 than the thirty-sixth week, that in those cases of this class bordering upon 
 absolute pelvic contraction the best prognosis for the child is obtained by 
 Caesarean section, and this should be the operation of choice in such instances. 
 
 In Labor. — In the lesser degrees of contraction of this class the same gen- 
 eral principles obtain as in Class One. 
 
 In the cases bordering upon absolute contraction, interference will almost 
 surely be required. Should a decided disproportion between head and inlet 
 exist, or if after several hours of second-stage contractions the head has shown 
 no tendency to engage and descend some, the likelihood of spontaneous deliv- 
 ery or of delivery by forceps or version is quite out of the question. The 
 choice will now rest between Caesarean section, symphyseotomy, and perforation. 
 Version, in these cases, only adds to the dangers of the situation. It almost 
 surely destroys the child, and the extraction gives a bad prognosis for the 
 mother. 
 
 The forceps should only be used tentatively, for a short time, assisted by 
 the Walcher posture, and never with great force or prolonged traction. 
 
 As in absolute contraction, Caesarean section should here be the operation 
 of choice, but with this exception, namely, only when the fetus is alive. This 
 class of deformity will usually permit of craniotomy when the child is dead, 
 and here, as in other forms of pelvic contraction, no sentimental or esthetic 
 
664 PATHOLOGICAL LABOR. 
 
 reasons should ever prevent us from mutilating a dead fetus, when thereby we 
 lessen the dangers to the mother. 
 
 My experience with and observation of many cases of symphyseotomy for 
 pelvic contraction, does not permit me to recommend the operation as a 
 competitor with Caesarean section. The physician may be met with the refusal 
 of the mother and her family to accept Caesarean section. 
 
 Again, in sparsely-settled country districts, where assistance is not at hand, 
 and in tenement-house practice, where a patient refuses to be removed to the 
 hospital, the practitioner is occasionally compelled to sacrifice a living child. 
 
 In city practice, however, the physician can always refuse to perform 
 embryotomy on a living fetus, as there are competent physicians at hand to 
 whom the case can be transferred. 
 
 Again, if the patient when first seen already shows symptoms of infection 
 by reason of a midwife's attendance, or repeated unsuccessful attempts at 
 delivery, Caesarean section should not be attempted by reason of the high 
 maternal mortality in such cases. 
 
 In this last class, however, should the demands of the Catholic Church or a 
 great degree of pelvic deformity demand Cesarean section, a complete or in- 
 complete hysterectomy should follow the operation. 
 
 Forceps and Version in Contracted Pelves. — To expectancy in the management 
 of pelvic contraction, we may add, according to the indications, the forceps 
 and version, the latter followed by immediate manual extraction. 
 
 Both the measures have often been sufficient to overcome considerable 
 degrees of pelvic dystocia. The forceps is indicated in those cases in which the 
 head is engaged or can be made to partially engage by suprapubic pressure, 
 and in which our previous examination assures us there is no decided dispropor- 
 tion between the head and pelvic inlet. As a general rule, a tentative attempt 
 to assist delivery by the careful use of the forceps should be made in all cases, 
 before any more serious operation is undertaken. Excessive and prolonged 
 traction with the forceps must not be made use of, as destruction of the fetus 
 and possibly fatal results for the mother are quite likely to result. 
 
 At the Bellevue and Manhattan Maternity services undelivered women are 
 frequently received, seriously torn and infected following prolonged and brutal 
 attempts at forceps delivery. 
 
 It is a good plan, before doing any operation, to attempt to assist delivery 
 by the means suggested for prolonged unobstructed labor (page 572) and by 
 the Walcher position. Too much must not, however, be expected by this last 
 manoeuvre. 
 
 The forceps possesses the advantages of permitting a great degree of trac- 
 tion and a gradual extraction of the head. Its disadvantages are (i) that 
 pressure over one diameter increases the length of the opposite; (2) the in- 
 strument occupies a certain space in the already small pelvis. Version has for 
 its advantages : (i) the diameter.s of the head are not increased by a foreign 
 body; the wedge-shape of the after-coming head adapts better to the inlet than 
 the shape of the fore-coming head. Its disadvantages are : (i) no great force 
 can be exerted upon the fetal body or neck; (2) rapid extraction, ten minutes 
 at the longest, is necessary to secure a live child; (3) the complications of 
 extension of the head and arms are always liable to occur, seriously affecting 
 the prognosis. 
 
 Face, Brow, and Breech Presentations in Contracted Pelves. — Face and brow 
 presentations always suggest pelvic deformity of some variety (p. 509), but not 
 necessarily to a serious degree. In moderate degrees of pelvic contraction, the 
 
MATERNAL DYSTOCIA FROM GENERAL CONDITIONS. 665 
 
 treatment of face and brow presentations which I have suggested elsewhere 
 (p. 517) is to be relied upon. In more marked deformity too much cannot be 
 expected of the face or of the converted brow in the way of moulding and 
 engagement, and radical measures for the safety of mother and fetus should be 
 considered at the outset. 
 
 Breech presentation is rather unfavorable for the fetus, because of the delay 
 in the moulding and engagement of the breech, in the likelihood of prolapse of 
 the cord, and fatal asphyxia in the extraction of the aftercoming head. 
 For the mother, unless the deformity is severe, a breech presentation 
 is rather favorable, because of the less dangerous pressure caused 
 by the buttocks of the fetus, and since extraction can usually be safely accom- 
 plished should occasion arise. 
 
 The prophylactic bringing down of a foot, soon after the rupture of the 
 membranes, is a good plan in moderate relative contractions, to afford us a 
 handle for subsequent extraction, should the latter become necessary. 
 
 MATERNAL DYSTOCIA FROM GENERAL MATERNAL CONDI- 
 TIONS. 
 
 XXII. LABOR IN ELDERLY PRIMIPARAE. 
 
 Definition. — An elderly primipara is one who is thirty years of age and up- 
 ward. Some authorities would even make twenty-eight years the boundary- 
 line, while others regard thirty-two as the proper limit of youth. 
 
 Etiology. — The causes of late primiparity by no means coincide with late 
 marriage. They are to be sought in part in uterine malpositions, metritis, cer- 
 vical catarrh, tumors, congenital malformations, sexual frigidity, also in inabil- 
 ity of the husband to procreate. The condition of the woman of which she is 
 most conscious and which influences her against matrimony is contracted pelvis. 
 When, as often happens, this is due to rickets or some skeletal deformity, she is 
 not sought in marriage during the age at which men pay attention to externals 
 in selecting brides. Sooner or later, too, these women learn something about con- 
 tracted pelves, and therefore fear conception. The causes of the prolongation of 
 these labors are described under "anatomical rigidity of the cervix" and 
 "rigidity of the vagina, vulva, and perineum." 
 
 Symptoms. — After an elderly primipara conceives, her pregnancy and labor 
 may exhibit certain peculiarities. Twin pregnancy appears from statistics to be 
 common among these women. There is a higher proportion of malaise and gas- 
 tric disturbance in the elderly. Kleinwachter thinks that the tendency to pla- 
 cental hemorrhages is less marked. The same author found a high percentage of 
 renal mischief in those above thirty-five, while there is testimony from numerous 
 sources that eclampsia is more frequent. In regard to the duration of labor, 
 Courtade obtained an average of twenty-two hours and twenty-seven minutes. 
 Nearly nineteen hours of this time was consumed in dilatation. As intervention 
 was practised in a number of cases, the results, after eliminating the latter, 
 showed about sixteen and a half hours for the entire labor, and fourteen and three- 
 quarters hours for dilatation alone. After the further elimination of some pre- 
 mature cases, Courtade decides that the average duration of labor in the elderly 
 is sixteen hours ; his cases begin at the age of twenty-eight. Ahlfeld, with whom 
 the age of elderly primiparity does not begin till thirty-two, finds the average 
 duration of labor to be twenty-seven hours ; while Kleinwachter makes the figure 
 
666 PATHOLOGICAL LABOR. 
 
 eighteen hours. In 30 spontaneous labors after the thirtieth year I found the 
 average duration of labor to be fifteen hours and forty-nine minutes. There are 
 no known modifications of the third stage of these labors with the exceptions 
 according to some, of a tendency to adhesion and retention of the placenta. As 
 might be expected, lacerations of the birth tract are more common in the elderly, 
 amounting to 30 per cent. Statistics readily show that the proportion of cases 
 of operative interference increases with age: thus, from thirty to thirty-five, 13.6 
 per cent.; over thirty-five, 14.58 per cent.; jointly, 14.2 per cent. In regard to 
 children, the tendency of the elderly primipara is to produce more boys than 
 girls. The average weight of the newly bom is, according to Mangiagalli and 
 Kleinwachter, less than that of children of young primiparae. The tendency to 
 vicious presentation is greater with the advance of age of the primipara; I found 
 6 per cent, in 47 cases. Finally, the child mortality is said to be much higher. 
 The figures range from 14.24 per cent. (Courtade) to 44.8 per cent. (Cohnstein). 
 In my 47 cases the maternal and fetal mortality was nil. I append the private 
 statistics of Courgenon, obtained from a study of all labors in women over thirty 
 at the Clinique Tamier, 1898-1899, as well as my own material. 
 
 In the Clinique Tamier of Paris, of a total ntiniber of iii cases, 81 ended spontaneously 
 (73 per cent.) and the remainder were terminated with forceps. Post-partum hemorrhage 
 occurred in 8 per cent. The average duration of labor was seventeen hours thirty minutes. 
 There were about 5 per cent, of vicious presentations and 8 per cent, of pelvic deformity. 
 Uterine inertia was present in 19 per cent. About 6 per cent, of women had albuminuria, 
 but none developed eclampsia. There was one case of placenta prsevia. The maternal 
 mortality was less than 2 per cent., the fetal less than 4 per cent. In 2200 cases of labor I 
 found the total number of elderly primiparas to be 47, of which 30 ended spontaneously 
 (63.8 per cent.); the remainder terminated with forceps. Four patients (8.5 per cent.) 
 had post-partum hemorrhage. The average duration of spontaneous labor was fifteen 
 hours forty-nine minutes. There were about 6 per cent, of vicious presentations and 25 per 
 cent, of pelvic deformities. Uterine inertia was present in but 4 per cent.; if, however, we 
 reckon the cases of post-partum hemorrhage under inertia, the percentage is nearly 13. 
 There were no cases of placenta prcevia. The maternal and the fetal mortality was each o. 
 
 Conclusions. — The statistics of Courtade, of Courgenon of the Tamier Clinic, 
 and my own material appear to show that labor in elderly primiparae is but 
 slightly longer on the average than in primiparae in general. Normal labor with 
 first-bom children is computed to last from twelve to fifteen hours (Tamier). In 
 the author's material the average duration was fifteen hours twenty-nine minutes — 
 only some twenty minutes less than in the elderly alone. Hence the duration 
 obtained by Ahlfeld and others. (twenty-seven hours, twenty-five hours, etc.) can- 
 not be attributed to mere age. Again, the low maternal and fetal mortality of 
 the Tamier Clinic and my cases show that the heavy mortality of certain 
 statisticians (14.2 per cent., 44.8 per cent.) should be attributed neither to the age 
 of the parturients nor to the instrumental intervention. The most, then, that 
 can be said of the influence of age on primiparity is that it slightly prolongs the 
 first stage of labor and somewhat increases the frequency of indications for the 
 use of the forceps. The same conclusion is also reached by Courgenon. This is, 
 of course, opposed to the tradition which prevails in both medical and lay circles 
 and also appears to discredit the existence of what is known as "anatomical 
 rigidity of the cervix," which is believed to be almost uniformly present in elderly 
 primiparae (page 606). Tamier and Budin hold that the condition of absolute 
 undilatable cervix, which sometimes gives way to circular rupture rather than 
 yielding naturally, is excessively rare, and not to be confounded with the rigidity 
 which is almost universally present in the primipara, and even in the multipara 
 in premature labors. The coincidence of extreme anatomical rigidity in a few 
 labors in elderly primipars might well beget the impression that such an associa- 
 tion was inevitable, but, as has been shown, there is no sound basis for such an 
 
MATERNAL DYSTOCIA FROM GENERAL CONDITIONS. 667 
 
 opinion. What were the real causes of the extreme duration of labor and the 
 high maternal and fetal mortality registered by competent observers in connection 
 with primiparity after thirty years of age ? Possibly the mothers were influenced 
 unfavorably by the belief in the fatal issue of such labors. The problem is an 
 important one, for in an era of late marriage and low birth-rate many women 
 avoid maternity on the ground that they are too old for bearing children without 
 great hazard to themselves. It is known that for some reason late breeders 
 possess a higher proportion of pelvic deformity than younger women. I found 
 25 percent, of pelvic deformity in my 47 cases of elderly primiparity. 
 
 XXIII. INTESTINAL HERNIA. VAGINAL HERNIA. 
 
 The ordinary forms of* hernia — inguinal, crural, and umbilical — can hardly 
 be ranked among causes of maternal dystocia. On the other hand, there is a 
 special type of hernia — namely, the vaginal — which should be enumerated among 
 such causes. Here the usual course of the prolapsed intestine is to occupy 
 Douglas's pouch, although in rare instances it may descend in front of the uterus. 
 The gut may remain in Douglas's cul-de-sac or descend between the vagina and 
 the rectum. In the latter case it may appear at the perineum or in one of the 
 labia majora. For vaginal hernia to occur, some anomaly of form of Douglas's 
 cul-de-sac should furnish a predisposition. Such anomalies may be produced by 
 a prolapse or retroversion of the uterus which tends to stretch the retrouterine 
 ligaments. The accident, essentially rare, occurs much more frequently in the 
 multiparous. Vaginal hernia may consist of both intestine and omentum. In 
 the rare anterior form the hernia may comprise part of the bladder. These 
 hernias seldom cause symptoms during gestation. In a few rare instances the 
 size of the mass has been known to cause obstructive phenomena affecting the 
 rectum and bladder. In a few cases rupture of the sac has been known to occur 
 before delivery. From the standpoint of dystocia, vaginal hernia, if large, offers 
 some hindrance to the descent of the head; but the danger concerns the mother 
 principally, since the prolonged compression of the hernia may terminate in 
 strangulation and necrosis of the gut. Diagnosis should be easy. If in the 
 course of digital examination the finger encounters a bulging, elastic mass 
 in the posterior cul-de-sac, and if this tumor is reducible, there can be little 
 doubt as to its nature. Nevertheless, vaginal hernia has been mistaken for 
 a great number of conditions, including the bag of waters, rectocele, cyst of 
 the vagina or ovary, etc. If the hernia has made its way to the labium majus and 
 the fact of intestinal protrusion is recognized, the physician will naturally be- 
 lieve it to be an inguinal hernia. In such a case Stoltz's test should be 
 applied as follows: The hernia is reduced, the inguinal ring closed by the thumb, 
 and the woman instructed to cough; if now the tumor reappears in the labium, 
 an inguinal hernia may be excluded. The hernia is now reduced for the second 
 time and a finger in the vagina compresses the latter against the ischium on 
 the side of the hernia. If the patient coughs now, the hernia does not reap- 
 pear. Treatment: If the diagnosis of vaginal hernia is made early enough in the 
 course of the labor, the indication is to reduce the hernia and hold it back until 
 the descent of the head into the vagina prevents any further probability of pro- 
 lapse during labor. To reduce the hernia it may be necessary to apply the taxis 
 under an anesthetic, although the knee-chest position may answer in some cases. 
 Conjoined manipulation (abdomino-vaginal and vagino-rectal) may in certain 
 cases serve for the reposition. In irreducible hernia during labor the indica- 
 tion is to terminate the latter with all haste after dilatation has occurred. 
 
668 PATHOLOGICAL LABOR. 
 
 XXIV. CARDIAC AND PULMONARY DISEASE. 
 
 Asystole in Labor. — The bearing of organic heart disease upon marriage, 
 pregnancy, and the interruption of gestation has already been considered 
 (page 326). If a patient in whom the disease has passed the period of com- 
 pensation should become pregnant and go on to term, death is pretty cer- 
 tain to happen during delivery. Neumann * publishes a case of this sort and 
 cites a number of similar instances. Under these circumstances, however, it 
 has been possible to save the child's life by rapid forceps extraction. (See Coffin 
 Birth, page 669.) If the woman is not dead but nearly moribund when the 
 physician reaches the lying-in chamber, it is still possible to rescue her, as shown 
 by a case cited by Neumann. The patient, six months pregnant, was asystolic, 
 presenting anasarca, ascites, and orthopnea. She was held in a nearly upright 
 position by several attendants for some hours, or until the cervix could be dilated 
 and the child perforated and extracted. She recovered from the asystole. In 
 labor with organic heart disease properly compensated, the indications do not 
 vary from those which obtain in delivery under normal conditions. It has been 
 claimed that the rapid fall in the intra-abdominal pressure which follows the 
 emptying of the uterus in these cases may lead to death post-partum. To lessen 
 the danger a sand-bag can be placed upon the abdomen after delivery. 
 
 Pulmonary Disease. — Acute obstruction of the larynx from any cause may 
 bring on labor, and under these circumstances the fetus is likely to perish from 
 asphyxia in utero. Tracheotomy is indicated in the interest of both mother 
 and fetus. If after tracheotomy the mother is moribund, Caesarean section 
 may save the child. If pneumonia coexists with labor, the cardiac insufficiency 
 which accompanies this disease may lead to acute pulmonary oedema and death. 
 If labor is impending during pneumonia, efforts should be directed to securing 
 delay. After labor is under way it should be hastened with all due speed. 
 
 XXV. CEREBRAL AND SPINAL DISEASE. 
 
 The severe forms of neuroses, such as epilepsy, hysteria major, and the grave 
 form of chorea gravidarum, appear to exert but little influence on the labor. 
 Meningitis has sometimes occurred in pregnancy either with or without erysipelas. 
 When labor begins, convulsions develop. Cases of labor complicated with chronic 
 spinal diseases are on record. One case is recorded in which there was a chronic 
 myelitis of the whole cord with paraplegia and anesthesia extending as high as 
 the umbilicus. The mother suffered no pain. In tabes dorsalis the course of 
 labor is normal in the great majority of cases. 
 
 Delirium or Insanity of Labor. — In very sensitive patients the natural 
 suffering and restlessness incident to labor may pass into a state of transient 
 fury, the explosions occurring during the pains. These women tear their hair, 
 beat the wall, and indulge in furious cursing. This acute psychosis is especially 
 noticeable in unmarried women, as I have observed numerous cases at the 
 Emergency and New York Maternity Hospitals among this class of patients. 
 After delivery the patient has no recollection of this state of mind. Technically 
 this condition is an acute delirium and not true insanity. The treatment is 
 based upon general principles. 
 
 * ■' Centralbl. f. Gynak.," March 10, 1900. 
 
MATERNAL DYSTOCIA FROM GENERAL CONDITIONS. 669 
 
 XXVI. DIGESTIVE DISTURBANCES. 
 
 Pernicious Vomiting. — Under certain circumstances labor may be much 
 disturbed by pernicious vomiting. The causes comprise actual organic disease 
 of the stomach and functional disturbance from errors in diet. The determining 
 cause of a paroxysm of vomiting is a severe labor pain. The coincidence of 
 labor and vomiting is not unusual in anemic primiparas. Mental emotion is also 
 a cause. As this vomiting may presage the development of eclampsia or some 
 other affection, it is best to terminate labor at once. Hematemesis may occur 
 during labor when gastric cancer or ulcer is present, but it does not constitute 
 an indication for hastening delivery. Rupture of the spleen sometimes occurs 
 during labor and always ends fatally. 
 
 XXVII. SUDDEN DEATH DURING LABOR. 
 
 Sudden death may occur during parturition from a great variety of causes. 
 Predisposing causes may exist before labor, the latter acting as a determining 
 cause; or the death may be the termination of a condition produced by pregnancy 
 itself, (i) The predisposing causes independent of pregnancy : (a) Circiilatory 
 — valvular heart disease, rupture of a diseased aorta, hydropericardium, fatty 
 heart; (b) respiratory — suffocation during labor from presence of a goiter, or 
 from hydrothorax; (c) digestive, etc. — rupture of spleen; (d) cerebrospinal — 
 cerebral apoplexy. (2) Predisposing causes as a consequence of pregnancy: 
 (a) Eclampsia; (b) hemorrhage, as from placenta praevia, too early detach- 
 ment of a normally seated placenta, rupture of the uterus, or of varicose veins in 
 the broad ligament; (c) entrance of air into veins: this accident occurs in pla- 
 centa praevia, cancer, rupture of the uterus, and in manual and instrumental 
 intervention. (3) Unknown causes of death. Death has occurred suddenly 
 from the mere introduction of the hand into the vagina for the purpose of per- 
 forming version. (4) Shock. (See Part VH.) (See Sudden Death in the 
 Puerperium, Part VIL) 
 
 XXVIII. POST-MORTEM DELIVERY— COFFIN BIRTH. 
 
 Post-mortem parturition acquires its obstetrical and medico-legal importance 
 from the possibility of physicians and midwives — the latter particularly — being 
 made defendants in suits for malpractice on the ground of the delivery of the 
 child after the death of the mother, and on the contention that this accident was 
 preventable and due to lack of skill or to ignorance on the part of the practi- 
 tioner. The case reported by Moritz * is the best illustration to be found of this 
 charge. Three theories, according to Aveling,t have been advanced in explana- 
 tion of the phenomenon. The first is that it is caused by the contraction of the 
 uterine walls in rigor mortis. This seems hardly worth consideration, for the 
 contractions are not sufficiently powerful to overcome the natural obstacles 
 to the passage of the child, with the superadded narrowing and rigidity of the 
 parturient canal from the same cause. The second theory is the pressure of the 
 putrefactive gases in the abdominal cavity, acting on the point of least resistance, 
 expelling the fetus and pushing the uterus before it until it lies outside the 
 
 ♦Moritz: " Vierteljahresschrift f. gericht. Med.," p. 93, Bd. v, 1893; also Bleisch: 
 " Vierteljahresschrift f. gericht. Med.," 1892, Bd. iii, p. 38. 
 
670 PATHOLOGICAL LABOR. 
 
 genitals distended with foul-smelling gaseous products.* There can be no doubt 
 that this explanation is the true one in a majority of instances, but there still 
 remains a class of cases which it will not explain, since the birth took place too 
 early for decomposition to have advanced so far as to produce sufficient pressure 
 of gas. To cover this ground a third cause has been proposed in the conservation 
 of power in the uterine muscle for some time after death (two hours is the limit 
 generally placed). This contractile irritability preserved after death has been 
 noted by various writers. Fodere f says that "the uterus may expel the fetus 
 after death, its organic action being conserved after dissolution has taken place." 
 BaudelocqueJ found the uterus contracted after the lapse of a few hours in a 
 woman whom he had delivered immediately after death. Arbeiter § found a 
 like condition of affairs, delivery of the child having been accomplished by 
 version and extraction three-quarters of an hour after death. During the 
 operation the uterus was flaccid, but it contracted later into a hard ball. Leroux|| 
 cites a case of the same character, and others are on record. The uterus is often 
 said to be the last portion of the body to lose its power of contraction and the 
 last also to undergo decomposition. It is possible, then, to believe that when 
 birth occurs within a few hours after the mother's death, the force retained in the 
 voluntary muscles of the walls of the uterus is sufficient to complete the labor. 
 
 Dr. W. W. Rangeley, of Christainsburg, Virginia, in a personal communication, has 
 kindly furnished me with the following case of coffin birth: Upon May 7, 1901, Mrs. J. Vaden 
 died suddenly, and after the usual interval was buried, she being at the time of her death 
 ten months pregnant. All the parties present at the time the body was placed in the coffin 
 testified that at that time there was no evidence of birth. Subsequently the husband was 
 suspected of having poisoned his wife, so on May 18, 1901, the coffin was opened in the pres- 
 ence of a coroner's jury, and the body examined by Drs. Rangeley and M. B. K. Linkous. 
 The abdomen was partly distended with gas so as to resemble pregnancy, and it was the 
 first impression that the fetus had not been bom. Incision of the abdomen caused it to 
 collapse, and then search was made for the child, which, with cord and placenta attached, 
 was found well down under the thighs. The child weighed nine and a half pounds and was 
 dead. The uterus was, unfortunately, not examined. The body was in a state of decomposi- 
 tion, but the fetal cadaver was well preserved. The cord was strong enough to sustain the 
 weight of the placenta when suspended. The opinion of the_ physicians present was that the 
 intra-abdominal gas pressure expelled the fetus after the effects of rigor mortis had subsided. 
 
 Can the Fetus Live After the Death of the Mother? — While we may be per- 
 mitted a doubt in such a case as that of Reiss,** in which, according to that 
 author, a day passed before a living child was bom, the answerto the question must 
 be in the affirmative when the interval is only an hour or less. In the discussion 
 of Aveling's paper. Dr. Madge ff stated that he had observed fetal movements 
 after death in several cases and wished to extract the child by Cassarean section 
 but was not permitted. Brunton %% after a quarter of an hour extracted a living 
 child from the mother's corpse. BufEon and Shierig have taken living animals 
 from the bodies of female beasts hours after death. The author has done the 
 same in the case of a fox.§§ 
 
 * See cases 65 to 67, author's article in Witthaus and Becker: " Medical Jurispru- 
 dence," vol. II, pp. 370—376. 
 
 t "M6d. L6g.," vol. II, p. II. X "Diet, des Sciences M6d.," xxx, p. 388. 
 
 § "Monats. f. Geburtsh.," April, 1862. |I "Traits des Pertes de Sang." 
 
 ** G. A. Reiss: "Gentleman's Magazine," vol. xxix, p. 390. 
 tt "Trans. Obstet. Soc. London," xiv, p. 240. %% Ibid., xiii, p. 88. 
 
 §§ For instances in which living children have been extracted from fifteen to thirty-two 
 minutes after the mother's death, consult Breslaw: "Monats. f. Geburts.," B. 20, p. 62; 
 Pringler: "Monats. f. Geburts.," B. 34, S. 244 u. 251; Botherston: "Edinburgh Med. Jour.," 
 April, 1868, p. 930; Welponer: "Wiener med. Presse," No. i, 1897; Buckel: "Trans. Lon- 
 don Obstet. Soc," XIX, p. 179; Edgar: Witthaus and Becker, "Medical Jurisprudence," vol. 
 II, pp. 369-379 (William Wood & Co., New York, 1894). 
 
MATERNAL DYSTOCIA FROM GENERAL CONDITIONS. 671 
 
 XXIX. THE METRORRHAGIA OF LABOR; PARTUM OR INTRA-PARTUM 
 
 HEMORRHAGE. 
 
 For convenience' sake, I am accustomed to describe intra-partum hemor- 
 rhages as those of — (i) the first and second stages; and (2) of the third stage, 
 (i) Intra-partum hemorrhage of the first and second stages: This is due principally 
 to (a) premature separation of a normally or abnormally situated placenta; (b) 
 ruptures of the uterus or cervix; and (c) fibroid tumors, malignant disease of the 
 genital tract, or rupture of varicose veins. (2) Intra-partum hemorrhage of the 
 third stage; Here, first and foremost stands (a) uterine inertia as the most impor- 
 tant etiological factor; uterine inertia occurring with a partial or complete separa- 
 tion of the placenta. Next in importance come (6) lacerations of the genital 
 tract, namely, of the lower uterine segment, the cervix, vagina, and perineum. 
 Another important cause, not often taken into account, is (c) insufficient con- 
 traction of the lower uterine segment in cases of low implantation of the placenta. 
 Here, while the fundus contracts firmly and completely, an imperfectly contracted 
 lower segment permits of fatal hemorrhage from the open blood-vessels of the 
 low-situated placental site, (d) Partial or complete inversion, although a most 
 infrequent cause, must be enumerated ; and the likelihood of fibroids of the uterus 
 or cancer of the genital tract must be borne in mind. 
 
PART SIX, 
 
 Physiological Puerperium* The Puerperal 
 
 Woman* 
 
 DEFINITION. INTRODUCTION. 
 
 I. GENERAL PHENOMENA, (Page 673.) Exhaustion. Chills. After-pains. 
 Pulse. Temperature. Respiration. Skin. Kidneys. Muscles. Blood. 
 Heart. Weight. Psychical Changes. 
 
 H. LOCAL PHENOMENA. (Page 677,) External Genitals, Vagina. Cervix 
 and Cervical Canal. Lochia. Bladder. Involution. (1) Height of 
 Fundus. (2) Uterine Muscles. (3) Vessels. (4) Decidua. (5) Placental 
 Site. (6) Adnexa. Alterations in Mammae and Milk Secretion. Sub- 
 sequent Impregnation. 
 
 HL DIAGNOSIS OF THE PUERPERIUM, (Page 687.) 1, Signs of Recent 
 Delivery in the Living and the Dead. 2. Primipara and Multiparas 
 Feigned Lying-in State. 
 
 IV. MANAGEMENT OF THE PUERPERIUM. (Page 688.) 1. Introduction. 
 2. Asepsis. 3. Rest. 4. Professional Visits. (1) Temperature. Pulse. 
 Respiration. (2) Height and Condition of the Uterus. (3) The Lochia, 
 (4) External Genitals. (5) Bladder. (6) The Bowels. (7) (8) The Breast, 
 and Nipples. 5. Diet. 6. Posture and Duration. 7. Prophylaxis. (1) 
 Abdominal Binder. (2) Pelvic Binder. (3) Medication. (4) Massage 
 and Exercise. (5) The First Use of the Corset. 8. The Examination 
 of the Puerperium. 
 
Definition. — The puerperium is the period from the completion of the third 
 stage of labor to the time when the uterus has returned to its normal dimensions. 
 Its duration is six weeks or more. 
 
 Introduction. — The size of the uterus at the fortieth week is 12 inches X 
 9 inches X 8j inches; its weight two poim.ds, and capacity 400 cubic inches 
 The size of the uterus at the end of the puerperium is 3^ inches X zh inches 
 X i^ inches; its weight an ounce and a half to two ounces, and capacity one 
 cubic inch. The changes which go on in the uterus and its adnexa during 
 this period and that bring about the above results are known as the changes 
 of involution. The process is a physiological one, but closely borders on the 
 pathological. To understand this we have only to remember (i) the absorption 
 of two pounds of uterine tissue; (2) the formation of thrombi in the uterine 
 walls; (3) the rapid cell production upon the internal surface of the uterus; 
 (4) the atrophy and fatty metamorphosis in the uterine walls; (5) the tearing 
 across of blood-vessels at the placental site, leaving large raw surfaces with 
 the dangers of septic absorption; and, finally, (6) in most cases, including 
 all primiparas, the actual traumatic lesions in the nature of contusions and 
 lacerations of the cervix, vagina, and vulva. 
 
 I. GENERAL PHENOMENA. 
 
 Exhaustion. — The action of the recuperative forces of nature is seen to 
 great advantage after normal labor. As a rule, the patient recovers from 
 the trying ordeal much more rapidly than would be expected, and in the absence 
 of excessive hemorrhage or septic infection, this is usually the case even after 
 severe and protracted labors and operative delivery. Immediately after 
 delivery there is a natural tendency to rest and sleep, and from this repose 
 the woman wakes in a state of perspiration and much refreshed and strengthened. 
 Nervotis, irritable women, however, do not readily fall asleep at this period. 
 More or less thirst is present, due to increased excretion by the skin and kidneys, 
 with a certain amount of burning pain in the external genitals, depending 
 upon birth traumatisms. 
 
 The Post-partum Chill. — A chill of short duration, but which may be pro- 
 nounced in character, frequently follows the completion of labor. The pulse 
 and temperature are not altered and the chill is not of clinical importance. 
 It is most frequently observed after rapid labors, and is probably due to the 
 internal congestion caused by the sudden decrease in the intra-abdominal 
 pressure which causes a rapid recession of blood from the surface of the body. 
 The chill disappears without treatment, but something can be done to aid 
 the recovery of the circulatory equilibriimi by covering the patient with warm 
 blankets. The chill may also be due to the wetting of the surface by perspira- 
 tion, blood, and amniotic fluid; to the sudden cessation of muscular effort ; to 
 loss of blood, or to withdrawal of the warm fetus and placenta. 
 43 673 
 
674 
 
 PHYSIOLOGICAL PUERPERIUM. 
 
 After-pains. — Post-partum contractions which continue for several days into 
 the puerperium are frequently seen in practice and are quite painful at times. 
 They may occur spontaneously or only when the child is applied to the breast. 
 They appear more commonly on the first than on the second day and affect 
 multiparas by preference. When a primipara has after-pains, they occur, as 
 a rule, as a sequel to some particular type of labor, such as involves precipitate 
 delivery, or previous overdistention of the uterus, i.e., twins or hydramnios. 
 They are also associated at times with the retention of blood-clots and decidual 
 structures. While the same factors may be present in the after-pains of mul- 
 tiparas, they are often notably absent. 
 
 Pulse. — With the rapid fall in arterial tension which occurs during and 
 after delivery there is a marked diminution in the frequency of the pulse. From 
 60 to 70 is about the normal rate after delivery, and occasionally it is even 
 less. A rapid pulse at this time should lead the attendant to suspect the exist- 
 ence of hemorrhage or some other complication. I found the pulse in 141 7 
 observations one hour after delivery as follows : 
 
 40 t( 
 
 3 50 
 
 m 2 
 
 cases. 
 
 100 
 
 
 to no 
 
 m 
 
 48 
 
 =;o ' 
 
 60 
 
 13 
 
 
 110 
 
 
 120 
 
 
 23 
 
 60 ' 
 
 70 
 
 345 
 
 
 120 
 
 
 " 130 
 
 
 3 
 
 70 ' 
 
 So 
 
 " 566 
 
 " 
 
 130 
 
 
 140 
 
 
 2 
 
 80 • 
 
 90 
 
 302 
 
 
 140 
 
 
 150 
 
 
 . 2 
 
 90 
 
 100 
 
 1 10 
 Total 
 
 
 160 
 141 
 
 7 
 
 cases. 
 
 
 I 
 
 The pulse of the normal puerperium is slow and soft, and often irregular and 
 intermittent. It is also very irritable and easily accelerated by trivial causes. 
 But these qualities are by no means constant in all puerperae, at least in notable 
 degrees. Temesvary states that a slow pulse occurs in but 60 per cent, of 
 normal puerperal women. In certain cases the pulse-rate falls to 36, 32, even 
 to 30 beats per minute. The frequency before delivery is about 86, while 
 the average frequency throughout the puerperal period is about 63, so that 
 the result of delivery is a reduction in the pulse-rate of over 20 beats. Imme- 
 diately after delivery the pulse falls to about 72, but after irregular labors 
 not below 75. The rate now sinks a little each day until it arrives at a minimum 
 (average 57) on the eighth day. It remains at this level until a period near 
 the end of the second week, when it begins to rise again until it attains its 
 normal level. This tendency to a lowering of the pulse-rate is antagonized 
 by hemorrhage or fever from any cause ^ so that a pulse-rate of moderate 
 frequency early in the puerperium may or may not have an unfavorable sig- 
 nificance. As the effects of the complications wear away, the slowing of the 
 pulse may assert itself later in the puerperal period. When a slow puerperal 
 pulse becomes accelerated without evident cause, we should fear possible em- 
 bolism of the lungs. The causes of the slow pulse of the puerperal period 
 are still unknown. It is likely that several factors co-operate to produce this 
 result. One is the absolute rest in bed, another the lowering of the arterial 
 tension, a third the relief of the lungs which leads to slowing of the respiration, 
 etc. But if these factors alone were the occasion of a slow pulse, the latter 
 should be common to all puerperce. The absence of constancy in this respect 
 appears to point to the nervous system, which shows such individual peculiarities, 
 as largely responsible. Certain unknown factors may produce the slow pulse 
 through the vagus nerve or accelerator nerves of the heart. The apex of the 
 heart is lowered nearly f inch (2 cm.) after expulsion of the f^us, and a slight 
 impurity of the first sound manifested by a blowing murmur persists for 
 
.GENERAL PHENOMENA. 675 
 
 about a week in about three-fourths of all puerperae. The uterine soufifle has 
 been found to last, on an average, about fifty-six hours after delivery, and con- 
 siderably longer if the puerperium is abnormal. It is less marked than during 
 pregnancy and its persistence beyond a certain period shows a delay in the 
 process of involution. 
 
 Temperature. — This is slightly raised by the act of labor, so that the measure- 
 ments taken just before and just after labor should exhibit a certain difference. 
 This physiological increase is not to be confounded with a considerable elevation 
 seen in individual cases, which lasts but a short time, and which is attributable 
 to constipation, a disordered stomach, or mental influence. The physiological 
 rise averages about 0.48° F. (0.27° C). For the first six or seven hours after 
 delivery the temperature continues elevated, and then sinks slowly, so that 
 considerably before the expiration of the first twenty-four hours it has returned 
 to the ante-partum point. The temperature curve is the same in primiparae 
 and multiparse. It varies slightly with the period of the day at which delivery 
 occurs. The normal rise of temperature in the puerperium is attributed 
 by Temesvary to the changes in the circulation which follow expulsion of the 
 child, there being an increase of pressure in the capillaries of the kidneys, liver, 
 lungs, and skin. While the temperature is practically normal after the first 
 day, there is a very slight constant daily fluctuation throughout the first few 
 days, which is doubtless dependent upon the secretion of milk. In 1420 obser- 
 vations of the temperature one hour after labor I obtained the following table : 
 
 Temperature, 97.0° F. to 98.4° F. in 380 cases. 
 
 98.5° F. " 98.4° F. 
 
 99.5° F. " 100.4° F. 
 
 100.5° F- " 101.4° F. 
 
 101.5° F- " 102.4° F. 
 
 748 
 
 255 
 29 
 
 4 
 
 102.5° F. " 103.4° F. '; 4 
 
 Total 1420 cases. 
 
 Respiration. — After delivery the rate of respiration is lowered, and may 
 be anywhere between 14 and 20. The vital capacity is increased. An equi- 
 librium is reached at about the third or fourth day. The type of respiration 
 either continues to be thoracic from the habit acquired in pregnancy, or it 
 becomes abdominal or mixed. The expired air contains a larger proportion 
 of water and carbon dioxid than normal. This fact may be readily appreciated 
 in a hospital ward full of recently delivered women if the ventilation is not 
 of the best. I found the respirations in 11 73 cases one hour after delivery 
 as follows: 
 
 Respirations, 
 
 15 to 20 in 486 case 
 
 
 20 " 25 " 461 
 
 
 25 " 30 " 186 
 
 
 30 " 35 " 23 " 
 
 
 35 " 40 " 14 
 
 
 40 " 45 " 2 
 
 
 55 " 60 " I case. 
 
 Skin. — The free perspiration of the first four or five days of the puerperium 
 is due undoubtedly to the increase in metabolism which is connected with uterine 
 involution and the puerperal loss of weight. This active sweating exposes the 
 woman to colds, and she must be carefully protected from overheating, sudden 
 cooling, draughts, etc. The functions of the skin become normal at the end 
 of the first week. The sweating is accompanied by abundant desquamation, 
 which aids in the disappearance of the pigmentation and oedema of pregnancy. 
 The puerperal sweat is rich in butyric acid. 
 
676 PHYSIOLOGICAL PUERPERIUM. 
 
 Stomach and Bowel. — The puerperal woman appears to have Httle inclination 
 for solid food until lactation is established, after which the appetite becomes 
 awakened. Digestion is slow throughout the puerperium and indigestion 
 is readily provoked. These peculiarities appear to be due to the readjustment 
 of the gastro-intestinal tube following the expulsion of the child. Thirst is 
 often notably increased at the outset of the puerperium. A spontaneous move- 
 ment of the bowels seldom occurs during the earliest puerperal days. The 
 bowels have generally been evacuated thoroughly before delivery, and but 
 little nutriment is taken until some hours after this event; the intra-abdominal 
 pressure is reduced to a minimum and the natural peristalsis is much depressed; 
 the woman is in perfect repose in the recumbent position; the perspiratory 
 function is highly augmented, to say nothing of the activity of the kidneys, 
 the lochial discharge, and the beginning secretion of milk. Through the 
 coincidence of all these factors a natural stool would be almost an impos- 
 sibility. 
 
 Kidneys. — During the first few hours after delivery there is usually little 
 desire for urination, owing to a paretic state of the muscles of the bladder, the 
 result of the strong compression during the expulsion of the child. The early 
 urine is concentrated. An important fact in the physiology of the puerperium 
 is the length of time which the patient can retain her urine without any sensa- 
 tion of repletion. In the statistics of Temesvary 35 per cent, of the women 
 went from twelve to twenty-four hours without a spontaneous passage of 
 urine, and in 6 per cent, this interval was prolonged to a period between twenty- 
 four and thirty-six hours. The amount of urine which collects in the bladder 
 during these protracted intervals is considerable. Catheterization under these 
 circumstances is not desirable, and should be replaced by gentle frictions over 
 the bladder, warm wet compresses or poultices, or simple elevation of the 
 upper part of the trunk. (See Treatment.) The quantity of urine passed daily 
 during the first puerperal week is larger than that voided by the non-pregnant 
 woman, but considerably less than the amount secreted during the last weeks 
 of pregnancy. In the first day or two of the puerperium the amount of urine 
 is increased over that of subsequent days, and the density should be below 
 1020; after the third day it is usually above 1020. An increase in the 
 amount of urea excreted during the lying-in period is attributed to the 
 process of involution. Albumin occurs in the urine of many puerperal women, 
 not reckoning cases of albuminuria of pregnancy. This is the result of the 
 renal stasis which results from the act of labor. After the first twenty- 
 four hours albumin should disappear from the urine. If the woman had 
 albuminuria before pregnancy, the urine does not clear up until toward 
 the close of the first week. Sugar (lactose) is found in the urine whenever 
 there is any impediment to the secretion of milk, as in cases in which the child 
 does not nurse sufficiently. But this stops abruptly if the woman does not 
 nurse her child at the outset. The percentage of sugar is greatest at about 
 the fourth or fifth puerperal day. Peptonuria attributed to the involution 
 of the pregnant uterus begins in the second half of the first puerperal day 
 and, as a rule, lasts four or five days. This phenomenon is not constant. 
 
 Muscles. — The muscular fatigue and the semi-paretic state of certain muscles 
 which result from the act of labor disappear promptly, as a rule; but exception- 
 ally they last for days or even weeks. The woman has a somewhat similar 
 experience when she first gets up, but this also rapidly disappears. Delicate 
 women often exhibit an unnatural degree of mobility of the pelvic articu- 
 lations.- 
 
LOCAL PHENOMENA. 677 
 
 The Blood. — It was formerly supposed that the watery elements of the 
 blood were increased during pregnancy, while the hemoglobin and red cor- 
 puscles were relatively diminished. Later investigations have tended to dis- 
 prove this statement. The decrease in hemoglobin and red corpuscles observed 
 after delivery is probably due to hemorrhage, which occurs even in normal 
 cases. The hyperinosis of pregnancy is increased during the puerperium owing 
 to the presence of effete material in the circulation. The number of leucocytes 
 in the blood is at a maximum during the third stage of labor. It sinks rapidly 
 after delivery and attains a minimum at about the twelfth hour of the puerperal 
 period. It begins to increase on the second day or a little later, to undergo 
 another reduction when the secretion of milk has become established. The 
 number of red blood-corpuscles and the proportion of hemoglobin also undergo 
 a diminution after delivery, dependent in degree upon the amount of blood 
 lost during labor. This reduction is followed by an increase, so that by the 
 end of the first puerperal week the blood is of the same quality as before de- 
 livery. 
 
 The Heart. — In normal cases the heart speedily adapts itself to the decreased 
 arterial tension and diminished volume of blood. It has been asserted that 
 in consequence of the extra work required during pregnancy a hypertrophy 
 of the left ventricle takes place which disappears after delivery, but this is 
 not proved. (Compare Physiological Pregnancy, Part II.) 
 
 Weight. — During the first week there is loss of weight consequent upon 
 the diminished appetite, the increased excretions by the skin, and the normal 
 retrograde changes in the intra-pelvic viscera attendant upon the process 
 of involution. The loss is estimated at nine or ten pounds. In addition to the 
 loss of weight through the act of labor itself, there is a further loss which results 
 from the great activity of the various secretions, the lochial discharge, involution 
 of the uterus, absorption of oedema, etc. But with a proper amount of nourish- 
 ment the reduction is not excessive. Equilibrium in weight is reached in 
 about six or eight weeks, when it corresponds to the average before conception. 
 In primiparse, after twin pregnancies, and in women who do not nurse their 
 children the loss in weight is proportionately greater. Delicate women may not 
 regain their normal weight for months. 
 
 Nervous System. — During the first few days of the puerperium the woman 
 is in a condition of irritable weakness which involves the special senses and 
 the mind. This condition is aggravated by after-pains and by attempts of 
 the child to nurse, etc. Mental excitement sometimes leads to rise of tem- 
 perature (see Fever, Part VI), sleeplessness, and other ill effects. It is self- 
 evident that every source of annoyance should be avoided. 
 
 II. LOCAL PHENOMENA. 
 
 External Genitals. — After delivery the external genitals are bruised and 
 swollen and, especially in primiparas, are the seat of various abrasions and lacera- 
 tions. There is gaping of the labia majora and minora, and if labor has been 
 prolonged considerable oedema may be present (Fig. 467). The vulva and 
 perineum lose their secretions through absorption of the infiltration; the vari- 
 cosities in the veins diminish, and pigmented areas fade out. The various super- 
 ficial and deep contusions and lacerations gradually disappear, healing by epithe- 
 lial migration, leaving whitish scars. In primiparas, in addition, the remains of 
 
678 
 
 PHYSIOLOGICAL P UERPERI UM. 
 
 the hymen undergo necrosis with the persistence of the so-called camncular for- 
 mations (Fig. 28). The abdomen remains wrinkled and pendulous for weeks and 
 never regains its original appearance. Striae atrophicae are often apparent, 
 dating from pregnancy. 
 
 Vagina. — The vagina is at first relaxed, its mucous membrane is smooth and 
 flabby and the rugas are absent. In a few weeks it very nearly regains its normal 
 condition. It becomes narrower and shorter, although it never returns to its 
 original dimensions. The folds which were effaced by the act of labor form 
 anew, but never acquire their original number or sharpness of contour. The 
 ostium vaginas tends to remain somewhat patulous, especially behind, and a 
 certain prolapse of the vaginal walls within the ostium is often present. The 
 process of involution goes on more rapidly near the ostium vaginae than in the 
 upper portion. 
 
 Cervix and Cervical Canal. — The cervix after delivery is much distorted, but 
 the external OS can always be recognized (Figs. 531 and 636). 'Lacerations at this 
 point are usually present. The cervix and vagina cannot at first be clearly 
 
 Fig. 907. — Lochia on the 
 Second Day of the 
 PuERPERiuM. I, 2, Epi- 
 thelium; 3, 4, white blood- 
 corpuscles; 5, red blood- 
 corpuscles; 6, decidual 
 cell.— (Winckel.) 
 
 Fig. 908. — Lochia on the 
 Fourth Day of the 
 PuERPERiuM. I, Decid- 
 ual cell; 2, white blood- 
 corpuscles; 3, red blood- 
 corpuscles; 4, epithelium; 
 5, micro-organisms. — 
 (Winckel.) 
 
 Fig. 939. — Lochia on the 
 Seventh Day of the 
 Puerperium; Afebrile 
 Case, i, Red blood-cor- 
 puscles; 2, diplococci and 
 monococci; 3, white blood- 
 corpuscles; 4, epithelium; 
 5, decidual cells. — (Win- 
 ckel.) 
 
 distinguished from each other, but after twelve hours the distinction becomes 
 marked. At the tenth day post partum the internal os admits the passage 
 of the index-finger readily in about 60 per cent, of primiparae and about 70 per 
 cent, of multiparae,* but soon thereafter closes. The external os admits the 
 finger much longer and never exactly regains its former condition. Immediately 
 after delivery the cervix gapes, and the canal is so patulous that it will accom- 
 modate half the hand. This condition rapidly changes through thickening of 
 the cervical wall, the cervical folds reappear at the same time, and by the 
 twelfth day its involution is almost complete. On the contrary, the portio 
 vaginalis requires some five or six weeks to regain its original condition. The 
 lips of the external os immediately after delivery project into the vagina as soft 
 tumors. If the anterior lip has been incarcerated during labor, it may reach 
 as far as the vulva. 
 
 The Lochia. — By this term is understood the utero-vaginal discharge which 
 continues for two or more weeks after delivery. For the first three or four days 
 it is called the lochia rubra (red lochia), and consists principally of blood and 
 
 * Author's observation of several hundred cases. 
 
LOCAL PHENOMENA. 
 
 679 
 
 blood-clots with some admixture of the epithelial elements of the vagina and 
 cervix and fragments of decidua (Fig. 907). For the next three or four days it 
 is mainly serous in character and is called the lochia serosa {serous lochia) 
 (Fig. 908). After this, as the separation, disintegration, and casting-off of the 
 products of involution go on, it becomes thicker and whiter in color and is 
 called the lochia alba (white lochia) (Fig. 909). It contains disintegrated tis- 
 sues of the birth canal, the secretions from granulating wounds, and micro- 
 organisms, which, it should be noticed, are not found for the first day or 
 two, are confined to the vaginal secretions, and under ordinary circum- 
 stances do no harm. In normal conditions the uterine lochia is to be 
 regarded as sterile. The amount of the discharge has been estimated as 
 follows: For the first four days 2^ pounds (i kilo); for the second two davs, 
 about 9 ounces (256 gm.); until 
 the ninth day, nearly 7 ounces 
 (199 gm.). Under ordinary circum- 
 stances if more than one change of 
 napkins is needed every four hours 
 for the first few days, the amount 
 is to be regarded as excessive. 
 After the first two or three days 
 the lochia has a peculiar sickish, 
 but not putrid, odor. It is import- 
 ant that the physician should be 
 familiar with this odor in order that 
 he may recognize a departure from 
 the normal and that odorless vulval 
 dressings be employed. The dis- 
 charge is more profuse in multi- 
 parae than in primiparee and in 
 women who do not nurse their 
 children than in those who do. A 
 diminution in the usual amount of 
 the discharge should be regarded 
 with suspicion. Suppression is 
 often a sign of sepsis. 
 
 The Bladder. — Owing to the in- 
 creased quantity of urine, the sud- 
 den decrease of intra-abdominal 
 pressure, reflex urethral spasm, the 
 bruising and swelling of the tis- 
 sues, and especially to the recumbent position, retention of urine frequently 
 occurs. 
 
 Involution. — After the expulsion of the fetus and secundines the uterus 
 contracts upon itself, so that the fundus is. below the level of the umbilicus. 
 Immediately after delivery examination reveals a mass equal to that of a preg- 
 nant uterus at the twentieth week. Its weight is 26 to 35 ounces (750 to 1000 
 gm.); length 6.3 to 7 inches (16 to 18 cm.); length of cavity 5.9 inches (15 cm.); 
 thickness of wall 0.98 to 1.57 inches (25 to 40 mm.). At the eighth day of the 
 puerperium the mass of the uterus should be reduced one-half. Thus, the 
 weight after delivery is 26 to 35 ounces (750 to 1000 gm.) ; at eighth day, 14.9 to 
 17.6 ounces (400 to 500 gm.); on the fourteenth day, 13 ounces (350 gm.); on the 
 fourth week, 7.5 ounces (200 gm.). Finally, at the end of two months the uterus 
 
 SHD of First D^y 
 
 SYMPHYSIS 
 
 Fig. 910. — Height of the 
 THE First Ten Days of 
 
 — {From the author's measurements.) 
 
 Fundus during 
 THE Puerperium. 
 
680 
 
 PHYSIOLOGICAL PUERPERIUM. 
 
 has regained its original weight of 1.85 to 2.78 ounces (50 to 75 gm.) and length 
 of 2.95 inches (7 cm.). I found the length of the uterine cavity from the external 
 OS, measured with a sound on the tenth day of the puerperium in 119 primiparae, 
 3.21 inches (8.15 cm.), and in 99 multiparse 3.53 inches (8.97 cm.).* The first 
 step in involution is the permanent contraction of the uterus, which should 
 
 occur about one and a half 
 or two hours after the birth 
 of the child and immediately 
 after the expulsion of the 
 placenta. Active contrac- 
 tions are succeeded by a 
 period of retractility due to 
 the natural resiliency of the 
 uterine wall and muscular 
 tonus. This is also exerted 
 during the period of active 
 contraction in such a man- 
 ner that each active post- 
 partum contraction effects 
 an absolute and permanent 
 reduction in the size of the 
 uterus. It is due to the per- 
 sistence of this retractility 
 that involution becomes 
 possible. Uterine retractil- 
 ity is under the influence of the central nervous system, as shown by its inhibition 
 under the influence of mental emotion even late in the puerperium. Its arrest 
 under these conditions may be accompanied by secondary hemorrhage. The 
 amount and character of nutriment and the rate of metabolism are also known 
 to modify the process of involution, which goes on more slowly by night than by 
 
 Fig. 911. — Puerperal Uterus Fifty-three Hours 
 Post Partum. Normal Puerperium. — {Modified 
 from Sellheim.) 
 
 Thnrmms. 
 Blood Qot mUtCainn 
 Transverse 
 andOUtoue muxleBum/ies 
 
 Boundary , 
 
 lose attachment of Pentoneim 
 l/terv-ves.7>oucfi 
 
 eattacfimenz/i/? _ 
 Paiiomum •' 
 
 PoitVagJomix 
 Oouglm pouch 
 
 Hectum 
 
 Hertun 
 
 AniVag. /orniK, 
 Prepuce qf Clitoris 
 aitoris 
 
 Vrethra 
 Laiium minus 
 Vayina 
 Vaq. portion Of Cervix 
 f^nneum 
 Ext Sp/uniterAm. 
 Int. SphinOerAni 
 W-^^. _ Ru^oas muaiusMejn.0/ Rectum 
 Anus 
 
 Ext. SphinclerAnL 
 
 Fig. 912. — Sagittal Section of a Puerperal Uterus Fifty-three Hours Post Partum. 
 
 Normal Puerperium. — {Sellheim.) 
 
 day. The uterus in which involution is already under way may still undergo 
 active contractions (after-pains) from reflex stimulation by the nursing child. 
 The uterus is known to be slightly smaller just after delivery than at the com- 
 pletion of the first three puerperal days. This is due to the manipulation of the 
 
 * If the practitioner wishes to estimate the progress of involution with the sound, the 
 bladder should first be completely emptied. 
 
LOCAL PHENOMENA. 
 
 681 
 
 uterus in connection with the third stage of labor and the early post-partum 
 hours, producing an initial reduction in size which is followed by a slight reac- 
 tion. Measurements of the height of the fundus above the symphysis during 
 the early puerperal days are as follows. 
 
 Ci) Height of Fundus. — From careful measurements taken in 321 primi- 
 paras and 709 multiparae, during non-febrile puerperia, I found the height of the 
 fundus above the symphysis to be as follows: 
 
 TABLE OF HEIGHT OF FUNDUS ABOVE SYMPHYSIS.* 
 
 Time. 
 
 321 Primipar^, 
 Average Height. 
 
 Immediately after 
 
 third stage 5.93 
 
 First day ; 6.06 
 
 Second day \ 4.61 
 
 Third day 
 
 Fourth day 
 
 Fifth day 
 
 Sixth day 
 
 Seventh day 
 
 Eighth day 
 
 Ninth day 
 
 Tenth day 
 
 709 Multipara, 
 Average Height. 
 
 5-92 
 
 in. ( 
 
 .=;-3.=; 
 
 m. ( 
 
 4 
 
 66 
 
 m. ( 
 
 4 
 
 26 
 
 m. ( 
 
 .3 
 
 68 
 
 in. ( 
 
 3 
 
 27 
 
 m. ( 
 
 2 
 
 97 
 
 m. ( 
 
 2 
 
 89 
 
 m. ( 
 
 2 
 
 60 
 
 m. ( 
 
 2 
 
 10 
 
 m. ( 
 
 I 
 
 96 
 
 in. ( 
 
 (15.10 
 
 (13.60 
 
 (11.50 
 
 (10.79 
 
 ( 9-20 
 
 ( 8.30 
 
 ( 7-5° 
 ( 7-40 
 ( 6.45 
 ( 5-3° 
 5.00 
 
 cm.), 
 cm.), 
 cm.), 
 cm.), 
 cm.), 
 cm.), 
 cm.), 
 cm.), 
 cm.), 
 cm.), 
 cm.). 
 
 Total Average. 
 
 5-92 
 5-7° 
 4-63 
 
 4 37 
 3-75 
 3.20 
 
 3-42 
 2.90 
 2-55 
 2.32 
 2.22 
 
 15-8 
 12.90 
 11.30 
 II. 10 
 9-52 
 8.00 
 
 cm.), 
 cm.), 
 cm.), 
 cm.) . 
 cm.), 
 cm.). 
 
 8.48 cm.). 
 
 7.40 cm.). 
 
 6.40 cm.). 
 
 6.00 cm.), 
 
 5.60 cm.). 
 
 Statistics of the width of the uterus show a corresponding diminution. During 
 the first two puerperal days the width is greater than immediately after de- 
 livery. Upon the tenth day post partum the uterus does not lie entirely in 
 tlie true pelvis, as is so often stated. My observations show that in primiparce 
 the fundus on the tenth day is still 2.49 inches (6.34 cm.) above the symphysis, 
 and in multiparae 1.96 inches (5.00 cm.) — a total average of 2.22 inches (5.60 
 cm.). While its position at the onset of the puerperium is one of retrodis- 
 placement (Fig. 912) as a result of its weight and the laxity of its ligaments, the 
 conditions are reversed in involution, so that by the ninth day the position 
 is one of anteversion or anteflexion, which increases as involution progresses 
 (Fig. 911). A certain degree of rotation on the longitudinal axis is often pres- 
 ent. Hansen (cited by Temesvary) has made measurements which show that 
 the distance from the fundus to the external os diminishes up to the tenth 
 week post partum. These figures appear to be a suitable criterion for the 
 duration of the process of involution. They also show that the uterus never 
 entirely regains its original length. By this means it may also be shown that 
 involution occurs with less delay in multiparae and nursing mothers. Involution 
 is also known to be delayed after hydramnios, twin births, labor in contracted 
 pelves, hemorrhage, premature delivery, puerperal disease, and the action of 
 psychical influences. 
 
 (2) Muscle. — We know that the original muscular fibers of the uterus 
 
 * Temesvary gives the following table: 
 
 Immediately after delivery 4.29 inches (10.91 cm.). 
 
 First day ' 5.33 " (13.55 cm.). 
 
 Second day 4.9 " (12.45 cm.). 
 
 Third day 4-39 " (11. 16 cm.). 
 
 Fourth day 4.02 " (10.21 cm.). 
 
 Fifth day 3.66 " ( 9.29 cm.). 
 
 Sixth dav 3.24 " ( 8.22 cm.). 
 
 Seventh day 3.00 " ( 7.61 cm.). 
 
 Eighth day' '2. 88 " ( 7.32 cm.) 
 
682 
 
 PH Y SI LOGIC A L P UERPERI UM . 
 
 increase in size during gestation. Therefore in involution the hypertrophied 
 individual elements must undergo reduction to their normal dimensions. This 
 is effected by fatty metamorphosis of the protoplasm of the muscle- fibers. The 
 primitive fat-drops coalesce to form large collections between the muscular bun- 
 dles, whence the fat is taken up by the blood- and lymph-capillaries. The appear- 
 ance of fat-drops in the uterine muscle-cells is an evidence on the first day post 
 partum. The process of involution affects the nuclei of the muscle-cells as well 
 as the substance proper. Within recent years it has been shown that a glyco- 
 genesis occurs at the same time as fatty transformation (Fig. 913). 
 
 (3) Vessels. — Involution of the larger vessels is accomplished by prolifera- 
 tion of the intima occurring side by side with fatty de- 
 generation of the media. The capillaries appear to be 
 destroyed outright by compression, passing rapidly into 
 a state of fatty degeneration. The nutrition of the 
 uterus is maintained by the partially obliterated vascular 
 trunks. 
 
 (4) Decidua. — When the membranes are cast off 
 at the completion of delivery, the separation occurs at 
 the so-called ampullary layer of the decidua. This 
 leaves a thin stratum of decidual tissue which serves as 
 a temporary lining for the uterus (Fig. 914). At the 
 serotinal portion the surface is more or less bloody. 
 The remainder of the lining is raw, shreddy, and uneven 
 through the forcible separation of the dilated uterine 
 glands. Portions of the decidual layers which are nor- 
 mally cast off at birth may remain to undergo gradual 
 necrosis and expulsion with the lochia (Figs. 907 to 
 909). The persistent portion of the decidual tissues 
 undergoes transformation into connective-tissue corpus- 
 cles, thereby laying bare the original mucous membrane 
 of the uterus, from the epithelial cells of which a new 
 mucosa is generated. The epithelium in this case comes 
 from the uterine glands and rapidly proceeds to cover 
 the bare septa between them. This process of repair is 
 always accompanied by an abundant exudation and 
 leucocytosis. According to some authorities, the per- 
 sistent decidual cells become transformed into epithe- 
 lium. 
 
 (5) Placental Site. — This portion of the inner 
 surface of the uterus necessarily undergoes a reduction 
 in size corresponding to that of the uterus itself. 
 
 The open sinuses are at first protected by firmly adherent clotted blood and 
 the majority become occluded by thrombosis, the remainder by muscular 
 compression. The placental site is still recognizable for from four to six weeks 
 after delivery and is indicated by a prominence f to -f- inches in width (i to 
 2 cm.), the former blood-vessels persisting only as pigmented points. It thus 
 appears that the placental site is the last portion of the uterus to undergo 
 complete involution. 
 
 (6) Adnexa.— The ovaries, enlarged during pregnancy, gradually resume 
 their original dimensions; the dilated and stretched tubes become narrow 
 and tortuous; the peritoneal coat of the uterus contracts, and the laminae 
 of the broad ligament become unfolded and once more approach each other. 
 
 Fig. 913. — Muscle-fi- 
 bers OF THE Uterus 
 ON THE Sixth, Tenth, 
 AND Eighteenth 
 Days of the Puer- 
 perium. 
 
LOCAL PHENOMENA. 
 
 683 
 
 Changes in the Breast and Milk Secretion. — The changes m the breast up 
 to the time of the puerperium have already been described. During the first 
 three days of this period the so-called colostrum, an immature milk, is secreted. 
 This is a turbid, watery fluid which exhibits whitish or yellowish streaks. The 
 microscope shows that colostrum is an irregular emulsion, its fat-drops being of 
 unequal size and adhering to one another (Fig. 917). This point serves to dis- 
 tinguish between this fluid and milk, the latter bemg a perfect emulsion (Fig. 
 916). Agglomeration of the fluid fat-drops into compact masses constitutes 
 the so-called colostram corpuscles. It is probable, however, that the latter 
 really represent a complete 
 
 fatty degeneration of the epi- r i 4 2 ■; 3 
 
 thelium of the mammary gland. 
 Colostrum is poor in casein and 
 rich in serum-albumin; there- 
 fore, unlike milk, coagulates on 
 boiling. The secretion of the 
 breast loses its coagulability at 
 the latest by the fourth day, 
 showing the period of transi- 
 tion from colostrum to milk. 
 The amount of breast secretion 
 during the colostrum period is 
 relatively insignificant. After 
 its transition into milk the 
 amount rapidly increases. 
 From the third puerperal day 
 the breasts increase rapidly in 
 size and usually exhibit fulness 
 and tension. Individual lobuli 
 may often be felt, giving the 
 gland a nodular character (Fig. 
 918). ' The swelling about the 
 gland proper may even extend 
 to the axilla, and may be ac- 
 companied by more or less 
 pain. That a milk stagnation 
 or milk fever ever occurs as a 
 physiological phenomenon is 
 now disputed; all evidence of 
 this sort will doubtless, in 
 time, come to be regarded as 
 due to bacterial infection. (See 
 Fever, Part X.) The period of 
 
 active congestion which ushers in the secretion of milk proper does not last 
 over two days when the woman nurses her child, and somewhat longer when 
 she does not. In the latter case, when there is no demand for its secretion 
 the milk gradually assumes the character of the original colostrum, and 
 finally disappears altogether. The emptying of the breast in lactation is 
 brought about as follows : The infant first causes an erection of the nipple so 
 that the first milk that enters the sinuses of the excretory duct is abstracted 
 by the pressure and suction of its lips. The vis a iergo is then brought into 
 play through reflex stimulation of the gland by the act of suction, so that an 
 
 v^t\';0/'fa!'(«l» f'fy V.!i 
 
 ^M 
 
 j ^^ 
 
 Fig. 914. — Regenerating Mucous Membrane of 
 THE Uterus on the Sixth Day of the Puer- 
 perium. I, Portion of necrosed decidua with leu- 
 cocytes free and embedded; 2, edge of firm decidua; 
 3, beginning formation of new epithelium; 4, glands 
 lined with epithelium ; 5 , wall of granulation tissue 
 under the necrosed decidua; 6, gland; 7, capillary 
 blood-vessels; 8, disintegrating and degenerating 
 decidual cells in a network of connective tissue; 
 9, muscle of the uterus; 10, deepest portion of the 
 decidua containing spindle-shaped cells. — (Bnmm.) 
 
684 
 
 PHYSIOLOGICAL PUERPERIUM. 
 
 increase occurs in the secretory pressure. In a few moments after the appli- 
 cation of the child a pain is felt in the breast and the milk is then seen to 
 jet forth. This may often be observed simultaneously in the opposite breast, 
 and even in both glands quite independently of the act of suction, from the 
 mere thought of suction. 
 
 Human milk proper is a white, opaque fluid with an alkaline reaction, sweetish 
 taste, and density of 1030. The microscope shows it to be composed of an 
 
 emulsion of fat-drops in a fluid known as 
 the milk plasma (Fig. 916). These fat- 
 drops rise after the milk has stood for a 
 few hours and compose the cream. During 
 the first eight days of the puerperium, or 
 up to the fourth or fifth day of actual 
 secretion of milk, extraneous formed ele- 
 ments may be recognized by the micro- 
 scope — blood-corpuscles, fibrin, colostrum 
 corpuscles, etc. The fat-drops of the milk 
 are composed of a number of fatty acids 
 (palmitic, stearic, oleic, myronic, butyric, 
 etc.) in combination with the glycerin 
 radical, thereby forming triglycerides or 
 neutral fats of the same class as those 
 which make up adipose tissue of animals 
 in general. The most important soluble 
 ingredient of milk is the proteid matter, 
 which appears to undergo considerable fluc- 
 tuation m quality, ^ that a given test does 
 not always respond in the same fashion. 
 It is admitted that the principal proteid 
 constituent is casein, and some chemists 
 regard it as the sole proteid of milk. 
 The majority, however, regard serum-albu- 
 min and nuclein as normal proteid ingre- 
 dients. The existence of an albuminoid 
 envelope about the fat-drops, so long main- 
 tained undisputed, is to-day denied. Hei- 
 denhain claims that the mere colloidal ac- 
 tion of the casein in solution suffices to pre- 
 vent the coalescence of the fat-drops. The 
 casein is combined in the milk with calcium 
 phosphate, which holds it in solution. If 
 this salt is withdrawn from the combination 
 by the addition of a few drops of a weak 
 solution of hydrochloric or acetic acid, the 
 casein is immediately precipitated. Spon- 
 taneous coagulation is due to the action 
 of the Bacillus acidi lactici, which forms lactic acid from the lactose of the milk 
 and thereby precipitates the casein. This separates the milk into a soHd and 
 a fluid portion known respectively as the curd and whey. Milk which curdles 
 spontaneously is made sour through the formation of lactic acid. The action 
 of rennet or lab ferment coagulates the milk without souring it. In human 
 milk casein is always precipitated in small flocculi. In addition to the 
 
 Fig. 915. — Section through an Inac- 
 tive Breast at the Third Week 
 OF the Puerperium. i, Skin; 2, 
 adipose tissue; 3, tubercles of Mont- 
 gomery; 4, nipple; 5, milk duct; 6, 
 muscle; 7, glandular tissue; 8, milk 
 ducts; 9, muscle. — {Bumm.) 
 
LOCAL PHENOMENA. 
 
 685 
 
 proteid matter, milk contains milk-sugar (lactose), salts, and traces of a 
 diastatic ferment. The amount of milk secretion is capable of increase up 
 to the eighth month, after which it gradually declines. The daily average 
 for the first week is about a pint (500 c.c), which gradually increases till at 
 its maximum it is over a quart (i.i liters). As a general rule, lactation is com- 
 pleted at the end of a year, but this period is subject to many variations. A 
 secretion of milk out of all proportion to the demands of the child is known 
 as polygalactia, and if it persists when the child is not nursing it is termed 
 galactorrhea (see Part VII). Defective secretion of milk is common in the 
 very young or the elderly, in the delicate, weak, and cachectic. The obese also 
 suffer in this respect, the breasts in such women being subdeveloped. According 
 to Baumm and Illner, there are no true galactogogues, nor can the secretion 
 of milk be modified by the diet; but the amount of milk can be much lessened 
 by insufficient diet and then brought to the normal by generous regimen. The 
 composition of milk varies more or less in the same woman, and while the 
 gross amount is not affected by diet, the milk may be made richer in fat by 
 
 Pig. 916. — Contents of Milk, i, Fat- 
 globules (milk corpuscles); 2, milk cor- 
 puscles with the remains of the proto- 
 plasm of the gland epithelium; 3, milk 
 corpuscles covered with nucleated pro- 
 toplasm. — (Bumm.) 
 
 Fig. 917. — Contents of Colostrum, i, 
 Fat-globules of different sizes; 2, epi- 
 thelium of the milk ducts; 3, colostrum 
 corpuscles. (Leucocytes containing fat- 
 corpuscles.) — (Bumm.) 
 
 generous living. The limits of variability appear to be as follows: Proteids, 
 1.41 to 3.50 (per cent.); fat,. 1.42 to 5.25; sugar, 5.04 to 7.76; ash, 0.16 to 
 0.36. The milk of a primipara is somewhat richer in solids than is that of a 
 multipara. Age alone, within certain limits, is without effect upon the com- 
 position of the milk. The period of lactation exerts ver}' little influence, al- 
 though during the first ten days of the puerperium there is a steady decline 
 in the proteid, which thereafter remains constant. Baumm and Illner have 
 made many studies in connection with feeding nursing mothers. The milk 
 as a whole, when in normal quantity, cannot be increased by feeding, although 
 individual constituents may be thus affected. Thus, forced feeding with 
 proteids or fats increases the percentage of fatty matter. Carbohydrates 
 have no effect whatever. Increased ingestion of fluids is practically without 
 effect. Illness of the nursing woman does no more than diminish slightly 
 the solid constituents. Neither menstruation nor mental emotion has any 
 notable effect on the milk. To sum up, we can maintain only one prominent 
 truth in this connection: viz., that the richness of the milk — or, in other words, 
 
686 
 
 PHYSIOLOGICAL PUERPERIUM. 
 
 the proportion of fat — can be modified in various ways. The following are 
 some of the medicaments which, administered to the mother, may enter the 
 milk: Certain coloring-matters, ethereal oils (wormwood, garlic, etc.), salicylic 
 acid, potassium iodide, the heavy metals (lead, mercury, iron, bismuth), arsenic, 
 antimony, atropin, chloral. Narcotics, including alcohol, while having a 
 tendency to enter the milk, do so in such small quantities that the infant is 
 not menaced. Human milk is practically sterile when secreted, but can readily 
 be contaminated with staphylococci from the milk-ducts and nipple. In 
 estimating the amount of milk, the usual methods of palpating the breasts 
 and noting the force with which the milk spurts from the nipple are more or 
 
 Fig. 918. — Section through an Inactive Breast during the Puerperium. The epi- 
 thelium of the acini shows various conditions. i, Quiescent acinus ;_ 2, acinus dis- 
 tended with milk; 3, 4, 5, secreting acini ; 6, interacinous connective tissue; 7, capil- 
 laries; 8, secreting gland epithehum with large fat-corpuscles in the protoplasm, the 
 nuclei being pressed against the cell-wall; 9, formed milk. — (Bumm.) 
 
 less sources of fallacy. A more sensible way of arriving at this knowledge 
 is by the examination of the infant. By means of a proper scale the child 
 may be weighed before and after each feeding. It should nurse from 1.8 to 
 7.2 ounces (50 to 200 gm.) according to age every two hours. Direct analysis 
 of the milk is required only for the determination of the percentage of fat. 
 High specific gravity means low percentage of fat. and vice versa. The micro- 
 scope also gives information of some value in this direction, as does allowing 
 the milk to stand twenty-four hours and computing the thickness of the super- 
 natant cream, which should be 10 per cent, of the whole. For quantitative 
 work the lactobutyrometer will give approximate results to the practitioner. 
 Subsequent Impregnation. — How soon after delivery can a woman again 
 
DIAGNOSIS OF THE PUERPERIUM. 687 
 
 be impregnated? G. L. Bonnar * reached some interesting conclusions in 
 regard to this question. Not being satisfied with the then generally accepted 
 opinion that a month must elapse between the termination of labor and 
 a fresh conception, he undertook an investigation into what was known as 
 "Hodge's Peerage and Baronetage." His results were as follows: In at least 
 nineteen cases the interval between one birth and another was less than 309 
 days. In ten cases the interval varied from 309 to 300 days, in two from 
 299 to 290, in four from 289 to 280, in one it was 273, in another 252, in 
 another 182, in another 173, and in one 127 days. Taking these cases into 
 consideration, as well as the post-partum conditions of the uterus, lochia, 
 and vagina. Dr. Bonnar placed the earliest date after confinement when the 
 woman could again become pregnant as the fourteenth day. Leopold's ob- 
 servations appear to prove that the repair of the uterine mucous membrane 
 after confinement is not complete earlier than the end of the fourth week; 
 that the red and yellow lochia cease at the beginning of the second week, and 
 that the white lochia continues until the sixth week. Observations would 
 tend to indicate that one-half of those women who do not nurse their children, 
 and also those women who menstruate during the period of lactation, have 
 their first post-partum menstrual period, and hence ovulation and capability 
 of impregnation, within six weeks after confinement. 
 
 III. DIAGNOSIS OF THE PUERPERIUM. 
 
 I. Signs of Recent Delivery. — As the physician is required to render a decision 
 not only in the case of the living, but also in the dead, he must, from signs 
 present, state whether or not a recent expulsion of the contents of a pregnant 
 uterus has taken place. In the first instance, the case of the living, the decision 
 is reached by the usual methods of diagnosis ; in the case of the dead, the value 
 of an inspection of the uterus and its appendages is added. 
 
 (i) Signs in the Living. — As in the diagnosis of pregnancy, so in the deter- 
 mination of the existence of a recent delivery in the living, there are a large 
 number of signs of greater or less value. Doubtful signs: The uncertain symp- 
 toms prove nothing; they can exist in conditions other than that of the puer- 
 perium, and in the male as well as in the female. Probable signs: These include 
 signs existing in -the genital tract and in the mammary glands. (See Local 
 Phenomena of Puerperium.) Positive signs. Positive proof of the occurrence 
 of birth is furnished only by the discovery of parts of the ovum. If, upon careful 
 microscopic investigation of the lochial discharges (see Figs, 907, 908, and 909) 
 we fail to find any evidence of remains of the ovum, we can with the finger or 
 curette remove the remains of the placenta from the inner surface of the uterus, 
 and demonstrate under the microscope the tissue found, thus fully establishing 
 the diagnosis. The demonstration of the shreds of decidua with large nucleated 
 and fatty cells is of itself a sure proof. The diagnosis of the puerperal condition 
 will rarely be found difficult within ten or fourteen days after parturition. In 
 multiparas the diagnosis cannot in some instances be positively established after 
 the lapse of even a week or ten days. If the case is one of a primipara, the 
 character, intensity, and persistence of the signs present will permit a diagnosis 
 to be made at a later date. 
 
 Date of Delivery. — We are enabled to answer this question by carefully 
 
 * " Critical Inquiry Regarding Superfoetation, with Cases." 
 
688 PHYSIOLOGICAL PUERPERIUM. 
 
 observing the character of the secretion from the breasts; the appearance and 
 composition of the lochial discharge; the height of the fundus uteri in the ab- 
 dominal or pelvic cavity; and particularly the freshness of the wounds that may 
 exist in the genital tract. 
 
 (2) Signs in the Dead. — The diagnosis of recent delivery in the dead rarely 
 presents any difficulty. Many, if not all, of the signs of recent delivery occurring 
 in the living may be found in the dead, and, in addition, we are able to see 
 the alterations in the uterine body and its appendages. The rate of return of 
 the uterus to its normal size depends upon so many factors — as the period of 
 gestation at which labor occurs, pathological conditions in the pelvis prior or 
 subsequent to labor, the general condition of the woman, etc. — that any 
 attempt to state positively from a post-mortem examination the exact 
 date upon which parturition took place must result in failure. Four to six 
 weeks after labor the placental site may still be recognized, but it is smooth 
 and barely two-thirds of an inch across, and the places formerly occupied by 
 the vessels are now marked by yellow and black spots of pigmentation. As to 
 the signs of pregnancy revealed by a post-mortem examination, those of an objec- 
 tive character will in most cases be present. There are two which have not yet 
 been mentioned: namely, (i) The finding of the ovum, embryo, or fetus within 
 its envelopes in the uterus. The gross appearance of the ovum, embryo, and fetus 
 in the several months of gestation will be found described on pages 82 and 83 , and, 
 of course, this furnishes reliable evidence. (2) The presence in one or both ovaries 
 of a true corpus luteum. After the Graafian follicle or ovisac ruptures and dis- 
 charges the ovum, a certain change takes place in the ruptured follicle which 
 results in the formation of the corpus luteum (page 19). Modern investigation 
 would seem to sustain the statement that no positive evidence is to be derived 
 from either the false or the true corpora lutea. Instances are on record in which 
 the so-called true corpus luteum has existed in the absence of pregnancy. 
 
 2. Primipara and Multipara. — In primiparas we find the fragments of the 
 freshly torn hymen, fourchette, and possibly permeum. The external genitals 
 are usually, also, more swollen, reddened, and sensitive to the touch than in 
 multiparas. 
 
 3. Feigned Lying-in State. — (See Feigned Delivery, page 449.) 
 
 IV. THE MANAGEMENT OF THE PUERPERIUM. MOTHER. 
 
 latroduction. — The borderland between the physiological and pathological 
 puerperium is not sharply defined. The parturient suffers from slight trauma- 
 tisms almost through the entire genital tract; she has thrombi in the uterus at 
 the former site of the placenta, and the birth canal is hypertrophied above and 
 unduly relaxed below. Physiological conditions may so readily become 
 pathological that the obstetrician should constantly be on his guard until 
 the time of danger has passed (see page 673). As alread}^ stated (Part IV), 
 the physician should remain with the patient for at least an hour after 
 the completion of the third stage of labor. During this period, which is 
 called "the physician's hour," the abdominal binder and first vulval dressing are 
 applied as already described (page 496), after a thorough cleansing of the 
 external genitals and neighboring parts with an antiseptic solution. The 
 draw-sheet has, of course, been removed and all soiled clothing and bed- 
 ding have been replaced by clean material. It is essential, however, that during 
 
THE MANAGEMENT OF THE PUERPERIUM. MOTHER. 689 
 
 this process the patient be disturbed as little as possible, and if she is much 
 exhausted she should be allowed to rest for a short time before anything is done. 
 The head should be kept low and the patient not allowed to turn on the side, 
 since she might assume the Sims position, which favors the entrance of air into 
 the uterine sinuses and possibly air embolism. The management of the puer- 
 perium consists chiefly in: (i) cleanlmess and (2) rest. In regard to cleanliness 
 the woman should be aseptic when she enters the lying-in bed; and after labor 
 she should be kept as aseptic as possible. In regard to asepsis before labor, 
 it is taken for granted that the pregnant woman has formed the daily habit of 
 general bathing, cleansing the mouth, and external genitals. 
 
 I. Asepsis during the Puerperium. — In ordinary cases the resources of nature 
 cannot be equaled by those of art. I have noted the importance of limiting vaginal 
 examinations as much as possible in the first and second stages, and the danger of 
 unnecessary manipulation in the third stage. No physician is competent to 
 manage a case of labor who cannot in the great majority of cases so conduct the 
 third stage that no internal manipulations are necessary. The same principles 
 
 RETENTION STRAP 
 
 Fig. 919. — Abdominal Binder and Breast Support for the Normal Puerperium. 
 The retention straps connecting the lower edge of the binder to a band about the thighs 
 are used only when the binder shows a tendency to slip up above the pelvis. — {From 
 a photograph^ 
 
 of treatment should guide him in the management of the puerpermm. Douches 
 are not indicated unless unfavorable symptoms arise; e. g., high temperature or 
 local fetor. (See Treatment of Septic Infection, Part VII.) Cleanliness of the 
 patient and bedding, strict antisepsis of the external genitals, including disin- 
 fection of lochia and thorough ventilation of the lying-in room, are important 
 points to be remembered, (i) Antisepsis of the external genitals: This is best 
 secured by washing with sublimate i : 4000, lysol solution (2 per cent.), and pay- 
 ing special attention to the flexures of the thighs or any folds or creases of skin 
 which may serve as receptacles for septic material. The lips of the vulva need not 
 be separated ; all washing should be done from above downward and the tissues 
 about the anus should be scrupulously avoided till all the other parts are cleansed. 
 This cleansing of the external genitals should precede each application of the 
 vulval dressing, and is best accomplished by vulval irrigation (Fig. 1055) supple- 
 mented with sterile cotton wipes. In all cases internal douches or other internal 
 manipulations, especially by the nurse or others, in the absence of a distinct 
 indication, are to be absolutely forbidden. There are alwavs some abrasions 
 44 
 
690 PHYSIOLOGICAL PUERPERIUM. 
 
 and small wounds in the genitals which if not treated antiseptically may become 
 the starting-point of an infection; it is therefore necessary to conduct the vulval 
 dressing with strict attention to these details. (2) The vulval dressing: There 
 are three essentials of a vulval dressing: (a) It should be of absorbent material, 
 that the accumulation of lochia! discharge about the vulva may be prevented; 
 (6) it should be saturated with an antiseptic material that the discharge may 
 be sterilized; (c) it should be impermeable, that the air may be excluded. As 
 an absorbent, gauze or cotton may be used, and should be borated or salicylated; 
 sublimate is too irritating for this purpose. Deodorizing chemicals, or those 
 with any odor, should not be used on the vulval dressing, as these mask the 
 fetor of decomposing lochia, a valuable sign of early septic infection. Over the 
 vulval dressing a long strip of salicylated cotton wrapped in gauze should be 
 placed and attached in front and behind to the abdominal binder. The vulval 
 dressing should be changed every four to six hours. While the foregoing pre- 
 cautions cannot be carried out in every case, it is fortunately true that if the 
 vaginal examinations in the first two stages of labor are made with great 
 care as to asepsis and limited as to number, if internal manipulations are care- 
 fully avoided during the third stage, and if strict cleanliness of the patient and 
 bedding is observed, very good results can be obtained even in the most un- 
 favorable surroundings. 
 
 2. Rest. — The first and most important requisite is that the patient should 
 have a period of refreshing sleep. She may be allowed to see her husband or 
 mother for a short time if she desires, but all other visitors should be rigidly 
 excluded. She should not be disturbed by the congratulations of friends 
 nor the intrusions of the curious, and if it is impossible to exclude them she 
 should not, know of their presence in the house, nor should she be disturbed by 
 the crying of the baby. The room should be darkened and perfect qtiict ob- 
 served. It cannot be too often repeated that perfect cleanliness and absolute 
 physical and mental rest shotdd usher in the puerperium. The nurse, however, 
 should from time to time note the pulse and general aspect of the patient, and 
 the presence of uterine contractions. The exclusion of visitors and the ob- 
 servance of quiet should not be limited to the first day or few days, but should 
 continue at least as long as the patient is confined to her bed. 
 
 3. Special Directions. — The patient should be seen again within twelve 
 hours after delivery, or sooner if required by the frequency of the pulse, rise of 
 temperature, excessive flowing, or any other unfavorable symptoms. Morning 
 and evening visits may be made for the first two or three days, and daily visits 
 till the tenth day or later, the patient being kept under observation till involu- 
 tion is complete. At each visit attention should be paid to (i) the mother's tem- 
 perature, pulse, and respiration (a.m. and p.m.); (2) the height and condition 
 of the uterus; after-pains; (3) the quantity, odor, and character of the lochia; 
 (4) the condition of the external genitals; (5) the condition of the bladder; 
 (6) the condition of the bowels; (7) the condition and secretion of the breasts; (8) 
 the nipples; (9) diet; and (10) the general condition of the patient and the neces- 
 sary treatment if any is required. Note should also be taken of (i) the child's 
 temperature, pulse, and respiration, but it is unusual to take the infant's rectal 
 temperature except for special indications; (2) the condition of the stump of the 
 cord and the umbilicus; (3) the number and color of the stools; (4) the passage 
 of urine; (5) the color and condition of the skin; (6) the condition of the eyes 
 (inflammation); (7) maternal nursing or artificial diet; (8) the stomach as shown 
 by vomiting; (9) the weight; (10) the condition of the nose and mouth; (11) the 
 general condition as to sleep, excessive crying, colic, irritation. For the care of the 
 
THE MANAGEMENT OF THE PUERPERIUM. MOTHER. 691 
 
 newly bom infant, see Part VIII. (i) Temperature, pulse, resptration: A diurnal 
 record should be made of the temperature and pulse, and when the latter is taken 
 by the attending physician it is advisable to note its rapidity both at the begin- 
 ning and at the end of his visit. Any departures from the normal standard should 
 call for rigid investigation into the cause. (See Part VIII.) These three 
 conditions should all return to normal on the second day. The pulse 
 is accelerated during and immediately after delivery and the temperature may 
 show a moderate rise during the first thirty-six hours, but after that any elevation 
 of temperature should be regarded with suspicion (Part VIII). (2) The height 
 and condition of the uterus: The height of the uterus above the symphysis should 
 be estimated or measured; and the sensitiveness and contractility determined 
 by abdominal palpation, not neglecting at the same time to search for evidences 
 of perimetritis or parametritis by palpating over the adnexa and in the iliac 
 fossae. After-pains: These are caused by irregular and painftd uterine contrac- 
 tions, and are often due to clots in utero. The use of the fluid extract of ergot, 
 one drachm every three hours, is usually beneficial in cases of retained blood- 
 clots. Should the sleep be much disturbed, codein in moderate doses, one- 
 quarter grain every two hours for two or three doses, may be used as less likely 
 to produce unpleasant after-effects than other preparations of opium. De- 
 pressants should be avoided. When pain is moderate and not due to blood- 
 clots, phenacetin, five grains every three hours for two or three doses, will be 
 found useful. I have found antipyrin, five grains, with a teaspoonful of aromatic 
 spirits of ammonia every hour for two or three doses, efficient. When the pain 
 is severe and not due to retained clots, the following will answer well: Tincturae 
 opii deodoratae, 5i; chloralis hydratis, gr. xl; elixiris aromatici q. s. ad .^i. 
 Sig. : Teaspoonful in water not oftener than every four hours. (3) The lochia: 
 The physician should not neglect to inform himself as to the amount and char- 
 acter of the lochia. Marked diminution or suppression or the presence of a 
 putrid odor should lead to the suspicion of sepsis and a careful investigation. 
 If the red color persists much longer than usual, it is probably due to subinvo- 
 lution (page 708). The lochial stain in healthy cases is red in the center, gradu- 
 ally fading away toward the periphery. In cases of putrid lochia the circum- 
 ference of the stain is well marked,while the color at the center is lighter. Famil- 
 iarity with the sometimes heavy but not offensive odor should be cultivated 
 in order to avoid mistakes. (4) The external genitals: Antisepsis of the external 
 genitals has already been referred to (page 689). (5) The bladder: A frequent 
 and annoying complication of the puerperium is the retention of urine, of which 
 the causes have been noted (page 676). At his first visit the physician should 
 satisfy himself by percussion and palpation as to the condition of the bladder. 
 The use of the catheter should be avoided if possible and urination encouraged 
 by the application of hot cloths to the abdomen and vulva, by small doses of 
 ergot and the sound of running water, by tightening the binder or compressing 
 the abdomen to reinforce the action of the lax walls. The patient may succeed 
 after the first three days, by the cautious assumption of the sitting posture. 
 The dangers of sitting up at this time have been very much exaggerated, and 
 if the uterus is well contracted and the pulse not affected by the position it is 
 probably preferable to the passage of the catheter. It should be remembered 
 that the danger of cystitis from the passage of the catheter is decidedly in- 
 creased after the second or third day on account of the beginning decomposition 
 of the lochia. As a rule, the patient may be allowed to hold water for twelve 
 hours if the uterus is well contracted and there is no danger of hemorrhage, and 
 she should be encouraged in the effort to avoid the catheter. If its use becomes 
 
692 PHYSIOLOGICAL PUERPERIUM. 
 
 inevitable, it shotdd be passed with all aseptic precautions. The external genitals 
 should be carefvdty cleansed, the region of the meatus should be sponged with 
 a I : 4000 sublimate solution, and the catheter inserted under the guidance of 
 the eye, A glass catheter should be used when possible, as it admits of perfect 
 sterilization by boiling. It is a useful precaution for women during the last few 
 weeks of pregnancy to become accustomed to urinating in the recumbent posture. 
 (6) The bowels: A laxative shoiild be given at the end of the first forty-eight 
 hours. Castor oil, from one-half to one ounce, if not offensive, is preferable. Com- 
 pound licorice powder is a good preparation. When the patient feels an incli- 
 nation for a movement, it is well to soften the rectal contents by an injection 
 of two or three ounces of olive oil or water, since owing to the bruises and small 
 lacerations incident to labor, the passage of hard fecal masses is sometimes very 
 painful. The same procedure is valuable in perineorrhaphy cases (Part X). A 
 laxative may be given from time to time while the mother remains in bed, but 
 if enemata are sufficient they are preferable. Many women are unable com- 
 pletely to empty the bladder or bowel by the use of the bed-pan, and resulting 
 pelvic congestion and pressure are favored. The difficulty could have been 
 avoided had the patient been trained in the use of the bed-pan during preg- 
 nancy. Another remedy for incomplete bladder or bowel evacuation, and a 
 method which at the same time favors uterine drainage, is permitting the patient 
 to sit upon the vessel placed in the bed or upon a commode at the bedside, early 
 in the puerperiimi, for bladder and bowel evacuation. This has in the past been 
 recommended by some in selected cases, and by others in all. In my observa- 
 tion during the past ten years on many thousands of cases confined in the tene- 
 ments, I have never seen dangerous symptoms result from this practice, and 
 yet the majority of patients within six or eight hours of their confinement either 
 sat upon a vessel in bed or at the bedside to pass urine. (7 and 8) The breasts 
 and nipples: The management of the nipples during the latter months of preg- 
 nancy in cases of deficient development has been mentioned (page 187). With 
 the establishment of the milk secretion on the third day the breasts sometimes 
 become the seat of painftil distention, owing to the excessive secretion, and the 
 relief afforded by putting the infant to the breast may not be sufficient to relieve 
 the condition. One of the best methods to correct the overdistention is massage 
 and milking the breasts through a piece of hot sterile flannel, the milk being 
 allowed to flow into the warm flannel (Part VII) (Fig. 967). Breast-pumps are 
 to be avoided if possible, but if used-the action should be assisted by the nurse, 
 who should gently compress the breast and massage it with the finger-tips from the 
 periphery toward the nipple (Figs. 967, 968, 969). All rough handling should be 
 avoided. Uniform compression and considerable relief may be afforded by the 
 use of a breast bandage, with or without hot stuping (Fig. 972). If the distention 
 is very great, it may be advisable to administer a saline cathartic and restrict the 
 supply of liquids, milk included, for a time. The application of a hot lead and 
 opium wash may afford relief, but great care should be taken when applying the 
 child to the breast. Before and after each nursing the nipples shotdd be care- 
 fully cleansed with a saturated solution of boric acid and covered with sterilized 
 gauze without exercise of pressure. It is a useful precaution against cracks and 
 fissures of the nipple to anoint the nipple and tissues about its base with steril- 
 ized sweet oil after each nursing. The importance to both mother and child of 
 the proper performance of the fimction of lactation is universally admitted. 
 Its favorable influences upon uterine contraction and involution and the subse- 
 quent prevention of uterine disease should never be forgotten. 
 
THE MANAGEMENT OF THE PUERPERIUM, MOTHER. 693 
 
 If the child is still-born or dies subsequent to labor or it is necessary to wean 
 for any cause the proper care of the breasts is important. 
 
 Of the various treatments proposed for controlling and drying up the milk 
 secretion, I have been most successful with the following: 
 
 1. The application of a tight well-fitting breast binder, after the breasts 
 have been lightly smeared with a solution of atropin sulphate in glycerin 
 (gr. i to Bj). This is repeated twice in the twenty-four hours. 
 
 2. The cutting-down of the liquid intake to a minimum. 
 
 3. The causing of free watery stools with saline cathartics. 
 
 4. The avoidance of all massage of the breasts or the use of breast-pumps 
 if possible. 
 
 Should the breasts become very hard and painful, the application of hot 
 flannel stupes, and the massaging out of the milk secretion through and into 
 the stupes is permissible. 
 
 In the case of still-born children, and when the above treatment can be 
 instituted before the fiUing-up of the breasts on the third day, stuping and 
 massage are rarely necessary, and should be avoided if possible in any case. 
 
 4. Diet. — Individual characteristics must be considered, also the character of 
 the delivery and whether it was accompanied with little or great loss of blood. 
 A mixed diet seems to give the best results and may be begun on the first day. 
 This form of diet causes the least loss of weight. During the first few days 
 it is well to give a highly albuminized diet, and alcoholics should not be used 
 except in the presence of collapse or weakness. Milk, wheaten and other 
 forms of bread, soups, and well-cooked meats form the basis of the diet. Until 
 the bowels have moved on the second or third day a light diet, is advisable. 
 Milk, milk-toast, soup, gruel, or clam-broth may be given. A small amount 
 of tea may be allowed if the patient is accustomed to its use and desires it. 
 Coffee is apt to cause insomnia. After the bowels have moved, the appetite 
 of the patient may be trusted as a safe guide. The starvation diet is obsolete. 
 In view of the amount of disintegrated tissue to be eliminated, it would seem 
 that an excess of nitrogenous food is not indicated. Articles which cause con- 
 stipation should be avoided. If the breast secretion is deficient, however, a 
 liberal quantity of milk is the best remedy. 
 
 Diet-list After Normal Confinement. First Day or Two. 
 
 Liquids. — Milk, hot or cold; beef -tea, weak tea; beef -broth or chicken-broth; 
 beef -juice; egg shake; clam-broth; simple soups and cocoa. 
 
 Solids. — Thin bread and butter; saltine or soda crackers; milk-toast; dr>'' or 
 buttered toast; dropped or soft-boiled eggs; any breakfast cereal thor- 
 oughly cooked. 
 
 After First Two Days. — Liquids as above with addition of coffee. Solids: 
 Any breakfast cereal; scrambled, soft-boiled, or dropped eggs; broiled 
 whitefish; lamb chop; beefsteak; roast lamb; broiled, baked, or creamed 
 chicken; baked, mashed, or stewed potatoes; macaroni; celery; lettuce; 
 fruits; fresh vegetables, such as peas, asparagus, and string-beans in season 
 and in moderation; boiled or baked custard; curds and whey; wine jelly; 
 simple puddings, such as rice, tapioca. Avoid: Nursing mothers should 
 avoid whatever previously disagreed with them, and usually also pork, 
 veal, corned beef, cabbage, turnips, cucumbers, com, beans (canned and 
 dried), vinegar, strawberries, and melons unless thoroughly ripe. 
 
 Sample Breakfasts. — (i) Any breakfast cereal; soft egg; tea. (2) Orange; cereal 
 and cream; scrambled egg; tea or cocoa. (3) Cereal; broiled whitefish; 
 
694 PHYSIOLOGICAL PUERPERIUM. 
 
 bread and butter; tea, coffee, or cocoa. (4) Lamb chop; stewed potatoes; 
 
 toast; tea, coffee, or cocoa. (5) Orange; scrambled or dropped egg; minced 
 
 chicken; graham bread; coffee. 
 Sample Dinners. — (i) Broiled or roast chicken; sweet potato; baked cup custard. 
 
 (2) Roast lamb; mashed potato; macaroni; wine jelly. (3) Roast beef; 
 
 celery; mashed potato ; rice pudding. (4) Simple soup; chicken; stewed 
 
 potatoes; baked cup custard. (5) Raw oysters with any of the above. 
 Sample Suppers. — (i) Creamed chicken on toast; milk or cocoa. (2) Oyster 
 
 stew; bread and butter; cocoa. (3) Minced chicken on toast ; baked apples 
 
 and cream; tea. (4) Dropped eggs on toast; graham bread and butter; 
 
 cocoa or tea. (5) Raw oysters with any of the above. 
 
 5. Posture and Duration of the Puerperium. — For the first few hours after 
 labor the pillows should be removed and the head kept low to guard against 
 the occurrence of cerebral anemia. For a day or two, and especially when the 
 binder is not in place, the patient should on no account be allowed to turn 
 on her side, for reasons stated (page 689). For the first two or three days 
 the patient should remain quiet, lying on the back, which position is most 
 favorable for the closing of the uterine sinuses, the healing of abraded surfaces, 
 and escaping lochia. She should retain the recumbent position in bed until 
 the uterus can no longer be felt by external palpation; that is, ten days or 
 two weeks. The practice of keeping the patient on her back for all of this period 
 is not to be recommended. It is unnatural and depressing, and tends to cause 
 posterior displacement of the uterus, sacculation, and interference with drainage. 
 After the first seventy-two hours the patient should be encouraged to turn 
 first on one side and then on the other, and later to lie on the abdomen, and 
 finally to sleep in this position. At the beginning of the third week the patient 
 may be lifted into a reclining chair or on a sofa, and may sit up for a short 
 time each day as her strength permits. After the fourth week she may go 
 about the house or drive in the open air, but on no account should she resume 
 her household duties or do any lifting, long standing, or walking until the 
 period of involution is complete. The physician will not only do his duty 
 to his patient, but will save himself subsequent reproach, by insisting on 
 the observance of these rules, and he will find that every intelligent patient 
 will submit willingly to restraint or inconvenience if he explain to her how 
 largely her future health or even life may depend on care and moderation 
 during the lying-in period. Getting up too soon, and especially too early 
 resumption of household duties, are important factors in the production of 
 displacements and even prolapse, particularly when delivery has been at- 
 tended by some lesion of the pelvic floor which has been neglected or im- 
 properly treated. Patients even after leaving the bed shotdd spend part 
 of each day in the recumbent posture, and the occurrence of a backache 
 should be regarded as a warning against standing or walking and against any 
 kind of work. One reason why the puerperal woman is better for a considerable 
 rest in bed after delivery, and why the same kind of rest is not necessary in 
 the case of quadrupeds, is that in the erect posture natural to human beings 
 the uterus and its appendages and the floor of the pelvis are subjected to a 
 downward pressure which does not occur in a quadrupedal position. When 
 the woman does not rest recumbent long enough after deli\rery, she is liable 
 to many forms of uterine displacement, and her too early getting up may cause 
 hemorrhage by dislodging clots from the uterine sinuses, or thrombosis may 
 occur in the veins of the broad ligament with danger of embolism in the heart 
 
THE MANAGEMENT OF THE PUERPERIUM. MOTHER. 695 
 
 or lungs. The duration of the rest in bed is variously given as seven, fourteen, 
 to twenty-one days. The first is too short except in very unusual cases. A 
 rest of two weeks followed by gradual resumption of ordinary activities is 
 the usual period required. Involution of the uterus is not completed for a 
 period of five or six weeks, but if a patient is kept in bed as long as that she 
 loses flesh and strength and her appetite fails. When the patient first gets up, 
 she should remain up only an hour or so in the day. 
 
 6. Prophylaxis in the Puerperium. — While we cannot be so aggressive in 
 our methods in the puerperium as in labor, yet there is much that may be 
 accomplished in the way of prophylaxis. The all-important question at this 
 
 Fig. 920. ^Pelvic Binder and Pelvic Fig. 921. — Pelvic Binder and Perineal 
 
 Floor Support for Use after the Support. Posterior View. 
 
 Puerperium.* — (From a photograph.) 
 
 time is. How can we best secure involution in the puerperal state ? It is during 
 the puerperium that we should rivet our attention on the prevention of sub- 
 involution, especially in cases following the premature interruption of preg- 
 nancy. Were closer attention given this subject in practice, the sequelae 
 of subinvolution — metritis, endometritis, retrodisplacements, and prolapse 
 — would be less frequently met with. 
 
 (i) The Abdominal Binder. — The proper treatment of the relaxed ab- 
 dominal walls after delivery is of great importance for cosmetic reasons 
 and to prevent the results of pendulous abdomen. A certain amount of 
 
 * These binders may be obtained from the Home Bureau, 52 West 39th Street, New 
 York City. 
 
696 
 
 PHYSIOLOGICAL PUERPERIUM. 
 
 fixation is necessary for proper involution of the abdominal walls, and this is 
 best secured by a binder. The binder tends to prevent atony and lack of contrac- 
 tion in the uterus, splanchnoptosis of the abdominal viscera, and obviates the 
 danger of sudden filHng of the abdominal veins due to the greatly lessened intra- 
 abdominal pressure after confinement. The binder when properly applied con- 
 duces to the patient's comfort, especially by permitting her to assume the lateral 
 position. It should not be applied too tightly, as this, combined with prolonged 
 dorsal decubitus, tends to cause posterior displacement of the uterus. 
 
 (2) The Pelvic Binder. — After the patient begins to move about, the ordi- 
 nary abdominal binder is with difficulty kept in place, and, moreover, by this 
 time has pretty much served its purpose. At this time in all cases, but especially 
 in those of undue pelvic-floor projection, and in patients with weak and over- 
 distended abdominal walls (twins, hydramnios), I am accustomed to replace the 
 abdominal with a pelvic binder, to sustain the pelvic floor and the antero-lateral 
 
 abdominal wall for three months following 
 the puerperium (Figs. 920, 921, and 922). 
 The binder is made of muslin, linen, mull, 
 canton flannel, or two thicknesses of heavy 
 gauze, and, as the illustrations show, is made 
 to encircle the pelvis and lower abdomen at 
 a level with the crests of the ilia and to sup- 
 port the pelvic floor by a strap of the same 
 material passing between the thighs, and, 
 tightly drawn, is pinned in front or behind as 
 convenient. Ordinary corset lacing down the 
 front or back secures a snug fitting to the bin- 
 der. The pelvic binder, when applied, laced, 
 and the perineal band secured, is not unlike 
 in appearance and shape the ordinary swim- 
 ming trunks worn by bathers. I am accus- 
 tomed to have half a dozen pelvic binders 
 fitted and made in the latter part of the 
 puerperium and to replace the use of the ab- 
 dominal binder with them as soon as the 
 lochia has practically ceased in the third 
 week, when the patient first commences to 
 sit up in bed or changes from bed to lounge, 
 and to continue its use for three months from 
 that time. The results obtained by the use 
 of this support have been more than satisfactory. It is appreciated by the patients 
 themselves, some having used them after four confinements, (i) It prevents or 
 corrects undue sagging of the pelvic floor. This is especially noticeable in. cases 
 in which during labor the levator ani muscle has been subjected to severe or pro- 
 longed pressure, severe lacerations with bad union, and in which the levator ani is 
 torn, the perineum remaining intact. (2) It assists in the ultimate union of severe 
 lacerations of the pelvic floor which have been repaired. (3) It preserves the 
 woman's figure after confinement by its support of the lower anterior abdominal 
 wall and the pelvic floor. (4) It lessens the danger of displacement of the pelvic 
 contents. (5) It tends to prevent pelvic congestion. (6) It usually adds to the 
 comfort of the patient, giving her a feeling of security and well-being and allowing 
 her to obtain needed exercise earlier and more freely than would otherwise be the 
 case. Unless preexisting pelvic disease is present, with the use of this pelvic sup- 
 
 VIEW. 
 
 Fig. 922. — ^Pelvic Binder and Peri- 
 neal Support, showing Shape. 
 
THE MANAGEMENT OF THE PUERPERIUM. MOTHER. 697 
 
 port we rarely see the danger signals of pelvic congestion— backache and irritable 
 bladder; and the complex nervous manifestations of splanchnoptosis in general 
 and of gastroptosis, nephroptosis, and enteroptosis in particular. 
 
 (3) Medication. — What place have drugs and various non-medicinal methods 
 of treatment of the puerperium in the prevention of subinvolution and subse- 
 quent gynecological conditions? During the past ten years I have experimented 
 with various methods of managing the puerperium with the object of deter- 
 mining, if possible, the best treatment for the prevention of subinvolution 
 and subsequent gynecological conditions. Ergot, quinine, repeated hot vaginal 
 irrigations, apparently have no effect in hastening uterine involution. The 
 best results were obtained with (i) strychnin administered both during the 
 
 Fig. 923. — Breast Support for Nursing 
 Women. — (From a photograph.) 
 
 Fig. 924. — India Gauze Bodice used as 
 Breast Support. — {From a photograph.) 
 
 latter part of pregnancy and during the first ten days of the puerperium; (2) 
 rotation of the patient as regards posture during the lying-in state; (3) early 
 use of the vessel in bed or the commode at the side of the bed, favoring drainage 
 and avoiding pelvic congestion. 
 
 (4) Massage and Exercise. — Massage, including dry friction of the skin 
 of the whole body, general massage with deep manipulations, kneading and 
 deep rubbing, local massage of the abdominal viscera, through the abdominal 
 walls, and exercises, including principally passive and resisted movements 
 of the extremities, are valuable therapeutic agents in the prevention of sub- 
 involution of the uterus and abdominal walls, and splanchnoptosis with its 
 attendant digestive, circulatory, and nervous phenomena. Like other remedial 
 agents, such measures are to be used with care, and are not applicable to all 
 
698 PHYSIOLOGICAL PUERPERIUM. 
 
 cases alike. Stimulation of the cutaneous circulation by dry friction with 
 the hand or Turkish glove or by an "alcohol rub" can generally be used 
 with advantage after the first day of the puerperium. In the absence of com- 
 plications, general massage with deeper manipulations, kneading, and rubbing 
 can be gradually introduced toward the end of the first week if the lochia 
 is not increased thereby, and in the second week gradually increasing passive 
 and resisted movements of the extremities may be added. All forms of septic 
 infection, but especially the thrombotic variety, are contraindications to the 
 use of anything more active than surface stimulation. 
 
 (5) The Ftrst Use of the Corset. — It is especially important in the first use 
 of the corset that a properly fitting garment be employed. At this time espe- 
 cially should the corsets which exert a downward pressure into the pelvis, and 
 form excessive pelvic floor projection, retro displacement, and prolapse of the 
 uterus, be avoided. Corsets made to support the lower abdomen with an upward 
 and backward pressure should be used (Figs. 36 and 37). 
 
 7. The Examination of the Puerperium. — The importance of routine examina- 
 tion of the pelvic contents and noting the tonicity or sagging of the pelvic floor 
 (levator ani muscle) at the completion of the puerperium cannot be overesti- 
 mated. If this is made a routine, many minor derangements could be corrected, 
 which, if untreated, would become aggravated by time. A routine physical exam- 
 ination of every woman toward the close of the puerperium and before she passes 
 out of the observation of the obstetrician is of the greatest value in detecting 
 departures from the normal process of involution and in drawing attention 
 to them when they are amenable to treatment. Were some simple, orderly 
 method of history-keeping in obstetric cases in private practice adhered to, this 
 examination in the puerperium would readily become a routine and give us valu- 
 able records for subsequent reference. (See Appendix.) The following obser- 
 vations should be made: (i) Height and position of the fundus uteri ; (2) con- 
 dition of the breasts and nipples ; (3) condition of the pelvic floor, perineum, 
 and ostium vaginse ; (4) quantity and quality of the vaginal .discharge; (5) 
 position, sensibility, and mobility of the uterus; (6) condition of the adnexa 
 and perimetrium and parametrium; and (7) general condition of the patient. 
 
PART SEVEN. 
 
 Pathological Puerperium* 
 
 I. PUERPERAL HEMORRHAGES. (Page 701.) I. Hematoma of the Vagina 
 and Vulva. 
 
 II. INTESTINAL ANOMALIES. (Page 705.) 1. Constipation. 2. Tympanites. 
 3. Hemorrhoids. 
 
 III. URINARY ANOMALIES. (Page 705.) 1. Hematuria. 2. Incontinence. 
 3. Retention. 4. Cystitis. 5. Pyelonephritis. 
 
 IV. ANOMALIES OF THE GENITAL TRACT. (Page 708.) 1. Subinvolution. 
 2. Superinvolution. 3. Atrophy of the Uterus during Lactation. 4. 
 Uterine Displacements. 
 
 V. ANOMALIES OF THE PELVIC ARTICULATIONS. (Page 710.) 
 
 VI. DIASTASIS OF THE ABDOMINAL MUSCLES. (Page 711.) 
 
 VII. MORBIDITY IN THE PUERPERIUM. (Page 711.) 
 
 VIII. ANOMALIES OF THE BREASTS. (Page 759.) 1. Absence of Mammae. 
 2. Hypertrophy. 3. Lactation Atrophy of the Breast. 4. Supernumerary 
 Breasts. Polymastia. 5. Anatomical Anomalies of the Nipples. 
 
 IX. ANOMALIES OF THE MILK SECRETION. (Page 760.) 1. Deficient 
 Secretion. 2. Excessive Secretion, Polygalactia, Hyperlactation, Galact- 
 orrhea. 3. Qualitative Anomalies. 
 
 X. DISEASES OF THE BREASTS. (Page 761.) 1. Areolar Inflammation. 
 2. Congestion and Engorgement. 3. Sore Nipples. 4. Inflammation of 
 the Breasts, Mastitis. 5. Qalactocele. 
 
 XI. BLOOD CONDITIONS. (Page 768.) 1. Thrombosis and Embolism. 
 2. Hematoma. 3. Anemia. 
 
 XII. DISEASES OF THE NERVOUS SYSTEM. (Page 769.) 1. Lesions of the 
 Sacral Plexus. 2. Puerperal Neuritis and Paralyses. 3. Hemiplegia and 
 Aphasia. 4. Myelitis and Paraplegia. 5. Puerperal Insanity. 
 
 XIII. SKIN DISEASES. (Page 773.) 
 
 XIV. GENERAL DISEASES. (Page 773.) 
 XV. SUDDEN DEATH. (Page 773.) 
 
I. PUERPERAL HEMORRHAGES. 
 
 Definition. — Puerperal hemorrhages are those occurring any time from 
 twenty-four hours after the completion of the third stage of labor until the 
 period of involution is complete, namely six weeks. They are also called 
 secondary or late hemorrhages. 
 
 Frequency. — Puerperal metrorrhagia depends largely upon the management 
 of the third stage of labor, and the care that the puerperal woman receives 
 during the first few hours of the lying-in stage. Secondary hemorrhage is 
 not nearly so frequent as the primar>^ post-partum hemorrhage. The amount 
 of lochia varies in different patients. In some the duration of the lochial 
 discharge is longer and its quantity greater than in others, and still it is not 
 abundant enough to amount to a secondary or remote post-partum hemorrhage. 
 True secondary hemorrhage is generally sudden. The quantity of blood varies 
 and the bleeding may cease for a time and then recur. As in primary post- 
 partum hemorrhage or flooding, so in the secondary variety, the hemorrhage 
 may be entirely unlooked for, and may occur suddenly without premonitory 
 symptoms of any kind. The first sign is the external flow of blood. The 
 abruptness of its onset may preclude any opportunity for consultation, and 
 if previous preparation for such an emergency has not been made, the result 
 may be fatal. Besides the hemorrhage, there is often a fetid discharge resulting 
 from decomposition of the retained parts. There may also be septic symptoms, 
 which will offer an additional diagnostic point. 
 
 Etiology. — The causes of secondary hemorrhages may be conveniently divided 
 into general and local. Among the general causes may be classed: (i) Disturb- 
 ances of the general circulation, such as occur in certain abnormal conditions 
 of the heart, lungs, or liver, and result in the damming back of the blood into 
 the pelvic vessels, or from the overuse of chloroform or stimulants; (2) acute 
 infectious diseases; (3) peculiar blood conditions, as in puerperal fever, albu- 
 minuria, and general malarial poisoning; (4) mental emotions, surprises, shocks, 
 joy, anger, fright, such as fire in the immediate neighborhood, explosions, or 
 sudden approach of an intoxicated husband, producing vasomotor changes 
 or a relaxation of the uterus. Among the local causes are: (i) Uterine relaxa- 
 tion; (2) retained placenta or membrane; (3) retained blood-clot; (4) a secon- 
 dary placenta; (5) secondary hemorrhage from lacerations of the cervix, vagina, 
 or vulva; (6) active pelvic congestion; (7) displaced thrombi; (8) metritis; (9) 
 fibromata; (10) hematomata; (11) carcinomata; (12) uterine displacement; (13) 
 distended bladder or rectum. 
 
 1. Simple uterine relaxation is of rare occurrence as a cause of puerperal 
 hemorrhage. It rarely occurs after the third day of the puerperium, and is 
 usually caused by the retention of debris in the uterine cavity or by a defect in 
 the control of the nervous system. 
 
 2. Retained placenta or membrane results from careless management or 
 an incomplete third stage of labor, and may usually be prevented by careful 
 examination of the placenta and membranes at the time of labor, and removal 
 
 701 
 
702 
 
 PATHOLOGICAL PUERPERIUM. 
 
 of retained fragments. Small pieces of retained membrane, it should be remem- 
 bered, do not necessarily produce puerperal hemorrhage. This is the most 
 important cause of secondary hemorrhage as well as the most frequent. Such 
 a retention may be suspected if the lochial discharge is normal in amount and 
 character at first, but becomes profuse and amounts to an actual hemorrhage 
 after ten or fourteen days. The detachment of the retained placental fragments 
 is apt to open one or more of the uterine sinuses. 
 
 3. Retained blood clots are common in multiparas and may be prevented by 
 careful watching of the uterus for one hour after the completion of the third 
 stage. They are often secondary to retained placenta and membranes and to 
 uterine displacement. The clots can usually be expelled by Credo's method. 
 
 4. Secondary placenta, when it exists, may in like manner produce hemor- 
 rhage. 
 
 5. Secondary hemorrhage from lacerations of cervix, vagina, or vulva. Milder 
 cases may be treated with plain hot water or acetic acid (two per cent.); more 
 
 severe bleeding requires ligation. (See 
 :yr Part X.) The lacerations in the peri- 
 
 neum and vulva are generally appar- 
 ent, but sometimes those in the vagina 
 are not visible without special exam- 
 ination. Tears of the cervix some- 
 times extend to the vaginal fornix and 
 at times through a venous sinus. 
 
 6. Active or passive pelvic conges- 
 tion. Active pelvic congestion may be 
 produced by moving about too soon 
 after labor or by too early sexual in- 
 tercourse. Passive congestion may 
 result from subinvolution, increasing 
 and prolonging the red lochia, or may 
 be due to obstruction to the return 
 circulation ; or it may come from vari- 
 cosity of the pampiniform plexus or 
 from disease of the adnexa. General 
 diseases in this connection have been 
 noted above. (See Postpartum 
 Hemorrhage.) 
 
 7. Displaced thrombi may occur primarily as the result of rapid heart 
 action and high arterial tension following labor, or secondarily from septic 
 disintegration of thrombi formed in the uterine sinuses. This accident may 
 also occur from sudden strain, or from turning in bed or sitting up. 
 
 8. Metritis. This inflammatory condition of the uterus sometimes makes 
 it prone to bleed easily. (See Metritis, page 730.) I^lf'' fil 
 
 9. Fibromata are liable to cause excessive and prolonged red lochia and 
 may produce violent hemorrhage. Mucous polypi may also have the same 
 effect (Fig. 925). 
 
 10. A hematoma is an internal, interstitial, or concealed hemorrhage, ^which 
 may be submucous, subcutaneous, or subperitoneal. As a rule, it doesjnot 
 require treatment.* 
 
 11. Carcinoma is usually seated in the cervix and may require curettage 
 and packing. Malignant disease of the uterus, as a rule, hinders or prevents 
 conception, consequently this condition is rare. 
 
 * See N. Y. Obstet. Soc., April, 1901. 
 
 Fig. 925. — Fibrinous Polypus of the Puer- 
 peral Uterus. — (Frdnkel.) 
 
PUERPERAL HEMORRHAGES. 703 
 
 12. Uterine displacement may be caused by overdistended bladder, pro- 
 longed dorsal position, getting up too early, or sudden effort on the part of 
 the patient. Backward displacement is the most common. The heavy uterus 
 is in a condition to be easily displaced and the direction varies widely. Any 
 cause hindering the normal involution of the uterus tends toward this result. 
 Immediately after labor the uterus is freely movable, and confinement of the 
 patient to one position or the imperfect application of binders is most injurious. 
 An abnormal flexion of the uterus will cause a retention of the secretions until 
 the occurrence of putrefactive changes. Immediately after labor the normal 
 position of the uterus is increased anteversion with a slight prolapse. When 
 inversion takes place, it is usually very soon after labor, and may follow some 
 severe strain. It must be differentiated from a polypoid tumor. Retroflexion or 
 retroversion is often caused by the application of a tight binder before the uterus 
 has returned to its normal position below the pubis, the pressure on the abdo- 
 men forcing the organ backward. Subinvolution from any cause may produce 
 this anomaly. Prolapse may occur from great straining, especially when labor 
 has been attended by marked injuries. 
 
 13. A distended bladder or rectum, especially the former, may act as a 
 cause (Fig. 926). 
 
 Symptoms. — These are general and local, the former being those characteristic 
 of hemorrhage in general — pallor, weakness, dimness of vision, small, thready 
 pulse, tendency to syncope, cold perspiration. The local symptoms are a soft- 
 ened condition of the uterus and an internal and external hemorrhage, although 
 at first the latter may not appear. 
 
 Prognosis. — The amount of hemorrhage may vary within wide limits and 
 the loss of blood may occur gradually or in a sudden gush. The great danger 
 from puerperal hemorrhage lies in the opportunities for infection, which always 
 threatens the puerperal woman, since the gaping vessels afford such an easy 
 port of entry to septic products. 
 
 Treatment. — This must vary with the cause. As in primary hemorrhage, 
 the best treatment is preventive. All the general and local causes of the accident 
 should be prevented, or if present they should be corrected. The lying-in 
 woman should be protected against (i) mental emotions; (2) disturbances of 
 the general circulation ; and (3) blood conditions that might cause a hemor- 
 rhage during the puerperal state. If the third stage of labor, as well as the first 
 few days of the puerperium, is properly managed there will be avoided (i) 
 the retention of placental tissues, (2) of membranes, and (3) of blood-clots, and 
 (4) a distended bladder or rectum. The patient should be kept quietly in bed 
 till involution is complete and sexual intercourse should be prohibited for two 
 months. The curative treatment of this condition consists, as in primary' 
 hemorrhage, in making sure that the uterus is completely emptied, and in 
 securing complete contraction. A vaginal examination should always be made, 
 and, if the cervical canal allow it, the uterine cavity explored and any retained 
 material removed. If the cervix will not allow of the passage of the finger 
 and the hemorrhage is profuse, the canal must be dilated and the interior of 
 the uterus examined. Should the evacuation of the uterus not stop the bleeding 
 its interior should be swabbed out with a 2 per cent, acetic-acid solution — or 
 the plan of irrigating the uterus with hot water at a temperature of 110° F. 
 may be tried. The contracted state of the cervix may prevent the proper 
 outflow of the water, and this must be guarded against by using a small intra- 
 uterine tube or return-flow tube and first securing ample dilatation of the 
 cervical canal. If there are symptoms of septicemia, creolin injections are 
 
704 PATHOLOGICAL PUERPERIUM. 
 
 excellent. Ergot, one to two drachms, with tincture of cannabis indica fifteen 
 minims, is indicated and may be repeated as necessary. Rest, both physical 
 and mental, must be insisted upon, while tonics and a nutritious Hquid diet 
 will be subsequently needed. If relaxation of the uterus is the cause, packing 
 the uterine cavity with gauze is the best treatment. (See Part X.) This is 
 also used in the case of sepsis or displaced thrombi. And here the curette 
 must not be employed. Uterine polyps should be removed. Faradism is of 
 some value. A hard bed and a cool room should be provided, and the rectum 
 and bladder should be emptied by enema and catheter if necessary. 
 
 I. Hematoma of the Vagina and Vulva. — Definition. — An extravasation o 
 blood into the subcutaneous and submucous tissue of the vulva, extending in 
 some cases into the perineum as far as the anus, or into the paravaginal tissue 
 as far as the abdominal cavity. Etiology. — The predisposing factor is the vascul- 
 arity of the tissues in the pregnant state, with the varicosity of the pudendal 
 veins. Exciting causes are usually connected with delivery, as in manual and 
 instrumental extraction. Since the fetal head exerts a hemostatic action during 
 its birth, the hematoma becomes in evidence, as a rale, during the third stage 
 of labor. Sometimes it happens that the extravasation precedes labor as a re- 
 sult of some act of violence. In 
 twin pregnancy it is not uncommon 
 to see a hematoma follow the birth 
 of the first child, and constitute an 
 obstacle to the passage of the other 
 twin. Pathology. — The extravas- 
 ated blood tends to coagulate at 
 once, and the hemorrhage usually 
 ■" becomes arrested before it becomes 
 extensive. The oozing, as a rule, 
 ceases after two or three hours. 
 Exceptionally, hemorrhage con- 
 tinues intermittently for a much 
 Fig. 926.— Hematoma of Vagina and Vulva. longer period. The tendency is 
 — {Hill. J toward resolution, effected by 
 
 gradual absorption, which is com- 
 pleted in four or five weeks. Rupture often occurs, especially when the 
 hematoma precedes the second stage of labor; there is then danger of infection. 
 Symptoms. — The extravasation is accompanied by pain, which varies greatly 
 in degree and kind. A tumor forms rapidly, usually on one side of the vulva, 
 having a dusky or livid color. As a rule, some tenesmus of the bladder, rectum, 
 or both coexists. If the extravasation is in the paravaginal tissue alone, no ex- 
 ternal tumor is apparent. Non-appearance of the lochial discharge should 
 suggest such an accident. Diagnosis. — The tumor when suspected is mapped 
 out by inspection and by digital exploration of the vagina and rectum. Since 
 there is always a zone of edema about the extravasation proper, an ede- 
 matous area ma}'- conceal a small hematoma. Hematoma has been mistaken 
 for a variety of conditions, such as inversion of the uterus, cysts of the vagina, 
 etc. Prognosis. — At the present antiseptic period this is favorable, but even 
 to-day the mortality is computed at 12 per cent. The chief cause of death is 
 profuse hemorrhage, which is usually the result of rupture of a vaginal hematoma 
 which precedes the second stage of labor. The likelihood of a fatal hemorrhage 
 is fully as great here as in placenta prsevia. Treatment. — In hematoma antedat- 
 ing the second stage of labor, interference despite the danger of rupture, is con- 
 
INTESTINAL ANOMALIES— URINARY ANOMALIES. 705 
 
 traindicated, unless the tumor actually obstructs the birth of the child. The 
 mass should then be -incised and the clots extracted. The cavity should be 
 packed with gauze after securing all bleeding vessels. In very large hema- 
 tomata, which threaten to rupture spontaneously in the puerperium, from 
 the effects of pressure, incision and packing should also be practised. Under 
 all other conditions, treatment should be expectant. Pressure and cold appli- 
 cations should be used to arrest further hemorrhage and promote absorption. 
 
 II. INTESTINAL ANOMALIES. 
 
 1. Constipation. — This is the rule in the puerperium, and is caused by weak- 
 ened musculature of the abdominal parietes and intestinal muscle-coats and by 
 the prolonged rest in bed. This condition often causes fever, possibly from the 
 absorption of animal alkaloids. Evacuation of the bowels should occur by the 
 end of the third day (unless there has been a complete suture of the perineum, 
 when treatment should be deferred until the fourth day), and the administration 
 of laxatives during this period is not necessary if the bowels were well opened 
 before labor. But if no movement occurs in this time and diet seems to have 
 no effect, it is well to try a simple injection of water, to which a little glycerin 
 may be added. For not only the mother's condition must be taken into con- 
 sideration, but, if she nurses her child, the latter demands equally careful con- 
 sideration. If the injection is not effective, castor oil, calomel, a saline laxative, 
 or the well-known combination of aloin, strychnin, and belladonna maybe given. 
 The regular action is then generally established, although an obstinate constipa- 
 tion may persist which will demand much skill to overcome. 
 
 2. Tympanites. — There sometimes occurs in neurotic women an excessive 
 amount of gas in the intestines following a sudden paralysis of their muscu- 
 lature. The abdomen is greatly distended, so that there may be true orthopnea 
 from upward pressure of the diaphragm, and there is obstinate vomiting with 
 persistent constipation and other signs of obstruction of the bowels. There 
 are no symptoms of peritonitis, but there is a serious outlook for the patient's 
 life, demanding radical treatment. Nerve sedatives, large hypodermic doses 
 of strychnin, enemata of asafetida and turpentine, and gentle cathartics by 
 the mouth are all indicated. If these measures fail, the rectal tube and high 
 enemata may be used. 
 
 3. Hemorrhoids. — Pregnancy may cause such a degree of congestion of the 
 rectal veins that it may persist after labor. This condition may. show itself 
 only during the period of parturition or it may persist afterward. The pain 
 is very severe. Ulceration and gangrene may result. In treating this con- 
 dition the bowels must be kept regular, and either hot or cold local applications 
 will relieve the pain. Astringent, sedative suppositories sometimes give relief, 
 as belladonna, opium and lead, and compound ointment of gall. If strangu- 
 lation occurs, the tumors must be excised. 
 
 III. URINARY ANOMALIES. 
 
 I. Hematuria. — This condition in the puerperium generally follows a hemor- 
 rhoidal condition of the vesical veins induced by pelvic congestion in the last 
 part of pregnancy. It may be due also to injurv from pressure of the child's 
 45 
 
706 
 
 PATHOLOGICAL PUERPERIUM. 
 
 head or from instruments or the result of vesico-vaginal fistulae. The differential 
 diagnosis may be made from the history. Blood when present in the urine 
 generally disappears spontaneously in a few days, but occasionally astringent 
 injections are necessary. Unusual care should be observed at this time in the 
 use of the catheter. 
 
 2. Incontinence of Urine. — Incessant dribbling may be due to paralysis of 
 the sphincter or to fistulse. If the urine escapes involuntarily soon after delivery, 
 an examination should be made at once. If there are also present severe abdom- 
 inal pains and the urine escapes a few drops at a time, or with an occasional gush 
 or spurt, there will be grounds for the diagnosis of incontinence of retention. Ex- 
 amination will reveal a median abdominal tumor having a dull percussion note. 
 The catheter will empty the bladder and relieve the distention. If, however, 
 there is no pain on the escape of urine, and if labor has been abnormal, a fistula 
 
 will probably be discov- 
 ered. When this is very 
 small, it may heal spon- 
 taneously. But if this is 
 impossible, a plastic oper- 
 ation may be necessary 
 later. Rarely pressure 
 paralysis of the vesical 
 sphincter and the urethra 
 may be the cause of this 
 trouble. Such cases some- 
 times do not seem amen- 
 able to treatment of any 
 kind, though tonics, elec- 
 tricity applied to the ure- 
 thra, and massage may be 
 successful. 
 
 3. Retention of Urine. 
 — After labor retention of 
 urine is very common, 
 and, indeed, may be ex- 
 pected for a few hours. 
 This is caused by the ex- 
 pansion of the bladder 
 and its loss of sensibility 
 after the uterus has expelled its contents, and often by the cessation of action of 
 the abdominal muscles. There may also be a real obstruction from traumatism 
 of the urinary apparatus, especially the urethra. Before resorting to the use of the 
 catheter, which is always attended with some risk of bladder infection, all other 
 known means for relieving the condition should be tried, as the sound of running 
 water, allowing a stream of warm water to flow over the vulva into a douche pan, 
 the application of hot chloroform stupes to the vulva, and, if not contraindicated, 
 allowing the patient to assume the sitting posture in bed on the vessel or douche 
 pan. If this last procedure is permitted in the first twenty-four hours of the 
 puerperium, the nurse should be instructed carefully to watch the fundus uteri 
 during the evacuation of the bladder. Whatever the cause, a period not longer 
 than eighteen hours should be allowed to pass before the patient is catheterized, 
 and in this operation all possible antiseptic precautions should be taken. Reten- 
 tion is most common after suture of the perineum. The bladder may be injured 
 
 Fig. 927. — Retention of Urine and Distended Blad- 
 der DURING THE EaRLY PaRT OF THE PuERPERIUM. 
 
URINARY ANOMALIES. 707 
 
 by retention and uterine hemorrhage occur from the excessive distention of 
 the organ. (See Puerperal Hemorrhage, page 701.) (Fig. 927.) 
 
 4. Cystitis. — This is unfortunately quite common in the puerperium and is 
 a serious affection of the urinary system to be guarded against, since it may 
 lead to a fatal result. Frequently it does not pass beyond the mild form, 
 and its duration is then only transitory. Etiology: The common cause is 
 careless introduction of the catheter. This should always be done under 
 the strictest antiseptic precautions. The urethral orifice should never be 
 sliielded by the bed-sheet, but ought in all cases to be perfectly exposed to 
 the view of the operator. Again, though rarely, overdistention of the bladder 
 or pressure of the child's head may injure the vesical walls sufficiently to cause 
 a catarrhal cystitis. This type is generally of short duration unless an intro- 
 duction of micro-organisms takes place. Under these circumstances the simple 
 lesion may develop into a suppurative inflammation which does not limit 
 itself to the bladder, but extends along the ureters to the kidneys and ends 
 in disease of these organs. Even when the catheter is not used there may 
 be migration of vaginal micro-organisms into the urethra, and, according to 
 some authorities, micro-organisms from the various pelvic viscera may find 
 their way into the bladder. Symptoms: The symptoms of the milder type are 
 those of an ordinary cystitis: viz., frequent urination, discomfort, burning pain, 
 and alkaline urine. With the development into the septic form, the symptoms 
 increase in severity, especially with the extension of the disease to the ureters. 
 Sometimes delirium occurs, the temperature is high, and anemia and prostra- 
 tion are extreme. The constant desire to urinate gives rise to great distress. 
 The condition of the bowels is quite variable. 
 
 Urinary examination shows the amount to be small, the specific gravity 
 low, reaction acid. The microscopic examination reveals epithelium of several 
 varieties, pus- and blood-corpuscles, urates and uric acid crystals. The mucous 
 membrane may exfoliate and pass off in the urine. In such severe cases the 
 presence of albumin and tube casts will be detected. The prognosis of this 
 affection will depend upon prompt attention and careful treatment. The great 
 danger lies in extension to the kidneys. Prophylaxis is most important. After 
 its occurrence the bladder should be irrigated several times a day with boric- 
 acid solution; creolin, 0.5 per cent., or sublimate, i : 20,000, is sometimes used. 
 The internal administration of salol, urotropin, boric or benzoic acid and buchu 
 is also advisable, as these drugs affect the quality of the urine. The patient's 
 strength and general tone must be kept up by tonics and stimulants as well as 
 by nourishing food. Subsequently change of climate is often beneficial. 
 
 5. Pyelonephritis. — This may occur from the extension of the vesical lesion 
 along the ureters to the pelvis of the kidney. There are cases in which the 
 bladder trouble is so slight that it is not noticed, and it is only the lighting-up 
 of the renal inflammation that draws attention to the disturbance. This 
 infection may also be caused by the irritation of renal calculi or may occur 
 from the blood. The prognosis is doubtful, many cases ending fatally. The 
 treatment is essentially the same as in cystitis, with the addition oftentimes 
 of incision of the pelvis of the kidney or of the perinephritic abscess, in case the 
 latter develops. Post-mortem examination has shown the kidney to be involved 
 as a whole, forming a large bag of pus, or to be honeycombed throughout with 
 tiny abscesses. 
 
708 PATHOLOGICAL PUERPERIUM. 
 
 IV. ANOMALIES OF THE GENITAL TRACT. 
 
 I. Subinvolution. — Subinvolution is a retarded or incomplete involution of 
 the uterus. The normal process requires generally from six to ten weeks. 
 Pathology: The process of involution is one of fatty degeneration, absorption, 
 and atrophy. It is not believed that the whole muscle cell is destroyed by 
 fatty degeneration, but rather that atrophy accompanies the fatty process 
 and ceases after the muscle fiber reaches its original size. The uterine adnexa, 
 vagina, and vulva undergo the same process. (See Part VI.) It can readily be 
 seen how slight influences, either acting directly on the uterus or through the 
 mother's blood, can Interfere with the process of involution, resulting in the 
 pathological condition known as subinvolution. Arrested involution depends 
 entirely upon changes in the circulation of the uterus or its vicinity ; congestion, 
 either active or passive, being the important etiological factor. Etiology: (i) 
 Causes interfering with the proper contraction and retraction of the uterine 
 muscle or with its blood-supply must be looked for as originating the condition 
 of subinvolution. As a rule, these causes are local, though there are a few ex- 
 ceptions. Among the local causes may be mentioned: habitual distention of the 
 bladder or rectum, retained secundines, displacement of the uterus, fibroid 
 or polypoid tumors, or old peritoneal adhesions. (2) Causes either increasing 
 the blood-supply to, or obstructing the return flow from, the uterus are: 
 inflammatory conditions subsequent to septic processes, fibroid and other 
 pelvic tumors, retained hypertrophied decidua as in incomplete abortion. 
 Endometritis from other causes, cardiac and pulmonary disease, inflammatory 
 conditions interfering with pelvic circulation, and all the causes of obstructed 
 portal circulation also belong under this head. Nervous disorders, such as 
 puerperal insanity or a great shock, not infrequently retard involution. 
 Too early sexual intercourse after abortion or delivery may not only 
 hinder but arrest involution. Women who do not nurse their children 
 are more prone to this abnormality. It has been held by some that 
 constitutional disturbances having no connection with any local cause 
 may furnish the etiological factor. The local cause, however, should al- 
 ways be carefully looked for. Diagnosis : An early diagnosis is important, 
 in order to avoid the numerous disorders which are so likely to follow sub- 
 involution. Abdominal palpation will detect approximately any defect in the 
 involution of the uterus; later, however, the diagnosis is generally made by 
 the gynecologist. The uterus is large, boggy, soft, and tender on pressure. 
 The size of the organ does not correspond to the period of the puerperium. 
 Symptoms: These include a feeling of weight in the pelvis, lochia profuse and 
 red, or serous lochia changing to bloody lochia late in puerperium, backache, 
 reflex symptoms, pain or tenderness over the lower portion of abdomen. Irrita- 
 ble bladder or rectum may be present if acute displacement exists. Treatment: 
 The prophylactic treatment of subinvolution is most important to save the pelvic 
 organs from various subsequent gynecological conditions. (See Management of 
 the Puerperium, Part VI.) The curative treatment must depend upon the 
 cause. If this is retention of placental or decidual tissue, the uterus should be 
 curetted and disinfected. If there are lacerations of the cervix or vagina, they will 
 have to be repaired. Displacement of the uterus should be remedied by a suitable 
 pessary, which is to be changed from time to time as the organ decreases in 
 size. A pelvic tumor may be removed. The general functions of the body 
 must be maintained by hygienic measures. Massage of the uterus may assist 
 
ANOMALIES OF THE GENITAL TRACT. 
 
 709 
 
 it to return to its natural size. When the amount of lochia is excessive, hot 
 vaginal douches should be given. The pelvic viscera should be depleted by 
 hot injections and vigorous catharsis. Ergot is sometimes employed when it 
 seems especially indicated by muscular weakness or the presence of small 
 fibroids. Tonics and electricity are at times beneficial. 
 
 2. Superinvolution, Hyperinvolution. — A condition known as superinvoluiion 
 or hyperinvolution, depending upon a prolongation of the fatty degeneration 
 and atrophy of the parturient uterus, has been known to exist. It is very 
 infrequent. In very rare cases the uterus may almost disappear. It is prob- 
 ably the result of profound anemia; protracted lactation may coexist. The 
 symptoms are usually not pronounced. Menstruation may not return. Diag- 
 nosis should be made by bimanual examination. For treatment, the child must 
 be weaned, tonics administered, the diet made nutritious and generous, and 
 hygienic measures instituted, such as a change of air and scene, with massage 
 or carefully regulated exercises. 
 
 3. Atrophy of the Uterus during Lactation. — This condition is not to be 
 confounded with hyperinvolution, which is pathological in character. I mean 
 
 Bladda 
 Ut.ve^ verinenm 
 Poslsriar Van. rcm/y 
 iaijms caveiTwsun ei im Cluori 
 
 Urethra ~ 
 AmerterVao. fornLx ^ 
 
 Anterior cavica/Lifi— 
 Vaolna — 
 MroBuis vaninGe. 
 External oi 
 Penr"' m 
 
 Rt Com. I Hoc Artery 
 Lefl Com. II lot Vein 
 
 m Sacral Vert 
 Zervical Canal 
 Fundus uteri 
 Left Homei L'terui 
 - Hectum 
 
 Anil' /^ V 
 
 mtaiuit .ptiLncicj- / • 
 "External ^mwter 
 
 Fig. 928. — Retroflexion of the Puerperal Uterus in a Multipara. — (Sellheim.) 
 
 by lactation-atrophy a physiological phenomenon which appears to be due 
 chiefly to nursing alone. This subject, rarely mentioned by obstetricians, has 
 been described by Vineburg. 
 
 It is known that in connection with involution the uterus becomes smaller 
 at one period than even the non-parous organ; and that it undergoes regener- 
 ation either during or after the lactation period. The period of minimum size 
 has been placed by various authorities at any time between six and twenty 
 weeks. This phenomenon is best seen in the multipara, and is much less 
 marked in primiparae. Although known as lactation-atrophy, something of the 
 same sort is seen in mothers who do not nurse their children, although in a 
 much less degree. 
 
 If the uterus is studied microscopically during this period, the muscular 
 fibers are seen to have undergone atrophy, while the usual fatty changes of in- 
 volution are also in evidence. The part played by the ovaries in this connection 
 is not known. In very high degrees of lactation-atrophy there should be a 
 suspicion that the ovaries are in some way involved. A normal condition 
 should not give rise to pathological symptoms, yet during this stage of minimal 
 
710 PATHOLOGICAL PUERPERIUM. 
 
 size the patients almost always complain of backache and vague pelvic pains. 
 Other symptoms, such as leucorrhea, are absent, this going to show that the 
 condition is not necessarily pathological. 
 
 A typical case gives the following clinical picture : A woman during the lacta- 
 tion period develops backache and pelvic pain, without leucorrhea or other symp- 
 tonris. Examination shows an undersized uterus. Although this atrophy is 
 physiological and should be succeeded by regeneration, cases are not wanting in 
 which the latter does not set in. The condition then may become permanent, 
 but differs from hyperin volution, through the fact that weaning the child may 
 be followed by recovery. As a prevention it has been suggested that weaning 
 should occur after the seventh month, in order to save the uterus from damage. 
 
 4. Uterine Displacements. — (i) Inversion. (See Pathology of Labor, page 
 590.) (2) Prolapse: The degree of this displacement varies to a great extent. 
 When the injuries during birth have been severe, some great strain during 
 the puerperium, such as lifting a heavy weight, causes occasionally a pro- 
 lapse of the puerperal uterus. The latter is greatly increased in weight 
 and deficient in muscular tone, both conditions favoring displacement. (3) 
 Retroflexion and retroversion (Fig. 928): Retroflexion and retroversion are most 
 commonly found in women who have suffered from these displacements before 
 conception and in those who have aborted. A sudden strain, failure to empty 
 the bladder when the desire is felt, and the use of tight binders, as noted 
 before, may all contribute to these forms of displacement. These patients 
 should stay in bed longer than usual and they should lie on the side as much 
 as possible. In the latter part of the puerperium astringent douches should 
 be given. (4) Anteflexion and anteversion : Extreme anteversion or anteflexion 
 may also occur in the puerperium; the latter especially will cause a reten- 
 tion of the uterine secretions. Other abdominal organs are also sometimes 
 displaced during the puerperium; floating kidney may be mentioned as an 
 example. 
 
 V. ANOMALIES OF THE PELVIC ARTICULATIONS. 
 
 The joints affected are the symphysis pubis and sacro -iliac synchondroses. 
 The cause is sometimes pathological change, sometimes the violent use of the 
 forceps, or a combination of the two. These joints, as has already been noted, 
 become relaxed in normal pregnancy so that they allow a slight amount of 
 movement of the bones on one another. Various etiological factors are men- 
 tioned by different authorities, besides those noted above, among which are 
 extreme exertion on the part of the patient, pressure of a large fetal head, 
 and traumatism, which may cause inflammation. There is hyperemia and 
 swelling of the synovial membrane and an increased secretion of the synovial 
 fluid until the extremities of the bones become separated from each other. If 
 this condition becomes more serious, the formation of pus takes place and abscess 
 develops. The bone is gradually eroded and even becomes carious. Complete 
 rupture of the joints of the pelvis may occur. Symptoms: These are noticed 
 when the patient first gets up and tries to walk. There is pain, extending 
 into the lower extremities, and increased mobility of the articulations. The 
 latter fact can be proved by manual examination. The patient probably 
 walks with difficulty. However, there may be considerable movement and 
 little impairment of walking, or there may be slight movement only, with 
 
MORBIDITY IN THE PUERPERIUM. 711 
 
 much pain and lameness. The gait is very like that of the osteomalacic patient. 
 In case of suppuration the symptoms are greatly intensified, chill and fever 
 come on, abscesses of the soft parts develop, and the patient becomes unable 
 to move the legs. Relapse is not unlikely to occur in the next pregnancy. 
 In rare instances septicemia or pyemia results. Diagnosis: This is easily 
 made from a few characteristic symptoms. The pain can always be exactly 
 located by the patient in the diseased joint. There is tenderness on 
 pressure or motion. The usual symptoms of suppuration indicate its pres- 
 ence. The prognosis is favorable in simple cases, but increases in gravity 
 with the development of suppuration. Treatment: Rest in bed in the dorsal 
 position and a strong, firm bandage, whose upper border is level with the iliac 
 crests while the lower reaches just below the trochanters (Fig. 919). The 
 patient may then walk around as she would ordinarily, even if there is pain. 
 The condition generally terminates in recovery, the bones becoming fixed after 
 some months, but, in a very few cases, this does not happen and the bandage 
 has to be worn continuously. When the pain is severe, the ice-bag is indicated. 
 Narcotics may also be given. The disease may become chronic, and in that 
 case change of climate, sea-bathing, mild counterirritation, and continuous 
 tight bandaging may be efficacious. 
 
 VI. DIASTASIS OF THE ABDOMINAL MUSCLES. 
 
 In patients whose abdomens have been unusually distended or whose 
 abdominal muscles are weak, and especially in those who have borne many 
 children, the recti are not infrequently separated. This condition sometimes 
 allows the protrusion between the muscular borders of part of the abdominal 
 contents, with the resulting symptoms of hernia. If properly reduced, the 
 intestines may be quite easily held in place by means of a suitable bandage, 
 and an operation subsequently performed. 
 
 VII. MORBIDITY IN THE PUERPERIUM. 
 
 Since the general adoption of asepsis and antisepsis by obstetricians severe 
 puerperal morbidity has become of too infrequent occurrence for a single ob- 
 server to be personally familiar with all its phases. As a natural result, the 
 descriptions of these affections in standard works contain many contradictions, 
 and it is by no means easy to obtain definite ideas as to the various manifesta- 
 tions of infection and intoxication occurring in the puerperium. The data 
 accumulated by Lenhartz, in his great monograph on septic affections, are by 
 no means in harmony with the teaching found in the leading text-books on 
 obstetrics. I have therefore tried to subject the entire matter of puerperal 
 morbidity to a careful analysis, based upon the latest authoritative data and 
 my own clinical experience, and to classify and describe the various tvpes of 
 disease in such a way as to eliminate some of the sources of contradiction and 
 confusion. 
 
 Frequency of Morbidity in the Puerperium.— The usual rough test between a 
 normal and a pathological puerperium is furnished by the temperature. If 
 the latter is over 100.4° F. (38° C.) in the axilla, the case is enumerated under 
 morbidity. 
 
712 PATHOLOGICAL PUERPERWM. 
 
 The morbidity of the Paris cUnics is shown by the following figures compiled by Budin: 
 Charit6, 1891-1894, 10.7 per cent.; Maternite, second half of 1895, 12.8 per cent.; 1896, 
 10.6 percent.; 1897, 10.6 per cent.; Tarnier's clinic, 1898, 8.93 per cent.; 1899, 12 per cent. 
 These figures make the average morbidity nearly 1 1 per cent. The statistics of some of the 
 leading German clinicians are as follows: Merman, 6 per cent, fever of over 100.4° F- (38° C.) ; 
 Leopold, considerable variation from year to year, limits from 8 to 20 per cent, approxi- 
 mately, average 14.6 per cent.; von Szabo, 19.75 P^^ cent.; Zweifel, 17.4 per cent.; Hof- 
 meier and Steffeck, 8.5 per cent.; Madlener, 18.6 per cent.; the average morbidity in these 
 German clinics is therefore a little over 14 per cent. Ahlfeld, who has collated figures from 
 many clinics, finds that the morbidity varies from 9 to 54 per cent. Such fluctuation 
 appears to show that differentiation between puerperal and other fevers is very difficult. 
 
 Sellheim believes that high and persistent temperature occurs in about 
 2 per cent, to 4 per cent, of institutional cases. In an analysis of 2200 cases 
 of confinement I found that a rise of temperature to 100.4° F. (38° C.) or 
 over took place in 405 cases, or 18.45 P^^ cent. In 204 cases the fever con- 
 tinued but a few hours, there being but a single elevation, and in only 72 of 
 the 405 cases did the fever last for more than three days. In the 405 cases 
 of fever the rise of temperature was: 
 
 Due to constipation in 259 cases, or 63.95 P^^ cent. 
 
 " " reflex irritation in 42 " " 10.37 " " 
 
 " " complicating disease in 20 " " 4.94 " " 
 
 " " neurotic condition in i " " 0.24 " " 
 
 79.50 per cent. 
 
 " " septic infection in 55 " " 13.58 per cent. 
 
 " " no assignable cause in 25 " " 6.92 " " 
 
 20.50 per cent. 
 
 This gives a morbidity percentage from non-septic conditions of 79.50 per 
 cent.; from sepsis, of 13.58 percent.; and from unknown causes, of 6.92 per cent. 
 
 Classification. — I believe this subject is best considered under three main 
 headings: viz., {A) Morbid conditions of the puerpera which antedate labor.- 
 (B) Morbid conditions which result from labor. _(C) Morbid conditions which 
 originate or first appear in the puerperium. While it is customary to allude to 
 many of the conditions presenting themselves under Divisions A and B as pre- 
 disposing causes of puerperal morbidity, a little reflection will show that they 
 themselves may represent morbidity of pronounced types. Conditions under 
 division C are loosely spoken of as " puerperal infection," "puerperal fever," " pu- 
 erperal sepsis," etc. Once regarded as manifestations of a single specific dis- 
 ease, they are now known to comprise a variety of local and general conditions. 
 
 CLASSIFICATION OF PUERPERAL MORBIDITY. 
 
 (A) MORBID CONDITIONS OF THE PUERPERIUH WHICH ANTEDATE LABOR. 
 
 Acuie: I. Acute Toxemia of Pregnancy. II. Antepartum Sapremia or Bacteriemia. 
 III. Chance Infection with Acute Specific Diseases. Chronic: IV. Chronic 
 Toxemia of Pregnancy. V. Chronic Toxemia, etc, not Due to Pregnancy. 
 VI. Genital and Extragenital Inflammations. 
 
 (B) MORBID CONDITIONS WHICH RESULT FROM LABOR. 
 
 General: I. Shock and Extreme Fatigue from Dystocia. II. Acute Anemia from 
 Hemorrhage. Local: III. Incomplete Labor. Faulty Contraction, Evacua- 
 tion, AND Drainage. IV. Birth Traumatisms. V. Changes in the Locality 
 and Activity of the Bacteria of the Genital and Perigenital Regions In- 
 duced BY THE Act of Labor and its Management. Migration. Inoculation. 
 Mobilization. 
 
MORBID CONDITIONS WHICH ANTEDATE LABOR. 713 
 
 (C) MORBID CONDITIONS WHICH ORIGINATE OR FIRST APPEAR IN THE 
 
 PUERPERIUM. 
 
 Primary, Consecutive, and Metastatic Focal Infections. 
 Primary Focal Injections. 
 Genital: I. Puerperal Ulcers. II. Endometritis from Saprophytes. Putrid Endo- 
 metritis. III. Endometritis from Pyogenic Bacteria. Simple Infectious 
 Endometritis. IV. Endometritis from Mixed Infection. Composite Endo- 
 metritis. Extragenital: V. Mastitis. 
 
 Consecutive Focal Injections. 
 Extension by Continuity. VI. Infection of Urinary Tract. VII. Proctitis. Vlll. 
 Salpingitis. Peritonitis. Extension by Lymphatics: IX. Metritis. X. Para- 
 metritis. XL Peritonitis. Circumscribed or Perimetritis. General. Ex- 
 tension by Veins: XII. Metrophlebitis. Femoral Phlebitis. XIII. Specific 
 Diseases. Gonorrhea. Diphtheria. Erysipelas. Miscellaneous. 
 
 Metastatic Focal Injections. 
 Blood States or General Conditions. 
 Simple. 
 I. Sapremia. II. Bacterial Toxemia. III. Bacteriemia. 
 
 Composite Sepsis. 
 IV. Bacteriemia with Toxemia. Septicemia. Pyemia. Septicopyemia. V. Sap- 
 REMic Sepsis. (Gas Sepsis.) 
 
 Anomalies oj Temperature. 
 VI. Hyperthermia. VII. Fever. VIII. Hypothermia. 
 
 (D) CLINICAL TYPES OF PUERPERAL MORBIDITY. 
 
 The puerpera inherits from the pregnant state any morbid condition from 
 which she may have suffered during that period, whether called forth by preg- 
 nancy or not. While some of these conditions, especially those due directly to 
 pregnancy, have a natural tendency to improve after delivery, others remain 
 unaffected, and not a few tend to become worse; while conditions absolutely 
 dormant are sometimes roused into being for the first time. The possible legacy 
 of the puerpera must therefore always be borne well in mind. To conditions of 
 this character must be added the shortcomings and accidents of labor itself, 
 and the various readjustments rendered inevitable by the transition from preg- 
 nancy to the puerperium. 
 
 (A) MORBID CONDITIONS OF THE PUERPERIUM WHICH ANTEDATE 
 
 LABOR. 
 
 I. Acute Toxemia of Pregnancy. — This condition is described on page 291. 
 
 II. Antepartum Sapremia or Bacteriemia. — This subject includes septic 
 abortion (pp. 355); sapremia, etc., from dead fetus (pp. 272), and infection which 
 begins in the course of an arrested labor, which is only an anticipation of 
 postpartum conditions (pp. 570). 
 
 III. Chance Infection with Acute Specific Diseases. — These when severe tend 
 ta make labor premature or incomplete and thereby favor sepsis. The cause of 
 death in such cases is often sepsis instead of typhoid or other antecedent in- 
 fectious malady. (See Diseases of Pregnancy, Part III.) 
 
