-^Jr-^^ •'5^ :\G^s^ Ar y\Q>\ Columbia ^nttojfiJttj) ISrfj^r^nr^ Hthrarg BOOKS BARTON COOKE HIRST, M. D. Obstetrics Octavo of 1013 pages, with 815 illustra- tions, 52 in colors. Cloth, ^5x0 net ; Half Morocco, $6.50 net. Seventh Edition Diseases of "Women Octavo of 741 pages, with 701 illustra- tions, many in colors. Cloth, ^5.00 net; Half Morocco, ^6.50 net. ^eco7id Edition ATEXT-BOOK OF OBSTETRICS BY BARTON COOKE HIRST, M.D. PROFESSOR OF OBSTETRICS IN THE UNIVERSITY OF PENNSYLVANIA; GYNECOLOGIST TO THE HOWARD, THE ORTHOPEDIC, AND THE PHILADELPHIA HOSPITALS, ETC. Seventh Edition, Revised and Enlarged with 895 Illustrations, 53 of them in Colors PHILADELPHIA AND LONDON W. B. SAUNDERS COMPANY 1912 Copyright, 1898, by W. B. Saunders. Revised, reprinted, and recopy- righted May, 1899. Reprinted May, 1900. Revised, reprinted, and recopyrighted April, 1901. Reprinted December, 1901. Revised, reprinted, and recopyrighted July, 1903. Re- printed July, 1905. Revised, reprinted, and recopy- righted August, 1906. Reprinted October, 1907. Revised, reprinted, and recopyrighted July, 1909. Reprinted July, 1910. Revised, reprinted, and recopyrighted August, 1912. Copyright, 1912, by W. B. Saunders Company. \^\1l PRINTED IN AMERICA PRESS OF W. B. SAUNDERS COMPANY PHILADELPHIA TO RICHARD A. F. PENROSE, M.D., LL.D. EMERITUS PROFESSOR OF OBSTETRICS AND OF THE DISEASES OF WOMEN AND CHILDREN IN THE UNIVERSITY OF PENNSYLVANIA trbfs :fiSooft is ©ratefuUs DeOlcateD BY HIS FORMER PUPIL, THE AUTHOR rj Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/textbookofobsteOOhirs PREFACE. This work is the result of a practice devoted for the past twelve years exclusively to gynecology in both its branches — obstetrics and gynecic surgery. The author has served during this period as consulting and attendant gynecologist and obstet- rician in eight of the principal hospitals of Philadelphia. His experience in obstetrical complications and operations has con- sequently been exceptionally large. He has been engaged, moreover, during the whole of his professional career, in teaching medical students in clinics, hospitals, laboratories, and in the lecture-room. He ventures to entertain the hope, there- fore, that his training has fitted him for the preparation of a book which shall serve as a guide to undergraduate students and to physicians in active practice. It has been his constant aim to condense the text as far as is consistent with a comprehensive treatment of the subject. Illustrations have been extensively employed, the majority of them from original photographs and drawings. The task, impossible within a single volume, of presenting a complete bibliography of each subject has not been attempted. The student who desires such information is referred to the " Catalogue of the Surgeon-General's Library," the ten volumes of the " Jahresbericht iiber die Fortschritte auf dem Gebiete der Geburtshilfe und der Gynakologie," and to the " In- dex Medicus." References are given to articles and books which have been most helpful to the author or which have been epoch-making in the history of obstetrics. 1821 Spruce Street, Philadelphia. CONTENTS, PACE PART I.— THE PHYSIOLOGY, DIAGNOSIS, AND MANAGEMENT OF PREGNANCY 17 Chapter I.^Anatomy 17 Anatomy of the Pelvis 17 The Female Sexual Organs 37 Chapter II. — The Methods, the Postures, and the Implements FOR the Examination of Women 55 Palpation 55 Inspection of the Pelvic Organs and Abdomen 61 Percussion and Auscultation 70 Mensuration of the Abdomen 71 Chapter III. — Menstruation, Ovul.ation, Insemination, Fertili- zation, Etc 72 Menstruation 72 Ovulation 7^ The Corpus Luteum 70 The Connection between Ovulation and Menstruation 81 Insemination 82 The Causes and Treatment of Sterility qo Changes in the Ovum Following Impregnation 93 Chapter IV. — The Development of the Embryo ant) Fetus.... 05 Development during the Months of Pregnancy 05 The Mature Fetus 106 Chapter V. — The Fetal .\ppend.\ges 113 The Amnion i i.S The Chorion J 1 7 The Placenta "8 The Umbilical Cord or Funis 1 23 The Membranse Decidual i -5 Ch.apter VI. — The Maternal Changes in Pregnancy 131 Changes in the Uterus 131 Changes in the Several Systems of the Body 136 The Diagnosis of Pregnancy i4- 13 14 CONTENTS. PAGE PART II.— THE PHYSIOLOGY AND MANAGEMENT OF LABOR AND OF THE PUERPERIUM 1 70 Chapter I. — Labor 170 Chapter II. — The Puerperal State 206 PART III.— THE MECHANISM OF LABOR 245 Forces Involved in the Mechanism of Labor 249 Mechanism of the Several Presentations and Positions 252 Abnormalities of Mechanism and their Management 259 Mechanism of the Third Stage of Labor 290 PART IV.— THE PATHOLOGY OF PREGNANCY, LABOR, AND THE PUERPERIUM 296 Chapter I. — Diseases of the Ovum and Fetus 296 The Amnion 296 The Chorion 303 The Placenta 312 The Cord 322 The Membranae Deciduae 327 Diseases of the Fetus 332 Chapter II. — Displacements of the Uterus in Pregnancy, Labor, AND THE PUERPERIUM 357 Chapter III. — Diseases of the Genital Canal and Neighboring Structures 376 Diseases of the Uterine Muscle 376 Neoplasms 378 Diseases of the Cervix 385 Diseases of the Vagina 387 Diseases of the Vulva 392 Diseases of the Breasts 399 Chapter IV. — Systemic and Other Diseases 400 Auto-intoxication or Toxemia 4°° Diseases of the Alimentary Canal 401 Diseases of the Urinary Apparatus 409 Diseases of the Nervous System 419 Diseases of the Circulatory Apparatus 422 Diseases of the Respiratory Apparatus 426 Skin Diseases 428 Injuries and Accidents 43 1 Surgical Operations 432 Chapter V. — Abortion, Miscarriage, and Premature Labor. ... 432 Chapter VI. — Extra-uterine Pregnancy 447 COXTRNTS. 1 5 PACE Chapter \II. — An(jmalies in the Forces of Labor 471 Labor Complicated by Accidents and'Diseases 591 Dystocia Due to Disease 646 Chapter VIII. — Abnormalities in the Involution of the Uterus After Child-birth 661 Puerperal Hemorrhage 666 Non-infectious Fevers 677 Acute Intercurrent Affections 684 The Exanthemata 686 Puerperal Diphtheria 693 Puerperal Malaria 693 Rheumatism and Arthritis 695 Gonorrhea 697 Skin Diseases 698 Diastasis of Abdominal Muscles 698 Tympanites 698 Diseases of the Urinary System 699 Diseases of the Nervous System 704 Developmental Anomalies of the Breast 705 Anomalies in the Milk Secretion 708 Diseases of the Mammary Glands 716 Relaxation and Disease of Pelvic Joints 725 Chapter IX. — Puerperal Sepsis 726 PART v.— OBSTETRIC OPERATIONS 780 Chapter I. — Aseptic and Oper.atwe Technique in General .... 780 The Hospital Operating-room 780 The Private House Operating-room 782 The Operating Table 784 Hand and Skin Cleansing; the Surgeon's Dress 785 The Preparation of the Patient 787 Ligatures and Sutures 789 Anesthetics; Instruments " 790 Chapter II. — The Artificial Dilatation of the Cervical Canal. Curettage, and the Operations to Deliver the Embryo and Fetus 791 Hydrostatic Dilatation 791 Manual Dilatation 794 Instrumental Dilatation 795 Dilatation by Incisions 803 Vaginal Cesarean Section 804 Vaginal Hysterotomy for Inversion of the Uterus 808 Curettage 808 Induction of Abortion 808 Induction of Labor 810 1 6 CONTENTS. Chapter II. — (Continued). PAGE Forceps 8ii Extraction of the Breech 835 Version 838 Embryotomy 853 Symphyseotomy 859 Hebotom}^ 863 Cesarean Section 865 Extraperitoneal Cesarean Section 870 Chapter III. — Operations for the Complications and the Path- ological Consequences or the Child-bearing Process 872 Preparation for Operations in the Lower Birth Canal 872 Operations on the Vulva 875 Operations on the Vagina 876 Lacerations of the Posterior Wall 876 Lacerations of the Anterior Wall 886 Fistulae Between the Genital and Urinary Canals 888 Operations for Acquired Stenosis and Atresia 905 Operations on the Cervix: Vaginal Section (ColpotomjO 909 Myomectomy by the Vaginal Route 911 Preparation for Abdominal Operations: The Incision, the Closure of the Wound, Dressing, Drainage 911 Hysterectomy: Partial, Total, Vaginal, Combined 914 Panhysterectom}' 914 Salpingo-oophorectomy 921 Excision of Pelvic and Abdominal Tumors by Abdominal Section 928 Inguinal Section 929 Abdominal Operations for Retrodisplacement of the Uterus. . . . 933 Operation for Diastasis of the Recti Muscles and Abdominal Hernia. 937 Coccygectomy 938 Operations on the Breast 938 The After-treatment of Abdominal Operations 940 PART VI.— THE NEW-BORN INFANT 942 Chapter I. — Physiology of the New-born Infant 942 Chapter II. — Pathology of the New-born Infant 950 Injuries to the Infant during Labor 950 Diseases of the New-born Infant 960 INDEX 973 A TEXT-BOOK OBSTETRICS. Introduction. "Obstetrics," derived from a Latin word meaning to stand in front of, as a midwife stood or knelt before her patient on the birth stool, originally signified the assistance afforded a woman in labor. Its modern significance is wider. It includes a study of the physiology and pathology of conception, gestation, parturition, and the puerperium, with all the compHcations and pathologic consequences of the child-bearing act at all periods. It embraces, therefore, a study of all the diseases peculiar to women. PART THE PHYSIOLOGY, DIAGNOSIS, AND MANAGEMENT OF PREGNANCY CHAPTER I. Anatomy of the Pelvis; Development and Anatomy of the Female Generative Organs. THE ANATOMY OF THE PELVIS. The hip-bones together with the sacrum, including the coccyx, compose the pelvis, which forms the basin-like lower portion of the trunk. In the erect position of the body the pelvis is bent obliquely backward from the vertebral column above, so that the crest of the pubis descends nearly to a lev^el with the end of the sacrum. The pelvis is divided into two parts by a prominent rim, named the brim of the pelvis, which is formed on each side by the iliopectineal line continued behind the crest of the pubis and by the curved ridge and promontory of the sacrum. The upper part is formed by the ilia, and includes the widest space of the pelvis which pertains to the abdominal cavity. The lower part is distinguished as the true pelvis, and incloses the cavity of the pelvis. It is a complete bony girdle, formed by the sacrum and coccyx, the ischium and pubis, and a small portion of the ilium. The upper extremity 2 17 . 1 8 PREGNANCY. of the pelvic cavity, corresponding with the brim, is the inlet, or superior strait ; the lower extremity is fhe outlet, or inferior strait. In consequence of the curvature of the sacrum and coccyx the pelvic cavity appears as a curved cylinder, slightly narrowed toward the outlet. It is deepest behind and shallowest at the pubic symphysis. Its lateral wall is deep and vertical. It extends from the iliopectineal line to the end of the ischial tuberosity, and is mainly formed by the body of the ischium with small portions of the ilium and pubis. The anterior depth of the pelvis (height of the symphysis) is 4 cm. (1.57 in.). The lateral depth is 9 cm. (3.54 in.). The posterior depth is 13 cm. (5.12 in.). The pelvic inlet is cordiform, with the notched base con- forming with the base of the sacrum and the rounded apex with the pubes. The outlet, rather smaller than the inlet, when completed by the great sacrosciatic ligaments has the same shape, with the notched base formed by the coccyx and the apex Fig. I. — Female pelvis (one-third natural size) (Dickinson). by the pubic symphysis. Its fore part is the pubic arch, the base of which extends between the ischial tuberosities ; and the sides are formed by the conjoined rami of the pubes and ischia. On each side of the outlet is the deep sacrosciatic notch, formed in front by the ischium, above by the ilium, and behind by the sacrum and coccyx. It is converted into the great and small sciatic foramina by the sacrosciatic ligaments, which also sepa- rate them from the pelvic outlet. The pelvis of the female not only differs from that of the male in accordance with the usual THE AMATOMY OF TflE PELVIS. 19 difference in other parts of the skeleton, but also exhibits impor- tant modifications which relate to the sexual function. The female pelvis is proportionately larger, but of more delicate con- struction. It is proportionately, and often absolutely, of greater breadth, and is of less depth. The ilia spread more laterally, so as to produce greater breadth or prominence of the hips than in the male. The true pelvis has greater horizontal capacity, less depth, and is commonly less curved and less contracted at the outlet. The inlet is larger, less intruded upon by the sacral promontory, and is more circular or transversely oval. The outlet is hkewise larger, with the ischial tuberosities less conver- gent, and with the pubic arch wider, lower, more truly arched, and with the sides more everted. Fig. 2. — The funnel-shaped false pelvis. In the female the sides of the pubic arch are narrower, more flattened, and less ridged than in the male. ^ The hip or innominate bones — in the adult a single piece — are composed, in fetal life and in childhood, of three separate bones, — the ilium, the ischium, and the pubis. The three bones are united by a triradiate cartilage in the acetabulum, which begins to ossify at puberty, the ankylosis being complete in the 1 This brief anatomical description of the pelvis is taken, moditied, from Leidy's *' Anatomy." 20 PREGNANCY. eighteenth year. The descending ramus of the pubis and the ramus of the ischium are also originally united by a cartilage which ossihes at about the eighth year. The bony pelvic girdle in the adult is united by three joints, the symphysis pubis and the two sacro-iliac joints. The former is a .synchondrosis; the junction of the pubic bones by the inter- vening cartilage is strengthened by hgaments above, before, behind, and below the s\Tnphysis. The last named is the strong- est. It is the arcuate ligament of the pubis. The pubic junction will withstand a weight of 197 kg. before rupturing (Selheim). The sacro-iliac joints are true joints (amphiarthroses), with all their characteristic features. The joint surface of the sacrum is broader behind and above than it is before and below, so that the sacrum cannot be pushed forward or downward without separat- ing the innominate bones. The joints are reinforced by com- paratively wxak ligaments anteriorly, but by strong ligaments pos- teriorly, the best developed of which are the sacro-iHac ligaments. The sacro-iliac joints Avithstand a pressure of 160 to 310 kg. The Anatomy of the Pelvis Obstetrically Considered. — To the obstetrician the pelvis is a canal and not a basin, and is to be studied m.ainly in its relation to the fetal body which must pass through it. The false pelvis is of minor im- portance, acting simply as -a funnel -shaped structure to di- rect the present- ing part toward and into the superior strait of the true pel- vis. The ob- stetrical study of pelvic anatomy may be confined to the shape, size, position, and direction of the true pel- vis. Pelvic Shape. — The pelvis might be described as a truncated cylinder, but the description would not be exactly accurate. As a matter of fact, the pelvic canal is of different shapes at different levels, and it is necessary to study certain typical planes of the pelvis The shape of the superior strait. THE ANATOMY OF THE PELVIS. 21 in order lo understand fully the relationship of fetal to pelvic shape in labor. The first of these imaginary planes is laid at the entrance to the pelvic cavity or canal, the pelvic inlet or superior strait, and is bounded by the promontory of the sacrum, the iliopectincal lines, the crests of the pubis, and the upper edge of the symphysis. The shape of the pelvic inlet is cordi- form. In the bays on either side of the promontory rest the important nerve-trunks and blood-vessels of the pelvis, where they are guarded from the pressure of the fetal head. It was thought formerly that the shape of the pelvic inlet was elliptical, but this is only exceptionally the case, as in certain justominor pelves, in which the nerve-trunks and vessels may be subjected to such excessive pressure that disease and disability result. In studying the pelvic canal from above downward it appears that the canal expands below the pelvic inlet and then contracts again as it approaches the outlet. It is convenient, therefore, to lay off a plane at the level of greatest expansion and another at the level of greatest contraction, which are called, respectively, the plane of pelvic expansion and the plane of pelvic contraction. The shape of the pelvic canal at the plane of pelvic expansion, passing through the middle of the sym- Fig. 4. — The diameters of the superior strait. physis, the top of the acetabula, and the sacrum, between the second and third vertebrae, is almost exactly circular, being only 22 PREGNANCY. a trifle larger in its anteroposterior than in its transverse diameter. The shape of the peh'ic canal at the plane of pelvic contraction, passing through the tip of the sacrum, the spines of the ischia, and the lower surface of the symphysis, is distinctly elliptical, being a centimeter longer anteroposteriorly than it is transversely. Finally, the shape of the pelvic outlet, or inferior strait, is cordiform, from the projection forward of the tip of the sacrum and the coccyx. Pelvic Size — In determining the size of an irregularly shaped canal like that of the pelvis it is necessar>^ again to resort to certain typical planes at different levels, and to measure typical diameters in these planes. Beginning with the cordiform pelvic inlet it is obvious that its dimensions may best be expressed by the following diameters : An a?iteroposterior diameter measured from the middle of the promontory of the sacrum to the sym- physis pubis, about 3.17 mm. {yi in.) below its upper edge ; this measurement averages, in the well-developed Caucasian woman, 11 cm. (4.33 in.). A transverse diameter, the longest distance from side to side of the pelvic inlet, measuring on the average 13.5 cm. (5.32 in.), and two oblique diameters, the right from the top of the right, the left from the top of the left sacro-iliac junction to the opposite ilio- pectineal eminences, measuring 12.75 cm. (5.02 in.). At the plane of pelvic expansion it is possible to measure but two diameters, an anteroposterior and a transverse ; the former is 12.75 cm. (5.02 in.), the latter, 12.5 cm. (4.92 in.). At the plane of pelvic contraction the anteroposterior diam- eter is 1 1.5 cm. (4.43 in.), the transverse, 10.5 cm. (4.13 in.). At the inferior strait the anteroposterior diameter, measured from the tip of the coccyx to the lower edge of the symphysis pubis, is 9. 5 cm. (3.74 in.) ; but this is not a fixed measurement, as the coccyx is normally movable and is displaced backward in labor ; the obstet- rical anteroposterior diameter, therefore, is measured from the tip of the sacrum to the lower edge of the symph}'sis pubis ; it is II cm. (4.33 in.). The transverse diameter, measured from one to the other tuberosity of the ischium, is 11 cm. (4.33 in.). Pelvic Position. — By pelvic position is meant the angle or inclination of the pelvis to the trunk and to the horizon. The inclination of the plane of the superior strait to the horizon, as the individual stands erect, is fifty-five degrees, and of the inferior strait, ten degrees. The inclination of the pelvis, however, changes with changes of posture. It disappears in a squatting or sitting posture, and is increased if the individual leans backward. The greater the inclination of the pelvis, the more the axis of the superior strait diverges from the long axis of the uterine cavity, and con- THE ANATOMY OF THE PELVIS. 23 Fig. 5. — The inclination of the pelvis. sequently the greater must be the divergence in direction of the presenting part from that of the rest of the fetal body when the former engages in the superior strait. Much stress was once laid upon this fact, but, by placing a woman upon her side and flexing the thighs upon the trunk, the inclination of the pelvis fig. 6. — Variation in sacral cur\'es : /*, Promontory of sacrum ; C, coccyx. (Trac- ings of sacra in the author's possession.) 24 PREGNANCY. is made practically to disappear. The obliquity of the pelvis, therefore, need not be seriously considered, as a rule, in labor, but the habitual inclination of the pelvis as the woman stands erect must be taken into account in a study of the pelvic deformities of rachitis, lordosis, kyphosis, spondylolis- thesis, and osteomalacia; ,some of the anomalies of labor in these pelvic deformities; and the abnormal relations of the ex- ternal genitalia to the pelvis, whenever the latter shows an excessive or deficient inclination. Pelvic Direction. — By this term is meant the direction of the central .axi?*^ the pelvic canal. It was the custom in a former generation to express pelvic direction by a complicated mathe- matical formula, yielding what was called the "curve of Cams." Not only is this formula unnecessarily comphcated, but it is also- incorrect. The direction of the pelvic canal depends entirely upon the curve of the sacrum, which varies greatly. Taking, at random, -any half-dozen or so of sacra frorh a collection, the utmost diversity'of curvature is seen. The direction of the pelvis may be described with approximate accuracy as a line parallel with the sacral curve, and equally distant at all points from the pelvic wallfe. The Development of the Pelvis. — It may be easier to understand the peculiarities of the adult pelvis if one considers the forces imposed upon it and their influence upon the individual bones and upon the pelvis as a whole. The pelvis is subjected to the weight of the trunk imposed upon it from above, the counter- pressure of the limbs below, and the pull of powerful ligaments, muscles, and joints. The weight of the trunk, transmitted from above downward and from behind forward, tilts the pelvis forward by a rotary movement on its transverse axis and confers upon it the characteristic position or inclination. This force, however, is resisted by the pull of the muscular and ligamentous con- nections between the trochanters of the femora and the tuber- osities of the ischia and by the pressure of the heads of the femora on the acetabula. By the former force the tuberosities of the ischia are pulled apart and the normal width of the pelvic outlet is secured. The sacrum bears the greatest weight of the trunk, and in consequence its top is forced downward and for- ward. It is also pulled forward and downward, even in fetal life, by the extension of the thighs. The natural consequence would be to tilt the lower end of the sacrum and the coccyx back- ward, but they are subjected to the powerful pull forward of the ligaments and muscles attached to them and to the lateral and ante- rior pelvic walls. Hence the sacrum, subjected to these two oppos- ing forces, is bent like a bow between them, and thus acquires its perpendicular curve. As the upper portion of the sacrum moves THE ANATOMY OF THE PELVIS. 2$ do\^^lward anrl forward, it drags with it the posterior superior por- tions of the iliac bones, to which it is attached by the sacro-iliac junctions and by the strong sacro-iliac ligaments. The natural result of the movement of the posterior portions of the in- nominate bones inward, downward, and forward would be to throw outward the anterior extremities of these bones, were they not joined firmly at the symphysis. Subjected to the force behind and restrained by their junction in front, the innomi- nate bones are bent upon themselves, and thus acquire their lateral curve. These few illustrations by no means exhaust the dynamics of the pelvis. The subject will be referred to again in the study of some of the pelvic deformities. The Bony Pelvis in Life Filled with Soft Tissues. — Besides the generative organs, the obstetrical anatomy of the pelvis must Fig. 7. — The pull of the ligaments and the pressure of the femora upon the pelvis (Schroederj. take into account the muscles, ligaments, connective tissue, blood-vessels, lymphatics, and nerves. 26 PREGXAXCY. The Muscles. — The iliopsoas, the obturator internus, and the pyriformis clothe the pelvic walls, modifying the diameters of the pelvic cavit>' and acting as buffers or cushions to protect the child's body in its passage through the birth-canal. The bulky iliopsoas muscles diminish the transverse diameter of the pelvic inlet by 5 cm. (2 in.), thus making the oblique diameters of the pelvic inlet the longest and insuring ordinarily an oblique position of the presenting part, but these muscles are subject to compres- sion and to some displacement under pressure in labor, and, if the pressure is great, the transverse diameter again becomes the longest ; hence the transverse position of the head in ob- structed labors. The coccygeus, the levator ani, the retractor ani, the sphincter ani, the constrictor vaginae, and the transversus perinei are the muscles of the pelvic floor giving the direction to Fig. S. — The pelvis wiih its sou parts (bladder, rectum, uterus and its appendages, having been removed) (from a model in the University of Pennsylvania). the lower part of the parturient tract in labor and directing the presenting part forward, outward, and upward under the pubic arch. The levator ani is by far the most important muscle in the THE ANATOMY OF THE PELVIS. 27 pelvic floor. It is a strong, horseshoe-shaped band of muscle, consisting of two symmetrical halves slung back from the anterior pelvic wall and surrounding the vagina and rectum. It is the chief factor in pushing the presenting part forward away from the perineum and out through the vulvar orifice. It is thus the chief conservator of the integrity of the pelvic floor in labor. Its injury robs the rectum and posterior vaginal wall of their strongest sup- port, allowing them to drop downward, outward, and forward in the rectocele, with which the surgeon has to deal in secondary operations upon so-called lacerations of the perineum. Fig- 9- — The pelvic canal encroached upon by the soft structures (Veit). The ligamentous structures of the pelvis of greatest interest to the obstetrician are the obturator membranes and the sacrosciatic ligaments, which close the pel\-ic walls, help to impart to the canal its shape and direction, and, by their situation at either end 28 PREGNANCY. of the oblique diameters, receive upon their yielding surfaces the greatest pressure from the extremities of the long diameters of the fetal head, — an arrangement much more favorable for the child than would be the compression of the longest diameters of the head between bony pelvic walls. • The Connective Tissue of the Pelvis. — An intimate knowledge of the complex arrangement of the pelvic fascia is not essential Fig. lO. — The pelvic diaphragm from above : a, Ischio-coccygeus muscle ; b, iliac portion of the levator ani ; c, pubic portion of the levator ani ; d, arcus tendineus (Bumm). to the obstetrician. For his purpose it sufifices to remember that the arrangement of the pelvic connective tissue may be compared, roughly speaking, to a six-pointed star centering at the uterus, the three arms on each side being disposed as follows : A lateral Fig. II. — The pelvic diaphragm, seen from below: a, Ischio-coccygeus; b, iliac portion of levator ani ; c, pubic portion of levator ani ; d, urogenital dia- phragm, including muscle of the urogenital trigonum (Bumm). arm running out from the uterus between the layers of the broad ligament and becoming continuous with the subperitoneal connect- THE ANATOMY OF THE J'ELVJS. 29 Fig. 12. — Schematic representation of the superior strait: a. Promontory; b, symphysis; I, I, iliopsoas muscles; 2, 2, rectus abdominis; dotted line, the pelvic inlet (Veit). ive tissue of the lateral pelvic wall; an anterior arm skirting the bladder; a posterior arm skirting the rectum and continuing in Fig. 13. — The plane of pelvic expansion : a. Sacrum ; b, pubis ; c, lateral pelvic wall; i, I, pyriformis ; 2, 2, obturator internus ; 111, nt, obturator menibrane ; I, i, sciatic nerve. 30 PREGNANCY. the mesorectum to the posterior pelvic wall. Branching pro- cesses, in addition, follow the round ligament to the groin and Fig. 14. — Plane of pelvic contraction: a. Tip of sacrum; b, b, ascending ramus of pubis; c, c, ischium; I, I, obturator internus. mons veneris, the vessels and nerves escaping through the sacro- sciatic notch to the buttocks, the three canals of the pelvis — the urethra, vagina, and rectum — to the subcutaneous connec- tive tissue of the external genitalia and perineum. Fig. 15. — Sacrosciatic ligaments. The BIood=vessels. — The ovarian arteries, leaving the aorta, enter the pelvis on their respective sides and, passing between the THE ANATOMY OF THE PELVIS. 31 laminae of the broad ligament a short distance under its upper edge, send branches to the ovaries and tubes and a branch to the fundus, while the main trunk turns at a right angle downward Fig. 16. — The pelvic ligaments from above: a. Tip of sacrum; b, subpubic ligament ; c, tuber ischii ; d, sacrosciatic notch ; e, aperture for femoral vessels and nerves ; h, Poupart's ligament (Hart). alongside the uterus, to anastomose with the uterine artery, giving off on its way numerous branches to the uterine wall. The uterine artery on both sides passes downward from the anterior trunk of the internal iliac to the neck of the uterus, gi\ang off a Fig. 17. — The pelvic ligaments from below. Lettering same as above, except X, sacrosciatic foramen. large branch to the lower uterine segment and cervix, the circu- lar artery of the cervix, and numerous smaller branches to the uterine wall as it rises to meet the ovarian artery. The veins of 32 PREGXAXCY. Fig. 1 8. — The arteries of the uterus and ovaries : O.A., Ovarian artery ; b, artery of the round hgament ; b' , branch to the tube; c, c, c, branches to the ovary; (/, continuation of main trunk; e, branch to the comu ; U.A., uterine artery; e, main trunk ; f, bifurcation ; g, vaginal branches ; h, vaginal branch from the cervical artery (Hyrtl). Fig. ig. — The veins of the uterus (Hyrtl). THE ANATOiVY OF THE PELVIS. 33 Fig. 20. — Distribution of lymphatics, externally : b. Inguinal glands ; c, d, ducts of the labia; e, lymphatics of the mons veneris (Sappey). Fig. 21. — The lymphatic ducts of the uterus and its appendages injected, in a woman who died shortly after delivery. 3 34 PREGNANCY. '""16 15 Fig. 22. — Lymphatics of the pelvic viscera and abdomen : A, Aorta; B, B, iliac arteries ; C, C, the bifurcation and two branches of the iliac arteries ; D, vena cava ; E, left renal vein; F, right renal vein; G, iliac veins; H, H, ureters; I, rectum; K, uterus; L, cervix; M, M, vaginal walls; N, N, Fallopian tubes; P, P, ovaries; Q, Q, round ligaments ; i, Deep lymphatic vessels of the right kidney, and ganglia into which they empty; 2, 2, 2, 2, superficial lymphatic vessels ; 3, 3, 3, 3, the same ; 4, two ganglia that receive these superficial vessels ; "7, 7, subovarian plexus of lymphatics ; 8, 8, ducts leading from this plexus ; 9, 9, the same ; lo, 10, II, II, glands receiving these ducts ; 12, 12, 12, 12, lymphatic ducts, originating in the fundus uteri, and terminating in the same glands as the ovarian ducts; 13,13, ducts from the anterior surface and sides of the uterus ; 14, I4, glands into which they empty ; 15, 15. ducts originating in cervix and upper part of vagina ; 16, 16, glands into which they empty; 17, 17, efferent vessels of these glands; 18, 18, lymphatic ducts from posterior surface of the uterus and glands into which they empty ; 19, lumbar gland (exceptional) ; 20, gland into which occasionally a duct fr^m lower uterine segment empties (Sappey). THE ANATOMY OF THE TEL ITS. 35 Fig. 23. — The nerves of the pelvis: A, Abdominal aorta; B, lumbar vertebrae with intervertebral discs; C, the right portion of the sacrum sawn after removal of os innominatum ; D, ureter ; E, pyriformis muscle cut at its exit from the pelvic cavity ; F, the curve of the rectum, corresponding to the anterior surface of the sacrum ; H, virginal uterus feebly developed ; A', right ovary displaced somewliat upward ; Z, bladder; M, levator ani muscle, cut in part ; jV, ischiocavernosus muscle ; O, corpus cavernosum clitoridis, joining on the other side the clitoris, covered with nerve-fila- ments ; P, symphysis pubis (the whole body being inclined forward, it has become hori- zontal); T, fimbriated end of Fallopian tube ; I, I, Lumbar 7te>fes, passing out of the intervertebral foramina to form the lumbar plextis; the lower lumbar and the upper sacral nerves joining to form the sacral plexus in front of the pyriformis muscle ; 2, sacral plexus ; 3, gluteal neii'es cut ; thepudic nerve springing by several roots from the plexus 36 PREGA'.^XCY. the pelvic organs of chief interest to the obstetrician are the large trunks between the layers of the broad ligament alongside the uterus and the complicated pampiniform plexuses in the neigh- borhood of the ovaries. The lymphatic ducts of the pelvic organs are of interest mainly in the part they play in the absorption of the involuting uterus and by conveying septic micro-organisms and the products of their activity into the system. The lymph-spaces of the uterus, lying between connective-tissue bundles and clothed with endo- thelial cells, empty by means of ducts into the pelvic system of lymphatic glands. The most important groups of the pelvic lymphatic glands are the uterine, obturator, hypogastric, lumbar, sacral, and inguinal. It is interesting to note that the lymphatic ducts of the lower fourth of the vagina terminate in the inguinal glands. The enlargement, inflammation, and suppuration of the inguinal glands, therefore, indicate infection of the parturient outlet. The nerves of the generative organs are derived from the spinal and the sympathetic systems. The sexual processes, however, of ovulation and of menstruation and the action of the' uterine muscle in labor are controlled by the sympathetic nerves, derived from the abdominal aortic plexuses one on each side of the aorta just above the pelvic brim, and from the renal plexuses in the angle made b}- the junction of the renal arteries with the aorta. The clinical observation that paralysis of the spinal nerves supplying the pelvic organs in nowise interferes vnXh. gestation and labor, and the experiments on bitches of resecting the lumbar cord and seeing the animals exhibit rut, become gravid, and bear pups, show what a subordinate part the spinal nerves play in the sexual processes of the female. formed by the lower sacral nerves; 5» fine twigs passing from the pudic nerve to the ischiocavernosus muscle ; the main trunk goes under the symphysis, and ends as the dorsal nerve of the clitoris (21); 6, 6, branches of communication which carry s}Tnpathe- tic twigs to the spinal nen-es and spinal twigs to the hypogastric plexus of the sympathe- tic; 7, principal trunk of the sympathetic in front of the lumbar vertebrae ; S, continuation of the sympathetic in front of the sacrum; 9, 9, aortic plexus : lo, hefnorrhoidal plexus, following the arteries of the same name ; II, superior hypogastric plexus, or iliohypo- gastric plexus, which receives many spinal and sympathetic branches ; 12, inferior hypogastric plexus, communicating with I3, anto-ior sacral plexus, made up of spinal and sympathetic branches ; 14, from the many ganglia placed in this plexus it has a network appearance ; 15, inferior rectal twigs, which pass down even to the sphincter, where they form a network covered by the levator ani ; 16, vagijial plexus ; 17, that part of the inferior hypogastric plexus in the shape of a fine network at the upper end of the vagina gives branches to the bladder, the Fallopian tube, and the clitoris ; 18, nerve twigs which run on the side wall of the uterus, giving branches to it, upward to the Fallopian tube and ovaiy, where they join the nerves following the ovarian artery, which correspond to the spermatic plexus in man; 19, vesical nerves; 20, uterine plexus ; 21, dorsal nerve of clitoiis, which joins with the cavernous plexus of the clitoris from the sympathetic to the glans clitoridis (Rydygier). THE FEMALE SEXUAL ORGANS. THE FEMALE SEXUAL ORGANS. The development of the sexual organs may be briefly de- scribed as follows : The development of the genito-urinary organs up to a certain point is common in both sexes. In late stages the duct of Wolff almost disappears in the female, while in the male it constitutes the vas deferens ; the Miillerian ducts, on the contrary, atrophy in the male, but form Fallopian tubes, uterus, and vagina in the female. The accompanying illustrations (Figs. 24, 25, 26, and 27) may aid the student to understand the subdivision of the primary cloacal chamber. As they refer to the female embryo, the Wolffian ducts are omitted. Fig. 26. Fig. 27. Fig. 24. — d. Cloaca which has opened into primitive hind-gut, and commu- nicates with the rectum and allantois; the posterior portion, all, of the latter has commenced to dilate to form the urinary bladder; m, duct of Miiller; r, rectum. Fig. 25. — The cloaca has divided into a ventral portion, su, the urogenital sinus, which communicates ventrally with the urethra, u, and the bladder, 6, and more dorsally with v, the vagina, formed by fusion of the ducts of Miiller; ;-, rectum. Fig. 26.- — The perineum or tissues separating the rectum from the urogenital sinus are well developed; the neck of the bladder has become constricted to form the primitive urethra, and is separated from the vaginal passage, though both open into the common urogenital sinus, 5, and the clitoris, c (in the male the rudiment of the penis), has appeared; r, rectum. Fig. 27. — The urogenital sinus of the female, 5, remains as the cleft between the sides of the external aperture of the labia minora; it communicates in front with the bladder, h, and dorsally with the vagina, v; y, rectum. The essential sexual glands develop in both sexes in close association with the ducts of Wolff and Miiller, and in the neigh- borhood of the mesonephros. The cells lining the abdominal region of the primitive celom. early become differentiated as its lining epithelium ; in most regions they quickly become flat scales, but over the bulging of the intermediate cell-mass they enlarge and become columnar in form. These enlarged cells remain for some time over all of the projecting surface of the intermediate cell-mass, and even extend beyond it upon the outer side of the developing mesentery. They soon become flattened over most of the mass, but remain columnar and multiply for some time on its inner and outer sides. On the latter they give ?8 PREGNANCY. origin to the Miillerian duct and some segmental tubes and soon cease to be distinct ; on the former they constitute the primi- tive germinal epithelium. The mesoblast lying beneath this epithelium gives rise to the blood-vessels and connective tissue (stroma) of the ovary or testis, as the case may be. At this stage it is difficult or impossible to detect the sex of the em- bryo from the structure of the sexual glands. In the female some cells of the germinal epithelium enlarge to form the primitive ova. Surrounded by other cells from the germi- nal epithelium, they-grow into the ovarian stroma as the egg-tubes or cords and give rise to the primitive Graafian follicles. Fig. 28. — Diagrams to illustrate the development of the internal genital organs in both sexes. I, Hermaphrodite or undifferentiated condition : d. Ovary or testis, lying upon the tubules of the Wolffian body ; W, Wolffian duct ; M, duct of Miiller ; S, urogenital sinus. 2, Modifications in the female : T, Primitive Miillerian duct, forming the Fallopian tube and, developing fimbrise, F, around its peritoneal opening ; h' , ovarian hydatid ; U, uterus formed by fusion of the posterior ends of the ducts of Miiller; S, urogenital sinus; O (ansvrering to D in I), ovary; P, parovarium, or remnant of Wolffian body and duct. 3, Modifications in the male : H, Testis (corresponding to Z> in I) ; E, epididymis ; h, hydatid of Morgagni ; a, vas aberrans ; V, vas deferens, or Wolffian duct ; u, uterus masculinus, the remnant of the lovt^er ends of the fused ducts of Miiller ; S, urogenital sinus (from Landois and Stirling). The testicle is distinguishable from the fetal ovary about the eighth week. The cells which in the female form ova, in the male subdivide and give origin to the spermatozoa, while the cells which correspond to the lining cells of the female egg-tubes develop the lining cells of the seminiferous tubules. These canals may be detected in the human embryo of ten weeks ; they branch, and during the third month are collected into groups, indicating the lobular subdivision of the adult testis. The genital cord is a cylindrical mass in which, in both sexes, the ducts of Miiller and Wolff become imbedded near the uro- genital sinus. The four ducts (two from each side) are at first THE FEMALE SEXUAL ORGANS. 39 separate. The Miillerian ducts coalesce at their lower ends and in the female enlarge to form the vagina and the posterior por- tion of the uterus ; in the male the lower fused portions of Miil- lerian ducts remain as the prostatic vesicle, or uterus masculinus. Fig. 29. — Diagrammatic outline of the Wolffian bodies and their relation to the ducts of Miiller and the reproductive glands : of. Seat of origin of ovary or testes ; ■w. Wolffian body; 70, Wolffian duct; w, w, duct of Miiller; gc, genital cord; ug, urogenital sinus; /, rectum; d, cloaca (from Allen Thompson). Fimbria. Fig. 30. — Diagram illustrating changes taking place in development of female generative organs (modified from Allen Thompson). In the female the anterior portions of the ducts of Miiller form the upper part of the body of the womb and the Fallopian tubes. In the female the Wolffian ducts almost entirely disap- pear, but traces of them may be found as the canals of Gartner. 40 PREGNANCY. Pathological development and distention of these ducts some- times give rise to vaginal cysts, which may obstruct labor. Meanwhile most of the Wolffian body (mesonephros) disap- pears on each side, but remnants of it may be found in adults. In the female they constitute the parovarium (epoophoron, or body of Rosenmiiller). The Development of the External Genitals. — The forma- tion of the cloaca is common to both sexes, as is also its separa- tion into an anal and a urogenital portion. The urogenital sinus is at first narrow and deep, but soon becomes shallow, and meanwhile the perineal tissues separate it more and more from the anus. Before the subdivision of the cloaca a genital emi- nence appears at its ventral or anterior end about the sixth week. On each side of the cloacal slit outgrowths of skin and Fig. 31. — To illustrate the development of the human external genitals: I. h. Genital eminence ; r, cloacal aperture ; s, tail or coccyx of embryo. 2. h, Genital eminence; r, cloacal opening; 7v, commencement of labia majora or scrotum, accord- ing to sex ; s, embryonic tail. 3. Next stage, practically permanent in the female ; c. Genital eminence (clitoris); /, nymphse ; L, labia majora; a, anus. 4. Later or male condition : P, Penis ; R, edges of embryonic folds enfolding to inclose the penial urethra ; .S", scrotum ; a, anus. 5 and 6 illustrate the descent of the testicle (from Landois and Stirling). subcutaneous tissue (Fig. 31,1) become prominent. At the eighth or ninth week there is a groove in the under (posterior) side of the genital eminence, with well-marked side-walls leading back to open into the cloaca. The development of the perineum divides this groove (during the third month) transversely into a smaller anal opening and a larger urogenital. This condition is but slightly modified in the female. The genital eminence in that sex remains small and constitutes the clitoris. The side walls remain separate and form the labia minora, while the cuta- neous folds, enlarge and become the labia majora (Fig. 31, 3). The urogenital sinus is, therefore, permanent in woman, and forms the vestibule, which has in front of it the clitoris, and, opening THE FEMALE SEXUAL ORGANS. 41 into it, the urethra and vagina. The skinfolds remain separate in the female to form the labia majora. ^ The genital organs and structures of woman are divided into the external and the internal genitalia. The former, described often as the genitalia, pudendum, or vulva, comprise the mons veneris, the labia majora, the labia minora, the vestibule, with Fig. 32. — Diagram of the genitalia (Diclcinson). the urethral orifice, and the clitoris ; the latter, the hymen, the vagina, the uterus, the Fallopian tubes, and the ovaries. The Mons Veneris and the Labia Majora. — The mons veneris is a flat protuberance over the symphysis pubis, consisting of fat and connective tissue covered with a tough skin clothed with coarse hair. In females the upper border of the hairy region ^ The description of the development of the sexual organs is taken, with modifi- cations, from Newell Martin's article in " The American System of Obstetrics," edited by the author. 42 PREGNANCY. is a horizontal line ; in males the hair rises in a triangular shape to a point upon the median line of the abdominal wall. The labia majora are folds of skin containing fat, connective tissue, and involuntary muscle-fibers, continuous with the mons veneris and uniting below an inch in front of the anus. They surround the urogenital fissure. Their points of junction above and below are called the anterior and posterior commissures. Just within the latter there is a crescentic transverse fold of skin, called the fourchet. The region between the fourchet and the posterior commissure is the fossa navicularis. The Labia Minora, or Nymphse. — Just below the anterior com- missure of the labia majora the nymphae begin on each side as two leaflets of delicate skin ; one, the upper, with its fellow of the other Fig. ■^2i- — Hypertrophied nymphae (author's case). side, constituting the prepuce of the clitoris ; the lower leaflet, with its other half, forming the frenum of the prepuce. Uniting below and to the outer side of the clitoris, the nymphae run downward to merge into the labia majora at about their middle or lower third. The labia minora are often asymmetrical. They lie apposed to each other in the middle line, completely covered by the labia majora. They vary much in size. In some races CHottentots) they are enormous, projecting far beyond the labia majora. As an exception this condition is sometimes seen in the Caucasian race. The skin of the nymphae is in a transition stage between mucous membrane and skin. It merges on its outer side into the delicate skin of the inner surface of the labia majora, and on its inner side into the mucous membrane of the THE FEMALE SEXUAL ORGANS. 43 vestibule. The venous spaces and the unstriped muscular fibers in the nymphae resemble the structure of erectile tissue. The vestibule is the space between the clitoris, nymphae, and vaginal entrance. It is pierced in its mid-line by the urethral orifice, — the external meatus. The bulbs of the vestibule are two masses of venous plexuses about an inch long, lying along the sides of the vestibule below the clitoris and within the nymphae. They are the homologues of the corpora spongiosa in the male. In sexual excitement, by muscular compression of their efferent vessels, they become turgid and erect. The clitoris has the structure and anatomical features of the penis, but in miniature, and modified by the cleft below, the absence of the urethra, and the separation of the spongy bodies into the bulbs of the vestibule. The cavernous bodies of the clitoris are erectile. The glans of the clitoris is surrounded at its base by sebaceous follicles secreting a smegma, which may be confined by preputial adhesions, and is likely to cause irritation by its decomposition. The urethral orifice or external urinary meatus is a round, slit-like or star-shaped opening on an eminence, usually crescentic in shape, sometimes with two lateral labia, occasionally surrounded by four tubercles. Directly below this eminence is the tubercle representing the end of the anterior column of the vagina. Just within the orifice of the urethra on its posterior wall are two efferent ducts (Skene's), 12-20 mm. long, communicating with small groups of tubular glands, said to be homologues of the pros- tatic glands. Bartholin's glands, or the vulvovaginal glands, are muco- serous, racemose glands about a third of an inch in diameter, lying under the mucous membrane of the lateral vaginal walls and emptying by long, slender ducts below the vestibule and to either side of the vaginal entrance. The Hymen. — The crescentic septum, occluding usually the posterior portion of the vaginal entrance, with the concavity of its opening directed upward, but presenting often an annular, cribriform, cordiform, crenelated, or cleft appearance, is a fold of mucous membrane reinforced by fibrous tissue, usually ruptured with ease, but occasionally so firm and unelastic that it even resists the impact of the descending head in labor. The hymen is usually torn at the first coitus, sometimes by gynecological examinations, or by masturbation. It is partially destroyed in labor, the remnants persisting as isolated protuberances around the vaginal orifice, — the caruncul^e myrtiformes. The Vagina. — The vagina is a musculomembranous canal extending from the hymen to the base of the vaginal portion of 44 PREGNANCY. the cervix uteri. The posterior wall of the canal is about 9 cm. (3.5 in.) long, the anterior 6.5 cm. (2.5 in.). The axis of the canal is slightly sigmoid in shape, but corresponds quite closely to the axis of the pelvic canal. The upper portion of the canal is expanded into the vaginal vault, the recesses being particu- larly well marked anteriorly and posteriorly, constituting the anterior and posterior fornices. The vagina, therefore, is flask- shaped. The vaginal walls are composed of three structures, — the mucous membrane, the muscular coat in two layers (the inner circular and the outer longitudinal), and a fibrous sheath. The anterior and posterior walls should be in contact, while the lateral walls are thrown into folds which give a transverse section of the vagina the shape of the letter H. The mucous membrane is covered with squamous epithelium, and with numerous papillse, but has no glands except a few tubular structures in the upper part of the canal. The mucous mem- brane is thrown into numerous transverse folds or rugae, most marked upon the anterior wall and in nulliparous women. There is an anterior and a posterior cord-like process in the median line, the anterior and posterior columns of the vagina, indicating the lines of junction of the ducts of Miiller. The Uterus. — The uterus is a hollow, muscular organ, in the adult virgin measuring 7.5 cm. (3 in.) in length, 4 cm. (1.6 in.) in breadth, and 2.5 cm. (i in.) in its anteroposterior diameter. In shape the uterus is a flattened, pyriform body, the anterior wall be- ing almost perfectly flat, the posterior more convex. It is divided into the body, the isthmus, and the neck, or cervix. The first occupies about three-fifths of its length, the last, two-fifths. In structure the uterus consists of a muscular wall with a mucous lining and a peritoneal covering. The muscle is unstriated and is arranged, roughly speaking, in three layers, — an external, a middle, and an internal. The middle layer constitutes the bulk of the wall ; its fibers are arranged in a somewhat spiral form, though no very definite arrangement is to be distinguished. The fibers of the inner and outer layers are arranged in longitudinal and circular bands. The mucous membrane of the body of the uterus is composed of columnar, ciliated, epithelial cells, resting upon a delicate basement membrane. The cilia of the uterine epithelium lash in the same direction as those of the tubes, namely, from within outward, or from above downward. ^ As there is no submucous tissue, the mucosa of the uterus rests di- rectly upon the muscle. The uterine mucous membrane is richly supplied with tubular glands, divided in their lower ends 1 This has long been a disputed point. See Mand!, " Ueber die Richtung der Flimmerbewegung im menschlichen Uterus," " Centralbl. f. Gyn.," No. 13,1898. THE FEMALE SEXUAL ORGANS. 45 usually into two branches or forks. In the cervix the mucous membrane is thrown into longitudinal folds \\ ith lateral branches, — the arbor vitae of the uterus. The epithelial cells in the upper two-thirds of the cervical canal are columnar, ciliated, in the lower third stratified, squamous cells. In addition to the tubu- lar glands of the uterine body the cervical mucous mcmibrane contains wide mucous crypts, the orifices of which easily become obstructed, so that they are converted into retention cysts, which commonly stud the cenax in cases of old inflammation or in- jury, — the glands or follicles of Naboth. Fig. 34. — Perpendicular section througii normal uterine mucous membrane ; showing glands and interstitial tissue (Doderlein). The uterine cavity is normally fusiform, widened in its upper part into a triangular space, most contracted below at the level of the internal os uteri. It has three openings, the internal OS communicating with the cervical canal and the two uterine orifices of the Fallopian tubes. The cervical canal in the nul- liparous woman is a slender ovoid in shape, contracted at its upper and lower boundaries. — the internal and the external os uteri. In a woman who has borne children the cervical canal is 46 PREGNAXCY. often funnel-shaped, the external os, or the cavity just above it, being the most expanded portion. The cenix itself is divided into two portions, the vaginal and the supravaginal. The former projects into the vaginal vault: SupnA VAGINAL <-0^ PoRTIOli ^ ^ PORTIOfi PoRnotJf // Fig. 35. — Diagram illustrating the relations of the uterus to the vagina, bladder, and peritoneum (DickinsonJ. Fig- 36.— Uterus didelphys : a, Right segment ; b, left segment ; c, d, right ovarj and round ligament ; /, e, left ovary and round ligament ; g, j, left cervix and va- gina ; k, vaginal septum ; h, i, right cervix and vagina. the latter is attached to the vaginal walls and extends a short distance above their attachments. The anatomist commonly speaks of the supravaginal portion as being entirely above the THE FEMALE SEXUAL ORGANS. 47 vaginal attachments and extending to the isthmus. This view, however, is erroneous, as it assumes that the lower uterine seg- ment is a part of the cervix. It is usual to describe an anterior, shorter lip of the cervix and a longer posterior one. This description is more accurate in the parous woman with a bilateral tear of the cervix. As may be seen in figure 35, the supravaginal portion of the cervix is longer anteriorly than posteriorly. The normal position of the uterus F'g- 37- — Uterus bicornis duplex : a, a, Double entrance to vagina; b, meatus urinarius ; c, clitoris ; d, urethra ; e, e, double vagina ; f, f, external orifices of uterus ; g, g, double cervix ; h, h, bodies and horns of uterus ; i, i, ovaries ; k, k, tubes ; /, /, round ligaments ; tn, m, broad ligaments. is almost horizontal as the woman stands erect. It is slung between the layers of the broad ligament, supported by lateral, anterior, and posterior musculofibrous bands and folds of peri- toneum. It is so freely mobile that it rises and falls with every breath the woman draws. The uterus is formed by the junction and fusion of the two ducts of Miiller. An arrest of development in embryonal life 48 PREGXANCY. results in a partial junction or a complete failure to unite on the part of the ^vliillerian ducts. The consequent deformities of the uterus may occasion abnormalities ia pregnancy or complications in labor and after-delivery. If there is complete disjimction of the Fig. 38. — Uterus bicomis unicollis : a. Vagina ; b, single neck ; c, c, horns ; d, d, tubes ; e, e, ovaries ; f, f, round ligaments. Fig. 39. — Uterus cordiformis : a, Indented fundus ; b, b, tubes ; c, c, round liga- ments ; d, central longitudinal ridge on posterior wall of uterine cavity ; e, e. lateral ridges of same ; /, internal 05 ; g, g, cervix. hvo ducts, the deformit}- is known as uterus didelphys (Fig-. 36). If there is an outward junction but a complete disassociation of the two tubes except for their superficial union externally, the condi- tion is called uterus bicomis duplex (Fig. 37). If there is a junction THE FEMALE SEXUAL ORGANS. 49 at the cervix but separation of the ducts above, there is a uterus bicornis unicolHs (Fig. 38). There may be complete junction of Fig. 40. — Uterus incudiforrais. the two Miillerian ducts, but the fusion of the two canals is incom- plete; a uterus subseptus or semipartitus is the result. Finally, Fig. 41. — Schematic drawing of double vagina and single uterus: ^, Left vagina; B, right vagina; C, cervical septum. Fig. 42. — Double vagina. the form of the uterus may indicate its double origin: there may be a uterus cordiformis (Fig. 39) or a uterus incudiformis (Fig. 50 PREGNANCY. 40). Occasionally one duct of Miiller develops normally, while the other is present as a mere rudiment. There is, in consequence, a uterus unicornis ((Fig. 43). The vagina is double in uterus didelphys and often in uterus bicornis duplex. The duphcity of the birth-canal may be con- Fig. 43. — Uterus unicornis : LH, Left horn ; L T, left tube ; Lo, left ovary ; Z Zr, left round ligament ; JiH, right horn ; H T, right tube ; Ro, right ovary ; R Lr, right round ligament. fined to the vagina (double vagina) or it may affect the cervix without involving the rest of the uterus, — uterus biforis (Fig. 41). The oviducts, or Fallopian tubes, are tubular structures about 10 or 12 cm. (3.93 or 4.5 in.) long, running from the cornua of the uterus at the upper edge and between the layers of Fig. 44. — 111 development of right side of uterus; congenital lateral flexion. the broad ligament outward, upward, and at their outer extremi- ties downward and backward to the free surface of the ovary. The canal of the tube begins in the uterine wall as a fine open- ing (ostium internum); it expands to about 2 mm. (0.079 ^^•) THE FEMALE SEXUAL ORGANS. 51 in diameter, becomes wider as it runs outward, again contracts where it passes the ovary, widens again to a distinct opening 4 mm. (o. 157 in.) in diameter (ostium abdominale) into the apex of the pavilion, or infundibulum, a funnel-shaped expansion at its outer extremity surrounded by fringed processes, — the fimbriae. ^ The fimbriated extremity is connected with the ovary by the tubo-ovarian ligament. The tube has three coats, — a mucous, muscular, and serous. The mucous membrane of the tube consists of a single layer of columnar, ciliated, epithelial cells, tlie cilia lashing toward the uterine cavity. The membrane is thrown into deep longitudinal Fig. 45. — Longitudinal section of Fallopian tube, exposing the complicated longitu- dinal plications of the mucosa which expand into the fimbriae (Sappey). folds, becoming more complex as the fimbriated extremity is approached. There are no glands in the mucous membrane. The muscular coat consists of circular fibers of unstriped muscle, with an outer, ill-developed layer of longitudinal fibers. The serous covering is continuous with the serous covering of the broad ligament. The ovaries are almond-shaped bodies var^-ing in size in differ- ent individuals and under different circumstances, but having aver- age diameters of 3.5 cm. (1.38 in.) in length, 2 cm. (0.79 in.) in width, and 1.5 cm. (0.54 in.) in thickness. They are attached to the posterior layer of the broad ligament by the hilum. The ovary is a gland secreting eggs. It has, therefore, a gland-struc- ture, stroma, parenchyma, and gland-spaces. Tiiere are, how- 1 Older anatomists divided the tube into the isthmus, .omprising the inner third, the ampulla, the outer or expanded portion, and the fimb iae. 52 PREGNANCY. Fig- 46. — Normal Fallopian tube, uterine end : in, Mucosa ; /, lumen of canal ; t, tube-wall. Fig. 47. — Normal Fallopirn tube, section near abdominal end : t. Tubal wall V, villus-like plications. THE FEMALE SEXUAL ORGANS. 53 ever, certain distinctive peculiarities al^out this gland. It is not covered by peritoneum, but by a modified form of cells resembling those of mucous membrane, — the germinal epi- thelium. The gland-spaces have no ducts, but excrete their contents by a rupture of their walls. The body of the ovary is divided into a cortex and a medulla. The former contains the Fig. 48. — Section through part of ovary of adult bitch : :> CHAPTER II. The Methods, the Postures, and the Implements for the Examination of Women. Palpation of the pelvic organs in women is most often practised by a digital examination of the vagina, assisted by counterpressure upon the lower abdomen {combined vaginal and abdominal examination; bimanual examination). The patient is usually placed upon her back, preferably on a specially con- structed table, with the buttocks projecting slightly beyond its edge, the trunk flexed just above the sacrum, the pehas slightly elevated, the thighs well flexed upon the abdomen, the legs upon Fig. 51. — Instruments laid out for routine office work: A Sims', skeleton, Goodell, and Collin's speculum; a repositor, uterine sound. Emmet's curetment forceps, Thomas' applicator, a single tenaculum, and two dressing forceps of different lengths. The instruments have been boiled, are laid on a clean towel upon a glass-top table and covered with another towel so that they shall not alarm the patient. If the temperature of the examining room is over 70°. as it should be. the instruments need not be warmed before introduction into the vagina. If the room is cold, they should be momentarily dipped in the water boiling in the sterilizer. Immediately after use they are washed, boiled again, dried, and laid out as before. the thighs, the knees widely separated, and the feet supported upon stirrups not too far apart. This posture relaxes the ab- dominal muscles and removes the intestines from the pelvic cav- ity. The lower bowel and the bladder should be empty. Corsets should be removed and the clothing loosened around the waist. A sheet is so arranged about the patient that her limbs and body are covered and her underclothing is concealed from view, but ready access to the genitalia by touch and sight is permitted. 56 PREGXANCY. If a suitable table is not at hand, the patient may be arranged across a bed with the feet supported on chairs. The physician cleanses his left hand and anoints the first two fingers with an unguent. The best for the purpose is composed of glycerin and Iceland moss, scented with oil of roses. ^ If there is leukorrhea. a foul discharge, a suspicion of gonorrhea or s>^hilis, a short rubber glove without a gauntlet should be worn. The forefinger approaches the \'ulvar orifice in such a manner that it first comes in contact with the posterior commissure, which is pushed backward toward the sacrum as the finger enters Fig. -Patient in the dorsal gynecological position, with sheet draped to protect the underclothing, but exposing the genitalia. the vagina. Unless care is exercised about this point, the ves- tibule and the region around the clitoris, the most sensitive por- tions of the external genitaha, may be first touched before the vaginal orifice is found, causing the patient unnecessary pain. In inserting the finger into the vagina it should be remembered that the canal runs backward toward the sacrum, and not upward in the axis of the trunk. As soon as the cervix is located, pres- sure is made upon the lower abdomen w^th the fingers of the free 1 A glycerin jell}', a jelly of cucumbers and hydrastis, a thick mucilage of quince seeds, or plain glycerin are all preferable to petrolatum, which stains linen and clothing. POSTURES AND IMPLEMENTS FOR EXAMINATION. 57 hand to locate the fundus uteri and to press it downward toward the linger in the vagina, until the corpus uteri is caught between the lingers of the hand above and the linger in the vagina, which has been shifted from the cervix, against which its palmar surface first rested, to the anterior vaginal vault. In this way the posi- tion, size, shape, consistency, and mobihty of the uterus are deter- mined. To palpate the appendages on the left side, the middle finger of the left hand is inserted alongside the forefinger, because thus a half-inch in length is gained, the third and little lingers are flexed in the palm of the hand, the thumb is extended, and the hand is semi-supinated. The ex- tended fingers of the right hand are placed with their tips in a line above Poupart's ligament, and perpendicular to it, well outward toward the anterior spine of the ilium, with the palmar surfaces of the fingers directed downward and inward. This hand is semi- pronated. Pressure is exerted by the external hand downward and inward, until the ovary is caught between the external and internal fingers, and the tube can be rolled between them. To ex- amine the appendages on the right side, the first two fingers of the right hand must be inserted in the vagina and the fingers of the left hand are used externally. It is sometimes helpful to pull the uterus down by a single or double tenaculum in order to pal- pate it and its appendages, but in the vast majority of cases more can be accomplished by pres- sure from above than by traction from below, and every one should aim to dispense with the tenaculum in a combined exam- ination, for it causes unnecessary traumatism and may be re- sponsible for infection. As the woman lies upon her back it is usually advisable to follow the vaginal by a rectal examination. The forefinger, pro- tected by a thin rubber finger-cot, is well anointed and is passed into the rectum its full length. Pressure is made above the pubis by the free hand, as in a combined vaginal and abdominal exam- 1 \ Fig 53. — Short rubber glove for vaginal examinations. 58 PREGNANCY. ination. To palpate the uterine appendages, the left forefinger is used for the left side of the pelvis, the right forefinger for the right side, counterpressure being made in the iliac regions, as already described. It may be desirable to make a combined rectal, vaginal, and abdominal examination, which is accom- phshed by inserting the forefinger of the left hand in the rectum, the thumb in the vagina, and by making pressure with the free hand on the lower abdomen. The cervix and lower uterine seg- Fig. 54. — Bimanual examination. ment can then be grasped between the thumb and the fore- finger. It is sometimes necessary to examine a patient in the erect posture — for example, to determine the degree of prolapsus uteri. For this purpose the woman's skirts are raised above her waist and are pinned behind or are removed. A sheet is pinned around her waist, draped so that it falls to the ground, and the two edges overlap in front six to twelve inches. The patient stands with her legs apart. The examiner kneels on his right knee, facing the patient; the left hand is inserted under the sheet, POSTURES AND IMPLEMENTS EOR EXAMINATION. 59 through the opening in the front, and the forefinger is passed into the vagina, the physician's elbow being supported by his knee. Palpation of the abdomen should constitute a part of every routine examination. Tumors or other abnormalities may thus be detected which might not be appreciable in a vaginal or a combined examination. Abnormal mobility of the kidneys is overlooked in a considerable proportion of women if abdominal palpation is omitted. The patient is prepared for abdominal palpation b}- removing the corsets, loosening the skirts and the underclothing about the waist, and exposing the skin from the sternum to the pubis. Fig. 55. — Abdominal palpation. The woman lies fiat upon her back, with the knees slightly ele- vated and the feet supported. The examiner stands beside her and with outstretched hands makes pressure at first lightly, then more deeply from the flanks toward the median line, and from top to bottom of the abdomen. Deep pressure with the finger-tips may be needed in certain areas. The contour of an abdominal tumor may be determined by grasping it as one grasps the fundus uteri in Crede's method of expressing the placenta. By approximating the finger-tips from mthout inward and at the same time making deep pressure the abdominal walls are lifted away from the abdominal contents. In this way mere obesity is differentiated from an intra-abdominal tumor. To palpate the kidneys the patient should be made to sit bolt upright, upon the examining table, with the abdomen freely 6o PREGNANCY. exposed, the back and head supported, the arms hanging loosely by her side, and all the muscles relaxed. The ex- aminer, standing beside her, places one hand on the lumbar region and slips the fingers of the other under the floating ribs in front. In this manner the kidney is caught between the two hands and its mobility can easily be tested. Another posture frequently used for palpation of the kidneys is assumed by the patient, seated, leaning forward, with the upper portion of her trunk supported by a nurse. The examination of the kidney in Fig. 56. — Testing the thickness of the abdominal walls. the erect posture with flexed trunk, in the knee-elbow, and in the Sims position may be required. A satisfactory pelvic and abdominal palpation may be impos- sible without anesthesia. In a virgin anesthetization should always be insisted upon, unless she has been examined and per- haps treated before. If the patient is a young girl, it is better to keep her in ignorance of what is to be done, and, if possible, the vaginal should be replaced by a rectal examination. If there is uncontrollable rigidity of the abdominal and pelvic mus- cles, hypersensitiveness of the genital region, or if for any cause the examination is difficult and the result is not perfectly clear, a physician should refuse to give his opinion of the case until an examination under anesthesia is permitted. The best anesthetic for the purpose is ch.loroform. It secures perfect relaxation POSTURES AND IMPLEMENTS FOR EXAMINATION. 6i quickly, and does not, as a rule, nauseate the patient, used in the small quantities and for the short time required. Ether is too slow in its action and causes too much nausea. Nitrous oxid gas does not relax the muscles enough. Ethyl bromid is too dangerous and ethyl chlorid has the disadvantages that the stage of excitement is sometimes exaggerated, the muscular Fig. 57. — Exposure of the clitoris, vestibule, vaginal introitus, and fossa navicularis. relaxation is not sufficient, and the nausea afterward is often ex- treme. Inspection of the Pelvic Organs and of the Abdomen. — As the patient is arranged for a digital examination of the vagina, her vulva is exposed to view and should be inspected before the physician inserts his finger. The entrance of the vagina and the vestibule are exposed by separating the labia majora with the thumbs or forefingers. The vagina itself, its vault, and the cervix uteri are exposed by the use of a bivalve or a duck-bill (Sims') speculum. The former is the more useful instrument of the two. The Collin's, Goodell's, and the skeleton are the most convenient 62 PREGNANCY. models. Two sizes must be provided, for multiparous and nulliparous women. To introduce a bivalve speculum, the instrument is grasped in the fingers of the right hand, near the junction of the blades, Fig. 59. — Goodell's speculum. Fig. 60. — The author's skeleton bivalve speculum. which are held close together. The tips of the blades are dipped in a jar of unguent. The forefinger of the left hand is inserted in the vagina to locate the cervix and to indicate the direction of the vaginal canal. As the finger is withdrawn the POSTURES AND IMPf.EMEXTS FOR EXAM IN ATI ON. 63 right labium majus is pushed to one side and the vaginal entrance is thus made to gape. The speculum is now inserted with the long axis of the blades corresponding with the direction of the vagina — namely, backward toward the sacrum, rather than up- ward in the line of the trunk; the tips are turned so that their long axis corresponds with the long axis of the vulvar orifice, and the screw is directed downward. As the instrument is passed into the vagina it is turned on its long axis so that the blades rest against the anterior and posterior vaginal walls, and the screw which separates them is on the left-hand side of the woman's Fig. 61. — Introduction of the bivalve speculum. pelvis, where the examiner's right hand may easily manipulate it. If the proper direction of the speculum is maintained while it is being inserted, the cervix is exposed as the blades are separated; but the mistake is commonly made of not pointing the instru- ment far enough backward, so that when it is opened the ante- rior vaginal vault is exposed and the cervix is hidden beneath the posterior blade. Should this be the case, the blades are allowed to collapse, the instrument is withdrawn a little and then pushed far backward toward the sacrum until the cer\dx comes into view as the blades are separated. If the vagina is 64 PREGNANCY. long and its walls are relaxed, a single tenaculum may be required to catch the cervix, by passing it into the external os with the hook directed upward and catching hold of the anterior lip. A bivalve speculum properly introduced and widely enough Fig. 62. — Sims' specula. Detachable blades of varying sizes and handle. Fig. 63. — Sims' speculum. Blades of two sizes in one instrument. Fig. 64. — Nott's vaginal depressor. opened is usually self-retaining, lea\dng the operator's hands free for whatever manipulations may be required. If a Sims speculum is used in the dorsal position, the ante- rior vaginal wall prolapses into the vulvar orifice and obscures the view of the deeper portion of the canal, so that a retractor POSTURES AND IMPLEMENTS FOR EXAMINATION. 65 is required to push it uj)\vard out of the way. Special instru- ments are devised for the purpose, but the ring handle of one blade of a two-bladed instrument, such as a Pean's forceps, an- Fig. 65. — Sims' position. Fig. 66. — Sims' position. Patient draped with sheet, arranged so as not to inter- fere with the examination or manipulations. swers the purpose perfectly. Edebohls has dcNdsed a self-retain- ing duck-bill speculum with an attachment to catch discharges and irrigating fluids, which is often very useful in the dorsal decubitus. 66 PREGXANCY. Fig. 67. — Knee-chest posture. Thighs perpendicular to the table; back at an angle of 45 degrees. Fig. 68. — Knee-chest posture. Sheet draped around patient. Posture faulty. Thighs not perpendicular. POSTURES AND IMPLKMKNTS FOR EXAMIXATION. 6/ Nu. mr- ^^^^^H Ft J^ "*^.. ^^B ^I^^^^^^Pw:^ Fig. 69. — Introduction of a Sims speculum. Fig. 70. — Sims' speculum introduced and held b}' a nurse. 68 PREGNANC\r The best results with the Sims speculum are obtained, how- ever, in the Sims or semi-prone lateral position and in the knee- chest posture. In the Sims position the patient is placed upon her side, usually the left, with the under arm behind her back, the trunk in a semi-prone position, the thighs weU flexed upon the abdomen, and the legs upon the thighs, the upper leg and thigh being somewhat more strongly flexed than the lower. The advantages of the Sims position are increased if the table on which the woman lies is tilted so that the abdomen is made still more dependent. The knee-chest posture is assumed by resting upon the knees and chest, the face turned aside so that one cheek rests upon a flat pillow and the arms so disposed that the patient can not yield to her instinctive impulse to rest upon the elbows. The thighs should be perpendicular to the surface of the table, and the back should present a straight line or a somewhat con- cave curve at an angle of 45 degrees. To introduce the Sims specu- lum in the Sims position, the convex surface of the blade is well anointed, the handle is grasped in the full hand, the vaginal orifice at its posterior commissure is opened by raising the upper buttock, and the blade of the instrument is in- serted with the long axis of its tip in coincidence with the long axis of the \nilvar orifice. As it is inserted the blade is turned until the handle points directly backward toward the sacrum. The handle must also be inclined somewhat away from the perineum, else the blade will slip out. An assistant holds the handle firmly in the full hand and makes considerable traction backward and outward. A retractor may be needed for the anterior wall, and a tenaculum may be required to bring the cer- vix into \dew, although usually the vagina is well distended with air and every part of the canal is plainly displayed, except that covered by the blade of the instrument. To insert the Sims speculum in the knee-chest posture, the same maneuvers are practised, except that the vulvar orifice is opened for the inser- tion of the blade by one or two fingers. There are several models of self-retaining duck-bill specula, permitting one to dispense with an assistant; but they are bulky Fig. 71. — Edebohls' self-retaining speculum. POSTURES AND IMPLEMENTS FOR EXAM/NATION. 69 and expensive instruments, scarcely ever employed by any one who can command the services of a nurse to assist in g}''necological examinations/ Edebohls' instrument is sometimes a conveni- ence in the dorsal decubitus, to receive discharges or fluids in a tin cup attached to its lower end. The cyhndrical speculum is very rarely employed. It is only useful for the purpose of bathing the cervix in medicinal solutions, which are poured into it after its insertion until the cervix is submerged. As the speculum is withdrawn the solution bathes the successive layers of the vaginal wall which prolapse into its opening. To introduce the cylindrical speculum the longer end is placed posteriorly. A rotary motion facilitates its introduction. It is pushed backward and upward until the cervix is engaged in its distal end. Cylindri- cal specula are made of metal, glass, hard rubber, and wood. The last-named material is designed for the appHcation of the actual cautery to the cer\dx. Ferguson's speculum has a mirror coating on its internal surface. The inspection of the abdomen may furnish information of the greatest value. Flaccidity of the walls, indicating enteroptosis and gas- troptosis, when the individual stands erect, tympany, obesity, pregnancy, ascites, hernia, the various new growths in the pelvis and abdomen, often have a characteristic mor- phology which suggests at a glance the nature of the patient's disease or condition. To in- spect the abdomen it must be entirely exposed. The examiner stands some distance off and looks at it first in pro- file; then from the patient's knees. In obesity the lower ab- dominal walls rest upon the patient's thighs. In ascites the ab- dominal surface is flat, the sides bulge outward. A small ovarian cyst may distend only one side of the abdomen; a fibroid tumor may have an irregular surface, or if it is symmetrical, the outline of the tumor viewed in a profile is bolder than that of other growths. A huge cystic tumor of the abdomen is probably ^ A word of caution in this connection is necessary to the inexperienced. At least four or five of the author's personal friends in recent years have been falsely accused of attempts at assault during office examinations of female patients. The physician, therefore, who expects to treat women should make any sacrifice to secure the services of an office nurse, who is not only an invaluable aid in the prep- aration of the patient for examination and in the various methods of examination and treatment, but is also a safeguard against a serious risk of attempts at black- mail. speculum. Ferguson's 70 PREGXANCY. an ovarian cyst; a tumor distending the upper abdomen alone probably springs from the liver, kidney, spleen, or stomach. In the degree of tympanitic distention which accompanies obstruction of the bowels, the outhne of the coils of intestine ma}^ be seen. Extreme emaciation usually accompanies a large ovarian cyst or a malignant tumor with ascites. But there are numerous exceptions to these rules. Ascites and hydraninios may produce as excessive and as uniform a distention as a large ovarian cyst. The latter may be situated in the upper abdomen.i Fig. 73. — Measurements of the abdomen to indicate the growth of an abdominal tumor. A fibromyoma of the uterus often looks surprisingly hke a pregnant uterus, and t}Tnpany sometimes shows as bold an out- line as a fibroid tumor. \\Tiile. therefore, considerable value must be attached to the outhne of the abdomen, too much de- pendence must not be placed upon mere appearances. Percussion and Auscultation. — A duU or t}Tnpanitic note on the percussion of the abdominal contents has the greatest sig- nificance; the former indicates a sohd or cystic tumor; the 1 The author has seen an ovarian cN'st adherent to the liver in pregnancy and held in the upper abdomen as the uterus descended during involution; also an ovarian tumor displaced under the floating ribs by tight lacing, and connected w-ith the broad ligament by a very long pedicle. POSTURES AND IMPLEMENTS EOK EXAMINATION. Jl latter, distended intestines. It should be remembered, how- ever, that inflated intestines may i)rolapse in fn^nt of an intra- abdominal tumor, or that there may be a retroperitoneal growth. Deep percussion is necessary in such a case to detect the solid mass beneath the bowels. In ascites there is tympany on the anterior surface of the abdomen, dulness in the flanks, as the patient lies upon her back. The fluid gravitates to the lowest portion of the abdominal cavity, so that the dulness changes with alterations in the patient's posture. In an ovarian cyst there is dulness on the abdominal surface and a corona of tym- pany around the tumor on the flanks and in the epigastrium. Auscultation is employed in the differential diagnosis be- tween pregnancy and other abdominal tumors to detect the fetal heart-sounds and the funic souffle. The so-called " placental bruit " is of no diagnostic value. It may be heard in fibroid tumors as well as in the pregnant uterus. Auscultation may also be of use in the diagnosis of peritonitis to detect the presence or absence of peristalsis. Mensuration of the Abdomen. — To record the dimensions of any abdominal tumor or to determine its rate of growth, abdominal measurements are taken with a tape-measure, preferably in the metric scale. The greatest girth of the abdomen is measured; then the distances between the ensiform cartilage and the umbili- cus; between the umbilicus and the symphysis pubis; the anterior superior spines of the ilia; the spines of the ilia and the sym- physis; the spines of the ilia and the umbilicus. J 2 PREGNANCY. CHAPTER III. Menstruation, Ovulation, Insemination, and Fertilization; The Changes in the Ovum After Fertilization* MENSTRUATION. Menstruation is the periodic discharge of a sanguineous fluid from the uterus, and perhaps from the Fallopian tubes, during the time of a woman's sexual activity, from puberty -until the meno- pause. From the earliest ages of medical literature many theories have been advanced to account for menstruation. The oldest explanation was founded upon woman's supposed uncleanliness. Menstruation was thought to be an effort on the part of nature to rid the woman's body of noxious humors.^ Again, it was explained that woman was plethoric and that nature provided a periodic vent for the superfluous blood. In modern times Pfliiger has advanced the theory that menstruation occurs in consequence of a conges- tion brought about as follows : A Graafian follicle by its growth finally produces so great a reflex irritation as to determine a local: congestion, which manifests itself in a bloody discharge from the uterine mucous membrane. Sigismund, Lowenhardt, and Rei- chert propounded the doctrine that menstruation occurs because the ovum discharged prior to the menstrual period is not impreg- nated ; consequently, failing this stimulus to further growth and development, a retrograde change with bleeding occurs in the uterine mucous membrane. As a matter of fact, the cause of menstruation is one of the many life -phenomena at present beyond human comprehension. All that can be said is that a nervous influence proceeds periodically from the sympathetic ganglia in the lower abdomen and pelvis, stimulating and congesting the sexual organs. It is probable that the stimulus to the sympathetic nervous system originates from the internal secretion of the corpus luteum. Certain facts from compara- tive physiology throw a glimmer of light upon the subject. For instance, it is asserted that if sheep fall into heat and are not 1 Many popular superstitions are founded upon this idea ; for example, that a drop of menstrual blood withers a flower, and that a menstruating woman in a dairy turns the milk sour. The modern physician is still influenced by this old super- stition, if the author may judge from grave discussions he has heard as to the pro- priety of allowing a menstruating nurse to be present during the performance of an abdominal section. MKNSTK UA TION. 7 3 gratified, the rut returns in a month. Menstruation in the female is obviously what rut is in the lower animals, and the bloody discharges from human females are probably the result of their erect posture and the pelvic congestion which is a con- sequence of it. The mechanism of menstruation is better understood than its causes. It is mainly a diapedesis of blood through delicate new- formed capillaries in a thickened and congested endometrium, the provision for carrying blood to the membrane being better than that for bearing it away by the efferent vessels. Some of the newly formed delicate-walled capillaries no doubt rupture. Leopold has given the following description of the uterine mu- cous membrane during menstruation : The mucous membrane is 8 mm. (0.315 in.) thick, swollen, dark brownish red, soft almost to liquefaction, but perfectly intact and separated by a sharply defined boundary-line from the paler muscular tissue of the uterus. The uterine glands, 0.5 to 0.75 mm. (0.0197 to 0.0296 in.) wide, are considerably lengthened andean be seen by the naked eye. In the superficial portion of the mucous membrane, which is very well preserved and only in certain spots lacks its epithelium and subjacent cells, may be seen an immense and enormously hypertrophied capillary net- work, the vessels of which have irregular outlines and lie in the uppermost layer of the mucous membrane. Gebhard ^ gives the following results of his studies : About ten days before the menstruation there is a serous infiltration of the mucous membrane, separating the meshes of the stroma. Just before the flow there is a marked dilatation of the blood- vessels. The glands increase in size, become tortuous in their course, and are dilated by secretion. The swollen capillaries in part rupture, in part permit a transudation of blood. There is an extravasation infiltrating the stroma, forcing its way upward under the epithelium, which it raises from the subjacent tissues in little hillock-like projections. The blood escapes into the uterine cavity in two ways : First, it is pressed out between the epithelial cells of the intact mucosa ; second, the greater quantity by far makes its exit through openings formed by the separation of the cells on the summits of the hillocks just described. If the bleeding is profuse, epithelium may be carried away by the blood-stream. Exfoliation of the epithelium, however, is not the rule. After the exudation and transudation of blood ceases, the swollen membrane shrinks again, the epithelium sinks to its nor- mal level and becomes attached to subjacent tissues. The ex- travasated blood in the stroma is absorbed. ^ Veit's " HandFbucli der Gynakologie," vol. HI. 74 PREGNANCY. From these observations of Leopold's and Gebhard's, and from other studies of mucous membrane removed by the curet during menstruation and observed in recently extirpated uteri, it appears that the theory of hemorrhage in consequence of degen- eration of the mucous membrane is untenable. The uterus is increased in size and softened in consistency, these changes being most marked just before the flow appears. The uterine cavity is enlarged, the cervix is slightly dilated, and the cervical glands secrete an increased amount of mucus. The tubes and ovaries are swollen, heavy, and congested. There are certain clinical phenomena of menstruation which must often be taken into account by the physician. Time of First Occurrence and of Cessation. — The onset of menstruation is influenced by race, climate, mode of life, heredity, and genital sense. In temperate climates and in the home of the Teutonic and Anglo-Saxon races, menstruation occurs oftener in the fifteenth than in any other year. In these same races transplanted to the eastern middle sea-board of the United States, menstruation appears a year or two earlier. In Hungary the three races, Slavonic, Magyar, and Jew- ish, living side by side in the same climate, begin to menstru- ate, respectively, at sixteen, fifteen, and thirteen years of age. Hindu girls of Calcutta and negresses of Jamaica, living in similar climatic conditions, begin to menstruate at the eleventh and at the fifteenth year. Climate, however, does influence the onset of menstruation. It appears at eighteen years in the girls of Lapland and at ten years in Egypt and Sierra Leone. The social conditions of a girl determine, to a certain extent, the age at which menstruation begins. If she lives in a city, subjected, perhaps, to indiscriminate association with the other sex and to sexual temptations, the function appears earlier than it does in the country, or in a girl carefully brought up in com- parative seclusion. The same rule applies to lower animals. If a bull is admitted to the pasture of a herd of heifers, heat appears earlier in the latter than it would if they were segre- gated. It is a matter of common observation that peculiarities of menstruation run in certain families. Thus, through several gen- erations of females menstruation appears late and ends early, or vice versa. By genital sense is meant the strength of sexual feeling. In women of strong sexual passion the function of menstruation is commonly instituted earlier and lasts to a greater age than common. Precocious menstruation is not uncommonly associated with nymphomania. Menstrual Molimina. — By this term is meant the local and MENS TK UA TION. 7 5 reflex subjective symptoms of menstruation. There is a feeling of weight and heaviness in the pelvic organs, due to their con- gestion and increase of size. There is a general nervous ex- citation, so that women disposed to hysteria and epilepsy exhibit outbreaks at this and perhaps at no other time. The breasts swell and may secrete milk. The thyroid gland is enlarged and the tonsils are swollen, so that singers may lose their voice. There is increased vascular tension, increased activity of the heart, shown by sphygmographic tracings, and the pulse is accelerated. The temperature is elevated by 0.5° C. The skin is more vascular and shows unusual pigmentation, especially in the dark rings under the eyes. v. Ott has demonstrated a regu- larly recurring wave in all the physiological processes of women, shown by heat production, muscle strength, lung capacity, force of inspiration and expiration, and tendon reflexes. The greatest activity is manifested just before the appearance of the flow, when there is a sudden subsidence. The Character of the Flow. — The discharge consists, in great part, of blood. It is alkaline in reaction. It contains, besides blood, mucous secretion from the glands along the genital canal and epithelial cells. It is dark in color, and should not clot. It has a peculiar odor from the secretions of the sebaceous glands at the vaginal outlet, excited, as are all the structures of the genital canal, to unusual activity. The Duration of the Flow. — Menstruation rarely lasts less than three days ; a continuance of four, five, or seven days, if the natural and invariable habit of the individual, may indicate nothing pathological. In the first two or three days the greatest amount of blood is lost. After that the discharge grows less until it ceases. A leukorrhea or mucous discharge for a day or two after the cessation of the bloody flow is common. The Quantity of the Flow. — The actual quantity of dis- charge during menstruation has been estimated at four to six ounces. It is not practicable for the physician, however, accur- ately to measure the amount of flow. He must estimate it by the number of napkins worn in twenty-four hours. If a woman is obliged to change her napkins during the height of the flow more than three times a day, or to wear them double, the quan- tity of the flow is excessive. The Cessation of the Flow — The menstrual flow ceases usu- ally in the forty-fifth year, becoming infrequent and more scanty over a period of six, nine, or twelve months, until it stops alto- gether. There are many exceptions, however, to this rule. A woman who begins to menstruate much later than the fifteenth year will often have the menopause before forty. Or, if she ^6 PREGNANCY. begins to menstruate early, she will often continue beyond the forty-fifth year. As a rule, therefore, it may be stated that a woman menstru- ates from about the fourteenth to the forty -fifth year of her age. Precocious menstruation, however, has been recorded in the infant of one or two years old, and the discharge has continued to the sixty-fifth and even to the eightieth year. OVULATION. By ovulation is meant the discharge of a mature ovum from its Graafian follicle. The study of the process involves a consideration of the development of the Graafian follicle and its rupture ; the maturation of the ovum ; the transmi- gration of the ovum from the surface of the ovary to the uterine cavity. The Development of the Graafian Follicle and its Rup= ture. — The germinal epithelium on the surface of the ovary sends down into the ovarian stroma columnar prolongations called egg-cords. These cords become constricted at intervals, so that they are converted into a number of spherical gland- spaces unconnected with one another and without efferent ducts. The gland-space is surrounded by a containing membrane (the theca folliculi) divided into two layers, — the tunica fibrosa and the tunica propria. The interior of the gland-space is lined with a layer of epithelial cells, — the membrana granulosa. One of these cells, more highly specialized than the rest, the ovum (discovered by K. E. von Baer, 1827), is surrounded by an aggregation of the cells of the membrana granulosa, — the proligerous disc. The cavity of the gland-spaces is dis- tended with fluid (the liquor folliculi) containing paralbumin. As the Graafian follicle develops, it retires deeper into the in- terior of the ovary, following the direction of least resistance. Finally, however, the most mature follicle, under the influence of premenstrual congestion, rapidly secretes liquor folliculi, swells to the size of a pea or a cherry, so that it stands out plainly from the surface of the ovary. On the most promi- nent portion of its free periphery the tunica propria fails at one spot (the stigma), so that the integrity of the follicle is preserved only by the tunica fibrosa, which soon gives way under the pressure imposed upon it from within, and the follicle ruptures. The ovum and surrounding discus proligerus, usually attached to the follicle- wall just under the stigma, are washed out into the free peritoneal cavity by the escaping liquor folliculi. The Maturation of the Ovum. — The primordial ovum in ovulation: 77 the immature Graafian follicle is an epithelial cell without a cell-wall, but with cell-con- tents called the yolk, a nu- cleus called the germinal vesi- cle, and a nucleolus called the germinal spot. As the ovum matures, it acquires a cell-wall with three coats or layers, — the zona pellucida, the vitelline membrane, and the internal cell-membrane. The human ovum is holoblastic, — that is, it completely segments, — and contains much more proto- plasm, or germ-yolk, than deutoplasm, or food-yolk. In its maturation, or preparation for impregnation, the ovum shows the curious movement of its nucleus observable in all segmenting cells (karyoki- nesis), which approaches the cell-periphery, arranges itself in two star-shaped figures by the activity of the centrosome (the amphiaster stage), and extrudes portions of its sub- stance as little globules (polar globules) upon the ovular surface, the chromatin in the nucleus dividing into sixteen chromosomes for the ovum and the same number for the polar globule at each extrusion of the latter. These globules then disappear and are lost. It is supposed that they contain, perhaps, substances which might unite with the, female portions of the ovum to produce an imperfect being, as is done in certain hermaphroditic animals. Nature, it is presumed, takes this measure to prevent partheno- genesis, or the closest kind of inbreeding. A similar action may be observ^ed in the spermatozoon dunng its development. After the extrusion of the polar globules the nucleus retreats into the interior of the ovum and becomes the female pronucleus. The chromosomes are reduced in number one-half, so that by a similar reduction in the male pronucleus the number characteristic of the human species, sixteen, is maintained when the two unite. The ovum is now ready for fertilization. The Discharge of the Ovum from the Ovary and its Migra= tion to the Uterine Cavity. — Ova are discharged from the ovary from pubert)' until the menopause, — that is to say, on the average, Fig. 74. — Section through part of a mammalian ovary : KE, Germinal epitheli- um ; FS, an egg-cord ; U, U, primitive ova ; G, investing cells ; A', germinal vesicle ; S, follicular cavity arising in one of the older follicles ; Lf, follicular cavity, more enlarged ; Ei, nearly mature ovum, which has developed around it the zona pellu- cida, ATp ; Alg, membrana granulosa ; D, Discus proligerus ; So, ovarian stroma ; Tf, capsule of follicle ; g,g:, blood-vessels; ti, immature Graafian follicle (after Wie- dersheim) . 78 PREGNANCY. from the fourteenth to the forty-fifth year. Ovulation, however, may begin before menstruation, may cease before the menopause, or possibly may continue after it. A young girl has been im- pregnated as early as the ninth year.^ In the child-marriages of Fig. 75. — Formation of polar bodies in ova of Aste7'ias glacialis : ps, Polar spinale ; pb\ first polar body; pb'^, second polar body; n, nucleus returning to condition of rest (Hertwig). India impregnation has occurred before menstruation had begun ; but usually premature maternity is preceded by precocious men- struation. Ovulation has continued, as proved by impregnation, Fig. 76. — A, Mature ovum of echinus : n, female pronucleus; B, immature ovarian ovum of echinus (Hertwig). until the fifty-second, fifty-fourth, fifty-eighth, and even to the six- tieth and sixty-second year ! A case is recorded of delivery at the age of fifty-nine years and five months, and one at the age of sixty- ^ Strassmann has collected six cases of precocious pregnancy from eight years and ten months to ten years of age. " Handbuch d. Geburtsh.," v. Winckel, vol. i, p. 91. TlIJi CORPUS LUTEL'M. 79 one.i A physician investiij^ating the nature of an abdominal tumor should remember, therefore, that pre^^nancy is possible from tiie ninth to the sixty-second year. .Vfter the ovum is dis- charged from the ovary it is caught in a current of fluid moist- ening the surface of the ovary, and is carried to the interior of the corresponding tube. The existence of this current of fluid is explained by the movement of the ciliated epithelium in the tubes. In some animals there is a development of ciliated epi- thelium on the peritoneum at the time of ovulation. Arrived in the tube, the ovum is transported to the uterine cavity by the movement of the cilia on the epithelium and by the vermiform movements of the tubal walls. In certain cases of extra-uterine pregnancy an anomalous transmigration of the ovum has been demonstrated. Thus it is possible for the ovum, after its dis- charge from the ovary, to be taken up by the fimbriated extremity of the opposite tube, — an external transmigration of the ovum. It is also possible for the ovum to traverse one tube and the uterine cavity and to enter the uterine ostium of the opposite tube, — an internal transmigration of the ovum. It has been calculated that the human ovary at birth contains 70,000 ova. As it is unlikely that any woman discharges many more than 360 ova, even if she ovulates uninterruptedly for thirty years, an enormous number of ova must atrophy, disintegrate, and disappear within the ovary. THE CORPUS LUTEUM. The changes which occur in the Graafian follicle after its rup- ture and the discharge of the ovum, discus proligerus, and liquor folliculi lead to a formation within the Graafian follicle called the corpus luteum. There is an effusion of blood into the cavity of the follicle and an enormous development of the connective-tissue elements in the follicle-wall. 2 The internal layer of the theca folliculi is enor- mously thickened and thrown into numerous folds which eventu- ally fill up the whole space in the interior of the follicle. The mem- brane is composed mainly of large hexagonal cells, like those of the liver, the lutein cells, containing a yellow substance — lutein — solu- ble in alcohol, and fat globules. The cells are separated by ray- like septa, extensions of fibro- connective tissue from the theca. Leopold thus describes the development of the typical corpus luteum : It appears on the first day as a follicle just broken open, the interior filled with blood. From the eighth day on there ^ Strassmann quotes cases of impregnation at the sixty-second, sixty-third, and seventieth year. " Handbuch der Geburtsh.," v. Winckel, vol. i, p. 95. 2 "The Origin, Growth, and Fate of the Corpus Luteum as Observed in the Ovary of the Pig and Man." J. G. Clark, "Johns Hopuins Hospital Reports," vol. vii. 8o PREGNANCY. appears a fine capsule around the blood-extravasation, while the inner portion becomes lighter and clearer. From the twelfth day the capsule grows thicker and is thrown into folds ; from the sixteenth day it becomes a pale red, merging into a yellow. About the twentieth day the central matter of the broken follicle has become much shrunken, while the capsule, more decidedly a pale yellow, projects toward the center of the follicle in rays and narrow folds. The corpus luteum of menstruation, or the so- called false corpus luteum, reaches its highest development in ten to thirty days. Nine days later it is merely a lamina of fibrous tissue beneath a little pit or depression of the ovarian surface. The true corpus luteum of pregnancy, so called, is simply an exaggeration of the corpus luteum of menstruation, the longer growth and greater size being due to the stimulation and congestion of gestation. It grows for thirty or forty days after conception, occupying a third, perhaps, of the ovarian area. It then remains stationary until after the fourth month, when it begins to atrophy ; at term it is only two-thirds its largest size ; one month later it is reduced to a small mass of fibrous tissue. The true corpus luteum is of value as an indication of the ovary from which the impregnated ovule came. It should be remembered, however, that the ovaries of virgins have exhibited corpora lutea like those of pregnancy in consequence of intense and prolonged congestion. There is a secretion from the corpus luteum which influences the nutrition of the uterus, the occurrence of menstruation, and the development of the ovum and of the uterus in early preg- nancy. Experiments and observations of Fraenkel and others demonstrate that an overproduction of lutein cells in the ovary causes a hyperplasia of the syncytial cells of the trophoblast and that a destruction of the corpus luteum in early pregnancy blights the ovum.^ Loeb^ has demonstrated that the endometrium develops into decidua on irritation if the corpora lutea are preserved, but not otherwise. The injection of human lutein extract has a decided influence on the function of the sexual organs and on the general organism of women.^ It is now gener- ally admitted that the corpus luteum is the most important source of the internal secretions of the ovum, and that these secretions not only influence the sexual organs of women, in- cluding the breasts,^ but have a peculiar influence upon the other organs with internal secretions, such as the pancreas.^ 1 Fraenkel: " Die Funktion des Corpus luteum," Arch. f. Gyn., Bd. Ixviii. 2 " The Experimental Production of the Maternal Placenta," Proc. Path. Soc. of Philadelphia, June, igio. ^ Maits, University Medical Bulletin, 1910. ^ Frank and Unger, Arch, of Internal Medicine, June, 191 1. ^ Rebaudi, Zentralbl. f. Gjoi., No. 41, 1908. OVULATION AND MENSTRUATION. THE CONNECTION BETWEEN OVULATION AND MENSTRUATION. Neither one of these functions is dependent upon the other, but they both depend upon a common cause, — the periodic nervous excitation and congestion due to an impulse from the sympathetic nervous system. Dependent as they are upon the same cause, their occurrence is usually synchronous, — that is, the ovule is discharged at the height of menstrual congestion. But this is by no means the invariable rule. Leopold, ^ in an examination of twenty-nine pairs of ovaries removed on suc- cessive days up to the thirty-fifth after a menstrual period, found a Graafian follicle bursting on the eighth, twelfth, fifteenth, sixteenth, eighteenth, twentieth, and thirty-fifth day after the menstrual period. In other words, ovulation may occur without menstruation at any time in the intermenstrual interval. In five cases there was no ovulation at the menstrual period, or men-- struation occurred without ovulation. Many examples might be given, from clinical observation, of the mutual independence of these two functions. The common occurrence of impregnation during lactation is a good instance of ovulation without men- struation. ^ Menstruation after oophorectomy and during the first three months of pregnancy occurs without ovulation. I attended, in her first childbirth, a young woman twenty -two years old, who had never menstruated. She had obviously, however, ovulated. In the child marriages of India impregnation has been known to precede menstruation. Renoudin saw pregnancy and labor in a woman sixty-one years old, who had ceased to menstruate twelve years before. Repeated ovulation without menstruation is seen also in those curious cases of postniarital amenorrhea, lasting for years. The wife of a physician among my acquaintances menstruated once after marriage ; in the fol- lowing fifteen years she bore ten children without ever men- struating. Three years after the birth of the last child, or eighteen years since its cessation, menstruation returned copi- ously and regularly, but more frequently than normal, for twelve years. The menopause then began, at the age of forty-eight. ^ A recent ovulation has been observed in an extra-uterine preg- 1 " Archiv f. Gyn.," Bd. xxix, S. 347. 2 Remfry (" Revue internationale de Medicine et de la Chirurgie," 1896, No. 5) has found by an investigation among 900 nursing women that in 57 per cent, only did there occur an absolute amenorrhea. Menstruation was regular in 20 per cent, and irregular in 43 per cent. It was also common for conception to occur during lactation, 60 per cent, of the menstruating women conceiving. Among the non-menstruating women but 6 per cent, conceived during lactation. ' Similar cases are reported in " Amer. Jour, of Obstetrics," 1892, p. 352, and " N. Y. Med. Record," 1893, p. 717. 6 82 PREGNANCY. nancy of three months' duration (Slavjansky). Coitus four days postpartum has resulted in impregnation (Kronig). It is sometimes necessary to resort to oophorectomy in cases of ill-developed, infantile wombs, or entire absence of the uterus associated with well-developed ovaries, in which there is a violent exaggeration of the m^enstrual molimina every month without a discharge of blood and the consequent relief of menstrual conges- tion. The ovaries are found, after their removal, to be filled with well-developed Graafian follicles and numerous depressions repre- senting corpora lutea. It may also be necessary to remove ovaries left in the abdomen in a hysterectomy possibly years before. The menstrual molimina are so severe as to cause occasionally hysterical convulsions. INSEMINATION. By the term insemination is meant the ejaculation of seminal fluid from the male organ and its deposition within the genital canal of the female. The study of insemination A B involves a consideration of the seminal fluid, the development and life-history of its active constituent (the spermatozoa), the mechan- ism of its ejaculation from the penis, and of its reception within the vagina and womb. The seminal fluid is yellowish white in. color, thick and sticky in consistency, vary- ing in quantity at each emission from \ to 2 drams. It possesses a peculiar odor and is neutral or alkaline in its reaction. The constituent parts, on chemical examination^ are found to be water, 82 per cent.; salts,, mainly phosphates; -protein matter, fats^ albumose, nuclein, lecithin, guanin, hypo- xanthin, cholesterin, and spermatin. On microscopical examination there are seen seminal cells, crystals of phosphates, and spermatozoa^ discovered by Hammen in 1677 and demonstrated to be the active principle in fertilization by the filtration experiments of Spallanzani and others. A spermatozoon is "s^-o of an inch in length and possesses a power of motion by which it can travel with a rapidity variously estimated: its own length in a second, one inch in seven and. one-half minutes (Henle), or from the hjTnen to the neck of the womb in three hours (Marion Sims). Sper- Fig. 77. — Hu- man spermatozoa : A, Spermatozoon seen en face; k, head; m, middle-piece; t, tail; e, end-piece; B, C, seen from the side (after RetziusJ. INSKMINA TION. 83 matozoa have been found in the uterine cavity thirty minutes after a coitus (Schuwarski) ; in the tube sixteen hours post- mortem in a prostitute who was killed during coitis. Strass- mann calculates that they should make their way to the infun- dibulum of the tube in an hour and a half. Their progressive force is sufficient to overcome obstacles that appear insuperable; Fig. 78. — Seven stages of the conversion of a spermatic cell into a spermatozoon (Meves). Figs, a iof: Zs, Cell contents ; K, nucleus ; FC, proximal central body ; /?C, distal central body; SF, tail-piece. Fig. g: Head-piece; Ekn, neck; Vst, junction piece; Hst, main piece; Est, end-piece. they may be seen, under the microscope, to push aside epithelial cells ten times their size. Their vitaHty under favorable cir- cumstances is remarkable. They have been found alive in the testicles of criminals who had been executed three days, and of bulls which had been killed six days before. In the cow they have been found six days after insemiration; in a rabbit, eight days; 84 PREGXANCY. in the female bat they may be found ahve for months, and in the queen-bee for three years. In the human female living spermatic particles have been found in the vagina seven and one-half to seventeen days, in the cervical canal eight days after copulation.^ They have been found alive in the tubes three and a half weeks after the last coitus rDiihrssen), and have been kept alive in a culture-oven for eight days. On the contrar}', they are extremely susceptible to certain unfavorable influences. They are de- stroyed by heat, cold, acid solutions, lack of water, and the mineral poisons. A solution of bichlorid of mercurs', i : 10,000, is fatal to them. As a consequence of chronic disease in the man, of alcohohc or sexual excess, or of catarrh of the seminal vesicles, the spermatozoa may be dead when emitted. As a result of inflammation and obliteration of the seminal ducts or of ana- tomical defects the seminal particles may be absent from the seminal fluid. Lode estimates that there should be about 60,000 spermatozoa to the cubic millimeter of semen. Therefore milUons of these bodies are deposited in the vagina at each coitus. The indifferent constituent parts of the seminal fluid are derived from Cowper's glands, the prostate, and the vesiculae seminales. The spermatozoa are developed from mother-cells, or spermatoblasts, specialized from the epithelium of the testicle. In the course of their development a portion of the cell is extruded (seminal granule or accessory corpuscle) just as in the maturation of the ovum the polar globules are cast off. In the fully developed spermatozoon the head represents the nucleus of an epithelial cell, and the tail cell-contents specialized in the form of a cilium, of much larger size and greater power, however, than the cilia of ordinary cihated epithelium. Spermatic particles first appear in the seminal fluid at about the fifteenth or sixteenth year. There is often, in boys of twelve or thirteen, a seminal discharge, but it contains, as a rule, no spermatic particles. I have had charge, however, of a girl four- teen years of age impregnated by her brother, aged thirteen, who had stimulated his sexual development by masturbation. Sper- matozoa often disappear from the sexual discharge of old men, but the age at which this disappearance occurs varies greatly. As a general rule it might be put down as sixty-five, but it will be remembered that the French engineer, de Lesseps, was a father at eighty-two, and that old Thomas Parr illegitimately impregnated a woman after he had passed his hundredth birth- day. ^ " Handbuch d. Geb.," v. Winckel, vol. i, p. 146. INSEMINA TJON. 85 The Mechanism of the Ejaculation of Seminal Fluid and of its Reception within the Genital Canal of the Female. — The mechanism of ejaculation is explained by a study of the anatomy of the penis, which need not be considered here. It is sufficient to state that at the height of the orgasm in the male the seminal fluid is emitted by the action of the circular and longitudinal muscle-fibers of the vesiculae seminales and of the urethra. The mechanism of the reception of the fluid within the genital canal of the female is more important to the obstet- rician, for on a knowledge of this subject depends the compre- hension of conception and sterility. It has been found, in studying the sexual congress of animals, especially in horses, that during the emission of semen and for a short time afterward the uterus exerts an intermittent suction, or aspiration action, upon the seminal fluid, drawing it into the uter- ine cavity. In the observation of sexual excitement in bitches it has been noticed that the uterus is drawn down into the small pelvis. In experimenting with the electrical stimulation of the sexual organs in female animals, it was observed that the uterus grew shorter, but broader ; that it descended toward the vaginal outlet ; that the cervix projected farther than normal into the vaginal canal, at the same time becoming softer and shorter, but broader, by which action the os uteri was opened. The stimulus being removed, the uterus returned to its normal condition and the OS closed. These interesting experiments upon animals have been con- firmed by observations which gynecologists occasionally have the opportunity of making upon erotic females during a specular examination. It is justifiable, therefore, to state that in the orgasm a woman's uterus becomes broader and shorter; that it descends into the small pelvis ; that the cervix projects into the vagina, becomes broader, shorter, and softer, and that the os opens ; these actions being intermittent, the uterus might be likened to an animal gasping for breath. It would appear that the intention of this action is to suck the seminal fluid directly into the uterine cavity. The postmortem examination of two women murdered at the conclusion of a copulation in whom the uterine cavity was found full of seminal fluid, ^ and the investiga- tions of Natanson and Konigstein, demonstrating the presence of spermatozoa in the uterine cavity as early as three hours after coitus, confirm this view.- A normal mechanism of the reception of seminal fluid may ' See Janke, " Hervorbringung des Geschlechts," Berlin and Lcipsic, 1887. ^ Wien. klin. Wochenschr., No. 22, 1910. 86 PREGNANCY. be thus briefly described: The orgasm of male and female should be synchronous; as the seminal fluid is ejaculated from the penis it is, if not actually sucked in part into the uterine cavity, at least by the extrusion and retraction of the mucous plug of the cervix, drawn in part into the cervical canal. An absolutely normal mechanism, however, is not always neces- sary to impregnation, though a lack of it explains some cases of sterility. One of my patients bore a child within a year after marriage and then remained sterile for six years. During the whole of this time she did not once experience sexual excite- ment during intercourse. Finally, for the first time in six years there was an orgasm, and it was synchronous with the husband's. This coitus proved fruitful. The resultant pregnancy, curiously enough, was tubal. There are many women who have abso- lutely no sexual feeling and who never experience an orgasm, but who, nevertheless, become pregnant repeatedly. Insemination has occurred also when the woman was asleep, drunk, asphyx- iated, or unconscious from some other cause. These cases are explained by the deposition of semen in the vault of the vagina, in what is called the seminal lake, into which the cervix projects. The spermatozoa, attracted by the alkalinity of the cervical mucus and repelled by the acidity of the vaginal secretions, make their way through the cervical canal into the uterus. This explanation presupposes a normal position of the uterus. A retroverted uterus, therefore, with the cervix tilted so far for- ward that it is not bathed in the seminal lake, is often, but not necessarily, a bar to conception. The motility of the sper- matozoa enables them to penetrate the canal, although it may be diflicult of access. Retroversion, however, is a cause of sterility. One of my patients bore a child and was sterile for five years afterward. She had a complete retroversion. The malposition was corrected. In the next six years the woman bore five children. The motility of the spermatozoa ac- counts, too, for the cases of conception without insemination at all, — that is, after a mere deposition of seminal fluid upon the external genitals. I have attended in confinement married women with unruptured hymens, and have examined young girls with an intact hymen, impregnated, during an embrace in the erect posture, from the deposition of semen upon the labia majora. The Meeting Place of Ovule and Spermatic Particle. — It is generally assumed that the spermatozoa meet the ovum in the ampulla of the tube. That this may be the meeting place is proved by cases of tubal pregnancy. There are some arguments, PLATE I. 26. Two ova Mvith surrounding membrana granulosa in the Fallopian tube. 27. The spermatozoon, ha\-ing entered the ovum, the head is swollen. 28. Ovum in dvaster stage of mitosis for first polar body. 29» The second polar spindle, placed obliquely. Chromosomes undivided. The polar bodv with some chromosomes, discharged. 30. Dispirem stage of the second polar mitosis with mid-body in central spindle. 31. Ovum with pronucleus. 32. 0^•um with pronucleus; large nucleolus in sperm nucleus. 33. Chromosomes forming in the pronuclei. 34. The spirem with centrosome. 35. Ovum with first segmentation-mitosis. 36. O-sTim in dvaster stage of the first segmentation-mitosis. ■ 37. Ovum in dispirem stage of the first segmentation-mitosis. _ 38. 0^'^lm ■nnth twelve segmentation-spheres (blastomeres); mitosis in two of them. 39. Unimpregnated o\Tam in the Fallopian tube on the third day after ovulation. Chs, Chromosomes; ek, nucleus; rk, rk^, rK, polar bodies; schw, tail of a spermatozoon; spk, sperm-nucleus (Sobotta). PLATE I. 26. schjv. ^^''" O . ^ 30. /, ' j"- v' .. '' %>■ ■* 3*. ,S ■c . .. ■ ^ '7 9 if, INSKMINA TION. 87 however, in favor of the fundus uteri as the normal meeting place of spermatic particle and ovum based on the supposition that it is the ovum of the last menstrual period which is impregnated. If ovulation occurs at the height of menstrual congestion, the ovum has probably reached the uterine cavity before the fruitful coitus occurs. HyrtP found the ovum in the uterine extremity of the tube in a girl who had died on the fourth day of men- struation. In Jewesses, who are proverbially prolific, copulation is not allowed until a week after the cessation of menstruation. The ovum by this time has not only reached the uterine cavity, but has probably been washed out or has disintegrated. It is Fig. 79. — Portions of the ova of Asterias glacialis, showing the approach and fusion of the spermatozoon with the ovum : a. Fertilizing male element ; b. elevation of protoplasm of egg ; b' , b" , stages of fusion of the head of the spermatozoon with the ovum (Hertwig). still a disputed point whether the impregnated ovum dates from the last or the expected and missed period, but the weight of evidence and the belief of the majority of experts is in favor of the impregnation of the ovum of the first missed period. The spermatozoa may have been deposited in the genital canal weeks before, but they retain their vitality and await the advent of the ovum in the ampulla of the tube. My own belief is that it is not usually the ovum of the last period which is impregnated, but exceptionally it may be." The Fertilization of the Ovum. — From what has been seen in the lower animals and in the vegetable kingdom, it is probable that the ovum, during its passage through the tube or on its arrival in the uterine cavity, excretes some material which attracts the spermatic particles, as the female elements of some plants attract 1 Miiller's " Handbuch," vol. i, p. 151. ^ Schaeffer, Zeitschr. f. Geb. u. Gyn., Bd. 67, p. 511. 88 PREGNANCY. the male elements by an excretion of malic acid. From the swarm of spermatozoa around it a number may penetrate the cell-wall of the ovum, but only one, as a rule, penetrates the cell-contents. From what is seen in sea-urchins it is claimed that two or more spermatozoa may enter the ovum through the same opening in the cell periphery, especially if it is immature or atrophic, and that thus multiple pregnancy may result. The Fig. So. — A, Fertilized ova of echinus : The male, a, and the female pronucleus, b, are approaching; in B, they have almost fused; C, ovum of echinus after com- pletion of fertilization ; s.n., segmentation-nucleus (Hertwig). female pronucleus divides into as many portions as there are male pronuclei. The mechanism of ovular penetration is as follows : the head of the spermatozoon fuses with a pro- jection from the protoplasm of the ovum ; the tail disappears. The head then penetrates the cell-contents and becomes the male pronucleus, — a small, oval body (containing the chro- matin of the male cell) with a .striated arrangement of cell- contents about it derived from the centrosome. Finally, the male pronucleus unites with the female pronucleus. Conception occurs at the moment of this union, and from this instant dates the life-beginnins: of the future embryo, fetus, and infant. INSEMINA TION. 89 The Time when Coitus is Most Likely to Result in Con- ception. — Statistical studies show that impregnation is most hkely to occur after copulation during the first eight days suc- ceeding the cessation of menstruation. There is a period, begin- ning fourteen days after the cessation of menstruation and lasting for a week, during which coitus is least likely to be followed by conception. Some women claim that they can avoid impregnation or become pregnant at will, by following or disregarding this rule. I! I "TTTT" Figs. 81 and 82. — Curves showing relative frequency of conception following coitus at different times in relation to menstruation. In both diagrams the divisions on the abscissa line correspond to days : in the first, to days after the onset of menstruation ; in the second, to days after the cessation of menstruation. The curves indicate the proportion of conceptions to copulations on each day of the menstrual month (Hansen). As any woman, however, may ovulate at any time during the in- termenstrual period, and as spermatozoa may retain their vitality for more than three weeks in the Fallopian tubes, this method of preventing conception is not reliable. The Average Date of Conception after Marriage. — Nor- mally, impregnation should succeed the first menstmation fol- lowing marriage, but marriages are only called sterile after eighteen months have elapsed without conception. Pregnancy is possible, however, after years of sterihty. The author has had charge of women who conceived for the first time nine, thirteen, and twenty- four years after marriage. go FREGXAXCY. THE CAUSES AND TREATMENT OF STERILITY. In at least 20 per cent, of sterile marriages the fault lies with the male. His spermatozoa should be examined under the micro- scope and his potentia cceundi should be ascertained in every case as part of the routine investigation of sterility in the female. The causes of sterility in the wife may be classified as follows : Anatomical or developmental defects preventing normal insemi- nation or presenting mechanical obstacles to the access of the sper- matozoa to the ovum. Atresia or stenosis of any part of the genital tract, absence or arrested development of the ovaries may prevent impregnation. The commonest development anomaly responsible for sterility is stenosis of the cervical canal and a U-shaped ante- flexion of the uterus. Diseases, injuries, and displacements of the vulva, such as vaginismus, kraurosis, and neoplasms may prevent normal in- semination, and are usually, but not necessarily, a bar to conception, the mere deposition of semen upon the external genitals being fol- lowed sometimes by impregnation. An injury of the vulva which the author has twice seen responsible for sterility is a perforation of the fossa navicuiaris into the rectum at the first coitus, the hymen remaining intact. Subsequent intercourse occurred by way of the fistula. Stenosis of the vagina may prevent conception. In a case of the author's, however, with the vagina reduced by acquired stenosis to a narrow sinus throughout its whole length, barely admitting a surgeon's probe, impregnation occurred by the deposition of, semen upon the vulva. Coitus in such cases has not infrequently been practised by the urethra, which has been gradually dilated. With a coincident vesicovaginal fistula above the site of complete atresia impregnation is possible and has occurred. Injury of the pehic floor, destruction of the perineum, inversion of the vagina, may be causes of sterility by preventing the retention of seminal fluid. Retroversion of the uterus may be, but is by no means neces- sarily, a cause of steriHty. In the supine position the cervix is tilted upward and is not bathed as it should be in the seminal lake occup}-ing the posterior vault of the vagina. The motility of the spermatozoa may overcom.e the obstacle, but cases of sterility are cured sometimes by a pessary or the operative treatment of retroversion, A complete prolapse of the uterus usually prevents conception, but in a case of the author's impregnation took place in spite of a total prolapse of years' duration. A fibromyoma or other neo- plasm of the uterus or of the endometrium may prevent conception THE CAUSES AND TREATMENT OE STERILITY. 91 by opposing obstacles to the ascent of the spermatozoa, but the motility of the latter may enable them to surmount barriers mountains high in comparison with their microscopical size and to traverse the most tortuous canal. Scipiades' statistics of 985 cases of myoma with 75 pregnancies demonstrate the possi- bility of conception in spite of these growths. On the con- trary, as a proof of the part that fibromyomata play in the etiology of sterility, conception has followed myomectomy in 18 to 20 per cent, of the women under forty years of age (Winter). Endometritis with a profuse mucopurulent leukorrhea may prevent conception, but there is often an associated salpingitis which is the real bar to impregnation. An intensely acid dis- charge from the cervix may be inimical to the activity or the exist- ence of the spermatozoa. The commonest disease of the genitalia accountable for steril- ity is salpingitis, with closure of the abdominal ostium by adhesive inflammation. The common cases of "one-child sterility" are usually due to this cause, and it also explains the infrequency of conception in prostitutes. Diseases and neoj^lasms of the o^^aries, destroying them as egg-producing glands, their inclosure in an adventitia of inflammatory exudate, and a thickening of the proper capsule, prevent ovulation and, therefore, preclude con- ception. Anemia and wasting diseases may deprive the Graafian follicles of the blood required for their maturation and rupture and so may prevent ovulation. The Psychic Causes of Sterility. — It is true that wom.en may be impregnated while asleep, drunk, asphyxiated, or unconscious from any cause ; by the mere deposition of semen upon the external genitaha; by the artificial injection of seminal fluid into the genitalia; without ever experiencing the least sexual sensation. Nevertheless, a lack of affinity between the man and woman, an absence of sexual passion and of an orgasm, may account for sterility. Treatment. — It is obvious that the treatment must be directed to the cause and must vary greatly in individual cases. A careful study of the patient should naturally precede the treatment. The case may call for the removal of tumors from the vulva; the cure, if possible, of kraurosis; the gradual dilatation of the introitus vaginae; the destruction of sensitive papillae around the vaginal introitus by the electrocautery needle, or cutting the levator ani muscles in vaginismus; the correction of atresia or stenosis in the genital canal; the excision of the hymen and the closure of fistula?; the repair of vaginal injuries, or the reposition of a displaced uterus. A thorough dilatation of the cervical canal cures more cases of sterility than any other single procedure. The most 92 PREGNANCY. eflScient and permanent dilatation of the cervix is effected by the author's modification of Schatz's metranoikter (see p. 797). WyHe's drain entails too much risk of injecting the endometrium and tubes. Dudley's operation (p. 804) has not been as satis- factory in my hands as mechanical dilatation. The restoration of patency in the tubes stands next in order of efficiency among the operations for sterility (see p. 927). The assumption of the knee- chest posture after coitus may be recommended. A tonic treat- ment for anemia may be indicated. An improvement of general health and strength by travel, open-air exercise, and a generous diet will sometimes be successful when local treatment has failed. Experiments upon the lower animals, as well as upon human beings, have demonstrated the possibility of transplanting the ovary to some other situation than its normal one in the peritoneal cavity, or even of implanting the ovary recently removed from another person with continued functional activity and a subsequent con- ception. A myomectomy or the removal of any pelvic or abdominal tumor exerting pressure upon the genital canal may remove the obstacle to conception. If there is uterine or cervical leukorrhea, a curettage and applications of antiseptics or astringents to the endometrium are indicated. If the uterine discharge is intensely acid, it is claimed that intra-uterine applications of milk of magnesia shortly before coitus make conception possible. A gouty diathesis sometimes associated with this acid dis- charge should be treated appropriately. From their nature many cases are incurable. Occasionally a marriage sterile for many years may inexplicably prove fruitful without special treat- ment. The author has had under his charge in confinement a woman who conceived for the first time after more than twenty years of married fife, when she had given up aU hope of such an event. The physician should usually be careful not to inform his patient bluntly that she is hopelessly sterile. She should be allowed to entertain some hope of maternity until the lapse of years has reconciled her to the idea that she can not expect offspring. The Sterilization of a Woman, — Artificial sterility is a justifiable subject for discussion in the casuistry of obstetrics. There are conditions in which pregnancy may be dangerous or fatal to the woman, such as nephritis and tuberculosis. Con- ception may be prevented by cutting the tubes loose from the uterine cornua and sewing the perimetrium over the wounds in the latter, or by burying the ovary between the layers of the broad ligament.^ ^ Labhart, " Korrespondenzbl. f. Schweizer Aerzte," No. 17, 1911; Bucura^ " Wien. klin. Wochenschr.," No. 46, 1910; ibid., No. 13, 191 1 ; Neumann, ibid.. No. 17, 1911. CHANGES IN THE OVUM FOLLOWING IMPREGNATION. 93 Fig. 83. — Diagrammatic section of a mammalian blastoderm after the cover-cells have completely closed in the blastoderm, and the embryo proper has become two-layered: ep' , Non-em- bryonic epiblast ; ep, embryonic epi- blast ; hy, hypoblast ; ys, yolk-sac (from Haddon). CHANGES EST THE OVUM FOLLOWING IMPREGNATION. » Directly after the formation of the nucleus of segmentation by the fusion of male and female pronucleus the ovum begins to segment. The original mass di- vides itself into two cells (blasto- meres), these into four, and so on until the whole ovum is sur- rounded by a layer of cells inclos- ing a group of soinewhat larger cells (morula, or mulberry mass), and a hollow cavity containing albuminous fluid. This stage of development is called the blastula, or blastodermic vesicle. The cells of the ovum next arrange them- selves into a thinned-out, lami- nated layer around the periphery of the ovum, and another layer just within this, the offspring of the central mass of cells (the ectoderm), and the proliferating central mass itself, — the entoderm. Regarding the surface of the ovum, an oval, opaque region may be observed (the embryonal area), and in the middle of this area a streak of greater opacity appears, — the prim- itive streak. At the site of this streak a depression next appears, — the prim- itive groove. A microscopic examination of a section through this region now shows the development of a median layer of cells (the mesoderm), made up of cells derived in part from a Fig. 84.— Embryonic area of rabbit em- layer furnished by the ecto- ^'"^11 Primitive streak beginning in cell- ■^ -' proliferation, known as the " node 01 Hensen derm and by another fur- (e. v. Beneden). ^ It is not intended to give more than a mere sketch of the development of the embryo. The student interested in the subject is referred to special works, such as Minot's " Embryology." 94 PREGNANCY. nished by the entoderm. In the course of its development the mesoderm develops lateral reduplications and parts into two layers (the parietal and visceral layers) inclosing spaces, — the body-cavity, or celom (Fig. 85). The parietal or somatic layer unites with the ectoderm to form the somatopleure. The Primitive groove. Beginning amnion fold. Visceral layer 0/ mesoderm. Entoderm. jTjg 8^ — Transverse section of the embryonic area of a fourteen-and-a-half-day ovmn of sheep (Bonnet). Axial zone. Lateral plates for body-iiialls. Lateral plates for gut-tract. Somite. Lateral zone. , Neural canal. Cavity within somite. Parietal mesoderm. Pleu roperitoneai cavity. Vitelline vein. Fig. 86. — Transverse section of a seventeen-and-a-half-day sheep embryo (Bonnet). visceral or splanchnic layer joins the entoderm to form the splanchnopleure. At the end of the second week the de- velopment of the embryo proper begins, by the formation of the neural folds, the neural canal, the chorda dorsalis, or notochord, and the somites, or provertebrae. The normal de- velopment of the embryonal body now depends, in its gross features, upon an arching-over process of cells which inclose Plate 2. Iniur ctll Outer cell- Outer cetli. Inner eetta Outer cells. I, 2, 3, Diagrams illustrating the segmentation of the mammalian ovum (Allen Thomson, after van Beneden). 4, Diagram illustrating the relation of the primary layers of the blastoderm, the segmentation-cavity of this stage corresponding with the archenteron of amphioxus (Bonnet). DEVELOPMENT OF THE EMBRYO AND FETUS. 95 the spinal canal, the abdominal and thoracic cavities, and the cranial cavity. An arrest in these developmental processes re- sults in such deformities as spina bifida, exomphalos, celosoma^ hydrencephalocele, and anencephalia. Assuming that impregnation occurs in the ampulla of the tube, some five to seven days elapse before the ovum arrives in the uterine cavity. The implantation of the ovum in the uterine mucous membrane occurs in the following manner: Either by pressure or by an active erosion of the uterine cells by the primitive peripheral cells of the ovum the epithelium of the endometrium is penetrated, and the o\aim imbeds itself in the connective tissue of the mucosa, the epithelium closing over it again and thus ex- cluding it from the uterine cavity (Peters). CHAPTER IV. The Development of the Embryo and Fetus. The changes in the developing embryo and fetus ^ from month to month have practical value for the obstetrician when he would determine the probable date of impregnation from the appearance of the cast-off ovum. The intelligent explanation of many congenital deformities and intra-uterine accidents and dis- eases also depends upon a knowledge of intra-uterine develop- ment. First Month. — Direct observation of the human ovum dur- ing and shortly after impregnation fails us. The theories as to the site in which this phenomenon occurs, as to the changes that immediately succeed it, are based upon what has been actually seen in the lower animals, and upon the clinical history of pregnancies in which the ovum is developed in an unnatural situation. Thus it is argued that the spermatic particle must penetrate the ovule shortly after its escape from the Graafian fol- licle, for the occasional occurrence of abdominal and tubal preg- nancies proves that the spermatozoa can make their way far into the tube and even on to the surface of the ovary ; and what is seen in animals makes it probable at least that the outer coating of the ovule, during its passage through the tube, receives an ad- ditional thickness from an albuminous deposit upon it, or that the original cell-w^all becomes denser and tougher by a process ^ The usual plan of calling the product of conception "embryo" for the first three months, and afterward " fetus," is the one adopted here. 96 PREGNANCY. of coag-ulation ; either of which conditions would render i e penetration of the ovule by a spermatic particle unlikely, if .lOt impossible. On the other hand, it is claimed ^ that if the ovule escapes from the ovary at the beginning of the menstrual flow, and if the fruitful coition occurs only some days after menstru- ation has ceased, as is common at least among civilized people, the time that intervenes between the rupture of the Graafian follicle and the deposition of semen in the female genital tract has been too great for the ovule to remain in the ovarian ex- tremity of the oviduct, but, on the contrary, insures its presence in the uterine cavity. It is asserted that the rhythmical contrac- tion of the muscles in the tubal walls which drives the exuded menstrual blood, as well as the ovule, toward the uterus, offers an additional barrier to the ascent of the spermatozoids. This argument is invalidated, however, by the occasional occurrence of extra-uterine pregnancy. The old explanation of the migra- tion of the ovum to the abdominal orifice of the tube was that the fimbriated extremity of the latter became "e~ected" at the time the ovule escaped, and grasped with its fimbriae the sur- face of the ovary, thus displaying a sort of independent in- telligence. The anatomical impossibility of the fimbriae being closely and accurately applied to the surface of the ovaiy has been demonstrated, ^ and the tube contains no true erec- tile tissue ; this theory, therefore, has long been exploded. The fact that the fimbriae are provided with ciliated epithe- lial cells which work actively toward the uterus, and create a stream in the moisture which is always present upon the peritoneal surface, accounts for the transference of the ovule from the ovary to the oviduct. The ovule, being discharged from the Graafian follicle, is either brought directly in contact with the cilia of a fimbria, or else, dropping upon the peritoneum, it is caught in the gentle current of a minute quantity of fluid that always bathes that membrane, and is so conveyed to the wide opening of the abdominal end of the oviduct. This explanation also accounts for the so-called "external migration" of the ovule, which, discharged from an ovary and failing for some reason to be taken up by the corresponding tube, finds its way to the opposite tube, — an occurrence that has been observed in certain cases of tubal pregnancy. ^ ^ See Wyder: " Beitr. zur Lehre v. d. Extrauterinschwangerschaft u. dam Orte der Zusammentreffens von Ovulum u. Spermatozoen," " Archiv f. Gyn.," Bd. xxviii, ■^- 325- 2 Henle, " Handb. Anat. d. Menschen," 1864, Bd. ii, S. 470; and Bischoff, *' Entwickelungsgeschichte," S. 28. 3 Wyder, loc. cit. DEVELOPMENT OF THE EMBRYO AND EETUS. 97 The changes in the ovum immediately before impregnation arv. described in the preceding chapter. It only remains to notice the successive changes in size and development that determine the age of the ovum and embryo and that explain intra-uterine deformities and diseases. The youngest human ova seen and described have been eight to thirteen days old/ Peters' claim that the ovum in his famous case was only, three or four days old is not generally admitted. In this case the diameter of the ovum was about i mm.; the chorion is furnished with thin and simple villi, the allantois is not to be detected, and almost the whole ovum is occupied by the yolk-sac. Waldeyer has described an ovum, twenty-eight to thirty days old, that measured 19 mm. (0.748 in.) in length, 16.5 mm. (0.649 in.) in breadth (about the size of a pigeon's &gg), and weighed 2.3 gm. (36 grs.). The length of the embryo, in a straight line from cephalic to caudal extremity, was 8 mm. (0.315 in.), w^^ile the actual length of the dorsal line was 20 mm. (0.79 in.). During the first month the human embryo is indistinguish- able from that of other mammals. The ovum at this early period may be described as a double-walled, flattened vesicle, filled with fluid. The outer wall bears the branched villi ; the inner one is smooth. The connection of the villi with the decidua reflexa, and even with the decidua serotina, is a super- ficial one, and the ovum is easily separated from its uterine attachments. 2 The yolk-sac, at first occupying nearly the whole ovum, even at the end of the first month is larger than the cephalic extremity of the embryo. The visceral arches are distinct ; the limbs are merely rudimentary ; the cord is straight, thick, and short ; and the amnion is still quite close to the embryo, and is separated from the chorion by a clear space. During the first month the heart appears as a cylindrical body, which soon becomes S- shaped, and by the fourth week displays four distinct cavities and is covered by its peri- cardium. It is probably functionally active by the third week.^ The brain and spinal cord are inclosed; the intes- 1 " Edinb. Med. Jour.," vol. lii ; "Verhandl.d. Ak. d. W. Amsterdam," iii, 3; " Historie du Develop.," pi. iii; "Arch. f. Gyn.," Bd. v, S. 170; "Abhandl. d. Konigl. Ak. d. W. zu Berlin"; " Wien. med. Wochen.," 1877,8. 502; "Arch, f. Gyn.," Bd. xii, S. 42I ; ibiJ., Bd. xii, S. 482; Peters, " Ueber die Einbettung des Menschlichen Eies," 1899; Leopold, " Centralbl. f. Gyn.," 1896, p. 1057; also " Uterus u. Kind." 2 See Br. Hicks, " Obst. Tr.," xiv, p. 149; Langhans, "Archiv f. An. u. Phys.," 1877, ii u. iii, S. 231 ; Ahlfeld, "Arch. f. Gyn.," Bd. xiii, S. 231. * Preyer, " Specielle Physiologie des Embryos." 7 98 PREGNANCY._ *- M o • 35 s 3 s o 0) > r_ ^ a. o . a 1 3 ^ a. w ^ ^ ,-^ ^T • ^ « .. If: s (U en c o in OJ • ^ 1 13 C I- s O >p ti f o S p 'a 15 3 o ■^ TJ ^ c; ^ >^ in •^ 00 ■^ 1> "la C3 ^ .£ us ■3 1> s rr n &: s o .^ Ti c j^ c CS rt S c^ oJ O 1^ X. ^ a. S^"!^ ^c s "5 0) M n D ^ 1 2 • - o ■vT 1 1 b^ cs ^ •jT -d CS .« t-~ - CC s ^ 'S, tri P a a >> £ c: "t £ vC "'•£ U ;c 'T "o DEVELOPMENT OF THE EMBRYO AND FETUS. 99 tinal tract is also closed over, but the connection with the umbilical vesicle is still a wide one ; the first traces of a liver appear ; the primitive kidneys may be seen ; and toward the end of this period the eyes may be distinguished at the sides of the head and the rudimentary extremities become visible as four bud- like processes. The oral and anal orifices of the intestinal tract are formed by depressions in the integuments, which open into the extremities of the tract after the absorption and disappearance of the intervening tissues. Second Month. — At the beginning of the second month the ovum is the size of a pigeon's egg, and the embryo measures 8 mm. (0.3 inch) in a straight line from head to tail. During this month the embryo grows to 2.5 cm. (i in.) in length and the ovum reaches the size of a hen's ^g,%. The visceral clefts close, with the exception of the first, which eventually forms the external auditory meatus, the cavity of the tympanum, and the Eu- stachian tube. The first visceral arch, dividing into two branches, forms the superior and inferior maxillary processes. The latter, one from each side, approach each other and finally unite to form the lower jaw. The superior maxil- lary processes, while ap- proaching each other, are kept from uniting by the interven- tion of the frontal process. At the point of junction of the latter with the two superior maxillary processes there occurs occasionally the deformity known as harelip, from the fail- ure of the processes to unite ; but as union is always perfect before the end of the second month, the arrest of development that results in this deformity must have taken place at some tmie prior to the third month. During the second month, from the growth of the viscera, the body becomes less curved, and from the development of the brain the head increases in Fig. 88. — Human embryo of about six weeks, enlarged five times (His). lOO PREGNANCY. size. The umbilical vesicle atrophies, and may be found at- tached to the body by a slender pedicle. The umbilical ring is somewhat contracted, but still contains a few loops of intes- tine ; so that if there is at this time an arrest in the develop- ment of the abdominal walls, an extensive umbilical hernia or exomphalos results. The umbilical cord runs straight to the periphery of the ovum. The eyes occupy a position on the sides of the head ; behind them may be seen the ears, and in front arises the external nose. The limbs are separated into their three divisions, and the first suggestions of hands and feet .appear, with the fingers and toes webbed. The Wolffian bodies .are much lessened in size, but the kidneys and suprarenal cap- sules are developed. The external genitals make their appear- ance, but neither internally nor externally is the sex to be dis- tinguished, for the elements of both sexes are present in equal degree. Toward the end of the second month or at the begin- ning of the third the eyelids appear. There are points of ossifi- cation to be seen in the lower jaw and clavicle. The villi of the chorion have taken on a more luxuriant growth at the point where the future placenta is to be developed, and the fetus draws its nutriment from the maternal blood. Third Month. — During this month the ovum attains the size of a goose's &'g^, 9.5 to ii cm. (3.74 to 4.3 in.) long, and the embryo grows to a length of 7 to 9 cm. (2.75 to 3.5 in.) and weighs about 30 gm. (460 grs.). The umbilical cord in- creases in length to 7 cm. (2.7 in.) and becomes twisted. The umbilical ring is smaller and the intestines are retracted within the abdomen. The fingers and toes lose their webs, and the nails appear as fine membranes. The eyes approach nearer to each other and are protected by the lids. Points of ossi- fication may be found in most of the bones, and the neck separates the head from the trunk. The ribs divide the trunk plainly into chest and abdomen ; the oral and nasal cavities are separated by the palate ; the lips close over the mouth and teeth begin to form in the jaws. The sex may be distinguished by the presence or absence of a uterus ; cutaneous folds form a scrotum or the labia majora, but the clitoris and penis are still of equal length. The chorion loses its villi, except at the point where the placenta is developing. The latter, though small, can plainly be distinguished. Fourth Month. — In the fourth month the fetus attains a length of 10 to 17 cm. (4 to 6.75 inches) and a weight of 55 gm. (850 grs.).i The umbilical cord is more twisted than in 1 Given by Spiegelberg as Hecker's weights and measurements. Spiegelberg, " Lehibuch," tr. by Syd. Soc, p. 118. DEVELOPMENT OF THE EMBRYO AND FETUS. lOI the preceding month, and the placenta is increased in size. The head of the fetus now amounts to a quarter of the whole length of the body, and the cranial bones are in part ossi- fied, although the fontanels and sutures gape widely. The sex is plainly seen, the genital fissure, in the case of a male, hav- ing united to form the scrotum, leaving in the median line a distinct raphe. The future prostate is indicated by a thickening at the point of meeting of the genital cord and the urethra. A fine growth of down appears upon the fetal skin (lanugo), and a few hairs are seen on the scalp. The intestines contain meco- nium ; the limbs may be feebly moved ; and the fetus may live, if born, as long as four hours (Cazeaux). Fifth Month. — During this month the fetus is about i8 to 27 cm. (7 to 10.5 inches) long and weighs about 273 gm. (8 ounces). The umbilical cord is about 31 cm. (12 inches) long. The liquor amnii exceeds the fetus in weight. The head is relatively very large ; the face has a senile look and is wrinkled, and the eyelids begin to open. The skin is richer in fat, is covered with lanugo, and in places with vernix case- osa, a sebaceous material containing also epithelial scales and downy hairs. Some time during the fifth month the mother usually experiences "quickening," — that is, the movements of the fetus, — and the fetal heart-sounds may be heard on auscultation. If the fetus should be born at this time, it may make efforts to cry, but it dies in a few hours. Sixth Month. — The fetus toward the end of the sixth month is from 28 to 34 cm. (11 to 13.5 inches) long and weighs 676 gm. (23^ ounces). The skin is better supplied with fat; the hairs of the scalp grow longer ; eyebrows and eyelashes are distinct. The umbilical cord is inserted in the middle third, between the pubic symphysis and the xiphoid cartilage. The head is still relatively large. The testicles in boys approach the inguinal rings. If a fetus at this stage should be born, it might live from one to fifteen days, but would, in all probability, eventually die from insufficient assimilation of food, from rapid loss of heat, and from imperfect respiration, owing to the undeveloped state of the finer ramifications of the air-passages. Seventh Month. — At the end of this month the fetus measures in length 35 to 38 cm. (13.75 to 15 inches) and weighs 1 170 gm. (41 y^ ounces). The whole body is covered with lanugo except the palms of the hands and the soles of the feet. The large intestine contains a considerable quantity of meconium. The pupillary membrane, which had hitherto obscured the pupil, I02 PREGNANCY. now disappears. A child born between the twenty-fourth and twenty-eighth weeks usually dies.^ Eighth Month. — The fetus measures in length 39 to 41 cm. (15.25 to 16 inches) and weighs 1571 gm. (3^ pounds). The hair on the scalp is more abundant ; the down on the face is disappearing. One of the testicles, usually the left, has de- scended into the scrotum. The nails are firmer, but do not yet project beyond the finger-tips. At the end of the eighth month ossification begins in the lower epiphysis of the femur. The cord is inserted a little below (0.6 to 1.2 inches) the middle point, between the xiphoid appendix and the pubic symphysis. A child born at this period may, with proper care, survive. Ninth Month. — The length of the fetus measures 42 to 44 cm. (16.5 to 17.25 inches) and the weight is 1942 gm. (4^^ pounds). There is a decided increase in subcutaneous fat. The nails are not yet perfectly developed. Toward the end of this month, near the thirty-sixth week, the weight is about 5 y^ pounds, and the diameters of the skull about i to 1.5 cm. (0.39 to 0.50 in.) less than in a normal fetus at term.^ The bones of the skull are compressible and easily molded to the shape of the pelvic cavity ; and if born at this time, the infant with ordinary care will certainly live. Tenth Month. — During the tenth month (thirty-sixth to for- tieth week) the fetus is developing from the condition just de- scribed — that is, characteristic of the thirty-sixth week — into the infant at term, distinguished by all the features that indicate the arrival of the fetus at maturity. It is during the last month of pregnancy that the physiology of the fetus can be studied to the best advantage. It has now reached a large size and requires a considerable quantity of oxygen ^ for its blood and nourishment 1 There persists, even yet, in the minds of some general practitioners, as well as among the laity, as the writer can testify, the idea that children born in the seventh month will be more likely to survive than those born at the eighth month. Professor Parvin (" Science and Art of Obstetrics ") shows how this superstition has descended, through more than two thousand years, from Hippocrates, who explained that the fetus is placed with its head uppermost in the uterine cavity until the seventh month, when the increasing weight of the head causes it to fall down to the os uteri. As soon as this occurs, the fetus attempts to make its escape, and if it is strong it suc- ceeds, but if the attempt fails, it is repeated at the eighth month, and if the infant now succeeds in escaping from the womb, being exhausted by its previous effort, it is likely to die. 2 Schroeder, from the measurements of 68 premature infants, gives the average biparietal diameter of the head as 8.83 cm. (3.5 in.) from the thirty-sixth to the fortieth week; 8.69 cm. (3.42 in.) from the thirty-second to the thirty-sixth week; 8.16 cm. (3.21 in.) from the twenty-eighth to the thirty-second week, showing that this diameter, a most important one, is relatively very large even early in fetal life. 3 That the fetus obtains oxygen from the maternal blood has been proved by (l) cutting off the blood-supply to the uterus, when the fetus will die of asphyxia (Vesal, Seyl) ; (2) by the discovery, by means of spectral analysis, of oxyhemoglobin in the umbilical vein of the cord (Zweifel). DEVELOPMENT OF THE EMBRYO AND FETUS. IO3 for its tissues, both of which it obtains from the maternal blood through the medium of the epithelial cells that form the outer- most fetal layer of the placenta (the syncytium). From the fact that the fetus undoubtedly swallows considerable quantities of liquor amnii during the latter months, at least, of pregnancy,^ and because that liquor contains a small proportion of albumin, 2 it has been claimed that the fetus derives its whole nourishment from the amniotic fluid, while the func- tion of the placenta is confined to the oxygenation of the fetal blood, — a theory not likely to find general acceptance. Another fact, however, in its favor is the secretion of the gastric glands during the latter period of intra-uterine life.^ The urine, secreted in considerable quantity, and, as a rule, albuminous,* is voided freely into the amniotic cavity. The fetus, from time to time, moves its limbs vigorously, and its heart beats from one hundred and twenty to one hundred and sixty times a minute. The circulation of the fetal blood has certain peculiarities that deserve consideration. Beginning at first by a very simple arrangement in a tubular heart and four vessels (two arteries and two veins), which carry the blood to and from the umbilical vesicle, it soon assumes the characteristics that are most plainly to be seen in the stage of pregnancy under consideration. The blood that has been oxygenated in the terminal villi of the placental tufts is returned by veins of increasing size to the large branches of the umbilical vein, which may be seen directly under the amnion on the fetal surface of the placenta. These branches, converging, unite in the umbilical vein, which is carried by the cord to the fetal body at the umbilicus. Thence it runs along the anterior surface of the abdominal cavity to the under surface of the liver, where, giving off branches to the lobus quadratus, lobus Spigelii, and to the left lobe, it divides into two main trunks at the transverse fissure, the larger of which enters the portal vein, while the other empties into the ascending cava and is called the ductus venosus. Thus by far the greatest quantity of oxygenated blood that is returned to the fetus from the placenta must first pass through the liver before entering the general circulation. The ascending cava conveys 1 Zweifel, " Untersuchungeniiber das Meconium," "Arch. f. Gyn.,"Bd. vii, 1875, P- 474- 2 Anderson, "Am. Jour. Obstetrics," Aug., 1884. 3 Krukenberg, *' Magensecretion des Fotus," " Centralbl. f. Gyn.," No. 22, 1884. * Ribbert, " Ueber Albuminuria des Neugeboren u. des Fotus," Virchow's Archiv," Bd. xcviii, S. 527. I04 PREGNANCY. then to the right auricle a large proportion of arterial blood, but mixed with it is the venous blood from the lower extremities and the blood returned from the liver. But this great volume of blood having arrived at the right auricle, instead of descending into the right ventricle and being carried thence to the lungs, which in their unex- panded condition could not contain it, is guided across the right auricle by the Eus- tachian valve, and enters the left auricle by means of an opening in the interauricular septum, — the foramen ovale. From the left auricle the blood from the ascending cava enters the left ventricle and is driven thence into the aorta, by which it is conveyed pri- marily to the upper extremity of the fetus by the ascending branches of the arch of the aorta. Here may be seen an arrangement peculiar to fetal life, by which the blood is di- verted from the unused lungs and conveyed instead to the aorta. Just beyond the point at which these branches are given off there opens into the aorta a large branch from the pulmonary artery (the ductus arteriosus), which conveys the blood that enters the right auricle, and then the right ventricle, from the descending vena cava. Only a small quantity of blood, sufficient for their nutrition, goes to the lungs. Thus the aorta conveys a mixed blood, still further devitalized from the infusion of the venous blood from the head, neck, and upper extremities, to the trunk and lower extremities. It is by this arrangement that a greater quantity of arterial blood is conveyed to the brain, which develops so Fig. 89. — Diagram of the fetal circu- lation : a, a. Aorta; 6, innominate artery; f, left carotid ; d, left subclavian; e, iliacs ; y, internal iliac arteries ; g, hypogastric arteries; k, pulmonary artery; i, right ventricle ; /, left ventricle ; k, ductus ar- teriosus ; /, left auricle ; m, left auriculo- ventricular opening ; n, foramen ovale ; o, right auricle ; /, Eustachian valve ; ^, right auriculoventricular opening ; r, vena cava ascendens ; s, liver ; /, hepatic vein ; u, branches of the umbilical vein to the liver ; V, umbilical vein ; 7v, umbilical cord ; x, bladder ; y, vena cava descendens ; 2, ductus venosus (Flint). DEVELOPMENT OE THE EMBRYO AND EETUS. 105 rapidly during intra-uterine life. Following the blood-current down the aorta to the iliac arteries, and thence to their internal branches, two arteries, one from each branch, ascend to the umbilicus whence they pass out of the body to form the two arteries of the umbilical cord. Within the body they are known as the hypogastric arteries. The two arteries of the cord carry to the placenta vitiated blood, which, in the terminal placental villi, discharges into the maternal blood the effete products of the life-processes in the fetus and re- ceives in return a fresh supply of oxygen and nutriment, and probably a fair share of the soluble salts of the blood, as well as any other substance, medicinal ^ or otherwise, that the maternal blood may contain in solution or possibly even in suspension. While the passage of matter from the maternal into the fetal blood seems to occur so frequently, it would appear to be more difficult for substances, aside from the effete products of tissue activity, to pass from fetus to mother. There is reason to believe, however, that the spirochaeta of syphilis may take this course. It has also been demonstrated that certain drugs, as strychnin, may pass from fetus to mother. ^ The ease with which medicinal substances pass from mother to fetus has caused anxiety lest in the administration of powerful drugs to the mother the fetus might be injuriously affected. ^ It is possible, of course, to harm the fetus by administering poisonous substances to the mother, but it is extremely unlikely that the fetus will be much affected unless the dose to the mother much exceeds the usual therapeutic limit. But, like the adult, the fetus may become accustomed to a drug, and be able finally to endure large quantities of it in the maternal blood.* The temperature of the fetus in utero is slightly higher than that of its mother. Priestley, ^ in experiments on rabbits and cats, found the temperature of the fetus about i ° F. ^ Chloroform, carbonic oxid gas, salicylate of sodium, benzoate of sodium, atropin, strychnin, morphin, quinin, corrosive sublimate, iodid of potassium, ether, urea, the bile-salts, soluble salts of lead, tobacco, sulphindigolate of soda, the germs of many diseases, have all been known to pass from mother to fetus. ^ Schroeder, " Geburtshiilfe," 8th ed., p. 63. ' Parvin's "Obstetrics," 148. * I was obliged on one occasion to administer very large doses of morphin daily for a period of some weeks to a patient who was suffering from general septi- cemia in the seventh month of pregnancy. The fetus continued to move actively in utero, and I could detect no change in the fetal heart-sounds. The woman finally gave birth to a living infant. ^ " Lumleian Lectures on the Pathology of Intra-uterine Death," rep. for "Brit. Med. Jour.," 1887, p. 16. I06 PREGNANCY. higher than that of its mother. Taking the temperature in ano of a fetus coming down during labor by the breech, and com- paring it with the temperature of the vagina, ^ or taking the temperature of infants immediately after birth, ^ the fetus is found warmer than the mother by o. 5 ° C. Of all the organs in the fetal body, the liver is the most active. Almost all the oxygenated blood from the placenta goes first to the liver. The great quantity of meconium in the fetal intestines — a substance composed mainly of bile- salts — attests the active secretory work of this organ, and to it, also, may be attributed the source of the large quantity of glycogen ^ found in fetal tissues, especially the muscles, where this substance probably has work to perform, the nature of which is not yet understood. THE MATURE FETUS. There is no single sign that enables one to declare a given fetus to be fully mature ; but the weight, measurements, and stage of development, taken together, indicate with tolerable accuracy the length of time that the fetus has remained in utero. A mature healthy fetus should weigh about 3317 to 3459 gm. (73 to 7f pounds), according to the statistics of Lusk and Parvin; but in Europe the weight of the mature fetus is some- what less, for the statistics of Scanzoni, Ingerslev, Hecker, Fesser, and Bailly, including a large number of observations, give a weight of less than 3175 gm. (7 pounds). Variations in weight at term between 2728 and 4082 gm. (6 and 9 pounds)* are by no means rare, and the range of possibility in the weight of a mature fetus is a very wide one. Thus Harris^ refers to an infant that weighed but a pound, and to another, the child of the Nova Scotia giantess, that weighed 13,040.78 gm. (28I pounds) at term. A decided departure, however, from 1 Wurster, "Berlin, klin. Wochens.," 1869, No. 37, and " Beitr. z. Tocother- mometrie," D. i, Zurich, 1870. 2 See Barensprung, Miiller's " Archiv," 185 1 ; Schafer, D. i, Greifswald ; Andral, " Gaz. Hebd.," July, 1870; Schroeder, Virchow's "Archiv," Bd..xxxv, S, 261 ; and the " Lehrbuch," 8th ed., 1894, p. 65 ; also, Alexeeff, "Archiv f. Gyn.," Bd. X, S. 141. s Marchand, " Ueber das Glykogen in einigen fotalen Geweben," Virchow's "Archiv," Bd. c, S. 42. * An infant of over nine pounds is not common, while heavier weights are pro- gressively rare. Out of looo infants, Dr. Parvin saw but one that weighed II pounds (Parvin's "Obstetrics," p. 138). Of I156 infants born in my service in the Mater- nity Hospital, the heaviest weighed 12 pounds. 5 Note to Playfair's " Midwifery." THE MATURE EETUS. lOJ the normal average indicates, on the one hand, prematurity or a weak development; on the other, the prolongation of preg- nancy, race peculiarities, the \dgor or excessive size of the parents, especially the mother, or the preoccurrence of several pregnancies. Sex also influences the size of the infant, males being, on an average, larger than females. The length of a mature fetus is 51 to 53 cm. (20 to 21 in.). The width across the shoulders (binacromial diameter) is about 12 cm. (4.75 in.); the dorsosternal diameter is 9 to 9.5 cm. (3.5 to 3.75 in.); the binihac, 9.5 to 10 cm. (3.75 to 4 in.). The length of the foot is about 8 cm. (3.15 in.).^ The dimensions of the head are im- portant as a sign of the development of the fetus. The following dimensions of the fetal head may be consid- ered characteristic of the normally developed infant directly after its expulsion from the uterus : Bitemporal (B. T.) diameter, 8 cm. (3.15 in.). Biparietal (B. P.) diameter, 9j4^ cm. (3.64 in.). Occipitofrontal (O. F.) diameter Ii^ cm. (4.56 in.). Occipitomental (O. M.) diameter, 13 cm. (5. 12 in.). Maximum (M. M.) diameter, 13^ cm. (5.32 in.). Suboccipitobregmatic (.S. O. B. ) diameter, . 9^ cm. (3.74 in.). Trachelobregmatic (T. B.) diameter, . . . g}i to 10 cm. (3.74 to 3.94 in.). Circumferences: O. F., 34;^ cm. (I3.58in.); S. O. B., 30(11.8); 0. M., 37 (14.5). These dimensions are subject to modification. Any of the causes that tend to increase the size of the infant as a whole like- wise influence the size of the head ; but even with a normal body-weight and length the head may be disproportionately large, without being diseased. Another valuable sign of maturity in the fetus is the appear- ance and extent of certain centers of ossification. ^ In the center of the lower epiphysis of the femur is found at birth a spot of ossification measuring five millimeters in diameter, while a similar but smaller spot is just appearing in the upper epiphysis of the tibia. The center of ossification in the astrag- alus is found without difficulty, for it first appears at the seventh month of intra-uterine Hfe. The center of ossification in the cuboid bone is at birth beginning to make its appearance. The "ossified spot in the lower epiphysis of the humerus only appears some months after birth. The general appearance of a new-born infant is of value as indicating whether or not the fetus had reached maturity before its expulsion from the uterus. A healthy infant at term looks ^ Negri says ("Ann. di Ostet.," ISIay to June, 1885) that when the foot measures eight centimeters the fetus is well developed and weighs about 3500 gm. * See Rossie, "Amer. Jour, of Obstetrics," 1886, p. 18. I08 PREGNANCY. stout and well-nourished. The face is plump and is free from lanugo ; miliaria are seen about the tip of the nose, but are not nearly so evident as they were in the ninth month of intra-uterine existence. The eyes are usually opened, the limbs move vigorously, and the child seizes with its lips the nipple when presented to it, and sucks with energy. The vernix caseosa is abundant only on the back of the child and on the flexor surface of the limbs. The nails project beyond the finger- tips ; the cartilage of the ears and nose feels firm ; eyebrows and eyelashes are well developed ; the hairs of the scalp are about an inch long ; the bones of the head are hard and lie close together. The breasts in both sexes are large, and usually a thin fluid can be squeezed out of them. In boys the testicles are usually to be felt in the scrotum, although the tunica vaginalis is not yet closed. In girls the labia majora are usually approxi- mated, although occasionally the nymphse project between them. The Determination of Sex. — In all countries the number of male children born exceeds the number of females, the average proportion being io6 to lOO ; but, as more boys die than girls, by the time puberty is reached the sexes are about equal in num- ber. The law that governs the production of sex has long beert a subject of discussion and speculation. The Hippocratic doc- trine that the right ovary produced boys and the left girls was accepted for centuries, and upon this belief was founded the precept that women who desired male offspring should lie during coitus upon the right side, while those who desired daughters must lie upon the left side. By experiments upon animals, by the observation of women in whom one ovary was destroyed by disease or removed by an operation, and by a more complete knowledge of the mechanism of impregnation, the long-accepted teaching of Hippocrates was disproved, although not until com- paratively recent times. At present it is undecided whether the question of sex is determined, before impregnation occurs, — that is, whether certain spermatic particles or ovules are predes- tined to produce males, while others produce females ; whether the sex is impressed upon the ovule at the moment of conception, or whether the embryo is possessed of the elements of both sexes until one or the other acquires a preponderating influence owing to causes which may be operative during the early part of pregnancy. The first theory receives its chief support from the fact that unioval twins are invariably of the same sex, which looks as though the ovule was predestined in the ovary to the formation of one or the other sex. The last theory is based upon the study of plants and lower animals, in which the sex is only determined at some time after fertilization by the influence THE MATURE FETUS. IO9 of nourishment ; overfeeding being found to produce females, underfeeding to produce males. It is possible in the case of certain animals to alter the sex, or at least to produce her- maphrodites, even after the sexual organs have begun to be dif- ferentiated. ^ This theory is further supported by the fact that in the human embryo the elements of both sexes are always present apparently in equal force during the early part of em- bryonal life. The belief that the sex of a human embryo is impressed upon it at the moment of conception rests upon the fact that in certain conditions of nutrition or sexual vigor in one or the other parent one sex preponderates, while under opposite conditions the other sex is most frequently produced. ^ The most diverse conditions have been held accountable for departures from the normal numerical relation of the sexes at birth. Illegitimacy, ^ age of parents,^ conception at certain periods after menstruation, ^ deformities in the female pelvis,^ the nutrition or sexual vigor of the parents,'^ the tendency of each sex to produce the opposite or the reverse,* the tend- ency to produce that sex which is most needed to perpetuate the species,^ the season of the year, ^"^ climate and altitude, ^^ 1 In the case of the larvae of bees from impregnated eggs, when the female gen- ital organs have begun to appear, if the nourishment is very insufficient, instead of becoming female workers these animals will actually develop into true hermaphro- dites, with the organs of both sexes (Fiirst). * Thury (" Zeitsch. f. w. Zoologie," 1863, Bd. xiii, S. 541) found in 29 experi- ments upon cattle that in every case, if connection occurred at the beginning of heat, females were produced ; if at the end, males. 3 Fiirst ('* Archiv f. Gyn.," Bd. xxviii, S. 19) says that in illegitimate births the males fall below the average (based upon 807,332 cases). This coincides with my experience in the Maternity Hospital in more than looo cases of illegitimate births. ■* See Hofacker, " Ueber die Eigensch. welche sich von den Eltem auf die Nachk. vererben," 1828 ; Sadler, "Law of Population," London, 1830 ; Hecker, "Archiv f. Gyn.," Bd. vii, S. 448; Bidder, "Zeitsch. f. Geburtsh.," Bd. ii, S. 358; Ahlfeld, " Archiv f. Gyn.," Bd. ix, S. 448; Wall, " The Causation of Sex," London " Lancet," 1887, i, pp. 261, 307. 5 Thury, loc. cit. ; Coste, " Comptes Rendus," 1865 ; Schroeder, " Lehrbuch," 8te Aufl., 1884, S. 33; Fiirst, " Knaben Ueberschuss nach Conception zur Zeit der postmenstruellen Anamie,'' " Archiv f. Gyn.," Bd. xxviii, S. 18. ^ Olshausen, " Klinische Beitrage," Halle, 1884; Linden, "Hat das enge Becken einen Einfluss auf die Entstehung des Geschlechts ? " Dis. Inaug. , Mar- burg, 1884; R. Dohm, "Zeitsch. f. Geburtsh. u. Gyn.," Bd. xiv, S. 80. ^ See Fiirst, loc. cit., and Schroeder, op. cit., S. 33. Also Schenk (Determination of Sex, authorized translation, Chicago, 1898), who believes that imperfect metabolism and glycosuria in the mother predispose to female offspring, while a strong nitrogenous diet and absence of sugar in the urine prepare a woman to bear male offspring. * See Fiirst, loc. cit. 8 Diising, " Die Regulirung des Geschlechtsverhaltnisses bei der Vermehrung der Menschen, Thiere, u. Ptlanzen," Jena, 1884. 1" According to Diising [loc. cit.), women impregnated in summer give birth to fewer boys than those impregnated in winter (conclusions based on more than 10,500,000 births). ^ 1 Floss found, in Saxony, that up to 2000 feet, the greater the altitude, the larger was the number of male births [a.1 2000 feet, 107.8 to 100). no PREGNANCY. diet/ and the degeneration of a race, as during the decadence of imperial Rome,- — have all been advanced as reasons for ap- parent excess in the number of male or female births. These theories, however, have been found false or inadequate upon further investigation. An explanation of the determination of sex is not yet obtained, and the production of the sexes at will is still impossible. Multiple Fetation. — It is the rule that but one fetus at a time is developed within the uterus of a human female. Once in about 1 20 pregnancies,' however, two fetuses are developed simultaneously in the same uterus, so that twins are not of un- common occurrence. Triplets are found once out of 7900, quadruplets once out of 371,126 births. Quintuplets are ex- tremely rare. There is one case of sextuplets on record.* Multiple fetation maybe the result: (i) Of the impregnation of a single ovum that contains two or more germinal vesicles, or in which the formative material of the area germinativa divides ;^ (2) of the impregnation of two or more ova which were contained either in one Graafian follicle or in separate follicles, the latter being situated either in one or both ovaries; (3) of the penetration of the ovum by more than one spermato- zoon ; (4) of the impregnation of ovules escaping at different times from different Graafian follicles (superfetation).® There may be a hereditary disposition to multiple fetation. Boer reported, in 1808, an extraordinary example:' A woman aged forty had in 1 1 pregnancies during twenty years given birth to 32 children, to wit: quadruplets twice, triplets six times, twins thrice. The woman herself was one of quadru- plets and her mother had had 38 children. Her husband was one of twins, and there was a history of other plural births in his family. Dr. M. M. Magofi&n, of Mercer, Pa., reports to me the case of a woman who gave birth twice within a year to quintuplets, and again within a year to twins, or 12 children in twenty months. She then died. If the multiple fetation is the result of the impregnation of a single ovum, there is but one chorion and one decidua 1 J. C. Webster, " Some Fundamental Problems in Obstetrics and Gynecology," "Amer. Med.," Dec. 10, 1904. 2 Darwin's Collected Works. 3 According to statistics collected by Veit, based on more than 13,000,000 births, twins occur once in 89 pregnancies ; in New York and Philadelphia the proportion is about I to 120. * Vassali, "Gaz. Med. Ital. Lombardia," Milano, 1888, No. 38. 5 Ahlfeld, "Archiv f. Gyn.," Bd. ix, S. 196. ^ Slavjansky has observed a recent ovulation in a woman three months pregnant, but with extra-uterine pregnancy. ' " Wien. med. Wochens.," No. 3, 1897. THE MATURE FETUS. I II reflexa, although each fetus is inclosed in its own amnion.' The fetuses are always of one sex. The placentae are intimately united with extensive arterial and venous anastomoses — a condition that may give rise to the deformity of one of the twins, known as acardia. But in the early stages of development each placenta, even in unioval twins, is separate. When the em- bryos are derived each from a separate ovum, there should be separate deciduae reflexae, chorions, and pla- centai. Occasionally, how- ever, when the ova are im- planted close together, the placentae may be joined, there may be but one decidua reflexa, and it may be difficult to detect the double layer of chorion that should separate the two ova. Although twins are not infrequently born, the con- dition should be regarded as pathological. From statis- tics collected by Schatz,^ it appears that in twins from different ova one is born dead in every twenty-three cases, while from the same ovum the death-rate is one in six. One fetus may outstrip its fellow in growth, and divert the greater part of the nourishment from the mother to itself, thus growing rapidly and encroaching so much upon the room that should belong to the weaker fetus that the latter is killed and finally pressed flat against the uterine wall (foetus papyraceus). Hydramnios is also very common in twin pregnancies, and occasionally one fetus is converted into an acardiac monster. If the fetuses of a twin pregnane}' escape the dangers of intra-uterine life, there are many complications 1 Occasionally two fetuses are found in a single amniotic cavity, which is to be explained (i) by the atrophy and absorption of the contiguous amniotic walls; (2) by rupture of the amnion in the latter months from the vigorous move- ments of the fetus; or (3) by the development of but a single amnion from the very beginning (Myschkin, Virchow's " Archiv," Bd. cviii, S. 133, 146). 2 " Archiv f. Gyn.," Bd. xxix, S. 438. Fig. 90. — Fetus papyraceus (author's specimen). 112 PREGNANCY. awaiting them in labor. Should one fetus die during pregnancy, it is usually retained until term, when the Hving and the dead child are cast off together, widely different in appearance and develop- ment ; 1 or else one ovum may be aborted at an early period of pregnancy, while the other goes on developing until term.^ Even though both children have been retained hi utero an equal length of time, there is usually a marked difference in their length and weight, especially if they have resided in one ovum. ^ In cases of uterus duplex, fetuses of different ages have been found in the two divisions of the uterus. Fordyce Barker reports a case of deliver}^ of two mature children from a woman with a double uterus, one male, the other female, at an inter\'al of two months."* Upon such cases, and also upon the fact that of twins in negresses rarely one is light and the other dark, showing probably different paternity, has been based the theory of superfetation ; but as there is no clear proof, as yet, of the occurrence of ovulation during pregnancy, the possibility of the impregnation of ovules which escaped from their Graafian follicles at rather wide inter\^als of time, say weeks or months, is doubtful. 5 1 Sclmltze, " Volkm. Samml. klin. Vortrage," No. 34. 2 Sirois, "L'Union medicale du Canada," July, 1887; and Warren, "Am Jour. Obstetrics," 1887. 3 Schatz, loc. cit. 4 See Lusk, op. cit.. p. 233, ed. 1886. 5 For some interesting observations which would seem to indicate the possibility, at least, of ovulation during pregnancy, see " Ovulation During Pregnancy," Chris- topher, " Am. Jour. Obstetrics," 1886, p. 457. Tin-: AMNION. 113 CHAPTER V. The Development of the Fetal Appendagfes: the Membranes, the Placenta, and the Umbilical Cord. THE AMNION. After segmentation has occurred, and after the interior of the ovum has become reduced to a granular mass, around which is a membrane composed of a single layer of cells, at a certain point — the embryonal area — in this membrane there appears a thickening, by a heaping up of the cells. Finally this mass of cells resolves itself into two layers (ecto- and entodermj, and between these two appears another layer of cells (mesoderm). The outer layer, the ectoderm, sends a prolongation around the whole interior surface of the ovum, and this layer receives a Fig. 91.— ir, Embryo ; ec, cephalic Fig. 92. — e, Embn'O ; a, amnion; extremity ; eg, caudal extremity ; ca, oa, amniotic umbilicus ; cac, amnio- f(?, amniotic hood ; //,//, pleuroperi- chorional cavity ;//,//, pleuroperito- *oneal cavity ; j, umbilical vesicle. neal cavity; ch, chorion; mv, vitel- line membrane ; vo, umbilical vesicle. reinforcement from the middle layer of cells, or the meso- derm. The observations of Peters and Graf Spee demonstrate that the amniotic cavity is closed at a very early date. There must, therefore, be a separation in the cells of the ectoblast consti- tuting a cavity, which as it distends with fluid presses the em- bryonal area toward the umbilical vesicle or yolk-sac, and folds 114 PREGNANCY. the amnion around the embryo till the latter is completely en- closed. The Fully Developed Amnion. — The amnion forms the innermost of the membranes that surround the fetus at term. It is continuous with the fetal epidermis at the umbilicus, forms a complete sheath for the umbilical cord, and covers the Amniotic cavity Amniotic cavity Amniotic cavity Periembryonal mesodermal cleft Periembryonal mesodermal cleft Amniotic cavity Allantois Periembryonal mesodermal cleft Periembryonal mesodermal cleft Yolk-sac Fig. Q3. — Scheme of development of the amnion (Pfannenstiel) . fetal surface of the placenta. In its structure it consists of a single layer of flat endothelial cells turned toward the cavity of the amnion, and externally of a layer of young- connective tissue, in which may be seen long spindle- or star- shaped cells with long nuclei imbedded in a fibrous substance. The regular disposition of the inner layer of endothelial cells, however, is disturbed at certain points of the amnion lying over 'rilK AMNION. I I 5 the placenta, where numbers of cells are heaped together, forming a little villus-likc projection. There are, normally, no blood- vessels in the amnion, — at least, in its later stages of develop- ment; their possible occurrence in hydramnios is referred to later. The Liquor Amnii. — It is the physiological function of the amniotic membrane to furnish a fluid medium (the liquor amnii), which distends the uterine walls and allows the fetus some free- dom of movement, and, by its density, approaching the specific gravity of the fetus, robs these movements of much muscular effort. It acts as an additional protection to the fetus from ex- ternal violence, pressure, and changes of temperature ; it receives the urine secreted in the latter part of fetal life ; and, perhaps, plays a part in the nutrition of the fetus, or at least in supplying the fetal tissues with the excess of water which they possess during intra-uterine life.^ That the fetus actually swallows considerable quantities of liquor amnii admits of no doubt, for lanugo and epidermis-scales have been found in the meconium, 2 and also particles of colored matter which had entered the amniotic fluid from the maternal structures (Zuntz). It is not likely that the liquor amnii plays an important part in the nutrition of the fetus, as claimed by von Ott and others ; for if it did, the birth of well-nourished children with a breach of con- tinuity in the upper part of the alimentary tract from the mouth to the small intestine would be inexplicable. The Composition of the Liquor Amnii. — The amniotic fluid is usually almost clear ; occasionally, however, opaque, whitish, greenish, or a dark brown from the presence of meconium, or of a reddish color when the fetus is macerated. The specific gravity varies from 1002 to 1028 (Schroeder), being usually about 1007 to loii. Its reaction is slightly alkaline. It contains salts, urea, carbonate of ammonia, kreatinin, albumin, lanugo, seba- ceous matter, epidermis-scales from the fetal skin, and epithe- lium from the bladder and kidneys. The quantity of the liquor amnii differs at different periods of pregnancy ; in the early stages it develops with great rapidity, and at the middle of pregnancy has reached its maximum of about i to 1.5 kilograms (2.2 to 3.3 pounds) (Landois). From this time it diminishes in amount, until at the end of pregnancy its average quantity is 680 gm. (1.5 pounds).^ The Origin of the Liquor Amnii. — The liquor amnii is derived 1 Preyer, " Physiologic des Embryos." ^Zweifel, " Untersuchungen iiber das Meconium," " Archiv f. Gyn.," Bd. vii, 474- ' Fehling, " Archiv f. Gyn.," Bd. xiv, S. 221. Il6 PREGNANCY. from both mother and fetus. The maternal origin ^ of the amniotic fluid has been demonstrated by Zuntz, who injected sodium sul- phindigolate into the veins of pregnant rabbits, and found a blue coloration of the amniotic fluid, although there was no coloring matter in the kidneys of the fetus. In cases in which the em- bn.^o is destroyed very early, moreover, an amount of amniotic fluid may be found corresponding not to the age of the embryo. but to that of the ovum. And it is not unusual to find hydram- nios associated with some other serous effusion in the mother.^ The fetus also contributes to the formation of liquor amnii. The excretion of urine during the latter part of fetal life reaches a considerable amount. More than three pints of urine have been found retained in the fetal bladder.^ Gusserow** injected benzoic acid into the mother, and re- covered it as hippuric acid in the liquor amnii, — proof that it had passed through the kidneys of the fetus. Wiener found sodium sulphindigolate in the fetal kidneys and bladder after it had been injected into the maternal tissues. The constant presence of urea^ in the amniotic fluid after the sixth week is additional proof of the renal activity of the fetus. It is probable also that the vasa propria, discovered by Jungbluth,^ lying close under the amnion in the early life of the embryo, have something to do with the production of the amniotic fluid. Prochownik^ claimed that the skin of the fetus secretes amniotic fluid during the early months of gestation. There have been cases of hydramnios associated with morbid conditions of the skin, notably one instance observed by Budin, * in which the skin of the fetus was the seat of extensive nevi. Thus it appears that the amniotic fluid is derived from a fetal as well as a maternal source, but the relative importance of the fetal and maternal supply of liquor amnii at different periods of pregnancy is still undetermined. 1 Ahlfeld (" Ueber die Genese des Fruchtwassers," " Archiv f Gjm.," Bd. xiii pp. 160-241) gives an ingenious explanation of the manner in which the maternal structures take part in the formation of the hquor amnii: As the uterus develops by an eccentric h3'pertroph3^ the pressure within the uterine cavitj' becomes less than that of the abdominal cavity, and consequently there is a disposition for the serum of the maternal blood to exude into the amniotic cavity. As Phillips (" Edin. Med. Jour.," March, 1887, p. 811) remarks, however, the case of hydram- nios in extra-uterine pregnancy (" Archiv f. Gj'n.," Bd. xxii, p. 57), reported by Teuffel, would seem to invalidate this theor}'. "^ Pfliiger's " Archiv," Bd. xvi, S. 548; and Wiener, " Archiv f. Gjm.," Bd. xvii, S. 24. ' Lefour, " Archives de Tocol.," June 30, 1887. ^ ■* Archiv f. G>ti.," Bd. xiii, S. 56. * Prochownik, " Archiv f. Gyn.," Bd. xi, S. 304-561. * " Beitr. zur Lehre v. Fruchtwasser," Inaug. Dissert., Bonn, 1869; Vir- chow's " Archiv," Bd. xlviii, S. 523; "Archiv f. Gyn.," Bd. iv, S. 534. ' hoc. cit. 8 Tarnier et Budin, loc. ciL, p. 279. THE CHORION. 117 THE CHORION. When the ovum first enters the uterine cavity and imbeds itself in the thickened uterine mucous membrane, its i)roto- plasmic cell- wall sends out numerous prolongations, which bur- row into the connective tissue of the decidua, fix the egg in its position, and draw nutriment for the whole ovum from the blood- vessels of the uterine mucous membrane. This cell-wall, with Fig. 94. — A young ovum a, Natural size ; /', magnified, showing chorionic villi (author's specimen). its villus-like projections, constitutes the false chorion, which soon disappears and is replaced by the layer of cells springing from the outer layer of the blastodermic membrane and surround- ing the whole ovum (the trophoblast). This membrane, in its turn, sends out branch-like processes (the villi of the chorion), which, at first non-vascular but hollow, soon receive into the interior of each branch of the villi loops of the blood-vessels that have been carried from the fetus to the periphery of the egg by the allantois. The villi are covered by two layers of cells, the syncytium and Langhans' layer (Fig. 95). These vascular villi absorb nutriment from the whole ex- tent of the decidua reflexa until the third month, when they atrophy and finally disappear, except at that portion of the periphery of the ovum which is in direct contact with the decidua vera (decidua serotina), where the chorion villi develop still further to form the placenta. The Fully Developed Chorion. — Restricting the term chorion to that portion of the original membrane which undergoes ii8 PREGNANCY. atrophy at the third month of pregnancy, it is found to con- sist of a thin, transparent membrane made up of connective- tissue elements continuous with the substance of the umbih- cal cord and very dehcate, atrophied vilh connecting it with the decidua refiexa. This portion of the chorion is called chorion ^^ \ Fig. 95. — Chorion villus of two months' ovum in longitudinal and transverse section: a, Syn- cytium; h, Langhans' layer of cells; c, stroma of the villus. Leitz, oil immersion, ocul. i and obj. 4, ocul. 3. (Moraller and Hoehl.) Fig. 96.— Human embryo at the third week, showing villi covering the entire chorion (Haeckel). lave to distinguish it from the chorion frondosum that forms the placenta. The fibrous membrane, constituting what is usu- ally called chorion at term, is derived from the endochorion, so named to distinguish it from the outer epithelial layer (the exochorion), which is to be found persisting in the epithelial covering of the placental villi. THE PLACENTA. The placenta, as a separate organ, dates from the third month of pregnancy. At this time the chorion villi atrophy over the whole periphery of the ovum, except at the point v\^here it comes in direct relation with the true mucous membrane of the uterus — the decidua serotina. Here the villi take on an extraordinary growth, forming buds of epithelial cells (syncytium) upon their surface, which rapidly take on the shape of new villi, thus send- ing out branches in every direction, into each of which a loop of blood-vessels is projected. Separating the villi from one another, and dipping down to the base of the chorion between the parent stems of the villous projections, are processes of the decidua, carrying capillary loops of maternal blood-vessels. nil': PLACE X7'A. 119 Very early in the history of the ovum' the arterioles of this sys- tem open directly into the intervillous spaces of the placenta, so that the placental villi are bathed directly in maternal blood. So far almost all authorities are agreed, but as to the relation of the terminal villi to the uterine mucous membranes, the 97. — The fetal surface of the placenta (Minot) action of the chorional and decidual epithelium, the changes that convert the uterine capillaries at first surrounding the villi into the large blood-sinuses that are later found in the placenta, many conflicting theories have been advanced. It is now well established, however, that the placental villi im- bed themselves in the soft interglandular substance of the 1 In Leopold's ovum of seven to eight days this arrangement was already visible. " Uterus u. Kind.," Leipsic, 1897. I20 FREGXAXCY. decidua serotina, often projecting into the mouth of the small veins, and that the connective-tissue cells multiply and h}-per- trophy around them (decidual cells). The epithelium of the uterine mucous membrane disappears, except in the glands. The chorion villi are at first covered with two distinct layers of cells; an inner layer composed of single large nucleated cells arranged side by side with distinct cell walls (Langhans' layer), and an outer layer or band of protoplasm in which are imbedded nuclei at irregular interv^als (the syncytium). Both of these layers are derived from the chorion and not from the uterine epithehum or the endothehum of the uterine blood-vessels. Early in embryonal Hfe (the third monthj the Langhans layer disappears and the syn- c}iium remains as the sole epithehal covering of the villi. In the youngest ova yet obser^'ed the trophoblast contains lacunae to which blood is conveyed from the maternal circulation by little curling arteries that wind their way up through the decidual cells to empty directly into the placental sinuses. These arteries are provided with only a delicate endothelial wall. From Leopold's^ obsen-ations it appears that the arterioles of the decidua become more and more distended as they approach the placental ^•illi, so that their terminal expansions maybe com- pared to a sea into which project peninsulas and capes of decidual masses and placental vilH. The sync}'tial cells of the latter have the power to penetrate the endothe- lium of the decidual ar- terioles and thus open a direct commimication between the placental vilK and the maternal blood. By this ana- tomical arrangement the fetal and maternal blood is, of course, kept separate. The former circulates within the capillary system of the vihi; the latter bathes the exterior of the villi. The Fully =developed Placenta. — The placenta at term is a circular mass, measuring about seven inches in diameter, about two-thirds of an inch to an inch in thickness at the point of insertion of the cord, and weighing about sixteen ounces. Upon ^ Loc. cit. Fig. q8. — The capillary system of a placental villus (from Minot). THE PLACENTA. 121 the surface of the placenta into which the cord enters is seen a smooth, shining membrane, continuous with the sheath of the cord — the amnion. The fetal side of the placenta contrasts Fig. 99. — Section of placental villi of a normal placenta at term : M, Fetal mesoderm ; S, syncytial masses ; V, V'', fetal vessels ; L, maternal lacunae, con- taining maternal blood (Durante). strongly with the maternal surface. The latter is of a dark red hue, divided by deep sulci into lobules of irregular outline and extent — the cotyledons. Over the maternal surface of the placenta is stretched a delicate, grayish, transparent membrane, Fig. 100. — Surface of villus at three weeks, showing syncytial band, A, and Langhans' cells, B (500 enlargement) ; C, stroma of villus. which is made up of the cells that compose the upper layer of the decidua serotina. This constitutes the maternal portion of the placenta. In separating from the uterine wall, therefore, the line 122 PJ^EGiVAXCY. of separation does not divide the fetal from the maternal struc- tures, but is found in the mucous membrane of the uterus, in the lower portion of the cellular layer of the decidua. Around the peripher^^ of the placenta ma}' be seen a large vein, the circular vein of the placenta, which returns a part of the maternal blood from the organ, the remainder returning to the maternal circula- tion by means of the continuit}' between the placental lacunae and the uterine sinuses. The situation of the placenta within the Fig. loi. — Diagram of uterus and placenta in the fifth month: Ch. Chorion; am, amnion; V, F, villi; L, L, lacunje; 5, serotina; v, small arteries; /, glandular layer; m, uterine muscle (Leopold). uterus may Avith equal frequency be found upon the posterior or the anterior wall ; occasionally, however, upon one of the lateral walls, more frequently the right. A perpendicular section through the middle of a placenta that is still attached to the uterine wall reveals an intimate connection between the two. The delicate terminal \-illi, and even branches a millimeter in thickness, are imbedded in the upper portion of the decidua, and held in place by their extremities bulging out into club-shaped masses, so that the exercise of considerable force will not extract them from the uterine mucous membrane, but will, instead, always lacerate the maternal structures. The functions of the placenta are manifold. Not only does it act as a lung, or, rather, gill, in oxygenating the fetal blood, but it may be said to take the place of the alimentar}- tract in absorbing nutritive material from the maternal circulation. It pla}'s, moreover, the part of an excretor\' organ, getting rid of the surplus carbonic acid gas in the fetal blood and TJJE UMBILICAL CORD, 123 of the other waste-products of tissue-activity. Bernard has shown that in the earher months of prcLi'nancy the placenta has a glycogenic function. The epithelial cells of the chorion villi exercise selection in the passage of substances between the fetal and the maternal blood. Some pathogenic micro- organisms — as, for instance, those of variola — pass easily from mother to fetus, while the bacilli of tuberculosis, a disease often present in pregnant women, are almost never found in the fetus. Certain drugs, also (iodid of potassium, benzoic acid, bichlorid of mercury), enter the fetal from the maternal blood, while it is asserted that others, as woorara, will not pass to the fetus from the mother. Again, while nutritive material must pass from mother to fetus, the escape of the same material from .the fetal into the maternal blood would prove destructive to the fetus. THE UMBILICAL CORD OR FUNIS. The early development of the umbilical cord, or the formation of the allantois, has been studied upon the lower animals, as in all the human embryos observed the connection between the embryo and the chorion was already established. Indeed, accord- ing to His, the human embryo is from the first in connection with Fig. 102. — A, Umbilical arteries forming spirals (;', x) around the vein; con- strictions indicating the presence of folds W, f); circular folds (rf, c)\ lateral open- ings showing the arterial walls; B, vein opened upon the side showing a constric- tion {h) corresponding to an interior valve (c); semilunar valves (c, d, c)\ C, section of vein and arteries showing valve of vein (a), a semilunar arterial valve {b), and a circular arterial valve (c) (Tarnier et Chantreuil). the periphery of the ovum. Very early, therefore, in embryonal life there may be observed a sac-like projection from the posterior end of the intestinal tract, which, at first solid, but later contain- ing a canal, grows outward and backward, owing to the presence of the large umbilical vesicle anteriorly, until it comes in contact 124 PREGNANCY. with the peripher}- of the o\nim. Within this sausage-shaped* projection are blood-vessels, which are carried with its growth Fig. 103. — A, Section of the navel: C, Outer covering with blood-vessels; v.u., umbilical vein; a.u., a. 11.. umbilical artery; v.o., omphalic duct; ii., remnant of the urachus. B, Section of the cord; A'.^., Sheath of the cord. Other lettering as in A. to the peripher}' of the ovum, where they enter the \dlli of the chorion in the manner already described. Reduced to two arteries and a vein within the allantois itself, they constitute the vessels of the umbilical cord, which are destined to carry i^^^^vf ■#.''