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 http://www.archive.org/details/obstetricspractiOOcrag 
 
it IS with deepest sorrow that we announce 
 the death of Dr. E. B. Cragin. For a good 
 many years Dr. Cragin 
 has been one of the 
 best known specialists 
 in gynecology and ob- 
 stetrics in this country. 
 As a teacher he was 
 known and affection- 
 ately regarded by many 
 physicians who have 
 had the privilege of 
 studying under him. He 
 had a fine scientific 
 mind and his contribu- 
 tions to the branches of 
 medicine which engaged his attention have 
 been of a high order. The following facts 
 are from the New York Times (Oct. 23, 
 1918) : 
 j'Dr. Edwin Bradford Cragin, prominent 
 I in New York for many years as a^ ob- 
 stetrician and gynecologist, died on October 
 21st of pneumonia at his home, 10 West 
 Fiftieth Street, in his fifty-ninth year. He 
 had been in ill-health for more than a year, 
 but continued to carry on his practice until 
 a month ago. 
 
 Dr. Cragin was born at Colchester, Conn., 
 the son of Edwin Timothy and Ardelia 
 Ellis Cragin, and graduated at Yale in 1882, 
 got his M. D. from the New York College 
 of Physicians and Surgeons in 1886, and 
 commenced his practice of medicine in this 
 city the same year, after serving for a time 
 on the hospital staff of Roosevelt Hospital. 
 He was later appointed assistant gynecol- 
 ogist to the hospital and assistant surgeon 
 to the New York Cancer Hospital, and in 
 1899 became attending surgeon to the 
 Sloane Maternity Hospital. 
 
 Dr. Cragin became prominent as a gyn- 
 ecologist and obstetrician early in his career 
 and was consulting surgeon to the City Ma- 
 ternity, Italian and New York Nursery and 
 Child's hospitals and consulting gynecol- 
 ogist to the Presbyterian, New York, Roose- 
 velt, Lincoln, St. Luke's and New York In- 
 firmary for Women and Children. 
 
 He was Professor of Obstetrics and Gyn- 
 ecology at the College of Physicians and 
 Surgeons, Vice-President New York Acad- 
 emy of Medicine, member of the New York 
 Medical and Surgical Society, New York 
 Obstetrical Society, American Gynecolog- 
 ical, American Medical Association, and 
 many others. He was a member of the Re- 
 publican, University and Yale Clubs and 
 the Board of Elders of the Central Pres- 
 byterian Church. 
 
 Dr. Cragin wrote a number of works on 
 obstetrics. He is survived by his wife, a 
 son, and two daughters, one of whom was 
 
PLATE I 
 
 The Vulva. 
 
 For key see Fig. 1. 
 
OBSTETRICS 
 
 A PRACTICAL TEXT-BOOK FOR 
 STUDENTS AND PRACTITIONERS 
 
 BY 
 
 EDWIN BRADFORD CRAGIN, A.B., A.M. (Hon.), M.D., F.A.C.S. 
 
 PROFESSOR OF OBSTETRICS AND GYNECOLOGY, COLLEGE OF PHYSICIANS AND SURGEONS, 
 COLUMBIA UNIVERSITY, NEW YORK. 
 
 ATTENDING OB.STETRICIAN AND GYNECOLOGIST TO THE SLOANE HOSPITAL FOR WOMEN; CONSULTING 
 
 OBSTETRICIAN TO THE CITY MATERNITY HOSPITAL, THE ITALIAN HOSPITAL AND THE NEW 
 
 YORK NURSERY AND CHILD's HOSPITAL; CONSULTING GYNECOLOGIST TO THE 
 
 PRESBYTERIAN HOSPITAL, THE ROOSEVELT HOSPITAL, THE LINCOLN 
 
 HOSPITAL, THE NEW YORK INFIRMARY FOR WOMEN AND 
 
 CHILDREN AND TO ST. LUKe's HOSPITAL, NEWBURG, N. Y. 
 
 ASSISTED BY 
 
 GEORGE H. RYDER, A.B., M.D. 
 
 INSTRUCTOR IN GYNECOLOGY, COLLEGE OF PHYSICIANS AND SURGEONS, COLUMBIA UNIVERSITY, 
 
 NEW YORK; ASSISTANT ATTENDING OB.STETRICIAN, SLOANE HOSPITAL FOR 
 
 women; ASSOCIATE SURGEON, WOMAN* S HOSPITAL. 
 
 ILLUSTRATED WITH 499 ENGRAVINGS AND 13 PLATES 
 
 LEA & FEBIGER 
 
 PHILADELPHIA AND NEW YORK 
 
Entered according to the Act of Congress, in the year 1916, by 
 
 LEA & FEBIGER, 
 in the Office of the Librarian of Congress. All rights reserved. 
 
TO THE MEMORY 
 
 OF 
 
 DR. JAMES W. McLANE, 
 
 HIS OLD TEACHER AXD FRIEXD, AND THE FIRST ATTENDING PHYSICIAN 
 
 TO 
 
 THE SLOANE MATERNITY HOSPITAL, 
 
 THIS BOOK IS RESPECTFULLY DEDICATED 
 
 BY THE AUTHOR. 
 
PREFACE. 
 
 During a protracted service as medical head of the Sloane Hospital 
 for Women, where over eighteen hundred deliveries annually occur, 
 the author has enjoj^ed exceptional opportunities for_observation and 
 experience in obstetrics; and for several years he has felt the growing 
 sense of a duty to place before the profession and students of medicine 
 the methods of this institution and the results obtained. The present 
 Text-book of Obstetrics has seemed to him the most rational and perhaps 
 the most useful way in which to meet this obligation. It will hardly be 
 necessary to point out to the reader that the work, in the methods advo- 
 cated, is based upon the statistical results of the Sloane Hospital and 
 upon the experience gained by the author in the hospital and in private 
 practice. Another object of the work has been to present American 
 statistics in obstetrics. 
 
 The fact that many of the text-books now before the profession, 
 although very valuable for reference, are too large for the undergraduate 
 student, has long been appreciated by the author; hence in the following 
 pages he has endeavored to cover the subject concisely and to eliminate 
 unnecessary discussion. With this in view he has made no effort to 
 present a complete bibliography of the subject, although references to 
 important articles on most subjects are given. 
 
 It will be noticed that the subjects of pelvimetry and the antepartum 
 examination are included in Chapter Y under the Management of Normal 
 Pregnancy. The author maintains that for the proper management 
 of a pregnancy the obstetrician should inform himself at the earliest 
 opportunity as to both the exact size and shape of the pelvic canal, 
 and should ascertain the presentation of the fetus. 
 
 Opinions will probably differ as to the wisdom of placing Chapter VI, 
 Multiple Pregnancy, in Part II under Physiological Pregnancy. The 
 author's reason for doing so is that in the majority of instances multiple 
 pregnancy is physiological and the labor not abnormal. The troublesome 
 question is the location of complicated labor in multiple pregnancy. It 
 more logically belongs in Part V under Pathological Labor, but this 
 arrangement would involve a division of the subject of multiple pregnancy 
 
VI PREFACE 
 
 and a separation of the parts by many intervenins; chapters, Mhich 
 seemed to the anthor nnwise. He has therefore completed the sul)ject 
 in one chapter even if in discussing the management of compHcated 
 hxbor in multiple i)regnancy he has anticipated methods of treatment. 
 
 For great assistance in preparation of the part of the work treating 
 of embryology the author is pleased to acknowledge his obligation to 
 Adam M. Miller, Ph.D., professor of anatomy at The Long Island College 
 Hospital. 
 
 In the matter of illustrations, both drawings and ])hotographs, the 
 author wishes to express to ]Mr. K. K. Bosse, of New York, appreciation 
 of his painstaking work. 
 
 E. B. C. 
 
 New York, 19 1G. 
 
CONTENTS. 
 
 PART I. 
 ANATOMY AND EMBRYOLOGY. 
 
 CHAPTER I. 
 
 Anatomy of the Female Generative Organs 17 
 
 CHAPTER II. 
 
 Embryology and Physiology 54 
 
 PART II. 
 PHYSIOLOGICAL PREGNANCY AND ITS MANAGEMENT. 
 
 CHAPTER III. 
 
 Changes Produced in the Maternal Organism 123 
 
 CHAPTER IV. 
 
 The Symptoms and Signs of Pregnancy. Their Relative Value in 
 
 Diagnosis 140 
 
 CHAPTER V. 
 
 The Management of Normal Pregnancy 149 
 
 CHAPTER VI. 
 Multiple Pregnancy 191 
 
 CHAPTER VII. 
 Normal Labor ~ 204 
 
 (V) 
 
viii CONTENTS 
 
 CHAPTER VIII. 
 
 The Mechanism of Labor 2H) 
 
 CHAPTER IX. 
 
 The Management of Normal Labor / 307 
 
 CHAPTER X. 
 
 Care of Child in Abnormal Condition at Birth 351 
 
 CHAPTER XL 
 The Puerperitjm and its Management 369 
 
 PART III. 
 PATHOLOGICAL PREGNANCY. 
 
 CHAPTER XII. 
 Toxemia of Pregnancy 417 
 
 CHAPTER XIII. 
 Local and General Affections and Diseases Complicating Pregnancy 444 
 
 CHAPTER XIV. 
 
 Diseases of the Fetal Membranes 491 
 
 CHAPTER XV. 
 
 Abortion 506 
 
 CHAPTER XVI. 
 
 Ectopic Gestation. Pregnancy in Malformed Uteri 522 
 
 CHAPTER XVII. 
 Hemorrhage 564 
 
 CHAPTER XVIII. 
 Pyelitis Complicating Pregnancy 596 
 
CONTENTS IX 
 
 PART IV. 
 PATHOLOGICAL LABOR. 
 
 CHAPTER XIX. 
 Abnormal Labor from Anomalies in Forces 609 
 
 CHAPTER XX. 
 
 Abnormal Labor from Anom.u^ies in the Passages 624 
 
 CHAPTER XXI. 
 Abnormal Labor from Anomalies op the Fetus ant) in Presentation 697 
 
 CHAPTER XXII. 
 
 Prolapse of the Cord 718 
 
 PART V. 
 
 OBSTETRIC SURGERY. 
 
 CHAPTER XXIII. 
 
 Injuries to the Parturient Canal -723 
 
 CHAPTER XXIV. 
 Induction of Abortion and Premature Labor 732 
 
 CHAPTER XXV. 
 
 Forceps ' '*^ 
 
 CHAPTER XXVI. 
 
 Version 
 
 768 
 
 CHAPTER XXVII. 
 Delivery by Methods Distinctly Surgical 776 
 
X CONTENTS 
 
 PART VI. 
 
 PATHOLOGICAL PUERPERIUM. 
 
 CHAPTER XXVIII. 
 Puerperal Infection 809 
 
 CHAPTER XXIX. 
 
 Infant Mortality 836 
 
 Index 841 
 
OBSTETRICS. 
 
 PART I. 
 ANATOMY AND EMBEYOLOGY. 
 
 CHAPTER I. 
 
 ANATOMY OF THE FEMALE GENERATIVE ORGANS. 
 
 The art of obstetrics comprises the study and care of the woman and 
 the product of her conception from the time of her impregnation until 
 subsequent to her deUvery she is able to resume her usual occupation. 
 A thorough knowledge of the factors involved in this process of repro- 
 
 iVICULARIS 
 
 Fig. 1. — The vulva. 
 
 duction demands a careful study of the female generative organs and 
 those neighboring organs which, although not distinctively " generative/' 
 are intimately associated with the process. 
 
 For purposes of description the female generative organs are divided 
 into the external and the internal. 
 
 2 (17) 
 
18 
 
 ANATOMY OF THE FEMALE GENERATIVE ORGANS 
 
 THE EXTERNAL ORGANS OF GENERATION. 
 
 The external organs of generation, grouped under the common term 
 of the ndva, or imdendum, inchide the mons veneris, the labia majora, 
 the labia minora, the clitoris, the vestibule with the urethral orifice, the 
 hymen and certain erectile and glandular structures. 
 
 It will be seen from Plate I and Fig. 1 that the vulva is bounded in front 
 by the anterior abdominal wall, behind by the perineum, and laterally 
 bv the inner surface of the thighs.' 
 
 r^ 
 
 FOUI^CHETTL 
 
 FOSSA NAVICULARS 
 
 Fig. 2. — Nulliparous woman, labia separated. 
 
 Mons Veneris. — The mons veneris is a cushion of areolar and adipose 
 tissue situated in front of the upper part of the symphysis pubis. It is 
 covered with skin, which after puberty becomes pigmented and thickly 
 set with hair. 
 
 Labia Majora. — The labia majora are two folds of modified integument 
 bordering the cleft of the vulva. They are continuous with the mons 
 veneris in front, where, by their junction, they form the anterior com- 
 missure; posteriorly they extend to within an inch of the anus, and there 
 becoming very thin, unite in the posterior commissure, or fovrchette, 
 which forms the anterior edge of the perineum. 
 
 When the labia majora are separated in the \'irgin or nulliparous 
 woman (Plate II and Fig. 2) there is found between the fourchette and the 
 hymen a depression called the fossa navicularis. After puberty the outer 
 
 1 In the illustrations and description of the external generative organs the woman is sup- 
 posed to be in the lithotomy position, i. e., on the back, with thighs flexed and separated. 
 
PLATE II 
 
 Nulliparous Woman. Labia Separated. 
 
 For kev see Fiq 2. 
 
THE EXTERNAL ORGANS OF GENERATION 19 
 
 surface of the labia majora is deeply pigmented, covered with hair, 
 and abundantly supplied with sebaceous and sudoriparous glands. The 
 inner surface is also covered with skin, near the free border resem- 
 bling that on the outer surface, but deeper in, more delicate, moist, and 
 resembling mucous membrane. Rudimentary hairs are visible on close 
 inspection and there are numerous sebaceous glands. In well-nourished 
 virgins the labia majora are usually closely approximated and conceal 
 the parts within. In the aged, emaciated and those who have borne 
 many children, the labia majora usually gape. 
 
 Beneath the skin of each labium majus there is found a tissue resem- 
 bling the dartos of the scrotum but thinner; beneath this are layers 
 of adipose, connective, and elastic tissue. At the upper part of each 
 labium there may sometimes be found the remains of the canal of Nuck. 
 The labia majora correspond morphologically to the scrotum in the 
 male. 
 
 The Labia Minora or Nymphae. — The labia minora or nymphse are 
 two smaller folds of modified skin lying within the labia majora and 
 extending from the clitoris in front downward and backward to merge 
 into the labia majora, usually about their middle or lower third. In some 
 women they seem to join each other in the posterior commissure. The 
 labia minora are triangular in shape with bases upward. At the clitoris 
 the base of each divides into two portions, the upper uniting with its 
 fellow of the opposite side above the dorsum of the clitoris to form its 
 prepuce; the lower uniting w^ith its fellow just beneath the clitoris to 
 form its frsenum. The labia minora vary greatly in shape and size; they 
 are sometimes asymmetrical and sometimes, as in the Hottentot M^oman, 
 greatly hypertrophied. They are directly continuous externall}^ with 
 the labia majora and internally with the mucous membrane of the 
 vestibule. In the virgin they are usually concealed by the labia majora; 
 their skin is then delicate and moist and greatly resembles mucous 
 membrane. 
 
 When, however, as a result of child-bearing or frequent coitus they 
 project beyond the labia majora, they lose more or less of this character 
 and become dry and pigmented. Their surfaces are free from hairs and 
 sudoriparous glands but are richly supplied with sebaceous glands and 
 with sensitive papilla?. Beneath the surface of the labia minora is a 
 vascular connective tissue rich in elastic and smooth muscle fibers but 
 containing no fat. 
 
 The Clitoris. — The clitoris, the homologue of the penis in the male is 
 a small erectile organ about an inch long situated between the anterior 
 extremities of the labia majora at the forepart of the vestibule. Like 
 the penis it consists of a glans, a body and two crura; it has a prepuce 
 and a frsenum both derived from the labia minora, and is also provided 
 with a suspensory ligament. 
 
 The clitoris differs structurally from the penis in possessing no corpus 
 spongiosum and no urethra, the latter being situated just above the 
 anterior wall of the vagina with its meatus in the base of the anterior 
 triangular portion of the vestibule. 
 
20 ANATOMY OF THE FEMALE GENERATIVE ORGANS 
 
 The Glans. — The glans, visible when the labia minora are separated, is a 
 mass of erectile tissue about the size of a small pea and is highly sensitive, 
 being richly supplied with nerves ending in the so-called genital corpuscles. 
 
 The glans is surrounded at its base by sebaceous glands secreting a 
 smegma which may be retained by preputial adhesions and give rise to 
 irritation. 
 
 The Body. — The body of the clitoris is composed of two corpora cavernosa, 
 similar in minute structure to those of the male, and separated by an 
 imperfect septum. 
 
 The Crura. — The crura are the prolongations of the corpora cavernosa 
 which diverge posteriorly to be attached to the ischiopubic rami super- 
 ficial to the triangular ligament. They are covered by the ischio- 
 cavernosi (erectores clitoridis) muscles. 
 
 The Vestibule (see Fig. 1). — The vestibule, best understood as the 
 remains of the urogenital sinus, is the space lying between the labia 
 minora and the hymen. It is bounded in front by the clitoris, behind 
 by the fourchette, laterally by the labia minora. Opening into it are 
 the urethra and the ducts of the vulvovaginal glands. The anterior 
 portion of the vestibule is triangular in shape and by some authors the 
 term vestibule is restricted to this triangular area. The meatus urinarius 
 lies in the base of this triangular portion, the mucous membrane sur- 
 rounding it being usually elevated and corrugated from the encircling 
 non-striated muscular fibers. Near the meatus are often seen the 
 openings of several large mucous crypts. 
 
 The Hymen. — The hymen is a thin fold of mucous membrane arising 
 from a reduplication of the lowermost part of the vaginal walls and 
 closing to a greater or less degree the vaginal orifice. In structure it is 
 composed of a connective-tissue framework rich in elastic fibers and 
 supplied with bloodvessels and nerves; it is covered on both sides with 
 mucous membrane. The hymen varies greatly in shape and extent in 
 different individuals, as seen in Figs. 3 to 10. The most usual shape is the 
 crescentic (see Fig. 3), occluding the posterior portion of the vaginal orifice, 
 the concavity looking forward toward the pubes. Other forms are the 
 anmdar, forming a ring about the opening; the fimbriated or fringed; the 
 bilabial with a central longitudinal cleft; the septate with two openings 
 divided by a septum; the cribriform with numerous small openings; and 
 rarely the hymen completely occludes the vagina, forming the imper- 
 forate variety. The hymen is usually, though not always, torn during the 
 first sexual intercourse; it is also often torn in a gynecological examina- 
 tion. Its presence intact is therefore not a certain proof of chastity 
 nor its rupture a sure evidence of intercourse. After parturition there 
 remains of the hymen only fleshy tags attached around the vaginal 
 orifice; these are called the carunciilce myrtiformes (see Fig. 10). 
 
 The bulbs of the vestibule {bidbi vestibidi) (see Plates III and IV) 
 are two leech-shaped venous plexuses about ap inch in length lyin^ on 
 either side of the vestibule underneath the labia minora; they may be 
 regarded as the cleft homologue of the corpus spongiosum in the male. 
 These venus plexuses, enclosed within a thin fibrous capsule, are rounded 
 
THE EXTERNAL ORGANS OF GENERATION 
 
 21 
 
 posteriorly but taper anteriorly and are continued forward on each side 
 by means of a venous plexus, the j)<^>'s intermedia,, which communicates 
 with its fellow beneath the clitoris. There is here free communication 
 
 Fig. 3. — The crescentic. 
 
 Fig. 4. — The annular. 
 
 Fig. 5. — The fimbriated. 
 
 Fig. 6.— The bilabial. 
 
 between the bulbs of the vestibule, the veins of the labia majora and 
 minora, and the veins of the clitoris. The bulbs of the vestibule are 
 overlapped by the bulbocavernosi {constrictores vagince) muscles and by 
 
00 
 
 AX ATOMY OF THE FEMALE GENERATIVE ORGANS 
 
 their contractions during sexual excitement the hulhs become turgid 
 and erect, tlnis narrowing the vaginal orifice. 
 
 The vulvovaginal glands, or glands of Bartholin, are two racemose 
 glands, round or o\"al in outline, lying on either side of the vaginal orifice 
 
 Fig. 7. — The septate. 
 
 Fig. S. — The cribriform. 
 
 Fig. 9. — T;.>. ::;.,,■.: lurate. 
 
 Fig. 10.— ( 
 
 mvrtiformes. 
 
 usually superficial to the triangular ligament. They are overlapped by the 
 lower extremities of the bulbs of the vestibule. (See Plate III.) They 
 measure about a third of an inch in diameter and their ducts, each about 
 
PLATE III 
 
 FIC. 1 
 
 The Bulbs of the Vestibule. (Playfair.) 
 
 a, bulb of vestibule; 6, muscular tissue of vagina; c,d,e,f, the clitoris and 
 muscles; g, h, i, k, I, m, n, veins of the nymphas and. clitoris communicating 
 with the epigastric and obturator veins. 
 
 FIG. 2 
 
 The Clitoris. (After Kobelt.) 
 
 A, bulbus vestibuli ; C, pars internmedia ; E, glans clitoridis ; F, corpus clitoridis ; 
 H, dorsal vein; L, right crus ; M, vestibule; N, gland of Bartholin. 
 
ANATOMY OF THE FEMALE GENERATIVE ORGANS 
 
 23 
 
 half an inch in length, open just in front of the hymen on each side. They 
 are homologues of Cowper's glands in the male and secrete a glairy mucus. 
 
 Plane of median sagittal section 
 
 Plane of lateral sagittal section 
 
 Fig. 11. — Anterior view of cadaver indicating lines of median section shown in Figs. 13 and 
 14 and of lateral section shown in Figs. 15, 16, and 17. 
 
 Plane of lateral sagittal section Plane of median sagittal section 
 
 Fig 12 —Superior view of cadaver, showing planes of lateral sagittal section (Figs 15, IG^ 
 and 17), median sagittal section (Figs. 13 and 14), and coronal section (Fig. 21). 
 
 The vagina, internal generative organs and pelvic floor will be best 
 understood by a careful study of the accompanying illustrations. Figs. 
 
24 
 
 ANATOMY OF THE FEMALE GENERATIVE ORGANS 
 
 11 to 17 jiiid 21, from frozen sections made for the author by J)r, 
 Frederick T. Van Beuren, Jr., of New York. 
 
 The Vagina (see Fig. 13).— The vagina is the canal connecting the 
 external organs of generation with the uterus, the canal through which 
 sexual intercourse takes place and along which the child passes from 
 the uterus to the outside world. It is a musculomembranous canal 
 lying in the median line of the pelvis between the bladder and urethra 
 in front and the rectum behind; it being separated from the latter below 
 by the pyramidal bod>- called the perineum. The vagina is smaller 
 
 Body of 
 5th L. V. 
 
 Peritoneum 
 
 Prevesical 
 
 space 
 Svniphj'sis 
 
 "pubis 
 Bladder 
 
 mucosa 
 Mods veneris 
 
 Urethra 
 
 Vaginal 
 
 mucosa 
 Clitoris 
 
 Labium minus 
 Fourchette 
 
 Fig. 13. — Median sagittal section. 
 
 below, expanded above into the fornix or vault which receives the cervix. 
 With the exception of the upper expanded portion of the vaginal canal 
 it is normally found collapsed anteroposteriorly ; the anterior and posterior 
 walls lying in contact in the median line, slightly expanded laterally, 
 giving on transverse section the shape seen in Fig, 18, sometimes 
 resembling the letter H. The axis of the canal is somewhat sigmoid in 
 shape corresponding with the forward curve of the rectum, but in general 
 it conforms to the axis of the pelvic canal. The anterior vaginal wall is 
 shorter than the posterior; the cervix, as it were, being set into the anterior 
 wall and shortening it to this extent. 
 
THE VAGINA 
 
 25 
 
 The anterior wall measures about 6.5 cm. (2| in.) the posterior wall 
 9 cm. (3| in.). For convenience in describing organs or conditions felt 
 through the upper expanded portion of the vagina, the fornix or vault 
 is often subdivided into the anterior, posterior, and lateral fornices. 
 
 In structure the vaginal wall consists of three coats: (1) an outer, 
 connective-tissue coat derived from the rectovesical fascia; (2) a middle, 
 muscular coat of unstriped muscular fibers in two layers, an outer, 
 longitudinal and an inner, circular layer; and (3) an internal coat of mucous 
 
 Rectum 
 
 Coccyx 
 
 Posterior fornix 
 Anterior fornix 
 
 Recto-uterine pouch - 
 
 Ixternal sphincter ani 
 Ampulla of rectum 
 
 Anal orifice 
 
 T^^W- 
 
 ^ ' ' '. 
 
 External sphincter ani Peri- Vaginal muscularis 
 neal 
 body 
 
 Fig. 14. — Median sagittal section. 
 
 membrane. The mucous membrane is covered with stratified squamous 
 epithelium continuous with the epithelium covering the vaginal portion 
 of the cervix above and the hymen below. The mucous membrane is 
 thrown into two median longitudinal ridges called the columns of the 
 vagina, situated one on the anterior, the other on the posterior wall. 
 From these extend transversely numerous folds, or rug(B. All of these 
 vaginal markings are more distinct below than above, and most distinct 
 on the anterior vaginal wall in a virgin. With the exception of a few 
 tubular follicles in the upper part of the canal the vagina normally has 
 
26 
 
 ANATOMY OF THE FEMALE GENERATIVE ORGANS 
 
 no glands. The acid reaction of the \aginal secretion is at present 
 assigned to the action of several microorganisms. 
 
 The rekdiun.s of the vagina are as follows: The upper half of the anterior 
 wall lies in relation with the bladder, the lower half with the urethra. 
 The bladder and upper third of the urethra are separated from the 
 vaginal wall by areolar connective tissue; the lower two-thirds of the 
 urethra lie imbedded within the anterior vaginal wall. The posterior 
 vaginal wall is covered above, for about an inch, by peritoneum as it 
 descends from the uterus to form the pouch of Douglas; its middle portion 
 
 Peritoneum 
 Transversalis fascia 
 
 Pelvic fascia 
 "White line"- 
 Reetovesical fascia 
 Obturator facia . 
 Levator ani muscle 
 Anal fascia 
 Deep layer triang. lig. . 
 Intraligamentous space 
 Superficial layer of 
 triangular ligament 
 
 Fig. 15. — Lateral sagittal section. 
 
 lies in relation with the rectum, its lower portion diverges from the rectum 
 from which it is separated by the perineal body. The lateral fornices 
 of the vagina lie in relation with the bases of the broad ligaments which 
 extend from the sides of the uterus to the lateral walls of the pelvis. 
 
 The bladder and urethra bear such intimate relations to the uterus, 
 vagina and the practice of obstetrics that they will be briefly described 
 here. 
 
 The Bladder. — The bladder when empty lies within the true pelvis 
 between the symphysis pubis in front and the uterus and vagina behind 
 (see Fig. 13). The summit in this condition is flattened or depressed 
 
THE BLADDER AND URETHRA 
 
 27 
 
 so that the cavity of bladder and urethra together appear Y-shaped 
 on sagittal section. The summit of the bladder is covered by peritoneum 
 which is reflected thence forward to line the anterior abdominal wall; 
 backward to cover the uterus. The bladder has a muscular wall lined 
 with mucous membrane. The muscular structure consists of two coats, 
 the outer being circular, the inner longitudinal, which are continued 
 downward over the urethra. The mucous membrane is covered with 
 stratified transitional epithelium. The bladder when distended rises 
 into the abdomen above the pubes and tends to displace the uterus 
 backward. 
 
 1st sacral 
 vertebra 
 
 Pyriformis 
 - Peritoneum 
 
 Rectum 
 
 Coccygeus 
 
 Levator ani 
 Fig. 16. — Lateral sagittal section. 
 
 The Urethra.— The urethra, a canal about 4 cm. (1| in.) in length 
 and 5 mm. in diameter, extends from the neck of the bladder downward 
 and forward to the meatus urinarius in the base of the triangular portion 
 of the vestibule. Its muscular coat, consisting of an outer circular and 
 an inner longitudinal layer, corresponds to, and is continuous with, the 
 muscular coat of the bladder. The mucous membrane is thrown into 
 longitudinal folds by the elastic fibers which are numerous in the 
 submucous layer; it' is covered with stratified transitional epithelium 
 continuous with that of the bladder. 
 
28 
 
 ANATOMY OF THE FEMALE GENERATIVE ORGANS 
 
 Numerous tubular glands are present and in the Hour of the urethra 
 near the meatus are two tubules of larger size known as Skene's glands. 
 
 x\round the meatus urinarius the mueous membrane is often thrown 
 into folds of various shapes, sometimes called urethral labia. 
 
 The Rectum. — The only jjortion of the rectum which especially con- 
 cerns the obstetrician is that part which perforates the pelvic floor and 
 is uncovered by peritoneum. Beginning at the point where the peri- 
 toneum is reflected from the anterior surface of the rectum on to the vault 
 of the vagina, forming the pouch of Douglas or recto-uterine pouch (see 
 
 Uterus 
 Fallopian tube 
 Body of pubis 
 Bladder 
 Broad ligament 
 Obturator ext. 
 Obturator int. 
 
 Glass rod above 
 superior layer 
 triangular lig. 
 Crus clitoridis 
 
 Glass rod below 
 inferior layer 
 triangular lig. 
 
 Intraligamentous space 
 Fig. 17. — Lateral sagittal section. 
 
 Fig. 19), the rectum runs for a short distance parallel to the posterior 
 wall of the vagina and is adherent to it. At about 4 cm. (1| in.) above 
 its lower extremity it curves backward away from the vagina to terminate 
 in its external opening, the anus. 
 
 The space thus formed by the divergence of the lower ends of the 
 rectum and vagina is occupied by the pyramidal mass of muscular, 
 fibrous and adipose tissue called the perineal body. Below the point 
 of reflection of the peritoneum from the rectal wall the coats of the 
 rectum are muscular and mucous, united by submucous tissue. The 
 
THE RECTUM 
 
 29 
 
 muscular coat is composed of two layers, an external longitudinal and 
 an internal circular. 
 
 The lower extremity of the rectum is guarded by two constricting 
 bands of muscle; the external and internal sphincters. The former is 
 composed of voluntary muscle fibers, while the latter consists of an 
 aggregation of the involuntary circular fibers of the rectal wall. 
 
 The External Sphincter. — ^The external sphincter arises from the pos- 
 terior surface of the coccyx and from the fibrous layer of the skin over 
 it and passes forward to surround the anus. It is composed of two 
 layers, the superficial and deep. 
 
 The deep layer of the external sphincter is circular and entirely sur- 
 rounds the anus. The fibers of the superficial layer at first run parallel, 
 then separate to surround the anal portion of the rectum, then reunite 
 to be inserted into the tendinous centre 
 of the perineum, some of the fibers being 
 continuous in front with the fibers of the 
 bulbocavernosi (constrictores vaginae) 
 muscles (see Fig. 23). 
 
 The external sphincter is intimately 
 adherent to the integument surrounding 
 the anus; this integument being pig- 
 mented and throwm into radiating folds. 
 
 The Internal Sphincter. — The internal 
 sphincter, composed of an aggregation of 
 the circular fibers of the rectal wall, begins 
 about 4 cm. (1| in.) above the anal margin 
 and increases in thickness as it descends 
 until it reaches the anorectal line, then 
 thins out again. Its lower fibers lie be- 
 low and within the grasp of the external 
 sphincter but are separated from it by a 
 narrow zone of connective tissue. The 
 mucous membrane of the lower end of the 
 rectum is thrown, especially during con- 
 traction of the sphincter, into longitudinal folds called the columns of 
 Morgagni or columns of the rectum. The grooves between these 
 columns deepen from above downward and end in the semilunar 
 valves or crypts of Morgagni. 
 
 The rectal mucous membrane above the crypts of Morgagni is thrown 
 into irregular horizontal folds most of which disappear when the rectum 
 is distended but at three or four points they usually remain permanent 
 and are called the valves of Houston or the rectal valves. These valves 
 vary in number from three to five. Usually there are three, called the 
 superior, middle and inferior rectal valves (see Fig. 19). The middle 
 valve is the most constant and arises from the right anterior quadrant 
 of the rectal wall about 6 to 9 cm. (2f to 3| in.) above the anal margin. 
 The superior valve arises from the left posterior quadrant 9 to 11 cm. 
 (4| to 5| in.) above the anus and the inferior valve lies in about the 
 
 Fig. 18. — Transverse section of 
 the lower portion of the vagina. 
 (Henle.) L, levator ani muscle; R, 
 rectum; U, urethra; V, vagina. 
 
30 
 
 ANATOMY OF THE FEMALE GENEHATIVE ORGANS 
 
 same quadrant, 25 to 30 millimeters (1 to li in.) above the anal 
 margin. 
 
 Lining the bony framework of the true pelvis and largely closing the 
 openings in its wall are two muscles on each side, the obturator intcrnus 
 and the yyriformis. 
 
 The Obturator Intemus. — The obturator internus muscle on each 
 side of the pelvis arises from the bony surface between the obturator 
 foramen in front, the great sacrosciatic notch behind, and the iliopec- 
 tineal line above. It also arises from the inner surface of the obturator 
 
 Fig. I'J. — The rectum luid its relations. 
 
 membrane, except a little of its lower part, and from the tendinous arch, 
 completing the canal for the passage of the obturator vessels and nerve. 
 It is inserted into the upper border of the great trochanter. The obturator 
 internus muscle thus lines and cushions the greater part of the anterior 
 and lateral wall of the pelvis on each side. The inner surface of this 
 muscle is covered by the obturator fascia. 
 
 The Pyriformis Muscle. — The pyriformis muscle arises from the 
 anterior surface of the second, third and fourth sacral segments, between 
 and external to the anterior foramina; from the margin of the great 
 sacrosciatic foramen and from the anterior surface of the great .' xtq- 
 
PELVIC FLOOR 
 
 31 
 
 sciatic ligament. It is inserted into the upper border of tlie great tro- 
 chanter, its tendon usually blending with that of the obturator internus. 
 The pyriformis muscle thus helps to form and cushion the posterior and 
 posterolateral wall of the true pelvis. 
 
 The nerve supply of the obturator internus and pyriformis muscle is 
 from the sacral plexus. 
 
 Pelvic Floor. — Before describing the internal organs of generation 
 it is fitting that the pelvic floor, above which they are placed and from 
 which they gain support should be studied. This pelvic floor, which is 
 bounded externally by skin and internally by peritoneum, closes the 
 irregularly shaped opening at the bottom of the pelvis. Composed chiefly 
 of muscle, the different fascise and connective tissue, it is perforated by 
 the rectum and vagina and in the anterior wall of the latter canal is 
 
 Fig. 20. — The pelvic floor, seen from above. 
 
 located the lower end of the urethra. Mewed in a median sagittal 
 section (see Fig. 13), the pelvic floor is seen to be divided by the vagina 
 into two portions, an anterior and a posterior, called respectively by 
 Hart the pubic segment and the sacral segment. 
 
 During labor the pubic segment is drawn upward; the sacral segment 
 is forced downward. 
 
 Stretching across the outlet of the pelvis and with the fascia? above and 
 below forming the chief part of the pelvic floor are two muscles on each 
 side, the levator ani and the coccygeus. 
 
 The Levator Ani (see Fig. 20).— The levator ani, the most important 
 muscle of the pelvic floor, consists of two portions, namely the pubo- 
 coccygeus and ischiococcygeus; the former arises from the posterior 
 aspect of the horizontal ramus of the pubes and extends backward 
 to t.ie last two segments of the coccyx. The inner portion of this 
 
32 ANATOMY OF THE FEMALE GENERATIVE ORGANS 
 
 pubococcygeus, sometimes called the piiborectalis, sends a few fibers to 
 the urethral and vaginal walls; some to the tendinous centre of the peri- 
 neum, while others pass to the rectal sheath and some interlace with the 
 fibers of the external sphincter. Behind the rectum the inner fibers of 
 the two pubococcygei are linked together by fascial structures and the 
 companion muscles thus united pass to the anterior surface of the coccyx 
 to be inserted into the ligamentum sacrococcygeum anterius. The outer 
 portions of the pubococcygei, larger than the inner, pass directly from 
 pubes to coccyx. 
 
 The ischiococcygeus, the main portion of the levator ani muscle, arises 
 from the white line between the pubes and s])ine of the ischium and from 
 the spine of the ischium, and extends backward, downward, and inward 
 to the sides of the coccyx. It is thus seen that the former idea of the 
 levatores ani blending with each other behind the vagina and behind 
 the anus and forming a U-shaped muscle about the lower ends of these 
 canals is erroneous. As a matter of fact the ischiococcygeus, the main 
 portion of the levator ani, meets its fellow in the median line only when 
 it reaches the coccyx. 
 
 It is the attachment of the inner fibers of the jnibococcygeus to the 
 vaginal and rectal walls and the linking of the two pubococcygei in the 
 median line by means of fascial or fibrous structures which gives the 
 apparent sling action in elevating the lower ends of the rectum and 
 vagina when the levatores ani contract. 
 
 The nerve supply of the levator ani is from the fourth sacral and the 
 perineal branch of the pudic nerve. 
 
 The Coccygeus. — The coccygeus is a thin triangular-shaped muscle 
 which supplements the levator ani in completing the posterior portion 
 of the muscular pelvic floor. 
 
 It arises on each side from the spine of the ischium and is inserted into 
 the lateral margin of the coccyx and the last segment of the sacrum. 
 
 The coccygei muscles acting with the levatores ani draw the coccyx 
 forward after it has been displaced backward, as in defecation or par- 
 turition. 
 ^ The nerve supply is the fourth sacral. 
 
 The Pyriformis Muscle. — The pyriformis muscle on either side lies 
 l)ehind the coccygeus and helps to fill in the posterior and lateral portions 
 of the pelvic floor but is of little obstetrical importance. 
 
 The strength of the pelvic floor, so-called, depends very largely upon 
 the layers of fascia which serve to unite the various muscles and viscera 
 of the pelvis. This fascia will now be described. 
 
 The Pelvic Fascia. — Covering the levatores ani above and lining them 
 below, are two sheets of fascia, derived from the pelvic fascia which is 
 a direct continuation into the pelvis of the transversalis and iliac fascije 
 which belong to the abdomen. 
 
 The layer covering the upper surface of this muscular diaphragm is 
 called the rectovesical fascia (see Figs. 21 and 22), and is the upper and 
 inner division of the pelvic fascia which separates from the lower and 
 outer division or ohhtrator fascia along a line called the "white line" 
 
ANATOMY OF THE FEMALE GENERATIVE ORGANS 
 
 33 
 
 Iliacus 
 Psoas muscle Cecum muscle Ilium 
 
 Gluteus medius 
 
 Iliopectineal ridge 
 Gluteus minimus 
 
 Iliotibial band 
 Pelvic fascia 
 
 Obturator int. _ 
 "White line -, 
 Obturator fascia ' 
 Bladder 
 Rectovesical fascia 
 Levator ani 
 Anal fascia 
 Levator ani 
 Deep layer triang. lig. 
 Superfieial layer 
 triangular ligament 
 
 Fig. 21. — Coronal section. 
 
 Fig. 22. — Pelvic fascia key corresponding to fascia outlined in white in frozen section 
 
 in Fig. 21. 
 
 3 
 
3-4 ANATOMY OF THE FEMALE GENERATIVE ORGANS 
 
 already referred to, extentling from the posterior surface of the body 
 and ramus of the pubes in front to the spine of the ischium behind. 
 
 This rectovesical fascia, aside from covering the levatores ani above, 
 is continued on to the rectum, vagina and bladder, forms the true liga- 
 ments of the bladder and connects the bladder and rectum to the vagina. 
 It adds greatly to the strength of the pelvic floor and thus aids in the 
 support of the pelvic viscera. 
 
 The layer of fascia covering the under surface of the levatores ani is 
 called the anal, or ischiorectal fascia and is derived from the obturator 
 fascia soon after it separates from the rectovesical. 
 
 The obturator fascia, on each side of the pelvis, covers the inner surface 
 of the obturator muscle, being attached to the bony surface around its 
 margin, and forms the outer wall of the ischiorectal fossa. 
 
 The Ischiorectal Fossa. — The ischiorectal fossa is a pyramidal space on 
 each side of the pelvis, bounded superiorly and internally by the levator 
 ani muscle covered with the anal fascia, and externally by the obturator 
 muscle covered by the obturator fascia. 
 
 The floor of this fossa is formed by the skin and fasciae, both superficial 
 and deep, reinforced and limited anteriorly by the transversus perinei 
 muscle; reinforced posteriorly, when standing, by the gluteus maximus. 
 Filling in the anterior portion of the pelvic outlet between the ischiopubic 
 rami in front and a line drawn through the tuberosities of the ischia 
 behind are two fasciae, the superficial and the deep, and between these 
 fasciae several pairs of muscles which will soon be described. 
 
 These fasciae each consist of two layers, they are perforated by the 
 vagina and urethra and the muscles which lie between them are placed 
 on either side of the canals by which the fasciae are perforated. 
 
 The deep fascia, called the triangular ligament (see Fig. 15), is tri- 
 angular in shape and extends from the pubic arch in front to the centre 
 of the perineal body about an inch in front of the anus where it joins with 
 the superficial fascia. This deep fascia consists of two layers, the superior 
 or deep layer, and the inferior or superficial layer. The superior layer 
 may be regarded as an extension from both the rectovesical and the 
 obturator fascia. Between the superior and inferior layers of the tri- 
 angular ligament or deep fascia, are situated a portion of the urethra 
 which perforates both layers, the constrictor muscle of the urethra, 
 vessels, and nerves. 
 
 The superficial fascia also consists of two layers, the superficial and 
 deep. 
 
 The superficial layer lies just beneath the skin and is continuous with 
 the general superficial fascia of the body, it is loose and areolar and its 
 spaces are occupied by adipose tissue. 
 
 The deep layer of the superficial fascia, divided in the median line by 
 the genital orifice, is attached on each side to the rami of the ischium 
 and pubes and extends from the pubic arch in front to the centre of tlie 
 perineal body behind, where it unites with the inferior layer of the tri- 
 angular ligament or deep fascia. Between this deep layer of the super- 
 ficial fascia and the inferior or superficial layer of the triangular ligaments 
 
ANATOMY OF THE FEMALE GENERATIVE ORGANS 35 
 
 are the muscles already referred to and now to be described (see Fig. 23). 
 As the muscles occur in pairs, one on either side of the median line, only 
 one side will be spoken of. 
 
 The bulbocavernosus or constrictor vaginae muscle arises from the centre 
 of the perineal body where it fuses with the sphincter ani and trans- 
 versus perinei and passes forward over the vaginal bulb of that side 
 and is inserted with its fellow into the sheaths of the corpora cavernosa 
 of the clitoris. Its action is chiefly to compress the bulb of the vestibule. 
 It has little, if any, power in constricting the vagina. 
 
 The ischiocavernosus or erector clitoridis muscle (see Fig. 23) arises 
 from the tuberosity and ramus of the ischium and extending forward 
 is inserted into the corpus cavernosum of the clitoris. Its action is to 
 compress the crus clitoridis and so cause and maintain erection. 
 
 Fig. 23. — Muscles of the pelvic floor, seen from below. 
 
 The Transversus Perinei Muscle. — The transversus perinei muscle arises 
 on each side from the inner surface of the tuberosity of the ischium, 
 passes inward and is inserted into the centre of the perineal body, fusing 
 there with its fellow of the opposite side, with the sphincter ani and with 
 the bulbocavernosi muscles. 
 
 The transversi perinei serve to fix the perineal body and thus aid the 
 action of the other muscles inserted into it. The nerve supply of the 
 three pairs of muscles just described, the bulbocavernosi, the ischio- 
 cave^rnosi and the transversi perinei is the perineal branch of the pudic 
 nerve. The line of union of the superficial fascia and the triangular 
 ligament is along the posterior border of the transversi perinei. 
 
 The Perineal Body.— The perineal body is the pyramidal mass of muscle, 
 fascia and connective tissue filling in the space between the tuberosities 
 of the ischium and the diverging rectum and vagina which at their 
 external openings are separated about 2.5 cm. (1 in.) but unite about 
 4 cm. fl| in.) above their orifices. The perineal body, being the rneeting- 
 point of most of the muscles and fasciae comprising the pelvic floor, 
 
30 
 
 ANATOMY OF THE FEMALE GENERATIVE ORGANS 
 
 serves when intact to maintain the proper position and rehition of the 
 canals perforating the pelvic floor, and of the internal organs of generation 
 which lie above it The arteries, veins and nerves of the pelvic floor 
 may be seen in Plate IV. 
 
 THE INTERNAL ORGANS OF GENERATION. 
 
 Having studied the external generative organs, the pelvic floor and 
 the vagina which perforates it and connects the external organs with 
 the internal, we are now ready for the study of the internal organs of 
 generation, consisting of the uterus, Fallopian tubes, and ovaries. 
 
 The Uterus. — The uterus is a hollow muscular organ, pyriform in 
 shape, lying in the pelvis between the bladder in front and the rectum 
 behind. It measures approximately 2.5 cm. (1 in.) in its anteroposterior 
 diameter; nearly 4.5 cm. (2 in.) in its transverse diameter at the upper 
 
 Fig. 24. — Fundus of uterus, seen from above. 
 
 or larger extremity and 7.5 cm. (3 in.) in length. It is flattened on 
 the anterior surface; much more convex on its posterior surface and 
 upper extremity (see Fig. 24). Slightly below the middle of the 
 uterus there is seen to be a constriction called the isthmus, dividing the 
 organ into a body, that portion above the isthmus, and a cervix, that 
 portion below it. The relative length of cervix and body depends upon 
 whether the uterus is that of an infant or an adult. In F'ig. 25, A was 
 taken from an infant at birth; B froin a nulliparous woman; C from a 
 multipara. 
 
 It is seen that in the infant uterus the length of the cer\'ical canal 
 is nearly two-thirds that of the whole uterine canal, while in the adult 
 uterus the cervical canal is only about one-third of the uterine canal. 
 
 The attachment of the vagina to the cervix divides the latter into two 
 portions: (a) the infravaginal portion (see Fig. 2()), which projects 
 into the vagina, and (b) the supravaginal ])ortion, which lies above it. 
 
PLATE IV 
 
 bulbus vestibuli 
 
 Ischiocavernosus 
 
 art. of clitoris 
 
 perineal branches 
 of posterior ... 
 femoral cutaneous 
 nerve 
 
 'posterior labial 
 arteries 
 
 'Urogenital 
 trigone 
 
 -Transversus perinei 
 superficialis 
 
 .'•'perineal nerve 
 
 cluneal lit . . . ^ 
 
 Inf. haemorrhoidal and perineal' ,-• 
 
 nerves inlmal pudU 
 
 itltcnial pudic art. y 
 
 nudic nerve 
 Gluteus marimus X 
 
 Levator am 
 
 anococcygeal lig. 
 
 Gluteus maximus 
 ■.^ internal pudic vessels 
 
 inferior haemorrhoidal artery 
 medial inferior cluneal nerve 
 
 ^ Sphincter ani externus 
 
 Anatomy of the Pelvic Floor. (Sobotta.) 
 
THE INTERNAL ORGANS OF GENERATION 
 
 37 
 
 x\s the vaginal wall is attached to the cervix lower in front than behind, 
 the infra vaginal portion of the cervix is shorter anteriorly than posteriorly. 
 
 Fig. 25. — Uteri of infant, nullipara, and multipara. 
 
 The upper convex extremity of the uterus, lying above the entrance of 
 the Fallopian tubes, is called the fundus. In practical obstetric work the 
 use of this term fundus is commonly extended to apply to the whole 
 of the upper part of the uterus, felt through 
 the abdominal wall. The lateral angles of 
 the uterus marking the entrance of the 
 Fallopian tubes are called the cornua. 
 
 The uterus, supported by the pelvic floor 
 below and by the ligaments above, lies 
 normally inclined forward toward the blad- 
 der; its position, however, is constantly 
 changing with the movements of respi- 
 ration and with the condition of distention 
 of bladder and rectum, especially the 
 former. Beginning with the isthmus ante- 
 riorly and extending over the fundus down 
 to the attachment of the vaginal wall 
 posteriorly, the uterus is covered by peri- 
 toneum. 
 
 The cavity of the uterus extends from 
 the opening of the cervix into the vagina, 
 the external os, to the inner surface of the 
 fundus and measures about 6.25 cm. (2| in.) in length. It is constricted 
 about opposite the isthmus by a narrowing of the canal called the 
 
 Supravaginal') p^^.^ion 
 
 Of 
 Infravaginal Cervix 
 
 Fig. 26. — Infravaginal and supra- 
 vaginal portion of the cervix. 
 
38 ANATOMY OF THE FEMALE GENERATIVE ORGANS 
 
 internal os, which divides the cavity of the body above from tliat of the 
 cervix bek^w. 
 
 A coronal section of the nterns throngli the tnl)es shows tlie ca\ity 
 of the body to be triangular with the sides convex inward. The cavity 
 of the cervix is fusiform, the external os being larger than the internal, 
 but both smaller than the cavity of the cer\'ix. The anterior and posterior 
 walls of the uterus normally lie in contact. A probe 3 mm. (| in.) in 
 diameter will, as a rule, just about fit the internal os of a normal virgin 
 uterus. 
 
 The cavity of the uterus is lined throughout by mucous membrane 
 called endometrium. 
 
 The uterus is thus seen to consist of three coats: 
 
 1. The serous or peritoneal coat. 
 
 2. The muscular coat, which constitutes the chief thickness of the organ. 
 
 3. The mucous coat or endometrium, which lines the uterine cavity. 
 These coats will now be considered more in detail. 
 
 The Serous Coat.^ — For a better understanding of the serous coat one 
 may well trace the course of the peritoneum as it leaves the anterior 
 abdominal wall to dip into the pelvis (see Fig. 13). Passing over the 
 upper surface of the bladder it dips down between the bladder and uterus 
 until it reaches the level of the isthmus whence it passes to the uterus, 
 thence over it, forming its serous coat, to the attachment of the posterior 
 wall of the vagina behind. It passes down this vaginal wall for about 
 an inch and is then reflected to the anterior surface and sides of the 
 rectum. From the sides of the uterus the peritoneum is reflected to the 
 sides of the pelvis, covering the Fallopian tubes and covering and helping 
 to form the ligaments leading from the uterus. 
 
 Peritoneal Pouches. ^ — The peritoneum, as it passes from the uterus 
 to the sides of the pelvis, divides the pelvic peritoneal cavity into two 
 pouches: one between the uterus and the bladder, called in its deeper 
 portion the uterovesical pouch, and one between the uterus and the rectum, 
 called in its deeper portion the recto-ideririe jiovch or the pouch of Douglas. 
 These pouches are usually occupied by coils of small intestine. 
 
 The Muscular Coat. — ^The muscular structure of the uterus constitutes 
 the chief bulk of its wall and is composed of non-striated muscular fibers. 
 It is interspersed wuth areolar tissue, bloodvessels, and nerves. In the 
 unimpregnated condition no distinct arrangement of the fibers is visible 
 but in the gravid uterus the muscular fibers, generally speaking, are 
 arranged in three layers — an external, a middle and an internal, all more 
 or less connected. The external layer is thin and is intimately connected 
 with the peritoneum. It contains both longitudinal and circular fibers, 
 the former predominating. From this layer fibers pass to the Fallopian 
 tubes and the ligaments of the uterus. 
 
 The middle layer forms the chief part of the muscular structure of the 
 uterus. Its fibers have no definite arrangement but interlace in e^'ery 
 direction about the bloodvessels which are very abundant. This layer 
 develops greatly in pregnancy and its contraction is the chief agent 
 in the control of uterine hemorrhage. 
 
THE IXTERXAL ORGANS OF GENERATION 39 
 
 The internal layer is thin and is intimately connected with the endo- 
 metrium. It contains both longitudinal and circular fibers, the latter 
 predominating especially about the openings of the Fallopian tubes and 
 at the internal os. 
 
 The Mucous Coat, or Endometrium. — The mucous coat differs in the body 
 of the uterus from that in the cervix. In the body it is smooth, covered 
 with columnar, ciliated epithelial cells, and presents the openings of 
 numerous tubular glands, the utricular glands. The mucous membrane 
 rests directly upon the internal layer of the muscular coat, there being 
 no submucous layer. The cilise of the epithelium float in the direction 
 from fundus to cervix. The utricular glands are tubular structures 
 lined with columnar, ciliated epithelial cells similar to those on the 
 surface of the endometrium. The glands take a varied course, straight, 
 oblique, or spiral, from the surface of the endometrium down to the 
 muscular coat. ]Many are bifurcated at their outer extremities, and 
 these bifurcated, blind extremities abut against the muscular tissue. 
 
 The mucous membrane of the cervix is thicker and firmer than that 
 of the body of the uterus and is thrown into numerous folds or ridges, 
 longitudinal and transverse. On the anterior and posterior wall of the 
 canal is a median longitudinal ridge giving the so-called arbor vitae 
 formation. The epithelium in the upper part of the canal is columnar 
 and ciliated, as in the body of the uterus. In the lower third of the canal 
 it is stratified squamous epithelium, similar to that covering the vaginal 
 portion of the cervix. Aside from tubular glands, similar to those of the 
 uterine body, there are found in the cervical mucosa numerous racemose 
 glands secreting an alkaline, glairy mucus. By the occlusion of their 
 duets these glands not infrequently become cystic, forming the so-called 
 ovula of Nahoth or Nabothia?i follicles. 
 
 The epithelium covering the vaginal portion of the cervix is of the 
 stratified squamous variety. 
 
 Ligaments of the Uterus. — ^The ligaments which se^^•e to maintain 
 the position of the uterus are six in number, arranged in pairs: The 
 round, the broad, and the uterosacral. They are all covered by folds of 
 peritoneum and contain muscular fibers derived from the uterus. 
 
 The round ligaments, about 12.5 cm. (5 inches) in length, arise on each 
 side of the uterus in front of, and a little below, the attachment of the 
 Fallopian tube. Aside from the muscular fibers mentioned above, they 
 contain "areolar tissue, bloodvessels, and nerves. The ligaments extend 
 from the uterus obliquely forward and outward to enter the internal 
 inguinal rings on each side. After traversing the inguinal canals they 
 terminate in the tissues of the mons veneris and labia majora, some 
 fibers being attached to the pillars of the external ring and the pubic 
 bone. 
 
 The covering of peritoneum in the young subject follows the round 
 ligament into the inguinal canal as a tubular prolongation. E^'en in the 
 adult this sometimes remains pervious and is called the canal of Xuck. 
 
 The Broad Ligaments.— The two folds of peritoneum which extend 
 from the sides of the uterus and upper part of the vagina to the lateral 
 
40 ANATOMY OF THE FEMALE GENERATIVE ORGANS 
 
 walls and Hoor of the pohis are called the broad ligaments of the uterus. 
 These two folds are continuous with the peritonenm covering the anterior 
 and posterior surfaces of the uterus and the\' themselves meet above 
 the Fallopian tubes to form their covering as far as the fimbriated 
 extremity. The portion of the broad ligament on each side between the 
 fimbriated extremity of the P'allopian tube and the side of the pelvis 
 is called the infundihuhpehic ligament. The broad ligaments contain 
 within their folds, aside from the Fallopian tubes which occupy their 
 superior border, the round ligaments in front, the utero-ovarian liga- 
 ments behind, the remains of fetal structures, and numerous bloodvessels, 
 lymphatics, and nerves. 
 
 The vterosacral ligaments are two folds of peritoneum, reinforced by 
 muscular fibers, extending from the upper part of the cervix to the sides 
 of the rectum and to the second sacral vertebra. 
 
 As their muscular fibers are continuous with the superficial muscular 
 layer of the uterus and vagina, and as the direction of the ligaments 
 is nearly parallel with that of the vagina, they not only tend to draw 
 the cervix backward but the vagina upward. 
 
 The two uterosacral ligaments form the lateral boundaries of the 
 pouch of Douglas. The two folds of peritoneum extending between the 
 cervix and the sides of the bladder and forming the lateral boundaries 
 of the uterovesical pouch are sometimes spoken of as the uterovesical 
 ligaments, but they are very unimportant. 
 
 The Fallopian Tubes or Oviducts. — The Fallopian tubes are two 
 curved muscular canals 10 to 12.5 cm. (4 to 5 inches) in length, leading 
 from the ovary on each side to the cornu of the uterus and serving to 
 conduct the ova to the uterine cavity. Although constantly changing 
 in position with that of the uterus their general direction from the 
 cornua of the uterus is outward, then backward, downward and in- 
 ward to be attached to the ovary by one of the fringes of the distal 
 extremity. 
 
 The Fallopian tube on each side from the cornu of the uterus to the 
 opening near the ovary lies within the upper border of the peritoneal 
 folds forming the broad ligament. The portion of the broad ligament 
 between the Fallopian tube and the ovary is sometimes called the meso- 
 salpinx. The Fallopian tube is lined with mucous membrane continuous 
 with that of the uterine cavity. The tube thus forms a communication 
 between the uterine and peritoneal cavities. The uterine opening of 
 the tube, ostium uterinum, is very small, scarcely large enough to admit 
 a fine bristle. The abdominal opening, osti^im abdominale is expanded 
 to a diameter of 4 to G mm. and here the peritoneal covering of the tube 
 joins the mucous membrane of its lining. For purposes of description 
 the Fallopian tubes are divided into four portions: (a) The interstitial 
 portion, (b) the isthmus, (c) the ampulla, (d) the infundibulum, or 
 fimbriated extremity. 
 
 The Interstitial Portion. — The interstitial portion is that part of the tube 
 which is contained within the uterine wall. Its lumen is small, continuing 
 nearlv the diameter of the ostium uterinum. 
 
THE FALLOPIAN TUBES 
 
 41 
 
 The Isthmus. — The isthmus is the straight horizontal portion of the 
 tube 3 cm. (1 to 1 1 inches) in length just outside the cornu of the uterus. 
 
 Fig. 27. — Fallopian tube laid open. (After Richard.) a, h, uterine portion of tube; 
 c, d, pliese of mucous membrane; e, tubo-ovarian ligaments and fringes; /, ovary; g, round 
 ligament. 
 
 Fig. 28. — Fallopian tube; cross-section through ampulla, under low power. (After 
 Luschka.) a, submucous layer; h, muscular layer; c, serous coat; d, mucous membrane; 
 e, e, vessels; 1,1, small primary folds; 2, 2, larger longitudinal and accessory folds; 3, 3, 
 small folds united forming canaUcuU. 
 
42 ANATOMY OF THE FEMALE GENERATIVE ORGANS 
 
 Its lumen, though still small, is larger than that of the interstitial portion 
 and has a diameter of about 3 mm. (I inch). 
 
 The Ampulla. — The ampulla is the dilated, tortuous portion of the tube 
 extending from the isthnnis to the fimbriated extremity and forming 
 more than one-half of the extra-uterine portion of the tube. Its lumen 
 gradually increases from the uterus outward, averaging about twice 
 that of the isthmus. Its walls are thimier and more flexible than those 
 of the isthmus. 
 
 The Infundibulum or Fimbriated Extremity. — The infundibulum is the 
 funnel-shaped abdominal end of the tube surrounded by diverging 
 fleshy processes or flmbrije (fringes) arranged in two or three concentric 
 circles. 
 
 One of the fimbria longer than the rest extends from the infundib- 
 ulum of the tube to the neighboring extremity of the ovary. This 
 fimbria {fimbria ovarira) is grooved, lined with mucous membrane, and 
 resembles a gutter leading from the surface of the ovary to the abdominal 
 opening of the tube. 
 
 As thus described, the Fallopian tube is seen to consist of three coats: 
 
 1. A serous coat, the peritoneal folds of the broad ligament which 
 surround the tube, save a narrow strip along its under surface where 
 the folds approach each other. 
 
 2. A muscular coat, consisting of two layers, an outer longitudinal 
 and an inner circular, both continuous with the muscular structure of 
 the uterus. A few fibers of the longitudinal coat are continued into the 
 fimbria ovarica as far as the ovary. 
 
 3. A mucous coat continuous with the mucous lining of the uterus. 
 
 The mucous membrane of the tube is thrown into numerous longi- 
 tudinal folds, forming furrows, extending the whole length of the canal 
 (see Fig. 27). These furrows are continued along the fimbriae. The 
 mucous membrane is covered by a single layer of columnar ciliated epithe- 
 lial cells, the cilise of which float toward the uterus. The longitudinal 
 folds in the mucous membrane of the ampulla are quite complicated, giving 
 on transverse section of the tube the appearance shown in Fig. 28. Xot 
 infrequently there is found attached to one of the fimbriae a small cyst 
 called the hi/datid of Morgagni. It is lined with columnar, ciliated epithe- 
 lium, is filled with a clear fluid, and is a relic of a fetal structure. Accord- 
 ing to Heisler it is derived from the upper series of Wolffian tubules. 
 
 The Ovaries. — The ovaries, the source of the ova, are two flattened, 
 ovoid bodies lying on either side of the uterus a little below the Fallopian 
 tubes and attached to the posterior layer of the broad ligaments. They 
 vary in size in diflerent individuals but in general each ovary measures 
 about 4 cm. (1| inches) in length, 2 cm. (f inch) in breadth, and 1 cm. 
 (I inch) in thickness, and weighs from 1 to 2 drams (4 to 8 gms.). 
 The anterior attached border is nearly straight and is called the hiluvi. 
 It is here that the bloodvessels and nerves enter the ovary from between 
 the layers of the broad ligament. The posterior border is convex and 
 projects into the peritoneal cavity. The outer extremity of the ovary 
 is broad and convex; the inner is narrow and is continued into the utero- 
 
THE INTERNAL ORGANS OF GENERATION 
 
 43 
 
 ovarian ligament, a rounded cord about 3 cm. (1 incli) in length running 
 between the folds of the broad ligament and connecting the ovary with 
 the uterus a little behind and below the origin of the Fallopian tube. 
 This ligament contains muscular fibers derived from the muscular 
 structure of the uterus. The ovary is further maintained in position 
 by the fimbria ovarica, sometimes called the hihodmrian ligament, con- 
 necting it with the tube; and by the infundibulopelvic or suspensory 
 ligament connecting it with the side of the pelvis. Except at its 
 attached border the ovary is covered by modified peritoneum called 
 germinal epithelium. 
 
 On section of the ovary its structure is seen to differ in its periphery 
 from that of its central portion. 
 
 Fig. 29. — Diagrammatic cross-section of a vertebrate to show the fundamental-relations 
 of the ui-ogenital S5-stem. Md, medullary tube; Nch, notochord; Ao, aorta; B, genital 
 ridge; W.D, Wolffian duct; M.D, Miiller's duct; A, W^olffian ridge; Msth, mesothelium; Coe, 
 celom; Som, somatopleure ; Ach, archenteron. (Minot.) 
 
 The periphery is less vascular, contains the Graafian follicles and ova, 
 and is called the cortex. 
 
 The central portion, rich in bloodvessels and nerves but containing 
 no Graafian follicles, is called the medulla. 
 
 The stroma of the ovary consists of a connective-tissue framework 
 containing numerous spindle-shaped cehs. This stroma is more dense 
 in the cortex than in the medulla. The surface of the ovary is covered 
 by so-called germinal epithelium, composted of a single layer of columnar 
 cells, thus differing from the mesothelium which it joins at the attached 
 border of the ovary. After puberty the surface of the ovary is irregular, 
 due to the projections of the developing Graafian follicles situated in 
 the cortex and to the depressions caused by their rupture and cicatrization. 
 
 On account of the condensation of the cehs of the stroma at the per- 
 iphery of the cortex this layer is called the tunica albuginea. It bears. 
 
44 
 
 ANATOMY OF THE FEMALE GENERATIVE ORGANS 
 
 however, l)ut a sliglit resemblance to the tunica albuginea of the testicle 
 and must not be considered as a distinct envelope. (The Graafian 
 follicles will be described in the chapter on Embryology, page 55). A 
 better understanding of the ovary and the parovarium with their relation 
 to the Fallopian tube on each side of the uterus will be gained by a brief 
 study of their histogenesis. 
 
 About the fifth week of intra-uterine life there is found in the human 
 fetus on the posterior wall of the body cavity two ridges on each side 
 of the median line, see Fig. 29. The outer of these two ridges (A) is called 
 the Wolffian ridge and leads to the formation of the kidney. The inner 
 (B) is called the genital ridge which develops in the female into the ovary; 
 in the male into the testicle. This genital ridge is formed by a localized 
 thickening of the mesothelial cells lining the body cavity and an increase 
 of the connective-tissue stroma beneath. The mesothelial cells covering 
 the surface of this genital ridge become modified in character, penetrate 
 the ridge and eventually give rise to the germ cells, viz., the ova. For 
 this reason they were called by Waldeyer the germinal epithelium. 
 
 Fig. 30. — Fallopian tube and the parovarium (diagrammatic). A, oophoron; B, paro- 
 ophoron; C, vertical tubes of the parovarium; K, Kobelt's tubes; G, Gartner's duct. 
 (Redrawn from Bland Sutton.) 
 
 Wolffian Body; Wolffian Duct. The Parovarium. — From the Wolffian 
 ridge, the outer of the two ridges at the back of the body cavity of the 
 embryo, are developed the Wolffian body and the Wolffian duct. These 
 have a diiTerent destiny and importance in the two sexes. In the female 
 they are rudimentary and unimportant (see Plate V). 
 
 In the male they are of great functional importance. In both sexes 
 they remain intimately connected with the sexual glands. The middle 
 series of Wolffian tubules together with the Wolffian duct, which in 
 the male develops into the epididymis, in the female become an atrophic 
 structure known under different names : the parovarium, epoophoron, or 
 organ of RosenmuUer. 
 
 The Parovarium. — This structure on each side of the pelvis lies between 
 the folds of tliat portion of the broad ligament situated between the 
 Fallopian tube and the ovary, called the mesosalpinx (see Fig. 30). It 
 consists of a larger horizontal tube, representing a portion of the Wolffian 
 duct, and a series of shorter vertical tubes which join it. These shorter 
 
ARTERIAL SUPPLY OF THE GENERATIVE ORGANS 45 
 
 tubes converge toward the hilum of the ovary to which they are attached. 
 The horizontal tube Hes parallel to the Fallopian tube and nearer to it 
 than to the ovary. It usually disappears before reaching the uterus but 
 occasionally persists as a canal to be traced down along the side of the 
 uterus to be lost upon the vaginal wall, or it is occasionally found within 
 the wall of the uterus itself. When persisting as a pervious canal in the 
 above manner it is called the dud of Gartner and is occasionally the seat 
 of retention cysts. 
 
 The lower series of small Wolffian tubules, which in the male become 
 the paradidymis or organ of Giraldes, in the female form a similar 
 atrophic structure called the paroophoron. 
 
 OVARIAN 
 ARTERY* VEIN 
 
 ^UTERINE 
 ARTERY&VEiN 
 
 Fig. .31. — Vascular supply of the uterus and ovary. 
 
 ARTERIAL SUPPLY OF THE GENERATIVE ORGANS. 
 
 The arteries of the external organs of generation and the vagina are 
 all derived from the internal iliacs, or their branches. The external 
 organs, comprising the vulva, are supplied by the external and internal 
 pudics (see Plate IV) . 
 
 "The vaginal artery, corresponding to the inferior vesical in the 
 male, runs along the lateral borders of the vagina, supplying arteries 
 to the anterior and posterior surfaces. A small vaginal branch from the 
 uterine and anastomosing branches from the remaining vesicals, middle 
 hemorrhoidal and internal pudic are also suppHed." (Gerrish.) 
 
 The arterial supply of the uterus is derived on each side of the pelvis 
 chiefly from the uterine, a branch of the anterior division of the internal 
 iliac, and from the ovarian, a branch of the abdominal aorta (see Fig. 31). 
 
40 ANATOMY OF THE FEMALE GENERATIVE ORGANS 
 
 The uterine artery passes along the pelvic wall to the back of the 
 l)roa(l ligament, then crossing in front of the ureter passes to the side 
 of the cervix near the level of the vaginal attachment. Giving off several 
 branches to the vagina it passes up along the side of the uterus to the 
 fundus where it anastomoses freely with the ovarian artery. In its 
 course upward it gives off numerous tortuous, transverse branches to 
 the anterior and posterior surfaces of the uterus which anastomose with 
 corresponding branches from the opposite side. Near the level of the 
 isthmus the circular artery is formed by the anastomosis of the trans- 
 verse branches which are here larger than elsewhere. The ovarian artery 
 arising from the abdominal aorta passes between the folds of the broad 
 ligament near its upper border and after giving off branches to the ovary 
 and tube, passes to the cornu of the uterus and anastomoses with the 
 uterine artery. 
 