 IV. Chronic or Benign Toxemia of Pregnancy. — (See Toxemia of Pregnancv, 
 Part III.) 
 
 V. Chronic Toxemias not Due to Pregnancy. — Here belong such affections 
 
714 PATHOLOGICAL PUERPERIUM. 
 
 as tuberculosis, s^'philis, diabetes, uremia pure and simple, the cardiac cachexia, 
 leukemia, exophthalmic goiter, cancer, etc., etc., all of which are considered 
 elsewhere. (See Part III.) As a rule, they originate before conception, but 
 sometimes do not manifest themselves until afterward, pregnancy appearing to 
 hasten their development. In none of these conditions does delivery lead to 
 any permanent improvement, and in many it rapidly hastens the end; so that 
 they add somewhat to the mortality of the puerperium. Naturally sepsis is 
 often present as a complication or is an actual cause of death. 
 
 VI. Genital and Extragenital Inflammations. — The former are described under 
 diseases of the deciduas (pp. 191), with special reference to gonorrheal affec- 
 tions. Ahlfeld has claimed that a latent gonorrheal pelvic peritonitis may be 
 lighted up by pregnancy. Pelvic abscesses, pyosalpinx, etc., from any cause, 
 may be ruptured during labor. Extragenital pyogenic processes of any sort 
 (otorrhea, whitlow, etc.) may be the remote cause of a septic puerperium. 
 
 (B) MORBID CONDITIONS WHICH RESULT FROM LABOR. 
 
 I. Shock and Extreme Exhaustion from Dystocia naturally favor infection. 
 Fatigue itself i^ regarded as due to auto-intoxication. 
 
 II. Acute Anemia from Hemorrhage. — This occurs after high degrees of post- 
 partum hemorrhage and favors infection. The blood must lose much of its 
 alexin or bactericidal ferment. As shock or exhaustion and acute anemia are 
 often conjoined, it is not easy to comprehend how so many women escape 
 infection. 
 
 III. Incomplete Labor. — This term is used to denote an incomplete third 
 stage, although it might be extended to include retention of the fetus or ovum. 
 An imperfect third stage may be manifested in various ways ; and while due in part 
 to natural shortcomings, may often be attributable to unskilful management. 
 It comprises the following subdivisions: (i) Incomplete contraction and retrac- 
 tion: This condition is fully considered elsewhere (page 568). In an uncon- 
 tracted uterus the venous sinuses do not close naturally and thrombi form 
 in situ. Thus, hemorrhage and the development of metrophlebitis, embolism, 
 and air embolism are favored. (2) Incomplete evacuation: This is considered on 
 page 574. A variety of tissues may remain behind after incomplete expulsion 
 of the uterine contents: viz., portions of the ovum in abortion, portions of and 
 even the entire placenta, fragments of membranes, and blood-clots. This dead 
 tissue forms a natural breeding-place for saprophytes. Decidual fragments and 
 blood are hardly to be regarded as foreign bodies and escape piecemeal in the 
 lochial discharge. (3) Incomplete drainage: Lochiometria. In some cases the 
 normal anteflexion of the uterus becomes exaggerated to such an extent that 
 there is an acute angle of flexion of the cervix and lower uterine segment which 
 suffices to prevent the exit of the lochia. The uterus is large and soft and there 
 are well-marked symptoms of sapremic infection. The absence of lochial dis- 
 charge is of course noted. The symptoms are at once relieved by the manual 
 replacement of the uterus. This is followed by a copious discharge of an ill- 
 smelling fluid. As a rule, nothing is necessary, except irrigation. Much less 
 commonly the cause of lochial retention is retroflexion of the puerperal uterus. 
 Lochiocolpos . In rare instances the source of obstruction is in the vagina. 
 This rare condition is known as "lochiocolpos." Ahlfeld reported three cases. 
 In one the cause of retention was an intravaginal hematoma, and in another, 
 a too thorough repair of the perineum ; in the last case the patient had had a 
 bad laceration of the perineum and her thighs had been tightly bound 
 
MORBID CONDITIONS WHICH RESULT FROM LABOR. 715 
 
 Fig. 929. — Infection of the Vulva. Fig. 930. — Infection of the Vulva and 
 
 Vagina. 
 
 Fig. 931. — Infection of the Vagina and 
 Endometrium. 
 
 Fig. 932. — Extension of Infection 
 
 THROUGH THE TuBES TO THE OvARY. 
 
 Fig. 933. — Extension of Infection 
 through the lymphatics from the 
 Uterine Cavity to the Parame- 
 trium AND Peritoneum. 
 
 Fig. 934. — Extension of Infection 
 through the Veins from the Uter- 
 ine Cavity in Puerperal Pyemia. 
 
716 PATHOLOGICAL PUERPERIUM. 
 
 together. The treatment consists in the removal of the cause and in vaginal 
 irrigation. 
 
 IV. Birth Traumatisms. — These have been considered under Pathological 
 Labor (Part V). They include rupture of the uterus, lacerations of the cervix, 
 vagina, vulva, and perineum; also certain more remote lesions, like peroneal 
 paralysis. These injuries, especially those of the cervix, are generally recognized 
 as among the most important factors in puerperal morbidity. 
 
 V. Changes in the Bacteria of the Genital Region. — It is conceded that in 
 the great majority of cases the uterus and its contents are sterile before 
 delivery. Exceptions are found in cases of endometritis and putrefaction of 
 the dead fetus. It was formerly believed that the vagina was also sterile save 
 in cases of gonorrhea, but the very extensive researches of Stolz,* Hofmeier, 
 and Lenhartz have shown that a healthy vagina may harbor pathogenic germs 
 which have evidently migrated from the vulva. The external genitals have 
 always been recognized as swarming with germ-life. During and after delivery 
 it has been shown that in a large number of instances the bacteria which are 
 harbored in the vagina manage to reach the uterine cavity, where under favor- 
 able circumstances they are destroyed by the uterine secretions before they 
 can multiply. 
 
 In regard to the nature of the germ-life concerned, the bacteiiology of the 
 vulva, vagina, and uterine cavity is practically the same; for we simply have an 
 upward migration of the vulval germs. Hence, whatever are comprised under 
 the latter head may be found in the upper passages. Ordinar}^ saproph^'tes 
 and pathogenic cocci may occur side by side ; the saprophytes or microbes 
 sometimes develop pathogenic qualities, while the pathogenic bacteria, so called, 
 may play the role of saprophytes. Nothing appears to be gained by an exten- 
 sive classification and description of these germs. The important facts to bear 
 in mind are that the ordinary pyogenic cocci, acting temporarily as saprophytes 
 or scavengers, may become virulent; and that the saprophytes proper, i. e., the 
 ordinary bacteria of putrefaction, may multiply prodigiously if there is any dead 
 matter in the uterus, and set up conditions to bedescribed later. 
 
 The bacteriology of the puerperal state is discussed more fully under the 
 Etiology of Endometritis, page 721. 
 
 (C) MORBID CONDITIONS WHICH ORIGINATE OR FIRST APPEAR 
 
 IN THE PUERPERIUM. 
 
 General Remarks. — As already stated these conditions had best be divided 
 into focal infections, including both primitive and consecutive ; and blood-states 
 or general conditions , including toxaemias, bacteriemias (sepsis), pyemia, septi- 
 copygemia; and anomalies of temperature, such as true fever, simple hyper- 
 thermia, hypothermia, etc. This classification is essentially pathological and 
 must be accompanied by some of the clinical types of morbidity. Thus 
 focal infection may or may not be associated with toxaemia or bacteriemia; of 
 the blood-states, toxemia often occurs without bacteriemia, but the latter is 
 naturally associated with toxemia, and may pursue its course with the picture 
 of toxffimia. PyEemia may occur by itself or associated with bacteriemia (sep- 
 ticopyemia). While toxaemia and bacteriemia are usually associated with 
 hyperthermia, simple rise of temperature may be due to nothing more than 
 
 * " Studien zur Bakteriologie des Genitalkanales in der Schwangerschaft und in Wochen- 
 bette," Wien, 1903. 
 
MORBID CONDITIONS ORIGINATING IN THE PUERPERIUM. 
 
 v;.v^.'V 
 
 
 
 Fig. 935. — Putrid Endometritis in the 
 Process of Healing, i. Necrotic surface 
 ofdecidua; 2. granulation wall; 3, decidua; 
 4, muscle. — {Bumm.) 
 
 Fig. 936. — Septic or Streptococcus 
 Endometritis. Endometritis in 
 Process of Repair. i, Necrosed 
 decidual surface with streptococci; 2, 
 granulation wall; 3, muscle. — {Bumm.) 
 
 Fig. 937. — Infection of Thrombi at Pla- 
 cental Site, i, Surface of serotina; 2, 
 septic thrombus; 3, granulation wall; 4, 
 muscle; 5, thrombus; 6, artery. — (Bumm.) 
 
 Fig. 938. — Septic Thrombophlebitis op 
 the Uterus. i, Loosened portion of 
 thrombus; 2, vein wall; 3, vein cavity; 4, 
 thrombus. — (Bumm^.) 
 
 
 Fig. 939. — Streptococci in the Smallest Lymph-spaces between the Muscle-fibers 
 
 OF the Uterine Wall. — (Bumm.) 
 
718 PATHOLOGICAL PUERPERIUM. 
 
 mental emotion or other nervous perturbation; and in the gravest types of 
 infection the temperature may be subnormal. 
 
 PRIMARY, CONSECUTIVE, AND METASTATIC FOCAL INFECTIONS. 
 
 Focal infections may be divided into primary and consectUive. The former 
 represent a direct inoculation of the germs into an exposed surface, while the 
 latter include the lesions which result from extension of the primary mischief, 
 whether by continuity of surface or contiguity. In the latter case extension 
 occurs by the lymphatics or the blood-vessels. When bacteria are transported by 
 the blood or lymph streams to remote regions, causing metastases, we may 
 speak of the latter also as consecutive lesions, although they are usually treated 
 as mere subsidiary features of a general infection of the entire organism. 
 
 Primary Focal Lesions. 
 
 Generally speaking, these result from a direct inoculation of germs into 
 traumatic areas resulting from labor or delivery. These comprise, from above 
 downward, the exposed placental site with its torn venous sinuses ; laceration 
 of the cervix (always present in primiparee) ; and laceration of the vagina, vulva, 
 and perineum. These lesions may vary greatly in extent, may increase in 
 size, may coexist, or one infected area may involve another. But the primary 
 lesions, while they may be very extensive, are not diffuse. We refer here to 
 ordinary pyogenic cocci and saprophytes. Conditions like acute gonorrhea, 
 erysipelas, and diphtheria, if contracted in the puerperium, are much less de- 
 pendent on traumatism, and are consequently able to cause a diffuse process. 
 But such conditions are so rare that good descriptions of them are not readily 
 found. 
 
 Primary lesions may be discussed independently, although they are, as a 
 rule, accompanied by complications. They may be subdivided into (i) puer- 
 peral ulcers and (2) endometritis. 
 
 I. Puerperal Ulcers. — By this term is meant the infected lacerations of the 
 vulva, vagina, and cervix. These traumatisms have a natural tendency to 
 repair, but if the vaginal secretions or lochia contain virulent pyogenic bacteria, 
 healing does not occur; and if the lacerations have been closed by sutures, the 
 latter cut through. Infection is indicated by the formation of a diphtheroid false 
 membrane, due to the irritating properties of the bacterial toxins. Even after 
 infection there is still a decided tendency to ultimate recovery, for the formation 
 of a defensive wall of leucocytes and proliferation tends to prevent the penetra- 
 tion of the bacteria and the false membrane is exfoliated. It is important to 
 know the clinical significance of these ulcers. In the first place, they are 
 frequently associated with septic endometritis, in which case they represent 
 only a minor complication. If the cervix if found free from such ulcers, there 
 is little likelihood of an intrauterine lesion. Uncomplicated puerperal ulcers 
 are generally spoken of as relatively harmless, but Lenhartz finds that small 
 external ulcers may frequently cause sepsis of a severe character; the amount 
 of toxins formed in such cases must be small, so that the sepsis produced is of 
 the purest type. 
 
 Endometritis. — Puerperal endometritis comprises several varieties. In re- 
 spect to cause, we have putrid, pyogenic, and mixed forms, according as the 
 pathogenic microorganisms are infective, or saprophytic, or both combined. In 
 respect to degree, we have simple, benign, or localized forms, in which the forma- 
 tion of the leucocyte barrier and the occlusion of the placental sinuses respec- 
 
MORBID CONDITIONS ORIGINATING IN THE PUERPERIUM. 719 
 
 lively protect the contiguous structures and organism at large from the exten- 
 sion of the disease; the constitutional reaction being akin to simple surgical 
 fever or simple toxemia, and malignant forms, in which the microorganisms 
 invade the periuterine tissues by the lymphatic route or penetrate into the 
 uterine veins, producing in many cases such formidable complications as peri- 
 tonitis and pyemia. 
 
 II. Simple Putrid or Saprophytic Endometritis. — Introduction. — In every nor- 
 mal puerperium there is a slight degree of sloughing of the endometrium in- 
 cidental to regeneration of that structure. Some little time is required for the 
 formation of the regenerative leucocyte layer and the lochial secretion with its 
 bactericidal function. During the interval which elapses between evacuation 
 and retraction of the uterus 
 and the establishment of 
 these defenses, saprophytes 
 undoubtedly enter the uterus 
 from the vagina in a large 
 percentage of cases and mul- 
 tiply to a certain extent. 
 These comprise not only a 
 number of species of harmless 
 "carrion-eaters," which have 
 never been recognized as 
 pathogenic, and certain forms 
 of saprophytes which are sus- 
 pected of pathogenic qualities 
 under certain conditions, but 
 also highly virulent germs 
 which are capable of behaving 
 as saprophytes in particular 
 cases, including the strepto- 
 coccus pyogenes. We do not 
 know whether these sapro- 
 phytes should be regarded as 
 physiological scavengers or as 
 meddlesome intruders. Since 
 the discovery of the existence 
 and properties of intracellular 
 ferments, we recognize the 
 fact that bacteria are not es- 
 sential to the breaking up of 
 cast-off protein matter. After 
 the establishment of the lochial discharge, the tendency of the uterus is to purify 
 itself of germ-life. Bearing in mind this fact, in association with the treacherous 
 character of bacteria, it is probably best to regard all germ-life in the puerperal 
 uterus as something foreign and undesirable ; but whether accomplished by tissue- 
 ferments, saprophytes or both conjoined, there is no doubt that the refuse proteid 
 matter of the regenerating endometrium, in breaking up into simpler and more 
 soluble and diffusible cleavage-products, is able to cause a very mild and tran- 
 sitory autointoxication, recognizable by the thermometer in a half — perhaps even 
 more — of all puerpera. This condition, commonly known as "one-day fever," is 
 described under clinical types. Endometritis as such does not coexist — aside from 
 the normal regenerative changes in the endometrium which hardly merit such a 
 
 
 MiE 
 
 MiE 
 
 MIE 
 
 MjE 
 
 ME 
 
 M~E 
 
 MjE 
 
 M'E 
 
 MiE 
 
 M|E 
 
 MIE 
 
 M!E 
 
 m:e me 
 
 ME ME 
 
 ,'A1l-l, 
 
 0,0 
 
 o|o 
 
 ilo 
 
 
 
 
 
 lil 
 
 2I0 
 
 0!0 
 
 :;i;i 
 
 0[l 
 
 11 
 
 111 
 
 i;o 
 
 17: 
 
 0;1 
 
 
 
 s. ,"!"".'.■ 
 
 
 
 
 ! 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 lor' 
 1 loe" 
 
 1 105° 
 6 104° 
 103° 
 102' 
 101° 
 100° 
 99° 
 1 ' 98° 
 
 ■3 97 
 
 1 -> 
 
 Vai, of 
 
 Disease 
 
 PiiUe 
 
 Heap 
 
 
 
 
 ' 
 
 
 
 
 
 ! 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 , 
 
 
 
 
 
 
 
 
 
 
 j 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ( 
 
 
 
 ; 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 i^ 
 
 
 
 , 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ,- 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 f 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ( 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ( 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 if 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \ 1 
 
 \\ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 1 
 
 
 V 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 / 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 / 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 / 
 
 
 
 _ 
 
 1/ 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 - 
 
 p 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 1 
 
 I 
 
 
 
 
 1 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 L 
 
 1 
 
 2 
 
 3 
 
 A 
 
 5 
 
 6 
 
 7 
 
 8 
 
 9 
 
 10 
 
 11 
 
 
 13 
 
 14 
 
 15 
 
 ^'s'o 
 
 '"-/s 
 
 .-ae 
 
 ^>k 
 
 'Vs 
 
 /8,' 
 
 '-64 
 
 !°r. 
 
 '.'-lo'j 
 
 "'I'oo 
 
 "sa 
 
 "il 
 
 ''°;6 
 
 "'64 
 
 "e's 
 
 68,- 
 
 ,-5o 
 
 ^°-^ 
 
 ?'i; 
 
 'Vi 
 
 "s'a 
 
 !?2'0 
 
 '.°i^ 
 
 IVs 
 
 ^S'o 
 
 "28 
 
 =.Vo 
 
 V-i--, 
 
 'yii. 
 
 ,'-'ls 
 
 "5'o 
 
 'Vb 
 
 Fig. 940. — Fever due to Sapremia (Septic Intoxi- 
 cation) ON THE Seventh Day of the Puer- 
 perium, Relieved by One Uterine Irrigation, 
 
 FOLLOWED BY THE USE OF ErGOT. 
 
720 
 
 PATHOLOGICAL PUERPERIUM. 
 
 name. Bumm, who believes that in a normal puerperium the -uterine cavity is 
 sterile from first to last, asserts that the normal lochia are always sterile until 
 they reach the vagina, when they quickly putrefy. Such a condition of affairs 
 may frequently occur, but is not the rule. 
 
 Since saprophytes multiply in proportion to the amount of dead material 
 present in the uterus, it is evident that the local and general reaction must 
 depend largely upon the latter factor. Even if these germs are essentially 
 foreign to the uterine cavity, the presence of a certain amount of putrefaction 
 of residual shreds of decidua, blood coagula, etc., during the establishment of 
 the lochia is not necessarily a pathological process, and is not regarded as con- 
 stituting an indication for intervention. This condition, which may be termed 
 
 simple putrescence of the 
 lochia, will be alluded to 
 again under clinical types. 
 The process is not sufficiently 
 active to produce endometri- 
 tis or toxemia, or to interfere 
 with normal regeneration. 
 It is otherwise when there is 
 considerable retained matter, 
 either from imperfect evacu- 
 ation of the placenta or mem- 
 branes, or defective drainage 
 (lochiometra). A double dan- 
 ger is present when the uterus 
 is not completely emptied, 
 for normal contraction and 
 retraction cannot occur. The 
 placental sinuses, instead of 
 closing by adhesion of their 
 walls, become plugged by 
 thrombi, and the process of 
 normal regeneration with 
 formation of -a bactericidal 
 lochia, is somewhat dis- 
 turbed. In retention of the 
 entire placenta, of the entire 
 ovum or fetus, in gangrene of 
 the uterus from pressure — in 
 general wherever there is an 
 opportunity for extensive 
 putrefaction, one of two things must happen if the uterus is not promptly evacu- 
 ated: viz., putrid endometritis with high degrees of sapremia develops as an un- 
 complicated condition, or from virulent and infectious germs already present in 
 the uterus or conveyed there by attempts at evacuating the uterus becoming 
 roused to activity, a mixed endometritis, to be considered later, is set up. 
 
 Definition. — Putrid or saprophytic endometritis is an endometritis set up 
 by the contact of the irritating secretions of the saprophytic bacteria together 
 with some of the products of the putrefaction of the dead proteid matter 
 retained within the uterus; in other words, the irritant material is composed of 
 bacterial toxalbumoses and ptomaines. It is never, perhaps, a purely local 
 affair, being accompanied by the results of absorption of the irritant material 
 
 
 M|E 
 
 M 
 
 E 
 
 M 
 
 E 
 
 M E 
 
 ME 
 
 M 
 
 E 
 
 m[e 
 
 M 
 
 E 
 
 M 
 
 E 
 
 ME 
 
 M|E 
 
 MiE 
 
 M 
 
 E 
 
 MtE 
 
 M 
 
 E 
 
 «'°"iV-%, 
 
 
 
 
 
 
 
 
 1 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 i 
 
 
 
 war"'".,. 
 
 
 
 
 
 
 
 
 1 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 F. 
 
 107° 
 
 = 100' 
 1 105 ° 
 1? 104 ' 
 103' 
 102' 
 101' 
 100' 
 99' 
 
 j '" 
 
 1 ^' 
 1 -^ 
 
 Day of 
 
 Dueaae 
 
 Pulse 
 
 Resp. 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 — 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 - 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ... 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 k 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ' 
 
 
 
 
 
 
 / 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 il 
 
 
 
 v 
 
 
 
 ^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 j 
 
 
 
 
 
 
 
 
 
 
 
 ' 
 
 \/ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 I 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 / 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 i 
 
 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 / 
 
 \ 
 
 
 
 
 
 / 
 
 
 
 
 / 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 / 
 
 '1 
 
 
 
 
 / 
 
 \ 
 
 
 / 
 
 
 
 
 
 
 
 — 1 
 
 — 
 
 — 
 
 — 
 
 1 — 1 
 
 _ 
 
 
 — 
 
 
 _ 
 
 > 
 
 rf- 
 
 -A 
 
 
 ; 
 
 -V- 
 
 -4- 
 
 _\_ 
 
 
 
 
 
 
 
 ~ 
 
 Ij 
 
 ~ 
 
 ~ 
 
 ~ 
 
 ~ 
 
 ~ 
 
 
 z: 
 
 
 
 _ ..._ 
 
 V= 
 
 _T_*^ 
 
 \ 
 
 i- 
 
 
 
 
 IJ 
 
 — 
 
 
 — 
 
 
 — 
 
 ' — '■ 
 
 — 
 
 
 — 
 
 
 — 
 
 
 — 
 
 
 
 
 
 
 
 
 
 f- 
 
 
 
 — 
 
 
 
 
 
 
 A 
 
 ■T 
 
 — 
 
 — 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 -^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 L 
 
 1 
 
 2 
 
 3 
 
 4 
 
 5 
 
 G 
 
 7 
 
 8 
 
 9 
 
 10 
 
 11 
 
 12 
 
 13 
 
 
 ';-9'o 
 
 '•/s 
 
 '°fo'o 
 
 "104 
 
 !-M4' 
 
 tVs 
 
 IVo'o 
 
 '.°'6B 
 
 90,'' 
 
 I'-eo 
 
 "as 
 
 ,100 
 
 "i04 
 
 90,' 
 
 ,'■ 
 
 "22 
 
 ,'24 
 
 "■'' 
 
 "" 
 
 IV2 
 
 20/ 
 
 -1(0 
 
 "'2'2 
 
 ,,20 
 
 '°'20 
 
 ,=A-o' 
 
 °°2 
 
 -'' 
 
 
 ,--' 
 
 Fig. 941. — Fever due to Mild Intra-partum Infec- 
 tion FOLLOWING Version on a Macerated Fetus. 
 Maternal Syphilis. 
 
MORBID CONDITIONS ORIGINATING IN THE PUERPERIUM. 721 
 
 by the lymphatics and veins, expressed clinically by the phenomena of sap- 
 remia {q. v.) (p.; 741). 
 
 Pathology and Pathogeny. — The irritant substances in question set up an 
 endometritis which has a more or less constant tendency to end in necrosis of 
 varying degrees. If the uterus is evacuated within a reasonable interval, necro- 
 sis of the endometrium does not result ; but if the condition is left to itself, the 
 saprophytes accumulate in such numbers and activity that the endometrium, 
 already in the act of throwing off dead material, becomes involved in the ne- 
 crosis. If the degree of the latter is slight, we have only an intensification of 
 the normal exfoliation of the mucosa; and, with cause removed, the formation 
 of the leucocyte layer and the bactericidal lochia, albeit somewhat delayed, pre- 
 vails in the end over the pathogenic factors. If the circumstances are less 
 favorable, the degree of necrosis may be sufficient to interfere utterly with normal 
 regeneration and purification of the endometrium. Mixed infection then devel- 
 ops, or in certain cases the putrid endometritis may acquire such severity that 
 the patient may die of intense sapremia, or even in rare cases of a generali- 
 zation of the saprophytes throughout the system (gas-sepsis). The latter ter- 
 mination must be of very rare occurrence, and its existence is difficult to demon- 
 strate. In the majority of such cases mixed infection is present; or the 
 saprophytes do not become generalized until the patient is dead or at least mori- 
 bund. (Figs. 935 and 936.) 
 
 Symptoms. — In putrid endometritis, the uterus is not properly contracted, 
 and more or less tenderness is present. The lochia are very fetid, and contain 
 much necrotic debris and are frothy from admixture of gas-bubbles. Pus is not 
 present. An examination of the secretions shows the presence of saprophytes. 
 The lochia may be "suppressed"; this is not due to a drying up of the secreting 
 surface, but to some form of mechanical obstruction — either anteflexion of the 
 uterus or plugging of the os with necrotic tissue. When the obstruction is re- 
 moved, there is a profuse escape of pent-up lochia having the characters already 
 described. Putrid endometritis is always accompanied by sapremia which varies 
 in degree with the amount of putrefaction. Pure sapremia, which is always 
 due to this condition, is discussed separately on page 741. 
 
 Diagnosis. — The various diagnostic points are included in the preceding para- 
 graph. An absolute diagnosis must rest upon the bacteriology. 
 
 Prognosis. — As long as the condition is simply a putrid endometritis, the 
 prognosis depends largely upon the promptness and completeness with which 
 the uterus is evacuated. But even after existing for a number of days, emptying 
 of the uterus may be followed by recovery. Much also depends upon the rapidity 
 of absorption of the toxins. The sapremia may be so acute that the patient's 
 vital organs are quickly overwhelmed. On the other hand, the steady and pro- 
 tracted absorption of toxins in an unrelieved case naturally tends to cause 
 death by exhaustion. 
 
 Treatment. — See page 726. 
 
 III. Simple Pyogenic or Infectious Endometritis. — Definition. — A puerperal 
 focal lesion due to the pathogenic action of infectious microorganisms upon the 
 endometrium which is in course of regeneration. 
 
 Etiology and Pathogeny. — The various predisposing and exciting causes of 
 pyogenic endometritis have been outlined in the general sections on the mor- 
 bidity of the puerperium. We do not find here the unevacuated or undrained 
 uterus which is a necessary factor in the production of the putrid and mixed 
 forms of endometritis. Other factors come into play, such as the ascent into 
 the uterus, during or after delivery, of infectious germs which have in some 
 46 
 
722 
 
 PA THOLOGICAL P UERPERI UM . 
 
 manner found their way into the vagina; or the direct inoculation of the uterine 
 cavity by the surgeon's instruments or hands in connection with the artificial 
 termination of labor. Epidemic prevalence of the disease is a prominent fac- 
 tor. In certain cases the endometrium is infected from birth wounds of the 
 lower genitals. It is often impossible to determine how infection takes place, 
 so that we are forced to think of a preexisting endometritis or a hematogenous 
 infection. Finally, predisposition plays an important part. Whatever greatly 
 lowers the resisting powers of the puerpera during the early days of the puerpe- 
 rium, before the establishment of the natural defenses — especially hemorrhages, 
 eclampsia, preexistent toxic states, the shock of protracted labor, etc., etc., 
 all render it possible for pyogenic cocci, which ordinarily would enter the uterus 
 as saprophytes, to become pathogenic. In many of these cases the uterus, 
 
 which has been completely 
 evacuated, is nevertheless 
 unable to contract properly. 
 The placental sinuses remain 
 patulous, or are imperfectly 
 closed by thrombi; and it is 
 this locality which is usually 
 first attacked by the pyo- 
 genic cocci, many cases of 
 simple infectious endometri- 
 tis remaining localized in this 
 area. (Figs. 937 and 938.) 
 
 The bacteria which cause 
 this form of endometritis 
 consist of the common pyo- 
 genic microorganisms, chiefly 
 the streptococcus pyogenes, 
 but occasionally the staphy- 
 lococcus aureus and albus, 
 and more rarely of other pyo- 
 genic bacteria. A mixture of 
 infection is not uncommon. 
 
 The pathogeny of infec- 
 tious endometritis differs 
 notably from that of the pu- 
 trid form. In the latter, as 
 already stated, the bacteria 
 do not attack the living 
 tissues, and the inflammation is produced entirely by the corrosive action of the 
 bacterial secretions and decomposition products of the dead tissue. In pyogenic 
 endometritis, on the other hand, the bacteria attack the living tissues, and through 
 multiplying therein, produce a necrotic layer which greatly resembles the false 
 membrane of true diphtheria, and which may vary greatly in thickness and extent. 
 In its lightest form it has been compared to a mere "haziness," while in the higher 
 degrees the necrotic endometrium may come away in large shreds. When dead 
 tissue thus appears in the uterus to this extent, certain complications may arise. 
 Thus the os may be obstructed temporarily, and the lochia pent up. Again the 
 presence of the dead tissue favors the development of an associated putrid endo- 
 metritis. 
 
 Symptoms; Course. — If the endometrium is attacked by pyogenic cocci during 
 
 N 
 
 W] 
 
 viT 
 
 El^ 
 
 IeT 
 
 viTT 
 
 ME IV 
 
 Te" 
 
 VI 
 
 E 
 
 M 
 1 
 
 Ejiv 
 
 ■jeTw 
 
 "IeIv 
 
 E 
 
 M 
 
 E ^ 
 
 .E ^/ 
 
 E 
 
 ME 
 
 VIE 
 
 ,A°.1'rt, C 
 
 1 
 
 
 
 
 
 
 
 1 
 
 1 
 
 
 
 1 
 
 
 
 c 
 
 1 
 
 1 c 
 
 1 
 
 2 
 
 2 1 
 
 t 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 _ 
 
 _ 
 
 
 
 F. ^ - 
 
 -t— 
 
 -- 
 
 -- 
 
 T~ 
 
 — 
 
 
 
 
 " 
 
 Z 
 
 zi 
 
 
 IZI 
 
 IZ 
 
 Z 
 
 z: 
 
 
 __ 
 
 zl 
 
 _ 
 
 i]z 
 
 107 - 
 
 
 
 — 
 
 
 -J — 
 
 — 1 — 
 
 
 
 
 
 — '■ 
 
 
 
 
 
 — 
 
 
 — 
 
 
 — 
 
 
 ~ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 -- 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 — 
 
 
 — 
 
 — 
 
 1 — 
 
 £ 
 
 
 
 — 
 
 
 — 
 
 — 
 
 
 
 
 
 
 V- 
 
 
 
 
 
 
 — 
 
 
 — 
 
 
 
 
 
 
 i 
 
 
 
 
 
 
 
 
 
 _ 
 
 
 
 
 
 
 
 
 _ 
 
 
 
 
 — 
 
 — 
 
 — 
 
 
 
 :§ 105 - 
 
 -- 
 
 — 
 
 
 - — 
 
 — 
 
 
 
 — 
 
 
 ^ 
 
 
 
 
 
 
 
 ~ 
 
 zi 
 
 
 __ 
 
 
 
 — 
 
 
 
 ■:; ., - 
 
 
 
 — 
 
 
 — 
 
 — 
 
 
 
 
 — 
 
 
 
 
 
 
 
 — 
 
 — 
 
 — 
 
 
 
 
 
 
 ■~ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 _ 
 
 
 
 
 
 
 -, — 
 
 
 — 
 
 
 
 
 
 — 
 
 
 
 g 104 - 
 
 "l— 
 
 — 
 
 
 — 
 
 — 
 
 
 :— 
 
 ~ 
 
 
 z 
 
 z: 
 
 
 
 
 
 
 _ 
 
 
 
 
 __ 
 
 _ 
 
 — 
 
 
 
 - 
 
 — 
 
 — t 
 
 
 — 
 
 — i— 
 
 
 — 
 
 — 
 
 
 
 
 
 
 
 
 
 
 — 
 
 
 — 
 
 — 
 
 ~ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 103 - 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 "■ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 — 
 
 
 
 
 — 
 
 — 
 
 
 
 - 
 
 
 
 — 
 
 
 — 
 
 — 
 
 
 
 — 
 
 
 
 
 
 
 
 
 
 
 
 — 
 
 
 
 ■■ 
 
 - 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 — 
 
 
 — 
 
 — 
 
 
 
 
 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 - 
 
 
 
 
 
 
 ' II 
 
 \ 
 
 
 T 
 
 
 
 / 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 I 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 + 
 
 r^~f 
 
 
 
 
 / 
 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 100 - 
 
 jj 
 
 — 
 
 B 
 
 =r 
 
 TF 
 
 ^\ 
 
 -p 
 
 V 
 
 
 — 
 
 3 
 
 
 
 7-Z 
 
 
 -\ 
 
 J-: 
 
 ~z 
 
 z 
 
 ~ 
 
 
 99' 
 
 l^ 
 
 k 
 
 k:: 
 
 F 
 
 3E 
 
 
 
 z 
 
 - 
 
 E 
 
 E: 
 
 ==- 
 
 TT 
 
 zz 
 
 4 
 
 1 
 
 
 z. 
 
 s~ 
 
 - 
 
 V 
 
 £ 
 
 
 
 
 ' 
 
 
 
 
 
 
 
 
 
 
 
 
 
 J 
 
 _ 
 
 L 
 
 
 - L 
 
 A 
 
 / 
 
 V 
 
 
 
 
 — 
 
 
 — 
 
 — 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ~ 
 
 *- 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 :^ "^ 
 
 
 - 
 
 ■■ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 _ 
 
 _ 
 
 _ 
 
 _ 
 
 
 
 
 
 _ 
 
 _. 
 
 
 — 
 
 — 1 — 
 
 
 Days of 
 
 L 
 
 — 
 
 1 
 
 2 
 
 3 
 
 4 
 
 5 
 
 6 
 
 7 
 
 8 
 
 9 
 
 10 
 
 n 
 
 12 
 
 13 
 
 14 
 
 
 Puhe 
 
 ,,', 
 
 "-I'o'o 
 
 ^'im 
 
 74- 
 
 "I'o'o 
 
 ,^'Hr. 
 
 °'VnB 
 
 »V„; 
 
 >^■2 
 
 '108 
 
 /'lOO 
 
 'yio 
 
 ,%; 
 
 "'86 
 
 «b' 
 
 ,»' 
 
 ^%\ , 
 
 X 
 
 ,"' 
 
 'il. 
 
 '?.; 
 
 l%l 
 
 "ii 
 
 °'U 
 
 "j'4 
 
 
 ;•%, 
 
 
 
 20 
 
 
 Fig. 942. 
 
 -Fever due to Mild Streptococcus Infec- 
 tion. 
 
MORBID CONDITIONS ORIGINATING IN THE PUERPERIUM. 723 
 
 the period of regeneration, a struggle for the mastery ensues between the micro- 
 organisms and the defensive forces. If the latter prevail, the leucocyte barrier 
 increases in extent, pus is formed in increasing amounts, and through the 
 mechanical action of this fluid, the necrotic tissue is broken up and washed 
 away. The lochia acquires bactericidal properties, and the uterine cavity tends 
 to become sterile. Under these circumstances the disease runs a benign course. 
 The uterus exhibits some tenderness, and an ordinary surgical fever is present, 
 caused by absorption of the toxins secreted by the bacteria. The lochia are 
 purulent and entirely devoid of odor and the microscope reveals the presence 
 of one or more forms of pyogenic cocci. 
 
 If, on the other hand, the disease-germs prevail over the vital forces, malignant 
 endometritis results. Two very different types of the latter are recognized and 
 the two may be combined to form a third. Since infection usually begins at 
 the placental site, much depends upon the condition of the latter at the time. 
 If the uterus is well retracted and the sinuses closed, the defense at this point 
 is effective. If the sinuses are simply plugged with aseptic thrombi, virulent 
 germs may infect the latter directly, or may first penetrate between the sinuses, 
 and eventually through the walls of the latter from without. This type of 
 malignant endometritis which passes directly into pyemia, is manifested usually 
 by a succession of chills denoting the sudden entrance into the circulation of 
 a large amount of toxic material. In the other type of malignancy we may 
 suppose that the placental sinuses escape, but that the endometrium is the seat 
 of extensive pyogenic infection ; the virulence or numbers of the germs enable 
 them to penetrate the leucocyte barrier and enter the subjacent lymph-spaces 
 in such numbers and activity as to infect the parametrium or perimetrium or 
 even the blood itself. Clinically this type of endometritis would be expressed 
 by evidences of pelvic inflammation superadded to uterine pain and tenderness. 
 As is readily apparent from what has been said, the moment an endometritis 
 is to be classed as malignant, the infection has already extended beyond the 
 uterus — either along the uterine veins or into the pelvis. These two types of 
 malignant endometritis, viz., the venous and lymphatic, may be conjoined, and 
 we then have a special blood-state termed septicopyemia (q. v.). 
 
 Diagnosis. — In the milder forms of pyogenic endometritis there may be but 
 little constitutional disturbance — nothing beyond a slight resorption-fever — and 
 local symptoms may likewise be absent. Under such circumstances diagnosis 
 can be made only by the purulence of the lochia, and the presence therein of 
 the pyogenic cocci in large quantities. In higher degrees we find tenderness " 
 and the toxemic state more highly developed, this accentuation, as in other 
 suppurating cavities, being sometimes dependent upon imperfect drainage. The 
 evidences of malignancy have already been enumerated. Since streptococci 
 have been known to enter the circulation and remain therein in a latent state 
 for days, we should examine the blood in all cases of persistent elevation of 
 temperature, even in the absence of symptoms of blood infection, or extension 
 of the morbid process beyond the uterus. 
 
 Prognosis. — As long as the uterus is movable, drainage maintained, blood 
 examinations negative, and the march of the temperature in accord with simple 
 localized suppuration, the prognosis is good, the condition hardly calling for 
 active treatment. As soon as there is evidence of extension of the process by 
 the veins or lymphatics, the question is no longer one of endometritis, for the 
 latter, per se, could hardly endanger life. In those extreme cases in which the 
 entire uterus is inflamed and softened, extension of the disease has already 
 occurred, death really taking place from pyemia or peritonitis. 
 
724 
 
 PATHOLOGICAL PUERPERIUM. 
 
 Treatment. — See page 726. 
 
 IV. Endometritis from Mixed Infection ; Composite Endometritis. — AVhile this 
 affection is of frequent occurrence and is naturally grave in character, its charac- 
 teristics have been so thoroughly discussed under the individual types of en- 
 dometritis that but little more need be given here than a recapitulation. 
 
 mlMmMrVerL ^■ 
 
 SuspmsonjUnmCofOiwy 
 
 Fig. 943. — Puerperal Uterus, Three Hours Post Partum, the Site of Streptococcus 
 
 Endometritis. — {Sellheim.) 
 
 Whenever an unevacuated uterus leads to the development of putrid endome- 
 tritis, a pyogenic infection is readily grafted upon the initial trouble. If strepto- 
 cocci are present at the outset, as "acting saprophytes," they may be roused 
 
 PkKxntaUite 
 bladder ^ 
 
 (/reffira 
 .AntiCbrvicaiLip. 
 Introitus Vc^?tae / ■/ v^v /^ 
 
 £ji;t.03. -Ts-ff^ V. 
 
 PostCerv-^P- 
 
 Perineum 
 
 Anus /^ 
 /nt5p/ii7iaer 
 £xt.3p/nn€terAni. 
 
 /'ouc/io/'Dou^las ~ 
 
 Fig. 944. — Sagittal Section of a Puerperal Uterus Three Hours Post Partum with 
 Streptococcus Endometritis. Same case as Fig. 943. — {Sellheim.) 
 
 to the virulent or infectious state through rapid multiplication in the presence 
 of the necrotic tissue. From another point of view the presence of a putrid 
 endometritis causes a lowering of the local resisting power, an impairment of 
 
MORBID CONDITIONS ORIGINATING IN THE PUERPERIUM. 725 
 
 the regenerative faculty of the endometrium, and a depreciation of the bacteri- 
 cidal power of the lochia. Under these circumstances streptococci, however 
 introduced into the uterus, are able to flourish and exert their pernicious 
 influence. 
 
 We have already seen that putrid endometritis need not always be the 
 primary lesion; for the diphtheroid membrane which results from pyogenic 
 infection of the endometrium constitutes necrotic tissue upon which saprophytes 
 are able to feed and increase in numbers. According to Bumm, the pyogenic 
 cocci usually take precedence in associate infection; they cause necrosis of the 
 
 Fig. 945. — LocHiAL Secre- 
 tion OF Putrid Endome- 
 tritis. — (Bumm.) 
 
 Fig. 946. — LocHiAL Secre- 
 tion OF Septic Endome- 
 tritis. — (Bumm.) 
 
 Fig. 947. — LocHiAL Secre- 
 tion OF Gonorrheal En- 
 dometritis. — (Bumm.) 
 
 endometrium, and thereby enable the saprophytes to obtain a foothold. Gener- 
 ally speaking, the conditions are such that the development of mixed endometritis 
 is naturally favored. Pure examples of saprophytic or pyogenic infection are 
 doubtless less frequent than is usually taught. 
 
 Symptoms; Course. — In the majority of cases composite endometritis doubt- 
 less begins with the putrid form; i. e., with an unevacuated uterus. If the 
 latter is emptied, the expected defervescence does not occur, and it becomes 
 apparent that the composite endometritis has been transformed into the simple 
 pyogenic form. The prognosis of the latter is, however, much graver than is 
 
 Fig. 948. 
 
 -Glass Cannula for Obtaining Lochial Secretion from the Uterus. 
 (i natural size.) 
 
 the case when the pyogenic affection is primary; and it is very evident that the 
 associate affection has so crippled the defenses of the organism that the endome- 
 tritis is very likely to become malignant. 
 
 As already implied, unless the putrid endometritis is of such intensity or 
 duration as to necrotize the endometrium, thorough evacuation of the uterus will 
 transform the composite into the simple pyogenic form — since the saprophytes 
 are thereby deprived of nutriment. Under unusual circumstances, such as 
 retention of a large amount of fetal tissue for a protracted period, or pressure- 
 gangrene of the uterus, the putrefaction of the latter is so extensive that removal 
 
726 
 
 PATHOLOGICAL PUERPERIUM. 
 
 or disinfection of the necrotic tissue is impossible. If after repeated douching 
 of the uterus the lochia continue fetid, it is evidence that the endometrium has 
 been extensively involved in the putrefactive process. Such cases naturally 
 remain composite to the end, and are comparable with neglected cases in which, 
 for one reason or another, there has been no attempt to evacuate the uterus. 
 
 When under such circumstances the affection remains composite to the end, 
 the condition known as sapremic sepsis develops; or, in other words, the blood 
 changes which tend to accompany each disease singly, are found side by side. 
 
 
 M 
 
 E V 
 
 /I E 
 
 M 
 
 T 
 
 M 
 
 E 
 
 M 
 
 E 
 
 M 
 
 E 
 
 M 
 
 E 
 
 M 
 
 E 
 
 M 
 
 E 
 
 M 
 
 E 
 
 M 
 
 E 
 
 M 
 
 E 
 
 M E 
 
 M 
 
 E 
 
 M 
 
 E 
 
 M!E 
 
 M E 
 
 M 
 
 E 
 
 MlE 
 
 m!e 
 
 M 
 
 E 
 
 ,.u""i'/or 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 1 
 
 
 
 0.a.";".'.T. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 F. 
 
 107° 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 i 
 
 ' 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ' 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ' 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ' 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 106° 
 
 s 
 
 1 105 
 
 ^ ^ 
 
 1 
 
 1 104 
 
 103° 
 
 102° 
 
 101° 
 
 100° 
 
 99° 
 
 1 "^^ 
 
 1 97° 
 1 -^ 
 
 Hay of 
 
 Duease 
 
 Pulse 
 
 Uetp. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 S 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ?; 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 L 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ¥ 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 O 
 
 
 
 
 1 
 
 
 » 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 « 
 
 
 
 
 1 
 
 
 ? 
 
 
 1 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 s 
 
 
 
 
 1 
 
 1 ^ 
 
 
 1 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 s 
 
 
 
 
 1 
 
 
 ' 
 
 
 1 
 
 
 
 
 
 
 
 j 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •^ 
 
 
 
 
 1 
 
 
 ~ 
 
 1 
 
 1 
 
 
 
 
 
 
 ! 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 1 
 
 
 
 
 1 
 
 
 
 i 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 j 
 
 
 ■>. 
 
 
 
 
 
 
 1 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 ! 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 [ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 i 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ^ 
 
 ; / 
 
 
 
 ! 
 
 
 
 
 
 
 
 
 
 
 
 
 
 r 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 /^ \ 
 
 ' / 
 
 
 
 i f 
 
 1 
 
 
 
 
 
 / 
 
 
 
 
 
 / 
 
 
 . -I 
 
 
 
 
 
 
 
 / 
 
 
 
 
 
 I / 
 
 \ 
 
 / 
 
 
 I 
 
 V 
 
 
 
 
 
 
 
 
 
 
 1/ 
 
 
 1 A 
 
 
 
 
 
 
 
 / 
 
 
 
 
 
 \ / 
 
 I 
 
 / 
 
 I i 
 
 it 
 
 \ 1 
 
 
 
 
 
 
 
 J 
 
 
 
 
 
 \ '/' 
 
 
 
 
 
 
 V 
 
 
 
 
 
 
 1 / 
 
 I 
 
 / 
 
 
 / 
 
 s. 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 \ 1 
 
 
 
 
 
 
 \ 
 
 
 
 
 
 1/ 
 
 ll 
 
 / 
 
 
 / 
 
 \ 
 
 ! 
 
 
 
 
 1 
 
 
 j 
 
 
 1 
 
 
 i/i 
 
 
 1 
 
 I 
 
 
 
 
 
 
 
 
 
 
 (i 
 
 If 
 
 i 1 
 
 / 
 
 
 _yi 
 
 
 \ 
 
 1 
 
 
 \ 
 
 
 ] 
 
 
 1 
 
 
 t 
 
 
 * 1 
 
 \ 
 
 
 i 
 
 
 
 
 
 
 
 
 
 
 / 
 
 1 
 
 1 
 
 / 
 
 
 i 
 
 
 
 \^ 
 
 - '. 
 
 
 k 
 
 
 
 1 
 
 
 1 
 
 \ 
 
 1 
 
 \ 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 ' 
 
 1 
 
 I 
 
 
 
 
 [ 
 
 
 
 \/\ 
 
 
 \ 
 
 ■ r 
 
 
 
 
 
 1 
 
 \ 
 
 
 
 
 
 \ 
 
 
 1 
 
 
 
 
 
 
 
 , 
 
 
 V 
 
 1 
 
 / 
 
 
 1 
 
 1 
 
 
 
 
 
 \ 
 
 
 
 
 
 
 
 1 
 
 \ 
 
 
 
 
 
 \ 
 
 
 \ j 
 
 
 
 
 
 
 
 / 
 
 
 1 
 
 [ \j 
 
 
 
 
 1 
 
 
 1 
 
 
 
 
 
 
 
 
 
 1 
 
 V 
 
 
 
 
 
 1 
 
 
 Y 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 1 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 j 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 I 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 \ 1 
 
 
 
 
 
 ' 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 i 
 
 
 
 
 
 
 1 
 
 
 1 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 i 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ! 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 1 
 
 
 1 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ] 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 1 
 
 ; 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ' 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 i 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 L 
 
 1 
 
 2 
 
 3 
 
 4 
 
 5 
 
 6 
 
 7 
 
 8 
 
 9 
 
 10 
 
 11 
 
 12 
 
 13 
 
 U 
 
 IS 
 
 16 
 
 17 
 
 18 
 
 19 
 
 20 
 
 '^92 ' 
 
 'Vns 
 
 , '''as 
 
 ^°(oB 
 
 "'a,' 
 
 -Is 
 
 ';%; 
 
 "'so 
 
 ^'''so 
 
 !°-eo 
 
 "'lie 
 
 ,7f' 
 
 '>76 
 
 "'76 
 
 ,0=' 
 
 -'es 
 
 "V 
 
 ',"'96 
 
 J'se 
 
 "n's 
 
 f-'il 
 
 Itu 
 
 
 "'" 
 
 ,!.'-'i8 
 
 '°-,3 
 
 "'se' 
 
 Iho 
 
 "Xi 
 
 33 -' 
 
 ao^- 
 
 "Jb 
 
 ^,=6- 
 
 "30 
 
 /30 
 
 ,»^^ 
 
 t°^ii 
 
 .% 
 
 °--s's 
 
 "'<, 
 
 22^- 
 
 "i^ 
 
 Fig. 949. — Fever due to Suppurative Mastitis. Two abscesses in one breast incised 
 and drained. Temperature on the twenty-seventh day of the puerperium normal and 
 pulse seventy-four. 
 
 Moreover, in the very highest type of puerperal morbidity, the saprophytes 
 may enter the circulation before death and cause the so-called gas-sepsis (g. v.). 
 Uncomplicated sapremia (from putrid endometritis) and uncomplicated sepsis 
 are without doubt responsible for many deaths among puerperae ; yet it is very 
 likely that in untreated cases mixture of infection results sooner or later. 
 
 Diagnosis. — The lochia afford the sole means for a rational diagnosis. If 
 this discharge is both fetid and purulent, containing in addition gas-bubbles; 
 and if a microscopic examination reveals both saprophytes and pyogenic cocci 
 in large numbers, the diagnosis is assured. 
 
MORBID CONDITIONS ORIGINATING IN THE PUERPERIUM. 727 
 
 Prognosis. — If defervescence occurs within a reasonable period after the 
 uterus has been emptied and irrigated, the prognosis is good. If the fever does 
 not disappear, or if it returns after a short fever- free interval, it is probable 
 that the streptococci have passed beyond the confines of the endometrium. 
 
 V. Mastitis. — (See Diseases of the Breast, Part VII.) 
 
 Primary focal lesions in the genital canal which result from specific infectious 
 processes, as gonorrhea, diphtheria, and erysipelas, receive separate attention on 
 page 737. 
 
 I have already insisted that malignant puerperal endometritis implies some 
 form of secondary extension 
 of the primary mischief; in 
 other words, it is not merely 
 the going from bad to worse 
 of the uterine lesion. I shall 
 first enumerate the results of 
 extension by continuity of 
 surface, which are relatively 
 benign in comparison with 
 the conditions which result 
 from extension along the 
 vessels. From puerperal ul- 
 ceration near the urethra, the 
 urinary tract may become in- 
 volved; from ulceration of a 
 complete perineal tear, the 
 rectum may be involved, at 
 least in theory. Finally, in 
 pyogenic endometritis the 
 tubes are readily involved by 
 continuity. These conditions 
 are now briefly described. 
 
 Consecutive Focal Infec- 
 tion. 
 
 Consecutive Lesions from Ex- 
 tension by Continuity. 
 
 VI. Puerperal Infection of 
 the Urinary Tract {Pyogenic 
 Urethritis, Cystitis, Pyelitis, 
 Pyelonephritis). — Naturally 
 these conditions do not differ 
 materially from ordinary 
 urinary infection from the 
 
 use of septic catheters. Indeed, this very accident may occur in the puerperium, 
 and hence catheterization is to be avoided as far as possible and done only under 
 the strictest asepsis (see Management of Puerperium). 
 
 VII. Puerperal Proctitis. — This condition, which is extremely rare, and might 
 also occur from some accident, as from a septic syringe, represents an inoculation 
 of some raw surface, and is in fact a puerperal ulcer of the rectum, having the 
 same symptoms, diagnosis, and treatment. Puerperal rectal gonorrhea may 
 occur. 
 
 
 M 
 
 E 
 
 M 
 
 E 
 
 w\ 
 
 E 
 
 M 
 
 E 
 
 M 
 
 E 
 
 M 
 
 E 
 
 M 
 
 E 
 
 MiE 
 
 M 
 
 E 
 
 Wl 
 
 E 
 
 M 
 
 E 
 
 M 
 
 E 
 
 M 
 
 E 
 
 :£f£;; 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ,..t"'"L,. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 V. 
 
 107° 
 
 f 
 
 « 106° 
 
 1 105° 
 
 ^ 104° 
 
 103° 
 
 102° 
 
 101° 
 
 100° 
 
 99° 
 
 1 ^^" 
 
 ■5, — > 
 
 £ 97° 
 
 ^ _^ 
 
 bays of 
 Ehsease 
 
 Pulse 
 
 Xesp 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 j 
 
 — 
 
 1— 
 
 -,-- 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 J 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 — 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 . 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 / 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 / 
 
 
 I 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 
 
 
 A 
 
 
 
 
 
 
 
 
 
 A 
 
 
 
 
 
 
 
 
 
 i 
 
 
 
 t 
 
 
 
 
 r\ 
 
 
 
 
 
 
 
 
 
 ' 
 
 
 
 
 
 
 
 
 
 / 
 
 
 
 
 
 I 
 
 
 / \ 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 
 
 
 V 
 
 
 
 ' 
 
 
 
 
 
 1 
 
 
 / 
 
 ' 
 
 f 
 
 
 
 
 
 
 
 
 
 
 j 
 
 
 \ 
 
 A 
 
 / 
 
 
 
 
 
 
 ^ 
 
 
 
 
 
 ■ 
 
 
 
 
 
 
 
 
 
 ^ 
 
 
 ^ 
 
 i 
 
 
 
 
 
 
 
 
 
 
 
 
 \ / 
 
 
 
 
 
 
 
 
 
 1 
 
 
 ^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \ ' 
 
 \r 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 V 
 
 \\ 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 T!^ 
 
 j 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 i 
 
 \ 
 
 
 / 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 I 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ! 
 
 1 
 
 
 
 
 
 
 L 
 
 1 
 
 2 
 
 3 
 
 •1 
 
 b 
 
 G 
 
 7 
 
 8 
 
 9 
 
 10 
 
 11 
 
 12 
 
 °'i^o 
 
 98^^' 
 
 !-•'" 
 
 Bi X 
 
 ^'84 
 
 "^e' 
 
 '^Xoo 
 
 '^r^ 
 
 '-"•s'l 
 
 ">8'^ 
 
 '-<^ 
 
 I''/* 
 
 .- 
 
 ^^ .. 
 
 ,.--" 
 
 ^-- 
 
 --' 
 
 
 .'" 
 
 . -'' 
 
 ^^ 
 
 y 
 
 '•■ 
 
 y 
 
 ,'' 
 
 
 Fig. 950. — Fever due to Gonorrheal Cystitis in 
 THE Puerperium, the Gonococcus being found 
 IN the Pus from the Urethra. Irrigation of 
 the bladder practised and urotropin administered. 
 
728 PATHOLOGICAL PUERPERIUM. 
 
 VIII. Puerperal Salpingitis. — This is stated to be a somewhat infrequent con- 
 secutive lesion and must be distinguished from salpingitis which occurs secondarily 
 to peritonitis. Uncomplicated salpingitis from direct extension of pyogenic endo- 
 metritis has the characters of abscess-formation, supervening with a rigor, a fever 
 which may reach 104°, and in some cases severe pain. Physical examination will 
 reveal a tumor which when developed is of a sausage shape. 
 
 Consecutive Lesions Due to Extension Along the Uterine Vessels. 
 
 We know that evefi in relatively mild cases of endometritis, streptococci are 
 able to break through the leucocyte barrier into the uterine lymph spaces, 
 although they do not necessarily set up metritis or other consecutive lesions. 
 Generally speaking, whenever the pyogenic cocci pass this barrier, we should 
 no longer speak of endometritis, for with these germs once in the lymph spaces 
 there is nothing to prevent the further extension of infection which may involve 
 the uterus, parametrium, perimetrium, or ovary; in fact all the accidents of 
 extension result here save those which arise from direct extension along the 
 veins at the placental site. We therefore differentiate between lymphatic and 
 venous septicemia, the latter being known as pyemia. 
 
 Consecutive Lesions from Lymphatic Extension. 
 
 These comprise metritis, pelvic lymphangitis, parametritis, oophoritis, peri- 
 metritis (or benign peritonitis), and malignant or general peritonitis. The par- 
 ticipation of the peritoneum may be secondary to metritis or parametritis. 
 With any of the accidents we see always the occurrence of toxemia with or 
 without bacteriemia. It should be stated, also, that a low form of peritonitis 
 may follow simple putrid endometritis and also gonorrhea. On the other hand, 
 sepsis may be so sudden and intense in development that dissolution of the 
 blood may outstrip the formation of consecutive foci. Under such circumstances 
 there would probably be found at autopsy some such coincidence as antepartum 
 sepsis, with pressure-gangrene of some part of the uterus and evidences of 
 beginning peritonitis. From the blood and some of the viscera we may obtain 
 pyogenic cocci in association with putrefactive bacteria. 
 
 The consecutive lesions enumerated above will now be discussed individually. 
 
 IX. Metritis. — This term is practically synonymous with malignant endome- 
 tritis. As the endometrium and muscularis are continuous the latter is invariably 
 infected whenever the leucocyte barrier does not withstand the attacks of the 
 infecting organisms. The streptococci usually multiply along the coarser 
 lymphatics of the uterus, and may not pass through the vascular walls. In this 
 case the parametrium may be the first structure to feel the brunt of the attack 
 or the peritoneum may be selected. In other cases the streptococci multiply 
 throughout the finer lymphatics as well, and also pass through the vascular 
 walls, setting up intramuscular abscesses, and sometimes lead to necrosis of 
 entire portions of the musculature (metritis dissecans). This so-called lymphatic 
 infection of the uterus is probably less common than the direct infection of 
 the veins at the placental site. The latter is the first and commonest seat of 
 puerperal endometritis, and Lenhartz states that at least one-half of all puerpera 
 who come to the autopsy-table show some evidence of thrombophlebitis. The 
 streptococci may not only enter the lumen of the veins, but may also proceed 
 along their outer walls and eventually penetrate them. As soon as the thrombi 
 once become infected, it is no longer a question of metritis, for the disease is 
 
MORBID CONDITIONS ORIGINATING IN THE PUERPERIUM. 729 
 
 propagated along one or more of the uterine veins, and we have special con- 
 secutive lesions. 
 
 Consecutive lesions beyond the limits of the uterus must now be considered. 
 As already stated, these are divisible into (i ) lesions due to lymphatic extension — 
 parametritis, ovaritis, perimetritis (or benign peritonitis), and general or malig- 
 nant peritonitis — and (2) lesions due to venous extension, which comprise the 
 various types of puerperal phlebitis. 
 
 X. Parametritis. — This lesion is caused by propagation of the streptococci 
 from the lymph spaces of the muscularis of an infected uterus and also from 
 extensive cervical puerperal ulcers which extend directly into the parametrium. 
 In the former case the germs are propagated along the pelvic lymphatics where 
 they set up a lymphangitis; while in the latter case cellulitis is the immediate 
 result. In the absence of natural barriers the loose tissue of the pelvis is quickly 
 
 /'%,. 
 
 ■■^"W. :<*^~*sS^,^ 
 
 ,-- .sJi^ 
 
 Fig. 951. — Uterus and Adnexa from a Case of Acute Streptococcus Infection and 
 Septicemia Lymphatica. Death on twelfth day after Cassarean section. No peri- 
 tonitis and no pus in the tubes; macroscopic appearance of endometrium normal. — 
 (Author's case at the New York Maternity.*) 
 
 infected. The parametrium of one or both sides becomes the seat of hyperemia 
 and serous infiltration. The diseased foci, usually miliary, are then invested by 
 a wall of leucocytes which limits the further extension of the process. Abscess- 
 formation occurs whenever the miliary foci coalesce, but the natural leucocyte 
 defense is generally so vigorous that the streptococci are vanquished at an early 
 stage before coalescence occurs. In this termination the exudation is gradually 
 absorbed. When abscess-formation occurs the pus tends to gravitate into the 
 perirectal and retroperitoneal connective tissue. The abscess may penetrate 
 into the rectum or vagina or may point externally at the groin above Poupart's 
 ligament. (Figs. 954 and 955.) 
 
 Parametritis may, of course, be but a single feature in a compHcated septic 
 process, in association with endometritis and other local lesions and septicemia; 
 
 ♦See "Trans. N. Y. Obstetrical Society," April 16, 1895. 
 
730 
 
 PATHOLOGICAL PUERPERIUM. 
 
 but when parametritis is the principal lesion, it simply gives rise to the same 
 constitutional reaction as does any other large acute abscess, and it would 
 hardly be proper to rank such a condition as puerperal sepsis. Thus, invasion 
 of the parametrium is heralded by a chill and a sharp rise of temperature, and 
 a typical suppuration-fever follows. If the leucocyte defense succeeds in keeping 
 the minute initial abscesses from coalescing, the process is aborted in about 
 ten days or two weeks and defervescence results ; but if the streptococcus pre- 
 vails, the gradual formation of the abscess is marked by the usual temperature 
 curve of an abscess fever. High evening temperatures are succeeded by profuse 
 sweats and morning remissions. Relief by natural or surgical evacuation is 
 followed by defervescence. Clinically the rigor and rise of temperature are 
 associated with pain and tenderness in situ and in some cases pressure-pain is 
 also referred to the lower extremities or loins. Bimanual examination reveals 
 the presence of a mass at one side of the uterus (exceptionally at both sides); 
 several days, however, being required for the development of the exudate. The 
 mass at the side of the uterus tends to increase in size, and the sensitiveness 
 
 VAGINA 
 RECTUM 
 
 Fig. 952. — Parametric Inflammation 
 IN THE Cellular Tissue of the 
 Right Broad Ligament Pushing 
 THE Uterus to the Lbft .^(Dakin.) 
 
 VAGINA 
 
 Fig. 953. — Parametric Inflammation of 
 THE Cellular Tissue of the Right 
 Iliac Fossa, and Slight Induration in 
 the Right Broad Ligament. The Uterus 
 is in the Normal Position. — (Dakin.) 
 
 to manipulation increases, especially in cases in which the peritoneum becomes 
 involved secondarily. The respective terminations in resolution and suppura- 
 tion have already been noted. In either case more or less of the infiltration 
 may persist as organized connective tissue, and incidentally the uterus may 
 become displaced in any one of several fashions. 
 
 The diagnosis of parametritis is naturally considered with that of perimetritis, 
 for the two conditions not only present much in common, but very often coexist. 
 
 XI. Peritonitis. — Benign Forms Of. — Under this head belong various types 
 of circumscribed peritonitis which comprise perimetritis, perisalpingitis, peri- 
 oophoritis, etc., and which are due to a simple extension of inflammation from 
 the uterus, parametrium, tubes, ovaries, etc. The peritoneum may also be 
 involved as a result of rupture of the uterus, of a parametritic abscess, and of 
 emigration of bacteria (practically only the gonococcus) from the tube into the 
 peritoneal cavity. Unless the bacteria which come in contact with the peri- 
 toneum possess a high degree of virulence, the inflammation remains circum- 
 scribed, chiefly because the exudation brings about adhesion of the parietal and 
 visceral peritoneum with resulting encapsulation of germs. The systemic reac- 
 
MORBID CONDITIONS ORIGINATING IN THE PUERPERIUM. 731 
 
 tion in these cases is that of localized peritonitis rather than what is comprised 
 under puerperal infection. In regard to the genesis of peritonitis in the puer- 
 perium, the lymphatics are in most cases the organs at fault; the bacteria 
 passing from the lymph spaces of the uterus directly into the peritoneal cavity 
 Thus perimetritis becomes much the more common localization. The other 
 local types already mentioned occur with greater infrequency, by reason of their 
 special etiology. It may be stated that a severe parametritis almost necessarily 
 extends to the peritoneum, and that the same is true of acute salpingitis, acute 
 oophoritis, etc. When peritonitis results from rupture of the uterus, or from an 
 acute abscess, etc., its character must depend wholly upon the relative virulence 
 or sterility of the escaping substances, and the same is true of the escape of 
 
 Deaenerated fliop&oas Muscle 
 Abscess Cavity 
 CrunaL Artery 
 
 Crural Vc/n 
 
 li icpsoas Muscle 
 Crura/ Vein 
 
 DegencrcUe^ _ 
 Int ObUqiie \> 
 Muscle \ 
 
 Rl Ureter 
 Ant LLpofCervi.jc 
 
 Le/t round 
 Ligament 
 
 SubperLtcn£cd 
 Pus 
 
 Le/t Ureter 
 
 Para, vaainal 
 Iri/la rrCm/i tion 
 
 PeLvCc Floor 
 
 Pelvic Floor 
 
 Left Va^y^aU 
 
 Fig. 954. — Transverse Section of the Pelvis from a Primipara Four and a Hal? 
 Months Post Partum, showing Parametritis and the Formation of Puerperal 
 Pelvic Abscesses. — (Sellheim.) 
 
 pus from the tubes into the peritoneal cavity. In all such cases the perimetrium 
 is necessarily attacked. Hence for practical purposes benign peritonitis is vir- 
 tually equivalent to perimetritis. (Fig. 956.) 
 
 Perimetritis. — This condition, like endometritis and parametritis, possesses 
 a distinct clinical individuality, and occurring as the chief clinical feature of a 
 morbid puerperium may run its course as a local infection with its natural 
 systemic reaction. The most important thing to know about perimetritis is 
 that it occurs chiefly from propagation of bacteria through the lymph spaces 
 of the muscularis of the uterus, without the necessary production of a high 
 degree of metritis. When the streptococci enter these lymph spaces, it is only 
 when of the highest virulence that they occupy the finer radicles and from these 
 
732 
 
 PA THOLOGICAL P UERPERI UM. 
 
 attack the muscular substance. Under ordinary circumstances they simply 
 travel along the coarse spaces until the peritoneum is reached; so that peri- 
 metritis is much more likely to result than severe metritis. Through this pecu- 
 liarity we are able to imderstand why bacteria of low virulence, such as the 
 gonococcus and even saprophytes (as Ahlfeld implies) , may in some cases reach 
 the peritoneum and set up a low grade of perimetritis. Ahlfeld believes that 
 the puerperium often rouses to activity a preexistent slight localized perimetritis, 
 especially in latent gonorrhea. 
 
 The course of benign peritonitis has already been stated. The exudate which 
 is shut off by adhesions may be either serofibrinous or purulent. Of great 
 interest is the frequent occurrence in pus of this source of the bacillus coli, 
 which is believed to pass through the intestinal wall after adhesions have formed . 
 
 Sacro- iliac ArticulatioTt 
 Intrapert^ncaZpus 
 fi/ri/drm mtisc/a 
 JsdiialTieric 
 
 Ifi/pogcatric 
 Greater tschial/oramer 
 Jitjpo^astnc Vet?i 
 Ureter 
 
 UterimArt 
 
 Jnte7mxl Obturator mtiscle 
 TArombus Obturator Vem 
 
 Obturator Fora?nen ~ 
 Internal ObmmtOr.mus ~ 
 Pectinsus muscle 
 
 /idductormttsde 
 
 Rtrareetai eztmpentonealpu.^ camti/ 
 Ischial nerve 
 Superior ^lutealArt. 
 IJtfpc^astncArt. 
 
 Ureter 
 
 nrmnbus g^ffifjogastric VHtv 
 Intrafjento^eal pits cavitij' 
 
 Uteri7ie/n 
 TJirombus 
 
 Of Otftwator Veitv 
 - Umnne&odt/ 
 
 ^■Viti/(^Ut(^rU3 wizh blood-clot 
 Fu^ in utero >jes.pouc}i 
 
 Bl'Mlder 
 
 M N5 
 
 Fig. 955. — Horizontal Section of a Pelvis from a Primipara Three Weeks Post 
 Partum, showing Abscess Cavities in Utero-vesical Pouch, in Douglas's Cul- 
 de-sac, AND also Pararectal and Extraperitoneal Suppuration. — {Sellheim.) 
 
 When pus forms in connection with perimetritis, the almost invariable result is 
 intestinal perforation. 
 
 While perimetritis may occur as part of a general septic process, or in asso- 
 ciation with parametritis, it may also in certain cases constitute the principal 
 feature of the puerperal morbidity, especially in the cases described by Ahlfeld 
 in which an old perimetritis is roused to activity by labor. Under such circum- 
 stances we should expect to see the symptoms of an ordinary peritoneal reaction, 
 including great pain and tenderness, small, rapid, and incompressible pulse, rapid 
 breathing, thirst, and vomiting. The patient lies in the dorsal position with 
 knees drawn up to diminish abdominal tension. Perimetritis is ushered in by 
 a chill and a sharp rise of temperature, which continues moderately high 
 and without morning remissions while somewhat higher at night. When pus 
 forms, a second chill and renewed ascent of temperature occur. After perime- 
 tritis has lasted for several days the presence of the exudate may be made out in 
 
MORBID CONDITIONS ORIGINATING IN THE PUERPERIUM. 733 
 
 Douglas' cul-de-sac, or in some cases in the entire lesser pelvis. This having 
 become encapsulated, the uterus is immobilized. If suppuration does not occur, 
 this exudate may be absorbed after several weeks; but with the formation of 
 pus, softening and fluctuation become apparent, and the abscess, as already 
 stated, may be expected to rupture into the intestine, or exceptionally into the 
 vagina, or externally, or even through the limiting wall into the general peri- 
 toneal cavity. The diagnosis of perimetritis should not be difficult, since the 
 phenomena of the peritoneal reaction are so characteristic. The chief point of 
 interest lies in distinguishing at the outset between perimetritis and parametritis ; 
 since both affections begin at about the third or fourth puerperal day with a chill 
 and sharp rise of temperature, and are attended with pain, tenderness, and the 
 formation of plastic material. The peritoneal reaction should be sufficient for 
 discrimination. It frequently happens that the two affections coexist, and in 
 this case the symptoms of parametritis are naturally masked, and a bimanual 
 examination becomes indicated, which, owing to the great pain and tenderness 
 resulting, can with difficulty be carried out. 
 
 General or Malignant Peritonitis. — Bacteria of comparatively low virulence 
 bring about benign peritonitis or perimetritis; and under precisely the same 
 circumstances, highly virulent germs cause a general peritonitis. According to 
 the general teaching the latter affection follows most commonly upon an en- 
 dometritis set up by highly infectious germs ; Lenhartz, however, has shown 
 the great relative frequency with which severe parametritis can bring about 
 malignant peritonitis. But this affection is not due necessarily to lymphatic 
 extension, since it may result from direct inoculation of the peritoneum by the 
 contents of a ruptured uterus or a preexisting abscess. It has been commonly 
 taught that malignant peritonitis is usually a complication or feature of severe 
 general sepsis, both being the natural consequence of highly virulent strepto- 
 cocci ; but many case-histories seem to show that the general condition in malig- 
 nant peritonitis is not septic infection of the blood, but profound toxemia caused 
 by the rapid multiplication of germs over the entire peritoneal surface. In 
 other words, malignant peritonitis may often represent a purely local infection, 
 limited only by the great extent of the peritoneum. 
 
 Malignant peritonitis is undoubtedly due to the high virulence of bacteria 
 which spread over the peritoneal surface without any attempt at the formation 
 of isolating adhesions. It does not appear that the germs are necessarily of 
 unusual virulence before gaining the peritoneum, but may find conditions there 
 which favor their rapid multiplication. 
 
 Case-histories show that a woman may be fatally septic and yet have only a 
 localized peritonitis ; while as already stated, complete purulent peritonitis may 
 not be accompanied by general sepsis. (Fig. 956.) There is much evidence to 
 show that lymphogenic malignant peritonitis is a phase of puerperal morbidity 
 which is sui generis, bearing no definite relationship to perimetritis, endometritis, 
 or septic infection of the blood. It is preeminently a streptococcus disease. 
 The symptoms are those of general peritonitis from other causes. The most 
 striking symptom is the extreme degree of meteorism which results from intes- 
 tinal paresis, and which produces compression of the thorax and dyspnea. The 
 prodigious amount of toxins produced and absorbed tends to overwhelm the 
 heart, and the pulse-rate rapidly mounts to the neighborhood of 150. Ahlfeld 
 regards malignant peritonitis as essentially a disease of the very early puer- 
 perium — ^jnost frequently of the first day. The chill is often wanting, and 
 the rapid supervention of great agony referred to the bowels; vomiting, 
 restlessness, and anxiety suggest that the patient has swallowed an irritant 
 
734 
 
 PATHOLOGICAL PUERPERIUM, 
 
 
 Peritoneum covered 
 with fibrin atid 
 pus. 
 
 Unaffected muscle 
 
 I Portion of muscle 
 omitted. 
 
 Moderate exuda- 
 tive endometritis . 
 
 Fig. 956. — Section through the Wall of a Uterus showing Streptococcus Endo- 
 metritis, AND Extension of the Infection through the Lymphatics to the Peri- 
 toneum, Causing Peritonitis. Death on the thirteenth day post partum, after a 
 full-tenn dehvery, from general purulent peritonitis and exhaustion. Patient was 
 at first treated on the basis of a diagnosis of acute malarial infection. No local treat- 
 ment was at any time used. X 75. — {From, a specimen in the Pathological Laboratory 
 of Cornell University Medical College.) 
 
MORBID CONDITIONS ORIGINATING IN THE PUERPERIUM. 735 
 
 poison. Lenhartz, however, described an entirely different course, in which 
 the puerperium begins favorably, then parametritis develops, and eventually 
 general peritonitis ; the evolution of the disease being much less fulminant. He 
 found the symptoms to occur in the following order: chill (always present); 
 vomiting; abdominal pain; diarrhea. These were succeeded by great weakness 
 and meteorism. All authors speak of the euphoria and mental clearness which 
 are sometimes presented by women who are already nearly pulseless. They no 
 longer feel pain nor distress. As the symptomatology of this condition agrees 
 with that of acute general peritonitis from other causes, further details may be 
 omitted. 
 
 The diagnosis should be self-evident and the prognosis is all but hopeless. 
 Since occasional recoveries occur, the selection of favorable cases becomes of 
 great importance. As the bacteria spread over the peritoneum and proliferate, 
 with production of tox- 
 ins, a serofibrinous exu- ^, 
 date appears which .■f°~W' n, ^ 
 tends to become puru- "'* ^ 
 lent. 
 
 Consecutive Lesions from M - - _ ■»« 
 
 Venous Extension. -^ - , 
 
 XII. Metrophlebitis, " -' V 
 
 Septic Phlebitis, or Sep- """' ^^ ^-'L,-^ '' 
 
 ticaemia Venosa. — The . ' 
 
 microorganisms which ** 
 
 cause infection may gain ^ . "^ 
 
 access to the circulation ~*'^^ ^ .C 
 
 in two ways: by the "^^ ' 7, J ' 
 
 lymphatics (Fig. 956), ^ * -^ '^ '■ 
 
 as already noticed, and ^, - 
 
 by the veins (Figs. 937, % 
 
 938). The placental site 
 
 is naturally most likely 
 
 to be the starting-point pj^^ g^j — Small Blood-vessel from the Endometrium 
 of the latter process. of Fig. 956, showing Streptococci among the Blood 
 
 The diffusion through ^^° Endothelial Cells. X 700. 
 
 the general circulation 
 
 of pyogenic organisms and the transportation of these organisms to distant tissues 
 and organs give rise to a long train of symptoms and complications which 
 are usually grouped under the name pyemia. Some of these complications, 
 however, may occur as the result of other varieties of sepsis; e. g., endocarditis 
 is sometimes seen in connection with the lymphatic form of sepsis and arthritis 
 may occur when the infection is due to gonorrhea. 
 
 Uterine and Para-uterine Phlebitis. — Pathology: Thrombosis of the 
 uterine or pelvic veins is not a rare occurrence (Fig. 978). Uterine re- 
 relaxation predisposes to its development. Normally a thrombus becomes 
 organized and converted into an impervious cord of tissue, or a channel may 
 be formed and the circulation re-established. When a thrombus becomes 
 infected, which naturally happens most frequently at the placental site, it 
 disintegrates, and fragments may be carried to distant parts of the body. 
 Septic phlebitis may occur when the vessel is surrounded by infected tissue. 
 
736 PATHOLOGICAL PUERPERIUM. 
 
 In this case the endothelium proliferates and thrombi occur. Thrombi 
 resulting from phlebitis may remain organized, but usually become puru- 
 lent; and we then have abscesses in the uterine wall and the extension 
 of the process along the veins of the pelvis. When in a case of endome- 
 tritis the necrosed endometrium at the placental site is removed, the 
 thrombi are found to be but little affected. Extension of endometrial infection 
 along the placental thrombi does not ordinarily occur. Organization of the 
 thrombi is to be regarded as Nature's safeguard against infection, and probably 
 organization in the deeper layers has already occurred before labor. When, 
 however, the organisms possess a high degree of virulence, or when they gain 
 access to the placental sinuses before or early in the course of labor, the thrombi 
 remain soft and permit the propagation of the bacteria, and cases of severe 
 infection may be marked by the breaking-up of thrombi already organized. 
 
 Etiology: The usual causes of sepsis are, of course, operative. Manipulations 
 about the placental site seem to constitute a predisposing cause. This type 
 of infection has often been noticed in sepsis from retained placenta, in cases 
 of placenta praevia, and after manual separation of the placenta. Infection 
 occurring early in labor, before the organization of the placental thrombi, is 
 especially apt to result in uterine phlebitis. Symptoms: These generally appear 
 rather late in the puerperium, perhaps at the end of a week or two, although 
 they have been noted three or four days after delivery and as late as three 
 weeks and more. There is a sudden rise of temperature to 103° or 105° F., and 
 the pulse becomes rapid. A chill is not usually present. The fever soon 
 becomes remittent or intermittent, profuse sweats occur at intervals, and 
 there are evidences of great prostration. Diagnosis: Bimanual examination 
 shows no subinvolution or special sensitiveness or exudation as in pelvic peri- 
 tonitis or cellulitis. In some cases sudden and severe hemorrhage may occur 
 from the disintegration and dislodgment of infected thrombi. The diagnosis 
 is based upon the symptoms mentioned above, together with the negative 
 results upon external and bimanual examination. Prognosis: This is grave, 
 not only on account of the danger inherent in the condition, but of the various 
 complications which may ensue in the course of a metastatic pyemia. 
 
 Femoral Phlebitis, or Phlegmasia Alba Dolens. — This condition 
 is still called "milk-leg" by the laity, and was formerly supposed to be 
 due to metastasis of milk. It is characterized by venous obstruction and 
 enormous swelling of the leg. Pathology: It occurs in two forms — the thrombo- 
 phlehitic and the cellulitic. The first is much more common. The two varieties 
 may be combined, since a phlebitis may lead to inflammation of surround- 
 ing structures, and, vice versa, a cellulitis may cause phlebitis or thrombosis. 
 The student will notice that phlegmasia may occur as a complication either 
 of uterine phlebitis or of cellulitis — much more commonly, however, of the 
 former. The thrombo-phlebitic form may arise in two ways: either by the 
 extension of a septic inflammation of the walls of the vessel from the placental 
 site, with resulting clotting of blood in the vessel, or by primary thrombosis. 
 According to Widal, micro-organisms are especially prone to attack the wall 
 of the femoral vein near Poupart's ligament, the circulation being notably 
 sluggish at this point, and particularly so when the patient first assumes the 
 erect position after delivery. Etiology: The condition is usually to be regarded 
 as a result of septic infection. The method of extension is made clear by the 
 pathology. It is possible that it is occasionally non-septic in origin. Among 
 the causes which may predispose to non -septic thrombosis may be mentioned 
 slowing of the circulation, as in varicose veins. Symptoms: In the thrombo- 
 
MORBID CONDITIONS ORIGINATING IN THE PUERPERIUM. 737 
 
 phlehitic form the symptoms usually appear two or three weeks after delivery, 
 and often after the patient has been up for a few days. As in other forms 
 of infectious phlebitis, there are fever and perhaps chilly sensations and a chill. 
 The tongue is coated and there are evidences of gastro-intestinal disturbance, 
 loss of appetite, constipation, eructations, nausea, and vomiting. There is a 
 feehng of weight and stiffness in the leg. Pain in the calf of the leg is often 
 a prominent symptom. There may be tenderness along the course of the 
 femoral vein which may be marked by a red line. Sometimes other superfi- 
 cial veins present similar signs. The leg swells rapidly from below upward 
 and soon attains an enormous size. When the swelling is at its height, the 
 skin is so tense as not to pit on pressure. In the celluUtic form the symptoms 
 are in many respects similar, but the swelling is from above downward and 
 there are the accompanying evidences and previous history of pelvic cellulitis. 
 The left leg is affected oftener than the right. In some instances though be- 
 ginning in one leg, the other after a brief interval is also affected. 
 
 The foregoing lesions have been considered because they frequently occur 
 in cases of metastatic pyemia, but it is easy to see that the list might be in- 
 definitely multiplied. Wherever an infected embolus finds lodgment, metastatic 
 abscesses may occur. The liver, kidneys, and spleen, and even the brain and 
 eye, have been so affected. Parotitis has been observed; multiple abscesses in 
 the muscles and connective tissue and diffuse cellulitis may occur. Pleuritis 
 and pericarditis are common. 
 
 XIII. Specific Diseases. — Originating Intragenitally. — Here belong three 
 diseases which are capable of producing diffuse primary inflammation of the 
 genital passages, followed by toxemia or bacteriemia. The disease is contracted 
 in most cases from an individual having the same affection ; and herein it differs 
 from ordinary infection, which does not represent the extension of a specific 
 infectious disease. (i) Gonorrhea: According to Ahlfeld, the gonococcus is 
 found with surprising frequency in the vaginal secretions of a pregnant 
 woman. It is, however, usually present in small numbers. (Fig. 947.) But 
 after delivery we may find in the same subject that the number has greatly 
 augmented. This rule is believed to hold good for the endometrium, tubes, and 
 peritoneum; so that when a puerpera develops clinical gonorrhea, we are not 
 to think first of an infection from without. The latter, however, is possible; 
 obstetricians do not usually describe a puerperal gonorrheal vulvitis or vaginitis, 
 although such might readily occur under conditions of exposure. Infection of 
 the newly born usually arises from endocervicitis. A puerpera with pre-existing 
 gonorrheal endometritis, salpingitis, etc., may develop fever from gonococcus 
 toxins or very rarely actual gonococcus sepsis with metastases. (2) Diphtheria : 
 True diphtheria may occur in the vulva and vagina, either in patches upon 
 wounds made in delivery, or as a continuous membrane. It may represent a 
 primary inoculation or be secondary to faucial diphtheria. High temperature 
 and other accidents due to toxemia occur, but sepsis is excluded by the nature 
 of the disease, which readil}'' yields to antitoxin. (3) Erysipelas: It has usually 
 been believed that a puerperal woman exposed to erysipelas contracts ordinary 
 puerperal fever, owing to the apparent identity of the streptococcus erysipelatis 
 and streptococcus pyogenes. However, these women sometimes contract true 
 erysipelas which begins in the cutaneous aspect of the vulva. Some authors 
 mention a diffuse inflammation of the genital tract. Ahlfeld mentions an ery- 
 sipelatous inoculation of birth-traumatisms. Good descriptions of all these 
 focal affections are difflcult to find in literature. We may expect to see bac- 
 teriemia develop in these cases. Whenever a puerpera is attacked by ordinary 
 47 
 
738 PATHOLOGICAL PUERPERIUM. 
 
 facial erysipelas, we do not usually see an implication of the genitals. (4) Mis- 
 cellaneous: Theoretically any infectious bacterium might set up local intragenital 
 lesions in the puerpera. The bacillus of tetanus produces no known local altera- 
 tion in the puerperium; hence this condition may be discussed under toxemia. 
 When germs like the bacillus coli and pneumococcus cause focal affections they 
 are indistinguishable save by the microscope and by cultures from ordinary pyo- 
 genic infection. 
 
 Originating Extragenitally. — Of the acute infectious diseases, a certain 
 number tend to cause focal affections of the genitals ; so that if a puerpera should 
 contract one of these diseases we naturally expect to see the formation of hematog- 
 enous genital lesions. Thus cholera and other severe diseases produce endometritis, 
 which, occurring in the recent puerperal uterus, might readily cause hemorrhage. 
 (Vinay mentions only a single case of post-partum hemorrhage in connection with 
 puerperal cholera.) Variola should give rise to a specific vaginitis as well. 
 
 Metastatic Focal Infection. 
 Metastatic Lesions. — These develop only after the establishment of bacteri- 
 emia, with which they are necessarily associated. Speaking generally, when a 
 woman has once become septic her condition should not differ materially from 
 that of septic patients in general; and the subject of metastases might well be 
 left to general treatises on pathology. Most authors describe some of the more 
 commonly occurring and important metastases in this connection, such as endo- 
 carditis, pneumonia, various dermatoses, etc. According to Lenhartz, pulmo- 
 nary abscesses, as a rule, represent the only form of suppurative metastasis; next 
 in frequency come intramuscular and intra-articular or periarticular lesions, 
 affecting by preference the knee. Very rare metastases are those of the eye 
 (panophthalmitis) and meninges. Other metastases are renal and splenic in- 
 farcts, cutaneous hemorrhages, and pustular eruptions. An important lesion of 
 sepsis not always classed among ordinary metastases is endocarditis, which is in 
 itself responsible for metastases of the eye, meninges, etc. 
 
 BLOOD-STATES OR GENERAL CONDITIONS. 
 Simple Blood-state or General Condition. 
 
 I. Sapremia. — Sapremia is a blood or general state characterized by the ab- 
 sorption of decomposition-products of putrefying tissue. While often spoken of 
 indifferently as toxemia, it is of a different character from the toxemia of bacterial 
 origin. While the saprophytes, which set in motion the putrefactive changes in 
 the dead tissue, secrete poisonous substances, these must be greatly overshadowed 
 in importance by the decomposition products of the tissues themselves. Sapre- 
 mia is therefore a sort of ptomainemia. The substances which by their decom- 
 position furnish these toxic substances are varied, comprising retained placenta 
 and decidua, pent-up lochia, the retained ovum or fetus in missed labor, por- 
 tions of gangrenous uterus, fibroid tumors, etc., etc. The necrotic surface of 
 puerperal ulcers is also a source of sapremic intoxication, and according to some 
 authorities, this is even true of the tissue cast off during normal regeneration of 
 the endometrium. 
 
 Lenhartz believes that pure sapremia is not so frequent as has been believed, 
 and that a bacteriemia often coexists. Clinically the phenomena of sapremia 
 depend upon the amount of poisonous matter absorbed. In the most fulminant 
 cases we see the picture of a most intense toxemia. There is a chill, followed 
 by high fever, headache, vomiting, and complication of the higher nervous 
 
MORBID CONDITIONS ORIGINATING IN THE PUERPERIUM. 739 
 
 centers, as shown by motor excitement and delirium. Meteorism is present, 
 as a rule, so that the dyspnea of fever is increased. The pulse may reach i6o. 
 In the most fulminant forms the patient may die in the first twenty-four or 
 forty-eight hours or she may linger for one or two weeks. There is, as a rule, 
 no tendency to compromise permanently important organs, so that in pure 
 sapremia striking improvement follows the removal of the putrefying material. 
 In fatal cases the same alterations are found as in non-metastatic septicemia. 
 
 Every degree of sapremia may be encountered between the acute fulminant 
 type and the "one-day "or even "one-hour" rise of temperature seen in a large 
 proportion of normal puerpera. 
 
 Of considerable interest in this connection is the possibility of a different 
 type of sapremia due to intestinal resorption incidental to the prolonged consti- 
 pation of the puerperal week when the bowels are not artificially relieved. In 
 cases in which the woman's bowels have not been relieved before delivery, this 
 species of sapremia might antedate labor. It is true that Kustner and Zange- 
 meister have apparently shown independently that constipation on one hand, 
 and the routine use of castor oil on the other, have no effect on the temperature 
 of the puerpera, which when elevated must be due to sapremia from the uterus. 
 But a few experiments made perhaps upon phlegmatic peasants will hardly 
 convince American practitioners that women in this country do not develop 
 a rise of temperature in many cases when the bowels are confined and dis- 
 tended with gas. It is true that toxemia of intestinal origin (stercoremia) may 
 not be the cause of rise of temperature, for the latter may be due to reflex ex- 
 citation of the heat center by the distended bowels. 
 
 II. Bacterial Toxemia. — Pure Toxemia of Bacterial Origin. — This con- 
 dition frequently accompanies the puerperium, where it may be caused by the 
 ordinary pyogenic cocci, and exceptionally by the tetanus bacillus, Klebs- 
 Loetfier bacillus, etc. 
 
 Pyogenic Cocci. — Wherever there is an acute local suppurating focus in the 
 puerperal genitals, we almost invariably see the development of the toxemia, 
 which is a feature of the ordinary surgical or wound fever. While this may 
 readily be complicated by sapremia, whenever necrosis or imperfect drainage 
 leads to putrefactive changes, a pure toxemia is of common occurrence, especially 
 in abscess formation, or wherever saprophytes may be excluded. Walthard and 
 others have made the claim that the streptococcus itself, when of low virulence, 
 may act as a saprophyte, feeding on dead tissue only and setting up sapremia 
 in addition to the secretion of its proper toxins. He thus holds the streptococcus 
 responsible for some of the mild resorption fever which is present in a normal 
 puerperium. Such a condition would naturally belong to sapremia. It is 
 otherwise, however, in some of the severe focal affections of the puerperium. 
 Thus in a pure streptococcus endometritis with an efficient leucocyte bar- 
 rier against extension by the lymphatics; in a parametritic abscess; in local 
 suppurative peritonitis, and even in some cases of fatal general peritonitis, the 
 accompanying blood-state is a pure toxemia without any evidence of bacteri- 
 emia, whether bacteriological or clinical. It is therefore a mistake to speak of 
 such affections as varieties of sepsis. They represent only toxemia, although 
 very prone to lead to sepsis. In a certain class of cases the bacteria reach the 
 blood, yet clinically the condition is still a toxemia. In the majority of cases 
 of bacterial toxemia, recovery is the rule, whether or not abscess-formation 
 occurs. An exception is furnished by acute general peritonitis, owing to the 
 great extent of surface involved, and the fatal degree of the toxemia, which 
 overwhelms the heart. 
 
740 PATHOLOGICAL PUERPERIUM. 
 
 Puerperal gonorrhea may be accompanied by toxemia, rarely by bacteri- 
 emia as well (gonococcus-sepsis). 
 
 The suppurative focus may be extragenital. This is illustrated by mastitis 
 developing near term, the toxemia extending into the puerperium. 
 
 Bacterial Toxemia of Tetanus. — It is well known that the tetanus bacillus 
 sometimes reaches the uterus, not only from direct transportation (usually in 
 connection with attempts at criminal abortion), but in purely spontaneous labors 
 in unexamined women. The tetanus germ does not induce any local lesion, but 
 its toxins, formed in situ, are absorbed with the production of the full clinical 
 picture of tetanus. Sapremia or sepsis or both may of course coexist. Vinay 
 has reported io6 cases, in 37 of which there had been operative interference. 
 Hirst has reported three cases in which the disease was apparently due to in- 
 jections of unboiled river- water. According to Heyse, a previous septic infection 
 is always necessary to pave the way for the tetanus bacillus. This claim has, 
 however, been denied. The symptoms and etiology are practically those of 
 tetanus in the non-pregnant state. Premature emptying of the uterus seems 
 to be a predisposing cause, since the disease develops oftener under these cir- 
 cumstances than after labor at full term. In my study of 635 cases of prema- 
 ture interruption of pregnancy, no tetanus occurred. The diagnosis can present 
 little difficulty, although the affection has been confounded with hysteria. The 
 condition is usually fatal. 
 
 Bacterial Toxemia of Diphtheria. — This occurs in primary diphtheria 
 of the puerperal genitals, in ordinary diphtheritic angina, etc., as a con- 
 current affection. Unless some associate infection or intoxication is present, we 
 have the pure toxemia which characterizes simple diphtheria. 
 
 Puerperal Toxic Erythema. — As already mentioned, an erythematous 
 rash is not infrequently noticed during the puerperium. It may occur in cases 
 of profound toxemia or in mild cases. Its principal importance is that it has 
 been frequently mistaken for scarlet fever. I have in three instances been 
 asked to see cases ol so-called puerperal scarlatina which proved to be septic 
 erythema. In one case the patient was about to be transferred to the Hospital 
 for Contagious Diseases. The rash is attended b}^ itching and sometimes by 
 desquamation. It is usually regarded as due to Nature's effort to eliminate 
 toxic materials by the skin. (See Fever Due to Intercurrent and Complicating 
 Diseases.) 
 
 Puerperal Pemphigus. — Very rarely the occurrence of a pemphigoid erup- 
 tion in connection with mild cases of sepsis has been noted. The fact that it 
 spreads rapidly through a lying-in ward indicates a specific infection of some kind. 
 Isolation and the treatment of the coexisting sepsis are of course indicated. 
 
 Puerperal Toxic Neuritis. — This has been described by Mobius, Laury, 
 and others. It may occur in the course of a general toxemia, and most commonly 
 affects the arms, taking the form of a bilateral median and ulnar neuritis, but 
 the involvement of many other nerves has been noticed. The spinal cord 
 may be affected. In other cases it may be the result of direct extension of 
 the infectious process, as in cases of pelvic exudation. There is also a non- 
 toxic variety, due to pressure upon the nerve structures by the fetal head, 
 the gravid uterus, or instruments. It is most likely to occur in cases of pelvic 
 deformity. (See page 769.) The symptoms and diagnosis are the same as in 
 the non-puerperal condition together with those of coexisting toxemia. 
 
 This affection must hot be confounded with polyneuritis due to the toxemia 
 of pregnancy, which may extend into or develop during the puerperium. 
 
 III. Pure Bacteriemia. — This condition denotes the presence of bacteria in 
 
MORBID CONDITIONS ORIGINATING IN THE PUERPERIUM. 741 
 
 the blood without the association of bacterial toxins. Naturally the bacteria 
 must be of very low virulence. Pure bacteriemia has been found on several 
 occasions by Lenhartz in blood examinations made in connection with endo- 
 carditis. Despite the constant presence of streptococci in the blood for weeks 
 and even months, no further symptoms were produced, and the temperature 
 was practically within normal limits. Pure bacteriemia must occur occasionally 
 in the puerperium, as shown in cases of uncomplicated endocarditis, following 
 slight genital lesions. In the vast majority of cases, bacteriemia is associated 
 with toxemia, constituting septicemia. 
 
 Composite or Septic Blood-states or General Conditions. 
 
 IV. Bacteriemia with Toxemia. — i. Septicemia. — Septicemia is a blood or 
 general condition characterized by (a) bacteriemia and toxemia; (b) certain 
 clinical phenomena; and (c) certain post-mortem findings. Bacteria cannot 
 always be obtained from the blood, but their presence therein is assumed if 
 the other conditions are in evidence. When metastatic lesions are present we 
 have a special clinical or anatomical variety, but metastases do not necessarily 
 occur. Endocarditis when it develops is not usually counted as a metastasis, 
 but a complication which is itself a cause of metastatic foci. 
 
 In non-metastatic septicemia the post-mortem lesions are slight, and con- 
 fined to cloudy swelling of the kidneys, liver, and heart, with an enlarged and 
 relaxed spleen. Clinically septicemia may be ushered in with a chill, followed 
 by high fever of remittent type ; or it may develop in a most insidious manner, 
 the temperature rising gradually. The pulse-rate varies with the temperature 
 and may reach 150. There are great prostration and a cyanotic pallor. The 
 disease may be malignant from the start, destroying life in a few days or a 
 fortnight or it may extend over many weeks. Clinically it is usually accom- 
 panied by severe focal affections. From these primary foci the bacteria and 
 toxins continue to enter the blood by the lymphatic route ; hence the course and 
 prognosis depend somewhat on the progress of the primary lesion. In a certain 
 proportion of cases endocarditis develops, while in others true metastases occur. 
 These elements also exert great influence over the ultimate outcome of the 
 disease. 
 
 Sepsis with endocarditis and metastatic sepsis do not differ from those affec- 
 tions in non-puerperal subjects and need not be dwelt upon. 
 
 In the narrower sense of the term, puerperal sepsis is due to the ordinary 
 pus-exciters, principally the streptococcus. Sepsis due to the staphylococcus, 
 bacillus coli, pneumococcus, etc., also occurs, as well as does mixed infection. 
 Septicemia of a character similar to the ordinary streptococcus type might be 
 associated with puerperal scarlatina and erysipelas ; also with gonorrhea. 
 
 Septicemia in the wider sense of the term, not due to the familiar pyogenic 
 bacteria, may occur in the puerperium. Here would belong typhoid fever and 
 acute general tuberculosis. 
 
 2. Pyemia. — Pyemia is merely a form of septicemia which follows phlebitis 
 and suppuration of thrombi. The peculiarity of the primary lesion leads to 
 clinical and anatomical peculiarities, for large amounts of bacterial toxins have 
 ready and repeated access to the blood, as do likewise pus corpuscles and portions 
 of infected thrombi. In ordinary septicemia, when pus enters the blood it is 
 usually as a result of secondary ulcerative endocarditis; while in pyemia, the 
 pus proceeds directly from the infected uterine sinuses. Ulcerative endocarditis 
 is also very common in pyemia. Generally speaking, no absolute distinction can 
 be made between the blood-states in p3^emia and septicemia. 
 
742 PATHOLOGICAL PUERPERIUM. 
 
 Pyemia, like septicemia, may run a fulminant or a subacute course. In the 
 first place the large amount of toxins which enter the blood gives the disease 
 the character of a severe toxemia which may be fatal before metastases are 
 in evidence; in the subacute form, toxemia is less marked and metastatic com- 
 plications may succeed one another. 
 
 As a rule, pyemia is characterized by repeated chills, which may occur daily, 
 sometimes to the extent of several in a day. The fever curve is irregular and 
 either intermittent or remittent. In acute cases the symptoms resemble those 
 of acute septicemia; in fact there is no essential difference between the two 
 states. (See Metastatic Focal Affections.) 
 
 3. Septicopyemia. — This term is sometimes used to denote a special blood- 
 state, which is said to be inevitably fatal, but it does not appear just what is 
 meant by the term septicopyemia. In former years it was evidently used 
 as an equivalent for pyemia. Following modem terminology we shall restrict 
 the term to cases in which the blood is infected by the venous and lymphatic 
 routes combined. Thus Trendelenburg found that in forty-three fatal cases 
 of puerperal fever there were eighteen cases of septicemia, twenty-one cases of 
 pyemia, and four of combined lymphatic and venous infection (septicopyemia). 
 Clinically such a condition may be regarded as a pyemia. 
 
 V. Sapremic Sepsis, including Gas Sepsis. — Sepsis representing an association 
 of bacteriemia and toxemia, the term sapremic sepsis may be used to denote 
 several conditions. Thus, in simple sapremia of a fulminating type, the sapro- 
 phytes may be found in the blood during life, as shown by Lenhartz. Ordinarily, 
 however, the expression sapremic sepsis would imply a mixed or associate condi- 
 tion, in which ordinary septicemia or pyemia is associated with sapremia from 
 putrefaction of the uterine contents and perhaps of the endometrium itself. Such 
 a condition is overwhelmingly toxic, because the blood contains both bacterial 
 toxins and the products of putrefaction. It represents a severe and fulminant 
 type of disease, and one which should be essentially malignant. Recovery may 
 occur, however; Lenhartz's case No. 48 represents a sapremic sepsis in which 
 sapremia was associated with bacillus coli bacteriemia. The bacterium disap- 
 peared from the blood as the case progressed to recovery. In such cases of mixed 
 infection removal of putrescible material from the uterus is not necessarily fol- 
 lowed by improvement in the lochial discharge, which may remain offensive for 
 days, signifying that the endometrium itself is the seat of putrescence. Doubtless 
 this severe involveraent of the endometrium — mixed putrid and pyogenic endome- 
 tritis — is responsible for the associated implication of the blood. Another still 
 more formidable type of sapremic sepsis is the so-called "gas sepsis" — a condi- 
 tion which is rare and not fully understood. It is known that most of the 
 saprophytes which attack the tissues after death, or gangrenous tissue during 
 life, generate gases which may or may not be fetid. Some saprophytes, such as 
 the bacillus aerogenes capsulatus, and bacillus phlegmones emphysematosae, 
 appear to be able to attack living tissues and form gas. But the so-called 
 tympania uteri may be due to a variety of causes, and the part played by bacteria 
 is not well defined. In many cases which end fatally, it is not easy to decide 
 whether the gas-forming bacteria have attacked the tissues before or after d-eath. 
 It is admitted, however, that in some of the severest forms of putrid or mixed 
 endometritis, gas-forming saprophytes may attack the uterus during life and 
 also set up a gas-bacteriemia and gas-forming metastatic lesions. In most of 
 such cases ordinary septicemia or pyemia coexists. 
 
MORBID CONDITIONS ORIGINATING IN THE PUERPERIUM. 743 
 
 General Conditions with Anomalies of Temperature 
 
 VI. Simple Hyperthermia. — This condition, also known as pseudo-fever, con- 
 sists, as its name implies, of a simple elevation of temperature without any of 
 the collateral pnenomena of true fever. It has been noticed under a variety 
 of circumstances, and is due apparently to a variety of causes. Slight elevation 
 of temperature may follow a hot bath. Rise of temperature has been produced 
 by suggestion, and by mere nervous excitement. The thermal center is doubtless 
 under the influence of emotional and reflex excitation in subjects with nervous 
 instability. When we remember that the latter condition is common in the 
 pregnant woman and can hardly disappear at once after delivery, it should not 
 surprise us to see paradoxical elevations of temperature in the puerpera. Not 
 only do we find simple hyperthermia in the presence of nervous excitement 
 and physical discomfort (constipation) ; but even in sapremia up to a certain 
 degree, rise of temperature is not attended with collateral evidences of fever. 
 Simple hyperthermia is not of long duration, as a rule. 
 
 Caution. — It is to be hoped that the student will not infer from the list 
 of possible causes of fever which I mention that any of them, except perhaps 
 the constipation and reflex influences, are at all common during the puerperium. 
 The undoubted possibility of their occurrence, however, makes it incumbent 
 upon the physician in every doubtful case carefully to search for the evidences 
 of acute or chronic disease, just as he would in any patient and at any time. 
 Typhoid fever and malaria, especially the latter, have been convenient names 
 by which to designate the results of improper management of labor and the 
 puerperium. When the practitioner realizes that he should either wear sterile 
 rubber gloves or disinfect his hands and arms as carefully for a vaginal exam- 
 ination as for a laparotomy; that vaginal examinations should be as infrequent 
 as possible, and should be preceded by careful cleansing of the vulva and 
 that all unnecessary manipulations should be avoided after delivery, — he will 
 find that fever, except transient rises of temperature from constipation and 
 reflex causes, will be of the rarest occurrence, and that he will seldom be called 
 upon to make the differential diagnosis between puerperal sepsis and other 
 febrile affections. 
 
 Some difficulty arises in classifying the causes of pseudo-fever, since in 
 some cases the fever is of reflex origin, while in others it is not so or only 
 in part reflex in character. I believe, however, that the following arrange- 
 ment will be of service in enabling the student to recall and to differentiate tlie 
 different kinds of fever. 
 
 I. Constipation. — That constipation may cause a rise of temperature during 
 the puerperium is a matter of everyday experience (Fig. 959). Doubtless this 
 fever is partly reflex in character from the distention of the bowel and 
 consequent local discomfort, but it is also toxic, as shown by the head- 
 ache and general malaise which accompany it. This condition was recog- 
 nized and described by Oilman, Schroeder, Roswell Park, and others, as the 
 result of the absorption of products of decomposition. It is not peculiar to 
 the puerperium, but there is, at this time, a special predisposition to it, on 
 account of the accumulation of feces in the later weeks of pregnancy and 
 the sluggish intestinal action during the puerperium, the causes of which have 
 already been considered. It is also a well-known fact that a prolonged re- 
 cumbent posture predisposes to obstinate constipation. The treatment consists in 
 the proper regulation of the bowels during the later weeks of pregnancy, by atten- 
 tion to the diet, and the administration of a laxative on the evening of the second 
 
744 PATHOLOGICAL PUERPERIUM. 
 
 or morning of the third puerperal day, followed, if necessary, by an enema. 
 (See Management of the Puerperium and Diet of the Puerperal Woman, 
 pages 688 to 698.) In the presence of fever or headache, reasonably attribu- 
 table to constipation, the prompt administration of a saline cathartic is in- 
 dicated. It is wise, however, not to wait for the action of a cathartic, but 
 to give at once a copious enema of soapsuds. Subsequent attention to diet 
 is important. 
 
 2, Hyperthermia from Reflex Irritation. — That a sharp but usually transient 
 rise of temperature ma}^ be produced by reflex irritation is a fact with which the 
 obstetrician soon becomes familiar (Fig. 961). In this case the fever is, without 
 doubt, due to the effect of the exciting cause upon the nervous system, but 
 the modus operandi is largely a matter of speculation, and need not be discussed 
 here. It is a matter of clinical experience, however, that the circumstances 
 attendant upon pregnancy, labor, and the puerperium, tend, especially in patients 
 of the neurotic type, to an exaggeration of reflex nervous excitability. Fever 
 of reflex origin is usually to be traced to some source of pain or discomfort 
 purely physical in character, and not of infectious origin. The most frequent 
 source of trouble in this respect is overdistention of the breasts with milk. 
 I. Mammary Irritation: Among the sources of reflex irritation, distention 
 of the breasts is perhaps the most frequent and important. The so-called 
 "milk fever" of the older writers has already been alluded to, and is now re- 
 garded as obsolete, but it is nevertheless true that the extreme and painful 
 distention which sometimes occurs with the establishment of the milk secretion 
 may, and frequently does, cause a considerable rise of temperature, which 
 promptly subsides with the disappearance of the cause (Fig. 961). Diagnosis : 
 Fever resulting from overdistention of the breasts is to be distinguished from 
 septic infection of the genital tract by determining the fact of overdistention 
 of the breasts and its resulting discomfort, by the fact that the fever is of short 
 duration, disappearing with the removal of the cause. The various kinds of 
 infection may be excluded by the methods described in connection with the 
 diagnosis of the different varieties of sepsis, but this will not usually be necessary. 
 Especial care should, however, be taken not to mistake a beginning mastitis 
 for overdistention of the breast, since the treatment of these conditions is 
 radically different, and a mistake is likely to result disastrously for the patient. 
 The diagnosis of mastitis is considered elsewhere (page 762). As regards treat- 
 ment, the child should be put to the breast and the surplus amount of milk 
 removed, if necessary by the breast-pump, or better by gentle massage under 
 hot stupes; but all rough handling of the breast must be avoided. If necessary, 
 a saline cathartic may be given and the amount of fluids, especially milk, limited 
 for a time. A properly applied breast bandage may be a source of comfort 
 to the patient. Abscess of the breast is considered elsewhere as a form of 
 local sepsis. 2. Sore Nipples: The pain attending a cracked or fissured 
 nipple, especially during nursing, may cause a transient rise of temperature, 
 although in such a case we would ordinarily suspect infection through the 
 nipple (Fig. 971). 3. Rupture of the Uterus: Among the causes of fever 
 which may be regarded as purely reflex in character, may be noted the rise 
 of temperature which may almost immediately follow uterine rupture. Al- 
 though fever due to septic peritonitis and other infectious conditions may, 
 of course, follow later, it seems reasonable to ascribe the first rise of temperature 
 to reflex irritation. 4. Retrodisplacements of the Puerperal Uterus: 
 A rise of temperature due to this cause and promptly disappearing after replace- 
 ment I have observed as late as the fourth week. 
 
MORBID CONDITIONS ORIGINATING IN THE PUERPERIUM. 745 
 
 It is obvious that the hst of possible causes of non-septic fever may be 
 indefinitely extended. Colic, the peristaltic action evoked by cathartics, the 
 discomfort attending the passage of hard fecal masses, or the prolonged retention 
 of urine, might cause, in patients of the neurotic type, a fever, disappearing 
 promptly with the removal of the cause. Exposure to cold is an occasional 
 cause, and I have observed fever, excitement, and neurotic symptoms late 
 in the puerperium from the presence of a tapeworm, which was subsequently 
 secured. 
 
 3. Hyperthermia from Neurotic Conditions. — The possible occurrence of fever 
 as the result of organic nervous disease has already been noted. It remains to 
 
 
 M 
 
 E 
 
 M 
 
 E 
 
 M 
 
 E 
 
 M 
 
 E 
 
 M 
 
 E 
 
 M 
 
 E 
 
 M 
 
 E 
 
 M 
 
 E 
 
 M 
 
 E 
 
 M 
 
 E 
 
 M 
 
 
 M 
 
 E 
 
 M 
 
 E 
 
 M E 
 
 ME 
 
 m|e 
 
 m|e 
 
 m|e 
 
 ME 
 
 mIe 
 
 m!e 
 
 MiE 
 
 ME 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 1 
 
 1 
 
 
 
 1 
 
 
 
 1 
 
 
 
 1 
 
 
 
 
 
 
 
 1 
 
 
 
 
 Nuw^a'f'/^or 
 
 
 
 U 
 
 
 
 
 
 
 
 oio 
 
 r 
 
 
 
 olo 
 
 o!o 
 
 o!ai 
 
 Oio 
 
 ^ 
 
 /n 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 0.. ";"'.'.>. 
 
 
 
 
 
 
 
 
 
 
 t 
 
 1 
 
 
 
 1 
 
 i 
 
 
 F. 
 
 107° 
 
 ^ 100° 
 
 1 105° 
 
 g 10-1° 
 
 103° 
 
 102° 
 
 101° 
 
 100° 
 
 99° 
 
 S 98° 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 F. 
 
 107° 
 
 -§ 100° 
 
 1 
 
 1 105° 
 
 S 104° 
 
 103° 
 
 102° 
 
 101° 
 
 100° 
 
 99° 
 
 i 
 
 s ytj° 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 1 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 i 
 
 
 1 
 
 ■ 1 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 . 
 
 1 
 
 , 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 j 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 } 
 
 
 ; 
 
 ! 
 
 1 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 1 
 
 I 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ■ 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 ' 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 i 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 i 
 
 
 i 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 1 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ■ 1 
 
 
 
 
 
 1 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 t 
 
 
 
 ■ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 « 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Us^ht 
 
 I ■< I 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ; 
 
 
 
 ' - *" 
 
 ^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 I 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 / 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 " 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 i 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 i 
 
 
 
 
 
 
 / 
 
 ^ 
 
 
 
 
 
 
 
 
 
 
 
 > 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ' 
 
 1 
 
 
 
 
 
 1 
 
 I 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 / 
 
 V 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 f 
 
 
 
 
 
 / 
 
 ' 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 / 
 
 
 
 1 
 
 
 / 
 
 
 L 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 1 
 
 
 
 
 
 / 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 1 
 
 1 
 
 
 
 
 
 1 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 , 
 
 
 
 j 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 f 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 l[ 
 
 I 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ^rs 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 /' 
 
 V 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 J 
 
 
 1 
 
 
 
 
 
 / 
 
 y 1 
 
 
 
 
 
 
 
 
 
 
 
 * 
 
 
 s 1 
 
 
 «^ . 
 
 
 
 
 
 
 
 
 ' 
 
 
 1 I 
 
 A 
 
 
 .»^ 
 
 / \ 
 
 / 
 
 \ 
 
 
 
 
 
 
 
 
 
 / 
 
 
 
 
 s 
 
 
 '^^^ 
 
 
 
 
 
 
 
 
 
 I 
 
 
 
 
 /< 
 
 
 
 
 
 
 
 
 
 / 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 1 
 
 ... 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 1 
 
 
 1' 07° 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •5. 
 
 1 97° 
 
 Vail of 
 
 Disease 
 
 Pulse 
 
 Resp. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 I 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ! 
 
 
 
 Day of 
 
 DUease 
 
 Pulse 
 
 Resp. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 : 
 
 
 — 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 j 
 
 
 
 
 
 1 
 
 
 ; 
 
 , 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 h 
 
 r 
 
 2 
 
 3 
 
 4 
 
 5 
 
 (J 
 
 7 
 
 8 
 
 9 
 
 
 h 
 
 1 
 
 2 
 
 3 
 
 4 
 
 5 
 
 G 
 
 7 
 
 s 
 
 9 
 
 10 
 
 11 
 
 90. 
 
 ^ 
 
 y 
 
 ^- n 
 
 "'0 
 
 "<8 
 
 "so' 
 
 !'9''o 
 
 Sf 
 
 
 "fo 
 
 
 ly 
 
 78^' 
 
 
 /■'8b 
 
 'Xs 
 
 y 
 
 ''.-?= 
 
 /'so 
 
 "<4 
 
 y 1^0 
 
 "-81 
 
 ;"'« 
 
 ."="0 
 
 i.^ 
 
 1 
 
 -;„ 
 
 20 
 
 ^0 
 
 ''-IS 
 
 "-I's 
 
 '>,;' 
 
 'Ve 
 
 >20 
 
 'J-tI 
 
 
 
 y 
 
 •'' 
 
 y 
 
 
 ^/. 
 
 
 y 
 
 ' 
 
 ^^ 
 
 y' 
 
 Fig, 958. — Post- 
 lowing 
 
 OPERATIVE Fever 
 Craniotomy. 
 
 Fig. 959.— 
 on the 
 perium. 
 
 Fever due to Constipation 
 Ninth Day of the Puee- 
 
 notice the role played by functional neuroses in the production of fever during 
 the puerperium. Emotional Excitement: This frequently causes a tran- 
 sient rise of temperature. Fright, grief, anger, excessive annoyance from any 
 cause, may have this effect. As in the case of reflex irritation from causes 
 purely physical, the modus operandi is not well understood. These cases are 
 most likely to occur in patients of the neurotic type. Hysteria : The occa- 
 sional, though very rare, occurrence of sustained high temperature in hysterical 
 cases cannot be doubted. The diagnosis is to be made by eliminating the 
 various forms of sepsis, by the previous history of the patient, and by the 
 absence of the general symptoms due to septic infection. The treatment is 
 
746 
 
 PATHOLOGICAL PUERPERIUM. 
 
 obvious. During the puerperal period all visitors except the patient's mother 
 or husband should be excluded, and every source of annoyance and excitement 
 eliminated as far as possible. The importance of securing for the patient a 
 sufficient amount of undisturbed sleep has been referred to in connection with 
 the management of the puerperium, and cannot be overestimated. In cases 
 of hysteria, in addition to measures adapted to the morale and surroundings, 
 the bromides and other nerve sedatives will be of service. 
 
 VII. True Fever. — True fever is characterized by a number of phenomena, 
 of which hyperthermia is the chief. It begins in general with a precursory 
 hypothermia, sometimes expressed by chilliness or rigors, and after its establish- 
 
 
 M^ 
 
 E 
 
 M 
 
 £ 
 
 M 
 
 E 
 
 M 
 
 E 
 
 M 
 
 £ 
 
 tJT 
 
 e 
 
 M 
 
 E 
 
 M 
 
 E 
 
 M 
 
 E 
 
 M E 
 
 M 
 
 E 
 
 M 
 
 E 
 
 ME 
 
 
 M 
 
 T 
 
 M 
 
 T 
 
 M 
 
 E 
 
 ME 
 
 ME 
 
 ME 
 
 ME 
 
 m|e 
 
 ME 
 
 M,E V 
 
 H'Sfl,%, 
 
 
 
 
 
 
 
 
 
 
 
 U 
 
 
 
 1 
 
 
 
 1 
 
 
 
 
 
 
 
 1 
 
 
 
 1 
 
 
 
 ] 
 
 (J 
 
 u 
 
 U 
 
 
 
 1 
 
 U 
 
 uui^^V^t 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 A^ 
 
 /V\ 
 
 /V\ 
 
 A\ 
 
 /V\ 
 
 ^ 
 
 «„","'";«. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 0.,;;'"'.-, 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 ! 
 
 F. 
 
 107° 
 
 106° 
 
 1 105° 
 
 1, ^ 
 
 |l04° 
 103° 
 102° 
 101° 
 100° 
 
 99° 
 
 S 
 1 98 
 
 si ^ 
 
 1^ 
 
 IHaease 
 Pulse 
 Reap. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 F. 
 
 107° 
 
 106° 
 
 1 105° 
 
 ^— » 
 
 1 
 
 1 104 
 
 s 
 
 103 
 102° 
 101° 
 100° 
 
 99° 
 
 1 
 1 
 
 1 ^^° 
 1 97° 
 
 Disease 
 ^Pulse 
 ^Jtesp. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ! 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 i 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 j 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 . 
 
 
 
 
 
 ! 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 1 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 h 
 
 tt.Stv. 
 
 "" 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 I 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \/ 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Y 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 12 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 I 
 
 
 — 
 
 
 
 
 
 
 
 
 
 
 
 
 I 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 , 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 V 
 
 
 
 
 
 
 
 
 
 
 j 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 J 
 
 
 
 
 1^ 
 
 1 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 / 
 
 
 
 
 
 1 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ~^ 
 
 
 
 
 
 
 
 
 
 
 J 
 
 
 
 
 
 
 ' 
 
 
 
 
 
 
 
 
 
 
 /" 
 
 
 s 
 
 
 \ 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 J 
 
 
 
 
 1 
 
 1 
 
 ^. 
 
 .^ 
 
 
 
 
 
 
 
 
 _ 
 
 -^ 
 
 
 _ 
 
 >s 
 
 Z 
 
 [_> 
 
 /_ 
 
 \ 
 
 
 
 /^ 
 
 
 ._ 
 
 
 
 
 
 — 
 
 —. 
 
 , 
 
 __ 
 
 
 ^ 
 
 
 
 _ 
 
 
 _ 
 
 (_ 
 
 — \— 
 
 _ 
 
 
 
 
 
 
 — 
 
 — 
 
 
 — 
 
 
 — 
 
 — 
 
 
 ~ 
 
 — 
 
 
 — 
 
 — 
 
 ~ 
 
 ~ 
 
 b^ 
 
 
 
 ' 
 
 — 
 
 ~ 
 
 — 
 
 —-_ 
 
 ^ 
 
 r: 
 
 
 — 
 
 
 
 ^ 
 
 
 — 
 
 rz 
 
 
 : 
 
 ' 
 
 
 
 
 
 L_ 
 
 — 
 
 
 — , 
 
 
 — ' 
 
 — 
 
 
 — 
 
 — 
 
 
 — 
 
 — 
 
 
 — 
 
 
 
 — 
 
 
 
 
 — 
 
 
 — 
 
 — 
 
 — 
 
 — 
 
 
 — 
 
 
 
 — 
 
 
 — ' 
 
 ' — 
 
 — \ — 
 
 ' — 
 
 
 k-' 
 
 :^- 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 N^ 
 
 ^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ! 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 , 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 , 
 
 1 
 
 L 
 
 1 
 
 2 
 
 3 
 
 4 
 
 5 
 
 u 
 
 7 
 
 s 
 
 a 
 
 10 
 
 11 
 
 12 
 
 L 
 
 1 
 
 2 
 
 3 
 
 4 
 
 5 
 
 G 
 
 7 
 
 S 
 
 & 
 
 '."'80 
 
 't-B-; 
 
 '>a''8 
 
 
 'x^3 
 
 'J-Ja 
 
 "°--ei 
 
 ""X^ 
 
 ?-ro 
 
 ViT 
 
 
 ''loo 
 
 ^^ 
 
 't--'' 
 
 so^/ 
 
 ".' 
 
 "'■ 
 
 54,.- 
 
 133.' 
 
 "'' 
 
 ' "Jy ' 
 
 ".- 
 
 80^. 
 
 .-'' 
 
 ..-' 
 
 X' 
 
 y 
 
 y 
 
 y- 
 
 y^ 
 
 y 
 
 ,,-' 
 
 ^-^ 
 
 
 
 / 
 
 y 
 
 .y 
 
 
 y^ 
 
 .-' 
 
 '' 
 
 ,' 
 
 
 
 
 Fig. 960. — Fever due to Epidemic In- 
 fluenza. 
 
 Fig. g6i. — Fevek due to Reflex Irri- 
 tation OF Caked Breasts. Relieved 
 by massage through hot stupes. 
 
 ment pursues a certain course with intermissions or remissions. In most cases 
 it is due to a toxic principle in the blood, which is akin to the albumoses. An 
 albumose-reaction can be obtained from febrile urine in the majority of cases. 
 This substance, while affecting the heat center, also acts upon the vasomotor 
 center as well, so that fever is accompanied by circulatory phenomena, chiefly 
 local congestions. Since true fever is due to the action of a toxin, we find it 
 associated as a rule with malaise, headache, pain in the limbs, anorexia and 
 other evidences of toxemia. The pulse-rate increases, as a rule, with the tem- 
 perature. A certain group of symptoms is caused by the persistent high tem- 
 perature and increased interchange of gases, as thirst, dryness of the mouth. 
 
CLINICAL TYPES OF PUERPERAL MORBIDITY. 747 
 
 scanty urine, etc. In the puerperium it is important to discriminate between 
 mere hyperthermia and true fever, for the former, as a rule, requires no inter- 
 vention directed to the uterus. The fever of sapremia, toxemia, septicemia, etc., 
 is essentially one and the same, being due either to products of putrefaction or 
 bacterial toxins, both classes of substances being akin to toxalbumoses. 
 
 VIII. Hypothermia. — Hyperthermia and fever do not necessarily accompany 
 the blood-intoxications and infections of puerperal morbidity. Instead we 
 may encounter hypothermia, under which term we may, for simplicity's sake, 
 include normal temperatures when present in severe systemic affections. Len- 
 hartz states that hypothermia is known to occur under three conditions, i. 
 Severe collapse or adynamia such as complicates perforation of the uterus and 
 peritoneum (as an accident of forceps delivery). He relates a typical case in 
 which a woman lived for seven days without rise of temperature, a feeble eleva- 
 tion occurring just before death. 2. Subfebrile periods in ordinary cases of 
 sepsis. These occur under various circumstances. Thus in a case of what 
 proved to be combined putrid and infectious endometritis, emptying the uterus 
 resulted in four days of normal temperature, after which pyogenic endometritis 
 asserted itself with fatal sepsis. When pyemia leads to secondary suppurative 
 foci in the joints, empyema, etc., evacuation of the pus may be followed for 
 a time by normal or subnormal temperature. 3. Terminal hypothermia. This 
 phenomenon is sometimes seen just before death in severe cases of sepsis or 
 pyemia. 
 
 (D) CLINICAL TYPES OF PUERPERAL MORBIDITY. 
 
 Introduction. — Without a definite understanding of the various focal affec- 
 tions and blood conditions, it is impossible to understand the clinical pictures 
 which puerperal morbidity may assume. The number of these conditions is 
 very large, although they readily fall into certain categories. Thus we may 
 have certain local lesions with little or no general reaction, and general sepsis 
 with but little local disturbance. We may have local putrefaction of dead 
 tissue associated with sapremia; local suppuration (abscess) with toxemia (fever 
 of suppuration); local inflammation with bacterio-toxemia ; metrophlebitis with 
 so-called pyemia; various combinations of the preceding, etc. 
 
 The General Symptoms of Puerperal Infection. — There are certain symptoms 
 common to most cases. The most prominent of these is fever. An elevation 
 of temperature, commonly occurring about the third day, is usually the first 
 sign that attracts attention. The pulse is increased in frequency, and when 
 the increase is not in proportion to the amount of fever, we have a valuable 
 diagnostic symptom. In puerperal sepsis the pulse ratio is greater than with 
 fever due to other causes. Liebermeister * gives the pulse-rates which should 
 result from corresponding temperature markings: Temperature 98.6° F., pulse- 
 rate 78; temperature 100.4° F-. pulse-rate 88; temperature 102 2* F., pulse-rate 
 Q7; temperature 104° F., pulse-rate 105; temperature 105° F., pulse-rate 109; 
 temperature 107° F., pulse-rate 121. A chill or chilly sensation may be present, 
 but is frequently absent, especially in the milder types of infection. It may, 
 however, be present in any variety of sepsis, and is not necessarily indicative of 
 metastasis, as it was at one time thought. Pain and tenderness in the pelvis are 
 not constant symptoms, and the same may be said of distention of the abdomen 
 due to paralysis and consequent relaxation of the intestines, of nausea and 
 vomiting, a coated tongue, constipation or diarrhea, special changes in the 
 
 * " Vorlesungen iiber specielle Pathologic und Therapie," Band in. 
 
748 PATHOLOGICAL PUERPERIUM. 
 
 urine, sleeplessness, and delirium. Headache is a prominent symptom, as are 
 disturbances in the process of involution, shown by a soft, flabby uterus. 
 Diminution in the quantity of the lochia, especially for twenty-four or forty- 
 eight hours at the outset of the attack, is quite constant, but a marked foul 
 odor to the lochia, except in cases of retained secundines, is not necessarily 
 present. Foul odor is often absent in the severest types of puerperal sepsis. 
 
 I would give the following symptoms as most pathognomonic of the various 
 types of puerperal sepsis, aside from a bacteriological examination of the blood 
 and the secretions of the genital tract: (i) Fever; (2) increase in pulse-rate out 
 of proportion to the amount of fever; (3) sensitiveness of the pelvic organs 
 to pressure; (4) disturbed involution; (5) persistent diminution in the amount 
 of the lochia. When the symptoms begin a few hours after labor, they are 
 probably due to infection before or during labor. If no symptoms appear 
 by the end of the fifth day, the patient may usually be regarded as 
 out of danger from sepsis. There are exceptions to this rule, however, as 
 will presently be noted. The student should remember that while in the 
 majority of cases the infection starts from the vagina or cervix, the symptoms 
 first noticed are usually those of an endometritis. 
 
 1. Purely Local and General Conditions. — Extension of an aseptic thrombus 
 from the uterine to the pelvic veins, producing the so-called benign form of milk- 
 leg, may be mentioned as an uncomplicated local affection. The so-called 
 cryptogenous sepsis without evidence of local lesion represents an uncomplicated 
 general state. Simple hyperthermia, from neurotic or reflex conditions, may 
 occur without evidences of local or general conditions. Mild sapremia or 
 toxemia (bacterial) may accompany an ordinary puerperium (so-called resorp- 
 tion or "one-day" fever). 
 
 2. Marked sapiemia occurs as a result of much putrescible material in the 
 uterus — as in lochiometria, putrefaction of retained or adherent placenta, putrid 
 abortion, missed labor with fetal putrefaction, gangrene of uterus, etc. When- 
 ever it is possible to empty the uterus in time the severe symptoms usually 
 subside. 
 
 3. Marked bacterial toxemia (without sepsis), corresponding to ordinary 
 surgical fever, occurs whenever pyogenic bacteria attack the birth-tract, para- 
 metria, tubes, pelvic peritoneum, etc. As a rule, the degree of toxemia varies 
 with the amount of pus-formation. Bacteria may reach the blood in small 
 numbers and yet sepsis need not result. As long as the suppurative focus is 
 surrounded by a barrier of granulation tissue, sepsis is prevented and toxemia 
 held in check. If general peritonitis develops the toxemia is sufficient to cause 
 death (malignant toxemia). 
 
 4. Simple septicemia, pyemia, sapremic sepsis, are conditions in which bac- 
 teria enter the blood in large numbers along with toxins ; yet the majority of 
 these conditions is not due so much to the bacteria as to the degree of toxemia, 
 which is naturally much greater when the insufficiency of the leucocyte barrier 
 allows a wholesale absorption. Hence, sepsis without metastases is practically 
 a malignant toxemia. 
 
 5. Metastatic septicemia and pyemia represent not only states of intense 
 toxemia, but the occurrence of metastatic deposits in vital organs gives these 
 conditions a hopeless character. In septicemia proper, metastases are the 
 results of septic endocarditis; while in pyemia, which results from metrophlebitis, 
 metastases to the various viscera occur without the intermediation of the 
 cardiac lesion. 
 
 At the present moment, the belief that the syncytial cells of the placenta 
 
TREATMENT OF PUERPERAL INFECTION. 749 
 
 play a principal role in the toxemia of pregnancy, appears to be gaining ground, 
 although there is much diversity as to the manner in which the results are 
 produced. From one point of view these cells cause embolism in the liver and 
 kidneys, thereby setting up the characteristic lesions of these organs. From 
 another point, the cells are believed to secrete a poisonous substance which 
 attacks the predisposed organs. These views are not incompatible with the 
 theory of hepatic toxemia. 
 
 TREATMENT OF PUERPERAL INFECTION. 
 I. PREVENTIVE TREATMENT. 
 
 This has been largely discussed in connection with the management of 
 labor, and it cannot too often be repeated that when the management of normal 
 labor is regarded as very largely identical with the preventive treatment of 
 puerperal infection, the latter will be of the rarest occurrence. I sum up 
 the preventive treatment of puerperal sepsis under four heads: (i) General 
 hygienic measures. (2) Asepsis of patient, physician, and accessories. (3) 
 Limitation of internal examinations and manipulations. (4) Antistrepto- 
 coccic serum. 
 
 (i) Hygienic Measures. — Under this head is to be considered everything 
 which tends to fortify the system against disease in general. Good blood 
 is the best of germicides, hence the importance of good hygiene during preg- 
 nancy; an out-of-door life, good diet, freedom as far as possible from sources of 
 worr}^ and care. The correction of anemia by iron and other tonics, the treat- 
 ment of any constitutional dyscrasia, should be carefully attended to in order 
 to prepare the patient against the inroads of septic infection. Under the same 
 heading come certain precautions already discussed elsewhere; e. g., the selection 
 of a sunny and commodious lying-in chamber, as far as possible removed from 
 toilets, sinks, and plumbing, and securing good ventilation. All these precau- 
 tions should be regarded as important because they prepare the patient to 
 resist infecting agents; but it should not be forgotten that all the agents thus 
 combated do not of themselves act as the immediate causes of infection. Nor 
 should the physician forget, in his attention to such details, that the actual cause 
 of puerperal infection is contact of wounds in the birth canal with an infected 
 agent. 
 
 (2) Asepsis of Patient, Physician, and Accessories. — The patient (see Manage- 
 ment of Labor, page 472): The arrangement of the vulval pads and the subse- 
 quent cleaning of the external genitals have already been described in connection 
 with the management of the puerperium (page 688). The physician: A physi- 
 cian who is dressing suppurating wounds, attending cases of erysipelas, scarlet 
 fever, diphtheria, or other cases of infectious or contagious diseases, should 
 not attend obstetric cases if he can help it. If he is obliged to do so, he should 
 take a full bath, change his clothing, disinfect his hands and arms with special 
 care, and make no internal examinations that are not imperatively necessar}', 
 and then only with his hands encased in sterile rubber gloves. The method of hand 
 disinfection has been described (page 150). It is needless to say that any 
 man who practises obstetrics should himself be free from infectious or conta- 
 gious diseases; he should be cleanly as to his habits, should bathe fre- 
 quently, should wear clean clothing, should keep his nails trimmed short and 
 carefully cleaned, and should be particular even to fastidiousness about the 
 care of his hands. The use of a sterile operating gown or duck suit and of 
 sterile rubber gloves is an additional safeguard (page 151). The nurse: As 
 
750 PATHOLOGICAL PUERPERIUM. 
 
 already stated, she should be free from any contagious or infectious disease 
 especially suppurative coryza or skin disease, nor should she recently have 
 attended a case of infectious or contagious disease. She should also have 
 had a full bath and change of clothing, paying special attention to the hair, 
 which should be well washed with soap and water, then with plain water, and 
 then with a bichloride solution (i : 10,000). She should be expressly forbidden 
 to give douches or practise any internal manipulations while cleansing the 
 external genitals. Instruments and water used: All instruments or other appli- 
 ances which are to come in contact with any part of the parturient tract should 
 first be thoroughly scrubbed with green soap and water, especial attention being 
 paid to any cracks or crevices, and then boiled for not less than twenty minutes. 
 They should then be removed by an aseptic instrument and kept in a solution 
 of carbolic acid or lysol until needed, or, better, used directly from the boiler 
 or sterilizer. All instruments which cannot thus be sterilized should be avoided. 
 Catheters and douche tubes should be of glass or metal, preferably glass. If it 
 becomes necessary to use a Barnes bag, a gum catheter, or similar appliance, it 
 should first be thoroughly washed with green soap and water and then sterilized 
 by boiling or by steam under pressure. All water used for immersing instru- 
 ments, washing the external genitals, and giving douches should first be boiled. 
 
 (3) Limitation of Internal Examinations. — This is perhaps the most im- 
 portant precaution of all, as has been fully stated in connection with the manage- 
 ment of normal labor (page 476). It is of special importance if the physician 
 has recently been in attendance upon any case of infectious or contagious 
 disease, or if his hands have been contaminated by septic discharges of any 
 kind, and in all cases during and after the third stage of labor, even if sterile 
 rubber gloves are used. 
 
 It is, of course, true that in many cases it is impossible to carry out all 
 of the above rules in practice. Skilled nursing and sterile accessories are not 
 always available. But if the physician will but remember that septic contact 
 is the one source of infection, if he insists upon and personally supervises cleanli- 
 ness and antisepsis of the external genitals and their immediate surroundings, 
 and avoids all unnecessary interference, especially after delivery, very satis- 
 factory results may be secured even among most unfavorable surroundings. 
 
 (4) Antistreptococcic Serum. — The preventive power of Marmorek's serum 
 was tested by Wallich upon 383 women who bade fair to have a septic puer- 
 perium either by reason of certain acts of exposure or accidents of delivery. De- 
 spite the precaution, 56 developed phenomena of infection. Streptococci have 
 been more successfully combated without than with the aid of the serum. 
 
 2. CURATIVE TREATMENT. 
 
 The non-surgical treatment of puerperal infection comprises, at the present 
 day, supporting measures, antipyretics, and various specifics and quasi-specific 
 remedies of more or less doubtful utility, such as Marmorek's serum and Credo's 
 silver ointment. 
 
 (i) Supporting Measures. — These differ in nowise from the same class of 
 remedies employed in the treatment of typhoid fever, pneumonia, etc. The 
 patient receives whisky or brandy according to the state of the pulse, with 
 strychnin, -^-j^ grain, every three or four hours, and digitalis as necessary. Quinin 
 is much less used than formerly, although individual authorities continue to 
 prescribe it. Diarrhea should not be checked, and many authorities even 
 advocate the routine use of aperients in puerperal infection, especially calomel 
 and laxative salts. Vomiting requires cracked ice and champagne. In order 
 
TREATMENT OF PUERPERAL INFECTION. 751 
 
 that the patient's vitality may be kept at the highest point, it is necessary 
 that she should receive a plentiful supply of nutritious food. Milk, koumyss, 
 broths, eggs beaten up with milk or broths, beef-juice, panopeptone, beef 
 peptonoids, and so on, should be administered in as large quantities as the 
 patient can assimilate. It is well, also, to try the effect of solid food — e. g., 
 raw oysters, meat, etc. In prolonged cases it is of great importance to a patient 
 suffering from sepsis that the stomach should be in such condition as to retain 
 an abundant supply of nutritious food and stimulants, which is a cogent reason 
 for not giving medicines whose utility is doubtful and which may derange 
 that organ. Good results are obtained from the subcutaneous injection of salt 
 solution in large quantities. A more direct method, of course, is that of venous 
 infusion. From one to two pints may be injected. (See Part X.) Washing out 
 the colon by means of decinormal salt solution is worthy of further trial, not only 
 upon theoretical grounds, but because occasional favorable results have been re- 
 ported in puerperal as well as non-puerperal forms of sepsis. Finally, a very 
 valuable remedy in these cases is oxygen, which should be inhaled in large quan- 
 tities and systematically. The use of ergot to promote involution, and by causing 
 uterine contraction to prevent the transmission of infection through the lymph- 
 atics, has already been mentioned and constitutes a rational method of treatment. 
 I am inclined to believe that it prevents also the absorption of pathogenic germs 
 which may be present in the vagina. The absorbent power of a lax uterus is 
 very marked. 
 
 (2) Antipyretics. — Quinin, phenacetin, and other antipyretics have been 
 advocated by various observers. In a process like acute peritonitis, which 
 runs a rapid course and in which death is due to other causes than fever, they 
 are of little or no service, and may do harm by causing cardiac depression and 
 disturbing the stomach. In prolonged cases — i. e., in pyemia — they are some- 
 times beneficial", and when fever is attended by headache they may afford relief. 
 Under such circumstances they should be given tentatively if bad effects on 
 the heart and stomach are not noticed. If the coal-tar derivatives are given, 
 those least depressing to the heart should be selected, and it is well to give 
 a stimulant at the same time. Hydrotherapy offers a better means of reducing 
 fever in these cases. There is considerable testimony as to the efficacy of the 
 cold bath, and if it is not, as occasionally happens, too depressing to the patient, 
 its use is to be advised. My practice is to rely mainly upon the wet pack, cold 
 sponging, and the abdominal coil as antip3^retics. For local inflammatory ten- 
 derness, whether from endometritis, affections of the parametrium, or general 
 peritonitis, the intermittent application of cold, as the coil or ice-bag, applied 
 to the fundus, is usually a wise precaution. 
 
 (3) Specific Medication. — Antistreptococcic serum: Orrhotherapy in puerperal 
 fever is still on trial. While many have abandoned it, others continue to 
 employ it. It is necessary to exhibit the remedy in large doses. The initial 
 injection should be 0.7 oz. (20 c.c), while the total daily dose should be 2.1 oz. 
 (60 c.c.) in desperate cases. In one class of cases prompt and permanent 
 recovery appears to follow the treatment, while in others improvement is either 
 wanting or may be only temporary. The use of this serum is, of course, irra- 
 tional without evidence that the streptococcus is present in pure culture. In 
 communities where bacteriological tests of the lochia cannot be obtained the 
 serum may be used in any desperate case as a last resort. Crede's ointment: 
 This preparation of silver, which was introduced in 1895, as a general remedy 
 for sepsis, has been used to a limited extent in puerperal infection. As appar- 
 ently hopeless cases of the latter may suddenly take a turn for the better 
 
752 PATHOLOGICAL PUERPERIUM. 
 
 a few seemingly successful tests of a remedy prove nothing. On account of 
 the desperate nature of the disease, however, the remedy may be tried, because 
 it is harmless and can be exhibited by simple inunction. From 15 to 45 grains 
 (2 to 3 gm.) at a time should be rubbed into the internal aspect of the thighs 
 once or twice daily. The duration of the inunction should be twenty minutes 
 and the site should be afterward covered with rubber tissue.* Nuclein. 
 Intravenous injections of silver salts. Nuclein has been proposed to produce 
 an artificial leucocytosis. From a limited experience I have failed to obtain 
 any marked results. I am compelled to make the same statement regarding 
 the intravenous injection of the silver salts. Mercurial ointment: This is still 
 employed in some European clinics, the drug being pushed to the point 
 of salivation. By most authorities, however, this method is justly ignored. 
 Abscess of fixation: This method of treatment, which is evidently the same 
 in principle as that of the seton and issue formerly used, has been tried 
 in a few cases of puerperal sepsis with apparent benefit. Professor Fochier, 
 of Lyons, who is the advocate of this mode of treatment, states that in 
 certain cases of general infection we see the patient's condition improve suddenly 
 and materially after the development of a localized suppuration. This he 
 terms "fixation abscess." In cases of grave sepsis he attempts the production 
 of an artificial abscess by injecting turpentine under the skin. If no pus forms, 
 the prognosis is hopeless. If a large abscess can be formed and allowed to 
 increase at will without opening, the patient undergoes a change for the better. 
 Intravenous infusion of formaldehyde solutions: On January 13, 1903, Barrows, 
 of New York, reported to the New York Obstetrical Society the cure of a severe 
 case of puerperal sepsis, by the infusion of a 0.02 per cent, solution of formalin 
 or 0.008 per cent, solution of formaldehyde gas into a vein of the arm. The 
 remedy has since been used with varied results by many. Further experience 
 is necessary to prove its usefulness. Pryor's Iodine Treatment: An investigation 
 of the uterine discharges and the contents of the pelvic cavity in cases of puer- 
 peral sepsis has resulted in a more definite idea of the conditions which must be 
 treated. W. R. Pry or f has operated upon thirty-seven cases, in all but 
 one of which streptococci, generally mixed with other germs, have been 
 found in the uterine discharge and in all the cases streptococci were found in 
 the pelvic cavity. He not only does a curettage in these cases and packs the 
 cavity with iodoform gauze, but he also does a posterior section of the vagina 
 and packs the cul-de-sac full of iodoform gauze.. The results have been uni- 
 formly good, and on the third day the germs have in every case been absent 
 from the discharges. This excellent result is attributed to the local iodism 
 which is caused by the action of the exudates upon the iodoform, thus setting 
 iodine free. The absorption of this iodine through the infected lymphatics is 
 supposed to have a decided and beneficial effect. The after-treatment of these 
 cases is so technical and consumes so much time that it would be difficult to 
 secure for it a very general adoption. Attempts are now being made to secure 
 this local and general iodism by more easily effected means. Ichthyol Treatment: 
 I have found ichthyol apparently of value in cases in which after clearing 
 the uterus of debris, and irrigating, the symptoms still persisted, without any 
 marked symptoms of extra-genital infection. After the final irrigation of the 
 uterus with a saline solution, the cavity is packed with gauze soaked in a sterile 
 
 * Unguentum Cred6, containing 15 per cent, of coUargolum, can be obtained in stiitable 
 half-ounce jars from Messrs. Schering and Glatz, 58 Maiden Lane, New York. Care must 
 be taken that an inert preparation is not used. 
 
 t" N. Y. Med. Jour ," Aug. 22, 1903 
 
TREATMENT OF PUERPERAL INFECTION. 753 
 
 solution of ichthyol in water (i to i). It has also been proposed to inject re- 
 newal drams of a 50 per cent, solution of ichthyol in water into the uterine 
 cavity. With this latter method I have had no experience. I usually have 
 the ichthyol gauze in the uterus for twenty-four hours, remove it, irrigate with 
 a saline solution and repack. In certain cases to avoid too much disturbance 
 of the patient I have left the gauze in the uterus for from forty-eight to 
 seventy-two hours. The uterus should not be tightly packed. 
 
 (4) Endometritis. — For various reasons, and especially because nearly every 
 case of endometritis may be regarded as containing the possibilities of a mixed 
 infection, it is better to consider the treatment of all the forms of endometritis 
 under a single head. The best authorities are now inclined to conservatism as 
 regards the local treatment of puerperal endometritis, the weight of evidence 
 tending to the conclusion that active intrauterine treatment indiscriminately 
 applied, in the presence of streptococcic endometritis, as proved by a bacterio- 
 logical examination of the uterine secretion, does much more harm than good, and 
 my experience has led me to coincide with this conclusion. I hold the opinion 
 that it is neither necessary nor advisable to invade the uterine cavity in every 
 mild case of endometritis; such cases are best treated by rest in bed, the applica- 
 tion of an ice-bag over the uterus, the administration of ergot and vaginal 
 irrigations, the last only when the lochia are foul. The local application of 
 cold tends to promote uterine contraction and perhaps helps to inhibit the 
 growth of bacteria, while the administration of ergot, as elsewhere noted, aids 
 in promoting contraction and in furthering the processes of involution by 
 closing the lymphatics of the uterine wall. Vaginal irrigation, if carefully 
 given (Part X), is harmless and probably beneficial. A 2 or 3 per cent, solution 
 of carbolic acid, or 0.5 or i per cent, solution of lysol, or a 25 to 50 per cent, 
 solution of hydrogen peroxide may be injected every four to six hours. When, 
 however, the symptoms are of a more severe type, especially if they begin 
 to appear soon after labor, in all cases in which placental retention exists or 
 is strongly suspected, the interior of the uterus should be digitally examined 
 (Part X). If placental or other debris, such as clots or pieces of membrane, 
 is found, it should be digitally removed and the uterus irrigated (Part X). 
 The digital examination of the puerperal uterus, the removal of the placenta, 
 and the method of giving the intrauterine douche are described in connection 
 with obstetric operations (Part X). The mere retention of membranes in the 
 absence of symptoms of infection is not a justification for invading the uterine 
 cavity after delivery, nor should any violence be done to the uterine wall in 
 the effort to remove them, even if symptoms are present. In either case the 
 remedy is more dangerous than the condition. On the other hand, if the interior 
 of the uterus is smooth it may be irrigated, but further manual or instrumental 
 interference can do nothing but harm. It is possible that these injections act 
 simply by emptying the uterus of septic contents, and that sterile water would 
 serve as well as disinfectant solutions. Of the latter, perhaps a 50 per cent, 
 solution of alcohol is well worth trial, as much as one and a half to two quarts 
 being used. If no benefit is observed, the injection may be repeated in twelve 
 hours; but if improvement does not follow the second injection, little benefit 
 is likely to be derived from further intrauterine treatment. Should the in- 
 jections appear to cause improvement, the}'- may be cautiously repeated from 
 time to time, according to results. Should no benefit be observed, it is unwise 
 to continue them, as they are by no means free from danger. A careful bimanual 
 examination should be made in each case, and in those cases in. which the para- 
 metrium is involved, intrauterine injections should not be given, but vaginal 
 4S 
 
754 PATHOLOGICAL PUERPERIUM. 
 
 injections may be employed. Antiseptics may be introduced into the uterine 
 cavity in the form of suppositories or on gauze. The use of the iodoform pencil 
 is strongly advised by some, while others advocate the use of iodoform gauze. 
 I have abandoned the use of both. Carossa fills the uterus with gauze which 
 he saturates at hourly intervals with 25 to 50 per cent, alcohol. Among other 
 substances which may be introduced by the tampon are chlorine water, tincture 
 of iodine, and especially the colloidal silver of Cred^ (see page 751). In the 
 past the curette has played an important part in the treatment of puerperal 
 endometritis, but the best authorities have now reached the conclusion that 
 its use, while often productive of the greatest good in the treatment of sepsis 
 following abortion, does far more harm than good in the treatment of sepsis 
 at full term. The objections to its use may be stated as follows: (i) It is 
 difficult to go thoroughly over the whole surface of the uterus; (2) the puerperal 
 septic uterus is soft and easily perforated; this accident has happened to expe- 
 rienced operators; (3) whatever is necessary can usually be done more intelli- 
 gently and thoroughly by the finger; (4) last and most important, curetting 
 destroys the barrier which nature has established against the progress of infec- 
 tion, and which has been discussed in connection with the pathology of puerperal 
 septic endometritis (page 719, Fig. 940). Moreover, experience has shown that 
 good results have been obtained by methods similar to those which I have 
 described. Kronig obtained, by expectant and supporting measures, a mor- 
 tality of 4 per cent., and in all his cases the presence of the streptococcus was 
 demonstrated in the lochia. It is doubtless true that in certain cases of 
 fever following delivery there is prompt subsidence of symptoms after curet- 
 tage. Such cases, however, are cases of sapremia which almost always termi- 
 nate favorably, either spontaneously or under treatment. If streptococci as 
 well as saprophytes happen to be present, curettage may result in the exten- 
 sion of the infectious process and in serious and even fatal accidents. 
 
 Resume. — To sum up the treatment of puerperal endometritis: (i) retained 
 placenta should, when possible, be removed digitally; (2) mild cases should be 
 treated expectantly by the use of the ice-bag, ergot, etc., vaginal douches being 
 used if the lochia are offensive; (3) in severe cases the uterine interior should 
 be carefully examined digitally, and when practicable, bacteriologically ; debris 
 should be manually or instrumentally removed; the uterus carefully irrigated 
 and the irrigation repeated if necessary within twelve hours, preferably with a 
 50 per cent, solution of alcohol. This treatment to be commenced as early 
 as possible. If intrauterine treatment is not beneficial, it should be discontinued 
 and every precaution taken to prevent injury to the soft parts of the mother 
 during manipulations. 
 
 (5) Mastitis. — (See page 765.) 
 
 (6) Pyogenic Urethritis, Cystitis, Pyelitis. — If infection has already occurred, 
 as shown by the onset of cystitis, the bladder should be washed out every four 
 hours with a weak solution of boric acid. This is best done by means of a silver 
 return catheter and fountain syringe, the bladder having been emptied. The 
 reservoir should have but a slight elevation above the bladder. No air should 
 be admitted. As soon as the patient feels the sense of fulness in her bladder, 
 she should be allowed to empty it. Urotropin should be given inwardly. If 
 the upper part of the urinary tract becomes infected, the resulting case is one 
 for operative surgery. Puerperal gonorrheic urethritis is mentioned elsewhere. 
 (Fig. 950) 
 
 (7) Puerperal Salpingitis. — The treatment is that for localized suppuration 
 elsewhere. If the diagnosis is made early an ice-bag may be applied. After 
 
TREATMENT" OF PUERPERAL INFECTION. 755 
 
 pus has collected it must be evacuated, it being understood that the primary 
 focus in the uterus has been properly treated. The conservative vaginal inci- 
 sion should be employed to reach the pus. Gonorrheal puerperal salpingitis 
 will be mentioned elsewhere; likewise salpingitis secondary to septic peritonitis. 
 
 (8) Metritis. — We must reiterate that puerperal metritis is not a clinical 
 entity. The moment the leucocyte barrier is overcome, or the thrombi in the 
 uterine sinuses are attacked, the infection is already to be considered as having 
 extended beyond the uterus. This is best shown clinically by the fact that no 
 indications for hysterectomy for puerperal sepsis can be laid down save in ex- 
 ceptional cases like an adherent placenta, an infected myoma, etc., in which the 
 operation is really prophylactic. 
 
 (9) Parametritis. — The .management of a parametritis, whether essential or 
 a complication, is that of an impending or actual abscess-formation in general. 
 At the outset an ice-bag is applied and opiates given, both rendering especial 
 service in warding off suppuration and peritonitis. The patient must also be 
 kept immobilized to the greatest possible extent. This management, when put 
 in force at an early period, justifies a good prognosis. If suppuration is under 
 way warm compresses about the abdomen may hasten it. Pus should be 
 evacuated by the posterior vaginal incision. In order to hasten resolution, both 
 in abortive cases and after suppuration, the patient should be placed on her 
 back with elevated hips, and the posterior cul-de-sac irrigated twice daily with 
 several quarts of hot water. 
 
 Oophoritis may be regarded practically as a parametritis ; it is caused usually 
 by lymphatic extension from the endometrium. 
 
 (10) Perimetritis. — Perimetritis and parametritis require precisely the same 
 management, viz., absolute rest, the ice-bag, and opiates; so that a differential 
 diagnosis during the early days is not a matter of supreme importance. Rest 
 must be so absolute that no attempts at irrigating the birth tract are permissible, 
 even if the lochia are foul and purulent. The surgical treatment is along the 
 lines of parametritis and will be discussed more fully in the general section. 
 
 (11) General Peritonitis. — In the absence of general sepsis, there is an oppor- 
 tunity of accomplishing something by treatment directed to the peritoneum. In 
 the very earliest stages an attempt should be made to limit the process by ice and 
 opiates. After meteorism has fully developed it is of course useless to expect any- 
 thing from abortive treatment. In theory, prompt laparotomy with evacuation of 
 all the contents of the peritoneal cavity — bacteria, exudate, etc. — is indicated ; but 
 only in a very few cases is this heroic resource efificacious. The most promising 
 cases are those in which a sudden escape of pus, etc., has inoculated the entire 
 peritoneum, such as occurs in rupture of an abscess. The surgical treatment of 
 general peritonitis will be discussed more fully later (page 756). In the absence 
 of surgical intervention, palliative treatment may give some relief. The inflated 
 abdomen may be subjected to warm packs; tympanites may be relieved by 
 means of a long colonic tube. Stimulants of all kinds and appropriate nutriment 
 are indicated. Fortunately, ^.s already stated, the end of these patients is often 
 peaceful. 
 
 (12) Metrophlebitis or Septicaemia Venosa. — There is practically but a single 
 indication in this affection — the prevention of metastasis. This is best fulfilled 
 by absolute rest in bed. The least effort, as in having the bedding changed, may 
 bring on a chill. It may happen at times that the loosening of the thrombi as 
 a result of their suppuration is attended by hemorrhage (secondary post-partum 
 hemorrhage). The uterus and vagina in these cases must be tamponed, and 
 ergot should be given in large doses. If the tampons do not arrest the hemor- 
 
756 PATHOLOGICAL PUERPERIUM. 
 
 rhage, intrauterine injections of hot acetic-acid, solution, 2 to 6 per cent., may 
 be used with vaporization as a last resort. 
 