-:W Fig. 104. — Transverse section through umbilical cord: a, Amnion: b, arteries; c, vein; d, obliterated allantois canal; e, Wharton's jelly. Leitz, obj. 2, ocul. 3 (jMoraller and Hoehl). the blood of the fetus to the placenta for aeration and nutri- tion, the two arteries conveying dark, venous blood; the vein 1 'A/./df, a sausage. THE MEMBRANyE DECWUyE. \2$ returning bright, oxygenated blood, resembling in this respect the pulmonary arteries and vein. Surrounding the blood- vessels of the cord is a gelatinous substance, furnishing the vessels the most perfect protection possible under the cir- cumstances (the so-called gelatin of Wharton), derived from the outer layers of the amnion and the allantois, both in their turn being derived from the median layer of the blastodermic membrane. As the amniotic cavity is distended the amnion is pushed out on all sides until it meets in front of the embryo, and surrounds the cord like the finger of a glove, at the same time inclosing the already atrophied umbilical vesicle, the ductus omphalicus, and the pedicle of the allantois. That por- tion of the allantois that remains within the abdominal cavity of the fetus forms the bladder and urachus. The umbilical cord at term measures about 50.8 cm. (20 in.) in length and about 0.9 to 1.3 cm. (^ to \ in.) or more in diameter, the latter measure- ment being irregular, from the fact that the arteries are coiled around the vein, usually from right to left, giving a twisted appearance to the cord, and also because the gelatin of Wharton is deposited irregularly, being in some places quite thick, and forming thus the so-called false knots of the cord. Both the arteries and the veins of the cord have walls of almost the same thickness, and both are provided with semi- lunar and circular valves. The caliber of the vein is greater than that of the arteries. According to Leopold, ^ it measures nor- mally 2 to 4 mm. (0.079 to 0.157 in.) in diameter, but at a point about 8 to 10 cm. (3.15 to 3.94 in.) from the placental insertion there occurs a physiological narrowing. THE MEMBRANAE DECIDUAE. The explanation which John Hunter gave of the plates pub- lished by his brother William" was, for a long time, accepted as the true history of the development of the uterine membrane which envelops the fetus at term. According to theHunterian theory, the uterus throws out upon its inner surface an inflammatory exudate forming a closed sac whose walls stretches across the openings of the tubes and the os internum cervicis. As the impregnated ovule enters the uterus from one of the tubes it pushes the sac-wall in front of it, but leaves behind it a bare sur- face, which is soon covered by an exudate similar to the one ^ " Archiv f. Gyn.," Bd. viii, S. 221. ^ " Anatomia ut. hum. grav. tab. illustr.," Birm., 1774, table 34. 126 PREGNANCY. at first thrown out. That portion of the original membrane which remained attached to the uterine wall Hunter called the membrana decidua vera ; that portion pushed out in front of the ovule, the membrana reflexa ; and that membrane last formed be- hind the ovule, the membrana serotina. These names have sur- vived until the present day, although modern investigation has robbed them of their original significance. Costi ^ was the first to expose the fallacy of the Hunterian doctrine, and since his time the investigations of Robin, Friedlander, Kundrat, Leopold, En- gelmann, Peters, Bryce, Teacher, and others have enabled us to follow the changes that occur in the uterine mucous membrane Fig. 105. — Uterus, decidua, and ovum, on the eighth day of pregnancy (Leopold). from the entrance of the impregnated ovule into the uterine cavity until the fetus, with its enveloping membranes, is expelled at term. By the time the fertilized ovum arrives within the uterine cavity the hning mucous membrane of the uterus has become very much thick- ened,- owing to edema and congestion of the upper layers and to hy- pertrophy of the uterine glands. After the third week the develop- ment of decidual cells begins: large cells developed from the connec- tive tissue, in certain areas pressed close together, in others separated by amorphous tissue. The thickening of the membrane is most marked on the anterior and posterior v;alls, least at the fundus ^ " Originie de la Caduque," " Acad, des Sciences," Paris, 4 et 25 Juillet, 1842. -Tenfold according to Engelmann (" x\m. Jour. Obstetrics," May, 1875); from the normal 2\ to 3 or 8 mm. according to Pfannenstiel. THE MKMBRAN^K DECIDUAL. 127 ' ■.'.*■.;'.■.!».' XiriS' , . pi. cap. pi' Fig. 106. — Diagram of Teacher-Bryce ovum. (Magnified about 50 diameters.) (T. H. Bryce, Del.) : E.e., Point of entrance; cyf, cyto-trophoblast ; //, plasmodi- trophoblast; n.z, necrotic zone of decidua; ^/, o-land ; ca/, capillaries; //', masses of vacuolating plasmodium invading capillaries. The cavity of the blastocyst is completely filled by mesoblast, and imbedded therein are the amnio-embryonic and entodermic vesicles. The natural proportions of the several parts have been strictly observed (Bryce and Teacher). Fig. 107. — The decidua vera and the chorion. Fig. io8. — Diagram illustrating relations of structures of the human uterus at the end of the seventh week of pregnancy (modified from Allen Thomson). Fig. log. — Decidua vera, decidua reflexa, the chorion and amnion. 128 THE MEMBRANAi DECIDUAL. 129 and cornua, and it ceases abruptly above the cervix; the cervical endometrium is unchanged.' As a consequence of this thickening the mucous membrane is thrown into folds. In a depression between two of these folds of membrane or on the summit of one of them the ovule imbeds itself when it first enters the uterine cavity. The ovule, being thus imbedded in the uterine mu- cosa, is inclosed by the arching over of the folds of the membrane, or, as Leopold" claims, by their simple approximation owing to the increas- ing thickness of the mucous mem- brane. Peters'^ famous ovum was found imbedded on the apex of one of the folds of uterine mucous mem- brane, being implanted in the com- pact layer of cells, and not surrounded completely by the reflexa, but with its internal pole covered by clotted, degenerated blood Fig. no. — Decidua serotina, decidua vera, decidua reflexa, and the ovum: d.s., Decidua serotina; d.v., d.v. , decidua vera; ' in the Nicholson apparatus, or of the needle in the Tycos. The last gives the highest readings. The patient should be cautioned to reduce her physical exercise below what she is ordinarily accustomed to. and always to stop short of fatigue, avoiding particularly any sudden jolt or jar or any of the movements that strain the abdomen and in- crease intra-abdominal pressure, such as lifting a weight down 142 PREGNANCY. from a height (a closet-shelf) or raising from the ground a heavy weight. The diet must be regulated so that the kidneys shall not be overtaxed. Meat should be eaten but once a day, red meat only four times a week, and a ravenous appetite, which sometimes appears in pregnancy, must not be fully gratified. Three simple meals a day with no nutritious food between meals should be the rule. Otherwise the fetus may reach an abnormal size.^ The patient must be cautioned against exposure to cold and wet ; one such exposure or sitting in a draft after being overheated has frequently determined an acute nephritis, with fatal results to both mother and child. Tonic remedies are some- times called for if the hydremia of pregnancy is exaggerated or if there is not a normal gain in weight. The syrup of the lacto- phosphate of lime is administered with advantage to stay the ravages in the teeth of pregnant women, and with this remedy internally should always be prescribed a mouth-wash of milk of magnesia to correct the acidity of secretions and to arrest the development of leptothrix buccalis, which, in the opinion of dental surgeons, are more detrimental to the teeth than the drain on the system for bone salts to build up the fetal skeleton. Strychnin in the later months is claimed to influence labor benefi- cially and to favor puerperal involution. This I believe to be correct. The nipples should be prepared for their future function by applications of glycerol of tannin and water, equal parts, twice a day for four weeks preceding confinement. THE DIAGNOSIS OF PREGNANCY. It might seem to the inexperienced that the recognition of pregnancy is easy. Every physician has ample opportunity to familiarize himself with its signs, and these signs are gross and easily appreciable, at least in the later months. But in reality there is scarcely a common condition in the human body that is so often overlooked or mistaken for something else, and there are no mistakes in diagnosis so detrimental to a physician's reputation, or sometimes so fatal to the patient, as mistakes in the diagnosis of pregnancy. To cite as illustrations only cases of which the author has personal knowledge : A physician per- formed what he believed would be a Cesarean section on a 1 To reduce the size of the child in cases of moderately contracted pelves, Pro- chownick ("Centralbl. f. Gyn.," No. 33, 1889) proposed a diet of nitrogenous food and the least possible amount of fluids, beginning in the seventh month. Preble ("Obstetrics," May, 1899) collected 47 cases managed by this plan with apparently gratifying success. THE DIAGNOSIS UF PREGNANCY. 1 43 rachitic dwarf, thought to be in labor at term. Several other physicians examined the patient before the operation, and all agreed that she was pregnant and in labor. There was nothing in her abdomen but the usual contents and a huge mass of omental fat. It was a case of pseudocyesis. A gynecologist on the staff of a large hospital has twice operated for fibroid tumors of the womb, and only after the am- putation of the uterus found that it was pregnant, and not the seat of a fibroid tumor at all. Both patients died. In a public clinic, before a large audience, a gynecologist removed what he called a myoma. The tumor was cut open immediately and all the spectators had the opportunity of seeing a pregnant uterus with a fetus in it. There was no myoma. The woman died. Another specialist in a large hospital operated for ovarian cyst. He punctured the "cyst" after opening the abdomen, and found a pregnant uterus with hydramnios. An entirely unnecessary hysterectomy was performed. An obstetrician on the staff of another hospital attempted to induce labor on a patient in the last stages of phthisis who evi- dently would not live till term. The bougie, however, could not be inserted more than 2 ^ inches. On the following day the patient died. In anticipation of her death, all the arrangements had been made for a postmortem Cesarean section the moment she expired. The operation was performed before a large audi- ence. The abdominal tumor proved to be an ovarian cyst, and not a pregnant uterus. A woman was admitted to the medical wards of a hospital with what was thought to be a cancer of the stomach. Gastric lavage was energetically carried out with unlooked-for success ; in several wrecks all gastric symptoms ceased. At the same time an abdominal tumor was observed, which, on examination, proved to be a pregnant uterus. The patient had been suffering from the vomiting of pregnancy. A> young unmarried girl of good family was about to be operated upon for a splenic tumor when it was discovered that the tumor was a pregnant womb much displaced and distorted by tight lacing. A woman was sent to the author from a distant State for operation on account of a large fibroid tumor of the uterus ; she was pregnant with twins, had no fibroid, and was easih' deliv- ered. A young girl was referred to the author for the removal of an ovarian cyst ; her physician stated that the eminent re- spectability of the girl precluded the idea of pregnancy. Re- spectability had proved no bar to the penetration of a sperma- tozoon. She w^as pregnant at term. The author once examined in consultation a woman who was supposed to be pregnant twelve months. Her physician and 1 44 PRE GATANC V. nurse had been engaged and every other preparation made for the expected childbirth. The husband was obhged mean- while to sell his house, but a clause was inserted in the deed that possession was not to be given the new owner till the vendor's wife should be delivered. An examination showed the womb to be unimpregnated. There had been very scanty but regular menstruation, marked enlargement of the abdomen due to omental and abdominal fat, and many of the subjective signs of pregnancy. It was a typical case of pseudocyesis. Instances of mistakes in the diagnosis of pregnancy could be multiplied to a tedious length from the author's own experience.; but the cases cited should be sufficient to demonstrate the liability to error. If a physician would avoid such mistakes, he should cultivate the habit of making a routine, methodical, careful ex- amination of every patient who may be pregnant,^ neglecting none of the important subjective and objective signs, and looking for them in a regular order, which will preclude negligence or omission. The signs of pregnancy, in accordance with the laws of symptomatology in general, are divided into the subjective and the objective signs ; the former being the symptoms experienced by the patient herself, and the latter presenting themselves to the senses of the examining physician. The subjective signs of pregnancy are obviously of subor- dinate value. The woman may wilfully deceive others or may be deceived herself She may be unable to describe her symp- toms clearly or may misinterpret them. She may be entirely unconscious of her condition, though pregnant at term. She may not even recognize the fact that she is in labor, and the birth of her infant is her first intimation that she was pregnant.^ The subjective signs of pregnancy, arranged as far as possible in the order of their relative importance, are : Cessation of Menstruation. — ^This is the most valuable of the subjective signs. It is always inquired for by the physician, and is usually first mentioned by the patient if she is acting in good faith ; but it is by no means a sure indication of pregnancy, and it is not available if a woman conceives during the amenorrhea of lactation, before menstruation is established, or after the meno- pause. Amenorrhea may depend upon many other conditions, such as change of climate, mental and nervous disorders, peri- uterine inflammations, the growth of pelvic and abdominal tumors, acquired atresia of the cervix, anemia, chlorosis, and 1 This includes all females from nine to sixty-one years of age. 2 See " Unconscious Pregnancy," Gould and Pyle, "Curiosities of Medicine," P- 72. THE DIAGNOSIS OF PREGNANCY. I45 phthisis. The fear of impregnation in the unmarried, the ex- pectation of it in newly married women, the intense longing for maternity in some sterile, women, and a belief in the existence of pregnancy in some cases of pseudocyesis are mental states that have been known to suspend the function. On the con- trary, menstruation, or a periodical bloody discharge, persists during the first three months of pregnancy in a very small minority of cases. Rarely the flow may recur regularly, though scantily, throughout the first half or even the whole of gesta- tion. There may, therefore, be cessation of menstruation with- out pregnancy, or persistence of menstruation in pregnancy. The patient's statements, moreover, are not always to be depended upon. She may deny the cessation of menstruation ; she may even stain her napkins regularly with the blood of animals to deceive her family;^ or, in cases of spurious pregnancy, she may assert that the flow has stopped, when in reality it persists, although sometimes so scantily as scarcely to attract her atten- tion. Nausea and Vomiting. — This symptom depends upon the dis- tention of the gravid uterus in the beginning of pregnancy, upon a mild toxemia, and upon the irritability of the nervous system. It usually first manifests itself at the sixth or seventh week. It appears so constantly and to such a marked degree in many patients that they regard it as a certain indication of their condition, and in such cases considerable value may be attached to the patient's statement by the examining physician. I have had patients in whom nausea and vomiting appeared within the week following a fruitful coitus, though they did not suspect that they were pregnant.- But any irritation of the pelvic organs may produce the same result, as displacement or inflammation of the uterus, congestion or in- flammation of the tubes and ovaries, and the growth of pelvic tumors. The stomach itself may be disordered and the vomiting may not be reflex. On the other hand, this symptom is entirely absent in a considerable proportion of pregnant women. Some degree of salivation is usually associated with the nausea and 1 I was called to empty the uterus of a young girl, eighteen years of age, suffer- ing from an incomplete abortion criminally induced. To this day her family has no suspicion of what really occurred. The girl had put her napkins in the wash at the periods when she should have menstruated, stained with beef's blood obtained from an abattoir. 2 A Mrs. E. under my charge began vomiting within four days of the fruitful coitus in four successive pregnancies. Her uterus was retroflexed and adherent. A gentleman asked me to attend his wife in confinement, between eight and nine months later. When asked how he could suspect pregnancy so early, he replied that after breakfast that morning he had been seized with nausea and vomiting, — an in- fallible sign on several previous occasions that his wife had become pregnant. 146 PREGNANCY. vomiting of pregnancy. In rare cases the ptyalism is the pre- dominant phenomenon. Changes in the Size and Shape of the Abdomen. — It has been asserted that at first there is a hypogastric flattening, due to the sinking of the uterus during the first few weeks of pregnancy on account of its increased weight, but I have never found a woman who noticed this change in her shape.^ The descent of the womb, the congestion of the pehds, and the pull upon the uterovesical ligament, however, cause an irritability of the blad- der, and of this symptom the patient often complains. Later, the abdomen is steadily and progressively enlarged until the last month, when the subsidence of the uterus diminishes the dis- tention of the abdomen, and at the same time gives rise to symptoms of pressure on the other pelvic organs and on the blood-vessels and nerves of the pelvis and lower extremities. There are many other causes, however, for abdominal en- largement besides pregnancy, as a deposition of fat in the omen- tum and abdominal walls, accumulation of fluid within the abdominal cavity, and the various abdominal and pelvic tumors. On the other hand, the enlargement of the abdomen due to advanced pregnancy may actually escape the observation of the patient herself,' or may be so well concealed by tight lacing as to be almost imperceptible. Changes Due to Increased Blood-supply to the Genitalia and Breasts Owing to the congestion of the parts there is a tingling sensation and a feeling of fullness in the breasts, with the appear- ance in them of colostrum. A sense of heat and congestion may be experienced in the pelvic organs, and there is very likely to be some leukorrhea. These symptoms are obviously of little value. The striae on the breasts, due to their sudden enlargement, may be the first sign of pregnancy to attract the woman's attention.^ The sudden swelling of old varices is sometimes a valuable indication of pregnancy. Quickening. — This is the name given to the sensation experi- enced by the mother as the result of fetal movements, which, as a rule, become powerful enough to be appreciated by her midway between the fourth and fifth month of gestation. They may be felt as early as the third month or not until the last month of 1 The French have a proverb : " En ventre plat Enfant il y'a." 2 I have seen an intelligent married v^oman, the mother of several children, be- tween seven and eight months pregnant, unconscious of the abdominal enlargement and entirely ignorant of her condition. 3 This was the case in one of my patients, a young woman of exceptionally good social position, who was illegitimately pregnant and, I believe, entirely ignorant of her condition. THE DIAGNOSIS OF PREGNANCY. 1 47 pregnancy, and some women do not experience them at all or overlook their presence. They are not felt, of course, when the child is dead. The woman interested to conceal her condition will deny the occurrence of fetal movements; and other women, deceived by the action of the intestines, may honestly behevc that they feci them. Alterations in the Nervous System. — The nervous system is almost uniformly disordered in pregnancy. Characteristic nerv- ous disturbances are described by the vast majority of pregnant women. These are changes in disposition, mental peculiari- ties, and perversions of tastes. There is often also a sense of dizziness, a disposition to faint, and actual syncope. For ex- ample, a woman usually amiable in disposition becomes irritable, sullen, or morose; a phlegmatic, placid individual may become unusually vivacious, and the strangest fancies for eating unusual and disgusting articles may appear. Morbid desires impelled one woman to murder her husband that she might eat his flesh, and another to revel in the sight of a butcher slaughtering ani- mals. In some women, however, these nervous symptoms are entirely wanting or so slight as to escape observation. There are also many other causes besides pregnancy for changes in a woman's nervous organization, such as nervous strain and hys- teria. Objective Signs. — The objective symptoms are obviously of much more importance and value than the subjective. They present themselves to the physician's senses of sight, touch, and hearing. Signs of Pregnancy Ascertained by Inspection. — Tlie Woman' s Face. — Splotches of irregular pigmentation, called chloasmata, appear on the brow and cheeks, and there are often dark rings under the eyes. Moreover, as a physician questions a patient in regard to her condition, he may observe evidences of truth or untruth in her countenance as she replies; though the pregnant woman determined to conceal her condition is often an actress of consummate ability. Breasts. — The mammary glands are enlarged and obviously distended ; they stand out prominently from the chest, and tortuous veins are seen plainly under the skin. As pregnancy advances, striae may be observed in the skin of the breasts. The nipples are more prominent than in the non-pregnant condition. Around the nipples there is a deepening in the color of the pigmentation areola, and a widening of the pigmented area by the development of the so-called secondary areola of pregnancy (Fig. 121). In the pigmented area may be observed the seba- 148 PREGNANCY. ceous glands named after Montgomen% although he was not the first to direct attention to them and misunderstood their significance. They are often as large as buckshot in the pregnant woman, and project quite conspicuously from the surface of the skin. They are frequently, however, entirely absent. If the breast is seized at its base and compressed toward the nipple between the outspread thumb and four fingers of one hand, a drop or two of turbid fluid (colostrum ) may be seen to collect upon the surface of the nipple. All these mammary symptoms, however, may be observed independently of pregnancy, and rarely may be absent altogether in that condition. The mamman," glands of some women dis- play a marked physiological activity at each menstrual period, even to profuse milk-secretion, and it is by no means rare to observe all the mammary signs of pregnancy accompanying the grovv-th of a pelvic or abdominal tumor, especially one of the womb itself. Moreover, the woman may be impregnated during lactation, or some activity of the glands may persist long after a Pig. 121. — Showing the prominence of the breasts, the stris upon them, and the pigmented areola. previous labor. Under such circumstances the m.ammary signs of pregnancy are valueless. The Abdomen. — As pregnancy advances the abdomen becomes more and more prominent; obviously containing a tumor pyri- form in shape, with the narrow end downward, situated in the median line, and spreading with approximate equality to either side. There are other abdominal tumors, however, which have the same shape as a pregnant womb, and the gravid uterus is Plate 4- Figure i. — Breast of a non-pregnant woman of the blonde type. Figures 2 and 4. — Breasts of pregnant women of tlie brunet type. Figure 3. — Breast of a pregnant woman, a blonde. Painted from life, showing the irregular distribution of Montgomery's glands and comparative distention of the veins in the pregnant and the non-pregnant woman when the breasts are allowed to hang unsupported by the clothing for a few minutes. THE DIAGNOSIS OF PREGNANCY. 1 49 often anomalous in form. In twin pregnancies, in breech pres- entations, in transverse positions, in some deformities of the fetus, in some varieties of contracted pelvis, and in the presence of Fig. 122. — Normal pregnancy at terr Fig. 123. — Uterus deformed liy scolio.sis of tlie spine (paralytic). other tumors coincident with pregnancy, the pregnant uterus is altered in shape. Displacements of the uterus may also give it an unusual appearance in pregnancy. ISO PREGNANCY. Fig. 124. — Six months pregnant, with a large fibroid tumor. Seen in consultation with Dr. R. II. Hamill. Fig. 125. — Breech presentation, at term. Fig. 126. — The pendulous belly of rachitis. Pregnant at term. Fig. 127. — Twins. THE J )IA GNOSIS OF J'A' EGjVANCY. ItI Fig. 128. — Pregnant uterus distorted by rachitic kyphoscoliosis. Fig. 129. — Linea nigra, well marked above and below the umbilicus. Exaggera- tion of the pigmentation around the nipples. Half-breed Indian squaw. (University Maternity.) 152 PREGNANCY. The umbilicus at the sixth month is level with the surface of the abdomen, and, later, pouts. It is surrounded by a ring of pig- mentation, which extends above as high as the fundus uteri, and below along the linea alba, which in pregnancy becomes the linea nigra (Figs. 129, 130). By a disorder in the arrangement of the fibers in the cutis there appear to be cracks in the skin of the ab- domen, especially toward the flanks, over the surface of the iliac bones, and upon the outer aspects of the thighs. There is a dis- position to hypertrichosis all over the body, but most marked on the abdomen, especially along the linea alba (Halban). If the pregnancy is far advanced, and if the fetus is alive, fetal move- ments may be plainly seen. These are of two kinds : there is a heaving movement of the fetal back, and a sharp, sudden tap of the fetal extremities. Fetal movements, if unmistakable, are positive signs of pregnancy, but they have been simulated by twitching of the abdominal muscles and by the vermiform movements of the intestines. Vagina and Vulva. — The mucous membrane of the vestibule and of the vagina assumes a purple hue in the later months of gestation, which has been aptly com- pared in color to the lees of wine. The discoloration of the mucous membrane of the vagina and of the vaginal intro- itus is usually most marked upon the inner surface of the labia majora and upon the fold of vaginal mucous mem- brane on the anterior wall that comes into view when the labia are separated (Plate 5, Figs. 3 and 4). It is occa- sionally confined to the fossa navicula- ris (Plate 5, Fig. 2), or to the deeper portions of the vaginal rugae. The pigmentation of the mucous membrane begins in some cases as early as the fourth week. Chadwick ^ in 281 cases found it diagnostic in thirteen per cent, at the end of the second month; in forty-six per cent, at the end of the third month. John- son ^ calls attention to a regularly recurring change of color in the cervix from violet to pink as an early and reliable sign of pregnancy. It is due to the intermittent contractions of the uterus. The violet color of the vaginal and vulvar mucous membrane is by no Fig. 130. — Linea nigra, visible only below the umbilicus. ^ "Tr. Am. Gyn. See," vol. ii, 1886, p. 399. Med. and Surg. Jour.," vol. cxvii, No. 3, 1887. 2 " Journ, Am. Med. Assoc," Feb. 20, 1904. See also Farlow, ' ' The Boston Plate 5. 3. Figure I. — Normal color of the vaginal mucous membrane in a woman not pregnant (blonde). Figure 2. — Color of vaginal mucous membrane and introitus in a brunet. Figure 3. — Color of vaginal mucous membrane and introitus in a negress. Figure 4. — Color of the vaginal mucous membrane in a light blonde. Note the scarlet color of the mucous membrane of the introitus, in addition to the blue discoloration. The former is always present, even if the latter is absent. The complexion of the individual does not necessarily influence the depth of the blue discoloration. In figure 2, a dark brunet, it is lighter than in figure 4, a light blonde. THE DIAGNOSIS OF PREGNANCY. 153 means an infallible sign of pregnancy. It is often absent alto- gether in early pregnancy, and I have frequently noted its entire absence at term. There are, moreover, other conditions than pregnancy which can give rise to it : erethism, pelvic tumors, intense congestion of the pelvis. But even if the blue discolora- tion is not visible, one may always notice in the later months a transformation of the pink color of the mucous membrane of the introitus into a bright scarlet. Fig. 131. — Hegar's sign of pregnancy elicited by a combined vaginal and abdominal examination. Signs Appreciated by the Sense of Touch. — Abdominal Palpa- tion. — By this method are learned the size and shape of the uterus, and after the sixth month the fetal back, head, and ex- tremities may be felt.^ By placing the outstretched hand over the fundus, the intermittent uterine contractions, to which atten- tion was first called by Braxton-Hicks, are perceived. At inter- vals of about ten minutes throughout gestation the whole uterine muscle contracts as it does in a labor-pain, the uterus hardening 1 For a more extended description of abdominal palpation see " Mechanism of Labor. ' ' 154 PREGNANCY. under the hand so that its contents can no longer be easily ap- preciated. This sign is available at the end of the third month, and although it may be produced by any tumor distending the uterine walls, as a collection of blood, an intra-uterine polyp, or a soft myoma, it is almost a positive sign. It may, however, occur sympathetically in extra-uterine pregnancy, and it is said that the contractions of an overdistended bladder may be mistaken for the rhythmical contractions of the gravid womb. Finally, fetal movements may be felt as pregnancy advances. The sensation conveyed to the hand is usually that of a finger-tap under a blanket. The other fetal movement, however, — a heaving action of the back, — is equally characteristic. This symptom is natur- ally a positive sign of gestation. Fetal movements may be ex- cited by placing a cold hand suddenly upon the woman's abdo- men, or by pushing the fetus about in the womb. Combined Examination. — The cervix in pregnancy is notably softened as a result of the increased blood-supply and an edema of the part. Goodell is the author of the ready rule of practice, that when the cervix is as hard as one's nose pregnancy does not exist, but when it is as soft as one's lips pregnancy is likely. Rapidly growing myomata, however, acute metritis, and hematometra can produce as soft a cervix as is felt in pregnancy, and should the neck of the pregnant womb be the seat of an old injurj^, with dense and extensive cicatrices, or should the cervix be cancerous or syphilitic, there may be no appreciable soften- ing in pregnancy. Johnson^ declares that a change in consistency of the cervix mav be noted at regular intervals very early in gestation, being the first appearance of the intermittent contractions that are felt later by abdominal palpation. To detect this sign the finger must be kept in the vagina for ten minutes at a time perhaps, which is, to say the least, inconvenient. Hegar's sign of early pregnancy depends upon a marked softening of the lower uterine segment, by which it appears on combined examination that the body and the cervix are discon- nected, though on closer examination, the outer edges of the lower uterine segment appearing a little firmer than the inter- mediate portions, it seems that the cervix is joined to the body of the womb by two indistinctly appreciable longitudinal bands. The best method to elicit this symptom is to insert the forefinger far into the rectum and the thumb into the vagina, while the womb is pressed down by the other hand applied upon the abdominal wall. 1 Loc. cii. THK jyJACNOS/S OF PREGNANCY. 155 It is not always necessary, however, to make a rectal exami- nation. By combined pressure, either through the anterior or posterior vaginal walls and the abdominal wall above, the finger- tips can be brought into relationship with the lower uterine segment. Hegar's sign is by no means a certain one. It is not invariably appreciable in pregnancy, and it might be felt in a non- pregnant uterus, softened by congestion, inflammation, or the presence in it of fluid. The uterus may be asymmetrically enlarged, one side being greater than the other, and a longitudinal line or furrow separat- ing the two (Braun-Fernwald's sign). Enlargement of the uterus, with a change in its shape and consistency, is one of the most important symptoms in the early weeks. The womb becomes more spherical in outline, softer in consistency, and distinctly enlarged, while there is usually a marked anteflexion in consequence of the weight of the body of the uterus and of the softened lower uterine segment. By plac- ing one hand over the fundus and the fingers of the other in the vagina an impulse may be conveyed by the latter to the uterine contents, which are displaced upward, communicating an impact Fig. 132. — The shape and size of the non-pregnant uterus. Fig. 133. — The sliape and size of the uterus altered by early pregnancy (Budin). to the external hand and falling again into its original situation ; a tap is felt upon the uterine and vaginal walls by the fingers 156 PREGNANCY. applied internally. To this symptom the name " ballottement "■ has been given, and to the experienced examiner it is a positive sign of the condition, though a small cystic tumor of the ovary with a long pedicle may simulate it closely, and the same symp- tom might, of course, be elicited in an advanced extra-uterine gestation. Symptoms Ascertained by Auscultation. — Mayor, a surgeon of Geneva, was the first to discover, in 1 8 1 8, that the fetal heart- sounds could be heard by applying the ear to the abdomen of a pregnant woman when the child is alive. Three years later this valuable symptom of pregnancy was described in an article by Kergaradec presented to the French Academy. It is a symptom available as early as the fifth month, although its value increases with the advance of pregnancy. The fetal heart beats at the rate of about 120 to 160 a minute, and the sound has aptly been compared to the ticking of a watch under a pillow. The beat is a double one, as in the adult heart. The area of the maximum intensity of the fetal heart-sounds in anterior positions of the vertex is about an inch below the umbilicus to the left or the right of the median line, or in posterior positions of the vertex in the flanks on a line passing through or somewhat below the umbilicus. In breech presentations the maximum intensity is usually above the umbilicus, and in transverse positions the pulsations may be heard low upon the abdominal wall near the symphysis. Occasionally they can best be heard over the fundus uteri, the sound being transmitted by the fetal spine. Their absence by no means excludes the existence of pregnancy. They are not heard if the child is dead, if there is an abnormal quantity of liquor amnii in the uterus, if the abdominal walls are excessively thick, or in certain positions of the fetus. On the other hand, the beat of the maternal aorta has often been mistaken for the fetal heart, though this error is easily avoidable if one feels the maternal pulse as he listens for the fetal heart- sounds, and remembers that the aortic impulse is a single, the fetal heart -beat a double, sound. Another sign of pregnancy appealing to one's sense of hearing is dullness on percussion along the median line of the abdomen and for some distance on either side. It is possible, however, in very rare cases of excessive tympanitic distention of the intestines, to obtain a tympanitic note all over the anterior wall of the abdomen, though the woman may be pregnant at term. In such cases the distended intestines have surrounded the womb and cover its anterior surface. The uterine bruit, synchronous with the maternal heart-beat^ rilK DIAGNOSIS OF PREGNANCY. 1 57 is often heard in pregnancy, but it may l^e heard also in large uterine myomata and in ovarian cysts. It can usually best be distinguished on the left lateral aspect of the pregnant womb, as it is caused by some obstruction to the blood flowing through the uterine artery. The funic souffle, present in about fifteen per cent, of cases, if heard, is diagnostic of pregnancy. It is a high- pitched, whistling, or hissing murmur, synchronous with the fetal heart-beat. It is caused by some obstruction to the flow of blood through the umbilical arteries. The fetal movements may be heard, in auscultation of the abdomen,^ as a dull thud against the abdominal walls. Feeble movements may be heard as early as the fourth month. It was while listening for the fetal movements that Mayor first heard the fetal heart-sounds. In auscultating the abdomen of a woman for the signs of pregnancy, the examining physician should first use his ear directly applied to the abdomen with nothing but a thin towel intervening. A stethoscope should also be employed, however, in doubtful cases and in situations where the ear can not be con- veniently applied. A positive diagnosis of pregnancy before the sixth week is impossible, and the diagnosis may be only presumptive until the fetal heart-sounds can be heard and fetal movements are felt. Clinically, the signs of pregnancy may be divided into those of three trimesters, or periods of three months each. It is useless for the practitioner to look for certain signs in one trimester only available in the next. First trimester. — In this period the follow- ing signs of pregnancy are available : Enlargement, change in shape and bogginess of the uterine body, soft cervix, enlargement and functional activity of the breasts, Hegar's sign, cessation of menstruation, nausea, and vomiting. The second trimester exhibits, in addition to the above, enlargement of the abdomen, intermittent contractions of the uterus, feeble fetal movements, ballottement, fetal heart-sounds, and blue discoloration of the vaginal mucous membrane. In the third triinester all the symp- toms just enumerated become more easily appreciable. The outlines of the fetal body are distinguishable by abdominal palpation, and the presenting part may be felt through the roof of the vaginal vault. Differential Diagnosis of Pregnancy from Other Pelvic and Abdominal Tumors. — Early pregnancy must be distinguished ' First reported by Kergaradec in 1822. 158 PREGNANCY. occasionally from small fibromyomata, hematometra, hydrometra, and pyometra, small cystic and solid tumors of the broad ligaments and appendages, inflammatory swellings of the broad ligaments and ovaries including exudates. In all tumors not involving the uterus itself the latter may be mapped out by careful bimanual examination, which also determines its size, consistency, and shape, and thus decides whether it is pregnant or not. In the case of pelvic and peritoneal exudate it may be impossible to feel anything through the vaginal vault except the inflammatory mass from which the cervix projects like a nipple. It may therefore be impossible to tell whether there is a coincident preg- nancy and pelvic inflammation except by an exploratory abdomi- nal section, which would not, however, be justified simply to clear up the diagnosis. Time would decide the question. If the tumor is situated in the uterus itself, the differential diagnosis may not be easy, but is almost always possible. Fibromyomata are usually stony hard, irregular in shape, and cause, as a rule, menorrhagia. Accumulations of fluid in the uterus may for a time be very puzzling, but there is usually the history of cramp- like pains at the menstrual periods, the amenorrhea has often been of longer duration than would be the case in early preg- nancy, there may have been an impossibility of impregnation, and the congenital or acquired atresia of the cervix is almost always demonstrable. The differentiation between later pregnancy and the other ab- dominal tumors is made by the patient's history, by inspection, abdominal palpation, auscultation, and a combined examination. It should be remembered that the pregnant uterus is by far the commonest abdominal tumor. It is numbered by the thousands in all large communities, while other growths are rare. All women, therefore, between the ages of nine and sixty-one, with an abdominal tumor, should be regarded as pregnant until they are proved to be otherwise, though the physician will do well to keep his suspicion to himself and to keep an open mind, so that he may not suffer in reputation from an egregious mistake or be responsible for a tragedy like that of Lady Flora Hastings. Many abdominal tumors may be distinguished from preg- nancy at a glance; thus, obesity (Fig. 134); an abdominal hernia (Fig. 135); a tumor in the upper abdomen (Fig. 136); an enor- mous abdominal distention from a large ovarian cyst, ascites, or a huge myoma (Figs. 137-139) look so unlike the abdominal distention of pregnancy that no suspicion of gestation enters the observer's mind, but it should be remembered that there may be a coincident pregnancy with any of the abdominal tumors and THE DIAGNOSIS OF PREGNANC\. 159 that the pregnant uterus may assume a distorted form, occupy an unusual position, and reach an enormous size in consequence of multiple pregnancy, fetal monstrosity, deformities of the spine, tight lacing, or hydramnios. There are many abdominal tumors (Figs. 142, 143) that re- semble closely or exactly the pregnant uterus on inspection; thus. Fig. 134. — Obesity. a fibromyoma, an ovarian cyst, tympanites, or a distended blad- der may furnish a degree and kind of abdominal distention c|uite like that of pregnancy, and in the two former instances there may have been an amenorrhea corresponding in duration with that of pregnancy. In two cases under the author's notice, one of a fibroid tumor, the other of an ovarian cyst, the patients' state- ment to the examining physicians that they had missed their i6o PREGNANCY. Fig. 135.— Hernia. Fig. 136. — Sarcoma of the liver. THE DIACiVOSIS OF PREGNAiXCY. i6r Fig. 137. — Ovarian cyst. Fig. 138. — Carcinoma of uterus and ascites. Fig. 139. — Ascites from car- cinoma of pelvic- organs. l62 PREGXAXCY. Fig. 140. — Elephantiasis of abdominal walls with engorgement of hTnphatics. Fig. 141. — Tuberculous peritonitis and ascites. THE DIAGNOSIS OF PREGNANCY. 163 Fig. 142. — Distended bladder. Fig, 143. — Fibroid tumor. 164 PREGNANCY. sickness for nine months gave rise to such a strong preconceived idea of pregnancy that a false diagnosis was made. The correct diagnosis can ahnost certainly be made by a systematic search for all the subjective and objective signs of pregnancy in regular order, and in their absence by discovering the characteristic symptoms of the abdominal growth that may be present. In the case of tympanitic distention of the abdomen, deep abdominal palpation — if necessary, under anesthesia — and percussion show the absence of a solid abdominal tumor. Estimation of the Duration of Pregnancy. — The duration of -pregnancy is variable and can not be accurately determined , as no one can tell when the junction of spermatozoon and ovum occurred. If the date of the fruitful coitus can be ascertained, labor may be expected, on the average, two-hundred and sixty- nine days later. ^ Ordinarily, the history of cessation of men- struation is depended upon in making an estimate of the probable date of labor. Nagele- is the author of the convenient rule for predicting the date of the expected confinement by counting back three months from the first day of the last menstruation and add- ing seven days. For seven months of the year this method is ab- solutely correct. In April and September six days, in December and January five days, and in February four days should be added to obtain the date of a period two hundred and eighty days after the first day of the last menstruation. It is to be noted that the prediction of the date of labor can never be more than approxi- mately accurate, as labor occurs only exceptionally two hun- dred and eighty days from the first day of the last menstrual period.^ A variation of a few days either way is the rule, and prolongation of pregnancy, even to a month or more, is by no means exceedingly rare. Lowenhardt has proposed multi- plying by ten the number of days between the last normal menstruation and the one preceding, thus predicting, with a greater accuracy than is otherwise possible, the probable dura- tion of pregnancy. Thus, if the interval is twenty-six instead of twenty-eight days, the pregnancy will last two hundred and sixty days. Lusk says he has seen occasionally a curious con- firmation of Lowenhardt's view, but my own experience would not lead me to prefer this method to Nagele's. If the patient is not menstruating when she conceives, as in lactation, if the his- tory of menstruation is not attainable, or is not to be depended ^ Ahlfeld, " Monat. f. Geburtsh.," Bd. xxxiv, p. 208, based on 425 cases; also Winckel's " Handbuch," vol. i and vol. iii. 2 " Lehrbuch der Geburtshiilfe." ' Ahlfeld's statistics, based on 653 labors, show that pregnancy was ended in the thirty-eighth week in 15.93 per cent., in the thirty-ninth in 27.56 per cent., in the fortieth in 26.19 P^r cent., and in the forty-first in 10 per cent, of the cases. THE n/AGNOS/S OF PREGNANCY. 165 upon, an approximate idea of the date of pregnancy may be gained by noting the height of the fundus. At the fourth month it rises above the pelvic brim ; at the fifth it is midway between the umbilicus and the symphysis ; at the sixth month on a level with the umbilicus ; at the seventh month about four fingers' breadth above the navel ; at the eighth month about midway between the umbilicus and the xiphoid cartilage ; at the ninth month the fundus reaches its highest level near the xiphoid cartilage ; during the ninth month the fundus descends again almost to the level at which it was at the eighth month, the pre- senting part having entered the superior strait. The date of quickening is of some value in estimating the duration of preg- nancy. It may be expected in the twentieth week in primigrav- idae, in the twenty-first and twenty-second weeks in multigravidae. But this symptom is exceptionally observed as early as the fifteenth, thirteenth, or even the tenth week, and some women do not notice it till the seventh month. Diagnosis of the Life or Death of the Fetus. — The fetal heart-sounds are a most valuable sign of fetal life when they can be heard. Positive knowledge on the part of the patient of fetal movements is also of great value, and if the movements can be felt, seen, or heard by the physician, there is, of course, certain evidence of fetal Hfe. All the signs of pregnancy without fetal heart-sounds or fetal movements usually mean a dead fetus. The most valuable sign of fetal death in pregnancy is the cessation of growth in the abdomen, which is determined by successive weekly measurements of the abdomen with a tape-measure, care being exercised to ascertain on each occasion the maximum girth. If the fetus is alive, there is a steady increase from week to week. If it is dead, there is no increase in the abdominal measurements, and there may be a decrease. For a more extended account of the diagnosis of fetal life and death the student is referred to the section on the diseases and death of the fetus. It is obvious that a diagnosis of life or death of the fetus is often of great importance, as a physician would be inclined to induce labor to evacuate the womb of a dead fetal body if he could be certain that the child had died ; and a knowledge of fetal life or death would influence the treatment of nephritis or of other complicating diseases of gestation. In case of doubt it should be assumed that the fetus is still alive. Diagnosis of the Sex of the Fetus. — It was thought for some time that the diagnosis of fetal sex could be made by listening to the rate of the fetal heart-beat, — a rate of 120 to 140 in the minute indicating the probability of a male fetus, while a quicker heart-beat is indicative of a female child ; but observa- 1 66 PREGNANCY. THE DIAGNOSIS OF PREGNANCY. 1 67 tions conducted by Budin, also those in the Boston Lying-in Hospital, and others made by the author, show that there is such a variability in the fetal heart-rate from time to time that it is impossible to predict by this means the sex of the fetus. Diagnosis of a Prior Pregnancy. — The determination of this point may be of medicolegal importance. A vaginal ex- amination detects some degree of laceration of the cervix, usually bilateral. The cervix is large and cylindrical. The cervical canal is patulous, usually admitting the first joint of the index finger. There are old scars upon the skin of the ab- domen, pointing to a former distention of the abdominal cavity, the recti muscles are separated by at least three finger-breadths, and the abdominal walls are more flaccid than in a primigravida or a nulliparous woman. The pelvic floor may be relaxed, and there may possibly be tears of the levator ani muscles. The hymen is not only torn, but is in great part destroyed, the rem- nants forming the carunculse myrtiformes. The vaginal mucous membrane is smooth, and the vulva gapes so that by separation of the labia majora often a great part of the vaginal canal can be brought into view. There is often some degree of cystocele, the anterior vaginal wall bulging downward and forward into the vulvar orifice. The breasts are ill supported and sag down, while upon the skin, especially at the base of the glands, may be seen the white and glistening scars of old striae. Parturition in very rare cases, especially if the child is pre- mature and small, may leave hardly a trace behind it, and the delivery of a submucous fibroid may produce the same lacera- tions of the cervix and pelvic floor that occur in childbirth. Pseudocyesis, or Spurious Pregnancy — In women who ardently desire offspring, in those who fear impregnation, and in individuals who, without longing for or dread of maternity, believe themselves pregnant, the subjective and some of the objective signs of pregnancy may appear to so striking a degree that the patient herself is completely deceived, and not infrequently her physician shares her belief in the existence of pregnancy. I was once consulted by a prostitute who firmly believed she had been pregnant for a year, or ever since her occupation had exposed her to the danger of impregnation. The ab- domen was distended; the breasts were enlarged and painful, though not secreting; menstruation was very scanty and irregu- lar, and the woman asserted that she felt fetal movements. The abdominal distention was due to fat and gas. The uterus was unimpregnated. I have frequently seen women who put on an excessive amount of abdominal and omental 1 68 PREGNANCY. fat as they approach middle age, and who, in consequence of the abdominal enlargement, believe themselves pregnant. Men- struation may be entirely absent or so scanty as scarcely to attract the woman's attention, and all the subjective signs of pregnancy may be accurately described. It often requires in these cases an examination under anesthesia before the unimpregnated condition of the uterus can be detected. Weir Mitchell asserts that once Fig. 145. — Pseudocyesis : Amenorrhea for eight months, but vicarious men- struation from nose every month. The uterus is normal in size, position, and mobility. The abdominal distention is due solely to tympanites and fat. these women's minds are disabused of the idea that they are preg- nant, the abdominal enlargement rapidly subsides, and all the subjective symptoms of pregnancy immediately disappear. Oc- casionally it is imposible to convince a woman that she is not pregnant if she has allowed the idea of pregnancy to take entire possession of her mind. A little, wizened old lady with gray hair, apparently sixty years old, applied for admission at the Maternity Hospital of Philadelphia. She volunteered the statement that many years before she had subjected herself to the dangers of ille- THE DIAGNOSIS OF PREGNANCY. 1 69 gitimate impregnation, and that ever since she had been pregnant. Nothing could convince her of the truth, and she indignantly left the hospital firmly possessed of her monomaniacal idea. The case shown in figure 15.1- is interesting. The woman had haxl an attack of pelvic peritonitis just nine months before. Her menstruation had been absent ever since, but there had been a vicarious flow regularly from her nose. The abdomen steadily and rapidly enlarged and the woman was firmly con\'inced that she was pregnant. With this idea she obtained admission to the maternity wards of the Philadelphia Hospital, having been pre- viously examined by a physician who pronounced her pregnant at term. The abdominal distention was due entirely to tympanites, the result of partial obstruction of the sigmoid flexure, which was involved in the adhesions of the uterine appendages on the left side. PART II. THE PHYSIOLOGY AND MANAGEMENT OF LABOR AND OF THE PUERPERIUM. CHAPTER I. Labor. This chapter deals vnth the management of a woman in labor. The questions involved in this study confront every practitioner of medicine at some time. 'Every physician is pK)pularly supposed to be able to manage a labor, and such cases are among the first that he is called upon to attend. To a beginner in obstetric practice there is much that is em- barrassing. The novel and intimate relations \^'ith his pa- tient; her e\"ident dread of the necessar}' examinations more or less revolting to every woman ; the doctor's keen conscious- ness of a lack of experience; mistrust of his capacity to re- cognize the stage of labor, the presentation and position of the fetus; the knowledge that his ever}' mo\ement is watched by critical friends or attendants of the patient, who possess, perhaps, just what he lacks, — practical experience, — all unite to produce a most unenviable frame of mind in the practitioner attending his first few cases of labor. Some consolation, however, can always be found in the reflection that labor is a natural and a comparatively ea.sy process, in the large majority of cases; that a physician's duty is one mainly of inaction and non-interference, and that most probably the labor will terminate fortunately for mother and child, in spite of his inexperience. But it is evident that no one can predict what may occur in any given case. There may sud- denly arise some accident of the gravest nature, which must be immediately recognized and promptly treated. It is under such 170 LABOR. 171 circumstances that a physician's education and knowledge arc put to the test. It is plain, therefore, that in a work on obstet- rics it must be the writer's aim to impart the requisite knowl- edge to cope with all sorts of dangerous emergencies. This consideration makes it necessary to dwell at length upon all the possible complications, accidents, and difficulties of the child- bearing process, leaving upon the student's mind the impression that parturition is a more dangerous process than is really the case. It is well to recollect, therefore, that nature alone, in the majority of cases, with very little artificial aid, is capable of termi- nating safely the birth of the child; but at the same time it should not be forgotten that at any moment a dangerous complication may occur, which must be immediately recognized and promptly dealt with. Labor is the process by which a female expels from her uterus and vagina the ovum at its period of full maturity, which is reached, on the average, two hundred and eighty days after the first day of the last menstruation. The process is divided into three main stages or acts, — the expansion of the birth-canal, the expulsion of the fetus, and the delivery of the remainder of the ovum. Why labor occurs at a definite time has given rise to endless speculation in all ages of medicine.^ Several explanations may be offered. The period of two hundred and eighty days, or forty weeks, or ten lunar months, is the tenth menstrual period since pregnancy began. At the menstrual period in the non- pregnant uterus there is always distinct muscular action, in- duced probably by the presence of a foreign body — blood — in the uterine cavity. During pregnancy it has long been known that by the unconscious memory of living tissue there occurs, at regular intervals corresponding to the menstrual period, a dis- position to muscular action, which is sometimes so exaggerated as to bring about an expulsion of the ovum, — an accident espe- cially to be feared at such times in women prone to abort. This cause of labor is described as periodicity. The hollow muscles in the body admit of distention up to a certain point, but, that point being reached, they are stimulated to contraction. This is illustrated in the stomach of the young 1 Hippocrates explained the onset of labor by the hunger of the fetus, which impelled it to make its exit from the womb to seek something to eat. The following explanations have been offered in recent times: thrombosis of the veins at the placenta site; excess of CO.^ in the maternal blood; excess of CO.^ in the fetal blood; deficiency of CO.^ in the blood; pressure upon the ganglia in the supravaginal por- tion of the cervix; excess of urea in the blood, etc. See Blumreich, " Experimente Zur Frage nach den Ursachen des Geburtseintrittes," " Archiv f. Gyn.," Bd. Ix.xi, H. I. 172 LABOR AND THE PUERPERIUM. infant, or in the ventricles of the heart. The same action is seen in the pregnant uterus. It admits of distention up to a certain point, until it is well filled by the mature fetus, when the tension of its walls stimulates them to muscular action which terminates in the expulsion of the ovum. This cause of labor is defined as over distention of the uterus. In the human ovum that has reached full maturity there occurs a degenerative process, a fatty change in the connections which bind the ovum to the uterus, that brings about a separa- tion more or less extensive between the uterine wall and the ovum, and the latter, becoming a foreign body in the uterine cavity, is cast off. This cause of labor is called the maturity of the ovum. Heredity, the unconscious memory of tissue transmitted from generation to generation, plays an important role in the causation of labor. Thus, at the end of two hundred and eighty days the fetus has reached such a size that it is just pos- sible for the woman, at the expense of much effort, to expel it through the birth-canal. Had it grown much larger, its expul- sion would be difficult or impossible. On the other hand, an infant born much before two hundred and eighty days is not sufficient!}^ well developed to endure the lower temperature that it encounters, and the necessity for obtaining its own nourish- ment and oxygen, and consequently it may not survive. There- fore, it is plain that only those women who gave birth to their offspring about the two hundred and eightieth day of pregnancy could successfully perpetuate the human species. Those that fell in labor later probably died ; those whose young Avere bom earlier were not able to rear them ; and so the habit of bear- ing children at the end of forty weeks from conception, trans- mitted from generation to generation through many ages, became a factor in determining the duration of pregnancy. Finally, the biochemical actions and reactions of the fetus and mother may influence the onset of labor. It is claimed that the fetus near maturity pours into the maternal blood an excess of antigen, which reacts with the antibody already present in. the maternal organism to produce an anaphylactic result,, stimulating the uterus to contract. Injections of fetal serum into pregmant women seemed to have a stimulating effect upon the uterus in a majority of the experiments.^ To recapitulate, labor comes on at the two hundred and eightieth day from the beginning of the last menstrual period, by reason of the influence of periodicity; the overdistention of the uterine cavity; the maturity of the ovum; heredity, and ' A. von der Heide, " Miinch. med. Wochenschr.," Aug. 8, igii. LABOR. 173 possibly anaphylaxis. All these causes beinp; operative together, it requires a slight stimulus or none at all to inaugurate effective uterine contractions, f^xercise, a stimulant to the uterus, a dose of purgative medicine, a jolt or a jar may provoke muscular action on the part of the uterus that ends in the expulsion of the child. This knowledge may be put to practical use. If it is desirable that labor should not be delayed, a dose of castor oil the night before the expected date and 15 grains of quinin the next morning with a hypodermic injection of pituitrin, often bring on effective pains. Before entering upon a study of labor the student should be sure that he is able to recognize its occurrence. The diagnosis of labor, therefore, is a necessary preface to the study of its physiology and management. First and fore- most, in the woman supposed to be in labor, the existence of pregnancy should be determined. Many ludicrous and some tragic errors have been due to a disregard of this rule.^ There is a valuable premonitory sign of labor which should always be inquired for: the subsidence of the uterine tumor at periods vary- ing from four weeks in the primigravida to two weeks or less in the multigravida before the actual advent of labor. This sink- ing of the uterine tumor is the result of the engagement of the lower uterine segment with the presenting part of the fetus in the superior strait and in the cavity of the pelvis. It has its cause, probably, in the action of the muscles inclosing the ab- dominal cavity. Just as the stomach, the heart, and the uterus bear distention up to a certain point, so the abdominal mus- cles allow a certain distention of the abdomen to occur, but resent anything beyond it. This point is reached in primi- gravidae at about the thirty-sixth week of pregnancy, but later in multigravida^ owing to a greater laxity of their muscles. The abdomen being distended to its utmost, the abdominal mus- cles contract vigorously and drive the lower part of the uterus down through the superior strait into the cavity of the pelvis by diminishing the area of intra-abdominal space, thus accomplish- ing the first step in the expulsion of the child, the passage of the head, presuming it to be a cephalic presentation, through the superior strait, long before the labor itself begins. This .sinking of the fetus and uterus occurs often suddenly, so that iQne of my students, on duty in the out-patient obstetric department, receiving his first call, hurried to the woman's house, spent some fifteen minutes sterilizing his hands, and made a prolonged vaginal examination, much to the patient's surprise, as she had sent for a physician on account of rheumatism. She was not pregnant. On one occasion I figured as an expert witness in a trial for damages on account of an attempted Cesarean section. The patient, a rachitic dwarf, was not even preg- nant when the operation was performed. 174 LABOR AND THE PUERPERIUM. the pregnant woman may rise one morning entirely relieved of the distressing abdominal pressure symptoms that had previously, perhaps, tormented her. But the relief in one direction is fol- lowed by an aggravation of the varices about the vulva, anus, or lower limbs, by neuralgic pains extending down the thighs, by increased vaginal secretion, — all due to the greater pressure within the pelvic cavity. So constant is this phenomenon, the descent of the pregnant uterus near term, that, should it' fail to occur, some cause for the failure should be looked for. It is usually found to be a malposition of the fetus or a deformity of the pelvis. There are three signs indicating that labor has actually begun : (i) Recurrent pains of characteristic duration, situation, and nature ; (2) the escape of a small quantity of blood-tinged mucus from the vagina, and (3) the dilatation of the os. The characteristic pains of commencing labor recur at intervals of from five minutes to half an hour, usually being about fifteen minutes apart. The pain is located in the abdomen, or is de- scribed as passing from the umbilicus in front to the sacrum behind, or in some cases is confined altogether to the back. It comes on suddenly. - The woman is walking about the room, or perhaps conversing, when suddenly she pauses, bends over, contorts the facial muscles, sets her lips, and clinches her teeth. The pain rarely lasts more than a minute; w^hen it passes off the woman resumes her interrupted occupa- tion. If the hand were laid over the abdomen when the pain came on, the uterus would be felt as a firm, hard, well-defined body, more globular than in its relaxed condition. As a consequence of the dilatation of the internal os, the lower portion of the o^oim begins to sever its connection with the uterine wall, small blood-vessels are torn, and there is a slight oozing of blood, which stains the large plug of tenacious mucus that has filled the cervical canal during preg- nancy. The cervix being gradually obliterated from above downward by the descending ovum, the blood-stained plug of mucus is expelled from the cervix into the vagina, whence it escapes externally and becomes what is popularly called the show, which is regarded, and rightly, too, as a valuable sign of beginning labor. But the uterus may contract quite vigorously and bloody mucus may escape externally in many a case when labor has not really begun. The most reliable sign, after all, is the obliteration of the cervical canal and the dilatation of the OS. If these conditions become plainly appreciable, one may safely diagnosticate a beginning labor, although it would be well to bear in mind exceptional cases in which the os has LABOR. 175 actually dilated up to an inch or more, but has afterward retracted and remained undilated until true labor finally ap- peared.' Having made a diagnosis of beginning labor, the physician is immediately plied with questions by the patient or her family as to its probable duration. Unfortunately, a definite answer can not be given. It is a common experience to see a variation in the length of labor from one hour or less to many hours; indeed, in. rare cases to a week or more. So that it is impos- sible to predict with any degree of accuracy how long a given labor might last. One can usually obtain an approximate idea, however, by bearing in mind the average duration of labor in multiparae, eight hours, while in primipara? the time is usually double that or longer. One should recollect that a large parturient canal with a normal fetus, or one under- sized, along with vigorous muscular action, means a quick labor; that the opposite conditions mean delay. In the case of multiparas one should always inquire into the history of past labors, for many women have marked individual peculiari- ties in regard to the duration of parturition, in some the process being usually rapid and easy, in others the reverse. A consid- eration of all these factors will enable one to form some definite idea in his own mind of the probable duration of labor, but he would do wisely to keep his opinion to himself. To the in- quiring family a non-committal statement should be made, such as "the length of the labor will depend on the strength of the pains." ^ Before proceeding to a consideration of the management of labor, the student will find it of service to observe the process as a passive spectator. Nothing is so conspicuous in the first stage of labor as the contractions of the uterine muscle. It has been asserted that the uterine walls contract in a sort of peris- taltic wave, beginning at the cervix, running up over the fundus, and returning again to the cervix ; but this action has never been actually demonstrated, and it is more convenient, if, indeed, it is not strictly correct, to regard the uterus as a hollow muscle 1 1 have seen a young primigravida with the os dilated so that I could put four fingers side by side into it, and with the membranes bulging into the vagina, who walked about the house for a week in this condition before labor-pains appeared. In this and in similar cases, however, the cervical canal was not effaced. ^ As those labors which end in the day-time often begin at night, and vice versa, an obstetrician's rest is disturbed in a very large proportion of his cases. There is, consequently, a prevalent idea that almost all cont'incmcnt cases occur at night. As a matter of fact, 40 per cent, only are delivered between the hours of 11 p. M. and 7 A. M., according to the statistics of West, based on 2010 cases (" Amcr. Med. Jour.," 1854). Lynch's statistics of 22,873 labors show that 41 per cent, end be- tween 9 p. M. and 6 a. m. (" Surg., Gyn., and Obstct.," Dec, 1907). 176 LABOR AND THE PUERPERIUM. which contracts at once and equally in all its parts. The effects of these contractions are : (i) To drive the liquor amnii in the direction of least resistance, which is through the internal os into the cervical canal, where, contained in the membranes, it dilates the cervical canal in the very best manner for the mater- nal tissues, as a hydrostatic dilator. (2) To drive down the fetal mass in the same direction by diminishing the area of the intra-uterine space. (3) To distend the lower uterine segment and upper cervical canal by mechanical pressure, and, finally, to dilate the os in the same manner after the circular, sphincter-like muscle of the cervix has been paralyzed by stretching and pro- longed pressure. The av^erage duration of the uterine con- tractions during labor is one .minute. The intervals between them decrease as labor goes on, and the pains become more powerful until, finally, there should intervene between them but two or three minutes. No one could observe the process of parturition in the capacity of a scientific obsen^er without re- garding the action, appearance, and condiiio7i of the woman. It will be found that her whole bearing and manner present two distinct types in the course of the process. At first the advent of each pain is announced by a sudden setting of the teeth, a distortion of the facial muscles, suffused eyes, and a flushed face, and, the pain increasing in intensit}^, she suddenly emits a sharp cry of pain. The woman, if in bed, assumes almost any attitude that is most comfortable to her. In a normal first labor of some seventeen hours' duration, this condition of affairs lasts about fifteen hours, when a marked change may be observed in the woman's action. If she were left entirely to herself she would be ver\^ likely to assume a squatting posture in bed or upon the floor, — a position assumed by the women of many savage tribes during the latter stage of labor. Now, as a pain comes on the woman draws a deep breath, clinches her teeth, fixes her diaphragm, and evidently, from her behavior, calls into play the action of the abdominal muscles with all her might. Her face is suffused, the eyebrows knit, and beads of perspiration stand out upon her brow. As long as the breath can be held this straining action is continued, until the air is suddenly expelled from the lungs with a charac- teristic grunting sound, the diaphragm is again relaxed, and the abdominal muscles cease for a moment to act until a full in- spiration is taken, when the straining again begins, and continues until the uterine contraction passes off. If a vaginal exami- nation were made at this time, a reason would be found for the change in the clinical aspect of the case. It would be discovered that the os is fully dilated and that the presenting part is begin- LABOR. 177 ning to descend, cither carrying the membranes before it or else, as is more common, the membranes ru|)ture just as the os is Fig. 146. — The bag of waters or pouch of membranes. Fig. 147- — The distention of the vulva and the appearance of the child's scalp. fully dilated and the child's presenting part is driven through the rent in the amnion and chorion. In this condition of affairs 178 LABOR AND THE PUERPERIUM. is found a good explanation for the action of the abdominal muscles; so long as the presenting part acts simply as a wedge, dilating the os, but not descending to any appreciable degree, the muscles of the abdomen are useless, and are, in fact, inhibited, for their action would drive the presenting part against the undi- lated cervix with such force as to give great pain, if not to do Fig. 148. — The escape of the head and the resumption of its oblique position (external restitution). great damage. The main obstruction to the descent of the child, the cervix, being removed, the abdominal muscles are called into play, and act effectively in the displacement of the fetal body downward along the birth-canal. For convenience definite names are given to these stages of labor, presenting" each such distinctive features. The period of dilatation is called the first stage ; the period of descent or expulsion is called the second stage. The first stage begins with the onset of labor and ends with the complete dilatation of the os. The second stage begins with the dilatation of the os and ends with the LABOR. 17 79 complete expulsion of the child. As labor is not complete until the whole ovum is expelled, there is a third stage of labor, that period of time from the extrusion of the fetus until the pla- centa and membranes are expelled. To return to the clinical phenomena of labor. The wo- man has passed from the first to the second stage. As the latter progresses the pains become more frequent and more violent, the suffering is increased, and her complaints grow Fig. 149. — The transverse rotation of the head (external rotation). louder. Finally she declares, perhaps, that she must rise to evacuate her rectum and bladder, and the reason for this feel- ing is clear when one sees the perineum bulging far outward, the anus widely dilating, the rectum becoming slightly everted, and the presenting part, the head, filling up the whole lower part of the pelvis and pressing as firmly on the bladder in front as it does on the rectum behind. And now, with his eye upon the vulva, — for this part of the labor, in the best interests of the i8o LABOR AND THE PUERPERIUM. patient, ought always actually to be observed, both in a scientific study of the process and in its management, — the physician sees the labia separate during a pain and the child's scalp come into view, but, with the subsidence of the pain, disappear. With the next uterine contraction a little more of the head appears, again to disappear as the pain passes off, and so on with every pain for perhaps twenty minutes or an hour, although every time, as more and more of the head appears, it looks to the inexperienced observer as if that pain must be the last, until Fig. 150. — The support of the head and the escape of the anterior shoulder. finally the vulva is stretched to its 'utmost limit and the largest diameters of the head are engaged, when, with a sudden shriek of pain from the woman, the child's head is born. There comes then a pause in the uterine action ; the head may protrude from the vagina for a minute or much longer, while the woman's natural powers are being recuperated, after their tremendous ex- ertion, for a fresh effort. Meanwhile, the child's face turns im- mediately after birth toward one or the other tuber ischii, and from the constriction about the neck becomes livid, and it seems that the child's life is threatened by strangulation. The medi- cal attendant feels at first an almost irresistible impulse to pull on the head and terminate labor. But this is a useless, indeed, a reprehensible procedure, for the child is perfectly safe, its respiration still going on normally in the placenta, and to ex- LABOR. l8l tract the shoulders rapidly through the overstretched and bruised maternal tissues is almost certain to lacerate the peri- neum. Moreover, the child is insensible at this time ; it has been almost comatose during its passage through the pelvic canal, and is now recovering, its brain-centers, especially that of respi- ration, becoming ready to respond to the stimulus to act when the child is born. Any unnecessary interference, therefore, at this stage of labor may harm both mother and child. The woman's uterus having regained power, in a few minutes begins to contract. The abdominal muscles aid it. The child's face turns still more to one side or the other until it looks quite transverse. The expulsive force still acting, the anterior shoulder appears under the symphysis pubis, the posterior shoulder shortly afterward sweeps over the perineum and escapes ; the anterior shoulder follows it, and the rest of the body, too small to present any longer an effective resistance, is expelled im- mediately and the child is born. Its birth is announced, as a rule, at once by a lusty cry, which expands its lungs and initiates the pulmonary respiration. Immediately after the ex- pulsion of the child the woman becomes perfectly quiet and composed, no matter how noisy she may have been before. The passive pleasure of relief from suffering is so great that it becomes a positive enjoyment simply to be quiet, and the woman does not wish to be disturbed. In the course of some fifteen or twenty minutes, in a perfectly natural and normal case, such as is now under description, the patient again experiences pain ; the uterus is again contracting, and the woman is again instinctively aiding it with her abdominal muscles, until after one or two such pains the placenta with the membranes is expelled. The manner in which the placenta is separated from the uterine wall and is expelled from the uterine cavity is a matter still under dispute, and there is the greatest difference of opinion in regard to it. "If," says Dr. Berry Hart, the distinguished obstetrician of Edinburgh, " the delivery of the placenta de- pended upon obstetricians knowing how it separated, no woman in labor would complete her third stage." To explain the first phenomenon, the separation of the placenta, many theories have been advanced, of which I shall give only the three most reasonable, each of which has its prominent adherents. These three theories are: (i) The diminution in the area of the placental site; (2) the detrusion theory, which is founded on the belief that the uterus seizes the placenta and pushes it off from the uterine wall; and (3) the theory that an effusion of blood occurs behind the placenta, and that this " retroplacental effusion," as it is called, 1 82 LABOR AND THE PUERPERIUM. pushes off the placenta from the uterine wall. Of these three theories, I am an adherent of the first. In a strictly normal case the retraction of the placental site is alone sufficient to account for the separation of the placenta. It has been demonstrated that, as the uterus contracts, the placenta follows the retrac- tion of the uterine walls up to a certain point without becom- ing detached, until the placenta is reduced to about one-half its natural size. Now, this is easily explained if one recol- lects the structure of the placenta, Hke a sponge, with its branching villi and intervening blood-spaces. But as soon as these villi are squeezed together so that the placenta forms one solid mass, it can no longer follow the retraction of the uterine wall, but is that moment, in a typically normal case, sprung off from its attachment to the uterus, and is for a varying period of time loose within the uterine cavity, until, acting as an irritating foreign body upon the uterus, it is finally driven out into the cer^'ical canal and upper part of the vagina by the uterine contractions that its presence within the uterus excites. In the cervix and vagina, however, the placenta may remain a long time without exciting the benumbed and almost paralyzed muscles of these regions to action. And thus it is that, in civiHzed women, at least, it is often impossible to leave the third stage of labor entirely to nature, for the placenta may remain so long undeliv- ered that its succulent mass may putrefy and so become a source of septic infection. In describing a perfectly normal case of labor, I must presume that the placenta is expelled by the natural forces, and must describe the manner of its expulsion. But here, again, one encounters the greatest difference of opinion, even about so apparently simple and trivial a matter. One set of observers, led by the English obstetrician, Matthews Duncan, declares that in natural labor the placenta comes out edgewise, and that any other mode of exit indicates something abnormal ; while Schultze, of Germany, and his followers de- clare that the placenta always escapes like an inverted umbrella. My observation compels me to adopt the latter view. In consequence of the enormous effort put forth, the nervous excitation, the acute suffering, and the injury inflicted upon the soft structures of the birth-canal, it is not surprising that sys- tematic thermometry of the recently delivered woman shows almost always some elevation of temperature in the first twelve or twenty-four hours after child-birth. After a brief observation of the main clinical phenomena of labor, the student is better prepared to take up a consideration of its management. The advice offered applies to private and not to hospital practice, and to the beginning of the process. In LABOR. 183 the vast majority of cases a physician is engaged to attend a woman in confinement a considerable length of time before labor is expected, and there are ])oints in the preliminary management of the j:)atient which it is important to appre- ciate, but they have been considered in the section upon the management of pregnancy. The present section begins with the first intimation that the doctor receives of beginning labor, the summons to attend his patient in confinement. The call may come at the most inconvenient time, — late at night ; in the early hours of the morning ; at the beginning of a meal ; in the midst of a press of other work, — but no one should practise ob- stetrics who does not make it an inflexible rule to give such a summons precedence over everything, over personal con- venience and all other engagements. It is customary, in this connection, to offer advice to young practitioners in regard to their personal demeanor and appear- ance when about to attend a woman in labor. While such ad- vise is usually superfluous, it does no harm to remind the phy- sician of the especial requirements of obstetric practice. He should remember that the irritability and increased sensibility characteristic of pregnancy are even more exaggerated during labor. Any unusual appearance in the medical man — slovenliness of dress, abruptness of speech and manner, harshness of voice, the odor of liquor on his breath or of tobacco in his clothing — may disgust his patient. Bearing in mind the increased sensi- tiveness of women in labor, recollecting that the agony which they are about to endure, and that the despondency due to dread of im- pending suffering, if not of death, demand the greatest sympathy and consideration, no one fitted by nature for the practice of medi- cine will go far astray in his conduct toward his parturient patients. A more important question arises as soon as a physician is summoned to a case of labor. What shall he take with him ? As a part of his management of the pregnant woman he has directed the patient or her friends to have at hand the articles enumerated in the list of directions to mother and nurse on pages 231-233. A well-equipped obstetrician should take with him in his obstetric bag, to an ordinary case of confinement, the following articles : 1 razor. Nest of basins (3). 2 brushes. 4 towels. I metal tube for sterile cotton, vulva pads and packing. I gown. 1 tube unguent. 2 pair rubber gloves. 184 LABOR AND THE PUERPERIUM. I clinical thermometer. I hypodermic syringe. I douche bag, glass nozzle, and rectal tube. I bottle containing eye wipes, pipet, and boric acid solution (gr. XV to oz.). I jar containing umbilical tape. I jar containing soft soap. 1 bottle ergot. 2 ampoules of ergotin for hypodermic injection. I bottle nitrate of silver (i per cent.). I bottle bichlorid tablets. I powder shaker, containing powder for umbiHcal dressing (i part salicylic acid to 8 parts starch). I package of umbilical cord dressing. I sterile catheter. I hypodermoclysis needle. I bottle tablets for making normal salt solution. CONTENTS OF INSTRUMENT PAN. I pair Simpson's forceps. i tube catgut. I tenaculum forceps. i dressing scissors. 1 intra-uterine catheter. i umbilical scissors. 2 hemostatic forceps. Alcohol lamp and stand. 1 curet forceps. Small instrument tray. 2 needles. This is the equipment furnished my students in the outpatient department of the University Hospital. The basins, brushes, towels, gown, gloves, douche bag, cord dressing, and catheter are done up in separate packages, covered with muslin, and sterilized in the autoclave. The metal tube and powder shaker, with their contents, are also sterilized. A physician who takes obstetric cases should have in his office a sterilizing outfit by means of which he can keep his ob- stetric bag replenished with a sterile equipment. Arrived at the dwelling to which he has been summoned, the physician finds the woman in the room selected for her con- finement, which should be, if possible, the sunniest and best ventilated in the house, and in care of a nurse in whom he has confidence from past acquaintance or from good recommenda- tion. He has been summoned because the woman believes her- self to be in labor, but she may be mistaken, or, on the other hand, may be much farther advanced than she imagines. It is the physician's first care to determine this point, and to do it he LABOR. 185 must make an examination. This the patient fully expects and will in no way object to, but it must be done in a manner as little revolting to her feelings as possible. After a few indifferent remarks in a Cjuiet tone to the patient; a few questions in regard to the time the pains first came on, their duration, character, and situation, and the intervals of time between them ; after feeling the pulse, perhaps, and looking at the tongue, and assuring her that her general condition is very good indeed, the nurse is in- formed that the patient is to be prepared for abdominal palpation. While the nurse is arranging the patient on her back with a single layer of some thin material, as a bed-sheet, spread smoothly over the abdomen, the physician himself either leaves the room or turns his back upon the bed while he dons a surgical gown and gives his hands a preliminary washing. This whole subject of the obstetric examination is so im- portant that space may well be devoted to its consideration. Abdominal palpation is described fully in the chapter upon The Mechanism of Labor. It is, therefore, only necessary to state here that, after determining the position of the fetus in iitero, and investigating its condition by listening to the heart-sounds, the nurse is directed to place the patient upon that side toward which the fetal back is directed and to prepare her for a vaginal examination. For this purpose the parturient woman is placed upon her side, with the hips brought well to the edge of the bed, the thighs flexed upon the abdomen, the legs upon the thighs. The clothing is rolled up above the waist, or so arranged that it shall not interfere with the access of the examining hand, and the bed-sheet is draped over the patient so that a wide margin of it falls over the side of the bed. While this is attended to the physician is cleansing his hands by a method described in the chapter on Aseptic Technic (p. 785). In addition to the hand disinfection, it should be an invariable rule to wear rubber gloves that have been boiled, steamed, or soaked in a i : 1000 sublimate solution. The physician uses the hand for the internal examination next the patient, as he takes a seat beside the bed, facing her genitalia. Everything being in readiness for the vaginal ex- amination, the examining finger is dipped into a jar of car- bolated vaselin, or the unguent is squeezed upon it from a col- lapsible tube; the nurse Hfts up the sheet covering the buttocks, the obstetrician raises the upper buttock with his free hand, wipes off the vulvar orifice with pledgets of cotton soaked in a 1 : 2000 sublimate solution, and by the sense of sight inserts the forefinger of the examining hand directly into the gaping vaginal orifice. Nothing is more foolish than the ancient practice of grop- 1 86 LABOR AND THE PUERPERIUM. ing about under a sheet for the woman's genitalia, thus dangerously soiling the examining hand which had been made sterile by a pains- taking disinfection, only to be iafected again before its insertion into the vagina. The abihty to derive easily all the desired infor- mation from a vaginal examination only comes from practice and an education of the tactile sense. It would be well, therefore, for the practitioner, in the beginning of his obstetric experience, to bear in mind a series of questions in their natural sequence, which he desires to have answered, and to persist in his earlier cases until repeated and long-continued examinations have satis- fied his mind. Thus : the character of the vaginal discharge ; the state of the perineum, whether relaxed, rigid, or torn perhaps from a previous labor; the rigidity and distensibilit>^ of the vaginal walls and the quantit}^ of secretion upon them, — nature's lubricant ; the capacit}" of the pelvis ; the condition of the cer\dx, whether it is rigid or yielding, thickened, edematous, or thinned out ; the degree of dilatation of the os ; the portion of the fetal ellipse which is presenting itself at the os ; the engagement of the presenting part in the pelvis ; the position that the present- ing part may have assumed ; the rupture or the integrit}^ of the membranes ; and, if the examination continues during a pain, the effect of the expulsive forces upon the fetal mass. All these are questions of great importance in their bearing upon the diag- nosis of the woman's present condition and upon the prognosis as to the character, duration, and termination of the labor. Having satisiied his mind upon all these points, the obstetri- cian enters upon the management of labor. The first step in the treatment of the first stage of labor is the evacuation of the rectum. If the pelvic canal is occupied by a distended rectum full of feces, labor is delayed, the woman's suffering is greater, and the danger of a tear in the distended vagina is increased. It is only the rectum and sigmoid flexure that need be emptied, and this result is best secured by an enema of a pint of soapsuds with a teaspoonful of turpentine in it. A well-trained nurse ^^'iU already have done this, perhaps before the doctor's arrival, if she thinks that labor has really begun. The enema acts quickly and eft"ectually. whereas a purgative administered at the beginning of labor begins its action possibly when the os is too much dilated to allow the woman to use a com- mode. The lower bowel being emptied, the woman may be al- lowed to walk about the room or to sit up in a chair, the physi- cian making an examination from time to time to determine the progress of labor and to avoid the serious accident of a precipitate dehver}- in the erect posture, an accident dangerous to the mother and usuall}- fatal to the child. This statement leads to the inquiry LABOR. 187 how often and how long to examine a parturient woman in the first stage of hibor, and how long she should be allowed to re- main out of bed in a standing or a sitting posture. In a normal case during the first stage of labor, the intervals between the examinations are from two to four hours, or even longer. But two or three examinations need be made during the whole labor. As to the time for putting a woman in labor to bed and keep- ing her there, it is usual to lay down the rule that as soon as the OS has reached the size of a silver dollar the woman should be confined to bed. Many patients might be allowed to be up longer than this, while others with a history of, or conditions predisposing to, quick labors must be put to bed earlier. A patient may express a desire to go to the toilet at this time, but it can not be allowed. Many a woman has discharged her infant into the seat of a water-closet or into the well of a pri\y, either by design or under the impression that she was having an evacuation of the bowels.^ Before the woman is put to bed it should be arranged for the labor in the manner illustrated in figure 151. The mattress is protected by a mackintosh and the bed-sheet is guarded by a pad of nursery cloth. As the first stage of labor advances, the suffering of the woman increases with each succeeding pain. The alleviation of this pain is naturally demanded by the patient. The dangers and disad- vantages that, it is claimed, result from the use of anesthetics in labor are: a prolongation of the process by weakening the uterine contractions and increasing the intervals between them; a dis- position to postpartum hemorrhage; an increased liability to sepsis after labor by a relaxation of the uterine muscle, and a subinvolu- tion of the uterus. These objections are ill-founded if the anes- 1 The resident physician on my service at the Howard Hospital was called to a house in the neighborhood, and fished out of the privy-well, twelve feet deep, an infant which had been immersed in the contents of the well up to its neck for eight hours. The mother had deliberately sat upon the seat until her baby dropped from her. She had then thrown three bricks down upon it. In spite of these disadvantages the child was extracted alive, by means of a pole and some twine. It was received into my wards at the Philadelphia Hospital, where it thrived. On another occasion one of the patients in the University Maternity locked herself in the water-closet, dropped her baby down the bowl, and turned on the water. A nurse's attention was at length attracted to a stream of water running across the floor of the corridor. The water-closet door was broken open, the woman pulled oft the seat, and the child, whose head accurately stopped up the e.xit-pipe of the bowl, was extracted alive, though it had been under water probably five minutes. One of my patients, in the winter of 1907, with a permit to enter the University Hospital, was coming to Phila- delphia on the New York express. Between North and West Philadelphia, the train running at least 40 miles an hour, the woman dropped her fetus through the water-closet to the tracks below. It was found more than an hour later by a track- walker lying alive and uninjured on the snow. All cases of this kind do not end so fortunately. 1 88 LABOR AND THE PUERPERIUM. thetic is administered in a proper manner. An anesthetic, if not pushed too far, has no influence on the power, duration, or frequency of the pains. By reheving suffering that causes exhaustion the danger of postpartum hemorrhage is avoided. Subinvolution is never seen as a result of anesthesia unless it is complete and long continued. Occasionally labor is little more than an inconvenience or a discomfort, and by no means an agony. Women have been known to expel a full-term child Fig. 151. — Bed arranged for child-birth. The mattress is protected by a mackin- tosh, over which a clean sheet is spread. The upper bed-clothes are rolled up at the foot of the bed. The woman's buttocks rest upon a square yard of nursery cloth. The chair is for the obstetrician ; at his feet is a waste-bucket, into which the pledgets of cotton used to clean the anus are thrown. The table, in easy reach, has upon it a large basin of sublimate solution, I : 2000, in which are many large pledgets of cot- ton ; a small tin cup on an alcohol lamp to boil the scissors for the cord ; a half dozen clean towels ; a pot of carbolated vaselin ; a tumbler of boric-acid solution with squares of clean soft linen in it for the child's eyes and mouth ; a tube of sterile silk for the cord. when they were hardly conscious that labor had begun. ^ Some show the fortitude of Isabella, wife of Charles V. To resort, therefore, to an anesthetic when there is no suffering or no com- plaint is unnecessary. Granting, however, that in many cases anesthesia in labor is an advantage, if not a necessity, the ^ Dr. B. B. Gates, of Knoxville, tells me of a case in which there was no pain whatever during labor, but at every uterine contraction the patient said she felt as though she had a croquet ball in her mouth (globus hystericus). LABOR. 189 physician must select the anesthetic, and must determine when and how he shall use it. The choice lies between ether and chlo- rofonn. Cocain applied to the vaginal portion of the cervix proved a failure. Belladonna is also useless, although it dimin- ishes rigidity; the same may be said of chloral taken internally. Injections into the cervix of novocain or /''-eucain with adrenalin solution are difficult to administer and increase the risk of infec- tion. Repeated hypodermic injections of hydrobromate of hyoscin, gr. -^\-^ (scopolamin) , and morphin, gr. \, are sometimes useful, but do not compare in efficiency with ether or chloro- form.^ After a personal trial of this anesthetic I have given it up. There is a tendency to prolongation of labor, to post- partum hemorrhage, and to asphyxia of the infant if the woman is brought deeply enough under its influence to relieve her pain. Morphin alone is occasionally indicated, but it usually delays labor. Pantopon is recommended recently as an improved preparation of opium superior to morphin and without its dis- advantages. It is given in ^ to ^ grain doses, and repeated if necessary during the first stage of labor. Spinal anesthesia by the injection of cocain, novocain, stovain, or eucain solution into the lumbar spine, while enthusiastically tried for a time, deserves no consideration in the management of an ordinary case.^ The proposition of StoeckeP to utilize Cathelin's procedure is more reasonable. A solution of novocain 0.15, suprarenin 0.000325 in 33 c.c. normal salt solution, is injected in the sacral canal through the sacral hiatus at the end of the bone. This method has proved satisfactory in the University maternit}\ I tried to anesthetize the pudic nerve some years ago by cocain injections, but failed. Ilmer and Sellkeim, howTver, claim that they have succeeded. The choice of an anesthetic during labor in the eastern seaboard of the United States will usually be ether. Chloroform is in disfavor in this part of the world, although, per- haps, unjustly Ether is an efficient, safe, convenient, and satis- factory anesthetic in obstetrical practice. There are, however, two precautions to be observed in its administration — not to 1 " Schmerzverminderung und Narkose in der Geburtshiilfe mit spezieller Beriicksichtigung der Kombinierten Skopolamin IMorphium Antesthesie," Stein- buchel, Leipzig u. Wien, 1903. Franklin S. Newell. " Anesthesia in the First Stage of Labor," " Jour, of Surg., Gyn., and Obstet.." July, 1006. Gauss, Hocheisen, and Lehman report their results in 670 cases. '" ^led. Klinik.," Xo. 6, 1006. " jNIuench. Med. Wochenschr.," No. 37, 1906. " Ztsch. f. Geb. u. Gyn.," Bd. Iviii, p. 297. - " jNIedullary Narcosis," W. L. Rodman, " Therapeutic Gazette." Jan. 15, 1901; good description of technique, " Transactions of Southern Surgical and Gynecol. Assoc, for 1910," " Year-Book of Medicine and Surgery," 1901-1902, " La Presse Medicale," Nov. 9, igoi. No. 9. ^Zentralbl. f. Gyn., No. i, 1909. ipo LABOR AND THE PUERPERIUM. give it too long and not to give too much of it. The first error is avoided by beginning its administration as late in labor as possible; postponing it until the second stage, when the suffer- ing in the first stage is not too great. One avoids giving too much: (i) By using a light towel thrown over the face and dropping only a few drops at a time, just below the tip of the nose, at the end of an expiration, so that the whole vapor is sucked into the lungs with the succeeding inspiration; (2) by only beginning the administration of ether as the pains come on, and discontinu- ing it between them; and (3) by endeavoring to produce not complete anesthesia, but only analgesia. As labor advances and the first stage is about to pass into the second, one should expect the rupture of the membranes and the escape of liquor amnii. Provision must be made for the sudden escape, often rather startling to the patient or to an inexperienced practitioner, of a pint or more of hquor amnii, which must be caught in some clean towels or mopped up by sterile absorbent cotton. If the membranes fail to rupture at the end of the first or at the beginning of the second stage of labor, the physician must consider whether he shall artificially break the bag of waters. In the case of a primipara such interference is not justifiable. The bag of waters is a perfect hydrostatic dilator, acting without great force, and in primiparae a slow, gradual, and conservative dilatation of the maternal soft parts is most desirable, to avoid lacerations of the cervix, vagina, or perineum. In multiparse the artificial rupture of the membranes is admissible after the completion of the first stage of labor ; the interference certainly hastens the expulsion of the child, and as the soft parts of a woman who has already borne children are distensible there is not the same necessity for care to preserve nature's conservative dilator. Under no circumstances, in an ordinary uncomplicated labor, should the membranes be ruptured before the full dilata- tion of the OS. Any one who has observed what in the nurse's parlance is called a dry labor — that is, one in which the mem- branes rupture early — will not dispute this assertion. Occasion- ally, even in primiparae, the first intimation that a woman receives of the beginning labor is the escape of the liquor amnii, the mem- branes having ruptured before the os is at all dilated. In these cases the labor is longer, the woman's suffering is much greater, and the likelihood of damage to the maternal tissues is very con- siderably increased. If the membranes are artificially ruptured during the second stage of labor in a multipara, the following rules must be observed : In the first place, the membranes are not to be ruptured during a pain, for the sudden gush of liquor amnii might carry with it a loop of the cord. It must be clearly established LABOR. 191 that the tissues to be punctured are the membranes, and not the child's scalp or the distended lower uterine segment. It is often possible to hook the finger-tip into a fold of the mem- branes and to tear them by pulling outward. They may also be pinched through between the forefinger and the thumb or middle finger. If these manual methods do not succeed, the Emmet curette forceps may be used to pinch and tear a fold of the mem- branes. During the second stage of labor a new and important element enters into its mechanism — the powerful action of the abdominal walls. Indeed, it has been claimed that the contraction of the Fig. 152. — Sterile towels adjusted around the vulva prior to delivery. abdominal muscles is the principal, the uterine force the second- ary, expulsive power in this stage of labor. By the employment of a "puller" which fixes the chest above and the pelvis below^ the power of the abdominal muscles may be utilized to its utmost extent. This is done by fixing the feet, protected by a pillow, against the foot-board of the bed, and attaching to one corner of it a rope or a twisted sheet on which the woman can pull with her hands. As soon as the second stage is well established, the vulvar orifice is surrounded with four sterile towels, pinned together (Fig. 152). _ ^ ' _ . ., The straining accompanying the uterine action, denoting 192 LABOR AND THE PUERPERIUM. that the second stage of labor has begun and that the presenting part is descending into the birth-canal, lasts in the typically- normal case about an hour and a half or two hours, when, if the physician observes the genitalia, — and the period of labor has arrived when it is desirable actually to observe the process, — he notices that the anus is opened and the rectal mucous membrane is exposed to view ; with every pain small masses of feces are extruded from the anus which must be wiped away always toward the coccyx with large pledgets of cotton soaked in sub- limate solution ; the perineum bulges outward, and the vulvar orifice opens a little, disclosing a small portion of the child's scalp. With every pain the perineum becomes more distended, the vulva gapes more widely, until, finally, the perineum, by the tremendous tension to which it is subjected, becomes almost as thin as paper, and it seems a physical impossibility for the head to escape through the vulva without tearing the over- stretched tissues that form the pelvic floor. In fact, frequently the fetal head does make a way for itself through the perineum, instead of over and in front of it as nature intended, and after labor there is found a more or less extensive laceration of the pelvic floor. Schroeder's statistics show that in primiparae the fourchet, the little fold of skin at the posterior commissure of the vulva, is torn through in 61 per cent., while in 34 per cent, of all primiparae and in 9 per cent, of multiparas the peri- neum is more or less lacerated. If the patient is placed upon an examining or operating table a few days after labor and a careful examination is made of the genital canal, the proportion of lacera- tions in the anterior and posterior vaginal walls involving the underlying muscle will be found at least twice as great as Schroe- der's statistics indicate. The problem presents itself, therefore, to every obstetrician in every case to avoid these accidents if possible. Although the management of a perfectly normal labor is here considered, so frequent an accident is laceration of the birth canal, and so constant is the danger of it, that it is necessary to take up, in this connection, the study of its causes, in order to devise an effective preventive treatment. The causes of laceration of the pelvic floor may be divided under three heads: (i) A relative disproportion in size between the outlet of the birth-canal and any part of the fetus, which makes the escape of the latter a physical impossibility unless the aperture is enlarged by tearing its least resisting border ; (2) such a rapid expulsion of any part of the fetal body that the maternal tissues can not gradually dilate, but give way before the sudden strain imposed on them ; and (3) any abnor- mality in the mechanism of labor which pushes the present- LABOR. 193 ing part backwark against the center of the perineum and prevents its propulsion forward under the symphysis pubis. In the first category, relative disproportion, might be put those cases in which the head is too large or the vulva too small ; and, further, those cases in which the head presents its largest instead of its smallest diameters, as happens in insufficient flexion in vertex presentations. Under the second heading, precipitate expulsion, might be put all cases in which the expulsive forces are too strong ; cases of straight sacrum, in which the fetal head is shot through the pelvic canal and suddenly puts great strain on the perineum ; cases in which too powerful traction is made with the forceps. Under the third head, an abnormal backward direction of the presenting part, might be placed those cases in which a pelvis of a male type, with approximated pubic rami, pushes the head backward and throws a greater strain on the perineum ; cases again, in which the woman, just as the head is passing through the vulva, suddenly straightens her legs and brings them close together ; further, cases in which a straight sacrum allows the head to descend directly upon the perineum instead of directing it forward toward the vulvar opening, as a normally curved sacrum should do ; and, finally, cases in which overflexion brings the vertex to bear directly upon the center of the perineum. It must appear, from these many different causes, that the preventive treatment of laceration of the perineum differs con- siderably in order to meet the diverse conditions that threaten the integrity of the pelvic floor ; thus, if there is a very great relative disproportion between the head and the vulva and the opening must be artificially enlarged, instead of allowing the perineum to tear, perhaps into the rectum, it has been claimed that it is better to nick the margin of the vulva on the side, and to allow the tear to occur where it can not extend too far, and can do no harm. This simple operation is called episiotomy. It should be distinctly understood that it is called for only in rare and exceptional cases. Personally, I have no confidence in it whatever, as I believe it t3 be based upon an incorrect idea as to the mechanism of pelvic tears. After the delivery of the child and the placenta the small wound is to be closed by catgut or silk- worm-gut sutures. If the danger to the perineum comes from a precipitate expulsion of the head, the proper preventive treatment is a retardation of labor, either by holding the advancing head back with the hand or with the forceps, or by giving an anesthetic to control the voluntary muscles. Faulty mechanism, as over- flexion or extension, may be corrected by the forceps. It is evident, therefore, that no single plan of preventive treatment, 13 194 LABOR AND THE PUERPERIUM. no inflexible method of "supporting the perineum," as it is called, will avail in all cases. There is, however, a routine practice directed against the commonest cause of "lacerated perineum" that may prevent a laceration, or at least a very extensive tear extending into the rectum. There are excuses for the lesser grades of laceration, and it is true that no physician, be his skill what it may, can absolutely avoid this accident ; but a complete destruction of ' the perineum, a tear through the rectum, is rarely justifiable. It is most frequently the result of some blunder, carelessness, or error of technic. As the head distends the vulva almost to the utmost, it fails to recede as it has done after the previous pain, but remains in view until the next uterine contraction, which, with the abdominal contraction that accompanies it, suddenly expels the head through the widely stretched external outlet. The expulsive force acting suddenly and being much greater than is necessary to overcome the slight resistance now offered by the soft parts, lacerates the tissues instead of dilating and stretching them. This being the most frequent cause of lacerated perineum, it is easy to devise a means to meet and overcome the difficulty. The main requirement is to regulate the expulsive force so that it is just sufficient to over- come the slight resistance offered by the distended perineum, and as an auxiliary measure to restrain the progress of the head should this force become too great or be exerted too suddenly. It is obvious that one can not govern the force of the uterine contractions, which are involuntary ; but one can regulate the force and duration of the abdominal contractions by appealing to the woman's will. Thus, the physician can call upon her to strain forcibly or gently, as the case may require, bringing into more or less active play the expulsive action of the abdom- inal walls ; he can command her to stop straining, or to open her mouth and breathe rapidly, which amounts to the same thing, thus inhibiting the greater part of the expulsive force; or, if a powerful uterine contraction should come on, or if the woman should exert her voluntary muscles too violently, or should fail to obey the command to stop straining, the expulsive forces may be neutralized simply by making such firm pressure against the child's head with the hand that it will not budge. At the same time the outspread hand, which can most conveniently be used for the purpose, is applied to the distended perineum so- that the thumb and forefinger encircle the posterior commissure of the vulva. This hand helps to flex the head when the occiput is anterior ; it restrains the progress of the head, and it LABOR. 195 pushes it forward under the arch of the pubes, away from the overstretched muscles of the pelvic floor. In order to avoid crowding the fetal head backward toward the perineum by the approximated thighs of the woman a pillow made into a roll, covered with a towel and pinned together, has been placed be- tween her knees as soon as the \ailva begins to gape. This is the best plan of supporting the perineum, as it is called, though it is not really a support of the perineum at all, but a diminution of the expulsive forces and a regulation of the progress of the fetal head, which is supported, restrained, and directed by pressure, partly through the perineum, partly directly upon the head itself^ Presuming that these precautions have been successful, that the perineum has been safely retracted over the child's head, and that the head is born, the face at first appears white, but almost immediately turns quite purple and looks as if the child must be choking to death. It is, as a rule, however, in no seri- ous danger. The head being the only part of the fetal body free from pressure the blood is determined to it, and is prevented from returning freely by the pressure about the neck, thus giving the child's head, as it protrudes from the vagina, a most alarm- ing appearance of deep asphyxia. But there is in some cases a more serious element in the asphyxiated look of the child; in one out of four labors the cord is found coiled about the child's neck, usually only once, and that lightly, but occa- sionally many times, nine coils having been recorded in one case, and so tightly occasionally as to completely strangulate the infant, not by pressure upon the neck, but upon the cord. This anomaly occurring so frequently, and having such serious results, must always be borne in mind, and as soon as the head is born and the neck becomes accessible the medical attendant must at once ascertain whether the cord encircles it or not, by sweeping a forefinger between the child's neck and the maternal symphysis. If the cord is found in this situation, it should be gently pulled upon, and whichever portion yields should be dra^^-n out, so enlarging the loop that it may be slipped over the head; or, if that is impossible, making the loop at least large enough to allow the shoulders to pass through ; or if that, again, is not feasible, if the cord so firmly constricts the child's neck that the loop or loops can not be loosened, it may be hastily ligatured 1 Sarwey in "Winckel's Handbuch" (vol. i-, 1904) gives some fifteen different methods of supporting the perineum. There is no one of them that insures the woman against injury. The plan advocated by the author is a modified Ritgen manoeuvre, the physician seated alongside the bed facing the woman's vulva, and the patient lying upon her side. tgO LABOR AND THE PUERPERIUM. with a double thread and then cut between the Hgatures. The child, in such a case, must, of course, be extracted immediately, else it will be fatally asphyxiated. The cord not being felt, or having been attended to, if found around the neck, the physician next turns his attention to the child's head. The head is protruding from the vulva, the face is swollen and almost purple, looking as if the only hope for the fetus lay in speedy delivery ; the labor is almost concluded, the medical attendant sees his anxiety and attendance almost at an end, and for all these reasons, especially if he is inexperi- enced, he feels strongly impelled to terminate a process that seems to endanger the fetus, that has caused his patient much suffering, and himself, perhaps, fatigue, by pulling on the head and rapidly extracting the fetal body. If he does so, however, the shoulders hastily pulled through the vulva will almost Fig. 153. — Retarding the escape of the head and pushing it away from the peri- neum. The patient is on her left side. The physician sits alongside the edge of the bed, facing the vulva. The woman's knees are held apart by a pillow between them. surely lacerate the perineum, perhaps deeply. Many a case of lacerated perineum, even into the rectum, is explained in this way. A still more serious consideration is that immoderate traction upon the head may seriously injure the child's spine and the spinal column. As experience has shown that the fetus is not subjected to great danger in this situation, and as premature LABOR. • 197 efforts to extract it entail upon both woman and child a danger more imminent than that which it is endeavored to avert, it is better to do nothing at this stage of labor but simply to support the head upon the hand, waiting for the action of the natural expulsive forces, which will rotate the shoulders, and with them the head, and shortly after expel the rest of the body. While the child's head protrudes from the vulva the opportunity should be taken to cleanse the eyelids with squares of clean soft linen, soaked in boric acid solution, gr. x to fsj of distilled water, and to inject this solution into the eyes with a pipet. If there is the slightest reason to suspect gonorrhea in the mother, one drop of a I per cent, solution of nitrate of silver should be instilled in each eye before the conjunctival sac is flushed with boric acid solution. After waiting a minute or two, the physician may stimulate the uterus by rubbing or kneading it, and may as- sist its contractions by pressure upon the abdominal walls over the fundus. This is all the assistance required in a normal case. With this slight addition to the natural forces the shoulders descend and rotate; the anterior shoulder slips out first under the symphysis pubis, the posterior shoulder and arm quickly follow, the anterior arm then emerges, and, the shoulders being born, the rest of the body is immediately expelled so rapidly that it is difficult to follow the mechan- ism. It is admissible, if one is careful not to use too much force, to pull the child's head backward to facilitate the birth of the anterior shoulder, forward to assist the birth of the posterior shoulder (Figs. 154 and 155). Indeed, it is an advantage to do so, if traction is not made too soon or too forcibly. The moment the child escapes from the birth-canal it emits a lusty cry, which is usually synchronous with a sigh of intense satisfaction from the mother, who has in an instant been entirely relieved of long and intense suffering. There are now two patients on the physi- cian's hands at once, and, although he must in practice devote his attention to both equally and at the same time, it is more conve- nient here to consider their management separately. Although the child's expulsion from the mother gives her such immense relief, it by no means terminates the labor nor brings her an immunity from all danger ; indeed, the chief, the most common danger of parturition, hemorrhage, may be said to begin with the expulsion of the child, and sometimes a most difficult and dangerous complication of labor, adhesion of the placenta to the uterine wall, only manifests itself after the complete escape of the child from the birth-canal. There are, therefore, two problems with which to deal in the third stage of labor in almost every igS LABOR AND THE PUERPERIUM. case, no matter how normal it may appear, — the deliver}^ of the placenta and the prevention of hemorrhage. As hemorrhage may occur before the expulsion of the placenta, and therefore stands first in point of time ; as this accident is of the gravest nature and its prevention of the greatest importance, the first thought of the Fig. 154. — Pulling the infant's head toward the maternal sacrum to facilitate the escape of the anterior shoulder (Bumm ). medical attendant should be the routine means to adopt in every case to prevent its occurrence. Provided the uterus contracts and remains contracted, the enormous blood-vessels in its walls are obliterated and hemor- rhage is impossible. On the other hand, if the uterus remains flaccid and uncontracted while the placenta is being separated, or if the organ, at first contracted, afterward relaxes, hemorrhage of the most alarming character must as necessarily occur. LABOR. 199 The whole problem, therefore, of preventing hemorrhage after deUvery resolves itself into a problem of securing and of maintaining uterine contraction. Firm Contraction of the Uterus After Labor is Secured by Ex- ternal and by Internal Stimuli to Contraction. — The internal stimulus consists of a dram dose of the fluid extract of ergot in a httle water, administered as soon as the child's body is born. It has been claimed that ergot should never be administered before Fig. 155. — Pulling the infant's head toward the maternal symphysis to extract the posterior shoulder ( Bumm) . the expulsion of the placenta for fear of hour-glass contraction of the uterus. But it requires at least fifteen minutes after ergot is administered by the mouth before its action is felt by the uterus; meanwhile, in a normal case the placenta is expressed and the in- fluence of the ergot is felt at the time it is most needed, as a rule, just after the conclusion of the third stage of labor. The external stimulus consists of manipulation of the uterus. Luckily the uter- ine muscle is irritable, and shows its irritation by contracting its fibers. Luckily, again, it is accessible. One can easily grasp it through the abdominal walls ; can rub it and exert direct pressure upon it, these actions exercising a powerful irritant in- fluence upon the uterus and bringing about, in the ordinary case, 200 LABOR AND THE PUERPERIUM. firm contraction. This is the most efficient, readily appHed ex- ternal stimulus to uterine contraction, and one that must be in- variably applied, and that, too, continuously from the moment the infant's body is expelled until a milder form of external stimulus which is to maintain uterine contraction is adjusted, — the obstet- rical binder. The moment that the child escapes from the woman's body the physician or nurse seizes the uterus through the ab- dominal wall and exerts constant pressure upon it, irritating it still more from time to time by a kneading or a rubbing motion. If the woman is fortunate enough to have a good nurse, this duty may safely be left to her, while the doctor washes his hands and takes a brief rest. Some fifteen minutes having elapsed, the placenta being delivered, the woman having been cleaned and made more comfortable, the constant pressing and kneading of the uterus may be replaced by the more gentle and more continu- ous external stimulus of the hinder and abdominal pad. The binder holds an important place in the treatment of English- speaking women. In some civihzed countries it is not used at all, and, it must be confessed, it is unnecessary, from the medical point of view, after the first twenty-four hours. The obstetrical binder, however, adds greatly to the woman's comfort by maintaining the intra-abdominal pressure and thus preventing cerebral anemia. It undoubtedly preserves the figure, — a fact to which no woman is indifferent, — it diminishes the risk of permanent diastasis of the recti muscles,^ and it lessens the danger of postpartum hemorrhage by maintaining a tonic con- traction of the uterus. For all these reasons the use of the ob- stetrical binder is well justified^ — is, in fact, demanded — in the intelligent management of the puerpera. The best binder is a piece of unbleached muslin, about a yard and a quarter long and wide enough to reach from the trochanters to the floating ribs. It is pinned together from above downward, and is made to fit more snugly and comfortably by making gores at the sides above and below the hips. The pad should consist of one or two folded towels put above the navel to fill the hollow in the epigastrium left by the evacuation of the womb and its reduction in size. The second problem of the two that confront a physician in the management of the woman in the last stage of labor is the delivery of the placenta. To superintend this process intelli- gently it is necessary to recall the chief phenomena of the mech- anism of the third stage of labor. The placental structure resembles a sponge, and as the uterine ^ For a period of about six months I omitted the binder at the request of Dr. Stan- ton, who was studying blood-pressure in the puerperae of the University Hospital. During that winter I was obliged to operate on more cases of diastasis of the recti muscles than I would normally do in two or three years. LABOR. 201 wall contracts and retracts, the placenta follows the reduction in the size of the placental site by a corresponding reduction in the placental area, up to a certain point. The placenta diminishes in size until all its villi come in actual contact with one another; until, instead of being a spongy organ with the intervillous blood- spaces separating the villa from one another, the whole organ becomes a sohd mass, and can not accompany a further reduction in the area of uterine wall to which it is attached, so that the smallest additional contraction of the uterine muscle must spring off the whole placental mass at once. This point is reached when the placenta has been reduced to about one-half of its natural area — a fact that has been demonstrated in uteri removed by the Porro Cesarean section or in postmortem examinations of patients who had died during or directly after labor. The expulsion of the placenta after its detachment is easily under- stood; lying in the uterine cavity as a loose foreign body, all that is re- quired is the vigorous action of the uterine muscle to drive it out. But, once beyond the province of the thick, muscular portion of the uterus, above the contraction- ring, there is no further force to expel the placenta, for it lies in the semiparalyzed lower uterine segment (see Fig. 156), cervix or vagina, where it may remain for hours or days, until it undergoes de- composition.^ As the lower animals never require an artificial delivery of the after-birth, many obstetricians of the eighteenth century argued that the delivery of the placenta should be left entirely to nature. The result was disastrous, as may be imagined. It is, therefore, a necessary part of the management of the third stage of labor to secure the separation of the placenta by stimulating the uterus to contract and by aiding it to expel ' V. Campe ("Zeit. f. Geburtsh. u. Gyn.," Bd. x, H. 2) in 120 observations found that in 24 instances the placenta had not been expelled in twelve hours. Fig. 156. — Dilated lower uterine segment and cervix after labor, from a frozen section (Benckiser and Hofmeier). 202 LABOR AND THE PUERPERIUM. its contents by exaggerating its expulsive power. These two objects are best obtained by what is known as Crede's method, a method first proposed to the profession in a systematic m^anner by the late Professor Crede, of Leipsic/ in 1861. A similar plan had been in use in Dublin for a long time before, and many primitive and savage people have employed, perhaps for ages, methods based upon the same principle. Fig. 157. — The expression of the placenta. Fig. 158. — The reception of the placenta in a basin. In applying Crede's method the uterus is seized in a grasp illustrated in figure 248, is kneaded and rubbed until it con- tracts with vigor; only then, and only in conjunction with the uterine contraction, should it be firmly pressed down in the direction of the axis of the pelvic inlet, while it is compressed 1 " Monats. f. Geburtskunde," xvii, p. 274. LABOR. 203 between the fingers and thumb with considerable force. The placenta is squeezed out as the stone is pressed out of a cherry. It should be expressed twelve or fifteen minutes after the child is born, as complete separation has not occurred in the average case till this time has elapsed. As it slowly emerges from the vulva it should be caught in the obstetrician's hand, while a nurse holds a basin pressed close into the mother's lower buttock, to receive the blood that usually spurts out with the after-birth. The mem- branes trail after the placenta, running up into the vagina and the uterine cavity. To extract them without tearing them, and thus leaving a portion behind, they should be seized between the whole length of the thumb and forefinger and gently pulled, first forward toward the symphysis, then backward toward the sacrum, the uterus meanwhile being allowed to relax. It is a mistake to turn the placenta over several times to make a "rope" of the membranes. To return to the infant. The head and shoulders having escaped, the rest of the body slips out almost immediately, the child's arrival being announced usually by a vigorous cry, a purely reflex action caused by the sudden shock which the new-born experiences on suddenly emerging from an aquatic existence, in which its immediate surroundings have a temperature of about 99°, into the atmosphere and a temperature not over 70°. This violent shock produces not only a spasmodic action of the diaph- ragm and the muscles of respiration, but also of the bladder, and of all of the muscles of the body as well, so that often urine is voided directly after birth, and the arms and legs are moved about quite violently. As soon as the child is born, it is well to see that its air-passages are clear and not clogged by mucus or blood that might have been inspired during labor. This is done by crooking the little finger and introducing it back of the epiglottis; if, however, the child at once emits a vigorous cry, it is proof enough that the respiratory tract is not obstructed. The infant is then placed on its right side, this posture favoring the closure of the foramen ovale and facilitating the passage of the blood from the ascending cava over the Eustachian valve into the right auricle. The position should also be so arranged as to turn the child's face from the mother's genitals and to protect the infant's air-passages from the maternal discharges incident to the third stage of labor, care being taken, also, not to put the cord too much on the stretch, for all this time, of course, the infant remains attached to the mother by the umbilical cord. Now arises the question, in every case, as to the advisability of severing the cord at once and getting the child out of the way. The placenta, it has been argued, no longer performs its vital functions ; the child breathes, 204 LABOR AND THE PUERPERIUM. and, therefore, it might be better to cut the cord, to remove the infant from the bed, and to turn it over to the nurse. This plan, however, does not take into account the fact that there remains a considerable quantity of fetal blood in the placenta ; that it is an advantage to have all of this blood, if possible, returned to the infantile body w^here it belongs, and that, further, the deple- tion of the placenta renders its expulsion easier. The blood in the placenta will return to the child's body, if time is allowed for it ; on the one hand, the action of the respiratory muscle exerts a suction upon the placental vessels, which aspirates the blood from the placenta ; on the other hand, the pressure upon the placenta by the uterus drives the placental blood into the fetal body. To demonstrate the advantage of late ligation of the cord, Budin ^ conducted a series of experiments, with the following results : the cord ceased beating in 22 cases, on the Fig. 159. — The position in which the child should be placed after birth. average, in two and one-half minutes. In these cases the average weight of the placenta was 520 gm. (i^ lb.), and the amount of blood that escaped from the umbilical vein in 20 cases was 92 gm. (3.2 oz. Avoir.) less in late than after immediate section of the cord. Thus, by immediate ligation 92 gm. (3.2 oz. Avoir.) of blood are lost to the infant's body. Moreover, in contrasting the weights of children after immediate and late hgation of the cord there was a gain of two to three ounces in favor of late ligation. It is better, therefore, to wait two or three minutes after the birth of the infant before cutting its cord.^ The proper time having arrived, the cord should be ligated about two fingers' breadth from the child's ^ Publications du " Progres Medical," 1876; also " Obstetrique et Gynecologie,"' l886. 2 There has been some criticism of Budin' s proposition to ligate the cord late;, several German authors have attributed a number of infantile complications to it, but the objections to the plan are ill founded. LABOR. 2Cf5 body with a piece of stout surgeon's silk or narrow bobbin, steril- ized. The ligature is tied firmly once around with a double knot. The ends are then doubled around again and are tied with a single and a bow knot, so that the nurse, after the child is washed, may slip this last knot and may then retie the ligature firmly. This precaution surely avoids a primary or secondary hemorrhage from the cord, which sometimes occurs in consequence of a shrink- age of the mucous tissue, making the original ligature too loose. The obstetrician is now ready to cut the cord. The child is slippery and hard to hold; its legs and arms are jerked about in a very disconcerting manner to the beginner, so that carelessness in the use of scissors at this juncture might result in injury to the Fig. 1 60. — Cutting the cord. fingers, the toes, or, in the male child, to the penis. The manner of cutting the cord illustrated in figure 160 surely avoids all such accidents. The child's connection with its mother being severed, it is wrapped in a blanket ready to receive it and is put in some safe place, where it will not be trodden nor sat upon. Its own crib is the best place for it. The cut end of the cord attached to the placenta is not tied, but is allowed to drain into a basin, so as to lessen as much as possible the bulk of the placenta. In case of twins, however, a double ligature on the cord is required, else the second child might bleed to death on account of anastomosis between the vessels of the olacenta. 2o6 LABOR AND THE PUERPERIUM. CHAPTER II. The Puerperal State. The moment that labor terminates with the expulsion of the placenta, there begins an effort on the part of nature to restore to their normal condition the organs and systems that have been in an active state of development for nine months before ; there is destroyed in a few weeks what it has taken months to build up, and with this destructive process goes on with equal rapidity one of growth and repair. There is a reduc- tion of the sexual, the circulatory, and the nervous systems to their normal capacities and functions by the destruction of redundant material ; at the same time there is a repair of the injuries of child-birth, the formation of a new endometrium, and the rapid development of an entirely new and complicated func- tion, lactation. And yet, by a provision of nature which is almost beyond comprehension, these two opposed processes of decay and regeneration go on at the same time in one body, involving whole systems and organs, without manifesting themselves in the slightest derangement of the individual's health. Under no other circumstances could an organ weighing two pounds, and as large as the liver, degenerate and in great part disappear without the gravest symptoms of constitutional disorder. In no other condition could the whole composition of the blood be materially altered ; the heart changed in size, power, and capacity ; the nervous system modified in sensibility ; a large body-cavity, stripped of its mucous membrane and again resupplied with a new lining ; large organs, as the breasts, suddenly assuming great functional activity, without very marked evidence of dis- ease ; and yet in the puerperal state there are all these remarkable changes while the woman in appetite, feeling, and temperature is in perfect health. But it is obvious that in a condition which, though it is called physiological, borders so closely on the patho- logical, very little is required to pass the boundary-line into dis- ease. Anomalies of excess and deficiency in the natural processes are common ; the raw surface of the uterus with the wounds of the vagina and vulva give ready entrance to infectious bacteria and their toxins, and the whole individual seems especially sen- sitive to unfavorable external influences, both mental and physical. Consequently this is the period in the history of the child-bearing woman that is most beset with difficulties and dangers and most likely to be marked by accidents and complications. The pre- THE PUEKPERAL STATE. 207 vcntive and curative treatment of these complications is one of the most difficult tasks in obstetrics, and success here, as else- where in medicine, depends to a great extent upon a knowledge of the natural processes. The puerperal state, or the puerperium, comprises the time from the termination of labor until the uterus has regained its natural size. This is a period, in the normal case, of six weeks} The physiological phenomena in the puerperium, or puer- Fig. 161. — a, Uterine muscle-fibers nine days postpartum; 3, uterine muscle- fibers eight days postpartum ; c, uterine muscle-fibers in the eighth month of pregnancy. peral state, are the reduction of the uterus directly after delivery to the uterus of the healthy non-pregnant woman — a process called technically " the involution of the uterus "; the involution of the vagina, the destruction of the deciduous mucous mem- brane, and the regeneration of the endometrium; the retrograde ^ The word puerperium comes from piicr, a child, and pario, to bear, and denoted, in the original Latin, the child-bed period, the lying-in period; so it is an appropriate term to designate this one of the four periods in obstetrics, — pregnancy, labor, the puerperium, and lactation. 2o8 LABOR AND THE PUERPERIUM. changes in the uterine Hgaments and peritoneal covering and in the ovaries; the alterations by which the blood and the heart regain their normal condition and the changes in the pulse; the changes in the body- weight, the temperature, the skin; the action of the bladder and of the alimentary canal; and the es- tablishment of milk secretion. The Involution of the Uterus. — Three theories have been advanced to account for it : (i) A fatty degeneration of the muscle-fibers and the absorption of the fine granular fat-globules to the complete destruction of the uterine muscle, its place being taken by a new growth of muscle-fibers developed from the embryonal muscle-cells in the outer layers of the myometrium. (2) A partial degeneration and an atrophy of the large muscle- fibers seen in a pregnant uterus at term. (3) The conversion of the muscle-cell contents into a peptone, its absorption into the Fig. 162. — Muscular tissue of the pregnant and of the puerperal uterus. blood-current and discharge through the kidneys, giving rise to the peptonuria of puerperal women (Fischel). Kilian, Heschl, Robin, Mayor, Kolliker, Winckel, Sanger, and others have investigated the subject with some difference in re- sult. Goodall, one of the most recent investigators, in a study devoted mainly to the blood-vessels of the involuting uterus recognizes a fatty degeneration of the muscle cells. ^ IVIicro- scopic sections of five uteri in my possession, obtained respec- tively in the last week of pregnancy, two hours, thirt}'-six hours, seventy-two hours, and seven days after labor, indicate that fatty degeneration plays a part in the reduction of the large muscle-cells characteristic of pregnancy to the much smaller muscular fibers of the unimpregnated uterus. My own belief is that the redundant material within each cell is destroved ' " Studies from the Royal Victoria Hospital," Alontreal, vol. ii, Xo. 3 (Gj-ne- colog}^, II). THE PURR PER A L STATE. 209 by some degenerative process (chiefly fatty), but that the cell is not destroyed in ioto. Measurements made by Sanger' show plainly that the reduction of the uterus after labor is effected by a diminution in the size of the individual libers, and not by their destruction." The skrinkage of the uterus in the process of involution is ex- pressed by the following average measurements : Height of fundus above symphysis, directly after labor, 10.9 cm.; on the first day Fig. 163. — Lochia on the second day (lochia cruenta), showing a few cocci and streptococci : a, Decidual cells ; b, red blood-corpuscles ; c, white blood- corpuscles ; d, epithelium (Winckel). Fig. 164. — Lochia on the fourth day: a. Decidual cells ; b, white blood- corpuscles ; c, a few red blood-corpus- cles ; d, epithelium ; e, micro-organisms (Winckel). Fig. 165. — Lochia on seventh day ; afebrile case: a, Blood-corpuscles ; ^, diplo- cocci and monococci ; c, white blood-corpuscles ; d, epithelium ; c-, decidual cells (Winckel). the fundus rises to 13.5 cm.; on the eighth day it has sunk to 7.3 cm. The breadth of the fundus at the tubal insertions is 1 1 cm. hoc. cil. Fiber-length in pregnant uterus " in first few hours postpartum .... " until the fourth day postpartum . . . " in first half of second week postpartum " in beginning of third week postpartum " at end of fifth week postpartum . . . 14 208.7 /'• 158.3 ."■ 1 17.4". 82.7 ". 3-^-7 "• 24.4 fi. 2IO LABOR AND THE PUERPERIUM. directly after labor; 12.2 cm. on the first day; 8.1 cm. on the eighth day. The uterine cavity measures 14.8 cm. on the first day; 10 cm. by the fourteenth day. There is a greater unanimity of opinion in regard to the invo- lution of the serous covering, connective tissue, blood-vessels, and mucous membrane of the puerperal uterus. Mayor ^ found, in the peritoneal covering of the uterus after delivery, a number of folds in the membrane; at the bottom of these folds the endothelial cells seemed to be transformed into a spherical shape. KiHan^ found the cells in this region infil- trated with fat-globules. Bernstein^ in a study of involution in the rabbit's uterus, paid especial attention to the behavior of the connective tissue. He found that the reduction of this tissue in the puerperal uterus was effected by a fatty degeneration of the connective-tissue cells, and by a drying out, as it were, of the connective-tissue fibers; these, deprived of the excessive blood- supply of pregnancy, dry up and shrink. Bernstein incidentally mentions the fatty degeneration of the peritoneal endothelium, and expresses the opinion that the muscle-cells, while they do undergo a fatt}^ degeneration, are not completely destroyed. The chief changes in the blood-vessels seem to be shrinkage, the obliteration of many large vessels by a connective-tissue growth in the intima, associated with fatty degeneration of the media, ^ and the development in the adventitia of the vessels not obliterated of new elastic fibers. GoodalP claims that the old blood-vessels are destroyed and that the new are regenerated within the caliber of the old. The involution of the endometrium is now clearly under- stood, thanks to the investigations, first of Friedlander,*^ then of Kundrat,^ Engelmann,^ Langhans,^ Leopold, ^° Wormser," and others. When the ovoim is cast off at term, it carries with it, in the strictly normal case, the whole o\ailar or epichorial decidua and the upper cellular layer of the uterine decidua, leaving behind on the uterine vrall the lovs^er cellular layer and the glandular por- tion of the uterine mucous membrane. This membrane, deprived in great part of its nutriment by the contraction of the uterine 1 Loc. cit. • Loc. cif. ^"Ein Beitrag zur Lehre von der puerperalen Involution des Uterus." D. i, Dorpat, 1885. ■* Balin, " Ueber das Verhalten der Blutgefasse im Uterus nach stattgehabter Geburt," " Archiv f. Gyn.," Bd. xv. ^ Loc. cit. ^"Physiol. Anatom. Untersuchungen iiber den Uterus," Leipsic, 1870; "Archiv f. Gyn.," Bd. ix. " " Wicn. med. Jahrbiicher," 1873. 8 Ibid. 3" Archiv f. Gyn.." Bd. viii. ^<^ Ibid.. Bd. xii. i^Wormser, "Die Regeneration der Uterusschleimhaut noch der Geburt.," "Arch f. Gyn.," Bd. l.xix, H. 3 (good recapitulation on p. 584). THE PUERPERAL S7\4TE. 211 wall and the obliteration of many of its blood-vessels, loses its vitality in that portion furthest removed from its source of nutri- ment — the superficial layer of decidual cells. These die and are cast off with the lochial discharge in a condition of coagulation- necrosis, fatty degeneration or disintegration. By the shedding of these cells the glandular layer of the decidua is laid bare. Now the involution of the endometrium ceases and a regeneration of the membrane begins. The epithelial cells within the glands take on an active growth and reproduction; the interglandular con- nective tissue shares in the new development; by its growth it rises in embankments between the glands, making them deeper, and so in time reproduces the characteristic utricular glands of the uterine mucous membrane. This process requires some time. Mayor says: "On the twenty-fourth day after delivery I have not found glands in the region of the placental insertion. The mucous membrane, although reconstructed at the second month, is then furnished with fewer glands, less regularly disposed, and of a greater caliber than in the normal state." The uterus is not the only organ of the sexual system that experiences a retrograde change after labor. The ovaries and tubes, the broad and round ligaments, the pelvic connective tissue, blood-vessels, and lymphatics, all undergo modification. That portion also of the birth-canal — the lower uterine segment, the cervix, the vagina, and the vulva — which is dilated to an extreme degree to allow the passage of the fetal body, must likewise exhibit rapid involution to regain its wonted tone and caliber. In these structures the process is mainly one of retrac- tion of overstretched tissue ; but there is, in addition, a certain amount of degeneration and atrophy of the redundant cells that the increased blood-supply and increased stimulus to growth of pregnancy called into existence. Particularly is this true of the lower uterine segment and cervix, which in their involution dis- play an intermediate process between that by which the reduc- tion of the uterine body is effected and that by which the lower portion of the parturient tract regains its normal state. The involution of the uterine adnexa progresses satisfac- torily if the uterine involution itself is normal. The reduction of the overstretched vagina and vulva is sure to occur if these parts have not been seriously lacerated, although, like all over- stretched muscular canals, they never quite return to their original caliber. From the large sinuses at the placental site, laid bare after the separation of the placenta ; from the innumerable little ves- sels of the decidua that have been torn in the separation of the ovum from the uterus ; from the rents of various degrees that 212 LABOR AND THE PUERPERIUM. have been made in the cervix, vagina, and vulva during labor, it is inevitable that there should be, for some time after delivery, an oozing of blood in considerable quantity. As the residue of the decidua and the blood-clots remaining in the uterine cavity are disintegrated, the products of this decomposition must also escape externally. And as the whole genital canal, lined by a mucous membrane, is stimulated and irritated by foreign sub- stances and a large blood-supply, it is obvious that the mucous secretion of the genital tract will be considerably increased, and must make its escape also from the vagina. This composite discharge after labor, made up of blood, degenerated epithelial cells, the debris of disintegrating animal material, mucus, and large numbers of harmless micro-organisms, is called "the lochia."^ It is important to appreciate the normal character of this discharge, for changes in its quantity, odor, or constituent parts often point to some morbid process. The older writers on obstetrics paid great attention to this feature of the puerperal state, and gave to the discharge three names, which indicate the three changes that it undergoes in appearance. For the first five days it is called lochia rubra ; for the next two days, lochia serosa ; and after that, lochia alba. At first, as might be ex- pected, the discharge is almost wholly bloody — the lochia rubra. As the repair of the injuries of parturition progresses and the hem- orrhage ceases, the discharge is a serous exudation and a catarrh of the mucous lining of the genital tract — the lochia serosa. The dead tissue in the genital canal is cast off in increasing quan- tities as the involution of the birth canal progresses ; disintegrated and fatty epithelial cells are mixed in the discharge ; micro-organ- isms are found in it, while tlie pus from the granulating wounds all along the genital tract forms an important constituent of the discharge after the sixth or seventh day. To the lochial dis- charge at this period is given the name lochia alba. The last stage of the lochial discharge lasts from the seventh until the tenth, twelfth, or fourteenth day, or even longer. Two other features of the lochial discharge are also of clinical inter- est — the quantity and the odor. The amount of discharge at the three different periods may be expressed scientifically thus : During the first four days the amount of discharge is i kilo- gram, or 2.2 pounds ; during the next two days, 280 grams, or about 10 oz. Avoir.; and until the ninth day, 205 grams, or about 7 oz. Avoir., the entire loss amounting to 3^^ pounds. These figures, however, are of no value to the practical clinician. No physician in private practice can accurately measure the amount of lochial discharge. It is estimated by noting the number 1 A word derived from the Greek /'-o;i'oc, pertaining to a woman in child-bed. THE PUERPERAL STATE. 213 of napkins or pads that are soiled in the twenty-four hours. The normal puerpera should not require a change of the vulvar pads oftcner than six times in the twenty-four hours for the first four or five days. The importance of being able to distinguish between a normal and abnormal amount of lochial discharge is obvious. Otherwise a dangerous hemorrhage might be over- looked; a diminution or suppression of the lochia might be un- noticed. The odor of the lochia during the period of sanguinolent discharge is that of fresh blood or raw meat. Later, when the mucous secretion forms a considerable part of it, the predomi- nant odor is that pecuhar to the secretion from these parts. If masses of decidua, placenta, membranes, or blood-clots are retained in iitero and saprophytes gain access to them in a situation favorable to their decomposition, the lochia has a putrid odor. This is frequently the first signal of a possible toxemia. While recognizing the value of a putrid odor as a danger-signal, it must be remembered that absence of odor is possible with dangerous streptococcic infection. The involution of the uterus has been described as a continu- ous process. But as it depends primarily upon the contraction of the uterine muscle-libers it is indicated graphically by a series of waves, representing contractions of the uterus of more or less force and frequency, and intermissions of less firm contraction; the retraction of the uterine muscle, however, maintaining fairly well what is gained by contraction. Each case has a certain degree of individuality; in one the contractions are firm and the intervals between them short; in another it is the reverse, and all gradations may be found between the ex- tremes; but while there are in every case individual pecuhari- ties, the action of the uterus after labor is governed by a few general laws. Directly after labor there is a firm contraction which reduces the size of the uterus in all directions below the measure- ments obtained a few hours later; then follows a relaxation, the fundus rising 2 cm. or more and its breadth increasing by more than a centimeter. Suckling the child stimulates the contraction and retraction of the uterus. If the child is not nursed involution is slower and less complete. In primipara?, the uterus being more powerful, better supplied with muscular tissue than it will ever be again in a subsequent coniinement, contracts so vigorously, relaxes so little, that after the expulsion of the placenta the uterine cavity is almost obliterated, and the amount of bloody lochia is reduced to a minimum. On the other hand, in mul- tiparas, the uterine muscle being in some degree weakened by stretching and perhaps by some destruction of muscle-substance 214 LABOR AND THE PUERPERIUM. that has occurred in previous involutions, the uterus after labor does not contract so firmly and the relaxations between the contractions are greater in degree and duration. If the uterine muscle has been overstretched, as it is in plural pregnancies or in cases of hydramnios, or if the labor has been exceedingly long or unusually precipitate, very firm contraction does not ap- pear after labor and there are apt to occur periods of over-relaxa- tion. This condition, in civihzed women, is so very common that it is necessary to study it under the head of the physiology of the puerperium, and yet the consequences of a failure on the part of the uterine muscles to contract with maximum intensity after labor are always unpleasant, and may be disastrous. A relaxation of the uterine muscle-fibers imphes a loosening of the countless Hving ligatures that bind the large vessels of the puerperal uterus. The immediate effect is an escape of blood into the uterine cavity. Oozing out gradually from the imperfectly closed blood-vessels and sinuses, and, finding space in the enlarged uterine ca-vity to collect, it forms clots often of considerable size, which act upon the uterus, like any foreign body in it, as an irritant, exciting it to active contractions which only cease when the foreign substance is expelled. These active contractions of the uterus are always painful, with a pain like that of a cramp in any muscle. The painful contractions of the uterus after deHvery. caused primarily by lack of firm contraction, and immediately by the presence of clots of blood in utero, are called after-pains — the painful contractions of the uterus after labor. For the reasons already given they are not experienced by primiparas unless the uterus has been unduly distended or the labor has been too prolonged or too precipitate. On the other hand, they are a constant phenomenon in multiparas and the physi- cian's treatment of them constitutes almost always a part of his routine management of the puerperal state in such patients. Apparently a trifling matter, it is really one of considerable im- portance. The pain is sufficiently distressing to demand relief, but. more important still, it indicates the presence "^-ithin the uterus of blood-clots or other putrescible material; and until they are expelled, and the uterus is induced to remain in a state of firm contraction, the woman is not entirely safe from septicemia. Moreover, it is necessarv' to be familiar enough with the clinical features of after-pains to be able to dis- tinguish them from the pain of peri-uterine inflammation. This should not be difficult. The intermittent character of after-pains ; their cramp-like nature; exacerbations when the child is suckled; the fact that pressure does not increase the pain, and that the pulse THE PUERPERAL STATE. 21$ and temperature are unaffected, sufifice to distinguish the painful contractions of the uterus after labor from the pain of inflammation. The appropriate treatment of after-pains is suggested by their cause and nature. It is the administration of ergot to stimulate vigorous contraction and firm retraction of the uterine muscle, and of opium to diminish the pain of the contraction. A mixture of fluid extract of ergot and paregoric is a useful prescrip- tion, though, in cases of extreme pain, ergot by the mouth and morphin hypoderuiatically give a better and quicker result. Although the most remarkable changes that occur in a woman's organism after labor are seen in the genital organs, the whole body undergoes a modification. The respiratory, circulatory, nervous, and excretory apparatuses are affected, with accompanying peculiarities of respiration, pulse, temperature, weight, the excretion of urine and sweat, and the evacuation of the bowels, while the nervous system shows a gradual change from the nervous irritability characteristic of pregnancy to the de- gree of equanimity that the individual may have before possessed. Alterations in tlie Circulatory Apparatus of the Puerpera. — The pulse of a woman during labor is rather rapid, full, and bounding. In the first twenty-four hours after delivery it usually becomes slpw^; if the individual's normal pulse-rate were 70 to 80, it might, during labor, rise to 90, but directly afterward it sinks, perhaps, to 60 or even lower. It is occasionally as low as 40 in a perfectly healthy young woman. In looking for the cause of this alteration in pulse-rate one must recall the influence of ges- tation upon the heart and the alterations in the constitution of the blood during pregnancy. The whole volume of the latter is in- creased, but not by an equal increase of all the constituent parts ; the corpuscles are relatively decreased in proportion to the liquor sanguinis ; the watery element of the blood is propor- tionately increased, making the condition of the blood during pregnancy one of hydremia. There is a relative decrease of albumin, blood-salts, and the percentage of hemoglobin, a relative increase of the fibrin-making ferment. Expressed definitely, this decrease is to the extent of about 700,000 red blood-corpuscles per cubic milHmeter and about eight per cent, of hemoglobin. Within the first twenty -four hours after labor the decrease in red blood-corpuscles and hemoglobin is yet more marked, on account, no doubt, of the escape of blood in the third stage of labor and immediately after it. But after the first twenty-four hours the blood begins to recover its normal constitution, and at the end of two weeks it is so far on the road to perfect involution ^ " The Bradycardia of the Puerperium," F. W. Lynch, " Surg., Gyn., and Obstet.," May, 1911. 2l6 LABOR AND THE PUERPERIUM. that it is much nearer a normal condition than it was in the latter half of pregnancy, although it is still somewhat deficient in red blood-corpuscles and in hemoglobin. The leukocytes decrease rapidly after labor, reaching their minimum number twelve hours post-partum; the number then increases as a moderate leukocytosis until lactation is estabhshed, whereupon the number is again diminished. These changes, however, do not explain the cause of a slow pulse in the puerperal state: it is discovered in the heart. ^It is claimed that the area of cardiac dullness is increased in pregnancy, and that there is a hypertrophy of the walls of the left ventricle. As the whole volume of blood is increased in pregnancy, and as additional resistance to the circulation is offered by increased intra-abdominal pressure and by direct pressure of the uterus upon the pelvic vessels, it is reasonable to assume that the heart, in addition to being hypertrophied, is also dilated. The additional force and capacity of the heart is acquired to meet the additional demands of pregnancy : A greater volume of blood is propelled through the vessels by an enlarged and strengthened heart, beating with a normal rapidity. Labor comes on, the uterine cavity is emptied, and suddenly the increased vascular power has become unnecessary if not dangerous. The amount of work done by the heart is repre- sented by two factors ; the rapidity plus the strength oi the beat and the power of the heart can be lessened by diminishing either one of these factors. It is obvious that the increased power of the hypertrophied heart-muscle can not be abrogated in a moment. It is equally obvious that the other factor in heart- power can be modified at once to suit the new and lesser requirements. And this, probably, is the method nature adopts to avoid excessive heart-action and an excess of blood in important organs after labor. The heart-beats are reduced some twenty to thirty in a minute. Changes in the Urinary System After Labor. — Many women after labor are unable to urinate and consequently require the use of a catheter. The bladder, in pregnancy, from the pressure of the gravid uterus behind, is unable to expand in a normal manner, but must accustom itself to a distention, chiefly upward. When the uterus is empty and has shrunk to half its former size, the bladder has room at once to distend in all directions, and can thus hold a very large quantity of urine before its walls are subjected to the same degree of tension to which they were accustomed during pregnancy. Thus large quantities of urine may collect be- fore there is a disposition to urinate. Moreover, the abdomi- THE rUEKPERAL STATE. 2iy nal walls, so long- kept on the stretch, are suddenly released from the intra-abdominal pressure, and do not for some time regain their tone ; so that the action of the abdominal muscles, which are, perhaps, the chief factors in emptying the blad- der, is, to some extent, inhibited. In some women recently delivered the abdomen is scaphoid, so that a contraction of the abdominal muscles actually decreases, instead of increasing, intra-abdominal pressure. There is a third reason for the retention of urine after labor : The tissues immediately behind the symphysis pubis bear the brunt of the pressure of the child's head as it descends the birth-canal ; and this pressure is exerted not directly forward, but to one side or the other, by the oblique position of the head; the tissues about the urethra are left edema- tous after labor, from the contusion they have suffered, and the urethra is dragged a little to one side, so that in a twofold man- ner the urethral canal is partially occluded, namely, by the edema, of surrounding parts and by the acquired tortuosity in its course. The urine itself does not differ much from that of pregnancy. The water is increased; the urea and solids are both relatively and actually below the normal. Glycosuria is quite common. Blot claims that the sugar in the urine is the result of the absorp- tion of lactose from the mammary glands, and that the larger the secretion of milk, the greater the quantity of sugar in the urine, and therefore he proposed that the quantity of sugar in the urine be taken as a test for the suitability of a wet-nurse. It has been claimed, by others, that the sugar has a hepatic origin. About 50 per cent, of puerperas have albuminuria. Fischel declares that peptonuria is a constant phenomenon of the normal puerperium.^ The sweat=glands after labor are unusually active. The skin of a pregnant woman is often harsh and dry, and during labor, unless the muscular effort is great or the weather warm, the same condition of the skin persists. But in the puerperal state the sweat secretion is profuse ; the skin is constantly moist, and during sleep the secretion may become excessive. This action of the sweat-glands plays an important part in the involu- tion of the whole organism after labor. It is one of the factors by which the h)'dremia of pregnancy is corrected, and by the dissipation of heat that accompanies the rapid evaporation of water all over the body the temperature in the puerperal state is retained at a normal level, in spite of many provocations to fever. The lungs after labor take on a slightly different action. Their capacity is increased, for the pressure from below is re- moved and the play of the diaphragm is freer. Each inspiratioa ' '■ Arch. f. Gyn.," Bd. xxiv u. xxvi, S. 120 u. 400. 2l8 LABOR AND THE PUERPERIUM. drawing in more air than before, the number of respirations in the minute is lessened; the breathing is deeper, fuller, quieter, and slower than it was during pregnancy, and the expired air contains an excess of water and of effete products, the result of tissue de- struction. As a result of the great excretion of water from the kid- neys, the skin, and, to a lesser extent, the lungs, the thirst of the lying-in woman is increased ; the appetite, on the other hand, is much diminished. More than a pound of meat in the involuting uterus is absorbed into the system during the puerperium, and the woman is in bed quiet and inactive. During pregnancy there is a great increase of the subcutaneous fat. This accumulation of fat before labor and its absorption after delivery account for the changes in weight during pregnancy and after labor. This is a matter of some practical importance, which does not usually ob- tain the attention that it deserves. It has been studied systemat- ically by Gassner and later by Baumann. According to Gassner, the gain in weight during pregnancy and the loss afterward are about one-thirteenth of the body-weight. This, I am inclined to think, from some investigations of m}' own, is an underestimate, and Baumann's observations bear me out; he found that the loss of body-weight was about one-tenth after labor, the greater part of it, of course, occurring in the first week, when a woman of aver- age weight loses some nine or ten pounds. All the remarkable changes observed in the lying-in woman occasion no manifestation of disease, not even fever. This assertion some years ago would have been incorrect, for fever was so common in the puerperal state that it was regarded as physio- logical ; it occurred usually within the first {&^ days after labor and as, at this time, there were marked manifestations of con- gestion in the breasts, due to the inception of lactation, it was called milk fever. In reality it was the fever of infection. If, however, the temperature in the puerperal state is studied closely, it must be confessed that there is some little irregularity, but that irregularity is measured, in the normal case, by tenths of degrees. Directly after labor, for instance, the body-heat is always a little raised. Although there is distinctly no such thing as milk fever, the temperature is slightly affected when the breasts suddenly assume activity; but the rise is rarely more than a few tenths of a degree. So many causes, transitory in their effect, can produce slight disturbances in the temperature of the lying-in woman, who is peculiarly sensitive to external influences, that the rigid boundary which divides fever from a normal temperature at other times must be a trifle relaxed. Thus, it is agreed among obstetricians THE PUERPERAL STATE. 219 not to regard as fever a transient rise of temperature, lasting only a few hours, which does not go above 100.5°. This is the so-called physiological limit to the rise of temperature in the puerperal state. The Mammary Changes in the Puerpera. — Heretofore the involution of important organs and systems in the puerperal state has claimed attention. The mammary action after delivery is a process of evolution. The mammary glands, as their name denotes, are glandular organs, only reaching their full develop- ment, as a rule, in the female ; situated, usually, toward the lateral aspect of the pectoral region ; occupying the space bounded above by the third and below by the sixth rib, to the inner side by the edge of the sternum, to the outer side by the axillary line. They are derived from the epiblastic layer of the blasto- dermic membrane, and belong essentially to the skin, as do the £71^ Fig. 166. — CE, Cuboidal epithelial cells ; F, fat globules stained black with osmic acid, and seen both in the cells and in the central cavity of the acini ; CV, connective-tissue frame with blood-vessels. Magnified 600 diameters (C. Heitzmann). sweat and sebaceous glands. They are closely akin to the latter, occurring in rare instances on indifferent parts of the body, as the axilla, the abdomen, or even the thighs, where a sebaceous gland has undergone a specialized development. In the female they are hemispherical in shape ; they are held in their normal position upon the pectoral muscles by the super- ficial fascia, which splits into two layers, one running above, the other below, the breast. Externally, a little below the middle ot the organ, is a protuberance, — the nipple ; around this is an area of pigmented skin, — the areola ; in this space are a number of large sebaceous glands, — the glands of Montgomer}^ Internally the breast is divided into excretory ducts, lobes, and lobules ; 220 LABOR AND THE PUERPERIUM. between the lobes and lobules are connective tissue and fat. The lobules are ultimately divided into little vesicles ; these empty into a small excretory duct ; the small excretory ducts from contiguous lobules unite to form a single large, lactiferous canal ; of these there are some fifteen or twenty, each conveying the secretion from a separate lobe to the nipple ; just before emerging upon the surface of the nipple each duct is dilated to Fig. 167. — Mammary gland : I, Lacteal ducts; 2, glandular acinus (Playfair). Fig. 168. — Colostrum and ordinary milk-globules, first day after labor; primipara aged nineteen (after Hassall). form a small ampulla or reservoir for the milk ; as it passes through the skin of the nipple it is again contracted. The epi- thelium of the gland is continuous with that of the integument ; in the superficial portions of the lactiferous ducts it is squamous ; in the deeper portions of the gland, columnar. The function of the gland is the secretion of milk. Colostrum. — During the latter part of pregnancy a thin, opalescent fluid may be squeezed out of the breast ; directly after labor this fluid is somewhat increased in quantity, and be- comes a little whiter and more opaque. At the end of about forty-eight hours a decided change takes place in the breasts ; they suddenly enlarge ; the skin over them becomes tense ; the cutaneous veins are engorged with blood, and show swollen and distinct beneath the skin ; the THE PUERPERAL STATE. 221 nipple projects; to the feel the breasts are hard and lumpy; to the woman they are painful and tender on pressure. If the child is applied to the nipple, there runs out, almost without suction, a quantity of human milk — a fluid different from the colostrum just described. It is white, opaque, of a specific 3 4 Fig. i6q. — The production of milk. Section of the mammary gland of a nursing puerpera (Bumm): I, Epithelium of acinus inactive; 2, epithelium compressed by milk in acinus; 3, 4, 5, epithelium actively secreting milk; 6, intra-acinous connec- tive tissue; 7, capillaries; 8, secreting epithelial cells with large fat drops in the protoplasm, the nucleus pressed into cell wall ; 9, milk. gravity about 1025, is said to have a sweet, agreeable taste, and is without odor. The influences which determine milk secretion after childbirth are still a mystery.^ Lactation is observed even though the spinal and sympathetic nerve connection with the genitalia is severed. Indeed, lactation has occurred in the mammary gland of a rabbit transplanted to its ear five months before, and in one of conjoined twins when the other became pregnant. It may be in part a secretion from the corpus luteum, which stimulates milk production, but this theory does not account for it in ^ " An Experimental Study of the Causes which Produce the Growth of the Mammary Gland," Robert T. Frank and A. Unger, " Archives of Internal Aledi- cine," June, 1911. 222 LABOR AND THE PUERPERIUM. the infant during the first few days after birth, in young girls, in cases of imaginary pregnancy, in women with pelvic or ab- dominal tumors, and in men. The pituitary body and the endo- metrium of the involuting uterus produce hormones which are stimulating to the mammary gland. Injections of their extracts have produced milk in the breasts of non-pregnant animals. The quantity of milk secreted in the twenty-four hours is dif- ficult to determine. It might seem easy enough to draw the milk from the breast at stated intervals with a breast-pump and to measure it, but it is difficult to get a breast-pump as mechanically effective as a child's mouth, and, moreover, the secretion of milk depends, to some extent, upon the maternal emotion ; the breast might almost be described as an erectile organ ; certainly, the sight of the child arouses a maternal instinct which sends an additional blood-supply to the mammary gland and undoubtedly increases the supply of milk. It has been estimated that at first the quantity of milk is about 300 to 400 grams (10 to 13^ fl. oz.) ; by the seventh day it is 400 to 500 grams (14 to 17 fl. oz.) ; after the second week, 1500 to 2000 grams — i i/^ to 2 liters (3 to 4 pints). In a microscopic section of a mammary gland, procured during lactation, there may be seen large epithelial cells in the process of proliferation. Toward their inner periphery may be seen globules of fat. One of two things must happen to account for the production of the milk : either the whole cell, which has begun to show signs of fatty degeneration, or rather fatty metamorphosis, is cast off, then bursts and discharges its con- tained fat, as well as other cell-contents, into the liquid medium which has exuded from the blood, or else each cell, having accu- mulated its store of fat, discharges it in little globules, along with the casein, which must also be derived from the cell- contents. The latter process is the one generally accepted. The Diagnosis of the Puerperium. — Occasionally a physi- cian must decide by an appeal to his own senses, without regard to the woman's statement, whether or not she has been recently delivered. Women accused of infanticide, for example, may deny their recent delivery. The diagnosis, in such a case, is not dii^cult. The large uterus, reaching to the umbilicus ; the bloody discharge, showing, under the micro- scope, decidual cells ; the secretion in the. breasts ; the charac- teristic fragments of decidua that may be scraped out of the uterine cavity with a curet ; the rents in the cervix, the vaginal mucous membrane, and the perineum ; the relaxed abdominal walls, and the striae upon them, — all unite to make the diagnosis easy to establish and absolutely sure. THE PURR PENAL STATE. 223 Management of the Puerperium. — The prevention of in- fection must be the chief care of both doctor and nurse in charge of a puerpera (see The Preventive Treatment of Puerperal Sepsis). Having secured, so far as possible, a perfect cleanliness of the patient, all her surroundings and attendants, the physician may turn his attention to other matters. Visits. — It is wise to wait in the house for an hour after the woman's delivery, to see that there is no hemorrhage. She should be visited again in about twelve hours ; then once a day for the first two weeks, every other day during the third week, and once or twice in the fourth week. For the first week at least the following items should be investigated routinely at each visit : The pulse ; the temperature ; the odor, quantity, and char- acter of the lochia ; the condition of the bladder and size of the womb, learned by abdominal palpation ; the condition of the breasts and nipples ; the occurrence of after-pains ; the evacua- tion of the bladder and bowels, and last, but by no means least, the condition of the infant. Many physicians fall into the habit of neglecting the baby altogether. There could be no worse policy, not to speak of higher considerations. The mother resents an indifference to her infant's condition, and a failure to make a routine investigation at each visit of the child's feeding, sleeping, and gain in development ; of its umbilicus, its bowel and bladder evacuations, and digestion, often results in a failure to correct some abnormality until it is too late. Many a sudden and inexplicable death in the new-born could have been avoided by greater watchfulness and care. Rest and Quiet. — Perfect repose is most favorable for the occurrence of the complicated phenomena of the puerperium without detriment to the woman's health. It seems almost superfluous to insist upon the advisability of preventing any mental or physical disturbance, muscular effort, a glaring light, loud conversations, and the entrance into the lying-in room of undesirable \dsitors, — and yet this is a matter that in many cases requires the physician's express attention. It was the custom in France in the seventeenth century to baptize the in- fant on the third or fourth day, when a collation was served in the lying-in room, to which all the friends of the family were in\dted, who were expected to drink the mother's health w4th much hilarity and many congratulations, — a ceremony lasting through a whole afternoon. Mauriceau speaks of this as a "very ill custom." We must agree with him, and should be inclined to go to the opposite extreme in enforcing rest and seclusion during the whole lying-in period. The physician must give specific directions in regard to the following matters, under the head of Rest and Quiet: 224 LABOR AND THE PUERPERIUM. 1. The position that the patient must occupy in bed, and how long she must retain it. The length of time she must remain in bed. The earliest date she may stand upon her feet, and the time when she may go down-stairs. 2. The degree of quiet and decorum to be observed in the room ; and — 3. The admission of visitors. The rules in regard to these matters, expressed, as rules, ■dogmatically, might run as follows : 1. The patient shall lie flat on her back for the first six hours after labor and the head shall not be supported by a pillow, but shall be on a level with the body, in order to avoid a dis- position to cerebral anemia and syncope from the greatly de- creased abdominal pressure. After that time she is allowed pillows and whatever posture is most comfortable to her. If she can not urinate lying down she may be raised to a semi- recumbent posture on the bed-pan. The woman must lie in bed until the involution of the uterus is so far complete that the fundus uteri has sunk to the level of the symphysis pubis or below it. It is a safe rule to insist upon strict confinement to bed for fourteen days. Then the patient may be allowed to shift herself from the bed onto a lounge rolled alongside of it, passing the day upon the lounge and sit- ting up as long at a time as she can without fatigue. During this week she may use a commode. At the end of three weeks she begins to walk about the room, and at the end of four goes down stairs for the first time. There has been of late a disposi- tion to encourage early getting up after childbirth in imitation of the early getting up after surgical operations, but this is a passing fad which will again be given up. Surgeons on our In- dian reservations have told me that there is not a child-bearing woman over thirty-five whose womb is not hanging out of her body. My dispensary services are crowded with poor women whose wombs are prolapsed or retroverted in consequence of early getting up after childbirth, and the practice has aire?-" been responsible for a number of deaths.^ 2. The woman's rest must be mental as well as pi therefore, no loud noises should offend her ear, no glarin^ should irritate the eye, and no extended conversation shoi allowed in the lying-in room; at any rate, for the first few - 3. No visitor should be allowed in the lying-in room ex the patient's mother and her husband, and it is someti. necessary to restrict the visits as to frequency and length. 1 " Das Friihaufstehen der Wochnerinnen und operierten und die hierl beobachten Todesfalle," Aichel, " Zentralbl. f. Gym.," No. 6, 1911. THE PUERPERAL STATE. 225 These rules in regard to quiet after labor will suit the aver- age case among the upper classes. They must, however, be modified on occasion. The length of time, for instance, required for the involution of the uterus varies greatly in different classes of society. Examinations. — An examination of the birth canal should be made on the third or fourth day to detect possible injuries. The patient is put in the gynecological dorsal position across the bed or on a table. The condition of the pelvic floor, peri- neum, anterior vaginal wall, and cervix is determined. At the end of three weeks a vaginal examination is made to ascer- tain the position of the uterus.^ At the end of six weeks the third or final examination is made (p. 233). Medication. — The question whether the routine admin- istration of ergot would insure perfect involution or hasten its completion has occurred to many minds, and has found its answer in practical experimentation. Numbers of women have been placed on a routine treatment of ergot three times a day, and the progress of these cases has been carefully compared with that of an equal number of women left to nature. The result of these observations has not been favorable to ergot as a sure means of shortening the duration of the puerperal state: nothing was gained in point of time, while disadvantages were found in this plan of treatment that might have been foreseen. The stomach rebels against a prolonged use of the drug in considerable quanti- ties. While contracting the uterus, it has an astringent action also on the breast and so diminishes milk secretion, and, passing from the maternal blood into the milk and into the infant's stomach, it exerts an unfavorable influence upon both mother and child. The Diet. — Almost all the vital functions are performed in a sluggish manner for the first few days after labor. The pulse is less rapid, the respiration slower, the bowels are inacti\'e, and there should be no voluntary muscular effort. These conditions require, for the first few days, nourishment small in quantity, easily ingested, and readily digested. After the third da}', however, a new element must be taken into account. At that time the milk secretion begins with a drain on the whole system to provide the large quantity of fat and nitrogenous material which are excreted when the breasts have assumed their full activity. To meet this additional demand upon the resources ' If the uterus is found retroverted between the third and fourth week, it should be replaced, and the patient instructed to assume the knee-chest posture twice a day for five minutes at a time. I find the postural treatment of displacements of the puerperal uterus permanently successful in a considerable proportion of cases. .A. pessary is contraindicated before the sixth week. 15 226 LABOR AND THE PUERPERIUM. of the body the simple diet of the first few days should be mate- rially, though gradually, increased. Urination. — Retention of urine is an abnormality in the puer- peral state, as annoying as any one feature of a normal case. Its causes have already been described. Its detection would seem perfectly easy, and yet it is just as easy to overlook it without the careful attention which should be, but is not always, directed toward this point. It is a common experience for a consultant to be asked to see a woman some days after labor, because the attending physician thinks that alongside the uterus there is a large and peculiar abdominal tumor, and the patient suffers great pain. What is taken for the uterus is an immensely distended bladder, reaching half-way or quite to the umbilicus; the pecuhar abdominal tumor is the uterus itself pushed far upward and to one side, almost always the right. Catheterization removes immedi- ately both tumor and pain. The mistake on this point often arises from the trust that the physician puts in the woman's statement that she has urinated regularly. One should never trust any one's assertion as to action of the bladder, but should always examine for himself, by abdominal palpation, to see if it is full or not. A nurse sometimes falsely asserts that her patient has urinated, because she is ashamed to confess her inabihty to pass a catheter. If the urine must be drawn, the catheter is used by a trained nurse, should there be one. In her absence the physician himself must attend to the catheterization ; even if a skilful nurse is in attendance, the physician is not infrequently appealed to, as the nurse can not discover the urethra, or is unable to insert the catheter. It is well, therefore, under all circumstances, to know how to use a catheter and to have a definite opinion as to the kind of instru- ment that should be employed. A soft-rubber catheter is to be preferred, because it is incapable of doing any harm, does not irritate the urethra, and is easily sterilized in boiling water. ^ The hands of the individual who inserts it must be aseptic. It saves time and is safer to wear rubber gloves, which have been soaked in a i : looo subhmate solution or have been boiled. To introduce the catheter, it is necessary to expose the urethra to view, to wipe off its orifice, as well as the sur- rounding mucous membrane, with a piece of absorbent cotton soaked in a sublimate solution, i : 2000. The catheter is then inserted directly into the urethra, so that it does not carry 1 A glass catheter is objectionable for two reasons: The eye of it scratches the mucous membrane of the urethra; it may be cracked in boiling water and broken off in the bladder. This accident happened to one of my patients, who retained the greater part of a glass catheter in her bladder for a week, the nurse being afraid to report it. TIIR PUERPERAL STATE. 227 with it into the bladder some of the decomposing vaginal dis- charge, which would be likely to set up a very troublesome or a very dangerous cystitis. The old practice of locating the urethra by the sense of feel, using the linger of the left hand and then introducing the catheter held in the fingers of the right hand, under a sheet, is unreservedly coiidemned. In the Directions to Nurses, appended to this chapter, occurs the passage, "Twelve hours after labor the woman shall be cathe- terized, and after that three times a day if necessary." Twelve hours may seem a rather long period to allow urine to collect after la- bor; but the bladder is capable of great dis- tention at this time; almost all the natural processes are sluggish; the kidneys directly after labor are not very active, and if the catheter is used too soon, the patient is very likely committed to its use throughout the greater part of the lying-in period, whereas if the woman can be induced to urinate natur- ally at first, there will be no difficulty after- ward. At the same time it would be unwise to allow an overdistention of the bladder; twelve hours, therefore, is a good compromise time for the first use of the catheter. After that three times a day is usually quite suffi- cient; it should not be used less frequently, and if the patient's feelings demand it, the bladder must be emptied more frequently. It is possible, by a long delay, to avoid the use of a catheter. In the Baudelocque Clinic they wait twenty-four hours or longer and have used the catheter in 6666 cases only twenty times. ^ Before resorting to catheter- ization every effort should be made to induce the woman to urinate naturally. Sometimes this is accomplished by putting hot water in the bed-pan, by the use of a turpentine stupe over the bladder, and by the sound of running water. The patient may be raised to a semirecumbent posture on the bed- pan if she can not urinate lying down. The Bowels. — On account of the small amount of food in- gested during the early part of the puerperium, the flaccidity of 1 Recht, " These de Paris," 1894. Fig. 1 70. — Short soft rubber catheter. 228 LABOR AND THE PUERPERIUM. the abdominal walls, the torpor of the intestinal muscles from long pressure, and the general muscular inactivity, there is a re- markable sluggishness of the bowels, and an exaggeration of the constipated habit almost invariably acquired in pregnancy. This is no great disadvantage at first, as the food is principally liquid and small in quantity, so that there is very little detritus to be thrown off by the intestines. It is not advisable, however, to allow the feces to accumulate too long. If the woman eats in a day perhaps a third of what an ordinary person would devour, by the third day there would be a considerable collection in the lower bowel ; at this time, too, the diet is a little increased, and the sudden onset of milk secretion on the third day always seems, at least, to threaten an inflammation of the breasts, which might be averted by a derivative and depletive course. For all these reasons, therefore, it is customary to administer as a routine treatment a laxative on the evening of the second or third day. A good routine prescription is a half-bottle of citrate of magnesia on the evening of the second day, the rest of the bottle the follow- ing morning before breakfast, and, if the bowels are not moved two hours later, a simple enema. If the patient is plethoric or the mammary glands are swollen and tender, a more active saline purge is preferable. The Mammary QIands. — In almost every instance the estab- lishment of lactation is accompanied by some local disturbance. The increased blood-supply to the breast, the proliferation of cells, and the transudation of a serous exudate are phenomena usually characteristic of inflammation. The enlarged breast, the engorged veins under the skin, the hard, tense feel of the gland-tissue, and the great tenderness, all seem to point to an inflammatory attack instead of a natural physiological process. This state of the breasts usually demands treatment to ameliorate the discomfort and to prevent the transition of a natural process closely bordering on the pathological to a condition of actual disease. If the engorgement of the breasts is marked and the accompanying symptoms of heat, pain, and fullness are pro- nounced, the administration of a saline purge is usually sufficient to relieve some part of the mammary congestion. Care must be taken, in addition, to empty the breast. For this purpose nothing is so good as the infant's mouth, which should be applied to the nip- ple regularly every two hours. If the child dies, does not empty the breast, or is weaned, a breast-pump must be used, and the nurse, in addition, should rub and massage the breast with oiled fin- ger-tips in a direction toward the nipple, thus making the skin more supple and emptying the breast at the same time. The constant dragging upon the nipple when the child is nursing, the pinching THE PUKRPKRAL STATE. 229 and squeezing it receives from the infant's gums, and its continual moisture from milk and the secretions of the infant's mouth, all tend to bring about an unhealthy condition of the skin upon and around it. It ])ccomes at first irritated and inflamed, then ex- coriated, chapped, and fissured, and, consequently, exceedingly sensitive and painful, so that suckling the child is dreaded. Ncjr is this the only disadvantage ; in the little cracks and fissures the milk collects and decomposes ; the patient or nurse ma}', in careless handling of the breasts, deposit, in these raw places, pathogenic micro-organisms, and the consequence is very likely to be septic infection of the connective tissue of the breast and the formation of a mammary abscess — of all the minor complica- tions of the puerperal state the one to be most dreaded. The preventive treatment of this complication is an important part of the management of the puerperal state. The main thing, ob- viously, is to keep the skin healthy and clean. This is done by carefully washing the nipples after every nursing with absorbent Fig. 171. — Diagram pattern for Murphy-Cooke breast binder. By enlarging until each square represents a square inch, and tracing an outline, a binder of ordinary size will be secured. If the binder is cut from folded muslin, only one-half the pat- tern need be made. cotton and boracic acid solution, and by cautioning nurse and patient against touching the nipples. ' The adjustment of a suitable mammary binder is an important means of preventing congestion and inflammation. The Murphy binder or its modi- fication by Cooke is best for this purpose (Figs. 171 and 172). The Child.— The management of a healthy infant is easy. If a few common-sense rules are observed, nature does the rest. The management of the new-born child consists simply 230 LABOR AND THE PUERPERIUM. in seeing that food is administered at proper and regular in- tervals, that attention is paid to bodily cleanliness, and that ample opportunity is afforded for an almost unlimited amount of sleep; with ordinary precautions in regard to warmth. The proper interval between the nursing should be two hours during the day, four to five hours in the night. If the child is taught regular habits in this respect, the burden of its care-takers is immensely lightened. The infant arouses itself and is ready for nursing at the proper feeding-time, and in the intervals sleeps peace- fully. Regularity in nursing is of importance, further, from its favorable influence upon the constitution of the milk. Too frequent nursing results in a concentrated milk, which is difficult to digest. Too infrequent nursing results in a watery milk, The Murphy breast-binder. which is not nutritious. If the infant is allowed to be irregular in the hours for feeding, bathing, and sleeping, it grows fretful, wakeful, and capricious in its appetite. A word of caution is necessary about the infant's bath. The temperature of the water should be about 90° ; certainly not much higher, nor, on the other hand, too low. Nurses are often extraordinarily insensi- tive to hot water. The temperature of the bath, therefore, should not be tested by their hands, but by a bath-thermometer. The bath should be given about midday, in the warmest part of the room, preferably in front of an open fire. There are many apparently small, but really important, details in the preparation for and management of labor and the puer- perium, which might easily be forgotten. It is convenient, there- fore, to give patients and nurses a printed list of instructions. THE PUERPERAL STATE. 23 1 DIRECTIONS FOR THE MOTHER. Send a specimen of urine (mixed night and mornino;), about four ounces, every two weeks until the last month, then every week. Re- port at once scanty urination, severe headache, swelling of the feet or face. Visit the physician's office every two weeks to have the blood-pressure measured. Have ready for the labor: towels, ether (one-half pound), brandy (two ounces); four ounces tincture of green soap; a bottle of anti- septic tablets (corrosive sublimate); a skein of bobbin; a fountain syringe; bed-pan; new, soft-rubber catheter; a small package of absorbent cotton; a one-ounce bottle of carbolized vaselin; two yards unbleached muslin (for binder) ; a one-pound package of salicy- lated cotton; five yards of carbolized gauze; eight yards of nursery cloth. The last is to be boiled for half an hour in clothes-boiler, dried thoroughly, pinned up in a clean sheet, and put away out of the dust. A mackintosh or rubber cloth is necessary to protect the mattress ; two yards of rubber cloth, one yard wide, is sufficient. Prescription No. 1 1 is to be procured about four weeks before expected confinement. It is to be applied to the nipples, night and morning, with absorbent cotton. Prescription No. 2^ is to be obtained about a week before- hand and kept in readiness. Instead of providing these articles separately, a complete outfit for labor, sterilized, put up in a closed package or box, may be ordered. The author recommends the outfit described in the appended Hst. Two sterilized bed pads (30 ins. Fluid extract ergot. square). One hundred grams chloroform Two sterilized mull binders (18 (Squibb 's). ins. wide). One hundred grams ether. Six sterilized towels. Boric acid, powdered. Stocking drawers, sterilized. Bichloride tablets. Ten yards sterilized gauze. Talcum powder. Five yards carbolized gauze. Four quart sterilized douche bag One pound package salicylated with glass nozzle. cotton. Douche pan, sterilized. One pound sterilized absorbent Two agate basins, sterilized. cotton (half pounds). Bath thermometer. Rubber sheet i yard X i/^ yards. Sterilized nail brush. sterilized. Safety pins. Rubber sheet i^ yards X 2 yards, Sterilized tape. sterilized. Sterilized soft rubber catheter. Two tubes sterilized petrolatum. Sterilized glass catheter. One tube K-Y lubricating jelly. One pair sterilized rubber gloves Tincture green soap. No. i]A. ^ R. Glycerol of tannin, Aqua, aa, ^j 01. rosas, gtt. ij. 2R. Ext. ergot, fld., fgj. 232 LABOR AND THE PUERPERIUM Baby-clothes. Four to six dozen diapers. Four to six pairs knit (woolen) socks. Three to four shirts (woolen). Four flannel night-skirts. "^ * n i • . . i j -.i. • 1. • ^ j ^^ ,, j^ ,. f^ All skirts to be made With waists instead Q3.y "SKirtS. r r Vv J Four to six white day-skirts. ) Six to ten slips. " " dresses. Material for four or five flannel bands (45- to 50-cent flannel). Soft pillow (good size, 14 x 18 inches). Soft pillow covers. Knit wrapping blankets. Sacques, wrappers, bibs, caps, blankets, veils, etc. Baby's Basket. Large and small safety-pins. Talcum powder (box and puff). Fine, soft sponge. Soft brush (for hair). Castile soap. Cold cream. Alcohol for rubbing child. Blunt scissors for nails, etc. Old linen for cleaning mouth. Soft towels for bath. Bath-blanket. Wooden forms for drying socks. DIRECTIONS FOR THE NURSE. Give rectal enema as soon as pains begin (pint of soapsuds, dram of turpentine). Wash the external genitals thoroughly with soap and warm water. As soon as labor begins, fill three pitchers with water that has been boiling for half an hour; tie clean towels over their tops. This water is to be used for all purposes about the patient and for making the antiseptic solutions. No vaginal injection to be given unless ordered. Take the temperature three times a day, — morning, noon, and evening. Place pad of nursery cloth tinder patient ; change it when soiled. Occlusive bandage to be made up of salicylated cotton and carbolized gauze, with sterile hands, and to be changed, for the first five days, every four hours. The external genitals to be irrigated four or five times a day with warm sterile water. If, at the end of twelve hours, the bladder can be emptied naturally, use a catheter. Afterward, if necessary, catheterize patient three times a day. THE PUERPERAL STATE. 235 The patient is to lie on her back ; she may be moved from one side of the bed to the other several times a day ; her limbs may be rubbed with alcohol and water or bathing-whisky once a day. The nurse's hands must be protected by sterile rubber gloves before catheterizing the patient, cleansing the genitals or breasts. Diet. — First 48 hours. — Milk {i]4. to 2 pints a day), gruel, soup, one cu[j of tea a day, toast and butter. Second 48 hours. — Milk toast, poached eggs, porridge, soup, cornstarch, tapioca, wine-jelly, small raw or stewed oysters, one cup of coffee or tea a day. Third 48 hours. — Soup, white meat of fowl, mashed pota- toes, beets, in addition to above. After sixth day, return cautiously to ordinary diet, — that is, three meals a day, meat at one of them, of an easily digested character, — white meat of fowl, tenderloin of beef, etc., — and a glass of milk at least three times a day, between meals and before going to sleep at night ; also a glass in the middle of the night. Child. — After being well rubbed with sweet-oil, the child is to be washed on the nurse's lap. The bath-tub may be used by the end of the first week. Water not over 100° F. The cord is to be dressed with salicylated cotton. Ob- serve carefully for bleeding. A good dusting-powder for the navel is salicylic acid i part, starch 5 parts. The child should be bathed daily, about midday, in the warmest part of the room. Use Castile soap and a soft sponge ; avoid the eyes. Diapers changed often enough. For chafe, use cold cream and talcum powder. Nursing. — The child is to be put to the breast every four hours for the first two days. No other food is to be given it. After the second day it should be nursed every two hours, from 7 a. m. to 9 p. M., and twice during the night (i a. m. and 5 a. m.). After every nursing the nipples are to be carefully dried and then smeared with a little sweet-oil for the first week or two, applied with fresh pledgets of absorbent cotton. The Final Examination at the End of the Puerperium. — The recently delivered w^oman should be subjected to three careful examinations: The first a few^ days after labor, to detect the injuries of child-birth; the second before she leaves her room, to determine the position of the uterus; and the third at the end of six weeks after delivery. The final ex- amination should be conducted in a methodical manner, as follows: 234 LABOR AND THE PUERPERIUM. Fig. 173. — Perfect preservation of the vulvar orifice and pelvic floor in a primipara, six weeks after labor. Fig. 174. — Gaping vulvar orifice from injury to the perineal body, retract'ion of the ends of the transversus perinei and bulbo-cavernosus muscle, overstretching and subinvolution of the vagina. THE PUERPERAL STATE. 235 Fig. 175. — Gaping vulvar orifice, injury of urogenital trigonum muscle, and prolapse of lower anterior vaginal wall. Fig. 176. — Gaping vulvar orifice with rectocele and cystocele from a former labor. Fig. 177. — Complete tear of the peri- neum directly after labor. Fig. 178. — Same patient six weeks later, before operation, which had been postponed on account of al- buminuria and infection. 236 LABOR AND THE PUERPERIUM. The Inspection of the Vulva. — As a woman lies on an exam- ining table or across the bed with her thighs separated, the labia majora should be in close apposition, closing the vulvar orifice and concealing the vaginal entrance. A gaping vulvar orifice and vaginal introitus indicate subinvolution of the vagina, over- stretching of the tissues, and injury of the perineal center or body. By placing the thumbs on either side of the labia and stretch- ing them apart a view of the lower third of the vaginal canal is Fig. i7g. — Complete tear of the perineum six weeks after labor; sphincter muscle masked by large hemorrhoidal vein. obtained; injuries in the posterior sulci to the levatores ani mus- cles are visible; lacerations of the anterior sulci manifest them- selves by a dropping of the lower anterior vaginal wall downward and forward, making a pouch of mucous membrane filling the distended vaginal entrance. This is the injury which later, if not repaired, results in cystocele. If there is a complete tear of the perineum through the sphincter, it should immediately be detected on inspection, or certainly when the labia are separated. If there is any doubt about it, the forefinger of the left hand, protected by a finger- cot, in the rectum, and the thumb in the vagina determine the thickness of the tissues between the two. THE PUERPERAL STATE. 237 Fig. i8o.