 The ovaries and Fallopian tubes are supplied with arterial blood by 
 the ovarian arteries on their way toward the fundus of the uterus. 
 
 VEINS OF THE GENERATIVE ORGANS. 
 
 The veins of the external organs of generation are abundant and as 
 a rule correspond to the arteries (see Plate IV). They communicate with 
 the vaginal veins w^hich surround the vagina and are especially abundant 
 at the lateral borders where they form the vaginal plexuses. These plexuses 
 communicate freely with the vesical and hemorrhoidal plexuses and with 
 the veins of the broad ligament, and finally empty into the internal 
 iliac vein. The veins of the vulva are frequently the seat of marked 
 varicosities during pregnancy. The veins of the uterus, always abun- 
 dant and large, are much increased during pregnancy, forming the uterine 
 sinuses within the muscular structure of the uterus. These uterine ^'eins 
 are directed to the lateral borders of the uterus where they form on 
 each side the uterine plexus from which a portion of the blood through 
 the uterine vein is directed into the internal iliac vein. The remainder 
 (save that which follows the funicular artery in the funicular vein) 
 joins with the blood from the Fallopian tube and ovary in the plexus 
 about the ovary called the pampiniform plexus. From the pampiniform 
 plexus the blood is directed, on the right side into the inferior vena cava, 
 on the left side into the left renal vein. The veins of the generative 
 organs contain no valves. 
 
 LYMPHATIC SUPPLY OF THE GENERATIVE ORGANS. 
 
 The lymphatics from the vulva and the lower fourth of the vagina 
 empty into the inguinal glands. Those from the upper three-fourths of 
 the vagina join with those from the cervix to empty into tlie internal 
 iliac and sacral glands. 
 
 The lymphatic supply of the uterus is always abundant, and like the 
 veins, much increased during pregnancy. This is important to the 
 obstetrician as emphasizing the danger of infection and explaining one 
 
PLATE V 
 
 Sinus Poculo.r'i^ 
 
 Diagrammatic representation of the development of the genito-urmary 
 system the Wolffian body and its derivatives being colored red, the Muilerian 
 duet and its derivatives, green: 1, indifferent type; 2, indifferent type, later 
 stage the Wolffian and Muilerian duets and the primitive ureter now opemng 
 into the urogenital sinus; S, male type, lower ends of Muilerian duets fused 
 to form the sinus pocularis; 4, female type. (Heisler.) 
 
DEVELOPMENT OF FALLOPIAN TUBES, UTERUS AND VAGINA 47 
 
 of the avenues of its conveyance. Beginning in the lymph spaces of the 
 mucous membrane and joining with the lymphatics of the muscular wall 
 of the uterus, the lymph channels of the uterus form a rich plexus cover- 
 ing the surface just beneath the peritoneum. The lymphatics from the 
 body of the uterus join with those from the Fallopian tubes and ovaries 
 to terminate in the lumbar glands. Lymphatics from each uterine 
 cornu follow the round ligament to the deep inguinal gland. A lymph 
 node is usually found in the base of the broad ligament. 
 
 NERVES OF THE GENERATIVE ORGANS. 
 
 The generative organs, both external and internal, receive their nerve 
 supply from the inferior hypogastric or pelvic plexuses. These are two 
 plexuses lying on each side of the rectum, vagina and bladder and are 
 formed by the bifurcation and continuation of the hypogastric plexus, 
 situated in front of the promontory of the sacrum; by branches of the 
 second, third and fourth sacral nerves and by a few fibers from the 
 sacral ganglia. 
 
 The branches from these plexuses to the generative organs largely 
 accompany the branches of the internal iliac artery. The Fallopian tubes 
 and ovaries, in addition to the inferior hypogastric or pelvic plexuses, are 
 supplied by the ovarian plexuses derived from the renal and aortic. 
 
 The origin of the ovary and the Graafian follicle from the genital 
 ridge and the germinal epithelium, and the origin of the parovarium and 
 paroophoron from the Wolffian tubules and duct have already been 
 referred to. The student should now study briefly the origin of the 
 Fallopian tubes, the uterus and the vagina. 
 
 DEVELOPMENT OF THE FALLOPIAN TUBES, UTERUS AND 
 
 VAGINA. 
 
 During the development of the Wolffian body there appears lying 
 parallel with, and to the outer side of, the Wolffian duct, on each side 
 of the body cavity, a tube called the dud of Midler, the exact origin 
 of which is under dispute. By the descent and rotation of the broad 
 ligament the duct of Midler which is external to the Wolffian duct above, 
 is internal to it below. The upper end of this duct (see Plate V) com- 
 municates by means of an expanded funnel-shaped opening with the 
 body cavity. The lower end of each duct of Miiller opens into a cloaca 
 in common with the Wolffian ducts and the intestine. The further 
 development of the lower end of this duct will be studied with the devel- 
 opment of the external generative organs. For the present it is sufficient 
 to understand that by the union and fusion of the lower portions of these 
 ducts are formed the vagina and uterus and that the upper ununited 
 portions constitute the Fallopian tubes or oviducts; the fimbriated 
 extremities being formed by the trumpet-shaped expansion of the upper 
 ends of the ducts. Realizing that by the complete fusion of the lower 
 portions of the ducts of Miiller and the disappearance of the partition 
 
48 
 
 ANATOMY OF THE FEMALE GENERATIVE ORGANS 
 
 walls formed hy their approximation, the perfect vagina and litems are 
 formed, it is easy to understand how any fault in this fusion and absorp- 
 tion process will produce a malformed Aagina and uterus in the shape of 
 bands or septa dividinji; the canals to a greater or less extent. 
 
 Until about the fifth month the embryonic vagina and uterus persist 
 as a single pouch-like structure, the two organs not being difi'erentiated. 
 At this time the development of a circular ridge in the wall of the pouch 
 divides them; the part above the ridge developing the thick muscular 
 wall of the future uterus; the part below the ridge remaining thin- 
 walled and more roomy, the future vagina. 
 
 The uterus of the third month is bilobed at its upper extremity, a 
 condition persisting as the normal condition in certain animals and 
 sometimes found as an abnormality in the human subject. 
 
 Fig. 32. — Uterus didelphys: a, right cavity; b, left cavity; c, right ovary; d, right round 
 ligament; e, left round ligament; /, left tube; g, left vaginal portion; h, right vaginal portion; 
 i, right vagina; j, left vagina; A', partition between the two vaginae. (Mann.) 
 
 While all grades of maldevelopment may be found in the uterus and 
 vagina from a complete separation of the right and left halves, the 
 double uterus and vagina, to a slight indentation of the fundus of the 
 uterus, or a band across the vagina, only those malformations will be 
 described which are typical, well marked, and not very rarely met with. 
 
 The Uterus Didelphys. — In this malformation (see Fig. 32) there are 
 two separate uteri, each representing one-half of the normal organ, 
 there being a complete absence of union and fusion of the ducts of 
 Miiller in that part of their course where such union and fusion should 
 take place. 
 
 Uterus Bicornis. — In the uterus hicornis (see Fig. 33) the luiion and 
 fusion of the ducts of Miiller are complete below, forming a normal 
 vagina and normal lower portion of the uterus, but the ducts remain 
 
DEVELOPMENT OF FALLOPIAN TUBES, UTERUS AND VAGINA 49 
 
 Fig. 34. — Uterus septus, completely double uterus, and incompletely double vagina of a 
 girl, aged twenty-two years: o, a, tubes; b, b, fundus of the double uterus; c, c, c, partition of 
 uterus; d, d, ca^dties of the uterine bodies; e, e, internal orifices;/,/, external walls of the two 
 necks; g, g, external orifices; h, h, vaginal canals; {, partition which di^-ided the upper third 
 of the vagina into two halves. (Mann.) 
 4 
 
50 
 
 ANATOMY OF THE FEMALE GENERATIVE ORGANS 
 
 separate above, forming a double-honied uterus with a sulcus extern- 
 ally between the rornua and a partition internally dividing the upper 
 portion of the uterine cavity. 
 
 Uterus Septus. — In the uterus sejjius (see Fig. o4), union and fusion of 
 the ducts of ]\Iiiller have been complete so far as the external appearance 
 of the uterus is concerned, but a septum dividing the cavity of the uterus 
 or uterus and vagina shows a fault in the absorption of the partition 
 formed by the imion of the walls of the two ducts. 
 
 The uterus unicornis (see Fig. 35) is formed by the development of 
 one of the ducts of ^Iiiller while the other is rudimentary or absent. 
 
 The above typical malformations of the uterus are important to the 
 obstetrician as leading to possible confusion in diagnosis or to compli- 
 cations of parturition. 
 
 The Mammary Glands. — The mammary glands, or lireasts of the 
 human female, bear such a close functional relation to the generative 
 organs and their changes and care so greatly concern the obstetrician, 
 that a brief description of them will here be given. 
 
 Fig. 35. — Uterus unicornis. LH, left horn; LT, left tube; Lo, left ovary; RH, right horn; 
 RT, right tube; Ro, right ovary; RLr, right round ligament; LLr, left round ligament. 
 (Mann.) 
 
 The mammary glands may be considered as collections of highly 
 specialized, highly developed sebaceous glands, whose secretion is 
 de\'oted not to purposes of lubrication, but to nutrition. In the well- 
 developed virgin after puberty they appear as hemispherical masses 
 presenting a little below the centre of the convexity a projection called 
 the nipple, or mammilla, surrounded by a circular area of modified 
 integument of a darker color than that covering the remainder of the 
 breast. The size of the breasts varies greatly in different individuals, 
 depending largely on the development of the gland tissue proper and on 
 the amount of adipose tissue surrounding it. The left breast is usually 
 a little larger than the right. While usually hemispherical in shape and 
 prominent in the virgin, they are usually more or less pendulous in 
 those who have borne children. 
 
 The breast usually covers on each side of the median line a nearly 
 circular space extending from the sternal border to the anterior axillary 
 
THE MAMMARY GLANDS 
 
 51 
 
 margin, and from the second to the sixth rib. The nipple is usually 
 situated at about the level of the fourth rib. The color of the nipple 
 and of the areola varies from a rosy pink in the blonde to a delicate 
 brown in the brunette. 
 
 The skin of the nipple and of the areola differs from that of the rest 
 of the body. That of the nipple is wrinkled, is beset with numerous 
 sensitive papillae, and its summit presents the opening of the lactiferous 
 ducts. The nipple, unlike the areola, has neither sweat glands nor hairs. 
 The skin of the areola resembles that of the nipple but is more delicate 
 in texture. Dotted over the surface of the areola are numerous 
 sebaceous glands which become much enlarged during pregnancy and 
 present the appearance of small tubercles called the tnhercles or glands 
 of Montgomery. 
 
 Fig. 36. — Breast, showing lobes, lubules and lactiferous ducts. 
 
 The nipple and areola are vascular and among the vessels are numerous 
 unstriped muscular fibers, both circular and longitudinal, especially the 
 former. The contraction of these circular fibers, under the stimulus of 
 mechanical or other irritation, causes the nipple and areola to become 
 more prominent and undergo a sort of erection. 
 
 The secreting structure of the breast consists of from fifteen to twenty 
 separate lobes. Each lobe is a compound racemose gland and consists 
 of a number of lobules. Each lobule consists of acini or alveoli sur- 
 rounding a central canal. The canals from the lobules unite to form the 
 excretory ducts of the lobes, fifteen to twenty in number, called the 
 lactiferous or gaJactoyhoroiis duds (see Fig. 36). 
 
 These lactiferous ducts converge toward the nipple and on reaching 
 the areola each dilates into a sinus or amimUa which serves as a reservoir 
 
52 ANATOMY OF THE FEMALE GENERATIVE ORGANS 
 
 for the milk. At the base of the nipple the duct becomes contracted 
 and pursues a straight course to the summit where it terminates in a 
 contracted orifice. Aside from the lobes of the gland proper, there 
 may be found near the base of the nipple minute glandular bodies called 
 accessory milk glands whose ducts open independently upon the surface 
 of the areola or may empty into the ducts traversing the nipple. 
 
 The walls of the ducts are composed of areolar tissue containing both 
 longitudinal and circular elastic fibers and in the larger ducts are un- 
 striped muscular fibers. The epithelial lining of the ducts is continuous 
 at the summit of the nipple with the integument. The epithelium varies 
 in different parts of the gland. Near the orifice of the ducts it is of the 
 squamous variety, while in the deeper portions of the gland the epithe- 
 lium is columnar. The secreting structure of the breast is supported by 
 a framework of fibrous tissue which invests the entire surface of the 
 
 Fig. 37. — Supernumerary mammary gland in axilla. 
 
 organ, sends processes inward between the lobes and lobules, and out- 
 ward to the under surface of the skin. Adipose tissue surrounds the 
 surface of the breast, save immediately beneath the areola and nipple, 
 and occupies the space between the lobes and lobules. 
 
 Supernumerary mammary glands (polymastia), either with or without 
 nipples, occasionally occur. It is quite common to find in the axilla, 
 as shown in Fig. 37, a mass of mammary-gland tissue which enlarges 
 as the breast becomes engorged with the establishment of lactation. 
 There is usually, however, no nipple present on this axillary swelling, 
 and although it may feel hot and painful for a short time it speedily 
 subsides either without treatment or with simply the application of an 
 ice-bag. 
 
 The author has met with a number of instances where a supernumerary 
 nipple as seen in Fig. 38 was located either on the breast or on the ante- 
 
THE MAMMARY GLANDS 53 
 
 rior wall of the chest. Often these nipples are thought by the patients 
 to be warts or moles and their true structure is only determined when 
 lactation is established and it is found that milk can be expressed from 
 them. 
 
 Aside from being found in the axilla and on the anterior wall of the 
 chest, supernmnerary mammary glands sometimes occur on the thigh 
 or on the back. In a case reported by Hirst the woman had nine mammae 
 and as many nipples. 
 
 Fig. 38. — Supernumerary nipple. 
 
 The arterial supply of the breast is from the thoracic branches of the 
 axillary, the internal mammary and the intercostals. The veins corre- 
 spond to, and for the most part accompany, the arteries; the superficial 
 veins are especially prominent during the latter months of pregnancy 
 and lactation. 
 
 The Ijrmphatics for the most part empty into the axillary glands, al- 
 though a few from the inner side of the breast perforate the intercostal 
 spaces and empty into the mediastinal glands. 
 
 The nerve supply of the breast is chiefly from the intercostal nerves 
 through their cutaneous branches. 
 
CHAPTER II. 
 
 EMBRYOLOGY AM) PHYSIOLOGY. 
 
 For an understandinji; of the process of fertilization and develo})ment 
 of the ovum, a study of the sjerm cells is essential. 
 
 THE GERM CELLS. 
 
 The cells composing multicellular animals {meiazoa) fall into two 
 categories: (1) the cells which make up the various tissues and organs 
 of the body, ser\ing the purposes of the individual and then perishing 
 without descendant, and (2) the cells which serve to perpetuate the 
 species, playing a subordinate role in the general economy of the indi- 
 vidual. The cells of the first class are spoken of as the somatic cells 
 (soma, body) in contradistinction to those of the second class which 
 constitute the germ cells or sex cells. 
 
 In the higher animals the germ cells are found in the organs of repro- 
 duction, from which they are eventually discharged and form, under 
 certain conditions, the starting-point of a new individual. Furthermore, 
 the germ cells differ widely in the two sexes, manifesting a fundamental 
 physiological division of labor. The germ cell of the female (ovum, 
 ovium), produced in the ovary, is a large, relatively non-motile cell 
 containing nutritive materials in the form of fatty substances (yolk, 
 deutoplasm). The germ cell of the male (spermium, spermatozoon), 
 produced in the testis, is an extremely small cell unencmnbered by 
 non-protoplasmic substances and possessing a high degree of motility. 
 
 The Ovum. — The mature human ovum has not yet been observed. 
 The description that follows applies to the female germ cell in a well- 
 developed Graafian follicle in the ovary, and which is properly called a 
 primarv oocyte. The significance of the mature ovum will appear in 
 the section on "maturation." 
 
 With the exception of some of the large nerve cells, the primary oocyte 
 is the largest cell in the human body. It measures approximately 250 
 micra (0.25 mm.) in diameter. The living egg-cell, as described by 
 Xagel (Fig. .39), is spherical in shape and more transparent than cells 
 in general. The cytoplasm (ooplasm) can be divided into two regions: 
 a central, somewhat opaque region in which highly refractive and feebly 
 refractive yolk granules of various sizes are seen, and a marginal region 
 which is more transparent and much more finely granular. The outer 
 region contains the nucleus (germinal vesicle) which appears nearly 
 homogeneous. Within the nucleus is a distinct nucleolus (plasmosome) 
 in which Xagel was able to observe ameboid mo^•ement. Surroimding 
 (54) 
 
THE GERM CELLS 55 
 
 the egg-cell is a thick, transparent membrane, the zona pellucida, which 
 shows fine radial striations. It has been thought that these striations 
 represent minute canals permitting the passage of food substances to 
 the ovum. Nagel figures a thin cleft between the egg-cell and the zona 
 pellucida and calls it the perivitelline space. Some other observers dis- 
 pute this on the ground that in the case of a ruptured ovum the cyto- 
 plasm clings to the zona pellucida. The clear membrane is in turn 
 surrounded by radially arranged cells, derived from the germ hill of the 
 Graafian follicle and constituting the corona radiata. 
 
 Stained sections of the human primary oocyte exhibit structures only 
 slightly different from those of the fresh cell. The corona radiata, zona 
 pellucida, outer and inner zones of the cytoplasm, and the nucleus are 
 all clearly shown. The nuclear membrane is distinct and within the 
 nucleus is a well-marked plasmosome, while the chromatin is rather 
 scanty. A centrosome has never been observed in the human egg-cell. 
 
 Perivitelline 
 space 
 
 Germ hill 
 
 rff 
 
 pellucida c^ " ', - ) _..-..—-- , radiata 
 
 Zona " "^^ / V!^\ Corona 
 
 Protoplasmic _ ■... ... 
 
 zone ■ ■ ,. 's^ii}' Nucleus 
 
 
 Deutoplasmic 
 zone 
 
 Fig. 39. — Ovum and some of the surrounding follicular cells from the ovary of a woman 
 twenty-seven years old. . (Nagel.) 
 
 The Graafian Follicle. — The Graafian follicle (Fig. 40), at or near its 
 maturity, is a spherical vesicle located in the stroma of the ovary, and 
 measures 8 to 12 millimeters in diameter. It consists of a wall of epi- 
 thelium enclosing a cavity filled with fluid. The greater part of the 
 wall is composed of several layers of granular cells and is known as the 
 stratum granulosum. At one point the wall is considerably thickened 
 and protrudes into the cavity of the follicle. This thickening is known 
 as the germ hill (discus proligerus, cumulus ovigerus), and within it is 
 embedded the ovum. The cells immediately surrounding the ovum 
 are radially disposed and constitute the corona radiata (Fig. 39). The 
 follicular cavity is often spoken of as the antrum, and the contained 
 
56 
 
 EMBRYOLOGY AND PHYSIOLOGY 
 
 fluid is known as the liquor folliculi. The folHcle is surrounded by a 
 double layer of connective tissue, a differentiated part of the ovarian 
 stroma, the inner layer being markedly vascular and the outer layer 
 densely fibrous. These two layers constitute the theca folliculi. 
 
 - 3 
 
 Fig. 40. — From a section of the ovary of a girl twelve years old, showing a well-developed 
 Graafian follicle. Photograph. 1, stratum granulosum; £, germ hill containing the ovum; 
 3, follicular cavity; 4, theca folliculi; 5, ovarian stroma. 
 
 At its maturity the Graafian follicle usually occupies the entire thick- 
 ness of the ovarian cortex, and produces a rounded eminence on the 
 surface of the wall, its theca at one point merging with the tunica albu- 
 ginea. Thinning of the tunica albuginea and of the follicular wall nearest 
 the surface of the ovary, along with the general vascular congestion of the 
 ovary and greater pressure within the follicle due to increase in the 
 liquor folliculi, results in the rupture of the follicle and surface tissues 
 
THE GERM CELLS 
 
 57 
 
 of the ovary and the discharge of the ovum and Kquor folHcuh. (For a 
 more detailed description of ovulation, see page 61.) 
 
 The Spermatozoon. — The male germ cell or spermatozoon, in contrast 
 with the egg-cell, is one of the smallest cells in the human body and is 
 especially adapted for locomotion and for penetration of the ovum. 
 The name spermatozoon reflects the once-current belief that it was a 
 
 Hem 
 
 Connecting 'piece 
 
 •Perfo7'ator 
 
 ) Neck 
 
 Tail'. 
 
 End-piece - 
 
 7 Head-cap 
 
 Anterior centriole 
 ""Posterior centriole 
 
 Spiral thread 
 
 Mitocliondria sheath 
 
 Terminal disc 
 Axial filament 
 
 Fig. 41. — Human spermatozoon. Diagrammatic. A, surface view; B, profile view; in 
 C the head, neck, and connecting piece are more highly magnified. (Howden-Gray.) 
 
 parasite; but subsequent studies of its developmental history proved 
 it to be a highly specialized cell. 
 
 The spermatozoon, as seen in the seminal fluid, is an extremely slender, 
 delicate cell in which three general parts can be recognized: (1) a head, 
 (2) a connecting piece and (3) a tail (Fig. 41). The head on side view 
 is approximately oval; when seen on edge it is pear-shaped. After a 
 basic dye it is seen to contain the nucleus of the cell. It measures about 
 
58 EMBRYOLOGY AND PHYSIOLOGY 
 
 4.5 X I X I niicni. The coniiectiiig piece is a cylinder al)out six micra 
 in len<;;th and slightly thinner than the head. Some investigators recog- 
 nize a slight constriction or neck between the head and the connecting 
 piece. The latter merges with the long, slender tail which measures from 
 40 to 50 micra in length. 
 
 Closer analysis of the spermatozoon by special methods of technic 
 shows a wealth of detail in the three parts (Fig. 41), The head, in addi- 
 tion to containing the nucleus, shows also a mass of cytoplasm, the galea 
 capitis, terminating in a fairly sharp edge, the perforator. The perforator 
 probably assists the spermatozoon in clinging to, or liurrowing its way 
 into, the ovum. Immediately behind the head is a structure known as 
 the anterior centriole or centrosome, followed by a disk of undiffer- 
 entiated cytoplasm. The connecting piece proper then begins in the 
 posterior centriole or centrosome and extends as far as the annulus or 
 end-ring. The connecting piece consists of a central filament, a delicate 
 sheath surrounding the latter, then a spiral filament embedded in a 
 homogeneous substance, and on the outside a sheath characterized by the 
 presence of mitochondria. The central filament of the tail is a continua- 
 tion of the central filament of the connecting piece and is surrounded 
 along the greater part of its course by a sheath, the involucrum, which 
 is probably continuous with the inner sheath of the connecting piece. 
 For a short distance from its end the central filament of the tail is naked, 
 forming the end-piece. 
 
 As stated previously, spermatozoa are highly motile cells. They propel 
 themselves by undulatory movements of the tail. They swim against 
 a current, even dead spermatozoa floating with their heads in a similar 
 direction, the explanation for which is probably to be sought in their 
 physical structure. This adaptation is of the greatest importance for 
 fertilization because it determines that the motile cells will proceed 
 against the outwardly moving current set up by the cilia of the uterus 
 and oviducts. They swim at a rate which has been variously estimated 
 from 25 to 50 micra per second. 
 
 Spermatozoa possess rather remarkable vitality. The motile cells 
 have been found in the testis of a criminal three days after execution. 
 In the female genital passages they retain their activity for several days 
 or even weeks. Weak alkaline solutions cause an increase in their 
 activity, while acids destroy them. 
 
 Several abnormal forms of human spermatozoa have been observed, 
 such as giants, dwarfs, forms with two or more heads, and forms with 
 multiple tails. It has been thought that the atypical forms resulted 
 from general weakening of the body by illness or drugs. 
 
 Development of the Germ Cells. — The individual, in the vast majority 
 of animal species, l)egins with the fertilized ovum or spermovium which 
 is the result of the union of a mature germ cell from the male with a 
 mature germ cell from the female. The spermovium then by a succes- 
 sion of cell divisions gives rise to all the cells of the organism. These 
 in general, as mentioned in a preceding section, can be divided into 
 somatic cells, which play the dominant part in the economy of the 
 
THE GERM CELLS 
 
 59 
 
 individual and then perish without descendant, and germ cells or sex 
 cells, which under proper conditions serve to perpetuate the species. 
 The term germ plasm is frequently used to designate the substance 
 which, as the chromatin of the sex cells, passes from generation to genera- 
 tion, constituting the hereditary factor and carrying on the line of the 
 race. 
 
 In some of the lower animals the sex cells can be traced directly from 
 the first division of the spermovium to their final position in the genital 
 glands of the adult. Among the higher animals, on the other hand, 
 it has not been possible to follow their course for a period after the first 
 division of the spermovium, but they are first distinguishable in a modified 
 part of the peritoneum when the embryo has attained a fairly high 
 degree of development. At this time they are spoken of as primordial 
 germ cells, but exhibit no structures which characterize them as either 
 male or female. A little later in development, however (fourth or fifth 
 
 Female 
 
 Frimordial Germ Cell 
 
 Male 
 
 Oorjonia / \ < ^^ 
 
 Oocytes ftii^i^ik\ 
 
 Oocyte 1st Order 
 Oocyte 2nd Orde 
 Ovum (l) 
 
 
 / \ 
 / \ 
 
 iij^ei-matogoma / \ ; \ 
 
 /; /\ >'\ \\ 
 
 STAGE 
 
 I OF 
 
 GERMIN- 
 ATION 
 
 Spermatocytes^ *4hdii-^^ 
 j 
 
 1 STAGE 
 
 1 r °^ 
 
 1 GROWTH 
 
 Spermatocytes 1st Ord. ^ <- 
 
 Spermatocytes 2nd Ord. 4 \ V ^"^ 
 
 / 1 1 \ [ MATUR- 
 
 Spermatozoa (4) W 4 i ^ J 
 
 ATION 
 
 Fig. 42. — Schema of comparative descent of ovum and spermatozoa. The dotted lines 
 indicate successive cell generation, the continuous lines connect successive stages of one cell. 
 (Modified from Boveri.) 
 
 week in the human embryo), they differentiate into either male sex cells 
 (spermatogonia) or female sex cells (oogonia) according as the embryo 
 becomes a male or female. From the time of differentiation their his- 
 tories are divergent. 
 
 In the male the spermatogonia continue to proliferate in the testis 
 during the sexual activity of the individual. Some of the spermatogonia 
 increase in size to form primary spermatocytes. Each of these divides 
 equally to form two secondary spermatocytes, each of which in turn 
 divides equally to form two spermatids. The spermatids are then 
 transformed directly into spermatozoa. Each primary spermatocyte thus 
 gives rise to four spermatozoa, and furthermore, during the last two 
 divisions the number of chromosomes is reduced one-half (see Fig. 42). 
 
 In the female the sex cells cease proliferating at or usually before 
 birth, consequently their number is limited. After birth the oogonia con- 
 tinue to increase in size, and to a much greater degree than the sperma- 
 
60 EMBRYOLOGY AND PHYSIOLOGY 
 
 togonia, to form primary oocytes. Each primary oocyte divides miequally 
 into a large cell, the secondary oocyte, and a very small cell, the first 
 polar body. Each secondary oocyte divides imequally into a large cell, 
 the mature ovum, and a very small cell, the second polar body. Each 
 primary oocyte thus gi\'es rise to one large functional cell and two small 
 abortive cells (or three in case the first polar body divides). During 
 o6c^'te divisions the number of chromosomes is reduced one-half (see 
 Fig! 42). 
 
 While it is not within the province of this book to trace the entire 
 history of the germ cells, yet it is important to describe in some detail 
 the process by which the number of chromosomes is reduced since the 
 reduction occurs in preparation for the union of the male with the female 
 sex cell, a condition necessary among the higher animals for the develop- 
 ment of a new individual. 
 
 Maturation of the Ovmn. — The process of maturation, or reduction of 
 chromosomes, has not been observed in the human egg-cell. Conse- 
 quently we must draw^ upon the knowledge gained from the study of 
 lower forms. The classical objects for study are the ova of Ascaris megalo- 
 cephala, variety bivalens (a round-worm parasitic in the intestine of 
 the horse), in which the successive stages can be easily followed. 
 
 In this form, in which the somatic number of chromosomes is four, 
 the process is initiated in the primary ooc^le by the aggregation of the 
 chromatin elements at one side of the nucleus. This is the stage of 
 synapsis. The chromatin then becomes arranged in a convoluted thread 
 or spireme. The spireme splits longitudinally into equal halves and each 
 half in turn splits longitudinally into equal parts. The result is a quad- 
 ruple spireme, which then segments, that is, breaks transversely, into 
 two equal portions. Each portion is thus composed of four rod-shaped 
 pieces of chromatin and is kno^^Ti as a tetrad; and the number of tetrads 
 is one-half the somatic number of chromosomes. 
 
 An achromatic spindle next forms, as in ordinary mitosis, and the tetrads 
 become arranged in an equatorial plate. Then two pieces from each 
 tetrad pass out into a small mass of cytoplasm which becomes separated 
 from the main mass of the egg-cell as the first polar body. The foiu- 
 chromatin rods that remain in the cell, now the secondary oocj'te, con- 
 stitute two dyads. Without the return of the chromatin to the reticular 
 condition, the second polar body is given off in the same manner as the 
 first, one-half of each dyad remaining in the large egg-cell which is now 
 the mature ovum. 
 
 The result of the maturation process is thus one large cell, the mature 
 o\aun, and two small polar bodies (or three in case the first polar body 
 dix'ide.s). The mature egg-cell contains one-half the number of chromo- 
 somes and is prepared to unite with the spermatozoon. The polar 
 bodies which are sometimes spoken of as abortive ova, disintegrate and 
 disappear. 
 
 In ascaris, as described above, the reduction in the number of chro- 
 mosomes takes place with tetrad formation, the chromatin rods or chro- 
 mosomes in the tetrads resulting from a double longitudinal splitting 
 
THE GERM CELLS 61 
 
 of the spireme. While the scope of this work does not permit a detailed 
 discussion of the variations, it should nevertheless be pointed out that 
 in most animals the reduction is accomplished without tetrad formation. 
 The differences in the latter case are found in the behavior of the chro- 
 mosomes during the maturation process. The spireme segments into 
 a number of rods or chromatin masses equal to one-half the somatic 
 number of chromosomes. In some cases these split twice longitudinally, 
 but the second split occurs some time after the first so that no tetrad 
 figure is apparent. In other cases a transverse break takes the place of 
 one of the longitudinal splits. In either case, however, the reduction 
 to one-half the somatic number of chromosomes is effected. 
 
 Fig. 43. — From a section of a mature Graafian follicle at the surface of the ovary of a 
 young woman: 1, stratum granulosum; 2, germ hill containing an oocyte (ovarian ovum); 
 3, same as i; ^, germinal epithelium; 5, tunica albuginea; 6, theca folliculi, internal vascular 
 layer; 7, theca folliculi, external fibrous layer; 8, same as 1. (Kollmann's Atlas.) 
 
 Ovulation. — By ovulation is meant the periodic discharge of the ovum 
 from the ovary. The mature Graafian follicle (p. 55) ruptures at the 
 surface of the ovary through the thinned portion of its own wall and 
 of the tunica albuginea (Fig. 43). The cause of the rupture is possibly 
 twofold: increased pressure within the ovary due to increased vascular- 
 ity of the organ and increased amount of liquor folliculi. The ovum is 
 discharged into the peritoneal cavity in the immediate vicinity of the 
 fimbriated end of the Fallopian tube whence it normally passes into the 
 tube and so to the uterus. The liquor follicuH and some of the follicular 
 cells, especially those of the corona radiata, escape with the ovum. 
 
 The Corpus Luteum.— Following the discharge of the contents of the 
 Graafian follicle the walls collapse and a considerable quantity of blood 
 
62 
 
 EMBRYOLOGY AND PHYSIOLOGY 
 
 escapes into the central cavity from ruptured vessels of the theca. The 
 follicle becomes a closed vesicle again through closure of the ruj)tured 
 wall, and, with the blood-clot in the interior, is called the corpus hemor- 
 rhagicum. This represents the first stage in the development of the 
 corpus luteinn. Gradually the blood-clot is replaced by lar^e, closely 
 packed cells containing yellow granules (whence the name corpus luteum, 
 although in other mammals the colors are different, being brick-red 
 in the mouse and pale brown in the sheep). These granules are of a 
 fatty nature. There is difference of opinion as to the origin of the lutein 
 (yellow) cells, some believing that the>' arise from the epithelium forming 
 the stratum granulosum of the follicle, others holding that they come 
 from the connective-tissue cells of the theca folliculi (Figs. 44 and 45). 
 
 Fig. 44. — An ovary of a girl nineteen years old. The organ has been cut open longitudin- 
 ally and shows a young corpus luteum and a number of Graafian follicles. The lower half 
 of the figure shows a remnant of the corpus homorrhagicuni. (Kollmann's Atlas.) 
 
 By degeneration and subsequent absorption the lutein cells are dimin- 
 ished in number and the corpus luteum is gradualh' replaced by connec- 
 tive tissue which grows in from all sides. Eventually there remains only 
 a small area of scar tissue to mark the position of the original Graafian 
 follicle. 
 
 The behaA'ior of the corpus luteum, but not the structure, is influenced 
 materially by the fate of the ovum from that particular follicle. If the 
 ovum is not fertilized and consequently pregnancy does not follow, the 
 corpus luteum reaches its maximimi within two or three weeks and then 
 undergoes the characteristic regressi\'e changes. Under these conditions 
 it is known as a false corpus luteum (corpus luteum spurium). In case 
 fertilization occurs and pregnancy supervenes, the life history of the 
 corpus luteum is much prolonged. It becomes much larger than in cases 
 of non-pregnancy and reaches its maximum about the sixth month 
 
THE GERM CELLS 
 
 63 
 
 of gestation. After that it undergoes the usual regressive changes. 
 Although called by older writers the true corpus luteum (corpus luteum 
 verum), it is now generally agreed that, apart from size and longer his- 
 tory, there is no essential histological difference between it and the 
 so-called false corpus luteum. 
 
 Maturation of the Spermatozoon. — The reduction of chromosomes in 
 the male germ cell of ascaris is accomplished in the same manner as in 
 that of the female. The behavior of the cytoplasm is different, however, 
 
 Point of rupture 
 
 >^^^ Tunica _ 
 ""VS^if^ albuginea 
 
 Remnant 
 
 of corpus 
 
 hemorrhagioum 
 
 Lutein cells 
 Theca folliculi 
 
 Theca folliculi 
 
 Bloodvessels of 
 ,., ., -^ ^ — ,- -,.,_^ .^ , ^ ^ '^ -r,, theca 
 
 Fig. 45. — From a section of a human ovary, showing portion of a well-advanced corpus 
 luteum (eight to ten daj-s). (Kollmann's Atlas, after Kreis.) 
 
 in that each primary and secondary spermatocyte di^"ides into equal 
 parts. The result, therefore, is four equal cells, each containing one-half 
 the somatic number of chromosomes. 
 
 As regards the maturation of the human male sex cell, a most inter- 
 esting and important piece of work has been done recently by Guyer. 
 This investigator has been able not only to follow the successive 
 generations of sex cells in the testis, but also to estimate the number 
 of chromosomes in each generation. 
 
 In all spermatogonia in which a definite count can be made during the 
 
64 EMBRYOLOGY AND PHYSIOLOGY 
 
 mitotic process twenty-two chromosomes occur. In a few cases two of 
 the chromosomes Ue apart from the main mass, surrounded by a clear 
 area of cytoplasm. These two are considered "accessory" chromosomes. 
 In preparation for division in the primary spermatocyte twelve chromo- 
 somes appear. Of these, two are the "accessories" and the other ten 
 represent double or bivalent chromosomes which have resulted from 
 pairing of the twenty that constituted the main mass of chromosomes in 
 the spermatogonium. In division of the primary spermatocyte the two 
 "accessory" chromosomes pass undivided to one pole of the spindle while 
 the ten double chromosomes divide and ten single ones go to each 
 daughter cell. Of the two secondary spermatocytes arising from the 
 division of the primary, one receives ten single chromosomes and the 
 other receives ten single and two "accessory" chromosomes. 
 
 The ten single chromosomes that pass to one secondary spermatoc}i:e 
 again unite in pairs, resulting in five double or bivalent chromosomes. 
 \Vhen this spermatocyte divides each of the two daughter cells receives 
 five double chromosomes which are equivalent to ten single chromosomes. 
 The ten single chromosomes that pass to the other secondary sperma- 
 toc^iie behave in the same manner as described above; but each of the 
 "accessories" also divides like an ordinary chromosome, so that each 
 spermatid in this case receives not only five double but also two " acces- 
 sory" chromosomes, thus making a total of seven. The five double are 
 of course equal to ten single chromosomes. 
 
 Of the total number of spermatids, then, half have received ten chro- 
 mosomes and half have received twelve (ten plus two "accessory"). 
 Since the spermatids are transformed directly into spermatozoa, it 
 follows that there are two classes of the latter, differing as to whether 
 they do or do not contain the two "accessory" chromosomes. 
 
 It is not improbable that the "accessory" chromosomes in man are 
 analogous to similar structures found in certain other vertebrates and 
 in many species of insects, myriapods and arachnids. In these lower 
 forms it has been found also that not only do some of the male sex cells 
 possess additional or "accessory" chromosomes but that the somatic 
 cells of the female are characterized by the extra number of chromo- 
 somes. On the assumption that in the human species the number of 
 chromosomes in the female sex cell is twenty-four, or twelve in the 
 mature ovum, the fertilization of the ovum by a spermatozoon possessing 
 ten chromosomes would result in a male, with twenty-two chromosomes; 
 on the other hand the fertilization of an ovum by a spermatozoon with 
 twelve (ten single plus two "accessory") chromosomes would result 
 in a female, with twenty-four. 
 
 The results of some other investigations are at variance with the 
 above account as to the number of cliromosomes in the human being. 
 Wieman, for instance, has counted thirty-three, thirty-four and thirty- 
 eight chromosomes in somatic cells during the cell-di\'ision in the embryo. 
 These differences remain to be explained. 
 
 The transformation of the spermatid into the spermatozoon, referred 
 to above, is the expression of the change which a relatively non-motile 
 
FERTILIZATION 65 
 
 cell undergoes to become adapted to a function requiring a high degree 
 of motility. The change is essentially one of form (cytomorphosis) in 
 which most of the cytoplasm is drawn out into a long, slender flagellum 
 or organ of locomotion. The chromatin of the spermatid returns to the 
 reticular condition and a nuclear membrane appears around it. The 
 centrosome, at one side of the cell, divides into a diplosome and the 
 nucleus moves to the opposite side. The nucleus becomes more compact, 
 and, together with a small amount of cytoplasm, is destined to become 
 the head of the spermatozoon. The part of the diplosome nearer the 
 nucleus becomes disk-shaped, and, retaining this position, becomes the 
 anterior centrosome or end-knob. From the other part of the diplosome 
 a slender filament grows out, extending beyond the boundary of the 
 cytoplasm. Along this filament most of the cytoplasm becomes drawn 
 out, the former constituting the axial filament and the latter the sheath 
 or involucrum of the tail. The body from which the filament grew also 
 becomes disk-shaped and forms the posterior centrosome or end-knob. 
 Originating from it also is a ring which apparently slips along the filament 
 for a short distance and, as the end-ring, marks the posterior end of the 
 connecting piece. Certain granules in the cytoplasm (mitochondria) 
 probably unite to form the spiral filament of the connecting piece while 
 others remain as a characteristic feature of the mitochondrial sheath. 
 
 As regards the number of germ cells produced, it has been estimated 
 that about 36,000 primary oocytes develop in each ovary, of which 200 
 become ripe. It has been calculated that the average ejaculate contains 
 about 200,000,000 spermatozoa, and that during his life a man would 
 produce 340,000,000,000. These estimates make it appear that for each 
 mature ovum 850,000,000 spermatozoa are produced. 
 
 FERTILIZATION. 
 
 In sexual reproduction the starting-point of the new individual is the 
 single cell resulting from the union of the mature germ cell of the male 
 with the mature germ cell of the female. This union is known as fer- 
 tilization and the resulting cell as the fertilized ovum, or spermovium. 
 Nothing is known concerning this process in the human subject, but the 
 presumption is that it occurs in essentially the same manner as in other 
 mammals. 
 
 Broadly speaking, fertilization includes all the phenomena from the 
 time the spermatozoon enters the egg until the two nuclei (often called 
 the male pronucleus and female pronucleus) unite. It may therefore 
 be conveniently divided into three phases: (1) the entrance of the sper- 
 matozoon, (2) its progress to the centre of the egg cytoplasm and (3) 
 zygosis of the two pronuclei. 
 
 The approach of the spermatozoon to the ovum, apart from the swun- 
 ming movements of the former through the genital passages of the 
 female, probably depends upon a positive chemotaxis. This attraction, 
 in the majority of cases, is specific for the germ cells of a given species, 
 that is, there is a positive chemotaxis between ova and spermatozoa of ■ 
 5 
 
66 
 
 EMBRYOLOGY AXD PHYSIOLOGY 
 
 the same species onlv. In some animals the ovum sends out a sma 1 
 cytoplasmic projection or attraction cone, analogous to a i)seudopod, 
 to meet the sperm cell (Fig. 4(5). Some ova that possess a vitelline mem- 
 brane are permeable at all points, while others are permeable onl>- at one 
 
 Zona pellucida 
 
 Nucleus 
 -— SDcrmaiozoon 
 
 --^--A-— Cytopl 
 
 asm 
 
 Female 
 pronucleus 
 
 Head of 
 
 j^ —spermatozoon 
 I with centrosome 
 
 Female pronucleus 
 
 Male pronucleus 
 
 -Centrosome 
 
 Male pronucleus 
 Female pronucleus 
 
 Chromosomes of 
 A-" icnialc pronucleus 
 
 ■Chromosomes of 
 male pronucleus 
 
 'Centrosome 
 
 Chromosome from 
 female pronucleus 
 
 ixmim 
 
 ---Centrosome 
 
 Fig 46 -Diagram of fertilization of the ONtim. (The somatic number of chromosomes 
 is 4.) (Boveri, Bohm and von Davidoff.) 
 
 point where there is a minute opening, or micropxle, in the membrane. 
 In mammals normallv only one sperm cell enters the egg. Should more 
 than one enter, as in pathological pol>spermy, the result is an irregular 
 formation of mitotic figures and the early <leath of the egg. As a rule 
 onlv the head and a portion ..f the cnnecting piece of the spermatozoon 
 
CLEAVAGE AND FORMATION OF THE GERM LAYERS 67 
 
 actually penetrate the egg-cytoplasm, and the tail, having performed its 
 function, is left on the outside. Thus the nucleus and centrosome, the 
 two elements essential to further development, are carried into the egg 
 (Fig. 46). After the entrance of the sperm-cell requisite for fertilization, 
 all others are excluded (except in certain animals where several enter 
 normally but only one unites with the egg-nucleus). 
 
 The sperm nucleus and centrosome, now within the egg, move to the 
 centre of the cytoplasm, the centrosome usually in advance of the nucleus 
 (Fig. 46). After the last maturation division of the ovum the female 
 pronucleus also moves toward the centre of the cell and eventually 
 takes a position beside the male pronucleus. The centrosome lies between 
 the two (Fig. 46). 
 
 Zygosis does not signify the literal fusion of the two pronuclei to form 
 a single nucleus, but the behavior of the cliromatin preparatory to the 
 first cell division. The centriole divides and a spindle is formed between 
 the two pronuclei. The chromatin in the pronuclei becomes arranged 
 in chromosome form, each pronucleus giving rise to one-half the somatic 
 number. The chromosomes then form a common equatorial plate in 
 the spindle (Fig. 46) . The equatorial plate therefore contains the somatic 
 number of chromosomes, as in ordinary mitosis. Each chromosome 
 splits longitudinally into two equal parts, of which one part passes to 
 one pole of the spindle and the other to the opposite pole. It follows 
 that the two daughter nuclei resulting from the first division of the 
 sperm-ovium receive equal numbers of maternal and paternal chromo- 
 somes (Fig. 46). 
 
 The point where fertilization normally occurs in the female genital 
 tract is not definitely known. In the lower mammals it takes place in 
 the Fallopian tube, or oviduct, and the general opinion is that in the 
 human subject also it occurs in the tube, probably in the outer third. 
 Not only does the occurrence of tubal pregnancies certify that sperma- 
 tozoa enter the Fallopian tube, but they have also been observed there. 
 In rare cases they may pass all the way through the tube and fertilize 
 the ovum on the surface of the ovary or even in the Graafian follicle, 
 resulting in ovarian pregnancy. 
 
 ' CLEAVAGE AND FORMATION OF THE GERM LAYERS. 
 
 Cleavage or segmentation constitutes a series of cell divisions fol- 
 lowing fertilization of the ovum, the phenomena in general being iden- 
 tical with those of ordinary mitosis. The sperm-ovium divides into two 
 cells, each of these in turn divides, and so on, division succeeding division 
 until a multicellular mass is formed which, from its resemblance to a 
 mulberry, has been called a morula. The proliferation of cells from the 
 sperm-ovium is therefore the first of the series of processes in the develop- 
 ment of a new individual. 
 
 The details of cleavage have been studied for the most part in the 
 lower animals. Observations have also been made on mammalian forms, 
 particularly the mouse, rabbit, and bat. In the mouse Sobotta found 
 
68 
 
 EMBRYOLOGY AXD PHYSIOLOGY 
 
 that the fertihzed ovum divided into two approximately equal cells, 
 that the second cleavage was completed in one of these before the other 
 began to di\ade, thus resulting in a three-cell stage, and that then 
 cleavage continued irregularly (Fig. 47, a, h, c, d, e). Fig. 48, from 
 
 
 ©\^-. 
 
 
 
 
 d e 
 
 Fig. 47. — Five stages in cleavage of the o\Tim of the mouse: a, the first division has 
 resulted in two subequal cells; a polar body is shown at upper side of figure; h, section of a 
 four-cell stage, only three cells showing in the figure; c, eight-cell stage, five cells showing in 
 the section; d, twelve-cell stage, seven cells showing in the section; e, twenty-cell stage, ^ath 
 marked difference in size and structure of cells. (Sobotta.) 
 
 
 
 Fig. 48. — From a section of the morula of 
 the bat. (Van Beneden.) 
 
 Fig. 49. • — Ovum of a monkey in 
 segmentation, from the tube of Maca- 
 cus nemestrinus. (Selenka.) 
 
 Van Beneden's w^ork, shows a section of the morula of the bat. Fig. 49 
 shows a four-cell stage of the ovum of a monkey (Macacus nemestrinus), 
 which is the onl\' primate ovum in the cleavage stage known at the 
 present time, and was found at about the middle of the oviduct. 
 
CLEAVAGE AND FORMATION OF THE GERM LAYERS 
 
 69 
 
 'J 7 
 
 ■^J 
 
 ■^1 
 
 'h 
 
 io 
 
 iVX^ 
 
 In mammals whose ova contain a relatively small amount of yolk 
 (deutoplasm) the cells of the morula are similar in appearance and 
 approximately equal in size. The eggs of other vertebrates exhibit 
 great differences in this respect. In amphibians, for example, while 
 the whole egg divides the cells at one pole remain larger than at the 
 opposite pole omng to the fact that the 
 yolk, which is accumulated at one pole, ,-'"''^^^%5v. 
 
 retards the process of cell division. In the ^ 
 
 eggs of birds and reptiles, which contain a 
 very great amount of yolk and the cyto- 
 plasm is almost wholly confined within a 
 small area at one pole of the egg, cleavage 
 goes on only in the cytoplasm and the 
 result is merely a disk of cells lying upon 
 the large unsegmented mass of yolk. The 
 presence of yolk therefore not only modi- 
 fies the cleavage process but has a far- 
 reaching influence upon later development, 
 and the mammalian egg-cell, while it con- 
 tains but a small amount of yolk, develops 
 after cleavage in many respects as if it were 
 laden with the nutritive substance. This is usually considered as a point 
 of evidence in favor of the view that mammals have descended from 
 animals whose ova possessed large quantities of yolk. 
 
 The first visible differentiation of cells in the mammalian morula 
 occurs in the superficial layer. The cells of this layer acquire a more 
 regular shape, and a- section of the morula at this stage presents a picture 
 of a covering layer surrounding a central mass of irregular (polygonal) 
 
 ^ ^K( 
 
 -J/ 
 
 
 Fig. 50. — From a section of a 
 later stage of the morula than in 
 Fig. 49, showing differentiation of 
 the outer layer of cells. (Van 
 Beneden.) 
 
 
 l-za^^^tt^^'^^^ 
 
 "_/ 
 
 Fig. 51. — From a section of the devel- 
 oping ovum of a bat, showing vacuolation 
 of the inner cells. (Van Beneden.) 
 
 Fig. 52. — From a section of a later stage 
 than Fig. 51, showing outer layer (tropho- 
 derm) and inner cell mass. (Van Beneden.) 
 
 cells (Fig. 50). The morula is then transformed into a vesicle by the 
 vacuolation of most of the inner cells and the confluence of these vacuoles 
 to form a common cavity. The few inner cells that do not become 
 vacuolated remain attached in a group to the outer layer. The mam- 
 malian ovum at this stage thus consists of two groups of cells: an outer 
 
70 
 
 EMBRYOLOGY AXD PHYSIOLOGY 
 
 group or layer of cuboidal cells to which the name tro})hotlerni (tropho- 
 blast) is given and an inner group which has received the name inner 
 cell mass. 
 
 The vacuolation of the inner cells of the morula probai)ly represents 
 a late and abortiv^e attempt at yolk formation, and the cavity formed 
 by the coalescence of the \'acuoles corresponds to the yolk mass. The 
 inner mass is comparable with the disk of cells that rests upon the yolk 
 in eggs of the lower vertebrates (reptiles and birds). In man the nutri- 
 tive yolk is unnecessary since the attachment of the developing ovum 
 to the wall of the uterus provides for direct parental nutrition. In the 
 process dividing the cells of the morula into an inner cell mass and 
 trophoderm is seen the earliest differentiation into cells which will, on 
 the one hand, give rise to the embryo proper and on the other hand 
 engage in the development of certain accessory or extra-embryonic struct- 
 ures, the fetal membranes (Fig. 51 and 52). 
 
 
 
 W<0^ 
 
 Fig. 53. — From a section of the blastodermic vesicle of a bat, shownng formation of entoderm. 
 
 (Van Beneden.) 
 
 The next step in mammalian development, as exemplified by the ovum 
 of the bat, is the differentiation and splitting off of the deeper cells of 
 the inner cell mass. These cells, as a single layer, then gradually extend 
 in all directions on the inner surface of the trophoderm until they line 
 the entire vesicle. This new layer of cells is the entoderm (Fig. 53). 
 While the entoderm is developing the superficial cells of the inner cell 
 mass become vacuolated (Fig. 54), and the vacuoles coalesce to form a 
 cavity between the overlying trophoderm and the deeper cells of the 
 inner cell mass. This cavity is the amniotic cavity (Fig. 55). Its roof 
 is trophoderm and its floor is formed by the remaining cells of the inner 
 cell mass which are now arranged in a regular layer. This lies in contact 
 with the entoderm and constitutes the embryonic ectoderm, the two 
 layers together in this region forming the embryonic disk. 
 
 The ovum at this stage is thus a vesicle, known as the blastodermic 
 vesicle, with a small amniotic cavit>- at one pole and a much larger yolk 
 cavity extending to the opposite pole, the cavities being separated by 
 the embryonic disk. The amniotic cavity is lined in part (the roof) 
 
CLEAVAGE AND FORMATION OF THE GERM LAYERS 
 
 71 
 
 by trophoderm, in part (the floor) by embryonic ectoderm. The yolk 
 cavity is lined by entoderm. The vesicle wall is composed of trophoderm 
 and, around the yolk cavity, also of entoderm. 
 
 The two-layered stage of the embryonic disk in this case is arrived 
 at by the simple process of the splitting off (delamination) and dift'eren- 
 tiation of the deeper cells of the inner cell mass. To attempt to homol- 
 ogize this process with the process of invagination by which the two 
 primary germ layers (ectoderm and entoderm) are formed in lower 
 
 Fig. 54.- 
 
 -From a section of the blastodermic vesicle of a bat, showing vacuolation of the 
 inner cell mass to form the amniotic cavity. (Van Beneden.) 
 
 mammals and other vertebrates and in the invertebrates would neces- 
 sitate a much longer and more detailed description than the scope of 
 this book justifies. The student is therefore referred to the text-books 
 of embryology. . 
 
 Soon after the completion of the two-layered stage of the blastodermic 
 vesicle there appears a thickening of the ectoderm over a small area in 
 the embryonic disk. This thickening is known as the embryonic shield 
 (Fig. 56), and occurs in all mammals thus far studied. On surface view 
 
 Fig. .55.- 
 
 -Fiom a section of the blastodermic vesicle of a bat, showing the amniotic cavity. 
 Cf. Fig. 54. (Van Beneden.) 
 
 there next appears, in the dog, for example, a small more opaque spot 
 near the centre of the embryonic shield. This is the primitive node (Fig. 
 56). Then a narrow opaque band, extending from the node to the border 
 of the shield, develops and is known as the primitive streak (Fig. 56). 
 A slight furrow in the ectoderm in the line of the primitive streak is 
 spoken of as the primitive groove. 
 
 A section taken vertical to the surface of the embryonic shield and at 
 right angles to the primitive streak shows that the ectoderm and ento- 
 
72 EMBRYOLOGY AND PHYSIOLOGY 
 
 derm are fused with an intermediate layer along the line of the streak 
 and that the intermediate layer extends laterally for some distance 
 as a band of cells apposed to the entoderm. This new layer is the meso- 
 derm (Fig. 57). 
 
 
 Fig. 56. — Surface ^-iew of the embryonic shield of the blastodermic vesicle of a dog 
 thirteen to fifteen days old — precise age unknown: Sh., embrj-onic shield; Kn., Hensen's 
 knot; p.s., primitive streak. 100 diameters. (From Minot, after Bonnet.) 
 
 In the case under consideration the primitive streak represents a line 
 of fusion of the three germ layers. Its real significance can be appre- 
 ciated only when its history is traced back through the series of lower 
 animals. In general it can be compared with the blastopore, although 
 perhaps cannot be homologized directly with it. The blastopore in 
 
 Ectoderm 
 
 
 Jli'"' ,V t ft***^!/*^*-*.-^ Mesoderm 
 
 Entoderm Primitive 
 
 streak 
 
 Fig. 57. — From a transverse section through the primitive streak and groove of the embry- 
 onic disk of a dog (shown in Fig. 56.) (Bonnet.) 
 
 lower forms is the opening into the interior (archenteron, primitive gut) 
 of the developing organism at the point where invagination occurs to 
 give rise to the entoderm. Since in mammals the entoderm arises by 
 delamination of certain cells of the inner cell mass and not by invagina- 
 
CLEAVAGE AND FORMATION OF THE GERM LAYERS 73 
 
 tion, conditions in the region that would otherwise have been occupied 
 by the blastopore are different. The difference is expressed in the forma- 
 tion of the primitive streak. 
 
 As regards the origin of the mesoderm in mammals, and even in birds 
 and reptiles, there is much difference of opinion. That it appears along 
 the line of the primitive streak is undisputed, and that it grows out 
 from this region for some distance between ectoderm and entoderm is 
 practically certain (Fig. 57), but whether it arises from ectoderm or 
 entoderm has not yet been determined. In the lower vertebrates and 
 Amphioxus it obviously originates from entoderm. 
 
 In addition to that arising in the region of the primitive streak there 
 is also in mammals a considerable amount of mesoderm which appears 
 in the wall of the blastodermic vesicle, between the trophoderm and the 
 entoderm lining the yolk cavity. There is likewise some doubt as to the 
 origin of this portion of mesoderm, but the view best supported by 
 evidence is that it arises in loco by differentiation and splitting off 
 (delamination) from the entoderm, as it does around the yolk sac in 
 reptiles and birds and around the yolk-laden entoderm in the frog. 
 
 Through the formation of mesoderm in the region of the primitive 
 streak and around the yolk cavity, both the embryonic disk and the 
 wall of the yolk cavity become three-layered. Subsequently the roof 
 of the amniotic cavity also acquires a layer of mesoderm which separates 
 the trophoderm on the outside from a layer of ectoderm on the inside, 
 the latter being continuous with the ectoderm of the embryonic disk. 
 
 At this stage, therefore, the developing organism is approximately 
 spherical in shape and consists of a triple-layered wall surrounding a 
 double cavity. The smaller amniotic cavity is lined with ectoderm and 
 the larger yolk cavity with entoderm, the two cavities being separated 
 by the embryonic disk. The disk is composed of ectoderm, mesoderm 
 and entoderm, the three layers being fused in the primitive streak. 
 The trophoderm, as the outer layer of the wall, forms a complete covering 
 for the vesicle. The mesoderm of the wall is also a complete layer and 
 is continuous with that of the embryonic disk. All three layers are 
 everywhere in close apposition. The disk alone will give rise to the 
 body of the embryo and the other structures to embryonic appendages 
 which serve to protect and bring the embryo into proper nutritional 
 relations with the maternal tissues. 
 
 The Germ Layers in Man. — While there are no observations on the 
 segmentation of the ovum, the first differentiation of cells or the origin 
 of the germ layers in the human subject, it is not unreasonable to assume 
 that the foregoing account of the early processes of development, which 
 applies to mammals in general, would apply also in the main outline to 
 man. In the youngest human ovum thus far known, which has been 
 described by Bryce and Teacher and the age of which reckoned at thir- 
 teen to fourteen days, all three germ layers are already present (Fig. 72). 
 The ovum as a whole comprises an outer layer of trophoderm surround- 
 ing a relatively large amount of mesoderm in which two cavities are 
 situated. This stage is thus comparable with the three-layered vesicle 
 
74 EMBRYOLOGY AM) PHYSIOLOGY 
 
 ;iinl einlirx oiiic disk of niaininals (Icxrilxd in tlu' prt'cediiifj; para,ura])h, 
 although there are some well-marked difi'ereiiees. 
 
 The trophoderm, disregarding; the irregular projections from the 
 surface which will be considered in connection with the fetal membranes, 
 forms a complete covering layer. The two cavities within the ovum are 
 relatively small, the smaller of the two being regarded as the yolk 
 cavity lined with ento<^lerm and the larger as the amniotic cavity lined 
 by ectoderm. One of the most striking features is the large amount of 
 mesoderm, which is here a delicate, loosely arranged tissue resembling 
 mesenchyme. The embryonic disk is represented merely by a small 
 portion of ectoderm and entoderm in the wall of the amniotic and yolk 
 cavities respecti^•ely, together with the mesoderm that lies between. 
 The roof of the amniotic cavity is separated from the trophoderm by a 
 considerable amount of mesoderm. 
 
 In a slightly older embryo (14-15 days) described by Peters, the 
 embryonic disk is a more definite structure, the ectoderm being a flat 
 layer of stratified or pseudostratified cells and the margin reflected upward 
 as the lining of the roof of the amniotic cavity, and the entoderm, sepa- 
 rated from the ectoderm by a definite layer of mesoderm, reflected 
 downward as the lining of the yolk cavity (Fig. 73). The most con- 
 spicuous difterence between this and the Bryce-Teacher embryo is the 
 large cavity within the ovum. This has apparently arisen through a 
 splitting of the loosely arranged mesoderm, the peripheral portion of 
 the latter clinging to the trophoderm and a remaining portion to the 
 entoderm of the yolk cavity. The trophoderm and peripheral meso- 
 derm together constitute the chorion. The entoderm and tlie mesoderm 
 clinging to it, form the yolk sac. The ectodermal roof of the amniotic 
 cavity and the apposed mesoderm form the amnion. The yolk sac, 
 embryonic disk and amnion are attached to the chorion by the meso- 
 derm of the amnion. The large cavity within the chorionic vesicle is the 
 extra-embryonic body ca^'ity or exocelom. 
 
 While neither of the human ova just considered gives any clue to the 
 origin of the germ layers, they are of extreme interest and importance 
 in that they show the earliest known conditions in the development 
 of the human being, and furthermore, show a very early stage of differ- 
 entiation in the structures which give rise on the one hand to embryo 
 proper and on the other hand to embryonic appendages essential to 
 intra-uterine life. 
 
 Further Development of the Germ Layers. — Body Form. — To return 
 to the embryonic disk in a mammal, the dog for example, it will 
 be remembered that the disk, composed of ectoderm, mesoderm and 
 entoderm, was generally circular in shape and that the three germ 
 layers were fused in the primitive streak which extends from a point 
 near the centre to the margin of the disk (Figs. 56 and 57). And it 
 should be noted here that the primitive streak not only indicates the 
 direction of the long axis of the future embryo but also marks the caudal 
 end of the body; and that consequently the body will develop between 
 the primitive node and the opposite margin of the disk. 
 
CLEAVAGE AND FORMATION OF THE GERM LAYERS 75 
 
 Sections of the embryonic disk, taken in front of the primitive streak 
 node and at right angles to the projected hne of the primitive streak, 
 show the mesoderm and entoderm fused and the ectoderm as a distinct 
 and separate layer (Figs. 58 and 59). This condition probabl}^ arises 
 from that seen in the primitive streak by means of a separation of the 
 ectoderm from the other two layers and a concomitant recession of the 
 front end of the streak. While this process is not extensive it nevertheless 
 yields a short band of cells composed of fused mesoderm and entoderm, 
 extending forward from the primitive streak. These cells proliferate 
 
 'v: 
 
 . * "St** e 
 
 ^J.^uV'i^''^ "" ""s' - i , ®- ^ Mesoderm 
 
 Entoderm 
 
 ^^^^ ^ S -«. — r ' -^^^^to^ ^^-— --^ -«^^*!:^ 
 
 -«)**> 
 
 
 Kctodenn 
 
 «^'^y^'~" f^^ ^- ^ ^*0^^^ "e"^ * '^ ^ Mesoderm 
 
 ^^3> 0^ Entoderm 
 
 ,® ^ 
 .^ ® 
 
 Figs. 58 and 59. — From transverse sections of the embryonic disk of a dog. Sections 
 taken from upper third of disk shown in Fig. 56. (Bonnet.) 
 
 rapidly and soon give rise to an opaque band prominent enough to be 
 seen from the surface of the disk. This band is known as the primitive 
 axis (head process), and corresponds to the region in which the body 
 proper of the embryo develops (Fig. 60). 
 
 While the primitive axis, as such, is still increasing in length a separa- 
 tion is effected between entoderm and mesoderm near its anterior end 
 and the mesoderm itself is divided in the median line, thereby giving 
 rise to the condition shown in Fig. 61 . This process continues from before 
 backward along the primitive axis to the point where the axis becomes 
 
76 
 
 EMBRYOLOGY AND PHYSIOLOGY 
 
 continuous with the primitive streak. Here the axis can increase by the 
 same process that gave it origin, namely, the separation of the ectoderm 
 from the fused mesoderm and entoderm. The mass of cells in the region 
 of the primitive streak, having iu' the meantime increased in volume, 
 but still representing all three germ layers, is known as the trunk bud 
 (or tail bud). The processes of differentiation and development, as 
 
 Hensen's 
 node 
 
 Primitive 
 streak 
 
 Primitive axis 
 
 Fig. 60. — Surface view of the embryonic disk of a dog. (Bonnet.) 
 
 exemplified by the changes in the primitive axis noted above in general 
 begin in the anterior or cephalic region of the embryonic body and pro- 
 gress toward the posterior or caudal region. Out of the trunk bud, 
 therefore, are difi'erentiated the germ layers in discrete form, the 
 bud itself gradually receding as other structures develop in front of it 
 and the embryonic body increases in length. 
 
 Neural folds 
 
 Entoderm 
 
 Fig. 61. — From a transverse section of the embryonic disk of a dog. Section taken at level 
 
 of Ss in Fig. 60. (Bonnet.) 
 
 Changes in the Mesoderm. Origin of the Celom.^ — After the mesoderm 
 has divided along the axial line, as shown in Fig. 61, numerous slight 
 fissures appear in it and gradually coalesce to form two slit-like cavities, 
 one on each side, situated a short distance from, and extending parallel 
 to, the median line. These cavities enlarge as the mesoderm continues 
 to split in the lateral direction and eventually become continuous with 
 
CLEAVAGE AND FORMATION OF THE GERM LAYERS 
 
 77 
 
 the wide space around the yolk cavity which in man and the higher 
 animals develops at an early stage and which has already been noted as 
 the extra-embryonic body cavity (see page 74). With the exception 
 of a portion along the axial line, which will be considered subsequently, 
 the mesoderm is thus split into two layers. The outer layer, which 
 remains apposed to the ectoderm, is the somatic or parietal mesoderm. 
 The inner layer, closely applied to the entoderm, is the visceral or 
 splanchnic mesoderm (Fig. 62). 
 
 The new cavity now separating these two layers is the celom. The 
 portion that becomes enclosed within the body is the forerunner of the 
 three great serous cavities of the adult, namely, the pleural, pericardial, 
 and peritoneal cavities. The angle formed by the junction of the somatic 
 and splanchnic layers of mesoderm near the axial line of the embryo is 
 the celomic angle. The extra-embryonic portion of the celom consti- 
 tutes the large space separating the amnion and yolk sac from the chorion. 
 
 Neural 
 groove 
 
 Meso- Inter- 
 dermic mediate 
 somite cell mass 
 
 
 Parietal and 
 visceral mesoderm Ectoderm 
 
 Celom Entoderm 
 Fig. 62. — From a transverse section of a dog embryo with 10 primitive segments. (Bonnet.) 
 
 As the celom develops the cells bounding it become flat or scale-like 
 and form a pavement or simple squamous epithelium. This is known as 
 mesothelium and constitutes the lining of the large serous cavities men- 
 tioned in the preceding paragraph. 
 
 The somatic mesoderm and the apposed ectoderm together constitute 
 the splanchnopleure. These two double layers are to a great degree 
 elementary parts out of which adult structures are produced. Although 
 the cells in each are derived from two germ layers, they are intimately 
 associated in the development of certain organs. In each, moreover, 
 it is convenient to distinguish between an embryonic portion, which 
 enters into the formation of the embryo proper, and an extra-embryonic 
 portion which gives rise to embryonic appendages that are lost at birth. 
 In general the embryonic portion of the somatopleure is concerned in the 
 formation of the body wall, while the corresponding portion of the 
 splanchnopleure gives rise to visceral structures. 
 
78 
 
 EMBRYOLOGY AND PHYSIOLOGY 
 
 Mesodermic Somites. — Metamerism. — There remains to be considered 
 the band of mesoderm along each side of the median line in which in the 
 higher forms there is but slight indication of a separation into a parietal 
 and a \isceral la>er. Soon after the mesoderm breaks away from the 
 entoderm along the ])riniitive axis, a loosening of the cells occurs in a 
 narrow, transverse line in the mesoderm a short -distance in front of the 
 primitive streak. Almost immediately a similar trans^'erse loosening 
 of the cells takes place near b>-. The mesoderm is thereby cleft twice, 
 the cells between the clefts constituting a mesodermic somite; and since 
 the i)hen()mena are identical on both sides of the median line, two somites 
 are formed which are bilaterallv s^'mmetrical. 
 
 Telencephalon 
 Diencephalon 
 Mesencephalon 
 
 Metencephalon 
 
 Myelencephalon 
 
 Fig. 63. — Dorsal view of a doK niilnyo with 10 primitive segments. (Bonnet.) 
 
 The first pair of somites develops in what will be the occipital region 
 of the embryo. All further somites are formed successively in the same 
 manner as the first pair, the series growing by additions from the meso- 
 derm l)etween those already formed and the primitive streak, thus again 
 exemplifying the progress of devek)pment from the head of the embryo 
 toward the caudal region (Fig. (),')). 
 
CLEAVAGE AXD FORMATION OF THE GERM LAYERS 79 
 
 Between each somite and the celom there is left a small group of cells, 
 fused both with the somite and the parietal and visceral mesoderm. 
 This is the intermediate cell-mass, or, since it subsequently gives rise to 
 a part of the urinary system, is spoken of as the nephrotome. These 
 structures, corresponding to the somites, are bilaterally s\Tnmetrical and 
 segmentally arranged. 
 