 (13) Phlegmasia Alba Dolens. — The patient should be kept perfectly quiet in 
 bed and all manipulations should be avoided in order to prevent embolism. The 
 leg should be elevated and wrapped in cotton. A nutritious diet is indicated, but 
 over-stimulation should be avoided on account of the danger of embolism. The 
 patient should remain in bed for two weeks after the subsidence of the swelling. 
 The resulting oedema is best treated by the application of a bandage. In the 
 cellulitic form abscesses are likely to develop in the femoral region, and should 
 be opened as soon as practicable in order to avoid the fistulae which are apt 
 to occur. 
 
 Many local remedies are advised for this condition. Am^ong them are: paint- 
 ing along the course of the swollen veins, once daily or upon alternate days, 
 with tincture of iodine; wrapping the limb in 2 per cent, carbolic acid solution 
 or a solution of hamamelis; the local application of the ointments of belladonna 
 and mercury either alone or in combination; and the use of various strengths 
 of ichthyol in aqueous solution. Of these, I have found a 25 to 50 per cent, 
 ichthyol solution to give the best results. In some cases I have used it even' 
 undiluted. 
 
 3. SURGICAL TREATMENT. 
 
 (i) Curettage. — This resource, used by many in a routine fashion, is regarded 
 by others as a dangerous practice. We sometimes see the temperature rise 
 and the disease take a fatal turn after this operation. During an interval 
 of ten years Bumm * has seen in his own practice ten untoward results of curet- 
 tage: 5 cases of phlegmasia alba dolens, 3 of fatal pyemia, and 2 of fatal peri- 
 tonitis. The endometrium should never be curetted in streptococcic infection; 
 in the first place, 80 per cent, of these patients recover spontaneously from the 
 formation of a protective layer of leucocytes in the decidual lining of the uterus. 
 The germs leave the uterus in connection with the necrosis and expulsion of 
 the decidua; the use of the curette is therefore distinctly meddlesome. It 
 breaks down the defensive wall and allows the streptococci to penetrate into 
 the uterus and gain the peritoneum; this being the method by which curettage 
 may set up peritonitis. Less virulent streptococci may attack the exposed 
 placental site and enter the venous sinuses, there causing purulent disintegration 
 of thrombi or perhaps an endophlebitis of the crural vein with resulting phleg- 
 masia alba dolens. Curettage, in fact, is indicated only in putrefaction of 
 decidual and placental remains with resulting sapremia. Here the results are 
 very satisfactory because these saprophytes can exist only on dead tissue. 
 Even here, however, the fingers should be used to remove all large masses 
 and the placental site should never be curetted. 
 
 (2) Vaginal Incision and Drainage. (Figs. 962 and 963.) — Incision through 
 Douglas's pouch in acute pelvic suppuration of puerperal origin necessarily pre- 
 supposes an accurate diagnosis which can be made only by bimanual examination 
 under narcosis. Kronig warns against the employment of this resource lest a 
 recent adhesion be ruptured with subsequent development of diffuse peritonitis. 
 As there is no certainty that vaginal incision will lead to evacuation of the pus, the 
 operator, according to Kronig, would best pursue the expectant plan. Quite 
 recently certain operators have advocated vaginal incision and drainage in acute 
 pelvic peritonitis and cellulitis. f A parallel instituted between this procedure 
 and the expectant management apparently shows the superiority of the former. 
 
 * "Ueber die chirurgische Behandlung des Kindbettfiebers," Halle, 1902. 
 t "American Journal of Obstetrics," Mar., 1902. 
 
TREATMENT OF PUERPERAL INFECTION. 
 
 757 
 
 The majority of authors do not even mention early vaginal incision in this 
 connection. The ultimate removal of pus by incision through the Douglas 
 pouch, after due waiting for resorption to occur, is permissible if the pus is 
 walled off and the patient in good condition. 
 
 (3) Extirpation of the Infected Uterus and Laparotomy. — This is indicated 
 in cases which do not improve after evacuation of the uterus, providing the 
 disease is still confined to the latter. Schultze performed this operation success- 
 fully for retained placenta, Stahl for suppuration of a myoma in the puer- 
 perium, Sippel in putrid endometritis, Prochownik in septic abortion, etc. 
 Many of these hysterectomies have been performed in America. Bumm * has 
 performed five extirpations of the uterus with two recoveries. The fatal cases 
 were all examples of streptococcic infection. The indications for this operation 
 are difficult to determine. If one waits for the infection to reach the confines 
 of the uterus, as shown by local symptoms in the immediate neighborhood 
 
 Fig Q62. — Vaginal Incision 
 AND Drainage. Shows the 
 incision being made through 
 the posterior utero-vaginal 
 junction into Douglas' cul- 
 de-sac. 
 
 / 
 
 i;.^x^^<^ 
 
 Fig. 963. — Vaginal Incisiox and Drainage. Gauze 
 and rubber drainage-tube introduced through the 
 vaginal incision. 
 
 of the latter, operation as a rule will result in stump infection and subsequent 
 peritonitis. On the other hand, there is a natural hesitancy in regard to per- 
 forming hysterectomy in incipient cases, because spontaneous recovery is 
 likely to follow any type of infection. The infectious germs may be propagated in 
 all directions — into the tubes, veins and lymphatics, and upon the peritoneum. 
 Cases of this type are inoperable. Something can be done toward the diagnosis 
 of operability by anesthetizing the patient and a thorough bimanual palpation of 
 the tubes, ovaries, and pelvic connective tissue. To perform laparotomy 
 as a last resort, in default of precise indications, is not justifiable, although 
 now and then a cure may be accomplished. If a puerperal pyosalpinx develops, 
 the germ is usually the streptococcus which maintains its virulence un- 
 changed. The danger of infecting the peritoneal cavity in attempting to 
 remove a pyosalpinx is very great. Miliary abscesses and detached colonies 
 , * Vide supra. 
 
758 PATHOLOGICAL PUERPERIUM. 
 
 of germs may be present in the inflammatory zone which surrounds the tumor. 
 Premature intervention in pyosalpinx is strictly contraindicated, for it may 
 be that the septic process is about to become localized. In regard to septic 
 peritonitis, all our resources — simple incisions, irrigation, and drainage — notably 
 fail when a large amount of peritoneal surface is involved. Bumm * cites a 
 case in which he made a free incision in the linea alba, took out a portion of 
 the intestine, removed all exudate, irrigated the abdominal cavity with many 
 quarts of saline solution, tamponed the pelvic cavity with iodoform gauze, 
 and finally made counteropenings to secure abundant drainage. These patients 
 usually perish rapidly from collapse; enormous numbers of streptococci are found 
 post mortem upon the peritoneum of all the abdominal organs. To combat 
 peritonitis successfully, laparotomy would have to be performed as soon as 
 the disease begins, with removal of the infected uterus at the same time. This 
 intervention is too severe for most patients to undergo. The only recoveries 
 common in puerperal peritonitis occur in cases of encapsulated collections of 
 pus. Pelvic abscess is in itself a favorable termination for puerperal sepsis, 
 because it indicates arrest of the infective process. There is little danger that 
 the pus will burrow, and incision is indicated only when the original small 
 purulent foci have coalesced to form a large abscess. Puncture is more practi- 
 cable than incision in these cases. If the abscess is opened at the abdominal 
 wall, a count crop ening should be made in the vagina, and vice versa. 
 
 (4) Excision of Veins. — The question of the excision of veins as preventive 
 of pyemia naturally arises. Autopsies frequently show veins plugged with 
 purulent thrombi which were amenable to excision, the lesion being limited 
 to a small portion of a single vein ; for example, one of the spermatics. Physical 
 exploration under deep narcosis will sometimes enable the operator to feel 
 the infundibular ligament of the pelvis as a thick, indurated cord. The technique 
 required for the excision of these veins is not difficult. Bumm has operated 
 three times, but unfortunately without success. In one case a septic phlegmon 
 was found in association with the thrombo-phlebitis ; in a second, which prom- 
 ised well, the left spermatic vein was the seat of suppuration. It was resected 
 within wide limits and the pyemic chills ceased within three days. The patient 
 succumbed, however, from a fresh purulent focus in the same vein. In the 
 third case, as in the first, the phlebitis was accompanied by an extravascular 
 phlegmon. Trendelenburg succeeded in saving a patient by this operation in 
 1902.* This form of intervention appears to be justifiable as a last resort. 
 
 (5) Atmocausis. — Sneguireff's method of vaporization has been suggested 
 by Diihrssen t for septic or putrid endometritis. As this form of intervention 
 must necessarily produce obliteration of the uterine cavity with consecutive 
 atrophy of the organ, it could be employed only in women near the climacteric, 
 and even then solely as a last resort. The technique is very simple. A boiler 
 heated by alcohol has a metallic supply tube attached which is introduced 
 into the uterine cavity through a fenestrated catheter which is surrounded in 
 turn by another tube of non-conducting material for the protection of the 
 cervix. The contact of the steam with the uterine cavity should not exceed 
 one and a half to two minutes. The pain is insignificant, so that no anesthetic 
 is required. I have had no experience with this method. 
 
 * Vide supra. 
 
ANOMALIES OF THE BREASTS. 
 
 r59 
 
 VI 
 
 ANOMALIES OF THE BREASTS. 
 
 1. Absence of Mammae, or Amazia. — This anomaly is extremely rare. It 
 has been said that absence of one breast occurs only in women, and absence 
 of both only in monsters who are otherwise extremely deformed. A stunted 
 condition of the breasts is often associated with imperfect development of the 
 true sexual organs. 
 
 2. Hypertrophy. — This anomaly is also rare, and generally occurs in those quite 
 young. One breast is often larger than the other. Lactation sometimes dimin- 
 ishes the size of the hypertrophied breasts. 
 
 3. Lactation Atrophy of the Breast. — A phenomenon well known to the laity, 
 but seldom or never alluded to in textbooks on obstetrics, is frequent dwindling 
 away of the mammary fat after lactation. That the gland itself is not involved 
 is shown by the restoration of the original bust after a new conception, subject, 
 of course, to the changes incidental to multiparity. The cause of this atrophy 
 appears to have nothing specific in its character, but it is one of the greatest 
 sources of anxiety to modem 
 
 woman, as shown by the num- 
 ber of expedients in vogue to 
 overcome or conceal it. Theo- 
 retically, it is possible to pro- 
 duce mammary hypertrophy by 
 massage and inunctions of fats. 
 Clinically, the results are most 
 disappointing. 
 
 The same is true of the use 
 of goat's rue and other drugs. A 
 relatively small amount of par- 
 affin injected into the breast will 
 produce the desired effect; I 
 have had no personal experience 
 in the matter, but know of acci- 
 dents from its use. 
 
 4. Supernumerary Breasts : 
 
 Polymazia or Polymastia. — This condition is rare. These extra mammee are gen- 
 erally found on the chest below the normal gland and more median in situation. 
 However, instances are on record of their being found in the most varied situa- 
 tions. This fact does not admit the theory of reversion. Men seem to exhibit 
 this phenomenon as frequently as women, if not more so. Heredity seems to 
 account for it in some instances. Supernumerary breasts vary in size from a 
 minute collection of glandular tissue to a full-sized breast secreting the normal 
 amount of milk (Fig. 336). 
 
 5. Anatomical Anomalies of the Nipples (Fig. 964). — (i) Congenital absence 
 (athelia) : This condition rarely occurs. When acquired, it is generally due to 
 injury, or it may result from suppuration of the infantile breast. (2) Flat and 
 inverted nipples (microthelia) : This anomaly may be either congenital or acquired 
 and is common as the result of corset pressure. It should be recognized at the 
 examination of pregnancy (Fig. 964). The treatment consists in drawing 
 out the nipple with the fingers or breast-pump in the latter part of gestation. 
 Breast-shields may obviate the difficulty of nursing. Artificial feeding may 
 become necessary. (3) Fissured nipples (Fig. 971): The nipples are exposed to 
 
 Fig. 964. — Comparison of Faulty and Normal 
 Development of the Nipples. 
 
760 
 
 PATHOLOGICAL PUERPERIUM. 
 
 the discomfort of chafing from the continual changes of dryness and moist- 
 ure to which they are subjected. Many parturient women suffer from this 
 trouble. There is danger of the entrance of micro-organisms and of subsequent 
 inflammation. Treatment is chiefly prophylactic, as elsewhere described (page 
 187). ■ Exposure of the nipples to the ordinary atmosphere is excellent to 
 harden them. Boric-acid solution as a wash is most useful. After ulceration 
 has once been established vigorous measures are necessary. 
 
 IX. ANOMALIES OF THE MILK SECRETION. 
 
 I. Deficient Secretion : Oligolactia or Agalactia. — A deficiency of milk in 
 the nursing woman is quite common, but a complete suppression is not 
 frequent. Deficiency may be caused by a congenital or acquired defect in 
 the structure of the mammary glands. Ill health, advanced age, or obesity 
 may also be a cause. It sometimes occurs after a pre- 
 mature or still-birth, and also follows a previously abund- 
 ant supply of milk, and is then often due to continuous 
 overexertion. The milk secretion is mainly dependent 
 upon the general condition of the mother and upon the 
 diet. Treatment: If the cause is some defect in the struc- 
 
 FiG 965. — Ordinary 
 Breast-pump. 
 
 Fig. 966. — Nipple Shield. 
 
 ture of the breasts, treatment is of little avail. If, however, there are other causes, 
 such as ill health, overwork, etc., a carefully regulated diet, change of air and 
 scene, tonics, and other hygienic measures are often effective. Gentle massage 
 has been followed by beneficial results. Crabs, whether hard- or soft-shelled, 
 have been found the best milk producers among foods. Many kinds of sea food, 
 especially shell-fish, seem to have the same influence. Boiled fresh beets, with- 
 out vinegar, are one of the best vegetables. 
 
 2. Excessive Secretion. — (i) Polygalactia: This condition is one of an excessive 
 amount of milk. Congestion and engorgement of the breast are not necessarily 
 present. Its occurrence is not frequent. It may develop during the first part 
 of lactation and gradually subside. If it continues, to the great discomfort 
 of the mother, means should be taken to overcome it. Treatment consists in 
 regular times of nursing, in emptying the breasts by massage, the breast- 
 pump, or compression. The diet may be restricted and the amount of fluids 
 diminished. Laxatives should be given. (2) Hyper lactation: Lactation pro- 
 
DISEASES OF THE BREAST. 761 
 
 longed beyond the ninth month may result in an exhausted physical condition 
 of the mother, which is sometimes termed tabes lactealis. This habit is most 
 prevalent in the lower walks of life. The mother may develop symptoms of 
 anemia accompanied by neuralgic pains. Nervous manifestations often follow. 
 The symptoms are profound anemia and pains in the upper extremities during 
 nursing. Phthisis also may develop. The child must be weaned at once. Tonics 
 must be administered to the mother, while a change of air will be found very 
 beneficial. (3) Galactorrhea: This affection consists in a continuance of the 
 milk secretion with constant flow between the periods of nursing. The milk 
 is of poor quality. Both breasts are generally affected. In certain cases the 
 quantity of milk is excessive, resulting in exhaustion of the mother. The 
 causes are unknown. It may be a nervous affection. The almost continuous 
 flow of milk with loss of strength and interference with nutrition brings about 
 anemia, emaciation, and nervous disorders. The treatment is unsatisfactory. 
 Iodide of potassium and ergotin are recommended; atropin locally (i gr. to i oz. 
 of glycerin) I have found of great value. Return of menstruation sometimes 
 increases the flow. Belladonna ointment is preferred by some; I have found 
 it less certain than atropin in glycerin or vasogen. A lotion for bathing the 
 nipples, consisting of a 5 per cent, solution of cocaine hydrochlorate in equal 
 parts of glycerin and water, often assists in the treatment. Saline laxatives to 
 keep the bowels open are of benefit. Electricity is not always attended by the 
 results hoped for. 
 
 3. Quailitative Anomalies. — The quality of the milk is also variable, depending 
 upon many conditions. The diet of the mother is a very potential factor in in- 
 fluencing the quality of the milk. This should, as a rule, be about the same as 
 she has always been accustomed to; it should comprise plain, mixed foods 
 with a slight excess of fluids; milk taken between meals is beneficial; the inter- 
 vals between nursing periods should be carefully regulated; excessive emotion 
 of any kind is always to be avoided. 
 
 X. DISEASES OF THE BREAST. 
 
 1. Areolar Inflammation. — Inflammation and even abscess of the glands of 
 Montgomery may occur, but may be prevented by cleanliness or treated by in- 
 cision. 
 
 2. Congestion and Engorgement. — Engorgement and congestion of the breasts, 
 " caked breasts," usually occur on the third day; the pressure and irritation being 
 so great as sometimes to cause pyrexia. The treatment consists in securing 
 profuse serous discharges from the intestines with saline cathartics, in the appli- 
 cation of heat to the breasts in the shape of hot stupes under pressure, and in 
 emptying the breasts by digital massage through hot stupes (Figs. 967, 968, 
 969). Saline catharsis, moist heat with pressure, and rest are the principles 
 in the treatment of caked breasts. 
 
 3. Sore Nipples. — Simple erythema, excoriation, erosion (Fig. 970), fissures or 
 cracks, and eczema of the nipples are all included under the term " sore nipples," 
 and all these conditions can usually be prevented by proper attention to the nip- 
 ples during pregnancy and the early puerperium. The prophylactic treatment 
 consists in the preparation of the nipples for lactation during pregnancy. During 
 the later months the nipples should be washed daily with soap and water and 
 carefullv massaged with sterile vaseline and alcohol. (See page 187.) The cura- 
 
762 
 
 PATHOLOGICAL PUERPERIUM. 
 
 tive treatment consists in careful cleansing after each nursing with boric-acid 
 solution; in the use of a nipple shield (Fig. 966); in the application of bismuth 
 and castor oil, compound tincture of benzoin, oxide of zinc, or nitrate of silver, 
 
 4. Mastitis ; Mammary Lymphangitis; Galactophoritis. — Varieties: Three 
 varieties may usually be recognized: namely — (a) subcutaneous, (6) parenchyma- 
 tous, {c) submammary (Fig. 971). Mastitis was formerly of common occurrence, 
 but since its infectious nature has been recognized it is much less common. It 
 occurs more frequently in primiparae and during the second and third weeks of 
 the puerperium, but may occur late in lactation. It is rare after the fourth preg- 
 nancy. Etiology: All forms 
 of mastitis are to be re- 
 garded as forms of infec- 
 tion. The infecting agent 
 is usually Staphylococcus 
 aureus, less often the strep- 
 tococcus. Staphylococcus 
 albus is found in the secre- 
 tions of healthy women in 
 from 80 to 94 per cent, of 
 cases, and, as a rule, is of 
 no pathological importance 
 to either mother or child 
 (Olshausen and Veit). The 
 starting point of infection 
 is usually a fissure or an 
 erosion of the nipple, but 
 the milk ducts may be- 
 come infected without this. 
 Occasionally the process 
 starts from an abrasion of 
 the areola or skin surface of 
 the breast. Infection by 
 micro-organisms circulat- 
 ing in the blood has been 
 assigned as a cause, but 
 this claim has not been 
 proved. Metastatic ab- 
 scesses of the breast may, 
 of course, occur in pyemia 
 as the result of thrombotic 
 infection. Inspissation of 
 milk, caked breasts, was 
 formerly supposed to be the cause, but this has been disproved. It is, in my 
 opinion, a predisposing cause. The superficial varieties of mastitis are the result 
 of lymphatic infection, while in the more deeply seated it is generally believed 
 that the infection is transmitted through the milk ducts. Contact of the 
 nipple or breast, especially if eroded or fissured, with unclean hands, clothes, 
 breast-pump, etc., and, under certain conditions, with the child's mouth, are all 
 sources of infection. 
 
 (a) Subcutaneous Mastitis (Fig. 971). — This is a superficial and circum- 
 scribed inflammatory process usually located under or near the areola. It is 
 always due to infection through the lymphatics. The gland proper is not 
 
 Fig. 967. — Massage and Milking of Distended or 
 "Caked" Breasts through Hot Moist Flannel. 
 The left hand supports the breast, while the fingers of 
 the right hand produce gentle but firm massage radiat- 
 ing from the base toward the nipple. 
 
DISEASES OF THE BREAST. 
 
 763 
 
 involved. The treatment includes, in the early stages, supporting measures and 
 the application of a 50 per cent, ichthyol solution, and, if abscess forms, incision 
 and evacuation of the pus, followed by an antiseptic dressing. In this form of 
 mastitis it is not always necessary to remove the child from the breast. Care 
 should be taken to make the incision either entirely within or entirely without 
 the areola, since pigmentation may follow the line of incision. In very rare 
 cases the inflammation takes on an erysipelatous type, becomes rapidly dif- 
 fused, and is followed by extensive suppuration and sloughing. The axillary- 
 glands may be enlarged and tender. Accompanying the local process are grave 
 constitutional symptoms, such as chills, high fever, and general prostration. 
 
 Inflammation of the 
 Glands of Montgomery. — 
 Suppuration of the glands 
 of Montgomery within the 
 areola sometimes occurs, 
 and after rupture obstinate 
 ulcers may form. The glands 
 should be incised, the pus 
 evacuated, and an antiseptic 
 dressing applied. An ulcer, 
 if present, should be treated 
 on general surgical princi- 
 ples. 
 
 (6) Parenchymatous 
 Mastitis. — Inflammation of 
 the gland proper is usually 
 called "parenchymatous 
 mastitis." There are, how- 
 ever, two distinct forms 
 which may be clinically rec- 
 ognized : in one the inflam- 
 mation begins in the acini 
 (Fig. 971), and in the other 
 it begins in the interstitial 
 tissue (Fig. 971). When it 
 begins in the acini, the in- 
 terstitial tissue becomes 
 secondarily involved, and 
 vice versa. If the inflam- 
 matory process begins in the 
 parenchyma, the symptoms 
 are a chill or chilly sensation 
 
 and a sharp rise of temperature, perhaps to 104° F. or even higher. The 
 patient seldom complains of pain in the breast, but examination discloses a 
 hard, localized swelling which is tender to the touch but not unbearably so; 
 there may also be a slight redness of the skin. When the process begins in the 
 interstitial tissue, it is also accompanied by localized swelling, which, how- 
 ever, is not at first well defined. This swelling gradually increases and redness 
 of the skin soon appears. In this form of mastitis the temperature rise is 
 gradual and a well-marked chill is not common, although chilly sensations 
 may occur. Whenever the fever continues for thirty-six hours, it is likely 
 that a suppuration is taking place; a rapid pulse is also considered suspicious. 
 
 Fig. 968. — Massage and Milking of Distended or 
 "Caked" Breasts through Hot Moist Flannel. 
 Both hands are used to jointly massage the breast 
 and empty the milk ducts. 
 
764 
 
 PATHOLOGICAL PUERPERIUM. 
 
 Fig. 969. — Massage and Milking of Distended or "Caked" Breasts through Hot 
 Moist Flannel. After softening of the breasts by the methods shown in Figs. 967 
 and 968, the fingers of one hand are often sufficient to relieve the tension and empty 
 the milk ducts by massaging from the base to the nipple. 
 
 Fig. 970. — Superficial Erosion of the Left Nipple. 
 
DISEASES OF THE BREAST. 
 
 765 
 
 The prophylactic treatment has already been referred to and applies to all 
 varieties of mastitis. It embraces the proper care of the breasts and nipples 
 and of the child's mouth, and also the prompt treatment of erosions and fissures. 
 Engorgement of the breasts and inspissation of milk should be treated by mas- 
 sage through hot flannel, thus softening and relieving tension by milking into 
 the flannel (Figs. 967 to 969), by bandaging the breast in such a way as to 
 secure firm compression (Fig. 972); and by the administration of a saline 
 
 Jhf&rstitial 
 Mastitis 
 
 Retromastitis 
 J^3ubmammary Abscess) 
 
 Deep lobe 
 
 Infected 
 lobules 
 
 ErosioTt 
 
 MUkDticts 
 
 Parsnchi/mat^is 
 Mastitis 
 
 Pig. 971. — The Extension of Infective Processes in the Breast. The course and 
 site of the infection are shown in color. 
 
 cathartic. After an inflammatory process has begun, however, manipulation 
 can only do harm. 
 
 The curative treatment before suppuration has occurred consists first in re- 
 moving the child from the breasts, which should then be supported but not 
 compressed. An ice-bag should then be applied over the inflamed area and relief 
 may be afforded by compresses soaked in lead-and-opium wash and covered by 
 oiled silk or rubber tissue. Free serous movements of the bowels should be early 
 
766 
 
 PATHOLOGICAL PUERPERIUM. 
 
 secured. These measures, however, should not be allowed to delay timely sur- 
 gical treatment, which should be instituted as soon as the presence of pus can 
 be determined. 
 
 After suppuration has occurred in cases of subcutaneous abscess, local anes- 
 thesia will usually be sufficient, as by cocain or ethyl chloride. In some cases 
 general anesthesia will be required, nitrous oxide being most desirable. The 
 lowest point of the abscess should be located as nearly as possible and the incision 
 should be large enough to admit the finger, and should be in a direction radiating 
 from the nipple in order to avoid severing one of the lacteal ducts. When prac- 
 ticable the incision should be made in the mammary fold so as to avoid an un- 
 sightly scar of the breast. The finger 
 should be used to remove broken- 
 down tissue and to break up any thin 
 partitions which may separate or only 
 partially separate a neighboring pus 
 cavity. One or more counter open- 
 ings may be made in order to secure 
 free drainage. The cavity is then irri- 
 gated with peroxide of hydrogen or 
 some other mild antiseptic solution, 
 the opening packed with gauze, and 
 an antiseptic dressing with a moder- 
 ately firm bandage is applied. In from 
 twenty-four to thirty-six hours the 
 gauze should be removed and the 
 
 A 
 
 16 1 
 
 nc^es 
 
 
 B 
 
 
 
 W 
 (D 
 
 X 
 
 u 
 
 c 
 
 lO 
 (0 
 
 C 
 
 
 
 
 Cloth folded rcaiy for cutting. 
 
 Fig. 972. — Murphy Breast-binder in 
 Place. 
 
 Blndpr completed. Piece N03. 1 and 2 together and Chen 3 and 4 together to fonn the ahouldei' 
 
 Fig. 973. — Pattern of Murphy Breast- 
 binder Used at the New York Maternity 
 Hospital. 
 
 openings lightly packed. As soon as the discharge becomes very slight the gauze 
 is removed and the breast firmly compressed. If healing is not satisfactory or if the 
 cavity remains full of thick pus, better results may perhaps be secured by the use 
 of perforated drainage-tubes, which should not be less than one-fourth inch in 
 diameter. The dressing is changed the following day, and after that allowed to 
 remain for four days, when the tube or tubes should be removed and shortened 
 one-half. It is desirable to remove the tubes within two weeks or less if 
 possible. Their prolonged retention is likely to cause fistulce. The aim of 
 either method is to secure drainage while at the same time promoting the rapid 
 closure of the cavity. As a rule, this is better accomplished by gauze than 
 
DISEASES OF THE BREAST. 
 
 7G7 
 
 by drainage-tubes. If the latter should be deemed best at first, it is wise to 
 substitute a light gauze packing as soon as circumstances will permit. 
 
 (c) Submammary Abscess (Fig. 971). — This variety of abscess is situated 
 under the gland and is the result of the extension of abscess formation from the 
 gland proper. The symptoms include pain, which is deeply seated, oedematous 
 swelling of the breast and surrounding skin with little or no redness, inability 
 to move the arm freely, swelling of the axillary glands, and the general symp- 
 
 FiG. 974. — Y-Shaped Breast-binder Used at_the 
 Boston Lying-in Hospital. 
 
 Fig. 975. — Cross Bandage op one 
 Breast. 
 
 Fig. 976. — Cross Bandage of the Two Breasts. 
 
 Fig. 977. — Triangle Bandage of 
 One Breast. 
 
 toms of sepsis — chills, fever and prostration. The breast feels as though it were 
 floating on a fluid base. If the pus is not evacuated, it may burrow in any 
 direction, and has even been known to perforate the chest-wall and enter the 
 pleural sac. I once- saw a case in consultation in which [a submammary 
 abscess had passed unrecognized, death resulting from sepsis and pyemia, 
 as was proved by autopsy. The presence of pus is determined by the aspirating 
 needle, the breast being drawn upward and held while the needle is introduced 
 along the chest-wall beneath the gland. A grooved director is then passed in 
 and an opening made large enough to admit the finger. The further treatment. 
 
768 PATHOLOGICAL PUERPERIUM. 
 
 by irrigation, drainage, etc., is the same as that already described for abscess of 
 the gland proper. Special care should be taken to secure free communication 
 between a submammary abscess and any abscess in the gland proper. 
 
 5. Galactocele. — Galactocele is a milk tumor due to occlusion of one or more 
 lactiferous ducts, and is a rare condition and of little importance. Puncture of 
 the tumor may become necessary, but heat with pressure or massage through 
 hot stupes (Figs. 967, 968, 969) will usually suffice. 
 
 XI. BLOOD CONDITIONS. 
 
 1. Puerperal Thrombosis and Embolism. — The blood in pregnancy is pecu- 
 liarly coagulable and the circulation sluggish. With these conditions only 
 mechanical obstruction is necessary to cause the formation of a clot. This takes 
 place in one of the venous trunks and is followed by serious consequences. The 
 great importance attaching to thrombi is their liability to break up and form 
 emboli. These are carried along to the smaller peripheral vessels. Puerperal 
 thrombosis is most common after severe post-partum hemorrhage. Throm- 
 bosis of the veins is the most common cause of sudden death both in labor 
 and in the puerperium. The femoral, pelvic, and uterine veins are the most 
 frequent seat of this trouble. Large soft clots may be formed in the event of 
 partial detachment of the placenta, or of imperfect contraction of the uterus 
 followed by sudden hemorrhage which causes a weakened heart action. These 
 clots extend from the larger sinuses toward the heart. Any sudden disturbance 
 may dislodge bits of these masses and the blood-current will drive them on as 
 emboli. The symptoms of puerperal thrombosis are very sudden. With no 
 prodromes there occur a distressing dyspnea and air hunger. The patient 
 suffers the throes of suffocation. Cyanosis or pallor spreads over the surface 
 of the body, which becomes cold and clammy. The heart is rapid and irregular 
 and the pulse small and feeble. The patient fears impending death. This may 
 occur with a sudden convulsion. However, recovery may gradually take 
 place from the slow absorption of the clot. A rare occurrence is the formation 
 of clots in the arteries of puerperal women, instead of, or coincident with, 
 the formation of clots in the veins. The symptoms will depend upon the 
 particular organ affected. If the cerebral arteries are obstructed, then par- 
 alysis and aphasia result; if the ophthalmic, blindness follows. When the clot 
 is in the brachial or femoral artery, the corresponding limb will grow cold with 
 loss of sensation and motion, or it may be the seat of neuralgic pain. Pulsation 
 is absent below the obstruction and increased above it. If the collateral circu- 
 lation is not sufficient for the needs of the limb, then gangrene may occur. The 
 diagnosis is usually not difficult. The prognosis is grave. Most of these patients 
 die before medical aid can be summoned. The cause of death is disputed, some 
 believing it to be cerebral anemia, others cardiac syncope, but it is probably 
 asphyxia. For treatment, full doses of cardiac and respiratory stimulants should 
 be administered. To relieve pulmonary congestion leeches should be applied. 
 The most absolute rest and quiet must be enjoined. The diet must be liquid. 
 Oxygen inhalations may be of benefit. 
 
 2. Hematoma. — (See Maternal Dystocia, page 613, and Puerperal Hemor- 
 rhages, page 704.) 
 
 3. Puerpieral Anemia. — A tendency to anemia probably exists during preg- 
 nancy. After the child is bom there is a return to the normal condition of the 
 blood before the completion of involution of the uterus. When this change 
 
DISEASES OF THE NERVOUS SYSTEM. 769 
 
 does not occur, the woman becomes markedly anemic. The etiology is not 
 clear. It may be due to a serious constitutional disorder. The patient 
 may be possessed of slight powers of recuperation. Acute anemia caused 
 by hemorrhage may be the forerunner. The symptoms are great weakness 
 and pallor, neuralgic pains and backache. There is poor appetite. Hemor- 
 rhages are readily caused, and, as a rule, are from the mucosa. The diagnosis is 
 made from the symptoms, physical signs, and blood examination. The prog- 
 nosis is uncertain. The disease yields generally to prompt treatment, but if 
 neglected it may develop into pernicious anemia. For treatment, strict hygienic 
 measures must be enforced and the diet should be nutritious and carefully regu- 
 lated. Rest and fresh air are most beneficial. The child may have to be 
 weaned. Change of air and scene and mental diversion are very useful. 
 Tonics, especially iron and arsenic, are indicated. 
 
 XII. DISEASES OF THE NERVOUS SYSTEM. 
 
 1. Lesions of the Sacral Plexus. — In a generally contracted pelvis, or in one 
 with a flattened promontory, or in septic pelvic inflammations or exudates, 
 pressure upon the sacral plexus may result during labor or the puerperium. 
 Neuralgia, hyperesthesia, paralysis, anesthesia, and atrophy may occur. The 
 sacral and sciatic nerves are extremely sensitive to pressure, and movement of 
 the leg on the affected side causes extreme pain both in the pelvis and down the 
 leg. The prognosis is favorable, and the treatment consists in the cure of the 
 septic condition if this is the cause, and in the general treatment of neuralgia. 
 
 2. Puerperal Neuritis and Paralysis. — Definition: Puerperal neuritis is a 
 combination of neuritis and paralysis which is single or multiple and of 
 toxic origin. The form which develops first during the puerperium is 
 believed to be of septic origin. It is also possible for a polyneuritis of 
 pregnancy to extend into the puerperal period. Etiology: While puer- 
 peral neuritis may depend directly upon a toxin connected with some form 
 of puerperal sepsis, it is likely that a predisposition exists in these cases. 
 Symptoms: Puerperal neuritis may be general or localized. The latter type is 
 more common. Localized neuritis may attack either an upper or a lower limb. 
 Puerperal neuritis cannot be distinguished in any way from the non-puerperal 
 type. The generalized form is usually a survival from pregnancy, and is often 
 associated with uncontrollable vomiting. Its consideration, therefore, belongs 
 properly to the Pathology of Pregnancy. The association of polyneuritis with 
 insanity known by the name of " Korsakoff's psychosis " has been seen in preg- 
 nant women. The localized type of puerperal paralysis is almost peculiar to the 
 puerperal period. Its onset is usually preceded or accompanied by fever, with 
 evidence of neuritis, such as pain and tenderness. The resulting paralysis may 
 be mild and transient, a mere paresis, or it may be of various grades of severity. 
 The affection may develop early or late after delivery, thus recalling the various 
 periods of supervention of the puerperal psychosis. A favorite locality is the 
 ulnar or median nerve. After a period of hyperesthesia, pain, and tenderness 
 the sensibility to pain, temperature, and touch begins to diminish and motor 
 insufficiency appears with the resulting inability to flex the fingers and adduct 
 the thumb, the reaction of degeneration may develop, and in severe cases 
 muscular atrophy develops rapidly in the ball of the thumb and in the fore- 
 arm. In rare cases the nerves supplving the shoulder muscles are the seat of the 
 
 49 
 
770 PATHOLOGICAL PUERPERIUM. 
 
 lesion. When the lower extremities are involved, the peroneal nerve is the 
 favorite site and a traumatic paralysis is closely simulated. When paraplegia 
 develops, it is believed to be due to bilateral neuritis throughout the sacral 
 plexus. This condition is very rare, and when present naturally simulates a 
 myelitis. Diagnosis: The recognition of a neuritis should not be difficult. In 
 the peroneal nerve the resulting paralysis, however, is not readily distinguished 
 from the traumatic type. Generally speaking, neuritic paralysis develops at a 
 later period in the puerperium with a history pointing to an acute toxic neuritis 
 and a much more rapid supervention of the reaction of degeneration and mus- 
 cular atrophy. In paraplegia from neuritis, a spinal origin may be excluded 
 by the fact that the integrity of the sphincters is preserved. Prognosis: This 
 depends upon the character of the electric reactions, exactly as in the traumatic 
 form. Treatment: The initial neuritis must be treated by rest, sedatives, a 
 hypodermic of morphin, and counter-irritation. Vinay recommends ergotin 
 subcutaneously at this stage, one gram every second day. When the neuritis 
 has subsided, the muscles should be subjected to alcohol frictions and massage. 
 Traumatic Paralyses. — Definition: Traumatic puerperal paralyses are 
 unilateral motor palsies confined to some portion of the distribution of the sciatic 
 nerve, usually the peroneus, and due to compression or contusion of the latter. 
 They belong to the maternal birth traumatisms and their existence becomes 
 apparent soon after labor. Etiology: These paralyses were originally con- 
 founded with the results of neuritis and other motor palsies of non-central 
 origin. Narrow pelves are believed to furnish a predisposition to these nerve 
 traumatisms. Other alleged contributory factors are premature ossification of 
 the fetal cranium, unduly prolonged labor and the arrest of the head in the pelvic 
 excavation; forceps extraction, etc. It is nevertheless true that these paralyses 
 may result after a labor which is normal in every respect. The great sciatic 
 nerve is known to undergo compression in all labors, but the nerve-trunks which 
 traverse the pelvis are all protected naturally from undue compression, with the 
 exception of the lumbo-sacral, which is exposed to contact with the fetal head, 
 and especially with the high forceps as it crosses the pelvic inlet. The fact 
 that the peroneus branch of the sciatic nerve is the seat of the paralysis in most 
 instances, and that the muscles which it supplies may be seen to contract forcibly 
 during the use of high forceps, is sufficient evidence that the deleterious pressure 
 is exerted upon the lumbo-sacral feeder of the sacral plexus and sciatic nerve. 
 According to Windscheid,* normal spontaneous labor never causes anything 
 bej^ond a slight transitory peroneal paralysis; the severe and perhaps permanent 
 injuries being traceable always to forceps or unusual delivery. Symptoms : As 
 the fetal head passes the pelvic inlet, the pressure upon the sacral nerves causes 
 intense pain throughout the distribution of the sciatic nerves, which subsides after 
 delivery. When paralysis follows, an interval of two or three days generally 
 elapses before it becomes apparent. Various paresthesias and a sensation of cold- 
 ness may precede the motor anomalies. When the latter appear, they take the 
 form of a paresis of the thigh muscles, but this is merely a transitory forerunner 
 of the actual paralysis which, as already said, tends to affect the peroneus nerve, 
 while the thigh muscles and those of the calf retain their functions. The muscles 
 antagonistic to the paralyzed group throw the foot into an equinus position. 
 The electric reactions of the affected muscles are normal. The condition found 
 is simply a paralysis of the tibialis anticus, extensor communis digitorum, 
 extensor hallucis and pedis muscles. When the patient walks, she lifts her foot 
 much higher than normal to compensate for the loss of power in the extensors 
 
 * Sanger and von Herff's Encyclopaedia. 
 
DISEASES OF THE NERVOUS SYSTEM. 771 
 
 of the foot. The gait is characteristic. When the paralysis is of long standing, 
 anomalies of sensation are also present in the cutaneous area supplied by the 
 peroneus. The sensibility to pain, temperature, and the faradic current is 
 more or less abolished, while the reaction of degeneration appears in the mus- 
 cles. Trophic changes have been noted in some cases. Prognosis: The general 
 outlook in these cases is favorable. Even if the reaction of degeneration appears 
 in the muscles, the muscular sense is usually preserved. Treatment: The patient 
 should lie in bed and have the affected muscles rubbed and kneaded. If the 
 electric contractility is preserved, faradism should be applied once daily If the 
 reaction of degeneration develops, the interrupted galvanic current is preferable. 
 
 Ocular Paralyses. — These affections vary much in origin and severity. 
 They include hemiopia, amblyopia, and amaurosis. In regard to their origin, 
 they may be due to the occurrence of pregnancy-kidney, and belong then to the 
 pathology of pregnancy. This is true also of paralyses of hysterical origin. 
 Strictly puerperal ocular paralyses are due generally to post-partum hemor- 
 rhage, and have even been seen after metrorrhagia from abortion. The strictly 
 puerperal ocular disturbances appear to consist chiefly of hemiopia. 
 
 Auditory Paralyses. — These, as far as known, originate during pregnancy 
 and are due generally to nephritis. 
 
 3. Hemiplegia and Aphasia. — Definition: Puerperal hemiplegia represents 
 paralysis of one-half of the body with or without implication of the speech- 
 center, and is due directly to the puerperal state. Etiology: Hemiplegia and 
 aphasia occurring in the puerperium are due either to extravasation of blood or 
 to embolism within the brain, the latter being the more common cause. Ex- 
 travasation of blood from rupture of a vessel is a condition not likely to occur 
 in the puerperium, and post-partum eclamptic convulsions represent about the 
 only species of violence which can naturally occur during that period. Symp- 
 toms: Hemiplegic symptoms are doubtless always present in aphasia, but may 
 be so slight and transitory that the loss of speech is practically the only affection. 
 The two conditions may coexist in the full development of each. Puerperal 
 aphasia is chiefly of the motor type. Prognosis: When these affections are of 
 hemorrhagic origin, the outlook is grave, although many patients survive. On 
 the other hand, the prognosis is generally favorable in the embolic type, though 
 fatalities do occur. In either type a repetition of the pregnancy would very 
 likely cause a relapse. Treatment: As we have already seen that these puer- 
 peral affections are made possible chiefly by eclampsia and sepsis, the preven- 
 tive treatment is embraced in the prophylaxis of these evils. 
 
 4. Myelitis and Paraplegia. — Unlike the intracranial affections just enumer- 
 ated, there is no evidence that any of the various recorded cases of spinal menin- 
 gitis, myelitis, hematomyelia, etc., which have occurred during the puerperium, 
 represent anything beyond simple coincidence, with the possible exception that 
 in a very few instances the lesions of the cord may have been due to puerperal 
 sepsis. 
 
 5. Insanity of the Puerperium. — Insanity of pregnancy continued into the 
 puerperal period hardly belongs to this category. The essential puerperal 
 psychoses do not begin until several days after delivery. A distinction is made 
 between the early and late puerperal psychoses, the latter appearing toward the 
 end of the puerperal period, or at the period in which the menses would ordi- 
 narily be re-established. In regard to the type of this species of maternity- 
 insanity, it may be either maniacal or melancholic. A dementia is also recog- 
 nized by alienists, but it is practically only a terminal stage of one of the primary 
 types. 
 
772 PATHOLOGICAL PUERPERIUM. 
 
 Etiology. — There is no doubt that the presence of puerperal sepsis in many 
 of the cases is something more than a coincidence. AHenists assure us that since 
 the introduction of antisepsis into midwifery the frequency of puerperal insanity 
 has been marvelously diminished. Many cases of this type of psychosis — such 
 as is seen, for instance, in typhoid fever — are said to exhibit more the nature of de- 
 lirium than of actual insanity. Again, the coincidence of severe local infection 
 has often been remarked, and gives color to the toxic theory; while a further 
 coincidence of insanity of the puerperium with puerperal mastitis, phlebitis, and 
 other inflammations remote from the genitals helps justify the assumption of 
 this point of view. Of other special contributory factors may be mentioned the 
 exhaustion which follows delivery, extreme prostration being a well-known 
 cause of certain psychoses or of low delirium. In this connection should be 
 mentioned the influence of post-partum hemorrhage. In women already dis- 
 posed to insanity the physiological adjustment which follows child-birth is 
 doubtless sufficient to set up mental disorder. 
 
 Symptoms. — According to alienists, 80 per cent, of all cases of puerperal 
 psychoses begin within the first fortnight, and, generally speaking, the longer 
 the period following the first month the rarer the supervention of this type of 
 insanity. It is generally stated that puerperal insanity is essentially maniacal 
 in contradistinction to the insanity of pregnancy, which tends to the melancholic 
 type. It has even been claimed that no less than 90 per cent, of these pyschoses 
 are maniacal in type. But, as has already been mentioned, much which passes 
 under the name of mania is hallucinatory insanity, and this is especially true of 
 puerperal mania. This affection supervenes with prodromes of hallucinatory 
 character which affect the patient's mind and cause certain peculiarities of 
 disposition and temper. At the same time insomnia also develops. Clin- 
 ically the expression of the affection comprises an attitude of suspicion and 
 hostility to others, which often extends to the person of the child. Suicidal and 
 homicidal impulses are to be feared. Side by side with the mental aberration 
 we often see characteristic physical changes, such, as suppression of the lochia 
 and milk, poor circulation, constipation, etc. But grave affections like peri- 
 tonitis are sometimes hidden by the psychosis, or, in other words, we may have 
 to deal with a delirium secondary- to some local infiammation or general sepsis. 
 
 Prognosis. — While recovery is the rule, fatalities are by no means rare, in- 
 cluding deaths from terminal dementia. In the fatal cases the cause of 
 death is usually exhaustion, and this termination is said to be common in 
 cases which have the appearance of acute delirium, due to some local or 
 general affection. Many cases are so mild that recovery ensues after a good 
 sleep. In some instances we see recurring insanity with lucid intervals, and a 
 tendency to ultimate recovery. If a favorable termination does not result, the 
 case becomes chronic, with one of three or more possible terminations: ultimate 
 recovery under proper management, terminal dementia, or paranoia, — the two 
 latter incurable. A high pulse-rate is a bad prognostic sign with regard to early 
 fatality. The special prognosis of late puerperal psychoses is good, although 
 the duration is said to be longer than in the early forms. 
 
 Insanity of Lactation. — Not much need be said of this type of maternity- 
 insanity. Psychoses which develop after the puerperal period have received 
 this designation. They may be classed, from the etiological standpoint, as 
 psychoses of exhaustion, having the same exciting causes, symptoms, and prog- 
 nosis as the late puerperal psychoses, from which they can with difficulty be 
 separated. 
 
 Treatment. — In cases due to sepsis the infection must first be carefully treated 
 
SKIN DISEASES— SUDDEN DEATH IN THE PUERPERIUM. 773 
 
 (See page 752.) Sedatives will be needed for the maniacal symptoms, and during 
 the whole course of the disease the patient must never be left alone, for fear that 
 she may do herself injury. As in the insanity of pregnancy, the advice of an 
 alienist should be sought. (Compare Insanity of Gestation, page 332.) 
 
 XIII. SKIN DISEASES. 
 
 1. Sudamina. — This is a trivial affection which appears in infectious diseases 
 as well as in the lying-in period. Vesicles containing a clear, crystal-like fluid 
 appear scattered over the abdomen. They are generally not accompanied by 
 inflammation, break readily, and leave a lightly scaling surface. They owe 
 their appearance to a retention of sweat, the ducts being blocked by swelling 
 of the epidermis which surrounds their lumen. Treatment is hardly necessary, 
 but an astringent lotion, such as calamine and zinc in lime-water, may hasten 
 resolution. 
 
 2. Eruptions of Septic Infection. — In addition to those diseases which are due 
 to direct infection of the skin itself, such as impetigo and erysipelas, there are a 
 number of eruptions caused by lodgment in the skin of pus organisms from 
 internal foci. Their diagnosis is very materially aided by concomitant symp- 
 toms, an infected uterus, the characteristic temperature movement, arthritis, 
 endocarditis, and all the clinical evidences of pyemia. The cutaneous signs vary 
 greatly. They may consist of an erythema only, or a patch of redness irregular 
 in outline on which is seated a number of pustules in various stages of transforma- 
 tion into crusts. The erythema may fade on pressure or it may not, owing to 
 the presence of hemorrhage. Purpura may be the only sign. There is a septic 
 pemphigus in which bullae occur on all the surfaces except the palms, soles, face, 
 and mucous membranes. 
 
 XIV. GENERAL DISEASES. 
 
 The puerperal woman is quite as susceptible to the influences of the general 
 diseases as her non-puerperal sister, if not more so. One must bear in mind, 
 however, that all such diseases are modified somewhat by the peculiar con- 
 ditions of the puerperal state, and also that there is the possibility in all 
 instances of a mixed infection. These general diseases have already been 
 considered in the section on Puerperal Morbidity, page 741, Part VII. 
 
 XV. SUDDEN DEATH IN THE PUERPERIUM. 
 
 Sudden death during the puerperal period must naturally include all causes 
 enumerated under the head of Sudden Death during Labor (page 669), since 
 death may not occur until after delivery. But if very soon after the com- 
 pletion of labor, should be ranked in the class with death during labor. There 
 are also some cases in which the act of labor is not so likely to provoke death 
 as is the puerperal state. Thus, after delivery a diabetic patient may pass 
 into the condition of diabetic coma; a patient with contracted kidneys or tuber- 
 culosis may develop cardiac paralysis, etc. Again, the mischief may be due 
 
774 
 
 PATHOLOGICAL PUERPERIUM. 
 
 primarily to the act of labor itself, death being deferred until the puerperal 
 period. In hemorrhages of all kinds this happens from the profound anemia 
 induced by the loss of blood. Air embolism is of more infrequent occurrence, 
 but is also deserving of special study. 
 
 Frequency. — Sudden death in the puerperal state is by no means rare. Porak 
 was able to report before a meeting of the Paris Obstetrical and Gynecolog- 
 ical Society * four cases which had occurred within a relatively short interval. 
 The causes were as follows: chronic heart disease, profound anemia following 
 hemorrhage, air embolus following an intrauterine injection, and embolism of 
 the pulmonary artery. 
 
 General Etiology. — Conditions of sufficient importance to require individual 
 discussion are shock, heart disease, embolism, air embolism. It is necessary to 
 
 consider these conditions sep- 
 
 VENA CAVA 
 
 SPERI/ATK 
 
 HTPOCASTRIC 
 
 OVARY 
 
 arately in order to note the 
 various indications for treat- 
 ment. 
 
 I. Syncope and Shock. — 
 Syncope is a natural termin- 
 ation of fatal organic heart 
 trouble, embolism, air embol- 
 ism, etc. After excessive loss 
 of blood a condition of syn- 
 cope is also a logical pheno- 
 menon. But we encounter 
 fatal syncope at times in pa- 
 tients who have lost no blood, 
 and who present at autopsy 
 no evidence of embolism, 
 thrombosis, or air in the 
 blood, and who have no val- 
 vular heart disease. Some of 
 these women doubtless suffer 
 from a certain amount of de- 
 generation of the myocar- 
 dium. In death from shock 
 the fatal termination does not 
 supervene so early as in car- 
 diac paralysis. The patient 
 enters into a state of collapse with rapid and feeble pulse, cold and moist 
 skin, pallor, etc. While shock follows naturally from loss of blood, operative 
 intervention, we also observe it in physiological labor in the highly sensitive 
 woman. The mere emptying of the uterus may produce this condition, doubt- 
 less from the sudden lowering of the intra-abdominal pressure. Treatment: 
 The management of syncope and shock is practically the same in each affection. 
 Stimulants, such as brandy, ether, strychnin, and camphor, and similar remedies 
 hypodermically with brandy and ammonia by the mouth, are to be employed, 
 with nitrite of amyl inhalations. The foot of the bed should be elevated and 
 the body surrounded by dry heat. Oxygen may be administered. It must be 
 remembered that syncope is not necessarily a dangerous condition, but may be 
 little more than an ordinar}^ fainting attack with a tendency to spontaneous 
 recovery. 
 
 * " Le Bulletin Medical," Dec. 14, 1898. 
 
 Fig. 978. — Aseptic Thrombosis of the Uterine and 
 Para-uterine Veins in the Normal Puerperium. 
 
SUDDEN DEATH IN THE PUERPERIUM. lib 
 
 2. Pulmonary Embolism. — This affection may occur during any of the phases 
 of maternity: pregnancy, parturition, the puerperium, and the post-puerperal 
 period. Ehology: Pulmonary embolism in the course of pregnancy is due, 
 doubtless, to detachment of a portion of a thrombus in a uterine sinus, which 
 affection in turn is to be attributed to a partial detachment of the placenta, 
 and is sometimes seen as a result of attempts to produce premature delivery. 
 Embolism after delivery may also be attributed in part to a uterine 
 thrombosis, but the development of a thrombotic state of the pelvic, iliac, 
 and crural veins is doubtless the remote cause of most of the cases of pul- 
 monary embolism occurring in the puerperium. In other words, the predis- 
 posing causes of pulmonary embolism in the various phases of maternity are 
 comprised under the head of the causes of maternity-thromboses. Exciting 
 causes which determine the production of embolism from thrombosis are some- 
 times evident. The phenomena of embolism have occasionally followed par- 
 oxysms of coughing, the act of rising in the bed, and efforts at defecation. 
 But such are not necessary for the detachment of a portion of a thrombus. The 
 clot of blood may be extremely friable, and this is especially true in septic cases. 
 Symptoms: Pulmonary embolism expresses itself clinically by well-marked 
 types, depending on the degree of obstruction within the pulmonary circulation. 
 In the fulminant or apoplectic type the patient immediately drops dead. In a 
 less severe type there is a brief interval of irregular pulse, dilated pupils, and 
 dyspnea before death supervenes. A third type, while fatal, may not destroy 
 life for some hours. The symptoms begin with anxiety, a marked degree of 
 dyspnea, and restlessness, the patient passing quickly into a state of collapse, with 
 an icy feeling, and a vanishing pulse. The mode of death in these cases is acute 
 pulmonary edema. The preceding types are necessarily fatal by reason of the 
 large calibre or the number of the obstructed vessels. In a second class of cases 
 the affection, while severe, is not necessarily fatal. The symptoms agree closely 
 in character with those produced by shock. There are a cadaveric pallor, a 
 pulse barely distinguishable, and extremities of icy coldness. In a small pro- 
 portion of cases premonitory symptoms of embolism occur. Sudden diminution 
 in the volume of a milk leg should be sufficient to awake anxiety in the mind 
 of the medical attendant. One obsei-ver (von Herff) has had this warning in 
 two of his personal cases. Other premonitions have been noted — pain in 
 the left shoulder-joint, angina pectoris, etc. Diagnosis: The recognition of 
 pulmonary embolism is often very difficult or for an inexperienced practitioner 
 even impossible. Even experts may be deceived, and it is related that a 
 specialist of immense experience in this field once diagnosticated pulmonary 
 embolism as ruptured tubal pregnancy with fatal hemorrhage. The symptoms 
 pointing to the lungs are not well defined, for if the embolism is sufficient for the 
 production of dyspnea and cyanosis, the picture of collapse develops. If the 
 patient is not destroyed quickly by the disease, the symptoms of hemorrhagic 
 infarction develop which should be easy of recognition. Prognosis: The prognosis 
 can be discussed only from the standpoint of the chances of ultimate survival 
 after the patient weathers the first shock of the disease. (See Hemorrhagic 
 Infarction.) Treatment: There is no treatment for the fulminant type of tlie 
 affection. If the patient survives the first onset, she should be treated for the 
 coincident shock by rest, hot applications, and cardiac stimulants. In order 
 to prevent the deposition of fresh emboli in the lungs, absolute rest is indi- 
 cated and should be continued for weeks. 
 
 3. Primary Thrombosis of the Pulmonary Arteries. — Embolism from fragments 
 of coagula is by no means the sole lesion of this sort encountered in connection 
 
776 PATHOLOGICAL PUERPERIUM. 
 
 with maternity, for primary thrombosis may develop in the arteries of the lungs 
 in cases in which puerperal phlebitis and thrombus are absolutely non-existent. 
 In past years the question of the relative frequency of primary and secondary 
 thrombosis has been actively debated. Some have gone so far as to state, with 
 Playfair, that the majority of cases are primary rather than secondary. A 
 third variety of thrombus may be due to clotting in the right heart, a detached 
 portion of the coagulum plugging the artery; but practically we may regard 
 such a case as primary, restricting the term secondary to cases in which the 
 parent thrombus forms in a pelvic vein. The consensus of opinion is that 
 primary thrombosis of the pulmonary arteries during the puerperium is a rare 
 occurrence, and that the great majority of cases of sudden death from obstruc- 
 tion of the pulmonary arteries are due to embolism. Clinically there is no 
 method by which primary and secondary cases may be differentiated. 
 
 4. Air Embolism. — This accident, which may occur either during or after 
 labor, is by no means as common as pulmonary embolism proper, but doubtless 
 ranks as the next most frequent cause of sudden death in connection with 
 maternity. Definition: Air embolism is simply a form of pulmonary embolism 
 in which the blood-vessels are obstructed by air bubbles which have found their 
 way into the circulation through the uterine veins. Etiology: For air embolism 
 to occur there are required a number of factors acting in concert. Air must have 
 entered the uterine cavity from without (or gas must have been formed within) ; 
 the uterus must be uncontracted; the uterine sinuses must be patulous; and, 
 finally, a certain amount of air must have obtained access to the circulation, 
 since the ingress of a small quantity may not give rise to embolism. For air to 
 enter the uterine sinuses before delivery, the placenta would have to be detached 
 prematurely to a greater or less extent. This accident has actually happened 
 before labor in connection with attempts to induce premature delivery. In 
 cases of this sort the relation of cause and effect is very apparent ; since the air 
 which is often injected with the water by a bulb syringe may pass directly 
 into the circulation. Air may doubtless enter the birth tract from the 
 difference in the pressure within and without the abdomen, its ingress being 
 favored by a patulous condition of the vulva, such as exists immediately after 
 delivery, and by all kinds of manual and instrumental intervention. The re- 
 laxation of the uterus which follows a pain should also be enumerated among the 
 possible factors in the aspiration of air by the uterus. The air which enters the 
 circulation may not proceed from without, since it may be generated in the uterus 
 as the result of the death and putrefaction of the fetus, and enter the veins 
 only after removal of the latter with the placenta. The symptoms are entirely 
 similar to those of pulmonary embolism in general. Treatm.ent: As in the case 
 of ordinary thrombotic embolism, the management consists in prophylaxis and 
 in the treatment of the pulmonary lesion per se in case the patient survives. 
 Prophylaxis consists in the greatest care in all procedures whiqh might possibly 
 introduce air into the vagina or uterus, such as the induction of labor, vaginal 
 and uterine irrigations, and the introduction of the hand for various operations 
 The secret of the prophylaxis, aside from the foregoing, is a firm grasp upon 
 the fundus and uterine body before and during all vaginal and uterine manipu- 
 lations. 
 
PART EIGHT. 
 The Physiology of the Newly Bom* 
 
 I. GENERAL PHENOMENA. (Page 779.) Establishment of Respiration, 
 Changes in the Fetal Circulation. Umbilical Stump and Ring. Tem- 
 perature. Pulse. Meconium. Feces. Urine. Digestion. Liver. Heart. 
 Blood. Weight. Signs of Normal Nutrition. Breasts. Shape of Head. 
 Sutures and Fontanelles. 
 
 II. HYGIENE AND MANAGEMENT OF THE NEWLY BORN. (Page 785.) First 
 Care. The Bath. Care of Cord. Dressing the Child. Infant Feeding. 
 (1) Maternal Nursing. (2) Wet=nurse. (3) Artificial Feeding. (4) Pat- 
 ented or Proprietary Foods. Open Air. Sleep. Bladder and Bowels. The 
 Nursery. Environment. Weaning. 
 
I. GENERAL PHENOMENA. 
 
 Establishment of Respiration. — Until the fetus has ended its stay in uiero 
 and is finally expelled into the outer world, its lungs are normally in a condition 
 of complete atelectasis. The first respiration, however, is accomplished as soon 
 as the fetus has entered the external atmosphere. Notwithstanding the many 
 theories advanced, respiration is probably not caused by any one agent 
 alone, but by the combined influence of at least two important conditions 
 affecting the respiratory center in the medulla oblongata. The first and most 
 important is stimulation of the respiratory center through the nervous system, 
 and, secondarily, stimulation of this center through changes in the fetal blood. 
 For the sake of convenience we consider the latter first. Changes in the fetal 
 blood are brought about by a shutting-ofE of the oxygen supplied to the fetus ; 
 for the strong and tonic contraction of the uterus immediately following fetal 
 expulsion constricts, if it does not entirely occlude, the placental blood-vessels 
 which have carried on intrauterine respiration. As a result of this, the supply 
 of oxygen through the umbilical vein, which has furnished the fetus an abun- 
 dance, is cut off. Following this stoppage a proportionately larger amount of car- 
 bonic acid accumulates in the fetal circulation, as, for the same reason that the 
 oxygen supply is lost, carbonic acid gas absorption by the placenta is also shut 
 off. Carbonic acid gas greatly stimulates the center of respiration and respiratory 
 action is established. The cause is occasionally illustrated as acting singly by the 
 efforts of the fetus to respire before birth. The fetus leaves a liquid cushion with 
 a temperature of 99° F. and quickly passes into the air of the lying-in room, usually 
 at a temperature of 70° F., or 29° F. lower. This change produces an irritation 
 of the skin, the shock of which is alone sufficient to cause a reflex action of the 
 muscles, and a stimulation of the respiratory center. This fact is illustrated 
 by our ability to induce respiratory effort in cases of suspended respiration in the 
 newly bom by the skin irritation caused when we immerse an infant alternately 
 in hot and cold water, after the accumulation of carbonic acid gas in the blood 
 fails to stimulate the respiratory center. It is easy to conceive of this mechanical 
 irritation being alone sufficient to produce respiration, and therefore that this is 
 the first great cause. With the first respiration the muscles both of ordinary' 
 and extraordinary respiration are brought into action, as shown by the lusty cry 
 usually uttered at the moment of birth. By this too, the chest-walls, before 
 unexpanded,* expand and remain so; the diaphragm is drawn up, the muscles 
 of the nose and throat become active, and the physiological function of respira- 
 tion is thoroughly established. The rate of respiration at birth varies physio- 
 logically between 40 and 45, being a little more frequent in females than in males, 
 as in after life, and a little less frequent in large robust infants than in weakly 
 ones. The breathing in the infant is almost entirely abdominal, as the dia- 
 phragm is the chief muscle causing it, the chest-walls and intercostal muscles 
 taking very little part after the first few respirations, until later in life. Auscul- 
 
 * According to Ballantyne, rhythmic movements of the thorax occur in utero. This 
 abortive activity may be due to a precocious action of the respiratory center. 
 
 779 
 
780 THE PHYSIOLOGY OF THE NEWLY BORN. 
 
 tation of the newly bom reveals the presence of fine crepitant rales as the lungs 
 expand. 
 
 Changes in the Fetal Circulation. — Concomitant with the establishment of 
 the first respiratory action, there occurs a change in the fetal circulation, as the 
 oxygenation is no longer carried on through the placental circulation. This is 
 now accomplished by pulmonary respiration in the infant. As the placenta is 
 now useless, the functions of the omphalic vessels no longer exist, and the circu- 
 lation connected with them ceases. In order clearly to understand these changes, 
 it is important that the fetal circulation should be thoroughly understood. (See 
 page 79.) Coincident with the first respiration the blood is diverted from the 
 umbilical vessels, and is at once, — by aspiration, as it were, — following the draw- 
 ing up of the diaphragm and expansion of the chest walls, carried through the 
 pulmonary arteries and distributed by its capillary terminals to the vessels of the 
 lungs. By this sudden change in the chief fetal blood-currents, equally important 
 changes occur in the circulatory apparatus itself. The abdominal continuations 
 of the umbilical vessels close and by thrombosis and atrophy become organized 
 into strong, hard, fibrous cords. There being no propelling force of blood through 
 the ductus arteriosus, it also closes. The blood, instead of being directed through 
 the foramen ovale by the Eustachian valve, now passes into the right ventricle, 
 and hence the usefulness of the valve and foramen is lost, the foramen closes, and 
 the valve contracts. From the right ventricle the blood is forced into the pul- 
 monary artery, and as there is no longer excessive pressure in it — as the capillary 
 terminals in the lung are open — there is not the tendency of the blood to pass 
 on into the aorta through the ductus arteriosus, the current to the lungs being 
 no longer dammed back upon the pulmonary artery and this duct. The duct 
 therefore collapses or contracts. By thrombosis here also organization begins, 
 and in later life the duct is distinguishable only as a round cord. The blood is 
 both forced and aspirated into the lungs through the pulmonary artery. From 
 the lungs it is returned reoxygenated to the left auricle through the pulmonary 
 veins, and is then ready to furnish nourishment to the entire economy. It 
 is therefore pumped into the left ventricle through the auriculo-ventricular 
 orifice, and thence into the great blood-main of the body, the aorta, whence it 
 is distributed through the branches, terminals, and capillaries. That these 
 changes are anticipated during fetal life is shown by the fact that the ductus 
 arteriosus and ductus venosus do not increase in size in the same ratio as the 
 aorta, venae cavae, etc. 
 
 Umbilical Stump and Ring. — A line of demarcation appears at the base of the 
 umbilical stump at the end of twenty-four hours ; necrosis of the covering of the 
 cord and mummification of the jelly of Wharton follow (Figs. 979, 980, 981). 
 The remains of the umbilical vein and arteries are gradually destroyed. The 
 line of demarcation deepens and the stump falls at about the fourth day (Fig. 
 981). Retraction of the granulating remnant of stump within the umbilical ring 
 follows and is apparently complete about the tenth day (Fig. 982). The umbil- 
 ical ring is merely the opening in the abdominal wall around which the cord 
 substance is fastened and through which the umbilical vessels pass. There is 
 a distinct line of division from the cord substance, about a fourth to a third of 
 an inch from the abdominal wall, which pouts to form the ring. This line, 
 which also marks the point of separation of the cord, is distinguished from 
 the soft, gelatinous, pearly-white substance of the placental end of the cord as 
 a red ring formed of a network of capillary blood-vessels covered by a very 
 thin, delicate skin. The ring, after the falling off of the cord on the fourth or 
 fifth day, leaves a healthy granulating surface which soon cicatrizes (Fig. 982). 
 
P-I < 
 
 H Q 
 
 CO ;c5 
 
 O 
 
 < w 
 uco 
 
 
 
 P 
 
 <5 
 
 1 
 
 Q 
 
 « 
 
 
 .c< 
 
 p^ 
 
 fe 
 
 p^ 
 
 t: z 
 
 o 
 
 w 
 
 Z 
 
 > 
 
 < 
 
 lj 
 
 
 w 
 
 Pj 
 
 § 
 
 p 
 
 t5 
 
 « 
 
 E-i 
 
 w 
 
 CO 
 
 H 
 
 
 fe 
 
 hJ 
 
 < 
 
 < 
 
 
 U 
 
 t« 
 
 13 
 
 
 M 
 
 o 
 
 ^ 
 
 i-M 
 
 H^ 
 
 > 
 
 
 
 '. 
 
 W 
 
 c^ 
 
 fe 
 
 o\ 
 
 
 
 < 
 
 Pi^ 
 
 
 COU 
 
 pt. 
 
• GENERAL PHENOMENA. 781 
 
 Owing to this cicatricial contraction and to the shortening of the intra- 
 abdominal remains of the umbilical vessels, the ring sinks into the abdominal 
 wall to the depth of a fourth or a third of an inch as a small, puckered scar, 
 and remains thus through life as the navel or umbilicus. This is always wider 
 and deeper in the female than in the male. 
 
 Temperature. — At birth the fetal temperature varies slightly, averaging 
 about 99.5° to 100.5° F. This is about 0.5° to 1° higher than the vaginal tempera- 
 ture of the mother. It is what would be expected, as the fetus has been en- 
 compassed in the uterus by a liquid cushion at the internal maternal temperature 
 of 99° F., which can take up very little of the temperature of the fetus, as 
 radiation from this liquid must be slight. Hence the metabolic changes occur- 
 ring in the growing fetus are sufficient to keep its temperature about 1° F. higher 
 than the maternal temperature. Soon after birth the temperature has fallen 
 about 1.8°, but again reaches the normal infant temperature of 99.4° F- in about 
 twenty-four hours. The temperature varies irregularly during the first few 
 weeks of life, being elevated sometimes even 0.5° by prolonged and vigorous cry- 
 ing, and dropping 0.6° to 1° during sleep. 
 
 Pulse. — The pulse-rate in the newly born varies between 130 and 140 per 
 minute, depending upon the activity and robustness of the child, also being 
 slightly faster in a healthy female than in a male. As has been stated, the respi- 
 rations are much more rapid and shallower in the infant than in later life, and 
 the temperature is higher. An increased pulse-rate would consequently result. 
 This rate varies greatly physiologically, being increased from 20 to 30 beats per 
 minute by muscular activity from any cause, such as crying or being raised 
 from the recumbent to the upright posture. Great excitement sometimes 
 increases its frequency and also its force. It may in perfect health, especially 
 when very rapid, be very irregular physiologically. As throughout life, it 
 varies in proportion to the respirations and temperature, though much more 
 irregularly. 
 
 Meconium ; Feces. — A study of the stools in infancy is valuable not only on 
 account of the information it gives concerning the alimentary processes, but also 
 because it determines in a great degree the necessary strength and quantity of the 
 infant's food. Besides, it aids us in determining the nature of many of the 
 disturbances so frequent at that period of life. The newly bom infant passes 
 stools greenish-black in color, known as meconium, composed of mucus, bile, 
 vernix caseosa, epithelium, hair, fat crystals, phosphates, and bacteria. After the 
 fourth or fifth day the stools of a baby fed upon milk alone, whether from breast 
 or bottle, should be yellowish, pasty in consistency, of acid reaction, and not 
 disagreeable in odor. The color is due to bilirubin and the reaction to lactic 
 acid, the source of which is the milk sugar. Mucus and epithelium are always 
 present. Miller, who has carefully studied the various micro-organisms in the 
 mouth, found that the majority of them could again be located in the intestinal 
 canal. In the feces, two germs. Bacterium lactis aerogenes and Bacterium coli 
 commune, are the most important. In the first two weeks the stools number 
 from three to six each day; after the first month they vary from one to three 
 daily — the average being two each day. Later in infancy, when other articles 
 are added to the milk diet, the stools, while remaining soft and watery, become 
 darker in color and contain a greater variety of bacteria. The gases present are 
 hydrogen (H) and carbon dioxide (CO.), the adult odor being acquired later, 
 due to the presence of hydrogen sulphide (H.S). The bulk of the stool is com- 
 posed of about 85 per cent, water, and fat varying in amount from 2 to 4 per 
 cent. Pathologically the stools may assume one of a variety of colors and con- 
 
782 THE PHYSIOLOGY OF THE NEWLY BORN. 
 
 tain any of a long list of materials. Green stools are of very frequent occurrence. 
 When very acid or thin, they often cause irritation of the buttocks and are 
 accompanied by colic. The green color is due to pre-formed bilirubin. These 
 stools usually contain more or less undigested casein and fatty acids. Stools 
 varying in color from pale greenish-yellow in the early stages to grass green later, 
 are seen in cases of acute intestinal indigestion, the result of improper feeding 
 An excess of sugar causes thin, acid, green stools. Bismuth, tannic acid, and 
 the iron salts color the stools from deep brown to black. Blood gives the char- 
 acteristic tarry stool when the blood is admixed higher up in the intestinal 
 canal; when lower down, it is brighter red in color. An excess of mucus indi- 
 cates some inflammatory condition of the large intestine. Light or light gray 
 stools of a pasty consistency, or in dry balls, contain an excess of fat and are 
 usually offensive in odor. When proteids are in excess or too much food is 
 given at a time, curds appear in the stools, sometimes with diarrhea, but more 
 often with constipation and colic. Curds are especially liable to occur in infants 
 fed upon cow's milk, particularly when sterilized. 
 
 Urine. — As a rule, almost immediately after birth the infant voids urine 
 at or just before the time it passes meconium. It is of 
 a slightly urinous odor, aqueous in color, markedly acid, 
 specific gravity 1004 to loio, containing an unusual 
 amount of albumin in t,7, per cent, of cases, a few 
 granular and numerous hyaline casts, an inordinate 
 amount of uric acid, and frequently some sugar. These 
 ^^^. ?f ^tTT.Vc^^^^ rSf ^J are all characteristics of the urine of the newlv born. 
 
 TRAL iNCISOR 1 OOTH . - 
 
 Extracted with In a short time, varying from three days to three months, 
 Thumb-forceps from these change. In about three days the specific grav- 
 AN^NFANT ^^^^ ^Ys ^^^ drops to from 1003 to 1006, the albumin disappears 
 terfered with nursing with the casts, epithelium, and excessive mucus ob- 
 by causing an erosion served at first. The urine is passed frequently during 
 at the Eimrgency Hos- ^^^ waking hours, but less frequently during sleep. 
 pital.) Normal urine should not stain the napkin. 
 
 Digestion. — As milk contains all the nutritive prin- 
 ciples found in the various foods ingested by the adult, we would expect to find 
 in the infant the numerous digestive agents necessary in adult life, and such is 
 the case, though they are present in smaller quantities. Besides these, there is 
 in the stomach, in proportionately larger quantity than in adults, a ferment 
 especially adapted to the infant food, known as the rennet ferment, the 
 action of which is to curdle milk on its entrance into the stomach. As the 
 milk rapidly passes through the mouth during nursing, there is very little 
 use for saliva, with its power of changing starch into sugar. The milk 
 having been sucked into the mouth, it is swallowed at once. Owing to the 
 small amount of saliva, and consequently of ptyalin, and also of the deficiency 
 of the pancreatic secretion, provision for the digestion of starches is lacking 
 in young children. The practical application of this fact will be noted in con- 
 nection with infant feeding. With the above exception infantile digestion is 
 accomplished in the usual way. It is aided, however, by the presence of bac- 
 teria in the alimentary canal. As soon as milk enters the stomach the rennet 
 ferment causes a soft flocculent curd to be formed. This is the chief part of 
 gastric digestion in the infant, as the pepsin and hydrochloric acid begin to 
 digest this curd only when it is passed on into the intestine. It will be remem- 
 bered in this connection that in the newly bom the stomach serves more the 
 part of a reservoir than of a digestive organ. The proteids have been partially 
 
u 
 
 ;o 
 
 pq 
 
 > H 
 
 O 2 
 
 — X 
 
 X ^ — 
 
 r a is 
 
 ::j 
 
 fe 
 
 1^ « ^ 
 oc o b; 
 C7. i: ,-> 
 
 fe 
 
 h 
 
 
 hH < 
 
 8< £ 
 
 ^- i A ^ 
 
 g^E § 
 
 22 ,_■; i- ■" 
 
 a ^ K — 
 
 - s ^ j; 
 
 •J r < o 
 
 I xS H 
 
 ON.-*^ fcj 
 
 c 
 
GENERAL PHENOMENA. 
 
 783 
 
 Fig. 988. — Two Middle 
 Lower Incisors. Ap- 
 pear third to tenth 
 month; average, 
 seventh month. 
 
 changed into peptones and some absorption has taken place. Having been 
 poured into the intestinal tract, the milk is here brought in contact with the pan- 
 creatic secretion, which contains all the ferments necessary for converting more 
 completely the proteids into peptones, for emulsifying fats, and for changing 
 starch into sugar. Here, too, it is brought in contact with the bile from the 
 liver, which further helps to emulsify the fats. These fats are principally 
 absorbed from the small intestine, as are also the peptones, salts, and sugar; the 
 glands of the large intestine are as yet imperfectly developed, hence its absorb- 
 ing power is slight. 
 
 Liver. — At birth it is well to remember the very large size of the liver in 
 proportion to the body, it being about one-thirtieth 
 the entire body-weight. This is readily understood 
 when it is remembered that the liver and the head are 
 nourished in fetal life by the practically pure freshly 
 oxygenated blood, and consequently these parts are well 
 developed. Immediately after birth the secretion of 
 bile is lessened because of the diminished blood-supply to 
 the liver. Pressure upon the hepatic veins is lessened. 
 During exfoliation of the stump of the cord the capsule 
 of Glisson may become swollen. 
 
 Heart. — At birth the heart is relatively larger in com- 
 parison with the body-weight than at any other time of 
 life. The walls of the two ventricles are found to be 
 nearly of the same thickness, for the two sides of the 
 heart have been doing about the same amount of work. 
 At birth the work thrown upon the left ventricle 
 is greatly increased, in comparison with the right, 
 hence the left increases in thickness more rapidly, and 
 later in life we find- that it has reached the proportion 
 of about 2 : i instead of about 6 : 7 as at birth. The 
 heart's action is much more frequent at birth than 
 later, being also more frequent and less regular in 
 females than in males. Its position is not so oblique as 
 in the adult. The apex impulse is farther to the left 
 than later in life, and usually for the first few days is 
 just outside the mammary line in the fourth intercostal 
 space. The sounds are much louder comparatively 
 than in adult life, owing to the thinness of the chest- 
 walls and the greater area of cardiac dulness — the lung 
 not overlapping the heart to so great an extent. 
 
 Blood. — At birth the proportionate amount of blood 
 is less than in the adult, averaging about iV the body-weight, while later in life it 
 is about xV- This varies in the newly bom, depending largely upon the time 
 when the umbilical cord is tied. In immediate ligation the weight may be 
 only Ys, while if ligation is postponed until cessation of pulsation in the cord it 
 may be even greater proportionately than in the adult, often being as high as 
 tV the body-weight. While the specific gravity and hemoglobin are higher, and 
 the proportionate number of red and white cells is greater, and the proportion 
 of white cells to red is also increased, — about i : 160, — the blood is thinner, 
 more watery, contains less fibrin, and therefore does not coagulate or clot so 
 readily as adult blood. There is also a much greater variation in the size and 
 appearance of the blood-corpuscles, as the blood-glands continue to form new 
 cells in greater quantities for about three days. 
 
 Fig. 989. — Four Upper 
 Incisors. Appear 
 ninth to sixteenth 
 month. 
 
 Fig. 990. — Order op 
 THE Eruption op the 
 Eight Incisors (Milk 
 Teeth). 
 
784 THE PHYSIOLOGY OF THE NEWLY BORN. 
 
 Weight. — At full term an average fetus weighs about 7.3 pounds. The 
 weight varies largely, as would be expected, depending on numerous influences 
 which it is well to mention: (i) Depending upon the parents, (a) The size of 
 the parents seems to influence somewhat the size of the infant; infants bom of 
 parents of large stature are, on an average, larger than those whose parents are 
 small, (i) Strong, healthy parents may also expect larger children than do those 
 in feeble health, (c) The age of the mother seems to influence the size of the 
 infant, — women between twenty-four and thirty-four bearing the largest children, 
 as this is the prime of motherhood, {d) Parity. The offspring of primiparae 
 average less in size and weight than those of multiparge. Also, each fetus seems 
 to weigh a little more than the preceding one when sufficient time elapses be- 
 tween births, {e) Frequency of child-birth greatly influences the size of the 
 fetus, as in pregnancies rapidly following one another each succeeding child 
 is less robust. (2) Sex. Males average a greater weight than females. There 
 is for three days a continuous loss in weight, due partly to the frequent 
 discharge of urine and feces, but largely to the excess of tissue waste over 
 tissue reconstruction. This averages about 11 per cent, of the body -weight. 
 The weight is gradually regained, however, from the third day on, and by the 
 tenth day has reached the weight at birth. This steady increase should there- 
 after continue uninterruptedly in a healthy child. 
 
 Signs of Normal Nutrition. — The end of the first week of life generally finds 
 an infant at the weight accredited to it at birth; the slight loss attendant upon 
 the elaboration of the mother's milk during the first three or four days is made 
 up at the end of the first week. After this period the weight of a properly 
 , developing infant will increase from 6 to 8 ounces each week, or, roughly speak- 
 ing, an ounce a day for the first two or three months. At the end of the fifth or 
 sixth week this gain is slightly lessened, but it is steady. Taking seven pounds 
 as the average weight of an infant at birth, it should weigh fourteen pounds at 
 the end of the first five months and twenty-one pounds at the end of the first 
 year. 
 
 TABLE SHOWING THE GAIN IN A HEALTHY INFANT FED AT THE BREAST 
 
 Normal weight at birth, 7 lbs Gain at end of first week, none. 
 Weight when 2 weeks old, 7 lbs. 6 oz. " " 2d " 6 oz. 
 
 3 " "7 lbs. 14 oz. " " 3d " 8 oz. 
 
 " " 4 " "8 lbs. 6 oz. " " 4th " 6 oz 
 
 In a breast-fed infant when the weight does not increase, the milk should 
 be examined to determine which ingredient is at fault. Any failure to gain 
 steadily in a baby fed upon modified milk warrants a change either in the quan- 
 tity or the strength of its food. Besides the gain in weight, which emphasizes 
 more strongly than any other factor that the baby is thriving, its general con- 
 dition, whether it is comfortable, its sleep quiet and sufficient, the stools, with 
 their number, color, and consistency, should be taken into consideration. It 
 is not a rapid but a steady gain in weight which is all-important. 
 
 Breasts. — At birth the breasts of the infant are sometimes found to be com- 
 paratively large, swollen, and secreting. This secretion is greatest usually at 
 the end of the first or beginning of the second week. At this time the glands 
 are increased in size, red, with elevation of temperature, rather hard, and very 
 sensitive. The vessels are turgid and the whole merely presents a picture of a 
 functionating gland (Fig. 970). Normally this secretion continues only for 
 about two weeks, but may be found much later, the secretion itself being about 
 the same in appearance as the mother's milk. The amount of secretion is the 
 
HYGIENE AND_ MANAGEMENT OF THE NEWLY BORN. 785 
 
 same in the two sexes, it being merely a physiological gland activity. No harm 
 commonly results, but all manipulation or attempts to express secretion should 
 be forbidden, since they may result in the development of an abscess. (See Part 
 IX.) 
 
 Shape of Head. — After moderate moulding during labor, the head usually 
 resumes its normal shape in four or five days. In the excessive moulding of per- 
 sistent occipito-posterior positions, in temporary mento-posterior positions, and 
 in presentation of the anterior parietal bones (Naegele's obliquity) a return to the 
 normal contour may be delayed as long as two weeks or more. I have tracings 
 of the head taken at birth in the first and second of the above positions, and also 
 one and two weeks after delivery, showing the tardy return to the normal. The 
 caput succedaneum rapidly disappears even when extensive. Change in shape 
 largely due to a cephalohematoma may persist for two or three weeks, or until 
 the blood-clot is absorbed. (See Part IX.) 
 
 Sutures and Fontanelles. — The edges of the cranial bones are normally in 
 apposition at birth. Separation is commonly due to prematurity, syphilis, or 
 rachitis. Ossification does not usually occur until the end of the sixth month 
 or later. The posterior fontanelle is usually closed about the end of the second 
 month and the anterior about the eighteenth. 
 
 Post-mortem Observations. — These in the infant should include (i) the rela- 
 tively large size of the thymus gland and heart; (2) whether the thymus ob- 
 structs the trachea; (3) whether the lungs are inflated and overlap the heart; 
 (4) the relatively large size of the bladder, sigmoid flexure, appendix, and 
 liver; (5) infection of the hypogastric arteries from a septic umbilical ring. 
 
 II. HYGIENE AND MANAGEMENT OF THE NEWLY BORN. 
 
 First Care of the Infant. — After the cord has been tied and cut and the eyes 
 have been washed with a solution of boric acid, the baby should be wrapped 
 in a soft, warm piece of flannel, laid in some convenient place out of harm's 
 way, and covered with a shawl or other covering, taking care to allow sufficient 
 breathing space. Here it may remain till the mother has received proper 
 attention. It should occasionally be noted that the respirations are regular 
 and that there is no oozing from tne cord (page 489). 
 
 The Bath. — After making the mother comfortable the nurse may attend to 
 bathing the child. The necessary articles have been provided and stand ready 
 for use, in winter near a fire or register. They consist of a. small tub or bowl 
 of water at 95° to 100° F., a soft rag, and a warm, soft towel. The nurse should 
 wear a flannel apron or may have a flannel apron or petticoat spread over 
 her lap. The vernix caseosa is miscible with sweet oil and is best removed 
 by a free use of oil. The infant is then gently sponged with a soft cloth and 
 tepid water. Only a small part of the body is bathed at a time, the rest being 
 kept covered. The bathing is done in the warmest part of the room, before 
 the stove, register, or best an open fire. All manipulations should be gentle, 
 and feeble or premature children should not be washed, the vernix being cau- 
 tiously removed, care being taken that the surface does not become chilled. It is 
 better not to give a tub-bath till the tenth day, as it is something of a shock, 
 and its repetition tends to prevent healing and desiccation of the umbilicus 
 and may result in infection. The usual tendency is toward too much bathing, 
 scrubbing, and exposure. During the first ten days the child should be cleansed 
 50 
 
\ 
 
 >< / 
 
 ^ ^-•' 
 
 •■•N 
 
 a-' 
 
 
 /■•■■■ 
 
 
 r,'yk;..-..S=>d-.-:J7,..,,-. 
 
 -W y{ 
 
 \ 
 
 ■4 
 
 
 / 
 
 / 
 
 X 
 
 \ 
 
 786 THE PHYSIOLOGY OF THE NEWLY BORN. 
 
 daily as above described. Soap should be used moderately, and chiefly about 
 the genitals and axillas. Fine castile soap is to be preferred. Powders are 
 unnecessary except about the genitals and flexures of the joints and folds of 
 skin; powdered starch, talc, or lycopodium may be used. 
 
 Care of Cord. — The cord should be dusted with a non-toxic antiseptic or 
 aseptic powder, as pulverized boric acid or sterile starch, wrapped in borated 
 absorbent cotton, and kept as dry as possible. Since septic infection may occur 
 at the umbilicus, the nurse should carefully disinfect her hands before touching 
 this region. After separation of the cord the umbilicus should be kept per- 
 fectly clean, but not washed more than necessary, and should be dusted with 
 powdered boric acid or sterile starch. 
 
 Dressing the Child. — The infant's clothing should be warm, loose, easily re- 
 moved, and not irritating. The band is unnecessary, and when pinned as tightly 
 
 as is often done, is decidedly injurious by interfering 
 with respiration and leading to defective develop- 
 ment of the abdominal wall. If used, it should be 
 applied loosely, should be of flannel or knitted wool, 
 and should extend from the pubis to the axillary 
 region. The undershirt should be of soft flannel, 
 with high neck and long sleeves, and buttoned all 
 the way so that it can easily be removed. The 
 dress should be of flannel, twenty-five inches from 
 neck to hem, opening in front; over which may 
 be worn a muslin slip, opened behind if desired. 
 
 ■p -n ^„.,, oT,^„/ Long woolen socks should be added and the baby 
 
 Fig. 991. — Diagram show- . => , _. r ^ -, r ,- 
 
 iNG Sterile Gauze Dress- is dressed. Diapers should be of old soft Imen or 
 iNG FOR Umbilical Cord. cotton diapering; they should not be hemmed, as 
 
 this makes little ridges. They should be rough 
 dried, as ironing makes them hard and less absorbent. They should be 
 changed as soon as wet and not used again without washing. If used without 
 washing, they cause chafing. Infants are, as a rule, too warmly clad in 
 summer. The amount and quality of the clothing should be changed accord- 
 ing to temperature, so that sudden chilling of the surface may be avoided. 
 In cold weather it is necessary to protect the baby thoroughly, but if the 
 house is kept at the average temperature of American homes, a more decided 
 difference than usual should be made between the indoor and outdoor garments. 
 
 INFANT FEEDING. 
 
 I. Maternal Nursing. — After delivery is completed and the abdominal binder 
 is applied the patient must be allowed a number of hours of sleep, after 
 which the child may be placed at the breast. The suction exerted by the 
 infant at this time favors the contraction of the uterus, assists in the formation 
 of the first milk, and abstracts the colostrum from the breasts. The latter 
 substance is supposed to exert a favorable influence on the digestive apparatus 
 of the infant. Whenever possible the mother should nurse her own child, 
 since the nutriment thus supplied is unquestionably the most natural and 
 wholesome food in the earliest period of life, and it can be proved that involution 
 is more satisfactory in women who nurse their children. Unfortunately, this 
 is not always possible for a variety of reasons, some of which are due to 
 the strain of modern civilization and abnormal environment, others of which 
 
HYGIENE AND MANAGEMENT OF THE NEWLY BORN. 
 
 787 
 
 depend upon deformity or disease on the part of the mother or child. Some 
 of the most important conditions are, on the part of the mother, syphilis, phthisis, 
 mammary abscess, marked anemia, and depressed or absent nipples; and, on 
 the part of the child, harelip. 
 
 The secretion of milk is usually established in the second twenty-four-hour 
 period after delivery, and it is not necessary to supply any form of nutriment 
 to the child before the expiration of that period, except what it gets from the 
 breast. Warm water, however, should be freely administered. It is a mistake 
 to give milk and water, sugar-water, or any artificial food during this period ; 
 though if proper milk secretion is not established by the beginning of the third 
 day, it may be necessary to begin artificial feeding at least temporarily. Even 
 in the first two days of life it is practicable to feed infants with a modified 
 milk containing a very low percentage of proteids, about 0.25 to 0.5 per cent. 
 Such infants do not lose weight, as is often the case when all food is withheld 
 for this time. (See Treatment 
 of Prematurity, page 802.) 
 When the flow of milk is prop- 
 erly established, the child must 
 be trained to nurse at regular 
 intervals, and it must not be 
 put to the breast every time it 
 cries. The proper intervals vary 
 somewhat according to the age 
 of the child, and may be roughly 
 estimated as follows: Up to the 
 age of six weeks, every two 
 hours between 6 a.m. and 10 
 P.M., and one feeding between 
 10 P.M. and 6 a.m.; from six 
 weeks to four months, every 
 two and a half hours, with one 
 night feeding; from four to 
 nine or ten months, every three 
 hours, without any feeding be- 
 tween 10 p.m. and 6 a.m. Water 
 may be given occasionally be- 
 tween feedings. Each breast must get its share of use, and it is best to 
 alternate regularly. The child should be allowed to nurse for fifteen or 
 twenty minutes and no longer. Irregularity in feeding is a prolific cause of 
 indigestion and flatulence in the infant, and is often the cause of maceration 
 of the nipple, besides being a great annoyance to the mother. If the child 
 shows an inclination to nurse longer than twenty minutes, it indicates that 
 there is a deficient supply of milk in the breast. Failure to nurse satisfac- 
 torily may be caused by placing the child in such a position that it cannot 
 secure a proper hold on the breast and has to seize the nipple obliquely, or 
 the child's nose may be pressed so closely against the breast that breathing 
 may be interfered with and thus satisfactory nursing becomes impossible. 
 These are matters very easily regulated, and though apparently insignificant, 
 should never be neglected. The physician shovild satisfy himself by actual 
 observation that all is being done properly, since carelessness and lack of 
 knowledge are all too common. 
 
 The average composition of average normal human milk is put down thus : fat 
 
 Fig. 992. — Baby Scales. 
 
788 
 
 THE PHYSIOLOGY OF THE NEWLY BORN. 
 
 4.00; sugar, 7.00; proteids, 1.50; alkaline reaction and no bacteria. Variations 
 occur frequently, but between moderate limits are not significant and do not dis- 
 turb the infant's digestion. The quantity of milk raay be increased by attention 
 to the general health of the mother and by allowing plenty of fluids. Cathartics 
 and curtailment of fluids have the opposite effect. Malt preparations, milk, 
 and gruel seem to have a special faculty of increasing the milk-supply. The 
 quality of the milk may vary from over-rich to bad. Too much rich food, 
 improper habits of life, and insufficient exercise will cause the milk to contain 
 too high a proportion of solid ingredients, the chief disturber of the infantile 
 digestion being the increase of proteids. The remedy for the condition is 
 obvious. A poor milk usually contains too much proteid and a subnormal 
 amount of sugar and fat, while a bad milk accentuates this disproportion. 
 Overwork and improper diet will cause the milk to be poor, while the causes 
 of the production of a bad milk are usually put down as 
 neurotic. 
 
 2. Wet-nurse. — The best substitute for the milk of 
 the mother is the milk of a healthy woman who is 
 nursing a child of about the same age as the infant she 
 is to feed. To be a desirable wet-nurse, a woman should, 
 in addition to having a child of about the same age as 
 the child she is to nurse, be free from any communicable 
 disease, such as tuberculosis, syphilis or gonorrhea; she 
 should have a good quantity of milk and the nipples 
 should be normal in development and general condition. 
 If possible, her child should be examined for evidences 
 of syphilis, which when it occurs is sometimes more 
 evident in the child than in the mother. Until the 
 character of the nurse is proved, she should be watched 
 while she is nursing the child, and if all goes well, the 
 result will be as good as if the child were nursed by its 
 mother. The diet of the nurse will, of course, require 
 supervision, and in many cases it will be necessary to 
 guard against overindulgence in malt liquors. There 
 is no more difficult or thankless task than the procuring 
 and supervision of a wet-nurse, and she has been defined 
 by some one "as one part cow and nine parts devil." 
 -This must be resorted to when the mother cannot nurse 
 It is only when maternal nursing is 
 
 Fig. 993. — Materna 
 Graduate Glass for 
 Artificial Infant 
 Feeding. 
 
 3. Artificial Feeding. 
 
 her child and a wet-nurse is not available, 
 impossible or when it presents conditions which are unsuitable, such as when the 
 milk is unreliable in quantity and too poor in quality properly to nourish the child, 
 that artificial feeding should be resorted to. Breast-milk practically does not 
 change its composition during a normal lactation, but it has been observed 
 that infants cannot take so rich an artificial food as a natural one, and it is 
 necessary to alter the proportion of some ingredient in preparing the artificial 
 food. In certain cases the woman can supply a portion of the milk required 
 by the infant and the deficiency must be made up by the use of a modified 
 cow's milk. The intervals between feedings must be just as carefully regulated 
 as in the case of nursing. It is also necessary to regulate the amount of food 
 given at a time. A good rule is at the age of one week to give one ounce each 
 time; at four weeks, 2^ ounces; at three months, 4 ounces; at six months, 6 
 ounces; and gradually to increase to 8 ounces, which is as much food as a child 
 should ever take at a time until weaned. The best results are obtained by 
 
HYGIENE AND MANAGEMENT OF THE NEWLY BORN 789 
 
 making certain modifications in the ingredients of cow's milk to make it conform 
 to human milk, and by starting with a very low proportion of fat and proteid, 
 gradually increasing as the child approaches eight or nine months. The various 
 strengths which seem to give the most satisfactory results at various ages are 
 thus tabulated. The ingredients should be, in the first months of life: 
 
 Fat. Sugar. Pkoteio. 
 
 First week 2.00 5 • 00 0.50 
 
 Second " 3 -oo 6 .00 o -75 
 
 First month 4.00 , 7.00 i . 00 
 
 Second " 4. 00 7. 00 i-5o 
 
 Fourth " 4.00 7.00 2.00 
 
 Sixth " 4 . 00 7 . 00 2.50 
 
 Eighth " 4.00 7.00 2.75 
 
 A properly constituted artificial food must contain only substances normally 
 found in milk; it must be alkaline and sterile,* easily obtained, and its prepara- 
 tion not too complicated. It must as nearly as possible be of the composition 
 of human milk and susceptible of modification to suit individual cases. Cow's 
 milk is the most easily obtainable basis for modification. According to Meigs, 
 the comparative average composition of human and cow's milk is: 
 
 Human Milk. Cow's Milk. 
 
 Water, 87.16 87.10 
 
 Fat 4.28 4.20 
 
 Casein, 1.04 3-25 
 
 Sugar, 7.40 5 ■ 00 
 
 Salts o.io 0.52 
 
 Human milk is also alkaline and practically sterile, while cow's milk as it reaches 
 the consumer is usually slightly acid and always contains bacteria. Other 
 analyses give somewhat different results, but these may be taken as an average. 
 Human milk differs in two important respects — it contains more sugar and 
 markedly less proteid. The proteids of human milk are casein and lactalbumin, 
 both not in solution but suspension, and capable of making a finely divided 
 curd more readily digestible than that of cow's milk. Further, the proteid 
 matter is of a different character. Fats are about the same. In some respects it 
 is easy to make cow's milk conform to the standard. A sufficient amount of milk- 
 sugar added makes this ingredient satisfactory, and the acidity can be corrected 
 by the addition of lime-water. Brush and Jacobi maintain that cane-sugar is the 
 ideal addition. Milk-sugar is rapidly changed into lactic acid. Sometimes it is 
 borne well, at others not, because of the excess of lactic acid, which interferes with 
 digestion. The presence of harmful bacteria must be prevented by care and 
 cleanliness and their action may be overcome by sterilization. The regulation of 
 fats and proteids is not so easy. A simple way is to dilute with water till the pro- 
 teid is properly reduced and then add cream. When a fair trial has been given 
 water as a diluent and vomiting of tough curds or their presence in the stools 
 persists, barley or oatmeal water should be used to "split" the curds. Diluting 
 milk with water does not prevent the formation of tough curds, but diluting 
 
 * Concerning the advisability of sterilization, it may be well to mention that children 
 do not thrive well upon milk which has been subjected to a temperature of 212° F. for 
 an hour and a half. The casein is made more firm and certain changes occur in the fat 
 which tend to constipation. In the summer, when diarrheal diseases are prevalent, it 
 may be of advantage to resort to sterilization when clean, fresh milk cannot be procured. 
 Human milk obtained from 73 breasts of 64 nursing women, examined by Honigman with 
 all aseptic precautions, contained Staphylococcus aureus or albus in all but four cases, 
 the number varying from i to 9000 in a cubic millimeter which seems to confirm the 
 belief that micro-organisms are not necessarily prejudicial to health. 
 
790 THE PHYSIOLOGY OF THE NEWLY BORN. 
 
 with gruels does prevent the hardening of the curds, as is proved experi- 
 mentally and clinically. Barley water is used to prevent the formation of large 
 curds by mechanical separation of the milk globules, but this is not always 
 a good plan, because before the third month of life starch digestion practically 
 does not exist on account of the lack of development of the pancreas. Whatever 
 modified milk is used may be sterilized or pasteurized, if necessary, by keeping it 
 at a temperature of 157° to 168° F. for twenty minutes. When boiled, the mixture 
 is apt to cause constipation. The preparation of a modified milk can be under- 
 taken without great trouble at home, but in the larger cities the matter may 
 be left to certain laboratories, which may be depended upon to furnish an 
 accurately modified food according to directions. The cost is considerable, how- 
 ever, and among the poor the plan is not feasible. In this case home modi- 
 fication is necessary. The principle on which milk is modified depends on the 
 separation of the fatty portions in the cream, by standing or by centrifugal- 
 ization; by these methods the cream and fats are separated to one part of the 
 mass while the proteids and milk-sugar remain equally distributed throughout. 
 By regulating the time of standing and selecting certain portions of the milk 
 mass it is not difficult to select a specimen which contains any desired strength 
 of cream. For example, a specimen standing six hours gives: 
 
 Upper i, fat, 12.0 %; sugar, 4-4%; proteids, 3.78%. 
 
 Upper i " 10.0%; " 4.5%; " 3-85%- 
 
 Lower i, " 0.25%; " 4-5%; " 3-&5%- 
 
 Longer standing increases the percentage of fats in the upper fifth. 
 
 In preparing modified milk it is necessary to work on a percentage basis entirely if 
 good results are desired. Baner * has given a simple and on the whole satisfactory method 
 of calculating the composition for any desired modification of milk for infants' use. 
 
 Q = the quantity in ounces for twenty-four hours. F = the desired percentage of fat. 
 S = the desired percentage of sugar. P = the desired percentage of proteids. 
 A = the desired percentage of alkalinity. C = cream; M = milk; L.W. = lime- 
 water. 
 
 Cream, t^—. X (F — P). 
 
 Percentage of fat in cream — 4 
 
 Milk, QXI-c. 
 
 4 
 
 Lime-water, — X Q. 
 
 100 
 
 Water q _ (C + m + L.W.). 
 
 Dry milk-sugar, (s - P) x Q_ 
 
 100 
 
 Example: If 40 ounces of a mixture containing 4 per cent, fat, 7 per cent, sugar, and 
 2 per cent, proteids is required, proceed as follows: Cream, ,2 (quantity^f creain used) gives 
 6f ounces. Milk, lOO minus 6f equals 13^ ounces. Milk sugar, IfL^li equals 2 oz. Lime- 
 water q. s. to make alkaline; plain water up to 40 ounces. Mix and divide into as many 
 bottles as desired. 
 
 From this it is a simple matter to prepare the food, though it will from time to time 
 be necessary to vary the proportions of some ingredients. The usual percentage of lime- 
 water is five, but it is sometimes necessary to use 'ten or fifteen. 
 
 Winters t gives the formulas on page 857 for the home modification of milk. 
 I give these formulas in full because they are the simplest and most explicit 
 with which I am acquainted. A somewhat more gradual strengthening of 
 the food during the summer months should be used than is indicated in these 
 formulae. As a rule, an infant of three or four months will not digest more 
 
 * " N. Y. Med. Jour.," Mar. 20, 1898. 
 
 t "The Feeding of Infants," Button & Co., New York, 1901. 
 
HYGIENE AND. MANAGEMENT OF THE NEWLY BORN. 
 
 791 
 
 s P- 
 
 ^ 
 S 
 
 O O \J~> 
 O O c< +J 
 
 . t/T 
 
 . W) 
 
 c 
 
 : p^ ?^ 
 
 :2 5 s 
 
 
 W a. 
 
 ^t: 
 
 
 " o 5^ 
 
 ^ -5 "^ a; o i 
 «-S t" e " 
 
 &<-^ C * O G s 
 
 ■^ .y, • '■ "" M 
 
 ^ ^ ^ a^ s 
 
 
 o 
 
 +J 
 
 o . 
 
 ■ S 
 
 •'5 
 
 Co .H-i 
 
 I— I '^ O O "^ 
 
 • ;* O O f^ Ul" 
 4 t4 M '"^ 
 
 ■ - > 
 
 
 C I 
 
 "O 
 
 •2 o o o 
 •t: o lo o 
 
 "^^ : ■ : 
 
 2 S o o o 
 
 OJ 
 
 rt 
 
 t/: u3 
 
 Q r't : « 
 
 Z "^ . bo, 
 
 (o 
 
 tvj 
 
 O O H -+ 
 
 cd 
 
 
 Ph >= 
 
 ^ •J^^ 
 
 
 w 
 
 
 
 o 
 
 « s § 
 
 O bJ3 
 +^ G 
 
 rog 
 
 0) 
 
 <D 
 
 
 jii 2 4^ S 
 
 >^ ;y to +j CO 
 
 
 O G J 
 
 S o o M 
 
 ^ s t/3 ca 
 
 B e-l^ o G 
 
 H «>:^ c - o 
 
 M § 3 -»-> 
 
 « « S o ^ 
 
 O g >^ Tt- bo 
 
 >'■'-« o 
 
 ^^e . . c 
 
 - i- 
 
 Z -J Hn,_ 
 
 ^ ^ O M 
 
 W -y-. Op, 
 
 fe a I c - ^ 
 
 On ^ Co 
 
 3 
 O 
 
 o-« 
 
 o 
 
 2: S 
 
 
 <D 
 
 z:^ G -iJ cc 
 
 >N 
 
 *-* <u t* 
 
 << r^ CS +J t> 
 
 2 §^ « 
 
 <! § 2 
 
 ►J O"-^ 
 
 3 « 
 
 - t4 nj 
 
 1 d) i> 
 
 bo cd^ 
 
 4) a; 
 
 o ^ 
 
 'd ■ 
 
 w 
 
 01 
 
 
 
 P^ 
 
 Q 
 
 O 
 
 Z 
 
 fe 
 
 ■< 
 
 ^ 
 
 Q 
 Z 
 
 H-) 
 
 o 
 
 ^ 
 
 CJ 
 
 w 
 
 S 
 
 C/D 
 
 ;^ 
 
 . 
 
 o 
 
 r/J 
 
 t^ 
 
 b! 
 
 ^ 
 
 flH 
 
 o 
 
 o 
 
 O 
 
 o 
 
 CN 
 
 
 S 
 
 (S 
 
 r~ 
 
 O 
 
 o 
 
 G 
 ;3 
 
 0) 
 
 
 U 
 03 
 bo 
 
 co" 
 
 o 
 
 1 
 
 
 ^j'O 
 
 
 1 
 
 
 CO 
 
 ti) 
 
 l>.^ 
 
 * 
 
 ^ 
 
 +-> 
 
 o3 
 
 1 
 
 
 () 
 
 T-t 
 
 N 
 
 
 
 
 
 
 feSOn 
 
 G 
 
 s 
 
 03 
 
 0) 
 
 to 
 
 
 O 
 
 o 
 
 <; 
 
 +-> 
 
 •F^ 
 
 
 to 
 
 
 r<l 
 
 G 
 
 
 Ti 
 
 1 
 
 +-> 
 
 () 
 
 
 G 
 o3 
 
 o 
 
 
 o 
 
 
 1 
 
 "^ .§ O O r^S^ 
 
 „ _->^ IT) O fri> 
 
 'U f • • • o 
 
 Q g • - • to 
 
 2 ^ : ri . "^ 
 
 ■^ ^ i bo to" to 
 
 ^ci3-3 tH m 
 fin § (!( M-, 
 
 ™ ■ G 
 
 «-5 
 
 ^ to 
 
 oj 
 
 ■ <U (U 
 
 G c : 
 
 
 w 
 
 ^ G 
 
 &, 
 
 
 o o .b 
 
 CiO 
 
 bO 
 
 , S"^ to w 
 
 ft! o^:^ <u <u 
 
 O ^ cj o ; 
 
 pZ, a s G C 
 
 M S ^ O M 
 
 
 bo 
 
 « ■ ^ -S 
 
 I ^ O O -CI 
 
 ^ Q M <S O vSi 
 
 il 
 
 W (U s. 03 . 
 
 booj^ >~>o 
 
 - 03 
 
 : T3 -M 
 
 CO 
 
 <U 
 
 C O 
 
 ?gS^3 . 
 
 o ^ S2 • 
 
 g M bo o3__, >> 
 
 fe ^ 6 S ^ S 
 1:3 s j£o» 
 
 A <u OJ c 
 :^ c ii 03 
 
792 
 
 THE PHYSIOLOGY OF THE NEWLY BORN. 
 
 n^umber of 
 Feedings. 
 
 Intervals 
 
 lO 
 
 
 2 hours 
 
 lO 
 
 
 2 " 
 
 10 
 
 
 2 " 
 
 lO 
 
 
 2 " 
 
 10 
 
 
 2 " 
 
 8 
 
 
 2§ " 
 
 7 
 6 
 
 
 3 
 
 3h " 
 
 than I per cent, of proteid during the hot weather. During this time also 
 many of the digestive disturbances may be averted by increasing the proportion 
 of Hme-water to one-fourth of the total quantity of the mixture. The prepared 
 mixture is placed in as many bottles as there are feedings for the twenty-four 
 hours, each bottle containing the amount of one feeding; the bottles are then 
 stopped with sterile absorbent cotton, placed in a refrigerator, and kept 
 at a temperature of 45° to 50° F. until needed. The two unerring guides to 
 the quantity of each feeding are the capacity of the infant stomach and the 
 amount of milk secreted by the breasts of a healthy nursing woman. The 
 following table, also from Winters, shows the proper quantity, number of 
 feedings, and intervals for artificial feeding up to nine months: 
 
 TABULAR GUIDE FOR ARTIFICIAL FEEDING. 
 
 Age. Quantity. 
 
 ist, 2d, and 3d days, ^ ounce 
 
 4th, 5th, 6th, and 7th days, . . . i 
 
 2d week, i^ ounces. 
 
 3d week 2 
 
 4th, 5th, and 6th weeks, 2^ " 
 
 ■7th, 8th, and gth weeks, 3 
 
 3d and 4th months 3 to 4 " 
 
 5th to 9th months, 5 to 6 " 
 
 For young infants, milk should not be added to cream. Milk and cream do 
 not unite. If shaken together, and then allowed to stand for a short time, separa- 
 tion is complete. The same occurs in the stomach. The stomach has practically 
 to cope with whole milk. Many failures are due to this prevalent error. 
 
 The following percentages and relative proportions of fat and proteid must 
 be adhered to for successful feeding (Winters) : 
 
 Fat. Proteid. 
 
 First three days, 2.00 0.25 per cent. 
 
 Succeeding days — first week, 2.50 _ 0.33 " 
 
 Second week, 3-oo 0.50 " 
 
 Third week, 3.50 0.75 
 
 Fourth to eighth weeks, 4.00 i.oo 
 
 Ninth to twelfth weeks, 4.00 1.25 
 
 Fourth month, 4.00 1.50 " 
 
 Fifth and sixth months, 4.00 1.75 
 
 Seventh, eighth, and ninth months 4.00 2.00 
 
 Tenth and eleventh months 4.00 2.50 " 
 
 Twelfth month, 4.00 3.00 " 
 
 In summer the strengthening must be more gradual, as follows (Winters) : 
 
 Fat. Proteid. 
 
 First week, 2.00 0.25 per cent. 
 
 Second week, 2.50 0.33 
 
 Third and fourth weeks, 3.00 0.50 
 
 Fifth and sixth weeks, 3.50 0.75 
 
 Seventh week to end of third month, 4.00 i.oo 
 
 Fourth month, 4.00 1.25 
 
 Fifth and sixth months, 4.00 1.50 
 
 Seventh month, 4.00 1.75 
 
 Eighth and ninth months, 4.00 2.00 
 
 General Directions. — A certain amount of systematic preparation and a 
 few articles in the way of apparatus are necessary for home modification and for 
 the use of the modified milk after it is prepared. These are: two or three glass 
 jars to set the milk in, fruit-jars will do, a glass siphon, a dairy thermometer, 
 a graduated measure up to 8 ounces, and a number of 4-ounce and 8-ounce 
 
HYGIENE AND- MANAGEMENT OF THE NEWLY BORN. 793 
 
 bottles for feeding. A good supply of rubber nipples and plenty of sterilized 
 cotton are necessary. A good-sized vessel for sterilization is also needed. All 
 these articles are to be used sterile, and those which can stand it are subjected 
 to boiling in a soda solution at frequent intervals. The same feeding-bottle should 
 not be used at consecutive feedings and between times should lie in a soda solu- 
 tion. When the milk is received, it is allowed to stand in the sterile jars in a 
 cool place as long as desired. The lower part may then be siphoned ofE and 
 mixed in a sterile vessel with cream, lime-water, sterile water, and milk-sugar in 
 
 Fig. 994. — A Good Type of Rubber 
 Nipple. 
 
 Fig. 995. 
 
 -A Good Type of Feeding- 
 bottle. 
 
 the necessary proportions. The formulae which have been given may be used. 
 When sterilization is necessary, the modified milk may be placed in the feeding- 
 bottles, the mouths of which are to be plugged with sterile cotton, and placed 
 in a wire rack in the sterilizing dish and lowered into the water, the temperature 
 of which is then slowly raised to 167° F. and kept there for twenty minutes. 
 After this the bottles are to be kept cool till needed, when they are to be warmed 
 in water to between 99° and 101° F., the proper temperature for infant food. 
 
 Fig. 996. — Nipple Sterilizer. 
 
 Not more than a day's supply of food should be prepared at a time. A complete 
 outfit for the preparation of modified milk can be bought, but it is no more 
 serviceable than are the articles mentioned. Whatever preparation is used, the 
 greatest care as to cleanliness must be observed if good results are to be ob- 
 tained. After each nursing, the bottle is rinsed in cold water which removes 
 the particles of milk without coagulating them and then scalded; the nipple 
 should be washed in cold water and both nipple and bottle kept in a soda 
 solution to prevent acid fermentation. The short nipple only should be used, as 
 
794 
 
 THE PHYSIOLOGY OF THE NEWLY BORN. 
 
 it is the only one which can be properly cleansed. While the child is feeding the 
 bottle should be encased in a knitted bag to maintain the temperature as long as 
 possible. The amount usually required at one nursing by a new-bom child for the 
 first week is one ounce, gradually increased till the sixth week, when it receives 
 two and a half ounces, but the amount varies with the size of the child. The 
 bottle should be held so that the child can suckle advantageously; that is, so 
 that its mouth is directly opposite the summit of the nipple. Certain symptoms 
 may point to the necessity of modifying the composition of the child's food; 
 e. g., if it regurgitates its food unchanged, it is getting too much, or the amount 
 .of fluid is too large; if it takes its food eagerly but seems continually hungry 
 and does not gain in weight, the proportion of solids may be increased, which 
 is accomplished by diminishing the water. 
 
 Fig. 997. — Bottle-brush for Cleansing Feeding-bottles. 
 
 4. Patented or Proprietary Foods. — There is one truth which by this 
 time should be taken as an axiom — namely, that mother's milk is the most 
 appropriate food to be taken by the infant in all stages of development and 
 no patented infant food can even approximate it in value. The majority 
 of such foods now on the market are either. farinaceous, made from cereals 
 and consisting largely of unconverted starch, or malted foods, also made 
 from cereals but having the starch transformed into soluble maltose and 
 dextrin. They vary in composition and strength, but as a class contain an 
 excess of carbohydrates, little if any fat, and proteids which do not resemble 
 those in mother's milk. Chittenden * analyzed certain proprietary foods 
 according to directions for infants of six months, with the following results: 
 
 Imperial granum, i • 54 
 
 Nestl6's food, 0.36 
 
 Malted milk 0.68 
 
 Mellin's food, 2 
 
 Peptogenic miilk powder, 4.38 
 Condensed milk.j i .70 
 
 Sugar. 
 
 Proteid. 
 
 Starch. 
 
 2.71 milk 
 
 2-15 
 
 I .22 
 
 0.84 " 
 
 0.81 
 
 1.99 
 
 2.57 cane 
 
 
 
 1 . 1 8 milk 
 
 1-15 
 
 
 3.28 maltose 
 
 
 
 0.92 dextrin 
 
 
 
 3.25 milk 
 
 2 .62 
 
 
 2.20 maltose 
 
 
 
 0.53 dextrin 
 
 
 
 7.26 milk 
 
 2 .09 
 
 
 6.00 cane 
 
 I .50 
 
 
 2.26 milk 
 
 
 
 Reaction alkaline. 
 
 INFANT'S WEIGHT. 
 
 First week 7 pounds 
 
 Second week 7 to 8 
 
 Third week 8 to 9 
 
 Fourth to eighth week. ... 9 to 10 
 Ninth to twelfth week ... 10 to 12 
 Fourth month 12 to 14 
 
 Fifth to sixth month 14 to 16 pounds 
 
 Seventh, eighth, and ninth 
 
 month 16 to 18 " 
 
 Tenth to eleventh month. 18 to 19 " 
 Twelfth month 19 to 20 " 
 
 Open Air. — A baby can be taken into the open air when a month old ih mild 
 weather, and at about two months in winter. In southern climates it can of 
 
 * " N. Y. Med. Jour.," July 18, 1896. 
 
 t The percentages of condensed milk are those found in the Milkmaid brand, diluted 
 with seven parts water. 
 
HYGIENE AND MANAGEMENT OF THE NEWLY BORN, 795 
 
 course go out much earlier than in northern ones. Under proper conditions the 
 more open-air life a baby can have, the better. As for exercise, it should be 
 allowed to kick and roll about in its crib unhampered by long, clogging skirts; 
 and to creep if it wishes, if there are no draughts near the floor. Walking 
 belongs to a later period, from about the thirteenth month. 
 
 Sleep. — A very young infant will sleep about twenty-one hours of the twenty- 
 four, and should be allowed to sleep and not be roused to be displayed to friends. 
 It should never sleep in bed with the mother from danger of being overlaid and 
 also because it is apt to be covered with the bedclothes and the fresh air kept 
 from it. It should have a crib, not a rocking cradle, near the mother's bed, and 
 should be laid there to sleep without previous handling or carrying about. 
 Babies greatly prefer the delicate attentions of rocking and carrying, and are 
 clever enough to insist upon having it if they have ever experienced it, where- 
 fore it is for the peace of all concerned, as well as better for the baby's nervous 
 system, not to accustom it to the luxury. Other habits may also be formed 
 at a far earlier age than is usually supposed; I refer to the evacuation of the 
 bladder and bowels. 
 
 Bladder and Bowels.— It is difficult to regulate the passing of water, but 
 some nurses are successful in securing a certain amount of regularity by placing 
 the babies upon a vessel soon after feeding. The bowels can almost invariably be 
 trained to regularity by trying to secure a movement at the same hour every da v. 
 There will be as many as four a day for the first week, gradually diminishing till 
 there are usually two a day after the sixth month. Sometimes there is only 
 one, but provided that is abundant, soft, and yellow, not lumpy, it need cause 
 no anxiety. Constipation is to be avoided as it is the cause of serious troubles 
 and of future bad habits. Unceasing care must be exercised to secure a good 
 movement at the same hour every day, and should the child show " a constipated 
 habit," or have hard, painful stools, the condition of the food must be investi- 
 gated. Some infants are constipated while nursing but become perfectly 
 regular when put on solid diet. Constipation in the mother will have a great 
 effect on the infant's bowels, and she cannot be too careful to keep herself 
 regular and avoid sweets, starchy foods, cakes, pastries, and acids. In a bottle- 
 fed child the milk is found frequently to be deficient in fats. Cream and water 
 will then have to be added. As far as possible the use of drugs should be avoided 
 and the desired end attained by a healthful mode of life for both mother and 
 child, plenty of fresh air, exercise, a rational diet, loose clothing, quiet, calm- 
 ness, and regular habits. Exercise may be given in the passive form to an 
 infant by gently rubbing its abdomen with a circular motion. Diarrhea is more 
 often due to overnursing and overfeeding and to drinking too little w^ater than to 
 other causes. The habit of putting the child to the breast every time it cries 
 defeats its own end, for it is the best way to sow the seeds of colic, vomiting, 
 diarrhea, and discomfort. 
 
 The Nursery. — When it is possible, let the nursery for the baby be a sunny 
 room in which there is no plumbing and which can be well ventilated and easily 
 heated. A board eight inches wide slipped under the whole length of the lower 
 sash will allow of the entrance of air without draught, and a register, an open 
 fire, or a stove with a pan of water always on top, should keep the temperature 
 at about 70° or preferably 65° F. The temperature should not vary much from 
 this during the night and the fresh air should not be excluded. Whatever the 
 prejudice against night air, it is better than carbonic acid gas laden with im- 
 purities from the lungs, and such will be the air of a closed room in which sleep 
 a child and a nurse. Cleanliness, simplicity, cheerfulness, should be the guiding 
 
796 THE PHYSIOLOGY OF THE NEWLY BORN. 
 
 maxims in arranging a nursery. The fewer curtains, hangings, and carpets, the 
 better, as they lodge bacteria. No soiled napkins should be allowed to stay in 
 the room and vessels should be removed and cleaned as soon as used. 
 
 Environment. — Even in infancy it is well to preserve a calm environment 
 for the baby. Noise, excitable actions and tones, and much prancing and 
 dancing for the baby's entertainment should be avoided. Children suffer from 
 too much attention in the line of amusement, and a little wholesome neglect in 
 this respect will not only teach them to amuse themselves, but will induce 
 calmer nerves and subsequent better health. 
 
 Weaning. — Weaning should occur between the ninth and fourteenth months, 
 but some conditions may make it desirable earlier. It is better to have it a 
 gradual than a sudden process, substituting a little bread and milk, hominy, or 
 other cereal for one of the regular feedings. 
 
 Prepuce and Hood of Clitoris. — i. In male infants, beginning on the sixth 
 or seventh day after birth, the nurse should be instructed to retract the prepuce 
 daily, drawing it back a little every day until all adhesions are broken up, 
 and the glans, as far as the corona, is exposed. It usually takes two or three 
 daily attempts to expose the glans completely. Daily retraction should there- 
 after be practised by the nurse and all smegma removed with a saline, boric 
 acid or very weak soap solution and clean absorbent cotton. To prevent the 
 readhesion of the raw surfaces, the free application of sterile vaseline between the 
 prepuce and glans I have usually found sufficient. Occasionally sterile gauze 
 or cotton, placed just back of the corona, will be demanded for this purpose. 
 The mother or child's nurse should subsequently be instructed to repeat the 
 cleansing daily during infancy, and until the boy can be taught to attend to 
 the matter himself. 
 
 Adhesions between the prepuce and glans penis are quite common, and 
 are often causative factors of many reflex nervous affections and even con- 
 vulsions. 
 
 In both private and hospital practice I insist that firm adhesions shall be 
 promptly reported to me. In one of my services at the New York Maternity 
 two cases of persistent infantile convulsions were promptly cured by circum- 
 cision. The above described "stripping" of the glans penis will in the newly 
 bom usually be found a simple procedure, and it is much preferable that it 
 be done in infancy by the nurse or physician, than several years later by the 
 boy of six or eight. 
 
 2. In my experience the nymphae in female infants are rarely so firmly 
 adherent to each other or to the labia majora as in the male is the prepuce to 
 the glans. This statement is based upon several thousand observations. The 
 hood of the clitoris can usually be readily drawn back, and the proper cleansing 
 secured, but this is not so necessary as in the case of the prepuce. 
 
PART NINE. 
 The Pathology of the Newly Born^ 
 
 I. PATHOLOGY DUE TO INTERRUPTED PREGNANCY. PREMATURITY. 
 
 (Page 800.) 
 
 II. AFFECTIONS OF ANTENATAL ORIGIN WHICH EXTEND INTO EXTRA- 
 UTERINE LIFE. (Page 807.) 1. Malformations and Monstrosities. 2. 
 Acute Infectious Diseases. 3. Chronic Infectious Diseases. 4. General 
 Conditions. 5. Infantile Syphilis. 
 
 III. AFFECTIONS WHICH ORIGINATE INTRA PARTUM. (Page812.) 1. As- 
 
 phyxia Neonatorum. 2. Birth Traumatisms. 3. Aspiration Pneumonia. 
 
 4. Contagious Diseases Contracted from the Mother. (1) Ophthalmia 
 Neonatorum. (2) Gonorrheal Stomatitis. 
 
 IV. DISEASES INCIDENT TO CHANGE OF ENVIRONMENT. (Page 837.) 
 
 1. Primary Asphyxia of the Newly Born. 2. Atelectasis Neonatorum. 3. 
 Failure of Circulation. 4. (Edema Neonatorum. 5. Failure of Digestion 
 and Assimilation. Inanition. 6. Inanition Fever. 
 
 V. DISEASES DUE TO BACTERIA AND FUNGI. (Page 840.) 1. Umbilical 
 Sepsis. 2. Septic Coryza. 3. Septic Pneumonia. 4. Gastro-intestinal Sep- 
 sis. (1) Ulcerative Stomatitis. (2) Gangrenous Stomatitis. Noma. (3) 
 Parotitis. (4) Retropharyngeal Abscess. (5) Gastro-enteritis. 5. Cutaneous 
 Sepsis. (I) Dermatitis Exfoliativa (Ritter's Disease). (2) Pemphigus Acu- 
 tus Neonatorum. Septic Pemphigus. (3) Impetigo Contagiosa Neonatorum. 
 Periumbilical Pemphigus. (4) Ecthyma Neonatorum. (5) Multiple Abscess. 
 (6) Erysipelas. 6. Tetanus. 7. Aphthae. 8. Thrush. 
 
 VI. DISEASES OF UNKNOWN NATURE. (Page 847.) 1. Omphalorrhagia. 
 
 2. Melena. 3. Miscellaneous Hemorrhages. 4. Sclerema Neonatorum. 
 
 5. Buhl's Disease. 6. Winckel's Disease* 7. Mastitis. 8. Jaundice. 
 
 VII. GENERAL POST-PARTUM CONDITIONS. (Page 852.) 1. Ulceration of 
 the Hard Palate. 2. Sublingual Cysts. 3, Vomiting. 4. Colic. 5. Diar- 
 rhea. 6. Constipation. 7. Intestinal Obstruction. 8. Pneumonia. 9. Con- 
 vulsions. 10. Infantile Cachexia. II. Sudden Death. 12. Medication of 
 the Newly Born. 
 
General Considerations. — While it is customary to assign particular causes 
 for individual infantile deaths, the fact must remain that in the struggle for 
 existence many fetuses and newly born children are simply unable to survive, 
 and that the particular disease which terminates their existence is almost a 
 matter of indifference as compared with the marked predisposition to early 
 
 Antenatal 
 ConditMns. 
 ' Congenital Debiliti/ 
 Diseases and 
 Malformations 
 ^Dfo 
 
 Fetal and 
 Maternal 
 
 Dptocia 
 Intrapartum 
 
 CoTiditions 
 
 ^5fo 
 
 Fig. 998. — Diagram showing the Mor- 
 tality OF THE Newly Born in New 
 York. — {Modified from A. Brother's 
 tables.) 
 
 Fig. 
 
 Jepsis or 
 ^"-^^ostpartum 
 
 Intermptirm ofPregmncy^^l^^^^L 
 (Prematurity) 
 -13% 
 
 999. — Diagram showing the Mor- 
 tality OF THE Newly Born. 
 
 Fig. 
 
 -Diagram showing the Mortality of Infants in the First Year of Life. 
 
 {Biidin.*) 
 
 death. Nevertheless, these various conditions of the fetus and newly born 
 must be carefully considered, because many of them are not only capable of 
 producing death independently of predisposition, but are doubtless largely 
 preventable. In countries in which the birth-rate is falling off from unwilling- 
 ness on the part of wedded couples to procreate, the rescue of the fetus and 
 
 * "L'Obst^trique," September 15, 1901. 
 799 
 
800 THE PATHOLOGY OF THE NEWLY BORN. 
 
 newly born from some of these fatalities assumes tremendous importance. 
 The pathology of the newly born comprises phases set forth above (Figs. 998, 
 999, 1000). 
 
 I. PATHOLOGY DUE TO INTERRUPTION .OF PREGNANCY. 
 
 PREMATURITY. 
 
 Introduction. — The premature expulsion of the contents of the uterus is neces- 
 sarily fatal before a certain period at which the fetus becomes viable, and is 
 known as abortion and miscarriage. On the other hand, interruption very 
 shortly before term need not compromise the child's existence. Between these 
 limits the fate of the infant is problematical. It is, of course, difficult to fix pre- 
 cisely the age for survival of the child. In some statistics the mortality of these 
 premature children is excessive; in others the death-rate is relatively low. 
 Generally speaking, "prematurity" is an unscientific term; for death, whether 
 in titer o or after delivery, must have some cause, and prematurity is only a 
 predisposition. No distinction can be made in practice between prematurity 
 and congenital debility, and the exciting cause of death should be sought for. 
 But while the exact cause of death should be determined in each case, no one, of 
 course, denies that true prematurity is a most common and potent cause of still- 
 birth and infantile death, and that it affords a predisposition for the action of all 
 other pernicious elements. The further removed the labor from term, the greater 
 the influence of the predisposition (Figs. 998, 999, 1000). 
 
 Definition. — Prematurity might be defined as the act or state of being born 
 before term. A very brief study of modern obstetrical teaching will convince 
 one that this subject has never received due consideration. Premature children 
 are usually regarded as constituting a large share of those congenitally weak 
 infants who require special care at birth. One does not find in obstetric writings 
 any sharp line of demarcation between weak premature and weak mature 
 infants, at least from the practical point of view. Nevertheless prematurity 
 should constitute a particular field in obstetrics and should receive adequate 
 consideration from all points of view. 
 
 Percentajge of Premature Births. — The actual percentage of premature children varies 
 within wide Umits. In the Rotunda Hospital, Dublin, the number of premature births is but 
 1 or 2 per cent. On the other hand, Braun, of Vienna, claims that his proportion of pre- 
 maturity cases amounts to over 35 per cent, of all births. Numerous observers report a per- 
 centage about half-way between these figures, and the average of ten large clinics in various 
 parts of the world is about 17.50 percent., which must therefore be accepted as final. In other 
 words, one birth out of six, the world over, is probably premature. The great variability in 
 different clinics and in the same clinic in different years is as yet inexplicable. The dis- 
 crepancy in the death-rate in different clinics matches that of the birth-rate. In the 
 English vital statistics 13 per cent, of the mortality of the first year of life is due to pre- 
 maturity. The rate in the Paris Maternity is about 20 per cent. Rosthorn reports a 
 death-rate of but i per cent., Ahlfeld of 2 per cent., Hofmeier of less than 3 per cent. On 
 the other hand, Winckel's figures are 11.5 per cent., and the mortality in certain clinics 
 rui's up to 30 per cent., while a few go beyond this limit, and even one as high as 50 per 
 cent. Murillo, of Santiago, Chili, has kept records for a number of consecutive years, 
 and his death-rate from prematurity varies from 5 to 10 per cent. As far as may be de- 
 termined, the mortality of prematurity will average something like 20 per cent., the indi- 
 vidual variatiori and general average being much the same as those of the birth-rate. 
 
 Etiology. — Prematurity is not solely a matter of chronology, for the develop- 
 ment of the fetus does not necessarily keep pace with the calendar. A child may 
 be bom at term and yet be backward in development; and, conversely, children 
 may be bom before term and yet be fully mature. Prematurity, therefore, is an 
 
PATHOLOGY DUE TO INTERRUPTION OF PREGNANCY 801 
 
 ambiguous term which may refer ahke to the date of labor and the state of de- 
 velopment of the child. Such ambiguity should not exist, and terms should be 
 introduced to distinguish between these two ideas. Of these two conceptions of 
 maturity, the merely chronological phase should be regarded as incidental, while 
 the element of the state of development of the fetus at birth should be regarded 
 as essential. 
 
 Symptoms. — The objective qualities of a premature child are well known 
 and tolerably constant. As compared with a mature child, the premature 
 infant presents a bright red color with a small quantity of vernix caseosa; 
 there is a dearth of subcutaneous fat, so that the skin hangs in folds. The child 
 is somnolent, has a weak cry, limp muscles, and shallow breathing. Sucking 
 and swallowing are performed with difficulty. The eyes are closed. In regard 
 to relative dimensions, the head is larger in proportion to the body than in 
 maturity and the belly is more prominent. A still closer investigation of the 
 premature child shows a number of minor peculiarities. The head is com- 
 pressible, the sutures and fontanelles being wide open, and asymmetry may 
 result from compression in one portion. The ears lie fiat against the head. 
 The skin is very delicate, showing the subcutaneous veins, and is covered 
 uniformly with lanugo. The nails are soft and do not extend to the ends 
 of the fingers. From the twentieth to the twenty-fourth week the lanugo and 
 vernix caseosa first appear; the scalp hair has become differentiated In the 
 male the scrotum is small, and as yet empty, while in the female the labia 
 majora are separated by the clitoris. The surface of the child is bright red. 
 Children born at this period can move and breathe. From the twenty-fourth 
 to the twenty-eighth week subcutaneous fat begins to appear in the region of 
 the neck shoulders, and breast. The nails are represented only by firm folds 
 of integument. Children born during this period are able to cry softly. From 
 the twenty-eighth to the thirty-second week the pupillary membrane disappears, 
 the intense red color fades out, the subcutaneous fat becomes diffused over the 
 body, and the nails are developed nearly as far as the finger-tips. Children born 
 during this period are viable. From the thirty-second to the thirty-sixth week 
 the child resembles a mature infant, the differences being of degree only. Thus, 
 there is less subcutaneous fat present, so that the skin is somewhat wrinkled; 
 the cranial bones are more pliable, the nails are shorter and less firm, and the 
 lanugo is more abundant. The scrotum of a male child born at this period 
 exhibits wrinkles and folds. (Compare pages 85 and 86.) 
 
 Physiological Peculiarities. — The premature child has physiological as well 
 as anatomical peculiarities. In heat-making power it is defective, doubtless 
 because of its imperfect respiration, and the temperature constantly fluctuates 
 by reason of the defective action of the heat-regulating mechanism or instability 
 of the respiratory center. The thorax is somewhat inelastic and the lungs are 
 prone to atelectasis. Respiration is carried on only by the anterior portion 
 of the lungs. The premature child does not regain its initial loss of weight 
 for a month. Naturally these infants are ill fitted to sustain the traumatisms 
 of labor, where the compression favors congestion and hemorrhage. I have 
 often noted the frequency of ecchymoses in breech deliveries of the premature. 
 Interstitial hemorrhage into the nervous centers is doubtless favored, with 
 production of athetosis and cerebral diplegia. In addition to the natural 
 inability to nurse, the contact of the rubber nipple or teaspoon, as well as the 
 operation of gavage, is a source of dangerous irritation. The premature child 
 is especially liable to hernia, both inguinal and umbilical, because its orifices 
 are insufficiently closed. The descent of the testicle also favors inguinal hernia. 
 51 
 
S02 THE PATHOLOGY OF THE NEWLY BORN. 
 
 The first attempts at respiration may provoke fatal paroxysms of cyanosis. 
 While some authorities mention a "premature" quality of pulse and respiration, 
 a pulse of 140 and respiration of 40 to 60 are not incompatible with perfect 
 health. Anuria is sometimes seen in the premature. Determination of the age 
 of the fetus by the calendar is at best very difficult, for obvious reasons. Prac- 
 tical obstetrics recognizes no distinction in congenitally feeble children inde- 
 pendent of the date of birth. It is better, I believe, to do away with the 
 element of time in these cases and to be guided solely by the state of develop- 
 ment of the child. At the same time, however, in the matter of artificially 
 induced premature delivery, we have to rely largely upon the calendar, because 
 we have no means by which we may be able to estimate the degree of develop- 
 ment of the child in utero. The newly developed science of external cephalom- 
 etry, as practised to-day in Paris, may possibly become effective in determining 
 the degree of development through intrauterine mensuration of the head. 
 (Compare page 180.) At present the real criterion of maturity is the develop- 
 ment of the child at birth. Of the various criteria proposed, some authorities 
 prefer the temperature; others, the dimensions and weight. Eross, of Budapest, 
 made 11 50 measurements in 50 premature children. Of them, 19 had normal 
 temperature, 18 hyperthermia (due to some febrile complication), while in the 
 remaining 13 the temperature was subnormal. To estimate the degree of pre- 
 maturity or debility we must consider (i) age (development), (2) weight, (3) 
 temperature. Budin regards every newly bom infant with a rectal temperature 
 of not more than 90° F. (32° C.) as a candidate for the incubator. Some would 
 regard all children as congenitally feeble whose weight does not exceed 4.37 
 pounds (2000 grams); others make the limit 5^ pounds (2500 grams). In 
 regard to the causes of congenital debility, we find children born at term who 
 are nevertheless premature in development when the mother suffered during 
 gestation from anemia, hyperemesis, and cancerous cachexia. At the same 
 time very poorly nourished women may bear fine children. 
 
 Prognosis. — The prognosis varies with the degree of prematurity and the 
 development of the infant. A child bom but a few weeks before full term, 
 with a vigorous cry, circulation well established, and capable of taking nourish- 
 ment, will require scarcely more attention than a full-term baby, but, as a 
 rule, in premature infants the problem of feeding and maintaining the animal 
 heat is not easy to solve. Premature infants or those inherently delicate 
 require the utmost care and attention. Only a small proportion of children 
 bom before the seventh month survive, but after the seventh month, the recog- 
 nized period of viability, the percentage of infants saved varies from 50 to 
 96. The nearer full term, the greater the child's chances of life. 
 
 Treatment. — There are three main principles in the treatment of prema- 
 turity: (i) The temperature immediately surrounding the child should be such 
 as is adapted to its requirements; (2) its nutrition should be maintained by 
 proper feeding; (3) the amount of handling or other disturbance should be re- 
 duced to a minimum. 
 
 Management at Birth. — The temperature of the lying-in room should 
 be carefully regulated and the child should be handled with the greatest care 
 from the moment of birth. The rule that the cord should not be ligated until 
 it has ceased pulsating is here obviously of special importance. Meanwhile the 
 child should be wrapped in warm blankets. As soon as the cord is ligated 
 the child should be thoroughly wrapped in warm cotton batting, the face only 
 being uncovered. It should then be wrapped in warm blankets and transferred 
 to the incubator. If artificial respiration is necessary, those methods which 
 
PATHOLOGY DUE TO INTERRUPTION OF PREGNANCY. 803 
 
 involve the most rough handling and exposure to cold should be avoided if 
 possible. (See page 819.) 
 
 Bathing; Dressing. — Premature children should not be bathed, but may 
 be cleansed as becomes necessary with a soft cloth and warm sweet oil. The 
 action of the skin may be improved by anointing the body every two or three 
 days with the same material. All handling not absolutely necessary should 
 be prohibited. The child enveloped in warm cotton batting or in the heated 
 air of the incubator needs no clothing except a diaper, and should have none, 
 since even the passive movements necessary in dressing are somewhat of a 
 shock to these feeble children. Absorbent cotton, which may be used and 
 thrown away as required, should be preferred to the ordinary diaper. Chafing 
 should be carefully guarded against. 
 
 Alimentation. — Ordinarily the weakened condition of the infant precludes 
 the possibility of nursing or of taking the proper amount of nourishment 
 from a bottle. Feeding with a small medicine-dropper, at intervals of one 
 or two hours, is advised. The amount given at each feeding depends on 
 the capacity of the infant. One-half ounce is a proper amount to begin 
 with. In many cases, however, gavage, or forced feeding, — described else- 
 where, — is indispensable. Breast-milk from a woman having a child between 
 two or three weeks and several months old is the best form of nourishment, 
 and when given makes the prognosis decidedly better. Equal parts of a 
 sugar solution should be added to the breast-milk. Cow's milk is employed 
 only when it is impossible to obtain breast-milk, and then in weak propor- 
 tions. I have used modifications containing fat, 0.5 to i ; sugar, 4.0 to 8.0; 
 and proteids, 0.25 to 0.75 with success. The amount and frequency of such feed- 
 ings are increased as the infant's nutrition warrants. Plain sterile water should 
 be given freely ; it adds to the body-weight and helps elimination through the skin, 
 bowels, and kidneys. These children must be fed in proportion to their weight, 
 which may not exceed 4 pounds (1800 grams). They must be fed promptly 
 after birth; insufficient nourishment is shown by cyanosis, almost inevitably 
 a fatal prognostic symptom. Budin sought to determine the stomach capacities 
 of these children by autopsies upon fetuses of different uterine ages, and quite 
 recently Planchon * has proceeded with a similar aim in a different fashion. 
 While Budin experimented with the cadaveric stomach, Planchon's work has 
 been done upon the living subject. .An account was taken of the quantity of 
 milk ingested, whether from the breast or by gavage, spoon-feeding or drinking 
 from a glass. It was ascertained that the amount of milk increased with each 
 day, and the heavier the child, the greater the amount of milk taken, 
 
 Gavage. — In the treatment of premature and congenitally weak infants, 
 it is necessary at times to resort to gavage or forced feeding, by which is meant 
 the introduction through a tube of food into the stomach (Fig. 1002). A small 
 funnel of rubber or glass, two feet of rubber tubing, a No. 7 French scale rubber 
 catheter, and a small glass tube three inches long to connect the tubing with the 
 catheter, are required — practically the same apparatus used in stomach wash- 
 ing. When gavage is to be performed, the infant should lie flat on its back 
 in the arms of a nurse, its arms held at the sides, and the head steadied 
 by an assistant. The catheter is then quickly passed into the stomach 
 and the food poured into the funnel, which is raised. As soon as the funnel 
 is empty the catheter is withdrawn, pinching it to prevent the escape of any 
 fluid into the pharynx. In very young infants the jaws can readily be separated 
 by the fingers of the operator; in older children a mouth-gag may be required. 
 
 *" L'Obst^trique," 1901, vi, No. 5. 
 
804 
 
 THE PATHOLOGY OF THE NEWLY BORN. 
 
 If the food is regurgitated, the process should be repeated. After feeding the 
 child should be kept as quiet as possible. The children nourished in this manner 
 should be fed at longer intervals than those suited to other conditions, the length 
 
 ' --^x^' 
 
 
 
 yf<') 
 
 
 
 — -._ 
 
 
 ^^^f 
 
 ■ > 
 
 // 
 
 Fig. iooi. — The Operation of Stomach Washing (Lavage). For forced feeding (gavage) 
 the infant is placed fiat on its back (Fig. 1002). The same apparatus is used in both pro- 
 cedures, and both operations are valuable in the treatment of premature and congeni- 
 tally weak infants. 
 
 of the interval being determined by the requirements in each case. It is a good 
 plan to wash the stomach before the first feeding of the day (Fig. looi). Gavage 
 is more largely used in the treatment of premature infants kept in incubators, 
 
PATHOLOGY DUE TO INTERRUPTION OF PREGNANCY. 
 
 805 
 
 but it is also indicated after operations on the nose and throat and about the 
 neck, and in habitual vomiting. Food given by a tube often remains in the 
 stomach when other methods of feeding are followed by vomiting. In certain 
 serious conditions, such as pneumonia, diphtheria, and scarlet fever, the life of 
 the child may depend upon gavage. In cases in which disease of the mouth, 
 spasm of the muscles of the jaws, or intubation renders swallowing difficult or 
 impossible, nasal feeding is resorted to. A soft-rubber catheter lubricated with 
 vaselin or glycerin is gently pushed into the 
 nostril, through the pharynx into the eso- 
 phagus and stomach, and the feeding ac- 
 complished as described above. Stimulants 
 and other medicines may be given by these 
 methods. 
 
 Incubation. — History: According to 
 Baumm,* the first incubator was devised 
 by Denuce, of Bordeaux, in 1857. Crede's 
 apparatus dates from 1864, and served as 
 a model for many years. In 1880 Winckel 
 introduced his permanent water-bath to 
 the profession, but it proved cumbersome. 
 Tarnier's incubator dates from the same 
 
 
 Fig. 1002. 
 
 -The Operation of Forced Feeding 
 OR Gavage. 
 
 Fig. 1003. — A Good Type of Incuba- 
 tor OR CouvEusE. (Lion Pattern.) 
 
 period. Quite recently numerous improvements have been added to the 
 older incubators and new designs have been introduced. At present the well- 
 known "Lion couveuse" takes precedence over all others. It is self-regulat- 
 ing within two degrees (Fig. 1003). In the absence of an incubator, or until 
 one can be procured in private practice, the application of artificial heat may 
 be carried out by swaddling the infant in raw cotton, head and all, leaving 
 * "AUgem. med. Ztg.," April 4, 1900. 
 
806 THE PATHOLOGY OF THE NEWLY BORN. 
 
 only the face exposed, wrapping it about with a blanket and tying it around 
 with a roller bandage. Hot bottles should be placed on each side of it. 
 A very convenient method is to place the infant in a baby's basket half- full of 
 raw cotton in which numerous hot bottles have been placed. The only other 
 covering is a diaper and a shirt. The temperature of the room should be com- 
 fortably warm, particularly when the infant is stripped for a rubbing with 
 oil. When these means fail to meet the indications, an incubator must be 
 employed.* Action: When a child is placed in the incubator, its pulse and 
 respiration are slightly accelerated, returning to the normal toward the sixth 
 day, save that the respiration still remains slightly increased. The peripheral 
 temperature is increased to a higher degree in the axilla than in the rectum. 
 Proper temperature: It may vary from 86° to 98.6° F. (30° to 37° C.) according to 
 the circumstances. Tarnier thought the average should be about 90° F. (32° C), 
 Pinard 93° F. (34° C), while Colrat claimed that a higher temperature than 
 86° F. (30° C.) was discomforting to the child. Bonnaire obtained good results 
 at 90° F. (32° C). This temperature, 90° F., I have found to be satisfactory, 
 although as high as 95° F. (35° C.) is occasionally required. Whatever the 
 initial temperature, it should gradually be diminished, and it should descend 
 to 77° F. (25° C.) before the child is withdrawn from the incubator. Dangers: 
 The incubator is not unanimously recommended for prematurity. Serious 
 objections are found to its use. The trouble with the premature child is 
 a lack of thermogenic power, rather than superradiation. Hence, the incu- 
 bator is essentially meddlesome and possibly contraindicated. The air of the 
 incubator necessarily becomes foul, but this is somewhat offset by the method 
 of construction of the latest models. The sudden change of the child's tem- 
 perature when it is taken from the incubator to be bathed, etc., has never 
 been shown to be prejudicial, despite the views of theorists. The possibility 
 of the transmission of disease by the apparatus must receive the most serious 
 consideration, and constitutes a weighty contraindication to its employment. 
 The danger here is twofold, for the child may not only contaminate itself from 
 a putrefying cord or feces, but the incubator serves well for the incubation 
 and maintenance of germs which may infect the next child destined to occupy the 
 apparatus. The problem of ventilation has not yet been solved. Most modem 
 incubators are entirely too small for the amount of air required by the child. 
 There is a serious danger in the possibility of suffocation in connection with 
 vomiting, and to avoid this, constant supervision is necessary. In a case of 
 Wormser's a child choked to death, milk coagula having been found in the 
 bronchi. The closed incubator made it impossible to hear the warning cough 
 of the child, which should have been kept out of the incubator for some time 
 after feeding. Baumm's studies with the "Lion couveuse" gave the following 
 results: At 98.6° F. (37° C.) 200 cubic inches (3300 c.c.) of air are admitted 
 every second, which means that the entire air of the couveuse is renewed every 
 minute. This amount is fully sufficient for all demands. A child which has 
 been in the incubator two hours shows in the waste air a gain of carbonic acid 
 amounting to but 0.16 per thousand, showing that the purification of the air 
 of the incubator has been very complete. As to the children suited for the 
 incubator, there is no necessary relationship between weight and vigor on the 
 one hand, and production of heat on the other. A child which has subnormal 
 temperature and cannot be kept warm by packing should go to the incubator. 
 
 * The Lion Incubator may now be rented in New York city from The Kny-Scheerer 
 Co., 225 Fourth Avenue, New York, at a cost of $5.00 for installation, $5.00 for removal, and 
 50 cents per day for rental. 
 
ANTENATAL AFFECTIONS IN EXTRAUTERINE LIFE. 807 
 
 Duration of Treatment. — The child should be fed till it is able to nurse 
 without exhaustion. Seven months' children will probably need to be fed for 
 weeks, while those of eight months may be able to nurse. The duration of 
 the child's stay in the incubator will vary with its progress and development. 
 It may not be necessary to keep it there till full term. Attempts at discon- 
 tinuing the treatment should be cautious and tentative. The temperature 
 of the apparatus should be lowered gradually. As the child grows stronger, it 
 may be taught to nurse by feeding it through a nipple shield, which should be 
 perfectly clean.* 
 
 II. AFFECTIONS OF ANTENATAL ORIGIN WHICH EXTEND 
 INTO EXTRAUTERINE LIFE. 
 
 ./. Malformations and Monstrosities. 2. Acute Infectious Diseases, j. Chronic Infectious 
 Diseases. 4. General Conditions. 5. Infantile Syplnlis. 
 
 It has already been stated in the section upon this subject that the fetus 
 may be attacked in vitero by a number of conditions, many of which render its sur- 
 vival impossible (pages 242 and 255). If the pernicious influences are exerted 
 during the embryonal period, certain malformations and monstrosities arise, some 
 of which are compatible with survival. During the fetal period pathogenic influ- 
 ences produce alterations more like those seen in extrauterine life. But aside 
 from definite diseases, it is probable that in many toxic or cachectic states 
 of the mother the fetus undergoes a sort of arrest of development or stunting, 
 so that it presents many of the phenomena of prematurity. No distinction is 
 possible between a condition which breaks out in utero and one which appears 
 just after delivery. It is certain that the agencies which produce the disease 
 act in utero, and if their action is exerted very late in pregnancy, or if it super- 
 induce labor, the manifestations of the disease will occur post partum. An 
 antenatal affection may run its course before delivery takes place; or may begin 
 before birth and complete its cycle post partum; or, finally, may be contracted 
 before labor, but manifested only afterward. 
 
 I. Malformations and Monstrosities. — The various congenital malforma- 
 tions and monstrosities have been noted elsewhere (Part III). Of the lesser 
 monsters, some are compatible with survival (harelip, exstrophy of the bladder, 
 etc.); some naturally incompatible with survival are amenable to treatment 
 (imperforate rectum, etc.), while others, likewise incompatible with survival, 
 are also beyond the resources of treatment; e. g., imperforate esophagus. Of 
 the major monstrosities, many cases of teratomelus are capable of survival 
 (phocomelus [Fig. 353], etc.), but other single monsters can live only when the 
 malformation is very slight, as in the first degree of cyclopia. 
 
 * Statistical. — In 1900 Berend and Deutsch ("Arch. f. Kinderheilkunde," xxviii, 1900) 
 addressed 170 letters of inquiry to the chiefs of maternities in Europe and America in 
 regard to congenital debility. They received about thirty-six replies, the most satisfactory 
 of which were from Wiirzburg, Prague, Bologna, and Dublin. The circular letter referred 
 to comprised eight queries, viz.: (i) What percentage of new-bom children are premature? 
 (2) What is the mortality of the new-bom? (3) Is the incubator used? (4) Is it dis- 
 infected? (5) What is the average number of days spent in the incubator? (6) Has the 
 incubator lessened the mortality among the premature? (7) If no incubator is used, what 
 replaces it? (8) What is the mode of feeding? In regard to the use of the incubator 
 32 answers from clinics were received by Berend and Deutsch. It appears that but three 
 institutions use the Lion couveuse; 11 the Tamier-Auvard apparatus; 7 the Crede apparatus; 
 while in the other 11 the old custom of wrapping the children in cotton still obtains. In 
 regard to the temperature of the incubator, "it should vary inversely with that of the child." 
 
808 
 
 THE PATHOLOGY OF THE NEWLY BORN. 
 
 2. Acute Infectious Diseases. — Children have been born with a full variolous 
 eruption, or the exanthem may not appear until several days post partum. 
 Such cases occur very infrequently. The child dies as a rule, but recovery 
 has been recorded. Both variola and vaccinia of the mother may confer im- 
 
 i, 
 
 Fig. 
 
 1004. 
 
 -Large Umbilical Hernia in the Newly Born Containing a Portion of 
 THE Intestines, Liver, Stomach, and Spleen. — {Author's case.) 
 
 \ 
 
 munity against smallpox on children who have escaped actual infection in utero, 
 but such immunity is short-lived. In the recorded cases of measles the children 
 have always been bom with full rash, the disease apparently exploding in the 
 mother and fetus at the same time. It is otherwise with scarlatina, which in 
 
 some cases has not broken out 
 in the child until the first day 
 postpartum. In a few cases 
 the newly bom have been 
 healthy at first, but contract- 
 ed the maternal disease 
 secondarily, probably from 
 the breast-milk. No case of 
 intrauterine transmission of 
 diphtheria is known, but the 
 newly bom have been infected 
 through other channels when 
 the mother was suffering from 
 the disease. The children 
 bom of women with typhoid 
 jever exhibit a high degree of 
 congenital debility and often 
 succumb. The same is true 
 of the children of malarious 
 mothers who also show at times positive evidences of the disease itself (congeni- 
 tally enlarged spleen, etc.) . Children may, of course, be bitten soon after delivery 
 by infected mosquitos, and, generally speaking, malaria may from one cause or 
 
 Fig. 1005. — Congenital Bilateral Fissure of the 
 Hard Palate, Cleft Soft Palate, and Slight 
 Degree of Hare-lip. — {Author's case.) 
 
ANTENATAL AFFECTIONS IN EXTRAUTERINE LIFE. 809 
 
 another be encountered in the newly born of highly malarious districts. It 
 presents but little difference from the type found in older individuals. Children 
 have been bom with the evidences of influenza. In regard to sepsis of the newly 
 born which has been contracted in utero, children have been born with a septic 
 form of pneumonia, and it is supposed that some of them survive this experience, 
 although this is only an inference. Children have been born of rheumatic mothers 
 with all the phenomena of acute rheumatism. For further information upon this 
 and analogous affections, see Antenatal Diseases, page 255. 
 