- — Palpation of pouch due to laceration and retraction of the transversus perinei muscle : a. Photograph from nature; b, diagrammatic sketch. Fig. 181. — Testing the levator ani muscle in the right posterior vaginal sulcus. In this case there was a deep tear. 238 LABOR AND THE PUERPERIUM. • The Digital Examination of the Vagina (Indagation). — First injury and retraction of the transversus perinei muscles is detected by the tip of the forefinger as shown in Fig. 180. Next, the in- tegrity of the levatores ani muscles is tested as follows : The fore- finger of the left hand is inserted to the second joint; pressure is made in each posterior sulcus dow^nward and outward toward the tuber ischii; if the muscle is lacerated, the finger sinks into a deep cleft almost or quite to the bony pelvic wall. The forefinger is then swept over the posterior vaginal wall from one descending ramus of the pubis to the other; if the levator ani is injured on either side, the cleft in it is plainly felt. Both forefingers are in- serted in the posterior sulci; pressure is made outward and down- ward. The levator ani is palpated between the thumb and fore- finger; one being inside the vagina, the other upon the labium. Next, the integrity of the urogenital trigonum muscle ^ and fascia is tested by pressing the forefinger into each anterior sulcus upward against the lower edge of the pubic bone. A muscular cushion is felt in the normal case. If there is a submucous laceration of the muscle, the finger comes in close contact with the sharp edge of the bone. The left anterior sulcus is usually the site of injury, as the long diameter of the fetal skull almost always lies in the right oblique diameter of the maternal pelvis. The finger is now inserted more deeply in the vagina to feel the cervix in order to detect the kind and degree of injuiy it may have suffered. The direction of the cervix is of no importance in diagnosticat- ing uterine position ; it may look forward in anteflexion and backward in retroflexion. The position of the uterus is next investigated — of all single items of information in this examination, the most important. A combined examination is necessary. If the corpus uteri can be grasped between the finger or fingers in the anterior vaginal vault and the fingers of the other hand upon the hypogastrium, and the fundus points sufficiently far forward for the weight of the intra-abdominal contents to rest upon the posterior uterine wall, the uterus is in satisfactory position. If it is impossible to take this bimanual grip of the uterus, the internal fingers are shifted to the posterior vaginal vault, and if there is a retro- flexion, the corpus uteri is easily traced backward toward the sacrum and the angle of flexion is plainly felt in the lower uterine segment. Pressure from above through the abdominal wall facilitates the palpation of the retroflexed uterus. 1 For the best description of this muscle the student is referred to Waldeyer's "Das Becken." It runs across the anterior vaginal wall from one ischiopubic junc- tion to the other. It is the only muscle actually inserted into the vagina, and is the strongest support of the lower anterior vaginal wall ; its laceration, which frequently occurs in lai)or, is the first step in the formation of a cystocele. THE PUERPERAL STATE. 239 Fig. 182. — Examining the position of the uterus. Fig. 183. — Protrusion between gaping recti muscles of coils of intestines, in which peristalsis could be seen. 240 LABOR AND THE PUERPERIUM. During the bimanual examination the size and consistency of the uterus are noted to determine the degree of involution. Fig. 1S4. — Pyramidal elevation of the abdomen when the woman strained. Fig. 185. — Retraction instead of protrusion of the abdominal wall between the recti muscles when the patient attempts to rise to a sitting posture. Finally, the broad ligaments, the tubes and ovaries, and the utero-sacral ligaments are palpated by a combined examination THE PUERPERAL STATE. 24 1 CO detect inflammatory swelling, di.s[)lacemcnts, fixation, and peri- toneal or cellulitic exudate. The specular examination of the vagina and cervix follows the digital examination to detect ulcerations of the vagina or injuries in its upper part, and particularly to determine the kind and degree of injuries to the cer\ix, the existence of eversion and erosion of the lips. A bivalve speculum (Collins) is most con- venient to examine the cervix. The author's skeleton bivalve speculum gives the best view of the vaginal walls. The abdominal wall is palpated and inspected to test its tonicitv, and particularly to detect a diastasis of the recti muscles. The separation of the latter is measured by sinking the outspread fin- ger-tips of one hand crosswise between the muscles. If there is doubt as to the degree of separation, while the fingers are held in position, the physician helf)s the patient to rise to a sitting posture by grasping her hand. In a normal case the muscles are Fig. 186. — Testing the separation of the recti muscles. approximated as the patient rises. If there is diastasis, the degree of separation is evident, as the muscles are clearly outlined when they contract. By inspection, protrusion of intestines can be seen in extreme cases. If the woman strains, the abdominal wall is thrown outward in a wedge shape between the muscles. Rarely it is retracted instead of protruded. 16 242 LABOR AND THE PUERPERIUM. Fig. 187. — Palpation of a floating kidney in the erect posture. Fig. 188. — Examination of the coccyx. THE PUERPERAL SPATE. 243 The kidneys are palpated to determine their position and mobil- ity. The woman sits bolt uprii^ht, her back and head supported, her arms han<;ini:^ down limp alonf:^side of her, and all her muscles relaxed as much as j)ossiblL'. The outspread fiuL^ers of the physi- cian's hands grasp the kidney through the anterior and the poste- rior abdominal walls. If the kidney is in good position, the fingers of the anterior hand must be inserted under the floating ribs. Another method is to examine the patient on her feet, the trunk flexed and the arms supported on the back of a chair (Fig. 187). ^ ^ " m mgr^^^^- 1 K \ i Fig. 189. — Examination of the sacro-iliac joints, to detect loose painful joints and abnormal mobility of the innominate bones as the woman takes a step. The coccyx is examined to detect injury of its joints as illus- trated in Fig. 188, the woman being placed in Sims' position and the physician's forefinger protected by a rubber finger-cot. The sacro=iliac joints are examined for relaxation, pain, and abnormal mobility by placing the thumbs over each joint, as the patient in the erect posture takes a step or two forward and backward. It is only by such a methodical and thorough examination that the physician avoids overlooking the ill consequences of 244 LABOR AXD THE PUERPERIUM. labor. The invalidism of women following child-birth could be enormously reduced, a reproach to medicine could be removed, if this plan were uniformly adopted. There is no vahd excuse for a rectocele, injured cer\-ix with all its consequences, including cancer, cystocele, uterine displace- ments of puerperal origin, including prolapse, subinvolution, and endometritis follo^^'ing child-birth, coccygod3'nia from a ruptured joint in labor, painful sacro-iliac joint, pendulous belly with ptosis of the abdominal \'iscera from a relaxed ab- dominal wall, and diastasis of the recti muscles. All the in- juries of child-birth, including those of the cer\TS and of the. anterior vaginal wall, can be successfully repaired during the puerperium by an intermediate or by a secondary' operation, in- stead of alloT^ing the woman to endure 3'ears of suffering and invalidism "v^^th such impairment of physical and nervous strength that she can never be restored to her original health. Ever)' one of the conditions enumerated above is amenable to appropriate treatment, and none of them should be allowed to become chronic. PART III. THE MECHANISM OF LABOR. The mechanism^ of labor is the manner in which a fetus and its appendages traverse the birth-canal and are expelled. It takes into account the complicated structure of the maternal and fetal parts, considering their movements and the mechanisms of their motions. It is necessary to define, further, certain terms that will be used constantly in the study of the mechanism of labor. By presentation is meant that part of the fetal body which presents itself to the examining finger in the center of the plane of the superior strait. The term position may be applied to the position of the child in utero, whether it is longitudinal, oblique, or transverse ; or, in another sense, it is the varying relations which the present- ing part of the fetus bears to the surrounding maternal structures at the plane of the superior strait. The presentation and position of the fetus are determined by abdominal palpation, by auscultation, and by vaginal exami- nation. Abdominal Palpation. — For this kind of obstetrical exami- nation the woman should be placed on her back, with the abdomen exposed. The examiner, standing to one side of the patient, by a series of stroking, patting, and rubbing motions with his hands, determines the height of the fundus uteri, the tension of the abdominal walls, the irritability of the uterus, the quantity of liquor amnii, the size of the fetus, its position, and its presentation. It has been claimed that in favorable cases the placenta can be felt, and that its position can thus be diagnosti- cated (Spencer). It is further asserted that if the greater bulk of the uterus is anterior to the insertion of the tubes, the pla- centa is anterior, and vice versa (Leopold). 1 From the Gieek /x>/;(ai'i/, contrivance, machine (from root n'iXOQ, a manner, a way, a means). 245 246 THE MECHANISM OF LABOR. The Diagnosis of Fetal Position and Presentatio7i by Abdomi- nal Palpation. — The examiner stands alongside the patient, facing her head; the tips of the fingers of both hands, moving together and at equal distances from the middle line, are carried up the sides of the abdomen by a series of tapping movements ; and upon one side (for example, the left, in the L. O. A. position) is Fig. 190. — Abdominal palpation : locating the fetal back. Fig. 191. — Abdominal palpation : finding the lower extremities of the fetus. noticed a firm, broad, even sense of resistance, contrasting with the cystic, tumor-like sensation of the other side, with the occasional encounter of firm, irregular bodies, — the fetal extremities. This firm, broad, even resistance is produced by the fetal back, and, to confirm this fact, the extremities are felt for by a rubbing motion with one outstretched hand on the opposite ABDOMIX. 1 1. PA /. PA TION. 247 side. They are felt as cylindrical, irregular bodies, slipping away from the hand, and changing their position from time to time. Having located the back and the extremities, the portion of the fetal ellipse presenting at the superior strait is next ascertained. The examiner now faces the woman's feet, and, with the out- stretched hands, the fingers parallel with and the middle finger over the center of Poupart's ligament, on either side, the fingers dip down beneath the ligament into the pelvic cavity. If the head is presenting, it is felt as a hard, regular, round body, the greater mass of the occiput, the sharp point of the chin, and the groove between occiput and back being often distin- guishable. At the same time, the density of the head, its com- pressibility, its approximate size, and its relative size to the pelvis may be learned. Fig. 192. — Abdominal palpation : locating the fetal head. By auscultation the fetal heart-sounds are located, and their rate and intensity are noted. The uterine bruit and the funic souffle are often heard. The former is a low-pitched musical murmur synchronous with the maternal heart-beat. The latter is a high-pitched whistling murmur synchronous with the fetal heait-beat. The position on the^ abdomen at which the fetal heart-sounds are heard with greatest intensity is of diagno.stic value in confirming the find, by abdominal palpation, as to posi- tion and presentation. By vaginal examination the finger detects the varying por- tions of the fetal body which may present at the superior strait, as the cranium, the face, the shoulder, the buttocks, the knees, feet, and, exceptionally, the elbow or hand. The position of the fetus in Jitcro is longitudinal in 99^ per cent, of all cases. The cephalic extremity presents in about 95^ per cent., 95 per cent, being vertex presentations. In about one-half of i per cent, of cases the face presents ; the brow very rarely. In about 3 per cent, of all cases the breech 248 THE MECHANISM OF LABOR. presents, and in about one-half of i per cent, the fetus occupies a transverse position in utero. An explanation of the great frequency of cephalic presentations is found in a voluntary assumption of that position by the fetus, because it affords it the greatest degree of comfort and the best opportunity for growth and development, the largest room being found in the fundus uteri for the lower extremities, which are freely moved and exercised. ^ ^ An explanation of the great frequency of presentations of the vertex is afforded by the mechanical arrangement of the connec- tion between fetal head and body, diagram- matically represented by two bars attached to each other, — that representing the head joined to that representing the spinal col- umn, not at its middle, but at a point nearer one end of the bar (Fig, 193). An equal force exerted upon both ends of Fig- 193- — Diagram the lever represented by the child's head ;hrSq°„Lc?°orvr„;x wm result in the greater flexion of the presentations. longer bar, which is that portion of the fetal skull in front of spinal column. The positions of the various presentations are named by the relationship which the most prominent anatomical feature of the presenting part bears to the acetabula or to the sacro-iliac junc- tions of the maternal pelvis. They are, therefore, four in number. Positions of Vertex Presentations. — I. L. O. A., left occipito- anterior, the occiput looking to the left acetabulum. 2. R. O. A., right occipito-anterior. 3. R. O. P., right occipitoposterior, the occiput looking to the right sacro-iliac joint. 4. L. O. P., left occipitoposterior. Of all vertex presentations about seventy per cent, are L. O. A., thirty per cent. R. O. P. The long axis of the fetal skull very rarely lies in the left oblique diameter of the maternal pelvis. Explanation of the Frequency of L. O. A. and R. O. P. — The position of the rectum shortens the left oblique diameter of the pelvis ; therefore the long diameter of the head, seeking the direction of least resistance, adjusts itself in the right oblique ^ It is probable that other factors often enter into the assumption of a cephahc presentation by the fetus. Tlie fact that the cephalic extremity is the heavier, and so falls toward the pelvis as the woman stands erect, and the growth of the uterus in a perpendicular rather than a lateral direction, forcing the long axis of the fetus to coincide with the long axis of the uterus, are no doubt instrumental in determining a cephalic rather than a pelvic presentation ; but if one accepts this explanation unre- servedly, he could not explain a breech presentation at all, nor could he account for the return of a fetus to a breech presentation after it had been turned by external version. Sir James Y. Simpson's theory, therefore, given in the text is, on the whole, the most satisfactory. FORCES INVOLVED IN MECHANISM OF LABOR. 249 diameter of the pelvis and the projection of the lumbar spinal column, to which the fetus by choice adapts its anterior concave surface, usually results in the back being turned forward and tilted a little toward the right, because of the usual right lateral version of the pregnant uterus. Thus, the left occipito-anterior position of the vertex is the commonest position in labor. Should the child's back be directed to the right, the occiput is turned posteriorly, because the chin w'ould be pushed forward by the sigmoid flexure and rectum, this being a stronger force in the arrangement of the head than the child's inclination to adapt its concave abdominal surface to the convex surface of the maternal lumbar spine. THE FORCES' INVOLVED IN THE MECHANISM OF LABOR. There are certain forces operative in ever>' labor irrespec- tive of fetal presentation and position. These are the forces of expulsion contributed by the uterine muscle and the abdominal muscles, and the forces of resistance con- tributed by the lower uterine segment, the cervix, vagina, 'vulva, the pelvis, and the fetal body. The forces of expulsion are furnished by a great part of the uterine muscle (the upper uter- ine segment) and by the mus- cular action of the abdominal wall. That portion of the uterine canal which must be dilated to allow the escape of the fetus is called the lower uter- ine segment. Its boundaries are : above, the firm attachment of the peritoneum to the uterine wall, and, below, the internal OS. That portion of the uter- ine wall above the point at which the dilatation of the uterine cavity begins is called the upper uterine segment; the boundary-line between these seg- ments, often marked by a perceptible ridge, especially in ob- structed labors, is called the contraction ring, or the ring of Bandl. Fig. 194. — Diagram showing the diminution of the upper uterine seg- ment and the expansion of the lower segment during each contraction. 2;o THE MECHANISM OF LABOR. The manner in which the uterine muscle exerts its force upon the fetal body is by a diminution of the intra-uterine area. The uterine muscle in contraction somewhat increases the longi- tudinal diameter of the uterus, but decidedly diminishes the transverse and anteroposterior diameters. The contraction of the abdominal muscles likewise diminishes the area of intra- abdominal space. The degree of force exerted by the combined action of uterine and abdominal walls has been estimated to be from seventeen to fifty-five pounds. The forces of resistance are furnished by that portion of the parturient tract which must be dilated, — i. e.-, from the contraction ring to the vulva, including the lower uterine segment, the cervix, the vagina, and the vulva. The dilatation of the cer\'ix is effected, if the membranes are preserved, by the displacement of the most easily displaceable of the uterine contents, the liquor amnii, in Fig. 195. — Diagram illustrating alteration in shape of a cross-section of a uterus during its contractions. The heavy line represents the non-contracted, the dotted line the contracted uterus (compare Fig. 196) (Dickinson). Fig. 196. — Diagram illustrating the alteration in the shape of a sagittal section of the uterus during its contrac- tions. The heavy line represents the non-contracted, the dotted line the con- tracted uterus (Dickinson) . the direction of least resistance, — through the cervical canal. A pouch of the membranes insinuated in the canal subjects the surrounding ring of cenacal muscle to water-pressure, equally exerted in all directions, but felt by the cer\dx only in a lateral or horizontal direction. If the membranes are ruptured and the presenting part impinges directly on the cervix and lower uterine segment, the former is subjected to a lateral pull from all sides at once, as the presenting part pushes from above downward. The presenting part, moreover, whatever it be, is somewhat con- ical in form, and subjects the cer\'ix to a lateral push as it is wedged into the cer\'ical canal (Fig. 197). The dilatation of the lower uterine segment and of the cer\dx is not, however, simply mechanical, the serous infiltration of the lymph-spaces and the Plate 6. Fetal skull seen (i) from the side, (2) from above, (3) from behind, and (4) from in front, showing sutures, fontanels, and diameters (Dickinson). FORCES IXrOLVED LV MECJIAXISM OE LABOR. 25 I separation of the muscle-fibers lessening the power of resistance gained by cohesion of muscle-bundles. The dilatation of both the lower uterine segment and the cer- vical canal is also assisted by the longitudinal muscle-fibers in these regions drawing the cervix up over the presenting part. Finally, the circular muscle of the cervix, subjected to the strain of constant push and pull, becomes fatigued and, at length, para- lyzed. Below the cervix dilatation is effected mainl}' by the mechanical stretching of the walls of the birth-canal. The bony walls of the pelvis, in a normal case, only offer enough resistance to delay the progress of the presenting part suffi- ciently to insure a gradual dilatation of the soft, resisting structures. The Fetal Body. — The head is by far the most important anatomical division of the fetal body in labor, on account of its bulk and density. The fetal head may be divided into the yielding and the unyielding portions. The former consists of the cranium, composed of the two frontal, the two temporal, the Fig. 197. — Diagrams illustrating the lateral "pull " and "push" on the cervix. two parietal, and the occipital bones. These bones are separated from each other as follows : The two frontals by the frontal suture, the frontal from the parietal by the coronal suture, the two parietal by the sagittal suture, and the two parietal from the occipital by the lambdoidal suture. At the junction of the lambdoidal and the sagittal sutures there is a membranous space, called the posterior fontanel, triangular in shape. At the junction of the frontal, coronal, and sagittal sutures there is also a membranous space, called the anterior fontanel, kite- shaped, and larger than the posterior fontanel. This portion of the skull, the cranium, yields to pressure, and is reduced in size by an overlapping of the bones. The unyielding portion of the skull comprises the face and the base of the skull. The bones of this region are fixed and unyielding. A transverse vertical section of the skull is somewhat wedge- shaped, the wedge tapering toward the neck. A longitudinal medial section is distinctly conical in form. 252 THE MECHANISM OF LABOR. Possible Presentations of the Head. — Vertex. — By this term is meant that conical portion of the skull with its apex at the smaller fontanel and its base at the planes of the biparietal and trachelobregmatic diameters, — the face; the brozi' ; the larger fontanel ; the parietal eminence ; the ear. THE MECHANISM OF THE SEVERAL PRESENTATIONS AND POSITIONS. The Mechanism of Labor in a Vertex Presentation and a Left Occipito=anterior Position. — It is convenient to begin the study of each presentation with a consideration of its diagnosis. The diagnosis of position and presentation is made by abdom- inal palpation, auscultation, and vaginal examination. By these Fig. 198. — Left occipito-anterior position of a vertex presentation. methods of examination in the position and presentation under discussion the fetal back is found to the left, the extremities to the right and above, the head below ; the heart-sounds are heard most distinctly about an inch below and to the left of the umbili- cus ; the examining finger in the vagina detects the vertex pre- senting, with the occiput directed toward the left acetabulum ; the sagittal suture is in the right oblique diameter of pelvis ; the smaller fontanel, recognized by the junction of the lambdoidal and the sagittal sutures, is the most dependent portion of the presenting part ; the tip of the occipital bone is overlapped by the parietal bones. As the direction or axis of the pelvic canal diverges from that of the uterine cavity, running, at first, more MECJfANISM OF PR KSENTATIOXS AND POSITIONS. 253 posteriorly, there is usually a lateral inclination of the head so that the sagittal suture is posterior to the normal position of the oblique diameter of the pelvis, and one parietal bone (the anterior) is deeper in the pelvis than the other one. The mechanism of labor in a left occipito-anterior position of a vertex presentation may be taken as a type of the mechanism of all labors, the variations in the process imposed upon it by Fig. 199. — Vertex presentation, left occipito-anterior position. the different positions and presentations of the fetus being readily understood if the typical mechanism of the commonest presenta- tion and position is thoroughly mastered. It is convenient to divide the mechanism of labor into a number of steps or acts, as follows : First Step. — Accommodation of the size of the fetal skull to the size of the pelvic canal by flexion ; accommodation of the shape of the fetal skull to the shape of the pelvic inlet by molding ; accommodation of the direction of the head to the direction of 254 'THE MECHANISM OF LABOR. the pelvic canal by lateral inclination. These movements occur prior to labor, when the head enters the pelvic inlet with the subsidence of the uterus. i_ 1 » J h rf_-: e — \> 1 I d V' -..in u ■ s Fig. 200. — Genital tract with fetus removed, showing divergence of the pelvic axis from that of the uterine cavity: a, a. Membranes; d, b, contraction ring; c, c, point down to which membranes are unseparated ; d, promontory ; e, region of os internum (above which fragments of deciduaare found, and below it cervical glands) ; f, bulging of wall into neck of fetus ; g, g, os externum ; h, pouch of Douglas ; i, posterior vaginal wall (elongated and thinned) ; j, rectum ; k, stretched anal canal ; /, placenta ; w, uterovesical peritoneum ; n, region of os internum (above which fragments of membranes are found, and below it portions of cervical glands) ; o, lower limit of bladder; /, anterior vaginal wall (not elongated) ; q, urethra; r, vagina; s, vulva; t, perineum with blood extravasation (Barbour and Webster). Second Step. — Further flexion, molding, and accommodation of the head to the pelvis by lateral inclination, when labor-pains appear, and the head is subjected to a propulsive force and to the resistance of the lower uterine segment, the cervix, and the pelvic walls. MECHAXISM OF PRESENTATIONS AND POSITIONS. 255 Third Step. — Dilatation of the lower uterine cavity and of the cervical canal. Fourth Step. — Descent of the head to the pelvic floor, mainly by an extension of the fetal spine. The fetal body, a.s a whole, is not yet propelled along the birth-canal, because, during a pain and while the head is obviously descending to the pelvic floor, the fundus uteri and the breech do not sink to a lower level. On the contrary, there is a slight elevation of the fundus, an Fig. 201. — The descent of the head in a vertex presentation, left occipito-anterior position. elongation of the uterus, and the distance between the head and the breech increases during a uterine contraction. Fifth Step. — Anterior rotation of the occiput. TJie Cause of This Movement. — The most dependent portion of the head, the tip of the occiput, driven through the funnel- shaped parturient canal, first strikes the resistance of the upper por- tion of the pelvic floor, which is represented by a curved line or plane running inward, downward, and forward. These directions are imposed, therefore, upon any movable body impinging upon the pelvic floor and impelled by a force from above. The occiput can only travel in the directions named by a rotary mo\'ement of the head upon the spine. The pelvic canal is a spiral canal making half a turn in its course. The wall of each half of the 256 THE MECHANISM OE LABOR. pelvic canal might be represented by innumerable spiral lines crossing one another from behind forward and from before back- ward. But the lines running from behind forward are much bolder and more pronounced in their curve than those running from before backward ; hence, any body encountering the re- sistance of the pelvic wall or floor is impelled to take a direction by preference downward, forward, and inward ; if, however, there should be an insuperable obstacle to movement in these directions, Fig. 202. — The descent of the head in a vertex presentation, left occipito-anterlor position. the course of the more feebly marked lines is followed — namely, downward, inward, and backward. Anterior rotation of the presenting part is therefore the rule ; posterior rotation, even from an anterior position, is the exception, but is possible. Sixth Step. — Propulsion and extension of the head in the direction of least resistance under the pubic arch until it is deliv- ered, again following the direction of the lower pelvic floor, which is now upward, forward, and outward. Seventh Step. — Restitution. The rotary movement of the head, previously described, is not followed by the shoulders. As the former escapes from the vulva with the sagittal suture running MECHAXISM OF PKESEXTAriONS AND POSITIONS. 257 Fig. 203. — The rotation of the head being completed, its propulsion forward and outward begfins. Fig. 204. — The passage of the head over the perineum. anteroposteriorly, the neck is necessarily twisted. As soon as the head is released from the forces which compel its rotation, it imme- 17 258 THE MECHANISM OF LABOR. diately resumes its natural relationship with the shoulders, which lie with their long axis in the oblique diameter of the pelvis. Eighth Step. — External rotation. This movement of the head is explained by the movement of the shoulders within the birth- canal. Fig. 205. — Birth of the shoulders. Frozen section (Zweifel). Ninth step — Descent, rotation, and birth of shoulders. The anterior, or right, shoulder first strikes the resistance of the pelvic floor. In obedience to the universal law already enunciated, that whatever portion of the fetal body first encoun- ters this resistance is directed downward, forward, and inward, ABNORMALfTIKS IX MECHANISM. 259 the anterior shoulder is compelled to travel in these directions by a rotary movement of the shoulders on the spine. The anterior shoulder finally appears under the arch of the symphysis ; unable to move further forward, the posterior shoulder and arm are propelled over the floor of the pelvis and are born, their escape being followed by the birth of the anterior shoulder and arm. Tenth Step. — Delivery of remainder of the body by a move- ment so rapid that the eye can not well follow it, the birth-canal being so widely dilated that its walls offer no resistance to the escape of the small and compressible thorax, abdomen, and lower extremities. ABNORMALITIES IN MECHANISM AND THEIR MANAGEMENT. Abnormalities of Flexion at the Inlet. — Imperfect Vertical Flexion in a Flat Pelvis. — This action is conservative on the part of nature, and has the effect of bringing the small bitemporal diam- eter (8 cm. — 3j^ in.) in relation with the contracted conjugate. Associated with this abnormality are found anomalies of position and lateral flexion. The head lies transversely, the sagittal suture running in the transverse diameter of the pelvis, and the lateral flexion is exaggerated as the result of the increased obliquity of the pelvis, the increase of the conjugatosymphyseal angle and the posterior parietal bone catching on the promontory. The exaggerated lateral inclination of the head is accompanied by overlapping of the right (anterior) parietal bone. In much exaggerated lateral flexion the anterior parietal bone, or even the ear, may present. In exceptional cases (one-tenth) the pos- terior parietal bone may present in consequence of the anterior portion of the head catching upon the pubic spines. These anomalies of mechanism require no treatment, as a rule. They should not, indeed, be interfered with, as only by these means is the obstacle of a contracted pelvis to be obviated spontaneously. It is, however, occasionally necessary to interfere on account of exaggerated lateral inclination. A presentation of one ear may demand podalic version. A less exaggerated lateral inclination, especially in case the anterior parietal bone catches on the pubis, is ordinarily easily dealt with by using one blade of the forceps as a vectis to pry down the retarded half of the head. It is some- times possible to secure spontaneous engagement by exaggerating lateral inclination; for this purpose one blade of the forceps is used to pry still further down the lower half of the head. Anomalies of Direction. — In anterior displacements of the parturient uterus with a pendulous belly there is an abnormal backward direction of the presenting part, or a direcdon even 26o THE MECHANISM OF LABOR. upward and backward, and in lateral tilting of the uterus the presenting part is propelled against the opposite wall of the pelvic inlet and canal. All progress may cease as the head butts in vain against the unyielding bony walls. An abdominal binder cor- rects the anterior displacements. Placing a woman on the side toward which the fundus uteri is tilted and putting- under her flank a rolled blanket or pillow corrects the lateral displacement. Anomalies of Rota= tion. — There may be abnormal weakness in resistance or propulsion, resulting in incomplete rotation. Anomalies of rotation are more impor- tant in cases of posterior positions of the occiput. Anomalies in Vertical Flexion at the Pelvic Out= let. — Flexion may be in- complete if the head does not encounter normal re- sistance in the pelvic cav- ity or upon the pelvic floor, or it may be exag- gerated, in which case the vertex impinges on the center of the perineum and may perforate it. Both of these anomahes may be corrected by applying the forceps and lower- ing the handles for incomplete, raising them for overflexion, as the woman lies upon her back. Anomalies of Extension and Forward Propulsion. — Failure of extension and of a forward propulsion of the head under the pubic arch occurs as the result of weakness of the pelvic floor, in conse- quence of destruction of thelevatores ani muscles in a former labor. Paradoxical, therefore, as it may sound, a laceration of the pelvic floor in one labor may predispose to further lacerations in the next. Anomalies of Restitution. — This movement is more or less theoretical and is rarely perfectly performed. It fails altogether if the neck is a long time twisted or is tightly gripped by the ring of the vulvar orifice. Anomalies of external rotation are due to an imperfect or anomalous rotation of the shoulders. They are of frequent occurrence. Fig. 206. — l^endulous belly. ABNORMALITIKS AV MFA'JIANISM. 261 Anomalous Descent and Rotation of Shoulders. — Rarely the anterior shoulder is cau^^dit at the pelvic brim and does not descend. The posterior siioulder is then the first portion of this part of the fetal body to encounter the resistance of the pelvic floor. It is consequently turned forward, inward, and downward, the head externally followin<^ this movement and turning un- expectedly with the face to the left and the occiput to the rigJit, though it had descended the birth-canal and escaped from the parturient outlet in a left occipito-anterior position. Mechanism of a Right Occipito=anterior Position of a Vertex Presentation. — Diagnosis. — Palpation reveals the back to the right anteriorly ; the extremities to the left above ; the head below. The heart-sounds are heard near the median line, below the umbilicus. Digital examination shows the small fontanel toward the right acetabulum ; the sagittal suture in the left oblique diameter of the pelvis. The mechanism of this position does not differ from the mechanism of the L. O. A., except in that the occiput being directed toward the right acetabulum, the rotation of the head and face takes the opposite direction, — that is, the occiput rotates anteriorly, moving from right to left. The Mechanism of Posterior Positions of a Vertex Pres= entation, R. O. P. and L. O. P. — Posterior positions of the occiput are primary or acquired. They are primary if the head enters the inlet with the occiput posterior. They are acquired if the head rotates from an anterior position at the beginning of labor to a posterior position at its close. Acquired posterior positions of the occiput are very rare. Diagnosis. — Palpation reveals the fetal back in the maternal flank (to the right in R. O. P., to the left in L. O. P.). The ex- tremities are found on the opposite side in front, the head below. The heart-sounds are heard in the flank below a transverse line through the umbilicus. Digital examination shows the small fontanel toward the right or left sacro-iliac joint ; the sagittal suture in an oblique diameter of the pelvis. The mechanism is the same as the mechanism of anterior positions, including anterior rotation of the occiput under the arch of the symphysis. As a consequence, however, of the pro- longed rotation of the occiput, sweeping over about one-third of a circle, a peculiarity in the mechanism is the rotation of the shoulders at the superior strait through a third of a circle, — a movement not seen in anterior positions. And, further, in con- sequence of the greater distance which the occiput must traverse, the clinical manifestations of this position are dift'erent, there is greater pain, and labor is more prolonged. After rotation has occurred the shoulders descend and rotate on the pelvic floor, as 262 THE MECHANISM OF LABOR. in anterior positions. The remainder of the mechanism is identical with that of anterior positions. The cause of the forward rotation of the occiput is the same as it is in anterior positions, — namel}", whatever portion of the fetal body first strikes the resistance of the pelvic floor, whether it encounters this structure behind or in front of the median transverse Fig. 207. — Posterior positions of a vertex presentation. line, is directed forward, inivard, and downward, under the arch of the symphysis. As the occiput or the region around the smaller fontanel is the most dependent part of a vertex presentation, it must first encounter the resistance of the pelvic floor, and must, accordingly, be rotated in the directions named. Abnormalities in Mechanism. — Backward rotation of the occiput complicates labor by protracting its course, increasing the danger of fetal death, and subjecting the mother to increased risk of injury. The causes may be divided under three heads : Anomalies of Force. — Anterior rotation is the resultant of the forces of expulsion and resistance ; hence, any condition disturbing the normal relation of these forces interferes with the normal rotation. Thus, backward rotation occurs if there is dimin- ished expulsive power, increased resistance or decrease in resist- ance, as occurs in cases of very large pelves, relaxed pelvic floors, small and yielding heads. Anomalies 0] Flexion. — If flexion is imperfect, the anterior vault of the cranium (as in those rare cases of presentation of the large fontanel), the brow, or the chin first strikes the pelvic ■floor, and is, therefore, directed forward, and the occiput is thus directed backward. ABXORMALITIES IN MECHANISM. 263 Insuperable Obstacles to Forward Rotation. — In some cases if flexion is only fairly good, and the occiput does first strike the pel- vic floor, the occii)ut rotates backward, because the large diam- eter of the head (fronto-occipital, 1 1 ^ cm. — 4^8 i") '-^ t;ngaged, Fig. 208. — Posterior position of a vertex presentation : backward rotation ot" the occiput. and rotation from one oblique diameter of the pelvis to the other oblique is impossible, on account of the very tight fit ot the 264 THE MECHANISM OF LABOR. head in the pelvis. The occiput is also directed backward for the same reason, if the fetal head is oversized. The wedge of a prolapsed extremity may prevent forward rotation. In some deformities of the pelvis, particularly in kyphotic, generally contracted, and Naegele's pelves, the occiput rotates backward. If there is an abnormal projection of the lumbar and sacral vertebrae, interfering with rotation of the shoulder, the head may not be able to rotate anteriorly. Rarely there may be rotation of the head without a corresponding movement of the body, and the result is an exaggerated torsion of the neck. I have seen a child fatally injured in this manner. In the other cases under my observation and in most of the re- ported cases, however, the infant has escaped unharmed. The Mechanism of Labor when the Occiput Rotates into the Hollow of the Sacrum. — The occiput is propelled forward over the peri- neum by increased flexion until the face is finally born under the symphysis by partial extension. This mechanism subjects the cranium of the fetus to dangerous pressure, and greatly increases the risk of perineal rupture by subjecting the structures of the pelvic floor to an enormous strain. Abnormalities in the Mechanism Just Described. — There may be abnormal resistance to the descent of the occiput, resulting in a conversion of the presentation into one of the large fontanel, brow, or face, by an extension of the head. As causes of this anomaly, projecting ischiatic spines or a central tear of the perineum have been reported. Treatment of Posterior Positions of Vertex Presentations. — The medical attendant must bear in mind the causes of backward rotation, and should try to prevent its occurrence. For this pur- pose it is essential to secure perfect flexion of the head by placing the patient on that side toward which the fetal back is directed, and to obtain a normal action of the expulsive and resisting forces. If the pelvic floor is weakened, and does not supply sufficient resistance, it should be reinforced by two fingers in the vagina or by a single blade of the forceps, imitating the shape and direction of the pelvic floor, and used as a lever to pry the occiput forward. In a favorable case with a capacious pelvis and vagina and a comparatively small head it is possible to insert the whole hand in the vagina and, grasping the head with the outstretched fingers and thumb, to twist the occiput forward. It is occasionally possible to favor rotation of the head by an external manipulation of the shoulders. Pushing that shoulder forward or backward which is most easily accessible, the anterior rotation of the back is secured, followed perhaps by a corresponding rotation of the head. If the expulsive power is faulty, a hypo- dermic injection of pituitrin may be administered, or forceps may ABNORMALITIES IN MECHANISM. 265 be applied. I find that forceps used as a rotator is the easiest and surest means to secure forward rotation of the occiput on the pelvic floor. As traction is made the blades are gradually turned till they are three-quarters of the way upside down (Scanzoni). They are then removed and reinserted in the appropriate man- ner for a right occipito-anterior position. This is a better plan than the rotation of the head at or above the pelvic brim. As in the vast majority of cases rotation occurs spontaneously on the pelvic floor, the deep insertion of the hand and the rotation of the head at the brim is usually unnecessary. If backward rota- tion occurs in spite of the precautions to prevent it, extraordi- nary care should be exercised to protect the vaginal walls and the perineum from laceration, and to avoid a protracted second stage of labor. These results can usually be accomplished by a judicious use of the forceps. It might be an advantage, in rare cases, to convert the vertex into a face presentation by retarding progress of the occiput and assisting the extension of the head. Prognosis. — The outlook is not so favorable as it is in Fig. 209. — Face presentation : right mento-anterior and right mentoposterior positions. anterior positions of the occiput. The forceps is often required (once in seven cases). Laceration of the maternal soft parts is much more frequent. The mortality of the fetus is increased from less than 5 per cent, (the average mortality of normal vertex) to more than 9 per cent.^ Fortunately, backward rotation of the occiput in vertex pres- entations occurs in only about 1.50 per cent, of all labor cases. 1 In 321 cases in Munich the maternal mortality was 1.58 per cent.; the fetal, 17. 1 per cent. (Nagel, " Inaug. Diss.")- 266 THE MECHANISM OF LABOR. Face Presentations. — In this presentation the head is ex- tremely extended. The chin is the most dependent and prom- inent portion of the presenting part; hence the positions are named by its relations to the maternal structures, as left mento- anterior, right mento-anterior, etc. Every face presentation be- gins as a presentation of the brow, the extreme extension only occurring when the head is subjected to the action of the uterine pains and the resistance of the walls of the genital canal. . Frequency. — Face presentations occur about once in 250 labors, or in less than 0.5 per cent. Diagnosis. — The unusually prominent bulk of the cranial vault is felt in one hypogastric region ; a deep groove between the occiput and the child's back may often be made out. The fetal heart-sounds are loudest over the anterior surface of the fetus, or on that side of the maternal abdomen upon which the fetal extremities are felt. The diagnosis, however, must usually rest on a digital examination, which shows before the onset of labor a high situation of the presenting part ; a flattening of the anterior vaginal vault ; a sharp contrast between the smooth Fig. 210. — Face presentation. Delivery of tlie face. outline of the fetal forehead and the irregular contour of the face. As soon as the os is dilated, the characteristic features of the face may be felt. A face presentation has often been mis- taken for a presentation of the breech. The orbital ridges, the ABNORMALITIES IN MECHANISM. 267 eye-sockets, the chin, and, most distinctive of all, the hard gums williin the mouth, should enable any one to make the differential diagnosis. This presentation should be considered as a pathological one, for it entails great danger upon both mother and child. The causes of face presentations are divided under three heads, as follows : (i) Conditions preventing flexion, as tumors of the neck ; increased size of the thorax ; constriction of the cervix about the neck ; coiling of the cord around the neck ; tonic contraction of the neck muscles. (2) Conditions favoring extension, as mobility of the fetus ; oblique position of the child and uterus, especially when the abdominal surface of the child is directed downward and the pelvis is flat ; a dolichocephalic head, in which the posterior segment of the skull is longer than the anterior ; tumors upon the back, as spinal meningocele. Causes which promote exten- sion of the trunk and shoulders, and consequently of the head, as an overfilled bladder of the mother pressing upon the child's back. After the head has descended into the pelvic cavity, the face presentation may be due to the conversion of an occipito- posterior position into that of the face, as already described. (3) Anything that interferes with the normal engagement of the head in the pelvis, as overgrowth of the fetus, deformed pelvis, pelvic tumor. The Mechanism. — The successive steps of the mechanism of labor in a face presentation occur in the following order : Extension. The head presents at the superior strait imper- fectly extended, so that every case of face presentation may be said to begin as a brow presentation. There is also at first imperfect engagement of the presenting part, on account of the large diameters presented at the superior strait. Under the influence of the expulsive action of the uterus and the resistance of the pelvic walls, the brow, caught upon the pelvic brim, is held stationary, while the chin descends lower and lower by an extreme extension of the head. Molding, or an accommodation of the shape of the presenting part to the shape of pelvis, occurs to a moderate degree or not at all, because the face is a loose fit in the normal pelvis. The molding is confined to the back of the skull. Lateral inclination is a constant feature, so that one cheek is a little deeper in the pelvic canal than the other one. Descent of the presenting part follows the dilatation of the cervical canal, the descent of the chin being accomplished almost solely by the extension of the head, and not by a descent of the head as a whole. Anterior rotation of the chin occurs as soon as it encounte-rs 268 THE MECHANISM OF LABOR. Fig. 211. — Face presentation, chin directed laterally. Fig. 212. — Face presentation, chin posterior. ABNORMALITIES IN MECHANISM. 269 the resistance of the pelvic floor. Anterior rotation is followed by the engagement of the chin under the symphysis pubis. Then follows the delivery of the head by flexion and propul- sion, the mouth, nose, eyes, and forehead sweeping over the peri- neum and appearing successively at the posterior commissure. ' Restitution and external rotation follow the escape of the head from the same causes that impose these movements upon the head in a vertex presentation. The delivery of the body takes place as in a vertex presentation. Abnormalities in Mechanism. — The most common and most important anomaly of mechanism is a delay in the forward rotation of the chin under the symphysis. This delay is due to the difference between the lateral depth of the pelvis (8.8 cm., or 3 j^ in.) and the length of the fetal neck (3.8 cm., or I ^ in.), as a consequence of which the chin may not encounter the necessary resistance to turn it forward, and without this for- ward movement it is impossible for the head to escape through the vulvar orifice. Should the chin be directed posteriorly, where Fig. 213. — Face presentation, chin posterior; enormous elongation of neck. the depth of the pelvis is even greater (5 inches), the delay is absolute, and such cases can only be terminated by artificial assistance. If the condition is left to nature, there is an effort to force the upper portion of the thorax (9 cm.) into the pelvic cavity, along with the posterior half of the child's skull (9^ cm.), for only thus can the chin descend sufificiently to be turned anteriorly under the pubic arch, but it is obviously impos- sible for the bulk of these two diameters to pass through the pelvis. If the chin is posterior, it may rotate to a transverse position, and Fig., 214- — Face presentation. Fig. 215. — Face presentation. Fig. 216. — Face presentation. Specimen presented to tlie author by tlie late Dr. Formad, coroner's physician. The woman had died during futile attempts to extract tlie head with forceps. The chin was posterior, but had rotated to a lateral position, without corresponding movement of the shoulders. This brought the occi- put in relation with the right shoulder, so preventing any further extension of the head and adding thereby to the difficulties of the case. ABNORMALITIES IX MECIIAXISM. 271 then all progress may cease, because the occiput catches on a shoulder and so further extension of the head is prevented ( Figs. 214, 215, 21 6j. A most serious complication of face presenta- tion for the child is the displacement of the arms posteriorly on the child's back or neck.^ Prognosis. — The fetal mortality of face presentations is i 3 to 1 5 per cent. The maternal mortality rises from less than i per Fig. 217. — Schatz's method of cephalic version. cent, in all labors to 6 per cent, or over, if one takes into account cases of anterior and posterior positions and those which are mismanaged or neglected in general practice. Treatment. — If the chin is directed well forward of the transverse diameter of the pelvis, the labor may require no interference. In posterior positions of the chin, how- e\'er, the case is always diffi- cult, and demands active treatment. Before labor be- gins, or in its early stages, the face presentation may be con- v^erted into one of the vertex b\- the method of Schatz — external manipulation (see Fig. 217). By combined pres- sure upon the breech b}' an assistant, and upon the an- terior wall of the thorax and Fig. 218.— The conversion of a face into a the occiput, the fetal body ^'ertex presentation (Baudeiocque). is flexed and flexion of the the head is secured. If this plan fail, the methods of Baudelocque ^ Lindenthal, " Centralbl. f. Gyn.," No. 25, 1899. 2/2 THE MECHANISM OF LABOR. (internal and external manipulation) should be tried (see Figs. 218, 219, 220). The chin is pushed up by the internal hand, Avhile the occiput is pressed down by external pressure, or the Fig. 219. — The conversion of a face into a vertex presentation (Baudelocque) Fig. 220. — The conversion of a face into a vertex presentation fBaudelocque). occiput is pulled down by the internal hand, while external pressure flexes the child's body. This attempt also fail- ABATOR A/A LIT/ES IN MECHANISM. 2/3 ing, version should be tried if the face is not impacted in the pelvis. While labor is in progress, care should be exercised not to rupture the membranes, that the os may be more thor- oughly dilated and the liquor amnii shall not be drained away. If the presenting part is impacted in the pelvis, and if anterior rotation of the chin is delayed, it may be hastened by two fingers pressing on the posterior cheek and chin, supplying the kind and shape of resistance that should be afforded by the pelvic floor, which the chin can not reach ; or, if more convenient, pressure may be applied with a single blade of the forceps. If anterior rotation can not be effected in this manner, a straight forceps may be used to compel rotation by twisting the head, and, if the chin is directed anteriorly, traction may be made upon the for- ceps. If the chin is directed backward, traction should never be attempted. Finally, after failure of efforts to convert the face presentation into a presentation of the vertex, to perform version and to rotate the chin craniotomy is necessary, or pubiotomy may be considered if the child has not been injured and the heart sounds are good. At the last part of the second stage of labor care must be exercised in the final delivery of the head, not to push the neck too forcibly against the symphysis while trying to prevent lacera- tion of the perineum. Presentation of the Brow. — In this presentation the head remains throughout labor midway between complete extension and complete flexion. Therefore, the largest diameters of the head present at the superior strait. Of all presentations of the head this is the most unfavorable for both mother and child. The four positions of the presentation are named according to the direction of the chin. Frequency. — In Guy's Hospital there were 14 brow pres- entations among 24,582 births (i in 1756). In Bern it occurred 44 times in 19,725 labors^ (i in 448). The diagnosis is made by digital examination. It would be practically impossible to distinguish by abdominal palpation the difference between a face and a brow presentation. Mechanism. — The steps of the mechanism are the same as those of a face presentation. If the chin is directed posteriorly, progress is impossible, for the same reasons that make a poste- rior position of a face presentation an insuperable obstacle in labor. Prognosis. — The fetal mortality has been computed to be thirty per cent. ; the maternal, ten per cent. The latter, however, depends entirely upon the woman's treatment. Competent man- agement should insure the mother's safety. Treatment. — Before labor, or in its early stages, the brow ^ Moosmanii, " Inaug. Diss., Bern," 1903. 18 274 THE MECHANISM OF LABOR. should be converted into a vertex presentation. This can some- times be accompHshed by external pressure on the occiput to secure flexion, as in Schatz's method of treating a face pres- entation. If this plan fail, the hand may be inserted into the vagina and uterus to pull the occiput down. Should this attempt not succeed, it would be best to convert the brow into a face presentation if the chin is anterior. Failing in this, version should be tried if the waters are not drained off or if the presenting part is not fixed in the superior strait. If the chin is anterior and the presenting part is firmly fixed in the pelvis, the application of the forceps usually succeeds; if the chin is posterior, and if conversion into a vertex pres- entation, performance of version and rotation are all impos- sible, craniotomy is indicated or pubiotomy may be considered. In face and brow presentations with the chin posterior, it is a cardinal rule not to use forceps except as rotators; if traction is resorted to at all, even in mento-anterior positions, it should be employed with the greatest caution and gentleness. Very rarely Fig. 221. — Presentation of the greater fontanel. the head may be brought down far enough to meet with resist- ance, and thus be rotated anteriorly ; but unless the head yields to moderate traction, embryotomy is preferable. Presentation of the Greater Fontanel. — The head in this very rare presentation is set squarely upon the shoulders in a sort of military attitude of attention, turned upside down. In its clinical features this presentation resembles that of a brow. The descent of the head is difficult and tedious ; the anterior (frontal) portion rotates forward, but with great difficulty, and ABNOHAf.iriTlES IN MECHAN/SM. 275 serious injury to the maternal soft parts is almost unavoid- able. The stretching of the vaginal walls is so great that the perineum may be lacerated into the rectum before the head has fairly impinged upon the pelvic floor. Fig. 222. — Presentation of the greater fontanel ; descent of the head, without flexion, to the pelvic floor. Treatment. — The abnormal position of the head should be altered into a vertex presentation by pulling down the occiput 2^6 THE MECHANISM OF LABOR. with the fingers or by pushing up the brow while pressure is made upon the occiput from above through the abdominal walls. Presentation of the Breech. — By a presentation of the breech is meant a presentation of any part of the pelvic extrem- ity of the fetal ellipse. The term, therefore, includes a presenta- tion of the nates, the knees, or the feet. The classification of the positions is made by the direction of the sacrum, as a left sacro-anterior, right sacro-anterior, etc. Frequency. — Breech presentations occur in 1.3 per cent, to 3 per cent, of all cases, the first figures referring to mature births alone. Causes. — Abnormalities in the shape of the fetus or in that of the uterine cavity are the chief causes of a breech presenta- tion. Included under this head are reversal of the uterine ovoid (the lower uterine segment larger than the upper), fetal monstrosi- ties, twin pregnancy. Increased mobility of the fetus accounts for a small proportion of the cases, especially in premature births. Diagnosis. — By abdominal palpation the head is found above, the breech below. The heart-sounds are heard above the level of the umbilicus. Digital examination shows a high position of the presenting part ; an absence of the dome-like projection of the vaginal vault which is found in a presentation of the head ; the bag of waters projects through the os as a pouch-like protru- sion ; by pressure on the fundus with the external hand the characteristic features of the breech may be detected by the finger in the vagina — namely, the nates and the sulcus between them, the tip of the sacral bone and the coccyx, the thighs, the external genitalia, and the anus. Evacuation of meconium is the rule in a breech presentation ; so that the examining finger is found stained with it, after the membranes have ruptured. The Mechanism of Labor. — The following steps are to be- noted : Dilatation of the cervix and descent of the breech to the pelvic floor. This occurs very slowly, because the soft breech is an imperfect dilator of the cervix and an ineffectual irritator of reflex uterine contractions ; hence many hours may be required for the first stage of labor. Rotation forward of the anterior hip, which is the first to encounter the resistance of the pelvic floor. Owing, however, to the insufficient resistance which the soft breech encounters, its rotation is imperfect. There then follows the birth of the anterior hip, posterior hip, the thighs, and the trunk. The next and a very important step is the engagement and descent of the shoulders in an oblique diameter of the pelvis. The anterior shoulder, first encountering the resistance of the pelvic floor, is turned forward under the pubic arch. Then occurs the birth of the anterior followed by that of the posterior shoulder. The head by this time has ABNORMALITIES IN MECHANISM. 277 Fig. 223. — 'Breech presentation, right sacroposterior position. Fig. 224. — Breech presentation, left sacro-anterior position. 2/8 THE MECHANISM OF LABOR. Fig. 225. — Breech presentations, left sacro-anterior position. Fig. 226. — Breech presentations, anterior and posterior positions. ABNOKMALI'lIES IN MECHANISM. 2/9 Fig. 227. — Same as figure 224, showing descent of breech through the pelvic canal Fig. 228. — Same as iiguie 227, showing engagement of the siiouldurs in tlie pelvis. THE MECHANISM OE LABOR. Fig. 229. — Same as figure 228, showing escape of extremities. Fig. 230. — Breech presentation — rotation of the hips. ABXORMAI.irrKS IN MECHANISM. 281 entered the pelvis with its long diameters in the oblique diameter of the pelvis, opposite to that in which the shoulders engaged. The head descends the birth-canal to the pelvic floor in a position of extension. The occiput, which is always the part first to strike the pelvic floor, is rotated forward under the Fig. 231. — Breech presentation. Waldeyer's section of an X-para at full term, who died from hemorrhage some hours after both her legs had been cut off by a loco- motive : a. First lumbar vertebra; /', placenta ; " Zur Kasuistik des Prolapsus Placentae bei normalem Sitz derselben," zdt" demonstrated the fact that the cancer has its origin in the s\Ticytial cells of the chorion villi. Even in the metastases the sync}' tium of the placenta is everywhere repro- duced. From recent sections of the original tumor studied by Fig. 262. — Syncytial cancer: Masses of fibrin. A, containing islands of proliferated syncytial cells. Sanger, it appears that it really was a sarcoma. It is now ad- mitted that both sarcoma and carcinoma may develop at the placental site, the former from the decidual cells (deciduosar- coma, deciduoma malignum), the latter from the syncytium (chorio-epitheKoma, carcinoma syncytiale, syncytial cancer, s>Ticy tioma maHgnum) . Cancer of the placental site is vastly more common than sarcoma. Gaylord has collected 55 reported cases; Veit,^ 89; Teacher,^ 189; and Briquel,^ 254. Both of these 1 " Tr. of the Section on Gyn.," College of Physicians of Philadelphia, 1898- ^ " Jour, of Obstet. and G\ti. of the Brit. Empire," August, 1903. ' " Tumeurs du Placenta et Tumeurs Placentaires," p. 260, Paris, 1903. THE PLACENTA. 319 malignant growths have a rapid course, ending fatally in from three to six months. Metastases are numerous and occur early. A metastatic growth of syncytial cancer is possible with- out a trace of the original tumor. Schmorl^ reports a syncytial cancer of the vagina with numerous metastases, the uterus being Fig. 263. — Chorio-epithelioma of the vagina without involvement of the rest of the genital tract (Hiibl). healthy. It is supposed that the original growth is removed with the exfoliation of the decidua serotina, or that there is metastasis or deportation of chorion villi, followed by malignant degeneration of their epithelium." Stoeckel, Runge and Jaffe, and Pick^ have demonstrated an invariable association with chorio-epithelioma, in all the cases 1 " Centralbl. f. Gyn.," 1896. - Zagorjanski-Kissel has collected 17 cases; ]oc. cit. ' " Centralbl. f. Gyn.," No. 34, 1Q03; see also Krebs, " Centralbl. f. Gyn.," Oct. 31, 1903, No. 44; " Arch. f. Gyn.," Bd. l.xxi, H. 3. 320 PATHOLOGY. Fig. 264. — A chorio-epithelioma, from which the exuberant growth had been completeh- removed by a curetage the daj' before the panhysterectomy. There were numerous lutein cysts in the ovar>\ Fig. 265. — Neoplasm of the endometrium, opposite the placental site, diagnos- ticated as chorio-epithelioma. but consisting of leukocyte and small round-cell infiltration, possibly a barrier against syncytial invasion of the myometrium. Plate 8. Chorio-epithelioma : Removed by pan-hysterectomy during puerperal conva- lescence from a premature delivery. Patient without recurrence a year after the operation. THE PLACENTA. 321 they examined, of an over-production of lutein and frequently of multiple corpus luteum cysts and an infiltration of the ovarian stroma by lutein cells. The association of hydatidiform mole and chorio-epithelioma is intimate. Bri(iuel found that in 45.5 per cent, of 217 cases the degeneration of the villi had preceded the cancer. Symptoms and treatment: Profuse uterine bleedings with a foul-smelling discharge weeks, months, and even years ^ after an abortion or delivery at term should arouse suspicion of a malignant growth. If friable neoplastic masses of a dark purple color are removed, and recur with the original symptoms in a few weeks, the suspicion is strengthened. A microscopic examination of the material removed may make the diagnosis certain, but the penetration of the myo- metrium by syncytial cells, always observed in pregnancy and exagger- ated in cases of retained fragments of placenta or other diseases of the en- dometrium, must be re- membered. ^Metastases are often observed in the vagina. The uterus is large and soft, the os pat- ulous. Chorio - epithe - Homa has been demon- strated in dermoids of both the ovary and testi- cle, in a young virgin and in the brain of a man, derived from a tropho- blast developed in the course of a dermoid growth. ^ Schmorl and Hiibl report metastatic growths in the vagina, the uterus being healthy. A striking peculiarity of chorio-epithelioma. differentiating it from all other malignant growths, is the occasional disappear- ance of metastases after the removal of the original tumor. This remarkable fact is best explained by the theory that the organism produces an antibody (syncytiolysin) to antagonize the hyperplasia of the syncytium; that this antibody may be over- whelmed by the exuberant growth of the syncytium, but that ' Veit mentions cases occurring two, three and one-half, and three and three- fourths years after delivery. " Handbuch der Gyniik.," iii, 2, p. 585. - Zabinsky, " Zentralbl. f. Gyn.," No. 18, 1Q04. Fig. 266. — Metastasis of syncytial cancer in liver, showing cells from Langhans' layer and true syncytial cells. 322 PATHOLOGY. if the original and largest mass of proliferating s}mcytium is removed, the normal balance between syncytiolysin and syn- cytium is restored, resulting eventuall}' in the destruction of the metastatic growths.^ The treatment is h^'sterectomy. Veit has collected 29 suc- cessful operations out of 89 cases. Teacher's statistics give 63.6 per cent, recoveries in 99 cases.- Other tumors of the placenta are myxomata fibrosa, localized h}-per trophies, angiomata,^ and organized thromboses. Pitha reports three and has collected 60 cases of placental tumor from the hterature.^ Placental pol^-ps developing at the placental site after labor are due to a sort of stalactitic deposit of blood- fibrin on a mass of decidua or a fragment of placenta. Localized tumors in the placenta are rare. Leopold in more than 7000 placentae found only one.* THE CORD. Anomalies of the Cord. — The cord may be abnormally long, measuring rarety as much as 70 inches (178 cm.),*' or it may be naturally or artificially too short; and it may be absent altogether. The cord is artificially shortened in adhesive in- flammations of the amnion, which result in the agglutination of the coils or in their attachment to the fetal skin or amnion. Exaggerated Torsion. — The cord ma}^ be so t\visted upon its longitudinal axis that the vessels are nearly or quite obliterated, and the cord itself, especially near the umbilicus, is reduced to a ver}' small diameter. Most modern observers regard it as a postmortem occurrence, resulting from the great mobility wdthin the uterine cavity of a fetus that has died from the fifth to the seventh month of pregnancy. The number of twists ^ See Hegar's " Beitrage," vol. viii. - Ewing f" Svirg., G},ti., and Obstet.." igio, p. 366), in an able review of the sub- ject, attempts to differentiate by a histological examination of material removed from the uterus and by cHnical evidence, between the various grades of pathologi- cal hyperplasia of the sj-ncytium from simple infiltration of the myometrium to true cancerous proliferation, and to establish rules of practice as to non-interven- tion, curetage, and hj^sterectomj'. The clinician must be guided by the advice of a competent pathologist who has made a special study of the subject. • 'Albert, " Archiv f. G>ti.," Bd. Ivi, H. i. p. 144; C. Finzi, " Archivio di Ostet. e Gin.," No. 9, 1904. " Gjmecologia," No. 6, 1908. " Monatschr. f. Geb. u. G}Ti.," H. 3. Bd. xxix. ^ " Wien. klin. Rundschau," Nos. 28-32, 1907. ^ V. Mars. " Monatschr. f. Geburtsh. u. Gjti.," Bd. iv, H. 3, p. 229. ® Chantreuil, " Disposition de Cordon." Paris, 1875. I have seen one cord 48 and another 56 inches long. The latter was coiled twice around the neck and once around the trunk. THE CORD. 323 may be surprisingly great. In Schauta's' case it reached 380. Torsion occurs more frequently in male than in female children. Edema and cystic degeneration of the cord may often be found with exaggerated torsion. Stenosis of the Umbilical Vessels. — The umbilical vein may be narrowed by new connective tissue in the intima.^ The result is edema of the placenta or a dilatation — to 15 mm. (0.6 in.) — of the undiseased portion of the vein, ending occasionally in its Fig. 267. — Torsion of the cord. Fig. 268. — Distention of the umbilical vessels. Varices of the cord. rupture (Leopold) and the extravasation of blood into the sub- stance of the cord. This disease of the vein is usually attributed to syphilis. The umbilical arteries are occasionally obstructed by atheroma and thrombosis. The umbihcal cord of a syphilitic infant sometimes shows an enormous development of connective tissue throughout the wall of the arteries, so that it is impossible to distinguish the different coats; the lumen of the vessels is often obliter- ated, not only by the thickened walls, but by the infiltration ^ Leopold, " Archiv. f Gyn.," Bd. xvii, S. 20; see also Winckel. " Berichte u. Studien." ^ " Neue Zeitschr. f. Geb.," Bd. iv, S. 62; and Leopold, \oc. cit. 324 PATHOLOGY. of the whole substance of the cord with granulation cells. Pinard^ has seen the vessels of the cord obstructed by an over- development of the valves that are found in both arteries and veins. Varices and Rupture of the Vessels in the Cord Figure loi represents a varicose condition of the vein of the cord which predisposes to rupture. Five cases of this accident have been collected by Albert.^ True Knots of the Umbilical Cord. — Rarely the fetus slips through a loop of the cord, and, the two ends of the loop being then put upon the stretch, a true knot is tied. This process may be repeated either during pregnancy or while the child is descend- Fig. 269. — A false and a true knot in the cord (author's cases). ing in labor, and thus a double knot is tied. In the case of twins in a common amniotic cavity the most complicated knotting of the two cords may occur. The effect upon the circulation of the fetus is usually not serious, but the knots can be drawn so tight as to completely shut off the placental blood-supply, es- pecially in the case of unioval twins. The gelatin of the cord is often displaced at the seat of the knot, so that when the latter is untied its situation is marked by deep depressions. '' False knots " of the cord are localized collections of the mucous tissue in it. A loop of the cord may adhere by its proximal edges, giving rise to a lateral projection such as is shown in figure 269, in which there is a loop of the three blood-vessels. 1 " Diet, encycloped. des Sc. med., art." " Fetus." 2" Archiv f. Gyn.," Bd. Ivi, H. i, p. 136. THE CORD. 325 Coiling of the Cord Around the Fetus.— Loops of the cord may be wound a?30ut different portions of the fetal body. The neck may be encircled once or twice, more rarely from four to nine times (Braun), or loops may be thrown around the limbs. Marginal and Velamentous Insertion of the Cord. — The cord is usually inserted somewhere near the center of the pla- centa. As the insertion approaches the edge of that organ, the condition receives the name of marginal insertion, or battledore placenta. If the cord enters the membranes at some distance from the placenta, to and from which the vessels, unprotected and more or less separated from one another, pursue their course Fig. >7o. — Entanglement of cords in twins (Winckel). Fig. 271. — Velamentous insertion of cord. between the amnion and chorion, a condition known as insertio velamentosa exists. The explanation of such an occurrence is obvious: The allantois is conveyed at first indifferently to any portion of the periphery of the ovum, but as the placenta begins to be differentiated the embr^'o, by a movement of rota- tion, enables the umbilical vessels to pursue a straight course toward their insertion in the placenta. If the rotation of the fetus is interfered with, or if the newly formed umbilical cord contracts adhesions wdth the amnion or chorion that prevent the vessels following or compl}-ing wdth the rotation of the embryo, they enter the membranes opposite the abdominal face of the embryo, or at that point where adhesions arrested their move- 326 PATHOLOGY. ments. The blood-vessels thus exposed are liable to laceration during labor, usually with a fatal result to the fetus unless delivery is quickly effected. Umbilical Hernia. — Occasionally children are born with some portion of the abdominal contents protruding into the umbilical cord and covered by nothing but the distended and attenuated amnion. There has been an arrest of development in the abdominal walls, preventing the completion of the arching- over process by which the abdominal cavity is closed. Cysts of the Cord. — Cystic formations in the cord are due either to an abnormally fluid condition of the mucous tissue or else to a collection of serum in the pedicle of the allantois, which in horses, swine, and cows is found persisting as a vesicle up to the time of birth. Fig. 272. — Tumor of the cord: c, c, c, ( or; a, a, arteries; v, vein (Budin). Calcareous degeneration is rare. The lime may be deposited in the walls of blood-vessels or in the substance of the cord. Tumors of the Cord may be cysts, localized hypertrophies, or accumulations of the mucous tissue, hematomata, a small fetus amorphus, as in Budin's case^ (Fig. 272), and telangiectatic myxosarcomata. The last named should be excised immediately after birth, with the umbihcal ring.^ 1 " Femmes en Couches et Nouveau Nes," Paris, 1897, p. 181. 2 V. Winckel, " Centralbl. f. Gyn.," 1894, p. 397, reported one case and col- lected four others. THE MEMBKANAi DECIDU.-E. 327 THE MEMBRANAE DEQDUAE. Diseases of the Deciduae, -The decidual mucous mem- brane of the pregnant uterus may be the seat of many of the diseases that attack the endometrium of the non-gravid uterus. They often manifest themselves, however, in exaggerated forms, owing to the enormous hypertrophy of the mucous mem- brane. Moreover, in consequence of its relation to the fetus, a disease of the decidual endometrium has more serious conse- quences than a similar affection of the non-gravid uterus. Diffuse Hyperplastic Inflammation of the Decidual Endometrium. — The cause is usually a preexisting endometritis. But the death of the embryo or some disease of the ovum may prove irri- tating enough to incite the mucous membrane of the uterus, pre- viously healthy, to overgrowth. As the constituent parts of the mucous membrane are more or less affected, the manifestations of the disease vary. Diffuse iiyperplasia of the decidual endometrium is an exag- geration of the hyperplasia that occurs normally in the early months of pregnancy. Abortion usually results, either on ac- count of the hemorrhages into the mucous membrane, separating it from the uterine wall, or owing to the death of the embryo, from which all nutrition has been diverted to supply the rapidly growing decidua. In such cases the embryo may be absorbed and the deciduae afterward cast off as an empty sac with greatly thickened walls, forming one variety of the so-called fleshy moles. Or, the embryo may be destroyed in consequence of the hemorrhages into the h\pertrophied decidua, the blood bursting its way through all the membranes and occupying the cavity of the ovum, as well as surrounding it externally. If the hypertrophy of the decidua is gradual, the fetus may not be expelled before it becomes viable, or even until the normal end of pregnancy.^ The structure of the hypertrophied decidua is usually only an exaggeration of what may be seen in the decidua of early pregnancy. There is a great multiplication of the decidual cells, some of which are elongated and seem to be transforming themselves into connective tissue; the blood-sinuses are much en- larged in the deeper portions of the membrane, and there is usually an abundance of connective tissue. Polypoid Endometritis. — The decidua may display upon the uterine surface projections or e.xcrescences where the hyper- plastic process seems to have been exaggerated over a limited 1 1 have seen a living fetus, delivered at the sixth month, from a woman who three days afterward expelled a piece of decidua i cm. thick and measuring 6 cm. in diameter. 328 PATHOLOGY. area. Such cases have been described by Hofe^ and Schroeder.^ To the most advanced type of this polypoid condition of the Fig. 273. — Polypoid endometritis : a. Fine apertures of the glands ; b,b, larger apertures of the glands; c,c, protuberances or polypi. Tuberous projec- tions. Uterine wall. Decidua. Fig. 274. — Tuberous subchorial hematomata of the decidua (Walther). uterine mucous membrane Virchow ^ first gave the name of endo- metritis deciduahs polyposa or tuberosa. ' D. I. Marburg, 1869: " Ueber Hyperplasie der Decidua." - Op. cil., p. 402. ^ " Die Krankh. Geschw.," Bd. ii, S. 478. THE MEMBRANAi DECIDU^. 329 Villus-like projections stand out from the mucous membrane to the height of half an inch or more, smooth of surface and very vascular. In the intervals between the projections are the openings of the uterine glands, which are not found on the polypoid elevations. The whole membrane is greatly thick- ened, owing to the hypertrophy of the connective-tissue elements and to an increase in the decidual cells, which contain nuclei of enormous size. The connective tissue forms fibrous bands constricting the openings of the glands, as well as the blood- vessels in the diseased membrane ; and \'et the whole decidua Fig. 275. — Tuberous subchorial hematomata of the decidua (author's case). is exceedingly vascular. In Virchow's case there was a s}-ph- ilitic history, and, therefore, he ascribes the disease to syphilis; in other instances no cause whatever could be discovered, but often this disease, as well as other affections of the decidua, depends upon a preexisting chronic endometritis. It is a dis- ease of young ova, and frequently the chorion villa implanted in the diseased mucous membrane are in a condition of mucous degeneration. In all the cases hitherto described the o\-um 330 PATHOLOGY. has been expelled between the second and the fourth months of pregnancy (Schroeder). Polypoid endometritis is closely simulated by blood extravasations between the decidua and the chorion, as shown in figures 274 and 275. Catarrhal Endometritis. — A chronic inflammation of the de- cidual endometrium may affect chiefly the glands. There is a hypersecretion of a thin, watery mucus, which collects between the chorion and deciduce, and is suddenly expelled, after a rupture of the ovular decidua, in the later months of pregnancy. This occurrence gives rise to sudden gushes of fluid from the vagina, which may reach a pint in quantity. Afterward the fluid may dribble away for a considerable length of time without affecting seriously the course of pregnancy, or else, accumulating once more in considerable quantities, it may again be suddenly expelled. Two or three repetitions of the accumulation of fluid and its sudden discharge usually excite the uterus to muscular action, and termi- nate pregnancy. This affection occurs more frequently in mul- tiparge than in primiparae, and seems to depend in some cases upon hydremia. The mucous discharge is one of the forms of hydror- rhoea gravidarum. Cystic Endometritis. — If there is a hypersecretion of the uterine glands, and the escape of the fluid contained in the glandular spaces is prevented, a condition results, found only in very young ova, known as cystic endometritis. It is not improbable that this condition might be found quite constantly in the earlier stages of the chronic hyperplastic decidual endo- metritis already described, the glands being destroyed and oblit- erated as the disease advances. A section of mucous membrane affected with cystic disease presents a cavernous appearance, due to numerous small cysts. Their connection with the uterine glands may be demonstrated by the relation between the cysts and the ducts of the glands.^ About the cysts the decidua is hypertrophied, presenting the overdevelopment of connective tissue, increase of decidual cells, and embryonal tissue already described.^ The prognosis of all these chronic affections of the decidual en- dometrium is unfavorable for the fetus and for the mother. There is danger to the fetus from hemorrhages, separating the mem- branes, or bursting through all the fetal envelopes, and over- whelming the embryo with blood; there may be diversion of nutriment from the embryo to the overgrown decidua, and the irritation of the chronic inflammation or of a hemorrhage may 1 Leopold, " Gesselsch. f. Geburtsh.," Leipsic, Feb., 1878. ^ See Breus, " Ueber cystose Degeneration der Decidua Vera," " Archiv f, Gyn.," Bd. xix, S. 483. THE MKMBRAiWK DECIDU.-K. 33 1 excite contractions of the uterus, which expel the ovum. The woman is liable to hemorrhage and infection. The treatment of this condition during pregnancy is impos- sible. Its prevention may be attempted, however, by a curet- age before impregnation occurs again. Acute Inflammation of the Deciduae. — Acute inflammation of the decidual membranes may develop in the course of cholera and other infectious diseases, especially the exanthemata, in consequence of unsuccessful attempts to induce abortion, or as a result of traumatism. Hemorrhagic decidual endometritis is a condition found in two cases of cholera,^ and, no doubt, present in other grave infectious diseases. The decidua is thickened, of a dark, purplish hue, and extravasated with blood. Exanthematous Decidual Endometritis. — Klotz,- in eleven cases of measles in pregnancy, noted in nine a premature ex- pulsion of the fetus, the time at which the expulsive efforts began coinciding with the appearance of the rash. The uterine action is excited by an exanthema upon the uterine mucous membrane, irritating in its action, just as the photophobia, the coryza, the bronchitis, and the vesical tenesmus of measles indicate an irritated condition of the mucous membranes of the eyes, nose, lungs, and bladder. Salus^ in thirteen cases saw the same tendency to miscarriage. It is probable that this con- dition of the uterine mucous membrane accounts for the abor- tions or premature labors that often occur when pregnant women are attacked by any of the eruptive fevers. Purulent and Microbic Decidual Endometritis. — Donat ^ has de- scribed a case of purulent endometritis in pregnancy. A woman expelled at term a placenta about the periphery of which could be seen masses of decidua infiltrated with pus. The amnion and chorion were both thickened and opaque, and between them was an accumulation of purulent fluid. It was suspected that the suppuration of the decidua was the result of unsuc- cessful attempts on the part of the woman to bring on a miscarriage. Tuberculous endometritis ^ in pregnant women has been re- ported by several observers. In three instances pregnancy went to term in spite of the caseous degeneration of the mucosa. In one case rupture of the uterus occurred at the third month. ^ Slavjansky, " Archiv f. Gyn.." Bd. iv, S. 285. 2 " Archiv f. Gyn.," Bd. xxix, S. 448. ' " Prager med. Wochenschr.," 1899, No. 7. '^ " Archiv f. Gyn.," Bd. xxiv. ^ Vineberg, " American Gynecology," October, 1903. 332 PATHOLOGY. Atrophy of the Decidual. — The deciduae, instead of undergoing inflammatory and hyperplastic changes, may rarely atrophy. This process has been described by Hegar/ Matthews Dun- can,2 Spiegelberg,^ and Priestley.^ The uterine, ovular, or placental deciduae may be singly or conjointly the seat of atrophy, resulting in the attachment of the ovum by a slender Fig. 276. — Atrophy of the decidua, external surface of the vera (Duncan). pedicle to the uterine wall, or in its rupture and the discharge of its contents from the uterus. As a result of the stretching of the pedicle in cases of placental atrophy the ovum may be pushed downward by the uterine contractions until it rests in great part within the cervical canal. This condition consti- tutes the cervical pregnancy of Rokitansky. THE DISEASES OF THE FETUS. Fetal mortality exceeds that of any other period of life. For every four or five labors there is one abortion, and if to this number is added still-births, the proportion of fetal deaths to living births is large. In addition to the diseases having a fatal termination there are others running their course wholly or in part during intra-uterine Hfe and ending in recovery; so that the list of fetal diseases is extensive. The present chapter treats of the diseases of the fetus, of weakness dependent upon defects in the paternal elements entering into the composition of the embryo, and of maternal 1 " Monatsh. f. Geburtsh. u. Fr.," Bd. xxi; Supplem., pp. 11, 19, 1863. 2 " Researches in Obstetrics," p. 295, 1868. ^ " Lehrbuch," p. 328. " Op. cit. THE DISEASES OF THE FETUS. 333 conditions which are incompatible with the healthy develop- ment or with the continued existence of the product of concep- tion. Fetal Syphilis. — According to Ruge/ 83 per cent, of repeated premature and still-births have their cause in syphilis of one or both of the parents. Of 657 pregnancies in syphilitic women collected by Charpentier,^ 35 per cent, ended in abortion, and of the children that went to term a large number were still-born. Of 100 conceptions in syphilitic women, only seven children were ahve a year later.'' The syphilitic infection of the fetus is due to syphilis in the mother or father before conception or to syphilitic infection of the mother during pregnancy. Syphilis may be transmitted from a syphihtic father direct to the embryo without infection of the mother.^ As the fetus grows, the mother becomes mildly infected in her turn directly from the fetus through the uteroplacental circulation.^ The longer the time since the acquisition of the disease by either parent, the less likehhood there is of syphihs in the embryo; but the limit of safety has not yet been discovered. According to Fournier,'' four years is the maximum of time that syphilis can remain latent, but Lomer^ reports the birth of a syphilitic infant ten years after the first infection of the father, and Kassowitz^ records a latent syphilis of twelve years' duration. These statements must be modified since the use of salvarsan has become general. I have seen a woman delivered of a per- fectly healthy child one year after the appearance of a secondary syphilitic eruption in the father, with a positive Wassermann reaction. He received two doses of " 606," followed by mercury and potassium iodid. Three months later he procreated a healthy child. ^ See Lomer, " Zeitschr. f. Geburtsh.," Bd. x, p. 189. 2 " Traite pratique des Accouchements." ' Pileur, " Bull, de la Soc. d'Obst. et de Gyn.," Paris, Dec. 13, 1888. ■• From the fact that the Wassermann reaction is positive in such women and that spermatozoa are not spirochaete carriers it has been declared that the mother of a syphilitic fetus is always herself diseased, that a fetus will not have s>philis unless the mother is syphilitic ; but a prolonged clinical observation of such women without ever seeing in them the secondary or tertiary lesions of syphilis induce me to leave this statement of former editions unaltered. ^ See Tamier et Budin, op. cit.; Priestley, loc. cit.; J. Hutchinson, "British Med. Jour.," Feb., 1886, p. 329; Harvey, " Fetus in Utero," 1886; G. S. West, ■"Amer. Jour. Obstet.," 1885, p. 182. ^ " Syphilis et Marriage." ' " Zeitschr. f. Geburtsh.," Bd. x, 94. 8 Strieker's " Jahrb.," 1875, p. 476. 334 PATHOLOGY. Vajda^ and Hutchinson- describe cases in which preg- nant women were infected near term and gave birth to syph- ilitic children. Neumann^ has pubHshed observations of 20 women who were infected with syphilis during pregnancy ; 5 of this number gave birth to syphilitic children, and of these 5 2 were infected at the fourth and i each at the third, seventh, and eighth months. Hirigoyen * has reported 1 2 cases in which the mother contracted syphilis during the first four months of pregnancy ; all the children were still-born ; in cases of infection from the fourth to the sixth month, about half the children were still-born ; and in 7 cases of infection during the last three months of pregnancy there were 4 still -births. ^ The manifestations of fetal syphilis are bullous eruptions of the skin, condylomata, inflammations of the mucous and serous membranes, gummatous and miliary deposits, morbid growth of connective tissue in the brain, lungs, pancreas, kidneys, liver, spleen, the muscular system, the coats of the intestines and walls of the blood-vessels, and a characteristic osteitis and osteo- chondritis. The prognosis is unfavorable. If the fetus is not destroyed before it is viable, it is often retarded in development, feeble, and diseased. There is an enlarged abdomen, due to ascites, to enlarged liver or spleen ; nodes in the lungs or in the bronchial glands ; hydrocephalus ; separation of the epiphyses of the long bones from the diaphyses ; extensive pemphigoid eruptions on the skin, or, possibly, the fetus is deformed or monstrous in appearance. There are cases, however, in which the course of intra-uterine life does not seem to be influenced in the slightest degree by syphilis. The children are born apparently healthy and well developed, but exhibit unmistakable signs of their hereditary taint within the first few weeks after birth. Diagnosis of Fetal Syphilis. — The infection of the fetus may be inferred with reasonable certainty if either parent had acquired syphilis at a date not too remote from the procreation, or if a Wassermann reaction is positive in either parent. If a woman acquires a chancre during pregnancy, the fetus will probably be infected. Often the signs of fetal syphihs can be looked for only in ^ " Centralbl. f. Gyn.," 1880, p. 360. 2 " British Med. Jour.," 1886, i, 239. ' " Wien. med. Presse," 29, 30, 1885. * Abstract in " N. Y. Med. Record," April 12, 1887. 5 The author has seen a woman impregnated by a healthy man, but infected with syphilis in the third month of pregnane)', give birth to a syphilitic child. PLATE 9. - Head of femur removed from a fetus expelled, dead and macerated, at the seventh month. The liver weighed one-tenth of the body-vpeight ; the spleen, one- forty-eighth. The mother was infected with syphilis one year before. THE DISEASES OE THE EETUS. 335 the fetus itself after its expulsion from the uterus, and much may depend upon a correct diagnosis. The parents' history, from ignorance or design, may be entirely negative. They may refuse a blood examination or it may be impracticable. The child may be born with no distinctive mark upon its body. If it is living, the coryza and characteristic eruptions during the first few weeks usually point clearly to the hereditary taint. If it has pemphigus the spirocha?ta pallida may be found in the fluid from the blebs. If the child is dead, the diagnosis can easily be made. To a trained pathologist, the detection of syphiHs is easy. The bullous eruption on the skin, the condylomata and inflam- mations of the mucous membranes and serous membranes, the gummatous deposits and the morbid growth of connective tissue in the brain, lungs, pancreas, kidney, liver, spleen, in the coats of the intestines and walls of the blood-vessels, and a charac- teristic osteochondritis, demonstrate the character of the dis- ease. The spirochaeta pallida may be found in the fetal tissues, the umbilical cord, and the placenta (p. 315). The fetal blood may give the Wassermann reaction.^ The general practitioner often observes cases of repeated fetal death the cause of which is obscure, although suspicion naturally rests upon syphilis. Thanks to the investigations of Wegner,'- Ruge,^ Lomer,^ and others, syphilis can be recognized in the fetus by a few signs easily found, perfectly reliable, and requiring for their detec- tion no special training in the methods of pathological research. Wegner was the lirst to call attention to a curious condition of the dividing line between diaphysis and epiphysis of the long bones of a syphilitic infant. Instead of a sharp, regular, delicate line, formed by the immediate apposition of cartilage to bone, as in a healthy fetus, there is seen in syphilis a broad jagged yellow line^ (Plate 9). A microscopic study of this portion of the bone show^s that there has been a premature at- tempt at ossification, which has ended in necrosis, fatty degenera- tion, and suppuration. In the Frauenkhnik, at Berlin,'' and in my ser^^ce in the 1 " Wassermann Reaction in Congenital Syphilis," O. Thomsen and H. Boas, " Berlin, klin. Wochenschr.," No. 12, 1909. ^ Virchow's " Archiv," Bd. i, S. 305. 3 " Zeit. f. Geburtsh.," Bd. i. '■ Ihid.. Bd. X. ^ To discover Wegner's sign, an incision should be made over the trochanter, as though for excision of the head of the femur. The end of the thigh bone is turned out after cutting its ligaments, and a median section of the epiphysis and diaphysis of the bone is made with a strong cartilage-knife. ^ Lomer, loc. cil. 33^ PATHOLOGY. PMladelphia Hospital, this sign was investigated, and found reliable.^ According to Ruge- the Uver of a healthy infant should constitute about -^ part of the body-weight. In syphilitic infants this proportion is much exceeded, the liver reaching, in extreme cases, \ of the total body-weight. The spleen, too, usually -gi-g- of the body -weight, is much enlarged in syphiUs. Upon these three signs, — the yellow line between epiphysis and diaphysis, the increased weight of liver, and increased weight of spleen, — all easily discovered, the diagnosis of syphilis may rest with reasonable certaint}-. Valuable indications of syphilis are also found in the lungs ^ : an interstitial overgro\\th ; the pres- ence of gummata ; a peculiar catarrhal inflammation, resulting in what is called white pneumonia. The interstitial overgrowth is the most common. The newly formed connective tissue about the blood-vessels and alveoli gi\-es the lungs greater weight and more solidit}- than usual ; their color is often dark red ; if the infant has breathed for a short time after birth, the lungs wull not float buo}-anth-, although they do not usually sink outright. The alveoli are much encroached upon by the interstitial thickening; lung-expansion and adequate respiration are impossible. The catarrhal pneumonia due to syphilis is rare. The lungs are large and heavy; they completely fill the thoracic cavity and bear upon their external surface the imprint of the ribs ; in color they are yellowish-white, from fatt}^ degeneration. The alveoli are filled with desquamated epithelial cells. This condition is incompatible with extrauterine life : the infant never breathes. The treatment of fetal S}^hihs during pregnancy is the intra- venous administration of salvarsan to the mother, followed by mercurial inunctions and iodide of potassium by the mouth. If a pregnant woman has had SA-pbilis. if she is impregnated by a 5}philitic man. although healthy herself, or if she acquires a chancre subsequent to conception, she should receive mercury and iodid of potassium. I prefer mercurial ointment inunctions daily, and about 15 gr. fi gm.j of iodid of potassium three times a day, after meals, in milk, during the whole duration of preg- nancy. Under this treatment women who had given birth to a succession of stiU-bom s}-phihtic fetuses may bear K\dng children ^ Zweifel thus describes the progress of the disease: " There is formed, in a certain region of the cartilage, granulation-tissue insufficient!}' supplied with blood- vessels and ill- nourished. There results necrosis of this tissue, with an attempt at exfoliation and accompanj'ing suppuration." 2 Loc. cit. ' For an exceedingly interesting paper on this subject see Heller, " Die Lung- enerkrankungen bei angeborener Syphilis," " Deutsch. .\rchiv f. Klin. Med.," Bd. xlii. S. 159. THE DISEASES OF THE FETUS. 337 perfect in health and development, without a trace in after life of hereditary taint. There are objections to mercurial inunc- tions: the treatment may betray to a woman or her friends the fact that she is being treated for syphilis; and the daily ap- plication of mercurial ointment is disagreeable to say the least. Whether Ehrlich's treatment will supplant it must be deter- mined by experience. I am giving salvarsan to pregnant women who have born syphilitic children or in cases of known infection of either parent, but I follow it with mercury and iodid of potas- sium. Other Infectious Diseases of the Fetus. — As the infectious diseases are dependent upon the entrance of bacteria into the system for their characteristic symptoms, it is impossible that they should directly affect the fetus, unless pathogenic micro- organisms are able to pass from the maternal blood through the uteroplacental septum into the fetal portion of the placenta. It appears from experiments extending over the last fifty years with various bacteria that micro-organisms may, but do not al- ways, pass from mother to fetus. Moreover, there is a long list of diseases due to the presence of specific micro-organisms, which have in well-authenticated cases undoubtedly attacked the fetus. Variola. — Many cases are recorded in which a child marked with pustules was born of a mother who had had variola during pregnancy. But the susceptibility of the fetus to the disease varies. In the majority of cases it is not infected. On the contrary, the mother may have only varioloid and yet the child be born with the marks of small-pox ; ^ or the mother, having been exposed to the contagion of small-pox, but having shown no sign of the disease, may give birth to a child covered with pus- tules. ^ Again, it has been noted that, of twins, one or both of the children may be affected,^ The fact that small-pox can attack the fetus has led many observers to test the possibility of an intra-uterine vaccination. Behm * vaccinated 33 women, and of their children 25 were successfully vaccinated after birth. Wolff ^ says that he has repeatedly vaccinated pregnant women, and has never failed to vaccinate successfully their offspring. Ridgen^ reports 8 cases of small-pox occurring in pregnant 1 Charcot, " Comptes rendus de la Soci6t6 de Biologic," 1851, p. 39, and 1853, p. 88 ; Chaigneau, " Th^se de Paris," 1847 ; Chantreuil, " Gaz. des Hopitaux," 1870. 2 Laurent, " Lyon Medicate," June 15, 1884. 3 " Obstet. Trans.," London, vol. iii, p. 173. * " Zeitschr. f. Geburt.," Bd. vii, p. i. 5 Virchow's " Archiv," Bd. cv, p. 192. 6 " British Med. Jour.," 1877, i, p. 229. 22 338 PATHOLOGY. women, in whose children, born aUve, a subsequent vaccination "took." On the other hand, Desnos^ and Chambrelent ^ each relate a case in which vaccination was several times unsuccess- fully performed upon children whose mothers had shortly before their delivery recovered from an attack of small-pox. Chambre- lent, moreover, vaccinated 7 pregnant women, but of their chil- dren he was able successfully to vaccinate only 3. The fetus^ therefore, in exceptional cases acquires immunity from small-pox by the vaccination of its mother. Measles. — The transmission of measles from mother to fetus is rare. Thomas^ was able to collect 6 cases from medical lit- erature. There are also recorded cases of measles appearing in the first few days of extra-uterine life, making it probable, from the short period of incubation, that infection had occurred in utero. Scarlatina. — Leale * reports the birth of a boy at the begin- ning of a well-marked attack of scarlet fever in the mother, which she had contracted from an older child. The new-born infant presented a dark, congested, red hue and a characteristic rasp- berry tongue. The eruption lasted seven days and desquama- tion began on the tenth day, when albuminuria and general anasarca indicated a desquamative nephritis. The child recov- ered. Other cases are recorded by Hiiter, Meynet, Asmus, Baillou, Tourtual, Gregory, and Stichel. Saffin* has reported an interesting case of intra-uterine scarlet fever: A woman, who had had scarlet fever in childhood, was nursing her child through the disease, while she herself was in the last month of pregnancy. She was apparently not infected, but complained of a bad sore throat. Two weeks later she was delivered of a male child with a typical scarlet rash upon it ; the disease ran a course of nine days, with desquamation in large and small flakes, begin- ning on the fifth day. The infant's temperature ranged from 100° to 104° F.; it recovered.® Erysipelas. — Kaltenbach,^ Runge,^ and Stratz ^ have re- ported cases apparently of fetal erysipelas. Lebedeff ^" reports. 1 Societe med. des Hopitaux, 1871 (see Tarnier et Budin, op. cit., p. 13). ^ Loc. cit., p. 385. ^Ziemssen's "Handbook," vol. ii, p. 50 (see also Underbill, " Obstet. Jour.,. Great Britain and Ireland," 1880, p. 285, and MacDonald, " Edin. Med. Jour.," 1884-85, 699). ■• "Medical News," 1884, p. 636. 5 "New York Med. Record," April 24, 1886. * For full bibliograpby see Ballantyne and Milligan, " Edinb. Med. Jour.,"' July, 1893. ' " Centralblatt f. Gyn.," No. 44, 1884. 8 «' Centralblatt f. Gyn.," No. 48, 1884. » " Centralblatt f. Gyn.," ix, 213, 1" " Zeitschr. f. Geburt.," xii, 2, p. 321. THE DISEASES OE THE EETUS. 339 the following case : The child of a woman delivered at the sev- enth month in the midst of an attack of erysipelas presented alternate patches of red and white on its skin at birth ; it lived ten minutes ; after death streptococci were found in tiie subcutaneous adipose tissue, were cultivated, and rabbits inoculated with the cultures acquired the disease. No microbes, however, were found in the placenta or cord. Lebedeff believes that the streptococci entered the placenta through a villus deprived of epithelium. Malaria. — Behrmann reports two cases of intra-uterine infec- tion in which the disease manifested itself directly after birth. Malaria in the mother retards the growth and development of the fetus. Bompiani ^ says that children born of malarial mothers very rarely reach 3250 gm. (7.17 lbs.) in weight or 50 cm. (19.7 in.) in length, and Negri ^ observed 34 cases in preg- nant women, of which 18 per cent, terminated by premature expulsion of the fetus. Quinin in large doses to the mother is indicated. " Quinin in this condition is the best prophylactic treatment against abortion or premature labor" (Tarnier). Economos^ has found the plasmodium in 6 out of 7 newborn infants whose mothers had malaria. Tuberculosis. — In view of the large number of tubercu- lous women who become pregnant, it is an extraordinary fact that the direct transmission of the disease from the mother to the fetus is an extremely rare occurrence. Runge* infected a number of pregnant guinea-pigs with tuberculosis, but invariably failed to find the characteristic bacilli in the fetal tissues or pla- centa. Ballinger, Davaine, Brauell, and Wolff have denied the existence of congenital tuberculosis, and Jani's observations have already been noticed. But Demme once found tubercle bacilli in the macerated fetus of a tuberculous woman, and Johne'' discovered tubercles in a still-born calf, in which he found the bacilli." Runge has demonstrated tubercle bacilh in the placenta and in the maternal decidua. Tubercle bacilli have been demonstrated in the fetal portion of the placenta by Lehman, Schmorl, Kockel, Auche, and Chambrelent. While, therefore, there is a remote possibility of the passage of tubercle bacilli from mother to fetus, it is an exceptional occurrence.'' 1 "AnnaL di Obstet.," vi, 42, 46, 1884. ^ "Annal. di Obstet.," viii, p. 277. ^ " Soc. d'Obstet. de Paris," 25, February, 1907. * Quoted by Ott, loc. cit, 5 Quoted by Wolff, loc. cit. 6 Ravenel reported a similar case to the Philadelphia Pathological Society, Feb. 23, 1899. ' See A. S. Warthin, " Ectopic Gestation ; Tuberculosis of Tubes, Placenta, and Fetus," "Med. News," Sept. 19, 1896; Birch-Hirschfeld, " Beitr. z. path. Anat. u. zur allgera. Path.," 1891 ; "Archiv f. Gyn.," Bd. xliii, H. I, p. 162. Hauser, " Deutsch. Arch. f. klin. Med.," 189S, vol. Ixi, p. 221, 18 cases. Gottschalk, "Arch. f. Gyn.," Bd. Ixx, H. 1 ; "Arch. f. Gyn.," Bd. Ixviii. 340 PATHOLOGY. Septicemia. — The possibility of the transmission of septic micro-organisms from mother- to fetus has been denied by many, but the antenatal infection of the fetus has been demonstrated by Koubassoff, Chambrelent, Pyle, Mars, H. von Hoist, and others. Cholera. — Tarnier^ says that there is nothing to justify the belief that cholera affects directly the fetus; and QueireP asserts that it is doubtful whether cholera can be conveyed to it, but early abortion is the rule, and if the child should be born near or at term it dies in a few days. Typhoid fever is usually disastrous to the fetus, resulting in its premature expulsion in about sixty-five per cent, of the cases.^ The elevation of the temperature, the alteration of the blood, and the respiratory embarrassment are considered the causes of the abortion or premature labor. Neuhaus "* found typhoid bacilli in the lungs, spleen, and kidneys of a fetus expelled at the fourth month from a woman who was convalescing after a pro- longed attack of the disease. Both bacilli and the Widal reac- tion have been found in the fetal blood (Lynch). In 30 cases collected by Hicks and Frank the bacilli were found in the fetal blood in 1 5.^ Articular Rheumatism. — There are two instances on record of the transmission of the disease from mother to fetus, reported by Pocock^ and Schaffer.'' In each a woman affected with articular rheumatism at the end of pregnancy gave birth to a child presenting, in one case at once, in the other at the end of three days, all the symptoms of the disease. Recurrent Fever. — Albrecht*^ has described three cases of con- genital recurrent fever, and in the blood of one fetus he discov- ered the spirilla. Yellow Fever. — Bemiss,'' of New Orleans, says : " The preg- nant woman being attacked by yellow fever and recovering with- out miscarriage, immunity from future attacks is conferred upon the offspring contained in the womb during the attack." 1 Loc. cit. 2 " Nouv. Archiv d'Obstet. etde Gynec," April 25, 1887, p. i. ^ Duguyot, " Thdse de Paris," 1879. Sacquin's statistics show interruption of pregnancy in 199 out of 310 cases. "These de Nancy," 1885. *" Berlin, klin. Wochens.," 1886, p. 389. See also Speier, " Zur Kasuistik des placentaren Ueberganges der Typhusbacillen von der Mutter auf die Frucht," Inaug. Diss., Breslau, 1896. Lynch, " Placental Transmission, with the Report of a Case during Typhoid Fever," "John Hopkins Hospital Reports," vol. x, Nos. 3, 4, and 5. Exhaustive bibliography. ^London "Lancet," Dec. 30, 1905. 6 London " Lancet," 1882, ii. p. 804. "^ " Berlin, klin. Wochens.," 1886, S. 79. " "St. Petersburg, med. W^ochens.," 1880, No. 18, and 1884, p. 129. 'See Parvin's "Obstetrics," p. 222. THE DISEASES OF THE FETUS. 34 1 Pneumonia. — The placental transmission of pneumococci has been demonstrated in a number of instances, resulting in a pneumococcus septicemia if tlic lung has not expanded or in pneumonia if it has.^ Non-infectious Diseases of the Fetus. — The infectious dis- eases are transmitted from mother to fetus. The non-infectious diseases have an independent origin in the latter. It appears occasionalh', however, as if a non-infectious disease occurring at the same time in mother and fetus were transmitted from one to the other. Some of the diseases of the fetus owe their origin to a vitiated condition of the maternal blood, to an inherent weakness in the building material of the fetus, as in cases of chronic systemic affections of either parent, or to a perverted nervous action in the mother. Others are inexpHcable. Many of the fetal diseases are interesting only to the pathologist, but a few deserve some notice here. Rachitis ; Chondrodystrophia Foetalis ; Achondroplasia — Schor- lau - collected the records of forty-three cases of congenital rachitis, and added to the number two of his own ; while Graf e ^ mentions the cases that have been described by Sandefort, Winckler, Schultz, Virchow, Kehm, and Fischer; Fehling^ and Hennig^ have also described specimens of fetal rachitis. Antenatal rachitis depends upon malnutrition; but the fact that the mother has at some time had rachitis herself, as evidenced by the shape of her pelvis, does not predispose the fetus to the same affection. The appearance of a rachitic fetus is distinctive. It has an enlarged head, perhaps hydrocephalic; gaping sutures and fontanels, a "chicken" breast and a much distended abdomen; the extremities are short, thick, and often bent at an angle, or curved, and the joints are large and prominent. The spine is often curved either laterally or anteroposteriorly.^ The bones are either abnormally hard and firm or so brittle that they are fractured by the slightest force. This condition of the bones in rachitis may be simulated by the arrest of bony development in cases of sporadic fetal cretinism.' Bidder and ^Miiller have de- scribed bone diseases in the fetus which appear to be varieties of rachitis. 1 Levy, ".\rch. f. experiment. Path." Bd. xxvi, and Netter, " Comp. rend. Biol.," May 15, 18S9. ^ " Monatscbr. f. Geburtsh.," Bd. xxx, S. 401. 3 "Arch. f. Gyn.," Bd. viii, S. 500. ♦ Ibid., Bd. x. 5 " Transactions of Meeting of German Naturalists and Physicians," Berlin, 1886. 6 Grafe, loc. cit. '' Virchow' s '"Arcliiv,"' BJ. c, S. 256. 342 PATHOLOGY. Chondrodystrophia joetalis or achondroplasia depends upon an arrest of development in the epiphyses, with a consequent shorten- ing of the long bones of the extremities. The appearance of the Fig. 277. — Chondrodystrophia fcetalis. fetus suggests rachitis, but an examination of the skeleton estab- lishes the diagnosis.^ Anasarca. — General anasarca of the fetus is occasionally seen. The distention of the fetal skin ma}^ reach such dimensions that the expulsion of the child is exceedingly difficult.^ Such children are, however, usually born prematurely from the fourth to the eighth month, and are, as a rule, still-born, although cases are recorded in which they lived for a short time after birth. The causes of this condition must be various. It has been attributed to anasarca of the mother, to syphilis, to absence of the thoracic duct ; ^ in one instance to ieukemia of the fetus,* in another to obstruction of the umbiUcal vein.^ The serous infiltration of the skin is usually accompanied by a collection of fluid in the abdominal and pleural cavities, and the membranes and placenta are often markedly edematous. 1 " Handbuch d. Geburtsh.," F. v. AVinckel, II., 2, 1905. 2 Keiller, "Edinburgh Med. and Surg. Jour.," April, 1855. * " The Diseases of the Fetus," Ballantyne, Edinburgh, 1S95, 2 vols. Complete bibliography. * Klebs, " Prager med. Wochens.," 1878, No. 49. 5 " Breslauer Klin.," Bd. i, S. 260. THE DISEASES OF THE FETUS. 343 Congenital Cystic Elephantiasis. — In this disease there is a great overgrowth of the subcutaneous connective tissue all over the body, and at intervals in the hypertrophied tissue there are cysts varying in size. Malformations of a grave character are commonly associated with tiie disease. The infants scarcely ever survive their birth. One child, however, lived thirty min- utes and another was twenty months old when the case was re- ported. Ballantyne ^ has collected more than eighteen cases of this very rare disease. Spontaneous Fractures in Utero. — The fetal bones may be broken by external violence, or a child may be born presenting numerous fractures, especially of the long bones, either recent or already undergoing repair, without the history of an accident of any kind to the mother during pregnancy. If syphilitic osteochondritis can be excluded, with a separation of the ep- iphysis and diaphysis, or an injury to the child during labor, Fig. 278. — Congenital cystic elephantiasis. there must have been a rachitic condition of the bones or an arrest of ossification, to allow of fracture by the slight force which could be exerted by the fetal muscles or the pressure of the uterine walls. Link- describes a case of numerous frac- tures of the ribs, clavicle, and extremities, in which syphiHs, rachitis, and chronic parenchymatous osteitis could be ex- cluded, and he, therefore, concludes that these fractures were ^ " Diseases of the Fetus," Edinb., 1895, 2 vols. 2 " Archiv. f. Gyn.," Bd. xxx, 2, p. 264, 1887. 344 PATHOLOGY. caused by an " unknown intra-uterine fetal bone disease," in which the bones became soft and brittle. A similar bone disease has been described by Schmidt. Luxations and Ankylosis. — Luxations affect females four times as often as males, ^ and are much more common in the lower than in the upper extremities. An apparent ankylosis ^ after birth occasionally appears when, in breech presentations, the presenting part has remained a long time in the cavity of the pelvis. The lower limbs remain in the position — of flexion of thighs upon abdomen and extension of legs upon the thighs — that they occupied in utero, and it is impossible for a while to restore them to a proper position.^ Intestinal Invagination. — Lauro* has described a double invagination of the descending colon during intra-uterine life. Intra=uterine amputations are rare.* They are usually due to amniotic bands. But this explanation will not suffice for all cases. It has been demonstrated that a gangrenous process ^ at a certain point in the limb may determine an amputation, just as it would in extra- uterine life, or that a peculiar morbid process ''may produce a constriction from the circular contraction of connective tissue at a certain point, or, again, that an amputation * may follow a fracture. The amputated part may float loose in the amniotic liquid, may possibly be absorbed if detached early in embryonal Hfe, or may be attached to the sound portion of the limb by a filament. Fetal Traumatism. — The fetus is well protected from external violence, but it may experience injuries of the gravest nature, either in connection with serious injury to the mother or occasionally with very slight evidences of violence to the maternal tissues. Thus, in cases of gunshot, ^ stab, ^ ^ or other perforating wounds of the abdomen in pregnant women, the fetus has likewise been severely 1 Tarnier et Budin, loc. cit. 2 Lefour, " Presentation du Siege decomplete Mode des Fesses," Paris, 1882. 3 The fixation of the limbs or trunk in abnormal positions by muscular contrac- tion may occur m utero during pregnancy, as in the interesting case of *^' contracture " in utero ( Ribemont-Dessaigne, abstract in " Nouv. Archiv d'Obstet.," Sept., 1887). In this connection the student should consult also the paper by Matthews Duncan on "Extensions and Retroflexions of the Fetus, especially of the Trunk, during Preg- nancy" ("Trans. London Obstet. See," xxvi, 1884, p. 206) * "Annali di Ostet. e Ginecol.," Luglio-Agosto, 1887. 5 For an extensive bibliography see Tarnier et Budin. 8 Chaussier, " Proces verbal de la Distribution des Prixes a la Maternity," 1822. ' Kristeller, " Monatschr. f. Geburtsh.," Bd. xiv, p. 817. 8 Martin, " Gaz. Hebdom.," 1858, p. 384. 9 Hays, "Ann. de Gyn.," 1880, xiii, p. 153; Tucker, Jour. A. M. A., June i, 191 2. lopennell, "Trans. N. Y. Path. Soc," iii, 249; Tarnier et Budin, loc. cit., p. 345; Guelliot, "Gaz. des Hop.," 1886, p. 405. THE DISEASES OF THE FETUS. 345 and fatally wounded. Also, in the performance of celiotomy, 1 by a mistaken diagnosis the trocar that was plunged into what was thought to be an ovarian cyst has penetrated the fetus, and wounds have been inflicted by both sharp and dull instruments ignorantly used to bring on an abortion or in the hands of physicians who overlooked the condition of pregnancy. On the other hand, as instances of fatal injury to the fetus without apparent injury, ex- ternally, at least, to the mother, might be cited the cases of Mascka 2 and Gurlt,^ in which the cranial bones of the fetus were fractured by the mother falling from a height, or the case described by G. von Hoffman,-* of a woman in the fifth month of pregnancy who threw herself out of a fourth-story window and was killed by the fall, although she exhibited no signs of external injury ; the uterus was uninjured, and the fetus externally was ap- parently unharmed, but on opening its abdomen the liver was found almost disintegrated. The case reported by Lumley ^ shows more clearly how slight violence to the mother may be fatal to the fetus : A pregnant woman, within ten days of term, attempting to enter a doorway, slipped and struck the left lower portion of her abdomen against the edge of the door. The movements of the child thereupon ceased, and eight days after- ward a dead fetus was born with a fracture of the left frontal and parietal bones of the skull. One of my patients was thrown from a carriage two months before her delivery. Her infant, otherwise healthy, had a fractured clavicle, almost entirely healed, but with a large mass of callus about the site of fracture. These cases of fetal injury are not only interesting from their rarity, but they are also important from a medicolegal point of view. Thus, Gorhan^ records the death of a fetus from violence done the mother at the hands of another woman in the course of a brutal quarrel between two sisters-in-law, during which the pregnant woman, being at the time in the sixth month of gestation, was thrown to the ground and stamped upon by her infuriated relative. Two months afterward a dead fetus was born, corresponding in development to the sixth month of pregnancy, and exhibiting a transverse fracture of both parietal bones. A young girl illegitimately pregnant, under my charge in the Maternity Hospital, ran a long hat-pin up to its head into her 1 Goodell, " Lessons in Gynecology," p. 352. 2 " Prager Vierteljahrschrift," 1857. 3 "Monatsch. f. Geburtsh.," 1857, p. 343. * "Wien. med. Presse," xxvi, 1S85, Nos. 18, 20, etc. 5 " N. Y. Med. Rec," 1886, p. 359. «J. Taber Johnson, "Trans. Am. Gyn. Soc," vol. iii, p. 107. 346 PATHOLOGY. abdomen at the umbilicus. She transfixed her fetus, which was born dead a few days later. She suffered no other inconvenience than a slight purulent discharge from the umbiHcus. It is important to distinguish injuries experienced during labor, as fractures of the extremities or of the spine/ or depressions of the skull,- from the effects of traumatism during pregnancy.. Conditions of the Mother Which Injuriously Affect the Fetus. — The Influence of Maternal Fever Upon the Fetus. — Runge,^ in 1877, called attention to the danger to the fetus of high temperature in the mother. Pregnant rabbits placed in a hot box until their body-temperature had risen to 105.8° F. usually died, and almost invariably the fetuses were found dead upon opening the animal's body immediately after its removal from the box. But Doleris^ showed that if the temperature of the ani- mals was slowly raised to 105° or 106° F., and not within an hour, as in Runge's experiments, they seemed to bear it without much inconvenience, even if long continued, and, if pregnant, their young remained perfectly healthy. These results were con- firmed by Runge^ in a second set of experiments, in which he found, however, that if the animal's temperature was raised, even very gradually, to 109.4° F., there occurred the same symptoms — death of the fetus and heat-stroke of the mother — as though the temperature had been quickly raised to 106° F. Preyer*^ has also shown that the fetus is capable of enduring a much higher tem- perature than was formerly supposed, for in one instance he ac- tually observed a fetal temperature, in a guinea-pig, of 112.2° F.,^ the fetus Hving nine minutes, or until the cord was severed and it was removed from the uterus. It appears, therefore, that fever in the mother does not necessarily threaten the Hfe of the fetus unless the temperature rises suddenly, as in the case of brain- tumor, described by Runge, or in cases of recurrent fever re- corded by Kaminski,'' or is very high, as in insolation. No special treatment is required if the temperature rises grad- ually and remains under 105° F., but above this point the dan- ger to the fetus begins, and active antipjo-etic treatment is re- quired. Should a pregnant woman die with a temperature as 1 " Wien. med. Presse," xxvi, p. 370. - There are, however, two recorded cases of this injury occurring from trau- matism during pregnancy. ^ " Archiv. f. Gyn.," Bd. xii, p. 16; Bd. xiii, p. 123. * " Comptes rend. hebd. Seances de la Societe de Biologic," Nos. 28, 29. Doleris' results were confirmed by experiments of Dore (" Arch, de Tocol.," 1884, p. 141), and by Negri (see abstract in " Nouv. Arch. d'Obstet. et de Gynec"). ^ " Archiv f. Gyn.," Bd. xxv, S. i. ^ " Physiologie des Embryo," Leipzig, 1884. ^ " St. Petersburg med. Zeitung," 1868, 117. THE DISEASES OF THE FETUS. 347 high as 109° F., the performance of postmortem Cesarean sec- tion would be useless. The operation would likewise be futile if death had followed a sudden rise of temperature. The Influence of Maternal Emotions Upon the Fetus. — Maternal emotions and impressions may possibly affect the embr^'O or fetus. Many cases of mental peculiarities or disease?, or of physi- cal defects, that have been attributed to a strong impression upon the mother during pregnancy, are explained by the ex- istence of some systemic disease, as syphiUs, nephritis, diabetes, cancer, or chronic lead-poisoning in either father or mother; by an arrest of development; by mechanical disturbance of the ovum, or, in the case of intra-uterine amputations, by the formation of amniotic bands or the disposition of the cord; there are cases of congenital defects or peculiarities ^ which bear a startling resemblance to an impression upon the mother during pregnancy, but they are almost always explicable on other grounds. A strong emotion on the part of the mother may be imme- diately fatal to the fetus.- Profound impressions upon the mother certainly influence the psychical development of her offspring. The idiocy of Barnaby Rudge due to maternal shock and fright is a fiction founded upon fact. The horror of King James at the sight of a naked sword may well have had its origin in the murder of Rizzio before the eyes of the pregnant Queen Mary. There is no question that certain maternal conditions may so modify the blood in its capacity of a bearer of ox3^gen and nutriment to the fetus as to seriously interfere with the latter 's health, if not to destroy its existence. Icterus gravidarum endangers the life of the fetus, either by bringing on an abortion or by first destroying its life by the poisonous action of the bile-salts,'' or, perhaps, by the induction of cholemic convulsions.'* Thus, Spath^ describes 8 cases, in 4 of which the fetus was born dead; and Frerichs** mentions 3 cases, all fatal to the fetus. Saint VeP has described an epi- demic of jaundice on the island of Martinique. Of 30 preg- nant women affected, 20 were delivered prematurely, and of ^ See the very interesting paper by Dr. Fordvce Barker in "Gynecol. Trans.," vol. xi, 1886. - " Lancet," vol. ii, 1874. ^ Valenta, " Osterreichische Jahrb.," xviii, i86q, S. 163. 4 Strumpf, " Archiv f. G>ti.," Bd. xxviii, H. 3. ^ " Wiener med. Wochenschr.," 1854, S. 757. ^ " Klin, der Leberkrankheit.," 1858, Bd. i. ^ " Gaz. des Hop.," 1862, p. 538. 348 PATHOLOGY. these 20 children 19 were either still-born or died shortly after birth. Bardinet^ has also recorded the birth of 6 dead infants out of 13 pregnant women who were suffering from jaundice during an epidemic of the disease in Limoges. Fre- quently as the bile-salts must traverse the uteroplacental septum. and enter the fetal circulation, as evidenced by the high per- centage of still-born children in women affected with jaundice during pregnancy, the coloring-matter of the bile seldom stains the fetal tissues. Lomer^ collected 56 cases in which naturally colored children were bom of jaundiced mothers, and 43 more in which the color of the child was not mentioned, so that it was presumably natural ; and to these might be added another case described by Parrish. There are 6 recorded cases, however, in which the fetus or the whole ovum was undoubtedly jaun- diced (Lomerj. Eclampsia. — It has been estimated that about one-half the children are still-bom after the eclampsia of pregnancy or labor. The cause of fetal death is the carbonic-oxid gas in the maternal blood, the stagnation of the blood- current during a compulsion, or the toxins in the blood. The death of the mother kills the fetus, but not necessarily at once. Life may continue in the fetus for some time after it is extinct in the mother. There is on record a case of the extrac- tion of a li\ing child from the womb of a woman who had been dead two hours.^ Tarnier* performed a postmortem Cesarean section upon a woman who during the Commune in Paris had been killed by a stray bullet in the wards of the Matemite. and extracted a li^dng child, certainly three-quarters of an hour — perhaps an hour and a quarter — after the death of the mother. Numerous other instances are recorded of postmortem Cesarean operations, or the extraction of infants per vias naturales. at inter- vals of time ranging from a few minutes to a half hour after the death of the mother. The prospect of success, however, is not great. Of 330 cases collected by Weiswange only 6 or 7 children sursdved.-^ The sun-dval of the fetus after maternal death is ex- plained by the cases of children born asphyxiated, whose hearts continue to beat, although they do not breathe for a long time after birth, or by the experiment performed by Haller** of forc- * " Union Medicale," 1863, Nos. 133 et 134. 2" Zeit. f. Geburtsh.." xiii. p. 169, 1886. 'Hubert, " Traite d'Accouchements," vol. li, p. 160. *Tamier et Budin, ii, p. 571. ^See Thies, " Sectio Caesarea Postmortem," " Zeitschr. f. Geb. u. Gyn.,"^ Bd. Ixvi, p. 652. ^ " Elem. Physiol.," vol. vi, p. 314, quoted in Tarnier et Budin, op. cit., p. 570, THE DISEASES OE THE EETUS. )49 Fig. 279. — Two years in the abdomen (Baer ing a bitch to give birth to her pups under water, where they crawled about and hved for half an hour. The death of the fetus may be due to many causes. It may be the result of injuries, deformities, or diseases in the fetus itself, or in its appen- dages, the membranes, and the placenta. It may be due to inherent weakness in either the ovule or the sper- matic particle, which does not prevent conception, but renders the embryo incapa- ble of development beyond a certain point ; or it may be the consequence of a mis- placed ovum, as in tubal, ovarian, and abdominal preg- nancies. The condition of the maternal blood, the ex- istence of a very high tem- perature in the mother, and \doIent emotions, are occasion- ally responsible for the destruction of fetal life. All these conditions have been or will be considered in their appropriate places ; but it remains to notice the effect of fetal death upon the mother, the diagnosis of fetal death, the habitual death of the fetus, and the changes that ensue in the fetus itself after death. The effect of the death of a fetus upon its mother is often 7iil. There may be depression, loss of appetite, and chilly sen- sations. When the dead body putrefies, or when, after absorp- tion of the soft parts there is an attempt to discharge the fetal bones by ulceration into the bladder, vagina, rectum, or exter- nally through the abdominal walls, the mother's health and safety are seriously endangered. Thus, after ectopic gestation the dead fetus may remain for an indefinite period within the mother's abdomen with no inconvenience except the enlargement of the abdomen; but should the germs of putrefaction gain access to the dead body, as they may by reason of the contiguity of the intestines (Litzmann), then a general suppurative peritonitis may be developed and rapidly prove fatal. So, too, in the retention of blighted ova^ or in cases of missed labor there is usually no evi- dence of serious harm to the mother until the putrefaction of the 1 See Gehrung, "Weekly Med. Review," Chicago, 1885, p. 131 ; "Westmins- ter Hospital Reports," 1885, i. 119 ; " Tokio Med. Journ. ," 1886, No. 439. Graefe, in Ruge's "Festschrift"; Stager, Inaug-Diss., Bern, 1895. 2 Lusk, " Science and Art of Midwifery," lS86, p. 304. 350 PATHOLOGY, dead body begins, when there may be shortly manifested all the symptoms of septicemia, unless the uterine cavity is speedily cleared of its contents and well disinfected. It is not easy to determine that the fetus is dead. If death oc- curs during early pregnancy, the uterus usually ceases to grow and the circumference of the abdomen no longer increases steadily from week to week; the breasts soon become flabby, although it is not rare for milk to appear for a time after the death of the fetus; the woman may complain of subjective symptoms, as a feeling of weight and discomfort in the hypogastric region; but doubt ^^^ Fig. 280. — Calcification of cap- Fig. 281. — Lithopedion. Two years sule (in abdomen unknown length of in abdomen (Baer). time). is usually soon solved by the expulsion of the ovum. Should the fetus die in the later months of pregnancy, the movements,, theretofore perhaps active, are no longer felt by the mother, and the fetal heart-sounds are no longer heard. Neither of these signs, however, is entirely reliable, for the woman's statement is not always perfectly credible, and it is impossible occasion- ally to hear the fetal heart-sounds, although the child is alive and well. The urine of the mother commonly undergoes a change after fetal death. Albuminuria sometimes disappears when the fetus dies. On the contrary, I have seen albuminuria appear in consequence of fetal death. Peptonuria may be looked for if there is decomposition of the fetal body, and acetonuria, it is claimed, is an invariable consequence of a dead fetus in utero^- The statement is made that the urobilinuria, present in 1 Acetonuria was found 9 times in 139 pregnant women, and in each of the 9 cases it was demonstrated that the woman was carrying a dead fetus. Vicasella,. "Wien. med. Presse," 1894, p. 205. THE DISEASES OE THE EETUS. 35 1 all pregnant women, is always more exaggerated in the first few days after fetal death. ^ Negri •^ was able to make the diagnosis of fetal death during pregnancy by abdominal palpation, the fetus presenting a rather confused outline and giving rise, upon pres- sure on the mother's abdomen over the region of the fetal head, to an indistinct crepitus. During labor a doubt may arise as to whether the fetus is dead or alive, and upon the decision often de- pends the performance of embryotomy or of a more conservative operation. It has been suggested by Cohnstein^ and Fehling'* that if the temperature of the uterus is no higher than that of the vagina, the child may safely be pronounced dead ; for the living fetus, having a higher temperature than its mother, imparts some additional heat to the maternal structures about it. Priestley ° more practically suggests that the hand be introduced into the uterus in order to feel in the precordial region for the impulses of the fetal heart, or to feel the pulsations in the cord. After death the fetal tissues in time saponify (adipocere), partially calcify, mummify, or else are totally or partially ab- sorbed. Shortly after death there may be maceration and putrefaction. Before the second month the product of con- ception may be entirely absorbed. After that time the changes that take place depend to some extent upon the posi- tion of the fetus. Within the uterus the dead fetus is first macerated, becoming bloated in appearance, with a grayish- colored skin deprived of its epidermis in spots of varying extent ; the head is enlarged, the cranial bones are loose under the scalp, and the tissues become so soft and friable that very slight force is sufficient to detach the limbs from the body. If saprophytes gain access to the fetus in this condition by rup- ture of the membranes, decomposition rapidly ensues. The other changes that affect the fetal tissues after death are a sap- onification, and possibly mummification, in which latter state they will remain for an indefinite period without change. It is in abdominal pregnancies that the dead fetus becomes converted into a so-called lithopedion, which consists not of a calcification of the whole mass, but (i) of a calcification of the membranes after absorption of the liquor amnii ; (2) of a cal- cification of the membranes and those points on the fetus where the membranes adhere to the fetal surface ; or (3) of a deposition of lime in the vernix caseosa after the membranes have been ^Merletti, " Centralbl. f. Gyn.," No. 16, 1902. ^ " Annali di Ostetricia," May, June, 1885, p. 223. 3 " Archiv f. Gyn.," Bd. iv, H. 3. '^Ihid., Bd. vii, S. 143. * " Lancet," January 22,, 1887. 352 PATHOLOGY. ruptured and the fetus has escaped into the abdominal ca\dty. ^ The fetus in the abdominal cavit>' may undergo all the other changes that have been described, including putrefaction, and, in addition, the soft parts may be absorbed, the bony skeleton remaining as a foreign body in the abdomen until it is discharged piecemeal, through openings into the bladder, intestines, rec- tum, uterus, and vagina, or externally through the abdominal walls. The Habitual Death of the Fetus. — There are women who in two or more successive pregnancies, usually at the same period in each, give birth to dead children. It is important to learn, if possible, the cause of the repeated fetal death, for upon it depends the treatment adopted to secure the birth of a Hving child. Although by no means the only cause of the habitual death of the fetus s^phihs is by far the most frequent. According to Ruge's^ estimate, eighty-three per cent, of repeated premature and still-births are due to s}'philis in the parents. The Wasser- mann reaction should be taken, therefore, in a woman who has given birth to a number of dead children. But there are many cases in which s3-ph.ilis can be excluded, and in which fetal death must be ascribed to other causes. Certain Conditions of the Uterus which Interfere with the Development of the Fetus. — There are no reliable statistics in regard to the relative frequency of the causes, other than syphilis, of habitual death of the fetus, but I should place first chronic endo- metritis and chronic metritis, which interrupt pregnancy, either by effusions of blood into the hyperemic mucous membrane, and the consequent excitation of muscular action in the uterus, or by an active growth of the decidua and the diversion of the nutritive blood-supply from the fetus to the uterine mucous membrane.^ Abarbanell ^ first called attention to chronic metritis as a cause of habitual abortion, from the excessive development of fibrous tissue in the body of the uterus, which by loss of elas- ticity would interfere with a sufficient dilatation of the uterine cavity. Such, perhaps, is the explanation of Baudelocque's case, •' in which, after a Cesarean section, a woman successively gave birth to four children at the seventh month of pregnancy. In two cases under my observ-ation an ill-developed uterus was the cause of repeated premature births. In one the woman gave ^ K-iichenmeister, " Archiv f. Gyn.," Bd. xvii. p. 153. 2 " Zeit. f. Geburtsh.," Bd. i. 5 " Geburtshiilfe,'' 8th ed., Bonn, 1884, p. 405. ^ " Alonatschr. f. Geburtsh.," xix, S. 106. * Leopold, " Archiv f. Gyn.," Bd. viii, p. 253. TIIK DISEASES OE THE EE'EUS. 353 birth to thirteen children at the sixth month, none of which sur- vived. In the other there were three premature births before the children were viable. In this woman menstruation began in the eighteenth year; there were long periods of amenorrhea, and a vaginal examination before marriage revealed an infantile uterus. Dr. J. J. Fraenkel reports to me the case of a woman with an infantile uterus who gave birth to seven unviable premature in- fants each a little more advanced in development than the last, until finally the eighth child was retained in the uterus until the eighth month and survived. Alterations in the Maternal Blood that Are Fatal to the Fetus. — Scanzoni^ pointed out that a high grade of anemia in a pregnant woman might be fatal to the fetus. It may be due to an exaggeration of the hydremia of pregnancy, to pernicious anemia," to sudden loss of blood, or to lack of food as in the siege of Ley den (Hoffmann), or in Germany during the year 1826, when the crops failed (Nagele), and during the siege of Paris (Priestley). Plethora might possibly prove a predisposing cause to effu- sion of blood into the membranes or placenta, especially at a time corresponding to a menstrual period. The Effect of Chronic Diseases of the Mother upon the Fetus. — Women affected with tuberculosis,^ cancer, or chronic malarial poisoning* may give birth to a succession of dead chil- dren. Icterus gravidarum also, whether simple, epidemic, or pernicious, might be a cause of repeated fetal death, although the course of the last two is usually too rapid to allow of repeated impregnation. Nephritis. — Fehling^ has called attention to the influence of maternal nephritis as a cause of repeated still-births. The death of the fetus is often the result of the morbid condition of the blood-vessels in the maternal portion of the placenta, corre- sponding to the condition found in the lungs, brain, and other organs in chronic nephritis. The brittleness of the capillary walls leads to apoplexies and to the formation of large infarcts in the intercotyledonic spaces, which so compress the neighbor- ing placental villi that they can not perform their physiological functions. The effusion of blood may also cause a premature detachment of the placenta.^ 1 " Geburtshiilfe," Bd. ii, S. 3 u. 70. 2 Gusserow, " Archiv f. Gyn.," Bd. ii, S. 218. ^ Tarnier et Budin, op. ciL, p. 89. '' Bompiani, " Annal. di Ostet.," vii, 42, 46; discussion of Dr. Schrady's paper, " Med. News," 1885, i, 358; Negri, " Annal. di Ostet.," viii, p. 277. s " Archiv. f. Gyn.," Bd. xxvii, p. 300. 6 Winter, " Zeit. f. Geburtsh.," Bd. xi, S. 398. 23 354 PATHOLOGY. Charpentier and Butte ^ have shown that an excess of urea in the maternal blood ma}' fatally poison the fetus. Disturbances in the maternal blood-pressure (Runge) and insufficient oxygena- tion of the maternal blood may also occasionally be responsible for the fetal death. Diabetes has a disastrous influence upon the fetus. Mat- thews Duncan^ collected the record of 19 pregnancies occurring in 17 women, in 7 of which the fetus died in the latter part of pregnancy. In 2 cases the children were feeble at birth, and i child was diabetic. Chronic Poisoning. — Constantin PauP first described the ill effects of saturnism upon pregnancy. Of 123 conceptions in women ^nth lead-poisoning, 64 ended in abortion, 4 in pre- mature labor, and there were 5 still-births; only 10 children passed the age of three years. These observations have since been confirmed by Roque^ and Rennert.' It has also been asserted that female workers in tobacco are peculiarly liable to abortion or to still-births Qacquemart, Kos- tial). but there is dift'erence of opinion on the subject. The late Professor Hunter ]Maguire. of Richmond, Virginia, kindly in- quired for me of some of the largest tobacco manufacturers in that city as to the effect of tobacco on the pregnant women in their employ. There was no e\'idence of a deleterious influence upon pregnant women or their oft" spring. Causes of Death Residing in the Fetus Itself. — As already stated. 5}-philis of the fetus or o\TLm is by far the most frequent cause of habitual death; but there are other causes. Deformities mav be hereditary in certain families, carried through every member of several generations.*^ A woman might, therefore, give birth to a number of children, each presenting the same deformity, grave enough perhaps to destroy life.^ Leopold^ discovered the cause of death in several dead fetuses born suc- cessively of one woman to be a thickening of the fibrous and mus- cular coat of the umbilical vein so that its caliber was seriously diminished. S}^hilis w^as excluded. 1 " Trans. Ninth International Medical Congress." 2 " Obstet. Trans.," London, vol. xxiv, p. 256. 3 Tamier et Budin^ op. cit.. p. 31. ^ " These de Paris," 1873. 5 " Archiv f. Gjti.," Bd. xv'm. p. 109. « " British Med. Jour.." Jan. 22, 29, 1887: " Am. Jour. Obstet.," 1886, p. 1108. ' A lioness in the Philadelphia Zoological Garden has given birth, on three sep- arate occasions, to cubs that were deformed about the jaws and palate, and lived only a few moments after birth. This is said to be the nile with Honesses in cap- tivity. ^ " Archiv f. Gynak,." Bd. x, p. 191. THE DISEASES OF THE FETUS. 355 The Causes of Fetal Death Referable to the Father. — In case it is impossible to attribute the habitual death of the fetus to inherent defects or to ill-health of the mother, the explanation may be sought in the condition of the father. He may be too old or too young to furnish a fecundating germ of sufficient vigor to enable the fetus to reach maturity ; or he may be the subject of some chronic debilitating disease, as nephritis, dia- betes,^ phthisis,^ cancer,^ or chronic lead-poisoning,'* which may not affect the fecundating power of the spermatic particle, but renders it incapable of performing its part in building up a healthy embryo. Thus, Priestley tells of a healthy young woman, whose husband had albuminuria, giving birth first to a sickly infant and afterward aborting in three successive preg- nancies, or until her husband succumbed to uremia. In D 'Outre- pont's case a woman married to a phthisical man became preg- nant five times, in each instance giving birth to a dead child at the eighth month. Remarried to a healthy husband, she gave birth to four healthy infants in succession. Paul, in 39 pregnan- cies in 7 women whose husbands were afflicted with saturnism, observed ii abortions and i still-born child, while of the 27 children born alive only 9 survived early infancy. The Habit of Giving Birth to s'till=born Children.— If maternal causes are excluded, if there is no sign of abnormality or disease in the fetus or ovum, or if there is nothing in the condition of the father to account for the repeated still-births, their occurrence may be attributed to a habit of the mother of giving birth to dead children. Such cases are extremely rare, as may be imagined, but are not unknown. Two ex- amples may be cited: A woman" subjected to a severe fright in the last month of pregnancy afterward gave birth to a dead child. In twelve successive pregnancies she gave birth to dead children at the seventh month. The mother of HohP gave birth alternately to living and dead children. The first child was living and healthy, the second dead, and so on until the tenth pregnancy, when so certain was everyone that the child would be born dead that nothing was provided for it. It w^as born alive, however, and was Hohl himself. ^ Priestley, " Lumleian Lectures on the Pathology of Intra-uterine Death," rep. from " British Med. Jour.," 1S87, p. 8. 2 D'Outrepont, " Neue Zeit. f. Geburtsh.," 1838, Bd. vi, p. 34- 3 Jacquemier, " Diet. Encyc. des Sc. med.," art. " Avortement," vol. vii, P- 537- ■* Constantin Paul, \oc. cit. ^ Hayes, London " Lancet," 1874, vol. ii. 8 Tarnier et Budin, op. cit., p. 365. 356 PATHOLOGY. The Diagnosis of the Cause of Repeated Still Births. — Syphilis, as the most frequent cause of habitual death of the fetus, must be excluded before another cause is sought. To determine the other causes of repeated fetal death, endo- metritis and metritis should be looked for. The uterus may be ill-developed. The blood of the mother should be examined for anemia. The lungs should be examined for phthisis, and the urine for sugar or for albumin and casts. The history of the patient may point to malaria or to chronic lead-poisoning. Physical signs may denote a cancer, or there may be unmistaka- ble jaundice. The fetus itself must be examined for some hereditary defect, and the cord for stenosis of the umbilical vein. Finally, the condition of the father must be inquired into. The Preventive Treatment of Habitual Death of the Fetus. — In syphilis of the parents antisyphilitic treatment should be administered. So frequently is an antisyphilitic treatment suc- cessful in these cases that certain writers have recommended the administration of potassium iodid and mercury to every woman who was in the habit of giving birth to dead children. Chronic endometritis indicates a curettage.^ Displace- ments of the uterus and lacerations should be attended to. Anemia and plethora require appropriate treatment. Phthisis, cancer, diabetes, or nephritis in the mother are irremediable. In chronic malaria, quinin and arsenic; in saturnism the elimi- nation of the poison should enable the woman to bear a living, healthy child. The father's health, if impaired, should be improved, if pos- sible. There are women who carry a living child up to a certain period of pregnancy, but if allowed to go to term give birth re- peatedly to dead infants. In Tarnier's- case, a woman, appar- ently in good health, gave birth to thirteen dead children suc- cessively, although it was demonstrated that the fetus was in each instance alive until the last month of pregnancy. The same authority cites another instance of a woman who in seven successive pregnancies experienced the active movements of her child until within fifteen days of the normal time of deliv- ery, and yet always gave birth to a dead infant. In such cases labor should be induced before the fetus dies. 1 Schroeder, " Geburtsh.," 8th ed., p. 405. ^ Loc. cit., p. 365. DISPLACEMENTS OE THE UTERUS. 357 CHAPTER II. Displacements of the Uterus in Pregfnancy, Labor, and the Puerperiom, The uterus may be displaced forward, backward, to either side, or downward. It may form part of the sac contents in inguinal and ventral herniae, and it may be twisted upon its pedicle, the cervix. Anteflexion of the Gravid Uterus. — Usually the growth of the uterus upward into the abdominal cavity corrects the ante- flexion spontaneously, but if it is bound down by bands of adhe- sion the result of pelvic inflammation, or the consequence of ante- rior fixation of the uterus by an abdominal or vaginal operation, pain in the uterus and difficulty in urination result, until finally the uterus expels its contents or forces its way up into the abdominal cavity. A number of cases have been observed of late years in which, after an anterior fixation of the uterus, the uterine cavity enlarged solely by the distention of the posterior uterine wall, the fundus and anterior wall much thickened, remaining at the level of the pelvic brim. Treatment. — Pelvic massage, tampons, and digital pressure upward through the anterior vaginal vault may stretch or break the adhesions and allow the uterus to ascend normally into the abdominal cavity. An abdominal section and the severance of adhesions may be justifiable. Late in gestation the whole body of the uterus may fall forward, producing a pendulous abdomen, in consequence of greatly relaxed abdominal walls; diminution in the length of the abdominal cavity, as in kyphosis; prevention of the entrance into the pelvis of the presenting part, as in a rachitic pelvis; or by reason of an exaggerated separation of the recti muscles. This anterior displacement is treated by an ad- dominal binder, not tight enough to increase the intra-abdominal pressure injuriously, but firm enough to afford support (Figs. 282-285). Anterior displacement of the uterus in labor is a common anomaly, seen to some degree in all cases of obstructed labor, as in deformed pelvis, and in all cases in which the length of the ab- dominal cavity is decreased, as in kyphosis. A peculiar example of forward displacement is seen in those rare instances of hernia of the parturient womb between the recti muscles or to one side of the median line during the second stage of labor (Fig. 286). 358 PATHOLOGY. w eHisi ma T ^ u ^ ^Pt^B,',.'^, --- / ^^H llh^ _ '-t Q m o o 3 S. 3 =t. op C- DISEASES OE THE VAGINA. 389 Varices of the vagina may be dangerous if the veins are large and their walls thin. The part should be guarded from trau- Fig. 312. — Hypertrophy of the urethral walls in pregnancy (author's case). Fig. 313. — Suluirctliral abscess. matism, which might result in rupture of the distended veins and an alarming if not a fatal hemorrhage. 390 PATHOLOGY. Polypoid hypertrophies of the vaginal mucous membrane, usu- ally at the site of the carunculas myrtiformes, may attain con- siderable size, causing discomfort during pregnancy, and possibly obstructing the canal in labor. I have seen one case of such enormous hypertrophy of the tissues surrounding the meatus urinarius that the urethra completely filled the vaginal entrance (Fig. 312). Suburethral abscess is an accumulatian of pus in the anterior vaginal wall, bulging out at the vulvar orifice like a cystocele, and on pressure discharging the pus slowly and imperfectly into the urethra through the opening of Skene's glands. The abscess should be opened through the vagina. Vaginal cysts (Fig. 314) grow larger in pregnancy, but they should not be operated on, as the hemorrhage is formidable and the operation may interrupt gestation. They may be punctured in labor and removed at the end of puerperal con- valescence. Cancer and sarcoma of the vagina (Figs. 315, 319), if oper- able, should be operated upon, regardless of the pregnancy, by enucleation of the vagina and by hysterectomy. If in- operable, a Cesarean section is indicated when the fetus is viable. Vaginal Enterocele — Vaginal hernia is a very rare obstruction in labor. The author has been able to collect but 27 cases from medical literature. Of these, only two were anterior entero- celes ; the others were lateral and posterior. The distention of the hernial sac in labor is apt to become excessive, and to threaten its rupture with protrusion of intestinal loops. An effort should be made to reduce the hernia as soon as it is discovered. The reduction may be facilitated by placing the woman in the knee- breast posture and by inserting the whole hand into the vagina. If this treatment is instituted in pregnancy, it should be followed by the insertion of a large tampon or a globe pessary and by pro- longed rest in bed ; in labor the presenting part should imme- diately be brought down past the hernial ring. If there are adhesions about the latter, preventing the reduction of the hernia, the tumor should be supported and held to one side by assistants while the child is artificially extracted by forceps or after version. Should the sac rupture and the intestines protrude, the child must be delivered hastily, the intestines be cleansed thoroughly and replaced, and the opening be sewed up. In the case of a very large irreducible vaginal hernia, Cesarean section would be preferable in a labor at term. Other growths or tumors in the pelvic inlet cavity com- plicating pregnancy and obstructing labor have been fibrocystic DISEASES OE THE VAGINA. 39 1 tumors of the ovarian ligament, requiring an abdominal section; fibroma of the ovary; sarcoma of the ovar\'; a displaced adherent Fig. 314. — Vaginal cyst. W^MB^. , ,^,j^>^^^^^^^^^^^ f Fig. 320. — Cyst of labium minus. Edema of the vulva may be unilateral or bilateral, and in some pregnant women reaches an extreme degree. It is due to the pres- sure upon the pelvic veins, to kidney insufficiency, or, in the uni- lateral form, to labial abscess. There are some women who develop a vulvovaginal abscess regularly in every pregnancy, and not at other times. Treatment. — If the cause can be removed, the edema disap- pears. The treatment of kidney insufficiency removes the dropsy of the labia associated with that condition, as it does the other dropsies of the body. If the edema is due to pressure, 396 PATHOLOGY. rest in bed, with the occasional assumption of the knee-chest posture, often gives relief If the edema does not yield to gen- eral treatment and to hot fomentations locally, the labia may be punctured. It should be remembered, however, that even this slight operation may terminate pregnancy. The vitality of the part, moreover, is so lowered that infection and even gangrene may follow the puncture. In the unilateral edema, associated with labial abscess, the vulvovaginal gland should be laid open in the last month of pregnancy, curetted, cauterized with car- bolic acid, and packed with gauze, or else should be exsected entirely, which is the safest plan. The operation is bloody. Several large vessels must be clamped and tied. Otherwise it is Fig. 321. — Sarcoma of urethra. not difficult. The deep wound remaining after the removal of the gland is united with interrupted sutures. A drain of silk- worm-gut strands must be laid along the bottom, and allowed to remain at least forty-eight hours. Some severe infections are due to the rupture of a vulvovaginal abscess during labor. Periuterine Inflammations and Adhesions. — Old cases of pelvic adhesions may be benefited by massage and tampons. The most satisfactory results, however, are secured by appropriate treat- ment during the intervals between pregnancies. Fresh attacks of periuterine inflammation in pregnancy, depending upon oopho- DISEASES OF 77/E VULVA. 397 Fig. 322. — Venereal warts and the flat condylomata of syphilis combined. Fig. 323. — Abscess of vulvovaginal gland. 398 PATHOLOGY. ritis and pyosalpingitis, are exceedingly dangerous. Unlikely as it may seem, a woman may be impregnated, though she- have at conception a pyosalpinx and densely adherent tubes and ovaries. The inflammation of the adnexa may be lighted up afresh by the congestion of pregnancy. In such cases a septic peritonitis may Fig. 324. — Varices of the vuiva (author's case). be averted only by a prompt abdominal section and the removal of the appendages. Loosening of and Pain in the Pelvic Joints. — If the normal relaxation of the pelvic joints in pregnancy is carried to an ab- normal degree, it may interfere with locomotion. The diagnosis of relaxation of the pubic joint is made by a vaginal examina- tion, the patient, in the erect posture, taking a step or two, while the examiner holds his index-fmger in the vagina against the posterior surface of the symphysis. DISEASES OF TIIK BREASTS. 399 Relaxation of the sacro-iliac joints is recognized by planting the thumbs firmly in the dimples on the back over the joints and making the patient step forward and backward. Treatment. — Application of a firm binder or broad rubber adhesive strips about the hips will usually make the patient comfortable. Rest in bed may be necessary in exaggerated cases. The pelvic joints, especially one sacro-iliac, may be the seat of severe pain of rheumatic origin. The patient may be entirely disabled by her suffering. This pain yields to antirheumatic remedies like the salicylate of strontium. Fig. 325. — Edema of vulva iu Uic eighth month of pregnancy, due to pres- sure. Justominor pelvis. Fetal head unengaged above the pelvic brim. Swell- ing disappeared in a few hours after multiple punctures (University Maternit}')- Diseases of the Breasts in Pregnancy. — Mammary Abscess. - — Its cause, course, and treatment are the same as when it occurs during the puerperium. Eczema of the nipples may be very obstinate in its resistance to treatment. Relief may only be secured after delivery. Mean- while the usual treatment for eczema may be tried with more or less success. Mammary tumors may take on a ver\^ rapid growth under the stimulus of pregnancy. A simple adenoma the size of a walnut, quiescent for years, may reach the size of a cocoanut during pregnancy. 400 PATHOLOGY. CHAPTER IV. Systemic and Other Diseases. AUTaiNTOXICATION OR TOXEMIA. Auto=intoxication or toxemia in pregnancy is still the subject of earnest study, which has thrown much additional light on it, but has not yet enabled any one to speak dogmatically. There is an auto-intoxication in the first half of pregnancy, probably due to the growth and secretion of syncytial cells/ which produces a hemolytic agent and excites the production of an antibody, syn- cytiolysin. The chief symptom of the auto-intoxication of early pregnancy is exaggerated vomiting. The blood-pressure is low. In fatal cases a degeneration of the hepatic lobules is found beginning in the center and extending to the periphery. There is also an auto-intoxication in the second half of pregnanc3% probably due to the reception into the maternal blood of the prod- ucts of metabolism in the fetal body. There are many ad- herents of the placental origin of the toxemia of late gestation; of the theory that the placental cells are the source of the tox- emia. "\ATiether the placenta or the fetal body is the source of the toxins, there may be an anaphylactic action in the mater- nal blood determining an auto-intoxication. Abnormal internal secretions of the thyroid, the parathyroids, and the suprarenals may have something to do with late gestational toxemia, as these structures are certainly influenced by pregnancy. A recent theor}^ (Sellheim), that the mammar>' glands are the source of the intoxication, has little clinical or experimental evidence to support it. Adhering to definitely established facts, it appears that there may be toxins in the blood of a pregnant woman, exciting contractions of the arterioles and raising the blood- pressure; that the liver deals with these products and breaks them up by oxidization into substances suitable for elimination, mainly by the kidneys. Either one of these organs may prove insufficient for the extra work thrown upon it, and thus toxins accumulate in the blood. As far as clinical observation goes, the kidneys are more frequently at fault than the liver. In less than a fifth of the cases toxemia manifests itself without prece- dent albuminuria. In more than four-fifths of the cases the symptoms of toxemia are preceded by well-marked albuminuria 1 Behm, " Arch. f. Gyn.," Bd. Ixix, H. 2. DISEASES OF THE ALLMENTAKY CANAL. 4OI and other symptoms of kidney insufficiency. The systemic symptoms of the toxemia of late pregnancy are usually ag- gravated pari passu with increased evidence in the urine of dis- turbances in the kidneys, and improve as the urine improves; they are high blood-pressure, a furred tongue, indigestion, vomiting, headache, pain in the epigastrium. There are usually scanty urine, edema, casts, and albumin. Ultimately there is somnolence, failing vision, and finally an outbreak of eclampsia. Of all these symptoms, high blood-pressure is the most con- stant. In a minorit}' of cases the liver is primarily and mainly afi'ected. The symptoms in such cases are those of hepatic degeneration; the urinary examination may be negative, and there may be a fatal issue without con\-ulsions. It is to this kind of case that the paradoxical name of " eclampsia without convulsions " has been given. Auto-intoxication occasions sometimes a train of symptoms suggesting miliary tuberculosis. There is irregular and prolonged fever, profound emaciation, and a rapid pulse. The patient may appear hopelessly ill and yet a termination of pregnancy cures her. The treatment of auto-intoxication is considered under the head of Eclampsia, of the Kidney Diseases in Pregnancy, and of Pernicious Vomiting. DISEASES OF THE ALIMENTARY CANAL. Mouth. — Caries of the teeth frequently troubles a pregnant woman. It is a common saying that for every child a woman loses a tooth. As a rule, prolonged and painful dental opera- tions are inadvisable during pregnancy. Temporary work only should be done by the dentist, who should be acquainted with his patient's condition. The syrup of the lactophosphate of lime. f5j(3.75 c.c.) t. i. d., internally, a mouth-wash of milk of mag- nesia, frequent brushing of the teeth, and rinsing the gums with diluted listerine should be prescribed for all pregnant women who display a tendency to dental decay. In 60 per cent, of pregnant women there is some hypertrophy of the gums. Gingivitis. — In this disease the gums are spongy, inflamed, bleed easily, and are possibly ulcerated. The condition may obstinately resist treatment until pregnane}- is concluded. Occa- sionally the gingivitis extends to a stomatitis, and rarely lasts through, and is aggravated by lactation, only disappearing when the child is weaned. The inflammation ma}' extend down the esophagus to the stomach, producing dyspepsia and an obstinate vomiting. Astringent and cleansing mouth-washes, containing 26 402 PATHOLOGY. tincture of myrrh give the best results in the treatment of this affection. Toothache may develop with or without pathological changes in the mouth, and in the latter case may resist treatment. It usually subsides in the second half of gestation if it is a neurosis. If it is due to dental caries, temporary dental treatment should give relief. Ptyalism occurs usually in the first half of pregnancy. The saliva is alkaline and ptyalin is lacking. The causes are the same as those of pernicious vomiting. They are : a neurosis, a reflex irri- tation of the sympathetic nervous system, or an auto-intoxi- cation. Astringents, belladonna, chloral, etc., may be employed. It disappears usually in the later months, but may recur in each succeeding pregnancy. One of my patients had saUvation in five successive pregnancies. Every night a large receptacle was placed by the bedside into which saliva was expectorated in astonishing quantities. A case is reported in which 1600 c.c. (51 oz.) was expectorated daily (Levoff). The Stomach. — There is a physiological, an exaggerated, and a pernicious vomiting in pregnancy. The last is a serious disease, with a high mortality. Pernicious vomiting is such an exaggeration of the physio- logical nausea and vomiting of pregnancy that the stomach becomes almost or quite unretentive. Causes. — There are three causes for the pernicious vomiting of pregnancy: toxemia, reflex irritation, and a neurotic condition of the individual. The toxemic vomiting in early pregnancy is not yet satisfactorily explained. The most reasonable theory is an intoxication from the cells of syncytium, the balance between hemolysis and sync3^tiolysis being disturbed. There is accu- mulating e\ddence of an anaphylactic action. The toxemic vomiting late in pregnancy depends upon an imperfect elim- ination or oxidization of the products of fetal metabolism, and is usually associated v^th kidney insufficiency and albu- minuria. The urine should always be carefully examined and the blood-pressure taken if vomiting appears late in preg- nancy. The reflex vomiting is due to an irritation of the stomach from the distention of the uterus and an irritation of the latter's sympathetic nerv^e-endings, in consequence of the stretching of the uterine walls. It is, therefore, more common in primigrav- idae, especially in elderly women; in twin pregnancies; in hydram- nios; in chronic metritis or displacements of the uterus, especially if complicated by adhesions; in cases of chronically thickened, inelastic, or diseased cervices, and in a hyperesthetic or disordered condition of the nervous system. In one of my cases I had re- D/SEASES OE THE ALIMENTARY CANAL. 403 moved five fibromyomas by enucleation three months before impregnation. Another cause may be found in inflammation of the Hning mucous membrane of the cervix or of the uterus. Engorgement or inflammation of neighboring organs, as inflamed tubes or ovaries, or an old or fresh appendicitis, increases the irritation of the distending womb, usually by reason of adhesions which bind it down. A pathological condition of the stomach, as gastroptosis, chronic gastritis, or gastric ulcer, naturally increases gastric irritability, so that the stomach feels acutely the reflex irritation of pregnancy. There may rarely be some pathological condition of the intestinal tract, as polypi or bands of adhesions, as a cause of pernicious vomiting. Immoderate indulgence in sexual intercourse is a not infrequent cause. The neurotic vomiting appears in women of the neurotic type and may be neither reflex nor toxemic; but both reflex and toxemic vomiting are more likely to appear in neurotic women or are aggravated in such women. Diagnosis. — The recognition of the cause may be difificult, but the diagnosis of the condition is easy. There is usually a subnormal temperature, but there may be fever ; there is great emaciation, pallor, and loss of strength. The lips are dried and cracked, the tongue brown and coated, and the breath foul. The blood-pressure is low. The urine is normal, but concen- trated. There is constant retching, and everything put into the stomach is either immediately rejected or comes up undigested in a short time. Whether anything is ingested or not, mucus and bile are vomited from time to time. A gastric ulcer is not uncom- monly the result of the disordered secretion of the stomach and the reduced vitality of its walls. In such cases the vomiting be- comes bloody and the patient may succumb to repeated gastric hemorrhages, which she can not endure in her enfeebled condition. The most unfortunate mistake in the diagnosis of the pernicious vomiting of pregnancy is the failure to recognize the existence of gestation and the consequent belief that the emesis is that of hysteria, gastric ulcer, or cancer. Persistent vomiting in a woman of child-bearing age should always arouse a suspicion of pregnancy and should always indicate a vaginal examination. An attempt has been made to make a differential diagnosis between reflex and toxemic vomiting by the percentage of ammonia nitrogen in the urine, an increased percentage indicating toxemia. The author's investigations do not support this contention. There is an increase of ammonia nitrogen in the urine as a con- sequence of any form of vomiting ; a percentage of 1 7 has been found in a typical reflex case. 404 PATHOLOGY. The treatment of hyperemesis gravidarum should be directed toward the cause if it is ascertainable or amenable to treatment. The various remedial measures required in individual cases may be conveniently studied under the following heads: Hygienic. — This includes regulation of the diet, attention to the gastro-intestinal tract, to the woman's sexual relations, and to her mode of life. The physician should advise a light breakfast of tea and toast or milk, taken in bed before getting up, the patient lying flat upon her back. Resting quietly for a half-hour or so after the ingestion of light, simple food, the distressing nausea and vomiting usually felt on first rising in the morning may be entirely avoided. Sexual intercourse should be forbidden. Oc- casionally there is improvement when the sensation of swallowing is removed by a cocain spray of the fauces, or by injecting food into the stomach through an esophageal tube. Lavage of the stomach and of the colon has been beneficial. An electrical current applied over the neck and the epigastrium has occasion- ally been of service. Rectal alimentation must be resorted to in the worst cases, the enemata being non-irritating, so as not to provoke an exhausting diarrhea, partially digested, easily absorbed, and not administered in too large amounts or too frequently. Four to six ounces may be given three or four times a day, of liquid peptonoids, pancreatized milk, or pep- tonized beef-tea. The rectum should be washed out twice a day, and after the irrigation a pint of normal salt solution should be injected high up in the bowel for the relief of the distressing thirst that is a constant symptom. A tolerance of the stomach may at times be secured by allowing appar- ently unsuitable articles of food if they are strongly craved by the patient. In all cases of true pernicious vomiting the patient must be confined to bed, the room should be darkened and kept absolutely quiet, and every atom of the patient's strength should be saved by careful nursing. It must be remembered that the vomiting of pregnancy is sometimes a neurosis. Hence a strong nervous impression upon the patient or the establishment of a moral control over her, as in the treatment of hysteria, will often give brilliant results. A case of hyperemesis may be cured by making a vaginal examination, and the entrance into the patient's bedroom of a consultant may immediately check a vomiting previously uncontrollable. Again, a positive statement that a certain remedy would unfailingly stop the vomiting has made it immediately successful. In one case the appointment to induce abortion the following day so frightened the patient that she never vomited again. DISEASES OF THE ALIMENTARY CANAL. 405 The Medicinal Treatment. — The drugs that have been lauded as specifics in the treatment of hyperemesis include a large pro- portion of those in the pharmacopeia. The remedies most worthy of mention are : lodin, gtt. j ij (0.06 to 0.12 c.c.j in water; oxalate of cerium, subnitrate of bismuth, tincture of nux vomica, antipyrin, wine of ipecacuanha in small doses, adre- nalin chlorid solution, 10 drops of a i : 1000 solution, menthol, hydrobromate of hyoscin, and cocain. The nerve sedatives — the bromids, chloral, and opium — are the most reliable (sodium bromid, gr. x — 0.65 gm. — in aq. camph., .5iv — 15.50 gm. — four times a day, is a useful routine prescription). If the stomach is intolerant of drugs, recourse may be had to enemata of sodium or potassium bromid, gt. xl (2.60 gm.), and chloral, gr. xx (1.3 gm.), two or three times a day, dissolved in several ounces of water. Injections of normal salt solution in the bowel, in a vein, or under the breast have succeeded in some cases, it is claimed, by wash- ing the blood, stimulating the kidneys, and thus combating the toxemia. In the early stages of the disease calomel and salts may be effectual. The Gynecological Treatment. — If the vomiting of pregnancy becomes exaggerated and resists the ordinary hygienic and medicinal treatment, a vaginal examination should be insisted upon. Various abnormal conditions of the pelvic organs may be discovered and must be treated. A displaced uterus must be replaced. If the cervix is engorged, thickened, or cicatricial, or if its canal is inflamed, applications may be made to it through a cylindrical speculum, a twenty-grain solution of nitrate of silver, for example, being poured into the speculum until the cervix is submerged in it. Multiple punctures of the cervix or the use of glycerin tampons may be considered, though these measures would be employed at the risk of inducing abortion. Peroxid of hydrogen has been found useful poured into the speculum as just described. It is obvious that if applications to the cervical canal are made with an applicator and cotton, abortion might result. If there is metritis, with a large, heavy, inelastic womb, treatment may not accomplish much during pregnancy. Glyc- erin tampons may be tried if the knee-chest posture, rest in bed, and free purgation fail, but they may induce abortion. An adher- ent, displaced womb, with old or recent peri-uterine inflammation, is not infrequently responsible for a particularly obstinate and vio- lent form of emesis. Pelvic massage, vaginal packing, or the col- peurynter must be resorted to at the risk of terminating pregnancy. An operation for appendicitis during pregnancy may be indicated. A strong solution of cocain, applied to the cervix and to the vagi- nal vault, has been beneficial in a {q\s cases. Dilatation of the cer- 406 PATHOLOGY. \\y. with the fingers or with a bougie has occasionally been wonderfully successful. This so-called Copeman plan of treat- ment has many enthusiastic advocates, but experience has taught me that it is unreliable. Its occasional success is ex- plained, I beheve, by the nervous impression produced upon the patient. The Serum Treatment. — If pernicious vomiting depends upon a toxemia due to the syncytium, then the serum of a woman who has spontaneously recovered from the physiological vomiting of pregnancy should contain an antibody to the activity of the syncytial cells which are foreign invaders of the woman's organ- ism, necessarily exciting hostihty on the part of the body cells. Experiments with this treatment, begun in the University Mater- nity two years ago, appear to promise good results. The Obstetrical TreatineJit. — Induction of abortion or of pre- mature labor should be regarded as the last resort, but it should not be delayed too long. If a patient retains absolutely nothing on her stomach and must be fed by the rectum ; if she vomits incessantly whether anything is put into the stomach or not ; if the pulse rises to 1 20 and the prostration is really alarm- ing, abortion must be induced. As a rule, I do not continue rectal alimentation more than a week. There is one case on record in which rectal feeding was employed with success for almost two months, but this single instance should not encourage physicians to persist for an inordinate length of time in rectal alimentation. There are many deaths recorded of women fairly well nourished by food injected in the bowel, but fatally ex- hausted by incessant retching and vomiting. It has been claimed that a high percentage of ammonia nitrogen in the urine indicating a toxemic vomiting calls for the induction of abortion. But as this condition may be an effect and not a cause, as it is found in reflex as well as toxemic cases, as a sponta- neous recovery has been observed with a percentage as high as thirty, the physician can not be guided by this test in deciding for or against the radical treatment. The mortality of the pernicious vomiting of pregnancy is high. Of 239 cases, 95 died; of 57 cases treated by the usual means, 28 died ; of 36 cases treated by the induction of abortion, 9 died. I have induced abortion for hyperemesis fifteen times. Two patients died. In one case I was called to see the woman in consultation when she was almost moribund. The induction of abortion proved too great a shock to her, easy and simple as the operation is. In the other case the religious scruples of the family prevented the termination of the pregnancy when I first advised it. Ten days later, the patient being obviously at DISEASES OF THE ALIMENTARY CANAL. 407 death's door, the operation was demanded, but was performed too late. The Intestines. — Constipation should be guarded against to prevent overwork of the kidneys. The small compressed pill of aloin, belladonna, cascara, and strychnin, kept in stock by all pharmacists, is a good routine remedy. My routine prescription at present is: R. Phenolphthalein, Ext. cascar., Ext. colocynth. com aa gr. j ; Ext. luic. voni., Ext. belladonn aa gr. yV- Sig. — In pill form at bed-time. The weaker mineral waters, effervescent phosphate of soda, and pulv. glycyrrhizae comp., may be used. Agar-agar alone or in the proprietary remedies, reguHn and scoragene, has the ad- vantage of a purely local action on the intestines. A mild course of calomel followed by a seidlitz powder is indicated, as a rule, about once a month. Active purges not only disturb digestion, but may interrupt gestation.^ Diarrhea. — When the ordinary astringent remedies fail to check a diarrhea in pregnancy, nerve sedatives should be tried. There is a nervous diarrhea of pregnancy due to the mechanical irritation of the intestines by the growing uterus. Gastric and Intestinal Indigestion. — The latter is not uncommon in primigravidae, and may give rise to such severe abdominal pains that a suspicion of extra-uterine pregnancy seems justified. These conditions, too, may be a neurosis, and may yield to valerian, bromids, and similar remedies after the ordinary treatment for dyspepsia has failed completely. The liver is always under a strain in pregnancy. Toxins derived from the ovum or the embryo are conveyed by the maternal blood to the liver for oxygenation or preparation for elimination, mainly by the kidneys. Jaundice may result from a mild catarrhal condition of the bile-ducts, which may have existed before preg- nancy. This class of cases is of little clinical importance. It should be remembered, however, that a serious condition may develop in pregnancy as the result of excessive work thrown upon the liver — namely, an acute degeneration of the whole hepatic structure. Locahzed degenerations of the liver are seen in all * Herrgott reports a remarkable case of neglected constipation in pregnancy in which the urethra was obstructed and the bladder contained 4450 c.c. of urine ; the posterior vaginal wall was pressed firmly against tlie anterior and the uterus was displaced upward and to one side by an enormous mass of feces, "Ann. de Gyn.," April, 1899. 408 PATHOLOGY. fatal cases of eclampsia, and the toxins circulating in the blood in that disease ma}^ act upon the liver like phosphorus, producing acute yellow atrophy. There is a difference between the degeneration of the toxemia of early pregnancy with excessive vomiting and that of the tox- emia of late pregnancy with kidney insufficiency and eclampsia. In the one the atrophic and necrotic process begins in the center of the lobule, extending to the periphery ; in the other the process is reversed. Treatment. — As the liver is called upon for extra work in preg- nancy, care should be exercised not to impose too heavy a burden on it by heavy food, immoderate indulgence of a capricious appetite, alcoholic drinks, cold, or sluggish action of the bowels. Simple catarrhal jaundice is treated by regulation of the diet and of the bowels, and by the administration of calomel to secure a free discharge of bile. The graver form of hepatic degeneration is likely to be rapidly fatal. Pregnancy predisposes to the formation of gall-stones or ag- gravates their symptoms. The operative treatment should be postponed if possible till after delivery. Appendicitis in Pregnancy. — B abler has collected 235 cases of appendicitis complicating pregnancy, labor, and the puerperium;^ Renvall, 253;- Schley,^ 215. The author's experience with the operative treatment of appendicitis in pregnancy has taught him the following lessons: (i) If the patient has an attack of appendi- citis during early pregnancy, especially if she has had an attack before, operation should be advised. It is easy in the first half of pregnancy and should not endanger the continuance of gesta- tion. An operation after the fifth month, on the contrary, is much more difficult, and if an attack occurs late in gestation, in consequence of intense congestion and increased intra-abdominal pressure, it is likely to be very severe, with early perforation and virulent peritonitis. (2) If there is reason to suspect suppura- tion, the median incision is required in operations after the fourth month ; the uterus should be lifted out of the abdominal cavity to detect possible areas of suppuration deep in Douglas' pouch or on the left side. If there is no suppuration or peritonitis, the lateral incision is much better and safer. (3) If it is necessary to deliver the uterus from the abdominal cavity after the seventh month, it should be emptied by a Cesarean section before it is ^ " Perforative Appendicitis Complicating Pregnancy," " Jour. Am. ]\Ied. Assoc," Oct. 17, 1Q08. - " Mitteilungen aus der Gyn. Klin, des Prof. D. Otto Engstrom," Bd. vii, H. 3, Berlin, iqo8. ""Zentralbl. f. Gyn.," No. 27, 1910. DISEASES OE THE URINARY APPARATUS. 4O9 replaced in the abdominal cavity. If drainage is required after a Cesarean section the womb should usually be amputated. (4) Diffuse suppuration and the necessity for drainage is not neces- sarily incompatible with recovery or the continuance of preg- nancy. In one of the author's cases at four and one-half months the woman recovered and went to term. Hemorrhoids. — The pelvic congestion of pregnancy and the mechanical interference with the circulation by the bulk of the gravid uterus predispose to hemorrhoids, and aggravate them if they antedate conception. Palliative treatment alone is per- missible. An ointment of equal parts of ung. gall, and ung. stramon. will be found serviceable. Cocain, lead salts, and opium may also be useful. Rest in the horizontal posture, the knee-chest posture several times a day, and the routine use of laxatives may be necessary. Moderate dilatation of the sphincter with a conical dilator is often effectual. As in all cases of hemor- rhoids, the bidet gives great comfort. DISEASES OF THE URINARY APPARATUS. Examination of the Urinary Tract and of the Urine. — Cystoscopy and catheterization of the ureters is required for many complications and consequences of the child-bearing process. Two cystoscopes are needed, one for water, the other for air distention of the bladder. I find the 191 1 model Wappler best for the former, the Eisner cystoscope best for the latter. In F^^^ Fig. 326. — Wappler cystoscope, 1911 model. using the water distention instrument the bladder should be irrigated and filled with sterile water. For the air distention the position indicated in Fig. 327 is necessary. With either cystoscope the catheterization of the ureters is easy, but the air distention is impracticable late in pregnancy. In looking into a pregnant woman's bladder, allowance must be made for the ex- treme distention and multiplication of the blood-vessels, which 410 PATHOLOGY. under any other circumstances would be pathological. If it is necessary to obtain the urine from the two kidneys separately and the urethral catheters cannot be used, or urine does not flow from them satisfactorily, the Luys's segregator should be used. For the Fig. 327. — Position of patient for air distention cystoscopy, requiring long leg supports, set further back in the author's operating table than in the ordinary Edebohl position. The body held in position by shoulder clamps. Fig. 328. — Urethroscope and its obturator. examination of the urethra the instrument shown in Fig. 328 will be found most satisfactory. The urinalysis ordinarily required in the child-bearing woman is described on p. 140. If more complicated or delicate inves- DISEASKS O/' THE URINARY APPAKATIJS. 4I I Fig. 329. — Eisner's ureter cystoscope : A, Catheter; B. catheter carrier tubes; C, cystoscope; D, obturator; E, window; F, dilating bulbs ; G, stop-cock; H, lamp; I, irrigator and aspirator; K, current attachment ; M, Eisner stiletto probe ; N, cocain applicator. Fig. 330. — Luys's instrument for the intravesical separation of the two urines. tigations are necessary, the student is referred to special manuals on the subject. Kidneys. — The Kidney of Pregnancy. — There is a pathological condition of the kidneys so frequently developed in pregnancy 412 PATHOLOGY. (fifty-eight out of seventy, Fischer^) that it deserves the name of " kidney of pregnancy." Pathology. — There is anemia with fatty infiltration of the epi- theHal cells, without acute or chronic inflammation. Etiology. — The causes of the common changes in the kidney during pregnancy are still obscure. They have been attributed to pressure on the renal blood-vessels, to the direct compression of the kidneys by the gravid uterus, to a serous condition of the blood in pregnancy, to the influence of the weather, to pressure upon the ureters, and to spasmodic contraction of the renal arter- ies. It is likely that the condition is toxic, with contraction of the renal arterioles. Symptoms. — There is albuminuria. Hyaline and granular casts, with epithelium filled with fat, may be found. The blood- pressure is raised. The kidneys may prove physiologically insufficient, and there may appear all the symptoms of renal insufficiency observed in true nephritis. Frequency and Course. — ^About six per cent, of all pregnant women have albumin in the urine in decided amounts, though a vastly larger proportion show some degree of the kidney of preg- nancy, if there is an opportunity for a postmortem examination. Albuminuria occurs most frequently in primigravidae. The kidney disturbance runs a subacute course, manifesting itself most plainly in the latter months of gestation. It may influence the general health, the course of pregnancy, and the occurrence of eclampsia, just as inflammatory renal diseases would do. The renal insuffi- ciency exerts a malign influence upon the fetus, also, especially in the production of placental apoplexies. If the mother becomes uremic, the fetus is also poisoned and rarely survives its birth more than a few hours. The dangers to both mother and child are greatest if the condition develops suddenly. The renal in- sufficiency of the kidney of pregnancy disappears with the cessation of gestation. The treatment is practically the same as for true nephritis, so that the management of the kidney complications of pregnancy will be considered without reference to the cause of the kidney insufficiency. Acute and Chronic Nephritis. — These diseases may occur at any time during pregnancy, with their usual symptoms. The extra amount of work thrown upon the kidneys during pregnancy makes the prognosis of kidney diseases graver than at other periods of adult life, and a more energetic treatment may be demanded in the pregnant than in the non-pregnant woman. Premature expulsion of the ovum and outbursts of eclampsia are 1 " Prager med. Wochens.," 1892, No. 17. DISEASES OF THE URINARY APPARATUS. 413 frequent. Chronic nephritis may be acquired before or during pregnancy. Acute nephritis or a sudden insufficiency of the kidneys may be the result of exposure to cold, wet feet, sitting in a draft when overheated, or a single gratification of a ravenous appetite. Differential Diagnosis between True Nephritis and the Kidney of Pregnancy. — If the kidney disease existed before pregnancy, well-marked symptoms will develop in the earlier months. The appearance of the first symptoms after the sixth month usually justifies the assumption that the disease has had its origin during pregnancy, and is nothing more than a mani- festation of the toxemia of that condition. Chronic Nephritis. The history may point to its existence before pregnancy. Quantity of urine increased and its spe- cific gravity low; but these condi- tions arc normal in pregnancy. Sudden diminution in quantity may appear. Occasional presence of albuminuric retinitis. The symptoms of kidney insufficiency — albuminuria, edema, somno- lence, headache — apt to be pro- nounced in the earlier months. The autopsy shows inflammatory changes, chronic or acute. Persists after delivery. Casts usually appear early and abundance. Kidney of Pregnancy. The history would indicate that the kidneys were normal before con- ception. Quantity of urine likely to be increased and Its specific gravity is low. Sudden diminution possible, as in true nephritis. Not so frequent in the kidney of preg- nancy. Do not appear, as a rule, until after the sixth month of gestation. Anemia and fatty degeneration of the kidney epithelium are found post- mortem. No inflammatory changes, though the kidneys may become secondarily congested if convulsions have occurred. Disappears after delivery. Casts onl}^ in bad cases, not appearing usually until the other symptoms of kidney insufllciency have de- veloped. Treatment. — It is important to know, in any case of preg- nancy, the condition of the kidneys; hence in all cases the urine should be repeatedly examined, at least every two weeks during the earlier months and once a week during the last month. If albumin appears, but if its quantity is small, if the total amount of urine in twenty-four hours is not diminished below the normal, if there are no casts, no history of a previous nephritis, if the blood-pressure is below 140, and there are no symptoms of general systemic disturbance, dietetic and hygienic management may be sufficient, so long as the case is kept under careful obser- vation. Meat should be forbidden. Large drafts of water should be systematically drunk. Prudence must be exercised 414 PATHOLOGY. about adequate underclothing, exposure to cold and wet feet, and a laxative should be taken regularly if it is required. If the blood-pressure is above 140, if the amount of urine voided is decidedly diminished, if casts are discovered and edema ap- pears, the patient should be put to bed; a sweat in a sweat cabinet should be given at least once a day for thirty minutes; the bowels must be kept freely open, but not by saline purges; the diet should be reduced to milk and Basham's mixture, or some other diuretic should be given. Three-grain doses of caffein and benzoate of sodium are satisfactory. If an exclusive milk diet is impossible, milk soups, a small amount of toast, the lighter vegetables — squash, asparagus, beets, salad, spinach, etc. — may be allowed in small quantities. If under this plan of treatment the symptoms grow progressively worse, especialty if the blood-pressure steadily rises, the termination of preg- nancy is necessary. There is no disease of pregnancy \^dth which the physician can so ill afford to trifle as this. Obscurit}^ of vision or actual bhndness, demonstrating usually the presence of albuminuric retinitis, indicates the induction of labor or of abortion without delay. Both ophthalmologists and obstetricians of experience are agreed that if the woman's vision, nay, if her hfe, is to be saved, pregnancy must be terminated. Renal tumors are rare. They are to be diagnosticated and treated according to the individual features of the case, but it must be borne in mind that any disease or abnormalit}^ of the kidney predisposes to insufficiency of excretion. The anatomic cally perfect kidney is likely, but not certain, to be physiologically sufficient. The unhealthy kidney will probabh', but not certainly, be insufficient.! Dislocation of the Kidney. — The right kidney is almost always the one affected. The displacement of the kidney is not infre- quently associated with displacements of the gravid uterus. Abortion may result if the floating kidney happens to become twisted upon its pedicle. From the pressure to Avhich the displaced kidney is subjected, and in consequence of interference with the renal circulation by torsion of the vessels, the kidney of pregnancy may develop. There sometimes occurs acute hydro- nephrosis with high fever, rapid pulse, great abdominal tender- ness, sudden increase in the size of the kidney, and the periton- itic expression. Ice applications over the kidney may relieve the patient. The most immediate and permanent relief is ob- tained by catheterizing the ureter. Induction of labor may be ^ For two cases of hypernephroma associated with the child-bearing act see Noble, " American Gynecology," Jul}', 1902; Bo^^d, " Am. Jour. Med. Sci.," June,. 1902. DISEASES OE THE URLYAKY APrAKATUS. 415 necessary. A congenital fixation of the kidney in the pelvis has been noted in the child-bearing woman. ^ It is usually the left (fourteen out of fifteen cases (Cragin)). Pregnancy Following Nephrectomy. — Pousson'" collected the reports of 74 nephrectomies during or jireceding pregnancy with only 2 deaths in the child-bearing woman; one from eclampsia, one from kidney insufficiency. The danger of gestation, therefore, in a woman with only one kidney is not great. Diseases of the Pelvis of the Kidney. — Pyelitis has the history of all the infectious diseases in pregnancy; it is aggravated by the condition, and reacts unfavorably upon it. It is a disease of the last four months of pregnancy. Premature expulsion of the fetus is apt to occur. Pyelitis is a comparatively frequent com- plication of pregnancy. The right kidney is most often affected for several reasons: The torsion of the uterus, its right lateral inclination, and the position of the presenting part in the right oblique diameter of the pelvis subject the right ureter to more pressure than the left; the common dislocation of the right kid- ney predisposes to congestion and to a kink in the ureter. The attack may be ushered in by a chill and there is often severe pain in the renal region and along the course of the ureter. The fever may be high, but is usually moderate. There is leukocy- tosis. The pyelitis is often due to lowered resisting power of the kidney the result of pressure upon the ureters, and is usually the result of a colon bacillus or a gonococcus infection, but the pathogenic bacteria may be staphylococci, streptococci, pneu- mococci, or tubercle bacilli. The infection usually ascends from the bladder, but may come from the blood. There is pus in the urine, but usually no cystitis. Cystoscopy and catheteriza- tion of the ureters are required in order to make an accurate diagnosis. A common error in diagnosis is to mistake pyelitis for ap- pendicitis. The treatment is rest in bed on the side opposite the diseased kidney; ample draughts of water; salol and helmitol; an anti- toxemic diet; an ice-bag over the upper outer segment of the abdomen and distention of the bladder by irrigation to excite peristalsis in the ureters and thus to drain the kidneys. A single catheterization of the ureters often benefits or cures the patient by removing some obstruction to free drainage. In- jection of argyrol into the pelvis of the kidney through a ureteral 1 Cragin has collected five cases in addition to his own. The author has re- ported a case not included in Cragin's statistics, " Am. Jour, of Obstet.," July, 1898. -"Ann. de Gynec. et d'Obstet.," October, 1910. 41 6 PATHOLOGY. catheter may be required. My experience %nth autogenous vaccines has been uniformly unfavorable. Nephrostomy in uni- lateral cases may be considered. Even nephrectomy may be de- manded if the suppuration involves the substance of the kidney, but such cases are very rare in pregnancy.^ They occur more frequently in the puerperium. The induction of labor is indi- cated if there are fever, large quantities of pus in the urine, a high leukocyte count, and a failure to respond to treatment. There is usually a spontaneous recovery after labor, sho-^ing the influence exerted by the pressure of the gravid womb upon the ureters. 2 Hydronephrosis. — A displaced and adherent gravid uterus may occlude the ureters, with this result. The condition requires the reposition of the uterus. A renal calculus is apt to induce abortion. Renal colic in pregnancy is to be treated in the usual manner, without regard to the patient's condition. The surgical treatment is not contra- indicated. Diseases of the Bladder. — Irritability is a functional disturb- ance, and occurs in an exaggerated degree in hyperesthetic in- dividuals, who feel acutely the pressure of the gravid uterus, the pull upon the uterovesical ligament, and the congestion of all the pelvic viscera. Some degree of irritabihty of the bladder is seen, as a rule, in pregnant women. Tlie treatment, \i ■asvy IS required, may consist of the reposition of a displaced uterus. If the disturbance is purely neurotic, nerve sedatives are indicated. The incontinence of retention is one of the most distinctive symptoms of a backward displacement of the gravid uterus. There may be, however, a neurotic incontinence and a paretic incontinence in pregnancy. Vesical hemorrhoids are due to an increased blood-supph' to the part and an interference with the circulation by the pressure of the pregnant uterus. Hematuria may be a symptom. If the loss of blood becomes alarming, astringents may be injected into the bladder ; the knee-chest posture should be assumed at frequent intervals, and the bowels must be kept freely opened. Cystitis is more frequent after labor than in pregnancy ; com- plicating pregnancy, it may be due to gonorrhea. Vesical Calculi. — It is important that \-esical calculi be dis- covered before labor. They should be removed through the 1 Germain, " La Gjti.," July, 1909, collected 26 cases of nephrectomy in pregnane}' with a mortalit}' of 7.6 per cent. 2 Kendirdjy collected 62 cases with 2 deaths, " Gaz. des hop./' April. 1904. DISEASES OF THE BLADDER. 417 urethra or by vaginal lithotomy during the last month of preg- nancy, so that if labor is induced by the operation, the child shall not suffer by reason of its prematurity. If the woman falls in labor with an undetected stone in the bladder, a vesicovaginal fistula is likely to be the result. Anomalies of the Urine in Pregnancy. — Polyuria is an ex- aggeration of the physiological increase of the urine in pregnancy. It sometimes reaches an astonishing degree. One of my patients passed 220 ounces of urine a day. There is usually great thirst and the urine has a very low specific gravity, but should contain no albumin or sugar. The woman's health remains unimpaired, and it is unwise to attempt to diminish the excretion. After delivery, the polyuria disappears. The urine may be diminished in quantity, may be high colored, and may have a high specific gravity, as the result of errors in diet and inactivity of the skin and bowels. This condition should never be regarded with indifference. It shows an in- creased strain upon the kidneys that may determine their break- down. Meat should be temporarily excluded from the diet. The bowels should be kept open, and water must be drunk in large quantities. Lipuria, occasionally observed in the pregnant woman, is ex- plained by the unusual quantity of fat in all the tissues of the body, making its way even into the blood-current. An oiled catheter may be the source of the fat. This abnormality does not necessarily affect the woman's general health. Chyluria occasionally, but very rarely, appears. It is of no pathological import. Peptonuria and acetonuria may develop in pregnancy in conse- quence of fetal death or without ascertainable cause. The latter condidon is not infrequently associated with eclampsia. The char- acteristic odor of the woman's breath may be well marked. Hematuria may be the result of vesical hemorrhoids. It may, however, indicate acute cystitis, ulceration, a vesical tumor, stone, acute nephritis, or some other disease of the kidneys pre- disposing to hemorrhage. Mellituria in the pregnant woman ranks next in cHnical im- portance to albuminuria. It has been found by some observers in from sixteen to fifty per cent, of cases, but this is not my ex- perience. In the routine examination of the urine of all pregnant women under my charge, I do not find sugar by Fehling's test in one per cent, of the cases. There are two distinct varieties of mellituria in pregnancy. One is due to absorption from the breasts; the sugar in the urine 27 41 8 PATHOLOGY. is lactose, and not glucose.^ There are no systemic symptoms in this variety. The other is true diabetes melhtus, which is said to occur more frequently in pregnant than in non-pregnant women,^ and if it exists before pregnancy is aggravated by the latter condi- tion. In 7 out of 19 cases the disease determined fetal death, and in 4 out of 15 cases the mother died shortly after labor.^ Stengel's* statistics show that diabetes mellitus developing in pregnancy is not quite so dangerous if the patient is subjected to careful die- tetic and medicinal treatment. In 27 pregnancies among 19 women there was a satisfactory recovery in 17. There were five deaths within a few days of the labor. Offergeld^ in 60 cases found that half the mothers were dead in two and one-half years, and that only 24 per cent, of the infants survived. Diabetes mellitus may appear in pregnancy with all its characteristic symptoms and may disappear after labor. I have one patient who regularly develops the disease in every pregnancy. It is not certain, however, to reappear in subsequent gestations. It is sometimes only a temporary manifestation of dietetic errors, especially the ingestion of too much sugar. If it persists and is not manageable by a diabetic diet, pregnancy should be termi- nated. Albuminuria. — The more exact and careful examination of urine in recent years shows a much larger proportion of pregnant women with albumin in the urine than was formerly acknowl- edged. Volkmar, Fischer, Trautenroth, Saft, and Zangenmeis- ter, in 920 examinations found an average percentage of 22.42, but the estimate varied from 5.41 per cent. (Saft) to 68.33 P^^ cent. (Volkmar). The test employed was acetic acid and ferro- cyanid of potassium, and a mere trace of albumin was regarded as albuminuria. If more than a mere trace is demanded as proof of albuminuria, the older statistics averaging 6 per cent, are more accurate, and for the purposes of the clinician the latter standard is alone valuable. A faint trace, without increase, is of no moment. A decided amount has important significance as a premonitory sign of toxemia. ^ In cases of mellituria a chemical or polariscopic examination should alwaj's be made, if possible, to determine the kind of sugar in the urine. Lactosuria requires no treatment. True glycosuria demands rigid dieting. - The idea that diabetes mellitus is more likely to occur in pregnant than in non-pregnant women maj' have been due to the rather common appearance of lac- tosuria. In 517 cases of true diabetes mellitus in women, reported by Griesinger and Frerichs, only 3 were in pregnant women. ' Matthews Duncan, " On Puerperal Diabetes," " Obstet. Tr.," vol. xxiv, p. 256. ^ " Univ. of Penna. Med. Bulletin," October, 1903. B " Arch. f. Gyn.," Bd. Ixxxvi, H. i. DISEASES OE THE NEKl'OUS SYSTEM. 