 The only indication of a splitting of the mesoderm in the higher verte- 
 brates in the region under consideration is a Iqosening of the cells in the 
 central portion of the somite. In the lower vertebrates and many inver- 
 tebrates the celom extends tlirough the nephrotome into the somite, 
 thereby leaving the somatic and splanchnic mesoderm connected only 
 by the mesial wall of the somite. 
 
 In the formation of the mesodermic somites is expressed the beginning 
 of the segmentation of the body, or metamerism, characteristic of all 
 vertebrates and many of the invertebrates. The somites themselves 
 are the primary morphological segments, and each pair is called a primi- 
 tive segment. They produce during development many structures which 
 are arranged in series in the adult. For example, the history of the 
 vertebrae, the ribs and many of the muscles, especially the intercostal 
 muscles, depends upon their segmental origin. jMoreover the nervous 
 system, as well exemplified in the spinal nerves, and to a considerable 
 extent the bloodvessels, exhibit a metameric arrangement correlated 
 with the mesodermic segmentation. 
 
 Derivatives of the Germ Layers. — The germ lasers, as already seen, differ 
 from one another not only in position but also in structure. Their 
 formation constitutes a fundamental differentiation of the cells of the 
 developing organism. By constantly increasing differentiation all the 
 tissues and organs of the body are produced, each layer giving rise to 
 its own special group. In general terms it can be stated that ectoderm 
 gives rise to the covering of the body, namely, the epidermis, the most 
 important function of which is protection, and to that mechanism which 
 enables the animal to react to stimuli — the nervous system; that the 
 entoderm produces the epithelium of the alimentary tract and appended 
 organs; and that mesoderm is mainly concerned in the formation of the 
 various supporting and coimective tissues, although it gives rise also to 
 the epithelium of the genito-urinary and vascular systems. The quality 
 by virtue of which each layer gives rise only to certain tissues, or more 
 particularly to parts of certain organs, is known as the specificity of the 
 germ layers. The tissue derivatives of the germ layers are as follows: 
 
 Ectoderm. ^1. Epithelium of skin and its appendages — hair, nails, 
 sweat glands (and their smooth muscle), sebaceous glands and mammary 
 glands. 
 
 2. Nervous system (central and peripheral), neuroglia, retina. 
 
 3. Epithelium of mouth and anus, of glands opening into mouth, 
 enamel of teeth. 
 
 4. Epithelium of nasal passages and connected glands and cavities. 
 
 5. Epithelium of external auditory canal and membranous labyrinth. 
 
80 EMBRYOLOGY AND PHYSIOLOGY 
 
 6. Epithelium of anterior surface of cornea and of conjunctiva, crys- 
 talline lens. 
 
 7. Epithelium of penile portion of urethra. 
 
 8. Epithelium of pituitary body. 
 
 9. Chromaffin tissue. 
 
 Entoderm. — 1. Epithelium lining alimentary tract (except mouth and 
 anus) and of glands connected with the tract. 
 
 2. Epithelium of trachea and lungs. 
 
 3. Epithelium of thyroid (including lateral thyroids), parathyroids, 
 reticulum and Hassall's corpuscles in thymus. 
 
 4. Epithelium of middle ear and Eustachian tube. 
 
 5. Epithelium of bladder (except trigonum), female urethra, prostatic 
 portion of male urethra. 
 
 Mesoderm. — 1. All connective tissues except neuroglia. 
 
 2. Striated, cardiac and smooth muscle. 
 
 3. Epithelium of genito-urinary system (except urethra and greater 
 part of bladder). 
 
 4. Lymph organs (excluding reticulum and Hassall's corpuscles in 
 thymus), blood cells, bone-marrow. 
 
 5. Epithelium (endothelium) of bloodvessels and Ijmiph vessels. 
 
 6. Epithelium (mesothelium) lining the serous cavities. 
 
 7. Epithelium of cortex of adrenal gland. 
 
 MENSTRUATION. 
 
 At intervals during the child-bearing age of a healthy woman there 
 occurs a series of phenomena which, from its monthly periodicity, is 
 called menstruation. Much of the process of menstruation and many 
 of its relations are not thoroughly understood. It is well known, how- 
 ever, that, beginning with puberty and ending with the menopause, 
 except during pregnancy and lactation, there is a time each month 
 when the normal woman presents local and general symptoms which 
 are characteristic of her sex. Of these the most pronounced is a dis- 
 charge of blood from the uterus. 
 
 While menstruation, as a rule, ceases during pregnancy, it occasionally 
 occurs during the early months of pregnancy before the decidua capsularis 
 (reflexa) reaches the decidua parietalis (vera) and closes the uterine 
 cavity. The closure takes place about the middle of pregnancy, and 
 after this time true menstruation is regarded as impossible. Absence 
 of menstruation is the rule also during lactation. Many exceptions are 
 met with, however, and not infrequently a woman will menstruate regu- 
 larly throughout the entire lactation period. 
 
 The menstrual cycle can be divided into four periods during which 
 the uterine mucosa exhibits more or less definite histological changes. 
 The longest period is the interval or intermenstrual period, lasting about 
 fourteen days. Following this, without sharp limitation, is the pre- 
 menstrual period of six or seven days. This leads to the period of men- 
 
MENSTRUATION 81 
 
 struation, from three to five days in duration. The postmenstrual 
 period, of from four to six days, completes the cycle. 
 
 The mucous membrane of the uterus during the intermenstrual period 
 (Fig. 64) is usually described as normal or resting, although it undergoes 
 a slight increase in thickness. It is on the average 2 millimeters thick. 
 The surface epithelium is simple columnar or cuboidal, with varying 
 amounts of ciliation. The glands are of the simple or sparingly branched 
 tubular type and are directed obliquely to the surface. The glands 
 usually reach all the way through the mucosa and occasionally extend 
 into the deepest layer of the muscle coat. The gland epithelium is 
 nonciliated, simple cuboidal or columnar, the cells being small during 
 
 |Si (J ' ■£>■■ "X, rf 
 
 W'l 
 
 0> ' O' 
 
 . D 
 
 i-*v 
 
 
 
 
 Fig. 64. — From a section of the uterine mucosa during the intermenstrual period. 
 (Hitschmann and Adler.) 
 
 the first half of the period but during the second half increasing in size 
 and acquiring an acidophile character. The stroma resembles a richly 
 cellular embryonic connective tissue, in which the fibers are extremely 
 delicate and the cells irregularly stellate or fusiform in shape with rela- 
 tively large nuclei. Small lymph nodules and scattered lymphocytes 
 are present. Toward the end of the intermenstrual period the gland 
 cells produce granules which are discharged into the lumina of the glands. 
 The stroma becomes slightly edematous. 
 
 During the premenstrual period (Fig. 65) the mucous membrane 
 
 rapidly increases in thickness up to 4 to 6 millimeters. The increase is 
 
 due to greater edema, enlargement of the component cells, and, toward 
 
 the end of the period, engorgement of the bloodvessels. The glands 
 
 6 
 
82 
 
 EMBRYOLOGY AND PHYSIOLOGY 
 
 Fig. 65. — From a section of the uterine mucosa, showing the premenstrual condition. 
 
 (Hitschman and Adler.) 
 
 Fig. 
 
 GO. — From a section of the uterine mucosa (endometrium). Premenstrual liyperplasia, 
 one day before menstrual date. (Photograph.) 
 
MENSTRUATION 83 
 
 become much larger, principally in their deeper portions, through enlarge- 
 ment of the cells and free discharge of secretion into the lumina (Fig. 
 66). The secretion changes to mucus. The connective-tissue (stroma) 
 cells, especially near the surface of the mucosa, increase in size, and 
 assume roundish or polygonal shapes, both cytoplasm and nuclei losing 
 much of their affinity for dyes. These larger, clearer cells resemble 
 closely the decidual cells that differentiate from the stroma cells during 
 pregnancy (see p. 103), and in fact are often called decidual cells of 
 menstruation. On account of the localization of the changes in the 
 glands and stroma, two layers can be distinguished in the mucosa — a 
 superficial compact layer and a deep spongy layer (Fig. 6.5). With 
 the engorgement of the bloodvessels, numerous small extravasations 
 occur which reach the surface of the mucosa, the epithelium is torn and 
 the blood escapes into the uterine cavity. This is the beginning of actual 
 menstruation. 
 
 
 m^ 
 
 Fig. 67. — From a section of the uterine mucosa. Condition on the third daj- of menstrua- 
 tion, showing separation of the superficial layer. (Hitschmann and Adler.) 
 
 During the menstrual period (Fig. 67) there occur an effusion of blood 
 and edema fluid and an expulsion of the glandular secretion into the 
 uterine cavity, and a concomitant, rapid shrinkage of the mucous mem- 
 brane. The surface epithelium may be in part retained or, as the 
 other extreme, may be wholly expelled along with the greater part 
 of the compact layer of stroma. In the latter case there are usually 
 painful contractions of the musculature of the uterus. The glands, 
 their contents discharged, diminish in size and the cells become smaller; 
 there may be considerable desquamation. Many of the stroma cells 
 break down and are expelled or carried off by leukocytes; the rest 
 decrease in size and become fusiform. The surface epithelium is always 
 regenerated by the time menstruation has ceased. 
 
 In the early part of the postmenstrual period (Fig. 68) the mucous 
 membrane is thin, with straight, narrow glands and closely packed, fusi- 
 form stroma cells (Fig. 69). The glands then slowly increase in size, the 
 stroma cells become more succulent and the mucosa as a whole returns 
 to the relatively quiescent condition of the intermenstrual period. 
 
84 
 
 EMBRYOLOGY AND PHYSIOLOGY 
 
 Ij4»"' St - *^^ 
 
 Fig GS. — From a section of the uterine mucosa. Postmenstrual condition, one day after 
 menstruation. (Hitschmann and Adler.) 
 
 Fig. G9. — From a section of the uterine mucosa (endometrium). Postmenstrual gUinds. 
 Reparative stage. Mitosis in epithelial cells of gland. (Photograph.) 
 
MENSTRUATION 85 
 
 The bleeding during menstruation occurs in the body and fundus of 
 the uterus. The cervix, although congested, is regarded as taking little 
 or no part in actual menstruation. The blood, as discharged from the 
 vagina, is mixed with cells from the uterine mucosa and with the secre- 
 tion of the uterine glands (mucus), coagulation being prevented probably 
 by the mucus. It has a peculiar penetrating odor. The amount of blood 
 discharged is difScult to estimate, but varies greatly in different indivi- 
 duals. Five or six ounces are regarded as an average loss. The duration 
 of menstruation also varies in different women of good health, the flow 
 not lasting longer than two days in some and as long as a week in others. 
 Four or five days may be considered an average. 
 
 The type or periodicity of menstruation varies to a considerable degree. 
 In about 86 per cent, the periods are regular; that is, there is uniformly 
 the same number of days from the beginning of one period to the begin- 
 ning of the next. The most common is the twenty-eight-day type; the 
 next most most common is the thirty-day type; a few show the twenty- 
 one-day type, and in some there seem to be no typical occurrence. As 
 healthy woman has been known to menstruate regularly every forty- 
 two days. 
 
 The changes in other parts of the body, accompanying the menstrual 
 (structural) changes in the uterus, are marked in some women but 
 scarcely noticeable in others. The breasts are often enlarged and tender. 
 The glands about the vulva may show stimulation. The thyroid, the 
 parotids and the tonsils are not infrequently enlarged. Increased pig- 
 mentation about the eyes and breasts is common. The individual is 
 usually more excitable and self-control is more difficult to maintain. 
 There is usually a feeling of weight in the pelvis owing to congestion 
 of the pelvic organs. Many complain at the beginning of the period of 
 a feeling of fulness in the head and back. Just before the flow there 
 is frequently a slight rise in temperature (one-half of one degree), pulse- 
 rate, and arterial tension. Following the establishment of the flow there 
 is a corresponding decline. 
 
 The Age of Puberty. — The first appearance of menstruation is usually 
 regarded as marking the transition from girlhood to womanhood, or the 
 age of puberty, when the generative organs become functionally mature. 
 Exceptionally menstruation may begin in infancy or later than puberty. 
 Rarely it begins in a woman only after she has given birth to a child. 
 
 The age at which sexual maturity occurs varies greatly in different 
 climates, different races, and different families. It is also influenced by 
 mode of life and environment. Women in temperate climates as a rule 
 begin to menstruate earlier than those in cold climates and later than 
 those in warm climates. In temperate climates and among Anglo- 
 Saxon women, the age of thirteen to fourteen years may be considered 
 the usual age of puberty. One hundred consecutive cases taken from 
 my private case-book show that menstruation began at ten years in 1; 
 at eleven years in 5; at twelve years in 8; at thirteen years in twenty- 
 seven; at fourteen years in 28; at fifteen years in 14; at sixteen years 
 in 8; at seventeen years in 9. Thus at thirteen to fourteen years of age 
 
86 EMBRYOLOGY AND PHYSIOLOGY 
 
 menstruation began in 55 per cent, of cases met with in private practice 
 among American women in New York City. Jewesses, as a rule, men- 
 struate earlier than Anglo-Saxon women. In some families menstruation 
 is uniformly late in beginning; in other families it appears uniformly 
 early. Girls brought up in the city, who lead a life of high, nervous 
 tension, surrounded by many means of sexual excitement, menstruate 
 earlier than those reared in the country, who eat plain food, retire early, 
 and spend much time out of doors. 
 
 In the establishment of menstruation it is not an uncommon experi- 
 ence for a girl to menstruate once or twice and then not again for several 
 months, or a year, when menstruation returns and continues regularly. 
 In the interval of amenorrhea there may or may not be present at monthly 
 intervals the feeling of weight in the pelvis and fulness and throbbing 
 in the head and back, without the bloody discharge. 
 
 With the appearance of menstruation other evidences of sexual maturity 
 are usually associated. Hair appears upon the mons veneris and labia 
 majora and in the axillae, the breasts enlarge, the hips become broader, 
 and the general contour of the body becomes more rounded. 
 
 The Menopause. — The cessation of menstruation, or the menopause, 
 occurs at different ages in different people. In the climate of New York 
 the average age is about fifty years. Many women who begin to men- 
 struate late cease menstruation early. On the other hand, many who 
 begin to menstruate early do not cease menstruation till they reach the 
 age of fifty-two to fifty-five. This varies greatly in different families. 
 The menopause may be established abruptly but often there is a period 
 of a year or two in which menstruation becomes more and more infre- 
 quent and irregular. 
 
 Many marked exceptions to the usual ages for puberty and the meno- 
 pause are recorded as, for instance, where children began to menstruate 
 between one and two years of age and where women did not reach the 
 menopause till after sixty. These must be looked upon merely as irreg- 
 ular types and the years from thirteen to fifty be regarded as the usual 
 ages of sexual maturity and possible child-bearing. With the appearance 
 of the menopause women usually suffer more or less with a lack of balance 
 of the vasomotor and general nervous system. Frequent flushings of 
 the face, perspirations and nervous irritability are well known and 
 generally recognized. At this time the woman generally adds to her 
 weight. Her abdominal wall especially increases its fat and she often 
 suffers with flatulence and other expressions of intestinal indigestion. 
 
 Relation of Menstruation to Ovulation. — There are still several con- 
 flicting opinions as to the relationship between these two series of phe- 
 nomena. That menstruation is dependent upon periodic activities of the 
 ovaries seems clearly demonstrated. If both ovaries are removed men- 
 struation ceases and the uterus atrophies. If both ovaries fail to develop 
 the condition of amenorrhea exists. In cases of removal or congenital 
 absence of both ovaries a piece of ovary transplanted into the broad 
 ligament or uterus, or even under the skin, occasionally brings on men- 
 struation, although this is apt to be irregular. 
 
MENSTRUATION 
 
 87 
 
 INIany facts have been accumulated by gynecologists to show that 
 ovulation may occur independently of menstruation. For example, 
 impregnation may occur during lactation when the menstrual function 
 is in abeyance, and it may occur in young girls before the onset of men- 
 struation or in women after the menopause. Some years ago the author 
 was obliged to remove from a woman who had not menstruated for seven 
 years the ovaries shown in the accompanying illustration (Fig. 70). 
 One ovary contained a fresh corpus luteum showing that the woman 
 was ovulating in spite of her amenorrhea. It is generally conceded, how- 
 ever, that as a rule ovulation and menstruation occur in a definite sequence 
 and that the significance of menstruation is to be found in its physio- 
 
 FiG. 70. 
 
 -Ovaries of a woman who had not menstruated for seven years, sho'U'ing a fresh 
 corpus luteum. (Photograph.) 
 
 logical connection with the fate of the ovum, i. e., whether it is to be 
 fertilized or not. 
 
 The older view (Pfliiger) was that the uterus was influenced by pro- 
 cesses in the ovary through nervous reflex. ]\Iore recently it has been 
 shown experimentally in the dog that when the nerves supplying the 
 uterus are cut the animal can nevertheless become pregnant and bear 
 offspring. The transplantation experiments mentioned above also show 
 that the connection between the ovary and uterus is not essentially 
 nervous in character. The present view is that the influence upon the 
 uterus is brought about through the blood and is based upon the very 
 reasonable assumption that the ovary elaborates an internal secretion. 
 
88 EMBRYOLOGY AND PHYSIOLOGY 
 
 The latter view is strongly supported by Fraenkel, who believes that 
 the internal secretion is furnished by the cells of the corpus luteuni. 
 This observer holds that ovulation nomiallx" occurs two weeks ])rior to 
 menstruation and that the activity of the lutein cells is responsible for 
 the secretion (hormone) which stimulates the uterine mucosa to the 
 growth that takes place during the premenstrual period. 
 
 FETAL MEMBRANES. 
 
 Stated in very general terms, the fetal membranes are certain 
 structures that develop from, or as parts of, the embr>'o, functionate 
 for a period, during which the embryo is dependent upon its immediate 
 environment, as organs of nutrition and excretion, and then, when the 
 embryo is able to maintain an independent existence, are cast off or 
 atrophy and disappear. More specifically, the human fetal membranes 
 are structures of the above nature, which establish an extraordinarily 
 intimate structural and functional relationship between the embryo and 
 the maternal tissues, by virtue of which the embryo is nourished and 
 discharges its waste products during gestation. 
 
 Under this head are to be considered (1) the yolk sac, (2) the amnion, 
 (3) the chorion, (4) the allantois, and (5) the umbilical cord. In addi- 
 tion it is necessary to discuss also the changes in the mucous membrane 
 of the uterus since this is particularly affected by the growth of the 
 chorion. 
 
 In the different mammals there is much variation, not only in the 
 origin of the fetal membranes, but also in their ultimate structure and 
 the relationship established with the uterine mucosa. In some forms 
 the amnion appears as folds of the somatopleure (ectoderm plus parietal 
 mesoderm) which grow dorsally and eventually meet and fuse dorsal to 
 the embryonic body. The inner limb of the fold, formed from without 
 inward of parietal mesoderm and ectoderm, constitutes the amnion, 
 the cavity between it and the embryo being the amniotic cavity (Fig. 
 71). The outer limb of the fold, formed from within outward of parietal 
 mesoderm and ectoderm, constitutes a portion of the chorion which is, 
 of course, continuous with the more peripheral part of the somatopleure, 
 the cavity between the amnion and chorion being a continuation of the 
 extra-embryonic body cavity (Fig. 71). This cavity gradually extends 
 around the original yolk cavity through splitting of the mesoderm, so 
 that eventually the portion of the somatopleure forming the chorion is 
 separated from the splanchnopleure which now forms the yolk sac. 
 
 The embryonic body, as it develops, becomes constricted from the 
 yolk sac, a small portion of the latter being included in the body as the 
 primitive gut which remains attached to the yolk sac by means of the 
 yolk stalk (Fig. 71). With this constriction the border of the amnion is 
 carried ventrally and eventually the amnion, gradually increasing in 
 size, surrounds the embryo like a sac, being attached in annular form 
 to the ventral side of the embryo (Fig. 71). The allantois develops 
 as a diverticulum from the caudal end of the gut and grows out into the 
 
FETAL MEMBRANES 
 
 89 
 
 extra-embryonic body cavity as a sac-like structure which finally fuses 
 with the chorion (Fig. 71). As the embryo becomes constricted from 
 the yolk sac the amnion enlarges, as noted above, and pushes together 
 the yolk stalk and the narrow proximal portion of the allantois, or allan- 
 toic duct. There is thus formed a cylindrical structure, the umbilical 
 
 Embryonic disk 
 
 Exocelom 
 
 Amniotic folds 
 
 Chorionic villi 
 
 Chorionic villi 
 Chorion 
 
 Allantois 
 
 Exocelom 
 
 Fig. 71. — Diagrams of the development of the fetal membranes in a mammal. A, B, C, 
 represent cross-sections; D, represents a longitudinal section. (Bonnet.) 
 
 cord, which is- covered with ectoderm and includes not only the yolk 
 stalk and allantoic stalk, with their quota of mesoderm (Fig. 71), but 
 also the bloodvessels whose branches ramify in the walls of the yolk 
 sac and allantois, the vitelline (omphalomesenteric) and umbilical 
 (allantoic) vessels respectively. 
 
90 EMBRYOLOGY AND PHYSIOLOGY 
 
 The yolk sac in mammals containing little nutriment, the vitelline 
 vessels are of minor importance in nourishing the embryo. On the 
 other hand, the allantois fusing with the chorion, the latter becomes 
 vascularized by branches of the umbilical vessels; and since the chorion 
 comes in contact with the uterine mucosa the umbilical vessels thus 
 acquire prime importance in the nourishment of the embryo and elimi- 
 nation of its waste products. 
 
 The chorion, at first possessing a smooth ectodermal surface, sub- 
 sequently increases its surface area through the development of num- 
 erous projections, or villi (Fig. 71), which involve both ectoderm and 
 mesoderm. The chorionic ectoderm, from its functional character, is 
 given the name trophoderm. The chorionic villi may be rudimentary, as 
 in the pig, or acquire an increasing degree of complexity up through the 
 mammalian series, eventually reaching the exceedingly complicated 
 condition characteristic of the human chorion. 
 
 The chorion, lying within the cavity of the uterus, forms a union with 
 the uterine mucosa. The process of union is spoken of as placentation. 
 The structural result of the union is known as the placenta. This union 
 is obviously either an apposition or a fusion, and upon the intimacy 
 of the relationship is based one of the classifications of placentae. 
 
 (1) In case the chorionic and uterine epithelia are merely in contact 
 (as in the pig) the placenta is a placenta epitheliochorialis. At par- 
 turition the chorionic villi are withdrawn from depressions in the uterine 
 mucosa, like fingers from a glove, leaving the maternal mucosa intact, 
 and no blood escapes from the uterine vessels. (2) In case the uterine 
 epithelium is destroyed wholly or in part during placentation and the 
 chorionic ectoderm (trophoderm) comes in contact with the maternal 
 connective tissue, the placenta is of the syndesmochorialis type. At birth 
 some of the smaller uterine vessels are likely to be torn, and a little blood 
 thus escape. (3) If the chorionic epithelium comes in contact wath the 
 endothelium of the maternal vessels during the formation of the placenta 
 (as in carnivores), the placenta is of the endotheliochorialis type. In 
 this case a considerable amount of blood escapes at birth, due to rup- 
 ture of the uterine vessels. (4) If, during placentation, all the maternal 
 partitions are broken down and the chorionic ectoderm comes in direct 
 contact with the maternal blood (as in man), the placenta is a placenta 
 hemochorialis. At birth a large quantity of blood escapes from the 
 uterine vessels following the separation of the placenta. In the last 
 three instances, and notably in the human subject, some of the maternal 
 tissues in addition to the blood remain attached to the chorion and come 
 away with it at parturition. These tissues constitute the decidua. 
 
 Placentse are also classified on the basis of form. In the pig the villi 
 are more or less uniformly distributed over the surface of the chorion 
 and the placenta is spoken of as diffuse. In other cases, while the villi 
 at first developed uniformly over the surface of the chorion, they sub- 
 sequently disappear except in definitely restricted areas. If they per- 
 sist in groups, as in the cow and sheep, the placenta is of the multiplex 
 (cotyledonary) t\'pe. When they persist in an area girdling the chorion, 
 
FETAL MEMBRANES 91 
 
 as in the dog and cat, a placenta zonaria is the result. Persisting in a 
 disk-shaped area, as in man, a discoidal placenta is formed. 
 
 Fetal Membranes in Man. — The development of the human ovum 
 prior to the stage in which the amniotic cavity and yolk cavity are 
 already present is unknown. However, the conditions in the youngest 
 human ovum so closely resemble those at a corresponding stage in some 
 of the lower mammals in which previous development has been studied 
 that we may infer at least a similarity in the antecedent processes in 
 man. 
 
 In those mammals in which the processes have been studied, seg- 
 mentation results in a solid mass of cells, the morula (Fig. 48). The 
 superficial cells of the morula are differentiated from those in the interior 
 to form the covering layer which subsequently becomes the chorionic 
 ectoderm or trophoderm (Fig. 50). Most of the central cells then 
 become vacuolated and the vacuoles coalesce to form the yolk cavity, 
 a few cells remaining attached to the covering layer as the inner cell 
 mass (Fig. 52). From this point on the development of the bat's ovum 
 may be taken to represent the stages in the human ovum up to the 
 earliest condition known. In the bat, following the formation of the yolk 
 cavity, those cells of the inner cell mass bordering upon the cavity dif- 
 ferentiate and spread out in a single layer or lining which represents the 
 primitive entoderm (Fig. 53). In the meantime the interior of the 
 inner cell mass becomes vacuolated, thus forming the amniotic cavity 
 which is separated from the yolk cavity by the embryonic disk. The 
 disk is composed of entoderm and a single layer of cells of the inner cell 
 mass. This layer is continuous at its margin with the roof of the amniotic 
 cavity (Fig. 55). The next step in development is the appearance 
 of mesoderm everywhere between the covering layer and entoderm, 
 between the covering layer and roof of the amniotic cavity and between 
 the ectoderm and entoderm in the embryonic disk. In general the 
 conditions now resemble those in the earliest known human ovum, which 
 has been described by Bryce and Teacher and estimated by them to be 
 between thirteen and fourteen days old. 
 
 The Bryce-Teacher ovum is represented in section in Fig. 72. The 
 outer layer, exhibiting many irregular projections which will be con- 
 sidered in detail subsequently, is the trophoderm. In the interior of the 
 chorionic vesicle, or blastocyst (names which have been given to the 
 entire structure) are two cavities, the larger being the amniotic, lined 
 with ectoderm, and the smaller representing the yolk cavity, lined with 
 entoderm. Mesoderm of a very loose texture fills the space between 
 the two cavities and the trophoderm. 
 
 In Fig. 73 is represented a section of an ovum described by Peters 
 and now reckoned to be fourteen or fifteen days old. Here again the 
 trophoderm is seen to extend in all directions in irregular projections, 
 and the mesoderm has begun to invade the trophoderm, thus forming 
 rudimentary villi. Within the chorionic vesicle the mesoderm is divided 
 into two layers. The outer or parietal layer is apposed to the tropho- 
 derm and together with the latter constitutes the chorion proper. The 
 
92 
 
 EMBRYOLOGY AND PHYSIOLOGY 
 
 iiiiior or visctTul layer is api)lie(l to the entoderm of the yolk sac. 
 The space between the parietal and visceral mesoderm is the extra- 
 embryonic body cavity. The roof of the amniotic cavity is still fused 
 with the chorion. 
 
 A longitudinal section of an embryo 2 millimeters in length, described 
 by von Spee, is shown in Fig. 74, while Fig. 75 represents a dorsal 
 view of the same embryo in toto. It will be noted that the amnion has 
 split away from the chorion except at the caudal end of the embryo, 
 where a cord of mesoderm — the belly stalk — still serves to attach the 
 
 cyt. 
 
 cyt. 
 
 
 jspgSfgaa^w.^-: 
 
 • ie"! « 
 
 !j«-l»***>KRSlr''^WSi5iBi| e.p. 
 
 
 
 ."•vfS^v 
 
 -'*«*f^' - 
 
 
 
 V/^•'^;-.•.'N.>v;^.^ 
 
 
 ri' 
 
 
 
 
 '-■■>'»*»".'''■•'"' '^ ">\ 
 
 -' It „ 
 
 
 
 ^-iiii. ..-.■ 
 
 
 '^*"$ife;' 
 
 
 
 1 2 * *■ f. 
 
 
 ,»':»", - • 
 
 
 
 
 
 - 
 
 i^-'i^f. 
 
 
 
 "• 'OV 
 
 '-. 
 
 / -i'-l. 
 
 ^t^ 
 
 
 
 tro'. 
 
 iro'. 
 
 
 Fig. 72. — Diagram of human ovum of thirteen or fourteen days, embedded in the uterine 
 mucosa: cap., capillary; cyt., cellular layer (cyto-trophoderm) ; e.p., uterine epithelium; 
 gl., uterine gland; n.z., necrotic zone of decidua (uterine mucosa); P.e., point of entrance 
 of the ovum; tro., syncytium (plasmodium, plasmodi-trophoderm) ; tro'., masses of vacuolat- 
 ing syncytium invading capillaries. The cavity of the blastodermic vesicles is completely 
 filled by mesoderm, and embedded therein are the amniotic and entodermic (yolk) vesicles. 
 The natural proportions of the several parts have been observed. (Bryce and Teacher.) 
 
 amnion and embryo proper to the chorion. The allantois is a slender 
 diverticulum of entoderm which grows into the belly stalk. At the 
 cephalic end a slight constriction already marks the boundary between 
 the embryo and the yolk sac. All the rudiments, therefore, of the fetal 
 membranes are present. 
 
 The Amnion. — While the amniotic cavity and amnion in man prob- 
 ably originate through vacuolization of the inner cell mass, a process 
 quite different from the folding of the somatopleure as described in 
 some of the other mammals (c/. Fig. 71), their further development 
 
FETAL MEMBRANES 
 
 9'. 
 
 is essentially the same as in the other forms (cf. Fig. 71). At first small 
 and covering only the dorsum of the embryo, the amnion increases 
 
 
 8:5.2 
 ^ S S 
 
 o ^ o 
 -3 ■-" 
 
 tJ O •- 
 
 o o t; 
 
 "^ o 73 
 o 
 
 ...: O tn 
 
 O^ S 
 
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 s s^ 
 
 ;3 t- •- 
 c3 T) H 
 
 -a o -a 
 o <p o 
 
 * m " 
 
 S o &^ 
 
 *f <D — ' 
 
 o ° o 
 
 ■^ 2 '3 
 
 O S o 
 
 => .2 ^ 
 
 S ^ J2 
 S3 g g 
 
 » I S-S 
 •S c°, " < 
 S •--« 
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 0-2 o § 
 
 (U ^ 03 
 
 ,•" t) g ^ 
 
 S .2 S "o 
 <=> 2 « ^ 
 
 - ro o 
 
 ro 
 
 '•"-^^- •. 
 
 pR S3 -^ :3 
 3 "o '> 
 
 rapidly in size and envelops the Avhole embryo as the latter is con- 
 stricted from the volk sac. Bv the end of the second month it obliterates 
 
94 
 
 EMBRYOLOGY AXD PHYSIOLOGY 
 
 Chorionic villi 
 
 "IT--— --Chorion 
 
 _ Mesoderm 
 ^ of chorion 
 
 -liellv Stalk 
 
 Primitive streak 
 Allantois 
 
 Mesoderm 
 of yolk sac 
 
 h — Blood vessel 
 
 Fig. 74. — Medial section of human embryo 2 mm. in length. {Cf. Fig. 75.) (Von Spoe.) 
 
 Yolk-sac 
 
 Amnion 
 
 Neural groove 
 
 Neureyiteric canal 
 
 Primitive streak 
 Body-stalk 
 
 Fig. 75. — Human embrj^o — length, 2 mm. Dorsal ^aew, with the amnion laid open. X 30. 
 
 (After von Spee.) 
 
FETAL MEMBRANES 
 
 95 
 
 the extra-embryonic body cavity and fuses with the mesodermal layer 
 of the chorion, although not so firmly but that even at birth it can easily 
 be separated as a transparent, glistening membrane. Bloodvessels are 
 lacking in the amnion. The amniotic cavity becomes filled with liquor 
 amnii, a watery fluid of slightly alkaline reaction and containing about 
 1 per cent, of solids. The fluid, which amounts to about 1 liter at the 
 end of pregnancy, is probably secreted by the amniotic epithelium, the 
 
 X 
 
 
 Fig. 76. — Human embryo of 2.6 mm., with amnion and yolk sac. The amnion closely 
 invests the embryo. 1, belly stalk; 2, heart; 3, vitelline vein; 4, vitelline artery; 5, yolk sac. 
 (His, Kollmann's Atlas.) 
 
 evacuations of the fetal urinary bladder being inconsiderable. The 
 functions of the liquor amnii are important: (a) It serves as a water 
 supply for the fetus, both by absorption through the skin, especially dur- 
 ing the early months, and by swallowing. The latter is proved by find- 
 ing in the intestinal canal of the fetus epidermal cells, hairs and portions 
 of vernix caseosa which could have reached there only by being swallowed 
 with some of the liquor amnii. The amount of solid matter, however, 
 in the amniotic fluid is so slight (1 or 2 per cent.) that its nutritive 
 
96 
 
 EMBRYOLOGY AND PHYSIOLOGY 
 
 value must be regarded as slight, (b) It serves as a protection to the 
 fetus against blows, falls, pressure or other injury, (c) It allows free- 
 dom of motion, thus favoring muscular development, (d) It serves to 
 maintain a constant temperature, (e) Enclosed in the amnion it serves 
 as a fluid wedge in the gradual dilatation of the cervix, a function which 
 human art, by elastic bags, has often tried to imitate but never equalled. 
 The yolk sac in the human embryo is but a rudiment of the large 
 and important structure, full of nutriment, found especially in reptiles 
 and birds and also in some of the still lower forms. The mesoderm in 
 the wall does serve, however, in the mammalian forms, including man, as 
 
 Gut 
 
 Umbilical vein 
 
 Amnion 
 
 Allantois 
 
 Yolli stalk 
 
 Umbilical artery 
 Umbilical vein 
 
 Anmion 
 
 Chorionic villi 
 
 Fig. 77. 
 
 -Diagram of the umbilical vessels in the belly stalk and chorion. 
 
 Atlas.) 
 
 (Kollmann's 
 
 an important blood-forming organ in early embryonic life, and an exten- 
 sive vitelline circulation is established, which atrophies, however, with 
 the subsequent regressive changes in the sac. During the third week 
 a decided constriction occurs between the sac and the embryo (Fig. 76). 
 The sac remains for a time attached to the intestine by a pedicle, the 
 yolk stalk, which is embedded in the umbilical cord. The yolk stalk 
 eventually disa]>pears and the sac itself, as the amnion enlarges, is car- 
 ried away from the embryo. At birth the yolk sac can usually be found 
 between the amnion and chorion on the placenta near the attachment 
 of the umbilical cord, sometimes on the chorion \^^eve. It is a white or 
 
■ FETAL MEMBRANES 97 
 
 yellow body, round or oval, somewhat flattened, with a diameter of 
 1 to 5 millimeters. Its contents may be partly calcified. 
 
 The Allantois. — It has been noted that the allantois grows into the 
 belly stalk as a slender entodermal diverticulum composed of cuboidal 
 cells and often called the allantoic duct (Fig. 74). This rudimentary 
 structure contrasts sharply with the much larger sac-like allantois in 
 lower forms (especially birds and reptiles), where it serves as a reservoir 
 for waste products of the embryo and in part as an organ of respiration. 
 Its rudimentary character in man and mammals in general is due to 
 the intimate relationship established between the embryo and maternal 
 tissues, in which case the excretions are transmitted to the maternal 
 blood. The allantoic (or umbilical) bloodvessels, however, since they 
 extend through the belly stalk to the chorion (Fig. 77) assume prime 
 importance in that they not only convey waste products to the maternal 
 blood but also carry nutritive substances back to the embryo. The 
 allantoic duct usually remains hollow in embryos up to 8 or 9 millimeters 
 in length. It then begins to atrophy. In the fourth month portions of 
 it, containing lumina, may still be found; and even in the mature um- 
 bilical cord occasional epithelial pearls persist as remnants of the duct. 
 The portion of the allantoic duct within the embryo, extending 
 from the apex of the bladder to the umbilicus, is known as the 
 urachus. 
 
 Implantation of the Ovum. — The Chorion and Decidua. — Nothing 
 is known concerning the behavior of the human ovum from the time 
 it escapes from the Graafian follicle until it becomes embedded in the 
 uterine mucosa. From conditions in lower mammals it is inferred that 
 the ovum, escaping from its follicle and entering the fimbriated end of 
 the Fallopian tube, is fertilized in the outer third of the tube; that it 
 then passes on through the tube into the uterus, the movement being 
 due to the action of the cilia on the epithelium lining the tube and uterus; 
 and that during this passage it loses its zona pellucida and corona radiata 
 and undergoes the early processes of development (segmentation and 
 beginning formation of the germ layers), probably deriving oxygen and 
 nourishment from the secretions of the mucous membrane. The time 
 occupied by the ovum in traversing the distance to the point of implan- 
 tation in the uterus has been estimated at seven or eight days. 
 
 By implantation is meant the processes by which the ovum, or blasto- 
 cyst, becomes embedded in the mucous membrane of the uterus. The 
 generally accepted view is that the ovum penetrates the mucosa like a 
 parasite through an opening which it makes for itself. The maternal 
 tissues are probably dissolved by the action of ferments secreted by the 
 trophoderm. The ferments affect not only the epithelium but the con- 
 nective tissue and endothelium of the bloodvessels of the stroma. The 
 cavity thus formed in the mucous membrane of the uterus therefore 
 contains the blastocyst and a large amount of maternal blood which has 
 escaped from the invaded vessels (Fig. 72). The invasion of the mater- 
 nal bloodvessels by the trophoderm results in the essential character 
 of a placenta of the hemochorialis t}npe (see p. 90), namely, that the 
 7 
 
98 EMBRYOLOGY AND PHYSIOLOGY 
 
 superficial embryonic tissue (chorionic ectoderm, trophoderm) comes 
 in direct contact with the maternal blood. 
 
 Implantation usually occurs either on the posterior or anterior wall 
 of the uterus and determines the situation of the placenta. It probably 
 does not take place in a gland but between glands. The cause of pene- 
 tration of the uterine mucosa by the ovum remains undetermined. It 
 is assumed, however, that ameboid activity of the superficial cells of 
 the trophoderm is at least one of the prime factors. 
 
 Regarding the time of implantation, obstetric experience seems to 
 indicate that fertilization of the human ovum is most likely to occur 
 in the week following menstruation and the Naegele rule for estimating 
 the probable date of confinement, the rule followed at the Sloane Hos- 
 pital, is based on this fact. Bryce and Teacher claim that fertilization 
 of the ovum in the Fallopian tube exercises an inhibiting effect upon the 
 premenstrual changes in the uterine mucosa; otherwise menstruation 
 would continue through early pregnancy. 
 
 The time elapsing between fertilization and implantation is not known. 
 The Bryce-Teacher ovum, estimated to be thirteen or fourteen days 
 old, was already perfectly embedded, and we may infer that the pro- 
 cess occurs before the end of the second Aveek. It has also been esti- 
 mated that the time required for the fertilized ovum to pass through 
 the tube is from seven to eight days. Implantation would therefore 
 occur between the eighth and thirteenth days. 
 
 The Chorion and Deciduse. — As soon as the ovum becomes embedded 
 in the uterine mucosa the latter can be divided into three parts in rela- 
 tion to the ovum: (1) a part beneath the ovum, (2) a part between the 
 ovum and the cavity of the uterus, and (3) the region exclusive of these 
 two. Much of the mucosa of pregnancy is cast off at birth as the decidua. 
 The three parts mentioned above are therefore named (1) decidua 
 basalis (serotina), (2) decidua capsularis (reflexa) and (3) decidua parie- 
 talis (vera) (see Fig. 78). It has been previously stated (p. 90) that 
 villi at first develop over the entire surface of the chorion and that sub- 
 sequently the great majority of these atrophy and disappear. The 
 portion of the chorion over which they disappear constitutes the chorion 
 Iseve and is associated principally with the decidua capsularis (Fig. 78). 
 The portion on which they continue to develop is associated with the 
 decidua basalis and forms the chorion frondosum. The decidua basalis 
 and chorion frondosum together form the placenta, which is thus made 
 up of a maternal portion and a fetal portion (Fig. 78). 
 
 The Decidua Basalis. — It has been seen that the Bryce-Teacher ovum 
 exhibits numerous irregular projections of the trophoderm (Fig. 72). 
 The destructive or digestive action of the trophoderm on the uterine 
 mucosa results in the relatively large implantation cavity. It is held by 
 some investigators that the action is phagocytic. The condition of the 
 zone of mucosa immediateh' surrounding the implantation cavity in 
 the Bryce-Teacher ovum would indicate, however, that the destruction 
 of maternal tissue is brought about by the action of some substance of 
 the nature of a ferment elaborated by the trophoderm rather than by 
 
FETAL MEMBRANES 
 
 99 
 
 phagocytic action. This coincides with the well-supported view that 
 the ovum first becomes embedded in the mucosa through the action 
 of ferments (p. 97). The destructive action of the trophoderm extends 
 to the walls of the maternal bloodvessels, and the blood, escaping from 
 the vessels, fills the implantation cavity and thus bathes the surface of 
 the chorion. This intimate relation between maternal blood and chor- 
 ion is of prime importance in nourishing the rapidly growing embryo. 
 Of much interest and importance is the fact that the extravasated mater- 
 nal blood does not coagulate while in contact with the trophoderm. The 
 trophoderm apparently acts in this respect as the living endothelium. 
 
 Fig. 78. — Semidiagrammatic outline of an anteroposterior section of the gravid uterus 
 and ovum of five weeks: a, anterior uterine wall; b, posterior uterine wall; c, decidua vera 
 (parietalis) ; d, decidua reflexa (capsularis) ; e, decidua serotina (basalis) ; ch, chorion with its 
 villi. (Jewett, modified from Allen Thomson.) 
 
 The chorion frondosum, associated with the decidua basalis, is char- 
 acterized by profuse growth of the chorionic villi. These structures arise 
 through invasion of the primary, irregular trophodermic projections by 
 the chorionic mesoderm, each villus thus being composed of a core of 
 mesoderm and an outer layer of trophoderm (Fig. 73). They grow 
 rapidly and branch freely, forming complex tree-like structures (Fig. 
 79). Some of the branches become firmly attached to the decidua 
 basalis and are known as anchoring villi. The majority of the branches 
 end free in the maternal blood sinuses as floating or terminal villi (Fig. 
 
100 
 
 EMBRYOLOGY AND PHYSIOLOGY 
 
 80). The villi are divided into groups by partitions of the decidua 
 basalis (Figs. SO, 81, and 82). These groups, corresponding to the lobes 
 of an ordinary gland, are known as cotyledons and the partitions as 
 placental septa. 
 
 Fig. 79. — Isolated villi from chorion frondosum of a human embryo of eight weeks 
 1, decidua; 2, anchoring villi; 3, terminal villi; 4., chorion; 5, artery; 6, vein; 7, chorion.' 
 (Kollmann's Atlas.) 
 
 The mesodermal core of the chorionic villus at first comprises a loose, 
 fibrous connective tissue which, during the second month of gestation, 
 becomes vascularized by branches of the allantoic (umbilical) vessels. 
 As development proceeds the connective tissue becomes denser and 
 toward the end of pregnancy the intercellular sulistance assumes a 
 hyaloid character. The tro|)hoderm early undergoes difl'erentiation 
 into two layers. The inner layer, apposed to the mesoderm, exhibits 
 
FETAL MEMBRANES 
 
 101 
 
 fairly distinct cell boundaries and is known as the cellular layer (of 
 Langhans) or cytotrophoderm. The outer layer, in contact with the 
 
 Fig. 80. — Diagrammatic section of placenta. (Strahl, Bonnet.) 
 
 maternal blood, exhibits no cell boundaries and is known as the syncytial 
 layer, or plasmoditrophoderm. The cj^oplasm of the inner layer is 
 
 Umbilical cord 
 
 Chorion laeve 
 
 7 jfr^ 
 
 f y 
 
 Cotyledon 
 
 s 
 
 \ 
 
 / . 
 
 <\ 
 
 —"i 
 
 Decidua basalis 
 
 Cotyledon 
 
 Fig. 81. — -Mature placenta, from maternal side. (Bonnet.) 
 
 granular and shades off into the homogeneous cytoplasm of the outer 
 layer (Fig. 83). ^ • 
 
102 
 
 EMBRYOLOGY AND PHYSIOLOGY 
 
 The intervillous spaces represent l)lood sinuses which are derixed 
 from the vessels of the mucous membrane of the uterus through disso- 
 lution of their walls, and are destitute of endotheliiun. They are filled 
 with slowly circulating maternal blood wliich enters through the arteries 
 of the uterine wall and leaves through the corresponding veins (Fig. 80). 
 At the border of the placenta is the marginal sinus, usually not invaded 
 by villi, which is separated from the chorion itself by a closing plate of 
 
 Fig. 82. 
 
 -Mature placenta, seen from the maternal side, showing the umbilical cord and 
 the placental lobes or cotyledons. (Photograph.) 
 
 maternal tissue (Fig. 80). There is never normally any mingling of 
 the maternal with the fetal blood, the blood in the intervillous spaces 
 (maternal sinuses) being separated from that in the core of the villus 
 by trophoderm, connective tissue of the villus and endothelium of the 
 fetal vessel wall. 
 
 During the first month of pregnancy the trophoderm on some parts 
 of the villi begins to proliferate with great rapidity, resulting in large 
 
FETAL MEMBRANES 
 
 103 
 
 masses of cells which project into the intervillous spaces (Fig. 84). 
 Whether the proliferation involves the cellular layer or the syncytial 
 layer, or both, has not been determined. Whatever the origin of these 
 masses, the cell bovmdaries are usually distinct. In some regions the 
 cells are small and granular, with densely staining nuclei, and in other 
 regions the cells are large and homogeneous, with large vesicular nuclei; 
 and every gradation between these two extremes can be seen. Large 
 multinuclear cells or giant cells also appear (Fig. 84). They appar- 
 ently lie free in the intervillous spaces, although it is generally claimed 
 that they represent sections of tips of the syncytial layer. 
 
 Soon after the masses of trophoderm appear they begin to undergo 
 degenerative changes which lead to the formation of a structure known 
 
 Fig. 83. — Transverse section of a chorionic villus from a human embryo of two months, 
 showing mesodermal core surrounded by the cellular and syncytial layers of trophoderm: 
 1, Hofbauer's cell; £, capillary. (Grosser.) 
 
 as canalized "fibrin" (Fig. 84). While this is not fibrin in the true 
 sense, it nevertheless is acidophilic and in sections stained with eosin 
 can be recognized by its brilliant red appearance. 
 
 In the later months of pregnancy the covering layer of the villi is 
 reduced to a thin homogeneous membrane. The cellular layer (cyto- 
 trophoderm) disappears and the syncytial layer (plasmoditrophoderm) 
 forms the thin membrane. At points in this membrane are knob-like 
 projections composed almost wholly of densely staining nuclei (Fig. 85). 
 
 Another important type of cell is found not only in the decidua but 
 also in the neighboring portions of the uterine wall. These are the 
 decidual cells and, although considerable controversy has arisen over 
 their origin, it has been well established that they represent modified 
 
104 
 
 EMBRYOLOGY AND PHYSIOLOGY 
 
 connective-tissue cells of the uterine stroma. They are large (30 to 100 
 microns in diameter) and vary in shape. Late in pregnancy they acquire 
 a brownish pigment which, owing to the great number of cells, gives the 
 
 
 ^,, 
 
 
 
 ir?«s'- 
 
 
 
 ' '<« 
 
 
 r^;|M 
 
 Fig. 84. — Section of human chorion of one month: 1, giauL Leil; ^, wyucytium; 5, tro- 
 phoderm mass; 4> syncytium; 5, canalized "fibrin"; 6, stroma of villus. (Grosser.) 
 
 Remnant of syncytium 
 Capillaries *■ 
 
 .Nucleai 
 groups 
 
 Remnant 
 ■ of syncytium 
 
 f Capillary 
 
 Nuclear group 
 Fig. 85. — Transver.se sections of chorionic villi at the end of pregnancy. (Schaper.) 
 
 brownish color to the superficial layer of the decidua. Each cell usually 
 contains a single large vesicular nucleus; occasionally multinucleated 
 cells are seen. These decidual cells are related not only as to their 
 
FETAL MEMBRANES 105 
 
 origin but also as to their general characters to the decidual cells of 
 the menstruating mucosa (p. 83). 
 
 The portion of the uterine mucosa beneath the chorionic villi can be 
 divided into two layers: (1) a compact layer of connective tissue which 
 gives off the placental septa and to which the anchoring \-illi are attached, 
 and (2) a spongy layer between this and the muscularis which contains 
 the flattened remnants of a few uterine glands lying parallel to the 
 muscularis. x\s will be noted subsequently the line of separation of the 
 decidua at parturition passes through the spong}' layer. 
 
 The Decidua Parietalis. — The changes in the uterine mucosa which 
 result in the formation of the decidua parietalis resemble those which 
 occur during the premenstrual period. These changes comprise mainly 
 an increase in size and tortuosity of the glands, congestion of the stroma, 
 and proliferation of its connective-tissue cells. The resulting thicken- 
 ing of the mucosa extends to the internal os where it ends abruptly, 
 no decidua being formed in the cervix. 
 
 In the superficial part of the mucosa the glands disappear, and the 
 connective tissue here forms a dense sheet known as the compact layer. 
 Beneath this are found remains of uterine glands in the form of tortuous 
 spaces extending mostly parallel to the muscularis. Some of these 
 glandular structures lose much of their epithelium. Lying in the stroma, 
 these spaces give to this portion of the mucosa the structure which has 
 led to the designation, spongy layer. 
 
 During the latter half of pregnancy the decidua parietalis becomes 
 markedly thinner, owing to pressure from the growing embryo and its 
 membranes. The glands in the spongy layer collapse and are reduced 
 to slit-like spaces parallel to the muscularis. The tissue in general 
 becomes much less vascular than in early pregnancy. 
 
 The Decidua Capsularis. — The older name, decidua reflexa, indicates 
 the earlier view that this portion of the decidua represented a portion of 
 the uterine mucosa which grew around the attached ovum. The later 
 researches have shown that the ovum buries itself in the uterine mucosa 
 (p. 97) and that the portion of mucous membrane between the ovum 
 and the cavity of the uterus as the ovum and its membrane continue 
 to grow constitutes the decidua capsularis (see Figs. 72 and 78). Early 
 in development it exhibits essentially the same structure as the decidua 
 basalis. By about the fifth month the rapidly growing embryo with 
 its membranes fills the uterine cavity and the decidua capsularis, now 
 but a thin transparent membrane, is pressed against the decidua parie- 
 talis, and, according to some investigators, eventually disappears or, as 
 held by others, fuses with the parietalis. The portion of the chorion on 
 which the villi ultimately disappear, namely, the chorion Iseve (p. 98), 
 is always associated with the decidua capsularis. The amnion in turn 
 is fused with the chorion Iseve as with the chorion frondosum (p. 98). 
 The amnion and chorion laeve together, in the later months of preg- 
 nancy, form therefore but a thin membrane which (in case the decidua 
 capsularis disappears) is applied to the decidua parietalis. 
 
 At parturition the Hne of separation of the deciduse from the uterine 
 
106 EMBRYOLOGY AND PHYSIOLOGY 
 
 wall passes through the deeper part of the spongy layer (see Fig. 80). 
 By this separation many of the larger maternal bloodvessels are opened, 
 but hemorrhage is held in check by the firm contraction of the uterine 
 muscle. The condition of the uterine mucosa after childbirth has 
 been described as an exaggeration of its condition at the height of the 
 menstrual period. Reconstruction of the mucosa takes place through 
 proliferation and rearrangement of the remaining glandular elements and 
 connective tissue. 
 
 The Placenta. — From the preceding study it is seen that the placenta 
 is a spongy discoid mass formed during the latter part of the third month 
 of pregnancy by the union of the decidua basalis and the chorion fron- 
 dosimi ; that it is covered on its fetal surface by the amnion and is attached 
 by its outer surface to the wall of the uterus, usually at its upper part. 
 The placenta is thus seen to consist of both a maternal and a fetal 
 portion. Through the umbilical cord it is attached to the fetus at its 
 umbilicus. 
 
 The Placenta at Term. — Examination of the placentae of 1000 consecu- 
 tive, normal full-term deliveries at the Sloane Hospital gave the following 
 results: The average weight was 651.92 grams; approximately 23 ounces. 
 The average diameters were 19.14 cm. x 17.14 cm. The placenta near 
 its centre measures from 3 to 4 cm. in thickness, gradually thinning toward 
 its circumference. As seen in Fig. 82, the maternal surface is rough, 
 covered by a thin, soft layer of decidua which in the cleavage of the 
 decidua basalis has remained attached to the chorion and has separated 
 from the uterus. By grooves formed by the indipping of septa of the 
 decidua basalis the maternal surface is divided into irregular lobes 
 or cotyledons 1 to 3 cm. in diameter. It is of a beefy-red color and shows 
 torn shreds of maternal bloodvessels. The inner or fetal surface of the 
 placenta (Fig. 86) is smooth, glistening and pearl-colored. It is covered 
 by the amnion through which are distinctly seen the branches of the 
 umbilical arteries and vein converging to the umbilical cord, which 
 usually leaves the placenta eccentrically. The amnion can readily' 
 be peeled off from the fetal surface of the placenta as a thin, almost 
 transparent, membrane. 
 
 A section through the substance of a normal placenta, when viewed 
 microscopically (Fig. 87), shows the field studded with chorionic villi 
 cut at different angles, transversely, longitudinally and obliquely. The 
 structure of these villi has already been described when discussing the 
 chorion frondosum. 
 
 The Functions of the Placenta. — Aside from the transmission of oxygen 
 and nutrition from the maternal to the fetal blood the placenta also 
 serves as an organ of excretion, as here not only CO2 but other waste 
 products of fetal metabolism pass from fetal to maternal blood. It 
 thus serves as the organ of mutual exchange; absorbing that which is 
 necessary to fetal existence and getting rid of excrementitious substances 
 deleterious to fetal life. The villi also seem to have certain selective 
 powers, as some drugs pass readily from maternal to fetal blood while 
 others will not. 
 
FETAL MEMBRANES 
 
 107 
 
 Pathology of the Placenta. — The unusual and pathological conditions 
 of the placenta may be conveniently grouped as follows: (1) Abnor- 
 malities of form and size, (2) degenerations, (3) diseases, and (4) neoplasms. 
 
 1. Abnormalities of Form and Size. — Occasionally there is an aperture 
 in the placenta (placenta fenestrata). Sometimes the organ is incom- 
 pletely divided into two parts (placenta bipartita). In some instances 
 there is a complete separation into two, three or more distinct lobes 
 
 Fig. 86. — Mature placenta, seen from the fetal side. (Photograph.) 
 
 (placenta duplex, triplex, or muliplex). In very rare cases the placenta, 
 in the form of a relatively thin structure, is adherent to the entire interior 
 of the uterus (placenta membranacea) . Not infrequently a single coty- 
 ledon or a group of cotyledons appears as a separate lobule connected 
 with the main organ by branches of the umbilical vessels (placenta 
 succenturiata) . 
 
 The causes underlying these unusual forms are not clear. It has been 
 assumed, and not without reason, that the portion of the chorion which 
 
lOS 
 
 EMBRYOLOGY AND PHYSIOLOGY 
 
 Fig. 87.— Vertical section of the human placenta, about the seventh month in situ. 
 X 6. Am., amnion; Cho., chorion; Vi., villous trunk: m., sections of villi in the substance of 
 the placenta; D , Z>", dccidua basalis; Mc, muscularis; Ve.. uterine artery opening into 
 placenta; the fetal bloodvessels arc drawn black, the maternal bloodvessels white- the 
 chorionic tissue is stippled, except the canaHzed fibrin, which is shaded by lines; remAants 
 ot the gland cavities in the decidua are stippled dark. (Minot ) 
 
FETAL MEMBRANES 109 
 
 de\-elops into the fetal part of the placenta is very largely influenced, 
 as regards its shape and attachment to the uterine wall, by the distribu- 
 tion of the decidual bloodvessels. The varieties in form and size of the 
 placenta in multiple pregnancy are shown and discussed under that head 
 (see page 195). 
 
 2. Degenerations. — X certain constant type of degeneration of the 
 trophoderm has already been mentioned (page 103). In addition to this 
 other degenerative changes occur in every placenta. The chief factor 
 in bringing about these changes appears to be a deranged blood supply 
 due to fibrosis of the vessel walls in the villi. With the narrowing and 
 obliteration of the lumina of the vessels in the villi the trophoderm fails 
 to act as an endothelium for the intendllous blood spaces around the 
 affected villi. Coagulation of the blood in the spaces then occurs and 
 fibrous replacement sets in. As a result patches of fibrous tissue including 
 villi and intervillous blood spaces appear in any full-term placenta. The 
 term generally applied to these fibrous structures is placental infarcts. 
 They are regarded merely as indications of senility in the placenta, and 
 no clinical significance is attached to them unless they become so exten- 
 sive as to interfere mechanically with the function of the organ. 
 
 Small areas of calcification are present in almost all full-term placentee. 
 They stand out very clearly in section after von Kossa's silver nitrate 
 method. Fatty degeneration is present in many placentse, usually in 
 the maternal side of the organ. ^Mucinous degeneration occurs most 
 frequently in the larger ^•illous trunks with endarteritis of the vessels. 
 Fibrinous degeneration is found in the walls of the bloodvessels of the 
 villi outside of the areas of infarction mentioned above. C^^stic degenera- 
 tion is most frequent on the fetal surface of the placenta just beneath 
 the amnion. 
 
 3. Diseases of the Placenta. — Placentitis, or inflammation of the pla- 
 centa, was a term frequently used by the earlier ■^Titers but was applied 
 by them to infarcts and other regressive changes. Acute inflammation, 
 which is very rarely present, is never primary in the fetal portion but is 
 due to an extension from the decidua of a uterus with marked endometritis. 
 
 In syphilis of the placenta three macroscopic features may be noted. 
 (1) There is a marked increase in the volume of the organ, due in large 
 part to hA-pertrophy of the villi. The ratio between the size of the placenta 
 and that of the fetus is frequently reduced to 1:3 and in extreme cases 
 1:1. (2) The color instead of being a beefy red is about that of brain 
 tissue. (3) The organ is firm or hard owing to the great amount of fibrous 
 degeneration. 
 
 Under the microscope sections of a syphilitic placenta show a diffuse 
 productive inflammation of the villi, the stroma, vessels and trophoderm 
 all taking part in the proliferation. Early cases show the origin of the 
 process in the tips of the villi. The connective-tissue elements of the 
 stroma proliferate and, with the thickening of the vessel walls, obliterate 
 the hmiina of the vessels. The villi then appear as solid strands of 
 connective tissue. Very uneven proliferation of the syncytial layer occurs 
 and in some \\\li these growing masses break through into the stroma. 
 
110 
 
 EMBRYOLOGY AND PHYSIOLOGY 
 
 It is claimed by some investigators that Langhans's cells also proliferate 
 in luetic placentae instead of disappearing as in normal cases. The 
 intervillous blood spaces are obliterated or much crowded owing to the 
 increase in size of the villi. The several forms of degeneration seen in 
 normal placenta are much more evident in s^'philitic cases. The Spiro- 
 cheta pallida has been found principally in the villi; it has also been 
 demonstrated in the miibilical cord. 
 
 Tuberculosis of the placenta is rare. It may be found in the presence 
 of a maternal miliary tuberculosis or in a tuberculous uterus. It is 
 assumed that the bacilli lodge in the ectoderm layer of the villi, invade 
 the stroma and there form topical tubercles (Fig. 88). 
 
 
 ^-r^ 
 
 .<r:> 
 
 fe 
 
 
 
 -^ 
 
 
 
 
 Fig. 88. — Tuberculosis of the placenta. The three black areas are tubercles which are 
 stained so intenselj'- that in this low-power photomicrograph no morphological elements 
 are distinguishable. 
 
 Neoplasms of the Placenta. — New groA\i:hs of the placenta are rare. 
 In 36 cases collected from the literature the tumors were all of the con- 
 nective-tissue t^'pe and grouped as follows: fibromyxoma, 14; fibroma, 10; 
 angioma, 9; sarcoma, 2; hyperplasia of chorionic villi, 1. 
 
 The Umbilical Cord. — The umbilical cord is the structure connecting 
 the placenta with the anterior abdominal wall of the fetus. It is of a 
 dull pearh' color and through its epithelial covering can be seen the 
 tortuous vessels. The cord is covered with several layers of epithelial 
 cells (ectoderm) continuous with the epidermis of the fetal abdominal 
 wall. It contains a characteristic mucinous connective tissue, often 
 
THE FETAL VASCULAR SYSTEM 111 
 
 called Wharton's jelly — through which pass the umbilical vein, two 
 umbilical arteries, the remnants of the allantois and of the umbilical 
 vesicle, although the two last-named structures appear usually only in 
 cross-sections near the fetal end. Because of the torsion of the contained 
 vein and arteries — the vessels are longer than the cord itself — the cord 
 has a twisted appearance. A study of the umbilical cords in 10,000 
 consecutive deliveries at the Sloane Hospital gave the following results: 
 The average length of the cord was 59.1 cm., or 23.6 inches, the longest 
 cord being 140 cm., the shortest 16 cm. An eccentric insertion was 
 about four times as frequent as a central, the implantation in the 10,000 
 cases being between the centre and the periphery in 73.5 per cent., central 
 in 19 per cent., marginal in 6.5 per cent, and velamentous in 1 per cent, 
 of the cases. The spirals starting from the child were: to the left in 
 59 per cent.; to the right in 23 per cent; to the left and right in 16 per 
 cent. ; no spirals in 2 per cent. 
 
 Anomalies of the Cord. — In this series of 10,000 cords the following 
 anomalies were observed: Varicosities in 11.5 per cent.; excess of Whar- 
 ton's jelly in 0.98 per cent.; knots of the cord in 0.98 per cent.; cysts of 
 the cord in 0.09 per cent.; tight twists of the cord in 0.05 per cent. 
 
 Cord About the Neck of the Child. — The cord was found about the neck 
 of the child at the time of delivery in 26.51 per cent, of the cases : Around 
 the neck once in 22.63 per cent.; tightly in 9 per cent. Around the neck 
 twice in 3.33 per cent.; tightly in 1.5 per cent. Around the neck thrice 
 in 0.48 per cent.; tightly in 0.24 per cent. Around the neck four times 
 in 0.06 per cent. Around the neck five times in 0.01 per cent. Around 
 body or an extremity in 1.5 per cent. 
 
 THE FETAL VASCULAR SYSTEM. 
 
 A discussion of the complex problem of the origin of bloodvessels is 
 not within the province of this work. Consequently attention will be 
 confined to the course of the main vascular trunks in the embryo with 
 special reference to the relationship between these and the vessels in the 
 fetal membranes. 
 
 The first main arterial trunks within the embryo are the primitive 
 aortse. From each of these arises a vessel, the vitelline artery, which 
 passes out through the splanchnopleure to ramify in the mesodermal 
 layer of the yolk sac. Subsequently the two aortse fuse to form the single 
 dorsal aorta, and the proximal portions of the vitelline arteries likewise 
 coalesce to form a single vessel within the embryo. The aorta is connected 
 with the heart by the aortic arches which pass through the branchial 
 arches (Fig. 89). Corresponding to the vitelline arteries are two vitel- 
 line veins which are formed by convergence of vessels on the yolk sac 
 and which enter the caudal end of the heart. 
 
 There is thus established the vitelline or yolk sac circulation (Fig. 76). 
 The blood is forced out of the heart into the aortic arches, thence into the 
 dorsal aorta and through the vitelline arteries into the vascular network 
 on the volk sac. From this network the blood flows into vessels converg- 
 
112 
 
 EMBRYOLOGY AND PHYSIOLOGY 
 
 ing to form the vitelline veins which in turn open into the heart. Branches 
 from the aorta convey blood to the tissues of the growing body. Small 
 venous channels collect the blood from the tissues and carry it to a pair 
 of longitudinal veins in the body, the cardinal veins, which open into 
 the heart in common with the vitelline veins (Fig. 89). 
 
 In animals such as birds and reptiles, the yolk sacs of which contain 
 large quantities of nutriment, the vitelline circulation is of prime impor- 
 tance in conveying the nutriment to the embryo. In mammals including 
 man, although the yolk sac contains but little yolk, the vitelline circula- 
 tion nevertheless temporarily undergoes extensive development. 
 
 With the establishment of intimate union between the chorion and 
 uterine wall another set of vessels develops, partly in the embryo and 
 
 Dor -sal aorta 
 
 Primitive jugular 
 vein 
 
 Cfwr ionic villi 
 
 Fig. 89. — Human embr>-o of 2.15 millimeters, with yolk sac. (After His.) 
 
 partly in the membranes. The umbilical fallantoic) arteries are given 
 off from the aorta near its caudal end and, passing along the urachus 
 (see page 97), extend through the belly stalk (later the umbilical cord) 
 to the chorion. Here they branch in the mesodermal layer and send 
 smaller radicles into the cores of the chorionic villi (Fig. 77). The 
 blood in the chorionic villi is collected in small veins which converge to 
 form larger channels and follow the course of the arteries back to the 
 embryo. In the mnbilical cord the two umbilical veins fuse to form a 
 single vessel. The vessels seen in the umbilical cord are therefore the 
 two umbilical arteries and single umbilical vein (Fig. 90). 
 
 The development of the intra-embryonic portion of the umlnlical veins 
 is much more complex. At first they are paired structures, one on each 
 side in the ventrolateral part of tlie l)ody wall, and open into the heart 
 
THE FETAL VASCULAR SYSTEM 
 
 113 
 
 in common with the cardinal and vitelhne veins. Later the left umbilical 
 vein establishes a more direct course through the liver, the portion within 
 the liver being known as the ductus venosus (Fig. 90). The bulk of 
 the blood from the placenta then follows this course and the right umbilical 
 
 Vena cava 
 superior 
 
 Ductus 
 venosus 
 
 Hepatic 
 vein 
 
 Ductus 
 arteriosus 
 
 Umbil. — I 
 artery 
 
 Fig. 90. — The fetal circulation. (Kollmann's Atlas.) 
 
 vein atrophies, loses its direct connection with the heart and becomes 
 merely a small vessel opening into the left vein at the umbilicus. 
 
 The umbilical arteries and veins constitute the channels for blood 
 circulating between the embryo and the placenta. This blood conveys 
 
114 
 
 EMBRYOLOGY AND PHYSIOLOGY 
 
 nourishment from the placenta to the embryo and waste products in 
 the reverse direction. In the placenta the exchange of food and waste 
 between fetus and mother takes place. 
 
 Changes in the Circulation at Birth. — During fetal life the course of 
 the blood is adapted to the placental circulation. The pure blood from 
 the placenta passes through the umbilical vein to the liver. Here a part 
 is distributed to the liver itself while a part passes on to the heart via 
 the ductus venosus and inferior vena cava (Fig. 91). In the vena cava 
 this pure blood mingles with impure blood from the cava itself and the 
 portal vein. The mixed blood then flows into the right auricle whence it is 
 directed bv the Eustachian valve throus'h the foramen ovale into the left 
 
 Sup. vena cava 
 Lungs 
 
 Right atrium 
 
 Right ventricle 
 
 Inf. vena cava 
 
 Liver 
 
 Ductus venosus 
 
 Placenta 
 
 Inf. vena cava 
 
 L nibilical vein 
 
 Umbilical 
 artery 
 
 Ant. part of 
 body 
 
 Carotid and 
 subclavian 
 arteries 
 
 Ductus 
 arteriosus 
 
 Pulmonary 
 
 artery 
 Left ventricle 
 
 Hepatic artery 
 
 Portal vein 
 
 Intestinal 
 circulation 
 
 Post, part of 
 body 
 
 Fig. 91. — Diagram illustrating the fetal circulation. The shading represents the relative 
 impurity of the blood in difTcrent regions, the darkest shading representing the most impure 
 blood. (Modified from KoUmann.) 
 
 auricle. From this it passes into the left ventricle and is forced out into the 
 aorta. A part of the blood then flows on through the aorta and a part is 
 carried to the head and neck and upper extremities by the carotid and 
 subclavian arteries. The latter part, becoming impure, is carried to the 
 right auricle by the jugular and subclavian veins and superior vena cava ; 
 it then passes into the right ventricle and is forced out into the pulmo- 
 nary artery. But since the lungs are non-functional, this ])]()()d passes 
 through the ductus arteriosus (Fig. 90) to join the stream in the aorta. 
 