 3. Chronic Infectious Diseases, — In a very few cases of actual congenital 
 tuberculosis the children were born tuberculous, succumbing to the disease 
 within a short time. The offspring of tuberculous mothers, while almost invari- 
 ably free from tuberculosis, exhibit a high degree of congenital debility and 
 perish readily from secondary mortality. It is not unlikely that some of the 
 children of the tuberculous are born with the virul-ent bacilli in their tissues and 
 are doomed to be infected perhaps forthwith, perhaps not until adolescence. If 
 fetal syphilis does not prove fatal in utero, — a rare exception to the general 
 rule, — the child, in addition to the visceral lesions already described (page 
 259), presents certain phenomena which are due evidently to failure in adjusting 
 itself to the new surroundings. Such infants can survive but a short time, 
 and their condition is known as syphilis neonatorum, to distinguish it from 
 syphilis contracted in utero, which does not manifest itself until a month or 
 thereabouts after delivery. This latter type, being extremely common, is the 
 familiar infantile or congenital syphilis. A peculiarity of syphilis of the newly 
 born is the general tendency to hemorrhage. The characteristic lesions of this 
 phase of syphilis comprise bullae which may exceptionally begin in utero, but 
 as a rule tend to appear soon after birth. Their seat of predilection is the 
 palms and soles, and they should not be confounded with septic pemphigus of 
 the newly bom (Fig. 1006). These bullae have a hemorrhagic tendency, and the 
 same disposition to bleed found in most of the tissues of the body constitutes 
 a sort of scorbutus of syphilitic origin. Aside from the bullse and general 
 hemorrhagic diathesis, these children may present all the lesions described under 
 the head of fetal syphilis. 
 
 4. General Conditions. — Chronic metal poisoning of the mother, alcoholism, 
 nicotinism,, diabetes, albuminuria and eclampsia, and the cancerous cachexia all 
 tend to the production of weak, undersized fetuses with a high degree of secon- 
 dary mortality. Lead- poisoning, alcoholism, and albumimtria also tend specially 
 to cause convulsions and bestow a highly neuropathic organization upon the 
 child. The offspring of the highly neurotic, hysterical, epileptic, and psycho- 
 pathic individual also develop these tendencies, but here it is an affair of pure 
 heredity. Children who appear normal at birth but develop tendencies in later 
 life are not included under the pathology of the newly bom. Ballantyne, for 
 the same reason, does not describe hereditary chorea, hereditary ataxia. Thorn- 
 sen's disease, etc., under affegtions of the newly bom. In regard to the various 
 local diseases which develop in titero, survival is largely a matter of accident. 
 In fetal ichthyosis of the grave type, for example, one victim of the disease 
 lived to the age of five months. Children with fetal anasarca have lived at 
 most but a few days after birth. An infant with congenital cystic elephantiasis 
 is known to have survived for twenty months. These are mere curiosities of 
 medicine, for as a general rule children with the aforesaid affections are practi- 
 cally still-bom, living at most but a few minutes. The condition known as 
 simple congenital elephantiasis, characterized by overgrowth of the soft parts of 
 a limb, is entirely compatible with life. The same is true of the mild form 
 
810 
 
 THE PATHOLOGY OF THE NEWLY BORN. 
 
 of ichthyosis. Other congenital affections in which survival readily occurs are 
 keratolysis, tylosis, anomalies of the pilous system, etc. The conditions com- 
 prised under the term fetal rickets are not incompatible with life. Children bom 
 with ascites seldom survive, but this is due principally to the relative impossi- 
 bility of birth without mutilation. At least one case has shown that this 
 affection is not per se incompatible with life. In peritonitis, as distinguished 
 from ascites, a brief extrauterine existence has been recorded. In congenital 
 obliteration of the bile-ducts the children may survive for a longer or shorter 
 interval, but the prognosis is almost hopeless, and the same is true of congenital 
 hypertrophic stenosis of the pylorus in which three months is considered the limit 
 of life. In fetal endocarditis there is an indefinite period of survival with occa- 
 sional recovery. Nephritis contracted apparently in utero proves fatal within a 
 short time after delivery ; one infant lived twenty-one days. If the degree of 
 hydrocephalus is not too extensive to prevent birth alive, or if the disease is 
 just beginning, the patients may survive for some years. It is evident that 
 the group of diseases of intrauterine origin which persist into extrauterine 
 
 existence is not one of great importance. 
 The most important is hydrocephalus, 
 which, while of intrauterine origin, per- 
 sists as one of the most important dis- 
 eases of infancy. Congenital debility, 
 characterized by small size and low 
 weight, evidences of prematurity, sub- 
 normal temperature, etc., while not a 
 disease, is a very common and import- 
 ant legacy of the antenatal period which 
 may arise from a host of maternal con- 
 ditions and which may predispose the 
 individual to an early death under a 
 variety of forms. 
 
 5. Infantile Syphilis. — Syphilis in in- 
 fants is either congenital or a postnatal 
 infection. (See Antenatal Syphilis, page 
 259.) In the first instance it is heredi- 
 tary; in the second, an acquired disease 
 with initial lesion and its sequences, 
 which do not differ from those of later life except in the modifications which 
 fetal tissue may bring about. Heredity is seen following syphilis of one or 
 both parents. Infection from the father is most frequent and least severe, be- 
 cause influence ceases with impregnation. It is most depressing in double 
 heredity, but maternal cases, owing to the nine months of interchange between 
 the fluids of the fetus and the mother, show a mortality almost as high. Ac- 
 cording to Foumier's statistics of five hundred cases, one-third are fatal from 
 transmission from the father, 60 per cent, from the mother, and 68 per cent, in 
 mixed descent. These figures are very materially modified by prompt treat- 
 ment. For pathology and symptoms, see Antenatal Syphilis, Part III. 
 
 Diagnosis. — To aid in the diagnosis of early inherited syphilis, there may be a 
 history of disease or evident efflorescence in one or both parents, or the tale of 
 repeated abortion may be elicited at progressively retarded periods, the fetuses 
 being macerated, shriveled, with enlarged, lobulated livers, skin eruptions, or 
 hydrocephalus. The infant presents signs of the disease at birth or they develop 
 in a few days. It may be rosy and well nourished, but is oftenest emaciated, gray 
 
 Fig. 1006. — Syphilitic Pemphigus in the 
 Newly Born. ^{Lepage.) 
 
ANTENATAL AFFECTIONS IN EXTRAUTERINE LIFE. 811 
 
 in hue, with a senile facies. The palms and soles show red areas on which bullae 
 develop, moist papules are seen around the anus and mouth, the mouth is filled 
 with sores. The baby has difficulty in nursing, breathes through the mouth, and 
 snuffles continually. The cry is feeble and hoarse; there may be a persistent 
 bronchitis. The eyes present no symptoms or there are a ciliary injection and 
 photophobia. The end of one or more of the long bones shows an inflammatory 
 
 yat Periosteum 
 
 Fig. 1007. — Syphilitic Osteochondritis in the Newly Born. Longitudinal Section. 
 X 100. — {From a specimen in the Pathological Laboratory of the Cornell University 
 Medical College.) 
 
 enlargement. All symptoms may be absent when a parent is known to be 
 syphilitic. The child must then be watched for developments (Fig. 1006). 
 
 Prognosis.— This is practically entirely dependent on treatment if the child is 
 viable. Mortality in maternal descent is reduced from 60 to 3 per cent. Re- 
 currence is unfortunately apt to occur, and in the shape of destructive lesions 
 later in life, but the large percentage of relapses is due to insufficient medication 
 
812 THE PATHOLOGY OF THE NEWLY BORN. 
 
 at the outset. Certain cases succumb to marasmus in spite of all that can be done. 
 As to the viability of a fetus, the prognosis is better as the parental syphilis 
 increases in age and as attention has been paid to treatment. Much can be 
 done in the way of prevention by careful mercurialization of the mother during 
 pregnancy. 
 
 Treatment. — Inunction should be instituted as soon as the diagnosis is made. 
 It is best done by smearing mercurial ointment under the belly-band, where the 
 child's movements will cause its absorption. The white precipitate or blue 
 ointment maybe used, a half-drachm of either, mixed with an equal part of lanolin, 
 daily until the symptoms have disappeared, then every other day for a month. 
 After that time the inunctions are continued with intermissions for a year, 
 or internal medication in the form of gray powder or the protiodid or tannate 
 may be substituted. It is well while mercury is being given systematically to 
 administer a little iron from time to time in the shape of the syrup of the iodid. 
 It is not enough to medicate the mother. The method is inaccurate and most 
 unscientific, but there is small hope for the child if she does not nurse it. Wet- 
 nursing is not to be considered on account of contagion, unless the nurse is 
 syphilitic. Medication should be continued for at least a year, but the child 
 should be kept under observation for two j'-ears. 
 
 III. AFFECTIONS WHICH ORIGINATE INTRA PARTUM. 
 
 I. Asphyxia Neonatorum. 2. Birth Traumatisms. j. Aspiration Pneumonia. 4. Con- 
 tagious Diseases Contracted from the Mother. (7) Ophthalmia Neonatorum. (2) Gonor- 
 rheal Stom-atitis. 
 
 Here belong most of the cases of asphyxia, the various birth traumatisms 
 aspiration pneumonia, and contagious diseases — chiefly gonorrhea — contracted 
 from the mother sub partu. So-called intranatal affections constitute a well- 
 defined group which in general bears little relation to antenatal or neonatal 
 disease. Some confusion may occur in the case of sepsis, which may be con- 
 tracted at any period of existence, whether intrauterine or extrauterine. The 
 pathogenic factors which operate intra partum may be mechanical or bac- 
 terial. The former consist largely of compression of the fetus, either by the 
 maternal passages or by the forceps, and of traction by the medical attendant or 
 of aspiration by the fetus of liquor amnii. The latter comprise a number of 
 germ infections, one of which, however, stands out with prominence over all 
 others: viz., gonorrheal ophthalmia. The mechanical element is equivalent to 
 the entire subject of dystocia. The immediate results of mechanical compression 
 may be general or local. There are but two examples of the general character. 
 (i) Asphyxia: Here the compression is of such a character that the aeration of 
 the fetal blood becomes arrested. (2) Apoplexy: Compression of the skull some- 
 times leads to endocranial hemorrhage, which may cause the death of the fetus, 
 or, if the latter survives, paralysis. 
 
 I. ASPHYXIA NEONATORUM. 
 
 Synonyms : Apnoea neonatorum ; asphyxia nascentium. 
 
 Introduction. — This subject, at first sight one of great simplicity, is in reality 
 one of the most difficult in the entire subject of obstetrics. The simple and 
 straightforward manner in which it is presented by the great majority of authors 
 
AFFECTIONS -WHICH ORIGINATE INTRA PARTUM. 813 
 
 involves a discreet suppression of numerous problems which would otherwise 
 confuse and perplex the student. Nevertheles^s I deem it the wiser plan to face 
 these difficulties and to attempt, at least, to distinguish between what is clear 
 and what is obscure. Asphyxia neonatorum is one of the neglected connecting 
 links between two specialties — obstetrics and pediatrics. Each one of these has 
 apparently been perfectly willing to abandon its care of this subject to the 
 other; each has considered it in a fragmentary way. The result has been that 
 important phases of the subject still await investigation and. our knowledge of 
 it is imperfect. 
 
 Definition. — Before a definition can be made it will be necessary to analyze 
 the meaning of the terms in use. What is meant by asphyxia, whether the 
 word is used in a general sense or refers only to the newly born, is practically 
 defective aeration of the blood, and this deficiency may be slight or extreme. 
 While I do not advise the doing away with a term so universally employed as 
 asphyxia, I prefer, when possible, to substitute some such expression as 
 "subaeration." The term apnea, which has been proposed as a substitute for 
 asphyxia, is open to the same objection as the latter word, and Ahlfeld has sug- 
 gested that it be used to represent the physiological inactivity of the fetal lungs 
 up to the time of ligation of the cord. Such terms as "suspended animation" 
 and "apparent death," often proposed as substitutes for asphyxia neonatorum, 
 appear to be even more objectionable than the latter, and, as a matter of fact, 
 all the synonyms and substitutes thus far proposed appear to be applicable only 
 to the terminal stage of subaeration of the blood. 
 
 Varieties. — The subject of asphyxia neonatorum consists of a number of 
 different conditions which have a common tendency. Thus, when the child 
 is in utero and labor is not impending various agencies may compress the cord 
 and bring about the death of the fetus. Such a state of affairs might be termed 
 "subaeration from cord compression ante partum " and might be fatal im- 
 mediately, or if the constriction were not complete, a chronic condition would 
 be set up, manifested by some form of arrested development. Under these 
 circumstances the term "intrauterine asphyxia" would apply. If the child is 
 alive and well up to the moment of the onset of labor, and during this act the 
 cord is compressed, we should then have a condition of subaeration from cord 
 compression intra partum. If the subaeration were complete, the child would 
 be dead long before it could be extracted; but if only partial or temporary, it 
 might be possible to reanimate the child after delivery. The cord being free 
 from compression, the very act of labor itself in compressing the skull and 
 thorax, and the added compression of the forceps when the latter is applied, 
 will give rise to a condition which may be described as "subaeration from com- 
 pression of the skull (intra partum)." What has been said of cord compression 
 applies equally to disturbance of placental circulation i;/ situ, and pre- 
 mature detachment of placenta. Some cases of this form are simple, others 
 are complicated by intracranial hemorrhage ; so that the children are bom both 
 asphyxiated and with paralyses of central origin. It is probable that most of 
 the infants that are born in a state of subaeration from which they may be re- 
 animated are examples of simple compression of the skull. If the child is 
 bom alive and does not begin to respire until the cord is 'cut, the condition 
 has been termed physiological apnea. Many children utter no cry at birth 
 and respiration is so shallow that it escapes observation. This is known as 
 "false asphyxia." The child is doubtless in a condition of subaeration because 
 the cord has been cut and the breathing is incomplete. From the fact that 
 these children soon begin to breathe more naturally, the condition may be 
 
814 
 
 THE PATHOLOGY OF THE NEWLY BORN. 
 
 regarded as physiological. This class of cases doubtless passes by imperceptible 
 degrees into a more serious one, especially noted in congenitally feeble and 
 premature children. Here the child attempts to breathe, but is unequal to the 
 task of aerating its blood. It becomes cyanotic and succumbs at a variable 
 period after birth. This might be termed "subaeration from prematurity or 
 
 debility, post partum." When 
 we consider that two or more 
 of the preceding types of sub- 
 aeration may coexist in the 
 same child, the extreme com- 
 plexity of the subject is ap- 
 parent. The list might also 
 be extended; thus, fetal sub- 
 aeration is doubtless present 
 in certain diseases of the 
 mother, especially in convul- 
 sions, and in any maternal 
 affection in which the blood is 
 imperfectly aerated, particu- 
 larly in cardiac and pulmon- 
 ary diseases. Again, during 
 labor chloroform narcosis 
 may favor subaeration in the 
 fetus. 
 
 Pathology. — Pathological 
 changes may be due to the as- 
 phyxia itself, in which case 
 the blood is fluid, the right 
 heart engorged, and the large 
 thoracic vessels, sinuses of the 
 dura, and hepatic vessels are 
 in a state of distention. Ex- 
 travasations often accom- 
 pany the distention, especi- 
 ally in the viscera, and oedema 
 has been noted in the pia, 
 scrotum, and cord. Another 
 set of pathological changes is 
 found in the thoracic organs 
 in cases in which premature 
 respiration has occurred. In 
 these cases the trachea and 
 bronchi may be filled with 
 mucus, amniotic fluid, meco- 
 nium, etc. (Fig. 1008). Such 
 substances constitute a 
 demonstration of the fact 
 that intrauterine respiration has occurred. These fluids may, however, be pre- 
 vented from entering the trachea by the interposition of the membranes or the 
 close contact of the maternal parts. The stomach may also contain meconium. 
 Pulmonary ecchymoses are less frequent here than in post-natal asphyxia. In 
 this form the evidences of premature respiration are absent. General atelectasis 
 
 Fig. 1008. — Respiratory Organs and Heart of a 
 Full-term Child Who Died During Labor of 
 Intrauterine Asphyxia from Premature Respi- 
 ration Caused by Probable Compression of the 
 Umbilical Cord, i, Aspired Tneconium in the res- 
 piratory passages; 2, numerous areas of ecchymoses 
 of asph}oda in the heart and lungs. — (Hofntann.) 
 
AFFECTIONS WHICH ORIGINATE INTRA PARTUM. 
 
 815 
 
 will be found, even in children who have been reanimated. The pathological 
 changes in the intrauterine form are analogous to those of ordinary suffocation. 
 The blood, which is thin, fills the cerebral sinuses. The membranes are oedema- 
 tous. The lungs have a dark hue and the respiratory passages are filled with 
 liquor amnii and debris. Occasionally air is found in the lungs. Extravasations 
 and ecchymoses are found in the various organs, which are congested (Fig. 1008). 
 Soft, dark clots distend the right heart. In the extrauterine form we often find 
 large areas of atelectasis in the lungs. There will be visible the external signs 
 of the forces that have produced the condition. The organs exhibit structural 
 changes. The lungs and heart as well as the diaphragm and brain are often im- 
 perfectly formed. Intrauterine pneumonia or pleurisy may be present. When 
 ineffectual respiratory efforts have occurred, the lungs are more markedly con- 
 gested and numerous hemorrhages 
 are scattered over the visceral 
 pleura. -The lungs are engorged 
 to such an extent that they are 
 heavier than water; when immersed 
 they sink at once. One proof of pre- 
 mature respiratory efforts is the 
 presence of a greenish fluid which 
 may be pressed from the cut surface 
 of the lungs and which may be 
 found in the trachea. 
 
 Etiology. — Anything which 
 tends to interrupt the flow of blood 
 toward the fetus through the pla- 
 centa and cord will shut off its oxy- 
 gen. Hence, either compression of 
 the cord or premature separation of 
 the placenta is the most natural 
 cause of asphyxia. Tetanoid con- 
 tractions of the uterus in which the 
 muscular action is continuous will 
 also arrest the placental circulation. 
 Another condition under which as- 
 phyxia may develop is the so-called 
 "vaginal birth" which occurs at 
 times in breech presentations. 
 Here the placental circulation is 
 
 interrupted while the head is still in the vagina and remote from atmos- 
 pheric air. There are a number of conditions which favor the development of 
 asphyxia and which are divisible into maternal and fetal. Such conditions do 
 not produce a forcible shutting-off of the oxygen supply, and the mechanism 
 by which asphyxia develops in these cases is by no means clear. There occurs 
 a suppression in the amount of oxygen which reaches the fetus, either because 
 of scarcity of that substance in the maternal blood, or of some anomaly of the 
 fetal organs which interferes with the oxj^genation of the blood. Hemorrhage 
 in the mother, by greatly reducing the number of red corpuscles, and thereby 
 interfering with the oxygen supply, becomes a cause of asphyxia. In fetal 
 asphyxia from eclampsia the shutting-off of the oxygen supply might be due 
 to interference with maternal respiration or to a tetanic condition of the uterus. 
 Only after the fetus is born can the various conditions, such as persistence 
 
 Fig. 1009. — Face of a Newly Born Child 
 Covered by a Portion of the Membranes. 
 A possible cause of asphyxia in the newly 
 born. 
 
816 THE PATHOLOGY OF THE NEWLY BORN. 
 
 of the foramen ovale, atresia of the pulmonary artery, etc., come into play. 
 Causes from interference with pulmonary respiration begin to be operative 
 before delivery to the extent that the entrance of maternal secretions, meconium, 
 etc., into the breathing passages may obstruct the first efforts at respiration. Per- 
 sistence of the membranes unruptured will have the same effect; likewise the 
 fact of so-called vaginal birth (Fig. 1009). Again, when the child first attempts 
 to breathe by the lungs the presence of a disease or malformation may be evident 
 for the first time; e. g. , atresia of the pulmonary artery, persistence of the foramen 
 ovale, congenital atelectasis. An entirely different mechanism obtains in asphyxia 
 from brain compression. When there are no evidences of interference with pla- 
 cental circulation through the agencies already described, we are forced to explain 
 asphyxia due to brain compression by the profound slowing of the fetal heart 
 which diminishes the oxygen received to such an extent as to cause death. It 
 is claimed that compression of the skull paralyzes the respiratory center. 
 
 Symptoms. — The phenomena known collectively as asphyxia, subaeration, 
 oxygen-hunger, etc., however produced, are essentially the same in nature, 
 presenting every degree of intensity from mere irregularity and superficiality 
 of breathing to a condition of apparent death. Despite this gradation in 
 intensity of manifestation, the great majority of authors still cling to the old 
 fundamental subdivision of blue and white asphyxia. The former term indicates 
 a condition of cyanosis, but differs from the white or anemic variety not so 
 much in color as in the behavior of the muscular system, the latter preserving 
 its tonus in the blue type, while in the white asphyxia a state of complete mus- 
 cular relaxation exists. Blue asphyxia or cyanosis due to a sudden accumula- 
 tion of carbonic acid in the blood is believed to pass naturally into the anemic 
 or white stage, which is therefore held to be the terminal manifestation; yet this 
 distinction is of little value in practice because in the white variety it is not 
 only often possible to resuscitate children thus bom, but spontaneous recovery 
 under these circumstances is far from exceptional. I am in favor of doing away 
 with the color test or blood test, and of placing the chief reliance upon the 
 state of the muscles in determining the degree of subaeration. In mild or 
 medium degrees of the latter the pharyngeal reflex is preserved, while in the 
 highest degrees it is absent. Whether or not there is coniplete concordance be- 
 tween the state of the blood and the condition of the musculature does not appear 
 to have been determined. When the pharyngeal reflex is absent, the lower 
 jaw hangs loose. Another test of extreme asphyxia is found in the failure 
 of the heart to respond to the various forms of cutaneous stimulation. The 
 blue asphyxia is characterized clinically by a livid redness or blueness of the 
 face and upper parts of the body. The face is turgescent and the eyeballs are 
 prominent and injected. The muscles of the extremities, neck, and jaws are 
 rigid, and the heart action is strong. In children thus born the cord is found 
 to pulsate strongly. The reflexes and sphincters behave in a normal manner. 
 Children bom with blue asphyxia may recover promptly or only after a con- 
 siderable interval; or the condition may pass into the white or anemic fonn. 
 Here the condition superficially present in blue asphyxia appears to be inverted. 
 The surface is pale instead of livid. The face is pinched, the muscles, includ- 
 ing the sphincters, are all relaxed. Circulation is at a standstill, and not only 
 is the heart-beat difficult to recognize, but there is no escape of blood when 
 the surface is incised. Children bom with white asphyxia have a small, almost 
 pulseless cord. All in all, the subject of the symptomatology of asphyxia 
 neonatorum is in a most unsatisfactory state. 
 
 Diagnosis. — -Diagnosis before delivery is made (i) by the aid of information 
 
AFFECTIONS.WHICH ORIGINATE INTRA PARTUM 817 
 
 afforded by the fetal heart-sounds, which undergo alterations in quality and 
 frequency; (2) by the presence of meconium in the discharges (except in breech 
 presentations), and occasionally (3) by the intrauterine cry heard in the lower 
 part of the canal or the evidence of respiration in the same locality. Diagnosis 
 after delivery is made by recognition of the clinical picture of diminution or 
 absence of circulatory and respiratory phenomena. In regard to vaginal birth, 
 inspiratory efforts of the fetus while the head is in the vagina are betrayed 
 by a peculiar quivering of the skull (in head presentations). In this connection 
 it should be stated that this phenomenon is equivalent to an indication to 
 terminate labor immediately. 
 
 Prognosis. — As long as there is cardiac action there is hope of resuscitation. 
 Generally speaking, the prognosis is always grave, varying with the degree 
 of asphyxia. Spontaneous efforts at respiration constitute a favorable sign. 
 It must be remembered that the failure of respiration may be owing not to 
 ordinary asphyxia, but to another affection, such as a trauma affecting the 
 respiratory center, atelectasis, intracranial hemorrhage, etc. If efforts at re- 
 animation are successful, the prognosis is still far from favorable, as death 
 frequently occurs from atelectasis, paralysis, convulsions, pneumonia, etc. 
 Regarding the prognosis in utero, we should not forget that the interruption 
 of the placental circulation may be only temporary. The tendency of the 
 child to make inspiratory efforts whenever the placental circulation is interfered 
 with is not one of self-preservation, for the asphyxia is thereby rendered worse, 
 since the blood is forced from the right heart into the lungs. On the other 
 hand, the aspiration of amniotic fluid, etc., does no harm, but tends to inhibit 
 the respiratory movements. 
 
 TREATMENT. 
 
 Prophylaxis. — This includes everything which tends to promote eutocia, 
 such as correction of malposition before labor is under way; acceleration of 
 delivery by manual compression; correction of positions which threaten im- 
 paction; speedy relief of spastic rigidity of the cervix ; preservation of the bag of 
 waters; avoidance of abuse of chloroform. Here also belongs the proper man- 
 agement of the child after birth. Extreme measures have sometimes been 
 recommended or practised for the prevention of asphyxia. Thus, Rapin per- 
 formed insufflation of the amniotic sac on a number of occasions. He introduced 
 the air by means of a catheter and syringe, 500 to 600 c.c. at a time. It is self- 
 evident that the air could not enter the uterine sinuses, protected as they were 
 by the amnion. Rapin claims good results.* A still more radical procedure is 
 the performance of tracheotomy when during a breech delivery the head is ar- 
 rested at the brim. By means of a tracheal tube the lungs may be inflated and 
 respiration begin in this locality. 
 
 Curative Treatment. — Here we have four well-defined indications — namely: 
 (i) immediate delivery, the diagnosis of intra-partum asphyxia having been 
 made (page S16); (2) removal of foreign substances from the respiratory pas- 
 sages immediately upon the birth of the child; (3) the restoration of respiration 
 by reflex stimuli, artificial respiration, or insufflation of the lung; (4) treatment 
 of shock. 
 
 I. Immediate Delivery. — The choice of means will in most cases be in 
 
 favor of the forceps. Often a preliminary bimanual completion of cervical 
 
 dilatation will be demanded. After the expulsion of the child, if cyanosis is 
 
 evident, the cord should be divided at once and allowed to bleed about an 
 
 * "Ann. de gyn. et d'obst6t.," Sept., 1S99. 
 
 52 
 
818 
 
 THE PATHOLOGY OF THE NEWLY BORN. 
 
 ounce. It should be remembered, however, that imimediate Hgation of the cord 
 is in itself equivalent to depriving the child of an ounce of blood. In the anemic 
 form of asphyxia we should cover the child with hot flannels and wait for the 
 pulsations of the cord to cease. 
 
 2. Removal of Foreign Substances from the Air-passages. — The 
 second indication is to cleanse the respiratory passages of fluids aspirated 
 during labor. This can be accomplished in part by inverting the child and 
 swabbing out its mouth with the little finger wrapped in gauze (Figs, loio, loii). 
 The contents of the nose should be squeezed out. This cleansing of the mouth 
 
 and nasal passages should be begun as soon 
 as the head is born. Some obstetricians 
 claim ihat respiration is the best and most 
 rational means for cleansing the lower air- 
 passages. Hence after the preliminaries 
 just described they either attempt to excite 
 natural respiration by reflex stimuli, or in 
 more serious cases proceed at once to arti- 
 
 
 Fig. ioio. — Suspension of the As- 
 phyxiated Newly Born Child by 
 THE Feet to Assist Gravity in 
 Freeing the Air-passages of For- 
 eign Matter. 
 
 Fig. ioii. — Suspension of the Asphyxiated 
 Newly Born Child by the Feet, and Clear- 
 ing the Posterior Pharynx of Foreign 
 Matter with the Little Finger Wrapped 
 WITH Gauze. 
 
 ficial respiration. Other authorities believe in the advisability of direct aspiration 
 of the secretions by special devices or by an ordinary catheter. This last practice 
 I am accustomed to follow. The same apparatus may be used to aspirate the 
 larynx and perform insufflation. All attempts, however, to enter the larynx 
 should be frowned upon. Practice upon the cadaver will readily impress one 
 with the barbarousness of such an attempt upon the newly bom child. The 
 most that can be accomplished by aspiration is the removal of mucus from the 
 lower part of the pharynx. A No. 6 catheter may be made to answer, into the 
 middle of which I insert a pipette, so that its bulbous expansion catches the 
 
AFFECTIONS- WHICH ORIGINATE INTRA PARTUM. 819 
 
 aspirated fluids which might otherwise enter the operator's mouth (Fig. 1012). 
 If a catheter is used, it should be open at the end. 
 
 3. Restoration of Respiration. — (i) Reflex Stimuli. — The third indi- 
 cation in the treatment of asphyxia is to excite the respirations. There are 
 two methods of doing this: viz., reflex stimulation and artificial respirat on. 
 The former may suffice in mild cases. The usual forms of stimuli applied 
 include blowing in the face, slapping the buttocks, sprinkling or immersing, 
 hot and cold water being used alternately. The child being nearly immersed 
 in warm water, cold water, alcohol, or ether may be dropped from a height 
 on the exposed chest. Laborde's method of tongue traction is really a reflex 
 stimulus, although usually classified under artificial respiration. Cooke's 
 method of dilating the anus with the finger also belongs here. 
 
 (2) Artificial Respiration. — The various methods now in vogue are as follows: 
 (a) Byrd's Method. — Dr. Byrd * described a method of artificial respiration 
 as follows : " Bring the ulnar sides of the hands together with the palmar surfaces 
 looking vertically; then prop them beneath the back of the infant so that the 
 extended thumbs may aid as far as possible in sustaining the vertex and inferior 
 extremities. Then, keeping the ulnar borders of the hands in contact so as 
 to form a fulcrum, the radial borders or sides are simultaneously depressed to as 
 great an extent as practicable, say 45 degrees, below the horizontal line, and then 
 gradually elevated or pronated as many degrees above that line, thus facilitating 
 
 Fig. 1012. — Aspirator for Removing Foreign Matter, as Blood, Mucus, and Meco- 
 nium, FROM THE Posterior Pharynx by Suction. 
 
 the escape of air drawn into the lungs during the downward movement of the 
 head and chest. These movements performed in a regular and gentle manner 
 and repeated at proper intervals seldom fail in the establishment of respiration 
 where it is possible of accomplishment." Dr. Byrd gives three illustrations of 
 this method. Byrd's method has been somewhat modified in the past thirty 
 years, principally by Dr. Dew, of New York, so that to-day it is often performed 
 as follows: It should be remembered that Byrd's method can be carried out with 
 the child in a warm bath. The infant is grasped with the right hand, the neck 
 supported between the thumb and the index-finger (Fig. 1013). The head is 
 allowed to fall backward unrestrained. The palm supports the shoulders while 
 the three last fingers in the axilla lift the arm upward and outward. The left 
 palm is placed beneath the thighs with the fingers grasping the knees (Fig. 1014). 
 Inspiration is induced by arching the body of the child. The depression of the 
 pelvis and lower limbs causes descent of the diaphragm through the traction upon 
 the abdominal viscera, while flexion at the upper portion of the vertebral column 
 elevates the ribs and separates them. Expiration is induced by reversing the 
 movements. The hyperextension of the spine is changed to extreme flexion (Fig. 
 1015). The elevation of the head and shoulders tends to approximate the ribs, 
 while extreme flexion of the thighs crowds the diaphragm upward through the 
 pressure of the abdominal viscera. At the completion of expiration the child 
 should be inverted, head downward, while an assistant clears the mouth and nose 
 
 *" Baltimore Med. Jour.," 1S70, i, 646. 
 
820 
 
 THE PATHOLOGY OF THE NEWLY BORN. 
 
 Fig. 1013. — Byrd's Method of Artificial Respira- 
 tion. Position for Inspiration. 
 
 rr^- 
 
 ^^^ 
 
 of any accumulated mucus with a gauze- wrap^jed finger (Fig. 1015). Byrd's 
 movements should be repeated six or eight times a minute. If properly per- 
 formed, the air can be heard 
 entering the glottis during 
 artificial inspiration, while 
 expiration often results in the 
 expulsion of aspirated amni- 
 otic fluid and mucus. 
 
 (b) Schultze's Method. — 
 This has been recently (1901) 
 described by Schultze himself 
 as follows: The child lying 
 upon its back is grasped by 
 the shoulders, the open hands 
 having been slipped beneath 
 the head. The last three fin- 
 gers remain extended in con- 
 tact with the back while each 
 index is inserted into an ax- 
 illa, the thumbs lying upon 
 and in front of the shoulders 
 (Fig. 1 01 6). When the child 
 thus held is allowed to hang 
 suspended, its entire weight 
 rests upon the two fingers in 
 the arm-pits. It is now swung 
 forward and upward, the 
 operator's hands going to the 
 height of his own head, the 
 pelvic end of the child rises 
 above its head and falls slowly 
 toward the operator by its 
 own weight, flexion occurring 
 in the lumbar region (Fig. 
 1 01 6). The thumbs in front 
 of the shoulders compress the 
 chest while the hyperflexed 
 lumbar vertebrae and pelvis 
 compress the abdomen, and 
 through it the thorax; finally, 
 the last three fingers on each 
 side compress the thorax 
 laterally. As a result of this 
 manoeuver when properly 
 done, aspirated secretions 
 flow abundantly from the 
 mouth. The distended heart 
 also feels the compression, 
 which forces the blood into 
 
 Fig. iois.-Byrd's Method of Artificial Respira- ^ j^ ^^^^ i^g ^^g- 
 
 TioN. Position for Expiration. Note the mver- . . . . j 
 
 sion of the child to assist in freeing the air-passages. inal position and supported 
 
 /"' 
 
 Fig. 1014. — Byrd's Method of Artificial Respira- 
 tion. Position between Inspiration and Expi- 
 ration. 
 
 
AFFECTIONS WHICH ORIGINATE INTRA PARTUM. 
 
 821 
 
 entirely by the fingers in the axilla (Fig. 1016). The compression of the thumbs 
 and last three fingers is removed. The downward swing elevates the sternum 
 and ribs while gravitation and the traction of the intestines depress the dia- 
 phragm. It is often possible to hear the air rush into 
 the infant's glottis as it reaches the original position, 
 although this can occur in a cadaver. The amplifica- 
 tion of the thorax lowers the intracardiac pressure. 
 The child should be swung up and down ten times for 
 the space of a minute. The effects of the manoeuver 
 should be as follows: The heart-beat increases in 
 frequency, the cadaveric pallor of the skin becomes 
 replaced by a rosy hue, and the muscular tonus ap- 
 pears. The child is then placed in a warm bath and 
 watched. If the inspirations are superficial, a momen- 
 tary dip in cold water is indicated. If the heart action 
 becomes poor, the child should be swung again. If pro- 
 longed swinging becomes necessary, the root of the 
 tongue should be compressed forward in order to raise 
 the epiglottis and permit the removal of secretions 
 with the fingers. In premature children the thoracic 
 walls are often too soft to benefit by the compression 
 of the fingers. In these cases insufflation of air should 
 be practised. 
 
 (c) Sylvester's Method {Modified). — This method of 
 artificial respiration requires an assistant. The child 
 is placed on its back with the head supported (not to 
 such an extent that the chin compresses the sternum). 
 The thorax is slightly elevated by a towel placed be- 
 neath it. The feet are firmly held by an assistant 
 with a towel. The physician stands behind the child 's 
 head. To imitate inspiration the arms are grasped 
 near the elbows and brought close together above the 
 head, while at the same time gentle upward traction is 
 made. The assistant makes counter-traction upon the 
 feet. The movements expand the ribs, although the 
 change in the intrathoracic pressure may be manifest 
 at first only by retraction of the abdomen. If the 
 movements are continued with the arms somewhat 
 everted to put the pectoralis major upon the stretch, 
 the air gradually begins to enter the chest. Expira- 
 tion is imitated by bringing the elbows down and 
 against the sides. The arms are somewhat inverted, 
 which brings the forearms across the chest. The 
 operator's hands also make compression upon the 
 thorax, so that air is forced from the latter, carrying 
 perhaps some secretion with it. The movements are 
 made at the rate of twenty a minute. The mouth 
 should be wiped out from time to time, and if the 
 passages are still clogged the child should be inverted 
 
 and the chest compressed. If spontaneous respiration begins, the movements 
 must be timed in harmony with it; this is of vital importance. When natural 
 respiration is able to replace artificial measures, it should be assisted by ordinary 
 
 Fig. 1016. — Schultze's 
 Swinging Method of 
 Artificial Respira- 
 tion. The upper figure 
 is the position of expir- 
 ation and the lower that 
 of inspiration. 
 
822 
 
 THE PATHOLOGY OF THE NEWLY BORN. 
 
 reflex stimulation. The efficacy of this method is shown by the fact that it can 
 maintain the circulation in cases in which the respiratory paralysis is complete. 
 
 (d) Prochownik's Method. — The child is held inverted by the legs, the opera- 
 tor's right hand grasping the ankles with the index finger between (Fig. 1027). 
 The head is supported below to an extent sufficient to produce full extension. 
 Both hands of an assistant compress the thorax until all secretions come away. 
 When the hold on the thorax is released, inspiration takes place. After repeating 
 the movements six or eight times the child is placed in a hot bath. An advan- 
 tage of Prochownik's method is that it antagonizes the development of aspira- 
 tion-pneumonia . * 
 
 (e) Laborde's Method. — This consists in exciting the respiratory center by 
 rhythmic tractions upon the tongue. The latter is drawn out with the fingers 
 
 Fig. 1017. — Prochownik's Method of 
 Artificial Respiration. 
 
 Fig. 1018. — Method of Infusing Saline 
 Solution into the Umbilical Vein of the 
 Newly Born for Some Varieties of As- 
 phyxia. 
 
 (enveloped in a piece of gauze) some fifteen to thirty times a minute. After 
 each act of traction it is allowed to fall back into its customary position. It 
 appears to stimulate the respiratory center through the proximity of the 
 latter to some of the other medullary centers which are acted upon by the 
 tractions. 
 
 (3) Insufflation. — Opinions as to the utility of this resource are of great 
 variance. Some mention it as the first, others as the last resort. It may be 
 practised with or without instruments. The former comprise special tracheal 
 tubes which are difficult of introduction, and apparatus designed to cover 
 the nose and mouth of the child. An ordinary stethoscope will answer the 
 latter purpose. If a tube is used, it should be introduced by the aid of a finger 
 
 * This author's original paper may be consulted in the "Ctbl. f. Gynakol.," 1894, 
 p. 226. 
 
AFFECTIONS WHICH ORIGINATE INTRA PARTUM. 823 
 
 which has previously located the arytenoid cartilages. If the tube enters the 
 esophagus, insufflation will inflate the belly. In insufflation without instru- 
 ments — the mouth-to-mouth method — the child lies supine with chest elevated, 
 as in Sylvester's method of artificial respiration. The operator breathes into 
 the mouth through gauze; the thorax should be compressed gently after each 
 insufflation. 
 
 (4) Shock Treatment. — The fact that measures that belong under this 
 head are of such value in asphyxia apparently justifies the theory that the con- 
 dition itself possesses a considerable element of shock. These measures comprise 
 the application of heat, either dry or moist, the child being wrapped in hot flannels 
 or immersed in hot water; hot saline infusion into the rectum; hypodermics of 
 brandy (flve or six drops) or of strychnin {-j^jj grain). 
 
 (5) Umbilical Infusion. — Success has attended infusion through the umbili- 
 cal vein after all the customary resources have proved inefflcient.* The infusion 
 is something more than an ordinary saline solution, for Schiicking added fructo- 
 sate of soda, a substance which is believed to take up the excess of carbonic acid 
 in the blood with the formation of sodium carbonate and sugar. The formula used 
 is as follows: Fructosate of soda, 0.5; sodium chloride, 0.7; boiled water, 50 c.c. 
 The apparatus employed is a graduated bottle, a tube, and a cannula (Fig. loi 8). 
 The umbilical vein is cut across and the cannula inserted. Thirty cubic centi- 
 meters are thrown in at first, followed by a second infusion of 20 c.c. As soon 
 as the heart and respiration start up, ordinary measures are resumed. 
 
 Resume. — (i) In premature and feeble children Byrd's method of artificial 
 respiration should be practised, with the child immersed in hot water or between 
 hot flannels. Insufflation should be practised by the mouth-to-mouth method 
 or by catheter. (2) In the apoplectic or livid form Byrd's method should be 
 used, varied with a few swings a la Schultze. Lest the surface become chilled 
 from exposure, the child should then be placed immediately in hot water. 
 (3) In the anemic or pallid form Sylvester's or Byrd's method should be used, 
 with the child between hot flannels. 
 
 2. FETAL TRAUMATISMS OF BIRTH. 
 
 I. Traumatisms of the Brain and Cord. — Injuries to the skull and brain 
 are due to obstructed labor, to the faulty application of the forceps, or to 
 faulty extraction of the after-coming head. The lesions which are thus brought 
 about comprise simple compression of the brain without hemorrhage (one of 
 the chief factors in the production of intra-partum asphyxia) and intracranial 
 hemorrhage, which is nearly always meningeal. Naturally the results of com- 
 pression often coincide with hemorrhage, so that to asphyxia are conjoined the 
 consequences of effusion of blood within the cranium. 
 
 Cerebral Apoplexy. — When the blood is extravasated upon the surface 
 of the brain or between the meninges, the term meningeal apoplexy is used; 
 if in the substance of the brain, cerebral apoplexy. No small number of infant 
 deaths either during or closely following the act of parturition are referred to 
 intracranial hemorrhage. Etiology: Some few cases are due to syphilis, and in 
 early hemorrhages the exact nature of which has not been definitely determined 
 direct injury, a blow or a fall in the later months of pregnancy, and the accidents 
 of precipitate labor have been responsible for others; but the great majority are 
 in some manner connected with tedious labor, whether as a result of breech, 
 
 * Schucking: "Ctbl. f. Gjmakol.," June 7, 1902. 
 
824 THE PATHOLOGY OF THE NEWLY BORN. 
 
 transverse, or brow presentation, contracted pelvis, insufficient uterine power, 
 version, the too early rupture of the membranes, or fetal abnormalities. The 
 injudicious and indiscriminate use of the forceps is a potent factor. Pathology: 
 Within the skull there is no zone of freedom from hemorrhage ; it may be epidural 
 or subdural, within the meninges or in the brain substance itself. It occurs 
 at the vertex or base, and varies in amount from very small extravasations 
 to those which cover the entire brain substance. In early life meningeal hemor- 
 rhage is much more common than the cerebral variety and basal hemorrhages 
 greatly outnumber those of the convexity. The most common seat is beneath 
 the pia mater, less frequently into the cavity of the arachnoid, the blood escaping 
 in these situations and spreading uniformly in all directions. Symptoms: 
 The symptoms agree quite closely with the pathological conditions jUst described. 
 They are more uniform, but vary according to the seat as well as the quantity 
 of the effused blood. When due to the ordinary causes of protracted labor, 
 the infant is bom apparently dead, resuscitation is gradual and difficult, the 
 cry is feeble, the eyes are motionless, and the extremities are limp and 
 flaccid. The face is livid or pallid and the respirations are gasping. By means 
 of hot and cold baths, artificial respiration, friction, the general condition of 
 the infants may show slight improvement, but ordinarily they succumb after 
 living a few hours or a few days. Depending upon the distribution of the 
 blood-clots and the amount of intracranial pressure, various degrees of 
 paralyses of the face, arms, and legs may occur, and convulsions and rigidity 
 of the entire body are often present. In the cases which survive the early 
 days of life the rigidity of the trunk and extremities may persist and the degrees 
 of paralysis may be definitely determined. In favorable cases the improvement 
 goes on more or less slowly and scarcely ever becomes more than partial. Con- 
 tractures and other deformities from the permanently paralyzed muscles are 
 sequelag of frequent occurrence. Prognosis: If the infant survives, the smaller 
 extravasations are gradually absorbed and the surrounding parts tend to assume 
 their normal functions. Extensive hemorrhage is usually fatal. As a rule, the 
 prognosis depends on the severity of the early symptoms ; the deeper the uncon- 
 sciousness and the more deficient the respirations and pulse, the less the prospect 
 of recovery. Many cases of epilepsy and idiocy can be traced to a probable hemor- 
 rhage in the brain occurring during or after a prolonged or an instrumental labor. 
 In other and rare cases recovery is to all appearances complete. Treatment : In 
 view of the fact that prolonged labor is responsible for the majority of cases, the 
 indications for treatment are almost wholly preventive. Impacted infants should 
 be delivered with all possible despatch. Forceps and other operative measures 
 must be employed with judgment, brain pressure being avoided as much as pos- 
 sible, remembering that during the progress of labor a child about to be bom is 
 made up of a mass of delicate organs and tissues incapable of resisting unneces- 
 sary force. Asphyxia demands immediate and persistent efforts to inflate the 
 lungs fully. 
 
 2. Injuries to Nerve-trunks. — (a) Facial Paralysis. — Traumatic facial par- 
 alysis is usually due to compression of the nerve by the forceps at or near the 
 stylomastoid foramen, but may sometimes occur in spontaneous delivery (Fig. 
 1 019). In forceps accidents only one or more of the branches of the nerve may be 
 injured, so that only a portion of the distribution of the nerve may be paralyzed 
 (most frequently the temporo facial branch). Forceps paralysis is chiefly uni- 
 lateral, because only one side of the face is exposed to the instrument. Sponta- 
 neous facial paralysis : The subject of forceps paralysis is a relatively simple one, 
 but it is otherwise with the facial paralysis of spontaneous delivery. This acci- 
 
AFFECTIONS- WHICH ORIGINATE INTRA PARTUM. 
 
 825 
 
 dent is of rare occurrence, and not more than a dozen cases were upon record up 
 to the year igoo. These cases have been collected and analyzed by Vogel.* 
 
 Etiology. — This is either traumatic or 
 sponiaueoiis in origin. The former is due 
 to compression with forceps and is usu- 
 ally unilateral, and limited to certain 
 portions of the nerve-distribution, most 
 frequently the temporo-facial branch. 
 The spontaneous type is much more 
 
 Fig. 1019. — Facial Paralysis OF THE Newly Fig. 1020. — Facial Paralysis Due to 
 Born. Pressure of a Forceps Blade. — (Ahl- 
 
 feld.) 
 
 Fig. 1021. — Depression in Left Parietal Fig. 1022. — Traumatic Depression of the 
 Bone Right Parietal Bone. — (Ahlfeld.) 
 
 complex. Recorded cases are few in number, and the mechanism appears to var}' 
 greatly. In the absence of any definite type every case has an atypical character. 
 
 * " Monatschrift f. Geburtshulfe und Gynakologie," vol xii. 
 
826 THE PATHOLOGY OF THE NEWLY BORN. 
 
 Contracted pelvis seems to be a factor of importance. Any clear evidences of 
 compression or stretching seem to be wanting. 
 
 Symptoms. — Facial paralysis may be apparent at birth or within the few 
 days following. It has no tendency to become worse. During repose the only 
 symptom in evidence may be the open eye of the affected side, — due to paral- 
 ysis of the orbicularis. When the child cries, the mouth is drawn to the af- 
 fected side. 
 
 Diagnosis. — This is self-evident, save that a similar monoplegia might pos- 
 sibly be due to an intracranial lesion. 
 
 Prognosis. — This is essentially benign; only in a few known cases has the 
 injury been so severe that recovery was impossible. 
 
 Treatment. — The eyeball, if exposed, must be protected. If spontaneous 
 improvement is in evidence after the tenth day, the case may be left to itself. 
 If no improvement sets in, or if progress is stationary, faradism should be 
 employed, followed, if necessary, by galvanism. This latter may be continued 
 for months if the reaction of degeneration does not appear. 
 
 (6) Brachial Birth Palsy. — This subject belongs principally to neurology 
 and orthopedics, because the nature and extent of the pathological state are 
 seldom in evidence during the lying-in period. In recent years the condition 
 has assumed considerable importance, and the older views are undergoing 
 marked changes. To those interested in the details, I recommend especially 
 the monographic study of Clark, Taylor and Prout,* and an article by J. J. 
 Thomas. t In the present connection I shall consider the subject only as it 
 concerns the obstetrician. 
 
 Definition. — Paralysis involving the muscles of the upper extremity depend- 
 ing upon injury to the brachial plexus during delivery. 
 
 Frequency. — This cannot be determined, because of our ignorance of the 
 state of the brachial plexus in the still-born and in infants who succumb 
 soon after delivery. Further, very mild and transitory cases in survivors 
 may pass unnoticed. The absolute frequency in surviving infants has been 
 computed at i : 2000. 
 
 Varieties. — The numerous varieties of palsy described by neurologists are 
 naturally not much in evidence during the lying-in period. It is enough to 
 state that while usually unilateral, both sides may be involved. A small pro- 
 portion of cases are mild and self-limited. Very exceptionally cord lesions may 
 coexist, with paralysis of the lower extremities. If the first dorsal nerve is in- 
 volved, we may see pupillary phenomena. 
 
 Etiology and Mechanism. — The injury to the plexus which causes the paral- 
 ysis may come about in various ways. We have to consider in this connection, 
 not only the character of the lesion, but the type of delivery through which the 
 latter is caused. While a certain number of cases may be due to mere compres- 
 sion, such as may arise in connection with simple disproportion, the hooked 
 finger in the axilla, forceps-pressure and fracture, dislocation and diastasis of bony 
 structures, the great majority must be due to a stretching or tearing of the roots 
 of the brachial plexus, the latter mechanism (laceration) being responsible for 
 most of the graver cases. Conditions favoring laceration are encountered in 
 head presentations with rotation or traction by forceps, and in attempts to ex- 
 tract the shoulders; also — in about equal proportion — in extraction of breech- 
 cases under all conditions. A small proportion of cases occur in spontaneous 
 head delivery. Experiments on the cadaver show that the fifth cervical root is 
 the first to give way in stretching, and it is probable that when this root is alone 
 
 * "Am. Jour. Med. Sci.," Oct., 1905. f " Boston Med. and Surg. Jour.," Oct. 19, 1905. 
 
AFFECTIONS 'WHICH ORIGINATE INTRA PARTUM. 827 
 
 involved, the case is a relatively mild one. AVith progressive increase in traction 
 the sixth, seventh, and eighth roots become involved. 
 
 Pathology. — Actual lesions are in plain evidence only when a nerve-root is 
 lacerated, either completely or in part. The neurilemma is the first structure 
 to yield and doubtless the sole one in some cases. A hemorrhage is bound to 
 follow, so that in any actual lesion a hematoma must result, although in mild 
 cases it may be slight and quickly absorbed. As a rule, the cicatrix left by organ- 
 ization of the clot is able to compress the nerve-trunk and prevent regeneration 
 in nerves torn through, as well as cause traumatic neuritis in trunks not actually 
 severed. 
 
 Symptoms and Diagnosis. — These vary greatly with the degree of injury and 
 are characteristic only for high degrees. In typical cases, these being of upper 
 arm type, the attitude is characteristic. There is palsy of the deltoid and 
 supraspinatus, so that the arm hangs powerless by the side; the forearm is in 
 extension (paralysis of flexors) and the hand in extreme pronation (paralysis of 
 supinator brevis and biceps), and the whole arm so rotated inward that the 
 palm looks backward and outward (paralysis of the supraspinatus, infraspinatus, 
 and teres minor). Aside from the clinical picture, there often develop later 
 evidences of traumatic neuritis due to compression of the organizing blood-clot. 
 The limb is tender and irritable on handling, and the child peevish and fretful. 
 As these evidences of neuritis are certain to be followed by more or less secon- 
 dary palsy, absence of them is a favorable sign. In the more severe cases some 
 of the antagonist muscles undergo more or less contracture, increasing the de- 
 formity due to atrophy of the disused paralyzed muscles. 
 
 Prognosis. — If the condition is due exceptionally to compression or very mild 
 laceration, spontaneous recovery may ensue in from three to nine months, although 
 the limb may never attain its natural development and usefulness. In higher 
 degress of laceration, the prognosis depends on the size of the clot and its 
 influence upon the continuity of the nerve. The limits vary between relative 
 recovery and total paralysis. If well-defined traumatic neuritis of the nerve- 
 roots develops, the prognosis is much worse, and the same is true if the deep 
 cervical fascia is injured and must undergo repair. 
 
 In general, considering all cases, the prognosis is unfavorable — about one re- 
 covery in four cases. 
 
 Treatment. — Palliative treatment should always be undertaken on account 
 of the uncertainty of the outcome, for delayed spontaneous recover}^ is not out 
 of the question. Here massage, hot and cold douches, passive motion, and 
 electricity come into play, as well as orthopedic devices, for all these measures 
 tend to overcome contractures and the like. But if there be marked evidence 
 of traumatic neuritis, complete immobilization is indicated until all evidences of 
 inflammation have subsided. The extremity should be immobilized in the 
 natural position, which overcomes the tendency to contracture of the great pec- 
 toral. After subsidence of the neuritis, active measures may be employed. 
 Electricity not only maintains muscular tonus, but is said by Bethe to promote 
 nerve regeneration. 
 
 Radical treatment may be undertaken whenever palliative measures seem to 
 have accomplished their limit of good. This period varies from three months 
 to a year. Apparently nothing is lost by waiting for the latter period, although 
 good results may be "obtained at a much "earlier date. A compromise may be 
 obtained in cases which show no improvement under medical measures by the 
 fourth to sixth month. 
 
 Whenever it appears that the obstacle to recovery is a cicatrix involving nerve- 
 
828 
 
 THE PATHOLOGY OF THE NEWLY BORN. 
 
 continuity, an operation is indicated. In certain cases simple neurolysis should 
 suffice; but as a matter of fact there is generally a separation of the nerve- 
 segments which requires suture of the divided ends. This treatment will at 
 least prevent many of the sequelae of neglected cases of paralysis, even if it does 
 not conduce to restoration of function. 
 
 3. Injuries to the Cranial Bones. — These comprise (a) depressions, (6) frac- 
 tures. 
 
 (a) Depressions or Indentations. — The occurrence of depressions or 
 indentations in the fetal cranial bones does not imply the existence of a de- 
 pressed fracture, although the latter might also be present. These lesions are 
 very infrequent occurrences — according to Ahlfeld, not over once in three hun- 
 dred living births. Etiology: They are due to some disproportion between the 
 fetal cranium and the maternal pelvis when the latter is contracted, the im- 
 pression being made by the sacral promontory, for example; or to the forceps, 
 or even to the finger of the accoucheur. 
 These impressions have usually the 
 dimensions of the imprint of a man's 
 thumb in wax (Fig. 1023). They are .^BF' "''^'' \ 
 
 Fig. 1023. — Depression in the Right Pari- 
 etal Bone Caused by the Faulty Appli- 
 cation OF THE Forceps. — {Author's collec- 
 tion of fetal skulls.) 
 
 Fig. 1024. — Contusion and Sloughing 
 OF THE Scalp Caused by a Contracted 
 V-E-LWis.— {Ahlfeld.) 
 
 chiefly encountered in children bom alive and the latter generally survive. Prog- 
 nosis: The lesion is quite likely to rectify itself spontaneously, either wholly or in 
 part, but in case it persists through life it has seldom been known to give rise to 
 any intracranial mischief. Treatment: It has been proposed to trephine in cases 
 in which paralysis appears to be due to this injury. I have seen good results in 
 one case. With this possible exception, there is hardly any treatment for im- 
 pressions of the skull. It is claimed that the application of dry cups is sufficient 
 to correct the deformity, which, however, had better be left to itself. 
 
 (6) Fractures. — These have also been noted after both spontaneous and 
 artificially aided delivery under the same circumstances which give rise to 
 indentations, although cases have been placed on record in which both the 
 pelvis and the fetus, were quite normal, and the only possible source of violence 
 was the uterine contraction, possibly excited by the use of ergot. The 
 parietal is said to be the bone most frequently fractured, but this was not the 
 
AFFECTIONS -WHICH ORIGINATE INTRA PARTUM. 
 
 829 
 
 case in the statistics collected by Lomer. Any one of the cranial bones may 
 be involved. Rupture of the sutures and detachment of some one of the bones 
 may take place under the same circumstances. If fracture of a bone or rupture 
 of a suture should be complicated by the laceration of a sinus or large blood- 
 vessel, fatal hemorrhage will result. Minor degrees of hemorrhage from rupture 
 of small vessels or some lesion of the substance of the brain may also complicate 
 these fractures. As in the case of trauma of the bones of the adult skull, we must 
 bear in mind the possibility of remote consequences. 
 
 Facial Bones. — Fracture of the bones which make up the orbit is of occasional 
 occurrence, as are likewise fractures of the lower jaw and diastasis of its sym- 
 physis. Fracture into the orbit — usually through the frontal bone — is followed 
 by exophthalmus, yet this latter phenomenon has also been noted after simple 
 application of the forceps over the temporal region without the production of 
 trauma. Rupture of the bulbus oculi and other intraorbital lesions may compli- 
 cate fracture into the orbit. While the latter form of injury is ascribed chiefly 
 to the use of forceps, all the phenomena thus 
 produced, including rupture of the globe, have 
 been noted in spontaneous delivery ; while, on 
 the other hand, experimental fracture on the 
 cadaver into the orbital cavity by means of the 
 application of forceps I have found to be an 
 impossibility. It is therefore evident that the 
 
 Blood between 
 Per/oitcum anJ Bone 
 
 Skin 
 Subcutaneous Tissue 
 Penostcum 
 Bone 
 
 DURA 
 
 SEROUS INFILlRATlbN BONE 
 
 PERIOSTEUM 
 
 Fig 1025. — Caput Succedaneum. 
 
 Fig. 1026. — Cephalhematoma. 
 
 rationale of these orbital injuries is not wholly clear. Fractures of the lower jaw 
 occur, as a rule, from traction on the after-coming head in breech presentations. 
 
 4. Fractures of the Long Bones. — As a rule, the violence exerted in connec- 
 tion with dystocia and its management tends to produce diastasis rather than 
 fracture, provided that the long bones of the fetus are healthy. When for any 
 reason (fetal rickets) these structures are brittle, very slight manipulation may 
 produce a fracture. But Ballantyne records the case of a fracture of the shaft 
 of the thigh in a healthy child during normal delivery. There were no evidences 
 of fetal rickets or prematurity. Apparently spontaneous fractures, whether in 
 the healthy or otherwise, cannot justly be put down as examples of birth- 
 trauma. If recognized, fractures and diastases may readily be healed. 
 
 Dislocations. — The luxations which are occasionally present at birth are 
 believed to be due in most instances to malformations of the joints. (See 
 Congenital Dislocation of the Hip.) The possibility of arrested development 
 of the joint in these cases tends to invalidate the notion that luxation occurs 
 as a pure birth traumatism, despite its general plausibility. 
 
830 
 
 THE PATHOLOGY OF THE NEWLY BORN. 
 
 5. Injuries to the Scalp. — Among those I include (i) the caput succedaneum 
 and (2) cephalhematoma. 
 
 (i) Caput Succedaneum. — The caput succedaneum, otherwise known as 
 "false cephalhematoma," occurs with such frequency as to be almost physiologi- 
 cal, the location varying with the position of the child's head during delivery. 
 This condition is a phenomenon of labor itself as well as an affection of the 
 newly bom child, and is a subcutaneous, serous infiltration of that portion of 
 the presenting part corresponding to the center of the birth canal (Fig. 1025). 
 As the presenting part is forced through the os uteri or the vulva, it escapes 
 
 the compression to which the surrounding 
 tissues are. being subjected, with the result 
 that in this free area a sero-sanguineous effu- 
 sion occurs, since the constriction about the 
 presenting part interferes with the circulation. 
 As a rule, this swelling does not form until 
 after the membranes have been ruptured and 
 frequently it may not form at all, as in cases 
 in which delivery occurs very rapidly, or if the 
 maternal parts are disproportionately large. 
 While a certain amount of blood is present in 
 the effused liquid, actual hemorrhage is rare. 
 The caput succedaneum varies considerably in 
 size and shape. It may be rounded, oval, or 
 elongated, and varies in its long diameter from 
 less than one inch (2.54 cm.) up to three inches 
 (7.62 cm.). The skin over the caput is con- 
 gested, and if the labor has been unusually 
 long, it may present a purplish hue. As the 
 presenting part must traverse several obsta- 
 cles to its egress, the caput succedaneum may 
 be formed within the uterus, within the pelvic 
 canal, or at the vulval orifice, and it is not 
 uncommon for a primary swelling to develop 
 when the head passes the os and a secondary 
 caput to form concentrically at a point farther 
 down, especially at the vulval orifice. If there 
 is narrowing within the resisting bony canal of 
 the pelvis, the caput may be of extreme di- 
 mensions and may be bom before the head has 
 traversed the superior strait. (Compare Ver- 
 tex, Part IV, and Face, Breech, and Shoulder 
 Presentations, Part V.) 
 
 (2) Cephalhematoma. — In this affection 
 the escape of blood is between the periosteum and bone, while in caput succeda- 
 neum the site of the effusion is subcutaneous. The extravasated liquid consists 
 wholly of blood (Fig. 1026). Site: The swelling is usually over a parietal bone 
 and limited by some of the sutures. Occasionally it transgresses the sagittal suture 
 and lies over both parietals. The right side of the head is the more commonly 
 affected. Location of the tumor over the other cranial bones occurs infrequently. 
 Symptoms: Cephalhematoma is seldom present at birth but appears two or three 
 days later. The overlying skin is not discolored. The tumor may be of any size 
 up to that of an apple. Fluctuation is present; the limitation of the mass by 
 
 Fig. 1027. — Caput Succedaneum of 
 Left Parietal Bone Seen from 
 Behind. Note also the lateral flex- 
 ion of the fetal body. Compare Fig. 
 573. — (From Dr. W. E. Studdiford' s 
 frozen section at the Emergency Hos- 
 pital.) 
 
AFFECTIONS WniCH ORIGINATE INTRA PARTUM. 831 
 
 sutures gives it a bony outline. This affection must not be confounded with 
 traumatic hemorrhage in the same locality which occurs occasionally as a result 
 of forceps delivery. Here the swelling is diffuse and is not limited by the sut- 
 ures. Frequency: The frequency with which cephalhematoma occurs is about 
 once in two hundred labors. Course: The cause of this affection is obscure and 
 the factors which obtain in caput succedaneum are not in evidence here. It has 
 even been found in breech presentations. The course is, on the whole, benign, 
 and the tendency is to self-limitation. The swelling usually persists for a month 
 or more. Occasionally infection of the blood-clots occurs and perhaps caries of 
 the bone. Diagnosis: Cephalhematoma appears several days after birth as a 
 bloody tumor underneath the pericranium, generally on the side of the head, and, 
 as a rule, is due to pressure. Caput succedaneum is present at birth as a serous 
 infiltration in the tissues over the pericranium and over the presenting part and 
 is due to lack of pressure. It is soft but does not fluctuate. Cephalhema- 
 toma has a soft, cystic feel, but later becomes crepitant. It exists for one or 
 two weeks and sometimes breaks down and suppurates. Caput succedaneum 
 
 Fig. 1028. — Single Cephalhematoma. Fig. 1029. — Triple Cephalhematoma. 
 
 {Author's case at Manhattan Maternity.) (Author's case at Manhattan Maternity.) 
 
 lasts only two or three days, after which it disappears. Besides these two 
 forms of tumor found on the head of the newly bom child several others may 
 be mentioned, the possibility of the existence of which at times complicates 
 the diagnosis, viz. : hemiae cerebri, vascular tumors, meningocele, encephalo- 
 cele, and hydrencephalocele. These abnormalities have been noted elsewhere. 
 (See page 265.) Meningocele consists of a tumor of the scalp partly formed 
 by the meninges; encephalocele is made up partly of brain substance; while 
 hydrencephalocele contains in addition a little liquid. (See page 265.) Treat- 
 ment: Absorption of the extravasated blood may be hastened by the use locally 
 of iodine, and by compression. It is not advisable to open the cavity unless 
 an abscess forms. The blood might possibly be aspirated to relieve the dangerous 
 tension of the scalp and pressure on the skull. In many cephalhematomata 
 seen in hospital and private practice, in only one was an incision demanded; in 
 this case, in private practice, a child of a primipara with a generally contracted 
 pelvis after a thirty-six-hour labor and a difficult forceps extraction developed an 
 enormous blood tumor. The tumor showed signs of sloughing and was freely 
 
832 THE PATHOLOGY OF THE NEWLY BORN. 
 
 incised, the fluid blood washed out with saHne solution, and a gauze drain 
 inserted. A rather tedious recovery resulted. 
 
 6. Hematoma of the Stemomastoid ; Caput Obstipum. — Traumatic hemor- 
 rhage intra partum into the substance of the stemomastoid of one or both sides 
 has been noted in connection with both forceps and breech deliveries and after 
 over- rotation. The extravasated blood sets up a myositis, and in time the 
 phenomenon known as wryneck or caput obstipum may result. This hypothesis 
 as to the origin of the deformity, however, is repudiated by many, but there is 
 no doubt that the patient may have a transitory wryneck. The blood is ab- 
 sorbed in the course of several months, and in many cases is known to leave 
 no deformity behind. This lesion may readily be mistaken for an enlarged 
 lymph-node, being most commonly about the size and shape of a pigeon's 
 egg. No treatment is required, least of all surgical intervention. 
 
 7. Aspiration Pneumonia. — The records of autopsies upon the newly bom 
 appear to show that a certain number of deaths are due to catarrhal pneumonia 
 which develops within two days after delivery. There is no evidence to show 
 that this condition can originate ante partum, nor that it ever arises from atelec- 
 tasis or infection. On the other hand, there is little doubt that it is due to no 
 other cause than the irritating effects of aspirated amniotic fluid which was 
 sterile at the time of the accident. This aspiration indicates that the fetus 
 has attempted to respire in utero during the act of labor as a result of temporary 
 oxygen hunger. The aspirated fluids do not appear to produce the pneumonic 
 state at the time of occurrence, for the child is usually healthy at birth, and 
 perhaps for some time afterward. The supervention of the disease is then 
 announced by rapid respiration, cyanosis, fever, and cough. Death probably 
 occurs as a rule, although percentages are wanting. It is known that recovery 
 is possible and that the child may be free from symptoms in the course of a 
 week or ten days. Diagnosis: This is attended with great difflculty. Aspira- 
 tion pneumonia has not been recognized as a clinical entity until recently. 
 It will be necessary to exclude a number of other conditions, which would be 
 almost impossible without autopsy. If the child is of , normal development, 
 without evidences of septic infection, and especially if there is a history of 
 dystocia with evidences of temporary intra-partum asphyxia, the presence of 
 the symptoms just narrated will make the diagnosis of aspiration pneumonia 
 very probable. Treatment: The infant, since it cannot nurse, must be fed by 
 stomach-tube or medicine-dropper, and must receive stimulants. The general 
 management corresponds largely to that of similar cases in older children. 
 
 4. INTRA-PARTUM INFECTION. 
 
 I. Ophthalmia Neonatorum. — This term is applied to a form of acute con- 
 junctivitis occurring in infants and first manifesting itself within a period of 
 from two to five days of birth. It has been customary to describe at least 
 two varieties of the disease: (i) one of which, of no great importance, may be 
 called catarrhal, and (2) the other, purulent, fraught with the greatest danger 
 of serious injury to the eye, the cornea, and consequently to sight. 
 
 Etiology. — (i) A mild or a moderate catarrhal ophthalmia in an infant 
 may be caused by any non-specific irritant, such as ordinary vaginal secretion, 
 the use of soap or antiseptics, too much exposure to strong light, and also the 
 prophylactic use of antiseptics in the conjunctival sac, notably silver nitrate. 
 (2) The exciting cause of the second variety of the disease is infection, and infec- 
 tion with the gonococcus alone or mixed with other pathogenic micro-organ- 
 
AFFECTIONS. WHICH ORIGINATE INTRA PARTUM. 833 
 
 isms which have reached the eyes, during or immediately after parturition, 
 from the maternal passages or from the hands or instruments of the physician. 
 There is now no doubt of the causative relation of the gonococcus, which has 
 been proved by numerous experiments both by culture and by inoculation. 
 It is possible that the infection sometimes occurs when the eyes are first washed 
 and not during parturition, and it is, of course, possible to infect the eyes of 
 an infant with the gonorrheal virus in the same ways that the eyes of an adult 
 are infected, but this would not be strictly ophthalmia neonatorum and might 
 occur at any time. In the milder cases the gonococcus is not found and the 
 condition must be attributed to infection with other pyogenic germs. The 
 proportion of cases in which the gonococcus is found has been estimated at 
 about 36 per cent. (Bartley). 
 
 Symptoms. — (i) Catarrhal ophthalmia could be dismissed in a very few 
 words were it not for the fact that many of the specific cases are, in the begin- 
 ning, deceptively like those belonging to the mild category, so that it is safer 
 to regard all with suspicion and treat them like commencing purulent cases 
 In those cases which are really catarrhal the inner surface of the lids is congested 
 and red and there is a serous or sero-mucous discharge, but the lids are not 
 swollen and there is no tendency for the symptoms to get worse rapidly. Patho- 
 logically, the condition is one of acute, non-specific, catarrhal inflammation, 
 and it tends to subside without causing structural change or necrosis in the 
 mucous membrane. Bacteria may sometimes be present, but never the gonococ- 
 cus. The symptoms are rarely severe and usually yield promptly to treatment. 
 
 (2) The symptoms of purulent ophthalmia appear, as a rule, on the third 
 day after birth, sometimes a little later, unless the infection has occurred after 
 delivery, when they appear at any time. The first signs are redness and oedema 
 of the lids, the latter increasing so much that it becomes difficult for the nurse 
 to separate the lids. The conjunctiva of the lids becomes very greatly swollen 
 and congested, and has a granular or uneven surface, due to the great exudation 
 of inflammatory products into the loose connective tissue. Very soon the con- 
 junctiva of the eyeball itself is involved and becomes swollen in the same way, 
 a condition called chemosis, and the cornea appears to be at the bottom of 
 a cavity formed by the swollen edges of this ocular conjunctiva. The discharge 
 at this stage is serous, or more often sero-sanguinolent. In very severe cases 
 the exudate may be so great that the conjunctival vessels are compressed and 
 the conjunctiva, instead of appearing red, looks grayish or yellowish-pink. A 
 very free secretion of pus soon begins and the intense swelling and oedema may 
 diminish to a certain extent. The pus may flow freely from the palpebral 
 fissure, or the edges of the lids may adhere to each other, thus allowing the 
 conjunctival sac to be ballooned out by the accumulation of the secretion. 
 This stage of the disease is the most dangerous for the nurses and attendants, 
 and the condition just described should be specially guarded against, since the 
 pus is under considerable tension and may fly into the faces of the bystanders 
 when it is suddenly released by the partial or complete separation of the lids. 
 The most serious complication which may occur in the disease is involvement 
 of the cornea, more often observed in adults, but still common enough in infants 
 Destruction of this membrane of course means blindness, and it is estimated 
 that at least 20 per cent, of all the blindness in the world is due to involvement 
 of the cornea in this form of ophthalmia. The severer the infection, of course, 
 the greater the danger of damage in this respect. The first sign of impending 
 trouble is an appearance of dullness and cloudiness of the whole or a part of 
 the corneal surface. The cloudy patches soon become distinct gray areas of 
 53 
 
834 THE PATHOLOGY OF THE NEWLY BORN. 
 
 infiltration which later turn yellow and ulcerate. The ulcers may perforate 
 into the anterior chamber or they may spread without perforation, the former 
 being the course with the best prognosis. If there is marginal infiltration 
 around the whole cornea, the so-called annular abscess is very likely to result, 
 and in that event the cornea will be destroyed, with perhaps pan-op hthalmitis 
 later. This means loss of the eye. In general, it may be said that the more 
 pronounced the chemosis, the greater the danger that the cornea will be involved 
 in the infectious process. Fortunately in infants, with proper measures, the 
 danger of serious damage is not great. When the disease progresses favorably, 
 the swelling, redness, and purulent discharge gradually diminish, and finally 
 the lids reach a normal condition, though several weeks may be required for 
 this. In infants there is rarely any tendency ior the inflammation to persist 
 and become chronic. A febrile movement is often present and evidences of 
 systemic gonococcus infection may occur; acute inflammation of the joints has 
 been observed. 
 
 Diagnosis. — This should present no difficulties except in the beginning 
 of the attack, and in doubtful cases it is wise to be upon the safe side and treat 
 the case as one of specific ophthalmia. The profuse purulent secretion and 
 swelling of the lids are characteristic. The history of the mother may be of 
 assistance, and an attempt should be made to confirm the diagnosis by micro- 
 scopic examination of both maternal and fetal secretions. 
 
 Prognosis. — In a large proportion of the cases that do not receive prompt and 
 intelligent treatment the sight is destroyed. It has been estimated before the 
 general adoption of prophylactic measures that from 26 to 30 per cent, of 
 all the cases of total blindness in adults was the result of purulent ophthalmia 
 of the newly born. 
 
 Treatment. — (i) Catarrhal: The treatment of catarrhal conjunctivitis con- 
 sists in cleanliness and protection from light. A solution of borate of sodium, 
 ten grains to the ounce of camphor water, or a solution of boric acid, may be 
 used frequently as an eye-wash, and it is a good plan to keep the edges of the 
 lids from adhering by using a little boric-acid ointment upon them. The eyelids 
 must be kept free from dried secretions by some such means, and it is better 
 to make the manipulations at regular intervals, longer or shorter as the case 
 is mild or severe, so that the child will rest without being interfered with need- 
 lessly. The condition is one which, as a rule, responds very promptly to treat- 
 ment. (2) Purulent: The treatment of purulent ophthalmia neonatorum re- 
 solves itself into two parts: namely, (i) prophylactic and (2) curative. 
 
 (i) Prophylaxis. — What is as important in this matter as treatment is prophy- 
 laxis, and no measure should be neglected which can assist in preventing the 
 occurrence of the disease. When the maternal passages are suspected, a pre- 
 liminary course of antiseptic treatment should be instituted, beginning about 
 two weeks before delivery. This should consist in daily or twice daily vaginal 
 douching, first with a mild alkaline solution and then with one of bichloride 
 of mercury, strength i : 5000. Just before delivery something must be done 
 to provide a substitute for the normal lubricating mucus which will have been 
 washed away by the douching process, and a i per cent, lysol solution will be 
 found useful for this purpose. The vagina may be washed out with it when 
 labor begins. As soon as the child is bom its face must be carefully washed, 
 special attention being given to the eyes, and even when infection is not suspected 
 one or two drops of a i per cent, silver-nitrate solution should be dropped into 
 each conjunctival sac. This may be washed away in a moment or two with 
 salt solution if desired. It has now become with most obstetricians in maternity 
 
AFFECTIONS -WHICH ORIGINATE INTRA PARTUM. 835 
 
 service a matter of routine practice to use this i per cent, solution in the eyes 
 of all infants, and since the method was introduced the number of cases of 
 ophthalmia neonatorum has decreased enormously. As an illustration, we 
 may cite the experience of Crede, who suggested the method. At his Lying- 
 in Asylum, at Leipsic, before the use of silver nitrate, this form of ophthalmia 
 occurred in 10.8 per cent, of all infants; after the treatment was systematically 
 carried out the percentage fell to o.i or 0.2 per cent. Other similar experiences 
 have been reported. The methods of procedure will almost invariably cure 
 or protect the infant from this infection, but we have the further duty of pro- 
 tecting nurses, relatives, and physicians. It is hardly necessary to point out 
 the extremely infectious character of the discharge from the eyes of a patient 
 with gonorrheal ophthalmia or to emphasize the importance of avoiding the 
 chance of infecting a clean eye. Every case should be promptly isolated and 
 placed under the care of a special nurse. Attendants must be trained in the 
 observance of antiseptic precautions, and no detail must be neglected. Cotton, 
 gauze pads, and dressings should be burned after use, and the minutest care 
 should be exercised to keep members of the family, especially children, away 
 from the patient or anything which has been used about him. The patient 
 himself must also be prevented from rubbing his eyes. If a clean eye 
 should accidentally be brought in contact with infection, a few drops of the 2 
 per cent, silver-nitrate solution should be instilled, after the eye has been flushed 
 with boric solution, and then cold applications should be made for two or three 
 hours. After this a boric-acid wash should be used occasionally. The duration 
 of this form of conjunctivitis may be several weeks, and treatment must be 
 kept up according to the symptoms as long as they exist. If corneal infection 
 occurs, it is a good plan whenever possible to get the assistance of an ophthal- 
 mologist, since there are often many details which can best be handled by the 
 specialist. 
 
 (2) Curative. — To cure a patient, the sooner the disease is attacked, the better 
 is the chance of prompt success. For at least a century silver nitrate in solutions 
 of varying strength has been the mainstay in the treatment of all forms of con- 
 junctivitis, and in 1882 Crede proposed its use as a prophylactic in infants. When 
 the disease is already present, active treatment must be at once instituted, and 
 what we must depend upon chiefly is antisepsis and local cold. The lids and the 
 conjunctival sac must be kept free from accumulated pus and some kind of anti- 
 septic must be applied to their surfaces. Often cold must be applied continuously 
 if we are to expect success. During the first three or four days before the dis- 
 charge becomes purulent, cold compresses must be applied continuously for an 
 hour twice or three times a day and free washing of the conjunctival sac should be 
 done in addition four or five times a day with a warm, saturated boric-acid solu- 
 tion or a I : 2000 potassium permanganate or a i : 10,000 sublimate solution. 
 This is of the greatest importance, and the washings should be frequent enough 
 to keep the eyes clear of pus. An eye-dropper, glass syringe, or absorbent 
 cotton dipped in the cleansing solution can conveniently be used (Fig. 1030). 
 The child on its side should be held on a piece of rubber on a nurse's lap 
 and the lower eye gently irrigated, the solution being first used to wash 
 away secretion from the outside of the lids, and then gently from between the 
 lids, enough force only being used to wash away the discharge and cleanse 
 the conjunctival surface. In addition to this, it is a good plan to instil 
 once a day a few drops of a 10 per cent, protargol solution (Fig. 628). It is 
 not necessary to use silver nitrate at this stage, and mercury bichloride will be 
 found too irritating in solutions of sufficient strength to exercise active antiseptic 
 
836 
 
 THE PATHOLOGY OF THE NEWLY BORN. 
 
 properties. If the case under observation should, turn out to be simply an 
 aggravated instance of catarrhal ophthalmia, this treatment will be found 
 sufficient; but if pus begins to form and all the symptoms increase, and also 
 if the gonococcus can be demonstrated, we must change our treatment to some 
 extent. The conjunctival sac must be cleansed much more frequently, at least 
 every hour during the day, but perhaps not so often at night, and the lids 
 must be kept from sticking together by the method already described. The 
 protargol solution must be increased in strength to 20 per cent, and it may 
 be used more frequently, preferably after the discharge has been thoroughly 
 washed away and the shreds of muco-pus carefully brushed from the conjunctiva 
 
 with bits of cotton or 
 gauze. If the action of the 
 protargol does not seem to 
 ^i^ be favorable, it will occa- 
 
 sionally be found advisable 
 to employ a 2 per cent, or 
 even stronger silver-nitrate 
 solution, but it is better 
 under such circumstances 
 to make the application 
 only to the everted lids and 
 to wash the residue away 
 at once with salt solution. 
 The extent of the use of 
 cold applications depends 
 somewhat upon the inten- 
 sity of the inflammation, 
 but in all cases ranging 
 from severe to bad, this 
 must practically be con- 
 tinuous. This involves un- 
 remitting care on the part 
 of the nurse, who will re- 
 quire rather frequent relief. 
 The best method to pursue 
 is to have a block of ice in 
 the room and to prepare a 
 number of soft gauze pads 
 about an inch or an inch 
 and a half in diameter, 
 which can be placed on the 
 ice and thus allowed to 
 become moist and cold. 
 These can be used as often as necessary and must be changed as soon as they 
 become warmed. Not infrequently it is necessary to place a fresh pad on each eye 
 every minute, at the same time that the antiseptic treatment is being kept up. In 
 cases of corneal involvement atropin must be used to dilate the pupil, and in all 
 bad cases its use is a wise precaution. If there seems to be danger of strangula- 
 tion of the corneal vessels on account of the density of the exudate and con- 
 sequent interference with the nutrition of the cornea, hot applications may be 
 substituted for cold for a time so as to stimulate the circulation and absorption. 
 It is also occasionally necessary to make radial incisions in the swollen con- 
 
 N 
 
 Fig. 1030. — AlETHOD of Irrigating the Eye of the In- 
 fant IN Cases of Ophthalmia Neonatorum. 
 
DISEASES INCIDENT TO CHANGE OF ENVIRONMENT. 837 
 
 junctiva in order to relieve the external tension. It is better not to use the 
 stronger solutions of silver nitrate and protargol more than once a day. In 
 the case of weak infants care must be taken not to disturb the child any oftener 
 than is absolutely necessary, for a certain amount of undisturbed rest is essential 
 and must be allowed, even if we are not able to cleanse the lids quite as often 
 as we should otherwise wish. The child must be kept warm and carefully and 
 regularly fed, and any gastro-intestinal disturbance must receive prompt atten- 
 tion. In a few very severe cases the swelling and chemosis may be so great 
 that a short incision may have to be made in order to relieve tension and give 
 access to the conjunctival sac. When such measures are thought necessary, no 
 hesitation need be felt in calling upon the expert ophthalmologist for assistance. 
 Sometimes a certain amount of chronic inflammation remains after the acute 
 symptoms have subsided. This may be treated by daily applications of a i 
 per cent, protargol or a 0.5 per cent, zinc sulphate solution. 
 
 Expert Advice. — In view of the danger of loss of sight from this disease 
 and the responsibility involved, it is always well for the obstetrician or general 
 practitioner to secure the services of an expert ophthalmologist, if possible, in 
 every case of the purulent disease. 
 
 2. Gonorrheal Stomatitis, — A gonorrheal infection in infants has its origin 
 in the genital tract of the mother, and for that reason it is confined almost 
 entirely to the newly bom. Etiology: The delicate mucous membrane of the 
 newly born child offers little resistance to this infection, especially after im- 
 proper efforts have been made to cleanse the mouth, and any abrasion offers 
 a favorable entrance for the gonococcus. A pre-existing or concomitant oph- 
 thalmia explains the origin of many cases. Pathology: The hyperemia of the 
 acute stage of inflammation is followed by the formation of creamy patches 
 upon the hard palate or tongue. But the process is distinctly local and shows 
 no tendency to affect the entire stomal mucous membrane. There is a possi- 
 bility, however, of an added infection due to staphylococci or streptococci result- 
 ing in pathological conditions more serious in character. Symptoms and diag- 
 nosis: With stomatitis of this character alone, constitutional symptoms are 
 usually absent, and the general health is not particularly affected. Microscopic 
 examination of the exudate reveals the nature of the exciting cause. Treatment: 
 A saturated solution of boric acid frequently applied is a most efficient agent. 
 In more severe cases a mixture of boric-acid solution and hydrogen peroxide 
 is very useful. The solid stick of silver nitrate may also be of service. 
 
 IV. DISEASES INCIDENT TO CHANGE OF ENVIRONMENT. 
 
 I. Primary Asphyxia of the Newly Born. 2. Atelectasis Neonatorum, j. Failure of Cir- 
 culation. 4. (Edema Neonatorum.. 5. Failure of Digestion and Assimilation. Inani- 
 tion. 6. Inanition Fever. 
 
 The fetus at birth not only changes its surroundings from an aqueous to 
 an aerial medium, but begins to use hitherto quiescent organs and to disuse 
 others previously active. Naturally a healthy child should encounter little or 
 no difficulty in this physiological readjustment; but it is otherwise with the 
 premature or undeveloped. Nearly every one of the more important functions 
 may be in abeyance as a result of this congenital debility. The lungs may not 
 expand, the heart's action may fail, the stomach may be unable to retain the 
 ingesta, assimilation may be impossible, etc. Mere functional incapacity may 
 be associated with various affections largely peculiar to this period of life, 
 
838 THE PATHOLOGY OF THE NEWLY BORN. 
 
 and believed to be the expression of incapacity of the fetus to adapt itself 
 to the external world. These affections do not appear to date from fetal life, 
 nor have they been brought into connection with any form of infection post 
 partum. They are not hereditary, and hence they may be regarded as due 
 to a "change of life," just as puberty and the climacteric have their own peculiar 
 disorders. 
 
 1. Primary Asphyxia of the Newly Bom. — This term is applied to the following 
 condition: When an infant delivered without dystocia, and with no symptoms 
 which point to subaeration ante partum or intra partum (livid or pallid hue, 
 anomalies of the circulation, etc.), fails to respire as soon as the cord is cut, 
 we have a state entirely distinct from the ordinary type of asphyxia which 
 accompanies dystocia. In some instances these infants do breathe for a short 
 time, or the failure of respiration may not set in until several days have elapsed. 
 This affection is purely an anomaly of readjustment of the infant to its new 
 environment and therefore to be met with, as a rule, in weak and premature 
 infants. It should be carefully distinguished from conditions due to labor 
 itself — for example, pneumonia due to aspiration of amniotic fluid; and also 
 from the so-called spurious asphyxia in which the respirations are so shallow 
 that they pass unnoticed. It must also be borne in mind that while many 
 cases of primary asphyxia of the newly bom are due to simple failure of the 
 lungs to expand, others are rendered possible by the presence of disease or 
 malformation of fetal origin (syphilis of the lungs, hydrothorax, defects of the 
 diaphragm, etc.). The mechanism of these cases is not difficult to understand. 
 Neither the lung tissue nor the parietes of the chest are sufficiently developed 
 for respiration, and when malformations or diseases are present, the mechanical 
 hindrance is also capable of accounting for the failure of respiration. The 
 thorax of the premature child may undergo rhythmic movements (this is said 
 to occur even in utero) without any corresponding inflation of the lung. For 
 all practical purposes the remainder of this subject may be considered under 
 Prematurity and Asphyxia Intra Partum. 
 
 2. Atelectasis. — In the healthy infant bom under favorable circumstances, 
 the function of respiration is established in the first minute of life, a few vigorous 
 cries expanding the lungs freely. In other infants, however, the lungs do not 
 undergo inflation, or only a portion of the upper lobes is inflated while the 
 remainder of the organs does not change from the fetal state. This is termed 
 congenital atelectasis. While atelectasis may occur without causing asphyxia, 
 and while the latter may not be due necessarily to inability of the lungs to inflate, 
 in the majority of cases the two conditions must necessarily coexist. The lungs 
 of a healthy infant expand as soon as the cord is cut, but in the weak or pre- 
 mature a certain portion fails to become aerated. The child may be threat- 
 ened with death from asphyxia, and the application of the usual management 
 for that condition may reanimate it. The atelectatic area, however, may still 
 persist and threaten the child's life during the ensuing hours or days. If the 
 newly bom has not succeeded in breathing at all and has succumbedfat once to 
 asphyxia, the atelectasis is of course absolute. But if, as often happens, respir- 
 ation has been inaugurated either spontaneously or as a result of treatment, some 
 of the lung tissue — as a rule, both upper lobes — is not only inflated but emphy- 
 sematous, the rest remaining in the fetal state. If the child survives, air be- 
 gins to enter the posterior aspect of the lower lobes. The central portion of the 
 lungs is the last to yield. Despite the apparent solidity of the atelectatic tissue, 
 it may readily be inflated artificially even months after birth. When these chil- 
 dren do not succumb at birth they simply present the picture of debility or pre- 
 
DISEASES INCIDENT TO CHANGE OF ENVIRONMENT. 839 
 
 maturity and are menaced by death in various forms (marasmus, convulsions, 
 etc.). If they are doomed to perish of asphyxia cyanosis gradually develops. 
 The prognosis, however, is not hopeless, as many of these children survive. 
 
 Etiology. — Abnormal conformations in the respiratory tract are rare, so that 
 practically it may be said that atelectasis is due primarily to feeble respiration 
 following some injury to the centers in the brain from prolonged labor or in- 
 strumental delivery. Atelectasis may occur, however, in infants whose respira- 
 tions are apparently normal in rhythm but not sufficiently full and forcible to 
 cause complete pulmonary expansion. 
 
 Pathology. — The conditions found at autopsy depend upon whether the 
 child lived a few days or longer. In the newly bom both lungs are generally 
 involved. The anterior borders of the upper lobes are inflated and light pink 
 in color and emphysematous from the added strain thrown upon them; while 
 the rest of the lung is in the fetal state, dark brownish in color, not inflated, and 
 firm to the touch. In older infants the posterior parts of the lower lobes are 
 found not inflated or only superficially so, the central portion of the lobes being 
 of no service in the act of respiration. Incidentally there may be found various 
 degrees of congestion of the liver, spleen, stomach, and intestines, due directly 
 to the imperfect pulmonary circulation. 
 
 Symptoms. — In infants with a history of asphyxia at birth atelectasis is most 
 noticeable. They gain little in weight, the circulation is poor, the extremities are 
 cold, they cry feebly if at all, and do not take nourishment well. In some cases 
 death occurs in a few days, while others live for weeks and months. Cyanosis 
 may develop at any time and death follow from asphyxia or convulsions. Many 
 infants, however, who begin life most unpromisingly gain steadily under favor- 
 able conditions and recover completely. 
 
 Diagnosis. — The general condition of the infant gives far more information 
 than does physical examination of the chest. Owing to the fact that both lungs 
 are generally involved, the ordinary advantage of comparing the two sides 
 of the chest is lost ; but if it happens that one lung only is the seat of the 
 trouble, we may find the respiratory murmur feebler- over that portion of 
 the chest. Cyanosis or convulsions in the very young should always suggest 
 the possibility of atelectasis. 
 
 Treatment. — If a vigorous cry does not occur spontaneously at birth, the 
 use of the hot and cold bath should be resorted to. Spanking is often effec- 
 tive and should be repeated at regular intervals if necessary. In those pre- 
 maturely bom careful attention should be directed to regulating the body 
 temperature by the use of cotton, hot baths, or an incubator. Friction and 
 gentle massage are of value in some cases. If convulsions or asphyxia develop, 
 the hot bath offers the greatest hope of benefit. 
 
 3. Failure of Circulation. — The various malformations of the heart are some- 
 times of such a degree that death results in the neonatal period. In the milder 
 varieties the duration of survival maybe indefinite. These anomalies give rise 
 to cyanosis. Some debilitated infants appear to succumb to simple arrest of the 
 circulation. The condition known as oedema neonatorum is probably associated 
 with a feeble right heart, with overfilling of the venous circulation. 
 
 4. (Edema Neonatorum. — The oedema appears in various superficial localities 
 and in some cases general anasarca may develop; the serous cavities, however, 
 are rarely involved. Unless the infant dies as a result of disability, the oedema 
 may disappear within a few da3^s. Relapses are frequent. In sclerema neo- 
 natorum failure of the circulation is one of the most striking S3^mptoms, although 
 it cannot be set down as the cause of the affection. 
 
840 THE PATHOLOGY OF THE NEWLY BORN. 
 
 5. Failure of Digestion and Assimilation. — Marasmus as ordinarily described 
 is a condition which develops after the neonatal period and extends over a con- 
 siderable period of time (see page 840). An analogous condition of the newly 
 bom, which, however, leads much more rapidly to death, is generally known as 
 inanition. A peculiar phenomenon connected with starvation in the newly 
 bom is a rise of temperature (hyperpyrexia neonatorum). According to Holt, 
 however, the trouble in these cases may lie entirely with the mother, whose 
 breasts are dry. Children who are bom healthy, if they obtain no milk by the 
 third or fourth day of life, show the commencement of inanition by a rise 
 of temperature to 101° F. or upward, which subsides as soon as the child 
 is fed. Inanition which is the fault of the child may be due to refusal of 
 the breast or of food, or to absolute inability to nurse or to retain the milk, or, 
 finally, to inability to digest and assimilate it. These causes are all operative 
 in weak and premature infants at birth. Naturally the various phenomena of 
 prematurity or debility coexist, so that it is difficult to assign particular symp- 
 toms to inanition. The exhaustion and debility are accentuated and the child's 
 life is rapidly forfeited, sometimes in two or three days. In cases in which 
 some nourishment is taken gain in weight is a good sign, and vomiting is a bad 
 one. The management of these cases is necessarily included under that of " pre- 
 maturity " and "congenital debility." Refusal of food is met by gavage. If 
 vomiting is present, the milk thus given should be diluted or an attempt should 
 be made to find something which the stomach will tolerate. (Compare Inan- 
 ition, page 840.) 
 
 6. Inanition Fever. — It was formerly supposed that inanition fever did not 
 occur as a distinct condition, but observations during the past ten years prove 
 it to be comparatively frequent, especially from the second to the fifth day. 
 It is really due to starvation, the infant being unable to obtain the proper 
 amount of nourishment from the breast as a result of limited or negative supply 
 of milk, of depressed nipples, or of inflammatory conditions. It is not confined 
 to premature or delicate infants, but occurs quite as frequently in those ordi- 
 narily vigorous. Fever is the most important symptom; it ranges from 102° to 
 105° F., and generally reaches its highest point on the third or fourth day of life. 
 The infants lose weight rapidly, not infrequently eight ounces in twenty-four 
 hours, and the condition is one that quickly causes alarm. Various other symp- 
 toms accompany the fever and loss of weight. A certain number of cases are fret- 
 ful and restless, while others show hot, dry skin, extreme irritability, and much 
 prostration. When all other causes of fever can be excluded, and investigation 
 proves that the proper amount of nourishment has not been taken by the infant, 
 the case may be called ' ' inanition fever. ' ' " Treatment consists in the administra- 
 tion of water at regular intervals until thirst is alleviated and the temperature 
 falls. If necessary, a wet-nurse should be secured or artificial feeding begun. 
 
 V. DISEASES DUE TO BACTERIA AND FUNGI. 
 
 I Umbilical Sepsis. 2. Septic Coryza. j. Septic Pneumonia. 4. G astro-intestinal Sepsis. 
 (i) Ulcerative Stomatitis. (2) Gangrenous Stomatitis, (j) Parotitis. (4) Retropharyn- 
 geal Abscess. (5) Gastro-enteritis. 5. Cutaneous Sepsis. (/) Dermatitis ex-foliaiiva 
 neonatorum (Ritter's Disease). (2) Pemphigus acutus neonatorum. Septic Pemphigus. 
 (^1 Impetigo contagiosa neonatorum (Periumbilical Pemphigus) . {4) Ecthyma neonatorum. 
 (5) Multiple Abscess. (6) Erysipelas. 6. Tetanus. 7. Aphthce. 8. Thrush. 
 
 The newly bom infant may be attacked by the omnipresent pathogenic bac- 
 teria, which may cause infection at the navel, in the mouth, or the gastro-enteric 
 
DISEASES DUE TO BACTERIA AND FUNGI. 841 
 
 tract, etc.; also by fungi. The principal members of this group are sepsis in its 
 manifold aspects, trismus, aphthae, etc. The bacteria which are pathogenic to the 
 newly born include the ordinary exciters of suppuration (streptococci and staphy- 
 lococci), the germs of tetanus and erysipelas, and to a certain extent any virulent 
 micro-organism which may cause chance infection. The newly born enjoys a 
 relative immunity from many infectious diseases, and, generally speaking, only 
 those bacteria need be discussed which show a particular tendency to attack 
 the infant as it emerges into the world. The gonococcus, since it menaces the 
 unborn child, is placed among the causes of intra-partum diseases. Of fungi 
 which tend especially to attack the newly bom, it will be sufficient to mention 
 those which cause aphthous stomatitis and thrush. 
 
 Septic Infection. — General Remarks. — By septic infection in the newly born 
 must be understood a systemic disease which takes the form of an extremely 
 severe infectious process, begins usually at the navel, and later involves in a 
 greater or less degree other parts of the body. It is one of the most dreaded 
 affections of early life. 
 
 Frequency. — When proper aseptic and antiseptic precautions enter into the 
 details of delivery and care of the newly born, few cases of septic infection follow. 
 The great majority of cases are referred to influences which seem to be present 
 and to flourish at intervals in lying-in hospitals or wherever puerperal infection 
 finds a harbor. It naturally is more common in those localities and among 
 those people who do not enjoy the blessings of modem obstetrical attendance, 
 though it has also its victims among the best classes of society. 
 
 Pathology. — In eight cases out of ten the process begins in the umbilical 
 vessels or in the connective tissue about the navel; the blood-clots in the vessels 
 and the clean-cut edges of the stump offering good soil for bacterial development. 
 Injuries or abrasions of the skin and mucous membranes and of the conjunctiva 
 offer other avenues of entrance. The precise manner of communication in these 
 cases is obscure, but careful search will reveal in the majority of cases the place 
 of infection, because the bacteria which are the real cause of the disease must 
 have penetrated into the body from the external world. When it is once in the 
 system, it can be disseminated through various channels. It may be carried 
 by the lymphatics into the general circulation or a purulent phlebitis may be 
 excited at the point of infection, and this in turn may excite by embolism 
 analogous lesions in other parts of the body. The most striking feature at 
 autopsy is that there is never a lesion of one organ exclusively. Several or, 
 it may be, almost all the organs and systems exhibit foci of disease. 
 
 Symptoms. — These usually begin in the first week, never later than the 
 twelfth day — and are those of a general septic poisoning with the local manifes- 
 tations at the point of entrance. The fever is characteristically irregular. It 
 may look like typhoid fever or so closely resemble quotidian or even tertian 
 intermittent fever as to lead to a wrong diagnosis. Other cases show little or 
 no elevation of temperature. Cutaneous symptoms, icterus, and either puncti- 
 form petechias or extensive hemorrhages are common. The pulse is generally 
 rapid and of poor quality and the respiration is disturbed. Emaciation always 
 occurs. The nervous symptoms are restlessness, irritability, and muscular 
 twitchings, with stupor or convulsions in the later stages. The abdomen is 
 generally swollen and tender, and we are able at times, by pressing along the 
 abdominal walls toward the umbilicus, to squeeze out a few drops of purulent 
 material. The spleen may be enlarged and palpable. There are sometimes 
 severe intestinal symptoms, a septic diarrhea with greenish or dark or bloody 
 stools of a very foul odor. The inflammatory processes in the brain, lungs, 
 and heart often fail to give well-defined symptoms. 
 
842 THE PATHOLOGY OF THE NEWLY BORN. 
 
 Diagnosis. — The diagnosis of septic infection is not difficult in well-marked 
 cases, particularly if the mother develops puerperal septicemia. It is more 
 difficult in isolated cases in which no entrance for bacteria can be discovered, 
 when the symptoms are ill defined, and when the child comes under observation 
 late with an imperfect history. Inflammation of the nose, 6)^6, or joints should 
 suggest the possibilities of the case, the importance of not regarding any single 
 local process as the whole cause of the illness being borne in mind. 
 
 Prognosis. — This should be guarded even in the milder forms. The severe 
 cases are generally fatal, owing to the feeble resistant power of the infant. 
 
 Treatment. — In the entire subject of septic infection nothing is so important 
 as the means employed for its prevention. Antisepsis in its relation to delivery 
 and the care of the infant is capable of preventing the disease. It is the duty 
 of the physician to carry out the strictest antiseptic details in every case of labor. 
 The utmost aseptic care must be observed in ligating the cord and in dressing 
 it. When infection occurs, the infant should be isolated at once. Since there 
 is no specific for septic infection the remedial treatment can only be sympto- 
 matic. The inflammatory processes within the body cannot be attacked 
 directly, and medicinal methods are resolved into proper feeding and necessary 
 stimulation. External suppurative processes require surgical procedure. 
 
 I. Umbilical Sepsis. — This variety represents the type of sepsis neonatorum, 
 and perhaps four-fifths of the clinical material. The cord may be infected 
 either at the time of ligation or afterward during the sloughing and healing 
 periods. Contaminated ligature material and dressings are chiefly responsible 
 for infection, but after the stump of the cord has fallen the often immature 
 scar is still exposed to the action of pathogenic germs. Before sloughing, the 
 arteries, veins, and lymphatics are all capable of absorption, but afterward 
 the vein alone, which often retains some of its lumen for a considerable period, 
 is held to be responsible for infection. The subject of umbilical sepsis is one 
 of extreme perplexity. The local lesions exhibit the greatest divergence of 
 type. While in one series of cases arteritis predominates, a second reporter 
 finds hardly any lesion but phlebitis, and a third finds more lymphangitis than 
 either of the other lesions. The same absence of law is seen in the consecutive 
 lesions. In some cases the local lesions, of whatever nature and severity, 
 remain localized throughout. In other cases generalization occurs, sometimes 
 rapid and fatal, at other times more deliberate and less malignant. The follow- 
 ing classification of umbilical sepsis is now recognized at the Tamier Clinique 
 (Paris): (i) Infection of the cord proper. This occurs only in putrefaction of 
 the stump. (2) Infection of the granulation tissue of the wound after detach- 
 ment of the stump. This occurs when for some reason the cicatrization is not 
 complete. A minute wound is left which suppurates and sometimes produces 
 excessive granulations. The discharge may be considerable, and is then known 
 as blennorrhea of the umbilicus; when the granulations attain a large size, they 
 are known as umbilical fungus. (3) Infection of the periumbilical tissues (skin, 
 subcutaneous tissue, lymphatics, etc.). This is manifested by erysipelas or 
 lymphangitis, with or without abscess formation. In rare cases gangrene 
 occurs, with the formation of the so-called umbilical ulcer of former days. 
 Another type of local infection is periumbilical pemphigus. (See Sepsis of the 
 Skin.) Phlegmon of the periumbilical region is indicated by the formation 
 of an indurated mass about the cord. Suppuration does not occur invariably, 
 although abscess-formation and sloughing form the usual termination. All the 
 preceding forms of sepsis are purely local; and in order that general infection 
 should occur, it is necessary for the vessels of the cord to be involved. Hence 
 
DISEASES -DUE TO BACTERIA AND FUNGI. 843 
 
 the final type: (4) Infection of the umbilical vessels. This is able to occur with 
 or without local mischief. The microorganisms may enter the circulation imme- 
 diately and set up fatal sepsis. It is possible that a very slight, transitory local 
 reaction always occurs, but it is frequently impossible to demonstrate its existence. 
 Treatment. — Local sepsis is managed on ordinary surgical antiseptic princi- 
 ples. Exuberant granulations should be touched with tincture of iodine or 
 nitrate of silver. Accumulations of pus should be evacuated and pyogenic 
 surfaces irrigated. For an ordinary dressing an antiseptic powder (boric acid) 
 may be used. In the more severe types ichthyol, 50 per cent., is recommended. 
 
 2. Septic Coryza. — The coryza of the newly bom is not necessarily due to 
 exposure. According to Bar, it is frequently encountered in children who have 
 been exposed to the contact of septic amniotic fluid. Despite its infectious 
 character, it is essentially a benign and self-limited affection, and only excep- 
 tionally does the inflammatory process invade the sinuses and middle ear. It 
 has recently been claimed that many children are bom with adenoids, and 
 that this condition is manifested by a coryza neonatorum. The treatment is 
 carried out along the same lines as that in older individuals. At the Tamier 
 Clinique mentholized oil is applied by a post-nasal tube of special pattern. 
 
 3. Septic Pneumonia. — The subject of pneumonia during the first few da3^s 
 of life is one of great obscurity, and doubtless comprises several quite distinct 
 conditions: (i) In aspiration-pneumonia, which is a simple catarrhal process, it 
 is conceivable that the amniotic fluid aspirated intra partum might be septic 
 and thereby directly infect the bronchi with streptococci, etc. When Bar states 
 that infectious pneumonia is often seen after a child has breathed in utero, 
 he alludes to a condition which is by no means necessarily septic. (See Aspira- 
 tion-pneumonia.) The course of this affection as described by Bar is that of 
 this simple irritant type. (2) Since bronchopneumonia is a deadly foe of 
 infancy in general, it is more than likely that many cases in the newly bom 
 are derived in the ordinary way, from epidemic influence, and do not represent 
 a type of neonatal disease. (3) Holt and other pediatrists describe a well- 
 marked form of septic purulent pleuropneumonia which is not recognizable 
 during life. Since it often accompanies sepsis in other localities, it doubtless 
 represents a phenomenon of general infection, and corresponds to the purulent 
 pleurisy of the newly born described by Bar . 
 
 4. Gastro-intestinal Sepsis. — Some of these infections may date from the 
 ante partum or intra partum period, as when the fetus swallows septic amniotic 
 fluid. The cause most in evidence after delivery would be nursing an infected 
 nipple or contact of the mouth with some unclean object. Some of the expres- 
 sions of this sepsis of buccal origin are as follows: 
 
 (i) Ulcerous Stomatitis. — This condition is usually due to the strepto- 
 coccus, and has received numerous designations. It appears in the form of 
 multiple plaques of a grayish hue representing a diphtheroid false membrane, 
 which when removed discloses ulcerated surfaces with sharply cut borders. 
 Their number and site are often characteristic, there being two plaques seated 
 symmetrically on the pterygoid border of the vault of the palate. In some 
 cases they are seated about the frenula of the lips. The course pursued is usually 
 benign, but erysipelas has sometimes been traced to the lesions. 
 
 (2) Gangrenous Stomatitis (Cancrum Oris, Noma). — This disease is 
 rare. It occurs also in other situations besides the mouth, such as the female geni- 
 tals, the nose, and the ear. It generally complicates some exhausting disease, 
 such as measles, the child being always in a weakened condition. Every case 
 must be isolated in order to avoid the spread of the disease. 
 
844 THE PATHOLOGY OF THE NEWLY BORN. 
 
 (3) Parotitis. — Both the parotid and the submaxillary glands have been in- 
 fected apparently by the migration of pyogenic germs from the mouth along 
 the excretory ducts. At first pus discharges by the latter structures, but in 
 time these become clogged and incisions are necessitated. 
 
 (4) Retropharyngeal Abscess. — This aflection, which, according to Bar, 
 is often overlooked, occurs as a variety of buccal sepsis. On account of the 
 resulting dysphagia the infant will perish unless relieved. There is also a 
 marked constitutional reaction in these cases. 
 
 (5) Gastro-enteritis. — Of recent years severe streptococcus gastro- 
 enteritis, followed perhaps by general sepsis, has been traced to nursing by 
 the newly born from an infected breast. If the condition cannot be explained 
 in this manner it may have been due possibly to intra-partum infection. The 
 disease begins with vomiting and diarrhea, the ejected matter having a foul 
 odor. If the infection is of a mild local type, the symptoms disappear within 
 a few days. Otherwise we see persistent diarrhea develop, with inanition and 
 evidences of systemic infection. If the infant continues to absorb pus from the 
 infected breast, the chances of a severe type of infection are increased. 
 
 5. Cutaneous Sepsis. — (i) Dermatitis Exfoliativa Neonatorum (Ritter's 
 Disease). — Definition: An exfoliative process in the skin of the newly bom 
 which is believed to bear the same relation to pemphigus neonatorum that 
 exfoliative pemphigus bears to common pemphigus in adult life. Etiology: Rit- 
 ter's disease is believed to be due entirely to septic infection of the child from 
 the maternal passages, from midwives, etc. The ordinary exciters of suppura- 
 tion may be cultivated from the skin. Quasi-epidemics have occurred. Symp- 
 toms: The affection usually begins about the mouth and extends over the entire 
 surface. The skin becomes intensely red and desquamates in large, loose flakes, 
 which tend to adhere to the bedding, etc. The temperature is subnormal. 
 Diagnosis: There is no affection of the newly born which simulates Ritter's 
 disease. Progno5W.' About one-half the children recover. Relapses occur. Treat- 
 ment: The continuous bath is indicated at first. If impracticable, alkaline lotions 
 should be applied until desquamation ceases, and followed ^yith ichthyol ointment. 
 
 (2) Pemphigus Acutus Neonatorum (Septic Pemphigus). — Definition: A 
 bullous exanthem not necessarily the same as pemphigus in the adult. It 
 corresponds to some extent with the bullous type of impetigo contagiosa. 
 Etiology : Pemphigus of the newly bom appears to be due to the ordinary 
 exciters of suppuration, which may be cultivated from the fluid contents of 
 the bullae. The source of the disease may be the maternal passages, or other 
 infants who have the same affection, etc. Symptoms: Within the first few days 
 of extrauterine life bullae make their appearance upon some portion of the 
 integument and tend to involve the entire surface. The contents may be 
 serous, purulent, or bloody. Numerous evidences of general sepsis may become 
 apparent. Diagnosis : While a few other diseases of the newly bom may present 
 bullae (syphilis, erysipelas), none should be confounded with pemphigus. Prog- 
 nosis: This is unfavorable and worse in proportion to the amount of suppuration, 
 hemorrhage, and constitutional disturbance. Treatment: The blebs should be 
 evacuated, the surface cleansed, and ichthyol ointment (50 per cent.) applied. 
 Measures must be directed against the constitutional infection. 
 
 (3) Impetigo Contagiosa Neonatorum (Periumbilical Pemphigus). — 
 For a description of impetigo contagiosa as it occurs in older children the reader 
 is referred to works on dermatology. While the newly bom infant might 
 exhibit the ordinary lesions of this disease if exposed in an epidemic, there is 
 one individual phase which it alone exhibits: viz., the so-called periumbilical 
 
DISEASES -DUE TO BACTERIA AND FUNGI. 845 
 
 pemphigus, — in reality a localized bullous form of impetigo contagiosa which 
 begins about the navel during the first few days of life. Staphylococci have 
 been cultivated from the contents of the blebs. This form of impjetigo is prob- 
 ably due to a mild local infection, and in fact appears to differ only in degree 
 from ordinary pemphigus neonatorum, which sometimes appears to start from 
 the navel. Periumbilical pemphigus should be treated like the more generalized 
 form of the disease. 
 
 (4) Ecthyma Neqnatorum. — Definition: Like the preceding affections, 
 ecth3^ma is a manifestation of sepsis of the newly born in which cutaneous 
 lesions predominate. In the future all these affections will doubtless be 
 regarded as types of one fundamental infection which may announce itself 
 by various lesions, bulls predominating in one case and pustules in another. 
 It is at present impossible to state positively whether these eruptions originate 
 in the skin or are preceded by a blood infection. Ecthymatous lesions of the 
 newly bom resemble those in the adult, and consist of large subepidermic 
 pustules having a broad indurated base. At this period of life there is a special 
 tendency for the pustule to ulcerate. In certain cases there is a marked inclina- 
 tion toward ulceration in depth (ecthyma terebrante). Etiology: The ordinary 
 exciters of suppuration are usually at fault (staphylococci and streptococci); in 
 particular instances some other germ, such as Bacillus pyocyaneus, may be 
 responsible for the lesions. According to the obstetricians of the Paris clinics, 
 this ecthyma occurs by preference in premature and congenitally feeble children, 
 in the cachectic, etc. Symptoms: The lesions occur most frequently on the 
 head, neck, and abdomen. When the process is at its height, they appear 
 chiefly as ulcers with rounded borders surrounded by areas of a purple hue. The 
 development of the pustules is preceded or accompanied by fever, vomiting, 
 diarrhea, etc. A special localized form of this suppuration is sometimes seen 
 about the nails of the newly born — the so-called "run round." Diagnosis: The 
 recognition of the pustulo-ulcerous lesions of ecthyma is not difficult, and the 
 real diagnostic difficulty lies in arriving at a knowledge of the predisposing 
 cause; for clinically ecthyma, while technically a contagious disease, is rather 
 the expression of an underlying cachectic state. Treatment: Measures must be 
 directed to the general condition. If the patient presents crusted lesions, the 
 scabs must be removed by sweet oil, etc. The exposed surface and ulcers in 
 general should be treated with mild solutions of nitrate of silver. 
 
 (5) Multiple Abscesses. — Multiple abscesses in the newly bom consist of 
 collections of pus of varying size and depth beneath the skin. Two types occur: 
 viz., the superficial or benign and the deep or septic. Etiology: The superficial 
 or benign type of abscess appears to represent a local infection with the sta- 
 phylococcus or streptococcus, which germs are often derived originally from 
 some maternal lesion such as purulent mastitis. The deeper sort may form in the 
 subcutaneous tissue or between contiguous muscles. In these cases the infec- 
 tious pus appears to have been swallowed by the infant while nursing from an 
 infected breast. Abscesses coexist in the large viscera, and the condition is 
 really one of profound pyemia. Symptoms: These abscesses cause swellings which 
 may be as small as a pea or as large as a small hen's egg. In the benign form the 
 abscesses appear in crops, and are usually of small dimensions. The larger, more 
 deeply placed abscesses of septic origin behave very much like ordinary cold 
 abscesses. Their number and extent make the condition most serious, to say 
 nothing of the great likelihood of the involvement of subjacent viscera. 
 Bar speaks of opening forty-five of these abscesses in one child. Death finally 
 occurred, and on autopsy a collection of pus was found in the posterior mediasti- 
 
846 THE PATHOLOGY OF THE NEWLY BORN. 
 
 num. Diagnosis: This should readily be made with the exploring needle if 
 any doubt arises as to the nature of the affection. Treatment: A newly born 
 infant should never nurse from a breast the seat of abscess, or with any lesion 
 whatever of the nipple, areola, or breast. If abscesses have formed, they 
 should be evacuated, and the larger sort may require drainage. If the earliest 
 abscesses are evacuated, irrigated with sublimate, and sealed with collodion, 
 the spread of the disease may be partially checked. 
 
 (6) Erysipelas. — Erysipelas in the newly bom, as in adults, is an inflam- 
 mation of the skin due to a specific germ, Streptococcus erysipelatis. It is 
 especially seen in the first two weeks of life, and usually has its origin in the 
 navel, the small fissures of the anus, or abrasions of the skin. Pathology: The 
 skin and subjacent connective tissue are congested and swollen and infiltrated 
 with serum, fibrin, and leucocytes, the process continuing in many cases to 
 suppuration, ulceration, and gangrene. Metastases may form in the lungs, 
 heart, brain, kidney, and spleen. If the umbilicus is the primary seat, it is 
 likely that localized or general peritonitis will follow. Acute degeneration of 
 the liver and kidneys is a common step in the progress of the infection. Symp- 
 toms: Invasion is usually marked by vomiting, high fever, and severe pros- 
 tration. Locally the skin is hot, dry, hyperemic, and tender, and the inflamed 
 area rapidly increases in size. Restlessness and vomiting with the fever and 
 prostration persist during the course of the disease, which in the newly bom 
 usually ends disastrously. Especially is the prognosis bad when the umbilicus 
 is the starting-point. Treatment: Isolation should be practised at once. Locally 
 an ointment of ichthyol, lo to 20 per cent, in lanolin, should be applied continu- 
 ously over the inflamed parts. If suppuration occurs, wet dressings of lysol, 
 creolin, or bichloride may be of advantage. Constitutionally we must support 
 the child with alcohol and strychnin in free doses and the regulated use of baths 
 and packs. Artificial feeding may be required during the entire illness, par- 
 ticularly when there is any danger of infecting the mother's breasts. 
 
 6. Tetanus. — Tetanus is an acute infectious disease of rather infrequent 
 occurrence, the main symptom of which is tonic spasm involving the muscles of 
 the jaws and neck or the entire muscular system. There is no ground for 
 establishing tetanus neonatorum as a distinct form, since its etiology and course 
 are analogous at all times and at all ages. The specific cause is a bacillus which 
 is rather widespread and in some places very abundant, occurring in the soil 
 with other germs. It produces no special local lesion, but affects the body by 
 its elaboration of tetano-toxin, a most virulent poison. The germ enters the 
 body through abrasions and fresh-cut surfaces, more often through the umbilicus. 
 Pathology: No characteristic lesions have been found in the spinal cord or brain. 
 Symptoms: These may develop within a few days after inoculation or they may 
 be deferred for one or two weeks. Ordinarily the first thing noticed is the in- 
 fant's inability to nurse, due to .rigidity of the muscles of the face and jaws and 
 nape of the neck. This rigidity spreads by degrees to the muscles of the trunk 
 and extremities. In many cases the continuous tonic spasm is occasionally 
 interrupted by sudden and irregular paroxysms, during which all the affected 
 muscles become still more tense and opisthotonos is pronounced. The jaws 
 are firmly pressed together and can be opened but slightly. The face has a 
 peculiar drawn painful expression, the respirations are embarrassed, the pulse 
 is rapid and weak, and prostration is pronounced. Fever is generally present, 
 often rising to 105° F. before death. Recovery sometimes occurs in the milder 
 forms, but when the disease is once established the prognosis is bad. Treat- 
 ment: Avoid infection by observing perfect aseptic precautions in the dressing 
 
DISEASES OF UNKNOWN NATURE. 847 
 
 of the cord and the treatment of denuded surfaces. When systemic poisoning 
 is evident, the point of entrance should be attacked and made as clean as possible. 
 Antitoxin should be administered by the hypodermic method. Further than 
 this we must rely upon the symptomatic remedies with the aim of preserving life. 
 Remedies which lessen the irritability of the nervous centers, such as potassium 
 bromide, gr. 4 to 8, every two hours; or chloral hydrate, gr. 2 to 4, every one or 
 two hours per rectum, have a certain amount of value. Calabar bean has been 
 much used in doses of gr. yV to ^ several times daily by the hypodermic method. 
 All unnecessary handling should be avoided and everything done to prevent dis- 
 turbing the infant. Feeding by the nasal tube is necessary when the jaws can- 
 not be forced apart, and stimulants may be given by the same channel. Spinal 
 puncture has given good results. 
 
 DISEASES DUE TO FUNGI. 
 
 Although there is no positive proof that these conditions are due to fungi, 
 still they are most conveniently classed here. 
 
 7. Aphthae. — Aphthae, sometimes called vesicular or follicular stomatitis, is a 
 morbid condition of the mouth characterized in the early stages by the appear- 
 ance of whitish vesicles followed by superficial ulcers, mostly on the inside 
 nf the lips and the edges of the tongue. It appears at any time in infancy, but 
 infrequently in the newly born. Authorities tend to the belief that it is nervous 
 in origin. So far there is no testimony to prove its bacterial origin. Probably 
 in some instances the exciting cause is some derangement of the digestive 
 organs which is not appreciable. Treatment: Prophylaxis consists in scrup- 
 ulous cleanliness of the mouth, especially at the time of nursing. Cold water 
 should be given freely. The mouth should be kept properly cleansed with 
 solutions of boric acid or Dobell's solution. Powdered alum dusted on or the 
 judicious use of solid alum or the solid stick of silver nitrate generally hastens 
 the process of healing. 
 
 8. Thrush. — The term thrush signifies a form of inflammation of the buccal 
 mucous membrane, the peculiar feature of which is the formation of curd-like 
 points or patches on the parts involved. It occurs any time in the first few 
 months of life. It has been definitely settled that Oidium albicans is not 
 the cause, but another variety of fungus, parasitic in character, the nature of 
 which has not yet been fully determined. It is more often seen in infants 
 who suffer from inattention and uncleanliness and in those who are constitu- 
 tionally enfeebled. Treatment: Prophylaxis is most important; careful attention 
 to cleanliness will prevent the majority of cases. 
 
 VI. DISEASES OF UNKNOWN NATURE. 
 
 I. Omphalorrhagia. 2. Melena. j. Miscellaneous Hemorrhages. 4. From Genitals in 
 Female Infants. 5. Sclerema Neonatorum. 6. Buhl's Disease. 7. WinckeVs Disease. 
 8. Mastitis, g. Jaundice. 
 
 The preceding causes named under Sections I to V, and often the cooperation 
 of two or more of them in a single case, are responsible for the large mortality 
 among the newly bom. The vital statistics of New York show that in about 6 
 per cent, of all births the children die within the first four weeks. If to this 
 number we add the still-births, we find that in 14 per cent, of all births the 
 
848 THE PATHOLOGY OF THE NEWLY BORN. 
 
 children are unable to survive. Eross made an extensive collective investiga- 
 tion in 1893 and found that 10 per cent, of all children die within the first month. 
 This author assigned "congenital debility" as the cause of death in these cases 
 in over 50 per cent, of the material. If more of these cases came to autopsy 
 the matter would assume a different complexion. Thus, Brothers * made 47 
 post-mortems on children who were either still-born or who died within a fort 
 night after birth, and found in most cases definite organic lesion sufficient to 
 have caused death. Disease acquired after birth is extremely rare. (Brothers 
 records one case of intussusception.) Intra-partum affections, on the other 
 hand, must be very common, judging from the amount of cerebral hemorrhage 
 and catarrhal pneumonia (provided that the latter is due to aspiration of amniotic 
 fluid). Enough has been said to illustrate the great complexity of the subject 
 of infantile mortality. There can be little doubt that a condition of subdevelop- 
 ment, whether due to prematurity or severe maternal disease or both, furnishes 
 a very strong predisposition to all the other conditions which menace the newly 
 born. If we exclude from consideration that element of birth mortality which 
 is due to actual fetal disease and malformation and to infection intra partum 
 and post partum, we may recognize as the two leading factors the subdevel- 
 opment of the fetus on the one hand, and dystocia on the other. The 
 condition of subdevelopment, which is practically synonymous with congenital 
 debility, is probably responsible for more than one-half of all infantile mortality, 
 and the actual exciting cause of death is of no special significance. The mor- 
 tality from dystocia is due principally to asphyxia and cerebral hemorrhage, 
 with a certain proportion of deaths from aspiration-pneumonia as a result of the 
 entrance of amniotic fluid into the lungs. 
 
 Hemorrhages in General. — Somewhat different in character from the preced- 
 ing is the marked tendency of the neonatal blood-vessels to rupture, insomuch 
 that a sort of hemorrhagic diathesis appears to exist. Hemorrhages either occur 
 independently or complicate other conditions, especially infectious conditions. 
 Independent hemorrhages occur principally from the navel (omphalorrhagia), 
 intestinal canal (melena), and the subcutaneous tissues., Hemorrhages into the 
 suprarenal bodies have been noted. They are of rare occurrence and have 
 no connection with hemophilia, since the disposition to bleed ceases with the 
 neonatal period. The true hemorrhagic diathesis is very seldom manifested 
 at birth. Traumatic hemorrhages are not considered in this connection, 
 although the tendency of the newly born to bleed acts undoubtedly as a 
 predisposing cause. Neither are the hemorrhages which characterize syphilis 
 in the newly born and septic infection post partum included here. The dis- 
 position of the newly born to hemorrhage may be attributed to the new demands 
 made upon the circulation by extrauterine life and the extreme fragility of the 
 capillaries. The blood itself may undergo some peculiar change, and the fact that 
 actual extensive hemorrhage is not of common occurrence has caused the belief 
 in some quarters that the blood is altered by some agency, perhaps a bacterium, 
 before it can escape in such large quantities. These hemorrhages are oftener 
 fatal than not, but if the child can survive beyond the neonatal period it is 
 usually safe, for then the unknown process of readjustment appears to be com- 
 pleted. 
 
 I. Omphalorrhagia. — This condition is associated with the falling of the 
 cord about the fifth or seventh day post partum. It is insidious in character, 
 consisting of a general sanguineous oozing from the umbilical stump. The blood 
 shows little tendency to coagulate. When the hemorrhage is not fatal, its 
 
 * "Infantile Mortality," 1896 
 
' DISEASES OF UNKNOWN NATURE. 849 
 
 tendency is to spontaneous arrest within a few hours or at most days. Other 
 hemorrhages may coexist, as may also other neonatal diseases, and in some 
 cases omphalorrhagia is simply a collateral phenomenon of syphilis neonatorum 
 or umbilical sepsis. The prognosis is almost hopeless, as the escape of blood is 
 with difficulty checked, and, moreover, death often occurs even after the bleed- 
 ing vessels have been completely ligated; suggesting that the fatal termination 
 is due not to the escape of blood, but to the basic condition which makes 
 the latter possible. The best treatment is probably compression with hare-lip 
 pins, which will do all that can be done by hemostatic procedures. In tliis 
 connection it may be mentioned that fatal omphalorrhagia may result from 
 failure properly to ligate the cord at birth. Fortunately, omphalorrhagia occurs 
 very rarely. 
 
 2. Helena, or Gastro-intestinal Hemorrhage. — Hemorrhage — generally capil- 
 lary — from the gastro-intestinal mucous surface occurs sufficiently often in the 
 early days of life to make it a disease of some importance. It rarely occurs after 
 the twelfth day. Etiology: No satisfactory cause has yet been assigned, but the 
 hemorrhage is due, no doubt, to changes in the blood or in the blood-vessels or in 
 both. There is reason to believe also that a tardy or incomplete establishment 
 of the respiratory and circulatory functions, giving rise to venous stasis, is an im- 
 portant factor in an etiologica way. Hereditary syphilis is associated with a small 
 percentage of cases. A microbic theory has been advanced but not accom- 
 panied with testimony sufficient to be of value. It develops at any time during 
 the first week of life. In three cases described by Brothers, omphalorrhagia 
 coexisted in all. Pathology: Many cases show no lesion at autopsy except the 
 hemorrhage and the blanching of the involved mucous membranes. There may 
 also be ecchymoses of the mucous membrane. Ulcers are found in the stomach 
 and intestine in a small proportion of cases. These ulcers are multiple and small, 
 usually superficial, but may extend to the muscular coat or even perforate the 
 intestine. The cause of these ulcers is somewhat obscure, but some are prob- 
 ably of infectious origin, while others are due to thrombi in the blood-vessels of 
 the mucous membrane. In a case in my service at the Emergency Hospital, 
 blood was vomited and passed by rectum. The autopsy disclosed no ulcers 
 of the stomach or intestines. Death occurred on the tenth day post partum. 
 Symptoms: The presence of blood is generally the first symptom to attract 
 attention, and blood in the stools is much more common than hemorrhage 
 from the stomach. The general condition of the infant may be good or there 
 may be pale skin, feeble heart action, and decided weakness. Vomited blood 
 is usually dark in color and small in quantity, the stools are always dark, the 
 blood and fecal matter being closely associated. Clots in the stools are not 
 common. Occasionally death follows internal hemorrhage and the condition is 
 discovered only at autopsy. It should be remembered that vomiting of blood 
 may result from nursing from a fissured nipple. The prognosis depends upon 
 the general condition of the infant and the frequency and amount of the hemor- 
 rhages. The mortality has been estimated as high as 50 per cent. Treatment: 
 General measures, such as proper food and appropriate stimulation directed 
 to the maintenance of the bodily strength, should be resorted to. Astringents, 
 either by mouth or per rectum or subcutaneously, have no influence upon the 
 bleeding. Suprarenal extract given by mouth is held to be of benefit. 
 
 3. Miscellaneous Hemorrhages. — Other localizations of this general hemor- 
 rhagic tendency are (3) the subcutaneous tissue (purpura hgemorrhagica), the 
 extravasations occurring by preference over regions exposed to pressure; uncom- 
 plicated purpura is a benign affection, although the loss of blood may be con- 
 
 54 
 
850 THE PATHOLOGY OF THE NEWLY BORN. 
 
 siderable. (4) The urinary passages (hematuria) and (5) the female genitals, 
 where the escape of blood suggests precocious menstruation (see page 850). 
 
 4. Hemorrhage from the Genitals in Female Infants. — This hemorrhage may 
 be a symptom of a number of ver}'- different conditions. In many instances the 
 plienomenon appears to be phj^siological, and more than once it has foreshadowed 
 precocious menstruation and early sexual development (St. Hilaire and others). 
 In these quasi-menstrual cases the flow of blood begins a short time after birth 
 and continues over a space which corresponds to a menstrual epoch. There is, 
 however, no recurrence on the following month. In other cases it appears to 
 have a sinister meaning, for it has been noted as a terminal phenomenon in 
 infants dying shortly after birth, especially premature infants. Doleris * looks 
 upon such cases as examples of a general infection of doubtful origin, and in one 
 such instance found a pericardial effusion from which he cultivated staphylococci. 
 
 A series of autopsies would doubtless throw light upon the nature of this 
 affection, or group of affections, but few such records exist. In one case of 
 prematurity Eross found blood in the uterine cavity, and an apparent condition 
 of hemorrhagic metritis. We may at the present day distinguish between a 
 physiological, benign type of hemorrhage, and another form which appears 
 to stand in relation with the uterine congestion of prematurity. It is also 
 quite probable that other conditions may produce this phenomenon. I have 
 
 observed during the past ten years 
 a number of cases of muco-sangui- 
 nolent discharge from the vagina 
 in full-term healthy children. 
 Mothers and nurses are often un- 
 duly alarmed at its occurrence. A 
 mild boric-acid wash is all the 
 treatment called for. 
 
 In addition to the hemorrhagic 
 
 state and icterus which might well 
 Fig. xo3i.-Sclekema^of^the Newly Born.- ^^ ^^^^^^ ^^^^^ ^j^-^ ^^^^^^ ^^^^^ 
 
 are a number of other affections — 
 
 sclerema. Buhl's disease, Winckel's 
 
 disease, mastitis, etc. It is impossible to state whether the leading element in 
 
 these cases is readjustment, infection, or the persistence of some intrauterine 
 
 affection. 
 
 5. Sclerema Neonatorum. — The subject of sclerema is in a hopeless state of 
 confusion. It appears to attack the subdeveloped child only, but is much too 
 rare to be ranked as a mere anomaly of readjustment. It is not necessarily a dis- 
 ease of the newly born, and hence can hardly represent the persistence of a fetal 
 state. It cannot be brought into relationship with an}^ infectious process. The 
 peculiar induration first appears in localities where adipose tissue is abundant, 
 and usually extends over most of the subcutaneous area (Fig. 103 1). At the 
 same time there is a marked lowering of temperature with failure of circulation, 
 cyanosis and cedema often appearing. The child seldom lives over three or 
 four days from the inception of the malady-. While the general prognosis is grave, 
 mild cases of sclerema are sometimes saved by the treatment for prematurity, 
 including the incubator. In a certain number of cases sclerema has been noted 
 as a mere terminal stage of exhaustion. There is a large amount of evidence that 
 
 * " Jour, de m6d.. de Paris," 1898, x, 349. 
 
 t "Dorsal Sclerema Neonatorum," William Browning, "Journal Cutan. and Gen.- 
 Urin. Diseases," vol. xviii, whole No. 219, Dec, 1900. 
 
DISEASES OF UNKNOWN NATURE. 
 
 851 
 
 the affection represents only a high degree of the defective readjustment of the 
 subdeveloped child. Unfortunately all sorts of exceptions to general rules have 
 been noted. Ballantyne even cites a case in which no adipose layer was present. 
 
 6. Buhl's Disease. 7. Winckel's Disease. — The former has been known as 
 "fatty degeneration of the newly born," and the latter as "epidemic hemoglobin- 
 uria of the newly born." Both conditions suggest sepsis as the cause, Winckel's 
 disease more so than Buhl's, because the former has occurred in epidemics. 
 
 The prognosis is hopeless and the treatment entirely symptomatic in both 
 these diseases. 
 
 8. Mastitis. — Mammary abscess belongs under "sepsis neonatorum," but the 
 condition usually referred to as mastitis includes the condition of physiologic^al 
 activity so often seen in children of both sexes at birth, by virtue of which milk 
 is for a few days secreted in minute amounts (Fig. 1032). As a result of handling, 
 want of cleanliness, etc., pyogenic germs may gain access to these secreting glands 
 and local sepsis may result. (See Sepsis.) The existence for two or three weeks 
 after birth of mammary secretion is 
 
 generally thought to be physiologi- 
 cal. In any event, it is quite com- 
 mon. It is found as frequently in 
 boys as in girls, the amount not 
 often exceeding a few drops. Its 
 chemical constituents are like those 
 of adult milk. The condition of 
 functional activity will generally 
 disappear spontaneously. Treat- 
 ment: In the majority of cases no 
 treatment is necessary. When the 
 glands are really inflamed, an ap- 
 plication of ichthyol ointment, 20 
 per cent., lead-water and laudan- 
 um, or lead plaster may be made. 
 In the event of pus formation im- 
 mediate incision and evacuation are indicated, together with supporting and 
 stimulating treatment. 
 
 9. Jaundice. — Icterus neonatorum may also be included among anomalies of 
 readjustment, although in certain cases it is a complication of sepsis, etc. The 
 pathogeny of primary icterus is obscure, although this affection occurs so fre- 
 quently that it may almost be regarded as physiological. It is often associated 
 with uric-acid infarcts in the kidney. Primary icterus appears during the first 
 week of life and lasts but a few days. It does not begin in the conjunctivae, 
 which are involved after the skin. The child loses weight during the evolution 
 of the disease. It is almost impossible to differentiate primary icterus from 
 the jaundice which accompanies sepsis, syphilis, malformations of the hepatic 
 tissues, etc. Nor is it possible to distinguish between a primary icterus from 
 anomalous action of the liver and a hypothetical hematogenous form. Jaundice 
 of the newly bom might also be of fetal origin in certain cases, and under these 
 circumstances the pigment would come from the mother. Little or no special 
 treatment is required, although syrup of rhubarb and calomel are often admin- 
 istered. 
 
 Fig. 1032. — Bilateral Mastitis of the Newly' 
 Born. — (Author's case at the Emergency Hos- 
 pital.) 
 
852 THE PATHOLOGY OF THE NEWLY BORN. 
 
 VII. GENERAL POST-PARTUM CONDITIONS. 
 
 ;■. Ulceratton of the Hard Palate, Bednar's Disease. 2. Sublingual Cysts, j. Vomiting. 
 4. Colic. 5. Diarrhea. 6. Constipation. 7. Intestinal Obstructions. 8. Pneumonia. 
 Q. Convulsions. 10. Infantile Cachexia. 11. Sudden Death. 12. Medication of the 
 Newly Born. 
 
 1. Ulceration of the Hard Palate, Bednar's Disease. — This is characterized 
 by the formation upon the hard palate of two ulcers, one on each side of the 
 median line; occasionally only one may be present. They are at first super- 
 ficial. It is supposed to be caused by friction against the rubber nipple, by 
 the habit of tongue-sucking, or by rough and careless manipulations in cleansing 
 the child's mouth. Marasmus is a predisposing cause. The treatment is 
 removal of the cause if possible. If marasmus or malnutrition is present, a 
 cure may be difficult or impossible. 
 
 2. Sublingual Cysts. — What is known as the lingual duct is represented by 
 a canal running from the foramen caecum between the geniohyoglossi muscles 
 to the posterior surface of the hyoid bone. In its course cysts may develop, 
 due no doubt to an inclusion of a minute portion of epiblast or hypoblast. 
 They are always congenital, but may not become manifest for many years, 
 when they may become attached to the hyoid bone behind or to the lower 
 jaw in front. The dermoid variety are lined with epithelium and contain 
 sebaceous matter and sometimes hairs. Another variety, by far the most 
 important, is ranula, a bluish, semi-transparent, ovoid or round swelling with 
 thin walls located in the floor of the mouth under the fore part of the tongue. 
 They are usually unilateral, contain glairy, mucoid material, and are painless. 
 As a rule, they are small, but they may attain the size of a walnut and so inter- 
 fere with speech and swallowing. The typical ranula is most frequently a 
 retent on cyst of the mucus-secreting glands of the floor of the mouth. The 
 treatment is entirely surgical. Radical extirpation is practised for dermoids, 
 wh^le incision and cauterization are the methods most commonly employed for 
 the cure of ranula. 
 
 3. Vomiting. — Regurgitation of food is sometimes due to the fact that the 
 child is fed too often or in too large quantity. Thus regurgitation is of 
 frequent occurrence. In other cases, and especially if the vomited matter 
 contains curds, some defect in the preparation or composition of the milk is to 
 be suspected. 
 
 4. Colic. — One of the most common symptoms which the physician is called 
 upon to treat is colic. Too often the symptom alone is treated without proper 
 consideration of the etiological factors in the case. Etiology: Some error in 
 diet is almost always the underlying cause. In a great majority of cases it 
 is the proteids of the milk, although any of its constituents may be at fault. 
 Flatulence follows, due to the formation in the intestine of gas from fermenta- 
 tion or decomposition, and colic ensues. All severe forms of intestinal inflam- 
 mation, chilling of the body-surface, or a diet containing cereals in excess are 
 prominent causes. When colic is unaccompanied by flatulence, the pain is due 
 to muscular spasm. It occurs in breast-fed as well as bottle-fed children, and is 
 most common during the first three months. The pain is often severe. Symptoms: 
 A child with colic presents a picture which is almost characteristic. The facial ex- 
 pression is one of misery, crying is violent and paroxA^smal, as a rule the lower 
 extremities are drawn up, the abdomen is tense and hard and more or less 
 tympanitic, and in severer cases there is cold, clammy skin, with feeble pulse 
 and possibly convulsions. The expulsion of flatus is followed by almost imme- 
 
GENERAL POST-PARTUM CONDITIONS. 
 
 8.53 
 
 diate relief. The possibility of intussusception or appendicitis must be borne in 
 mind. Treatment: Recalling the fact that flatulence is the predominant cause, 
 an enema affords the greatest hope of speedy relief. From three to eight 
 ounces of lukewarm water or a smaller quantity of sweet oil or glycerin is 
 ordinarily effectual. Heat to the abdomen and feet is of value. Turpentine 
 stupes to the abdomen are always grateful. When relief is afforded, it is wise 
 to purge with fractional doses of calomel or a mild saline. When the muscular 
 spasm is severe, opiates are indicated. A study of the patient's digestive 
 powers and scientific modification of its food are demanded when attacks of 
 colic show a tendency to recur. During the attack a drachm of soda-mint or 
 a few drops of gin or brandy in a little warm water, or a few drops of compound 
 tincture of cardamom, may afford relief. 
 
 5. Diarrhea. — Several varieties of this ordinary affection of infancy have 
 been described, but an elaborate classification seems unnecessary, since many 
 factors both in a causative and cura- 
 tive way are common to the various 
 forms. Three or four movements a 
 day, if normal in consistency and in 
 color, need excite no apprehension. 
 If the passages are greenish and con- 
 tain undigested particles, attention 
 should be directed to the feeding. 
 Treatment: To remove all irritant 
 matter from the intestine is the first 
 feature which requires attention. A 
 purge with castor oil, calomel, or a 
 saline should be given. At times a 
 high injection of a quantity of deci- 
 normal salt solution, with or without 
 some mild astringent, — witch-hazel, 
 for example, — is an effective adjunct 
 to catharsis. When a thorough evac- 
 uation has been accomplished, some 
 preparation of opium may be given to 
 lessen peristaltic activity. During the 
 attack the diet should be very limited ; 
 in some cases nothing but very moder- 
 ate quantities of water, plain or in combination with egg-albumen or barley, should 
 be administered in the first twenty-four or forty-eight hours. When the condition 
 of the patient warrants, the diet should be gradually increased. Plenty of pure 
 water must be given. If diarrhea continues and bids fair to be exhausting, two to 
 four drops of paregoric, with four drops of aromatic sulphuric acid or gr. iij to v 
 bismuth subnitrate, may be tried. The paregoric should not be repeated, how- 
 ever, until the effects of the first dose have entirely disappeared. The bismuth 
 may be repeated as indicated. 
 
 6. Constipation. — The term constipation in young children signifies any delay 
 beyond the normal period in the passage of fecal matter. Etiology: Anatomi- 
 cally the formation and disposition of the colon predispose to constipation. Its 
 relative length is greater than in the adult, its walls are relatively weaker, and 
 their physiological activity is not fully developed. Congenital abnormalities, such 
 as narrowing of the lumen of the gut, are rare causes in infancy. Among the 
 exciting causes, which include deficient glandular secretion, excessive perspira- 
 
 FiG. 1033. — Glass 
 Rectal Syringe. 
 
 Fig. 1034. — Rubber 
 Rectal Syringe. 
 
854 THE PATHOLOGY OF THE NEWLY BORN. 
 
 tion, inflammatory conditions, and frequent purgations, we find that improper 
 feeding and lack of general muscular tone furnish the majority of cases. The 
 mother's milk may be deficient in fats, while artificially prepared foods are not 
 only lacking in the proper amount of fat, but are also often too easily digested, 
 leaving but little residue to form the basis of a proper stool. Too great a quantity 
 of proteids or an insufficient fluid supply will also lead to constipation. Rickets 
 is a potent cause. Symptoms : The number and character of the stools in each 
 twenty-four hours give the most reliable information concerning the alimentary 
 processes. In the newly bom one or even two or three stools each day do not 
 preclude the existence of constipation when the movements are drier and flrmer 
 and more lumpy than normal and are expelled by straining. When daily stools 
 do not occur without medicinal or mechanical assistance, other symptoms may 
 arise, as flatulence, distention of the abdomen, colicky pains, restlessness, dis- 
 turbed sleep, and even high fever, convulsions, and much prostration. Hernia 
 and prolapsus ani may be resultant phenomena. Treatment: The attention of the 
 mother or nurse should be directed to the formation of a regular habit ; even very 
 young infants seem to appreciate the motive of being placed in the chair at certain 
 daily intervals. The method of feeding should be investigated and the cause re- 
 moved if possible. Constipation may be due to the presence of too little fat or 
 too much proteid matter in the food. The introduction of a suppository of pure 
 castile soap is a simple and usually effective way of causing a movement, since in 
 most cases the trouble is due to the presence of a rather hard fecal mass in the rec- 
 tum. If the continued use of the soap suppository causes irritation, the domestic 
 resource, a cone of oiled paper, may be used. The prolonged use of glycerin 
 suppositories may cause considerable irritation and even inflammation. The 
 habit of regular movement may be cultivated by giving the child a supposi- 
 tory at a certain hour each day. If it becomes necessary to give an enema, 
 not more than half an ounce of pure castile soap and water should be given, 
 since the rectum in young children is relatively small. When water is not 
 effective, the injection of a little sweet oil may be promptly successful. When 
 suppositories or enemata are ineffectual, a drachm or two of sweet oil by the 
 mouth is sometimes useful. Much benefit may often be derived from the 
 administration of fifteen drops of cod-liver oil three times a day. An effort 
 should be made to regulate the bowels by attention to food and by the use of 
 suppositories, and by dispensing as far as possible with the use of laxative 
 medicines. Castor oil should not be given in the habitual constipation of 
 infants. If medicine becomes necessary, a few drops of the fluid extract of 
 cascara sagrada may be given, or a little milk of magnesia. Massage of the 
 abdomen is often useful. 
 
 7. Intestinal Obstruction. — The majority of these cases occur during the first 
 year of life, and the prompt recognition and treatment of the condition are 
 most important. Etiology: In the newly bom, malformation — such as imperforate 
 anus, occlusion of the rectum, or maldevelopment of any portion of the intestinal 
 tract, more often of the duodenum — plays an important part. During the first 
 six months of life intussusception is responsible for one-half of the cases. Treat- 
 ment: The proper treatment of intussusception consists in efforts to reduce the 
 displacement by pressure from below. Two methods, inflation and injection, are 
 employed. Inflation should be practised under an anesthetic, the amount of air 
 introduced being regulated by the amount of tension of the abdominal walls. 
 Injections of lukewarm water are given, the buttocks being elevated to aid the 
 entrance of the fluid into the bowel. Reduction is generally followed by gurgling 
 sounds and the expulsion of flatus, with quick relief from all distressing symp- 
 
GENERAL POST-PARTUM CONDITIONS. 855 
 
 toms. Laparotomy must be resorted to at times. For the congenital causes of 
 intestinal obstruction surgical treatment is necessary. 
 
 8. Pneumonia. — (See Acute Infectious Diseases, page 808.) 
 
 9. Convulsions. — The term convulsions is here employed to designate the 
 bodily conditions characterized by acute seizures, clonic, rhythmic, sometimes 
 violent, generally involving one set of muscles, or the entire muscular system, 
 with unconsciousness as a usual accompaniment. They occur as a symptom in 
 a great variety of diseases, but here only those occurring in infancy will be con- 
 sidered. Etiology: Infancy itself is the great predisposing cause. The infant 
 cerebrospinal system is easily impaired and deranged, and readily loses its 
 equilibrium, especially during the period of its most active development. Some 
 children inherit susceptible nervous temperaments. In older children rickets 
 is the most prominent predisposing cause. Of the exciting causes, some irritant 
 in the alimentary canal, due to transitory changes in the mother's milk, or to 
 improper food, is the most frequent and leads to gastric or intestinal indigestion. 
 The irritant may produce convulsions reflexly, but authorities are now practi- 
 cally agreed upon the adoption of the toxic theory as the proper explanation. 
 Atelectasis, meningitis, and meningeal and cerebral hemorrhage are direct causes. 
 Dentition is an extremely rare cause. Retention of urine and phimosis are some- 
 times directly responsible. Symptoms: General convulsions do not differ materi- 
 ally from ordinary epileptic seizures so far as the infant's appearance is concerned. 
 In some cases prodromal signs of restlessness and irritability may give warning, 
 but most often the attack comes on suddenly. The face is pale or cyanosed, the 
 head is thrown back, the eyes roll or are staring, the hands are clenched with 
 thumbs adducted to the palms, then twitchings of the eyelids or the face or of one 
 extremity are soon followed by clonic movements of the entire body. Foaming 
 at the mouth is common, the heart is rapid and weak, the pulse irregular, res- 
 piration embarrassed, urine and feces may be voided involuntarily, and the entire 
 body surface is covered with clammy perspiration. Gradually the convulsions 
 cease and the child passes into a sleep or stupor, to be followed in most cases 
 by one or more convulsions. Unilateral convulsions make one suspicious 
 of a cranial lesion, while those occurring with fever of 103° to 106° F. are 
 suggestive of the onset of acute infectious disease. Treatment: This is first 
 directed to the controlling of the spasms. Baths at a temperature of 105° 
 to 110° F., given for from five to fifteen minutes, are the raost effective means 
 at our command. In infants under four months of age the skin is tender and 
 plain water is sufficient, but in older infants mustard — a handful to four gallons 
 of water — will enhance the effectiveness of the baths. In severe cases the temper- 
 ature of the bath should be increased to 112° or 115° F., and the child immersed 
 for at least ten minutes. Friction of the entire body, but particularly to the 
 extremities, should be performed. After the bath the infant should be wrapped 
 in a warm blanket and placed on its right side to relieve the overburdened 
 right heart. An ice-bag to the head and hot bottles to the feet are always 
 useful. Chloroform by inhalation is necessar}^ at times in older children, and 
 chloral hydrate and sodium or potassium bromide per rectum in proper doses 
 are useful and powerful sedatives. As soon as the convulsion is controlled an 
 enema should be given to insure a thorough action of the bowels. A purge 
 is always indicated, and castor oil is the best of that class. Up to the age 
 of five months the administration of one-half teaspoonful will ordinarily be 
 followed by good results. If there is much prostration, whisky in ten to thirty 
 minim doses should be given every two or three hours. 
 
 10. Infantile Cachexia. — (See Inanition, page 840.) 
 
856 THE PATHOLOGY OF THE NEWLY BORN. 
 
 11. Sudden Death of the Newly Bom. — In infants who present no visib'e 
 external changes sudden death is not an infrequent occurrence. The excita- 
 bility of the nervous centers in the young and their violent response to con- 
 ditions incapable of serious results in older persons tend to make this subject 
 one of extreme interest, especially in a medico-legal way. It is generally due 
 to one of the following causes: Asphyxia occurs from over-lying in bed, from 
 particles of food lodged in the larynx, or from an enlarged thyroid gland pressing 
 upon the trachea or pneumogastric nerve. Of the infants who are bom in a state 
 of asphyxia and respond to methods of resuscitation, about 4 per cent, die within 
 three days after birth and autopsy reveals a condition of atelectasis. Convul- 
 sive disorders: Seven per cent, of sudden deaths are referred to this cause. In 
 infants, in nine cases out of ten, convulsions are due to some irritant in the 
 alimentary canal; in older children rachitis is the great underlying cause. 
 Cranial hemorrhage is also a cause of convulsions, but children rarely die sud- 
 denly from it. Infantile cachexia: This is one of the common causes, and heart 
 failure is the most probable cause of death, since real lesions are rarely found at 
 post-mortem examination. Internal hemorrhage: Hemorrhage into the brain, 
 lungs, pleura, stomach, intestines, or any of the abdominal organs gives symptoms 
 of sudden collapse quickly followed by death. This occurs very early in life, 
 the infant seemingly being affected by the sudden change from intrauterine to 
 extrauterine existence. Pulmonary congestion: This may complicate any sudden 
 and great rise of temperature and cause death in a few hours. In the acute 
 infectious diseases, particularly bronchopneumonia, a certain number of infants 
 are overwhelmed by the intensity of the intoxication. As other causes of 
 sudden death may be mentioned congenital malformations of the principal 
 bodily organs, such as hernia, hydrocephalus, patent foramen ovale or ductus 
 arteriosus, defects in the ventricular septum, diaphragmatic hernia, narrowing 
 or occlusion of the stomach or intestines, imperforate anus, and abnormalities 
 of the kidney and ureter. 
 
 12. Medication of the Newly Bom. — The infant is often treated through the 
 mother, but the amount of a drug which reaches the former through the milk 
 is now believed to be too insignificant to produce therapeutic results. It there- 
 fore becomes necessary at times to administer medicines directly to the newly 
 bom. Stimulants: These have a very wide field, being indicated in the nu- 
 merous severe septic affections as well as in prematurity and general debility. 
 The dose is i to 3 drops of whisky hourly, increased in septic cases. Seda- 
 tives : In case of colic or other pain which resists attempts to regulate the 
 diet, etc., a mild opiate may be given (paregoric, i to 5 ^). The bromides 
 and chloral are useful per rectum. Stomachics: For indigestion, flatulence, 
 colic, etc., carminatives are indicated, with small doses of calomel (yV grain 
 every three hours). Antacids are also useful (soda, magnesia), as also is 
 pepsin. Laxatives: When mild remedies like sugar will not suffice, calomel, 
 castor oil, and cascara sagrada are most effective. Diuretics: Sweet spirits 
 of niter is the remedy usually chosen to produce diuresis in the newly bom. 
 Local remedies: The toxic antiseptics should be used well diluted, if at all {e. g., 
 corrosive sublimate i : 10,000). Boric acid is preferable, as a rule, to the 
 poisonous drugs. Counterirritation is practised chiefly for colic and vomiting, 
 in the form of a spice poultice over the abdomen. 
 
PART TEN. 
 
 Obstetric Surgery* 
 
 (A) INTRODUCTION. 
 
 I. PREPARATIONS FOR OPERATION. (Page 860.) II. DECINORMAL SALINE 
 
 SOLUTION INJECTIONS. (Page 861.) III. ANESTHESIA IN OBSTET- 
 RICS. (Page 865.) IV. POSTURE IN OBSTETRICS. (Page 868.) V. 
 VAGINAL EXAMINATION. (Page 879.) VI. DIGITAL EXPLORATION 
 OF THE UTERUS. (Page 880.) VII. VULVAL DOUCHE. (Page 881.) 
 VIII. VAGINAL IRRIGATION. (Page 881.) IX. INTRAUTERINE IRRI= 
 GATION. (Page 882.) X. VAGINAL TAMPON. (Page 884.) XL UTER= 
 INE TAMPON. (Page 885.) XII. PASSING THE CATHETER. (Page 
 887.) 
 
 (B) OPERATIONS PREPARATORY TO DELIVERY. 
 
 II. ARTIFICIAL RUPTURE OF MEMBRANES. (Page 887.) II. INDUCTION 
 
 OF ABORTION AND PREMATURE LABOR. (Page 888.) III. MANUAL 
 DILATATION OF THE CERVIX. (Page 895.) IV. INSTRUMENTAL 
 DILATATION OF THE CERVIX. (Page 902.) V. MANUAL AND IN= 
 STRUMENTAL DILATATION OF THE VAGINA AND VULVA. (Page 
 906.) VI. INCISIONS OF CERVIX, VAGINA, AND VULVA. (Page 907.) 
 