4I9 DISEASES OF THE NERVOUS SYSTEM. The Brain. — The inflammatory diseases of the brain are acci- dental complications of pregnancy and are rare ; they exert no special influence upon gestation, nor do they modify its course, except cerebrospinal meningitis, which is infectious, and therefore has the same influence upon and is influenced in the same way by pregnancy as the other infectious fevers. That is to say, it is aggravated by the woman's condition and exercises a deleteri- ous influence upon that condition. Congestion of the brain predisposes to apoplexy, an accident which, serious as it is, has no influence upon the course of preg- nancy or labor if the woman recovers from the cerebral hemor- rhage. The Spinal Cord. — Inflammatory diseases of this structure are also accidental complications, and are without influence upon pregnancy or labor. Paralyses: — The woman mav be the subject of paraplegia and yet pregnancy and labor are entnely uncomplicated. The latter process, indeed, is easier in such women. It would appear, there- fore, that the spinal nerves exercise an inhibitory action upon the uterine muscle, the removal of which facilitates parturition. The Peripheral Nerves. — Obstinate neuralgias appear in preg- nancv, which may be little benefited by treatment, and only disappear after labor. It should be remembered that localized pains of a neuralgic character in the head, face, or breast are often indicative of toxemia in pregnancy. Multiple neuritis may have its origin in gestation, especially in alcoholic subjects. The Neuroses of Pregnancy. — Chorea. — The milder grades of the disease are not uncommon in pregnancy. Buist ^ collected 225 cases. Sixty per cent, of the cases occur in primigravidae. Heredity, chlorosis, rheumatism, and the existence of the disease in the patient's childhood are predisposing causes. Chorea is almost always aggravated by the coexistence of pregnancy, though in one case recorded the chorea ceased when the woman became pregnant.^ In the graver variety of the disease premature expulsion of the ovum is apt to occur, followed by death of the mother in about one-fourth of the cases. Buist's statistics give 45 deaths out of 225 cases, — 17.6 per cent. Insanity is not 1 " Trans. Edinb. Obst. Soc," i8o4-05- 2 In a patient in the Maternity Hospital, a j^oung girl illegitimately pregnant, a chorea which she had had in childhood reappeared within a week of the fruitful coitus. I was obliged to induce labor in the eighth month on account of the severity of the symptoms. 420 PATHOLOGY. infrequently associated with or follows chorea in the child-bear- ing woman. Treatment. — Fowler's solution, iron, nerve sedatives, change of air, and nutritious diet are indicated in the milder cases. The graver cases may actually require an anesthetic for the temporary control of the violent movements until the induction of prema- ture labor can be effected, whereupon there is usually a spon- taneous recovery unless the termination of pregnancy has been delayed too long. Epilepsy is a rare complication of pregnancy. As a rule, epilepsy does not unfavorably influence the course of gestation. The convulsions are often absent during pregnancy, but make their appearance again during and after the puerperium or upon the reappearance of menstruation after the child is weaned. This disease is most likely to be confused with eclampsia (see Eclampsia). Cases have been reported in which the infant, after birth, presented the symptoms of the maternal disease and died. Hysteria in its minor grades occurs frequently during preg- nancy, but, as a rule, does not exert an unfavorable influence upon the course or duration of gestation. Tetany may have its origin in pregnancy and may recur in sub- sequent pregnancies.^ It is usually mild in type, ending in recov- ery, but it may possibly end fatally, in consequence of interference with respiration, by the firm contraction of the thoracic muscles. From recent experiments it appears that the parathyroids have some relationship with this disease and that calcium salts internally or parathyroid extract is the best treatment. Uncontrollable hiccup and coughing are usually pure neuroses, and yield most readily, if they yield at aU, to antispasmodic reme- dies, or to a profound nervous impression. The induction of labor may be necessary. Organs of Special Sense. — Eyes. — Failing vision should always indicate an estimate of the blood-pressure and an ex- amination of the urine. OccasionaUy, however, there occurs complete temporary blindness, associated only with anemia of the eye-ground, due to a reflex contraction of the retinal artery. Hearing. — Disturbances of this sense are rare and are usually 1 Neumann, " Zwei Falle von Tetanie Gravidarum," " Archiv f. Gyn.," Bd. xlviii, H. 3; Meinert, ibid., Bd. Iv, H. 2, has collected 21 cases; also "Tetanie in der Schangerschaft," " Monatschr. f. Geb. u. Gyn.," January, 1904; Schmidlech- ner adds another case, " Zentralbl. f. Gyn.," No. 4, 1905, and Gross two more, " Muench. Med. Wochenschr.," No. -^^^ 1906. DISEASES OF THE NERVOUS SYSTEM. 42 1 temporary, but they may be permanent. They are often inex- plicable. Some anomaly of the external auditory canal may be found, as a hematoma, which was the cause in one reported case of deafness in a gravid woman. In my experience the hearing of a deaf person has been worse during pregnancy than at other times. Psychical Disturbances. — Insanity. — Frequency. — Of all cases of insanity in women, about 8 per cent, have their origin in the child-bearing process. About one in four hundred par- turient women become insane. Predisposing Causes. — The nervous excitation of gestation in women predisposed by hereditary influence to mental breakdown, great reduction in physical strength, and prolonged mental strain or worry should excite the physician's anxiety for his patient's mind. Exciting causes may be exaggerated anemia, as from prolonged lactation ; septicemia ; albuminuria ; profound emotions, as exag- gerated fear of impending danger ; the remorse and shame of illegitimate pregnancy ; the grief of a deserted woman ; accidents, as hemorrhage ; great physical or mental exhaustion. Chorea, associated with insanity, results rather from the same predis- posing or exciting causes, and should not be considered in itself as a cause of the insanity. In my experience, insanity in the child-bearing woman has almost always resulted from some pro- found emotion. One of my patients became insane after the death of her child ; another, because her husband deserted her ; a third, some days after her delivery, received a letter from her seducer casting her off She fainted on reading it, became a raving lunatic that same night, and died of maniacal exhaustion within two weeks. Several cases were the result of futile efforts at delivery by operative procedures and repeated anesthetizations. Many women have gone mad from the shame of illegitimate im- pregnation. Physicians' Maves have lost their reason from reading their husbands' books on obstetrics. Symptoms. — The form of insanity may be mania, melan- cholia, or a condition of profound letharg}^, stupidity, and mental confusion. If a woman in this last condition is asked a question in a sharp tone of voice, there is a momentary flicker of intelligence in her face, but before the import of the question reaches her brain, she is sunk again in her extraordinary apathy and indifference to her surroundings. Time of Occurrence. — Most frequently mental breakdoM^n occurs during the puerperium, next in frequency during lacta- 422 PATHOLOGY. tion, and least frequently during pregnancy. Mania is the most, mental apathy or confusion the least, frequent form of puerperal insanity. Melancholia is commoner in pregnancy than in the puerperium. The diagnosis of insanity is usually easy. It is, however, important to distinguish puerperal insanity from the temporary delirium of labor, delirium tremens, the delirium of fever, especially that of septicemia, and from preexisting insanity. The temporary delirium of labor is common. It is usually momentary, in the midst of the most acute suffering of labor, and varies in degree, from an outbreak of hilarity to violent mania. Delirium Tremens. — Labor, like an accident or surgical ope- ration, may precipitate an attack in hard drinkers. The history of the patient, and her symptoms, should demonstrate the nature of the case. The delirium of fever in child-bearing women is commonly due to septic infection. It is frequently necessary to wait until the fever subsides to determine if it be the cause of the mental symptoms. Preexisting insanity is recognized by the previous history of the patient, if it can be obtained. Prognosis. — About two-thirds of the women recover their reason in from three to six months ; of the other third, from two to ten per cent, die of septic infection or exhaustion ; the rest remain permanently insane. The treaUnent is best carried out in an asylum. Many patients, hov/ever, will not be allowed by their families to enter an asylum. In such cases a modified rest-cure, combined with administration of iron, arsenic, and a nutritious diet, together with systematic exercise in the open air, will hasten the cure. The most careful supervision must be exercised at all times, to prevent the patient doing an injury to herself, her infant, or her attendants. DISEASES OF THE CIRCULATORY APPARATUS. Under this heading are considered those diseases of the heart, of the thyroid gland, of the blood-vessels, and of the blood, which have their origin in pregnancy or are much aggravated by that condition. The Heart. — Valvular disease of the heart usually antedates impregnation. It may, however, owe its origin to septic infection during the child-bearing process, or to rheumatism acquired DISEASES OF THE CIRCULATORY APPARATUS. 423 after conception. A woman may have valvular disease of the heart without murmur or other clinical signs until she becomes pregnant, when the disturbance of the circulation occasions a loud heart-murmur and symptoms perhaps of heart-weakness. One of my patients has a heart-murmur in her pregnancies, which may be heard some distance from her body, but which is inaudible at other times. Prognosis. — Abortion is induced in about twenty-five per cent, of all cases, as the result of placental apoplexies, or of the stimulation of the uterus to contraction by the accumulation of carbon dioxid gas in the blood. Pregnancy distinctly increases the danger of the heart-lesion. In fifty-eight serious cases, twenty-three died after a premature deliveiy of the child. In milder cases the prognosis is not grave, yet the woman's con- dition is by no means free from danger. The complications particularly to be dreaded during gestation are : afresh outbreak of endocarditis, fatty degeneration of the papillary muscles, and, especially, congestion of the lungs. If the disease be of long standing and serious in character, it appears, from statistical studies, that about half the women die.^ If there is good com- pensation, however, there may not be an untoward symptom, or, at most, occasional palpitations, some dyspnea, edema, and a tendency to renal congestion, with albuminuria. Treatment. — The pregnant woman with valvular disease of the heart must be carefully watched. Her urine should be examined at frequent intervals. On the first appearance of symptoms pointing to inadequate compensation, digitalis or strophanthus must be administered, and it is commonly necessary to increase the dose as pregnancy advances. The bowels must be kept freely opened. Moderate exercise in the open air is an advan- tage, but rest in the recumbent posture must be ordered at fre- quent intervals during the day. Meat should be eaten sparingly on account of the likelihood of kidney breakdown, and extra pre- cautions must be taken against suddenly throwing greater work upon the kidneys by chilling the skin. Flatulent dyspepsia is not infrequent in cardiac weakness. It should be carefully treated. It is almost unnecessary to state that the woman must avoid any sudden, violent physical effort, and should be spared any cause for mental excitement. Finally, pregnancy should never be allowed to continue longer than the thirty-sixth week in a woman who exhibits any symptom of imperfect compen- sation. ^ This is not, however, my experience ; with proper treatment I have no fear of heart disease in pregnancy (see Dystocia). 424 PATHOLOGY. The Heart=muscle. — Suppurative myocarditis is only seen in connection witli septic infection. Brown atrophy of the myo- cardium has been noted as a very rare complication of preg- nancy ; fatty degeneration of the heart-muscle may occur acutely in consequence of general systemic septic infection, or as a result of a gestational toxemia. Graves' Disease and Goiter. — These diseases are unfavor- ably influenced by pregnancy. The former may have its origin in gestation. It predisposes the woman to uterine hemorrhages and may be a cause of fetal death. It may and usually will dis- appear after delivery. I have one patient in whom exophthal- mic goiter with all its classical symptoms has recurred regularly in three successive pregnancies, the woman at other times being quite free from the disease. A goiter may take on so exag- gerated a development during pregnancy that asphyxia is threatened, and tracheotomy may be necessary. In Miiller's clinic in Bern it was found easier and better in two cases to resort to strumectomy. The dislocation of the thyroid from behind the sternum was immediately followed by relief of the asphyxia.^ In a case of Graves' disease seen with Dr. Pittfield a very sudden en- largement of the thyroid was accompanied by remarkable slowing of the pulse instead of the tachycardia which had been marked for some years. There was probably pressure on the vagus. Graves' disease is likely to be complicated by albuminuria. The induction of labor must be considered, but is not usually necessary. The Blood=vessels. — The disease of most clinical interest in these structures is varicose veins in the rectum, anus, broad ligament, bladder, vagina, external genitalia, the abdominal walls, and lower extremities. In the last there may develop a pressure edema, associated usually w*ith varicose veins. The causes of varices in pregnancy are changes in the invest- ing muscular sheath of the veins, the increased quantity of blood, and mechanical obstruction to the circulation by the bulk of the growing uterus. Atheroma and degenerative changes may be found in the vessel-walls as the result of toxemia. Complicatiojis. — There may be rupture, with possibly a fatal hemorrhage,^ a severe interstitial bleeding, or extensive extravasa- tion of blood under the skin. Thromboses and phlebitis, with suppuration and septic infection, may occur. As the result of itching and scratching, eczema or even erysipelas of the affected part may develop. Treatment. — An elastic bandage or stocking should be ordered for varices of the legs. Small doses of heart-tonics are l"Centralbl. f. Gyn.," No. 42, I903. ^ In 18 cases there were 1 1 deaths ; Brunei, " Zentralblatt fur Gyn.," No. 2, 1906, JUS EASES OF 'I'lfE C/A'CCLATOA' V AJ'PARATUS. 425 often of service. Constipation must be avoided. The patient siiould be advi.sed to lie down at intervals durin^^ the day. Abso- lute rest must be ordered in cases of thromboses, to prevent em- bolism. Lead-water and laudanum should be applied if there is inflammation. Absces.ses along the cour.se of a diseased vein should be opened early. A mechanical protection (soap- plaster) should be applied to the affected part to prevent the development of eczema or of erysipelas. Itching may be relieved Fig. 331. — Varicose veins of the lower extremity in a pregnant woman at term. by weak solutions of carbolic acid or by cocain. The woman herself should be instructed how to check hemorrhages, in case the distended veins burst. Aneurysms are naturally unfavorably affected by pregnancy. The hypertrophy of the heart, the increased quantity of blood, and the mechanical interference with the circulation in gestation are all unfavorable factors. Such a case should be managed on the same principles that govern the treatment of cardiac complica- 426 PATHOLOGY. tions. By this plan I have successfully delivered a young woman with an enormous aneurysm of the arch of the aorta. The Blood. — Pregnancy may have a decided influence in producing those blood diseases which are characterized by a marked alteration in its constituent parts. Pernicious anemia and leukemia^ may have their origin in gestation, and should they already exist, they are aggravated by the existence of pregnancy. Pregnancy should be promptly interrupted if these blood diseases are obviously progressing from bad to worse. The anemia of pregnancy may be so exaggerated as to appear pernicious, but arsenic, iron, and nutritious diet after delivery usually effect a cure. Purpura hcemorrhagica is apt to be rapidly fatal in preg- nancy, which it always interrupts. The disease usually destroys the fetus before it is expelled. The maternal death may be due to postpartum hemorrhage or to sepsis. DISEASES OF THE RESPIRATORY APPARATUS. The Nose. — The sense of smell may be more acute, and peculiarities in this sense are developed, as abhorrence for certain odors, which may excite nausea and vomiting in neurotic indi- viduals. More important is the disposition to epistaxis, which may be so severe as to threaten life. Epistaxis, however, is a more serious complication of parturition than of pregnancy. It can only be checked by the rapid termination of labor. Meanwhile the nares should be packed. The Larynx. — If a tumor, tubercular or syphilitic disease be present, there is a constant danger of edema of the glottis, which requires tracheotomy. The Bronchi and Lungs. — Bronchial catarrh ordinarily is not harmful, but prolonged coughing may cause abortion, and the hydremic condition of the blood in pregnancy predisposes to pulmonary edema. The cough may have a neurotic element in it, and may be most persistent. In its treatment I have obtained better results from oil of sandalwood than from any other single remedy. Pneumonia. — The symptoms of this disease are much aggra- vated by gestation, the mortality is increased, and in the vast majority of cases the fetus is prematurely expelled (see Pathology of Puerperium). Emphysema is quite common. The symptoms in a pregnant 1 Schroeder has collected ten cases and reports one, "Arch. f. Gyn,," Bd. Ivii, H. I, p. 26. DISEASES OF THE KESP/RATORY A /'/'A RATCJS. 427 woman are aggravated, and abortion is apt to occur. In ad- dition to the usual treatment inhalations of oxygen may be given to counteract the accumulation of carbon dioxid in the blood, which stimulates the uterine muscle to contract, and thus is the chief factor in determining an interruption of pregnancy. Asthma in some women may only appear during pregnancy. In such cases the disease disappears the moment gestation is terminated. In other cases asthma may only appear in labor. In asthmatic subjects the attacks may be much aggravated by gestation and may obstinately resist all treatment. Radical change of air and scene has proved efficacious when all medicinal remedies have failed. Phthisis Pulmonalis. — The influence of pregnancy upon this disease is most unfavorable, and in women predisposed to tuber- culosis gestation may be the determining factor in lighting up an attack. There is a superstition prevalent among the laity that pregnancy is beneficial to a phthisical patient. This idea has its origin in the accumulation of fat commonly seen in the pregnant woman, which gives her a fictitious appearance of improv^ed health. In reality the strain and drain of child-bearing exhausts the vitality of the tuberculous subject so seriously that her death is hastened by many months, and a pulmonary phthisis that might have been arrested becomes incurable. It is the duty of a physician to advise strongly against marriage and maternity in the case of a woman already infected with or predisposed to tuberculosis. If the patient is pregnant, the induction of labor should be considered, in some cases to secure the birth of a living child before the mother's death, in others to spare her the drain of the last four weeks of pregnancy and to insure her an easy labor. A tuberculous woman should not nurse her infant. Miliary tuberculosis is rapidly fatal in pregnancy or shortly after delivery. It may be mistaken for septic infection. I have seen several cases in child-bearing women in which this mistake was made. Pulmonary embolism is a possible accident in pregnancy. Pleurisy exerts no deleterious influence upon, nor is it af- fected by, gestation. Hemoptysis may occur in the latter months of pregnancy without phthisis or other lung disease. It is in these cases the result of " cardiac nerve-storms " in pregnant women of neurotic character. The cheeks are suffused, the eyes are bright, and the heart beats powerfully and tumultuously. The woman looks as though she had a high fever, but her temperature is normal. Chloral and the bromids will control the attack. 428 PATHOLOGY. Diseases of the Osseous System. — Osteomalacia of pregnancy is a decalcification of the bones due to a peculiar osteitis and periosteitis, the result of malnutrition/ Pott's disease, in its active stage, is aggravated by pregnancy, and the mortality is much. increased. The infectious diseases are always more serious when com- plicating pregnancy, their symptoms being more severe and their mortalitv' greater. Even measles at this time may become a deadly disease. Upon pregnancy their influence is, as a rule, unfavorable. Sixty-five per cent, of typhoid=fever cases are complicated by abortion or premature labor. The development of the infant may be seriously affected in prolonged infectious fevers during gestation. Idiocy has been noted in a considerable number of cases. Influenza is more serious in pregnancy than at other times. In 6 out of 2 1 severe cases abortion and premature labor oc- curred.^ Syphilis. — Should infection occur at the time of impregnation, the primary sore and mucous patches in the vagina may assume an almost malignant character, ulcerating the vaginal mucous membrane, resisting treatment, and seriously complicating the puerperal state. Flat condylomata on the buttocks and in the natal folds are usually more extensive and numerous in pregnant women. The treatment of all the infectious diseases in gestation is to be conducted with Httle reference to pregnancy. If abortion is threatened, the tendency should not be combated, as the termina- tion of pregnancy is often of advantage to the mother, and at any rate can not be averted. The treatment of syphiHs in the pregnant woman is dealt with in a preceding section. Skin Diseases. — The following skin diseases are said to have their origin in pregnancy : Impetigo Herpetiformis. — The favorite seat of the eruption is in the groin, around the umbilicus, on the breasts, in the axilla. The small pustules become crusts, around which new pustules develop until the entire surface of the skin is covered in the course of three or four months. Rigors, high intermittent fever, great prostration, delirium, and vomiting accompany the erup- tion. 1 See Deformities of the Pelvis. ^Moller, " Deutsch. med. Wochenschr.," No. 28. 1900. SK'/JV DISEASES. 429 The disease appears, as a rule, during the second half of ges- tation. Recent observation has shown that it is not absolutely confined to pregnancy. Of twelve cases ten terminated fatally, but the disease did not terminate gestation prior to the maternal death. Herpes gestationis is characterized by pem.phigoid efflores- cence, exhibiting erythema, vesicles, bullae, and scabs. It appears early in pregnancy, continues during gestation, and disappears Fig. 332. — Herpes gestationis of legs, appearing as soon as the woman realized that she was illegitimately pregnant ; first following the course of the nerves of the leg, but later coalescing. during the puerperal state. Neurotic symptoms are associated with it, showing its probable nervous origin. Molluscum Fibrosum, — Brickner^ describes a peculiar form of this disease appearing in consequence of pregnancy and disap- pearing after delivery. If the disease antedates pregnancy it may take on an exaggerated form from the stimulus of gestation (Figs. 333, 334). Pruritus. — Its usual seat is the external genitalia — pruritus vulva. It may, however, in rare cases be general (p. 698). Exaggerated Pigmentation. — Spots of quite dark pigmenta- tion may appear on the breasts, thighs, and abdomen, as large as ten-cent pieces or a quarter of a dollar. The chloasmata on the face may be so exaggerated as to disfigure the countenance. ^ " Am. Journ. Obstet.," vol. liii, 1006. 430 PATHOLOGY. This skin affection disappears after delivery, and is not amenable to treatment during pregnancy. Hypertrichosis.! — Halban pointed out that hypertrichosis was one of the signs of pregnancy. If it already exists, it may be exaggerated in pregnancy and may disappear after delivery. Fig- 333- — Aet. thirty-eight; VII para; sixth month. At eighteen four or five nodules appeared on the abdomen. With each of the seven successive pregnancies the nodules were increased in number. Loosening of the finger nails is a painful affection of pregnancy, apparently dependent upon malnutrition, and usually appearing- in neurotic individuals. Nerve tonics, especially strychin, good hygiene, and a general tonic treatment do something to arrest the progress of the disease ; but in the few cases under my observa- tion (one recurring in three successive pregnancies) the treatment was only palliative as long as pregnancy continued. 1 " Voriibergehende Hypertrichosis durch Schangerschaft verursacht," Jellinghaus, " Zentr. f. Gyn.," No. 14, 1910. INJURIES AND ACCIDENTS. 43 I Injuries and Accidents. — Severe injuries to a pregnant woman usually result in abortion. Among the most serious accidents of pregnancy are rupture of varicose veins in the ex- ternal genitalia, the vagina, or lower extremities. One of the rarest accidents of pregnancy is rupture of the uterus. It may occur spontaneously in conseqence of a previous Cesarean sec- Fig. 334. — Rear view of patient described in Fig. 2>2>Z- tion, a myomectomy, or a healed rupture of the uterus at a former labor, the scar bursting open ; it may be the result of chronic inflammation and degeneration of the uterine walls, reducing them to little more than connective tissue ; or it may be due to traumatism. Spontaneous rupture of the uterus in pregnancy almost always occurs at the fundus, and frequenth' at the pla- cental site. The accident is almost invariably fatal to both mother and child. It indicates an immediate abdominal section 432 PATHOLOGY. and usually a hysterectomy. A very serious accident of preg- nancy is detachment of a normally situated placenta, with con- cealed internal hemorrhage (see Dystocia). Surgical Operations. — If a pregnant woman's life or health IS seriously threatened by delay until the completion of puerperal convalescence, surgical operations are justifiable, and permission may be given for their performance without great fear of an abor- tion if septic infection is avoided. Keen successfully amputated the thigh at the hip-joint for sarcoma in a woman five months pregnant, without interrupting gestation. Tumors of the pelvic organs may be excised with no more risk of abortion than any woman runs (twenty per cent). It is even possible to remove a myoma from the uterine wall without inciting uterine contractions. In nervous and irritable women, however, slight operations, such as the extraction of a tooth, may interrupt gestation. The proper course, naturally, is to avoid operative interference in the pregnant woman if it can be deferred without serious detriment to her. If, on the contrary, there is a positive indi- cation for immediate operation, it should be undertaken without hesitation. CHAPTER V. Abottion, Miscarriagfe, and Pfemature Labor. The term " abortion " is applied to the expulsion of the ovum before the fourth month. Premature labor signifies the birth of a fetus that is viable. For the expulsion of the ovum during the intervening time from the fourth to the sixth month of preg- nancy a distinctive term is needed, as the process, in combining some of the features of both abortion and premature labor, pre- sents a clinical picture different from either of them. To denote the interruption of pregnancy at this time the word "miscarriage" is used.^ The Causes of Premature Expulsion of the Ovum. — There are conditions of the mother having as their primary effect the active contraction of the uterine muscle, which results 'In speaking to patients the word "abortion" should not be used by the physician; it is resented as implying something criminal. Miscarriage means to the laity the interruption of pregnancy before the viability of the fetus. ABORTION, MISCARRIAGE, AND PREMATURE LABOR. 433 secondarily in the premature expulsion of the ovum, although the latter may be normal in every respect. Under this head come: Irritable Uterus. — Every uterus has a special temperament, which, as the case may be, is irritable, equable, or apathetic. It is notorious that some pregnant women are liable to lose the product of conception from a trivial cause. A long walk, coitus, congestion of the pelvis from any cause, ovaritis, irritation of the breasts or nipples, the extraction of a tooth, irritation of the vulva, a dose of some mild purgative, the jolting of a carriage; a misstep, especially while descending a staircase; not to mention a sea-bath, exercise on horseback, motoring, or dancing, have been followed by expulsion of the ovum. The mere sight of another woman in labor has been sufficient cause for abortion in some nervous women. In case the disposition of the woman to abort is known, she must be guarded from anything which might stimulate uterine contractions, and at the time corresponding to the menstrual period, when the uterus is particularly irritable and prone from habit to contract, the precautions must be doubled. The opposite picture, while not so familiar, is occasionally seen. Some women can make the most violent exertion, can receive the roughest treatment, without bringing pregnancy to an end. English women have followed the hounds in the early months of pregnancy without aborting. Sounds have been introduced into the pregnant uterus; intra-uterine injections have been given ;^ strong applications have been made to the endometrium; trocars have been plunged through the uterine wall;- a pregnant woman has been thrown violently from her carriage;^ another fell from a third-story window, fracturing her skull and breaking a leg;* a young girl, five months pregnant, cast herself from the Pont Neuf into the Seine ;^ in another, fifteen leeches were applied to the cervix of a pregnant uterus; Emmet's operation has been performed upon the cervix during the second month of pregnancy; ovariotomy and other serious surgical operations have been repeatedly performed, the spleen has been ruptured by violence and has been extirpated "^ — all without inducing abortion or premature labor. ^ Scanzoni, " Lehrbuch d. Geb.," Wien, 1867, p. 83. ^ Many cases are reported of tapping a uterus distended bj' hydramnios in mistake for an ovarian cyst or ascites. ^ Tarnier and Cazeaux, 8th ed., p. 567. Also two of my patients. '' A patient of mine in the Philadelphia Hospital. She recovered from her injuries, received at the fifth month of pregnancy, and was delivered at term. 5 Juillard, " Nouvelles Archives d'Obstet. et de Gynec," iSSb, p. 1645. ^ Savor, " Centralbl. f. Gyn.," No. 6, 1899. 28 434 PATHOLOGY. Spasmodic Muscular Action in the Mother as a Cause of Prema= ture Expulsion of the Ovum. — Pregnant women affected \\dth chorea, eclampsia, uncontrollable vomiting or coughing, epi- leptic, hysterical, or cholemic conMilsions. or T^ith tetany, may expel the product of conception prematurely. Chm'ea. — Less than half of the women affected with cho- rea gravidarum go to term. Of 57 cases collected by Barnes, only 22 completed the full time of pregnancy. Bamberg's statistics of 64 cases show 33 arrived at term, and Spiegelberg, in 69 cases, saw only 29 delivered of mature infants.-^ In a case under my obser^'ation the uterine muscle toward the end of pregnancy seemed to take part in the choreic movements that convulsed the muscles of the extremities. Through the ab- dominal \vall the uterus could be felt firmly contracting at intervals of not more than a minute. Every contraction was extremely painful, but during the four days that this condition of the uterus lasted the os showed no signs of dilatation. The suft'ering finally becam.e so great that labor was induced.- Eclampsia. — The eclampsia of pregnancy in the great majority of cases determines the premature expulsion of the ovum. Fre- quently, no doubt, the life of the fetus is first destroyed; often, however, the immediate eff'ect is seen in expulsive eff'orts of the uterus, due to asphyxia of the organ, to the irritating effect of the toxemia, or perhaps to the fact that the uterine muscle shares in the convulsive action of the whole muscular system. UncontroUaUe Vomiting and Coughing. — The constant violent action of the diaphragm in cases of uncontrollable vomiting dur- ing pregnancy often leads to the expulsion of the ovum. Of 51 cases of uncontrollable vomiting collected by Gueniot, 20 ended in abortion or premature labor. ^ A violent and per- sistent cough is also, in rare instances, the cause of premature expulsion of the ovum by the constant succussion in the ab- dominal cavity. Epileptic, Hysterical, Cholemic, and Tetanoid Cotwulsions . — Attacks of epilepsy during pregnancy may be disastrous to the fetus, either killing it outright or bringing about its premature expulsion. Tanner mentions a case of h}"sterical convulsions which was followed by the expulsion of a dead fetus at the seventh month.'* Cholemic convulsions occur more frequently than is generally supposed.^ and they always interrupt preg- 1 Herve, "These de Paris,'' 1884. 2 For a report of the case see " Trans. Philadelphia Obstet. Soc.,'' Dec, 1887. ' Tamier et Budin, op. cit., p. 59. ^ " The Signs and Diseases of Pregnancy."' London, 1867, p. 304. ^ Stumpf , he. cit. ABORTION, MISCAKKTAGR, AND PREMATURE LABOR. 435 nancy, either by the death of the mother or the expulsion of the ovum. Meinert^ has collected 11 cases of a tetanoid con- dition in pregnancy, in 6 of which there was true tetany. In 2 of the 1 1 cases dead children were born, i prematurely at the seventh month, the other at term. In one other case the child was expelled at the eighth month, and in another eleven days before term. Conditions of the Maternal Blood which Stimulate the Pregnant Uterus to Contract. — The poisons of all the infectious diseases in the maternal blood may excite active contractions in the pregnant uterus. Whether this is due to some irritative action of the micro- organisms, or to the development of toxins, or to a diminution of the oxygenating power of the blood, as yet remains in doubt. The last condition explains the abortions occurring in pneu- monia, as well as in cases of chronic heart disease, in which the circulation is much interfered with. It is possible also that strong emotions alter the blood in some way that would account for the action of the uterus when women have been terrified. But it is more likely that the action is analogous to that of the rectal and vesical muscles in cases of nervous defecation and uri- nation. Baudelocque said in his lectures that, after the explo- sion of the powder-mill of Grenelle, he was called to see sixty- two women, either aborting or threatened with abortion. In all maternal diseases accompanied by fever the thermic irritation of the uterine muscle might be responsible for the expulsive efforts of the uterus. Uterine Contractions Excited by an Abnormal Situation or Posi= tion of the Uterus. — Retroflexion and prolapse of the gravid uterus may induce abortion, for the uterus is unable to expand properly in its unnatural position. This is true likevdse of pregnancy in one horn of a bicornate uterus.^ Perimetritis also, resulting in adhesions between the uterus and neighboring organs, or cellulitis, with plastic exudate in the broad ligaments, as well as diseases of a tube and ovary leading to adhesions, will, if pregnancy should occur, usually interrupt its course by interfering with the expansion of the gravid uterus. Appendicitis, with adhesions involving the uterine adnexa, may also have the same result. Fibromyomata of the uterine wall may act in the same manner, or else, by congestion or by irri- tation, may stimulate the uterine muscle to contraction. Overdistention of the Uterus as a Cause of Premature Expulsion of the Ovum. — If the uterus is unduly distended in hydramnios ^ " Archiv f. Gyn.," Bd. xxxi, S. 444. * L. Munde, " Case of Pregnancy in One Horn of a Double Uterus, with Successive Miscarriages," " Amer. Jour. Obstet.," 1887, pp. 337, 346. 43^ PATHOLOGY. or in cases of multiple pregnancy/ especially when there are three or more fetuses, the distention of the muscle may irritate it to expulsive efforts. In twin pregnancies, should one fetus die, the uterine muscle is occasionally stimulated to contraction, and the entire uterine contents are cast off, although the remaining fetus may be healthy and normal. In cows epidemics of abortion have been observed, which have been attributed to a specific form of micro-organism, said by Franck and Rolofif to resemble the leptothrix buccalis.^ Brocard ^ has also called attention again to this disease. It is improbable that the same disease can affect a woman, but in lying-in hospitals an epidemic of abortion or premature labor might occur from septic infection during pregnancy. Clinical History of Abortion and Miscarriage. — Premature labor is not referred to. Its course, management, complications, and after-treatment may be considered in the description of labor at term, from which it does not materially differ. The Frequency of Abortion. — So many women lose an im- pregnated ovum at an early period of its development, when they are not conscious of being pregnant; so many others fail to seek medical advice for an abortion uncomplicated by hemor- rhage or decomposition of retained secundines, that almost all the estimates of the relative frequency of abortion and labor at term place the figure for the former too low. Hegar* says that one abortion occurs to ever}- eight or ten labors at term; but the estimate of Guillemot and Devilliers,' of one abortion to every four or five pregnancies, is m.ore correct. Priestley® found that 400 women, among whom there had been 2325 pregnancies, gave a return of 542 abortions, or about one abortion to every four pregnancies. My own case-books also show this proportion. Clinical Phenomena of Abortion. — The main clinical phe- nomena of abortion are: (i) Hem.orrhage, (2) pain, and (3) the expulsion of portions of an impregnated ovum. These symp- tom.s are rarely all manifested in a topical manner in every case. Pain may be absent, hemorrhage not excessive, and the whole ovum when cast off so smail that it escapes unnoticed among the clots of blood discharged from the uterus. Such cases occur shortly after conception, and often pass for disordered menstrua- tion, while the fact that pregnancy had begun is not suspected. ^ See Doleris, " Nouvelles Archives d'Obstet. et de Gynec," 1886, p. 318. ^ Schroeder, " Geburtshiilfe," 8 Aufl., 1884, p. 460. ^ " Recherches sur I'Avortement eoizootique des Vaches," Broch., Paris, 1886. '' " Beitrage zur Pathologic des Eies," " Monats. f. Geburtsh.," Bd. xxxi, S. 34. ^ Tarnier et Budin, op. ciL, p. 474. ^ " Pathology of Intra-uterine Death," London, 1887, p. 8. ABORTION, MISCARRIAGE, AND PREMA TURE LABOR. 437 Fig. 335. — Fetus in its membranes. Fig. 336. — Dead embryo in a capsule of thickened decidua. Absorption of the liquor amnii. ^^^R||HHMiHPPH^,„^^|PP^ H ^^H^H ^B /^^HI^^M^I^i iH ^^^E 1 ^S^^^^^M^^KStFtj^/K ■ ■ H^^H ■ ^^V >^^| 1 ^^^^^L^^^^^l 1 Fig. 337. — Young embryo, thickened decidua, and ruptured ovum. Fig- 33^- — Ruptured membranes, embryo, and newly formed placenta. ABORTION, MISCARRIAGE, AND PREMATURE LABOR. 439 The duration of abortion varies. The French speak of an avortement mstantane and Cazeaux gives an example of a woman who fell upon her huttocks, and, on rising, found on her linen considerable blood and a six-weeks' ovum. The expulsion of the ovum may occupy about the time consumed in a normal labor, but frequently the process is much slower. Days, and even weeks, may be required for the uterus to get rid of its contents if left unaided to nature, and it is not rare for a frag- ment of the placenta or a portion of the uterine decidua to re- main behind indefinitely, firmly attached to the uterine wall and often continuing to grow and develop, constituting within the uterus a true pathological new formation. ^ In only 13 per cent. of 1683 cases in the Boston City Hospital was there a complete spontaneous evacuation of the uterus. ^ Of the two symptoms, pain and hemorrhage, the former is, in early abortions, usually the subordinate one. The hemorrhage is not often excessive, Fig. 339. — Embryo of about four weeks, with its membranes entire. but may become alarming. The blood is not expelled in a steady flow, but from time to time as coagula. When the uterus discharges its contents the appearance of the substance expelled differs as the ovum is cast off entire with its shaggy', chorional coat, or surrounded by thickened decidua; as the embryo, enveloped by its am.nion, is extruded without the decidua and chorion, or as the embryo, its delicate umbilical cord being ruptured, is expelled alone. The appearance of the embryo varies with the different periods of pregnancy; if still inclosed in its amniotic sac, a thin-walled, transparent vesicle may be found floating in the blood or imbedded in a clot, and within the sac the embryo is seen floating in the liquor amnii. In other cases the ovum resembles a ball of flesh, con- taining an embryo within a sac with thick walls, composed mainly of greatly hypertrophied decidua. The substance expelled from 1 A condition described under the names " placental pol^-p," " polypoid hema- tomata." ^ Young and Williams, " Boston Med. and Surg. Jour.," June 22. loii. 440 PATHOLOGY. the uterus may be a fleshy mass, the deciduous membrane, in shape a cast of the uterine cavity, within which there is an empty cavity. The embryo in these cases has either died and been absorbed, or else has been previously cast off unnoticed in the bloody discharge. If the o\aim proper is cast oft" entire, — that is, with its cho- rional covering intact, without adherent shreds of deciduous membrane, — it presents an appearance quite characteristic, espe- cially if floated in water; the chorional villi give the ovum the ap- pearance, except for its color, of a chestnut-bur. Most frequently the embryo alone, or at most the ovum, is discharged, while the uterine decidua remains behind within the uterus.^ The retention of this membrane after abortion can not be regarded with indifference. The thickened uterine decidua is infected and decomposes, or else portions of the decidua attract an increased blood-supply, retain their original development, and even increase in size, forming new growths within the uterus which give rise to frequent and alarming hemorrhages or to per- sistent metrorrhagia. It is this complication of abortion that often makes the prog- nosis uncertain, and is the main factor in raising the mortality after abortions higher than that of childbirth at term. ]SIaygrier saw four deaths in 698 spontaneous abortions, but 25 in 44 criminal abortions.^ In the Rotunda Hospital of Dublin, during the m.astership of Dr. Johnston, 234 abortions occurred, with but i death, and that from heart disease.^ But of 120 cases treated in the clinic and polyclinic of the Charite in Berlin, 2 died.^ Of 82 abortions in the Obstetrical and Gynecological Institute of Florence,^ 5 resulted fatally to the women, — a death-rate of 6 per cent. In the Charite at Paris (1883-86) there were 57 cases of abortion without a death; and in the ]\Iaternite, 153 cases with i death (Tarnier). In the Woman's Hospital of Bern, of 484 abortions, 4 ended fatally.^ In 74 protracted abortions the uterine cavity was found infected in every case by pathogenic 1 Diihrssen, " Zur Pathologic und Therapie des Abortus," " Archiv f. Gyn.," Bd. xxxi, H. 3. 2 Doleris, " Statistique sur rAvortement, Ann. de Gyn.," April, 1905. . ' Lusk's "Obstetrics," 1S86, p. 313. ^ Diihrssen, loc. cit. This same author mentions the statistics of 520 cases of abortion collected in the inaugural thesis of Lechler (Berlin). Half of these, treated by active interference, showed 4 deaths, — 3 from intercurrent affections, i the result of abortion. ^ Fasola, " 82 aborti nel trienno, 1883-85," " Annali di Ostet. e. Gynecol.," March, 1887. ^ " Swiss Dissertations," F. Moser, Bern, 1900. ABORTION, MISCARRIAGE, AND PREMATURE LABOR. 44I micro-organisms. In 12 cases there had been no digital examina- tion.' In 15,000 abortions treated in the University clinic of Berlin, 450 women were seriously ill and 94 died.'^ In 147 criminal abortions among the 2000 reported from the Boston City Hospital there was a mortality of 10 per cent.'^ Diagnosis. — It may be necessary in cases of suspected abor- tion to determine the existence of pregnancy; that fact being established, it becomes necessary to distinguish between threat- ened abortion, inevitable abortion, and an abortion partiall}^ or wholly accomplished. The Diagnosis of Threatened Abortion. — If there are the signs of early pregnancy, and a hemorrhage occurs from the uterus, associated with pain, a threatened abortion is probable. Suppression of menstruation from causes other than pregnancy, and its reestablishment by a profuse flow, accompanied by pain, arouse a suspicion of abortion. In these cases, however, the signs of pregnancy are absent and the os is not patulous. But if the symptoms should be due to an effort of the uterus to expel a polypoid tumor, the case may so closely resemble one of abor- tion that the diagnosis is only made after the expulsion of the uterine contents or the dilatation of the os. Membranous dysmenorrhea is often taken for abortion. But there is no cessation of menstruation, no sign of pregnancy, and the mem- brane has not the histological characteristics of decidua. The most serious and one of the most frequent mistakes in diagnosis is to regard the discharge of decidua and the metrorrhagia of ectopic gestation as an abortion. The Diagnosis of Inevitable Abortion. — When a threatened abortion becomes inevitable, the treatment should be altered. If there is persistent hemorrhage, abortion will usually occur, but even in spite of a bleeding which may continue for a con- siderable time or return at intervals during the whole duration of gestation, the pregnancy may go on to term. If the os dilates, the ovum will ordinarily be cast off; and yet the os has dilated sufficiently to admit two fingers, but has again retracted, and pregnancy has pursued its course. If portions of the uterine contents are expelled, it would seem that abortion was surely in- evitable; but Playfair, Charpentier, and Doleris have reported cases in which pieces of decidua were expelled from the uterus without the interruption of pregnancy. In Playfair's case four or five fragments of decidua, each as large as a fifty-cent piece, were cast off in the third month of pregnancy as a result of the intro- 1 Hellendal, " Zentralbl. f. Gyn.," No. 27, igos. 2 Seegert, " Ztschr. f. Geb. u. Gyn.," B. Ivii, H. 3, p. 344. ' Young and Williams, loc. cit. 442 PATHOLOGY. duction of a sound into the uterus; but the woman went on to term. The only two conditions which can be said to render the abortion almost inevitable are the rupture of the membranes and the death of the embryo; but even were it possible to as- certain with certainty, during early pregnancy, that the mem- branes were ruptured or that the embr^'o was dead, the liquor amnii has been resupplied after puncture of the pregnant uterus with a trocar (Chiara), and after rupture of the membranes, and there has been a retention of the ovum after the death of the embryo for months or years. If the hemorrhage is persistent; if the OS dilates; if the ovum is felt within the cervical canal; if the pain is considerable; and, above all, if portions of the o^alm are expelled, abortion may be pronounced inevitable. Tarnier'^ calls attention to a sign which is valuable as indicating an un- avoidable abortion. This is the effacement of the acute angle formed anteriorly between the neck and body of a pregnant uterus. The disappearance of this angle indicates a contrac- tion of the longitudinal fibers of the uterus and a descent of the ovum. The Diagnosis of an Abortion Partially or Wholly Accomplished. - — To determine whether a part or the whole of the uterine con- tents has been expelled it is necessary to examine everything discharged from the uterus; the clots should be floated in water, and should be carefully teased apart. If the embryo and o\aim are so small that they are lost in the blood that surround them, or if the discharges are removed from the patient and are not preserved, the os is usually patulous; the finger, passing into the cavity of the uterus, detects shreds of deciduous membrane attached to the uterine wall, a placenta, or some portions of the fetal membranes. If the abortion is complete the uterus is firmly contracted, the os is small, and a digital examination of the uterine cavity is difficult or impossible. The diagnosis must depend upon the history of the case, upon the examination of the discharge, upon the enlarged uterus, upon the lochial discharge, and upon the establishment of the milk secretion. The last phenomenon is more marked the later the date of preg- nancy, and is more evident in multiparse than in primiparas; but Budin observed a young girl in whom the menses were sup- pressed for only twenty days, and then returned as a profuse flow, who exhibited shortly afterward all the signs of commenc- ing lactation. If in the early months of pregnancy there is hemorrhage and a discharge of deciduous membrane, it is always wise while ^ Tarnier and Caseaux, vol. i, p. 574. ABOKTIOW MISCAKKIAGK, AXD PRKMATL-R E LABOR. 443 making the digital examination to feel on either side of the uterus for a tumor that might indicate a tubal pregnancy, and to inquire for the characteristic pain of that condition. A large proportion of the cases of extra-uterine pregnane}' in the author's case-books were mistaken by their medical attendants for an in- complete abortion. Membranous dysmenorrhea may be difficult to distinguish from abortion. The membrane, however, is discharged at a regular period, there may be a history of similar occurrences, and the membrane has not the characteristics of decidua under the microscope. Prognosis of Abortion and Miscarriage. — The destruction of the embryo is inevitable. Statistics have been given show- ing that every abortion or miscarriage entails a risk upon the woman. The hemorrhage, if rarely so great as to be immedi- ately fatal, may, b\' its persistence, so weaken a woman that she quickly succumbs if attacked by an intercurrent affection, or the syncope produced by loss of blood may favor the forma- tion of heart-clot. The retention of masses of decidua or of placenta is often followed by their decomposition, by chronic salpingo-oophoritis, or even by fatal septicemia. Tetanus is another complication which, in rare cases, helps to raise the mortality.^ Criminal abortions, with the additional risk of trau- matism from the unskilful use of instruments, and the probability of infection from unclean hands and implements, show a high mortality. The prognosis of abortion depends in great part upon the treatment. If every case could be treated by an aseptic and skilful curettage, the mortality of abortion should be nil. Treatment. — If a pregnant woman presents any of the con- ditions predisposing to the premature interruption of pregnancy, the treatment of these conditions constitutes the preventive treatment of abortion. In cases of irritable uterus the woman must be guarded against any nervous shock, undue physical exertion, errors in diet, sexual intercourse — anything, in a word, that would furnish the uterus an excuse for throwing off its contents. In exaggerated cases of this kind prolonged rest in bed, espe- cially at the time corresponding to the menstrual periods, or perhaps for the whole duration of pregnancy, may be neces- sary to secure the birth of a mature infant. If the pregnant uterus is displaced dov/nward or backward, it must be restored to its proper position, and be kept in place by a suitable pessary ^ For twenty-one cases of tetanus after abortion see Bennington, " British Gyn. Jour.," 1SS5. 444 ^^ THOL OGY. or by tampons until its increasing size prevents its displacement again. Uncontrollable vomiting or coughing must be treated appropriately. Asthma, which in some cases determines a pre- mature interruption of pregnancy, is best treated by change of chmate. 1 In general muscular spasms, as in eclampsia, chol- emia, chorea, epilepsy, hysteria, and tetany, the convulsions must be combated by appropriate remedies. The infectious and febrile diseases of pregnancy must be managed on. general principles, without special regard to the danger of abortion, which is often unavoidable. Chronic metritis and endometritis, fibromyo.ma of the uterus, lacerated cervix, perimetritis and cellulitis, disease of a tube or an ovary, and appendicitis, must be treated before impregnation. If, in spite of every precaution, the signs of threat- ened abortion manifest themselves, the treatment resolves itself into: (i) The treatment of threatened abortion; (2) the treat- ment, if necessary, of inevitable aboition; and (3) the after- treatment. The Treatment of Threatened Abortion. — The treatment to avert a threatened abortion should be perfect rest and the administration of drugs that diminish nervous sensibility and allay muscular irritability. The first can only be secured in bed in a supin^ position. The room should be darkened and kept quiet. The second object of the treatment is accomplished by giving opium, bromid of potassium, and chloral. Opium should be administered by the rectum as the extract in suppos- itories. The dose must often be large. Viburnum prunifo- lium^ should also be given. My routine medicinal treatment is a suppository of a grain (0.065 gi^-) o^ the extract of opium morn- ing and evening, and a dram (3.75 c.c.) of the fluidextract of viburnum three times a day.^ The Treatment of Inevitable Abortion, — If the hemorrhage is profuse before the os is dilated it can be controlled by a vag- inal tampon of sterile or iodoform gauze. The tampon should be removed after twelve or twenty-four hours. If the ovum is not discharged when the tampon is re- moved, the physician must choose the expectant or the active treatment of abortion. The latter is preferable, but not al- ways practicable for the general physician. Expectant Treatment. — When an abortion becomes inevitable, ergot may be substituted for the drugs that have been em- 1 See note by Harris to Playfair's " Midwifery," p. 243. ^Jenks, "Viburnum Prunifolium," "Trans. Amer. Gyn. Society," vol. i, p. 130. ' Negri has recommended large doses of asafetida if there had previously been a tendency to abort or to give birth to dead children. ABORTIOX, MISCARRIAGE, AND PREMATURE LABOR. 445 ployed to inhibit muscular action, but it should be remembered that the prolonged use of ergot in full doses complicates the case if later it is found necessary to evacuate the uterus, and the drug itself may cause retention of the ovum by constricting the cervix. If there is much bleeding, tampons are used in the manner al- ready indicated, and renewed every twelve hours until the ovum is expelled, or else so well separated from the uterine wall that it may be gently expressed or easily extracted by the fingers. Care must be exercised to avoid rupture of the membranes, which will probably lead to the retention of a portion of the ovum, whereas its expulsion as a whole is particularly desir- able in cases managed expectantly. If a part of the embryo or its appendages remain behind in the uterus, the woman is kept quiet in bed. If the discharge becomes foul, the tem- perature rises, or hemorrhage occurs the uterine cavity must be evacuated. The technic is described later. Active Treatment. — The tampon is used to control bleeding. When the dilatation of the os is sufficient to admit a finger, efforts are made, in early abortions, to turn out the ovum by sweeping the finger around it, and then extracting it with the finger hooked behind it ; or Hoennig's method of expression may be tried. ^ These methods are most successful wdien the ovum is lodged in the cervical canal and lower uterine segment, its escape being prevented by an undilated external os. The hemorrhage is usually profuse. The ovum being wholly or in part expelled, everything left behind in the uterine cavity, whether thickened decidua or placental tissue, must be extracted. For an adherent placenta nothing is better than the finger, which can be made to reach the fundus by pressing the uterus down fi"om above through the abdominal walls, the patient being anesthetized if necessary. The placenta is peeled off from the uterine wall, and afterward easily extracted. To remove the thickened decidua, which almost invariabh' remains behind in early abortions, nothing is so good as the Emmet placental or curet forceps. Occasionally a dull broad curet removes pieces of decidua that the forceps fails to grasp. If the os is so re- tracted that neither a finger nor an instrument can be inserted, the use of branched dilators or of a metranoikter for twelve hours obviates the difficulty. After the uterine cavity is evacuated, it should be irri- gated. - ^The uterus is squeezed between the fingers in a combined examination, and the uterine contents are pressed out as a stone is expressed from a cherry. ^ I have tried every model of a two-way uterine catheter on the market, and find Fritsch's modification of Bozcman's the best. 446 PATHOLOGY. The After=treatment of Abortion.^ — If active treatment has been pursued, the after-treatment is simple; the lochial dis- charge is slight and the involution of the uterus rapid. Until involution is complete the woman should be confined to bed. It is not safe, even in the earliest cases, to allow her to get up in less than a week or ten days. The after-treatment when an expectant plan has been pursued has already been indicated. Should infection occur, it is treated as after delivery at term. Missed Abortion.— By this term is meant the death of the embryo, threatened abortion, the subsidence of symptoms, and the retention of the ovum for a varying length of time.^ Missed abortion may give rise to undeserved suspicion of a woman's virtue or to ludicrous mistakes in diagnosis. A two month's ovum, retained for seven months and then expelled spontane- ously, was mistaken for a labor at term while the pains lasted. Miscarriage. — A pregnancy from the fourth to the seventh month is not likely to be overlooked, so that one difficulty in the diagnosis of abortion, the doubt as to the existence of preg- nancy, does not, as a rule, obtain in cases of miscarriage. It is easier to detect the two accidents which make the expulsion of the ovum almost inevitable — rupture of the membranes and the death of the fetus; the liquor amnii has reached such a quantity that its escape attracts attention, while the death of the fetus, followed by a cessation of fetal movements and of growth in the uterus, by a disappearance of the reflex, and psychical disturb- ances characteristic of pregnancy, and also, perhaps, by the ap- pearance of the milk-secretion, is not likely to pass unnoticed. The pain associated with miscarriage is greater than in abortion and assumes the type of labor-pains. The periodic contrac- tions of the uterus can be felt through the abdominal walls. The expulsion of the ovum resembles also a labor at term, as the fetus usually is first expelled and the membranes and placenta follow after. As pregnancy advances this sequence becomes more and more the rule, but occasionally the ovum is cast off entire, even at a late period of pregnancy. I have seen such an occurrence at the seventh month, and it has actually been reported to have occurred at term. Miscarriage is chiefly distinguished from abortion by the for- mation of the placenta, and from premature labor by the adhe- sion of the placenta to the uterine wall, its retention, and con- sequent serious hemorrhage or infection. ^The fetus has been retained in utero five, eleven, and even fifty-one years, L. C. Peter, " Amer. Gyn. and Obstet. Jour.," Feb., 1899. EX TKA- UTEKIXE PRE GXA XC Y. 44/ CHAPTER VI. Extra-uterine Pregnancy. By extra-uterine or ectopic pregnancy is meant the develop- ment of an impregnated ovum outside of the uterine cavity. The condition was described by Riolanus, Benedict Vassal (1669), and by Regnier de Graaf. Abdominal sections for extra-uterine pregnancies were performed by Nufer (1500) and by Dirlewang (1549). Bohmer (1752) differentiated the tubal, ovarian, and abdominal forms of ectopic gestation. Schmidt (1801) described interstitial pregnancy. Frequency. — The proportion of extra-uterine to intra- uterine gestations is difficult to determine. It has been said to be about i in 500 normal pregnancies. Winckel, however, saw but 16 cases in 22,000 births, and Bandl, in Vienna, but 3 out of 60,000. An experienced specialist in the larger cities of America usually sees from 12 to 24 cases annually. Classification Based upon the Situation of the Developing Ovum. Tubal. Tubo-uterine, or interstitial. The ovum develops in that portion of the tube which runs through the uterine wall. Tubal proper. Tubo-ovarian. The ovum is attached to the ovarian fimbria. Ovarian. The ovum develops in a Graafian follicle. Abdominal. In primary abdominal pregnancy the ovum im- beds itself in the peritoneum. Secondary abdominal. Ovario-abdominal. The ovum, beginning its growth in the ovary, pushes its way out into the abdominal cavity. Tubo-abdominal. The ovum, at first contained in the tube, escapes into the abdominal cavity by rupture or by a gradual separation of the fibers in the tubal coat. There is a form of tubal pregnancy often called secondary ab- dominal or tubo-abdommal, in which the ovum grows downward and backward behind the peritoneum. This should be known as a broad-ligament or retroperitoneal pregnancy. Utero-abdominal. The ovum grows at first in the uterine cavity, but, in consequence of a spontaneous rupture or separation of an old scar in the uterine wall, becomes an abdominal pregnancy, retaining its connection with the uterus by the placenta. 448 PATHOLOGY. Etiology. — The causes of ectopic gestation are conditions delaying the progress of the ovum from the ovary to the uterus until a stage of development is reached at which the ovum imbeds itself in maternal tissues. Any disease of the mucous membrane of the tube depriving its cells of their ciha, forming mucous polypi or otherwise obstructing its caliber, predisposes to an arrest of the impregnated o^alm in its passage to the womb. So does any condition interfering with the normal peristalsis of the tube. Chronic salpingitis, therefore, is often found associated with and preceding tubal pregnancy. Fig. 340. — Bifurcation of tubal canal (Hennig). Peritoneal adhesions from a precedent salpingitis ^ or appendi- citis constricting or distorting the tubes and congenital or ac- quired stenosis may also obstruct the tubal canals. A divertic- ulum in the tube, an accessory tubal canal, accessory abdominal ostia, and atresia of the tube have been noted in connection ■with ectopic gestation. An exaggeration of the characteristic serpentine course of the tube mav' make the progress of the o\Tjm difhcult and may arrest it before it can reach the uterus. Fibromyomata of the uterus and tumors of the broad ligament have caused tubal obstruction. Anything which increases the size of the ovum before it has emerged from the tube may be a cause of extra-uterine pregnancy; thus, external transmigration. twins, or an unusually long tube may result in such a de^'el- opment of the ovum before its arrival in the uterine cavity that it imbeds itself in the tube. 1 The majority of my cases have had a histors' of previous salpingitis, and I have treated several of them for gonorrhea months and years before the tubal gestation occurred. In one case I found a four weeks' ovum and embryo in the middle of a gonorrheal pus tube that had been under obser\-ation for a year. The operation was performed for what was supposed to be an exacerbation of the salpingitis. EXTRA- UTERINE PREGNANC Y. 449 Clinical History. — In each of the situations noted above the course of gestation may be somewhat different, and each may- present an individual clinical picture on account of the difference in the surrounding anatomical structures which are involved. The general presumptive signs of pregnancy are commonly the same as in intra-uterine gestation, but there is usually se\-ere pain. Extra-uterine pregnancy occurs oftenest betw-een the twentieth and thirtieth years. The youngest woman affected was fourteen, the oldest forty-seven years of age. Changes in Uterus and Vagina. — In all the forms these changes are alike. Most of the alterations characteristic of intra-uterine pregnancy are found: hypertrophy of the vaginal mucous membrane, with increased blood-supply (purple tinge) and increased secretion; a soft cervix and a patulous os; an enlarged uterus, and, in the majority of cases, a development of a deciduous membrane, under- going the same change as in intra-uterine gestation prepara- tory to its separation and extru- sion, which occurs in extra- uterine gestation usually between the eighth and twelfth week, the membrane being expelled as a complete cast of the uterus and even of the tubes, or in shreds. The usual clinical history of ectopic gestation is absence of menstruation until the death of the embryo or rupture of the sac, when the menses return with the discharge of the decidua. The metrorrhagia which thus begins may continue for a long time. The other changes in the maternal organism may vary with the situation of the developing ovum. Clinical History and Pathology of Tubal Pregnancy. — Usually the woman has had children, but a long time has elapsed since the birth of the last child. The most frequent situation of an extra-uterine gestation is the outer third of the tube (the ampulla ^). In this position it may grow upward into the abdominal cavity, distending the tube-walls to the point of ^ Martin's statistics of 55 cases of extra-uterine pregnancy give this situation Fif^. 341. — Decidual cast of the uterine cavity in extra-uterine preg- nancy (Zweifel). in 49. 29 45 O PATHOLOGY. rupture, or it may grow downward between the layers of the broad ligament, and then backward and upward behind the posterior parietal layer of the peritoneum (broad-ligament gestation). The tubal walls show irregular hypertrophy from the development of their muscle-fibers. The point of rupture is at the site of original attachment of the ovum, the cells of the chorion villi burrowing into the tubal wall and weakening it. Fever is often seen, sometimes to a high degree, even before rupture. The usual temperature, however, before rupture is between 99° and 100° F. After rupture there may be a low temperature indicative of hemor- rhage. Reaction may quickly occur, and fever is not incom- patible with profuse intraperitoneal hemorrhage. There is a moderate leukocytosis, usually about 12,000. Exceptionally, the tubal gestation may proceed to full term. In these cases the ovule has probably at first grown downward and backward. If perforation of the tubal wall occurs, it usually takes place between the eighth and twelfth weeks, but it may occur as early as the fourteenth day,^ or not till after the sixth month. If the tube ruptures upon the upper or posterior aspect of the sac, the sac- con- tents are extruded into the peritoneal cavity with an intra-peritoneal hemorrhage. If rupture occurs on the lower aspect, the con- tents of the ovum and the blood find their way between the layers of the broad ligament and the pelvic fascia, giving rise to an extraperitoneal hematocele. The first variety is usually fatal : the last is not always directly dangerous to life, but the layers of the broad ligament may rupture when distended with blood, and the bleeding then becomes intraperitoneal and unlimited. The bleeding may also be limited by peritoneal adhesions shut- ting off the peritoneal cavity and forming a closed sac in the iliac region. From adhesions to intestines, complications, such as perforation and obstruction of the bowel, may occur. Recent studies of the behavior of the ovum in relation with the tubal wall and the mucous membrane explain the difference of opinion once prevalent as to decidua formation and also explain the clinical course of tubal gestation. The ovum may imbed itself either in plications of the tubal mucous membrane or directly in the muscular tubal wall. In the former case the bed of the ovum is in the connective tissue of a stem of the mucous membrane folds. The maternal tissues, including blood-vessels, are eroded by the cells of the trophoblast; the thin capsule of the ovum is penetrated and, hemorrhage occurring into the lumen of the tube, 1 Ross, "Am. Jour. Obstet.," October. 1895. According to Hecker's statistics of 45 cases, rupture occurred 26 times in the first two months, li times in the third, 7 in the fourth, and once in the fifth. In two of my cases rupture occurred no later than the fourteenth day. EXTRA- UTERINE PRE GNANC Y. 451 escapes from the fimbriated extremity into the peritoneal cavity (tubal abortion). In the latter case the trophoblast makes a nest for the ovum in the tubal wall, burrowing into the muscle at Fig. 342. — Broad ligament pregnancy (Zweifel). the base of the plications of the mucous membrane or in the isthmus where these plications are not developed. At the point where the ovum attaches itself the cells of the villi penetrate toward the periphery of the tube, opening the walls of blood-vessels and penetrating the tubal wall to the serous covering, which eventually gives way. Thus the so-called rupture of tubal pregnancies occurs, with intraperitoneal hemorrhage. Fig. 343. — Ruptured broad ligament pregnancy. There can be no true decidual formation in the nest which the ovum makes for itself in muscular tissue, beneath the tubal 452 PATHOLOGY. mucous membrane, for the cells of the intermuscular connective tissue do not undergo this metaplasia, but in other portions of the tubal mucous membrane distant from the o^iim, even in the other tube, there is an irregular development in limited areas of decidual cells. The cells in the bed of the oMjm, often described as decid- ual cells, are really derived from the trophoblast (Langhans' cells). There may be a reflexa formation, irregularly and feebly Fig. 344. — Interstitial pregnancy, fourth month ; vaginal hysterectomy, a, Cav- ity of the ovum; b, uterine cavity; r, left tube; d, cervix; e, partially detached placenta; f, right tube; g, right ovary (Bumm). developed as the ovum grows and projects into the lumen of the tube, but there is often an underlying layer of muscular tissue and the capsule of the o\'um soon degenerates and is penetrated by the trophoblast, so that the vihi of the latter contract attachments with the plications of the tubal mucous membrane or, in the isthmus, with the opposite tubal wall. There may be multiple (twin and triplet^) extra-uterine gesta- tion; coincident intra- and extra-uterine pregnancy; pregnancy first in one tube and then in the other; sim.ultaneous pregnancies 1 Sanger, " Centralbl. f. Gyn.," No. 7. 1893. Krusen, " Tr. Phila. Co. Med. Soc," October, 1901. v. Xeugebauer, " Zur Lehre von der Zwilling Schwanger- schaft mit heterogenem Sitz der Fruchte," Leipzig, 1907. EXTRA-UTERINE PREGNANCY. 453 in both tubes'; of two successive pregnancies in the same tube.- Hydramnios was noted in one case of tubal pregnancy^ and a thoracopagus was found in another/ Several cases of hydatidi- form mole and also cases of chorio-epithelioma have been observed in tubal pregnancies.'^ Interstitial Pregnancy. — The ovum develops in the uterine wall, the inner side of the sac often projecting into the uterine cavity, and having on its outer side the round ligament and the whole length of the tube. The usual termination is rupture into the peritoneal cavity. Hecker collected twenty-six cases, all ending in rupture before the sixth month. Rupture into the Fig. 345. — Tubo-ovarian pregnancy: Sac ruptured. uterine cavity and expulsion of the fetus through the cervix are possible. Rupture into or growth between the layers of the broad ligament is also possible." Tubo=ovarian Pregnancy. — The ovum develops between the fimbriae of the tube and the ovary. The sac may rupture with the usual consequences of such accident. It is possible, how- ever, to see a development of the fetus to maturity. The ovum 1 Martin has collected 8 cases, " Zeitschr. f. Geburtsh. u. Gyn.," Bd. xxxviii, H. I. Jayle, 28 cases, " Rev. de Gyn. et de Chir. Abdom.," No. 2, 1904. ^Coe, " N. Y. Med. Record," May 27, 1893; Borland, "Repeated Extra- uterine Pregnancy," " Amer. Jour. Obstetrics," April, 1898; Royster, " Combined Intra- and Extra-uterine Pregnancy at Term," ibid., 1897, vol. xxxvi, p. 820; Mosely, ibid., 1896, "Thirty-eight Cases of Intra- and Extra-uterine Pregnancy." Zinke, ibid., xlv. No. 5, 1902, 88 cases. Neugebauer, 129 cases. Heinricius and Kolster report two fully developed fetuses in one tube, one macerated, the other well preserved, " Archiv f. Gyn.," Bd. Iviii. Pestalozza has collected 108 cases of repeated tubal pregnancies, " Arch. Ital. di Gin.," No. 5, p. 474, 1900, Naples. ^ " Archiv f. Gyn.," Bd. xxii, S. 57. " " Centralbl. f. Gyn.," 1894, p. 232. ^ Werth, " Winckel's Handbuch," 2^, p. 822. ^ Werth gives forty as the number of interstitial pregnancies in the literature which bear criticism, " Winckel's Handbuch," 2^, p. 739. 454 PATHOLOGY. may lodge upon the ovarian fimbria and may thence grow in- ward between the layers of the broad ligament. Ovarian Pregnancy. — The ovum, impregnated while it is still within the Graafian follicle, reaches some degree of growth and development within the ovary. The tube and ovarian fimbria are free, the uterus is connected by the ovarian Hgament with the gestation sac, the wall of which consists in great part at least of ovarian tissue. The condition is exceed- ingly rare, but there are a few indubitable cases on record.^ Fig. 346. — The ovum imbedded under the peritoneum of the broad ligament (author's case). A case reported by Baer went to term. Miiller and Widerstein have reported cases of the prolapse of a pregnant ovary into the inguinal ring and canal. Abdominal Pregnancy. — Primary abdominal pregnancy is exceedingly rare. Many gynecologists deny its occurrence, ^ Cases are reported by Potenko, Werth, Paltauf, Leopold, and Martin. See Winckel, " Geburtshiilfe "; Kelly, article in " .American Text-book of Obstetrics." Ludwig, " Wien. klin. Woch.," 1896, has collected 18 cases besides one of his own. Leopold claims that there are 13 authentic cases recorded, " Archiv f. Gyn.," Bd. lix. Catharine von Tussenbroek demonstrated a specimen removed by Kouwer, of Harlem, " Tr. Ill Congress of Gyn. and Obst.," Amsterdam, 1899. Micholitsch found 2 cases among 120 cases of extra-uterine pregnancy operated on in Wertheim's Clinic (" Zeitschr. f. Geb. u. Gyn.," Bd. xlix, H. 3). C. C. Norris, " Tr. Philada. Obstet. Soc," 1908; Bryce, Teacher and Kerr, " Early Ovarian Pregnancy," Glasgow, 1908. EXTRA- UTEKIXE PREGXANC V. 455 Fig. 347. — Reported as an ovarian pregnancy. Fig. 348. — Reported as an ovarian pregnancy. Fig. 349. — August Martin's case of ovarian pregnancy. The intact tube is seen lying above the ovarian sac containing the fetal envelopes. The ovarian liga- ment runs from the sac to the uterine cornu. 456 PATHOLOGY. but there have been a few authentic cases. ^ The conditions in the free abdominal cavity favor the progress of pregnancy to the mature development of the fetus. The peritoneum is con- verted into decidua-like membrane wherever the ovum comes in contact with it, and from this source the chorion and placenta derive nutriment. The ovum is surrounded by a fibrous and vas- cular capsule. In abdominal and in advanced tubal gestation abortive labor-pains appear at term. The child dies at or shortly after this period, and the liquor amnii is absorbed after the death of the fetus. The abdomen is consequently reduced in size and the tumor is changed in consistency. The fetus may be con- verted into a lithopedion and ma}' remain as an innocuous tumor in the abdomen for years (see Termination of Extra-uterine Pregnancy, and Changes in Fetal Bod}' after Death). The child is likely to be sma,ll and ill-formed, but occasionally over- grown children are reported, if fetal life is prolonged beyond the usual duration of pregnancy. In advanced cases of abdominal pregnancy the fetal movements are exceedingly painful to the mother. Abdominal pregnancies may end in rupture of the sac or there may be profuse hemorrhage into the sac-cavity. Utero=abdominal pregnancy is very rare. The pregnancy is at first intra-uterine, but the o\Tim escapes into the abdominal cavity through an opening in the uterine wall, retaining a connec- tion by the placenta with the uterine cavity. The process of extrusion must be gradual. These cases follow either a Cesarean section or a rupture of the uterus at a previous labor. The fetus may grow to full term.^ Terminations of Extra=uterine Pregnancy. — Death and Ab- sorption of the Voting- Embryo with Absorption of the Liquor Amnii, and Atrophy of the Gestation Cyst. — Of all the terminations of ectopic gestation, this is the most favorable. It is exceptional, and should never be counted on in practice. The embryo must die before the second month to be completely absorbed. At the best, chronic salpingitis with adhesions persists, and the woman may, therefore, be left a chronic invalid. 1 Schlechtendahl has reported a case of primar}^ abdominal pregnancy in which a fetus fifteen centimeters long was found incapsulated near the spleen. The tubes and uterus were normal (" Frauenarzt," 1887, ii, pp. 81-86). Braun's and Zweifel's cases (" Archiv f. Gyn./' Bd. xli, H. i and 2), in which the placenta was attached to the posterior uterine wall and to the sigmoid flexure, and Koberle's case, in which impregnation occurred through a vagino-abdominal iistula after hysterectomy^ were probably primary abdominal pregnancies. Five cases maj' be accepted as beyond criticism: Galabin's, Witthauer's, the author's (Hirst and Knipe, " Surgery, Gyn. and Obstet.," October, 1908), Grone's, " Zentralbl. f. Gyn.." No. 2, 1909, and a second case of the author's, " Trans. Phila. Obstet. Soc, Ma}^ 191 2. ^ " Ausgetragene secundare Abdominalschwangerschaft nach Ruptura uteri, im vierten Monat," Leopold, " Archiv f. Gyn.," Hi, 2, 376. Fullerton, " Annals of Gyn.," October, 1891. EXTRA-UTERINE PREGNANCY. 457 Rupture of the sac and profuse hemorrhage occur most com- monly in tubal gestation, when the growth is upward toward the abdominal cavity. At least two-thirds of all ectopic gestations end in rupture of the sac or in tubal abortion. Rupture may i ^^^ ^^^•^^^^^{'^ Fig, 350. — Ruptured tubal pregnancy ; sac involving the isthnnus.'^ occur when the ovule grows downward between the layers of the broad ligament; also in tubo-uterine, tubo-ovarian, ovarian, and abdominal pregnancies. The accident commonly destroys the embryo, which may escape into the abdominal cavity. Up to the second month the extruded embryo may be absorbed. Later, it may be found lodged among the intestines, perhaps far removed from the pelvic organs and usually surrounded by clotted blood.^ Rupture of the tubal wall has been reported without hemorrhage, the head of the embryo fitting into the gap and acting as a tam- pon. The hemorrhage may be fatal in as short a time as two hours; it usually takes from eight to sixteen hours, however, for the woman to bleed to death. The hemorrhage may be fatal as late as the second, third, or fourth day, or there may be succes- sive hemorrhages, perhaps days apart, until the patient is grad- ually exhausted or is suddenly destroyed by an unusually profuse outpour of blood. Surprisingly small tubal gestation sacs may, on rupture, give rise to fatal hemorrhage. In such cases the ovum is usually imbedded in the tube near the cornu of the ^ Figs. 343 and 350 to 353 inclusive, also Fig. 345 are from photographs presented to me by the late Dr. Formad, for some time coroner's physi- cian of Philadelphia. He obtained the specimens in his official capacity, while investigating the cause of sudden deaths. - Burford reports an extraordinary case in which the tube ruptured, the fetus was extruded through the rent, the cord was torn across, and the fetus with the cord attached was found in the abdominal cavity inclosed in an adventitious sac. The placenta remained in the tube and the rent in the latter, through which the fetus escaped, had healed, " Brit. Gyn. Jour.," 1892. 458 PATHOLOGY. uterus. The determining cause of rupture is not always apparent. It may occur while the patient is l}ing quietly in bed, but may follow the straining of defecation or urination, coitus, a blow upon the abdomen, a g_vnecological examination, an operation like curet- ment, or any sudden physical effort or mental excitement. The trophoblast having eroded the tubal wall to and even through the peritoneum, it requires little or no extra strain to establish a com- Fig. 351. — Ruptured tubal pregnancy; sac involving the ampulla. Fig, 352. — Ruptured tubal pregnancy; sac situated wholly in the isthmus. The size of the sac is very small to occasion, on rupture, a fatal hemorrhage ; its situation, however, near the uterus, is a very dangerous one. The decidua lining the uterine cavity is plainly seen. munication between the bed of the o\'um, \\\\\i its opened blood- vessels, and the peritoneal cavity. Rupture of the sac or of a blood-vessel in its wall, with profuse hemorrhage, has occurred long after the destruction of the embryo and cessation of growth in the sac (two years in one case). EXTRA-UTERINE PREGNANCY. 459 Rupture of sac with extrusion oj its contents, and interstitial hemorrhage into the sac-walls, without escape of blood into peri- toneal cavity or between the layers of broad ligament, was the termination of one case of tubal gestation under my observation. This occurrence might be followed by atrophy of the ovum and sac. Tubal moles are frequently seen as the result of an old tubal pregnancy ; the ovum is infiltrated and surrounded by blood, clotted and often organized. The tubal walls are also infiltrated with blood and arc much thickened. The whole mass constitutes a solid tumor of the tube in which the embryo may not be found, and atrophied chorion villi in small numbers are only discovered after a careful microscopic search. Grozvth of the Fetus after Third Monti i ; Its DeatJi at or before Maturity and the Changes that Occur Afterward. — A continued de- velopment of the fetus in the later months of pregnancy is seen most often in abdominal or in tubo-ovarian pregnancies, though it is possible in the tubal gestation with retroperitoneal growth (broad-ligament pregnancy). The fetus after death may be converted into a lithopedion or may be mummified, and in these conditions may remain in the abdominal cavity indefi- nitely (in Sappey's case fifty-six years), or may be removed by operation through the abdomen, vaginal vault, or possibly by the rectum. The soft parts may macerate and may be absorbed, leaving the bones, which remain as an innocuous abdominal tumor or ulcerate into the bladder, intestines, or through the anterior abdominal wall. Ulceration into the bladder is a par- ticularly unfortunate complication. I have seen an old lady die of peritonitis caused by the ulceration of a parietal bone through the transverse colon. Her history indicated an abdominal preg- nancy many years before. The fetal body may putrefy from the contiguity of the intes- tines and their contained micro-organisms and the consequent access of bacteria to the highly putrescible sac-contents. In the same way the gestation-sac is converted into an abscess. Terminations of Ovarian Pregnancy. — There may be an arrest in the development of the ovum at an early period. In one case the small, cystic, ovarian tumor containing the fetal bones was retained in the abdomen for years. In another case the fetus went on to lull development, then died, and was removed in a good state of preservation at least one year later. Rupture of the sac and profuse hemorrhage may occur. In tubo-uterine or interstitial pregnancies the o\-um and em- bryo may be discharged into the uterine cavity, and may be evacuated by the natural passages. There are at least two such 460 PATHOLOGY. cases well authenticated. Rupture of the sac and hemorrhage into the peritoneal cavity is, however, the rule. In Mascka's case the head of the fetus passed into the abdominal, the breech into the uterine, cavity. In cases of tubal abortion (so named by Werth) there is an internal rupture of the tubal wall, of its connection with the ovum, or the epithehal cells of the chorion vilH penetrate the wall of a vessel of some size, and blood is poured through the fimbriated extremity of the tube into the abdominal cavity. The Fig. 353. — Tubal abortion. blood-clots filling the pelvis in such a case may have a peculiar sausage-like form imparted to them by the tubal canal. The whole ovum may possibly be extruded through the abdominal orifice of the tube, and in one case in which the fimbriated ex- tremity was closed by inflammatory adhesions the outer end of the tube was converted into a hematoma. Tubal abortion is- much more frequent than rupture. In 75 cases the former oc- curred 59, the latter, 16 times. ^ It is possible that tubal pregnancy may rupture in its early stages, the embryo be expelled into the abdominal cavity, retain- ing its connection with the tube by the cord and placenta, and the fetus thus continue to further or to full development. This is called a secondary or tubo-abdominal pregnancy} Rupture in cases apparently of this character may not have occurred. There may have been a retroperitoneal growth of the ovum and an enormous dilatation of the tubal walls. 1 " Volkmann's Samml. klin. Vortrage," N. F., Nos. 244, 245. ^ Lusk has collected three such cases. The fetus survived the rupture of the tube, or the extrusion may have been gradual by a separation of the fibers in the tube wall. EXTRA- UTERIXE PREGXAXC Y. 461 Growth and development oj the placenta after fetal death has been described, but has not yet been demonstrated beyond doubt. It would seem unlikely, arj^uing from the behavior of the pla- centa in utero after fetal death. Profuse hemorrhage into the gestation sac, forming a large hematoma, occurred in one case under my observation. Fig- 354 — Tubal abortion and extruded mole. Uterus Bladder Fig- 35S-— Diagram showing pelvic hematocele posterior to the uterus, which IS crowded forward with the bladder behind the symphysis pubis, while the rectum IS compressed behind against the sacrum (Skene). Hematoceles and hematomata in tJie abdomen, pelvis, and pelvic connective tissue in one-third or more of the cases are due to the hemorrhage from a rtiptured gestation sac. The blood may 462 PATHOLOGY. collect in front of the uterus (ante-uterine hematocele), may be behind the uterus (retro-uterine hematocele), may be encapsulated in the neighborhood of either broad ligament, or may be contained in the pelvic connective tissue on either side of the uterus. These accumulations of blood may suppurate, and may thus prove fatal. They may be evacuated by puncture through the abdomen or often through the vaginal vault. If not too large, they are absorbed. Fig. 356. — Diagram of intraperitoneal rupture of tubal pregnancy. Free blood in Douglas' cul-de-sac, and among the intestines : S, Symphysis ; R, rectum (Dickinson). Symptoms of Extra=uterine Gestation. — The Subjective Signs. — In the early weeks or months the subjective signs of ectopic pregnancy may be indistinguishable from, those of normal intra-uterine gestation. In the tubal variety, which is by far the commonest, there may be no indication of any abnormality until rupture occurs or blood escapes into the peritoneal cavity from the fimbriated extremity of the tube. In the vast majority of cases, however, rupture or bleeding is preceded by severe cramp- like pains, usually in one or the other iliac region, often accom- panied or followed by the discharge of deciduous membrane. The pain of extra-uterine pregnancy is its most distinctive symptom. It is described by the patient in strongest terms; oc- curring in paroxysms, with intervals free from suffering; appear- EXTA'A-UTEK/XE PKEGXANCV. 463 ing at anytime from a few days to months after a normal menstru- ation; situated often in one groin, though frequently indefinitely referred to the lower abdomen; extending down one leg or up to the epigastrium; and so severe as to occasion profound systemic disturbance — syncope, followed by nausea and vomiting, a cold sweat, hysterical outbreaks, complete disabihty, and every ap- pearance of excessive shock. The temperature is almost always slightly elevated. The pulse is rapid and the blood-pressure low if there has been much hemorrhage. In one case extreme brady- cardia was reported, probably due to some indirect stimulus of the vagus. There may be high fever and the general health may be much impaired. When advanced developm.ent occurs, as in ab- dominal and in some cases of tubal gestation, no symptoms may arise until the time for labor has passed, when pain and other comphcations, due to the pecuHar character of the abdominal tumor, may appear. There is usually cessation of the menstruation for one or two periods; then a return of the flow as an irregular bleeding, which may last for months. In some cases irregular bleedings begin with conception and last until rupture — there is no cessation of menstruation. In others one period is slightly delayed; those after and before are normal. Again, the delayed period may be unnatural in character. In exceptional cases the menstruation occurs at the normal time, but is more pro- fuse or scantier than normal. In no cases upon which I have operated there was no absence of menstruation in i8; a cessation of menstruation varying from 10 to 90 days in 92. There was metrorrhagia lasting from 2 to 120 days in 92 cases; there was a discharge of decidua in 50 cases. Other symptoms noted have been irritable bladder or dys- uria; marked constipation or even obstruction of the bowels if the tumor is on the left side; edema of the corresponding limb and aching pain in it, especially at the groin ; or numbness and loss of power. Pulsating vessels may be felt in the vaginal vault. ^ Objective Signs. — In tubal pregnancies an exquisitely sensi- tive tumor may be felt to one side of, behind, or possibly in front, of the uterus, quite firmly fixed after the third or fourth week, and doughy in consistence. ^ The uterus is much smaller than would be expected from the duration of the pregnancy. After the third month ballottement may possibly be practised upon 1 Hofmeier claims that the pulsation of arteries on one side of the cervix and not upon the other is a valuable sign of extra-uterine pregnancy ; and, moreover, that it is a si<^n of life in the ovum, ceasing when the embryo dies and the ovum stops growing. 2 For three or four weeks the tubal tumor is free; quite suddenly it sinks into the pelvis from its increasing weight, and wherever it comes in contact with the pelvic peritoneum the latter is changed into a decidua-like structure to which the tube walls adhere. 464 PATHOLOGY. the tubal tumor. The uterus is usually displaced forward, backward, or to the side opposite the tumor. The decidua is expelled from the uterus in a large proportion of cases (45 per cent, of my own). If the discharged membrane can be obtained, it will present, under the microscope, unmistakable character- istics of decidua. It may be extruded in fragments or as a com- plete cast of the uterus. Symptoms of Interstitial Pregnancy. — A diagnosis is diffi- cult or impossible. The uterus enlarges to a greater degree than in any other variety of ectopic gestation, and it may be im- possible to determine whether or not it is symmetrically enlarged. The condition is recognized after an abdominal section or upon a careful intra-uterine exploration. Abdominal pregnancy may be recognized when the ovum occupies Douglas' pouch, as the fetal parts may be made out with startling distinctness through the posterior vaginal vault. A sacculated uterus, however, might easily be mistaken for an abdominal pregnancy. There is unusual pain from fetal move- ments, and abdominal palpation may give unusually distinct results. It may be possible to outline the empty uterus. Diagnosis. — A diagnosis of extra-uterine pregnancy can usually be made before rupture. In spite, however, of careful attention to the patient's history and a painstaking physical ex- amination by an expert, a diagnosis before tubal abortion or rup- ture is sometimes impossible. Usually the condition is not recog- nized in general practice until hemorrhage has occurred. At this time a history of early pregnancy, a paroxysm of frightful pain, sudden collapse, symptoms of internal hemorrhage, with abdominal distention, and a vaginal examination showing a pelvic tumor with possibly the physical signs of effusion into peritoneal cavity make the diagnosis perfectly clear, and indicate an immediate ceHotomy. These symptoms have been closely simulated by rup- ture of a varicose vein in the broad ligament, by rupture of an ovarian cyst or torsion of its pedicle, by acute suppurative salpin- gitis, by fulminating appendicitis with intra-uterine pregnancy, by criminal abortion followed by infection, in which a false history is purposely given, and by pelvic tumors coincident with intra- uterine pregnancy. But as all these conditions demand the same treatment, a mistake in differential diagnosis is not serious. If the cramp-like pains of ectopic gestation lead a patient to consult a physician ; if she give a clear history of impregnation ; if she present all the earlier signs of pregnancy, with the discharge of blood and membrane which the microscope shows to be deci- dual; if there is a very sensitive tumor in the neighborhood of the uterus, on which ballottement may, perhaps, be practised, EXTRA-UTERINE PREGNANCY. 465 and if the uterus is not so large as it should be, — the diagnosis is justified, and the necessary treatment also, an abdominal section. Among the conditions in the pelvis that may make the diagnosis impossible are: Abortion, in consequence of or coin- cident with some growth near the uterus; pyosalpinx, with an indistinct or untrustworthy history of pregnancy; intra-uterine pregnancy, with rai)id development of a fibroid on one side of the uterus; development of an impregnated ovule in one horn of a unicornate or bicornate uterus, or on one side of a double uterus; appendicitis complicating intra-uterine pregnancy and cornual pregnancy — the implantation of the ovum in one cornu of the uterus, whence it grows into the uterine cavity, but meanwhile causes such severe paroxysms of pain and distends the uterus so unevenly that interstitial pregnancy is suspected. A common error constantly occurring in general practice is to mistake an extra-uterine pregnancy for an incomplete abortion. I find in my notes of cases this mistake made by the attending physician in more than one-third. Membranous dysmenorrhea might also be confused with ectopic gestation, but the physical signs, the history, and a histologic examination of the membrane should solve the question.^ Prognosis. — Without surgical treatment about two-thirds of the cases die; one- third escape the immediate danger of death. - Treated by abdominal section, the mortality should be less than I per cent, if the operator sees the patient in time. Of the patients who do not die directly in consequence of the tubal gestation, a large proportion remain invalids, and many die at a remote period from various complications, as bowel obstruction, ulceration, suppuration, hemorrhage. Treatment. — As soon as the diagnosis is established with reasonable certainty, the removal of the gestation sac by celiotomy is the only treatment worthy of consideration. The only safe plan is either to operate immediately one's self, or to refer the patient to a competent surgeon without delay. 1 It has been claimed that acetonuria is al\\ays present in ruptured extra-uterine pregnancy with intra abdominal hemorrhage, and that this sign, therefore, is valuable in the differential diagnosis ; but acetonuria is so frequent in intra-uterine pregnancy and other conditions that I cannot see its value as a diagnostic sign in ectopic gesta- tion (Baumgarten and Popper, " Wien. klin. Wochenchr.,"' No. 12, 1906). More- over, it is not always present in ectopic pregnancy. In ten cases I investigated it was present in four, suspicious in one, and ai)senl in five. 2 In 265 cases without surgical intervention, 36.9 per cent, recovered, 63.10 per cent, died (Winckel's " Geburtshiilfe," 2. Aufl., S. 254). In loo cases col- lected by Kiwisch, the mortality was 82 per cent. ; in I32 collected by Hecker, 42 per cent. ; in 150 by Hennig, 88 per cent. ; in 500 cases collected by Parry up to 1876 the mortality was 67.2 per cent. ; in 626 cases collected by Schauta, from 1876 to 1890, 241 ended spontaneously, 75 in recovery, and 166 in death, a mortality of 68.8 per cent. Martin states that of 585 cases operated upon, 76.6 per cent, recov- ered ("Centralbl. f. Gyn.," No. 30, 1892). 30 466 PATHOLOGY. The Technic of Abdominal Section for Tubal Pregnancy. — • The operation is often performed in an emergency, and must, therefore, be hurried. Plent}' of time, however, should be taken to secure an absolutely aseptic condition of the field of operation in the patient, of the surgeon, assistants, dressings, and imple- ments. If possible, the patient should be transported to a well- appointed hospital. If there has been much bleeding and the patient's condition is bad, hypodermic stimulation and submam- mary injection of salt solution should precede the operation, the anesthesia should be limited and the operation should be fin- ished in the fewest minutes possible. It is possible to conclude the operation, to the last abdominal stitch, in less than eleven minutes and with less than an ounce of ether. No attention should be paid to the blood that gushes in enormous quantities from the abdominal cavity when the peritoneum is incised. It has already been shed and is of no use to the patient. The side affected should have been learned by the history,^ if not by the physical signs. This tube should at once be grasped between the thumb and fingers of one hand, the tube should be cut from the cornu, the broad ligament should be transfixed by a pedicle needle to the inner side of the round ligament, and hgated en masse with three turns of the catgut ligature, one to each side of the pedicle needle, the third around the whole stump. The turns of the liga- ture nearest to the uterus lie under the severed end of the tube so as to leave no stump. The tube and ovary are then cut away. The cornu is sewed with a double tier stitch of catgut. The ab- dominal cavity is flushed with a large quantity of sterile water ^ or normal salt solution. Drainage is rarely necessary'. For twelve or twenty-four hours after the operation \dgorous stimu- lation and an active treatment for the acute anemia are necessary if there has been profuse hemorrhage. Submammary or intra- venous injections of normal salt solution are invaluable. Vein- to-vein transfusion is indicated in the worse cases. If the operation is performed before rupture or after a moderate hemorrhage from a tubal abortion, its technic does not differ from the salpingectomy for other indications. The author would warn the inexperienced against waiting for 'It is often impossible to tell from a physical examination which tube is in- volved, but I have found the history of pain down one leg and not the other of great value in diagnosticating the side affected. ^ I have practically given up douching the abdominal cavity after abdominal sections, except in extra-uterine pregnancy. There is no other means which so rapidly and surely removes blood-clots from the abdomen. It is, moreover, a great advantage to leave the large quantity of hot water which remains in the abdominal cavity after irrigation. Gallons are required, and it is inconvenient to prepare such a. quantity of normal salt solution. There is, moreover, no disadvantage in the use of sterile water. EXTRA-UrKKINK PREGNANCY. 467 reaction in cases of ruptured tubal pregnancies with profuse hem- orrhage. Delay has been advocated, but could not be endorsed by any one with a large and varied experience. Reaction may occur, but quite often it does not, and the patient continues to bleed until she bleeds to death. As no one can foretell the course of any case, it is not justifiable to wait until the patient is mori- bund before deciding that reaction can not be expected. The vaginal operation for tubal pregnancy in the first three or four months has the serious disadvantages that, on account of uncontrollable hemorrhage, a vaginal hysterectomy or hasty abdominal section may be necessary, and if the tube is simply incised and not removed, a diseased and useless pelvic organ is left behind to be the source of future trouble. It is impossible through a vaginal incision to evacuate the blood and blood-clots lying in large quantities in remote portions of the abdominal cavity. Moreover, as in all vaginal sections, nicety and precision of work is impossible through the vaginal vaults. In interstitial pregnancy, on account of the difficulty of diag- nosis, treatment is not usually attempted until rupture and hem- orrhage have occurred, when an abdominal section must be per- formed. The sac should be emptied, and its edges should be sewed to the abdominal wall; after the bleeding vessels are se- cured, the sac should be drained. If this technic is impossible, ligation of the uterine and ovarian arteries is indicated, drainage of the sac, or possibly supravaginal amputation of the uterus. It is justifiable, if the diagnosis is clearly established, to evacuate the gestation sac into the uterine cavity after thorough dilatation of the cervical canal. A mistaken diagnosis, however, would lead to a premature termination of a normal intra-uterine preg- nancy. Tait describes a case in which he found it possible to incise the sac, turn out its contents, and drain it, after fetal death.^ Engstrom treated a case successfully by incising the uterine wall, extracting the dead fetus and its appendages, making and enlarg- ing an opening between the gestation sac and the uterine cavity, sewing the uterine wall firmly together, as after a Cesarean section, and closing the abdomen without drainage.^ Ovarian pregnancy is treated by excision of the sac with the ovary. As a matter of fact, the operation is undertaken in these rare cases for an ovarian tumor, and the operator discovers its contents, to his surprise, after opening the abdomen. In advanced exlra-uterine pregnancy the jctal sac should be enucleated and extracted whole when the fetus is viable. It ' London " Lancet," 1894, i, p. 38. - " Centralbl. f. Gyn.," No. 5, 1896. Werth, to 1Q04, has collected 31 opera- tions for interstitial pregnancy, " Winckel's Handbuch," 2-, p. 940. 468 PATHOLOGY. may be necessary to cut the cord off short, stitch the sac wall to the abdominal wall, and drain the sac. Forty operations (1889- 1896) after the seventh month of gestation, with living and viable infants, were collected by Dr. R. P. Harris.^ In this number there were ten maternal deaths; twenty-seven infants survived the operation. Von Both has collected 83 cases: in the first 30 operations there were 25 deaths; in the 53 following, 15; and in the last 8 operations, only i.^ Sittner's^ statistics show from 1887 to 1900 forty-eight operations with removal of placenta and fetal sac with a mortahty of 12.5 per cent.; thirty-five opera- tions during the same period without the removal of the placenta, with a mortality of 42.8 per cent. In the last five years of the period the mortality of the two procedures was respectively 5.5 per cent, and ■^■^ per cent. In a later article Sittner presents the statistics of 121 cases. From 1901 to 1906 the mortality of remov- ing the whole sac was 5.7 per cent.; of the removal of the placenta, leaving the sac behind, 30 per cent. When death of the fetus has occurred the fetus and its entire surrounding sac should be removed. If the exsection of the sac is found to be difficult or dangerous, on account of hemorrhage, the implantation of the placenta on the intestines, or its inaccessibility, it is permissible, some weeks after fetal death, to cut the cord off short, leaving behind the atrophied remains of the placenta. If this is done, the sac-wall should be stitched to the abdominal wall, and thus drained for a length of time until the placenta comes away. Meanwhile daily irrigations are required and antiseptic powders (tannic or salicylic acid) may be dusted in the sac-cavity. In case the gestation sac ^s low down in Douglas's pouch, bulging the poste- rior vaginal wall, vaginal section and the delivery of the fetus by the natural passage may be considered ; but the dangers and disadvantages of the vaginal operation should be carefully weighed ; these are : Difficulty of extracting the fetus, if it is large, uncontrollable hemorrhage, puncture of an intestine, infection of the general peritoneal cavity, either at the time of the operation, or in subsequent irrigations of the sac, and adhesions involving the uterus and appendages after the woman's recovery from the operation.* Vaginal section is indicated in case of an old gesta- tion sac undergoing suppuration and containing a much macerated or disintegrated fetus. In some cases of intraligamentary preg- 1 Kelly's " Operative Gynecology," vol. ii. 2 " Centralbl. f. Gyn.," No. 15, 1899. '"'Arch. f. Gyn.," Bd. Ixiv, Ixxxiv, H. i. W. R. Nicholson, "Am. Jour. Obstet.," No. 6, 1908. ^ For a good bibliography of the removal of extra-uterine fetuses through the vagina and by the rectum, see J. T. Winter, " Am. Jour. Obstet.," 1892, p. 34. EXTRA- UTERINE PREGNANCY. 469 nancy it is possible to open the sac extraperitoneally by an inci- sion above Poupart's ligament. It is always advisable, however, to make a preliminary abdominal section to learn the relations of the gestation sac. Pregnancy in One Horn of a Uterus Bicornis or Unicornis. — Pregnancy in an ill-developed horn of a uterus unicornis may exactly resemble a tubal or interstitial pregnancy, and will probably end in rupture at the apex of the cornu.^ This is particularly Fig. 357. — Pregnancy in the rudimentary horn of a uterus unicornis, which has become, secondarily, abdominal (author's collection, Obstetrical Museum, University of Pennsylvania). true if the impregnated ovule develops in a rudimentary horn, in which the conditions are almost the same as in a tube, except that rupture takes place later, A pregnancy in a uterus bicornis may possibly terminate prematurely, or even at term, by expulsion of the product of conception through the natural passage. There may be a coincident pregnancy in the rudimentary horn and in the better developed one; after the removal of the former the latter may progress to term.^ The diagnosis of pregnancy in a uterine horn is difficult or impossible. It is mistaken, usually, for tubal gestation. The removal of a gestation sac in a rudimentary uterine horn is commonly easy, as a convenient pedicle is formed by the attach- ment of the horn to the lower segment of the better-formed half of the uterus. Hydrorrhea Gravidarum. — A watery discharge from the vagina of a pregnant woman may have fotu- sources : catarrhal endometritis, rupture of the membranes, discharge of fluid from ^Tliree cases of pregnancy in rudimentary horns are reported by Turner. Werth, and Solin (Lusk's " Obstetrics" ). Kussmaul collected thirteen cases ; Mannierre 39, 24 of which ended fatally liy rupture, "Am. Gyn. and Obst. Jour.," vol. xv, No. 3. Werth gives the number published to 1904 as an even hundred, " Winckel's Hand- buch," 2'^ p. 984. 2Doran, "Journ. of Obst. and Gyn. of the Br. Empire,'" June, 1906. 470 PATHOLOGY. a hydrosalpinx {hydrops tuha profluens) ,^ and edema of the uterine walls. The last is a very rare cause indeed.^ In catarrhal endometritis the fluid is discharged suddenly in consider- able quantities; it reaccumulates and is again discharged, the recurrent hydrorrhea continuing, perhaps, until term, al- though usually after the second or third discharge labor is brought on. The fluid discharged in a case of catarrhal endo- metritis is thin mucus. In a typical case under my observation there was a discharge of more than a pint of fluid at the seventh month of pregnancy, while the patient was lying quietly in bed. It was supposed that the membranes had ruptured and that labor was imminent, but no pains appeared, and after confinement to bed for a week the patient was allowed to get up. A month later there was another profuse discharge, — certainly more than a pint, — again occurring while the patient was quietly at rest in bed. Twelve hours later labor-pains appeared ; in the latter part of the second stage of labor the membranes ruptured and about a quart of liquor amnii was discharged. A careful examination of the membranes failed to detect a perforation remote from the seat of rupture. Rupture of the membranes and the discharge of liquor amnii in pregnancy are commonly followed by labor-pains within thirty- six hours. It is not very unusual, however, for three or four days to elapse from the time of rupture to the onset of labor. I have several times seen a month intervene between the rupture of the membranes and the beginning of labor, and in one case under my care the membranes were perforated at four and one- half months without inducing labor. The patient was the wife of an English officer in India. She had been told by a skilful Indian masseuse that she was pregnant, but an English physician whom she consulted assured her she was not, and, to prove that he was correct, inserted a sound into the uterine cavity. There was immediately a gush of liquor amnii. In spite of a journey of some 1 500 miles from the interior to the coast, the long voy- age from India to England, and thence to the United States, liquor amnii flowing from the vagina at every roll of the ship or jolt of a carriage, labor did not appear until term, four and a half months from the time the membranes were punctured. There was found, after delivery, a round, regular opening in the membranes, about the caliber of a lead -pencil, midway between the seat of rupture and the placenta, which was attached at the fundus. 1 " Hydrorrhoea Gravidarum and Hydrosalpinx," Cowles, " Obstetrics," Nov., 1899. 2 Chazan, " Cenlralblatt. f. Gyn.," No. 5, 1894, p. 105. ANOMALIES JX THE FORCES OE LABOR. 47 1 CHAPTER VII. Anomalies in the Forces of Labor. In a normal labor the active forces of expulsion (the uterine and abdominal muscles) and the passive forces of resistance (the fetus, the pelvis, and the maternal soft structures) are so nicely balanced that the expulsive forces are just sufficiently resisted to insure a slow and gradual passage of the fetus along the birth- canal. The walls of the birth-canal and the structures around the vulvar orifice are by this arrangement slowly and gradually dilated, and are not violently torn apart, as they would be by a more rapid expulsion of the fetus. This balance between the powers of labor is easily disturbed. There may be anomalies by deficiency and anomalies by excess in the component parts of the forces of expulsion and in all the sources of resistance. Thus, the uterine muscle may be too weak or too strong com- pared with the resistance it must overcome ; and so also with the action of the abdominal muscles. The resistance furnished by the pelvis, the soft structures, and the fetus may be excessive or deficient. Deficient Power of the Uterine Muscle ; Inertia Uteri. — In this condition the uterine muscle is unable to overcome the normal resistance offered by the weight of the fetal body, by the friction of the pelvic walls, and by that of the undilated maternal soft structures. Inertia uteri is manifested, in the vast majority of cases, during the first stage of labor. The weakened uterine force, therefore, is almost always neutralized by the obstruction of an undilated cervix. There is scarcely another condition in obstetric practice that can be traced to such a variety of causes or that demands so many different plans of treatment. Etiology. — Deficient power of the uterine muscle in labor may be due to a defect of the muscle itself, to some anomaly of innervation, or to a mechanical interference with the full and effective action of the muscle. Examples of the first-named cause may be found in imperfect development of the uterus or in anomalies of development, as in uterus bicornis. The uterine 472 PATHOLOGY. muscle may be exhausted by rapidly succeeding pregnancies. It may be overdistended by twins or by hydramnios, thus losing the power gained by cohesion of muscular bundles. The uterus may be weakened by some cause — as an adynamic fever or a wasting disease — that weakens the whole organism, but it does not necessarily follow that uterine weakness always accompanies a reduction of body-strength. Women in the last stages of phthisis or in the midst of an attack of typhoid fever or pneu- monia occasionally exhibit a uterine power in labor above the normal. The uterus may be weakened by profuse hemorrhage, as in placenta prsevia. It may be rendered incapable of exerting normal force in dry labors. The liquor amnii having drained off completely early in the first stage, the uterus retracts upon the child's body, thus being subjected in certain regions to severe and long-continued pressure, and becoming in those spots anemic and friable, while in the areas free from the pressure of the child's body the uterine wall becomes congested, swollen, and edematous. Above all, the uterine muscle may be fatigued. This is the commonest cause of uterine inertia. It is seen oftenest in primip- arae, in whom inertia is more than twice as common as in mul- tiparae, on account of the difficulty of dilating the rigid cervical tissues. Inertia may appear in consequence of any serious obstruction in labor. At first the pains are feeble, infrequent, and inefficient, but as labor continues the uterine contractions gather force. The inertia from this cause is likely to be only temporary, seen at intervals between periods of stormy uterine action or of long-continued tonic spasms, until finally ex- haustion of the whole organism threatens the patient's life or the uterus ruptures. It has been asserted that an anomaly of innervation in the anatomical sense, a deficient supply of the terminal nerves in the individual muscle-cells, is a cause of uterine inertia, but it is not yet clearly demonstrated to be so. An inhibitory nervous im- pulse to the uterine muscle, on the contrary, is a frequent cause of uterine inaction. It is the result of some emotion or of great pain. That the "doctor has frightened the pains away" on his first arrival has become proverbial in the lying-in room. The presence of any one who is a cause of embarrassment or is disagreeable to the patient may have the same effect. In hyper- esthetic women the uterine contractions may be so exquisitely painful that their first onset is followed by an inhibitory impulse which cuts them short almost immediately. Every clinical observer has seen the phenomenon of rapidly recurring, very painful uterine contractions, which are, however, of short dura- ANOMALIES IN THE EORCES OE LABOR. 473 tion, and which secure no appreciable dilatation of the cervical canal. A woman may be tortured thus for hours in the early- part of the first stage of labor, when this inhibitory nervous im- pulse is commonly observed. With the continuance of labor the individual becomes more or less indifferent to her surroundings or more inured to suffering, and the inhibitory nei'ves, probably derived from the spinal cord, apparently lose the power of responding to the stimulus of pain. Among the mechanical causes of inefficient uterine action during labor are fibroid tumors of the uterine walls, displace- ments of the uterus, old peritoneal adhesions, and fresh out- breaks of periuterine inflammation. Diagnosis. — The recognition of uterine inertia should always be easy. The contractions of the muscle are of short duration and are separated usually by long intervals, and by palpation the observer may convince himself that they are feeble. The uterus during the pain does not assume the hard consistency which it does in consequence of normal vigorous action. The patient's expression, action, and demeanor point to deficient force during the pains. The woman is more placid, the face is less contorted, and there is less outcry during the contractions than in the normal parturient patient, except in those cases in which excessive pain inhibits uterine action. In these cases, however, abdominal palpation and the short duration of the pains are plain signs of the inertia. Finally, labor is delayed. During the first stage dila- tation is slow or does not progress at all, and in the second stage the presenting part does not advance. One fatal error in the diagnosis of inertia uteri should be avoided: the physician should be sure that labor is not delayed by some obstruction. It has happened in a careless and superficial examination that the ob- server has taken the distended and thinned lower uterine segment for an inert uterus. In such a case the measures adopted to stimu- late the supposedly inactive uterine muscle to overcome an obstacle that is insuperable might easily be interrupted by rupture of the uterus. A methodical and careful examination avoids this error. The source of obstruction is discovered. The firmly, perhaps tetanically, contracted upper uterine segment may be contrasted with the inactive lower segment by palpation of the whole anterior surface of the uterus. The contraction-ring should be visible, and the whole uterus stands out with unusual prominence, from the anteversion that always accompanies prolonged and powerful uterine contraction. Treatment. — From the diversity in the causes, of inertia uteri it follows that no single plan of treatment can be depended upon. 474 PATHOLOGY. If uterine action is inhibited by emotion, the cause of nervous disturbance should, if possible, be removed. An objectionable person should leave the room. If excessive pain prevents effective contractions, an analgesic should be administered. A quarter of a grain (0.0162 gm.) of morphin hypodermically is efficient. So is pantopon, gr. \. If the uterine muscle is simply apathetic, it can be aroused by some direct irritant. The insertion of a bougie as for the induction of labor answers the purpose well. A more effective but more troublesome measure is the dilatation of the cervical canal by the author's bags (p. 791), which not only irritate the uterine muscle and so bring on strong contractions, but also artificially dilate the cer- vical canal and thus relieve the uterine muscle of a great part of its task in the first stage of labor. If the head is well engaged in the pelvis, however, the insertion of the bag is difficult, and it is likely to cause malpositions. In such cases, if the os is dilated to the size of a silver dollar, nothing is so effective as the apphca- tion of forceps — not to drag the head through the undilated cer- vical canal, but to pull it at intervals firmly down upon the cervix. The impact of the head upon the cervix acts as a powerful reflex irritant, and excites as strong contractions as any direct irritant can do. Not only so, but the pull of the head upon the cervix gradually dilates the canal as effectually as could strong propulsion from above. As soon as effective pains are established and the dilata- tion of the cervical canal progresses satisfactorily, the forceps should be removed. Inertia uteri so profound as to demand the somewhat radical measures just described is, fortunately, rare. More commonly the physician sees the minor grades, in which there is simply a flagging of uterine effort during the first stage, especially in primiparae, accompanied by every evidence of temporary physical and mental exhaustion. After a period of rest effective contrac- tions reappear, even if nothing whatever is done to aid the patient. The more complete the rest, the more vigorous is the uterine action when it is resumed, and for this reason the administration of chloral and opium is often followed, after a time, by a satisfactory progress in labor. But these drugs neces- sarily retard the termination of labor by the time of rest they secure. It is ordinarily desirable, therefore, to resort to drugs of a stimulant character. Alcohol, quinin, pituitrin, and ergot alone deserve consideration. The last was employed extensively at one time, but clinical experience forbids its use to-day. The contractions of the uterus induced by ergot are likely to become tetanic. The uninterrupted contractions ANOMALIES IN THE FORCES OF LABOR. 475 interfere with the fetal circulation ; they may cause fatal intra- uterine asphyxia, and they often produce such exaggerated blood-pressure and stagnation of the current in the fetal body as to induce extravasations in important viscera, especially the brain. Further, the circular fibers of the cervix come under the influence of the drug, and by their firm contraction neutralize the contraction of the longitudinal fibers of the uterine body, and thus retard labor almost indefinitely ; and, worst of all, should there be some obstruction to the descent of the child in the maternal pelvis or in the fetal body, the administration of ergot predisposes to rupture of the uterus. For these sufficient reasons this drug, as a stimulant to the uterine muscle in the first and second stages of labor, should be banished from the obstetri- cian's pharmacopeia, except in the single instance of the birth of the second of twins. Owing to the recommendations of Albert H. Smith and of Fordyce Barker, quinin has had, and still has, a great reputation as a stimulant to the uterus in labor. My experience with the drug does not permit me to subscribe unre- servedly to its efficacy as a uterine stimulant in labor. Quinin has the positive disadvantage, moreover, of occasionally producing a violent postpartum hemorrhage. It is, however, undeniable that in multiparae, in the first stage of labor, i 5 grains of quinin often proves a valuable uterine stimulant. In the minor grade of inertia under description, so often seen in primiparse, and almost always the result of exhaustion, alcohol is useful in the shape of a wineglassful of sherry, taken slowly with a biscuit, and given with the positive assurance that it will bring back the pains and hasten the conclusion of labor, for the patient often needs moral and mental support as much as she requires a physi- cal and muscular stimulus. Of all the stimulants to uterine activity heretofore employed pituitrin^ has given the best results with the least disadvan- tage. I have used it extensively with great satisfaction. It is given hypodermically in doses of i c.cm. of a 20 per cent, solution. An impression prevails among general physicians that inertia uteri in the first stage of labor, before rupture of the membranes, may safely be disregarded. In a measure this view is correct. There is often a partial dilatation of the os, and then an en- tire cessation of uterine contractions for many hours and even 1 Hofbauer, " Zcntralbl. f. Gyn.," 1911, No. 4. V. Bagger- Jorgenson, ibid., No. 37, 1911; Kroemer, ibid.. No. 49, 191 1; Aarons, " The Lancet," December J4, 1910; White, " Brit. Med. Jour.," May 28, 1910; Th. Nagy, "Zentraibl. f. Gyn.," No. 10, 1912. 4/6 PATHOLOGY. for days. But should inefficient uterine contractions be ac- companied by much pain, as happens in some cases of inertia, the long-continued first stage should not be regarded with indif- ference. The patient in time shows the irritant and depressant effects of long-continued suffering in an elevated temperature, an accelerated pulse, and a lessened resisting power of body-cells, the last playing an important role in the predisposition to sepsis after labor. Another consequence of delayed, painful labor may be seen in sensitive, nervous individuals who are at first thrown into a state of excitement and then from gloomy forebodings of harm to themselves and to their infants, pass into an almost maniacal condition of terror and dread. It should be a rule of practice, therefore, to watch carefully all cases of inertia uteri, and to interfere as soon as the patient's mental condition or her pulse, temperature, and general vigor are demonstrably affected by the delay in labor. Excessive Power in the Expulsive Forces of Labor. — An actual excess of power in the expulsive forces in labor suffi- ciently great to expel the fetus precipitately is extremely rare. A relative excess is not uncommon. The child's body may be so small, the pelvis so abnormally large, the maternal soft parts so relaxed, that the ordinary power exerted by the uterine and abdominal muscles is far in excess of that required to over- come the weak resistance offered, and the child is fairly shot out of the birth-canal. The rapid delivery may cause serious re- sults to both mother and child. In the woman the structures of the pelvic floor may be lacerated severely ; the sudden evac- uation of the uterus predisposes to hemorrhage from inertia ; the placenta may be detached prematurely ; and the sudden evacuation of the abdominal cavity predisposes to dangerous syncope. For the child the chief danger is the possibility of unexpected delivery of the mother in the erect posture. The umbilical cord may rupture, and the child, falling to the ground, maybe fatally injured. Precipitate and unexpected labors occur most frequently when women are seated upon the water-closet. The child is evacuated into the waste-pipe or down a well and may be destroyed. Some astonishing examples of infantile vitality, however, are furnished by such cases. Unfortunately, the physician is usually not at hand to pre- vent a precipitate delivery and to avert its consequences. Should he find an infant descending the birth-canal with a rapidity dangerous to itself and to its mother, he can easily retard its progress by pressure with his hand against the presenting part. ANOMALIES IN THE FORCES OF LABOR. 477 Excess in the Resistant Forces in Labor. — Deformities of the Pelvis. — A comprehensive and satisfactory knowledge of deformities in the female pelvis has been gained only in the latter half of the nineteenth century, since the appearance of Michaelis' work in 1851.^ Until the announcement by Arantius in the last quarter of the sixteenth century that a contracted pelvis is a serious obstacle in labor, the prevailing belief had been that difficult labors from mechanical ob- struction by the maternal bones were due to a failure on the part of the pelvis to expand sufficiently for the passage of the child. This idea was entertained for a number of years after Arantius' time. According to Litzmann, Heinrich von Deventer (165 1 to 1724) should be regarded as the real founder of our knowledge of the pelvis and its anomalies. He described the inclination of the pelvis, the axis of the pelvic inlet, the con- tracted pelvis, and the flat pelvis. Pierre Dionis was the first to point out (17 1 8) the relationship between rachitis in childhood and a deformed pelvis in the adult. William Smellie's con- tributions to the study of the female pelvis were remarkably full and clear, when one considers how little was known before his time. His description of the rachitic pelvis, his reflections on its cause, and his accounts of illustrative cases may be read with profit to-day. Roderer, Stern, Cooper, Vaughan, Denman, Baudelocque, and Fremery added much to the stock of knowl- edge during the latter half of the eighteenth century. The men to whom we owe most of our present information about the pelvis and pelvimetry are Naegele, Kilian, Rokitansky, Michaelis, Robert, Litzmann, Neugebauer, and many others to whom refer- ence will be made in the sections devoted to the particular varie- ties of deformed pelvis. ^ Frequency of Deformed Pelves. — It is difficult to estimate the frequency in America of pelves sufficiently deformed to influence decidedly the course of labor. Statistics from our lying-in hospitals afford little aid to a correct conclusion, because the inmates are chiefly European immigrants and negresses. In the Boston Lying-in Hospital, however, deformed pelves were found in two per cent, of native-born and in six per cent, of foreign-born women (Reynolds).^ The statistics of Williams in Baltimore and of Crossen in St. Louis give a frequency of about seven per cent, among the white women of large American cities. Among negresses deformities of the pelvis are almost three times 1 " Das enge Becken." * Litzmann, "Drei Vortrage iiber die Geschichte von der Lehre der Geburt bei engem Becken," in his "Geburt bei engem Becken," etc., 1884. ' "Trans, of the Amer. Gyn. Soc," 1890, p. 367. 478 PATHOLOGY. as frequent as in white women. ^ My experience in hospital and consulting practice convinces me that deformed pelves are by no means rare among native-born women in the densely populated centers of the Eastern States. ^ No general practi- tioner, in a large c\\x at least, can hope to avoid such cases, and it is likely that each year will afford himi one or more striking examples. It follows that an ability- to recognize deform- ities of the female pelvis is a necessar}^ accomplishment for every practitioner of medicine who may be called upon to attend women in confinement, and that a knowledge of pelvimetry is as essential to the intelligent and successful practice of obstetrics as are percussion and auscultation to the practice of medicine. European statistics bearing on the frequency of contracted pelves give the following results : Michaelis found in lOOO parturient women 131 contracted pelves ; Litzmann, 149. Winckel found in Rostock 5 per cent., in Dresden 2.8 per cent, and in Munich 9. 5 per cent, of contracted pelves among pregnant and parturient women. Winckel believes that 10 to 15 per cent, of child- bearing women have contracted pelves, but that in only 5 per cent, is the obstruction serious enough to be noticed. Kalten- bach puts the frequency of contracted pelvis at 14 to 20 per cent. In Marburg it was found to be 20.3 per cent., in Gottin- gen 22 per cent., in Prague 16 per cent. Schauta estimates it at 20 per cent. In French statistics the frequency is from 5 to 16 per cent. ; in Austrian, from 2 to 8 per cent. ; in Russian, from I to 5 per cent. Classification of Anomalies in the Female Pelvis. — All classifica- tions are merely a convenience for the teacher and student. It is rarely possible to draw sharply defined lines between varying manifestations of a condition. The majority of German authors follow Litzmann' s classification of abnormalities of the female pelvis, by which they are broadly divided into those of size and those of shape. Modern French authors adopt the still less satisfactor}' division of oversize, undersize, and anomalies of inclination. .Schauta's classification is, in my opinion, the most convenient, and I have utilized it, with a slight modification.^ '■J. W. Williams, " Obstetrics," vol. i. Nos. 5 and 6. *In the Maternity, the Philadelphia, the University Hospitals, and in the South- eastern Dispensan' .Service there have been over 20,000 births during my connection with these instituiions. The proportion of deformed pelves is about the same as that found by Reynolds, Crossen, and Williams in their hospital statistics, so that I have had the opportunity of ol )ser^^ng more than a thousand deformed pelves, including many of the rarest types. In my own private patients, however, I have hardly ever seen a deformed pelvis, and I imagine they are extremely rare in the healthy agrical- tural districts of America. *Miillers "Handbuch." ANOMALIES IN THE EORCES OE LABOR. 479 ANOMALIES OF THE PELVIS THE RESULT OF FAULTY DEVELOPMENT. Simple flat pelvis. Generally equally contracted pelvi.s ( justo-minor). Generally contracted flat pelvis (non-rachitic). Narrow funnel-shaped, fetal, or undeveloped jielvis. Imperfect development of one sacral ala (Naegele pelvis). Imperfect development of both sacral alae (Robert pelvis). Generally equally enlarged pelvis (justo-major). Split pelvis. Assimilation pelvis. ANOMALIES DUE TO DISEASE OF THE PELVIC BONES. Rachitis. Osteomalacia. New growths. Fractures. Atrophy, caries, and necrosis. ANOMALIES IN THE CONJUNCTIONS OF THE PELVIC BONES. Abnormally firm union (synostosis), which is found in elderly primiparae, particularly at the sacrococcygeal joint and in the joints between the coccygeal bones : Synostosis of the symphysis. " " one or both sacro-iliac synchondroses. " " the sacrum with the coccyx. Abnormally loose union or separation of the joints : Relaxation and rupture. Luxation of the coccyx. ANOMALIES DUE TO DISEASE OF THE SUPERIMPOSED SKELETON. Spondylolisthesis. Kyphosis. Scoliosis. Kyphoscoliosis. Lordosis. ANOMALIES DUE TO DISEASE OF THE SUBJACENT SKELETON. Coxalgia. Luxation of one femur. Luxation of both femora. Unilateral or bilateral club-foot. Absence or bowing of one or of both lower extremities. 480 PATHOLOGY. Diagnosis of Pelvic Anomalies; Pelvimetry. — Deformities of the female pelvis may be detected by the history of the patient, by her appearance, by palpation of the exterior and interior of the pelvis, and by external and internal measurements of the pelvic diameters that are accessible, or of salient points on the woman's body corresponding as nearly as possible with the internal measurements desired, the relations between the last two having been ascertained by many observations on dead and living bodies. It has been proposed to utilize the Roentgen rays in the diagnosis of pelvic deformities, but this method, while it shows anomalies of form, as in a Naegele pelvis,^ is inferior to digital and instrumental pelvimetry in determining the extent of anomalies in size.^ For taking pelvic measurements the ex- aminer's fingers, a tape-measure, and a modified mathematician's calipers — a pelvimeter — are usually employed. Baudelocque (1775) was the first to devise the pelvimeter in ordinary use. He laid the foundations of pelvimetry; his instrument and methods are in use at the present time (Figs. 358, 359). It is convenient to describe the measurements of the diameters of the pelvic inlet, pelvic cavity, and pelvic outlet separately. Measurement of the Anteroposterior Diameter of the Superior Strait. — This measurement, the most important in the pelvis, can not be taken directly. It must be estimated by several plans. Baudelocque was the first to point out the relation be- tween the measurement from the depression under the last spinous process of the lumbar vertebrae to the upper edge of the symphysis pubis, and the true conjugate diameter of the pelvic inlet. To this external measurement the name "external conju- gate" was given, but it is often called "the diameter of Bau- delocque" (Fig. 360). Its discoverer believed the relation between the external and internal diameters to be constant, — that the one exceeded the other by 8 to 8.75 centimeters, — but in this he was mistaken. The line of the external diameter does not usually coincide with the line of the internal, and the thickness of bones and superimposed structures differs, of course, in each individual. In thirty cases in which Litzmann had an opportunity to compare the measurement of the external conju- gate taken during life with the actual measurement of the true conjugate taken after death, there was an average difference of ' Budin, " L'Obstetrique," 1897, P- 500. ■^ See Lewy and Thumin, "Deutsche med. Wochenshr.," 1897, No. 32; also MuUerheim, ihid.^Y^o. 39. Bouchacourt and Fabre surround the pelvis with a rec- tangular metal frame with indentations i cm. apart, which, reproduced in the photo- graph, are said to enable one to estimate the size of the pelves. " L'Obstetrique," 1900, p. 320; Donnezan, " These de Lyon," 1906. ANOMALIES IN THE EORCES OE LABOR. 48 1 9.5 centimeters, but the maximum difference was 12.5 centi- meters and the minimum 7 centimeters, — a variation of 5.5 centimeters in a small number of cases. MichaeHs found a difference of 0.6 to 3.2 centimeters and Schroedcr 1.25 to 3 centimeters between the external conjugate of the living body and that of the dried specimen. The measurement of the exter- nal conjugate, therefore, is not to be relied upon in making an estimate of the size of the true conjugate. It simply serves to indicate the probability or the improbability of pelvic contrac- Fig. 358. — Martin's pelvimeter. Fig. 359. — Harris-Dickinson portable pelvimeter. tion. An external conjugate of 16 centimeters or under means certainly an anteroposteriorly contracted pelvis ; between 16 and 19 centimeters the pelvic inlet is contracted in more than half the cases; between 19 and 21.5 centimeters there are but ten per cent, of contracted pelves; and above 21.5 centi- meters it is almost certain that the conjugate diameter of the pelvic inlet is not contracted at all. The external conjugate 31 482 PATHOLOGY. can not be measured accurately without some practice. The beginner in pelvimetry will do well to remember the following rules : Have the patient dressed for bed. Place her upon her side, with the thighs slightly flexed and the clothing rolled well up out of the way, the lower part .of the body being covered with Fig. 360. — Measuring the external conjugate diameter upon the living female (Dickinson). a sheet. The examiner stands at the patient's back, facing her head. The depression below the last spinous process of the lumbar vertebrae is found by rubbing a finger-tip over the lumbar spines from above downward until the finger sinks into the de- pression sought and feels no more prominent spinous processes below. ^ Occasionally this point is perceptible, a lozenge-shaped 1 Michaelis preferred the measurement from the tip of the last lumbar spinous process, instead of from the depression below it. ANOMALIES IN THE EORCES OE LABOR. 483 fif^ure being made by the depression under the last lumbar vertebra, the posterior superior spines of the ilium, and the tip of the sacrum (Fig-. 361). The knob at the end of one branch of the pelvimeter is placed firmly in tiie depression under the spinous process of the last lumbar vertebra, and is held there with one Fig. 361. — Kite- or lozenge-shaped figure on the back, indicating position of the depression under the last lumbar vertebra and the posterior superior spines of the ilia. hand, while the fingers of the other hand find a point on the symphysis pubis about ^ of an inch below its upper edge, on which point the other branch of the pelvimeter is firmly set; the pelvimeter is so placed that the indicator is turned toward the examiner; the measurement is therefore easily read off as 484 PATHOLOGY. soon as the pelvimeter is in proper position. It is on the average, in well-built women, 20^ centimeters. The best measurements for determining the length of the anteroposterior diameter of the pelvic inlet are those taken from the lower edge of the symphysis pubis to the promontory of the sacrum, — the diagonal conjugate diameter, — and the distance between the upper outer surface of the symphysis pubis and the promontory of the sacrum. The diagonal conjugate diameter is one side of a triangle, the other two sides of which are the height of the symphysis and the true conjugate. The distance between the outer upper surface of the symphysis and the pro- montory of the sacrum differs from the true conjugate by the thickness of the upper portion of the symphysis. Smellie was accustomed to estimate roughly the length of the true conjugate by a digital examination, basing his estimate on the ease with which the promontory could be reached. In the latter part of Fig. 362. — Stein's instrument for direct measurement of the conjugate. the eighteenth century Johnson^ proposed, for estimating the size of the pelvic inlet, a method which consisted of inserting the fingers of one hand in the mouth of the womb and then spreading them between the promontory and the pubis. A few years later the elder Stein devised a graduated rod for measuring the distance between the lower edge of the symphysis pubis and the division between the second and third sacral vertebrae. This dis- tance he believed to be one-half to one inch greater than the true conjugate. Stein later constructed the instrument for the direct measurement of the conjugate shown in figure 362. Many in- struments have since been constructed on this principle, but tiiey are impracticable in the living female, for obvious reasons. Baude- locque was the first to propose the measurement of the diagonal conjugate and the subtraction from it of an average figure (half 1 Robert Wallace Johnson, "A New System of Midwifery," etc., London, 1769. ANOMALIES IX TJIE FORCES OF LABOR. 48: an inch) to determine the length of the true conjugate. His metiiod, exactly as he described it, is still in use, with the excep- tion that two fingers instead of one are employed in measuring the distance between the symphysis and the promontory. To measure the diagonal conjugate correctly, the examiner must have the skill that comes of practice, and he must conduct his Fig. 363. — Measuring the diagonal conjugate diameter (Dickinson) examination in a careful and methodical manner. The patient is put in the lithotom}' position and is brought to the edge of the table or bed on which she lies, so that the buttocks project well over it. The examiner, with a sterile rubber glove upon his left hand, anoints the first two fingers with an unguent; he then inserts these fingers, held stiffly extended, inward and upward, until the tip of the second finger finds and rests upon the promontory of the sacrum. Care must be exercised not to take the last lumbar for the first sacral vertebra or vice versa, nor the second for the first sacral vertebra — mistakes easily made in cases of so-called "double promontory." With the tip of the second finger resting firmly in place upon the middle line of the promontory, the radial side of the hand is elevated until the impress of the arcuate ligament under the lower edge of the symphysis is plainly felt upon it. With a finger- nail of the other hand a mark is made upon this point of the ex- amining hand, which is then withdrawn (Fig. 363). The distance between this mark and the tip of the middle finger held extended is taken by a pelvimeter. This distance is the diagonal conjugate. By the observation of many subjects, alive and dead, an agreement has been reached that 1.75 centimeters should be subtracted from 486 PATHOLOGY. the diagonal conjugate to obtain the true conjugate diameter. But the acceptance of this average difference depends upon a normal height of the symphysis, 4 centimeters; a normal angle between the axis of the pubis and the true conjugate, 105°; a normal thickness of the symphysis, and a normal height of the promontory (Figs. 364 to 368). These factors, however, are not constant, and if they vary much from the normal, the most skilful and most experienced obstetrician may be woefully misled in his estimation of the true conjugate. I have had under my care a rachitic dwarf in whom there was more than Fig. 364. — Effect of different inclinations of the pubis upon the relationship between the true and the diagonal conjugate diameter (Ribemont-Dessaignes). 3 centimeters' difference between the diagonal and true conju- gates, and Pershing found, among ninety pelves in the museums of Philadelphia, a difference vaiying from 0.8 centimeters to 3.6 centimeters. It is declared that these sources of error may be eliminated by the following corrections : For every degree of increase in the conjugatosymphyseal angle add half the number of millimeters to the sum to be subtracted from the diagonal conjugate, and vice versa ; also, for every 0.5 centimeter increase in the height of the symphysis over the normal add 0.3 centi- meter to the sum to be subtracted from the diagonal conjugate, and vice versa. While these rules are admirable for the study of the dried specimen in a museum, they are not easily applied to the living pregnant female. The height of the symphysis can be measured in the hving subject, but an allowance for variations in this respect eliminates error in only a small pro- portion of cases. The variations in the angle of the symphysis, ANOMALIES IN THE EORCES OF LABOR. 487 a much more important source of error, can only be surmised. In cases upon the border-line between the relative and abso- Fig. 365. — Effect of different thicknesses of the symphysis upon the relationship between the true and the diagonal conjugate diameter (Ribemont-Dessaignes). lute indications for Cesarean section in which the difference of a centimeter would decide one for or against the operation I Fig. 366.— Effect of different heights of the promontory upon the relationship between the true and the diagonal conjugate diameter (Ribemont-Dessaignes). prefer the measurement between the upper outer edge of the symphysis pubis and the promontory of the sacrum for the 488 PATHOLOGY. Fig. 367. — Effect of different heights of the s-sTtiphysis upon the relationship between the true and the diagonal conjagate diameter (Ribemont-Dessaignes). Fig. 368. — Effect of the lessened slant outward of the symphysis in a rachitic pelvis upon the relationship between the true and the conjugate diameter (Ribemont- Dessaignes). ANOMALIES IN THE JORCES OF LABOR. 489 estimation of the true conjugate, having demonstrated its supe- rior accuracy in practice. For taking this measurement the patient is put in the dorsal posture, with the buttocks projecting beyond the edge of the table or bed on which she lies. A mark with the point of a lead-pencil is made on the skin over the symphysis pubis, about J^ of an inch below the upper edge. The two fingers of the left hand are inserted in the vagina, as in measuring the diagonal conjugate. The tip of the middle finger, having found the middle line of the promontory, is moved a little to the patient's right, and tip b of the pelvimeter, shown in figure 369, is made to take its place. While the examining physician holds the shaft of the pelvimeter firmly in Fig. 36Q. — Author's pelvimeter: «, For measuring the true conjugate plus the thickness of the symphysis ; b, with extra tip added for measuring the thickness of the symphysis. place, an assistant adjusts tip a of the movable bar over the mark made on the symphysis. This bar is then screwed tight, the whole pelvimeter is removed, and the distance between the tips is found by a tape-measure. This distance is the con- jugate plus the thickness of the symphysis (Fig. 370). The latter I have found to be i centimeter in twenty-six dried pelves, I y^ centimeters in nine, i ^A centimeters in thirteen, 1 3/^ centi- meters in four, and 2 centimeters in three specimens — one a high-grade rachitic pelvis, another of the masculine type, and the third a justomajor pelvis. The thickness of the symph)'sis is measured as shown in figure 371.' In living subjects the index- finger of the left hand must find the inner surface of the symphy- sis pubis, and must follow it up to within about i^ of an inch. 490 PATHOLOGY. of the top, where it bulges to its full thickness. On this point one tip of the pelvimeter is placed, and it is then held in position between the ends of the first and second fingers ; the other tip of the instrument is adjusted over the mark made on the skin Fig. 370. — Measuring the true conjugate, plus the thickness of the symphysis, with the author's pelvimeter. Fig. 371. — Measuring the thickness of the symphysis, with the author's pelvimeter. externally ; the distance is read off from the indicator provided for the purpose. It is not necessary to make an allowance for the thickness of the tissues over the symphysis, for this is included in both measurements, and on subtracting one from the other the necessary correction is made. The tissues over ANOMALIES hV 77/E FORCES OF LABOR. 491 the inner surface of the symphysis can usually be so com- pressed by the knob of the pelvimeter as to be practically elimi- nated. If this is impossible, as may happen in some primiparae, a small allowance may be made for these tissues — say, at the most, 0.5 centimeter. In measuring a pelvis by this method it may be necessary to anesthetize the patient ; and this is well worth while if a decision between some of the more serious ob- stetrical operations is to be based, as it must be, upon an accur- ate estimation of the true conjugate. ^ Farabeuf has invented an ingenious pelvimeter for the direct mensuration of the true conjugate (Fig. 372). Its only fault is the danger of traumatism to the vesical mucosa from the intravesical Fig. 372. — Farabeuf 's instrument for measuring the true conjugate. The detachable retrosymphyseal bar is inserted in the bladder. bar, which must be firmly pressed against the inner surface of the symphysis. V. Bylicki ^ has devised a series of angulated metal rods for the direct measurement of the true conjugate (Fig. 373). The author has no experience with them. Neumann and Ehrenfest have devised ingenious instruments (Figs. 376 a-376 e) for directly measuring the internal pelvic diameters, for finding the inclination of the pelvis, and for graphi- cally recording the results obtained. The author has tried these instruments, but has found them so difficult to use without much practice and expert assistance that they are only practicable in a well-equipped clinic and are only needed in rare cases. 1 Wellenbergh was the first to employ this principle in pelvimetry. His pelvimeter was improved upon by van Huevel, and in recent times by Skutsch and by Bullitt ("Deutsche med. Wochen.," No. 13, 1890; "Amer. Jour. Obstetrics," 1893; Muller's "Handbuch der Geburtshiilfe," vol. ii, pp. 255, 260, 261). 2 " Monatshr. f. Geb. u. Gyn.," vol. xx, 1904. 492 PATHOLOGY. Ahlfeld, Zweifel, and Jastrebow have also devised instruments for exact pelvic measurements.^ Measurement of the Ti^ajisverse Diameter of the Superior Strait. — The transverse diameter of the pelvic inlet can not be measured directly, nor can it be estimated accurately. Fortu- nately, it is not necessary to do it. It is sufficient to deter- mine whether there is a decided diminution of the measurement, without determining the exact degree of lateral contraction. To do this the following measurements are relied upon : The Fig- 373- — ■"■• Bylicki's pelvimeter for measuring the conjugate directly, _-- vf<'-; ---j»^=,ii^- --.. ^■J^ Fig. 374. — Skutsch" s method of measuring the conjugate diameter. distance between the anterior superior spinous processes of the iliac bones, which in well-formed women is 26 centimeters; the distance between the crests of the iliac bones, 29 centi- meters; the distance between the trochanters, 31 centimeters; the distance between the posterior superior spinous processes of the iliac bones, 9.8 centimeters; the distance between the subpubic ' " Samml. klin. Yortrage Gyn.," No. l6l, 1906; " Zentralbl. f. Gyn.," Nos. 4 and 27, 1906. ANOMALIES IN THE FORCES OF LABOR. 493 ligament and the upper anterior angle of the great sacrosciatic notch, which, according to Lohlein, is 2 centimeters less than the transverse diameter of the inlet; finally, an estimation of the width of the pelvic inlet by a vaginal examination. In tak- ing the external measurements the woman is placed upon her back. The salient points are easily found except in the case of the ihac crests. They are discovered by moving the knobs of the pelvimeter evenly along the crests of the ilia until the two opposite points most widely separated from each other are found. If the crests are no further, or even less, separated from each other than the spines, points five centimeters back of ^ig- 375- — Skutsch's method of measuring the transverse diameter of the pelvic inlet. the latter are arbitrarily selected as the sites of the crests. The pos- terior superior spinous processes are often marked by distinct dim- ples on the woman's back. The internal measurement of Lohlein is made by the fingers in the vagina. If all these measurements are much less than normal, a lateral contraction of the pelvis may be assumed, and the degree of contraction is roughly estimated by the amount of decrease in the measurements, although the relation between these measurements and the distance sought is 494 PATHOLOGY. very variable. The efforts of Skutsch and of others before him, accurately to measure the transverse diameter of the pelvic inlet by combined internal and external measurements, have not yet been crowned by success. The softness of the tissues externally permits the external knob of the pelvimeter to sink into the flesh to a varying degree, and the same is true of the structures within the pelvis. It is difficult also to keep the pelvimeter in the same straight line when the internal knob is changed from one side to the other (Figs. 374 and 375). Moreover, better results in practice may be obtained by an estimate formed by a vaginal and a com- bined examination, under anesthesia if necessary, of the relative size of the transverse diameter of the pelvic inlet and the antero- posterior diameter of the child's head. Measurement 0] the oblique diameters of the pelvic inlet is required Fig. 376. — Measurement of the anteroposterior diameter of the pelvic outlet. only in obliquely contracted pelves. It will be referred to in the description of these pelves. T/ie Measiireineiit of the Capacity of the Pelvic Cavity. — The capacity of the pelvic cavity must be estimated by vaginal exami- nation. There is no plan by which accurate measurements can be made. It is sufficient to estimate the size and the shape of the pelvic canal by palpating the lateral walls of the pelvis ; by determining the curve, perpendicularly and laterally, of the sacrum; by noting the height of the sacrosciatic notches, the approximation of the tuberosities of the ischia, the depth of the pelvis, and the direction of its canal ; by detecting, possibly, the presence of an exostosis, an osteosarcoma, an abnormally project- ing spinous process, an old fracture, or asymmetry of the pelvic walls from any cause. Measurement of the Transverse Diameter of the Pelvic Outlet. — The anteroposterior diameter of the inferior strait is enlarged ANOMALIES IN THE EORCES OF LABOR. 495 Figs. 376 a-376 e. — Neumann and Eiirknkest's PKLVicRArn amj Ki.iseomktkr. [Amer. Jour. Obstet., No. j, igoj^) Fig. 376 a. Fig. 376 a. — The pelvigraph : e, Arm for the promontor)' ; a, extrapelvic por- tion; /', marker; c, screw; L will be used throughout to designate the true conjugate, the transverse, and oblique diameters of the pelvic inlet. •'Creile found, in nine pelves with a double promontor), the conjugate from the true promontory longer in four anil shorter in three cases than the conjugate meas- ured from the false promontory. In two ca.ses the two conjugates were of equal length (" Klin. Vortrage iiber Geburtshiilfe,"' Berlin, 1853). 500 PATHOLOGY. Diagnosis. — The simple flat pelvis is easily overlooked. There is nothing in the patient's appearance or history to sug- gest the deformity, unless she has had difificulty in previous labors. The characteristic signs are the diminished anteropos- terior diameter, determined by internal and external measure- ments, and a transverse diameter as great as, or greater than, normal, or perhaps a trifle under the normal measurement. This last point is determined by measurements externally and by the internal palpation of the pelvic canal. In measuring the conju- gate diameter of the flat pelvis one must take into account the lessened inclination of the symphysis outward, its height, some- Fig. 378. — The two conjugates of a double promontory : Protn., True promontor)' ; F. P., false promontoiy (Ribemont-Dessaignes). what below the normal, and the low position of the promon- tory. Usually the average sum of i y^ centimeters is a sufficient amount to subtract from the diagonal conjugate. If there is a double promontor^^ as is frequently the case in this form of pelvis, the conjugate must be measured from the promontory nearest to the symphysis, usually the lower (Fig. 378). Influence upon Labor. — From the failure of the presenting part to enter the pelvis during the last weeks of gestation there is frequently some degree of pendulous abdomen, especially in women with abdominal walls relaxed from previous pregnancies. The uterus is sometimes broader than common, and is often ANOMALIES IN THE FORCES OE LABOR. 501 tilted to one side. The presenting part, if the head, may be loose above the superior strait, resting on one iliac bone or on the symphysis, or it may be pressed down firmly upon the brim in a transverse jjosition, to accommodate its longest diameter to the longest diameter of the pelvic inlet. Malpresentations are com- mon, as is also prolapse of the cord and of the extremities. The membranes may protrude in a cylindrical pouch from the exter- nal OS as the liquor amnii is forced out of the uterus without obstruction from the imperfectly engaged head. From the same cause an early rupture of the membranes is likely. According to Litzmann, natural forces end the labor in 79 per cent, of cases, but in 50 per cent, the head is not fully engaged until the OS is completely dilated. The later statistics of v. Boennighausen and Kissinger shov^ a spontaneous termination by labor in a much smaller proportion of cases. According to the former, 36 per cent, in pelves with a conjugate above 8 cm., and none with a conjugate below 8 cm.; according to the latter, 85 and 17 per cent, respectively. The dila- tation of the OS proceeds slowly, for the head does not descend low enough to press upon the cervix. Consequently the dilatation must be affected by a retraction of the cervix over the head or by the distended membranes. Should the latter rupture, the os, although considerably dilated, may retract until the head at length descends and again dilates it. After the obstruction at the superior strait is passed, — where, of course, it is greatest, — the head usually de- scends the remainder of the birth-canal with ease and rapidity, but labor may be prolonged by an exhaustion of the natural forces in the attempt to secure engagement. The apparent anomalies in the mechanism of labor characteristic of this deformed pelvis are in reality the best possible provision for the spontaneous obviation of the obstruction. The transverse position of the head at the inlet, the increased lateral inclination, and the imperfect flexion are designed to accommodate the size and the shape of the head to the unnatural size and shape of the pelvic inlet. An explana- tion of these peculiarities in the engagement of the head may be found in the altered relation of expulsive and resistant forces. The head, forced down upon the flattened brim and free to move upon the neck, rotates until its longest diameter is adjusted to the greatest diameter of the inlet — the transverse. It seeks the direction of least resistance, as any inert body will when propelled through a contracted canal. But the transverse position of the head alone is not sufficient to overcofhe the obstruction. The biparietal diameter of the head is too large to enter the conjugate of the pelvis. The occiput, the bulkiest portion of the skull, 502 PATHOLOGY. seeks the greater space to one side of the promontory, and is pushed against the lateral brim of the pelvis — the iliopectineal line. Here it is arrested. Further propulsion of the head is secured by a movement of partial extension, which brings the small bitemporal instead of the larger biparietal diameter of the head in relation with the contracted conjugate. Still, the obstruc- tion may not be overcome. Both sides of the head may be unable to enter the pelvis at once. One side is propelled into the pelvic canal, the other is held back. That side which encounters the most resistance will naturally be the last to enter. Thus it is that usually the anterior parietal bone, slipping more easily past the symphysis, enters first. To this result also the inclination of the pelvic axis to the axis of the trunk contributes. Owing to the anterior position of the whole sacrum and to the diminished anteroposterior diameter of the pelvic outlet ; on account, also, of the transverse position of the head and of its imperfect flexion, rotation of the head on the floor of the pelvis occurs late, and occasionally fails altogether, the head being expelled from the vulva in its original transverse or in an oblique position. The localized pressure to which the maternal structures are subjected results sometimes in necrosis of cervical tissue over the promontor}^ and of the anterior vaginal wall behind the sym- physis. On the child's head the caput succedaneum is not exaggerated, because the head, when once firmly engaged in the pelvis, descends the birth-canal rapidly, but there is apt to be a depression on that portion of the skull applied to the promontory — namely, on the posterior parietal bone between the greater fontanel and the parietal eminence, usually quite close to the sagittal suture (Fig. 379). Sometimes a succession of these depressions or a gutter-shaped groove may be noted in a line running outward and forward on the child's skull. More fre- quently the course of the head and face over the promontory is marked by a red streak running from the depression before noted in a line parallel with the coronal suture toward the temple if the head is well flexed after engagement, or to the outer corner of the posterior eye, or, in case of extreme flexion, to the cheek (Fig. 380). Usually the posterior parietal bone is depressed below the anterior, which overlaps it at the sagittal suture. The pos- terior side of the skull is also flattened from the greater and more prolonged pressure to which it is subjected. Ordinarily the lateral inclination of the child's head is in a direction from before backward, so that the anterior parietal bone presents at the center of the superior strait. Occasionally this inclination is so ANOMALIES IN THE lOKCES OF LABOR. 503 Fig. 379. — Depression in the parietal bone caused by the pressure of the promontory (Winckel). FIr. 380. — Marks made by the promontory on the child's head and face (Fritsch and Kiistner). 504 PATHOLOGY. exaggerated that the ear is the presenting part. Exceptionally the lateral inclination takes the opposite direction, the anterior parietal bone catches on the rim of the pubic bones, and the posterior parietal bone is the iirst portion of the child's head to enter the pelvis. The presentation of the posterior parietal bone occurs even in normal pelves as a rare exception, but is seen in about ten per cent, of contracted pelves (Schauta), and is the result in them very likely of firm abdominal walls and an increased inclination of the pelvic inlet to the axis of the trunk. In these cases the anterior parietal bone is pushed under the posterior at the sagittal suture. When the posterior side of the head by descent finds room in the hollow of the sacrum and moves backward, the anterior portion of the skull glides over the symphysis and the sagittal suture moves from its original position, just behind the symphysis, toward the median line of the pelvic canal. In addition to these anomalies of mechanism Breisky describes what he calls an " extramedian " engagement of the head in cases of flat pelvis in which there is considerable lordosis of the lumbar vertebrae. The head in extreme flexion is forced down upon half of the pelvic inlet, and enters the pelvic canal on this side alone. Directly the obstructing promontor}^ and lumbar vertebra are passed the head descends the pelvic canal with rapidity and ease. This mechanism was noted nine- teen times in Breisky's clinic among 2002 labors. ^ Justominor Pelvis. — In this type of contracted pelvis the form of the female pelvis is preserved, but the size is diminished. Three divisions of this pelvis are commonly made : The juvenile, in which the bones are small and slender ; the masculine, in which the bones are large, heavy, and thick ; and the dwarf, or pelvis nana, in which the pelvis is very diminutive in size and the pelvic bones are not joined by bony union, but are separated by cartilage as in the infant. The innominate bones are divided into their three parts, and the sacral vertebrae are distinct from one another. The justominor pelves pass by insensible grada- tions into the simple flat, the transversely contracted, and the generally contracted flat pelves. In the larger cities of the United States the justominor pelvis is very frequently encoun- tered. It is certainly as common here as is the simple flat pelvis, and if one were to judge from hospital patients, among whom there is a large proportion of shop- and factory girls, ^ "Die Becken Anomalien," by Friedrich vSchauta, in Miiller's " Handbuch dei Geburtsbiilfe," Bd. ii ; Betschler, " Annalen der klinischen Anstalten," i, pp. 24, 60; ii, p. 31; Engelken, " Dis.-Inaug. ," Miinchen, 1878; " Zur Kentniss der extra- median Einstellung des Kopfes," Kohn, " Prager Zeitschrift f. Heilkunde," Bd. ix. ANOMALIES IN THE EOA'CES OE LABOR. 505 this variety of contracted pelvis would be regarded as the com- monest. CJiaractcvistics. — While it is convenient to speak of the justo- minor pelvis as the normal female pelvis in miniature, the de- scription is not strictly accurate. There are peculiarities due to an arrest of development which give to the equally generally contracted pelvis some of the features of an infantile pelvis. The alae of the sacrum are narrower than they should be in comparison with the bodies of the vertebrae. The sacrum is short and is not pushed as far forward between the iliac bones as it usually is ; it shows also a diminished forward inclination, and on its anterior surface a greater lateral and a less marked perpendicular concavity than common. The distance between the posterior superior spinous processes of the iliac bones is relatively great, on account of the posterior position of the sacrum and its slight rotation forward. The conjugatosym- physeal angle is greater than normal, by reason of the lessened inclination outward of the symphysis and the pubic bones. The promontory is high and not prominent, and the inclination of the pelvic entrance to the abdominal axis as the individual stands erect makes a more obtuse angle than it does in the normal pelvis. The bones in this form of contracted pelvis are com- monly small and slender, except in the rare masculine pelvis, in which they are firm and thick beyond the normal. Women with a justominor pelvis are ordinarily of slight build and below the medium height ; but this pelvis may be found in individuals of ordinary stature, and sometimes actually in tall women with a large frame. The true dwarf pelvis is very rare. It is found only in women of dwarf stature. The bones are slender and fragile, and the cartilaginous junction between the original divisions of the pelvic bones is preserved. There is extreme contraction of the pelvic canal. While, strictly speaking, the dwarf pelvis is one in which there is an arrest of development and a failure of ossification m the junction of the three component parts of the innominate bones, there are three other types of dwarf peh'is in which there is extreme contraction of all the pelvic diameters: the cretin, the achondroplastic, and the hypoplastic. The distinctive dift'erences between these types may interest the pathologist, but are of no importance to the obstetrician. In the commoner kinds of justominor pelvis the contraction is not often very great. The conjugate diameter is seldom below 9 and scarcely ever as low as 8 centimeters. The pelvic outlet in some cases is laterally contracted; in others it is compar- atively roomy. 5o6 PATHOLOGY. Etiology. — The justominor pelvis is the result, of arrested development ; it may be found in women descended from a stock that has deteriorated phys- ically, or in women sub- jected during childhood, infancy, or intra-uterine existence to unfavorable hygienic surroundings or conditions. Diagnosis. — The jus- tominor pelvis is easily confused with a rachitic pelvis, but the distinction is readily made by careful pelvimetry. All the meas- urements, while equally reduced, bear their normal proportion to one another, except in the case of the external conjugate diam- eter, which is apt to be longer than would be ex- pected, on account of the posterior position of the sacrum and its lessened inclination forward. In estimating the true conjugate diameter from the diagonal conju- gate one must often take account of the increase in the conju- gatosymphyseal angle, and must remember that the sum to be subtracted from the diagonal conjugate is not infrequently greater than common. The symphysis is less in height than in the normal pelvis, but the error of computation from this source may be disregarded. Lohlein lays special stress upon the importance of measuring the pelvic circumference in making the diagnosis of this form of contracted pelvis. It is always far below the normal, ninety centimeters. An internal examination of the pelvic cavity and inlet should be made carefully, to determine approxi- mately their capacity, with a special regard to the approximate length of the transverse diameters. hiflnejice on Labor. — The mechanism of labor shows far fewer anomalies in this than in any of the other forms of con- tracted pelvis. The head, from the greater resistance encoun- tered, is strongly flexed. It may be placed transversely, but is quite commonly oblique, and may even be anteroposterior in position if there is a tendency to lateral contraction of the pelvic canal. By the perfect flexion of the head the obstruction to the Fig. 381. — Dwarf pelvis (model in author's collection). ANOAIAI.IKS IN THE FORCES OF LABOR. 507 Fig. 382. — ^Justominor pelvis with rup- tured pelvic joints, following forceps applica- tion : C. v., 914 cm. ; tr. , I2}4 cm.; obi., 1 1 3^ cm. (author's collection). progress of labor is in great part obviated. If anything inter- feres with this movement of the head, as a faulty application of the forceps, engagement and descent may become impossible. Pelvic presentations in labor are a great disadvantage by reason of the difficulty experienced in freeing the arms and in bringing the head last through the generally contracted pelvic canal. To secure its rapid passage, the child's head must be flexed strongly by the oper- ator's finger in its mouth before an attempt is made to secure engagement in the superior strait. While the woman escapes local- ized necroses of the soft tissues following labor in the justominor pelvis, there is greater likelihood of rupturing pelvic joints in this than in any other variety of contracted pel- vis, and there is also an extraordinary liability to eclampsia (Fig. 382). The caput succedaneum, which is very large on account of the early fixation of the head and the long labor, is situated directly over the smaller fontanel. There is an overlap- ping of the cranial bones, both laterally and anteroposteriorly. The generally contracted, flat, non=rachitic pelvis presents the combined features of the flat and the generally contracted pelvis. CJiaracteristics. — All the diameters are below normal, but the conjugate is less in proportion than any of the others. This pelvis has many of the features of a rachitic pelvis, but the anterior half of the pelvic circumference is not markedly broad- ened ; indeed, it is often the reverse. The sacrum is small and is not rotated on its transverse axis ; it is placed further back between the innominate bones than in the normal pelvis, and very much further back than in the rachitic pelvis. The pro- montory is high and is not prominent. The influence of this deformity of the pelvis upon labor is that of a flat pelvis, but the difficulties are greater than in the case of the simple flat pelvis, for there is less compensatory room in a transverse direction. The generally contracted, non-rachitic, flat pelvis is comparatively rare. The flattening, according to Litzmann, is due to a short- ening of the innominate bones, especially at the iliopectineal line. In estimating the true conjugate diameter of the generally contracted flat pelvis it is safer to subtract 2 instead of 1 3/^ cen- 5o8 PATHOLOGY. timeters from the diagonal conjugate, on account of an increase in the conjugatosymphyseal angle, the result of the high posi- tion of the promontor}^ and the diminished slant outward of the symphysis. Etiology. — The generally contracted flat pelvis is due to hereditar}^ influence or to an arrest of development in the embryo, fetus, or infant. It is claimed, however, that it may be produced by premature attempts to walk and by long standing upon the feet in very early life. Diagnosis. — The recognition of a generally contracted flat pelvis is difficult. The measurements usually resemble those of a generally equally contracted pelvis, but the conjugate diameter is less than one expects in that form of contracted pelvis, and the mechanism of labor is that of a flat pelvis. The diagnosis can be made by finding the reduced conjugate diameter and by the ease with which one can reach the lateral pelvic wall in the palpation of the interior of the pelvic canal. A certainty of diag- nosis can be obtained during life only by the direct measurement not only of the conjugate diameter, but also of the transverse, by the methods of Lohlein and of Skutsch. The Narrow, Funnel=shaped Pelvis ; Fetal or Undeveloped Pelvis. — This variety' of pelvis is contracted transversely at the pelvic outlet, or both in the transverse and anteroposterior diameters, mthout abnormalities in the spinal column except an assimilation sacrum, with six instead of five vertebra. The depth of the pelvic canal is much increased by the length of the sacrum, of the sym- physis, and of the lateral pelvic walls. The sacrum is narrow, has Httle perpendicular curve, and is placed far back between the ilia (Fig. 383). Schauta ascribes this form of contraction to an anomaly of development by which the pelvic walls are lengthened downward and the weight of the body is thrown backward upon the sacrum. \A'illiams believes that in three-fourths of the cases it is due to a high assimilation sacrum. It is said to be very rare, but it has been found quite frequently in those hospitals where the outlet of the pelvis is regularly measured. It comprises from 5 to 9 per cent, of all contracted pelves, according to Breisky, and Fleisch- mann found twenty-four examples in 2700 parturient women. ^ Wilhams found that 8 per cent, of the pregnant women examined (573 in number) had this form of pelvis. A slight manifestation of the deformity is often called a "masculine" pelvis, by reason of the diminution in the breadth of the pubic arch. This degree of the funnel-shaped pelvis is frequently encountered (Fig. 384). Diagnosis. — The diagnosis of a narrow, funnel-shaped pelvis is made by U comparison of the measurements of the pelvic inlet with those of the outlet. The former are found to be normal or 1 " Prager Zeitschrift f. Heilkunde,"' Bd. ix, H. 4 and 5. ANOMALJES IN THE FORCES OE LABOR. 509 Narrow, funnel-shaped pel- '; cm. ; tr. (inlet), 83^ cm. ; Fig. i'ii.- vis : C. V. , 10 tr. (outlet), 7 cm. ; ant. post, outlet, 7^ cm, (specimen in the author's collection even greater than normal, while the measurements of the outlet are diminished. If, as is the rule in extreme degrees of tliis deformity, the inlet and cavity are contracted, the outlet is still smaller in jjro- portion. A careful palpa- tion of the pelvic canal is an important aid to a cor- rect diagnosis. The pelvic walls are felt to conxerge as they approach the outlet; the narrowness of the pubic arch is appreciated, and the approximation of the tuber- osities and spines of the is- chiatic bones is noticeable. Klein ^ pointed out the necessity of measuring what he calls the posterior sagittal diameter in these pelves. This is a measurement from a line drawn between the tuberosities of the ischia to the tip of the sacrum, method of measurement is suggested by Williams. of suitable length is placed between the tuberosities. measures the distance be- tween the center of the lead pencil and the external sur- face of the tip of the sacrum. One centimeter deducted from this measurement gives the posterior sagittal diam- eter. Williams is responsible for the statement that if there is lateral contraction (not specifying how much), and if the posterior sagittal diameter is below 8.5 cm., there is a positive indication for Cesarean section or pu- biotomy. This statement must be confirmed or confuted by wider experience. Influence upon Labor. — The peculiarities of mechanism in labor are malpositions of the head at the outlet (as backward rota- tion of the occiput), obliciue and transverse position of the head, and imperfect flexion. There is also an insufficiency of the expul- sive forces, the greater part of the fetal body being contained in the 1 " Volkmann's Samml. klin. Vortrage," 1S96. A convenient A lead pencil A pelvimeter Fig. 384. — Minor grade of narrow, funnel- shaped pelvis with contracted pubic arch (from a plaster cast in the author's collection). 5io PATHOLOGY. lower uterine segment, cervix, and vagina, while the upper muscu- lar segment of the uterus is in great part emptied and, therefore, powerless. By the approximation of the pubic rami the presenting part is forced backward, and serious lacerations of the perineum are to be feared. The pressure of the head upon the lower birth- canal may result in necrosis of soft structures or in lacerations along the descending rami of the pubis and the ascending branches of the ischium. The tissues over the projecting spines of the ischia are also the seat of tears or of necroses. The narrow- ing of the pubic arch may lead to serious injuries if forceps is appHed. Lacerations in the anterior vaginal walls and pro- fuse hemorrhage may follow the use of instruments. In well- marked examples of the narrow, funnel-shaped pelvis, with a trans- verse diameter at the outlet not much below 7.5 cm. (3 inches), pubiotomy gives the best chance of a successful termination for mother and child. Higher grades of contraction, with a diameter of 5 cm. (2 inches) and under, demand Cesarean section. In lesser grades the woman may be delivered spontaneously or by forceps. By strongly flexing and abducting the thighs and extending the legs the transverse diameter of the pelvis is increased. By this means a spontaneous delivery may be effected in contrac- tion of the outlet that otherwise might be impossible.^ Obliquely Contracted Pelvis from Imperfect Development of the Ala on One Side of the Sacrum {Naegele Pelvis). — This pelvis was first described in 1834 by Franz Carl Naegele,^ but had been noticed as early as 1779 without a full understand- ing of its significance (Fig. 385)- Charactenstics. — The pelvic inlet has an oval shape, with the small point of the oval directed to the atrophied side of the sacrum. The sacral ala is atrophied or is absent not only in that portion of the bone entering the sacro- iliac joint, but also in the transverse process along its whole length. The sacro-iliac joint on this side is ankylosed in the vast majority of 1 Devraigne and Descomp, " Obstetrique," May, 1910; van Rooy, " Ann. de Gyn. et d'Obstet.," 1910. , ,, , , . , j 2 " Die Heidelberger klinischen Annalen," Bd. x, p. 449. More elaborately de- scribed in his folio atlas, " Das Schrag verengte Becken, nebst einem Anhang iiber die wichtigsten Fehler des Weibl. Beckens Ueberhaupt," mit 16 Tafeln, Mainz, 1837. Fig. 385. — Obliquely contracted pelvis. ANOMALIES IN THE FORCES OF LABOR. 5 I I cases, but not invariably. The sacrum is narrow, asymmetrical, and turned with its anterior face toward the deformed side of the pelvis. The promontory is not only turned in this direction, but is also pulled over to the diseased side. The innominate bone on the deformed side is pushed as a whole upward, backward, and inward, and its anterior face is pushed inward and backward. The tuber- osity of the ischium, as a necessary consequence of the displace- ment of the innominate bone, is higher than its fellow, projects further into the pelvic canal, and is so turned that it looks rather anteroposteriorly than laterally. The spine of the ischium is brought quite close to the corresponding edge of the sacral bone and juts prominently forward into the pelvic canal. The whole in- nominate bone on the diseased side lacks its normal curvature at the iliopectineal line, and may run almost straight from the sacro- iliac junction to the symphysis pubis. The opposite innominate bone has a greater curvature than common, especially in its anterior half; otherwise it is practically normal in structure, position, and inclination. The symphysis pubis is pushed toward the healthy side of the pelvis, and its outer surface, instead of looking directly forward, is inclined to the diseased side. The pubic arch likewise faces somewhat in this direction ; its aperture is asymmetrical and irregularly contracted, as the ischiac and pubic rami on the diseased side are pushed inward upon the pelvic canal and over toward the healthy side (Fig. 385). Etiology. — The cause of the obliquely contracted pelvis under description is an absence of the bony nuclei in the ala or lateral process on one side of the sacrum. The lateral process conse- quently fails to develop, and the innominate bone is brought in re- lation with the bodies of the sacral vertebrae. As a result, there must be some distortion of the innominate bone even in fetal and infantile life, but this is increased to an exaggerated degree when the individual begins to walk. Instead of receiving the pressure from the lower extremity approximately on the keystone of an arch, as does a normally curved innominate bone, the deformed bone in a Naegele pelvis transmits the pressure in almost a straight line upward and backward, so that the extremity of the posterior arm of the arch slides past the sacro-iliac joint instead of resting lirmly on it as an arch does on its abutments. The irritation and strain of this unnatural movement bring about in time the atrophy and ankylosis of the joint. That the deformity in this kind of oblique pelvis does not follow a primary ankylosis of the sacro-iliac joint is proven by the fact that the innominate bone is pushed backward and upward on the sacrum — a movement that would be impossible were this joint first ankylosed. As a further proof of primarv' lack of development and secondary ankylosis, there is no trace 512 PATHOLOGY. of inflammation in or about the ankylosed joint, and the alae or transverse processes of the sacrum are atrophied or are absent along the whole length of the sacrum, and not only in that portion of it which enters into the composition of the sacro-iliac joint. Diagnosis. — The recognition of an obliquely contracted pelvis from arrested development of the sacral alae may be very difficult. There is nothing to direct the attention of the phy- sician to the possibility of the deformity. There is no history of previous disease or of accident, no scar of an old fistula over the joint, and the patient does not limp. The diagnosis can be made only by a methodical external and internal palpation of the pelvis and by careful measurements. If the outspread hands are laid over the innominate bones, it is noticed that the dorsal surfaces are directed obliquely forward and backward as they lie upon the diseased and healthy sides. An internal palpation of the pelvis detects one lateral wall much nearer the median line than the other, and the diagonal conjugate is found to run not anteroposteriorly in direction, but from before backward and from the healthy to the diseased side of the pelvis. There are a number of points from which measurements may be taken that show inequalities where in the normal pelvis the dis- tances should be the same or should differ by a very small sum. Naegele recommended the following measurements: (i) The distance of the tuber ischii on one side from the posterior superior spinous process of the ilium on the other ; (2) from the anterior superior spinous process of one ilium to the posterior superior spinous process of the other ; (3) from the spinous process of the last lumbar vertebra to the anterior superior spines of both ilia ; (4) from the trochanter major of one side to the posterior superior spinous process of the opposite iliac bone ; (5) from the lower edge of the symphysis pubis to the posterior superior spinous processes of the iliac bones. In addition to these measurements, others of value have been suggested by Michaelis and by Ritgen. These are the distances from the middle line of the spinal column to the posterior superior spinous processes of the iliac bones, and the distance from the lower edge of the symphysis to the ischiac spines, and from these spines to the nearest point on the edges of the sacrum. In this latter measurement it is found that the distance from the symphy- sis to the ischiac spine is longest on the diseased and shortest on the healthy side, while the distance from the ischiac spine to the edge of the sacrum is very much shorter on the diseased than on the healthy side. The last, which is a very important meas- urement, can easily be taken by laying finger-breadths between the points to be measured. As in all anomalies of form in the ANOMALIES IN THE EORCES OE LABOR. 513 female pelvis, an x-ray photograph shows the condition often surprisingly well. Infltience on Labor. — The mechanism of labor in an obliquely contracted pelvis is, in the main, that of labor in a generally contracted pelvis. The shape of the pelvic entrance and canal is symmetrically ovoid, and the head can enter the contracted space only by extreme flexion. There are none of those anoma- lies of position, flexion, and inclination of the head which are seen in the flat pelvis. As the head descends the birth-canal, anomalies of mechanism may appear resembling those described in the narrow, funnel-shaped pelvis — namely, abnormal and ^-" v^. -^v C' .4 Fig. 386. — x-Ray of Naegele pelvis (autiior's case). imperfect rotation and anomalies of flexion. Depending upon the degree of deformity, there is more or less interference with the progress of labor to complete obstruction. The head is almost invariably found entering the pelvis and passing through the canal with its longest diameter in coincidence with the longest oblique diameter of the peKas, from the diseased sacro- iliac joint to the opposite iliopectineal eminence. Prognosis. — In the recorded cases the results of labor in the Naegele pelvis have been bad. Of 28 women reported by Litz- Z2, 514 PATHOLOGY. mann, 22 died in their first labor, 5 of them undelivered. Three of these women died in consequence of their second labor, and 2 after the sixth. Out of 41 cases, 6 were delivered spontane- ously, 12 by the forceps, 14 by craniotomy, 5 by version and extraction, 4 by premature labor, and 2 by Cesarean section. The following accidents were noted in the course of labor or shortly afterward : Rupture of the uterus or vagina, vesico- vaginal fistula, fracture of the horizontal ramus of the pubis, rupture of the sacro-iliac joint and of the symphysis. In another series of cases, 28 women furnished forty-two labors with the following results : 2 1 died as the result of the first labor, 3 of the second, and i after the sixth. These women were delivered seven times by craniotomy, once by Cesarean section, four times by premature labor, and in a number of instances by forceps. Out of 41 children in Litzmann's statistics, there were only 10 delivered alive, 2 of these by Cesarean section and 2 by premature labor. The 6 other living children were all born of the same mother. ^ Treatment. — Forceps and version are not, as a rule, success- ful in the treatment of labor obstructed by an obliquely con- tracted pelvis unless the degree of deformity is slight. The induction of premature labor and the performance of Cesarean section are the most successful means of delivery, but the former should be resorted to only when the distance between the lower edge of the symphysis pubis and the sacro-iliac joint of the healthy side is not under 8.5 centimeters. In twenty forceps operations thirteen women died. Pubiotomy is not suitable. The room gained by the movement outward of the innominate bone on the healthy side, the other being, of course, immovable, will be sufficient only in pelves so slightly contracted as to allow a delivery by simpler means. Transversely Contracted Pelvis the Result of Imperfect Devel= opment of Both Sacral Alae. — This pelvis was first described in 1842 by Robert, and is generally known as the "Robert pelvis" (Fig. 387). It is the rarest of all contracted pelves. Schauta was able to find but six examples recorded in child- bearing women. Ferruta has reported another case.^ Herman gives eight as the number of recorded cases; Sonntag,^ nine. The anatomical conditions are the same as in the Naegele pelvis^ except that both sides of the sacrum are affected instead of one. Other parts of the sacrum besides the alae may show imperfect development. There is a case reported in which the whole lower portion of the bone was absent. The sacrum in the Robert's 1 The writer is indebted for these statistics to Schauta (^loc. cit.). ^ " Studii di Ostetricia e Ginecol.," Milan, 1890. ^v. Winckel's " Handbuch," 2^, p. I959. ANOMALIES IN THE EORCES OE LABOR. r , - pelvis is extremely narrow, and the posterior superior spinous processes of the iliac bones are brought close together. The degree of contraction in the transverse diameter is so extreme that natural labor is out of the question. An asymmetry of the Robert pelvis has been observed, one side showing a greater degree of the deformity than the other, and thus approaching the type of an obliquely contracted pelvis. The cause of this deformity is an absence of the bony nuclei in the sacral alae of both sides. Secondarily, as in the Naegele Fig. 387. — Transversely contracted pelvis: C. v., 9'4 cm.; tr. (outlet), 5 cm.; tr. (inlet), 8 cm. (model in Miilter Museum, College of Physicians, Philadelphia). pelvis, there is usually an ankylosis of the sacro-iliac joints. That this ankylosis is secondary and not primary is demonstrated by the same condition which proves that ankylosis is not a primary cause of the oblique contraction and ill-development of one side in the Naegele pelvis — namely, a displacement of the ilia on the sacrum necessarily occurring before the ankylosis. The treatment of labor obstructed by a transversely contracted pelvis of this kind is Cesarean section. Justomajor Pelvis. — A generally equally enlarged pelvis is found in women of gigantic stature, but it may also occur in a woman of medium height. The pelvis of the Nova Scotian giantess was large enough to give passage to a child weighing 28^ pounds. The largest pelvis that has ever come under my notice was found in a woman somewhat below the average height, without an abnormally great de\'elopment of any other portion of her frame. Diagnosis. — The diagnosis of a justomajor pelvis is made mainly by external measurements. If all of them are found far in excess of the normal while preserving their normal relative proportion the diagnosis of a justomajor pelvis is justifiable. 5l6 PATHOLOGY. The internal examination, if considered necessary, shows that the promontory is quite inaccessible, and that it is much more difficult than common to reach the lateral pelvic walls. This anomaly of the pelvis does not, of course, obstruct labor ; on the contrary, it predisposes to precipitate delivery, although the resistance of the soft parts may be quite sufficient to delay the process considerably, even though the pelvis present no obstacle whatever. During pregnancy it is noted that the uterus has a tendency to sink deep within the pelvic canal, so that pressure- symptoms of the pelvic viscera and blood-vessels are common in the latter weeks of gestation, and these symptoms may become so exaggerated as to make locomotion difficult. In labor there may be anomalies in the mechanism dependent upon insufficient resistance to the engagement of the head. Thus imperfect flexion at the superior strait may be observed, and there may be a tardy rotation of the head on the pelvic floor. Split Pelvis. — The split pelvis, which is due to a defect in the development of the lower portion of the trunk in front, is almost invariably associated with exstrophy of the bladder. This pelvis has very rarely been observed in the child-bearing woman ; there are on record but seven examples complicating labor. The split pelvis presents no obstacle in parturition. There are the same peculiarities in labor as in the justomajor pelvis — namely, a tendency to precipitate birth, and anomalies in the mechanism the result of imperfect resistance. After labor it is almost certain that there will be a prolapse of the uterus. The diagnosis of this deformity presents no difficulties, and no ob- stetic treatment is called for in labor (Fig. 388). The assimilation pelvis is of greater interest to the anatomist than to the practical obstetrician. It is characterized by an assimilation of the last lumbar vertebra to the type of the first sacral vertebra or vice versa. The anomaly of development may affect one or both sides of the vertebrae. There may be an as- sociated double promontory, some asymmetry of the pelvis, slight anomalies in the transverse, anteroposterior, and vertical diame- ters of the pelvis, but not enough disturbance of pelvic size and shape to influence labor seriously. According to Wilhams this is the most frequent cause of the funnel-shaped pelvis. It is only possible to diagnosticate an assimilation pelvis during life by a careful palpation of the sacral bones in a vaginal or rectal exami- nation. The diagnosis is not often practicable. The Rachitic Pelvis. — In the healthy life and growth of bones two opposed processes are found : On the periphery there is an active proliferation of cells to form the bone-structure, while in the interior, bone-substance is being constantly absorbed by the marrow. In rachitis the absorption of bone-substance goes on ANOMALIES IN THE FORCES OF LABOR. 517 more rapidly than it does in healthy bone, and at the same time there is in the periphery a very much more rapid proliferation of cells, which do not, however, develop normal bone-structure. Their growth and multiplication result in the formation of an osteoid material deficient in lime-salts and much more pliable than healthy bone. The result of this pathological process in the pelvic bones is to make the pelvis yield more than it should to the mechanical forces that are brought to bear upon it. In the rachitic pelvis the size and shape of the pelvic canal Fig. 388. — Split pelvis (Schauta). are modified by three factors : the pressure from the trunk above and the counterpressure from the extremities below ; the pull on the pelvic bones by ligaments and muscles ; and an arrested development. Characteristics. — The effect of rachitis in the pelvic bones ■ ti"^ -'■iS^^R^ i^t;> Fig. 389. — Flat rachitic pelvis: C. v., 5 '4^ cm.; effective trans, diam., 11 cm. (Miit- ter Museum, College of Physicians, Philadelphia). upon the shape and size of the pelvic canal is not uniform. Several varieties of contracted pelvis may result. The com- monest is the flat pelvis with some contraction of all the diam- 5i8 PATHOLOGY. eters, but a most marked diminution in the anteroposterior diameter (Fig. 390), There may be found, in addition to this common form, a simple flat rachitic pelvis without alteration of the transverse diameters, a generally equally contracted rachitic pelvis (Fig. 389). and a so-called "pseudo-osteomalacic" pelvis, in which the effect seen in osteomalacia is produced by pressure upon the bones softened by rachitis. There are other rare forms of asymmetrical development, in connection usually with spinal disease of rachitic origin, that are described elsewhere. Fig. 390. — Generally equally contracted rachitic pelvis (author's collection). Characteristics of the Flat, Generally Contracted Rachitic Pelvis. — The sacrum is pressed forward and downward between the iliac bones, and is rotated on its transverse axis, mainly by the pressure of the trunk upon it, but partly by the pull down- Fig. 391. — Flat rachitic pelvis, with unusual descent of the promontory, rotation of the sacrum, and lordosis (Miitter Museum, College of Physicians, Philadelphia). ward of the psoas muscles upon the spinal column and the pull upward upon the posterior surface of the sacrum by the erectores ANOMALIES IN THE FORCES OF LABOR. 519 spinae muscles (Fig. 389). The effect of this movement would naturally be to throw the tip of the sacrum and the coccyx directly backward, so that the posterior surface of the sacral bone would run an almost horizontal course as the woman stood upon her feet. The attachments of the sacrosciatic ligaments and muscles to the lower sacrum and coccyx, however, prevent this backward movement of the bone as a whole, and, pulling the lower portion of the bone forward, cause a sharp bend in it, usually at the junction of the fourth and fifth sacral vertebrae. The sacrum is narrowed in its transverse diameter, and the Fig. 3Q2. — Flat rachitic pelvis with bowed femora : C. v., 5 cm.; tr., i2>^ cm. (Mutter Museum, College of Physicians, Philadelphia). lateral concavity of the anterior surface is effaced by the for- ward movement of the bodies of the vertebrae between the alae. The anterior surface of the sacrum, indeed, may be convex from side to side. By the pull of the strong sacro-iliac liga- ments running from the sacrum to the posterior superior spinous processes of the iliac bones the latter are pulled downward and 520 PATHOLOGY. forward by the descent of the sacral promontory, and are con- sequently made to approach one another behind, but they do not keep pace ^dth the movements of the sacrum, and conse- quently project more prominently than common on either side. The natural result of this movement for^'ard and in- ward on the part of the posterior superior portions of the iha would be to throw the anterior half of the innominate bones outward, but this movement is opposed by their junction at the symphysis, and to a less degree by the attachment of Poupart's ligament to their anterior superior spinous proc- esses. The iha, however, restrained by a somewhat }delding force, are throvvm to a certain degree outward and backward, so that their upper edges run almost horizontally outward, Fig. 393. — Schematic representation of the anterior position of the acetabula in a rachitic pelvis. The pressure of the femora from before backward contributes to the flattening of the pelvis (Schroeder). and the distance between their anterior spines becomes Httle less than, the same as, or even greater than, the distance between their crests. A further result of these combined forces pulling the innominate bones inward and forward behind and hold- ing them in place in front is to produce in them an abnormal cur\'ature, as in the case of the sacrum, or as in a bow bent between one's hand and the ground (Fig. 393). The point of angulation or greatest curvature is found on the ilio-pectineal line, back of the median transverse line of the pelvic inlet, near the sacro-iliac joints. On account of the flexion of the innominate bones the transverse diameter of the rachitic pel- vis is relatively increased, but, as the whole pelv-is is com- monly below the normal in size, this diameter rarely exceeds, if, indeed, it equals, the normal transverse measurement. A further consequence of the exaggerated curvature of the innom- inate bones is to throw the acetabula forward, so that the ANOMALIES IN THE EORCES OF LABOR. 