 The blood from the left ventricle going to the more cephalic portion 
 of the embryo is but slightly impure, for the very impure blood from the 
 ductus arteriosus joins the aortic stream distal to the subclavian and 
 carotid arteries. This probably accounts for the fact that the head and 
 
THE FETAL VASCULAR SYSTEM 
 
 115 
 
 upper extremities of the embryo are better developed than the lower 
 extremities. It may be noted, too, that the liver receives the purest 
 blood, which fact is correlated with the enormous size of this organ 
 in the fetus. 
 
 The impure blood of the dorsal aorta is in part distributed to the viscera, 
 body wall and lower extremities and in part carried to the placenta by 
 the umbilical (hypogastric) arteries. The blood distributed in the embryo 
 is carried back to the heart as impure blood which mingles with the pure 
 umbilical current at the liver. The blood taken to the placenta is there 
 purified and returns to the embryo via the umbilical vein. 
 
 Sup. vena cava ' 
 
 Lungs- 
 
 Pulmonary 
 veins 
 
 Right atrium - 
 Right ventricle • 
 Inf. vena cava ' 
 
 Hepatic vein ■ 
 
 Liver •" 
 
 Inf. vena cava 
 
 Post, part of 
 body 
 
 T^-V 
 
 Fig. 92. — Diagram illustrating the circulation in the adult. Compare with Fig. 91. 
 The shading represents the relative impurity of the blood, the white being the purest blood. 
 (Bailey and MUler.) 
 
 With the birth of the child and the detachment of the placenta, the 
 function of five structures, which up to this time have been important, 
 is no longer needed. These structures are: 
 1. The umbilical vein. 
 The ductus venosus. 
 The foramen ovale. 
 The ductus arteriosus. 
 ^. The hypogastric arteries. 
 With the detachment of the placenta and expansion of the lungs all 
 of these structures begin to be obliterated. 
 
 At the end of the first week the umbilical vein, the ductus venosus and 
 
116 EMBRYOLOGY AND PHYSIOLOGY 
 
 all but the proximal portions of the hypogastric arteries have normally 
 become impervious fibrous cords. The proximal portion of the last- 
 named vessels persist as the superior vesical arteries. The obliterated 
 imibilical vein becomes the round ligament of the liver. 
 
 With the assumption by the lungs of the normal function of respira- 
 tion, the communication between the two auricles and that between 
 the pulmonary artery and the aorta should cease. The foramen ovale 
 normally closes soon after birth. If this opening persists, allowing a 
 mixture of the blood of the auricles, a condition of cyanosis of the body 
 is produced called in the infant cyanosis neonatorum, and later morbus 
 cendeus. 
 
 By the end of the third week the ductus arteriosus has normally 
 become an impervious cord called the ligamentum arteriosum. 
 
 EXTERNAL FORM OF THE BODY. 
 
 It has been stated in the foregoing account of early development 
 that the rudiment of the mammalian embryonic body is a disk-shaped 
 structure composed of ectoderm, mesoderm and entoderm (compare 
 Figs. 60 and 61). The principles underlying the development of the 
 typical cylindrical or tubular form are the ventral flexion of the margin 
 of the disk, a concomitant elongation in the direction of the primitive 
 streak (which indicates the caudal end of the body), and of the primitive 
 axis and then a further constriction from the underlying yolk sac. This 
 last process is one of unequal growi;h rather than of actual constriction 
 in that the developing embryonic body grows more rapidly than its 
 attachment to the yolk sac. In a general way the application of the 
 above principles results in a tube within a tube, the outer comprising 
 the ectoderm and the inner the entoderm, with mesoderm between the 
 two. In the meantime the mesoderm splits into two layers — an outer or 
 parietal which is apposed to ectoderm and an inner or visceral which is 
 apposed to entoderm — the cleft between representing the body cavity 
 or celom. Ks the result of the flexion, therefore, the ectoderm and parietal 
 mesoderm (somatopleure) constitute the body wall while the entoderm 
 and visceral mesoderm (splanchnopleure) constitute the wall of the gut. 
 The body cavity is the space between the two walls. 
 
 The contour of the body is affected during development by the appear- 
 ance of certain additional structures. First a groove with ele\ated borders 
 appears on the dorsal side. This is the rudiment of the nervous system 
 —the neural groove (Fig. 75). The cephalic portion of the groove 
 expands more rapidly than the remaining portion, thus indicating the 
 differentiation into brain and spinal cord (Fig. 93). Both brain and 
 spinal cord subsequently become enclosed within the dorsal body wall, 
 the brain, however, leaving a permanent effect upon the contour of the 
 head region. 
 
 The further changes in the contour of the cylindrical liody are effected 
 mainly through the differentiation of the head, neck and body regions, 
 along with certain flexions, and through the development of the extremi- 
 ties. The first obvious change is an increase in size of the head end of the 
 
EXTERNAL FORM OF THE BODY 
 
 117 
 
 embryo, concomitant with the above-mentioned expansion of the neural 
 tube (Fig. 93). The extreme end of the head region is also bent at an 
 approximate right angle to the long axis of the body. This occurs in the 
 midbrain region and is called the cephalic flexure which remains as a 
 permanent feature of the brain. A slight concavity in the dorsum of 
 the embryo, which is but a temporary feature, is the dorsal flexure. 
 The depression on the ventral side of the head region, produced by the 
 cephalic flexure, is the rudiment of the oral and nasal cavities and is 
 known as the oral fossa. A slight protrusion on the ventral side of the 
 body is caused by the rapidly developing heart. 
 
 Midbrain 
 
 Hindbrain 
 
 Forebrain 
 
 Oral fossa 
 
 Amnion 
 
 Yolk sac 
 
 Neural'oanal 
 
 Belly stalk 
 
 Fig. 93. — Human embryo of 2.4 mm. (14 primitive segments). (Kollmann's Atlas.) 
 
 In further development the body becomes more robust (Fig. 76). 
 The dorsal flexure disappears, and the dorsum becomes convex, due to 
 the appearance of a cervical flexure, which indicates the future neck 
 region, and a sacral flexure indicating the rump. The heart protrusion 
 increases temporarily. The oral fossa increases in depth through the 
 development of certain structures along the sides of the neck region. 
 These are apparent on the surface as alternate elevations and depressions 
 extending dorsoventrally, the elevations comprising the branchial at'ches, 
 of which four are formed in the human embryo, and the depressions com- 
 prising the branchial grooves, of which a like number develops. The 
 
lis 
 
 EMBRYOLOGY AXD PHYSIOLOGY 
 
 first arch ditl'erentiates into two parts: a lower or mandibular process 
 which grows ventral to the oral fossa and forms the rudiment of the lower 
 jaw, and an upper or maxillary which grows lateral to the oral fossa and 
 represents the begiiniing of the upper jaw. The angle between the two 
 processes represents the angle of the mouth. The branchial arches and 
 grooves are homologues of the gill bars and slits in the lowest vertebrates, 
 the fishes. 
 
 The flexures mentioned above increase imtil the embryo reaches a 
 length of from 7 to 8 millimeters (an age of about four weeks), 
 resulting in a Ixxly form whose dorsal line is almost a circle (Fig. 94). 
 
 Cervical 
 depression 
 
 Branchial arch I 
 
 Dorsal flexure 
 
 Lower linih 
 bud 
 
 Primitive 
 segments 
 
 Upper limb bud Liver >a :;il Hexure 
 
 Fig. 94. — Human embryo with tweiity-seveu primitive segments (7 mm., twenty-six days). 
 
 (Mall.) 
 
 A new convex dorsal flexure in the thoracic region adds to the general 
 convexity of the dorsum of the body, while a slight concavity — the 
 cervical depression — indicates the back of the neck. The heart continues 
 to bulge on the generally concave ventral side of the body and the rapidly 
 developing liver produces a second protrusion. Two buds, or rather 
 sharply circumscribed elevations, appear on each side of the body. One 
 of these, opposite the new dorsal flexure, is the rudiment of the upper 
 limb; the other, opposite the sacral flexure is the beginning of the lower 
 limb (Fig. 94). The branchial grooves and arches become temporarily 
 more prominent.. 
 
EXTERNAL FORM OF THE BODY 119 
 
 During the fifth week the embrj'o becomes straighter, principally 
 through reduction of the cervical and dorsal flexures (Fig. 95, w)- The 
 sacral flexure is slightly reduced while the strong cephalic persists. The 
 protrusions on the ventral side of the body, caused by the heart and 
 liver, merge into a general rotundity. The fourth and third branchial 
 arches disappear in order, being incorporated in the neck which is gradually 
 appearing as a more slender portion of the embryo. The second and first 
 arches remain as prominent features for a time. The eye appears as a 
 prominent feature at the angle between the base of the first arch and the 
 forebrain region. Each limb bud begins to show a differentiation into 
 a flattened distal portion, the rudiment of the hand (or foot), and a cylin- 
 drical proximal portion, the rudiment of the arm and forearm (or thigh 
 and leg). 
 
 The further changes in the general contour of the body comprise 
 principally the further reduction of .the flexures (except the cephalic), 
 with the result that the embryo as a whole lies in a nearly straight line 
 (Fig. 96). The rudiments of the limbs, at first parallel to the long axis 
 of the body, turn at right angles to the long axis. Subsequently they 
 return to the original position. The conch of the ear develops from 
 external portions of the first and second arches, the external auditory 
 meatus being the dorsal end of the first groove. The rest of the second 
 arch becomes incorporated in the neck, while the first arch is in the main 
 involved in the development of the face. 
 
 As previously stated, the branchial arches and grooves for the most 
 part are incorporated in the neck. The first arch, however, is a most 
 important factor in the development of the face. Of the two processes 
 into which it is differentiated, the mandibular increases rapidly in size 
 and grows ventrally until it meets and fuses with its fellow of the opposite 
 side in the midventral line, thus producing the lower jaw and chin (Figs. 
 97 and 98). The maxillary process meets and fuses with a i^rocess 
 (the nasofrontal) which grows downward from the forebrain region 
 (Figs. 97 and 98). The line of fusion is indicated externally by the 
 naso-optic furrow. The nasofrontal process secondarily gives rise to a 
 middle and a lateral nasal process on each side, and a depression between 
 these two represents the nasal fossa. The maxillary process then fuses 
 with the lateral and also possibly with the middle nasal process on each 
 side and gives rise to the upper lip (Fig. 97). 
 
 Age and Length of Embryos. — The age of the embryo must be dated 
 from the time of fertilization; but owing to the fact that this time is 
 not definitely known in the human being the exact age cannot be deter- 
 mined. It is convenient for practical purposes, however, to have some 
 means of approximating the age. This is usually accomplished by the 
 following rule : According to Hasse, the length of the fetus in centimeters 
 is approximately the square of the age in lunar months up to, and includ- 
 ing, five lunar months. After that the length of the fetus in centimeters 
 may be calculated by multiplying the number of the lunar month by 5. 
 Thus : At 1 lunar month the length is 1 cm. ; at 2 lunar months the length 
 is 4 cm. ; at 3 lunar months the length is 9 cm. ; at 4 lunar months the length 
 is 16 cm.; at 5 lunar months the length is 25 cm.; at 6 lunar months the 
 
120 
 
 EMBRYOLOGY AND PHYSIOLOGY 
 
 Fig. 95. 
 
 -p. the embryos of His's Xormentafel, from the Xormentafel of Keibel and Elze. 
 X 5. His's numbers are given in parentheses. 
 
EXTERNAL FORM OF THE BODY 
 
 121 
 
 Fig. 96. — q-z, the embryos of His's Normentafel. X 2.5. His's numbers are given in 
 parentheses. (From the Normentafel of Keibel and Elze.) 
 
 o (H) embryo of 11.0 mm. 
 
 a { 1) embryo of 2.1 mn 
 
 b ( S) 
 
 2.2 
 
 c ( 3) 
 
 2.15 ' 
 
 d ( 4) 
 
 2.2 
 
 e ( 5) 
 
 2.6 
 
 f ( 6) 
 
 4.2 
 
 ( 7) 
 
 4.0 
 
 h ( 8) 
 
 5.5 
 
 i ( 9) 
 
 7.5 
 
 k (10) 
 
 10.0 
 
 I (11) 
 
 9.1 
 
 m (12) 
 
 9.1 
 
 n (IS) 
 
 10.5 
 
 P (15) 
 
 11.5 ' 
 
 q (16) 
 
 12.5 ' 
 
 r (17) 
 
 13.7 " 
 
 s (18) 
 
 13.8 " 
 
 t (I'J) 
 
 13.6 " 
 
 u (20) 
 
 14.5 " 
 
 V (21) 
 
 15.5 " 
 
 w (22) 
 
 16.0 " 
 
 X (23) 
 
 17.5 " 
 
 y (2h) 
 
 18.5 " 
 
 z (25) 
 
 23.0 ' 
 
122 
 
 EMBRYOLOGY AXD PHYSIOLOGY 
 
 length is 30 cm.; at 7 lunar months the length is 'Ao cm.; at S lunar months 
 the length is 40 cm.; at 9 lunar months the length is 45 cm.; at 10 lunar 
 months (term) the length is 50 cm. 
 
 Midbrain 
 
 Cerebral hemisphere 
 
 Lat. nasal process 
 
 Xasal pit 
 
 Med. nasal process 
 
 Angle of mouth 
 
 Eye 
 
 Naso-optic furrow 
 
 Maxillary process 
 Mandibular process 
 
 Branchial grooves 
 Branchial arch II 
 
 Fig. 97. — Ventral view of head of 11.3 mm. human embryo. (Rabl.) 
 
 Branchial groove I 
 (external ear) 
 
 Maxillary process 
 Med. nasal process 
 
 Fig. 98. — Ventral view of head of human embryo of eight weeks. (His.) 
 
 A description of the development of the various tissues, organs, and 
 systems, which, to be complete, would necessarily be long, is scarcely 
 within the scope of a book of this character. For this the student is 
 therefore referred to the various text-books of embr^'olog^^ 
 
PART II. 
 
 PHYSIOLOGICAL PREGNANCY AND ITS 
 MANAGEMENT. 
 
 CHAPTER HI. 
 CHANGES PRODUCED IX THE :NLATERXAL ORGANISM. 
 
 Although the existence of pregnancy naturally produces the most 
 marked changes in the uterus and the other distinctively generative 
 organs, and these changes will be first considered, there is hardly an organ 
 or tissue in the body which does not respond in greater or less degree to 
 the increased stimulation and increased demand caused by impregnation. 
 
 Changes in the Uterus. — Under the influence of pregnancy the uterus 
 changes from the small, firm organ measuring about 7.5 cm. (3 inches) in 
 length, 5 cm. (2 inches) in breadth at fundus, and 2.5 cm. (1 inch) in 
 thickness, with a capacity of about 1 cubic inch and weighing about 40 
 to 50 gm. (1| ounces), to the large, soft, muscular sac found at term meas- 
 uring about 30 cm. (1 foot) in length, weighing about 1 kilogram (2 
 pounds) and having a capacity of about 400 cubic inches, capable of 
 containing a fetus weighing from 7 to 10 pounds together with a quart 
 or more of liquor amnii. Not only is the uterus increased in size but 
 there are changes in its shape, structure and position. 
 
 Changes in Shape. — During the first month the uterus maintains its flat- 
 tened pyriform shape, but during the next few months the lower portion 
 of the uterine body expands more rapidly than does the upper portion 
 and the uterine body assumes nearly the shape of a sphere resting on 
 the cylindrical cervix. The lower uterine segment becomes more com- 
 pressible and on account of this and the increased weight of the uterine 
 body the normal anteflexion is increased during the early months. Later 
 this' gradually disappears. After the fourth or fifth month the uterus 
 resumes its pyriform shape. Owing to the pressure of the abdominal 
 walls in front and the spinal column behind the transverse diameter 
 of the uterus, after the middle of pregnancy, is, save during the period 
 of contraction, markedly in excess of the anteroposterior diameter. 
 With each uterine contraction the anteroposterior diameter increases 
 (see p. 212). _ . 
 
 Changes in Structure.— The first structural changes visible m the 
 uterus as a result of pregnancv appear in the mucous membrane which 
 
 (123) 
 
124 
 
 CHANGES PRODUCED IN MATERNAL ORGANISM 
 
 becoming more vascular, thicker and softer, results in the formation of 
 the decidua already described (see p. 105). 
 
 The increase in the size of the uterus during the first half of preg- 
 nancy is chieHy due to the h\ pertrophy of its nuiscular fibers, and an 
 increase in all the constituent elements of the muscular wall, the con- 
 nective tissue, blood^'essels, hmphatics and nerves. The muscular 
 fibers become immensely hypertrophied, some of them in the pregnant 
 uterus measuring ten times as long and five times as broad as in the non- 
 pregnant organ. These changes will be seen by compjaring Figs. 99 
 and 100. It is during this period of Inpertroph}' that the arrangement 
 of the muscular fibers in three lavers — the external, middle and internal 
 
 FlG. 99. — Normal, non-pregnant uterine muscle. X 200. 
 
 can be most easily differentiated. The connective tissue is markedly 
 increased at this time and sends in bundles between the muscular fibers. 
 The arteries increase greatly in length, caliber and tortuosity. At the 
 site of placental attachment they empty directly into the dilated uterine 
 veins. The veins of the pregnant uterus dilate, especially near the 
 placental site, into large uterine sinuses whose walls are intimately blended 
 with the connective tissue and surrounded by the muscle bundles of the 
 muscular wall. By the relaxation and contraction of these muscle- 
 fibers the uterine sinuses are opened and closed. 
 
 The lymphatics of the pregnant uterus share in the general hypertrophy 
 of the uterine structures. They become markedly developed just be- 
 neath the mucous membrane and beneath the peritoneum, especially at 
 
CHANGES IN THE UTERUS 
 
 125 
 
 the sides and about the fundus of the uterus. These plexuses of lym- 
 phatics, lining, covering and penetrating the muscular wall of the 
 uterus readily explain the easy passage of infection from the uterine 
 cavity to the general system. 
 
 The nerves of the pregnant uterus increase in size especially in the 
 thickness of the neurilemma. The ganglia about the uterus also undergo 
 hypertrophy, especially the cervical ganglion. The peritoneal covering 
 of the uterus keeps pace in growth with the constantly enlarging uterus. 
 It remains firmly attached to the upper part of the uterus but is easily 
 separated from the low^er uterine segment. 
 
 Fig. 100. — Muscle of uterus at term. X 200. 
 
 Changes in the Cervix. — During the first three months the cervix shares 
 in the general hypertrophy of the uterus, and reaches a length of about 
 5 cm. (2 inches). After this period relatively little change occurs, until 
 the last month of pregnancy when the cervix apparently shortens. As 
 a result of the hyperemia accompanying the development of the cervix, 
 its tissue softens, the cervix as a whole assumes a violet hue, and its 
 mucous follicles secrete a viscid mucus, which fills the cervical canal and 
 is called the mucous plug. 
 
 The softening of the cervix, which begins early in pregnancy about the 
 external os, gradually increases until it involves the whole cervix. 
 
 The cavity of the cervix dilates as pregnancy advances and during 
 the last month even in primigravidse admits the finger tip. This dila- 
 tation in primigravidse begins first at the internal os and extends down- 
 
126 CHAXGES PRODUCED IX MATERXAL ORGAXISM 
 
 ward giving the canal a funnel-shape with apex at the external os. In 
 miiltigravidse this dilatation begins earlier and is more pronounced than 
 in primigravidff. ^Moreover, in multigravidse the dilatation usually begins 
 at the external os first. 
 
 During the latter half of pregnancy on account of the softening of the 
 cervix and the softening and thickening of the vaginal walls about it, 
 the cervix gives an apparent feel of being shortened. During the last 
 two weeks there occurs an actual shortening of the cer^•ix as a result 
 of the contraction of the longitudinal muscle fibers of the uterus and 
 an appropriation of the upper part of the cervix by the lower uterine 
 segment. 
 
 Position of the Uterus. — During the first two months of pregnancy the 
 uterus from its increased weight sinks a little in the pelvis. During the 
 first three months the enlargement of the organ is chiefly in the antero- 
 posterior and lateral diameters and the fundus does not usually rise 
 above the pelvic brim. In the fourth month the fundus rises above the 
 s\'mphysis pubis. At five months the fundus lies midway between the 
 symphysis and the umbilicus; at six months at the level of the um- 
 bilicus; at seven months at one-third the distance between the umbilicus 
 and ensiform cartilage; at eight months at two-thirds the distance; and 
 at eight and one-half months approximately at the ensiform cartilage. 
 In speaking of months, calendar months are intended. During the last 
 two weeks of pregnancy the uterus with its contained fetus settles in 
 the pelvis, sometimes called "lightening," allowing more normal use 
 of the thoracic organs and bringing the fundus uteri to about the level 
 occupied at the end of eight months. On account of the presence of 
 the sigmoid flexure and rectum on the left side, the centre of the preg- 
 nant uterus usually lies a little to the right of the median line of the 
 abdomen and there is usually a slight rotation of the uterus on its longi- 
 tudinal axis so that its anterior surface looks a little to the right. The 
 abo\e given positions of the uterus are only approximate and, of course, 
 depend largely on the position of the woman and the laxit\' of the abdom- 
 inal walls. They apply chiefly with the woman in the dorsal position. 
 
 With the growth of the jjregnant uterus the round ligaments become 
 hypertrophied and can often be felt through the abdominal wall as 
 rounded cords extending from the inguinal canals to the uterus. As 
 the uterus rises in the abdomen the uterine ends of the Fallopian tubes 
 become elevated, so that the course of the tubes from uterus to o\aries 
 is more nearly vertical. The F'allopian tubes in a lesser degree present 
 the congestion and hy|>ertr()ph>' seen in the uterus. 
 
 Along with this upward gro^^■th of the uterus the ovaries gradually 
 rise out of the pehis. 
 
 Menstruation. — The function of menstruation is usually absent during 
 pregnancy. Exceptionally, occasional menstruation occurs during the 
 first three months. 
 
 Changes in the Vagina. — Owing to the increased vascularity of the 
 vagina there occurs a thickening and softening of the mucous membrane, 
 an increase in its secretion, a deepening of its color (the vagina in the 
 
CHANGES IN THE MAMMARY GLANDS 
 
 127 
 
 later months assuming a violet hue), and a general growth of the vaginal 
 walls. The external genitals share to a lesser degree the increase in 
 vascularity, secretion and color noted in the vagina. With the advance 
 of the pregnane}' there occurs a gradual downward displacement of the 
 pelvic floor. 
 
 Changes in the Mammary Glands.— Next to the pelvic organs the 
 mammary glands present the most marked evidences of growth and 
 development incident to pregnancy. As early as the latter part of the 
 second month they begin to enlarge and to feel fuller and firmer to the 
 patient. 
 
 Beginning near the periphery and extending toward the nipple can be 
 felt the knotted cords produced by the developing lobules and ducts. 
 
 Fig. 101. — Primary areola in a blonde. 
 
 The breasts themselves stand out more prominently from the chest and 
 over them course veins whose bluish markings become more distinct as 
 pregnancy advances. 
 
 The pigmented base upon which the nipple rests becomes gradually 
 darker from increase in pigment and is called the xjrimary areola. The 
 color varies with the complexion of the individual (see Figs. 101-104). 
 In the light blonde there is but little pigment, but even in her the areola 
 assumes a more congested appearance. In the brunette the areola 
 becomes dark brown, or in some cases even almost black. Scattered 
 over the primary areola, which is often elevated above the level of the 
 surrounding breast and varying from 1 to 20 in number, are little papil- 
 lary projections, often about the size of buckshot, called the "tubercles 
 
128 CHANGES PRODUCED IX MATERNAL ORGANISM 
 
 Fig. 102. — Primary areola in a brunette, showing tubercles of Montgomery and engorged 
 
 veins. 
 
 Fig. 10-3. — Primary and secondary areola in a ncgress. 
 
CHANGES IN THE MAMMARY GLANDS 
 
 129 
 
 of Montgomery." They are really sebaceous glands whose function 
 seems to be the lubrication of the nipple and areola. Under the influence 
 
 Fig. 104. — Primary areola in a brunette, showing tubercles of Montgomery. 
 
 of pregnancy the circular muscle underlying the areola becomes more 
 sensitive, and through the stimulation of friction, cold or sometimes 
 
 Fig. 105. — Primary areola, showing wrinkling from contraction of the circular muscle due 
 
 to stimulation of nipple. 
 
 even emotion, it readily contracts, throwing the areola into wrinkles, 
 converging toward the nipple (see Fig. 105), and making the latter more 
 9 
 
130 CHAXGES PRODUCED IX MATERXAL ORGAXISM 
 
 Fig. 106. — Primarj- and secondarj' areolae. 
 
 Fig. 107. — Showing primary and secondarj- areolae and stria of the breasts. 
 
GENERAL CHANGES DURING PREGNANCY 131 
 
 prominent. This is sometimes spoken of as "erection of the nipple," 
 although the nipple is not composed of erectile tissue. 
 
 By about the end of the third month of pregnancy there can often be 
 expressed from the nipple a few drops of fluid either clear or cloudy 
 called colostrum, the earliest representative of the milk. During the 
 later months the escape of some of this fluid from the nipple often forms 
 crusts upon it unless care is taken to keep the nipple clean. 
 
 Secondary Areola. — From about the middle of pregnancy there appears 
 immediately outside the primary areola a zone characterized by num- 
 erous whitish spots upon a darker pigmented background, each light spot 
 representing the opening of a sebaceous follicle (see Fig. 106). This 
 spotted zone is called the "secondary areola" and is usually more marked 
 in the brunette than in the blonde. 
 
 During the later months, as a result of the tension of the skin covering 
 the enlarging breasts, brownish or purplish strise often appear (see Fig. 107), 
 similar to those which will be described later as occurring on the abdomen 
 and like them they tend to remain as permanent silvery markings. 
 
 GENERAL CHANGES DURING PREGNANCY. 
 
 Digestion and Nutrition. — When it is considered that during pregnancy 
 the woman eats, breathes, secretes and excretes for two, it is easily 
 understood that the thoracic and abdominal viscera are taxed to an 
 extent far beyond the normal. While some women go through pregnancy 
 with no disturbances of digestion and never feel as well as in that condi- 
 tion, this is the exception, and disturbances of digestion with nausea and 
 vomiting are so common in the early months that they are recognized 
 as the usual accompaniments of the pregnant state. The nausea and 
 vomiting are most common during the second and third months, and 
 usually disappear gradually during the fourth month. In some women 
 the nausea begins almost immediately after impregnation. At the present 
 day, if the nausea and vomiting persist for any great length of time, the 
 condition ceases to be regarded as physiological, and is looked upon as 
 toxemia, as will be discussed later. 
 
 The nausea and gagging with or without vomiting is most apt to occur 
 on rising in the morning, perhaps on brushing the teeth, and throughout 
 the day it is rather more likely to occur when the stomach is empty, the 
 effort at vomiting simply resulting in the expulsion of glairy mucus. 
 
 It is a common experience with pregnant women during the early 
 months to reject their breakfast soon after taking it, yet be able to retain 
 and digest the other meals of the day. Although it is common during 
 the first three months for pregnant women to lose in nutrition and weight, 
 after three months the rule is a gain in appetite and general nutrition 
 and an increase of adipose tissue, especially during the later weeks, 
 amounting at the close of pregnancy, often to a gain of 10 to 15 pounds 
 irrespective of the weight of the enlarged uterus and its contents. 
 
 According t-o Williams this gain in weight is chiefly due to a diminished 
 excretion of water. Slemmons at the Johns Hopkins Hospital found this 
 excretion during pregnancy to be only 50 to 75 per cent, of the water 
 
132 
 
 CHANGES PRODUCED IN MATERNAL ORGANISM 
 
 ingested. In a case with a dead fetus it Avas as high as 93 per cent.^ 
 about the normal for non-pregnant women. 
 
 The appetite of a woman during pregnancy, especially' during the early 
 months, is very apt to be capricious; her likes and dislikes being often 
 directly at variance with her normal tastes. The increased nutrition oc- 
 curring during pregnancy seems to be a wise provision of nature for the 
 drain to which the woman is to be subjected during lactation. There 
 seems to be a storage of nitrogen in the bod>' during pregnancy. This 
 is shown by a diminished amount of nitrogen in the urine. This nitrogen 
 may be used as proteid material in the develo])ment of the fetus and 
 placenta and in the increased growth of the maternal organs. 
 
 Not only is there less nitrogen excreted in the urine during pregnancy 
 but it is excreted in different ratio; as is shown on page 418, the average 
 urea nitrogen being decreased while the ammonia nitrogen is usually 
 increased. As the pregnant woman has to excrete alike for herself and 
 her fetus, all her excretory organs are taxed beyond the normal and the 
 importance of their ready action is apparent. 
 
 The Blood and Circulation. — While the blood of a healthy pregnant 
 woman does not differ markedly from that of the non-pregnant state, 
 certain variations exist which are worthy of note. There is a moderate 
 hydremia, especially in the latter months, as shown by its lowered specific 
 gravity; there is an increase in its fibrin factors and a decrease in its 
 albuminous content. The amount of hemoglobin and the number of 
 red corpuscles remain practically normal. There is a moderate leuko- 
 cytosis in pregnancy which reaches its maximum during labor and then 
 gradually declines to normal on about the tenth day as is shown by the 
 following table which represents examinations of the blood of 100 women 
 at the Sloane Hospital taken before labor, during labor, on the third and 
 the tenth day of the puerperium. 
 
 LEUKOCYTE COUNT IX ONE HUNDRED PREGNANT AND PUERPERAL 
 
 WOMEN. 
 
 Polymorpho- 
 Duclear. 
 Per cent. 
 
 Large mono- 
 nuclear 
 
 Lympho- 
 cytes. 
 
 Eosino- 
 philes. 
 
 Transi- 
 tional. 
 
 Total. 
 
 During pregnancy. 
 During labor 
 Third day of puerperium 
 Tenth day of puerperium 
 
 71 
 
 72 
 65 
 
 3.2 
 2.5 
 .3.0 
 3.5 
 
 21 
 17 
 21 
 27 
 
 0.8 
 0.7 
 1.4 
 1.5 
 
 4.0 
 2.8 
 3.0 
 3.0 
 
 10,600 
 12,800 
 11,700 
 10,.300 
 
 To determine whether the leukocyte count was affected by lactation, 
 the blood of 15 women, who for different reasons, as for instance the loss 
 of the baby or previous inability to nurse, did not attempt lactation, was 
 examined on the third and tenth day of the puerperium with the following 
 results: 
 
 Third day, 15 cases 
 Tenth day, 15 cases 
 
 Polymorpho- 
 nuclear. 
 Per cent. 
 
 Large mono- 
 nuclear. 
 
 7.3 
 64 
 
 Lympho- 
 cytes. 
 
 19 
 27 
 
 Eosino- 
 philes. 
 
 Transi- 
 tional. 
 
 Total 
 
 12,000 
 9,700 
 
GENERAL CHANGES DURING PREGNANCY 133 
 
 It is seen from the above that the polymorphonuclear cells are relatively 
 increased during the latter part of pregnancy, reaching their maximum 
 during labor and gradually falling to normal by the tenth day. 
 
 The large mononuclear, lymphocytes, eosinophile and transitional cells 
 are not materially affected except as they are diluted either more or less 
 by the number of polymorphonuclear cells, their percentage diminishing 
 as the polymorphonuclear cells increase, and increasing again as these 
 return to normal. 
 
 The leukocyte count in the women who did not nurse was practically 
 the same as in those in active lactation. 
 
 Disturbances of the circulation with headache, palpitation of the heart, 
 and dyspnea are not uncommon, and during the early months are often 
 neurotic in origin, although aggravated by an anemic condition of the 
 blood. During the latter months the circulation is often disturbed by 
 upward pressure of the growing uterus upon the diaphragm and heart. 
 
 Owing to the hydremia and impeded circulation during pregnancy, a 
 moderate amount of edema is not uncommon. If it is only moderate, 
 however, and the urine is normal it need not occasion alarm. An extreme 
 anemia always needs attention. 
 
 Blood-pressure in Pregnancy. — The blood-pressure of the normal preg- 
 nant woman differs but little from that in the non-pregnant woman. In 
 normal pregnancy it usually ranges between 110 and 120. In a consecu- 
 tive series of 564 normal pregnant women at the Sloane Hospital the 
 average was 113. In many cases it is found as low as 90 and occasionally, 
 especially in elderly pregnant patients, it is found as high as 135 to 
 140. The importance of the observation of the blood-pressure of preg- 
 nant patients will be emphasized under the management of normal 
 pregnancy, and in the discussion of "Toxemia of Pregnancy" attention 
 will be called to the fact that a blood-pressure above 140 should always 
 be looked upon with suspicion. 
 
 Respiration. — The dyspnea which sometimes occurs during the early 
 months has already been spoken of as being often of neurotic origin. 
 During the later months of pregnancy, on account of the shortened longi- 
 tudinal diameter of the thorax by upward pressure upon the diaphragm, 
 respiration is often mechanically embarrassed. The transverse diameter 
 of the lower part of the thorax is somewhat increased, but this additional 
 room for lung expansion does not equal the increased demand in furnish- 
 ing oxygen and getting rid of carbon dioxide (CO2) for both mother and 
 child. During the last two weeks of pregnancy, on account of the settling 
 into the pelvis of the uterus and its contents, respiration becomes easier. 
 This is sometimes spoken of as "lightening." 
 
 The Nervous System. — ^From the beginning to the end of pregnancy, 
 though especially in the early months, the nervous system of the preg- 
 nant woman is apt to show marked changes. Her disposition may be 
 completely altered and her power of nerve control almost lost. Her 
 nervous system seems to be at high tension, and under excitation, which 
 in the non-pregnant state would scarcely disturb, she may become 
 emotional, irritable or even unreasonable. Certain it is that husbands 
 
134 CHANGES PRODUCED IN MATERNAL ORGANISM 
 
 jiiul friends should make allowances for the dispositions of women (hiring;' 
 pregnancy and causes of irritation should be as far as possil^le exchided 
 during this time. 
 
 Neuralgia in dift'erent parts of the body, especially about the face, in 
 the back, and down the thighs is quite common in pregnancy, as a result 
 of the hydremia, the pressure, and the neuroses incident to tlie condition. 
 
 The Liver and Spleen. — The liver and spleen are usually increased 
 in size and fatty degeneration may occur in both viscera. 
 
 The Kidneys. — The kidneys, like the liver and spleen, are usually 
 enlarged during pregnancy and their functional activity greatly increasecl. 
 The urine is normally increased somewhat in amount with a specific 
 gravity of about 1013.^ This increased amount of urine is probably in 
 part due to the large amount of water patients are advised to drink. 
 
 The chlorides, phosphates and sulphates are usually diminished, as is 
 also the nitrogen output. In the later weeks of pregnancy, and espe- 
 cially during lactation, lactose not infrequently appears; occasionally 
 glucose occurs which may be due to faulty metabolism or to diabetes 
 and will be considered later. In quite a large percentage of pregnant 
 women a transient, slight albuminuria appears without other symptoms. 
 According to Sondern^ this frequency is as high as 50 per cent. 
 
 The Heart. — Until recently there was a belief that the heart is enlarged 
 during pregnancy. Attempts to ascertain this have followed general 
 lines, namely: (1) By percussion or auscultation of the living woman; 
 (2) by measuring the walls of the heart at autopsy; (3) by weighing the 
 heart at autopsy; and (4) by inference from studying the blood-pressure 
 in pregnancy. 
 
 1. In 1827, Larcher,^ finding an increased area of cardiac dulness, 
 concluded the heart was enlarged. Gerhardt"* showed this increased area 
 of dulness was due to the upward displacement of the heart by the grow- 
 ing uterus, and not to hypertrophy. This increased area of dulness 
 disappears after delivery.'^ In cases when there is marked separation of 
 the recti muscles of the abdomen, allowing the uterus to sag forward, 
 and lessening the tendency to upward pressure on the heart, this in- 
 creased area is less marked.*^ 
 
 2. Larcher'^ and Ducrest^ found the average thickness of the left 
 ventricular wall in pregnancy greater than 10 mm. supposed to be the 
 average for normal hearts of the non-pregnant women,^ and claimed 
 hypertrophy. BuhP'^ found the conclusions wrong, as the average was 
 16 and 17 mm. and not 10 mm. He claimed no hypertrophy. 
 
 ' Urine in Normal Pregnancy (Mathews), Amer. Jour. Med. Sciences, June, 1906. 
 
 2 The Urine in Pregnancy, Bulletin of the Lying-in Hospital, New YoVk, December, 190G. 
 
 ' Quoted from Stengel and Stanton, Archiv. generales de med., 1859, i, 291; also from 
 Williams, from Ribemont-Dessaignes and Lepage, Precis d'obstetrique, Paris, 1894. 
 
 ^ De situ et magnitudine cordis gravidarum, Jena, 1862. 
 
 ^ Stengel and Stanton, The Heart and Circulation in Pregnancy and the Puerperium, 
 Univ. of Penna. Med. Bull., September, 1904, p. 202. 
 
 •■ Larcher, loc. cit. ' Loc cit. 
 
 •* Quoted from Stengel and Stanton, Archiv. generales de med., S. 7, F. .5. 
 
 s Bizot, Quoted from Stengel and Stanton. 
 
 '" Quoted from Stengel and Stanton, Delaficld and Pruddcn, Handbook of Path. Anatomy, 
 1901. 
 
GENERAL CHANGES DURING PREGNANCY 135 
 
 3. Miiller^ and Lohlein^ found no increase in weight; Dreysel/ a slight 
 increase. Stengel and Stanton, of the University of Pennsylvania/ taking 
 the findings of 15 different authors, established the average weight of 
 the normal heart of the non-pregnant woman as 263 gms. After weigh- 
 ing a series of hearts from pregnant women they found no increase. 
 
 4. Many have held that there was an increased blood-pressure during 
 pregnancy, and therefore the heart, having more work to do, must become 
 larger. Stengel and Stanton^ by a series of experiments showed there 
 was no increase of blood-pressure at any time during pregnancy, and in 
 labor only during the second stage. 
 
 Williams^ thinks there is a slight increase of blood-pressure during 
 pregnancy, and therefore a hypertrophy. 
 
 It is difficult to arrive at a conclusion. None of the methods are con- 
 clusive. Physical examination, if it does not show a hypertrophy, at 
 least does not preclude it, as a moderate hypertrophy would be hard to 
 detect, especially with the enlarged breasts. 
 
 Measuring and weighing the hearts are not certain methods, for many 
 of the hearts available are diseased, and therefore enlarged from causes 
 other than pregnancy. Moreover, the weight of the heart depends on 
 the amount of surrounding tissue removed. 
 
 Arguments based on the blood-pressure are only inferential and not 
 conclusive. 
 
 Hence the question is still undecided, but the burden of proof points 
 to no great enlargement of the heart during pregnancy. 
 
 The Thyroid Gland in Pregnancy. — The ancient tradition that a 
 woman's neck enlarges at onset of the first menses, at each succeeding 
 reappearance of them and during pregnancy has found support in recent 
 investigations which explain this enlargement by the increase in the 
 size of the thyroid gland on these occasions. The occurrence of such 
 increase during pregnancy is, however, variously stated by different 
 observers. Thus Freund observed augmentation in the volume of the 
 gland in 45 out of 50 women examined by him. Lange confirmed this 
 observation and showed that a clinically demonstrable enlargement of 
 the gland does not exist in the first three months of pregnancy; it appears 
 among the multigravidse as early as the fifth month, while among primi- 
 gravidse it is usually not evident until the sixth month. Markoe and 
 Wing have quite recently observed 1586 pregnant women and have found 
 among them 132 goitres or 8.3 per cent. It occurred in 83 out of 852 
 primigravidse (9.7 per cent), and in 49 of 734 multigravidse (6.7 per cent.). 
 In some of these cases goitres have existed since childhood, in others 
 they appeared at onset of menstruation, in still others between this 
 period and marriage. In 20 cases among the primigravidse and in 17 
 
 1 Quoted from Hirst, Muller's Handbook, vol. i; also from Stengel and Stanton, Die 
 Massenverhaltnisse des Mensch. Herzens, 1883. 
 
 2 Ueber das verhalten des Herzens bei Schwangeren, Zeitschr. f. Geb. u. Frauenkrank- 
 heiten, 1876, i, 482-516. 
 
 3 Quoted from Stengel and Stanton, Inaug. Dissert., Miinchen, 1891. 
 
 < Stengel and Stanton, loc. cit. ^ Loc. cit, 
 
 « Obstetrics, 1912 ed., p. 177. 
 
136 CHANGES PRODUCED IN MATERNAL ORGANISM 
 
 inultigravidie it positi^'eIy appeared during j)regnancy. (Jreat variations 
 were noted both in the month of pregnaney and, among the mnltigravidae, 
 in the number of the pregnancy, in which the thyroid was found enhirged. 
 
 Several case reports of preexisting goitre enlarging during pregnancy 
 have been published. Some of the authors state that the enlargement 
 involved the non-cystic portions of the gland. Cases have been reported 
 in which the enlargement of a preexisting goitre and even of a previously 
 normal thyroid has been sufficiently^' marked to cause obstruction in 
 breathing and occasionally necessitate operation. 
 
 The enlarged thyroid usually decreases rapidly after labor, complete 
 subsidence being noted in the great majority of cases within two weeks. 
 Occasionally a more or less marked enlargement of the gland remains 
 permanently. 
 
 It is fairly certain that the increase in size of the thyroid is accom- 
 panied by increased function. The few microscopic examinations that 
 have been published show that in addition to hyperemia there appear 
 such evidences of hyperfunction as increase in the colloid substance 
 and in the intracellular granules. Lange has noted that absence of the 
 enlargement of the thjToid is frequently accompanied by such untoward 
 symptoms as albuminuria, etc. Freund has thought that the adminis- 
 tration of thyroid substance during pregnancy had a beneficial effect. 
 Lange has shown, experimentally, by removing large portions of the 
 thyroid in cats, that insufficiency of the thyroid leads to pathological 
 states in pregnancy. These and similar observations have led to the 
 establishment of a theory according to which a certain proportion of 
 the toxemias of pregnancy are due to alteration in the function of this 
 gland, that is to dysthyroidism, whether this alteration be marked by 
 excessive or insufficient activity. This aspect of the question will be 
 considered in the discussion of the Toxemias of Pregnancy. 
 
 In conclusion it may be stated that the thyroid gland is usually 
 increased in size during pregnancy, and in women whose thyroids are 
 already enlarged pregnancy often greatly stimulates the growth. Lange, 
 in 1899, found an increase in the size of this gland in 108 out of 133 
 women observed during the last three months of pregnancy. 
 
 The Bladder and Rectum. — Throughout pregnancy the functions of 
 the bladder and rectum are more or less interfered with by the pressure 
 of the growing uterus. Disturbance of the bladder is usually most marked 
 during the first two months and during the last two weeks, during both 
 of which periods the uterus with its contained fetus settles in the pelvis. 
 
 Throughout pregnancy the space allowed for distention of the bladder 
 is limited so that frequent micturition and irritability of the bladder 
 are common. As a result of the constantly increasing pressure upon the 
 rectum more or less constipation is to be expected during pregnancy, 
 especially in women with a constipated tendency. On account of the 
 obstruction to venous return, hemorrhoids are not infrequent. 
 
 The Skin. — Under the influence of pregnancy two marked changes 
 take place in the skin: (a) An increased deposit of pigment; (b) the 
 changes resulting from stretching. 
 
GENERAL CHANGES DURING PREGNANCY 
 
 137 
 
 (a) Pigmentation. — One of the characteristic changes occurring at 
 about the middle of pregnancy is the increased deposit of pigment in 
 different parts of the bod\'. This deposit is most marked upon the breasts 
 (giving the primary and secondary areolae already described), the abdo- 
 men, and the face. Brunettes show this increased deposit much more 
 than blondes. 
 
 On the abdomen the deposit of pigment occurs along the median line 
 from umbilicus to s^Tnphysis pubis (see Fig. 108), sometimes reaching 
 from umbilicus to ensiform cartilage. 
 
 On the face it is most apt to occur on the forehead and cheeks, sometimes 
 appearing in large blotches called chloasmata which are very disfigur- 
 ing (see Fig. 109). Most of the increased pigmentation disappears after 
 parturition but some usually remains, especially upon the breasts and 
 abdomen. 
 
 Fig. 108. — Pigmentation along median line of abdomen; also abdominal striae. 
 
 (b) Strise. — ^As a result of overstretchmg of the skin during pregnancy, 
 especially during the last three months, strise appear upon the breasts 
 (already* described), upon the abdomen, especially at the sides and lower 
 part, aiid down the thighs (see Fig. 110). These strise are due to a 
 separation of the deeper elastic fibers of the cutis and the formation of 
 cicatricial tissue. At first they are brownish or piu-plish in color but 
 after parturition the color fades, although markings remain as permanent 
 silvery strise. The presence of these old strise do not necessarily prove 
 the preexistence of a pregnancy, as they can occur from distention of 
 the skin bv ascites and may occur in men as well as in women. 
 
138 CHAXGES PRODUCED IX MATERXAL ORG AX ISM 
 
 Fig. 109. — Pigmentation of the face due to pregnancy. 
 
 Fig. 110. — Striae of breasts, abdomen, and thighs. This photograph was taken soon 
 
 after delivery. 
 
GENERAL CHANGES DURING PREGNANCY 139 
 
 The sebaceous and sweat glands of the skin are stimulated to increased 
 activity by pregnancy. 
 
 Up to the sixth month of pregnancy the umbihcus gradually lessens in 
 depth. At six months it is usually level with the surrounding skin and 
 after that gradually protrudes. 
 
 Posture. — During the latter months of pregnancy, owing to the 
 increased abdominal weight, the head and shoulders of the pregnant 
 woman are thrown backward, in standing and walking, so as to main- 
 tain her equilibrium. 
 
 Bones and Teeth. — There is a slight increase in the mobility at the 
 pelvic articulations during pregnancy. This, as a rule, is insufficient to 
 affect locomotion. 
 
 In certain rare cases, however, the mobility at the symphysis is so 
 great as to make walking difficult. 
 
 On the inner surface of the cranial bones of pregnant women there 
 have been observed small, irregular outgrowths of new bone. These were 
 first foimd by Rokitansky and called by him "puerperal osteoph^^tes." 
 Their significance is not known. 
 
 The teeth during pregnancy are apt to decay more rapidly than in the 
 non-pregnant state, and this gave rise to the old saying, "For every child 
 a tooth." ^ 
 
CHAPTER IV. 
 
 THE SYIMPTOMS AND SIGNS OF PREGNANCY. THEIR 
 RELATIVE VALUE IN DIAGNOSIS. 
 
 For convenience of description the symptoms of pregnancy will be 
 grouped into: (a) Those occurring during the first three months, and 
 (b) Those occurring during the last six months. 
 
 SYMPTOMS AND SIGNS DURING THE FIRST THREE MONTHS. 
 
 One of the first symptoms of pregnancy, and the one for which every 
 married woman is always more or less upon the watch, is cessation of 
 menstruation. While exceptionally a menstrual flow occurs after impreg- 
 nation has taken place, the rule is ivith the occurrence of pregnancy men- 
 struation ceases. The usual experience is that impregnation occurs 
 soon after a regular menstruation; that before the time for the next 
 menstruation the impregnated ovum has reached and has become 
 imbedded in the endometrium, and no menstruation appears. One of 
 the explanations of menstruation appearing after impregnation has 
 occurred is as follows : 
 
 Instead of impregnation occurring just after a regular menstruation, 
 it may not occur until just prior to the succeeding menstrual period. 
 In this case menstruation may not be checked, although it is usually 
 lessened in amount and changed in character. Although in accordance 
 with the established habit of a periodical loss of blood there may appear 
 for a few months a bloody discharge, certain it is that after the third 
 month when the decidua capsularis (reflexa) covering the ovum is 
 brought in apposition with the decidua parietalis (vera) of the opposite 
 side of the uterine cavity, no true menstruation can occur. The bloody 
 discharges reported by women as occurring during pregnancy usually 
 mean either an endometritis; a polypus of the cervix; a low attachment 
 of the chorionic villi or of the placenta. "We have then the well-estab- 
 lished rule that when a healthy married woman, living with her husband, 
 during active menstrual life, ceases to menstruate she is probably pregnant. 
 This is one of the most valuable symptoms in arriving at the diagnosis 
 of pregnancy in the early months. 
 
 Certain exceptions occur, however, which must be considered and 
 appreciated. The occurrence of an occasional bloody vaginal discharge 
 after the beginning of pregnancy has already been mentioned. On the 
 contrary, there are numerous causes of amenorrhea aside from preg- 
 nancy. Among these causes anemia and phthisis act most frequently. 
 Other common causes of amenorrhea or delayed menstruation are changes 
 
 (I40p 
 
SYMPTOMS AND SIGNS DURING FIRST THREE MONTHS 141 
 
 of climate, obesity, sudden chilling near the time of the menstrual period, 
 and violent mental emotion. The fear of pregnancy after illicit inter- 
 course; the expectation or dread of pregnancy in the newly married; 
 these at times seem to have the effect of postponing the menstrual period. 
 Some women are so irregular in their menstrual habit that absence of 
 menstruation even for several months is a matter of no importance. 
 Furthermore, the occasional occurrence of pregnancy before menstrua- 
 tion has ever occurred, and also after the establishment of the menopause, 
 and the occurrence of pregnancy during the physiological amenorrhea 
 of lactation — all these exceptional occurrences prove that the symptom 
 of cessation of menstruation in the diagnosis of pregnancy has many 
 limitations to its value. 
 
 Nausea and Vomiting. — The occurrence of nausea and vomiting 
 during the early months of pregnancy has already been referred to, and 
 when associated with the x^essation of menstruation is a presumptive 
 symptom of considerable value. It occurs most usually in the morning 
 on rising or after breakfast and during the second and third months of 
 pregnancy. Exceptionally it begins within a few days after impregna- 
 tion and continues throughout the whole of pregnancy. 
 
 Although in conjunction with other symptoms, it is of considerable 
 value in the diagnosis of pregnancy, when taken by itself its value is 
 slight. As it arises as a reflex symptom from stretching of the uterine 
 muscle and nerves and from pressure, it may arise from various patho- 
 logical conditions in the pelvis. Its gastric causes, as in the non-pregnant 
 state, are also frequent. 
 
 Salivation. — With the nausea of pregnancy there is often an increase 
 in the salivary secretion which at times becomes excessive and very 
 annoying. 
 
 Breast Symptoms. — Although the changes in the breasts resulting 
 from pregnancy are more or less permanent and in a multigravida are 
 of much less value in diagnosis than in a primigravida, in every preg- 
 nancy they are characteristic. 
 
 As early as the second month the breasts usually feel fuller and firmer 
 to the patient and on palpation the knotted cords formed by the develop- 
 ing ducts can usually be detected. The increased pigmentation and 
 elevation of the primary areola and the development of Montgomery's 
 tubercles appear at this time. During the third month a little colostrum 
 can usually be expressed from the nipple. 
 
 These breast symptoms when present in a primigravida are a very 
 strong presumptive evidence of pregnancy. It must be remembered, 
 however, that in a multigravida they may have persisted from a pre- 
 vious recent pregnancy, and furthermore various uterine and ovarian 
 disorders may produce similar symptoms, including even the possibility 
 of expressing colostrum from the nipple. 
 
 The Violet Hue of Vagina and Cervix. — During the third month, and 
 sometimes earlier as a result of venous congestion, the vagina and vaginal 
 portion of the cervix present a violet hue which is quite characteristic 
 of pregnancy. Remembering, however, that this deepening of color is due 
 
142 
 
 THE SYMPTOMS AND SIGNS OF PREGNANCY 
 
 to venous congestion it is readily seen that anything obstructing venous 
 return such as pelvic inflammation, tumors, etc., may produce simihir signs. 
 
 Fig. 111. — Asymmetrical pregnant uterus. 
 
 Fig. 112. — Hegar's sign of pregnancy. 
 
 Softening of the Cervix and Uterine Body. — During the second month 
 the cervix is found on ])alpation to have begun around the external os 
 
SYMPTOMS AXD SIGNS DURING LAST SIX MONTHS 143 
 
 a softening which is gradually to involve the whole cervix. Nor is this 
 softening confined to the cervix. It has already been stated (see page 123) 
 that beginning with the second month the uterine body becomes 
 more spherical. There is a bulging and softening of the uterine body 
 which may be symmetrical and the projection easily felt per vaginam, 
 a little above the cervix, usually more distinct on the anterior wall on 
 account of the anteflexion. On the other hand the bulging and softening 
 may be asymmetrical and correspond to the location of the developing 
 ovum. In the latter case the furrow separating the bulging softened 
 portion from the remainder of the uterus (see Fig. Ill) may suggest the 
 possibility of the gestation being ectopic. 
 
 Between the bulging uterine body and the cervix the lower uterine 
 segment becomes so soft and compressible that the bimanual examina- 
 tion gives the impression that the fingers on the anterior and posterior 
 wall of the uterus can be brought nearly in apposition (see Fig. 112). 
 This is called Hegar's sign of pregnancy, and when clearly obtained is 
 of considerable value in diagnosis. It must be remembered, however, 
 that the softening of the uterus resulting from inflammation may give 
 signs somewhat resembling the Hegar's sign of pregnancy. 
 
 The symptoms and signs of pregnancy during the first three months, 
 the amenorrhea, the nausea and vomiting, the breast changes, the violet 
 hue of vagina and cervix, and the softening of the cervix and uterus, 
 although of strong presumptive evidence, especially when several are 
 conjoined, are none of them positive proof of pregnancy when taken 
 individually. It is found that any one of them may be simulated by 
 the results of inflammation or disease and therefore the diagnosis of 
 pregnancy prior to the fourth month should be very guarded. It is only 
 by finding several of the above symptoms conjointly present that the 
 physician is justified in stating his diagnosis. 
 
 SYMPTOMS AND SIGNS OF PREGNANCY DURING THE LAST '^ 
 
 SIX MONTHS. 
 
 During this period occur three so-called positive symptoms of preg- 
 nancy, all being present during the first three months of the six. 
 
 1. Ballottement. 
 
 2. Fetal movements. 
 
 3. Fetal heart sounds. 
 
 In addition to these positive symptoms there are several of more or 
 less presumptive value: Eiflargement of the uterus; uterine souffle; 
 funic souffle; secondary areola; general increase of pigmentation; inter- 
 mittent uterine contractions; changes in the cer^•ix. 
 
 Ballottement. — If the woman is placed in the dorsal position (better 
 with head and shoulders elevated) and one or two fingers placed in the 
 anterior vaginal fornix, a gentle tap with the finger between the fourth 
 and seventh month, will usually cause a displacement of the fetus upward 
 through the liquor amnii only to be followed by a return to the pre- 
 senting finger. This displacement and return is called "ballottement" 
 
144 THE SYMPTOMS AND SIGNS OF PREGNANCY 
 
 and is considered a positive symptom of pregnancy. In the hands of a 
 skilled observer and taken in conjunction with other symptoms it may 
 be so regarded, but it should not be forgotten that a small fibroid or 
 ovarian cyst with a long pedical or a vesical calculus might respond to 
 the finger tap in a way which would deceive a careless examiner. Bal- 
 lottement is onl\' obtained after the fetus is large enough to impart 
 sensation to the finger, therefore usually not before the fourth month and 
 as a rule not after the early part of the seventh month, after which the 
 fetus too nearly fills the uterine cavity. With twin pregnancy, placenta 
 previa and scanty liquor amnii, ballottement is usually difficult or 
 impossible to obtain. 
 
 Fetal Movements. — At about the middle of pregnancy, viz., about 
 four and a half months, the uterus has risen sufficiently out of the pelvis 
 to come in contact with the anterior abdominal wall and movements of 
 the fetus are transmitted through it to the mother and later to the hand 
 of the examiner placed upon it. The transmission of the sensation of 
 fetal movements to the mother is called "feeling life" or "quickening," 
 and as it usually occurs at about the middle of pregnancy, i. e., four and 
 a half months, it is of some value in determining the probable date of 
 confinement in cases where the date of the last menstruation cannot be 
 utilized for that purpose, as when impregnation occurs during a period 
 of amenorrhea, either the result of disease, or the physiological amenor- 
 rhea of lactation. In multigravidse the sensation of " feeling life " is often 
 detected at an earlier period in pregnancy than in primigravidse who 
 experience it for the first time. 
 
 The sensation of fetal movements is regarded as a positive symptom 
 of pregnancy, but attention must be directed to the fact that in women 
 extremely desirous of progeny, and in whom hope has been aroused after 
 years of disappointment, movements of gas in the intestine have been 
 mistaken for fetal movements. 
 
 Fetal Heart Sounds. — Of all the signs indicative of pregnancy the 
 detection of the fetal heart sounds is the most positive. They were first 
 recorded as heard by Mayor, of Geneva, in 1818, and since then more 
 and more importance has been placed upon them not only as an indica- 
 tion of the existence of pregnancy, but in the diagnosis of multiple 
 pregnancy, the position of the child and its general condition. 
 
 The fetal heart sound can usually be heard a little after the middle 
 of pregnancy, viz., the latter part of the fifth or the beginning of the 
 sixth month. The time at which it can be heard depends considerably 
 upon the skill and experience of the listener, the position of the fetus, 
 the thickness of the abdominal wall, and the amount of liquor amnii 
 present. It is usually a double sound resembling that heard at the apex 
 of an adult heart but much more rapid. It is often compared to the 
 ticking of a watch under a pillow. Its rate varies from 120 to IGO per 
 minute. During the beginning of a uterine contraction the rate is usually 
 increased only to decrease below the normal at the height of the contrac- 
 tion, then to normally resiune its rate. Tlie rate of the fetal heart beat 
 was for a time considered a guide to the diagnosis of the sex of the child. 
 
DIFFERENTIAL DIAGNOSIS OF PREGNANCY 145 
 
 a slow fetal heart indicating a boy, and a rapid fetal heart a girl. Further 
 experience and observation have, however, proved this fallacious as a 
 guide (see page 183). 
 
 DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 
 
 One of the most difficult problems presented to the obstetrician or the 
 gynecologist is the diagnosis of early pregnancy. So difficult is it in many 
 cases, and so embarrassing is an error in the matter, alike to the patient 
 and the medical attendant, that it is never advisable until the third 
 month of pregnancy to diagnose that condition without reservation. 
 
 Pregnancy may be to the patient the greatest delight and the object 
 long sought, or on the other hand it may be the condition most dreaded. 
 It may be the condition of greatest importance to her socially, morally, 
 legally, and financially, hence her interest in an accurate diagnosis. 
 To the obstetrician an error in the diagnosis of pregnancy may be the 
 cause of ridicule and injured reputation which will require months or 
 years to overcome. Hence the need of caution. The reasons for error 
 in the diagnosis of pregnancy are numerous. One of the chief signs of 
 pregnancy is an enlargement of the uterus. Yet many enlargements 
 of the uterus exist without pregnancy and our problem is their differ- 
 entiation. 
 
 The uteri of different women may vary in size. Some women normally 
 have a larger uterus than others, and unless the usual size of the uterus 
 of the individual case is previously known to the examiner, her normal 
 uterus may be considered enlarged and pregnancy suspected. 
 
 Again, a uterus may be enlarged from a subinvolution or a metritis, 
 and such enlargement gives rise to the suspicion of pregnancy. Some 
 of the usual differential features are as follows : 
 
 Pregnancy vs. Subinvolution or Metritis 
 
 Amenorrhea. MenorrhaKia. 
 
 Body of the uterus soft. Body of the uterus firmer. 
 
 Body of the uterus jug-shaped. Body of the uterus less jug-shaped. 
 
 Perhaps cer\dx soft in each. 
 
 One of the commonest enlargements of the uterus presenting difficulty 
 in diagnosis from pregnancy is that due to the presence of one or more 
 fibromyomata, especially one of the interstitial or submucous variety in 
 which the outline of the uterus is nearly symmetrical. 
 
 The following differential features should be borne in mind: 
 
 Pregnancy vs. Fibromyoma. 
 
 Uterus shows rapid growth. Growth slow. 
 
 Shape usually symmetrical. Shape usually irregular and nodular. 
 
 Amenorrhea. Menorrhagia. 
 
 Cervix soft. Cervix firm. 
 
 Nausea perhaps present. Nausea absent. 
 
 Positive symptoms of pregnancy. (Fetal Positive symptoms of pregnancy absent. 
 
 heart; fetal movements; ballottement 
 
 perhaps present). 
 
 Breast signs perhaps present. Breast signs absent. 
 
 10 
 
 ^-^ 
 
 a*-- 
 
146 THE SYMPTOMS AND SIGNS OF PREGNANCY 
 
 The unusual difficulties in diagnosing these conditions may well be 
 mentioned here. A fibromyoma will occasionally undergo a degenerative 
 change from disturbed circulation, will soften at the centre, and will 
 grow almost if not quite as rapidly as a pregnancy, thus resembling 
 pregnancy in softness and growth, but, unless near the menopause, not 
 giving the amenorrhea usually associated with pregnancy. 
 
 The impregnated ovum lodging in one horn of the uterus occasionally 
 gives an asymmetrical shape to the organ which may be mistaken for 
 a myoma. This, however, does not disturb other signs and symptoms 
 usually presented by pregnancy. 
 
 It would hardly be expected that an ovarian tumor should present 
 marked difficulties in diagnosis from pregnancy, yet the following case 
 seen in consultation by the author will indicate such a possibility. A 
 young unmarried girl, eighteen years of age, an inmate of an institution 
 for the feeble-minded, was supposed to be pregnant and an orderly of 
 the institution was suspected of the crime. The girl's abdomen was 
 about the size of a pregnancy at term. The girl had never menstruated 
 and her continued amenorrhea was assigned to her pregnancy. To further 
 strengthen the diagnosis of supposed pregnancy, fluid could be expressed 
 from her nipples. Careful examination, however, revealed an intact 
 hymen; a small uterus separate from the tumor which proved to be an 
 ovarian cyst. The anemia and poor nutrition of the girl explained the 
 amenorrhea and the ovarian stimulation resulting from the presence of 
 the tumor explained the breast secretion. 
 
 The differential features by which it is usually possible to distinguish 
 pregnancy from an ovarian cyst are given in the following table: 
 
 PhEGNANCY vs. OVARIAX Ctst. 
 
 Amenorrhea. Normal menstruation. 
 
 Tumor more central. Tumor more lateral. 
 
 Tumor less elastic, perhaps fetal parts felt. Tumor more elastic, no fetal parts felt. 
 
 Breast signs present. Breast signs absent. 
 
 Positive sjonptoms of pregnancy perhaps Positive symptoms absent, 
 present. 
 
 If both pregnancy and an ovarian cyst exist the signs of each are present 
 and the diagnosis may be difficult. 
 
 Spurious Pregnancy or Pseudocyesis. — ^At first thought it seems 
 strange that a woman should become so convinced that she is pregnant 
 as to carry this conviction through nine months or more of supposed 
 pregnancy and anxiously await the onset of labor. However, the three 
 signs which the laity recognize as evidences of pregnancy are the cessa- 
 tion of menstruation, an increasing size of the abdomen, and fetal 
 movements. 
 
 These three signs may 'occasionally be apparently present and the 
 woman suppose herself pregnant when in reality this is not her condition. 
 The explanation is as follows: 
 
 In the first place this spurious pregnancy is most apt to occur near the 
 menopause when amenorrhea is the rule. Furthermore, at this period 
 of a woman's life an increase of abdominal fat and intestinal fermentation 
 
DIFFERENTIAL DIAGNOSIS OF PREGNANCY 147 
 
 is common. The two signs of pregnancy, amenorrhea and an enlarged 
 abdomen are thus furnished. The third, or fetal movement, is now sup- 
 plied by the motion of the intestinal gas supplemented by a vivid imagina- 
 tion on the part of the woman. Not infrequently these cases of pseudo- 
 cyesis occur in women who for years have longed for pregnancy and who 
 have been anxiously watching for the first indication. Is it any wonder 
 then that they should be deceived? The embarrassment, alike to the 
 attending physician and the patient, resulting from an undiagnosed 
 pseudocyesis, is well illustrated by the following case seen by the author 
 in consultation. The patient, a woman of wealth, and her physician had 
 supposed her labor past due and the consultation was held to determine 
 why labor did not ensue. On being conducted to the patient's chamber 
 the author was obliged to pass through a room prepared as a nursery 
 for the expected child. A more complete private nm-sery it would be 
 difficult to find and this was supplemented with all sorts of beautiful 
 articles of a baby's wardrobe, the gifts of numerous friends, all interested 
 in the arrival of the first, much-longed-for child in this family. On 
 reaching the bedside of the patient and after careful examination it 
 was his painful duty to inform the physician that his patient was not 
 pregnant. 
 
 The difficulty in these cases usually lies in the fact that the attending 
 obstetrician has taken the statements of the patient at their face value 
 without making a careful examination which would usually disclose a 
 small, firm uterus and would enable the examiner to exclude pregnancy. 
 The usual differential features are as follows: 
 
 Pregnancy vs. Pseud octesis. 
 
 Cervix soft. Cervix firm. 
 
 Uterine body enlarged. Uterine body not enlarged. 
 
 Positive signs of pregnancy perhaps present. Positive signs of pregnancy absent. 
 
 Tumor does not disappear on pressure. Tumor disappears on steady pressure, or 
 
 under anesthesia. 
 
 As an illustration of the completeness of the patient's subjective decep- 
 tion in the condition of pseudocyesis, the author remembers distinctly 
 a case brought to his hospital service, who after nine months of supposed 
 pregnancy had eaten an indigestible meal, was taken with severe intes- 
 tinal colic, supposed herself in labor at about the right time and was 
 brought to the hospital in the ambulance. The difficulty in persuading 
 this woman that she was not pregnant was so great that it made a lasting 
 impression. 
 
 Ascites. — The differentiation between advanced pregnancy and ascites 
 is usually easy on careful examination. The usual differential features 
 are as follows : 
 
 Pregnancy vs. Ascites. 
 
 Patient on back. Percussion note dull in Resonance in front. 
 
 front. 
 Fluctuation not distinct. Fluctuation distinct. 
 
 Amenorrhea. Regular menstruation. 
 
 Cervix soft. Cer\ax firm. 
 
 Uterine body enlarged. , Uterine body not enlarged. 
 
 Positive symptoms of pregnancy present. Positive sj-mptoms of pregnancy absent. 
 
148 
 
 THE SYMPTOMS AND SIGNS OF PREGNANCY 
 
 Is the Patient a Primigravida or a Multigravida? — The answer to this 
 question sometimes has considerable importance and hence the usual 
 differential features are given. 
 
 Primigravida i 
 
 Abdominal wall firm and tense. 
 
 Fetal parts less distinct. 
 
 Striie appear late, and are reddish bruwii 
 in color. 
 
 Breasts full and firm, perhaps with fresh 
 striae. 
 
 Labia in apposition. 
 
 Vagina narrow. Rugaj distinct. 
 
 Hymen fissured but different portions pre- 
 served. 
 
 Os externum closed until late in pregnancy. 
 
 Lacerations of cervix and perineum absent. 
 
 -Multigravida. 
 
 Abdominal wall lax, often wrinkled. 
 
 Fetal parts more distinct. 
 
 Besides fresh striae as in a primigravida, old 
 
 white, silvery striae exist from the start. 
 Breasts flabby, pendulous, perhaps with 
 
 both fresh and old striae. 
 Vulva gaping, showing vagina of violet hue. 
 Vagina more capacious; rugae less distinct. 
 Carunculae myrtiformes alone remain. 
 
 Os externum patulous. 
 
 Lacerations of cervix and perineum perhaps 
 present. 
 
 The absence of the above signs described as belonging to a multigravida 
 does not absolutely exclude a premature labor or even, in rare cases, the 
 delivery of a small fetus at term. 
 
CHAPTER V. 
 THE MANAGEMENT OF NORMAL PREGNANCY. 
 
 Until recent times pregnancy was considered a physiological process 
 which should be followed by a normal completion, and there was 
 thought to be no necessity for the pregnant woman to place herself in 
 the care of the obstetrician until a short time before her expected 
 confinement. 
 
 Fortunately for the patient and her unborn child these views are now 
 obsolete, and the laity have become educated to the fact that while normal 
 pregnancy is physiological, the possibility of pathological conditions 
 intruding themselves insidiously is so great that the pregnant patient 
 can only safeguard her pregnancy by placing herself in the hands of her 
 obstetrician almost immediately after her pregnant state is suspected. 
 
 If the pregnancy is her first she is probably ignorant as to the proper 
 mode of life during this condition, and it is a comfort to her as well as 
 adding greatly to her safety to have the obstetrician carefully outline 
 and supervise her conduct during the entire period of gestation. 
 