 VII. CORRECTION OF FAULTY POSTURES, MALPOSITIONS, AND 
 MALPRESENTATIONS. (Page 911.) VIII. VECTIS. (Page 915.) IX. 
 FILLET. (Page 915.) X. REPOSITION OF PROLAPSED SMALL PARTS, 
 FOOT AND CORD. (Page 916.) XL VERSION. (Page 919.) XII. 
 PELVIOTOMY. (Page 936.) XIII. SYMPHYSEOTOMY. (Page 937.) 
 XIV. EMBRYOTOMY IN GENERAL. (Page 942.) XV. PERFORATION. 
 (Page 944.) XVI. RACHIDOTOMY. (Page 946.) XVII. CRANIOCLASM. 
 (Page 947.) XVIII. CEPHALOTRIPSY. (Page 951.) XIX. DECAPITA= 
 TION. (Page 955.) XX. EVISCERATION. (Page 960.) XXI. AMPU= 
 TATION OF EXTREMITIES. (Page 961.) XXII. CLEIDOTOMY. (Page 
 961.) XXIII. SPONDYLOTOMY. (Page 963.) 
 
 (C) OPERATIONS FOR DELIVERY. 
 
 III. EXPRESSION OF THE FETUS, EXPRESSIO FCETUS. (Page 963.) II. 
 
 FORCIBLE DELIVERY, ACCOUCHEMENT FORCE. (Page 964.) III. 
 MANUAL EXTRACTION OF THE FORE=COMING HEAD. (Page 965.) 
 
 IV. SHOULDER EXTRACTION IN HEAD=FIRST LABORS. (Page 966.) 
 
 V. BREECH EXTRACTION. (Page 968.) VI. EXTRACTION OF THE 
 AFTER=COMING HEAD. (Page 974.) VII. FORCEPS. (Page 983.) 
 
 VIII. SLING OR SOFT FILLET. (Page 1007.) IX. BLUNT HOOK. (Page 
 1009.) X. CROCHET. fPage 1010.) XL EXTRACTION OF THE FETUS 
 MUTILATED BY EMBRYOTOMY. (Page 1011.) XII. C/ESAREAN SEC- 
 TION. (Page 1011.) XIII. ABDOMINAL HYSTERECTOMY. (Page 
 1016.) XIV. PORRO C/ESAREAN SECTION. (Page 1020.) XV. VAGI= 
 NAL C/ESAREAN SECTION. (Page 1022.) XVI. POST=MORTEM 
 C/ESAREAN SECTION. (Page 1025.) XVII. DELIVERY OF PLACENTA 
 AND MEMBRANES. (Page 1025.) Crede's Method. Dublin Method. 
 Digital Extraction. Manual Extraction. Instrumental Extraction. Curet= 
 tage. 
 
 (D) OPERATIONS FOR THE CORRECTION OF INJURIES. 
 
 IV. CELIOTOMY FOR RUPTURE OF THE UTERUS. (Page 1031.) II. CELIO= 
 
 TOMY FOR SEPSIS OF THE UTERUS. (Page 1032.) III. REPAIR OF 
 INJURIES TO CERVIX, VAGINA, RECTUM, PERINEUM, CLITORIS. 
 (Page 1032.) 
 
(A) INTRODUCTION. 
 
 The subject of obstetric surgery falls naturally into three divisions: The fi-rst 
 embraces operations preparatory to delivery, such as the premature induction of 
 labor; removal of the barrier of the cervix; correction of faulty presentations, 
 attitudes, and positions; increasing the size of the pelvis by symphyseotomy or 
 diminishing the size of the fetus by craniotomy or cutting operations on the 
 trunk. The second division includes operations for delivery, such as expres- 
 sion, manual and forceps extraction, Cocsarean section, and various methods of 
 placental delivery. In the third division fall the various operations for the 
 correction or repair of injuries produced during labor. 
 
 In considering the subject of obstetric surgery, my aim will be to give briefly 
 and concisely an account of the best method of dealing with the various forms 
 of dystocia, and an effort will be made to give in condensed form the gist of 
 modern scientific teaching and of my own experience in each case. The dis- 
 cussion of unconfirmed theories, disputed points, and measures of doubtful ex- 
 pediency will be avoided as unsuited to a work of this character. 
 
 Labor is a physiological process, and in normal cases the less interference 
 the better. No consideration of time or convenience, or even the entreaties of 
 the patient or her friends, should be used as an excuse for interference unless 
 such interference is distinctly indicated in the interest of mother or child. 
 Various abnormal conditions and causes, however, into which it is not now 
 necessary to enter, may render operative interference not only justifiable 'but 
 imperative. 
 
 Primum non nocere is a principle not always easy to impress upon the under- 
 graduate student. The student in his two or four weeks' course in practical 
 obstetrics may possibly witness many obstetric operations and naturally draw 
 the conclusion that interference in cases of confinement is of common occurrence, 
 when we desire to impress upon the student's mind quite another picture. 
 With a false impression the young physician enters upon his practice, and 
 one unnecessary operation leads often enough to a long train of misfortunes. 
 Unfortunately we see many examples of the foregoing. A primipara, for in- 
 stance, has been in labor for twelve hours; the membranes have ruptured several 
 hours previously; the head rests upon a rigid pelvic floor; which latter delays 
 the second stage; the fetal heart is good; the mother is in excellent condition, 
 and as yet there is no danger of damage to the soft parts, as the head has only just 
 reached the pelvic outlet ; there is, therefore, no indication for interference. A hur- 
 ried low-forceps operation is performed ; a third degree laceration of the pelvic floor 
 results; a hurried operation for repair is done, which in the absence of proper 
 assistance and ligatures gives a bad result. What follows? A subsequent opera- 
 tion must be performed by an expert, and in the mean time, and possibly after 
 the second operation, should it too fail, the patient is doomed to rectal inconti- 
 nence ahd becomes an exile from society, and all because in the first instance 
 in the absence of a positive indication, a "hannless low-forceps operation" was 
 
 859 
 
860 OBSTETRIC SURGERY. 
 
 performed. Still another clinical picture presents itself. A pelvic presentation 
 occurs in a multipara. One foot prolapses and appears at the vulva. Mother 
 and fetus are in perfect condition. There is positively no indication for inter- 
 ference, but the temptation is too great. In order to facilitate delivery, the 
 attending physician seizes and makes traction on the prolapsed leg. What re- 
 sults? The head, as well as one or both arms, becomes extended. Delay in the 
 delivery of the extended arms and head causes death of the fetus. The difficult 
 extraction results in deep laceration of the cervix extending into the folds of 
 the broad ligament. Severe hemorrhage follows. A hasty tamponade of uterus 
 and vagina, not under aseptic precautions, results subsequently in severe en- 
 dometritis and parametritis. What is the termination of such a case? Death 
 of the child, and the mother left with crippled pelvic organs, perhaps for life, 
 all from an attempt to facilitate the progress of labor by traction upon a pro- 
 lapsed leg. 
 
 The student cannot have too often repeated to him the statement that 
 obstetric operations of any kind should be undertaken only in the presence 
 of a positive indication; that even what are apparently innocent operative pro- 
 cedures in obstetrics may terminate in tragedies. The more impressed the 
 student is with the full meaning of the term primum non nocere during his 
 residence in the medical school and maternity, the more conservative and the 
 better accoucheur will he become in his private practice, the better the fate of 
 the mother and child entrusted to him, and the better his professional reputa- 
 tion. 
 
 I. PREPARATIONS FOR OPERATION. 
 
 Patient. — Many obstetric operations may be performed with the patient placed 
 across the bed in the lithotomy position, the buttocks being drawn to the edge. 
 The flexed thighs are either held or, better, confined with a sheet or canvas crutch. 
 Rubber sheeting or a Kelly pad and a pail are used for drainage (Fig. 1048). 
 It is far better, however, in private practice, to improvise an operating table 
 by pressing into use the kitchen, dining-room, or other table. This should be 
 covered with an old blanket and a clean, freshly laundered bed-sheet, and a 
 Kelly pad or a rubber sheet placed at the foot to drain into a pail or foot-tub. 
 The patient should be anesthetized in bed and afterward placed upon the table 
 in the lithotomy position, with thighs held in flexed position by a twisted 
 sheet under the shoulders or a Clover crutch (Fig. 1079). The rectum must 
 have been emptied by an enema. The external genitals should be scrubbed 
 with soap, brush, and warm water. For all intrauterine or cutting operations 
 the pubes and vulva should be shaved. A catheter should be passed and a 
 final scrubbing with a sublimate solution (i : 2000) or i per cent, lysol performed. 
 The immediate field of operation should be surrounded with sterile towels. 
 The vagina should be carefully washed out, before all intrauterine operations, 
 with a I per cent, lysol or creolin solution. This should be done with the 
 fingers, a cotton swab, or a jeweler's brush, never with a stiff brush, which 
 would injure the vaginal mucous membranes. 
 
 Instruments and Dressings. — The antiseptic agents used in obstetrical practice 
 are the same as those used in general surgery. Heat is the most useful and easily 
 applied means for making dressings and instruments sterile. Dry heat is the 
 least convenient form to use, since it takes longer to accomplish its purpose than 
 does moist heat and is slow in penetrating to the interior of a bundle of dressings. 
 
DECINORMAL SALINE SOLUTION INJECTIONS. 861 
 
 Moist heat may be used as steam at ordinary or increased pressure, or in the 
 form of boiling water. Superheated steam does not penetrate much better than 
 dry heat. Many hospitals use an instrument which subjects its contents to 
 steam at about 250° F. (121° C.) at 15 pounds pressure, and this is found very 
 efficacious for dressings and other materials. Boiling in plain water, or, better, 
 in water to which about i per cent, of sodium carbonate or bicarbonate 
 has been added, is an exceedingly convenient method of sterilizing instru- 
 ments or anything which will stand the treatment. The addition of the soda 
 prevents rusting and shortens the time necessary for boiling. Five minutes of 
 active ebullition is enough. The soda should be chemically pure; otherwise sub- 
 stances might be present which would injure the instruments. In private practice 
 obstetric instruments should be contained in canvas cases (page 468) or pinned 
 in towels before boiling. They are then brought to the operating table on a 
 dish without removing the towel and taken directly from the towel for use in 
 the given operation. Trays and antiseptic solutions for instruments are thus 
 dispensed with. 
 
 Operator. — (See Asepsis in Obstetrics, page 148.) 
 
 11. DECINORMAL SALINE SOLUTION INJECTIONS. 
 
 INFUSION, ENTEROCLYSIS, HYPODERMOCLYSIS. 
 
 On account of the great importance of this resource in obstetrics and the 
 number of conditions for which it maybe indicated — including eclampsia, hemor- 
 rhage, and sepsis — I have thought it advisable to devote a special section to 
 the general principles and technique of the various methods of exhibiting the 
 saline solution. 
 
 Preparation of the Solution. — The decinormal saline solution consists, roughly 
 speaking, of a drachm of salt (sodium chloride) to a pint of water, but this 
 simple formula has been modified in various ways. Water alone, provided that 
 it is not distilled, may replace the salt solution in emergencies; and any propor- 
 tion of salt will answer which does not exceed three times the proportion nor- 
 mally contained in the blood. As a matter of fact, the solutions in use varv' 
 from yV per cent, to jjj per cent. To prepare a solution with accuracy, forty-six 
 grains are added to a pint of water, but in emergencies a small teaspoonful, 
 not heaped up, will suffice. After the solution has been prepared it should 
 be boiled and filtered. While the saline solution is supposed to be freshly pre- 
 pared at the time of use, it is necessary in hospital practice to have it constantly 
 on hand, and the custom which generally prevails is to prepare a concentrated 
 solution which can be diluted as required. The solution must be exhibited at 
 a certain temperature. While 100° F. is the conventional temperature, some 
 obstetricians prefer 105° to 110° F. as representing a gain in stimulating proper- 
 ties. 
 
 Rectal Infusion. — From four ounces to a pint and a half of the decinormal 
 salt solution, at a temperature of 110° to 120° F., should be kept in the bowel 
 continuously. Any of the usual rectal tubes may be used, but a soft-rubber 
 catheter attached to the tube of a fountain syringe usually causes the least 
 irritation. The patient may be placed in the dorsal or lateral position, and 
 it is convenient to have the buttocks project a little over the edge of the bed. 
 I have found that the left lateral posture with elevation of the hips favors 
 retention of the solution, and is least objectionable to the patient (Fig. 105 1). 
 
862 
 
 OBSTETRIC SURGERY. 
 
 WfX' 
 
 Indications: As a preventive or curative measure in cases of shock, especially of 
 shock from hemorrhage. 
 
 Intra-arterial Infusion. — The radial artery is the vessel usually chosen for 
 infusion, on account of its accessibility. The skin is scratched over the artery 
 as a guide, the limb is elevated, and a tourniquet is applied to the upper arm. 
 The incision is i or 2 inches (2.5 or 5 cm.) long and crosses the artery obliquely. 
 The vessel is carefully isolated, divided, and ligated at the central end. A 
 cannula is then inserted into the peripheral end and tied in while infusion is pro- 
 ceeding. The tourniquet is then loosened, and after the infusion is completed 
 the cannula is withdrawn and the peripheral end of the vessel is also ligated. 
 This form of intervention is too radical and complicated for routine use. 
 
 Intravenous Infusion. — Indica- 
 tions. — The indications for intraven- 
 ous infusion are similar to those of 
 other methods of exhibiting the salt 
 solution. Generally speaking, it is 
 the typical method, the others hav- 
 ing a more limited field. In sepsis 
 and eclampsia or toxemia in general, 
 it is sometimes the custom to conjoin 
 phlebotomy with infusion. The in- 
 cision made for the cannula will 
 suffice for the escape of the blood, 
 which should average about a pint. 
 In certain cases venesection is carried 
 out in one arm and infusion in the 
 other, the operations being syn- 
 chronously performed. The reaction 
 against the teaching of the past, that 
 entrance of air into a vein is a fatal 
 accident, is believed to be unwise. 
 Fatalities certainly have occurred, 
 and it is well to take all precautions. 
 Experiments on animals show that 
 the rational treatment of air in the 
 veins is the persistence in the process 
 of infusion at 110° F., with artificial 
 respiration. 
 
 Techniqtie. — The solution should 
 be contained in a glass irrigating jar 
 having a capacity of five pints or more. The flow should never exceed the rate 
 of a pint in five minutes. The jar should be provided with a bath thermometer, 
 and an apparatus for raising and lowering it to any desired height. While 
 infusion is in progress it is well to wrap the irrigating jar in a large, hot, sterile 
 towel to assist in maintaining the requisite degree of heat. This outfit is 
 required because intravenous infusion is almost a routine procedure at the 
 present day. In emergencies a fountain syringe may be used, the infusion 
 being made as hot as the hand will bear. The tubing of the irrigating jar 
 is fitted with a transfusion cannula (Fig. 1038) or the glass tube of a 
 medicine-dropper may be used as a cannula. The operation is preceded by 
 the application of a tourniquet to distend the veins. The most conspicuous 
 vein should then be chosen, and this, as a rule, is the median basilic. A cuta- 
 
 
 FiG. 1035. — Colon Irrig.^tion 
 Double Catheter. 
 
DECTNORMAL SALINE SOLUTION INJECTIONS. 
 
 863 
 
 neous incision is made of sufficient length to expose about half an inch (1.25 cm.) 
 of the vein, which is then isolated and raised from the wound (Fig. 1036). The 
 vessel is then tied with fine catgut as low down as possible and a second ligature 
 is placed high up, ready to be knotted when desired. Half of the circumfer- 
 ence of the vein is now divided with scissors, the incision being just above 
 the knotted ligature. The cannula with its stream of running water is now 
 inserted as far as possible into the incision, with point directed toward the heart, 
 and the second ligature knotted to retain the instrument in place. The knot 
 should be a bow, in order that the ligature shall be only temporary. After 
 the cannula is removed the same ligature may be used for the purpose of tying 
 the central end of the exposed vein. After application of the temporary liga- 
 tures the tourniquet should be re- 
 moved. Kemp emphasizes the fact 
 that a very common mistake of the 
 beginner is neglecting to remove the 
 tourniquet before proceeding with 
 the infusion; under these circum- 
 stances the increase in intravenous 
 pressure will burst the vein sooner or 
 later. 
 
 V 
 
 Fig. 1036. — Infusion of Sal- 
 ine Solution into a Vein 
 OF THE Arm. 
 
 Fig. 1037. — Same as Fig. 
 1036, BUT Enlarged. 
 
 Fig. 103S. — Can- 
 nula for In- 
 travenous In- 
 fusion. 
 
 Enteroclysis. — No special apparatus is required, as the single- or double-cur- 
 rent irrigation tubes will suffice. Assuming that the solution should have a tem- 
 perature in the intestine of at least 100° F., it should be exhibited one or two 
 degrees higher to allow for slight cooling. The dorsal position appears to be the 
 best, the hips being slightly elevated. It is well to let the solution escape while 
 the tube is being inserted. A number of double-current rectal tubes have been 
 devised for the purpose of continuous exhibition of liquids. There are other 
 advantages connected with the double system, for the temperature as well as 
 the quantity is under control. Continuous irrigation may easily be maintained 
 for an hour or more, and the patient may remain entirely passive. A double- 
 
8G4 
 
 OBSTETRIC SURGERY. 
 
 current irrigator may be improvised as follows, if the operator has no special 
 delivery tube. Two catheters of different caliber should be so fastened 
 side by side that the tip of the smaller instrument projects an inch or two 
 beyond the larger, and above it, so that the inflow may be on the higher level. 
 These catheters should be made to pass through a perineal pad or substitute 
 before insertion into the bowel. The escape tube is the larger, for with mucus, 
 etc., it must carry away more than enters through its smaller fellow. Dr. 
 R. C. Kemp, whose valuable monograph * I have freely consulted in the prepara- 
 tion of this section, has devised a double-current irrigator which is the result 
 of much study and experience in this department of therapeutics f (Fig- 1035)- 
 Indications. — In shock, whether post-operative or following hemorrhage, irri- 
 gation is so managed that the patient has a pint or a quart of infusion in the bowel 
 at any given moment. Continuous irrigation, maintained for a considerable period, 
 is especially indicated in the toxemia of pregnancy. (Page^2 99.) The hot solution 
 (i 10° F. to 1 20° F.) is advocated in these cases. While enteroclysis has but few in- 
 dications in obstetrical practice, by 
 reason of the greater excellence of 
 hypodermoclysis and infusion, it can 
 nevertheless be employed to a con- 
 siderable extent by practitioners 
 who are unfamiliar with the other 
 methods, or who lack the necessary 
 apparatus for their performance. 
 
 Hypodermoclysis. — This method 
 of exhibiting the salt solution con- 
 sists in its injection into the subcu- 
 taneous cellular tissue. Indications: 
 Since hypodermoclysis increases the 
 quantity of fluid in the vessels, there- 
 by making good any deficit, as well 
 as acting as a circulatory stimulant ; 
 and since it promotes the action of 
 the emunctories, and both dilutes 
 and expels toxic substances, it is 
 naturally indicated in obstetrical 
 practice in the pregnancy kidney and 
 eclampsia, in post-partum hemor- 
 rhage, shock, and sepsis. Rnteroclysis is a valuable adjuvant to hypodermoclysis, ' 
 either during or after the performance of the latter. Dangers: The little operation 
 required for this purpose is simple, but by no means entirely free from danger. 
 Sloughing has followed hypodermoclysis beneath the female breast. The neces- 
 sary precautions in injecting the saline solution beneath the skin comprise avoid- 
 ance of overdistending the tissues by too much liquid or too great rapidity of flow, 
 and manipulation of the apparatus in such a manner that no air is able to enter 
 the tissues. Site of Injection: The iliolumbar site {i. e., the space between the 
 crest of the ilium and the lower border of the ribs) possesses natural advantages 
 as the site of injection. The patient may thereby retain the dorsal position 
 and have the free use of all her limbs. Submammary injections are also useful. 
 In shock or hemorrhage it may be necessary to give injections in more than 
 one locality. Technique: As a general rule, from 4 to 8 ounces constitute a 
 
 * " Enteroelysis, Hypodermoclysis, and Infusion." 
 top. cit., and "Medical Record," July 24, 1S97. 
 
 Fig. 10,^9. — Subcutaneous Infusion of Sa- 
 line Solution into Both Breasts (Hypo- 
 dermoclysis). 
 
ANESTHESIA IN OBSTETRICS. 865 
 
 single injection in hypodermoclysis. The solution to employ is the ordinary 
 decinormal formula. The technique of hypodermoclysis is as follows: The appa- 
 ratus required is simple, consisting of a fountain syringe and an aspirating 
 or hypodermic needle (Fig. 1039). If an ordinary hypodermic needle is used, 
 the bag of the fountain syringe must be raised to the height of from 4 to 6 
 feet, because of the increased resistance of the fine lumen; and, generally speak- 
 ing, the larger the needle, the lower the pressure required. Much time is wasted 
 if a hypodermic needle is used. The average height to hang the bag, if a 
 medium-sized aspirator is used, is two or three feet, depending on the rapidity 
 of the flow. The fountain syringe and its tube, together with the needle used, 
 should all be sterilized by boiling, and the bag should contain more water than 
 is injected lest air enter the in-flowing stream. The fluid should flow freely 
 from the needle as the puncture is made. The same precautions are to be used 
 as in any hypodermic injection in regard to the introduction of the needle. If 
 more solution is needed, — and as much as a pint may be employed with benefit 
 in some cases of hemorrhage, — it should be injected in divided quantities into dif- 
 ferent localities (Fig. 1039). The temperature of the solution should be about 105° 
 F. if a large needle is used, but at least five degrees higher if the small hypo- 
 dermic needle is employed, since fully that amount of heat will be lost with a 
 fine needle. Local anesthesia may be applied before the puncture, if desired. 
 
 III. ANESTHESIA IN OBSTETRICS. 
 
 I. During Labor. — Choice between Chloroform and Ether. — The rela- 
 tive advantages of chloroform and ether are very different when it is desired 
 to induce analgesia after the beginning of labor. Here two factors contribute 
 to increase the safety of chloroform. They are: First, the stimulating effect of 
 the labor pains upon cardiac innervation; second, the "physiological anesthesia" 
 attendant upon cerebral congestion induced b\'- the bearing-down efforts. The 
 first factor helps to prevent chloroform syncope, and the second to diminish 
 the amount of chloroform required. It is nevertheless true that the safety 
 of chloroform in labor is relative, not absolute, and that fatal cases have been 
 recorded. Its prolonged administration — e. g. , when commenced early in labor — 
 is not only injurious to the mother, but, as recent observations have shown, 
 is likely to be fatal to the child. Ether is used by a few obstetricians as an 
 analgesic during labor. It has been found that most of the objections to its 
 use have little force, or have been due to its improper administration, and 
 for six years past I have used it almost to the exclusion of chloroform in both 
 normal labor and obstetric surgery. 
 
 Indications. — The most common indication for anesthesia is unusual severity 
 of the pains. If the labor is long and the pains are abnormally severe, its use 
 is justifiable on the ground of humanity and to diminish the shock attendant 
 upon severe and prolonged suffering. The administration of the anesthetic, 
 however, should be delayed as long as practicable and confined principally 
 to the second stage. An anesthetic is frequently useful in aiding the progress 
 of labor, especially in the case of nervous and sensitive women who are badly 
 affected by the pains, and in cases in which the contractions, while very painful, 
 have but little power and in which the uterus does not relax between the pains. 
 In cases like the above, in which the reflex influence of the pains delays the 
 progress of labor, superficial anesthesia during the pains is frequently very 
 55 
 
866 
 
 OBSTETRIC SURGERY. 
 
 useful. Anesthesia in the second stage will often serve to induce timid and 
 nervous patients to assist the progress of labor by voluntary efforts. Anesthesia 
 to the surgical degree while the head is passing the vaginal outlet is often of 
 the greatest value in preventing perineal laceration, especially in primiparae. 
 In ordinary cases the anesthesia is to be used only during the pains, and in 
 quantities only sufficient to dull the pains, complete anesthesia being carefully 
 avoided. Anesthesia after delivery should be dispensed with unless impera- 
 tively indicated. Contraindications : The contraindications to the use of anes- 
 thesia during labor are the same as in general surgery, with the important 
 modification, however, that the excitement, suffering, and muscular exertion 
 which accompany labor without anesthesia may be more dangerous in certain 
 morbid conditions — e. g., cardiac disease — than the anesthesia itself. Advan- 
 tages: Anesthesia during labor diminishes pain; in certain cases aids in the 
 progress of labor; by relaxing the tissues aids dilatation of the cervix; and aids 
 
 materially in the preserva- 
 tion of the perineum. Dis- 
 ; advantages: In some cases 
 
 it diminishes or suspends 
 uterine contractions; pro- 
 duces unpleasant or dan- 
 gerous after-effects ; and 
 predisposes topost-partum 
 hemorrhages; and if exces- 
 sively used, to subinvolu- 
 tion and consequent sepsis. 
 Administration of 
 Chloroform. — The pa- 
 tient being in the recum- 
 bent position and the usual 
 precautions of examining 
 heart,, lungs, and urine, re- 
 moving false teeth, and 
 anointing the skin about 
 the mouth and nose having 
 been observed, at the be- 
 ginning of a pain a few 
 drops of chloroform are 
 dropped upon a towel or 
 napkin, held a few inches from the nose so as to allow a sufficient admix- 
 ture of air. This is the "drop" method. An Esmarch inhaler is convenient 
 (Fig. 1040). Valuable rules for the administration of chloroform are: (i) Use 
 as little chloroform as possible. (2) Use napkin, towel, or Esmarch inhaler 
 and the "drop method." (3) Have the chloroform vapor well diluted with air, 
 especially at the beginning of anesthesia. (4) At first use only during uterine 
 contractions. (5) When an operation is necessary, disease of the heart, lungs, 
 or kidneys, or exhaustion attendant upon the third stage, are not contraindica- 
 tions to anesthesia. Nevertheless the least dangerous anesthetic or combination, 
 such as nitrous oxide and ether or ether and oxygen, should be employed, and 
 extreme care exercised in their administration. Valuable danger-signals in 
 chloroform narcosis are: (i) Sudden paleness or lividity of the face. (2) Shal- 
 low, sighing respiration. (3) Rapid, irregular, intermittent, or failing pulse. 
 (4) Sudden dilatation of the pupils. 
 
 Fig. 1040.- 
 
 -The Administration of Chloroform with 
 AN Esmarch Inhaler. 
 
ANESTHESIA IN OBSTETRICS. 
 
 867 
 
 Administration of Ether. — If ether is used, the quantity may be somewhat 
 larger, and an improvised cone, made from a newspaper or a folded towel, may be 
 employed. Both in normal labor and obstetric surgery I am accustomed to use an 
 Allis inhaler (Fig. 1041)- I begin its use in the latter half of the second stage, often 
 earlier, as early as the end of the first stage; in the last instance, however, only 
 during the acme of the pains, and to a very moderate degree of anesthesia. 
 
 2. For Obstetric Operations. — Choice Between Chloroform and Ether. — 
 The choice of an anesthetic for obstetrical operations will vary with the operator. 
 In the case of an operation performed before the beginning of labor, we are 
 influenced in our choice by the same conditions which would influence us in 
 the performance of any surgical operation. The only exception to the rule is 
 in the case of puerperal eclampsia, in which most authorities advise the use 
 of chloroform in preference to ether. In Europe and in the southern and 
 western portions of this country chloroform is usually preferred, although ether 
 is undoubtedly gaining ground, while in the northern and eastern sections of 
 this country ether is used in the great majority of cases. In the face of modem 
 statistics there can be little doubt that under ordinary circumstances, and 
 especially in the hands of any but an expert anesthetist of large experience, 
 ether is the safer, and therefore the 
 
 preferable anesthetic. Chloroform 
 is undoubtedly the more convenient, 
 but, as I have remarked in another 
 connection, no question of conveni- 
 ence should be allowed to interfere 
 with the safety of the patient. The 
 ordinary alleged contraindications to 
 the use of ether, such, e. g., as pul- 
 monary and nephritic complications, 
 etc., are discussed in text-books 
 upon surgery, to which the student 
 is referred. 
 
 3. Anesthesia as an Aid in Diag- 
 nosis. — In doubtful cases it is some- 
 times necessary to insert the hand 
 into the uterus in order to make a 
 
 positive diagnosis. In these cases one should carry the anesthesia to the 
 surgical degree, since complete relaxation greatly facilitates the examination. 
 The anesthesia, however, should be discontinued as soon as practicable. 
 
 Other Anesthetics. — Chloral is a valuable agent for inducing analgesia during 
 labor. Under its influence the severity of the pains is diminished and between 
 the pains the patient is drowsy and comfortable. It also helps materially in 
 aiding dilatation of the cervix. It is especially useful in the case of nervous 
 and sensitive women and in cases in which the severity of the pain is out of 
 proportion to the progress of the labor. Chloral may be given in fifteen- 
 grain doses repeated at intervals of twenty minutes. Not more than three 
 doses should be given, and one or two are usually sufficient. Morphin, either 
 by the mouth or hypodermic ally, is sometimes useful, especially when anemia 
 or debility renders other agents inadvisable. (See Prolonged Labor, page 572.) 
 Antipyrin in large doses has been successfully employed, but in the presence 
 of safer methods its use does not seem advisable. The topical application 
 of a solution of cocain to the cervix produces a limited degree of anesthesia 
 during the stage of dilatation. The objections to its use are the possibility 
 
 Fig. 1041. — Self-administratiox of Ether 
 WITH AN Allis Inhaler for Dulling the 
 Intensity of the Pains. 
 
868 OBSTETRIC SURGERY. 
 
 of constitutional symptoms, and the danger of sepsis from intravaginal manipu- 
 lations. 
 
 Spinal Anesthesia. — Until further reliable confirmation of the safety and 
 value of lumbar anesthesia is received, it seems advisable for obstetricians in 
 general to refrain from exposing their patients to its dangers. 
 
 Conclusions. — (i) For operations requiring anesthesia to the surgical degree, 
 ether, unless contraindicated, is to be preferred, except in cases of eclampsia. 
 
 (2) In surgical anesthesia during labor in which the operation is begun 
 under chloroform, and especially in the case of anemic and exhausted patients, 
 ether may advantageously be substituted for the remainder of the operation. 
 
 (3) For dulling the pains of labor, chloroform carefully used, and carried only 
 to the extent of primary anesthesia, is both convenient and relatively safe; but 
 when this intermittent anesthesia is long continued, it is likely to affect the 
 fetus injuriously and is dangerous to the mother, and ether is to be preferred. 
 
 (4) Chloral and morphin, especially the former, are, when indicated, of great 
 value. (5) The production of local anesthesia by topical applications to the 
 cervix is not to be advised. 
 
 IV. POSTURE IN OBSTETRICS. 
 
 A study of the posture assumed during labor by the women of barbarous 
 and semi-civilized races teaches us nothing of practical importance. Custom 
 rather than instinct appears to dictate the choice of these obstetric attitudes. 
 The women of contiguous tribes may show notable differences in this respect. 
 Those who are interested in the subject of labor among primitive people may 
 consult the special works of Engelmann and Witkowsky. Instinct may indicate 
 the best position for the woman at a given moment, but we have no right to 
 assume hastily that this position would be the best for other women or for 
 the sex as a whole. Some of the poses adopted by women under these cir- 
 cumstances appear to be distinctly contraindicated at the time. Does a woman 
 ever instinctively assume the Walcher position when the head is trying to enter 
 the brim? However, the postures assumed by the vast majority of women in 
 the different stages of labor are such as harmonize with the mechanism of 
 labor; thus, when the fetal head is high the patient prefers to stand erect, 
 sometimes even leaning a little backward. After the head has passed the brim 
 she leans forward, or perhaps kneels to assume the sitting position; while if 
 lying down, she draws up her knees and perhaps raises the head and shoulders. 
 A rational study of the relation of posture to labor is of the greatest importance 
 and leads to most practical results. 
 
 There are but two classes of posture which have a special bearing upon 
 midwifery. First, those which alter the shape of the pelvis; second, those in 
 which the pelvis is elevated so that it becomes the highest portion of the trunk. 
 A knowledge of the former enables the obstetrician to facilitate delivery through 
 the resulting diminution of the osseous resistance; while familiarity with the 
 latter enables him to retard labor and replace small prolapsed parts, perform 
 version, etc. These classes will be considered in detail. 
 
 I. POSTURES WHICH ALTER THE SHAPE OF THE PELVIS. 
 
 Owing to the mobility of the pelvic articulations, certain changes in the 
 position of the patient are accompanied by corresponding changes in the dimen- 
 
POSTURE IN OBSTETRICS 
 
 869 
 
 sions of the pelvis. Owing to serous infiltration and consequent softening of 
 the pubic ligaments, the separation of the bones at the pubic symphysis is 
 normally exaggerated during pregnancy, and thus the circumference of the 
 pelvic inlet somewhat increased. It is not generally recognized, however, that 
 the limited but appreciable movements of which the sacro-iliac joints are capable 
 are an important factor in the production of changes in the pelvic dimensions. 
 In the erect position or in the horizontal position with extended thighs there 
 is a slight backward movement of the sacrum which tends to increase the antero- 
 posterior diameter of the inlet. On the contrary, if the thighs are strongly 
 
 Fig. 
 
 1042.- 
 
 -Erect Posture, showing the Parturient Tract and Degree of Pelvic 
 Inclination. 
 
 flexed and the body is bent forward the upper end of the sacrum is tilted forward 
 and its lower end backward, the antero-posterior diameter at the inlet being thus 
 diminished while that of the outlet is increased. As a result of the study of the 
 foregoing facts, and by imitating the methods of nature, the obstetrician is able to 
 produce at will an increase of the conjugate diameters of either the inlet or the 
 outlet of the pelvis. The fact is utilized in normal labor, as I have already noted. 
 It is also, as we shall presently see, of great value in the conduct of operative 
 deliveries. The pelvic inclination varies according to the position of the woman, 
 and may, of course, be abnormal in cases of pelvic deformity. This variation is 
 dependent upon the motion which exists at the sacro-iliac joints, the pelvic brim 
 swinging a little upward and downward according to the position of the patient. 
 
870 
 
 OBSTETRIC SURGERY. 
 
 Separation of the knees, by increasing the tension of the iho-femoral hgaments, 
 increases the angle of inchnation. The normal pelvic inclination in the standing 
 position is from 50 to 60 degrees (Fig. 1042). The pelvic inclination in the dorsal 
 position with the legs extended is 30 degrees (Fig. 1043); in the dorsal position 
 with the thighs and legs flexed and heels close to the buttocks with knees moder- 
 ately separated it is 40 degrees (Fig. 1045); while in the dorsal position with 
 the thighs strongly flexed upon the abdomen and the knees widely separated, 
 namety, the exaggerated lithotomy position, the angle is 60 degrees (Fig. 1047). 
 
 I. The Walcher Posture (Fig. 1046). — This is the opposite of the exaggerated 
 lithotomy position. The patient is placed on her back in the "cross-bed" 
 position, or preferably on a table, in such a manner that the sacrum rests upon 
 the edge of the table, the thighs and legs being allowed to hang downward 
 by their own weight. In this position the pelvic inclination is increased and 
 the Conjugate diameter of the pelvic inlet slightly increased. The vaginal outlet 
 
 Fig. 1043. — Dorsal Posture with Extended Thighs, showing the Parturient Tract 
 AND THE Degree of Pelvic Inclination. — (From a photograph taken at the Emer- 
 gency Hospital.) 
 
 is drawn so far down that the angle formed by the long axis of the uterus with 
 that of the vagina is diminished, and the utero-vaginal canal becomes less 
 curved and approaches a straight line (Fig. 1046). Manual manipulations are 
 thus much facilitated. According to Walcher,* the conjugate is increased from 
 0.33 to 0.5 inch (8.5 to 13 mm.). Fothergill estimates the average difference 
 between the conjugate in the lithotomy position and the same measurement 
 in the Walcher position as 0.36 inch (9.3 mm.). At the New York Maternity, 
 in 1898, I measured several series of cases from among the waiting women 
 with a Farabeuf pelvimeter (Fig. 214) in the lithotomy position with moderate 
 flexion of the thighs, and then in the hanging Walcher posture. A gain in the 
 true conjugate with the latter position was readily demonstrated. This increase 
 in the true conjugate varied from one-fourth to one-half an inch (0.635 cm. to 1.27 
 cm.), averaging higher in multigravidae than in primigravidae. The mechanism of 
 
 * "Ctbl. f. Gyn.," 18S9, S. S92. 
 
POSTURE IN OBSTETRICS. 871 
 
 the Walcher position is dependent upon the motion of the sacro-iliac synchron- 
 drosis, and is explained as follows : The weight of the limbs hanging from the edge 
 of the table causes the ilia to rotate forward and downward around the trans- 
 verse axis of the joint. Thus the angle made by the plane of the brim with the 
 horizon is increased, and consequently the symphysis pubis is brought a little 
 forward and downward and a little further from the sacrum. (See Fig. 1046.) 
 It should not be forgotten that the Walcher position may be utilized in breech 
 presentations as well as in vertex.* 
 
 2. Exaggerated Lithotomy Posture (Fig. 1047). — Dorsal postures are subdi- 
 vided in accordance with the position of the legs. If the latter are horizontal, 
 the angle of the inlet is 30 degrees (Fig. 1043). If the thighs and legs are flexed, 
 the feet resting on the table, the angle increases to 40 degrees (Fig. 1045); and 
 if the degree of flexion is extreme, the patient being in the exaggerated lithotomy 
 
 Fig. 1044. — Dorsal Posture with Elevation of the Thorax, showing the Par- 
 turient Tract and the Degree of Pelvic Inclination. — {From a photograph 
 taken at the Emergency Hospital.) 
 
 posture, the angle is 60 degrees (Figs. 1047, 1048). With increase in the size 
 of the angle of inclination, the fundus tilts backward more and more, while the 
 lower portion of the birth canal is correspondingly elevated. The angle of the 
 two portions of the birth tract, uterine and vaginal, appears to undergo but 
 little change during flexion of the limbs. The dorsal position with extreme 
 flexion of the limbs is indicated for slight degrees of obstruction at the pelvic 
 outlet and for all operations after the head has passed the brim. 
 
 2. POSTURES WHICH ELEVATE THE PELVIS. 
 
 These are four, in two of which the woman is prone, knee-chest and exag- 
 gerated lateral prone, in the others, supine, Trendelenburg and Trendelenburg- 
 
 * The Walcher position was described and illustrated in Italy many years ago. Its 
 use, however, was purely empirical. It was supposed to make the child more movable 
 and to be useful in the delivery of fat patients. It remained for Walcher to demonstrate 
 the mechanism involved and thus to place the matter upon a scientific basis. 
 
872 
 
 OBSTETRIC SURGERY. 
 
 Walcher. The general result of these high pelvic positions is naturally one of 
 gravitation. The pelvic viscera sink toward the diaphragm, and the result from 
 the obstetrical standpoint is twofold. First, the fetus sinks away from the cer- 
 vix, with the result in the first stage that the uterine contractions are diminished 
 in force and frequency. The second consequence of the high pelvic postures 
 is that the pelvis becomes more ample, so that the entire hand may readily be 
 introduced. The combined results of elevation of the pelvis give the obstetrician 
 a high degree of control over certain phenomena of normal and pathological 
 labor. He can delay rupture of the bag of waters, antagonize over-strong 
 pains, facilitate certain manoeuvers which are best done with the entire hand 
 in the vagina, and prevent the redescent of the small parts of the fetus. 
 
 I, Knee-chest Posture (Fig. 1049). — Sims,* in his original description of this 
 position, states that the woman should first kneel and then bend the body 
 
 Fig. 1045. — Dorsal Posture with Moderate Flexion of the Thighs, showing thb 
 Parturient Tract and the Degree of Pelvic Inclination. Note the slight up- 
 ward rotation of the symphysis and enlargement of the pelvic outlet. — (From a pho- 
 tograph taken at the Emergency Hospital.) 
 
 forward till the head reaches the level of the table, where it should rest upon 
 the two hands. The weight is supported by the left parietal bone, the elbows 
 being thrown out widely at the sides. The knees should be 8 or 10 inches 
 (20.32 or 25.4 cm.) apart and the thighs should form nearly a right angle with 
 the table. The woman thus supported should remain perfectly quiet, only the 
 necessary muscles being contracted. After a few moments' interval the abdomi- 
 nal and pelvic viscera gravitate toward the epigastrium. It is apparent that 
 in the knee-elbow position the weight in front is supported upon the forearms, 
 while a knee-chest position is impossible unless pillows are placed beneath 
 the chest. 
 
 2. Latero-prone Position with Elevated Hips (Figs. 1050 and 1051). — This is 
 perhaps superior, in filling certain indications, to both the knee-chest and 
 * "Clinical Notes on Uterine Surgery." 
 
POSTURE IN OBSTETRICS. 
 
 873 
 
 Trendelenburg positions. It is far more acceptable to the patient, who can 
 assume it for an indefinite period. She may lie at first in the ordinary lateral 
 decubitus and then have one side of the pelvis gradually elevated by slipping 
 cushions under the hip. Other cushions are placed beneath the head and 
 chest, as these structures support the weight in front. The woman rests upon 
 the side of the head, the entire breast, and the side of one knee. The elevation 
 of the buttocks appears to equal, for all practical purposes, that produced by 
 the Trendelenburg and knee-chest positions. Obstetricians of a bygone age 
 (Deventer, Ritgen) counsel the employment of this attitude, although they 
 seem to regard it as a makeshift for the more efficacious but hardly en- 
 durable knee-chest posture. It is probable that they did not attempt to 
 
 jts^_ 
 
 M. 
 
 "•'■ -•"^'■•■'"■^'iifiTrtT^r-lfTiif' 
 
 Fig. 1046. — Walcher Posture, showing the Parturient Tract and the Degree 
 OF Pelvic Inclination. Note the downward rotation of the symphysis and the 
 enlargement of the pelvic inlet. — (From a photograph taken at the Emergency Hospital.) 
 
 elevate the pelvis beyond a certain limited height. The superiority of the 
 exaggerated latero-prone position lies in its adaptability and modesty as com- 
 pared w^th the knee-chest position. For many years I have used it in my 
 practice to the exclusion of the uncomfortable knee-chest posture. 
 
 hidications for the Knee-chest and Exaggerated Lateral Prone Postures. — These 
 two postures are of service during pregnancy, labor, and the puerperium. In 
 pregnancy they are useful for external ballottement and also for exploring the 
 sides of the pelvis. Generally speaking, examinations in these positions give 
 results which supplement those obtained by exploration in the dorsal attitude. 
 From a therapeutic standpoint the postures are of some use in procuring tem- 
 porary relief from all conditions which arise from pressure of the gravid uterus 
 on the tissues beneath (hemorrhoids, constipation, vesical trouble, obstruction 
 
874 
 
 OBSTETRIC SURGERY. 
 
 of ureters, etc.). Late in pregnancy the woman may systematically assume 
 these positions at stated intervals. Early in the course of gestation it is sorae- 
 times possible to relieve the vomiting of pregnancy by this means. For one 
 complication of pregnancy, retrodisplacement of the uterus, this postural treat- 
 ment is indispensable, although manual reposition is used as an accessory 
 measure. (Seepage 278.) In labor the assumption of the knee-chest or lateral 
 prone position arrests contractions for the time being. In normal labor there 
 is no very strong indication for the assumption of these positions. They directly 
 antagonize the action of gravity in promoting labor, and are thus distinctly 
 contraindicated in the first stage. In theory they might be indicated when 
 precipitate labor is threatened, and in attempts to defer rupture of the bag 
 of waters. There is no indication for forceps delivery in these postures, but 
 
 Fig. 1047. — Dorsal Posture with Extreme Flexion of the Thighs, showing the 
 Parturient Tract and the Degree of Pelvic Inclination. Exaggerated 
 Lithotomy Position. Note the extreme upward rotation of the symphysis and the 
 enlargement of the pelvic outlet, and diminution of the pelvic inlet. — (From a photo- 
 graph taken at the Emergency Hospital.) 
 
 in version they present numerous advantages: (i) The uterus sags away from 
 the pelvis, giving the operator more room to introduce his hand; (2) labor pains 
 are arrested for the time being, and (3) there is a natural tendency on the part 
 of the knee-chest position to favor the rectification of the malposition for which 
 version is required. These postures are most valuable in connection with pro- 
 lapse of the funis, yet in this manual replacement must generally be employed 
 as an adjunct. In 1882 Galbraith brought about the unlocking of twins by 
 causing the mother to assume the knee-chest posture. In theory, at least, the 
 latter should favor the reposition of an inverted uterus. 
 
 Of the hanging dorsal or Trendelenburg, and the arched dorsal or Trendelen- 
 burg-Walcher positions, the latter is but little known, having been but recently 
 revived from mediaeval obscurity by Dr. R. L. Dickinson. The pelvic elevation 
 is very slight in the latter, and it might perhaps be better described as a hybrid 
 
POSTURE IN OBSTETRICS. 875 
 
 posture in which the size and height of the pelvis are simultaneously affected. 
 Each position is described in detail. 
 
 3. Trendelenburg Posture (Fig. 1052). — While this posture appears to be a 
 lineal descendant of an old method of applying taxis in hernia, its use has become 
 general only of late years, so that the knee-chest position is very much its 
 senior in obstetric practice. A woman in the Trendelenburg position lies upon 
 her back with her head and arms fiat upon the operating table while the rest 
 of her person is elevated to an angle of 45 degrees or less, except the legs, which 
 hang over the foot of an inclined plane. The weight of the body is supported 
 by the head and knees (Fig. 1052). If the angle of elevation attains a certain 
 size, it is necessary to strap the legs. This posture may be improvised in various 
 ways: thus, an incline may be formed from an inverted chair and several pillows, 
 
 7- 
 
 Fig. 1048. — Exaggerated Lithotomy Posture. 
 
 or the woman may rest, head down, upon the back of a strong attendant with her 
 knee hollows upon his shoulders and her legs held in his hands. This was the 
 earliest application of the method. The Trendelenburg position is used extensively 
 in the laparotomies incidental to obstetrical practice, as in ectopic pregnancy. 
 Aside from this, it has been proposed as a substitute in certain cases for the knee- 
 chest position. Its advantages over the latter are that it is more natural and 
 modest, andean be endured indefinitely, thereby antagonizing a further tendency 
 to prolapse of the small parts. It does not conflict with the administration of 
 anesthesia. 
 
 4. Walcher-Trendelenburg Posture (Fig. 1053). — In the Walcher position as 
 usually assumed, the direction of the axis of the utero- vaginal canal is almost 
 perpendicular, and traction with the hand or forceps must be directly down- 
 ward. For this reason a combination of the Walcher position with the well- 
 
876 
 
 OBSTETRIC SURGERY 
 
 known Trendelenburg is advised.* In this way the advantages of the former 
 position are realized while the vulva is at such a height that traction can con- 
 veniently be made. The axis of the utero-vaginal canal is horizontal and 
 manipulations are thus facilitated. A satisfactory table for this position may 
 be improvised by means of an ordinary inverted chair and a mattress. 
 
 Conclusions. — From the foregoing the following conclusions may be deduced: 
 (i) When the head is arrested at the pelvic brim, either the Walcher or the 
 Walcher-Trendelenburg position is worthy of trial. (2) For all operative cases 
 in which the greatest circumference of the head has passed the brim, the ex- 
 aggerated lithotomy position is to be preferred. 
 
 Fig. 
 
 1049. — Knee-chest Posture, showing the Parturient Tract and the Degree 
 OF Pelvic Inclination. — (From a photograph taken at the Emergency Hospital.) 
 
 Posture as an Aid to Childbirth. — In retroversion of the pregnant uterus the 
 patient should be placed in the knee-elbow or the exaggerated latero-prone posi- 
 tion, in order that reposition of the uterus may be attempted. In over-strong pains, 
 to prevent precipitate labor the patient should be placed upon her side and for- 
 bidden to bear down. In labor in contracted pelvis, with slight disproportion be- 
 tween the head and inlet, Walcher's position should be assumed during engage- 
 ment in the inlet. If a similar degree of contraction exists at the outlet, the 
 exaggerated lithotomy position should be assumed. In the ftrst stage of labor pos- 
 ture is generally left to the decision of the parturient. She may be seated or may 
 * Dickinson: "American Journal of Obstetrics," Dec, 1898, p. 791 
 
POSTURE IN OBSTETRICS. 
 
 877 
 
 walk about. An upright position is held to be of advantage because the weight 
 of the fetus may stimulate the cervix to dilate. However, when dilatation is 
 nearly complete there is some danger of precipitate expulsion, with possible 
 
 Fig. 1050. — Exaggerated Lateral Prone Posture. Anterior View. — (From a photo- 
 graph taken at the Emergency Hospital.) 
 
 rupture of the cord or injury to the child. It has been suggested as a com- 
 promise that the woman should squat or kneel during the latter part of the 
 first stage, for she thereby retains the benefit of the upright position without 
 the risks just enumerated. In the second stage of labor the natural tendency 
 
 ^" 
 
 ^ 
 
 -- ^H-^-^' 
 
 Fig. 1051. — Exaggerated Lateral Prone Posture. Posterior View.- 
 photograph taken at the Emergency Hospital.) 
 
 -{From a 
 
 during the expulsion period is toward the assumption of the dorsal position. 
 It has been ascertained that a reclining attitude facilitates the first half of 
 the second stage, while during the second half the woman should turn on that 
 
878 
 
 OBSTETRIC SURGERY. 
 
 side toward which the fetal back presents, with her legs strongly flexed. This 
 position is believed to favor perfect flexion of the child's head. It is used 
 almost universally in Great Britain throughout the second stage. While conduc- 
 ing to modesty, it also lessens the intensity of the expulsive forces during perineal 
 dilatation by bringing gravity into play. In the third stage of labor the woman 
 should lie flat on her back with the head low. In occipito-posterior positions 
 before labor has set in, the woman should assume the knee-chest or latero-prone 
 position with elevated hips in the hope that the head will engage in the natural 
 way After labor is under way she should assume the latero-prone position 
 on the side toward which the fetal back is directed. In mento-posterior positions 
 the patient should be placed on the same side as that toward which the fetal ab- 
 domen is turned. This posture favors the desired extension and anterior rotation 
 of the chin. With prolapse of an arm, after the head has been pushed up, the 
 
 Fig. 1052. — Trendelenburg Posture, showing the Parturient Tract and the De- 
 gree OF Pelvic Inclination. — {Froin a photograph taken at the Emergency Hospital.) 
 
 uterine obliquity usually present is corrected by having the patient lie on the side 
 opposite to that to which the fundus inclines. The head should now be able to 
 engage without the arm. With presentation and prolapse of the cord our resource 
 is often posture. The patient should be placed in the knee-elbow or exaggerated 
 semi-prone posture for ten minutes. The head then falls away from the os and 
 sinks into the cavity of the uterus. Actual prolapse of the cord requires the same 
 postural treatment. With short cord the mother may assume a squatting or kneel- 
 ing posture (page 559).* In heart failure an asystolic woman can often be safely 
 delivered in a reclining attitude with the thorax raised and afterward may regain 
 some compensation (Fig. 1044). It is held that this position aids the failing 
 heart and respiration by removing some of the pressure from the diaphragm. 
 In post-partum hemorrhage the patient should be flat on her back without pillows 
 and the foot of the bed elevated. This posture is indicated also in ante-partum 
 * Brickner: "Am. Jotir. Med. Sciences," Nov., 1899. 
 
VAGINAL EXAMINATION. 
 
 879 
 
 and intra-partum hemorrhages. In forceps delivery the patient is usually placed 
 in the lithotomy position. In England she lies in the ordinary obstetrical 
 position, upon the left side. The English and American methods can be com- 
 bined by applying the blades in the former and extracting in the latter position. 
 In very difficult extraction the Walcher position may be employed until the 
 head has passed the inlet, after which the lithotomy position is assumed. In 
 version the woman is placed in the Trendelenburg, Walcher, Trendelenburg- 
 Walcher or exaggerated lithotomy position according to the stages and difficulties 
 of the operation. In dorso-posterior positions one may employ the latero-prone 
 position, the woman lying on the side at which is the fetal pole which is to be 
 brought down. In case the presenting part is firmly engaged in the inlet, the 
 
 \ 
 
 ^A^*"'' 
 
 Fig. 1053. — -Trendelenburg-Walcher Posture, showing the Parturient Tract and 
 THE Degree of Pelvic Inclination. Note the downward rotation of the sym- 
 physis and the enlargement of the pelvic inlet. — {From a photograph taken at the Emer- 
 gency Hospital.) 
 
 knee-elbow position may be used, although I have found the exaggerated latero- 
 prone or Trendelenburg posture to answer better. In the puerperium, for the 
 first two or three days the dorsal posture is advisable (page 694). After the 
 third day the patient's time should be equally divided between the dorsal, two 
 lateral, and if possible the abdominal posture (fiat on belly) (page 694). Drain- 
 age is promoted by an early propping up of the shoulders. 
 
 V. VAGINAL EXAMINATION. 
 
 See Asepsis in Obstetrics, page 14S. 
 
880 
 
 OBSTETRIC SURGERY. 
 
 VI. DIGITAL EXPLORATION OF THE UTERUS. 
 
 This procedure is often necessary in the diagnosis of incomplete abortion 
 and septic conditions, and is performed as follows: The patient is placed in the 
 lithotomy position, the operator's hands and arms and the vulva are carefully 
 disinfected, and the vagina is irrigated. Two fingers of the right hand are then 
 introduced into the vagina and passed through the cervix, the left hand mean- 
 while being placed upon the fundus and the uterus being pressed downward 
 and backward into the axis of the bony pelvis (Fig. 1054). In this way the 
 
 Fig. 1054. — Digital Exploration of the Uterus, 
 
 uterus may be pressed over the examining fingers like a glove. The anterior, 
 posterior, and lateral walls of the uterus are then to be systematically palpated 
 especial attention being paid to the comua, where retained decidua, chorion, 
 or placenta is apt to escape notice (Fig. 1054). The condition of the uterine 
 walls is thus appreciated and the presence or absence of placenta or membranes 
 noted. In some cases it may be necessary to introduce the entire hand into 
 the uterus. This can be done only when the patient has been recently delivered 
 and the cavity is of sufficient size. If the patient is unusually nervous or sensi- 
 tive, primary anesthesia will first be necessary. 
 
VULVAL DOUCHE— VAGINAL IRRIGATION. 
 
 881 
 
 VII. VULVAL DOUCHE. 
 
 It is often important that the vulva should be flushed out thoroughly in 
 its inner aspect and not merely washed on the outside, as is the ordinary custom. 
 The inside of the vulva, in marked 
 contrast with the vagina, is the habitat 
 of many germs, and in certain cases 
 
 infection may be due to micro-organisms -(^^i^ 
 
 from the vulva carried into the birth 
 tract on the exploring finger. The vulval 
 douche is therefore intended to cleanse 
 the inner aspect of the external genitals. 
 The woman should lie on her back upon 
 a douche pan or a Kelly pad with limbs 
 somewhat abducted (Fig. 1048). The 
 labia majora are held wide apart by the 
 fingers (Fig. 1055), while by the aid 
 of an ordinary irrigation apparatus a 
 stream of water is directed through a 
 glass nozzle upon the labia minora, 
 clitoris, vestibule, and other parts com- 
 prising the vulva. The cleansing can 
 also be accomplished after wide open- 
 ing of the vulva with pledgets of 
 absorbent cotton first dipped in a 
 soap solution, then in sterile water, and 
 lysol or sublimate solution. To avoid 
 should always be from above downward. 
 
 Fig. 1055. — The Vulval Douche. 
 
 finally in an antiseptic, such as a 
 rectal contamination, the sponging 
 
 Vlll. VAGINAL IRRIGATION. 
 
 In this, as in all other obstetric procedures, every care should be taken to 
 prevent the introduction of infection. The vulva and adjacent regions and the 
 hands of the physician should be cleansed as before a vaginal examination. 
 (See Asepsis in Obstetrics, page 150.) The patient should be in the dorsal 
 position; a glass or metal tube which can be sterilized by boiling is to be pre- 
 ferred (Fig. 1057). The intrauterine tube may be used, but a straight tube 
 is less likely to enter the cervix or to carry fluid into the uterine cavity. In 
 all cases, as in vaginal and uterine manipulations, the vulval canal should first 
 be obliterated with the free hand before the introduction of the irrigating 
 tube (Fig. 1056). Special attention is to be directed to the posterior cul-de-sac, 
 where there is apt to be an accumulation of stagnant secretions. Special care 
 is to be taken also that the tube does not enter the cervix and that infectious 
 secretions are not washed into the uterus. If necessary, a finger in the vagina 
 should be employed to make sure that the uterine cavity is not invaded. A 
 common practice in recent years has been to close tightly the vaginal outlet 
 about the irrigating tube, in order to increase the intravaginal pressure, balloon 
 the walls, and secure a more thorough cleansing. This in the presence of a 
 puerperal uterus must be employed with caution, and never without a firm 
 grasp of the fundus, and only with moderate increase of intravaginal pressure. 
 56 
 
882 
 
 OBSTETRIC SURGERY. 
 
 A fountain syringe is to be preferred for vaginal as for intrauterine injections. 
 The temperature of the solution should be from 105° to 110° F. There is no 
 advantage in a high degree of heat unless hemorrhage exists. The resorptive 
 power of the vagina soon after delivery- 
 is greater than has generally been sup- 
 posed. Stronger sublimate solutions than 
 I : 5000 should not be used. For the 
 
 W^h 
 
 Fig. 1056. — The Vaginal Douche. 
 
 Fig. 
 
 1057- 
 
 -Blunt Vaginal Douche 
 Tube. 
 
 various solutions to be used in vaginal as well as intrauterine injections, see 
 Treatment of Puerperal Infection (page 726). Valuable ones are, i : 5000 
 sublimate; 2 per cent, carbolic acid; 0.5 per cent, lysol or creolin; decinormal 
 saline solution, and plain sterile water. 
 
 IX. INTRAUTERINE IRRIGATION. 
 
 j^An intrauterine injection is by no means an indifferent procedure, and 
 should be regarded as an operation — one to be performed with scrupulous 
 care and ^attention to detail. The following are the sources of danger. Shock 
 from uterine distention or from too hot or too cold solutions; poisoning, e. g., 
 by bichloride of mercury or carbolic acid; abrasions of the soft parts resulting 
 in new foci of infection; dislodgment of clots from the puerperal venous 
 
INTRAUTERINE IRRIGATION. 
 
 883 
 
 sinuses which may enter the general circulation, and entrance of fluid into 
 the Fallopian tubes and peritoneal cavity. 
 
 The intrauterine douche tube should be of glass or metal, that it may be 
 sterilized by boiling, should be of medium caliber, and have a suitable curve 
 (Fig. 1059). Tubes of tin, the shape of which can be altered at will, are con- 
 venient, and metal male catheters may be used in an emergency. The tube 
 should be perforated at the sides and there should be no opening at the end. 
 The current of fluid should be continuous, not interrupted; a fountain syringe 
 
 Pig 105S. — Intrauterixe Irrigation. The upper illustration shows a faulty method. 
 
 Note the firm grasp of the fundus. 
 
 is to be preferred, and every care should be taken to prevent the entrance 
 of air. The douche bag should be held at such a height that the current is 
 sufficient but not strong, two or three feet above the patient's pelvis being 
 usually the proper height. The quantity of fluid may vary with the indications, 
 less than one quart being rarely used. Solutions: Within the uterus we irrigate 
 with plain sterile water or sterile decinormal saline solution; 0.5 per cent, of 
 creolin or lysol, 50 per cent, alcohol, and sublimate solution in the strength 
 of I : 10,000, which last should be followed b}^ a second irrigation of plain 
 
884 
 
 OBSTETRIC SURGERY. 
 
 sterile water. Administration: The patient should be in the dorsal position, 
 and, when practicable, in the lithotomy position. As stated elsewhere, a 
 recently delivered patient should never be placed in the Sims position on 
 account of the danger of the entrance of air into the 
 uterine sinuses. It is rarely necessary, nor is it advis- 
 able, to introduce the finger into the vagina as a guide 
 to the cervix. The external genitals and hand having 
 been cleansed, the physician sits or stands at the side 
 of the bed or in front of the patient, and with the 
 fingers of the free hand obliterates the vulval canal 
 by placing the outer border of the thumb upon the 
 inner aspect of one labium and the first and second 
 fingers upon the inner surface of the opposite labium, 
 and widely separates them (Fig. 1056). The irrigating 
 tube is then passed directly into the vagina and first 
 a thorough vaginal irrigation is administered, during 
 which the free hand firmly grasps the fundus. The 
 fundus is then pushed backward, and by the sense of 
 touch the irrigating tube is passed on into the uterus, 
 always remembering to keep a firm grasp upon the 
 fundus to prevent dilatation of the uterus and opening 
 of the sinuses (Fig. 1058). 
 
 The tube should be carried to the fundus, and care 
 should be taken that the soft tissues of the uterine wall 
 are not injured by rough or careless movements. Some 
 instruments — e. g., the Fritsch-Bozeman intrauterine 
 catheter, and the author's irrigating tube — provide for 
 the return of the fluid, but this may be promoted, if 
 necessary, whatever instrument is used, by gentle pres- 
 sure with the instrument against the anterior lip of the 
 cervix. During the entire process the patient should 
 be carefully observed, and at the first evidence of 
 pallor or twitching of the facial muscles, or of pain 
 or constitutional disturbance, the injection should be 
 stopped. If there is uterine hemorrhage, showing the 
 dislodgment of a clot, the injection should be suspended. Retained fluid is 
 best expressed by compression of the fundus. 
 
 FRONT 
 VIEW. 
 
 CROSS ^ 
 SECTIONQD 
 
 Fig. 1059. — Author's 
 Return Flow Vag- 
 i.NTAL AND Uterine 
 Irrigating Tubes. 
 
 X. THE VAGINAL TAMPON. 
 
 This is best applied with the patient in the Sims position and the perineum 
 drawn back by a speculum. The dorsal posture and a perineal retractor can 
 also be used. The external genitals should be disinfected and the vagina care- 
 fully swabbed out with a piece of gauze soaked in an antiseptic solution. The 
 tampon should preferably be of gauze, but in the absence of this material may 
 be of absorbent cotton or lamp-wick, soaked in an antiseptic solution. The use 
 of plain sterile gauze is not advisable owing to the danger of decomposition 
 of retained secretions. In order to be efficient, the tamponing should be done 
 carefully and thoroughly. It requires from thirty to forty yards of four-inch 
 moist gauze to properly tampon the vagina in placenta prsevia. The vaginal 
 
THK UTERINE TAMPON. 
 
 885 
 
 fomices should first be packed, and as the speculum is gradually withdrawn the 
 rest of the vagina is filled (Fig. 1060). The tampon is held in position by a 
 rather tight-fitting T-bandage (Fig. 271). It should not remain in place more 
 
 Fig. 1060. — The Vaginal Tampon. 
 
 than twelve hours. At the end of this time it should be removed, and a second 
 tampon introduced and left for another twelve hours. 
 
 XI. THE UTERINE TAMPON. 
 
 As stated elsewhere, the intrauterine tampon is used for the purpose of 
 controlling hemorrhage and occasionally in the treatment of septic conditions. 
 The method of procedure is as follows: The patient being in the lithotomy 
 posture, the vulva and adjacent regions are cleansed and the vagina is irrigated; 
 the perineum is depressed with an ordinary retractor; the anterior and posterior 
 cervical Hps are seized with volsella forceps or tenacula and the uterus is 
 drawn down and held by an assistant (Figs. 1061 and 1062). A long strip of 
 gauze is now passed into the uterine cavity by means of a long, blunt-pointed 
 dressing forceps. The strips should be a hand's-breadth in width and folded, 
 and about three or four yards in length, for the full-term puerperal uterus, and 
 correspondingly smaller for the earlier months. Unmedicated sterile gauze is 
 to be preferred. Every precaution should be taken to prevent infection, and 
 the gauze should be carried by the dressing forceps directly from its special 
 receptacle into the uterus without touching any foreign body which might con- 
 taminate it. During the entire operation the dressing forceps holding the gauze 
 should be guided and controlled by the external hand grasping the fundus. 
 
886 
 
 OBSTETRIC SURGERY. 
 
 which makes sure that the gauze has reached the fundus. The gauze is gradu- 
 ally introduced, the object being completely to fill the uterine cavity from 
 above downward (Figs. 1061 and 1062). 
 A loose packing is left in the vagina. If, 
 however, in cases of hemorrhage, the 
 bleeding comes from the lower uterine 
 
 Fig. 106 1. — Method of Packing the Puer- 
 peral Uterus. — (From a photograph.) 
 
 Fig. 1062. — Method of Packing the 
 Puerperal Uterus. 
 
 segment, as in some cases of placenta praevia or cervical laceration, the vaginal 
 
 packing should be tight. 
 
 In some cases the uterus may be pressed down so far that it is not necessary 
 
 to draw it down by means of in- 
 struments, and if the latter are 
 lacking, the gauze may usually 
 be introduced by means of the 
 hand being passed into the 
 uterine cavity. If sterile gauze 
 is not at hand, clean linen or 
 other material which has been 
 boiled and soaked in a disinfect- 
 ant solution may be substituted 
 in the case of grave emergency. 
 A most convenient method for 
 uterine as well as vaginal tam- 
 ponade will be found in the use 
 of a mechanical surgical dress- 
 ing packer.* I have for several 
 years in hospital and private 
 YTj- inch, for the puerperal uterus of 
 
 Fig. 
 
 1063. — Packing the Puerperal 
 with a Metal Gauze-packer. 
 
 Uterus 
 
 work used two sizes. No. 3, outside diameter ■^-^ 
 
 * Darmack patent. 
 
ARTIFICIAL RUPTURE OF MEMBRANES. 
 
 887 
 
 the early months, and for packing the lower uterine segment to induce abortion; 
 and No. 4, outside diameter f inch, for packing the larger puerperal uterus and 
 the lower segment to induce premature labor. No. 3 
 carries gauze from ^ inch to i^V inches wide; No. 4, 
 from 4 inches to 6 inches (see Figs. 1063 and 1069). To 
 use the instrument, the lithotomy position, with the peri- 
 neum retracted and the cervix held with volsella forceps, is 
 to be preferred. 
 
 Hemorrhage coming on in from half an hour to an hour 
 after the insertion of the uterine tampon indicates that blood 
 is being squeezed from the gauze by uterine contractions. In 
 such a case further tamponing is not indicated, but, rather, 
 the removal of the gauze. The tampon should not be allowed 
 to remain in situ for more than twelve hours, and its re- 
 moval should usually be followed by uterine and vaginal irri- 
 gation with some non-toxic solution. 
 
 XII. PASSING THE CATHETER. 
 
 The patient is placed in the dorsal position with thighs 
 rotated outward. The labia are held apart by the fingers of 
 one hand (Fig. 1056), while with a pledget of cotton dipped 
 in an antiseptic solution, such as i per cent, lysol, the vesti- 
 bule is carefully wiped from above downward. A glass cath- 
 eter (Fig. 1064), previously boiled, is then introduced into 
 the meatus and the water drawn. Since antisepsis and asepsis 
 have been elaborated, it is considered wiser to catheterize the 
 woman by the aid of direct inspection than by the mere sense 
 of touch. For special directions for using the catheter, see 
 Affections of the Bladder in Pregnancy (page 318), Labor (page 478), and the 
 Puerperium (pages 706 to 708). 
 
 Fir.. 1064. — Gi,Ass 
 Catheter. 
 
 (B) OPERATIONS PPEPARATORY TO DELIVERY. 
 I. ARTIFICIAL RUPTURE OF MEMBRANES. 
 
 This procedure is of such simplicity that it hardly deserves to be ranked 
 as an operation. Indications : When the cervix is fully dilated and the bag of 
 waters is gtill intact, the obstetrician may interfere. The amniotic fluid has 
 completely discharged its function of aiding the first stage of labor and would 
 constitute an impediment in the period of expulsion. In twin labors after the 
 birth of the first child, the os being well open, the bag of waters of the second 
 twin will be of no further service, and should be ruptured after a short interval 
 of expectancy. When the bag of waters persists throughout labor, the mem- 
 branes should be ruptured immediately lest the newly born child be asphyxiated. 
 Artificial opening of the membranes is sometimes indicated with the os not 
 fully dilated. Thus the bag of waters may prolapse through a partially open os, 
 
888 
 
 OBSTETRIC SURGERY. 
 
 and even descend to the level of the vulva. This has been termed the " sausage- 
 shaped" protrusion of the bag of waters, and sometimes stands in causal relation 
 to premature detachment of the placenta. On this account alone it may be 
 necessary to rupture the membranes. Again, if there are adhesions between 
 the cervix and membranes which cannot be separated by the finger, artificial 
 rupture may be indicated. In placenta praevia lateralis the indication is for 
 early rupture of the membranes in advance of dilatation, in order that the 
 
 fetal head may descend and compress the lower seg- 
 ment (page 223). In premature detachment of a 
 normally seated placenta the indication is the same 
 (page 228). Finally, most cases of operative inter- 
 vention require rupture of the membranes. Tech- 
 nique : The fingers should pinch up a fold of the 
 membranes and tear it apart. If the membranes are 
 very firm or tense, the rupture must be produced by 
 scissors or dressing forceps, or any sterile pointed 
 instrument. 
 
 Fig. 1065. — Notched 
 Thimble for Artifi- 
 cial Rupture of the 
 Membranes. 
 
 II. INDUCTION OF ABORTION AND PRE- 
 MATURE LABOR. 
 
 Definitions. — The terms abortion and premature 
 labor are applied with considerable looseness by var- 
 ious writers to express the termination of pregnancy 
 at various periods before term. It seems logical, how- 
 ever, to draw the line at the approximate period of 
 pregnancy at which the child is fitted for extrauterine 
 existence, i. e., the seventh month, and to divide abor- 
 tions into early and late. An early abortion is one 
 occurring within the first twelve weeks. Up to this 
 time the ovum usually comes away in nearly a com- 
 plete condition, while after the third month three stages of labor may be distin- 
 guished. It is advisable to make this distinction between early and late abortions, 
 since the methods of treatment for each period are different. Induction of abor- 
 tion is performed entirely in the interest of the mother; induction of premature 
 labor may be done in the interest of either or both. 
 
 Importance. — For the conscientious physician the interruption of pregnancy 
 naturally involves great responsibility, but when it is the only method of saving 
 the lif^ of the mother, or when without it her life is placed in imminent danger, 
 it is usually regarded as not only justifiable but imperative. If possible, it 
 should always be preceded by a consultation, which may not only prevent 
 the unnecessary sacrifice of fetal life but protect the reputation of the physi- 
 cian. 
 
 Indications for the Induction of Abortion. — I am accustomed to make two 
 groups of these indications, namely, (i) General, and (2) Local Indications. 
 
 I . Chief among the general indications is the toxemia of pregnancy, which 
 shows itself chiefly in the early months, by the persistent vomiting of pregnancy. 
 Although I am not convinced that all cases of persistent vomiting of pregnancy 
 have an autotoxic origin, still I believe that a large proportion of these cases are 
 due to a toxemia peculiar to pregnancy, possibly of hepatic origin. My custom is 
 
INDUCTION OF ABORTION AND PREMATURE LABOR. 889 
 
 to advise immediate induction of abortion in all cases showing marked 
 toxic symptoms, and also in the milder type after stimulation of the 
 functions of the liver, kidneys, and skin, together with colonic irriga- 
 tions and rectal feeding fail to mitigate the symptoms. In instances 
 of uncontrollable vomiting in which there is a possible neurotic or 
 reflex cause, and in which decided toxic sympt6ms are absent, one is 
 justified in using an expectant treatment, for a time, but never after 
 food fails to be retained, emaciation becomes evident, and the pulse 
 very rapid. Under these latter conditions a therapeutic abortion is 
 not only justifiable but demanded, as too many lives have been sacri- 
 ficed in the past by procrastination. 
 
 Renal insufficiency from acute and chronic nephritis usually asserts 
 itself toward the last third of gestation, hence I have considered this 
 condition under the induction of premature labor. The same indica- 
 tions, however, hold good in the first two-thirds of pregnancy. 
 
 Advanced cardiac and pulmonary disease have been considered on 
 pages 325 and 331; and gestational mania, and neuroses, as cJiorea, 
 on page 335. 
 
 2. Foremost among the local indications stands pelvic contraction. 
 This only applies to absolute pelvic contraction (see page 659), as the 
 operation has no place in relative pelvic contraction unless the latter 
 be complicated by other maternal or fetal conditions demanding 
 emptying of the uterus. In instances of absolute pelvic contraction 
 the choice lies between induction of abortion and Caesarean section, 
 and in view of the excellent results attending the latter operation, it 
 should be the operation of choice in these cases, unless other compli- 
 cations exist (see page 659). Induced abortion has no place in un- 
 complicated ovarian tumors, as we know to-day that such tumors can 
 be removed by laparotomy without interrupting pregnancy, and this 
 should be the treatment as soon as the diagnosis of the tumor is 
 made (see page 604), In instances of uterine myomata complicating 
 pregnancy, likewise, induced abortion rarely is indicated, as unless 
 such tumors present urgent pressure symptoms pregnancy should be 
 allowed to proceed to viability or term, and a hysterectomy per- 
 formed either after spontaneous labor or Caesarean section, the latter 
 operation being possibly demanded by the tumor acting as an obstacle 
 to delivery through the pelvis (see page 604). Therapeutic abortion 
 is strictly contraindicated in cancer of the uterus. If the case is oper- 
 able, immediate total hysterectomy is the operation of choice; disre- 
 garding entirely the existence of pregnancy. In inoperable cases 
 pregnancy should be permitted to continue to viability or full term, 
 and delivery completed according to the indications. In cancer of the 
 cervix palliative measures in the interest of both mother and child 
 may be resorted to during pregnancy (see page 610). 
 
 Irreducible uterine displacements, as retroflexion, prolapse, and hernia 
 of the pregnant uterus, do occasionally require therapeutic abortion (see 
 pages 278 and 281). Hemorrhage in the middle third of gestation may 
 merely antedate a spontaneous abortion, but when such bleeding per- 
 sists to an alarming extent without the expulsion of the uterine con- 
 
 I f] 
 
 
 Fig. 1066. — Sterile Solid Bougie, for the Induction of Premature 
 Labor, Contained in Sealed Glass Tube. 
 
890 OBSTETRIC SURGERY, 
 
 tents therapeutic abortion is required, as the cause of the hemorrhage is prob- 
 ably a placenta prcevia or the premature separation of a normally situated placenta 
 (accidental hemorrhage). 
 
 Induction of abortion and irrigation of the uterine cavity is always demanded 
 in those cases of unsuccessful attempts at criminal abortion, in which there 
 is hemorrhage and possibly symptoms of sepsis as well (see page 360). The 
 same may be said of instances of missed abortion, as soon as the symptoms of 
 the death of the fetus can be determined (see page 358). Hydatidiform mole (see 
 page 201) and acute hydramnios (see page 208) are also indications for the 
 induction of abortion. 
 
 Indications for the Induction of Premature Labor. — These are principally 
 on account of some condition or disease of the mother, as contracted pelvis or 
 pregnancy toxemia, or, less frequently, because of some pathological condition 
 existing in the ovum, as placenta prsevia or habitual death of the fetus. 
 
 Endless discussion has arisen regarding the advisability of .this operation in 
 contracted pelves, several, as Pinard, Bar, and J. W. Williams, going so far as 
 entirely to abandon the operation for this indication, and they permit their cases 
 of relatively contracted pelves to go to term and then rely upon spontaneous 
 labor, symphyseotomy, or Ccesarean section for delivery. This opinion is 
 largely based upon the difficulty of determining with accuracy the comparative 
 size of the fetal head, and of predicting whether sufficient plasticity of the head 
 and strong uterine contractions will be present in a given case. From this 
 opinion I most strongly dissent, for reasons already set forth in the Treatment 
 of Pelvic Deformity (page 660), and especially because pelvimetry'- and cephalo- 
 metry have in the past few years made such great strides toward accuracy that 
 we can to-day draw very definite conclusions by our different methods of exam- 
 ination, concerning the relative size of a given pelvis and the fetal head. (See 
 Pelvimetry and Cephalometry, pages 167 and 180.) 
 
 Pernicious anemia occurs with greater frequency in the pregnant woman 
 than in the non-pregnant, although it is a very rare accident of gestation. Left 
 to itself, pernicious anemia tends to terminate in premature labor or fetal death 
 with eventual death of the mother. As this affection usually appears when 
 pregnancy is well advanced, an opportunity is afforded to aid the chances of 
 both mother and child by intervening soon after the diagnosis is made. The 
 loss of blood will be considerably less than at term, and this fact alone is suffi- 
 cient to establish the indication. The mother is known to have recovered in at 
 least one such case.* 
 
 Pregnancy Toxemia. — The mild, often self-limited, type of toxemia does not 
 always call for the interruption of labor. When this condition does not yield 
 to treatment, and when the clinical picture is that of the acute or fulminant 
 type, however, labor cannot be induced too soon. When the preeclamptic 
 state, representing as it does a severe but not necessarily pernicious form of 
 toxemia, does not subside or markedly improve under treatment, induced labor 
 is indicated. In acute and chronic nephritis, even if the toxic symptoms can be 
 held in control by suitable diet, hygiene, and medication, it must be remem- 
 bered that eventually spontaneous premature labor is almost certain to result, 
 and that the fetus of such a mother is usually very poorly developed, and not 
 likely to survive. There is always the likelihood in the continuance of preg- 
 nancy of acute nephritis becoming chronic and of chronic nephritis rapidly pro- 
 gressing, hence in the event of toxic symptoms or renal insufficiency in these 
 *Stieda: "Ctbl. f. Gynakol.," 1897. 
 
INDUCTION OF ABORTION AND PREMATURE LABOR. 891 
 
 cases, labor should be induced solely in the interests of the mother, those of tlie 
 fetus being ignored. 
 
 In the acute infectious diseases, as typhoid, pneumonia, and in the acute 
 exanthemata, spontaneous premature labor will often occur, but induction of 
 labor is contraindicated, as nothing is gained for the child, and the prognosis for 
 the mother is not bettered. 
 
 Pulmonary tiihsrcttlosis occasionally demands the operation (see page 331). 
 For the induction of labor in hydatidijorm mole, see page 201 ; in hydramnios, 
 page 205 ; placenta prcevia, page 222 ; in cardiac disease, page 325; and in chona, 
 page 335- 
 
 At one time induction of premature labor was frequently resorted to in 
 instances of uterine and ovarian tumors. This is no longer justifiable nor proper 
 (see page 604). 
 
 In rare instances, from the thirty-fourth to the thirty-eighth week, death of 
 the fetus has occurred in successive pregnancies in women in whom nephritis 
 and syphilis are absent as causative factors. Although the cause of this habitual 
 death of the fetus, as it is termed, is unknown, it is justifiable to induce labor a 
 week or so before the time at which fetal death occurred in previous pregnancies, 
 in the hope of securing a living child. The procedure is occasionally successful. 
 
 In 2200 hospital cases I found it was necessary to induce labor in 19 cases, 
 or 0.86 per cent., or once in 11 5.8 cases. The indications were: eclampsia, 4 
 cases; albuminuria, 4; pelvic deformity, 4; placenta praevia, i; cardiac disease, 
 i; shoulder presentation, i; pulmonary tuberculosis, i ; death of fetus, i. The 
 maternal mortality was in the 19 cases, as was the fetal mortality after the 
 thirtieth week, nil. In one still-birth the operation was performed for dead fetus. 
 
 METHODS OF INDUCING ABORTION AND PREMATURE LABOR. 
 
 Various drugs have been used; e. g., ergot, quinin, pilocarpin, ustilago 
 the oils of tansy, pennyroyal, rue, savine and parsley, sulphate of magnesia 
 and various irritant cathartics. Many of these drugs are dangerous and all 
 are unreliable. They act chiefly by causing congestion of the pelvic viscera. 
 
 The vaginal douche or tampon, the intrauterine injection of water or glycerin, 
 the artificial rupture or circular detachment of the membranes, and the use of 
 electricity, are either too uncertain or dangerous as methods for the induction 
 of labor, and have been to-day i uperseded by more reliable and safer methods. 
 
 Manual and Instrumental Dilatation of the Os. — Manual or instrumental 
 dilatation of the cervix may of itself be sufficient to cause the premature inter- 
 ruption of labor, and it is a necessary part of many of the operations designed 
 for that purpose (Figs. 1071 to 1093). Since, however, it is also a part of the 
 treatment of difficult labor, and is in itself a distinct and important part of 
 obstetric surgery, which merits separate attention, it will be considered by 
 itself. (See page 895.) 
 
 Catheterization of the Uterus (Krause's Method) . — The vagina and cervix are 
 carefully disinfected. A solid bougie (No. 17 French or 12 English) is disin- 
 fected by boiling or steaming (Fig. 1066). The patient being in the lithotomy 
 position, one or, if possible, two fingers of the operator's left hand are passed 
 into the cervix, which has been drawn down by a volsella forceps (Fig. 1067). 
 The bougie is passed by the right hand under the guidance of the fingers in 
 the cervix, between the membranes and the uterine wall posteriorly, or in 
 the direction of the least resistance, great care being taken not to rupture the 
 
892 
 
 OBSTETRIC SURGERY. 
 
 membranes or to separate the placenta (Fig. 1067). The bougie should be 
 inserted to within a short distance of the fundus. Another bougie may be 
 passed, if its introduction is easy, and a light vaginal packing of gauze will hold 
 the bougie or bougies in place and protect the vaginal wall. The bougie is 
 left to remain until labor is well under way. Labor usually begins in from 
 twelve to twenty-four hours. In introducing the bougie after the forma- 
 tion of the placenta has occurred, care must be taken to avoid separation of 
 the latter, desisting from pressure and passing the bougie in another direction 
 
 Fig. 1067. — Introduction of a Sterile Solid Bougie into the Uterine Cavity for 
 THE Induction of Premature Labor. 
 
 if resistance or hemorrhage is encountered. After introduction of the bougie 
 the patient should remain in bed until uterine contractions begin. Now and 
 then there will be a case in which active labor pains will not begin in 
 twenty-four hours, and then the tampon and bougie should be withdrawn, a 
 vaginal douche given, and a new bougie inserted in a position opposite to the 
 first. Although one introduction is generally sufficient, several are sometimes 
 required to produce the desired result, and, indeed, this method in certain cases 
 fails altogether, though in general when time is not an object it is to be chosen 
 
INDUCTION OF. ABORTION AND PREMATURE LABOR. 893 
 
 as the best and safest. Its chief danger is sepsis, and this is to be obviated 
 by the most rigid antiseptic precautions. I am accustomed to combine Krause's 
 bougie method with a gauze packing of the lower part of the uterus. The gauze, 
 iodoform or plain, is rapidly run into the uterus after the introduction of the 
 bougie with one of the modern cannula packers (see Fig. 1069) until slight resist- 
 ance occurs. Vaginal packing 
 is then accomplished with the 
 same instrument, by simply 
 withdrawing the end of the can- 
 nula from the os and continuing 
 the packing in the vagina. I 
 have never known this combined 
 method to fail to induce labor 
 within twelve hours. 
 
 Tamponade of the Vagina 
 and Cervix. — The above method 
 may be made considerably more 
 effective by a preliminary tam- 
 ponade of the cervix. After 
 
 about the thirtieth week artificial dilatation is not usually necessary. Before that 
 time the cervix may be dilated by Hegar's dilators or by the cautious use of one 
 of the branched dilators until it will admit the finger. The cervix should then be 
 packed with gauze and the vagina tamponed. (Compare page 884.) 
 
 Fig. 1068. — Management of Inevitable Abor- 
 tion. Packing the Cervical Canal and Va- 
 gina WITH Sterile Gauze. 
 
 Fig 1069. — Induction of Abortion by the Introductiox of Sterile Gauze into the 
 Uterus with a Cannula Packer. 
 
 Tamponade of the Uterine Cavity. — This method acts in the same way as 
 catheterization of the uterus, but affords a greater source of irritation and is 
 very likely to prove effective. The cervix is dilated if necessar3% and then, by 
 means of a uterine packer, a tube through whose lumen a strip of gauze is 
 pushed by a carrier (see Fig. 1068), a quantit}^ of sterile gauze is forced between 
 
894 
 
 OBSTETRIC SURGERY. 
 
 the membranes and the uterine walls (Fig. 1069). The membranes separate with- 
 out rupture, as the pressure exerted upon them by the mass of gauze is dis- 
 tributed over a considerable area. Unlike the bougie, the gauze cannot be 
 introduced up to the fundus. 
 
 Hydrostatic Bags of de Ribes. — An excellent method for the induction of 
 both abortion and premature labor is the introduction into the lower portion 
 of the uterus of a Champ etier de Ribes bag, or, better, one of its numerous 
 modifications (Figs. 1093 and 1070). A certain amount of preliminary dilata- 
 tion of the cervical canal is a necessity in this method. (Compare page 904.) 
 
 Methods Advised in Early Abortion of the First Third of Gestation. — Rapid 
 method: The patient should be anesthetized and placed upon a table. After 
 careful disinfection of the external genitals and vagina the anterior lip of the 
 cervix is grasped by a volsella forceps and steadied by an assistant. The 
 cervix is then dilated by Hegar's dilators or one of the branched dilators until 
 it will admit the finger, which is then passed through the cervix while the ex- 
 ternal hand grasps the uterus 
 through the abdominal wall 
 and forces it downward in the 
 axis of the inferior strait. 
 The desideratum is the re- 
 moval of an intact ovum, 
 / \ '' which cannot always be ac- 
 
 complished. An exaggerated 
 lithotomy position and ab- 
 dominal pressure are of the 
 greatest assistance. If, how- 
 ever, the finger cannot be 
 passed high enough to detach 
 the ovum, an effort may be 
 made to detach it by cau- 
 tiously passing a dull curette 
 between it and the uterine 
 wall, when it may be removed 
 by the finger or ovum forceps. 
 If this cannot be done, it 
 should be broken up and re- 
 moved by the curette. (The 
 technique of manual and instrumental curettage is described later.) The 
 uterus should then be carefully but thoroughly curetted with the sharp 
 curette and washed out with a non -toxic antiseptic solution, decinormal 
 salt solution, or boiled water. If the operation has been aseptically per- 
 formed, gauze drainage is superfluous. Some operators prefer to remove the 
 fetus and then tampon. If after twenty-four hours the rest of the ovum does not 
 come away when the tampon is taken out, they curette. As a rule, it is well 
 for a good operator to curette at the first sitting. It should be remembered 
 that in speaking of an intact ovum I mean simply that the bulk of the ovum 
 has not been broken up. It is probable that complete separation of the decidua 
 vera never takes place. For this reason the use of the curette is indicated even 
 when the so-called intact ovum has been removed by the finger. Slow method: 
 If the physician has not the necessary instruments or mistrusts his ability or 
 operative skill, catheterization of the uterus may be tried, or the ovum may be 
 circularly detached with the sound, or the cervix and vagina may be tamponed. 
 
 / 
 
 Fig. 1070. — Induction of Abortion with a Modifica- 
 tion OF Champetier de Ribes' Hydrostatic Bag. 
 
MANUAL DILATATION OF THE CERVIX. 895 
 
 or the last two expedients may be used together. A satisfactory, safe, and 
 fairly prompt method is to place the patient in the lithotomy position, and 
 after strict asepsis of vulva and vagina, retract the perineum, seize the anterior 
 lip of the cervix with a volsella forceps, slowly dilate the os with Hegar's 
 or a branched dilator until it admits the smaller gauze packer, and then pack 
 the uterine cavity with plain sterile or iodoform gauze until resistance is en- 
 countered, and after packing the vagina apply a T-bandage (Fig. 1069). Separa- 
 tion and expulsion of the ovum into the upper part of the vagina usually occur 
 within twelve hours. It is best to follow the expulsion of the ovum with curet- 
 tage. For the introduction of the gauze, anesthesia is usually unnecessary. 
 
 Method Advised in Late Abortions of the Middle Third of Gestation. — After 
 the third month, owing to the development of the supravaginal portion of 
 the cervix and the commencing formation of the lower uterine segment, forcible 
 dilatation without preliminary treatment is to be avoided. Catheterization of 
 the uterus under strict asepsis, combined with the intrauterine tampon, is 
 probably the best treatment. At this time the expulsion of an intact ovum 
 is not to be expected. It is neither practicable nor safe to remove a retained 
 placenta with the curette. It should be done with the fingers. The curette, 
 however, is best adapted to the removal of the decidua. (See Management 
 of Abortion, page 358.) (Compare accouchement force and instrumental and 
 manual dilatation of the cervix. Part X.) 
 
 Method Advised in the Induction of Premature Labor. — In this procedure 
 rapidity in emptying the uterus is not to be sought for except in cases of emer- 
 gency, such as eclampsia and placenta preevia. It is best to imitate as closely 
 as possible the phenomena of natural labor. Catheterization of the uterus com- 
 bined with uterine and vaginal tamponade, or the insertion of a Champetier de 
 Ribes bag or one of its modifications, offers the best means of exciting uterine 
 contraction. Owing to the deficient vitality of premature children, however, 
 great care should be used to avoid early rupture of the membranes. For 
 the same reason labor should not be allowed to continue too long after rupture 
 of the membranes, and a carefully conducted forceps operation, unless contra- 
 indicated, is less likely to be fatal to the child than is version. After uterine 
 contractions have begun the natural forces should be allowed to complete the 
 delivery, if possible. If catheterization with uterine and vaginal tamponade 
 has been employed, and it is not equal to the task, cervical dilatation 
 may be aided by the bag of Champetier de Ribes or by a partial manual dilata- 
 tion, and after rupture of the membranes the engagement of the head and its 
 further progress may be aided by external pressure (Fig. 1167). If the bags 
 of Champetier de Ribes alone are employed, partial dilatation of the cervdx 
 must first be secured (page 902). Occasional traction upon the tube leading 
 from the bag will often hasten the onset of pains. In the 19 cases already 
 referred to, labor was induced with the intrauterine bougie alone in 7 cases; 
 with the bougie and cervical and vaginal gauze packing in 2 cases; with cer- 
 vical and vaginal packing in 2 cases; with Barnes' bags in 8 cases. 
 
 III. MANUAL DILATATION OF THE CERVIX. 
 
 This procedure is our resource when a serious emergency, arising in the 
 presence of an undilated or but partially dilated cervix, makes immediate de- 
 livery a necessity. An important condition, however, should be noted. Under 
 no circumstances should delivery by this method be attempted until the internal 
 
896 
 
 OBSTETRIC SURGERY. 
 
 OS has disappeared or can be readily made to disappear (Figs. 1082 to 1085). 
 Such an attempt exposes the patient to the most imminent danger of rupture of 
 the uterus (Fig. 782). This method also presupposes a certain amount of dilata- 
 tion, enough to admit the finger. It is rarely necessary, however, to resort 
 to instrumental dilatation as a preliminary during the latter part of pregnancy. 
 It is essential to the success of this method that the dilatation should be slow 
 and gradual. Any attempt to overcome the resistance of the cervix by sudden 
 force is likely to be attended by consequences of a most disastrous nature. 
 As soon as the cervix is felt to contract around the finger, all efforts at dilatation 
 should cease, to be resumed when it is felt to relax. The operator should 
 remember that the cervix is a muscular organ and that its relaxation can but 
 gradually be effected, and that the physiological softening caused by the alternate 
 advance and retreat of the presenting part (Fig. 565) is absent. 
 
 Unimanual Dilatation. — It is not necessary to describe the various and prac- 
 tically unessential differences in the operation as practised by different operators 
 
 Fig. 1071. 
 
 -Unimanual Dilatation of the 
 Parturient Os. 
 
 Fig. 1072. — Unimanual Dilatation of 
 THE Parturient Os. 
 
 and described in different text-books. The method described by Harris is the 
 best of this variety of dilatation. The methods are practically the same, and 
 are' all based, I believe, upon an erroneous idea of the mechanism of cervical 
 dilatation. Operation: Perhaps the following will serve as an average descrip- 
 tion of the method as commonly used: One finger is passed into the os, and 
 this is followed by the gradual insertion of the other fingers successively, finally 
 of the thumb, and later by the expansion of the hand (Figs. 1071 and 1072). 
 When the closed fist can be withdrawn through the os, the operation is regarded 
 as complete. It will be observed that in this operation the natural method 
 of dilatation is reversed, the dilatation during the greater part of the operation 
 being from below upward rather than from above downward. Some advocates 
 of this method advise that after the closed fist has passed through the internal 
 OS it should be drawn down at intervals against the resisting cervical ring in 
 imitation of the advance and recession of the fetal head during natural delivery, 
 also that when the closed fist can be drawn through the canal the highest attain- 
 able degree of dilatation has been reached. It is apparent, however, that the 
 
MANUAL DILATATION OF THE CERVIX. 
 
 897 
 
 Fig. 1073. 
 
 Fig. 1074. 
 
 Fig. 1075. 
 
 Fig. 1076. 
 
 \ 
 
 57 
 
 Fig. 1077. Fig. 107S. 
 
 Figs. 1073-1078. — Bimanual Dilatation of the Parturient Os. 
 
898 
 
 OBSTETRIC SURGERY. 
 
 size of the closed fist is a variable quantity, and that it is by no means a standard 
 of the degree of dilatation attainable by the bimanual method about to be 
 described. It also seems likely that the presence of the closed fist above the 
 internal os would tend to displace the presenting part, and it is also more liable 
 to injure the vulnerable lower uterine segment than are the tips of the fingers 
 as used in the bimanual method (Figs. 107 1 and 1072). 
 
 Bimanual Dilatation. — The method to be now considered will perhaps be 
 better appreciated by a glance at the accompanying illustrations than by any 
 written description. (Figs. 1073 to 1080.) Like all methods of manual dilata- 
 tion it must be preceded, when necessary, by some degree of dilatation obtained 
 by one of the steel instruments, or by a tampon of gauze packed into the uterus 
 and cervix. This preliminary treatment is, of course, more important during 
 pregnancy than during labor. In all cases care should be taken that the pressure 
 applied in dilatation is applied to the internal os, especially in those cases 
 
 already mentioned in which 
 this has not been effaced. 
 
 Indications. — In placenta 
 prcEvia there is usually such 
 slight resistance to be over- 
 come that one may proceed 
 at once to dilate with the 
 fingers. If hemorrhage be- 
 comes severe, bipolar ver- 
 sion by the Braxton-Hicks 
 method may be done, and 
 while the fetal leg is held by 
 an assistant, hemorrhage be- 
 ing thus controlled, biman- 
 ual dilatation may be con- 
 tinued until a sufficient de- 
 gree of dilatation is reached 
 to permit extraction (Fig. 
 1080). Here the bimanual 
 method possesses a marked 
 advantage over all others. 
 Indeed, it is the only method 
 which is not rendered im- 
 practicable by the pressure in the cervical canal of the fetal thigh or half breech. 
 In eclampsia in pregnancy or labor when dilatation and softening have not com- 
 menced, preliminary treatment of the cervix will be necessary, and in the mean 
 time such medicinal treatment, in the way of elimination, etc., as may be neces- 
 sary should be continued. If labor has begun and the cervix is already partially 
 dilated, manual dilatation can be at once instituted. Manual dilatation may also 
 be found useful in cases in which sudden death of the mother renders post-mortem 
 delivery necessary, as, for example, in cases of maternal apoplexy or cardiac dis- 
 ease, in intrauterine asphyxia of the fetus from any cause, in faulty presentations 
 and positions, in prolapse of the cord, in delayed first stage, cervical rigidity, 
 uterine inertia, etc. 
 
 I believe that there is one use of bimanual dilatation which is too often 
 neglected; namely, its employment in the treatment of delayed first stage with 
 reference, not to immediate delivery, but to the acceleration of labor. When 
 delayed labor is due to reflex causes, — i. e., fear, excitement, pain, hysteria. 
 
 Fig. 1079. — Bimanual Dilatation of the Partu- 
 rient Os. — {From, a photograph taken at the Emer- 
 gency Hospital.) 
 
MANUAL DILATATION OF THE CERVIX. 
 
 899 
 
 etc., — a short, deep anesthesia accompanied by partial manual dilatation is 
 often followed by the happiest results. The temporary use of chloroform to 
 the obstetric degree, however, or perhaps, better still, the use of chloral, is 
 usually sufficient in these cases. It is, moreover, useful in cases in which, owing 
 to a faulty direction of the uterine axis or some slight departure from the normal 
 mechanism, cervical dilatation does not progress satisfactorily. In these cases 
 a partial manual dilatation is often followed by a rapid and satisfactory com- 
 pletion of labor. When used in this manner, manual dilatation is not to be 
 
 Fig. [oSo. — Bimanual Dilatation of the Parturient Cervix, Carried on after thb 
 Bringing down of One Leg by Braxton Hicks' Method of Bipolar Version, 
 for Placenta Pr^evia. 
 
 regarded as an interference with, but rather as an assistance to, the natural 
 process of labor. 
 
 Advantages. — The advantages of the bimanual method I believe to be the 
 following: (i) It is a closer imitation of the natural process of cervical dilata- 
 tion than are any of the other methods which are available when immediate 
 delivery is necessary. The preliminary dilatation and partial softening of 
 the cervix by the use of the cervical tampon or hydrostatic bag causes an 
 even closer approach to the natural process. (2) The membranes are pre- 
 served throughout the operation or until a full dilatation is obtainable. (3) 
 There is no interference with the original presentation and position. (4) 
 The sense of touch of the operator's fingers is unimpaired. (5) There is 
 
900 
 
 OBSTETRIC SURGERY. 
 
 no constriction of the operator's hands. (6) 
 can be better estimated, and hence there is 
 (7) In placenta prsevia there is less preliminary 
 separation of the placenta by this method than 
 by any other. (8) There is less danger of sepsis 
 and of injury to the lower uterine segment be- 
 cause of the limited amount of manipulation 
 within the uterus. (9) It can be performed 
 with a presenting part, as the leg, in the os 
 (Fig. 1080). 
 
 The amount of force exerted 
 less likelihood of lacerations. 
 
 Fig. 1081. — Dangers of a Rapid Breech Extraction 
 THROUGH an IMPERFECTLY DiLATED Os. The exter- 
 nal OS not being fully dilated or paralyzed, traction 
 on the legs or breech results in extension of the head 
 and both arms above the cervix. 
 
 Fig. 1082. — Cervical Canal 
 OF THE Fourth Month of 
 Pregnancy Unchanged. 
 
 Operation. — The patient is placed in the lithotomy position, the index-finger 
 of one hand is introduced within the cervix, which is drawn upward behind the 
 
 symphysis. (Figs. 1079 and 1073.) When 
 the dilatation is sufficient to permit the in- 
 troduction of the tip of the other forefinger, 
 this is introduced opposite its fellow and 
 pressure is made by both fingers in opposite 
 directions (Fig. 1074). A sterile towel drawn 
 tightly across the perineum and pinned to 
 a sheet covering the abdomen on either side 
 will prevent contact of the unused fingers of 
 the lower hand with the anus. This pressure 
 is continued as a sort of eccentric massage, 
 the fingers of the opposite hands always mak- 
 ing gentle and steady pressure outward and 
 downward and in opposite directions. The 
 pressure, at first made antero-posteriorly, is 
 subsequently made laterally and obliquely, 
 the points on which the force is exerted being constantly changed so that all parts 
 of the cervical ring are in turn subjected to it (Fig. 1076). As dilatation progresses 
 
 Fig. 1083. — Cervical Canal of a 
 Primipara, with Beginning Di- 
 latation of the Internal Os. 
 I, Internal os; 2, external os. — 
 (Leopold.) 
 
MANUAL DILATATION OF THE CERVIX. 
 
 901 
 
 the second finger of the right hand is introduced alongside of the first, then the 
 second of the left hand, as shown in the illustrations, and progressive pressure 
 continued as already described (Fig. 1077). After full dilatation is accomplished 
 some time should be spent in producing complete relaxation and paralysis of the 
 resisting cervical ring (Fig. 1078). After this is accomplished, however, extraction 
 should be performed as quickly as possible, since the cervix is likely to recontract. 
 I desire to protest against the rapid manual dilatation of the os; namely, 
 the complete dilatation performed within an hour, before the action of the 
 uterus has caused the cervix to become relaxed, at least to a certain degree. 
 If the internal ring is present and in a rigid state, as is shown in Fig. 1082, pre- 
 liminary treatment should be instituted by the use of a cervical dilator of gauze, 
 a hydrostatic bag, or the Bossi dilator, that will induce a certain amount of uterine 
 action with cervical dilatation and softening and cause the rings of the os to 
 
 Fig. 1084. — Cervical Canal in a Primi- 
 PARA WITH Beginning Dilatation of 
 THE Internal Os. Eclampsia. — (Leo- 
 pold.) 
 
 IN. OS 
 
 S.V.C 
 
 EX.OS. 
 
 Fig. 1085. — Cervix in Latter Part op 
 Gestation or at Beginning of Labor. 
 Vaginal and Supravaginal Portions 
 OF Cervix Unchanged, v.. Cuff of 
 vagina; ex.os., external os and infra- 
 vaginal portion of cervix; c.v.j., cervico- 
 vaginal junction; s.v.c, supravaginal 
 portion of cervix; in.os., internal os; 
 I.U.S., lower uterine segment. 
 
 become sufficiently relaxed so that rapid dilatation is rendered a safe operation. 
 Rapid manual dilatation may be undertaken and complete paralysis of the 
 cervix attained within an hour, as shown in Fig. 1078, even when there is a 
 minimum amount of uterine action or when the os is in a softened, yielding, 
 and relaxing condition, although the anatomical conditions pictured by Fig. 
 1084 may exist. A strictly expectant treatment in respect to emptying the 
 uterus is far preferable to the attempt quickly to overcome a rigid os by manual 
 means, when the supravaginal portion of the cervix still persists (Figs. 1082, 
 1085). To the writer's knowledge such a procedure has ended in complete 
 rupture of the uterus followed by a prolapse of the maternal intestines between 
 the operator's fingers in more than one instance. 
 
902 
 
 OBSTETRIC SURGERY. 
 
 IV. INSTRUMENTAL DILATATION OF THE CERVIX. 
 
 Indications. — Dilatation of the os is a part of the induction of abortion 
 and premature labor (see page 888). As a general rule, it may be said that 
 the physician should be slow to resort to manual or instrumental dilatation 
 simply for tedious labor, especially with unruptured membranes. Having satis- 
 fied himself that the delay is not due to malposition or malpresentation, and 
 the condition of mother and child does not require immediate interference, 
 better results will usually be obtained by the use of chloral or a light temporary 
 anesthesia, and by an effort to discover and remove the cause of the delay 
 (see Anesthesia, page 865, and Delayed Labor, page 568), and thus the mother 
 will be saved the dangers of shock and sepsis which to a greater or less extent 
 
 Fig. 1086. — Instrumental Dilatation of the Parturient Os Preparatory to Further 
 Manual Dilatation, Gauze Packing, the Introduction of Bougies for the Induc- 
 tion OF Labor, or Cervical Dilators. — (From a photograph of the author's model.) 
 
 attend even a carefully conducted operation. The instruments ordinarily used 
 for producing dilatation of the cervix are gauze or metal or vulcanite dilators, 
 bags of rubber or silk dilated with water, and the hand. 
 
 Uterine and Cervical Tampon. — A valuable method, although a slow one, of 
 securing cervical dilatation at any time in pregnancy is to pack the lower 
 uterine segment and cervical canal with iodoform or sterile gauze until moderate 
 pressure is attained. The packing cannula (Fig. 1069) is most convenient for this 
 operation. The vagina is subsequently packed and a T-bandage applied and the 
 gauze left in for from six to twelve hours. This method I find invaluable as a 
 preliminary to rapid manual dilatation of the os (see page 902), in cases of 
 eclampsia, placenta praevia, and accidental hemorrhage, as a preparatory 
 measure to cause the disappearance of the supravaginal portion of the cervix 
 
INSTRUMENTAL DILATATION OF THE CERVIX. 
 
 903 
 
 (internal os), and to soften the cervix and the whole lower uterine segment so that 
 the subsequent rapid dilatation can be easily and safely accomplished. 
 
 Graduated Hard Dilators. — These are made of steel or vulcanite and are 
 used in somewhat the same manner as uterine sounds ; the smallest being first 
 passed into the cervix and then the larger sizes successively until the dilatation 
 
 is deemed sufficient. There are several var- 
 ieties: Hanks', Hegar's, Peaslee's, Kam- 
 merer's, etc. Male sounds, Nos. 15 to 18 
 French, may often be used with satisfaction. 
 Method and Operation: The patient is in the 
 lithotomy position, the perineum is retracted 
 by a speculum. The anterior and posterior 
 lips of the cervix are drawn down by volsellum 
 forceps. A sound shows the depth and direc- 
 tion of the cervical canal. The smallest sound 
 is then introduced and the dilatation carried 
 as far as necessary by the successive introduc- 
 tion of the larger ones. 
 
 Fig. 1087. — Bossi's Dilator for 
 THE Parturient Cervix. 
 
 Fig. 
 
 loSS. — Gau's Dilator for the Parturient 
 Cervix. 
 
 Branched Steel Dilators (Fig. 1086). — This kind of dilatation, so useful in 
 gynecological practice, has hitherto played but a minor role in the department 
 of obstetrics. The branched steel dilators heretofore in use have been of service 
 only in cases in which a tightly closed external os rendered their use necessary 
 as a preliminary to other methods of dilatation. Dilatation is effected by passing 
 
904 
 
 OBSTETRIC SURGERY. 
 
 the closed instrument into the cervix and separating the branches by compres- 
 sion of the handles, applied either directly by the hands or through the 
 medium of a screw. Sims' and EUinger's may be regarded as types. There 
 have been various modifications. Recent work on the use of large obstetric 
 steel dilators, however, has opened up new possibilities in this direc- 
 tion. One of the more recent steel obstetric dilators is the four-bladed one 
 of Bossi (Fig. 1087). It is probably the best instrument now at our disposal. 
 Steel instruments are, of course, more easily rendered aseptic than is the hand. 
 It is difficult, however, to estimate the amount of force used, nor is a steel instru- 
 ment so perfectly under the operator's control. It is safe to say that, as an imi- 
 tation of the natural process, and therefore as a safe method of dilatation, no 
 steel instrument at present devised can be used which will entirely take the place 
 
 ? ' ?^% 
 
 Fig. io8g. — Barnes' Rubber Hydrostatic Dila- 
 tor IN Position in the Cervix. 
 
 Fig. tooo. — The Modified Cham- 
 petier de Ribes' Hydrostatic 
 Cervical Dilator in Position 
 in the LoviTER Uterine Seg- 
 ment. 
 
 of the dilating bags in cases which permit slow dilatation, or of the bimanual 
 method in cases of great emergency. Method of Operation: The position of the 
 patient and the preliminary manipulations are the same. The closed branches 
 of the dilator are passed as far as the shoulders. The blades are separated later- 
 ally, then the instrument is rotated and they are separated antero-posteriorly. 
 Dilatation should be very slow and gradual. Force is used to cause the cervix 
 to yield, not to tear; and the less force which will accomplish the purpose, the 
 better. 
 
 Hydrostatic Dilators. — These are of rubber or silk, are hollow, and are dis- 
 tended after their introduction by means of water which is forced into them 
 with a Davidson or piston syringe. Barnes' hydrostatic dilators have been 
 entirely supplanted by the Champetier de Ribes' bag and its modifications. 
 The bag of Champetier de Ribes (Fig. 1090) is made of rubber but has a silk 
 
INSTRUMENTAL DILATATION OF THE CERVIX. 
 
 905 
 
 lining to prevent bursting. It is in the shape of a cone, the larger end being 
 introduced first. When distended with water, nature's method of dilatation is 
 somewhat closely imitated. This is especially true of the bag of Champetier 
 de Ribes and its modifications, and the colpeurynter of Diihrssen. These 
 well-known instruments, which have the shape of a funnel or an inverted cone, 
 may be drawn into the cervical canal and against the internal os in a manner 
 closely simulating the method of nature. I regard the de Ribes bag or its 
 modifications as valuable for the following reasons: (i) The natural process is 
 more closely imitated, the cervix being dilated from within outward according to 
 
 Fig. 1091. — Method of Grasp- 
 ing THE Modified de Ribes 
 Bag for Introduction into 
 THE Cervix. 
 
 Fig. 1092. — Modification of Champetier de 
 Ribes' Hydrostatic Cervical Dilators. Two 
 Sizes Shown. 
 
 the natural process. (2) The bag does not slip out. (3) By gentle traction 
 upon the tube one can cause uterine contraction and assist in dilatation if 
 necessary. (4) The bag is not likely to burst. (5) It is a valuable agent in 
 prolapse of the funis or fetal small parts, in premature rupture of the mem- 
 branes, in placenta praevia and other complications. 
 
 Method of Introducing the Soft Dilators. — A certain amount of dilatation is 
 presupposed. The dilator should be folded upon itself, lubricated with a i per 
 cent, lysol solution, seized with a pair of long dressing forceps, and passed 
 
900 
 
 OBSTETRIC SURGERY. 
 
 within the cervix until the constricted part, if a Barnes bag is used, is at the 
 internal os, or until half the bag, if a de Ribes bag is used, is within the internal 
 OS (Fig. 1 091). The Barnes bag is provided with a pocket into which a sound may- 
 be inserted and the bag passed into the cervix with the sound. The first method, 
 however, is more satisfactory. Bags should not be distended with air, since 
 
 their rupture may then be attended with 
 serious consequences. Water should be used 
 and should, of course, be forced in slowly 
 and gradually. In using the Barnes bag, 
 when the smaller-sized bag has been ex- 
 pelled, the next larger one should be in- 
 serted if necessary. With the de Ribes bag 
 no change is necessary unless one uses 
 graduated sizes, which may now be obtained 
 of the instrument -makers in New York. In 
 every instance when a hydrostatic cervical 
 dilator is used, the bag should be carefully 
 tested before introduction. This is done by 
 forcing a given number of bulbfuls of water 
 from a Davidson syringe into the bag so as 
 fully to distend it; then, if the bag remains 
 intact, it is introduced and to insure against 
 rupture one bulb less of water is pumped in 
 than in the test examination. I have in 
 two instances seen rupture of the uterus, 
 as proved by autopsy, caused by the intra- 
 uterine explosion of an overdistended Barnes 
 bag. The large Champetier de Ribes dila- 
 tors, as originally sold, should be avoided, and 
 only the smaller ones used. The former occupy too much space in the lower 
 uterine segment, change its shape, and favor malpresentation of the fetus. In 
 my practice I observed a vertex presentation changed thus to a shoulder, for 
 which I was compelled to perform an internal podalic version. 
 
 CEBViX..... 
 
 Fig. 1093. — Coe's Modification of 
 Champetier de Ribes' Hydro- 
 static Cervical Dilator. 
 
 V. MANUAL AND INSTRUMENTAL DILATATION OF THE 
 VAGINA AND VULVA. 
 
 Indications. — Occasionally in very old or very young primiparae, in cases 
 of cicatrices from previous inflammation and ulceration, in malignant disease 
 and thrombosis, artificial dilatation of the vagina may be demanded. I have 
 occasionally been compelled to employ this operation in elderly primiparae 
 and in the very young. In cicatricial stenosis of the vagina, dilatation by the 
 fingers or hydrostatic dilators may occasionally be required, but in most cases 
 the natural forces will overcome the obstruction, even when the original opening 
 would admit but one finger. In cases in which the vagina is simply small and 
 rigid — e. g., in very young or in old primiparae — the resistance is chiefly at 
 the lower third, and the case should be left to nature as long as is judged safe. 
 A carefully conducted forceps operation with very slow extraction is then to 
 be considered as the best means of effecting further dilatation. If even this 
 bids fair to produce severe laceration, or if rapid delivery is imperative, episi- 
 
INCISIONS OF THE CERVIX, VAGINA, AND VULVA. 907 
 
 otomy (q. v.) may be re(iuired. In certain cases of a small and rigid vulva and 
 lower third of the vagina surprisingly good results may be obtained by manual 
 
 ) 
 
 **««. 
 
 Fig. 1094. — Digital Dilatation of the Vulva in a Primipara. 
 
 dilatation, one or two fingers being introduced into the posterior commissure 
 followed by intermittent backward massage-like pressure (Fig. 1094). 
 
 VI. INCISIONS OF THE CERVIX, VAGINA, AND VULVA. 
 
 I. Superficial, and 2. Deep Incisions of the Cervix. — (i) Superficial multiple 
 incisions: These as well as deep incisions are required only in exceptional cases, 
 and are especially liable to extend and involve the branches of the uterine 
 artery. Superficial incisions or nicks in the cervix are indicated only when the 
 use of chloral or some other anesthetic has failed, and when manual dilatation 
 without the use of a dangerous degree of force does not succeed. This most 
 often occurs in rigidity of the portio vaginalis in old primiparse, and in multiparse 
 when several years have elapsed since the birth of the last child. There is 
 a lack of elastic tissue, or atrophy of the elastic fibers has already begun. It 
 may also be indicated in cases of atresia in which the os cannot be opened 
 by the finger or dilator. In this case, if the os cannot be located, the stretched 
 cervix may be raised by tenacula at its thinnest point, and a crucial incision 
 made. The superficial incisions are made by a blunt-pointed bistoury or a 
 pair of blunt-pointed scissors. During a pain, the patient being in the 
 lithotomy position, the instrument is carried into the vagina under the 
 guidance of the fingers, and the stretched cervical rim is incised in several 
 places to the depth of 0.5 cm. (Fig. 1095). Dilatation sometimes occurs with 
 surprising rapidity after this procedure. Care should be taken that such 
 
908 
 
 OBSTETRIC SURGERY. 
 
 incisions are really superficial, since when carried further they are likely to 
 extend and to result in disastrous lacerations of the lower uterine segment. 
 (2) Deep incisions: Incisions of the cervix extending to the utero-vaginal junc- 
 tion and involving the entire vaginal portion were first proposed by Skutsch 
 and first performed by Duhrssen. Indications: Those usually given are: any 
 emergency which requires immediate delivery in the presence of an undilated 
 
 Fig. 1095. — Multiple Superficial In- 
 cisions OF THE External Os. 
 
 Fig. 1096. — Deep Incisions of the Par- 
 turient Cervix, Extending from the 
 Border of the External Os to the 
 Utero-vaginal Junction. 
 
 and rigid cervix; e. g., eclampsia, accidental hemorrhage. The operation should 
 not be performed until the supravaginal portion of the cervix has disappeared, — 
 in other words, when the defective dilatation is confined to the vaginal portion 
 of the cervix, — and is, therefore, much more frequently indicated in primiparag. 
 In multiparae mechanical dilatation is usually sufficient. In the presence of 
 
 (t 
 
 k 
 
 Fig. 1097. — Effect of the Four Deep 
 Incisions of the Cervix upon Dilata- 
 tion. 
 
 Fig. logS. — Author's Case of Deep 
 Bilateral Incisions of the Cervix 
 Thirteen Months after Delivery. 
 Partial Repair Has Taken Place 
 IN the Bilateral Incisions. 
 
 immediate danger, however, the supravaginal portion still being present, the 
 two procedures may be combined with advantage; that is, mechanical dilatation 
 until the internal os has been obliterated and rapid completion of the dilatation 
 by deep incisions. There is one condition in which they should always be 
 
INCISIONS OF THE CERVIX, VAGINA, AND VULVA. 
 
 909 
 
 avoided; namely, in arrest of the after-coming head during breech delivery, or 
 after version in multiparse. Here the resistance is at the internal os, and any but 
 the most superficial incisions would be likely to result in extension to uterine 
 rupture during the process of delivery. Operation: The patient being in the 
 lithotomy position, the free edge of the os is fixed between two bullet forceps, 
 and under the guidance of the index and middle fingers of the left hand, one 
 within and the other without the cervix, the vaginal portion of the cervix is in- 
 cised by a pair of long, blunt-pointed, straight or angular scissors or a bistoury, 
 care being taken that the incision is brought fully up to the utero-vaginal junction. 
 If the incision stops short of this point, full dilatation does not take place and ex- 
 tension beyond the vaginal attachment may occur from tearing. Care should be 
 taken that a fold of vagina is not included in the incision, since this, in case of 
 the posterior incision, might open into the pouch of Douglas, or in case of the 
 anterior incision might involve the utero-vesical pouch or even the bladder. 
 
 Fig. 1099. — Episiotomy.- 
 
 ■{The face presentation is from a photograph of the author's case 
 taken at the Emergency Hospital.) 
 
 The same mistake in the case of a lateral incision might result in severing a 
 ureter. Four incisions are usually made, two antero-posterior and two lateral 
 (Figs. 1096 and 1097). Suture is not necessary except in case of severe 
 hemorrhage, which should not occur if the incisions have been properly made. 
 Spontaneous union of the edges usually occurs. The risks of septic infection 
 are the same as in any other internal obstetric .procedure. The field of this 
 operation is most limited. The operation itself is a serious one and not lightly 
 to be undertaken. In all but exceptional cases rapid bimanual dilatation of the 
 OS, or rapid bimanual dilatation of the os combined with these incisons, will 
 fulfil all indications. 
 
 Incisions of the Vagina.— These are most often called for in cases of cicatricial 
 contraction or congenital defects, and are best made along the lateral vaginal wall 
 
910 
 
 OBSTETRIC SURGERY. 
 
 with a blunt bistoury. A comparatively large number of shallow incisions are 
 to be preferred to a few deep ones, since there is less danger of hemorrhage. 
 Lateral incisions are to be preferred to anterio: or posterior ones, when possible, 
 since the latter may involve important structures — bladder, peritoneum, rectum. 
 In all cases, however, labor may usually be terminated either spontaneously or 
 by the use of forceps or version, with manual dilatation of the vagina without 
 using the knife. Cases of unyielding circular cicatricial contraction may be 
 treated by a cruciform incision. 
 
 Incision of the Vulva. Episiotomy. — Definition: The operation of making 
 lateral incisions in the vulva in order to avoid laceration of the perineum. 
 Indications: It is indicated when delivery without severe perineal laceration is 
 deemed impossible — usually in cases of great disproportion in size between the 
 fetal head and vulval outlet. It is seldom necessary, however, and in the 
 
 absence of cicatricial contraction 
 better results will usually be ob- 
 tained by awaiting the natural pro- 
 cess of dilatation. Operation: The 
 operator should remember that it is 
 not the border of the vulva which 
 resists the progress of the head, but 
 the tense ring situated about half an 
 inch above. During a pain this ring 
 is readily recognized about half an 
 inch above the muco-cutaneous 
 junction. The incisions should not 
 be in the line of the vulvo-vaginal 
 outlet as it appears during the stage 
 of expulsion, or it will be found after 
 delivery that they have been direct- 
 ed too far backward.- They should 
 be made in a direction corresponding 
 to the long axis of the mother's body 
 as she lies in the recumbent position. 
 Under the guidance of the fingers a 
 blunt-pointed bistoury is passed flat- 
 wise against the resisting ring, then 
 turned, and the ring incised from 
 within outward. The incision should 
 not exceed an inch in length and 
 its depth should be about a quarter of an inch. It should be made at a point 
 about one-third of the distance from the posterior to the anterior commissure 
 when the parts are on the stretch. In this location the only parts severed are 
 the skin, fascia, and perhaps the bulbo-cavemosus muscle (Fig. 1099). If pre- 
 ferred, the incision may be made with blunt-pointed scissors (Fig. 1099). Care 
 should be taken that the head is not suddenly forced out during the operation. 
 For this reason it is better that the incisions should be made at the beginning 
 or toward the end of a pain, and that the progress of the head be retarded if 
 necessary. After delivery the incisions are at once closed by suture. In suturing 
 it is convenient that the mother lie upon the right side while the left incision 
 is being sutured, and vice versa. In this way the field of operation is kept clear 
 of blood. 
 
 Vagino-perineal Incision. — Diihrssen advises in some cases of small and 
 
 Fig. 1 100. — Deep Vagino-perineal Incisions 
 FOR Small and Rigid Vagina. — (Duhrssen.) 
 
CORRECTION OF FAULTY POSTURE. 
 
 911 
 
 rigid vaginae in which immediate delivery is urgent, incisions which divide 
 not only the constrictor cunni but the levator ani. These he calls vagino- 
 perineal incisions. He advises that when possible only one incision be made. 
 This method has thus far not met with general approval (Fig. iioo). 
 
 VII. CORRECTION OF FAULTY POSTURE, MALPOSITIONS, 
 AND MALPRESENTATIONS. 
 
 I. Manual Correction of Bregma, Brow, and Face Presentations. — (i) Schatz 
 
 External Method: This method is limited to those cases in which the head 
 
 Pig. iioi. — Manual Correction of Brow and Face Presentation. Rotation of the 
 head upon a transverse diameter to produce flexion with the internal hand, and down- 
 ward pressure upon the occiput with the external hand. (Baudelocque's method.) 
 
 is not engaged and is freely movable; the membranes are unruptured, or if 
 ruptured the fetus is readily moved about in the uterus ; and there is no imme- 
 diate demand for the rapid termination of labor. The method is only exception- 
 ally successful, there having been many failures, and by reason of the conditions 
 necessary for its performance, has a very limited field, being confined mainly 
 * Thorn: "Zeit. fiir Gynecol, v. Geburts ," xiii, i86. 
 
912 
 
 OBSTETRIC SURGERY. 
 
 to maternity hospitals, where the anomaHes are recognized early in labor. 
 Although Schatz describes his method as applicable to face presentations, from 
 a mechanical standpoint it is also applicable in bregma or brow presentations. 
 Operation: Anesthesia is not always required. The patient is placed in the 
 dorsal posture with knees partly drawn up; the operator stands on the side 
 toward which the occiput is directed. Between uterine contractions one hand 
 grasps the breech and one the anterior shoulder, and an even, strong pressure 
 is made upon the shoulder toward the occiput and somewhat upward; the 
 breech is at the same time pushed upward with the other hand and also toward 
 
 Fig. II02. — Manual Correction of Face, Brow, and Bregma Presentation. The 
 internal hand rotates the head upon a transverse diameter by drawing down the occiput, 
 and the external hand pushes the anterior shoulder to the side toward which the dorsal 
 plane lies. Thorn's method.* 
 
 the abdominal surface of the fetus; finally, the breech is pressed downward. 
 During the uterine contractions all manipulations cease and the head is grasped 
 through the abdominal walls and fixed. After the occiput is brought over 
 or into the pelvic inlet, the membranes may be ruptured and the head held until 
 engagement occurs (Fig. 684). (2) Combined External and Internal Method : 
 If the above method fails, which is pretty sure to be the case, one of the following 
 can be tried, (a) Digital pressure: In bregma and brow, and occasionally in 
 face presentations, passing two or three fingers into the vagina and pressing 
 up upon the bregma, brow, and at the same time using counter-pressure with 
 
CORRECTION OF FAULTY POSTURE. 
 
 913 
 
 the whole of the remaining hand upon the breech of the fetus, will often rotate 
 the fetal head upon its transverse axis (Fig. 1103). In this method the dorsal 
 posture with flexed thighs is used for the patient, and the operator stands or, 
 better, sits on the side of the patient toward which the occiput points. (6) 
 lAjting of the brow and face: With the same positions of patient and operator, 
 but under anesthesia, the hand, the palm of which corresponds with the fetal 
 face, is passed into the vagina and grasps the forehead or face and carries it 
 away from the pelvic inlet in the direction of the fetal chest, while the external 
 
 Fig. 1 103. — Combined Manual Method for the Correction of Face and Brow Pres 
 
 ENTATIONS. ScHATZ-ThORN MeTHOD. 
 
 hand presses the occiput down, through the abdominal walls, into the pelvic 
 inlet (Fig. iioi). Before the internal hand is removed the operator must satisfy 
 himself that the large fontanelle is actually higher than the small one, and that 
 the vertex is about to engage. In difficult cases the Trendelenburg posture will 
 be of great assistance. Humphrey used the knee-elbow posture for the patient, 
 (c) Drawing down the occiput {Thorn's method) : The posture of the patient is 
 the same as above, but the operator sits or stands on the side toward which 
 the fetal abdomen points. The hand, whose palm would naturally grasp 
 the occiput, is passed into the vagina, and draws down the occiput with 
 58 . 
 
914 
 
 OBSTETRIC SURGERY. 
 
 an even traction, while at the same time the external hand pushes the chest 
 of the fetus, or rather the shoulder, to the side toward which the dorsal plane 
 lies (Fig. 1 1 02). The Trendelenburg posture will greatly aid this manipulation, 
 (d) Combined methods: In very difficult cases a combination of Schatz's and 
 
 Fig. 1 104. — Manual Correction of a Persistent Mento-posterior Position by Manual 
 Anterior Rotation of the Fetal Chest and Chin. 
 
 the method of drawing down the occiput by internal manipulation has been 
 successful (Fig. 11 03). 
 
 2. Persistent Occipito-posterior Position. — (See Pathol6g>' of Labor, page 
 
 547-) 
 
 4. Persistent Mento-posterior Position. — (See Pathology of Labor, page 
 
 550-) (Fig- II04-) 
 
 4. Reposition of Prolapsed Cord.— (See Pathology of Labor, page 525.) 
 
 5. Reposition of Prolapsed Arms and Legs. — (See Pathology of Labor, pages 
 520 and 522.) 
 
THE VECTIS—THE FILLET. 
 
 915 
 
 VIII. THE VECTIS. 
 
 The vectis was one of the simplest forms of instruments used for extracting or 
 changing the position of the fetal head; it antedated the forceps, and has prac- 
 tically been abandoned as an instrument by itself, in favor of the forceps, which 
 has proved both safer and more effective. The principle of the vectis is still 
 used in obstetrics, however, by utilizing one blade of the forceps, and from time 
 to time attempts have been made to revive interest in the value of the original 
 instrument.* It resembles a single blade of a pair of straight forceps except 
 that the cephalic curve is much more pronounced, especially near the extremity 
 of the instrument, in order to permit of a better hold of the head (Fig. 1105). 
 
 Fig. 1105. — The Copeman Vectis. 
 
 Fig. 1 106. — The Fillet. — (Galabin.) 
 
 The vectis was used as a lever and a tractor, and some of the English writersf 
 still recommend its use in persistent occipito-posterior positions and brow presen- 
 tations. In the former case it was used as a combined lever and tractor to 
 favor anterior rotation, and in the latter as a tractor to convert the brow into 
 a vertex or face. I believe the forceps to be a safer and more efficient instru- 
 ment for the first purpose, and the hand of the obstetrician for the second. 
 
 IX. THE FILLET. 
 
 The whalebone fillet, consisting of an inverted U-shaped piece of whalebone 
 joined at the extremities of the U by a handle, is an instrument intended to 
 rotate the head upon its transverse axis, thus producing either flexion or exten 
 sion, as desired, by traction upon one pole of the head (Fig. 1106). The instru- 
 
 *Bartlett, John: " The Vectis," " The Clinical Review," Chicago, Nov., 1900. 
 t Galabin: "A Manual of Midwifery," London, 1900, p. 612. 
 
916 OBSTETRIC SURGERY. 
 
 ment antedates the forceps, and is now, perhaps with less justice than the vectis, 
 considered obsolete. Placed over the chin to produce extension of the head by 
 traction on the handles, the instrument was liable to injure the fetus, and its 
 hold on the occiput to increase flexion of the head was always uncertain and dan- 
 gerous by reason of the tendency of the fillet to slip. As in the case of the vectis, 
 the hand of the obstetrician passed into the vagina combined with bimanual 
 manipulation will do all and more than the fillet. (See page 911.) The contin- 
 gency might possibly arise when in the absence of instruments an improvised fillet 
 of whalebone or wire could be used to flex the extended head of a dead fetus, 
 and possibly of one living. 
 
 X. REPOSITION OF SMALL PARTS. 
 
 1. Umbilical Cord. — (See page 525.) (Also Figs. 1107 to 11 13.) 
 
 2. Other Small Parts. — If in the course of labor in cranial presentations with 
 unruptured membranes, some small part — the hand, for example — prolapses, it 
 will almost always be found at the facial side of the head. Reposition can 
 usually be effected by placing the woman on the side opposite that of the 
 
 \ 
 
 \ 
 
 >\ 
 
 Fig. 1 107. —Manual Reposition of a Prolapsed Cord. 
 
 prolapse, and when the head is allowed to re-engage the obstacle will be out of the 
 way. (i) In case the membranes have ruptured and a hand or arm has pro- 
 lapsed, reposition may often be effected by a simple manipulation, if the os is 
 fully dilated and the head high up. The woman is placed in the latero-prone 
 position (Fig. 1051) and the operator introduces his hand into the vagina and 
 endeavors to conduct the prolapsed part up along the face. The woman should 
 lie on the side opposite the prolapse until the head engages. If this manoeuver 
 fails, the operator may sometimes leave the case to nature. In a roomy pelvis 
 
REPOSITION OF SMALL PARTS. 
 
 917 
 
 it is quite possible for the head and an arm to engage at the same time. But 
 if the pelvis is contracted or if an indication arises to terminate labor at once, 
 podalic version may be attempted if the head is movable, but otherwise, forceps 
 delivery. In prolapse of a foot in head presentations, which is very rare, the 
 indications are similar. (2) Should the head be well down in the true pelvis, 
 an expectant treatment should be followed; and if any immediate danger 
 threatens, such as delayed labor from obstruction or oedema of the leg, extraction 
 of the head with the forceps should be done, taking care not to include the pro- 
 
 V 
 
 / 
 
 Fig. iro8. 
 
 — Instrumental Reposition of a Prolapsed Cord, .\ssisted by the Knee- 
 chest Posture of the Patient. 
 
 lapsed leg. Impaction in the case of a dead fetus of course calls for perforation. 
 (3) When the head is movable at the pelvic inlet or extra-medial by reason 
 of the prolapsed leg filling in one side of the pelvis, and the leg constitutes 
 an actual obstruction, manual reposition should be performed. In any event, 
 the existence of twins must be borne in mind, as one may present by the head 
 and the other by the leg or foot. The patient is placed in the lithotomy position 
 or, better, on her side (compare prolapse of cord and arm), and the foot or 
 knee is seized with the whole hand and pushed upward past the head; at the 
 same time a hand on the fundus presses the head into the pelvic inlet from 
 
918 
 
 OBSTETRIC SURGERY. 
 
 Fig. 1 109. — English Catheter 
 AND Sling for Reposition op 
 Prolapsed Cord. 
 
 Fig. 
 
 1 1 10. — English Catheter and Loop of Tape 
 FOR Reposition of a Prolapsed Cord. 
 
 Fig. nil. — Simple Long For- 
 ceps Used to Replace a Pro- 
 lapsed Cord. 
 
 Fig. 1112. — Whale- Fig. 1113. — Whalebone Re- 
 bone OR Metal positor for a Prolapsed 
 Repositor and Cord. 
 Sling. 
 
REPOSITION OF SMALL PARTS. 919 
 
 without. Anesthesia is necessary, and in some difficult cases the exaggerated 
 semi-prone, Trendelenburg, or knee-chest position will be required. After re- 
 position the dorsal position will give as satisfactory results as either of the 
 lateral, provided the head is kept applied to the pelvic inlet by pressure on 
 the fundus until engagement takes place. (4) In case manual reposition fails 
 the head may be pushed up and version and extraction promptly performed, 
 the possibility of the existence of twins, and of the presentation of one by the 
 head and of the other by the leg, being always remembered. 
 
 XI. VERSION. 
 
 Definition. — By version is meant the changing of the presentation of the 
 fetus so that one or the other of the two poles of the fetal ellipse is substituted 
 for a given presentation. 
 
 History. — Version is one of the most ancient of the obstetric operations, 
 and before the invention and introduction of the forceps was used much more 
 frequently than it is at present. Cephalic version was the first variety used, and 
 is said to have been recommended by Hippocrates and employed even in pelvic 
 presentations. Before the sixteenth century it was practically the only version 
 used, but at that time podalic version was introduced, and because of the ease 
 of its performance became very popular, and on this account cephalic version 
 was almost entirely abandoned, although more recently revived by some obstet- 
 ricians. 
 
 Classification. — Version is usually classified, first, according to the part of 
 the fetus which is caused to present at the pelvic inlet, into cephalic version, 
 podalic version, and pelvic version. The last of these, namely, pelvic version, 
 is to-day rarely, if ever, performed. Version is again subdivided, according to 
 the mode in which it is performed, into three varieties — namely, external ver- 
 sion, combined external and internal or bipolar version, and internal version. 
 External version is performed by external manipulation only; combined exter- 
 nal and internal or bipolar version by the use of one hand introduced into the 
 vagina and one or more fingers into the uterus to move one part of the fetus, 
 while the other hand upon the anterior abdominal wall moves another por- 
 tion of the fetus, thus assisting the internal fingers. Internal version is ac- 
 complished by passing the whole hand into the uterus to grasp some part of 
 the fetus, usually the feet, and the other hand is used on the abdomen to 
 steady the fetus and assist the internal hand as far as possible. (See table on 
 page 920.) 
 
 Frequency. — In 2200 confinements in New York hospitals I found that 
 version was performed in 44 instances, or 2 per cent., or once in 50 labors. 
 
 Indications. — In the 44 versions referred to, the indications were: de- 
 formed pelvis in II cases; shoulder presentation in 7; shoulder presentation 
 and prolapsed cord in 3 ; persistent occipito-posterior position in 2 ; placenta 
 prasvia in 6 ; prolapsed cord in 3 ; prolapsed cord and hand in i ; prolapsed hand 
 in I ; deformed pelvis and albuminuria in i ; deformed pelvis and shoulder pres- 
 entation in 2 ; uterine inertia in 2 ; prolapse of leg in vertex presentation in i ; 
 brow presentation in i ; hydrocephalus in i ; albuminuria in i . 
 
 Varieties. — Of the 44 cases analyzed, 35 were of the internal podalic variety; 
 3 bipolar; 6 not recorded. 
 
920 
 
 OBSTETRIC SURGERY. 
 CLASSIFICATION OF VERSION. 
 
 Parts CALtSED to Present 
 
 
 
 Mode of Performance. 
 
 Employed. 
 
 (A) Cephalic Version . . . . 
 
 1 
 
 V 
 
 I. 
 
 2. 
 
 3- 
 
 External Cephalic. 
 
 Combined External and Internal 
 
 Cephalic (Bipolar). 
 Internal Cephalic. 
 
 Occasionally. 
 Occasionally, 
 
 Rarely. 
 
 
 (B) Podalic Version 
 
 I. 
 
 2. 
 
 3- 
 
 External Podalic. 
 
 Combined External and Internal 
 
 Podalic (Bipolar). 
 Internal Podahc. 
 
 Rarely. 
 Frequently. 
 
 Most frequently. 
 
 
 (C) Pelvic Version 
 
 ( 
 
 I. 
 
 2. 
 
 3- 
 
 External Pelvic. 
 
 Combined External and Internal 
 
 Pelvic (Bipolar). 
 Internal Pelvic. 
 
 Rarely. 
 Rarely. 
 
 Obsolete. 
 
 
 Introduction of the Hand in Version. — The hand and forearm, being thor- 
 oughly aseptic, are enclosed in a rubber glove and well lubricated with i per 
 
 cent, lysol or creolin solu- 
 tion. The fingers of the 
 hand to be introduced are 
 then brought together in 
 the form of a cone, and 
 the labia separated by the 
 thumb and first and second 
 fingers of the disengaged 
 hand (Fig. 1114). (Com- 
 pare vaginal examinations, 
 page 153.) The apex of 
 the cone-shaped hand is 
 then pushed into the os- 
 tium vaginae, and entrance 
 is effected by pressing 
 steadily inward and back- 
 ward upon the distensi- 
 ble perineum. No sudden 
 movements or haste should 
 be used, and ordinary rota- 
 tion and boring-like move- 
 ments of the hand are 
 unnecessary and increase 
 the tendency to laceration. 
 Patience and lack of haste 
 are important factors for success and avoidance of lacerations, especially in 
 primiparous patients. After the hand is well in the vagina the cervix is 
 sought, and in combined or bipolar version one, two, or three fingers are care- 
 fully inserted through the os according to circumstances. In internal version 
 the hand is passed through the os in practically the same manner as through 
 the vulval orifice, but in all cases at this point in the passage of the hand the 
 fundus should be steadied and even pushed down with the external hand to 
 avoid dangerous stretching of the lower uterine segment, or too great traction 
 
 Fig. 1 1 14. — Introduction of the Hand in Internal 
 Version. Note that the vulva is widely separated and 
 that the entering fingers strongly depress the perineum. 
 
VERSION. 
 
 921 
 
 of the uterine attachments by the upward pressure of the internal hand. 
 The subsequent use of the fingers in combined version, and of the hand in 
 internal version is described under the proper sections. 
 
 
 •4*. 
 
 / 
 
 (A) CEPHALIC VERSION. 
 
 Cephalic version is not applicable to cases in which rapid delivery is desired, 
 nor in cases of decided flattening of the pelvis unless the delivery is to be by 
 symphyseotomy and forceps, for in head-first deliveries in flattened pelves we 
 lose the decided advantage secured by breech extraction and the entrance of the 
 head into the pelvic inlet base first. Theoretically cephalic version is to be pre- 
 ferred to podalic version in 
 all but a few exceptional 
 cases, because, as has been 
 stated before, the prognosis 
 for the fetus is always better 
 in cases in which it passes 
 head first through the pelvis 
 than in either spontaneous 
 or artificial feet-first labors. 
 On the other hand, the dex- 
 terity on the part of the oper- 
 ator required for its perform- 
 ance, the ease with which po- 
 dalic version can usually be 
 performed, and the frequent 
 necessity for rapid extrac- 
 tion after version, have un- 
 justly kept cephalic version 
 in the background. 
 
 Indications. — These are 
 very limited, principally in 
 shoulder and breech presen- 
 tation, but not when rapid 
 delivery is demanded, and 
 hence the method is unsuit- 
 able in placenta praevia and 
 prolapse of the cord 
 
 I. External Cephalic Ver- 
 sion. — Indications : Cephalic 
 version by external manipu- 
 lation only is chiefly applicable to cases of shoulder presentation or oblique 
 positions of the fetus in the uterus, discovered in the latter part of pregnancy 
 or at the onset of labor. Under favorable circumstances it may also be 
 used to convert a pelvic into a cephalic presentation. After labor has com- 
 menced this method may be used if sufiQcient liquor amnii remains and the 
 uterus sufficiently relaxes between the pains. Operation: The dorsal posture of 
 the patient with the pillows removed is to be preferred. As much relaxation 
 of the abdominal muscles as possible must be secured by flexing the thighs. 
 Anesthesia usually is not necessary, but in nervous patients may be required, 
 and employed to advantage. For success it is necessary to make out with certainty 
 
 Fig. 1 1 15. — External Cephalic Version in Breech 
 Presentation. Note that the fetus is made to travel 
 occiput first about the uterine cavity. 
 
922 
 
 OBSTETRIC SURGERY. 
 
 the existing position and presentation of the fetus, this being done by both 
 external and internal palpation. Before the operation is begun a clear mental 
 picture should also be formed of just what is to be done. In shoulder presenta- 
 tions and oblique positions of the fetus it is always desirable to have the head 
 take the shortest road to the pelvic inlet, and in pelvic presentations we should 
 aim to have the fetus revolve occiput first about the pelvis in order to avoid 
 unnecessary extension of the head, provided this can readily be accomplished. 
 With the palm of one hand upon the breech and the other upon the head 
 the breech is carefully pushed up, the head down, until the long axis of the 
 fetus corresponds to that of the uterus and the head lies over the pelvic inlet 
 (Figs. II 15 and 11 16). Revolution of the fetus is often readily performed, especi- 
 ally in shoulder presentations, but, the cause of the malpresentation existing, re- 
 turn of the fetus to its orig- 
 inal presentation often oc- 
 curs; this I have found 
 especially true of pelvic pre- 
 sentations. In such cases 
 I have found a pad on each 
 side of the uterus to hold 
 the fetus in place of little 
 use before labor actually 
 sets in, but the case should 
 be carefully watched and 
 reposition again performed 
 at the onset of labor and 
 the fetus held in position 
 until engagement occurs. 
 In private practice I once 
 thus changed a shoulder 
 into a vertex' presentation 
 in the beginning of the first 
 stage and held the head at 
 the pelvic inlet by grasping 
 it with one hand externally 
 for three hours, when it 
 finally engaged. No further 
 anomaly occurred and the 
 patient and fetus were thus 
 saved from the dangers of 
 a podalic version. In gen- 
 eral, after correction of the 
 malpresentation it is advisable to keep the patient quiet in bed in the dorsal 
 posture so that the fundus uteri shall not incline to one side or the other until 
 the desired presentation is effected. Fixation of the head in the pelvic inlet mav 
 be hastened and promoted by artificially rupturing the membranes, as soon as the 
 dilatation of the os warrants it. 
 
 II. Combined or Bipolar Cephalic Version. — Various methods of performing 
 version by one hand passed into the vagina, one or more fingers of which being 
 passed through the os, and the other hand upon the anterior abdominal wall, 
 have been described by Busch, Hohl, Wright of Cincinnati, and Braxton Hicks 
 of England.* The method as now usually practised is according to the principles 
 
 * Hicks: " Combined External and Internal Version," 1864. 
 
 Fig. 
 
 1 1 16. — External Cephalic Version in Shoulder 
 Presentation. 
 
VERSION. 923 
 
 laid down by Braxton Hicks, although priority has been claimed for Wright, 
 of Cincinnati.* Posture of the patient: Usually the dorsal posture is more con- 
 venient for both operator and patient. Hicks advises a choice of lateral position 
 to assist by gravity the performance of the operation. Thus, in shoulder pres- 
 entation with the fetal head to the patient's left side, and the breech therefore 
 toward the right. Hicks advises the left lateral posture of the patient, so that 
 the effect of gravity upon the fundus will assist in the operation by carrying 
 the breech to the left and the head thus over the pelvic inlet. The reverse 
 may be tried when the fetal head is to the mother's right. As in other varieties 
 of version, so here, the knee-chest posture of the patient has been recommended 
 and used to assist in the recession of a partially fixed shoulder or breech. This 
 posture I have found difficult for the patient to keep for any time, and not 
 more efficient than the exaggerated left latero-prone posture, which any patient 
 can easily assume (Fig. 1051). The right and left exaggerated latero-prone 
 posture can be used as directed. For ordinary cases the dorsal posture will be 
 found the most convenient. 
 
 In Shoulder Presentation. — It is in this presentation more than in pelvic 
 that combined cephalic version is used. The term "bipolar" cannot, strictly 
 speaking, be applied to combined cephalic version in shoulder presentation until 
 the latter part of the procedure, when both poles of the fetal ellipse are grasped. 
 Anesthesia is not always necessary but usually desirable, and it certainly facili- 
 tates the operation. As in all varieties of version, a certain diagnosis of the 
 exact position of the fetus is necessary for success. The operator should use 
 for the internal hand the one the palm of which would naturally face the 
 fetal breech, or the hand the fingers of which naturally flex toward the 
 fetal breech. Thus in right scapula positions of the shoulder he should 
 use the left hand internally, and in left scapula positions the right hand 
 in the vagina. If possible, he passes two fingers through the os, as thus 
 more force can be secured and there is less danger of rupturing the mem- 
 branes with two than with one finger. With the external hand steadying the 
 head, the two fingers in the lower uterine segment by a movement of flexion 
 push the apex of the shoulder upward and toward the side of the uterus occupied 
 by the breech; at the same time the external hand, already placed upon the 
 head, pushes the head down into the pelvic inlet, where it is recognized and 
 received by the two internal flngers and further adjusted to the inlet. For the 
 version to be completed the long axis of the fetus must correspond to that 
 of the uterus. In some instances the fetal breech will not readily rotate into 
 the fundus even after the head occupies the pelvic inlet. In such cases it is 
 advisable to withdraw the vaginal hand, the external hand still firmly holding 
 the head at the inlet, and to use this hand to push up the breech into the fundus. 
 It is only at this point in the operation that the operation, strictly speaking, 
 is "bipolar," namely, the forces are applied to the opposite poles of the 
 fetal ellipse. The head must be held by external palpation until it engages 
 or until engagement can be hastened by artificial rupture of the membranes. 
 
 In Breech Presentation. — It is often desirable at the onset of labor to convert 
 a breech into a vertex presentation in order to better the prognosis for both fetus 
 and mother. External version should always be tried first, and, failing in this, 
 we resort to combined external and internal version. Under such circumstances 
 the version is, strictly speaking, "bipolar," since force is applied to both poles 
 of the fetal ellipse. Operation: The same general principles as to preparation 
 and posture of the patient apply here as in cephalic version in shoulder presenta- 
 
 * " Amer. Jour, of Obstet.," vol vi, Part I, 1S73. 
 
924 
 
 OBSTETRIC SURGERY. 
 
 tion. As in shoulder presentation, so here, there is a distinct advantage to 
 the operator and the prognosis in the choice of the hand to be used internally. 
 The principle to be followed here as in other varieties of version is to have 
 the fetal ellipse revolve " occiput first " about the uterine cavity. Of course, it 
 is just as short a distance for the head to revolve one way as the other in pelvic 
 presentation. So in left sacro positions of the breech it is advantageous to 
 use two fingers of the right hand in the lower uterine segment, by flexing 
 these fingers to push the fetal breech to the mother's right, and thus the 
 occiput will traverse the left wall of the uterus and there will be little danger 
 of head extension or prolapse of the hands or arms. In left sacro positions the 
 left hand is used externally to push the head around the left wall of the uterus 
 in conjunction with the efforts of the internal right hand. As soon as the breech 
 has disappeared from the touch of the internal fingers these remain quiescent 
 until the apex of the shoulder can be reached, when it is pushed by a movement 
 of flexion with the fingers in the direction the breech has taken. After the shoulder 
 
 has been passed on, the internal fin- 
 gers at the OS await the coming of the 
 head, as in combined cephalic version 
 1 \ in shoulder presenfation. If after the 
 
 bringing down of the head it is found 
 that the fetal breech has not ascended 
 so far as the fundus, the vaginal hand 
 is withdrawn and used to push up the 
 breech, the head being still held in 
 place with the original external hand, 
 [n right sacro positions the choice of 
 hands is reversed, as the left hand is 
 used inte'mally and the right extern- 
 ally. 
 
 III. Internal Cephalic Version. — 
 Before the introduction of internal 
 podalic version internal cephalic ver- 
 sion was frequently performed by 
 passing the whole hand into the 
 uterus, grasping the fetal head, and 
 drawing it down into the os. The 
 operation is more difficult than com- 
 bined or internal podalic version and the maternal prognosis is not so good, 
 although theoretically the fetal prognosis is better. After the introduction of 
 podalic version the cephalic variety was practically abandoned, but has recently 
 been revived. Conditions necessary: Complete dilatation of the os with no dis- 
 proportion between the head and maternal parts. The operation is not intended 
 for rapid delivery. Operation — method of D'Outrepont: The uterus is supported 
 with the external hand. The internal hand seizes the presenting shoulder and, 
 during the intervals between the pains, pushes the shoulder upward and in the 
 direction of the breech, until the head descends into the pelvic inlet (Fig. my). 
 Method of Busch: The head, if on the left side, is grasped by the right hand through 
 the cervix while the other hand carries up the breech ; the head is then drawn 
 as far as possible into the cervix by the operator's hand, with the thumb and 
 little finger upon the temples and the other three fingers over the occiput (Fig. 
 in 8). Vienna method: By the Vienna method the head is guided to a position 
 over the os by the combined method of Hohl {q. v.) and then grasped and 
 drawn into the cervix. 
 
 Fig. my. — Internal Cephalic Version. 
 D'Outrepont's Method. 
 
VERSION. 
 
 925 
 
 ;'/: 
 
 / 
 
 (B) PODALIC VERSION. 
 
 Combined and internal podalic versions are performed more frequently than 
 all other varieties, so much so that in America the general term version is almost 
 synonymous with internal podalic version. 
 
 Indications. — Podalic version is indicated; (i) in shoulder presentation when 
 cephalic version has failed or the conditions are unfavorable for its performance; 
 (2) in cephalic presentation when the prognosis is bettered by feet-first delivery, 
 as in contracted pelves ; prolapse of the cord or extremities ; in certain malpresen- 
 tations and malpositions, such as face and brow presentations, and in persistent 
 occipito- and mento-posterior positions at the pelvic inlet ; (3) in certain emergen- 
 cies either for the control of hemorrhage or for rapid delivery, such as placenta 
 praevia and accidental hemor- 
 rhage, eclampsia, or sudden 
 death of the mother. 
 
 I. External podalic version is 
 never used, the combined or bi- 
 polar and the internal methods 
 being preferred. 
 
 II. Combined or Bipolar Po- 
 dalic Version. — The method used 
 to-day is practically the bipolar 
 method of internal and external 
 manipulation of Braxton Hicks. 
 I shall not enter into a compari- 
 son of the difference in the com- 
 bined methods of Busch,* D'Ou- 
 trepont,t Wright, J Hohl,§ and 
 Hicks, II since they differ merely 
 in detail, all simultaneously em- 
 ploying the external and internal 
 hand, but discuss only Hohl's 
 and Hicks 's methods, which limit 
 the internal hand to the intro- 
 duction of one or two fingers 
 through the os. The methods 
 
 of Busch and D'Outrepont, which required the introduction of the whole hand 
 through the cervix, are to-day practically obsolete. Any method of combined 
 podalic version which necessitates the introduction of the whole hand into 
 the uterus can scarcely give better results than internal podalic version. The 
 priceless advantage of the method described by Hicks is that it can be per- 
 formed early in labor, or even in late pregnancy, as its only requisites for 
 success are (i) sufficient mobility of the fetus in the uterus; (2) an exact 
 diagnosis of the fetal presentations and position; and (3) sufficient dilatation 
 of the OS to allow of the passage of two fingers. 
 
 I. In Shoulder Presentation. — Bipolar podalic version may be tried in 
 cases in which external or combined cephalic have failed, or in cases of shoulder 
 
 *Scanzoni: " Lehrbuch der Geburtshiilfe," 1S69, Bd. iii, p. 63. t Op. cit., p. 65. 
 
 t Wright: " Amer. Jour. Obstet.," vol. vi, Part I, 1873. 
 § Hohl: " Lehrbuch der Geburtshiilfe, " Auflage 1S62, p. 7S4. 
 
 II Hicks: "Combined External and Internal Version," "Trans. London Obstet. Soc ." 
 vol. V, p. 230; "Amer. Jour. Obstet.," July, 1S79, p. 593 
 
 V 
 
 / 
 
 Fig. 1118. 
 
 Internal Cephalic 
 Busch's Method. 
 
 Version. 
 
926 
 
 OBSTETRIC SURGERY. 
 
 presentations in which it is very important to bring down a leg to control 
 hemorrhage, as in placenta praevia, or for purposes of subsequent rapid delivery. 
 In all such cases in which the naembranes are intact, or in which they have not 
 long been ruptured, bipolar podalic version can" be attempted without any disad- 
 vantage or danger to mother or fetus ; for should circumstances prevent recession 
 of the shoulder, and version by this method fail, the hand can be passed into 
 the uterus, provided there is sufficient dilatation, and internal podalic version 
 promptly performed. Operation: Anesthesia as in combined cephalic version is 
 
 '(^■^. 
 
 Fig. 1 1 19. — -Combined or Bipolar Po- 
 dalic Version. Braxton Hicks's 
 Method. First Step. 
 
 Fig. 1120. — Combined or Bipolar Podalic Ver- 
 sion. Braxton Hicks's Method. Second 
 Step. 
 
 a practical necessity. The dorsal posture of the patient upon a sufficiently 
 high table is usually to be preferred, although the lateral or exaggerated semi- 
 prone can be substituted in difficult cases. (See page 872.) The internal hand 
 should be the one whose fingers naturally flex toward the fetal head; thus, in left 
 scapula positions the left hand is used internally, and in right scapula positions 
 the right hand. The proper hand is introduced into the vagina and two fingers 
 are passed through the os. The external hand rests over the fetal breech. 
 Now with the internal fingers the presenting shoulder is gently pushed upward in 
 the direction of the head and at the same time somewhat toward the fundus. This 
 
VERSION. 
 