52 1 counterpressure of the lower extremities is exerted more antero- posteriorly than in the normal pelvis (Fig. 393)- The pubic rami and the symphysis are diminished in height and show a lessened slant outward. The cartilage at the junction of the symphysis projects inward upon the pelvic canal, standing out above the level of the bones to such a degree that it is some- times a source of injury to the head or to the maternal struct- ures. The force of resistance at the symphysis to the outward movement of the innominate bones sometimes bends the ends of the pubic bones inward upon the pelvic canal, giving to the pelvic inlet the shape of a figure 8. From the traction of the adductor and rotator muscles of the thigh upon the tuberosities of the ischiatic bones (increased in rachitis by the positions of the acetabula and the bowing of the femora), the latter are pulled outward and forward so that the pubic arch is greatly widened and the transverse diameter of the pelvic outlet is increased. The anteroposterior diameter of the outlet is somewhat dimin- ished by the excessive perpendicular curvature of the sacrum, but the contraction is relatively much less than in the conjugate of the inlet. The whole pelvis is tilted forward on its transverse axis, so that the inclination of the superior strait is increased and the external genitalia are displaced backward. The bones of a rachitic pelvis are usually slighter and more brittle than common. They may, perhaps, show no peculiarities in structure, or in rare cases they may be found much thicker and heavier than normal. In the generally equally contracted rachitic pelvis — a rare type — is seen mainly an arrest of development, the consequence of rachitis in very early life, which retarded growth without much affecting the shape of the pelvic inlet and canal, from the fact that the pelvis had not been subjected to the pressure of the trunk during the active stage of the disease, because it ran its course to complete recovery before the child attempted to sit up or to walk. Possibly, also, the disease in some of these cases is not severe and lasts but a short time. As the deformity is the result of arrested development, a transverse contraction is found as in the fetal ill-developed pelvis. The diagnosis of the rachitic origin of this type of pelvis is made by the relations of iliac spines to crests, perhaps by the history of rachitis in early infancy, and possibly by the signs of the disease in other portions of the body. In the pse7{do-ostcoiiialacic pelvis (Fig. 394) the rachitis has progressed to an extreme degree and has been long continued. Efforts to walk have been made while the disease was in active 522 PATHOLOGY. progress, and possibly the weight of the trunk has been exag- gerated by attempts to carry heavy burdens. As a consequence of the pressure of the trunk and the counterpressure of the lower extremities, the pelvis bends under the forces imposed upon it. The sacrum sinks far down into the pelvic canal and is sharply curved or bent from above downward ; the innominate bones are bent at a sharp angle laterally, and the acetabula are Fig. 394. — Pseudo-osteomalacic pelvis. pressed inward upon the pelvic canal. When at length the bone disease has run its course, the pelvis is firmly set, by the hardening of the bones, in its unnatural position and shape. The differential diagnosis between this pelvis and the true osteo- malacic pelvis is made by the direction of the iliac crests, by the firm constitution of the bones after the disease has been arrested, and by the signs of rachitis in other portions of the body. Osteomalacia, besides, has certain peculiarities of its own that enable one to recognize it without difficulty. Diagnosis. — The diagnosis of a rachitic pelvis is made by external and internal measurements, by palpation of the ex- terior and interior of the pelvis, by the woman's history, and by her appearance. An individual who has had rachitis in childhood is usually of small stature, with short, thick, curved extremities ; a low, broad brow ; a large, square head ; a flat nose ; a " chicken breast," and enlarged joints. The lumbar lordosis and the rotation of the sacrum produce a sway-back, most noticeable when the woman lies on her back upon a hard surface. When she stands erect the pregnant uterus near term falls abnormally for- ward and downward, on account of the short abdomen and lack of engagement of the presenting part (Fig. 395). The most charac- teristic facts in her historv are that she walked first at three or four ANOMALIES IN TJIE FORCES OF LABOR. 523 years of age and was late in getting her teeth. By the pelvimeter the normal relation between the iliac spines and crests is found disturbed. The difference in distances between the former and between the latter is much reduced. The posterior superior spinous processes are approximated, and the depression under the last spinous process of the lumbar vertebra approaches or is actually in the line drawn between them. The external antero- posterior diameter of Baudelocque is below the normal. Inter- Fig- 395- — Pendulous belly of rachitis (Charpentier). nally, the diagonal conjugate is found considerably reduced. The symphysis has less of a slant outward than it should have ; the promontory is found low and prominent ; the sacral bone is sharply bent upon itself, and the pelvic canal is remarkably shallow. On account of the increase in the conjugatosymphys- eal angle due to the lessened slant outward of the S)'mphysis, at least two centimeters should be subtracted from the diagonal 524 PATHOLOGY. conjugate. The difference between the two would be greater were it not for the low situation of the promontory, which com- pensates to a certain extent for the lessened slant of the sym- physis, but does not entirely neutralize it. If a double promon- tory is found, which in these pelves is not uncommon (Fig. 400), the measurement should be taken from the promontory nearest the symphysis. Occasionally the lordosis of the lumbar vertebras, the result of spinal rachitis, is so great as to constitute itself an obstruction above the pelvic inlet. In such a case the effective n.^ 'V Fig. 396. — Appearance during life of the highest grade of rachitis ; pseudo- osteomalacia (Pippingskjold). Fig. 397. — Slteleton of a rachitic dwarf (Medical Museum, University of Pennsylvania). conjugate must be taken from a point above the sacrum to the symphysis pubis. Influence on Labor. — The influence of a fiat rachitic pelvis on labor is much the same as the influence of a simple fiat pelvis, except that the contraction, and consequently the obstruction to labor, is greater in the rachitic form, and that the promontory of the sacrum is more prominent and more sharply defined. The anomalies of mechanism at the inlet are the same in both varie- ties of pelvis, but they are exaggerated in the fiat rachitic pelvis. As soon as the obstruction at the inlet is overcome, the descent ANOMALIES I/V THE FORCES OF LABOR. 52; Pig. 398. — Woman with congenital rachitis (Ribemont-Dessaignes). Fig. 399. — Flat rachitic pelvis complicated bycoxalgia. Cesarean sec- tion (seen in consultation with Dr. Geo. I. McKelway). Fig. 400. — Rachitic pelvis with double promontory : C v., from first and from second sac. vert., 6!4 cm. ; tr. , 12^ cm. (Miitter Museum, College of Physicians, Philadelphia). 526 PATHOLOGY. Fig. 401. — Pressure of the promontory upon the head in a contracted pelvis. (Smellie). Fig. 402. — Overlapping of the cranial bones in a futile attempt of the head to engage in the superior strait of a rachitic pelvis (Smellie). ANOMALIES IN THE FORCES OF LABOR. 527 of the head and its escape are more rapid in the rachitic pelvis, because of the shallow canal and the expanded outlet. Injuries to the child's head and to the maternal tissues from pressure are Fig. 403. — Extreme degree of osteomalacia of trunk and extremities (Kaufmann). common. In the former, a sharp indentation may be seen on that portion of the skull pressed against the promontory in the efforts to secure engagement, the so-called "spoon -shaped" depression, with fracture of the parietal bone. Localized necroses are not infre- quently seen in the maternal structures, where they have been nipped between the child's head and ^prominent portions of the pelvic bones — nameh% in the cer- vical tissues over the promontory, or very rarely in the posterior vaginal vault, and in the anterior vaginal wall behind the symphy- sis and the ridge of the pubic bones. When the slough sepa- rates, openings may be estab- lished between the birth-canal and the peritoneal cavit}% the bowel, the bladder, and a ureter. Osteomalacic Pelvis. — Osteomalacia, a soft condition of the Fig. 404. — Schematic representation of an osteomalacic pelvis (Schroeder). 528 PATHOLOGY. Fig. 405. — Minor grade of osteomalacic pelvis bones in consequence of an osteomyelitis and an osteitis, is ex- ceedingly rare in America. There are certain parts of the world where it is frequently seen, notably Italy, Germany, and Austria, but in America there are but three or four examples on record. The bones of the pelvis in this disease become so soft that they yield to every force imposed upon them. They bend be- fore the pressure of the trunk from above, the extremities from below, and the pull of the muscles attached to the pelvic bones. The flexi- bility of the pelvis in extreme cases of osteomalacia may be appreciated when it is stated that the superior iliac spines may be bent backward until they touch the spinal column ; the horizontal rami of the pubis may be pushed inward until they almost obliterate the pelvic inlet; and the tuberosities of the ischium may be approximated until they nearly close the pelvic outlet. Not only are the pelvic walls so compressed that they almost obliterate the pelvic canal, but the spinal column also, sinking under the weight of the trunk, bends far for- ward and descends low into the pelvis, occupying the little remaining room in the inlet and canal, and be- coming itself a serious ob- struction to the engage- ment of the presenting part. From the lateral pressure of the thigh-bones the ischia and pubes are pushed inward and backward, making, by the former movement, a sharp beak-like projection of the pelvic inlet between the pubic rami, and by the latter much diminishing the size of the pelvic canal (Figs. 404 and 405). The sacrum is rotated on its transverse axis and is driven far down into the pelvic canal — an exaggeration of the move- ment seen in a rachitic pelvis. The lower portion of the sacrum and the coccyx are pulled far forward by the mus- Fig. 406. — Osteomalacia, showing asymme- trical contraction at outlet. ANOMALIES IN THE FORCES OF LABOR. 529 cles attached to them, so that the sacrum is bent at a sharp angle in its lower third. The innominate bones are bent laterally at a point slightly anterior to the sacro-iliac junction, and the iliac bones maybe folded upon themselves horizontally. The inclina- tion of the pelvis as a whole is much increased. The diagnosis may be based upon the following symptoms : The disease begins usually during preg- nancy or lactation, with dull aching pains in the extremities, the back, the lumbar region, and over the anterior portion of the pelvis. Every movement increases these pains. As the disease progresses, the bones of the spinal column are so bent and compressed that the individual is dimin- ished in stature to an extra- ordinar}' degree. She may lose as much as a foot and a half in height (Fig. 406). The gait of an osteomalacic patient is peculiar. In order to compensate for the approximation of the thighs brought about by the collapse of the pelvis, the individual must turn almost through a half-circle in order to bring one foot in front of the other. By palpation of the pelvis ten- derness upon pressure is discovered over its anterior walls. The flexibility of the pelvic bones may be demonstrated by direct pressure, and an internal examination reveals, in the early stage of the disease, the peculiar beak-like space behind the symphysis, and later the almost entire oblitera- tion of the pelvic outlet and canal by the sinking in of the pelvic walls. If it is possible to make a satisfactory internal examina- 34 Fig. 407. — Author's case of osteomalacia. 530 PATHOLOGY. tion of the pelvis, the low position and the projection of the promontory at once attract attention, and the sharp angulation on the anterior face of the sacrum can be felt. On account of the exaggerated inclination of the pelvis, it may be necessary to make an examination with the patient upon her side. An osteo- malacic pelvis has been taken for a kyphotic, a Robert, a pseudo- osteomalacic, a cancerous, or a fractured pelvis, but a careful, methodical examination of the patient should always lead to a correct diagnosis. Influence Upon Labor. — The results of labor in osteomalacic pelves show that the obstruction is a serious one, although by reason of the flexibility of the pelvis in some cases the head can distend the pelvic canal sufficiently to pass through. In 85 cases collected by Litzmann, 47 ended fatally. In another series of 128 cases the labor had a spontaneous termination in 27 cases, in 4 there was premature delivery, and in 5 abortion ; 4 times the labor was naturally terminated ; in 8 cases version was per- formed, in 4 the child was extracted by the feet, in 25 forceps were employed, in 1 1 craniotomy was performed, and, in 36 Cesarean section ; rupture of the uterus occurred in 5 women before any operation was undertaken. In still another series of cases reported from Milan, the flexibility of the pelvis was so great that the child was delivered in only two instances by Cesa- rean section. The most successful treatment is the performance of Cesarean section, and the operator should at the same time remove the ovaries, or, what is better, perform a Porro operation. The ces- sation of sexual functions favorably modifies or actually cures the disease. Tumors of the Pelvis. — The commonest pelvic tumors are bony excrescences, usually found over one of the pelvic joints.^ The excrescences are originally cartilaginous projections which become ossified by an extension of bony tissue from the two bones between which they lie. These exostoses may be found over the sacro-iliac joints, over the crests of the pubis, at the iliopectineal eminences, and over the promontory of the sacrum (Figs. 409, 410, 411, 412). They may attain the size of a pigeon's &^^, though they are usually not larger than a pea or nut. In the exostoses occupying the seat of the pubo-iliac junctions, directly above the acetabula, the bony growth is apt to assume a sharp, thorny shape, projecting with its point into the pelvic inlet. Kilian was the first to direct attention to this fact ; he called a pelvis thus deformed '' acanthopelys" (Fig. 413), or a ''pelvis spinosa." Another possible seat for a bony pro- 1 Daniel admits only four authentic cases of osteogenic exostoses complicating labor, including one reported by the author. "Annales de Gyn.," August, 1903. ANOMALIES IN THE EORCES OF LABOR. 531 jeclion is along the crests of the ])ubic bones, the exostosis taking here the form of a long, sharp edge, and probably owing its origin to an ossification of the attachment of the iliac fascia, a transformation of tissue analogous to the ossification some- times seen in Gimbernat's ligament. These bony outgrowths Fig. 408. — Cystic enchondroma (Zweifel). Fig. 400. — Button-like exostosis on the promontory (Schauta). Fig. 410. — E.xostosis on the symphysis (Schautal. are a serious obstruction in labor, not so much trom their encroachment upon the room of the pelvic inlet, as from the sharply localized pressure which they exercise upon the maternal structures and upon the fetal head. In the four cases 532 PATHOLOGY. reported by Kilian, death, it was claimed, resulted in each case from a perforated uterus. Other tumors of the pelvis obstruct- ing labor are enchondromata, fibromata, sarcomata, carcino- mata, and cysts (Figs. 408, 414). These tumors are rare, and Fig. 411. — -Exostoses at sacro-iliac junctions. Fig. 412. — Exostoses around the pelvic brim (model in the author's collection). their importance as obstacles in labor depends, of course, upon their size. Cysts of the pelvis are formed usually in sarcomata and in enchondromata, or are hydatid cysts. Cancer of the pelvic bones is always a secondary growth or is metastatic. It ANOMALIES IN THE FORCES OF LABOR. 533 may result in a number of small tumors in the bony pelvic walls, or may take on the form of cancerous infiltration with a conse- quent softening of the bones like that of osteomalacia. The treatment of labor obstructed by tumors of the pelvis is ordi- narily the performance of Cesarean section. There is one case on record (Aberncthy's) in which the tumor, an enchondroma, was removed by an incision in the posterior vaginal wall, but in the vast majority of cases these growths can not be reached or Fig. 413. — Acanthopelys. Fig. 414. — Enchondroma (Behm). safely excised. In 49 cases of labor obstructed by a pelvic tumor, 50 per cent, of the women and 90 per cent, of the children lost their lives (Winckel). Fractures of the Pelvis. — Out of 13,200 fractures reported from nine large hospitals in America and in Europe, but -^ of one per cent, were fractures of the pelvis. When one considers that almost all grave injuries of the pelvis end fatally, the rarity of a pelvic deformity dependent upon a united fracture of a pelvic bone in a woman of child-bearing age may be appreciated. Most 534 PATHOLOGY, frequently the fracture is found in the pubes, next in the iHum, next in the ischium, next in the acetabulum, and least frequently of all in the sacrum. The effect of a fracture of the pelvis upon the shape and size of its canal depends on the location of the fracture. The deformity may be due to distortion of the pelvic walls, to excessive callous formation, or to ossification of the pelvic joints nearest the seat of fracture. In a fracture of the acetabu- lum the result of hip-joint disease, the head of the femur may Fig. 415. — Fracture of the pelvis (Otto). Fig. 416. — Fracture of the acetabulum in consequence of coxalgia (Otto). project into the pelvic canal (Fig. 416). Fracture of the pubes results in an irregular distortion of the pelvic inlet, most marked, of course, on the injured side (Fig. 415). A fracture of the upper portion of the sacrum may result in a spondylolisthetic deform- ity (Fig. 417). Fracture of the lower portion of the sacrum is followed by a dislocation of the lower fragment inward. In a case under my observation the lower half of the sacral bone was turned in at right angles to the rest of the bone by the pull of ANOMALIES IN THE EOKCES OE LABOR. 535 the pelvic muscles attached to it. A fracture of the sacial alae may cause an oblique contraction of the pelvic inlet like that of the Naegele pelvis (Hg. 418). Neugebauer^ reported an ex- Fig. 417.— Transverse fracture of the sacrum with spondylolisthetic deformity (Neugebauer) . Fig. 418. — Fracture of the right ala of the sacrum (Fritsch). traordinary case of bilateral fracture of the pubic rami in which there was union with callous formation on one side and an ununited p. i{ 1 " Jahresbericht iiber d. Fortschr. a. d. Gebiete der Geburtsh.," etc., vol. iv, 536 PATHOLOGY. fracture on the other, the fragments moving on each other two or three centimeters when the woman walked. Caries and Necrosis. — The only effect of these diseases of the pelvic bones is the production, in rare cases of tuberculosis of a sacro-iliac joint, of an oblique contraction of the pelvis. When the sacro-iliac joint is affected, the ultimate result is the same as that produced by imperfect development of the sacral ala in a true Naegele pelvis. There is loss of tissue, ankylosis of the joint, and an arrest of development in the affected part if the disease occurs in early childhood. Ankylosis and Relaxation of the Pelvic Joints. — Synostosis may develop in any of the pelvic joints ; in the symphysis it occurs not infrequently, and often at an early age. A number of operators have encountered difficulty on this account in at- tempts to perform symphysiotomy. In otherwise unobstructed labor synostosis of the pubic symphysis is not a serious condi- tion, although it limits the slight expansion which every normal pelvis should exhibit preparatory to and during labor. If synostosis of the sacro-iliac joint develops in the indi- vidual's early childhood, it is followed by ill-development of the sacral alae on the affected side, and of that portion of the in- nominate bone concerned in the formation of the joint, an obliquely contracted pelvis of the Naegele type being the result ; but such cases are rarer than those in which lack of development in the sacral alae is the primary occurrence. If the synostosis of the joint occurs after puberty, the effect upon the p.elvis and upon the course of labor is practically nil. If both joints are early ankylosed, a form of laterally contracted pelvis like the Robert pelvis is the result. This kind of contracted pelvis is rarer than the transversely contracted pelvis due primarily to lack of development in the sacral alae. The sacrococcygeal joint becomes ankylosed, as a rule, between the thirtieth and fortieth years, but as the joint between the first and second coccygeal vertebrae is ordinarily unaffected, the pelvic outlet is capable of expansion during labor in its anteroposterior diameter nearly as well as if the sacrococcygeal joint were normal. Rarely, there is an ankylosis of all the coc- cygeal joints as well as of that between the sacrum and the coc- cyx. In these cases labor can be terminated only by a fracture of the coccyx or a rupture of a coccygeal joint, usually the first. The expulsive forces of labor may be sufficient to cause the fracture, and the bone has been heard to give way with a loud crack as the head was passing through the pelvic outlet. This accident, however, is more likely to be caused by the artificial extraction of the head. ANOMALIES IN THE FORCES OF LABOR. 537 An abnormal relaxation of the pelvic joints may be a simple exaggeration of the natural process by which the pelvic canal is made somewhat expansible preparatory to labor. It is more likely, however, to be due to some pathological condition within the pelvic joints, as an inflammatory process followed, perhaps, by suppuration, an accumulation of fluid within the joint, osteo- malacia, caries, or new growths. In pregnancy the pathological relaxation of the pelvic joints may occasion some difficulty in locomotion. During labor an exaggerated relaxation of the joints predisposes to their rupture. The Spondylolisthetic Pelvis. — The spondylolisthetic pelvis was first described in 1839 by Rokitansky, who reported two cases ; Kiwisch and Kilian each followed with a description of a specimen ; but we owe our knowledge of the condition mainly to the indefatigable researches of Neugebauer,^ who collected more than one hundred cases and specimens, and to the discov- eries of Lane, who has done much to clear up the etiology. The name *' spondylolisthesis " ^ indicates the condition — a slipping down or dislocation of the vertebrae. To affect the pelvis the spondylolisthesis must be in the lumbosacral region (Figs. 419- 421). Characteristics. — As the name denotes, there is a dislocation of the last lumbar vertebra in front of the sacrum, the body of the former slipping down in front of the first sacral vertebra, so that its inferior border, or in advanced cases its anterior surface, comes in contact with the anterior face of the sacrum, to which it becomes united by bony union. There is, also, of necessity, an exaggerated lordosis of the lumbar vertebrae and a descent into the pelvic inlet of at least the fourth and third, and even of the second, lumbar vertebrae, which diminish by their bulk and anterior projection the anteroposterior diameter of the pelvic canal. It is only the body of the last lumbar vertebra that is displaced, and not the arch, held fast by the lower posterior articular surfaces, nor the laminae surrounding the spinal cord ; so that the latter does not necessarily suffer compression by the displacement of the vertebrae, although this result has been noted in a few cases (Fig. 420). To allow the displacement of the 1 Franz Ludwig Neugebauer, " Bericht iiber die neueste Kasuistik und Littera- tur der Spondylolisthesis," etc. , " Zeitschrift f. Geburtshiilfe und Gynakologie," Bd. xxvii, H. 2,1893; "Spondylolisthesis et Spondylizdme," " Resume des Re- cherches litteraires et personelle depuis 1880 jusqu'en 1892," Paris, G. Steinheil, 1892 ; " Contribution a la Pathogenic et au Diagnostique du Bassin vicie par le Glissement vertebral," " Annales de Gynecologic," Feb., 1884; " Zur Entwicke- lungsgeschichte des spondylolisthetischen Beckens und seiner Diagnose," Halle and Dorpat, 1882, p. 294; see also " Archiv f. Gynakologie," Bd. xx, H. I, und Bd. xxi, H. 2. The best article in English is by J. Whitridge Williams, " Tr. Am. Gyn. Society," vol. xxiv, 1899, with full bibhography to date. -cit6v6v'aoc, vertebra, and iJ.iaOijaig, a slipping out or down. 538 PATHOLOGY. body of the last lumbar vertebra the interarticular segment of the spinal arch and the pedicles are enormously lengthened from behind forward and are bent at an angle downward (Fig. 420). After a time this segment may exhibit a transverse fracture or a solution of continuity from pressure and attrition. The deform- ity is always gradual in development. If it begin during the child-bearing period, successive labors become increasingly diffi- cult. As the vertebra descends, it pushes the sacrum backward Fig. 419. — Spondylolisthesis, well marked (Schauta). Fig. 420. — Spondylolisthesis, beginning (Schauta). Fig. 421. — Last lumbar vertebra of spondylolisthesis [a), contrasted with a normal fifth lumbar vertebra (Neugebauer). and downward, and with it depresses the posterior portion of the pelvic brim. To compensate for this movement the anterior half of the pelvic brim rises and the height of the symphysis is increased. This movement of the pelvis diminishes very markedly its inclination, and disturbs the normal relationship between the bones and the soft structures that overlie them. The base of the triangle formed by the pubic hair in women is well below the upper edge of the symphysis, and the external genitalia are pulled so far forward that the vulvar orifice is ANOMALIES IN 'JIIE FORCES OE LABOR. 539 directed anteriorly as the patient sits or stands. There are, more- over, the same disphicements of the pelvic bones that are seen in kyphosis — a rotation backward of the sacrum on its transverse axis ; a rotation outward of the upper portions, and inward of the lower portions, of the innominate bones on their antero- posterior axes. The descent of the lumbar vertebra; dra<^s the large arteries of the lower trunk into the pelvic inlet, so that the iliac vessels and the bifurcation of the aorta may be felt in a vaginal examination. The degree of contraction in the conjugate diameter of the inlet depends upon the descent of the last lumbar vertebra and the degree of the lordosis. The contraction is usu- ally not excessive, but it may be so great as to pre- clude the possibility of the engagement of the fetal head. Etiology. — The etiology of spondylolisthesis at the lumbo-sacral junction is still obscure. It has been attributed to direct injuries of, and to faults of devel- opment or ossification in, the interarticular segments of the spinal arch. It is certain that these are pre- disposing causes, but the observations of Lane ap- pear to demonstrate that the commonest cause of the deformity is an exaggerated pressure from the trunlc above exerted often upon healthy bone. As a result of this pressure a joint is formed in the intervertebral disc, and the interarticular segments of the last lumbar vertebra undergo stretching, pressure, angulation, and atrophy until the bone is actually severed. Following or accompanying these changes in the arch, the body of the last lumbar vertebra is gradualU' dis- placed downward and forward. Spondylolisthesis has followed an injur\% presumably a fracture, of the lumbar vertebra?. Frequency. — Neugebauer collected 115 cases, to which num- ber Williams added 8. The author has seen one case in a single woman, aged 59 (Fig. 422). Of the 124 cases, 8 were in men. Diagnosis. — The diagnosis of a spond\-lolisthetic pelvis is not Fig. 422. — Author's case of s[ioiulyl<>listhes 540 FATHOLOGl. easy ; ' it can be made only by close attention to the patient's histoty, by a careful observation of her appearance, by an inter- nal and external examination of the pelvis, and by pelvimetry. In the history of the case it may appear that the individual was the subject of a serious accident, such as a fall from a height or a fracture of the pelvis by the passage over it of a heavy weight, or it may be learned that she has carried excessively heavy bur- dens for a long time. The woman's height is diminished and the length of the abdomen is shortened. Viewing the patient from behind, there appears what is called the saddle-shape or "sway" back, the lumbar vertebrae projecting visibly far forward and being displaced downward, throwing into bold relief the Fig. 423. — Breisky's case of spond)-lolii>thesis. posterior superior spinous processes and the rims of the iliac bones, and producing quite a deep furrow along the course of the spinous processes of the lumbar vertebrae. The apposed articular processes of the first sacral and the last lumbar verte- brae stand out as button-shaped prominences on the inner surface of the posterior rims of the ilia. The buttocks are flat and are pointed below, giv'ing to the region a cordiform appearance. In front there is a pendulous belly; a deep crease is observed run- ning across the lower abdomen a short distance above the sym- physis. Laterally, the floating ribs are seen almost to rest upon the crests of the ilia or actually to sink between them, and the soft structures of the flanks are thrown outward in prominent ANOMALIES IN THE FORCES OE LABOR. 541 folds. The trunk is shortened, and tlie limbs appear relatively too long (Fig. 423). The patient's Ijody being thrown forward by the deformity of the spine, an effort to maintain an equilib- rium is made by carrying the shoulders far back; as the individual walks, a disposition to fall forward may be noted, and she states, perhaps, that she is unable to carry any load upon her arms in front of her body, for fear of toppling over upon her face. She may also complain of pain or of a grating sensation and sound in the small of the back (crepitus). The gait is peculiar ; the toes are not turned out, and the feet are swung around each 1 |BH^\ Jfl ^^^Hb' ■■I ■^ Fig. 424. — Footprints of author's case of spondylolisthesis. other so that the footprints fall in a straight line (Fig. 424) . Upon an internal examination of the pelvis, — best conducted, accord- ing to Neugebauer, in an upright or lateral position, — the lordosis of the lumbar vertebrae is at once discovered. The angle formed by the attachment of the last lumbar vertebra to the sacrum may be detected with ease, especially in a rectal examination, and it should be noted that the body of this vertebra does not possess lateral projections, transverse processes, or alae. By their absence the bone is distinguished from a projecting 542 PATHOLOGY promontory. Pulsating iliac arteries may be felt, and it is pos- sible even to reach the bifurcation of the aorta, — as first pointed out by Olshausen, — but this symptom is not pathognomonic. It is possible to reach the bifurcation of the aorta in a vaginal exam- ination in the extreme lordosis of some rachitic pelves and of the osteomalacic pelvis, in lumbrosacral kyphosis, and in some cases of dorsolumbar kyphosis. The external palpation of the pelvis demonstrates the absence of inclination. A measurement of the pelvis may show a diminution in the external conjugate diameter, an increased height in the symphysis pubis, an increased distance between the posterior superior iliac spines, and "a diminished distance between the anterior iliac spines and the crests. The external conjugate may not be decreased at all ; it may even be increased if meas- ured from the top of the sacrum, which is pushed backward, "There is some diminution in the diameters of the outlet. The internal conjugate diameter must be measured from the lumbar vertebra nearest the symphysis pubis, usually the fourth. This is called the "false" or " effective " conjugate diameter of the spondylolisthetic pelvis. On account of the decreased in- clination of the pelvis it is not necessary to subtract more than the ordinary sum from the diagonal conjugate. In fact, the diagonal conjugate may approach very nearly the length of the true, or may actually measure less. Influence Upon Laboj'-. — The influence of a spondylolisthetic pelvis upon labor is that of a flat pelvis. The obstruction in the former may be overcome more easily on account of the bow- like shape of the projecting vertebra and the coincidence of the uterine and pelvic axes. The obstruction to labor depends entirely upon the projection of the lumbar vertebrae. This pro- jection may be so slight as scarcely to influence the progress at all, or it may be so great as to make delivery by the natural channel quite impossible. There is noticed in labor something of the same mechanism that is seen in the flat pelvis for the pur- pose of overcoming the obstruction — namely, decreased flexion, transverse position, and exaggerated lateral inclination of the head. On account of the forward dislocation of the external genitalia and of the pelvic floor, lacerations of the latter are the rule, and the tears are often complete into the rectum. This liability to injury is explained by the fact that the presenting part impinges directly upon the middle of the pelvic floor as it descends the birth-canal, instead of being directed forward to the vulvar orifice. Fistulae of the anterior vaginal wall are likewise common, from the localized pressure to which this region is subjected while the head is passing the obstruction at the inlet. AA'OMALIES IN 'J'lIE FORCES OF LABOR. 543 The presenting part is thrown forward by the projecting ver- tebne, and is received upon the prominent ridge of the pubic bone, greater in height and higher in situation than in the nor- mal pelvis. Treatment of Labor Obstructed by Spondylolisthetic Pelvis. — The management of labor in these cases is governed by the same principles that obtain in the management of labor in a flat pelvis. If the effective conjugate is over 9.5 cm., the woman can be delivered spontaneously, by forceps, or by version. With an ef- fective conjugate of 7 to 9.5 cm., the in- duction of prema- ture labor and the performance of symphyseotomy ^ might be con- sidered ; or cranio- tomy should be done if the child is dead. If the effective conjugate is at or under 7 cm., delivery must be effected by a Cesarean section. These rules pre- suppose, of course, a child of average size. After the wo- man's convales- cence from her delivery she should be referred to an orthopedic surgeon for the adjustment of a brace which makes her more comfortable and might retard the progress of her disease. Kyphosis. — The k\'photic pelvis was first adequately described in 1865 by Breisky, although its peculiarities had been recog- nized by Litzmann in 1861 and by Neugebauer in 1863. The condition was called by Herrgott "spondylizema," a name adopted by Neugebauer and others (Figs. 426, 427). ^ Symphyseotomv has been performed twice for spondylolisthesis by Morisani and Williams. Both operations were fatal. The effective conjugate is apt to be less than it seems, so that in case of doubt as to the measurement Cesarean section should be performed. Fig. 425. — Angulation of the spine in kyphosis. 544 PATHOLOGY. Characteristics. — The degree of deformity in a kyphotic pel- vis depends upon the situation of the hump : the nearer this is to the sacrum, as a rule, the greater is the deformity in the pelvis. Lumbosacral kyphosis is almost as frequent as the lumbar and dorsolumbar combined. There is a compensating lordosis of the lumbar spine, but not enough to keep the center of. gravity of the trunk from being too far forward. In conse- Fig. 426. — Kyphotic pelvis from above (Barbour). Fig. 427. — Contracted outlet of a kyphotic Fig. 428. — Kyphosis: greatest pelvis (Barbour). transverse diameter at outlet, 7 cm. (Miitter Museum, College of Physi- cians, Philadelphia). quence, the weight of the trunk is transmitted in a direction from before backward, so that the sacrum is rotated on its transverse axis in a direction the reverse of that seen in rachitis — namely, backward and scarcely at all downward. The result of this movement is to make the sacrum straighter, narrower, more curved from side to side, and longer (Fig. 426) ; to pull the pos- terior superior spinous processes of the iliac bones closer to- Plate 13. I, Lumbodorsal kyphoscoliosis (Schauta) ; 2, lordosis from paralysis of spinal muscles (author's case) ; 3, skeleton of a girl with coxalgia (Medical Museum, University of Penna. ) ; 4, rear view, 5, side view, of obliquely contracted pelvis, the result of tuberculous disease in one knee-joint (author's case) ; 6, scoliosis from unilateral atrophy of spinal muscles (^author's case). ANOMALIES IN THE FORCES OF LABOR. 545 gether, and to separate the anterior spines more widely. The diminished width between the posterior superior spinous pro- cesses is caused partly by the pull of the sacro-iliac ligaments. The sacrum can not move in any direction without dragging the ilium on each side by these ligaments, thus approximating their upper posterior surfaces. The diminution of the interspinous Fig. 429. — Lumbosacral kyphosis, front and profile views (author's case). measurement posteriorly depends also upon the narrowness of the sacrum. To compensate for the movement of the upper portion of the sacrum backward, the lower portion of the bone projects forward, into the pelvic outlet. To preserve the body from falling forward, the legs are slightly flexed and the pelvic inclination is almost entirely lost. This posture puts 35 546 PATHOLOGY. the iliofemoral ligaments on a stretch, which pull outward the upper portions of the innominate bones. To compensate for the movement outward of the iliac bones the lower segments of the innominate bones move inward upon the pelvic outlet; in other v/ords, there is a rotation of the innominate bones upon their anteroposterior axes. The result of these movements in the pelvic bones is to enlarge the pelvic inlet in its anteroposterior diameter, and to contract the canal toward the outlet, where the diminution of the diameters is most marked in the transverse (Fig. 427). In the cases of lumbosacral kyphosis the upper portion of the sacral bone may be involved in the necrotic process and the sacrum may exhibit ' deformities by destruc- tion of its tissues (Fig. 433). The other characteristic deformities of the kyphotic pelvis are most marked in this type, unless, as in one instance, the body is bent almost double, and it is necessary to rest the anterior portion upon an artificial support, as a cane. In this case the pelvis, although relieved of the weight of the trunk, is obstructed by the overhanging lumbar vertebrae to such a degree, perhaps, that the inlet is practically obliterated (pelvis obtecta). In all cases of exaggerated lumbosacral kyphosis the pro- jecting lumbar spine blocks the pelvic inlet and seriously obstructs labor. The conju- gate diameter must be measured to the lumbar or even to the dorsal vertebrae, and is exceedingly short. In 2 1 labors compli- cated by this deformity of the pelvis, 66 per cent, of the mothers and 75 per cent, of the children were lost (Winckel). Influence on Labor. — The influence of the kyphotic pelvis upon labor is usually not felt until the presenting part has de- scended to the pelvic floor. In consequence of the shortened perpendicular diameter of the abdominal cavity there is always a tendency to a transverse position of the fetus in titero, but this position is ordinarily corrected by the first ^gw labor-pains. The head presents in 95 per cent, of cases, the breech in 2 per cent., according to the statistics collected by Klein, 1 embracing 172 Fig. 430. — Lum- bosacral kyphosis (rear). 1 " Archiv f. Gyn.," Bd. 1, H. I. ANOMALIES IN THE FORCES OF LABOR. 547 births in 95 women. When the head arrives at the pelvic floor, if the occiput is directed backward, as it is in a third of the cases, anterior rotation will very likely be prevented and there will be a Pubes Fig. 431, — Head arrested by spines of ischia in a kyphotic pelvis (Budin). Fig. 432. — Vertical section of kyphotic pelvis, showing the head arrested by the spines of the ischia (Budin). persistent posterior position. A posterior rotation of the occiput originally directed anteriorly is not rare. It occurred in fi\'e of Klein's cases and in one of the author's. If the occiput is 548 PATHOLOGY. directed anteriorly, the transverse diameter of the head may be caught between the approximated spines or tuberosities of the ischiatic bones, and labor be brought to an indefinite standstill (Figs. 431, 432). The head usually enters the pelvis obhquely or transversely. Rotation only occurs as the head emerges from the 'outlet. F'ace presentations occur in a large proportion of cases — ^four per cent, of the head presentations. Management of Labor i?i Kyphotic Pelves. — An exact meas- urement of the pelvis is essential to a determination of the proper means of deliver}^ If the child is of normal size, pregnancy may be allowed to go to term in pelves measuring 8.5 cm. and more in the transverse diameter of the pelvic outlet. Any asymmetry of the ischia constitutes a serious complication, necessitating operative interference that might be avoided in a symmetrical pelvis with smaller diameters. Below 8.5 cm. down Fig. 433. — Lumbosacral kyphosis (pelvis obtecta). to 6 cm. in the transverse measurement of the outlet, labor should be induced at the thirty-sixth week. With a measure- ment less than 6 cm. Cesarean section is indicated absolutely. If the w^oman is first seen in labor at term, the head, if it is presenting, should be allowed to descend to the pelvic floor and the woman should be encouraged to make vigorous ex- pulsive efforts. If the occiput shows a disposition to rotate posteriorly, the movement should not be interfered with, for the greater bulk of the occipital region finds more room poste- rior to the tuberosities than it does anteriorly. The author has seen an occipito-anterior position of the vertex, in a kyphotic pel- vis, remain stationary until the head rotated from an anterior to a posterior position, when the vertex was expelled without further difficulty. With a transverse diameter of 8.5 cm. spontaneous ANOMALIES I A' TI/E FORCES OF LABOR. 549 delivery may be ]jossiblc, though it may be necessary to use forceps. Below 8.5 cm. the forceps may be tried cautiously, but pubiotomy is likely to be recjuired. In no other form of con- tracted pelvis is this o])cration so successful. Klein found, by experiments on the cadaver, that by a separation of the symphy- sis to 6 cm. in a kyphotic pelvis, the tuberosities moved 4.5 cm. further apart. Puljiotomy, therefore, might be expected to Ije successful in a transverse diameter of 6 cm. or even a trifle less. If the child is dead or if the graver obstetrical operations are not admissible, craniotomy should be performed, in case the forceps fail. In employing forceps the operator must remember the dangers of rupture of the symphysis and deep tears of the vaginal walls to which kyphotic subjects are particularly liable. Version has given the worst results of all the obstetrical operations in kyphotic pelves. It is, therefore, as a rule, contraindicated, although in one of the author's cases, complicated by eclampsia, it proved the Fig. 434. — Asymmetrical contraction of the outlet from kyphoscoliosis. best way to extract the child. Klein's statistics show that in fifty- eight to sixty per cent, of cases the labor must be terminated by operative interference. Diagnosis. — The diagnosis of a kyphotic pelvis presents no difficulties. The hump-back is obvious, and the history is easily obtained that the spinal deformity developed early in life. The pelvic measurements diagnostic of this deformity show an increased separation of the iliac crests and the anterior spines, an abnormally long conjugate diameter of the inlet, a diminished distance between the posterior superior spines, an approximation of the tuberosities of the ischiatic bones, and some diminution in the anteroposterior diameter of the pelvic outlet. The buttocks are flat and pointed below, the external genitalia are displaced forward and upward, and the upper edge of the symphysis is above the upper edge of the pubic hair. Care should always be exercised to detect a^symmetry in these pelves, to discover an 550 PATHOLOGY. arrested development with general contraction which is common, and to diagnosticate lateral contraction at the pelvic inlet. These complicating deformities constitute often insuperable' obstacles in labor, even though the transverse diameter of the outlet is not excessively contracted. Klein gives the following table, showing the contrast between kv^hotic, normal, and rachitic pelves, taking a t}'pical example of each, the measurements being made upon the dried specimen : Sp. il. ant. 5up., 22.3 Cr.il., 26.8 Conj. extern., 16.3 Spin. il. post, sup., \ "J. "J Height of anterior surface of sacrum, . . . ( 10.4 Height of posterior surtace of sacrum, . . . f 9.3 Diagonal conjugate, 12. 5 True conjugate, • • 1 '°"9 Transverse diameter of pelvic inlet, . . • . | 12.9 Spines of the ischia, -. 10.2 Tuberosities of the ischia, 11. 4 <2 s::^ 28.1 28.7 18 5-7 14.2 9-4 19-3 17.7/ 14-5 9-5 10. 1 25 27-3 18.5 6.4 8.2 7-2 13.6 13.2 11.8 6.6 4-6 21.7 25.2 155 3-5 8 6.2 14-5 13-6 II. 2 5-9 4-5 27.25 27.75 14-5 8.7 7.6 14.2 13-5 13.2 Prognosis. — The outlook for the mother and child depends upon the degree of the deformit}^ and upon the management of the labor. In the minor grades of contraction in the cases collected by Klein, the maternal mortality was 6.6 per cent. In the graver cases it was 16 per cent. Xeugebauer puts the maternal mortality' at 24. 3 per cent. The mortalit}' of the in- fants has varied in the different statistical tables from 36 to 49 per cent. Freqiie7icy. — The kyphotic pelvis is said to be somewhat infrequent, but the practitioner in active practice will surely encounter several examples in the course of his career. The writer has had under his care eight well-marked cases of k}-photic pelvis, in two of which Cesarean section was necessary. In three deUver)' was spontaneous. One required forceps, another, version. Klein found, in 42,113 labors, only 7 women with k}'phosis — a proportion of i : 6016. Scoliosis. — In the scoliotic pelvis there is some degree of oblique contraction. The innominate bone, toward which the lumbar vertebrae are bent, receiving the greater part of the weight of the trunk, is pushed upward, inward, and backward by the ANOMALIES IN THE EORCES OE L.IIWA'. 5-1 extra pressure exerted upon it by the head of the femur. The acetabulum on this side is displaced anteriorly and upward ; tiie symphysis is pushed over to the opposite side. The degree of asymmetry is rarely sufficient to constitute an obstruction in labor. The scoliotic pelvis is, however, most often rachitic, and in addition to the asymmetry of scoliosis there may be the con- traction of a rachitic pelvis (Figs. 435, 436). Kyphoscoliosis. — In a combination of kyphosis and scoliosis of the spinal column the pelvis shows, perhaps, the combined Fig. 435. — Scoliosis. Rachitic pelvis: C. v., 8.25 cm. Craniotomy on a dead child (author's case). Fig. 436. — Scoliotic rachitic pelvis. features of both, but the kyphosis, being of rachitic, not of carious, origin, is not angular, and is situated high in the dorsal region, where it may be compensated for entirely by lumbar lordosis (Figs. 437, 438). The kyphoscoliotic pelvis is usually an asymmetrically contracted rachitic pelvis (PI. 11, Fig. i). Lordosis. — Primary lordosis not the result of pelvic deform- ity or of spinal disease is very rare. Aside from some illustra- tions of it in an article by Neugebauer (Joe. at.), the writer knows of no reference to the subject except his own (PI. 11, 552 PATHOLOGY. Fig. 437. — Kyphoscoliosis (Leopold). ANOMALIES IN THE EORCES OF LABOR. 553 Fig. 2). 1 It may readily be seen what an influence this deformity would have upon coition and parturition, and how it might be an insuperable obstacle to the natural completion of the latter. Fig. 438. — Kyphoscoliosis. Pelvis of rachitic type : C. v., 8.50 cm. (seen in con- sultation with Dr. Geo. I. McKelway). Anomalies Due to Diseases of the Subjacent Skeleton. — Coxalgia. — The deformity of the pelvis due to coxalgia in early childhood is of two types. In one there is an oblique contraction by a displacement of the innominate bone on the health)^ side up- ^ Hirst, " The Influence of the Habitual Inclination of the Pelvis in the Erect Posture upon the Shape and Size of the Pelvic Canal," " University Med. Maga- zine." 554 PATHOLOGY. ward, backward, and inward, on account of the pressure of the femur, the weight of the body being received mainly upon the sound leg. This form of coxalgic pelvis, as a r.ule, presents no serious obstacle to delivery unless it. is associated with a rachitic deformity (Fig. 439). Special attention, however, should always be paid to the length of the conjugate diameter of the inlet, and to the transverse diameter of the outlet. In the other variety of coxalgic pelvis the deformity is also an oblique con- traction, but it is the bone on the diseased side which is driven inward upon the pelvic canal. This displacement of the innomi- nate bone is the result of an arrested development on the corre- sponding side of the pelvis, and is usually .associated with an atrophy of the sacral ala and an ankylosis of the sacro-iliac joint. The contraction of the pelvic canal is much more serious in this Fig. 439. — Coxalgic pelvis (Mutter Museum, College of Physicians, Philadelphia). form, and there may be all the difficulties in labor encountered in the true Naegele pelvis. The pelvic canal may be reduced in size by perforation of the acetabulum or by an arthritis deformans. The ankylosis of the hip-joint and the fixation of the thigh in coxalgia may be a source of serious embarrassment in labor, especially in the application of forceps and the extraction of the fetal head through the pelvic outlet. Luxation of the Femora. — Dislocation of the thigh-bones, if congenital or occurring early in childhood and not corrected, has some effect upon the size and shape of the pelvis, but usually not enough seriously to obstruct labor. If one thigh is dislo- cated, the weight of the body may be thrown mainly upon the other leg, and this may produce an oblique contraction of the pelvis of the kind already described. If the thigh-bone is displaced forward, the anterior half of the pelvis may be driven in a little upon the pelvic canal, and the head of the thigh- ANOMALIES IN THE FORCES OF LABOR. OD Fig. 440. — Anterior dislocation of femur. Fig. 441. — Congential luxation of both femora : C, Crest of ilium ; F, trochanter of femur (Henry). Fig. 442. — Congenital dislocation of femora, rear view, showing wide separation of the thighs with the feet together (author's case). 556 PATHOLOGY. bone, as in one case reported, may project over the horizontal ramus of the pubis into the pelvic inlet (Fig. 440). In the con- genital luxation of both femora backward upon the iliac bones there is an excessive rotation forward of the sacrum, an increased width of the pelvic canal, and from the drag of the attached muscles and ligaments between the thighs and the pelvis the ischiatic tuberosities are pulled outward, upward, and backward, so that the pelvic canal is made shallow and its outlet ver^^ wide. The heads of the femora move up and down on the ilia when the patient walks, and the distance between the lower edge of the symphysis and the inner condyles of the femora is shortened. There is a peculiar waddling gait, a marked lordosis, and the shoulders are carried far back. The rear view of the patient shows an unusually wide separation of the thighs as the individual stands erect with the heels together. In the absence of one lower extremity the pelvis may be contracted obHquely to a serious degree, as in La Chapelle's case,^ by the pressure on one side of the remaining leg. Any condition which throws the weight of the bod}/ mainly on one leg Fig. 443. — Congenital luxation of both femora. may produce the same effect, as is shown in a case of the author's (PI. II, Figs. 4, 5), in which there was tuberculous disease of a knee-joint early in infancy, followed by marked shortening and atrophy of the leg. The weight of the body falling mainly on the sound leg, the corresponding innominate bone is pushed upward, backward, and inward, diminishing the area of in' trapelvic space on its own side. Torggler reports an inter- esting case of this kind in which the disabihty of one leg was due to scleroderma. ^ In the absence of both lower ex- tremities there is the characteristic " sitz-pelvis," in which the innominate bones are usually rotated on an anteroposterior axis, 1 " Pratique des Accouchements," iii, p. 413; according to Schauta, the only case on record. ^ " Centralbl. f. Gyn.," 1889, p. 612. ANOMALIES IN THE FORCES OF LABOR. 557 SO that the crests of the ilia are approximated and the tuberosi- ties of the ischia are separated. Minor deformities of Httle prac- tical importance may be the result of unilateral or bilateral club- foot or of the bowing of one or both lower extremities. In the former there is an increased inclination of the pelvis, an ap[)roxi- mation of the acetabula and of the ischiatic tuberosities, and a narrow pubic arch (Fig. 444)- Fig. 444. — Pelvic deformity, the result of double club-foot (Meyer). The Management of Labor Obstructed by the Commonest Forms of Contracted Pelvis : a Simple Flat, a Rachitic Flat, and a Generally Contracted Pelvis. — Tliere is nothing in medicine requiring more experience and good judgment than the management of labor obstructed by a contracted pelvis. It is extremely difficult to formulate hard-and-fast rules for the guid- ance of the inexperienced when so many factors must be taken into account. The rules given below govern the writer's prac- tice in the average case, but due attention must be paid to the history of past labors, the size of the child, its development, and the compressibility of its head, the relative size of fetal head and maternal pelvis, the age of the woman, the build of both parents, and the probable strength of the expulsive forces, great- est in the primipara and less with successive labors. If the diagnosis of a conjugate diameter of 9.5 cm. or less is made during pregnancy, the physician should consider induc- tion of premature labor, forceps, version, pubiotomy, or Cesarean section at term. If the conjugate diameter measures as low as 9.5 cm., it is a safe plan to induce labor two to four weeks before the expected termination of pregnancy if the fetal head is not already in the pelvis or can not readily be made to enter it. This course entails no great additional risk upon the child if its parents are in a position to afford it the best care and nursing. 558 PATHOLOGY. and it is much the safest plan for the mother, the induction of labor, done properly, haxdng no maternal mortality. ^ It is true that many women with a conjugate of 9.5 cm. can deliver them- selves without difficulty at term. Spontaneous dehverv wdth a measurement as low as eight centimeters and under has been recorded. I have seen a negress with a conjugate of 6j cm. de- liver herself spontaneously at term of a 5^ pound child. But the majority of women with a conjugate of 9.5 cm. will ex- perience abnormal delay and difficulty in labor, with added risk to themselves and to their children ; and in a certain propor- tion of cases a conjugate of 9.5 cm. proves an insuperable obstruction in labor, and is the cause of ruptured uterus or death from exhaustion in the mother or of injury to the child's brain. These results are to be feared especially if the child is over- grown or if the mother's expulsive powers are weak — two con- ditions impossible to predict with absolute certainty. For these reasons, then, the rule to induce premature labor when the con- jugate is at or below 9.5 cm. is a safe one. If the conjugate measures eight centimeters or more, the most successful treatment is still the induction of premature labor at the thirty-sixth week. By this plan the m-ajority of women with a conjugate of eight centi- meters or a trifle less are delivered spontaneoush' or mth no more serious operation than the application of forceps. With a con- jugate diameter of the superior strait at and below 7 cm., the woman should be allowed to go to term and should usually be delivered by Cesarean section. If the physician sees the patient for the first time in labor, or only discovers the deformity after labor has begun, he must choose one of the following modes of delivery: A waiting policy, to allow the engagement of the head by natural forces; the ap- pHcation of forceps; the performance of version, pubiotomy, or Cesarean section. While the child is alive, craniotomy should not be considered. The selection of the best mode of delivery in contracted pelves is one of the most difficult problems in obstetrics. If the patient is a primapara and the conjugate is above nine centimeters, natural forces, in the majority of cases, if the fetus is not overgrown, ^vill secure the engagement of the 1 This statement is based upon the writer's experience in private practice, and not upon hospital statistics. It does not hold good for labors induced before the thirty-sixth week. In the discussion at the International Congress at Amsterdam, in August, 1S9Q, the maternal mortality was acknowledged to be about i per cent., and for the infants Barnes gave a mortality of t,2> per cent. ; Bar, 26 per cent. ; Becker, 50 per cent. ; Herzman, 26 per cent., and Black, 50 per cent. These figures, however, are preposterously incorrect for private practice, and are much better of late years in hospital practice. Routh (" Journ. Obst. and Gyn. Brit. Empire," Jan., 1911) puts the fetal mortality at about 12 per cent, and the maternal mortality nil. ANOMALIES IN THE FORCES OF LABOR. 559 head/ althouj^h it may be by the expench'ture of considerable force, after long delay, and only after prolonged molding and an adaptation of the size of the head to the size of the contracted inlet by apparent anomalies in the position and flexion of the former. It is wonderful how successfully an obstruction may be overcome even in cases of contracted pelves with a conjugate of eight centi- meters or less. But while waiting for spontaneous delivery, the physician may see the uterus suddenly rupture or may find the child's head after birth seriously injured. It is permissible in most cases to wait for the full, or almost full, dilatation of the OS, keeping careful watch upon the woman's pulse, temperature, and general condition, upon the situation of the contraction-ring and the distention of the lower uterine segment, and taking whatever operative measures may be required in plenty of time to forestall the possibility of uterine rupture. The application of forceps to the head above the superior strait for the purpose of securing its engagement by forcible traction should in general be condemned, but it must be admitted that there are important exceptions to this rule. If one is skilled in the application of the forceps, bears in mind the transverse position of the head, and can gage the degree of traction which may be exerted without injury to the child's skull or to the maternal soft structures, he will occasionally succeed in securing an engagement with the in- strument that would otherwise, perhaps, be impossible. As a rule, however, it is safe to say that the choice lies between in- action and the performance of version. By the latter operation the smaller end of the wedge represented by the child's head is engaged in the contracted inlet, and there can be exerted upon the head coming last, both by traction on the body from below and by pressure on the head through the abdominal walls above, a degree of force that is impossible with forceps. It is well, however, to bear in mind the danger entailed upon fetal life when version is performed in a contracted pelvis. There is a con- siderable risk^ that the head will be retained long enough above the superior strait, or in it, to asphyxiate the child beyond re- vival. ^ Or the pressure upon the head by the pelvic walls may ^ FromiSSi to I S87 there was spontaneous delivery in 163 out of 444 cases of con- tracted pelvis in the Vienna Hospital, and in 47 women the conjugate was not above 8.5 centimeters (Braun u. Herzfeld, " Der Kaiserschnitt u. seine Stelluns^ zur kiinst- lichen Friihgeburt, Wendung, atypischen Zangenoperationen, Kraniotoinie bei u. zu den spontanen Cieburten," Wien, 18SS, ii, p. 144). In the Moscow Maternity there were 84 contracted pelves among 4000 births in 1894; 71 percent, of these cases were spontaneously delivered (Kiister, " Centralblatt f. Gyn.," No. 10, 1895). 2 The infantile death-rate will be at least twenty-five per cent., or more likely higher (Nagel, " Die Wendung bei engen Kecken," " .'Krchiv f. Gyn.," Bd. xxxiv). 3 Nagel reports sixty cases of version for contracted pelvis, with a fetal mor- tality of twenty-five per cent, [ibid., p. 168). 560 PATHOLOGY. fracture the skull and crush the brain, and the force employed in extraction may break the neck. If in the judgment of the oper- ator the danger entailed upon the fetus by version is too great, natural forces having failed to secure engagement, and if he has tried the forceps cautiously without success, his choice must rest between pubiotomy and Cesarean section. The former is only considered by the author in case the head is impacted in the pehdc canal and the greatest obstruction is at the outlet; the latter, always in cases of greater contraction than 7 cm., and occasionally as a relative indication with a conjugate as large as 8.5 cm. or over. These rules for the treatment of labor I'ig. 445. — Walcher posture: the conjugate of the brim is a black line, and the amount of space gained is a dotted continuation of this line. obstructed by a contracted pelvis presuppose, of course, a fetal body and head of average size. This point must always be in- vestigated carefull}^ by abdominal palpation or by mensuration of the fetal head, although it is difficult to determine.^ If the physician has reason to believe that the child is oversized, he must allow himself sufficient latitude to insure dehvery. If the child is undersized (a condition easier to detect by palpation 1 The relative size of head and pelvis may be determined approximately by the method of Miiller and Schatz. The fetal head is grasped between the extended fingers of the physician, and is pressed down steadily and for some time upon the pelvic brim, the direction of the force coinciding with the axis of the superior strait. If this maneuver succeeds in pressing the head within the pelvis, then natural forces will secure engagement. If it fails, the converse by no means necessarily follows. Other methods of antepartum fetometry are described on page 497. ANOMALIES IN THE FORCES OF LABOR. 561 than overgrowth), spontaneous deUvery may be expected through a pelvis that would not permit the passage of a child of normal size. Klein and Walcher pointed out that by raising the but- tocks and letting the limbs hang down as much as possible the conjugate diameter is lengthened by almost a centimeter. Clinical tests of the method have proved its efficacy.' The author has found it of decided advantage, and recommends it. The same result can be accomplished, with more comfort to the patient, by putting a thick cushion under her back as she lies supine in bed. There is a growing disposition to enlarge the indications for Cesarean section as against high forceps and version in moder- Fig. 446 . — The Walcher posture. ately contracted pelves. I am in sympathy with this movement, but only if the operator is a well-trained abdominal surgeon with sufhcient obstetric experience to judge correctly the difhculties to be anticipated in a vaginal delivery. An exceedingly puzzling problem is presented by cases brought to a speciaHst after hours of obstructed labor and many ^ " Zeitschrift f. Geburts. u. Gyn.," Bd. xxi, H. i, and " ^Med. Korresp. Bl. des Wiirtemb. Aerztl. V.," Bd. Ix, 5. Lebedeff and Bartosziurcz, by experiments on 25 cadavers, found that the Walcher position lengthened the conjugate of the inlet from i-:? mm., " International Congress for Gyn. and Obstct.," Amsterdam. Pinzani in 62 observations found an increase of i-S mm., ihid. 36 562 PATHOLOGY. internal examinations or manipulations with faulty asepsis. Cesarean section has a higher mortality in such cases, not on account of the length of labor, but because of an infected birth- canal. A suprasymphyseal incision and extraperitoneal section is advocated in these cases (p. 870). The advocates of pubiot- omy claim that under these circumstances it is a safer operation than Cesarean section, and this claim is in a measure correct, but with an infected birth-canal the difference in mortality between the two is not very striking. The classical Cesarean section is admissible in these cases, but with an extremely painstaking dis- infection of the birth-canal and the technic of the operation car- ried out as described on p, 867. As an example of what can be accomplished in this way: A woman was brought to the Uni- versity Hospital with the baby's arm protruding from the vulva. The head and shoulder were locked in a uterus cordiformis, with the membranes long ruptured. The patient had been under the charge of an ignorant midwife and came from a filthy hovel. The vulva was cleansed, the arm disinfected and returned to the uterine cavity; the vagina disinfected and packed. A conserva- tive Cesarean section proved entirely successful for both mother and child. The woman made an afebrile convalescence. As a rule, however, the Porro operation would be more suitable in such a case, with fixation of the stump in the lower angle of the abdominal wound outside the peritoneal cavity. Obstruction to Labor on the Part of the Soft Maternal Structures in the Parturient Canal. — Congenital Anomalies of Development in the Uterus. — A double or septate uterus may com- plicate labor in several ways. The bulk of the unimpregnated half may obstruct delivery, especially if this half is retroverted and is increased considerably in size in sympathy with the de- velopment of the impregnated side, and is hardened in consist- ency by sympathetic contraction during the labor-pains. The septum itself may prove an obstacle in labor, a/nd sometimes labor is obstructed by the strong vesicorectal ligament that runs between the horns of a bicornate uterus. If the placenta is at- tached to the septum, alarming hemorrhage may occur from im- perfect contraction of the sparsely supplied muscular fibers in it. Malpresentations of the fetus and a faulty direction and insuffi- cient power of the expulsive force are common. Rupture of the uterus is to be feared on account of the ill-developed uterine walls. Laceration of the septum frequently occurs. It has been noted that a decidual membrane may be retained within the non-pregnant half of the uterus, where, undergoing putrefaction after delivery, it may give rise to septic infection. There seems also to be a disposition AA'O.U.I/./ES IX THE FORCES OE LABOR. 563 to the retention of membranes in the pregniint side of the womb. Retention of the placenta is not uncommon, partly because of insufficient cxpulsiv^e force, partly on account of its situation, — perhaps attached in both di\'isions of the uterine cavity. The- vard^ reports the retention of the placenta in a double uterus for fifty days, when it was spontaneously discharged. It has hap- pened, in cases of double uterus and vagina, that the physician ex- amined the wrong side, and was ignorant of the progress of labor until the child was about to be born ; also that he examined first one side and then the other, finding first a dilated and then a contracted external os. In one woman with a double uterus there was noted a dis- position to become pregnant in regular alternation first on one side and then upon the other.- It is said that ovulation in these cases occurs in one ovary one month; in the other, the next.^ Prognosis. — In Kehrer's statistics of 84 cases, in 79 per cent, of which the impregnated horn did not communicate directly with the lower genital canal, the mortaHty was 47 per cent. Treatment. — In complete duplicity of the uterine body. Ces- arean section is indicated, if the child does not readily engage in the pehds.'* Closure and Contraction of the Cervix. — The cervix may ob- struct labor by reason of atresia, cicatricial infiltration, contrac- tion, and rigidity, or there may be longitudinal or transverse septa in the canal. According to Seitz,^ 65 per cent, of fetal deaths in labor are due to the resistance of the maternal soft parts, usually the cervix. Atresia of the cervix in a pregnant woman is acquired after impregnation (conghitinatio orificii uteri externi); it is rarely, however, complete. There is always an indication at least of the external os in a dimple evident to the sense of sight if not to that of touch. By pressing upon this point with a finger- nail or with the tip of a uterine sound, a small artificial opening may be made. Directly this is secured, the dilatation of the ex- ternal OS proceeds in a remarkably rapid manner, although hours of vigorous labor-pains before had been insufficient to begin it. If this plan fails, a crucial incision must be made in the cervical ^ " Nouvelles Archives d'Obstetrique et cle Gynecologic," iSqo, p. 640. ^ Southermann, " Berliner med. Wochen.," 1870, 41. ^ Guerin-\'almale. " De revolution de la puerperalite dans Tuterus dideiphe," " L'Obstetrique," May, 1904. ■* Mosher, "Weekly Bulletin Jackson Co. Med. Soc." (Missouri), March 10, 191 1 ; Winckel's " Handbuch," vol. ii^ ^ " Arch. f. Gyn.," Bd, xc, p. i, based on 26,000 births in ^lunich. 5^4 PATHOLOGY. tissues at the site of the external os. The dilatation of the small opening thus made is then left to nature. If hemorrhage follows the incisions, the bleeding points should be secured by sutures after the conclusion of labor. An active treatment is always called for. Without it the uterus may rupture, the vaginal portion of the cer\-ix may be torn off from the womb, or the head may emerge completely covered by the enormously distended cervix as by a caul.^ Cicatri- cial contraction or injiltration of the cervix is the result of old, unre- paired tears, of operations upon the cervix, of cauterization, of s}T3hihs, or of cancer. In the first instance the resistance to dilata- tion is scarcely ever great, and what there is may be almost always overcome by hydrostatic dilators, by the application of the forceps and forcible delivery of the head through the cerv'ical canal, or by the performance of version followed by rapid extraction. If the cicatrices are of syphilitic or of cancerous origin, the obstruc- tion is more serious. It may be overcome by radiating incisions with scissors or with a probe-pointed bistoury, but it is not un- likely to demand the performance of abdominal or vaginal Cesa- rean section. Rigidity of the cervix is seen normally in all primiparae, and to an exaggerated degree in elderly primiparae. It yields often to copious douches of warm water directed against the anterior wall of the cervix and frequently repeated — as often as once every fifteen minutes if necessar}'. Chloral internal!}- and bella- donna ointment applied directly to the cen'ix have been recom- mended, but these remedies are not to be depended upon except in the slight rigidity characteristic of all primiparae. If there is delay in such cases, fifteen grains of chloral everj^ fifteen minutes for three doses may advantageously be given. An anesthetic, after all, is the most valuable medicinal agent that we possess for the relaxation of this as well as of other rigid tissues. The rigid cervix yields at length to the steady pressure of the presenting part, and it is rarely necessary on account of rigidity alone to resort to artificial dilatation or to incisions. If interference is demanded, the bag devised by the author is eijicient (p. 791). In the course of a slow dilatation of the cervical canal and external OS the anterior lip may become incarcerated between the head and the pel\dc walls. In consequence of the pressure and the disturbance of circulation in the part the cer\dcal tissues rapidly become edematous, and the bulk of the anterior lip prevents the descent of the head. It is usually possible in such cases to push up the anterior lip over the head and above the symph}-sis in the intervals between the pains. If 1 Jeutzen, " Archives de Toxicologic," Paris, 1890, H. 8. ANOMALIES IN TIIK lOKCES OF LABOR. 565 there is hypertropliy of tlic anterior lip in consequence of an old laceration and eversion, or, all the more, should there be hyper- trophy of the whole infravaginal portion of the cervix, the ob- struction may become quite serious, and it may be impossible to push the cervix above the head. In such cases forcible traction on the forceps or radiating incisions in the cervix may be necessary. Longitudinal septa in the cervical canal are usually seen with duplicity of the uterine cavity from failure of the Miillerian ducts to fuse completely. Occasionally the lack of fusion is confined to the cervical canal alone {iitcnis biforis). Rarely, transverse septa have been found in the cervical canal. ^ It may be neces- sary to cut them before the child can pass into the vagina. Fig. 447. — Double vagina. Closure and Contraction of the Vagina or Vulva. — There may be obstruction of the lower birth-canal by longitudinal and trans- verse septa, by cicatrices, by hematomata, by partial atresia, either congenital or acquired, by unruptured hymen, b}' anus vaginalis, by vaginal tumors and cysts, by cystic and solid 1 Cases are reported by Miiller, Brei.sky, Budin, Henry, Bidder, and Blanc (Pozzi's "Gynecology," vol. ii, p. 456). 566 PATHOLOGY. tumors of the \ailva, by enlarged carunculae myrtifonnes, by varices, by vaginismus, by congenital narrowness of the vagina and vulva, and by rigidity of the tissues, especially in elderly primiparae. Longitudinal and transverse septa are not ordinarily very dense in structure, and they give way commonly before the advance of the presenting part. If they do not yield, it is easy to cut them in one or more places, the hemorrhage being con- trolled, if necessary, by sutures afterward, or, in the case of trans- verse septa, by a double ligature applied first, the septum being cut between, though there is not much tendency to bleeding even in those as thick as one's linger (Fig. 448). Fig. 448. — Transverse septum of the vagina (Heyderj. Fig. 449. — Anus vestibularis. Dot- ted lines show the limit of mucous membrane ; thickened skin marks the normal site of the anus (Dickinson). Hematoinata. — Hematomata of the parturient tract usually occur at the vaginal orifice, and most often between the birth of twins. They are considered here only as mechanical obstacles to labor. If the blood-tumor is large enough to constitute an obstruction to the escape of the child, its walls must be incised and its contents be turned out, and if hemorrhage follows, it must be checked by a firm tampon, preferably of iodoform gauze, in the cavity of the tumor. Exte7isive cicatrices in the vagina from syphilitic, malignant, or other ulceration, or from former injuries, may be stretched ANOMAT.nCS IX THE FORCES OF LABOR. 567 sufficiently b}- hydrostatic dilators or may be severed b}- multiple incisions, followed by the application of forceps if the head is presenting ; but they may be too dense and extensive to yield to these measures, and a Cesarean section may be required. Unruptured Hymen. — An unruptured hymen is not neces- sarily a bar to conception. There are a number of cases on record in which a persistent hymen with a small orifice has ob- structed to some degree the escape of the child's head in labor. In two cases under the author's notice the advance of the pre- senting part ruptured the hymeneal membrane without diihculty, but it has been found necessary by others to incise it. ^ Atresia of the J^jgina. — The canal may be obstructed by an annular membrane like the hymen. Although Cesarean section has been done for this condition, it is not required. The advance of the presenting part has dilated the narrowed vaginal canal with less difficulty than it experiences in dilating the cervical canal. The author has seen three cases. At the worst, the obstruction should be overcome by digital, instrumental, or hydro- static dilatation. In complete or almost complete acquired atresia of the lower portion of the vagina, in which insemination has taken place by way of a dilated urethra and a vesicovaginal fistula, the imperforate portion of the vagina may be opened by a transverse incision, the rectum and bladder being guarded by a finger in the one and a sound in the other. In a case of acquired stenosis of the vagina in which the canal throughout its whole length was narrowed to a sinus barely admitting a probe, the author was obliged to do a Cesarean section. Aims vaginalis or vestibularis may complicate labor b}' the accumulation of feces in the rectum, due to the unnatural position of the anus (Fig. 449). In one case in which this anomaly was associated with contraction of the vulvar orifice it was necessary to cut the perineal structures upward from the rectum toward the pubis, in order to permit the escape of the child's head. Cystic and Solid Tumors of the Vagina and Jldva, Edema, Elephantiasis, Suppuration, and Gangrene. — In the case of solid tumors excision may be necessar\', by transfixing the pedicle if they have one, and ligating it to prevent hemorrhage, or by an incision of the vaginal wall over them and tiieir enucleation, fol- lowed b}^ the immediate extraction of the child, and the control of hemorrhage by the needle and thread or b\' direct pressure. In a case of elephantiasis vulvae under the author's care there was no difficult)' in labor. The labia were amputated two weeks 1 Ahlfeld, " Zeitschrift f. Geburtshiilfe und Gynakologie," Bd. xxi, p. 160; ibid., Bd. xiv, p. 14. 568 PATHOLOGY. Fig. 450. — Cyst of the right labium majus (author's case). Fig. 451. — Elephantiasis vulva.- ( author' s case). ANOMALIES IN THE EORCES OF LABOR. 569 afterward. In the case of larf^e cystic tumors a puncture is sufficient to remove the obstruction. Guder' collected 60 cases of vaginal tumors complicating labor — 23 cysts and echinococcus sacs; 18 fibroids, fibromyomata, and polypi; 14 carcinomata, i sarcoma, and 4 hematomata. Delivery was accomplished by the following diverse methods: Spontaneously, 14; by forceps, 18; by version and extraction, 2 ; by traction on the feet, i ; by removal or puncture of the tumor, i6; by Cesarean section, 7; by induc- tion of premature labor and craniotomy, 2; by premature labor, 3 ; by laparo-elytrotomy, i ; by craniotomy i ; by pushing back the tumor and extracting the child past it, 2. Among the mothers there were 15 deaths; among the children, 13. In 1 1 of the mothers and in 22 of the children the result was not reported. Edema of the vulva may be the result of kidney insufficiency Fig. 452. — Edema and beginning gangrene of the vulva from prolonged pressure in an obstructed labor. Cesarean section (author's case). or of pressure in a prolonged labor. The increased bulk of the dropsical labia may interfere with the escape of the presenting part, or, what is more likely, the edematous tissues lose their elasticity, obstruct labor by their rigidity, and are prone to deep tears at the time of birth and to gangrene afterward. Punctures or incisions in the labia may be necessary to escape more serious injur}', but it is well to avoid them if possible, for they are apt to be followed by infection and gangrene. i"Ueber Geschwiilste der Vagina als Schwangerschaft und Geburtskompli- katicnen," " Diss.-Inaug.," Bern, 1889. 570 PATHOLOGY. An abscess of Bartholin's gland is seldom large enough to retard labor, though it has done so (Miiller), but it is likely to cause trouble afterward. It should be opened freely in the early part of the first stage of labor, curetted, swabbed out with car- bolic acid and glycerin, and packed with iodoform gauze, or, better, completely exsected by a deep dissection. Gangrene of the vulva is very rare before the termination of labor. Should it exist, it might determine an operator in favor of Cesarean section in a doubtful case, on account of the rigidity of the vulvar tissues, the certainty of laceration, and the likeli- hood of grave infection. Enlarged Carimculce Myrtifornies and Varicose Veins. — These tumors do not possess sufficient bulk, as a rule, seriously to ob- struct the last stage of labor. They may, however, be so bruised by the passage of the head as to slough afterward, or the veins in them may be ruptured, giving rise to subcutaneous or frank bleed- ing of an alarming character. Vaginismus may be overcome by an anesthetic. Congenital naj'-rozvness of the vagina and vulva is usually overcome by the advance of the presenting part, though often at the ex- pense of vaginal and perineal lacerations. It may be neces- sary to resort to hydrostatic dilatation, or even, in rare in- stances, to Diihrssen's plan of multiple incisions. In the case of extreme narrowness of the vulva there may be a central tear of the perineum, through which the presenting part begins to emerge. To avoid a rectal tear in such a case the perineum should be cut from the anterior border of the perforation to the posterior commissure of the vulva (Fig- 453)- Rigidity of the tissues in the cervix, the vaginal wall, and at the outlet occasions delay in the majority of all primiparse, but especially in the case of elderly primiparse — those over thirty years of age. Eckhard found the infantile mortality in such cases to be 19.81 per cent., the maternal mortality to be three times as great as in younger primiparae ; and the necessity for operative interference increases steadily with the age of the primiparae until, Fig. 453. — Central tear in the perineum, with contracted vulvar ori- fice (Ribemont-Dessaignes). ANOMALIES IN 7IIE FORCES OF L.MWR. 57 1 in those past forty, almost two-thirds arc cieHvcrcd by some operative procedure, usually forceps. Craniotomy should be done if the child is dead. Version is the least successful opera- tion in these cases. A cystocele and a rectocele should be replaced if they protrude to a great extent in front of the head, and should be held back until a forceps is applied and the head is pulled past them. Version and extraction have occasionally been found necessary. Large fecal masses in the rectum must be re- moved by an enema or must be dug out.^ Calculi in the blad- der should, if possible, be discovered and removed by the urethra or by vaginal lithotomy before the second stage of labor. They may become nipped between the head and the pubic bones, and may pinch a hole through the anterior vaginal wall and bladder if they are overlooked or neglected.^ The diagnosis of vesical calculus in the parturient woman is difficult : it has been taken for a pelvic exostosis or some other pelvic tumor, and in one case at least Cesarean section was performed on account of this mistake. Fortunately, vesical calculus in the female is rare. In 10,000 women examined by Winckel in fifteen years, it was found only once. A large papilloma of the bladder may obstruct labor. The bladder should be pushed up above the symphysis if pos- sible and the child extracted with forceps.^ The following conditions in and about the rectum may pre- sent mechanical obstacles to delivery : Cancer, anus vestibularis or vag-inalis, foreign bodies, contraction of the levator ani mus- cles, benignant tumors, such as cysts of the rectum, ovarian cysts which have perforated the rectum, and retrorectal dermoid cysts. Each of these conditions must be treated according to the indi- vidual indications. Incisions in the perineum may be required, foreign bodies must be removed, resisting muscles on the pelvic floor may be overcome by an anesthetic and by the application of forceps, and cystic tumors should be punctured or removed after ligation of their pedicles. Cancer of the rectum may de- mand Cesarean section by reason of the size of the tumor and the cicatricial infiltration of the birth-canal, as in Freund's case. 1 Corradi reports a case in which seven pounds of hardened feces were removed before the woman was delivered. - Kotschurowa has reported a case in which labor lasted three days. At the end of that time a gangrenous tumor protruded from the vulva, which proved to be the bladder and anterior vaginal wall. The midwife in attendance perforated the tumor with her finger, whereupon a calculus eighty-five grains in weight was discharged (" Jahresbericht ii. d. Fortschr. a. d. Gebiete der Geburtsh.," etc., vi, 225). ' H. Freund, " Miiench. med. Wochenschr.," No. 21, 1909. 572 PATHOLOGY. Obstruction in Labor on the Part of the Fetus. — Over- growth of the Fetus. — Excessive overgrowth of the fetus is rare. In looo children in the Maternity Hospital of Philadelphia only one weighed more than 12 pounds. The largest child the author has ever seen weighed 15 pounds; weights of 15, 16, 18, 23^, and 28f pounds have been recorded. The causes of overgrowth in the fetus are prolongation of pregnancy, over- size and ad- vanced age of one or both par- ents, and multi- parity. Rarely, it may be inex- plicable. The first named is, in the writer's experience, the most common cause. In six per cent, of women pregnancy may be expected to be prolonged be- yond the three- hundredth day, and for every day that the fetus is retained in the womb beyond the usual time there is an increase in its size and weight above the normal. So much difficulty and danger may be experienced from this cause that it is a good rule in practice to allow no woman to exceed the normal duration of pregnancy by more than two weeks. By inducing labor at that time one occasionally interferes unnecessarily, but he often avoids complications and difficulties of the most serious nature. Oversize and advanced age of one or both parents may be a cause of overgrowth in the fetus — the latter usually because it predisposes to a prolongation of pregnancy. It is commonly asserted that the size of children increases in successive pregnan- cies up to the fourth or fifth, and then remains stationary or even decreases; but there are important exceptions to this rule. The- Fig. 454. — Overgrowth of head obstructing labor. ANOMALIES IN THE FORCES OF LABOR. :>/ writer has seen the tenth child vastly exceed in size the nine pre- ceding ; it weighed 15 pounds, and it was necessary to dehver it by Cesarean section. The other children had been born natu- rally through a flat pelvis with a conjugate diameter of nine centi- Fig. 455. — Dicephalus. Fig. 458. — Dicephalus. Fig. 456. — ^Lymphangioma. Fig. 457. — Craniopagus. Fig. 459. — Ischiopagus parasiticus. meters. The increase in size of successive children must be borne in mind in cases of contracted pelvis. The first two or three infants may be delivered spontaneously, but the larger size of the fourth or fifth may make natural delivery impossible. ^ Overgrowth of the fetus is the most dif^cult condition in obstetric practice to diagnosticate with precision. A careful pal- pation of the head and body and an attempt to push the former ^ Lehmann in 712 labors through 198 contracted pelves found increasing diffi- culty in delivery with each succeeding labor. In first labors 50 per cent, ended spon- taneously ; in second, 43. 8 ; in fourth, 38. 4 ; in fifth, :iy/^ ; and in labors after the fifth only 9.8 per cent. ("Diss. Inaug.," Berlin, 1891). 574 PATHOLOGY. Fig. 460. — Prosopothoracopagus. Fig. 461. — Xiphopagus. Fig. 462. — Janiceps. Fig. 463. — Dicephalus : neither head engaged. into the pelvic inlet may give one an approximate idea of the relative size of fetal body and pelvic canal, and the methods of antepartum fetometry already described may enable the physician ANOMALfES IN THE EORCES OE LABOR. Fig. 464. — Hydrencephalocele (anterior). Fig. 465. — Sacral teratoma obstructing labor. 576 PATHOLOGY. to estimate the size of the fetal head accurately, but, as a matter of fact, the large size of the fetus is usually discovered in prac- tice only after prolonged delay when attempts at artificial delivery especially by version, have failed. By this time the fetus is com- monly dead, and should be delivered by embryotomy. But the practitioner must be on his guard against futile attempts to de- liver an infant too large, even when mutilated, to pass through the pelvis. The writer has seen, in consultation practice, several maternal deaths due to this cause. Premature Ossification of Cranium ; Wormian Bones ; ^ Large Heads ; Malformations and Tumors of the Fetus. — No single rule Fig. 466. — Myxoma of neck (Longaker). Fig. 467. — Sacral tumor (Miitter Museum, College of Physicians). of treatment can be laid down for the management of these cases. Forceps, version, or some form of embryotomy is usually de- manded. Spontaneous labor, however, is possible even in cases of monstrous bulk in which delivery through the birth-canal would seem out of the question. Thus, in double monsters joined loosely by the front or back (xiphopagus, the Siamese twins; pygopagus, the Hungarian sisters), one child may be born by the head, the other afterward by the breech, or vice versa. In dicephali one head may be pressed into the neck of the other or may rest upon the iliac bone of the mother until the first head makes its escape from the vulva. Even in thoracopagus, the commonest double monstrosity, in which two trunks are inti- mately joined front to front, spontaneous labor is possible by the mechanism shown in figure 470. On the other hand, the 1 Dr. Grace Peckam ("New York Med. Record," April 14, 1888) has reported three still-births, attributed in each instance to the development of Wormian bones in the smaller fontanel, and to the consequent interference with overlapping of the cra- nial bones at the sutures. This observation has not yet been verified by others. ANOMALIES IN THE FORCES OF LABOR. S77 greatest difficully may be encountered in labor, and a Cesarean section may be necessary.^ Fig. 468. — Anasarca. Fig. 469. — Mechanism of labor with dicephahis (Kiistner). Fig. 470. — Mechanism of labor in thora- copagus (Kiistner). Fetal tumors obstructing delivery may be hydrencephaloceles, lymphangiomata, myxomata, sacral teratomata. Cystic tumors should be punctured. Solid tumors may call for version or for 'There are two recorded deliveries of thoracopagi by Cesarean section (Hirst and Piersol, " Human Monstrosities"). 37 5/8 PATHOLOGY. embryotomy. In a case of sacral teratoma, the child presenting by the umbilicus, the author found it necessary to eviscerate the infant before it could be extracted. The tumor has been ampu- tated, embryotomy and version have been performed. The tumor not infrequently ruptures and often the labor is easy because the fetus is premature.^ Craniotomy may be required in monstrous enlargement of the cephalic extremity, as in syncephalus or in diprosopus. Decapitation may be necessary in duplicity of the cephalic extremity, as in dicephalus or in thoracopagus. In Reina's case of tricephalus the first head v^^as perforated and then amputated, the second was perforated, crushed, and amputated, and the third was amputated. Diseases and Deatli of the Fetus. — All diseases of the fetus that increase its bulk may obstruct labor. Cystic tumors, effu- sions in the serous cavities, anasarca, an enlarged liver, polycystic disease of the kidneys,^ and distended bladder from atresia of the urethra ' are examples. Liquid accumulations should be evacuated by puncture or by incisions. In polycystic disease of the kidneys one kidney at least must be morcellated and removed. The fetus usually presents by the breech. If it presents by the head, decapitation, section of the chest, and evisceration may be necessary. Hydrocephalus is the most important of the diseases increasing fetal bulk. It is not very rare,* is often overlooked, and is a frequent cause of ruptured uterus. The diagnosis may be made by a vaginal examination, by abdominal palpation, and by a com- bined examination, or, if necessary, by anesthetizing the woman, introducing the whole hand into the vagina, and thoroughly palpating the enlarged head resting above the pelvic brim. The gaping fontanel, the great width of the sutures, the fluctua- tion within the cranium, the large size of the head appreciated by bimanual examination, and possibly the abnormal mobility of the cranial bones, and in some cases their extreme tenuity, indicate 1 For interesting statistics of this condition see Uthmoller, " Ueber Geburten bei Steisstumoren," " Monatschr. f. Geb. u. Gyn.," Dec, 1903. Of the collected cases 126 have been girls, 60 boys. The frequency is reckoned at 1-34, 582 births. 2 Fussell, "Med. News," Philadelphia, 1891, p. 40. ^Schwyzer (" Archiv f. Gyn.," Bd. xliii) has collected 13 cases of dilatation of the fetal bladder from atresia of the urethra, stenosis of the urethra, and obstruc- tion of the urethra by a valve-like formation of mucous membrane. Miiller reports a case and quotes another (" Archiv f. Gyn.," Bd. xlvii, H. i). Lynch collected 38 cases of polycystic disease of the kidneys. Freund reported one in igo8, the author one in 1911, " Surgery, Gyn., and Obstet.," 1906; " Zentralbl. f. Gyn.," No. 20, 1908; " Tr. Philada. Obstet. Soc," 1911. ^ Schuchard found it sixteen times in 12,055 births; Lachapelle and Duges, fifteen times in 43,555; Merriman, once in 900. In 159 cases there were 38 mater- nal deaths, 20 of which were from rupture of the uterus. ANOMALIES IN THE FORCES OF LABOR. 579 the condition. Hydrocephalus is very often overlooked in practice as the result usually of a careless, superficial examination. A painstaking and methodical investigation of a suspected case should obviate this error. There are cases, however, in which there is no increased width of the sutures, no enlargement of the fon- tanels, and such slight enlargement of the head that it can not be appreciated; and yet the fluid contents of the cranium pre- vent compression of the skull and make the engagement of the Fig. 471. — Polycystic disease of the fetal kidneys. The legs of the fetus were pulled off; the abdominal cavity was opened with scissors; the right kidney was morcellated and removed piecemeal (author's case). head impossible. The writer has seen such cases (see Fig. 472). Hydrocephalus should always be suspected if the head in labor remains above the brim, although the pelvis is normal in size and no good reason can be found for the failure of engagement. 58o PATHOLOGY. The treatment of labor obstructed by hydrocephalus is punc- ture of the cranium with a perforator and evacuation of its fluid contents. A child with this disease deserves no consideration. After the reduction in the size of the head the labor may be left to the natural forces. If these prove insufficient, a cranioclast may be fastened to the skull and the child be extracted artificially. A cardinal rule in the treatment of these cases is to avoid at- tempts to deliver with forceps — a common error in practice, and one that has cost many a woman her life from ruptured uterus, ^^^■P^pm^ ■■ > ^^^^B m ^ 1 ^^H. V.,r~<*^H :" *-> Fig. 472. — Hydrocephalus: very ■moderate distention of the cranium, but sufficient to prove an insuperable ob- stacle in labor. / Fig. 473. — Hydrocephalus: enormous collection of fluid (author's collection : specimen presented by Dr. Alex. Fulton). from deep tears when the instrument slips, as it will, and from extensive sloughs after delivery. If the pelvic extremity of the hydrocephalic fetus presents, — as it does in almost a third of all cases, — and if the head remains inaccessible above the superior strait, so that it can not easily be punctured, the spinal canal may be opened, a catheter be passed through it into the cranial cavity (Van Huevel's method), and the fluid thus be evacuated (Fig. 474). Usually, however, there is no special difficulty or danger in the delivery of the after- ANOMALIES IN THE EORCES OF LABOR. 581 coming head of a hydrocephalic infant. The force required for its extraction not infrequently ruptures the walls of the ventricles and converts the case into one of external hydrocephalus, or possibly drives the fluid out of the foramen magnum into the tissues of the neck and back, so reducing the bulk of the head as to permit its extraction. At any rate, the condition can Fig- 474- — Tapping a hydrocephalus through the spinal canal (Varnier). scarcely escape the notice of the medical attendant, and a diag- nosis is made before the lower uterine segment is dangerously stretched or ruptured. The head may be punctured through the roof of the mouth, through the foramen magnum, or behind the ear. The difficulty in the delivery of a hydrocephalic fetus is not in direct proportion to the quantity of fluid in the ventricles and 582 PATHOLOGY. the size of the head. In cases of extreme distention, the cranial vault is hkely to rupture, while in moderate grades of hydro- cephalus the quantity of brain-substance surrounding the ven- tricles and the strength of the brain-membranes forbid this means of spontaneous delivery. Malpresentations and faulty positions include shoulder, face, brow, deviated vertex, and compound presentations. All but Fig. 475. — Compound presentation : head and hand. Braun"s section of a multipara who committed suicide by hanging in the last month of pregnancy : a. Venous sinuses ; b, uterovesical reflection of peritoneum ; c, symphysis pubis ; d, bladder ; e, vagina ; /", first lumbar vertebra ; g, promontory of sacrum ; h, rectum ; i, cervix ; j, pouch of Douglas. the last are considered elsewhere. By compound presentation is meant the presentation of two or more parts at the same time, as a head and a hand, a head and a foot, a hand and a foot, ANOMAL/KS JX Tl/E !■ URGES OF LAJWR. 583 nuchal position of the arm, or the head and all four extrem- ities. A compound j^resentation is met with aljout once in 250 labors. It is usually a head and a hand. The following table is furnished by Pernice from 2891 births in the clinic at Halle : Hand and head, 26 Arm and head, 8 Hand and unibihcal cord, 5 Both hands, 4 Foot and hand, 2 Two liands, umbilical cord, and foot, I Face, hand, and cord, i Kietz found in 7555 labors the foot and head presenting in 23,^ The cause of compound presentations is usually a lack of Fig. 476. — Compound presentation : head and foot (author's case). conformity in the presenting part with the pelvic inlet, as in mal- position of the fetus, a head of abnormal size, a displaced uterus, twins, hydramnios, contracted pelvis, and anomalous shape of the uterus. In the treatment of compound presentations before rupture of the membranes an attempt should be made to overcome the difficulty by postural treatment. The woman should be placed on that side opposite the prolapsed extremity. After rupture of 1 "Diss. Inaug.," Berlin, 1890. 584 PATHOLOGY. the membranes an attempt should be made to dislodge the pro- lapsed extremity and to restore it to its natural position. \"'ersion may, however, be required if this attempt fails, or even crani- otomy if the child is dead. If the head and extremities present, and if the former is engaged, it is usually best to apply forceps and to disregard the prolapsed extremities. In the case of nuchal position of the arm, an effort should be made to dislodge the latter, but it may be necessar}' to fracture it before the delivery of the child can be secured. Fig. 477. — Twins ; breech and face presentations. Multiple Births. — Twin labors are usually easy and uncom- plicated (75 per cent.j, but complications are more frequent than in single labors. ]\Ialpresentations are common. The following table from Spiegelberg, based on 1138 labors, gives the combined presentations in the order of their frequency : Both heads presenting, 49 per cent. Head and breech, 31.70 Both pelvic presentations 8.60 Head and transverse, 6. 18 Breech and transverse, 4-14 Both transverse, 35 ANOMALIES IN THE FORCES OF lABOR 585 It may be noted that a transverse position is found in 10.67 per cent, of cases. Mechanical difficulties in labor are frequent : the uterine muscle is usually weakened by ovenstretching, and there may be trouble in the third stage of labor in the delivery of the placenta. Some form of operative interference is demanded in about 25 per cent, of all cases. Fig. 478.— Impaction of heads in twin labor. Fig. 479. — Locking of heads in twin labor. In the majority of cases (79 per cent.) the interval between the delivery of twins is less than an hour.^ A longer delay than this indicates the likelihood of some obstruction to the birth of the second infant or a failure of expulsive forces. 1 In the " Semaine Med.," 1904, ii, 27, Paulin reports an interval of twenty-one days between the birth of twins. It was subsequently discovered that there was a uterus bicornis unicollis. This is probably the explanation of the cases occasionally reported of the birth of children weeks and even months apart. :86 PATHOLOGY. Serious difficulty in twin labors may arise in one of three wavs: Both heads present at once, one a little in advance of the other, the second impacted in the neck of the first (Fig. 478^ ; the first child descends by the breech, and the head of the second child is caught by the chin of the first and pushed into the pelvis (Fig. 479) ; one child sits astride of the other, which is transverse. If both children should be found attempting to engage by the head in the superior strait at one time, one child should be retarded while the other is artificially extracted. If this is impossible, the first head should be extracted by forceps, the second be treated in like manner, and then the trunks should be delivered one after the other. Embrj'-otomy is a last resort, but is scarcely ever necessar}-. A coiling of the cords (Fig. 480) and their entanglement may be a source of difficult}^ and delay in unioval twins. It ma}' be necessary to cut one or both cords between ligatures before the children can be delivered. In case one child presents by the head and the other by the feet, both ma}' come down together, and the two heads become locked in the pel- vic entrance and canal. An effort ma}' be made to push back the child presenting b}' the head. If this svyz- ceeds, the child presenting b}' the breech should be extracted immedi- atel}', for it is in imminent danger from asph}'xia. It ma}' be possible with' force.ps to pull the child pre- senting b}' the head past the bod}' of its fellow presenting b}" the breech. Failing in these attempts, the child presenting by the breech will almost surel}' have died, and there will be no pulsation in its cord. It should then be decapitated, whereupon the infant presenting b}' the head can be extracted without difficulty by forceps. In any case of twin labor, as soon as the first child is born, and the cord, ligated with a double ligature, is cut, the attendant should immediateh' investigate the position and presentation of the second child. A neglect of this rule leads ver}- often to the impaction of an unrecognized shoulder presentation in the second child, and its consequent death. If an abnormality is discovered in the presentation of the second child, it should at once be cor- / Fig. 480. — Entanglement of cords in twins (Winckel). ANOMAI.IKS IX TJIE J'Oh'CKS OF I.AUUR. 587 rected. Then, after waiting perhaps half an hour, the amniotic sac should be ruptured, and ergot should be administered in a full dose to secure a speedy delivery, or, if the stomach will not retain it, ergotin should be given hyjjodermically, for, the birth-canal having been dilated thoroughly, there is no obstacle to the birth of the second infant in twin labors, and consecjuently no objection to the employment of ergot, which not only hastens the con- clusion of labor, but promotes subsequent contraction of the much-distended uterus, and so prevents postpartum hemorrhage. As a further precaution against this accident which is always Fig. 481. — Twins, head and breech (modified from Hunter) threatened in twin labors, the fundus should be kneaded and compressed by the nurse for an hour or two after birth. There may be difficulty in the deH\ ery of the placentae in twin labors. Commonly the children are born first and the placentae afterward. Their bulk may make expression difficult, and it is often necessary to make some traction upon the cords — first upon 588 PATHOLOGY. one and then upon the other — to determine which placenta will come first and to assist in its expulsion. Occasionally one and rarely both placentae may be expelled after the birth of the first child. In a case of the writer's the placenta of the first child, prolapsing in front of the second, necessitated a difficult forceps operation for the extraction of the second. On account of the frequent and extensive anastomoses between the vessels of the placentae in unioval twins it is a necessary precaution to tie the cord of the first child with a double ligature and to cut it between the ligatures ; otherwise the second infant might bleed to death. The prognosis of twin labors is always doubtful. There are so many possible dangers for both mother and children that multiple labors must be regarded as distinctly pathological. Albuminuria in the mother is the rule in multiple pregnancies, and eclampsia is ten times more frequent than in single births. ^ There is a disposition to inertia uteri during and after birth from distention of the cavity, and consequently a likelihood of post- partum hemorrhage. Some operative interference or intra- uterine manipulation is called for in about twenty-five per cent, of cases, and this, in addition to the frequency of kidney insuf- ficiency, predisposes to sepsis. Finally, there may be insuperable obstruction in labor if locked twins are not managed properly, and the woman may die of ruptured uterus or of exhaustion. The maternal mortality in the Budapest Maternity was four times as great as in the single births, and Kleinwachter's statis- tics give a mortality of thirteen per cent. For the children there is greater danger than for the mother. Twin pregnancy is almost always prematurely interrupted, and even if it is not the children are, as a rule, under the normal size and weight. There is always the possibility that the development of one child at least will be seriously interfered with by the lack of room in the uterine cavity. Hydramnios of one sac and oligohydramnios of the other are not uncommon. In labor there are frequently complications from malposition, operative interference, entangle- ment of or pressure upon the cords, and more rarely the engage- ment of both bodies at once in the pelvic canal. In Klein- wachter's and Kezmarszky's statistics the fetal mortality was nearly forty per cent. Of thirty-eight children in cases of locked twins, only six survived, — a mortality of eighty -four per cent. Cases are on record in which an extra-uterine fetus has obstructed the delivery of the intra-uterine twin. It has been necessary to make a vaginal incision through which the former was extracted before the latter could be born. Death of the fetus during or before labor, followed by rigor 1 Of 627 cases of eclampsia, 69 were multiple pregnancies (Winckel). ANOMAIJES I.V TME FORCES OF LABOR. 589 mortis, has proven a source of obstruction in labor by the rif^idity of the child and the consequent interference with the normal mechanism of its delivery, especially of the shoulders and trunk. ^ Ankylosis of the large joints of the extremities may have the same effect to a less degree. Labor Complicated by Abnormalities in the Fetal Appendages. — Menibra)ics. — If the membranes are too thin, they may rupture prematurely, and thus give rise to what is called a " dry labor," in which the birth-canal must be dilated by the hard, unyielding presenting part instead of hy the bag of waters. Such labors are longer and more painful than the average, and there is a greater likelihood of lacerations in the cervix and a more frequent demand for an artificial termination with forceps. If the membranes are too thick, they rupture late, being preserved perhaps until the child's head presents at the vulvar orifice, or even until the complete escape of the head from the mother's body. In these cases the head and face are covered by the membranes as though by a veil, and care must be taken to free the mouth and nose quickly, that respiration may be instituted without interference. The mem- branes thus covering the head and face are spoken of as a " caul." It is possible for the whole ovum to be extruded unbroken at term. The writer has seen this occur as late as the seventh month, and it is actually recorded at the full period of gestation. Difficulties in labor may be encountered in consequence of an abnormality in the quantity of liquor amnii. If there is too little, the labor has the same clinical features as though there had been a premature rupture of the membranes. If there is too much liquor amnii, there may be inertia as the result of overstretching of the uterine muscle-fibers. Umbilical Cord. — If the umbilical cord is too short, it may cause premature detachment of the placenta or may prevent the advance of the child. The diagnosis of a short cord in labor is always difficult. It may be suspected, however, if there is exaggerated pain at the placental site, marked recession of the head after each pain, and an obvious retardation of labor without other ascertainable cause. Forceps should be applied in such a case if the presentation is cephalic. If the cord is too long, it may possibly prolapse should there be other conditions in the labor favorable to such an accident ; or it may be coiled about the child's neck, trunk, or extremities, and may consequently be fatally compressed during labor (Fig. 482). Obstruction of a mechanical character in labor on the part of the placenta is seen only in placenta prge\'ia and in prolapse of the placenta. The placenta may be adherent as the result of syphil- ^ Feis, " Ueber intrauterine Leichenstarre," *'Archiv fiir Gynakologie," Bd. xlvi, H. 2. 590 PATHOLOGY. itic or other inflammation of the endometrium during pregnancy, and, becoming partially detached in the third stage, may cause alarming hemorrhage. It is often simply retained in the lo^Yer Fig. 482. — Placenta prssvia : umbilical cord, caught in the axilla, encircling the shoulder and prolapsed (Hunter). uterine segment or in the vagina, whence it may be expressed by the proper application of Crede's method. In some cases atmospheric pressure obstructs the delivery of a retained placenta so effectually that it is necessary to hook one's finger over the edge of it, to allow the access of air behind it, before its expression is possible. Retention of the placenta may be due to its great bulk, as in twin placentae, or to tumors increasing its size. In such cases it may be necessary to extract the placenta manually. LABOR COMPLICAl-JiD BY ACCIDENTS AND DISEASES. 59I LABOR COMPLICATED BY ACCIDENTS AND DISEASES. Hemorrhage. — One of the gravest and, unfortunately, one of the commonest accidents during and directly after labor is hemor- rhage. The causes of hemorrhage during the first and second stages of labor are placenta praevia, premature separation of a normally situated placenta, rupture of the uterus, lacerations along the lower birth-canal, and rupture of a blood-vessel or of a hematoma. The causes of hemorrhage during the third stage of labor and directly afterward are relaxation of the uterus, lacera- tions of the birth-canal, rupture of blood-vessels or of hema- tomata. Placenta Praevia. — By placenta praevia is meant the attach- ment of the placenta to the lower uterine segment. In some varieties of the condition the placenta presents itself first to the examining finger, and may even emerge before or in front of the child ; hence the name. History. — Early writers (Guillemau and Mauriceau, 1609— 1668) recognized placenta prjevia, but they explained it as an accidental prolapse of the placenta. Portal (1685) described it more correctly, though indistinctly. Schaller (1709) demon- strated the condition in the dissection of a body. From Levret's time placenta praevia was well understood. Rigby (1789) defines it as the attachment of the placenta to that part of the womb which always dilates as labor advances — a definition that is strictly accurate to-day. It is to Rigby, too, that we owe the term "unavoidable hemorrhage " to describe the hemorrhage of placenta praevia, as opposed to the "accidental hemorrhage" from premature detachment of a normally situated placenta. Frequency. — Placenta praevia varies in the frequency of its occurrence in different localities and at different times, as the following table demonstrates : Cases of Number of Placenta Reporter. Labors. Pr.«;via. Proportion. C. V. Braun 7,853 15 1-522 Hugenberger 8.036 42 i-ioi Lomer 6,862 136 1-50 Winckel (1873-78) 6,324 7 1-Q03 Winckel (1879-S7) 8,500 30 1-283 Miiller 876,432 813 1-1078 Lusk 1 ,550 o 0-0 Schwarz. 510,3^8 2,^,2 1-1564 Midwives' report in Saxony (187S). . . . 119.553 78 1-1532 E. B. Cragin 25,000 223 1-112 Total 1,579,438 1676 1-942 The frequency of placenta praevia may be estimated at about I in 1200 labors. If the situation of the placenta were investi- 592 PATHOLOGY. gated by a careful examination of the rent in the membranes after every labor, placenta praevia would be found quite fre- Fig. 483. — Central placenta praevia, the os partly dilated (Hunter). quently. In my experience it has occurred about once in 300 labors ; but in only a quarter of the cases was the condition manifested before and during labor by its most characteristic symptom, hemorrhage. Etiology. — A perfectly satisfactory explanation for the occur- rence of placenta praevia has not yet been found. Clinical ob- servation shows that any chronic inflammation or congestion of LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 593 the womb predisposes to it. Hence placenta praevia is three to six times more common in multiparas than in primiparae, and is more often met with in the working classes. Uterine myomata and carcinoma of the cervix are predisposing causes, on account, no doubt, of the endometritis that accompanies them. Ingelby reports two cases of abnormally low situation of the tubal orifices, in one of which placenta prsevia occurred three times ; in the other, ten. Multiple pregnancies, according to Winckel, furnish four times as many cases of placenta praevia as do single preg- nancies, and a woman beginning to bear children late in life is liable to placenta praevia in subsequent pregnancies. Uterine malformations are apparently a predisposing cause. A case is reported by Schwarz of uterus bicornis in which placenta praevia recurred three times. Hofmeier and Kaltenbach^ furnish the best explanation for the abnormal situation of the placenta. These observers have demonstrated, by the examination of young ova, that the chorion villi in the lower pole of the ovum may develop in an hyper- trophied decidua reflexa, thus carrying the placenta down to and across the internal os. At first an adhesion between the decidua vera and the reflexa is prevented by catarrhal discharge, but as the ovum develops the reflexa may adhere to the vera, thus fixing the placenta in its abnormal situation, permitting its con- tinued growth, and giving rise to an apparent hypertrophy of the decidua serotina. Gottschalk's ^ observation of a young ovoim imbedded at the edge of the internal os demonstrates that an abnormally low attachment of the ovum in the uterine cavity may be accountable for placenta praevia. Varieties. — Four divisions are made of cases of placenta praevia — central, partial, marginal, and lateral. In the first the center of the placenta lies over the internal os ; in the second the greater mass of the placenta lies upon one side of the lower uterine segment, usually the right (56:37, Muller), though the internal os is completely covered by it ; in the third a margin of the placenta projects over the internal os ; in the fourth the placenta is situated upon one side of the lower uterine segment and only the edge of it projects into the cervical canal, if it does so at all, when the os is fully dilated. This classification is justified upon clinical grounds. In central and partial placenta praevia the hemorrhage begins early in pregnancy, is profuse and frequently repeated, and in labor is more dangerous than is the hemorrhage of the lateral variety. There is an added difficulty, too, on account of the obstruction offered by the placenta, stretched across the internal os, to the spontaneous descent of the ^ *' Lehrbuch der Geburtshiilfe." 2 " Verhandl. d. deutsch. Gesellsch. f. Gynak.," Bd. vii, 1S97, S. 2S9. 7,8 594 PATHOLOGY. child, or to the physician's efforts to reach and extract it. In lateral placenta praevia hemorrhage usually does not occur till labor is well ad\-anced, and often does not appear at all. Lateral and marginal placenta praevia are the commonest varieties. In 270 cases the placenta was marginal and lateral 217 times , cen- tral and partial 53 times (W'inckelj. Strictly speaking, central placenta prae'via is very rare. There is almost invariably more of the placenta on one side of the internal os. B Fundal. Fig. 484. — Varieties of placenta praevia : in A there are seen the normal, lateral, and marginal implantation ; in B there are represented the implantation of the pla- centa at the fundus, which is rare, and implantation over the internal os ; in C lateral implantation and that of a cotyledon immediatel)' over the internal os ; and in D partial implantation (Dickinson). Clinical History. — A woman with placenta praevia may begin to bleed as early in pregnancy as the second month, but the first hemorrhage usually occurs in the last trimester. There is a sudden gush of blood, often without apparent cause and without pain. The bleeding commonly recurs in increasing amounts and at de- creasing intervals as pregnancy advances. In ver}' rare cases the blood leaks away continuously (stillicidium), though this is more characteristic of the premature separation of a normally situated placenta. The cause of the hemorrhage during preg- nancy is the impact of the embr^-o and fetus upon the placenta, LABOR COMPLICATED BY ACCIDENTS AND DLSEASES. 595 the pressure of the ovum upon the lower uterine segment, and the imperfect attacliment of the placenta in certain areas to the uterine wall. A prediction of the amount of bleeding in labor can not always be made by the amount of blood lost or the fre- quency of the hemorrhages in pregnancy. The first hemorrhage may occur in labor, which may be ushered in by a tremendous outpour of blood, even in lateral placenta praivia. Ordinarily, however, the greater the bleeding during pregnancy, the more likelihood is there of serious hemorrhage in labor. The bleed- ing in labor is easily explained. The placenta is attached in that portion of the uterine cavity which must be dilated to allow the advance of the presenting part. The stretching of the uterine walls expands the area of the placental site, and necessarily de- taches the placenta, while the reversal of the ordinary mechanism of placental detachment keeps the gaping mouths of the torn uteroplacental vessels wide open, and allows the blood to pour from them till the hemorrhage is checked by syncope, by throm- bosis, by the pressure of the presenting part, or by a vaginal tampon. The source of the bleeding in rare cases is a rupture of the circular sinus of the placenta, a laceration of the fetal vessels or of the cervix. The bleeding is usually most profuse just as the uterine con- traction passes off During the height of the pains it may cease altogether, from the pressure of the presenting part or of the intra-uterine contents upon the placental site. As the placenta occupies a portion of the space in the lower uterine segment and may prevent the descent of the presenting part, abnormalities in the presentation and position of the fetus are common. Transverse and oblique positions are ten times, breech presentations four times, more frequent than in normal labors. In the first stage of labor, inertia uteri is common, partly be- cause the cervix is not pressed upon and reflex irritation is absent, partly on account of the loss of blood. The OS is usually patulous, even before labor begins, and the cervical canal is easily dilated. Occasionally, however (twelve per cent.), the os is contracted and the cervix rigid. The insertion of the cord is often marginal or velamentous, and prolapse of the cord is common. The placenta is often anomalous in shape, size, thickness, and weight. There is frequently a placenta succenturiata. As the OS dilates the placenta may be torn and thus separated into two parts. An adherent placenta may be expected in more than a third of the cases (Miiller, thirty-nine per cent.). After labor there is a tendency to inertia, and consequently to postpartum hemorrhage, and there is an extraordinary liability to septic infection. 596 PATHOLOGY. Placenta praevia, as a complication in labor, would be much more common than it is if it did not so often interrupt pregnancy. The frequency of abortion and miscarriage is placed in different statistics at forty to sixty per cent. In quite a large proportion of cases placenta praevia would be unrecognized in labor without a careful examination of the membranes and placenta afterward. Even in the marginal variety the presenting part, unobstructed, may descend quickly, exerting such pressure upon the placental site that bleeding does not occur. Symptoms and Diag?iosis. — Repeated hemorrhages during the latter part of pregnancy make the diagnosis of placenta praevia almost certain. On digital examination the cervix is found enlarged in all directions ; the vaginal vault is soft and bogg\' ; the presenting part can not be plainly felt ; pulsating vessels are detected around the cervix ; the external os is dilated and the cervical canal is patulous to the internal os, through which a finger can easily be pushed. Under favorable conditions the placenta may be felt through the abdominal walls, as was first pointed out by Spencer. Finally the maternal face of the placenta or its margin is felt over the internal os, the uneven surface of the cotyledons and a gritty feel distinguishing it from a blood-clot, the membranes, or the presenting part. During the first stage of labor the causes of hemorrhage are lacerations of the birth-canal, rupture of blood-vessels, and placenta previa. The hemorrhage of placenta praevia occurs early, with unruptured membranes, with feeble pains or in their absence altogether, and the symptoms of uterine rupture and of lacerations along the lower birth-canal are absent. In the rare event of a ruptured blood-vessel along the lower birth-canal, the blood does not flow from the uterine cavity. Treatment. — If a placenta praevia is detected during preg- nancy, gestation should be terminated at the end of the seventh month, or at any time thereafter that the diagnosis is estab- lished. The hemorrhage before the thirty-second week is scarcelv ever dangerous,^ thoug-h in one case I was obliged to induce abortion before the fifth month on account of a loss of blood that was almost incessant. After the seventh month the woman may bleed to death at any time before medical aid can reach her. The induction of labor and its conduct should be as follows : Send for an assistant to administer an anesthetic ; place the woman in the lithotomy position, with her knees sup- ported by nurses or attendants ; cleanse both hands and arms as for a surgical operation and put on sterile rubber gloves; wash the vulva and the vagina with tincture of green soap and hot water ^ In ihe 1 28 deaths of Miiller's statistics there was not one before the seventh month. LABOR COMPLICATED BY ACCIDENTS AND DISEASES. S97 Fijr 48 s —One leg has been drawn down, so that the os is tamponed and the ' placenta directly compressed by the hips of the child (Muller). 598 PATHOLOGY. by means of pledgets of cotton; give a vaginal douche of bichlorid of mercury 1:4000; dilate the cervix by inserting first one finger, then a second, and next the thumb of the right hand; search on the Fig. 486. — Placenta prjevia: vagina tamponed with gauze (Dickinson). v^oman's left side for the edge of the placenta; pass two fingers beyond it; perform bipolar version, assisted by the left hand externally; rupture the membranes; seize a foot and extract it until the knee appears at the vulva; then withdraw the anesthetic. If the bleeding has been alarming up to this time, it will cease as soon as the child's breech is impacted in the pelvic canal. From time to time the protruding leg may be gently pulled upon to hasten the dilatation of the cervical canal, but plenty of time must be allowed for it ; otherwise the head is caught by the circular fibers of the cervix, the child is asphyxiated by the pressure upon the cord, and there may be fatal hemorrhage from a badly torn cervix. At the expiration of an hour or more the child may be safely extracted. After the delivery the uterine cavity should always be packed with gauze to prevent postpartum hemorrhage and the patient should be given a hypodermic of ergotin and pituitrin. If the operator finds a rigid cervix and experiences L.I/WR COMPLICATED BY ACCIDENTS AND DISEASES. 599 great diflicult)- in its manual dilatation, he may employ Voor- hees' bags; but under anesthesia, and with a fair amount of strength in one's fingers, hydrostatic dilatation is not often required. Instrumental dilatation (Bossi's dilator) is not recom- mended, as the hemorrhage is more profuse than it is with the pressure of the hand or a bag in the lower uterine segment which partially controls it, and the deep lacerations of the cervix caused by rapid instrumental dilatation add to the Fie -Braun's colpeurynter used as a metreurynter in placenta prasvia: bleeding uteroplacental vessels (Bumm). bleeding. If a physician discovers placenta praevia for the first time in labor by a profuse outpour of blood w^hen the dilatation of the cervical canal begins, he should immediately pack the vagina as full as it can possibly be packed. The best material for this purpose is iodoform or sterile gauze if it is at hand, but a clean towel torn into strips will answer. The tampon serves the double purpose of controlling the hemorrhage and assisting the dilatation of the os. After a delay of an hour or two to allow 6oO PATHOLOGY. time for the os to dilate, the patient is anesthetized and the operator proceeds as before described. If the packing does not control the bleeding, or if it can not be done quickly enough, ]Momburg's tube (p. 6io) may be used temporarih'. If there is great difficulty in ffiiding the margin of the placenta and the mem- branes beyond it. too much time should not be lost in the search. The placenta should be perforated and the child's leg pulled through the perforation. If the operator distrusts his abihty to perform the version as quickly as it should be done (for the hemorrhage is likely to be furious during the attempt), he may adopt a plan oi treatment proposed by Wigand at the end of the eighteenth century. This consists in tamponing the vagina firmly and allowing the tampon to remain in place till the os is fully di- lated. If the labor lasts too long, the tampon must be removed, the vagina douched, and a fresh tampon inserted. It is well to u'-ite with the tampon treatment the procedure recommended by Barnes — separating the placenta by a sweep of the fingers around and beyond the internal os. This plan was suggested by the clinical obsen-ation that when the placenta separated and the presenting part descended the hemorrhage ceased. The com- bination of the Barnes^ and the \Mgand treatment gi^^es fairly good results for the mother, though it increases the risk of the sepsis. For the child it would seem to be bad, but we have testimony from "\Mgand, Murphy, and Winckel to the contrar)^ The fetal mortahty is 48.5 per cent. (Winckel). In cases of marginal placenta prsevia in which hemorrhage first occurs after the OS is fairly well dilated, in which the head presents and is easily accessible, the best treatment is rupture of the membranes, ap- plication of forceps, and traction upon the head till the bleeding ceases; whereupon the instrument may be removed and the labor is allowed to terminate spontaneously. The use of a dilatable rubber bag ^ (Braun's colpeur^mter or Voorhees' bags) in the lower uterine segment fFig. 487) should be considered in cases of lateral and marginal placenta praevia. It is inserted collapsed and sterile (boiled) through a cen^cal canal admitting one or two fingers; it is distended with water by a David- son or a piston s}Tinge, the bag resting against the ]etal surface of the placenta; it is necessary to rupture the membranes along- side the edge of the placenta to place it properly; the tube at- tached to the bag is clamped with an artery forceps; from time to time traction is made upon it to hasten the dilatation of the os. As soon as the bag can be pulled through the cervical canal by ' See the excellent article, with good bibliograph}'. by Dr. Lee. " Chicago Medical Recorder," 1901, p. 309, " The Use of the Colpeurynter in Obstetric Practice." LABOR C0MPLICA7-KD BY ACCIDENTS AND DISEASES. 6oi moderate force it is removed; forceps is applied if the head is presenting, a foot is pulled down in breech presentations, or bipolar version is performed. Cragin prefers the extraovuiar position of the bag against the maternal surface of the placenta without rupture of the membranes, and has carried out this treatment in 49 cases with excellent results (maternal mortality, 2 per cent.). It may finally be necessary to detach an adherent placenta, to control a postpartum hemorrhage, and to treat the woman for acute anemia. Cesarean section for placenta prsevia must be considered more frequently than it has been. The maternal death-rate Fig. 488. — Showing separation of the placenta with external bleeding (Dickinson). by version in hospital practice is about 5 per cent., while the child has about one chance out of two. But abdominal section should not be recommended indiscriminately. Unless there is some reason more than ordinarily urgent for saving the child at any cost, it does not seem right to subject the mother to an extra risk, such as would be involved in a Cesarean section performed by physicians in general. An expert might expect good results; Kronig,^ for example, had 16 operations without the loss of a mother or child; but the same result might have been obtained by less radical means. In young primipara^ with a narrow vagina and vulva, in cases complicated by contracted pelvis and over- * " Berlin, klin. Wochenschr.," Nos. i and 2, iqio. 602 PATHOLOGY. grown fetus, or by central implantation with a long rigid cervix, Cesarean section should be preferred, but ordinarily version, the tampon, or the metreurynter will suffice. Vaginal Cesarean section (hysterostomatomy) must also be taken into account, especially by the expert in a well appointed clinic. Doderlein^ collected 134 cases treated by this method with only one death. Bumm first advocated this treatment, but gave it up on account of the hemorrhage from the operation itself. He has again resumed it, however, with the use of the Momburg's tube, put in place around the woman's waist before the operation is begun and tightened as soon as the child is delivered. Prognosis. — The study of the m.ortuary statistics of placenta praevia is not very profitable. It appears that the maternal death-rate in general has been about 20 per cent., including the deaths from sepsis.^ But with the plan of treatment just described, carried out by men who understand aseptic methods, the mortahty almost disappears. Thus, Lomer (16), Hofmeier (37), Behm (35), and the writer (36) have had 116 cases, with 2 deaths (Hofmeier's and the author's). Pinard reports 183 cases treated by dilatable intra-uterine bags, with a 2.18 per cent, mortahty. Sigwart reports 121 cases from the out- patient department of the Charite, treated mainly by combined version with only one death. ^ In 344 cases of placenta praevia in Schauta's chnic in Vienna from 1 903-1 905, treated by rupture of the membranes, dilatable bags, and combined version, the maternal mortahty was 5.85 per cent., and in 274 cases in Zweifel's clinic the mortahty was 8 per cent., making 618 cases, with a mortahty of 6.92 per cent. Cragin, Edgar, and Fry report 49, 40, and 38 cases treated mainly by hydrostatic dila- tation and version, with a mortality of about 2 per cent."* For the children a mortahty of 50 per cent, may be expected. The outlook for the child is worse the more nearly the placenta praevia is central. Premature Detachment of a Normally Situated Placenta. — The placenta may become detached during pregnancy or before the third stage of labor, though it occupy a normal position near the fundus uteri. The necessary consequence is hemorrhage, often called "accidental," to distinguish it from the "unavoidable" hemorrhage of placenta praevia. If the lower margin of the pla- centa is detached, the blood separates the membranes from the J " Monatschr. f. Geb. u. Gyn.," Bd. xxxii, p. 485. 2 Futh found in the district around Coblenz, in 726 cases, a death-rate of 20 per cent, in general practice, " Zentralbl. f. Gyn.," p. 329, 1907. 3 " Zentralbl. f. Gyn.," No. 28, 1910. •* " Amer. Jour. Obstetrics," July, 1911. LABOR COMPLICATED BY ACCIDEN/'S A. YD IJ/SEASES. 603 uterine wall and escapes externally. The bleeding may, how- ever, be entirely concealed (i) if the center of tiie placenta is alone detached; (2) if the upper margin is detached and the blood accumulates between the membranes and the uterine wall ; (3) if the membranes are ruptured far from the internal os and the blood mingles with the liquor amnii ; (4) if the cervix is ob- structed by a blood-clot, the membranes, or the pre- senting part (Goodell). Concealed hemorrhage is, fortunately, rare. Causes. — The cause of premature detachment of the placenta may be ob- scure. The accident may occur during sleep and without ascertainable cause. The causes are often, how- ever, those of abortion : nephritis, congestion of the pelvis, external violence, physical effort, emotion. Prolongation of pregnancy, Avith irregular uterine con- tractions, was accountable for one of my cases. Death and disease of the fetus, hydramnios, a short um- bilical cord, and multiple pregnancy may cause it. It occurs more frequently in multiparae and toward the close of pregnancy. Frequency. — Holmes ^ estimates the frequency at i— 200 preg- nancies, but in only 1-500 cases is the separation serious enough to demand attention. Symptoms and Diagnosis. — Accidental hem.orrhage, especially if concealed, should be recognized without delay. The accident usually occurs before labor begins or in the first stage. The uterine contractions usually become weak and finally cease, being re- placed by persistent and severe pain, usually at the placental site, but occasionally the uterus is thrown into a tetanic contraction of the most violent character, associated with excruciating pain. 1 "Ablatio placentae" ; "Am. Jour, of Obstetrics," vol. xliv. 1901, a study of 200 reported cases ; also, "Jour. Am. Med. Assoc.,'' p. 1845, 1908. Fig. 489. — Premature detachment of the placenta occupying its normal site. Frozen section of an undelivered woman dead of eclampsia. A blood-mass under the placenta (after Winter). 6o4 PATHOLOGY. There is shock, the signs of internal hemorrhage become more and more apparent, and the uterus is distended by the accumulation of blood within it. Feeble but persistent contraction of the upper part of the uterine muscle may be felt. If there is a retroplacental effusion, a localized bulging at the placental site may be made out by abdominal palpation. The symptoms resemble somewhat those of rupture of the uterus. In both there are hemorrhage, shock, and perhaps sudden lancinating pain. But in rup4 Upperend ofc: ■ ^ /Jembr. ture of the uterus the accident\ occurs late in labor, the mem- branes are broken, the pre- senting part recedes, the uterus is well contracted, and per- haps its contents are evacu- ated into the peritoneal cavity; while in accidental hemorrhage the detachment of the placenta occurs early in labor, the membranes are not ruptured, the presenting part does not recede, and in con- cealed hemorrhage the uterus is distended by the accumu- lated blood. In frank acciden- tal hemorrhage the diagnosis rests between detachment of a normally situated placenta and placenta praevia. The pres- ence or absence of the latter is determined by a careful in- ternal examination. In exceptional cases a frank accidental hemorrhage appears as early in pregnancy as the fourth month. Abortion usually follows, but I have seen two cases in which the bleeding continued uninterruptedly for weeks, a large blood-clot formed between the site of the placental separation and the external os, and septic symptoms supervened. In spite of these unfavorable conditions pregnancy continued, and the fetus lived until I was obliged to terminate gestation on ac- count of the anemia and the symptoms of systemic infection. Prognosis. — The mortality in accidental hemorrhage is high. Goodell's statistics give 54 maternal deaths out of 107 cases, and of the 108 children (there being one case of twins) only 7 were saved. Holmes' statistics {Joe. cit.) give a much lower mortality. Fig. 490. — Accidental hemorrhage. Blood collected between placenta and part of membranes and the uterine wall (Pinard and Varnier). LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 605 Treatment. — The main object of treatment is to evacuate the womb as speedily as possible, so that the uterine muscle may contract. At the same time it must be remembered that the woman is in no condition to endure much additional shock. The best procedure is to dilate the cervix with rubber bags or with the fingers, to i)crforatc the membranes, and then to extract the child by the quickest plan available. If the presenting part is not engaged, the child should be rapidly extracted by the leg. If the head is engaged and a rapid forceps operation is practicable, the instrument should be employed. If not, crani- otomy should be performed. Ergot should be administered hypodermatically, for postpartum hemorrhage is to be feared. A Cesarean section should be considered in the gravest cases, in which a continuance of hemorrhage and the shock of a forced delivery are more to be dreaded than abdominal section and puer- peral hysterectomy. Rupture of the circular sinus of the placenta may give rise to symptoms indistinguishable from those of premature detach- ment, and calling for the same treatment.^ Postpartum Hemorrhage. — Hemorrhage may occur during the third stage of labor, or in the first twenty-four hours of the puer- perium, from relaxation of the uterine muscle, from injuries along the birth-canal, from ruptured vessels, tumors, malignant growths, or ulceration in the parturient tract. Postpartum Hemorrhage from Relaxation of the Uterine Muscle. — When the placenta is separated from the uterine wall and the large maternal blood-vessels communicating with it are neces- sarily torn across, every woman after labor would bleed to death were it not for the following provisions on the part of nature to prevent hemorrhage : Leukocytes begin to block the uterine sinuses in the latter weeks of pregnancy, and the excess of the fibrin-making elements in the blood of pregnant women, together with the sluggish blood-current in the sinuses, favor the forma- tion of firm blood-clots in their orifices when they are torn ; the uterine muscle contracts the moment the uterine cavity is emptied, so that the blood-channels running through the uterine walls are ligated throughout their whole length by the contracting muscle- fibers that encircle them ; the quality of retraction in the uterine muscle maintains what is gained by contraction. It is to the last two actions mainly that a woman owes her immunit}' from hemor- rhage after labor. The causes of postpartum hemorrhage are, therefore, those which interfere with uterine contraction. They are : S}-stemic ' Mynlieff has collected 30 cases, "Diss. Inaug., Amsterdam,"' refer. "Jabres- bericht," vol. xii, 1899, p. 757. 6o6 PATHOLOGY. weakness from disease ; unfavorable hygienic surroundings or anxiety ; weakness in the uterine muscle-fibers themselves, as when they are undeveloped, fatigued, overstretched by hydram- nios or twins, inactive by reason of surrounding inflammatory products, exhausted by many previous labors, or too suddenly called upon to contract by a rapid labor, especially if it is instru- mental ; anomalies in the innervation of the muscle-fibers ; a mechanical obstacle to firm contraction, as a retained placenta or clots within the womb, old adhesions upon its peritoneal surface, or a tumor such as a uterine fibroma, an ovarian cyst, a dis- tended bladder or rectum, that by its bulk keeps the womb distended or displaces it. Some sudden effort may displace the clots in the uterine sinuses and thus favor hemorrhage, as cough- ing, sneezing, siting up in bed, or defecation. Heart and lung disease or arterial tension from any cause may produce a conges- tion of the womb that predisposes to postpartum hemorrhage. Syniptonis and Diagnosis. — There is no difficulty in recogniz- ing postpartum hemorrhage when the blood soaks through the mattress and runs across the floor in a stream. The bleeding should be detected early, however, that it may be arrested at once. There is usually a sudden gush of blood, followed by the expulsion every few seconds of several ounces of liquid blood and clots. The uterus is relaxed and it is difficult to outline it through the abdominal wall. There is an absence of that firm, round, easily palpable tumor usually filling the hypo- gastrium, characteristic of a firmly contracted womb. The con- stitutional signs of hemorrhage become rapidly more and more evident. The face is blanched, the pulse is quick and feeble, vision fails, there is air-hunger, and the woman, to satisfy her in- stinctive craving for more oxygen in the rapidly emptying blood- vessels, makes a curious sound between that of a gape and a sigh. Finally, there are restlessness, jactitation, convulsions, coma, and death. In exceptional cases one tremendous outpour of blood, last- ing not more than five minutes, kills the patient. One can not always judge the extent of the hemorrhage by the amount of blood that escapes externally. The dilated womb may contain enough within its cavity to cost the woman her life. Very rarely, indeed, an uncontrollable postpartum hemorrhage is seen from a firmly contracted and an uninjured uterus. It occurred once from a ruptured aneurysmal vessel; again in con- nection with nephritis, presumably from atheromatous or diseased vessels ; in one case from a ruptured hematoma of the cervix ; in another from ulceration of the cervix that opened the uterine artery ; in another from a ruptured varicose vein in the cervix. LABOR CO. UP/. /C.I 77-:/) /^Y acc//j>/:a'ts and d/seas/-:.s. 607 Cases have been reported of paralysis of the placental site, with firm contraction of the remainder of the womb. ^ In high altitudes postpartum hemorrhage is said to be much more common than at lower levels, from the lessened atmos- pheric pressure. I have been told, by physicians practising in the high regions bordering upon the Rocky Mountains and in South Africa, that they have this complication to contend with veiy frequently. Treatment. — Postpartum hemorrhage may occur after any labor. Measures to prevent it consequently form part of the routine management of labor, as already described. If any of the predisposing causes of uterine relaxation exist during labor, additional precautions should be taken. As soon as the presenting part emerges from the vulva, ergotin and pituitrin should be injected into the woman's thigh, the placenta should be expressed without too much delay, and the womb should be kneaded and compressed more vigorously and for a longer time than usual, until it remains firmly contracted and shows no disposition to relax. Then a large abdominal pad should be laid above the umbilicus and a iirm abdominal binder should be adjusted. The nurse should receive instructions to watch the patient's appearance closely, to count the pulse frequently, and occasionally to turn down the bedclothes and observe the quantity of the discharge. Should hemorrhage occur in spite of these precautions, it must be controlled with the least possible delay, for so much blood is lost in a short time that the woman may die of acute anemia, even though the bleeding be finally checked. The beginner will do well to bear in mind the following plan of action that he may put it into immediate effect, without de- pending too much upon his presence of mind, readiness of re- source, or self-command — qualities that perhaps are lacking when he is first confronted with one of the most alarming acci- dents of obstetric practice: Give an intramuscular injection of ergotin and pituitrin. Seize the fundus uteri with one hand through the anterior abdominal wall; knead, compress, and rub it vigorously with the fingers applied to the posterior uterine wall, the palm to the fundus and the thumb in front, until the womb is felt firmly con- tracting. If external irritation does not effect the desired result, insert the free gloved hand into the vagina, pass it into the uterine cavity, feel for retained fragments of the placenta, blood-clots, or other substances that might by their bulk prevent contraction, re- move them, and while doing so rotate the hand somewhat roughly, ^ Miiller's " Handbuch," \'eit, vol. ii, pp. 121, 130. 6o8 PATHOLOGY. SO as to bring it in contact rather forcibly with the uterine wall ; at the same time continue the kneading, rubbing, and compression externally. If the combined irritation of the exterior and interior of the womb fails to secure firm contraction, try next the irri- tating effect of cold. Rub a piece of ice upon the hypo- gastrium. If the effect of cold is not immediately satisfactory, do not persist in its use, for the ultimate effect is relaxing rather than stimulating. A ready and convenient method of violently chilling the hypogastric region is to pour some ether Fig. 491. — Packing the puerperal uterus with gauze to control postpartum hemor- rhage (Edgar). upon it. The irritation of cold externally having proved in- effective, the uterine cavity should be packed with iodoform or sterile gauze. In the intra-uterine tampon we possess the surest and most reliable means of controlling postpartum hemorrhage.^ The technic of inserting the tampon is as follows: The vulva is cleansed; a Sims or weighted duck-bill speculum is inserted; the anterior lip of the cervix is seized with a double tenaculum and pulled down; the gauze in a long, continuous strip, con- tained in a glass tube or jar, is held near the vulva. The end of the strip should be inserted as far as the fundus by a long ^ Diihrssen, " Ueber die Behandlung der Blutungen postpartum,^'' Volk- mann'sche Sammlung, 347. LABOR COMPLICATED BY ACC/DE.VTS AXD DISEASES. 609 placental forceps, and the wliole uterine cavity firmly packed with the successive layers. It is removed in twenty-four hours. Other agents of value in promoting uterine contraction arc hot water, electricity, and styptic or irritating drugs, such as Monsel's solution, iodin, and turpentine. An intra-uterine injection of very hot water (120° F.) is effective, but it is difficult to regulate the temperature in private practice, and if this means fails, valuable time has been lost. A strong faradic current is ex- tremely efficient, but a battery is scarcely ever at hand when it is needed. Fig. 492. — Bimanual compression of the uterus. Monsel's solution will stop the bleeding, but it leaves such firm and adherent clots in the uterine cavity that septicemia will very likely follow from their decomposition, and there is danger, besides, of an extension of the thrombosis to the uterine and pelvic vessels. Iodin and turpentine have done good service by their irritating qualities, but there is danger of metritis from their use, and they might leak into the abdominal cavit}' through the tubes. Great vir- tue has been claimed for special modes of compressing the uterus (Fig, 492) that are supposed to close the mouths of the bleeding vessels. Fritsch advocates pressing the uterus forward and down- ward over the symphysis pubis, putting a large compress behind and above it, and applying a tight abdominal binder. When these methods are effective it is by irritating the uterine muscle, rather than by the pressure exerted upon the vessels of the placental site. Compression of the abdominal aorta has been proposed as a means of checking postpartum hemorrhage by diminishing the blood-supply to the womb. Momburg suggested knotting a strong rubber tube tight around the waist until the femoral pulse stops. ^ In a terrific outpour of blood this plan is worth ^ " Zentralbl. f. Gyn.," No. 41, iqoq. 39 6io PATHOLOGY. trying until arrangements can be made to pack the womb, or if the packing does not stop the bleeding, but there is some danger in the method both to the heart and to the kidneys. Digital compression of the aorta may be tried if Momburg's tube is not at hand. A plan well worth remembering that has succeeded when others have failed is to seize the lips of the cervix with bullet forceps and to pull the uterus forcibly downward. All operators know that hemorrhage during an operation on the uterus may be controlled in this way. Finally, the bleeding may cease spontaneously by thrombus Fig. 403. — Momburg's rubber tube to control hemorrhage from the uterus; it is applied around the waist of a woman just delivered. It is placed above the fundus uteri and tightened until the femoral pulse can not be felt. formation or by syncope, but these agencies are never to be awaited in practice. The physician's duty is not always done when he has checked the bleeding. An acute anemia must be dealt with that, if dis- regarded, is as dangerous as a continuance of the hemorrhage. There is a rapid, feeble pulse; or, it may be, an entire ab- sence of radial pulsation. The body-surface, especially of the extremities, is cold, and there is a disposition to syncope on the slightest effort. There is loss of vision, and the acute anemia of LABOR COMPIJCATED BY ACCIDEXTS AXD DISEASES. 6ll the brain may even lead to convulsions. With the dangers of heart-failure and cerebral anemia in mind, the physician, while cngajred in stopping the bleeding, directs the nurse to raise the foot of the bed on some books, bricks, or the seats of chairs, and, if there is a tendency to repeated syncope, to gi\'c a h\podcrmic injection of ether; or of nitroglycerin (two drops of one per cent. solution). As soon as the hemorrhage is checked, an enema of a pint of hot water containing about forty grains of common salt should be given. The patient shoLdd, in addition, be surrounded by hot bottles, should be well covered with blankets, and should be kept at absolute rest, with the body and head on a straight line and the foot of the bed well elevated to keep as much blood as possible in the brain. Heart-stimulants — digitalis, strychnin, nitroglycerin, and ether — should be given hypodermatically if the heart-action fails to improve. There is likely to be nausea and vom^iting, but, .is soon as the stom.ach will retain what is put in it, the woman should receive very small quantities of hot milk, hot concentrated coffee, hot water and brandy, frequently repeated. When reaction is once established, a hypodermic injection of morphin hastens the patient's recovery from the effects of the hemorrhage and prevents secondary shock by promoting physical quiet, calming nervous restlessness, and producing some degree of cerebral congestion. In desperate cases in which the measures just described are without satisfactory result, a pint to a quart of a sterile normal salt solution (0.6 per cent.), at blood heat, should be injected by gravity into the loose cellular tissue be- tween the shoulder-blades (hvpodermocl^'sis) , under the breasts, or directly into an artery or a vein. A good transfusion appara- tus is a large aspirating needle and a fountain syringe or funnel. With this appHance, with which every obstetrician should be provided, fluid may be forced into the cellular tissue under the breasts or into a vein. The funnel and needle should have a place in every well-supplied obstetric-instrument bag. The extremities should be bandaged toward the trunk (auto- infusion) so as to force as much blood as possible to the heart, the large blood-channels, and the brain. Compression of the abdominal aorta helps to this end. Actual transfusion of blood from one person to another by the vein-to-vein method (Dor- rance) is most helpful if practicable. The physician should make it an invariable rule to stay with his patient until her condition is entirely satisfactory. The anemia persisting after the hemorrhage is checked and reaction is established should be treated by a full liquid diet, animal broths, and iron. The intense headaches of cerebral anemia that may persist or recur for some time are best treated with opium. 6l2 PATHOLOGY. Actual transfusion may be considered if the patient fails to respond to other treatment or if a pernicious degree of anemia persists. Lacerations of the Walls of the Birth=canal. — Any portion of the soft structures surrounding the birth-canal, from the fundus uteri to the vulva, is liable to spontaneous rupture, or to trau- matic perforation during labor. Rupture of the Uterus. — The uterus may be ruptured by over- distention of the lower uterine segment. It may burst open from top to bottom in certain diseased conditions of its walls. It may be penetrated by the operator's hands or by instruments. Its wall may be perforated by a locahzed necrosis and ulceration. If the rupture involves all the coats and opens a v.-ay into the peritoneal cavity, it is called complete. If it spares the peritoneal covering of the uterus, it is called incomplete. Frequency. — The statistics of the frequency of ruptured uterus vary greatly. Bandl found . . . Tolly found . . . Lusk found . . . Collins found . . McClintock found Ramsbothan found Garrigues found . Winckel found . . Harris found . . Koblanck found . 1 200 labors. 3403 " 6000 " 482 " 737 " 4429 " 3-5000 " 666 " 4000 " 462 " Rupture of the uterus is much more common in the poorer than in the richer classes, chiefly because the former have less skilful medical attendants. Multiparae are more liable to the accident than primiparse (88 per cent. : 12 per cent., Bandl). Dis- ease of the uterine wall, as fatty degeneration, a myoma, a pre- vious injury to or operation upon the uterus, as a former rupture or Cesarean section, are predisposing causes. Causes. — The most frequent cause of ruptured uterus in labor is overdistention of the lower uterine segment, due to some ob- struction which prevents the descent of the child through the peMc canal. 1 Bandl first pointed out this fact.^ Another factor is the ascension of the upper uterine segment by stretching the round hgaments, adding to the tension of the walls of the low^er uterine segment. In a normal labor the lower pole of the uterine ovoid is gradu- ally dilated until the fetal body passes through it into the vagina. If there is an insuperable obstacle to the descent of the child, as 1 A contracted pelvis is the most common cause of uterine rupture, and a justo- minor pelvis is the kind of contracted pelvis most often accountable for it. In 1218 ruptures a contracted pelvis was the cause in 570 (Koblanck, " Uterusruptur, " Stutt- gart, 1895). ^ " Ueber Ruptur der Gebarmutter," Wien, 1875. LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 613 a contracted pelvis, rigid soft parts, a tumor in the pelvis, over- growth or enlargement of the child, hydrocephalus, an impossible presentation or position, the contraction of the upper uterine seg- ment continues until the child's body is driven in great part out of it, but, descent of the child being prevented, it is crowded into the enormously distended lower uterine segment and cervical canal, while the firmly contracting upper uterine segment is drawn up under the ribs until it sits upon the child's body like a cap. There is a sharply defined line between the firmly con- tracted thick wall of the upper uterine segment and the very thin wall of the distended lower uterine segment, a line visible and Fig. 494. — Vertical rupture of the uterus in fundal zone (Lobenstine) . palpable running across the abdomen between the symphysis and the umbilicus, approaching nearer the latter the greater the distention of the lower uterine segment, the upper boundary of which is normally about the level of the pelvic brim. This line is called the "contraction-ring" or the "ring of Bandl." It ordinarily coincides with the coronary vein of the uterine wall and with the firm attachment of the peritoneum to the uterus. It is not, as it was once supposed to be, the margin of the inter- nal OS or the upper limit of the cervical canal ; it is the boundary- line between that portion of the uterine muscle which contracts firmly in labor, diminishing the area of intra-uterine space and driving the child out of the uterine ca\-it}', and that portion of the uterine muscle which must be distended in labor to allow the 6i4 PATHOLOGY. passage of the child through the pointed end of the uterine ovoid. If there is a greater bulk of the fetal body in one side of the lower uterine segment, the contraction-ring is higher upon that side and thus runs an oblique course across the abdomen. There is a limit, of course, to the capacity of the lower uterine segment Fig. 495. — Vertical rupture through the entire length of the anterior uterine wall (LobenstineJ. and to the stretching and tenuity of its walls. That limit being reached, the overstretched wall tears and the fetus may pass from the uterine into the abdominal cavity. In rare cases the uterine wall is weakened by a previous rupture, by a blow or fall during pregnancy, by the scar of a Cesarean section, or by the removal J.AJiOR CO.yPI.ICA'rJ-.D BY ACCIDEXTS AXD DISEASES. 615 of a portion of the uterine wall in the excision of a myoma; the wall may be weakened by fatty degeneration, associated, perhai)S, with excessive general obesity ; ^ prolonged pressure upon a small area may destroy its vitality and lessen its resistance. In such cases rupture of the uterus may occur early in labor, or even in pregnancy, without distention of the lower uterine segment. Finally, external violence has ruptured or perforated tiie womb, instruments inserted in the vagina have pierced its walls, the appli- cation of Crede's method to ex})ress an adherent placenta '" and the insertion of the operator's hand in the uterine cavity to jjerform version have been the immediate cause of rupture.' Fig. 496. — Laceration of lower uterine segment. Morbid Anatomy. — The tear in the uterine wall almost always begins in the lower uterine segment, and usuall}' runs trans- versely. It may be upon the anterior, lateral, or posterior sur- face. The edges of the tear are usually ragged, swollen, and infiltrated with blood. The peritoneal covering of the uterus is 1 In a case of uterine rupture seen with Dr. U. G. Heil, of Philadelphia, the woman had become suddenly and enormously obese before her last pregnancy. She had experienced no special difficulty in the births of her other children, but in the last the uterus ruptured after a few hours of moderate labor-pains. 2 " Monatsciir. f. Geb. u. Gyn.," Sept., 1903. 8 Koblanck (loc. cit.) gives the following causes in 80 cases: Contracted pelvis, 8; transverse position of fetus, 7 ; other abnormal positions, 4 ; hydrocephalus, 4 ; over- growth of child, I ; misfit of presenting part in pelvis, administration of ergot, i ; vio- lence, 5 ; version, 29; Ilofmeier's grip, i ; forceps, 11 ; decapitation, I ; myoma, I. 6l6 PATHOLOGY. often stripped off for a considerable distance beyond the tear, and in the sac thus formed between the peritoneum and the body of the uterus the placenta may lie concealed, or even the fetus may be contained. There may be an enormous subperitoneal hema- toma or profuse intraperitoneal hemorrhage. The tear may run upward toward the fundus, or may extend so far transversely as almost to sever the upper and lower uterine segments. The rent may extend through the mucous and muscular coats without in- volving the peritoneum. The latter, in rare cases, may alone be split, and it is recorded in one case that the peritoneal and mus- cular coats were torn while the mucosa remained intact.^ If the tear is extensive and complete, the fetal body will probably pass %. Fig. 497. — Rupture through the scar of a former Cesarean section extending down to the undilated cervix 'Lobenstinej. into the abdominal cavit}', and intestines may prolapse into the uterus and into the vagina. - In one remarkable case^ there was a tear o{ the lower uterine segment and of the right lateral fornix of the vagina, through which the fetus entered the vagina, passing to one side of the undilated cervix. Fetal death is usually syn- 1 T. M. Withrow T" Lancet-Qinic," December, 1891) reports a case of ruptured uterus, the rent beginning in front, midway between the insertion of the tubes, ex- tending up over the fundus and down along the posterior wall to Douglas' pouch, involving the peritoneal coat and the muscular tissue, but not the mucous membrane. The uterus, filled with water after removal from the body, did not leak. A large dose of ergot had been given during labor. ^Crossen reports a case in which it was necessary to resect 13 feet of intestine prolapsed through a rent in the anterior wall of the uterus, " Am. Gyn. and Obstet. Jour.,' vol. xii, p. 45. *Slajmer, " Centralblatt f. Gyn.," No. 18, 1895. LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 617 chronous with the ru])turc of the womb, and if the child's body passes into the peritoneal cavity it rapidly putrefies, generating gases of decomposition so cjuickly that its bulk is enough in- creased to make its extraction diOicult. From the decomposition of the fetal body, or perhaps from the entrance of atmospheric air, there may be emphysema of the pelvic connective tissue and of the cellular tissue of the thighs, buttocks, mons Veneris, and abdomen. Septic peritonitis of a viru- lent kind usually develops with great rapidity. In a minority of cases the site of the rupture is walled off by a rapid outpour of lymph and by agglutina- tion of coils of intestines, leaving a comparatively small cavity to be drained through the tear. This cavity may secrete ascitic fluid in large quantities for a time, and during the woman's convalescence there may be a profuse watery discharge from the womb. I have seen two such cases. Occasionally a large area of intraperitoneal space is drained through the tear. Even the fetal body may be encapsulated, and a lithopedion may be formed. In the uterine ruptures or perforations due to pressure necroses the opening is round in shape, regular in outline, and small in extent. The opening is almost always on the posterior wall over the promontory of the sacrum. In the rare cases of exostoses of the pelvis the bony outgrowth may pinch a hole in the uterine wall. In these cases the opening corresponds to the site of the exostosis. Clinical History, Symfikviis, and Diagnosis. — Rupture of the uterus usually occurs after labor has lasted a long time, after rupture of the membranes, and with a well dilated os. There is usually an obstruction in the labor that should have been recog- nized, the lower uterine segment is enormously distended, and the contraction-ring is palpable and visible near the umbilicus ; the pains have been vigorous and frequent, the woman's suffering has Fig. 498. — Uterus perforated by the pres- sure of the promontory : a. Perforation ; b, laceration of the cervix ; c, c, c, vaginal tears ; d, contraction ring; e, posterior lip of cervix (Winckel). 6i8 PATHOLOGY. been extreme, and the abdominal muscles have been employed, perhaps, with each contraction, though the presenting part does not descend the birth-canal. Suddenly there is a sharp, excruci- ating, lancinating pain ; the woman may cry out that something has happened to her ; the uterine contractions cease, blood flows from the vagina, perhaps in alarming quantities, and the patient presents every evidence of shock. On making a vaginal ex- amination the physician finds that the presenting part has re- ceded ; hitherto easily reached, perhaps at the very outlet of the pelvis, it may be altogether inaccessible, and on passing the hand into the uterine cavity the rent may be felt, or intestines may be found within the uterus and protruding from the os. On abdominal palpation the upper uterine segment may be felt firmly contracted to the size of the uterus after labor, and the child's body may be easily detected in the abdominal cavity alongside of it. If the rupture of the womb is not complete, or is not large, it may not be discovered until the child is born, and may never be suspected at all unless the woman develops septic peritonitis after labor or discharges ascitic fiuid from the uterus. There may be no pain at the time of rupture, no hemorrhage, no abnor- mality of uterine contractions. Even with a complete tear of large dimensions and escape of the child into the peritoneal cavity there is occasionally an astonishing absence of symptoms. I have seen a case in which the child passed into the abdominal cavity twenty-four hours before I was summoned, and yet there was no alarming symptom of any kind until suddenly, at the end of twenty-four hours, the signs of virulent septic peritonitis appeared. In another case in which I opened the abdomen a month after labor for what was thought to be an intraperitoneal abscess, the fundus uteri was found ruptured from tube to tube, the rent being shut off from the general abdominal cavity by exudate, which was undergoing suppuration. The accident of labor most commonly mistaken for ruptured uterus is premature detachment of a normally situated placenta. The distinction between the two should be made easily by attention to the fol- lowing differences in symptoms: Rupture of the Uterus. Occurs late in labor. Membranes ruptured. Uterus diminished in size by evacuation of some or all of its contents into the abdominal cavity. Recession of presenting part. Discharge of blood from vagina. Exploration of the interior of the womb easy, and rent accessible to touch. Accidental Hemorrhage. Occurs before labor or early in the first stage. Membranes unruptured. Uterus dis- tended, perhaps irregularly in retro- placental effusions. Position of presenting part unchanged. No external bleeding in the concealed variety. Exploration of the interior of the womb impossible. LABOR COMPLICATED B Y ACCIDENTS AXD DISEASES. 619 As the placenta is often detached when the uterus ruptures, and as it may prolapse in front of the child, a ruptured uterus may be mistaken for placenta praevia. If the physician should have reason to suspect that the uterus is ruptured during' labor, he should extract the child without delay and should then explore the uterine cavity, preferably under anesthesia, from top to bottom. By unvarj-ing adherence to this rule he will not be guilty of the serious fault of ov^erlooking a ruptured womb with few symptoms until septic peritonitis occurs and all treatment is unavailing, or until the bleeding, internal or external, is so profuse that the patient can not be revived. The symptoms during the puerperium indicative of a ruptured womb in labor are : septic peritonitis, profuse uterine hydrorrhea, secondary hemorrhage (as late possibly as the twelfth day), and prolapse of the intestines. The last is the only positive sign, unless, on the occurrence of the others, a digital or instrumental examina- tion of the uterine cavity reveals the rent. Prognosis. — The prognosis of ruptured uterus depends upon the site, extent, and degree of the tear, and upon its treatment. In ten cases of rupture of the anterior wall in the Berlin Mater- nity every one ended fatally, and in three ruptures at the fundus the result was the same.^ Incomplete ruptures are not so fatal as those in which the peritoneum is also involved, and the result depends somewhat upon the escape of meconium, liquor amnii, blood, placenta, and fetus into the peritoneal cavity. Before the advent of asepsis and the improvement in the technic of abdom- inal surgery the mortality of ruptured uterus averaged about 90 per cent. Of late years the mortality has been much reduced. In 60 cases of complete rupture without active treatment the mortality was 78.8 per cent., in 70 cases treated by irrigation and drainage the mortality was 64 per cent., and in 193 cases treated by ab- dominal section the mortality was only 55.3 per cent.^ In about one-half the fatal cases death occurs within the first twenty-four hours. The great majority of the remainder die within three days. In some fatal cases, however, death occurs as late as the tenth or fourteenth day. The causes of death, in the order of their fre- quency, are sepsis, hemorrhage, and shock. The mortalit}- of the infants is usually over 90 per cent. In the 80 cases from the Berlin Maternity 10 children were saved, but this is an unusually large proportion. If the woman recovers from the rupture, she ^ I have performed hysterectomy for a complete rupture of the uterus across the fundus, with success, in one case. 2 Schuhz, " Inteniat. med. Rundsch," Jan. 10, 1S92. 620 PATHOLOGY. runs a great risk of a repeated rupture in a subsequent pregnancy and labor. There are cases on record, however, of women safely delivered in a subsequent labor. Couvelaire,^ in 17 women who had had a ruptured uterus and again become pregnant, reports 9 cases of repeated rupture, with 6 deaths. Treatment. — The preventive treatment of uterine rupture con- sists in obviating, in time, the obstructions in labor that predis- pose to the accident. If a woman has had a ruptured uterus and becomes pregnant again, she should be delivered by Cesarean section before she falls in labor. The treatment of the rupture itself differs as the rent is com- plete or incomplete, as its situation admits of good drainage or otherwise, and it depends greatly upon the escape of foreign matter into the peritoneal cavity. The first care of the physician must be to extract the child and to control the hemorrhage. If the child has escaped into the abdominal cavity, no effort should be made to extract it by the natural passages, but it should be removed through an abdominal incision. If the rent is small, and the child has only in part passed from the uterine cavity, it should be delivered rapidly by version, the application of forceps, or by craniotomy. The last is to be preferred. The placenta may be removed by the vagina, even though it has passed into the abdominal cavity ; but if difficulty is experienced in finding it, if the cord should break off by the efforts to pull the placenta through the rent, or if the placenta lies hidden under the perito- neum stripped off the womb, its extraction should be postponed until the abdomen is opened. In an incomplete tear it is sufficient to pack the rent with iodoform gauze, in order to control hemor- rhage and to secure good drainage. This may be preceded by irrigation, which may be repeated with advantage when it becomes necessary to renew the gauze packing. If the rent is complete, but small, and situated low down upon the posterior wall ; if there has been little, if any, foreign matter injected into the peritoneal cavity, the same treatment will suffice ; but if the tear is exten- sive, if considerable blood has passed into the peritoneal cavity, and, all the more, if the peritoneum has become contaminated by the entrance of liquor amnii, of the placenta, or of the child itself, an abdominal section is necessary. With the abdomen open a decision must be made between several plans of procedure. .Usually, it is best to amputate the womb, if possible, below the site of the tear. Occasionally, if the wound is not too ragged and can be thoroughly approximated, it will be sufficient to unite 1 "Rev. prat. d'Obstet. et de paed.," Oct. -Dec, 1903. LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 621 it with deep and superficial sutures, care being taken to cover over the Hne of rupture with inverted peritoneum. In case the peritoneum is stripped off the womb for a considerable distance, and it is impossible to secure a good stump, a flap of peritoneum may be dissected off the uninjured side of the womb and used to cover over the upper portion of the stump and its denuded sur- face; or it may be preferable to do a panhysterectomy, sewing up the opening left in the vagina in such a manner as to cover any denuded surfaces. If the tear is on the anterior wall, or at the fundus, an abdominal section is necessary. Even if the rupture is lateral, without extending into the peritoneal cavity, a hysterectomy may be necessary to control the bleeding. On opening the abdomen one of the procedures detailed above may be adopted, or it may be possible, as it was in one of Leopold's cases, to splint the womb by gauze packing in the pelvis and abdomen, so as to bring the torn surfaces firmly together. In an abdominal section for ruptured uterus the toilet of the peritoneal cavity must be made, of course, with the greatest care. It is better, if possible, to cleanse the abdominal cavity with pads of gauze, rather than to flush it with water ; but the latter plan is sometimes necessary to remove small clots of blood scattered throughout coils of intestines or hidden in the depths of the pelvis. Resection of the intestines and intestinal anastomosis is occasion- ally required. In one of my cases the medical attendants had pulled off both arms of the child in attempts to extract it, and then through a rupture of the lower uterine segment had pulled two feet of ileum loose from its attachment to the mesentery. Injuries to the Cervix. — The cervix is injured to some extent in every labor, but serious tears, that cause at the time profuse hemorrhage and give rise to symptoms subsequently, are com- paratively rare. The causes of serious injuries to the cervix are : precipitate delivery, premature rupture of the membranes, forcible extraction of the child by the forceps or after version before the -OS is thoroughly dilated, incarceration of the anterior lip of the cervix between the child's head and the pelvis, and abnormal rigidity of the cervix. The tear is usually bilateral, occasionally unilateral, in rare cases multiple, and in one instance under the writer's observation directly in the anterior median line. In rare instances the tear, instead of being longitudinal, maybe circular, and in consequence the vaginal portion of the cervix may be completely torn off from the womb. The most unusual injury is perforation of the cervix. In one of my cases a four months' ■embryo emerged through a lateral perforation, the site of a 622 PATHOLOGY former trachelorrhaphy, leaving the external os undilated. Schindler^ reports a posterior perforation. The cervical tear manifests itself immediately after delivery, usually by some hemorrhage, occasionally by profuse and dan- gerous bleeding. A digital examination of the vagina directly after the extraction or expression of the placenta informs the physician of the condition of the cervix, and, if the cervix is inspected through a speculum during the puerperium, a torn cervix that needs attention should never be overlooked. Fig. 499. — Lacerations of the cervix: a, Bilateral laceration and unequal eversion of lips; h, bilateral laceration and eversion; c, stellate laceration; d, mul- tiple incomplete lacerations; e, incomplete bilateral laceration;/, incomplete lacera- tion and crescentic shape of os. The hemorrhage from a torn cervix directly after labor may be controlled in two ways. First, by hgatures, which are per- fectly certain to effect the desired result, but which are not always easy to insert, and which increase the danger of septic infection, unless the attendant possesses gynecological skill and has the necessary equipment for operating in a perfectly aseptic manner. The easiest, and on the whole safest, plan for checking the hem- orrhage from a torn cervix in general practice is to insert a tampon in the form of a half ring in the lateral vault of the vagina. The best tampon material is iodoform or sterile gauze. ^ " Gyn. Rundschau," 1910, p. 775. Plate 14. \J Lacerations of the cervix : i, Two weeks after labor ; 2, one week after labor ; 3, four days after labor; 4, immediately after labor. The degree of involution shown in No. I should be awaited before repairing the cervix. LABOR COMPLICATED BY ACCIDENTS AXD DISEASES. 62^ I have never known this (le\-icc to fail in checking hemorrhage from a torn cervix. It is a moot c|uestion whether a torn cer\ix should always be repaired in the early puerperium. In general practice, the following arguments are usually advanced against the primary re- pair of the cer\'ix: Stitches placed in a relaxed cervix directly after labor will probably not be tight enough at the end of twenty-four hours to close the wound. To place them properly requires considerable skill, and necessitates dragging the cervix into view Fig. 500. -Spontaneous repair of a stellate laceration of the cervix, life, three months after labor. Drawn from by bullet forceps. There is increased risk of infection in the primary repair of a lacerated cervix. The necessary instru- ments are rarely to be found in the general practitioner's arma- mentarium, and many lacerated cervices heal spontaneously, if the woman is kept quiet on her back in bed for a sufficient length of time, without vaginal douching or other interference that could disturb the approximation of the edges of the tear. In a well- equipped clinic or in the private practice of a specialist, on the contrary the repair of lacerated cervices during the puerperium is recommended. It is the author's practice. It is better to wait five to seven days after labor. Clinical experience has shown that there is less danger of infection in the intermediate than in the primary operation. 624 PATHOLOGY. Circular Detachment of the Vaginal Portion of the Cervix Dur= ing Labor. — Rarely the whole vaginal portion of the cervix is torn off from the v^^omb and emerges from the vulva in front of the child's head. This accident may be the result of extreme rigidity of the cervix, or of the cervix being caught between Figs. 501 and 502. — Author's cases of annular detachment of the cervix. the walls of the pelvis and the child's head, if the former is con- tracted or the latter is very large. I have seen three cases, all due to extreme rigidity of the cervix (Figs. 501, 502). In each case the woman was an elderly primipara, and was quite obese. One of them was delivered a year later under my charge without difficulty. In one case (Fig. 501) there was a narrow tab of cer- LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 625 vical tissue left in the median line posteriorly. Although the injury at first sight appears serious, there is no hemorrhage, nor is the puerperal convalescence disturbed. This accident could almost always be averted by multiple incisions in the cervix. Lacerations of the Vagina. — The vagina may be torn bv the insertion of the hand, by the rapid extraction of the child, by the extension of tears from the cervix, by the propulsion of the child's body against the posterior wall without sufficient deflec- tion forward to facilitate its escape from the vulvar orifice, and, most frequently of all, by the blade of a forceps which does not lit the child's head properly, or which is not used with sufficient care as to the direction of the force that is applied in the extrac- tion of the head. The tears of the vagina accompanying a lacerated perineum or injured pelvic floor are described under the latter heading. Tears of the vagina extending from the cervix involve usually the lateral vaginal vaults, occasionally opening deep rents into the base of the broad ligaments, and involving possibly the uterine arteries or even the ureters. The hemorrhage from these tears is best controlled by ligating the bleeding vessels if they can be found, or by firmly tamponing the rent if it is impos- sible to locate the bleeding points. Drainage must be secured by gauze packing, and, when the wound begins to granulate, daily washing with sterile water should be employed. The tears of the posterior vaginal wall sometimes result in perforations of the rectum, and in consequence a portion of the child, as an extremity, may emerge from the anus. ^ These perforations should be repaired immediately after labor by buried running sutures of catgut and interrupted stitches of silkworm gut. The tears of the anterior vaginal wall made by a forceps- blade are almost always clean-cut, and are apt to bleed pro- fusely. They should be closed by a running catgut suture. In one case under my care the hemorrhage was so profuse that it was impossible to see the wound at all, and there was danger of the woman bleeding to death while I attempted to sew it up. After several abortive attempts the wound was successfully repaired without further bleeding by pushing a tampon into the vagina and following the tampon as it was pushed up along the course of the wound with a needle and thread, until the upper end of the tear was reached. Lacerations of the anterior and posterior vaginal vaults penetrat- ing to the peritoneal cavity are usually associated with rupture of the uterus. They are to be treated by gauze packing and drainage. 1 Fieri ng, " Centralblatt f. Gyn.," No. 48, 1891. See also Engelmann, ibid., No. 46, 1900. 40 626 PATHOLOGY. Figs. 503, 504, and 503. — Lacerations and abrasions of the vestibule and vaginal entrance (Bar). LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 627 Lacerations and Abrasions of the Vulva, of the Vestibule, and of the Vaginal Entrance. — The most frequent site for injuries in this re<^ion is the upper portion of the vestibule and the tissues on one side of the chtoris or of the urethra. Tears in this situation bleed profusely, and they are so common that it is a valuable rule of practice always to look in this ref^^ion for injury when there is a hemorrhage from the vagina after labor with a well-contracted womb. The bleeding points are in plain sight, and the hemor- rhage is easily controlled by a stitch or two, deep enough to undersew the whole depth of the tear. A catheter should be placed in the urethra to guard against occluding it. In abrasions of the labia and of the vestibule, care must be taken that the raw surfaces shall not unite, causing atresia of the vagina. This can easily be prevented by laying oiled lint over the raw surfaces, and by the use of douches. Figs. 506 and 507. — Perforations and lacerations of the nynipha: (Bar). Lacerations of the Perineum. — The causes and preventive treat- ment of lacerations of the perineum are considered elsewhere. The extent, situation, and recognition of the injury are dealt with in this section. The commonest form of torn perineum is shown in Plate 15 and in Figs. 514 and 515. It may be seen that the tear rarely involves the perineum alone, but usually extends up the posterior wall of the vagina, on one or both sides of the ])osterior column. Experience teaches, moreover, that lacerations of the perineum alone, when they do occur, have very little effect upon the patient's after-condition, even though they reach to the anus and sever the transverse perineal muscle (see Figs. 518, 519.) The 628 PATHOLOGY. greatest care should be exercised, therefore, to ascertain the extent of the injury to the vagina which is associated with the tear of the perineum. This is best done by placing the woman in the dorsal position across the bed or on a table, with her thighs- well flexed upon the abdomen and widely separated, and vsith the buttocks projecting beyond the edge of the bed or table. A nurse or other assistant, whose hands are protected by sterile gloves, holds the labia apart, and the phj^sician cleanses the torn surface of the poste- Figs. 508, 509, 510, 511. — Varieties of central tear of the perineum (" Precis d'Obstetrique''). rior wall of the vagina with pledgets of sterile cotton. In this way the exact nature and the extent of the injury may be seen. If the tear is complete, — that is, through the sphincter, — the fact should be evident on inspection. If there is any doubt about it, the forefinger of the left hand is inserted in the anus, the thumb in the vagina, and the thickness of tissues between, or their absence, can thus be appreciated. It is a serious error to overlook a com- plete tear. Alany suits for damages have been based on this PLATE 15. / / LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 629 ground. A central tear or perforation of the perineum presents the appearance represented in Figs. 508-51 1. A j)robe passed into the vagina through the i)erineal wound shows the nature of the injury. The laceration may be immediately repaired; but the author prefers repairing all the injuries of childbirth at the end of five to seven days after deli^•cry, making a formal plastic o])eration. After trying the different i)eriods for repair work, from a few minutes ' after labor to the end of the puerperium, in scries of many hundreds of cases, the end of the first week has been found the best time. Immediately after labor the tissues are bruised and edematous; the bloody discharge is profuse and embarrassing; it Fig. 512. — Testing the thickness of tissues between the rectum and the vagina. is impossible to make an accurate diagnosis of the extent of the injury and it is unwise to repair the cervix. Repairs of the peri- neum and pelvic i^oor at this time are often failures and must be done again. By waiting a. week the tissues are in more favorable condition for good union, and it is possible to make a careful ex- amination of the whole genital canal and to repair every one of the injuries of childbirth. If the woman is infected, has kidney disease, or has had a serious hemorrhage, it is desirable to wait several weeks. The operation should be performed on a suitable table, with sufficient assistants and implements, and under anes- thesia. 630 PATHOLOGY. Injuries of the Anterior Vaginal Wall. — There is quite fre- quently a submucous laceration of the muscle and fascia of the uro- genital trigonum (Waldeyer) in the anterior sulci, usually most marked in the left. This muscle is the main support of the lower vS#'5 Fig. 513. — Abrasions of the vulva and lacerations of the vaginal sulci (Bar). Fig. 514. — Deep laceration of the perineum and of one sulcus ; splits in the vaginal mucous membrane (Bar). ''^ y y Fig. 515. — Laceration of the perineum and of one sulcus (Bar). Fig. 516. — Laceration of the peri- neum and of the sulci ; abrasions of the vulva (Bar). anterior vaginal wall. Its laceration allows the anterior wall to drop backward and outward. The constant drag of this prolapsed portion of the wall upon the structures above is one of the factors that causes a cystocele in the course of time. The injury can be PLATE 1 6. Complete tears ol the perineum (painted from life a few hours after the injury) : I, Tear involving some of the fibers of the sphincter, but not all ; 2, median com- plete tear, with abrasion of the vulva, and two large hemorrhoidal veins exposed, one on either side ; 3, complete median tear, with sphincter muscle hidden by three large hemorrhoids; 4, lateral complete tear, involving left vaginal sulcus. LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 63 1 recognized by pressing a finger uinvard against the ])uljic bone. The j)resence or absence of the muscle is easily determined. Fig. 517. — Laceration of the vaginal sulci without a tear of the perineum proper (Bar). Figs. 518 and 519. — Lacerations of the perineum without involvement of the pelvic floor. Such tears would not afiect the woman's health or comfort subse- quently (Bar). Inversion of the uterus is the rarest of all the accidents to a parturient woman. In the Vienna Maternity, from 1849 to 1878, in more than 250,000 labors, there was not a case. In the Rotunda Hospital, in Dublin, there were 190,000 labors, with only one inversion of the womb. Winckel did not see a case in 20,000 labors. My own experience amounts to seven cases — six complete 632 PATHOLOGY. and one partial.^ In general practice, especially among the poorer Classes, inversion of the womb is not so rare. The accident happens with equal frequency before and after the dehvery of the placenta. It is commoner in young primipar^ than in multiparge. It is reported to have occurred on the third, fifth, sixth, and fifteenth day of the puerperium/ and has recurred on the fourth day.^ The inversion may be partial or complete, the former when the fundus simply protrudes into the uterine ca^^ty, the latter when the womb is turned completely inside out. In a complete inversion the fundus is just within the vulva; the ca\'ity of the womb is formed by the peritoneal surface, the orifice looking upward into the peri- toneal cavity. From this canity the tubes and the "ovarian and round ligaments run upward; the ovaries are usually above and to either side of the orifice. Inversion of the womb may be associ- ated with inversion of the vagina. In such a case the inverted womb is also prolapsed. Causes. — Inversion of the uter- us may occur spontaneously. In the so-called paralysis of the pla- cental site, — a condition in which this portion of the uterine wall be- comes so relaxed and flabb}- that it sags down into the uterine ca\^- ity, — the projecting portion of the wall, it is said, is seized upon by the remainder of the uterine mus- cle as a foreign body, and de- pressed further and further toward the cervical canal, as a polypoid tumor might be expelled. The explanation, however, is strained. A contraction of the uterine mus- cle under these circumstances would reinvert the womb. A much more plausible explanation for spontaneous inversion is found in an adherent placenta and en- tire relaxation of the uterine walls. In this condition of affairs the mere weight of the placenta is 1 Three cases were seen directly after labor; two were reduced by taxis; the other spontaneously. One case of complete inversion was reduced five da\-s after labor by taxis; one, three, and another five months after labor b\- the author's opera- tion. The seventh case of inversion was due to a myomatous pol\-p at the fundus. It was complete, but was easily reduced by taxis after the removal of the pol3p. 2 Lepage, " Comp. rend. Soc. d'Obstet. de Qiyn. et de Pjediatr.." 1905, p. 213. ^ Fisher, " Br. ]\Ied. Jour.," 1896, vol. ii, p. 11 78; and Burton. '' .\m. Jour, of Obstet.," vol. xxxvi, p. 548; " v. Winckel's Handbuch der Geburtshiilfe," III. Band, II. Theil, 1906, p. 162. Fig. 520. -Partial inversion of the uterus. LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 633 enough to drag the fundus down into the uterine cavity. A most favorable predisposing cause is furnished by a complete inertia uteri at the close of the second stage of labor. The expressive force of the abdominal muscles not only expels the child's body, but drives down the uterus after it. Inversion of the uterus may be most frequently explained by traction on the cord in the third stage of labor, when the placenta is adherent. It may occur in consequence of a short cord pulling upon the placenta '^'\, B- - C — G H- Fig. 521. — ( oiiiplete inversion with prolapse: .7, Mons veneris; B, labia majora ; C, labia minora ; D, clitoris ; E, urinary meatus ; /', external anterior bor- der of the vagina ; G, external border of the os uteri ; H, the internal surface of the uterus, now external (Hoivin and Duges). during labor. It has followed precipitate birth in the erect posture, straining the abdominal muscles to pass urine or to expel the pla- centa, the woman sitting erect, violent coughing or vomiting, and carrying a weight up stairs directly after deli\'ery. In a case under my observation the cord was wound three times around the child's neck. It is sometimes due to too vigorous compression of the fundus in efforts to express the placenta, and I have seen it occur on one occasion in an effort to extract an adherent placenta, in which 634 PATHOLOGY. the hand and the placenta grasped within it acted Hke the piston of a syringe and drew the fundus down into the uterine cavity. Another case under my observation appeared to be due to the universal adherence of the membranes after the detachment of the placenta. The weight of the latter, dragging on the uterus by the membranes, turned it inside out. A necessary predispo- sition to inversion of the womb is relaxation of its walls. If the uterus is firmly contracted the accident can not occur. Symptoms. — Inversion occurs suddenly, is usually associated with profound shock, and often with some hemorrhage. The patient at once passes into an alarming condition, that can scarcely fail to attract attention. The only causes for her condition would be hemorrhage, rupture of the uterus, syn- cope, or inversion. An immediate vaginal examination should Fig. 522. — Partial inversion of the uterus. always be made, whereupon the nature of the trouble should mani- fest itself at once. The inverted uterus is found filling up the vagina, and almost projecting from the vulva. By abdominal palpation one notes the absence of uterine tumor in the hypo- gastrium, and can detect, moreover, a groove or slit running across what remains of the cervix. If necessary, a rectal exam- ination would reveal the absence of the womb and the depression in the cervix where it is inverted even more plainly than these signs could be detected by abdominal palpation ; but a rectal ex- LABOR COMPLICATED BY ACCIDENTS AXD DLSEASES. 635 amination should scarcely ever be necessary. The cervix itself remains uninvcrted as a collar about the lower uterine segment. Between the cervix and the uterine wall a sound or the finger may be inserted a little way, but it is impossible to find a uterine cavity. This fact should always make the distinction between an Fig. 523. — Inversion of uterus showing necessity of pressure forward in taxis ior its reduction. inverted womb and a fibroid polypus or other tumor projecting from the uterine cavity. Mistakes, however, of the most serious character have been made in this connection. In one case the inverted womb was torn away in the belief that it was a fibroid tumor, and in another the wire of an ecraseur was adjusted about an inverted womb, and was about to be screwed tight, when the true character of the mass in the vajrina was detected. 636 PATHOLOGY. Treatment. — Occasionally, a spontaneous reduction of the inversion occurs, especially when inversion is partial. This occurred in one of the seven cases under my observation. If the inversion is complete, spontaneous reduction cannot be expected. If the placenta is still attached to the uterus, it should be first re- movedj and then pressure exerted with the fingers upon the lower Fig. 524. — I, Complete inversion of the uterus ; 2, first manoeuver to reinvert the lower uterine segment ; 3, second manoeuver to widen cervical ring and afford counterpressure by an assistant. Uterine segment in a direction forward and slightly upward. To do this, the hand must be inserted well into the vagina and back toward the sacrum, and the fingers must then be directed well for- ward toward the anterior abdominal wall, in the direction of the axis of the superior strait. The mistake is almost always made of pressing upward against the sacrum, so that the efforts to reduce the womb may fail altogether, and a chronic or permanent inversion may be left for the surgeon to deal with after the puerperium is com- pleted. With the proper direction of force in one's effort to reduce LABOR COMPLICATED BY ACCIDEXTS AXD DISEASES. 637 an inverted uterus, failure ought to be almost unknown, if the repo- sition of the womb is undertaken at once, as it always should be. If there has been a deep tear of the cervix, the best place to begin the rein version is just below the upper margin of the tear. I suc- ceeded by this plan in one case after two other physicians had failed and after my own attempts at reduction by pressure on the lower uterine segment posteriorly had been futile. Strange as it may seem, the inversion has been overlooked for some days or altogether in quite a large proportion of the cases. If the cer\-ix is allowed to contract firmly, as it will in a few hours, the reposition of the womb becomes extremely difficult. In one of my cases, seen in consultation, five days had elapsed since the woman's deliver}-. She had suffered great pain, had considerable fever, with a foul discharge, and had a very rapid pulse, yet no vaginal examination had been made, although the patient was in charge of a professed expert in gynecology ! The uterus was completely inverted. Reposi- tion was linally accomphshed by the following plan: One hand, made into a cone shape, was inserted in the vagina and the finger-tips were pressed steadily against one side of the lower uterine segment, forcing it into the cervical ring. After steady pressure for almost an hour, the cervix yielded considerably. Then an assistant helped in the dilatation of the cervical ring, in the manner shown in figure 524, and at the same time made counterpressure downward upon the cer\-ix. The womb was returned to its natural position shortly after this maneuver was tried. The woman recovered. If taxis fails the operative treatment is required (p. 933^. Prognosis. — The mortality of inversion of the womb has been extremely high. In one series of 109 cases there were 80 deaths, and 72 of these within a few hours after labor. In another series of 54 cases there were 1 2 deaths (W'inckel) . The 7 cases under my care recovered. The causes of death are: shock, hemorrhage, sepsis, peritonitis, and exhaustion from long- continued loss of blood. Injuries of the Urinary Tract ; Qenito=urinary Fistulas. — The commonest fistula is vesico-vaginal, due to pressure necro- sis of the vesico-vaginal septum in a prolonged labor. The bladder wall has been punctured or ruptured by the blunt hook; by forcible deliver}' with forceps, in cases of cystocele distended with urine; by craniotomy instruments; b}' spicules of fetal bone; by unskilful extraction of the head after version; by a vesical calculus caught between the fetal head and the maternal symphysis and by rough intravaginal manipulations. The first 638 - PATHOLOGY. symptom to attract attention is incontinence of urine. A visual examination, the use of a sound in the bladder, injections of col- ored fluid into the bladder, indagation, and, if necessary, cystos- copy, make the diagnosis certain. If there is no loss of sub- stance, the injury may be primarily repaired. Sometimes the opening, if small, is closed spontaneously by granulation tissue. Usually a secondary operation is required, which should be performed, if possible, four to six weeks after labor. Rupture of the symphysis occurs not infrequently,^ usually in consequence of some disease within the joint itself, occasionally as the result of great force in the extraction of the head with for- ceps or after version. The accident may be recognized at the time of its occurrence by feeling the bones give way, or by actu- ally hearing them snap. But it may not be detected until the woman complains of great pain in the symphysis, and of inability to sit up or walk when she rises from bed. Not infrequently rup- ture of the symphysis is followed by suppuration of the joint. The accident must be treated by a firm binder around the hips, and sand-bags such as are used after a symphysiotomy, and by keeping the patient in bed four or five weeks. Suturing the ends of the bones with silver wire may be required. If the joint suppu- rates, it should be opened as early as possible and should be well drained. The prognosis of the injury is not serious. Recovery may be expected as a rule, without impairment of locomotion or other disagreeable consequences, if the s}Tiiphysis alone is in- jured. Rupture of the sacro=iIiac joints has the same causes as rupture of the symphysis, and is often associated with it. Inflam- mation and suppuration in these joints often follow their injury. The symptoms in the puerperium are, great pain over the joints on attempting to walk, a feeling of insecurity in the pelvic bones, a wabbling gait, and loss of power in one or both lower limbs, with fever if the joints are inflamed or suppurate. The only treatment available is firm support of the pelvis by a pelvic binder, sand-bags alongside the pelvis, and extension to the lower limbs, or, best of all, the orthopedic surgeon's wire cuirass to immobilize the whole body. Prolonged rest in bed — six to twelve weeks — is necessary. In the case of suppuration of the joints, an incision into them from behind to evacuate the pus and to allow of drainage is indicated. The mortality of injury to the sacro-iliac joints in labor has been thirty per cent. 1 Ahlfeld collected 100 cases, to which number Schauta added 14 (Miiller's "Handbuch"). In 94, 149 labors this accident occurred three times. About 130 cases are on record. Kayser, "Arch. f. Gyn.," Bd. Ixx, H. i, 1903. LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 639 Fracture of the Pelvic Bones. — This very rare accident in labor has usually been the result of the unskilful use of forceps. It is serious but not necessarily fatal. In a case reported by Studley,^ of a fracture of the horizontal and of the descending ramus of the pubis, the woman recovered. Bird* also reports a recovery after a fracture of the horizontal ramus of the pubis before the application of forceps, and the author has seen one case with like result, in which forceps was applied and powerful traction was made. Fracture of the sacrococcygeal joint, or of the coccyx, occurs in elderly primiparae, in whom not only the sacrococ- cygeal joint, but the joints of the coccyx as well, are anky- losed. The fracture may be caused spontaneously by the expulsive efforts of the mother driving the presenting part down upon the pelvic floor ; but it is more commonly the result of the application of forceps and the forcible extraction of the head through the pelvic outlet. There are, in my experience, four types of injury to the coccyx in labor. In one there is an oblique fracture of a coccygeal vertebra involving a joint and resulting in painful mobility of the bone. In the second there is ankylosis of the two fragments with the lower one drawn in at a right angle, where it is out of the way and causes no inconvenience or discom- fort except in a subsequent labor. In the third the lower frag- ment is ankylosed in a perpendicular position, causing great pain when the patient attempts to sit. In the fourth there is a strain, sprain, or an actual rupture of a coccygeal joint, with abnor- mal mobility and chronic inflammation of the intervertebral disc, with consequent hypertrophy and softening. This last form is by far the commonest. The injury often results in the con- dition known as coccygodynia after the completion of the puerperium. Diastasis of the Abdominal Muscles. — Reference has been made to the escape of the uterus from the abdominal cavity between the recti muscles in labor. After delivery these muscles stand widely apart and threaten the woman with pendulous belly, ptosis of the abdominal viscera, and even with abdominal hernia when she rises from bed. Diastasis of the recti muscles is not uncommon after labor. It is usually observed without precedent actual hernia of the parturient uterus. The condition can usually be corrected by a firm abdominal binder during puer- peral convalescence or longer. If it is not, and does not yield to abdominal massage, electricity, and Swedish exercises, the oper- 1 "American Journal of Obstetrics," April, 1879. * "American Journal of Obstetrics," Jan., 1902. 