 By many it is thought unnecessary to make a physical examination 
 during the early months of pregnancy, but with this the author does not 
 agree, and in his mind there are many reasons why the obstetrician should 
 make a thorough physical examination, including both the vaginal and 
 the bimanual, as soon as the supposed pregnant patient places herself 
 in his care. Among these reasons may be mentioned the following: 
 
 The possibility of error in the diagnosis of pregnancy and the embar- 
 rassment alike to the patient and obstetrician resulting from this error 
 is so great, that the obstetrician should not commit himself to this diag- 
 nosis until he has absolutely satisfied himself of the existence of pregnancy 
 by a careful physical examination. Furthermore, the frequency of the 
 existence of a retroversion of the uterus, which if uncorrected may result 
 in an early miscarriage, furnishes a very strong argument for determining 
 early in pregnancy the condition and position of the pelvic organs. 
 
 Although, save in the case of manifestly markedly deformed pelves, 
 it is seldom necessary to perform pelvimetry before the seventh month 
 of pregnancy, it is the author's practise to carefully measure the pelvis 
 of the patient as soon as she places herself in his care, feeling that with 
 this detailed knowledge of her condition he is better able to advise her 
 during her pregnancy. 
 
 In giving advice to a pregnant patient it is always wise to consider 
 her ignorant of the proper mode of life in this condition, and give her 
 
 (149) 
 
150 THE MANAGEMENT OF NORMAL PREGNANCY 
 
 minute directions as to diet, dress, exercise, marital relations, regulation 
 of the bowels, etc. 
 
 Diet. — In the early months of pregnancy, if the urine is normal the 
 patient can usually be allowed to select her diet according to her taste, 
 which will often vary greatly from that in the non-pregnant condition. 
 
 If the patient suffers with nausea there are two rules of feeding which 
 will often add greatly to her comfort. 
 
 1. Have her take before rising in the morning some easily digested 
 food, as a cracker or two, a glass of milk or some toast and a cup of coffee 
 and then rest awhile before performing her toilet and dressing. 
 
 2. As the feelings of the pregnant patient resemble somewhat the 
 feelings when slightly seasick on shipboard, the author is in the habit 
 of advising his patients to follow the custom pursued at sea of eating 
 little and often. The patient usually feels worse when her stomach is 
 empty. By the fourth month, if not earlier, the patient's appetite usually 
 returns and she should be allowed a generous plain diet including meats, 
 vegetables, and fruits. During the last month, in order to lessen the work 
 of liver and kidneys, it is my custom to limit the ingestion of red meat 
 to three times a week. As advocated by Prochownick and others, if the 
 patient has pre\ioiisly borne very large children or the pelvis is slightly 
 contracted, the size of the child may be reduced without injury, by having 
 the patient during the last few months of pregnancy take less than the 
 ordinary amount of carboh>'drates, less fluid with her meals and rise from 
 the table with appetite not entirely satisfied. In this way the labors in 
 some women are rendered easier. 
 
 Drink. — To favor elimination so important during pregnancy, drinking 
 freely of water is very desirable and this is more easily regulated by 
 giving the patient directions as to when and how much she shall take. 
 An excellent plan is to tell her to take six glasses of water per day: one 
 early in the morning, two in the middle of the forenoon, two in the middle 
 of the afternoon, and one before retiring. 
 
 The ordinary articles of fluid diet, milk, chocolate, tea and coffee in 
 moderation are allowable in pregnancy but alcoholic beverages should be 
 avoided to save irritation of the already overtaxed liver and kidneys. 
 
 Dress. — The clothing of the pregnant woman should in general be 
 arranged with a view to her comfort rather than to suit the taste of the 
 Paris dressmaker. There is no objection to the use of corsets, if the\' fit 
 properly and can be easily adjusted to the increasing demand for room. 
 The object desired is support, not compression. In the primigravida 
 where the abdominal wall is tense, additional support will seldom be 
 needed, and all that is required is the use of gradually loosened corsets 
 of the ordinary type in early pregnancy and a maternity corset with few 
 "bones" and elastic sides, or a corset waist, in later pregnancy. In 
 women with well-developed breasts, a certain amount of breast support 
 is necessary for their comfort and if as at present the prevailing style 
 of corset is too low for this, it is well to have them wear one of the numerous 
 styles of breast supporter, usually made of plaited ribbons or bands. 
 
EXERCISE 151 
 
 In the case of multigravidse with very lax abdominal walls, and occa- 
 sionally even in primigravidse a well-fitting bandage which preserves 
 the proper uterine axis not only adds to the comfort of the woman but 
 favors engagement of the fetal head at the proper time. As far as possible 
 the weight of the clothing should be supported from the shoulders rather 
 than the waist. 
 
 Stockings should be held by side supporters rather than by circular 
 garters. 
 
 If the patient suffers with varicose veins of the lower extremities 
 elastic stockings may be needed for support and comfort. 
 
 Exercise. — Except in cases where the woman has suffered from previous 
 early miscarriages it is advisable to have her take regular, moderate 
 exercise. In the early months if she suffers much from nausea this may 
 be almost impossible for her and should not be insisted on. She needs 
 and will be benefited by fresh air, but this can be obtained by spending 
 much time on the porch, or by a carriage or slow motor ride. Just as 
 soon, however, as the nausea ceases, or markedly lessens and the feeling 
 of well-being returns she should be encouraged to take short walks which 
 are gradually increased until she walks regularly from one to two miles 
 a day. During early pregnancy it is well to lessen the exercise each month 
 on the days which would have been her menstrual period. 
 
 As to the variety of exercise, walking is the best. It is well to advise 
 against lawn tennis and horseback riding. It is well known that some 
 women can indulge in almost any form of exercise without interrupting 
 pregnancy and recenth' one of my patients who was fond of exercise and 
 of horses, not knowing she was pregnant had been enjoying the sport of 
 "breaking" some bucking horses up to the time when she came to me to 
 find out why she did not menstruate. She was then three months pregnant 
 and went to term with a perfectly normal pregnancy and puerperium. 
 However, it seems to require in others but a slight jolt or mental start 
 to interrupt the pregnancy, and for this reason it is well to advise against 
 horseback riding in this condition. 
 
 At the present day the question is constantly asked if it is safe for the 
 pregnant woman to motor. In the experience of the author this depends 
 entirely upon the condition of the roads and the carefulness of the 
 chauffeur. If the roads are smooth and the car is run slowly, motoring 
 does no harm and furnishes diversion and fresh air, both of which are 
 very desirable. 
 
 The exact amount of exercise must vary with the endurance of each 
 patient rather than be fixed by any rule. The object sought is exercise 
 without overfatigue. When the patient is unable to take a sufficient 
 amount of exercise, general massage, avoiding the abdomen, is of 
 value. 
 
 Traveling. — The physician is often asked as to the advisability of a 
 trip abroad or a long journey during pregnancy. It is wise as a rule to 
 advise against this for several reasons: The frequency with which inter- 
 ruption of pregnancy is caused by the jolting of railroad trains on the one 
 
152 THE MANAGE MEXT OF NORMAL PREGNANCY 
 
 hand and the straining of seasickness on the other is too great to be 
 neglected. Furthermore, the absence from skilled supervision of the 
 patient's urine and avenues of elimination coupled frequently with 
 inadequate facilities for -<lealing with com])licati()ns of all kinds when 
 far from home makes home or its neighborhood the best place for a 
 woman during her pregnancy. 
 
 Bathing. — The proper care of the skin during pregnancy is of marked 
 importance and the continuance of the daily bath is not only allowable 
 but desirable. The temperature of the bath may be that to which the 
 patient is accustomed, but sudden shocks of ^■ery cold water and bathing 
 in very hot water are to be avoided. Sea bathing in relatively still water 
 is beneficial, but bathing in heavy surf should not be allowed. 
 
 Fresh Air. — So long as it is remembered that the patient is breathing 
 for two it is seen how important it is that she should have fresh air and 
 plenty of it. The ease with which a pregnant patient faints in a room 
 which is overcrowded and where the air is bad shows nature's demand 
 for fresh air in abundance. For this reason overcrowded and over- 
 heated rooms with poor ventilation should be regarded as unfit for a 
 woman in this condition. 
 
 Marital Relations. — The question of marital relations during pregnancy 
 is an important one. It is well established that the frequent sexual 
 intercourse of newly married life is a frequent cause of miscarriage. 
 
 On the other hand it is too well known that the long abstinence of some 
 husbands during the pregnancy of their wives has caused them to yield 
 to temptation away from home, with dire results to the future happiness 
 and perhaps health of themselves and their wives. If there is no history 
 of previous miscarriages, pregnant patients may safely be told that they 
 may indulge in sexual intercourse one or twice a week up to the eight 
 month, except during the week each month which corresponds to their 
 menstrual period. During these times, and especially during the last 
 month of pregnancy, intercourse should be interdicted. The danger 
 of puerperal infection from intercourse during the last month of preg- 
 nancy makes such interdiction extremely important. As will be discussed 
 under the prophylactic treatment of miscarriages, if the patient gives 
 a history of repeated miscarriages all intercourse during pregnancy must 
 be avoided. 
 
 As to the sexual desire of women during pregnancy, while, as a rule, 
 it is normal or decreased, in a few, apparently from the greater pelvic 
 congestion, it is increased. 
 
 Regulation of the Bowels. — Great as is the tendency to constipation 
 in modern women, tliis tendency becomes increased in pregnancy from 
 the pressure of the enlarging uterus interfering with intestinal peristalsis. 
 It is very desirable (1) that the patient should have a regular movement 
 each day, (2) that this movement should be brought about with as few 
 drugs as possible. In some women the drinking freely of water as already 
 advised, and eating of fruits and green vegetables will accomplish the 
 desired result, especially if at the same time the bread eaten is very 
 
CARE OF THE VULVA AND VAGINA 153 
 
 coarse. In other women further help is needed. For this two methods 
 are at our command. (1) Enemata or suppositories, (2) mild laxatives. 
 It is well not to use continuously either the same method or the same 
 article in the method. An enema of soapsuds may be used at times 
 alternating with a glycerin or gluten suppository. Of laxatives, the two 
 which have given me the greatest satisfaction are (1) the fluidextract 
 of cascara in tablet form (aa TIlv) of which from one to three may be taken 
 at bedtime, and (2) a tablet composed of aloin, belladonna, strychnin 
 and cascarin to be taken at bedtime. It is often of value to administer 
 a small dose of calomel at intervals during pregnancy. The use of mineral 
 waters as laxatives during pregnancy, while perhaps beneficial for a time, 
 rather tend to constipation later. 
 
 Mental Condition. — During pregnancy the mental condition of the 
 woman is usually that of high tension and unstable equilibrium. There 
 are numerous causes for this: she may have found herself pregnant 
 unexpectedly, perhaps unwillingly; her plans for the year or two to come 
 may have to be entirely rearranged; she may feel like secluding herself 
 from her friends and abstaining from occupations she enjoys; she may 
 feel wretchedly from the nausea which, although made light of by her 
 friends, is disagreeable enough for her; she may dread the ordeal of her 
 labor, and last, but by no means least, she may be suffering from a toxemia, 
 the result of insufiicient oxidation and elimination which shows itself 
 chiefly in the nervous system. 
 
 The mental condition of some patients is well illustrated by the experi- 
 ence of one of my old teachers who said that he had a patient "whose 
 disposition when not pregnant seemed to him angelic, but who acted 
 when pregnant as though possessed of the devil." Certain it is that there 
 is often a tendency to nervous irritation, and the surroundings of the 
 patient should be made as cheerful and pleasing as possible, free from all 
 unnecessary causes of fret and worry. It is well to explain this condition 
 to the husband and to tell him that his share will consist in making 
 allowances for any little irritability on the part of his wife and in doing 
 all he can to add to her comfort, her diversion, and her cheer. 
 
 Breasts. — While speaking of the clothing of the pregnant patient, 
 attention was called to the fact that when the breasts were large and heavy 
 much comfort could be given by proper support. In addition to this much 
 discomfort can be avoided by proper care of the nipples during pregnancy, 
 especially during the latter half. Aside from the cleansing by the daily 
 bath, the nipples should be kept free from the crusts which tend to form 
 upon them as soon as secretion begins to exude. Many lotions have been 
 used for this purpose. The one which the author usually employs is 
 composed of borax, § ss, and 50 per cent, alcohol, § viij, with the direction 
 to bathe the nipples with it night and morning. If the nipples are 
 retracted the patient is told during the last third of pregnancy to draw 
 them out gently with the fingers each time she uses the lotion. 
 
 Care of the Vulva and Vagina. — Although more or less leucorrheal 
 discharge is quite common in pregnancy, especially in multigravidse, it is, 
 
154 THE MANAGEMENT OF NORMAL PREGNANCY 
 
 as a rule, unwise to use vaginal douches unless there exists some special 
 indiaition in the shape of disease. It has been shown by Kronig, Menge, 
 Williams and others that the vagina of the normal pregnant woman 
 does not contain pathogenic organisms and, save for the possibility of 
 gonorrheal infection, may be regarded as normally free from the source 
 of puerperal infection. 
 
 Kronig also showed that the vagina possessed certain bactericidal 
 powers which were weakened by antiseptic douches. Unless, therefore, 
 the woman is suffering from a gonorrheal infection which indicates treat- 
 ment, both for her sake and that of her baby, vaginal douches had, as a 
 rule, better be omitted. If the leucorrhea produces irritation of the vulva, 
 bathing the vulva with borax and water (5j~0j) will usually give relief. 
 In addition to this, bathing with milk of magnesia often gives marked 
 comfort. 
 
 It is especially important that all douching should be discontinued 
 during the last month of pregnancy so that the woman may enter upon 
 her labor with vagina untouched by douche, and, as already indicated, 
 by coitus for at least a month. 
 
 Urine. — There is no secretion which furnishes so good a criterion of 
 the condition of the pregnant woman as the urine, although it is freely 
 admitted that instances not infrequenctly occur in which the woman is 
 in grave danger without the ordinary clinical examination of the urine 
 detecting it, still it is the best single criterion which we possess and if 
 it is examined carefully and frequently it is rare that danger signals 
 escape. The knowledge of the importance of frequent urinary examina- 
 tions has now become so widespread among the laity that the physician 
 attending a case of obstetrics without these precautions is justly held 
 culpable. The urine should be examined every two weeks from early 
 pregnancy even if absolutely normal, and in order to prevent neglect on 
 the part of the patient it is wise to give the date on which the specimen 
 is to be sent. It is my custom to tell patients to send four ounces of the 
 morning urine, to insure its freshness when it reaches the office. This 
 ordinary examination of the urine should include not only the tests for 
 albumin and sugar, the reaction and specific gravity, but also the micro- 
 scopic examination for casts and other abnormal contents. In addition 
 to these it is also desirable to ascertain the condition of proteid metab- 
 olism by testing for acetone and diacetic acid. 
 
 The above remarks apply where the urine and course of pregnancy 
 seem normal. If albumin or other abnormalities are found the urine 
 should be examined much more frequently, even perhaps every day for 
 a time, and during the last month of pregnancy it is wise to have a speci- 
 men sent every week even if everything is normal. 
 
 A convenient blank for urine analysis is the following: 
 
OBSERVATION OF THE PATIENT 155 
 
 URINE ANALYSIS. 
 
 Name 
 
 Report No 
 
 Date 
 
 Volume in twenty-four hours Oz c.c. 
 
 Color - 
 
 Sediment Reaction 
 
 Specific gravity 
 
 _Urea Grains per ounce grains, twenty-four hours 
 
 Albumin Amount grains, twenty-four hours 
 
 Sugar Amount (polariscope) grains, twenty-four hours 
 
 Acetone 
 
 Diacetic acid .. 
 
 Indican 
 
 Bile 
 
 Blood pigments 
 
 MICROSCOPIC EXAMINATION. 
 
 Casts Leukocytes 
 
 Mucus Epithelia * — 
 
 Amorphous deposits Bacteria 
 
 Crystals Other elements 
 
 Red blood cells 
 
 Blood-pressure. — The importance of carefully taking the blood- 
 pressure of a patient at short intervals during her pregnancy has now 
 become well established. It is one of the most valuable criteria of the 
 condition of her elimination and the presence or absence of a toxemia. 
 This will be considered later when studying toxemia, but attention 
 should now be directed to its importance as a guide to the condition 
 of the woman during her pregnancy and the need of noting any departure 
 from the normal which usually varies between 100 and 130. 
 
 With the numerous portable sphygmomanometers now on the market 
 it is an easy task to follow the blood-pressure. 
 
 Observation of the Patient. — The patient should be seen frequently, 
 for it is only by frequent observation of the patient together with frequent 
 examinations of the urine that it is possible to surround the pregnant 
 
156 THE MANAGEMENT OF NORMAL PREGNANCY 
 
 wuiiian with the safeguards to which she is entitled. ]\Iuch can be told 
 by the appearance of the patient; her color and facial expression; the 
 presence or absence of edema; the tension of her ])ulse and by certain 
 symptoms which can be elicited by (questions but which would not have 
 been reported otherwise. It is a good plan to have patients send speci- 
 mens every two weeks and to come with the specimen at least every 
 other time even if feeling well. This enables the physician to see them 
 at least every four weeks. In addition it is wise to give them a printed 
 card like the following, calling their attention to certain symptoms 
 which should be reported if present: 
 
 Directions during Pregnancy. 
 
 Be careful to send or bring a specimen of the urine in a clean bottle holding 
 from -i to 6 ounces every two weeks. Have your name and address upon the bottle. 
 Even if feehng perfectly well, come to the office mth at lea.st eveiy other specimen. 
 
 Drink, if possible, six glasses of water each day between meals, i. e., one the 
 first thing in the morning; two during the forenoon; two during the afternoon 
 and one just before retiring. 
 
 Be careful to have the bowels move regularly each day and report any iualnlity 
 in this direction. 
 
 For exercise, walking is the best. Walk from one to two miles each day. Avoid 
 lawn-tennis, horseback riding, and fast or rough motoring. 
 
 Bathe the nipples night and morning with the solution prescribed. 
 
 Wear loose clothing, capable of being adjusted to the increasing size of the 
 abdomen. There is no objection to loose-fitting corsets. Do not wear circular 
 garters. 
 
 Report any unusual headache; any excessive vomiting (especially after the 
 middle of pregnancy); any marked swelUng of limbs or face; any disturbance 
 of vision; any bleeding or escape of water; any pain with regular recurrences. 
 
 The Teeth. — It is a common experience that the teeth decay more 
 rapidly during pregnancy than at other times. It is therefore of impor- 
 tance that they should receive especial care at this time. Not only are 
 the various antiseptic mouth washes of value, but often an alkali, such as 
 the milk of magnesia, will prove beneficial. The obstetrician is often 
 asked if it is safe to have dentistry done during pregnancy. ]My experi- 
 ence leads me to tell patients that minor work like the filling of small 
 cavities may safely be done, but that extraction of teeth and other major 
 work had better be postponed, if possible. 
 
 Patient's History and Examination. — The obstetrician who assumes 
 the responsibility of the care of a woman during her pregnancy and puer- 
 perium should acquaint himself with all facts in her previous history 
 which have a bearing upon the present pregnancy and confinement. 
 At the Sloane Hospital the history blank ('pages 158 to 163) has been 
 found of value and, although it is more complete than will probably be 
 used by the busy practising obstetrician, from it can easily be abstracted 
 a brief working history plan. 
 
 Duration of Pregnancy. — A great deal of annoyance and embarrass- 
 ment alike to obstetrician and patient woidd be saved if the exact dura- 
 tion of pregnancy in a given case could be determined, but this is impos- 
 sible for the reason that the exact date of fertilization is tmknown. Two 
 
DURATION OF PREGNANCY 157 
 
 » women may have fruitful intercourse on the same day and yet the dates 
 
 of their labors be widely separated. Usually labor begins about two 
 hundred and eighty days from the beginning of the last menstruation, 
 i. e., about two hundred and seventy-three days from intercourse, sup- 
 posing this to occur right after menstruation, but many variations occur. 
 Ahlfeld,^ analyzing 425 cases in which the date of coitus was thought 
 to be kno^Ti, found the duration of pregnancy in different cases to vary 
 from two hundred and thirty-one days to three hundred and twenty- 
 nine days. The cause of this variation is largely dependent upon two 
 facts : 
 
 1. The length of time between intercourse and impregnation varies in 
 different people and at different times. The possibility of this is readily 
 seen when we consider that spermatozoa have been found alive in the 
 uterus and Fallopian tubes three weeks or more after intercourse, as 
 reported by Diihrssen,^ and as shown by Issmer unimpregnated ova may 
 remain alive for sixteen days.^ 
 
 2. Some women habitually carry in utero their product of conception 
 longer than others. This is shown by the length, size and weight of the 
 child when born being larger than normal. This increased size often 
 adds greatly to the difficulty of the labor and will be referred to again 
 as an indication for the induction of premature labor if the pregnancy is 
 prolonged more than two weeks beyond term. This variation in the dura- 
 tion of pregnancy is not confined to the human race. In the cow whose 
 period of pregnancy corresponds closely to that of woman, the duration 
 of pregnancy is usually considered to be two hundred and eighty days, 
 but variations were noted by Tessier ranging between two hundred and 
 forty-one and three hundred and eight days. In the mare the average 
 duration of pregnancy is considered three hundred and sixty-six days, 
 but in a large series of cases studied by Franck-Albrecht-Goring,* varia- 
 tions occurred between three hundred and seven and four hundred and 
 twelve days. 
 
 Date of Expected Confinement. — ^The method followed by the author, 
 both in his service at the Sloane Hospital and in his private practice, in 
 computing the date of confinement is that which bears the name of 
 Naegele who considers that gestation continues two hundred and eighty 
 days from the first day of the last menstrual period. This is easily cal- 
 culated approximately by adding seven days to the date of beginning 
 of the last menstrual period and counting back three months. Thus, 
 if the last menstrual period began on September 10, adding seven days 
 would make September 17, and counting back three months would 
 give June 17 as the date of the expected confinement. This method 
 supposes the period of gestation to continue nine calendar months from 
 the date of intercourse; that menstruation is over and intercourse indulged 
 in, as a rule, in seven days from the beginning of the period. 
 
 1 Beobachtungen liber die dauer der Schwangerschaft. 
 
 2 Zeitschr. f. Geburts u. Frauenkrankh., vol. xvii, p. 305. 
 
 3 Ueber die Zeitdauer der menschlichen Schwangerschaft. 
 
 ■i Die Trachtigkeitsdauer, ThierartzHche Geburtshulfe, IV aufl., 1901, pp. 153-159. 
 

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164 THE MANAGEMENT OF NORMAL PREGNANCY 
 
 This method of calculation will sometimes fix the exact day on which 
 labor begins and usuall\' will come within a few days of the date. Some- 
 times, however, with this rule, as with every other, there will be an error 
 of two or even three weeks resulting either from the fact that impreg- 
 nation did not occur until just before the next period (which did not 
 appear), or that gestation continued over time. It must also be remem- 
 bered that in exceptional cases impregnation may occur any time during 
 the intermenstrual period. If impregnation followed a single intercourse 
 the date of which is known, the usual method of calculation is to count 
 back three months from the date of intercourse. 
 
 If impregnation, instead of occurring just after the last regular period, 
 occurred just before the next period, this period is usually not entirely 
 absent but is markedly diminished. Unless attention is called to the fact 
 that this menstruation was much less than normal the calculation might 
 be based on the date of the first day of this flow and the date of the 
 expected labor be placed much later than would really occur. This is 
 one of the instances where a menstrual flow occurs after pregnane}- has 
 started. 
 
 There are several other methods for computing the date of the expected 
 confinement, one being that of ^Mathews Duncan, which takes the last 
 day of the last menstruation and adds nine months, which is regarded 
 as two hundred and seventy-five days ; to this add three days or, if February 
 comes in these nine months add five days, making two hundred and 
 seventy-eight days. This date will be the middle of the fortnight in which 
 labor occurs. According to the Duncan rule, if the patient's last menstrua- 
 tion began September 10, it would probably end September 15. Adding 
 nine months to this would make June 15; now as February was included 
 in these nine months add five days, which would make June 20 as the 
 date for the confinement instead of June 17, calculated by the Xaegele 
 rule. The date of the first day of the last menstruation is much more 
 apt to be fixed in the patient's mind or on her calendar than is the last 
 day of that period, and in the experience of the author the Xaegele rule 
 forms a better working method than does that of Duncan. 
 
 Sometimes pregnancy occurs during a considerable period of amenor- 
 rhea, caused by lactation, anemia, or other conditions, and the patient 
 is perhaps surprised by the enlargement of the abdomen or by fetal 
 movements. If the patient is nursing her child, the first intimation of 
 pregnancy may be that her milk suddenly decreases in quantity or diges- 
 tibility for the infant. 
 
 The difficulties in the way of estimating the date of confinement 
 under these circumstances are very evident, and the obstetrician usually 
 has to rely upon the height to which the fundus of the uterus has risen, 
 in the abdomen. 
 
 At the fourth month the fundus is usually felt distinctly above the 
 s>Tnphysis pubis; at the fifth month midway between the sj-mphysis 
 and the imibilicus; at the sixth month at the level of the umbilicus; at 
 the seventh month about four fingers' breadth above the umbilicus; 
 at the eighth month two-thirds of the distance between the umbilicus 
 
OBSTETRICIAN'S ARMAMENTARIUM 165 
 
 and the ensiform cartilage. At the early part of the ninth month the 
 fundus reaches nearly to the level of the ensiform cartilage. During 
 the last two weeks of pregnancy as the presenting part enters the pelvic 
 brim the fundus descends until it reaches about the level it occupied at 
 the eighth month. There are naturally many sources of possible error 
 in calculating the duration of pregnancy in this manner. The umbilicus 
 is not always at the same height; the uterine body may be abnormally 
 large from the presence of twins or hydramnios; extreme laxity of the 
 abdominal wall may allow changes in the position of the uterus and non- 
 engagement of the presenting part, and excessive fat in the abdominal 
 wail may interfere with accurate palpation of the fundus. 
 
 Careful observation of the height of the fundus taken in connection 
 with careful palpation of the fetus, both externally and bimanually, 
 will usually enable the approximate duration of pregnancy to be arrived 
 at. On account of the variations in the height of the umbilicus above 
 the symphysis, as shown by Spiegelberg,^ it has been thought best by some 
 to estimate the duration of pregnancy by measuring the height of the 
 fundus above the symphysis with a tape-measure rather than comparing 
 it with the umbilicus. The results obtained by Spiegelberg in the use 
 of this method are as follows: 
 
 22d to 28th week 24 . to 24 . 5 centimeters 
 
 28th week 26.7 
 
 30th 
 
 32d 
 
 34th 
 
 36th 
 
 38th 
 
 40th 
 
 28.4 
 29.5 to 30.0 
 31.0 
 32.0 
 33.1 
 33.7 
 
 According to McDonald^ the duration of pregnancy in lunar months 
 equals height of the uterus in cm. (above the symphysis) divided by three 
 and one-half. These measurements, however, vary so greatly in different 
 people that for practical purposes the comparison of the fundal height 
 with the umbilicus is more useful. The time of feeling life or quickening 
 has frequently been used as a basis of calculation in estimating the date 
 of confinement, it being the rule that fetal movements are usually felt 
 at about four and a half months. This rule, however, is subject to 
 many exceptions, since in some women who have previously borne 
 children and have experienced the sensation of "life" this is felt much 
 earlier, while in others it is not felt until considerably later. In some, 
 moreover, the movement of gas in the intestines and other sensations or 
 imaginations are mistaken for " life." Taken in connection with the height 
 of the fundus and the history of the case the time of feeling life may be 
 of considerable value in estimating the date of confinement. By itself 
 it has little value. 
 
 Obstetrician's Armamentarium.— With the growth of modern ob- 
 stetrics there has grown the obstetric bag, both in size and contents. 
 
 1 Lehrbuch der Geburtshiilfe, III aufl., 1891, pp. 126-127. 
 
 2 Mensuration of the Child in the Uterus with New Methods, Jour. Am. Med. Assn., 
 December 15, 1906, xlvii. 1979 to 1983. 
 
166 
 
 THE MANAGEMENT OF NORMAL PREGNANCY 
 
 Tlie long, narrow black bag so popnlar \\ith obstetricians twenty years 
 ago has been relegated to the past as entirely unfit for the uses of the 
 present day. 
 
 There are many styles of obstetric bags on the market, but in the opinion 
 of the author the best obstetric bag is an ordinary dress-suit case contain- 
 ing two copper trays: a long one measuring on the inside 18 inches in 
 length, 6 inches in width, and 4 inches in height; and a short one 10 inches 
 in length, 5f inches in width, and 3f inches in height, each with covers 
 and the short tray just wide enough and high enough to fit, with cover 
 on, into the long tray and allow its cover to fit. 
 
 Fig. 113. — Author's bag with trays and covers. 
 
 The author's bag and contents are shown in Figs. 113 and 114. The 
 object of two trays is to have one long enough to boil a pair of forceps in, 
 and a smaller one for boiling small instruments like a perineorrhaphy 
 set, the smaller tray being much more convenient for ordinar\- use in 
 cases which do not require the forceps. In time of need the long tray 
 can be used for hand solution. 
 
 In these two trays can be carried man}' of the articles so necessary 
 to the obstetrician, and outside the trays can be carried the forceps and 
 miscellaneous articles. It is well to have a special place in the bag for 
 each article so that an inspection will show at a glance whether the bag 
 is properly packed or not, and also that in case of haste, the article 
 
OBSTETRICIAN'S ARMAMENTARIUM 
 
 167 
 
 Fig. 114. — Author's bag packed. 
 
 Fig. 115. — Perineorrhaphy set and short instruments often needed. 
 
168 THE MANAGEMENT OF NORMAL PREGNANCY 
 
 needed can l)e found at once. A reference to Figs. 114 and 115 will show 
 the articles carried by the author and tluMr proper place in the hag. In 
 the smaller tray are carried: 
 
 1. Box containing ruhber elastic dilators (XOorhces' bags). 
 
 2. Box containing syringe for distending elastic dilators. 
 
 3. Perineorrhaph\' and short instruments (see Fig. 115). 
 
 4. Rubber gloves. 
 
 In the large tray are carried. 
 
 1. Bottles of solutions: (a) Ergot; (b) chloroform; (c) ether; (d) 
 argyrol, 20 per cent, solution, for babv's eves; (e) tr. green soap; 
 
 (/) lysol. 
 
 2. Catgut in tubes. 
 
 3. Bottle of bichloride tablets. 
 
 4. Small scales. 
 
 Outside the trays are carried: (a) stethoscope; (6) pair of Tucker- 
 INIcLane forceps: (c) pair of axis-traction forceps; (d) chloroform mask; 
 (e) rubber apron; (/) sterilized gown; (g) sterilized bougie in tube; (A) 
 sterilized stilet in tube; (i) sterilized scrubbing brush; (j) sterilized 
 douche bag; (k) sterilized douche nozzle; (/) tube of sterilized iodoform 
 gauze; (m) tube of sterilized plain gauze; (n) sterilized soft-rubber catheter 
 (o) sterilized glass catheter; (p) leg holder. 
 
 The dress-suit case has many advantages for an obstetric bag over the 
 ordinary hand satchel. The contents are heavy and this amount of weight 
 can be carried much more easily in something thin like a dress-suit case 
 which hangs by one's side, than in a broader, bulging satchel. Further- 
 more, the square corners of a suitcase allow many articles to be packed 
 with an economy of space. 
 
 Obstetric Outfit for Patient. — The advantages of having everything 
 to be used about the patient in labor thoroughly sterilized and prepared 
 beforehand are so great that it has become the custom, where the patient 
 can afford it, to have her order one of the obstetric outfits, of which there 
 are many on the market, making sure that the articles are thoroughly 
 sterilized. One of the best contains the following articles: Two sterilized 
 bed pads (30 inches square); 2 dozen sterilized vulva pads; 2 sterilized 
 mull binders (18 inches wide); 6 sterilized towels: 10 yards sterilized 
 gauze; 1 pound sterilized absorbent cotton (^-pound packages); rubber 
 sheet, 1 yard by 1^ yards, sterilized; rubber sheet, 1| yards by 2 yards, 
 sterilized; 4-quart sterilized douche bag with glass nozzle; douche pan, 
 sterilized; sterilized nail brush; 2 agate basins, sterilized; safety pins; 
 2 tubes sterilized petrolatum; boric acid, powdered; 100 grams chloro- 
 form (Squibb's); fluidextract ergot; tincture green soap; lysol; tube 
 sterilized tape; sterilized soft-rubber catheter; sterilized glass catheter; 
 stocking drawers, sterilized; talcmn powder; bath thermometer. 
 
 Each article is wrapped in a separate package and separately 
 sterilized. 
 
 The outfit should be in the patient's home a month before the expected 
 confinement, and should only be opened by the doctor or nurse. 
 
 The comfort of the obstetrician in having at his command an outfit 
 
ANTEPARTUM EXAMINATION 169 
 
 upon which he can rely, both as to contents and sterility, can only be 
 appreciated by those who have worked both with and without it. 
 
 The expense, although quite an item, is more than counter-balanced 
 by the additional safeguarding of the patient. 
 
 Antepartum Examination. — If one has an office nurse, which is almost 
 a necessity if he is to do much work in obstetrics or gynecology, the most 
 satisfactory place for the preliminary pelvic examination is the office. 
 
 For the easy performance of this work, however, a certain arrangement 
 of offices is desirable. ^Yhatever the plan of the reception-room may be 
 the arrangement of consulting-room, and examining-room should be such 
 that the patient can go from consulting-room to examining-room and from 
 there to the dressing-room and toilet without returning to the consulting- 
 room. 
 
 From the examining-room the patient should also be able to pass out 
 of the house without returning to the consulting-room. The plan of offices 
 which in my experience has proved most convenient is sho'^ii in Fig. 116, 
 the patient being enabled to go from examining-room to dressing-room 
 and toilet as needed and through dressing-room to house exit without 
 
 \S5, 
 
 DRESS 
 
 EXAMINING ^ 7 ANDTOUET^^ 
 
 FT } 
 
 L./ HALL / 
 
 ROOM 
 
 A 
 
 Y..... J 
 
 CONSULTING ] reception | RECEPTION 
 
 I I 
 
 ROOM I ROOM I ROOM 
 
 J I 
 
 Fig. 116. — Plan of ofBces. 
 
 reentering consulting-room, thus enabling the obstetrician to see patient 
 No. 2 while No. 1 is dressing. It is understood, of course, that a young 
 man just starting in practice may find it impossible to have either office 
 nurse or more than one office, yet there is always benefit in studying what 
 is best suited for one's work and then striving to approach it as nearly 
 as possible. 
 
 After taking a careful history of the patient, she should be requested 
 to step into the examining-room and the nurse asked to prepare her 
 for examination. The nurse takes her to the dressing-room where 
 she removes her corsets and a specimen of the urine is obtained. 
 The patient is then arranged for pelvimetry on the examining table. 
 As a rule a table will be found more convenient for office work 
 than any of the numerous examining chairs on the market. The 
 table need not be a complicated one; a simple one is preferable. 
 What is needed is a strong table with a broad step to assist in mounting 
 and a foot-board containing a heel-hole which can be pulled out on either 
 side of the foot of the table. These foot-boards support the feet when 
 the patient is in the lithotomy position and the legs when she is on her 
 side. The table should be cushioned with a thin mattress covered with 
 
170 THE MANAGEMENT OF NORMAL PREGNANCY 
 
 a clean sheet and provided with a small pillow. A very good way to 
 arrange the sheet is to have the length of it across the table so that 
 enough is free to cover the patient when she is on the table. Many of 
 the tables are made of metal, although when used for examination pur- 
 poses only there are certain advantages in wooden tables painted with 
 white enamel. They are lighter, warmer in winter, and less expensive. 
 For pelvimetry the patient is first placed in the dorsal position, the 
 waist and undervest drawn up to the lower border of the ribs and the 
 skirts drawn down to the level of the trochanters. In this way enough 
 of the patient's abdomen and back is exposed for all ordinary pelvimetry 
 save that of the outlet which will come later. The ordinary measurements 
 taken in external pelvimetry are the folloAying: 
 
 (a) Distance between anterior superior iliac spines, called the inter- 
 spinous diameter. 
 
 (b) Distance between iliac crests, called intercristal diameter. 
 
 (c) Distance between left posterior superior iliac spine and right 
 anterior superior iliac spine, called left oblique diameter. 
 
 (d) Distance between right posterior superior iliac spine and left 
 anterior superior iliac spine, called right oblique diameter. ^ 
 
 (e) Distance between sulcus just beneath spine of last lumbar vertebra 
 and the upper anterior border of the symphysis pubis, called the external 
 conjugate or Baudelocque's diameter. 
 
 (/) Distance between the tuberosities of the ischium, called the trans- 
 verse diameter of the outlet. 
 
 The distance between the under surface of the symphysis and the tip 
 of the sacrum, called the anteroposterior diameter of the outlet, is sometimes 
 taken but is of little value, as in contracted pelves the pubic arch is so 
 narrow that but little of the space is available for the fetal head. 
 
 There are several good pelvimeters on the market, but the one used by 
 the author, both at the Sloane Hospital and in his private practice, is the 
 Breisky, a modification of Baudelocque's, which is broad enough to 
 surround the patient's hips in taking the oblique and external conjugate 
 diameters, yet rigid enough to give accurate measurements. The method 
 of taking the measurements is as follows : With the patient in the dorsal 
 position, the tips of the pelvimeter are held between the thumb, index 
 and middle fingers of each hand. Facing the head of the patient and 
 holding the pelvimeter with index upward, the tips are placed on each 
 anterior superior iliac spine (see 1 and 2, Figs. 117 and 118) and the reading 
 taken. The tips of the pelvimeter are then slid along the crest of the ilia 
 and the reading of the greatest amount of separation taken as the inter- 
 cristal diameter (see 3 and 4> Figs. 117 and 118). 
 
 The patient is then turned into the left lateral or Sims' s position, and 
 with the obstetrician facing the head of the table, the distance is measured 
 from the left posterosuperior iliac spine to the right anterosuperior 
 iliac spine (see 5 in Figs. 119 and 120 and 2 in Fig. 118). The location 
 of each posterosuperior iliac spine is usually indicated by a dimple 
 which with the dimple caused by the depression under the spine of the 
 last lumbar vertebra and the one over the lower part of the sacrum 
 
ANTEPARTUM EXAMINATION 
 
 171 
 
 forms what is called the rhomboid of Michaelis (see Fig. 121). These 
 four points are often not all visible and one frequently, especially in fleshy 
 women, has to locate the depression beneath the last lumbar spine by 
 
 Fig. 117. — Mensuration of iiitcrspinous and intercristal diameters. 
 
 10 9 
 
 Fig. 118. — Pelvis showing points taken in mensuration. 
 
172 
 
 THE MANAGEMENT OF NORMAL PREGNANCY 
 
 Fig. 119. — Mensuration of the left oblique diameter. 
 
 Fig. 120. — Pelvis showing points taken in mensuration. 
 
ANTEPARTUM EXAMINATION 
 
 173 
 
 the sense of touch alone. The dimples over the posterosuperior iliac 
 spines, however, are usually visible in proper light and are of value to the 
 beginner in pelvimetry. 
 
 1 Ij 
 
 
 
 w]^J 
 
 
 ^Ik^ -^""^^^fK 
 
 Fig. 121. — Dimples forming the rhomboid of :Micluieli; 
 
 Fig. 122. — Mensuration of right oblique diameter. 
 
174 THE MANAGEMENT OF NORMAL rRECXANCY 
 
 f5 
 
 Fig. 124. — Mensuration of external conjugate diameter. 
 
ANTEPARTUM EXAMINATION 
 
 - 175 
 
 The patient is now turned upon her right side and, with the examiner 
 facmg the foot of the table, the right obhque diameter, from the tip ot 
 
 Fig. 125.— Pelvis showing points taken in mensuration. 
 
 Fig 
 
 . 126.— Mensuration of the transverse diameter of the outlet. 
 
 the right posterosuperior ihac spine to t^e tip of the left ant^ero- 
 supeS ilia^c spine (see 6 in Figs. 122 and 123 and 1 m Fig. 118) is taken. 
 
17G THE MAXAGEMEXT OF XORMAL PREGXANCY 
 
 This right obhque diameter of the pelvis is usualh' a trifle longer than the 
 left. 
 
 With the patient still in the right lateral position the external conju- 
 gate diameter is measured. The posterior point taken is the depression 
 just below the spine of the last lumbar vertebra, and with one tip of the 
 pelvimeter placed in this position (see 7 in Figs. 123 and 124), the other 
 tip is carried between the patient's thighs and placed upon the anterior 
 upper border of the symphysis (see 8 in Fig. 123). 
 
 For taking the transverse diameter of the outlet the patient is placed 
 in the lithotomy position and the examiner, locating the tul)erosities of 
 the ischia with his thumbs, as illustrated in Fig. 126, measures the distance 
 with the pelvimeter between the points 9 and 10. 
 
 While marked variations occur in the external measurements of different 
 pelves called normal, it is well for the student to have in mind certain 
 measurements which may be regarded as normal. The following may be 
 considered as such, and for ease of memory fractions will be omitted: 
 
 External Measurements of Normal Pelvis. 
 
 Intcrspinous diameter ... 26 cm. Right oblique diameter . 22 + cm. 
 
 Intercristal diameter ... 28 cm. External conjugate diameter . 20 cm. 
 
 Left oblique diameter ... 22 cm. Transverse diameter of the outlet 11 cm. 
 
 Value of External Pelvimetry. — It is well known that pelvimetry, and 
 especially external pelvimetry, cannot be depended upon alone. The 
 author has met with a number of cases giving marked dystocia, perhaps 
 even requiring Cesarean section for deli^'e^y, in which pelvimetry gave 
 him no indication that the labor was to be anything but normal. This 
 is not difficult to understand when there is considered the fact that 
 obstruction at the brim produced by the lower lumbar ^•erteb^a? is often 
 not indicated in external pelvimetry and may be situated too high to 
 be reached by the examining fingers in the vagina. 
 
 External pelvimetry has value, however, and often great value in diag- 
 nosis of abnormal pelves and by giving information which otherwise 
 might come as a surprise to the obstetrician during labor, finding him 
 unprepared for dealing with complications which should have been met 
 by prophylaxis. 
 
 While the interspinous and intercristal diameters by themselves are 
 often of little value, their relative measurements are of great value in 
 diagnosis. If they are about equal, and especially if the interspinous 
 diameter exceeds the intercristal, the pelvis is probably rachitic. 
 
 The oblique diameters give valuable information, both as to the general 
 size of the pelvis, i. e., whether it is generally contracted or not, and also 
 show whether the pelvis is symmetrical or not, i. e., discloses an obliquely 
 contracted pehis. 
 
 The external conjugate varies greatly in size in different individuals 
 and often gives little information of value. If, however, the external 
 conjugate measures only 18 cm. or less, it is often a forerunner of dystocia, 
 and should indicate a very careful pelvic examination. 
 
 The measurement of the transverse diameter of the outlet and the 
 
THE PRESENTATION AND POSITION OF THE CHILD 177 
 
 palpation of the shape of the pubic arch give valuable information as 
 to the presence or absence of a funnel-shaped pelvis or one contracted 
 at the outlet. 
 
 Having ascertained the external characters of the pelvis, the abdomen 
 and its contents should now be inspected and palpated. The occasional 
 occurrence of dystocia resulting from previous operations upon the 
 pelvic organs makes it wise always to inspect the abdomen for cicatrices 
 and to ascertain if possible the character of the operation to which the 
 patient has been subjected. The abdomen should also be palpated for 
 abdominal tumors other than the pregnant uterus. So much knowledge 
 can be obtained by palpation of the pregnant uterus through the abdom- 
 inal wall during the last third of pregnancy that the student should 
 endeavor to make himself an expert in this direction. Furthermore, the 
 recognition of the fact that each vaginal examination in the later weeks 
 of pregnancy adds to the risk of maternal infection makes it desirable 
 to substitute, as far as possible, abdominal examinations for vaginal. 
 Aside from the information regarding the condition of the abdominal 
 wall, the presence of tumors and the size of the uterine body, the follow- 
 ing facts can, in the latter third of pregnancy, usually be determined by 
 skilled, careful palpation of the uterus through the abdominal wall. 
 
 The Presentation and Position of the Child. — Presentation may be 
 defined as the relation which the long axis of the fetus bears to that 
 of the mother, thus a longitudinal, an oblique, or a transverse presen- 
 tation (see page 244). A presentation is usually named from the "pre- 
 senting part" which is that part of the fetus which lies over the cervix 
 and is felt by the examining fingers. Thus a vertex presentation, a 
 breech presentation, etc. 
 
 Position is the relation of a selected position of the presenting part 
 to certain fixed landmarks in the maternal pelvis (see page 248). If 
 the examination is made during the early months of pregnancy and 
 the uterus is palpable above the pelvic brim, this palpation should 
 be made to see if the size corresponds with the supposed duration of 
 pregnancy. During the latter part of pregnancy the palpation should 
 be thorough and all available information obtained. 
 
 It is always well to have a definite order in any careful examination 
 and the one recommended by the author is as follows: 
 
 Location of the Fetal Back and Small Parts. — Standing with face toward 
 the patient's feet (see Fig. 127), the examiner carefully palpates both sides 
 of the abdomen with the palmar surfaces of the fingers, gently moving 
 them up and down. On one side is usually felt the broad, smooth back 
 of the fetus and on the other side the irregular nodules of the small parts. 
 
 This is sometimes brought out more distinctly by pressing gently with 
 the hand on the side where the small parts are, thus forcing the back 
 of the fetus up against the abdominal wall (see Figs. 128 and 129). In 
 women with thin abdominal walls the nodules can often be differentiated 
 into arms and legs, but with fat abdominal walls this is impossible. The 
 presence of the small parts on one side means, except in the case of twins, 
 that the back is on the other. 
 12 
 
178 
 
 THE MANAGEMENT OF NORMAL PREGNANCY 
 
 Having determined upon which side the back of the child Hes, the next 
 step is to decide whether it Hes anteriorly, laterally, or posteriorly. 
 
 Fig. 127. — Palpation of the fetal back and small parts. 
 
 Fi*;- 12S. — Fetal Viaek occupying left side of abdomen (L. O. A. ijujitioiij. Right side of 
 abdomen occupied by small parts easily depressed by hand. 
 
THE PRESENTATION AND POSITION OF THE CHILD 179 
 
 This is determined by the amount of the broad, smooth surface which 
 can be felt. If the back lies anteriorly the most of this convex surface 
 
 Fig. 129. — Fetal back occupying right side of abdomen (R. O. A. position). 
 of abdomen occupied by small parts easily depressed by hand. 
 
 Left side 
 
 Fig. 130. — Palpation of the lower fetal pole. 
 
 can be felt. If it lies laterally the surface felt is narrower and shows a 
 sulcus between the fetal head and shoulder. Furthermore, the nodula- 
 tions of the upper and lower extremities are more distinct. If the fetal 
 
180 
 
 THE MANAGEMENT OF NORMAL PREGNANCY 
 
 back lies posteriorly, little of this dorsal surface of the fetus can be felt, 
 but the small parts lie anteriorly, enabling one to feel the various nodules 
 presented by them. 
 
 Palpation of the Presenting Fetal Pole. — Still facing the feet of the patient 
 the examiner (see Fig. 130) passes his hands, applied flat upon the abdo- 
 men, down toward the brim of the pelvis. If the head presents, the fingers 
 of one hand at least soon impinge upon a hard, round body, the cephalic 
 extremity. This feeling of a hard, round body separated from the 
 trunk by the constriction of the neck determines the fact of a cephalic 
 presentation. 
 
 If the presenting part has descended into the pelvis before labor, 
 it is an evidence that the lower part of the fetus is cephalic rather than 
 the breech, which does not descend until labor begins. 
 
 P^iG. 131. — Palpation of the upper fetal pole. 
 
 The feel of the breech is not as distinct as is that of the head, and the 
 positive diagnosis of a breech presentation by abdominal palpation is 
 usually made by finding the head elsewhere. In transverse presentations 
 the lower fetal pole lies in one iliac fossa. 
 
 Having determined that the presentation is cephalic, the next step is 
 to make out the position of the head. In vertex presentations the promi- 
 nence arresting the fingers is on the same side as the small parts of the 
 fetus, while in face presentations the prominence is on the same side as 
 the back. In vertex presentations, as the prominence felt corresponds 
 with the forehead, the ease with which it can be felt tells the degree 
 of flexion of the head and its descent into the pel;^is. 
 
THE PRESENTATION AND POSITION OF THE CHILD 181 
 
 This method of examination is of value not only during the latter 
 months of pregnancy but also during labor, as by it can be determined, 
 in the intervals between uterine contractions, not only the presentation 
 and position of the child but also the amount of its descent into the 
 pelvis. 
 
 Palpation of the Upper Fetal Pole. — For this manipulation the examiner 
 faces the patient's head and applies the palmar surface of the fingers to 
 the fundus of the uterus (see Fig. 131). By gentle palpation can be 
 differentiated the hard, round, movable head which may be subjected to 
 ballottement from the softer, less movable, irregularly shaped breech 
 with the nodules of the small parts near it. 
 
 During uterine contractions careful palpation will often detect the 
 presence of small fibroid tumors, should any exist, and by palpating 
 between the internal abdominal rings and the fundus of the uterus 
 can often easily be made out the round ligaments which can be rolled 
 under the fingers. 
 
 Some authorities advocate, as a step in the routine method of examina- 
 tion, the grasping through the abdominal wall of the lower fetal pole 
 between the thumb and fingers of one hand and by palpation and test- 
 ing its mobility gaining such information as is possible. It seems to the 
 author, however, that little is gained by this that is not possible in the 
 methods already outlined. By careful practise with the three methods 
 above described, each time trying to learn as much as possible at each 
 step in the procedure, the student becomes expert in diagnosis by 
 external manipulation and learns to depend less and less upon vaginal 
 examination. 
 
 Auscultation of the Fetal Heart. — ^The recognition of the importance 
 of careful observation of the fetal heart sounds, especially during labor, 
 has grown in recent years. So important during labor are marked changes 
 in its normal beat as indicating excessive or too prolonged pressure that 
 the obstetrician should regard the auscultation of the fetal heart during 
 pregnancy as important, not only for verifying his diagnosis of the presen- 
 tation and position of the child but as giving him information as to the 
 normal heart sounds of the individual case with which he may contrast 
 the findings during labor. The fetal heart sounds are usually transmitted 
 through the portion of fetal trunk which is in contact with the abdominal 
 wall of the mother, i. e., usually through the back of the fetus in vertex 
 and breech presentations and through the anterior thorax in face pre- 
 sentations. It is evident, therefore, that the site of greatest intensity of 
 the fetal heart sounds will often indicate the presentation and position 
 of the child and the approach of this site toward the median line and 
 toward the symphysis pubis will mark the rotation and descent of the 
 child in labor. 
 
 Various factors may interfere with the ability to hear the fetal heart. 
 Among them may be mentioned a very fat abdomen, an excessive amount 
 of liquor amnii, an occipitoposterior position of the child, an anterior 
 attachment of the placenta and a very loud uterine souffle. Of course if 
 the child is dead the fetal heart sounds are absent, but on account of the 
 
182 THE MANAGEMENT OF NORMAL PREGNANCY 
 
 difficulty in many cases of obtaining the sound even if the child is alive, 
 the diagnosis of the death of the fetus should only be made after several 
 examinations and when taken in conjimction with other symptoms of 
 fetal death. 
 
 The character of the fetal heart sounds as an index of the condition 
 of the child will be discussed later; suffice it for the present to state that 
 any marked irregularity of the fetal heart, or any marked increase or 
 decrease in its rapidity, as compared with that previously noted as its 
 normal rate, is an indication of a disturbance of the fetal circulation and 
 is important. 
 
 Fig. 132. — Method of using stethoscope in listening to the fetal heart. 
 
 The heart sounds may be heard either with the naked ear or with 
 the stethoscope, and in the use of the stethoscope it is usually of assis- 
 tance to have attached to it two rubber bands, as shown in Fig. 132, 
 with which the instrument can be steadied and with which its press- 
 ure against the abdominal w^all can be regulated with ease, at the same 
 time avoiding the blurring of the heart sounds which comes from the 
 vibrations caused by holding the bell of the stethoscope with the fingers. 
 In cephalic presentations the fetal heart sounds are usually heard most 
 distinctly below the level of the umbilicus, while in breech presentations 
 the site of greatest intensity is usually above the umbilicus. In occipito- 
 anterior positions of vertex presentations the site of greatest intensity 
 is usually near the middle of the line joining the umbilicus with the 
 anterosuperior iliac spine of that side. In occipitoposterior positions 
 
FETAL HEART RATE, AGE AND SEX OF THE CHILD 183 
 
 the fetal heart is usually heard most distinctly outside of this line 
 and nearer the flank. As the most usual position of the fetus is with 
 head presenting and back to the left and anterior, the most usual site 
 for hearing the fetal heart sounds is about the middle of the line joining 
 the umbilicus and the left anterior superior spine of the ilium. The next 
 most usual site is the corresponding point on the right side of the abdomen. 
 Occasionally in occipitoposterior positions of the vertex the location of the 
 heart sounds is misleading, as in some cases flexion of the head is so imper- 
 fect that the thorax is crowded up against the anterior abdominal wall and 
 the heart sounds are transmitted through this rather than the back, and the 
 idea is given that the case is one of occipito-anterior position rather than 
 occipitoposterior. 
 
 In twin pregnancy tw^o fetal heart sounds should be heard, synchronous 
 neither with each other nor with the mother's pulse. The rapidity of the 
 fetal heart sounds varies between 120 and 160. 
 
 The attempt has often been made to determine the sex of the child 
 by the rapidity of the fetal heart beat. In order to determine the relation 
 between the fetal heart rate, weight and sex of the child, the author took 
 5000 consecutive normal cases at the Sloane Hospital in which the fetal 
 heart was counted during the first stage of labor at term and in which 
 the baby was carefully weighed at birth. In this series of 5000 there 
 were 2577 males and 2423 females. 
 
 In the 2577 males the average fetal heart rate was 141.86. 
 
 In the 2423 females the average fetal heart rate was 146.65. 
 
 This gave the average fetal heart rate in the 5000 cases, 144.25. 
 
 In this series of 2577 males the average birth weight was 7 pounds 4.1 
 ounces. 
 
 In this series of 2423 females the average birth weight was 7 pounds 
 1.9 ounces. 
 
 This gave the average birth weight in the 5000 cases as 7 pounds 3 
 ounces. 
 
 All of these cases were at term; none under 48 cm. in length being 
 included. 
 
 For a long time it was thought that boys were heavier at birth than 
 girls; that the heavier child had the slower heart rate; hence, that a slow 
 fetal heart rate (around 120) indicated a boy or a large girl, and that a 
 rapid fetal heart rate (around 160) indicated a girl or a small boy. A 
 comparison of the fetal heart rate and birth weight in the above series 
 shows that while the average weight of the boys was a little greater than 
 that of the girls and the average heart rate of the boys was a little slower 
 than that of the girls, the difference was so slight as to render the fetal 
 heart rate of very little practical value in determining the sex of the 
 child before birth. This is still further shown by the fact that in 400 
 cases in the above series in which the birth weight was 6 pounds or less, 
 the fetal heart rate averaged 144.67, while in 100 cases in which the birth 
 weight was 8 pounds or over, the fetal heart rate averaged 145.09. 
 This series of 5000 cases indicates that in New York City at least the 
 number of male births slightly exceeds that of the females— 2577 males; 
 
184 THE MANAGEMENT OF NORMAL PREGNANCY 
 
 2423 females. This corresponds with the vital statistics of the Board of 
 Health of the City of New York which for the years 1912, 1913, and 1914 
 were as follows: 
 
 Male. Female. 
 
 fWhite 68,169 65,046 
 
 1912{Black 1,245 1,171 
 
 [Chinese 11 13 
 
 (White 67,926 64,773 
 
 1913] Black 1,236 1,176 
 
 [Chinese 11 12 
 
 f White 70,315 67,810 
 
 1914{Black 1,274 1,226 
 
 [Chinese 13 9 
 
 It is seen from the above that, save in the small number of Chinese, 
 the males exceeded the females, and this has been the case for a long 
 period of years. 
 
 Vaginal and Bimanual Examination. — Attention has already been 
 directed to the fact that during the early months of pregnancy there 
 are marked advantages in having the obstetrician thoroughly familiar 
 with the condition of the pelvic organs and the cavity of the pelvis. Of 
 course at this period the former is much more important than the latter, 
 but in making a thorough examination of the pelvic organs it adds but 
 little to examine the pelvic canal at the same time. 
 
 In making a vaginal examination during the early months of pregnancy 
 it is not necessary to be as thorough in hand disinfection and prepara- 
 tion of the vulva as it is near term, yet the hands should always be 
 thoroughly scrubbed with soap and water and the examiner should culti- 
 vate the habit of always separating the labia with the fingers of one hand 
 before introducing the examining fingers in every pregnant patient, so as 
 to avoid carrying infection from vulva without to vagina w^ithin. 
 
 In this examination the obstetrician should by inspection and palpation 
 carefully note the condition of the pelvic floor; the height of the vulva 
 compared to the pubic arch, and, if the patient is a multipara, the results 
 of the previous labor or labors. He should also carefully examine for 
 evidences of gonorrheal infection in the ducts of the vulvovaginal 
 glands and urethra. Noting the condition of the vaginal canal and the 
 cervix as he proceeds, the examiner should now make a gentle bimanual 
 examination and determine if the uterus is in normal position; if it 
 presents the usual characteristics of pregnancy, if the size corresponds 
 with the supposed duration of pregnancy and, lastly, if there are any 
 abnormal growths in or about the uterus. After a little experience the 
 examiner unconsciously notes these different facts without thought of 
 order or detail of method. 
 
 It is well to bear in mind that during the early months of pregnancy 
 the uterus is more irritable at the times which correspond to the 
 menstrual periods and at these times even a bimanual examination may 
 tend to induce a miscarriage. In making a bimanual examination then, 
 the would-be menstrual periods should be avoided. The tendency of an 
 uncorrected retroversion to produce a miscarriage is so great that as 
 
VAGINAL AND BIMANUAL EXAMINATION 185 
 
 soon as it can be done the uterus should be replaced and supported by a 
 pessary until the pregnancy is three or four months advanced. This 
 replacement is usually easily accomplished by placing the patient on her 
 side with knees drawn up (Sims's position) or in the knee-chest position, 
 and then with the fingers in the posterior fornix pushing upward gently 
 on the fundus, then as it rises transferring the fingers to the front of the 
 cervix and pushing upward and backward on the cervix. In some cases 
 where the retroverted uterus has been fixed in that position by adhesions, 
 the uterus cannot be replaced at once and time must be given for nature 
 to soften and stretch the adhesions in the growth of the uterus. The 
 frequency with which a retroverted pregnant uterus has to be corrected 
 at the time of the preliminary examination is so great that it has seemed 
 wise to include a brief statement here concerning it. 
 
 Having determined the condition of the pelvic organs the next step 
 is the examination of the pelvic canal. 
 
 Fig. 133. — Mensuration of the diagonal conjugate. 
 
 The diameter which is most often shortened and the one most impor- 
 tant to know is the true conjugate, i. e., the distance between the promon- 
 tory of the sacrum and the upper border of the symphysis pubis. On 
 account of the difficulty of measuring this diameter by instruments 
 devised for this purpose the ordinary method employed is to measure 
 with the fingers the diagonal conjugate which is the distance from the 
 promontory of the sacrum to the lower border of the symphysis pubis, 
 this giving one side of a triangle of which the true conjugate, the side 
 desired, and the height of the symphysis form the other two. By 
 deducting H-2 cm., depending on the height and inclination of the 
 symphysis pubis, from the length of the diagonal conjugate, an approxi- 
 mation to the true conjugate is obtained. For this method we are largely 
 indebted to Baudelocque, whose name is also associated with the measure- 
 ment of the external conjugate diameter. To measure the diagonal 
 
186 TtiE MANAGEMENT OF NOUMAL PREGNANCY 
 
 conjugate the patient is placed in the dorsal position with knees flexed, 
 and the examiner introduces the middle and index-fingers of his left 
 hand (see Fig. 133) until his middle finger impinges upon the promontory 
 of the sacrum. 
 
 In order to reach this in the normal pelvis it is usually necessary to 
 flex well the ring and little fingers, to depress the elbow and slightly invert 
 the perineum and vulva. On reaching the promontory the radial side 
 of the hand is raised firmly against the subpubic arch and with the index- 
 finger nail of the right hand a mark is made on the left index-finger as 
 near the lower border of the symphysis as possible. The examining fingers 
 are then withdrawn and an assistant measures with 'a pelvimeter the 
 distance between the mark on the left index-finger and the tip of the 
 middle finger. This is the diagonal conjugate. While the fingers are 
 in the vagina feeling for the promontor\' they should be swept up and 
 down the posterior and lateral walls of the pelvis noting the vertical and 
 lateral curves of the sacrum, the condition of the coccyx, and the amount 
 of room at the sides of the pelvis. 
 
 The promontory of the sacrum in pelves where the posterior wall can 
 be palpated is, as a rule, easily made out as the bony margin at the 
 base of the sacrum. In some cases, however, the junction of the first 
 and second sacral vertebrae may form a prominence called a double 
 promontory, or the projection of the last lumbar vertebra may cause 
 confusion, but the mention and thought of these possibilities will usually 
 enable the operator to avoid the error. 
 
 The amount usually deducted from the diagonal conjugate to obtain the 
 true conjugate is 1^ cm., but this presupposes a normal height of the sym- 
 physis, about 4 cm. ; a normal angle between symphysis and true conjugate, 
 about 105°; a normal thickness of symphysis and a normal height of prom- 
 ontory, but unfortunately for pelvimetry all these factors are subject to 
 variations. In practise the general rule is to deduct 1| cm., if the 
 symphysis seems normal, and 2 cm. if it seems higher or more inclined 
 than normal. 
 
 Numerous instruments have been devised for the measurement of the 
 true conjugate, notably those of Stein, Skutsch and Farabeuf, but 
 although ingenious and theoretically .accurate, most of them have the 
 disadvantage of being cumbersome, difficult to introduce and so painful 
 to the patient as often to require anesthesia. For these reasons they 
 are very little employed. P'urthermore, Farabeuf's instrument, the 
 anterior bar of which is passed through the urethra into the bladder, is 
 rather apt to abraid the vesical mucosa. 
 
 i\lore recently Hirst has devised a simpler instrument (see Fig. 134), 
 which promises to be of marked value. The following illustrations and 
 description of the use of his instrument are taken from Hirst's Text- 
 hook of Obstetrics. "The patient is put in the dorsal position 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 | inch below the upper edge. The two 
 fingers of the left hand are inserted in the vagina as in measuring the 
 
VAGINAL AND BIMANUAL EXAMINATION 
 
 187 
 
 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 Fig. 1.34, is made to take its place. 
 While the examining physician holds the shaft of the pelvimeter firmly 
 in place the assistant adjusts tip A of the movable bar over the mark 
 made on the sjTnphysis. 
 
 "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 conjugate plus the thickness of the s^Tnphysis (see Fig. 135). 
 The thickness of the s}Tnphysis is measured as shown in Fig. 136. In 
 living subjects the index-finger of the left hand must find the inner 
 surface of the symphysis pubis and must follow it up to within about 
 I inch 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 
 
 Fig. 134. — Hirst's peh-imeter. 
 
 is adjusted over the mark made on the skin 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 the inner 
 surface of the sjTQphysis can usually be so compressed by the knob of the 
 pelvimeter as to be practically eliminated. If this is impossible, as may 
 happen in some primigravidse, a small allowance may be made for these 
 tissues, say, at the most 0.5 centimeter. Even with this pelvimeter 
 anesthesia is sometimes necessary, yet this is of small moment when 
 an accurate measurement of the conjugate is needed." 
 
 With all these methods for measuring the true conjugate it must be 
 remembered that the other factor in the problem, i. e., the fetal head is 
 exceedingly difficult to measure and that the real problem is whether 
 that individual head will pass through the pelvis in question, and this 
 cannot be determined by pure mathematics. For these reasons the 
 
188 THE MANAGEMENT OF NORMAL PREGNANCY 
 
 method already described of measuring tlie diagonal conjugate with the 
 fingers and then deducting a certain amount to obtain the true conjugate 
 is the method most generally useful. A sufficient knowledge of the 
 transverse diameter of the cavity of the pelvis is usually obtained by 
 
 Fig. 135. — Measuring the true conjugate, plus the thickness of the symphysis, with 
 Hirst's pelvimeter. (Hirst). 
 
 careful palpation of the lateral pelvic wall combined with consideration 
 of the interspinous, intercristal and oblique diameters obtained by exter- 
 nal pelvimetry. 
 
 So little is gained by measuring the distance between the trochanters 
 that this procedure is omitted in routine pelvimetry at the Sloane 
 Hospital. 
 
 Fig. 136. — Measuring the thickness of the symphysis with Hirst's pelvimeter. (Hirst.) 
 
 Although the sacropubic or anteroposterior diameter of the outlet may 
 be measured externally with a pelvimeter, a very good method is by the 
 use of the vaginal fingers in a manner similar to the method used in 
 measuring the diagonal conjugate. In this case feeling with the second 
 
CEPHALOMETRY 189 
 
 finger of the left hand the apex of the sacrum, the radial side of the index- 
 finger is marked with the index-finger nail of the other hand, just beneath 
 the pubic arch. The distance between this mark and the tip of the middle 
 finger is then measured with a pelvimeter. This gives the approximate 
 length of the sacropubic diameter. 
 
 A very valuable internal pelvimeter in all practical obstetrics is the 
 individual hand of the obstetrician, as has been well emphasized by 
 Edgar in his text-book. If the obstetrician knows the transverse diam- 
 eter of his flat hand and of his closed fist and the size of the latter as 
 compared to a normal fetal head, he can often, with the patient under 
 anesthesia, and hand in the vagina, tell better whether a fetal head will 
 pass than by any metal pelvimeter. 
 
 Cephalometry. — If the examination of the patient is at or near term 
 and the problem is presented of whether the given head will pass the 
 individual pelvis, after estimating the size of the pelvic canal as nearly 
 as possible, it is desirable to know the size of the child's head. 
 
 Various methods have been devised for determining the biparietal 
 diameter which is the one of chief consideration in the passage of the 
 head through a contracted pelvis. The first to practise direct measure- 
 ment of the fetal head through the abdominal wall was Ferret,^ who 
 had found from numerous measurements of fetal skulls that the biparietal 
 diameter is approximately 2| cm. shorter than the occipitofrontal 
 measurement. For measuring the occipitofrontal diameter through 
 the abdominal wall Ferret devised a special cephalometer, the tips 
 of which are applied to the occiput and forehead of the child through 
 the abdominal wall, after the head has been located by the hands 
 of the examiner, and the reading taken from the scale of the instru- 
 ment. The thickness of the abdominal wall is then measured by pinch- 
 ing up a fold of it and measuring this with the cephalometer or a pel- 
 vimeter. Subtracting this measurement from the previous one gives the 
 occipitofrontal diameter of the child's head. If 2^ cm. is now subtracted 
 from this we obtain the biparietal diameter, the measurement desired. 
 
 In the hands of Ferret the results were surprisingly good, and the 
 difference between the antepartum and postpartum measurement remark- 
 ably small. 
 
 In 1915 Stone^ published a modification of Ferret's method in which 
 an ordinary pelvimeter is used and no deduction made for the thickness 
 of the abdominal wall. Neither the Ferret method nor that of Stone 
 is applicable when the head is engaged, but when not engaged the head 
 can be measured by the Stone method as follows: 
 
 With the patient in the ordinary dorsal position, the examiner stands 
 facing the foot of the table and carefully maps out the position of the 
 fetal head, grasping the occipital and frontal poles between the fingers 
 of the two hands. An assistant facing the examiner then places the tips 
 of the pelvimeter firmly on the fetal head between the ends of the middle 
 and ring fingers of the examiner, who directs the location and amount 
 
 iLa cephalometrie externe, etc., L'Obstetrique, 1899, iv, 542-584. 
 2 New York Med. Record, November 4, 1905, p. 725. 
 
190 THE MANAGEMENT OF NORMAL PREGNANCY 
 
 of pressure. From this occipitofrontal diameter is subtracted 2.5 cm., 
 which is the average difference between the occipitofrontal and biparietal 
 diameters at the seventh, eighth, and ninth month of pregnancy. 
 