 927 
 
 latter movement brings the fetal abdomen in part over the os, and renders 
 descent and grasping of a foot more easy. At the same time, with the external 
 hand the breech is pushed down into the lower uterine segment to replace the 
 shoulder. If this substitution can be accomplished, the most available knee or 
 foot, which is usually the anterior, is sought for by the internal fingers and hooked 
 down into the vagina through the os. When once the knee or foot is caught, 
 the external hand is transferred from the breech, which it has been pushing down, 
 to the lower portion of the fetal head, which it pushes upward and into the fundus 
 uteri. The ease with which the operation is performed will depend, of course, 
 upon the mobility of the fetus in the uterus, and practically upon the amount of 
 liquor amnii. It is generally considered that prolapse of an arm renders the per- 
 formance of combined podalic ver- 
 sion in shoulder presentation im- 
 possible. Dr. Frank P. Foster, of 
 New York,* operated in such a 
 case by using the prolapsed arm 
 as an aid to the version. Thepre- 
 
 FlG. 1 12 1. ^COMBINED OR BiPOLAR PoDALIC 
 
 Version. Braxton Hicks's Method. Third 
 Step. 
 
 Fig. II22. — Half Breech Formed 
 WHEN One Leg is Brought down 
 IN Podalic Version. — (Leopold.) 
 
 sentation was a shoulder and the position right scapula anterior with the left arm 
 prolapsed into the vagina. With the right hand in the vagina Dr. Foster grasped 
 the arm, and, using it as a kind of handle, gently pushed upward in the direction 
 of the humerus. The shoulder and cephalic pole of the fetus were thus elevated, 
 and with the index- finger in the cervix the breech was reached and pushed in the 
 direction the head had taken until the leg was recognized and brought down. 
 
 2. In Cephalic Presentations. — (Figs. iii9toii22.) The indications and 
 conditions necessary for the performance of bipolar podalic version in cephalic 
 presentation — namely, vertex, brow, and face — are practically the same as in 
 
 * Foster: " On Prolapse of the Arm in Transverse Presentations," " Amer. Jour, of 
 Obstet.," vol. IX, p. 203. 
 
928 OBSTETRIC SURGERY. 
 
 shoulder presentation. The head must not be too firmly engaged. Operation: 
 Anesthesia here is also a necessity and the dorsal posture is to be preferred in 
 ordinary cases. As in shoulder presentation, a movable fetus and an exact diag- 
 nosis of the presentation and position are necessary for success. It is important 
 that the fetus shall revolve occiput first about the uterus. This causes the feet 
 to travel about the shortest possible distance in order to reach the cervix; there 
 is less danger of extended head and arms, and the revolution of the fetus thus is 
 more readily accomplished. Hence, contrary to many authorities, I believe that 
 there is a distinct choice in the hand used internally. In left dorso positions the 
 left hand should be used internally, and in right dorso positions the right hand, 
 (i) With the appropriate hand in the vagina, two fingers through the os, and the 
 external hand on the breech, the internal fingers by a movement of flexion gently 
 push the head upward and in the direction of the occiput, the external hand at 
 the same time pushing the breech b}'' a gentle sliding motion in the opposite direc- 
 tion. This is to be continued until the head has passed out of the reach of the 
 internal fingers. (2) As the head departs from the internal fingers, if all goes 
 well, the normal attitude of the fetus is preserved and no extension of the head 
 or displacement of the arms occurs. The external hand now simply continues its 
 pressure and forces the breech with the feet into the lower uterine segment, where 
 one of the latter or a knee is secured by the fingers of the internal hand. In less 
 favorable cases, by reason of the uterus enveloping the fetus too closely, extension 
 of the head takes place ; it does not readily pass upward along the side of the uterus 
 into the fundus, and the shoulder or fetal chest is felt by the internal fingers just 
 over the os. In such cases one must treat the shoulder or chest in the same way 
 as the head by gently pushing it upward in the same direction the head has taken. 
 Care should be used in this case not to confound an elbow with a knee. (See 
 page 931.) As soon as a knee or a foot is recognized it should be seized, and 
 the membranes be ruptured if still intact. (3) After the knee or foot is firmly 
 secured by the internal fingers, the external hand is transferred from the breech to 
 the other side of the abdomen and placed below the head, which-is by a gentle 
 sliding motion pushed upward into the fundus, while at the same time the foot is 
 drawn down through the os into the vagina. Some operators always bring down 
 a knee through the os and afterward extend the leg in the vagina, claiming that 
 a better grasp is to be had in the flexure of the knee than on the foot. I have 
 found it much more convenient and simple to seize the foot in the uterus, as it will 
 be found that the foot comes first within reach of the internal fingers. The leg 
 being through the os, traction should be made upon it until two-thirds of the thigh 
 has passed through the os and the half breech is beginning to enter. This will bring 
 the foot outside the vulva. As traction is thus being made upon the leg, external 
 palpation is used to make sure that the head occupies the fundus. Traction on 
 the leg until the thigh engages in the os, combined with external upward pressure 
 on the head, assists in completing the version and preventing recession of the part 
 engaged. When the long axis of the fetus corresponds to that of the uterus the 
 version is completed. Whatever is subsequently done in the way of extraction 
 will be quite another operation. Choice of the leg to he seized: It is generally 
 stated that in combined podalic version in head presentations there is no 
 choice as to which leg is seized and that it makes no difference whether it is 
 the anterior or posterior which is secured. There is a principle in all varie- 
 ties of internal version, namely, that the leg which is brought down always 
 eventually rotates forward behind the symphysis. This rule has few exceptions. 
 Hence it will be found expedient, in order to avoid unnecessary rotation of the 
 fetus within the uterus, always to attempt at least to seize the anterior knee or 
 
 < 
 
VERSION. 929 
 
 foot, unless some distinct indication to the contrary exists. There is practically 
 but one exception to the rule of seizing the anterior foot, and that exception exists 
 in flattened pelves after it has been definitely determined that more room exists on 
 one side of the pelvis than the other on account of the greater width of the sacral 
 ala on one side. In such a contingency it is desirable to bring the occiput and the 
 wide biparietal diameter into the roomiest lateral half of the pelvis. Since, as 
 stated above, the leg which is brought down always eventually rotates to the 
 symphysis, if we desire the occiput to occupy a roomy left side of the pelvis we 
 bring down the left foot, and the right if we want the occiput in the right half. 
 Fig. 882 (page 650) illustrates the type of pelvis referred to, in which, as will be 
 seen, the roomiest lateral half of the pelvis is the left half. It is not by any means 
 always possible to choose a given knee or foot with two or three fingers only in 
 the lower uterine segment, hence in cases in which the choice of the leg to be 
 seized is important in the prognosis, it is better to wait until spontaneous or 
 artificial dilatation is accomplished, to pass the whole hand into the uterus and to 
 select the desired leg, thus practically doing an internal podalic version. (Com- 
 pare page 933.) 
 
 III. Internal Podalic Version. — This is one of the most valuable resources in 
 obstetric emergencies. It is indicated when the safety of the mother or child 
 requires immediate delivery, and when the use of the forceps is contraindicated 
 (e. g., in placenta prasvia, puerperal eclampsia, prolapse of the cord, etc.). It 
 is also indicated in various malpositions in which natural delivery or deliver}' 
 by forceps is hazardous or impossible {e. g., in delayed first stage due to occipito- 
 posterior position, or to face presentation), and in cases in which the after- 
 coming head is better adapted than the fore-coming head to pass through the 
 birth canal (e. g., in flattened pelvis). Internal podalic version in both cephalic 
 and shoulder presentation is to-day performed so frequently that when the term 
 version is used it is often, if not always, understood to mean internal version. 
 Operation : The operation consists in the introduction of the whole hand into 
 the uterus, seizing a foot or two feet, bringing it or them into the vagina through 
 the OS, and pushing the fetal head into the fundus by external manipulation 
 with the external hand. Unfortunately the version by the internal method is 
 most easy of performance, hence it is often done without first giving ex- 
 ternal or combined version a trial. It should ever be borne in mind that the 
 operation of internal podalic version, whether in shoulder or cephalic presenta- 
 tion, is a serious operation and one not lightly to be undertaken; that there are 
 always distinct dangers of injury to the maternal soft parts, even to the extent of 
 rupture of the uterus; that the danger of the introduction of septic material and 
 air into the uterus and to the placental site is ever present; that podalic version 
 once completed means the delivery of the fetus spontaneously or, as usually 
 occurs, artificially feet first, and that in such delivery the mortality is always 
 greater for the fetus, and the morbidity for the mother, than in most cases of 
 spontaneous or artificial head-first deliveries. The fetus was intended by nature 
 to pass head first through the pelvis. Reverse nature's process and the breech, 
 a poorer dilator than the head, is the first to pass through and dilate the passages ; 
 then come the dangers of arms extended over and impacting the head; extension 
 of the head increasing the danger, and the delivery of the incompressible head 
 rapidly, in ten minutes at most, through passages imperfectly dilated by the fore- 
 coming breech. 
 
 Conditions Necessary and Contraindications . — Pelvic deformity must not 
 be too great, nor must it be of such a kind as to interfere with the passage of 
 the after-coming head. The cervix must be completely dilated. If this is not 
 59 
 
930 
 
 OBSTETRIC SURGERY. 
 
 the case, complete manual dilatation and paralysis should be secured as a pre- 
 requisite. In rare cases incision may be necessary. There must not be tetanic 
 contraction of the uterus, and it is highly desirable that the membranes should 
 not be ruptured or should only recently have ruptured. The presence of the 
 contraction ring above the fetal head or more than four inches above the sym- 
 physis renders the operation extremely hazardous, owing to the danger of 
 uterine rupture. If the head is impacted or firmly wedged in the pelvic inlet, 
 so that much pressure is required to dislodge it, version is of course contra- 
 indicated. Version should not be performed for the delivery of a very small 
 or of a premature child, unless the forceps is contraindicated, for forceps 
 delivery in these cases is usually easy, and if properly performed less likely to be 
 
 ■•^ 
 
 \ 
 
 Fig. 1123. — Internal Podalic Version 
 IN Cephalic Presentation. Intro- 
 duction of the internal hand into the 
 uterus, and downward pressure of the 
 external hand to bring the legs within 
 reach of the internal hand. 
 
 Fig. 1 124. — Internal Podalic Version in 
 Cephalic Presentation. Grasping the 
 anterior leg with the internal hand and 
 upward pressure upon the anterior shoulder 
 with the external hand. 
 
 fatal to the child. Internal version should not be performed for the delivery 
 of a macerated or dead fetus. If the child is dead, craniotomy should be per- 
 formed unless the delivery promises to be very easy and unattended by lacera- 
 tion of the maternal structures. 
 
 General Preparations. — The dorsal posture of the patient upon a high oper- 
 ating table is to be preferred to the lateral, exaggerated semi-prone, knee-chest, 
 and Trendelenburg postures, in all but exceptional cases. In difficult versions in 
 impacted shoulder presentation the Trendelenburg and exaggerated semi-prone 
 position will greatly assist our endeavors to dislodge the impacted shoulder. (See 
 page 879.) The bladder and rectum must be thoroughly emptied, the pubic hair 
 removed, and I am accustomed to prepare the external genitals, adjacent parts, 
 
VERSION. 
 
 931 
 
 and vagina, as for a major gynecological procedure; vaginal hysterectomy, for 
 example. Of course, vaginal mucus and lubrication are thus removed, but it will 
 be found that a good substitute is a i per cent, solution of lysol, with which the 
 vagina should finally be freely irrigated. Anesthesia is a necessity in internal ver- 
 sion, as it is important for the maternal and fetal prognosis that the greatest pos- 
 sible relaxation of the uterus be obtained. Theoretically, chloroform gives a more 
 thorough uterine relaxation than ether, but it will be found that ether, if properly 
 given, will answer every purpose, and it is certainly the safer anesthetic. (Com- 
 pare Anesthesia, page 865.) 
 
 r. In Vertex, Bregma, Brow, and Face Presentations. — The prepara- 
 
 \ 
 
 Fig. 1 125. — Internal Podalic Version in 
 Left Scapulo-posterior Position of the 
 Shoulder. The right hand is used inter- 
 nally to grasp the feet, and the left ex- 
 ternally to depress the fundus. This method 
 is not recommended. 
 
 Fig. 1126. — Internal Podalic Version 
 IN Left Scapulo-posterior Position 
 OF THE Shoulder. The left hand, the 
 palm of which naturally faces the fetal 
 abdomen, is used internally to grasp the 
 feet, and the right hand externally to 
 depress the fundus. This method is to 
 be preferred to that of Fig. 1125. 
 
 tions having been carefully made, here, as in other varieties of version, success 
 depends upon an accurate diagnosis of the presentation and position. Our 
 object in internal podalic version in cephalic presentations is to pass the whole 
 hand into the uterus, seize one or two feet, bring the latter into the vagina, 
 and assist the head with the external hand to pass upward and occupy the 
 fundus of the uterus. 
 
 Choice of Internal Hand. — According to many authorities, the primary 
 choice of hands is not a matter of great consequence. I believe, however, the 
 choice of hands to be an important factor in the prognosis; and the greater 
 the operator's experience, the greater care will he exercise in this respect. That 
 
932 
 
 OBSTETRIC SURGERY. 
 
 hand should be used internally the palm of which naturally without exaggerated 
 pronation or supination faces the fetal abdomen. Thus, in left dorso positions 
 — namely, left occipito-anterior and -posterior, right mento-anterior and -poste- 
 rior, and right fronto-anterior and -posterior — the left hand is the one to use in- 
 ternally for grasping the foot or feet, as this hand most naturally by the shortest 
 path and with least disturbance of the fetal ellipse comes to the feet and readily 
 selects one or both for traction. However, in right dorso positions — namely, in 
 right occipito-anterior and -posterior, in left mento-anterior and -posterior, and 
 in left fronto-anterior and -posterior — the right 
 hand should be used, for the above reasons. 
 In pelves flattened from any cause, and especi- 
 ally if the pelvic inclination is increased, there 
 may be a decided posterior obliquity of the 
 uterine axis in reference to the axis of the pelvic 
 inlet, with a perfectly movable head. Under such 
 circumstances rotation of the fetal back often 
 occurs and the feet are found not to one side, but 
 well up against the posterior wall of the fundus. 
 
 Here, of course, it. is immaterial which hand is ><j^ \ ;r 
 
 used internally, but in the great majority of cases ;/\ ] y 
 
 Fig. 1127. — Method of Grasping One Foot. 
 
 Fig. 1 12S. ^Method of Passing 
 A Sling over a Foot Pro- 
 lapsed INTO the Cervix or 
 Vagina. 
 
 of cephalic presentation external and internal examination will reveal the fetal 
 dorsum inclined either to the left or right. 
 
 Treatment of Intact Membranes. — If internal version is to be performed when 
 the membranes are intact, and it is most desirable and advantageous that they 
 shall remain unruptured until the hand is introduced into the vagina, and the 
 liquor amnii thus being dammed back in the uterus after the membranes are finally 
 artificially ruptured, the question is often asked. What is the treatment of the un- 
 ruptured membranes? Three plans have been practised by various authorities in 
 time gone by : ( i ) One plan is to seize the foot or feet through the unruptured 
 membranes and complete the version without rupturing them; (2) another is to 
 
VERSION. 933 
 
 pass the internal hand up between the uterine wall and membranes until oppo- 
 site the feet and then rupture; (3) and the third is to rupture the membranes 
 at the level of the os and introduce the hand into the amniotic cavity during 
 the escape of the water. The first plan is to-day practically obsolete, and the 
 passage of the hand up until opposite the feet, as in the second plan, carries 
 with it unnecessary dangers of septic infection, accidental hemorrhage from 
 premature placental separation, and rupture of the uterus. I have seen several 
 cases of alarming ante-partum hemorrhage from this method. It is not to be 
 recommended. The third method of low rupture is the safest of all and quite 
 as satisfactory as any other. In this method there is no danger of accidental 
 hemorrhage ; the liquor amnii is quite as readily dammed back in the uterus by 
 the wrist and forearm in the vagina; and then we have the great advantage of 
 working entirely within the membranes from the internal os, they forming, so to 
 speak, a protecting glove covering the internal hand and reducing the dangers of 
 infection to a minimum (Fig. 637). 
 
 Further Course of the Internal Hand. — In the absence of uterine contraction, 
 the internal hand should gradually be passed within the bag of membranes upward 
 toward the fundus and along the lateral uterine wall, disturbing the fetal ellipse as 
 little as possible. During the entire time the external hand must make careful 
 counter-pressure over the fundus until the feet are seized. If a uterine contrac- 
 tion at any time occurs, all upward movements of the internal hand must cease 
 and the hand lie flat against the uterine wall until the contraction has passed off. 
 Some difficulty will usually be encountered in passing the presenting head. This, 
 as a rule, can be overcome by gently pushing it toward the iliac fossa opposite the 
 internal hand. In late internal podalic versions in cephalic presentations atten- 
 tion must be paid to the condition and location of the contraction ring. Should 
 one palpate the contraction ring projecting markedly toward the fetal head, — and 
 there is difficulty, under deep anesthesia, of passing the hand by this ring, — the 
 version should be abandoned, since the conditions indicate retraction of the body 
 of the uterus, ascent of the retraction ring, and dangerous thinning of the lower 
 uterine segment. There would be great danger of uterine rupture in attempting 
 to displace the head upward and over such a retraction ring. 
 
 Choice of Leg to Bring Down. — Shall we seize one or both feet; and, if one 
 foot, the knee or foot, the anterior or posterior leg? If both legs only are brought 
 down and not one leg alone, the whole breech makes a better dilator for cervix, 
 vagina, and vulva than the half breech (Fig. 11 22), and hence the fetal prognosis 
 is improved because a fuller dilatation of the passages diminishes the danger 
 of the after-coming head and the disengagement of possibly extended arms. 
 If the fetus is dead or macerated; if it is small or medium-sized; and if in the 
 interest of the mother great haste is essential, the grasping of both legs will 
 also be indicated. If both legs are brought down, the feet are seized. There 
 are two advantages in seizing a knee and not a foot when one leg is brought down 
 first: the knee in a normal attitude is nearer the os than is the foot, and, second, 
 the flexure of the knee offers a convenient hold. One foot is difficult to grasp within 
 the uterus without doubling the hand into the shape of a closed fist, and this oc- 
 cupies much space. On the other hand, the knees lie near the elbows, and differ- 
 entiation with fingers whose sensation is partially lost by reason of uterine pres- 
 sure is not always easy. To distinguish the knee from the elbow, one should 
 recall that the knee is relatively broad, has not the sharp projection of the ole- 
 cranon, and usually points toward the head; while the elbow is sharp and points 
 away from the head. In doubt, one can follow along the extremity and differenti- 
 ate hand from foot, or in the opposite direction and distinguish shoulder from 
 
934 
 
 OBSTETRIC SURGERY. 
 
 breech. When the knee is selected, the forefinger is slipped into the fold of the 
 popliteal space, the knee is drawn down through the os into the vagina, and the 
 leg then extended and subsequent traction made upon the leg. As regards the 
 choice of legs when one is seized, many authorities state that it makes no difference 
 which is selected ; that the best plan is to seize whichever comes first and is most 
 readily found. As stated elsewhere, whichever leg is seized in version eventually 
 comes to the pubic angle, hence to avoid unnecessary torsion of the fetus it will 
 
 /''.••' ^ 
 
 %I 
 
 Fig. 1 129. — Difficult Podalic Version 
 IN Cephalic Presentation. Combined 
 manipulation, consisting in upward pres- 
 sure upon the head with the hand in the 
 uterus, and downward traction with a 
 sling attached to a prolapsed leg. 
 
 Fig. 1 130. — The Completion of Podalic 
 Version. The version is finished when 
 the knee is at the vulva, and the long 
 axes of fetus and uterus correspond. 
 
 be found advantageous always to select the anterior leg. To sum up, the plan I 
 have found most successful is to seize the knee when one leg is to be brought down 
 and the feet when both. I always endeavor to bring down the anterior leg in 
 single-leg versions. 
 
 Difficult Internal Version in Cephalic Presentation. — If one encounters diffi- 
 culty in the rotation of the fetus, the same two expedients may be used as are 
 made use of in difficult internal podalic version in shoulder presentation. The 
 manoeuvers constitute the so-called combined manipulations. One is by me- 
 
VERSION. 936 
 
 chanical means to apply greater traction on the leg than we are able to do with 
 the hand; and the second is, by an arrangement of the soft fillet or sling to 
 draw down on the leg or legs while we push up the head internally (Fig. 1129). 
 These methods are described on page 935, under "Version in Impacted Shoulder 
 Presentation." It must ever be remembered that in cephalic presentation diffi- 
 cult version by the combined manoeuver is usually a more dangerous procedure 
 for the integrity of the uterus than is an operation of equal difficulty in shoulder 
 presentation. Moreover, difficult version in a cephalic presentation is almost 
 always undertaken in the interests of the fetus; namely, in malpresentations 
 and malpositions; hence if the resistance to the rotation of the fetus is very 
 great, we must be careful not to persist and thus run too great a risk of uterine 
 rupture. 
 
 2. In Shoulder Presentation. — The preparation and the general principles 
 are the same as in cephalic presentation. 
 
 Choice of Internal Hand. — Because the feet are usually within easy reach in 
 the center of the uterus, the choice of hand is not so important as in cephalic 
 presentation. In general, the hand should be used the palm of which most 
 naturally faces the legs. Thus, in left scapula positions of the shoulder I always 
 use the left hand internally to grasp the foot or feet, and in right scapula posi- 
 tions, the right. 
 
 Treatment of Intact Membranes. — This is practically the same as in cephalic 
 presentation. 
 
 Choice of Leg to Bring Down. — Some operators attach little importance to the 
 choice between the upper or lower leg, and seize either foot indifferently. In 
 Germany preference is given to the lower leg, and in England the followers of 
 Simpson teach the doctrine of selecting the leg on the side of the body opposite 
 to the presenting shoulder. I hold that a distinct choice exists here, although 
 in extreme emergency, when the time does not allow of a positive diagnosis of 
 the position, one is only too glad to seize the first foot available. A study of the 
 mechanism of labor in pelvic presentation will convince one of the importance 
 of the fetus maintaining a dorso-anterior position. Further, in order that the 
 fetal attitude may be disturbed as little as possible, it is necessary that the leg 
 selected shall take the shortest road to the pubic arch. Both of these condi- 
 tions are fulfilled by selecting the lower leg in scapulo-anterior positions, and 
 the upper leg in scapulo-posterior positions. 
 
 Sling to the Prolapsed Arm. — In case an arm is prolapsed in the vagina or 
 through the vulva, there should never be any attempt at replacing it, but a 
 sling should be attached to the wrist, affording a distinct advantage. The 
 operator has thus complete control over one arm at least, and he will always 
 be able to prevent this arm from becoming extended above the head and so 
 delaying the extraction of the after-coming head. (Compare "The Sling.") 
 
 Version in Impacted Shoulder Presentation. — In instances in which version is 
 demanded after the membranes have been ruptured for some time and the uterus 
 is closely contracted around the fetus, we may find much difficulty in moving the 
 fetus, after the leg has been even seized, and with the assistance of external 
 manipulations. Three expedients will here usually prove successful, although in 
 the case of a dead fetus and dangerous thinning of the lower uterine segment 
 decapitation is the safer operation. First, an anesthetic to the full surgical 
 degree is demanded, in order to secure the greatest possible relaxation of the 
 uterus. Second, some means is employed to secure more powerful traction on 
 the leg than can be obtained with the internal fingers. The best way of making 
 powerful traction is by the aid of the sling (Figs. 112S and 1129). Third, the 
 
936 OBSTETRIC SURGERY. 
 
 internal hand is used not to draw down on the leg, but firmly to push up on the 
 shoulder. The sling to the leg leaves ample room for this, and we thus bring two 
 forces simultaneously into play on the opposite poles of the fetal trunk (Fig. 
 1 129). In very difficult cases the second leg can be brought down, a sling 
 applied to it, and traction made on both legs simultaneously. 
 
 (D) PELVIC VERSION. 
 
 Pelvic version, in which the breech is caused to present by external, com- 
 bined, or internal manipulation, without a leg being brought down, is to-day 
 rarely performed, being practically obsolete. The same general principles as in 
 cephalic or podalic version govern its performance. 
 
 Prognosis. — In the 44 cases analyzed by the author, one mother died from rup- 
 ture of the uterus following manual dilatation and internal podalic version for 
 placenta praevia. Of the children, 32, or 72.5 per cent., were delivered alive; 
 7, or 15.9 per cent., were still-bom; i, or 2.27 per cent., died in the puerperium, 
 and in 5 there was no record of the result. (Compare Forceps.) Forceps opera- 
 tion was attempted in 6 cases prior to the version. 
 
 XII. PELVIOTOMY. 
 
 Symphyseotomy is so well, if not so favorably, known that the practitioner 
 generally ignores the fact that this particular form of intervention is but one of 
 several methods of dividing the pelvic ring. Double Ischio-pubiotomy : A few 
 years after Sigault's introduction of symphyseotomy, Aitken performed an opera- 
 tion for enlarging the pelvic cavity by sawing through the two rami of the ischium 
 and those of the pubis on either side of the pubic bone. Double Pubiotomy : Pitois 
 modified this operation by carrying the incisions through the pubic bone on both 
 sides of the symphysis. Triple Pelviotomy : Finally Galbiati, the distinguished 
 symphyseotomist, added ischiopubiotomy to symphyseotomy, thus dividing the 
 pelvic ring in three different localities. These operations were practised as a 
 variation or extension of the principle of symphyseotomy, in cases in which the 
 latter operation could not sufficiently enlarge the pelvic cavity; such a state of 
 affairs could hardly occur save in high degrees of pelvic contraction, ankylosis, or 
 deformity, or in some condition of the symphysis in which its division is contra- 
 indicated. Operations dividing the pelvic bones have been looked upon as obso- 
 lete, being supplanted, since the antiseptic era, by artificial premature delivery, 
 CcBsarean section, etc. However, in 1892 Farabeuf revived this principle by 
 recommending and practising ischiopubiotomy (unilateral) in the asymmetrical 
 ankylosed pelvis. 
 
 Unilateral Ischio-pubiotomy. — This operation, according to Farabeuf, is one 
 which may be performed by any practitioner without difficulty or risk. Its 
 technique is as follows: The cutaneous incision should be parallel with the 
 median line and at a distance of i-j inches (4 cm.) from it. The rami of the 
 ischium and those of the pubis are thereby exposed sufficiently for the passage of 
 a chain-saw around them. The ramus of the ischium is to be divided by the 
 side of the perineum, to the right of the fourchette; the ramus of the pubis is to 
 be divided a finger's-breadth to the outer side of the pubic bone. A finger should 
 be kept in the vagina during the various steps which end in the division of the 
 ramus of the pubis. After the pubic bone has been exposed by incision through 
 
SYMPHYSEOTOMY. 937 
 
 the soft parts, a curved rasp is used to denude its outer aspect, lower border, dnd 
 inner aspect of the bone, the instrument reappearing at the obturator fora- 
 men. The chain-saw is passed around the bone by the aid of a blunt curved 
 needle, the soft parts are pushed back, and the bone is sawed through. The 
 ramus of the pubis is divided in a similar fashion, care being taken to respect the 
 inguinal canal. The pectineal aponeurosis and Gimbemat's ligament are de- 
 tached from the bone. The saw can be passed around the latter with very little 
 preliminary denudation. No separation of the bones occurs thus far, because 
 it is prevented by the obturator membrane, which must be disconnected from 
 the pubic ramus. With the aid of some strong, blunt instrument the severed 
 bones are now pried apart. The amount of separation obtained thereby is at 
 least I.I inches (3 cm.). After delivery the ramus of the pubis should be wired 
 together by strong metallic sutures. Ischiopubiotomy, being simply a variation 
 of symphyseotomy when the latter is insufficient, comprises certain principles 
 which will be considered in detail under the latter operation. 
 
 XIII. SYMPHYSEOTOMY. 
 
 Symphyseotomy, or division of the ligaments which unite the two halves of 
 the pubic bone, is an operation introduced into obstetrical surgery for the pur- 
 pose of enlarging the pelvic inlet in dystocia arising from disproportion between 
 the pelvis and the fetal head. It is quite radical as a piece of operative interven- 
 tion; for despite the apparent simplicity of the operation proper, it may be re- 
 garded as a crucial example of work. 
 
 Indications. — Symphyseotomy may be regarded as an independent procedure, 
 or as a mere accessory to version, high forceps extraction, etc. Broadly speaking, 
 it is a method for enlarging the pelvic cavity, and has many uses in theory which 
 cannot be realized in practice. Chrobak * states that there is hardly an obstetric 
 operation in which symphyseotomy might not be employed as an adjuvant. The 
 operation of division of the joint itself is insignificant in its consequences, and the 
 real complication lies in the injuries necessarily inflicted upon the soft parts. 
 Hence symphyseotomy as an adjuvant to other obstetric operations must neces- 
 sarily add to the risk already present. The indications and contraindications for 
 symphyseotomy necessarily vary with the point of view of the operator. The in- 
 tervention is ostensibly to save the child without thereby imperiling the life of the 
 mother. The Italian symphyseotomists, Morisani and Novi, do not look upon 
 premature delivery, Cassarean section, and symphyseotomy as competitive but 
 as entirely distinct procedures, each having its own special indications and con- 
 traindications. It is essential for the success of symphyseotomy that the pelvis 
 be not too small for the expulsion of the child , for the subsequent application of the 
 forceps must add greatly to the risk for both mother and child. It is also essen- 
 tial that the child be able to come into the world alive. Symphyseotomy is in- 
 dicated if the conjugate is between 3.46_inches (8.8 cm.) and 2.64 inches (6.7 cm.). 
 If this condition is insisted upon, the results of intervention are seen to be excel- 
 lent. It is, however, regarded as an error to make the indication for symphyseo- 
 tomy depend wholly upon the dimensions of the conjugate, as some account must 
 be taken of the shape of the pelvis as a whole. Symphyseotomy is especially 
 indicated in certain types of pelvic deformity, such as the funnel-shaped pelvis, 
 sacro-coccygeal ankylosis, etc. In the justo-minor pelvis the operation is indicated 
 
 * Cited by Neugebauer, p. 197. 
 
938 
 
 OBSTETRIC SURGERY. 
 
 without too implicit adherence to the size of the conjugate. Other indications 
 for symphyseotomy are found in normal pelves with excessive size of fetal head, 
 or in the presence of deformities. Neugebauer, who has doubtless devoted 
 more time to the study of symphyseotomy than has any other individual, with the 
 possible exception of Morisani, states that the operation possesses a strict indica- 
 tion, standing midway between artificial premature delivery and Cesarean sec- 
 tion, with the former of which it may also be combined to save the life of the 
 child. My experience in six cases of flattened and generally contracted pelves 
 does not lead me to look with favor upon the operation. I am accustomed to 
 consider the induction of premature labor and Cassarean section, and in special 
 cases even embryotomy, as competitive with symphyseotomy. 
 
 Morbidity. — Rubinrot's analysis teaches us that the operation of symphyseot- 
 omy abounds in accidents. The number of post-operative complications is not 
 less formidable. Shock occurs but rarely, but septic accidents are present in 
 not less than 30 per cent., this proportion including mild as well as severe forms. 
 There were to deaths from sepsis in 136 operations. Simple suppuration of the 
 
 Fig. 1 13 1. — Transverse Section of a 
 Pelvis Just below the Pelvic Inlet, 
 Mounted upon a Scaled Board to Il- 
 lustrate Symphyseotomy. 
 
 Fig. 1 132. — Asymmetric Separation at 
 THE Pubic and Sacro-iliac Joints in 
 Symphyseotomy. 
 
 symphyseotomy wound occurred in about 10 per cent, of all cases, and oedema of 
 the vulva in nearly the same proportion. Of the more unusual post-operative 
 complications may be mentioned hematoma, abscess, stitch-abscess, fistula, per- 
 manent separation of the pubic bones, lymphangitis, cystitis, incontinence of 
 urine, paresis of the bladder, urinary fistula, bedsores in various localities, infec- 
 tious myelitis, neuralgias, and arthritis or other disorders of the sacro-iliac syn- 
 chondrosis. In addition to the foregoing, a more remote series of post-operative 
 accidents should be mentioned, the presence of which is apparent for months after 
 the operation ; namely, disturbance of the gait, which is due to permanent separa- 
 tion of the symphysis, sacro-iliac disease, etc., bony sequestra, urinary inconti- 
 nence and fistulae, vesical paresis, cystitis, and sepsis. Sepsis, the most redoubt- 
 able post-operative complication, appears to be connected especially with hemor- 
 rhage, whether due to the intervention itself or to uterine inertia, and with lacera- 
 tions of the parturient canal, independent of coincident hemorrhage. In other 
 cases no cause for sepsis is apparent. It has been claimed that sepsis after sym- 
 physeotomy is especially favored by the jagged, uneven character of the opera- 
 
SYMPHYSEOTOMY. 939 
 
 tion-wound, which latter is in marked contrast with the clean-cut incisions of 
 the Caesarean section. More or less stormy convalescence followed all of my six 
 cases of symphyseotomy. 
 
 Mortality. — According to Rubinrot's analysis of 136 cases of symphyseotomy 
 from 1896 to 1898, the combined maternal mortality was in round numbers 11 
 per cent. Fifteen of the women died; two directly from the operation itself 
 and thirteen from post-operative complications (sepsis). This percentage is in 
 harmony with that obtained by Morisani for 241 miscellaneous operations per- 
 formed before 1894, and by Neugebauer in his analysis of 278 cases. In regard 
 to the infantile mortality, Rubinrot records 19 deaths in 136 operations, or nearly 
 14 per cent. These figures are higher than those of Morisani, who places the in- 
 fantile mortality at 12 per cent. This contrast is somewhat paradoxical, as 
 Rubinrot's statistics refer to purely modem operations, while Morisani deals 
 with all the cases since the first introduction of the operation. The infan- 
 tile mortality appears to be due to a variety of affections and by no means neces- 
 sarily to the operation. A certain number of deaths are due to attempts at 
 forceps extraction before the performance of symphyseotomy, as shown by the 
 presence of meningeal hemorrhage, fracture of the skull, etc., found at autopsy. 
 Some of the deaths are such as are inevitable in ordinary labor, e. g., from pro- 
 lapse of the cord, eclampsia of the mother, etc. Generally speaking, the infan- 
 tile mortality is rendered high by reason of the prolonged sojourn of the child in 
 the maternal passages, the use of anesthetics, shock, etc., — all of which condi- 
 tions tend naturally to favor still-birth, apparent death, asphyxia, etc. A very 
 large proportion of children delivered by symphyseotomy require reanimation. 
 
 OPERATION. 
 
 At the present time the operative technique is practically made up of three 
 distinct methods, each of which is upheld by the operators of a particular nation- 
 ality. Thus we have (i) the French or open method as performed by Pinard and 
 his followers; (2) the American or subcutaneous method; and, finally, (3) the 
 suprapubic method of Morisani and his pupils. All the French operations from 
 1896 to 1898 inclusive were done in the classical manner prescribed by Pinard and 
 Farabeuf save those of Porak^ who employs a method of his own. The French 
 method was also employed in most of the operations outside of France. Morisaini's 
 method, which prevails in Italy, was occasionally employed in other countries, 
 notably in America. Several Americans have operated by the subcutaneous 
 method, while Franck in Germany and Lauro in Italy have devised modifica- 
 tions of symphyseotomy which go by their names. 
 
 Italian or Suprapubic Method (Fig. 1133). — The original method employed 
 by Morisani, otherwise known as the Italian or suprapubic operation, is as fol- 
 lows: A transverse incision 1.18 inches (3 cm.) long is made 0.39 inch (i cm.) 
 above the pubis with the design of exposing the upper margin of the bone. The 
 Galbiati knife is then passed behind the symphysis, as far as its lower border, and 
 with a stroke of the instrument from behind upward and from below upward, the 
 symphysis is divided. Morisani then waits for spontaneous expulsion, and if this 
 is not forthcoming the forceps is applied. The cutaneous incision is then re- 
 paired and an immovable dressing of plaster-of- Paris or silica is applied about the 
 pelvis. Novi's method is practically the same, save that he uses a bistoury in- 
 stead of Galbiati's knife. He applies after the operation a simple spica_^bandage, 
 not reinforced in any manner. A special symphyseotome has been devised by 
 Spinelli, which is manufactured in three sizes. In order to use this instrument 
 
940 
 
 OBSTETRIC SURGERY. 
 
 the suprapubic incision does not suffice and the symphysis must be laid bare. 
 Morisani sometimes employs a bistoury in place of Galbiati's knife. He appears to 
 content himself with a simple roller bandage to secure the apposition of the pelvic 
 bones. The Italian method as practised by Morisani 
 and Novi is peculiar in that the symphysis is 
 divided from behind forward and from below up- 
 
 
 Fig. 1 133. — The Italian or Suprapubic Method of Fig. 1134. — The French or 
 Operation. Open Method of Opera- 
 
 ward, and that no attention is given to the insertion of the recti, or to the clitoris 
 and its vessels. The chief care lies in the dissection of the retropubic tissue to 
 
 ^ " 
 
 '■—^ 
 
 Fig. 1135. — Subcutaneous or Ayers's Method of Operation. 
 
 make a passage for the knife. Charpentier (quoted by Neugebauer) was much 
 impressed by the singular unanimity of the Italian operators as to technique. 
 French or Open Method (Fig. 1134). — Pinard's method, otherwise known 
 
SYMPHYSEOTOMY. 
 
 941 
 
 as the French or open operation, is as follows. The mons veneris is shaved, 
 and it is regarded as an essential step to make the incision exactly in the middle 
 line. The skin and subcutaneous tissues are divided, the incision being, as a 
 rule, 3.15 to 3.9 inches (8 to 10 cm.) in length, extending from above the pubis to 
 just above the clitoris, deviating a little from the middle line in order to avoid 
 wounding the vessels of the clitoris. The insertion of the recti is divided in the 
 upper angle of the wound, so that the finger may enter the prevesical space and 
 protect the bladder. The symphysis is then divided with a few strokes of the 
 knife from above downward and from before backward. If the separation of the 
 pubic bones is insufficient, Pinard has his assistants enlarge the breach by ap- 
 propriate pressure upon the lower extremities. The ligamentous mass beneath 
 the symphysis is divided last of all. Before waiting for the expulsion of the 
 child, the symphysis is carefully examined to see if detachment is "nearly 
 complete. If convinced that the sacro-iliac articulation will permit sufficient 
 separation of the pubic bones, Pinard immediately applies a temporar}'- dress- 
 ing to the cutaneous wound and leaves to the patient the task of expelling the 
 fetus. In the open method some operators insert periosteal sutures into the 
 pubic bones before closing the cutaneous wound, and one accoucheur, Fieux, 
 of Bordeaux, regards this periosteal suture as 
 quite sufficient for immobilizing the pelvis. 
 Others employ mechanical devices to retain 
 the pelvic bones in apposition. 
 
 Subcutaneous or Ayers's Method (Fig. 
 1 13 5). — The subcutaneous method is per- 
 formed as follows:* If possible, the cervix 
 must be fully dilated; the urethra and blad- 
 der are to be held to one side with a sound. 
 The initial incision must be made a little 
 above the subpubic arch and under the ele- 
 vated clitoris. The left index-finger is intro- 
 duced within the vagina and held against the 
 posterior aspect of the joint. A narrow tenot- 
 omy knife is then passed up to a point within half an inch of the summit of the 
 joint beneath the overlying soft tissues. A probe-pointed bistoury is then sub- 
 stituted for the tenotome and carried to the top of the joint, where it meets the 
 index-finger. It is then carried downward through the joint until the latter is 
 felt by the index-finger behind to give way. An assistant now presses a small 
 gauze compress against the incision beneath the clitoris. If possible, the child is 
 then delivered with the forceps. When pressure is made upon the pubic bones, 
 the bladder must be held to one side. A small piece of gauze is next forced into 
 the wound while another strip is left in the cervix. The operator must refrain 
 from immediate repair of the cervix or perineum if the latter is torn. A soft- 
 rubber retention catheter is left in the bladder until the power of voluntary mic- 
 turition returns. The vulva is dressed with gauze and the pelvis strapped with 
 adhesive strips. All the gauze is removed in thirty-six hours and the vulva and 
 vagina are irrigated twice daily, the vulva being carefully dressed between 
 times (Fig. 1136). 
 
 *Ayers: "The Pubic Symphysis in Parturition," " Amer. Jour, of Obstetrics and Dis. 
 of Women and Children," July, 1S97. 
 
 Fig. 1 136. — Mechanical Brace for 
 Holding the Joint after Sym- 
 physeotomy. 
 
942 OBSTETRIC SURGERY. 
 
 XIV. EMBRYOTOMY IN GENERAL. 
 
 Much ambiguity has arisen from the defective terminology of the mutilating 
 operations. There is not a word in general use to designate collectively all these 
 forms of intervention. Embryulcia, a word possessing this general significance, 
 is used by a few only. Embryotomy, which literally means mutilation of any 
 portion of the fetus, does not, with most authors, include operations upon the 
 skull, which are comprised indifferently under the terms craniotomy and perfora- 
 tion. In this narrow sense embryotomy comprises the operations of decapita- 
 tion, cleidotomy, eventration, amputation, etc. The absence of a general des- 
 ignation to include all these operations has led to the omission by many writers 
 of a general section upon embryotomy in the wider sense — its indications, fre- 
 quency, prognosis, etc. 
 
 Definition. — Embryotomy comprises all operations upon the fetus which 
 have for their object a sufficient reduction in size to make extraction possible 
 by the natural passages. 
 
 Varieties. — Embryotomy includes all degrees of mutilation, from simple acts 
 like cleidotomy and rachidotomy to complete morcellation of the fetus. It is per- 
 formed upon both the dead and the living child, and by reason of the feticide in- 
 volved in the latter case, the indications naturally diverge widely according to 
 the state of the child and the point of view of the operator, since feticide is justifi- 
 able only when the mother's life would otherwise be sacrificed. 
 
 Embryotomy in general, irrespective of the state of the fetus, comprises the 
 following operations: (i) Perforation of the skull. (2) Perforation of the 
 spine, or rachidotomy. (3) Crushing or comminution of the bones of the 
 skull — cranioclasis, cephalotripsy, basiotripsy. (4) Separation of the fetal head 
 from the body — decapitation. (5) Opening of the thoracic and abdominal 
 cavities, and removing the whole or a part of their contents — evisceration. (6) 
 Amputation of extremities. (7) Division of one or both clavicles — cleidotomy. 
 (8) Division of the spine, or spondylotomy. 
 
 Frequency. — Embryotomy is the oldest of all the methods of intervention in 
 difficult labors. Version, known during the classic period, subsequently became 
 a lost art until revived in the sixteenth century. With the gradual introduction 
 of version and the forceps the field of embryotomy became much restricted, 
 and it came to be regarded almost as a resource of the unskilful. Early in 
 the nineteenth century a few obstetricians expressed themselves in favor of doing 
 away entirely with the operation as having no legitimate field. Nevertheless it 
 holds a secure position to-day as regards its employment upon the dead fetus. 
 The explanation of its permanency is found it its comparative innocuousness. 
 Whereas the maternal mortality was once very high, it is at present the reverse. 
 The reasons for this are to be found in improvement in fixing the indications,' 
 a proper technique, and asepsis and antisepsis. During the past fifteen years 
 I have had exceptional opportunities to test every variety of embryotomy upon 
 the dead fetus in the Bellevue Hospital maternity service. To this service 
 are brought every year cases of neglected prolapsed cord, impacted shoulder 
 presentation, hydrocephalus, persistent occipito-posterior positions, persistent 
 mento-posterior positions, monsters, eclampsia, and pelvic contraction, which 
 have been abandoned by midwives and physicians. It is from this extended 
 clinical experience in the operating room, and not from laboratory or theoretical 
 deductions, that I can speak of the comparative innocuousness of embryotomy, 
 when properly performed and when the pelvis is not absolutely contracted. 
 In the forties it was customary at the Dublin Rotunda Hospital to end about 
 
EMBRYOTOMY IN GENERAL. 943 
 
 one labor in loo by embryotomy. In hospital practice in Germany in the 
 seventies and eighties there was one embryotomy in every 300 to 500 labors; 
 while in private practice the proportion was about 1:1500. In 2200 hospital 
 cases of confinement I find a record of six embryotomies. The indications 
 were as follows: Deformed pelves, 2; hydrocephalus, 2; albuminuria, i; epi- 
 lepsy, I. All the operations were examples of craniotomy. The maternal 
 mortality was o per cent. 
 
 Indications. — Embryotomy is indicated to-day in but two conditions. 
 First, in all instances in which the fetus is dead and delivery of the unmutilated 
 fetus would increase the danger for the mother. Second, upon the living fetus 
 in obstructed labor due to monstrosity; and in exceptional cases in which the 
 mother's condition, from hemorrhage, repeated attempts at delivery, sepsis, 
 or shock, is such as to render embryotomy by far the safer operation. 
 
 Although modern obstetrics demands that embryotomy upon the living 
 fetus shall, with the two above exceptions, never be performed, still two cir- 
 cumstances may greatly embarrass the physician in the performance of what 
 is clearly his duty. One is the refusal of the mother and her family to accept 
 Cesarean section in the presence of the relative indication, and the other is the 
 varied conditions of environment under which the physician and patient are 
 often placed. In the city or town a physician can refuse to perform embry- 
 otomy upon a living fetus, as there are always competent practitioners at hand 
 to whom the case can be transferred. In the sparsely settled country districts 
 the physician is occasionally brought face to face with an obstetric complica- 
 tion which demands an immediate operation in order to save the mother's life. 
 I know of several such cases. One was in the mountains of northern New York, 
 in which, during a three-day blizzard, a physician was unable to secure assist- 
 ance in a case of maternal dystocia from a generally contracted pelvis, and 
 was compelled to do an embryotomy to save the life of the mother. Who can 
 say that embryotomy under such circumstances was criminal? This same 
 case was subsequently, in her second pregnancy, sent to me in New York, and 
 I delivered her of a living child. Some practitioners who repudiate the opera- 
 tion of embryotomy propose that one shall wait for the fetus to die from birth- 
 pressure, in order that the operation can be performed without compunction. 
 This is a hazardous and possibly a fatal concession. For therapeutic feticide 
 see page 888. 
 
 Embryotomy upon the Dead Fetus. — Embryotomy upon the dead fetus is de- 
 manded when, the absolute indication for Cesarean section being absent, the 
 extraction of the fetus, undiminished in size, would increase the dangers to the 
 mother. 
 
 1. This indication includes moderate degrees of pelvic contraction, malpres- 
 entations and malpositions, deformities of the fetus, and slight obstruction in 
 the soft parts. 
 
 2. In markedly contracted pelves, with a transverse diameter at the inlet of 
 at least 3 inches and a true conjugate but little under 2 J inches, embryotomy 
 will be indicated. 
 
 3. In instances in which the conjugata vera is much under 2I inches, when 
 labor is obstructed by a fixed pelvic tumor, an extensive exostosis, or an ad- 
 vanced cancer of the cervix, celiotomy is to be preferred, whether the fetus is 
 dead or alive. 
 
 4. When the mother's condition demands rapid delivery, and the absolute 
 indication for Caesarean section is absent. 
 
 Embryotomy ttpon the Living Fetus. — i. Embryotomy upon the living fetus 
 
944 OBSTETRIC SURGERY. 
 
 is indicated during labor in certain rare instances, when the condition of the 
 mother, as shown by the temperature, pulse, dangerous thinning of the lower 
 uterine segment, whether from repeated unsuccessful attempts at delivery or 
 from prolonged labor, would render embryotomy by far the safer operation. 
 2. In obstructed labor due to monstrosities. 
 
 XV. PERFORATION. 
 
 Definition.^-Perforation consists in opening the fetal skull, incising the 
 meninges and brain in various directions, and removing the latter by irrigation. 
 Perforation of the fetal pelvis through the anus is occasionally performed. 
 
 Indications. — (See Embryotomy, page 942.) 
 
 Operation. — In most cases, if only for ethical reasons, an anesthetic should be 
 given. The patient should, of course, not be allowed to see the child. The 
 bladder and rectum should be emptied and the vagina properly cleansed with 
 lysol or creolin. The patient should be in the lithotomy position with the hips 
 drawn well over the edge of a table. The operator should now make a careful 
 
 Fig. 1137. — Smellie's Scissors Perforator. 
 
 examination in order to confirm the necessity for the operation. Three types 
 of perforator are in use: namely, the scissors (Fig. 1137); the screw with the 
 hidden knife; and the trephine perforator. In an emergency almost any cut- 
 ting instrument can be used; thus, twice in consultation I have opened the skull 
 without a classical perforator, once using an ordinary pair of scissors, and again a 
 scalpel. Before perforating, especially in high positions of the presenting part, the 
 head should be firmly fixed. This is done either by suprapubic pressure or by fixa- 
 tion with a strong volsella forceps. I prefer the latter (Fig. 1139). A principle in 
 perforation too often neglected and misrepresented in many works on obstetrics is 
 the proper location of the opening into the skull. Our aim should, always be so 
 to locate this opening that subsequent traction with the cranioclast (cranio- 
 traction) will imitate the natural mechanism of labor. I have records of a 
 number of cases in which craniotraction has been made with the cranioclast 
 applied over the forehead and face in vertex presentation, thus extending the 
 head and causing impaction even after perforation; and over the forehead and 
 sinciput in face presentation, thus flexing a greater diameter into the birth 
 canal; and over the occiput in head-last cases, producing the same result. In 
 all instances care must be taken to introduce the perforator deep enough into 
 the skull thoroughl}^ to break up the base of the brain and the medulla, for 
 possibly a mistaken diagnosis may result in the extraction of a mutilated child 
 
PERFORATION. 
 
 945 
 
 making attempts at respiration, than which no greater horror exists in mid- 
 wifery. The fetal scalp being seized by a volsella forceps and the head drawn 
 downward into the pelvis as far as pos- 
 sible, an assistant grasps the head 
 through the abdominal walls and fixes 
 it in the pelvic inlet. The fingers of 
 the left hand are carried up behind the 
 symphysis and their palmar surfaces 
 guide the introduction and subse- 
 quent movements of the perforator, 
 which is inserted with the right hand 
 and carried slowly and cautiously by 
 a twisting or boring movement 
 through the fetal skull. A suture or 
 fontanelle may be utilized, but it is 
 better, except in simple cases, to make 
 the opening in one of the cranial bones, 
 since in the latter case it is not so likely 
 to become closed and difficult to find 
 again. Every care should be taken 
 that the instrument does not slip and 
 bury itself in the maternal tissues. 
 After the perforator has entered the 
 skull as far as the shoulders of the in- 
 strument it should be twisted about 
 several times in order to enlarge the 
 opening. The blades may also be sep- 
 arated in different directions for the 
 same purpose. It is then carried into 
 
 the skull and twisted in every direction in order to break up the brain and facil- 
 itate its removal. If the trephine perforator is used, it is held against the skull 
 
 by the fingers of the left 
 hand, the right hand steady- 
 ing the shank of the instru- 
 ment. The crank is turned 
 by an assistant. Whatever 
 instrument is used, care 
 should be taken to remove 
 with the forceps all spiculae 
 of bone, and the scalp 
 should, if possible, be made 
 to cover the edges of the 
 opening in order to protect 
 the maternal tissues. The 
 cranial contents are then 
 washed out as far as possible 
 by means of a flexible tube 
 or catheter attached to a 
 syringe. The ordinary foun- 
 tain syringe will be found 
 useful. An antiseptic solution should be used, and in the case of a putrid fetus 
 the vagina should be frequently douched during the whole operation. If perfor- 
 60 
 
 Fig. 
 
 1 138. — Perforation of the After- 
 coming Head. 
 
 Fig. 1 139. — Perforation of the Fetal Skull. 
 
946 OBSTETRIC SURGERY. 
 
 ation and evacuation of the cranial contents do not reduce the size of the fetal 
 head sufficiently to permit safe delivery, it ma}' be necessary to resort to the 
 additional operation of cranioclasm or craniotripsy (pages 947 and 951). 
 
 Pelvic Presentation. — Perforation may occasionally, in contracted pelves 
 and with monsters, be applied with advantage to the breech if it fails to descend, 
 and traction with the forceps, fillet, blunt hook, or upon a prolapsed leg is impos- 
 sible or dangerous. An opening is made by way of the anus through the fetal 
 pelvis and the abdominal contents are " churned up " and removed by irrigation 
 (Fig. II47)- 
 
 After-coming Head (Fig. 1146). — Three sites for perforation are pro- 
 posed by different authorities, namely, the posterior lateral fontanelle behind 
 the ear, the occipital bone, and the fioor and roof of the mouth through 
 the hard palate. Many lives have been sacrificed by unskilful and prolonged 
 attempts to perforate and extract after opening the brain in the first two 
 localities, since extension of the head results, and the obstruction is often thus 
 increased instead of diminished. In most cases the after-coming head should be 
 perforated through the floor and roof of the mouth, then through the hard palate 
 into the brain. The head can then be extracted by flexing it. In those very rare 
 cases in which the chin rides up over the symphysis and cannot be gotten at, 
 the head must be delivered by extension after perforation through the occipital 
 bone. 
 
 Vertex Presentation (Figs. 1143, 1145)- — Both in occipito-anterior and 
 -posterior positions it is best to perforate toward the occipital end of the head- 
 lever, so that subsequent traction will flex rather than extend the head. If 
 cutting instruments are used, I have found that it makes little difference whether 
 a suture, fontanelle, or solid bone is selected for perforation; if the trephine is 
 used, a bone, preferably the posterior portion of a parietal, is selected. 
 
 Bregma Presentation. — It is best to return the head to its natural condition 
 of flexion, or if this is impossible to perforate as near the occipital bone as pos- 
 sible (Fig. 1143)- 
 
 Brow Presentation. — If the brow cannot be converted into a vertex and 
 perforated accordingly, it should, if possible, be changed into a face. If impac- 
 tion persists, the perforation should be made at the junction of the nasal and 
 frontal bones. 
 
 Face Presentation (Fig. 1144). — Perforation at the root of the nose 
 through the frontal bone gives the best results for subsequent craniotraction. 
 
 XVI. RACHIDOTOMY. 
 
 This operation consists in making a slight opening in the vertebral canal. 
 The operation was proposed by Van Heuvel in 1848, but was not carried out until 
 twenty years later by Tamier. Rachidotomy is employed only when a hydro- 
 cephalic fetus presents by the breech with retention of the head. The operation 
 has been used to some extent by Tamier and his pupils. Failure can occur only 
 through a disorganized state of the spinal column as a result of excessive trac- 
 tion. 
 
 Technique, — An incision is made down to the middle of the vertebral column. 
 A sound provided with a mandril is then forced through the vertebrae and thrust 
 into the spinal canal from below upward till it reaches the cranial cavity, when 
 the liquid is allowed to drain away. 
 
CRANIOCLASIS. CRANIOTRACTION. 
 
 947 
 
 XVII. CRANIOCLASIS. CRANIOTRACTION. 
 
 Definition. — Cranioclasis signifies the crushing or comminuting of the bones 
 of the skull within the scalp and without removing them. The operation is per- 
 formed with an instrument known as a cranioclast, of which Karl Braun's is 
 to-day the most perfect type. Others are Kehrer's, Simpson's, and Auvard's. 
 The cranioclast is not only a crusher but a tractor; thus, when the fetal skull is 
 securely seized by the two blades of the instrument it serves as a most convenient 
 handle to extract the head and fetal body. To-day perforation and cranio- 
 clasis are usually immediately followed by extraction, with the cranioclast as a 
 tractor. The procedure then becomes craniotraction. 
 
 Indications. — (See Embryotomy, page 942.) 
 
 Necessary Conditions. — (i) The pelvis must not be so greatly contracted that 
 the fetal trunk cannot pass. A true conjugate of over 2^ inches (6.5 cm.) is 
 necessary at full term. I believe it is generally conceded that cranioclasis 
 and extraction through a pelvis represented by a conjugata vera of 2+ inches 
 (6.5 cm.) or under is equally as dangerous as Cassarean section. (2) In difficult 
 
 Fig. 1 140. — Braun's Cranioclast. 
 
 trunk extractions the operator should never neglect to do, in addition, a clei- 
 dotomy — an operation much neglected in these cases. 
 
 Operation. — Instruments. — The original cranioclast, the device of Sir James 
 Y. Simpson, was an evolution of the ancient craniotomy forceps and was in- 
 tended by him to replace the cephalotribe. (See page 947.) It was proposed with 
 this instrument, the solid blade of which was introduced into the perforated skull 
 and the fenestrated blade upon the anterior portion of the skull, to wrench off the 
 bones of the calvarium, different portions being successively seized, and subse- 
 quently to use the instrument as a tractor to deliver the remainder of the skull. 
 Braun's cranioclast is intended to act primarily as a tractor and never as a bone 
 forceps to break up and remove the vault of the skull. The instrument as sup- 
 plied to-day by the makers consists of an exaggerated bone forceps made entirely 
 of metal with a cephalic curve to the blades and the shanks and handle so long 
 that the lock is outside the vulva even when the instrument is introduced high up 
 (Fig. 1 140). A hand-screw at the end of the handles aids compression. The 
 blades, as in the Simpson's cranioclast, consist of a larger or outer blade, fen- 
 estrated and grooved, which goes on the outer surface of the head over the scalp, 
 and a smaller or inner blade, solid and supplied with ridges which fat into the 
 grooves upon the opposite or outer blade. Although Braun's cranioclast pri- 
 marily was intended as a tractor alone, still I have found it most valuable as a com- 
 minuter of the bones of the calvarium by applying the instrument successively 
 
948 
 
 OBSTETRIC SURGERY. 
 
 over different portions of the perforated skull and crushing the bones underneath 
 the scalp without attempting to remove the fragments, but bringing all away 
 when the instrument is used as a tractor. The term " cranioclast " as applied to 
 the Braun instrument is a misnomer, and the term "craniotractor," as proposed 
 by Mund^, of New York, as a substitute for "cranioclast," is more accurate. 
 
 Application. — The application of the cranioclast is not difficult. Unfortu- 
 nately, for some reason the instrument is always made for application upon the 
 right side of the pelvis, and for proper application upon the left side — the most 
 frequent operation — the instrument must be reversed, with the button-lock down- 
 ward. This has caused much confusion to the novice and beginner, and many 
 applications of the instrument over the face, when a vertex application would 
 have rendered the extraction much easier. After perforation and the washing 
 
 away of the brain, if the head is movable the 
 scalp is seized with strong volsella forceps and 
 held by an assistant. The operator then in- 
 troduces two fingers of the left hand to the 
 margin of the opening in the fetal skull, and 
 with the right hand he grasps the inner or 
 
 Fig 1 141. — Elongation of the Fig. 1142. — Depression in the Right Parietal 
 
 Head after Perforation and Bone, Caused by Extraction with Braun's 
 
 the Use of the Cranioclast. — Cranioclast. — {Author's collection 0} fetal skulls.) 
 (Author's case.) 
 
 solid blade of the cranioclast like the blade of a forceps and introduces it 
 along the fingers of the left hand as a guide into the opening in the skull. 
 The handle is then held by an. assistant. Now if the portion to be seized 
 is along the left side of the pelvis, the outer or fenestrated blade is seized 
 like the blade of a forceps with the left hand, the right hand is passed into the 
 vagina, and the fenestrated blade is then introduced along the fingers of the 
 right hand between the fetal skull and the wall of the parturient canal, care being 
 taken not to include the cervix, an accident of not rare occurrence. In application 
 in the left half of the pelvis the fenestrated blade must be introduced under the 
 solid blade, so that the lock looks downward. The handles are now taken one in 
 each hand and the lock is adjusted and compression is made with the screw on the 
 handle, care being taken that none of the maternal parts are included in the 
 instrument and that the solid blade is well sunken in the cavity of the skull. 
 Rotation of the presenting part with the cranioclast is a subject still in dispute. 
 
CRANIOCLASIS. CRANIOTRACTION. 949 
 
 A twisting corkscrew-like motion with the instrument, as recommended by some 
 operators, I have found unnecessary and dangerous, since spiculae of bone do 
 occasionally in difiEicult cases perforate the skull, and these readily lacerate the 
 adjacent maternal soft parts, and the operator is not always able to detect these 
 perforations of the scalp. Rotation with the instrument, however, in order to 
 bring the vertex or chin anteriorly is permissible and advisable, as in forceps 
 operations. In ordinary cases reapplication of the instrument and comminution 
 of the bones will not be found necessary. Traction is now cautiously made in 
 the axis of that portion of the pelvis in which the head or breech lies, and if no 
 slipping of the instrument occurs, the amount of traction is gradually increased 
 so as to cause the perforated skull to mold itself to the shape of the pelvis, and 
 to bring the cranioclast away from the side of the parturient tract into the 
 middle of the pelvis. 
 
 Left Vertex Positions. — The cranioclast should be applied so as to include 
 the occipital bone (Fig. 1143). 
 
 Right Vertex Positions. — As in left positions, the best result is obtained 
 by application over the occipital bone. 
 
 Bregma Presentation. — The best results are obtained by grasping the 
 occipital end of the head-lever and if necessary rotating the occiput with 
 the cranioclast to the front of the pelvic outlet (Fig. 1143). 
 
 Brow Presentation. — If the brow cannot be converted into a vertex, the 
 cranioclast is applied as in face presentation (Fig. 1144). 
 
 Face Presentation. — The solid blade is passed into the skull through 
 an opening in the frontal bone at the root of the nose, and the fenes- 
 trated blade is made to include the lower jaw (Fig. 1144). The other two 
 sites of application — namely, the sides of the head and the occipital region — 
 are always, if possible, to be avoided. (See Perforation, page 944.) 
 
 After-coming Head. — Application of the solid blade through a perforation 
 passing up through the floor and roof of the mouth (hard palate) and the fen- 
 estrated blade over the face will give the best prognosis, as flexion of the head is 
 thereby insured (Fig. 1146). In exceptional cases in which the chin rides up 
 over the symphysis, the occipital application and delivery of the head by ex- 
 tension may become necessary. 
 
 Breech Presentation. — The solid blade is passed into the anus and the fen- 
 estrated blade is applied over the sacrum (Fig. 1147). 
 
 Persistent or Permanent Occipito-posterior Position (Fig. 1145). — Our 
 aim should be to secure a firm hold with the instrument over the occipital bone in 
 order to exaggerate, if possible, the existing flexion of the head. The solid blade 
 enters the skull at or near the small fontanelle, and the fenestrated blade, if pos- 
 sible, is adjusted over the center of the occipital bone, which latter, of course, is in 
 the hollow of the sacrum. In difficult cases an application made to the side of the 
 head over a limb of the lambdoidal suture will be found necessary on account of 
 the difficulty in applying the instrument in the sacral hollow over a tightly fit- 
 ting head. Less injury to the maternal soft parts will result if we can gradually 
 with our downward traction rotate the occiput into an anterior position. This 
 rotation of the head with the cranioclast is, under such circumstances, not only 
 justifiable but advisable, as by so doing a mechanism of labor much more favor- 
 able for the maternal prognosis is obtained. Great caution should be exer- 
 cised, should it be found necessary, after failure of anterior rotation, to deliver 
 with the occiput to the rear. This with full-sized heads should never be at- 
 tempted until after the head has been well elongated with the cranioclast, and, if 
 thought necessary, comminuted as well (Fig. 1141). 
 
950 
 
 OBSTETRIC SURGERY. 
 
 Fig. 1 143. — Application and Use of the 
 Cranioclast in a Left Occipito-pos- 
 TERioR Position of the Vertex.' 
 
 Fig. 1144. — Application and Use of the 
 Cranioclast in a Right Menio-pos- 
 terior Position of the Face. 
 
 Fig. 1 145. — Application and Use of the 
 Cranioclast in a Persistent Occipj- 
 to-posterior Position. 
 
 Fig. 1 146. — Application and Use of the 
 Cranioclast in Case of an After- 
 coming Head. 
 
 Pig. 1 147. — Cranioclast Applied to the 
 Breech, in Left Sacro anterior Posi- 
 tion. 
 
 Fig. 1148. — Application of the Cranio- 
 clast to the Decapitated Head in 
 Utero. 
 
CEPHALOTRIPSY. 
 
 951 
 
 Persistent Mento-posterior Position (Fig. 1144). — No matter how great 
 the temptation to apply thecranioclast over the forehead, this should alwavs be 
 avoided in face presentation, and the instrument applied to the chin end of the 
 presenting lever. This can be accomplished by passing the solid blade into an 
 opening at the root of the nose, and applying the fenestrated blade so as to include 
 the lower jaw (Fig. 1144). This, as in permanent occipito-posterior position, 
 necessitates the adjustment of the fenestrated blade in the hollow of the sacrum, a 
 manoeuver sometimes attended with much difficulty. Under such circum- 
 stances a compromise may be made by adjusting the outer blade at the posterior 
 extremity of an oblique diameter of the pelvis, and over a lateral angle of the jaw. 
 
 As already hinted at under " Perforation," the great principle in cranioclasis 
 or craniotraction is so to apply the instrument and so to make traction that the 
 normal mechanism of labor shall be imitated as closely as possible In othei 
 words, traction should be made so that the portion of the presenting part which is 
 naturally lowest tinder normal conditions shall be kept lowest in the pelvis and 
 delivered first, as in spontaneous delivery. This principle is often, if not always, 
 lost sight of; and because, as is well known, a firmer hold with the instrument can 
 be secured over the facial bones, or over the side of the skull over an ear, some 
 operators persist in using only these two localities, with an entire disregard of 
 the mechanism of labor, thus giving rise 10 serious, and, as I have seen, fatal com- 
 plications 
 
 XVIII. CEPHALOTRIPSY. 
 
 Definition. — Cephalotripsy is the crushing of the presenting part by an in- 
 strument resembling the obstetric forceps. In 1829 Baudelocque* invented an 
 instrument patterned somewhat after the obstetric forceps, which he designed for 
 crushing the fetal head by grasping it in the same manner as does the obstetric 
 forceps, and without previous perforation to force the brain from the mouth. 
 
 Fig. 1 149. — Cephalotribe Applied at the Sides of the Head. Side View. 
 
 orbits, and nose, crushing the cranial bones within an intact scalp, and thus pre- 
 venting edges of fractured bones from doing injury to the maternal soft parts. 
 In the early years of its use the cephalotribe was intended to abolish the per- 
 forator, the craniotomy (bone) forceps, and the crotchet. The cephalotribe was 
 originally intended only to crush the skull, just as the cranioclast is to-day really 
 an instrument designed for traction. To-day the cephalotribe is used both as a 
 crusher and a tractor. 
 
 *A. Baudelocque: " Revue M6d.," August, 1S29, p. 321. 
 
952 
 
 OBSTETRIC SURGERY. 
 
 Indications. — All forms of cephalotribe, but especially the broad-bladed type, 
 are useful to compress the head after perforation before it becomes fixed at the 
 brim. As a tractor after perforation in the lesser degrees of obstructed labor it is 
 also most valuable. A limit for the safe employment of the cephalotribe exists, 
 however — namely, in pelvic contraction when the clinical index of the pelvis is 
 represented by a conjugata vera of three inches the safe 
 limit is reached. Much depends, moreover, upon the 
 size of the fetal head and the resiliency of the cranial 
 bones. To-day the use of the cephalotribe is mainly 
 limited to a crushing of the head or breech before the 
 application of the cranioclast for purposes of traction, 
 and to crushing and extracting the base of the skull in the 
 exceptional cases in which the cranioclast has slipped and 
 torn away the vault of the 
 skull. In such cases the ceph- 
 alotribe is most useful to 
 secure a firm hold on the base 
 of the skull, to crush it, and 
 as a tractor to extract the 
 fetus. Practically this is the 
 only way the cephalotribe is 
 to-day used by most oper- 
 ators. Some operators still 
 follow perforation with the 
 application of the cephalo- 
 tribe as a crusher and an ex- 
 tractor, but for the latter pur- 
 pose the cranioclast is far 
 superior. 
 
 Cranioclast and Cephalo- 
 tribe Compared. — (i) The cephalotribe is bulkier and 
 heavier than the cranioclast and occupies more room 
 in the pelvis than the latter instrument, a great dis- 
 advantage in contracted pelves. (2) Both blades of 
 the cephalotribe lie outside the fetal skull, and unless 
 the narrow- bladed instrument is used — and this is very 
 liable to slip — they do not sink into the scalp as does 
 the outer blade of the cranioclast. On the other hand, 
 one blade of the cranioclast is hidden in the cranial 
 cavity not otherwise occupied, and the outer fenes- 
 trated blade soon sinks into the scalp and thus avoids 
 injury to the maternal soft parts. Further, after a short 
 period of traction with the cranioclast, the instrument, 
 if properly applied, comes to occupy the middle of the 
 pelvis, where it can be kept with the left hand from 
 contact with the maternal parts. (3) Traction with 
 the cranioclast as the head is being drawn through 
 the pelvis exerts an even pressure on all points of the 
 circumference of the parturient tract, finally elongat- 
 ing the fetal head, thus diminishing all the presenting diameters and even render- 
 ing the extraction easier as traction is continued. Extensive lacerations and in- 
 juries to the maternal soft parts are of rare occurrence after cranioclasis and 
 
 Fig. 1150. — Cephalo- 
 tribe Applied at the 
 Sides of the Head. 
 Anterior View. 
 
 Fig. 1151. — Breisky's 
 Broad-bladed Ceph- 
 alotribe. 
 
CEPHALOTRIPSY. 
 
 953 
 
 craniotraction. On the other hand, compression of the head with the cephalo- 
 tribe diminishes only one diameter, the compressed one, and correspondingly in- 
 creases the opposite ones — namely, those non-compressed (Figs. 1149 and 1150). 
 As the head is being drawn through the pelvis, pressure is thus concentrated at 
 two points of the parturient tract instead of being diffused over the entire cir- 
 cumference; thus preventing elongation of the head as in craniotraction, and 
 rendering the extraction more difficult and liable to injure the maternal parts. 
 (4) As a rule, the cranioclast takes a firmer hold of the fetal head than does the 
 cephalotribe, but T have seen many exceptions. 
 
 Instruments. — Practically there are two types of the cephalotribe in use to- 
 day — namely, the narrow or solid-bladed, and the broad or fenestrated-bladed in- 
 struments. Among the narrow or solid-bladed instruments are Blot's and Scan- 
 zoni's. Among the broad or fenestrated-bladed cephalotribes are Breisky's (Fig. 
 1 151) and its many modifications. Olshausen's cephalotribe (Fig. 11 52) is an ex- 
 cellent example of the narrow solid-bladed instrument, and Breisky's of the broad 
 fenestrated. All of the former are provided with a generous pelvic curve, but the 
 cephalic curve is absent in some, as the blades are in close apposition. In the 
 latter type cf instrument, provision is made for both a pelvic and a cephalic curve: 
 
 Fig. 
 
 -Olshausen's Narrow-bladed Cephalotribe. 
 
 the pelvic being 3^ inches (8.2 cm.) in extent, and the cephalic 2j inches (5.7 
 cm.), measured from the outer surfaces of the blades. A serious objection 
 exists to each type of cephalotribe, neither of which obtains in the case of 
 the cranioclast — namely, the narrow-bladed cephalotribes, whether they possess 
 cephalic carves or not, are liable to slip, and the broad type occupies too much 
 room in the pelvis, especially when the latter is contracted. 
 
 Operations. — The principles governing the application of the cephalotribe are 
 precisely the same as in the case of forceps. Following perforation, projecting 
 spiculas of bone must be carefully extracted with the fingers or dressing forceps 
 and the exact presentation and position again determined. 
 
 High Cephalotribe Operation (Fig. 1153). — When the head or breech is 
 still free above the pelvic inlet, great care must be taken to have the presenting 
 part firmly held at the inlet by suprapubic pressure by an assistant. Adap- 
 tation of the cephalotribe to the sides of the fetal head at the pelvic inlet is not 
 safe, or in fact necessary. Objection has been raised to the use of the cephalo- 
 tribe here, that seizing the head antero-posteriorly increases the transverse 
 diameters to an equal extent, and that this would be particularly disadvanta- 
 geous, especially in contracted pelves (Figs. 1149 and 11 50). This would be 
 
954 
 
 OBSTETRIC SURGERY. 
 
 Fig. 
 
 1 153. — Broad-bladed Cephalotribe Applied in Ver- 
 tex Presentation. Median Operation. 
 
 true were the head fixed transversely in the pelvis, but when the head is 
 free it will be found in an oblique diameter, and the cephalotribe seizes 
 the bead in the opposite oblique and not in an antero-posterior diameter. 
 Compensation of head compression thus takes place in an oblique diameter op- 
 posite to the one grasped by the instrument and not in a transverse diameter of 
 the head. Should, by chance, the head be seized in a transverse diameter, rotation 
 
 of the head with the 
 cephalotribe into an ob- 
 lique diameter can read- 
 ily be accomplished. 
 Dragging of a head or 
 breech through the pel- 
 vic inlet with so heavy 
 and powerful an instru- 
 ment as the cephalo- 
 tribe should rarely be 
 attempted, because of 
 the danger of pressure 
 of the blades upon the 
 maternal soft parts be- 
 tween the symphysis 
 and sacral promontory. 
 Should antero-posterior 
 adaptation occur, either 
 spontaneously or arti- 
 ficially, the instrument 
 must be removed and 
 reapplied in a transverse 
 or an oblique diameter, 
 or, better, the cranio- 
 clast substituted. Com- 
 pression with the hand- 
 screw should always be 
 slow, and repeated digi- 
 tal explorations should 
 be made to detect pro- 
 jecting spiculae of bone. 
 Low Cephalotribe 
 Operation. — The left 
 or lower blade is first in- 
 troduced at the extrem- 
 ity of the transverse or 
 oblique pelvic diameter 
 according to the posi- 
 tion of the presenting 
 part, followed by the application of the right or upper blade; great care being 
 used not to injure the uterine or vaginal tissues. As in high operations, com- 
 pression is made slowly with the hand-screw, on the lookout digitally for bone 
 spiculae. and during extraction the instrument is guided and the maternal parts 
 are protected by the fingers of the left hand (Figs. 1153 and 1155). 
 
 Cephalotribe to the Breech. — The same general principles apply here as in 
 head presentations, namely, to keep the instrument in an oblique or transverse 
 diameter of the pelvis (Fig. 1154). 
 
 Fig. 1154. — Broad-bladed Cephalotribe Applied to the 
 Breech. 
 
 Fig. 1 155. — Narrow-bladed Cephalotribe Applied to 
 Vertex. Low Operation. 
 
DECAPITATION, 955 
 
 After-coming Head. — Although some authorities (Lusk) do not consider 
 perforation necessary as a preliminary, still perforation through the floor and 
 roof of the mouth before the application of the instrument will be found to 
 prevent many maternal injuries. 
 
 Decapitated Head. — In instances of detachment of the fetal head from the 
 body and the retention of the former in the uterine cavity the cephalotribe will 
 often prove of use in its extraction. The head must be steadied at the inlet with 
 suprapubic pressure by an assistant, and I prefer to grasp the scalp or face from 
 below with a strong volsella forceps as well, and then apply the cephalotribe to 
 crush and extract. 
 
 Substitutes for Cranioclasis and Cephalotripsy. — Although great ingenuity has 
 been exerted to invent other and more satisfactory substitutes for the operations 
 of cranioclasis and cephalotripsy, still in spite of the shortcomings and defective- 
 ness of these latter measures for diminishing the size of the fetal head and breech, 
 most obstetric surgeons are agreed that these operations are at the present 
 time the best we have at our command. Craniotomy: This was the original 
 and now practically obsolete method of diminishing the size of the fetal skull, 
 and brought into use various forms of craniotomy forceps. After perforation and 
 removal of the brain, one of these bone forceps was introduced under the scalp 
 and the parietal, occipital, and frontal bones were seized and broken away piece- 
 meal by a twisting movement of the wrist. The operation was tedious and dan- 
 gerous, for unless the maternal soft parts were carefully guarded the withdrawal 
 of the sharp fractured bones caused dangerous lacerations. The craniotomy for- 
 ceps of Meigs and Taylor, which were nothing more than heavy bone forceps, 
 were at one time generally used in this country. Inquiry of the largest instru- 
 ment-makers in New York city shows that the demand for craniotomy forceps 
 has practically ceased. Cephalotomy: It has been proposed either to remove 
 the fetal head in segments or to divide the skull into two halves. The forceps saw 
 of Van Huevel was intended to divide the head from vertex to base into two 
 halves* to remove from the head a triangular segment the apex of which should 
 include the bones at the base of the skull. The wire 6craseur has been applied to 
 successive portions of the head for the purpose of crushing, as suggested by 
 Barnes, of London. f Hubert invented a transforateur which was intended to 
 bore through and break up the sphenoid bone, and thus diminish the resistance of 
 the base of the skull. Instruments which combined the principles of the trans- 
 forateur and the cephalotribe were invented by Valette, Huter, and Solline, and 
 were termed 'sphenotribes." To-day I know of no operation of cephalotomy that 
 for effectiveness and safety can successfully compete with cranioclasis. The 
 mechanical principles involved in many of the proposed cephalotomy procedures 
 are in the main correct, but the instruments are complicated, and some of them 
 are too bulky to be used with advantage in cases of pelvic contraction. 
 
 XIX. DECAPITATION. 
 
 Definition. — A separation within the uterus of the fetal head from its trunk. 
 
 Indications. — Infrequently in neglected impacted shoulder presentations 
 division of the fetal head from the body is demanded in order to break up the 
 triangular wedge which blocks the pelvis; dividing, so to speak, the wedge in two 
 
 * " Diet, de Medecine et de 'Chirugie," Art. " Embryotomie," page 6So. 
 t "Obstetric Operations," page 411. 
 
956 
 
 OBSTETRIC SURGERY. 
 
 f%. 
 
 parts, thus permitting the delivery first of the fetal body and subsequently of 
 the head. The indications are thus almost exclusively in neglected impacted 
 
 shoulder presentation, in which at- 
 tempts at any form of version to 
 correct the malpresentation would 
 jeopardize the already dangerously 
 thinned lower uterine segment. The 
 pelvis must have a true conjugate of 
 at least zf inches (nearly 7 cm.), and 
 full dilatation of the cervix must be 
 present or secured artificially. 
 
 Operation. — Various forms of de- 
 capitators are in use, ranging from a 
 simple whip-cord decapitator to most 
 complicated and expensive embryo- 
 tomes made up of many parts. All 
 types of decapitators may be in- 
 cluded among the following: (i) Karl 
 Braun's blunt hook; (2) Schultze's 
 sickle hook; (3) scissors; (4) the wire 
 ecraseur; (5) various embryotomes, 
 notably those of Pierre Thomas and 
 M. Tarnier; (6) the chain-saw; (7) the 
 whip-cord. In default of special in- 
 struments, a wire or a strong cord may 
 be passed around the fetal neck by 
 means of an English catheter or per- 
 forated blunt hook, and by a sawing 
 motion the neck may be divided The 
 chain-saw of the surgeons may be 
 adapted to the same purpose. Much 
 difficulty is often encountered in pass- 
 ing the cord, chain-saw, or wire of an 
 ecraseur over the neck, and ingenious 
 and complicated instruments have been invented to overcome the difficulty. 
 The simplest method is to thread a piece of bobbin two feet long into the end 
 of a No. 16 English catheter with stylet in place (Fig. 1109). A curve is next 
 
 Fig. 1 156. — Braun's 
 d e c a p itati n g 
 Hook. 
 
 Fig. 1157. — Decapi- 
 tating Sickle 
 Knife of Rams- 
 
 BOTHAM. 
 
 Fig. T158. — Dubois's Decapitating and General Embryotomy Scissors. 
 
 imparted to the catheter by placing it in warm water if necessary, and it is then 
 passed around the fetal neck. An end of the bobbin is caught with two fingers 
 
DECAPITATION. 
 
 967 
 
 -^rfr<«^^*9*._. 
 
 in the vagina or with dressing forceps, and the catheter is finally withdrawn with 
 the other end. The bobbin encircling the neck is used to drag up and around a 
 whip-cord or the wire or chain of an dcraseur. In the use of cord, wire, or chain 
 great care must be used to protect the maternal soft parts, and to make sure that 
 a portion of the cervix is not included in the instrument used. The choice of 
 instruments to-day usually lies between (i) Braun's blunt hook decollator (Fig. 
 1 156); (2) a stout pair of scissors, as Dubois's (Fig. 1158); (3) a curved knife- 
 edge hook, as Schultze's or Ramsbotham's (Fig. 1157). Perhaps nowhere more 
 than in obstetrics does tradition influence one in the choice of instruments and 
 operative procedure. For this reason the blunt decapitating hook of Braun is 
 described and recommended by each obstetric writer in turn. After many un- 
 prejudiced comparisons of the Braun hook with a strong pair of scissors and the 
 knife-edge hook, I am unable to 
 understand why one should prefer 
 such an awkward and unscientific 
 instrument as the first to either of 
 
 the latter. My choice of instru- , \ ~ 
 
 ments is for the scissors and sickle 
 knife. I rarely if ever use a Braun's 
 hook, except occasionally for 
 demonstration. The space occu- 
 pied by each of the three instru- 
 ments in a narrow pelvis is about 
 the same, the choice, if any, being 
 in favor of the scissors. 
 
 I. Braun's Blunt Hook De- 
 collator (Figs. 1 156 and 11 59). — 
 This instrument is a modified blunt 
 hook with its end bent nearly at an 
 acute angle, flattened somewhat 
 from side to side, and terminating 
 in a blunt button shaped like the 
 end of a foil. The handle, formerly 
 of ebony but now cast in one piece 
 with the rest of the instrument, is 
 set at right angles, thus imparting 
 when grasped with the whole hand 
 a powerful leverage movement to 
 the hooked end. Operation: Every 
 instrument should be thoroughly 
 
 tested upon a piece of soft wood, such as pine kindling, before being put into 
 use, to avoid an unexpected break and to guard against injury to the soft parts 
 of the mother. Decapitation is usually performed in shoulder presentation, and 
 although, so far as I am aware, no text-book mentions the fact, still I have found 
 in practice that there is a distinct choice of hands to be iised in left and right 
 shoulder positions. In all cases if an arm is prolapsed, it is advisable to apply 
 a sling to it and have an assistant make firm traction on it to fix the shoulder 
 firmly in the pelvic inlet. In left shoulder positions it is advisable, if the operator 
 has sufficient control over his left hand, to encircle the fetal neck with the fingers 
 of the right hand, the thumb to the front of the neck, namely, in the anterior por- 
 tion of the pelvic inlet, in both anterior and posterior right shoulder positions, and 
 index and other fingers behind. The neck is then grasped firmly and with the aid 
 
 Fig. 
 
 1 159. — Method of Decapitating 
 Braun's Decapitating Hook. 
 
958 
 
 OBSTETRIC SURGERY. 
 
 of the prolapsed arm drawn down as far as possible into the pelvis. The hook of 
 the decollator is next carefully passed with the left hand behind the symphysis, 
 along the right thumb of the operator as a guide, and the button end of the hook 
 passed over the neck and received by the right index finger at the other side of 
 the neck and in the rear of the pelvis. The handle of the instrument is now 
 seized with the left hand and by a rotary motion of the instrument between the 
 index finger behind and the thumb in front, thus guarding the point at all times 
 as far as possible, the neck tissues, portion by portion, are seized by the button 
 point and twisted off until the spinal column is divided with the same rotary- 
 motion or by direct downward traction on the remaining soft tissues of the neck. 
 Separation of these last tissues by twisting and downward traction must not be 
 
 too sudden, lest the sudden freeing 
 of the hook penetrate the maternal 
 soft parts. This accident may be 
 avoided by care in the use of the 
 hook or by substituting a pair of 
 scissors or a sickle knife to divide 
 the last few shreds of tissue. In 
 right shoulder positions I have 
 found it most convenient to reverse 
 the position of the two hands of the 
 operator, using the left hand to en- 
 circle the neck and the right to ro- 
 tate the instrument. This is the 
 usual position of the shoulder illus- 
 trated in the text-books, whereas 
 the left scapulo-anterior is the most 
 common, and the use of the oper- 
 ator's hands in this position is thus 
 left to the imagination. 
 
 2. Sickle-Knife or Curved- 
 Saw Decapitators. — A more con- 
 venient and safer mode of decapita- 
 tion, even for the experienced oper- 
 ator, is a sickle knife (Figs. 1157, 
 1 160, and 1 161), or a decapitating 
 hook with serrated edge. I am ac- 
 customed to use the scissors in con- 
 junction with one of these instru- 
 ments to the exclusion of the un- 
 scientific and awkward Braun's 
 hook. Operation: Each instrument should be carefully tested before use. The 
 shoulder should be brought as low in the pelvic inlet as possible by traction with 
 a sling upon a prolapsed arm. In left shoulder positions we encircle the neck 
 with the right hand and with the left carry the decapitator up in front of the neck, 
 the point being directly toward the head when the level of the neck is reached, 
 pass the point over the neck and palpate behind with the internal or right fingers 
 to make sure that the instrument is properly adjusted over the fetal neck. The 
 point being guarded with the internal hand, the decapitator is now drawn firmly 
 downward and with a to-and-fro movement, as far as the vaginal outlet will per- 
 mit, the neck is quickly cut through (Fig. 1161). A common mistake with the 
 novice is, after the vertebrae are divided, to incline the plane of section into the 
 
 Fig. 1 160. — Method of Decapitating with De- 
 capitating Sickle Knife of Ramsbotham. 
 
DECAPITATION. 
 
 959 
 
 fetal body or shoulder instead of cutting through the remainder of the neck. Re- 
 peated palpation with the internal hand will prevent this error, which unneces- 
 sarily prolongs the operation. The last shreds of cervical tissue should not be too 
 suddenly divided lest the sudden release of the decapitator lacerate the maternal 
 soft parts. In right scapulo-positions the left fingers encircle the neck and the 
 decapitator is used in the right hand outside of the vulva. In both right and 
 left positions the point of the sickle knife or curved saw decapitator should be 
 pointed to the posterior part of the pelvis to avoid injury to the bladder, and 
 the handle during the pendulatory movement inclined as far forward as possible. 
 We thus, by cutting downward and forward, avoid injuring the rectum. 
 
 3. Decapitation with Blunt Scissors (Figs. 1158, 1162). — Although the 
 objection has been raised to the scissors decapitator that it is apt to wound the 
 maternal soft parts or the operator's fingers, yet this method after a little practice 
 
 Fig 1161. — Method of Holding the 
 Sickle-knife Decapitator. 
 
 Fig. 1 162. — Decapitating with Scissors. 
 
 on the manikin will usually prove a safe and rapid one and will be selected in pref- 
 erence to the Braun hook or curved knife or saw methods. Operation: The arm 
 is prolapsed as in the first two methods, and the choice of hands is the same. The 
 cutting should be done from below upward, the outer surface of the blunt points 
 being guided with the internal finger. Some difficulty may be experienced in 
 dividing the last few shreds of tissue at the upper part of the neck, and this can be 
 overcome by hooking the index-finger over the string of tissue, drawing it down 
 into the vagina, and cutting along the finger as a director. All the decapitating 
 scissors have a common fault, namely, the handles are too small, admitting only 
 one finger into each. In active use these fingers become bruised and numb bv 
 reason of the severe pressure to which they are subjected. To overcome this 
 objection I have had made both a straight and a curved pair of obstetric scis- 
 sors with handles to admit several fingers. These scissors are powerful and 
 
960 OBSTETRIC SURGERY. 
 
 convenient, and serve equally well for decapitation, eventration, amputations of 
 extremities, or spondylotomy. 
 
 Extraction after Decapitation. — Toward the end of the operation the fetal 
 head should be fixed at the pelvic inlet by suprapubic pressure by an assistant 
 (Fig. 1 1 67). The obstructing wedge should be broken up by the complete sever- 
 ing of the neck, when the fetal body 
 may be readily delivered by traction 
 upon the prolapsed arm. The head 
 X may possibly be delivered sponta- 
 
 ''■'.-, neously; it is best, however, not to 
 
 wait for uncertainty, but to pass the 
 hand up and manually deliver at once. 
 : ( I ) The stump of the vertebral column 
 
 --_ ,, should be palpated for sharp project- 
 
 ^*"'-- ing vertebrse, and if, as usually hap- 
 
 pens, none are present, two fingers are 
 "^V^ passed into the mouth and the thumb 
 
 over the base of the skull for counter- 
 
 ,>-- "^ pressure and the head is delivered 
 
 -^itP^ J manually in a face presentation (Fig. 
 
 \ ^^ ^ 1163). (2) If much resistance is met 
 
 "-"""""^ -"'i*^'''*^ with, the blunt hook or a crotchet, if 
 
 Fig. 1 163.— Manual Extraction of the one is at hand, may be substituted for 
 Decapitated Head. .-l. r- • , 1 ,1 / \ rr 
 
 the fingers m the mouth. (3) If a 
 
 sharp projecting vertebral stump ex- 
 ists, extraction in face presentation may dangerously lacerate the maternal soft 
 parts. It is then better either to extract the head vertex first with the forceps, or 
 to perforate the vertex and extract with a cranioclast (Fig. 1148), or with two 
 fingers wrapped with aseptic gauze and passed into the opening in the skull, and 
 the thumb over the occipital bone for counter-pressure. The gauze is to protect 
 the fingers from laceration by the cranial bones. (4) In contracted pelves, per- 
 foration and extraction with the cranioclast or cephalotribe should be the method 
 of election (Fig. 1148) 
 
 XX. EXENTERATION OR EVISCERATION. 
 
 By this is meant the opening of the thorax or abdomen, or of both, and the 
 removal of their contents. 
 
 Indications. — The most common indication is in case of shoulder presentation 
 in which decapitation fails or is impossible, especially when the head and neck are 
 so high above the pelvic inlet as to be difficult to reach. Evisceration is occasion- 
 ally demanded in cases of monsters after perforation, extraction of the head, 
 and cleidotomy, and of fetal tumors, as cystic kidney, ascites, or distended 
 bladder. 
 
 Operations. — The opening into the abdomen or thorax can be made with any 
 of the perforators, or with a straight or curved pair of Dubois scissors, whichever 
 is most convenient. No matter what instrument is used, the maternal parts 
 must be carefully guarded from injury ; and if the part to be perforated is at all 
 movable, it should be firmly grasped with stout volsella forceps and fixed at the 
 inlet by suprapubic pressure. When the chest is entered, it is advisable to secure 
 
AMPUTATION OF EXTREMITIES— CLEWOTOMY, 961 
 
 an ample and permanent opening either by enlarging the original opening made 
 with the perforator by turning the instrument so as to make a second incision at 
 right angles to the first, or, better still, by cutting away several segments of ribs 
 with the heavy Dubois scissors. The viscera are removed with strong volsella 
 forceps, first breaking them up, if necessary, with the perforator or scissors. In 
 shoulder presentation the abdominal cavity may be reached directly from the 
 thorax by perforating the diaphragm, and, again, in difficult breech extractions 
 the thorax can be opened from the abdomen by the same route. After eviscera- 
 tion in impacted shoulder presentation the simplest method of delivery should be 
 chosen, (i) Usually the reduced bulk of the fetus renders it easy and safe to 
 pass up the appropriate hand, seize the feet or head, and do an ordinary podalic 
 version without injury to the distended uterine segment or cervix, thus imitating 
 nature's method of spontaneous version. (2) Should difficulty be experienced, a 
 further operation of disjointing the spine with the Dubois scissors in the dorsal 
 region may be performed, and, the fetus being divided in halves, each half is 
 separately delivered. (3) In cases of macerated or small fetuses it will not be 
 necessary to divide the spine, but with a blunt hook the fetus may be doubled 
 upon itself and delivered in imitation of nature's method in spontaneous evolu- 
 tion. This method of delivery is facilitated by prolapse of an arm, for then 
 traction can be made upon both blunt hook and prolapsed arm at one and the 
 same time. Extraction after mutilation of the fetal soft parts requires no 
 special technique, as the reduction in size is supposed to be so thorough that 
 general principles will suffice. 
 
 XXI. AMPUTATION OF EXTREMITIES. 
 
 Only rarely is the obstetrician called upon to amputate an extremity or 
 several extremities. Possibly it may be demanded in cases of fetal monstrosities 
 and impaction of multiple presentations (page 558). The amputation is best 
 performed with the curved obstetric scissors. 
 
 XXII. CLEIDOTOMY. 
 
 Cleidotomy or division of both clavicles is an obstetric operation which has for 
 its object the diminution of the bisacromial diameter of the dead fetus, when the 
 shoulders obstruct its passage. This simple operation, rarely mentioned in the 
 text-books, has never, I believe, taken its proper place in obstetric surgery, as a 
 means of lessening maternal morbidity and mortality. How often we hear of in- 
 stances in which, after perforation and extraction of the fetal head in the case of a 
 generally contracted pelvis or outlet, or an excessively large child, twenty minutes 
 or more were spent in extraction of first one and then the other shoulder, thereby 
 adding perhaps to the already existing shock! As a matter of routine in these 
 cases I am accustomed to divide the clavicles, and it is amazing how the diminu- 
 tion of the bisacromial diameter thus produced renders the subsequent extrac- 
 tion of the fetal shoulders a comparatively easy task. In a number of instances 
 at the Emergency Hospital, in which birth of the head had been accomplished by 
 forceps or perforation and craniotraction, the shoulders resisting all ordinary 
 methods of extraction, the simple operation of cleidotomy completely changed the 
 clinical picture. From measurements taken at the bedside, and from experi- 
 - 61 
 
962 
 
 OBSTETRIC SURGERY. 
 
 ments upon fetal cadavers, I have found that the bisacromial diameter is in 
 cleidotomy readily reduced from 5 inches (12.7 cm.) to 3^ inches (8.89 cm.). 
 Figs. 1 165 and 1166 show a fetal cadaver, photographed on the same scale 
 before and after cleidotomv. 
 
 Fig. 1164. — The Oper.^tion of Cleidotomy, Performed with Long Curved Scissors. 
 
 V 
 
 -41 /n.. 
 
 Fig. 1165. — Fetal Cadaver before Clei- 
 dotomy. 
 
 Fig. 1 166. 
 
 -Fetal Cadaver after Clei- 
 dotomy. 
 
 Operation. — This is best performed with the curved obstetric scissors (Fig. 
 1 1 58), two fingers of the left hand being used to guide the blunt points to the 
 middle of each clavicle. It will usually be necessary to extend or fiex laterally 
 the fetal head strongly so as to give room for the use of the scissors. (Fig. 1 164.) 
 
EXPRESSION OF THE FETUS. 
 
 963 
 
 XXIII. SPONDYLOTOMY. 
 
 spondylotomy is an operation for dividing the spinal column of the fetus very 
 much as it is divided in decapitation, and has been recommended * as an alter- 
 native for the latter operation. The operation as well as the subsequent extrac- 
 tion requires more time and is more difficult than decapitation. 
 
 (C) OPERATIONS FOR DELIVERY. 
 
 I. EXPRESSION OF THE FETUS. EXPRESSIO FOETUS. 
 
 (Fig. 1 167.) 
 
 Definition. — Expression of the fetus is the term applied to the method of de- 
 livery of the child by the exertion of pressure upon the fundus of the uterus. It 
 
 Fig. 1 167. — Expression of the Fetus. Expressio Fcetus. — (From a photograph taken 
 
 at the Emergency Hospital.) 
 
 acts by increasing the intra-abdominal pressure and stimulating the uterine 
 muscle to contraction. In one form or another this principle has been employed 
 from the earliest times by people of all nations, civilized and barbarous. 
 
 * Professor A. R. Simpson, of Edinburgh. 
 
964 OBSTETRIC SURGERY. 
 
 Indications. — Some hold that this method may complete delivery in the en- 
 tire absence of pains, but it is usually adopted only as a means of increasing the 
 duration and strength of the normal uterine contractions. In this way it is used 
 at the end of the second stage when the uterine contractions lack force and the 
 external genitals are not too tense and narrow. With a small fetus it may be of 
 great value when there is an indication for immediate delivery. In such a case 
 expression may complete the expulsion of the fetus more rapidly than any other 
 procedure. When pains have been weakened by anesthesia and the fetus is in 
 danger it is of value. A further indication results from failure of the head to en- 
 gage in the brim of the pelvis, although the uterus is contracting strongly and no 
 disproportion between the size of the head and that of the inlet exists. Such 
 a condition is present when a pendulous abdomen permits a marked anteversion 
 or anteflexion of the uterus. The same result may occur from the presence of a 
 maternal umbilical or ventral hernia. Under these circumstances properly ap- 
 plied pressure upon the abdominal wall will cause the head to enter the brim and, 
 assisted by the natural expulsive force of the uterus, it will advance rapidly. In 
 delivery of the second twin, expression is sometimes of assistance, but great care 
 must be exercised that the uterus is not emptied too suddenly. 
 
 Contraindications. — The presence of a large amount of fat in the abdominal 
 wall interferes seriously with the manoeuver. Marked tenderness and tonic con- 
 traction of the uterus are absolute contraindications. If inflammatory con- 
 ditions of the adnexa are present, external pressure may lead to dangerous re- 
 sults. Disproportion between the size of the fetus and of the parturient canal, 
 whether from narrowing of the pelvis or rigidity of the soft parts or other cause, 
 should prevent its employment. 
 
 Operation. — The woman is placed in the dorsal position, close to the edge of 
 the bed or upon a table. Anesthesia is of value in some cases, but in others it is 
 not desirable, as it diminishes the natural uterine contractions. The operator, 
 standing at the right side, grasps the fundus between the two hands and exerts 
 pressure upon the uterus in the axis of the inlet (Fig. 1167). This is done only 
 during the uterine contractions, beginning gently and gradually increasing the 
 amount of force employed. During the interval between the pains the uterus 
 may be gently massaged. Care must, of course, be exercised, as in the Cred^ 
 method of placental expulsion, that no injury is done to the appendages by the 
 use of undue force improperly applied. Even when the method is adopted in 
 cases in which there are no natural uterine contractions, intermittent pressure 
 alone should be used, imitating, as far as possible, the normal labor pains. 
 
 II. FORCIBLE DELIVERY. ACCOUCHEMENT FORCE. 
 
 Definition. — By accouchement force we understand three operations: viz., (1) 
 the complete rapid instrumental or manual dilatation of the cervical canal; fol- 
 lowed (2) by either combined or internal version or the application of the for- 
 ceps; and (3) the immediate extraction of the child. The accouchement forc^ 
 of the old writers upon obstetrics was often quite another and more serious 
 operation, for the condition of the cervical canal was frequently lost sight of 
 and the operation too frequently meant, (i) the plunging of the hand or the 
 application of the forceps through a cervical canal imperfectly dilated or torn 
 by the insertion of the hand, and (2) the immediate extraction of the fetus 
 through this constricted or lacerated os. That the latter definition of the term 
 still obtains is proved by the accidents that are constantly occurring during the 
 extraction of the fetus. 
 
FORCIBLE DELIVERY. 
 
 965 
 
 Indications. — In the event of placenta prasvia when the hemorrhage has been 
 temporarily arrested and there is necessity for immediate evacuation of the 
 uterine contents, there is probably presented the most urgent indication for the 
 performance of this operation. In case of the sudden death of the mother this 
 procedure is indicated only when there is hope of delivering the child more 
 quickly by this method (see Post-mortem Delivery, page 669). In cases of 
 eclampsia when other means fail and it is necessan.^ to empty the uterus, this 
 
 Fig. 1 168. — Dangers of a 
 Rapid Breech Extraction 
 through an imperfectly 
 Dilated Os. The external os 
 is not fully dilated or is para- 
 lyzed. Traction on the legs 
 results in extension of the 
 head and arms. 
 
 Fig. 1169. — ^Manual Extraction of the Fore-com- 
 iNG Head by the Introduction of Two Fingers 
 into the Rectum. Ritgen's Method. 
 
 method may be indicated, as rapidity is required, since convulsions are more 
 likely to occur as long as manipulation of the uterus continues. 
 
 Dangers. — Unless performed in the most rapid and scientific manner, this 
 operation is full of danger, being attended by a high percentage of maternal 
 mortality. It is apt to be very destructive to the tissues of the uterus. In 
 placenta prasvia the danger of uterine rupture and infection is a contraindica- 
 tion to this procedure. 
 
 Operation. — (See ]\Ianual Dilatation of Cervix, page 895, and Version, page 
 919, also Breech Extraction, page 968.) 
 
 III. MANUAL EXTRACTION OF THE FORE-COMING HEAD. 
 RITGEN'S METHOD (Fig. 1169). 
 
 Definition. — The digital extraction of the head in head-first delivery at the 
 end of the second stage by the introduction of two fingers into the rectum of 
 the mother, favoring extension of the head, in vertex presentation, through 
 
966 OBSTETRIC SURGERY 
 
 the vulval orifice. The operation is often combined with that of expressio 
 foetus. 
 
 Indication. — Tedious or powerless labor at the end of the second stage; when 
 the relative indication for the forceps exists at this time and no instrument is avail- 
 able. It may also be employed when the pains are so severe that control of the 
 head is impossible. In this case an anesthetic is given and the head is extracted 
 in the interval between contractions. 
 
 Dangers. — Injury of the rectal mucous membrane of the mother or of the eyes 
 of the fetus is liable to result from too vigorous or carelessly applied pressure. I 
 have seen severe venous hemorrhage. The operation is not aseptic. 
 
 Operation. — Anesthesia is not necessary, but in great rigidity of the part its 
 use is desirable, especially in primiparas. Two fingers of the right hand are intro- 
 duced into the rectum and continued pressure is brought to bear in vertex presen- 
 tation upon the forehead, the malar prominences, the superior maxilla, or the 
 chin, thus gradually extending the head through the ostium vaginas. Great care 
 must be taken to avoid, pressure upon the eyes. Similar procedures are advo- 
 cated by others, viz., combining pressure upon the face of the fetus by one or two 
 fingers in the rectum with restraint of the head during its advance by pressure 
 applied to the exposed portion of the vertex. The aim of all is to advance the 
 head gradually, in the absence of uterine contractions or in the intervals between 
 pains, under anesthesia in cases in which the contractions are so severe and fre- 
 quent that protection of the perineum is impossible without an anesthetic. It is 
 preferable to avoid the lack of asepsis involved in this operation by using a suffi- 
 cient amount of pressure upon the fundus to enable the middle finger of the right 
 hand to obtain a point of pressure upon the forehead of the fetus by reaching 
 behind the anus, without entering the rectum. (Compare Perineal Protection, 
 page 480 and Fig. 616 ) 
 
 IV. SHOULDER EXTRACTION IN HEAD-FIRST CASES. 
 
 After the birth of the head there sometimes occurs delay in delivery of the 
 shoulders, which may result in the death of the fetus from prolonged pressure 
 upon the cord Such delay may be of maternal origin, from inefficient contrac- 
 tions, pendulous abdomen, etc. Fetal causes include actual shortness of the um- 
 bilical cord or relative shortness from the presence of loops around the neck or 
 body; failure of rotation; diseases, such as ascites; deformities of the fetus, and 
 relative or actual largeness of the fetal shoulders or chest. ( i ) If the pains are 
 weak, and after allowing the uterus a little rest, stimulation of the fundus is indi- 
 cated. (2) If a pendulous abdomen retards expulsion, supporting the abdomen 
 and uterus and exerting pressure upon the fundus may obviate the difficulty. (3) 
 If expulsion of the shoulders is retarded by actual shortness of the cord, it may 
 be necessary to ligateit in two places and cut between the ligatures. If the cord 
 is around the neck, the loop should be drawn down if possible and passed over the 
 head so as to relieve it; failing in this, it should be loosened by traction and the 
 body delivered through the loop (Fig. 619). If this is not accomplished, it must 
 be divided between ligatures. (4) If the delay is from failure of rotation, one may 
 aid restitution of the head and thus cause rotation of the shoulders into the conju- 
 gate diameter. But if this fails, rotation of the shoulders maybe obtained by direct 
 pressure of the fingers in the vagina. If one is again unsuccessful, or if uterine 
 stimulation and pressure do not overcome the obstruction due to a large chest, 
 ascites, or a monstrositv, extraction of the shoulders is indicated. Mutilatory 
 
SHOULDER EXTRACTION IN HEAD-FIRST CASES. 
 
 967 
 
 operations are a final resort. (5) In extracting the shoulders traction is best 
 employed only during the pains. I am accustomed to hold the head in the hand 
 
 W 
 
 V^ iCERVICb,>CRbMIALD. 
 
 
 Fig. 1170. — Shoulder Extraction 'in 
 Head-first Labors. Directing the an- 
 terior shoulder well up behind the sym- 
 physis, thus securing the engagement of 
 the cervico-acromial diameter. 
 
 Fig. 1171. — Shoulder Extraction in 
 Head-first Labors. Delivery of the 
 posterior shoulder, either spontaneously 
 or artificially. 
 
 Fig. 1 172. — Shoulder Extraction in 
 Head-first Labors. Delivery of the 
 anterior shoulder by depressing the head 
 and making gentle downward traction 
 upon it. 
 
 Fig. 1 173. — Extraction of the Poste- 
 rior Shoulder by Traction with One 
 Finger in the Posterior Axilla and 
 the Palms of the Hands upon the 
 Head. 
 
 and gently raise it so that the anterior shoulder is well up behind the symphysis, 
 thus securing at the outlet the cervico-acromial diameter of the fetus instead of 
 
968 OBSTETRIC SURGERY. 
 
 the bisacromial diameter (Fig. 1170). The posterior shoulder is now delivered 
 over the perineum by pressure on the fundus (Fig. 1171), traction on the head 
 (Fig. 1 171) or in the axilla. The posterior shoulder is thus delivered first, con- 
 trary to the custom of many. (Compare Shoulder Delivery, page 486.) (6) The 
 anterior shoulder, up to this time behind the symphysis, is now delivered by de- 
 pressing the head, and making gentle downward traction upon it (Fig. 11 72). Trac- 
 tion with a finger in the anterior axilla may be necessary. (7) Some advise push- 
 ing up the anterior shoulder until the neck is under the pubic arch, drawing down- 
 ward until the posterior shoulder is at the edge of the perineum, then carr3dng the 
 head backward, so that the anterior shoulder may emerge under the arch (Fig. 
 1 173). (8) Blunt hooks are sometimes advised for exerting traction in place of 
 the finger. Either may cause fracture of the humerus, separation of its epi- 
 physis, or temporary paralysis of the arm. The blunt hook is the more likely 
 to cause such damage. 
 
 V. BREECH EXTRACTION. 
 
 The general rule for the conduct of labor with breech presentation is to do only 
 what is necessary to prevent early rupture of the membranes and so to obtain as 
 complete dilatation of the parturient canal as possible before passage of the head. 
 If everything progresses favorably, the physician is called upon to do nothing 
 until the umbilicus is delivered, except to support the trunk after it is bom, and 
 to watch the fundus carefully and constantly in order to prevent displacement of 
 the arms above the head. Occasionally, however, the breech may be arrested 
 either above or at the brim, or in the pelvic cavity. 
 
 Dangers. — Injury to either the mother or the fetus may result from breech 
 extraction. Fracture or dislocation of the femur of the fetus, injury of the femo- 
 ral blood-vessels, or temporary paralysis of the lower extremities may follow 
 traction by any method involving pressure in the groin, but is most likely to take 
 place when the blunt hook is used. Laceration of the maternal soft parts may be 
 caused by a slipping of the blunt hook or of the forceps applied to the breech. 
 The forceps may also injure the spinal cord or abdominal organs of the fetus, 
 and the blunt hook the genitals. It is thus seen that serious results may 
 follow the application of the forceps or the careless use of the blunt hook, and 
 therefore these procedures should not be indiscriminately employed. 
 
 (A) ARREST OF THE BREECH ABOVE THE PELVIC INLET. 
 
 Obliquity of the uterus may cause the breech to rest upon the pelvic brim, pre- 
 venting its advance. When this occurs, the fetus may be raised slightly and the 
 breech pushed over the pelvic inlet and held in that situation until it has engaged. 
 This manceuver may be executed by external abdominal manipulation or by two 
 fingers in the vagina or by the two combined. 
 
 (B) ARREST OF THE BREECH AT THE INLET. 
 
 This may be due to contraction or deformity of the pelvis or to unusual size 
 ofjj^the fetus. At times the obstacle may be overcome by simple pressure upon 
 the fundus. If this fails breech extraction may be demanded for the following 
 
BREECH EXTRACTION. 
 
 969 
 
 indications: on the part of the mother: (i) Exhaustion from prolonged efforts at 
 expulsion, (2) severe hemorrhage, (3) rise of temperature, (4) convulsions, (5) 
 
 prolonged compression of the soft parts 
 (6) varicosities or oedema of the exter- 
 nal genitals. Indications on the part of 
 i the fetus are: (i) Commencing as- 
 
 phyxia, shown by increased rapidity 
 and later slowness and irregularity of 
 i the fetal heart; (2) prolapse of the cord. 
 
 Fig. 1 174. — Breech Extraction with the 
 Breech at or above the Pelvic Inlet. 
 Bringing down the Anterior Leg. 
 
 Fig. 1175. — -Breech Extraction. Delivery 
 of a Small or Premature Fetus by 
 Direct Manual Traction upon the 
 Breech, the Thumb and Third and 
 Fourth Fingers in the Groins, and the 
 First and Second Fingers over the 
 Back of the Fetus. 
 
 Arrest of the breech at the brim of the pelvis may be overcome by one of the 
 following procedures, which can be assisted by pressure upon the fundus. Which- 
 ever method is employed, it is 
 imperative to keep the fundus 
 closely in contact with the fetus, 
 in order, as has been stated above, 
 to prevent displacement of the 
 upper extremities above the head. 
 Any form of traction used should 
 be exerted only during the pains. 
 I. Traction upon a Leg 
 Brought Down (Fig. 1174). — 
 Under anesthesia the hand whose 
 palm can most conveniently be 
 placed upon the abdominal sur- 
 face of the fetus is introduced into 
 the uterus in this position. The 
 anterior foot is seized and brought 
 down. It is important that this 
 foot should be chosen rather than 
 
 the posterior, because in the latter event traction tends to bring the anterior 
 buttock over the front portion of the brim of the pelvis, thus preventing descent. 
 
 "'^.. 
 
 -^E3:£2& 
 
 ov 
 
 Fig. 1 176. — Double Sling Applied to the 
 Breech, showing Faulty and Correct Lines 
 OF Traction. 
 
970 
 
 OBSTETRIC SURGERY. 
 
 Care must be taken that prolapse of the cord does not occur when the foot is 
 brought down. After the foot has been drawn out of the vulva traction on it is 
 exerted downward and backward in the axis of the pelvic inlet (Fig. 1179). Pres- 
 sure upon the fundus aids in bringing the posterior groin within reach, when one 
 or two fingers introduced into it may further assist extraction by distributing the 
 force over both lower extremities and so diminishing the danger of injury to the 
 one brought down (Fig. 1180). The other foot may be brought down also, but 
 better dilatation of the soft parts is obtained when this is not done. Traction 
 downward and backward is continued, the extremities being wrapped in a hot 
 sterile towel. As the breech emerges it is drawn forward to avoid lacerating the 
 perineum. If the legs are extended along the bod5^ and this is discovered early by 
 abdominal palpation before rupture of the membranes, the difficulty can be over- 
 come by external cephalic version. If not seen until later, great care must be used 
 in flexing the extended leg. I introduce the hand as far as the popliteal space, 
 
 Fig. 1 177. — ^Breech Extraction. Sling Applied to the Anterior and the Blunt 
 
 Hook to the Posterior Groin. 
 
 and with two fingers encircling the upper third of the leg gently flex the same 
 downward. The leg and the foot are thus easily reached and brought down. This 
 procedure is better than that of introducing the hand deep into the uterus to 
 reach the feet near the fundus. 
 
 2. Digital Traction.— If a foot is not or cannot be brought down, a finger 
 passed through the anterior groin may serve for applying traction. As soon as 
 this, aided by pressure upon the fundus, has brought the posterior groin within 
 reach, two fingers of the other hand in this groin can be used to assist. Various 
 modifications of digital traction are advised by different operators. Some apply 
 pressure in the posterior groin by an index-finger in the mother's rectum while 
 the corresponding finger of the other hand is employed in the anterior groin. 
 Others exert traction by the whole hand in the vagina with the thumb oyer 
 one iliac crest of the fetus and the little finger over the other, while the remain- 
 ing fingers are extended along the back (Fig. 1175). 
 
BREECH EXTRACTION. 
 
 971 
 
 3. The Fillet (Fig. 11 76). — This may be used when the groin cannot well be 
 reached in order to exert traction, and also when a greater amount of force is re- 
 quired than can be commanded by the digital method. The fillet, a strip of 
 sterile bandage, is passed up to and across the anterior groin and down on the 
 other side of the thigh, forming a loop over the groin. Some obstetricians employ 
 a second fillet over the opposite inguinal region in order to be able to use greater 
 force without increasing the strain upon one portion of the bod3^ The fillet may 
 be carried into position by a loop of string attached to a catheter containing a 
 stylet (Fig. 11 09). The latter is bent so as to form a curve, which when passed up 
 to the groin, turned toward the 
 
 child's abdomen, and drawn 
 down into the groin, will bring 
 its tip, threaded with a loop of 
 string, between the thighs of the 
 fetus. This loop is seized, drawn 
 down, and fastened to the fillet. 
 When the catheter and stylet are 
 withdrawn the fillet passes into 
 position. In exerting traction 
 by means of the fillet, care must 
 be taken to pull during the pains 
 in such a direction as to corre- 
 spond with the mechanism of 
 labor and so to diminish the 
 liability to fracture the femur. 
 
 4. The Blunt Hook (Fig. 
 1 1 7 7 ) . — A blunt hook, consisting 
 of a straight shank with an ex- 
 tremity whose curve should be 
 such as to fit the inguinal region 
 of the fetus, is advised by some 
 as affording means for stronger 
 traction. It is passed up, as is 
 the catheter for placing the fillet, 
 between two fingers of the left 
 hand and the child's body. Its 
 point is rotated so that when 
 drawn down its curve lies in the 
 groin and its point is felt be- 
 tween the thighs. The same 
 precautions must be taken in 
 regard to the line of traction as 
 
 with the fillet. With this, as with the fillet, a finger in the groin may assist 
 when the breech has been brought sufficiently low. 
 
 5. Forceps. — This may be applied to the breech as a last resort 
 ceps, page 1003.) 
 
 Fig. 117S.; — Breech Presentation with the Left 
 OR Anterior Buttock Caught at the Pelvic 
 Inlet behind the Symphysis, as the Result 
 OF Faulty Traction on the Prolapsed Leg in 
 A Horizontal Plane. 
 
 (See For- 
 
 ce) ARREST OF THE BREECH IN THE PELVIC CAVITY. 
 
 When impaction of the breech occurs in the pelvic cavit}^ it is usually impos- 
 sible to bring down a foot. The obstetrician must rely upon external abdominal 
 pressure alone, or combined with digital traction in the groin, or the use of the 
 
972 
 
 OBSTETRIC SURGERY. 
 
 \ f- 
 
 ,y 
 
 Fig. 1 179. — Breech Extraction. Trac- 
 tion ON A Leg. 
 
 Fig. 1 180. — Breech Extraction. Trac- 
 tion ON THE Anterior Leg and Groin 
 AND Posterior Groin. 
 
 ;! 
 
 Fig. 1 181. — Breech Extraction. Trac- 
 tion ON Both Groins. 
 
 / 
 
 Fig. 1 182. — Breech Extraction. Down- 
 ward Traction on the Groins. 
 
 \-^ 
 
 V V I 
 
 L^>lMMMHi<MM> 
 
 Fig. 1 183. — Extraction of the After-coming Head. Delivery of the Posterior 
 
 Arm. 
 
BREECH EXTRACTION . 973 
 
 fillet or blunt hook. The forceps may be employed as in cases of arrest at the 
 brim. Symphyseotomy has been advised in these cases. When the child is 
 dead and other methods have failed, the cranioclast applied to the breech will 
 usually succeed in effecting delivery. One blade is introduced into the fetal 
 rectum, the other applied over the sacrum (Fig. 1147), or the cephalotribe may 
 be applied over the trochanters and sides of the pelvis if it is necessary to diminish 
 the breadth of the breech (Fig. 1154). 
 
 The uterus must be made to retract closely over the fetus during the whole 
 period of its delivery. This is best accomplished by having an assistant grasp 
 the fundus with both hands, making a funnel, thus preserving head flexion and 
 reducing the danger of displacement of the arms (Fig. 1167). Traction should 
 be made during the pains when the latter are not too far apart; it should be 
 slow to allow the uterus completely to retract and thus lessen the danger of 
 hemorrhage; the direction of the traction should be downward and somewhat 
 backward, and steady tractions are preferable to rotary or pendulum movements. 
 
 Extraction by the Feet (Fig. 11 79). — If a single leg presents, the foot is 
 seized between the middle and index fingers with the thumb on the sole, and when 
 the leg is drawn outside the vagina it is wrapped in a warm towel and grasped 
 with the whole hand, the thumb always being directed upward and applied to 
 the dorsal surface of the leg. The fetus as delivered should always be covered 
 with warm moist towels (100° F. ) to lessen the danger of the air of the delivery 
 room (70° to 80° F.) exciting respiratory movements. The direction of the 
 traction should be sufficiently backward to avoid friction at the pubic arch, and 
 until the buttocks appear the extracting hand should shift upward so as to grasp 
 the leg as near the maternal parts as possible; whichever leg is seized rotates for- 
 ward into the pubic angle during extraction. Should both legs present in the 
 vagina, the middle finger is placed between the feet and the index and ring fingers 
 encircle the external malleoli until the legs are delivered, when the right leg 
 should be seized with the right hand and the left with the left hand. The nor- 
 mal rotation of the fetus can thus be controlled. Leg traction should, by reason 
 of the dangers of dislocation and fracture, be discontinued as soon as the buttocks 
 have been brought into the vulval outlet, when traction on the breech should be 
 substituted (Figs. 1180, 1181, 1182). 
 
 Extraction by the Breech (Fig. 1183). — The fetal pelvis is grasped by inserting 
 an index-finger in each groin, placing the thumbs over the fetal sacrum, and 
 steadying the remaining three fingers of each hand over the corresponding 
 thighs. Following the normal mechanism, the fetus is now slowly extracted 
 until the lower angle of the anterior scapula appears, during which time atten- 
 tion should be paid to the cord. 
 
 Management of the Cord. — Should the cord be found between the child's legs, 
 the placental extremity should be drawn down and the loop, if possible, slipped 
 over the posterior thigh. In rare cases, when this procedure fails, the cord should 
 be cut between two ligatures. In all cases as soon as the umbilicus appears at the 
 vulva the cord should gently be drawn down a few inches and placed, if possible, 
 in the posterior segment of the outlet, in order to avoid dangerous traction upon 
 the navel. 
 
974 
 
 OBSTETRIC SURGERY. 
 
 (/) 
 
 v.. 
 
 Fig 
 
 VI. EXTRACTION OF THE AFTER-COMING HEAD. 
 
 Delivery of Displaced Arm. (2) Manual Rotation of Transversely Placed Head, (j) 
 Uterine Compression. (4) F ace-and-shoulder Traction, or Sm-ellie Method. (5) Jaw- 
 and-shoulder Traction, or Method of Smellie-Veit, Mauriceau. (6) Jaw Traction and 
 Suprapubic Pressure, or Wigand-A. Martin Method. (7) Jaw, Shoulder Traction, and 
 Suprapubic Pressure, or the Combined Method. (<?) Foot-and-shoulder Traction, or 
 Prague Method, (p) Forceps for the After-coming Head. {10) Delivery of the Head in 
 Persistent Sacro-posterior Cases. 
 
 It should be remembered that in all breech cases delivery must be completed 
 within five to ten minutes of the emergence of the umbilicus, as the pressure ex- 
 erted upon the cord will usually result in fatal asphyxia if continued longer than 
 
 that time. It is also to be 
 understood that during all 
 these manipulations the 
 body of the child is to be 
 wrapped in hot, sterile 
 towels, as diminution of 
 the body-temperature is 
 extremely dangerous. In 
 the following descriptions 
 the direction of traction is 
 described in relation to the 
 long axis of the mother's 
 body; thus, downward 
 means toward her feet; 
 backward signifies toward 
 the floor if she lies upon 
 her back. 
 
 Dangers. — Traction 
 upon the legs ' may cause 
 separation of the epiphy- 
 ses. Pressure upon the 
 clavicles by the hand 
 grasping the shoulders may 
 fracture them and cause 
 paralysis of the upper ex- 
 tremities by pressure upon 
 the brachial plexus. Dis- 
 location of the cervical ver- 
 tebrae with laceration of 
 the spinal cord is more 
 likely to result from the 
 use of the Prague method 
 than from any other. Such 
 traction may also cause 
 laceration of blood-vessels 
 and may result in hema- 
 toma of the sternocleido- 
 mastoid. The compression to which the cord is subjected, particularly in forceps 
 delivery or birth of the head of a persistent sacro-posterior case, may cause cere- 
 bral hemorrhage or fracture of the skull. Traction on the jaw by the finger in the 
 mouth may lead to dislocation. Misdirected force in bringing down an extended 
 
 1 184. — Extraction OF the After-coming Head. 
 Delivery of the Posterior Arm. 
 
 ^ 
 
 ^ 
 
 Fig. 1 185. — Extraction of the After-coming Head. 
 Delivery of the Posterior Arm. 
 
EXTRACTION OF THE AFTER-COMING HEAD. 
 
 975 
 
 \ 
 
 s> 
 
 arm may cause fracture of the humerus, and attempts to cause rotation of the 
 head by force exerted upon the trunk alone may dislocate the cervical vertebras. 
 
 1. Delivery of the Extended Arms (Figs. 1183 to 1189). — One arm or both may 
 become extended from too energetic traction upon the body of the fetus in simple 
 breech presentations, or this may occur during the necessary manipulations in the 
 delivery of an impacted breech; and, indeed, without these causes the arms may 
 become extended at full length, beside the child's head. Before delivery of the 
 head is possible, unless the child is very premature, the arms must be brought 
 into a normal position. The posterior arm should first be manipulated, as the 
 sacral hollow gives more room than there is anteriorly. The child's legs being 
 grasped by the operator's left hand just above the malleoli, its body is carried 
 upward and flexed over the mother's right hip in left sacro-positions, and over 
 the left hip in right sacro-positions (Fig. 1184). This moves the jDOsterior fetal 
 shoulder down into the pel- 
 vis. The operator's index 
 and middle fingers of the 
 hand whose palm corre- 
 sponds to the dorsum of the 
 fetus are inserted into the 
 vagina till the child's sca- 
 pula is reached, and then 
 along the back of the arm to 
 the elbow, which is pulled 
 forward into the sacral cav- 
 ity so that the child's arm 
 comes in front of its face. 
 By hooking a finger through 
 the elbow-joint and pulling 
 downward the arm is flexed, 
 and by extension the fore- 
 arm is delivered on the chest 
 of the fetus (Fig. 1 186). The 
 process is now reversed and 
 the right hand grasps the 
 fetal body and carries it over 
 the mother's left thigh, etc., 
 till the other arm is deliv- 
 ered. These manipulations must be conducted with great gentleness and care 
 to avoid fracture of the humerus. 
 
 Dorsal Displacement of the Arm (Fig. 694). — A far less common accident 
 than simple extension is dorsal displacement of the arm. The arm is extended 
 along the head, the elbow flexed, and the forearm behind the neck. This displace- 
 ment may result from attempts to rotate the trunk or head, the arms not rotating 
 with the bod}^ and so passing behind it. This constitutes a serious obstacle to 
 delivery, as the forearm prevents the occiput from passing under the pubic arch. 
 It is overcome by rotating the body in the direction opposite to that which 
 caused the displacement, thus bringing the arm in front of the fetal head. 
 The extremity may then be drawn down, as in the case of simple extension 
 of the arm above the head. If the occiput has been directed posteriorly by 
 the manoeuvers and fails to rotate forward at once after extraction of the arm, 
 this should be brought about artificially in the following manner. 
 
 2. Manual Rotation of the Transversely Placed Head (Figs. 11 90, 1191). — 
 
 MttlMHtMMMaMbAIM 
 
 Fig. 1 186. — Extraction of the After-coming Head. 
 Delivery of the Posterior Arm. 
 
976 
 
 OBSTETRIC SURGERY. 
 
 When the head presses with its long diameter transverse or with the occiput in 
 the sacral hollow, the head and trunk should be firmly held by the SmelHe or 
 Smellie-Veit grasp, and rotated so as to bring the occiput to the front, when 
 the dehvery can be completed. (See below.) Rotation by grasping the trunk 
 alone must be carefully avoided, as it is Hable to cause injury to the spinal cord 
 
 „=^^5*^?>^^5S^v*.,5^--^ 
 
 V. 
 
 Fig. 1 187. — Extraction of the Aftercom- 
 iNG Head. Rotation of the Fetus in 
 Order to Bring the Anterior Arm in 
 the Posterior or Roomier Segment of 
 THE Pelvis. 
 
 Fig. 1 188. — -Extraction of the After- 
 coming Head. Delivery of the 
 Arms in the Sacro-posterior Posi- 
 tion OP THE Fetus. 
 
 ■y- 
 
 f 
 
 X 
 
 Fig. 1 189. — Extraction of the After-coming Head. Delivery of the Arms in the 
 Sacro-posterior Position of the Fetus. 
 
 if the head fails to rotate at the same time. I have found that one finger in 
 the child's mouth, the thumb, third, and fourth fingers over the shoulders, and 
 the second and third fingers on the occiput is a very reHable method for head 
 rotation (Figs. 1191, 1193). 
 
 3. Uterine Compression (Fig. 1194). — When conditions arise that demand 
 speedy dehvery, it may be attained by suprapubic uterine compression. Uterine 
 
EXTRACTION OF THE AFTER-COMING HEAD. 
 
 977 
 
 compression is of great value and power in expelling the head, as the force is ex- 
 erted almost directly upon the head itself. Applied by a trained assistant it 
 may advantageously be combined with the Smellie or Smellie-Veit method. 
 
 4. Face-and-shoulder Traction, or Smellie Method. — The operator's right or 
 left hand is passed between the thighs and then between the arms of the child, 
 whose body rests upon the forearm while the arms and legs hang down at each 
 side. For face traction that hand should be chosen the palm of whicn naturally 
 
 Fig. 1 190. — Extraction of the After- 
 coming Head. Manual Rotation of 
 the Fetus in Order to Favor Ante- 
 rior Rotation of the Occiput in 
 Sacro-posterior Positions. 
 
 Fig. 1 191. — -Extraction of the After- 
 coming Head. Manual Rotation of 
 the Transversely Placed Head. The 
 upper figure shows the rotation com- 
 pleted. 
 
 corresponds with the face of the fetus; thus, the right hand when the face looks 
 to the left, and vice versa. The index and middle fingers of this hand enter the 
 vagina and their tips are placed one at each side of the child's nose. The other 
 hand grasps the shoulders from behind, the index-finger over one, the other three 
 fingers over the other clavicle. The tips of these fingers first aid flexion of th e head 
 by pressing the occiput upward, while the fingers appHed to the face of the fetus 
 attempt to draw it down. When the head is well flexed, traction is made down- 
 62 
 
978 OBSTETRIC SURGERY. 
 
 ward with both hands, the second grasping the shoulders as described. As soon as 
 the occiput is well engaged under the pubic arch the body is raised over the 
 mother's abdomen while the fingers of the internal hand continue to exert trac- 
 tion, as those of the external do upon the shoulders. As the face emerges over the 
 perineum the shoulder hand must leave the shoulders and protect the perineum by 
 drawing the vulval tissues backward and toward the median line and by prevent- 
 ing sudden expulsion of the forehead. This method of traction is inferior to the 
 following, also recommended by Smellie, because the fingers on the face of the child 
 cannot secure a firm grasp upon the slippery skin for traction. It was suggested 
 by him as avoiding danger to the jaw, which the Smellie-Veit method involves. 
 5. Jaw-and-shoulder Traction, or Method of Smellie-Veit or Mauriceau 
 Method (Fig. 11 96). — This manoeuver differs from the last only in that traction is 
 applied by the index-finger in the mouth instead of by two fingers upon the face. 
 It affords a far more effectual grasp upon the face. Great care is necessary lest 
 the lower jaw be injured by the use of excessive force. 
 
 ^/ 
 
 Fig. 1 192. — Extraction of the After- Fig. 1193. — -Extraction of the After- 
 coming Head. Digital Flexion of an coming Head. Digital Flexion of a 
 Extended Head Above the Pelvic Partially Extended Head at the Pel- 
 Inlet, vic Inlet. 
 
 6. Jaw Traction and Suprapubic Pressure, or Wigand-A. Martin Method (Fig. 
 1 1 97). — The child's body lies astride the operator's right or left arm, as in the pre- 
 ceding methods, while the fingers are inserted into the vagina, the index-finger 
 being passed into the infant's mouth so that by traction complete flexion of the 
 head may be secured. The fingers of the remaining hand are placed on the ab- 
 domen over the occiput which lies just above the symphysis. By the combina- 
 tion of the pressure above in the axis of the parturient canal and the traction be- 
 low, the head is delivered. On the appearance of the head at the vulva the 
 child's body is carried upward toward the mother's abdomen, which lessens 
 the danger of perineal laceration. 
 
 7. Jaw, Shoulder Traction, and Suprapubic Pressure, or Combined Method 
 (Fig. II 98). — In difficult cases it is advisable to use a combination of the above 
 methods, namely, the operator performs jaw-and-shoulder traction as in the 
 Smellie-Veit method, while suprapubic pressure, as in the expression of the fetus, 
 is made by a competent assistant. 
 
EXTRACTION OF THE AFTER-COMING HEAD. 
 
 979 
 
 8. Foot-and-shoulder Traction, or Prague Method (Fig. 1199). — One of 
 the operator's hands grasps the child's feet from behind, the middle finger 
 passing between the ankles. The other hand grasps the child's shoulders 
 as in the Smellie method, and downward and backward traction is exerted 
 by both hands till the perineum is well distended by the head. The hand 
 grasping the shoulders is now used as a fulcrum around which the head 
 is rotated by raising the body and lower extremities over the mother's abdomen 
 while continuing to exert traction with the hand holding the ankles. This 
 method involves the use of great force, which may cause dislocation or fracture 
 of the neck or clavicles of the child, and should never he employed. 
 
 Fig. 1 194. — Extraction of the After-coming Head. Suprapubic Uterine Compres- 
 sion. — {From a photograph taken at the Emergency Hospital.) 
 
 9. Forceps for the After-coming Head. (See Forceps, page 1003). — This method 
 is rapid and valuable and may be used when the other methods fail. The child's 
 body is carried up over the maternal abdomen. The blades of the forceps are 
 applied to the fetal head and delivery proceeds as in the usual forceps operations. 
 It is used only after failure of manual extraction and never in cases with the 
 head above the inlet. 
 
 10. Delivery of Head in Persistent Sacro-posterior Cases (Figs. 1200). — If 
 manual rotation, as described above, of the head whose occiput fails to rotate 
 anteriorly is unsuccessful, the head must be extracted with the face anterior. 
 This is accomplished in one of two ways: (i) If the chin is caught above the sym- 
 physis, traction upon the fetus should be directly forward toward the ceiling when 
 
980 
 
 OBSTETRIC SURGERY. 
 
 the woman is in the dorsal position. External abdominal pressure is made down - 
 ward and backward upon the head at the same time. The head rotates around the 
 symphysis and the occiput is bom first. (2) If the chin is below the symphysis, 
 the woman is placed upon her back with the hips over the edge of the bed or 
 table, so that traction can be exerted directly backward — toward the floor. The 
 
 Fig. 1 195. — Extraction ok the After-coming Head. 
 
 Smellie Method. 
 
 Face and Shoulder Traction, 
 
 Other hand presses downward upon the head above the pubis, and, if necessary, a 
 
 finger in the rectum can further increase flexion of the head by pushing up the 
 
 occiput. Jaw traction will also assist. By this method the face is bom first. 
 
 Method Advised. — As a general rule, preference should be given to the Smellie- 
 
 FlG II96. 
 
 -Extraction of the After-coming Head. Jaw-and-shoulder Traction. 
 Mauriceau or Smellie-Veit Method. 
 
 Veit method, combined with suprapubic uterine compression by a trained assist- 
 ant, or the Wigand-Martin method if unassisted and the Smellie-Veit fails. If 
 these are not successful, the forceps must be rapidly applied, remembering that 
 five to ten minutes is the allotted time from the appearance of the umbilicus 
 to the birth of the head. 
 
EXTRACTION OF THE AFTER-COMING HEAD. 
 
 981 
 
 
 I 
 
 X 
 
 »>lirt»itffii;>^iit"iiwiifiwiituii 
 
 ' '^ ' " "■" ""• 
 
 D 
 
 Fig. 11Q7. — Extraction of the After-coming Head. Jaw Traction Combined with 
 Suprapubic Pressure. Wigand-A. Martin Method. 
 
 Fig. 119S. — ^Extraction of the After-coming Head. Jaw, Shoulder Traction, and 
 Suprapubic Pressure. The Combined Method. 
 
982 
 
 OBSTETRIC SURGERY 
 
 Fig. 1 199. — Extraction of the After-coming Head. Sacro-posterior Position. 
 Shoulder and Leg Traction. Prague Method. 
 
 >y 
 
 J 
 
 Fig. 1200. — Extraction of the After-coming Head. Persistent Sacro-posterior 
 Position. Jaw and Shoulder Traction and Extension of the Fetus. 
 
THE FORCEPS. 983 
 
 VII. THE FORCEPS. 
 
 Historical. — This instrument in some form evidently dates back to some time before 
 the Christian era, as crude patterns of it have been found in connection with archaeological 
 investigations in Egypt and elsewhere. By reason of the complete silence of classical 
 authors upon so important a subject as instrumental extraction of living children, it has 
 been assumed that the forceps of that period was used only for the extraction of dead 
 fetuses. Somewhere about 1600 it is believed that Peter Chamberlen, of London, began 
 to use the forceps as a matter of routine in obstetrical practice. We do not really know 
 when or by whom it was invented, nor how the inventor was influenced toward his inno- 
 vation. It is certain, however, that the Chamberlens possessed a monopoly of the instru- 
 ment, and that the secret was virtually preserved among the members and pupils of the 
 family until the independent invention of a forceps by Palfyn in 1723, together with Chap- 
 man's published description of Chamberlen's instrument in 1725, had made this discovery 
 the common property of the profession. The Chamberlen forceps consisted of fenestrated 
 blades joined to a scissor-like handle. The cephalic curve was admirable, but there was 
 no pelvic curve, shank, or lock. After adaptation the blades were held in place by 
 tape wound tightly between the handles and blades where the halves cross. The absence 
 of pelvic curve and shank shows conclusively that the Chamberlens practised nothing but 
 the low operation. After knowledge of the forceps had become the common property 
 of the profession, but a few years elapsed before the good results of publicity became appar- 
 ent. Levret, the leading obstetrician of his age and a man of mechanical genius, added at 
 one stroke the pelvic curve, shank, and lock (about 1747). The modern long forceps has 
 undergone but little alteration since his time. Smellie, his great British contemporary, 
 devised the so-called English lock, but his chief service to midwifery lies rather in his dis- 
 coveries concerning the mechanism of labor than in forceps construction. A century 
 elapsed before the forceps underwent another revolutionary advance. The imperfection 
 of forceps traction with the head at the brim appears to have been recognized during the 
 first quarter of the nineteenth century, and attempts in the direction of axis traction were 
 made by attaching traction cords, accessory rods, etc., to the blades of the high forceps. 
 None of these devices was successful in making true axis traction, as the " line of pull " neces- 
 sarily ran within the birth canal. The difficulty was overcome to a certain extent by using 
 the high forceps as a lever with the hand as a fulcrum. Finally, in 1877, Tarnier intro- 
 duced to the notice of the profession his axis-traction forceps which, in the opinion of most 
 obstetricians, has permanently solved the problem of traction at the inlet. During the 
 quarter century just elapsed there have been no advances in forceps construction. 
 
 Description. — The forceps consists of two halves almost identical in con- 
 struction. They cross like the branches of scissors and interlock, and are known 
 as the arms. The left arm is the one which is held with the left hand and 
 introduced into the left side of the pelvis and which contains the pin or 
 screw of the lock. The right arm, which is introduced into the right side 
 of the pelvis with the right hand, contains a notch for the reception of the 
 pin or screw. Each arm of the forceps consists of a blade, shank, handle, and 
 a portion of the lock. The blade is fenestrated to secure lightness, and its 
 free extremity is termed the apex (Fig. 1201). Solid-bladed forceps are pre- 
 ferred by a few operators, but by most are used only for special actions, such 
 as rotation (Fig. 1206). Some authorities reject the solid blades as liable to 
 slip over the head. The blade has a double curve, one being on the fiat, 
 which corresponds to the convexity of the fetal skull, the other on the edge, 
 to conform to the curve of the pelvic excavation. These are known respec- 
 tively as cephalic and pelvic curves (Fig. 1202). When the instrument is 
 locked, the handles come together to form a single grip for the operator's hand, 
 and several devices are added to increase the strength of the hold, such as expan- 
 sion at both ends, and corrugation in the continuity (Fig. 1202). The entire 
 instrument should be constructed of well-tempered steel, which is also suitable 
 for ready sterilization. In regard to correct proportions, the blades in position 
 should be at least 3 inches (7.62 cm.) apart at the acme of the cephalic curve, and 
 I inch (2.54 cm.) apart at the tips. When the instrument lies upon its convex 
 edge, the tips of the forceps should be 3^- inches (8.89 cm.) above the general 
 level ; in other words, the highest portion of the pelvic curve is at the tip. Forceps 
 
984 
 
 OBSTETRIC SURGERY. 
 
 having a short shank and no pelvic curve may be used for the low operation, but 
 such a pattern is unnecessary, as the ordinary instrument with its double curve and 
 
 longer shank can be used with equal 
 readiness in any part of the pelvis. Of 
 the innumerable patterns of forceps, the 
 following are the most popular: Nae- 
 gele and Breus in Germany ; Tarnier in 
 France (Fig. 122 1); Simpson's in Eng- 
 land; Simpson, Elliott (Fig. 1203), and 
 Tarnier in America. 
 
 Antero- posterior Forceps. — A 
 French writer, Penoyee,* has devised 
 a special form of forceps in which one 
 blade has a much greater degree of cur- 
 vature than the other, so that when 
 applied at right angles to the plane in 
 which the ordinary forceps is used the 
 blade with the more marked curvature 
 fits into the hollow of the sacrum, and 
 is thus supposed to render delivery 
 easier. It may, however, be pointed 
 out that the difficulties which require 
 forceps delivery are encountered not 
 while the head is in the hollow of the 
 sacrum, but at the superior strait and 
 at the outlet, at both of which points 
 the peculiar shape of this forceps is of 
 no advantage. 
 
 Straight Forceps. — Forceps without 
 the pelvic curve have been made and 
 recommended especially as rotators in 
 occipito- and mento-posterior positions 
 of the head. I have been unable to 
 satisfy myself that as rotators they pos- 
 sess any advantages over the ordinary 
 instrument. 
 Choice of Forceps. — Any instrument modeled after the Naegele or Simpson 
 forceps will prove satisfactory. Per- 
 sonally I prefer the Elliott modifica- 
 tion of Simpson's forceps in cases 
 not requiring much axis-traction, 
 and the Tarnier instrument for all 
 high and difficult cases. 
 
 Solid-bladed instruments are 
 convenient for operations calling for 
 much rotation, but the ordinary fen- 
 estrated forceps will give equally 
 good results if intelligently used. 
 Physicians providing themselves 
 with one forceps only, will do well to 
 procure the latest model of Tarnier's instrument, and accustom themselves to 
 
 *" Revue Clinique d'Andrologie et de Gyn6cologie," May 13 and June 13, 1S95. 
 
 Fig. 1201. — -The Forceps.- The Left Arm 
 IS the One which is Held in the Left 
 Hand and Introduced into the Left 
 
 Side of the Pelvis, 
 which is Introduced 
 Side of the Pelvis, 
 Right Hand. 
 
 The Right Arm, 
 into the Right 
 is Held in the 
 
 Fig. 
 
 1202. — The Cephalic and 
 Curves of the Forceps. 
 
 Pelvic 
 
THE FORCEPS. 
 
 985 
 
 its use in low as well as high cases. One should see to it that the forceps is 
 entirely of metal so as to withstand frequent boiling. 
 
 Frequency of Forceps Operations. — The proportion of cases in which delivery 
 is completed with the forceps naturally varies in different clinics. During three 
 years in the Paris Maternity (ending March i, 1899) the forceps was applied 
 236 times in 4380 deliveries, about 6 per cent., or i in 16.67. Of the 236 extrac- 
 tions, 211 were examples of the ordinary low or median operation, while the 
 remaining 25 were high- forceps cases, all for contracted pelves.* During one 
 year at the Glasgow Maternity there were 187 forceps deliveries in 2179 confine- 
 ments, about 8.5 per cent., or i in 11. 7. Of 482 cases confined at the Maternity 
 proper, there was 18 per cent, of forceps intervention, or i in 5.5; while of 1697 
 women confined at their homes by the Maternity staff, 6 per cent, were delivered 
 by forceps, or i in 16.7.! During the year 1898 there were 6 forceps deliveries 
 in 458 confinements at the Brussels Maternity, only about 1.3 per cent., or i in 
 77.+ Ahlfeld (1897) reports 4000 cases with no forceps operations, or 2.75 per 
 cent., or once in 36.3 cases. § In 2200 confinements in two hospitals I found that 
 
 Fig. 1203. — Elliott's Modification of Simpson's Forceps. 
 
 Fig. 1204. — McLane-Tucker Solid-bladed Forceps. 
 
 the forceps was applied in 208 cases, or in 9.45 per cent, of all cases, or once in 10.5 
 cases. In the 208 forceps operations, I found 24 were high operations, 43 
 median, 123 low, and 18 had no record of the position of the head in the pelvis. 
 Indications. — The question, "When is the forceps indicated?" is answered 
 broadly as follows: It is to be used whenever labor is to be quickly terminated, 
 whenever the life of the mother or child is in peril, provided that contraindica- 
 tions are absent. The dangers to which the mother, child, or both are exposed 
 must naturally be of the sort which are removed or diminished by the termi- 
 nation of labor. When the latter is uncomplicated by any special condition 
 like eclampsia or hemorrhage, the chief dangers are in exhaustion on the part 
 of the mother and in asphyxia of the fetus ; which is equivalent to stating that 
 the anomalies of labor which require forceps are largely mechanical in character, 
 and that therefore whatever imperils the mother by causing obstruction and 
 
 * Dubissy et Thoyer-Rosat: " M6d. Moderne," April 12, 1S99. 
 
 t Black: "Trans. Glasgow Obstet. and Gynecol. Soc," vol. i, 1S96-9, p. 71, appendix. 
 
 J " Journ. d'accouchements," Feb. 19, 1S99. 
 
 ^Ahlfeld: " Lehrbuch der Geburtshilfe," second edition, 1S98, p. 50S. 
 
986 
 
 OBSTETRIC SURGERY. 
 
 delay also endangers the fetus by compression of the cord, placenta, head, or 
 chest. The said anomalies of labor which produce these effects in the mother 
 and child are equivalent to dystocia, maternal or fetal. AVhile it is seldom 
 difficult to recognize the presence of maternal conditions which demand forceps 
 intervention, it is by no means always easy to determine when the fetus is in 
 peril. If the heart-beat either increases or diminishes steadily, evidence is thereby 
 furnished of disturbance of the placental circulation, which means peril for the 
 child. This behavior of the heart must not be confounded with the slight 
 variations w^hich occur during a uterine contraction. The presence of meconium 
 in the amniotic fluid is dubitable evidence of fetal distress. In breech presen- 
 tations it means nothing at all, for it is expressed from the anus mechanically; 
 and even in head presentations its presence may be inconclusive. I have fre- 
 
 FiG. 1205. — Classification of Forceps Operations. High Operation. Median 
 Operation with Complete Retraction of the Cervix over the Presenting Part. 
 Median Operation with only Partial Retraction of the Cervix over the Pre- 
 senting Part. Low Operation. 
 
 quently seen healthy, unasphyxiated children bom by the vertex after a copious 
 escape of meconium. (Compare Asphyxia, Part IX.) As other evidence of 
 the fetal state is not forthcoming, we must place our sole reliance on the fetal 
 heart. 
 
 Special Indications. — Maternal exhaustion and fetal asphxyia are the general 
 indications for forceps, but it is necessary to recapitulate the different forms of 
 dystocia which tend to produce these conditions. The indications may proceed 
 from anomalies of the expulsive functions, anomalies of resistance, certain 
 presentations and positions of the child, and miscellaneous or non-mechanical 
 complications of labor, (i) Anomalies of expulsive forces: Simple inertia with- 
 out obstruction may require forceps. (See Part V.) Protracted labor without 
 evidence of obstruction belongs here, but in the many cases of arrested labor 
 
THE FORCEPS. 987 
 
 with maternal exhaustion some mechanical hindrance is present, and therefore 
 such cases belong in the next subdivision. (2) Anomalies of resistance: Rigidity 
 and stenosis of the lower birth tract and contracted pelvis make up this category. 
 If the natural forces cannot overcome the obstruction, the forceps is used unless 
 contraindicated. (3) Fetal dystocia: Here belong such anomalies as occipito- 
 posterior and deep transverse cranial positions, face presentations, arrest of 
 after-coming head in breech cases, etc. (4) Miscellaneous: Here belong all 
 severe non-mechanical complications of labor requiring its immediate ter- 
 mination: Hemorrhage, rupture of the uterus, eclampsia, and accidental 
 complications; severe acute or chronic disease occurring intermittently. But 
 the use of forceps is not inevitable in these cases. In 208 high, median, and 
 low forceps operations, I found the most frequent indications for its use were 
 uterine inertia (75 cases); pelvic deformity (68 cases); persistent occipito- 
 posterior position (41 cases); and to hasten labor in face and brow presentations 
 and eclampsia. 
 
 Prerequisites and Contraindications. — (i) The cervix must be fully dilated. 
 If the OS is but partly open, resort to forceps will mean extensive injury to the 
 cervix both from the instrument when applied and from the head when it trav- 
 erses the OS. The lesions thus produced in the cervix may bleed profusely. 
 If, however, there is a very urgent indication to end labor quickly, a narrow 
 margin of undilated cervix may be incised or dilatation may be completed with 
 the fingers as a preliminary to employing the forceps. (2) The membranes 
 must be ruptured. If the forceps were applied to the head with membranes 
 intact, the entire ovum would come away with probable detachment of the 
 placenta. In delayed rupture it may be necessary to incise the membranes 
 in order to apply the forceps. Cases may arise in which it is by no means easy 
 to determine the condition of the membranes. Thus, a caput succedaneum 
 may be mistaken for a bag of waters. The distinction is usually made by the 
 presence or absence of hair, but in some cases it is necessary to use a speculum. 
 
 (3) The greatest circumference of the head must have passed the inlet and the 
 head must be fixed in the pelvis. A head movable at the brim constitutes a 
 contraindication to the use of forceps. Such a head must either be made to 
 engage by external manipulation or the labor must be completed by version. 
 
 (4) Generally speaking, the forceps requires the presence of a due proportion 
 between the head and pelvis. The latter must not be too narrow. A living 
 child cannot be bom in a pelvis with a conjugate of less than 2.95 inches (7.5 
 cm.), and even in this degree of contraction a forceps could hardly be applied 
 save to a very small and plastic head. Hence the conjugate should measure 
 at least 3 inches (7.15 cm.). The forceps should not be applied to an over-large 
 or hydrocephalic head, nor to an anencephalus. (5) The fetus should usually 
 be living if forceps is to be used. In case of a dead fetus perforation could be 
 more safely done. 
 
 Prognosis. — Very much depends upon the state of the mother at the time 
 of operation. If the pulse is slow and full, the woman's condition may be 
 pronounced good, even if the temperature is above normal. A rapid, low- 
 tension pulse, on the other hand, is somewhat unfavorable because puerperal 
 infection usually begins in this manner. Fetor of the vaginal secretions some- 
 times announces the existence of sepsis developing intra partum. Before under- 
 taking the high operation in contracted pelves we should examine the cervix 
 in regard to the possibility of abnormal stretching, which may precede a rupture 
 of the uterus. Whatever goes wrong in connection with forceps extraction 
 will be laid at the door of the operator unless he informs the relatives in advance 
 
988 OBSTETRIC SURGERY. 
 
 of the possibility of this or that accident. If a colleague is called in for con- 
 sultation, he too should be fully informed in this respect. If the forceps is 
 applied before the os is fully dilated, lacerations of considerable extent may 
 occur in the cervix with more or less hemorrhage, which require suture imme- 
 diately after delivery. Sometimes in the absence of complete dilatation a 
 portion of the cervix is grasped in the forceps and torn oH during extraction. 
 The vagina has been injured in many ways through use of the forceps. The 
 posterior fornix has been perforated. In locking the blades a portion of vaginal 
 mucosa may be included. The forceps very seldom contributes to the pro- 
 duction of a vesico-vaginal fistula, which is generally due to the condition for 
 which the instrument is applied. Contusions are caused by to-and-fro move- 
 ments which are permissible only when lateral and of small excursion ; by forcible 
 attempts at rotation; and, finally, by improper traction in the high operation. 
 Slipping of the forceps is always a serious accident. It may result from incor- 
 rect application of the blades or from uncontrolled traction. The perineum 
 is always ruptured when the forceps slips in the low operation, and extensive 
 lacerations of the vagina may result from slipping higher up. The majority 
 of cases of acquired stricture of the vagina are due to forceps injuries. Improper 
 traction is another source of maternal traumatism. The high operation occa- 
 sionally gives rise to peroneal paralysis through compression of the lumbo- 
 sacral nerve as it crosses the pelvic brim; and among injuries to the bony pelvis 
 which thus originate may be mentioned dislocation of the coccyx, rupture of 
 the symphysis, and loosening of the sacro-iliac synchondroses. (Page 615.) The 
 various forms of traumatism which have just been enumerated are almost all 
 preventable if the forceps is properly used. After forceps delivery there is 
 more or less atony of the uterus with the likelihood of hemorrhage. When the 
 child is extracted with forceps, the conditions are somewhat similar to those of 
 precipitate labor, which perhaps explains the presence of uterine atony under 
 these circumstances. For a consideration of the forceps injuries of the child, 
 see sections on Fetal Birth Traumatisms, Asphyxia, etc. (Part IX, pages 812 
 and 823.) I found in 208 forceps operations that 193, or 92.34 per cent., of the 
 children were delivered alive; 11, or 5.26 per cent., were still-bom; i, or 0.47 
 per cent., died in the puerperium, and there was no record in 4 cases (compare 
 Version, page 919). Podalic version was attempted in one case of prolapsed 
 cord. 
 
 TECHNIQUE. 
 