640 PATHOLOGY. ation of diminishing the width of the aponeurosis proposed by J. C. Webster 1 may be indicated. Rupture of Some Part of the Respiratory Tract and Sub= cutaneous Emphysema — During the straining of the second stage of labor, the larynx or trachea may be ruptured. This accident is fol- lowed by emphysema of the neck and face. The accident, if confined to the trachea or larynx, and resulting only in emphysema of the face, is not danger- ous. If the emphysema is more exten- sive, however, or if there is a rupture of the pulmonary vesicles, with emphy- sema of subpleural and interlobular connective tissue, with embarrassment of heart and lungs, the prognosis is not so good. As soon as the nature of the injury is recognized the patient must be forbidden to strain, and should be de- livered as quickly as possible by forceps or version." Sudden Death During or Directly After Labor. — The causes of this acci- dent to the parturient woman are set down, as far as possible, in the order of their frequency. Shock. — A few sudden deaths dur- ing and after labor may be explained by surgical shock, which is more likely to follow a serious accident, such as rup- tured uterus in labor, but may result from the strain and suffering of parturi- tion in weak, hyperesthetic individuals, without any serious complication. Heart=failure is usually due to acute dilatation in the second stage of labor, but may be the result of advanced kidney disease, of fatty degeneration of the heart itself, of a fibroid patch in its walls, of rupture of an aneurysm, of myocarditis, and of a number of other conditions that might interfere with normal heart-action. In women with diseased and weak hearts merely an intra-uterine injection has caused heart-failure. Fig. 525. — Median section of coccyx imbedded in paraffin, showing an oblique fracture run- ning through the second verte- bra. The vacant space between the lower end of the anterior fragment and the main body of the bone was filled with an ex- uberant mass of spongy bone- tissue that dropped off when the bone was taken out (author's case ) . H. 1 "Journal of the American Medical Association," Dec. 22, 1900. ''■ Scheffelaar Klots has collected 40 cases, " Ztschr. f. Geb. u. Gyn.," Bd. xli. LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 64! Fig. 526. — Coccyx ruptured in second joint by a forceps delivery. Ankylosis of all the other joints (author's case). Fig. 527. — Coccyx ruptured in first joint by a fall on the ice in eighth month of pregnancy. Injury aggravated by labor (author's case). 41 642 PATHOLOGY. Accidents of Labor. — ^Any of the serious accidents of labor may produce death by shock or by hemorrhage, as accidental, unavoidable, or postpartum hemorrhage; rupture or inversion of the womb. Rupture of hematomata, external or internal, may kill a patient by shock or by hemorrhage. In a case under my care a hema- toma in the outermost part of the left broad ligament, rupturing eighteen hours after delivery, caused death in a very short time by internal bleeding. Syncope. — There is a disposition in many women after labor to faint, but even complete syncope at this time is rarely fatal. If it depends, however, upon hemorrhage, thromboses may form in the heart, or those in the uterine sinus may be prolonged, and embolism may result. Prolonged syncope, associated with air- hunger and other symptoms of profuse internal hemorrhage, is usually fatal. Embolism and thrombosis of the pulmonary artery may be the result of SAmcope, or may be caused by the detachment of an embolus from the pelvic blood-vessels. The embolus, it is claimed, may be a globule of air,^ or may be fat from the pelvic connective tissue. The symptoms of the accident are: sudden shock, a rapid-running pulse, heart-failure, rapid respiration, air-hunger, followed usually in a few moments by death ; but the accident is not invariably fatal. The only treatment possible is stimulation, slight elevation of the body, and lowering of the head, with absolute quiet. Profound Mental Impressions. — Profound emotion may cause a woman's death during or directly after labor. The following case was described to me by a friend who witnessed it. A widow, in good position, applied for treatment for abdominal tumor. She was told that she was pregnant, but she vehemently denied the possibility of her condition. A little later her phy- sician was summoned to attend her in what he found to be labor. He told her again of her condition, but she again denied it, and throughout the whole of her labor she indignantly protested that it could not be so. Finally, when the child was delivered, it was held up before her as a proof that her physician was correct. She passed at once into a maniacal condition, crying out that the child was a tumor, that she had not been pregnant at all, and after a few minutes she died. A careful postmortem examination revealed no physical cause for her death. 1 Since I saw m}' friend, Professor H. A. Hare, inject whole syringesful of air into the jugular vein of a dog without detriment to the animal, I confess to a skepti- cism in regard to air-embolism as a cause of death in the child-bearing woman. LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 643 Other causes of sudden death during and after labor that have been reported are : a brain tumor, rupture of a gastric ulcer, acute purpura haemorrhagica, rupture of peritoneal adhesions, rupture of the aorta, rupture of a cyst in the auricular septum of the heart, retro-peritoneal hemorrhage frorn the head of the pancreas,^ and angina pectoris. Effect of Maternal Death upon the Fetus. — The fetus rarely survives its mother's death more than a few minutes, and usually the death of mother and" child is synchronous. An interesting case was reported to me by a surgeon on an American man-of- war in the harbor of Rio Janeiro during the revolution in Brazil. A pregnant woman, near term, was struck by a fragment of an exploding shell. She was killed immediatel^^ She had scarcely fallen to the ground when a Brazilian surgeon, who was standing near, cut open her abdomen and uterus with a penknife, but the child was extracted dead. Tarnier reports an extraordinary case in which it appeared that the child lived for two hours after its mother's death. During the Commune in Paris the rioters fired upon the Maternity Hospital. A pregnant woman, sitting upon her bed in a ward, was shot through the head and instantly killed. After a while she was discovered dead, and Tarnier was summoned to do postmortem Cesarean section, as fetal heart- sounds were still heard. Beginning the operation with his assist- ants, the rioters fired upon the operators, and it was necessary to remove the woman to the cellar before the attempt could be repeated. After an interval of an hour and three-quarters, or more, the operation was at length performed, and a living child extracted from the mother's womb. In case of death in a pregnant woman near term, the fetal heart-sounds should be listened for carefull}', and, if they are heard, an immediate attempt should be made to extract the child. This can be done by postmortem Cesarean section, or, better, I think, by forced dilatation of the cervix, version, and rapid ex- traction. I have had one experience in such a case, in which the dilatation of the cervax and the extraction of the child pre- sented no difficulties at all, and were completed in a very {t.\\ moments. If the patient is seen /;/ articido mortis, it is unques- tionably better to deliver her by forcible dilatation of the cervix and version rather than to await her death and then to perform a postmortem Cesarean section. Postmortem Delivery. — There is reported from time to time the birth of a child in its mother's coffin, giving rise to the horri- ble suspicion that the pregnant woman had been buried alive, and had fallen into labor when she awoke from her trance and ^ Van de Velde, " Jaliresbericht,"' vol. xii, p. 764. 644 PATHOLOGY. realized her dreadful position. These cases, however, may be explained by the accumulation of gas within the abdominal cavity due to decomposition, which so increases the intra-abdominal pressure as to drive the fetus out of the woman's body. Such cases are more common in hot climates, where decomposition progresses rapidly. ^ Accidents to the Fetus. — Prolapse of the Cord. — The cord is said to be prolapsed when it presents with or slips beyond the presenting part. Frequency . — According to Winckel, the frequency of prolapse of the funis varies in different clinics from i : 65 to i : 500. Churchill found it once in 245 labors; Christisen, once in 65; Meachem, once in 93 ; Bland, once in 1897 labors. Causes. — The causes of prolapse of the cord are, in the first place, a lack of conformity of the presenting part with the shape and size of the pelvic inlet, as in a flat pelvis or a compound pre- sentation, and with this condition an exaggerated length of the cord, placenta praevia, marginal insertion, hydramnios, sudden Fig. 528. — Trendelenburg po^turi; over a chair to guard a prolapsed cord from pre? sure and to facilitate its reposition (Dickinson). rupture of the membranes and violent expulsion of the liquor amnii ; delivery in the semirecumbent, sitting, or erect posture, and violent jolts or jars such as a parturient patient would ex- perience during transportation to a hospital in an ambulance. 1 Stumpf claims that postmortem deliveries may be due to a rigor mortis of the uterine muscles, " Monatschr. f. Geb. u. Gyn.," Bd. viii, p. 64. LABOR COMrLlCATKD BY ACCIDENTS AND DISEASES. 645 The diagnosis should present no difficulty. There is nothing else in the cervical canal or vagina, durin<^ labor, which feels like the cord or should be mistaken for it. It is sometimes actually visible at the vulvar orifice, and may, in case of doubt, be pulled out and inspected. If the child is alive, the pulsating vessels in the cord may be felt. I was once called in consultation, how- ever, by a young physician who believed that a coil of intestine had prolapsed into the vagina. The prognosis for the child is grave. The mortality in gen- eral is more than fifty per cent. The child obviously dies of asphyxia from pressure upon the cord; hence the danger is twice as great in head presenta- tions (sixty-four per cent.) as in breech presenta- tions (thirty-two per cent,). The danger to the mother lies in the operative procedures which are often required for the reposition of the cord, such as version and rapid extraction. Treatment. — The cord should be replaced by manipulation with the woman in a knee-chest posture, or, better, the Trendelenburg posture — over the back of a chair. It is advisable to hook a loop of the cord over an extremity or the chin to prevent its prolapsing again, which is extremely likely. The whole hand must be inserted in the vagina, and perhaps within the lower uterine segment; so that anesthesia is usually recjuired. While the anesthetic is administered, and while the physician makes his preparations for the reposition, the patient should be kept in the Trendelenburg posture, so as to guard the cord from fatal pres- sure. If the cord is satisfactorily replaced so that it will not come down again, forceps should be applied to the head to fix it firmly over the pelvic inlet. If the os is not sufficiently dilated to allow the application of forceps, a dilatable rubber bag (Barnes', Braun's, or Voorhees') should be inserted in the cervix or in the lower uterine segment and distended with water to prevent pro- lapse of the cord while the cervical canal is undergoing efface- ment and dilatation. If manipulation fails to replace the cord, podalic version should be performed without waste of time. The breech being firmly impacted in the pelvis, the case is managed as one of breech presentation — by delay until the os is well dilated and the cervix paralyzed, and then by rapid extraction. If the head is presenting and is engaged so that version is out of the question, the cord should be so disposed as to be least pressed upon (for example, opposite the left sacro-iliac junction in a left occipito-anterior position of a vertex presentation) and Fig. 529. — Impro- vised repositor. 646 PATHOLOGY. the head rapidly extracted mth forceps. In prolapse of the cord with a breech presentation, the cord should be replaced by manip- ulation in the Trendelenburg posture; a foot should be seized and brought down until the breech is firmly impacted in the pelvis. The instrumental reposition of the cord is usually unsatis- factory and unnecessary. Manipulation accomplishes more than can be done by a repositor. Occasionally, however, it might be convenient to remember the device illustrated in figure 529. A loop of string or tape is tied double around the end of a stiff catheter or bougie. The free loop is caught over the cord and the end of the instrument which is carried high up into the uterine cavity. Should it be desirable to withdraw the instru- ment, it can be done without pulhng the cord out with it. Rupture of the Cord. — It has been shown by experiments that the healthy umbilical cord can stand a strain of 8% pounds on the average, the weakest 5 ^ pounds, and the strongest 1 5 pounds. It is obvious, therefore, that the weight of an ordinary fetus may be enough to rupture the cord, and it is almost certain to do so if the weight is increased by a drop or violent expulsion, and if the placenta remains attached. Hence, precipitate delivery in the erect posture is often accompanied by rupture of the cord usually at the umbilicus, although in one of my cases it tore off at the placental insertion. Spaeth and Budin have each reported a case of rupture of the cord while the woman was recumbent, and the latter has also reported a case in which the weight of the placenta, suddenly expelled and dropping the full length of the cord, snapped the latter in two. A ruptured cord usually does not bleed. If it is torn off at the umbilicus and the vessels bleed, they should be pulled out by a tenaculum and ligated, or, if this is impracticable, hare -lip pins should be inserted under the umbilicus and a figure-of-eight liga- ture applied. The treatment of rupture of the umbilical cord is pre- ventive. Labor in the erect posture should, of course, never be allowed, and a precipitate labor must be retarded ; violent traction upon a coiled cord has ruptured it. It is better, in such cases, to cut the cord between ligatures and to extract the child quickly. DYSTOCIA DUE TO DISEASE. Convulsions. — Convulsions in the child-bearing woman may be defined as muscular spasms, with or without unconsciousness, occurring during pregnancy, parturition, or the puerperium. Causes. — The convulsions may be due to eclampsia, hysteria, epilepsy, tumors of the brain, cysticercus,^ and meningitis ; to the 1 Pestalozza, " Rivist. Critic, di Clinic. Medic," igcxj. DYSTOCIA DUE TO DISEASE. 647 profound anemia following postpartum and other hemorrhages, and to ai)0])lexy; or there may be an exaggeration of the nervous irritabihty characteristic of the child-bearing period, in conse- quence of which convulsions may arise from some trifling irri- tation, as that of an overdistended bladder, overloaded bowels, the introduction of the hand in j)erforming version, the pressure of the head upon the perineum, and excessive after-pains. Puer- peral convulsions, therefore, is a symptom indicative of a variety of pathological conditions. Eclampsia^ is a name given to the most frequent variety of convulsions in the child-bearing woman, the result of a gesta- tional toxemia. Causes. — Since Lever's^ discovery of the albuminuria usually preceding and accompanying eclampsia, kidney insufficiency has been regarded as the chief cause of eclampsia, but recent studies in the toxemia of pregnancy, while not diminishing the importance of imperfect elimination by the kidneys in the etiology of eclampsia, have established other factors in the causation of the disease. The several theories advocated at present start with the common assump- tion that the ovum or fetus is the source of toxins contaminating the maternal blood. What these toxins are and where they origi- nate is still unknown. Kollmann^ points out that the fibrin-form- ing elements of the blood are much increased in eclampsia. To these globulins, albuminous, large molecular bodies which furnish the excess of fibrin, is ascribed the toxicity of the maternal blood. There is much to support this view. Experimentally these sub- stances have been demonstrated to be toxic, producing eclamptic symptoms. The negative results of cryoscopy in the urine of eclamptic patients indicate that there is an excretion of high atomic large molecular substances. Whether these substances, if they are the toxins of eclampsia, are derived from fetal metabolism or from the placenta is disputed. The author favors the former view for the following reasons: The toxemia of early pregnancy, which is probably due to the syncytial growth, differs in its clinical manifestations from the toxemia of the latter half of pregnancy; ehminative treatment and dietetic management to spare the kidneys and liver favorably influence the toxemia of the second half of pregnancy, but have no effect on the toxemia of the first half. The symptoms of the toxemia of the latter half of pregnancy usually disappear with the death of the fetus; in mul- 1 Hippocrates used the word sx^^n/ii'ic to designate a sudden rise of tempera- ture. In the middle of the eighteenth century Boissier de Sauvagcs mistaicenly appHed the word to convulsions. The correct term would be eclactisma (ex/^axTii^Eiv^ " to kick backward "). 2 " Guy's Hospital Reports," 1843. 3 " Centralbl. f. Gyn.," 1897, No. 13. 648 PATHOLOGY. tiple pregnancies albuminuria and eclampsia are ten times more frequent than in single pregnancies; in hydatidiform mole with its enormous overgrowth of syncytium eclampsia is rare; only a few cases are recorded ;'^ the innumerable experiments to de- monstrate the placental origin of the toxins of eclampsia have as yet had no positive results.^ The toxins in the maternal blood are conveyed first to the liver, where they are converted into substances fit for elimination by the kidneys. If the liver fails in its functions or breaks down under the strain imposed upon it, the maternal blood contains toxic material irritating to the kidneys, the central nervous system, and the capil- laries everywhere. The kidneys manifest the irritation of their capil- laries and of their epithelium by the symptoms of parenchymatous nephritis. Clinically it appears that even if the hepatic function is imperfectly performed functionally active kidneys are competent to excrete the imperfectly oxidized excrementitious matters in the maternal blood. On the contrary, with impaired excretory power in the kidneys, a cumulative toxemia develops, ending in eclampsia. The following facts support this view: Hepatic degeneration, in some cases to the grade of acute yellow atrophy, is a constant con- dition in post-mortem examinations of eclamptic patients; a small proportion of cases display no kidney insufficiency prior to the eclampsia (10 to 16 per cent.). But some form of kidney disease is discovered post-mortem in the large majority of cases: In 18 out of 81 autopsies Herzfeld found the ureters compressed at the pelvic , brim and dilated; in more than four-fifths of the cases eclampsia is preceded by albuminuria and other signs of kidney breakdown; as the kidney symptoms increase in severity eclampsia becomes more imminent; with improvement in the kidney symptoms the danger of eclampsia decreases; examinations of the urine show apparently an imperfect oxidization of the nitrogenous bodies ex- creted.^ An effort has been made to discover the origin of the antibody to the gestational toxins. Nicholson^ claims that the thyroid gland is the most im- portant factor in furnishing an antibody for the toxins of preg- nancy. Adequate hypertrophy and hypersecretion of the gland, ^ Case of eclampsia and hydatidiform mole without fetus at eighth month reported and others referred to, " Centralbl. f. Gyn.," March, 1911. 2 See " The Placental Theory of Eclampsia: Further Experiments with the Complement Fixation Test," Frank and Heimann, " Surg., Gyn., and Obstet.," May, 1911. ' Massen, Ludwig, Savor, Whitney, Clapp; " Centralbl. f. Gyn.," 1895, No. 42; " Am. Gyn.," August, 1903. ^ " Journ. of Obstet. and Gyn. of the Br. Empire," July, 1902; " Brit. Med. Journ.," Oct. 3, 1903. DYSTOCIA DUE TO DISEASE. 649 which is the rule in pregnancy, safeguards a pregnant woman against toxemia; inadequate activity predisposes her to it. Other investigators have sought the cause of eclampsia in abnormal secretions of the parathyroids, the suprarenals, the pituitary body, and the mammary glands.^ Anaphylaxis is believed to be operative in eclampsia by many observers. In spite of the enormous amount of investigation to which this subject has been subjected in the last decade it is not yet possible to explain the etiology of eclampsia fully. The only facts on which there is agreement at present are that there is a toxin or toxins in the blood of the pregnant woman derived from the ovum or fetus; that these substances affect mainly the liver and kidneys; that a breakdown of either of these organs results in a toxemia ; that the accumulated toxins are intensely irritating to the capillaries; that either in consequence of an acute anemia of the brain, due to contraction of the capillaries or to a direct irritation of the central nervous system, convulsions appear. From the clinical point of view it is a mistake to minimize the importance of the kidneys. The examination of the urine gives a valuable premonitory sign of gestational toxemia in the latter half of pregnancy in more than four- fifths of the cases, and a treatment to avoid strain on the kidneys and to promote free urinary excretion is the only effective preventive treatment of eclampsia except the termination of pregnancy. There must be taken into account also the extreme nervous irritability of the child-bearing period, predisposing to convul- sive outbreaks." The kidneys in pregnancy may become insufficient excretors, by reason of the kidney of pregnancy, of nephritis, of increased intra-abdominal pressure, or of direct pressure upon the ureters. It is important in practice to appreciate that the kidneys may be diseased and yet functionally sufficient, or that they may be healthy anatomically, but functionally insufficient. Frequency. — Eclampsia occurs about once in 300 cases of pregnancy. It is most frequently seen in primiparas, and more frequently in women illegitimately pregnant. It most often occurs during labor, is next in frequency during pregnancy, and occurs least frequently during the puerperium. It is ten times as frequent in multiple pregnancies as in single pregnancies, and occurs with greater frequency in climatic conditions which inter- fere with the free activity of the skin and throw extra work upon the kidneys. ^ See the excellent review of the subject by Professor Bar, " Ann. de Gyn. et d'Obstet.," Nov., 1911. 2 Meyer-Wirz, " Klinische Studie ueber Eklampsie," "Arch. f. Gjii.," Bd. Ixxi, H. I. 650 . PATHOLOGY. Symptoms. — Eclampsia should always be feared if there are signs of kidney disease or disturbance during pregnancy, for diseased kidneys are more likely to be insufficient than healthy kidneys, and in more than four-fifths of the cases gestational toxemia is manifested by marked and increasing albuminuria, increasing blood-pressure, however, is the most constant symp- tom of gestational toxemia in the latter half of pregnancy, and is an invariable precursor of eclampsia. The other symptoms of toxemia should also serve as danger signals; namely, digestive disturbances, pain in the epigastrium, rapidity of pulse, anom- alies of vision, edema, and headache. The prodromal symptoms of the attack itself are: Sharp pains in the head, epigastrium, or under the clavicle; muscae volitantes, with failure of vision, great restlessness, or stupor. A few moments after the appearance of the prodromal symptoms the attack comes on with a stare; the pupils are at first contracted; the eyelids twitch, the eyeballs roll, the mouth is pulled to one side, the neck is then affected, and the head is pulled first toward one shoulder and then toward the other. The spasm finally spreads to the trunk and upper extremities; the arms are strongly flexed, the fingers are bent over the thumb, and the upper extremities work spasmod- ically to and from the median line in front of the chest. The spasm of the respiratory muscles with the closure of the teeth and lips give rise to a jerky sort of breathing with a characteristic suck- ing sound. The lower extremities are rarely affected, although the thighs may be flexed tonically upon the abdomen. Conscious- ness is lost during the convulsive attack and for some time after- ward; with each returning fit the stupor deepens, until at length there is unbroken coma. The convulsion lasts for a minute or two. The temperature usually rises higher with each convulsion. The patient often has no recollection whatever of events during, preceding, and following the whole period of her convulsive attacks, though she may have seemed to be perfectly conscious the greater part of the time. The urine is almost always albuminous after the first or second convulsion; albuminuria precedes the convulsions in more than four-fifths of the cases. The percentage of urea and of most of the urine salts except the chlorids is not necessarily lowered, though the total excretion is diminished owing to a scanty secretion of urine sometimes to a complete anuria. The urine may con- tain methemoglobin and oxyhemoglobin as well as free blood, numerous casts, and desquamated cells. Pathology. — The lesions of. eclampsia are by no means confined to the kidney, in which, however, extensive degeneration of the epithelium or interstitial nephritis is almost invariably found. In DYSTOCIA DUE TO DISEASE. 65 I 18 out of 81 autopsies Herzfeld found the ureters much dilated by compression at the pelvic brim.^ The most constant and char- acteristic changes are found in the liver, as pointed out by Schmorl- in 1893, consisting in numerous anemic or hemor- rhagic necroses and capillary thrombi. In the kidney, brain, and lungs are numerous thromboses of the small capillaries, extrava- sations, and necrotic areas. Emboli of liver cells are found in the important organs. There is degeneration of the m}-ocardium. In the lungs there may be edema or pneumonia and infection from the inspiration of foreign material from the mouth. There are also in the lungs emboli of giant polynuclear cells which Schmorl attributes to the surface of the placental villi, having, indeed, demonstrated their exfoliation, absorption into the circu- lation from the intervillous blood spaces, and their passage through the heart to the lungs, where they are arrested because they are too large to pass the capillaries.'' Schmorl attributes eclampsia to the exfoliation of these giant cells.'* At least 5 per cent, of women wdth diseased kidneys de- velop eclampsia, the proportion of one in twenty contrasted with one in three hundred showing the influence of imperfect kidney action in the etiology of gestational toxemia and eclamp- sia. As a matter of fact, only a small minority of patients with diseased kidneys go through pregnancy without some of the manifestations of toxemia. Diferential Diagnosis. — The convulsions of eclampsia must be distinguished from those of epilepsy, hysteria, brain disease, hemorrhage, or of some source of irritation within the body, as mentioned above. The distinction should be made without dilS- culty by an estimation of blood-pressure and by an examination of the urine. The former is rarely below 180. If the patient is catheterized, and the urine is heated in a spoon, it will turn almost solid by the coagulation of albumin in it. About 16 per cent, of the cases of true eclampsia show no albuminuria before the convulsions appear, but in every case, after the second con- vulsion at least, the urine contains albumin, almost always in large quantities. Casts are present in abundance. The other conditions causing convulsions in the child-bearing woman have their distinctive signs that serve to make the differential diag- nosis easy. ^" Centralbl. f. Gyn.," No. 40, 1901. - " Pathologisch-Anatomische Untersuchungen iiber Puerperal-Eklampsie," Leipzig, 1893. ^ Pels Lensden has found these giant cells in the lungs of non-eclamptic patients, " Ztsch. f. Geb. u. Gyn.," xxxvi, S. i. ^"Pathologisch-Anatomische Untersuchungen iiber Puerperal-Eklampsie," Leipzig, 1893. 652 PATHOLOGY. Prognosis. — In general practice it may be stated that the mor- taHty of eclampsia is thirty per cent, but in different localities, and at different times, the mortality varies widely. For example, the mortality in nine lying-in hospitals in this country during a period of five years was 38.4 per cent, in 78 cases. The mor- tality of the Royal Maternity in Edinburgh has been 66.6 per cent. That of Guy's Charity, in London, averages 25 per cent. In 209 cases in the Maternite, in Paris, from 1850 to 1856, the mortality was 33 per cent. Winckel reports 92 cases, with 7 deaths — a mortality of 7.6 per cent. Veit reports more than 60 cases, with 2 deaths — a mortality of 3.3 per cent. In 46 cases in the Charite, in Berlin, there were 6 deaths, 2 of these being due to complications, so that the mortality of the eclamptic cases was 8.5 per cent. It is claimed that in Germany in general the mor- tality has been reduced to between 7 and 10 per cent., but in 80 cases in the University Maternity of Berlin, the death-rate was 21.25 per cent. In the Maternity Hospital of Christiana there were 160 cases from 189 5-1 904, with a mortality of 26 per cent. In 496 cases in Olshausen's clinic the mortality was 21.4 per cent.^ In the Maternity of the University of Pennsylvania the mortahty in 128 cases was '^t, per cent., but, excluding the cases admitted in such bad condition that death ensued in less than twelve hours, the mortality is less than 13 per cent. The causes of death may be edema of the brain, of the lungs, or of the larynx; apoplexy, asphyxia, exhaustion, heart-failure; thrombosis and embolism in important vessels, especially the pul- monary arteries, insufflation of foreign substances (food, blood) into the lungs, and bronchopneumonia, or an overwhelming accu- mulation of the poison of eclampsia in the system. In one of my patients there was gangrene of the lungs and in another purpura hemorrhagica of the most malignant type. The mortality is greatest during pregnancy and least in the puerperium. The greater the number of convulsions and the shorter the interval between them, the graver the outlook; but death may follow the first convulsion and recovery has been observed after sixty-nine.^ Rapid pulse and high temperature are unfavorable s}'Tnptoms. Nothing is so uncertain as the result of eclampsia. The physi- cian should never relinquish hope of recovery until death ac- tually occurs, but should not be too confident even in apparently favorable cases. The mortality of the child, if eclampsia occurs during preg- nancy or labor, is about 50 per cent.^ i"Ztschr. f. Geb. u. Gyn.," Bd. Iviii. ^Lithgow, " Brit. Med. Jour.," March 26, 1904. ' Enormous statistics of eclampsia in " Jour. Am. Med. Assoc," Jan. 2, 1904, p. 67. Also Goedecke, " Zeitschr. f. Geb. u. Gyn.," Bd. xlv, S. 50; Glockner, "Arch. f. Gyn.," Bd. xxxvi, S. 171; Meyer-Wirz, " Arch. f. Gyn.," Bd. Ixxi, H. i. DYSTOCIA DUE TO DISEASE. 653 Treatment. — The preventive treatment of eclampsia has been in part referred to in the section upon the Management of Preg- nancy, and under the head of Gestational Toxemia and of Kid- ney Diseases during Pregnancy. As already stated, the blood- pressure should be taken and routine examinations of the urine should be made every two weeks until the last month, and then weekly. If the blood-pressure is above 140, if any abnormality is found in the urine, such as a high or low specific gravity, diminution in total quantity in the twenty-four hours, albumin or casts, or if the patient reports headache, disturbance of vision, edema, gastralgia, nausea, dyspepsia, palpitation of the heart, or a feeling of general malaise; if she presents an abnormal ap- pearance, has a rapid pulse, coated tongue, foul breath, or a dry, harsh skin, with a sallow complexion, the blood -pressure should be measured, the total quantity of urine passed in the twenty- four hours should be collected daily and examined for albumin, specific gravity, and casts. If the blood-pressure is high, whether the urinary examination is satisfactory or not, the patient should be put on a diet mainly of milk; meat, eggs, fish, and the stronger nitrogenous vegetables being excluded. A laxative at bedtime, copious draughts of water, and a diuretic should be prescribed. If, in spite of milk diet, confinement to bed, purgation, diuresis, and diaphoresis, the blood-pressure rises, the albumin increases and the urine decreases, labor should be induced. The treatment of the eclamptic convulsions themselves is best dealt with by considering the dift'erent plans of treatment separately, with their results, so that their relative merits may appear plainly. Anesthetization. — When chloroform first came into general use it was regarded by many as a specific for eclampsia. Series of 20, 12, and of 9 cases, treated by chloroform alone, were re- ported without a death. Charpentier reports 63 cases treated by chloroform alone with 7 deaths — a mortality of 1 1 per cent. But the mortality from this treatment in the Maternite was 50 per cent. As the prolonged administration of chloroform may produce the same degeneration of the liver seen in eclampsia, as it is not possible to use it with much effect when the convulsions appear, for respiration is practically suspended, it is not a valuable remed}' in eclampsia. If operative measures are necessary and an anesthetic is required, ether is preferable.^ Diaphoresis and Catharsis. — Eclampsia is the result of a toxemia, and can not be cured until the toxins are eliminated. i"The Treatment of Eclampsia," Cragin and Hull, '"Jour. .\m. Med. Assoc," Jan. 7, igit. 654 PATHOLOGY. The only emunctories available for quick and effectual action are those of the skin and bowels. No matter, therefore, what plan of medicinal treatment may be adopted, diaphoresis and catharsis must also be employed. For the former there is nothing so effective as the portable sweat cabinet (Fig. 530), with which every physician who may see cases of eclampsia should be provided. The injection of water into the sub- cutaneous cellular tissue or under the breasts is an indispensable aid to free elimination by the skin.^ It seems literally to wash the blood of its impurities. If, however, the patient does not sweat Portable sweat cabinet. or purge freely, the injection of water predisposes to pulmonary edema. Free catharsis is produced best by the use of croton oil, which may be administered in drop doses with a little sweet oil upon the back of the tongue, and can, therefore, be given to a woman whether she is able to swallow or not. Elaterium in quarter-grain tablets may be administered in the same manner. It is often advisable to wash out the stomach; if this is done, an ounce or more of castor oil with a couple of drops of croton oil may be put into the stomach through the stomach-pump. Venesection. — In a report of 15 cases in which bleeding seems to have been the only thing done, there was but one death. In ^Salt solution is inadvisable on account of the deleterious action of salt on the kidneys. DYSTOCIA DUE TO DISEASE. 655 appropriate cases the venesection should be done in time, and not, as sometimes recommended, only when sym])toms of jmlmonary edema ajjpear. The measure is preventive of this accident, not curative. A blood-pressure of 180 or over indicates venesection. Sixteen ounces of blood or more should be withdrawn. Morphin. — Older statistics of the morphin treatment for eclampsia show a death-rate of 57 per cent. (Winckel), but Veit in more than 60 cases had only 2 deaths — a mortality of 3.3 per cent. This result is obtained by giving very large doses of the drug. Veit has injected one-half grain in each convulsive seizure, and has administered as much as three grains in four to seven hours, and four and one-half grains in twenty-four hours. This treatment is permissible if, as is usually the case in eclampsia, there is parenchymatous ne])hritis. In interstitial nephritis it would almost surely kill the patient.^ It also antagonizes the eliminative treatment. For these reasons the author does not recommend it routinely, but uses it if the con- vulsions are unusually violent or frequent. Chloral. — Charpentier's statistics of 114 cases, with a mor- tality of 3 J per cent, from this treatment, is a strong argument in its favor. Winckel by its use has saved 85 out of 92 cases. It must be given in large doses to be effective. Thirty to sixty grains should be administered by enema at a dose, and as much as three drams may be given in the twenty-four hours. . Veratrum Viride. — Fearn, in 187 1, reported 11 cases of his own and 2 cases from the practice of professional friends treated with very large doses of veratrum viride. None of the women died of the convulsions, but one succumbed later to puerperal sepsis. Rushmore has collected 85 cases of eclampsia treated with veratrum viride, with 20 deaths — a mortality of 23^ per cent. Jewett reported to the American Gynecological Society, in 1887, 22 cases of eclampsia treated with veratrum viride. Four of the women died of the convulsions — a mortality of 18 per cent. In 50 cases of eclampsia collected by Trimble, veratrum gave much the best results. In 26 cases treated by this drug there were 3 deaths, while in the remaining 24 cases there were 6 deaths — a mortality, respectively, of 11.5 and 25 per cent. Mangiagalli reports 18 cases treated with veratrum viride with one death, not from the disease ;2 Zinke,^ 26 cases with a mor- tality of i5.78jper cent. I have used it in more than 200 cases in the last twenty-five years and believe it efficient in reducing blood-pressure. ^Meyer-Wirz found interstitial nci)hritis three times in thirtv-five autopsies, "Arch. f. Gyn.," Bd. Ix.xi, H. i. 2" Ann. di Ost. e Gin.," No. 7, 1900. ^ " Am. Journ. Obstct.," Feb., 1911. 656 PATHOLOGY. Other Remedies to Reduce Blood-pressure. — A rise of blood- pressure always precedes eclampsia, and increases with the severity of the attack. A fall in blood-pressure, with amehora- tion of the other symptoms, is the most favorable prognostic sign, but with aggravation of the other symptoms indicates im- pending death. The most successful remedial measures are those which reduce blood-pressure most quickly and most effectu- ally, namely: Puncture of the membranes; sweating; purgation; venesection; veratrum viride, and nitroglycerin. The remedial measures detailed above comprise all that should be seriously considered. Caffein, oxygen, and nitrite of amyl are occasionally indicated. Pilocarpin, as a routine treatment, is simply mentioned to be condemned. It causes edema of the lungs. In the Edinburgh Maternity, where it was employed for a time, the mortality was 66.6 per cent. Occasionally, however, if wet or dry heat fails to make the patient sweat, a single hypodermic injection of \ grain is of great service. This drug is least dangerous in eclampsia after delivery. Thyroid extract, recommended by Nicholson as a vasomotor dilator, is receiving a trial. It is often difficult to administer it if the woman can not swallow. Parathyroid extract promises more satisfactory results than thyroid extract, and should be systematically tested.^ Hirudin, intravenously, has been recom- mended on account of the capillary thromboses in important organs, but it is a serious matter to limit the coagulability of the- blood in view of the possibility of postpartum hemorrhage. Lumbar puncture, ^ decapsulation of the kidneys, and nephrot- omy have been tried for eclampsia. Decapsulation of the kidney^ has several advocates, especially in cases of scanty urine or anuria, but wet cups and a flax-seed meal poultice over the whole back with digitalis leaves is much safer and quite as efficacious. Amputation of the breasts advocated and per- formed by Sellheim^ and Herrenschneider is a fantastic pro- cedure not likely to be generally adopted. In eclampsia during parturition the obstetrical treatment must receive consideration. As a rule, it is better to avoid inter- ference with the progress of labor, unless the cervix is effaced and the OS is fairly well dilated. Should eclampsia come on before ^See Zanprogini, "La Clinic. Ostet.," " Riv. di Ostet.," etc., anno 7,_ 1905; also, " La Clinic. Ostet.," January, 1906; Vicarelli, " Giorn. d. R. Accad. di Med. di Torino," 1906. I am using it in i-grain doses every three to four hours; if necessary, given through the stomach-tube. 2" Lumbar Puncture for Eclampsia," "Zentralbl. f. Gyn.," No. 45, 1904; " Nephrotomie," ibid. ^ First proposed and carried out for eclampsia by Edebohls in 1903. ^"Zentralbl. f. Gyn.," No. 50, 1910, p. 1601. DYSTOCIA DUE TO DISEASE. 657 labor begins at all, or in its earlier stages, the physician's atten- tion should be confined to combating the convulsions, to reducing the blood-pressure, and to the eliminative treatment. Having secured some improvement in each of these particulars, attention may be turned to the delivery of the patient. It is usual to find that the os has dilated rapidly during the convulsive at- tacks or in consequence of vigorous eliminative treatment, and Day of Disease r" n 107" 106° 105° 104° 1037 102° 101° 100° 99° 98° 97° M E ML ~ M E M E M £ /^ ^ \f £ i \ .| }>^ § ^ -*s y s Si^ K \ V K % h \ : ■ . '■ Pulse '^ ^ 9£ V Resp. V 'n N^ Fig. 531. — Temperature-chart of a patient falling in labor in the midst of an attack of typhoid fever (author's case). that the completion of the labor is possible without shock or violence. There are many advocates of forced delivery {accouchement force) in all cases of eclampsia before or during labor, by vag- inal Cesarean section, instrumental dilatation by Bossi's or other branched dilators, by manual or hydrostatic dilation, or even by abdominal section. Zweifel's statistics show, it is claimed, a mortahty of only 15 per cent, in 223 cases treated by accouche- ment force as contrasted with a mortahty of 32.6 from the expectant plan. Abdominal Cesarean section has been per- 42 658 PATHOLOGY. formed in 40 cases with 21 maternal and 18 fetal deaths.^ 01s- hausen in 250 cases of eclampsia has performed three Cesarean sections with one death. ^ Vaginal Cesarean section is at present the operation most in vogue for the operative delivery of eclamptic patients. Peter- son,^ who advocates it, collected 530 operations with a maternal mortality of 23.4 per cent., and a fetal mortality of 21.2 per cent. It seems logical to evacuate the uterus as the first step in the treatment of eclampsia. The ovum or fetus is the source of the toxemia; many statistics show a less mortality after labor than before, and it is quite a frequent experience to witness a cessa- tion of the convulsions as soon as the child is expelled, but the necessary operation for the delivery of the woman distracts one's attention from the treatment of the convulsions, and adds for the time being a violent source of irritation to the already highly wrought nervous system. Eclamptic patients are particularly liable to fatal shock from forcible delivery or operative measures.* Any kind of accouchement force in a private house by a general physician has a high mortality. Moreover, by waiting', for a brief period, during which energetic treatment may be directed to the convulsive attacks, sufficient dilatation of the os is almost always secured naturally to permit the delivery of the woman without excessive violence or without too much loss of time. Puncture of the membranes hastens spontaneous dilatation and lowers the blood-pressure more quickly and effectually than any- thing short of actual delivery; hence, I resort to it routinely. As soon as the os is dilated beyond the size of a dollar, delivery may be hastened with advantage by bags in the cervix, by applying forceps if the head is engaged in the pelvis, or by performing ver- sion and extraction by the feet if the head is not yet engaged, or if the breech presents. In eclampsia gravidarum labor may be induced after the convulsions cease and the toxemic symptoms abate, or the uterus may be emptied if the patient fails to respond to treatment after a reasonable length of time. In considerably more than 200 cases I have given both methods an extensive trial. No doubt remains in my mind that much the lowest mortality is secured by avoiding accouchement force as a routine treat- ment. But if the patient fails to respond to the eliminative ^Hillmann, " Sectio Caesarea bei Eklampsie," " Montaschr. f. Geb. u. Gyn.," Bd. X. ^ " Geb. Ges. zu Berlin," Nov. 24, 1899. * A Consideration of Vaginal Cesarean Section in the Treatment of Eclampsia, based upon a Study of 530 Published and Unpublished Cases, " Am. Journ. of Obstet.," vol. Ixiv, No. i, 191 1. ^Seitz quotes 123 cases in which convulsions ceased after emptying the- uterus, but, nevertheless, 20 per cent. died. DYSrOCIA DUE TO DISEASE. 659 treatment, to sedatives, and to measures for the reduction of blood-pressure, the evacuation of the uterus should be tried by vaginal Cesarean section, by forced dilatation of the cervix, or even by abdominal Cesarean section. It may be useful to the student to have a scheme of treatment for the average case of eclampsia that he can put into effect with- out delay or confusion from considering the relative merits of the different remedies just detailed. The following plan should be successful in the majority of cases: During the attack itself put a towel like a bridle between the teeth to guard the tongue. As soon as the attack has passed off inject under the skin fifteen drops of the fluidextract of veratrum viride, and ad- minister by the bowel a dram of chloral in solution. Place upon the back of the tongue two drops of croton oil diluted with a little sweet oil. Or, if practicable, wash out the stomach and pour into the stomach-pump 2 ounces of castor oil w^ith two drops of croton oil. Give a thorough sweat for thirty minutes in the portable cabinet every four hours. Ice should be applied to the head while heat is applied to the body. Inject by gravity under the breasts or breast a pint or more of water, or, if the needle for subcutaneous injection is not at hand, inject several quarts slowly by gravity into the bowel. After the first injec- tion under the breasts, the subsequent injections should be into the bowel. The sweats and injections should be alternated every four to six hours. If convulsions recur, nitroglycerin, gr. y^y, should be given every four hours. If the blood-pressure is above 180, venesection should be resorted to, withdrawing sufficient blood from the veins to reduce the pressure. If the convulsions are violent and frequent half a grain of morphin should be given, and, if necessar}% repeated. If the face is pale and the pulse rapid and weak, stimulation may be required in the shape of digitalis, strychnin, nitroglycerin, caft'ein, brandy, ether, or ammonia h^-podermatically. If the convulsions cease and the patient lies in a stupor, elaterium should be given until free catharsis is established. If pulmonary congestion and edema develop, wet or dry cups should be applied over the chest. If the breathing is stertorous, the face cyanosed and swollen, wet cups or leeches should be applied to the back of the neck and behind the ears, and oxygen should be administered. If there is very scanty urine or anuria, wet cups over the lumbar region and a large poultice over the whole back with digitalis leaves in it should be used. Usually the kidneys recover after eclampsia, but often a true nephritis persists or there is kidney breakdown in subsequent pregnancies. One of my patients had albuminuria and convul- 66o PATHOLOGY. sions in five successive pregnancies, another in six. A woman who recovers from eclampsia should be watched for months and urinary examinations should be made at intervals for years. In subse- quent pregnancies dietetic precautions should be insisted upon. Shock. — The strain of labor in a weak woman, some of the accidents of parturition, or even forcible attempts to expel the placenta, may occasion shock after delivery, with lowered tem- perature, leaking skin, and a running, rapid pulse. Cases of this sort have been reported from compression of the left ovary in attempts to expel the placenta by Crede's method, the womb being turned upon the cervix so that the left side looks forward, and the ovary is grasped between the thumb and the uterine wall, when the hand is placed on the fundus of the womb in the effort of expression. The condition calls for the ordinary treatment of shock — heat externally and stimulants hypo- dermatically. Typhoid fever, pneumonia, and other adynamic diseases may occur in pregnant women, and in the majority of cases occa- sion premature delivery. In typhoid fever this occurs in sixty- five per cent, of the cases, and in pneumonia the proportion is quite as large. The advent of labor in the midst of these diseases is usually disastrous to the patient. Profound shock is often de- veloped ; the temperature falls abnormally low, even to 95° F., and the heart-action may be extremely weak. Active stimu- lation should be employed during the first stage of labor, and, as soon as the os is sufficiently dilated, the child should be artificially extracted as rapidly as possible without serious injury to the mother, in order to save her the strain of voluntary muscular effort in the second stage. Valvular Disease of the Heart. — Mitral disease is the most serious. Certain statistics show a mortality as high as fifty-three per cent. As pregnancy advances the heart becomes more and more embarrassed, and respiration more labored. The most dan- gerous period, however, is just after the expulsion of the child, when the circulation is much disordered and an extra quantity of blood is thrown back upon the heart. It has been noticed that when the discharge of blood from the vagina is profuse, cardiac failure rarely occurs. This clinical observation points to the most successful treatment in cases of threatened heart-failure, — namely, venesection, — with the removal of from eight to sixteen ounces of blood, if there is not much blood lost from the parturient tract after labor. Nitrite of amyl and nitroglycerin are the most valuable stimulants to employ during labor and directly after its completion. Digitalis should be administered hypodermatically during the first stage in large doses, and as soon as it is possible to insert the ABNORMALITIES IN INVOLVI'ION OF THE UTERUS. 66 1 forceps through the os, or to grasp the child's feet if the head is not engaged, the infant should be rapidly and, if necessary, forcibly extracted without anesthesia. Deej) incisions of the cervix are of the greatest value in cutting short the duration of labor and in lessening the force required in the artificial delivery of the child. With this plan of treatment the mortality of heart disease in labor will be much reduced. It has been my fortune not to lose a case, altliough charged with the care of a number, some of which were of the most serious character. CHAPTER Vlll. Abnofmalities in the Involution of the Uterus after Child-birth. An abnormal course in the return of the uterus from the post- partum condition to the ordinary dimensions and weight of a non- gravid womb may manifest itself by excess or by deficiency ; there may be superinvolution or subinvolution. Superinvolution is an abnormal prolongation or an exag- geration of the process by which the gravid womb returns, after delivery, to the dimensions of a healthy non-pregnant uterus. It is in consequence reduced to a size much smaller than normal. Trommel detected superinvolution in 29 out of 3000 cases; Simpson^ saw it in 22 out of 1300 cases; Sinclair,- in measuring 108 uteri after childbirth, found in 22 instances a uterine cavity of less than 2\ in. (5.7 cm.), and Fordyce Barker^ saw i to 3 cases every year; in his opinion superinvolution constitutes about i per cent, of uterine diseases. Hansen,'' among 120 nursing women, found 2 with a uterine cavity below 6 cm. (5.6, 5.4 cm., or 2.2, 2.1 in.) respectively at the eighth and tenth week after delivery. Cases have been reported after abortion. 1 A. R. Simpson, " Superinvolution of the Uterus," " Trans. Edinburgh Obstet. Soc," i882-'83, viii, p. S8. 2 "Trans. Amer. Gyn. Soc," vol. iv. This series of measurements, as well as others made later by Sinclair and Richardson ("Trans. Amer. Gyn. Soc," vols, vi and vii), are sharply criticized by Hansen, who declares them to be in great part in- correct. The criticism is apparently merited. 3 " Trans. Amer. Gyn. Soc," viii, 1883; discussion on Dr. Johnson's paper. * " Ueber die puerperale Verkleinerung des Uterus," " Zeitschr. f. Geburtsh. u, Gyn.," xiii, S. 16. 662 PATHOLOGY. The etiolog}' of the condition is obscure. It has been ascribed to wasting diseases, as phthisis, cancer, etc.; to ane- mia from hemorrhage at a previous birth or miscarriage; to nervous derangements, as puerperal insanity or chorea; to over- lactation; to a rapid succession of labors; to local inflammations, especially those which attack the ovaries and abrogate their functions. I have seen it follow a curettage repeated three times. The degree to which the superinvolution may occasionally pro- gress is surprising. A. R. Simpson reports a case in which the uterine cavity measured but \ of an inch. The treatment is the application to the uterus by a platinum intra-uterine electrode of galvanism, lo to 12 milliamperes, by the negative pole; slow and rapid interrupted Faradism for fifteen to twenty minutes every other day for six weeks. Subinvolution may be described as an arrested or a retarded involution of the puerperal uterus. Causes of Subinvolution. — Any condition which prevents a rapid diminution of the blood-supply to the puerperal uterus m_ay be a cause of subinvolution. Any condition which interferes Avith the contraction of the uterus is a cause of subinvolu- tion. It is necessar}' to make these two broad divisions in the etiology of subinvolution, for, although frequently interdepend- ent, they are not rarely independent of each other. In point of frequency there should be placed first those causes which pre- vent the normal decrease of blood-supply to the uterus after labor. Prominent among these should stand hyperplasia of the endometrium. Subinvolution by an excess of blood-supply may occasion- ally be traced to the presence of small fibroids, throughout the uterine wall. Other causes of subinvolution are lacerations of the cervix and peri-uterine inflammations ; inflammations of the uterine body and of its lining membrane, usually the result of sepsis ; re- tention within the uterus of placental fragments, shreds of mem- branes, placental or fibrinous polypi, and blood-clots ; chronic con- stipation ; displacements of the womb ; premature getting up ; premature resumption of sexual intercourse ; and anything which interferes with the return of the venous blood to the heart, causing a passive congestion of the pelvic organs, as increased intra-abdominal pressure from abdominal tumors, certain diseases of the liver, and valvular disease of the heart. Many examples of subinvolution by the mechanical prevention of perfect uterine contraction may be observed, as large intra- mural and submucous fibroids ; unusually large masses of hyper- trophied decidua that sometimes develop at the placental site ; the retention within the uterus of considerable portions of the ABNORMALITIES IX INVOLUTION OF THE UTERUS. 663 placenta, or j)lacentie succenturiata; ; large blood-clots ; the dis- placement of the uterus by a retroversion or flexion of the organ, or by an overfilled bladder ; peritoneal adhesions from old or recent inflammatory attacks, involving the serous covering of the uterus and adjacent parts. One fact stands out clearly from an observation of such cases : The cause of subinvolution is always some local disturbance, and not a constitutional de- rangement. The puerperal state may be complicated by any of the acute or chronic febrile affections, without the slightest in- fluence upon uterine involution. ^ One exception, however, must be made to this general state- ment : nervous derangements do influence involution. A. R. Simpson rightly as.signs to puerperal insanity a prominent role in the causation ot superin\olution. On the other hand, a sudden mental shock, some powerful emotion, may temporarily arrest involution. The diagnosis of subinvolution is easy. The fundus uteri should be a finger's breadth above the umbilicus on the first day of the puerperal state, higher than it is directly after birth ; on the second day, at the level of the umbilicus ; the third day, a little below ; the fourth day, about the same ; the fifth and sixth days, two fingers' breadth below the umbilicus ; the seventh, eighth, and ninth days, three or four fingers' breadth above the s}'m- physis pubis ; the tenth, eleventh, and twelfth days, at the level of or a little below the pubes. ^ Hansen, by measurements of 120 nursing women from the tenth day until the third month after delivery, gives the following as the normal course of in\-olution from the tenth day of the puerperium until the completion of the process : Average Intra-uterine Measurement. Minimum. Maximum. Tenth day (^114 measurements) . . 10.6 cm. 8 cm. 13.5 cm. Fifteenth day (1 19 • 9-9 " 8.3 " II. 5 " Third week ( 95 . 8.8 " 7-5 " 10.5 " Fourth week ( 80 . S.o " 7.0 " 9-3 " Fifth week ( 64 • 7-5 " 6.5 " 9.0 " Si.vth week ( 56 . 7.1 - 6.2 " 9.1 " Seventh week ( 40 . 6.9 " 6.0 " 8.5 " Eighth week ( 31 . 6.7 •' 5-6" 8.5 " Tenth week ( 22 . 6.5 " 5-4 " 7.5 " Twelfth week ( 15 . 6.5 " 6.0 " 7-5 " 1 Temesvary and Backer ("Studien auf dem Gebiet des Wochenbettes," "Archiv f. Gyn.," Bd. xxxiii, H. 3, S. 331, 18S8) correctly state that fever favors the involution of the uterus. 2 For an extensive bibliography of uterine measurements in the puerperal state see Schroeder's " Lehrbuch," 8th ed., 1884, p. 230, and Hansen, loc. cit. 664 PATHOLOGY. In two-thirds of the cases Hansen found involution completed in six to ten weeks; in one-sixth, not until the last half of the third month or later; in again a sixth, within six weeks. The most rapid involution occupied four weeks. A deviation from the normal course may be detected by abdominal palpation, by combined examination, or by the use of a sound, and there is usually a profuse lochial discharge. Ahlfeld^ claims that free perspiration after labor is a valuable sign of firm uterine con- traction in the early part of the puerperal state; when it fails to appear, he always looks for uterine relaxation. Treatment is directed to the cause. Evidently, therefore, it varies greatly. If the subinvolution depends upon the retention of hypertrophied decidua, a curet promotes rapid involution more effectively than anything else. If placental fragments or membranes are retained in utero, they should be removed. If involution is retarded by the presence of fibroids, the administration of ergo tin, strychnin, and quinin in pill form, and the application of a faradic current have given good results. The bladder should never be allowed to remain distended with urine nor the rectum with feces. Inflammation in or about the uterus must be combated by appropriate treat- ment. If the heart-valves are imperfect or the heart-muscle weak and the abdominal and pelvic veins are consequently engorged with blood, a heart-tonic, as digitalis or strophanthus, often assists involution. Charpentier has asserted that the routine administration of ergot in the puerperal state hastens involution. This sounds reasonable, but clinical experience has not borne out the statement. Herman and Fowler^ did find, in experimenting on two sets, of patients, — one, 58 in number, receiving an ergot mixture daily for a fortnight after labor ; the other, 68 in number, receiving a single dose of ergot after labor, — that in the first set involution advanced more rapidly, but that there was no difference in the lochial discharge. BoxalP also declared him- self in favor of the routine practice of giving ergot during the puerperium, asserting that in two series of cases, comprising each 100, — one treated without, the other with, ergot, — there were fewer blood-clots ; they were more quickly discharged, and the after-pains were less fi-eqiient, of shorter duration and diminished intensity in the latter series. Dakin,^ however, 1 " Der Zusammenhang zwischen Schweisseruption postpartum und Uteiuscon- tractionen," " Ber. u. Arbeit, a. d, Geburts. Gynak. Klinik zu Marburg," 1885-S6, Bd. iii, S. 81. ^ "On the Effect of Ergot on the Involution of the Uterus," "British Med. Jour." 1888, i. 299. ^ Ihid. nUd. ABNORMALITIES IN INVOLUTION OF THE UTERUS. 665 dissented from these views, and claimed, after testing the matter in practice, that the routine administration of ergot re- tarded the involution by at least twenty -four hours. Blanc ^ also declared that the administration of ergotin during the first five or ten days of the puerperal state has not a favorable influence upon involution, but seems to interfere with it to some extent. As it is doubtful, therefore, whether ergot does aid involution, as there are many obvious disadvantages connected with its routine ad- ministration in the puerperal state, the adoption of the practice is unwise, and is not to be recommended. Puerperal anemia might not inaptly be called a subinvolution of the blood. After the first twent\--four hours of the puerperal state there begins a change in the constitution of the blood by which it is converted from the hydremia of pregnancy to the normal proportion of its constituent parts in the non-gravid woman. At the end of two weeks the process is so far complete that the blood is more nearly in a normal condition than it was during preg- nancy.^ Many causes, however, ma}' disturb the recovery from the hydremia and leukocytosis of pregnancy. Illness of any kind during pregnancy, hemorrhage during labor or afterward,* nervous affections — as insanity or chorea — during the puerperal state, kidney disease, fevers, etc., may all induce puerperal anemia. The treatment of the condition must be governed by the circumstances of the individual case. The cause of the anemia being removed, the blood will improve, and the im- provement may be accelerated by tonic drugs and good diet. After hemorrhages, beef-tea, animal soups, milk, and as nutri- tious a diet as the patient can bear, hasten recovery. Iron is indicated in Blaud's pills, in the pyrophosphate with malt, or in ovoferrin. In some cases arsenic alone succeeds where iron fails. Osier-' has reported an interesting case of the kind. In extreme anemia threatening to become pernicious, or in case the usual remedies are ineffective, actual transfusion by the vein-to- vein method is indicated. Treatment of the Injuries of Child=birth. — Slight cracks in the mucous membrane, small rents in the cervix, vaginal wall, and vaginal outlet — unavoidable in almost every labor — either unite firmly or else are healed by granulation. Occasionally, 1 "Ann. de Gynec," March, 1888. ^ Meyer, "Untersuchungen iiber die Veranderung des Blutes in der Schwanger- schaft," "Archiv f. Gyn.," Bd. xxxi, S. 145. ^ It is extraordinary, however, to see how rapid occasionally is the recovery even from severest hemorrhage. A loss of 2000 to 25c«d grams (4.4 to 5.5 pounds) of blood is usually fatal to an adult, but Ahlfeld reports two cases in which, re- spectively, 2000 and 2500 grams of blood were lost without serious anemia after- ward ("Ber. u. Arb. a. d. Geb. G>ti. Klinik zu Marburg")- * " Boston Med. and Surg. Journ.," 1888, p. 454 666 PATHOLOGY. very extensive injuries are repaired by natural processes. Per- forations of the vaginal vault, fistulous openings into bladder and rectum, deep tears and perforations of the perineum, transverse rents and perforations of the labia, lacerations about the urethra, — all have been known to unite without interference. Winckel states that perineal tears, when left to themselves, will be found healed in two and a half to five weeks ; by this he means that they are skinned over with mucous membrane. The underlying muscles do not reunite. Extensive injuries should be repaired, by sutures (p. 876). Rents in the vaginal mucous membrane not involving subjacent muscles and cervical tears do not always require this treatment, unless there is profuse hemorrhage. In fistulse the result of sloughs after labor, if the opening is not too large, a cure can occasionally be effected by touching the edges of the fistula with a strong caustic, like nitric acid. To do this the diagnosis must be made early in the lying-in period, which, as a rule, is not difficult. The escape of feces and gas from the vagina, and a constant trickling of urine, point respectively to a rectovaginal or a genito -urinary fistula. It is necessary in the latter case to exclude the incontinence of urine due to paresis of the vesical sphincter, and the overflow of retention sometimes seen in the puerperal state. All doubt is cleared away by find- ing the anomalous opening between bladder or ureter and vagina or cervical canal. In abrasions and wounds along the parturient tract it is necessary occasionally to apply lint saturated with car- bolized oil to prevent an acquired atresia of the birth-canal. If the abrasions and wounds are infected and covered with exudate they should be cauterized with nitrate of silver solution, .^i-fsj. Edema of the external genitals, the result of injuries, pres- sure, or contusions during labor, gives rise to considerable pain and discomfort, which are best relieved by the application of cloths wrung out in hot sublimate solution, i : 4000. If the patient's skin is irritated by sublimate solutions, I use hot infusion of witch-hazel. Puerperal hemorrhage is bleeding from the genital tract of the female, occurring after the first day of the puerperium until involution of the uterus is completed — a period of about six weeks. The causes of this accident are numerous. The treatment is governed in most cases by a knowledge of the cause. The causes are placed, as far as possible, in the order of their frequency. Retained placenta and membranes usually cause hemor- rhage during the puerperal state. White^ describes 4 cases of retained placenta, with fatal hemorrhage on the fii;st, second, third, and fourth days. Puppel- reports 22 cases, in all of which it was necessary to extract placental fragments on account of 1 "A Treatise on the Management of Pregnant or Lying-in Women," Worcester, Mass., 1793, p. 215. 2 "Zeitschr. f. Geb. u. Gyn.," Bd. 64, H. 3. PUEKPF.RAL IIE.\rORRI[AGES. 667 hemorrhage. In 13 the hemorrhage occurred from the sixth to the sixty-third day postpartum. Stadfelt states that in 70 postmortem examinations of puer- perae placental fragments were found in 7, varying from the size of a hazel-nut to that of an egg. Clinical observation alone makes this complication of the puerperal state appear more rare. Of 2960 births in the Frauenklinik at Munich, from 1884 to 1887, there were reported 9 cases of retained placental fragments.^ It is possible, however, that small portions of placental tissue might escape unnoticed in the lochial discharge, or else by their disintegration form a part of the discharge. The retention of placental tissue does not always cause hemorrhage. I have seen a placenta succenturiata expelled on the second day of the puerperal state without any previous bleeding, the whole placenta left in utero for twenty-four hours without hemorrhage, and a large piece of the placenta discharged four days after a premature birth, very fetid, but with no bleeding. In the 9 cases reported by Martini there was a prolongation of the bloody lochia in i , a severe hemorrhage in 2; in 6 there was no excessive loss of blood. The cause of the retention of placental fragments is either some abnormal form of placenta (marginata, multiloba, succen- turiata, etc.), an abnormal adhesion to the uterine wall, or too forcible or premature efforts at extraction or expression. - Retention of the membranes after labor is of frequent occur- rence. Martini reports 71 cases out of 2960 births.-'' Reihlen^ found a retention of some portion of the chorion in 152 out of 3534 labor cases (4.3 per cent.). Another investigation gave 5.1 per cent, from an analysis of 11,381 births. Crede-^ reports 91 cases of retained chorion in 2000 births. Membranes retained in utero may give rise to septic infec- tion; whether or not they are a cause of puerperal hemorrhage is still a disputed question. Crede*^ beheves that retention of the chorion is not at all dangerous. Olshausen declares that the retention of the chorion never justifies interference to extract it.^ Reihlen^ says that he never saw hemorrhage as a result of re- tained chorion. Schroeder'-* asserts that retained amnion and chorion practically never cause bleeding, even when retained in 1 Martini, "Ueber das Zuriickbleiben von Eihaut u. Placentarresten bei vor u. rechtzeit. Gcburt," "Munchen. med. Wochenschr.." 1888, p. 653. - .\hife!d in Qq6 deliveries saw only 4 cases of puerperal hemorrhage. He attributes the freedom from this accident in his clinic to his conservative manage- ment of the third stage of labor. He insists upon waiting an hour and a half before expressing the placenta ("Ber. u. .\rbeiten," Marburg, Bd. iii). ^ Loc. cit. ■* "Zur Frage der Behandlung der Chorion Retention," ".\rchiv f. Gyn.," Bd. xxxi, S. 56. 5 "Archiv f. Gyn.," Ed. xvii. S. 27S. ^ Loc. cit. '' "Klin. Beitr. zur Gyn. u. Geburtsh.," 1SS4, S. 146. ^ Loc. cit. ^ "Lehrbuch." 10. Aufl., 7Q7. 668 PATHOLOGY. toto. On the other hand, WinckeP and Hegar^ have shown that retained membranes could give rise to puerperal hemor- rhage, as well as to septicemia. Martini reports 28 cases of retained chorion in which there was no fever — that is, no patho- logical condition, as uterine inflammation, decomposition of thrombi, etc. — to account for bleeding, and yet among these cases there were two severe hemorrhages, eight of minor grade^ and six times a prolongation of the bloody lochia. Retention of hypertrophied and angiomatous decidua is an etiological factor in puerperal hemorrhage. If the decidua is hypertrophied during pregnancy, the amount of tissue re- tained may be considerable. The mass may act as a foreign body within the uterine cavity, preventing firm contraction, and so predisposing to hemorrhage; or else, adhering to the uterine wall, it may attract an unnecessary amount of blood to the whole organ, with the same result. Even a small portion of deciduous membrane, as well as shreds of adherent chorion and amnion, or placental fragments, may form the foundation of poly- poid tumors reaching occasionally considerable size, composed chiefly of firmly clotted blood or fibrin. The growth of these bodies is like stalactite formations on stone. The same thing occurs in different shape when the placental site is left unusually rough and vascular. The blood oozing from the sinuses may deposit successive layers of fibrin until quite a thick mass is formed. Prognosis and Treatment. — The fact that a portion of the ovum has been retained in utero is usually easy to discover. A careful examination of the secundines after labor enables one to detect missing parts, which must have remained behind in the genital tract. It is not wise, as a rule, to invade the internal genitalia in order to remove small shreds of amnion and chorion ; if, however, a greater part of these membranes has been retained, it is advisable to remove it. The diagnosis of re- tained placenta is, as a rule, easy. When the whole organ re- mains ijt utero, the cord dangling from the external genitals points clearly enough to the condition. If one or more cotyledons remain behind, their absence may be noted from the placenta after its delivery. Occasionally, the diagnosis is more difficult, even if the whole placenta is retained. I recall a case in which a woman was delivered on her feet ; the child dropped to the floor, the cord was dragged off from the fetal surface of the placenta, and the latter remained behind in the uterus ; it was tightly adherent to the uterine wall, and its discovery, with no cord to guide one, was by no means an easy matter. It was finally 1 "Berichte u. Studien," 1874-79; "Path. u. Therap. des Wochenbettes." ^ "Path. u. Therap. der Placentar Retention," 1862. PUERPERAL HEMORRHAGES. 669 peeled off and extracted, the woman meanwhile bleeding furiously, Cotyledons torn off the periphery of the placenta may easily go undetected, and in certain roughly lobulated placentae it is very difficult to be sure that no placental tissue has remained behind.' If the medical attendant suspects the retention of placental masses after labor, he must attempt their removal. This is usually not difficult. The hand, covered by a sterile rubber glove, is inserted into the uterine cavity, the placental substance is felt for, caught by the fingers, and removed; if the placenta is adherent, the tip of the finger must be gently inserted, wherever most practicable, under the edge, and the whole organ gradually peeled off. If the uterine muscle is too firmly contracted to allow the introduction of the hand, the resistance must be over- come by firm, gradual pressure, first inserting one finger, then two, and so on until dilatation is eft'ected. To accomplish the dilatation it is often necessary to administer an anesthetic. If puerperal hemorrhage occurs, the presence of membranes or placental fragments within the uterus should be suspected, and their removal should be attempted by a curet forceps unless some other condition is clearly seen to be the cause of the bleed- ing. To reach the uterine cavity after involution and retraction have made some progress, it is often necessary to dilate the cervical canal. Not rarely, however, the cervical canal remains patulous in consequence of a foreign body in lUero; in this case access to the retained mass and its removal are easy. The possibility of chorion epithelioma as a cause of puer- peral hemorrhage must not be forgotten. The material removed from the uterus should be examined microscopically. Displacements of the uterus may cause hemorrhage (p. 370). ■ Dislodgment and Disintegration of Clots at the Placental Site. — The thrombus formation in the large sinuses at the pla- cental site plays a subordinate part in the prevention of hemor- rhage after delivery. In consequence of sudden exertion, sitting upright in bed, or actually standing on the floor soon after labor, some of these clots, plugging up important vessels, may be dislodged. It is with this possibility in mind that the woman is kept quiet after labor. Disintegration of the clots at the placental site occurs occasionally in consequence of their invasion by micro-organisms. This is, therefore, one of the phenomena of puerperal infection. The bleeding that follows is, of all puer- peral hemorrhages, b}' far the most dangerous. Diagnosis. — The hemorrhage that follows displacement of thrombi at the placental site is startling in its suddenness, and 1 " Zur Frage der Behandlung der Placentar Retention," etc., " Zeitschr. f. Geburtsh.," xvi, pp. 292, 302. 670 PATHOLOGY. alarming in the amount of blood lost. There may be no foreign body in the uterine cavity; the uterus may be well contracted and in good position. The true condition can, of course, only be inferred. Treatment. — The best treatment for this kind of uterine hemorrhage is the intra-uterine pack.^ Emotional Causes. — Sudden emotion of any kind arrests uterine contraction during labor and in the puerperal state. In the latter condition the usual result is a hemorrhage, which may be alarming. Barker^ gives an interesting example: A healthy young primipara almost bled to death in the second twenty-four hours after labor in consequence of the brutal con- duct of her husband, who was disgusted that his child was a girl. I have seen a sudden and profuse hemorrhage on the seventh day, the result of fright. The patient's step-son returned home late at night in a violent state of intoxication. Relaxation of the uterus is a rare cause of hemorrhage after the first twenty-four hours. It is scarcely ever seen later than the third day, and when it occurs after the first day it is in women depressed in mind and body, exhausted by prolonge'd labor, weak from insufficient food or bad hygienic surroundings. It is treated on the same general principles as a primary post- partum hemorrhage from the same cause. Retention of blood=clots is usually the result of uterine re- laxation, uterine displacements, or a retention of portions of the ovum, around which the clot is formed. If these conditions are promptly treated, the retention of blood-clots is prevented. The effect of a large clot retained in ntero is often a hemorrhage, possibly also septicemia. The mass of clotted blood should be removed as soon as the symptoms point to the presence of a foreign body within the uterus. Fibroids. — If the puerperal state is complicated by intra- mural or submucous fibroids of the uterus, there are certainly a prolongation and an increase in amount of the bloody lochia, pos- sibly a serious hemorrhage. The latter is most likely if the tumor is an intra-uterine polypus. The diagnosis is only made by a careful physical exploration. The best treatment is the removal of the growth by torsion, by splitting its capsule and enucleation, by cutting the pedicle with scissors after ligation of the base, or with the wire ecraseur. Hysterectomy may be indicated. In small intramural fibroid tumors in the puerperal state, ergo tin (gr. j), styptol (gr. ^), and hydrastenin (gr. ss) is a good routine treatment. 1 Diihrssen, " Die Uterus Tamponade mit Iodoform Gaze bei Atonie des Uterus nach normaler Geburt," " Centralblatt f. Gyn.," 1887, xi, 553. 2" The Puerperal Diseases," p. 15. PUKRPE KA L IIKMOR RIIA GES. 6y I Hematomata along the genital tract may burst during the puerperal state, with serious external hemorrhage. The condi- tion is described elsewhere. Pelvic Engorgement. — Congestion of the pelvic blood- vessels may lead to j)uerperal hemorrhage. The congestion may be due to heart, kidney, or liver disease; to increased intra-ab- dominal pressure from any cause; to the determination of blood toward internal organs during a chill ;'^ to premature sex- ual intercourse; to the erethism following the return of the hus- band to the wife's bed; to inflammation about the uterus; to subinvolution from any cause; to ovarian irritation, and to con- stipation. Mauriceau^ describes a case of puerperal hemorrhage that continued quite profusely for five or six days, and which was only checked when " a pretty strong clyster " resulted in the evacuation of " a panful of gross excrements." Wounds in the Genital Tract. — Secondary hemorrhage may occur from wounds in the cervix, vagina, and vulva. Occasion- ally, abnormally large blood-vessels are injured in these regions. On one occasion I saw a hemorrhage from an anomalous artery in the perineum that nearly proved fatal. The diagnosis is easily made if the parts are exposed to view. The bleeding vessel may be detected and should be ligated. Carcinoma of the Corpus Uteri and of the Cervix. — Carci- noma (syncytial) or sarcoma may develop at the placental site during the puerperium. Epithelioma of the cervix, if at all ad- vanced, will surely cause some hemorrhage. The best treatment for the immediate control of hemorrhage from this cause is a uterine or a vaginal tampon. Hysterectomy should be per- formed, if possible, without delay. In inoperable cases with hemorrhage, ligation of the internal iliac, the ovarian, and the round ligament arteries may be indicated, if pure acetone poured into a cylindrical speculum does not control it. Rare causes of puerperal hemorrhage are rupture of the uterine artery, reported by Hewitt,^ v/ith a fatal result six weeks after labor; the rupture of a distended vein in the cervix, followed by fatal bleeding, described by Hecker.^ Meschek'^ reports a simi- lar case, with Hke result, due to an eroding ulcer which opened a large vessel in the cervix. Traumatism in coitus, usually a rupture of the vaginal vault may be a cause. Johnston has reported a fatal puerperal hemorrhage due to rupture of a hematoma of the cerxdx.^ ^ Winckel (" Path. u. Therap. des Wochenb.'") reports 4 cases of this kind out of 114 of puerperal hemorrhage. I once observed a striking example during a malarial attack some days after labor. 2 " Diseases of Women with Child and in Child-bed," translated by Hugh Chamberlen, London, 1752. 3 " London Obstet. Trans.," vol. ix. " " Archiv f. Gyn.," Bd. vii, S. 2. ^ •' Zeitschr. d. Ges. d. VVien. Aerzte," 1854, x. * Sinclair, " Pract. of Midwifery," 1858, p. 501. 672 PATHOLOGY. Puerperal Hematoma. — A form of hemorrhage in the female genitalia during or after labor, much more rare than the second- ary hemorrhages just described, is an interstitial effusion of blood, with the consequent formation of a blood-tumor, varying in size with the amount of the hemorrhage. Levret seems to have been famihar with the accident, but the first systematic treatise on the subject is Deneux's monograph.^ It was also fully described by Dewees.^ The accident is rare, but individual experience differs widely as to its frequency. Deneux was able to collect 62 cases, but had himself only seen 3 in a practice of fourteen years. Paul Dubois saw but I case in 14,000 labors. Velpeau,^ writing five years after the appearance of Deneux's article, declared that it would be easy to collect the detailed accounts of 100 cases; that he himself had seen 25. Barker, of New York, reported 22 cases that came under his personal observation. Winckel quotes McClintock's claim that he had observed 25 cases, and places an exclamation mark after the quotation, evidently as a sign of incredulity.* The former has only met with 6 well-marked cases in an experience of almost 20,000 confinements. Bossi found hematomata twice among 5660 women in child-bed; Hugenberger, 11 times in 14,000 deliveries;^ in Vienna it was noted 18 times out of 33,241 births.*^ This would indicate a frequency of i to 1600 births. The situation is most frequently in one or the other labium majus, rarely in both. It may be beneath the vaginal wall, on either side, posteriorly or anteriorly; in the ischio-rectal fossa; in the labia minora; in the carunclse myrtiformes; under the skin of the perineum, between the superficial and median fascia; in the cervix; in the peri-uterine connective tissue; within the broad ligament; in the subperitoneal connective tissue, on the posterior and anterior abdominal walls, extending as high as the kidneys and navel (Cazeaux, Hugenberger, Winckel) ; under the skin of the mons veneris or over the inguinal ring (Velpeau). If the effusion occurs above the pelvic fascia, the blood forces its way upward toward the diaphragm; if below, downward toward the vulva. Size and Form. — Small extravasations of blood along the genital tract occur frequently after labor; this form of throm- bus is due to the fact that the mucous membrane is pushed in front of the presenting part with a glacier-like movement ^ " Tumeurs sanguines de la Vulve et du Vagin," Paris, 1830. 2 " Midwifery." ' " Traite complet de I'Art des Accouchements," Brussels, 1835. ^ " Lehrbuch der Geburtshulfe," 1889. ^ " Hematoma Vulvae im Verlauf der Schwangerschaft," " Archiv f. Gyn.," Bd. xxxiv, H. I. ^ These latter statistics are taken from Winckel's book, where a reference to the original authorities may be found. PLATE 17. ^ Hematoma of the vulva (author's case). PUERPERAL HEMORRHAGES. 673 over the underlying tissues, and there thus occurs a lacer- ation of the submucous connective tissue and the small blood- vessels contained in it. A careful examination often reveals numerous hematomata after labor, varying in size from that of a pigeon's egg to that of a walnut. It is the larger tumors that are rare. They may vary in size from that of a hen's egg to that of a child's head; in extreme cases, if the blood is diffused throughout a great part of the subperitoneal connective tissue, the size of the effusion would be very large were the blood contained within a limited, circumscribed tumor. In shape, blood-tumors of the genital tract may be globular; in the cervix they distend the tissues of one or both lips down- ward and outward, giving to the cervix the form of a shark's nose. In the vagina they may hang from the anterior or posterior wall in the form of a polypus (Fleischmann). In the labia the hematoma is sausage-shaped (see Plate 17). Etiology. — The predisposing causes of puerperal hematomata are the engorged condition of the blood-vessels along the genital tract and the strain that is imposed upon them either by the pressure of the fetal body or by the muscular effort of labor. The more engorged the vessels, the more likely is the oc- currence of hematomata. Halliday Croom^ attaches great importance to anteversion of the parturient uterus as a predis- posing cause of vaginal hematoma, believing that thus an ex- cessive strain is put upon the whole posterior vaginal wall, and a rupture of distended blood-vessels in this region is, therefore, more probable. Hypertrophic elongation of the cervix certainly predisposes to the formation of hematoma in that region during and after labor. The determining cause of the accident may be a direct injury to the tissues by forceps, a fall or a blow, or the violent straining efforts during the second stage of labor. In the majority of cases, however (86 per cent., Winckel), the occurrence of hematomata is apparently spontaneous. The im- mediate cause of hematoma is the rupture of a blood-vessel and the interstitial extravasation of blood; the vessel injured is com- monly a vein, not rarely of large size. Possibly a number of smaller vessels may be ruptured. The injury to the blood-vessels is either a direct and immediate laceration, or else, later, a perforation by pressure necrosis. Clinical History and Diagnosis. — The interstitial hemorrhage that results in a hematoma begins, with rare exceptions, during labor.^ The extravasation of blood may at first be gradual, so ' "On the Etiology of Vaginal Hematoma Occurring During Labor," "Edin- burgh Med. Jour.," vol. xxxi, pt. ii, p. looi. - Vinay reports a case in the sixth month of pregnancy after an epileptic fit, "CentralbL f. Gyn.," No. 7, 1897^ 43 6/4 PATHOLOGY. that it does not attract attention until some time in the puer- peral state. The distention of the vagina by the presenting part of the fetus may prevent all bleeding until the maternal tissues are relieved of pressure. If the bleeding results from necrosis of tissue, the result of prolonged pressure, the formation of a hematoma may first begin after delivery. In cases in which the accident has seemed to be the result of violent coughing or other exertion during the child-bed period, there had been, no doubt, some injury done the vessels during parturition. The sub- cutaneous or submucous laceration of tissue occurring, as a rule, during the second stage of labor is almost always associated with acute pain of a sharp, lancinating character, quite different from labor-pains. The suffering increases as the hematoma enlarges, and, in addition to the sharp pain of torn tissue, there are exaggerated and painful expulsive efforts excited by the presence of the tumor within or alongside the vagina. This is an almost constant symptom, but Barker reports a painless case. The hemorrhage into the tissues may be profuse enough to occa- sion the most marked signs of acute anemia. Pallor, failure of vision, a thready pulse, air-hunger, loss of consciousness, and, finally, death, may all be noted without the slighest external escape of blood. An examination of the patient shows a tumor occupying the situations already described, of varying size, and differing in consistency as the blood contained in it is fluid or clotted. If the hematoma is submucous, it presents a dark, pur- plish color, like clotted blood. If it is covered with skin. At presents a bluish, ecchymotic hue, although in the labium majus the color may be the same as in a submucous hematoma. As a rule, the swelling only appears after labor. It may, however, occur before the expulsion of the child, and it has repeatedly developed between the birth of twins. ^ If the tumor is formed during labor, it may present a formidable obstacle to delivery ; if it appears in the puerperal state, it may dam back the lochia or give rise to dysuria or to retention of feces. With the history of a sharp attack of pain during labor, the subsequent rapid de- velopment of a tumor along the genital tract characteristic in its appearance and situation, the signs of internal hemorrhage, the diagnosis of the true condition ought not to be difficult ; and yet a mistake is quite possible. Puerperal hematoma has been confused with varicose tumors of the labia, inguinal hernia, and inversion of the vagina. Once in Barker's experience a vaginal hematoma was mistaken for a fetal head, and once (or pi acejtta preevi a. Auvard^ says that on 1 One case reported by Dewees (" Diseases of Females," " Of Bloody Infiltra- tion in the Labia Pudendi"), and six by Madame Sasanoff (" Annales de Gyne- cologie," December, 1884). Four of these latter cases died. 2 "Trav. Obstet.," Paris, 1889, t. i, p. 449. PUERPERAL HEMORRHAGES. 67$ first sight he took a hematoma of the anterior lip of the cervix for a clot of blood lying in the vagina. The Barneses,' in describing their case of cervical hematoma, write that they found a fleshy tumor projecting from the vulva which looked like a mass of coagulated blood, or which might have been mistaken for an inverted uterus. The diagnosis is more difficult in cer- vical hematomata than in those of the lower genital canal. The former are rare. Besides the two just mentioned, others are described by Hohl, Braun, Earle (two cases), and Winckel.^ Hematomata along the genital canal may burst soon after their formation, with appalling and possibly fatal hemorrhage. In cases of labial tumors the point of rupture is likely to be the boundary-line between the greater and lesser labia. A hematoma within the pelvis may open into the peritoneal cavity, with fatal hemorrhage.^ In one case under my obser- vation a large hematoma formed between the layers of the broad ligament. Four hours later the posterior layer of the broad ligament ruptured, the bleeding became intraperi- toneal and unlimited, and the patient died before I reached her. In another case there was an enormous hematoma between the layers of the left broad ligament and behind the peritoneum to the kidney. A hysterectomy was necessary to get at the bleeding vessels. The woman recovered. After early rupture or primary incision of the tumor, profuse hemorrhage is likely, and secondary bleeding is apt to occur. This accident is rare when the tumor is opened after bleeding into it has ceased. Winckel has thus summarized the terminations of puerperal hematoma: (i) Death by hemorrhage with or without previous rupture of the tumor ; (2) death following suppuration of the sac and septicemia, most frequently after the sac has been opened ; (3) rupture of the tumor, with recovery ; (4) rupture of the tumor, with a resulting fistula ; (5) perfect recovery by absorp- tion of effused blood, without rupture of the sac. In fifty cases collected by Winckel from modern literature the tumor burst spontaneously in the first eight days in twenty-three. A hema- toma may be evacuated not only by escape of the contained blood externally, but by diffusion of its contents under the skin. Dill* reports a case of large hematoma of the right labium, which ruptured internally and produced ecchymoses reaching to the nates and to the right knee, to the umbilicus, and even as high as the right axilla. Suppuration may occur in a blood- tumor that has not been ruptured at all, and the effused blood may be converted into a large accumulation of pus. As these 1 " Sys. of Obst. Med. and Surg.," Philadelphia, 1885. - " Lehrbuch," 1889. ^ Williams, " Am. Jour, of Obstet.," Oct., 1904. 4 "Dublin Jour. Med. Sci.," November, 1886. 6/6 PATHOLOGY. abscesses are often in the neighborhood of the rectum, the pus may acquire a fecal odor, without a communication with the bowel. A rectovaginal fistula may result if the hematoma breaks its way into the rectum and also opens anteriorly into the vagina. Suppuration is most to be feared after the blood-tumor is opened and its cavity is exposed to the contamination of the atmosphere and of the lochial discharge. Pro^osis. — The formation of a hematoma during or after labor was formerly regarded as a more dangerous complication than it is considered to-day. Of Deneux's 62 cases, 22 died. Fatal cases have been reported by Cazeaux, Lubanski, Broers, Seulen, Josenhans, Hugenberger, Braun, and the author. The causes of death in these cases were hemorrhage (in two instances into the peritoneal cavity), septicemia, and typhoid fever (?). Blot collected 19 cases since Deneux's paper was published, with 5 deaths. Ferret, in an analysis of 43 cases, found 17 deaths. Of II cases observ-ed by Hugenberger,^ 4 died. Girard,^ in an analysis of 120 cases, found 24 deaths. Johnston and Sinclair^ report 7 cases during seven years' service in the Dublin Rotunda, with 2 deaths. Scanzoni met with 15 cases, i of which died. Winckel, among 50 cases, found only 6 deaths. Of the 6 cases in his personal experience, not one died. Barker reports 22 cases of his own, of which 2 died. Barnes* reports 2 cases with a favorable issue ; Auvard,^ i of cervical hematoma that disap- peared by absorption. Groom's 3 cases all recovered. Death from a puerperal hematoma at present should be rare, especially if the patient's general condition is good and her hygienic sur- roundings are satisfactory. Treatment. — If the hematoma is of moderate size, not larger than one's clenched fist, the main object of treatment is to secure absorption. It may, however, be necessary to remove an ob- struction to labor if the tumor develops before delivery; to con- trol the hemorrhage either before or after rupture of the sac; to treat the general symptoms of profuse bleeding; to evacuate the contents of the sac when suppuration has occurred, and to pre- vent septic infection. To secure the disappearance of a hematoma by absorption cleanliness of the parts and rest are necessary. If the tumor is vaginal or cervical, frequent irrigation of the vagina is ad- visable. If the effusion is subcutaneous, cooling lotions and inunctions with carbolized oil often prevent inflammation and rupture of the sac. If the tumor appears before or during labor, 1 "St. Petersburg med. Zeitung," 1865. ■^ "Contribution a I'etude des Thrombes de la Vulve et du Vagin dans leurs Rapports avec la Grossesse et F Accouchement," " These de Paris," 1874. '■ Barker, loe. cit. * Loc. cit. 5 Loc. cit. NON-LVFECT/OUS FEVERS. 677 and offers an obstacle to the delivery of the child, it must be freely opened ; the contents, whether fluid or clotted blood, evacuated ; pressure exerted by a tampon of iodoform gauze, in order to check the hemorrhage ; while the extraction of the infant by forceps or after-version is hastened as much as pos- sible. To control the hemorrhage into the tissues before exter- nal rupture has occurred, pressure, cold, and the internal admin- istration of ergot may be tried. An ordinary tampon in the vagina is not admissible, for it would dam back the lochial secre- tion, and would become foul. Braun's colpeurynter, or a large Barnes' bag, distended with ice-water, is the best appliance, for it can be easily removed at frequent intervals to allow an irri- gation of the vagina. If it is possible to avoid it, the tumor should not be opened while it is increasing in size, for there may be profuse hemorrhage at the time and a secondary bleed- ing later. This does not occur, as a rule, when the tumor is incised after the effusion ceases, and yet there are two cases on record in which hemorrhage occurred from tumors opened one and three weeks after their formation. ^ If the tumors are too large to be absorbed, or if there is threatened gangrene of their coverings, they should be opened. Hematomata may burst within the first few days after their formation, and there may be, in consequence of the rupture, an alarming hemorrhage. In such cases it is best to enlarge the opening ; to turn out the clots within the tumor ; to search for the bleeding vessels, which may be seen spurting from the walls, and to apply a ligature. If this is impossible, and bleeding still con- tinues, the cavity may be firmly packed with iodoform gauze, firm external pressure being exerted by a large pad and a T-bandage. After the coverings of a hematoma are incised or ruptured, suppuration commonly occurs in the cavity; septicemia must be avoided in such cases by an iodoform tampon in the ab- scess-cavity often renewed, and by frequently repeated irriga- tions. Suppuration may occur before the tumor has been opened at all. In such cases the pus must be evacuated. The opening should not be delayed too long, especially in suppu- rating hematomata of the posterior vaginal wall, or fistula? may result. The general treatment for loss of blood is to be con- ducted in the ordinary manner when the indications call for it- hypodermatics of ether, brandy, and other stimulants; hot ani- mal broths internally; " auto-infusion " by bandaging the limbs; subcutaneous or intravenous injections of a normal salt solution, or actual transfusion. Non=infectious Fevers. — Fever in the puerperal state not due to infection ma}' arise from emotion, from exposure to cold, ' Pars'in's " Obstetrics," p. 502. 6/8 PATHOLOGY. from constipation, from reflex irritation of any kind, from cere- bral disease, from eclampsia, from insolation, from syphilis, from the exacerbation or persistence of an acute or chronic disease contracted during or before pregnancy. Emotional Fever. — That fever may appear in consequence of emotions, clinical evidence leaves no doubt. The cause of the fever being transient, perhaps momentary, the elevated tempera- ture quickly sinks to normal. Emotional fever is most often seen in children, in hysterical girls,^ and in women after child-birth. Hunt's^ records of seventy-five cases, confined to women free from infection and inflammation, in which the temperature was Day of Disease / 1 Z 3 ^ s 6 7 8 9 w // ;. 2 /3 /♦ JS m\ M E M E M\ £ M E M E /u £. M £ M £ M £ M £ M £.\4 £M £. /w] £ f^ £ M £ 105° 104° 103° 102° 10L° 100° 99° 98° : ^\ \ \ \ \- : \- : \ ; i : M- K ,A /^ /^ iV H 1 '•J : 1 • /> Sr. ^ LiJ : Fig. 532. — Chart of emotional fever from dread of an operation. taken twice a day in the month, gives three apparently typical ex- amples of fever from emotion. I have seen a number of examples of emotional fevers. Failure to receive an expected letter, fear of exposure in illegitimate pregnancy, the expected removal of the woman's infant to an asylum, dread of an operation, and a variety of mental disturbances have given rise in my experience to a high but transitory fever. Figure 532 shows the tempera- ture record of a typical case. There had been an operation for mammary abscess in a hospital ward. It was witnessed by two puerperal patients. One of them, a young girl, shortly after experienced pain in the breast. She at once conceived a morbid dread of an operation in her own case. The beginning elevation of temperature in the chart indicates the commence- ment of engorgement and pain in the breast. These symptoms continued for a few days, when, after lying awake all night 1 The case reported by Dr. Matomed is a famous example ; the temperature is said to have reached 128° F. ("Lancet," 1881, vol. ii, p. 790). *" Normal Course of Puerperal Temperature," "Practitioner," London, 1888, p. 81. NON- INFE C TIO US FE VERS. 679 brooding on the subject, the girl's temperature began to rise in the morning, linally reaching the height indicated on the chart. The only antipyretic employed was the emphatic assurance of the Fig. 533. — Chart of fever case from exposure to cold. The patient left her bed twice against orders, in her bare feet and night-gown. Each time there was a rise of temperature, quickly subsiding. Day of Disease / 1 2 3 M- 5 6 7 6 9 n 1 n 72. /3 105° 104° 103° 102° 101° 100° 00° 98° M E M Ei M EA ^CMt '.ME A 'IE M £ u EMi EA/EA 4E A^ E : U^ :i: ifji ;j: ; \ k _A_ • v\ \ f .'^ ^ A: '• Js. :/^ ^'\ • \ Fig. 534. — Chart of a woman constipated for six days in the latter part of the puerperal state. There had been one movement of the bowels, five days after labor, and then none for si.\ days. A large dose of castor oil and an enema reduced the temperature to normal in a few hours. resident physician that there was not, and would not be, the slightest excuse for an incision in the breast. The patient's fears being allayed, her temperature quickly sank to normal, where it remained. 68o PATHOLOGY. Fever from Exposure to Cold. — In the sensitive condition of puerperae it is not uncommon to see a febrile reaction follow undue exposure. A careless nurse or attendant m.ay be responsible for too low a temperature in the lying-in room, or for ill-regulated ventilation, or for insufficient or ill-arranged bed-clothing. A D»y of Disease / z 3 ^ 5 6 1 7 8 9 70 // 72 73 . f^ 7S A nE M E M £ M E M E M E\ IE M £ \ ^E M e M £ M E M EM\E d£ E, '^ S '. ^ * -i- Li. ': 1 I t \^- '\ i^i ;' \- 100° - 99°- '■■ \ r h ] f \ \ \ \j } •• A • ^ J k -■ r^ S/ Sv ^i^ '■\ V ■ • S^ -, P> -i • \ 972. 1 • 1 ^ ^ Fig. 535. — Reflex fever from mammary congestion. * Breast incised without finding pus. wilful patient may leave her bed too soon and expose herself, thinly clad, to cold (Fig. 533). Fever from Constipation. — The temperature-chart, figure 534. is that of a woman in the Philadelphia Hospital who had had but one evacuation of the bowels — on the fifth day — in the eleven days Day of Dla«as« 1 z 1 ( ' t 5 1 6 7 & 9 1 10 // n /3 jf\ 15 J 6 17 /s 19 \ZQ 1 i if M f M £ M £- M E ^ 4£ A/ £ i^ £ /v £■1 4£ Hf £ M £ M £ M £^ \f<.£^^ £ ^£ ^ £ r £^f 103°- 102°- 101°- 100°- 99°- 98° - i ^ [ : A '■■ : * A A h l\ :\ '4 <} ^ :1 /N h i ] : \ ; \. ^ ; V y '■ L /l^ : ■ if ■-■ ^ ■ ■■ /■_<{ J V J : N / y . : : \ V : : x:^ h ■ / . . . \\ . V- ■ s- • jj \ Fig. 536. — Fever followed by expulsion of tape-worm. * Tenia passed from bowel. succeeding delivery. The temperature fell immediately after a large dose of castor oil and the administration of an enem.a, which produced an enormous fecal evacuation. Fever from Reflex Irritation. — Physical irritation, as well as psychical, may be reflected in general elevation of the body- NON-INFECTIOUS FEVERS. 68 1 temperature during the puerperal state. The irritating point is most often in the breast. There may frequently be found, in women of sensitive nervous organism, a well-marked fever, which can be traced to no other cause than engorgement and distention of the mammary gland. There is usually a history of exjjosure to colds or drafts of air in nursing the child. P'or twenty-four hours afterward there may be high fever and every evidence of acute illness. Hot fomentations on the breast, evacuation, support of the gland, and a sahne purge dissipate the symjjtoms in twenty- four hours. The appended temperature- chart (Fig. 535) illustrates the influence of mammary congestion upon the temperature. The focus of irritation may be anywhere in the body. A primipara was delivered under my care without difficulty of a healthy infant. During the early part of the puer- peral state she complained of a constant and distressing head- ache ; diarrhea appeared, which resisted treatment, and the woman's mental state tended rapidly toward pronounced melan- cholia. There was fever, apparently of a septic character. On the ninth day a tape-worm fourteen and one-half feet long was. Day of Disease ' ^ X 3 H M Em e: ME ' M E : : 106° ■ 105° • 104° ■ 103° ' 1 102° ■ }^ A 101° -i- •J \ l£tQ° J= FiR. 537. — Rise of ttmperalure following perforation of the uterus. passed from the bowel, and shortly afterward the temperature became normal. The great elevation of temperature which often follows per- foration of the uterus into the peritoneal cavity, appearing, as it commonly does, immediately, should also be attributed more to an intense reflex irritation than to septic peritonitis. The chart, figure 537, is from a case in which the placenta was abnormally adherent. Separation was accomplished four hours after delivery. Ulceration of a limited area in the placental site followed, which ended in perforation and death on the third day. High fever oc- 682 PATHOLOGY. casionally appears in consequence of an acute retrodisplacement of the puerperal uterus, sometimes as late as the fourth week. If the rise of temperature is simply due to irritation, it subsides within a few hours after the uterus is replaced. Fever in the Puerperal State from Cerebral Disease. — A puerpera might have a tumor in the brain or spinal cord, in- sular sclerosis, locomotor ataxia, or degenerative changes in the brain — all of which could give rise to elevations of temperature. ^ It is, however, to cerebral hemorrhages and embolism that one should usually look for an explanation of fever arising from brain disease, for these accidents are by no means rare in the puerperal state ; and if the hemorrhage or embolism affects certain regions, a rise of temperature, often to a great height, is almost sure to Day of Disease 7 2 3 4 S 6 7 \ A ^E M£ :M£A 'JEM £ME h±£ 106° \ \ 105°- 104° k l\\ 103° - h h\ j : : : : 102° - imo inno -. '•/ '■ PQ° - Fig. 538. — Fever-chart of patient who died of eclampsia. follow. A temperature of 108° in the axilla has been noted in a case of cerebral embolism following child-birth.^ Fever with Eclampsia. — It is justifiable to put the fever of eclampsia among the non-infectious fevers of the puerperal state. Winckel,^ writing in 1878, said he had observed and had called attention to the fever accompanying eclam-psia fifteen years before; he was accordingly the first to refer to it. Bourneville and Budin published this fact as an original discovery in 1872. ' W. Hale White, " The Theory of a Heat-center, from a Clinical Point of View," "Guy's Hospital Reports," 1884, p. 49. '^ Neve, "A Case of Cerebral Embolism with Hyperpyrexia following Child- birth," "Lancet," 18S4, ii, p. 103. 3 "Path. u. Theiap. des Wochenbettes," 3. Aufl., 1878, S. 493. NON-INFECTIOUS FEVERS. 683 With each convulsion there is a notable rise of temperature, until, finally, the fever may run very high. Insolation. — Sun-stroke, or heat-stroke, is by no means an impossible accident to lying-in women in the torrid tempera- ture of the American summer. The only case, however, that I know of occurred at sea in a ship sailing from France to New Orleans.^ The cabin in which the woman was confined was hot and ill -ventilated. The temperature of the air was 93.4° F. A portion of the membranes was left behind, and the discharge was offensive, but there was no fever. On the fourth day, however, the temperature rose to 104°, and shortly ; Z 3 ^ 5 6 7 8 9 10 11 n 1 /V7|g m. M\E M £ M\£ A^£ At \S M ^ M £ M ^ M £ M £■ 105° 104° 103° 102° 101° 100° 99° 98° 97° — — — — 1 — — — ' _J : V 1 \ 1 11 \ ■ \ / \ ( \ / / \ 1 / IZ \ 1 \ ) 1 1 \ 1 1 1 / 1/ 1 / \ 1 \ f \ f I ' \ { 1 \ 1 / \ / \ \ / s \ 1 \ / \ L'^ / \ J ^ \ r ■ -~j \ I / / 1 v - - — — — c:: - — Fig. 539.— Temperature-chart of sypliilitic fever. after mounted to 109.4° in the rectum. The woman ultimately recovered. Syphilitic Fever. — In syphilitic women puerperal convales- cence is complicated by the retention of hypertrophied decidua,^ by adherent placenta, by the development of pelvic exudates, and by septic infection. It is claimed, however, that there is a specific syphilitic fever without wound infection. Persistence or Exacerbation of Febrile Affections in the Puerperal State. — A woman may acquire any of the acute ' Skinner, " Sur un Cas d'Hyperthermie post puerperale," " Le Progres medi- cale," 1887, p. 269. 2 See Kaltenbach on " Syphilitic Endometritis in Pregnane^' and the Puerperal State," " Zeitschr. f. Geburtsh.," Bd. ii, S. 225. 684 PATHOLOGY. or chronic fevers during pregnancy, which may persist in the puerperal state or take on new activity during that period. This is true of all the infectious diseases, but particularly so of phthisis. The effect of labor upon the course of phthisis has interested many observers. It has been asserted that the disease makes no progress, or, at least, is very much retarded in the puerperal state. There is a fictitious appearance of regained health in the woman by reason of the accumulation of fat to which pregnancy disposes. The laity, therefore, enter- ^^ I 2-3 ^ 5 6 7 b 9 10 11 }Z n 1^ 15 J6 n M E.'m b'm B'm tM£. M t M't MC M I M £ M £ N £ M £i M £ M £i M e M £. •frna ■•■'■'■■'■■ ■■'■'■'■ J- '■■ '\ '•'■_ i •■•."• R ■ • "iiiiiiiMiiiiiiiiliihiiMiiiiilii ImiiiUiH ilii^^iii^i ij^iuuniii ':^iAi^ii:^i:|i1p:::1aiHmniIl|l 2iE • X.'^a : 5^1 :: E'r :::;.:::::;:: i -. * : J : nRo~ ■ V . -r . * . -t-r^ ..y -f-...-^. ^olJ.±^_J.J.^_^±A^^_Li-J.^_L±_^l±±^J.±L±^i-^J. Fig. 540. — Fever-chart of woman with advanced phthisis in pregnancy and the puerperal state. tain the idea that it is an advantage for the phthisical woman to become pregnant. No mistake could be more unfortunate.. The drain and strain of the child-bearing processes are often accountable for the origin of phthisis in a woman disposed to tuberculosis, and, if the disease already exists, there is after delivery an exacerbation of the fever, an aggravation of the pulmonary symptoms, and a rapid loss of strength and vitality, which shortens the patient's life by many months. It is the duty of a physician to advise the tuberculous subject against marriage or maternity. Acute Intercurrent Affections in the Puerperal State. — Any of the acute diseases may develop after child-birth. They acquire a special interest in this condition, for their course is often modified, the prognosis is commonly graver, and the diagnosis is more difficult. It is often difficult and occasionally impossible to distinguish certain diseases — as erysipelas, diph- theria, malaria, scarlet fever, and typhoid fever, occurring during the lying-in period — from septic infection. Pneumonia. — Pregnancy and the puerperal state are grave com- plications of the disease. They increase the gravity of the symp- toms and make the prognosis unfavorable. Pneumonia more frequently attacks a woman during the nine months of pregnancv INTERCURRENT DISEASES. 685 than during the six weeks of the puerj^cral state, but the pneumonia of pregnancy often becomes a comj>lication of the jjuerperium, for it frequently induces a premature expulsion of the ovum at the height of the attack, and convalescence or death occurs in the lying-in period. In 43 cases of pneumonia in pregnancy collecte<:l by Ricau,^ there was premature expulsion of the fetus in 21. From these statistics it further appears that the likelihood of the accident is increased after the sixth month. In 28 of the 43 observations the women had not passed the sixth month of pregnancy; of this number 1 1 aborted. Of the other 1 5 cases, in which the pregnancy was past six months, there was premature labor in 10 instances. The prognosis of pneumonia in pregnant women is grave. Of Ricau's 43 cases, 12 died: 5 before the sixth month; 7 after it. The infants were expelled in 21 cases prematurely ; and of those which had reached sufficient development to exist outside the uterus the majority died. Tarnier ^ sums up the outlook for mother and child in the following way : The more advanced the pregnancy, the greater the probability of an expul- sion of the fetus, the graver the prognosis for mother and child. Treatment. — The obstetrical treatment is important. The question to be decided is whether to induce labor or to avoid in- terference. Pregnancy complicates pneumonia by mechanically increasing the difficulty of respiration, by calling upon the heart for extra work, and by demanding unusual facilities for disposing of the waste-products of two organisms, part of which should be discharged through the lungs. It would seem, there- fore, that the uterine cavity should be emptied for the mother's sake, more especially as the infant deserves but small considera- tion, being almost certainly doomed. But the evacuation of the uterus, the contraction of its walls, and great diminution of its blood-supply favor a determination of blood to other internal organs, among them the lungs. The exhausting discharges of the puerperal state, moreover, may fatally waste the patient's strength, while in her feeble and unresisting condition it is pos- sible at least to have a general septic infection added to the pul- monary disease. Statistics certainly do not speak in favor of artificially inducing abortion or premature labor. Matton^ says that of 18 cases in which pregnancy was interrupted 9 women died, while in 20 women who suffered from pneumonia without abortion but i succumbed. Chatelain's^ statistics in- ^ " These de Paris," 1874. 2 Tarnier et Budin, " Traite de rx'\rt des Accouchements," t. ii, Paris, 1886. ^ " Jour, de Med. de Bruxelles," 1872, p. 412. ^ Ihii., 1870, t. 1, pp. 430, 516, and t. li, p. 11. 686 PATHOLOGY. elude 39 cases; in lo abortion occurred; in 9 premature labor was induced. Of the 19, 10 died, and of the remaining 20, 10 also died, showing that Httle was gained by the interruption of pregnancy. Pleurisy may possibly complicate the puerperal state. It is simply an intercurrent affection, to be treated on general prin- ciples. It does not influence the course of pregnancy, nor is it influenced by the woman's condition. The Exanthemata. — Scarlet Fever. — Although this disease in the puerperal state has attracted much attention and aroused extended discussion among medical writers, there are still several points in its relationship with the puerperium in dispute. It is not strange that there should be some confusion and difference of opinion in regard to scarlet fever in the puerpera, for its course is often much modified by the woman's condition ; it may be complicated by the coexistence of septic infection; there may be, on the other hand, scarlatiniform rashes in the course of septi- cemia, although scarlatina is excluded; and, moreover, there may be, in certain cases, after infection with scarlatina, pelvic symptoms indistinguishable from_ those of an infected birth-canal. Frequency. — Scarlet fever is a rare complication of the puerperal state. Prior to 1876 Olshausen^ collected 134 cases; Winckel- saw one in Rostock; single cases are likewise reported by Pal- mer,^ Parvin,* Busby, '^ Harvey,*^ Cummins,^ and the author. Braxton-Hicks ^ asserts that he has met with 37 cases (! ), chiefly in consulting practice, and Bernard^ in 18 cases of scarlet rash in the puerperium believed that 7 were due to scarlet fever. Epi- demics of scarlet fever among puerperse are described by Boxall^" and Meyer,^^ in which, respectively, 16 and 18 women were attacked by the disease. In the discussion on Box- all's paper several members of the London Obstetrical So- ciety related individual experiences. It can not be asserted that puerperae are peculiarly disposed to scarlet fever. Epi- 1 " Archiv f. Gyn.," Bd. ix, S. 169. 2 " Path. u. Therap. des Wochenbettes," 1878, p. 529. ^ " Cincinnati Lancet Clinic," 1887, ix, 481. ^ " Amer. Jour. Med. Sci.," 1884, 179. ^ Ihid.^ 1887, p. 394. ^ " Scarlet Fever and the Puerperal State," " N. Y. Med. Record," 1886, xxx, 376. ' " British Med. Jour.," 1884, i, 760. * " London Obst. Trans.," vol. xii, pp. 44-113. * " Contribution a I'etude des erythemes Scarlatiniformes a la Suites des Conches," " These de Lyon," 1909. 1" Abstract from " London Obst. Trans." in " .\mer. Jour, of Obstetrics," 1888, PP- 547, 553, 666. ^1 " Ueber Scharlach bei Wochnerinnen," " Zeit. f. Geburtsh.," Bd. xiv, S. 289. JNTERCUKRKNT DISEASES. 687 demies occur, it is true, in lying-in hospitals at long in- tervals, but the j)rop()rti()n of jjatients attacked is never very large. During the epidemic in the Maternity Hospital of Copenhagen, described by Meyer, only about i per cent, of the lying-in patients acquired the disease. Boxall says that 40 women were exposed to the contagion of scarlet fever during an epidemic, without the slightest detriment to their health. During the years 1871-85 there were only 2 cases of scarlet fever, in the lying-in period, among the patients in the Copenhagen Maternity; in six years but 3 cases of the kind were seen in the hospital for infectious diseases (Meyer). In twenty years' hospital service in the Philadelphia, Maternity, and Uni- versity Hospitals, I have seen but 2 cases of true scarlet fever in the puerperium. Infectio7i and Incubation. — Women after child-birth may be infected with scarlet fever in the ordinary manner — through the throat — -or through wounds in the genitalia. The latter state- ment has been disputed, but the short period of incubation, the fact that the rash often begins at the vulva and spreads thence over the trunk, the common occurrence of pelvic inflammations, and the fact that the diphtheric patches usually seen in the throat of scarlet fever patients are met with commonly in the vagina when the disease attacks a lying-in woman, while the throat is affected to a minor degree or entirely spared — all indicate the genitalia as the point of entrance for the specific infection. It is likely that the majority of women affected during the puerperium are infected by actual contact with the disease germs on fingers or instruments inserted into the vagina; but it is c(uite possible that the poison of the disease may be drawn into the throat from the atmosphere or may be conveyed to the genitalia by the same medium. Before the adoption of antiseptic measures in surgical practice it was well understood that the poison of scarlet fever might find entrance to the body through a solution of continuity in the skin and mucous membranes. Paget long ago pointed out that the wounded are more susceptible to scarlatina.^ The woman after child-birth is always a wounded person, and she is, therefore, more susceptible to attacks of the disease. This f)uerperal susceptibility explains the cases which, exposed to the contagion during pregnancy, only manifest the symptoms of the disease after labor, the poison lying dormant for varying lengths of time until its invasion of the body is faciUtated by the wounds and abrasions which always attend parturition (Olshausen). This mode of entrance would also explain the short period of incubation w^hen scarlet fever attacks a puerpera. Ordinarily, five to seven days inter\'ene between 1 See also Hoffa, Volkmann's " Samml. klin. Vortrage," No. 292. PATHOLOGY. the date of infection and the appearance of the first general symptoms. In the puerperal state, however, the time of incu- bation is shortened to twenty-four or forty-eight hours (Senn, Hervieux, Olshausen). In one of my cases the patient, two weeks before her confinement, had handled some old linen that had been used in a fatal case of scarlatina ten years before. She developed a violent and typical attack of scarlet fever forty-eight hours after her delivery. Olshausen ^ says that four-fifths of all puerperae attacked will manifest the first symptoms at some time in the fi.rst three days after labor ; and this assertion has been supported by the major- ity of the cases reported since the appearance of his article. Symptoms and Diagnosis. — A frank case of scarlet fever in the puerperal state is as easily recognizable as it is under any other circumstances in the adult male or female. But " in rare instances the disease may assume a masked form in which the ordinary signs of scarlatina are absent, or so slight and evanescent as to escape observation," and "in some such cases the only manifestation of the illness may be found in signs usually referred to septic poisoning " (Boxall).^ It is, more- over, a well-recognized fact that one of the manifestations or accompaniments of septicemia in occasional cases is the appear- ance of a scarlatiniform rash. And, again, there are reported, from time to time, erythematous eruptions in the puerperal state resembling, on the one hand, the rash of scarlet fever, and, on the. other, the eruption sometimes associated with general sepsis,^ and yet apparently unconnected with either of these diseases. Finally, there may coexist in the same individual local inflammations about the pelvic organs of septic origin and a general infection of the whole organism with the poison of scarlet fever, as the puerpera with scarlet fever is more prone to streptococcic infection than any other patient.* It is obvious, therefore, that a definite diagnosis of scarlet fever in the puerperal state may be difficult or even im- possible. The diffuse nature of the rash, followed by desquama- tion; the characteristic appearance of the tongue; the aff'ection of the throat; the more exaggerated diphtheroid inflammation of the vagina; the exposure to the contagion of the disease; the occurrence 1 Loc. cit. ^ Braxton-Hicks takes an extreme position in this connection. He says that among sixty-eight cases of puerperal diseases in his practice for which there was a demonstrable cause, thirty-seven were due to scarlet fever. This is an overestimate, and it has not met with general acceptance. Even Boxall's moderate statement has a long list of names arrayed in opposition to it, but, to the writer's mind, the weight of evidence is distinctly in favor of his view. 3 This word is used, in default of a better, to designate infection by the com- moner pyogenic micro-organisms. * T. Meyer, "Med. Klinik," 1905, Bd. i, No. 32, p. 800. INTERCURRENT DISEASES. 689 of scarlatinous nephritis; finally, tlie infection of those who come in contact with the patient and the subsequent outbreak in them of a ty])ical case of the disease/ make the diagnosis certain. But there are cases in which the existence of the disease, with symjjtoms closely resembling sepsis, is overlooked, or, if suspected, is only- inferred. The Peculiarities of Scarlet Fever in the Puerperal State. — Olshausen asserts that scarlet fever is modified in three ways when the disease appears during the puerperium ; it almost always appears in the first three days after labor ; the throat complica- tions are slight ; the eruption appears quickly, is rapidly diffused over the body, and is apt to assume a dark-red color. Winckel states that convalescence is commonly tedious. A careful study of the published cases must convince any one that scarlet fever exercises an unfavorable influence upon the puerperal state. The milk-secretion is often lessened, if not suppressed ; there is often some change in the lochia, denoting probably an exanthematous endometritis or a diphtheric inflammation of the vagina. In a number of the cases reported, fetid lochia is noted; in some a "peculiar odor" is described; the only change noticed may be an increase or a return of the lochia rubra. In a considerable proportion of all the cases the discharges from the genitalia are unaffected. In 10 of the cases reported by Meyer rheumatic complications were ob- served. In 2 1 of the cases collected by Olshausen there was an evanescent tenderness over the uterus. The occurrence of pelvic inflammation is reported in so large a proportion of the entire number of cases that the association can not be a mere coincidence. Of Meyer's cases, for instance, 6 presented evidence of peri- and parametritis. It is possible that the specific poison of scarlet fever is capable of causing a pelvic peritonitis or an inflammation of the pelvic connective tissue when it enters the body through the wounds along the genital tract or finds en- trance to the peritoneal cavity through the tubes. Or, per- haps, there may be a " mixed infection," as happens in gonor- rhea. Whatever the explanation, it is highly probable that pelvic inflammation may occur as a consequence of scarlatinous infection during or after labor. Diarrhea may develop early in the attack. It is an unfavorable sign. Of 21 women in Olshausen's series thus affected, i 5 died. Prognosis. — If the attack is a frank one ; if the genitalia are not much involved ; if the pelvic tissues are not extensiv^ely in- flamed, the woman will probably recover. The prognosis of scarlet fever in the puerperal state, however, is unfavorable. 1 See the cases reported by Palmer and Harvey, loc. cit. 44 690 PATHOLOGY. The death-rate among Olshausen's cases was 48 per cent.; of those infected immediately after labor, 75 per cent. Of Meyer's 18 cases, I died. The 3 cases observed by Martin all died. Of Braxton-Hicks' 37 patients, 27 died. Many of these, however, were not cases of scarlet fever, but were probably cases of puer- peral infection with a septic erythema. Galabin^ twice saw fatal peritonitis during desquamation. On the other hand, Hervieux had 7 cases which ended favorably. All of Boxall's cases recovered. Legendre- reports 23 cases without a death. The single examples reported by Palmer, Parvin, Busey, Harvey, and Cummins all ended in recovery. The two patients under my observation re- covered. Bonnet-Laborderie^ also reports 2 cases that recovered. In scarlet fever, as in all the contagious diseases of the puer- perium, the patient must be isolated and should not be allowed to nurse her child. Erythematous Rashes in the Puerperal State. — A rash some- what resembling the exanthem of scarlet fever sometimes makes its appearance on the skin of a puerpera, but a distinction can usually be made between the two. In the simple erythema there is apt to be a moderate and evanescent fever/ the pulse is rapid, and in most cases fetid lochia is noted,^ with some uterine or pelvic tenderness ; there is often intense itching and usually desquamation ; miliaria often make their appearance, especially on the abdomen under the binder, and there may be desqua- mation. The eruption is very likely the expression of a sep- tic infection, usually of a mild degree ; but occasionally ery- thema may be associated with the gravest forms of septicemia. Mackness explains the eruption by the supposition that some septic products are evacuated through the sweat-glands, irritat- ing the skin and producing a general hyperemia. His theory is supported by the fact that the rash is at first punctate, seeming to begin usually at the hair-bulbs, and soon after becoming diffuse. The belief in the septic nature of the eruption is shared by Winckel, Kaposi, Maygrier, Geneix, Farre, and many others. The superficial resemblance that this affection bears to scarlet fever has led many observers into error. Raymond® would have one believe that the eruption is the manifestation of an attenuated form of scarlet fever. With the same idea in mind Gueniot calls the rash scarlatinoid. It is likely that future ^ Discussion on Boxall's paper, loc. cit. ' See Parvin, loc cii. '" Journ. des Sciences Med.," Lille, 1910, p. 289. ■^ Mackness, "Some Scarlatinous Rashes Occurring During the Puerperium,'* "Edinb. Med. Jour.," August, 1888. * Mackness, loc. cit.; MacDonald, " Edinb. Obst. Soc. Trans.," 1884-85, x, ^3S\ Charpentier, Gueniot, "These," 1862; Poupon, " Erytheme scarlatiniform chez une Femme recemment accouchee," " La France medicale," 1884, i. 41. * " These d 'Aggregation." INTERCUKKENT DISEASES. 69 1 investigation will confirm an opinion, already expressed, that there is an '' infectious erythema " dependent upon the invasion of the body by a specific microbe, which, it is claimed, has been iso- lated.' Loviot ^ has reported an erythema recurring a number of times during a year after an attack of puerperal sepsis. Lipinsky ^ also reports two cases of recurrent erythema in the puerperium. Gaer- tig •* reports an erythema recurring after three successi\-e labors, twice with fever, the third time without. Measles. — Pregnant women are rarely attacked by measles. The disease is even more rare in the puerperal state, owing to the shorter duration of the period. The measles of pregnancy, however, usually becomes a complication of the puerperium by inducing an expulsion of the ovum. Nine out of eleven cases of measles during pregnancy reported by Klotz^ caused a pre- mature expulsion of the fetus. Occasionally, the disease first manifests itself in the puerperal state. Tarnier* describes an instance in his own experience. Measles in the child-bearing woman is a dangerous disease. There is a disposition to hemorrhage, and pneumonia is a frequent and a very dangerous complication.^ SmalUpox. — Pregnancy and the puerperium increase the gravity of all the eruptive fevers. This is true of small-pox as of the rest. Luckily, the disease is a rare one under any circumstances in this country, and as a complication of the puerperal state it is of very exceptional occurrence. A case of rotheln^ during the puerperal state has been re- ported. I have also observed one case, mild in character, end- ing in recovery. Erysipelas. — The practical identity of the streptococcus ery- sipelatis and the streptococcus pyogenes explains the fact that the germs of the disease, when introduced into wounds along the genital canal or into the uterus, are capable of generating a violent form of puerperal sepsis without manifesting externally the rash, which is supposed to be distinctive of erysipelas. A large number of cases might be cited in which contact with puerperal-fever patients originated an attack of erysipelas, or, on the other hand, ^ Simon et Legrain, "Contribution a I'Etude de I'Erytheme infectieux," "Ann. de Dermatol, et de Syphilog.," November, 1888. 2 "Annales de Gyn.," July, 1894. ^ " Centralbl. f. Gyn.," 1S94. * Ibid., p. 720. 5 "Archiv. f. Gyn.," Bd. xxix, S. 448. 6 Tarnier et Budin, " Path, de la Grossesse," p. 17. A good bibliography pre- cedes the chapter. ' Two fatal cases are reported by Hulburt, "St. Louis Courier of Medicine," 1887, xvii, p. 549. * Kite, " Boston Med. and Surg. Jour.,'' August 18, 18S7. 692 PATHOLOGY. in which puerperae exposed to the contagion of erysipelas developed virulent forms of puerperal sepsis/ Pneumonia is a frequent complication of puerperal erysipelas. During an epidemic that Winckel observed in 1880, six out of thirteen puerperae attacked manifested this complication. In relation to erysipelas, as to all the infectious fevers of the puerperium, it is important for the obstetrician to realize that if these diseases fasten themselves upon the w^oman after child-birth in the ordinary manner, — that is, erysipelas through a scratch in the skin, scarlet fever from the throat or lungs, and so on, — their course, symptoms, and treatment differ little from the ordinary manifestations and management of the respective diseases in an adult female; but when the woman's genital canal is infected, the history is different. The symptoms are, to a great extent, the same, no matter what the nature of the infection. There may be the same endometritis, the same involvement of the uterine walls, the lymphatics, the blood-vessels, the connective tissue, the tubes and ovaries, and the serous membranes after infection, of the pelvic or- gans by any one of the numerous pathogenic micro-organisms. Winckel has seen, in all, 42 cases of erysipelas during preg- nancy and the puerperal state; 36 of them developed after the delivery of the infant; 6 occurred during pregnancy. Of the cases in pregnant women, not one had its origin in the genitalia. Of the 36 cases in the puerperal state, 28 began in the genitalia, 2 in the breast, and the remainder in the face and scalp. Winckel, from an extensive study of the subject, offers the following points of evidence as to the etiology of erysipelas in the puer- peral state and its connection with puerperal sepsis: 1. By far the most frequent points of origin — in five-sevenths of all the cases — for puerperal erysipelas are the genitalia and nates. There are endemics in which not a single case of facial erysipelas appears. 2. Primiparae contract the disease three to four times as fre- quently as multiparae. 3. Puerperae with wounds upon the genitalia are particularly predisposed to the disease. 4. Those who have undergone difficult operative deliveries acquire the disease much more frequently than others. 5. The infants of women with erysipelas remain free from the disease. (Gusserow, in fourteen cases, saw the child infected twice ; Goodell, once.) 6. The larger the number of women diseased in a puerperal- fever epidemic, the larger is also the number of erysipelatous cases. 1 Winckel, " Ueber das puerperale Erysipel," Separat Abdruck aus dem "Aeizt- liclien Intelligenz-Blatt," Miinchen, 1885. INTER CURRENT DISEASES. 693 Frequency. — Erysipelas in the puerperal state manifested by a cutaneous eruption is very uncommon. Symptoms ami Diagnosis. — If the erysipelas manifests its ex- istence by a cutaneous eruption, the symptoms are distinctive and the diagnosis is plain. If, on the contrary, the streptococci in- vade internal organs and tissues, it is impossible to differentiate the case from one of ordinary streptococcus infection. Prognosis. — If the case is one of frank erysipelas, starting from the breast or the face, the prognosis is relatively favorable. Among 14 cases of the kind described by Winckel there were only 2 deaths. Of the 28 cases in which the erysipelas orig- inated about the vulva 12 ended fatally.^ Treatment. — The treatment of erysipelas of regions distant from the pelvic organs in the puerpera differs in no respect from the treatment of the disease under any circumstances, except that the greatest care must be exercised not to transfer the strepto- coccus infection to the genitalia, and not to allow the child to nurse from an infected breast. Puerperal Diphtheria. — If infection occurs in the throat, the disease is an accidental complication of the puerperal state. If the infection has occurred in the genitalia, a variety of puerperal sepsis ensues that is considered in another place. Puerperal Malaria. — Malaria is something more than an acute intercurrent affection of the puerperal state, for in some important particulars the condition of the woman's organism after labor modifies the disease. The liability to infection is increased after child-birth. Bonfils ^ has collected 140 observations of malarial fever in child-bearing women. His conclusions are as follows : Malarial fever after child-birth predisposes to puer- peral hemorrhages, which occur apparently in consequence of the disturbances in blood-pressure accompanying the chills and fever. The lacteal secretion is suppressed during the exacer- bation of fever, but appears again after the febrile stage ; it is, however, less abundant. Whether or not the milk can convey the protozoa of malaria from the mother to the nursing in- fant is an undecided question. The most striking phenom- enon in the puerperal state of women already infected with malaria is the reawakening of malarial manifestations, probably by reason of the traumatism and the physical depression follow- 1 It goes without saying that the puerperal state predisposes to attacks of ery- sipelas by furnishing so many points of entrance for the poison in the wounds of various degrees along the genital canal. It would seem, also, that the condition of the whole organism favored the occurrence of the disease. Doderlein ("Miinch. med. Wochens. ," xxv, 1888) reports a case in which the poison lay latent for a year in a lymphatic gland and broke out into fresh activity after an abortion. - " Paludisme et Puerperalite," " Ann. de Gynec," 1886, xxvi, 125. 694 PATHOLOGY. ing child-birth. The third day after labor seems to be the usual time for the reappearance of the disease, probably because of the slight elevation of temperature and of the general excitement of the organism which accompanies the estabhshment of lactation. In my experience the fever is at first usually continuous. As the patient is brought imder the influence of quinin the fever becomes intermittent and finally disappears (Fig. 541). The puerperal state predisposes to grave forms of malarial intoxi- cation. The disease may pursue the mildest possible course, with ver\' slight and irregular fever, which is easily controlled by quinin in small doses. On the other hand, the worst example of malarial infection which I have ever seen occurred in the last ' 1 1 1 1 1 1 1 ' 1 1 """"* D-linit- J \ 2 \ 3 \ U\ 5 \ 6 "^ 7 g 1 5 ! /£» i // /2 /i 1 /* /f 1 /t /7 /P /? zo ^/ 108= 1C6= IM' ^iC V £: ,k^e:m.b ^/' £Z/^ Ei mS /^^ /^ ci.'r^x: M£^ ^.'7£:,:^.£:.>^£. ' '^£ ^£1 .v/: MS. \MS.'^iE- fif £ 107^ 106° 105= 1(H° 103= 102= 101= 100= 89= B8= 97= \\\ ■ L:; U;-;: : : •J ■ ■ '. ; : ; \ : ; : : : : ; i ■ M : : : 1 , ; 102= 101= 100= 99- er= : : r^\ \;. \ ; : i r ; : ■ i ; r 1 : > 1 ; - : ': : : 1 \ : i : :^ '^- : : ^ V, ;/ ■ : . : : : f - ^- ^ s*- -T ] .\ ? V . ■ - \ ■ • ■ - ; • ; \ ^ : \ -^ -r 7 ^ "T^ ^ "; : : - i i ; \ u 1 I \ Fig. 541. — Malaria in the puerperium ^aelding to quinin when intra-uterine dis- infection had failed. month of pregnancy. During the pre^ious eight months the patient had had two attacks of malarial fever. Within a week or two of term, the disease reappeared in a grave form. There were congestive chills, a temperature running above 104°. and finally coma. The fever was almost continuous. In the midst of the attack labor came on, and after some diSiculty the child was extracted by the breech. After deUvery the woman grew worse, and death seemed inevitable, but by the daily administra- tion of seventy to eighty grains of quinin for several days, the fever was conquered and the patient made a rapid recovery. Diagnosis. — The microscopic examination of the blood should clear up a doubtful case. The whole subject of malarial fever in the puerperal state has been discredited by the tendency to conceal cases of puerperal infection imder this name. The prac- INTERCUKRENr DISEASES. 695 titioner should always be upon his guard in this respect. While not so satisfactory to him, it is far safer to his patient to err in the opposite direction; to regard a doubtful case of fever during the puerperium as of septic and not of malarial ori- gin, unless the proof in sup- port of the latter belief is con- vincing. Treatmentc — In the major- ity of cases larger doses of c^uinin are required than under other circumstances. Refer- ence has been made to a case in which, on the average, sev- enty-five grains were adminis- tered in the twenty-four hours for several successive days. In another case under my obser- vation, forty-five grains a day were given for a long time, with success in controlling the fever and with no ill effect upon the patient. Several times an attempt was made to reduce the dose to thirty grains, but the reduction in the quantity of the drug was always followed by the reap- pearance of the fever. It was at one time erroneously taught that quinin administered to a nursing woman had a disas- trous effect upon her milk. Even in very large doses it does not pass into the milk. Rheumatism and Arthri= tis. — Arthritis in the puerperal state is either a manifestation of septic infection, with a lo- calization of the septic inflam- mation in a joint, or else, as a rheumatic arthritis, is ^ s 1 \ ^ \ £ 2 \ |_ L \ \ I ^ — h 1 .uu ^ 1 -^ s xl -^ M — — K -- -^ — ^ __ ^ ^ 7?^ 7^ t> - — tt: tt: -r. ~ — — [TTTN ■■■< ':'... .... .... ! -E ■r-r ~ ^ i r: E: : — 1 ;^ S ^ > >■■ 1 ■Ii .. . a .... h — 1 TTt 1 ■■■■ ?5 % ■■■■ .... a ....3 ;- 1:^ ^ '^-\ ^ .^^ 11^ "^^ ^ -^ ^ ^ EI E-. — ^ .. . j-i^ ^ i ~£ ^ ...,^ :- 2 \z. ^: ifr 7^ rr^ / 11 ^ ^ TT i i ^ i¥ rr ^ ....^ ....3 .... h .... ^ .... ^ .... t .::. ■» .... r .... ti H :....1 ^ ^ ^ TTTT ^ ^ M .... 5 .... t :...s .... r .'...J .... > ...-5 .... t rrnf .... f ....3 .... t '....i .... ^ ....3 .... Y .. .i 1 ^- . ...y ..'T... tt: TTT rr rr l — ■ v ...J.... ....n \ ^1J§^§S^S|8|3 696 PATHOLOGY. simply an accidental intercurrent affection. The diagnosis be- tween septic arthritis and simple acute rheumatism is not always easy. In the latter, during the puerperal state, the symptoms are the same as in any adult. Inflammation of the joints following septic infection, on the other hand, presents certain peculiar signs. The joint affected is usually a large one, very often the knee ; the inflammation is not fugacious;^ it is exceedingly stubborn Day of Disease MEMElV,e:M£^ M~£^ M £ M £ f^ E M £^ r\4\E r\/, £. M E. loy^ _L _;: r; IT 11 _^ _: :r = _ ___ _L^ 4_ 44 4j_L j__;_ -L ^ 101° -i- -i- 4- -i- 4 A -r -r 4- - 100° • A ■ A ■ ' K ' -i L U : A =1 :A ; A_ ZJmii^^wi\i'm^'t : : : : » : V : vi : V = ■■ = V ^ V •• V • V A- A 88° 44 — 4--^-i- -r-r 4- r-TTT---T-T^^t| 97° — — 44 44 — -i- -r- > -^ ^ ^ -4H|-+rl Fig. 543. — Temperature-chart of a puerpera with fever and uterine tenderness, with no other symptoms of sepsis. Irrigation and curettage of the uterus had no effect upon the fever, which yielded immediately to the salicylate of sodium. There had been an attack of muscular rheumatism during pregnancy. in its resistance to all treatment ; the duration is usually pro- longed, and in many cases there follows a complete ankylosis of the joint. There may be very little evidence of general septic infection. The arthritis may make its appearance late in the puerperal state. It may be accompanied by very moderate fever of an irregular type. It is more apt to appear in women who have had gonorrhea. In the worst cases of general septic infection the joints may be the seat of metastatic abscesses as well as other portions of the body; but in these cases the symptoms pointing to a general septic infection are plain. Prognosis. — Tlie average duration of the septic arthritis is about three months. Recovery is the rule, but with an ankylosed joint (sixteen times out of twenty-three (Tison) ). In scrofulous subjects the affected joint may become the seat of a tuber- culous inflammation. Treatment. — General medication is of little use. The salicy- lates are of no value. A ring of iodin should be painted around the joint. A plaster of equal parts of mercurial and belladonna ointment is appHed over the joint and an ice-bag is put over the plaster. The joint at first should be immobilized, but as soon as the acute symptoms subside massage and passive motion should be employed to prevent ankylosis. ^ There are, however, occasional exceptions to this rule. IXTKKCCRKl'lNT DISEASES. 69/ Muscular rhcumatisin may complicate the puerperal state. If the disease affects the uterine muscle and is associated with much fev^er, the only means, practically, of distinguishing be- tween this affection and puerperal infection with septic inflamma- tion of the uterus is the therapeutic test — the administration of a salicylate. Gonorrhea. — The frequency of gonorrheal infection in the puerperal state depends upon the class of society to which the women belong. In the lower classes, seen in dispensary prac- tice, it is very common. In the upper classes it is decidedly rare. The proportion of cases varies, too, in different localities. Noeggerath and Sanger^ report that among 1930 gynecologi- cal cases during a single year, in private and polyclinic practice, 230 (twelve per cent.) owed their sufferings to gonorrheal infec- tion. Among 398 pregnant women, 100 had a purulent discharge, presumably from gonorrhea (twenty-six per cent.) ; forty of the children developed blennorrhagia. This estimate is too high to be correct as an average. The differential diagnosis between gonorrheal and other pyo- genic puerperal infections is made, according to Sanger, by the following signs : The progress of gonorrhea is slower. It very rarely breaks out in the early part of the puerperal state, appearing first about six or seven weeks after delivery. The most violent cases observed by Sanger were acquired during the period of uterine involution. It is difficult to draw a sharp distinction in all cases between infection by gonococci and by the other patho- genic micro-organisms causing local inflammation in the genital tract. On the one hand, there are many infectious bacteria which cause a severe inflammation of the mucous membrane along the whole canal; and, on the other hand, gonococci can, without doubt, excite inflammation of the deeper tissues, and are certain, if they escape from the tubes, to light up a sharp attack of peri- tonitis. The diagnosis may be made with approximate certainty if the disease existed during pregnancy, or if a careful examina- tion detects an inflammation of the urethra and of the vulvo- vaginal glands, or if it is possible to detect the gonococcus. The consequences of gonorrhea in the puerperal state may be most serious. There is often a mixed infection, gonococci prepar- ing the way for streptococci or other pathogenic micro-organ- isms. The local inflammation, under an}' circumstances, may become acute, and may be accompanied by violent peritonitis. There may be a rapid accumulation of pus in the tubes during the puerperium, but usually the pyosalpinx develops slowly. In 1 " Ueber die Beziehung der gonorrhoischeii Infection zu rut;rperalerkranl=f \. >>' DISEASES OF THE MAMMARY GLANDS. 723 on her back, and a counteropeninus. For both conditions the breast must usually be amputated. A fibro=adenoma, or localized hypertrophy on the under sur- face of breast, is quite commonly the result of irritation from the upper edge of ill-fitting corsets. The source of irritation being removed, the swelling in time disappears. Relaxation and Disease of the Pelvic Joints. — The pelvic joints, after labor, may be the seat of inflammation, accompanied by serous exudation, ending possibly in suppuration. In the symphysis pubis the abscess can easily be opened and drained. The prognosis, therefore, is good. In the other pelvic joints suppuration is commonly fatal, although in one case under my care both sacro-iliac joints suppurated, were opened, and drained with a good result. The pelvic joints may be ruptured by violence during labor. This accident is considered in connec- tion with the forceps operation and injuries to the woman in labor. Finally, there may be relaxation of the pelvic joints to a marked degree, much exaggerated beyond that seen in almost every pregnant woman, and persisting after delivery. The etiology is obscure. Abnormal motion in the pelvic bones has been seen in justomajor pelves. It has been noted after abortion. It may be traced to a large, hard fetal head which had stretched the joints. It occurs in justominor pelves rather frequently. It has been ascribed to obesity, to a cachectic condition, to sudden and powerful exertion in the latter months of pregnancy, to an unusually great circumference of the preg- nant uterus, 1 and to previous disease or abnormality of the joint. ^ The diagnosis is easy. There is difficult locomotion, unusual mobility in the joints, especially the symphysis pubis, and local- ized pain. The woman may not be able to stand on her feet at all, or to take a step without collapsing. The examination is best made in the erect posture, the physician placing a fore- finger behind and his thumb in front of the symphysis. As the patient takes a step forward and backward the abnormal mobility of the innominate bones is appreciable. If the woman cannot stand, the examination is made in the dorsal position, an assist- ant flexing, extending, abducting, and rotating one thigh. ' Winckel, " Geburtshiilfe," p. 873. - Schauta, in jMiiller's " Handbuch," vol. ii. 726 PATHOLOGY. The treatment is rest in bed with the appHcation of a firm binder about the hips reinforced sometimes by sand-bags. In the course of a few weeks the joints usually become firm. Oc- casionally, the relaxation persists for months. I have not yet seen a case that did not recover under the treatment described : Kelly reports one in which he resected the symphysis and wired the pubic bones together. CHAPTER IX. Puerperal Sepsis* Historical. — The history- of the acquisition of our knowledge of puerperal infection is distinctly modern. It had its earliest beginning about fift}" years ago, and dates back in reality scarcely thirty years. Indeed, one may say that a true comprehension of the causes and nature of puerperal sepsis was acquired only at the close of the nineteenth century, and that the past few years have contributed more information on the subject than all the previous ages of medicine. The histor}^ of medical views on the septic fevers of the puerperium prior to the past generation is a long record of error and ignorance. From the earliest beginning of medi- cal literature to the nineteenth century, puerperal sepsis was ascribed to suppression of the lochia. This belief was not ques- tioned until 1670, w^hen Puzos advanced the theory that all puer- peral fevers were due to a metastasis of milk, which flowed in the blood during pregnancy, and was normally attracted to the breasts after delivery, but which might be dra^ATi to other organs or structures, especially the peritoneum, with disastrous results. This theor}' found support in the reports of a number of post- mortem examinations, stating that milk had been discovered in the peritoneal cavity after deaths following childbirth. A little later English and German observ^ers explained the puerperal infectious fevers by attributing them to inflammations of the womb and of the peritoneum, without accoimting satis- factorily for the occurrence of the inflammation. Occasionally, one finds a reference to putrid fevers in the puerperium, a sug- gestion that putrefN-ing animal matter may occasion disease in human bodies with which it comes in contact, an intimation of the contagiousness of puerperal fever ; but these were mere rUF.RPERAL SEPSIS. 727 glimmerings of light that flickered out at once without illumi- nating the general ignorance. Credit, however, must be given to some of the English writers of the first half of the nineteenth century for insisting upon the contagiousness of puerperal fever. Three events laid the foundation of our present knowledge of puerperal sepsis : The publication of Oliver Wendell Holmes' paper on "The Contagiousness of Puerperal Fever," in 1843; the observations of Semmelweiss in the Vienna Hospital, 1846- '48 ; the publication of Sir James Y. Simpson's paper on " The Analogy between Puerperal and Surgical Fevers," in 1850. The first of these papers must always remain a classic in medical and English literature. It ended with these words : " I have no wish to express any harsh feeling with regard to the painful subject which has come before us. If there are any so far excited by the story of these dreadful events that they ask for some word of indignant remonstrance to show that science does not turn the hearts of its followers into ice or stone, let me remind them that such words have been uttered by those who speak with an authority I could not claim. ^ It is as a lesson rather than as a reproach that I call up the memory of these irreparable errors and wrongs. No tongue can tell the heart-breaking calamity they have caused ; they have closed the eyes just opened upon a new world of love and happiness ; they have bowed the strength of manhood into the dust ; they have cast the helplessness of infancy into the stranger's arms, or bequeathed it, with less cruelty, the death of its dying parent. There is no tone deep enough for regret, and no voice loud enough for warning. The woman about to become a mother, or with her new-born infant upon her bosom, should be the object of trembling care and sympathy wherever she bears her tender burden or stretches her aching limbs. The very outcast of the streets has pity upon her sister in degradation, when the seal of promised maternity is impressed upon her. The remorseless vengeance of the law, brought down upon its victim by a machinery as sure as destiny, is arrested in its fall at a word which reveals her transient claim for mercy. The solemn prayer of the liturgy singles out her sorrows from the multiplied trials of life, to plead for her in the hour of peril. God forbid that any member of the profession to which she trusts her life, doubly precious at that eventful period, should hazard it negligently, unadvisedly, or selfishly! " This unanswerable arraignment of the prevailing views in America in regard to puerperal sepsis fell upon deaf ears. The very men who should have first recognized its truth opposed the new 1 Dr. Bluiidell and Dr. Rigby, in the works already cited. 728 PATHOLOGY. doctrine with all their might, because it contradicted their teaching. At that time, in America, two men were so pre- eminent in obstetrics that they were practically without rivals, and autocratically dictated their views to a large number of un- questioning followers. They were Hodge and INIeigs, holding, respectively, the Chairs of Obstetrics in the Universit}' of Penn- sylvania and in the Jefferson Medical College. Meigs directed against Holmes' teaching all the satire and ridicule of which his brilliant mind was capable, descending often to undignified abuse ; Hodge inveighed against it with a pon- derous in\'ective. But in spite of this powerful opposition the doctrine of the contagiousness of puerperal fever made rapid headway, and gained from 3'ear to }'ear an increasing number of converts in America and in England. Hodge's immediate successor, Dr. Penrose, taught it most impressively. In 1846, Ignaz Philipp Semmelweiss, a young assistant in the Maternity Department of the General Hospital of Vienna, was struck with the frightful mortalit}' in one of the matemit}- wards, Avhile in a neighboring ward the death-rate was scarceh- one -tenth as great. He discovered that in the first ward the women Avere attended b\" students who were in the habit of com- ing fresh from postmortem examinations in the Pathological De- partment to the bedside of the parturient patients. In the second the women were attended solely b}' midwives. Semmelweiss conceived the idea that the students carried on their hands putrid products from the postmortem table to the lying-in women whom they examined, and that these products were responsible for the large number of fatal inflammations and fevers following their work. He consequently ordered that no student should exam- ine a woman until he had washed his hands in chlorin-water. The results were fairly startling, as is shown in the accompany- ing table : Confinements. Deaths. Per Cent. 1846, 4010 459 1 1.4 1847, 3490 176 5- 1848, 3556 45 1-27 It should be stated that the rule compelling the students to wash their hands in an antiseptic solution was put into effect in the middle of the year 1847. Semmelweiss recognized the transcendent importance of his discovery. He foresaw something of the lives preserved, the homes kept from bereavement, the mothers saved to their chil- dren, the wives to their husbands, in millions of families ; the in- calculable diminution of human suffering which his discover}' promised to the world ; but his was not the calm and confident PUERPERAL SEPSIS. 729 soul of a Harvey, wise enough to know that the truth is mighty and shall prevail : sure that niankind must accept it some day, and content to bide his time. Scmmclweiss' nature was not great enough for such patience. He fumed and fretted his life away in vain efforts to obtain recognition for his principle of chemical disinfection. He preached his new doctrine in season and out of season, endeavoring to im])ress it upon his imme- diate colleagues, and ujjon the medical societies and jjcriodi- cal medical literature of the time in Europe. During the latter days of his professorship in Buda-Pesth he would even stop acquaintances upon the street to importune them with his \-iews. But he got for his pains nothing but ridicule, contumely, opposi- tion, or indifference. He finally lost his mind entirely, from chagrin and disappointment, ending his life in a lunatic asylum in Vienna, where he died, strangely enough, from a septic wound on his finger, received during an operation performed just before his commitment to the asylum. More than twenty years after Semmelweiss' discover}-, the mortality of many lying-in hospitals in Europe remained as high as ten per cent. Then came the brilliant work of Pasteur in the field of bacteriology, the acceptance of the germ theor}- in disease, the application of antisepsis to surgery by Lister, and the adoption of the system almost immediately by obstetricians. From that day to this there has been a steady and increasingly rapid acquisition of knowledge of the etiology of septic infection, and of its most successful preventive and curative treatment. Etiology, — The effective study of the microbic flora of the vagina dates from Doderlein's monograph published in 1892.^ Before this time the presence of bacilli in vaginal secretions was noted by Hausmann, Conner, Bumm, Winter, and Steffeck. Conner, in 1887, found in vaginal secretions many varieties of micro-organisms, mainly, however, bacilli, which were extremely difficult to cultivate in the ordinary culture-media. The cocci in the secretions, many of which could be cultivated with ease, were found to be non-pathogenic. Doderlein examined the vaginal secretions of 195 pregnant women. In these examinations notice was taken of the macro- scopical appearance and of the reaction of the secretions, and as the result of this preliminary examination the secretions were declared to be normal or abnormal. In the two conditions the bacteriological find was quite different. In the normal secretion, which was of whitish color, of the consistency of curdled milk, un- mixed with mucus, containing epithelial cells and mucous bodies, 1 " Das Schcidcnsekret und seine Bedcutung fiir das Puerperal Fiebcr," Albert Doderlein, Leipsic, 1892. 730 PATHOLOGY. moistened by an exudate from the vaginal mucous membrane and of an intensely acid reaction, there was found almost exclu- sively a certain kind of bacillus possessed of distinctive and characteristic qualities. No pathogenic germ was ever found by Doderlein in normal vaginal secretions, except a thrush-fungus which is capable, to a very limited extent, of producing suppura- tion and destruction of tissue when injected under the skin or into the eye of an animal. In the pathological abnormal secre- tion, which was yellowish or greenish in color, of the consistency of cream, weakly acid or alkaline in reaction, mixed with mucus, containing often bubbles of gas and secreted usually in very large quantities, the greatest variety of cocci and bacilli could be found. Fig. 567. — Vaginal secretion of an infant (Doderlein). Fig. 568. — Vaginal secretion of a virgin (Doderlein). Of the 195 pregnant women, Doderlein found that 55.3 per cent, had normal and 44.6 had pathological secretions. The vaginal bacilli are antagonistic to pathogenic micro- organisms. Doderlein attributes the germicidal action of the normal vaginal secretion to the production of an acid environment by the vaginal bacillus. Doderlein's discoveries constitute the most important ad- vance in the knowledge of this subject achieved by a single individual. Following Doderlein's investigation there have appeared a large number of exhaustive studies, the most important conclu- sions of which may be briefly summarized as follows: The vulva, like any other skin surface, such as the physician's hands, may be infected with pathogenic bacteria, and from its PUEKPERAL SEPSIS. 731 situation is most likely to be surgically unclean. Micro-organ- isms on the vulva may be diminished in virulence, but may be- come actively infectious if transplanted deep within the genital canal. The vagina becomes infected almost immediately after birth. In a normal condition it contains no pathogenic bacteria, but occasionally streptococci, staphylococci, and other pathogenic micro-organisms are resident in the vagina before labor. These germs, if present, are usually diminished in virulence, the strep- tococci not being hemolytic; but they may regain their full pathogenic power under conditions favorable to their growth and propagation. The vaginal canal has strong germicidal proper- ties which serve to guard a woman against infection. They Fig. 569. — Normal secretion of a preg- nant woman (Doderlein). Fig. 570. — Pathological secretion of a pregnant woman (Doderlein). depend upon the presence of a special bacillus, and upon the products of its life-processes; upon the leukocytosis due to che- motactic action; upon phagocytosis; upon the germicidal powers, perhaps, of the anatomical elements of the vagina; of the cer- vical mucus, and of the bloody discharge during menstruation and the puerperium, and possibly upon the presence of tri- methylamin. The cervical canal and the uterine cavity are normally sterile, but after labor there may be found anywhere along the genital canal, even in the uterus, numerous cocci and bacilli, some pathogenic, some not, although the patient is apparently healthy.^ During and after labor mechanical safeguards of the most effective kind are furnished against infection. These are: the ' The bibliography of this subject is too extensive for a work of this kind. It may be found in the late volumes (iqoq, iqio, iqii) of the " Jahresbericht," and in " Puerperal Infection," Arnold W. Lea, London, 1910. 71^ PATHOLOGY. discharge of the Hquor amnii, washing the vagina out; passage of the child's body, scrubbing the vagina out; the descent of the placenta and membranes, and the bloody discharge which follows. Moreover, should the vagina contain pathogenic bacteria, they are likely to be in a condition of diminished or absent viru- lence. Bearing these facts in mind, it is apparent that the common practice of relying upon simple vaginal douching for disinfecting the vagina before labor, or before some gynecological maneuver or operation, is faulty. It has been clearly demonstrated that the injection of an antiseptic fluid into the vagina does not de- stroy pathogenic germs there, and robs the woman, to a certain extent, of the safeguards that nature provides for her against infection. If, therefore, under certain circumstances, it is desir- able to disinfect the vagina, mere douching should not be de- pended upon, but the vaginal mucous membrane should be thor- oughly scrubbed out as well as douched, just as one would pre- pare the skin for an important surgical operation. It is clear that these discoveries of micro-organisms in the vagina do not lessen the importance of aseptic precautions on the part of medical or other attendants upon a patient in labor. When one considers that the micro-organisms in the lower genital canal are not pathogenic in the vast majority of cases, and that when they are their virulence is diminished or absent, it is obviously unjustifiable to introduce into the vagina infecting bacteria which may, by their number and virulence, overcome all the safeguards that nature provides, and may, consequently, be the cause of a serious and fatal disease. The Pathogenic Microbes Capable of Producing Local In= flammation and General Systemic Infection when Introduced in the Genital Canal. — Streptococci were first observed in cases of puerperal infection by Mayerhofer in 1865 and were first cultivated from such cases by Pasteur in 1880.^ Doderlein found the streptococcus pyogenes as the sole-infecting agent in five cases of serious puerperal infection. Czerniewski, in 53 cases of puerperal infection, found strepto- cocci in 49. In a histological and bacteriological examination of 16 cases of puerperal fever, Widal found streptococci in 14, bacilli in 2. Bumm, in an examination of 17 cases of puerperal infection, found streptococci in all — 5 times as pure cultures, 12 times mingled with small numbers of staphylococci and of other 1 See the very instructive article, with full bibliography, by J. W. Williams, on " Puerperal Infection " in " The Practice of Obstetrics by American Authors," Jewett, 1899. PUERPERAL SEPSIS. 733 germs. Thus, in a total of 91 cases, the streptococcus was found to be the infectin<^- agent in 85, or 94 per cent. Following streptococci, but a long way behind as the cause of puerperal infection, are the pyogenic staphylococci, the colon bacillus, the gonococcus, the tubercle bacillus, the bacillus pyocy- aneus, the bacillus fcctidus, the pneumococcus, the Klebs-Loffler bacillus of diphtheria, the tetanus bacillus, the bacillus fecalis alcahgenes, and possibly any germ at all that, inserted into living tissues or deposited upon weakly resisting surfaces, is capable of causing local inflammation or general disease. In addition to specific septic micro-organisms, the anaerobic saprophytes of decomposition play an important role in the common form of puerperal sepsis, due to the absorption of toxins, or ptomains produced in the decomposition of dead animal matter, such as blood-clots, fragments of placenta, hypertrophied decidua, within the womb. Dobbin^ has reported an interesting case of fatal puerperal infection, in which the bacillus aerogenes capsu- latus (gas bacillus) was probably the infecting agent, or, at least, produced the toxins that fatally intoxicated the maternal organism, and, after death, developed the same emphysema in the maternal body which was found in the dead and macerated fetus at the time of delivery. This germ is accountable for cases of physometra or tympanites uteri. It develops by preference in dead bodies, and may not manifest its presence during Kfe. It finds in the dead fetus within the womb a habitat most suitable for its development; it gives rise to a horribly fetid inflammable gas, and probably to virulent toxins.- Blumer'^ reports a case of mixed puerperal and typhoid infec- tion in which the streptococcus and the typhoid bacillus were iso- lated both from the blood and the uterine cavity. J. Whitridge Williams, in forty patients, found- Streptococci in 8 cases Staphylococci in „ . 2 cases Colon bacilli in 6 cases Strictly anaerobic bacteria in 4 cases Unidentified aerobic bacteria in 5 cases Bacteria were found in cover-glass examinations, all cul- tures being sterile, in 4 cases Diphtheria bacilli in I case Bacillus aerogenes capsulatus in I case Typhoid bacilli in . . i case Malarial plasmodia in blood, cultures sterile, in . . . I case No bacteria on cover-glass, cultures sterile and blood negative, in II cases ' " Puerperal Sepsis Due to Infection with the Bacillus Aerogenes Capsulatus," " Johns Hopkins Hospital Bulletin," No. 71, February, 1807. - See also studies of five cases by Lindenthal " Beitragc zur Aetiologic dcs Tympania Uteri," " Monatschr. f. Geb. u. Gyn.," Bd. vi, p. 269. ' " Am. Jour, of Obstet.," Jan., 1899. 734 PATHOLOGY. In loo cases of infected abortion Schottmiiller^ found strep- tococcus putridus, staphylococcus, colon bacillus, vaginal strep- tococcus, erysipelatous streptococcus, phlegmonous emphys- ematous bacillus, pneumococcus, hemolytic colon bacillus, gonococcus, streptococcus viridans and bacillus parat}^hosus. The Manner in which Pathogenic Organisms Find an Entrance into the Genital Canal. — The majority of puerperal infections are traceable to the insertion of pathogenic germs by the examining finger or hand of the physician, who in the course of his daily work may have touched the dried sputum of diph- theria, the desquamated skin of scarlet fever, suppurating wounds, er^'sipelatous surfaces, and other virulent, infectious material ; so that at any time his hands may fairly reek with the m.ost dangerous poisons that could possibly be brought in contact with the parturient and puerperal woman. Many hundred cases have been traced directly to the association of the physician with infectious diseases, and there is scarcely a surer way of avoiding puerperal infection than by abstention from vaginal examinations. Epidemics of puerperal fever in hospitals have been quickly stamped out by avoiding all internal examinations, and the best morbidity and mortality records have been obtained in institu- tions in which vaginal examinations are eliminated as much as possible. Even if the examining hand is protected by a sterile glove, pathogenic bacteria may be carried into the vagina from the vulva, if there is a faulty technique in m_aking the examination. The hands of the nurse or other attendants may be the agents that deposit bacteria in the vagina or upon the vulvar orifice. The implements used in and about the parturient canal, an atmosphere laden with dust or vitiated by foul unhygienic conditions, and the water used to wash and douche the patient may carry disease germs to the parturient woman and may introduce them into the genital canal. The bed-clothing, the personal clothing, the mattress, the vulvar pads, the material used to cleanse the vulva (rags, sponges, cotton, cloths), may each and all be sources of infection. Putrescible material retained within the genital canal (espe- cially within the uterine cavity) attracts saprophytes and their spores. The development of these bodies in a situation favorable to their growth and active propagation may result in a toxemia, if not in actual invasion of the body by pathogenic germs. Coitus in the last weeks of pregnancy is a source of infection of the genitalia, by carrying pathogenic bacteria into the vagina. Finally, a certain proportion of cases may be traced to auto-infection — that is, to pathogenic germs ^ " Mitl. a. d. Grenzgeb. d. med. u. Chirurg.," Jena, Bd. 21, H. 3. PUERPERAL SEPSIS. 735 resident in the body, and not introduced from without during or after hdx)r. These germs may have had a lodgment in the vagina, as has been demonstrated in the bacteriological studies of that canal; or they may have been contained in a limited area near the genital canal, as in an old pyosalpinx, whence they spread by rupture of the pus-sac during labor, or in which they are incited to new activity by the compression and consequent reduction of vitality of surrounding tissue. There may have been tuberculosis of the genitalia, antedating conception. Or there may be, in the neighborhood of the uterus, tumors of low vitality and highly put- rescible material, which, being reduced in resisting power by com- pression from the descending child, become infected by germs that ordinarily can not influence vigorous body-cells. Dermoid cysts and fibroid tumors are the best examples of these growths. Even highly vitalized tissues like the pelvic muscles, espe- cially the iliopsoas, may be so bruised and injured by the child's head that they slough and become gangrenous. The iliac bone, too, has become carious after the bruising to which it was sub- jected in a prolonged forceps operation. The parturient woman may have had an infectious interstitial endometritis. The micro-organisms being lodged in the interstices of the mucosa, and the woman becoming pregnant, there is con- tained in the uterine cavity, even before conception, a cause of puerperal sepsis. The infection of the birth-canal may be hematogenic, the original infection of the blood being derived from the lungs, the tonsils, the breasts, or other foci. The Behavior of Pathogenic Micro=organisms when Intro= duced into the Genital Canal or Deposited upon its Entrance.^ — The consequences of microbic invasion of the genital canal by pyogenic germs are variable in the extreme. If the bacteria enter wounds in or near the vaginal outlet, the result may be the same as in the infection of any wound in general surgeiy — that is to say, local inflammation, suppuration, and perhaps general sys- temic infection ; but the infectious inflammation of a vaginal wound is almost certain to spread upward, for the conditions are more favorable to microbic growth and to systemic invasion in the uterine cavity and in the tubal canals than in the lower portion of the genital tract. Hence it is that the vast majority of serious puerperal infections have their effective starting-point within the womb. For example, it has been found, in a strepto- coccic infection of the whole genital tract, that the micro- organisms were present in the vaginal mucous membrane alone, ' " Ueber die im weililichen Genitalcanale vorkommenden Bakterien in ihrer ??eziehung zur Endometritis," "Archiv f. Gyn.," Bd. 1, H. 3. 736 PATHOLOGY. in the cer\dcal mucous membrane, and in the tissues immedi- ateh' subjacent ; in the endometrium, and deep within the uterine muscle, showing that they could easily penetrate the deeper tissues within the womb, while they were incapable of invading the tissues underlying the vaginal mucous membrane. In other words, the resisting power of the tissues under the mucous mem- brane is less the higher the micro-organisms are found in the genital canal. ^ Septic infection of the genital tract results often in the forma- tion of false membranes. This is true of pure streptococcic infections, of mixed infections (streptococcus, bacillus foetidus, bacillus pyocyaneus, the pyogenic staphylococci), and especially true, of course, of the rare cases of true diphtheria of the g-enital tract in which the Klebs-Loffler bacillus is found. The apparent false membrane in a septic endometritis is due to a necrosis of the endometrium, clothing the uterine walls with a dirt}', greenish-}'ellow covering. There is much yet to learn of the antagonisms and associations of pathogenic germs in puerperal infections. This much, however, may be asserted with confidence : the streptococcus is frequently associated with the pyogenic staphylococci, the bacillus foetidus, the bacillus pyocyaneus, and the colon bacillus, though it is said to drive away or to destro}' the staphylococci after a time. The gonococcus seems often to prepare the way for the strep- tococcus, which, in its turn, may destroy the gonococcus, con- quering the latter in a struggle for existence and remaining in sole possession of the field. The streptococcus appears often to prepare the way for the colon bacillus, which certainly wanders in frequently in the course of streptococcic infection. Streptococci, staphylococci, and the pyogenic bacilli have preeminently the power to penetrate the tissues of the uterus and to distribute themselves throughout the body. This is particularly true of the streptococci. Gonococci and the colon bacilli confine themselves most often to the endometrium and to the tubal mucosa. The former is the pathogenic agent in a large proportion of the cases of septic endometritis after labor. The latter is often found in cases of physometra. Both of these organisms, however, can pene- trate the uterine muscle, and ma}' be distributed through the system b}'' the lymph-channels or by the blood-vessels. Strep- tococci show a preference for the l}'mphatic channels in their invasion of the tissues. Hence they usuall}' pass from the endo- metrium to the myometrium, to the parametrium, and to the subperitoneal lymphatics, perhaps affecting the tubes and ova- • Labn, " Inaug. Diss.,"' Jahresbericht, 1894. Plate 20. Streptococcic infection of the vagina and vulva, with pseudomembrane. Cured by local irrigation, general stimulation, and support (University Hospital). PL-ERPKRAL SEPSIS. J 17 ries, secondarily, perhaps causing abscesses or general infection of the peritoneal cavity, or of the pelvic connective tissue. The putrefactive micro-organisms (saprophytes) are anaerobic, and confine their activity mainly to the decomposition of putrescible uterine contents, particularly of hypertrophied endometrium, which is practically cut off from its blood-supply by the contrac- tion of the womb, and is peculiarly liable to rapid decomposi- tion. During the process of putrefaction the saprophytes manu- facture soluble and absorbable products (toxins) of a highly pathogenic nature, causing possibly a fatal intoxication without actual microbic invasion of the body. Moreover, saprophytes occasionally attack blood-clots in the" uterine sinuses, and may be swept into the general circulation by detachment of a thrombus and deposited as a septic embolus in different portions of the body, causing metastatic abscesses. It is claimed also that the bacteria of putrefaction and their toxins increase the virulence of streptococci. Symptoms and Diagnosis of Puerperal Infection. — The symptoms of puerperal infection are local and general. The latter are : an elevated temperature, preceded perhaps by a chill ; a rapid pulse, and profound physical depression, with the devel- opment in some cases of metastatic inflammations of any of the organs or tissues in the body. The tongue is coated ; the breath is heavy. There is a disinclination to take food. There may be intense thirst ; nausea and vomiting are not uncommon, and a septic diarrhea appears in the worst cases. There may be blotches of a scarlatiniform eruption upon the skin. The local symptoms of septic infection are : a foul discharge, redness of the mucous membrane, spots of ulceration and false membrane formation along the lower genital canal, edema of the vulva, and, possibly, pelvic peritonitis with an exudate. Or there may be other inflammatory affections of the generative organs, such as superficial catarrhal colpitis or ulcerative metritis, the symptoms of which are described in their appropriate places. It is not likely that any case of puerperal sepsis will present all the symptoms just detailed. Elevation of temperature and rapid pulse alone after labor should be regarded as indicative of puer- peral infection if no other cause for them can be demonstrated. It is possible, indeed, to see elevation of temperature alone as a symptom of puerperal infection in the early part of the puer- perium, during which time the influences that normally reduce the pulse-rate are so active as to counteract the disposition to rapidity of pulse usually shown in septic infection. The slow pulse, however, does not continue long. At the end, usually, of thirty-six hours, rapid heart-action appears. 47 738 PATHOLOGY. It may be difficult to make a differential diagnosis between septic fever and some of the other causes of elevated temperature after labor. In these cases it is wise to treat the patient for puerperal sepsis by a thorough disinfection of the parturient tract, while at the same time the bowels are well evacuated and a full dose of quinin is administered to dispose of a possible intestinal toxemia, and to combat a possible malarial infection w^hich in many parts of the country, especially in the spring and fall, is a not improbable event. A microscopic examination of the blood is always advisable in a doubtful case, to discover the leukocytosis of sepsis or the protozoa of malaria. Typhoid fever may be most difficult to distinguish from puer- peral infection. The difficulty is increased in some cases by the fact that a Widal reaction may occasionally be obtained in strepto- coccic infection and that there may be a mixed infection by the bacillus typhosus and streptococci. Blood-cultures have enabled me to make a diagnosis of typhoid fever in several cases referred to the Maternity with the idea that they were streptococcic infec- tions. The appearance and number of the blood-corpuscles is of interest in all cases of sepsis and may have distinct diagnostic and prognostic value. Leukocytosis should be marked at first, unless the system Is overwhelmed with septic intoxication. The absence of leukocytosis, therefore, in a grave case is unfavorable. An exacerbation of the leukocytosis usually indicates a fresh focus of infection, an extension of the process, suppuration, or the development of new generations of micro-organisms. A sub- sidence of the leukocytosis indicates a spontaneous cure or a localization of the process. If the septic process is strictly limited, there may be no overplus of leukocytes at all. It should be remembered that leukocytosis does not necessarily mean suppuration. It may be absent in cases of abscess; it may be most marked in streptococcic infection of the lymph- channels without suppuration. In addition to the leukocy- tosis, the blood in puerperal sepsis shows degenerative changes in all its corpuscular elements. The differential count of the leukocytes is helpful. A high percentage of polymorphonuclear cells is usually indicative of suppuration. The absence of eosinophiles is a serious, their pres- ence and increase a hopeful sign. A small number of lobes in the polymorphonuclears with a reduction in the numbei of leukocytes is unfavorable. A reduction in the percentage of polymorphonuclears may be a favorable sign, or may,, on the contrary, show diminished resistance. PUERPERAL SEPSIS. 739 Any elevation of temperature after delivery' calls for the most careful investii,fation. A vai^iiin! ixamiiiation should be made, both digitally and with the speculum, to detect the following con- ditions : Redness of the mucous membrane and edema of the vulva ; false membranes and ulceration in the vagina ; arrested involution and fixation of the uterus ; bogginess and extreme Fig. 571. — Doderlein's lochial tube : a, Lochial tube within its test-tube ; h, tube with syringe attached; c, tube sealed, for transportation to laboratory. The cervix is exposed by a Sims speculum, is pulled down by a tenaculum, and wiped off with bichlorid solution on pledgets of cotton. The implements and operator's hands must be aseptic. tenderness of the uterine walls ; enlargement of the tubes ; en- largement, fixation, or displacement of the ovaries ; edema or exudate in the pelvic connective tissue, and thromboses in the pelvic veins. The abdomen should be carefully palpated for tenderness and exudate; the character and odor of the lochia must be observed. A leukocyte and a differential count should 740 PATHOLOGY. be made. The blood should be examined for the Widal reaction and for the protozoa of malaria. There are two methods of precision in the^diagnosis of puerperal sepsis which ought to be empIo3'ed if possible in doubtful cases: intra-uterine and blood cultures. The first is based on the assumption that the uterine cavity is sterile in the normal case or contains bacteria which are non-pathogenic or diminished in virulence; if virulent pathogenic bacteria are discovered in the lochia withdrawn by Doderlein's tube or one of its modifications, the patient is infected; if the cultures from the uterine cavity are sterile or contain non- virulent or non-pathogenic micro-organisms, it is assumed that Fig. 572. — Nicholson's modification of the Doderlein tube. the patient is not infected, though she has fever and other S}Tnptoms usually due to sepsis. But this method is not reliable. From 30 to 80 per cent, of afebrile cases show a positive result from intra-uterine cultures, the percentage increasing as the puerperium advances,^ and in streptococcic blood infection, which originated in the uterus but in which the bacteria have disap- peared from the lochia, there may be a negative result. The more careful the technique, to avoid contamination of the lochia, the more accurate is the diagnosis by this method, but with the very best technique it may be inaccurate and can not be depended upon. Cultures from the blood-serum are more reliable. 1 Brownlee, " The Germ Content of the Uterus and Vagina during the Normal Puerperium," " Jour, of Obstet. and Gjti. of the Brit Empire," September, 1905; Little, " The Bacteriolog}- of the Puerperal Uterus," " Am. Jour, of Obstet.," Dec, 1905; A. W. Lea, " Puerperal Infection," 1910. nilKPKRAL SETS IS. 74 1 Unfortunatel}-, both these methods demand the cooperation of an expert bacteriologist and the strictest aseptic technique on the part of the ch'nician. Any imperfection of technique vitiates the results and makes the examination worse than use- less, as it may lead to errors in diagnosis. Attention is now centered more on the virulence of the strep- tococci than on their presence, hemolysis being the test of viru- lence. Hemolytic streptococci are unquestionably the most dangerous, but the subject is confused by the fact that non-hemo- lytic cocci have been found in fatal cases, that recovery may occur in spite of the demonstrated presence of hemolytic cocci in the genital canal and in the blood, and that strains of strepto- cocci may lose and regain again their hemolytic power. Preventive Treatment of Puerperal Sepsis. — It is convenient to deal separately with the several sources of puerperal infection in describing the preventi\'« treatment. Atmosphere. — While the air is not so frequent a source of infection as it was thought to be in the beginning of the anti- septic era, it is undeniable that an atmosphere which is stag- nant, deprived of sunlight, im.pregnated with dust, tainted with foul odors and mephitic gases, may not only contain disease germs and spores in larger proportion than it should, but also may reduce the vitality and resisting power of the body cells until there occurs, perhaps, microbic invasion of the system that would have been successfully resisted had the organism pre- served its normal combative power against pathogenic bacteria. The lying-in room, therefore, should be sunny; should be well ventilated — best by an open fire-place; and if it or the adjoining room contains plumbing, it should be of the modern sanitary kind. If the room is heated by a hot-air furnace the intake for the air and the sanitary condition of the cellar may need investiga- tion. The nurse should be cautioned not to leave trays of food, an unemptied bed-pan, or a commode in the room over night or for any length of time. An antiseptic vulvar pad should be worn during the continuance of the lochial discharge, so as to protect the genital orifice from contact with the atmosphere, and the iriaterials of which this pad is composed, or, rather, the anti- septics with which it is impregnated, should be chosen with a view of keeping the bloody discharge from decomposing. The best materials for this purpose, in my experience, are salicylated cotton and carbolized gauze. Water. — The water used for douches, if they are employed, or for washing the vulva and perineum, may be the source of fatal infection. All the water used about the puerpera should 742 PATHOLOGY. be boiled beforehand for at least half an hour. It is not suffi- cient to make a germicidal solution — as, for example, of corrosive sublimate — in the belief that all germs in the water are killed by the antiseptic employed. Tetanus bacilli will live for hours in a 1 : 4000 bichlorid of mercury solution, and the other antiseptics usually employed in obstetric practice — lysol, kresin, creolin, triol — may be perfectly inert against many dangerous pathogenic germs during the time that usually intervenes between the preparation of an antiseptic solution and its use upon a patient. Three women in the University Maternity contracted tetanus from intra-uterine douches of unboiled water (creohn, 2 per cent.) during a time when the water of Philadelphia was unusually turbid in consequence of freshets in the Schuylkill Valley. The patient's vagina may be infected in the bath taken be- fore labor begins if she sits or lies in the tub full of water, which may be contaminated by the rinsings from her body. A sponge or douche bath in the erect posture is safest. The Patient. — The parturient and puerperal woman may be infected by disease germs carried upon her person, especially in the pubic and anal regions; by her personal clothing, by the bed-clothing and mattress, by the vulvar pads and the pads upon which the buttocks rest, by the material used to wash the vulva and perineum, and by pathogenic bacteria lodged in the vaginal or uterine mucous membranes before labor or even prior to con- ception. The woman falHng in labor is given a full bath, the genital region is scrubbed thoroughly mth soap, hot water, and a clean wash-rag. In hospital practice my patients are shaved. In private practice this is also done if the patient permits it. Some- times a depilatory is allowed if shaving is not permitted. After the bath, the woman should put on clean clothes throughout. The mattress on her bed should not be soiled by the discharges of previous labors, by urine, feces, or other putrescible matter. It should not have been used in any case of contagious or infectious disease, and it should be protected by a rubber cloth that has been carefully scrubbed clean. The bed-clothing should be clean, the bed being freshly made up for the labor. The pads on which the buttocks rest during labor and afterward should be made of nursery cloth prepared in the way described in the directions to the nurse (boiled and dried). It is scarcely necessary to say that a pad when soiled should be thrown away and not used again. The vulvar pads should be made of carbolized gauze and salicylated cotton — the best materials for disinfecting a bloody discharge. The nurse should make them up with sterile hands as they are required, or if she makes a number at a time they should be wrapped in a PrKR PENAL SEPSIS. 743 clean towel and taken out for use with sterile hands. The material used to wipe off the genital orifice, the mouth of the urethra, and the jKTineum should be absorbent cotton sterilized by heat or by soaking in a i : looo solution of sublimate for at least one-half hour before use. During the second stage of labor these ])ledgets of cotton are em])loyed to wipe away feces as it emerges from the anus, always in the direction from before back- ward. Care must be exercised to remove blood and blood-clots from the vulva before putrefaction sets in. This is best done by placing the woman on a bed-pan, letting a stream of boiled water run over the parts, and, if necessary, using cotton to wipe them off This should be done about six times in the twenty- four hours for the first four or five days. A careful examination should be made of every woman's vaginal discharges in the beginning of labor. If there is leukor- rhea, or any pathological condition of the vaginal secretions, the vagina should be thoroughly scrubbed with tincture of green soap, hot water, and pledgets of cotton, and should then be douched with a bichlorid of mercury solution, i : 2000, a little clear water being employed at the end of the douche to wash out any residual sublimate solution that might poison the patient or do harm to the infant's eyes in its descent through the birth-canal. It should be borne in mind, in the conduct of the labor, that excessive bruising, long-continued pressure of the maternal tissues, and extensive injuries, all conduce to microbic invasion of the parts by reducing their vitality and by affording, through solu- tions of continuity, a ready entrance into the s\'stem. The proper conduct of labor, therefore, is an extremely important item in the preventive treatment of puerperal sepsis. Finally, in the management of the third stage of labor and of the early puerperium, the greatest care should be exercised to evacuate the uterine cavity of all putrescible matter and to secure, as far as possible, firm contraction of the womb, for the presence of putrescible material within the uterine cavity attracts sapro- phytes, and an imperfect involution of the womb favors the direct invasion of the uterine sinuses and blood-channels by micro- organisms and the absorption of the products of microbic activity into the circulation and into the lymph-spaces. The Physician. — The physician should not carry infectious germs uj^on his person or clothing into the h'ing-in chamber, and he should be scrupulously careful not to insert pathogenic bacteria into the woman's x'agina in the course of his examina- tions. If a general practitioner is in attendance upon infectious 744 PATHOLOGY. and contagious diseases, he should either give up obstetric prac- tice or, if he can not do so, he should take a full bath, change his clothing completely, and be in the open air as long as pos- sible before attending a woman in labor or visiting a puerpera. A long linen gown or duck trousers and a cheviot shirt should be carried in the obstetric bag. The change of clothing should be made in another room before seeing the patient at all or, at any rate, before making an examination. The methods of hand cleansing are described in the section on Aseptic Technique. The routine use of sterile rubber gloves in addition to the hand disinfection is an indispensable precau- tion. If version or any manceuver is attempted involving the deep insertion of the hand into the uterine cavity, the long gaunt- let glove, reaching to the elbow, should always be worn. The examining linger should be anointed with carbolized vaselin (5 per cent.) or the sterile unguent provided in collapsible tubes, and in making the examination the vulvar orifice should be ex- posed by raising the upper buttock as the woman lies upon her side, so that the finger may be inserted directly into the vagina without becoming contaminated by being swept over the skin near the anus or pubes while searching for the vulvar orifice. Before inserting the finger, the skin around the vaginal entrance should be wiped off with a pledget of cotton soaked in a i : 2000 sublimate solution. As every examination entails some risk of infection, they should be as limited in number as possible. The best results in morbidity and mortality have been secured by an almost entire elimination of the vaginal examination, which has been replaced, in the practice of some enthusiasts, by abdominal palpation, and even by rectal examinations. It is unnecessary, however, and is, moreover, inadvisable to give up the vaginal examination al- together. Much may be learned by abdominal palpation, so that there is little necessary information to be gained by examin- ing per vaginam, but there are some conditions that can be learned in no other way. A few vaginal examinations in the course of labor are therefore indispensable. No harm is done if their num- ber is restricted, if the examining hand is protected by a sterile glove, and if the examination is conducted in the way just de- scribed. The Nurse. — The nurse should adopt the same precautions in regard to personal cleanliness that have been recommended for the physician. She should not have come from a contagious or infectious case. She should put on fresh clothing throughout for attendance upon the obstetrical patient. She must take a full bath, scrubbing her hair and scalp well with soap and water, and rinsing her hair in a i : 1000 sublimate solution. She should PL I'.KPERAL SEPSIS. ■45 cleanse her hands and put on sterile rubber gloves before attenij)t- ing any manipulation of a patient's genital region or of her breasts. It is her dut}- also, in the care of a puerpera, to enforce the sanitary and aseptic regulations already described under their appropriate heads. The Implements. — All implements to be used about the person of the parturient and puerperal woman should be boiled for at least five minutes. A i : looo sublimate solution should be employed for the disinfection of the few articles that might be injured by boiling water, a full half hour at least being allowed for the immersion, and the bichlorid solution being made \\\) with boiled water. Day ol Ciaeasc "1 107" 106° 105° 104° 103° 102° 101° 100° 99° 08° M £ M\ E M £ M E M E M £ m\e M e W £ M E kv £ M £ \ c : \ ; i- 1 \ '> b >: ?^- ti- : ^fc C'^ si:' \ h S> A f i \ i '■- \ I: '■■ ] i : ■ \ k y r. 1; A \ / : I- /' V •^ : \ < ;/ V • \ ^ •^ . ■■ u jj ; Fig. 573.— Teraperature-chart of a case treated in vain by intra-uterine irrigation, but cured immediately by the instrumental evacuation of the uterus. The Prophylactic Treatment of Puerperal Infection. — Efforts have been made to prevent the occurrence of infection in cases in which it might be expected by the administration of anti- streptococcus serum or of nuclein preparations. It is impossible to determine the efilicacy of such treatment, but its reliability is at least doubtful. The Curative Treatment of Puerperal Infection. — The treat- ment of puerperal sepsis is both local and general. Locally, a thorough disinfection of the whole genital canal is called for in every case of puerperal infection. It may appear unnecessary, and may prove, on actual experience, to be even harmful, but no one can tell beforehand how necessary this procedure is. In the majority of cases it is beneficial. It is only occasionally useless, and very rarely actuall}' harmful. It should, as already stated, precede all other treatment for puerperal infection. The method of disinfecting the genital canal may be described as follows: 746 PATHOLOGY. A double tenaculum, a placental forceps (Emmet's curetment forceps is the best), and an intra-uterine catheter are boiled for fifteen minutes. The operator disinfects his hands and arms and wears sterile gloves. The patient is placed in the dorsal posture across the bed, with her buttocks resting on a rubber pad. The external genitalia and the vagina are scrubbed with tincture of green soap and pledgets of cotton; the vagina is douched wdth a sublimate solution, i : 2000. An intra-uterine douche of sterile water, at least a quart, is administered. Then, with the placental forceps, the uterine walls are gone over thoroughly but lightly in all directions. A second intra-uterine douche of water and alcohol (each a pint) and tincture of iodin (i fluidram) concludes the treatment. If the womb is flabby and large, with a ten- dency to flexion, so that the drainage of the uterine ca\dty is not good, it is advisable to pack it with iodoform or sterile gauze. Much discredit has attached to this method of instrumental exploration and evacuation of an infected uterus, because it has too frequently been carried out like a curettage of a non-puer- peral uterus, which would often result in implanting infection in the myometrium or in perforating the uterus. In addition to cleansing the uterine cavity in the manner described, the operator should take the opportunity of carefully inspecting the visible portion of the parturient tract ; and if there are false membranes or areas of inflammation and localized infection on the cervix or in the vagina, they should be carefully treated — best by the application of a strong solution of nitrate of silver, a dram to the ounce. It may be necessary to repeat the intra-uterine douches several times — in fact, several times a day for many days ; in this case plain sterile water only should be used. Nothing is gained by the employment of strong sublimate solutions, which can not always reach and destroy the infecting micro-organisms of the genital tract, but which do have a most depressing action upon the body- cells of the walls of that tract, reducing their resisting power against the invasion of attacking bacteria, and which may fatally poison the patient. The author has employed a one per cent, formalin solutioninglycerinand water, tincture of iodin, i dr. to a pint each of water and alcohol, and a five per cent, argyrol solution as intra- uterine douches with better results than are obtained by sublimate solutions. It is rarely necessary to repeat the instrumental exploration and evacuation of the uterus. The general treatment is stimulating. The patient should have as much food of an easily digestible character, chiefly milk, as she can assimilate, and as much alcohol as she can consume /v ■!■: R /'/■: A' A /. sKPsis. 747 without showing llic i)h}'siologi(;il effects of it. Digitalis is useful as long as the pulse is above no. Strychnin may be combined with it in suitable ca.ses. To tide the patient over emei-f^encies, carbonate of ammonia in large doses, by the bowel, and nitroglycerin hypodermatically, may be required. Inhala- tions of oxygen may also be of service. Absolute rest and freedom from all disturbances, mental and physical, must be insisted upon, and the patient should be given the best nursing that the family can afford. The Serum=therapy of Puerperal Sepsis. — Stimulated by the success of this treatment in diphtheria and in other infectious dis- eases, an effort has been made to procure a serum that is antago- nistic to streptococci and antidotal to the products of their activity. A committee appointed by the American Gynecological Society! reported in May, 1899, that 352 cases had been treated by antistreptococcic serum, with a mortality of 20.74 per cent. After a personal trial of the method extending over three years I discarded it, but have resumed its use, as it undeniably is fol- lowed occasionally by decided and sometimes by brilliant results. From 20 to 80 c.c. are injected once to four times a day. Fur- ther studies of the antistreptococcic serum, as to its bacteriolytic power, agglutinating activity, and as a stimulating agent for the production of opsonins, with improvements in its production suggested by this investigation, promise a remedy in the future of great value. If antistreptococcic serum is without effect I am now using human blood serum, 5-7 oz. daily, subcutaneously, of the super- natant serum after the blood clots. The blood is drawn from a healthy, vigorous donor into a sterile beaker or dish.