 Stone, after further experience with the method, recommends that 
 with heads ha^'ing an occipitofrontal diameter of less than 11 cm., 2 
 cm. be subtracted, and where the occipitofrontal diameter is more than 
 11 cm., 2.5 cm. be subtracted. 
 
 Manual Methods. — In addition to the instrumental methods of meas- 
 uring the fetal head, various manual procedures for estimating the relati\'e 
 size of the head and pelvic canal, the real problem of importance, are in use. 
 
 In the method introduced by Miiller, and often called by his name, 
 the brow and occiput of the fetus are seized by the fingers of the two 
 hands through the abdomen and downward pressure made upon the 
 head in the axis of the superior strait, while an assistant with fingers in 
 the vagina notes the amount of engagement and descent. In a modifi- 
 cation of this method practised by Pinard, of Paris, and called by him 
 "Le palper mensurateur," no assistant is necessary, but after the fetal 
 head has been placed in the brim of the pelvis by the fingers of both 
 hands working through the abdomen, with one hand externally, the head 
 is pushed downward and backward so that its posterior surface lies 
 against the promontory, while the obstetrician with the fingers of the 
 other hand in the vagina tries to insert them between the head and the 
 symphysis and in this way determine the amoimt of additional room. 
 
 The method which has given the author most satisfaction might be 
 called a combination of the two above mentioned and consists of two steps: 
 
 1. Abdominal Manipulation. — With the fingers of both hands on the 
 long diameter of the head (as in Fig. 130), for palpation of the lower 
 fetal pole) endeavor to engage the head in the brim of the pelvis and 
 note the extent this is possible. 
 
 2. Bimanual Manipulation. — With the fingers of one hand in the vagina 
 and the other hand on the abdomen determine first by pressure on the 
 head above the symphysis and then by downward pressure on the fundus 
 of the uterus, the ease with which the head is made to engage and the 
 amount of descent as felt by the vaginal fingers. In all these manipula- 
 tions, if the patient is very sensitive or the abdominal wall very thick 
 it may be necessary for a satisfactory examination to place the woman 
 under an anesthetic. 
 
 A method which is often of ^'alue when the patient is anesthetized con- 
 sists in the insertion of the whole hand into the vagina, seizing and palpating 
 the fetal head for determination of its size, then closing the hand and com- 
 paring the size of the fist with the different diameters of the pelvis. 
 
 Of course the methods above described are ina])plicab]e in any save 
 cephalic ])resentations and are usually inapplicable in cases of placenta 
 previa except those of the extreme lateral type. In these manual proced- 
 ures, if the head can readily be made to dip into the pelvis, a favorable 
 prognosis of normal labor is easily justified, while on the contrary the 
 converse is not always true as the capacity of the head for molding 
 under the influence of labor is always uncertain. 
 
CHAPTER VI. 
 MULTIPLE PREGNANCY. 
 
 A MULTIPLE pregnancy (not including ectopic gestation) is one in 
 which the gravid uterus contains more than one fetus. It is called a 
 twin, triplet, quadruplet, quintuplet, or sextuplet pregnancy, according 
 to the number present. There are only a few sextuplet pregnancies on 
 record, and some of these the author by investigation has found to be 
 spurious. 
 
 Frequency. — Some idea of the frequency of multiple pregnancy may 
 be gained by a study of the 20,000 consecutive deliveries at the Sloane 
 Hospital. In this series there were 244 pairs of twins and 4 sets of trip- 
 lets. In a series of 33,000 consecutive deliveries at this hospital there 
 have occurred no quadruplets, quintuplets, or sextuplets. 
 
 Etiology. — ^Little is known concerning the etiology of multiple preg- 
 nancy, save that heredity plays a very important part. This is seen 
 especially on the maternal side, and cases are on record in which multiple 
 pregnancy has occurred in all the females of the family for several 
 generations. 
 
 The hereditary influence favoring multiple pregnancy, although usually 
 most marked on the maternal side, is not confined to it, as occasionally 
 the influence is seen to be paternal, as is shown by marriage to different 
 wives being followed by multiple pregnancy. According to Hellin^ the 
 ovaries of women who have had a number of multiple pregnancies con- 
 tain a greater number of ova than is usual and the frequency of multiple 
 pregnancy is probably due to the ripening each month of several ova 
 instead of one. 
 
 Multiple pregnancy seems to be much more common in some countries 
 than in others. Thus, reports seem to indicate that they are especially 
 common in Russia and in Greece. 
 
 Multiple pregnancy is more common in multigravidse than in primi- 
 gravidse. In the series of 244 twin pregnancies at the Sloane Hospital 
 there were 140, or 57.4 per cent, multigravidee and only 104, or 42.6 per 
 cent, primigravidse. In the 4 sets of triplets 3 were in multigravidse 
 and only 1 in a primigravida. 
 
 Twin Pregnancy. — As seen from the statistics of the Sloane Hospital, 
 twin pregnancy is by far the most common form of multiple pregnancy. 
 The frequency of 244 in 20,000 dehveries gives a percentage of 1.22 
 per cent., or about 1 in 82. 
 
 Twin pregnancy may result from the fertihzation of two ova from the 
 same or from difterent ovaries, or it may residt from the fertilization of 
 one ovum which has two nuclei (see Fig. 137), each nucleus being fer- 
 
 1 Die Ursache der Multiparitat der uniparen Thiere, etc., Miinchen, 189.5. 
 
 (191) 
 
192 
 
 M ULTIPLE rREGXAXCY 
 
 Fig. 137. — Ovum with two nuclei 
 (Bumm, after v. Franque). 
 
 tilized. Single ovum twin.s may also arise, as is believed today, by a 
 
 division of the blastodermic vesicle somewhat resembling the process 
 
 followed in the formation of double 
 monsters. Twins arising from a 
 single ovum are always of the same 
 sex. Twins from separate ova may 
 be of the same or of the opposite 
 >ex. Twins of course usually de- 
 \elop in the same uterine ca\'ity. 
 Twins, however, which arise from 
 two ova may each develop in 
 separate halves of a double uterus 
 or one may develop in the uter- 
 ine cavity and one in the Fallo- 
 pian tube. 
 Superfecundation and Superfetation. — In the ordinary type of twin 
 
 pregnancy the two ova are supposed to be fertilized as the result of a 
 
 single coitus. The term superfecundatioyi, however, is used to explain 
 
 the fertilization of two ova within 
 
 a short period of each other, but not 
 
 at the same intercourse. Superfe- 
 cundation undoubtedly occurs in the 
 
 lower animals and its occurrence 
 
 among human beings has been de- 
 
 monstraterl quite a number of times 
 
 where two men of different color, 
 
 race or distinctive characteristics 
 
 have had intercourse with the same 
 
 woman with a short period of time 
 
 between them and the children have 
 
 shown the characteristics of the 
 
 different fathers. 
 
 Superfetation implies the presence 
 
 in the uterus of a fetus of several 
 
 weeks, or months, development at 
 
 the time of the fertilization of the 
 
 second ovum. While theoretically 
 
 this is possible until the decidua cap- 
 
 sularis reaches the decidua parietalis 
 
 which lies opposite to it, its occur- 
 rence has been accepted with a good 
 
 deal of scepticism and its positive 
 
 existence is difficult to prove. The 
 
 term superfetation was introduced 
 
 to explain the marked difference in 
 
 development found in the two fetuses 
 
 at term and yet there are numerous cases in which one twin has api)ro- 
 
 priated a much larger part of the space and nourishment than the other. 
 
 Fir,. 1.3S. — Fetus papyraceus. 
 
TWIN PREGNANCY 
 
 193 
 
 seen in its extreme degree in the fetus papyraceus (see Fig. 138) in which 
 one twin has been killed and flattened out against the wall of the uterus, 
 
 Fig. 1.39. — Twin pregnancy from separate ova. Placentae separate. 
 
 Fig. 140. — Twin placentae separate. 
 
 the other twin appropriating all the nourishment. Lesser degrees of 
 inequality of nourishment give rise to fetuses of markedly unequal 
 13 
 
194 
 
 MULTIPLE PREGNANCY 
 
 development. If the smaller fetus is retained in the uterus for a consider- 
 able time after the birth of the first and only then gives evidence of the 
 development usually found at term it is only natural that the explana- 
 
 FiG. 141. — Twin pregnancy from separate ova. Placentae fused. 
 
 Fig. 142. — Twin placentae fused. 
 
 tion of superfetation should haxe been offered. While very rarely this 
 explanation may be the correct one, it must be extremely exceptional 
 and the explanation of unequal nourishment and space, or the presence 
 
TWIN PREGNANCY 
 
 195 
 
 of two fetuses in different halves of a double uterus, more commonly the 
 true one. 
 
 Arrangement of Placentae and Membranes. — Twins arising from the fer- 
 tilization of two separate ova have each a separate amnion and a separate 
 chorion, although the placentae may be separate, as shown in Figs. 139 
 and 140, or fused, as shown in Figs. 141 and 142. 
 
 Twins arising from the fertilization of a single ovum with two nuclei 
 have each a separate amnion, but a common chorion (see Fig. 143). 
 In rare cases the amniotic partition which originally existed between 
 the twins becomes perforated so that they lie in a common amniotic 
 sac. If the ova are imbedded in the decidua at sufficiently distant points 
 (see Fig. 144) each ovum will have its own decidua capsularis (reflexa). 
 If the embedding areas of the two ova are near each other, or the case 
 
 Fig. 143. — Twins from a single 
 ovum . 
 
 Fig. 144. — Twins with separate decidua 
 capsularis. 
 
 is one of single ovum twins with fused placentae, there is only one decidua 
 capularis (see Fig. 143). 
 
 In twins arising from a single ovum there is more or less anastomosis 
 in the placenta of the vascular systems of the two fetuses. This may 
 lead to unfortunate results in several ways. One fetal heart may be 
 stronger than the other and appropriate the larger portion of the placenta 
 and blood. The stronger heart steadily hypertrophies while the weaker 
 heart atrophies, even to the extent of causing the deformity called 
 " acardia." The stronger heart often causes a hypertrophy of the kidneys 
 of the larger fetus with an accompanying hydramnios. 
 
 The anastomosis of the two fetal circulations in twin pregnancy from 
 a single ovum explains the necessity of ligating twice before cutting 
 the cord in any case of suspected twins lest the second fetus should 
 bleed to death from the untied end of the first cord. 
 
196 MULTIPLE PREGNANCY 
 
 Presentations. — As a rule the long axis of twins corresponds with that 
 of the mother. Thus, in the author's series of 244 cases, 207 were longi- 
 tudinal presentations, while 37 were more or less transverse. 
 
 Among longitudinal presentations there is quite a variety. In the 
 207 longitudinal presentations of this series, there were 98 in which the 
 twins both presented by the vertex; 90 in which one presented by the 
 vertex and the other by the breech; and 19 in which both presented by 
 the breech. In longitudinal presentations the twins may be located one 
 on each side of the mother's abdomen or one twin may lie behind the 
 other. In transverse presentations, one twin may lie above the other 
 or one behind the other. It is readily seen that when one twin lies behind 
 the other it may be difficult to detect two fetal hearts. 
 
 Sex of Twins. — As already stated, twins arising from the fertilization 
 of a single ovum with double nuclei are always of the same sex. Twins 
 arising from the fertilization of two separate ova may be of the same or 
 of opposite sex. In the 244 sets of twins in the author's series the sex 
 was as follows: 
 
 Male and female 98 
 
 Both females 74 
 
 Both males 69 
 
 Sex not stated in history 3 
 
 244 
 
 Diagnosis. — The diagnosis of twin pregnancy can usually be made if 
 the three methods of inspection, palpation and auscultation are carefully 
 employed. 
 
 Inspection. — The shape of the abdomen is usually broader from side 
 to side in a twin pregnancy than in cases with a single fetus. Moreover, 
 a sulcus can sometimes be seen marking the partition between the two 
 fetal sacs. The excessive size of the abdomen and uterus naturally sug- 
 gests the presence of a twin pregnancy, but this suggestion is chiefly 
 of value in causing the employment of careful methods of palpation 
 and auscultation. Enough has been said to call attention to the fact 
 that while the results of inspection are chiefly suggestions, they are of 
 value as leading often to the correct diagnosis. 
 
 Palpation. — The feeling of two fetal heads and a breech, or two breeches 
 and a head, usually enables the making of at least a probable diagnosis 
 of twin pregnancy. It should not be forgotten, however, that certain 
 tumors, especially fibroid tumors of the uterus often resemble closely a 
 fetal head and maA' lead to an error in diagnosis. 
 
 Auscultation. — Of all the methods employed in making the diagnosis 
 of twin pregnancy, auscultation is the one most to be depended upon. 
 Even the diagnosis made by palpation usually has to be verified by auscul- 
 tation. Two fetal heart sounds synchronous neither with each other nor 
 with the mother's pulse is the criterion of twin pregnancy. No matter 
 how suggestive the evidence derived from inspection and palpation may 
 be, the obstetrician should seldom commit himself to a positive diagnosis 
 of twin pregnancy unless two fetal hearts can be heard, 
 
TWIN PREGNANCY 197 
 
 Course. — On account of the greater distention of the uterus in twin 
 than in single pregnancy the mother is more apt to suffer from mechan- 
 ical embarrassment of the circulation and respiration. Furthermore, 
 the increase in the size of the uterus naturally caused by the presence of 
 twins may be still further augmented by the condition of hydramnios 
 in at least one sac. From the fact that oxygenation and elimination are 
 required for three individuals instead of two, toxemia is more common 
 in twin than in single pregnancy. 
 
 Fig. 145. — Interlocking twins, both heads presenting. 
 
 As the uterus seems to endure only a certain amount of distention, 
 this limit appears to be reached earlier in twin than in single pregnancy; 
 therefore a certain amount of prematurity is to be expected. In the 
 author's series of 244 cases there were 119, or 48.8 per cent., in which 
 labor w^as two or more weeks premature. As a result of prematurity and 
 divided nutrition, twins are usually smaller and less well developed than 
 is the child of a single pregnancy. Moreover, one twin is frequently 
 smaller and less well developed than is the other. This is seen in its 
 extreme degree in fetus papyraceus already described (see page 193). 
 
 Labor in Twin Pregnancy. — As there is a greater distention of the uterus 
 in twin pregnancy, the uterine contractions are often less efficient and 
 farther apart than normal, thus prolonging the labor. Furthermore, as 
 
198 
 
 MULTIPLE PREGNANCY 
 
 the uterus has often to exert its expulsive power on tlie first child by 
 acting through the second, its action is frequently more or less handi- 
 capped. Twin labor may be complicated in several ways as by inter- 
 locking, hemorrhage, etc. 
 
 Interlocking. — As twins are usually each smaller than the fetus of a 
 single pregnancy the second fetus sometimes enters the pelvis while it is 
 still occupied by some part of the first, thus interfering with the fiu-ther 
 progress of the first. This complication is spoken of as interlochiiuj, or 
 collision. Several varieties of interlocking are possible, but the two 
 deserving most consideration are the following: 
 
 Fig. 146. — Interlocking twins. Breech and vertex presentation. 
 
 1. Both heads present and enter the pelvis, one a little in advance of 
 the other, the second head becoming impacted in the neck of the first 
 (see Fig. 145). 
 
 2. The first child presents by the breech but the second head enters 
 the pelvis before the first head, and facing each other the fetuses interlock 
 chin to chin (see Fig. 146). 
 
 Other varieties of interlocking are worthy of mention : The first child 
 sometimes presents by the breech and its occiput interlocks with the 
 occiput of the second child which has entered the pelvis. Again, the first 
 child sometimes presents transversely and the second child sits astride 
 of the first, the feet of the second presenting in the vagina. 
 
TWIN PREGNANCY 199 
 
 Hemorrhage. — Aside from the mechanical compHcations of twin labors, 
 hemorrhage is more common on account of the greater distention of the 
 uterus and lessened contractile power. Moreover, the puerperium is 
 more apt to be complicated by the toxemia which has already been men- 
 tioned as more common in twin pregnancy and by sepsis, which is always 
 predisposed to by a postpartum hemorrhage and by the greater manual 
 interference which is often required in a twin labor. 
 
 Management of Twin Labor. — The management of the first half of an 
 uncomplicated twin labor does not differ from that of an ordinary labor 
 in a single pregnancy. In fact, many cases of twin pregnancy are not 
 diagnosed until after the birth of the first child, when the uterus is found 
 too large to contain only a placenta. The author teaches the advisabilitj' 
 of a double ligature of the cord in every delivery so that the ligature of 
 the cord in a twin labor would not differ from that in a single delivery, 
 although the neglect of the double ligatm-e in a twin labor might result 
 in the death of the other twin if they were from a single ovum. 
 
 After the birth of the first twin the presentation and position of the 
 second shoidd be carefully determined and corrected if abnormal. After 
 waiting from one-quarter to one-half hour for the uterus to contract 
 on the second fetus the membranes should be ruptured if necessary 
 and the birth of the second child favored. On account of the distention 
 and lessened tone of the uterus, the fundus of the uterus should be held 
 for at least an hour after the birth of the second child to avoid the danger 
 of postpartum hemorrhage. Occasionally, one placenta and rarely both 
 placentse are expelled soon after the birth of the first child. In the latter 
 case the second child must be delivered as rapidly as the soft parts of the 
 mother will permit. 
 
 Management of Twin Labor Complicated by Interlocking. — If there is 
 marked delay in the delivery of the first tT\-in, some form of interlocking 
 should be suspected and under anesthesia the hand shoidd be passed 
 into the uterus and the exact conditions determined. If both twins 
 present by the vertex and the second has become impacted in the neck 
 of the first child as shown in Fig. 145, an attempt should be made to 
 push up the second head and deliver the first child with the forceps. 
 Occasionally, the best procedure is to deliver the second head past the 
 first, always remembering that craniotomy on one child in the hope of 
 saving the other may be good obstetrics. 
 
 If the first child presents by the breech and its body is born whUe 
 its chin is locked with the chin of its fellow (see Fig. 146) an attempt 
 should be made to unlock the heads, but if this attempt fails it is usually 
 wise to decapitate the first child, pushing up its head, and then to dehver 
 the second child, finally delivering the head of the first. The reason for 
 the ^dsdom of this com-se lies in the fact that with failure of the attempt 
 to dislodge the second child's head, the life of the first child usually 
 ceases during the endeavor to extract the second past it, and the second 
 child's life is much more likely to be saved if the canal is cleared of the 
 first child. 
 
 If the first child hes transversely and the second child sits astride with 
 
200 
 
 MULTIPLE PREGNANCY 
 
 feet in the vagina the best procedure is usually to perform version and 
 extraction upon the first child, although eacli of these cases presents 
 a problem of its own and must be dealt with individually, some cases 
 justifying Cesarean section and some craniotomy'. 
 
 Mortality. — The maternal mortality in twin pregnancy is slightly higher 
 than in single pregnancy on account of a slightly increased tendency to 
 toxemia, postpartum hemorrhage and sepsis as has already been men- 
 tioned. In addition to these complications there should be borne in 
 mind the possible rupture of the uterus in an attempted version in the 
 case of interlocking twins when the uterus is too tonic to safely allow of 
 this procedure. In the author's series of 244 twin deliveries there was 
 no maternal mortality. 
 
 Fig. 147. — Single ovum triplet placenta, maternal surface. 
 
 Some idea of the fetal mortality in twin pregnancy may be gained 
 from the results in the author's series of 244 cases. In this series: 
 
 Both children lived in 146 cases, or 59.8 per cent. 
 
 One child lived in 44 cases, or 18 per cent. 
 
 Neither child lived in 54 cases, or 22.1 per cent., but of these 54 cases 
 12 were so premature as to be non-viable. 
 
 Triplet Pregnancy. — Etiology. — ^The same effect of heredity is seen in 
 triplet as in twin pregnancy and many women having triplets will give 
 a history of having had twin births. Triplet pregnancy is more common 
 in multigravidse than in primigravida?. In the author's series of four 
 sets of triplets only one was a primigravida while three were multigravidte. 
 
TRIPLET PREGNANCY 
 
 201 
 
 Sex. — ^The sex of triplets is about equally distributed. In the four 
 sets of the author's series the sex was as follows: 
 
 In one set, all females. 
 
 In one set, all males. 
 
 In one set, one male and two females. 
 
 In one set, two males and one female. 
 
 Arrangement of Placentae and Membranes. — Triplets may all come from 
 
 the fertilization of a single ovum and the three placentae be fused in one 
 
 as is shown in Figs. 147 and 148, or they may come from the fertilization 
 
 of three separate ova and the three placenta be separate (as in Fig. 149) . 
 
 Fig. 148. — Single ovum triplet placenta. Fetal surface. 
 
 It is rather more common to find two placentae fused and one more or 
 less separate (as in Fig. 150), this arrangement arising from the fertiliza- 
 tion of one double and one single ovum. 
 
 Course. — ^The discomforts and complications mentioned above as 
 being possible accompaniments of twin pregnancy are exaggerated and 
 much more frequent in triplet pregnancy. In fact, a woman pregnant 
 with triplets is usually in the later months the subject of great discom- 
 fort. The distention' of the abdomen is so great that she suffers wdth 
 dyspnea and frequently has to sleep bolstered up in bed. Albuminuria 
 and other evidences of toxemia are usually present. Hydramnios^ is 
 common. Three of the four cases in the author's series suffered with 
 
202 
 
 MULTIPLE PREGNANCY 
 
 hydramnios and albuminuria. Triplet i)regnancy seldom goes to term. 
 In all four cases ot" the ai)ove series tiie labor was premature. 
 
 Fig. 149. — Triplet placenta; from three separate ova. Fetal aurJace. 
 
 Fig. 150. — Triplet placentae, two fused and one separate. 
 
TRIPLET PREGXANCY 203 
 
 Labor in Triplet Pregnancy. — The labor in triplet pregnancr is seldom 
 marked by dystocia, as the children are all small, but it may be tedious 
 on account of the excessive distention of the uterus and feeble uterine 
 contractions. The uterine inertia shows itself in the frequent occur- 
 rence of postpartum hemorrhage, which should be guarded against by 
 carefully holding and watching the fundus of the uterus after the delivery. 
 The birth of the second and third fetus often follows the first after a 
 short interval, but should this not occur within half an hour, it is usually 
 wise to rupture the second sac and expedite the delivery of the other 
 fetuses. Each cord should be ligated twice before cutting. 
 
 Mortality. — The maternal mortality is always somewhat higher than 
 in t-udn pregnancy on account of the greater distention of the uterus and 
 the greater tendency to toxemia, postpartum hemorrhage, and sepsis. 
 The fetal mortality is always high on account of prematurity and di\'ided 
 nutrition. In the foiu- sets of triplets in the author's series the results 
 were as follows: 
 
 In one set all were stillbirths, too premature for \ia1)ilit.\'. 
 
 In one set all died soon after birth. 
 
 In one set two lived. 
 
 In one set all three lived and grew up. 
 
 There was no maternal mortality in this series. 
 
CHAPTER VII. 
 NORMAL LABOR. 
 
 PHYSIOLOGY OF NORMAL LABOR. 
 
 Labor is the process by which the product of conception is separated 
 from the uterus and is propelled along the parturient canal to the outside 
 world. The term is usually applied to the termination of a gestation 
 which is mature or nearly so, yet the process may be strongly resembled 
 in the earlier months of pregnancy. Labor is either normal or abnormal. 
 A normal labor is one in which there is a vertex presentation and the 
 birth is accomplished unaided within a reasonable time, and it is this 
 normal labor which will here be considered. One of the questions which 
 constantly presents itself is that of the suffering of labor. Why should 
 nature, which usually illustrates so admirably the adaptation of means 
 to an end, require such suffering in the birth of the human race? While 
 this question cannot be answered with entire satisfaction, much can be 
 learned by comparison (1) of the human race with the lower animals, 
 and (2) of the higher classes of civilization with the lower. 
 
 Comparison of the Human Race with the Lower Animals. — That 
 labor in women is more difficult than in the lower animals is readily 
 understood when we compare the pelvis of the cow (see Fig. 151) with 
 that of the human female, and consider that in women the pelvis must 
 be suited for the erect posture. In the lower mammals, not assuming 
 the erect posture and therefore requiring but little support for the pelvic 
 organs, the pelvic cavity shows but little curve. There is no projecting 
 promontory to prevent engagement of the head and the symphysis is 
 lower. This allows ready entrance at the brim of the pelvis and as the 
 conjugate is longer than the transverse diameter through the whole 
 pelvic canal, there is not the need for the rotation of the fetal head that 
 often requires so much time and suffering in the human female. 
 
 The caudal extremity of the spinal column is easily movable so that 
 there is little obstruction at the outlet. Furthermore, in the lower mam- 
 mals the pelvic floor possesses much less resistance than in the human 
 female, and during pregnancy the ligaments and articulations of the 
 pelvis are much more relaxed. When it is considered that the fetal head 
 in the lower mammals is relatix-ely smaller and more conical, it can 
 readily be seen why labor in the lower mammals is less difficult than in 
 women. Furthermore, in the lower mammals the nervous system is at 
 lower tension and development, and less easily exhausted. In them the 
 mental condition, so often an important feature in women, can largely 
 be eliminated from the problem. 
 (204) 
 
PHYSIOLOGY OF NORMAL LABOR 
 
 205 
 
 Comparison of Higher Civilization with the Lower. — The fact that 
 labor among the Indians, when Kving their normal out-of-door life un- 
 touched by civilization, was a simple procedure, is well known, and often 
 referred to in comparison with the process as met with today. Yet in 
 my experience, when one of the '^ modern, civilized" Indians, so-called, 
 presents herself at the maternity hospital her labor differs but little, if 
 any, from that of other women living as she does. 
 
 ^Modern civilization, with its increased mental development, greater 
 nerve strain and lessened physical de^'elopment, adds greatly to the 
 
 Wing of 
 sacrum 
 
 Median 
 
 crest of Tuber 
 
 sacrum sacrale 
 
 Acetabulum 
 Tuber ischii 
 
 Ilio-pectineal eminence 
 
 Symphysis pubis 
 
 Obturator foramen 
 
 Ventral ridge 
 Fig. 151. — Pehdc bones of cow, ^■iewed from in front and somewhat from below. (Sisson.) 
 
 difficulty of labor. It increases the mechanical difficulties of the problem 
 by increasing [the size of the child's head, and lessens the ability to 
 overcome the difficulties by lowering nerve and muscle tone. 
 
 The same thing is seen to a certain extent in horses and cattle where 
 those of highest breed which are carefully housed, groomed and fed, 
 surrounded by protection from wind and weather, present more diffi- 
 culty in parturition than do those on the prairie. 
 
 Cause of the Onset of Labor. — ]\Iuch speculation has been indulged in 
 and manv theories advanced to explain why labor usually begins at 
 
206 NORMAL LABOR 
 
 about two hundred and eighty days from the beginning of the last men- 
 struation. 
 
 A satisfactory definite answer has never been given. It is probably 
 the result of a number of conditions no one of which can singly be pointed 
 to as the cause of the onset of labor. The following may be mentioned: 
 
 Placental Changes. — During the latter part of pregnancy there is 
 taking place in the decidual portion of the placenta a form of degeneration 
 which is preparing it for separation; in other words, is preparing the 
 product of gestation to become like a foreign body in the uterus. 
 
 It is well known that a foreign body in the uterus, whether it be a 
 polypus, a blood-clot, or the hand of the obstetrician, stimulates uterine 
 contractions, and this condition, present in the latter part of pregnancy, 
 has been adopted as one of the causes of the onset of labor. This theory 
 was advanced by Naegele, and has found many followers. 
 
 Uterine Distention. — On account of the frequency with which pre- 
 mature labor occurs in multiple pregnancy and hydramnios, uterine 
 distention has been looked upon as one of the causes of the onset of 
 labor and it is thought that when the uterus reaches a certain amount 
 of distention it will try to empty itself. While this certainly appears 
 to be the fact in most cases, numerous exceptions occur as when preg- 
 nancy is prolonged beyond term and the child is allowed to reach an 
 extreme size and weight. 
 
 Changes in the Lower Uterine Segment. — The softening, dilatation and 
 retraction of the lower uterine segment, as the presenting part settles in 
 the pelvis, is certainly a preparation for labor and in the same way that 
 an, elastic bag placed in the cervical canal will induce labor, so the pres- 
 ence of the presenting part with the amniotic sac in front of it, gradually 
 dilating the canal and pressing upon the pelvic nerves, tends to start 
 up uterine contractions. This view finds support in the fact that occa- 
 sionally, as has occurred several times in my experience, when the cervix 
 has previously been amputated and the lower uterine segment is dilated 
 during most of the latter half of pregnancy, it is extremely difficult to 
 carry the patient to term. In one patient, after several premature labors 
 with loss of the child, a successful issue was secured only by keeping the 
 patient in bed. The fact that at times the cervix shows marked dilata- 
 tion for weeks before term shows that this is not the sole cause of the 
 onset of labor. 
 
 Increasing Irritability of the Uterus. — It is well known that in the 
 latter part of pregnancy the uterus is more irritable, i. e., responds more 
 readily to stimulation and that the intermittent uterine contractions, 
 the so-called Braxton Hicks sign of pregnancy, although present from 
 early pregnancy, become more pronounced and more frequent as term 
 approaches. Furthermore, although usually these intermittent uterine 
 contractions are painless, in some w^omen they are painful and difficult 
 to distinguish from beginning labor. 
 
 Menstrual Periodicity. — Tyler Smith, Mende and others have ad- 
 \anced the view that labor is most apt to occur at a time which would 
 be the menstrual period were the patient not pregnant, i. e., the tenth 
 
PHYSIOLOGY OF NORMAL LABOR 207 
 
 menstrual period. This tendency of the uterus to contract and empty 
 itself at the would-be menstrual periods certainly seems, to exist in the 
 early months as is evidenced by the age of the specimens obtained from 
 miscarriages, and in all probability exists also in the later months of 
 pregnancy. 
 
 Stimulation of the Uterine Nerve Centres. — The theory has been 
 advanced by several, especially by Brown-Sequard, that the onset of 
 labor is caused by the irritation of the uterine nerve centres by an excess 
 of carbon dioxide circulating in the blood. Although this theory may 
 prove to have little influence upon the onset of labor, it is suggestive of 
 work along the line of determining whether some other substance in the 
 circulation, perhaps some product of fetal metabolism, may not be a 
 causal factor. 
 
 Exciting Causes. — It is well known that when the time is reached 
 that labor is really due, a very slight exciting cause like a bimanual 
 examination, a purgative, violent exercise, etc., may determine the onset 
 of labor. 
 
 This is sometimes made use of clinically by giving a purgative like a 
 large dose of castor oil at the time estimated to be the normal end of 
 pregnancy in order to prevent overgrowth of the child by the continua- 
 tion of pregnancy beyond term. 
 
 The above-mentioned theories are those which have been most widely 
 held and are most worthy of acceptance as influential factors. If, how- 
 ever, we frankly ask ourselves the question " What is the real cause of the 
 onset of labor?" we are forced to reply "We do not know." As the apple 
 when fully ripe falls from the tree, so the fetus when it is best suited 
 for independent life is, as a rule, expelled from the uterus. 
 
 The Characteristics of Beginmng Labor. — One of the questions fre- 
 quently asked by the patient expecting to be confined is "How shall I 
 know when I am in labor?" The question is a perfectly natural one, as 
 it is not unusual for women to have various aches and pains during 
 the latter part of pregnancy. These may be due to pressure upon the 
 pelvic nerves, to gas in the intestines whose normal peristaltic action is 
 interfered with by the enlarging pregnant uterus; finally, as already 
 indicated, the intermittent uterine contractions which continue during 
 pregnancy and are usually painless, in some women are painful and 
 resemble the pains of beginning labor, but are irregular in occurrence 
 and without increasing severity. These are the so-called false or 
 spurious labor pains. The best information that can be given to the 
 patient regarding the characteristics of true labor pains, is that the onset 
 of labor is marked by pains which recur regularly with distinct inter- 
 missions; that during these pains the abdomen seems hard; that these 
 pains are located at first either in the abdomen above the pubes, or in 
 the back in the lumbosacral region; that later they become more con- 
 stant in the lumbosacral region and extend down the thighs; that often 
 in the beginning the interval between pains is half an hour or more, but 
 as time goes on the intervals become shorter and the intensity of the 
 pains greater. In addition to this there is usually an increase in the 
 
208 NOHMAL LABOR 
 
 vaginal mucous discharge, which may or may not be colored, producing 
 what the laity speak of as a " show." In studying labor it is well to recog- 
 nize a 'preparaiory stage, in which the uterus and its contents settle in 
 the pelvis, thus allowing greater freedom of action to the diaphragm and 
 easier respiration to the patient, but greater discomfort below from 
 pressure upon the pelvic viscera, vessels, and nerves. There is more 
 irritability of the bladder and disturbance with the rectum, greater 
 interference with venous return, as shown by increased edema in the 
 lower extremities and vulva, and more pain in the pelvis radiating down 
 the thighs. 
 
 This settling, aside from being felt and noticed by the patient, is easily 
 made out by palpation of the abdomen. The fundus has receded from 
 the ensiform cartilage, returning to about the level of the eighth month 
 and on palpating the fetal head it is found to have dipped into the pelvic 
 brim. The settling usually begins in primigravidte at about two weeks 
 from term, but in multigravidje with less tone in the abdominal wall 
 and lower uterine wall it often does not occur until the last week of 
 pregnancy. 
 
 This is the stage during which the irregular, spurious, or false pains 
 occur, as already described, and a vaginal examination during this period 
 shows the following changes: The vulva is more gaping and more con- 
 gested. The cervix, which up to this time has retained its normal length, 
 with the external os and the internal os both present and more or less 
 closed, especially in primigravidtie, shows a dilatation and a gradual 
 disappearance of the internal os as the lower uterine segment retracts. 
 
 STAGES OF LABOR. 
 
 In the actual labor three stages are recognized: 
 
 First stage, or the stage of dilatation, which extends from the beginning 
 of labor to the time of complete dilatation of the cervix. 
 
 Second stage, or tJie stage of expulsion, which extends from the complete 
 dilatation of the cervix to the birth of the child. 
 
 Third stage, or the placental stage, which extends from the birth of the 
 child to the expulsion of the placenta. 
 
 Usually these three stages are present in every labor and a normal 
 labor has only to be observed to see the three follow each other in turn. 
 
 Occasionally, however, especially in women whose nervous systems 
 are at high tension and whose cervices are rigid, the patient becomes 
 completely exhausted in the first stage and in spite of attempts at rest, 
 she is unable to dilate her cervix until the long pressure begins to have 
 deleterious effect upon the fetal heart. 
 
 In such cases, although the patient may have had expulsive pains and 
 an expulsive stage, she has had no second stage, according to the defini- 
 tion given above, as she requires artificial dilatation of her cervix and 
 instrumental delivery before she herself has succeeded in dilating the 
 cervical canal. 
 
STAGES OF LABOR 209 
 
 First Stage. — With the onset of labor the patient begins to have 
 the true labor pains, at first with intervals perhaps of half an hour, but 
 becoming more frequent as time goes on. These pains are usually located 
 in the sacral region and often radiate to the lower part of the abdomen or 
 down the thighs. At first the patient is often rejoiced that labor which 
 she has been expecting so long has really come and she watches carefully 
 to see if the pains recur regularly and are becoming stronger and are not 
 the irregular, false pains, which she may have had for several weeks. 
 At first she feels very comfortable between pains and chats pleasantly 
 as she watches with interest the preparations of the bed and room. 
 The pains of the first stage, however, are wearing and after a time the 
 patient, especially a primigravida, is apt to become restless and nervous 
 and asks how much longer the labor is to last. She thinks she is not 
 accomplishing anything. She feels her abdomen and says it has not 
 gone down any. The pains by this time are probably sharp and she 
 cries out as they recur. As the cervix dilates she is apt to be nauseated 
 and perhaps vomits. The vaginal discharge, which perhaps at first was 
 only mucus, now contains a little blood, due to the separation of the 
 membranes from the cervix and lower uterine segment. • With the down- 
 ward pressure of the fluid wedge, produced by the unbroken amniotic sac, 
 together w^ith the retraction of the cervix and the lower uterine segment, 
 the cervical canal gradually dilates until its diameter is greater than 
 the width of four fingers of the examining hand. Usually at this time, 
 during one of the uterine contractions, in obstetrics called "pains," the 
 amniotic sac bursts with the escape of considerable liquor amnii. The 
 amount of this first escape varies greatly with the amount present in the 
 uterus, with the presentation of the child and with the point of rupture. 
 If it is a vertex presentation and the head is descending normally in the 
 pelvis but a little may escape at first, as the head, acting like a ball 
 valve, plugs the opening for a time. Then with each pain a little more 
 escapes, keeping the canal moist. On the other hand, if the presentation 
 is transverse, or the head is not engaged, all the liquor amnii may escape 
 at the time of rupture. If the point of rupture of the amniotic sac is 
 high up, the amount which escapes at the time of rupture may be very 
 slight. At times the rupture of the membranes is the first evidence of 
 the onset of labor and the woman may be aroused from sleep by a gush 
 of water which soaks her night-dress. As in this case there has probably 
 been but slight engagement of the presenting part, usually a large propor- 
 tion of the liquor amnii drains away and there results a so-called "dry 
 labor," one in which the fluid wedge to aid in dilating the cervix is absent 
 and hence a labor which is apt to be long and tedious. 
 
 Sometimes rupture of the membranes occurs several days or even 
 weeks before the onset of labor, but, as a rule, labor pains begin within 
 twenty-four hours, and according to my experience it is fortunately so, 
 as several cases have come under observation where, after the escape of 
 the liquor amnii, the long pressure upon the child and the entrance of 
 air to the amniotic sac has apparently caused the death of the child and 
 infection of the mother. 
 14 
 
210 
 
 NORMAL LABOR 
 
 For these reasons it is my custom to start the induction of labor in 
 a patient whose pains do not begin in twenty-four hours after the rupture 
 of the membranes. As to the duration of the first stage of labor, it is very 
 difficult to predict. 
 
 In 5000 normal labors at the Sloane Hospital, of which 2500 were 
 primigravidse and 2500 multigravidse, the average duration of the first and 
 second stages was as follows: 
 
 Primigravidse : first stage, fourteen hours, six minutes; second stage, 
 one hour, twenty-five minutes; total labor, fifteen hours, thirty-one 
 minutes. 
 
 Fjg. 152. — Upper and luwer uterine segments separated l)y the ring of Bandl. (Bumm, 
 
 after Braune.) 
 
 Multigravidae : first stage, ten hours, twenty-five minutes; second 
 stage, one hour, five minutes; total labor, eleven hours, thirty min- 
 utes. 
 
 Fourteen hours in the primigravida and ten and one-half hours in a 
 multigravida may therefore be taken as the average duration of the 
 first stage. 
 
 Changes in the Uterus during the First Stage. — With the onset of labor 
 the uterus is seen to divide itself into two portions or segments: The 
 upper uterine segment and the loiver uterine segment separated by a cir- 
 cular band which represents the lower edge of the upper uterine segment 
 
DILATATION OF THE CERVIX 211 
 
 and is usually called the ring of Bandl (see Fig. 152), although previously 
 described by Braune in his study of frozen sections.' 
 
 The upper uterine segment is active and becomes thickened as labor 
 advances. The composition of the lower uterine segment has been the 
 subject of much discussion, but it is generally regarded as formed in 
 part by the lower portion of the uterus just above the internal os and 
 by the cervix itself. This lower uterine segment becomes thinned as 
 labor advances; is largely passive during the process, and shows a 
 gradual obliteration of the cervical canal from above downward by a 
 funnel-shaped dilatation. The internal os gradually disappears and 
 leaves the lower uterine segment a thin, muscular canal, bounded above 
 by the contraction ring, or ring of Bandl, below by the external os which 
 in primigravidse may be thin, sharp and rigid for a time, but in multi- ^ 
 gravidae is usually much more patulous and readily dilatable. 
 
 The contraction ring, called also retraction ring by Lusk, which is 
 marked only during labor, is situated at a height in the uterus corre- 
 sponding to the reflection of the peritoneum from the uterus on to the 
 bladder, and is opposite a large coronary vein. Although beginning in 
 the first stage, the contraction ring is usually not well marked until 
 the second stage of labor. 
 
 In the normal mechanism of dilatation of the cervix, aside from the 
 contractile power of the upper uterine segment, aided perhaps by the 
 voluntary action of the muscles of the abdominal wall, we have four 
 factors at work: 
 
 1. Softening of the cervix. 
 
 2. The action of the fluid wedge. 
 
 3. The action of the solid wedge. 
 
 4. The retraction of the lower uterine segment. 
 
 Softening of the Cervix. — During the latter part of pregnancy on account 
 of pressure from above and interference with \-enous return, the cervix 
 becomes more congested, hj-peremic, softened and more dilatable. With 
 the onset of labor this hyperemia and serous infiltration increases, es- 
 pecially during uterine contractions, and when the thorax is fixed and 
 the abdominal muscles are brought mto play. The softening of the 
 cervix greatly aids in dilatation, as is seen in placenta previa where the 
 increased vascularity and softening usually renders the cervix easily 
 dilatable. 
 
 Fluid Wedge. — During uterine contractions the fluid contents of the 
 uterus are subjected to pressure and, although this pressure is transmitted 
 equally in all dhections, its eftect is most marked in the direction of 
 least resistance. As the cervix is perforated by its canal this naturally 
 is the direction of least resistance and the contractions of the uterus 
 force a sac of fluid into and through the cervical canal, serving as the 
 most important means of dilatation. The effect of the absence of the 
 cervical canal is occasionally seen in cases where the canal has been 
 obliterated durmg pregnancy by some inflammatory process, and during 
 
 1 Die Lage des Uterus und Fotus am Ende der Schwangerschaft, Leipzig, 1872. 
 
212 
 
 NORMAL LABOR 
 
 labor uterine contractions continue for hours without dilatation of the 
 cervix until an artificial opening is made, when dilatation proceeds 
 rapidly. 
 
 Fig. 153. — In the- interval between uterine contractions. 
 
 The Solid Wedge. — If rupture of the membranes has taken place early 
 in labor, instead of the fluid wedge produced by the conical sac of amniotic 
 fluid, nature has in its place the solid wedge formed by the presenting 
 
 Fig. 154. — Same patient as Fis- 15.3, during a uterine contraction. 
 
 part which becomes more and more conical through pressure and 
 molding. 
 
 As is well known, even to the laity, the solid wedge with its accompany- 
 ing dry labor is much more tedious for the patient than one with the 
 
STAGES OF LABOR 213 
 
 membranes intact, and is more apt to expose the child to a dangerous 
 amount of pressure. 
 
 Retraction of the Lower Uterine Segment. — Although during labor the 
 lower uterine segment is regarded as largely passive, apparently through 
 the action of the longitudinal fibers of the upper segment, it is gradually 
 retracted over the presenting amniotic sac or presenting fetal part, and 
 this process, taken in conjunction with the action of the fluid or solid 
 wedge, accomplishes the dilatation of the cervix. 
 
 During the first stage of labor if the patient is lying on her back (see 
 Fig. 153) the abdominal wall during the interval between uterine con- 
 tractions is flaccid and the uterus itself is not tense. During a uterine 
 contraction, however, the abdominal and uterine muscles become tense 
 and the uterus stands out from the abdominal cavity, increasing its 
 anteroposterior diameter and diminishing its transverse diameter (see 
 Fig. 154). 
 
 Second Stage. — ^Yith the completion of the dilatation of the cervix 
 the characteristics of the labor change. The patient instead of being 
 up and walking about instinctively takes to her bed. Her pains become 
 more regular, harder and expulsive in character. During the latter part 
 of the first stage she may have voluntarily during each pain, held her 
 breath and brought into action her abdominal muscles, but now this 
 action becomes involuntary. She has the desire to press her feet against 
 something; she fixes the muscles of her thorax and her diaphragm; she 
 wishes to pull upon something w^th her arms; she uses her abdominal 
 muscles to the best of her ability, thus greatly supplementing the expul- 
 sive power of the uterus. 
 
 The pressure of the presentiag part upon the rectum gives the patient 
 the feeliug that her bowels are to move, and she so expresses herself. 
 
 During the pains her face becomes flusTied and her pulse more rapid 
 while the fetal heart becomes a little slower. At the height of each pain 
 she lets out her breath with a grunt. During this stage she seems to 
 realize that she is reaching the end of her suffering, that there is work 
 for her to do, and although during the latter part of the first stage she 
 may have been nervous, irritable and discouraged, she now summons 
 her strength and will-power and is anxious to assist nature in every way 
 that she can. She soon learns that by holding her breath and not crying 
 out with the pain she can make better progress, and acts accordingly. 
 
 This picture of a woman with flushed face, knees flexed, straining with 
 each uterine contraction, anxious to pull on something with her arms, 
 and giving an expulsive cry at the acme of each pain is a picture of the 
 second stage of labor familiar to every obstetrician. 
 
 Changes in the Uterus during the Second Stage.— At the completion of 
 the dilatation of the cervix the need for the fluid wedge formed b}' the 
 amniotic sac ceases and, as a rule, the membranes forming the sac, 
 i. e., the amnion, chorion and decidua capsularis (reflexa), usually spoken 
 of as the "membranes," rupture and more or less of the liquor amnii 
 escapes, moistening the parts below 
 
 As aheady stated, however, the membranes may rupture at the onset 
 
214 NORMAL LABOR 
 
 of labor or even before this event occurs, and on the other hand in rare 
 cases the rupture may not take place until after the birth and the 
 fetus he born surrounded by the unruptured membranes, that portion 
 covering the fetal head being spoken of as a "caul." 
 
 The point of rupture is usually in the axis of the vagina, but occasion- 
 ally it is high up laterally, allowing only a little liquor amnii to escape 
 gradually, followed later by a gush when the sac lying just in front of 
 the head and containing the "forewater" ruptures. When the mem- 
 branes fail to rupture after the dilatation of the cervix is complete, labor 
 is usually delayed by it. 
 
 In the second stage the fundus during uterine contractions not only 
 moves forward but settles a little in the abdomen, only to rise again 
 as the contraction passes off. Permanent lowering of the fundus does 
 not usually occur until the presenting part begins to emerge from the 
 vulva. 
 
 Patients may often wisely be told of this fact during their period of 
 discouragement in the first stage when their abdominal swelling does 
 not descend as a result of their numerous pains. The division into the 
 upper and lower uterine segments which was gradually taking place 
 during the first stage now becomes more marked and the retraction or 
 contraction ring is more distinct. If, on account of some disproportion 
 between the presenting part and the pelvic canal, there is obstruction 
 to the advance of the child, the lower uterine segment becomes more 
 and more distended, while the upper segment contracts and retracts, 
 so that instead of the contraction ring being situated about midway 
 between the symphysis and the umbilicus, it may lie but little below the 
 latter. A vaginal examination during the second stage in a normal 
 labor shows the vulva more congested and dilatable, perhaps a thin 
 rim of cervix in the fornices crowning the presenting vertex, which is 
 becoming more and more molded as the caput forms. During each 
 pain this presenting part will be felt to advance, only to recede again 
 as the pain passes oft'. No student of nature can fail to be impressed 
 with the changes which are now to take place in the pelvic floor as the 
 presenting part descends to the outside world. No matter how many 
 times one has watched the process, each but adds to the conviction of 
 the wonderful provision and adaptability of nature in the construction 
 of a pelvic floor and canal which at other times furnishes the support 
 needed for the pelvic organs and a canal which just admits the male 
 organ or the fingers for examination and during labor dilates without 
 injury to a size sufficient to allow the passage of a full-sized child at term. 
 
 Should the vulva be watched from the early part of the second stage 
 of a normal labor the parts will be seen becoming more congested with 
 each pain, perhaps with the extrusion of a little blood-stained mucus; 
 then with each pain there is a little gaping of the vulva as the head 
 approaches the outlet. Soon at the height of a pain will be detected a 
 small portion of the caput slightly separating the labia (see Fig. 155). 
 The whole pelvic floor begins to bulge a little with each pain, the anus 
 pouts and begins to dilate and more and more of the caput appears. 
 
STAGES OF LABOR 
 
 215 
 
 Thus, with advances during each contraction of the uterine and abdomi- 
 nal muscles and recessions during each relaxation, more and more of 
 the head appears, gradually extending as the occiput emerges under 
 the pubic arch and bends upward toward the mons veneris, while the 
 forehead, nose, mouth and chin sweep over the edge of the perineum 
 and the edge of the vulva slips backward to the neck of the child. 
 
 Thus it is that the most acute suffering of the labor is ended and the 
 head is born, soon to be followed by the body of the child, and the second 
 stage is ended. 
 
 Third Stage. — After the birth of the child the woman experiences a 
 feeling of relief. The freedom from the suffering which probably has 
 lasted for hours, coupled with the joy that her long-anticipated child is 
 
 Fig. 155. — Caput appearing at \'ulvar outlet. 
 
 born, brings to the true mother such mental and physical peace as can 
 only be appreciated by those who have passed through it. A hand 
 placed on the abdomen detects the uterus now greatly reduced in size, 
 lying a few centimeters below the luubilicus. It is fairly firm, although 
 not as hard as during the previous uterine contractions. As the hand is 
 kept upon it, the uterus is felt after a few moments to alternately relax 
 and contract. At first these contractions are not severe enough to cause 
 pain to the patient, but soon they become more severe and painful, con- 
 tinuing until the placenta is expelled from the bod}" of the uterus. 
 
 If the abdomen is watched its contour is seen to change as time 
 passes. 
 
 Changes in the Uterus during the Third Stage. — The uterus instead of 
 remaining globular becomes more elongated and rises in the abdomen. 
 
216 NORMAL LABOR 
 
 At the same tiint- a prominence appears just above the symphysis. 
 CorresponcHng with tiiis change in contour the placenta has been ex- 
 pelled from the body of the uterus into the cervix and vagina. In a 
 normal case this usually occurs in from fi\e to thirty minutes. With 
 this descent of the placenta there occurs a corresponding increase in 
 the length of cord which lies outside the vagina. With the birth of the 
 child there takes place the discharge of the remainder of the liquor 
 amnii and following this there is usually a moderate discharge of blood. 
 
 Occasionally the placenta is expelled almost immediately after the 
 birth of the child, but this is very exceptional. As a rule, after the 
 placenta has been expelled from the active upper uterine segment into 
 the passive lower uterine segment and vagina it remains there for an 
 indefinite period. 
 
 According to Ahlfeld, a spontaneous expulsion occurred in only 13.6 
 per cent, of his cases, although he waited from one-half to two hours. 
 The chief factor in causing the normal expulsion of the placenta from the 
 lower uterine segment and vagina is the voluntary contraction of the 
 abdominal muscles, although, of course, gravity and the contraction of 
 the vagina are auxiliary forces. 
 
 Separation of the Placenta. — There are two chief views regarding the 
 method of separation of the placenta from the uterine wall, bearing 
 respectively the names of Shultze and Mathews Duncan. According to 
 the view of Schultze, the middle of the placenta is separated first and is 
 pushed forward by a blood eflfusion beneath it and the placenta is expelled 
 like an inverted umbrella co^•ered by the fetal membranes which also 
 trail behind it. 
 
 In this method of expulsion there is no external bleeding until after 
 the birth of the placenta. 
 
 According to the view of Mathews Duncan, the placenta is separated 
 at the edge, especially the lower edge first. It is then folded upon itself 
 like a roll within the cavity of the uterus and is expelled, edge first, with 
 or without the inversion of the membranes. In this method of expul- 
 sion there is no marked retroplacental hemorrhage, but a moderate 
 continuous bleeding from the birth of the child to the birth of the pla- 
 centa, this bleeding being more marked if the membranes are not 
 inverted. 
 
 The Duncan view is the one most generally held in this country and 
 is probably the usual method of expulsion when the placental attach- 
 ment is lateral or on the anterior or posterior uterine wall. If the pla- 
 centa is attached to the fundus of the uterus the method of Schultze is 
 probably often followed. 
 
 It seems to the author most rational to consider that in ordinary cases 
 as the uterus contracts the placenta is compressed and at first allows of 
 this compression without separation, its contained fetal blood being 
 expressed along the untied umbilical cord to the fetus; that after a 
 little time the contraction and shrinkage of the placental site detaches 
 it from the placenta which then becomes a foreign body in the uterus 
 and as the uterus is always stimulated to expell any foreign body from 
 
EXPULSION OF THE PLACENTA 217 
 
 within its cavit}' so the upper uterine segment is stimulated to expel 
 the placenta. 
 
 On examining the maternal surface of the freshly expelled placenta 
 it is found that the separation has taken place in the decidua basalis 
 and that a thin layer of this decidua is still attached to it. 
 
 In the above description the author has endeavored to describe the 
 third stage of labor as left to nature, but as will be seen in the chapter 
 discussing the Management of Normal Labor (see page 341), it is not 
 considered good practice to leave the expulsion of the placenta to nature's 
 unaided efforts. As the placenta may remain in the cervix and vagina 
 for an indefinite period and the discomforts of the patient are prolonged 
 by the delay, with the probability of greater loss of blood and perhaps 
 danger of infection, it seems to the writer that within a reasonable 
 time, as will be discussed later, the expulsion of the placenta should be 
 aided. 
 
 I As to the edge and surface of the placenta which is first expelled, 
 and the average maternal blood loss with each, the study of the late 
 Dr. Ervin A. Tucker^ at the Sloane Hospital gave the following results: 
 Of the 2710 placental births which were studied, 2561 were expressed 
 by the Crede method, while 149 came away spontaneously. The fre- 
 quency of the edge and surface of the placenta born first in these two 
 different methods of expulsion may be seen from the following table: 
 
 Crede expression. Spontaneous expression. 
 
 979 =38.2 per cent. 49 =32.9 per cent., were born edge first, fetal surface out. 
 
 703 =27.4 per cent. 26 = 17.4 per cent., were born fetal surface first and out. 
 
 555 =21.7 per cent. 47 =31.6 per cent., were born edge first, maternal surface out. 
 
 194 = 7.6 per cent. 21 = 14. 1 per cent., were born maternal surface first and out. 
 130 = 5.1 per cent. 6 = 4.0 per cent., were born edge first. 
 
 The summary of the 2561 placental births under the Crede method 
 of expression gives: 
 
 1682 = 65.6 per cent., born fetal surface out. 
 749 = 29.3 per cent., born maternal surface out. 
 130 = 5.1 per cent., born edge first. 
 
 It will thus be seen that, as observed clinically, the frequency of the 
 birth of the fetal surface out under the Crede method of expression is 
 more than twice that of the maternal surface out. 
 
 Tucker also found that the amount of maternal blood loss in these 
 2710 placental births varied with the edge and surface first born as follows : 
 
 Average loss when placenta born edge first, maternal surface out, 10.8 
 ounces (most). 
 
 Average loss when placenta born maternal surface first and out, 10.4 
 
 ounces. 
 
 Average loss when placenta born edge first, fetal surface out, 10 ounces. 
 Average loss when placenta born edge first, 9.2 ounces. 
 
 1 Birth of the Secundines, Amer. Gyn. and Obst. Journal, May, 190S. 
 
218 NORMAL LABOR 
 
 Average loss when placenta born fetal surface first and out, 8.S ounces 
 (least). 
 
 Following the birth of the child and placenta the patient often expe- 
 riences various chilly sensations which may amount to a distinct rigor. 
 
 It is purely physiological, probably of vasomotor origin and need 
 occasion no alarm, as it is not accompanied by a rise of temperature 
 or pulse and soon passes off with no other treatment than a warm blanket. 
 
 Its importance rests in distinguishing it from the chill occurring later 
 in the puerperium which usually indicates infection. 
 
CHAPTER VIII. 
 
 THE MECHANISM OF LABOR. 
 
 By the mechanism of labor is meant the manner in which the con- 
 tents of the pregnant uterus, the fetus and the placenta, are propelled 
 through the birth canal and enter the outside world. It is in the birth 
 of the fully developed fetus that nature exhibits this mechanism in its 
 most perfect shape; the birth of the premature fetus and of the placenta 
 being accomplished in a comparatively simple manner. 
 
 In the enlarged uterus is the fetus, fully developed, and only awaiting 
 its birth into the outer world to become a breathing, growing human 
 being. That this body so large, yet so delicate in structure can in the 
 course of a few hours be pushed through the narrow birth canal of the 
 mother without serious injury to either mother or child seems little short 
 of marvellous and may well excite admiration, yet it is an every-day 
 occurrence. 
 
 For a thorough understanding of the mechanism of labor the three 
 factors involved should be studied : 
 
 The parturient canal or passage. 
 
 The fetus or passenger. 
 
 The propelling force. 
 
 THE PARTURIENT CANAL OR PASSAGE. 
 
 The parturient canal or passage is composed of both hard and soft 
 structures. The former consisting of the bony pelvis; the latter of the 
 muscles and fascise lining the pelvis and forming the pelvic floor and of 
 the muscular canals of the uterus, vagina and vulva. 
 
 The hard and soft structures of the parturient canal will be studied 
 separately, the bony framework of the canal first being considered. 
 
 The Female Pelvis. — Considered obstetrically the pelvis presents 
 numerous points of interest (see Fig. 156). 
 
 It is composed of four bones: the two ossa innominata; the sacrum 
 and the cocc^oc, each composed in earl}^ life of separate segments united 
 by intervening cartilage. The segments of the innominate bone, the 
 ilium, the ischium and the pubes are the earliest to unite, presenting firm 
 bony union from the twentieth to the twenty-fifth year. The sacral 
 and coccygeal segments fuse still later, those of the coccyx remaining 
 movable until middle life. The coccyx does not normally become firmly 
 joined to the apex of the sacrum until late in life. 
 
 Consideration of the above method of pelvic development demon- 
 strates the fact that during the usual child-hearing age the segments com- 
 yosing the posterior wall of the yelins are not firmly united. 
 
 (219) 
 
220 
 
 THE MECHANISM OF LABOR 
 
 Furthennore, the mobility of the saerococcygeal joint allows consider- 
 able motion in the anteroposterior direction, often amounting to 2 cm. 
 or more, thus meeting the demand during labor for greater room at the 
 
 Fig. 150. — The female pelvis. 
 
 Fig. 157. — Increase of the conjugate diameter of the outlet by recession of the coccyx. 
 
 outlet. This is illustrated in Fig. 157, which represents the increase of 
 the conjugate diameter of the outlet from 9.5 cm. to 11.5 cm., bj' a 
 recession of the coccyx imder the pressure of the presenting part. 
 
THE PARTURIENT CANAL OR PASSAGE 
 
 221 
 
 The space included within this bony framework is divided into two 
 parts by a plane passing through the upper border of the symphysis 
 pubis in front, the linea iliopectinea on either side, and the middle of the 
 sacral promontory behind, called the plane of the iyilet or the jpJane of 
 the superior strait. The portion above this plane, or imaginary level, 
 is called the false pelvis, while that below is the true pelvis which is 
 chiefly concerned in the mechanism of labor. 
 
 The False Pelvis. — The false pelvis has relatively little importance in 
 the process of labor, it serves as a sort of funnel to guide the presenting 
 part into the true pelvis and as a support to the contents of the lower 
 abdomen, the intestines in the non-pregnant state and the enlarging 
 uterus as well as the intestines in the pregnant state. 
 
 Fig. 158.^The peh^ic inlet, seen from above. 
 
 The false pelvis really forms a part of the abdominal cavity, being 
 bounded behind by the lower portion of the lumbar spme, laterally 
 by the iliac fossae, and anteriorly by the lower part of the abdominal 
 wall. 
 
 The Pelvic Inlet. — ^The bony ring or dividing line between the false 
 pelvis above and the true pelvis below is variously spoken of as the 
 brim, the superior strait, or the pelvic inlet. It is irregularly oval in 
 shape with longest diameter running transversely (see Fig. 158). A 
 depression is made in the posterior side of the oval by the projection of 
 the promontory of the sacrimi. In describing the size and shape of the 
 pelvic inlet four diameters are considered: The anteroposterior diameter, 
 or the true conjugate, extending from the middle of the promontory of the 
 sacriun to the upper border of the s^^nphysis pubis. This normally gives 
 an average measurement of llcm. 
 
222 
 
 THE MECHANISM OF LABOR 
 
 The oblique diameters, taken from the sacro-iliac joint on one side, to 
 the iliopectineal eminence of the opposite side. These diameters are 
 called the right or left obliciue, according to whether it is the right or 
 left sacro-iliac joint which enters into the measnrement. 
 
 Thus the right oblique diameter of the pelvic inlet is the distance 
 from the right sacro-iliac joint to the left iliopectineal eminence and 
 vice versa. These oblique diameters normally give an average measure- 
 ment of 12 cm., the right being usually a trifle longer than the left. 
 
 The tran.sverse diameter is the greatest distance across the pelvic inlet 
 taken at right angles to the true conjugate. It usuall>' lies posteriorly 
 to the centre of the pelvis, the extremities of the diameter resting about 
 midway between the sacro-iliac joint and the iliopectineal eminence on 
 each side. The average measurement of this diameter is usually con- 
 sidered 13 cm. It is a difficult diameter to measure and is seldom accu- 
 
 Fig. 159. — The pelvic cavity 
 
 rately taken in practice. Although as stated elsewhere, it is the longest 
 diameter of the pehic inlet, the projection forward of the sacral promon- 
 tory prevents its being the diameter most available for entrance of the 
 fetal head into the true pelvis. 
 
 The True Pelvis. — The true pelvis is that portion lying beneath the 
 plane of the pelvic inlet and is the part chiefly concerned in the mechan- 
 ism of labor. It is bounded below by the plane passing through the tip 
 of the cocc\x, the tuberosities of the ischia and the lower border of the 
 symphysis pubis, called the plane of the outlet or the plane of the inferior 
 strait. This is hardly a mathematical plane, but rather two triangular 
 planes whose apices are at the coccyx and the under surface of the sym- 
 physis respectively, and whose bases meet on a line joining the two ischial 
 tuberosities. The cavity of the true pelvis (see Fig. 159) is bounded in 
 front by the pubic bones and the rami of the ischia, laterally by the 
 
THE PARTURIENT CANAL OR PASSAGE 
 
 223 
 
 ischial bones, with the obturator foramina and membranes in front, 
 and the saerosciatic notches with their hgaments and muscles behind. 
 Posteriorly the pelvic cavity is bounded by the sacrmn and coccyx. 
 It is thus seen that the only portion of the lateral wall formed entirely 
 by bone is the middle portion formed by the body of the ischium. 
 
 The middle portion of the lateral pelvic wall is of distinct importance 
 in the mechanism of labor and deserves further consideration. 
 
 As stated above, this portion is formed solely of bone and is entirel}- 
 unyielding while the portion in front, filled in with the obturator mem- 
 
 FiG. 160. — Ridge dividing anterior and posterior inclined planes. 
 
 brane and muscles, allows more or less yielding, as does the portion behind, 
 filled in by the saerosciatic ligaments and muscles. Furthermore, pro- 
 jecting from the posterior border of this bony middle portion is a sharp 
 projection, the spine of the ischium, which with its fellow of the opposite 
 side causes the least diameter of the pelvic cavity. 
 
 Between the spine of the ischium (A, Fig. 160) and the iliopectineal 
 eminence (B) is a ridge more or less marked in different pelves, which 
 divides the pelvic cavity on each side into two portions, the anterior 
 and posterior, which are concave from above downward and from before 
 backward. These may well be called the anterior and posterior pelvic 
 
224 
 
 THE MECHANISM OF LABOR 
 
 grooves. The portion of the ischial body in front of tlie ridge joining 
 the spine and iUopectineal eminence is in obstetrics often called the 
 anterior inclined plane, while that portion behind this ridge is called 
 the posterior inclined plane. Formerly these inclined planes were thought 
 to be important factors in the rotation of the presenting part. It is now 
 known that they are merely guiding slopes to the pelvic floor, which is 
 the chief factor in the rotation. 
 
 The dividing ridge may be compared to the ridge pole of a two-slope 
 roof (see Fig. 195), and in the same way that a ball falling on one side 
 of the ridge pole will roll down one side' of the roof, and falling on the 
 other side of the ridge pole will roll down the opposite side of the roof, 
 so in the pelvis. If the occiput, for instance, impinges on one of the 
 
 Fig. 161. — The pelvic outlet, seen from below. 
 
 anterior inclined planes, it tends to descend to the floor of the pelvis in 
 one of the anterior pelvic grooves, giving occipito-anterior positions. 
 While if it impinges on one of the posterior inclined planes, it tends to 
 descend in one of the posterior grooves, giving occipitoposterior positions. 
 
 This will be referred to again when discussing rotation of the head in 
 vertex presentations (see page 261). 
 
 The pelvic cavity is shallow in front, measuring only about 4 cm. in 
 depth, and deep behind where it measures along the curve of the sacrum 
 and coccyx about 12.5 cm. The lateral depth is approximately 9 cm. The 
 shape of the pelvic cavity is therefore that of a curved, obliquely trun- 
 cated cylinder, the curve presenting the concavity forward, as though 
 bent about the symphysis, although the greater part of this curve is in 
 the lower part of the cavity rather than the upper. For practical pur- 
 
THE PARTURIENT CANAL OR PASSAGE 225 
 
 poses the diameter of the normal pelvic cavity may be considered the 
 same in all directions and averages 12 cm. 
 
 The Pelvic Outlet. — The pelvic outlet, or the inferior strait, is of irregular 
 shape (see Fig. 161), bounded in front by the pubic arch, laterally by 
 the ischial tuberosities and the greater sacrosciatic ligaments, and pos- 
 teriorly by the tip of the coccyx. When the coccyx is in its normal posi- 
 tion this diameter, as already stated, averages 9.5 cm., but may be 
 increased to 11.5 cm. when the coccyx is pushed backward during the 
 birth of the child (see Fig. 157). 
 
 The transverse diameter of the outlet is the distance between the 
 inner margins of the ischial tuberosities and averages 11 cm. The 
 measurements of the other external diameters of the pelvis are considered ' 
 under the subject of Pelvimetry. 
 
 Pelvic Planes. — The planes of the pelvis are imaginary levels taken 
 at any height in the canal. Of course these could be innumerable but 
 in practical obstetrics only four are considered. Two of them, the j^^ane 
 of the inlet and the playie of the outlet, have already been considered in 
 studying the brim and outlet of the true pelvis. In addition to these, 
 two other planes are recognized as of importance, the jjlane of the greatest 
 pehic dimensions, first described by Levret, and the plane of the least 
 pelvic dimensions. The former passes from the middle of the posterior 
 surface of the symphysis pubis through the middle of the back of the 
 acetabula to the junction of the second and third sacral vertebrae. This 
 plane gives the largest diameters of the cavity; being larger than those 
 of the inlet. The plane of the least pelvic dimensions passes through the 
 lower margin of the symphysis pubis, the spines of the ischia and the tip of 
 the sacrum. This plane, as its name implies, gives the smallest diameters 
 of the cavit.y, being smaller than those of the outlet. 
 
 Pelvic Axes. — ^The axes of the pelvis are imaginary lines drawn at right 
 angles to the centres of the planes of the pelvis; thus the axis of the 
 pelvic inlet or superior strait would be a line which if projected upward 
 would pass approximately through the lunbilicus and if continued 
 downward would strike the coccyx near its tip (see Fig. 162). The axis 
 of the pelvic outlet if continued upward would strike the promontory 
 of the sacrum. The axes of the planes at different heights in the canal 
 would form tangents to a curve which represents approximately the 
 course of the child through the pelvis, although as shown by Naegele, 
 Pinard and others, the child in its passage through the bony pelvis does 
 not follow this curve, called the curve of Cams, accurately, but the head 
 normally descends almost perpendicularly to about the level of the 
 ischial spines before it begins to curve forward. 
 
 Inclination of the Pelvis. — The position of the pelvis in its relation to 
 the spinal column varies with each change of posture. In the erect 
 posture the base of the sacrum lies about 9 cm. above the upper border 
 of the symphysis puhis and the tip of the coccyx about 2 cm. above the 
 summit of the subpubic arch, hence the plane of the inlet and the plane 
 of the outlet each make an angle with the horizon. The former an angle 
 of about 60 degrees and the latter an angle of about 10 degrees (see Fig. 
 15 
 
226 
 
 THE MECHANISM OF LABOR 
 
 103). The angle which the plane of the inlet makes with the horizon 
 is called the inclinnfion of the pelris. The mobility of the pelvis at the 
 
 Fig. 162. — Planes and axes of the pelvic inlet and outlet. 
 