 Preparation for the Operation. — The preliminary steps in a forceps inter- 
 vention are antisepsis or asepsis, and the necessary arrangement of the patient 
 upon a bed or an operating table. The indication for the application of forceps 
 may arise so suddenly that but little time is available for preliminaries, which 
 must therefore be quickly performed. Much of the antiseptic regimen should 
 have been in force as part of the management of labor itself. The additional 
 precautions are as follows: The forceps must be quickly sterilized by boiling, 
 and if there is no time for this the forceps must be "fired" by being passed 
 repeatedly through an alcohol flame of sufficient size. This is readily accom- 
 plished by saturating a small piece of absorbent cotton with alcohol and allowing 
 it to bum on an ordinary dinner-plate. In a case of low operation in a multipara 
 no other instrument will need to be sterilized. In case the obstetrician is not 
 already prepared to meet post-partum hemorrhage and perform immediate 
 suture of extensive lacerations, — and this lack of precaution is, of course, un- 
 
THE FORCEPS. 989 
 
 avoidable under many circumstances, — all the material requisite for such emer- 
 gencies should be made ready and freshly sterilized. Vaginal disinfection, held 
 by many to be undesirable in normal labor, is indicated in forceps extraction. 
 Everything should be in readiness to reanimate a still-born child. The woman 
 can be placed in the lithotomy position across the bed, but it is preferable in all 
 operations to press into use the kitchen or other table and properly equip it 
 with sheets, Kelly pad, and pail for drainage. The extremities may be held by 
 leg-holders (Fig. 1079), by the sheet sling, or if necessary by assistants. The light 
 should fall upon the vulva. The urine must be drawn with a sterile catheter, 
 a somewhat difficult procedure when the urethra is compressed by the head in 
 the excavation. If a catheter cannot be made to enter, it will be necessary to 
 forego the act until after delivery. A suprapubic examination of the bladder 
 should always be made, however, because if the viscus is distended it may 
 simulate that thickening of the upper segment of the uterus which implies that 
 the lower segment is thinned to the extreme. Such a condition of the uterus is 
 produced in labor with contracted pelvis, and is a threat that rupture of the 
 lower segment may occur. If the suprapubic tumor disappears when the urine 
 is drawn, the operator need have no fear of this accident. If feces have accumu- 
 lated in the rectum since the beginning of labor, they should be removed by 
 an enema. In regard to anesthesia, it is hardly required in the low operation in 
 multiparas. Aside from this, incomplete anesthesia may be recommended in 
 easy extractions, and full surgical narcosis in all high and especially difficult 
 cases. The anesthetic should be given by a colleague who has had experience. 
 In rural practice the question of anesthesia is often very difficult to decide. 
 There is no time to summon trained assistance, nor can the administration of 
 chloroform be left to a novice. Under such circumstances the operator must 
 choose between no anesthetic and partial anesthesia. In these cases when no 
 assistant is at hand the woman should be etherized as deeply as appears neces- 
 sary, and a novice quickly instructed in the use of the cone and the amount 
 of ether to be used. An Allis inhaler is invaluable for such purposes. From 
 the operator's position in front of the vulva the patient's face and respiration 
 should be watched. Should cyanosis develop, he may be forced to leave the 
 forceps, draw out the patient's tongue, and resort to the Sylvester method of 
 artificial respiration. 
 
 Action of the Forceps. — The functions performed by the forceps comprise (i) 
 traction, (2) compression, (3) rotation, (4) leverage, and (5) reflex stimulation of 
 the uterus, or oxytocic action. This is the classification in vogue at the present 
 day. Skutsch and a few other authorities would eliminate compression and 
 rotation, so that, according to them, the instrument has but three distinct func- 
 tions, (i) Traction, which is applicable to head and breech presentations only, and 
 aids the natural forces of the uterus and abdominal muscles to expel the child. 
 (2) Compression, enumerated among the functions of the forceps, is admitted to be 
 a source of danger to the child and a meddlesome interference with head-mould- 
 ing. For such a purpose it is never indicated, and its production is unintentional 
 — an unavoidable evil. Only enough compression is indicated for the blades to 
 hold firmly. In extracting, therefore, the instrument should be grasped near 
 the lock, for if held by the tips of the handles the blades will be approximated to 
 an unnecessary degree. This advice is especially to be heeded when the forceps 
 is applied obliquely. The belief was formerly prevalent that in the application 
 of forceps at the inlet compression was necessary to cause the engagement of the 
 head. This originated from the fact. that as the head entered the excavation 
 the handles could be seen to approach each other, showing that the blades were 
 
990 OBSTETRIC SURGERY.' 
 
 compressing the skull. This explanation, however, is false. The head following 
 the natural descent — even in the presence of the forceps — presents certain of its 
 smaller diameters in succession, and the forceps in adapting itself to them causes 
 the approximation of the handles. While slight forceps compression may be 
 without effect on the fetal head, the results of forceps delivery in contracted 
 pelves show that in most cases it causes a great variety of cranial and endocranial 
 lesions, to say nothing of the part it plays in causing asphyxia. (3) Rotation is 
 classed as a function of the forceps. While available in certain conditions (see 
 treatment of occipito-posterior positions, page 999) in the hands of an expert, it 
 is a source of danger in other circumstances, menacing the maternal parts as well 
 as the fetus. Many authorities eliminate it completely from the list of functions, 
 stating that in the great majority of cases rotation is not an independent act but 
 is brought about by simple traction. (4) Leverage was once applied more freely 
 than at present. Its principal use to-day is in cases in which the head is advanc- 
 ing with unusual difficulty, when traction may be varied by horizontal to-and-fro 
 movements. The axis of the forceps should not depart more than 30 degrees 
 from the median plane of the pelvis. To-and-fro movements in the vertical 
 direction are strictly contraindicated, as the maternal passage may readily be 
 injured. The movement of the forceps in delivering the head is not leverage but 
 simple traction. (5) The oxytocic or rejiex action of the forceps upon the uterus 
 is manifest when the instrument is adjusted to the fetus after a period of uterine 
 inertia. Even the application of a single blade may be sufficient to revive uterine 
 action, and the uterus in some cases is sufficiently stimulated to finish the labor 
 without further aid. If the blades are cold, the oxytocic action is still more 
 marked. It is needless to state that no one ever applies forceps solely for the 
 sake of stimulating the uterus. 
 
 Classification. — The usual classification of simply high, median, and low 
 operations is defective and unsatisfactory for the student, since it confuses two 
 very different operations, namely, the high and median, and takes no cognizance 
 of the two widely differing varieties of the median operation, for in this last 
 variety the presence of an undilated or unretracted cervix is an element of great 
 importance in the prognosis and treatment. The classification adopted in this 
 work is as follows: A high operation is one in which the presenting part is still 
 above the pelvic inlet, a maximum circumference, such as the occipito-frontal 
 in vertex presentations, not having passed the plane of the inlet. A median 
 operation is one in which a maximum circumference of the presenting part has 
 passed the plane of the pelvic inlet. We should recognize two important 
 varieties of median operation ; first, those cases in which the ring of the cervix has 
 only partially retracted over the presenting part, the latter being practically 
 within the uterine cavity (Fig. 1205 ) ; and, second, those cases in which complete 
 retraction of the cervix over the presenting part has occurred, the head resting in 
 the vagina below the ring of the cervix (Fig. 1205). A low operation is one in which 
 the presenting part is at or in the vulva. 
 
 Cephalic Application (Figs. 1207, 1209). — The preferable method is to 
 apply the blades to the sides of the head, thus making compression in the 
 biparietal diameter, where it does the least harm and where the least room 
 is required for the blades, and more closely imitating the natural mechan- 
 ism of labor. If the occiput is to the left and anterior, the fingers of the right 
 hand are passed into the vagina through the cervix if it has not completely re- 
 tracted, and the left blade is passed under the guidance of the left hand well up 
 into the space between the head and the left sacro-iliac synchondrosis, a/nd held 
 there by an assistant. The right blade is now passed up in the same manner 
 
THE FORCEPS. 
 
 991 
 
 between the head and the right side of the pelvis wherever there is the most room. 
 This will usually be near the right sacro-iliac synchondrosis. It is then gently 
 urged forward along the right lateral wall of the pelvis until it occupies a posi- 
 tion near the obturator foramen opposite its fellow or over the right ear of the 
 fetus. This may be done by means of the fingers in the vagina, by depressing the 
 handle, rotating it on its long axis and carrying it to the left (Fig. 1207). 
 
 Fig. 1206. — -Pelvic Application of the 
 Forceps, a, a', Pressure exerted by 
 lower edge of the right blade upon the 
 fetal skull; b, b', pressure exerted upon 
 the fetal skull by the upper edge of the 
 left blade. 
 
 Fig. 1207. — Cephalic Application of the 
 Forceps, or Adaptation, b, Left blade. 
 The right blade is introduced opposite the 
 right sacro-iliac synchondrosis at a, and 
 carried with the internal fingers to a'. 
 
 Fig. 
 
 120S. — Pelvic Application of the 
 Forceps. 
 
 Fig. 
 
 1209. — Cephalic Application 
 Adaptation of the Forceps. 
 
 This is termed adaptation of the forceps to the biparietal diameter of the fetal 
 head. The second method — namely, the pelvic application — is perhaps the safest, 
 especially for beginners. If the cervix is not completely dilated, it should be digi- 
 tally dilated, and care must be taken, in guiding the tips of the blades through the 
 cervix and in bringing the right blade forward, that its concavity is carefully left 
 in contact with the fetal head. The blades now hold the head in its biparietal 
 
992 OBSTETRIC SURGERY. 
 
 diameter and tractions are begun. Artificial rotation is usually unnecessary, 
 and should be avoided by beginners. Traction should at first be somewhat 
 downward and backward according to the height of the head; the operator 
 endeavoring to make traction with reference to the axes of the different pelvic 
 planes through which the head must pass. If the head is in the upper part of 
 the cavity, it may be easier to pass the anterior blade first, as in the high 
 operation. 
 
 Pelvic Application {Figs. 1206, 1208). — In this case the forceps is applied as in 
 the low operation and the head is seized with one blade over the temple and the 
 other over the parietal protuberance of the opposite side. After the head has ro- 
 tated the forceps is removed and reapplied to the sides of the head. If the handles 
 are loosely held, the head may rotate between the blades. During the passage 
 of the head through the cervix undue haste must be avoided and the head allowed 
 to advance and recede in imitation of the natural process of dilatation. A finger 
 placed upon the cervical margin from time to time gauges the amount of tension. 
 A finger between the head and the symphysis pubis will also show how much 
 force is wasted in pulling against the symphysis. It should be the aim of the 
 operator to keep the head closely applied to the anterior pelvic wall, but with- 
 out pressing it against the symphysis. The operator should loosen his grasp 
 occasionally during a pain and see that he is not opposing rotation. The direc- 
 tion taken by the handles during a pain may serve to guide him. If the head 
 is in the upper part of the cavity, the axis- traction forceps should be preferred, 
 its skilful use improving the prognosis for both mother and child. If only the 
 ordinary forceps is at hand, good results can usually be obtained, and one hand 
 may be used as a fulcrum in the manner described in the high operation (page 
 997). In case of disproportion in size between the head and the upper part of 
 the pelvis, the Walcher position will be of service in increasing the conjugate 
 diameter and aiding engagement (page 870, Part X). 
 
 Low Operation. — In extraction under the simplest circumstances with the 
 head on the pelvic floor in the first vertex position, normal rotation having 
 occurred, the technique is as follows : 
 
 Introduction of the Left Blade. — The left blade is held with the left hand like 
 a sword in fencing, with the thumb at the inner aspect of the handle, the three 
 last fingers on the outer surface, and the index hooked over the flange-like 
 projection at the distal end (Figs. 1210 and 121 1). The right hand assists the 
 introduction by guiding the blade into the left side of the pelvis, and at the 
 same time protecting the maternal and fetal structures (Fig. 121 2). This work 
 is done by the index and middle fingers introduced into the left side of the pel- 
 vis as far as the child's ear and also paves the way for the forceps between the 
 fetal and maternal parts. The thumb, strongly abducted, lies in front of the left 
 labium majus. The handle is now elevated until it lies opposite the right groin 
 and the tip of the blade is introduced into the vaginal entrance between the 
 fingers of the right hand and the fetal head, on the left side of the pelvis. The 
 concave side of the blade is, of course, turned toward the fetus. The handle is 
 now gradually depressed until it is almost horizontal, and at the same time is 
 carried somewhat toward the patient's left. This movement carries the tip of the 
 forceps, protected by the two fingers, in a gentle curve about the head. The 
 border of the forceps slides along the thumb, from which it derives its direction. 
 
 Introduction of the Right Blade. — The right blade is introduced in the same 
 way, except that the movements are reversed and that the presence of the left 
 blade makes the introduction of its fellow somewhat more difficult. The utmost 
 gentleness is to be used in the foregoing movements; force is not allowable. 
 
THE FORCEPS. 
 
 993 
 
 The right hand now holds the right blade while the first two fingers of the left 
 hand are introduced into the right side of the pelvis preparatory to the intro- 
 duction of the right blade (Fig. 12 13). After the introduction of the right blade 
 both blades are held for a moment by the right hand while the left hand is with- 
 drawn from the vulva. If a blade cannot be introduced at first, it should be 
 withdrawn and a second effort made. To facilitate the introduction of the right 
 blade an assistant holds the handle of the left blade down and to the side. All 
 efforts to introduce the blades should be suspended during a uterine contraction. 
 
 Locking. — After both blades have been properly introduced they should lock 
 witliout difficulty. This is accomplished by taking a handle in each hand (Fig. 
 1214). Sometimes one blade is introduced further than the other, or the blades 
 may not be exactly opposite each other, and slight movements of adjustment 
 may be necessary. Difficulty in locking may indicate that the head has been 
 seized transversely or obliquely, in which case the instrument should be removed 
 and reapplied if possible; or it may indicate some 
 complication, e. g., an occiput posterior position or 
 hydrocephalus. 
 
 Test Traction. — The instrument is now grasped, 
 the lock by the right hand with the thumb under- 
 neath and the middle finger in the angle of the two 
 blades (Fig. 12 15). The left hand is now placed ^<«fe_w 
 
 across the right at a right angle, with the left index 1- Xj" 
 
 finger pointing forward at the site of the small fon- *^"^ ^ 
 
 tanelle; in this position gentle trial tractions are 
 
 Fig. 1210. — The Correct Manner of Holding a Blade 
 OF the Forceps. 
 
 Fig. 121 1. — Incorrect Ma.v- 
 NER OF Holding a Blade 
 of THE Forceps. 
 
 begun. The finger against the fetal head informs us whether the fetus follows 
 the traction and also detects slipping. 
 
 Method of Making Traction. — Tractions should be made by the use of the 
 arms and forearms, never by the weight of the body (Fig. 1216). They should 
 be made in imitation of nature during the pains, or, if these are absent at regu- 
 lar intervals, they should be intermittent, each traction lasting not more than 
 one minute. The aim should be to cause intermittent, alternate advance and 
 recession of the head, as in natural delivery. All haste and excitement should 
 be avoided. During the intervals between the tractions the handles should 
 be loosened in order to limit the compression of the fetal head. 
 
 Direction of Traction. — In every case the presenting part should conform 
 with the mechanism of labor. The traction should be downward until the ex- 
 ternal occipital protuberance is beyond the symphysis pubis. It is then made 
 in a forward direction, and as the occiput becomes visible it is gradually changed 
 until the handles are brought directly upward (Figs. 12 17 and 1218). 
 
 Extraction of the Fetus. — When the small fontanelle is visible, the left hand 
 is removed from the right in order to protect the perineum. Traction is con- 
 tinued until the nuchal region is in relation with the pubic arch ; this contact 
 63 
 
994 
 
 OBSTETRIC SURGERY. 
 
 being determined by the distance between it and the fontanelle. At this 
 stage of expulsion the right hand raises the handle until it almost rests upon the 
 abdomen and the head is born. The blades are now separated by the fingers. 
 It is usually advisable to remove the blades before final expulsion of the head 
 in order to lessen the stretching of the vulva and the risk of laceration. The 
 mechanism of labor may be aided during perineal dilatation by alternately 
 flexing and extending the head with the forceps, the handles being depressed 
 just as the external occipital protuberance clears the pubic arch in order to 
 produce complete flexion. The head may then be delivered at the pleasure of 
 the operator, or whenever he may think that sufficient perineal dilatation has 
 been secured. When the head is about to be delivered, many prefer to remove 
 the forceps and complete the delivery without it. This is advisable if the 
 adaptation is very close; e. g., in primiparas. If the forceps is removed too 
 soon, the head is apt to slip back into the vagina. Many authorities advise the 
 
 VAA^^^ 
 
 Fig. 
 
 -Introduction of the Left Blade of the Forceps. 
 
 introduction of the finger into the rectum in order to catch the child by the 
 chin, but it is better to keep the head in place when possible by pressure upon 
 the fundus or with a finger on each side of the coccyx (Fig. 1218). Intrarectal 
 manipulations are always to be avoided as far as possible, since they are not 
 conducive to asepsis, and even a careful use of this method may injure the eyes 
 of the child. 
 
 General Principles. — The left blade is applied first because of the construc- 
 tion of the lock. Two fingers suffice for guiding the forceps only when the head 
 is very low and when the margin of the os cannot be felt ; otherwise four fingers 
 should be employed. Great care is requisite lest the cervix be mutilated in the 
 grasp of the forceps. While the fingers guide the forceps in front, the thumb 
 performs the same function from the rear. Naturally an attendant could be of 
 assistance in the introduction of the instrument. All force is contraindicated 
 in the introduction of the blades. At times there is difficulty in locking the 
 instrument because the handles are not in the same plane. If the deviation is 
 
THE FORCEPS 
 
 995 
 
 slight, .they may be depressed a Httle, locked, and then elevated; but if it is 
 considerable, it is evidence that at least one blade has not been properly intro- 
 duced. In ideal forceps delivery the blades should be adapted to the convexity 
 of the parietal bone. Under these circumstances the handles are almost per- 
 pendicular to the sagittal suture. When they stand apart and cannot be locked, 
 an effort should be made to determine which blade is at fault by comparing the 
 direction of the handle with the suture. The difficulty detected, the blade 
 must be readjusted, but it is not always necessary to remove it. If simple 
 
 RIGHT 
 
 ^A!^[^ 
 
 ASSISTAUT 
 
 Fig. 12 13. — Introduction of the Right Blade of the Forceps. 
 
 traction with the hand crosswise over the lock is ineffective in moving the head, 
 light lateral movements, to-and-fro, may be made. If this is unsuccessful 
 traction may be made with both hands. Care must be taken not to compress 
 the handles, for this means compression of the fetal skull. The direction of the 
 traction should always be so ordained that the head describes movements 
 identical with those of natural labor. We must not attempt to use the forceps 
 as a lever at the time of the expulsion of the head ; the handles should be raised 
 during gentle, steady traction. To apply the principle of the lever would be to 
 
996 
 
 OBSTETRIC SURGERY. 
 
 brace the forceps against the symphysis, which has been known to lacerate the 
 venous plexuses by the side of the clitoris, while at the same time the pos- 
 terior margin of the blades may cut the posterior wall of the vagina. The for- 
 ceps occasionally slips or even comes entirely off. This may occur in two 
 forms: (i) Horizontal, (2) perpendicular. In the former the blades slip over 
 the sinciput or occiput, while in the latter the tips of the blades are pulled across 
 the head in the line of pull. When the hands are crossed over the lock of the 
 forceps, the index of the left hand is able to estimate the relations between the 
 pull and the advance of the head. 
 
 Median Operation. — Here, since rotation of the head has not occurred, the 
 
 4 ^ 
 
 Fig. 1214. — LocKixG the Blades of the FoRCEr's. 
 
 Fig. 121^. — Test Tractiox. 
 
 Fig. 12 r6. — Method of .Making Trac- 
 tion IN Anterior Positio.vs of the 
 Vertex. 
 
 sagittal suture lying in an oblique pelvic diameter, there are two methods of 
 operating. First, the forceps blades may be applied with relation to the sides of 
 tlie pelvis only, — this is the pelvic application (Figs. 1206, 1208); second, they 
 may be made to correspond or adapt themselves to the sides of the fetal head, 
 — this is the cephalic application (Figs. 1207, 1209). The latter procedure 
 or adaptation of the forceps should always be aimed at, and, after practice and 
 attention to the mechanism of labor, can always be accomplished. Cephalic 
 application secures a better prognosis for both mother and fetus by lessening 
 the amount of traction necessary for extraction, the amount of pressure to 
 secure a firm hold on the presenting part, and the danger of ruptures in the 
 genital tract. (Compare Rotation, page 1002.) 
 
THE FORCEPS. 
 
 997 
 
 Fig. 1217. 
 
 -Direction of the Traction in Anterior 
 Positions of the Vertex. 
 
 High Operation. — This operation should invariably be done under anesthesia. 
 The patient is put in the ex- 
 aggerated lithotomy posi- 
 tion on a table of sufficient 
 height. The operator is at 
 a great disadvantage if the 
 level is low, because in 
 making the necessary 
 downward traction he 
 would be compelled to 
 kneel. The buttocks 
 should be at the edge of 
 the table. 
 
 Ordinary Forceps. — The 
 operation is performed with 
 the ordinary forceps as fol- 
 lows: The blades should be 
 applied in the transverse 
 
 diameter of the inlet, therefore at the occiput and sinciput respectively, for the 
 
 head at the brim should usually not be 
 seized otherwise. The left blade is in- 
 troduced in the hollow of the right 
 hand into the left side of the pelvis, 
 and adapted by the aid of the fingers 
 to the fetal head, great pains being 
 taken to prevent the inclusion of the 
 thin margin of the dilated cervix. 
 The right blade is then introduced in 
 similar fashion and the instrument is 
 locked, strong pressure being made at 
 the same time against the perineum. 
 A trial traction is first made to see if 
 the hold is satisfactory, the forceps 
 being grasped over the lock by both 
 hands, the right overlapping the first 
 two fingers of the left (Fig. 12 15). 
 While the left hand makes traction in 
 the direction of the handle, the right 
 presses vertically downward over the 
 lock (Fig. 1 2 19). As a result the head 
 is drawn past the brim. The pressure 
 upon the lock is not transmitted to 
 the head as such, but the riglit hand 
 forms a fulcrum for the lock of the 
 forceps and the action of the left hand 
 carries the handle upward and the 
 blades and fetal head downward into 
 the pelvis. Traction should not be 
 prolonged over a minute, and after 
 every second traction an examination 
 should be made. The fetal heart should also be watched, and if fetal death occurs 
 the forceps should be detached and the head perforated. As the head enters the 
 
 Fig. 1218. — Remov.'VL of the Blades of the 
 Forceps, after Delivery of the Head. 
 
998 
 
 OBSTETRIC SURGERY. 
 
 pelvis the handles of the forceps are seen to rise. An examination should now 
 be made to determine the position of the head and whether or not rotation has 
 begun. If the head is turning, the handles are seen to approach each other. If, 
 on the other hand, the head is still transverse, careful and slight anterior rotation 
 of the occiput may be favored with the forceps. The head is then examined 
 again. As soon as rotation is apparent, I advise in all cases removal and adapta- 
 tion of the forceps to the sides of the head. The head may still persist in its high 
 transverse position, and in that case the blades must be reapplied obliquely. It 
 is not necessary to detach them, for each blade controlled by the finger may be 
 slipped along the head to the locality desired. This accomplished, traction is 
 made, while at the same time the occiput is rotated forward. The operation as 
 described is very difficult, especially if the degree of pelvic contraction is consider- 
 able. The obstetrician may be compelled to use the entire strength of both arms. 
 Excessive force, however, is to be deprecated, for the strength of one man is the 
 
 limit in this direction. If 
 still more force is neces- - 
 sary to pull the head into 
 the pelvis, fracture of the 
 cranial bones or intra- 
 cranial hemorrhage will 
 be certain to occur. If 
 traction is made in the 
 direction of the handles 
 without depressing them, 
 the force thus misdirected 
 does not advance the 
 child, but does make in- 
 jurious compression on 
 the anterior wall of the 
 pelvis. 
 
 Axis-traction Forceps. 
 — Since traction with the 
 ordinary forceps when the head is high in the pelvis necessarily tends to pull the 
 presenting part against the s^'-mphysis, numerous attempts have been made to 
 overcome this difficulty, (i) Some obstetricians use one hand as a fulcrum for 
 the shank of the forceps while the other hand seeks to tilt the fetal head into the 
 excavation, in which situation it becomes amenable to ordinary traction (Pajot) 
 (Fig. 1 2 19). These manoeuvers are described in full under the high operation. 
 (Page 997.) (2) Another old method consists in attaching tapes, so-called trac- 
 tion strings, to the blades of the forceps, so that the traction force exerted by the 
 operator would be more nearly in the axis of the birth tract (Poullet). (3) Still 
 another device consists in using one arm of the forceps as a lever, the blade being 
 passed between the fetal head and the symphysis, the latter serving as a fulcrum. 
 A tape is attached to the blade, and while one hand makes the leverage the other 
 performs traction (Farabeuf and Vamier). This principle, however, is best carried 
 out by a traction rod attached to the blades of an ordinary' long forceps which per- 
 mits of automatic traction and leaves little or nothing to the judgment of the oper- 
 ator. The credit for the introduction of the accessor}' traction rod into obstetrics 
 belongs wholly to Tamier (Fig. 1220). Owing to a sharp bend in the shank of the 
 rod, the "line of pull" actually passes through the pelvic floor, although traction 
 in this imaginary line is intended only to carry the head into the excavation. An 
 ordinary long forceps furnished with a two-armed traction rod constitutes the 
 
 Fig. 1219. — The Principle of Axis-traction Applied 
 WITH Ordinary Forceps. Pajot's Manceuver. 
 
THE FORCEPS. 
 
 999 
 
 Fig. I220. — The Principle of the Axis-tractio.v 
 Forceps. A, The blade of the forceps appHed to 
 the fetal head at the pelvic inlet. B, The traction 
 rod at right angles to the handle of the forceps. 
 A, B, The direction of the traction. 
 
 axis-traction forceps as originally introduced by Tamier. Numerous modifica- 
 tions of this principle are in use to-day. A further advantage of Tamier's forceps 
 is found in the movable joints formed at the insertion of the traction rod into 
 the blades of the forceps, by virtue of which the blades are left free to follow 
 the natural movements of the 
 head (Fig. 1221). 
 
 Application. — The blades 
 of the Tarnier forceps are ap- 
 plied like the ordinary instru- 
 ment, the traction rods being 
 grasped in the hand alongside 
 of the shank. The traction 
 handle is then adjusted, and 
 the force of traction is exerted 
 upon these handles with one 
 or both hands (Fig. 1223), the 
 handles proper of the instru- 
 ment merely serving to indicate 
 the direction the traction is 
 taking. 
 
 It is necessary for the suc- 
 cess of the operation that the 
 traction rods should be not 
 more than half an inch (1.5 cm.) 
 
 beneath the handles proper, and that the handle-bar of the traction rods should 
 be always in a horizontal plane, no matter what the position of the blades mav 
 be (Fig. 1222). After the head has been drawn into the pelvis the handle-bar 
 may be disconnected and the fetus extracted with the handles proper of the 
 instrument, or the entire forceps can be removed and further extraction per- 
 formed with the ordinary 
 forceps. 
 
 Occipito-posterior Posi- 
 tions. — The forceps is indi- 
 cated in occipito-posterior 
 positions only when the 
 life of mother or child is 
 threatened. The applica- 
 tion of the forceps in these 
 cases is much more difficult 
 than in the physiological 
 cranial positions. As the 
 parietal eminences are seat- 
 ed somewhat more deeply 
 than in the latter, the han- 
 dles of the forceps are more 
 nearly vertical when the 
 blades are applied. 
 (The treatment of occipito-posterior position is used. 
 
 Fig 
 
 1221. — ^Tarnier's Axis-traction Forceps. Latest 
 Pattern. 
 
 (i) In high cases. 
 page 545, Part V.) 
 
 (2) In medium cases. Should assistance be needed, the forceps will be called 
 for. The head being well engaged, I am accustomed always to use the cephalic 
 application of the instrument, namely, adapting the blades over the fetal ears. 
 
1001) 
 
 OBSTETRIC SURGERY. 
 
 When the forceps is to be used as a rotator, the cephalic in preference to the 
 pelvic application should always be aimed at, as the prognosis for both fetus and 
 
 maternal soft parts is more 
 X favorable. Downward trac- 
 
 tion should then be made in 
 the proper axis until the 
 head is brought to the pelvic 
 floor. If in its descent there 
 is a tendency on the part of 
 the occiput to rotate about 
 the shortest segment of the 
 pelvis to the pubis, this ro- 
 tation should be encouraged, 
 but no marked rotation with 
 the forceps as rotator should 
 be made until the head has 
 reached the levator ani mus- 
 cle. An excellent instru- 
 ment for this class of cases 
 as well as the high ones is the 
 last model of the Tarnier 
 axis-traction forceps. The 
 forceps is applied reversed 
 (inversion of the forceps); 
 namely, with the concavity 
 of the pelvic curve toward the posterior part of the pelvis, and, of course, 
 
 toward the occiput. Leaving the 
 handles to take care of themselves, 
 \ traction is made upon the traction 
 
 rods only, and the swivel connect- 
 
 ^ ,. \ ing these with the blades will allow of 
 
 ,. ^ \ spontaneous rotation on the part of 
 
 ; the head durin^ its descent. Ordi- 
 
 FiG. 1222. — Diagram Showing Traction with the 
 Tarnier Forceps. A, B, In proper, and X, Y, in 
 improper manner. — (Ribemont-Dessaignes.) 
 
 Fig. 1223. — Tarnier Forceps Applied to 
 the Head at the Inlet. (There should 
 be less space between the traction rod and 
 shank of the instrument.) 
 
 Fig. 1224. — Faulty Direction of Trac- 
 tion with the Ordinary Forceps 
 
 nary fenestrated or solid-bladed forceps will usually answer quite as well as the 
 axis-traction ones (Fig. 1229). 
 
THE FORCEPS. 
 
 1001 
 
 Double Application of the Forceps. — Another valuable procedure in high ar- 
 rest of an occipito-posterior position of the head, and which I frequently make 
 use of, is what is known as the double application of the forceps or Scanzoni's 
 mauceuver. 
 
 First Step. — In the right occipito-posterior or most common occipito-pos- 
 
 FiG. 1225. — Double Application of the 
 Forceps in Occipito-posterior Posi- 
 tion. First Application. 
 
 Fig. 1226. — Double Application of the 
 Forceps in Occipito-posterior Posi- 
 tion, Showing Rotation of the Head 
 into Transverse Position. 
 
 Fig. 1227. — Double Application of the 
 Forceps in Occipito-posterior Posi- 
 tion. Rotation into anterior position. 
 Inversion of the forceps. 
 
 Fig. 122S. — Double Application of the 
 Forceps in Occipito-posterior Posi- 
 tion. Second Application of the For- 
 ceps. 
 
 terior position, the Tarnier instrument is applied, as if the case were one of lett 
 occipito-anterior, namely, with the pelvic curve of the forceps looking toward 
 the left acetabulum and face of the fetus. The blades are adapted to the sides 
 of the fetal head, the ears being used as guides. The lower or left blade is in- 
 troduced first somewhat toward the hollow of the sacrum. The right blade is 
 then introduced into the right side of the pelvis, and with the left hand along- 
 
1002 OBSTETRIC SURGERY. 
 
 side of the head and the right grasping the handle, this blade is carried forward 
 and upward until it rests over the left ear and opposite the blade already in- 
 troduced (Fig. 1225). 
 
 Second Step. — Downward traction is now made on the traction handles until 
 the head is brought to the pelvic floor, and then anterior rotation of the occiput 
 is encouraged until the sagittal suture comes first into the transverse and then 
 into the left oblique pelvic diameter. The forceps are now found to be inverted 
 (Figs. 1226, 1227). 
 
 Third Step. — The forceps are now removed and reapplied as in the right 
 anterior position of the occiput (Fig. 1228). 
 
 At this step in the operation I am accustomed to substitute for the Tarnier 
 the ordinary forceps, and complete the delivery with the latter. 
 
 This method of treating persistent occipito-posterior of the head will often 
 succeed when one has failed in the attempt to deliver with the ordinary forceps, 
 or by first inverting the Tarnier instrument. 
 
 (3) In low cases. In operating, the usual conditions preparatory to any for- 
 ceps operation should be fulfilled, and straight, fenestrated, or solid-bladed forceps 
 may be used. I have used both the fenestrated and the solid-bladed forceps, and 
 find that the latter has certain advantages in ease of application, rotation, and 
 safety to the maternal soft parts not possessed by the former. This is particularly 
 true of difficult cases. The straight forceps with no pelvic curve, such as Taylor's, 
 is not necessary for the success of the operation. When the occiput is directly 
 toward the sacrum and not opposite either synchondrosis, I am accustomed to 
 reverse the forceps, applying it upside-down, so to speak, with the lock down and 
 pointing to the occiput. In all cases adaptation of the instrument renders the 
 prognosis more favorable for mother and fetus. The forceps being properly 
 applied, our object should be always to keep the points of the instrument in as 
 nearly the center of the pelvis as possible; always to combine rotation with down- 
 ward traction ; to rotate only in a very small segment of a circle during one trac- 
 tion; and, if uterine contractions are present, to time the combined traction and 
 rotation with uterine action. During the intervals of uterine contractions the 
 head should be held in the position obtained in order to allow the fetal body time 
 to rotate also and accommodate itself to the new position of the head. Body 
 rotation can be confirmed by abdominal palpation. In my experience abdominal 
 palpation with a view to assist body rotation is of little, if any, advantage. If the 
 forceps has not been reversed after the occiput has been rotated into the anterior 
 segment of the pelvis, it will be necessary to remove and reapply the instrument 
 if delivery is to be terminated at this time, which is the wisest course to pursue. If 
 the forceps was originally reversed, this removal and readjustment is, of course, 
 unnecessary. 
 
 Forceps as Rotators (Figs. 1229, 1 230). — Much controversy has arisen over this 
 question.* Many authorities claim that the production of rotation of the head by 
 instrumental means through an arc of 180 degrees or even 90 degrees is attended 
 by so much danger of producing lacerations of the maternal soft parts and injuries 
 to the fetal head or neck as rarely to be justifiable. A careful study of the subject, 
 and especially of the value of adaptation of the forceps to the sides of the fetal 
 head, will convince any unprejudiced operator that with care and due regard to 
 the mechanism of labor the operation is quite safe for both mother and fetus. 
 For ten years the author has been using straight, fenestrated, and solid-bladed 
 forceps as rotators in occipito-posterior cases, in tardy rotation of the head in 
 vertex and face presentations, and of the after-coming head in breech extractions, 
 * Compare treatment of persistent occipito-posterior position, page 545 
 
THE FORCEPS. 
 
 1003 
 
 and he sees no reason to abandon the procedure. The requirements for a good 
 result in instrumental rotation are: (i) An accurate diagnosis of the presenta- 
 tion and position, obtained under anesthesia and by the introduction of the 
 whole hand if necessary. (2) The cephalic application or adaptation of the 
 forceps blades to the side of the child's head as early in the operation as pos- 
 sible. (3) A close imitation of the normal mechanism of labor in the casein 
 question. (4) The combina- 
 tion of rotation and down- 
 ward traction at one and 
 the same time. (5) Most, 
 if not all, of the rotation 
 should be performed after 
 the lowest portion of the 
 presenting part has reached 
 the pelvic floor, as in spon- 
 taneous rotation. 
 
 Pelvic Presentations. — 
 Skutsch does not even dig- 
 nify this use of the forceps 
 with a paragraph in his re- 
 cent voluminous work on 
 obstetric operations. Most 
 authorities, however, con- 
 tinue to recommend it in 
 
 certain conditions. Forceps appear to be indicated in breech cases before it is 
 possible to use the finger or a fillet to produce traction. Jewett recommends 
 Olliver's axis-traction forceps. If the breech is fixed transversely in the pelvis, 
 the blades should be applied over the trochanters. Pressure over the iliac crests 
 is held to be dangerous and, generally speaking, the entire procedure is calcu- 
 lated to cause more or less injury to the fetus. As the hold cannot be very firm, 
 
 Fig. 
 
 1229.- 
 
 -ROTATION OF THE HeAD WITH ORDINARY 
 
 Forceps. 
 
 forte )J5 
 
 fovtefS 
 
 Fig. 1230. — Rotation with the Forceps. The head in i lies transverse in the pelvis, 
 with the occiput to the left. The forceps is applied in the left oblique pelvic diam- 
 eter, and the head is rotated (2, 3) from left to right until the occiput is anterior (3) 
 and the forceps in the right oblique pelvic diameter. 
 
 traction must be slight and made only during pains, assisted by manual compres- 
 sion of the fundus. In my experience fetal traumatisms are frequent. 
 
 After-coming Head (Figs. 1231, 1232). — The application of thefor ceps to the 
 after-coming head, formerly much in vogue, has been displaced gradually by 
 various methods of manual extraction, which, being capable of continued im- 
 provement, have greatly benefited the chances for survival of the child. Therefore 
 
1004 
 
 OBSTETRIC SURGERY. 
 
 it is not surprising that many obstetricians advise doing away with instru- 
 mental delivery in these cases altogether. A majority, however, are in favor 
 of using the forceps in certain cases, although the indications appear to be 
 much confused in most standard books. The forceps is indicated in but a very 
 small proportion of cases of after-coming head. It is positively contraindicated 
 when the head is above the brim, for if manual extraction is unsuccessful the 
 head will probably have to be perforated, since the child will almost certainly be 
 dead. The indications for the forceps are three in number, (i) The head is in 
 the excavation with its long diameter antero-posteriorly or oblique, and, man- 
 ual procedures having failed, immediate delivery is necessary to save the child's 
 life Experience has taught me that now and then a fetal life may be saved. 
 
 Fig. 1231. — The Forceps Applied to the After-comixg Head in a Sacro-anterior 
 
 Position. 
 
 (2) In abnormal rotation with the head extended, the face in front, and the chin 
 over the symphysis. (3) In cases in which prolonged traction on the trunk 
 threatens to rupture the child's neck. Such an accident might readily occur in 
 a fetus long dead or in the presence of some disease. If the head is thus left 
 behind, we have the condition known as detached head, to be described later. 
 Technique: The general rule in vertex anterior cases is to apply the forceps 
 below the child, which is lifted upon the mother's abdomen by the legs, care 
 being taken not to stretch its neck. The arms are raised with the trunk; 
 the forceps is applied in the usual manner, care being taken not to grasp the 
 cord. Traction should be made in the direction of the handle until the chin 
 appears. Thereupon the nuchal surface of the child should be made to rotate 
 beneath the pubic arch, the handles being turned toward the mother's ab- 
 
THE FORCEPS. 1005 
 
 domen. I am accustomed to apply the forceps above the child in occipito- 
 posterior positions, while others simply advise that the instrument be applied 
 in the easiest manner possible and independently of set rules. Detached head: 
 In breech extraction the head may be detached and left in the uterus by accident 
 or design. In the former instance the mishap arises from decapitation of the 
 dead child as a result of too forcible traction. In the latter case the head is left 
 after deliberate decapitation. If attempts at manual extraction fail, the forceps 
 may be applied, although cephalotripsy, if available, is the more rational 
 course. 
 
 Face Presentations (Fig. 1233). — The general principle in the management 
 of these cases is expectancy. There is no indication, from the position alone, 
 to apply the forceps. Only when the life of mother or child is threatened should 
 
 ""^ft.. 
 
 Fig. 1232. — The Forceps Applied to the After-coming Head in a Sacro-posterior 
 
 Position. 
 
 we resort to instrumental intervention. In mento-anterior positions with the 
 face in the antero-posterior diameter, extraction should be easily effected. The 
 handle of the forceps should be higher than in cranial occipito-posterior posi- 
 tions. If this point is overlooked, the tips of the forceps may compress the fetal 
 neck. Traction should be made in the direction of the handle until the chin is 
 born beneath the symphysis, the child's throat being in contact with the liga- 
 nientum arcuatum. The handle is now turned strongly upward toward the 
 mother's abdomen, and the face, brow, vertex, and occiput are born in suc- 
 cession over the perineum. The forceps carries the head from its position of 
 extreme extension to one of flexion. As the handle of the instrument arrives 
 at the abdomen the task is finished and the forceps should be detached. If 
 the mento-anterior face is in an oblique diameter, the forceps is applied trans- 
 
1006 
 
 OBSTETRIC SURGERY. 
 
 versely unless the obliquity is extreme. Then, under traction, the head rotates 
 normally. The oblique application is not contraindicated. In the second 
 facial position, chin to the right, the left blade should be applied in front; in 
 the second, chin to left, the right blade goes in front. In a deep transverse 
 facial position the forceps is applied obliquely with the pelvic curve turned 
 toward the chin. The conditions are analogous to forceps delivery in deep 
 transverse head (page 1006). Mento-posterior position: In mento-posterior 
 positions with the indication for immediate extraction the forceps is of no 
 service and the head must be perforated. Scanzoni's method of rotating 
 the head with the forceps must be condemned. Some obstetricians hold that 
 the mancEUver may be feasible in some cases in the hands of an expert, but it is 
 rarely safe. The head is grasped at the sides, the forceps being applied obliquely 
 with the concavity of the pelvic curve directed in front. The face is now rotated 
 into the transverse position. The blades are then detached and reapplied in the 
 
 Fig. 1233. — Forceps in Face Presentation. Mento-anterior Position. 
 
 manner described for deep transverse face. (Compare Treatment of Mento- 
 posterior cases. Part V, page 550.) 
 
 Brow Presentation. — The forceps should be applied as in bregma and face 
 presentations with the handles relatively high in order to obtain the best possible 
 grasp of the head. In making traction we should always be controlled by knowl- 
 edge of the mechanism in these cases. We should pull in the direction of the 
 handles until the root of the nose arrives at the ligamentum arcuatum. The 
 handles are then lifted well up and carried to the mother's abdomen, while the 
 vertex and occiput are bom over the perineum. The handles are then brought 
 down again, pressure being made at the same time with the hand on the brow, 
 and the remainder of the face is delivered. There is therefore an analogy, from 
 the standpoint of forceps delivery, between brow and occipito-posterior positions. 
 
 Deep Transverse Head. — There is no indication for the use of instruments 
 in this position save immediate danger to mother or child. The forceps, in order 
 to grasp the head over the parietal eminences, would have to be without pelvic 
 
THE SLING OR SOFT FILLET. 
 
 1007 
 
 curve (straight forceps). If the ordinary instrument is used, the blades must be 
 applied in an oblique diameter and the concavity of the pelvic curve must be 
 turned toward the occiput. The latter is then rotated forward till the concavity 
 of the forceps is turned to the anterior pelvic wall. If the occiput was on the 
 left side of the pelvis, it rotates into the L. 0. A., and vice versa. When the 
 head is ready for extraction, the concavity of the side of the forceps must corre- 
 spond with the curvature of the pelvic canal. Occasionally it happens that the 
 mere locking of the forceps produces some rotation forward of the occiput, so that 
 when the blades are brought into the transverse diameter the sagittal suture 
 is found to be in the antero-posterior diameter. In this case as soon as the 
 neck of the child reaches the pubic arch the handle is brought upright in the cus- 
 tomary manner. If the small fontanelle is not brought to the middle line when 
 the blades are in the transverse diameter, extraction must be accompanied by a 
 slight degree of rotation. 
 
 VIII. THE SLING OR SOFT FILLET. 
 
 The sling, soft fillet, noose, fillet, or loop, as it is variously called, is occasion- 
 ally used in obstetric manipulations, and could, I am certain, with advantage be 
 much more frequently employed. 
 
 Indications and Actions. — The sling is used chiefly in cases of high arrest of 
 the breech, and it should be noted that it has five 
 distinct uses: viz., (i) As a tractor; (2) to prevent 
 recession of the presenting part; (3) to facilitate 
 manipulations by drawing the presenting part to 
 one side; (4) to serve as an accessory when the 
 simultaneous employment of both hands is for- 
 bidden by lack of space; (5) to prevent extension 
 of the arm or arms. 
 
 Material and Carriers. — A yard of two-inch 
 gauze bandage boiled and moistened with i per 
 cent, lysol solution answers very well for a soft 
 fillet. Another excellent fillet is a yard of one- 
 fourth-inch rubber tubing through which a tape 
 is passed, stitched to the side of the tubing, and 
 allowed to project six inches at both extremities. 
 In many cases fillets can be passed over the thigh 
 with the index finger. This will often necessitate 
 the passage of the whole hand into the vagina. A 
 ready method is to take a No. 16 English catheter 
 with stylet in place, and bend the end of the cath- 
 eter into a hook of the shape of the ordinary 
 blunt hook (Fig. 1109). A doubled piece of tape 
 or bobbin is threaded into the edge of the catheter 
 by means of the stylet, and the hook with the tape 
 is passed over the thigh in the most convenient 
 
 manner. The tape is then caught with two fingers or a pair of dressing forceps and 
 the catheter withdrawn. The tape is now used as a sling to draw the desired fillet 
 into position Blunt hooks are often perforated with an eye at the extremity and 
 used instead of the catheter. A fillet carrier or porte-fillet is a special instrument 
 
 Fig. 1234. 
 
 JUSTING 
 
 Foot. 
 
 Method of Ad- 
 L Sling to the 
 
1008 
 
 OBSTETRIC SURGERY. 
 
 made for the purpose. It is on the principle of Bellocq's cannula used by sur- 
 geons in drawing up a plug into the posterior nares. It is curved like the ob- 
 stetric blunt hook and has a long piece of whalebone running through the canal. 
 In Pelvic Presentation. — Here the soft fillet is used as a tractor. In low arrest 
 of the breech the hand usually proves the best tractor, and even in high arrest 
 it is sometimes possible to pass a finger or several fingers into the flexure of 
 the groin; when the hand cannot be used, we resort to the soft fillet or forceps. 
 Traction with a single or double fillet, in impacted pelvic presentations, is a valu- 
 able means of extraction, much safer in the hands of most operators than the 
 blunt hook or forceps, and a method of delivery, I believe, too seldom resorted 
 
 to. Often in tardy breech ex- 
 pulsion the delay is caused by 
 flexion of the fetal pelvis upon 
 the trunk, and perhaps by ex- 
 tension of the legs alongside 
 of or above the fetal head. 
 Traction on one or both groins 
 extends the pelvis, draws 
 down the feet, and thus ren- 
 ders the passage of the breech 
 through the parturient canal 
 easier, provided no great dis- 
 proportion exists between 
 fetus and maternal pelvis. 
 Sling to one groin: When a 
 single sling is used, it should 
 encircle by preference the an- 
 terior or lower thigh, and in 
 the majority of cases a single 
 sling is sufficient. ~ I have in 
 difficult cases combined the 
 sling to the anterior groin and 
 the protected blunt hook to 
 the posterior (Fig. 1177). 
 Sling to both groins: Unless 
 too great difficulty is encoun- 
 tered it is preferable to pass a 
 soft fillet over both groins, as 
 by so doing the force of trac- 
 tion is more evenly distribut- 
 ed and there is less danger of 
 injury to the soft parts and 
 the heads of the femurs. Sling encirchng fetal pelvis: Although it is difficult and 
 often impossible to apply a fillet encircling the fetal pelvis, with the ends passing 
 down between the thighs, it is the safest and most efficient way. The English ad- 
 vise the use of a soft handkerchief for the purpose, but a piece of four-inch gauze 
 bandage a yard long, boiled and lubricated with a i per cent, lysol solution, an- 
 swers better. A. knot is tied at each end, and one knot is carried with the fingers-, 
 an English catheter, or a porte-fillet, on one groin from without inward, until the 
 knot can be reached between the thighs and drawn down. In like manner the 
 other end of the fillet is passed over the opposite groin from without inward, thus 
 bringing both ends of the fillet down between the thighs. With the whole hand if 
 
 Fig. 
 
 1235. — Adjusting .\ Slixg to the Left Ante- 
 rior Leg 
 
THE BLUNT HOOK. 1009 
 
 necessary in the vagina, the center of the fillet is adjusted up over the buttocks and 
 around the fetal pelvis by an upward movement of the internal hand and down- 
 ward traction on the two ends of the fillet with the external hand. The fillet is 
 thus made to make traction on the external circumference of the pelvis, thus re- 
 lieving the groins from the dangerous traction exerted by the other forms of fillet. 
 It is not always possible to adjust this sling after the breech is firmly impacted in 
 the pelvis, and even at the pelvic inlet it is at first difficult unless it has been 
 repeatedly practised on the puppet and pelvis or manikin (Fig. 1176). 
 
 In Version. — It is especially in complicated internal version that the soft fillet 
 finds its chief use (page 935). 
 
 Placenta Praevia. — It occasionally happens that a combined or internal ver- 
 sion is performed in placenta praevia; one leg is brought down and the half 
 breech used to tampon the partially dilated cervix. Under such circumstances 
 the version is not always followed by immediate extraction, and in the mean 
 while a soft sling to the prolapsed leg is a convenient way to keep up pressure 
 ■on the placenta and prevent recession of the leg (Fig. 1080). 
 
 Prolapse of the Cord. — In like manner the sling may be used after version in 
 prolapse of the cord to hold the half breech temporarily in the partiall}^ dilated 
 cervix and thus prevent recurrence of the prolapse. 
 
 In Prolapse of an Arm in Shoulder Presentation (Fig. 11 26). — In cases of ver- 
 sion in shoulder presentation complicated by prolapse of an arm the sling is ap- 
 plied to the wrist and used to draw the arm forward and backward, thus making 
 room for the passage of the hand into the uterus, and afterward to prevent 
 extension of the arm and subsequent difficulty in extracting the head. In all 
 cases care should be taken not to injure a fetal member by tying the sling too 
 tightly or making traction too forcibly. Sawing movements should be avoided, 
 since they may cause extensive laceration of the fetal parts. When the pre- 
 senting part is high and difficult to reach, it is often convenient to pass the loop 
 over the operator's arm. It may then be pushed up by a pair of long forceps 
 or some similar instrument (Fig. 11 28). 
 
 Combined Manipulation in Version. — When there is difficulty in turning in 
 internal podalic version, in cephalic or shoulder presentation, by reason of the 
 grasp of the uterus over the fetus, success may sometimes be obtained by attach- 
 ing a sling to a foot and making traction on the foot by means of the end of the 
 sling outside of the vagina, and at the same time, with the other hand in the 
 vagina, making upward pressure upon the head or shoulder. Skilled assistance, 
 by depressing the breech and pushing up the head externally, will greatly aid the 
 rnanoeuver (Fig. 11 29). 
 
 Prophylactic Sling inversion. — It has been proposed, as a preliminary to in- 
 ternal podalic version, to fasten a sling on one or both fetal wrists in iitero, the 
 object being at all stages of the operation thus to keep both forearms below the 
 chin and prevent extension of the arms. The procedure is a dangerous and 
 an unnecessary one, for, although theoretically correct, the manipulation of the 
 fetal thorax and umbilical cord will in many cases disturb the equilibrium of the 
 fetal circulation and cause asphyxia by premature respiration within the uterus. 
 
 IX. THE BLUNT HOOK. 
 
 The blunt hook, made entirely of metal for aseptic reasons, about twelve 
 inches long and with a semicircular curve at the end forming a hook the diameter 
 64 
 
1010 
 
 OBSTETRIC SURGERY. 
 
 of which is two inches, is still a valuable and useful instrument in operative 
 obstetrics (Fig. 1236). 
 
 Uses. — The use of the blunt hook should be confined principally, if not en- 
 tirely, to the extraction of the dead fetus. It may be passed over the groin in 
 breech presentation for traction, then over the brim of the fetal pelvis, and hooked 
 into the ribs or over the shoulders or a humerus in difficult shoulder extraction. 
 In the case of a living fetus the blunt liook should be used with the greatest care, 
 if at all ; the soft fillet or digital traction is usually to be preferred. On the living 
 its use is principally confined to traction on the anterior or pos- 
 terior groin or both in difficult breech extractions. It is not 
 desirable to use this instrument on a living fetus unless all 
 other methods of extraction fail, by reason of the injury to the 
 fetal soft parts and to the head of the femur liable to follow its 
 use. To avoid injury to the skin of the groin, the writer is 
 accustomed to slip a piece of tightly fitting rubber tubing over 
 the hook and shank of the instrument, sterilizing the whole 
 before use. Wrapping the hook and several ' inches of the 
 shank with a one-inch gauze bandage also answers very well 
 in the absence of the rubber tubing. The blunt hook, thus 
 protected, carefully and judiciously used, becomes a valuable 
 instrument in impacted breech cases, but in the hands of the 
 careless and inexperienced in its use it is capable of much in- 
 jury to the fetus. It is advisable to pass the hook over the 
 anterior thigh in breech cases, since this thigh is lowest and 
 most readily reached. It is passed up lying flat against the 
 thigh, with the hook pointing toward the anterior surface of 
 the fetal ellipse until opposite the groin, the hook then being 
 passed over the. flexure of the thigh, care being taken to have 
 the hook descend between the thighs and not catch on one 
 thigh, to avoid damage to the femur and the femoral vessels. 
 The proper adjustment is secured by digital palpation between 
 the thighs. 
 
 Fig. 1236. — The 
 Blunt Hook. 
 
 X. THE CROTCHET. 
 
 The crotchet was an instrument which in the days of cranio- 
 tomy was used for the extraction of the mutilated head after 
 the vault of the skull had been removed piecemeal with the 
 craniotomy forceps. It is practically a sharp hook about f inch 
 in length with a suitable handle for traction. The instrument 
 is now obsolete, but may be found among the collections of 
 instruments in the older maternity hospitals, and upon inquiry 
 at the three largest instrument-makers in New York I fotmd the instrument was 
 at first unknown, until reference was made to an illustrated price-list. Occasion- 
 ally in the past ten years I have used the instrument in the extraction of a dead 
 fetus, when fixed in an axilla, between the ribs, or any available part of the body. 
 The blunt hook may be used in the same way. Originally, for extraction after 
 perforation or craniotomy the hook was passed into the interior of the skull and 
 moved about until a firm hold was secured upon the bones of the vault or sides of 
 the skull. It was not intended, nor was it possible, to fix it in the foramen mag- 
 
CESAREAN SECTION. 1011 
 
 num, as is so often stated in the text-books. Quite another instrument, namely, 
 the vertebral hook, was used for that purpose. 
 
 XI. EXTRACTION OF THE FETUS MUTILATED BY 
 EMBRYOTOMY. 
 
 Extraction of the fetus after (i) perforation (page 944) 1(2) cranioclasis (page 
 947)1 (3) cephalotripsy (page 951); (4) decapitation (page 955); (5) eviscera- 
 tion (page 960); (6) cleidotomy (page 961); and (7) spondylotomy (page 963), 
 is described under the heads of these operations as above indicated. 
 
 XII. C^ESAREAN SECTION. 
 
 Definition, — The term Caesarean section is applied to the operation also called, 
 in accordance with modern ideas of nomenclature, laparo-hysterotomy, which 
 consists in the extraction of the child through an abdominal and a uterine in- 
 cision. 
 
 Historical. — The derivation of the term Cesarean is wrapped in some obscurity, but 
 the best evidence seems to connect it with the name Csesar, which in turn seems very hkely 
 to have its origin in the root of the verb "caedere," to cut. A form of the operation seems 
 to have been known early in the history of Rome, and it is recorded that an ancient ruler 
 of that city, Numa Pompilius, caused a law to be enacted requiring the operation on recently 
 dead women far advanced in pregnancy so that mother and child might be interred sepa- 
 rately. Certain tribes have likewise made it customary to remove the child even when there 
 was no thought of its survival. Medieeval records of the operation are few and unsatis- 
 factory, and of no great interest except historically. A case is recorded from Venetian 
 sources in 1491, and somewhat later a Swiss peasant is said to have done the operation 
 upon his own wife, though certainly not before death. Somewhat later, apparently, the 
 possibility of doing the operation upon the living began to be discussed, and the question 
 of how much risk the mother should be subjected to in order to save the child began to 
 be argued. The first operation upon the living appears to have been done in 1610 by 
 Trautman, though it is really only since the advent of antisepsis that the operation can 
 ' be said to have assumed a recognized and important place among obstetrical pro- 
 cedures. The consensus of opinion always has been, and still is, that the life of the mother 
 is more important than that of the child, and that the former should not be subjected to 
 chances the favorable results of which accrue to a great extent to the latter. The field for 
 Caesarean section is therefore limited, though under modem conditions, with a proper 
 selection of cases, the risks to the mother have been very greatly diminished and the opera- 
 tion has, in many instances, come into competition with embryotomy and symphyseotomy. 
 The doctrine of the Roman Catholic Church has always been that it is a mortal sin to com- 
 pass the death of the child in order to extract it, and among adherents of that faith this 
 fact may sometimes have a bearing upon the choice of this operation in preference to 
 embryotomy. The operation of embryotomy upon a living child at or near term is the most 
 revolting thing which a medical man can be called upon to do, and whenever there is a 
 reasonable prospect that the abdomen can be opened and the child thus removed with no 
 greater risk to the mother than is incurred by any procedure which involves the sacrifice of 
 the child, Caesarean section may be undertaken. The earlier writers in the last half of the 
 nineteenth century spoke very disparagingly of Caesarean section and looked upon it as a 
 last resort in desperate cases, a fact which explains to a great degree their almost uniform 
 lack of success. When antisepsis came in, and when cases began to be properly selected, 
 the proportion of successes began to rise, until at present it has reached a comparatively 
 encouraging figure. The few instances in history in which prominent men are said to have 
 been brought into the world by the abdominal route are not authenticated, and in all it is 
 uncertain whether the mother was alive or dead at the time of the alleged operation. 
 
 Indications. — The indications for this operation are of two kinds — positive 
 and relative; the former of which may be disposed of in a few words. Caesa- 
 rean section is positively indicated when the maternal or fetal dystocia is 
 
1012 OBSTETRIC SURGERY. 
 
 so great that it is impossible to remove the fetus even after embryo- 
 tomy. The relative indications for the operation are not so clearly marked. 
 When it is evident that embryotomy can be done successfully and without 
 great risk to the mother, the question in the presence of a dead child is 
 easily decided, but if the child is alive the proper course is not so clear. The 
 good results which have recently followed Caesarean section have led many 
 operators to consider that a conjugate of 3 inches (7.62 cm.) with the child 
 living, and 2.76 inches (7 cm.) with the child dead, requires the operation. 
 It is to be remembered that in cases in which the difficulty is due to a fiat rather 
 than a generally contracted pelvis, a shorter conjugate will suffice to effect 
 delivery through the natural passages. In 1887 Lusk, of New York, declared 
 that embryotomy in a greatly contracted pelvis was as dangerous to the mother 
 as Cassarean section, and that since the former operation always sacrifices the 
 child, we should not wait too long before resorting to the latter when other means 
 of delivery fail. These views have been substantiated by many later observers. 
 We. should remember that in rachitic dwarfs the indication for Cesarean section 
 is practically always present unless labor is induced at a very early date in the 
 pregnancy, and if such patients are met with later we must anticipate the neces- 
 sity of the operation. As a rule, Csesarean section should be done at term, but it is 
 not necessary to wait for labor to begin. A point in favor of the Caesarean opera- 
 tion is that by it measures can be taken to prevent future conceptions by tying 
 and dividing the Fallopian tubes. While pelvic deformity is the commonest 
 condition which requires this mode of delivery, carcinoma of the cervix pre- 
 venting dilatation and pelvic tumors of almost any kind may be the cause 
 of the dystocia. Eclampsia and placenta praevia have sometimes been put 
 down as conditions which may occasionally demand Caesarean section; how- 
 ever, while it is conceivable that it might be advisable to do the operation 
 in eclampsia, it is safe to say that placenta praevia will rarely demand 
 it. The decision to operate must always depend to some extent upon 
 the characteristics of individual cases, and experience alone will enable us to 
 draw uniformly just conclusions, but the figures given above — a conjugate of 
 3 inches (7.62 cm.) for a living child and 2.5 inches (6.35 cm.) for a dead one — may 
 be taken as correct in indicating the operation, barring special and unusual con- 
 ditions. In cases in which the conjugate is over 3 inches ( 7.62 cm.), but still some- 
 what or considerably under normal, judgment is required to avoid extremes and 
 decide between the comparative advantages of premature labor and symphyse- 
 otomy. We must not wait until the patient is so exhausted from shock, 
 hemorrhage, or sepsis from absorption that she has no recuperative powers left. 
 When we have concluded to operate, we have still to choose between Caesarean 
 section and the so-called Porro modification. Cameron has made about fifty 
 patients sterile by dividing the Fallopian tubes between ligatures, and has had no 
 bad results after the operation. This procedure must also be considered, since its 
 success naturally removes a great future danger, and the theoretical danger of 
 subsequent pelvic hematocele has not been encountered. 
 
 Prognosis. — The prognosis in Cesarean section is yearly improving. 
 I am unable, however, to give statistics that will cover all the different varie- 
 ties of cases. So long as the results of operations performed in well-equipped 
 operating rooms, with every convenience at hand, are included in the results 
 obtained under unfavorable environment and with faulty assistance, so long 
 will the statistics be misleading. We can state, however, that when the en- 
 vironment is favorable, when conveniences and competent assistants are at 
 hand, when the mother is in good condition and has not been infected by repeated 
 
CESAREAN SECTION. 
 
 1013 
 
 examinations and unsuccessful attempts at delivery, and when the fetus is 
 still strong and healthy in the uterus, the danger of Cesarean section to the 
 mother is almost nil, and we can assure the patient and her family that the 
 child will almost certainly survive. 
 
 OPERATION. 
 
 Preparation of the Patient. — The preparation of the patient, emergencies ex- 
 cepted, is exactly the same as for any other laparotomy, with the additional pre- 
 caution of cleansing the vagina by scrubbing and the use of alcohol and bichloride- 
 of-mercury or lysol solution. In an emergency as much as possible should be 
 done, and we can at least be sure of sterile hands, instruments, and dress- 
 ings. Provision must be made 
 for liberating the fetal head 
 from below in case it has be- 
 come firmly engaged in the 
 pelvis. 
 
 Instruments. — The instru- 
 ments required are few and 
 simple. Plenty of artery 
 clamps should be- at hand, 
 and these, in addition to a 
 knife, scissors, dissecting for- 
 ceps, needles, and needle for- 
 ceps, are all that are required. 
 Silk and catgut ligatures must 
 be ready, and a number of 
 good-sized needles already 
 threaded with catgut for use 
 in closing the uterine incision. 
 The bladder should be emp- 
 tied shortly before the opera- 
 tion is begun. Four assist- 
 ants besides the operator are 
 necessary — one to give the 
 anesthetic, one to assist the 
 operator at the wound, one to 
 hand the instruments and 
 ligatures, and another the 
 
 sponges. Preparations must also be made for the resuscitation of the child if 
 necessary, and a person versed in such methods should stand ready to receive 
 and care for the child. 
 
 Position of the Fetus. — The position of the fetus should previously be made 
 out as accurately as possible, as with this fact before us it is often easier to 
 extract the fetus. 
 
 Abdominal Incision. — The incision is made in the median line, five or six 
 inches (12.7 to 15.24 cm.) long, usually with the umbilicus as its middle point. 
 When the fundus stands very high in the abdomen, as it usually does in abso- 
 lute pelvic contraction, the bulk of the incision is best made above the umbili- 
 cus, thus securing a high opening in the uterus. Very little bleeding occurs 
 from the thin abdominal walls, and clamps should control any that takes place. 
 After the abdomen is opened there are some variations in the technique. It 
 
 Fig. 1237. — ^^CoNTROL of the Hemorrhage in CjES.\- 
 REAN Section by the Hands of an Assistant 
 Grasping Each Broad Ligament. 
 
1014 OBSTETRIC SURGERY. 
 
 is advisable to be sure that the uterus is not greatly rotated on its long axis, and 
 this fact can be ascertained by noting the position of the Fallopian tubes. The 
 next step is the opening of the uterus, before which two important matters are to 
 be attended to. These are the protection of the abdominal cavity and measures 
 for the control of hemorrhage. 
 
 Protection of the Abdominal Cavity and Control of Hemorrhage. — The abdo- 
 minal cavity is protected by the use of properly disposed gauze pads around the 
 edges of the widely retracted wound, and by an assistant lifting the uterus 
 firmly against the edges of the wound (Fig. 1237). The hemorrhage from the 
 uterine incision was formerly controlled by a strong elastic ligature drawn 
 right over the fundus and slipped down as low as possible and tightened, or, 
 better, by the hands of an assistant, one grasping each broad ligament and by 
 judicious pressure obtaining the same result, and at the same time steadying the 
 uterus (Fig. 1237). These are unnecessary if the operation is quickly per- 
 formed and are even dangerous by predisposing to subsequent uterine atony 
 and hemorrhage. 
 
 Uterine Incision. — Two methods of procedure are now before the operator, 
 namely, to open the uterus in situ, without delivering the organ through the ab- 
 dominal wound, and the other to lift the uterus out of the abdomen before 
 opening it. 
 
 The former plan should be pursued in all cases in which no infection is pres- 
 ent, and the latter when by reason of previous repeated attempts at delivery we 
 have reason to suspect infection of the uterus. [* J-. 
 
 X. The abdominal cavity being protected by gauze pads, and by an assistant 
 holding the uterus close up to the abdominal wound (Fig. 1237), the incision into 
 the uterus should be made rapidly down to the membranes, and should be about 
 six inches (15.24 cm.) long. If the placenta is met, it is separated and pushed 
 aside, or even bored through with the fingers, but not cut. 
 
 2. Should we have reason to suspect that the uterus is infected, then before 
 making the uterine incision, the organ should be lifted out through the abdomi- 
 nal incision, and not opened until we have thoroughly protected the abdominal 
 cavity from infection from the uterine contents by placing around and behind 
 the uterus sterile towels. 
 
 The proposition of Fritsch (1897) to open the uterus by a transverse incision 
 over the fundus, in order to cut parallel to the course of the ovarian blood-vessels, 
 and thus to avoid hemorrhage, has had many indorsers, but the method has no 
 special advantage over the classic longitudinal incision. 
 
 Rupture of Membranes and Delivery of Fetus. — As soon as the incision is com- 
 pleted the left hand of the operator is introduced and, without rupturing the 
 membranes if possible, the head is sought. The time has now come for the rup- 
 ture of the membranes and the seizure of the head or feet, after which the de- 
 livery should be completed as rapidly as possible. The hand in the uterus should 
 not be withdrawn until the complete extraction of the child is assured, since the 
 uterus contracts very quickly after the m.embranes have been opened. Extrac- 
 tion should be done very deliberately. The fetal head is sometimes firmly 
 grasped by the lower uterine segment, and to liberate it a finger of one hand 
 should be hooked into the mouth and the head flexed until the smallest diameters 
 are opposed to the superior strait and lower uterine segment. With the other 
 hand the operator makes traction upon the feet in the axis of the uterus. If the 
 head does not follow, the second hand placed astride the neck makes pressure 
 upon the shoulders, and at the same time endeavors to maintain the head in flexion. 
 (See Smellie-Veit method, page 978.) An extreme condition of incarceration 
 
CESAREAN SECTION. 
 
 1015 
 
 of the head in the superior strait should, of course, be recognized and corrected 
 before the operation. After the child is extracted it is handed to an assistant 
 to be wrapped in warm sterilized gauze, while the cord is clamped in two 
 places, between which it is divided, a ligature being applied to the stump sub- 
 sequently. 
 
 Placental Delivery. — To detach the placenta it should be grasped and squeezed 
 like a sponge, whereupon it gradually comes away. Under gentle traction the 
 membranes also peel off. In some cases the placenta lies loose in the uterus after 
 the fetus is taken out. Care is necessary at this stage to keep the fluids from en- 
 tering the general abdominal cavity. Many operators raise the uterus entirely 
 out of the abdominal cavity and hold it in position for suturing by slipping a hot 
 sterilized towel under it. 
 
 Uterine Sutures. — Sutures should be applied in three planes. Those of the 
 deepest row should be about one-half inch (1.27 cm.) apart, they should be intro- 
 duced into the external aspect of the uterus about one-fifth of an inch (0.53 cm.) 
 from the margin of the incision and should emerge at the level of the space be- 
 
 FiG. 1238. — Suture op the Uterine Wall Extending Fig. 1239. — Suture of the 
 TO but not through the Decidua. Peritoneum in Cesarean 
 
 Section. 
 
 tween the mucous and muscular layers (Fig. 1238). They are then carried across 
 the wound to the same stratum of the opposite cut edge and outward through the 
 uterine wall. The second plane consists of half-deep sutures, inserted between 
 the deep sutures for closer approximation. Finally, the superficial sutures 
 of fine silk unite accurately the peritoneal coat of the uterus (Fig. 1239). It 
 must be borne in mind, however, that the first or deep layer is capable of some- 
 thing more than mere coaptation and constitutes a distinct form of hemostasis. 
 If the usual measures for checking hemorrhage have been inadequate, the deep 
 sutures may be inserted and tied at once. The presence of a slight anemic layer 
 about the tightened suture shows us that the purpose of the latter is served ; to 
 go further would be to cut off some of the necessary blood-supply and favor septic 
 infection. There is no need of putting any antiseptic material in the uterine 
 cavity, nor does it need any other drainage than what takes place naturally 
 through the os, provided the latter has been previously dilated. 
 
 Ligation of the Fallopian Tubes. — With the consent of the patient, the next 
 step in the operation is the ligation and division of the Fallopian tubes. 
 
1016 OBSTETRIC SURGERY. 
 
 Omental Adhesions. — The next step has reference to the prevention of omental 
 adhesions. The omentum, which is normally situated in front of the uterus, is 
 brought down and carried behind that organ in order to avoid the formation of 
 utero-omental adhesions. 
 
 Abdominal Sutures. — The abdominal wound is closed with four planes of 
 sutures: viz., continuous catgut suture for the peritoneum, interrupted catgut 
 sutures for the muscles and fascia, and silkworm-gut for the skin. 
 
 Hemorrhage. — The operation of laparo-hysterotomy thus performed is not 
 attended, as a rule, by much hemorrhage. If the bleeding is more profuse than 
 usual, it may be controlled by tightening the elastic ligature or by the hands of 
 an assistant grasping the broad ligaments and their contained blood-vessels. It 
 is not well to constrict the ligature too persistently, or to tie more than one turn, 
 for fear of provoking a reactionary hemorrhage when the constriction is with- 
 drawn. It is better to control the hemorrhage by the measures customary in 
 natural delivery; viz., friction, heat (application of hot cloths in this case), and 
 the hypodermic injection of ergot. The latter drug may also be administered 
 as a prophylactic at the moment the fetus is removed. In parenchymatous 
 bleeding sponging with hot gauze is advisable. The suturing of the uterine in- 
 cision has naturally a. hemostatic effect. 
 
 Bladder. Bowels. Nursing. — The bladder should be emptied by catheter, at 
 the end of the operation and as often thereafter as necessary. After each evacua- 
 tion a thorough vulval douche should be administered (see page 88i). A hypo- 
 dermic of morphin is usually indicated during the first post-operative day, but 
 at the expiration of twenty-four hours the child should be allowed to nurse and 
 the drug should be discontinued. On the third post-operative day the bowels 
 should be moved by enema. 
 
 After-treatment. — The abdominal sutures should be removed from the eighth 
 to the twelfth day. An examination should be made after cicatrization is complete 
 to determine whether or not adhesions have formed with resulting fixation of the 
 uterus. As matters of interest and record it is valuable that the operator, after 
 emptying the uterus, should note the position of the contraction ring and measure 
 the true conjugate. The after-treatment is practically the same as after an ex- 
 tensive laparotomy for any condition. 
 
 XIII. ABDOMINAL HYSTERECTOMY. 
 
 This operation is performed through the abdominal incision, and consists 
 either in the amputation of the uterus at the junction of the body and the cer- 
 vix, and is then termed Incomplete Abdominal Hysterectomy, or, secondly, in 
 the extirpation of the entire uterus, including the cervix, and is then known as 
 Complete Abdominal Hysterectomy or Panhysterectomy. 
 
 Indications. — Hysterectomy proper has almost entirely superseded the Porro 
 operation in instances where it is considered best to remove the uterus after 
 Caesarean section or rupture of the uterus. Its principal application is in cases 
 in which in Caesarean section sepsis of the uterus is suspected or known to be 
 present; and in cancerous or myomatous growths of the uterus. In the excep- 
 tional cases of uterine atony following Caesarean section abdominal hysterectomy 
 may be the only means to control the resulting persistent hemorrhage. 
 
 Operation. — The operation is practically the same as in the non-pregnant 
 state, and for its minute technique the student is referred to works on gynec- 
 ology. 
 
ABDOMINAL HYSTERECTOMY. 
 
 1017 
 
 The position of the patient is the dorsal one with provision for raising the 
 pelvis into the Trendlenburg posture when required. The assistants are an 
 anesthetizer, two assistants, and a general nurse. The instruments required are, 
 scalpel, blunt-pointed scissors, 6 artery clamps, 2 abdominal retractors, heavy 
 hysterectomy traction forceps, 4 long-bladed broad ligament clamps, dressing 
 forceps, right and left pedicle needles, needle- holder, 6 full-curved needles, 3 
 straight needles. No. 12 braided silk or No. 2 or 3 chromic catgut. No. i and 2 
 plain catgut, silkworm-gut. Because of the laxness of the abdominal walls, 
 pelvic floor, and uterine ligaments, and the prominence of the uterine vessels, 
 the operation is more readily performed in the puerperal than in the non-puer- 
 peral state. By reason of this laxness, the entire uterus and upper portion of 
 the cervix can by traction be safely brought through the abdominal incision and 
 
 Fig. 1240. — Incomplete Abdominal Hys- 
 terectomy. Shows the uterus drawn 
 through the abdominal incision with the 
 broad ligament clamps applied; ovarian 
 vessels and round ligaments ligated sep- 
 arately, and broad ligaments divided. 
 
 Fig. 1 241. — Incomplete Abdominal Hys- 
 terectomy. Shows the uterus drawn to 
 one side and the opposite uterine vessels 
 being ligfated. 
 
 the clamps and ligatures applied upon the surface of the abdomen instead of in 
 the pelvic cavity. Except in septic and cancerous conditions the incomplete 
 operation will usually suffice, and is the one more quickly and safely performed. 
 
 Incomplete Hysterectomy. — Figs. 1240 to 1245 show the steps in incomplete 
 hysterectomy, and it will be noted from the illustrations that the entire uterus is 
 delivered through the incision. Also that the broad ligaments are clamped, and 
 the ovarian and uterine vessels and round ligaments ligated, the broad ligament 
 divided, the bladder stripped down and the uterus amputated at the level of the 
 utero-cervical junction, upon the surface of the abdomen. The uniting of the 
 stumps of the ovarian and uterine vessels, and closing-in of the raw surfaces by 
 uniting the anterior and posterior flaps of the peritoneum, of necessity is per- 
 formed within the abdomen (Figs. 1244 and 1245). 
 
 Complete Hysterectomy. — Figs. 1 246 to 1 250 show the steps in complete hyster- 
 
1018 
 
 OBSTETRIC SURGERY 
 
 Fig. 1242. — Incomplete Abdominal Hys- 
 terectomy. The broad ligaments are 
 clamped close to the uterus. The uterine 
 and ovarian vessels and round ligaments 
 ligated and incised. The incision above 
 the utero-vesical reflection of the perito- 
 neum has been made and the bladder is 
 being stripped down from the uterus with 
 the finger. 
 
 Fig. "^1243. — Incomplete Abdominal Hys- 
 terectomy. The bladder has been 
 stripped down and the uterus is drawn 
 upward and to one side and is being ampu- 
 tated at the utero-cervical junction. 
 
 Fig. 1244. — Incomplete Abdominal Hys- 
 terectomy. On the right side the stumps 
 of the ovarian and uterine vessels are trans- 
 fixed by a single ligature of No. 2 plain cat- 
 gut. On the left side this ligature is drawn 
 tight and tied, thus uniting the two stumps 
 over the pedicle of the round ligament, 
 and drawing the broad ligament tense to 
 assist in the support of the vault of the 
 vaofina. 
 
 Fig. 1245. — Incomplete Abdominal Hys- 
 terectomy. The stumps of the ovarian 
 and uterine vessels and the round liga- 
 ment are pushed under the peritoneiun 
 and the anterior and posterior flaps of the 
 peritoneum are brought together by a 
 continuous suture of No. i plain catgut. 
 
ABDOMINAL HYSTERECTOMY. 
 
 1019 
 
 Fig. 1246. — Total Abdominal Hysterec- 
 tomy. The broad ligaments are clamped 
 close to the uterus. The uterine and ovar- 
 ian vessels and round ligaments ligated and 
 incised. The incision above the utero- 
 vesical reflection of the peritoneum has 
 been made and the bladder is being strip- 
 ped down from the uterus with the finger. 
 
 Fig. 1247. — Total Abdominal Hysterec- 
 tomy. The uterus is drawn upward with 
 the traction forceps so as to put the vag- 
 inal junction on the stretch. The bladder 
 is pushed forward with the index finger of 
 one hand and with a scalpel in the other 
 hand the anterior vaginal cul-de-sac is in- 
 cised. 
 
 Fig. 1248. — Total Abdominal Hysterec- 
 tomy. The index finger of the left hand is 
 passed through the incision into the vagina, 
 and with a pair of scissors in the right hand 
 the incision is carried entirely around the 
 cervix, separating the latter from its vag- 
 inal attachments. 
 
 Fig. 1249. — Total Abdominal Hysterec- 
 tomy. The opening in the vagina is closed 
 with No. I plain catgut, after all bleeding 
 points have been Hgated and the stumps 
 of the ovarian and uterine vessels, and the 
 anterior and posterior flaps of the peri- 
 toneum treated as in Fig. 1244. 
 
1020 
 
 OBSTETRIC SURGERY. 
 
 ectomy, and I have purposely indicated in my drawings that the uterus is not 
 drawn up as high through the abdominal incision as in the incomplete operation, 
 though it could safely be drawn up much higher. The clamping of the broad 
 ligament, the ligation of the ovarian and uterine vessels and round ligament, 
 the dividing of the broad ligament, and the stripping down of the bladder are 
 the same as in the incomplete operation (Figs. 1240, 1242). The vagina is then 
 
 Fig. 1250. — Total Abdominal Hysterectomy. Shows the anterior and posterior flaps of 
 the peritoneum brought together as in Fig. 1245. 
 
 Opened into as in Fig. 1247, and the incision carried around the cervix, separating 
 the latter from its vaginal attachments as in Fig. 1247. The opening in the 
 vagina is now closed by a continuous suture of No. i plain catgut, and the 
 stumps of the ovarian and uterine vessels united (Fig. 1249). The anterior and 
 posterior flaps of peritoneum are now made to cover the raw surfaces by a con- 
 tinuous suture of plain catgut (Fig. 1250). 
 
 XIV. PORRO-C/ESAREAN SECTION. 
 
 This operation is essentially a supravaginal amputation of the uterus, and 
 under the name of Porro operation or Porro-Caesarean section it has long been 
 domiciled in Italy. 
 
 Indications. — The original indication for the Porro amputation was the pre- 
 vention of sepsis, when the uterine cavity gave evidences of infection, and to 
 escape the dangers of hemorrhage and leakage from the uterine incision of the 
 ordinary Cesarean section. 
 
 An additional indication was the prevention of further pregnancies in those 
 illegitimately pregnant in the destitute, and in cases of tubercular and cardiac 
 disease. 
 
 This last indication is to-day really secured in Csesarean section by excising 
 the tubes, removing the ovaries, or by an incomplete or total hysterectomy. 
 
 At the present day the Porro operation is rarely performed, because it is not 
 in keeping with advanced surgical principles, because of the prolonged slough- 
 ing and healing of the extra-peritoneal stump, and the inverted scar which re- 
 sults in the anterior abdominal wall. 
 
 I am describing and illustrating it here because I believe it is still a life-sav- 
 ing measure in cases of serious uterine rupture, and labor obstructed by a large 
 fibroid tumor in the hands of those who question their ability to perform the 
 undoubtedly more correct surgical procedure of modem hysterectomy; and also 
 when haste is of vital importance, as in rupture of the uterus, when the condi- 
 
PORRO-CMSAREAN SECTION. 
 
 1021 
 
 Pig. 1251. — PoRRO-C^SAREAN Section. 
 Clamps are applied to the broad ligaments 
 and the latter ligated, and cut through. 
 Elastic ligature is applied and tied tightly 
 above the cervix. Two transfixion pins 
 are passed above the ligature. 
 
 Fig. 1252. — PoRRO-C^SAREAN Section 
 The uterus is amputated a short distance 
 above the transfixion pins. 
 
 Fig. 1253. — PoRRO-CiESAREAN Section. 
 Shows the peritoneum closed with plain 
 catgut and the stitches for the abdominal 
 wall tied below and in place above. 
 
 Fig. 1254. — PoRRO-C.-ESAREAN Section. 
 Shows the abdominal wall closed, and the 
 stump of the uterus being closed with a 
 continuous suture. 
 
1022 OBSTETRIC SURGERY. 
 
 tion of the woman is such that the shock of operation must be reduced to a 
 minimum. 
 
 Operation. — The preparation and position of the patient are the same as for 
 Cassarean section proper. 
 
 Instruments. — Knife, stout straight scissors, six artery clamps, No. 2 plain 
 catgut, 3 medium curved needles threaded with No. 2 catgut, six 2^-inch 
 straight needles threaded with silkworm-gut, needle-holder, a stout rubber liga- 
 ture and two transfixing pins for the stump (Fig. 1252), adhesive plaster, dress- 
 ings. 
 
 Step One. — The abdominal incision is made as in Caesarean section, hemor- 
 rhage is controlled, the uterus is turned out of the abdomen, and the abdomi- 
 nal cavity protected from contamination as in cases of Caesarean section where 
 a septic process in the uterus is suspected. The uterine incision is now made 
 as in Caesarean section and the child delivered. The cord and placenta are best 
 left in the uterus. 
 
 Step Two. — The uterus is held well up in the abdominal incision by heavy 
 forceps grasping the fundus (Fig. 12 51) and a stout rubber ligature is firmly 
 knotted about the junction of the uterus with the cervix, care being taken not 
 to include the bladder, ureters or intestine (Fig. 1251). 
 
 Step Three. — The infundibulo-pelvic ligaments are now ligated with No. 3 
 plain catgut near the pelvic brim, and cut through on the uterine side (Fig. 
 1251). 
 
 Step Four. — Transfixion pins are passed through the stump at right angles 
 just above the rubber ligature and the uterus amputated a short distance above 
 (Fig. 1252). The transfixion pins rest upon the abdominal wall and prevent re- 
 cession of the stump, and care must be taken that they do not include the 
 bladder or ureters. 
 
 Step Five. — The stump is steadied in the lower angle of the abdominal in- 
 cision and through-and-through interrupted silkworm-gut sutures are introduced 
 to close the abdomen, the lowest of which transfixes the stump (Fig.~ 1253). 
 
 Step Sixth. — The peritoneum is closed by a continuous suture of No. 2 plain 
 catgut, the lower portion being stitched to the serous surface of the pedicle be- 
 low the transfixion pins, and the abdomen closed in the usual manner (Fig. 
 
 1254)- 
 
 Step Seven. — The peritoneum of the pedicle is drawn over the stump by a 
 continuous suture of No. 2 plain catgut. 
 
 Step Eighth. — The stump is dressed with dry dressings. After about two 
 weeks the stump with pins and rubber ligature sloughs away, leaving a concave 
 wound which heals by granulation. 
 
 XV. VAGINAL C/ESAREAN SECTION. 
 
 Definition. — A deep incision of the anterior cervical wall extending beyond 
 the internal os into the lower uterine segment, and the deliver}^ of the fetus 
 through this opening by the forceps or version. 
 
 To Accononci in 1896, and to Diihrrsen in the same year, belong the credit 
 for the introduction of vaginal Caesarean section. 
 
 Indications. — Although more than one hundred cases are now on record this 
 operation is still in its experimental stage, because we have yet to learn of the 
 danger of extension of the incision into the lower uterine segment in the extrac- 
 
VAGIlSfAL CESAREAN SECTION. 
 
 1023 
 
 -^ 
 
 Fig. 1255. — Vaginal Cesarean Section. 
 Shows initial incision. Transverse incis- 
 ion one and a half inches through mucous 
 membrane at utero- vaginal junction and 
 vertical incision extending from the 
 middle point of the transverse incision 
 longitudinally downward through mucous 
 membrane of anterior vaginal wall to a 
 point immediately below the urethra, thus 
 making a "T" incision. 
 
 Fig. 1256. — Vaginal Cesarean Section. 
 The flaps of the incision are turned back 
 with the finger or blunt dissector and 
 the bladder is strippd away from the 
 cervix. 
 
 y 
 
 .,-^r^. 
 
 Fig, 1257. — Vaginal Cesarean Section. 
 The anterior wall of cervix and lower uter- 
 ine segment are bisected in the median 
 line up to the reflection of the bladder, ex- 
 posing the amniotic bag. 
 
 Fig. 125S. — Vaginal C.^sarean Section. 
 The incisions in the cervix and lower uter- 
 ine segment are closed with catgut after 
 emptying of the uterus, and the vaginal 
 incisions are brought together over these 
 with catgut. 
 
1024 OBSTETRIC SURGERY. 
 
 tion of the fetus, and injury to the bladder resulting from the operation. It is 
 probable, moreover, that the scar of the vaginal Caesarean section in the thinned- 
 out lower uterine segment in subsequent pregnancies will more readily rupture 
 than that of the Csesarean section by the abdominal route, which latter is near 
 the fundus. In many of the cases reported and in most of those that have 
 come under my personal observation, delivery by the abdominal route, or even 
 by combined instrumental and manual dilatation of the cervix, would, it ap- 
 pears to me, have been preferable to the vaginal Caesarean section. 
 
 The chief indication of the operation is in eclampsia, where rapid delivery 
 is indicated and the condition of the cervix renders artificial rapid dilatation 
 dangerous or impossible. Maternal cardiac disease and stenosis of the cervix, 
 and possibly cancer of the cervix, are other indications. A markedly contracted 
 pelvis with a true conjugate of 3.1 inches (8 cm.) is always a contraindication 
 to the vaginal operation. Theoretically placenta praivia with a long undilated 
 cervix would appear to be an indication. 
 
 Operation. — The patient is placed in the ordinary lithotomy position, and 
 prepared as for a vaginal hysterectomy. The assistants required are, an anes- 
 thetizer, two assistants, and an obstetric nurse. The following instruments 
 should be in readiness : one perineal and three long vaginal retractors ; 4 bullet 
 forceps; strong straight scissors; scalpel; artery clamps; needle-holder; 6 full- 
 curved needles; No. i and 2 plain and No. 3 chromic catgut; vaginal dressings. 
 
 First Step. — The perineum is depressed with a broad speculum, and the 
 cervix is grasped with two bullet forceps, placed one on each side of the median 
 line about half an inch (1.25 cm.) apart. The cervix is now drawn downward and 
 backward into the vulval outlet, and the mucous membrane at the utero- vaginal 
 junction is incised laterally to the extent of an inch and a half (3.81 cm.). In 
 order to secure a larger field to work in, some add a second incision at right 
 angles to the above, and extending from the middle point of the transverse 
 incision longitudinally downward through the mucous membrane of the anterior 
 vaginal wall, thus making a "T" incision (Fig. 1255). 
 
 Second Step. — The bladder is now stripped away by the finger and blunt 
 dissection up to the point of deflection of the peritoneum (Fig. 1256). 
 
 Third Step. — A long narrow-bladed speculum is now inserted, which ele- 
 vates the peritoneum and exposes to view the length of the cervix and portion 
 of the lower uterine segment (Fig. 1257). 
 
 Fourth Step. — With a pair of strong, straight, blunt-pointed scissors the 
 cervix is now incised anteriorly in the median line through the internal os. 
 Little bleeding usually results (Fig. 1257). 
 
 FijtJi Step. — The incision in the uterus is now stretched either with the two 
 index- fingers (Fig. 1257) or with one hand inserted into the vagina after the re- 
 moval of all instruments. The fetal membranes now prolapse into the wound. 
 
 Sixth Step. — The fetus is now delivered by forceps or version, preferably 
 the latter, the placenta and membranes manually extracted, and the uterine 
 cavity washed out with normal saline solution and packed with iodoform gauze. 
 It will sometimes be necessary to extend the uterine incision in order to extract 
 the fetal head. 
 
 Seventh Step. — The perineal retractor is again placed in position, each side 
 of the incised cervix again caught with bullet forceps, and the long narrow re- 
 tractor placed to hold up the bladder and peritoneum anteriorly (Fig. 1257). 
 The incision in the cervix is now closed with interrupted suture of No. 3 twenty- 
 day chromic catgut, and the vaginal incisions with No. 2 plain catgut (Fig. 
 
DELIVERY OF' THE PLACENTA AND MEMBRANES. 1025 
 
 1258). The external portion of the cervical wound should be left in order to 
 prevent undue contraction and improper uterine drainage. 
 
 It is technically permissible to divide the pelvic floor (Fig. 11 00) and perito- 
 neum (episiotomy), should the extraction of the fetus be otherwise impossible. 
 
 XVI. CESAREAN SECTION ON THE DEAD AND DYING. 
 
 Cassarean section on the dead has fallen into disrepute at various times and in 
 different localities for one of three reasons: First, statistics covering a limited 
 experience have appeared to demonstrate that but few children were delivered 
 alive in this manner, and that these few succumbed to secondary mortality; 
 second, cataleptic women have been subjected to laparotomy under these circum- 
 stances; third, dead and dying women can be delivered by version or forceps 
 without mutilation, and the children thus delivered show a high percentage of 
 survivals. Nevertheless the spirit of the old lex regia which ordained that a dead 
 woman in advanced pregnancy should be delivered by celiotomy is still in force, 
 because it can be carried out with greater rapidity than version and extraction 
 and forceps delivery. We know that the fetus may survive its dead mother for 
 a certain period (see Coffin Birth, page 669), and that prompt intervention may 
 save life. Naturally the child thus delivered will be profoundly asphyxiated 
 from failure of the maternal circulation, but it may be resuscitated. When the 
 mother has succumbed to a severe type of disease, the child is usually profoundly 
 affected even before her death. The chances of survival are therefore far more 
 unfavorable than in cases of sudden death of healthy mothers, under which 
 circumstances children have survived in utero for as long a period as half an hour. 
 But even when the mother is dying by inches of some severe general disease, 
 the fetus still has a prospect of survival if celiotomy is performed before the 
 entire failure of the placental circulation. It is possible also to extract the child 
 rapidly per vaginam from its moribund mother. This operation is, of course, a 
 most delicate one, and could be put in practice only under certain conditions, 
 such as consent of the mother and her relatives in advance and after consulta- 
 tion with representative medical colleagues. The patient should be subjected 
 to the most valid differential tests of death or the moribund state. In operating 
 upon the dead or dying the same general technique obtains as in the ordinary 
 conservative operation on the living. One cannot, however, always be par- 
 ticular in the choice of an instrument for making the incisions. 
 
 XVII. DELIVERY OF THE PLACENTA AND MEMBRANES. 
 
 I. Credfs Adethod. 2. Dublin Method, j. Digital Extraction. 4. Instrumental Extrac- 
 tion. 5. Manual Extraction. 6. Digital Curettage. 7. Instrumental Curettage. 
 
 I. Crede's Method of Placental Expression. — According to Credo's original 
 account of his method,* " the simplest and most natural method of artificially 
 removing the placenta consists in inciting and invigorating the sluggish activity 
 of uterine contraction. A single energetic contraction of the uterus brings the 
 entire process to a rapid end. I have succeeded in innumerable cases, and with- 
 out exception, in producing an artificial and powerful contraction of the uterus 
 
 ♦"Klinische Vortrage uber Geburtshulfe," 1853, p. 599. 
 65 
 
1026 
 
 OBSTETRIC SURGERY. 
 
 in from fifteen to thirty minutes after the birth of the child, and when the uterine 
 action was ever so sluggish, by rubbing the fundus and corpus uteri through the 
 
 Fig. 1259. — Crede's Method of Placental Expression. — {The upper figure is from a 
 photograph taken at the Emergency Hospital.) 
 
 abdominal wall — gently at first but gradually with the expenditure of more force. 
 As soon as the contraction has reached its maximum, I grasp the uterus entire in 
 
DELIVERY OF THE PLACENTA AND MEMBRANES. 
 
 1027 
 
 such a way that the fundus lies in my palm while the fingers and thumb make 
 gentle pressure upon the body of the organ. I invariably feel the placenta slipping 
 from beneath my fingers, as a rule with such violence that it appears at the ex- 
 ternal genitals, or at least reaches the lowest part of the vagina. The patient 
 experiences no discomfort from this manipulation beyond an increased sensation 
 of pain during the uterine contractions, and it becomes unnecessary to introduce 
 the hand into the birth canal, which has already become extremely sensitive as a 
 
 Pig. 1260. — DicjiTAL Extractio.nt of the Placenta by Traction with Two Fingers 
 Introduced into the Cervix, Assisted by Suprapubic Pressure upon the Fundus. 
 
 result of the expulsion of the child. The uterus remains permanently contracted, 
 hemorrhage is therefore less to be feared, and an inversion of the uterus can never 
 occur as a result of a regular contraction, although this accident is always possible 
 with the usually adopted method of removing the placenta." Shortly before his 
 death Crede modified his method by allowing a delay of thirty minutes after ex- 
 pulsion of the child before beginning the use of his method. 
 
 In the absence of a positive indication, such as hemorrhage, artificial expul- 
 
1028 
 
 OBSTETRIC SURGERY. 
 
 pRE:ssui?£- 
 
 sion of the placenta should not be resorted to until post-partum uterine con- 
 tractions have failed, after at least half an hour, to cause a spontaneous separa- 
 tion of the placenta and membranes. During this time the fundus of the uterus 
 should be held in the hand and in atonic conditions gently rubbed, but never in 
 the absence of a positive indication vigorously rubbed, to hasten separation of 
 the placenta and membranes, nor should traction ever be made upon the cord for 
 the same purpose. To carry out the method properly the bladder must be empty ; 
 the patient is placed in the dorsal position with the knees drawn up to relax the 
 anterior abdominal wall (Fig. 1259); the fundus of the uterus is grasped with the 
 whole hand, four fingers behind and the thumb in front ; during a uterine contrac- 
 tion the fundus is compressed between the 
 fingers and thumb, the fundus being at the 
 same time directed as far backward toward 
 the sacrum as circumstances will permit. The 
 other free hand should be held in readiness at 
 the vulva to prevent a too precipitate de- 
 livery of the placenta, as otherwise the mem- 
 branes may be torn and portions retained. 
 
 Should expression at one post-partum 
 uterine contraction fail, we must wait for the 
 next contraction and repeat the process. In 
 urgent cases both hands may be used to grasp 
 the fundus, the eight fingers behind and the 
 two thumbs in front. In this case particular 
 care must be taken not to rupture a possible 
 salpingitis or diseased ovary. 
 
 As soon as the placenta emerges from the 
 vulval orifice it should be received into the 
 hand (Fig. 635). If the membranes do not 
 readily come away, it is best to rely upon uter- 
 ine compression to expel them rather than to 
 twist them into a cord by turning the placenta 
 over and over gently, and so gradually separ- 
 ating them. Should a fragment be left hang- 
 ing from the cervix or vagina, it may be care- 
 fully separated. Such bits as may be retained 
 within the uterine cavity are best left to be 
 discharged in the lochia if there is no hemor- 
 rhage. After the expulsion of the placenta and 
 membranes, they must be carefully examined 
 in order to see that they are complete (Fig. 
 
 637). 
 2. Dublin Method. — The so-called Dublin method of extracting the placenta 
 is none other than the procedure which goes by Crede's name. It is true that the 
 delivery of the placenta by external manipulation — as opposed to traction on the 
 cord — was independently originated by the distinguished Strasbourg professor, 
 and was popularized throughout the world through his personal advocacy; but 
 it is none the less true that this method of extraction has been carried out in 
 Dublin, almost from time immemorial. Hence a section on the so-called " Dublin 
 method " should possess chiefly a historical interest. This question of priority 
 was first agitated by M'Clintock and Barnes in 1876.* 
 
 Fig. 
 
 OF 
 
 1261.— Digital Extraction 
 A Piece of Retained Mem- 
 branes BY Two Fingers Intro- 
 duced into the Vagina, Assisted 
 BY Suprapubic Pressure upon 
 THE Fundus. 
 
 * " The Dublin Method of Effecting the Delivery of the Placenta." 
 M D., etc. Dublin, 1900. 
 
 By Henry Gellett, 
 
DELIVERY OF THE PLACENTA AND MEMBRANES. 
 
 1029 
 
 3. Digital Extraction. — In most instances of retention the placenta lies loose 
 in the uterine cavity or is only slightly attached to the uterus. In such cases, 
 although Credo's method of expression fails, something less radical than the in- 
 troduction of the whole hand into the uterus is called for to deliver the placental 
 The author is accustomed to resort to what may be termed digital extraction in 
 these cases. After proper preparation of the external genitals and vagina, the 
 first and second fingers of either hand are introduced into the vagina, and the 
 other hand on the fundus prolapses the uterus upon and over the two vaginal 
 fingers. The placenta is now seized between the fingers, and by combined ex- 
 pression and traction the placenta and membranes are slowly delivered (Figs. 
 1260, 1 261). Anesthesia is rarely necessary. 
 
 4. Instrumental Extraction, — Removal of the placenta and membranes by 
 
 Fig 1262. — Manual Extraction of the Placenta by the Introduction of the Whole 
 Hand into the Uterus, Assisted by Suprapubic Pressure upon the Fundus. 
 
 means of the placental forceps possesses no advantages over digital or instru- 
 mental curettage, and I have long since abandoned this method. 
 
 5. Manual Extraction. — As a rule, ether or chloroform should be used. The 
 patient is placed in the lithotomy position, the external genitals are thoroughly 
 cleaned, and the vulva is separated to its widest extent with one hand. The 
 other hand in the shape of a cone (Fig. 11 14) is then carefully passed into the 
 vagina. The hand separating the vulva is now transferred to the fundus, which 
 it firmly grasps (Fig. 1262). Constrictions, if any exist, should be overcome by 
 gradual dilatation with the cone-shaped hand. Should the placenta be found 
 free in the uterine cavity, it is simply grasped and removed. If adhesions 
 are present, however, the placenta is best separated by peeling it off by 
 means of the fingers from above downward (Fig. 1262). In the presence 
 of extensive and firm adhesions great care is necessary not to leave too much 
 
1030 
 
 OBSTETRIC SURGERY 
 
 placental tissue behind, and not to use the finger-nails too vigorously and 
 thus lacerate the uterine walls too deeply. In firm adhesion, after the bulk of 
 the placenta is removed, the placental site must be repeatedly gone over with the 
 finger-tips in order to insure the complete removal of all placental tissue. (See 
 digital curettage, page 1031.) In premature cases, and occasionally at term, the 
 use of the smooth or even the sharp curette will be found necessary to clear the 
 
 Fig. 1263. — Instrumental Curett- 
 age OF the Puerperal Uterus, 
 WITH A Cautious Up Stroke 
 OP THE Curette, and a Firmer 
 Downward One. 
 
 Fig. 1264. — Fig. 1265. — Fig. 1266. — Thim- 
 SharpPuer- Blunt Puer- ble Curette, 
 peral Cu- peral Cu- 
 rette. RETTE, 
 
 uterus of debris. The author has never found that the placental forceps pos- 
 sessed any advantages over the curette. Following the operation the uterine 
 cavity should be freely irrigated with a i per cent, solution of creolin or lysol, 
 decinormal salt solution, or i : 10,000 sublimate solution. Should atony and 
 hemorrhage persist after complete emptying of the uterus, the bleeding is treated 
 as in ordinary cases of post-partum hemorrhage. 
 
OPERATIONS FOR THE CORRECTION OF INJURIES. 1031 
 
 6, Digital Curettage. — After proper cleansing of the hands, external genitals, 
 and vagina, the os, if necessary, is either digitally or instrumentally dilated to 
 allow the passage of one or two fingers. The first and second fingers of either 
 hand are then passed into the vagina and the free hand upon the abdomen pro- 
 lapses the fundus upon and over the vaginal fingers. The tips of the fingers are 
 then made to pass over every portion of the endometrium, using them very much 
 as we would the blunt curette to remove all placental or membranous tissue. The 
 fingers can conveniently be used as a pair of forceps to withdraw loose pieces of 
 debris through the os (Figs. 1261, 1054). Anesthesia can often be dispensed with. 
 
 7. Instrumental Curettage. — The patient is placed in the lithotomy position 
 with the hips drawn well over the edge of the table. Anesthesia is necessary 
 and ether is to be preferred, especially if the patient is somewhat exhausted 
 from hemorrhage. The vulva, lower abdomen, and upper thighs are thoroughly 
 scrubbed with green soap and water and afterward with sublimate or lysol 
 solution. The vagina is then cleansed in the same way. A soft, five-inch 
 jeweler's brush or a swab of cotton or gauze upon long dressing forceps should 
 be used for the vagina. A perineal depressing speculum is now inserted and 
 the cervix seized with one or two pairs of volsellum forceps. Much traction 
 should not be made, the object being to steady the uterus. The os is then 
 dilated with a steel dilator of the Goodell type. The uterine cavity is washed 
 out with a sublimate solution (i : 10,000) or a lysol solution, 2 per cent., a digital 
 examination followed by another irrigation is made, and the uterus is curetted. 
 The size and position of the uterus should be carefully estimated before the 
 curette is introduced, and it may be necessary in rare cases to bend the handle 
 of the instrument to suit the utero-vaginal axis. The curette should be carried 
 carefully to the fundus, since perforations are usually caused by carelessness in 
 this respect. The downward stroke may be moderately firm. The anterior, pos- 
 terior, and lateral surfaces should be carefully scraped, especial care being taken 
 to clear the comua of debris, which frequently accumulates in these situations 
 (Fig. 1263). The operator may know when he has reached the uterine wall by 
 the characteristic grating sensation. 
 
 Choice of Instruments. — Much has been said as to whether the sharp or dull 
 curette is to be used. It will often be best to use both, first the dull curette in 
 order to remove the loosely attached decidua and placental tissue, and later the 
 sharp instrument for the detachment of smaller adherent fragments and the 
 thorough cleansing of the uterine walls. During and subsequent to the operation 
 the uterine cavity is freely irrigated. It is not necessary to pack the uterus or 
 vagina after the operation, unless this procedure is called for by severe hemor- 
 rhage or atony (see page 885). 
 
 (D) OPERATIONS FOR THE CORRECTION OF 
 
 INJURIES. 
 
 I. CELIOTOMY IN RUPTURE OF THE UTERUS. 
 
 See Rupture of the Uterus, page 589. 
 
1032 
 
 OBSTETRIC SURGERY. 
 
 II. CELIOTOMY FOR SEPSIS OF THE UTERUS. 
 
 See Fever, page 757. 
 
 Fig. 1267. — Repair of a Deep Laceration of the 
 Cervix. 
 
 III. REPAIR OF INJURIES TO CERVIX, VAGINA, RECTUM, 
 PERINEUM, AND CLITORIS. 
 
 1. Cervical Lacerations. — The varieties of these lacerations have been de- 
 scribed on page 593. Some writers have advised the immediate repair of all 
 
 cervical lacerations, but it 
 is now pretty generally con- 
 ceded that it is neither 
 necessary nor safe, since it 
 increases the danger of sep- 
 sis and has no compensa- 
 tory advantages, but rather 
 interferes with drainage. 
 Very deep lacerations, how- 
 ever, that cause severe 
 hemorrhage and favor ex- 
 tension of infection to the 
 parametrium should be 
 promptly sutured. 
 
 The instruments needed 
 are two pairs of volsellum 
 forceps, and a needle-holder 
 
 and large curved needles. In rare cases, as in cicatricial fixation of the cervix or 
 
 in the case of a primipara with very small birth canal, a large speculum may be 
 
 required. The patient being in the lithotomy position, the uterus is depressed by 
 
 external pressure over the fundus. The 
 
 anterior and posterior lips are then seized 
 
 by the volsellum forceps, which assists if 
 
 necessary in drawing down the cervix 
 
 (Fig. 1267). The stitches should be about 
 
 half an inch apart. The first should be 
 
 above the angle of the laceration. In some 
 
 cases a single stitch is sufficient. 
 
 2. Vaginal Lacerations. — Lateral and 
 anterior tears of the vagina should be re- 
 paired in accordance with the general 
 principles laid down regarding injuries 
 of the pelvic floor. Vesical and rectal 
 fistulcB should be promptly repaired if the 
 extent of the injury can be defined. In 
 cases of sloughing, however, this cannot 
 
 be done, and it will be necessary to wait for the secondary operation, which 
 in the interest of the patient should be performed as soon as possible. It is, 
 therefore, of the greatest importance to the patient that an exact diagnosis 
 should be made. The presence of vaginal fistula may be confirmed by injecting 
 
 Fig. 1268.— Repaired Lacerated Cer- 
 vix. Stitches in Place. — (From a 
 photograph taken at the Emergency 
 Hospital.) 
 
OPERATIONS FOR THE CORRECTION OF INJURIES. 
 
 1033 
 
 into the bladder warm milk which has been boiled, or some sterilized solution of 
 one of the anilin dyes in harmless quantity. Flatus and feces escape into the 
 vagina if the rectum has been penetrated ; urine if the fistula communicates with 
 the bladder. The immediate operation does not differ from the secondary opera- 
 tion except that there is, of course, no denudation. 
 
 3. Pelvic-floor Lacerations. — The term "perineal lacerations" as usually em- 
 ployed is anatomically incorrect, since it is made to include lacerations of the 
 posterior vaginal wall, perineum, and rectum. Since, however, lacerations in- 
 volving these structures frequently occur together, and since the operations for 
 their repair are frequently combined, it is convenient for clinical purposes to con- 
 sider them together under 
 
 three degrees. (See Part V, /> 'N A 
 
 page 595.) First Degree: , \ ^N^^r> 
 
 Superficial perineal or '•■ "^^ 
 
 perineo- vaginal lacera- 
 tions. These consist usu- 
 ally of a tear of skin and 
 mucous membrane, and 
 may be regarded as exten- 
 sions of the tear of the 
 fourchette which so often 
 occurs in first labors (Figs. 
 1269, 1270). Second De- 
 gree: Vaginal or vagino- 
 perineal lacerations which 
 extend more deeply but 
 do not involve the sphinc- 
 ter ani. These may or may 
 not involve the skin sur- 
 face of the perineum. The 
 former is most frequently 
 the case in operative de- 
 liveries. Very commonly 
 the internal laceration 
 takes the form of a trans- 
 verse tear within the vagi- 
 nal orifice with prolonga- 
 tions which extend up one 
 or both sides of the poste- 
 rior column (Fig. 1270). 
 This variety of laceration 
 may not be suspected un- 
 less the vagina is examined at the close of labor (Fig. 1269). Third Degree: 
 Vagino-perineo-rectal lacerations in which the sphincter ani is involved. Tears 
 of this degree involving the sphincter ani and rectum extend upward for a vari- 
 able distance, and, like tears of the second degree, are prone to follow one or 
 both sides of the posterior vaginal wall. Very rarely the column is divided in the 
 median line. Central perforations of the perineum or pelvic floor may occur. 
 (See Part V, page 597.) In central perforations the fold of skin at the perineum 
 may be torn away by the shoulder during delivery, the resulting laceration 
 looking like one of the second degree: 
 
 Reasons for hnmediate Operation. — Superficial tears of the fourchette which 
 
 Fig. 1269. 
 
 -First Degree 
 
 OR Superficial Perineo- 
 
 vaginal Laceration of the Pelvic Floor. Right 
 Vaginal Sulcus only Involved. Stitches for Re- 
 pair IN Place. Note the numerical order of passing 
 the stitches. 
 
1034 
 
 OBSTETRIC SURGERY. 
 
 usually occur in first labors do not require attention. Larger superficial tears — 
 e. g., those which have a base of from h to | of an inch — may become infected, or 
 in rare cases may lead to the formation of sensitive scar tissue and should be 
 sutured. All other tears should be immediately sutured, since otherwise not only 
 is the danger of sepsis increased, but the patient may be a life-long invalid as the 
 result of injury to the pelvic floor. If the patient's condition is such that the 
 operation is deemed unsafe, e. g., after severe hemorrhage, or if the laceration is 
 severe, and the operator distrusts his ability and needs skilled assistance, it may 
 be postponed for from twelve to twenty-four hours, careful asepsis being main- 
 tained in the mean time. 
 
 General Principles. — The operator should use great care as to asepsis, but 
 
 should not employ chemical 
 antiseptics. He should clear 
 the field of operation from 
 blood by irrigating with 
 saline solution and sponging 
 with sterilized gauze, and 
 bring the parts as nearly as 
 possible into their normal 
 relations by means of ten- 
 acula in order to appreciate 
 the extent and character of 
 the injury. He should aim 
 to secure exact approxima- 
 tion of denuded surfaces in 
 their normal relative posi- 
 tions. He should snip away 
 with the scissors necrosed 
 tags or bruised bits of tissue, 
 and leave no pockets for the 
 collection of stagnant secre- 
 tions. This is to be avoided 
 by not allowing the needle 
 to appear in the wound, or, 
 when the Emmet suture is 
 used, by entering the point 
 again in the deepest part of 
 the wound. 
 
 Operation. — In the slight- 
 er degrees of laceration an- 
 esthesia is not usually neces- 
 sary, the tissues being benumbed by pressure, and the patient still perhaps par- 
 tially under the influence of an anesthetic. In the severer forms in which careful 
 suturing is required, anesthesia will usually be needed, and if such a rupture occurs 
 it is best, if an anesthetic has been administered during the expulsion of the head, 
 to continue its use until the laceration has been repaired, thus obviating the 
 necessity of re-anesthetizing the patient, and lessening the amount of the anes- 
 thetic to be administered. (Compare Management of Labor, Part IV.) The 
 patient is placed in the lithotomy position with the hips drawn well over the 
 edge of the bed or table, and the upper part of the vagina is temporarily packed 
 with sterilized gauze to check the flow of blood and enable the operator to 
 see what he is doing. The instruments needed are: needle-holder; small and 
 
 Fig. 1270. — First Degree or Superficial Perineo- 
 vaginal Laceration of the Pelvic Floor. Both 
 Vaginal Sulci Involved. Shows Method of Pass- 
 ing THE Stitches for Repair. Note the numerical 
 order of passing the sutures. 
 
OPERATIONS FOR THE CORRECTION OF INJURIES 
 
 1035 
 
 medium-sized curved needles ; a pair of scissors ; a speculum or retractor for the 
 anterior vaginal wall (in tears of the third degree it is well to have two retractors, 
 one for each side) ; tenacula; suture material. 
 
 A needle-holder is not absolutely necessary unless the laceration extends far 
 up into the vagina. Retractors may be improvised from bent spoons. A single 
 suture with the ends left long and held by an assistant takes the place of a tena- 
 culum, and ordinary sewing-needles or darning-needles sterilized in a flame may 
 be used in an emergency. Silk, silkworm-gut, catgut, or silver wire may be used. 
 Catgut is preferable for the vagina, since it does not require removal. Silkworm- 
 gut is preferred by many 
 operators. It can be easily 
 rendered aseptic by boil- 
 ing for ten or fifteea min- 
 utes. It is especially ser- 
 viceable when deep su- 
 tures embracing a large 
 amount of tissue are to be 
 passed. 
 
 First Degree. — The op- 
 eration is very simple. 
 The sutures are passed as 
 in Figs. 1269, 1270. The 
 labia being separated by 
 the fingers of the left hand, 
 the wound is closed from 
 above downward by inter- 
 rupted sutures, the needle 
 being introduced close to 
 the upper angle of the 
 wound near its margin, 
 not appearing in the 
 wound but emerging at a 
 corresponding point on 
 the opposite side. Two 
 sutures, with perhaps two 
 or three additional su- 
 tures for the skin-surface, 
 will usually be sufflcient. 
 
 Second Degree. — The 
 anterior vaginal wall is 
 drawn up by a retractor 
 and the parts are tem- 
 porarily restored to their respective positions by tenacula. The vaginal 
 lacerations are sutured from above downward (Fig. 127 1). If there are two, 
 one on each side of the posterior column, they should, of course, both be re- 
 paired, but care should be taken that the posterior column, often bruised and 
 detached from below upward, is left in its normal position (Fig. 1271 ). In order 
 that the lower portions of the wounded surface may be lifted up and brought into 
 contact in the same relative positions which they previously occupied, the Emmet 
 suture should be used. In this method of suturing the needle is not passed 
 directly across the wound but downward until it appears in the floor of the lacera- 
 tion, then re-entered and carried upward again until it appears at a point on the 
 
 ^:^//\\\'-' 
 
 Fig. 1271. — Second Degree or Deep Vagino-perineal 
 Laceration of the Pelvic Floor, not Including 
 the Sphincter Ani. The Laceration in this Case 
 Involves the Left Vaginal Sulcus. Stitches fok 
 Repair in Place. Note the numerical order of pass- 
 ing the sutures. 
 
1036 
 
 OBSTETRIC SURGERY. 
 
 opposite side of the laceration corresponding to that at which it first entered. 
 The first suture closes the upper end of the laceration. " The sutures below this 
 must then be passed with the two distinct objects in view: of grasping the torn 
 muscular tissue on the lateral wall by deep suturing and of exercising a definite 
 lift, each suture helping to lift up the pelvic floor." They should be about one- 
 half inch apart, and care should be taken not to pass it into the rectum. After the 
 sulci have been closed in the manner above described, the remaining denuded area 
 will be found surprisingly small. It may be closed by a single purse-string suture, 
 
 which should also be made 
 to transfix and hold in its 
 proper place the end of 
 the posterior column. 
 The suture enters the skin 
 surface of the perineum 
 and emerges at a corre- 
 sponding point on the 
 opposite side. In place 
 of this purse-string suture 
 two or three interrupted 
 sutures may be used. A 
 few superficial sutures 
 should be inserted wher- 
 ever necessary to secure 
 accurate coaptation. 
 
 Third Degree. — The 
 results of this variety of 
 laceration are so deplor- 
 able that an immediate 
 operation is of special 
 importance. ~ If, how- 
 ever, the operator dis- 
 trusts his own skill or is 
 without suitable instru- 
 ments and suture mate- 
 rial, it is better to delay 
 the operation for from 
 twelve to twenty-four 
 hours until he can obtain 
 skilled assistance. The 
 patient being in the lith- 
 otomy position and the 
 field of operation being 
 exposed by retractors, one 
 on each side, the rectal tear is first closed from above downward by interrupted 
 sutures of silk and fine catgut about one-sixth of an inch apart (Fig. 1272). 
 These are passed from one-fifth to one-fourth of an inch from the edge of the 
 mucous membrane, taking up just enough of the tissues of the recto- vaginal 
 septum to secure a good hold. If catgut is used, the sutures are tied in the 
 rectum and the ends cut short. If silkworm-gut or other non-absorbable 
 material is used, the sutures are tied in the rectum and the ends left long so 
 as to hang out of the anus. The ends of the sphincter should be united by 
 two or three extra fine catgut sutures. If the sphincter has been badly torn 
 
 Fig. 1272. — Third Degree or Vagino-perineo-rectal 
 Laceration of the Pelvic Floor, in which the 
 Sphincter Ani is Involved. Shows Method of 
 Passing the Sutures. Note the numerical order of 
 the stitches, and that 9 transfixes the sphincter muscle 
 on both sides. 
 
OPERATIONS FOR THE CORRECTION OF INJURIES. 
 
 103' 
 
 and the ends have retracted, they should be drawn out with a tenaculum before 
 suturing and the extra sutures in the sphincters should be reinforced by one or 
 two sutures of silk or silkworm-gut, which should be passed through the exter- 
 nal skin at a greater distance from the torn ends of the sphincter and should 
 pass above the angle of the tear and emerge at a corresponding position on 
 the opposite side. The 
 laceration is thus con- 
 verted into one of the 
 second degree, the treat- 
 ment of which has been 
 already described (Fig. 
 127 1 ). If the vaginal 
 laceration extends far up 
 into the vagina, its upper 
 portion may first be su- 
 tured, next the rectal rent 
 and sphincter repaired, 
 and the operation com- 
 pleted as above described 
 (Figs. 1272, 1273). In 
 the rare cases of central 
 perforation of the peri- 
 neum already described, 
 the anterior portion of the 
 perineum should be divid- 
 ed, since it is of no ser- 
 vice and prevents proper 
 inspection of the deeper 
 part of the wound. The 
 laceration is then treated 
 as already described. 
 
 After-treatment. — The 
 knees should be loosely 
 bound together (Fig. 919). 
 The use of the catheter 
 should be avoided if pos- 
 sible. Scrupulous cleanli- 
 ness of the external geni- 
 tals should be secured, 
 and after urination and 
 defecation the parts 
 
 should be washed with a weak sublimate solution. If the lochia are normal, no 
 douches are indicated. The bowels should be kept open after the second 01 
 third day. If an enema is necessary, it should be intrusted only to an experienced 
 nurse. Since the tube has been passed into the sutured laceration, it should be 
 pressed against the posterior margin of the anus. If a vaginal douche becomes 
 necessary, the same care should be used, the syringe being pressed against the 
 anterior vaginal wall. The sutures should be removed about the eighth or tenth 
 day. 
 
 Fig. 1273. — -The Rectal and Vaginal Sutures of Fig. 
 1274 ARE Tied, the Former in the Rectum, Leav- 
 ing ONLY the Two Perineal or External Sutures, 
 
 10 AND II, AND the SpHINCTER SuTURE 9 TO BE TiED. 
 
APPENDIX. 
 
 HISTORY RECORDS. 
 
 In Private Practice. — I am in the habit of urging upon my students the im- 
 portance of starting some method of history-taking in order that they may subse- 
 quently profit by a study of their cases. Should the physician not take up 
 some methodical system of recording his cases at the outset of his practice, he is 
 not likely to do so later. Of course, it is not always pleasant to acknowledge one's 
 errors upon paper, but one can learn as much or more from a subsequent study 
 of such errors as from successes. I have at various times in the past used the 
 ordinary history sheets and history books for this purpose, but experience has 
 proved the card system to be more satisfactory, because simple, orderly, and self- 
 
 FiG. 1274. — Card Index Case for Obstetrical Histories. 
 
 indexing. The cards I use are of standard size (6 X 6y|- inches). Such cards are 
 elastic and portable and can readily be used at the bedside or operating room, 
 for, when doubled, the history of the patient can easily be carried in the pocket 
 or card-case. Any of the different methods of indexing the cards may be used. 
 For obstetric cases I use three printed cards: The first, pregnancy (Figs. 
 1275 and 1276); the second, labor (Fig. 1277) and puerperium (Fig. 1278); and 
 the third, a diagnosis card (Fig. 1279), which is practically a blank and is used 
 for complications and where the first two cards prove insufficient to contain 
 a given history. My index cards are made for me by the Globe-Wernicke Co., 
 380-382 Broadway, New York. 
 
 The observations to be noted under pregnancy (Figs. 1275 and 1276), labor 
 (Fig. 1277), and the puerperium (Fig. 1278) have been carefully selected, and are 
 the result of many years' experience in obstetric history-taking. Such card- 
 history records, of course, need not be limited to obstetrics, for the same case 
 with the blank "diagnosis" cards (Fig. 1279) may be applied to general medicine 
 and surgery. 
 
 1039 
 
1040 
 
 APPENDIX. 
 
 Method of using the History Cards. — As already stated, there are only three 
 printed cards for each case, as labor and the puerperium are contained upon one 
 
 JUn. 
 
 PREGNANCY. Diogm 
 
 faddrtAi) (Phone) 
 
 Date of exptcted labor 
 
 Age ^ »-. Para /^ur*f_ 
 
 ifenttrvation ilmu. j . . , , 
 
 Family hUtory „ , 
 
 Peraimdl history [ /wi.f^/'f/^'Wfci*'*''!. 
 
 __ . , rFulltrrm. ImtrmiplrJ. Manlti e/~\ 
 
 
 IWou.Mbo« r.$^^^^i.^'<^^1.^M 
 
 
 
 PrenouBWLervfHxam, Ffl^SI- ollSSf-zi;-..! 
 
 
 
 EXAMINATION or mKaNANCv: (DaU\ BreattM [<^^i!;^] 
 
 rfuaJHi. PrnnUlitm. Fortml krtri. Crnfi.l 
 
 
 
 r Prrimm. StcrrtmK. Crrva. CrreUal C^mmI. OimflUationi. 1 
 VflUINAl !'■«>" -W-«'- PmnlMhia. PaiiliBm. FiUmMtrd tw,m b,rt.m (TwfW J 
 
 
 
 Fig. 1275. — Pregnancy Index Card; this Side of Card is for a History of the Case 
 AND THE Examination of Pregnancy; this Card also acts with Others Arranged 
 Consecutively as an Index op the Dates of Expected Confinements. 
 
 card. For convenience in indexing and selecting, I use three colors — blue for 
 pregnancy, salmon for labor and puerperium, and buff for the diagnosis or blank 
 card. The pregnancy cards I keep by themselves, in the proximal end of the case, 
 
 URINE. TREATIENT. REIARKS. 
 nalt 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 i«»..,. 
 
 "™;ii."' 
 
 Fig. 1276. — Reverse of Pregnancy Card; upon this Side of the Card are Recorded 
 the Results of the Various Urinary Examinations of Pregnancy, as well as 
 Treatment or Remarks. 
 
 until finally indexed, and they constitute during this time an index of cases of 
 expected confinement. Upon seeing a case of pregnancy in the ofhce or at the 
 
APPENDIX. 
 
 1041 
 
 patient's home, the pregnancy card is made out and returned to its place in the 
 box, and this becomes a record of a case of an expected confinement (Fig. 1274) 
 
 Xn. 
 
 LABOR. DiagnotU 
 
 ^ Child \^' 
 
 Trut paint began at ___ 
 
 Duration. Ill Sugt, . sad 
 
 A7\ct»thaia (m.tmi,irdSi»tn- op 
 Membrana (Rufiurti tpti»iM<u«aii/ m 
 
 Praaitaiion. „ PotHion 
 
 Placenta [c^Jii"] 
 
 PoBtpartum douches 
 
 Action of uterus during physicia 
 
 Vaginal examinations, by.tphom made, and A'c. . 
 
 Temperature -„— , 
 
 i Pulse Se»pr. Antepartum douches ^ 
 
 d siaft „ Total duration of labor 
 
 
 Perineum 
 
 Hemorrhage _ 
 
 
 Pulac... 
 
 _ [one hqiff- after labor] 
 
 Fig. 1277. — Labor and Puerperium Card; upon this Side of the Card is Recorded 
 THE History of Labor; Should More Room be Required for History of Com- 
 plications OR Operations, a Diagnosis Blank Card (Fig. 1279) is Used in Addi- 
 tion. 
 
 Upon the receipt of the first specimen of urine, the analysis, with date, is 
 recorded upon the back of the card, as well as any subsequent treatment or re- 
 
 mothcr: puerperium. cmho: ] 
 
 ... 
 
 ,UI«„T»., 
 
 - 
 
 J^i!,c 
 
 :.i^t. 
 
 ."» 1 ::^.- 
 
 ""';:"' 
 
 ™ 1 r4r. 
 
 „,=-, 
 
 
 
 
 z 
 
 — 
 
 — 
 
 
 
 
 
 1 
 
 
 
 
 
 
 — 
 
 ■— 
 
 
 
 
 — 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 _._ 
 
 
 
 -- 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 — - 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 '"" 
 
 
 
 
 
 
 
 
 
 
 
 
 
 "i^ 
 
 
 
 
 — 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ™. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ■- 
 
 
 
 
 
 
 
 
 
 
 
 Remarks: 
 
 
 
 
 ™v.,c.u 
 
 IMHINDTION ON 0«Y OF PUCdPCIIIUII : LSt'.P««—. ■"«»'"««"' "•■'•»</"»'■■■ J 
 
 
 cMd. [""^.".zT"] ""^jj;-'^„"' 
 
 Fig. 1278. — Reverse of Fig. 1277; Record of Puerperium and Examination of the 
 Patient at the End of Puerperium and Attendance. 
 
 marks upon the case. Upon being called to a case of labor, one selects the 
 proper pregnancy card and a blank labor card to take with him to the case. 
 66 
 
1042 
 
 APPENDIX. 
 
 During or after labor, the labor card is filled in and left at the case for the nurse 
 to record the observations of the puerperium of both mother and child, the 
 pregnancy card being returned to its place in the case. 
 
 Should the labor or puerperium prove complicated, requiring more space, the 
 history is abstracted on the buff diagnosis card, and given a number referring to 
 the detailed account of the case, written on the usual bedside history charts, 
 which latter history sheets are filed in large letter-file boxes. The buff abstract 
 card is then indexed alphabetically with the other cards. 
 
 Fig 
 
 1279. — Blank Card Ruled; Used as Extra Card in Pregnancy, Labor, or Puer- 
 perium, OR AS Index Card for General Non-obstetric Subjects. 
 
 At the completion of the puerperium, the labor and puerperium card is re- 
 turned to the box. At the end of the year, or other convenient time, all cards 
 belonging to a given case are fastened together with a brass clip and indexed 
 among the alphabetical guides at the distal end of the box (Fig. 1274). 
 
 Institutional and Educational. — I append a serviceable, convenient, and more 
 elaborate obstetric history chart for institutional and educational work, which 
 is successfully used at the Manhattan Maternity and Dispensary, New York. 
 
]V[anl::ia.ttan IVLaternity and. Dispensary, 
 
 32T East 60tln Street, 
 
 Diagnosis NEW YORK CITY. Confinement No 
 
 ===:n=r=:=: Outdoor App. No. 
 
 GENERAL HISTORY. ^^'^"'^'"' 
 
 Date of Labor 19.. 
 
 Name Para Nationality Age 
 
 Address House Floor Married, Single, Widow. 
 
 Occupation (Husband's Occupation Wages per week No. in Family employed J ^"^^ A 
 
 Family History Tuberculosis, Syphilis. 
 
 Personal History of Rickets, Syphilis, Gonorrhoea, Leucorrhoea, Pelvic Trouble; Heart, Lung, and Kidney Disease 
 
 {Adde7ida) . 
 
 Last Menstruation. {;g^J5?y;,/_} First Day of 19... {^i;;^','^/;^/.} Date of Quickening iq... 
 
 Previous Pregnancies, Number Vomiting, Headache, Oedema Miscarriages No 
 
 Labor, Difficult, Instrumental, Prolonged Puerperii, Fever 
 
 Present Pregnancy, Vomiting, Headache, Oedema, Etc General Condition 
 
 Children, Weight at Birth, No. Living Health Causes Death 
 
 ANTEPARTUM EXAMINATION, ^ade / Before Labor 
 
 ' \ In Stage of Labor. 
 
 EXTERNAL. Dry Labor. 
 
 I Intact Membranes. 
 Date of Examination 19 \ Ruptured Membranes. 
 
 General Condition Lungs Heart 
 
 Breast, Nipples, Lacteal Capacity Abdomen and Uterus 
 
 Fetus, Size Location, Head Back Small Parts I r,"*^'^' . ^'S^' 
 
 1^ Movements, Ao" 
 
 (Above,'] (Rate 
 
 Presentation, < In. J-Brim. Position Foetal Heart-: 
 
 \Beloui \ (Location 
 
 Measurements, Intercrestal inches, Interspinous inches. Intertrochanteric inches. External 
 
 R 
 Conjugate inches. Right and Left Oblique^ 
 
 .inches 
 
 INTERNAL. 
 
 External Genitals and Vagina, Perineum Cystocele, Rectocele, Discharge 
 
 Cervix, Position External Os |OP^"\ Internal Osl OP^"-, 
 
 [Closed i Closed 
 
 Internal Measurements, PelvIs, Diagonal conjugate inches. True Conjugate inches 
 
 Interischial inches. Flexibility of Coccyx Abnormalities 
 
 SUMMARY OF EXAMINATION. 
 
 Size of Foetus, Estimated Size of Pelvis Probable Character of 
 
 Labor Quantity of Liquor Amnii, Estimated 
 
 Probable Date of Labor, ,9 Presentation Position 
 
 Abnormalities, Plural Pregnancies, 
 
 Addenda 
 
 Exam. Phys. 
 
 1043 
 
HISTORY OF LABOR. 
 
 Time of Call A. P. M J9 Arrival A. P. M 19 Length of Gestation Weeks 
 
 Patient, General Condition Before Labor, T P R Foetal Heart 
 
 Position of Parturient Antepartum Douche, | ^.f^' 
 
 Began At, 
 
 Duration, 
 
 Uterine Contraction, 
 
 Hemorrhage, 
 
 i Source, 
 ( Anioutit, 
 
 FIRST STAGE. 
 
 A. P. M., 19... 
 
 Hours, Minutes. 
 
 SECOND STAGE. 
 
 A. P. M , 19... 
 
 THIRD STAGE. 
 
 A. P. M., , 19... 
 
 Hours, Minutes. 
 
 Hours, Minutes. 
 
 
 ! 
 
 • 
 
 
 
 
 
 
 
 
 Total 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Cord tied before 
 or after Lung 
 
 
 
 
 
 
 
 
 
 
 
 
 
 (Intact, 
 t\Qxa\ir?me.s A Ruptured, . 
 yDeliveiy, 
 
 vagina, {g;^^:'^^. 
 Presentation. {^^S;.., 
 
 Delivery I Ope'ative, 
 ueuvery, | spo7itaneous 
 
 r- • r Dilatation, 
 Cervix, I j.^^,.^^ : . . 
 
 ( Condition, 
 Perineum, < Management, 
 (_ Tears, 
 (Prolapsed, 
 CotCl,< Management . . 
 \About Neck, 
 
 Manipulations, . . 
 
 Medication, {^ni'sthesia, 
 
 Bladder==Rectum, . . . 
 
 During Labor==Patient's T P R and Foetal Heart. 
 
 Placental Delivery, Method Time A.P.M 
 
 Actual Presentation Actual Position xotai Duration of Labor Hrs m 
 
 .19 Post Partum Douche | (_:j^^i,[g 
 
 Uterus Tonicity Height above Pubes inches. 
 
 ( Taken one hour after labor.) 
 
 Complications and Operations 
 
 Delivered by. 
 
 M.D. 
 
 Performed by Dr 
 
 CHILD'S RECORD. 
 
 Date of Birth A. P.M 19 Sex Maturity Weeks. Weight Lbs Ozs. 
 
 Total Length inches. Living, Stillborn, Macerated. General Condition 
 
 . (Cyanotic,') (Artificial, "l Method 
 
 Circulation-; iVbrwa/, yPulse Temperature Respiration < Spontaneous, > 
 
 \^AncE7nic,) [ Resuscitatioti, ) Time Required... M 
 
 ^ -c J fSize, (Defecated, i'es, A'O. 
 
 caput uucceaaneum, | Location, Moulding Size of Fontanelles \ Micturated, I'es, No. 
 
 Anomalies, Injuries, Umbilicus, Genitals, Eyes, Ear, Nose, Mouth, Skin 
 
 Circumferences, Blsacromial, inches. Suboccipito==Bregmatic Inches. 
 
 Diameters, Biparletal Inches. Suboccipito==Bregmatic Inches. Occipito==Mental Inches. 
 
 Bisacromial Inches. Length, Cord Inches, Insertion 
 
 Placenta, \^r°"^^K\^t I Size Form Anomalies 
 
 I Incomplete, J 
 
 Membranes, \'j°^conMete } ^'"^ °^ Rupture Anomalies Plural Births, Placenta, 
 
 Membranes, Cord 
 
 1044 
 
DAILY RECORD OF CHILD. 
 
 Name of Child Confinement No Sex 
 
 Weight at Birth Lbs Ozs. General Condition Nouiiblicd Color, Cry 
 
 Anomalies, Injuries Has ''atient | ^'^"^^^'^^^^ 
 
 The Babies' Temperature, Pulse, and liespirution taken only where specially indicated. 
 
 DATE. 
 
 
 
 1 
 
 DAY. 
 
 DAY OF BIRTH. 
 
 FIRST. 
 
 SECOND 
 
 THIRD 
 DAILY 
 
 VISITS. 
 
 A.M. VISIT 1 P.M. VISIT. 
 
 A. M. VISIT 1 P. M. VISIT 
 
 A. M. VISIT 1 P. M. VISIT 
 
 BLEEDING, 
 HEALED, 
 CORD OFF 
 
 UMBILICUS, PUS. 
 
 
 
 
 
 QUALITY, 
 QUANTITY 
 DIET, NURSING. 
 
 
 
 
 
 NUMBER 
 STOOLS COLOR. 
 
 
 
 
 
 WEIGHT. 
 
 
 
 j 
 
 VOMITING 
 
 
 
 1 
 
 TEMPERATURE. 
 
 
 
 
 PULSE. 
 
 
 
 1 
 
 RESPIRATION. 
 
 
 
 
 
 COLOR, 
 SKIN, ERUPTION, 
 
 
 
 
 
 EYES, DISCHARGE. 
 
 
 
 
 
 GENERAL 
 CONDITION. 
 
 
 
 
 
 TREATMENT. 
 
 
 
 
 
 ATTENDANT'S NAME. 
 
 
 
 
 
 DATE. 
 
 
 
 
 
 1 
 
 DAY. 
 
 FOURTH 
 
 FIFTH 
 
 SIXTH 
 
 SEVENTH 
 
 EIGHTH 
 
 NINTH 
 
 VISITS. 
 
 DAILY 
 
 DAILY 
 
 DAILY 
 
 DAILY 
 
 DAILY 
 
 DAILY 
 
 BLEEDING 
 PUS 
 
 CORD OFF 
 UMBILICUS, HEALED. 
 
 
 
 
 
 
 
 QUALITY, 
 DIET, QUANTITY, 
 NURSING. 
 
 
 
 
 
 
 
 COLOR 
 STOOLS, NUMBER. 
 
 
 
 
 
 
 
 VOMITING. 
 
 
 
 
 
 
 
 WEIGHT. 
 
 
 
 
 
 
 
 TEMPERATURE. 
 
 
 
 
 
 
 
 PULSE. 
 
 
 
 
 
 
 
 RESPIRATION. 
 
 
 
 
 j 
 
 
 COLOR, 
 SKIN, ERUPTION. 
 
 
 
 
 
 ■ 
 
 
 EYES, DISCHARGE. 
 
 
 
 
 ! 
 
 
 GENERAL 
 CONDITION. 
 
 
 
 
 
 
 
 TREATMENT. 
 
 
 
 
 
 
 
 ATTENDANT'S 
 SIGNATURE. 
 
 
 
 
 
 
 
 Remarks- 
 
 EXAMINATION ON DAY AFTER BIRTH 19 , (This E.xamination is made at last visit.) 
 
 General Condition Umbilicus Eyes Skin Weight Lbs Ozs. 
 
 I' Good, 
 ] Fair, 
 "S Poor, 
 I Critical. 
 
 Died, Discharged, or Transferred (to hospital) On 19 Condition 
 
 Remarks, Artificial Feedinar- 
 Urine Reports, Mothers,...'... 
 
 1045 
 
PUERPERIUM. 
 DAILY RECORD OF MOTHER 
 
 DATE. 
 
 
 
 
 DAY. 
 
 LABOR DAY 
 
 FIRST 
 
 j SECOND 
 
 A. M. VISIT 1 P.M. VISIT 
 
 THIRD 
 
 VISITS. 
 
 A.M. VISIT 1 P.M. VISIT 
 
 A.M. VISIT 1 P.M. VISIT 
 
 DAILY 
 
 CONDITION, 
 SECRETION 
 
 BREASTS, NIPPLES. 
 
 
 
 
 
 CHARACTER, 
 ODOR, 
 LOCHIA, QUANTITY. 
 
 
 
 
 
 CONDITION 
 FUNDUS, HEIGHT. 
 
 
 
 
 
 CHARACTER 
 STOOLS, NUMBER. 
 
 
 
 
 
 PULSE. 
 
 1 
 
 
 
 ■ 1 
 
 
 TEMPERATURE. 
 
 1 
 
 
 
 I 
 
 
 RESPIRATION. 
 
 
 
 1 
 
 
 URINE, QUANTITY. 
 
 
 
 
 
 DIET. 
 
 
 
 
 
 GENERAL CONDITION. 
 
 
 
 
 
 TREATMENT. 
 
 
 
 
 
 ATTENDANT'S NAME. 
 
 
 
 
 
 DATE. 
 
 
 
 
 
 
 
 DAY. 
 
 FOURTH 
 
 FIFTH 
 
 SIXTH 
 
 SEVENTH 
 
 EIGHTH 
 
 NINTH 
 
 VISITS. 
 
 DAILY 
 
 DAILY 
 
 DAILY 
 
 DAILY 
 
 DAILY 
 
 DAILY 
 
 CONDITION, 
 SECRETION, 
 
 BREASTS, NIPPLES. 
 
 
 
 
 
 
 
 CHARACTER 
 ODOR 
 LOCHIA, QUANTITY. 
 
 
 
 
 
 
 
 CONDITION, 
 FUNDUS, HEIGHT. 
 
 
 
 
 
 
 CHARACTER, 
 STOOLS, NUtWBER. 
 
 
 
 
 
 
 
 PULSE. 
 
 
 
 
 
 
 
 TEMPERATURE. 
 
 
 1 
 
 
 
 
 RESPIRATION. 
 
 
 ' 1 
 
 
 
 URINE, QUANTITY. 
 
 
 1 
 
 
 
 
 DIET. 
 
 
 1 
 
 
 
 
 GENERAL CONDITION. 
 
 
 i 
 
 
 
 
 TREATMENT. 
 
 
 
 
 
 
 
 ATTENDANT'S NAME. 
 
 
 
 
 
 
 
 Features of Puerperium. 
 
 EXAMINATION ON DAY AFTER LABOR 
 
 Uterus, Size Position Sensibility... 
 
 Perineum, Condition Cystocele, Rectocele, Rectal 
 
 Cervix Lochia, Quantity 
 
 Breasts Nipples Remarks. 
 
 19 , (Made at La.st Visit) 
 
 Mobility 
 
 ...Continence, Prolapse 
 
 .Color Odor 
 
 Discharged, Died, or Transferred (to hospital) On. 
 
 I Good, 
 
 .19 Condition v Fair, 
 
 Total Days Treated. 
 
 Signature. 
 1046 
 
 Poor, 
 Critical. 
 
 M. D. 
 
INDEX. 
 
 Abdomen, changes in, in pregnancy, 125, 
 in puerperium, 678 ; evisceration of, 960 ; 
 examination of, in pregnancy, 154-162; 
 fetal, enlarged, cause of dystocia, 620; 
 formation of, 60; pendulous, 274, 678; 
 pigmentation of, 125; striae of, 125. 
 
 Abdominal, binder in puerperium, 695; 
 muscles, action of, in labor, 428; dias- 
 tasis of, 711; section (see Lapar- 
 otomy); tumors, 282. 
 
 Ablatio placentae, 224. 
 
 Abortion, after-treatment of, 361; age of 
 patients in, 346; and premature labor, 
 induction of, 888-895; S'^d sexual 
 intercourse, relation betv/een, 188; 
 anemia after, 356; artificial, in pelvic 
 deformity, 656; cause of pelvic disease, 
 39; causes of, in ovum and embryo, 
 348, 349; local, 349; systemic, 348; 
 clinical phenomena of, 350; complete, 
 343; concealed, 343; concealed, diagno- 
 sis of, 354; criminal, 344, 353; curet- 
 tage in, 358, 361; definition of, 342; 
 diagnosis of, 352, 354; differential 
 diagnosis of, 354; duration of, 352; 
 endometritis after, 356; ergot in, 361; 
 etiology of, 348; frequency of, 345; 
 hemorrhage in, 354; habit, 350, 357; 
 in cholera, 257; in erysipelas, 336; 
 in measles, 336; in pneumonia, 337; 
 in retro-displacements of the uterus, 349 ; 
 i n scarlatina, 336; in typhoid fever, 336; 
 incomplete, 343; diagnosis of, 353; 
 indications for induction of, 888, 889, 
 890; induced, 343; inevitable, 343; 
 malignant disease after, 356; maternal 
 causes of, 348; membranes, retention 
 of, in, 351; methods of inducing, 891- 
 895; missed, 343, 368; month of gesta- 
 tion in, 348; parity of patients in, 347; 
 pathology of, 344; paternal causes of, 
 347; polypi after, 356; prophylaxis of, 
 357; prognosis of, 354; relative fre- 
 quency of, 349; septic infection in, 355 ; 
 sterility after, 356; symptoms of, 350- 
 352; tetanus following, 355; therapeutic, 
 in pelvic deformity, 675; threatened, 
 diagnosis of, 352; treatment of, 357- 
 361. 
 Abscess, mammary, in pregnancy, 291; m 
 newly born, 851; of fixation, in puer- 
 peral infection, 752; puerperal metasta- 
 tic, 738; retropharyngeal, in newly born, 
 844; submammary, in puerperium. 767. 
 
 Acanthopelys, 638. 
 Accidents in pregnancy ,369,370. 
 Accouchement forc6, 964; in eclampsia. 
 312-314; in hemorrhage, 228; in pla- 
 centa praevia, 222. 
 Acetabulum, union of parts of, 376. 
 Acetonuria, in pregnancy, 320; in puerper- 
 ium, 320. 
 After-birth. (See Placenta.) 
 After-coming head, cephalotribe to, 955, 
 cranioclasis in, 946; extraction of, 
 974-980; by forceps, 979, 1003, 1004; 
 by Mauriceau method, 978; by Prague 
 method, 979; by Smellie method, 
 977; by Smelhe-Veit method, 978; 
 by Wigand-Martin method, 978. 
 
 After-pains, 674; treatment of, 691. 
 
 Agalactia, 760. 
 
 Age, for establishment of menstruation, 21 ; 
 influence of, on primiparity, 666; on 
 progeny, 36; of fetus, calculation of, 83- 
 88. 
 
 Albuminuria, effect of, on newly born, 809; 
 in eclampsia, 308; in elderly primipara?. 
 666; in multiple pregnancy, 144; in 
 pregnancy, 117, 319; in puerperium, 
 676. 
 
 Alcohol, in acute infection, 817; in eclampsia, 
 300; in endometritis, 753; in erysipelas 
 of newly born, 846; in intrauterine ir- 
 rigation, 883; in irrigation of septic 
 uterus, 753; in pregnancy, 186 
 
 Alcohohsm, effect of, on fetus, 260; on 
 newly bom, 809: on spermatozoa, 28; 
 in pregnancy, 186. 
 
 Alimentary canal, origin of, 61. 
 
 Alimentary tract, diseases of, in fetus, 263; 
 in pregnancy, 321-324. 
 
 AUantois, 68; origin of, 61. 
 
 AlHs inhaler, 867, 989. 
 
 Alopecia in pregnancy, 339. 
 
 Amnion, 66; anomalies of, 201-203; dropsy 
 of, 204; in twin pregnancy, 142'. 
 secretion of, 66-68. 
 
 Amniotic fluid. (See Liquor amnii.) 
 
 Amputation, fetal, from amniotitis, 202; 
 of fetal parts to effect delivery, 961. 
 
 Anasarca, fetal, 270, 809; in newly born, 839. 
 
 Anemia, after abortion, 356; from post- 
 partum hemorrhage, treatment of, 584; 
 in etiology of accidental hemorrhage. 
 225; in pregnancy, 117; in puerperium, 
 714; pernicious, an indication for pre- 
 mature delivery, 890; pernicious, in 
 1 pregnancy, 328; puerperal. 714. 768. 
 
 1047 
 
1048 
 
 INDEX. 
 
 Anesthesia, in embryotomy, 944, in heart 
 disease of pregnancy, 326; in labor 
 479, 482, 490, 568, 865, in pelvic floor 
 operation, 1034; spinal, in labor, 868; 
 in threatened rupture of the uterus, 589, 
 
 Aneurism in pregnancy, 327. 
 
 Ankylotic pelvis, 626. 
 
 Annular placenta, 209. 
 
 Anteflexion of pregnant uterus, 274. 
 
 Antenatal, affections, extending into extra- 
 uterine Ufe, 807-812, cutaneous dis- 
 eases, 267, diseases of fetus, 255-272, 
 807-812, pathology, 242. 
 
 Ante-partum hemorrhage, causes of, 371. 
 
 Anterior parietal presentation, 518. 
 
 Antero-posterior diameter, of pelvic cavity, 
 383; of pelvic outlet, 166, 384. 
 
 Anteversion, of uterus, effect of, on fetus, 
 271; of pregnant uterus, 274,275. 
 
 Anthrax, in pregnancy, 258; of fetus, 258. 
 
 Antipyrin in labor, 867. 
 
 Antiseptics, chemical, 151, 152; in labor, 
 148; in treatment of puerperal infection, 
 
 754. . , . ^ 
 
 Antistreptococcus serum, m puerperal miec- 
 tion, 751. 
 
 Antitoxin in tetanus of newly born, 847. 
 
 Anuria in prematurity, 868. 
 
 Anus, formation of, 58 ; laceration of sphinc- 
 ter of, 1036. 
 
 Aphasia, puerperal, 771; in puerperal throm- 
 bosis and embolism, 768. 
 
 Aphthae of newly born, 847. 
 
 Apoplexy, cerebral, at birth, 823; diagnosis 
 of, from eclampsia, 307; fetal, 812; 
 in pregnancy, 333; of placenta, 229- 
 231, 345; of placenta, cause of ante- 
 partum hemorrhage, 372; cause of 
 fetal death, 272; of decidua, 195. 
 
 Appendicitis in pregnancy, 324, 370. 
 
 Appetite, in pregnancy, 115; in puerperium, 
 676. 
 
 Arm, delivery of extended, in breech pres- 
 entation, 975; dorsal displacement of, 
 521; in breech extraction, 975; paraly- 
 sis of, 826; prolapse of, 520; repo- 
 sition of prolapsed, 521; prolapse of, 
 in shoulder presentation, shng in, 1009; 
 treatment of, in breech presenta- 
 tion and breech extraction, 522; treat- 
 ment of, in cephalic presentation, 521. 
 
 Arterial, infusion of salt solution, 862, ten- 
 sion in labor, 431. 
 
 Arteries, curling, 71; fetal, 81, 82; primary 
 thrombosis of pulmonary, in puerperium , 
 
 776. 
 
 Artery, ovarian, changes of, m pregnancy, 
 108; uterine, changes of, in pregnancy, 
 107. 
 
 Articulations, anomalies of pelvic, 710; 
 pelvic, in puerperium, 677. 
 
 Artificial feeding, 788-794; tabular guide 
 for, 792. 
 
 Artificial respiration in asphyxia neona- 
 torum, 819-823. 
 
 Ascites, abdominal, diagnosis of, from hy- 
 dramnios, 207; and pregnancy, co- 
 existence of, 136; diagnosis of, from 
 pregnancy, 135; evisceration in fetal, 
 960; of fetus, 263; of newly bom, 
 809. 
 
 Asepsis, in labor, 464; in puerperium, 689, 
 
 749; in third stage of labor, 4^1; 
 obstetric, 148; of patient, physician 
 and accessories in 1 elation to puerpe- 
 rium, 749. 
 
 Asphyxia, neonatorum, 812-823; etiology of 
 815; treatment of, 817-823; varieties 
 of, 813. 
 
 Aspiration pneumonia, 832. 
 
 Asthma in pregnancy, 332. 
 
 Atelectasis, of lungs of fetus, 779; of newly 
 born, 814, 815, 838, 839. 
 
 Atmocausis in septic endometritis, 858. 
 
 Atresia, of vagina a cause of dystocia, 611. 
 
 Atrophy, of decidua, 196; of placenta, 209; 
 of uterus, during lactation, 709. 
 
 Attitude of fetus, 420. 
 
 Auscultation, 124, 143. 
 
 Avulsion of fetal extremities, 560. 
 
 Axis of pelvic cavity 387 ; of uterus, changes 
 in, in pregnancy, 103. 
 
 Axis-traction forceps, 998-1002. 
 
 B. 
 
 Baby's outfit, 466. 
 
 Bacillus, coh communis, in puerperal peri- 
 metritis, 732; of diphtheria in puerpei al 
 infection, 740; vaginas, of DOderlein, 
 149. 
 
 Bacteria, effect of labor on genital and 
 perigenital, 716; harmful in milk, 
 prevention of, 789; in puerperal septi- 
 cemia, 741; migration of vaginal in la- 
 bor, 716; pathogenic passage of from 
 mother to fetus, 68. 
 
 Bacteriemia, 740; antepartum, 713; puer- 
 peral, 748; puerperal, pure, 741; 
 with toxemia, puerperal, 741. 
 
 Bacteriology, of genital tract, 716; of puer- 
 peral infectious endometritis, 722; of 
 puerperal morbidity, 739; of vagina in 
 pregnancy, 148, 149. 
 
 Bag, obstetric, 466-469 ; of waters, at birth, 
 66, rupture of, 434; sausage-shaped 
 protrusion of, 888. 
 
 Ballottement, in pregnancy, 128, 132; ab- 
 dominal, in pregnancy, 125. 
 
 Bandl's ring, 402. 
 
 Barnes' bag in delayed labor, 573; water- 
 bag, 905, 906. 
 
 Baudelocque's diameter, 162, 164. 
 
 Bed, preparation of, for labor, 471. 
 
 Binder, abdominal, in pregnancy, 187, in 
 puerperium, 496; mammary, 766, 767 
 
 Births, percentage of premature, 800. 
 
 Bladder and rectum, distended, cause of 
 dystocia, 613, 614. 
 
 Bladder, care of, in puerperium, 691, 692; 
 changes in, in pregnancy, 113, 114, 130, 
 diagnosis of distended, from pregnancy, 
 134, 137; distention of, in fetus, 267; 
 in puerperium, 679; fetal, distended, 
 evisceration in, 960; malformation of, 
 287; irritability of, in pregnancy, 316. 
 
 Blastoderm, 53. 
 
 Blindness, in puerperal thrombosis and em- 
 bolism, 768. 
 
 Blood, changes in, in pregnancy, 117, 188, 
 328; clots, puerperal hemorrhage from 
 retention of , 701; count in septicemia, 
 741; in puerperium, 677, 739-742, 
 768; of newly bom. 783; states, com- 
 
INDEX. 
 
 1049 
 
 posite, in septic puerperae, 742; tumor 
 (see Hematoma); velocity of fetal cir- 
 culation of, 79. 
 
 Blood-vessels, diseases of, in pregnancy, 
 326, 327; of uterus, changes in, in 
 pregnancy, 106-108; origin of, 60, 78; 
 pelvic, 400. 
 
 Blunt hook, 1009. 
 
 Body cavity, 60. 
 
 Bones, formation of, 58; pelvic, 375. 
 
 Boric acid solution, in aphthae of newly 
 born, 847; in catarrhal conjunctivitis, 
 834; in fissured nipples, 759, 762; in 
 gonorrheal stomatitis, 837; in hemor- 
 rhage from genitals in female infants, 
 850; in ophthalmia neonatorum, 835; 
 in puerperal cystitis, 754; in umbilical 
 sepsis, 843. 
 
 Bottle, feeding, care of, 793. 
 
 Bowel excretion of fetus, 79. 
 
 Bowels, care of, in pregnancy, 186; in puer- 
 perium, 676, 692. 
 
 Brachial palsy, from injury in labor, 826, 
 827. 
 
 Bradycardia in puerperium, 674. 
 
 Brain, congestion of, in pregnancy, 332; 
 diseases of, in pregnancy, 332,333; origin 
 of, 61 ; traumatism of, at birth, 823, 824. 
 
 Braun's, blunt hook, 956, 957, cranioclast, 
 947, 948; decollator, 957. 
 
 Breasts, and nipples, care of, in puerper- 
 ium, 692, and pelvic organs, relation 
 between, 114, 115; anomalies of, 759; 
 areola of, 115 ; areolar inflammation 
 of, during puerperium, 761; caked, 
 761; care of, in nursing, 692; care 
 of, when nursing is contraindicated , 
 693; in pregnancy, 187, in puerperium, 
 692; changes in, in pregnancy, 114, 115, 
 126, 187; congestion and engorgement 
 of, 761, a cause of hyperthermia, 744; 
 diseases of , in puerperium, 761-768; in- 
 flammation of, 762 ; of newly born, 784 ; 
 sensations in, in pregnancy, 114, 115, 
 striae of, 114; supernumerary, 759. 
 