^ The Bacterin Treatment of Septic Infection. — As a result of the discoveries of Wright and others of the increased opsonic index produced by the injection of dead and sterilized micro- organisms of the kind which caused the infection, the injection of streptococcic, staphylococcic, gonococcic, and tubercular bacte- rins has been tried in puerperal infections. In localized inflam- mations without blood infection, such as subacute arthritis, the bacterin treatment has given the best results. In localized staphylococcic infections the method has proved satisfactory. In colon bacillus infection of the urinary tract it has not been satisfactory. The vaccine treatment is not as successful as the serum treatment of general infection. ' " Am. Jour, of Obstet.," vol. xl, No. 3, i8qq. - See Welsh, " Normal Human Blood Serum in Obstetric and Pediatric Prac- tice," "'Am. Jour, of Obstet.," April, 1912. 748 PATHOLOGY. The Treatment of Septic Infection by the Artificial Production of a Hyperleukocytosis. — Phagocytosis has been demonstrated to be particularly effective in destroying streptococci, if the blood serum is rich in opsonins, the mere overplus of leukocytes not being sufficient unless the bacteria are opsonated. It is logical^ therefore, to stimulate the production of leukocytes if at the same time measures are taken to increase the opsonins of the blood. Antistreptococcic serum does the latter to some extent, it is claimed. So do the bacterins. Several agents have leukocytic powers, notably pilocarpin, albumose, and nuclein. The last is the best remedy in septic infection. Two drams of a 2 per cent, nuclein solution may be given hypodermically twice a day. A peculiar method of increasing the polynuclear cells has been proposed in France: horse serum is heated every two hours for three days to 56° C. Some of the serum is dried by evaporation. The uterine cavity, previously cleansed and dried, is tamponed with gauze saturated with the serum and containing besides 1-3 gr. of the dried serum. The tampon is changed in twenty hours.^ Studdiford recommends a tamponade of the uterus by gauze soaked with antistreptococcic serum. The Treatment of Sepsis by Washing the Blood ; Hypodermatocly= sis; Intravenous Injections of Saline Solutions," is a modern treat- ment attended with decided success. The best fluid for the purpose is i i^ gr. CaCl, ii^ gr. KCI, to 34 oz. normal salt solution.^ Injections of large amounts — more than two quarts — of this fluid into the bowel seem to give as good results as hypodermatoclysis, and are much more convenient. The use of the modified normal salt solution is a valuable adjuvant to the other measures required in the treatment of puerperal sepsis. Colloidal Silver (protargol, collargol, argyrol) — by inunction (Crede's ointmxnt), by intravenous injections (3-5 cm. 2 per cent, solution of collargol repeated three to four tim_es), by rectal injections • — has its advocates. It has secured extensive clinical trials in Chrobak's Clinic, in the Charite in Berlin, in Buda-Pesth, and in other large maternities. The verdict, on the whole, is favorable. As an adjunct to other treatment it may be recommended.'* Abscess of Fixation. — In consequence of the observation that improvement sometimes occurs in general infection if there is localized suppuration, turpentine (2 drams) has been injected 1 " Bull. Soc. d'Obstet. de Paris," Tome ix, 1906. 2 Bose, " Presse medicale," No. 49, 1896. ' See experiments of W. H. Howell, in Boston, on frog's heart; modified Ringer fluid. " The Use of Intravenous Saline Injections for the Purpose of Washing the Blood," H. A. Hare, " Therapeutic Gazette," April 15, 1897. The technic of the injection is the same as for the injections required in the treatment of the acute anemia following severe hemorrhage. ■• " Wien. Klin. Wochenschr.," No. 10, 1906; " Med. Klinick," p. 816, Nos. 31-34, 1906. PUERPERAT. SEPSIS. 749 in the tissues of the abdominal wall to cause an abscess. The success following this treatment may have been due to the leuko- cytosis which is a result of it. The Operative Treatment of Sepsis in the Child ^bearing Period. — Since the first performance by Tait of abdominal section for puru- lent peritonitis there has been an extremely important develop- ment, in the scope of pelvic and alxlominal surgery for septic in- flammations during the child-bearing period. Regarded at first as a procedure analogous to opening an abscess anywhere on the body, the whole abdominal cavity being looked upon as an abscess-cavity and the abdominal walls as its capsule, abdominal section for puerperal sepsis has become a generic term of wide significance, including hysterectomy, salpingo-oophorectomy, evacuation of abscesses in the peritoneal cavity and in the pelvic connective tissue, removal of gangrenous or infected neoplasms of or in the neighborhood of the parturient tract, and exploratory incisions. Indications for Abdominal Section in the Treatment of Puer- peral Sepsis. — It is more con\enient to deal generically with the indications for abdominal section in the course of puerperal sepsis, for the operation is usually decided upon in practice without refer- ence to what may be required after the abdomen is opened, the surgeon holding himself in readiness to perform any of the pelvic or abdominal operations detailed above that may be found neces- sary when the abdominal cavity is exposed to view and to touch. In order to decide correctly for or against celiotomy in the course of puerperal septic fever, the physician must be familiar with the different forms of sepsis after labor, and should know which of them are most and which are least amenable to surgical treatment. In a general way, it may be stated that the opera- tion is demanded most frequently for localized suppurative peritonitis ; it may be indicated, and often is, for diffuse suppura- tive peritonitis ; for suppurative salpingitis and ovaritis ; for sup- purative metritis, if the inflammation extends outward toward the peritoneal investment of the womb or into the connective tissue of the broad ligament ; for abscesses in the pelvic con- nective tissue ; for infected abdominal or pelvic tumors. On the contrary, abdominal section is contraindicated or is not required in simple sapremia ; in septic endometritis of all forms — diph- theric, ^ ulcerative, suppurative; in dissecting metritis, sloughing intra-uterine myomata, which can be removed by enucleation or avulsion, or in suppurative metritis with the abscess pointing into 1 By diphtheric endometritis is meant a dirt3% grayish- or greenish-brown exudate on the endometrium, containing mixed micro-organisms, and not necessarily the Klebs-Loffler bacillus. For a report of one and the mention of four cases of true diphtheria of the genitalia see Williams, " Am. Jour, of Obstet.," .-Vugust, 1898. 750 PATHOLOGY. the uterine cavity; in phlebitis, lymphangitis, and in direct infection of the blood-current. One is most likely to perform an unnecessary operation in streptococcic endometritis. By the time that symp- toms justify surgical intervention in this condition it is almost always too late. It is difi&cult to formulate indications for a serious surgical operation in the midst of an adynamic fever with profound de- pression, rapid pulse, high temperature — in short, with every- thing a surgeon least desires in the face of a major operation. The operative treatment of puerperal sepsis should be avoided if possible, and is not indicated by the cardinal symptoms of sep- tic infection — high temperature, rapid pulse, and general depres- sion. There should be some demonstrable evidence of intra- pelvic or abdominal inflammation, necrosis, or suppuration. On the first appearance of symptoms that justify the diagnosis of diffuse suppurative peritonitis, the abdomen must be opened without more delay than is necessary for an aseptic operation. Even with the utmost promptness the operation is almost always too late, for the inflammation extends so rapidly and at first insid- iously that by. the time a diagnosis is possible the progress of the disease can not be stayed. It must be admitted, however, that an occasional success is possible by timely surgical interference.^ Again, in the presence of exudate, adhesions, or unnatural enlargement of any pelvic structure, suppuration may be sus- pected if the physical signs do not improve and if the tempera- ture, pulse, and general condition indicate a continuance of septic* inflammation. It is hardly necessary to state that if pus forms it must be reached and evacuated irrespective of its situation. Just how long to wait, however, is a question requiring experi- ence, good judgment, and a special study of each individual case for its correct answer. Enormous pelvic and abdominal exudates may disappear ; adhesions may melt away ; enlarged and inflamed tubes, ovaries, and uterus may resume their proper size, functions, and condition on the subsidence of the inflammation ; but in these favorable cases distinct signs of improvement manifest themselves in a few days, and the course of the disease is comparatively short. A mere protraction of septic symptoms is in itself suspicious, along with local signs of inflammation. Without the latter, the same general symptoms, sometimes lasting for months, indicate phle- bitis and infection of the blood-current. In this form of sepsis an operation, I believe, can do no good and may do the greatest harm. ^ Hirst, "A Diffuse, Unlimited, Suppurative Peritonitis in a Child-bearing Woman Cured by Abdominal Section," "Medical News," 1894. rUKKPEKAL SEPSIS. 75 I In infected tumors in and near the f^enital tract the indication for operation should be phiin and the decision easy. The j^res- encc of the tumor should, of course, be known. On the first sign of inflammation in it, or in the event of an elevated temperature for which there is no good explanation, the tumor should be removed. I^arly operations in these cases have furnished the best results, delayed operations the reverse.^ In cystic tumors the likelihood of twisted pedicle should be remembered, and in every case of child-birth complicated by a new growth the woman should be watched with extraordinary care to detect the first indication of trouble. An exploratory abdominal incision should be made, as a rule, only when it is desired to determine if a pelvic mass, presumably containing pus, is situated within or without the peritoneal cavity, and if the abscess had better be evacuated through the abdominal cavity or extraperitoneally. In the early period of experimentation with abdominal section for puerj)eral sepsis exploratory incisions were made in obscure cases without local symptoms of inflammation in the pelvis or the abdomen. None of these operations yielded information of value, nor did they bene- fit the patients. Consequently, it is a safe rule not to open the abdomen of a puerpera for sepsis unless there are physical signs of inflammation in the abdomen or the pelvis. The proposition of Bumm, v. Bardeleben,^ and others, to ligate or exsect the ovarian veins in thrombophlebitis, does not seem to me reasonable, and the results so far have not been encouraging. Thrombophlebitis is a conservative action to limit the spread of infection; if it is successful, the patient recovers, and this is the usual result. If the thrombus breaks down and there is septic metastasis (pyemia), the patient will probably die, even if the original site of the thrombus is removed. If the thrombus extends to the vena cava, the case is also hopeless. Another difficulty is the diagnosis. I know of no way by which a thrombus of the ovarian or hypogastric veins can be certainly diagnosticated before the abdomen is opened.^ If abdominal section is done because thrombophlebitis is suspected, many an unnecessary ojjeration will be performed. If the diagnosis is only made after the ab- domen is opened for some other indication, there will not often be 1 The most desperate cases, however, need not be despaired of. I have success- fully removed a gangrenous ovarian cyst from a puerpera who was so weak that complete anesthesia was not attempted. The late Dr. Goodell had declined the operation as necessarily fatal. - " Berliner Klin. Wochenschr.," 1908, p. 6. 3 " Mahler's sign," a steady increase in pulse-rate without corresponding eleva- tion of temperature {Kldlcr puis); pain in the loins; tympany; palpation of the thrombi may indicate thrombosis of the pelvic veins, but none of these signs is to be depended upon absolutely. /:>- PATHOLOGY. an excuse for ligating or excising the ovarian A'eins. I have had as ample an opportunity to inspect the pehic and abdominal cav- ities in cases of puerperal infection as an}^ of m}^ colleagues in this country, and yet I have very rarely indeed seen a condition of the ovarian veins that called for their ligation or removal. Occasion- aUy in the excision of necrotic tumors, infected appendages or uterus, it is obviously advisable to place the Hgature beyond a thrombus in the vein, but thrombophlebitis as the sole indication of an operation and as the only thing to be removed is not yet demonstrated to the satisfaction of the majority of surgeons. FoUoviing these general statements in regard to abdominal section for puerperal sepsis, it is now more convenient to describe in detail the different kinds of operations required for the various forms of intra-abdominal septic inflammations. Abdominal Section for hitraperitoiieal Abscesses and Diffuse Siippiirative Peritonitis. — The situation and extent of localized suppuration within the abdominal cavity vary greatly. A quarter of the abdominal cavity may be filled with pus, the huge abscess-cavit}^ being thoroughly walled off by dense exudate from the rest of the abdominal cavity. A smaller accumulation of pus about the orifice of the tube is not uncommon. Occasionally two or three abscesses the size of an orange are found between coils of intestine quite far removed from one another, and with- out apparent connection with the genital tract. Abscesses are found also between the fundus uteri and adjoining structures — the abdominal wall near the umbilicus, the caput coli, and the sigmoid flexure. In these cases infection travels through a sharply-defined area of uterine waU and appears in the same limits on its peritoneal investment. Exudate and adhesions immediately wall off the infected area, with the result of an encapsulated abscess between the uterine wall and the structure nearest to it at the time of inflam- mation. The treatment of these abscesses is evacuation, cleansing, and drainage. The cleansing may be effected by flushing with hot sterilized water, if the rest of the abdominal cavity can be guarded from contamination. It is usually best to avoid irrigation and in its place to thoroughly dry the cavities with gauze. For drainage, as a rule, sterile gauze with a glass or rubber tube is best. In certain cases of abscesses near the abdominal walls a rubber tube answers better than the gauze, and in deep-seated abscesses on the base and the back of the broad ligaments vaginal drainage by means of gauze or rubber tube is preferable. If the work dur- ing the operation is well done, there may be Httle or no subsequent discharge, and douching of the abscess-cavities during con^■ales- cence is imcalled for. Occasionally, however, if the abscess- ca^-ity is large and well isolated, daily douching with sterile hot water is an advantage. In dift'use suppurative peritonitis the rUKRPERAI. SEPSIS. 753 remote chance of success dei)en(ls greatly upon the earliest possible operation, though there are many virulent cases in which nothing could check the spread of the inflammation and the deadly effect of septic intoxication. This is not the ])lace to discuss the symj;toms of diffuse sup- purative peritonitis, but one fact should be insisted upon from the operator's point of view. It is usually supposed that true diffuse suppurative peritonitis appears early after delivery ; it may, however, develop at any time — as late as four weeks after confmcment. The technic of the operation is simple: A small incision is made, and the finger is rapidly swept about the pelvis and abdomen to determine the condition of the organs; then the irrigating tube is passed into the cavity at the lowest angle of the wound, and is swept about in all directions, while the return-flow is provided for by two fingers of the left hand distending the sides of the wound, which by the fingers and the irrigating tube is kept gaping as though by a trivalve speculum. The irrigating tube is pressed far over first on one flank and then upon the other, and the tip is cut down upon where it projects through the abdominal wall. Gauze and glass-tube drainage into the pouch of Douglas, a gauze drain in the flanks is provided for, and the wound is left open, or, at most, drawn together by a stitch or two. Puncture of the pos- terior vaginal vault and gauze drainage into the vagina should usu- ally be added. Rapidity of operation and the smallest possible quantity of anesthetic are essential to success. Salpingo-oophoi'ectomy for Puerperal Sepsis. — An acute pyo- salpinx in the puerperium is very rare. It is uncommon for acute septic infection after labor to travel by the tubes alone. Infection usually occurs in the uterine muscle, the veins, the lymphatics, or the connective tissue of the pelvis. When the track of the septic inflammation is confined to the mucous mem- brane of the genital tract, the pelvic peritoneum, in a case serious enough to demand operation during puerperal convalescence, becomes infected, inflamed, and suppuration quickly follows, so that the operation is usually performed for an intra-peritoneal pelvic abscess. The tube may be found somewhat swollen, inflamed, dark red in color, containing a {^.w drops of pus, with flakes of purulent lymph on its external surface, and its removal is required ; but the pyosalpinx is a subordinate feature in the pelvic inflammation. It is the more subacute case, not usually requiring operation in the conventional period of the puerperium, that results later in a typical uncomplicated pus-tube. Ovarian abscess is much more common than pyosalpinx. The infection may tra\'el to the ovary, both by way of the tube and by the connective tissue or lymphatics of the broad 754 PATHOLOGY. ligament. In the latter case the whole ovary may be infiltrated with a thin sero-pus of a particularly virulent character, and, unfortunately, in excising the ovary the exposure of the infected pelvic connective tissue in the stump may lead to infection of the peritoneal cavity and to a diffuse suppurative peritonitis. The commonest indication for salpingo-oophorectomy is fur- nished by a pus-tube antedating conception or by a pre-existing gonorrheal infection of the genital canal. The strain of labor excites a fresh outbreak of inflammation or leads to its spread, and the persistence of septic symptoms with the physical signs of pelvic inflammation justifies operative interference. Occasionally an operation must be performed on a presumptive diagnosis of old pus-tubes, based mainly upon the patient's history and the existence of serious septic symptoms, with tenderness on abdominal palpation over the region of the tube and ovary. The uterus is much too high in the abdominal cavity for a satisfactory pelvic examination of the uterine appendages. There is often nothing peculiar in the technic of these opera- tions. They differ, usually, in no respect from similar operations upon non-puerperal patients. The question of removing the uterus along with the tubes arises, however, rather more fre- quently than in the non-puerperal woman, on account of the infection of the endometrium or of persistent metrorrhagia. But in associated suppurative salpingitis, ovaritis, and infection of the connective tissue of the broad ligament, there is a modifi- cation of the ordinary technic, which is of vital importance. The tubes and ovaries should be excised, the blood-vessels of the broad ligaments tied separately ; the cut edges of the broad ligament should be allowed to gape ; the whole pelvic cavity should be filled with gauze and drained by a curved glass tube placed just posterior to the uterus. The dressings, sterile gauze and cotton, cover the tube and wound completely. They are not disturbed for twenty-four hours, when the tube is sucked out by a syringe. This is done daily for three or four days, when the tube is removed. The gauze is then withdrawn gradually, not being entirely removed for eight to ten days. Apparently most desperate cases may be saved by this technic. Hysterectomy }or Puerperal Sepsis. — Every physician who has seen many cases of puerperal infection during operations or post- mortem is aware that there are some in which the mere removal of infected tubes and ovaries, vaginal section and drainage, or the evacuation of pelvic abscesses through the abdomen can not be expected to save the patient. There remain infected and infil- trated broad Hgaments infecting the peritoneal cavity, or there are foci of suppuration or infection in the uterine body that spread to the peritoneum or result in septic metastases. The only hope for Plate 21. PUERPERAL SEPSIS. 75; the patient in such cases Hes in the entire removal of all infected areas, leaving behind in the pelvis a healthy, non-infected stump. To efTect this result the excision of the uterus, the broad ligaments, the tubes, and the ovaries is required. In addition to these cases there are others in which, if the tubes and ovaries must be excised, the uterus might be removed with advantage, on account of an infected endometrium or of persistent metrorrhagia. There may also be such wide-spread suppuration and disintegration of the broad ligaments, with tubal inflammation, that it is easier to re- move all the infected area and to control hemorrhage by a hyster- ectomy. There can be no doubt as to the necessity of hysterectomy in the cases brought to the author's clinic every year and saved by this operation. For example, in one there were abscesses in the uterine wall, directly under the perimetrium, about to break into the peritoneal cavity; one, indeed, did rupture dur- ing the operation. There was a septic ulceration at the placental site in one case so nearly perforating the uterine wall that by a light touch during the operation the forefinger passed into the uterine cavity. There was also a pyosalpinx in these cases that, judging by the history, antedated or was coincident with im- pregnation. The operations saved the patients. In another suc- cessful hysterectomy for puerperal sepsis, the author found the Fig. 574. — Submucous hbroma removed by hysterectomy in the early puerperium. (Author's case.) womb completel}- ruptured at the fundus from tube to tube. The diagnosis of the injury had not been made. The operation was undertaken some w^eeks after labor, for what was thought to be an intraperitoneal abscess. Areas of suppuration were dis- 756 PATHOLOGY. covered, but the greater bulk of the inflammatory mass was exudate which had shut off the general peritoneal cavity from infection through the gaping uterine wound. In cases of strepto- coccic infection the whole uterus may be found so necrotic that its consistence is that of cheese. No ligature holds in it and the uterine wall may be pinched through anywhere by the thumb and forefinger. One might as well expect a woman to live with a gangrenous coil of intestine in her abdomen as with such a gangrenous and necrotic uterus. She can only be saved, if at ail, by a hysterectomy. It may also be necessary to remove the uterus in the puerperium to get rid of an infected fibromyoma, as Fig. 575. — Necrotic fibroid, myomectomy in puerperium. illustrated in figure 574. This uterus was removed on the fourth day of the puerperium, the patient's temperature having been 104° and the pulse 140. Streptococci were found in the interior of the tumor and there was general systemic infection, with phlebitis and septic pneumonia, but the woman recovered. Indications for the Operation. — The indications for hysterec- tomy during puerperal sepsis are furnished by the condition of the pelvic organs when they are exposed to sight and touch after the abdomen is opened. The conditions described are the types calling for hysterectomy. It is not often possible to determine upon hysterectomy before the abdomen is opened, but it should be remembered that in any abdominal section for puerperal sepsis PUERPERAL SEPSIS. 757 hysterectomy may be necessary. The surgeon, therefore, should be provided with the implements recjuired for amputation of the womb in every abdominal section for puerperal sepsis, and should be prepared to remove it for any one of the indications described above, but should rest content with the least radical measure that promises his patient safety. The operation that is quickest done and shocks the patient least is most successful, provided, of course, that it is adequate. An excision of one or both cornua or of the fundus may suffice instead of a hysterectomy. Technic of the Operation. — There are four points in which the technic of hysterectomy for puerperal sepsis may differ from the technic of the operation performed for other conditions: One is the necessity often of doing pan-hysterectomy; another is the necessity often of tying the hgatures in a broad ligament much Fig. 576. — Streptococcus and staphylococcus infection of the endometrium : a. Necrotic layer of the endometrium; i>, zone of inflammatory reaction; c, gland spaces ; d, blood-vessels; e, remnants of glandular epithelium (Bummi. thickened by inflammatory exudate, or of ligating the blood-ves- sels separately so as not to include an infected mass in the liga- ture. The third is the possibility of exsecting a portion of the uterus, usually the fundus or cornua, which is necrotic, while the rest of the uterus may be safely left. The fourth is the neces- sity for drainage, usually by the glass tube and gauze. The author prefers amputation of the uterus, leaving as little cervix as possible, unless an examination of the cervix by a spec- ulum shows septic ulceration or exudate upon it or in its canal. The reasons for this preference for amputation of the womb over pan-hysterectomy are that the former can be done more quickly, there is not the same anxiety about the cleanliness o-' the vagina, the suture material is more certainly guarded from infection after- ward, and there is less danger of cutting or ligating the ureters. 758 PATHOLOGY. The thickened broad ligaments are often a source of serious embarrassment in placing and tying the ligatures around the uterine arteries. There is this difficulty to contend with in the majority of the operations. In some cases the inflammatory exu- date within and below the ligature breaks down into pus, but an incision in the posterior vaginal vault evacuates the pus and secures an immediate disappearance of somewhat alarming symptoms. Vaginal hysterectomy is usually unsuitable for cases of puerperal sepsis on account of the danger of clamping or ligating large masses of infiltrated and infected broad ligament, on account of the stiff- ened and adherent broad ligaments, which make downward trac- tion on the uterus difficult or impossible, and because it is imprac- ticable in a vaginal operation to explore the pelvis and abdomen for foci of infection at some distance from the pelvic organs. Exploratory Abdominal Section for Puerperal Sepsis. — An exploratory incision should be made only in cases of suspected extraperitoneal pelvic abscess, to confirm one's suspicion, to be certain that none of the pelvic organs, especially the tubes, are diseased, and to determine the best situation for the incision to evacuate the abscess-cavity without contaminating the peritoneal cavity. This rule of practice would exclude exploratory abdominal section in cases with no physical signs of pelvic inflammation, but in which there is evident septic infection of a nature difficult to determine. There are possible -exceptions to the rule, however, as in suspected pyosalpinx without physical signs, owing to the high position of the recently emptied womb and of its appendages'. Cases of true extraperitoneal pelvic abscess due to puerperal infection, and without intraperitoneal inflammation, are rare. There are some gynecologists who deny their existence, but the writer has had a number of cases under his charge in which the diagnosis was estabHshed by abdominal section. In some cases the suppuration is so evidently extraperitoneal than an abdominal section may be dispensed with. Vaginal Section for Pelvic Suppuration or for Infection of the Pelvic Connective Tissue. — If there are physical signs of an ab- scess in Douglas' pouch and no evidence of involvement of the rest of the peritoneal cavity, or if the woman's condition is too bad to admit of an abdominal section, a colpotomy of the poste- rior vaginal vault and an irrigation of the pelvic cavity with sterile water is indicated. After cleansing the vagina with tincture of green soap and a sublimate douche, the mucous membrane of the posterior vaginal vault is incised with a knife, and then with sharp-pointed scissors or one's fingers the opening into the peri- toneal cavity is completed. Adhesions are cautiously separated so as to avoid opening the general peritoneal cavity and the pel- vic organs are carefully palpated to detect isolated foci of sup- PUERPERAL SEPSTS. 759 puration, which if found are opened. The pelvis is irrigated through a two-way catheter witH sterile water and then packed quite firmly with a strip of iodoform t^^auze. The vagina is also packed. The pelvic packing is removed after two days or more and is replaced by a T-shaped rubber drainage-tube through which the pelvic cavity is irrigated daily with sterile water for ten to fourteen days. Incisions in the lateral fornices and gauze drainage are of service in suppuration of the parametrium or in accumu- lations of infected serum in it. The Ligation and Resection of Thrombotic Veins. — Although the author does not approve of the operative treatment of throm- bophlebitis, and believes that it will disappear from the list of legitimate obstetrical operations, a description of the technique is appended: A long abdominal incision is made and the patient raised in the Trendelenburg position. If the spermatic veins alone are thrombotic, it is easy to tie them or to exsect them. If the uterovaginal plexus is involved, the broad ligament must be divided between ligatures or clamps to its base. There is danger of tying the ureter. If the hypogastric or common iliac veins are involved, the ligature must, if possible, be placed above the thrombus. It is so difhcult to separate the artery and vein in these cases, matted together as they are by inflammation, that the former has been tied for the latter. It goes without saying that only one iliac vein can be tied. The mortality of the operation in 50 to 60 cases has been 62 per cent. (Lea), and would probably be higher if all the fatal cases were published. As the mortality of 339 cases collected by Opitz was 55 per cent, without operation, and of 70 cases published by Seegert was 39 per cent., the success of the operative treatment is not apparent. The Morbid Anatomy and Clinical History, the Diagnosis and Treatment of the Different forms of Infection and Septic Inflammation of the Genital Region After Labor. — The mani- festations of puerperal sepsis differ with the various infecting bacteria that are lodged in the genital tract or have invaded the system, but especially with the organs or structures that are involved in the septic inflammation. The terms, therefore, "puerperal infection," "puerperal sepsis," or "puerperal fever," are generic in significance and include a number of distinct dis- eases, widely different in their symptoms, their prognosis, and their requirements for treatment. The lesions of puerperal sepsis may be found in the mucous membrane of the genitalia from the vulva to the abdominal orifices of the tubes, in the mucous mem- brane of the bowel, and of the urinary tract, the myometrium, the pelvic connective tissue, the peritoneum, the lymphatics, the veins, and in the parenchyma of the ovaries. Neighboring organs and tissues may be involved secondarily, as the bowels, appendix, 760 PATHOLOGY. ureters, and pelvic nerves, and tumors of the pelvis and abdomen may be the starting-point of septic infection and inflammation. Endocolpitis, Endometritis, and Salpingitis. — These inflamma- tions are most often of the superficial suppurative variet}^, in which the prognosis is good, except in the case of the tubes, whence the inflammation may extend to the peritoneum, causing diffuse peri- tonitis or a circumscribed abscess near the fimbriated extremities, usually involving the ovary, or may result in a pyosalpinx. The streptococcic inflammation of these membranes with an exudate and necrosis of tissue is much more dangerous. It may be localized in the vagina in the shape of ulcers near the ori- fice or extending up the wall to the cervix. It may be a diffuse, yellowish-green, foul-smelling exudate, occupying the whole inte- rior of the uterus, in which streptococci, the bacillus pyocyaneus, the bacillus fcetidus, and the staphylococcus pyogenes albus or aur- eus are found. Under the necrotic layer of the endometrium there is a layer of granulation-cell infiltration upon which the woman's life depends. If it is well developed, it resists the invasion of the septic micro-organisms. If not, there is a likelihood of systemic in- fection of a grave character. In rare instances the Klebs-Loffier bacillus may be discovered in the pseudomembrane, showing that the case is one of true diphtheria, and the diphtheria of the vagina may be associated with diphtheria in the throat.^ If the diph- theric inflammation affects the lower portion of the vagina, there is edema of the vulva in at least two-thirds of the cases. Diagnosis. — The diagnosis of these inflammations is made in the case of vaginitis by inspection, in salpingitis by a combined examination, and in endometritis perhaps by the character of the lochia, 2 or b}' inspection of the cervical canal, which may be lined with the same exudate that covers the endometrium. The diag- nosis between pseudodiphtheric membranes and true diphtheria can only be made by a bacteriological examination. It is most important that this should be done, for cases of true diphtheria should be isolated. The treatment of these inflammations is frequently repeated irrigations of the wliole genital tract. Sterile water is best for this purpose. An antiseptic simph" diminishes the resisting power of the body-cells without destroying the micro-organisms that are ^ J- ^^- Williams, five cases, loc. cit., to which should be added one of my own, with diphtheria of the throat in the husband and true diphtheria of the vagina in the wife, demonstrated by bacteriological examination. 2 A foul odor is not distinctive of anything except decomposition. The necrosis of the endometrium usually gives rise to this symptom. But the worst streptococcic infection may be associated with odorless lochia. There is usually, however, a pro- fuse serosanguinolent or purulent discharge, but the lochia may be suppressed. Pi -ERrKKAL SEPSIS. 761 the cause of the inflammation. In cases of septic endometritis the systemic symptoms are grave, and a supporting, stimulating treatment is required in addition to the local treatment. In sali^ingitis a celiotomy may be demanded. If the inflammation is localized and the in- flamed area accessible, it should be touched with a nitrate of silver solu- tion, 5j-f5J. Metritis and Cellulitis of Subcutan= eous and Pelvic Connective Tissue; Septic Metritis. — As a later stage of septic endometritis all the stmctures of the womb may be involved— connective tissue, muscles, lymphatics, and often the veins, especially, however, the first. In the process of the inflammation por- tions of the uterine muscle may be undermined by ulceration and may slough off (dissecting metritis).* Liep- mann reports a case associated with diabetes melhtus, and another with perforation into the bowel.^ A limited area of uterine tissue may be involved, not larger in circumference, perhaps, than a dollar. The inflammation ex- tends directly through the uterine wall, still confined within its original hmits, until the peritoneal covering is reached. Here the inflammatory process is also strictly limited by the rapid develop- ment of adhesions w^hich bind the womb to those structures in the peritoneal cavity nearest the diseased area. The uterus may be anchored 10 the caput coli, the anterior abdominal wall, and the sigmoid flexure. In these cases involution goes on imper- fectly, of course, for the womb can not be normally reduced in size, held as it is at a high level in the abdominal cavity by adhesions. There are, however, besides the fixation and ar- rested involution of the womb, no other local evidences of inflam- mation, excepting some tenderness on pressure. It is usually impossible to locate the intraperitoneal abscess, by abdominal palpation or combined examination, on account of its situation. ' In 63 cases of dissecting metritis, Offergcld found a mortality of 2S per cent., " Deutsche. Med. \\'ochenschr.," No. iq, IQ07. Sitzinsky reports 7, all recov- ered, " Zentralbl. f. Gyn.," No. 46, igio. "- " Arch. f. Gyn.," Bd. Ixx, H. 2. Fig. 577. — Dissecting metriiis (Liepmann). 762 PATHOLOGY. The course of these cases is slow, but they are ultimately almost certain to be fatal, for an abscess commonly develops on the diseased area of uterine surface between the uterus and the structures attached to it, usually the bowel or omen- tum, x^ bacteriological examination of some of these cases has shown the presence in the uterine wall of pyogenic staphy- lococci. If the pelvic connective tissue is involved, it is at first edema- tous. The serum is then absorbed, leaving a dense infiltrate, if there has been much cell-proliferation, or entirely disappearing if the cell-element is scanty. The infiltrate, if not too extensive, is likewise absorbed in about four-fifths of all cases. Occasionally, however, in about one-fifth of the cases an abscess results, which may be opened above Poupart's ligament, or through the vaginal vault without entering the peritoneal cavity, but which may spontaneously rupture into the abdominal cavity, or may perforate the rectum, bladder, vagina, or uterus. Diagnosis. — The diagnosis of metritis is difficult. The womb is large in size, the walls feel boggy, and the uterus is very sensitive to pressure; but it is almost impossible to be positive that metritis exists unless one can feel an abscess in its walls by an intra-uterine examination, or unless the collection of pus breaks into the uterine cavity. If the abdomen must be opened for the septic infection, the condition of the womb is, of course, easily determined. Ab- scesses may be seen in its walls, and ulceration may so nearly perforate them that when the operator's finger is laid upon the peritoneal covering of the womb, it penetrates at once into the cavity. The diagnosis of pelvic cellulitis is usually easy to establish. The exudate and infiltration can be felt on a vaginal examination. It is often, however, impossible to decide whether the inflam- mation is limited strictly to the pelvic connective tissue, or whether the pelvic peritoneum is also involved. If the exudate is situated only upon one side of the womb and does not involve Douglas' pouch, one has the right to suspect pelvic cellulitis without pelvic peritonitis, but in my experience it has almost always been necessary to open the abdomen before obtaining a positive answer to this question. Treatment. — Occasionally, septic metritis ends in recovery by the discharge of pus-collections into the uterine cavity, or by the resolution of inflammation. But the worst cases demand hys- terectomy. CelluHtis yields in the majority of cases to rest in bed, counterirritation, the ice-water coil or poultices over the lower abdomen, and hot vaginal douches. If it fails to do so, an Plate 22. Suppurative metritis and abscess between layers of broad ligament. 7'V •V ... V Suppurative metritis with abscess of cornu. PUERPERAL SEPSIS. 763 abdominal section should be performed, in order to be sure that the peritoneum is not involved. If the inflammation is found, after the abdomen is opened, to be confined strictly to the pelvic connective tissue, the abdominal wound should be closed, and the infected area, if* it has suppurated, should be opened by an incision above Poupart's ligament, or through the vaginal vault. Pelvic Peritonitis and Diffuse Peritonitis. — Pelvic peritonitis is the result of the extension of a septic endometritis, either through the tubes or directly through the tissues of the womb, or it fol- lows pelvic cellulitis, the germs penetrating the peritoneum be- tween the endothelial cells or through the lymphatic interspaces. In an extension through the tubes or by the spread of a cellulitis the ovaiy is likely to be involved, and an ovarian abscess develops. A leakage of lochial or catarrhal discharge through the abdominal orifice of the tubes is by no means uncommon. It is followed by a sharp localized peritonitis, though it is not certain that the discharge is always septic. It may be simply irritating. The infected or irritated region may be surrounded by large areas of peritoneal exudate. A large section of the abdominal cavity, one-fourth or more, may be thus, as it were, solidified. On palpation, the abdominal contents feel hard as stone, with the muscles of the abdominal wall involuntarily fixed over them for protection, on account of great sensitiveness to pressure. Occasionally, the exudate communicates to the fingers a sensation as though snow were being kneaded through a covering of some flexible material. The symptoms are not alarming, and the common termination of this kind of peritonitis is recovery. The exudate is absorbed, the tenderness disappears, the temperature sinks to normal, and no ill-effects are left behind ; but the exu- date may break down and encapsulated abscesses may thus be formed, opening into the bowel, into the bladder, through the abdominal walls at the umbilicus, or possibly undergoing caseous changes. General peritonitis after labor may result from an exten- sion of pelvic peritonitis ; from infection through rents in the vaginal or uterine walls ; from the rupture of old pus-collections in the tubes or elsewhere in the pelvis ; from putrefaction of tumors in the pelvis, as of dermoids and fibroids ; from the transmission of pathogenic bacteria by the lymphatics, and from the extension of septic inflammation through the bladder- walls. Perforating gastric and duodenal ulcers, ruptured abscesses in the spleen or liver, are possible causes of septic peritonitis in the puerpera. 764 PATHOLOGY. If the suppurative peritonitis is not limited, the intestines are lightly glued together; are bathed in a thin pus, which lies in pools between their coils and are covered with a yellow- ish exudate, which can be stripped off, leaving a raw, bleeding surface. There is a form of septic peritonitis so virulent and poisonous that no signs of inflammation accompany it, and the patient dies before pus or exudate can be formed {^peritonitis lymphatica). The abdomen is found, after death, filled with a dirty fluid, composed of serum, some blood, and numberless micrococci. In all forms of septic peritonitis the coats of the intestines are paralyzed and tympanites is marked. Day of Disease M E \M_ E M E M, E ^ E ME ME 103° 102° 101° 100° 99° Fy ': ". %\\ w ; »4 • - • • ^ : : : : ■^ ^ > -s h *•:::: \ ^ "^ y J, : Fig. 578. — Temperature-chart of diffuse purulent peritonitis. Diagnosis. — The diagnosis of pelvic peritonitis is made by the general symptoms and by the local physical signs. There is fever of varying degree, with accelerated pulse and general depression. There is marked tenderness over the lower ab- domen, and there is tympanitic distention of the abdomen. Aus- cultation shows absent or feeble peristalsis. On making a vaginal examination exudate is found in Douglas' pouch and to the sides of the womb, which is firmly fixed. The exudate is usually ex- quisitely sensitive to pressure. It is sometimes fi.rm and hard, and, again, may be soft and boggy. If the latter condition persists, it is indicative of suppuration. General peritonitis is usually sudden in its onset and very rapid in its course. It occurs ordinarily in the first few days of the puerperium. There is extreme distention of the abdomen ; a rapid, running,, wiry pulse ; an extremely anxious, pinched expression of the face ; the eyeballs are sunk deep in their sockets and there are dark rings under them ; there is a peculiar grayish color of the skin, and. PUERPERAL SEPSIS. 765 perhaps, high fever, agonizing pain, and possibly dullness on percussion at certain points in the abdominal cavity ; but the latter signs may be entirely absent. There may be absolutely no tender- ness nor pain, no dullness, and very little fever. MaHgnant cases may end fatally within forty-eight hours from the tirst appearance of symptoms, with a temperature never exceeding iooJ° by the mouth, though the rectal temperature is often much higher. Treatment. — It is difficult to determine at first whether a pelvic peritonitis will end in suppuration or resolution. As the latter is alwa}'s possible, the treatment should at first be expectant. Counterirritation and poultices may be used over the lower ab- domen ; an ice-bag or the ice-water coil is often of the greatest service ; the bowels may be thoroughly drained by a strong purgative, so as to diminish intra-abdominal congestion and inflammation, and copious hot vaginal douches may be given. If the symptoms persist much beyond forty-eight hours in their original intensity under this form of treatment, suppuration has prob- ably occurred, or must be expected. In such a case the abdomen should be opened. Abscesses, if they are found, must be evacuated and the cavities thoroughly cleaned, disinfected, and drained. Dis- tended tubes and ovaries must be removed, and it may be necessary to perform hyster- ectoni}'. If the abscess is localized in Douglas' pouch, or if the patient's condition is very bad, vaginal section is preferable, followed by drainage through the posterior cul-de-sac. General, diffuse, suppurative peritonitis is almost invariably fatal, let the treatment be what it may. The only possible chance for such a case is in the - earliest possible performance of an abdominal section with free irrigation of the abdominal cavity and drainage through the abdominal wall, the flanks, and the posterior vaginal vault; but even though this be done within twelve hours of the onset of symptoms, it will almost invariably be of no avail. Once in a long while, however, a case of true diffuse suppurative peritonitis may be saved by a timely operation. Fowler advocates raising the head of the bed after these opera- tions, so that the patient's body has a downward slant of 30 degrees Fig. 579._Clots in sinuses of uterine walls (from specimen in the Army Medical Museum, Washington, D. C). 766 PATHOLOGY. or more, to facilitate drainage.^ Combined with Murphy's con- tinuous instillation of salt solution in the rectum, it should be adopted in the after-treatment of operations for peritonitis, but noth- ing like the results Murphy reports can be expected in the strep- tococcic peritonitis, which is the form commonly seen after child-, birth. Uterine and Para=uterine Phlebitis. — The veins of the uterus and of the surrounding connective tissue are prone to thrombosis by reason of the sluggish circulation, the pressure during preg- nancy, and the altered constitution of the blood in a puerpera. The clots, when formed, may be directly infected, usually at the placental site. They may then be disintegrated and swept into the circulation, producing pyemia, or the veins may be infected from passing through a septic region. Then the walls are first involved, the blood clots, and perhaps thus opposes the further spread of the process. Or, more likely, the clot is in its turn infected, disintegrated, and carried into the larger venous trunks. In the course of the inflammation clots may be dislodged or vessel-walls may be perforated and a most serious hemorrhage may result. Repeated bleedings may occur at short or long intervals. This form of septic infection is least likely to produce peritonitis or local inflammation in the pelvis, but is most likely to produce pyemia. If infected emboli are swept into the circulation, they may find lodgment in many different parts of the body, causing abscesses in the abdominal viscera, the eyeballs, the brain or spinal cord, the lungs, the pleura, the thyroid, or in the subcu- taneous connective tissue at any portion of the body-surface. I have seen, for example, the whole anterior portion of the left leg and the right forearm riddled with the abscesses of suppurative cellulitis in the course of a case of puerperal phlebitis; and in another case an abscess in the thyroid threatening suffocation. The thrombosis in a puerpera is not always limited to the veins of the uterus and of the pelvis. I have observed, for example, a fatal case, death occurring on the seventeenth day postpartum, preceded by convulsions and coma. It was not known whether the woman had had fever after delivery. In the postmortem examination the longitudinal and lateral sinuses of the brain were found perfectly solid with thromboses. There had been a very severe postpartum hemorrhage, and there were evidences in and about the womb of septic phlebitis. Maygrier and Letulle report a case of puerperal thrombosis of the mesen- teric vein with partial necrosis of the small intestine. ^ I have seen the same thing in both the mesenteric and gastric veins. 1 " Med. News," May 28, 1904. ^ " Bull. Soc. Anat. de Paris," tome Ixxiii, p. 507. PUERPERAL SEPSIS. 767 An almost constant accompaniment of uterine and pelvic phlebitis is jjhlegmasia alba dolens. Diagnosis. — The characteristic signs of uterine and pelvic phle- bitis are: a high, irregular, and long-continued fever; profound Day of IMsease ?-^ ^.\ = . .h . . s i \ ^ : : 1 ?4; I \ 1 \ i • '■■ T ■4 i 4 T K 4 U 4 : :\ ■ J a. -I- -4- 101 - J A<»; ^^^ ^ <^^. >^ w ^^ ji d^ f : \i 4 U:^m -^ T <; ii v-r ^f? : y/: ■ • ■ ^ • . ^ nil . ■ • ^ ■ -^1 ii ii u Fig. 580. — Case of phlebitis in which there was a sharp rise of temperature after two attempts to disinfect the birth-canal. DlseOAC 1 1 1 107" 106° 105° 104° 103° 102° 101° 100= 99° B8° 97° M /■ /t* -f Af f /w /TA fe A l£ M\e M £ M s M £ M'£- A? £ Af ^ /l/r^ /V|^ /i^ ^ /w e f ^f Af ^/l If M t : : - 107- - 106° : '■ :l : : : 5 : \ ji ft / i\ A ; f ^ 1 k v /! A '■■ - 103° f. U i^i^ ^^ ;i «. ^ J 4 \ : ; ^ : / ; / \\ li- :i ^ :i : : : V S : 1 . V . . ) . . . . . . . . . . ■ - ■ , <> Qft° - 97° - ■ - • ■ ■ • • • , •^ • 1 ^ • ^ _ .-— .il_L __^ ^_ Fig. 581. — A case of phlebitis. Twice the temperature rose above 107°, as a result apparently of an intra-uterine douche, the hyperpyrexia occurring directly after it. Recovery. depression and great rapidity of pulse, with an entire absence of all local symptoms of septic infection or of septic inflammation. The womb is normal in size, is freely movable, and involution goes on uninterruptedly. There is no tenderness, no tympany. Any interference with the uterus, as in an attempt to disinfect its cavity, occasions an exacerbation of the fever and may cause a serious hemorrhage. The woman's face is apt to show a dusky flush on one or both cheeks, and red splotches appear on other parts of the body, especial!}^ upon the chest. 768 PATHOLOGY. In the course of the disease evidences of pyemia may appear, and phlegmasia alba dolens will almost surely develop, either as the predominant symptom or as a mere incident in the course of the disease. It is a common experience to note intermissions of apparently perfect health with a normal temperature lasting per- haps for several days and then a recurrence of all the symptoms in their original intensity. Treatment. — The treatment of phlebitis should consist of a preliminary disinfection of the uterine cavity. In a perfectly typical case this will prove unnecessary or even harmful, but it is so difficult to determine whether or not there remains in the womb infected and necrotic endometrium, that the risk of doing the patient some damage should be incurred in order to escape the serious error of leaving in the uterus material which, if not removed, may result in her death. The successful treatment of the phlebitis itself consists of absolute rest and stimulation. Enormous quantities of alcohol may be used with advantage, and as much food of an easily digested character should be administered as the patient can assimilate. The vast majority of these cases end in recovery, but the disease may run a course of weeks or months. On account of the danger of a recurrence of the symptoms the patient should be kept in bed for at least ten days after the temperature has become normal. It has been proposed to ligate and excise the ovarian, the hypogastric, and even the iliac vein in cases of septic thrombosis^ (see p. 759). Pyemia. — Olshausen says that if an infected woman has two chills in rapid succession she has pyemia or pus in the blood. This form of sepsis has been regarded as the most fatal of all ex- cept suppurative peritonitis, but in Olshausen's series, 8 out of 11 recovered, i with as many as seventy chills in the course of seventy-one days. There is no localization, as a rule, but long- continued irregular fever with numerous chills. Blood-cultures should be positive. Stimulation and support is the most reliable treatment, but salt solution, nuclein, colloidal silver, antistrep- tococcic serum, human blood serum, and fixation abscess may all be tried. A large proportion of the deaths from sepsis are due to this form. In 200 fatal cases, 77 were due to pyemia (Lea). Phlegmasia Alba Dolens, or Milk=Ieg. — This condition receives its name from the appearance that the leg presents, and from the old idea that most of the inflammatory conditions of the puerperium were due to a metastasis of milk. There are two distinct kinds of phlegmasia after delivery. In one there is an 1 International Gynecological Congress, Rome, 1902. PUERPERAL SEPSIS. 769 occlusion of the veins of the pelvis and of the lower extremities, interfering with the circulation and leading to an intense edema. The leg is enormously swollen ; the skin is tense, glistening, and milk-white in color. The swelling is so great that the skin does not at first pit on pressure. In the other class of cases there is a septic inflammation of the connective tissue of the pelvis and of the thigh, the infection spreading from the perineum or from the deeper pelvic fascia through some of the larger foramina of the pelvis. Cases of the first class — thrombotic phlegmasia — are much more common than those of the second — cellulitic phlegmasia. Thrombotic phlegmasia should be also divided into two classes. In one the thrombosis is primary, and is due to the pres- sure to which the blood-vessels are subjected during pregnancy, to extensions of thrombi from the uterine sinuses, to stagnation of the blood-current. In the other there is a septic inflammation of the blood-vessel wall, leading to secondary thrombosis. The clinical manifestations are quite distinct in the two kinds of cases ; in the first there is little fever and few systemic symp- toms ; in the second the fever is high and the systemic symp- toms grave, but one often sees the first pass into the second by an infection of the blood-clot. Symptoms. — Usually from the tenth to the thirtieth day^ there develop a heaviness and stiffness in the leg, with pain, especially in the calf of the leg, soon followed by swelling, beginning at the ankle and gradually ascending to the groin, if the phlegmasia is due to thrombosis of the veins ; or at Poupart's ligament or the buttocks, extending down the thigh, if the condition is due to a septic inflammation of the connective tissue. In the former case there is very likely to be tenderness along the course of the femoral vein, which may also be marked by a line of inflam- matory redness. Other superficial veins may be likewise affected, and may appear as red streaks under the skin. The lymphatics may also be involved, becoming thickened and reddened. There is almost always slight fever, which usually precedes the swell- ing of the leg and disappears commonly long before the swelling subsides. There is also gastric and intestinal disturbance, with a foul tongue, loss of appetite, nausea, and vomiting. There is profound physical depression, sometimes with great restlessness and sleeplessness. There is often a dusky flush upon one or both cheeks. Phlegmasia is a very frequent complication of septic phlebitis, in which disease it may occur as a mere incident, the swelling of the leg appearing, perhaps, during the height of the septic fever, 1 Phlegmasia may antedate labor, and I liave seen it appear seven weeks after delivery. 49 770 PATHOLOGY. lasting a comparatively short time, and disappearing entirely long before the subsidence of the other symptoms of the septic infection. The left leg is more frequently affected than the right. Occasionally, one leg is involved after the other, and possibly they may both be swollen at the same time. Frequency. — Phlegmasia is a comparatively rare disease. As already stated, the thrombotic variety of phlegmasia is very much more common than the cellulitic kind. Of twenty-five cases or more under my observation, only one was of the latter sort. Causes. — The commonest cause of phlegmasia is a septic in- flammation of the blood-vessel walls, beginning at the placental site and extending through the pampiniform or utero-vaginal plexuses down to the femoral vein, or upward through the sper- matic vessels to the vena cava. In consequence of the inflammation of the vein-walls the blood clots in the vessel, and the clot extends even more rapidly than the inflammation of the vessel-walls. Occasionally, the thrombus is the primary occurrence. This is proven by the cases which develop before labor. In these instances the pressure of the pregnant womb upon the pelvic vessels, the stagnation of the blood-current, and the composition of the blood all conduce to the formation of extensive clots. But even if the primary occurrence is a thrombosis, the clot usually becomes infected in time ; so that almost every case of phleg- masia, some time in its course, is septic in its nature. It has been claimed by Widal that the thrombus of the femoral vein after child-birth is explained by the presence of pathogenic micro-organisms in the blood, which fasten themselves upon the vein-wall near Poupart's ligament, where the circulation is sluggish and stagnant, especially when the woman first stands up, and is favorable, on this account, to the deposition of bacteria along the walls of the blood-vessel. This theory very likely has some truth in it. It would explain the occurrence of phlegmasia in the course of infectious diseases, such as typhoid fever and grip ; and it would also explain the thrombosis of other vessels than those in the pelvis, as, for instance, of the sinuses in the brain. Prognosis. — The outlook in a case of phlegmasia is always somewhat doubtful ; the dangers are manifold. There may be pyemia from the detachment of a portion of an infected clot ; abscesses may develop in the vessel itself, extending rapidly to surrounding structures until the thigh-muscles are dissected one from the other by an ulcerative process and the whole limb becomes infiltrated with a foul sero-pus. The circulation may be PUERPERAL SEPSIS. 771 SO interfered with that gangrene of the Hmb occurs,' or the vena cava may be blocked up, practically cuttin<^ off the whole lower portion of the body from its blood-supply by preventing the return flow. Or, if there is only partial compensation for the obstructed circulation, there is a chronic con'pertrophic endometritis, metrorrhagia, infection, or sterihty. Sims' sharp curets and Mar- tin's spoon curet are best for the non-puerperal womb. The author's dull broad curet is intended for the removal of decidua. With these instruments, after dilatation, the uterine wall is scraped in the non-puerperal womb with sufficient vigor to re- move the superficial endometrium, in the puerperal uterus as lightly as possible to remove loosely attached necrotic or h^^Der- trophied decidua. An intra-uterine douche concludes the oper- ation. INDUCTION OF ABORTION By the induction of abortion is meant the interruption of preg- nancy bejore the viabiHty of the child — that is, prior to the sixth month of pregnancy. Indications. — -The induction of abortion should be undertaken as reluctantly as one would commit justifiable homicide. If, in the course of pregnancy, some disease arises as a direct con- sequence of gestation, or if a woman suffering from disease is made much worse by the existence of pregnancy, and if her hfe is distinctly endangered in consequence, it is not only justifiable, but it is the physician's duty to terminate gestation, and thus save one hfe, and that the more valuable of the two, instead of sacri- ficing both mother and fetus. The following conditions occasion- ally furnish a justifiable indication for the induction of abortion. Pathological Vomiting. — When ah the remedies for this con- dition have been conscientiously and carefully tried without avail, when rectal aHmentation has been continued for a week or ten days without marked improvement in the woman's condition, and it is evident that she is in danger of death if her pregnancy continues, the induction of abortion for uncontrollable vomiting is justifiable. Toxemia, Albuminuria, and Kidney Breakdown. — If ominous INDUCTION or ABORTION. ' 809 symptoms appear, such as progressive edema, persistent headache, steady or rapid increase in the amount of alljumen, sudden dimi- nution in the (juantity of urine, casts in great number in the urine, and faiUng vision, in sjjite of careful dietetic and medicinal manage- ment, the induction of abortion is called for. Death 0} the Embryo or Fetus. — If it can be demonstrated that the embryo or fetus is dead within the uterus, its removal is de- sirable; but it must be remembered that the signs of fetal death are difficult to elicit, and that a certain diagnosis can be made only after an observation extending over some days or weeks, unless the membranes are ruptured and the fotal body has begun to putrefy. Certain Intra-iiteruie Diseases. — As pointed out in the section on Intra-uterine Diseases, acute hydramnios and cystic degenera- tion of the chorion villi may call for the induction of abortion. Uterine HcmorrJiage. — Uterine hemorrhage, from placenta praevia or from the detachment of an abnormally situated pla- centa, may be so profuse or so long continued as to demand the evacuation of the womb early in pregnancy. Displacement of the Gravid Uterus. — Retroflexion, prolapse, and anteflexion of the gravid womb, resisting other treatment, and threatening to become incarcerated, may call for the termina- tion of gestation. Certain Nervous Diseases. — In the course of acute mania and melancholia, or in chorea, and possibly in general pruritus, the question of terminating pregnancy may be considered. Certain Blood Diseases. — If pernicious anemia or leukocy- themia arises in pregnancy or is made much worse by the advent of pregnancy, the question of terminating the woman's condition may be considered. In any of these indications the question is an anxious one, and should not be decided by the attending physician on his own responsibility, no matter what his experience or skill may be. There should invariably be a consultation, so that the responsibility may be shared and the operator may be free from criticism. Methods of Inducing Abortion. — Many plans have been advo- cated, but most of them have been found either too slow, too dangerous, or ineffectual. Such are the administration internally of ergot, rue, sabina, aloes, and of cotton-root; injections upon the cervix or between the membranes; the insertion of inflated rubber bags in the vagina or in the uterus; rapid or gradual dila- tation of the cervix; perforation of the membranes; injections of irritating substances, as jNIonsell's solution, into the womb; and an electrical current. The method employed by myself with satisfaction in a num- ber of cases may be described as follows: The woman is anesthet- ized and placed in the dorsal position upon an operating table. 8lO OBSTETRIC OPERATIONS. The vagina and \iilva are disinfected. The anterior Hp of the cervix is fixed with a double tenaculum, and the cervical canal is dilated cautiously with branched dilators (Baer's and Wathen's). An Emmet's curetment forceps is inserted into the womb, opened and shut in several directions so as to crush flie ovum, and then withdrawn with whatever portion of the ovum or embryo that comes with it. It is usually impracticable to remove the whole o\njm at once. Iodoform gauze is then packed in the lower uter- ine segment and in the cervical canal, and gauze is packed in the vagina. The gauze remains in place twenty-four hours. On its removal, if the remainder of the ovum is not yet discharged from the external os, the cervix, now much softened and easily stretched, is further dilated by branched dilators or by the fingers, and the uterine cavity is emptied of all its contents as after an ordinary abortion by the dull curet, the finger, and a placental forceps (Emmet's curetment forceps). If, for any reason, as in the ex- haustion of hyper emesis, the administration of an anesthetic is undesirable, the dilatation of the cervix may be made almost painless by the injection into the cervix at four different points of Barker's fluid, /S-eucain, adrenalin chlorid, and normal salt solution. \\Tiile the interruption of pregnancy before the sixth month is called the induction of abortion, the m.ethod just described is only practicable up to the fourth month. After that time abortion is induced in the same manner as premature labor. INDUCTION OF PREMATURE LABOR. In addition to the indications for the induction of abortion there are special indications for the premature interruption of pregnancy after the child has become viable. The most impor- tant of these is a contracted pelvis. The next in importance, perhaps, is placenta praevia. It may be necessary, in advanced phthisis or in grave heart disease, to secure the mother's delivery before term, in order that the child may be born before the fatal termination of her disease, which is evidently close at hand, or to save her the strain of the last month of pregnancy and to insure her an easy labor. Labor at term, or shortly after, may be induced in a woman showing a disposition to prolongation of pregnancy. Last of all, in the rare cases of habitual death of the fetus just before term, it is advisable to induce labor before the period at which the child's death may be expected. Methods of Inducing Labor. — Krause's ^ method is the easiest for the general practitioner without special training in gynecological 1" Die kiinstliche Friihgeburt, monographisch daigestellt," von Albert Krause, Breslau, 1855. FORCEPS. 8ll manoeuvers. An asei)tic, stiff, silk or linen bouf^ie (No. 17 French), which has been soaked for at least one-half hour in a cold corrosive sublimate solution (i: 1000), is anointed with sterile glycerin. The patient is placed in the dorsal position. The operator passes two fingers of his left hand into the vagina, inserting one or, if possible, both finger-tips into the cervical canal, which dilate the cervix and are swept around the lower uterine segment to sever the attach- ment of the membranes. The bougie is then passed along the groove between the two fingers until it enters the cervical canal and passes into the lower uterine segment. It is pushed further in until it has entirely disappeared within the uterus, with the ex- ception of an inch or a little more that protrudes from the external OS. An iodoform gauze tampon is packed lightly in the vagina to keep the bougie in place. Active and effective labor-pains may begin in from thirty minutes to thirty-six hours. In the majority of cases labor begins within twelve hours. If it has not begun at the end of that time, a second bougie should be inserted alongside the first. If, after twenty-four hours more, labor has not yet begun, the cervix should be artificially dilated with bags or Bossi's dilators, and, if necessary, the membranes should be ruptured, forceps may be applied to the head, or version may be performed, and the child extracted by the feet. Instead of a bougie, a rectal tube of soft rubber, boiled, may be inserted into the lower uterine segment where it lies in coils. In about one-fifth of the cases the bougie method fails to ex- cite labor-pains. The following plan is the most certain and efficient: Dilatation of the cervical canal to a linear diameter of about 7 cm. with the modified Gau dilator; the insertion of two bougies and also of the author's bag (m.edium or large size) . Two hours later a hypodermic injection of pituitrin, i c.c, 20 per cent, solution, is given. If the mother's condition demands immediate delivery, the following methods are available (accouchement force): The cer- vical canal is dilated forcibly by the hand or by Bossi's dilator, the membranes are ruptured, a forceps is applied, or version is performed and the child is extracted by the feet; vaginal C^esarean section; the use of Pomeroy's bag for ten to fifteen minutes and then the forcible extraction of the child by forceps or version. FORCEPS Historical. — Three years before the massacre of St. Barthol- omew, in 1569, William Chamberlen, a Huguenot physician, fled from France to England. He settled in Southampton and raised a large family of children, two of whom, both named Peter, became prominent physicians in London. The younger Peter 8l2 OBSTETRIC OPERATIONS. was in continual conflict, however, with his brother practitioners, and was several times summoned for reprimand and punishment before the College of Physicians. On one of these occasions he was accused of boasting that "he and his brother and none others ex- celled in these subjects" (difficult labors). This was in the begin- ning of the seventeenth century (1616), and is the first record of the secret which remained in the Chamberlen family for more than three generations, which was the foundation of their boast that they alone could be regarded as skilled obstetricians, and which enabled them all to grow rich by the practice of their hidden method of dealing with difficult labors. But instead of being honored as the discoverers of one of the most important inventions of medicine, posterity has condemned them for depriving the world of knowledge that might have saved thousands of lives and have prevented untold suffering during a hundred years. The younger Dr. Peter Chamberlen had a son, also named Peter, who was a remarkable character : a man of great, but ill-directed talents ; possessing some inventive genius ; an extensive traveler ; an accomplished linguist ; obtaining the favor and friendship of the British royal family, and engaged during the greater part of his mature life in a lucrative prac- tice among the upper classes in London. It is to this man, who made such a mark in his time, that the invention of the forceps was formerly credited ; but there is no doubt, from evidence recently come to light, that he inherited the secret from his father, who, in his turn, obtained it from his elder' brother, Peter Chamberlen, senior. ^ The idea that the younger Peter invented the instrument was no doubt fostered by himself, for he was a man of intense egotism. A short time before his death he wrote his own epitaph, which began — " To tell his learning and his life to men Enough is said by, ' here lies Chamberlen.' " This Peter had a son, Hugh,^ who also studied medicine, and to whom his father disclosed the family secret of the Chamber- lens. Hugh, who was extravagant, determined to make the most of his inheritance, and to part for a consideration with the secret that had remained in his family so long. He accord- ingly went to Paris and offered to acquaint Mauriceau with his secret method of dealing with difficult head presentations, which up to that time had been managed by tearing the child to pieces with sharp hooks. For the disclosure of his secret Chamberlen asked the enormous sum — in those days — of ten thousand '"The Chamberlens," J. H. A veling, London, 1882. ^ The Hugh Chamberlen whose bust may be seen in Westminster Abbey is the son of this Hugh. He was a man of higher character and much greater repute thaa his father. FORCEPS. 813 dollars (ecus). Mauriceau took the matter under consideration, and, happening to have a deformed dv^arf in labor, Chamberlen was asked to test his method in the case. He did so and failed completely, the patient dying from a ruptured uterus, unde- livered. This ended the negotiation for the sale of the secret in Paris. On his return to England Chamberlen translated and published Mauriceau's book, with a preface written by himself, in which he says: "My Father, Brothers, and my Self (tho none else in Europe as I know) have by God's Blessing and our Industry, attained to, and long practised a way to deliver Women in this case without any Prejudice to them or their Infants." Hugh Chamberlen is next heard of in Amster- dam, whither he had fled from England on account of some financial difficulties. Here he had better fortune than in Paris, managing to sell his secret to the College of Physicians of Amsterdam. This insti- tution immediately induced the govern- ment to pass a law which forbade any one to practise medicine in the town who had not given satisfactory evidence of possess- ing the secret now owned by the college, and imparted to each aspirant for a medical degree who was able to pay for it. The traffic in the Chamberlen secret continued until the middle of the eighteenth century, when two public-spirited citizens of Amsterdam, thinking it an outrage that a method for which such extravagant claims were made should remain a secret, took a course in medicine, pur- chased the knowledge required of them from the College of Physicians, and published it to the world. It was a single blade of the obstetric forceps ! Whether Chamberlen tricked the college or the college cheated its students is not known. ^ Before this time, howev^er, certainly as early as 1725, the true secret had leaked out in England, and during the middle of the eighteenth century the forceps came to be widelv knoAMi and quite generally used. There was for a long time m.uch Fig. 627. — Smellie's straight forceps. An eighteenth centur}- Eng- lish forceps, the blades wrapped with leather, to keep them from slip- ping. ' Other stories are that Roonhuysen sold the secret to Riiysch and a number of others; that a student of Roonhuysen's made a surreptitious drawing of the instru- ment and published it ; that Jacob de Vischer and Hugo van der Poll obtained the secret from the daughter of a former possessor. 8i4 OBSTETRIC OPERATIONS. speculation as to the kind of instrument that the Cham- berlens really invented, and there were many, some years ago. Fig. 628. — Palfyn's forceps or " hands." Fig. 629. — The four forceps found in the Chamberlen chest. tig. 630. — Chamberlen's vectis. who doubted that the invention had been the forceps at all. It was thought at one time to have been a forcing powder or a blunt hook. It was believed for a while that Jean Palfyn (1716) had FORCEPS. 815 first conceived the idea of an instrument which was developed later by otliers into the forceps. Hut these doubts have been set at rest. At Woodhani, Mortimer Mall, in Essex, owned and occupied by Peter Chamberlen, junior, was discovered, in 1813, a chest in which were found the instruments shown in figure 629. It is obvious that the successive possessors of these instruments received all that were in existence in order to pre- serve the secret. The evolution of the forceps at the hands of the original inventor or of his descendants is plainly seen in the illustrations. The Chamberlens were also the inventors of the vectis, or lever, an instrument no longer made, for a single blade of the obstetric forceps answers the purpose perfectly. The Chamberlen mstrument had not been long known and employed before certain defects in it were noticed. It was found difficult to introduce it, especially if the head was high up in the parturient tract. It was also found difficult to lock it, and the necessity of binding the handles together was found to be incon- venient. The first of these disadvan- tages, the difficulty of introduc- tion, was soon discovered to be dependent upon the curve of the pelvic canal, and it was recog- nized that an instrument to be introduced into this curved canal should itself be curved to corre- spond with the direction of the canal. Almost simultaneously, in England and France, about 1750,^ a pelvic curve was added to the forceps — in England by Smellie, in France by Levret, Each of these men, distinguished obstetricians of their time, added other important modifications to the forceps, which are worthy of careful attention, for the two ' Levret presented his forceps to the Academy of Surgery in 1747- Smellie first published a description of his in 1 75 1, though he had invented the pelvic curve ten years before. Fig. 631. — A, Levret's forceps with a pelvic curve; B, Smellie's for- ceps with a pelvic curve. 8i6 OBSTE TRIG OPERA TIONS. instruments known as the forceps of Levret and the forceps of Smellie are the direct progenitors of the two types of forceps in use at the present time. The Enghsh forceps, as may be seen in figure 631, B, is small, short, and light. It has, as may be seen, the English lock ; the pelvic curve is inadequate, and to keep the instrument from slipping it was originally wrapped in leather ; but the instrument had good points about it, which are found modified in the modern English forceps of Simpson. The French forceps (Fig. 631, A) is a heavy, long instrument, with powerful handles and closely approximated blades. The lock is the pin or French lock, which the French forceps carry at the present time. In this instrument, too, the pelvic curve is inadequate, but the forceps has certain advantages, which, modi- fied, may be found in many modern instruments. It was not long before the disadvantage of the inadequate pelvic curve "ivas Fig. 632. — A, French, B, English, C, German locks. appreciated, and soon after the time of Smellie and Levret this feature was improved, and a forceps with a better constructed pelvic curve came into use. It may be noticed that the handles of both the Levret and the Smellie forceps are rather difficult to grasp, if one desires to make a strong traction upon them. This disadvantage was overcome by Busch, a German, who was the first to add the cross-pieces or shoulders to the handles, which enable the operator to take a firm and convenient grip of the in- strument. It is plain that both the French and English locks each possess some advantages and some disadvantages. The English lock is easy of adjustment, but is not very secure. The French lock is difficult to adjust, but when once fastened, is firm and unyielding. Briinnighausen united the advantages of both these locks and did away with their disadvantages in the lock known as that of Briinnighausen, or the German lock (see Fig. 632). FOKCKPS. 817 Almost e\cry eminent obstetrician of the last century added some modification of slight importance to the forceps to which he attached his name; so that the ])atterns, differing in a slight degree from one another, ha\e been almost innumerable. There are two types of modern forceps, howe\er, that merit descrip- tion — that of Hodge, in this country, and that of Simpson, in Fig. 633. — Hodge's forceps. Fig. 634. — Simpson's forceps. Fig. 635. — Davis' forceps. Fig. 636. — Small forceps, modified by the author for use at the vulvar orifice and pelvic outlet. Edinburgh. They embody the best features of the two distinct classes that they represent, Hodge's forceps is the direct de- scendant of Levret's; Simpson's, of Smellie's. The Hodge for- ceps has the advantage of taking an extremely firm grip upon the child's head, and of allowing great power in extraction and compression of the head. Its great disadvantage is that it may injure the child's head more easily than almost any other instru- ment. Simpson's forceps — the best modern instrument for ordi- 8i8 OBSTETRIC OPERATIONS. nary use — has a cephalic curve so well constructed that it can scarcely injure the child's head, even when great force is used in extraction. The pelvic curve is sufficient, but is not so great as to embarrass the operator when the instrument is applied to Fig. 637. — Showing the direction in which traction must be made by the handles,' and the correspondence of the direction in traction upon the traction-handle and the direction in which the head must move. Fig. 638. — Hermann's forceps. the head low down in the pelvic cavity. The blades are of such length that the instrument may be used with equal convenience at the superior strait or at the pelvic outlet. The lock is the English lock, which has the great advantage of easy adjustment; and the handles are provided with shoulders for two fingers, and with depressions along the handle for the remaining fingers and thumb of the hand, so that a firm and convenient grasp can be taken of the instrument. Another modern instrument deserving description is the Davis FORCEPS. 819 forceps, carefully constructed upon iron models of the fetal head. If this instrument is adjusted to the sides of the normal child's head in the j)elvis, it is no doubt provided with a better cejjhalic curve than any other forceps; but if it should not be applied accu- Fig. 639. — Tarnier's axis-traction forceps; probably in more general use than any other. To show the details, the hand is represented in an improper position for traction; below is one of the traction rods. Fig. 640. — Poulet's forceps. lately to the sides of the head, it is capable of doing the child's head great damage. A useful instrument in the author's experience is a light, short forceps for use at the parturient outlet (Fig. 636). As the mechanism of labor was better appreciated, and the forceps came into more general use in the latter part of the nine- teenth century, it was realized that a certain amount of force was lost in the extraction of the child's head by the necessity of pulling the forceps in great part in the Hne of their handles. The angle at which this force met the direction it is desired to impose upon the head is shown in figure 637. This difficulty has been overcome by the axis-traction principle, first proposed and car- ried out by Hermann, but popularized a generation later by Fig. 641. — The Breus, Tarnier, and Milne-Murray axis-traction forceps. Fig. 642. — The Farrier axis -traction handle and the Dewees axis-traction forceps. 820 FORCEPS. 821 Tarnier, of Paris, Figures 639, 640, 641, 642 show the axis-trac- tion forceps in most general use.^ Figure 637 illustrates the coincidence of the line of traction with the direction in which the head must move. Many modifications of the axis-traction forceps have been made. None of them are commendable that do not allow the oblique application of the blades while traction is made backward in the median line. The cheapest is Poulet's, with strong tapes passed through eyelets in the forceps blades, and fastened to a handle bent at right angles. The best in my judgment is Dewees'. Farrior,^ at the time one of my students in the University of Pennsylvania, has devised an excellent handle that may be applied to any forceps, and that enables one to utilize the axis-traction principle perfectly. Uses and Functions of the Forceps. — The main function of the forceps is that of a tractor, which is by far the most impor- tant. Another function sometimes to be remembered is that of a rotator, as, for example, when a straight forceps is applied to the head in face presentation, with the idea of twisting the chin for- ward. In a difficult forceps operation the instrument sometimes has the function of a lever ; the operator, swaying his arms a little from side to side, pulls down first one side of the head and then the other, in this way dislodging it from its impacted posi- tion. Last of all, least frequently to be employed, and most dan- gerous of all functions, the forceps may occasionally be regarded as a compressor ; but the instrument is to be used for this pur- pose only in cases where there is a choice between compressing the head with the forceps and performing craniotomy, by the former action extracting a child that is almost certainly dead, or with a brain injury that makes death preferable, but with one or two chances for life out of a hundred. Indications for the Application of the Forceps. — The for- ceps is an instrument designed mainly to reinforce the vis a tcrgo in labor. The most important indication for the use of the in- strument is found in actual and relative uterine or abdominal inertia. The expulsive force may be relatively too weak if the resistance is greater than normal ; hence the forceps is indicated in contracted pelves, rigidity of the soft parts, and ov^ergrowth of the fetal body. It may be necessary, in any case of head presentation in labor, hastily to terminate the process. This is especially desirable ^ Tarnier is said to have destroyed ninety-nine models before he accepted the one-hundredth as entirely satisfactory; for the description of his first models see Tarnier, " Description de deux nouveaux forceps," Paris, 1877; and " Gaz. des hop.," Paris, 1877. 2"A New Axis Traction Handle," James \V. Farrior, "Surg. Gyn. and Obstet.," Feb., 1912. 822 OBSTETRIC OPERATIONS. if conditions exist threatening the child's safety, as premature detachment of the placenta, compression or prolapse of the cord, prolonged pressure on the fetal head, feebleness and slow action of the fetal heart, or sudden danger to the mother during the second stage of labor, as in eclampsia or acute dilatation of the heart. There is a valuable indication of fetal condition during labor in the action of the fetal heart. In. case of serious disturbance the heart-sounds first increase in rapidity, but soon become slower. If they sink to loo and remain at that rate for any length of time, it is Hkely that the child will be born dead. It is a good practical rule in obstetrics, therefore, to apply the forceps and to deliver the child rapidly whenever the fetal heart-sounds sink to loo and remain at that rate for a minute. It may be desirable to save the mother the muscular exertion necessary in the second stage of labor, especially if labor is complicated by some adynamic disease, as phthisis, typhoid fever, or pneumonia. It is most desirable to avoid all muscular effort in the second stage of labor in valvular disease of the heart. Finally, labor may be obstructed by abnormal positions of the cephalic extremity, or by anomalies in the mechanism of labor, as, for example, in face presentations when the chin does not rotate forward, or in vertex presentations when the head is insufficiently or excessively flexed. A good rule of thumb to govern the obstetrical practitioner is to apply the forceps in head presentations whenever the presenting part remains stationary for two hours in the second stage of labor. It is quite as important to recognize the contraindications to the use of the forceps as it is to understand when the instrument is needed. The contraindications to the use of the forceps, ex- pressed dogmatically as rules of practice, are as follows : The forceps must not be applied unless the os is dilated. There are exceptions to this rule. When the maternal or fetal life is threatened, it may be permissible to apply forceps through a partially dilated os, as, for example, when rupture of the uterus is threatened. It may be necessary, in some cases of rigid cervix, to dilate the os artificially by applying forceps and pulling the head down upon the cervix. It is also necessar}-, in cases of valvular disease of the heart and in the adynamic fevers, to shorten labor as much as possible by applying forceps to the head through an undilated os and rapidly extracting the child. The forceps must not be applied until the head is engaged in the superior strait. This rule, too, admits of some excep- tions. It is rarely possible to fix the head in a contracted pelvis with forceps, when the powers of nature are insufficient to attain this end. It is also justifiable to apply the forceps to the head loose above the superior strait in cases of placenta praevia FORCEPS. 823 with the head presenting, and to bring it down as a tampon in the pelvic canal. Tlic forceps must not be aj>j>lied until the membranes have been ruj^tured. This rule admits of no excejjtion. The forceps must not be used as tractors in impossible posi- tions and presentations, as, for example, face presentations with the chin posterior. The forceps must not be employed unless the head be of avcrat^c size. If the fetal head is too large or too small, the instrument is apt to slip and to inflict dangerous injuries upon the maternal soft parts. The forceps must not be used when the disproportion be- tween the head and the pelvic canal is too great. In selecting an instrument, the author would recommend the beginner, if he must restrict himself to a single forceps, to pur- chase Simpson's. As soon as practicable, the Tarnier axis-trac- tion forceps should be added, and it is a great advantage to possess, in addition to these two instruments, a light short forceps for use at the pelvic outlet. Preparation for the Operation. — The patient's consent, or the consent of her husband or nearest relative, should always be first secured. An anesthetic renders the operation less difficult, and is to be recommended to beginners ; but if it is possible to deliver the woman in a short time, — say, half an hour or under, — and if the difficulty of extraction promises to be slight, the anesthetic may be dispensed with. The woman should be placed in the dorsal position upon a table, if possible, or, if not, across the bed, her legs supported by assistants or held by an improvised leg-holder made of a twisted sheet. With the small forceps used at the pelvic outlet the lateral position need not be altered. The forceps should be boiled in a suitable instrument tray. Just before its insertion the w^hole blade, both outer and inner surfaces, should be smeared with carbolated vaselin or sterile glycerin. The Application of the Forceps. — In using the Simpson forceps, or any other with a non-detachable pin-lock, the left-hand blade is always inserted first. The left blade lies upon the left-hand side of the woman's pelvis, and is held in the left hand of the operator. The right-hand blade of the forceps lies upon the right-hand side of the pelvis when introduced in position on the child's head, and is held in the right hand of the operator. Assuming that the diagnosis of the presentation and of the position of the presenting part has been made, and that the vagina is rendered surgically clean, the successive steps in the applicadon of the forceps-blades may be summarized as follows : Having introduced two fino-ers of the rieht hand into the OBS TE TRIG OPERA TIONS. Fig. 643. — Introduction of the left blade: first step. Fig. 644. — Introduction of the left blade: rotation on its long axis. FORCEPS. 82s Fig. 645. — Insertion of the right blade, the left wrist being depressed to crowd the: handle of the left blade out of the way. Fig. O46. — Both blades inserted, unrotated. 826 OBS TE TRIG OPERA TIONS. Fig. 647. — Rotation of a blade (the left). Fig. 648. — Both blades joined by the lock after the rotation of the right. FORCEPS. 827 vagina, the left blade, grasped at the lock by the left hand as a pen, is held perpendicularly to the woman's body, with the tip of the blade opposite the vulva. The tip of the blade is inserted in the vagina, and is pressed backward along the pelvic floor toward the sacrum. The blade is then rotated outward on its long axis to bring it in apposition with the posterior inclined plane of the pelvis, and to escape the promontory of the sacrum : the handle is depressed and the tip of the blade is thus elevated into the uterine cavity, the fingers of the right hand in the vagina guiding the blade and protecting the soft parts ; finally, the handle is carried to the left side in order to engage the tip of the blade over the curve of the child's head. The right-hand blade is in- troduced in a similar manner, substituting the right for the left, Fig. 640. — The grip on the forceps. of course, in the foregoing description. As the blades lie after their insertion it is impossible to lock them, for both of them have ascended the posterior inclined plane of the pelvis, after being rotated outward on their long axes. It is necessary to bring one of them forward toward the region of the acetabulum, if the head lies in the oblique position, before the blades will lock. 828 OBSTETRIC OPERATIONS. Obviously, the blade to be rotated forward within the pelvis differs with the different positions of the presenting part. In the left occipito-anterior position of a vertex presentation the right- hand blade must be rotated forward, the left-hand blade lying as it was when first introduced. To rotate the right blade the handle is lightly supported by the fingers of the right hand, while the first two fingers of the left hand are inserted under and to the outer side of the heel of the blade and gently pry it upward, outward, and then inward. If the operator finds it more con- venient, he may reverse the hands. If there is difficulty in locking the blades, a depression of both handles toward the perineum often facilitates their conjunction. Fig. 650. — The grip on the forceps and the direction of traction. The handles being approximated and the blades joined, the operator takes the grip upon the instrument shown in figure 650. The forefinger of the right hand is kept extended against the child's scalp to detect the first inclination on the part of the in- strument to slip. Too great compression of the child's head may be avoided by placing a folded towel between the handles, and by using the slack of this towel to cover the shoulders of the forceps-handles, the operator saves his fingers from excessive fatigue and even bruising. The grip represented in figure 650. with pressure exerted downward, outward, and on the ends of the handles upward, enables the operator to impose upon FORCEFS. 829 Fig. 651. — The extraction of the head from the vulvar orifice: first stage. Fig. 652. — The extraction of the head from the vulvar orifice: second stage. 830 OBS TE TRIG OPERA TIOXS. Fig. 653. — The extraction of the head from the vulvar orifice: thuu stage. Fig. 654. — The extraction of the head from the vulvar orifice: fourth stage. FORCEPS. 83 1 the head a movement corresponding with the axis of the parturient canal. If traction were made directly outward by pulling straight upon the forceps-handles, much of the force would be lost by dragging the head against the symphysis pubis. In making traction, nature should be imitated as closely as possible, the intervals between one's efforts corresponding to the usual intervals between the pains, and the traction lasting for about a minute. In the intervals of rest the blades should be loosened, or even unlocked, to spare the fetal head from long- continued and uninterrupted compression. The force should be exerted by the muscles of the shoulders and arms. It is inad- visable to throw the weight of the trunk upon the forceps and it is absolutely inexcusable to utilize the muscles of the back and legs, plus the weight of the body, by bracing the feet while pulling upon the forceps. The tractive force should take a different direction as the head progresses along the parturient tract. When the forceps is at rest, the direction of the handles is a good indication of the direction in which the next traction should be made; as the head descends the birth-canal and appears at the vulvar orifice, distending the perineum, care should be exercised to moderate the tractive force, otherwise the head might be violently pulled out through, instead of over, the perineum. When the degree of distention shown in figure 651 is reached, the grip of the forceps is changed. The handles are seized in the right hand, as shown in figure 651, the operator standing to one side of the patient. In- stead, now, of making traction, the forceps-handles with each pain are lifted and carried up over the woman's abdomen, very little force being employed. The outspread fingers and thumb of the left hand push the head away from the perineum and guide it up- ward under the pubic arch. When the pain passes oft', the forceps- handles are allowed to sink again. Finally, just before the head emerges, the grip on the instrument is again changed so that the handles may be almost laid on the woman's abdomen (Fig. 654), Used in this way there is no better safeguard for the integrity of the pelvic floor than the obstetric forceps. In the description of the application of the forceps it has been assumed that the head is in a normal oblique position of a vertex presentation and that the blades of the instrument are applied to the sides of the fetal head, where they do the least damage, and to the contour of which their cephalic curve has been adjusted. It often happens, however, that the head occu- pies an abnormal position, and the question arises whether the forceps shall be applied at the sides of the maternal pelvis, where the blades are not likely to injure the woman, or whether an 832 OBSTETRIC OPERATIONS. attempt must be made to adjust the blades to the sides of the fetal head regardless of the additional risk to the mother. If, for example, the head is transverse, as it usually is when detained at the pelvic inlet in a contracted pelvis, one blade must lie behind the symphysis and the other in front of the promontory if they are to be placed at the sides of the fetal head. It is pos- sible to so adjust them, if one possesses manual dexterity and is skilled in the use of the forceps, but there is always a danger of perforating the posterior uterine wall in the attempt. It is better under these circumstances to place the blades obliquely, the posterior behind the promontory of the occiput, the anterior in front of the chin and mouth. By this adjustment the fetal head is not likely to be so. badly damaged as if the forceps were applied directly over the face and the occiput, the anterior rota- tion of the latter is facilitated, and the woman is subjected to no extra risk. It is not infrequently necessary to apply the forceps to the head in a normally oblique position, but with the occiput directed posteriorly. As the head descends, anterior rotation should occur, and it is to be considered whether the grip of the instru- ment will interfere with the rotary movement of the head upon the pelvic floor. As a rule, it does not if the precaution is ob- served to disengage the blades completely from each other by unlocking them after each tractive effort. If spontaneous rotation does not occur, the forceps is used as a rotator with each traction till the instrument almost turns upside down. As soon as rotation' is accomplished, the forceps-blades must be rotated into their ap- propriate positions over the sides of the head, or, if it is difficult to do this, they should be withdrawn and reinserted. To give a concrete example : In a right occipitoposterior position of a vertex pres- entation the two blades of the forceps are inserted along the posterior walls of the pelvis to either side of the promontory ; the right blade is then rotated forward until it lies under the right acetabulum. As the occiput rotates forward after encoun- tering the resistance of the pelvic floor, the long anteroposterior diameter of the head shifts from the right to the left oblique diameter of the maternal pelvis, bringing the forceps-blades directly over the face and the occipital protuberance. The left blade must, therefore, be rotated forward and the right backward, or, if it is difficult to rotate the blades, they must be withdrawn and reinserted as for a right occipito-anterior position of a vertex presentation. If the occiput rotates into the hollow of the sacrum, the head should be extracted from the vulvar orifice by the following manoeuver : The forceps-handles are raised gradually and inter- mittently until almost the largest diameters of the head have FORCEPS. 833 Fig. 655. — Overdistention of the perineum in persistent occipito- posterior deliveries ; the nose rests under the pubic arch. The handles at this point should be depressed. escaped ; then, instead of continuing the elevation, the left hand firmly supports the head through the perineum and the forceps- handles are depressed, turning the fetal face out from behind the symphysis. In this way the perineum and pelvic floor are some- what relieved of the tremendous strain imposed upon them in a persistent posterior position of the occiput. In applying the axis- traction forceps, the bars are closed against the blades, which are in- serted in the ordinary manner. After adjusting the blades to the sides of the child's head if possible, or in an oblique diameter of the pelvis, the blades are locked; the pin-lock of Tarnier's instrument is screwed moderately tight; the con- necting bar between the handles is thrown across, locked, and screwed until the blades take a firm but not too forcible grip on the fetal head. The traction bars are then sprung loose at their lower end and the handle is adjusted to them and locked. Traction should be made in a line as nearly as possible coinciding with the axis of the pelvic inlet — namely, backward and downward. To do this even approximately the woman must be placed upon a bed or table with her buttocks projecting well beyond the edge and the axis-traction handle of the forceps must be pulled downward and backward as far as possible. To pro- tect the perineum from injury by the traction rods a Sims specu- lum should be held in place during the tractive efforts. Between the tractions the bar joining the handles should be unscrewed and thrown out of place and the pin-lock should be unscrewed, thus relieving the fetal head from continued pressure. As soon as the fetal head has descended well into the pelvic cavity the axis-trac- tion principle becomes unnecessary. The handle should, therefore, be removed, the bars fastened in their places by the blades, and the forceps used as an ordinary instrument or else withdrawn and replaced by a Simpson forceps. Statistics as to \\\& frequency of forceps operations have neither interest nor value. They vary enormously in different clinics, in different classes of society, and in the hands of different operators. The author is an advocate of the frequent use of forceps, believing that more harm arises from inordinate delay in labor to mother and infant than can be traced to the use of the instrument in careful and skilful hands. The mortality of a forceps operation, per se, should be ;///. The 53 834 OBSTETRIC OPERATIONS. Fig. 656. — Tarnier's axis-traction forceps; head at the superior strait. Fig. 657. — Tarnier's axis-traction forceps; head in the pelvic cavity. EXTRACTION OF THE BREECH. 835 most rric:;^litrul damage, however, has been inflicted upon both mother and child by the unskilful and careless use of the instru- ment. The pelvic joints have been sprunt^ apart by too forcible traction ; the lower uterine segment with an undilated os has been n the grip of the caught blades through and has been cut into the peritoneal cavity; the posterior wall of the lower uterine segment has been perforated by the tip of one blade; the child's scalp has been cut and a forceps- blade forced between its scalp and the skull; in an attempt to apply forceps to the breech in the mistaken notion that it was the head, the tip of a forceps-blade has torn the perineum of a female infant into the rectum; the vaginal vault has been perforated and the vaginal walls deeply cut, and frequently, indeed, is the pelvic floor torn, often into the rectum, by a failure to elevate the handle sufficiently and to moderate the tractive force as the head is extracted from the vulvar orifice. Fig. 658. — To bring down a foot when it is against the face, the knee may be bent by pressure in the pop- liteal space (modified from Farabeuf and Vamier). EXTRACTION OF THE BREECH. Breech labors are normally slow and tedious. The indica- tions for interference are: delay for much more than twenty-four hours, rapid and feeble pulse, signs of exhaustion, elevation of temperature in the mother, and abnormally slow fetal heart- sounds. Methods of Extraction in the Order of their Efficiency. — ■ Manual Method. — Seizing a foot by passing a hand into the uterus, extracting the leg up to the knee, thus decomposing the breech presentation and affording a convenient handle to the fetus by which to control the subsequent progress of labor, is the best of all methods for extracting the breech, if it is practicable. Pinard's suggestion to push one thigh outward and backward, thus flex- ing the leg upon the thigh, occasionally makes it easier to grasp the foot. 836 OBSTE TRIG OPERA TIOXS. Another plan of manual extraction is to place the hand on the infant's back, so that the little and fore-fingers hook over the crest of the ihum, while the middle and third fingers are ex- Fig. 659. — Manual extraction of breech. Fig. 660. — Forceps on breech. Fig. 661. — Fillet on breech. tended along the spine. This is not so good. For both manoeuvers the patient must be anesthetized. Forceps. — If the breech is low in the pelvic canal, and it is impossible to pass the hand into the uterine cavity to seize a foot, it may be most convenient to apply forceps over the EXTRACTIOX OF THE BREECH. 837 trochanters. By avoiding compression of the handles, and simply making traction by hooking one's fingers over the shoulders of the instrument, the breech may be extracted readily, with no danger to the child. Extraction by Fillet. — Each end of a strip of bandage about two inches wide may be passed between the thigh and the abdomen and brought down in front of the external genitalia. If drawn tight, the loop of the band- age is in contact with the child's Fig. 662. — Markel's fillet-carrier for breech presentations. Fig. 66 J -The handle of a long forceps used as a blunt hook. sacrum. A firm and convenient grip is thus taken upon the breech. The fillet is very difficult to apply with the fingers. A fillet-carrier, shown in figure 662, makes the application much easier. It is constructed like a Bellocq's cannula, and was devised by R. M. Markel, at the time a student in the Univer- 838 OBSTETRIC OPERATIONS. sity of Pennsylvania. An anesthetic is required. This plan is excellent if manual extraction is impossible, or if it is inad- visable to use forceps. Blunt Hook. — This instrument is passed between the thigh and the abdomen. It is extremely dangerous for the infant. It is very likely, indeed, to fracture the thigh or to perforate the groin. It is, therefore, not recommended, and is never employed by the author unless the child is dead. VERSION. Version maybe defined as an operation or manceuverto change the position of the fetus in utero. The object of version is usually to change a transverse into a longitudinal presentation, or to change the presentation of one pole of the fetal ellipse into a presentation of the opposite pole. The changes in the position of the fetus are effected by four methods — postural treatment of the mother, external manipu- lation alone, internal manipulation alone, and a combination of internal and external manipulations. As the child is brought to present by the cephalic or pelvic presentation, the operation is called version by the head or version by the breech. If the foot is seized and is extracted in the operation of version, the operation is called podalic version. The operation of version is an old one. Hippocrates speaks of the difficulties encountered when a child lies crosswise in the uterus. He compares it to an olive lying crosswise in a bottle with a narrow neck. But Hippocrates believed that the infant could only be delivered if it presented head first, and therefore, in cross-positions of the fetus, if the effort to turn it with the head toward the maternal pelvis did not succeed, embryotomy was to be performed by tearing the child to pieces with sharp hooks. In some aboriginal tribes a woman is seized by the feet, sus- pended head downward, and vigorously shaken if labor is delayed. In Japan, before the country reached its present high stage of civilization, it was customary to apply massage to the abdomen of pregnant women in order to straighten out a possibly faulty position of the fetal ellipse. In many primitive races some form of version has been and is in vogue, handed down as a custom of ancient origin. Indications for Version. — The most important and the most frequent indication for version is found in a transverse posi- tion of the fetus in utero. In order to secure delivery, one or the other of the poles of the fetal ellipse must be substituted for the shoulder, which usually presents in a transverse position of the fetus. VERSION. 839 Contracted pelves arc an indication for the performance of version, when it is thought that the child's head can be brought through the contracted pelvic canal more easily with the small end of the wedge coming first than last. If it is necessary to deliver the mother rapidly, in cases of sudden danger, when the head is presenting but not engaged, as in eclampsia, premature detach- ment of the placenta, rupture of the uterus, embolism, and death of the mother, podalic version furnishes the most rapid means of delivery. In malpositions of the head, as presentation of the ear, of one parietal bone, of a brow or face, it may be better to substitute for the unfavorable presentation of the head the more favorable presentation of the breech, which is secured by podalic version, or by version by the breech. In placenta praevia, if the head is presenting, version is indicated, in order to bring down the breech as an intrapelvic tampon upon the bleeding placental site. In prolapse of the umbilical cord, version is indicated if the cord can not be returned into the uterine cavity and kept there. Before undertaking the operation of version, it is quite as important to realize the contraindications to the operation as it is to recognize the indications. Version is positively contra- indicated if the presenting part is firmly engaged in the pelvic canal and has passed out of the external os ; also, if the con- traction-ring is so high that a rupture of the lower uterine seg- ment is threatened if version is attempted. While these are the only positive contraindications to the operation, the following conditions may make it difficult, dan- gerous, or quite impossible : An undilated and undilatable vagina ; a similar condition of the cervix. These obstructions may usually be overcome under anesthesia, but they may be insuperable obstacles to the per- formance of version. It may be impossible to effect an entrance into the uterus, as when the liquor amnii has long been drained away and the uterus is firmly contracted, if the uterus is permanently con- tracted in what is called a tetanic spasm, if there is some obstruc- tion on the part of the fetus, as hydrocephalus and spina bifida with a large meningocele, or if the presenting part is pressed firmly upon the superior strait. The last-named difficulties may be obviated by placing the woman in the knee-chest posture. Prolapse of the arm, at one time considered a serious ob- stacle to the performance of version, is no longer so. The phy- sician's hand can readily pass by the arm, and indeed it is some- times an advantage to pull the arm out of the external os before attempting version. It may be impossible to bring the feet down in podalic version after they are grasped. This difficult)' may be overcome by 840 OBSTETRIC OPERATIONS. applying a fillet to the foot, and, while traction is made upon it, the other hand of the physician in the vagina pushes the shoulder upward and in the direction of the child's head. In a case of the author's the shoulder and head were locked in the cornua of a uterus condiformis, making version impossible. Certain conditions may interfere, also, with the manipulation of the external hand in combined and in podalic version, as an excessive amount of fat in the abdominal wall, or convulsions in eclampsia, epilepsy, chorea, and hysteria. On the other hand, the conditions most favorable for the operation are: a uterus dis- tended by liquor amnii, a dilated os, a uterine muscle that is not irritable, abdominal muscles that are flexible and thin, and a cervix well dilated or easily dilatable. Fig. 664. — Diagram of knee-elbow po-ture f .r internal version. The lower part of the hollow of the uterus is lifted out of the pelvis (Dickinson). Postural Version. — In this method the woman is put in dif- ferent positions to influence the position of the child by the force of gravity. For example, if the brow presents, the woman is turned on that side toward which the fetal back looks, so that the breech may drop to that side, and thus bring the vertex to the center of the superior strait; or, if the head should be tightly fixed in the superior strait, the woman may be turned on that side toward which the face looks, in order to promote the flexion of the child's head, and thus favor a conversion of the brow presentation into one of the vertex. This is a simple, safe, and easy means of performing version, if practicable, but it usually fails. Version by external manipulation may be used before VERSION. 841 labor to convert a breech presentation into a presentation of the head, or to correct a transverse presentation. When the child has been brought into the position desired, by a series of stroking movements, pads and a binder should be applied to prevent the return of the child to its original position. This method, while successful in a fair proportion of ca.ses, requires often an expert's skill ; a diagnosis of the position before labor has begun ; the preservation of the membranes ; thin, flexible uterine and abdominal walls, and non-irritable muscles. Combined version was first proposed by Busch, D'Outre- pont, and by Dr. Wright, of Cincinnati, and was later advocated by Braxton Hicks, of London. The operation is performed as follows: The patient is placed in the dorsal position and is anesthetized. Externally, the hand nearest the fetal part to be acted upon by external manipulation seizes this part through the abdominal walls, the operator being seated facing the vulva. The internal hand pushes the presenting part up and to that side opposite the fetal part acted upon by the external hand. For example, in a shoulder presentation, with the face of the child turned forward and the head in the right iliac fossa, the physician seizes the head with his left hand, inserts the right hand in the vagina, and with two fingers of this hand passed into the uterine cavity pushes the child's right shoul- der upward and toward the mother's left-hand side, while the head by external manipu- lation is pulled downward and toward the median line. In all shoulder presentations, version by the head should be pre- ferred to version by the breech in the combined method, for this presentation is more favor- able to the child, and the head is more readily brought to present at the superior strait, making the version easier and quicker than if the breech were brought down. Podalic version was known in the time of the Roman Em- pire, but was forgotten in the middle ages until Ambrose Pare and his students revived it in the sixteenth century. The opera- tion is performed as follows: Relaxation of the uterus and of the abdominal muscles is secured b\- an anesthetic. The lowest Fig. 665. — Version in dorsoposterior posi- tion (Farabeuf and Varnier). 842 OBSTETRIC OPERATIONS. Fig. 666. — D'Outrepont's method of combined version, modified by Scanzoni. Fig. 667. — Combined version by the breech. Fig. 668. — Combined version, Wright's method. VERSION. 843 Fig. 669. — Seizing the anterior foot in podalic version (Nagel). Fig. 670. — Version in dorso-anterior position, first stage of traction on lower limb (Farabeuf and Varnier). 844 OBSTETRIC OPERATIONS. possible position of the fetal feet is secured by turning the mother on that side toward which the feet point. The hand which, midway between pronation and supination, as the operator faces the woman's vulva, corresponds with its palmar surface to the abdomen of the child is inserted into the uterine cavity, until it meets the anterior foot. This foot is grasped by the first two fingers and the thumb, and is then extracted until the knee appears at the vulva. "^ Fig. 671. — Tlie upper buttock is moving downward and the lower shoul- der rising (Dickinson). Fig. 672. — Assisting podalic version by external manipulation (Dickinson). The advantages of resting content with the anterior foot, and of drawing upon it alone without seeking for the other, are these: A further entrance into the uterus is unnecessary. It is easier to hold one foot than two. The other leg is folded upon the abdomen, and thus secures a more thorough dilatation of the cersacal canal. Finally, by pulling upon the anterior foot one VERSION. 845 is more likely to secure a sacro-anterior position of the breech. While making traction upon the foot, the version of the child is facilitated by external manipulation of the head (Fig. 672). It is Fig. 673. — Seizing the leg instead of the foot. Fig. 674. — Seizing a knee instead of the foot. occasionally easier to seize a leg or the knee than the foot (Figs. 673, 674). In such a case time need not be wasted seeking for the foot. Combined version by the breech may precede or re- 846 OBSTETRIC OPERATIONS. place podalic version with great advantage, as first pointed out by Braxton Hicks, obviating the necessity of introducing the hand into the uterine cavity and enabling the operator easily to seize the knee or foot after it is brought near or into the superior strait. As soon as the knee is born, the operation of podalic version is finished, and, unless there is some indication for immediate Fig. 675. — Extracting an arm (Nagel). dehver}', the anesthetic should be removed, the patient turned upon her back, and allowed to expel the child spontaneously until the umbilicus appears in view. The delay secures a more thorough dilatation of the cervical canal, and produces a paretic condition of the circular muscle of the cervix. The advantages of this condition of the cervix are obvious when it comes to the extraction of the after-coming head. With an undilated cervical canal and a rigid cervical muscle, the neck is likely to be grasped in so firm a hold that all efforts to extract the head VERSION. 847 are unavailing until the child is asphyxiated. In rare cases rapid extraction may be indicated. If it is, the legs and trunk are pulled upon forcibly, as shown in figures 676 and 677. The child's body being slippery, should usually be enveloped in a towel. When the child is born to the umbilicus the pressure upon the cord is great, and delay in its extraction means an as- phyxia so deep that it is unlikely the child can be revived. From this moment, therefore, the attendant must put forth every effort possible to secure the most rapid delivery of the infant by the following methods: The arms, if extended alongside of the child's head, as they usually are after version, must be extracted Fig. 676. — Method of seizing both Fig. 677. — Method of seizing the feet. breech. as follows : locate the posterior arm by the position of the trunk and shoulders. To deliver the right arm, grasp the legs with the left hand. Raise the child's body upward and outward over the mother's right thigh. This movement should be suffi- ciently forcible to bring the right shoulder well down in the pelvis. The first two fingers of the right hand, entering the vagina in contact with the right scapula, are passed along the posterior surface of the arin beyond the elbow, when the arm and forearm are pushed in front of the child's face as though the elbow- joint did not exist. The fingers are now hooked in the elbow- joint and pulled directly downward until the elbow appears at the vulva, the forearm being flexed by this movement upon the arm. The forearm is then easily delivered by extension. The 848 OBS TE TRIG OPERA TIONS. left arm is brought down and delivered in the same manner, sub- stituting, of course, right for left. The right hand grasps the child's feet and hfts them over the mother's left thigh, at the same time rotating them on their long axes so as to twist the body and thus bring the anterior arm into the posterior portion of the pelvis. The fingers of the left hand are inserted into the vagina past the elbow-joint. The arm is swept forward over the face, as though it were a single piece without the elbow-joint. The elbow is then flexed, pulled downward, and the forearm extended at the Fig. 678. — Delivery of the after-coming head by flexion through seizure of lower jaw, and extrusion by means of pressure in axis of brim. vulvar orifice. Should the shoulders occupy a transverse posi- tion, either arm may be brought down and delivered first. Don Carlos Guffey^ proposes a modification of this plan which promises greater ease and rapidity of delivery. As soon as the foot or feet are delivered, the operator inserts a hand deep enough to grasp a hand of the fetus, preferably the right, which is then pulled upon until it emerges from the vulva with the breech. As the trunk is pulled upon the arm is grasped also and extracted with the trunk. This leaves but one arm and the head to be extracted after the shoulders. After delivering the arms, the ^ " Surgery, Gyn., and Obstet.," Jan., 191 1. VERSION. 849 head may be extracted by one of the following methods, given in the order of their efficiency and safety: Wigand's Method. — In -this method the first three fingers of the supinated hand are inserted into the vagina, that hand being employed whose palm corres])onds to the abdomen of the child. Over the forearm of this hand the child's body rests astride. Fig. 679. — First step of Mauriceau's method, an assistant making suprapubic pressure on the head. The index-finger of the hand in the vagina is inserted in the child's mouth, care being exercised to avoid the eye-sockets. Sufficient traction is exerted upon the lower jaw to secure and 54 850 OBSTETRIC OPERATIONS, maintain flexion of the head. The disengaged hand now locates the head through tlie abdominal wall above- the pubes, and delivery is accomplished by suprapubic pressure in the axis of the parturient canal, and by the elevation of the child's body toward the mother's abdomen. Mauriceau's Method. — One hand is inserted in the vagina, as described above, and one finger is placed in the child's mouth. The other hand is passed along the child's back until the middle finger rests upon the occipital protuberance. The index- and Fig. 6So. — Second step of Mauriceau's method. ring-fingers are flexed over the clavicles, and traction is made by both hands at once, the force upon the jaw and the pressure upon the occipital protuberance keeping the head well flexed, while the traction upon the shoulders extracts the head in the VERSION. 851 direction of the parturient canal. As the head descends upon the pelxic lloor, .the child's body is carried uj)\vard toward the mother's abdomen. Properly directed suprapubic pressure by an assistant increases the efficiency of this method, and makes it, indeed, the most effective of all methods in extracting;" the after- coming head. Combined with the Walcher posture in the mother it should be the method of election in cases of contracted pelvis. Prague Method. — The child's ankles are grasped with the right hand pronated, the middle finger being placed between the legs just above the internal malleoli, the index- and ring-fingers above the external malleoli. The index-finger of the left hand is flexed over one clavicle, and the remaining fingers of the same hand over the other clavicle. Traction directly downward is now made with both hands until the perineum is well distended. Fig. 681. — The method of extracting the trunk. Fig. 682. — The Prague method of extracting head. The right hand then loosens its hold upon the ankles, and again grasps them as described above, but approaching them at their anterior surface. The child's feet are now in contact with the back of the right hand. The feet are then raised by a circular movement toward the mother's abdomen, while the left hand as originally placed is used as a fulcrum, around which the head moves until it is finally forced out of the parturient outlet by a lever-like movement on the part of the child's body. 852 OBSTETRIC OPERATIONS. Forceps. — An assistant should raise the child's body, sup- porting its arms and legs, and thus keeping them out of the way of the opjerator, who rapidly apphes the blades to the sides of the child's head. Traction is made in the direction of the axis of the parturient canal, and the head is finally delivered by lifting the handles of the forceps, the disengaged hand protecting the perineum as much as possible. Deventer's Method. — The child's body is seized as in the Prague method, but the arms are still alongside the child's head Fig. 683. — Deventer's method of extraction of the after-coming head and arms. and need not be extracted first. The body is pulled directly do-vMiward toward the ground, until the shoulders descend and press upon the pehdc floor. The child's body is then carried do-\Miward and backward under the woman's buttocks, the head EMBRYOTOMY. 853 being rolled out of the parturient outlet between the arms, which easily follow after. To do this the woman's buttocks must I^roject well beyond the edge of the bed, and the child must be carried well under them. The operation is only possible under the most favorable conditions, and is not always to be relied upon. It has, however, the merits of simplicity and rapidity. EMBRYOTOMY. Embryotomy is a mutilating operation upon the fetus. The term is generic, and includes the following operations: Craniotomy, decapitation, evisceration, and amputation of the extremities. Craniotomy. — The child's head is perforated, the contents evacuated, and the head thus diminished in size. The forcible extraction of the evacuated head is often also a part of the operation. The operation may be indicated upon a dead or upon a living child. In the former case the indications for the operation may be comparatively trivial. If the mother can be saved any additional risk or suffering by the rapid delivery of the mutilated child, craniotomy is not only justifiable, but advis- able. In case of prolapse of the umbilical cord, with a con- tracted pelvis, the commonest condition that calls for craniotomy upon a dead infant, it is far better to open the head and to deliver the child easily with a cranioclast, than to apply the forceps to the head at the superior strait and to subject the mother to the delay, pain, and danger of a prolonged forceps operation, when nothing is to be gained by it. Craniotomy upon the living child is only justifiable in excep- tional circumstances. To condemn this operation, however, unreservedly and without exception is a mistake. In cases of difficult labor, if the pelvis is contracted or the child over- grown, and the physician must make a choice between Cesa- rean section, pubiotomy, or craniotomy, if he has no skiU in sur- gical work and is unable to procure expert assistance, it is better, unc[uestionably, to sacrifice the child for the mother's sake, rather than to attempt a serious surgical operation, amid unfavorable surroundings, and performed by an unskilful operator whose mortality must be very great. The destruction of a living child must be avoided if possible, and if the operator feels himself possessed of sufficient skill to attempt the more serious operations of Cesarean section or pubiotomy with fair prospect of success, or if he can summon to his aid an expert surgeon, he should not think of performing crani- otomy upon the living child. But under certain circumstances 854 OBS TE TRIG OPERA TIOXS. craniotomy upon a living infant is a justifiable operation, and one not to be unreservedly condemned. The Instruments for the Operation. — Embryotomy is the oldest operation of obstetrics and the instruments for perform- ing it make an interesting historical collection. The sharp hook or crotchet in its numerous forms had a place in the obstet- rician's armamentarium for many centuries. At the present day the operator may need for craniotomy a perforator, a head seizer Fig. 684. — Smellie's perforator. Fig. 685. — Blot's perforator. Fig. 686. — Braun's cranioclast modified by the author with a pelvic curve. Fig. 687. — Tarnier's basiotribe. or cranioclast, and a head crusher in its various forms of cephalo- tribe, basiotribe, or basilyst. Perforators. — The best perforator is Blot's. Smellie's perfora- tor or Hodge's scissors answer the purpose well enough, and in the absence of an instrument specially devised for the purpose, any long, sharp-pointed scissors serves admirably. EMBRYOTOMY. 855 Head Seizers or Craniociasts. — This instrument was invented by Sir James Y. Simpson. It has been much improved by Carl Braun and the author has added to the latter instrument a pelvic curve, which facilitates its application at the superior strait. The cranioclast is made with two blades : one for insertion inside, the other outside, the skull. The handles are provided with a screw Fig. 688. — Tarnier' s basiotribe (separate parts). Fig 689. — Tile second blade of the basiotribe lias cruslied tlie sinciput. and nut to bring them close together, so as to give the blades a powerful grip upon the skull. Head Crushers or Cephalotribes. — The cephalotribe is the in- vention of the younger Baudelocque. It is simply a heavy, powerful forceps with the handles screwed together so as forci- bly to compress the skull between the blades. The best cephalo- tribe is Tarnier's basiotribe, which combines a perforator and a powerful head crusher. Other modern instruments for the extraction of the mutilated head are Simpson's basilyst and Van Huevel's laminator. The latter is designed to saw off the face and the occipital protuber- 856 OBS TE TRIG OPE RA TIONS. ance. A wire ecraseur answers the purpose perfectly well, as was shown by Barnes. In addition .to these instruments, the operator needs a heavy volsella forceps and a large metal catheter to break up the brain and to wash it out of the skull. The technic of the operation is as follows : The woman should be anesthetized not so much because the operation is •painful or prolonged, but to spare her the sight of her mutilated Fig. 690. — Perforation of the head begun: the right hand is grasping the handles of the instrument. The tips should not be separated until they have entered the fontanel. infant. The patient is placed in the lithotomy position, and brought well to the edge of the bed or table on which she lies. The child's scalp is seized by a strong volsella forceps, which is handed to an assistant, who pulls upon the instrument firmly, so as to fix the head at the superior strait. The operator then in- serts two fingers of his left hand and feels for a suture or a fontanel. The perforator is inserted into the vagina, along the palmar surface of the fingers, and is plunged into the skull at a point upon which the finger-tips rest — that is, through a fontanel or a suture. When it has entered the skull the perforator is twisted about in all direc- tions, in order to break uj? the brain, and is also opened in several different directions to enlarge the opening in the skull. The large catheter is next inserted and attached to a syringe. A column of water is injected into the cranial cavity to wash out the remaining brain-substance. Next, if it is necessary, the size of the emptied head may be reduced with a cephalotribe. This is only called for in case of extreme pelvic contraction, or in the presence of some EMBRYOTOMY. 857 };cl\'ic tumor seriously diminisliinf^ llic capacity of tlic pchic canal. In the majority of cases a cranioclast may be used instead of the cejjhalotrilje. The internal branch of this instrument is inserted witiiin the skull. The outer branch is next introduced in the same manner that one would insert a blade of the forceps. The two branches are then locked, and the handles are screwed firmly together, care beintj taken that the internal branch isin.serted deeply within the cranial cavity, so that it shall get a firm grasp upon the skull. The child is now extracted in the same manner that one would extract the head with the forceps, except that the tractive efforts are made uninterruptedly and with greater Fig. 691. — Craniotomy on the after-coming head: one method of perforating. force. In certain cases it is sufficient simply to perforate the skull. This applies particularly to cases of hydrocephalus. The head being evacuated, the forces of nature are sufficient to in- sure the child's delivery. If it is necessary to perforate the after- coming head, the perforator may be inserted behind the ear, in the lambdoid suture, under the chin, through the roof of the mouth, or, possibly, through the foramen magnum. In a case of hydrocephalus with breech presentation, should there be great difficulty in reaching the after-coming head, it is possible to evacuate the fluid by perforating the spinal column and passing a catheter through the spinal canal into the cranium. Decapitation. — The chief indication for decapitation is an impacted shoulder presentation, in which it is impossible to do 858 OBS TE TRIG OPERA TIOXS. version, either on account of the inabihty to move the child or because of the risk of ruptured uterus owing to the enormously Fig. 692. — Hirst's sharp angulated hook for decapitation. distended lower uterine segm.ent. The instrument needed for this operation is the author's sharp hook. It is fastened firmly over the child's neck, when with two or three quick rocking motions the neck and the soft structures are cut through ^^•ith the knife blade in the angle of the hook. The author's hook is more easily ap- pHed than the Ramsbotham and is more efficient than the Braun. In the absence of specially de\dsed instruments for the purpose, a string may be car- ried over the neck and the child decapitated by a sa\^ing movement mth the string, the vagina and perineum being pro- tected by a Sims speculum. Amputation and e\'iscera- tion are very rarely indicated. Some monstrosities or tumors may require these operations. A long-handled scissors is the best instrument for the pur- pose. Cutting or breaking the clavicles icleidotomy) was pro- posed on theoretical grounds to secure dehver\- of the shoulders. I found it t\\T[ce of great service. Fi 693. — Decapitation with author's hook. S YMPH } 'SE OTOMY. 859 Symphyseotomy is a division of the pubic joint, allowing a diastasis of the bones during labor, the child being extracted through the vagina. The operation was suggested for the first time in 1598, was performed for the first time on a woman dying in labor by Jean Claude de la Courree, in 1655, and for the first time on a living woman in 1777 by Sigault in Paris. For a time symphyseotomy was in high favor, but the mortality that followed it and the accidents which frequently marred its success prejudiced the medical world against it, and it gradu- ally died out. In 1866 the operation was revived in Italy, and from that time to 1886 it was performed 71 times with a death- rate of 25 per cent. The success achieved in the latter years of this period attracted the attention of the Parisian school of obstetricians. The operation was revived in its original home, and was quickly adopted throughout the civilized world. In the following three years there were 74 operations in the United States, with 10 maternal deaths and 18 infantile deaths. The mortality for America was about 12 per cent., but certain opera- tors abroad have had as many as 20 cases in succession without a fatal result, and in Italy 54 symphyseotomies have been per- formed with but 2 deaths. In 275 cases collected by Kerr the maternal mortahty was 6.5, the fetal, 10 per cent.^ It may be said that Cesarean section has a slightly higher mortality in the mother than symphyseotomy in the hands of a surgeon not specially trained, but a decidedly lower infantile mortality. The expert abdominal surgeon, with a thoroughly aseptic technique, should have a very low and about an equal maternal mortality in both operations. A separation of the symphysis up to 7 cm. (2I in.) secures an increase in the anteroposterior, the transverse, and the diagonal diameters of the pelvis of 1.4 cm. (0.55 in.), 3.1 cm. (1.22 in.); and 3.5 cm. (1.4 in.) respectively. It is possible to achieve success with a conjugate as low as 6.5 cm. (2.56 in.), but in a pel- vis so badly contracted symphyseotomy is more dangerous than Cesarean section, and it is possible that after the symphysis is severed it may be found necessary to deliver the child by crani- otomy. The indications for symphyseotomy are very limited. If sec- tion of the pelvis is required at all, pubiotomy is to be preferred. There are few surgeons to-day who perform s}Tnphyseotom}'. I shall not do it again. The Technic of the Operation. — An incision is made just above the symphysis, about an inch long, through the skin, fat, and su- perficial fascia. The attachment of the recti muscles to the pubic ^ Routh, " Jour. Obstet. and Gyn. Br. Empire," January, 191 1. 86o OBSTETRIC OPERATIONS. bones is then severed by a transverse cut just sufficient to admit the forefinger behind the symphysis. The forefinger of the left hand is passed behind the symphysis and hooked Fig. 694. — Galbiati's knife for cutting the symphysis. Fig. 695. — Author's knife for cutting the subpubic ligament. Fig. 696. — Subcutaneous section of the symphjsis. under it, while an assistant inserts a metal catheter in the woman's urethra, holding it down and a little to one side, usually the woman's right. The curved or sickle-shaped knife S i MPII } '.SYs O TOM ) '. 86 1 of Galbiali is then seized firmly in the riti.," Bd. x, p. 417. A case is reported of spontaneous rupture of the uterus in a subsequent pregnancy. (Ekstein, " Zentralbl. f. Gyn.," No. 44, 1904.J CESA RE A N SE CTION. 869 Fig. 701. — A, The interrupted sutures; ?], the lower tier of the running catgut stitch. Fig. 702.— A, The upper tier of the running catgut stitch ; B, the running stitch in the peritoneum, which goes up again to where it began, the needle being inserted between the punctures made coming down, and there being but one knot on the peri- toneal surface above the upper angle of the wound. The completed stitch is like a shoe-lace. 8/0 OBSTETRIC OPERATIONS. objection to a repeated. Cesarean section, so that it is justifiable to allow a woman to become pregnant again, even with the certainty of a repeated section.^ The author's experience in Cesarean section amounts to 125 operations, "^dth six deaths, performed for the following indications: fibroid tumors, 3; dermoid cysts impacted in pelvis, 2 ; cancer of the cer^dx, i ; partial atresia of vagina, 2; comual pregnancy, i; impacted shoulder presentation, 2; placenta pr£e\'ia, 2; eclampsia, 2; contracted pelves, no, of which there were 2 kyphotic pelves, 3 obhquely con- tracted and flat, 2 transversely contracted, 5 justominor, and 98 flat rachitic. Among this number it was necessary to perform a Porro operation in 17 cases. In 10 of the opera- tions for contracted peh-is the patient had been in labor many hours. Futile attempts at delivery had been made with forceps, and in two instances by craniotomy. The uterus was already infected and the birth-canal injured by shpping instru- ments or by the exercise of unjustifiable force in efforts at ex- traction. In one of the cases of impacted dermoids the woman had been in labor four daj's. The peh-ic connective tissue and lower uterine segment were extraordinarily edematous and the endometrium was almost black in color. In the two cases of fibroids attached to the lower uterine segment a hysterectomy was necessars' to remove the tumors. In the cases of atresia of the vagina and of cancer of the cervdx it was obviously improper^ to leave the womb behind. It appears that a Porro operation is required in practice about one-sixth as often as the conservative Cesarean section. ^ Extraperitoneal Cesarean Section. — {Laparo-elytrotojny, Su- ■prasymphyseal Cesarean Section.) — Frank^ has revived the old idea of Joerg and Ritgen. later carried out in America by Thomas and Skene, ^^•ith a mortality of 50 per cent., to make a transverse incision over the SATiiphysis, to push up the peritoneal reduplica- tion, and to incise the lower uterine segment below it. The high mortality of Cesarean section in infected cases as compared with the results in beginning labor or the last weeks of pregnancy* ^ " Repeated Cesarean Sections," Haven and Young, " Am. Jour, of Obstet- rics," October. 1903; also, " Annalesde Gyn.," Oct., 1904, p. 577. In 175 operations in Schauta's Clinic there were 18 repeated sections. Neumann, " Arch. f. G}ti.," Bd. Ixxix. 2 Leopold in 100 Cesarean sections performed the Porro operation twenty-nine times; Ueber 100 Sectiones Csesareae, " Arch. f. Gyn.," Bd. Ivi. ^ " Zentralbl. f. G>ti.," Xo. 36, 1906. ^ Routh {loc. cit.) found in Great Britain that Cesarean section in beginning labor or before labor in 469 cases had a mortality of 2.9 per cent., while in 230 cases long in labor, examined frequently and after futile attempts at delivery by the vagina, the mortality was 17.3 per cent. CESAREAN' SECTION. 8/1 has prompted the attempt to devise several methods of extra- peritoneal operation. This may be done by Doderlein's, Latzko's, or Bumm's technique. The woman is put in the Trendelenburg position, a transverse incision is made above the symphysis, the recti are separated, and the right nicked at its insertion trans- versely; the bladder, moderately distended so as to be easily located, is pushed to the left. The connective tissue is separated by blunt dissection and the right side of the lower uterine seg- ment exposed. An incision is made from above downward with scissors, ending at the external os, large enough to permit the ex- traction of the child. The wound is sutured and the abdomen closed, usually without drainage. If drainage is advisable, a gauze drain is pushed into the vagina and the abdominal wound closed over it. If the os is well dilated, it is better to complete the operation before expressing the placenta in the usual way by the vagina. By this plan profuse hemorrhage is avoided.^ The peritoneum is not infrequently torn and infected. The pelvic connective tissue may also be infected with a fatal result. The maternal mortality ranges from 3.08 to 8 per cent. The technical difficulties of the operation are not great, but it is a more difficult operation than the classical Cesarean section; injuries to the bladder are more frequent and the infantile mor- tality is greater. Solms- proposes a technique which more surely avoids opening the peritoneal cavity: An incision parallel with Poupart's liga- ment; ligation of the epigastric artery; displacement of the bladder; incision of the vagina, distended with a metreurynter, and discission of the cervix. Still another plan is to stitch the parietal peritoneum to the perimetrium before opening the womb. The mortality of these various procedures has been about 7 per cent. The alternatives of extraperitoneal Cesarean section in pre- sumably infected cases are the Porro operation or panhyster- ectomy. In the former the cervix is clamped above the line of section with a right-angled clamp and cut across with a cautery knife, the peritoneal flaps having first been prepared; or the cer- vical stump may be fixed in the lower angle of the abdominal wound above and outside the peritoneum which is sewed closely around its base. 1 E. Frank, " Zentralbl. f. Gyn.," No. 6, loii. 2 " Berlin, klin. Wochenschr.," No. 5, 1909. OBSTETRIC OPERATIONS. CHAPTER III. Operations for the Complications and the Pathological G)nse- quences of the Child-bearing- Process. The preparation of the patient and the room has already been described. In hospital practice, dressings, cotton, gauze, nail brushes, gowns, etc., are sterihzed by the fractional method in containers, which are then set upon enamelled stands with a foot pedal by which the}' can be conveniently opened when their con- tents are needed. The gauze pads for abdominal surgery are provided in an invariable number. By using an invariable number the nurse who prepares the package has no excuse for a mistake in this re- spect, and by making this number as small as practicable, time and trouble are saved in the final count of the pads. For plastic operations sea sponges are preferable, and are safe if soaked over night in a i : looo sublimate solution. They are used once only. In private-house operations the patient is given a list of the articles to provide as follows: For Plastic Operations. — One 250-gram can Squibb's ether (un- opened); I pint alcohol; 8 ounces tincture of green soap; i pound absorbent cotton; 5 square yards sterilized gauze; 3 small sea sponges (size of lemon), to be soaked over night in a i : 1000 bi- chlorid solution; i bottle bichlorid tablets; i square yard iodo- form gauze (5 per cent.). For Abdominal Section. — One 250-gram can Squibb's ether (unopened); i quart alcohol; i pint tincture green soap; i pint benzine; i quart i per cent, formalin ; i bottle bichlorid tablets; 4 ounces collodion ; 2 ounces carbolic acid (pure) ; i roll 3-inch Z. O. adhesive plaster; i pound absorbent cotton; 5 square yards ster- ilized gauze. If plastic also, add i square yard iodoform gauze (5 per cent.) and 3 small sea sponges, soaked over night in a i: 1000 bichlorid solution. The operator carries, in addition to his instruments, a bag con- taining the following articles: Nest of 6 basins, steriHzed; 4 brushes, sterilized; 6 pair of gloves, sterilized; douche bag, sterilized; 4- ounce bottle of sterilized glycerin; 4-ounce bottle of sterilized al- cohol; I sterilized razor; i bottle of sterilized normal salt tablets; njy:ESS/NGS AND PACKING OF AUTOCLAVES. S73 Fig. 703. — Protection ot tield of operation by sterile towels. Fig. 704.— A slieet of rubber dam over the buttocks tied with tape to the uprights of the table, with a slit corresponding with the vulvar orifice. 874 OBSTETRIC OPERATIONS. bag of cotton balls; chloroform mask; bottle of chloral chloro- form; small can of ether; 3 ounces of collodion; 3-ounce bottle of pure carboHc acid; i square yard of iodoform gauze (unopened); I bottle of bichlorid tablets; i sterile hypodermoclysis needle. Fig. 705. — Y'Shaped incision through the levator ani muscles and the perineum for vaginismus. Fig. 706. — Insertion of the sutures in the operation for vaginismus. For all vaginal operations the patient is arranged in the dorsal position, with the legs covered by sterilized leggings, supported by Edebohls' leg supports. The field of operation is either sur- rounded by sterile towels (Fig. 703) or protected by rubber dam (Fig. 704). OPERATIONS OiY THE VULVA. 875 Operations on the vulva are for perineovaginal fistula; vaginismus; imperforate or resisting hymen; agglutination of Fig. 707. — Agglutinated labia in infant : I, Before separation; 2, afterward. Fig. 70S. — Steps in operation for elephantiasis. the labia; exsection of the five pairs of A-ulvar nerves; exsection of neoplasms. Perineovaginal fistula, the result of a central tear or perfora- tion of the perineum, is treated by inserting a scissors blade in 8/6 OBSTETRIC OPERATIOXS. the sinus, slitting the perineum into the vagina, denuding the granulations along the sinus tract, and uniting the wound "^-ith sutures. Vaginismus, a possible cause of sterility, if it does not }"ield to gradual dilatation or to the electrocauterization of painful papillae, is treated by incising the perineal body and carrying the incisions up the posterior vaginal sulci, in imitation of the commonest form of laceration in labor. Interrupted sutures unite skin and mucous membranes, but do not include muscle or fascia Imperforate or resisting hymen requires exsection of the h5Tnen bv cutting it with scissors around its base. The narrow wound left is closed with interrupted catgut sutures. Agglutination of the labia is usually seen only in young infants, but may persist to adult hfe. A blunt dissection separates the labia. If a raw surface remains it is covered by suturing, or else a light pack keeps the labia apart tiU the abraded surfaces are healed (Fig. 707). Exsection of the vulvar nerves is required in the worst cases of pruritis resisting aU other treatment. Four incisions are made: two parallel with the ascending ramus of the ischium, two o^"er Poupart's ligament. Through the first the long pudendal nerves are exsected, as large a segment as possible being puUed out. After opening the triangtilar Hgament, the terminal branches of the pudic, the perineal nerve, and the nerve of the dorsiun of the cHtoris are removed. Through the second incision the genitocriural and the iHo-inguinal nerA-es are remoA'ed. Amputation of the labia and clitoris ; removal of the inguinal glands is required for the removal of mahgnant gro\\i;hs. The incisions and closure of the woimds are sho-un in Fig. 708. The same technic, v^-ithout the inguinal section, is required for elephantiasis vulvge. The removal of poh'poid and sessile tiunors of the vulva present no difficulties, as a rule, though control of the hemorrhage in the latter, if large, may be awkward. Operations on the vagina are required for lacerations of the posterior v.-all, including the perineum, possibly the sphincter ani and the rectovaginal septum; rectovaginal fistulae; lacerations and injuries of the anterior waU, including urinary fistulse; for acquired stenosis and atresia of the vagina; vaginal sections for opening the vaults. Lacerations of the posterior wall, like all the lacerations of the genital canal, are best repaired a week after labor, imder an anesthetic, on an operating table, -^ith sufficient assistance and implements, exactly as in a secondan' operation: The labia are seized with Allis' forceps at the level of the lowest carimculs m}T- tiformes. A guide stitch is placed in the posterior vaginal wall directly under the external urinary m.eatus. By pulling one AlUs l''iL,^ 709- — 1 111- Kiinn.-t ()[)craiii ui : ,/, 'I'hc- l;ui(1<- suiurr 'ii iiu > i.j ~i nl the rectocele an, marking with scissors the area to be denuded in the left sulcus. Fig. 710. — -The Emmet operation : c. Denuding the left sulcus ; ulciis for lacerations of the levator ani muscle. Fig. 714- — The Emmet operation : /•, The insertion of the crown stitches by a back handed stroke on the right side which catches the retracted end of the transversus perinei muscle ; /, by forcible traction on the edges of the vulvar wound the needle catches more firmly the retracted ends of the transversus perinei muscles and the stitch is continued in the usual manner from right to left. 88o OBS TE TRIG OPE RA TIONS. >''^ Fig. 715. — The Emmet operation: Perineal sutures joining the transverse perineal muscles and the perineal bodv in the middle line. L _ _ __ . J Fig 716.— Vaginal sutures for the Fig. 717. — Perineal sutures for lacera- repair of a laceration through the perineal lion of the perineal body, body. OPERATIONS ON TJJE ]'AGIXA. 88 I Fig. 718. — Vaginal and perineal sutures for laceration of the perineal body. F~ig. 719. — Vaginal and perineal su- tures for laceration of the posterior vagi- nal sulci and of the perineal body. Fig. 720. — N'aginal and perineal su- tures for an extensive tear involving the whole length of the perineum down to the anus. 56 tig. 721. — Rectal and anal sutures in a complete tear of the perineum. OBS TE TRIG OPERA TIONS. Fig. 722. Fig. 723. Figs. 722, 723.— Operation for complete laceration of perineum: i. Complete tear; 2, stretching the sphincter; 3, incision to expose ends of sphincter; 4, su- tures in rectovaginal septum and sphincter; 5, sphincter and rectal stitches (silk- worm gut) knotted in the rectum, with ends protruding from anus; 6, operation completed. OPERATIONS ON THE VAGINA. 883 forceps and the guide stitch in opposite directions outward and downward, the posterior sulcus is exposed; denudation is required, even in a recent tear, for a part of it is always submucous. The other sulcus is exposed and denuded. Then by holding the guide stitch upward in the middle line and pulling the forceps apart the mucous membrane between the sulci is denuded or freshly torn surfaces covered with granulation-tissue are scraped with the edge of a knife. The ruptured levator ani muscle in the posterior sulci is united with a double tier suture of chromic gut, two half-hitches being taken in the stitch as it turns upward after coming down pig. 724. — Hegar operation. First in- cision in vagina! wall. Fig. 725. — Hegar operation. Trian- gular iiap of vaginal wall dissected and cut off. from the apex of the wound, in its deeper portion to the base. One knot at the apex of the sulcal denudation secures the stitch. The retracted ends of the transversus perinei and bulbocavernosus muscles are brought together by sills:worm sutures, which are in- serted by the technic represented in Fig. 714. Finally, a single stitch at the top of the perineal wound unites the posterior com- missure of the vulva, restoring the fossa navicularis. The perineal stitches are knotted ; they are removed on the twelfth day. If the operator prefers the older method of an inunediate oj^er- ation the sutures may be inserted as represented in Figs. 716- 720. This method, however, does not give as good results in the repair of the genital canal as the intermediate operation at the end of a week. If the injury to the pelvic floor is an old one, with considerable rectocele and atrophy of the central portion of the levator ani 884 OBSTETRIC OPERATIONS. Fig. 726. — Hegar operation. Sutur- ing the upper angle of the wound with two-tier suture of catgut. Fig. 727. — Hegar operation. Silk- worm-gut sutures, shotted, in lower portion of wound. Fig. 728. — Hegar operation. Peri- neal wound closed with silkworm-gut sutures. Fig. 729. — Hegar operation. Inser- tion of last stitch in closure of upper angle of perineal wound. OrE RATIONS ON THE VAGINA. 8S5 muscles, the Hegar technique gives a better result than the Emmet. The Hegar operation can be performed b_\- lixing two forceps at the u])])er margins of the perineal tear and catching the vagi- nal mucous membrane in the middle line with a hemostat about 2 inches within the vulva. The method of denudation and suturing is shown in Figs. 724-729. Lacerations of the sphincter ani can be successfully repaired almost without exception b}' the following technique. Any one i- Fig. 730. -Denudation r)f the anterior vaginal sulcus for submucous laceration of the muscle and fascia of the urogenital tritronum. w^ho must confess to as much as 5 per cent, of failures has not yet learned how^ to perform the operation: The sphincter ani is seized between the forefinger and thumb of both hands and thoroughly stretched. The denudation is made so as to expose the retracted ends of the muscle. Two good- sized tenacula are hooked deeply in the muscle and its ends are brought into plain sight. They are easily recognized, being a 886 OBSTETRIC OPERATIONS. lighter yellowish red, contrasted with the deep red of the tissues around them. Two or at most three stitches of silkworm gut are inserted through the ends of the sphincter and through its sheath, beginning and ending in the rectum. It may be neces- sary to put two or three sutures above the sphincter if the tear involves the rectovaginal septum. All these stitches are knotted in the rectum. The remainder of the perineal or pelvic floor laceration is repaired as usual. The bowels are kept fluid for "V .-?• Fig. 731. — ^Junction of the urogenital trigonum muscle by a two-tier catgut suture. two weeks by Carlsbad water and Sprudel salts. The stitches are removed on the fourteenth day. Lacerations of the anterior vaginal wall occur in the anterior vag- inal sulci, involving the muscle and fascia of the urogenital trigo- num, the only support of the lower third of the anterior vaginal wall. They are repaired by a triangular denudation, for they are almost always submucous, and a two- tier chromic gut suture (Fig. 730, 731), If these in juries are neglected and a cystocele results, two other factors must be taken into account in the damage sustained OrKKATIONS ON THE VAGIXA. 88; by the anterior vaginal wall in labor: the separation of the fascial plates under the vaginal wall and the pull of the uterovesical liga- ment on the bladder. The cystocele may be ];ermanently cured by the following technic: A T-shaped incision through the vaginal wall and dissection of the flaps exposes the blaxlder, which is com- pletely separated from the vagina by Goffe's dissector. The utcro- ,;v'ii'i>*':''"'.>>>V''/vr •■'■•■ '^"•. '♦■'hi ^i^!^ Fig. 732. — Showing the fascia between the cervix uteri and the bladder: e. r. u., recto-uterine excavation; o. i., internal os; e. v. u., vesi co-uterine exca- vation; a, pars anterior retinaculi uteri; p, pars posterior retinaculi uteri; m, pars media retinaculi uteri (Martin). vesical ligament is cut. The bladder is pushed up into the peMs. A stitch of chromic gut No. 2 is passed through the base of the left broad ligament, catching the cardinal ligament; the needle then is inserted in the corpus uteri well above the cervix to pull the uterus into an anterior position and is then passed through the base of the right broad ligament; by pulling the stitch taut the edges of the anterior pelvic fascial plates are seen (Fig. 732). They are caught by curved needles and brought together in the middle line by figure-of-8 sutures of chromic gut, each insertion of the needle being from above downward. The vaginal wall is united by interrupted sutures, but is not relied OBS TE TRIG OPERA TIONS. upon for support. A formal cystocele operation may be per- formed two weeks after child-birth (Figs. 733-738). Fistulae between the genital and urinary canals are usually the result of pressure-necroses following labor. They are becoming very rare in all civihzed countries in which women receive proper attention in parturition. It is a question whether more are not encountered to-day from injuries in gynecologic operations, es- pecially in hysterectomy for cancer of the cervix. A neglected pessary sometimes ulcerates through the vesicovaginal septum. Other causes are fractured pelvis, injury of the vagina in attempts at criminal abortion, ulcerations through the vaginal wall of a vesi- Fig. 733. — Operation for cystocele. Incision in anterior vaginal wall. cal calculus or of a foreign body inserted in the bladder, injury to the bladder-wall in anterior vaginal fixation of the uterus, anterior colporrhaphy, symphysiotomy, pubiotomy, or myomectomy, and in obstetrical operations, such as the use of blunt hooks, attempts at version, clumsy insertion of the forceps, forcible extraction of the head past a prolapsed cystocele, and craniotomy. OPERATIONS ON TJIE VAGINA. 889 The fistuku following i^ressurc-nccroses in a jjrolonged labor are easily avoidable by the proper and timely use of the forceps or by the other obstetric operations that may be indicated in an insuperably obstructed labor. In more than 20,000 women delivered in the hospital ser\-iccs with which the author is con- nected there has not been a single urinary fistula following labor, Fig. 734. — Separating bladder from vagina with Goffe's dissector. but a few are referred to his clinics from year to year, delivered elsewhere. Urinary fistulas may be classified as follows: ^Tsicovaginal fistulas; vesicovestibular fistula?, uterovesicovaginal fistulse — (a) superficial, through the anterior lip of the cervix, which forms the upper wall of the sinus, and (/?) deep, through the uterine w-all, the anterior lip of the cervix having sloughed ofi"; utcro\-esical fis- tulas; urethral fistulas; enterovesical fistula?; colovesical fistula-; ureterovaginal and uretero-uterine fistulas. The opening into the bladder varies in size and shape from a 890 OBSTE TRIG OPERA TIOXS. pin-point orifice to a defect of the whole base of the bladder, and from a round hole, regular, as if pimched out \Nith an instrument, to a jagged opening usually running across the vagina, with off- shoots running up the anterior sulci or in the median Hne. The vesical mucous membrane may prolapse through a large opening. Fig. 735. — Cutting the uterovesical ligament. Irritated by discharges and attrition, it becomes h}'pertrophied and inflamed. The urethra is often wanting in its upper part and its canal may be obhterated. Uterovesical fistulae are usually situated in the anterior lip of the cervix, near the internal os. They are usually on the left side of the median line and are small in caHber. Enterovesical fistulae are exceedingly rare. Fritsch,'^ in his enormous experience, has seen but a single case. iFritsch operated on 2O0 urinary fistulae in ten years (" Handbuch der Gyn.," vol. ii, p. 84). OPERATIONS ON THE VAGINA. 891 Colovesical fistuUe are more common. They are usually the result of a pelvic abscess which opens both into the bowel and into the bladder. Ureteral listukc more fre(juently follow gynecologic operations than labor. They are naturally small in size and are usually situated in the vaginal \'ault, though they may empty into the uterus. Diagnosis. — It is usually easy to recognize a vesicovaginal fistula. There is incontinence of urine, and the orifice in the Fig. 736. — Figure-of-eight sutures to bring together the lateral fascial plates under the anterior varjinal wall. vesicovaginal septum is visible by the aid of a Sims speculum. If the fistula is small, a uterine sound introduced in the bladder may be made to emerge from the orifice in the vagina, or the sound being held in the bladder, a surgeon's probe may be in- serted into every suspicious-looking depresion in the anterior vaginal wall until the communication is discovered and the two instruments grate on one another. Colored fluid (a weak per- manganate solution, methylcne-blue, or sterilized milk) may be in- 892 OBSTETRIC OPERATIONS. jected in the bladder and will be seen oozing out of a small open- ing on the anterior vaginal wall. A cervical fistula may be detected on inspection: separating the lips of the cervix, the tip of an intravesical sound is projected into the cervical canal; or, injecting the bladder with colored fluid, it flows out of the cervix, which is exposed by a bivalve vaginal speculum. A ureteral fistula may be recognized by the fact that part of the urine is voided naturally, while part constantly dribbles away; Fig. 737. — Lateral fascial plates united and redundant vaginal wall excised. by sounding with a metal ureteral catheter every little indenta- tion in the vaginal vauk or cervical canal until the ureter is cathe- terized and the urine flows from the lower end of the catheter drop by drop or by injecting methylene-blue hypodermatically, draining the bladder with a rubber tube, and packing the vagina tightly with gauze. If there is a ureteral fistula the deepest portion of the packing will be most intensely stained. An enterove.sical or a colovesical fistula is recognized by a 0PERA7I0XS ON THE VAGINA. 893 microscopic examination of the urine, which shows food par- ticles and feces. "A fecal odor to the urine is not always pres- ent and does not always denote a communication with the bowel" (Fritsch). An ingenious method of diagnosticating these tistulae was demonstrated by Noble after Senn had discovered the hy- drogen gas test for fecal hstulie. A catheter was inserted in the urethra, the bowel was inflated with hydrogen, and the gas was ignited as it escaped from the end of the catheter. Fig. 738. — Vaginal walls united with interrupted sutures. Treatment. — There is always a chance of a vesicovaginal fistula healing spontaneously. There are three methods by which a spontaneous cure is effected: First, by granulation tissue filling the opening and e^•entually closing it. This result is fa^•ored by irrigation of the vagina to keep it clean, by draining the bladder after the fifth day postpartum with a catheter or rubber tube, and by touching the edges of tlie fistula with a little nitric acid to promote exuberant granulation, although the application of the caustic had better be omitted if the case is apparently pursuing a favorable 894 OBSTETRIC OPERATIONS. Fig. 739. — Fistulse of the genital organs: a, Vesico-uterine fistula ; b, vesico- cervical fistula ; c, vesicovaginal fistula ; d, urethrovaginal fistula ; e, rectovaginal fistula; f, perineovaginal fistula (Beigel). Fig. 740. — Vesicovaginal fistula. OPERATIONS ON THE VAGINA. 895 course. Second, by an inflammatory infiltration and swelling of the vaginal walls, which ai)ijroximate the edges of the fistula and keep them close together until union is secured. Third, by cicatrization, which in the course of three months may close an opening as large as a silver dollar. The operative treatment should be jjostponcd until at least a month after labor, to allow for the chance of sj)ontaneous closure, to obtain firmer tissue for the plastic surgery, and to secure contraction of the fistula. The vagina, bladder, and vulva should be ren- dered as healthy as possible by sitz-baths and irriga- tions with boracic acid and weak permanganate solutions. If the fistula is caused by a foreign body, such as an embedded pessary or a stone, sufficient time must be allowed after its removal to secure a complete healing over of ulcerated surfaces and a cessation of purulent discharge. • General anesthesia is usually required. Local anesthesia is not to be recommended. The dorsal position, with raised buttocks and limbs fixed in leg-holders and stirrups, is most suit- able for the majority of cases. In fistulae deep within the genital canal, Sims's position or the knee-chest posture may be necessary. For the latter a specially constructed wedge-shaped cushion is the most con- venient and safest support. Sims's specula with blades of varying length and breadth and lateral ^•ag- inal retractors ; scissors, curved on the flat, sharp pointed, with thin blades; knives set at an angle on the shaft, as well as an ordinary narrow-bladed scalpel; bullet-forceps; two Ulrich tenacula and single tenacula; a rat-toothed tissue forceps; a needle-holder and as- sorted needles, most of which should be full curved, round -pointed, and delicate, and some of which should have the fish-hook curve, are the instruments rec[uired. The suture material should be silkworm gut, formalin catgut, and fine silk. The last is recommended most highly b}' Fritsch, whose experience with these operations is greater than that of any other surgeon. The field of operation is exposed by pulling down the cervix with a strong silk ligature, transfixing its hps at a sufficient height above the external os to prevent the ligature cutting out (i centimeter), by vaginal retractors or by fixing the labia with bullet-forceps and pulling them apart. It is occasionally necessary to dilate the vaginal canal narrowed by cicatrization, and to cut, stretch, or tear cicatricial bands obstructing access to the fistula. Fig. 741.— Uliich's ten- aculum. 896 OBSTETRIC OPERATIONS. The shape and extent of the denudation are governed by the situa- tion and extent of the fistula. The length of the wound should, if possible, run across the vagina, as the vaginal walls are more easily approximated from above downward than transversely. For small fistulee a long linear incision having the fistula as its midpoint, with a broad denuded surface secured by a flap-splitting dissection, is the best. For larger listulce the denudation repre- sented in Figs. 743 aiid 744 is preferable. The breadth of the denudation should never be less than i to 2 centimeters. If one edge of the fistula is adherent to the pubis or so fixed by cicatrices that it is immobile, a thick flap may be prepared from the vaginal Fig. 742. — Denudation for a small Fig. 743. — Denudation for fistula wilh ten- fistula (Fritsch). sion on the edges of the wound (Fritsch). \ Fig. 744. — Insertion of the suture after the denudation : a, a. Suture just above the vesical mucosa; b, b, suture emerging in the vagina (Fritsch). wall with a broad base, with the least torsion of the pedicle possible, and larger in all its dimensions than the denuded surface it is de- signed to cover. The flap is fixed by buried sutures of fine catgut, the edges of the mucous membrane being united by superficial stitches of silk or silkworm gut. A flap may be prepared by a semicircular incision with its base alonside the fistula; it is turned on its base so that the vaginal mucous surface projects into the bladder; after the edges are fixed by fine catgut in the denuded edges of the fistula, the raw surface is covered by the approxima- tion of the vaginal mucous membrane surrounding it (Martin). Ferguson proposes a circular incision around the fistula 3 to 6 mm. from its margin, down to the vesical wall. The vagi- nal flap is dissected loose, turned inward, and its free edges united OPERATIONS ON THE VAGINA. 897 with fine formalin gut, thus closing the fistula. The raw surfaces left in the vagina are approximated by interrupted sutures. It may be impracticable to close a large, irregularly shaped fistula at one sitting. The most easily approximated edges are united at one oj:)eration and the remainder of the opening is closed subsequently. The anterior lip of the cervix may be used as a plug to cover in a considerable defect in the bladder wall. The author has thus closed a fistula admitting four fingers, due to the ulceration of a neglected pessary through the vesicovaginal septum. The lateral extremities of the fistula were closed in the ordinary way and the denuded vaginal portion of the cervix was fastened in the center of the wound, where a defect existed too extensive to be covered by vaginal flaps. In closing fistulae extending a consid- erable distance transversely, care must be exercised to locate the ureteral orifices, which otherwise might be buried in the denuded surface or occluded by a suture. In suturing a denuded area around or a transplanted flap over a vesical fistula, the needle must not penetrate the vesical mucous membrane. If it does, an in- travesical hemorrhage will probably re- sult in a failure of the operation or the suture tract may develop into another fistula. Acquired atresia of the vagina is a method of spontaneous cure not infrequently seen. If the patient has passed the menopause, she remains comfortable ; but if she men- struates into the bladder, there may be severe distress at the periods/ and if the lower portion only of the vaginal canal is closed, a sac exists beneath the level of the fistula in which blood, pus, and de- composed urine collect. It is occasionally impossible to close a serious defect in the posterior wall and base of the bladder. In such cases a colpodeisis is justifiable, if the precaution is taken to close the canal up to the level of the fistula, leaving no vaginal sac below for the retention of decomposed urine and menstrual dis- charge. Fritsch has closed a fistula by denuding the anterior surface of the posterior lip of the cervix in a case of defect of the ante- rior lip and implanting the posterior lip in the vesical opening. Fig. 745. — Apposition wlien the denudation is properly made and the suture correctly inserted (Fritsch). 1 In a case of vesicovaginal fistula, acquired atresia of the vagina, a retioflexed and fixed uterus with salpingo-ociphoritis, menorrhagia and severe dysmenon-hea, due to the passage of clots from the urethra, the author has been obliged to perform hysterectomy. 57 898 OBSTETRIC OPERATIONS. The woman menstruated into the bladder, but nevertheless re- mained comfortable for years. To close the vagina (colpocleisis), a circular denudation is made around the whole canal 2 centimeters broad, at a sufficient height to preclude the formation of a sac below the level of the fistula; a row of interrupted sutures across the vagina, inserted from before backward, closes the canal. In difficult cases of extensive fistulag deep within the vagina, and of fixation of the bladder by cicatricial adhesions, the following procedures have been advocated and adopted : Incision into the anterior bladder-wall by suprapubic cystot- omy in the Trendelenburg posture and closure of the fistula from Fig. 746. — Flap-formation as suggested by Ferguson. Fig. 747. — Flap turned in and vesical opening closed. above, silk ligatures, if they are used, being left long and led out of the urethra, whence they are removed by traction after they have cut through the tissue; or buried catgut sutures may be employed (Trendelenburg). A transverse incision over the pubis, freeing the bladder, and closure of the fistula from the vagina (Fritsch). Separation of the vagina from the bladder around the fistula, closure of the opening in the bladder, and a separate closure of the vaginal wound, as in anterior colporrhaphy (^^'internitz, Mackenrodt). Opening Douglas's pouch, retroverting the uterus into the OPERATIONS ON THE VAGINA. 899 vagina, using its posterior surface (which becomes anterior in the complete retroversion) as a plug to fill in a large defect in the vesicovaginal septum, and making an artificial os in the fundus to allow the escape of menstrual discharge (Freund). If the urethra is absent or partly destroyed, its restoration is alwa}'s doubtful. The most hopeful plan is to prepare a flap of mucous membrane as thick as possible from one side, to turn it inward so as to bring the mucous surface within the newly made canal, and to fasten it in a denuded area on the opposite side. The new urethra should be established before the vesical fistula is closed. Fortunately, continence may be established without the pres- ence of a urethra by leaving a narrow orifice at the neck of the Fig. 748. — The vesical opening closed and sutures inserted to unite the vaginal walls. bladder. This was accomplished in one of the author's cases after several futile attempts to construct a new urethra, which was entirely lacking, directly back of the external meatus. If there is such a serious defect of urethra and base of bladder that no plastic operation succeeds in restoring even partial con- tinence, colpocleisis and a rectovaginal fistula may make the patient's condition endurable. But if there is a cystitis at the time of operation, the result may be fatal from an exacerbation of the inflammation and infection of the ureters and kidneys. Indeed, there is always danger after such an operation of pyelo- 900 OBSTETRIC OPERATIONS. nephritis, though occasionally, as in one of Fritsch's cases, the patient remained comfortable and well for years. The rectovaginal fistula, admitting a forefinger, should be made by a transverse incision just above the sphincter ani, the vaginal and rectal mucous membranes being united by interrupted sutures of catgut. The vaginal orifice is then closed. A double rubber drainage-tube is inserted through the fistula, and during the patient's convalescence the vesicovaginal pouch is frequently irrigated with a boracic acid solution. The most important question to decide in the a]ter -treatment of a vesicovaginal fistula operation is whether to resort to drainage of the bladder or to catheterization. After trying both plans, I prefer the mushroom retention catheter for four days. After the operation the bladder is injected with water to test its imperme- ability. The vagina is lightly packed with iodoform gauze. The stitches of fine Pagenstecher thread are removed in a week. If a ureter has been included in one of the stitches, there are the symptoms of deficient urinary secretion, rapid pulse, pain in the back, a tendency to somnolence, and sometimes, though rarely, high fever. There are two courses open to the operator: one is to remove the stitches and to do the operation over again; the other is to trust to nature to overcome the difficulty, which is often done by the stitch cutting through, by the urine under pres- sure forcing its way through the loop of the ligature, or by the estab- lishment of a ureterovaginal fistula. Occasionally the kidney on the affected side atrophies and the remaining kidney performs the work of two, as after a nephrectom.y. If there is a persistence of incontinence after the operation, the flow of urine may come from a suture track, from a failure of union at some part of the wound, or from a second fistula not detected at the time of the operation. The last two conditions require subsequent operations. A sm.all suture-track fistula often closes spontaneously, and some time should be allowed for this result before subjecting the patient to a second operation, which might be unnecessary. Intravesical hemorrhage will not occur after an operation for vesicovaginal fistula if the sutures are properly placed. If it does, it is an awkward compHcation. The bladder should be washed out with boracic acid solution every two hours to prevent the formation of a large clot. If a clot does form in the bladder, causing tenesmus, the injection of pepsin solution has been rec- ommended to soften it. The Treatment of Ureteral Fistulae and of Surgical Injuries of the Ureters. — There are three kinds of surgical treatment for ureteral fistulse: nephrectomy, a plastic operation in the vagina {colpo- OPERATIONS ON THE VAGINA. 9OI uretero-cystostomy or ureteral anastomosis) and an abdominal sec- tion, followed by the junction of the ureter (cclio-urelero-iireteros- tomy) or its implantation in the bladder (celio-uretero-cysiosiomy). A nephrectomy is often the easiest way to remove the dis- agreeable symptoms of a ureteral fistula, but it is not the ideal operation. There must always be some doubt as to the ade- quacy of the remaining kidney, and the natural impulse is to avoid the removal of such an important organ unless it is itself diseased. It must be admitted, however, that the operation has been repeatedly performed with success. Several of the women ^ have subsequently been delivered at term without the slightest disturbance of health. As in nephrectomies for any indication, the most scrupulously careful examination should be made of the secretion from the remaining kidney by catheterizing the ureter or by vesical segregators (Harris's, Cathelin's, or Luys's). If the kidney corresponding to the ureteral fistula shows evidence of pyelonephritis or hydronephrosis, there is additional justification for its removal, but it should be remembered that both of these conditions have disappeared after closure of the fistula by vaginal or abdominal operations. Nephrectomy should, in general, be limited to those cases in which the closure of the iistula has proved impracticable by both the vaginal and abdominal routes or in which there is marked hydronephrosis or pyelitis. The operation may be performed by a lumbar incision or by the transperitoneal method. The latter is often easier for the surgeon, but may not be so safe for the patient. There is no necessity for the exsection of the ureter, and there need be no fear of the regurgitation of urine from its lower segment. If the transperitoneal operation is selected, the incision should be made laterally through the abdominal wall directly over the kidney. The posterior parietal layer of the peritoneum is opened, the kidney delivered, and its pedicle (blood-vessels and ureter) is tied with silk or catgut by passing a pedicle needle through its middle, tying in both directions, and then back again around the whole stump. This step in the operation is usually easier in the trans- peritoneal than in the lumbar operation. Both layers of peri- toneum are closed. In the lumbar operation the kidney is delivered and the ves- sels, with the ureter, ligated. The lumbar incision should always be preferred if there is pyelonephritis or perinephritis, or if the most perfect aseptic technic is impracticable. Many operators accustomed to neph- rorrhaphy by this method prefer it uniformly. 1 Fritsch reports three cases {/oc c-/7.). 902 . OBSTETRIC OPERATIONS. The Vaginal Operations for Ureteral Fistula. — The first requi- site for a successful plastic operation by the vagina is to find the upper end of the ureter and its orifice, which is not always easy to do. If there is not too much scar-tissue the ureter may be dissected out, implanted into an incision made into the bladder, and fastened in place by several interrupted sutures of fine catgut. The vaginal wound is closed over the end of the ureter and the opening in the bladder into which it has been implanted (Parvin, Mc Arthur). It has sometimes been possible to sew the mucous membrane of the bladder to the mucous membrane of the ureter and so to fasten the latter in place. The vaginal mucous mem- brane, dissected back on each side by a flap-splitting dissection, is united over the ureter and the newly made opening into the bladder, Scheie's operation has given, on the whole, the best results: a vesicovaginal fistula is made close by the ureteral fistula, the mucous membrane of the bladder and that of the vagina being united by interrupted sutures of catgut; an oval denudation is made i centimeter wide around both the ureteral and the vesical fistula, leaving a strip of undenuded membrane 0.5 centimeter wide immediately surrounding both fistulse. The denuded sur- faces are united by interrupted sutures, thus directing the stream of urine from the ureter into the bladder. BandVs operation is only practicable if both ends of the ureter are discoverable and are normally patent. A ureteral catheter is passed into both the lower and the upper segments of the ureter, emerging from the urethra. A denudation is made and united as in Schede's operation, but without making a vesicovaginal fis- tula. If the catheter is fenestrated the whole bladder is drained by it, or the urethra may be drained by a rubber tube through which the ureteral catheter passes. Mackenrodfs operation is very ingenious and has been suc- cessful in the few cases in which it was tried. A vesicovaginal fistula is made near the ureteral fistula. A semicircular thick fl.ap of vaginal mucosa is dissected off, so that it carries the ureteral opening in its center, has its attached base next to the vesico- vaginal fistula, and its free edge away from it. By turning this flap over a half circle on its base it closes the vesicovaginal fistula like a lid; it is sewed in place by catgut sutures, with the vaginal mucous membrane directed into the bladder, and so turning the ureteral fistula into the bladder. The raw surfaxes left by the removal of the flap and over the vesicovaginal fistula are united with interrupted sutures or are allowed to granulate. Dudley^ s operation, as Reynolds^ says, is a crude procedure, 1 " Boston Med. and Surg. Jour.," 1901, p. 84. OPERATIONS ON THE VAGINA. 9O3 but has succeeded when other plans have failed. A sharp-pointed artery or other similar forceps is passed into the urethra; a vesi- covaginal opening is made; one blade of the forceps, which is opened for the purpose, is pushed out of the incision in the bladder; the renal end of the ureter is threaded on it; the handles of the instrument are closed and tied, thus clamping the end of the ureter to the bladder wall. The forcej^s is lightly pulled upon after eight or ten days. If it does not come away it is opened and extracted. The Abdominal Operation for Ureteral Fistula or Injury. — If the ureter is injured during an operation, it may be repaired in several ways: If the incision is linear or fails to sever the ureter completely^ the wound may be repaired by tine catgut sutures, mattress or interrupted, with considerable certainty of success. If the ureter is completely severed, is fenestrated or badly crushed, as by clamp forceps, it may be rejoined by an end-to-end anas- tomosis (Tauffer, Bovee), by an end-to-end (Pozzi), or a lateral invagination (Van Hook's uretero-ureterostomy), or by a lateral anastomosis. In the first, a section of a ureteral catheter is passed into both segments of the ureter, with a silk ligature tied around its middle to recover it by if it should sKp down the lower portion of the canal. Interrupted sutures of fine silk or formalin catgut are passed through walls of the two ends of the ureter; before the knots are tied the catheter is withdrawn. The author has had one successful end-to-end anastomosis. Van Hook's lateral invagination is the most reliable opera- tion. The upper end of the lower segment of the ureter is ligated ; a linear incision is made through its wall below the ligature twice as long as the diameter of the ureter; the upper segment is im- planted into this incision and is fastened by fine sutures at both ends of the wound; the edges of the incision are then carefully sewed to the ureteral wall passing between them, so that the open- ing is securely closed. If a junction of the two ends of a severed ureter is impossible, as in a case of old injury, extensive destruction of tissue or the removal of a considerable portion of the ureter in the wall of a cyst or a fibroid tumor, implantation of the upper segment into the bladder (celio-uretero-cystostomy) is indicated. This may be done by a transperitoneal or an extraperitoneal operation. In the former the peritoneum over the ureter is incised, usually in the neighborhood of the bifurcation of the iliac arteries; the ureter is dissected free, care being taken not to isolate it too extensivelv, on account of danger to its nutrition. An incision is made into anv portion of the bladder-wall which the ureter reaches without ten- sion; the end of the ureter is inserted into the opening so that it projects somewhat into the bladder; the edges of the wound in the 904 OBSTETRIC OPERATIONS. latter are carefully sewed to the wall of the ureter by interrupted or mattress sutures, and its angles are closed by separate sutures. Penrose recommends splitting the end of the ureter, putting a mattress suture in each lip, and passing each end of the mattress sutures, rethreaded on a fine needle, through the bladder-wall, tying them on the peritoneal surface of the bladder. This plan avoids occlusion of the ureteral orifice and prevents the ureter slip- ping out of the bladder. There are disadvantages in the transperitoneal operation. Failure may mean fatal peritonitis in spite of drainage; and the band of isolated ureter tra\'ersing the pehic and lower abdominal cavities may cause intestinal complications. The extraperitoneal operation is the ideal one if it is prac- ticable. The implantation of the ureter in the bladder by a vagi- nal operation has been described (p. 902). In an abdominal operation it may be possible to reach the upper segment by in- cising the anterior layer of the broad ligament and the vesico- uterine pouch, and to implant the ureter under the peritoneal covering of the latter. Witzel proposes to free the ureter as in the transperitoneal operation, carrying its end by forceps around the brim of the pelvis under the peritoneum, and bringing it forward above the anterior parietal peritoneum. Both incisions in the peritoneum are closed and the operation is concluded extraperitoneally by implantation of the ureter in the bladder, the ureter being cut obliquely, so that its end is a point, the bladder being incised obliquely, so that the implanted ureter runs some distance in its wall. It is necessary to fasten the bladder wall to the pelvic con- nective tissue by catgut sutures to avoid tension on the implanted ureter. Mackenrodt modifies this procedure by making his ab- dominal incision at the outer edge of a rectus muscle; separating the peritoneum to the bifurcation of the iliac artery, bringing the end of the ureter forward above the peritoneum, pimcturing the bladder from within by a trocar, and drawing the end of the ureter into it. If the ureter is so much shortened that its upper portion cannot be made to reach the bladder without too much tension, the following ingenious plans have been proposed to sphce it: The two ends of the ureter are brought out on the abdominal skin and fastened there; after the wound has healed, a tube of skin is made between the two ureteral orifices by par- allel incisions, and uniting the free edges of the skin; the tube is depressed and covered over by uniting the outer edges of the parallel incisions (Rydygier) . A diverticulum is constructed from the anterior bladder wall, into which the upper end of the ureter is implanted (Van Hook, Boari, Casati). The ureter is sphced by a hollow, decalcified turkey's-v^ng bone sewed in the ureter OPERATIONS ON 77/ E VAG/NA. 905 and the bladder (Van Hook). The ureter is spliced by a seg- ment of small intestine, separated from the bowel which is joined, by an end-to-end anastomosis; the segment of gut is left attached to its mesentery and is closed by sutures at both ends. The two ends of the ureter are implanted in the segment of bowel (Bacon). The appendix is used to sj)lice the ureter (Giannettasio). The ureter is implanted in the Fallopian tube (D'Urso and Fabii). These propositions have been theoretical or else the result of experiments on dogs.^ As in all intra-abdominal operations on the ureters and blad- der, the Trendelenburg posture is essential, and gauze drainage afterward is necessary in case the closure of the bladder or junc- tion of the ureters proves imperfect. Bovee ^ collected iir uretero-cystostomies to 1903. Operations for Acquired Stenosis or Atresia of the Vagina. — The treatment of stenosis of the vagina has for its object the dilata- tion of the canal. This is accomplished in various ways. Gradual dilatation with bougies may suffice; but the treatment must be con- tinued persistently a long time and may not lead to a perm.anent cure. Fibromyxomatous bands and membranes stretched across the vagina should be excised. Usually there is no occasion for hemostasis, but it is advisable to draw the mucous membrane over the wounded surfaces by interrupted sutures of catgut. Cicatricial bands under the mucous membrane should be incised as deeply as possible wherever they are felt to be most tense. They may be torn by the finger even more deeply than they can safely be cut. The mucous membrane alone is united over the wounds with interrupted sutures introduced in a direction parallel with the cut, so as to further enlarge and not to contract the vagina. A vaginal plug (Sims') of glass, hard rubber, or metal should then be inserted, and should be retained continuously for a month, being removed daily to be cleansed and to allow irrigation of the vagina. The plug should be worn for a few hours daily during the year succeeding the operation, being re- tained by a napkin or by special apparatus which the author has emj)loyed with satisfaction (Fig. 749). If the stenosis exceeds the whole length of the vagina and is extreme in degree, the success of any treatment is problematical. If the patient comes under the physician's observation when she is pregnant, a Porro Cesarean section is required at term. After the removal of the uterus the stenosis of the vagina requires no treatment. ' Henry Morris, "Surgical Diseases of the Kidney and Ureter," vol. ii, p. 60S, and Nicholson, "Treatment of Severed Ureters,'' " Amer. Jour. Med. Sci.,"' April, 1902. ''■ "Am. Gyn.," July, 1903. 9o6 OBSTETRIC OPERATIONS. The treatment of atresia has for its object the restoration of the caUber of the vagina and the restitution of an external outlet for the discharge of the genital tract. The same principles ob- tain in the treatment of congenital and acquired atresia, but the latter is often more difficult to deal with. The condition of the tubes should receive the first attention. If there is hematosalpinx, the tubal sac should be removed by an abdominal section before the vagina is opened and the blood in the' uterus and vagina is evacuated. The numerous deaths after operations for atresia have Fig. 749. — Silver plug (Sims' ) supported by abdominal belt and rubber bands. been due to tubal infection or rupture and a consequent peri- tonitis. To open the occluded vaginal canal it may be sufficient to make a crucial incision in a membranous septum or to excise it at its base. The retained blood, as thick sometimes as tar, flows out slowly and should be thoroughly washed away by a boracic acid solution. The w^ounded surface encircling the vagina, if the membrane is excised, is covered with mucous membrane by inserting interrupted sutures from above downward, uniting the mucous membranes of the healthy portions of the vagina. If the atresia involves a considerable length of the vagina, a blunt dissection is required between the bladder and rectum, with a sound in one and the forefinger of the left hand or a bougie in the other, the tissues being separated by the blunt end of a closed scissors, the occasional stroke of a knife, and the opera- tor's fingers. When the accumulated fluid is reached and evacu- OPI<: RATIONS ON THE VAGINA. 907 ated, the opening which has been secured by a blunt dissec- tion should be enlarged as much as possible by graduated bougies, the fingers, or jjowerful branched dilators, the force being ap- I)lied laterally so as to avoid injury to the bladder or rectum. The ])roblem is how to prevent a reclosure of the canal. This has been accomplished in several ways : The ])rolonged retention of a j)lug with the idea that the caliber of the vagina shall be maintained while a proliferation and extension of the vulvar e])ithehum finally covers the raw surfaces with a new mucous membrane ; the implantation of flaps gained by cutting loose the labia minora except at their bases, sphtting them longitudinally, join- ing them together, suturing their edges, and inverting them into the vagina, where they are sewed fast (Kustner); implanting a tube of vaginal mucous membrane ob- tained from a prolapsed vagina in another patient, as has been suc- cessfully done by Mackenrodt and by the author;^ implanting a seg- ment of intestine secured by re- section of the bowel in the place of the vagina in cases of absent vagina and uterus (performed eight times, with questionable propriety merely to form a coitional vagina at the risk of the patient's life) ,2 making a flap anteriorly of the tissues occluding the vagina and a posterior flap of the skin on the labium ma jus; then by a blunt dissection between the bladder and rectum forming a cavity into which the flaps are sutured (Fleming). In all of these methods some plan must be adopted to keep the vagina distended and the transplanted flaps or implanted membrane in close apposition with the raw surfaces. A tam- 1 In the author's case a woman with total prolapse was operated upon first; two broad strips of mucous membrane were excised, sewed together with catgut around a cylindrical speculum, and placed in a warm normal salt solution. A rapid blunt dissection was then performed on the patient with atresia to a depth of 3 inches. The vaginal mucous membrane on the speculum was implanted, the latter with- drawn after being filled with iodoform gauze, which remained in the vagina undis- turbed for two weeks. ^ Stoeckel, " Zentralbl. f. Gyn.," No. i, 191 2. Fig. 750. — Fleming's operation for making an artificial vagina : I, An- terior flap; 2, posterior flap. These flaps are turnecl into the canal made by a blunt dissection and are sutured in place. 9o8 OBSTETRIC OPERATIOXS. pon left undistiirbed for a number of da}-s and a vaginal plug have been emplo3'ed for this purpose, but there are objec- tions to both plans. Xoble's suggestion to insert a pouch of thin rubber tissue and to distend it -^ith gauze packing is a good one. \Mien the newly made ^"agina is clothed "^ith mucous membrane by any one of the methods just described, systematic attempts to retain a sufficient cahber in the canal should be begun about three weeks after the operation, either by regular daily dila- tation T^-ith a bougie or by the use of the vaginal plug, worn daily for at least an hour. Occasionally the most satisfactory operation for atresia is hvsterectomv. In a case under the author's care a Fig. 751. — Repair of a stellate tear of the cervix. Le Fort operation on the vagina had been performed by another operator three years before; on examination a row of silver sutures was found extending across the vagina, where they had been for three vears. There was complete atresia, with extremely firm cica- tricial contraction, a pyelythrometra, which had ruptured into the bladder, an extensive vesicovaginal fistula above the site of atresia, double pyosalpinx, and a general septic intoxication. The patient was cured by a hysterectomy and the removal of the uterine ap- pendages. With no further discharge into the upper vagina the vesicovaginal fistula closed spontaneously. The atresia was not corrected, as the only purpose of such treatment would have been to establish a coitional vagina, which is not always prac- ticable in the absence of the uterus. Even were permanent sue- OPERATIONS OX THE VAGINA. 909 cess assured, the propriety of medical treatment to that end is questionable. Siieguireff 1 has thrice successfully performed a curious operation fur making a coitional vay shortening the infundibulopelvic liga- ment : I. Suture inserted ; 2, suture tightened. By making three insertions of the needle there is no loophole left between the edges of the broad ligament. the ligament is shortened by the distance between the first and third insertion of the needle. 928 OBSTETRIC OPERATIONS. If the operation on the tube is to restore its patency on ac- count of closure of the abdominal ostium, partial salpingectomy, salpingostomy, or forcible dilatation of the abdominal ostium is required (Fig. 779). Salpingostomy consists in buttonholing the tube on its upper aspect near the abdominal extremity and uniting its mucous lining to its peritoneal investment by a few interrupted sutures. To dilate the abdominal ostium the ag- glutinated orifice is opened, a hemostat is passed into it and opened. Exsection of Abdominal and Pelvic Tumors by Abdominal Section. — The removal of ovarian cysts; the enucleation of par- ovarian cysts; myomectomy for fibromyomata of the uterus and of the broad ligament are not infrequently indicated in the child- bearing woman. Oophorectomy for pseud omucin, serous cystadenomatous, simple retention and serous, lutein, and dermoid cysts, teratomata, fibro- mata, and the malignant tumors is accomplished by transfixion and hgation of the mesovarium or of the broad ligament, as already described in the technic of salpingo-oophorectomy. The chain Hgature is required for a broad pedicle. If the operation is per- formed after delivery when the involution of the uterus is far ad- vanced or accomplished, the uterus should be suspended to prevent the adherent retroversion which is a common sequel of the removal of ovarian tumors. If the cyst is twisted on its pedicle, the pedicle should be untwisted and the ligatures placed in the broad ligaments beyond the thrombus, which is usually seen in the ovarian vein. The cyst should not be punctured if its contents might contami- nate the peritoneum or cause implantation metastases. If the operation is undertaken in pregnancy the following rules should be observed: In early pregnancy not to disturb the pregnant uterus; in operations near term to perform a coincident Cesarean section and to remember the unusually large proportion of dermoids found among ovarian cysts in pregnant women (one-quarter), and therefore not to puncture the cyst if there is any doubt about its contents. The enucleation of broad ligament tumors is accomplished by incising the anterior face of the broad Hgament, shelling out the tumor from its bed, removing redundant portions of the broad ligament capsule, obliterating as far as possible the raw bed of the tumor by tier sutures draining the cavity by vaginal puncture, packing the cavity \vith gauze, and uniting the peritoneum above it or marsupializing the sac and fastening its upper extremity to the abdominal wound and draining it from above wdth gauze. Myomectomy for uterine fibromata requires ligation of the pedicle PKEPA NATION FOR ABDOMINAL OPERATIONS. 