 Pig. lt)3. — Inclination of the pelvis. 
 
 sacro-iliac joints allows of slight rotation of the innominate bones iipoji 
 the sacrum, thus changing the pelvic inclination as the posture changes. 
 If the woman Hes in the Hthotomy position (see P'ig. 164) the plane 
 
THE PARTURIENT CANAL OR PASSAGE 
 
 22V 
 
 of the inlet makes with the horizon an angle of 40 degress. If she lies in 
 the dorsal posture with thighs extended the pelvic inclination is 30 
 degrees. If she lies with hips at the edge of the table and thighs hanging 
 
 Fig. 164. — Pelvic inclination in lithotomy and in dorsal position. 
 
 downward, the so-called Walcher position, the pelvic inclination is 
 only about 12 degrees (see Fig. 165). 
 
 Pelvic Articulations. — Uniting the four bones M^hich constitute the 
 pelvis are four articulations: the two sacro-iliac the sacrococcygeal, and 
 
 Fig. 165. — Pelvic inclination in dorsal and in Walcher position. 
 
 the symphysis pubis. The sacro-iliac articulation on either side is an 
 amphiarthrodial joint. The articular surface of both the sacrum and 
 the ilium is covered with a thin plate of cartilage which is thicker on the 
 
228 THE MECHANISM OF LABOR 
 
 sacrum than on the ilium. Separating these cartilaginous plates there 
 has been demonstrated, especialh' during pregnancy, the presence of a 
 synovial membrane which allows of a certain amount of motion; this 
 motion being a rotation of the innominate bones on the sacrum so that 
 the symphysis is elevated or depressed, thus allowing a change in the 
 conjugate diameter during labor. The ligaments connecting the sacrum 
 and innominate bones are the anterior and posterior sacro-iliac, of which 
 the posterior are much the stronger. Instead of being a true keystone 
 of the pelvic arch the sacrum is really an inverted keystone (see Fig. 166), 
 being wider in front than behind, and would tend to slip downward and 
 forward under the pressure of the trunk were it not held by these strong 
 posterior sacro-iliac ligaments. 
 
 The sacrococcygeal articulation is an amphiarthrodial joint analogous 
 to those between the bodies of the vertebrae. The two bones are con- 
 nected by the anterior and posterior sacrococcygeal ligaments and an 
 
 Fig. 16G. — The sacrum as an inverted keystone. 
 
 interposed fibrocartilage. This fibrocartilage is somewhat thicker in 
 front and behind than at the sides. During pregnancy a synovial 
 membrane is usually to be found in this joint which allows considerable 
 mobility. 
 
 Differences between the Male and Female Pelvis.— The pelvis of the 
 female when compared with that of the male presents marked differences 
 which adapt it to the important function of maternitv, as seen in Figs. 
 167 and 168. 
 
 The female pelvis is lighter, broader and more shallow than the male. 
 The points of muscular attachment are less strongly marked and the 
 pelvis as a whole is less massive in structure. The iliac fossae are broader 
 and the iliac spines more widely separated. The acetabula are farther 
 apart, hence the hips of the woman are more prominent. 
 
 The pubic arch is wider, measuring 90 to 100 degrees in the female, 
 as compared to 70 to 75 degrees in the male. 
 
THE PARTURIENT CANAL OR PASSAGE 
 
 229 
 
 The inlet of the female peh'is is larger than in the male, as the promon- 
 tory is less prominent and the sacrmn is broader. The cavity is more 
 
 Fig. 167. — Female pelvis. 
 
 shallow; the ischial spines project less into the canal; the curve of the 
 sacrmn is usually less, hence the cavit}' as a whole is more roomy. 
 
 Fig. 168.— Male peh-is. 
 
 The outlet of the female pelvis is the larger, as the ischial tuberosities 
 are farther apart. The edges of the wider pubic arch are more everted 
 and the coccvx is more movable. 
 
230 
 
 THE MECHANISM OF LABOR 
 
 Pelvic Lining. — ^'ie^vell ohstetrically the bony pelvis, both the false 
 and the trne, is cushioned with muscles and fascia in such a way that 
 while protecting; the uterus and its contents from the hard, bony struct- 
 ure they diminish but slightly the size of the parturient canal. The 
 funnel of the false pelvis is lined by the iliacus and psoas muscles (see 
 Fig. 1G9) which serve as a cushion for the uterus and its contents while 
 above the brim. 
 
 The true pehis is lined by two muscles on each side the obturator 
 internus and the pyriformis, which have already been described (see 
 page 30). 
 
 ; 
 
 Fig. 169. — False pelvis lined by the iliacus and psoas muscles. 
 
 Stretching across the outlet of the pelvis and serving both as a cushion 
 and as a support for the pelvic organs is the pelvic floor described on 
 page 31, a diaphragm composed chiefly of two pairs of mu.scles, the 
 levatores ani and the coccygei, with the fascial and connective tissue 
 covering them. This diaphragm is perforated by the urethra, the vagina 
 and the rectum. It is covered above by the peritoneum and below by the 
 skin. Between the skin and the main muscular structure of the dia- 
 phragm (the levatores and coccygei) are several superficial muscles sur- 
 rounding the entrance to the vagina and the rectum (see page 35). 
 
 THE PARTURIENT CANAL. 
 
 The parturient canal may be looked upon as composed of two portions, 
 an outer canal, consisting of the abdominal wall and the bony pelvis with 
 
THE PARTURIENT CANAL 231 
 
 the muscles and fascise forming its lining and floor, and an inner canal 
 composed of the uterus and vagina. 
 
 The muscular canal formed hy the uterine body serves also as a propel- 
 ling force and will be considered later under that heading (see page 241). 
 
 It will here be studied as forming a part of the parturient canal. 
 
 The Uterine Canal. — At the end of pregnancy the uterus has grown 
 from a small muscular structure, about 8 cm. in length and weighing only 
 an ounce, to a large muscular sac about 36 cm. long, 25 cm. wide and 24 
 cm. deep, and weighing about two pounds. It has been estimated by 
 Krause that its capacity is increased 519 times during pregnancy. This 
 enlargement has been brought about both by an hypertrophy in the 
 individual muscular fibers and by an increase in their number. The walls 
 of the uterus are very thin, only about 5 to 10 mm. in thickness, and very 
 soft and yielding, as can be seen by watching the fetal movements in 
 a woman with thin abdominal walls. 
 
 The uterus has risen from the pelvis and has become an abdominal 
 organ, freely movable, held chiefly by the broad ligaments, and changing 
 in position with the posture of the woman. It is usually anteflexed, 
 but when the woman lies on her back, this anteflexion is lessened and the 
 uterus falls backward on to the vertebral column. When the woman 
 stands erect, the uterus falls forward, increasing the anteflexion and 
 pushing out the abdominal wall, so that it becomes much more prominent. 
 As it lies in the abdominal cavity it is twisted on its longitudinal axis, 
 slightly to the right, so that its left border becomes more anterior. 
 
 This lateral torsion is easily demionstrated in the course of a Cesarean 
 section, as although the incision is made in the median line of the abdomi- 
 nal w^all, the incision in the uterine wall lying just beneath it is found 
 to be much nearer the left than the right uterine cornu. This is shown in 
 Fig. 170, which is a drawing from a photograph of a uterus removed by 
 the author during the performance of a Cesarean section. 
 
 The Cervix. — The cervix at the end of pregnancy shows certain changes 
 due to the increased vascularity, causing an increase in its violet hue and 
 a greater softening in its structure. Furthermore, during the last two 
 weeks of pregnancy, owing both to this increased softening and to the 
 retraction of the upper part of the cervix into the lower uterine segment, 
 there appears a shortening of the cervix which in some cases is very 
 marked. At this period, moreover, especially in multigravidse, the 
 cervical canal becomes more patulous. 
 
 Soon after the beginning of labor an interesting change may be noted 
 in the uterine wall. The upper portion contracts more vigorously 
 and becomes thicker than the lower portion, which remains nearly 
 passive. This difference in behavior divides the uterus into two seg- 
 ments which have already been referred to (see page 210), viz., the 
 upper and lower ute'rine segments; the line of demarcation between 
 them being about 11 cm. above the external os, at the line of 
 reflection of the peritoneum from the anterior surface of the uterus. 
 Here a slight contraction ring, known as Braune's or Bandl's ring may 
 be noted. This ring and the difference in thickness between the upper 
 
232 THE MECHANISM OF LABOR 
 
 and lower uterine segments becomes more marked A\itli the progress 
 of labor, especially in the second stage, and in long and difficult labors 
 the ring often stands out sharp and unyielding. Below the ring the walls 
 of the uterus are very thin, perhaps about 1.5 mm. in thickness and 
 show very little, if any, contractile power, thus presenting a marked 
 contrast to the segment above the ring, which is thick and powerfully 
 active, Avith walls 5-10 mm, thick. 
 
 The origin of this lower uterine segment has been the subject of much 
 discussion. Braune^ claimed that it was derived entirely from the cer- 
 
 
 ^M^' 
 
 ^s^ 
 
 / ; 
 
 Fig. 170. — Uterus removed during a Cesarean section, showing uterine incision nearer k'ft 
 
 cornu than right. 
 
 vix, and that the ring corresponded with the internal os. If this is so, 
 the cervix must change greatly in length, for before labor it is only 3-4 
 cm. long, and Bandl's ring is 11 cm. from the external os. The other 
 theory is that the upper part of the lower uterine segment is derived from 
 the uterus and the lower 3-4 cm. is derived from the cervix. 
 
 The problem is not easy of solution, but the latter theory seems to 
 be gaining more and more credence. Williams,^ of Baltimore, describes 
 
 * Die Lage des Uterus und Foetus am Ende der Schwangerschaft, Leipzig, 1872. 
 2 Obstetrics, 1908, p. 239. 
 
THE PARTURIENT CANAL 
 
 233 
 
 a section of the lower segment taken from a woman who died m premature 
 labor, in which for 3-4 cm. above the external os the lining is distinctly 
 cervical mucous membrane, while above this the tissue is uterine in 
 appearance and covered by decidua. In the author's specimen (see Fig. 
 171) microscopic examination under a high power shows in the upper 
 part of the lower uterine segment, structure much more suggestive of 
 body than cervix in origin. The belief that the lower uterine segment 
 
 Fig. 171. — Uterus removed soon after labor, showing upper and lower uterine segments. 
 
 is derived both from the body and cervix has received the endorsement 
 of such authorities as Schroeder, Ruge, Veit, and others. 
 
 The Vagina. — The vagina at the end of pregnancy shows an increased 
 vascularity. It is bluish in color and the secretion from its glands is 
 much increased. The discharge is thick, whitish in color, cheese-like 
 in consistency and acid in reaction. It is composed of cast-off epithelium 
 and contains numerous bacteria, mostly bacilli. They are normally 
 non-pathogenic, and indeed the normal vaginal secretion possesses bac- 
 tericidal properties. 
 
234 
 
 THE MECHAXISM OF LABOR 
 
 The vajiimrl walls are increased slightly in length so that a slight 
 fulness of the tissues is often observed anteriorly — a cystocele. 
 
 \ iewed as a whole the parturient canal may be looked upon as com- 
 posed of three divisions (see Fig. 172). 
 
 1. The suprapelvic division, of which the abdominal wall forms the 
 outer coat and the uterine wall the inner coat and together they serve 
 as a propelling force as well as a part of the parturient canal. 
 
 2. The pelvic division, of which the bony pelvis with its mu.^cular 
 and fascial lining forms the outer coat, and the lower uterine segment 
 and the vagina the inner coat. This division of the canal being passive 
 in labor and being the seat of most of the resistance. 
 
 Fk;. 11 
 
 -Divisions of the parturient canal; suprapelvic, pelvic, and infrapeh-ic. 
 
 3. The infrapelvic division, of which the muscles and fascite of the 
 pelvic floor form the outer coat and the vagina the inner coat. 
 
 This division is also resistant in action, but in a lesser degree than the 
 pelvic division. Its chief function in labor seems to be the maintenance 
 of flexion and the close approximation of the presenting part to the 
 pubic arch. 
 
 THE FETUS OR PASSENGER. 
 
 Considered obstetrically, the head is the most important part of the 
 fetus, as it is the hardest, the least compressible, and usually presents 
 the greatest difficulty in delivery. The birth of the body is usually 
 simple and gives but little trouble. The fetal head presents certain 
 
THE FETUS OR PASSENGER 
 
 235 
 
 characteristics which have a marked influence in the mechanism of 
 labor, and therefore deserves careful consideration. 
 
 It is made up of two parts: the face and the cranium (see Fig. 173). 
 
 The Face. — The bones of the fetal face at term are well united and 
 the face as a whole presents but slight compressibility compared with 
 the cranium. 
 
 However, the face composes but a small part of the head and the 
 absence of teeth and the shortness and obliquity of the ramus of the 
 inferior maxilla in the fetus makes the fetal face relatively much smaller 
 than the face of adult life. 
 
 The Craniiim. — The cranium for obstetri^cal study is composed of 
 two portions: the base, which is hard and'^'compressible, with bones 
 firmly united, and the vault, whose bones areseparated from each other 
 by spaces filled with membrane, which under compression allows mold- 
 
 FiG. 173. — The fetal head and its diameters. 
 
 ing by approximation and perhaps overlapping of the bones. In this 
 way the diameters of the fetal head are reduced and the large cranium 
 is made to conform to the shape of the pelvic canal, the compression 
 occurring over the hemispheres of the fetal brain where the least damage 
 is done. 
 
 It is thus seen that the incompressible portions of the fetal head are 
 the face and the base, and the compressible portion is the vault. 
 
 This is composed of the two frontal bones, the two parietal, the 
 wings of the sphenoid, the two temporal bones, and the upper portion 
 of the occipital bone. 
 
 Sutures. — In the adult skull the different bones composing it are 
 united by interlocking dentated processes of bone called sutures. 
 
 In the face and base of the fetal skull this same method of union can 
 be seen, but in the compressible fetal vault the edges of' the composing 
 
236 
 
 THE MECHANISM OF LABOR 
 
 l)oiies are united hy inciiihraiie, althougli the connection is still called 
 a suture. 
 
 Tlie sutures having obstetrical importance, because palpable during 
 labor and useful in diagnosis of the position of the fetal head, are the 
 lanibdoid suture, between the occipital and the two parietal bones; the 
 sagittal, between the parietal bones; the coronal, between the frontal 
 and parietal bones; and the frontal, between the two frontal bones. The 
 other sutures are usually so covered by soft parts or so distant as not to 
 be palpable through the cervix. 
 
 Fontanelles. — Where two or more sutures meet together leaving an 
 intervening space filled with membrane, this space is called a jontanelle. 
 There are two main fontanelles which are usually present in every fetal 
 skull and utilized in diagnosis of position. They are the posterior fon- 
 tanelle and the anterior Jontanelle. 
 
 Fig. 174. — The posterior fontanelle. 
 
 Fig. 175. — The anterior fontanelle. 
 
 The posterior fontanelle (see Fig. 174), mentioned first because the one 
 most often felt in a normal presentation, is that at the junction of the 
 sagittal and lambdoid sutures; it is triangular in shape, bounded by the 
 occipital and two parietal bones, is smaller than the anterior fontanelle, 
 and in fact, as labor advances, may be practically closed by the lapping 
 of the parietal bones over the occipital. 
 
 The anterior fontanelle (see Fig. 175) is that formed at the junction 
 of the coronal, sagittal and frontal sutures. It is larger than the posterior, 
 is quadrilateral in shape, and is also called the bregma. 
 
 In diagnosing the anterior and posterior fontanelles it is evident from 
 the above that, aside from the difference in size, the anterior fontanelle 
 has four lines of sutures running into it, while the posterior has only three. 
 
THE FETUS OR PASSENGER 
 
 237 
 
 The posterior fontanelle usually closes within a few months after 
 birth, while the anterior may remain open during the first year, and in 
 rare instances even beyond the second year. Of less obstetrical impor- 
 tance, because not palpable, save in marked lateral obliquity of the fetal 
 head, are two fontanelles of irregular shape, called the temporal fon- 
 tanelles, found at the anterior and posterior extremity of each parietal 
 bone where it joins the temporal. 
 
 Occasionally on account of faulty ossification a fontanelle is found in 
 the sagittal suture about midway between the anterior and posterior 
 fontanelles. It is called the sagittal fontanelle and resembles the anterior 
 fontanelle in shape but is usually smaller in size. 
 
 Articulation. — A lateral view of a fetal skeleton (see Fig. 176) shows 
 that the occipito-atloid articulation (B) is much nearer the occipital pro- 
 
 FiG. 176. — Articulation of the fetal head. 
 
 tuberance (C) than it is to the mental process of the inferior maxillary 
 bone (.4), i. e., the articulation between the head and spinal column is 
 posterior to the centre of the head (E, D). As the anterior arm of the 
 lever (distance between articulation and chin) is greater than the pos- 
 terior arm (distance between articulation and occipital protuberance) 
 pressure on the vault of the craniimi at its centre or am-uhere in front 
 of it tends to make the chin approach the sternum, a motion which is 
 called flexion. :Moreover, even if the pressure was evenly distributed 
 over the cranial vault, as more of the vault lies in front of than behind 
 the line of articulation with the spine, flexion would normally result. 
 Hence the frequency of flexion, as the normal attitude of the fetal head, 
 produced by the resistance of the pelvic canal to the advance of the 
 fetus, with its accompanying pressure on the vault of the fetal craniimi. 
 
238 
 
 THE MECHAXISM OF LABOR 
 
 Motions of the Fetal Head. — It is well in this connection to study the 
 different motions oi the fetal head upon the spinal column. The most 
 frequent (flexion) has just been considered and may be defined as follows: 
 P'lexion of the head is a motion on its transverse axis b\' which the chin 
 approaches the sternum. It takes place chiefly in the occipito-atloid 
 articulation, although it may be increased by a forward bending in the 
 cervical spine. Lateral flexion of the head is a motion on its antero- 
 posterior axis, by which one parietal eminence approaches the shoulder 
 of that side. A certain amount of lateral flexion is possible at the occipito- 
 atloid articulation; a continuance of it is produced by a lateral bending 
 of the whole of the cervical portion of the spine. 
 
 Extension. — Extension of the head is a motion on its transverse axis 
 by which the chin recedes from the sternum. This motion takes place 
 
 at the occipito-atloid articulation, and 
 is produced in one of two ways: either 
 (1) by greater pressure being applied 
 to the vault of the cranium behind the 
 line of the spinal articulation than is 
 applied in front of it, or (2) an obstacle 
 to flexion being present, pressure ap- 
 plied even in front of the line of spinal 
 articulation may cause recession of the 
 chin from the sternum. 
 
 Rotation. — Rotation of the head is 
 a motion on its vertical axis by which 
 the chin approaches the line of either 
 shoulder. This motion begins at the 
 atlo-axoid articulation and is continued 
 by a rotation of the cervical portion 
 of the spinal column. 
 
 Diameters of the Fetal Head. — P'or 
 
 the comparison of the shape and size 
 
 of the child's head with the shape and 
 
 size of the pelvic canal through which 
 
 it has passed, the postpartum measurements are taken of various diameters 
 
 of the fetal head. At the Sloane Hospital it is the routine custom to 
 
 measure the following cephalic diameters (see Figs, 173 and 177). 
 
 The Suboccipitobregntatic. — The distance from a point on the under 
 surface of the occipital bone where it joins the neck to the middle of the 
 anterior fontanelle. 
 
 The Snboccipitofronfal. — The distance from the same point behind 
 to the root of the nose in front. 
 
 The Occipitofrontal. — The distance from the most prominent part 
 of the occipital bone to the root of the nose. 
 
 The Occipitomental. — The distance from the most prominent part of 
 the occiput to the most prominent part of the chin. 
 
 The Bijjarietal. —The greatest distance between the two parietal 
 eminences. 
 
 Fig. 177. — Biparietal diameter. 
 
THE FETUS OR PASSENGER 239 
 
 In addition to these cephalic diameters it is the custom to take the 
 diameter of the shoulders, called the hisacromial — the greatest distance 
 between the two acromial processes. 
 
 The measurement immediately after birth of the heads of 100 children 
 born at the Sloane Hospital, w^th presentation other than breech, and 
 of 100 children born with breech presentation, gave the following average 
 diameters : 
 
 Presentation other Breech 
 
 Diameters. than breech. presentation. 
 
 Suboceipitobregmatic 9.4250 cm. 9.6250 cm. 
 
 Suboccipitofrontal 10.2830 cm. 10,7895 cm. 
 
 Occipitofrontal 11.4750 cm. 11.5300 cm. 
 
 Occipitomental 13.2205 cm. 12.7600 cm. 
 
 Biparietal 9.2270 cm. 9.6100 cm. 
 
 Bisacromial 12.4225 cm. 12.5300 cm. 
 
 The measurement immediately after birth of another series of 100 
 children without regard to the presentation and omitting small fractions 
 gave the following average diameters: 
 
 Suboceipitobregmatic 9.50 cm. 
 
 Suboccipitofrontal 10.50 cm. 
 
 Occipitofrontal 11.50 cm. 
 
 Occipitomental 13 . 25 cm. 
 
 Biparietal 9.25 cm. 
 
 Bisacromial . . . .' 12.25 cm. 
 
 It is the custom of the author to regard these measurements as the 
 average diameters of the fetal head. 
 
 In addition to the above diameters it is the custom at the Sloane 
 Hospital to measure the following circumferences and the length of the 
 child at birth. 
 
 Circumferences. — The suhoccijntofrontal, taken in the plane of the sub- 
 occipitofrontal diameter. 
 
 The occipitofrontal, taken in the plane of the occipitofrontal diameter 
 — the largest cephalic diameter thrown across the pelvis (save perhaps 
 in brow presentation). 
 
 The hisacromial, taken in the plane of the bisacromial diameter. 
 
 The measurement immediately after birth of a series of 100 children 
 with presentation other than breech, and a series of 100 children with 
 breech presentation, gave the following average circumferences: 
 
 Fetal Circumferences. 
 
 Presentations other Breech 
 
 than breech. presentation. 
 
 Suboccipitofrontal 32.455 cm. 34.3050 cm. 
 
 Occipitofrontal 34.515 cm. 34.9275 cm-. 
 
 Bisacromial 35.880 cm. 36.2950 cm. 
 
 For practical purposes not regarding the presentation of the fetus 
 the following may be considered the average circumferences : 
 
 Suboccipitofrontal 33 . cm. 
 
 Occipitofrontal 34.5 cm. 
 
 Bisacromial 36.0 cm. 
 
240 
 
 THE MECHANISM OF LABOR 
 
 Length of the Child. — The measurement of the length of several 
 thousand children at birth gave the average length of the normal child 
 at full term as 50 cm. or 20 inches. 
 
 Fig. 178. — Parietal bones overlapping the occipital and the frontal bones. 
 
 Molding. — ^Although the above are given as the average measure- 
 ments of the fetal head, it must be noted that by a wise provision of 
 nature these measurements may be greatly changed under pressure, 
 and the various diameters altered to meet the demands of the individual 
 parturient canal without injury to the fetus. Thus the bones of the 
 cranial vault being united by membranous sutures, and being more or 
 
 1 Fig. 179.— One parietal bone overlapping the other. 
 
 less pliable in themselves, may allow reduction in the cephalic diameters 
 in one of two ways: either (1) by approximation and o^•erlapping of 
 opposing bones, or (2) by bending of the pliable individual bones. A 
 
THE PROPELLING FORCE 241 
 
 certaiD rule ma}' be noted in the overlapping of cranial bones. Thus 
 the parietal bones usually overlap the occipital and the frontal bones 
 rather than vice versa (see Fig. 178). Furthermore, one parietal may 
 overlap the other (see Figs. 179). 
 
 The diameters of the fetal head may be further reduced by compression 
 of its contents; some of the cerebral fluid being expressed into the spinal 
 canal and some of the blood being forced out of the cerebral vessels, all 
 of this being only temporary and usually without injury to the child. 
 
 As a result of this molding, however, the shape of the child's head 
 at birth and the expression of its features are sometimes a disappoint- 
 ment to the parents, and require for their peace of mind the assurance 
 by the obstetrician that the disfigurement is only temporary and will 
 all disappear in a day or two. 
 
 THE PROPELLING FORCE. 
 
 The forces concerned in the expulsion of the child are two: (1) the 
 uterine; (2) the ahdominal ivall. 
 
 The Uterine Force. — The uterine force is rhythmical, intermittent and 
 involuntary. It is rhythmical in the sense that there is an approximate 
 regularity in the recurrence of the uterine contractions; the interval 
 between these contractions, however, varies greatly in the different stages 
 of the labor. Thus in the early part of the first stage there may be an 
 interval of thirty minutes, while in the latter part of the second stage 
 the contractions may be separated by only two or three minutes. It 
 is fortunate, alike for mother and child, that the contractions are intermit- 
 tent. The woman could not endure the continuous suffering of unin- 
 terrupted uterine contractions. The wise provision of nature for the 
 maintenance of the strength of the patient, by the intervening periods 
 of rest, is now^here seen to better advantage than in the intermittent 
 character of uterine contractions. Furthermore, but for these periods 
 of relaxation, the uterine muscle would lose its vitality and sloughing 
 would result. Rupture of the uterus also, the result feared in all cases 
 of tonic uterus, would be more frequent. Moreover, in the interest of 
 the fetus, intermissions in the contractions of the uterus are absolutely 
 essential, as otherwise the uteroplacental circulation would be impeded, 
 and asph\':sia of the fetus would result. 
 
 The length of time occupied by a uterine contraction varies according 
 to the stage of labor. In the first stage the contraction usually lasts 
 onl}^ about half a minute, while in the second stage it may last a minute 
 or more. 
 
 The uterine contractions are involuntary, as is shown by their con- 
 tinuance when the patient is under the influence of an anesthetic, or as 
 is occasionally seen in cases of spinal paralysis. 
 
 The effect of the uterine contractions varies in the stages of labor. 
 In the first stage, before the rupture of the membranes, the force of the 
 contraction is spent chiefly in bringing about the dilatation of the cervix, 
 and but little in causing descent of the presenting part. 
 16 
 
242 THE MECHANISM OF LABOR 
 
 It causes the dilatation of the cer\ix by retraction of the muscular 
 structure from the lower toward the upper uterine segment, and by 
 forcing downward the fluid wedge produced by the distention of that 
 portion of the amniotic sac which lies over the internal os with the 
 liquor amnii lying in front of the presenting part. 
 
 After the rupture of the membranes the force of the uterine contrac- 
 tions causes a further retraction of the ce^^'ix toward the upper uterine 
 segment, and continues the dilatation of the cervix by forcing downward 
 the solid wedge of the presenting part. 
 
 During the second stage the uterine contractions })ring about descent 
 of the fetus, both by direct rlownward pressure of the fundus upon the 
 fetal trunk and also by indirect fluid pressure upon the fetus, where only 
 a small amount of liquor amnii has escaped and more or less of the fetus 
 is surrounded by it. 
 
 The Abdominal Wall Force. — The abdominal wall force comprises 
 the action both of the diaphragm and of the muscles of the anterior and 
 lateral portions of the abdominal wall. That the force of these muscles 
 is not absolutely essential to the birth of the child in many instances 
 can be easily demonstrated in cases deeply anesthetized. That the 
 abdominal force greatly assists and accelerates the progress of labor is 
 often seen when the patient, after a little instruction and encouragement, 
 brings into play her abdominal muscles, which up to that time she had 
 not employed. During the first part of the second stage the force of 
 the abdominal muscles is largely voluntary and may be used or not at 
 will. In the latter part of this stage, however, when the presenting part 
 rests upon the pelvic floor, the action of the abdominal muscles is prac- 
 tically involuntary. It is very difficult to accurately determine the 
 amount of the propelling force in the synchronous contraction of the 
 uterine and abdominal muscles. It is variously estimated at from 
 40 to 100 pounds. 
 
 Schatz^ inserted into the uterus a rubber bag connected with a man- 
 ometer. He found that the force of the pains varied from 8^ to 27^ pounds, 
 increasing as the head reached the perineiun. 
 
 Joulin- tried to estimate the force b\' using forceps to which was 
 attached a dynamometer which recorded the amount of traction neces- 
 sary to deliver the fetus. This varied from 80 to 100 pounds. Neither 
 of these methods would seem to be very accurate. Every obstetrician 
 has some idea of the force required to prevent the head coming over 
 the perineum too rapidly, and often roughly estimates it at about 50 
 pounds, although of course this is only approximate. 
 
 The force undoubtedly varies with the strength and posture of the 
 woman. In the squatting posture the force would be greatest, while 
 in the lateral or semiprone position it would be least. When the head 
 is passing over the perineum the expulsive force is often diminished. 
 
 1 Uel>er die Eutwickelung der Kraft des Uterus im Verlaufe dcr Geburt, Verb. d. deutschen 
 GeseU. fiir. Gyn.. 1895. vl, 5.31-.542. 
 
 * Mcmoire sur I'cmploi de la force in obstetri(jue, Arch. gen. de med. fev. et mars, 1867, 
 i, 149, .313. 
 
ATTITUDE— PRESENTATION— POSITION 243 
 
 This is due to the fact that the excessive pain from the stretching and 
 tearing of the soft parts, causes the woman to cry out — "the perineal 
 cry" — thus releasing the diaphragm " and nullifying the contractions of 
 the abdominal muscles. Thus does nature by this wise provision tend to 
 save the perineimi. Anesthesia given at this stage has t^e double advan- 
 tage of lessening the muscular contractions and of diminishing the suffer- 
 ings of the woman. 
 
 Aside from the expulsive forces of the uterus and abdominal wall, 
 a third factor enters into the descent of the fetus in the pelvic canal, 
 viz., the straightening out of the body of the fetus, caused by the uterine 
 contractions during the second stage. Schroeder estimates this increase 
 in length of the fetus as 5.5 cm., and Olshausen, as 7.2 to 10 cm. This 
 is seen especially in vertex cases where, with the fundus steadying the 
 breech, the increase in the length of the fetal ovoid causes descent of 
 the head in the pelvis. During the first stage it is probable that the 
 position of the fetus changes but little. It must be remembered that in 
 many cases before labor the fetus with the uterus has settled into the 
 pelvis so that the biparietal diameter is on a level with the ischial spines. 
 This is generally true in prunigravidse, while in multigravidae, on the 
 other hand, the head may remain at the brim until the beginning of the 
 second stage of labor. In the second stage, with the presenting part 
 resting on the pelvic floor, over half of the fetal body is below the con- 
 traction ring, and the uterine contractions are acting upon the upper 
 part of the fetal ovoid alone, pushing it downward and outward. Fur- 
 thermore, pressure of the presenting part upon the pelvic floor tends to 
 stimulate contractions of the diaphragm and the abdominal wall and 
 the expulsive force is now the greatest. The relation of the different 
 parts of the fetus to each other and to the parturient canal may next 
 be studied with advantage and under three heads. 
 
 ATTITUDE. PRESENTATION. POSITION. 
 
 Attitude. — The attitude of the fetus is the relation which different 
 parts of its body bear to one another, irrespective of the presentation 
 or position. The attitude which the fetus normally assumes in the 
 uterus (see Fig. 180) is one of universal flexion — the back curved forward; 
 the chin on the sternum; the arms and legs sharply flexed and close 
 to the body, with the hands and feet respectively crossing each other, 
 the feet being turned in. 
 
 The umbilical cord lies between the thighs. In this attitude the fetus 
 occupies the least possible space. This attitude gives the fetus some- 
 what the shape of an egg, and for this reason it is often spoken of as the 
 "fetal ovoid." It must be noted, however, that only one side (the back) 
 is convex, while the opposite side, the abdominal, is concave. One end 
 of the fetal ovoid is called the cephalic, and the other the pehic, corre- 
 sponding respectively to the head and the buttocks. 
 
 The attitude of universal flexion is the normal one, for in this attitude, 
 whether the cephalic or the pelvic end of the fetal ovoid presents, labor 
 
244 
 
 THE MECHANISM OF LABOR 
 
 is easiest. Any variation from this attitude is abnormal and usually 
 makes labor more difficult. 
 
 Presentation. — Presentation is a term used to denote the relation 
 which the long axis of the fetus bears to that of the mother. When these 
 axes coincide the presentation may be said to be longifinlinal, while if 
 there is a marked variatio nbetween them it is called (ihliqiie or iransxersc 
 
 Oblique Presentations. — Oblique presentations are of little importance, 
 as they tend to become either longitudinal or transverse. 
 
 Longitudinal Presentations. — Longitudinal ]:)resentations are divided 
 into two: the cephalic and pelvic, according to the end of the fetal o\'oid, 
 
 Fig. ISO. — The attitude of universal flexion. 
 
 which lies at the brim of the pelvis and can be felt by the examining 
 fingers. Longitudinal presentations are, as a rule, favorable presentations, 
 while transverse presentations are unfavorable, as they generally neces- 
 sitate interference on the part of the obstetrician. Fortunately over 99 
 per cent, of all presentations are longitudinal. In 20,()()() consecutive 
 labors in the author's service at the Sloane Hospital, 99.1 per cent, 
 were longitudinal presentations. 
 
 The term "presenting part," often employed, refers to that i)()rtion 
 of the fetus which lies over the cervix and is felt through the vagina by 
 the examining fingers. By distinguishing the presenting part we are 
 enabled to divide presentations more accurately. Thus in cephalic pre- 
 
ATTITUDE— PRESENTATION— POSITION 
 
 24^ 
 
 sentations with the head well flexed (the normal attitude), the vertex 
 lies over the cervix and w^e have a vertex presentation (see Fig. 181). 
 
 Fia. 181. — Vertex presentation 
 
 Fig. 182. — Bregma presentation. 
 
246 
 
 THE MECHANISM OF LABOR 
 
 When the head is slightly extended, the large fontanelle or bregma is 
 the presenting part — a bregma presentation (see Fig. 182). ^Yhen 
 the head is more extended we have a brow presentation (see Fig. 183). 
 
 Fig. 183. — Brow presentation 
 
 Fig. 184 — Face presentation. 
 
ATTITUDE— PRESENTATION— POSITION 
 
 247 
 
 With the head in extreme extension the face lies over the cervix — a face 
 presentation (see Fig. 184). 
 
 In pelvic presentations the breech lies over the cervix and is the pre- 
 senting part, hence the name breech presentation. When the legs are 
 flexed upon the thighs and upon the abdomen, the presentation is called 
 a "normal" or "complete" breech presentation (see Fig. 185). At 
 times, however, the fetus lies in an abnormal attitude, with the legs 
 extended straight along its body, the feet near the upper part of the 
 chest. This is called a "frank" or "incomplete breech" presentation 
 
 Fig. 185. — Normal or complete breech presentation. 
 
 or a "breech with extended legs" (see Fig. 186). At times the foot or 
 knee may lie over the cervix giving a "foot" or "knee presentation." 
 These last two are of little importance as the prognosis and treatment 
 differs but little from that of the normal breech presentation. The 
 two important varieties are the "complete" and the "frank" breech 
 presentations just described. 
 
 In transverse presentations, while either the shoulder, the hip or any 
 portion of the trunk may at first lie over the cervix at the brim of the 
 pelvis, as the labor progresses these other parts usually change into 
 
248 THE MECHANISM OF LABOR 
 
 presentation of one or other shoulder so that transverse prcsentadon is 
 usually regarded as synonymous with shoulder presentation. 
 
 The hand or elbow may be the presenting part, but this is extremely 
 rare except in transverse presentations and here the prolapse of the 
 upper extremity does not materially alter either the prognosis or the 
 treatment. The separate nomenclature of hand presentation and elbow 
 presentation is little employed. 
 
 ^'- 
 
 ^ \ 
 
 ^ 
 
 7 '^ ^ 
 
 Fig. 186. — Frank breech presentation. 
 
 A Compound Presentation. — A compound presentation is one in which 
 there is a prolapse into the peh'is of one or both of either the upper or 
 lower extremities alongside of the presenting part. Thus there may be 
 various combinations in the presentation, as the head and a hand, or 
 the head and both hands, or the head and a hand and a foot, etc. It 
 will be noted that the chief presenting part in these cases is usualh' the 
 head. 
 
 Position. — The position of a fetus is the relation of a selected portion 
 of the presenting part to certain fixed landmarks in the maternal pelvis. 
 In a vertex presentation the selected portion of the presenting part is 
 
ATTITUDE— PRESENTA TION— POSITION 249 
 
 the occiput; in a breech presentation it is the sacrum; in a face presen- 
 tation it is the chin. 
 
 The fixed landmarks in the pelvis to which reference has been made are 
 the sacro-iliac joints behind and the iliopectineal eminences in front. 
 
 It is evident that the selected portion of the presenting part may 
 assume any position in the circle of the pelvic cavity, but only eight are 
 considered: four primary and important, and four secondary or tran- 
 sitional and of less importance. The four primary positions are deter- 
 mined by the relation of the selected portion of the presenting part to 
 the four fixed landmarks already mentioned which lie at the extremities 
 of the right and left pelvic diameters, as for instance, in a vertex presen- 
 tation, the four primary positions are: 
 
 1 . Occiput opposite left iliopectineal eminence. 
 
 2. Occiput opposite right iliopectineal eminence. 
 
 3. Occiput opposite right sacro-iliac joint. 
 
 4. Occiput opposite left sacro-iliac joint. 
 
 In addition to these primary positions there are four of less impor- 
 tance in which the selected portion of the presenting part lies in the 
 pelvis at points which are midway between the four landmarks above 
 mentioned. Thus in a vertex presentation the occiput may lie directly 
 anterior or directly posterior, directly to the left or directly to the right. 
 
 It is customary to abbreviate thus: 
 
 O — occiput; M — chin (from mentum) ; S — sacrum; L — left; R — aright; 
 A — anterior; P— posterior. 
 
 In a vertex presentation then the eight positions may be summarized 
 as follows: 
 
 Positions of a Vertex Presentation. — Left occipito-anterior — L. O. A. — 
 occiput at left iliopectineal eminence. Right occipito-anterior — R. O. A. — 
 occiput at right iliopectineal eminence. Right occipitoposterior^R. 0. 
 P. — occiput at right sacro-iliac joint. Left occipitoposterior — L. O. P. — 
 occiput at left sacro-iliac joint. Occiput anterior — O. A. — occiput 
 directly anterior. Occiput posterior — O. P. — occiput directly posterior. 
 Occiput left — ^L. O. — occiput directly to left. Occiput right — R. O. 
 — occiput directly to right. 
 
 In face presentation, substituting chin for occiput, we derive eight 
 similar positions, thus: 
 
 Positions of Face Presentation.^ — ^Left mento-anterior — L. M. A. — chin 
 at left iliopectineal eminence. Right mento-anterior — R. M. A. — chin 
 at right iliopectineal eminence. Right mentoposterior — R. M. P. — chin 
 at right sacro-iliac joint. Left mentoposterior — ^L. M. P. — chin at left 
 sacro-iliac joint. Mento-anterior — M. A. — chin directly anterior. 
 Mentoposterior — ^M. P. — chin directly posterior. Mentoleft — L. M. 
 — chin directly to left. Mentoright — R. M. — chin directly to right. 
 
 1 It would, of course, be more consistent when speaking of positions of the chin to use 
 the initial "C" rather than "M" as the abbreviation for chin, while the English woids 
 right and left are used; or else to use the Latin words Dextra and Sinistra with abbrevia- 
 tions "D" and "S"; but the abbreviation "M" has so long been in general use with the 
 English words right and left, that it has been decided to retain this nomenclature. 
 
250 THE MECHANISM OF LABOR 
 
 In breech presentations, substituting sacrum for occiput, eight similar 
 positions are possible, thus: 
 
 Positions of Breech Presentation.^ — Left sacro-anterior — L. S. A. — sacrum 
 at left iliopectineal eminence. Right sacro-anterior — R. S. A. — sacrum 
 at right iliopectineal eminence. Right sacroposterior — R. S. P. — sacrum 
 at right sacro-iliac joint. Left sacroposterior — L. S. P. — sacrum at left 
 sacro-iliac joint. Sacro-anterior — S. A. — sacrum directly anterior. 
 Sacroposterior^ — S. P. — sacrum directly posterior. Sacro-Ieft — L. S. 
 — sacrum directly to left. Sacro-right — R. S. — sacrum directly to right. 
 
 Brow and bregma (also called sincipital) presentations are transitional 
 presentations only and it is therefore unnecessary to tabulate the 
 eight possible positions of each of them. This, however, may easily be 
 done if desired. 
 
 By the three letters used in the abbreviation are indicated at once the 
 presentation, the position and the attitude of the fetus. Thus L. O. A.: 
 the presentation is a vertex, the position is that with occiput at the left 
 iliopectineal eminence, and the attitude is one of flexion. 
 
 As has been said, longitudinal presentations occur in over 99 per cent, 
 of all cases. This great predominance is very fortunate, and can easily 
 be explained by the fact that the long diameter of the fetus naturally 
 seeks the long diameter of the uterus. The uterus being a muscular 
 structure, relaxing and contracting throughout pregnancy, and the 
 fetus being freely suspended in the liquor amnii within it, make this the 
 more reasonable; for if the fetus for any reason becomes obliquely or 
 transversely placed, the wall of the uterus is put on the stretch, and con- 
 tractions occur which turn the fetus back into the longitudinal diameter. 
 
 Cephalic presentations predominate greatly over pelvic. Li a con- 
 secutive series of 20,252 births at the Sloane Hospital, 95 per cent, were 
 cephalic presentations 4.12 per cent, were breech, 0.17 per cent, were 
 brow, 0.38 per cent, were face, and 0.89 per cent, were transverse pre- 
 sentations. 
 
 Schroeder,^ from a study of several hundred thousand cases, gives 
 the percentage of vertex presentations as 95 per cent. ; face presentations, 
 0.6 per cent.; breech, 3.11 percent.; and transverse presentations as 0.56 
 per cent. 
 
 Pinard^ gives statistics very similar (95.5 per cent., 0.4 per cent., 3.3 
 per cent, and 0.8 per cent.). 
 
 If only labor at term is considered, there is a still greater predominance 
 of vertex presentations, 96.97 per cent., while breech presentations occur 
 only in 1.77 per cent. 
 
 Thus it is seen that in the vast majority of cases, nature causes a 
 cephalic presentation, which is usually the most favorable for both mother 
 and child. IVIuch has been written and many experiments have been 
 performed to find the cause for this predominance of cephalic presenta- 
 tions. 
 
 The gravitation theory has been thought by some to explain it. 
 
 1 Lehrbuch der Geburtshiilfe, xiii, Aufl., 1899. 
 
 * L'acCommodation foetale. Traite du palper abdominal, Paris, 1878, 2me ed, 1889. 
 
MECHANISM OF LABOR IN VERTEX PRESENTATION 251 
 
 This resulted from the following experiment: A dead fetus was sus- 
 pended in a salt solution of a specific gravity equal to that of the fetus 
 (1.050-1.055), when it was found that the head and right side sank down- 
 ward (Duncan/ Veit^). It was shown later, however, that when the 
 specific gravity of the fluid was the same as that of normal liquor amnii 
 (1.008-1.009) the breech always sank first (Schatz,^ confirmed by 
 Williams'^). Therefore the gravitation theory does not seem satisfactory. 
 The most generally accepted theory to account for the predominance 
 of cephalic presentation is the "accommodation theory." 
 
 According to the above the fetus best fits the cavity of the uterus when 
 it lies with the head down and if it be turned to any other presentation 
 so that the breech is down, or the body is transverse or oblique, the 
 uterus by its contractions will usually turn the fetus back to the position 
 with the head below. Moreover, in conditions where the fetus does not 
 fit the cavity of the uterus, such as in prematurity, excessive liquor 
 amnii, twin pregnancies, monstrosities, tumors, etc., abnormal presenta- 
 tions such as breech or transverse may result. This theory seems to be 
 borne out by facts; the upper part of the uterine cavity is more roomy 
 than the lower, while the breech with the thighs and legs is more bulky 
 (though more compressible) than the head. Thus the fetus fits the 
 uterine cavity best in cephalic presentations and is usually found (95 
 per cent, of cases) with head downward. It is in the birth of the head, 
 however, that the greatest difficulty lies, for this is the largest and least 
 compressible part of the fetus. The birth of the body is usually simple 
 and gives little difficulty. 
 
 MECHANISM OF LABOR IN VERTEX PRESENTATION. 
 
 In cephalic presentations, when the head is well flexed and the occipi- 
 tal and parietal bones about the posterior fontanelle constitute the 
 presenting part, it is called a vertex presentation. 
 
 This is the most frequent of all presentations; in 20,000 consecutive 
 labors at the Sloane Hospital, occurring in 94.4 per cent, of the cases. 
 
 The vertex presentation, moreover, is the most favorable and if with 
 a vertex presentation the occiput lies anteriorly, we have the ideal posi- 
 tion for the fetus at the beginning of labor. The mechanism of labor in 
 vertex presentations may be taken as the type of mechanism in all 
 presentations and a thorough understanding of this will make the com- 
 prehension of the whole subject of mechanism of labor comparatively 
 easy. 
 
 1 The position of the Fetus. Researches in Obstetrics, Edinburgh, 1868, pp. 14-37; also 
 EdiL burgh Med. and S\u-g. Journal, 1855. 
 
 2 Die Lagenverhaltnisse bei Fnih-und Zwillingsgeburten, Scanzoni's Beitrage, 1860, 
 iv. 279-292. 
 
 sUeber den Schwerpunkt der Frucht, Zentralbl. f. Gyn., 1900, No. 40, 1033-36; Die 
 Ursachen der Kindeslagen, Archiv f. Gyn., 1904, Ixxi, 541-651. 
 4 Obstetrics, 1908, p. 210. 
 
252 THE MECHANISM OF LABOR 
 
 The following tables^ each from a large series of eases, show the relative 
 frequency of the different positions in vertex presentation: 
 
 Dubois,' Williams,'- Cragin, 
 
 from 1913 cases. from 1687 cases from 2000 cases. 
 
 L. O. A. 71.00 per cent. 60.9 per cent. 63.25 per cent. 
 
 R. O. P. 25.00 per cent. 14.2 per cent. 8. 10 per cent. 
 
 R. O. A. 2.87 per cent. 22.3 per cent. 25.70 per cent. 
 
 L. O. P. 0.63 per cent. 2.6 per cent. 2.95 per cent. 
 
 The variation in the relative frequenc,^' of the positions R. O. A. and 
 R. O. P. in the different series undoubtedh' results from the fact that 
 a large percentage of cases, which at the beginning of labor are R. O. P., 
 become R. O. A. as labor advances. Examinations made late in labor 
 would give a predominance of R. O. A. positions, while only tho.se made 
 early would give the true result. This reasoning holds true with regard 
 to the L. O. P. and L. O. A. positions also, but is of less importance, 
 because of the relative infrequency of the L. O. P. positions. 
 
 Several reasons have been given for the preference of the fetal head 
 for the right oblique rather than the left oblique diameter of the pelvis. 
 The rectum is on the left side and this makes the left oblique diameter 
 practically the smaller, while external measurements at least would 
 indicate that the left oblique is actualh' smaller, usually by about ^ cm. 
 The lateral torsion of the uterus to the right with its left border slightly 
 anterior, would also account for this tendency. 
 
 The reason for the predominance of the L. O. A. over that of R. O. P. 
 may be found in the shape of the fetal ovoid. This presents, as will be 
 remembered, a conca\'ity on its abdominal side, into which the convexity 
 of the mother's vertebral column readily fits, thus making the anterior 
 position of the fetal back the easier. 
 
 A study of the figures (Figs. 157 and 15S) will show why the fetal 
 head seeks the oblique diameter at the brim of the pelvis rather than 
 the transverse or anteroposterior diameter, and why it traverses the 
 pelvis as it does. 
 
 The diameters at the brim of the pelvis are: 11 cm. anteroposteriorly, 
 12 cm. obliquely, and 13 cm. transversely. The transverse diameter, 
 however, is not available, for the promontory of the sacrum juts forw^ard 
 at the widest part, throwing the presenting head forward where the 
 diameter is much less. 
 
 In the hollow of the pelvis all three of the diameters, anteroposterior, 
 oblique, and transverse are 12 cm. each. At the outlet tlie transverse 
 and oblique diameters are each 11 cm. while the anteroposterior is only 
 9.5 cm. However, when the tip of the coccyx is pushed back, as it is 
 during labor, this last diameter becomes 11.5 cm. It is seen, therefore, 
 that the longest available diameter at the brim is one of the obliques, in 
 the hollow of the pelvis all are long, while at the outlet the anteroposterior 
 is the longest. 
 
 * Quoted by Pinard, also by Lusk. The science and art of midwifery, 1895, p. 175. 
 " Obstetrics, 1908, p. 254. 
 
MECHANISM OF ANTERIOR POSITIONS OF THE VERTEX 253 
 
 The diameters of the fetal head are the biparietal, 9.25 cm.; the sub- 
 occipitobregmatic, 9.5 cm.; the suboccipitof rental, 10.5 cm.; the occipito- 
 frontal, 11.5 cm.; while the occipitomental is 13.25 cm. 
 
 It is obvious that the biparietal diameter will meet with no obstruc- 
 tion in any direction as it passes through the normal pelvis. It is also 
 apparent from the other measurements that the more sharply flexed 
 the head is on the body, the smaller will be the diameter presented. 
 
 In sharp flexion the suboccipitobregmatic, 9.5 cm., would present, 
 followed closely by the suboccipitofrontal, 10.5 cm. These diameters 
 could pass through any diameter of the normal pelvis. With the head 
 much extended the largest possible diameter, the occipitomental, 13.25 
 cm., would be presenting. This could not pass through any of the pelvic 
 diameters. Some flexion is therefore absolutely necessary. (If the head 
 is very sharply extended a new diameter, the frontomental, presents — a 
 face presentation. This will be discussed later.) With the head in 
 moderate flexion, the occipitofrontal diameter, 11.5 cm., would present. 
 This diameter could only enter the brim of the pelvis in one of the 
 obliques; in midpelvis it would be free in any direction, and at the 
 outlet it could pass only in the anteroposterior diameter. If the occipito- 
 frontal diameter presented, we should expect it therefore to enter the 
 pelvis obliquely, to turn in midpelvis, and to leave the pelvis antero- 
 posteriorly. 
 
 Such, as a matter of fact, is the manner in which the fetal head does 
 pass through the normal pelvis; and it is the occipitofrontal diameter 
 which presents at the brim. As the fetus lies in the uterus before labor 
 with head downward in its normal attitude of universal flexion, the 
 head is in moderate flexion. There is no reason to suppose the head is 
 in sharp flexion. Indeed abdominal palpation would seem to indicate 
 that it is not, and in the absence of any marked pressure there is nothing 
 to cause it. Sharp flexion does not occur until in labor the head is 
 crowded down on to the pelvic floor, or against some other obstruction. 
 
 Therefore, as the head in moderate flexion presents at the pelvic brim 
 before labor, it is the occipitofrontal diameter which lies across the 
 pelvis. 
 
 This diameter (11.5 cm.) cannot settle into the brim in the antero- 
 posterior or transverse diameters, because as we have seen, they are too 
 small, and it necessarily selects one of the oblique diameters. The reason 
 for the more frequent selection of the right oblique has been explained. 
 
 Thus at the onset of labor the head is most frequently found in the 
 L, O, A. position. As the mechanisms of the L. O. A, and the R. O, A. 
 positions are exactly similar, these will be described together. 
 
 MECHANISM OF ANTERIOR POSITIONS OF THE VERTEX 
 (L. O. A. AND R. O. A,). 
 
 Diagnosis. — For a clear understanding of the mechanical problem 
 presented an accurate diagnosis of the presentation and position is neces- 
 sary. This is made, as already indicated on page 177, by the combination 
 
254 
 
 THE MECHANISM OF LABOR 
 
 of three methods: (A) Abdominal palpation. (B) Auscultation of the 
 fetal heart. (C) Vaginal examination. 
 
 I'iG. 187. — Palpation of fetal back and small parts 
 
 Fig. 188. — Palpation of small parts in the L. O. A. position. 
 
MECHAXISM OF ANTERIOR POSITIONS OF THE VERTEX 255 
 
 A. Abdominal Palpation. — In the manner just referred to, the obstet- 
 rician, standing with face toward the patient's feet, palpates the two sides 
 of the abdomen and locates: 
 
 Fig. 189. — Palpation of small ijart; in rh,. I{. ( ), A. position. 
 
 Fig. 190. — Palpation of the lower fetal pole. 
 
 1. Fetal hack and small parts (see Fig. 187). 
 
 In the L. O. A. position the fetal back is on the left and the small 
 parts are on the right of the mother's abdomen (see Fig. 1S8). 
 
256 
 
 THE MECHANISM OF LABOR 
 
 In the R. O. A. position the location of the fetal back and small parts 
 is just reversed, the back lying to the right and the small parts to the 
 left (see Fig. 189). 
 
 I'll.. I'Jl. -PaliiatiDii of the upper fetal pole. 
 
 Fig. 192. — Point of greatest intensity of fetal heart sounds in the L. O. A. position. 
 
MECHANISM OF ANTERIOR POSITIONS OF THE VERTEX 257 
 
 2. Palpation of the presenting fetal pole determines that the fetal head 
 has below and 'that in the L. O. A. position the least prominent part of 
 the head is on the left side, the side of the fetal back, while the most 
 prominent part of the head is on the right, the side of the fetal small 
 parts (see Fig. 190). In the R. O. A. position these relations are reversed. 
 
 3. Palpation of the upper fetal pole discloses the characteristics of the 
 breech (see Fig.- 191). 
 
 B. Auscultation of the Fetal Heart. — Auscultation of the fetal heart 
 determines the fact that in the L. O. A. position the point of greatest 
 intensity is on the left, approximately at the centre of a line between 
 the umbilicus and the anterior superior spine of the ilium (see Fig. 192). 
 In the R. O. A. position the point of greatest intensity is in a corre- 
 sponding location on the right side (see Fig. 193). 
 
 Fig. 193. — Point of greatest intensity of fetal heart sounds in the R. O. A. position. 
 
 C. Vaginal Examination. — When the cervix is sufficiently dilated to 
 allow the finger to palpate the sutures and fontanelles, it is found that 
 in the L. O. A. position the sagittal suture lies in the right oblique 
 diameter of the pelvis, with the small, posterior fontanelle near the left 
 iliopectineal emiiience, while the large ^anterior fontanelle lies in the 
 direction of the right sacro-iliac joint. The examining finger first impinges 
 on the right parietal bone. 
 
 In the R. O. A. position these relations are reversed. The sagittal 
 suture lies in the left oblique diameter of the pelvis, with the posterior 
 fontanelle near the right iliopectineal eminence and the anterior fon- 
 tanelle in the direction of the left sacro-iliac joint. The examining finger 
 first impinges on the left paiietal bone. 
 
 Mechanism. — In L. O. A. and R. O. A. positions of the vertex the 
 mechanism consists of engagement, molding, flexion, descent, lateral 
 17 
 
258 THE MECHANISM OF LABOR 
 
 inclination, internal rotation, extension, restitution and external rotation, 
 birth of the shoulders and l)ody. 
 
 Engagement. — The head, in the pelvic brim, is usually on an even 
 keel, so to speak, with the parietal bones on the same level with each 
 other. 
 
 If the woman has a i)endulous abdomen, however, and the uterus 
 falls f()r\\ard, the sagittal suture approaches the promontory and the 
 anterior parietal bone is felt first through the cervix (Naegele's obli- 
 quity). With the axis of the uterus backward the sagittal suture 
 approaches the symphysis; and the posterior parietal bone is felt first 
 (\'arnier's obliquity). 
 
 The method of engagement has given rise to much discussion, many 
 holding that Naegele's obliquity generally exists, and others favoring 
 Varnier's obliquity. It is probable that under normal conditions neither 
 the one nor the other exists, the biparietal diameter lying directly in 
 the plane of the pelvic brim. The extent of the engagement of the head 
 depends upon the size of the j)elvis. When this is relati\ely large the 
 head may sink to midpelvis before labor. In smaller pelves it simply 
 dips lightly into the brim. In deformed pelves there is often no engage- 
 ment until expulsive pains have taken place. In multigravida?, owing 
 to the lax abdominal walls which are easily distended and do not readily 
 contract to push the uterus down, the head generally engages but slightly 
 until after labor is well ad\'anced. In primigravidie the head engages 
 much sooner and to a greater extent before labor. 
 
 With the beginning of labor there is at first little change in the posi- 
 tion of the fetus, and during the dilatation of the cervix the head moves 
 little if any. With the full dilatation of the cervix and the advent of 
 expulsive pains, howe^^er, the head begins to move. Three changes take 
 place together, molding, flexion and descent. 
 
 Molding. — By molding is meant the compression of the head so that 
 its shape corresponds more closely to that of the pelvic canal. 
 
 In large pelves little molding is necessary, and after labor in such cases 
 there is slight evidence of it. In smaller pelves, however, molding is 
 necessary. The head is compressed laterally, so that the transverse 
 diameters of the head are smaller, while the longitudinal diameters are 
 increased. This has the effect of making the head longer and narrower. 
 The transverse diameter is lessened from 1.5 to 2 cm. (Edgar).' This 
 is accomplished by the closing of the sagittal suture and the overlapping 
 of the parietal bones. The anterior parietal bone overlaps the posterior 
 parietal and both o\'erlap the occipital and frontal bones. In L. O. A. 
 positions the right parietal bone overlaps the left, and bulges slightly, 
 while the posterior or left is flattened. In R. O. A. positions the left 
 overlaps the right parietal bone, which is posterior and flattened. At 
 the same time there is flattening of the skull at the brow and around 
 the anterior fontanelle. The presenting part is thus molded into a 
 long, narrow cone. At the point of least resistance, that is, at the cervi- 
 
 ' Practice of Obstetrics, p. 503. 
 
MECHANISM OF AXTERIOR POSITIOXS OF THE VERTEX 259 
 
 cal canal, there appears a swelling of the scalp in the loose connective 
 tissue, from the edema and obstructed venous circulation, which is 
 kno'^Ti as the "caput succudaneum." 
 
 In the L. O. A. position this will be found on the right parietal bone 
 at the posterosuperior angle. In the R^O. A. ])osition it will be found 
 on the left parietal bone at its posterosuperior angle. Thus after labor 
 the original position can often be told by the molding and by the posi- 
 tion of the caput succudaneum. 
 
 IMolding favors flexion and descent. 
 
 Flexion. — A moderate amount of flexion exists before labor, which is 
 increased during labor. The cause of this flexion is easily understood 
 when the manner in which the head is attached to the vertebral column 
 is seen (see Fig, 176). The articulation is nearer the occiput than the 
 sinciput, consequently the downward pressure exerted by the uterus 
 on the fetal body will be transmitted more directly to the occiput 
 and will tend to force this downward. ]^Ioreover the head in its articu- 
 lation with the vertebral column is like a two-armed lever, of which the 
 occiput constitutes the shorter and the sinciput the longer arm. As the 
 head meets counter-pressure from below, that exerted on the sinciput, 
 the longer arm acts to greater advantage than that exerted on the 
 shorter arm, the occiput, and the sinciput is thus pushed up, flexion 
 resulting. j. 
 
 Full flexion usually does not occur until the head is on the pelvic 
 floor, for usually there is no resistance until this is reached. Resistance 
 higher up, as in small or deformed pelves will cause flexion sooner. 
 
 Descent. — ^Molding and flexion favor descent which takes place with 
 them. This is caused by the uterine contractions, acting indirectly 
 through the liquor amnii, or by direct pressure on the fetus; by the 
 abdominal contractions; and by the straightening out of the fetal 
 body. 
 
 Lateral Inclination. — As the head descends in the pelvis, the posterior 
 parietal bone (the left in L, O. A.) strikes the promontory of the sacrum 
 and is retarded, the head thus being turned sidewise. This serves to 
 bring the axis of the head perpendicular to the brim and makes engage- 
 ment easier. If it were not for this lateral inclination the head would 
 impinge on the sjTnphysis pubis. 
 
 As the posterior pelvic wall from the promontory of the sacrum to 
 the tip of the coccyx is 12.5 cm. long, and the anterior pelvic wall from 
 the symphysis pubis to the .under surface of the pubic arch is only 4 
 cm. long, it is plain that the posterior part of the fetal head must descend 
 more rapidly than the anterior if both parts are to reach the outlet at 
 the same time. To this movement the name synclitism has been given 
 (see Fig. 194). 
 
 Dilatation of the Cervix. — ^The cervix becomes softer, shorter, and its 
 canal more dilated. These changes are due to increased vascularity 
 making it softer; to contraction of the longitudinal muscular fibers, 
 making it shorter; and to the relaxation of the circular fibers, allowing 
 dilatation. The dilatation is also caused by intra-uterine pressure of 
 
260 
 
 THE MECHANISM OF LABOR 
 
 the bag of waters acting as a wedge, and after rupture of the bag of waters 
 by the direct pressure of the presenting part itself (in vertex presenta- 
 tion, the head). 
 
 Fig 194. — Lateral inclination and synclitism. 
 
 Fio. 195. — Illustration of course taken hy hall on roof. 
 
 Internal Rotation. — As the head reaches the pelvic floor the occiput 
 rotates forward to the median line under the pubic arch, so that the 
 
MECHANISM OF ANTERIOR POSITIONS OF THE VERTEX 261 
 
 head lies with its long diameter in the anteroposterior diameter of the 
 pelvis. In this position it is born. Except in very large pelves, or with 
 very small heads, this rotation always occurs and is essential for delivery. 
 The cause of the forward rotation of the occiput has given rise to more 
 discussion than has any other part of the mechanism of labor. Medical 
 literature is full of theories and explanations. 
 
 For many years it was thought that the bony inclined planes at the 
 side of the pelvis, as already described on page 224, were the chief factors 
 in internal rotation of the fetal head, but while they might be used to 
 explain the rotation of the anterior position of the occiput (L. O. A. or 
 R. O. A.) forward to an O. A., or a posterior position of the occiput (R. 
 O. P. or L. O. P.) backward to an O. P., they could not explain the rota- 
 tion of a posterior position of the occiput forward to an O. A., as these 
 inclined planes are fixed quantities, always acting in the same manner 
 in the same pelvis. It is now considered that the inclined planes of 
 the pelvis or pelvic grooves act as the slopes of a two-slope roof act on 
 a ball, one turning the ball one way to the gutter, the other another way 
 to the gutter (see Fig. 195). The pelvic grooves simply guide to the 
 pelvic floor anteriorly or posteriorly that which rests upon them. 
 
 It is probable that no one cause is entirely responsible for internal 
 rotation of the fetal head, but the chief cause is the levatores ani muscles 
 of the pelvic floor. Contraction of these muscles tends to throw forward 
 any body resting on them. With the head well flexed the occiput is its 
 lower part and first strikes the pelvic floor and is then turned forward 
 under the pubic arch. 
 
 That the internal rotation of the fetal head is chiefly caused by the 
 pelvic floor has received its most convincing proof from the experiments 
 of Paul Dubois. He tried placing fetal cadavers of various sizes in the 
 uterus of a w^oman who had just died in parturition. They were placed 
 in the uterus with occiput posterior and were then pushed from above 
 downw-ard through the parturient canal. For two or three times (each 
 successive fetus being larger than the preceding) the fetal head rotated 
 so that the occiput was born in the anterior position. After the second 
 or third trial the pelvic floor became so stretched that this rotation did 
 not occur and the head was born with occiput in the posterior position. 
 
 This experimental result was verified by Edgar^ who screwed a swivel 
 into the head of a fetal cadaver and repeatedly dragged the head through 
 the pelvis of a woman w^ho had just died in parturition. He found that 
 the head invariably rotated to the front, even w^hen it entered the pelvis 
 with the occiput in posterior positions, so long as the pelvic floor retained 
 its integrity; but when the tonicity of the floor became impaired by 
 overstretching, the head traversed the pelvis in very nearly the same 
 position as that in which it had entered-. 
 
 Rotation of the occiput is easy when the head is well flexed, for then 
 the presenting part is shaped like a ball, the suboccipitobregmatic diam- 
 eter measuring 9.5 cm. and the biparietal diameter 9.25 cm. When 
 
 1 Practice of Obstetrics, 1907, p. 442. 
 
262 THE MECHANISM OF LABOR 
 
 the occiput strikes one side of the gutter-sliaped pelvic floor obliquely, it 
 naturally slides off anteriorly as would a ball on striking the gutter 
 of a house obliquely. 
 
 Again the anteroposterior diameter of the pelvis is the largest diam- 
 eter at the outlet, and the long diameter of the head naturally seeks 
 this when the head is forced down by the intermittent contractions of 
 the uterine and abdominal muscles. 
 
 Extension. — After the head has been molded sufficiently, has been 
 well flexed, has reached the pelvic floor and has rotated so that the 
 occiput has turned forward to the pubic arch, the occiput continues 
 to advance until it has passed under the arch for about 3 cm. There the 
 advance of the occiput ceases temporarily, flexion ends, and extension 
 begins by the advance of the sinciput, which is pushed out little by little, 
 advancing and receding with the intermittent pains, upward and for- 
 ward o\er the perineiun, until successively the forehead, eyes, nose, 
 mouth and chin are born. The nape of the neck is firmly crowded against 
 the pubic arch and the occi])ut approaches this little by little, as the head 
 is extended and the forehead rises higher and higher over the perineum. 
 Thus the head is born by extension. The reason for this extension is 
 easily understood. The anterior pelvic wall is 4 cm. deep, and the 
 fetal neck, from shoulders to occiput, is 7 cm. long. Consequently when the 
 occiput has i)assed under the pubic arch for a distance of 3 cm. it can go 
 no further until the shoulders descend, and this cannot happen until 
 the head is entirely born, for the pelvis is not large enough to hold both 
 the head and body at the same time. The occiput being stationary, the 
 expulsive forces acting on the fetal body will be effective on the sinciput 
 alone. There is nothing to ])revent the a(hance of this, and it is there- 
 fore pushed on up over the perineum — extension. As the head extends, 
 the forehead naturally slides upward, for this is the direction of the 
 pelvic outlet, and it is the only direction in which it can go. The uterus 
 pressing downward and the perineum pressing upward, give a resultant 
 force in the direction of the outlet. When the perineum is \ery lax or 
 tears, extension is, of course, not so complete. Conversely, the way to 
 prevent tearing of the perineum is to favor complete extension of the 
 head, by which the forehead is lifted over and away from the perineum. 
 It is to be noted, howe\'er, that extension does not take place until the 
 occiput has passed well under the pubic arch. This gi\'es the smallest 
 diameter for passage through the vaginal outlet, the suboccipitobreg- 
 matic followed by the suboccipitofrontal, 9.5 cm. and 10.5 cm. respec- 
 tively. If, through the action of the accoucheur, extension should be 
 made to take place before the occiput has passed the pubic arch, the 
 occipitofrontal diameter, 11.5 cm., would have to pass through the outlet, 
 with greater difficulty and with more certain damage to the perineum. 
 
 Restitution and External Rotation. — As the chin slips over the perineum, 
 the head is fully born. This immediately drops down so that the chin 
 approaches the anus of the mother. At the same time the occiput may 
 be seen to turn slightly to that side to which it previously pointed. 
 The neck, as it were, " untwists" itself. The.occiput having rotatefl toward 
 
MECHANISM OF ANTERIOR POSITIONS OF THE VERTEX 263 
 
 the median line without corresponding movement of the shoulders, 
 naturally turns part way back again, as soon as the head is free. This 
 is called "restitution" of the head. There is usually a slight cessation 
 of pains and then the occiput is observed to turn decidedly to the side 
 toward which it originally pointed. This seems like a continuation 
 of the original movement of restitution, but is much more marked and 
 has a different cause. This is "external rotation" and is caused by the 
 rotation of the shoulders, as they enter the brim of the pelvis. In an 
 L. O. A. position, the external rotation of the occiput is toward the 
 mother's left thigh. In an R. O. A. position, it is toward her right thigh. 
 
 The long diameter of the shoulders is at right angles to the long diam- 
 eter of the head. Consequently it will occupy the opposite diameter 
 from that of the head. In an L. O. A. position, the head is in the right 
 oblique diameter, while the shoulders will enter the left oblique. The 
 right shoulder will be anterior, and from the obliquity of the pelvic canal 
 will first strike the pelvic floor and will be rotated forward to the pubic 
 arch, the posterior or left shoulder being necessarily rotated posteriorly to 
 the sacrum. This turning of the shoulders from right to left, causes the 
 turning of the occiput from right to left — external rotation. 
 
 In an R. O. A. position the shoulders occupy the right oblique diameter, 
 and turn to the right as the left shoulder rotates anteriorly, thus causing 
 the occiput to rotate to the right externally. 
 
 Very rarely external rotation takes place in the opposite direction 
 from which the occiput originally pointed. This only happens where 
 the pelvis is very large or the fetus very small, and is caused by the 
 fact that the shoulders, being relatively small, can enter the pelvis in any 
 direction irrespective of the obliques, that is, transversely. Consequently 
 either shoulder has an equal chance of rotating anteriorly. With a very 
 small premature fetus the shoulders sometimes do not rotate at all 
 but are born transversely. This cannot happen at term with normal 
 relations between child and pelvis, for the bisacromial diameter of the 
 fetus in 12.25 cm., while the transverse diameter at the outlet of the pelvis 
 is only 11 cm. 
 