 Breech, and face, differential diagnosis of, 
 in pelvic presentation, 536; arrest of, 
 above pelvic inlet, 968; at inlet, 968- 
 971, in pelvic cavity, 971-973; ex- 
 traction, 968-974, dangers of, 968, 
 by forceps, 971, by fillet, 971, by blunt 
 hook, 971, manual method of, 969, 
 time limit of, 974, traction upon a 
 leg brought down, 969; impaction of, 
 in the pelvic cavity, 973; presentation, 
 527-538. (See Pelvic presentation.) 
 
 Bregma, 410, 411; brow, and face presenta- 
 tion, manual correction of, 91 1-9 14; 
 presentation, 500. 
 
 Breisky's, cephalotribe, 953, method of bi- 
 manual compression of the uterus, 584, 
 method of measuring the antero-pos- 
 terior diameter of pelvic outlet, 166. 
 
 Bright's disease, chronic, effect of, on preg- 
 nancy and fetus, 316. 
 
 Broad ligaments, changes in, in pregnancy, 
 109. 
 
 Brow, fetal, 409; permanent posterior rota- 
 tion of, in labor, 505, 506; presenta- 
 tion, 503-508. 
 
 Bruit, placentaire, in pregnancy, 124; 
 uterine, in pregnancy, 124. 
 
 Buhl's disease, 851. 
 
 Byrd's method of artificial respiration, 819, 
 823. 
 
 C. 
 
 Caesarean section, 1011-1025; after vagino- 
 fixation, 601 , in accidental hemorrhage, 
 228; in cancer of uterus, 610; in case 
 of monsters, 561 ; in cornual pregnancy, 
 36S; in eclampsia, 313; in funnel- 
 shaped pelves, 623; in kyphosis, 646; 
 in myoma of uterus, 604; in Naegele's 
 pelvis, 626; in obstruction of vagina, 
 612, in ovarian tumor. 604, 605; in 
 pelvic deformity, 656, 657, 658, 659, 
 660, 663, 664; in pelvic tumors, 638; in 
 persistent mento-posterior positions, 
 652; in pregnancy after ventrofixation, 
 601; in Robert's pelvis, 626; inshoulder 
 presentation, 544; in threatened rup- 
 ture of uterus, 589; in tumors caus- 
 ing absolute obstruction to delivery, 
 602; on the dead and dying, 1025; 
 vaginal, in occlusion of external os, 609 
 
 Calcareous degeneration, of placenta, 235. 
 of umbilical cord, 240 
 
 Calcification of fetus, 306. 
 
 Calculi, placental, 235; vesical, in preg- 
 nancy, 318, cause of dystocia, 615. 
 
 Canal, alimentary, formation of, 57, 58; 
 neurenteric, 54; parturient, description 
 of, 400—408. 
 
 Cancer, cause of intra-partum hemorrhage, 
 671; in menopause, 39; in pregnancy 
 263; indication for prevention of re- 
 production, 38 ; of cervix, cause of ante- 
 partum hemorrhage, 3 7 2 ; of uterus, cause 
 of dystocia, 610, treatment of, 610 
 pelvic, 638; syncytial, 196. 
 
 Cancerous cachexia, effect of, on fetus, 263, 
 on newly born, 809. 
 
 Cancrum oris of newly bom, 843. 
 
 Caput, obstipum, 832, succedaneum, 437 
 452, 453, 830, 831. 
 
 Carbolic acid, as an antiseptic, 152 ; m endo- 
 metritis, 753 ; in phlegmasia alba dolens 
 736; in vaginal and intrauterine in- 
 jections, 882. 
 
 Carcinoma. (See Cancer.) 
 
 Cardiac diseases, dystocia due to, 668; effect 
 of, on fetus, 263; in pregnancy, 263. 
 
 Caries of teeth, in pregnancy, 322. 
 
 Cartilage, origin of, 60, 62. 
 
 Caruncular formations after labor, 678. 
 
 Casein of milk, 789. 
 
 Castration, indicated in rudimentary uterus, 
 285; in osteomalacia, 342. 
 
 Catheterization, 887; in labor, 614; in puer- 
 perium, 692, 706; in urinary retention 
 in pregnancy, 318; of uterus (Krause's 
 method), 891. 
 
 Celibacy, advisable in case of pelvic de- 
 formity, 656; pelvic disorders due to. 
 
 Celiotomy. (See Laparotomy.) 
 
 Cellular tissue of pelvis, 399. 
 
 Cellulitis, puerperal, 729, 737. 
 
 Centers of ossification as sign of maturity of 
 
 fetus, 85, 88. 
 Cephalhematoma, 830. 
 Cephalometry, 180-185. 
 
1050 
 
 INDEX. 
 
 and cranioclast com- 
 
 Cephalotomy, 955. 
 
 Cephalotribe, 951, 
 pared, 952. 
 
 Cephalotripsy, 951-955. 
 
 Cerebral diplegia of fetus, 266. 
 
 Cervical canal, 9 1 ; changes in, in pregnancy, 
 91, 147; shortening of, 91. 
 
 Cervix, affections of, cause of ante-partum 
 hemorrhage, 371, 372; bimanual dilata- 
 tion, indications for, 898, 899; canal of, 
 in pregnancy, 9 1 ; condition of, in men- 
 struation, 2 1 ; consistency of, in preg- 
 nancy, 89; deviation or malposition of, 
 cause of dystocia, 608; dilatation of, 
 403; dilatation of, instrumental, 902- 
 906; dilatation of, in labor, 435, in 
 primiparse and multiparae, 403 ; dilata- 
 tion of, manual, 895-902; incisions of, 
 907; in puerperium, 678; inflamma- 
 tion of, in pregnancy, 371; lacerations 
 and contusions of, 592; rigidity of, 606; 
 softening of, in pregnancy, 123. 
 
 Chamberlen's forceps, 983. 
 
 Champetier de Ribes' bag, 894, 904, in 
 delayed labor, 573, in placenta prasvia, 
 223. 
 
 Child. (See Newly-born child.) 
 
 Chill, in puerperal infection, 75; physiolog- 
 ical, after labor, 440; post-partum. 
 673; in puerperal perimetritis, 735; in 
 pyemia, 741; in sapremia, 738, in sep- 
 ticemia, 741. 
 
 Chloasmata of pregnancy, 117, 130. 
 
 Chloral in eclampsia, 311; in labor, 867, 868 ; 
 in tetanus of newly born, 847. 
 
 Chlorine water in puerperal infection, 754. 
 
 Chloroform, administration of, 866; and 
 ether; choice between, 867; in con- 
 vulsions of infants, 855; in labor, 480, 
 482; in labor, fetal asphyxia from, 261; 
 in manual extraction of placenta, 1029; 
 transmission of, from mother to fetus, 
 67. _ 
 
 Cholera, in pregnancy, 257; puerperal, 738. 
 
 Chorda, 56. 
 
 Chorea, in pregnancy, 335; of fetus, 266. 
 
 Chorio-epithelioma malignum, 196. 
 
 Chorion, 63, 68; diseases of, 198—201; 
 fibromyxomatous degeneration of, 201; 
 formation of, 57; frondosum, 69; in- 
 flammation of, 201; teve, 69. 
 
 Chyluria in pregnancy, 320. 
 
 Circular vein of placenta, 71. 
 
 Circulation, changes in fetal, 780; charac- 
 teristic features of feta , 82; develop- 
 ment of chorionic, 78; development of 
 placental, 78; earliest embryonic, 78; 
 fetal, 79; of newly born, failure of, 839; 
 peculiarities of fetal, 82. 
 
 Circulatory system, diseases of, in preg- 
 nancy, 325-328. 
 
 Cleidotomy, 961; in dystocia from un- 
 usual width of shoulders and chest, 564. 
 
 Climacteric, 26, 39; conception after, 121. 
 (See Menopause.) 
 
 Cliseometry, 179. 
 
 Clitoris, defects in, 287; adhesion of hood 
 of, in newly born, 796. 
 
 Clothing, in pregnancy, 187; of newly born, 
 786; in prematurity, 803, 805. 
 
 Coccygodynia from labor, 615. 
 
 "Coffin birth," 669. 
 
 Coitus, in pregnancy, 188; interruptus, 
 38; reservatus, 38; time of, most favor- 
 able for conception, 27. 
 
 Cold, in mastitis, 831, in ophthalmia 
 neonatorum, 835, in puerperal endo- 
 metritis, 753, 754; in puerperal pel- 
 vic peritonitis, 755, in puerperal par- 
 ametritis, 755; in puerperal perimet- 
 ritis, 736; in puerperal salpingitis and 
 oSphoritis, 754, in puerperal infection, 
 
 751- 
 
 Colic, of newly born, 852. 
 
 Colon irrigation in puerperal infection, 751. 
 
 Colostrum, description of, 683. 
 
 Colporrhexis, 595. 
 
 Coma in eclampsia, 301. 
 
 Compression, danger of forceps, 989; in 
 treatment of cephalhematoma, 831. 
 
 Conception, 27; after climacteric, 121; avoid- 
 ance of, in pelvic deformity, 715; means 
 of preventing, 37, 38; sequelas of pre- 
 vention of, 39; time favorable for, 27. 
 
 Condensed milk, components and reaction 
 of, 794- 
 
 Confinement, calculation of date of, 146, 147. 
 
 Congestion, of organs, in pregnancy, 130; 
 passive, of placenta, 228. 
 
 Conjugate diameter of pelvis, 166; external 
 (Baudelocque's), 164; external in preg- 
 nancy, 164; external and internal, 
 relation between, 164; true, 168-171. 
 
 Connective tissue, origin of, 62. 
 
 Constipation, cause of nonseptic puerperal 
 fever, 743; in pregnancy, 115, 323, 
 treatment of, 186, 323, 324; in puer- 
 perium 705, 739, 743; of newly born, 
 853; treatment of, 743. 
 
 Contracted pelves. (See Pelvic deformiir.) 
 
 Contraction, false uterine, 43 1 ; intermit- 
 tent, in pregnancy, 123; uterine, in 
 labor, 429-431; in third stage of labor 
 
 439- 
 
 Contraction ring, uterine, 402. 
 
 Convulsions, in eclampsia, 304; of the 
 newly bom, in atelectasis, 839, in colic, 
 852, in constipation, 854, in septic in- 
 fection, 841. 
 
 Cord, spinal, origin of, 62; umbilical (see 
 Umbilical cord). 
 
 Corpus luteum, 18, retrograde changes in, 19. 
 
 Corsets, 36; first use of, in puerperium, 698; 
 French, maternity, in pregnancy, 194. 
 
 Coryza neonatorum, septic, 843. 
 
 Cotyledons, placental, 71. 
 
 Cough, nervous and spasmodic, in preg- 
 nancy, 331. 
 
 Counter-irritation, in puerperal neuritis, 
 770. 
 
 Cow'smilk, and human, compared, 789; com- 
 position of, 789. 
 
 Coxalgic pelvis, 649. 
 
 Coxitis, 649. 
 
 Cramps, in pregnancy, 114. 
 
 Cranial bones, injuries of, at birth, 828. 
 
 Cranioclasis, 947-951; in pelvic deform- 
 ity, 663; substitutes for, 955. 
 
 Craniotabes, 268. 
 
 Craniotomy, 955; in dead fetus, 930; in 
 interlocking of fetal heads, 658; in ky- 
 phosis, 646; in obstructed labor due to 
 levator ani, 612; in threatened rupture 
 of uterus, 590. 
 
INDEX. 
 
 1051 
 
 Cranium, changes in cavity of, in preg- 
 nancy, 1 1 8. 
 
 Cravings in pregnancy, 115. 
 
 Crede's, method of placental expression, 
 491, method with eyes of newly born, 
 835, ointment in puerperal infection, 
 751, silver in endometritis, 754. 
 
 Creolin, its use in obstetrics, 753, 882. 
 
 Crochet, loio. 
 
 Curettage, 103 1; choice of instruments for, 
 1031; digital, 1031; in abortion, 35 9- 
 361; in puerperal infection, 756; effects 
 of. 7531 objections to, 756. 
 
 Cutaneous sepsis of newly born, 844. 
 
 Cyanosis, in atelectasis of newly born, 
 839; in failure of circulation in newly 
 born, 839; in prematurity, 802; in 
 puerperal thrombosis and embolism, 
 768; of newly born, 816. 
 
 Cystic degeneration of chorion, 198. 
 
 Cystic tumor of broad ligament, diagnosis 
 of, from hydramnios, 206. 
 
 Cystitis, in pregnancy, 317; in puerperium, 
 707, 727; septic, treatment of, 754. 
 
 Cystocele, cause of dystocia, 614; in preg- 
 nancy, 318. 
 
 Cysts, fetal, 270; of umbilical cord, 240; 
 ovarian, diagnosis of, from hydramnios, 
 206; pelvic, 638; placental, 235; sub- 
 lingual, in newly born, 852; vaginal. 
 
 D. 
 
 Deafness in pregnancy, 335. 
 
 Death, from prolonged labor in case of can- 
 cerous uterus, 610; maternal, effect of, 
 on fetus, 670; of fetus, 272; sudden, in 
 labor 669, in pregnancy, 369, in puer- 
 perium, 773-776. 
 
 Decapitation, 955-960; extraction after, 
 960. 
 
 Decidua, apoplexy of, 195; atrophy of, 
 196; changes in, in puerperium, 
 682; development of , 48 ; disappearance 
 of, 48; disease of, 1 91-198; fatty de- 
 generation of, 49 ; graviditatis, 45 ; re- 
 flexa, 45, 66; in twin pregnancy, 142; 
 serotina, 45; vera, 45, 66. 
 
 Deformities, fetal, classifications of, 244; 
 fetal, producing dystocia, 660; of 
 genital organs, clinical significance of, 
 287; recurrent, 266, 267; pelvic, diag- 
 nosis of, by Rontgen pelvimetry, 177. 
 
 Delirium in labor, 668; in puerperal infec- 
 tion, 748. 
 
 Delivery, calculating date of, 146, 687; 
 different signs of, in primiparas and 
 multiparas, 688; feigned, 449; forcible, 
 964; immediate, in asphyxia neon- 
 atorum, 817; impregnation subse- 
 quent to, 689; of placenta and mem- 
 branes, 1025-1031; operations for, 963- 
 1031; post-mortem, 669; premature 
 indication for, 890; signs of recent, 
 687; treatment of mother after, 688; 
 unconscious, 449. 
 
 Dermatitis exfoliativa neonatorum, 844. 
 
 Dermoid cysts, cause of dystocia, 605; of 
 newly born, 852; of umbilicus, 242. 
 
 Deutoplasm of ovum, 42. 
 
 Diabetes, an indication for prevention of 
 
 reproduction, 38; effect of maternal, 
 on newly born, 262; in pregnancy, 
 262, 320. 
 
 Diagonal conjugate diameter, 168. 
 
 Diameters of pelvis, 168, 380, 381, 384. 
 
 Diaphragm, action of, in labor, 428; forma- 
 tion of, 60. 
 
 Diarrhea, in newly born, 853, 841; in preg- 
 nancy, 115, 324. 
 
 Diastasis, of abdominal muscles, 711; of 
 long bones at birth, 829; of pelvic 
 joints, cause of dystocia, 615. 
 
 Diet, effect of mother's, on milk, 685 ; 
 improper, a cause of subinvolution, 186; 
 in diarrhea of newly born, 853; in pel- 
 vic deformity, 651; in pregnancy, 186; 
 in puerperium, 693 ; in threatened 
 eclampsia, 309. 
 
 Digestion, and assimilation of newly born, 
 failure of, 840; in newly born, 782; 
 in puerperium, 676. 
 
 Digestive disturbances, cause of dystocia, 
 669. 
 
 Digestive tract, changes in, in pregnancy, 
 
 "5- 
 
 Dilatation, of cervix, in labor, 435, mstru- 
 mental, 902-906, manual, 895-902, of 
 vagina and vulva, 906. 
 
 Diphtheria, bacterial toxemia of, 740; in 
 puerperium, 737, 740. 
 
 Diseases, antenatal, 807-812; due to bac- 
 teria and fungi, in newly born, 840-847; 
 general, in puerperium, 773; inci- 
 dent to change of environment in newly 
 born, 837-840; of unknown nature of 
 newly born, 847-851. 
 
 Disinfection, of hands, 1 51-153; of field of 
 operation, 860. 
 
 Dislocations, fetal, 270. 
 
 Displacements, after interrupted pregnancy. 
 
 356. 
 
 Diuretics for newly born, 856. 
 
 Double uterus, 283, 367. 
 
 Douche, vaginal, 881. 
 
 D'Outrepont's method of version, 924. 
 
 Dress, hygienic, 36. 
 
 Drink in pregnancy, 186. 
 
 Droysen's weights of embryo and fetus, 86. 87. 
 
 Dry labor, 570. 
 
 Duct, of Arantius, 81; right, of Cuvier, 81; 
 Mullerian, formation of, 60; Wolffian, 
 formation of, 60. 
 
 Ductus arteriosus, 81, 82, closure of, 780; 
 venosus 78, 81, 82 
 
 Dystocia, fetal, from faulty attitude, 499" 
 527, from faulty position, 545-555. from 
 faultv presentation, 527-545, from gen- 
 eral fetal conditions, 555-566; maternal, 
 from the forces, 567-574, from general 
 maternal conditions, 665-671, from ob- 
 structed labor, 602-665, in parturient 
 tract and adnexa, 574-602, 
 
 Dysuria, due to urinary retention, 318; in 
 pregnancy, 317. . 
 
 E. 
 
 Ear, external, formation of, 56; origin of, 
 62. 
 
 Eclampsia, 964; albuminuria in, 307; al- 
 buminuria absent in, 309; aura in, 305; 
 bimanual dilatation in, 900; bleeding 
 
1052 
 
 INDEX. 
 
 in, 312; blindness in, 305; Caesa- 
 rean section in, 1012; cause of sudden 
 death in pregnancy, 369; control of 
 convulsions in, 311; curative treatment 
 of, 310-315; definition of, 304; diagno- 
 sis of, 307, from apoplexy, 307, from 
 epilepsy, 307, from hysteria, 307, from 
 meningitis, 307; diet in threatened, 
 309; drugs in (see Treatment); effect of, 
 on fetus and labor, 306, on newly born, 
 809; elimination of posions presumed 
 to cause convulsions in, 311, emptying 
 of uterus in, 312; etiology of, 304; 
 frequency of, 304; in primiparas, 314, 
 665; internal podalic version in, 929; 
 operative treatment of, 312-314; path- 
 ology of, 304; preventive treatment of, 
 308-310; prodromal period of, 305; 
 prognosis of, 307; saline solution in- 
 jections in, 861; stage of coma in, 
 306; stage of invasion in, 305; sympto- 
 matology of, 305; and acute toxe- 
 mia of pregnancy, differences between, 
 296; treatment of, 308-315; urine m, 
 307; vaginal Caesarean section in, 1024; 
 venesection in, 312. 
 
 Ecthyma neonatorum, 845. 
 
 Ectoderm, 53, 55, 58, 61, 64 
 
 Ectopic gestation, 361-366; celiotomy in, 
 1025; diagnosis of, 365; etiology of, 362; 
 laparotomy in, 366; pathology of, 362; 
 symptoms of, 363-365; treatment of, 
 365,366; varieties of, 361. 
 
 Eczema, in pregnancy, 291, 337. 
 
 Edgar's, irrigating tube, 884, method of en- 
 gaging fetal head, 184. 
 
 Education in relation to sexual functions, ^6 
 
 Elbow and knee presentation, differential 
 diagnosis of 536. 
 
 Electricity, in galactorrhea, 761 ; in paralysis 
 of arm, 827; in paralysis, traumatic, 
 771; in subinvolution, 709. 
 
 Elephantiasis, congenital, 808; general cys- 
 tic, 268. 
 
 Ellipse, fetal, 420, 443. 
 
 Emanuel's disease, 231. 
 
 Embolism, air, in puerperium, 776; puer- 
 peral, 768; pulmonary, cause of sud- 
 den death in puerperium, 775. 
 
 Embryo, anatomy of, 53-66; arrested de- 
 velopment of, 243; characteristics of, in 
 different lunar months, 83-88; nutrition 
 of, 78; pathology of early human, 242; 
 vitelline circulation of, 78. 
 
 Embryotomy, 942, 943; in cancer of uter- 
 us, 610; in face presentation, 518; in 
 over-developed fetus, 562; in pelvic de- 
 formity 658, 659, 660; in persistent 
 mento-posterior positions, 552; in 
 threatened rupture of uterus, 589; 
 indications for, 10 12. 
 
 Emotion, in etiology of accidental hemor- 
 rhage, 226; a cause of fever in puer- 
 perium, .745; in relation to menstrua- 
 tion, 23, 24, 120, 121. 
 
 Emphysema in pregnancy, 329. 
 
 Encephalocele, of fetus, 265, cause of dys- 
 tocia, 563. 
 
 Endocarditis, in pregnancy, 325; of fetus, 
 263, 875; puerperal, 806. 
 
 Endometritis, a cause of interrupted preg- 
 nancy, 3 49 ; cervical, a cause of ante-par- 
 
 tum hemorrhage, 371 ; chronic, a cause of 
 fetal death, 270; catarrhal, 192; de- 
 ciduae cystica, 195; due to mixed in- 
 fection, in puerperium, 724-726; in 
 etiology of accidental hemorrhage, 226; 
 puerperal, 718-724; puerperal, infec- 
 tious, 722; puerperal, malignant, 733, 
 730; puerperal, results of, 714; puer- 
 peral, saprophytic, 719-721; puerperal, 
 varieties of, 718; puerperal, treatment 
 
 of, 753- 
 
 Endometrium, changes in, during menstru- 
 ation, 21. 
 
 Enema, ante-partum, 472. 
 
 Engagement of head in vertex presentation, 
 
 441,453,457- 
 
 Enteroclysis, 863. 
 
 Entoderm, 53, 54, 62. 
 
 Epidermis, 55; origin of, 63. 
 
 Epilepsy, diagnosis of, from eclampsia, 307; 
 due to cerebral hemorrhage in labor, 
 824; indication for prevention of re- 
 production, 38; in pregnancy, 335. 
 
 Episiotomy, 910; in dystocia due to cedema, 
 613. 
 
 Epithelium, origin of, 61. 
 
 Ergot, after abortion, 361; after labor, 
 493; cause of rupture of uterus, 585; 
 in accidental hemorrhage, 228; in hem- 
 orrhages of newly born, 850 ; in puerperal 
 endometritis, 753; in puerperal hemor- 
 rhage, 704; in puerperal septic phlebi- 
 tis, 736; in puerperal infection, 817; 
 in puerperium, 679; in subinvolution, 
 
 709- . , 
 
 Erosions, cervical, cause of ante-partum 
 
 hemorrhage, 372. 
 Eruptions, in septic infection in puerperium, 
 
 773- 
 
 Erysipelas of fetus, 256; of newly born, 
 846; in pregnancy, 256, 336; m puer- 
 perium, 739. 
 
 Erythema, puerperal septic, 740. 
 
 Ether, administration of, 867; and chloro- 
 form, choice between, in labor, 865, 
 868; in obstetric operations, 867, 868; 
 in first stage of labor, 572; in labor, 
 480, 482; in labor, fetal asphyxia 
 from, 261; in manual extraction of 
 placenta, 1029. 
 
 Eustachian valve, 81, 82. 
 
 Evisceration, 960. 
 
 Evolution, spontaneous, in shoulder pres- 
 entation, 541. 
 
 Examination, methods of, in diagnosis of 
 pregnancy, 123; limitation of inter- 
 nal, in obstetrics, 953. 
 
 Excitement, emotional, cause of fever in 
 puerperium, 974; effect of, on men- 
 struation, 24; to be avoided in preg- 
 nancy, 188. 
 
 Exercise, in pregnancy, 185; in puerperium, 
 697; in threatened eclampsia, 309. 
 
 Exophthalmic goitre in pregnancy, 328. 
 
 Expression of fetus, 537, 963. 
 
 Extension of fetal head, 412, 455, 457. 
 
 Extrauterine pregnancy. (See Ectopic ges- 
 tation.) 
 
 Extremities, changes in lower, in preg- 
 nancy, 114. 
 
 Exudations, pelvic, diagnosis of, from preg- 
 nancy, 135. 
 
INDEX. 
 
 1053 
 
 Eyes, formation of, 56; of newly born child, 
 cleansing of, 485; loss of, from purulent 
 ophthalmia, 833. 
 
 F. 
 
 Face presentation, 508-518; and breech pres- 
 entation, differential diagnosis of, 536; 
 diagnosis of, 514; embryotomy in, 
 518; forceps in, 518; manual correc- 
 tion of, 91 1-9 1 4; mechanism of, 510, 
 511; perforation in, 946; treatment of, 
 518; version in, 527, 528. 
 
 Fallopian tubes, ciliary current in, 18; 
 hgation of, in Caesarean section, 1015; 
 obliteration of, for prevention of con- 
 ception, 39; origin of, 61; pregnancy 
 in, 361. 
 
 Fats, regulation of, in modified milk, 789, 
 790. 
 
 Fatty degeneration of newly born, 851; 
 of heart in pregnancy, 326; of placenta, 
 236. 
 
 Feces, of newly born, 781. 
 
 Fecundation, 27. 
 
 Feeding, artificial, 786-794; infant, proper 
 intervals for, 787. 
 
 Feet, extraction by, in breech presentation. 
 
 973- . 
 
 Feigned delivery, 449. 
 
 Female pronucleus, 42. 
 
 Feticide, 39, 344; therapeutic, 39. 
 
 Fetus, 408; acute poisoning of, 261; ante- 
 natal diseases of, 255-272; atelectasis 
 in, 779; attitude of, 420; bladder disten- 
 tion of, 267; blood, circulation of, in, 
 79-82; blood of, 79; bone disease of, 
 268; bones, cranial, of, 410; calcifica- 
 tion of. 274; cardiac lesions in, 263; cere- 
 brospinal meningitis of, 258; death of, 
 272-274; deformities and monstrosities 
 of, classification of, 244; delivery of, 
 in Cesarean section, 10 14; develop- 
 ment of, in different months of gestation, 
 84-88; diameters of head of, 414-416; 
 diseases of, 262-269; embryotomy upon 
 dead, 943, upon living, 944; excretions 
 of, 67, 79; expression of, 963; extrac- 
 tion of, in low forceps operation, 993; 
 fontanelles of, 411; head of, 408-417; 
 heart sounds of, 127, 463; hereditary 
 predispositions of, 266; maternal in- 
 fluence on, 188; measurements of, 
 414-422; over-size of, 561; posture of, 
 420; traumatisms of, 269; trunk 
 measurements of, 417; viability of, after 
 death of mother, 670; vitality of, in 
 different months, 85; weight of, in 
 different months, 86, 87. 
 
 Fever, due to constipation, 743; due to 
 intercurrent and complicating disease 
 in puerperium, 737; due to reflex 
 irritation, 744, 750; inanition, 840; in 
 convulsions of newly born, 855; in 
 neurotic conditions, in puerperium, 743, 
 745, treatment of, 751; in pregnancy, 
 371; in puerperal infection, 747, 748; 
 in septic infection of newly born, 841; 
 in tetanus of newly born, 846 ; maternal, 
 effect of, on fetus, 271 ; non-septic, 743- 
 747; pseudo in puerperium, 743; 
 puerperal, classification of, 712, puer- 
 
 peral, defined by Semmelweis, 148; in 
 puerperal phlebitis, 736; in pyemia, 
 741; in sapremia 738; in septicemia, 
 741; "one-day," 719, 748; in retro-dis- 
 placements, of puerperal uterus, 744; 
 resorption, 748; in rupture of the uter- 
 us, 744, true puerperal, 746. 
 
 Fibrin, increase of, in blood, m pregnancy, 
 117. 
 
 Fibroids, cause of intra-partum hemorrhage, 
 671 ; in pregnancy, 282. 
 
 Fibroma, diagnosis of, from pregnancy, 134; 
 fetal, 270; of virgin uterus, 37; pelvic, 
 638. 
 
 Fibrous tissues, changes of, in pregnant 
 uterus, 105. 
 
 Fillet, 915; as tractor, 1007; in breech 
 extraction, 971 ; soft, 1007-1009. 
 
 Finger-nails, care of surgeon's, 150. 
 
 Fistula, vaginal, diagnosis of, 1032; vesical 
 and rectal, repair of, 1032. 
 
 Fixation abscess in puerperal infection, 752. 
 
 Flat pelvis, 63 1 ; induction of premature 
 labor in, 890. 
 
 Flat rachitic pelvis, 631. 
 
 Flatulence in pregnancy, 115. 
 
 Flesh moles, 345. 
 
 Flexion, 412; incomplete, 412, 500-503; in 
 vertex presentation, 451, 457, 460; of 
 head in breech, 531; in brow, 508; in 
 face presentation, 513. 
 
 Flooding, 577. (See Post-partum hemor- 
 rhage.) 
 
 Follicles, arrangement of, in ovary, 42; 
 sebaceous, in pregnancy, 89. 
 
 Fontanelles, false, 412; fetal, 411; of newly 
 born, 785. 
 
 Food, in prematurity, 803; in puerperal 
 infection, 751; in relation to sexual 
 functions, 36. 
 
 Foods, patented or proprietary, for newly 
 born, 794. 
 
 Foot and hand, differential diagnosis of, in 
 pelvic presentation, 536. 
 
 Foot and shoulder traction in breech pres- 
 entation, 979. 
 
 Foramen, ischio-pubic, 379; ovale, 81. 
 
 Forceps, 983-1007; action of, 989; antero- 
 posterior, 984; application of, cephalic, 
 990-992, pelvic, 992; as rotators, 
 1002; axis-traction, 998; in high opera- 
 tion, 997, Breus's, 984; cause of rup- 
 ture of vagina, 594; Chamberlen's, 983; 
 classification of, 990; delivery, posture 
 in, 879; description of, 9S3; Elliott's, 
 984; facial paralysis due to, 824; high, 
 990, 997; in pelvic deformity, 657; his- 
 torical, 983; in after-coming head, 979, 
 1003-1005; in asphyxia neonatorum, 
 817; in breech extraction, 973 ; inbreech 
 presentation, 538; in brow presen- 
 tation, 508, 1006; in cancer of uterus, 
 610; in congenital hydrocephalus, 563; 
 in deep transverse head, 1006; in de- 
 layed labor, 573; in dorsal displace- 
 ment of arm, 521; in dystocia due to 
 affections of fetal trunk, 564 in eclamp- 
 sia, 314; in elderly primiparag, 666; in 
 face presentation. 518, 1005, 1006; in 
 funnel-shaped pelves, 626; in interlock- 
 ing of fetal heads, 558; in kyphosis, 
 646; in mento-posterior positions. 1006; 
 
1054 
 
 INDEX. 
 
 in obstructed labor due to levator ani, 
 612; in occipito-posterior positions, 
 999; in occlusion of external os, 609; 
 in over-developed fetus, 562; in pelvic 
 deformity, 658; in pelvic presentation, 
 1003; in persistent mento-posterior 
 positions, 552; in persistent occipito- 
 posterior positions, 548; in prolapse of 
 arms, 521; in prolapse of umbilical cord, 
 526; in rupture of uterus, 589, 590; in 
 scoliosis, 647; in short cord, 559; in 
 transverse position of head at pelvic out- 
 let, 554; in vaginismus, 610; indica- 
 tions, 985; low, 990, 992-996; extrac- 
 tion, of fetus, 993, 994, general princi- 
 ples of, 994, median, 990, 996; Naegele's. 
 984; operations, frequency of, 985, 
 high, ordinary forceps, 997, axis-traction 
 forceps, 998; preparation for, 988; tech- 
 nique of, 988; Penoyee's, 984; placental 
 in abortion, 360; prerequisites and con- 
 traindications for, 987, prognosis of, 987; 
 Scanzoni's manoeuvre with, 1006; Simp- 
 son's, 984; slipping of, 988; Smellie's, 
 983, sterilization of, 988; straight, 
 984; Tarnier's, 984. 
 Fore-coming head, manual extraction of, 
 
 965- . , 
 
 Formaldehyde solutions, intravenous infu- 
 sion of, in puerperal infection, 752. 
 
 Fourchette, rupture of, 597; lacerations, 
 repair of, 1035. 
 
 Fractures, fetal, 269; of cranial bones at 
 birth, 828 ; of facial bones at birth, 829 ; 
 of long bones at birth, 829; of pelvis, 
 anomalies due to, 638. 
 
 Functions of pelvic joints, 379. 
 
 Fundus, care of, in third stage of labor, 
 490; height of, in puerperium, 681, 
 in different months of pregnancy, 146; 
 pressure on, in labor, 488. 
 
 Funis. (See Umbilical Cord.) 
 
 Gait, change of, in pregnancy, 118 
 
 Galactocele, 768. 
 
 Galactogogues, 685, 760. 
 
 Galactorrhea, 685, 761. 
 
 Ganglia, nervous, origin of, 56, 62. 
 
 Gangrene in puerperal thrombosis and em- 
 bolism, 768. 
 
 Gangrenous stomatitis of newly born, 843. 
 
 Gas-bacteriemia, 742; gas sepsis, 742. 
 
 Gastro-enteritis of newly born, 844. 
 
 Gastro-intestinal infection of newly born, 
 843,844. 
 
 Genital organs, clinical significance of de- 
 formities of, 287, 288; malformations 
 of, in pregnancy, 282-288 ; origin of, 62 ; 
 external, in pregnancy, 89, in puer- 
 perium, 677. 
 
 Germ-layers, formation of, 5 1 ; inversion 
 of, 64; organs and tissues derived from, 
 62. 
 
 Gestation, ectopic, diagnosis of, from preg- 
 nancy, 136; protracted, 144, 145. 
 
 Gestational, insanity, 335; melancholia, 
 mania and dementia, 332-335; neu- 
 ralgias, 335; paralyses, 335. 
 
 Giant pelvis, 627. 
 
 Gingivitis in pregnancy, 321. 
 
 Glands, decidual, 45, 46; inflammation of 
 Montgomery's, 761 ; lymphatic, changes 
 of, in pregnancy, 116; mammary, 
 origin of, 62 ; mucous vaginal, in preg- 
 nancy, 89; pelvic, 400; salivary, origin 
 of, 62, 84, in pregnancy, 322; sweat, in 
 pregnancy, 117; thymus, origin of, 
 62; uterine, changes in, in menstrua- 
 tion, 21; uterine, in pregnancy, 78; 
 vaginal, 89; vulval, 89. 
 
 Gloves, rubber, 151; sterilization of, 153. 
 
 Glycosuria, in pregnancy, 319; in puer- 
 perium, 320. 
 
 Goitre, congenital cystic, cause of dystocia, 
 563; in pregnancy, 328. 
 
 Gonococcus, in puerperal infection, 149, in 
 ophthalmia neonatorum, 832-837. 
 
 Gonorrhea, puerperal, 727, 737. 
 
 Gonorrheal stomatitis, 837. 
 
 GOttengen's weights of embryo and fetus, 
 86,87. 
 
 Graafian follicles, development of, 17; 
 rupture of, 17. 
 
 Granuloma, infectious, of placenta, 232, 233. 
 
 H. 
 
 Habitual death of fetus, 891. 
 
 Hand, choice of internal, in internal podalic 
 version in cephalic presentation, 93 1 , 
 choice of, in internal podalic version 
 in shoulder presentation, 935; diagnosis 
 of, from foot, 536, 933 ; disinfection, 151- 
 153 ; origin of, 61. 
 
 Head, fetal, 408-420; after-coming (see 
 After-coming head) ; changes in shape of, 
 according to presentation, 502, 504, 512, 
 518, 519, 546, 785; delivery of, 481-485; 
 in persistent sacro-posterior cases, 979, 
 980; detached, forceps to, 1005; en- 
 gagement and descent of, in vertex pres- 
 entation, 451; excessive flexion of, 499; 
 fore-coming (see Fl re-coming head); m 
 complete flexion of, 500-503; inter- 
 locking, 614; manual engagement of, 
 1 83 ; oversize of , 5 - 2 ; in brow presenta- 
 tion, 508; rotation of, in breech cases, 
 447; transverse position of, at pelvic 
 outlet, 553, 554. 
 
 Heart, beginning of function of, 84; changes 
 in, in pregnancy, 115, 116; develop- 
 ment of, 79, 81; disease of, indication 
 for prevention of reproduction, 38, 
 dystocia due to, 668; failure, posture 
 in, treatment of, in labor, 878; fetal, 81; 
 location of, 161; hypertrophy of, in 
 pregnancy, 115, in puerperium, 677; 
 murmur, in puerperium, 674; muscle, 
 affections of, in pregnancy, 326; of 
 newly born, 783; rate of fetal, 128. 
 
 "Heat" and menstruation, relation be- 
 tween, 23. 
 
 Hegar's, dilator, 903 ; sign, in pregnancy, 123. 
 
 Hematocele, extrauterine and extraperito- 
 neal, 585; in pregnancy, 327; origin 
 of> 327, 364; pelvic, 364; diagnosis 
 of, from pregnancy, 137. 
 
 Hematoma, cause of dystocia, 613; of 
 broad ligament, 366; of placenta, 
 229-231; of sternomastoid, 832; of 
 umbilical cord, 241; of vagina and 
 vulva, 291, 613, 704. 
 
INDEX. 
 
 1055 
 
 Hematometra, diagnosis of, from pregnancy, 
 132. 
 
 Hematosalpinx, origin of, 364. 
 
 Hematuria, in newly born, 850; in preg- 
 nancy, 319; in puerperium, 705. 
 
 Hemiopia, in puerperium, 771. 
 
 Hemiplegia and aphasia, puerperal, 771. 
 
 Hemoglobin of newly born, 783. 
 
 Hemoglobinuria in Winckel's disease, 851. 
 
 Hemorrhage, accidental, 224-228; after 
 abortion, 354, 355; ante-partum, causes 
 of, 371, 372; cause of, in placenta 
 praevia, 215; cerebral, of newly born, 
 823; concealed, 224; in premature 
 detachment of normally situated pla- 
 centa, 225; control of, in third stage 
 of labor, 439; in Ceesarean section, 1014; 
 curettage in, 358, 359; from genitals 
 in female infants, 850; from umbil- 
 ical cord, 241; in abortion, 354; 
 in atony of uterus, 360; in congen- 
 ital syphilis, 809; in general, of newly 
 born, 848-850; in hydatidiform mole, 
 200; in inversion of uterus, 591; 
 in paralysis of placental site, 580; 
 in placental polypi, 237; in hemor- 
 rhoids in pregnancy, 324; in pre- 
 mature labor, 354; in puerperal anemia, 
 768; in retained placenta, 574; in rup- 
 ture of fetal cyst, 366; in septic infec- 
 tion of newly born, 841; in twin labor, 
 556; interstitial, of placenta, 229-232; 
 partum or intrapartum, 671; patho- 
 logical, and menstruation, confu- 
 sion of, 121; periovular, 345; post- 
 partum, 556, 577-584; posture in, 
 878; puerperal, 701-705; treatment 
 of, 228, 229, 581-584, 861-865; sec- 
 ondary, 701; in atony of uterus, 579; 
 in retained placenta, 574. 
 
 Hemorrhoids, in pregnancy, 324; vesical, 
 in pregnancy, 318. 
 
 Hepatic lesions and eclampsia, 304, 305; 
 and the toxemia of pregnancy, 292. 
 
 Hernia, cause of dystocia, 605 ; in preg- 
 nancy, 118; of umbilical cord, 240; 
 vaginal, cause of dystocia, 667; ven- 
 tral, and pregnancy, coexistence of, 
 138. 
 
 Hernial protrusion of pregnant uterus, 281. 
 
 Herpes gestationis, 338. 
 
 Hicks', method of bipolar podalic version, 
 advantages of, 925, sign of pregnancy, 
 123, 207. 
 
 Hook, blunt, 10 10; in breech extraction, 
 971. 
 
 Hour-glass contraction of uterus, 574. 
 
 Hydatidiform mole, 198-201. 
 
 Hydrsemia in pregnancy, 327. 
 
 Hydramnios, 66, 204-208; treatment of, 
 208. 
 
 Hydrencephalocele, 265; cause of dystocia, 
 
 563- 
 
 Hydrocephalus, congenital, 264, 562; diag- 
 nosis of, 562; treatment of, 562, 563. 
 
 Hydrometra, diagnosis of, from pregnancy, 
 132. 
 
 Hydronephrosis, cause of dystocia, 564. 
 
 Hydrorrhea, amniotic, 203; gravidarum, 
 192. 
 
 Hymen, after rape, t,;^; carunculae myrti- 
 f ormes of , 7 3 5 ; congenital , absence of, 31 ; 
 
 forms of, 31; persistent, cause of dys- 
 tocia, 612; sign of virginity, 31. 
 
 Hyperemesis gravidarum, 323. 
 
 Hyperinosis, in pregnancy, 117; in puer- 
 perium, 677. 
 
 Hypertrophy, congestive, of uterus, diag- 
 nosis of, from pregnancy, 134. 
 
 Hypodermoclysis, 864, 865. 
 
 Hypoplasia uteri, 286. 
 
 Hypospadias, 273. 
 
 Hypothermia, puerperal, 747. 
 
 Hysterectomy, in puerperal infection, 757, 
 
 758. 
 Hysteria, diagnosis of, from eclampsia, 307; 
 in pregnancy, 335. 
 
 I. 
 
 Ichthyosis congenita, 267, 268, 809. 
 
 Icterus, gravidarum, 303 ; in septic infection 
 of newly born, 841; neonatorum, 263. 
 
 Idiocy due to fetal cerebral hemorrhage in 
 labor, 824. 
 
 Iliacus muscle, description of, 395. 
 
 Impetigo herpetiformis, 339; cause of sud- 
 den death in pregnancy, 369. 
 
 Impregnation, 27, 44; artificial, 29; rela- 
 tion between, and menstruation, 28; 
 time most favorable for, 29. 
 
 Inanition fever, 840. 
 
 Inanition of newly born, 840. 
 
 Incarceration of pregnant uterus, 275. 
 
 Incontinence of urine, in pregnancy, 318: 
 in puerperium, 706; diagnosis of, from 
 hydrorrhoea gravidarum, 193. 
 
 Incubator, Denucl's, 805 ; dangers from, 806 ; 
 in prematurity, 803; Lion, 805; proper 
 temperature of, 806; Tarnier's, 805. 
 
 Indigestion, gastric and intestinal, in preg- 
 nancy, 115. 
 
 Infant feeding, 786, 795, 
 
 Infant, first care of, 785; rape upon, 35 
 
 Infarcts, placental, 229, 231, 233, 234. 
 
 Infection, consecutive, focal, puerperal, 727. 
 738; primary, focal, 718-727; septic, 
 in interrupted pregnancy, 355. 
 
 Infectious diseases, in pregnancy, 336, 337. 
 of newly born, acute, 808, 809; chronic, 
 809. 
 
 Inflammations, genital and extra-genital, 
 in puerperium, 714. 
 
 Infusion, saline (See Saline infusion.) 
 
 Injuries, and accidents in pregnancy, 369, 
 370; from labor, repair of, 103 2-103 7; 
 to cranial bones at birth, 828; to 
 placenta, 224; to scalp at birth, 830. 
 
 Inlet, pelvic, anatomical, 381. 
 
 Insanity, 332-335; of labor, 668; of lac- 
 tation, 772; of pregnancy, 332—335; 
 of puerperium, 771-773. 
 
 Intercourse, sexual, stages of. 38. 
 
 Interlocking of fetal heads, 558. 
 
 Internal cephalic version, 924. 
 
 Internal podalic version, 929-936. 
 
 Intestinal, anomalies in puerperiimi, 705. 
 obstruction of newly born, 854. 
 
 Intestines, topographical relations of, at 
 term, 112. 
 
 Inversion of uterus, 590. 
 
 Involution, 679-682; disturbed, in puer- 
 peral infection, 748; effect of nursinq 
 on, 786 
 
1056 
 
 INDEX. 
 
 Ischio-pubiotomy, 936; in Naegele's pel- 
 vis, 626. 
 
 J. 
 
 Jacquemier's sign in pregnancy, 125. 
 
 Jaundice in newly bom, 851; in preg- 
 nancy, 296. 
 
 Joints, pelvic, 376-379; changes of, in 
 pregnancy, 114. 
 
 Justo-minor sequabiliter pelvis, 618. 
 
 K. 
 
 Kidney, congenital cystic degeneration of, 
 cause of dystocia, 564; floating, cause 
 of dystocia, 605 ; incarceration of, 
 in pregnancy, 316; in puerperium, 676; 
 origin of, 60; of pregnancy, 292; 
 tumors of, in pregnancy, 316 
 
 Knee and elbow differential diagnosis of. 
 1002; in pelvic presentation, 589. 
 
 Knots in umbilical cord, 238 
 
 Kyphoscoliosis, 648. 
 
 Kyphosis, 643-646. 
 
 L. 
 
 Labice in pregnancy, 89. 
 
 Labor, abdominal binder after, 496; acute 
 psychosis during, 668; after operations 
 involving genitals, 490, 600-602; an- 
 esthesia in, 865-868, anesthetics in, 
 480, 482; fetal asphyxia from, 261 ; anti- 
 pyrin in, 867; asepsis in, 465; asystole 
 in, 668; auxiliary forces in, 428, 429; 
 bed in. 471; bimanual dilatation in 
 delayed first stage of 898, 899, caput 
 succedaneum in, 437, 453; CeiA'ical 
 dilatation in, 404; cervical shorten- 
 ing in, 433; chill after, 440; chloral 
 in, 867; chloroform in, 866; cleans- 
 ing of patient and bed after, 495; 
 conduct of, first stage of. 478, sec- 
 ond stage of, 479, third stage of, 
 490, 491; Death during, 669; deep 
 transverse position in, 446; definition 
 of, 375; delirium of, 668; dehvery 
 of body in, 488; delivery of head 
 between uterine contractions, 480-485 ; 
 delivery of placenta and membranes, 
 491; delivery of shoulders, 486; dila- 
 tation of internal os, 433; dry, 570; 
 duration of, 448, 464; Effect of eclamp- 
 sia on, 307; engagement and des- 
 cent during, 441 ; entrance of air into 
 uterine sinuses in, 776; episiotomy in, 
 910; ergot after, 493; ether in, 
 867; etiology of, 431; examination 
 in, 473-478; examination of placenta 
 and membranes after, 491, 492; 
 expelUng forces in, 428; expulsion of 
 first part of fetal ellipse in, 446; 
 expulsion of head in normal, 454, 457. 
 460; expulsion of second part of fetal 
 ellipse in, 447; expulsion of trunk 
 in, 455, 460, extension of head in 
 normal, 454; external examination 
 in, 474; Factors concerned in, 375; 
 false, and time of its appearance in 
 ectopic gestation, 364; false contrac- 
 tions or pains before, 431; false pains 
 
 distinguished from true, 433; feigned 
 delivery, 449; fetal impaction in, 
 459; first stage of, 433-437, bladder 
 and rectum in, 478; care of mem- 
 branes in, 478, food and drink during, 
 479, limits of, 464, presence of physician 
 during, 478, sleep during, 478, vaginal 
 examination in, 478, voluntary forces 
 in, 4 7 8 ; flexion of head in vertex presenta- 
 tion, 451, 457; Head delivery in, 
 480-485; head rotation in breech cases 
 during, 447; hematemesis in, 669; 
 hemorrhage during third stage of, 439; 
 immature (see Miscarriage) ; Inconri- 
 plete, 714, contraction and retraction 
 in, 714, drainage in, 714; indications 
 for induction of premature, 890, 891; 
 in elderly primiparse, 665 ; inspection 
 and repair of perineum after, 464, 490; 
 Management of, 463, first stage of, 47S, 
 second stage of, 479-490, third stage 
 of, 490—496; means for accelerating 
 first stage of, 572-574; mechanism of, 
 440-448, in breech presentation, 529, 
 in brow presentation, 504, in face pre- 
 sentation, 510-514, in vertex presenta- 
 tions, 451-461; metrorrhagia of, 671; 
 missed, 368; morbid conditions result- 
 ing from, 714-716; morphia during, 
 
 867, 868; Obstructed, 567, due to levator 
 am, 612; pains of, 429-431; Pathologi- 
 cal, 499; perineal protection in, 479- 
 488; pernicious vomiting during, 669; 
 physiological chill in, 440 ; placental de- 
 livery in, 439; posture as an aid in, 876- 
 879; positions in vertex presentation, 
 451-461; position of fetal heart sounds, 
 in vertex presentation, 463 ; position of 
 fetus, in vertex presentation, 463 ; post- 
 partum douche, 495; posture in, 478, 
 
 868, 876; precipitate, 567, 568; prepar- 
 ations for, 465-473; premature, 342- 
 361, induction of, 888-895, in pelvic 
 deformity, 663, in placenta previa, 222, 
 in pernicious vomiting, 303; prevention 
 of too rapid advance of head in, 480 ; pro- 
 longed, 566, 653; pulmonary embolism 
 in, 775; pulse in, 431; response to 
 summons in, 472; retention of secun- 
 dines after, 492; rubber gloves in, 151; 
 rupture of membranes in, 435, 479; 
 Second stage of, 437; management 
 of second stage of, 479-489; shoulder 
 delivery in, 456; show in, 435; spinal 
 anesthesia in, 868; stages of, 432- 
 440; stage of dilatation in, 435-437; 
 strength of uterine contractions in, 
 431; sudden death in, 669; syncope in, 
 580; Temperature during, 431; third 
 stage of, 439, management of, 490-493; 
 care of patient after, 493-496; time of, 
 25; twin, mortaUty of, 148; Uncon- 
 scious delivery in, 449, 450; uterine 
 contractions in, 429, 437; uterine walls 
 during, 404, 405 ; Vaginal examination 
 during, 476-478; vertex presentation, 
 diagnosis of, after labor, 462, during 
 labor, 461, 462, prognosis of, 462; Wal- 
 cher's position during, 876; without 
 internal examination, 477. 
 
 Laborde's method, of artificial respiration, 
 822; of tongue traction, 819, 822. 
 
INDEX. 
 
 1057 
 
 Lacerations, of cervix, vagina and pelvic 
 
 floor, 592-600; repair of, 1032-1037. 
 Lactation, insanity of, 772; pregnancy dur- 
 ing, 121; in relation to psychoses of 
 pregnancy, 334; menstruation sup- 
 pressed during, 24. 
 
 Lanugo, development of, 85. 
 
 Laparotomy in ectopic gestation, 366; in 
 intestinal obstruction of newly born, 
 855; in ovarian tumor in pregnancy, 
 604; in puerperal infection, 757; in 
 puerperal malignant peritonitis, 755; 
 in rupture of uterus, 590; in shoulder 
 presentation, 544. 
 
 Larynx, acute obstruction of, a cause of 
 labor, 668. 
 
 Latero-flexion during pregnancy, 278. 
 
 Latero-prone posture, exaggerated, indica- 
 tions for, 873. 
 
 Latero-version during pregnancy, 278. 
 
 Lead-poisoning, effect of, on newly born, 809. 
 
 Lens, crystalline, origin of, 61 ; optic, forma- 
 tion of, 62. 
 
 Leucocytosis in pregnancy, 117. 
 
 Leucorrhea, in pregnancy, 187, 288; treat- 
 ment of, 187. 
 
 Leukemia, effect of, on fetus, 263. 
 
 Levator ani muscle, cause of obstructed 
 labor, 612; description of, 396; func- 
 tions of, 397. 
 
 Ligaments, pelvic, 376, 398; changes of, in 
 pregnancy, 114; uterine, 286; changes 
 of, in pregnancy, 109. 
 
 "Lightening" before labor, 102. 
 
 Limbs, development of, 54, 58; lower, 
 changes in, in pregnancy, 114; of 
 fetus, fractures of, at birth, 829. 
 
 Lineag albicantiae, in pregnancy 117. 
 
 Liquor amnii, 66; anomalies of, 204. 
 
 Lithopedion, 274. 
 
 Live birth, 448. 
 
 Liver, acute yellow atrophy of, and preg- 
 nancy, relation between, 292; displaced 
 and pregnancy, coexistence of, 136; 
 fetal, part taken by, in circulation, 81; 
 formation of, 58; in fetal syphilis, 259; 
 in pregnancy, 116; of newly born, 783; 
 lesions of, in toxemia of pregnancy, 292; 
 origin of, 62. 
 
 Lochia, alba, 678; in puerperium, 678, 679; 
 examination of, 75; in puerperal infec- 
 tion, 748; rubra, 678; serosa, 678; vari- 
 ation of, in different patients, 701. 
 
 Longings in pregnancy, 323. 
 
 Lordosis pelvis, 649. 
 
 Lungs, formation of, 58, 62; in fetal syphilis, 
 260; in pregnancy, 116, 668. 
 
 Lymphangiomata, fetal, 270. 
 
 Lymphangitis, mammary, during puer- 
 perium, 762. 
 
 Lymphatics, changes of uterine, in preg- 
 nancy, 108; pelvic, 400. 
 
 Lysol, 151; in endometritis, 726; in vaginal 
 and intrauterine injections, 883. 
 
 M. 
 
 Maceration of fetus, 273. 
 
 Malacia, in pregnancy, 323 
 
 Malaria, in fetus, 257; in newly born, 808; 
 
 in pregnancy, 257, 337. 
 Male pronucleus, 43. 
 67 
 
 Malformations and monstrosities of newly 
 born, 807. 
 
 Malformations, fetal, in plastic exudation 
 of amnion, 202; producing dystocia, 
 .560-565. 
 
 Malignant disease, after abortion, 356; of 
 vagina, cause of ante-partum hemor- 
 rhage, 372. 
 
 Mammae, absence of, 759; changes in, in 
 pregnancy, 114, 115, 126; hypertrophy 
 
 of, 759- 
 
 Mammary, abscess in newly born, 851, irri- 
 tation, a cause of fever during the puer- 
 perium, 744, lymphangitis in puerpe- 
 rium, 762-768. 
 
 Mania in pregnancy, 116; in puerperium, 
 772. 
 
 Manual, dilatation of cervix, 895, 896; ex- 
 traction of placenta, 1029. 
 
 Marasmus of newly born, 840. 
 
 Marginal insertion, of cord, 237; of pla- 
 centa prasvia, 213. 
 
 Marriage as related, to heart disease, 668', 
 to pelvic deformity, 656, to pelvic 
 disease, 37, 38. 
 
 Massage, in agalactia, 760; in caked breasts, 
 761; in constipation of newly born, 
 854; in galactocele, 868; in infantile 
 cachexia, 856; in mastitis, 765; in 
 paralysis of arm, 828; in puerperal 
 neuritis, 770; in puerperium, 697; in 
 traumatic paralysis, 771; of nipples, 
 761; of uterus in subinvolution, 708. 
 
 Mastitis, 762-768; in newly born, 851; 
 parenchymatous, 763; treatment, 765. 
 766. 
 
 Maternal impressions, 266. 
 
 Maturity, of fetus, signs of, 88; of ovum, 42. 
 
 Measles, in fetus, 256; in newly born, 808, 
 in pregnancy, 191, 256, 336. 
 
 Mechanism of labor, 440-448; in breech 
 presentation, 529; in bregma presenta- 
 tion, 501; in brow presentation, 504; 
 in pelvic deformity, 616-665 ; in coxitis, 
 650; in deep transverse position, 553; in 
 face presentation, 510; in generally con- 
 tracted, nonrachitic pelvis, 619; in Nae- 
 gele's pelvis, 623; in occipito-posterior 
 presentation, 545; in pelvic presentation, 
 529; in persistent mento-posterior 
 position, 551; in persistent occipito- 
 posterior position, 545; in scoliosis 
 706; in shoulder presentation, 540; 
 in simple flat, non-rachitic pelves 
 620, 621; in simple flat pelves, 553; 
 in vertex presentation, 451. 
 
 Mechanism, of post-partum hemorrhage, 
 578; of traumatisms of the pelvic floor, 
 599- 
 
 Meconium, first appearance of, 85; of newly 
 born, 781; pathological discharge of, 
 70. 
 Medullary, folds, 55, 56; cords, 56; grooves, 
 
 56; ridges, 56; plate, 55. 
 Melancholia, in pregnancy, 116; melan- 
 cholia, mania, and dementia, gesta- 
 tional, 332-337; the element of sepsis in, 
 334- 
 Melena, or gastro-intestinal hemorrhage of 
 
 newly born, 840. 
 Membranes, anomalies of, cause of dysto- 
 cia, 605; artificial rupture of, 479 
 
1058 
 
 INDEX. 
 
 S87, 888, 894, indications for, 887, 
 technique of, 888; at term, 65; defi- 
 nition of, 63; delivery of, 490, 491, 
 1025-1031; dystocia from adherent, 
 605; examination of, 491, 492; obtur- 
 ator, 398; origin of, 63; retention of, 
 5 7 4~5 7 7 ' rupture of, in Caesarean sec- 
 tion, 10 14; in labor, 435; synovial, 
 pelvic, changes in, in pregnancy, 114; 
 treatment of intact, in internal podalic 
 version, 932, 933, in shoulder pres- 
 entation, 935. 
 
 Meningitis, cerebrospinal, of fetus, 258; 
 diagnosis of, from eclampsia, 307; in 
 abor, 668. 
 
 Meningocele, 265, 831. 
 
 Menopause, 25, 41. 
 
 Menorrhagia from natural defects, 24; in 
 incarceration of uterus, 277. 
 
 Menses, 20; retained, from natural defects, 
 24; suppression of, in pregnancy, 120. 
 
 Menstrual blood, characteristics of, 24; 
 prejudice as to deleterious effects of, 
 24. 
 
 Menstrual cycle, 23. 
 
 Menstruation, 20 ; abnormal, in subinvolu- 
 tion, 133, 134; age for establishment 
 of, 21; and impregnation, relation 
 between, 28, 29; and ovulation, rela- 
 tion between, 25; and pathological 
 hemorrhages, confusion between, 121; 
 anomalies of, 24; cessation of, as sign 
 of pregnancy, 120; in acute affections, 
 conditions leading to, 120, 121; changes 
 in endometrium during, 21; conditions 
 influencing, 21, 22; definition, 20; dis- 
 regard of, dangers from, 36; duration 
 of, 20; in infants, 850; in the obese, 
 134; in pregnancy, 121; persistence of, 
 cause of ante-partum hemorrhage, 371; 
 phenomena of, 20, 21; precocious, 22, 
 850; profuse, in uterine tumors, 134; 
 prolonged, 26; vicarious, 25. 
 
 Mensuration in pelvic deformity, 656. 
 
 Mercurialism, effect of, on fetus, 262; in 
 pregnancy, 262. 
 
 Mercuric bichloride, as antiseptic, 151; 
 ffect of, on spermatozoa, 28. 
 
 Mesoderm, 53; tissues derived from, 6t. 
 
 Metastases, in deciduoma malignum, 198; 
 puerperal, 738; in septicemia, 741. 
 
 Meteorism in malignant peritonitis, 755; in 
 sapremia, 739. 
 
 Metritis, chronic, cause of fetal death, 270; 
 diagnosis of, from pregnancy, 133; in 
 pregnancy, 281, 282; puerperal, 728, 
 729. 
 
 Metrophlebitis, puerperal, 736, 737. 
 
 Metrorrhagia, following coitus interruptus, 
 39; in deciduoma malignum, 196; of 
 labor, 671; of pregnancy, 371, 372; 
 puerperal, 701. 
 
 Milk, breast, characteristics of, 684-686, 789; 
 causes of poor, 788; changes in, dur- 
 ing puerperium, 783-786; cows', 789; 
 comparative average .composition of 
 human and cows', 789; composition 
 of average normal htiman, 788; con- 
 densed, components and reaction of, 
 794; deficient secretion of, 760; effect 
 of diet on, 685, 788; establishment of 
 secretion of, 787; excessive secretion 
 
 of, 760, 761; formulae for a home 
 modification of, 791; general direc- 
 tions for the modification and sterili- 
 zation of, 792-794; in breasts of newly 
 born, 918; fever, 744; in newly born, 
 784; in pregnancy, 115; qualitative 
 anomalies of, 761; "uterine," 78; 
 variations in human, 788. 
 
 Miscarriage, 342-361. 
 
 Missed abortion, 368; labor, 368. 
 
 Molar pregnancy, 198. 
 
 Mole, blood, 195, 345; flesh, 345; hydatidi- 
 form, 198-201; placental, 198; uterine, 
 345; vesicular, 198. 
 
 Monstrosities of fetus, illustrated, 245—254. 
 
 Montgomery's glands, prominence of, in 
 pregnancy, 115. 
 
 Morbidity in the puerperium, 711-759. 
 
 Morning sickness, in pregnancy, 115. 
 
 Morphinism, effect of, on fetus, 262; in 
 pregnancy, 262. 
 
 Mortality, in abortion, 354; in accidental 
 hemorrhage, 227; in accouchement 
 force, 1035; in asphyxia of newly 
 born, 856; in brow presentation, 506; 
 in congenital hydrocephalus, 562; in 
 convulsive disorders of newly-born, 
 856; in eclampsia, 307, 308, 310, 313; 
 in elderly primiparae, 666 ; in face 
 presentation, 517; in gestational cho- 
 ^sa, 335; in infants in the first year of 
 life, 799; in infantile syphilis, 810; in 
 insanity of the puerperium, 772; in 
 inversion of the uterus, 592; in kypho- 
 tic pelvis, 645 ; in labor with vaginal 
 obstruction, 612; in melena, 849; in 
 miscarriage, 354; in Naegele's pelvis, 
 625 ; in osteomalacia, 637 ; in pelvic pres- 
 entation, 534; in pelvic tumor, 638; 
 in persistent occipito-posterior posi- 
 tions, 547; in persistent mento-poste- 
 rior positions, 552; in penetrating 
 wounds of the gravid uterus, 370; in 
 pregnancy after ventrofixation and 
 ventrosuspension, 600; in prolapse of 
 umbilical cord, 525; in rupture of 
 uterus, 588, 589; in typhoid fever 
 in pregnancy, 336; in version, 936; 
 maternal, in placenta prasvia, 218-220; 
 of newly born, 865, 847. 
 
 Morula, 50. 
 
 Mother's outfit, 466. 
 
 Moulding, in labor, 440; of fetal head, 414; 
 in vertex presentation, 451—453, 457, 
 462. 
 
 Mouth, formation of, 58; of newly born 
 hild, cleansing of, 485; origin of, sto- 
 modeal portion of, 62. 
 
 Movements of fetus, 126, 127. 
 
 Mucosa, uterine, characteristics of, 44; 
 normal thickness of, 45; thickness of, 
 in pregnancy, 45. 
 
 MuUer's method of engaging fetal head, 
 182; test in pelvic deformity, 661. 
 
 MuUerian duct, formation of, 61. 
 
 Multigr^vida, 41; description of, 137. 
 
 Multipara, 42; definition, 27. 
 
 Multiple abscesses, in newly born, 845. 
 
 Multiple birth, 555-559- 
 
 Multiple pregnancy, course of labor in, 555; 
 diagnosis of, 143; etiology of, 140; 
 hemorrhage of, 556, 557; membranes 
 
INDEX. 
 
 1059 
 
 and placenta in, 142, 143; mummi- 
 fication of fetus in, 143; size of 
 children in, 143; treatment of, 556-558. 
 
 Multiple presentation, 558. 
 
 Mummification of fetus, 274. 
 
 Murmur, cardiac, in pregnancy, 115, n6; 
 funic, 129; umbilical, in pregnancy, 
 129; uterine, in pregnancy, 124. 
 
 Muscles, action of abdominal, in labor, 428; 
 changes of, in pregnant uterus, 103, 104; 
 during puerperium, 676; formation of, 
 58; origin of, 59, 61; pelvic, 393. 
 
 Myocarditis in pregnancy, 326. 
 
 Myoma, uterine, cause of dystocia, 602, 603; 
 Cassarean section in, 604; diagnosis of, 
 603; diagnosis of, from pregnancy, 134; 
 effect of pregnancy on uterine, 602, 603 ; 
 prognosis of, 603, 604; treatment of, 
 604. 
 
 Myotome, 58, 61. 
 
 Myxoma chorii multiplex, 198-201. 
 
 Myxoma fibrosum, 201; of placenta, 236. 
 
 N. 
 
 Naegele's, pelvis, 623-626; forceps, 984; 
 rule for calculating date of confinement, 
 146. 
 
 Naevi, fetal, 267. 
 
 Nails, development of, 85; origin of, 61. 
 
 Nausea in pregnancy, 115, 299; in hydatidi- 
 form mole, 200; in phlegmasia alba 
 dolens, 736. 
 
 Navel, changes in, in pregnancy, 118. 
 
 Neck, formation of, 84. 
 
 Neoplasms, fetal, 270; uterine, in pregnancy, 
 282; .pelvic, dystocia from, 638; ves- 
 ical, in pregnancy, 135, 319. 
 
 Nephritis, in pregnancy, 292, 304; fetal, 
 267 ; indication for prevention of repro- 
 duction in, 38; of newly born, 810. 
 
 Nerve, optic, development of, 56. 
 
 Nerves, changes of uterine, in pregnancy, 
 108; origin of, 61; pelvic, 400; sen- 
 sory, origin of, 56; sympathetic, 
 origin of, 56. 
 
 Nerve-trunks, injuries of, at birth, 824-828. 
 
 Nervous system, diseases of, in pregnancy, 
 333-336; in puerperium, 769-773; dis- 
 turbances of, in pregnancy, 116; dur- 
 ing puerperium, 677; origin of, 61; 
 effect of menopause upon, 41. 
 
 Neural tube, 55, 56. 
 
 Neuralgia, gestational, 335; in hydramnios, 
 206; of legs, in pregnancy, 114. 
 
 Neuritis, puerperal, 769, 770; toxic, in 
 puerperium, 740. 
 
 Neuroses, following coitus interruptus, 39; 
 following interrupted pregnancy, 351; 
 in pregnancy, 335; fever from, in puer- 
 perium, 743. 
 
 Newly born child, 779-856; abscesses, mul- 
 tiple, of, 845; acute infectious diseases 
 of, 808; anasarca of, 809, 839; aphthas 
 of, 847; artificial feeding of, 788; 
 asphyxia of, 812-823, atelectasis of, 
 838, 839; Bednar's disease of, 852; 
 bladder and bowels of, 795; blood of, 
 783; breasts of, 784; Buhl's disease of, 
 851; Cachexia of, 855; cancrum oris of, 
 843; care of, 485, 489, 490, 690, 785; 
 changes in circulation in, 780; chronic 
 
 infectious diseases of, 809; clothing of, 
 786; colic of, 852; constipation of, 85^, 
 854 ; convulsions of, 855; cutaneous sepsis 
 of, 844-846; cyanosis of, 816; cystic 
 elephantiasis of, 809 ; Dermoid cysts of, 
 852; diarrhea of, 853; digestion of, 
 782; diphtheria of, 808; diseases due 
 to bacteria and fungi of, 847 ; Ecthyma 
 of, 845; endocarditis of, 810; envi- 
 ronment of, 796; erysipelas of, 846; 
 establishment of respiration in, 488, 
 779; eyes of, 485; Failure of circula- 
 tion of, 839; failure of digestion and 
 assimilation of, 840; feces of, 781, 
 782; feeding of, 786-795; foramen 
 ovale of, 780; Gastro-enteritis of, 844; 
 gastro-intestinal sepsis of, 843 ; Head 
 of, 785; heart of, 783; hemorrhagic 
 diathesis of, 847-850; hemorrhages 
 from genitals of female, 850; hema- 
 turia of, 850; hydrocephalus of, 810; 
 Ichthyosis of, 809; icterus of, 851; 
 inanition fever of, 840; influenza of, 
 809; intestinal obstruction of, 854; 
 Length of, 419; loss of weight of, 784; 
 liver of, 783; Malformations and mon- 
 strosities, of, 807; marasmus of, 840; 
 mastitis of, 851; maternal diseases and 
 conditions affecting, 809, 810; measles 
 of, 807; meconium of, 781; medica- 
 tion of, 856; melena or gastro-intes- 
 tinal hemorrhage of, 849; milk in 
 breasts of, 851; mortality of, 799, 847, 
 848; mouth of, 485; Nephritis of, 810; 
 noma of, 843; nursery for, 795; Oblit- 
 eration of bile-ducts in the, 810; oedema 
 of, 839; omphalorrhagia of, 848; oph- 
 thalmia of, 832-837; Parotitis of, 844; 
 pathology of, 799-856; peritonitis of, 
 810; periumbilical pemphigus of, 844, 
 845; physiology of the, 779-796; pneu- 
 monia in the, 809, 909; post-mortem 
 observations of, 785; pulse of, 781; 
 purpura haemorrhagica of, 850; Ranula 
 of, 852; retropharyngeal abscess of, 
 844; rheumatism of, 809; rickets of, 
 810; "run round" of, 845; Scarlatina 
 of, 808; sclerema of, 850; sepsis of, 
 809, 842; septic coryza of, 843; septic 
 infection of, 841, 842; septic pem- 
 phigus of, 844; signs of normal nutri- 
 tion in, 784; simple elephantiasis of, 
 809; sleep of, 795; stenosis of the 
 pylorus of, 810; stools of, 781, 782; 
 sublingual cysts of, 852; sudden death 
 of, 856; syphilis of, 810-812 ; tempera- 
 ture of, 781; tetanus of, 846; thrush 
 of, 847; tuberculosis of, 809; Ulcera- 
 tion of hard palate of, 852; ulcerous 
 stomatitis of, 843; umbilical cord of, 
 780; urine of, 782; Variola of, 808; 
 vomiting of, 852; weight of, 784; 
 Winckel's disease of, 851. 
 
 Nipple, anatomical anomalies of, 759, 760; 
 care of, in pregnancy, 187; care of, in 
 puerperium, 692; changes in, in preg- 
 nancy, 114,115; eczema of, in pregnancy, 
 291; fissured, 744, 759; treatment, 
 760; in puerperium, 761; 
 
 Noma of the newly born, 843. 
 
 Nostrils, origin of, 61. 
 
 Notochord, 57. 
 
1060 
 
 INDEX. 
 
 Nullipara, 43; definition of, 27. 
 
 Nurse, obstetric, 470; asepsis of, 749; wet, 
 788. 
 
 Nursery, 795. 
 
 Nursing, length of period of, 787; of newly 
 born, maternal, 786-788; proper inter- 
 vals between 787. 
 
 O. 
 
 Obesity, cause of interrupted pregnancy, 
 348; tendency to, in menopause, 25, 
 36; menstruation in, 134. 
 
 Obstetric bag, 466—469. 
 
 Obstetric surgery, 858-1037. 
 
 Obstructed labor (see Dystocia). 
 
 Obturator, internus muscle, 397; membrane, 
 398. 
 
 Occipito-anterior position, left, 451-456; 
 right, 456, 457. 
 
 Occipito-posterior positions, 457-462; per- 
 sistent, 545-550, treatment in, 547-550. 
 
 (Edema, general fetal, 270; in pregnancy, 
 130; neonatorum, 839; of legs, in preg- 
 nancy, 114; of placenta, 228, 229; of 
 vulva and vagina, a cause of dystocia, 
 613, 969. 
 
 Olfactory organs, origin of, 61. 
 
 Oligohydramnios, 204. 
 
 Omentum, malignant growths of, diagnosis 
 from pregnancy, 136. 
 
 Omphalorrhagia of newly born, 848; prog- 
 nosis, treatment, 849. 
 
 Oophoritis, during puerperium, 730; fol- 
 lowing coitus interruptus, 38. 
 
 Operations, choice between chloroform and 
 ether for, 867; for correction of in- 
 juries, 1031-1037; for delivery, 963— 
 1031; in pelvic-floor lacerations, 1034— 
 1037; i^ pregnancy, 370; in rupture 
 of uterus, 589, 590; preparations for, 
 860, 861; preparatory to delivery, 887- 
 962. 
 
 Ophthalmia neonatorum, 832-837; preven- 
 tion of, 490. 
 
 Opiates in colic of newly born, 853; in 
 malignant peritonitis, 755; in puer- 
 peral parametritis, 755; in puerperal 
 perimetritis, 755; in psychoses of preg- 
 nancy, 334; in rigidity of the os uteri, 
 607. 
 
 Oral sepsis in pregnancy, 323. 
 
 Organisms (see Bacteria). 
 
 Organogenesis, 242. 
 
 Organs, embryology of, 54; enlarged ab- 
 dominal, diagnosis of, from pregnancy, 
 136; formation of primitive, 54; genital 
 origin of, 61; of taste, origin of, 61; 
 olfactory, origin of, 61; tactile, origin 
 of, 61; urinary, origin of, 61. 
 
 Orgasm, 26. 
 
 Orrhotherapy in puerperal sepsis, 751, 
 
 ^ 752. .... 
 
 Os uteri, ngidity of, a cause of dystocia, 606, 
 607; normal dilatation of, during labor,, 
 433; manual and instrumental dilata- 
 tion of, 891; occlusion of the external, 
 a cause of dystocia, 609. 
 
 Osiander's sign in pregnancy, 125. 
 
 Osseous system, diseases of the, in fetal 
 syphilis, 260; in pregnancy, 340, 341. 
 
 Ossification, placental, 235. 
 
 Osteomalacia, 634-637; in pregnancy, 340, 
 341- 
 
 Outlet, pelvic, 165, 166, 383, 384. 
 
 Ovarian, cyst, diagnosis of, from hydram- 
 nios, 205, 206; pregnancy, 361; tu- 
 mors, a cause of dystocia, 604. 
 
 Ovaries, anomalies of, 286; changes in, be- 
 fore ovulation, 24, 25; origin of, 61. 
 (See Graafian follicles.) 
 
 Ovariotomy, effect of, on menstruation, 25; 
 in osteomalacia, 635, 636. 
 
 Ovate pelvis, 623-626. 
 
 Ovoid, fetal, 421. 
 
 Ovulation, 17; and menstruation, relation 
 between, 24, 25; a periodic process, 17; 
 nervous control of, 25. 
 
 Ovum, 41, 42; characteristics of, in the sev- 
 eral lunar months, 83 ; cystic disease of, 
 198; definition of, 77; description of pri- 
 mordial, 78; deutoplasm of, 78; diag- 
 nosis of, from blood-clot, 354; diseases 
 of, 242, 243; earliest human, 65; de- 
 scription of, 82; fecundation of, with 
 double yolk, 140; fertilization of, 28; 
 in abortion, 344; maturation of, 42; 
 metaboUsm of , 78; migration of , 18, 23; 
 morula of, 49, 50; nutrition of, 78; 
 primitive streak of, 53; pronucleus of, 
 42 ; Reichert's, 69 ; segmentation of, 
 49 ; segmentation-nucleus of, 49 ; size 
 of mature, 42; Spee's, 54; zona pel- 
 lucida of, 43. 
 
 P. 
 
 Pain, false labor, 431, distinguished from 
 true, 433; in accidental hemorrhage, 
 226; in deciduoma malignum, 196; in 
 ectopic gestation, 363; in hydatidiform 
 mole, 200; in legs, in pregnancy, 1x4; 
 in puerperal infection, 747; in uterine 
 inertia, 570; labor, 429, 430, 431; over- 
 strong labor, posture in, 876; in pre- 
 cipitate labor, 667. 
 
 Pajot's, law of accommodation, 421; man- 
 oeuvre, 998. 
 
 Palate, time of formation of, 84; ulceration 
 of, in newly born, 852. 
 
 Palpation in pelvic deformity, 656; of 
 uterus, in pregnancy, 121. 
 
 Palper-mensurateur, 183. 
 
 Palpitation in pregnancy, 327; treatment 
 
 of, 327- 
 
 Pancreas, formation of, 58; origin of, 61. 
 
 Paralysis, auditory, in puerperium, 771; 
 facial (see Facial Paralysis) ; gesta- 
 tional, 355; in puerperal thrombosis 
 and embolism, 768; ocular, in puer- 
 perium, 837; of arm at birth, 826, 827; 
 of placental site, 580; cause of inver- 
 sion of uterus, 591; puerperal, 770. 
 
 Parametritis, 729, 730; coexistent with 
 perimetritis, 729; treatment of, 755. 
 
 Parity, in relation to interrupted preg- 
 nancy, 347, 348. 
 
 Parotitis, fetal, 258; in newly born, 844; 
 puerperal, 737. 
 
 Parturient canal, 400, 408; definition of, 
 400; diameters of the, 444, 445; shape 
 of, 444. 
 
INDEX. 
 
 1061 
 
 Parturiometer, 431. 
 
 Passages, the, 375-408. 
 
 Pathology, embryonal and fetal, 242, 243; 
 of labor, 499-671; of newly born, 598- 
 856, due to interruption of pregnancy, 
 800-807, general considerations of, 799; 
 of pregnancy, 199-372; of puerperium, 
 700-776. 
 
 Patient, preparation of, for examination in 
 pregnancy, 150; for operation, 860. 
 
 Pelvic, angles, 387; articulations, anoma- 
 lies of, 710; binder in puerperium, 696 
 axis, 387; cellulitis, puerperal, 795 
 diameters, comparison of different, 388 
 disease in relation to mode of life, 37 
 floor, lacerations of, 5^41:600^ 1033- 
 1037; inlet, description 'oi7~38 1 ; plane 
 of. 385; joints, diastasis of, cause of 
 dystocia, 615; exaggerated motion or 
 separation of, 639; functions of, 379; 
 inflammation of, in pregnancy, 340; 
 relaxation of, in pregnancy, 340; out- 
 let, description of, 383; plane of, 386; 
 planes, 385. 
 
 Pelvic deformity, 616-665; abortion in, 723; 
 absolute contraction in, 659; treatment 
 in, 659, 660; avoidance of conception 
 in, 656; Cassarean section in, 658, 659, 
 660, 662, 663, 664; celibacy advisable 
 in, 656; cephalometry in, 661; classi- 
 fication and description of different 
 varieties of, 617, 618; combined meth- 
 ods of treatment in, 664; cord, pro- 
 lapse of, in, 654; cranioclasm in, 660; 
 diet in, 657, 658; embryotomy in, 658, 
 659, 660, [662, 663, 664; expectant 
 method in, 658, 662; forceps in, 658, 
 662, 664; frequency of, 616; general 
 diagnosis of, 656; general etiology 
 and development of, 617; general 
 symptomatology of, 652-655; indica- 
 tion in absolute, 660; indications 
 in relative, 662; induction of pre- 
 mature labor in, 657; labor prolonged 
 in, 653; laparohysterectomy in, 664; 
 marriageability of women with, 656; 
 mensuration in, 656; methods of man- 
 aging dystocia from, 657; Muller's 
 manoeuvre in, 663; Muller's test in, 
 661; palpation in, 656; parental char- 
 acteristics in, 656; . pelvimetry in, 656; 
 pendulous abdomen in, 653; perfora- 
 tion in, 662; Perret's method in, 663; 
 previous history in diagnosis of, 656; 
 Prochownik's diet in, 657, 658, 663; 
 prognosis of, 656; prophylactic treat- 
 ment in, 656-658; relative contraction 
 in, 659, treatment of, 660-665; sub- 
 jective symptoms in, 652-655; statis- 
 tics showing course of labor in, 660, 
 662; symphyseotomy in, 658, 659, 660, 
 662, 663; therapeutic abortion in, 
 656; treatment of, 656-665, prophy- 
 lactic, 656-65S; version in, 662, 663, 
 664; Walcher posture in, 662. 
 
 Pelvigraphy, 178. 
 
 Pelvimeter, Baudelocque's, 162; Farabeuf's, 
 172; Schultz's, 168; Skutsch's, 172; 
 Stein's, 171. 
 
 Pelvimetry, external, 162-167, S^o; L5h- 
 lein's measurement in, 175; indirect, 
 by measuring the sternum, 17S; in 
 
 pelvic deformity, 656; in labor, 474; 
 internal, 167-177; internal manuaj 
 175, 176, 177; objects of internal, 167; 
 ROntgen, 177. 
 
 Pelviotomy, 936. 
 
 Pelvis, as influenced by age, 389, 390; as 
 influenced by dress, 36; anatomical, 375; 
 anomalies, due to, defective develop- 
 ment, 618-630, as a result of disease 
 of the pelvic bones, 618, 629-639, due 
 to disease of superimposed parts of the 
 skeleton, 618, 641—649, due to disease 
 of the weight-bearing parts of the skele- 
 ton, 618, 649-652, due to fractures, 
 638, in junction of pelvic bones, 639, 
 640; articulations of, 376; assimila- 
 tion, 649, 650; axes of, 387; Blood- 
 vessels of, 399, 400; bones of, 375, 376; 
 bony, 375, 376; Cavity of, 382; cellular 
 tissues of, 399; clinical measurement 
 of, 422; cordiform, 635; coxalgic, 
 649; Definitions of, 375; deformed, 
 general symptomatology of, 652-655; 
 disease of, due to abortion, 39, in rela- 
 tion to marriage, 37, 38; Exostoses of, 
 638; measurements of, 162-167, 380- 
 385, 472; external surface of, 379; 
 False, 380; forces leading to the pro- 
 duction of the adult, 390-393; func- 
 tions of, 393; Generally contracted 
 fiat, non-rachitic, 621; glands of, 399, 
 400; Inclination of, 38 7; infantile. 
 390, 618; inlet of, 381; internal sur- 
 face of, 379; Joints of, 376; justo- 
 major, 627; justo-minor, 618; juvenile, 
 390; Ligaments of, 3 98; lordosis of, 649; 
 lymphatics of, 399, 400; Male, 389; 
 muscles of, 393; Naegele's, 623-626; 
 funnel-shaped, 621; nerves of, 400; 
 new growths of, 638; Obliquely de- 
 formed or contracted, 623-626; ob- 
 turator membrane of, 398; -osteoma- 
 lacic, 634, 635; outlet of, 383-384; 
 Planes of, 385-387; postures which 
 alter shape of, 868-871 ; postures which 
 elevate, 871-876; Prague, 641, 643; 
 pseudo-osteomalacic, 63 1 ; rachitic, 
 629-634; Robert's, 626; Scoliotic, 647; 
 sex in relation to, 389; sexual differ- 
 ences in, 389; simple flat, non-rachitic, 
 620; simple fiat, rachitic, 631-633; 
 size and shape of, factors influencing, 
 389; soft parts of, 393-400; split, 627; 
 spondylolisthetic, 641-643; true, 380, 
 3S1. 
 
 Pemphio;us, acutus, neonatorum, 844; peri- 
 umbilical, of newly born, 844, 845; 
 puerperal, 740. 
 
 Penoy^e's forceps, 984. 
 
 Peptogenic milk powder, components and 
 reaction of, 794. 
 
 Peptonuria in pregnancy, 319; in puer- 
 perium, 676. 
 
 Perforation (see Craniotomy), 944-946; in 
 accidental hemorrhage, 228; in after- 
 coming head, 946; in bregma presenta- 
 tion, 946; in brow presentation, 946; 
 in congenital hydrocephalus, 563; in 
 face presentation, 946; in pelvic de- 
 formity, 626, 660; in pelvic presentation, 
 946 ; in threatened rupture of the uterus, 
 589; in tumors causing absolute ob- 
 
1062 
 
 INDEX. 
 
 struction to delivery, 604; in vertex 
 
 presentation, 946; indications for, 943, 
 
 944; operations of, 944-946. 
 Pericarditis, puerperal, 737. 
 Pericardium, formation of, 60. 
 Perimetritis, 731, 732; puerperal, 731, 732; 
 
 diagnosis of, from parametritis, 733. 
 Perineal lacerations, 1033; repair of, 1033- 
 
 1037- 
 
 Perineum, central perforations of, 1033, 
 repair of, 103 3-1 03 7; inspection and 
 repair of, 490; preservation of, during 
 delivery of shoulders, 486; protection 
 of, during second stage of labor, 481-485. 
 
 Peritoneum, changes of, in pregnancy, 109. 
 
 Peritonitis, a result of curettage in puer- 
 peral infection, 756; encysted, diag- 
 nosis of, from pregnancy, 136; of 
 fetus, 260, 263; of newly bom, 810; 
 puerperal, 730-783; puerperal, benign 
 forms of, 730, 731; circumscribed, 730; 
 general, 735-738; genesis of, 733; 
 puerperal, mahgnant, 733-735; diag- 
 nosis and prognosis of, 837, 838; 
 etiology of, 733; symptoms of, 733; 
 treatment of, 755. 
 
 Periuterine inflammation and adhesion dur- 
 ing pregnancy, 281. 
 
 Pernicious ansemia, an indication for pre- 
 mature delivery, 890. 
 
 Perret's method of cephalometry, 180; in 
 pelvic deformity, 661. 
 
 Pessary, in retroflexion of gravid uterus, 278. 
 
 Peter's, embryo, 45, 65; ovum, descrip- 
 tion of, 82. 
 
 Pharynx, origin of, 61. 
 
 Phlebitis, in pregnancy, 241; puerperal, 
 cellulitic, 735, 736; puerperal, femoral, 
 733. 737; puerperal, septic, 735, 736; 
 puerperal, uterine, 735, 736. 
 
 Phlegmasia alba dolens, 736, 737; a result 
 of curettage, 756. 
 
 "Phobias," in pregnancy, 333, 334. 
 
 Phthisis (see Tuberculosis). 
 
 Physician, asepsis of, 150, 749, 750; duties 
 of family, 39. ; 
 
 Physician's obstetric bag, 466, 467. i 
 
 Physiological pregnancy, 41-188. 
 
 Physiology of newly born, 779-796. 
 
 Physometra, after putrefaction of fetus 
 274; diagnosis of, from pregnancy, 133. 
 
 Pigmentation, cutaneous, in pregnancy, 114, 
 115, 117, 118, 125, 130, 338; of genitals, 
 in pregnancy, 89. 
 
 Placenta, 70-71; accidental hemorrhage 
 from, 224-228; adhesions of, 233, 234; 
 and membranes, delivery of , 102 5-1029; 
 angioma of, 237; annular, 209; anom- 
 alies, 208-215; apoplexy of, 229-231, 
 345, a cause of ante-partum hemor- 
 rhage, 372; atrophy of , 209; Battledore, 
 212, 213; bilobed, 209; Calculi o±, 235; 
 circular vein of, 71; circulation of, 70- 
 77; cotyledons, 71; Crede's method of 
 expressing, 491, 1025-1028; curling 
 arteries of, 71; delivery of, 439; in 
 Caesarean section, 1015; Degeneration 
 of, 233-236; dimensions of, 71; dis- 
 eases of, 208—237; duplex, 210; Eman- 
 uel's disease of, 231, 232; examination 
 of, 492; expulsion of, in case of twins, 
 557; Fenestrated, 209; fetal surface of, 
 
 71; formation of, 65, 70; functions of. 
 70, 78, 79; Haematoma of, 229-231; 
 horseshoe, 209; hyperplastic changes in, 
 233; hypertrophy of, 209; In albumi- 
 nuria, 319; in ectopic gestation, 366; 
 infarcts of, 229-231, 234; infectious 
 granulomata of, 232, 233; inflamma- 
 tion of, 231, 232; injuries of, 224—228; 
 interstitial hemorrhage of, 229-231; in 
 twin pregnancy, 142, 143; Lobate, 209; 
 low implantation of, 216, a cause of 
 intrapartum hemorrhage, 671; mal- 
 formation of, in placenta praevia, 216; 
 manual extraction of, 1029; marginata, 
 213; membranacea, 222 ; multiple, 209, 
 210; Origin of, 84; ossification of, 235; 
 Pigment deposits in, 236; polypi of, 
 236, 237; prsevia, 214-224, diagnosis 
 of, 217; Treatment of, 220-224; pre- 
 mature detachment of a normally situ- 
 ated, 224—228; retention of, 492, 493, 
 574-577, in miscarriage, 355; Sclerotic 
 changes in, 233; secondary altera- 
 tions in, 233-236; separation of, cause 
 of ante-partum hemorrhage, 372; site 
 of, 71, paralysis of, 580; syphilis of 
 232, 233; Thrombosis of, 229; trans- 
 mission of disease by (see Antenatal dis- 
 ease of fetus), 255-272, 807-813; tu- 
 berculosis of, 232; tumors of, 236, 237; 
 weight of, 71, as related to fetal weight, 
 209; white infarcts of, 234, 235. 
 
 Placentitis, 231, 232; varieties of, 231, 232. 
 
 Planes, pelvic, 385-387; of fetal trunk, 419. 
 
 Pleurae, formation of, 60. 
 
 Pleuritis, in pregnancy, 329; in puerperium. 
 
 737- 
 
 Pleuropneumonia, septic purulent, of the 
 newly born, 843. 
 
 Pneumococcus sepsis, of fetus, 258. 
 
 Pneumonia, aspiration, 832; coexistent with 
 labor, 668; in fetus, 258; in pregnancy, 
 257, 258; septic of newly born, 809, 843. 
 
 Podalic version, 925-936. 
 
 Poisoning, acute, of fetus, 261, 262; cause 
 of fetal death, 272; chronic, in preg- 
 nancy, 262; of newly bom, 809. 
 
 Poisons, elimination of, in eclampsia, 311; 
 effect of, on spermatozoa, 28. 
 
 Polygalactia, 685, 761; treatment of, 761. 
 
 Polyhydramnios, 204—208. 
 
 Polymazia, 759. 
 
 Polypi after abortion, 356; intracervical, 
 cause of antepartum hemorrhage, 372; 
 placental, 236, 237; uterine, diagnosis 
 of, from inversion of uterus, 291. 
 
 Polyspermism, 28. 
 
 Polyuria in pregnancy, 319. 
 
 Porro-Caesarean section, 102 0-1022. 
 
 Portio vaginalis, changes in, in pregnancy, 
 147. 
 
 Posenheim's formula for rectal feeding. 303. 
 
 Position of fetus, 425—428; definition of, 
 425; English, French, and German 
 classification of vertex, 426; diagnosis 
 of, 154-162; frequency of first vertex, 
 explained, 426; left vertex, occipito- 
 posterior, persistent, 545; persistent 
 mento-posterior, 550-553; relative fre- 
 quency of each, 426; transverse, 538; 
 transverse, of the head at the pelvic 
 outlet. 553, 554. 
 
INDEX. 
 
 1063 
 
 Postmortem Caesarean section, 1025. 
 Posture in obstetrics, 868. 
 Pregnancy, abdominal ballottement in, 
 125, 126; binder in, 194; abnormal, 
 191; abnormal age of , 21, 22; abnormal 
 conditions in twin, 143; abnormal crav- 
 ings in, 116; accidents and injuries in, 
 369, 370; acetonuria in, 320; acne in, 
 337; acute nephritis during, 315; after 
 operations involving the genitals in, 1 
 370; after ventrofixation and ventrosus- 
 pension, 600; albuminuria in, 11 7, 304, 
 307, 319; alcoholism in, 262; alopecia in, 
 339; amaurosis in, 116, 335; amblyopia 
 in, 116; anemia in, 117; abdominal 
 tumor in, 137; appendicitis in, 137, 370; 
 ascites in, 136; bladder in, 112-114, 130, 
 137; floating kidney in, 137; hydrosal- 
 pinx in, 141; displaced liver in, 137; 
 and lactation, relation between, 25; and 
 ovarian tumor, 135, 139; pelvic tumors 
 in, 137; pyosalpinx in, 137; and tuber- 
 culosis, 329-331; and tumor of broad 
 ligament, 137; ventral hernia in, 137; 
 aneurism in, 327; anorexia in, 322; ante- 
 flexion of uterus in, 274, 2 7 5 ;_ anthrax 
 in, 258; areola, secondary in, 115; 
 asthma in, 332; Bacteriology of vagina 
 in, 148, 149; ballottement in, 128; binder 
 in, 187; blood in, 328; bowels in, 186; 
 breasts in, 126, 187; bronchitis in, 329; 
 Cancer in, 263; cardiac diseases in, 263; 
 care of nipples in, 187; cephalalgia in, 
 335; cephalometry in, 180-184; cere- 
 bral disease in, 332; cervical canal in, 
 9 1 ; cervical consistence in, 89 ; cervical 
 softening in, 89, 123; cervix in, 89; 
 changes in abdomen in, 125, in bladder 
 in, 112, 113, 114, in blood in, 117, 188. 
 in breasts in, 114, 115, 126, 187, in cer- 
 vix in, 89, 90, 91, 147, in cranial cavity 
 in, 118, in disposition in, 116, in gait in, 
 118, in liver in, 116, in lower extremi- 
 ties in, 114, in lungs in, 116, in lym- 
 phatic glands in, 116, in navel in, 118, 
 of ovarian artery in, 108, in pelvic 
 joints in, 114, 340, 341,. in portio vag- 
 inalis in, 147, in rectum in, 114, in skin 
 in, 117, in spleen in, 116, in symphysis 
 in, 114, in urine in, 117, in uterus in, 
 91-113, 120, 125, in vagina in, 125, in 
 vulva in,'i25; chloasma of, 117; cholera 
 in, 257; chorea in, 335; chyluria in, 320; 
 cliseometry in, 178; clothing in, 187; 
 constipation in, 115, 323; corsets in, 
 187; contractions, uterine, intermit- 
 tent, in, 123; cough in, 331; cramps 
 of legs in, 114; cravings in, 115; cys- 
 titis in, 316, 317; cystocele in, 289; 
 Deafness in, 335; death, sudden, in, 369; 
 death of fetus in, 272; dementia in, 116; 
 diabetes in, 262; diagnosis of, 119-133; 
 differential diagnosis of, 132-138; diag- 
 nosis of fetal position, 154-162; diar- 
 rhoea in, 115, 324; diet in, 186; diseases 
 of the alimentary tract in, 321-325, of 
 the circulatory system in, 325-329, of 
 the genital organs in, 274-290, of the 
 nervous system in, 332-336, of the 
 osseous s3'-stem in, 340-342, of the 
 respiratory system in, 329-332, of the 
 urinary tract in, 315-321; duration of. 
 
 144-146; during lactation, 121; douches 
 in, 187; drink in, 186; dyspnoea in, 11 6, 
 331; dysuria in, 317; Eclampsia in, 304- 
 314; ectopic (see Ectopic gestation); 
 ectopic and normal pregnancy, coex- 
 istence of, 136; eczema in, 291, 337; 
 emphysema in, 329; endocarditis in, 
 325, 326; endometritis in, 193, 194; en- 
 teralgia of, 323; epilepsy in, 335; ery- 
 sipelas in, 256, 336; examination in, 
 148-184; excitement, avoidance of, in, 
 188; exercise in, 185, 186; exopthalmic 
 goitre in, 328; extrauterine (see Ectopic 
 gestation, 361); Feigned, 138; fetal 
 heart, location of, 161; fever of, 371; 
 fibroid tumors in, 282; Gastric and in- 
 testinal indigestion of , 115,323; general 
 phenomena of, 115-119; gingivitis in, 
 321; glycosuria in, 319, 320; gonor- 
 rhoea in, 289; headache in, 335; heart- 
 bum in, 115, 324; heart changes in, 
 115, 116, 326; Hegar's sign in, 123; 
 hematocele in, 326; hematuria in, 
 319; hemorrhoids in, 324; hernia in, 
 118; hernial protrusions of uterus in, 
 281; herpes in, 338, 339; Braxton 
 Hicks' sign of, 123; hydrsemia in, 327; 
 hydronephrosis in, 316; hydrophobia 
 in, 258; hygiene and management of, 
 184-188; hyperosmia in, 329; hysteria 
 in, 335; Icterus in, 293, 303; idiosyn- 
 crasies in, 1S8; impetigo in, 339; incon- 
 tinence of urine in, 318; indigestion in, 
 115; infectious diseases in, 336, 337; 
 influenza in, 257; injuries and accidents 
 in, 369, 370; insanity of, 323, 332-334; 
 insomnia in, 334; interrupted, 39, 342- 
 361, 888-906, displacements after, 356 
 duration of, 352, etiology of, 348-350, 
 frequency of, 345, 346, hemorrhage m, 
 354. 355. immediate dangers of, 354, 
 neuroses following, 357, prophylaxis of, 
 357, prognosis of, 354, psychoses fol- 
 lowing, 357, recurrent interruptions of, 
 350, relative frequency of, 349. remote 
 dangers of, 356, subinvolution after, 
 356, symptoms of, 350-352, table of sta- 
 tistics of, 349, treatment of, 357-361; 
 irritability, mental, in, 188; Jacque- 
 mier's sign of, 125; kidney, floating, in, 
 316; kidney, incarceration of, in, 316; 
 jaundice in, 303, 324; Kidnej^ of, 292; 
 hypodermoclysis in, 864; Labiaein, 89; 
 lactosuria in, 319; latero-flexion in, 278; 
 latero-version in, 278; leucocytosis in, 
 120; leucorrhea in, 187, 288, 289; leuke- 
 mia in, 263; lineae albicantiae in, 117; 
 lipuria in, 320; longings of, 323; lower 
 extremities in, 130; lungs in, 116; Ma- 
 laria in, 257, 258, 337; malformations 
 of genital organs in, 282-2S8; mam- 
 mary abscess in, 291; mania in, 116; 
 measles in, 191, 256, 336; melancholia 
 in, 116; menstruation in, 23; mental 
 condition in, 188; mercuriaUsm in, 262; 
 metritis in, 281, 282; metrorrhagia of, 
 371, 372; milk secretion in, 115; molar, 
 198; Montgomery's glands in, 115; 
 morbid appetite in, 115; morphinism in 
 262, 263; multiple, 140-144; eclampsia 
 in, 304-314; murmurs, cardiac, in, 116; 
 umbilical, in, 119, uterine, in, 124; Nau- 
 
1064 
 
 INDEX. 
 
 sea and vomiting in, 115, 299-303; ne- 
 phritis, chronic in, 315; neuralgias in, 
 114,335; neuroses in, 114, 335; oedema 
 in, 114, 130, 290; operations in, 370; oral 
 sepsis in, 322; osteomalacia in, 340; 
 Palpation in, 123, 154-162; paralyses 
 ii^' 335; pathological, 191-372; pel- 
 vigraphy in, 178; pelvimetry in, 162— 
 178; peptonuria in, 319; peri-uterine 
 inflammation and adhesion in, 281; 
 pernicious anaemia in, 328; pernicious 
 vomiting in, 3 00 ; phenomena in maternal 
 organism produced by, 89-119; phle- 
 bitis in, 326; pleurisy in, 329; pneu- 
 monia in, 258, 337; poisoning, acute 
 in, 261; poisoning, chronic in, 262; 
 polyuria in, 319; position of uterus 
 in different months of, 125; prioritus 
 in, 290, 337; psoriasis in, 337; psychic- 
 al changes in, 116; puerperal osteo- 
 phytes in, 118; pyelonephritis during, 
 316; pyorrhoea alveolaris in, 322; 
 pyrosis of, 323; quickening in, 126; 
 Rasch's sign of, 124; relapsing fever 
 in, 258; relaxation of pelvic joints 
 in, 340; renal calculi in, 316; renal insiif- 
 ficiency in, 292; respiration in, 116; 
 Salivation in, 322; scarlatina in, 256, 
 336; sciatica in, 130; sebaceous follicles 
 in, 89 ; secretions of genitals in, 89 ; 
 sense-perception in, 116; sense perver- 
 sion in, 188; sepsis in, 258; sexual inter- 
 course in, 188 ; signs of, 1 19-132 ; abdom- 
 inal, 125, 126; classification of, accord- 
 ing to months, 131, 132 ; cutaneous, 130; 
 doubtful, 131; fetal, 126-129; mam- 
 mary, 126; positive, 131; pressure and 
 congestion, 130; probable, 131; sub- 
 jective, 130; sympathetic and reflex, 
 129; uterine, 120—125; vaginal, 125; 
 skin, care of, in, 186, 187; skin diseases 
 in, 337—340; sternum, indirect pelvim- 
 etry by measurement of, 178; striae 
 atrophicae after, 678; stris in breasts 
 in, 114; sweat glands in, 89; syncope in, 
 ^27; symptoms of (see Signs of); syph- 
 ilis in, 232, 233, 337; Teeth, care of, in, 
 321, 322; teeth, caries of, in, 321; throm- 
 bosis in, 768; toxemia of, 291-299, 
 clinical types of, 296, and eclampsia, 
 differences between, 296, diagnosis of, 
 297, 298, etiology of, 293, 294, path- 
 ogeny of, 294, 295, pathological an- 
 atomy of, 292, symptomatology of , 295, 
 treatment of, 298-303; tuberculosis in, 
 258, 259, acute miliary in, 331; twin, 
 explanation of, 141, 142; typhoid fever 
 in, 256, 257; Unconscious, 139; uremia 
 in, 307; urine in, 117, examination of, 
 in, 1S8, retention of, in, 318; uterine and 
 cornual, coexistence of, 137; uterus in, 
 91-113, prolapse of, in, 279; retrover- 
 sion and retroflexion of, in, 275-277, 
 rupture of, in, 282, torsion of, in, 280; 
 uterus, incarceration of, in, 277—279; 
 spontaneous rupture of, in, 282; 
 Vaccination in, 336; vaccinia in, 256; 
 vagina in, 89; vaginal examination in, 
 149, 167-177; vaginal pulse in, 92; 
 vaginitis, cystic, in, 289; vaginitis, spe- 
 cific in, 289; varicosities in, 89, 114, 
 130, 290, 326; variola in, 255, 256, 336; 
 
 vertigo in, 334; vesical calculi in, 318; 
 vesical hemorrhoids in, 319; vesical 
 irritation in, 316, 317; vomiting in, 118, 
 299-303; vulval vegetations in, 290. 
 
 Premature births, percentage of, 800. 
 
 Premature labor, artificial, in pelvic de- 
 formity, 658-665; indications for the 
 induction of, 890, 891; method advised 
 for the induction of, 895. 
 
 Premature rupture of the membranes, cause 
 of dystocia, 605. 
 
 Prematurity, 800-807; bathing in, 803; 
 clothing in, 803; estimation of degree 
 of, 802; etiology of, 800, 801; feeding 
 in, 803-805; incubation in, 871, 872; 
 physiological peculiarities of, 801, 802; 
 prognosis of, 802; symptoms of, 801; 
 treatment of, 802-807. 
 
 Prepuce, adhesion of, 796; management of, 
 in newly born, 796. 
 
 Presentation, abnormal, in multiple preg- 
 nancy, 144, and prolapse of cord, 522— 
 527, 878; breech, 527-538; bregma, 
 500-503; brow, 503-508; cause of ver- 
 tex, 423; classification of varieties of, 
 423; definition of, 421; frequency of 
 the several varieties of, 423; multiple or 
 compound, 558; parietal, anterior and 
 posterior, 518, 519; pelvic, 527-538; 
 shoulder, 538-545; vertex, 450-463. 
 
 Primipara, 41; definition of, 27; diagnostic 
 points of, 138; signs of recent delivery 
 in, 687, 688. 
 
 Primiparse, labor in elderly, 665-667. 
 
 Primitive streak, 53, 55, 58. 
 
 Prochownik's, diet in pelvic deformity, 657; 
 method of artificial respiration, 822. 
 
 Proctitis, puerperal, 727. 
 
 Prolapse, of arm, 520-522, in shoulder pre- 
 sentation, sling in, 935, 1009, posture 
 of mother in, 879; of cord, 522-527, 
 breech extraction in, 969, podalic ver- 
 sion in, 925, sling in, 1009; of legs, 522; 
 of pregnant uterus, 279, effect of, on 
 fetus, 271; of uterus in puerperium, 
 710. 
 
 Pronucleus, female, 42; male, 43. 
 
 Protargol solution in ophthalmia neona- 
 torum, 835, 836. 
 
 Proteids, regulation of, in modified milk, 
 789, 790. 
 
 Pruritus, hiemalis, 338; in menstruation, 21; 
 in pregnancy, 33; vulvae, in pregnancy, 
 290. 
 
 Pryor's iodine treatment in puerperal infec- 
 tion, 752, 753. 
 
 Pseudo-fever, puerperal, 743. 
 
 Psoas magnus muscle, 395. 
 
 Psoas parvus muscle, 395. 
 
 Psoriasis in pregnancy, 337. 
 
 Psychosis, acute, in labor, 668; following in- 
 terrupted pregnancy, 357; Korsakoff's, 
 769; puerperal, 771-773. 
 
 Ptyalism in pregnancy, 322. 
 
 Puberty, 20; signs of, 20. 
 
 Pubic ligaments, 398. 
 
 Pubis, 306, 375; arch of, 384. 
 
 Puerperae, care of, 40. 
 
 Puerperal infection, 747-749; antistrepto- 
 coccic serum in, 750; endometritis iru, 
 718-727; orrhotherapy in, 752, 753, 
 sapremia in, 738, 739; symptoms of. 
 
INDEX. 
 
 1065 
 
 747, 748; treatment of, 749-759; ulcers 
 in, 718. 
 Puerperium, abdominal binder in, 695; 
 abdominal muscles, diastasis of, in, 
 711; metastatic abscesses in, 737; acute 
 specific diseases in, 713; after-pains in, 
 674, 691; air embolism during, 776; 
 albuminuria in, 676; anemia in, 714, 
 768, 769; antistreptococcic serum in, 
 750, 751; aphasia in, 771 ; asepsis in, 689, 
 690, 749, 750; atrophy 'of uterus 
 during, 673, 709; auditory paralysis in, 
 771; Bacterial toxemia in, 739, 740; 
 bacteriemia in, 741, with toxemia in, 
 741; bacteria in uterus in, 716; blood 
 condition in, 677, 768; blood-states in, 
 73S-742; bowels in, 676; breasts, an- 
 omalies of, in, 759; breast changes in, 
 683; care of the bladder in, 691, 692; 
 of the bowels in, 692 ; of the breasts and 
 nipples in, 692; of the mother in, 690; 
 Cellulitis in, 737; cervix and cervical 
 canal in, 678; changes in uterine adnexa 
 in, 683; changes in uterus in, 679-683; 
 chill, post-partum, 673; cholera in, 
 738; chronic toxemia not due to preg- 
 nancy in, 713, 714; constipation in, 705, 
 739, 743, 744; corset in, 698; cystitis in. 
 707, 727; Decidua during, 682; defini- 
 tion of, 673; diagnosis of, 687, 688; diet 
 in, 693, 694; digestion in, 676; diph- 
 theria in, 737, 738, 740; diseases of 
 breast in, 761-768; diseases originating 
 intragenitally in, 737, 738; diseases of 
 nervous system in, 769— 773 j duration of , 
 673; Effects of dystocia in, 714; em- 
 bolism in, 768, 776; emotional ex- 
 citement, cause of fever in, 745 ; 
 endocarditis in, 741, 742; endome- 
 tritis in, 718-727; ergot in, 697; 
 eruptions of septic infection in, 773; 
 erysipelas in, 737; examination of, 698, 
 750; excision of veins in, 758; exercise 
 in, 697, 698; exhaustion in, 673; exter- 
 nal genitals in, 677, 678; Fever in, 746, 
 due to mammary irritation in, 744, 
 due to neurotic conditions in, 745, 746, 
 due to reflex irritation in, 744-746, due 
 to uterine displacements, 745, due to 
 uterine rupture, 744; Galactocele in, 
 768; general diseases in, 773; general 
 phenomena in, 673-677; genital tract, 
 anomalies of, in, 708-710; glycosuria 
 in, 319, 320; gonorrheal infection in, 
 737; Heart in, 677; heart murmur in, 
 674; hematuria in, 705, 706; hemiplegia 
 and aphasia in, 771; hemorrhoids in, 
 705; hyperinvolution in, 709, 710; hy- 
 perthermia in, 743—747; hypothermia 
 in, 747; hysteria, cause of fever in, 745; 
 Impregnation in, 687; infections, con- 
 secutive focal in, 727-741; infections, 
 primary focal in, 718-727; inflamma- 
 tions, genital, extragenital, and peri- 
 genital, in, 714; insanity in, 771-773; 
 intestinal anomalies in, 705; involution 
 in, 679-6S3; Kidneys in, 676; Lacto- 
 suria in, 676; lochia, in, 678; lochio- 
 colpos in, 714; local phenomena of, 
 677-687; Mammary irritations in, 744; 
 management of, 688-698; massage in, 
 697; mastitis in, 762-768; medication in, 
 
 691, 697; metastatic lesions in, 738; me- 
 tritis in, 728, 729; metrophlebitis in, 735, 
 736; milk secretion in, 683-687, anoma- 
 lies of, in, 760, 761; muscles in, 676; 
 morbidity in, 711-759; bacteriology 
 of, 716; classification of, 712; clinical 
 types of, 713, 747-749; statistics of, 
 712; morbid conditions of, antedating 
 labor, 713, 714; morbid conditions orig- 
 inating in, 716-747; resulting from 
 labor, 714-716; mortality of, increased 
 by chronic toxemias not due to preg- 
 nancy, 714-715; myelitis and para- 
 plegia in, 771; Nervous system in, 677; 
 neuritis and paralysis in, 669-671; neu- 
 ritis, toxic, in, 740; sore nipples in, 747, 
 761; Ocular paralysis in, 771; oedema of 
 genitals in, 677 ; oophoritis in, 755; Pain 
 in genitals in, 673 ; parametritis in, 729- 
 755 ; pathological, 701-776; pelvic arti- 
 culations in, 676, 677; pelvic binder in, 
 696; pemphigus in, 740; peptonuria 
 in, 676; pericarditis in, 737; perito- 
 nitis in, 730-735; phlebitis in, 735- 
 737; phlegmasia alba dolens in, 736; 
 physiological, 673-698; placental site 
 in, 682; pleurisy in, 737; posture in, 
 694, 879; proctitis in, 727; professional 
 visits in, 690; prophylaxis in, 695-698; 
 pseudo-fever in, 743; psychoses in, 771- 
 773; ptomainemia in, 738, 739; pul- 
 monary embolism in, 7 7 5 , cause of sudden 
 death in, 775; pulse in, 674; pyelitis in, 
 727; pyelonephritis in, 707; pyemia in, 
 741; respiration in, 675; rest in, 690; 
 Salpingitis in, 728; sapremia in, 738, 
 739; sapremic sepsis in, 742, 743; 
 septicsemia in, 741, 742; septic blood- 
 states in, 741-742; septic erythema in, 
 740; shock from dystocia in, 714; skin 
 in, 675, 676, diseases of, in, 773; ster- 
 coremia in, 739; stomach in, 676; sub- 
 involution of uterus in, 708; submam- 
 mary abscess in, 767; sudden death in, 
 773-776; superinvolution in, 709; syn- 
 cope and shock cause of sudden death 
 in, 774; Temperature in, 675, 711, 712; 
 thrombosis in 735, 775; tuberculosis in, 
 714; tympanites in, 764; Urea excretion 
 in, 676; urethritis in, 727; urinary 
 anomalies in, 705-707; urine in, 676, 
 incontinence of, in, 706; retention of, 
 in, 676, 679, 691, 692, 706, uterine 
 adnexa in, 683; uterine displacement 
 in, 710; uterine muscle in, 682; uterine 
 souffle in, 675; uterine vessels in, 682; 
 Vagina in, 678; variola in, 738. 
 
 Pulmonary, arterj-, fetal, 81, arteries, prim- 
 ary thrombosis of, in puerperium, 776, 
 disease, effect of, on labor, 668, embol- 
 ism, cause of sudden death in puer- 
 perium, 775. 
 
 Pulse , funic , 7 7 ; in placental hemorrhage ,226; 
 in colic of newly born, 852; in convul- 
 sions of newly born, 855; in eclampsia. 
 306; of newly bom, 781; in malignant 
 peritonitis, 734; in puerperal fever, 747; 
 in puerperal infection, 747; in insanity 
 of puerperium, 772; in labor, 431; in 
 prematurity, 802; in puerperium, 674; 
 in pulmonary embolism, 775; in septic 
 infection of newly bom, 841; in tetanus 
 
1066 
 
 INDEX. 
 
 of newly born, 846 ; vaginal, in preg- 
 nancy, 89, 125; in sapremia, 739; in sep- 
 ticemia, 741; uterine, in pregnancy, 124. 
 
 Purpura hsemorrhagica of newly born, 849. 
 
 Purpura, puerperal, 773. 
 
 Putrefaction of fetus, 274. 
 
 Pyelitis in puerperium, 727. 
 
 Pyelonephritis, in pregnancy, 316; in puer- 
 perium, 727. 
 
 Pyemia, a result of curettage in puerperal 
 infection, 752; puerperal, 741; types of, 
 
 747- 
 Pylorus, congenital hypertrophic stenosis 
 
 of, 263, 810. 
 Pyogenic cocci in bacterial toxemia, 739. 
 Pyometra, diagnosis of, from pregnancy, 
 
 133- 
 Pyorrhoea alveolaris in pregnancy, 322. 
 Pyosalpinx, and pregnancy, coexistence of, 
 
 .137- 
 Pyriformis muscle, 397. 
 Pyrosis of pregnancy, 323. 
 
 Q. 
 
 Quickening, in pregnancy, 126; the relation 
 of, to the vomiting of pregnancy, 299. 
 
 Quinine, as accelerator of first stage of labor, 
 572; in malaria of pregnancy, 257; 
 in puerperal infection, 751; in puer- 
 perium, 697. 
 
 R. 
 
 Races, intermarriage of, a factor in maternal- 
 fetal dystocia 656. 
 
 Rachidotomy, 946. 
 
 Rachitic pelves, 629-634. 
 
 Rachitis (see Rickets). 
 
 Radiography, metric, 178. 
 
 Rales in lungs of newly born, 842. 
 
 Ranula of newly born, 852. 
 
 Rape, 29-35. 
 
 Rasch's sign in pregnancy, 124. 
 
 Rauber's layer, 53, 63, 64, 65. 
 
 Rectal, feeding in pernicious vomiting of 
 pregnancy, 303, infusion of saline solu- 
 tion, 861, 862, syringes for newly born, 
 ?54. 
 
 Recti, separation of, in puerperium, 711. 
 
 Rectocele, cause of dystocia, 614, 615. 
 
 Rectum, changes in, in pregnancy, 114; 
 disturbances in, in pregnancy, 130; 
 distended, cause of dystocia, 613, 614; 
 repair of, 1036*, 1037. 
 
 Reflex irritation a cause of hyperthermia, 
 
 744, 745- 
 
 Reichert's ovum, 69. 
 
 Relapsing fever, in pregnancy, 258; of fetus, 
 258. 
 
 Renal calculi in pregnancy, 316. 
 
 Renal disease, effect of, on fetus, 263. 
 
 Renal insufficiency, in pregnancy (see Tox- 
 emia of pregnancy). 
 
 Rennet, action of, 685. 
 
 Repositors for prolapsed small parts, 918. 
 
 Reproduction, indications for prevention of, 
 
 Respiration, artificial, in asphyxia neona- 
 torum, 819-823; character of, in labor, 
 431, in prematurity, 801, 802, 803, in 
 
 puerperium, 675, 691; establishment of, 
 in newly born, 488, 779; rate of, at 
 birth, 779. 
 
 Respiratory system, diseases of, in preg- 
 nancy, 329-332. 
 
 Rest, in puerperium, 747. 
 
 Retention, of placenta and membranes, 574- 
 577; of urine in puerperium, 737, 748, 
 
 749. 765- 
 
 Retina, formation of, 56; origin of, 61. 
 
 Retraction of the uterus in "dry labor," 570. 
 
 Retraction ring (see Contraction ring). 
 
 Retroflexion and retroversion of uterus in 
 puerperium, 710. 
 
 Retroflexion of uterus, diagnosis of, from 
 pregnancy, 135; in pregnancy, 275-278; 
 and incarceration, an indication for in- 
 duction of abortion, 278. 
 
 Retropharyngeal abscess in newly born, 844. 
 
 Retroversion of uterus, diagnosis of, from 
 pregnancy, 135; in pregnancy, 276-278. 
 
 Rheumatism in newly born, 809; of fetus, 
 258; of uterine muscle in pregnancy, 
 281. 
 
 Rickets, 629-634; cause of constipation in 
 newly born, 854; cause of convulsions 
 in newly bom, 855; fetal, 629, 630, 810; 
 in lower animals, 630. 
 
 Rigidity and atresia of vagina and vulva, 
 cause of dystocia, 610-612. 
 
 Ring, Bandl's, 402; contraction, 402; re- 
 traction, 451; umbilical, 780. 
 
 Ritgen's method of extracting forecoming 
 head, 965, 966. 
 
 Ritter's disease, 844. 
 
 Robert's pelvis, 626. 
 
 Roederer's obliquity, 451, 499. 
 
 Rokitansky, "cervical pregnancy" of, 196; 
 "puerperal osteophytes" of, 118; pelvis 
 of, 641—643. 
 
 RSntgen, cephalometry, 184; pelvimetry, 177, 
 178. 
 
 Rostrate pelvis, 635. 
 
 Rotation, digital, in transverse position of 
 head at pelvic outlet, 554; excessive, of 
 occiput, in vertex presentation, 454; 
 dangers from forceps, 990; of fetal head, 
 413 ; of first part of fetal ellipse in labor, 
 442-446 ; of second part of fetal ellipse in 
 labor, 446, 447; posterior, of occiput, and 
 impaction, 459, 460. 
 
 Rotators, forceps as, 1002. 
 
 Round ligaments, changes of, in pregnancy, 
 III. 
 
 Rubber gloves, 151. 
 
 Rupture, of membranes, premature, dysto- 
 cia from, 605; of membranes, tardy, 
 dystocia from, 605 ; of pelvic floor, 
 muscular, 597; spontaneous, of uterus, 
 in pregnancy, 282. 
 
 Rupture of uterus, 584-590; celiotomy in, 
 589; following ventrofixation of uterus, 
 600, 601; in contracted pelvis, 655; in 
 pregnancy, 584; in pregnancy in cancer- 
 ous uterus, 610; in puerperium, 584; 
 intra-partum, 584. 
 
 S. 
 Sac, amniotic, 66. 
 
 Sacral plexus, lesions of, during puerperium, 
 769. 
 
INDEX. 
 
 1067 
 
 Sacro-coccygeal, joint, 378; symphyseotomy 
 in ankylosis of, 937; synostosis at, 
 639; ligaments, 398; tumors, cause of 
 dystocia, 564, 565. 
 
 Sacro-iliac joints, diastasis of, in labor, 615; 
 movements in, 378; synostosis at, 639. 
 
 Sacro-posterior cases, persistent, delivery of 
 head in, 979, 980. 
 
 Sacro-sciatic ligaments, 398. 
 
 Sacro-vertebral, angle, 378; joint, 426. 
 
 Sacrum, 375, 376; imperfect development of, 
 623-626; molaility in joints of, 379. 
 
 Saline infusion, 861 ; intra-arterial, 862 ; intra- 
 venous, 862, 863; in eclampsia, 312; in 
 post-partum hemorrhage, 584; prepara- 
 tion of solution for, 861; in puerperal 
 infection, 751; umbilical, in asphyxia 
 neonatorum, 823; rectal, in shock, 861, 
 862; vaginal and intrauterine, 881, 882. 
 
 Salines, in overdistention of breast, 744; in 
 puerperal constipation, 744. 
 
 Salivation in pregnancy, 322. 
 
 Salpingitis, puerperal, 728. 
 
 Saponification of fetus, 274. 
 
 Sapremia, antepartum, 713; puerperal, 720, 
 721, 738, 739, 748; from neglect of ex- 
 cretions in adolescence, 36. 
 
 Saprophytes in puerperal endometritis, 719- 
 721. 
 
 Sarcomata, fetal, 270; pelvic, 638. 
 
 Saw decapitator, 958. 
 
 Scales, baby, 787. 
 
 Scanzoni's, cephalotribe, 953; manoeuvre, 
 1006. 
 
 Scarlatina of fetus, 256; in newly born, 808; 
 in pregnancy, 256. 
 
 Schultze's measurements of embryo and 
 fetus, 86, 87, 88; method of artificial 
 respiration, 820, 821 ; method of placen- 
 tal delivery, 439; sickle hook, 956, 957. 
 
 Sciatica, in pregnancy, 130. 
 
 Scissors, decapitation, 959. 
 
 Sclerema neonatorum, 850. 
 
 Sclerosis of placenta, 233. 
 
 Scoliotic pelvis, 647. 
 
 Sebaceous follicles in pregnancy, 89. 
 
 Secundines, retention of, 492, 493. 
 
 Sedatives, in convulsions of newly born, 855; 
 in insanity of puerperium, 773; in puer- 
 peral neuritis, 770; in threatened abor- 
 tion, 358; in painful labor, 572. 
 
 Segmentation of the ovum, 53. 
 
 Semen, 27. 
 
 Semmelweiss on puerperal fever, 148. 
 
 Senses, acute, in pregnancy, 116; perversion 
 of, in pregnancy, 18S. 
 
 Sepsis, acute puerperal, 747 ; bacteria of puer- 
 peral, 148,149,741, 742; a sequel of labor 
 in typhoid fever, 336; conditions which 
 predispose to, 722; fetal, 25S; in newly 
 born, 809 ; in pregnancy, 258 ; in relation 
 to psychoses in pregnancy, 334; puer- 
 peral, gas, 742; puerperal, sapremic, 726, 
 742; treatment of, 749; umbilical, 842, 
 
 843- 
 
 Septa, decidual, origin of, 71; of vagina, a 
 cause of dystocia, 612. 
 
 Septic, coryza of newly born, 843 ; infection, 
 in interrupted pregnancy, 355, of newly 
 born, 809, 841-847, puerperal, organisms 
 causing, 721, 722, puerperal, treatment 
 of, 753-755; neuritis, puerperal, 741; 
 
 pemphigus of newly born, 844 ; phlebitis, 
 puerperal, 735; pneumonia of newly born, 
 809, 843- 
 
 Septicaemia, 741, 742; clinical phenomena 
 of, 741; primary foci of puerperal, 741; 
 puerperal, 741; venosa, puerperal, 735, 
 736. 
 
 Septicopyemia, puerperal, 723, 742. 
 
 Serotina, decidual, 45. 
 
 Serous cachexia in pregnancy, 327. 
 
 Serum, antistreptococcic, in puerperal infec- 
 tion, 750, 751, 752. 
 
 Sex, as indicated by fetal heart-beat, 161; 
 influence of, on weight of newly born, 784, 
 850. 
 
 Sexual, intercourse, a cause of abortion, 188, 
 effect of, on health, 36, 37, effect of, on 
 menstruation, 2 2 , effect of, on ovulation, 
 17, in pregnancy, 188, life, 36, 37; 
 functions, hygiene of, 35, 36. 
 
 Shock, enteroclysis in, 864; from dystocia, 
 714; from post-partum hemorrhage, 
 treatment of, 584; treatment of, in as- 
 phyxia neonatorum, 823. 
 
 Short cord, posture of mother in, 878. 
 
 Shoulder presentation, 538-544; bipolar po- 
 dalic version in, 926, 927; combined 
 cephalic version in, 922, 923; definition 
 of. 538,539; diagnosisof, 543, 544; etiol- 
 ogy of, 539, 540; evisceration in, 960; 
 frequency of, 539, 540; mechanism and 
 course of labor in, 540-543; palpation 
 in, 161; podalic version in, 925-927, 935; 
 prognosis of, 544; synonyms of, 538; 
 treatment of, 544. 
 
 Shoulders, delivery of, 456, 486-488, 966-968. 
 
 Show, in labor, 431, 435. 
 
 Sickle knife decapitator, 558. 
 
 Silver, nitrate, as preventive of ophthalmia, 
 490; in aphthas of the newly born, 847; 
 Credo's coUodial, in endometritis, 754; 
 in ecthyma neonatorum, 845 ; in gonor- 
 rheal stomatitis, 837; in leucorrhea, 187; 
 in ophthalmia neonatorum, 834, 835; 
 in treatment of sore nipples, 761 762; in 
 umbilical sepsis, 842, 843. 
 
 Simple, flat, rachitic pelvis, 631; non-rachitic 
 pelvis, 620, 621. 
 
 Simpson's, cranioclast, 947; forceps, 984. 
 
 Sims', dilator, 904, knee-chest posture, 87a. 
 
 Sinciput, 409, 411. 
 
 Skiagraphy, pelvic, 178. (See ROntgen 
 Pelvimetry and Rontgen cephalometry.) 
 
 Skin, care of, in pregnancy, 1S7, in relation 
 to hygiene of sexual functions, 36; 
 changes of, in pregnancy, 117; diseases, 
 in pregnancy, 337-340, in puerperium, 
 675, 676; formation of, 55, 58; in fetal 
 syphilis, 260. 
 
 Skull, fetal, measurements of, 1S0-1S4, pre- 
 mature ossification of, 562. 
 
 Skutsch's pelvimeter, 171. 
 
 Sling, indications and uses of, 1007; in pelvic 
 presentation, 1008; in placenta praevia, 
 1009; in prolapse of cord, 1008; in pro- 
 lapse of an arm in shoulder presentation, 
 935, 1009; in combined podalic version, 
 1009. 
 
 Small parts, fetal, location of, by palpation, 
 156. 157; reposition of prolapsed, 916, 
 917. 
 
 Smallpox. (See Variola.) 
 
106S 
 
 INDEX. 
 
 Smellie-Veit method in breech presentation, 
 978-980. 
 
 Solayre's obliqmty, 451. 
 
 Somatopleura, 63; formation of, 58. 
 
 Souffle, funic, in pregnancy, 129; uterine, in 
 pregnancy, 124, in puerperium, 675. 
 (See Murmur.) 
 
 Spee's embryo, 83. 
 
 Spermatozoa, 27, 28; as affected by acids, 28, 
 by alcoholism, 28, by alkalies, 28, by 
 cold, 28, by heat, 28, by sexual excesses, 
 28; appearance of, 27; ascent of, 28; 
 disappearance of, 28, motion of, 27, 28; 
 age for first appearance of, 28; rate of 
 motion of, 28; theories of ascent of, 28; 
 vitality of, 28. 
 
 Sphincter and muscle, external, 398. 
 
 Spina bifida, 265, 266. 
 
 Spinal, anesthesia in labor, 868; cord, origin 
 of, 61; disease in relation to labor, 668. 
 
 Splanchnopleure, 64; formation of, 59; origin 
 of, 61. 
 
 Spleen, changes of, in pregnancy, 116; ef- 
 fect of hepatic insufficiency on, 326; 
 floating, cause of dystocia, 605, diagnosis 
 of, from pregnancy, 137; in septic in- 
 fection of newly bom, 841; rupture of, 
 in labor, 669. 
 
 Spondylolisthesis, 641—643. 
 
 Spondylolizema, 643. 
 
 Spondylotomy, 963. 
 
 Spurious pregnancy, 138. 
 
 Staphylococci, in human milk, 789; in puer- 
 peral sepsis, 149; in vulval canal, 149; 
 sepsis of fetus due to, 258 
 
 Stercoremia, puerperal, 739. 
 
 Sterility, after abortion, 356; artificial, 37; 
 following coitus interruptus, 38; from 
 displacements of the uterus, 275, 276; 
 posture in coitus, an aid in overcoming, 
 876. 
 
 Sterilization of instruments and dressings, 
 860,861; of milk, 789, 793. 
 
 Sternomastoid, hematoma of, 832. 
 
 Stoltz's sign of death of fetus, 273; test for 
 vaginal hernia, 667. 
 
 Stomatitis, gangrenous, of newly born, 843; 
 gonorrheal, 837; ulcerous, of newly born, 
 843 ; vesicular or follicular of newly bom, 
 
 847. 
 
 Stools of newly born. (See Feces of newly 
 born.) 
 
 Strait, inferior, definition of, 383; superior, 
 definition of, 381. 
 
 Streak, primitive, 53, 54, 58. 
 
 Streptococcus, erysipelatis, 846; pyogenes 
 in puerperal sepsis, 149, in vulval canal, 
 149, in fetal sepsis, 258. 
 
 Striae, abdominal, in pregnancy, 125; atro- 
 phicas, after pregnancy, 678; of breast 
 in pregnancy, 114. 
 
 Strychnin, after abortion, 361; in asphyxia 
 neonatorum, 823; in eclampsia, 312; in 
 erysipelas of the newly born, 846; in 
 heart disease of pregnancy, 326; in last 
 weeks of pregnancy, 573; in puerperal 
 infection, 751; in puerperium, 697. 
 
 Subinvolution, 708; causes of, 192, 356, 708; 
 diagnosis of, 708, diagnosis of, from 
 pregnancy, 133; treatment of, 708. 
 
 Sublingual cysts in the newly bom, 852. 
 
 Sudamina, puerperal, 773. 
 
 Sudden death, in pregnancy, 296, 369; ac- 
 couchement force in, 965; podaUc ver- 
 sion in, 925, in puerperium, 773-776; of 
 newly laorn, 856, 857. 
 
 Sugar, regulation of, in modified milk, 789- 
 
 o 795- 
 
 Superfetation, 140, 141. 
 
 Surgery, obstetric, 859-1037. 
 
 Sweat glands, in pregnancy, 89. 
 
 Sylvester's modified method of artificial res- 
 piration, 821. 
 
 Symphyseotomy, 937-941; French or open 
 method of, 941; Italian or suprapubic 
 method of, 939, 940; subcutaneous or 
 American method of, 941. 
 
 Symphysis pubis, 376; changes of, in preg- 
 nancy, 114, 377; measurement of length 
 of , in pregnancy, 166; synostosis at, 639. 
 
 Syncope and shock, cause of sudden death in 
 puerperium, 774; treatment of, 774; 
 following labor, 580; in hydatidiform 
 mole, 200; in pregnancy, 327. 
 
 Synostosis, at sacro-iliac joints, 639; at sac- 
 rococcygeal joint, 639; at symphysis, 
 
 639- 
 Syphilis, an etiological factor m fetal death, 
 272, cause of interrupted pregnancy, 
 337, 348, 349; congenital, 259—261, 810; 
 in pregnancy, 259-261, 337; indication 
 for prevention of reproduction, 38; in- 
 fantile, 809, 810-812; diagnosis of, 810, 
 prognosis of, 811; treatment of, 812, of 
 placenta, 232; of umbilical cord, 241; 
 treatment of, in pregnancy, 261; trans- 
 mission of, to fetus, 260. 
 
 T. 
 
 Tactile organs, origin of, 61. 
 
 Tampon, uterine. 885, 886; uterine and cer- 
 vical, 902; vaginal, 884, 893; medicated, 
 contraindicated in pregnancy, 289. 
 
 Tamponade, in accidental hemorrhage, 228; 
 in inversion of uterus, 592; in rupture 
 of uterus, 589, 590; of uterine cavity, 
 893 ; of vagina and cervix, 893. 
 
 Tapeworm, in pregnancy, 325; a cause of 
 fever in puerperium, 745. 
 
 Tamier's, embryotome, 956, forceps, 984, 
 incubator, 805, sign of abortion, 352. 
 
 Taste, delicacy of, in pregnancy, 116. 
 
 Taste, organs of, origin of, 61. 
 
 Teeth, caries of, in pregnancy, 321; develop- 
 ment of, 84; extraction of, in pregnancy, 
 370. 
 
 Temperature, constipation a cause of irregu- 
 lar, 743, 744; mammary irritation a cause 
 of, 744; in labor, 431, in puerperium, 
 675, 691; fetal, 781; in eclampsia, 306; 
 in pregnancy, 118; in puerperal infec- 
 tion, 747; in sclerema neonatorum, 850; 
 of genitalia, in pregnancy, 125 ; of newly 
 born, 781; of premature child, 801; a 
 test of a pathological puerperium, 711; 
 subnormal (see Hypothermia). 
 
 Tenesmus, vesical, in pregnancy, 114. 
 
 Testicles, time of descent into scrotum, 88. 
 
 Tetanus, after interrupted pregnancy, 355; 
 bacterial toxemia of, 740; in pregnancy, 
 258; of newly born, 846, 847; puerperal, 
 740. 
 
INDEX. 
 
 1069 
 
 Thorax, formation of, 60. 
 
 Thrombosis, in pregnancy, 327; infective, 
 735-737; of placenta, 229-231; of pul- 
 monary arteries, primary, puerperal, 
 733, 736, 776; of umbilical arteries, 240; 
 vaginal and vulval, cause of dystocia, 
 613. 
 
 Thrush of newly born, 847. 
 
 Thymus gland, in fetal syphiUs, 260; origin 
 of, 61. 
 
 Thyroid extract in osteomalacia, 636. 
 
 Toothache in pregnancy, 322, 335. 
 
 Topography, uterine, at term, 112. 
 
 Torsion of pregnant uterus, 280. 
 
 Touch, sense of, acute, in pregnancy, 116. 
 
 Toxemia, bacterial, 739, clinical course of 
 malignant, 742; and fever, without sep- 
 sis, 748; a cause of interrupted preg- 
 nancy, 348, 349; of pregnancy, 291-299, 
 persistent in puerperium, 713, blood in, 
 294, 297, cUnical types of, 296, Ewing's 
 theory of, 292, kidney in, 292, liver in, 
 292, spleen in, 292, symptoms of, 295, 
 treatment of, 298-303. 
 
 Toxemias, chronic, in puerperium, not due 
 to pregnancy, 713, 714. 
 
 Tracheotomy in asphyxia neonatorum, 817. 
 
 Traction-straps in labor, 574. 
 
 Transverse diameter, of pelvis, 383; of pel- 
 vic outlet, 384. 
 
 Transverse head, deep, forceps in, 1006, 1007. 
 
 Transverse, position, 538, of the head, at 
 pelvic outlet, 553, 554; presentation, 
 
 538-545- 
 
 Trans versus perinei muscle, 398. 
 
 Traumatism, fetal, 269; in etiology of acci- 
 dental hemorrhage, 225; fetal, birth, 
 823-832, of brain and cord, 823, 824; of 
 nerve-trunks, 824-828; maternal, 716; 
 surgical treatment of, after labor, 464, 
 
 465- 
 
 Trendelenburg posture, 875, 879. 
 
 Trendelenburg-Walcher posture, 879. 
 
 Triple labor, management of, 557. 
 
 Trismus uteri, cause of dystocia, 606. 
 
 Trunk, development of, 54; dystocia from 
 affections of, fetal, 564; expulsion of, in 
 labor, 455, 488; internal rotation of, in 
 labor, 446, 460. 
 
 Tubal abortion, pathology of, 364; preg- 
 nancy, 361, pathology of, 362, 363. 
 
 Tube, eustachian, 61; neural, 55, 56. 
 
 Tuberculosis, acute miliary, in pregnancy, 
 331; cause of interrupted pregnancy, 
 349; and pregnancy, 258, 259, 329-331; 
 in newly born, 809; an indication for 
 premature delivery, 331 ; in puerperium, 
 714; an indication for prevention of re- 
 production, 38; of fetus, 258, 259; of pla- 
 centa, 232; pregnancy a predisposing 
 cause of, 329, 330. 
 
 Tuberculous toxemia, fetal, 259. 
 
 Tubes, ovarian, condition of, in menstruation, 
 2 1 ; distended, diagnosis of, from preg- 
 nancy, 136. 
 
 Tumors, coexistence of abdominal, ovarian, 
 and pelvic with pregnancy, 136-138; con- 
 genital, of umbilical cord, 241, 242; orig- 
 inating in urinary apparatus, cause of 
 dystocia, 564; diagnosis of, from preg- 
 nancy, 135; pelvic, 638, dystocia due to, 
 564, 638, prognosis of, 638, treatment of, 
 
 638; placental, 236; removal of, in preg- 
 nancy, 370; uterine, ovarian, renal, and 
 peritoneal, cause of dystocia, 602-605. 
 
 Twin labor, hemorrhage after first birth in, 
 556; management of, 556, 557. 
 
 Twin monstrosities, general fetal oedema in, 
 270. 
 
 Twin pregnancy, common in elderly primi- 
 parae, 665 ; diagnosis of, from hydram- 
 nios, 207. 
 
 Twins, abnormal conditions in, 143; expla- 
 nation of, 141; fetal heart-beat in, 161; 
 fetal membranes of, 142; management 
 of, 556, 557. 
 
 Typhoid fever in pregnancy, 256, 257; of 
 fetus, 257. 
 
 Typhus, fetal, 258; in pregnancy, 336. 
 
 U. 
 
 Ulcer, puerperal, 718. 
 
 Ulceration of hard palate in newly born, 852. 
 
 Umbilical arteries, fetal, 82; thrombi in, 240. 
 
 Umbilical cord, 71-77, adenomata of, 242; 
 anomalies of, 237-242; arteries of, 77; 
 arterial valves of, 77; atheromata of, 
 241-242; battledore insertion of, 237; 
 calcareous deposits in, 240; care of, 486, 
 489, 786; central insertion of , 237; about 
 neck of child, 238, 486; cysts of, 240; 
 dermoids of, 241; development of, 71; 
 diameter of, 77 ; dressing for, 786; eccen- 
 tric insertion of, 237; entero-teratomata 
 of, 242; epithelium of, 71; excessively 
 long, 559; false knots in, 77; formation of, 
 60 ; function of , 7 1 , 7 7 ; hsematoma of , 2 4 1 ; 
 hemorrhage from, 241, hernia of, 240; 
 hypertrophy of valves of, 241 ; infection 
 of, 842. 843; insertion of, 237; knots of, 
 238; lateral insertion of, 237; length of, 
 77, 237; ligation of, 488, 489; in prema- 
 turity, 802; marginal insertion of, 237; 
 obstruction of vessels of, 241; origin of, 
 65, 71; prolapse of, 522-527; in con- 
 tracted pelvis, 654; pulse of, 77; reposi- 
 tion of prolapsed, 916, 1009; rupture of, 
 560; short, 559, symptoms and treat- 
 ment of, 559, 560; stenosis of vessels of, 
 240; strength of. 77, structure of, 71; 
 syphilitic lesions of, 241; tangling of, 
 238, 239; thickness of, 237; torsion of, 
 239; traction on, cause of inversion of 
 uterus, 591; tumors ot, 241, 242; veins 
 of, 77; velamentous insertion of, 237; 
 venous valves of, 77. 
 
 Umbilical, infusion in asphyxia neonatorum, 
 823; murmur in pregnancy, 129; sepsis. 
 842; stump and ring, 780, 781; vein, 81, 
 82; dilatation of, 241, stenosis of, 240; 
 vesicle. 71. 
 
 Umbilicus, congenital tumors of, 241; dif- 
 ference between male and female, 781. 
 
 Unconscious delivery, 449, 450. 
 
 Urachus, origin of, 68. 
 
 Urea, changes in, in relation to eclampsia, 
 308; excretion of, in menstruation, 
 20, in puerperium, 676; in liquor amnii, 
 66. 
 
 Uremia in pregnancy, 307; and eclampsia, 
 difference between, 307. 
 
 Ureter, changes in, in pregnancy, 114. 
 
1070 
 
 INDEX. 
 
 Urethra, malformations of, 287; origin of, 
 61. 
 
 Urethritis, pyogenic puerperal, 727. 
 
 Urinary, anomalies in puerperium, 705-707; 
 organs, origin of, 61; retention, in 
 pregnancy, 318; tract, diseases of, in 
 pregnancy, 315, puerperal infection of, 
 
 Unne, examination of, in pregnancy, 188, 
 308, 309; fetal excretion of, 66, 67; 
 fetal, albumin in, 79; in cystitis, 707; in 
 eclampsia, 307; in newly born, 782; in 
 pregnancy, 117, importance of ex- 
 amination of, 188; in puerperium, 676; 
 in toxemia of pregnancy, 295; retention 
 of, 676, 679, 691; incontinence of, in 
 pregnancy, 114, 318; in distended 
 bladder, 134; prenatal, 67; toxicity of, 
 
 30?- 
 
 Urogenital, apparatus, fetal diseases of, 267; 
 ystem, origin of, 60, 61. 
 
 Urotropin in puerperal cystitis, 754. 
 
 Utero-sacral ligaments, changes in preg- 
 nancy, III. 
 
 Uterus, absent, 283; accessory, 286; ante- 
 flexion and anteversion of, in pregnancy, 
 274, 275; asymmetry of, in pregnancy, 
 loi; atrophy of, during lactation, 709; 
 axial torsion of, 42 7 ; Backward displace- 
 ments of, 427: bacteriology of, 716; 
 Bandl's ring of, 402; bicornis, preg- 
 nancy in, 367; Cancer of, cause of 
 dystocia, 610; capacity of, at fortieth 
 week, 673, at end of puerperium, 673; 
 catheterization of (Krause's method), 
 891-893; changes of, in labor, 429, 430, 
 in menstruation, 21, in pregnancy, 91- 
 112, in puerperium, 673, 679-686; changes 
 in arteries of, 106—108, in axis of, 
 102, 103, in consistence of, 103, 123, 
 in contractility of, 1 1 1 , in fibrous tissue 
 of, 105, in irritability of , iii, 350, in liga- 
 ments of, 109-111, in lymphatics of, 
 
 108, in nerves of, 108, in muscular 
 layers of, 103, 104, in peritoneum of, 
 
 109, in position of, 102, in sensibility of, 
 III. in shape of, 100, loi, in size of, 
 92-100, in veins of, 106, 107, in walls 
 of, 112; congenital prolapse of, 267, 
 286; congenital retroflexion of, 286; 
 congestive hypertrophy of, diagnosis 
 of, from pregnancy, 134; contractile 
 power of, persistent after death, 
 670; contractions of, in labor, 429, 
 in post-partum hemorrhage, 583, 584, 
 in second stage of labor, 437-439, 
 in third stage of labor, 439; contraction 
 ring of, 402, 403; cordate, in pregnancy, 
 287, 288; digital exploration of, 880; 
 Duplex, 283 ; Excessive right lateral 
 obliquity of, 592; Fetal and infantile, 
 286; fluctuations of, in pregnancy, 124; 
 Hernial protrusion of, in pregnancy, 281 ; 
 Incarceration of pregnant, 275, 277, 278; 
 inertia of, 566, 568-574; in pregnancy, 
 94-112; involution of, in puerperium, 
 679-683; Lateral displacements of, 
 in pregnancy, 279; Malformations of, 
 in pregnancy, 282, 283, 287, 288; multi- 
 parous, description of, 137, 138; murmur 
 in, in pregnancy, 124; muscle of, in 
 puerperium, 682; Non-development of 
 
 maternal, effect of, on fetus, 271; non- 
 pregnant, enlargements of, 132, 133; 
 Origin of, 60; Parturient, proper- 
 ties of, 216; penetrating wounds of 
 gravid, 370; perforation of, in curet- 
 tage after interrupted pregnancy, 355, 
 356; position of, in different months of 
 pregnancy, 102; pregnant, parts of, 
 216; prolapse of pregnant, 279, 280; 
 puerperal, description of, 137, 138, 687; 
 Retraction of, 571; retrodisplacements 
 of, 275-278, a cause of fever in puer- 
 perium, 744, effect of, on fetus, 275, 276; 
 rheumatism of muscle of, in pregnancy, 
 281; rudimentary, 284, 285.; rupture of, 
 584-590; a cause of fever, 744, diag- 
 nosis of, from accidental hemorrhage, 
 226, 227; in osteomalacia, 342; Spon- 
 taneous, 370; spontaneous in pregnancy, 
 282; shape of, in different months ,86,87; 
 sinking of, in labor, 432; size of, at end 
 of puerperium, 673, at fortieth week 
 of pregnancy, 673, in different months 
 of pregnancy, 86, 87; souffle in, in 
 pregnancy, 124; Tetanoid action of, 
 571; tetanoid state of, 566; topo- 
 graphical relations of, at term, 
 112; torsion of, in pregnancy, 280; 
 trismus of, cause of dystocia, 606; uni- 
 cornis, in pregnancy, 288, 367; Vessels 
 of, in puerperium, 682; virgin, 94; 
 Walls of, in labor, 404, 405 ; weight of, at 
 end of puerperium, 673, at fortieth 
 week of pregnancy, 673. 
 
 V. 
 
 Vaccination in pregnancy, 336. 
 
 Vaccinia in pregnancy, 256; of fetus, ,256. 
 
 Vagina, abnormal conditions of, a cause of 
 dystocia, 668, 669; absent, 286, 287; 
 atresia of, a cause of dystocia, 610- 
 612; bacteriology of, 148, 149, 716; 
 changes of, in pregnancy, 152; color of, in 
 pregnancy, 89 ; condition of, in menstrua- 
 tion, 2 1 ; deformities of, 28 7 ; development 
 of, 60, 61 ; disinfection of, in forceps opera- 
 tion, 989; in puerperium, 678; exami- 
 nation by, in pregnancy, 149, 167-177; 
 hernia of, 667; incisions of, 909, 910; 
 in pregnancy, 89 ; lacerations and con- 
 tusions of, 594, 595, repair of, 1032- 
 1037; nialignant disease of, cause of 
 antepartum hemorrhage, 372; ob- 
 struction of, treatment of, 612; origin of, 
 61; prolapse of, in pregnancy, 289; 
 rudimentary, 286, 287; secretions of, in 
 pregnancy, 148; treatment of obstruc- 
 tion of, 612. 
 
 Vaginal and vulval thrombosis, cause of dys- 
 tocia, 613. 
 
 Vaginal, Caesarean section, 1022-1025, drain- 
 age in puerperal sepsis, 756; douche, 88 1 ; 
 examination in pregnancy, 149, 167—177; 
 hernia, 667; irrigation in puerperal en- 
 dometritis, 726; tampon, 884, 893. 
 
 Vaginismus, cause of dystocia, 610. 
 
 Vaginitis, cystic, in pregnancy, 289; granu- 
 lar, in pregnancy, 89; specific, in preg- 
 nancy, 289. 
 
 Vaginofixation, labor after, 602. 
 
INDEX. 
 
 1071 
 
 Vagino-perineal incision, 910, 911. 
 
 Vagino-perineal lacerations, 597, 1033. 
 
 Valve, eustachian, 81, 82. 
 
 Vaporization in septic endometritis, 758; in 
 septic phlebitis, 755. 
 
 Varicosities, in pregnancy, 89, 130, 290, 326; 
 of umbilical vein, 241 ; rupture of, cause 
 of intrapartum hemorrhage, 671. 
 
 Variola, in newly born, 808; in pregnancy, 
 25s. 33^'> of fetus, 225; puerperal, 
 738. 
 
 Vas deferens, origin of, 60. 
 
 Vectis, 915. 
 
 Vegetations, vulval, in pregnancy, 290. 
 
 Vein, effect of air in, 862; placental "circu- 
 lar," 71; primitive, jugular, 81 ; umbili- 
 cal, 8r, 82. 
 
 Veins, excision of, in puerperal infection, 
 758; infusion of, in puerperal infection, 
 751; omphalomesenteric, origin of, 78. 
 
 Vense cavae, fetal, 81. 
 
 Ventricles, fetal, 81. 
 
 Ventrofixation, and ventrosuspension of 
 uterus, followed by pregnancy and labor, 
 600-602. 
 
 Vernix caseosa, origin of, 85; removal of, 
 
 785. 
 
 Version, 919—936; classification of, 919; 
 combined or bipolar podalic, 925-929, 
 in cephalic presentation, 927, 928, in 
 shoulder presentation, 925, 926; def- 
 inition of, 919; in breech presentation, 
 537; in brow presentation, 508; in- 
 dications for, 919; in cancer of uterus, 
 610; in case of monsters, 561; in 
 face presentation, 518; in impacted 
 shoulder presentation, 935; internal 
 cephalic, 924; internal podalic, 929- 
 936; in pelvic deformity, 658, 
 664; in pelvic presentation, 537; in 
 persistent occipito-posterior position, 
 549; in placenta prasvia, 223; in 
 pregnancy, 537; in prolapse of arms, 
 521; in prolapse of umbilical cord, 527; 
 in rupture of uterus, 589, 590; in shoul- 
 der presentation, 544; pelvic, 936; 
 posture in, 921, 922; podalic, 925-936; 
 prognosis of, 936; sling in, 935, 936; 
 spontaneous, in shoulder presentation, 
 541; varieties of, 919, 920. 
 
 Vertex presentation, 450-463; diagnosis of, 
 461, 462, after labor, 462; etiology of, 
 423, 424; frequency of, 423; causes of 
 frequency of, 423, 424; prognosis of, 462. 
 
 Vertigo in pregnancy, 334. 
 
 Vesical, calculus in pregnancy, 318, cause 
 of dystocia, 615; hemorrhoids in preg- 
 nancy, 318; irritation in pregnancy, 
 316; neoplasms and traumatisms in 
 pregnancy. 319. 
 
 Vesicle, blastodermic, 64; chorionic, 44; 
 umbilical, 71. 
 
 Vicarious menstruation, 24. 
 
 Vienna method of internal cephalic version, 
 24. 
 
 Villi, anchoring, 70; chorionic, 44, descrip- 
 tion of, 69, 70; degeneration of, 198. 
 
 Virginity, signs of, 30. 
 
 Vision, disturbances of, in pregnancy, 1 16. 
 
 Vitelline, stalk, 57; veins, origin of, 78. 
 
 Vitellus, 41, 42. 
 
 Vomiting, benign, 300 ; in hydatidiform mole, 
 200, 299; in newly born, 852; in preg- 
 nancy, 115, physiological, 299; in 
 phlegmasia alba dolens, 736, 737; perni- 
 cious, in labor, 669, in pregnancy, 300- 
 303, diagnosis of, 301, due to metritis, 
 282, due to toxemia, 300, etiology of, 
 300, prognosis of, 301, symptoms of, 
 300-303 treatment of, 300, 301, types 
 of, 300. 
 
 Vulva, atresia of, 287; bacteriology of, 149, 
 716; changes in, in pregnancy, 125; 
 condition of, in menstruation, 21; 
 hematoma of, in pregnancy, 291, 613; 
 oedema of, in pregnancy, 290, 291; 
 pruritus of, in pregnancy, 323; rigidity 
 of, cause of dystocia, 612. 
 
 Vulval, douche, 881; dressing, 490, 496, 690; 
 lacerations, 597-599. 
 
 W, 
 
 Walcher's position, 379, 387, 870, 871, 975; 
 
 in forceps delivery, 879; in labor, 876; 
 
 in pelvic application of forceps, 998; 
 
 in pelvic deformity, 657. 
 Walcher-Trendelenburg posture, 875. 
 Waters, bag of, at birth, 66. 
 Weaning, 796. 
 Weight, fetal, 86, 87, 419, 784; of newly born, 
 
 784; in puerperium, 677; placental and 
 
 fetal, comparison of, 222. 
 Wet-nurse, 788. 
 
 Wharton's jelly, 73; formation of, 85. 
 White infarcts of placenta, 234. 
 Widal reaction with fetal blood, 257. 
 Wigand-Martin method in breech presenta- 
 tion, 978, 980. 
 Winters', formulae for home modification of 
 
 milk, 791; tabular guide for artificial 
 
 feeding, 792. 
 Wolffian, body, formation of, 60; duct, 
 
 formation of, 60. 
 Wounds, fetal, 269; penetrating, of gravid 
 
 uterus, 370. 
 Wry neck, traumatic, 832. 
 
 Yellow fever, in pregnancy, 258; of fetus, 
 
 25S. 
 Yolk sac, 64; mammalian, 57; origin of, 
 
 63. 
 
 Zona, pellucida, 43; radiata, 43. 
 Zoosperm, maturation of, 44; origin of, 60. 
 
 Appendix (1039-1046) 
 
 Card index case for obstetrical histories, 1039. ' History cards, method of using, 1039-1042. 
 
 Cards for history records, 1040. History records, 1039-1042; in private prac- 
 
 Chart for institutional and educational work, tice, 1039-1040. 
 1039-1042. 
 
^^^^ 
 

 
 i^mQx