929 if it is small enough (no larger than one's thumb), exsecting it by a we(lge-shai)e<^l incision if it is too large to ligate, or splitting its capsule and shelling it out, the bed of the tumor being comj)letely obliterated by tier sutures. If myomectomy is re(|uired near term or during labor, a Cesarean section should be part of the operation. The o])erator must remember that it is usually safer to remove the uterus after it is evacuated, but in a case peculiarly suitable for myomectomy alone, it is perfectly possible to leave the uterus intact. Inguinal section is required for the removal of fibromyomata of the round ligament and for shortening the round ligaments. For the first purpose an incision the length of the tumor is made parallel with Poupart's ligament through the skin, fat, and trans- versalis fascia. The tumor is shelled out if possible without open- ing the peritoneal cavity. The base of the tumor, however, may be adherent to the peritoneum, in which case a wide opening into the peritoneal cavity is required. The wound is closed so that the inguinal canal is obliterated, as in the Bassini oj^eration; the oblique muscle is joined to the peritoneum at the base of the canal and to Poupart's ligament by a tier stitch; the fascia is united by a running stitch; the fat and superficial fascia by a double-tier stitch of No. o unchromicized gut ; the skin by a subcuticular stitch. Of all the operations for retrodisplacement of the uterus, more can be said in favor of shortening the round ligaments in the groin than of any other. ^ In fifteen years and in more than 200 opera- tions I have seen two recurrences, though some of miy patients have had five children since the operation ; no one anywhere has ever reported a serious disturbance of a subsequent pregnancy on account of the operation, and it is entirely free from risk. It can be performed at any time after the fourteenth to seventeenth day of the puerperium. As much can not be said for any of the other operations. Unfortunately, it is only to be recommended if there is no suspicion of intrapelvic adhesions or disease, or of appendicitis. The operator places his forefinger on the pubic spine, his thumb on Poupart's ligament, about an inch and a half intervening be- tween the two. The points of the forefinger and of the thumb are then moved upward about a quarter of an inch and an incision through the skin is made between them. The fat and superficial fascia are divided to the deep fascia. Several blood-xessels are severed, the bleeding ends of which must be seized by hemostats. All the ' Proposed by Alquie in 1840; performed by Alexander in 1881 and described in 1883; performed and described by Adams in 1882. Hence, it is sometimes re- ferred to by the clumsy title of the " Alquie-Alexander-Adams operation." ' 59 930 OBSTETRIC OPERATIONS. Fig. 7S1. — Kouncl iigamem freed, but not yet detached. Fig. 7S2. — Round ligaments pulled out of inguinal canals four to six inches. PKEPARATION FOR ABDOMIXAL OPERATIONS. 931 bleeding must be controlled before the deep fascia is opened, other- wise the difficulty of findinf^ the round ligaments is much increased. The fascia is incised just above Poujjart's ligament, the incision running through the pillars of the external inguinal ring. On the l)Osition of the incision depends the ease with which the round ligaments are found. If it is too high, they may not be located at all, or only with such difficulty and delay that the operation is scarcely justifiable. The inguinal canal being laid open by the division of the fascia, the edges of the wound are retracted with Fig. 7S3. — Round ligaments crossed and fastened together in mid-line. forked retractors. The round ligament is at once seen as a whitish or pinkish cord about as large as a slate pencil, running along the floor of the canal. It is picked up by a blunt hook and gently drawn out of the internal ring, the genitocrural nerve which ac- companies it being avoided. The peritoneal in^■estiture which soon appears "is stripped back by a gauze pad and the ligament is pulled out until it is freed for at least four inches. It becomes thicker and stronger as it emerges from the internal ring, until it may reach almost half the caliber of one's little finger. One ligament being extracted, the wound is covered with a gauze pad and the other 932 OBSTETRIC OPERATIONS. groin, opposite the operator, is opened in the same way, except that if the operator stands on the patient's right hand, the thumb of his left hand marks the position of the pubic spine and the fore- finger is placed upon Poupart's ligament about one and a half inches away. Difficulty may be encountered in finding the round ligaments if they are small and ill-developed, if they pursue an abnormal course outward and upward, or if they are abnormally placed above their usual situation and behind the oblique muscle. Fig. 784. — Deep tier of buried running suture of formalin catgut, embracing in- ternal oblique and transversalis muscles, round ligament, and Poupart's ligament. Deep part of uppermost loop of suture (not showing in cut) passes at level of and embraces margins of internal ring : s, Skin; j. c.f., subcutaneous fat ; a. e. 0., apon- eurosis of external oblique ; i. 0., internal oblique muscle ; ;-. /., round ligament ; P. /. , Poupart's ligament. Both ligaments being freed as far as possible (at least four inches, oftener more), they are pulled upon by an assistant, while the operator lays his outspread hand upon the hypogastrium, against which he feels the fundus uteri bump as the ligaments are pulled upon. The terminal ends of the ligaments are cut off, they are crossed in the middle line over the mons veneris, and a hemostat fastens them both where they cross to insure an equal amount of traction on each when they are sewed fast in the inguinal canal. The sutures are now inserted. A strand of catgut (size No. i) on a curved needle is passed through the fascia at the upper angle PKE PA RATION FOR AIWOMIXAL OI'ERATIOXS. 933 of the wound, the end remaininp; loose, not knotted ; the needle then jjasses throu^di the internal ol)li(|ue muscle, goes through the center of the round ligament, picks uj) the Hoor of the inguinal canal, and finally passes through Poupart's ligament. Four or five turns are thus taken, in the same order, each one passing through the center of the round ligament until the external ])illars of the ring are united. The next turn of the needle passes under the round ligament, oblit- erating the external ring from above downward. All the redun- dant portion of the round ligament is cut off; the same needle and thread are then passed through the fascia alone midway between the turns of the continuous suture already in place, until the suture ends op])osite the point where it began and is knotted in a triple knot, tlie only one required. The superficial fascia and fat are joined by a continuous fine catgut suture in two tiers. The skin is united by a continuous suture of catgut or an intracutaneous stitgh, as the operator prefers. The groin wound nearest the operator being closed, the other one is treated in the same way, except that a right-handed man naturally passes the needle in reverse order through Poupart's ligament, floor of inguinal canal, round liga- ment, oblique muscle, and fascia. As the round ligament is sewed in place an assistant holds the hemostat, keeping it in the middle line of the mons veneris, so as to insure equal traction on both sides. The wounds are covered with gauze and collodion. It is safer, but not necessary, to insert a pessary before shortening the round ligaments, which remains in place for six weeks after the operation. A convenient time to insert the pessary is after the curetment, which ordinarily precedes an Alexander operation, for almost e\-ery case of retroversion is complicated by a chronic endometritis with menorrhagia and leukorrhea. Abdominal Operations for Retrodisplacement of the Uterus. — Of the numerous operations devised for the purpose, the author avails himself now of only two — namely, uterine suspension and the Baldy operation. Uterine Suspension} — While this operation has been so gener- ally available that it has been more frequently utilized than any other, it has many objectionable features: The attachment of the fundus uteri to the abdominal wall is unnatural; the suspensory ligament if made too weak will not maintain the uterus in good position long and does not survive a subsequent pregnancy; if, on the contrary, it is made too firm, (uterine fixation), there may be ^ Olshausen was the first to perform a modern uterine suspension. Kelly in- troduced it in America after a visit to Olshausen's clinic. Sims, Kaltenbach, Koeberle, Schroeder, Hennig, and Tait had previously attempted to fasten the uter- ine fundus to the anterior abdominal wall. Boldt and Leopold, in iSoo, passed the sutures through the uterine fundus instead of through the uterine cornua and ova- rian ligaments, as Olshausen and Kelly originally did. 934 OBSTETRIC OPERATIONS. serious, even fatal complications, in a subsequent pregnancy or labor. Nevertheless, it is quick, easy to perform, and has fulfilled its purpose fairly well, so that its vogue has been extensive until something better is devised to supplant it. The technic of the operation is as follows: After opening the abdomen, two stitches of fine celloidin linen thread are passed through the peritoneum, a part of the rectus muscle, the perimetrium, and about an eighth of an inch of the myometrium of the fundus, as illustrated in Fig. pjg yg- — Suspension suture through fundus uteri, peritoneum, and a part of the recti muscles. 785. As these stitches are tied so that the knot falls within the peritoneal cavity, an assistant holds tw^o fingers back of the uterus to prevent the inclusion of a loop of bowel. The patient remains in bed three weeks and avoids violent strains, jolts, and jars for several months afterward. The Baldy operation'^ utilizes the round ligament in an in- genious manner to hold and support the uterus in an anterior ^ Baldy has employed this principle for about eight years, but has modified and improved the technique. Webster utilized the same principle, but in a less perfect manner, not joining the round ligaments behind the uterus. PREPA RATION FOR ABDOMINAL OPERATIONS. 935 Fig. 786. — The Baldy opeiation for retroversion of the uterus: Round liga- ments caught in the grip of a hemostat and pulled back through the broad ligament. Fig. 787. — The Baldy operation for retroversion of the uterus: Round liga- ments approximated in the mid-line posteriorly and united by a suture of linen 936 OBSTETRIC OPERATIONS. Fig. 788. — The Baldy operation tor retroversion of the uterus: Round ligaments joined. Fig. 789. — The Baldy operation for retroversion of the uterus: Round ligaments joined and fastened to the uterus. PR EPA RATION POR ABDOMINAL OPERATIONS. 937 position. A hcmostat i)ierccs the broad Hfi;ament from behind under the ovarian Hgament and close to the edge of the uterus. The forceps seizes the round Hgament about an inch and a half to two inches from its origin at the cornu and pulls it through the hole in the broad ligament. The same is done on the other side. The loops of round ligament are approximated behind the uterus and are sewed with linen thread to one another and to the posterior uterine wall in the middle line at two points, one about an inch below the fundus, the other about an inch and a half lower down. Midway between these two points the ligaments are sewed together, this stitch not including the uterus. This operation utihzes the strong uterine end of the round hgaments, which play like a rope through a pulley, the latter being repre- sented by the unyielding ovarian ligamant. I have used this operation in an increasing number of cases during the past four years and like it better the more I see of it. Figs. 790, 791. — Abdominal belt after abdominal sections. Front and rear views. The Operative Treatment of Diastasis of the Recti Muscles.— If the recti muscles gape more than four fingers' breadth after child-birth and if they afford insufficient support to the abdominal wall, the patient shotdd wear an abdominal supporter, should have electricity and massage applied to the abdomen, and should be put through a course of Swedish exercises. If, after some months of treatment, the abdominal support is insufficient and if ptosis of the abdominal viscera begins to be manifest, operative treatment is indicated. Webster has devised an operation for the purpose which is satisfactory. Its technique is as follows: A long incision is made 938 OBSTETRIC OPERATIONS. through the skin in the middle hne of the abdomen, beginning well above the umbiHcus and extending to the SATnph3'sis. The fat, superficial fascia, and skin are dissected back in one piece until both recti are exposed. The anterior sheaths of the recti are not spht. They are brought together in the middle hne by inter- rupted and continuous chromic catgut sutures, so that the inter- vening tissues are tucked into the abdominal cavity. The rest of the wound is closed and dressed hke any abdominal section. Coccygectomy. — One of the coccygeal joints is frequently sprained in labor and the patient complains of pain for some time afterward, but the vast majority of cases are spontaneously cured within six months. If after that time pain persists so severe that the patient is seriously annoyed by it, and if a physical examination demonstrates a rupture of a coccygeal joint, an- chjdosis of the bone in a straight Hne, or caries of one of the coccygeal vertebrae, cocc3^gectom3ds indicated.^ The technique of the operation is as follows: An incision is made through the skin and fat over the middle of the bone, from above the two tubercles on the end of the sacrum to within a short distance of the tip of the coccyx, to keep the wound as far from the anus as possible. The edges of the wound are retracted with forked retractors. The coccyx is severed with scissors from all its attachments, ex- cept its junction \\'ith the sacrum. A Gigli saw is slipped under the coccyx, care being taken to place it above the alee of the first coccygeal vertebra. The bone is sawed ofi', taking the extreme tip of the sacrum with it. The wound is closed "v^dth interrupted silkworm-gut sutures, which must include the two fibrous bands on the back wall of the rectum and must obliterate all dead spaces. A drain of five strands of silkworm gut, knotted together at both ends, is laid in the bottom of the wound under the interrupted sutures. The wound is sealed with a collodion dressing. The drain is remo^'ed on the third day when the wound is dressed after the first bowel movement. Operations on the Breast. — The operative treatment of mam- mary abscess has been described (p. 721). The other operations are excisions of benign tumors; amputation of the breast for such conditions as tuberculosis, actinomycosis, large tumors occu- pying the whole gland and exaggerated h}-pertrophy; amputa- tion of the breast; removal of the pectoral muscles and of the axillary glands for cancer; Paget's disease, and sarcoma. Excision of benign tumors can be effected by an incision through the skin under local anesthesia, or, if the tumor is deep- seated, by a semicircular incision around the inferior margin of 1 It is necessarj^ to exclude hysterical pains in the coccyx, rheumatism, and the reflex coccygeal pain of a retrodisplaced uterus. PKEPAKATIOX J-OA' A /U)OA//jy.l L OPERA 'IJoXS 939 Fig. 792. — Removal of breast and pectoral muscles. Fig. 793. — JModiticd Jackson's incision for amputation of tiic breast. 940 OBSTE TRIG OPERA TIOXS. the breast, turning the gland up. remo\-ing the tumor, replacing the breast, and suturing the wound so as to avoid deformity. Amputation of the breast is performed by making an eUip- tical incision vAXh the nipple in the center, peeling the breast off the fascia of the nipple and closing the skin wound. For mahgnant conditions, an incision shown in Fig. 793 is made. The attachment of the pectorahs major to the humerus is severed, -^-ith the linger under it as a guide; the pectoral mus- cle with the breast and the skin over it is partly peeled, partly Fig. 794. — Incision closed and wound drained. cut off, blood-vessels being clamped as they are cut. The pec- toralis minor is next removed. Moist gauze covers the chest as the axillary glands and fat are dissected out and removed. The subcla\'icular and supraclavicular spaces are examined for enlarged glands. The clamped blood-vessels are tied with cat- gut: the wound closed and drained as in Fig. 794. The After=treatment of Abdominal Operations. — The routine management of the uncomplicated case has been described. The following hints may be serNiceable to the occasional operator or the general physician forced in an emergenc}' to operate. PA'EPAK AT/ON' FOR A/U)0.]r/XAL OPKRATIOXS. 941 The Treatment of Tympany and Unusual Sluggishness of the Bowels. — Enemata of magnesium sulphate, oss; tur])entinc, foss; glycerin, f5J; water, foij; milk of asafetida, fovj; Hoffmann's anodyne, foj; water, fovj; alum, oj; water, Oj; quinin bisul- phate, oij; water, Oij, may be tried in succession two hours apart; eserin (gr. ^'o) and pituition (i c.cm. of a 20 per cent, solution) may be given hypodermically. As a purge, either calomel (gr. 5) every half-hour for eight doses, and two hours after the last dose I gr. of elaterium or f.lij of castor-oil emulsion, 50 per cent, every hour for eight doses, followed by elaterium. Vomiting. — Excessive vomiting is most effectually relieved by the stomach-pump and a lavage with soda solution. An easier plan is to give the patient large draughts of water as often as desired. The Differential Diagnosis of Internal Hemorrhage, Shock, and Septic Peritonitis. — Hemorrhage. Low temperature. Pallor, especially marked in visible mucous mem- branes, rapid compress- ible pulse, sighing respir- ation. Mind-clear. Blood-count shows pro- gressive anemia. Progressive aggravation of symptoms. Shock. Clammy skin, grayish color, rapid feeble pulse. Syncope, low tempera- ture. Improvement of symp- toms with reaction. Septic Peritonitis. Fever (by rectal tem- perature). Distention. Pain. Vomiting (coffee- grounds). Rapid pulse, with higher tension than in hemor- rhage or shock. Leukocytosis. PART VI. THE NEW-BORN INFANT. CHAPTER I. Physiology of the New-born Infant. Respiration. — There are two factors which explain the in- stitution of respiration : ( i ) External irritation, the result of a change of environment. The child is almost instantaneously transformed from an aquatic to a terrestrial animal, passing from a liquid medium, with a temperature of 99° F., to the air, with a temperature of 70° F., the shock of this sudden transition causing a reflex action of all the muscles, including those of respiration. (2) The maternal supply of oxygen being cut off from the fetal blood as the placenta is separated or compressed, there is an ac- cumulation of COg, the primary action of which is that of a stim- ulant to the respiratory apparatus and to the brain-centers governing respiration. The power of the latter factor is often shown during or before labor. Should anything diminish the supply of oxygen to the fetal blood, such as pressure upon the cord, there is an immediate effort to respire. If the membranes are unruptured, liquor amnii is sucked into the lungs. If the head is in the vagina, or if air is admitted to the uterus after rup- ture of the membranes, respiration may be begun long before birth, and the child has actually been heard to cry aloud within the womb {vagitus titerinus). The rate of respiration at birth is 44 to the minute, sinking shortly to 35. The weight at birth is about 7 V^ pounds. There is a steady increase of about i 3^ pounds each month before and i pound after the fourth month. Weight, MontM. Pounds. 7 16 8 17 9 18 10 19 Weight, Month. Pounds. I 7-75 2 9-5 3 II 4 12.5 5 14 6 15 11 20 12 21 942 PIIYSIOLOGY OF THE iVElV-BORN JXFANT. 943 There is normally a loss oi ^yi ounces, on the average, during the first two to five days, which is usually made up by the end of the first week. Some children, however, gain steadily fi"om birth. Digestion is accomplished by the digestive juices, except the diastatic ferment of the pancreas and of the salivary glands. It is partially dependent upon the bacteria normally present in the alimentary tract. A knowledge of the capacity of the stomach is important to avoid the common error of overfeeding a new- born infant. The capacity of the infant's stomach is, on the average, dur- ing the first week, 46 c.c. (1.5 fl. oz.) ; second week, 78 c.c. (2.5 fl. oz.); third and fourth weeks, 85 c.c. (nearly 3 fl. oz.) ; third month, 140 c.c. (nearly 5 fl. oz. ); fifth month, 260 c.c. (about 9 fl. oz.) ; ninth month, 375 c.c. (12.5 fl. oz.). The greater the infant's weight, the greater the gastric capacity. One one-hundredth of the body-weight plus one gram each day is a fairly accurate formula for the expression of gastric capacity in the new-born. In a child of normal weight the capacity should be one ounce at birth and an increase of one ounce per month up to the sixth month, after which it is some- what less (Holt). The Position of Stomach. — Its axis is almost longitudinal, which in part explains the frequent regurgitation and vomiting of early infancy. It is placed high on the left side under the false ribs, so that it is influenced by the movement of the float- ing ribs in respiration. Excretions. — The urine is albuminous for the first few weeks. The quantity is difficult to estimate. It is always acid in reac- tion. The specific gravity is low, 1003—5. K trace of sugar is often found in breast-fed infants and in those fed upon an arti- ficial food containing sugar of milk. The urine is voided six to twenty times in twenty-four hours. It does not, as a rule, stain the diapers, and the mistake may thus be made of supposing none to have been voided. The movements from the bowels consists for the first forty- eight hours of meconium, a substance greenish-black in color, and consisting mainly of bile-salts and coloring matter. Later, the evacuations become light yellow, are not formed, are sour in smell, acid in reaction, and have a slightly fecal odor. The nor- mal frequency of evacuation is from three to four times in the twenty -four hours. The temperature is alwa}-s slightly elevated directly after birth. It then sinks a little below normal. Its subsequent course is marked by considerable irregularity, with the variations usu- ally above 98°. Comparatively slight causes produce high tem- peratures. 944 THE NEW-BORN INFANT. The eyesight is always hypermetropic. The pulse beats from 125 to 160 in the minute. It should be counted by listening to the beat of the heart, and not by feeling the pulse, as in an older child or adult. The blood has a total bulk to the body-weight of 8 per cent.; there are six to seven millions red blood-corpuscles to the cubic milHmeter; they are more spherical than in the older child, and do not tend to form rouleaux. Shadow corpuscles are abundant. White blood-corpuscles are more numerous, viscid, and deliques- cent than in the adult. There is a large amount of hemoglobin at birth compared with the mother's blood — 120.2 per cent, in the infant and 93.8 per cent, in the mother. At thirty-six to forty-eight hours after birth the percentage of hemoglobin is highest, and then begins to diminish.^ The ordinary jaundice of the new-born infant is due to the superabundance of red blood- corpuscles which are destroyed in the liver, giving rise to an excess of bile-pigment. It is reasonable to suppose that it may also be in part hematogenic, the destruction of the red blood- corpuscles setting free a certain amount of coloring matter in the blood, which is directly absorbed by the tissues. The heart exhibits a transition from the fetal to the infantile circulation by the closure of the foramen ovale, the obliteration of the ductus arteriosus and venosus, the obliteration of the hypogastric arteries, and the disappearance of the Eustachian valve. The umbilical cord, after twenty-four hours, shows a line of demarcation at its base. There is then a necrosis of the amniotic covering, a mummification of the mucous tissue, and a destruc- tion of its vessels. The cord drops off about the fourth day. Its detachment is followed by the retraction of the granulating stump within the umbilical ring. Abnormalities in the Physiology of Premature Infants.— The two main deviations are low temperature — variations below 98° — and inability to ingest and digest food. The management of premature infants consists of incubation and gavage. In the absence of a specially constructed incubator, such as that represented in Figs. 795 and 796, one can be readily improvised with an ordinary infant's bath-tub, several layers of cotton-wool or lambs' wool, and a number of bottles filled with hot water. In fact, better results can be obtained by not shutting the infant up in the confined space of an incubator, even with forced draught. Gavage is the regular feeding of the infant with freshly drawn mother's milk through a small soft catheter passed into the stomach at each feeding. A more convenient and quite as efficient a plan is to draw the mother's milk with a breast- ^ Cattaneo, " Diss. Inaug.," Basel, 1892. PIIYSIOLOGY OF THE NEW-BORN INFANT. 945 pump and to feed it to the child through a medicine dropper, a few drops being allowed to trickle into its mouth at a time. The intervals between feedings should be an hour and the quantity administered should at first be no more than a dram. The child should not be bathed, but should receive, instead, a daily rub with warm oil. It should not be clothed, but should be buried in wool except its face. A diaper should be put under but not around the buttocks, and must be changed often enough to pre- vent chafing. The mortality of this treatment has so much improved the chances of a premature infant that at six months, according to Tarnier's statistics, 22 per cent, are saved ; at seven months, 38 Fig- 795- Fig. 796. Figs. 795 and 796. — The Kny-Scheerer improveii incubator. per cent, are saved. Charles, ^ from an analysis of 932 premature births, found that at six months 10 per cent, were saved ; at six and a half, 20 per cent. ; at seven, 40 per cent. ; at seven and a half, 75 per cent. Sclerema is a disease of premature infants, seen most often 1 "Viability des nouveau nes il ternie et avant ternie," "Archives d'Obstet.," 1893, p. 412. 60 946 THE NEW-BORN INFANT. in lying-in hospitals. The most prominent symptom is a har- dening of the skin, beginning in the legs and spreading over the body, usually sparing the breast and abdomen. Jaundice or a hemorrhagic tendency often accompanies it. The temperature is very low, remaining at or below 95°. The pathology of the disease is not well understood. It has been ascribed to edema. The most probable explanation is that the large excess of stearin and palmitin in the subcutaneous fat of infants solidifies when the temperature falls below normal. The condition is a grave one and is likely to be fatal. The treatment consists in incubation, stimulation, and support. The Management of the New-born Infant. — Clothing. — An infant should be clothed in winter as follows : A binder, of flannel or knit wool, twice around abdomen ; a knit shirt, diaper, knit shoes, and two skirts, the first flannel (in midsummer, linen), and finally its dress. The skirts should be supported from the shoulders by sleeves or tapes. Each skirt should be made Avith a body, and not with a band. A knit jacket may be worn over the dress. A light flannel shawl or cap is desirable to protect the child's head from cold, when it is lifted from its crib or carried to another room. As an infant urinates frequently, the diapers are changed about twenty to twenty-four times a day. The buttocks should be carefully dried and powdered with compound talcum, borated talcum, oxid of zinc and lycopodium, or rice-flour powder. Feeding. — Human Milk. — The secretion is established at the end of forty-eight hours. It derives its origin from an over- growth of epithelial cells lining the ducts of the mammary glands, their infiltration with fat, and subsequent rupture. The specific gravity is 1024-35, the reaction alkaline. Each minute fat- globule is surrounded by a pellicle of serum-albumin. Chemical Constitution. Meigs. Vogel. Gautrelet. Water 87.163 89.5 88.1 Fat 4.283 3.5 4-0 Casein 1. 046 2.0 2.2 Sugar 7- 407 4-8 6.2 Ash o.ioi 0.17 0.5 Fat. — This constituent of human milk is subject to wide variations in quantity under the influence of diet and general health. Under normal conditions, however, it stands quite con- stantly at four per cent. Proteids of Milk. — The proteids of milk are casein and lact- albumin. niYSIOLOGY OF THE NEW-BO KN INFANT. 947 Casein. — Casein is, strictly speaking, the curd of milk, formed by a digestive ferment acting upon " caseinogcn," a protcid analogous to fibrinogen, myosinogen. Caseinogen is a peculiar substance, neither an alkali-albumin nor a globulin, but occupy- ing a distinct position among protcids. Lactalbiiuiin. — A proteid resembling closely serum-albumin, but somewhat different from it. It is present in small quantities — one-half of one per cent. When the milk is curdled, a new proteid appears in whey, called " whey-proteid," which is soluble and non-coagulable by heat. TIic sugar is lactose ; it is not strong in sweetening properties. The ash of human milk is made up mainly of potassium, sodium, calcium, and phosphoric acid. The quantity of milk at each nursing is difficult to determine. It maybe estimated by: (i) The infant's gain in weight after each feeding. This is not constant, varying from three to six ounces. (2) The capacity of the infant's stomach. (3) The quantity secreted in twenty-four hours, divided by the number of nursings. At the end of the seventh day the quantity in twenty- four hours is fourteen ounces ; at the end of the fourth week, two pints. If the mother can not nurse her child, the best substitute, theoretically, is a wet-nurse. The selection of a wet=nurse should be governed by the fol- lowing considerations : She should have milk of good quality, which is best judged by the appearance of her own child. She should, preferably, be a multipara, and of suitable age ; her child should be, approximately, the same age as the one to be nursed ; her nipples should be well shaped ; and it is an ad- vantage to have made a chemical analysis of her milk. She should have an equable disposition and an absence of disagreeable qualities. Above all, she should not have syphilis. The Wassermann reaction should be taken both of the serum and of the milk. As a matter of fact, wet-nurses are so inconvenient and disagreeable in the average household, and the results of artificial feeding have so markedly improved, that the vast majority of children who are not nursed by their mothers are raised on the bottle. Artificial Feeding. — Asses' and goats' milk are more like human milk than is cows' milk, but, as they are not conveniently procurable, the last is universally used. To appreciate why so large a proportion of artificially fed children die annually, particu- larly in the hot summer months, it is sufficient to glance at the 94^ THE NEW-BORN INFANT. differences between cows' and human milk.^ The most important differences may be briefly tabulated as follows : Gross Appearances. — Cows' — a dead white in color, and opaque. Human — often yellow ; sometimes bluish. More translucent. Reaction. — Cows' — acid. Human — alkaline. Specific Gravity. — Cows' — 1030—35. Human — 1024—35. Curd Comparison. — The coagulum produced by a digesting ferment, as rennet, is dense, tough, and digested with difficulty in cows' milk ; light, flocculent, and easily digested in human milk. This difference is due merely to the larger quantity of case- inogen in cows' milk, and to the acidity. Dilute cows' milk and make it alkaline, and the curd, on the addition of rennet, is as hght and flocculent as in human milk. Chemical Comparison. — Cows' milk contains more casein and less sugar. Comparative Analyses. Meigs. Vogel. Lehman. Gautrelet. Human. Cows'. Human. Cows'. Human. Cows'. Water 87.16 87. 1 Fat 4.28 4.20 3 Casein 1. 04 3-25 2 Sugar 7.40 5.0 4 Ash o. 10 0.52 o 5 87.5 88.1 85.61 5 3-5 4-0 4-0 o 3-5 2.2 3.5 8 4.8 6.2 6.0 17 0.75 0.5 0.85 Histological Comparison. — It is asserted that the albuminous envelope surrounding the fat-globules is thicker and tougher in cows' milk. Colostrum-corpuscles are found in human milk, normally, up to the eighth or tenth day. They return under influences interfering with lactation, as heretofore described. Bacteriological Comparison. — Human milk comes from the breast practically sterile. Cows' milk in cities, particularly in hot weather, after twenty-four hours, swarms with all kinds of pathogenic and non-pathogenic micro-organisms and their pro- ducts, some of which are virulent toxins. Quantitative Comparison. — Human milk is furnished in quan- tity and at intervals suitable for the infant. Artificially fed children are often overfed. Preparation of an Artificial Food. — In making an artificial food with cows' milk as a basis, three factors must be borne in mind : 1 According to official statements relating to the Russian foundling hospitals at St. Petersburg and Moscow, about 1,000,000 newly born children have been given over to them during the last hundred years, most of them illegitimate. Of this la^ge number, nearly 800,000 have died in the first months or first years of their existence. A well-known authority on statistics satirically calls it " chronischer Kindermord auf Staatsk osten " ("chronic infanticide at the cost of the State"). PJIYSIOLOGY OF THE NElV-fiORX INFANT. 949 the quantity required, the differences in chemical composition and reaction, and the microbic infection. The first may be regu- lated by the following table, based upon a study of the capacity of the infantile stomach : Number of Fekdings IN Twenty- four Hours. Amount of Food Total Amount Age. Interval. ,x, ^r'Tl^"]!X't. at Each in Twenty- Feeding, four Hours. First week 2 hrs. 10 I oz. 10 ozs. Second to fourth week . . 2 " 9 i^ ozs. ^3/4 " Second to third month . . 3 " 6 3 " 18 " Third to fourth month . . 3 " 6 4 " 24 *' Fourth to fifth month . 3 '* 6 4-4^ " 24-27 " Sixth month 3 " 6 5 " 30 " Eighth month 3 " 6 6 " 36 " Tenth month 3 " 5 8 " 40 " The difference in chemical composition and reaction may be removed by diluting the whole to reduce the casein, adding cream and milk-sugar, and making the mixture alkaline. The microbic infection of cows' milk may be obviated by pasteuriza- tion. 1 The following formula accomplishes these purposes : Milk for one bottle 4 drams Water (boiled) 5 " Cream I dram Lime-water I " Milk-sugar 20 grains. By taking the " top milk " with a Chapin's dipper the formula may be simplified: Top milk 5 drams Water S " Lime-water i dram Sugar of milk 20 grains. To pasteurize the milk, six bottles should be made up for the ensuing twelve hours. Stopper the mouth of each bottle with dry, baked cotton ; put them in an Arnold's pasteurizer; raise temperature to 170°- Put on hood and let stand off the stove for thirty minutes. Set aside to cool and then put in a refrigerator. Apply a plain rubber nipple to the bottle before use. Warm it to blood heat in a warming cup before giving it to the child. Cleansing, — The infant should receive a daily bath in the middle of the day in the warmest part of the room. The tem- 1 By this term is meant the subjection of the milk to a temperature of 167°-! 75° which sterilizes it but does not impair its nutritive value as steam sterilization 01 boiling does. 950 THE NEW-BORN INFANT. perature of the water should be not much over 90°. The nurse, whose hands are commonly insensible to hot water, should be required to use a bath thermometer. Castile-soap and a soft sponge should be used, and care must be exercised not to irritate the eyes. For the first week the child should be simply sponged on the nurse's lap. After that, if it is strong and vigorous, it may be immersed in the tub. Airing. — In summer the baby may be taken out after the second month ; in winter after the third month, for a short time, in the warmest part of the day. The resting place should be a crib, and not a cradle. CHAPTER II. PathoIogf7 of the New-born Infant. INJURIES TO THE INFANT DURING LABOR. [J^lassified According to the Seat of Injury y, The first four v/eeks of life show the highest mortahty. About 10 per cent, of the children bom die of immaturity, asphyxia, atelectasis, malformations, injuries and infection.^ Brain. — Injury to the brain is most frequently the result of- the faulty use of forceps or of the violent extraction of the after- coming head. It may be a meningeal hemorrhage, varying in extent from the rupture of a small vessel and a slight extrava- sation of blood to the laceration of the longitudinal sinus and a fatal intracranial hemorrhage. If less in degree, the child may live to adult age, but is apt to show impaired physical or mental development. The brain-substance may be crushed. Injuries may be inflicted upon the brain not so grave, but affecting intel- lectual or physical centers, and the subsequent mental or physical development of the individual. There may be simply com- pression of the brain, causing perhaps asphyxia. Persistent priapism may be seen occasionally, as a result of injury to the brain or cord.^ Peripheral Nerves. — The facial and brachial plexuses are the peripheral nerves most frequently damaged. The majority of cases of facial hemiplegia are due to the faulty use of forceps 1 Based on the statistics of i ,439,000 births (Snow, "Archives of Pediatrics," September, 1903). 2 In one of my cases priapism persisted for two weeks, to the dismay of the mother, who feared it would be permanent. INJURIES TO THE INEANT DURING lABOR. 951 Recovery may be expected, usually in the course of a week. Should this fail to occur, the faradic current may be used with advantage. Facial palsies at birth are usually unilateral and transitory ; they may, however, be bilateral and permanent. The bracliial palsies result from unskilled attempts at extracting the shoulders and arms, and are likely to be permanent. Skull. — Spoon^shaped depressions of parietal or frontal bones may be caused by a prominent promontory or by forceps. It has been suggested to elevate the depression by pneumatic trac- tion or by trephining. Fractures, if compound, require an aseptic dressing. Re- covery, even from so grave an injury, sometimes occurs. Fig. 797. — Spoon-shaped depression and fracture of a parietal bone (Winckel). Fig. 798. — Formation of caput succedaneum : o. e., External os ; b, bladder; //, urethra ; v, vagina. Distortion of the head is very common, almost constant. Its variations in form are the result of the different presentations and positions. The deformity, even though \'ery marked, disappears within the first three days (Figs. 799-804). 952 THE XEW-BORX IXFAXT. Fig. 799. — The undistorted head of a breech presentation (Schroeder), Fig. 8cx>. — Right occipito-posterior position of the vertex (^Schroeder). Fig. 801. — Normal vertex 'Schroeder). Fig. 8o2. — OutUne of head after de- liver)-, the brow presenting (Budinj. Fig. S03. — Brow presentation. (Schroeder). Fig. 804. — Face presentation (Schroeder). INJURIES TO THE INEAiXT DURING LABOR. 953 Scalp. — Caput Succedaneum. — A serous infiltration of that portion of the presenting part corresponding to the external os. It disappears in two or three days, and requires no treatment. Cephalhematoma is a more important condition, and is to be distinguished from a caput succedaneum. It occurs about once in two hundred cases. Usually two or three days after birth a swell- ing develops, rapidly increasing in size, possessing the physical signs of a cystic tumor, distinctly confined by the boundaries of one of the cranial bones. It may be bilateral. It may occupy the parietal and the occipital bones, and it may possibly develop Fig. 805. — Cephalhematoma. Fig. 806. — Double cephalhematoma. Fig. 807.— Longitudinal section through a cephalhematoma: a. Dura mater; b, cranium; c, pericranium; c' ,c' , beginning hyperostosis ; e, scalp (Davis). before birth. It is due to a subpericranial hemorrhage, which lifts the pericranium from the bone, irritates it, and stimulates it to bone-production, thus giving rise to a bony sensation at the lifted edges of the pericranium, and later to a peculiar crackling^ or crepitus over the surface of the tumor, due to the movement of the thin bone-plates on one another. Non-interference is the 954 THE NEW-BORN INFANT. treatment, except when the hemorrhage is excessive or suppura- tion occurs. The former may be controlled by pressure and cold ; the latter requires incision and drainage, with strict asepsis. In spite of the greatest care, septic meningitis may develop. Contused and lacerated wounds, usually the result of a forceps operation, are to be treated on general surgical prin- ciples. Sloughs. — The vitality of the scalp may be destroyed by for- ceps or by prolonged pressure from the pelvic bones, and sloughs may appear in the first few days after birth. They require the ordinary surgical treatment for the same condition any- where on the body. Face. — A caput succe- daneum may occupy the face if it presented in labor. The eyes and the mouth may be injured by careless examinations or by violent extraction of the after-com- ing head. The former may be injured by the forceps. The globes may be luxated to complete exophthalmos ; the recti muscles may be permanently paralyzed;' there may be subconjunc- tival or palpebral ecchy- moses, edema of the lids, and temporary ptosis ; frac- ture in the roof of the orbit ; exudation of blood into the anterior chamber. The cheeks, temples, and forehead may be bruised, crushed, or cut by forceps. Hematomata may develop in the cheeks within twenty-four hours of birth. The blood- tumors should be let alone, as in the case of a cephalhematoma. Neck. — There may be injury and thrombosis of the neck- muscles, with reactive inflammation, most frequently of the sternocleidomastoid, with the development of torticollis. This sort of wry-neck usually recov^ers without treatment. Fracture, Dislocation, or Decapitation. — The author has been told the details by eye-witnesses of three cases in which the head was pulled off after version. In each instance Cesarean section Fig. 808. — Child in face presentation. lAyUA'/ES TO r//E INFANT J)UA'/NG LABOR. 955 was done to extract the head. The women all died. Crani- otomy should obviously have been the operation for the extrac- tion of the head. There is occasionally injury to the cervical spine and to the larynx and trachea, in consequence of the excessive twisting of the neck that occurs when the occiput turns forward from a posterior position and the shoulders do not follow the movement of the head. Limbs. — Fractures, which are usually a separation of diaph- ysis and epiphysis, require, in the case of the lower extremities, surgical fixation, extension, and a plaster bandage. In the case of the arms, fixation in the Velpeau position by a jacket with only one arm-hole, for the sound arm. Union is prompt. Frac- tures are usually the result of faulty management on the physi- cian's part, but they may be spontaneous. Avulsion of the limbs sometimes occurs in efforts to extract a premature or macerated fetus. In a case admitted to the University Maternity, both arms of a well-developed infant were pulled off in an attempt at version; the uterus was ruptured and two feet of ileum were pulled loose from the mesentery. Trunk. — Perforations of the groin and perineum may be due to the use of a blunt hook or a forceps applied to the breech. There may be rupture of some important viscus, like the spleen, liver, or lungs, with fatal hem- orrhage into the peritoneal or pleural cavities, especially in syphilitic children; or visceral hemorrhage may occur, as in the kidney, without actual rup- ture, but to a suflftcient degree to abrogate the functions of the organ. Fracture of the clavicle in extracting the after-coming head may result in the puncture of the lung by the broken end of the bone and in fatal emphy- sema. The kidney, spleen, and liver have been ruptured in attempts to extract the breech. Subcapsular hemorrhages in these organs are observed quite frequently. In the pleura there are often ecchymotic spots in asphyxiated children, with minute but multiple extravasations in lungs and brain. The pleura may be lacerated, with a hematothorax as the result.' The ' Ein Fall von traumatischen Hemalothorax beim NeuRcborenen," " Z. f. G. u. G.," Bd. XXX, I und 2; Gebhard, p. 402. There was a rupture of an inter- costal vein and of the pleura in attempts to extract a breech and trunk. Fig. 809. — Child bom in face presen- tation (Schroeder). g^6 THE NEW-BORN INFANT. body may remain distorted for some time as the result of a face presentation, and there may be ecchymoses upon the body if there is a presentation of the trunk. Bowel. — The large bowel may rupture from preexisting ulceration or necrosis, usually at the sigmoid or other flexures. Fig. 8io. — Back presentation. Disposition of the serosanguineous ecchyraosis (Budin). Fig. 8ii. — Fetus after a presentation of the back, shoulder, and elbow. Disposition of serosanguineous ecchymosis (Budin). Asphyxia. — Asphyxia of the new-born child results in con- sequence of an insufficient supply of oxygen to the blood. To understand its causes it is necessary to review the Physiology of the Institution of Respiration. — The sudden changes in the environment of the fetus (from a liquid medium at 99° to the air at 70°) produces an exaggerated stimulation of all the muscles to reflex action, including the muscles of respira- tion. Placental respiration is, moreover, abolished, and the accumulated CO2 primarily stimulates, but finally paralyzes, the respiratory center. The causes of asphyxia are : First, intra-uterine. Under this head come — Fetal inspiration. Any interference with placental respiration, paralyzing the brain-centers, as premature detachment of placenta ; coiling, compression, or prolapse of the cord'; diminution of the caliber of the umbilical vessels, as from syphilitic periphlebitis ; excess- ive and prolonged uterine contraction. INJURIES TO THE INEANT DURING LABOR. 957 Prolonged pressure on the fetal brain by the pelvis or by forceps, paralyzing the brain-centers. Grave systemic diseases of the mother, and accidents, includ- ing hemorrhage, uterine or pulmonary. Anomalies or diseases of the fetus, preventing the entrance of air into the respiratory tract, or preventing the proper distribu- tion of blood from right ventricle to the lungs, as a patulous fora- men ovale or atresia of the pulmonary artery. Second, extra-uterine causes, as — Placing the infant after birth in a position unfavorable for respiration. Precipitate labor. Interference with the access of air to respiratory passages, as by a caul, unruptured membranes, or maternal discharges. Asphyxia neonatorum is divided into two stages : 1. Asphyxia Livida. — In this stage there is an accumula- tion of CO2 in the blood, yet the circulation continues and the reflexes are preserved. The prognosis of this stage is favorable. 2. Asphyxia Pallida. — This is an advanced stage of the for- mer, characterized by weakness of the heart, slowing of its pulsa- tions, and the abolition of the reflexes. The prognosis of this stage is naturally unfavorable. Treatment. — If possible, asphyxia should be prevented by removing the possible causes during labor. The treatment of the condition after labor consists of: 1. Extraction of mucus from the throat and fauces by hold- ing the child by the feet and cleaning the mouth with a finger. 2. The application of exaggerated stimuli to respiration, as slapping of the buttocks, vigorous rubbing of the back and •chest ; immersing the body in warm water, and pouring ice -water •on the epigastrium ; applying electricity, if practicable, preferably in the shape of a faradic current, one pole being placed on the •epigastrium and the other applied on the sternum, flanks, and thighs. The electric brush is most efficacious. \\\ the pallid variety only the most powerful of these stimuli are useful. 3. Artificial respiration is induced by one or all of several methods. Sylvester's is not to be recommended because the pectoral muscles of the infant are too weak to inflate the chest when pulled upon by the manipulation of the arms. Marshall Hall's method, modified to suit the requirements of the new-born infant by suspending it in a towel, and thus rolling it from side to side, is sometimes useful. Byrd's method, flexing and extending the trunk, and holding the child upside down so that mucus may run out of its throat, is efficient. 958 THE NEW-BORN INFANT. Schultze's method is one of the best. The infant should be wrapped in a towel to protect it from being chilled, should be held as shown in figure 812, and should be swung between the physician's knees and over his shoulder; after practising the swinging movements fifteen to twenty times, the child should be immersed for a few 'seconds in warm water to raise its tem- perature, when the movements may be repeated. Mouth-to-mouth insufflation ranks with Schultze's method, Fig. 812. — Schultze's method of artificial respiration : A, Inspiration ; B, expiration. or is superior to it. The exit of air from the lungs should be facilitated by placing the infant's neck over a mug or cup with the head extended, and after inflating the lungs flexing the head and compressing the chest. The nose should not be held to prevent the escape of air, as is sometimes advised. The physi- cian draws a full breath and through a clean towel spread over the child's face blows the first part of the expired air into the child's mouth. The open nostrils serve as safety-valves. The air-vesicles of the lungs are not so likely to be damaged. Draeger's pulmotor adapted to the new-born infant is receiv- ing a trial in the University Maternity. It is a convenient means of conducting artificial respiration with oxygen (Fig. 813). Catheterization of the larynx with a soft catheter and direct inflation of the lungs is only advisable if there is tumefaction of the neck or some other mechanical interference with the entrance of air into the larynx. Great care must be exercised not to injure the posterior wall of the trachea nor to catheterize the esophagus. INJURIES TO THE INFANT DURING LABOR. 959 S Fig. 813. — The Draeger infant pulmotor. Fig. 814. — Dorrance's intratracheal pressure-bulb canula. The canula with sty- let in place. The canula is ready for introduction. Fig. 815. — Dorrance's intratracheal pressure-bulb canula. The canula with bulb distended and clamp in place. 960 THE NEW-BORN INFANT. Dorrance^ has devised an efficient tracheal catheter. The child's head should hang down over the edge of a table; the tongue should be pulled forward by an AUis' forceps, and the catheter inserted by hooking a forefinger behind the epiglottis to keep it from going into the esophagus. The small balloon is inflated to fill up the trachea, and air is then gently blown into the catheter at intervals corresponding to normal respiration. As a last resort, tracheotomy and catheterization through the wound may be required. It is only required in most ex- ceptional cases.^ Risks Attending Artificial Respiration. — Injuries, as apo- plexies ; Schultze's method may injure the spine ; hemorrhagic effijsions in the pleurae and lungs ; rupture of the air-vesicles in insufflation ; the trachea and larynx may be injured ; the lung may be punctured if the clavicle is broken. After=treatment of Asphyxia Neonatorum. — A child deeply asphyxiated and revived with difficulty will, more likely than not, die within forty-eight hours of birth. It should be carefully watched, therefore, for at least two days, in order to detect rapid respiration, feeble heart-action, and evidence of intracranial dis- turbance. It is a good practice to administer routinely to such children five drops of brandy and a drop, of tincture of digitalis in hot water, every four or every two hours, to keep them swathed in cotton-wool, and possibly to surround them with, hot-water bottles or bags, if their vitality is low. DISEASES OF THE NEW-BORN INFANT. Diseases of the Lungs. — Atelectasis. — The causes are not known. Sometimes it may be due to obstruction of the air- passages, as by an enlarged thymus, a clot of blood, curd of milk, etc. The diagnosis is usually not made during life. Dullness on percussion might be detected on one side if the atelectasis were unilateral. The respiration is accelerated and imperfect. There is an absence of fever. The symptoms are present at birth. Pathological Anatomy. — One lung is found shriveled up, is not crepitant, and sinks when placed in water. The prognosis is necessarily grave. 1 " Surg., Gyn., and Obstet.," August, 1910. ^ I was obliged to resort to this treatment in a case of face presentation with such distortion of the neck that mouth-to-mouth insufflation and catheterization of the larynx were impossible. The child was kept alive for an hour, but would make no attempt at respiration. DISEASES OF THE NEW- BORN INFANT. 96 1 Treatment. — If the dias^nosis is made, y;cntlc insufflation of the lung with a catheter might be attempted. Syphilis of the Lung. — The diagnosis may be made by a his- tory of syphihs in the parents, by the signs of fetal syphilis, together with the cyanosis and physical signs of pneumonia. The temperature is very low, suggesting the use of an incu- bator. Treatment, however, is of no avail, the child usually dying within twenty-four to thirty-six hours. PatJiological Aiiatoviy. — An enormous overgrowth of connec- tive tissue is found, compressing the blood-vessels and diminish- ing the capacity of the air-vesicles. As some air has entered the lung, a cut-off portion never sinks, but does not float buoyantly. The "white pneumonia" of syphilitic infants is rare. It is the result of proliferation, desquamation, and fatty degeneration of the epithelial cells in the lungs, giving the latter a white appearance, and distending them so that the thoracic cavity is well filled out and the lungs bear the imprint of the ribs. Respiration is impossible. Septic infection of the lungs is common. It is the result of in- spiration of septic matter from the vagina or from the decomposi- tion of inspired blood-clots or vaginal discharges. Tuberculosis may be caused by mouth-to-mouth insufflation on the part of a tuberculous person. Pneumonia of the new-born is usually caused by the inspiration of maternal discharges, resulting from intra-uterine respiratory efforts when asphyxia is threatened. The result is usually an in- fection of the lungs, septic pneumonitis, and a general blood infec- tion. Blood cultures usually demonstrate streptococci. Pneumonia arising from this cause develops about twenty- four hours after birth, in a child apparently healthy, the tempera- ture at this time beginning to rise and the respiration growing more rapid. Cough, although a variable symptom, is occasion- ally incessant. The child is restless, refuses the nipple, is cyanotic, at times gasps for breath, and there may be dullness over one or both lungs. The diagnosis can not always be made by the physical signs ; only a small patch ma\' be involved. There is usually a history of dystocia. When a new-born infant has a high temperature, septic pneumonia and general infection should be suspected as the most probable causes of the fever. The prognosis is grave. The treatment should consist of stimulation — gr. ^/( to % carbonate of ammonium in oss-oj mucilage of acacia every four hours if it does not irritate the stomach. Tincture of digitalis, in drop doses, should be given cvcrv two or four hours. A 61 962 777^ NEW-BORN INFANT. mustard-bath once, twice, or thrice daily^ is an important item in the treatment if there is cyanosis and very rapid respiration. A cotton jacket should be appHed. The mother's milk should be drawn from the breast and fed to the infant from a medicine dropper in small quantities every two hours; a few drops of brandy may be added to it. Pulmonary apoplexy is a rare accident in young infants, the result of severe straining in crying or coughing. There is hemoptysis, the quantity of blood lost usually not being very great, though it stains the front of the dress and alarms the child's caretaker exceedingly. The pr gnosis is favorable. Syphilis of New=born Infant. — Symptoms. — The child is often ill-developed and ill-nourished, but the characteristic signs of the disease may not appear before four or six weeks. In the order of their diagnostic value these signs are : Cor}^za syphilitica. The discharge from the nose is irri- tating to the upper Hp, and frequently produces crusts and even ulceration. Maculopapular syphilide; roseola, especially marked on the heels; cutaneous papules and mucous tubercles; rhagades oris et ani; pemphigus; cutaneous ulcers; paronychiae; pseudo- paralyses of extremities, due to infirm connection between diaph- ysis and epiphysis, or to painful periostitis which inhibits motion; hemorrhagic diathesis; bone diseases; fever, disease of the testicles, which are enlarged from the overgrowth of connective tissue. Spirochete may be found in blebs upon the skin if they" are present and the Wassermann reaction is positive. Treatment. — Good results are obtained from the internal use of calomel with chalk or soda, yV of a grain given twice a day, gradually increasing the dose. Should vomiting or diarrhea occur, mercurial inunctions must be employed, rubbing a piece of mercurial ointment as large as the end of the Uttle finger on the child's abdominal binder ever}" other day. This treatment should be kept up intermittently for months, being replaced from time to time by tonics, as drop doses of S}Tupus ferri iodidi. The child's food requires careful attention .^ Salvarsan administered to the mother who is nursing her infant may have a surprisingly good effect upon the latter. In- travenous injections of salvarsan in the new-born are practicable with a hypodermic needle and have given excellent results. The ^ The bath is made as follows: Three large pitcherfuls of water at 100° F., and a tablespoonful of mustard; allow the child to remain in the bath for five minutes, or until the temperature of the latter falls to 95°, when the infant should be removed and wrapped, undressed, in a warmed blanket, in which it remains for a half-hour. DISEASES OF THE NEW-BORN INFANT. 963 dosage should be 0.04-0.1 gram in severe cases, less in the milder manifestations. This should be followed by mercury, as already recommended . ^ . Prognosis. — If the child is well nourished by its mother or by a wet-nurse, the prognosis is very good, so long as some impor- tant internal organ is not seriously affected. In artificially fed children the prognosis is unfavorable. The wet-nurse is liable to be infected, and she should not be ignorant of her danger. Mastitis. — Four days after birth the breasts in both sexes contain colostrum, which has disappeared by the twentieth day. During this period there may occur in the breast of the child pathological processes like those in the breast of the puerpera. The breasts may enlarge and become painful ; the skin over them may be an angry red ; the secretion maybe much increased, so that the milk runs out in a stream, and even a mammary ab- scess may develop. Treatment. — The nurse must avoid squeezing the glands. Cooling lotions should be applied, and the skin should be oiled, to relieve tension. If suppuration occurs, the abscess should be incised without delay, as there is always a tendency for the pus to burrow inward toward the pleura. Specific or Essential Fevers. — Exanthemata. — The infant may exhibit the exanthem at birth or may contract the disease subsequently. The treatment is the same as under other cir- cumstances. Septic infection occurs by inspiration of infected discharges from the vagina during birth or through the umbilicus. The most important treatment is the preventive (see Diseases of Umbilicus). The infection of the umbilicus usually occurs in the first two weeks of life, but the symptoms may appear as late as the fourth week. The Treatment of Certain Congenital Deformities. — Hare= lip. — This deformity may prevent suckling ; if so, an immediate plastic operation is indicated, which may be undertaken in the first few hours of life. The operation for cleft=palate is too serious to be undertaken during early infancy. A rubber flap over the nipple of the bottle may enable the child to suck. It can not nurse from the breast. Supernumerary digits should be ligated and cut off. If they are mere fleshy appendages, a thread may be tied around their base, and they may be left to fall off. In a tongue-tie the frenum should be snipped superficially with blunt-pointed scissors, and then torn with the fingers to the floor of the mouth. The child's head is placed between the ^ See " Zur Technik u. Dosierung der Salvarsaninjektion bei der Behandlung von Neugeborenen, F. Engelmann," " Zentralbl. f. Gyn.," No. 3, igi2. 964 THE NEW-BORN INFANT. knees of the operator ; the two first fingers of the left hand are inserted on either side of the frenum, to hold the mouth open and to protect the tongue from injury. Umbilical Hernia, — There are two varieties of this deformity. In one, a knuckle of intestine covered by skin projects from the navel. This degree of deformity is common, occurring in two per cent, of infants. It is treated by a convex button, cork, or hard-rubber compress on a strip of adhesive plaster, which encircles two-thirds of the child's body. This improvised truss is renewed from time to time, and should be worn six months. In the second variety there is an exomphahc condition, due to defective development, the intestines protruding from the umbili- cus covered only by amnion. An immediate plastic operation is indicated even if the mass of protruding intestines is as large as an apple. The results of this operation have been excellent. Spina bifida is to be distinguished from the less serious con- ditions — fibroma, myxoma, or lipoma of buttocks — and from parasitic teratomata. In spina bifida a hardened patch is found at the prominence of the tumor, due to the attachment at that point of the Cauda equina. Treatment. — Lay the tumor open, dissect out the sac, make traction upon the latter, when the cauda equina will retreat into the canal ; ligate with catgut the pedicle formed, and accurately close up the wound with buried catgut sutures, with strict asep- sis. The prognosis is not good. If the child survives the opera- tion, it is not unlikely to die of hydrocephalus. Imperforate Rectum. — The anus and rectum should be exam- ined immediately after birth in all cases. To avoid the danger of fecal accumulation, inguinal or lumbar colotomy may be necessary. In simple cases with merely a transverse septum between the anus and the rectum, a cruciform incision over the imperforate anus is sufficient to open the rectum. The mucous membrane of the bowel is then stitched to the skin of the anus. An attempt should always first be made to reach the rectum from the perineum. I have succeeded in one case in which it was necessary tomake a blunt dissection two inches up into the infant's pelvis. Should this attempt fail, colotomy is necessary. Nasal Catarrh (Snuffles). — Causes. — When the disease is not syphihtic, it is due, usually, to faulty clothing or to drafts of air. The crib should be protected, and the child should w^ear a thin lawn cap until its head is covered by a grow^th of hair. Diseases of the Mouth. — Aphthae are rounded, pearl-colored vesicles seen in the mouth and on the lips. Boric acid, gr. v-x to the ounce, as a wash, is curative. The practice of washing the mouth out with a wash-rag has D/SE.ISFS OF 77/ E NEW-BORN INEANT. 965 produced aphthous patches on the gums (Bednar's aphthae), which usually heal promptly, but may sometimes be the source of serious infection.' In true thrush there is a coalescence of white spots, with an areola of reddened mucous membrane. The disease is often seen in hospital practice, or in infants whose hygienic surroundings are bad. It is due to the presence of a parasite, the saccharo- myces albicans. Treatment. — Boric acid, gr. xvj-xx to 3J of honey. One-half of a dram of this mixture is put in the mouth three or four times a day. The associated symptoms of malnutrition, diarrhea, and vomiting indicate attention to hygienic surroundings, to the general health of the child, and to its diet. In gonorrheal stomatitis there is violent inflammation of the oral mucous membrane, due to the presence of gonococci. Cleanliness and mild disinfection of the mouth with boric acid solution will effect a cure. The disease is rare. I have seen but one case in all my hospital services. Sublingual cysts are probably the result of the occlusion of the duct of a submaxillary gland. The cyst appears in the first few days after birth, and ma}/- reach such a size as to displace the tongue and to interfere with sucking. The treatment consists of puncture of the cyst, which does not return. Colic, Diarrhea, Constipation. — Colic always indicates a careful attention to diet. Medicinally, gr. j of pepsin may be given in 3J of hot water, with a few drops of brandy or gin. Milk of asafetida, gtt. xx— xl, or soda-mint, 3J, may be used, and a spice- plaster may be applied to the abdomen. Diarrhea indicates almost always some error in the diet. Frequent serous movements, draining the child's strength and demanding a remedy, may be checked with the following : R. Acid, sulphuric, aromat., Tinct. opii camph., aa gtt. iv. One dose, not to be repeated. Constipation. — In simple cases a dose of castor oil (3J), the soap-stick, a glycerin suppository or injection (gtt. xv— xx in fgj of water) suflfice, or the following may be used : R . Calcined maojnesia, Sugar of milk, of each 7 '2 grains. For chronic constipation the daily injection of warm soap- suds (fsij) by a soft -bulb rubber ear-syringe is least harmful. Medicinally, the treatment may consist of a piece of flake 1 " Sepsis bei Neugeborenen .\usgehend von den Bednar'schen Aphthen," Linzenmeier, " Zentralbl. f. Gyn.," No. 50, 1911. 966 THE NEW-BORN INFANT. manna in each bottle of artificially fed children ; the administra- tion of ten drops of the syrup of figs, with two to four drops of the fluid extract of cascara ; a pinch of salt in the bottles ; the addi- tion of Mellin's food, and daily abdominal massage ; the addition to each bottle of milk of two to four grains phosphate of soda ; an increase in the proportion of cream ; Tarrant's Seltzer Aperient (ten grs.) in the milk ; a little milk of magnesia, added to one or more bottles or given in water to a nursing baby. Intussusception. — In a case in the University ]\Iaternit}% the child died forty-eight hours after birth. The symptoms began in the first twenty-four hours ; the child passed blood and mucus by the bowel, developed high fever, and \-omited incessantly. Postmortem examination showed the intussusception in the ileum ; the bowel above was much distended ; below, inflamed and ver)^ dark in color for a couple of inches. Skin Diseases. — Gum, a sort of acne, is due to the irritation of the skin by the atmosphere and the clothing. It is exceed- ingly common. Treatment. — Cleanliness, proper clothing, and some simple ointment, perhaps as a salve to the mother's anxiet}- as much as to the infant's skin. Furuncles are likely to be small and numerous. The condi- tion is an exaggeration of gum, with enlargement and suppura- tion of the pimples. The diet and h}'gienic surroundings should be investigated. The small boils may be washed twice daily with a solution of boric acid, gr. xv, and resorcin, gr. iij-fsj, and boric acid ointment, .5J-5J, ung. aq. rosae, may be applied. The boils may be opened with a needle when they come to a head. Simple acute pemphigus is very rare. From the second day to the fourth, fifth, or sixth week, vesicles the size of a pea to a quarter- or half-dollar appear indifferently over the whole body, except the soles of the feet and the palms of the hands. The disease lasts from twelve to fourteen days, without manifestation of constitutional disturbance. It is contagious, and may be carried by the nurse or be com- municated to a mother or nurse. It disappears without treat- ment. A specific micro-organism, it is claimed, has been discovered, but the staph3'lococcus pyogenes aureus is generallv regarded as the infecting agent. Syphilitic pemphigus usually begins in utero, and the child is bom with the vesicles upon it, the soles of the feet and the palms of the hands being most often affected. The disease is associated with marked evidence of malnutrition and constitutional disturb- ance, and yields only to specific treatment. DISEASES OF THE NEU'-BOKN INFANT. 967 Ophthalmia Neonatorum. — Symptoms. — True ophthalmia is the result of the infection of the conjunctivae by gonococci. Usually after twenty-four to forty-eight hours the eyelids are edematous and puffed out, and between them there appears a seropurulent discharge, which soon becomes greenish-yellow pus, and in which gonococci are found under the microscope. When the lids are separated, the conjunctivae are seen to be red and velvet-like in ai)pearance, and later the cornea may lose its epithelium, become glazed, ulcerate, and be perforated. Treatment, Prophylactic. — As soon as the head is born, the orbital region is wiped clean with soft linen squares, soaked in a boracic acid solution. When the delivery is completed, the eyes are again cleansed by injecting into the conjunctival sacs boracic acid solution (gr. x to aq. destil. {%']) by an eye-dropper. In hospital practice uniformly, in private practice if there is reason to suspect a gonorrheal infection of the mother's vagina, a drop of a I per cent, solution of nitrate of silver is instilled in each eye. Curative. — The eyes are cleansed every hour, day and night, with a concentrated solution of boric acid. Cold compresses are kept upon the lids. Morning and evening argyrol solution, 25 per cent., is instilled. If only one eye is affected, the other should be carefully bandaged with a pledget of lint to protect it. A drop of a weak solution of atropia is occasionally required. If possible, the case should be placed under the care of an oculist. The author invariably refuses to accept the responsibility of treating such a case. The mouth, the nose, and the ears of a new-born infant may be the seat of gonorrheal inflammation. There is frequently a subacute conjunctivitis after birth, often affecting one eye alone, and yielding to the mildest treat- ment, or disappearing spontaneously. The inexperienced phy- sician not infrequently mistakes this innocuous inflammation for ophthalmia, and by the injudicious energy of his treatment con- verts a mild into a very severe conjunctivitis. I have seen per- manent opacity of the corne?e from the unnecessary use of nitrate of silver in such a case. The severest possible inflamma- tion, ending in total blindness, has resulted from the injection of sublimate solution in the vagina during labor, the corrosive sub- hmate gaining access to the child's eyes and causing inflamma- tion and perforation of the corneae. Hemophilia is an inherited pathological disposition to bleed from apparently normal or slightly injured surfaces. The manner of transmission is peculiar; it is always through the mother to male children, who do not transmit it. The female children are said to show no evidence of the disease, but transmit it. The cause is not known, and it manifests itself throughout life. Treat- 968 THE NEW-BORN INFANT. ment is of no avail. It should be remembered that a hemorrhagic diathesis is sometimes due to syphilis, and in such cases specific treatment is of value. I have seen a hemophilic infant bleed to death from its conjunctivae, incessantly weeping tears of blood, and another lose its life from hemorrhage following a superficial abrasion under the tongue. Dr. M. D. Hoyt gives me the notes of a female infant which bled to death from its wrists, ankles (hemidrosis), cord, nose, and lungs. The hemorrhage continued four days. Treatment. — Horse or human serum, 15-20 cm. a day, may be tried in these cases. Icterus. — There are two classes of cases : In the first the jaundice is slight in degree. The face and breast only are affected. This grade of jaundice is very com- mon, the majority of children manifesting it. The cause is said to be hepatogenic. The very small com- mon biliary duct fails to empty into the bowel the excess of bile produced by the liver. The discoloration disappears a few days after birth, and the condition usually requires no treatment. Fractional doses of calomel may be given if the child's digestion is impaired, or if the jaundice is deeper than common. In the second variety the whole body is jaundiced. The urine and feces are discolored, and may contain blood. This variety is decidedly rare, and is a manifestation of grave systemic derangement, usually general septic infection. Causes. — This kind of jaundice is said also to be, as a rule,' hepatogenic. It is seen in Buhl's and Winckel's disease, in atresia of the bile-duct, and in polycystic disease of the liver. In streptococcic infection of the blood-current producing disinte- gration of the blood, the jaundice, I believe, is in part hemato- genic, resulting from a disintegration of the blood-corpuscles. The prognosis of the malignant variety is extremely grave. The result is almost invariably fatal. Cyanosis was once thought to be synonymous with congeni- tal heart disease. The laity still regard a "blue baby" as one with a defective heart. The causes of cyanosis, in the order of their frequency, are : pneumonia (often syphilitic), premature birth, asphyxia, atelec- tasis, degeneration of the blood, malformation of the heart and blood-vessels, interference with the function of the nerves of respiration, malformation of the respiratory tract, congenital pleurisy, and partial occlusion of the trachea. Congenital heart affections may result from intra-uterine endocarditis, as stenosis of the right and left auriculoventricular orifices, stenosis of the aortic and pulmonary orifices, and insuffi- DISEASES OF THE NEW-BORN' INFANT. 969 ciency of the valves. Or they may be the result of defective development, as patency of the foramen ovale, atresia of the pulmonary artery, stenosis of the conus arteriosus, and defects in the ventricular septum. A child with congenital heart disease must be managed with extraordinary care. Exposure to cold is particularly danger- ous, as there is a tendency to pulmonary congestion and pneu- monia. Artificial heat may be necessary ; mahiutrition must be combated ; heart tonics may be required. The prognosis is relatively favorable. Compensation may often be secured in apparently the most unfavorable cases. Diseases of Umbilicus. — Septic Infection. — The ulcer on an infected umbilicus is covered with a grayish, diphtheritic mem- brane, has a reddened areola, and the local inflammation leads to general infection. An acute, high fever in a new-born infant suggests septic infection or pneumonia. The latter may be sep- tic. The so-called Buhl's and Winckel's diseases, with fatty degeneration of the organs, icterus, cyanosis, and hemoglob- inuria, are merely the result of streptococcic infection of the blood-current. Treatment, PropJiylactic. — The ulcer should be exposed at the daily bath, cleansed with soap and water, and dressed with sali- cylic acid, I part ; starch, 5 parts. An aseptic ligature should always be used to ligate the cord at birth, and the daily dressing of the cord with fresh salicylated cotton should be carefully carried out with clean hands until the cord drops off. Curative Treatuieiit. — The ulcer should be touched with a solution of bichlorid of mercury, i : 500, or with nitrate of silver solution, 3J-f|j. It should be thoroughly irrigated and dusted with salicylic acid and starch, and covered with salicylated cotton. Umbilical fungus is usually an overgrowth of granulation tissue. It projects in a mass like a strawberry from the navel. It should be cauterized with a solid stick of nitrate of silver, whereupon it promptly melts away. In about one-fifth of the cases cauterization fails, the tumor is more solid in feel, and is found, on microscopic investigation, to be the remains of the om- phalic duct. This kind of umbilical fungus is called an entero- teratoma. It should be ligated and cut off. The stump of the cord may persist, unchanged, almost indefinitely, covered with an angry, red layer of granulation cells, or a spur of well-organized connective tissue may project from the umbilicus. In such cases there is a small supply of blood to the cord in spite of the h'ga- ture. The projecting mass must be cut off. I ha\-e been obliged to amputate the persistent stump of a cord on the sixteenth day. 970 THE NEW-BORN INFANT. Omphalitis is a peculiar inflammation of the umbilicus and surrounding structures, in which the abdomen becomes conical in shape ; the skin and subcutaneous connective tissue are hard, red, and infiltrated. It is always septic in origin. It requires dis- infection of the umbilicus, poultices, and early incisions, with stimulants and supporting treatment. A later stage of the in- flammation is gangrene. The prognosis is very grave. It is difficult to avert general systemic infection. Inflammation of the umbilical vessels is always due to septic infection, and invariably leads to systemic infection, which is commonly fatal. Hemorrhage from the Umbilicus (Omphalorrhagia). — The bleed- ing may come from the cord or from the umbilical ulcer. It may be primary, from careless ligation of the cord ; or second- ary, after the cord drops off The vessels of the cord close from the placental end inward, and the hypogastric arteries may be patulous after the cord drops off, when increased blood-pressure or handling the ulcer may bring on hemorrhage. The mortality of this accident is computed at seventy-six to eighty-three per cent. Treatment. — In primary hemorrhage the cord must be promptly re-ligated. In bleeding from the umbilical stump, if the bleeding vessels are seen, they should be ligated. Usually, it is impossible to isolate the bleeding vessels. In such cases the hemorrhage may be controlled by Monsel's solution and pressure by liquid plaster-of- Paris poured into the navel, where it "sets," by powdered suprarenal extract, or by successive' layers of powdered bismuth, with gauze and collodion. Ergotin hypodermatically (gr. ss), gallic acid (gr. j) by the mouth, and gelatin (5 c.c. of a 10 per cent, solution in sterile normal salt solution) hypodermatically should be employed in addition to the local treatment. As a last resort, the abdominal wall around the navel should be transfixed with harelip pins or ordinary large- sized needles, and a figure-of-eight ligature should be applied under them. If there is sufficient stump of the cord left, it should be drawn out and transfixed with two pins or needles and ligated below them. I was able to check a hemorrhage in this way several days after the cord had dropped off". If this is im- possible, one pin and a ligature may suffice; it should transfix the abdominal wall just below the umbilicus, so as to occlude the hypogastric arteries. Before inserting the pin the abdominal walls should be compressed and rolled between the thumb and forefinger to get rid of coils of intestines. Should the hemor- rhage continue, it can be controlled by a pin and a Hgature above the umbilicus to occlude the umbihcal vein. DISEASES OF THE A'EU'-BOA'N INFANT. 97 1 Tetanus of the new=born is the result of the entrance of tetanus bacilli through the umbilicus. The disease in temperate climates occurs almost exclusiveh' in hospitals. It is usually fatal, the death-rate being over go per cent. The treatment should be antitoxin serum and a thorough disinfection of the navel. Melena, or gastro=intestinal hemorrhage, is an extravasation of blood into the stomach and intestines, occurring most often in the first few hours of life. In 67 collected cases by Vassmer,^ with 22 deaths, the causes were ulcers in the duodenum, stomach, esophagus, and ileum; defective development of the heart; ste- nosis of the duodenum; invagination of the intestines; syphilis, and a blood infection by parat}'phoid and colon bacilH. The child may vomit bright, unaltered blood, or the vomit may be " coffee-grounds " in character. The blood from the bowel is black in color, and is mixed with meconium, hence the name melena. It is to be carefully distinguished from the vomiting of blood derived from a fissured nipple in the mother and ingested with the milk. In melena the infant shows unmistakable s}'mp- toms of internal hemorrhage. Treatment. — Corpechot- cured a case of melena by injecting horse serum and antidiphtheritic serum; gelatin and adrenalin have been used with success; but the most remarkable results were obtained by Welch,^ who cured 12 successive cases by the sub- cutaneous injection of human blood-serum, 10 c.cm., three times a day for several days. Larger quantities may be given in bad cases and the treatment should begin as early as possible. The blood, freshly drawn from a \agorous, health}- donor, is allowed to clot and the supernatant serum is injected. Bloody discharge from the genitalia of female children is not very rare. It shows' an actixity of the sexual organs anal- ogous to the breast changes in the new-born. The condition is not dangerous, and requires no treatment. The blood comes from the uterus, like the menstrual discharges — in fact, the dis- charge is a true menstruation, as has been demonstrated in postmortem examinations of infants who died from intercurrent affections. It appears three or four days after birth, and lasts only a few da\s. Sudden death of apparently healthy children is an accident not infrequently demanding an explanation b}- the attending physician. 1 " Arch. f. Gyn.," Bd. 89, p. 275. 2 " Bull. Soc. Obst.," Paris, 1909. ' John Edgar Welch, Am. Jour, of the Med. Sci., June, loio; also Am. Joum. Obstet., April, 191 2. 9/2 THE NEW-BORN INFANT. Among the causes may be found overlying by the mother, accidentally or intentionally. In one of the reports of the Regis- trar-general of England, there was a record of 1500 cases, the majority occurring on Saturday night ! Diseases. — Most commonly pneumonias, apoplexies, more rarely perforation or intussusception of the bowels, rupture of a large viscus, or any of the diseases previously described, which had not been detected during life. Occlusion of the trachea by an enlarged thymus or by curds of milk. Congenital deformities of important internal organs, as atresia of the ureter. Medication of the New=born. — In administering medicine to a newly born infant, the physician should remember its peculiar intolerance of opium and its tolerance of some other remedies. The following are some of the drugs and their doses re- quired in the first four weeks of life : Opium, only as paregoric, from two to five drops in one dose, not repeated ; mercury, always as calomel, ^^ to i gr. ; castor oil, 1 5 gtt. to 3J ; nitrate of silver, To to 4V g^- ; pepsin, gr. j-ij ; gallic acid, gr. ss-ij, etc. INDEX. Abdomen, appearance, in pregnancy, 14S auscultation, in examination, 70 changes in size and shape, in preg- nancy, 146 flatulent, distention, in puerperal state, 698 gauze pad for, 788 inspection, in examination, 61, 69 mensuration, in examination, 71 palpation, in examination, 59 in pregnancy, 153 percussion, in examination, 70 preparation, for abdominal section, 788 tumors, pregnancy and, differentia- tion, 157 Abdominal and vaginal examination, combined, 55 aorta, compresion, in postpartum hem- orrhage, 609 belt after abdominal section, 937 binder in postpartum hemorrhage, 607 muscles, action, in second stage of labor, 191 diastasis, in labor, 638 in puerperal state, 698 in labor, 178 palpation at end of puerperium, 241 diagnosis of position of fetus by, 246 in labor, 185, 245 pregnancy, 447, 454 secondary, 447 symptoms, 464 section, abdominal belt after, 937 after-treatment, 040 drainage after, 913 exploratory, for puerperal sepsis, 7S8 for abdominal tumors, 928 for diffuse suppurative peritonitis, for interstitial pregnancy, 467 for intraperitoneal abscess, 752 for pelvic tumors, 928 for tubal pregnancy, 466 for ureteral fistula, 903 in private house, articles required, 872 in puerperal sepsis, 740 of retrodisplacement of uterus, 933 preparation for, 7S7, on y\bdominal section, preparation for, afternoon before operation, 787 iodin method of preparing skin, 789 morning of operation, 788 of abdomen in, 788 of nurse in, 788 sluggishness of bowels after, treat- ment, 941 tympany after, treatment, 941 vomiting after, treatment, 941 supporter, Patterson's, 358 tumors, abdominal section for, 928 degeneration and putrefaction, in puerperal sepsis, 776 walls, changes, in pregnancy, 136 wound, closure, 912 Abortion, 432 after-treatment, 446 causes, 432 cholemic convulsions in, 434 clinical history, 436 phenomena, 436 diagnosis, 441 duration, 439 epilepsy in, 434 frequency, 436 from abnormal position of uterus, 435 from alterations in maternal blood, 435 from anemia, 353 from cholera, 340 from chorea, 434 from chronic endometritis, 352 from coughing, 434 from diffuse hyperplasia of decidual endometrium, 327 from eclampsia, 434 from irritable uterus, 433 from maternal diabetes, 354 from metritis, 352 from poisoning of mother, 354 from spasmodic muscular action in mother, 434 from typhoid fever, 340 from vomiting, 434 hemorrhage in, 430 hysteric convulsions in, 434 in placenta prasvia, 506 in retrodisjilacement of pregnant uterus, 362 973 974 INDEX. Abortion, induction, 808 indications, 808 methods, 809 inevitable, diagnosis, 441 Tamier's sign, 442 treatment, /\ \ /\, active, 445 expectant, 444 missed, 446 mortality, 440, 443 overdistention of uterus as cause, 435 pain in, 439 partially or wholly accomplished, diagnosis, 442 prognosis, 440, 443 tetanoid convulsions in, 434 threatened, diagnosis, 441 treatment, \ t\ \ treatment, 443 tubal, 451, 460 Abscess, intraperitoneal, abdominal sec- tion for, 752 ischiorectal, in puerperal sepsis, 777 of Bartholin's gland, obstruction of labor by, 570 of breasts, 721 in pregnancy, 399 in puerperal state, 229 of fixation in puerperal sepsis, 748 of placenta, 316 of vulvovaginal gland in pregnancy, 397 postmammary, 722 suburethral, in pregnancy, 390 Absorption, putrid, in puerperal sepsis, 772 Acanthopelys, 530 Acardia in multiple fetation, in Accessory corpuscle of spermatozoon, 84 Accidental hemorrhage, 591, 602 rupture of uterus and, differentia- tion, 618 Accidents, labor complicated by, 591 of labor, 642 to fetus, 644 Accouchement force for induction of pre- mature labor, 811 in eclampsia, 657 Acetabulum, fracture, 534 Acetonuria in pregnancy, 417 Achondroplasia of fetus, 341, 342 Acne in newborn infant, 966 Actinomycosis of breasts, 725 Adenoma of breasts, 723 Adhesions of placenta, 292 diagnosis, 293 treatment, 293 peri-uterine, in pregnancy, 396 Adhesive inflammation in formation of amniotic bands, 302 Adipocere, 351 Adnexa, uterine, involution, 211 After-coming head, delivery, by forceps, 852 Deventer's method, 852 Mauriceau's method, 849, 850 Prague method, 851 Wigand's method, 849 After-pains, 214 treatment, 215 Agalactia, 709 Agglutination of labia, treatment, 876 Airing newborn infant, 950 Albimiinmia as indicating induction of abortion, 808 in pregnancy, 418 in puerperal state, 699 Albuminuric retinitis in puerperal state, 701 Alimentary canal, diseases, in pregnancy, 401 Allantois, 123 Alquie-Alexander-Adams operation for retrodisplacement of uterus, 929 Amastia, 705 Amnion, 296 abnormalities, 296 of secretion, 296 anatomy, 114 cysts, 303 development, 113 dropsy, 296 fully developed, 114 Amniotic bands, formation, 302 fluid, 115. See also Liquor amnii. Amphiarthroses, 20 Amputation, intra-uterine, 344 of breasts in eclampsia, 656 technic, 940 of cervix uteri, 909 Hegar's method, 910 of clitoris, indications, 876 of,fetal parts to effect delivery, 858 of labia, indications, 876 Amyl nitrite in eclampsia, 656 Anasarca, 577 of fetus, 342 Anastomosis, ureteral, for ureteral fistula, 901 Anemia as cause of abortion, 353 in pregnancy, 426 puerperal, 665 Anesthesia, chloroform in, 189 in examination, 60 in obstetric operations, 790 Anesthetics in labor, 187-189 Anesthetization in eclampsia, 653 Aneurysm in pregnancy, 425 of gluteal artery in pregnancy, 392 Angioma of placenta, 322 Ankylosis in fetus, 344 of pelvic joints, 536 of sacrococcygeal joint, 536 Annular placenta, 313 INDEX. 975 Anteflexion of gravid uterus, 357 treatment, 357 Antepartum fetometry, 497. See also Fetomelry, anlepartiim. Anteroposterior diameter of pelvic inlet, measurement, 480 outlet, measurement, 407 Antc-utcrine hematocele, 462 Antistreptococcus serum in pucrj^eral sepsis, 745, 747 Anus vaginalis, obstruction of labor by, 567 vestibularis, obstruction of labor by, 567 Aorta, abdominal, compression, in post- partum hemorrhage, 609 Aphthae, Bednar's, in newborn infant, 965 in newborn infant, 964 Apoplexies in puerperal state, 704 Apoplexy, pulmonary, in newborn in- fant, 962 Appendicitis in pregnancy, 408 Arbor vitse of uterus, 45 Areola, inflammation, 716 Argyrol in puerperal sepsis, 748 Armamentarium for labor, 183 Arms, delivery, after podalic version, 847 Arteries of pelvic organs, 30 of uterus, 31, 32 ovarian, 30 Arthritis in puerperal state, 695 Articular rheumatism of fetus, 340 Artificial dilatation of cervical canal, 791 feeding of infant, 947 of newborn infant, 947 food, preparation, 948 hyperleukocytosis in treatment of puerperal sepsis, 748 respiration, 957 Byrd's method, 957 Hall's method, 957 mouth-to-mouth, 958 risks attending, 960 Schultze's method, 958 sterility, 92 vagina, Fleming's operation for mak- . ing, 907 Ascites, hydramnios and, diff'erentiation, 30o_ Aseptic technic in obstetric operations, 780 Ash of human milk, 947 Asphyxia livida, 957 neonatorum, 957 after-treatment, 960 causes, 956 treatment, 957 of newborn infant, 956 pallida, 957 Assimilation pelvis, 516 Asthma in pregnancy, 427 Atelectasis of newborn infant, 960 Atmosphere, [)uerperal sepsis from, 741 Atresia of cervix, obstruction of labor by, 563 of vagina, hysterectomy for, 908 obstruction of labor by, 567 surgical treatment, 906 Atro[)hy of dccidua, 332 Auscultation, diagnosis of position of fetus by, 247 in examination, 70 in pregnancy, 156 Auto-infusion in postpartum hemor- rhage, 611 Auto-intoxication in pregnancy, 400 Avortement instantane, 439 Axis-traction forceps, application, 833 Baby-clothes, 232 Baby's basket, 232 Bacelli's treatment of tetanus in puer- peral sepsis, 777 Bacillus aerogenes capsulatus in puer- peral sepsis, 733 colon, in puerperal sepsis, 733, 736 fecalis alcaligenes in puerperal sepsis, 733 foetidus in puerperal sepsis, 733 Klebs-Lofifler, in puerperal sepsis, 733 pyocyaneus in puerperal sepsis, 733 tetanus, in puerperal sepsis, 733 tubercle, in puerperal sepsis, 733 Back presentation, 283, 286 saddle-shape, 540 sway, 540 Bacteria, behavior, in genital canal, 735 capable of producing puerperal sepsis, 732 in milk, 715, 718 manner of entrance into vaginal canal, 734 of vagina, 729 of vulva, 730 pathogenic, in vagina, in pregnancy, 387 Bacterin treatment of puerperal sepsis, 747 Bag of waters, 177 Baldy's operation for retrodisplacemen t of uterus, 934-937 Ballottement, 156 Bandl's operation for ureteral fistula, 902 ring, 133, 249, 613 Barnes' bag for artificial dilatation of cervical canal, 791 treatment of placenta praevia, 600 Bartholin's glands, 43 abscess, obstruction of labor by, 570 Basal decidua, 130 Basiotribe, Tamier's, 854, 855 Bathing newborn infant, 230, 949 9/6 INDEX. Baudelocque, diameter of, 4S0 method of cephalic version, 271 Bednar's aphthae in newborn infant, 965 Bier's cups for breast, 721 hj'peremic treatment of mastitis, 721 Bimanual examination, 55, 58 Binder, abdominal, in postpartum hem- orrhage, 607 breast-, Murphy's, 230 for sjTnphyseotom}', 86 2 Hirst's, for symphyseotom}^ 862 obstetric, 200 Birth wnth doubled body, 289 Bivalve speculum. Hirst's, 62 method of introducing, 62, 63 Bladder, calculi in, obstruction of labor by, 571 in pregnane}^, 416 changes, in pregnancy, 136 diseases, in pregnane}', 416 hemorrhoids, in pregnancy, 416 implantation of ureter into, for ureteral fistula, 903 irritability, in pregnancy, 416 papilloma, obstruction of labor by, 571 Blastodermic vesicle, 93 Blastomeres, 93 Blastula, 93 Bhndness in pregnancy, 420 in puerperal state, 701 Blood, changes, in pregnanc3% 136 circulation, in fetus, 103 diseases as indicating induction of abortion, 809 in pregnanc3% 426 in newborn infant, 944 in pregnancy, 215 in puerperal state, 215 maternal, alterations in, as cause of abortion, 435 fatal to fetus, 353 transfusion, in postpartum hemor- rhage, 611, 612 washing of, treatment of puerperal sepsis by, 74S Blood-clots, retention, puerperal hemor- rhage from, 670 Blood-corpuscles in puerperal sepsis, 738 Blood-pressure apparatus, Nicholson's, 141 Rogers', 140 Tycos, 140 in pregnane}', 141 increasing, in eclampsia, 650 remedies to reduce, 656 Blood-serum and syncytium, relation, .137 in puerperal sepsis, 747 Blood-suppl}', increased, to genitalia and breasts, in pregnancy, 14(3 Blood-vessels, changes, in involution of uterus, 210 Blood-vessels, diseases, in pregnancy, 424 of pehac organs, 30 of uterus, changes, in pregnancy. 131 Bloody discharge from genitalia of fe- male children, 971 Blot's perforator, S54 Blue baby, 968 milk, 716 Blunt hook, 838 Bossi's dilator, 799 Bougie method for induction of prema- ture labor, 810 Bougies, graduated, artificial dilatation of eer\-ical canal b}', 802 Hegar's, 803 Bowels in puerperal state, 227 movements, in newborn infant. 943 of child, injur}', in labor, 956 sluggishness, after abdominal section, treatment, 941 Brain, congestion, in pregnancy, 419 diseases, in pregnancy, 419 inflammator}' diseases, in pregnancy, 419 injur}', during labor, 950 Branchial palsy from injur}' during labor, 951 Braun-Femwald's sign of pregnancy, 155 Braun's colpeur}Titer in placenta prae\na, 600 cranioclast, 854 metreurynter, artificial dilatation of cer\'ical canal by, 791 Breast-binder, Murphy's, 230 Breast-pump, 719 Breasts, abnormalities, 708 abscess, 721 in pregnancy, 399 in puerperal state, 229 absence, 705 actinomycosis, 725 adenoma, 723 amputation, in eclampsia, 656 technic, 940 areola, inflammation, 716 caked, 718, 721 cancer, 723 congestion and engorgement, 716 developmental anomalies, 705 diseases, 716 in pregnancy, 399 fibro-adenoma, 725 h}'pertrophy, 705 in pregnancy, 147 in puerperium, care, 228 changes in, 219 increased blood-suppl}' to, in preg- nancy, 146 inflammation, 720 massage, 716, 717 operations on, 938 INDEX. 977 Breasts, sebaceous cysts, 716 structure, 2ig supernumerary, 705 tuberculosis, 725 tumors, 723 benign, operative treatment, 938 in pregnancy, 399 malignant, operative treatment, 940 Breech, extraction of, 835 by blunt hook, 838 by fillet, 837 by forceps, 836 manual method, 835 presentation, 276. See also Presenta- tion, breech. Breus' axis-traction forceps, 820 Broad ligament, pregnancy, 450, 459 technic of ligating, in salpingo- oophorectomy, 922 tumors, enucleation, 928 Bronchi, diseases, in pregnancy, 426 Bronchial catarrh in pregnancy, 426 Brow presentation, 274. See also Pre- sentation, brow. Bruit, placental, 71 uterine, in pregnancy, 156 Bulbs of vestibule, 43 Bylicki's pelvimeter, 491 Byrd's method of artificial respiration, 957 Caffein in eclampsia, 656 Caked breast, 718, 721 Calcareous degeneration of placenta, 314 of umbilical cord, 326 Calculus, renal, in pregnancy, 416 vesical, in pregnancy, 416 obstruction of labor by, 571 Cancer of breast, 723 of cervix uteri in pregnancy, 386 puerperal hemorrhage from, 671 of pelvis, 532 of placenta, 318 of uterus, puerperal hemorrhage from, 671 of vagina in pregnancy, 390 of vulva in pregnancy, 394 syncytiale, 318 Caput succedaneum, 953 in flat pelvis, 502 in justominor pelvis, 507 Cardiac nerve-storms in pregnancy, 138, 427 Caries of peh'is, 536 of teeth in pregnancy, 401 Carunculae myrtiformes, 43 enlarged, obstruction of labor by, 570 Carus, curve of, 24 Casein of milk, 947 Caseinogen, 947 62 Catarrh, bronchial, in pregnancy, 426 nasal, in newborn infant, 964 Catarrhal endometritis, 330 Catgut, preparation, 789, 790 Catharsis in eclampsia, 653 Catheter, Dorrance's tracheal, 959, 960 Catheterization in puerperal state, 226 of ureters in pregnancy, 409 Caul, 589 Celiohysterectomy, 867 Celiohysterotomy and celiohysterec- tomy, choice, 868 Celio-ureterocystostomy for ureteral fis- tula, 901, 903 Celio-uretero-ureterostomy for ureteral fistula, 901 Cell-membrane, internal, of ovum, 77 Celloidin thread, preparation, 790 Cells, decidual, 120, 130 of Friedlander, 130 interstitial, of ovary, 53 Langhans', 452 Cellulitic phlegmasia in puerperal sep- sis, 769 Cellulitis in puerperal sepsis, 761 Cephalhematoma, 953 Cephalic presentation, 247 explanation of frequency, 248 version, Baudelocque's method, 271 Schatz's method, 271 Cephalotribes, 855 Cerebral disease, fever in puerperal state from, 682 Cervical canal, artificial dilatation, 791 by anterior vaginal hyster- otomy, 804 by Barnes' bag, 791 by Braun's metreurjTiter, 791 by Champetier de Ribes' bag, 791 by Diihrssen's method, 803, 804 by Edgar's method, 794 by forceps, 795 by graduated bougies, S02 by Harris' method, 794 by Hirst's bag. 792 by hysterostomatomy, 804 by incisions, 803 in non-pregnant uterus, 803 in pregnant uterus, 803 by manual methods, 794 by Pomeroy's bag, 791 by Tarnier's bag, 791 by vaginal Cesarean section, 804 by \'oorhees' bags, 791 curettage of uterus after, 808 Dudlej^'s operation, 803, 804 hydrostatic, 791 instrumental, 795 in non-pregnant uterus, 795 in pregnant uterus, 798 978 INDEX. Cervical canal, artificial dilatation, Wylie's method, 797 septa of, obstruction of labor by, 565 fistula, diagnosis, 892 myoma in pregnancy, 385 polj^s in pregnancy, 385 pregnancy of Rokitansky, 332 Cervicitis in pregnancy, 385 Cervix uteri, alterations, in pregnancy, amputation, 909 Hegar's method, 910 anatomy, 46 appearance, in pregnancy, 152 atresia, obstruction of labor by, 563 cancer, in pregnancy, 386 puerperal hemorrhage from, 671 cicatricial contraction, obstruction of labor by, 564 circular detachment, in labor, 624 closure and contraction, obstruction of labor by, 563 diseases, in pregnancy, 385 displacement, 369 edema, in pregnancy, 385 epithelioma, puerperal hemorrhage from, 671 examination, specular, at end of puerperium, 241 in pregnancy, 154 injuries, in labor, 621 laceration, repair, 910 myoma, in pregnancy, 385 operations on, 909 polyps, in pregnancy, 385 rigidity, obstruction of labor by, 564 Cesarean section, 865 extraperitoneal, 870 in eclampsia, 657, 658 in placenta prsevia, 601 indications, 866 Porro's method, 867 postmortem, 865 Sanger's method, 867 suprasymphyseal, 870 upon living woman, 865 vaginal, artificial dilatation of cer- vical canal by, 804 in placenta praevia, 602 varieties, 865 Chamberlen forceps, 814 vectis, 814 Champetier de Ribes' bag for artificial dilatation of cervical canal, 791 Child, newborn, 229. See also iVew- horn infant. Child-bearing process, operations for complications and pathologic conse- quences, 872 Chloral in eclampsia, 655 Chloroform in anesthesia, 189 in eclampsia, 653 Cholemic convulsions, abortion from, 434 Cholera of fetus, 340 Chondrodystrophia foetalis, 341, 342 Chorea, abortion from, 434 in pregnancy, 419 treatment, 420 Chorio-epithelioma, 318 Chorion, 303 at term, 118 chronic inflammation, 312 description, 117 development, 117 diseases, 303 epithelioma, puerperal hemorrhage from, 669 fibromyxomatous degeneration, 311 frondosum, 118 lasve, 118 rupture, 311 villi of, 117 cystic degeneration, 303. See also Cystic degeneration. dropsy, 304 Chyluria in pregnancy, 417 Cicatrices of vagina, obstruction of labor by, 566 Cicatricial contraction of cervix, obstruc- tion of labor by, 564 Circular detachment of cervix uteri in labor, 624 vein of placenta, 122 Circulation of fetal blood, 103 Circulatory apparatus, alterations, in puerperal state, 215 diseases, in pregnancy, 422 system, changes, in pregnancy, 136 Claudius' iodin gut, 790 Clavicles, fetal, cutting or breaking, to facilitate delivery, 858 Cleft-palate of newborn infant, 963 Cleidotomy, 859 Cleveland dilator, 796 Clitoris, 43 amputation, indications, 876 Cloaca, 37, 40 Clothing of newborn infant, 946 Club-foot, pelvic deformity from, 557 Coccygectomy, 938 Coccyx, examination, at end of puer- perium, 243 fracture, in labor, 639 Coitional vagina, Isaacs' operation for making, 909 Sneguireff's operation for making, 909 Coitus, time most likely to result in con- ception, 89 Cold, exposure to, fever in puerperal state from, 680 Colic in newborn infant, 965 Collargol in puerperal sepsis, 748 INDEX. 979 Collin's speculum, 62 Colloidal silver in puerperal sepsis, 748 Colon bacillus in jjucrperal sepsis, 733, 736 Color of milk, anomalies, 716 Colostrum, 148, 22c, 708 corpuscles, 708 in milk, 715 in pregnancy, 148 Colovesical fistula, 889, 891 diagnosis, 892 Colpitis, emphysematous, in pregnancy, 388 Colpocleisis in vesicovaginal fistula, 897, 8q8 Colpohyperplasia cystica in pregnancy, 388 Colpo-ureterocystotomy for ureteral fistula, 901 Combined version, 841. See also Yer- sion, combined. Commissures, anterior, 42 posterior, 42 Compact layer of uterine decidua, 130 Compound presentation, 582 treatment, 583 Conception, average date, after mar- riage, 89 time most likely to occur, 89 Condyloma, pointed, of vulva, in preg- nancy, 392 Congestion of brain in pregnancy, 419 of breasts, 716 Conglutinatio orificii uteri externi, 563 Conjugate diameter, false, of spondylo- listhetic pelvis, 542 of pelvis, diagonal, measurement, 484 manual method, 484 external, measurement, 480 true, measurement, 484 Conjunctivitis of newborn, 967 Connective tissues of pelvis, 28 of uterus, changes, in pregnancy, 131 Constipation, fever in puerperal state from, 680 in newborn infant, 965 in pregnancy, 140, 407 Contracted pelvis, flat, 507 generally, 507 management of labor in, 557 management of labor in, 557 obliquel}', 510 transversely, 514 Contraction, cicatricial, of cervix uteri, obstruction of labor by, 564 of vagina, obstruction of labor by, 565 ring, 133, 249, 613 Convulsions, 646. See also Eclampsia. Cord, umbilical, 322. See also Umbilical cord. Corpore reduplicato, 290 Corpus luteum, 79 false, 80 lutein in, 79 of menstruation, 80 of pregnancy, 80 Corpuscle, accessory, of spermatozoon, 84 Corpuscles, colostrum, 708 in milk, 715 Coughing, abortion from, 434 in pregnancy, 420 Cows' milk compared to human, 948 composition, 948 Coxalgia, 553 Coxalgic pelvis, 553 Cranioclast, 854, 855 Braun's, 854 Craniopagus, 573 Craniotomy, 853 instruments for, 854 technic, 856 Cranium, premature ossification, ob- struction of labor by, 576 Crede's method of expressing placenta, 202, 291, 292 ointment in puerperal sepsis, 748 Cuneiform hysterectomy, technic, 914 Cups, Bier's, for breast, 721 Curettage of uterus after artificial dila- tation of cervical canal, 808 Curve of Carus, 24 Cyanosis of newborn infant, 968 Cylindric speculum, 69 introducing, 69 Cyst of labium minora in pregnancy, 395 of ovary, hydramnios and, differentia- tion, 300 Cystic degeneration of chorion villi, 303 clinical history, 309 diagnosis, 309 etiology, 310 frequency, 310 pathologic anatomy, 306 treatment, 310 of umbilical cord associated with edema, 323 elephantiasis, congenital, of fetus, 343 endometritis, 330 Cystitis in pregnancy, 416 septic, in puerperal sepsis. 774 Cystocele, obstruction of labor by. 571 operation for, 888 Cystoscope, Eisner's, 411 Wappler, 409 Cystoscopy of ureters in pregnancy, 409 Cj'sts, hydatid, of pelvis, in pregnancy, 392 of amnion, 303 of pelvis, 532 of placenta, 317 of umbilical cord, 326 ovarian, in pregnancy, 382 980 INDEX. Cysts, sebaceous, of breasts, 716 sublingual, in newborn infant, 965 vaginal, in pregnancy, 390 Davis' forceps, 817, 818 Death of fetus, causes, in fetus itself, 354 referable to father, 355 detection, 350 effect on mother, 349 growth and development of placenta after, 461 habitual, 352, 355 in utero, 349 of mother, effect on fetus, 348, 643 sudden, in labor, 640 of apparently healthy children, 971 Decapitation, 857 during labor, 954 Decapsulation of kidneys in eclampsia, 656 Decidua, 125, 327 atrophy, 332 basal, 130 catarrhal endometritis, 330 cystic endometritis, 330 diffuse hyperplasia, 327 diseases, 327 epichorial, 130 exanthematous endometritis, 331 hemorrhagic endometritis, 331 inflammation, acute, 331 microbic endometritis, 331 ovular, 130 placental, 130 polypoid endometritis, 327 purulent endometritis, 331 reflexa, 130 serotina, 117 tuberculous endometritis, 331 tuberous subchorial hematoma, 328, 329 uterine, 130 glandular laj^er, 130 spongy layer, 130 vera, 117, 130 Decidual cells, 120, 130 of Friedlander, 130 endometritis, exanthematous, 331 hemorrhagic, 331 microbic, 331 purulent, 331 endometrium, diffuse hyperplasia, 327 fragments, retention, after labor, 668 Deciduoma malignum, 318 Deciduosarcoma, 318 Deformities of pelvis, 477. See also Pelvis, deformities. Degeneration, calcareous, of placenta, 314 of umbilical cord, 326 Degeneration, cystic, of chorion villi, 303. See also Cystic degeneration. of umbilical cord, associated with torsion, 323 fibromjTcomatous, of chorion, 311 myxomatous, of placenta, 313 nerve, in puerperal state, 704 of pelvic and abdominal tumors in puerperal sepsis, 776 of placental viUi, 313 Delirium of fever in pregnancy, 422 temporary, of labor, 422 tremens in pregnancy, 422 Delivery of placenta, 200 Crede's method, 202 postmortem, 643 Deutoplasm of ovum, 77 Deventer's method of delivering after- coming head, 852 Dewees' axis-traction forceps, 820 dilator, 803 Diabetes, maternal, effect on fetus, 354 mellitus in pregnancy, 418 Diagonal conjugate, measurement, 484 manual method, 484 Diameter, diagonal conjugate, measure- ment, 484 manual method, 484 false conjugate, of spondylolisthetic pelvis, 542 of Baudelocque, 480 of pelvis, 22 anteroposterior, of inlet, measure- ment, 480 of outlet, measurement, 497 external conjugate, measurement, 480 oblique, of inlet, measiurement, 494 transverse, measurement, 492 of outlet, measurement, 494 true conjugate, measurement, 484 Diaphoresis in eclampsia, 653 Diarrhea in newborn infant, 965 in pregnancy, 407 Diastasis of abdominal muscles in labor, 639 in puerperal state, 698 of recti muscles, operative treatment, 937 Webster's operation, 937 Dicephalus, 573, 574 birth of, 576 Dickinson-Harris pelvimeter, 481 Diet in pregnancy, 142 in puerperal state, 225 Digestion in newborn infant, 943 Digestive tract, changes, in pregnancy, 138 Dilatation, artificial, of cervical canal, 791 of OS uteri in labor, 174 Dilator, Bossi's, 799 INDEX. 981 Dilator, Cleveland's, 796 Dc wees', 803 Hcf^iir's, 80? Hirst's (J. C), 798 S( hiitz's, 797 Diphlheria, bacillus, in puerperal sepsis, 733 in puerperal state, 693 relation, to puerperal sepsis, 777, 779 Dijjrosoinis, craniotomy for, 578 Direction of presenting iiart, anomalies, 259 Discus ]iroligcrus, 76 Dislocations in fetus, 344 of femora, effect, on pelvis, 554 of kidney in pregnancy, 414 in ijuerpcral state, 703 Displacements, lateral, of pregnant uterus, 370 in labor, 370 of cervix uteri, 369 of gravid uterus as indicating induc- tion of abortion, 809 of uterus, anterior, in labor, 357 in pregnancy, labor, and puerpcrium, 357 in puerperium, 370 diagnosis, 372 treatment, 373 puerperal hemorrhage from, 370, 669 diagnosis, 372 treatment, 373 Dissecting metritis in puerperal sepsis, 761 Distortion of head during labor, 951 Doderlein's lochial tube, 739 Nicholson's modification, 740 Dorrance's tracheal catheter, 959, 960 Double promontory, 485 uterus, obstruction of labor by, 562 vagina, 49, 50, 565 D'Outrepont's method of combined ver- sion, 842 Draeger's pulmotor, 958, 959 Drain, Wylie's, for artificial dilatation of cervical canal, 797 Drainage after abdominal section, 913 Drops}' of amnion, 296 of chorion villi, 304 Dry labor, 190, 589 Duck-bill speculum, 68 Ductus arteriosus, 104 venosus, 103 Dudley's operation for dilatation of cer- vical canal, 803, 804 for ureteral fistula, 902 Dtihrssen's method of artificial dilatation of cervical canal, 803, 804 Dulncss on jiercussion in pregnancy, 156 Dwarf pelvis, 504, 505 Dystocia due to disease, 646 Dysuria in retroflexion of [jrcgnant uterus, 3O2 ECLACTISMA, 647 Eclampsia, 647 abortion from, 434 accouchement force in, 657 amputation of breasts in, 656 anesthetization in, 653 caffein in, 656 catharsis in, 653 causes, 646, 647 Cesarean section in, 657, 658 chloral in, 655 chloroform in, 653 decapsulation of kidneys in, 656 diagnosis, differential, 651 diaphoresis in, 653 effect on fetus, 348 elaterium in, 654 frequency, 649 hirudin in, 656 in labor, 656 increasing blood-pressure in, 650 lumbar puncture in, 656 morphin in, 655 nitrite of amyl in, 656 nitroglycerin in, 656 obstetric treatment, 656 oxygen in, 656 parathyroid extract in, 656 pathology, 650 pilocarpin in, 656 portable sweat cabinet in, 654 prognosis, 652 puncture of membranes in, 656 remedies to reduce blood-pressure, 656 scheme of treatment, 659 symptoms, 650 thyroid extract in, 656 treatment, 653 urine in, 650 venesection in, 654 veratrum viride in, 655 without convulsions in pregnancy, 401 Ectoderm, 93, 113 Ectopic pregnancy, 447. See also Exlra- ittcrine pregnancy. Eczema of nipples in pregnancy, 399 Edebohls' self-retaining speculum, 68 Edema of cervix in pregnancy, 385 of genitals after labor, 666 of placenta, 313 of umbilical cord associated with tor- sion, 323 of vulva in pregnancy, 395 obstruction of labor by, 569 Edgar's method of artificial dilatation of cervical canal, 704 Effective conjugate diameter of spondy- lolisthetic pelvis, 542 982 INDEX. Effusion, retroplacental, 182 Egg-cords, 76 Ehrenfest-Neumann kliseometer, 491, 495, 496 pelvigraph, 491, 495, 496 Elastic tissue of uterus, changes, in pregnancy, 131 Elaterium in eclampsia, 654 Electricity in postpartum hemorrhage, 609 Elephantiasis, congenital cystic, of fetus, 343 in puerperal sepsis, 771 of vulva, obstruction of labor by, 567 treatment, 876 Eisner's cystoscope, 411 Embolism of pulmonary artery in labor, 642 pulmonary, in pregnancy, 427 Embryo, death, as indicating induction of abortion, 809 development, 95 in first month, 95 in second month, 99 in third month, 100 harelip in, 99 Embryonal area, 93 Embryotomy, 853 instruments for, 854 Emmet's operation for laceration of posterior wall of vagina, 877-880 Emotional fever in puerperal state, 678 Emotions as cause of puerperal hemor- rhage, 670 death from, in labor, 642 effect, on milk, 711, 714 maternal, influence, on fetus, 347 Emphysema in pregnancy, 426 subcutaneous, in labor, 640 Enchondroma of pelvis, 532 Endocervicitis in pregnancy, 385 Endochorion, 118 Endocolpitis in puerperal sepsis, 760 Endometritis, catarrhal, of decidua, 330 cystic, of decidua, 330 decidual, exanthematous, 331 hemorrhagic, 331 microbic, 331 purulent, 331 decidualis polyposa, 328 tuberosa, 328 in puerperal sepsis, 760 placentaris, 315 gummosa, 315 polypoid, of decidua, 327 tuberculous, 331 Endometrium, decidual, dififuse hyper- plasia, 327 involution, 210 English forceps, 816 Engorgement of breasts, 716 Enterocele, vaginal, in pregnancy, 390 Enterovesical fistula, 889, 890 Entoderm, 93, 113 Epichorial decidua, 130 Epilepsy, abortion from, 434 in pregnancy, 420 Epistaxis in pregnancy, 426 Epithelioma of cervix, puerperal hemor- rhage from, 671 of chorion, puerperal hemorrhage from, 669 of vulva in pregnancy, 393 Epoophoron, 40 Erect posture, examination in, 58 Ergot for involution of uterus, 225 in after-pains, 215 Ergotin in postpartum hemorrhage, 607 Erysipelas in puerperal state, 691 of fetus, 338 relation, to puerperal sepsis, 777, 778 Erythematous rashes in puerperal state, 690 Ether in labor, 189 Evisceration, 858 Evolution, spontaneous, 289 Examination, 55 abdominal and vaginal, combined, 55 anesthesia in, 60 auscultation, 70 bimanual, 55, 58 implements, 55 in erect posture, 58 inspection of abdomen, 61, 69 of pelvic organs, 61 mensuration of abdomen, 71 methods, 55 nurse as aid, 69 palpation, 55 of abdomen, 59 of kidneys, 59 percussion, 70 postures, 55 rectal, 57 rubber glove for, 57 vaginal and abdominal, combined, 55 Exanthemata in puerperal state, 686 of newborn infant, 963 Exanthematous decidual endometritis, 331. Exercise in pregnancy, 141 Exochorion, 118, 304, 306 Exophthalmic goiter in pregnancy, 424 Exostoses of pelvis, 530 Expulsion, forces, 249 Expulsive forces of labor, excessive power, 476 Exsection of vulvar nerves, 876 Extension of fetal head, anomalies, 260 in labor, 256 External conjugate, measurement, 480 Extramedian engagement of head, 504 Extraperitoneal Cesarean section, 870 INDEX. 983 Extra-uterine preKnancy, 447 abdominal section for, 466 advanced, treatment, 4O7 changes in uterus in, 449 in vagina in, 449 classification, 447 clinical history, 449 diagnosis, 4O4 etiology, 448 freciuency, 447 multiijlc, 452 prognosis, 465 symptoms, 462 objective, 463 subjective, 462 terminations, 456 treatment, 465 vaginal operation for, 467 Exudate, masses, in pregnancy, 392 Eyes, diseases, in pregnancy, 420 of infant in labor, care, 197 Eyesight in newborn infant, 944 Face, appearance, in pregnancy, 147 of fetus, injuries, during labor, 954 presentation, 266. See also Presenta- lion, face. Fallopian tubes, anatomy, 50 examination, method, 57 False conjugate diameter of spondylolis- thetic pelvis, 542 corpus luteum, 80 knots of umbilical cord, 125, 324 pelvis, 20 funnel-shaped, 19 Farabeuf's pelvimeter, 491 Farrior's handle for axis-traction forceps, 820, 821 Fascia, pelvic, 28 Fat of human milk, 946 Feces, impacted, obstruction of labor by, 571 Feeding of newborn infant, 946 artificial, 947 Femora, luxation of, effect on pelvis, 554 Ferguson's operation for vesicovaginal fistula, 896 speculum, 69 Fernwald-Braun's sign of pregnancy, 155 Fertilization of ovum, 87 Fetal appendages, abnormalities, labor complicated by, 589 development, 113 blood, circulation, 103 body, 251 manner in which uterine muscle acts on, 250 head, extension, anomalies, 260 in labor, 256 flexion, 254 abnormalities, 259 Fetal head, possible presentations, 252 rotation, 255 anomalies, 260 external, 258 structure, 251 heart sounds, diagnosis of life or death of fetus by, 165 in pregnancy, 156 membranes, development, 113 mortality, 332 movements in pregnancy, 146, 152, 157 pelvis, 508 diagnosis, 508 influence on labor, 509 syphilis, 33;^ causes, 333 diagnosis, 334 manifestations, 334 prognosis, 334 treatment, 336 Weger's sign, 335 tissue, mummification, 351 saponification, 351 traumatism, 344 Fetation, multiple, no Fetometry, antepartum, 497 Hirst's method, 498 Miiller's method, 497 Ferret's method, 497 Stone's method, 498 Fetus, accidents to, 644 achondroplasia, 341, 342 alterations in maternal blood fatal to, 353 amorphous, 326 anasarca, 342 ankylosis, 344 articular rheumatism, 340 cholera, 340 chondrodystrophia, 341, 342 circulation of blood in, 103 coiling of umbilical cord around, 325 conditions of mother which injure, 346 of uterus which interfere with de- velopment, 352 congenital cystic elephantiasis, 343 death, as indicating induction of abor- tion, 809 causes in fetus itself, 354 referable to father, 355 detection, 350 effect on mother, 349 growth and development of placenta, after, 461 habitual, 352 in utero, 349 obstruction of labor by, 578 development, 95 in eighth month, 102 in fifth month, loi in first month. 05 in fourth month, 100 984 INDEX. Fetus, development, in ninth month, 102 in second month, 99 in seventh month, loi in sixth month, loi in tenth month, 102 in third month, 100 diagnosis of hfe or death, 165 of sex, 108, 165 diseases, 296, 332 obstruction of labor by, 578 dislocations, 344 effect of death of mother on, 643 erj^sipelas, 338 fractures of bones, in utero, 343 habitual death, 352 harelip in, 99 head, large, obstruction of labor by, 576 infectious diseases, other than syphilis, 337 influence of chronic diseases of mother 911, 353 poisoning of mother on, 354 of death of mother on, 348 of eclampsia on, 348 of icterus gravidarum on, 347 of jaundice on, 347 of maternal diabetes on, 354 emotions on, 347 fever on, 346 nephritis on, 353 injuries, 344 intestinal invagination in, 344 intra-uterine amputations in, 344 kidney, polycystic disease, obstruc- tion of labor by, 578 liver of, 106 luxations, 344 lymphangioma, obstruction of labor by,_S77 malaria, 339 malformations, obstruction of labor by, 576 mature, 106 measles, 338 myxoma, obstruction of labor by, 577 non-infectious diseases, 341 overgrowth, obstruction of labor by, 572 papyraceus, in pneumonia, 341 position, abdominal palpation to de- termine, 246 auscultation to determine, 247 definition, 245 presentation, definition, 245 rachitis, 341 recurrent fever, 340 sacral teratoma, obstruction of labor by, 577 scarlet fever, 338 Fetus, septicemia, 340 sex, determination, 108 diagnosis, 165 small-pox, 337 syphilis, 333. See also Fetal syphilis. temperature, in utero, 105 traumatism, 344 tuberculosis, 339 tumors, obstruction of labor by, 576, 577. typhoid fever, 340 yellow fever, 340 Fever, delirium of, in pregnancy, 422 in puerperal state, emotional, 678 from cerebral disease, 682 from constipation, 680 from exposure to cold, 680 from reflex irritation, 680 frcm sun-stroke, 683 non-infectious, 677 persistence or exacerbation, 683 s>'philitic, 683 with eclampsia, 682 Fibro-adenoma of breasts, 725 Fibrocystic tumors of ovarian ligament in pregnancy, 390, 391 Fibroids of uterus, puerperal hemorrhage from, 670 Fibroma of ovary in pregnancy, 391 of pelvis, 532 of uterus in labor, 379 prognosis, 381 in pregnancy, 378 Fibromyoma of round ligament in groin in pregnancy, 378 Fibrom^Tcomatous degeneration of cho- rion, 311 Fillet, extraction of breech by, 837 Fillet-carrier, 837 Fimbriae of oviduct, 51 Finger-nails, loosening, in pregnanc^^ 430 Fistula between genital and urinary canals, 888 cervical, diagnosis, 892 colovesical, 889, 891 diagnosis, 892 entero vesical, 889, 890 diagnosis, 892 genito-urinary, in labor, 637 perineovaginal, treatment, 875 ureteral, 891. See also Ureteral fistula. uretero-uterine, 889 ureterovaginal, 889 urethral, 8S9 urinary, 888 classification, 889 uterovesical, 889, 890 uterovesicovaginal, 889 vesicovaginal, 889. See also Vesico- vaginal fistula. in labor, 637 vesicovestibular, S89 INDEX. 985 Flat pelvis, non-rachitic, 507 rachitic, management of labor in, . 557 simple, 4q8 management of labor in, 557 rachitic pelvis, 518 Flatulent distention of abdomen in puerperal state, 698 Fleming's operation for making artificial vagina, 007 Flexion of fetal head, 254 abnormalities, 259 Follicles, Graafian, 53 development, 76 rupture, 76 Naboth's, 45 Fontanel, anterior, 251 greater, presentation of, 274 treatment, 275 posterior, 251 Food, artificial preparation of, 948 Food-yolk of ovum, 77 Foramen ovale, 104 Forceps, 811 application, 823 artificial dilatation of cervical canal by, 795 axis-traction, application, 833 Breus' axis-traction, 819 Chamberlen, 814 contraindications, 822, 823 Davis', 817, 818 Dewees' axis-traction, 820 English, 816 French, 816 German, 816 Hermann's, 818 Hirst's, 817 historic sketch, 811 Hodge's, 817 in after-coming head, 852 in breech presentation, 836 in occipitoposterior position, 832 in transverse position of head, 832 indications for application, 821 introduction, 823 Levret's, 815 locking, 827, 828 Milne-Murray axis-traction, 820 Palfyn's, 814 position for, 823 Poulet's, 819 preparation for application, 823 Simpson's, 817 Smellie's, 813 sterilization, 823 Tarnier's axis-traction, 819, 820 traction on, 831 uses and functions, 821 Forces of expulsion, 249 of labor, anomalies, 471 expulsive, excessive power, 476 Forces of labor, resistant, excess iii, 477 of resistance, 249 Fossa navicularis, 42 Fourchct, 42 Fowler's position after operation for diffuse suppurative peritonitis, 765 Fracture in utero, 343 of coccyx in labor, 639 of limbs of child during labor, 955 of pelvic bones in labor, 640 of pelvis, 533 of sacrococcygeal joint in labor, 639 of skull during labor, 951 French forceps, 816 method of symphyseotomy, 861, 863 Friedlander's decidual cells, 130 Fritsch's method of treating postpartum hemorrhage, 609 Frontal bones, injuries, during labor, 951 Fundus uteri, height, as indication of duration of pregnancy, 165 Fungus, umbilical, of newborn infant, 969 Funic soufifle in pregnancy, 157 Funis, 123. See also Umbilical cord. Funnel-shaped false pelvis, 19 pelvis, 508. See also Pelvis, funnel- shaped. Furuncles in newborn infant, 966 Galactocele, 723 Galactorrhea, 713 Galbiati's knife for cutting symphj'sis, 860 Gall-stones in pregnancy, 408 Gangrene in puerperal sepsis, 771 of vulva, obstruction of labor by, 57c Gartner's canals, 39 Gas bacillus in puerperal sepsis, 733 Gastro-intestinal hemorrhage in new- born infant, 971 Gauze pad for abdomen, 78S Gavage of premature infants, 944 Gelatin of Wharton, 125 Generative organs, female, develop- ment and anatomy, 17 nerves, 36 Genital and urinary- canals, fistula be- tween, 888 canal and neighboring structures, dis- eases, 376 cord, 38 eminence, 40 tract, wounds, puerperal hemorrhage from, 671 Genitals, edema, after labor, 666 external, de\'elopment, 40 increased blood-supply to, in preg- nancy, 146 internal, dev-elopment, 37 Genito-urinary fistula in labor, 637 German forceps, 816 986 INDEX. Germinal spot of ovum, 77 vesicle of ovum, 77 Germ-yolk of ovum, 77 Gingivitis in pregnancy, 401 Girdle, bony pelvic, 20 Glandular layer of uterine decidua, 130 Globus hystericus in labor, 188 Gloves, rubber, 57, 785 sterilization, 787 Gluteal artery, aneurysm, in pregnancy, 392 Glycosuria in puerperal state, 217, 699, 701 Goiter in pregnancy, 424 Gonococcus in puerperal sepsis, 733, 736 Gonorrhea in pregnancy, 387 in puerperal state, 697 Gonorrheal stomatitis in newborn in- fant, 965 Goodell's sign of pregnancy, 154 speculum, 62 Graafian follicles, 53 development, 76 rupture, 76 Graves' disease in pregnancy, 424 Guffey's method of delivery of arms in podalic version, 848 Gums in newborn infant, 966 Habitual death of fetus, 352, 355 diagnosis of cause, 356 preventive treatment, 356 Hall's method of artificial respiration, 957 Hands, cleansing, for obstetric opera- tions, 785 Harelip in embryo, 99 of newborn infant, 963 Harris-Dickinson pelvimeter, 481 Harris' method of artificial dilatation of cervical canal, 794 Head crushers, 855 distortion, during labor, 951 extramedian engagement, 504 fetal, extension, anomalies, 260 in labor, 256 flexion of, 254 abnormalities, 254 large, obstruction of labor by, 576 possible presentations, 252 rotation of, 255 anomalies, 260 external, 258 structure, 251 of mature fetus, dimensions, 107 seizers, 855 Hearing in pregnancy, 420 Heart, changes, in pregnancy, 137 disease in labor, 660 in pregnancy, 422 prognosis, 423 Heart disease in pregnancy, treatment, 423 of newborn infant, 968 in newborn infant, 944 sounds, fetal, diagnosis of life or death of fetus by, 165 Heart-failure in labor, 640 Heart-muscle, diseases, in pregnancy, 424 Hebosteotomy, 863 Hebotomy, 863 Hegar's dilators or bougies, 803 method of amputation of cervix uteri, 910 operation for laceration of posterior wall of vagina, 883-885 sign of pregnancy, 153, 154 Hematocele, ante-uterine, 462 from tubal pregnancy, 461 retro-uterine, 462 Hematoma from ruptured tubal preg- nancy, 461 of vagina, obstruction of labor by, 566 polypoid, 439 puerperal, 672 cHnical history, 673 diagnosis, 673 etiology, 673 frequency, 672 hemorrhage from, 671, 672 prognosis, 676 situation, 672 size and form, 672 treatment, 676 rupture, in labor, 642 tuberous subchorial, of decidua, 328, 329 Hematuria in pregnancy, 417 in puerperal state, 702 Hemidrosis of newborn infant, 968 Hemiplegia in puerperal state, 704 Hemophilia of newborn infant, 967 Hemoptysis in pregnancy, 427 Hemorrhage, accidental, 591, 602 rupture of uterus and, differentia- tion, 618 complicating labor, 591 from laceration of cervix, 622 from umbilicus in newborn infant, 970 gastro-intestinal, in newborn infant, 971 in abortion, 439 in placenta prasvia, 594 in third stage of labor, prevention, 198 internal, shock, and septic peritonitis, differentiation, 941 intravesical, after operation for vesico- vaginal fistula, 900 placental, 316 postpartum, 605 abdominal binder in, 607 auto-infusion in, 611 INDEX. 987 Hemorrhage, postpartum, causes, 605 compression of abdominal aorta in, 609 of uterus in, 609 diaf^nosis, 606 electricity in, 609 ergotin in, 607 Fritsch's method of treating, 609 for relaxation of uterine muscle, 605 Momburg's tube in, 609, 610 Monsel's solution in, O09 morphin in, On pituitrin in, 607 salt solution in, 611 symptoms, 606 tampon in, 608 transfusion of blood in, 611, 612 treatment, 607 puerperal, 666 from cancer of cervix uteri, 671 of uterus, 671 from dislodgment of thrombi, 669 from displacements of uterus, 370, 669 diagnosis, 372 treatment, 373 from emotional causes, 670 from epithelioma of chorion, 669 from fibroids, 670 from hematoma, 671, 672 from pelvic engorgement, 671 from relaxation of uterus, 670 from retained placenta and mem- branes, 666 prognosis, 668 treatment, 668 from retention of blood-clots, 670 from wounds in genital tract, 671 unavoidable, 591, 602 uterine, as indicating induction of abortion, 809 Hemorrhagic decidual endometritis, 331 Hemorrhoids, edematous, in puerperal state, 699 in pregnancy, 409 vesical, in pregnancy, 416 Hensen's node, 93 Heredity, function, in labor, 172 Hermann's forceps, 818 Hernia of placenta, 295 of pregnant uterus, 359, 360, 361 treatment, 361 umbilical, 326 in newborn infant, 964 vaginal, in pregnancy, 390 Herpes gestationis, 429 Hiccup in pregnancy, 420 Hip bones, 19 Hirst's bag for artificial dilatation of cervical canal, 791 for effaced cervix, 791 bags in inertia uteri, 474 Hirst's canvas binder for symphyse- otomy, 862 (J. C.j dilator, 798 double tenacula, 796 forceps, 817 hook for decajjitation, 858 knife for cutting subpubic ligament, 860 method of antepartum fetometry, 498 of hand and skin cleansing, 786 operating table, 782 pelvimeter, 489 skeleton bivalve speculum, 62 Hirudin in eclampsia, 656 Hodge's forceps, 817 Hook, blunt, 838 Hirst's, for decapitation, 858 Hospital operating room, 780 House, private, operating room in, 782 operations in, articles required, 872 Hydatid cysts of pelvis in pregnancy, 392 Hydatidiform mole, 304 Hydramnios, 296 acute, 297 ascites and, differentiation, 300 diagnosis, 299 etiology, 297 frequency, 297 from abnormal pressure in blood-ves- sels of cord, 297 from amnion itself, 299 from both fetal and maternal sources, 299 from deficient absorption of liquor amnii, 299 from excessive secretion of fetal urine, 298 from fetal skin, 298 in multiple fetation, 11 1 of fetal origin, 297 of maternal origin, 297 ovarian cyst and, differentiation, 300 symptoms, 299 treatment, 301 twin pregnancy and, differentiation, 300, 301 Hydrencephalocele, 575 obstruction of labor by, 578 Hydro-amnion, 296 Hydrocephalus, 578 diagnosis, 578 treatment, 580 Hydronephrosis in pregnancy, 416 Hydrops tubae proflucns, 470 Hydrorrhea gravidarum, 469 Hymen, 43 imperforate, treatment, 876 resisting, treatment, 876 unruptured, obstruction of labor by, Hyperlactation, 712 988 INDEX. Hyperleukocytosis, artificial, in treat- ment of puerperal sepsis, 748 Hyperplasia, diffuse, of decidual endo- metrium, 327 Hypertrichosis in pregnancy, 152, 430 Hypertrophy of breasts, 705 of placenta, 322 polypoid, of vaginal mucous mem- brane, in pregnancy, 390 Hypodermatoclysis in puerperal sepsis, 748 Hysterectomy, combined, technic, 921 cuneiform, technic, 914 for atresia of vagina, 908 for puerperal sepsis, 754 indications, 756 technic, 757 partial, technic, 913 supravaginal, 915-917 technic, 914 vaginal, technic, 912 Hysteria in pregnancy, 420 Hysteric convulsions, abortion in, 434 Hysterostomatomy, artificial dilatation of cervical canal by, 804 in placenta praevia, 602 Hysterotomy, vaginal, anterior, artificial dilatation of cervical canal by, 804 for inversion of uterus, 808 Icterus gravidarum, influence, on fetus, 347 of newborn infant, 968 Iliopsoas muscles, 26 Imperforate hymen, treatment, 876 rectum in newborn infant, 964 Impetigo herpetiformis in pregnancy, 428 Impregnation, changes in ovum follow- ing, 93 time most likely to occur, 89 Incarceration of pregnant uterus, 362 treatment, 364 Incision, Jackson's, modified, for am- putation of breast, 939 Incontinence of urine after operation for vesicovaginal fistula, 899, 900 in pregnancy, 416 in puerperal state, 703 Incubation, 944 Kny-Scheerer, 945 Indagation of vagina at end of puerpe- rium, 238 Indigestion in pregnancy, 407 Induction of abortion, 808. See also Abortion, induction. Inertia uteri, 471 diagnosis, 473 etiology, 471 Hirst's bags in, 474 treatment, 473 Infant, newborn, 229. See also New- born infant. Infantibus, 719 Infarcts, placental, 313 Infectious diseases in pregnancy, 428 of fetus, 337 fevers, relation, to puerperal sepsis, 777 Inflammation, acute, of decidua, 331 adhesive, in formation of amniotic bands, 302 chronic, of chorion, 312 diffuse hyperplastic, of decidual endo- metrium, 327 of umbilical vessels in newborn infant, 970 peri-uterine, in pregnancy, 396 Inflammatory diseases of brain in preg- nancy, 419 of spinal cord in pregnancy, 419 Influenza in pregnancy, 428 Infundibulopelvic ligament, 54 Inguinal glands, removal, indications, 876 section, technic, 929 Innominate bones, 19 Insanity in pregnancy, 421 causes, exciting, 421 predisposing, 421 diagnosis, 422 frequency, 421 preexisting, 422 symptoms, 421 time of occurrence, 421 Insemination, 82 Insertio velamentosa, 325 Insolation, fever in puerperal state from, 683 Inspection in pregnancy, 147 of abdomen in examination, 61, 69 of pelvic organs in examination, 61 Instrumental dilatation of cervical canal, 795 Instruments in obstetric operations, 790 Internal cell-membrane of ovum, 77 Interstitial cells of ovary, 53 pregnancy, 447, 453 abdominal section for, 467 symptoms, 464 terminations, 459 Intestinal invagination in fetus, 344 Intestines, diseases, in pregnancy, 407 relation of pregnant uterus to, 134, 13s Intoxication, auto-, in pregnancy, 400 Intraperitoneal abscess, abdominal sec- tion for, 742 Intra-uterine amputation, 344 diseases as indicating induction of abortion, 809 Intussusception in newborn infant, 966 Invagination, intestinal, in fetus, 344 IXDEX. 989 Inversion of uterus in labor, 631. See also Uterus, inversion. vaj^inal hysterotomy for, 808 Involution of uterus, 207, 20S abnormalities, 661 adnexa in, 211 chanf^es in blood-vessels in, 210 in musclc-fibers in, 208 endometrium in, 210 erf^'ot for, 225 lodin method of preparing skin for ab- dominal section, 789 Irritability of bladder in pregnancy, 416 Irritable uterus, abortion from. 433 Isaacs' operation for making coitional vagina, 909 Ischiopagus parasiticus, 573 Ischiorectal abscess in puerperal sepsis, 777 Jackson's incision, modified, for ampu- tation of breast, 939 Janiceps, 574 Jaundice, influence, on fetus, 347 newborn infant, 968 Johnson's sign of pregnancy, 152, 154 Joints, pelvic, ankylosis, 536 changes, in pregnancy, 136 loosening, in pregnancy, 398 pain in, in pregnancy, 39S, 399 relaxation, 536, 537 after labor, 725 suppuration, in puerperal sepsis, 777 sjmostosis, 536 sacrococcygeal, ankylosis, 536 fracture, in labor, 639 sacro-iliac, 20 examination, at end of puerperium, 243 rupture, in labor, 638 synostosis, 536 Jorisenne's sign of pregnancy, 137 Justomajor pelvis, 515 Justominor pelvis, 504. See also Pelvis, jiislominor. Juvenile pelvis, 504 Karyokixesis in ovum, 77 Kidney breakdo\\Ti as indicating induc- tion of abortion, 808 calculus, in pregnancy, 416 decapsulation, in eclampsia, 656 dislocation, in pregnancy, 414 in puerperal state, 703 displaced, in pregnancy, 391 in puerperal state, 702 of fetus, polycystic disease, obstruc- tion of labor by, 578 of pregnancy, 411 course, 412 etiology, 412 Kidney of pregnancy, frequency, 412 ne|)hritis and, differentiation, 413 pathology, 412 symptoms, 412 treatment, 412 palpation, at end of puerperium, 243 in examination, 59 pelvis of, diseases, in pregnancy, 415 tumors, in pregnancy, 414 Klebs-Loffler bacillus in puerperal sep- sis, 733 Kletter puis, 751 Kliseometer, Neumann-Hhrenfest, 491, 495- 496 Knee-chest posture, 66 introduction of Sims' speculum in, 68 Knots, false, of umbilical cord, 125, 324 true, of umbilical cord, 324 Kny-Scheerer incubator, 945 Krause's method of inducing premature labor, 810 Kyphoscoliosis, 551 Kyphoscoliotic pelvis, 551 Kyphosis, 543 lumbosacral, 544, 548 Kyphotic pelvis, 543. See also Pelvis, kypholic. Labia, agglutination, treatment. 876 amputation, indications, 876 majora, 41, 42 cyst, in pregnancy, 394 varices, in pregnancy, 392 minora, 42 cyst, in pregnancy, 394 Labor, abdominal muscles in, 178 palpation of, 1S5, 245 accidents, 642 action, appearance, and condition of woman in, 176 anesthetics in, 187-1S9 anomalies in forces, 471 anterior displacement of uterus in. 357 armamentarium for, 183 bed arranged for, 1S8 brachial palsy from injury during. 951 caput succedaneum in. 953 causes, 171, 172 circular detachment of cervix uteri in, 624 clinical phenomenon, 175, 170 coiling of umbilical cord around neck of fetus in, 105 treatment in. 105 complicated by abnormalities in fetal appendages, 580 by accidents and diseases, 591 by heart disease, 660 by former operation to suspend or fix uterus anteriorly, 359 990 INDEX. Labor complicated by pneumonia, 660 by typhoid fever, 660 contraction of uterine muscle in, 175 of uterus after, method of securing, 199 decapitation of fetus during, 954 deficient power of uterine muscle in, 471. See also Inertia uteri. definition, 171 descent of uterus in, 173 diagnosis, 173 diastasis of abdominal muscles in, 639 dilatation of os uteri in, 174 disease of pelvic joints after, 725 displacements of uterus in, lateral, 370 distortion of head during, 951 dry, 190, 589 duration, 175 eclampsia in, 656 edema of genitals after, 666 embolism of pulmonary artery in, 642 ether in, 189 etiology, 171, 172 examination of patient in, 185 expulsion of trunk in, 259 expulsive forces, excessive power, 476 eyes of infant, care, 197 fibroma of uterus in, 379 prognosis, 381 first stage, 178 anesthetics in, 187 management, 186 pain in, 187 • forces involved in, 249 anomalies, 471 fracture of coccyx in, 639 of limbs of child during, 955 of pelvic bones in, 639 of sacrococcygeal joint in, 639 of skull during, 951 genito-urinary fistula in, 637 globus hystericus in, 188 heart-failure in, 640 hemorrhage complicating, 591 heredity in, function, 172 induction, 810 in placenta praevia, 596 influence of biochemical actions and reactions of mother and fetus on onset, 172 of funnel-shaped pelvis on, 509 of justominor pelvis on, 506 of kyphotic pelvis on, 546 of obliquely contracted pelvis on, 513 of osteomalacic pelvis on, 530 of rachitic pelvis on, 524 of simple flat pelvis on, 500 of spondylolisthetic pelvis on, 542 injuries of anterior vaginal wall in, 630 of cervical spine in, 955 of face during, 954 Labor, injuries of larynx in, 955 of scalp during, 953 of trachea in, 955 of trunk of child during, 955 of urinary tract in, 637 to bowel of child during, 956 to brain during, 950 to cervix uteri in, 621 to frontal bones during, 951 to infant during, 950 to neck during, 954 to parietal bones during, 951 to peripheral nerves during, 950 to skull during, 951 treatment, 665 inversion of uterus in, 631. See also Uterus, inversion. laceration of perineum in, 192, 627 treatment, 193, 629 of vagina in, 625 of vaginal entrance in, 627 of vestibule in, 627 of vulva in, 627 of walls of birth-canal in, 612 lateral displacement of uterus in, 370 leukocytes after, 216 management, 170, 182 in kyphotic pelvis, 548 when obstructed by contracted pel- vis, 557 manner in which uterine muscle acts on fetal body in, 250 maturity of ovum as cause, 172 mechanism, 245 abnormalities in, 259 forces involved, 249 in breech presentation, 276 in brow presentation, 273 in face presentation, 266 in greater fontanel presentation, 274 in left occipito-anterior position, 252 in occipitoposterior position, 261 in right occipito-anterior position, 261 in shoulder presentation, 283 in third stage, 290 abnormalities, 291 in vertex presentation, 252 when occiput rotates into hollow of sacrum, 264 mental impressions in, effect, 642 missed, 139 obstruction of, by abnormal conditions about rectum, 571 by abnormalities in fetal append- ages, 589 by abscess of Bartholin's gland, 570 by anus vaginalis, 567 vestibularis, 567 by atresia of cervix, 563 of vagina, 567 by calculi in bladder, 571 INDEX. 991 Labor, obstruction of, by cicatrices of vagina, 566 by cicatricial contraction of cervix, 564 by closure and contraction of cervix, 563 of vagina, 565 by congenital anomalies of uterus, narrowness of vagina, 570 of vulva, 570 by cystocele, 571 by death of fetus, 578 by diseases of fetus, 578 by double uterus, 562 by edema of vulva, 569 by elephantiasis of vulva, 567 by enlarged carunculae myrtiformes, 570 by hematoma of vagina, 566 by gangrene of vulva, 570 by hydrencephalocele, 578 b}' hydrocephalus, 578 by impacted feces, 571 by large fetal head, 576 by lymphangioma of fetus, 577 by malformations of fetus, 576 by myxoma of fetus, 577 by overgrowth of fetus, 572 by papilloma of bladder, 571 by polycystic disease of fetal kidney, 578 by premature ossification of cra- nium, 576 by rectocele, 571 by rigidity,,of cervix uteri, 564 by sacral teratoma of fetus, 577 by septa of cervical canal, 565 of vagina, 565, 566 by septate uterus, 562 by short umbilical cord, 589 by soft maternal structures in par- turient canal, 562 by tumors of fetus, 576, 578 of pelvis, 530 of vagina, 567 of vulva, 567 by twins. 584 by unruptured hjTnen, 567 by varicose veins, 570 by Wormian bones, 576 ovarian cysts in, 382 overdistention of uterus as cause, 172 pains, 174 pathology, 296 periodicity as cause, 171 personal demeanor of physician in, 183 physiolog}-, 170 polypi of uterus in, 382 premature, 432 induction, 810 preparations for, 182-185 Labor, profound emotions in, 642 pulse in, 215 relaxation of pelvic joints after, 725 resistance of bony walls of pelvis in, 251 resistant forces, excess, 477 rupture of hematoma in, 642 of respirator^' tract in, 640 of sacro-iliac joints in, 638 of symphysis in, 638 of uterus in, 612. See also Uterus, rupture. second stage, 178, 191 action of abdominal walls in, 191 shock in, 640, 660 show, 174 signs, 174 sloughs of scalp from injury during, 954 stage of descent, 178 of dilatation, 178 of expulsion, 178 stages, 178 subcutaneous emphysema in, 640 sudden death during or after, 640 syncope in, 642 temperature in, 182 temporar>' delirium of, 422 third stage, 179 hemorrhage in, prevention, 198 mechanism, 290 abnormalities, 291 thrombosis of pulmonary artery in, 642 tumors in, 378 twin, 484 coiling of cords in, 586 placenta in, 587 presentations in, 584 prognosis, 588 uterine contractions in, 175 vaginal examination in, 185 vesicovaginal fistula in, 637 vulva in, 179 Lacerations of anterior vaginal wall, treatment, 886 of cervix uteri, repair. 010 of perineum in labor, 192, 627 causes, 192 treatment. 193, 629 of posterior wall of vagina, Emmet's operation. 87 7-880 Hegar's operation. 883-8S5 treatment, 876 of sphincter ani, treatment, 8S5 of vagina in labor, 625 of vaginal entrance in labor, 627 of vestibule in labor, 627 of vulva in labor, 627 of walls of birth-canal. 612 Lactalbumin of human milk, 947 992 INDEX. Lactose, 947 Lactosuria in pregnancy, 418 Langhans' cells, 452 layer, 120 Lanugo, loi Laparo-ehiirotomy, 870 Lan^nx, diseases, in pregnancy, 426 injuries, in labor, 955 Lateroflexion of pregnant uterus, 370 Lateroposition of pregnant uterus, 370 Lateroversion of pregnant uterus, 370 Leukemia in pregnancy, 426 Leukocytes after labor, 216 Leukocytosis in puerperal sepsis, 738 Leukorrhea, vaginal, in pregnancy, 387 Levator ani, importance, 26 Levret's forceps, 815 Ligament, infundibulopelvic, 54 ovarian, fibrocystic tumors, in preg- nancy, 390, 391 ovariopelvic, 54 round, in groin, fibromyoma, in preg- nancy, 379 sacrosciatic, 18, 27 tubo-ovarian, 54 utero-ovarian, 54 Ligamentous structures of pelvis, 27 Ligation and resection of thrombotic veins, 759 Ligatures, preparation, 789 Lilienthal's portable operating table, 782, 783 Limbs of fetus, fractures, during labor, 955 Linea nigra in pregnancy, 151, 152 Lipuria in pregnancy, 417 Liquor amnii, 115 abnormalities, 301 of secretion, 296 composition, 115 deficiency, 296 excessive quantity, 296 origin, 115 putrefaction, 302 folliculi, 76 Lithopedion, 351 Liver, diseases, in pregnane}', 407 treatment, 408 of fetus, 106 L. 0. A. presentation, 248 frequency, 248 Lochia, 212 alba, 212 amount discharged, 212 in puerperal state, 212 odor, 213 rubra, 212 serosa, 212 Locking of forceps, 827, 828 Lohlein's method of measuring trans- verse diameter of pelvic inlet, 493 Longings in pregnancy, 138 Loosening of finger-nails in pregnancy, 430 of pelvic joints in pregnane}', 398 L. O. P. presentation, 24S Lordosis, pelvis of, 551 Lowenhardt's method of estimating duration of pregnane}', 164 Lumbar puncture in eclampsia, 656 Lumbosacral k\phosis, 544, 54S Lungs, diseases, in newborn infant, 960 in pregnancy, 426 in puerperal state, 217 septic infection, in newborn infant, 961 s}'philis, in newborn infant, 961 tuberculosis, in newborn infant, 961 Lupus of vulva in pregnane}', 394 Lutein in corpus luteum, 79 Ltxxation of femora, effect, on pelvis, 554 Luys' instrument "for separation of urines, 411 Lymphangioma of fetus, obstruction of labor by, 577 Lymphatic ducts of pelvic organs, 36 of uterus, 33, 36 glands of pelvis, 36 L}'mphatics of uterus in pregnancy. 132 L}'mph-glands, caseous, in pregnancy, 392 Mackenrodt's operation for ureteral fistula, 902 Mahler's sign in puerperal sepsis, 751 Malaria in puerperal state, 693 of fetus, 339 relation, to puerperal sepsis, 777, 779 Malignant placental pol}'ps, 317 Mammary abscess, 721 glands. See Breasts. tumors, 723 Manual method of dilating os uteri, 794 of extracting breech. 835 Marginal insertion of cord. 325 Markel's fillet-carrier, 837 Marriage, average date of conception after, 89 Martin's peh'imeter, 481 Masculine pelvis, 504, 508 ]Mask, operating. Vienna, 787 Massage of breasts, 716, 717 Mastitis. 720 in newborn infant, 963 treatment, 721 Maternal blood, alterations in, as cause of abortion, 435 fatal to fetus, 353 changes in pregnane}'. 131 emotions, influence, on fetus, 347 fever, influence, on fetus, 346 plethora, effect, on fetus, 353 Maturation of ovum, 76 ]\Iature fetus,- io6' INDEX. 993 Mature fetus, dimensions of head, 107 general appearance, 107 lenf^th, 107 weight, io() Maturity of ovum as cause of ialjor, 172 Mauriceau's metiiod of delivering after- coming head, 849, 850 Measles in fetus, 338 in pregnancy, 428 in puerperal state, 6qi Meatus, external urinary, 43 Mechanism of labor, 245. See also Labor, mechanism. of various [)ositions, 252 presentations, 252 Meconium, loO Melena of newborn infant, 971 Mellituria in pregnancy, 417 Membrana decidua serotina, 130 vera, 126 granulosa of Graafian follicle, 76 reflexa, 126 serotina, 126 Membrana; deciduae, 125, 327. See also Decidua. Hunterian theory of development. Membranes, fetal, abnormalities, com- plication of labor by, 589 development, 113 retention, puerperal hemorrhage from, 667 Menstrual molimina^ 74 Menstruation, 72 and ovulation, connection between, 81 cause, 72 cessation, 74, 75 as sign of pregnancy, 144 without pregnancy, 145 changes in uterus before, 74 character of flow, 75 corpus luteum of, 80 definition, 72 duration, 75 mechanism, 73 Pfliiger's theory, 72 quantity of flow, 75 recurrence, in pregnancy, 145 time of onset, 74 Mensuration of abdomen, 71 Mental impressions, effect, on milk, 715 in labor, effect, 642 Mercurialism, effect, on milk, 715 Mesoderm, 93, 94, 113 Mesonephros, 40 Metranoikter, Schatz's, 797 Metreurynter, Braun's, artificial dilation of cervical canal by, 791 Metritis, chronic, as cause of abortion, 352 dissecting, in puerperal sepsis, 761 in pregnancy, 376 63 Metritis, septic, in puerperal infection, 7O1 Mi( robic decidual endometritis, 331 Micromastia, 705 Miliary tuberculosis in pregnancy, 427 Milk, anomalies of color, 716 bacteria in, 715, 718 blue, 716 breast, 221 quantity, 222 colostrum-corpuscles in, 715 cows', composition, 948 effect of emotions on, 711, 714 of mercurialism on, 715 syphilis on, 715 fever, 218 human, as food, 946 constitution, 946 pasteurization, 949 qualitative anomalies, 714 red, 716 secretion, 708 anomalies, 708 deficient, 709 treatment, 711 excessive, 712 quantitative anomalies, 712 Milk-leg in puerperal sepsis, 768 Milk-tumor, 723 Milne-Murray axis-traction forceps, 820 Miscarriage, 432, 446. See also Abortion. Missed abortion, 446 labor, 139 Mole, hydatidiform, 304 tubal, 459 vesicular, 306 Molimina, menstrual, 74 Molluscum fibrosum in pregnancy, 429 Momburg's tube in postpartum hemor- rhage, 609, 610 Mons veneris, 41 Monsel's solution in postpartum hemor- rhage, 609 Montgomery's glands, prominence, in pregnancy, 148 Morning sickness in pregnancy, 138 Morphin in eclampsia, 655 in postpartum hemorrhage, 611 Morula, 93 Mother, chronic diseases, effect on fetus, 353 conditions of, which injuriously aft'ect fetus, 346 death of, effect on fetus, 348, 643 directions for, 231 effect of death of fetus on, 349 spasmodic muscular action in, as cause of abortion, 434 Mouth diseases in newborn infant, 964 in pregnancy, 401 Mouth-to-mouth artificial respiration, 958 994 IXDEX. Mucous plug, 136 Mulbem^ mass, 93 Miillerian ducts, 37, 38, 39 Miiller's method of antepartum fetom- etry, 497 Multiple fetation, no. See also Feta- tion, multiple. Mummification of fetal tissue, 351 Murphy's breast-binder, 230 continuous instillation of salt solution in rectum in peritonitis. 766 Muscle-fibers, changes, in involution of uterus, 208 of uterus, alterations, in pregnane}^, 131 Muscles, abdominal, diastasis, in labor, 639 in puerperal state. 698 of pelvis, 26 recti, diastasis, operative treatment, 937 Webster's operation, 937 uterine, diseases, in pregnancy, 376 manner in which act on fetal body, 250 Muscular rheumatism in puerperal state, 697 _ Mycosis of vagina in pregnancy, 388 Myelitis, ascending, in puerperal state, 704 Mj'oma, cervical, in pregnancy, 385 of uterus, vaginal myomectomy for, technic, 911 vaginal, for myoma of uterus, technic, 911 Myometrium, rheumatism, in pregnancy, 376 Myxoma fibrosum placentae, 311, 313 of fetus, obstruction of labor by, 577 MjTcomata fibrosa of placenta, 322 Mj'xomatous degeneration of placenta, 313 Myxosarcoma, telangiectatic, of umbili- cal cord, 326 Naboth's glands or follicles, 45 Naegele pelvis, 510 method of estimating duration of preg- nancy, 164 Xails, finger-, loosening, in pregnancy, ,430 Nasal catarrh in newborn infant, 964 Nausea in pregnancy, 138. 145 Neck, injuries, during labor, 954 Necrosis of pelvis. 536 Nephrectomy for ureteral fistula, 901 pregnancy following. 415 Nephritis in pregnancy, 412 kidney of pregnancy and, differen- tiation, 413 treatment, 413 Nephritis in puerperal state, 702 maternal, effect on fetus, 353 Nerve degeneration in puerperal state, 704 Ners'es of pelvis, 35, 36 of uterus in pregnancy, 132 peripheral, injurj^ to, during labor, 950 vulvar, exsection, 876 Nerve-storms, cardiac, in pregnancy, 138, 427 Nervous diseases as indicating induction of abortion, 809 system, changes, in pregnane}'-, 138, 147 diseases, in pregnancy, 419 in puerperal state, 704 Neumann-Ehrenfest kliseometer, 491, 495^ 496 peUigraph, 491, 495, 496 Neuralgia in pregnancy, 419 Neurilemma of uterus in pregnancy, 132 Neuritis in puerperal state, 704 Neuroses of pregnancy, 419 Newborn infant, 942 acne, 966 airing, 950 aphthae, 964 artificial feeding, 947 asphj'xia, 936 atelectasis, 960 bathing, 230, 949 Bednar's aphthae, 965 blood, 944 blood}' discharge from female geni- talia, 971 capacity of stomach, 943 care, 203, 229 directions to nurse for, 232 cleansing, 949 cleft-palate, 963 clothing, 946 colic, 965 conjunctivitis. 967 constipation, 965 cyanosis, 968 deformities, treatment, 963 diarrhea, 965 digestion, 943 diseases, 960 of lungs, 960 of mouth, 964 of umbilicus, 969 essential fevers, 963 exanthemata, 953 eyesight, 944 feeding, 946 artificial, 947 furuncles, 966 gastro-intestinal hemorrhage, 971 gonorrheal stomatitis in, 965 gum, 966 harelip, 963 heart affections, 968 IXDEX. 995 Newborn infant, heart in, 944 hcmidrosis, 968 hemophilia, 067 hemorrhage from umbihcus, 970 icterus, 968 imperforate rectum in, 964 inliammation of umbilical vessels, 970 injuries, during labor, 950 intussusception, 966 jaundice, 968 manafjement, 946 mastitis, 9O3 medi(ation, 972 mclena, 971 movements of bowels in, 943 nasal catarrh, 9(34 nursing, 2j,i omphalitis, 970 ophthalmia, 967 omphalorrhagia, 970 pathology, 950 pemphigus, 966 physiology, 942 pneumonia, 961 position, after birth, 204 of stomach, 943 pulmonary apoplexy, 962 pulse, 944 respiration, 941 physiology, 956 resting place, 950 septic infection, 963 of lungs in, 961 of umbilicus, 969 skin diseases, 966 snufHes, 964 specific fevers, 963 spina bifida, 964 sublingual cysts, 965 sudden death, 971 supernumerary digits, 963 syphilis, 962 of lungs in, 961 syphilitic pemphigus, 966 temperature, 943 tetanus, 971 thrush, 965 tongue-tie, 963 tuberculosis of lungs, 961 umbilical cord, 944 fungus, 969 hernia in, 964 urine in, 943 weight. 04^ wet-nurse for, 947 Nicholson's blood-pressure apparatus, 141 modification of Doderlein's tube, 740 Nipples, anomalies, 707 eczema, in pregnancy, 399 in pregnancy, 142, 147 Nipples, sore, 718 supernumerary, 705 Nipple-shield, 719, 720 Nitrite of amyl in eclampsia, 656 Nitrciglycerin in eclampsia, 656 Node of Hensen, 93 Nose, diseases, in pregnancy, 426 Nott's vaginal depressor, 64 Nurse as aid in examination, 69 directions for, in puerperal state, 232 precautions on part of, in puerperal sepsis, 744 preparation, for abdominal section, 788 wet-, selection of, 947 Nursing newborn infant, 233 Nympha;, 42 Oblique diameter of pelvic inlet, meas- urement, 494 Obliquely contracted pelvis, 510. See also Pelvis, contracted, obliquely. Obstetric binder, 200 examination in labor, 185 .^^ operations, 780 aseptic technique, 780 operative technique, 780 treatment of eclampsia, 656 Obstetrics, detinition, 17 Obturator membranes, 27 Occipito-antcrior position, left, mechan- ism of labor in, 252 right, mechanism of, 261 Occipitoposterior position, diagnosis, 261 forceps in, 832 mechanism, 261 prognosis, 265 rotation of occiput in, 262 abnormalities, 262 treatment, 264 Occiput, rotation, into hollow of sacrum, mechanism of labor in, 264 Oligohydramnios, 296 Omphalitis of newborn infant, 970 Omphalorrhagia of newborn infant, 970 One-child sterility, 91 Oophorectomy, technic, 928 Operating mask, Vienna, 787 room, furniture. 781 hospital, 780 private house, 782 suit, 787 table, 784 Hirst's, 782 Lilienthal's portable, 782, 783 Ophthalmia neonatorum, 967 Os uteri, artificial dilatation, 791. See also Cervical canal, artificial dila- tation. dilatation, in labor, 174 996 INDEX. Osseous system, diseases, in pregnancy, 428 Ossification centers in mature fetus, 107 premature, of cranium, obstruction of labor by, 576 Osteomalacia of pregnancy, 428 Osteomalacic pelvis, 527 diagnosis, 529 influence upon labor, 530 treatment, 530 Osteophytes in pregnancy, 137 Ostium abdominale of oviduct, 51 internum of oviduct, 50 Ovarian arteries, 30 cysts in pregnancy, 382 ligament, fibrocystic tumors, in preg- nancy, 390, 391 pregnancy, 447, 454 operation for, 467 terminations, 459 veins, ligation or exsection, in throm- bophlebitis, 751 Ovario-abdominal pregnancy, 447 Ovariopelvic ligament, 54 Ovary, anatomy, 51 cyst, hydramnios and, dififerentiation, 300 cysts, in pregnancy, 382 discharge of ovum from, 77 examination, method, 57 fibroma, in pregnancy, 391 interstitial cells, 53 sarcoma, in pregnancy, 391 suspension of, technic, 925 Overdistention of uterus as cause of abortion, 435 of labor, 172 Oviducts, anatomy, 50 Ovular decidua, 130 Ovulation, 76 and mensuration, connection between. 81 Ovum and spermatic particle, meeting place, 86 changes in, following impregnation, 93 deutoplasm, 77 discharge from ovar}', 77 diseases, 296 fertilization, 87 food-yolk, 77 germinal spot, 77 vesicles, 77 germ-yolk, 77 implantation in uterine mucous mem- brane, 95 internal cell-membrane, 77 karyokinesis in, 77 maturation, 76 maturity, as cause of labor, 172 migration, external, 96 to uterine cavitj^, 77 polar globules, 77 Ovum, premature expulsion, 432. See also Abortion. protoplasm, 77 vitelline membrane, 77 yolk, 77 zona pellucida, 77 Oxygen in eclampsia, 656 Pagexstecher's cellular thread, prep- aration, 790 Pain in abortion, 439 in pelvic joints in pregnancy. 398. 399 of labor, 174 Pains, after-, 214 Palate, cleft-, of newborn infant. 963 Palfjm's forceps. 814 Palpation, abdominal, at end of puerpe- rium. 241 diagnosis of position of fetus by. 246 in labor, 1S5. 245 in examination. 55 of abdomen in examination. 59 in pregnancy, 153 of kidneys at end of puerperium, 243 in examination, 59 Palsy, brachial, from injury- during labor. 951 Panhysterectom}', technic, 914, 918-921 Papilloma of bladder, obstruction of labor by. 571 Paralysis in pregnancy. 419 in puerperal state. 704 of placental site. 632 Paraplegia in puerperal state. 704 Parathj'roid extract in eclampsia, 656 Para-uterine phlebitis in puerperal sepsis, 766 Parietal bones, injuries, during labor. 05 1 Parovarium, 40 Parturition. See Labor. Pasteurization of milk, 949 Patterson's abdominal supporter. 358 Pelvic bones, fractures, in labor. 639 cavity, measurement by capacity, 494 connective tissue, infection, vaginal section for, 758 direction, 24 engorgement, puerperal hemorrhage from. 671 fascia, 28 joints, ankylosis. 536 changes, in pregnancy. 136 loosening, in pregnane}', 398 pain in, in pregnancy, 398, 399 relaxation, 536, 557 after labor, 725 suppuration, in puerperal sepsis, 777 synostosis, 536 organs, inspection, in examination, 61 peritonitis in puerperal sepsis, 763 position, 22 INDEX. 997 Pelvic shape, 20 size, 22 sui)punition, v;if^in;il section for, 758 tumors, aljdominai sec tion for, Q28 degeneration and jjiitrefac lion, in puerperal sepsis, 776 Pelvigraj)!!, Neumann-Ehrenfest, 491, 495, 49^^ Pelvimeter, Bylicki's, 491 Farabeuf's, 491 Harris-Dickinson, 481 Hirst's, 489 Martin's, 481 Pelvimetry, 480 Skutsch's method, 492, 493 Pelvis, anatomy, 17, 20 anomalies, 477. See also Pelvis, de- form ilics. anteroposterior diameter, 22 of pelvic outlet, measurement, 497 of superior strait, measurement, 480 arteries, 30 assimilation, 516 blood-vessels, 30 bony walls, resistance, in labor, 251 brim, 17 cancer, 532 caries, 536 connective tissues, 28 contracted, generally, 507 diagnosis, 508 etiology, 508 management of labor in, 557 rachitic, 518 management of labor in, 557 obliquely, 510 characteristics, 510 diagnosis, 512 etiology, 511 influence on labor, 513 prognosis, 513 treatment, 514 transversely, 514 cause, 515 treatment, 515 version in, 839 coxalgic, 553 cysts, 532 deformities, 477 description, 498 diagnosis, 480 frequency, 477, 478 from absence of both lower extremi- ties, 556 of one lower extremity, 556 from club-foot, 457 from diseases of subjacent skeleton, 553 depth, 18 development, 24 diameter, anteroposterior, 22 Pelvis, diameter, oblique, 22 transverse, 22 dimensions, 22 direction, 24 dwarf, 504, 505 effect of luxation of femora on, 554 enchondroma, 532 exostoses, 530 false, 20 funnel-shaped, 19 fascia, 28 fetal, 508 diagnosis, 508 influence on labor, 509 fibroma, 532 flat, non-rachitic, 507 rachitic, 518 management of labor in, 557 simple, 498 characteristics, 498 diagnosis, 500 etiology, 499 influence upon labor, 500 management of labor in, 557 fractures, 533 funnel-shaped, 508 diagnosis, 508 influence upon labor, 509 measuring posterior sagittal diam- eter in, 509 girdle, bony, 20 hydatid cysts, in pregnancy, 392 inclination, 22, 23 inferior, strait, 18 shape, 22 inlet, 18, 21 shape of, 21 justomajor, 515 justominor, 504 characteristics, 505 diagnosis, 506 etiology, 506 influence on labor, 506 juvenile, 504 kyphoscoliotic, 551 kyphotic, 543 characteristics, 544 diagnosis, 549 frequency, 550 influence on labor, 546 management of labor in, 548 prognosis, 550 ligamentous structures, 27 lordosic, 551 lymphatic ducts, 36 masculine, 504, 508 muscles, 26 Naegele, 510 nana, 504 necrosis, 536 nerves, 35, 36 oblique diameters, 22 998 INDEX. Pelvis obtecta, 546, 548 of kidney, diseases, in pregnancy, 415 osteomalacic, 527 diagnosis, 529 influence upon labor, 530 treatment, 530 outlet, 18 shape of, 22 plana, 498 plane of contraction, 21 of expansion, 21 position, 22 pseudo-osteomalacic, 518, 521 rachitic, 516 characteristics, 517 diagnosis, 522 flat, 518 influence on labor, 524 Robert, 514 sarcoma, 532 scoliotic, 550 shape, 20 simple, flat, 498 sitz-, 556 size, 22 soft tissues, 25 spinosa, 530 split, 516 spondylolisthetic, 537 characteristics, 537 diagnosis, 539 etiology, 539 frequency, 539 influence on labor, 542 treatment, 543 superior strait, 18, 21 transverse diameter, 22 true, 17 tumors, 530 undeveloped, 508 veins, 31, 36 Pemphigus in newborn infant, 966 in puerperal state, 698 syphilitic, in newborn infant, 966 Peptonuria in pregnancy, 417 Percussion in examination, 70 Perforator, Blot's, 854 Smellie's, 854 Perineovaginal fistula, treatment, 875 Perineum, lacerations, Emmet's opera- tion, 877-880 Hegar's operation, 883-885 in labor, 192, 627 causes, 192 treatment, 193, 629 supporting, 194 Periodicity as cause of labor, 171 Peripheral nerves, diseases, in pregnacy, 419 injury, during labor, 950 Peritoneal covering of uterus, changes, in pregnancy, 131 Peritonitis, diffuse, in puerperal sepsis, 763 suppurative, abdominal section for, 752 Fowler's position after operation for, 765 Murphy's treatment, 766 lymphatica in puerperal sepsis, 764 pelvic, in puerperal sepsis, 763 septic, internal hemorrhage, and shock, differentiation, 941 Peri-uterine adhesions in pregnancy, 396 inflammations in pregnancy, 396 Pernicious vomiting in pregnancy, 402. See also Vomititig. Perret's method of antepartum fetom- etry, 498 Pflijger's theory of menstruation, 72 Phlebitis, para-uterine, in puerperal sepsis, 766 uterine, in puerperal sepsis, 766 Phlegmasia alba dolens in puerperal sepsis, 768 cellulitic, in puerperal sepsis, 769 thrombotic, in puerperal sepsis, 769 Phthisical placenta, 313 Phthisis pulmonalis in pregnancy, 427 Pigmentation, exaggerated, in pregnancy, 429 Pilocarpin in eclampsia, 656 Pinare's method of extraction of breech, 835 Pituitary body, changes, in pregnancy, 138 Placenta, 118, 312 abscess, 316 adhesions, 292 causes, 293 diagnosis, 293 treatment, 293 anatomy, 120 angioma, 322 annular, 313 anomalies, 312 of number, 313 of position, 312 of shape, 313 of size, 312 of weight, 312 calcareous degeneration, 314 carcinoma, 318 circular sinus, rupture, 605 vein, 122 cysts, 317 delivery, 200 Crede's method, 202 in twin labor, 587 detachment, premature, 602 causes, 603 diagnosis, 603 frequency, 603 prognosis, 604 INDEX. 999 Placenta, delivery, detachment, rupture of circular sinus and, 605 of uterus and, differentiation, &18 symptoms, 603 treatment, 605 development, 120 duplex, 313 edema, 313 expression of, Crcde's method, 202 functions, 122 growth and development, after fetal death, 461 hemorrhage, 316 hernia, 305 hy[)crtrophy, 322 in multiple fetation, iii infarcts, 313 malignant polyps, 317 membranacca, 303 multiloba, 313 myxomata fibrosa, 322 myxomatous degeneration, 313 phthi:dcal, 313 prasvia, 591 abortion in, 596 Barnes' treatment, 600 Braun's colpeurynter in, 600 Cesarean section in, 601 clinical history, 594 diagnosis, 596 etiology, 592 frequency, 591 hemorrhage in, 594 history, 591 hysterostomatomy in, 602 induction of labor in, 596 prognosis, 602 symptoms, 596 tampon in, 600 treatment, 596 vaginal Cesarean section in, 602 varieties, 593 Voorhees' bags in, 600 Wigand's treatment, 600 prolapse, 295 retention, 291, 590 Crede's method of expressing, 291, 292 in double uterus, 563 prognosis, 205 puerperal hemorrhage from, 666 sarcoma, 317 separation, from uterine wall, 181 succenturiatne, 313 syphilis, 314 thrombosis, 322 tripartita, 313 tuberculosis, 316 tumors, 317 symptoms, 321 treatment, 322 Placenta, villi of, 118 degeneration, 313 Placental bruit, 71 decidua, 130 hemorrhages, 316 infarcts, 313 polyp, 439 malignant, 317 site, paralysis, 632 syphilis, 314 villi, degeneration, 313 Plastic operations, preparation for, 789, 872 evening before operation. 789 morning of operation, 789 Plethora, maternal, effect on fetus, 353 Pleurisy in pregnancy, 427 in puerperal state. 086 Plexuses, sacral, lesions, in puerperal state, 704 Plug, mucous, 136 Pneumococcus in puerperal sepsis, 733 Pneumonia in newborn infant, 961 in pregnancy, 426 in puerperal state, 684 labor complicated by, 660 of fetus, 341 Podalic version, 841 Poisoning, chronic, of mother, influence on fetus, 354 Polar globules, 77 Polycystic disease of kidney of fetus, ob- struction of labor by. 578 Polygalactia, 712 Polyhydramnion, 296 Polymastia, 705 Polypoid endometritis, 327 hematoma, 439 hjpertrophies of vagina! mucous mem- brane in pregnancy, 390 Polyps, cervical, in pregnancy, 385 malignant, of placenta, 317 of uterus in pregnancy, 382 placental, 439 Polythelia, 705 Polyuria in pregnancy. 417 Pomeroy's bag for artificial dilatation of cervical canal, 791 Porro's method of Cesarean section, 867 Position, definition, 345 mechanism, 252 occipito-anterior, left, mechanism of labor in. 252 right, mechanism of. 261 occipitoposterior, diagnosis, 261 mechanism of, 261 prognosis, 265 rotation of occiput in, 262 abnormalities, 262 treatment, 264 of fetus, diagnosis, by abdominal pal- pation, 246 lOOO IKDEX. Position of fetus, diagnosis, by auscul- tation, 247 Posterior sacculation of uterus, 365 Postmammary abscess, 722 Postmortem Cesarean section, 865 delivery, 644 Postpartum hemorrhage, 605. See also Hemorrhage, postpartum. Postural version, 840 Posture, erect, examination in, 58 for examination, 55 knee-chest, 66 introduction of Sims' speculum in, 68 Sims', 65 introduction of Sims' speculum in, 68 Walcher, 560, 561 Poulet's forceps, 819 Prague method of delivering after-com- ing head, 851 Pregnane}^, abdomen in, 148 abdominal, 447, 454. See also Abdom- inal pregnancy. abscess of breast in, 399 of vulvovaginal gland in, 397 accidents of, 431 acetonuria in, 417 anemia in, 426 aneurysm in, 425 of gluteal artery in, 392 anomalies of urine in, 417 appendicitis in, 408 areola in, 147 asthma in, 427 auscultation in, 156 auto-intoxication in, 400 ballottement, 156 bhndness in, 420 blood in, 215 blood-pressure in, 141 Braun-Fernwald's sign, 155 breasts in, 147 broad-ligament, 450, 459 bronchial catarrh in, 426 cancer of cervix uteri in, 386 of vagina in, 390 of vulva in, 394 cardiac nerve-storms in, 138, 427 caries of teeth in, 401 caseous lymph-glands in, 392 catheterization of ureters in, 409 cervical myoma in, 385 of Rokitansky, 332 polyps in, 385 cervicitis in, 385 cervix uteri in, 152, 154 cessation of menstruation in, 144 changes due to increased blood-supply to genitalia and breasts, 146 in abdominal walls, 136 in bladder, 136 Pregnancy, changes in blood, 136 in breasts, 147 in cervix, 135 in circulatory system, 136 in digestive tract, 138 in heart, 137 in nervous system, 138, 147 in pelvic joints, 136 in pituitary body, 138 in rectum, 136 in respiratory apparatus, 139 in several bodily systems, 136 in size and shape of abdomen, 146 in suprarenals, 138 in thyroid gland, 138 in urine, 138 in uterus, 131 in vagina, 136 in vulva, 136 in weight, 138 chorea in, 419 treatment, 420 chyluria in, 417 colostrum in, 148 colpitis emphysematosa in, 388 colpohyperplasia cystica in, 388 combined visual and touch examina- tion, 154 congestion of brain in, 419 constipation in, 140, 407 corpus luteum of, 80 coughing in, 420 cyst of labium minora in, 395 cystitis in, 416 cystoscopy of uterus in, 409 cysts of vagina in, 390 dehrium of fever in, 422 tremens in, 422 diabetes mellitus in, 418 diagnosis, 142-169 diarrhea in, 407 diet in, 142 diminution of urine in, 417 diseases of ahmentary canal in, 401 of bladder in, 416 of blood in, 426 of blood-vessels in, 424 of brain in, 419 of breasts in, 399 of bronchi in, 426 of cervix uteri in, 385 of circulatory apparatus in, 422 of eyes in, 420 of heart in, 422 prognosis, 423 treatment, 423 of heart-muscle in, 424 of intestines in, 407 of kidneys in, 411 of larjTix in, 426 of liver in, 497 treatment, 408 INDEX. lOOI PreRnancy, diseases of lungs in, 426 of mouth in, 401 of nervous system in, 419 of nose in, 42(1 of osseous system in, 428 of perii^heral nerves in, 41Q of respiratory apparatus in, 426 of skin in, 428 of spinal cord in, 419 of stomach in, 402 of urinary apparatus in, 409 of uterine muscles in, 376 of vagina in, 387 of vulva in, 392 dislocation of kidney in, 414 displaced kidney in, 391 spleen in, 392 dulncss on percussion in, 156 duration, 139 estimation, 164 eclampsia without convulsions in, 401 ectopic, 447. See also Exlra-uterine pregnancy. eczema of nipples in, 399 edema of cervix uteri in, 385 of vulva in, 395 emphysema in, 426 emphysematous colpitis in, 388 endocervicitis in, 385 enterocele of vagina in, 390 epilepsy in, 420 epistaxis in, 426 epithelioma of vulva in, 393 exaggerated pigmentation in, 429 examination of urinary tract in, 409 of urine in, 140, 409 exercise in, 141 exophthalmic goiter in, 424 exposure to cold, wet, or draft in, 142 extra-uterine, 447. See also Extra- uterine pregnancy. face of woman in, 147 Fernwald-Braun's sign, 155 fetal heart-sounds in, 156 movements in, 146, 152, 157 fibrocystic tumors of ovarian ligament in, 390, 391 fibroma of ovary in, 391 of uterus in, 378 fibromyoma of round ligament in groin in, 379 following nephrectomy, 415 funic souffle in, 157 gall-stones in, 408 general changes in, 136 gingivitis in, 401 goiter in, 424 gonorrhea in, 387 Goodell's sign, 154 Graves' disease in, 424 hearing in, 420 Hegar's sign, 153, 154 Pregnancy, hematuria in, 417 hemoi)tysis in, 427 hem(jrrhoids in, 409 hernia of vagina in, 390 heri)es in, 429 hiccup in, 420 horn of uterus bicornis or unicornis, 469 hydatid cysts of [jelvis in, 392 hydronephrosis in, 416 hydrorrhea in, 469 hyy)ertrichosis in, 152, 430 hysteria in, 420 impetigo herpetiformis in, 428 in uterus bicornis, 469 unicornis, 469 incontinence of urine in, 416 indigestion in, 407 infectious diseases in, 428 inflammatory diseases of brain in, 419 of spinal cord in, 419 influenza in, 428 injuries of, 431 insanity in, 421. See also Insanity. interstitial, 447, 453. See also Inter- stitial pregnancy. irritability of bladder in, 416 Johnson's sign, 152, 154 Jorisenne's sign, 137 kidney of, 411. See also Kidney of pregnancy. lactosuria in, 418 leukemia in, 426 linea nigra in, 151, 152 lipuria in, 417 longings in, 138 loosening of finger-nails in, 430 of pelvic joints in, 398 lupus of vulva in, 394 mammary abscess in, 399 tumors in, 399 management, 17, 140 masses of exudates in, 392 maternal changes in, 131 measles in, 428 mellituria in, 417 metritis in, 376 miliary tuberculosis in, 427 molluscum fibrosum in, 429 Montgomery's glands in, 148 morning sickness, 138 multiple, no. See also Fetation, mul- tiple. mycosis of vagina in, 388 myoma of cervix in, 385 nausea in, 138, 145 nephritis in, 412 neuralgia in, 419 neuroses of, 419 nipples in, 142, 147 objective signs, 147 osteomalacia of, 428 I002 IXDEX. Pregnancy, osteophytes in, 137 ovarian. 447. 454. See also Ovarian pregnancy. cysts in. 3S2 ovario-abdominal. 447 pain in pelvic joints in. 30S. 300 palpation of abdomen in. 153 paralyses in, 419 pathogenic micro-organisms in vagina in, 3S7 pathology-. 296 peptonuria in. 417 peri-uterine adhesions in. 396 inflammations in, 306 pernicious vomiting in, 402. See also Vomiting. phthisis pulmonalis in, 427 physiology-, 17 pleurisy in. 427 pneumonia in, 426 pointed condyloma of vulva in. 392 poh"pi of uterus in. 3S2 pohpoid h>"pertrophies of vaginal mucous membrane in, 390 pohps of cer\-ix in, 3S5 poh"uria in. 417 prior, diagnosis of. 167 prolongation, 139 pruritus in. 420 vulvae in. 304, 429 psychical disturbances in. 421 ptyahsm in. 156, 402 pulmonan,- embolism in, 427 purpura hemorrhagica in, 426 pyelitis in, 415 treatment, 415 quickening in, 146 recurrence of menstruation in, 145 renal calculus in, 416 tumors in, 414 rheumatism of myometrium in, 376 salivation in, 145 sarcoma of ovar\" in. 391 of vagina in. 390 of ^^llva in. 304 sebaceous glands in. 147, 148 secondary', 460 areola, 147 signs, divisions, 157 objective, 147 on auscultation, 156 on inspection, 147 on sense of touch, 153 subjective; 144 skin diseases in, 42S spurious, 167 striae in, mamman.-. 147 subjective signs. 144 suburethral abscess in, 390 surgical operations in, 432 swelling of old varices in, 146 s>phihs in, 42S Pregnancy, systemic and other diseases in. 400 teeth in. 142 tetany in. 420 toothache in. 402 toxemia in, 400 tubal, 447. See also Tubal pregnancy. tuberculosis in, 394 tubo-abdominal 447, 460 tubo-ovarian, 447, 453. See also Tiibo-ovarian pregnancy. tubo-uterine. 447 tumors in, 3 78 of abdomen and, differentiation. 157 of breasts in, 399 of kidney in. 414 t-nin, hydramnios and, differentiation. 300, 301 t>-phoid fever in. 428 umbilicus in. 152 urinalysis in. 410 urine in. 13S. 140 uterine bruit in. 156 utero-abdominal, 447, 456. See also Ulcro-ahdom inal pregnancy. uterus in, 131 vagina in, 152 vagina] cysts in, 300 enterocele in, 390 hernia in, 390 leukorrhea in, 387 varices in, 424 of labia majora in. 392 of vagina in, 389 varicose veins in. 424 rupure. 431 vegetations of ^-ulva in. 392 venereal warts of \nalva in, 392 vesical calculi in. 416 hemorrhoids in, 416 vomiting in. 138, 145 pernicious, 402. vulva in. 152 Pregnant uterus, alterations in, 131 anteflexion. 357 treatment. 357 displacements, lateral, 370 in labor. 370 hernia. 359. 360, 361 treatment. 361 incarceration, 362 treatment, 364 lateral displacements, 370 in labor, 370 lateroflexion. 370 lateroposition, 370 lateroversion, 370 prolapse. 366 relation, to intestines, 134, 135 retroflexion, 361 retroversion, 361 torsion, 370 INDEX. 1003 Premature infants, abnormalities in physiology, 944 gavage, 944 management, 944 sclerema, 945 labor, 432 induction, 810 ossification of cranium, obstruction of labor by, 576 Presentation, back, 283, 286 breech, 276 blunt hook in, 838 causes, 276 diagnosis, 276 extraction of, 835 by fillet, 847 by manual method, 835 forceps in, 836 frequency, 276 mechanism, 276 abnormalities in, 282 prognosis, 281 treatment, 282 brow, 273 diagnosis, 273 frequency, 273 mechanism, 273 prognosis, 273 treatment, 273 cephalic, 247 explanation of frequency, 248 compound, 582 treatment, 583 definition, 245 diagnosis, by abdominal palpation, 245 by auscultation, 247 by vaginal examination, 247 face, 266 causes, 267 diagnosis, 266 frequency, 266 mechanism, 267 abnormalities in, 269 prognosis, 271 treatment, 271 L. O. A., 248 explanation of frequency, 248 L. O. P., 248 mechanism, 252 abnormalities in, 259 management, 259 of greater fontanel, 274 treatment, 275 R. O. A., 248 R. O. P., 248 explanation of frequency, 248 shoulder, 283 causes, 288 diagnosis, 283 mechanism, 288 treatment, 290 trunk, 287 Presentation, umbilicus, 283, 287 varieties, 252 vertex, 252 diagnosis, 252 explanation of frequency, 248 mechanism of labor in, 252 positions of, 248 restitution in, 256 Priapism from injury to brain during labor, 950 Primitive groove, 93 streak, 93 Private house operating room, 782 operations in, articles required, 872 Proctitis, septic, in puerperal sepsis, 775 Prolapse of placenta, 295 of pregnant uterus, 366 of umbilical cord, 644 Proligerous disk of Graafian follicle, 76 Promontory, double, 485 Pronucleus, female, 88 male, 88 Prosopothoracopagus, 574 Protargol in puerperal sepsis, 748 Protoplasm of ovum, 77 Pruritus in pregnancy, 429 of vulva in pregnancy, 429 vulvas in pregnancy, 394 Pseudocyesis, 167 Pseudo-osteomalacic pelvis, 518, 521 Psychical disturbances in pregnancy, 421 Ptyalism in pregnancy, 146, 402 Pubes, fracture, 534 Pubiotomy, 863 Puerperal anemia, 665 fever, 736. See also Puerperal sepsis. hematoma, 672. See also Hematoma, puerperal. hemorrhage, 666. See also Hemor- rhage, puerperal. infection, 726. See also Puerperal sepsis. sepsis, 726 abdominal section for, 749 exploratory. 758 abscess of fixation in, 748 antistreptococcus serum in, 745, 747 argyrol in, 748 atmosphere in, 741 bacteria of, manner in which they find entrance, 734 that produce, 732 bacterin treatment, 747 bacteriologic examination of uter- ine cavity in, 740 bacteriology, 729 behavior of bacteria in genital canal, blood-corpuscles in, 738 blood-cultures in diagnosis, blood-serum in, 747 care of patient in, 742 740 I004 IXDEX. Puerperal sepsis, cellulitic phlegmasia in, 769 cellulitis in, 761 clinical history, 759 collargol in, 748 colloidal silver in, 748 Crede's ointment in, 748 curative treatment, 745 degeneration of pelvic and abdomi- nal tumors in, 776 diagnosis, 737, .759 diffuse peritonitis in, 763 dissecting metritis in, 761 elephantiasis in, 771 endocolpitis in, 760 endometritis in, 760 etiology, 729 exploratory abdominal section in, 758 gangrene in, 771 historical review, 736 hypodermatoclysis in, 748 hysterectomy for, 754 indications, 756 technic, 757 ischiorectal abscess in, 777 leukocytosis in, 738 Mahler's sign, 751 metritis in, 761 milk-leg in, 768 morbid anatomy, 759 operative treatment, 749 para-uterine phlebitis in, 766 pelvic peritonitis in, 763 peritonitis lymphatica in, 764 phlegmasia alba dolens in, 768 precautions in regard to implements, 745 on part of nurse in, 744 of physician in, 743 preventive treatment, 741, 745 of physician in, 743 protargol in, 748 putrefaction of pelvic and abdominal tumors in, 776 putrid absorption in, 772 pyelitis in, 774 pyemia in, 768 relation of diphtheria to, 777, 779 of erysipelas to, 777, 778 of infectious fevers to, 775 of malaria to, 777, 779 of scarlet fever to, 777, 779 saline solutions in, 748 salpingitis in, 760 salpingo-oophorectomy for, 753 sapremia in, 772 septic cystitis in, 774 metritis in, 761 proctitis in, 775 septicemia in, 772 serum-therapy, 747 Puerperal sepsis, suppuration of pelvic joints in, 777 symptoms, 737 tetanus in, 776 thrombophlebitis in, 751 operative treatment, 759 thrombotic phlegmasia in, 769 treatment, by artificial hyperleuko- cytosis, 748 by washing blood, 748 curative, 745 preventive, 741, 745 typhoid fever and, differentiation, 738 ureteritis in, 774 uterine phlebitis in, 766 state, 206 abdominal palpation at end, 241 abscess of breast in, 229 acute intercurrent affections in, 684 after-pains in, 214 albuminuria in, 699 albuminuric retinitis in, 701 alterations in circulatory apparatus in, _2i_s anemia in, 665 apoplexies in, 704 arthritis in, 695 ascending myelitis in, 704 blindness in, 701 blood in, 215 bowels in, 227 breasts in, care, 228 changes, 219 care of child during, 223 catheterization in, 226 changes in urinary system in, 216 diagnosis, 222 diastasis of abdominal muscles in, 698 diet in, 225 digital examination of vagina at end, .238 diphtheria in, 693 directions for mother, 231 for nurse, 232 diseases of nervous system in, 704 of urinary system in, 699 dislocation of kidney in, 703 displacements of uterus in, 370 diagnosis, 372 treatment, 373 edematous hemorrhoids in, 699 emotional fever in, 678 erysipelas in, 691 treatment, 693 erj^thematous rashes in, 690 examination in, 225 of coccyx at end, 243 of sacro-iliac joints at end, 243 exanthemata in, 686 fever in, emotional, 678 INDEX. 1 00 = Puerperal state, fever in, from cerebral disease, 682 from constipation, 680 from exposure to cold, 680 from rcllcx irritation, O80 from sun-stroke, 683 non-infectious, 677 persistence or exacerbation, 683 syphilitic, 683 with eclampsia, 682 final examination at end, 233 flatulent distention of abdomen m, 0q8 glycosuria in, 217, 699, 701 gonorrhea in, 697 hematuria in, 702 hemiplegia in, 704 incontinence of urine in, 703 indagation of vagina at end, 238 inspection of vuKa at end, 236 involution of uterus in, 207, 208. See also Involution of uterus. kidneys in, 702 lesions of sacral plexuses in, 704 lochia in, 212 lungs in, 217 malaria in, 693. See also Malaria in puerperal state. mammary glands in, care of, 228 changes in, 219 management, 223 measles in, 691 medication in, 225 milk fever in, 218 muscular rheumatism in, 697 nephritis in, 702 nerve degeneration in, 704 neuritis in, 704 palpation of kidneys at end, 243 paralysis in, 704 paraplegia in, 704 pathology, 296 pemphigus in, 698 pleurisy in, 686 pneumonia in, 684 position of uterus at end, 238 pulse in, 215 quiet in, 223 rest and quiet in, 223 retention of urine in, 216, 226 rheumatism in, 695 muscular, 697 rotheln in, 691 scarlet fever in, 686. See also Scarlet fever in puerperal state. skin diseases in, 69S small-pox in, 6qi specular examination of vagina and cervix at end, 241 suppression of urine in, 703 sweat-glands in, 217 temperature in, 218 Puerperal state, tympanites in, 698 urination in, 226 urine in, 699 visitors in, 223, 224 weight in, changes, 218 Pucrperium, 206. See also Puerperal slate. Pulmonary apoplexy in newborn infant, 962 artery, thrombosis, in labor, 642 embolism, in labor, 642 in pregnancy, 427 Pulmotor, Draeger's, 958, 959 Pulse in labor, 215 in newborn infant, 944 in puerperal state, 215 Pump, breast-, 719 Puncture, lumbar, in eclampsia, 656 of membranes in eclampsia, 656 Purpura ha;morrhagica in pregnancy, 426 Purulent decidual endometritis, 331 Putrefaction of liquor amnii, 302 of pelvic and abdominal tumors in puerperal sepsis, 776 Putrid absorption in puerperal sepsis, 772 Pyelitis in pregnancy, 415 treatment, 415 in puerperal sepsis, 774 Pyemia in puerperal sepsis, 768 Pyopagus, birth of, 576 Quickening, ioi, 146 value, in estimating duration of preg- nancy, 165 Quiet in puerperium, 223 Rachitic pelvis, 516. See also Pelvis, rachitic. Rachitis of fetus, 341 Rashes, erythematous, in puerperal state, 690 Rectal examination, 57 Recti muscles, diastasis, operative treat- ment, 937 Webster's operation, 937 Rectocele, obstruction of labor by. 571 Rectum, abnormal conditions about, ob- struction of labor by, 571 changes, in pregnancy, 136 imperforate, in newborn infant, 964 Recurrent fever of fetus, 340 Red milk, 716 Reflex irritation, fever in puerperal state from, 680 Relaxation of pelvic joints, 536, 537 after labor, 725 of uterus, puerperal hemorrhage from, 670 Renal calculus in pregnane}-, 416 ioo6 INDEX. Renal tumors in pregnancy, 414 Resistance, forces of, 249 Resistant forces in labor, excess, 477 Resisting h>Tnen, treatment, 876 Respiration, artificial, 957 Byrd's method, 957 Hall's method, 957 mouth-to-mouth, 958 risks attending, 960 Schultze's method, 958 of newborn infant, 942 phj'siology, 956 Respiratory apparatus, changes, in pregnancy, 139 diseases, in pregnancy, 426 tract, rupture, in labor, 640 Rest and quiet in puerperium, 223 Restitution, anomalies, 260 in vertex presentation, 256 Retinitis, albuminuric, in puerperal state, 701 Retrodisplacements of uterus, persistent, treatment, 373 treatment, 929. See also Uterus, retrodis placement. Retroflexion of pregnant uterus, 361 prognosis, 363 symptoms, 362 terminations, 362 treatment, 363 when uterus is incarcerated, 364 Retroplacental effusion, 181 Retro-uterine hematocele, 462 Retroversion of pregnant uterus, 361 Rheumatism, articular, of fetus, 340 in puerperal state, 695 muscular, in puerperal state, 697 of myometrium in pregnancy, 376 Rigidity of cervix, obstruction of labor by, 564 Ring, Bandl's, 133, 249, 613 contraction, 249 R. O. A. presentation, 248 Robert pelvis, 514 Rochester sterilizer, 781 Rogers' blood-pressure apparatus, 140 Rokitansky's cervical pregnancy, 332 R. O. P. presentation, 248 explanation of frequency, 248 Rosenmiiller's body, 40 Rotation, external, anomalies of, 260 of fetal head, 255 anomalies, 260 external, 258 of occiput in occipitoposterior posi- tion, 262 abnormalities, 262 into hollow of sacrimn, mechanism of labor in, 264 Rotheln in puerperal state, 691 Round ligament in groin, fibromj'oma, in pregnancy, 379 Round ligament in groin, shortening, for retrodisplacement of uterus, 929 Rubber gloves, 785 for examination, 58 sterilization, 787 Rupture of chorion, 311 of circular sinus of placenta, 605 of Graafian follicle, 76 of hematoma in labor, 642 of respiratory tract in labor, 640 of sacro-iliac joints in labor, 638 of sj'mphysis in labor, 638 of tubal pregnancy, 451 of umbilical cord, 646 vessels, 324 of uterus, 612. See also Uterus, rup- ture. of varicose veins in pregnancy, 431 SACCtJLATiON of uterus, 363, 365 posterior, 365 Sacral curves, variation, 23 plexuses, lesions, in puerperal state, 704 teratoma of fetus, obstruction of labor by, 577 . . Sacrococcygeal joint, ankylosis, 536 fracture, in labor, 639 Sacro-iliac joints, 20 examination, at end of puerperium, 243 rupture, in labor, 638 synostosis, 536 Sacrosciatic ligaments, 18, 27 notch, 18 Sacrum, fracture, 534 Saddle-shape back, 540 Saline solutions in puerperal sepsis, 748' Salivation in pregnane)^ 145 Salpingectomy, partial, technic, 925 technic, 922 Salpingitis in puerperal sepsis, 760 Salpingo-oophorectomy for puerperal sepsis, 753 technic, 921 Salpingostomy, technic, 928 Salt solution in postpartum hemorrhage, 611 Salvarsan in syphilis of newborn infant, 962 Sanger's method of Cesarean section, 867 Saponification of fetal tissues, 351 Sapremia in puerperal sepsis, 772 Sarcoma of ovary in pregnancy, 391 of pelvis, 532 of placenta, 317 of vagina in pregnancy, 390 of vul\-a in pregnancy, 394 Scalp, injur}-, during labor, 953 sloughs, from injury during labor, 954 Scarlet fever in puerperal state, 686 INDEX. 1007 Scarlet fever of fetus, 338 relation, to puerj)eral fever, 777, 77Q Schatz's method of cephalic version, 271 metranoikter, 707 Schede's operation for ureteral fistula, 902 Schultze's method of artilicial respira- tion, Q58 Sclerema of premature infants, 945 Scoliosis, 550 Scoliotic pelvis, 550 Sebaceous cysts of breasts, 716 glands in prej^nancy, 147, 148 Segment, uterine, lower, 249 upper, 249 Seminal fluid, 82 mechanism of ejaculation, 85 of reception, within genital canal of female, 85 spermatic particles in, first appear- ance, 84 time of disappearance of spermato- zoa from, in old men, 84 granule of spermatozoon, 83 lake, 86 Sepsis, puerperal, 726. See also Puer- peral sepsis. Septa of cervical canal, obstruction of labor by, 565 of vagina, obstruction of labor by, 566 Septate uterus, obstruction of labor by, 562 Septic cystitis in puerperal sepsis, 774 infection of lungs in newborn infant, 961 of newborn infant, 963 of umbilicus in newborn infant, 969 in puerperal sepsis, 761 internal hemorrhage, and shock, dif- ferentiation, 941 proctitis in puerperal sepsis, 775 Septicemia in puerperal sepsis, 772 of fetus, 340 Serum, antistreptococcus, in puerperal sepsis, 745, 747 blood-, in puerperal sepsis, 747 treatment of pernicious vomiting in pregnancy, 406 Serum-therapy in puerperal sepsis, 747 Sex, determination, 108, 165 Sexual organs, female, development, 37 Shield, nipple-, 719, 720 Shock in labor, 640, 660 death from, 640 internal hemorrhage, and septic peri- tonitis, differentiation, 941 Shortening round ligament for retrodis- placement of uterus, 920 Shoulder presentation, 283. See also Prcsenlalioii, shoulder. Shoulders, anomalous descent and rota- tion, 261 Shoulders, descent, rotation, and birth, 258 Show, 174 Silkworm gut, preparation, 790 Silver, colloidal, in puerperal sepsis, 748 Sim[)son's forceps, 817 Sims' position, 65 introduction of Sims' speculum in, 68 speculum, 64 introduction, 67, 68 in knee-chest position, 68 in Sims' position, 68 Sitz-pelvis, 556 Skene's ducts, 43 Skin, cleansing, for obstetric operations, .785 . diseases in newborn infant, 966 in pregnancy, 428 in puerperal state, 698 Skull, fractures, during labor, 951 injury, during labor, 951 Skutsch's method of pelvimetr}', 492, 493 Sloughs of scalp of infant from injury during labor, 954 Sluggishness of bowels after abdominal section, treatment, 941 Small-pox in puerperal state, 691 of fetus, 337 Smellie's forceps, 813 perforator, 854 Sneguireff's operation for making coi- tional vagina, 909 Snuffles in newborn infant, 964 Solms' method of extraperitoneal Ces- arean section, 871 Somatopleure, 94 Sore nipples, 718 Souffle, funic, in pregnancy, 157 Speculum, bivalve, method of introduc- ing, 62, 63 Collin's, 62 cylindric, 69 duck-bill, 68 Edebohls' self-retaining, 68 Ferguson's, 69 Goodell's, 62 Hirst's bivalve, 62 Sims', 64 introduction. 67, 68 Spermatic particle and ovule, meeting place, 86 in semen, first appearance, 84 Spermatozoa, 82 and ovum, meeting place, 86 power of motion, 82 time of disappearance, from semen of old men. 84 vitality, 83 Spermatozoon, 82 Sphincter ani, laceration, treatment, 8S5 Spina bifida, 9O4 ioo8 INDEX. Spinal cord, diseases, in pregnancy, 419 inflammatory diseases, in pregnancy, 419 Splanchnopleure, 94 Spleen, displaced, in pregnancy, 392 Split pelvis, 516 Spondylizema, 543 Spondylolisthesis, 537 Spondylolisthetic pelvis, 537. See also Pelvis, spondylolisthetic. Spongy layer of uterine decidua, 130 Spontaneous evolution, 289 version, 289 Spurious pregnancy, 167 Staphylococci in puerperal sepsis, 733 Stein's instrument for direct measure- ment of conjugate, 484 Stenosis, acquired, of vagina, operation for, 905 of umbilical vessels, 323 Sterility, artificial, 92 causes, 90 psychic, 91 one-child, 91 treatment, 91 Sterilization of forceps, 823 of woman, method, 92 Sterilizer, Rochester, 781 Sterilizing hands and skin, 785 outfit, 780 rubber gloves, 787 Stigma of Graafian follicle, 76 Still-births, habit, 355 repeated, diagnosis of cause, 356 Stillicidium, 594 Stomach, diseases, in pregnancy, 402 of newborn infant, 943 Stomatitis, gonorrheal, in newborn in- fant, 965 Stone's method of antepartum fetometry, 498 Streptococcus in puerperal sepsis, 732, 736, 741 Striae, mammary, 147 Subcutaneous emphysema in labor, 640 Subinvolution of uterus, 662 causes, 662 diagnosis, 663 treatment, 664 Sublingual cysts in newborn infant, 965 Suburethral abscess in pregnancy, 390 Sugar of human milk, 947 Sun-stroke, fever in puerperal state from, 683 Superfetation, no Superin volution of uterus, 661 treatment, 662 Supernumerary breasts, 705 digits, treatment, 963 Supporting perineum, 194 Suppression of urine in puerperal state, 703 Suppuration of pelvic joints in puer- peral sepsis, 777 pelvic, vaginal section for, 758 Suppurative peritonitis, diffuse, abdomi- nal section for, 752 Suprarenals, changes, in pregnancy, 138 Suprasymphyseal Cesarean section, 870 Supravaginal hysterectomy, 915-917 Surgeon's dress, 787 Surgical operations in pregnancy, 432 Suspension of ovary, technic, 925 for retrodisplacement, 933 Suspensory ligament of ovary, 54 Sutures, preparation, 789 Sway back, 540 Sweat cabinet, portable, for use in eclampsia, 654 Sweat-glands in puerperal state, 217 Symphyseotomy, 859 after-care, 863 French method, 861, 863 Hirst's canvas binder for, 862 indications, 859 technic, 859 Symphysis pubis, rupture, in labor, 638 Syncephalus, craniotomy for, 578 Syncope in labor, 642 Syncytial cancer, 318 Sjmcytiolysin, 321 Syncytioma malignum, 318 Syncytium, 103, 118, 120 and blood-serum, relation, 137 Synostosis of pelvic joints, 536 of sacro-iliac joint, 536 Syphilis, effect, on milk, 715 fetal, 333. See also Fetal syphilis. in pregnancy, 428 of lung in newborn infant, 961 of newborn infant, 962 placental, 314 Syphilitic fever in puerperal state, 683 pemphigus in newborn infant, 966 Systemic and other diseases in preg- nancy, 400 Tabes lactea, 713 Tampon in postpartum hemorrhage, 608 in treatment of placenta praevia, 600 insertion, after operation, 789 Tarnier's axis-traction forceps, 819, 820, 834 bag, artificial dilatation of cervical canal b}^ 791 basiotribe, 854, 855 sign of inevitable abortion, 442 Teeth, care, in pregnancy, 142 caries, in pregnancy, 401 Telangiectatic myxosarcoma of umbili- cal cord, 326 Temperature in labor, 182 in newborn infant, 943 INDEX. 1009 Tempcniture in pucrpenil slate, 218 of fetus in ulero, 105 Tenaculum, Hirst's, 796 Ulrich's, 895 Teratoma, sacral, of fetus, obstruction of labor by, 577 Tetanoid convulsions, abortion from, 434 Tetanus bacillus in puerperal sepsis, 733 in puerperal sepsis, 77() of newborn infant, 971 Tetany in i)regnancy, 420 Theca follicle, 76 Thif,'h bones, dislocation, effect on pelvis, 554 Thoracopagus, birth of, 576 Thrombi, dislodgment, as cause of puer- peral hemorrhage, 669 Thrombophlebitis in puerperal sepsis, 751 ligation or exsection of ovarian veins in, 751 operative treatment, 759 Thrombosis of placenta, 322 of pulmonary artery in labor, 642 Thrombotic phlegmasia in puerperal sepsis, 769 veins, ligation and resection, 759 Thrush in newborn infant, 965 Thyroid extract in eclampsia, 656 gland, changes, in pregnancy, 138 Tissues, connective, of pelvis, 28 soft, of pelvis, 25 Tongue-tie in newborn infant, 963 Toothache in pregnancy, 402 Torsion, exaggerated, of umbilical cord, 322 of pregnant uterus, 370 Touch, signs of pregnancy appreciated by, 153 Toxemia as indication for induction of abortion, 803 in pregnancy, 400 Trachea, injuries, in labor, 955 Trachelorrhaphy, 909 technic, 910 Transfusion of blood in postpartum hem- orrhage, 611, 612 Transverse diameter of pelvic outlet, measurement, 494 of pelvis, measurement, 492 Transversely contracted pelvis, 514 Traumatism, fetal, 344 Triol, 786 Trophoblast, 117 True conjugate, measurement, 484 pelvis, 17 Trunk of child, injuries, during labor, 955 presentation, 287 Tubal abortion, 451, 460 moles, 459 pregnancy, 447 abdominal section for, 466 64 Tubal pregnancy, atrophy of sac in, 456 clinical history, 449 hematocele fn^m, 461 pathfjjogy, 449 rupture, 451 of sac and profuse hemorrhage of, 457, 459 vaginal operation for, 467 varieties, 447 Tubercle bacillus in puer[)eral sepsis, 733 Tuberculosis, miliary, in pregnancy, 427 of breasts, 725 of fetus, 339 of lungs in newborn infant, 961 of placenta, 316 of vulva in pregnancy, 394 Tuberculous endometritis, 331 Tubo-abdominal pregnancy, 447, 460 Tubo-ovarian ligament, 54 pregnancy, 447, 453 Tubo-uterine pregnancy, 447 Tumors, abdominal, abdominal section for, 928 degeneration and putrefaction, in puerperal sepsis, 776 pregnancy and, differentiation, 157 fibrocystic, of ovarian ligament, in pregnancy, 390, 391 in labor, 378 in pregnancy, 378 milk-, 723 of breast, 723 benign, operative treatment, 938 in pregnancy, 399 malignant, operative treatment, 940 of fetus, obstruction of labor by, 576, 578 of kidney in pregnancy, 414 of pelvis, 530 of placenta, 317 symptoms, 321 treatment, 322 of umbilical cord, 326 of vagina, obstruction of labor by, 567 of vulva, obstruction of labor by, 567 pelvic, abdominal section for, 928 degeneration and putrefaction, in puerperal sepsis, 776 Tunica fibrosa of Graafian follicle, 76 propria of Graafian follicle, 76 Twin labor, 584. See also Labor, twin. pregnancy, hydramnios and, differen- tiation, 300, 301 Twists of umbilical cord, 322 Tycos blood-pressure apparatus, 140 Tympanites in puerperal state, 698 Tympany after abdominal section, treat- ment, 941 Typhoid fever in pregnancy, 428 labor complicated by, 660 of fetus, 340 lOIO INDEX. Typhoid fever, puerperal sepsis and, dif- ferentiation, 738 Ulrich's tenaculum, 895 Umbilical cord, 123, 322 anomalies, 322 calcareous degeneration, 326 coiling, around fetus, 325 neck of fetus, 195 treatment, 195 in labor, 586 cutting, 203, 205 cystic degeneration associated with torsion, 323 cysts, 326 description, 123 development, 123 edema, associated with torsion, 323 exaggerated torsion, 322 false knots, 125, 324 hernia, 326 in newborn infant, 944 ligation, 204 marginal insertion, 325 measurement at term, 125 prolapse, 644 rupture, 645 short, obstruction of labor by, 589 telangiectatic myxosarcoma, 326 torsion, exaggerated, 322 true knots, 324 tumors, ^26 twists, 322 velamentous insertion, 325 fungus of newborn infant, 969 hernia, 326 in newborn infant, 964 vessels, inflammation, in newborn in- fant, 970 rupture, 324 stenosis, 323 varices, 324 Umbilicus, changes, in pregnancy, 152 diseases, in newborn infant, 969 hemorrhage from, in newborn infant, 970 presentation, 283, 287 septic infection, in newborn infant, 969 Unavoidable hemorrhage, 591, 602 Undeveloped pelvis, 508 Unruptured hymen, obstruction of labor by, 567 Ureter, implantation, into bladder for ureteral fistula, 903 Ureteral anastomosis for ureteral fistula, 901 fistula, 891 abdominal operation, 903 ^ Bandl's operation, 902 celio-ureterocystostomy for, 901 , 903 Ureteral fistula, colpo-ureterocystotomy for, 901 diagnosis, 892 Dudley's operation, 902 implantation of ureter into bladder for, 903 Mackenrodt's operation, 902 nephrectomy for, 901 Schede's operation, 902 treatment, surgical, 900 ureteral anastomosis for, 901 vaginal operations for, 902 Van Hook's operation, 903 Witzel's operation, 904 Ureteritis in puerperal sepsis, 774 Uretero-uterine fistula, 889 Ureterovaginal fistula, 889 Ureters, catheterization, in pregnancy, 409 cystoscopy, in pregnancy, 409 surgical injuries, treatment, 900 Urethral fistula, 889 orifice, 43 Urethroscope, 410 Urinalysis in pregnancy, 410 Urinary and genital canals, fistula be- tween, 888 apparatus, diseases, in pregnancy, 409 fistula, 888 classification, 889 meatus, external, 43 system, changes, in puerperal state, 216 diseases, in puerperal state, 699 tract, examination, in pregnancy, 409 injuries, in labor, 637 Urination in puerperal state, 226 Urine, anomalies, in pregnancy, 417 changes, in pregnancy, 138 diminution, in pregnancy, 417 examination, in pregnancy, 140, 409 excessive secretion, as cause of hy- dramnios, 298 in eclampsia, 650 in newborn infant, 943 in puerperal state, 699 incontinence, after operation for vesi- covaginal fistula, 899, 900 in pregnancy, 416 in puerperal state, 703 retention, after labor, 216 in puerperal state, 226 suppression, in puerperal state, 703 Urogenital sinus, 37, 38, 40 trigonum muscle, 238 Uterine adnexa, involution, 211 bruit in pregnancy, 156 contractions in labor, 175 decidua, 130 compact layer, 130 glandular layer, 130 spongy layer, 130 INDEX. ion Uterine hemorrhage as indicating induc- tion of abortion, S09 mucous membrane, implantation of ovum in, 95 muscle, diseases, in pregnancy, 376 manner in which it acts on fetal body, 250 relaxation, postpartum hemorrhage from, 605 phlebitis in puerperal sepsis, 766 segment, lower, 249 upper, 249 wall, separation of placenta from, 181 Utero-abdominal pregnancy, 447, 456 Utero-ovarian ligament, 54 Uterovesical fistula, 889, 890 Uterovesicovaginal fistula, 889 Uterus, abnormal position, abortion from, 435 anatomy, 44 at full term, 132 arbor vitas, 45 arteries, 31, 32 bicornis duplex, 47, 48 pregnancy in one horn, 469 unicollis, 48, 49 biforis, 50, 565 blood-vessels, changes in, pregnancy, 131 cancer, puerperal hemorrhage from, 671 changes in, before menstruation, 74 in extra-uterine pregnancy, 449 in form, position, direction, topo- graphic relations, in pregnancy, 133 in volume, capacity, weight, in pregnancy, 133 compression, in postpartum hemor- rhage, 609 conditions, which interfere with de- velopment of fetus, 352 congenital anomalies, obstruction of labor by, 562 connective tissue, in pregnancy, 131 contraction, after labor, method of securing, 199 in labor, 175 cordiformis, 48, 49 curettage, after artificial dilatation of cervical canal, 808 deformities, 48 descent, in labor, 173 didelphys, 46, 48 displacements, anterior, in labor, 357 in pregnancy, labor, and puerperium, 357 in puerperium, 370 diagnosis, 372 treatment, 373 puerperal hemorrhage from, 370, 669 diagnosis, 372 Uterus, displacements, puerperal hemor- rhage from, treatment, 373 double, obstruction of labor by, 562 elastic tissue, changes, in pregnancy, 131 examination, method, 57 fibroma, in labor, 379 prognosis, 381 in pregnancy, 378 puerperal hemorrhage from', 670 incudiformis, 49 inversion, in labor, 631 involution, 207, 208. See also Invo- liition of uterus. abnormalities, 661 irritable, abortion from, 433 lymphatic ducts, 2>ij 36 lymphatics, in pregnancy, 132 migration of ovum to, 77 muscle-fibers, in pregnancy, 131 myoma, vaginal myomectomy for, technic, 911 nerves, in pregnancy, 132 neurilemma, in pregnancy, 132 overdistention, as cause of abortion, 435 as cause of labor, 172 peritoneal covering, changes, in preg- nancy, 131 polypi, in pregnancy, 382 position, at end of puerperium, 238 pregnant, 131. See also Pregnant ute- rus. relaxation, puerperal hemorrhage from, 670 retrodisplacement, abdominal section for, 933 Alguie-Alexander-Adams operation for, 929 Baldy's operation, 934, 937 persistent, treatment, 373 shortening round ligament for, 929 treatment, 929 uterine suspension for, 933 rupture, 612 accidental hemorrhage and, differ- entiation, 618 causes, 612 clinical history, 617 diagnosis, 617 frequency, 612 morbid anatomy, 615 prognosis, 619 symptoms, 617 treatment, 620 sacculation, 363, 365 posterior, 365 septate, obstruction of labor by, 562 subinvolution, 662. See also Suh- invohilion. superinvolution, 661 treatment, 662 IOI2 IXDEX. Uterus, suspension of, for retrodisplace- ment. 933 unicornis, 50 pregnancy in one horn, 469 veins, 2,2 Vagina, alterations, in pregnancy, 136 anatomy, 43 anterior wall, lacerations, treatment, 886 artificial, Fleming's operation for making, 907 atresia, hysterectomy for, 908 obstruction of labor by, 567 surgical treatment, 906 bacteria of, 729 bacteriolog\% 729 cancer, in pregnancy, 390 changes in, in extra-uterine pregnancy, 449 cicatrices, obstruction of labor by, 566 closure and contraction, obstruction of labor bj^ 565 coitional, Isaac's operation for making, 909 Sneguireff's operation for making, 909 cj^sts, in pregnancy, 390 diseases, in pregnancy, 387 double, 49, 50, 565 enterocele, in pregnancy, 390 examination, digital, at end of puer- perium, 238 specular, at end of puerperium, 241 hematoma, obstruction of labor by, 566 hernia, in pregnancy, 390 in pregnane}', 152 indagation, at end of puerperium, 238 lacerations, in labor, 625 leukorrhea, in pregnancy. 387 mycosis, in pregnancy, 388 narrow-ness, congenital, obstruction of labor b}', 570 operations on, indications, 876 pathogenic micro-organisms in, in pregnancy, 387 posterior wall, lacerations, Emmet's operation, 877-880 Hegar's operation. 883-885 treatment. 876 sarcoma, in pregnancy. 390 septa of, obstruction of labor by, 566 stenosis, acquired, operations for, 905 tumors, obstruction of labor by, 567 varices, in pregnane}', 389 Vaginal and abdominal examination, combined, 55 Cesarean section, artificial dilatation of cer\acal canal by, 804 in eclampsia, 658 Vaginal Cesarean section in placenta praevia. 602 cysts in pregnancy, 390 depressor, Nott's. 64 enterocele in pregnancy, 390 entrance, laceration, in labor, 627 examination for diagnosis of present- ing part, 247 in labor, 185 hernia in pregnancy, 390 hysterectomy, technic, 921 hysterotomy, anterior, artificial dila- tation of cer\-ical canal by, 804 for inversion of uterus, 808 leukorrhea in pregnanc3^ 387 mucous membrane, pol}T)oid hyper- trophies, in pregnancy, 390 myomectomy for myoma of uterus, technique, 911 operation for tubal pregnancy, 467 for ureteral fistula, 902 preparation for, 789, 874 evening before, 789 morning of, 789 section for infection of pelvic connec- tive tissue, 758 for pelvic suppuration, 758 technique, 911 wall, anterior, injuries, in labor, 630 Vaginismus, obstruction of labor by, 570 treatment, 876 Vagitus uterinus, 942 Valvular diseases of heart, labor com- plicated hy, 660 Van Hook's operation for ureteral fis- tula, 903 Van Huevel's method of treating fetal h\'drocephalus, 580 \'arices in pregnancy, 424 of labia majora in pregnancy, 392 of umbilical vessels, 324 of vagina in pregnanc^^ 389 old, swelling of. in pregnancy, 146 Varicose veins in pregnane}'. 424 rupture. 431 obstruction of labor by, 570 Variola. See Small-pox. Vegetations of vulva in pregnancy, 392 Veins of pelvic organs, 31, 36 of uterus, 32 ovarian, ligation or exsection, in thrombophlebitis, 751 thrombotic, ligation and resection, 759 varicose, in pregnancy. 424 rupture. 431 obstruction of labor b}'. 570 Velamentous insertion of cord, 325 Venereal warts of vulva in pregnancy, 392 Venesection in eclampsia, 654 Veratrum viride in eclampsia, 655 Vemix caseosa, loi INDEX. IOI3 Version, 838 by external manipulation, 840 cephalic, liaudelocque's method, 271 Schatz's method, 271 combined, 841 D'Outrepont's method, 842 Wright's method, 842 contraindications, 839 in breech jiresentation, 282 in contracted pelves, 839 in shoulder ])resentation, 290 indications, 838 podalic, 841 postural, 840 spontaneous, 289 Vertex presentation, 252 diaf;nosis, 252 explanation of frequency, 248 mechanism of labor in, 252 positions, 248 restitution in, 256 Vesical calculi in pregnancy, 416 hemorrhoids in pregnancy, 416 Vesicovaginal fistula, 889 colpocleisis in, 897, 898 diagnosis, 891 Ferguson's operation, 896 in labor, 637 incontinence of urine after opera- tion for, 89Q, 900 intravesical hemorrhage after op- eration for, 900 treatment, 893, 895 after operation for, 900 Vesicovestibular fistula, 889 Vesicular mole, 306 Vestibule, 43 bulbs, 43 laceration, in labor, 627 Vienna operating mask, 787 Villi of chorion, 117 cystic degeneration, 303 dropsy, 304 of placenta, 118 degeneration, 313 Visitors in puerperium, 223, 224 Vitelline membrane, 77 Vomiting, abortion from, 434 after abdominal section, treatment, 941 as indication for inducing abortion, 808 in pregnancy, 138, 145 pernicious, 402 Voorhees' bags for artificial dilatation of cervical canal, 701 in placenta prrevia, 600 Vulva, bacteria of, 730 cancer, in pregnancy. 394 changes, in pregnancy, 136 diseases, in pregnancy, 392 edema, in pregnancy, 395 obstruction of labor by, 569 Vulva, elephantiasis, obstructing labor, 567 treatment, 876 epithelioma, in pregnancy, 393 gangrene, obstruction of labor by, 570 in labor, 179 in pregnancy, 152 inspection, at end of puerperium, 236 laceration, in labor, 627 lupus, in pregnancy, 394 narrowness, congenital, obstruction of labor by, 570 operations on, indications, 875 pointed condyloma, in pregnancy, 392 pruritus, in pregnancy, 394, 429 sarcoma, in pregnancy, 394 tuberculosis, in pregnancy, 394 tumors, obstruction of labor by, 567 vegetations, in pregnancy, 392 venereal warts, in pregnancy, 392 Vulvar nerves, exsection, 876 Vulvovaginal glands, 43 abscess, in pregnancy, 397 Walcher posture, 560, 561 Wappler cystoscope, 409 Warts, venereal, of vulva, 392 Washing of blood, treatment of puerperal sepsis by, 748 Water in puerperal sepsis, 741 Webster's operation for diastasis of recti muscles, 937 Weger's sign in fetal syphilis, 335 Weight, changes, in pregnancy, 138 in puerperal state, 218 of newborn infant, 942 Wet-nurse, selection, 947 Wharton's gelatin, 125 Wigand's method of deli\-ering after- coming head, 849 in breech presentation, 282 treatment of placenta prtevia, 600 Witzel's operation for ureteral fistula, 904 Wolfiian body, 38-40 ducts, 37, 38, 39 Womb. See Uterus. Wormian bones obstructing labor, 576 Wound, abdominal, closure, Q12 in genital tract, puerperal hemorrhage from, 671 Wright's method of version, 842 Wylie's method of instrumental dilata- tion of cervical canal, 797 Xiphopagus, 574 birth of, 576 Yellow fever of fetus, 340 Yolk of ovum, 77 Zona pellucida, 77 RG524 H61 Hirst of obj 1912 Text- book 3tetricB. ■ < :— / / ^2^j^^^ZS:^0 ^ ■mm^:m^E^f kii{i;ii4^