 Birth of the Shoulders. — The shoulders enter the brim of the pelvis in 
 one of the oblique diameters. This they can readily do as they are easily 
 compressed, and the bisacromial diameter is 12.25 cm. and that of the 
 oblique is 12 cm. They then rotate, the anterior to the pubic arch, and 
 the posterior to the sacrum, as we have seen. They now occupy the 
 anteroposterior, or widest diameter of the outlet, as did the head. 
 Birth of the shoulders can now take place in one of three ways: the 
 posterior first, followed by the anterior; the anterior first, followed by 
 the posterior; or both together. It is clear that either the first or second 
 ways are favorable, while the last is distinctly unfavorable, and can only 
 take place with a small fetus or with much compression of the shoulders 
 (12.25 cm., bisacromial diameter of the fetus, through 11.5 cm., antero- 
 posterior diameter at the pelvic outlet). However, this does occur at 
 times, though rarely, and is necessarily dangerous to the integrity of the 
 soft parts. 
 
264 THE MECHANISM OF LABOR 
 
 Frequently tlie method is that of the posterior shoulder first. Tlie 
 anterior shoulder is crowded up behind the pul)ic arch and is fixed 
 there, while the posterior shoulder is pushed out and up over the peri- 
 neum, as was the oceii)ut j)reviously. After this is born, it dr()])s back 
 over the i)erineum, and thus releases the anterior shoulder, which is 
 rapidly pushed out under the pubic arch. AVhen this mechanism is per- 
 fect, the diameter passing through the outlet is very small, from the 
 neck to the opposite shoulder about 8 cm., and deliv^ery is very easy. 
 This method is more likely to occur if the head is supported by the hand 
 of the accoucheur, as is often the case. This serves to raise the posterior 
 shoulder, or at least to prevent its falling backward in the vagina and 
 also to elevate the anterior shoulder behind the pubic arch. 
 
 ^Yhen the woman is lying on her back unassisted, the second method 
 is more likely to occur. Here the weight of the unsupported head tends 
 to drag down the anterior shoulder, so that it comes first under the 
 pubic arch, the posterior shoulder remaining in the vagina, and then 
 being born later over the perineum, as the forehead follows the birth of 
 the occiput. 
 
 The natural method of delivery among savages is in the squatting 
 position. Here the recently born head is unsupported, and the anterior 
 shoulder is probably born first. Leonet^ asserts that the anterior shoulder 
 is born first in 90 per cent, of the cases, when the head is not supported. 
 When it is supported, the ]:)Osterior shoulder is born first in 90 per cent, 
 of the cases. Edgar- says that the posterior shoulder is born first two 
 and one-half to three times as often as the anterior, but in nearly all his 
 cases upon which his observations were based, the head was supported. 
 At the Sloane Hospital the anterior shoulder is always born first, as the 
 posterior shoulder is held Ijack in the vagina with the right hand of the 
 obstetrician, while the head is forced gently downward toward the 
 mother's perineum with the left hand, thus causing the birth of the 
 anterior shoulder first. 
 
 The reason for the adoption of this method lies in the fact that a very 
 small laceration of the perineum at the fourchette made by the birth 
 of the head is often greatly increased when the posterior shoulder passes 
 the \-ulvar outlet and may be still further increased if this outlet is sub- 
 jected to tension by the weight of the trunk in the disengagement and 
 delivery of the anterior shoulder from beneath the symphysis. 
 
 It has seemed to the author that there was less tendency to laceration 
 of the perineum if the birth of the head was followed by the delivery 
 of the anterior shoulder (see Fig. 230), during which only the trachelo- 
 acromial diameter was thrown across the vulvar outlet and then by 
 support of the head and neck the posterior shoulder was lifted in its 
 delivery away from any little tear which may have been started by the 
 head. 
 
 Patients at the Sloane Hospital are all delivered in the dorsal position. 
 
 » Quoted from Edgar, Practice of Obstetrics, 1912 edition, p. 428. 
 * Op. cit. 
 
MEC-HANISM OF AXTERIOR POSITIONS OF THE VERTEX 265 
 
 Birth of Body and Hips. — The body is born by lateral flexion up over 
 the perineum, following the curve of the vaginal outlet. The obstetrician 
 usually lifts the body of the child as it is born, thus aiding nature. The 
 savage woman, anxious to claim her newborn, might well be supposed 
 to seize it and lift it upward, thus unconsciously following the method 
 of the obstetrician of today (King). The birth of the body is very 
 rapid, however, and the obstetrician must be on the alert or it will be 
 fully born before it can be lifted. Anyone watching the first delivery 
 by a student will appreciate this. The hips are usually so small that 
 they are born without any particular mechanism. However, if large or 
 the pelvis small, the mechanism will be similar to that of the shoulders, 
 the anterior rotating to the pubic arch, and the posterior to the sacrum. 
 
 The arms are usually born flexed on the chest, practically unchanged 
 in position, during labor. At times, however, they are found in abnor- 
 mal attitudes, as prolapsed, or on the opposite shoulder, or straight out 
 along the side. This is usually of no special significance. 
 
 The legs are usually born still flexed, though occasionally they may 
 present deviations from the normal attitude. 
 
 Summary of Mechanism. — L. O. A. Position. — The occipitofrontal 
 diameter of the head occupies the right oblique diameter of the pelvis. 
 Molding, flexion and descent occur together, chiefly during the second 
 stage. When the occiput strikes the pelvic floor, it is rotated forward 
 and inward to the pubic arch — from L. O. A. to O. A. It passes well 
 under the pubic arch and then stops. The nape of the neck is crowded 
 up against the pubic arch and extension begins by the advance of the 
 sinciput which slides up little by little over the perineum, while fore- 
 head, eyes, nose, mouth and chin successively emerge over the perineum. 
 The head is now completely born and the chin drops back toward the 
 anus, the occiput turning slightly to the mother's left thigh, as the neck 
 " untwists" — restitution. 
 
 Shortly after the occiput turns decidedly to the left — "external rota- 
 tion" — as the shoulders engage and rotate. These enter the brim in the 
 left oblique diameter, the right anterior or lower shoulder rotates to the 
 pubicarch. This slips under the pubic arch for a short distance and stops, 
 while the posterior is forced upward over the perineum ; or the anterior 
 shoulder is crowded up against the pubic arch, while the posterior first 
 glides over the perineum followed by the anterior. The body is born 
 quickly by lateral flexion to the right, the hips slipping out with little 
 or no mechanism. After labor the rigJit parietal bone will be found over- 
 lapping the left parietal bone and the caput will be found over right 
 parietal bone at its posterosuperior angle. 
 
 R. O. A. Position. — The occipitofrontal diameter of the head occupies 
 the left oblique diameter of the pelvis. Molding, flexion, and descent 
 occur as before, the occiput rotates forward to the pubic arch but from 
 right to left— R. O. A. to O. A. 
 
 The head is born by extension, the occiput turning to the mother's 
 right thigh in restitution and external rotation. The shoulders enter 
 the brim in the right obHque diameter; the left, anterior and lower 
 
266 THE MECHANISM OF LABOR 
 
 rotates to the pubic arch. Delivery follows with either the anterior or 
 posterior shoulder first, and the body is born by lateral flexion to the 
 left. The Icjt ])arietal bone will be found overlai)i)ing the rlf/lit parietal 
 bone, and caput will be found on the left i)arietal bone at its postero- 
 superior an^le. 
 
 MECHANISM OF POSTERIOR POSITIONS OF THE VERTEX 
 (R. O. P. AND L. O. P.). 
 
 Frequency. — The occiput is posterior at the beginning of labor in 
 about 1 7 per cent, of cases. At the Johns Hopkins Hospital, in 1687 cases, 
 it occurred in 16.8 per cent. In the 500 cases of Pinard it occurred in 
 49.8 per cent, or in nearly one-half of the cases, while in the 1913 cases 
 studied by Dubois the posterior position was found in 26.23 per cent, or 
 a little over one-fourth of the series. 
 
 In the Sloane Hospital, in 2000 cases observed during the first stage of 
 labor, posterior position occurred in 11.0.5 per cent. 
 
 The R. O. P. position is much more frequent than the L. O. P. posi- 
 tion. In Dubois's series it was twenty-five times as frequent. In Pinard's, 
 approximately three and one-half times as frequent, while in the series 
 of Williams it was about five times as frequent. At the Sloane Hospital 
 it was about three times as frequent. Therefore, while the R. O. P. 
 position is often found, the L. O. P. position must be considered as 
 exceptional and rare. 
 
 The reason for this preference for the right oblique diameter has 
 already been discussed (see page 252). 
 
 Etiology. — Inquiry into the cause of posterior positions of the occiput 
 at the beginning of labor is of little interest, as the frequency is so vari- 
 able. In Pinard's cases the posterior positions occurred practically as 
 often as the anterior. Lack of the cause or causes usually operating 
 to bring about the anterior position is probably the reason. The con- 
 cavity of the abdominal side of the fetal ovoid, corresponding to the 
 convexity of the mother's vertebral column, tends, it is supposed, to 
 cause the anterior position. In other words, the fetus best fits the pelvis 
 in the anterior position of the occiput. Slight changes in the shape of 
 the fetal ovoid or of the pelvis may make the posterior position the 
 more natural. 
 
 Diagnosis. — By employment of the usual methods of diagnosis: 
 abdominal palpation, auscultation of the fetal heart, and vaginal 
 examination, it is determined first of all that, in the posterior positions 
 of the vertex there is an absence, on both sides of the abdomen in front, 
 of the feel of the smooth, firm fetal back, felt on palpation in the anterior 
 positions of the vertex; and that on auscultation the usual point of 
 greatest intensity of the fetal heart sounds is not near the centre of the 
 line joining umbilicus and the anterior superior iliac spine on either 
 side (exceptionally the anterior wall of the fetal chest may be crowded 
 up against the anterior wall of the mother's abdomen so as to make the 
 
MECHANISM OF POSTERIOR POSITIONS OF THE VERTEX 267 
 
 above point that of greatest intensity even in posterior positions). The 
 first diagnostic features are therefore negative, although of great value. 
 
 Abdominal Palpation. — Abdominal palpation does detect small parts of 
 the fetus in front, and palpatioiTof the lower fetal pole in the R. O. P. 
 position detects the head in the right oblique diameter of the pelvis. 
 -B^'this time a posterior position is usually suggested, and recurrence to 
 the abdominal palpation usually detects the fact that the small parts 
 are on the left side, and the fetal back lies in the right flank. 
 
 Auscultation of the Fetal Heart. — Palpation of the upper fetal pole 
 discloses the breech, and the auscultation of the fetal heart usually shows 
 its point of greatest intensity in the right flank, outside of the line join- 
 ing umbilicus and anterosuperior iliac spine (see Fig. 196). 
 
 Fig. 196. — Point of greatest intensity of fetal heart sounds in the R. O. P. position. 
 
 Vaginal Examination. — A'aginal examination shows the sagittal suture 
 in the right oblique diameter of the pelvis with the anterior fontanelle 
 near the left iliopectineal eminence, and the posterior fontanelle in the 
 direction of the right sacro-iliac joint. The examining finger usually 
 first impinges on the left parietal bone. 
 
 In the L. O. P. position these relations are reversed. The fetal back 
 lies in the left flank, the small parts on the right side of the abdomen, 
 and the head in the left oblique diameter of the pelvis with the fore- 
 head in front. Auscultation usually discloses the point of greatest 
 intensity of the fetal heart sounds in the left flank (see Fig. 197) and 
 vaginal examination shows the sagittal suture in the left oblique diameter 
 with the anterior fontanelle near the right iliopectineal eminence, and 
 the posterior fontanelle in the direction of the left sacro-iliac joint. The 
 examining finger usually first impinges on the right parietal bone. 
 
268 THE MECHANISM OF LABOR 
 
 Mechanism. — In the majority of cases the mechanism of the posterior 
 l)osition (litters but shglitly from that of the anterior. The occiput rotates 
 anteriorly as in the latter, but turns through 1.35° instead of 45°, while 
 the labor as a consequence is somewhat more prolonged. Varnier,^ 
 from a study of labor in a series of 400 posterior positions and 6C0 ante- 
 rior, found that in posterior positions it took on an average three hours 
 and sixteen minutes longer in primigravida^ and one hour and fifty min- 
 utes longer in multigravidje than in anterior positions. 
 
 In over 90 per cent, of the cases with occiput posterior, anterior rota- 
 tion occurs. In the author's experience, however, this percentage applies 
 to hospital practice rather than to private practice in the so-called 
 
 ■1 
 
 
 Fig. 197. — Point m greatest uitcnsity of fetal heart sounds in the L. O. P. position, 
 
 "higher walks of life." Here, with lower muscle tone and higher tension 
 of nervous system, spontaneous anterior rotation occurs much less 
 frequently. 
 
 Molding, descent and flexion occur as in the -original anterior posi- 
 tions. The head being flexed, the occiput first strikes the pelvic floor and 
 is thrown forward by the resistance of the pelvic floor; the head rotating 
 from R. O. P. to R. O. A. or from L. O. P. to L. O. A. when labor becomes 
 the same as in the original anterior positions. 
 
 In a small number of cases, however, rotation of the occiput takes 
 place in the opposite direction, or posteriorly to the hollow of the sacrum. 
 
 1 De I'attitude de la t^te au detroit superieur et du mechanisme de son engagement, 
 Annales d'obstet. et de Gyn., 1897, xh-iii, 422-444. 
 
MECHANISM OF POSTERIOR POSITIONS OF THE VERTEX 269 
 
 Varnier^ gives this as 2 per cent., Naegele^ as 1.37 per cent., West^ as 
 3 per cent., Edgar^ as 4.04 per cent. At the Sloane Hospital, in 20,000 
 deliveries, it occurred 337 times or 1.6 per cent. (1 to 60) = 
 
 After the occiput has rotated into the hollow of the sacrum, labor 
 unassisted may end in one of three ways. 
 
 1, The head is forced down until the sinciput strikes the pubic arch. 
 The anterior fontanelle is crowded up against this (see Fig. 198) and the 
 occiput by tardy flexion of the head is pushed up over the perineum; 
 when by extension the brow, nose and mouth slip down under the pubic 
 arch, and the head is born by extension. This termination takes place 
 only when the fetus is small or the pelvis large. The labor is hard and 
 
 Fig. 198. — Mechanism in persistent occipitoposterior position. 
 
 long, the head is greatly molded, and the perineum is terribly stretched, 
 and unless very lax, badly torn. The reason for this stretching or tear- 
 ing is.F*^in. In the anterior position the nape of the neck catches under 
 the pubic arch, the occiput being already born before the head comes 
 over the perineum (see Fig. 199 and 200). Consequently it is the sub- 
 occipitofrontal diameter (10.5 cm.) which comes through the vaginal 
 outlet. In the method just described (see Fig. 198) it looks at first sight 
 as though again the suboccipitofrontal might come through the outlet. 
 In Fig. 198 it is the suboccipitobregmatic which is presenting in the 
 bony outlet, but the neck has now been stretched to its utmost, and the 
 
 1 Op. cit. 
 
 2 Die lehre vom Mechanismus der Geburt, Mainz, 1838. 
 
 3 Cranial Presentation, etc., Glasgow, 1857. 
 ■* Practice of Obstetrics, 1905, p. 597. 
 
270 
 
 THE MECHANISM OF LABOR 
 
 Fig. 199. — Mechanism in occipito-anlerior position 
 
 Fig 200. — Mechanism in occipito-anterior position, later stage. 
 
( 
 
 MECHANISM OF POSTERIOR POSITIONS OF THE VERTEX 271 
 
 occiput can rise no higher over the perineum. Consequently the sinci- 
 put must now advance and extension (late) begins. Extension brings 
 the forehead under the pubic arch, and great pressure is made on the 
 perineum, as the occipitofrontal diameter 11.5 cm. presents at the 
 outlet. At this point the perineum usually gives way unless very lax. 
 Dubois first pointed out the scientific reason for the difficulty of deliv- 
 ery in these posterior positions. The anterior pelvic wall is 4 cm. long, 
 while the fetal neck is 7 cm. long from shoulders to occiput. Hence 
 in anterior positions the occiput easily passes under the pubic arch and 
 rises above it before the shoulders are born, as we have seen fFig._200). 
 The posterior pelvic wall, however, from the promontory of the sacrum 
 
 Fig. 201. — Tracing of child's head 
 immediately after birth. Persistent 
 occiput posterior. 
 
 Fig. 202. — Same head as shown in Fig. 
 201. One week later. 
 
 to the tip of the coccyx is 12.5 cm. and 12.5 cm. from this to the edge 
 of the perineum, 25 cm. in all. Therefore in posterior positions, even 
 when with a small fetus the shoulders have descended into the pelvis 
 (Fig. 198), the occiput has 12.5 cm. or more to rise before it can pass 
 over the edge of the perineum. Hence the difficulty and the cause for 
 extension and stretching of the perineum. 
 
 The molding in cases of persistent occiput posterior is apt to be exces- 
 sive. The occipitomental diameter is much increased, while the sub- 
 occipitofrontal is lessened. The parietals overlap the frontal and occipi- 
 tal bones, while the caput is large and is generally situated over the 
 anterior fontanelle, directly over the sagittal suture, as the head has been 
 in the median diameter O. P. for some time. This excessive mold- 
 
272 THE MECHANISM OF LABOR 
 
 ing and the large caput, give the head a peculiarly elongated appearance 
 (see Fig. 201). Often the excessive molding and long-continued press- 
 ure is fatal to the fetus. The shoulders and body are born by exactly 
 the same mechanism as in those cases where the occiput is originally 
 anterior. 
 
 2. Very rarely labor terminates spontaneously in another way. After 
 the occiput has rotated to the hollow of the sacrum, its advance becomes 
 in some manner arrested, and the forehead proceeds alone, extreme 
 extension resulting. The chin passes first under the pubic arch, when 
 the neck is crowded up against the arch, and the head is born by flexion, 
 the mouth, nose, eyes, forehead and occiput passing up easily in succes- 
 sion o\"ev the perineum, as flexion increases. In other words, the presen- 
 tation becomes converted spontaneously into a face, and delivery takes 
 place with the chin anterior (see Fig. 211). This favorable outcome is 
 extremely rare. In the 337 cases of persistent occiput posterior on record 
 in 20,000 labors at the Sloane Hospital, this outcome has never been 
 seen. (The mechanism in face presentations will be considered in detail 
 later.) 
 
 3. The head with the occiput posterior sometimes becomes impacted. 
 This occurs when the fetus is large or the pelvis small, or where the liga- 
 ments are stiff and unyielding. At the Sloane Hospital 3 out of 337 cases 
 quoted became impacted. 
 
 The head, with the occiput persistently posterior, is pushed down 
 through the pelvis. The head becomes sharply flexed, but the occiput 
 is prevented from rotating by some obstruction, or the flexion occurs 
 too late. The neck is stretched to its utmost, and the occiput is pushed 
 toward the coccyx. To reach it the shoulders must follow into the 
 pelvis, for the posterior pelvic wall from the promontory of the sacrum 
 to the coccyx is 12.5 cm. and the fetal neck is only 7 cm. Consequently 
 both the body and the head of the fetus are crowded into the pelvis at 
 once. As the dorsosternal diameter or depth of the fetal body is 9.5 
 cm., and the frontomental diameter or depth of the fetal face is 8.25 
 cm., the entire diameter of 17.75 cm. (see Fig. 203) is seeking progress 
 through a bony canal, the widest part of which is 12 cm. Hence impac- 
 tion occurs. (When spontaneous delivery occurs, the combined diam- 
 eters of the body and head must be small enough to pass through the 
 pelvis. That is. the fetus must be small or the pelvis large, as has been 
 said.) 
 
 In the ^■ast majority of cases then, in posterior positions of the occiput, 
 the occiput rotates all the way round and becomes anterior, the labor 
 differing but little from that in which the occiput is originally anterior; 
 while in a very small proportion of cases, roughly about 4 per cent.,^ the 
 occiput rotates in the opposite direction to the sacrum, a persistent 
 occiput posterior position resulting. 
 
 The cause of this anterior rotation, and of its occasional failure, is of 
 the greatest interest. 
 
 * At the Sloane Hospital it was estimated that 1.3 per cent, of the occiput posterior posi- 
 tions failed to rotate anteriorly (about 1 in 8). 
 
MECHANISM OF POSTERIOR POSITIONS OF THE VERTEX 273 
 
 In the consideration of the mechanism of anterior positions of the 
 occiput (see page 261) it was stated that the most satisfactory explanation 
 of the forward rotation of the occiput, and one which appUed equally 
 well when the position of the occiput was posterior, was found in the 
 theory which attributes to the pelvic floor the power of rotating forward 
 under the pubic arch the part of the fetus which first reaches it, provided 
 this action is not otherwise interfered with. 
 
 This power of the pelvic floor is free from interference only when the 
 part of the fetus which first strikes it can behave like a ball. 
 
 When the head is well flexed it is shaped like a ball, the suboccipito- 
 bregmatic and biparietal diameters, 9.5 cm., and 9.25 cm., being nearly 
 equal; and when the head is thus flexed the gutter of the pelvic floor 
 has the power to turn the occiput forward whether its original position 
 was anterior or posterior to the transverse diameter of the pelvis. 
 
 Fig. 203. — Impacted occiput posterior. 
 
 When the head is not well flexed it is not like a ball and forward rota- 
 tion in posterior positions of the occiput is prevented by the spines of the 
 ischia striking the sides of the sinciput. If flexion was complete the 
 sinciput would be above the spine of the ischium and its backward rotation 
 would not be prevented. It is seen from this, that when the head is not 
 flexed so that its shape resembles a ball, both sinciput and occiput have 
 to be considered in the rotation of the latter, and that when the occiput 
 rotates forward, the sinciput must rotate backward, and in poor flexion 
 this is prevented by the spines of the ischia. In this condition, then, the 
 fetal head simply descends with occiput posterior, as it was originally, 
 and the pelvic floor acting on both occiput and sinciput, simply has the 
 ability of making the long diameter of the head coincide with the direc- 
 tion of its gutter; or extension may occur instead of flexion, and the 
 sinciput strikes the pelvic floor first and is rotated forward by it, while 
 the occiput goes backward. 
 18 
 
274 THE MECHANISM OF LABOR 
 
 If the pelvic floor is damaged by previous overstretching or tearing, 
 it may lose its power of causing forward rotation, as proved by the 
 experiment of Dubois and verified b\' Edgar. (These experiments were 
 referred to when discussing anterior rotation of the fetal head, see page 261, 
 and are repeated more in detail here.) 
 
 The experiment of Dubois is classical. "In a woman who had died 
 a short time previously in childbed the uterus, which had remained 
 flaccid and of large size, was opened up as far as the cervical orifice and 
 held by assistants in a suitable position above the superior strait. The 
 fetus of the woman was then placed in the soft and dilated uterus in the 
 right occipitoposterior position. Several pupil midwives, pushing it 
 from above, readily caused it to enter the pelvis. Much greater force 
 was needed to make it travel over the perineum anfl clear the vulva, and 
 it was not without astoinshment that we saw, in three successi\c attempts, 
 that when the head had traversed the external genital organs, the occiput 
 had turned to the right anterior position, while the face was turned to 
 left and to the rear. In a word, rotation had taken place as in natural 
 labor. We repeated the experiment a fourth time, but as the head cleared 
 the vulva, the occiput remained posterior. We then took a deadborn 
 fetus of the previous night, but of much larger size than the preceding, 
 and placed it in the same position as the first, and twice in succession 
 witnessed the head clear the vulva, after having executed the move- 
 ment of rotation. Upon the third and following essays, delivery was 
 accomplished without the occurrence of rotation. Thus, the movement 
 only ceased after the perineum and vulva had lost the resistance which 
 had made it necessary, or at best, had been the exciting cause of its 
 accomplishment." 
 
 Edgar^ has quoted the results of an experiment made by him, in which 
 he attached a swivel and a yard of cord to the head of a dead fetus, one 
 inch in front of the small fontanelle. With these he repeatedly dragged 
 the fetus through the pehis of a woman dead after recent deli^■ery. His 
 findings agree entirely with those of Dubois. Rotation always occurred 
 until the pelvic floor lost its tonicity, when it ceased. He sums up the 
 experiment as follows: "Given the normal attitude of the fetus (extreme 
 flexion of the head), and good expulsive powers, and the most important 
 remaining condition for forward rotation, and a normal mechanism 
 is a firm pelvic floor." 
 
 It seems, therefore, that forward rotation of the occiput is caused 
 largely, if not entirely, by the resistance of the pelvic floor. It is clear, 
 however, that there must be good expulsive pains, that flexion must be 
 complete, and that there must be absence of mechanical obstruction to 
 rotation. 
 
 While we assign to the resistance of the pelvic floor the chief cause 
 for forward rotation of the occijjut, we can summarize the causes for 
 failure of forward rotation or posterior rotation of the occiput, as follows: 
 
 > The Practice of Obstetrics, 1912, p. 424. 
 
MECHANISM OF POSTERIOR POSITIONS OF THE VERTEX 275 
 
 Anomalies of Force or Resistance. — Poor expulsive pains; relaxed pelvic 
 outlet; large pelvis or small fetal head. 
 
 Partial Extension Instead of Flexion. — Sinciput first reaches resistance 
 of pelvic floor and is rotated forward. 
 
 Obstacles to Rotation. — Poor flexion, occiput and sinciput reach flopr 
 at about same time and rotation prevented by spines of ischia; different 
 varieties of contracted pelvis, especially an obliquely contracted pelvis; 
 timiors of the pelvis; a compound presentation. 
 
 Under normal conditions nature has arranged that the occiput shall 
 always rotate forward, and it is only when marked abnormalities exist 
 that nature fails. 
 
 In 20,000 consecutive labors at the Sloane Hospital there were found 
 337 persistent occipitoposterior positions. Among the cases tabulated 
 were poor expulsive pains, 21.9 per cent.; relaxed pelvic outlet, 32.3 
 per cent.; small fetus, 26.7 per cent. 
 
 Summary of Mechanism in Posterior Positions. — The R. d. P. Position. 
 —The occipitofrontal diameter of the head occupies the right oblique 
 diameter of the pelvis. Molding, flexion, and descent occur as in the 
 anterior positions. The occiput strikes the pelvic floor first and is 
 rotated anteriorly to the pubic arch R. 0. P. to R. O. to R. 0. A. to 0. A. 
 through 135", when the rest of the labor is the same as in an original 
 R. O. A. position. This occurs in 96 per cent, of the cases. ^ Very rarely, 
 in 4 per cent, of the cases,^ owing to anomalies of force, resistance, or 
 flexion, or to abnormalities of the pelvis or presentation, the occiput 
 remains posterior, often rotating directly to O. P. Termination of labor 
 takes place in one of three ways : 1 . With a small fetus or a large pelvis, 
 the head descends with little or no flexion until the forehead reaches 
 the pubic arch. Extreme, tardy flexion then occurs, and the occiput is 
 pushed up over the perineum; then by extension the brow, nose and 
 mouth slip under the pubic arch and the head is born, usually tearing 
 the perineum. 
 
 Restitution and external rotation of the occiput to the right occurs, 
 as the left or anterior shoulder rotates to the pubic arch. 
 
 The anterior or left shoulder is born first, followed by the posterior, 
 and the body is born by lateral flexion to the left. 
 
 Exceptionally the posterior shoulder is born first. 
 
 The caput is usually located on the anterosuperior angle of the left 
 parietal bone. It may, however, be found on the posterosuperior angle 
 of the left parietal, as in an original R. O. A. position, or directly oyer 
 the anterior fontanelle. The location depends upon the position in which 
 the head was longest delayed. If long in the R. O. P. position before 
 rotation, either anteriorly or posteriorly occurred, the caput will be in 
 the location first indicated. If long in the R. O. A. position, the caput 
 will be in the second location indicated; while if long directly O. P., 
 the caput will be in the last location indicated. The parietal bones 
 
 1 Eighty-seven per cent, at the Sloane Hospital. 
 
 2 Thirteen per cent at the Sloane Hospital. 
 
276 THE MECHANISM OF LABOR 
 
 will be found overlapping the frontal and occipital hones, and the left 
 parietal overlapping the right. 
 
 2. The presentation is converted into a face, and delivery takes place 
 with the chin anterior. This is very rare. 
 
 .3. Impaction occurs after extreme flexion, with the body and head both 
 forced into the pelvis. 
 
 The L. O. P. Position. — The occipitofrontal diameter of the head lies 
 in the left oblicjue diameter. Molding, flexion and descent occur as in 
 the anterior positions^ 
 
 The occiput strikes the pelvic floor first and is rotated anteriorly to the 
 pubic arch, L. O. P. to L. O. to L. O. A. to O. A. through 1.35°, when 
 the rest of labor is the same as in an original L. O. A. position. This 
 occurs in about 96 per cent, of all cases. 
 
 Very rarely (in 4 per cent, of all cases) anterior rotation fails. 
 
 Labor terminates in one of three ways: 1. With a small fetus or a 
 large pelvis, by late flexion, followed by extension, the head is born O. P. 
 Pestitution and external rotation of the occiput to the left occur, as the 
 right or anterior shoulder rotates to the pubic arch. 
 
 The anterior or right shoulder is born first, followed by the posterior, 
 or the posterior shoulder is born first and the body is born by lateral 
 flexion to the right. The caput is located on the anten)superior angle 
 of the right parietal bone; or on the })osterosuperior angle of the 
 right parietal bone; or directly over the anterior fontanelle, the location 
 depending upon the position in which the head was longest delayed. 
 
 2. Delivery by the mechanism of a face presentation with chin anterior 
 — very rare. 
 
 3. Impaction occurs, after extreme flexion, with the body and head 
 forced into the pelvis. 
 
 Frequency and Results. — The management of persistent occipitopos- 
 terior positions will be considered later (see page 762) but the frequency 
 and results as they occurred in 20,000 labors at the Sloane Hospital 
 may well be considered now. 
 
 In 2000 consecutive labors there were hy actual count 221 occipito- 
 posterior positions, making the frequency 11.05 per cent. Estimated on 
 this basis there would have been found in the 20,000 labors, 2210 posterior 
 positions. 
 
 By actual count in the 20,000 labors there were 337 cases of yersiatcnt 
 occipitoposterior positions, making a percentage of cases failing to rotate 
 13.1 per cent. 
 
 Prognosis. — The results of labor with persistent occipitoposterior 
 positions as they occurred in 20,000 consecuti^'e labors at the Sloane 
 Hospital will be seen from the following table: 
 
 Maternal Mortality. — In 337 cases of persistent occipitoposterior 
 positions in 20,000 labors. 
 
 One death from sepsis. 
 
 Fetal Mortality. — 78, or 23.1 per cent. 
 
 Stillbirths, 45. 
 
 Died subsequently, before mother left hospital, 33. 
 
MECHANISM OF POSTERIOR POSITIONS OF THE VERTEX 277 
 
 Causes of. Fetal Death. — Premature labor, 31 cases; difficult labor, 23 
 cases; macerated fetus, 14 cases; toxemia of mother, 3 cases; syphilis, 
 2 cases; hemorrhage of newborn, 2 cases; accidental hemorrhage, 3 
 cases; total, 78 cases. 
 
 It is seen from the above that the prognosis for the mother is excellent, 
 although the fetal mortality is considerable, based chiefly on the fact 
 that the labor is prolonged and more manipulation is necessary. 
 
 Treatment. — The management of cases with persistent occipitoposterior 
 positions of the vertex will be discussed more fully under the head of 
 Forceps (see page 762). 
 
 Some idea of the treatment needed will be gained from the following 
 table which gives the method of delivery in the 337 cases occurring at 
 the Sloane Hospital in 20,000 consecutive labors. 
 
 Method of Delivery in 337 Cases of Persistent Occiiyitoposterior Posi- 
 tion of the Vertex. — As> occipitoposterior, 196 cases; rotation by hand to 
 O. A., 96 cases; rotation by forceps to-O. A., 42 cases; craniotomy, 3 
 cases; podalic version, 0; total, 337 cases. 
 
 The deliveries as occipitoposterior positions occurred chiefly in the 
 earlier portion of this series, as in recent cases the posterior positions 
 have usually been converted to anterior positions by the hand or the 
 forceps. 
 
 Considering the fact that posterior positions of the occiput are usually 
 associated with imperfect early flexion, an increase in the amount of 
 flexion present and the favoring of anterior rotation of the occiput are 
 the objects sought by the obstetrician. To accomplish flexion some have 
 recommended placing the women on the side toward which the fetal 
 back is directed. Although there is no objection to a trial of this pro- 
 cedure, the author has never felt that its employment proved very 
 efficacious. 
 
 In his experience two methods of flexion and rotation are available: 
 (1) manual; (2) by forceps. 
 
 When the cervix is only partly dilated, rotation forward of a posterior 
 occiput can often be facilitated by introducing two fingers through the 
 cervix, and then increasing the flexion of the head and turning the 
 posterior fontanelle toward the symphysis. With the fingers covered 
 with a sterile rubber glove and with strict aseptic precautions this may 
 be tried with little risk. If this method fails and labor is unduly pro- 
 longed, the author believes that with cervix dilated the best means of 
 dealing with occipitoposterior positions is by a combination of manual 
 rotation and forceps delivery, as will be described under the subject of 
 Forceps (see page 762). Introducing the fingers or even the whole hand 
 into the vagina, the head is rotated manually so that the posterior fon- 
 tanelle is brought as near the symphysis as possible. The forceps are 
 then applied so as to maintain the corrected position and the delivery 
 is completed. As will be described later, the blade of the forceps first 
 introduced in such cases is that corresponding to the side toward which 
 the occiput is directed. Some obstetricians recommend podalic version 
 under these conditions and if the contra-indications to version are absent, 
 
27S 
 
 THE MECHAXISM OF LABOR 
 
 this procedure may he justifiable, hut is seldom necessary, as is shown by 
 the fact that in the author's series of ooT cases above referred to, none 
 were delivered l)y podalic version. 
 
 THE MECHANISM OF FACE PRESENTATIONS. 
 
 A face presentation is a cephalic presentation with the head in sharp 
 extension (see I"ig. 20-i). 
 
 The occiput touches the back. The chin is the most dependent por- 
 tion and corresponds to the occiput in vertex presentations. 
 
 Face presentations occur about once in every 250 labors. Pinard,' 
 in 92,026 cases, found 374 face presentations; 1 in 250, or about 0.4 per 
 
 Fig. 204. — Face presentation. 
 
 cent. Edgar,- in 2200 cases, found only 5 face presentations; 1 in 440, or 
 about 0.22 per cent. 
 
 At the Sloane Hospital, in 20,000 labors, there have occurred 77 face 
 presentations; 1 in 260, or 0.38 per cent. 
 
 The majority of face presentations are converted vertex presentations, 
 and occur only after the onset of labor, when some mechanical obstruc- 
 tion causes extension or prevents flexion. Indeed, it has been claimed 
 that face presentations never exist before labor, and though there is 
 the best authority to prove that occasionally they have been diagnosed 
 previous to labor, it is undisputed that such cases are very rare. These 
 
 1 Traite du palper abdominal, 2me ed., Paris, 1889, pp. 32-50. 
 - The Practice of Obstetrics, 1905, p. 561. 
 
MECHANISM OF FACE PRESENTATIONS 
 
 279 
 
 cases are called primary face presentations, while those occurring during 
 labor are called secondary. 
 
 Etiology. — The causes of face presentation are many. In the jfirst 
 place conditions tending to prevent flexion of the head, sucji as coils 
 of cord around the fetal neck, tumors of the neck such as goitre, spastic 
 contraction of the muscles of the back of the neck, marked obesity and 
 dropsical conditions of the fetus — all tend to produce face presentations. 
 
 Fig. 205. — Pendulous abdomen, causing 
 extension of the head. 
 
 Fig. 206. — The same case, resulting 
 in a face presentation as the uterus 
 contracts and the head engages in the 
 pelvis. 
 
 In the second place, anything favoring extension of the head, such 
 as undue mobility of the fetus, or pressure on the fetal back, as by 
 distended maternal bladder, may cause a face presentation. A long 
 head, dolicocephalic, may cause extension if the occiput catches on the 
 brim of the pelvis. It is claimed, however, that these long heads are 
 the result rather than the cause of the condition, being due to molding. 
 
280 THE MECHANISM OF LABOR 
 
 IVIathews Duncan called attention to the fact that an oblique position 
 of the uterus favors extension of the head by allowing the buttocks of 
 the fetus to drop forward, thus bringing the occiput and back together 
 (see Figs. 205 and 206). This is more apt to occur in nudtigravida? with 
 lax abdominal walls. Hence the greater frequency of face presentations 
 in multigravidie. At the Sloane Hospital, of the 77 face presentations 
 mentioned, 45, or 58 per cent., were in nudtigravida^, while 82 were in 
 primigravida?. 
 
 Anything which makes engagement of the head difficult, as a deformed 
 pelvis or a large head, tends to produce a face presentation. The intro- 
 duction of the largest-sized dilating bag has been known thus to convert 
 a vertex into a face presentation. Hence the rule at the ^-'loane Hospital 
 never to use the largest-sized dilating bag excepting in breech presenta- 
 tions, or in such cases as placenta previa, where the use of the bag is to 
 be followed by podalic version. 
 
 Finally, the causes of malpresentations in general will favor face 
 presentations: twins, monstrosities, especially anencephalus, hydramnios, 
 tumors of the pelvis, and prematurity. Winckel^ says that in 30 per 
 cent, of his cases hydramnios was present, in 30 per cent, contracted 
 pelvis, and in 22 per cent, coiling of the cord around the neck. He 
 regards as. the most frequent causes contracted pelvis, large fetus, and 
 pendulous abdomen. At the Sloane Hospital only 12, or 15.2 per cent., 
 of the 77 face presentations were in deformed pelves. 
 
 Hirst^ says that all face cases were originally brow presentations. 
 
 With the advent of labor the occiput catches on the brim and extreme 
 extension results. The eight possible positions of the face named from 
 the chin have alreadv been mentioned (page 249). They are L. M. A., 
 R. M. A., R. M. P., L. M. P., and M. A., M. P., L. M., R. M. 
 
 The face usually occupies the right oblique diameter of the pelvis, 
 L. M. A. or R. INI^ J'., the other positions being much less frequent. 
 At the Sloane Hospital 47 of the 57 face presentations were in the right 
 oblique diameter, and probabh' a higher percentage would have been 
 found if examination had always been made before anterior rotation 
 occurred. 
 
 This usual occupancy by the face of the right oblique is not surprising 
 since most of the cases were originally vertex presentations, where the 
 long diameter of the head usually occupies the right oblique diameter of 
 the pelvis. The exact frequency of the different positions in the series 
 of 77 cases at the Sloane Hospital was as follows: 
 
 Positio7is.--L. M. A., 22; R. M. A., 20; R. M. P., 25; L. M. P., 5; 
 L. M., 2; R. M., 1; M. P., 1; not stated, 1. 
 
 ' Zur Lehie von den Gesichtslagen. Klinische Bcobachtungen zur Pathologie der Geburt. 
 Rostock, 1869, pp. 59-65. 
 
 2 A Text-book of Obstetrics, 1906, p. 398. 
 
MECHANISM OF MENTO-ANTERIOR POSITIONS 281 
 
 MECHANISM OF MENTO-ANTERIOR POSITIONS 
 (L. M. A. AND R. M. A.). 
 
 Diagnosis. — By following the ordinary methods of diagnosis, abdom- 
 inaJ palpation in the L. ]M. A. position shows the fetal back on the 
 right and posterior, while the small parts are on the left and anterior 
 portion of the mother's abdomen. 
 
 Palpation of the lower fetal pole shows marked prominence of the fetal 
 head on the right side with a sulcus between the occiput and the fetal 
 back, while the fingers can be depressed deeply on the left side. 
 
 Palpation of the upper fetal pole discloses the breech. 
 
 Auscultation of the fetal heart sounds shows the point of greatest inten- 
 sity to be on the left side and below the level of the umbilicus. 
 
 Vaginal examination is most important in the diagnosis of face piesen- 
 tations. At the beginning of labor it shows the presenting part high up 
 with a flattening of the anterior fornix. As the cervix becomes dilated, 
 the characteristic features of the face may be detected : the orbital 
 ridges, the eyes, the nose, mouth and chin, lying in the right oblique 
 diameter of the pelvis. 
 
 The mouth, with the hard alveolar processes, is the most important 
 feature in differential diagnosis. 
 
 In the R. M. A. positions the conditions are reversed. The back lies 
 to the left and posterior; the small parts lying on the right. 
 
 The prominent part of the head lies at the left, the same side as the 
 back. The fetal heart sounds are heard on the right, and vaginal examina- 
 tion shows the face in the left oblique diameter of the pelvis. 
 
 Mechanism. — This is easily understood if we remember that the chin 
 takes the place of the occiput in vertex cases, and is similarly acted upon. 
 
 With this in mind we find labor in the mechanism following the same 
 general principles as in vertex cases, but with important differences, as 
 will be seen. 
 
 The mechanism of labor in L. M. A. and li. M. A. positions in face 
 presentation consists in: engagement, molding, extension, descent, 
 internal rotation, flexion, restitution, and external rotation. 
 
 Engagement. — Occasionally a face presentation occurs before labor, 
 but usually only after labor begins. The diameter presenting at the 
 pelvic brim is the frontomental. This is so small (8.25 cm.) that it 
 could easily engage in any diameter. 
 
 The fact that it usually engages in the right oblique seems to confirm 
 the theory that face cases were originally vertex presentations. The 
 head engages readily, owing to the small diameter presenting and when 
 the widest transverse diameter, the biparietal, is at the brim it is already 
 deep in the pelvis. The distance from the parietal boss to the chin is 
 greater than from the parietal boss to the occiput. Hence when well 
 engaged a face is lower in the pelvis than a vertex would be (see Figs. 
 207 and 208). INIolding, extension, and descent take place together. 
 
 Molding. — Usually this is slight as the diameters are small. The 
 bones of the face are closely united and are capable of little change 
 
282 
 
 THE MECHANISM OF LABOR 
 
 in position owing to early ossification. When the i)elvis is small the head 
 is flattened at the cranial vault, the frontal bones increased in convexity, 
 and the supra-occipital region pushed back (see Fig. 209). 
 
 Fig. 207. — Face presentation. Head low in pelvis when parietal boss is at the brim. 
 
 Fig. 208.— Vertex presentation. Head high in the pelvis when parietal boss is at the brim. 
 
MECHANISM OF MENTO -ANTERIOR POSITIONS 
 
 283 
 
 The anterior cheek will present first, the left in L. M. A. and the right 
 in R. M. A., and will show a capnt, but this will vary in location accord- 
 ing to the position in which the face longest remains. If there is much 
 delay after rotation of the chin, the entire face may be involved in the 
 caput. 
 
 Extension. — ^This corresponds to flexion in vertex cases, and is brought 
 about by the same agencies. 
 
 The head presents a two-armed lever, the longer from the occipito- 
 atloid articulation to the occiput and the shorter from this articulation 
 to the chin (see Fig. 184). Counter-pressure from below tends to push 
 up the longer arm of the lever, causing extension. Moreover, the force 
 exerted by the uterine and abdominal muscles through the body of the 
 fetus acts more directly on the chin than on the occiput, also producing 
 extension. 
 
 Fig. 209. — Face presentation. 
 
 In vertex presentations the same forces tend to produce flexion. Here 
 the long arm of the lever is in front of the articulation. Compare Fig. 
 176. 
 
 As in vertex presentations, flexion is necessary in order to allow the 
 small diameter, the suboccipitofrontal, 10.5 cm., to present, instead of 
 the larger occipitofrontal diameter, 11.5 cm.; so in face presentations 
 extension is even more necessary in order to allow the small fronto- 
 mental diameter, 8.25 cm., to present, instead of the very large occipito- 
 mental diameter, 13.25 cm. 
 
 Descent. — This is also brought about by the same factors as in vertex 
 cases, and is favored by molding and extension, although little molding 
 is usually necessary. Owing to the small diameter presenting, 8.25 
 cm., descent would be very rapid if extension were complete from the 
 beginning. This is rarely so, and descent takes place little by little 
 with extension. However, as has been seen, the forces of the uterine and 
 
284 THE MECHANISM OF LABOR 
 
 abdominal muscles act to poor mechanical achaiitage throiitih the fetal 
 body. Therefore descent is generally slow. 
 
 Internal Rotation. — As extension increases, the head slowly descends 
 until the chin reaches the pelvic floor. J3y the resistance of the levatores 
 ani, it is then rotated forward under the pubic arch, as is the occiput 
 in vertex presentations. Rotation is not as easy, however, as in vertex 
 cases. In the first place the distance from the trunk to the chin, 5 cm., 
 is less than the distance from the trunk to the occiput, 7 cm. The lateral 
 wall of the pelvis is 9 cm. deep, so that the chin has 4 cm. to descend 
 after complete extension before reaching the pelvic floor, while the 
 occiput in vertex cases has only 2 cm. to descend after full flexion. There- 
 fore the chin must be pushed down that much farther than the occiput 
 
 Fig. 210. — Face presentatiou. Mouth and nose emerging. 
 
 before rotation can occur. Again the chin is very small and is not acted 
 upon as readily as is the larger occiput in vertex presentations. Still 
 further, until the head is low enough in the pelvis for the occiput to pass 
 the promontory, rotation is prevented, except with a very small head 
 or in a large pelvis, by the occiput hitting on the promontory. P'or 
 these reasons labor is slow. 
 
 Flexion. — After the chin reaches the pubic arch it passes under it for 
 about 1 cm. and then stops. As the length of the neck from the sternum 
 to the chin is 5 cm. and the anterior pelvic wall is 4 cm., it can go no 
 farther until the descent of the shoulders, which is not possible until 
 the head is born. The expulsive forces now^ act on the forehead which 
 advances (flexion), and the mouth, nose, eyes, forehead and occiput sue- 
 
MECHANISM OF MENTO-ANTERIOR POSITIONS 
 
 285 
 
 cessively appear and are pushed up over the perineum (see Figs. 210 
 and 211). The neck is crowded up against the pubic arch tightly, until 
 the occiput is over the perineum. It will be observed that, contrary to 
 the usual statements, the diameters emerging through the vulvar outlet 
 are not much larger than in normal vertex cases. They are the mento- 
 frontal, the cervicobregmatic, and the cervico-occipital, 8.25 cm., 10 
 cm., and 10 cm. respectively. Much tearing of the perineum is not neces- 
 sary, if the chin is born before flexion begins, and the neck is crowded well 
 up against the pubic arch. The measurement at the Sloane Hospital, 
 of 100 babies from one to thirteen days old, gave the following average 
 diameters: mentofrontal, 8.24 cm.; cervicobregmatic, 10.02 cm.; cervico- 
 occipital, 10.07 cm. 
 
 Fig. 211. — Face presentation. Face emerging. 
 
 Restitution and External Rotation. — As soon as the head is fully born it 
 drops back toward the anus of the mother. The chin immediately turns 
 slightly to the side to which it originally pointed, to the left in L. M. A. 
 and to the right in R. M. A., untwisting itself, as it has rotated from 
 left to right or right to left as the case may be, and the shoulders have 
 not followed — restitution . 
 
 After a short interval the chin turns decidedly to the side to which 
 it originally pointed, to the left in L. M. A., to the right in R. M. A., as 
 the shoulders rotate from right to left or from left to right— external 
 rotation. 
 
 Birth of the Shoulders and Body. — The long diameter of the shoulders 
 enters the pelvis in the opposite oblique diameter from that previously 
 
286 THE MECHANISM OF LABOR 
 
 occupied l)y the face. The anterior shoulder first strikes tlie i)elvic floor 
 and rotates anteriorly to the pubic arch, and the shoulders are born 
 either anterior or posterior first, as in vertex cases. The body is born 
 by lateral flexion. 
 
 It will be observed that after the i^irth of the head, conditions differ in 
 nowise from those of a vertex presentation with the occiput posterior, an 
 L. M. A. corresponding exactly to an R. O. P. position, and an IX. M. A. 
 to an L. O. P. The occiput and the chin each restitutes and rotates 
 to the side to which it originally pointed, but in opposite directions. 
 It may simplify matters for the student if he will remember that the 
 bodv of the fetus has the same position in L. M. A. and \\. O. P.; in 
 R. M. A. and L. O. P.; in L. M. P. and R. O. A.; and in R. M. P. and 
 L. O. A. Or anterior positions of the chin correspond to posterior posi- 
 tions of the occiput in the same oblique, and vice versa. After a face 
 delivery the features of the fetus are markedly distorted, but in twelve 
 to twenty-four hours this "caput" has disappeared and the features 
 are normal again. 
 
 Summary of Mechanism, L. M. A. — The long diameter of the face 
 occupies the right oblique diameter of the pelvis. The position of the 
 body is that of an R. O. P. ; molding, extension and descent occur together, 
 little molding being necessary. The chin strikes the pelvic floor late 
 in the second stage, and is rotated forward and inward to the pubic 
 arch — L. IM. A. to ]\I. A. It passes under the pubic arch and then stops. 
 The anterior part of the neck is crowded up against the arch and flexion 
 begins as the forehead and occiput are pushed forward, and slide up over 
 the perineum, while mouth, nose, eyes, forehead, bregma and finally 
 occiput emerge over the perineum. The head now drops back toward 
 the mother's anus. The chin turns slightly and then decidedly toward 
 the left in restitution and external rotation. The shoulders enter the 
 pelvis in the left oblique diameter, the left shoulder rotates anteriorly 
 to the pubic arch, and the shoulders are born anterior or posterior first, 
 and the body by lateral flexion to the left (birth of the body as in R. O. P. 
 persistent). After labor little molding of the facial bones is seen, but 
 the cranial vault may be flattened. The caput is on the left cheek, 
 or it may in\"olve the whole face, if there has been much delay after 
 rotation. 
 
 Mechanism of R. M. A. — The long diameter of the face occupies the 
 left oblique diameter of the pelvis. The position of the body is that of 
 an L. O. P. Molding, extension, and descent occur together. The 
 chin strikes the pelvic floor (late) and rotates forward and inward to 
 the pubic arch — R. ]\I. A. to ]\I. A. The chin passes under the arch and 
 the head is born by flexion, the chin turning to the right in restitution 
 and external rotation. The shoulders enter the pelvis in the right oblique 
 diameter, and the right rotates anteriorly to the pubic arch. The bwly 
 is born by lateral flexion to the right (birth of the body as in an I/. 0. P. 
 persistent). The caput is on the right cheek. 
 
MECHANISM OF MENTOPOSTERIOR POSITIONS 287 
 
 THE MECHANISM OF MENTOPOSTERIOR POSITIONS 
 (R. M. P. AND L. M. P.). 
 
 These posterior positions of the chin occur with almost as great a 
 frequency as do the anterior positions. R. M. P. and L. M. A. positions, 
 with the face in the right obHque diameter of the pelvis are most fre- 
 quent; while L. M. P. and R. M. A. positions, in the left oblique diameter, 
 are rare. In our series of 77 face cases R. M. P. occurred 25 times; 
 L. M. P., 5 times. 
 
 The causes of the posterior position are the same as those of the 
 anterior, most being converted vertex cases, and the rest the result of 
 abnormalities of development or position in mother or fetus. 
 
 Diagnosis. — The exact conditions in face presentation with chin 
 posterior are seldom made out by external palpation alone. Abdominal 
 palpation shows certain characteristics of face presentation in the marked 
 sulcus between occiput and fetal back, but in the mentoposterior posi- 
 tions the small parts are not as distinct, and the. fetal heart sounds are 
 usually transmitted through the back of the fetus. It is the vaginal 
 examination which usually determines the position, disclosing the face 
 in the right oblique diameter, less often in the left with chin posterior. 
 
 Mechanism. — In the vast majority of cases the mechanism is prac- 
 tically the same as in anterior positions. Engagement followed by mold- 
 ing, extension and descent — ^all are the same. Extension must be more 
 complete and descent lower in order that the chin may reach the pelvic 
 floor. When this is accomplished the chin rotates anteriorly to the 
 pubic arch, and the rest of the labor is the same as in anterior positions. 
 Labor is apt to be longer and interference is more often necessary, for 
 the chin must be lower before rotation can occur, and of course this is 
 through a greater distance, 135° rather than 45°. Aside from this the 
 outcome is as favorable as in anterior positions. 
 
 In over 99 per cent, of all cases this is true. In about 1 per cent, of 
 the cases, however, anterior rotation of the chin does not occur, but the 
 chin rotates posteriorly into the hollow of the sacrum; further advance 
 becomes impossible and impaction occurs.^ 
 
 The cause of the backward rotation of the chin is incomplete extension 
 of the head. As a consequence the sinciput reaches the peh'ic floor first 
 rather than the chin, and is therefore rotated anteriorly to the pubic 
 arch, while the chin is necessarily carried backrs'ard. It is claimed that 
 even where the chin is originally anterior, this same result may occa- 
 sionally follow, the sinciput being carried all the way around to the 
 pubic arch, while the chin becomes posterior. 
 
 With the chin remaining posterior in a face presentation, it is generally 
 agreed that the birth of a live child is impossible. Indeed, unless the 
 fetus be very small any birth is impossible, for impaction nuist occur. 
 
 The reason for this is plain. The length of the fetal neck from sternum 
 
 1 At the Sloane Hospital out of the 77 face presentations, 1 or a little less than 1^ per cent, 
 became impacted after posterior rotation of the chin. It must be remembered, however, 
 that impaction, when threatened, was generally prevented by operative measures. 
 
288 
 
 THE MECHANISM OF LABOR 
 
 to chin is only 5 cm. This can easily subtend the anterior pelvic wall 
 4 cm., but is entirely too short to subtend the posterior pelvic wall, 12.5 
 cm. to the tip of the coccyx, and 12.5 cm. more to the edge of the peri- 
 neum (see Fig. 212). Consequently the progress of the chin is arrested 
 after the neck is stretched to its utmost. The occiput is jammed against 
 the back, and the wedge thus formed by the body anfl the head is crowded 
 down into the pelvis. It cannot pass through, for the combined diam- 
 eters of the head and the thorax, 19 cm. (dorsosternal of the thorax, 
 9.5 cm., and suboccipitobregmatic of the head, 9.5 cm.), is far greater 
 than the widest diameter of the pelvis, 12 cm. Hence the inevitable 
 impaction. 
 
 Summary of Mechanism, R. M. P. — The face occupies the right 
 oblique diameter of the pehis, the position of the body is that of an 
 L. O. A. 
 
 Fig. 212. — Impacted face. Cbin posterior. 
 
 Engagement, molding, extension and descent occur. In the xnst 
 majority of cases the chin reaches the pelvic floor and anterior rotation 
 to the pubic arch takes place, R. M. P. to R. M. to R. M. A. to M. A. 
 After the R. M. A. position is reached, labor progresses as though this 
 had been the original position. The caput is on the right cheek, if the 
 longest delay was before rotation; and o^•e^ the whole face, if longest after 
 rotation is complete (to ]M. A.). In the small minority of cases owing to 
 incomplete extension the chin rotates into the hollow of the sacrum jM. P. 
 and impaction occurs. 
 
 Summary of Mechanism, L. M. P. — The face is in the left oblique 
 diameter of the pelvis. The position of the body is that of an R. O. A. 
 
 Engagement, molding, extension and descent occur. In the vast 
 majority of cases, internal rotation to the pubic arch, L. M. P, to L. j\I. 
 to L. M. A. to ]\I. A. takes place. After the position L. M. A. is reached. 
 
MECHANISM OF MENTOPOSTERIOR POSITIONS 289 
 
 labor progresses as though this had been the original position. The caput 
 is on the left cheek or over the whole face, according as to whether the 
 delay was longest at L. M. P. or M. A. In the small minority of cases 
 the chin rotates to M. P. and impaction occurs. 
 
 Prognosis. — While many cases of face presentation with chin anterior 
 deliver themselves spontaneously and with relatively little delay, still 
 face presentations are always viewed with considerable anxiety, and this 
 is especially so when at the beginning of labor the chin is found in a 
 posterior position. 
 
 The results as they occurred in the series of 77 cases at the Sloane 
 Hospital were as follows : 
 
 Maternal Mortality. — There were 2 maternal deaths, 2.59 per cent. 
 One died from ruptured uterus and 1 from sepsis. 
 
 Fetal Mortality. — In the 77 deliveries there were 16 stillbirths and 11 
 died before the mother left the hospital, making a total fetal mortality 
 of 27, or 35 per cent., but of these 6 were monstrosities, 2 were macerated, 
 2 were too premature to be viable, leaving only a fetal mortality of 17, 
 or 22 per cent., which could be assigned to the presentation and delivery. 
 Of these 16 children lost, 13 were lost on account of the difficult labor, 
 and 3 from prolapsed cord. 
 
 Treatment. — Considering the fact that the delivery of a face with 
 chin anterior is so nearly normal, and all others abnormal, it naturally 
 follows that the only face presentations to be left to nature are those 
 with chin in anterior positions, and in all others some conversion is 
 indicated. 
 
 In mentoposterior positions the object most desired is a marked 
 flexion by which the face with chin posterior is converted into a vertex 
 with occiput anterior. Many methods of accomplishing this have been 
 suggested. The method recommended by Schatz consisted in an attempt 
 to flex the head by external manipulation, raising and pushing the shoulder 
 in the direction of the occiput and the breech in the opposite direction, 
 thus favoring the descent of the occiput. 
 
 This method is only applicable during pregnancy or the early stage 
 of labor and has never proved efficient in the author's hands. 
 
 In a certain number of cases, with two fingers of one hand in the vagina 
 and through the cervix, and the other hand on the abdomen, the fetal 
 head can be flexed into a vertex. If this fails it is perfectly justifiable, 
 with the patient under anesthesia, to insert the whole hand into the 
 vagina and then with the fingers of that hand through the cervix and the 
 other hand on the abdomen to push up the chin and flex the head into a 
 vertex presentation with occiput anterior; a method whose principle 
 was recommended by Baudelocque in 1789. 
 
 If conversion of a face into a vertex is impossible and the chin still 
 remains posterior, the best procedure is a podalic version, provided 
 version is not contra-indicated on account of a tonic condition of the 
 uterus. The use of the forceps in delivery of the face will be discussed 
 later. If conversion to a vertex is impossible and podalic version is 
 contra-indicated, the face usually should be allowed to descend to the 
 19 
 
290 THE MECHANISM OF LABOR 
 
 outlet of the pelvis, with the hope that either by the hand or the forceps 
 the chin can then be rotated anteriorly. If this fails, craniotomy is usually 
 the procedure of choice. At a certain stage of the labor, with chin per- 
 sistently posterior, Cesarean section should theoretically be considered, 
 although the author has never met with a case in which he thought it 
 indicated. 
 
 The methods of delivery practised in the series of 77 face presentations 
 were as follows: 
 
 Delivered as face, without instrimients, 43. In some of these the 
 anterior rotation of the chin was assisted manually. 
 
 Delivered as face, with forceps, 1 1 . 
 
 Delivered as vertex after partial cephalic version, 8. 
 
 Delivered as breech after internal poflalic version, 14. 
 
 Delivered by craniotomy after impaction, 1. 
 
 A few precautions should be emphasized in the management of face 
 presentations. It is desirable to maintain the membranes intact until 
 the dilatation of the cervix is complete, hence the need of care in vaginal 
 examinations. After the rupture of the membranes, care should be 
 observed that the eyes of the fetus are not injured by the examining 
 fingers, and in the birth of the head and neck care should be taken not 
 to crowd the neck of the child too forcibly against the pubic arch lest 
 the larynx and trachea be injured. 
 
 THE MECHANISM OF BROW PRESENTATIONS. 
 
 A brow presentation is a cephalic presentation midway between a 
 vertex and a face (see Fig. 213). The head is neither well flexed nor 
 well extended, but only sufficiently extended to make the brow the most 
 dependent portion. 
 
 BroAv presentations have the same frequency as have face presenta- 
 tions. They are practically all transitional from vertex to face presen- 
 tations, and it is probable that even the primary face cases were at one 
 time brow presentations. 
 
 Brow presentations are nearly alwa\'s converted spontaneously into 
 either face or vertex presentations. Occasionally they are persistent 
 and only then are they of importance. 
 
 Persistent brow presentations are very rare. x\ccording to Williams 
 they occur about 1 to 1500 or 2000 cases. Von Weiss^ claimed them 
 occurring as often as 1 to 1000. In Guy's Hospital in 24,582 labors 
 there were 14 brow presentations, 1 to 1756.^ Edgar,^ in 2200 cases 
 previously quoted, found persistent brow presentations only three 
 times, 1 to 733, or 0.13 per cent. 
 
 In 20,000 consecutive labors at the Sloane Hospital there were 34 
 
 1 Zur Behandlung der Gcsichts und Stirnlagen, Volkmann's Sammlung Klin. Vortrage, 
 N. F. No. 74. 
 
 2 Quoted from Hirst, Text-book of Obstetrics, 1900, p. 399. 
 2 Practice of Obstetrics, 1905, p. 555. 
 
 ^,*-!**sat%aR 
 
MECHAXISM OF BROW PRESENTATIONS 
 
 291 
 
 persistent brow presentations, or 0.17 per cent; 15 occurred in primigravidse 
 and 19 in multigravidee ; 4 occurred in deformed pelves. 
 
 Brow presentations result from the same general causes as do those 
 of the face, and as in face presentations the most frequent positions are 
 those in which the long diameter of the head lies in the right oblique 
 diameter of the pelvis; L. F. A. and R. F. P. (Y. standing for "frontal" 
 or brow). 
 
 Diagnosis. — A brow presentation offers even more difficulties in diag- 
 nosis by abdominal palpation than does the face, although the same 
 general characteristics are present. In the palpation of the fetal pole, 
 however, the prominence of the head on the side of the fetal back and the 
 sulcus between the two are much less marked than in the typical face 
 presentation. 
 
 Fig. 213. — Brow presentation. 
 
 The prominence of the chin on the side of the small parts is often 
 palpable. The diagnosis is usually made by vaginal examination and 
 is based on feeling at one end of one of the oblique diameters, the large 
 fontanelle and at the other the orbital ridges, eyes and nose. The frontal 
 suture can be felt extending along this oblique diameter. 
 
 Mechanism. — Strictly speaking there is none. The presentation 
 is transitional only. In the rare cases, where the presentation is per- 
 manent, labor is usually arrested, and impaction occurs. 
 
 The reason for this is clear. The diameter presenting is the largest 
 possible diameter of the head, the occipitomental, 13.25 cm. 
 
 This is too large to pass through the normal pelvis, the largest avail- 
 able diameter of which is 12 cm. 
 
 If the head is very small, it is occasionally crowded through without 
 
292 
 
 THE MECHANISM OF LABOR 
 
 any niechanisni, that is, if the occipitomental diameter is small enough 
 to pass throu.gli the contracted portions of the pelvis unchanged. This 
 occurs only in premature births. 
 
 It is claimed that very rarely with a small head and after frightful 
 molding there is a mechanism in l)row cases which may result in spon- 
 taneous birth as a brow. In this the brow corresponds to the occiput 
 in ^•ertex, or the chin in face presentations. Engagement occurs in one 
 of the oblique diameters of the pelvis. 
 
 The head is molded so that the mento-occipital diameter is less and 
 the occipitofrontal greater. The head neither becomes more nor less 
 extended in its descent, as the two arms of the lever are practically equal 
 (see Fig. 214). The brow reaches the pelvic floor still the most dependent 
 
 Fig. 214. — Brow presentation, 
 of lever practically equal. 
 
 Arms 
 
 Fig. 215. — Molding in brow presentation. 
 
 portion, and is rotated forward to the pubic arch. The forehead, orbital 
 ridges and the root of the nose appear at the vulva. The superior maxil- 
 lary bone lodges against the pubic arch and the head is born by extreme 
 flexion, the brow followed by the bregma and the occiput appearing over 
 the perineum. 
 
 The molding shows a decrease in the mento-occipital and an increase 
 in the occipitofrontal diameter. The caput is situated between the 
 anterior fontanelle and the root of the nose (see Fig. 215). 
 
 It may be observed that the mechanism is similar to that of a persis- 
 tent occiput posterior, where at the last, flexion is not complete, and where, 
 owing to the small size of the fetus, the head is not born by late exten- 
 sion (the usual method) but by continued flexion, the small body descend- 
 ing into the pelvis to allow this. 
 
MECHANISM OF BROW PRESENTATIONS 293 
 
 Indeed, it might be simpler to consider all these rare so-called brow 
 deliveries as persistent occipitoposterior positions, terminating by 
 continued flexion rather than by late extension, because of the small 
 size of the fetus. 
 
 At any rate it must not be forgotten that a spontaneous birth with 
 the brow presenting is very rare, and can only take place when the 
 fetus is relatively very small or the molding is excessive. At any 
 time the condition may be converted spontaneously into a vertex or a 
 face presentation, or impaction may occur. Consequently the delivery 
 of a brow presentation as such is never to be expected. It is better for 
 practical purposes to think of brow presentations as transitional, and if 
 permanent, as impossible of delivery. 
 
 In the 34 cases of persistent brow presentation, occurring in 20,000 
 labors at the Sloane Hospital, none was delivered as a brow, either spon- 
 taneously or instnunentally. 
 
 Prognosis. — In brow presentation the prognosis depends largely 
 upon the skill of the obstetrician in recognizing and early correcting the 
 condition when the brow shows a tendency to become persistent. 
 
 In the series of 34 brow presentations, in 20,000 consecutive deliveries 
 at the Sloane Hospital, there was one maternal death from rupture of 
 the uterus. This gave a maternal mortality of 2.9 per cent. The total 
 fetal mortality in this series was 17, or 50 per cent., but only 10, or 29.4 
 per cent., were due to the presentation or delivery. The details of the 
 total fetal mortality are as follows: 
 
 Difficult labor, impaction, etc., 9; macerated fetus, 4; prolapsed cord, 
 1; premature, nonviable, 1; hemorrhage of newborn, 1; anomaly of 
 
 ^t, 1; total, 17. 
 
 Treatment. — A brow presentation of a full-term child should never 
 be left to nature to deliver as a persistent brow. There are three methods 
 of choice in dealing with the delivery. 
 
 1 . Flex to a vertex. 
 
 2. Extend to a face with chin anterior. 
 
 3. Perform podalic version. 
 
 As previously stated, a brow presentation is usually transitional, and 
 if it is seen that it is being gradually converted by nature into a face 
 presentation, with chin anterior, it is well to leave the case alone. If, 
 however, the brow tends to be persistent as a brow, the methods of con- 
 version mentioned above should be tried in that order. A conversion 
 to a vertex with the fingers of one hand through the cervix and the other 
 hand on the abdomen is often possible, if too much molding, as a brow 
 has not already taken place, and is the best outcome. Next to this 
 is a conversion to a face with chin anterior, simply assisting nature in 
 her usual procedure. Failing in this, if version is not contra-indicated 
 on account of a tonic condition of the uterus, internal podalic version 
 is a much better procedure than extension to a face with chin posterior, 
 with its associated difficulties of delivery. However, in rare instances, 
 with version contra-indicated, this may be the only alternative. Some 
 cases with or without the help of the forceps may be rotated at the out- 
 
204 THE M EC II A \ ISM OF LABOR 
 
 let, Imt ill iiKiiiy iiistimces (Taiiiutoiny must he resorted to. Pubiotoiny 
 
 has heeii performed suceessfully for this (•oii(liti(»ii hut the author does 
 
 not feel hke recoininen<nnf; it. 
 
 The methods of (K-hvery employed in the series of thirty-four brow 
 
 presentations just referred to were as follows: 
 
 As a \ertex, 17) . ,: ,. , , ,. . ^^ 
 
 . e ,,>Atter partial cephalic version, J(>. 
 
 As a face, Dj ' ^ 
 
 As a breech after internal podalic version, 5. 
 
 Impacted brow — cram"otom\', 'A. 
 
 BREGMA PRESENTATIONS (PRESENTATION OF THE ANTERIOR 
 
 FONTANELLE). 
 
 Bregma presentations are sometimes described as shown in Fig. 182. 
 The\- are midway between brow and vertex presentations, and are 
 reall\- oidy vertex presentations with poor flexion of the head. They 
 have the same causes as have face and brow presentations, and probably 
 occur (juite frequently. The mechanism is that of vertex presentation, 
 but it is the occipitofrontal, rather than the suboccipitofrontal diameter 
 which presents, 11.,") cm. instead of 10..") cm., so the labor is harder, 
 and tearing of the soft parts much more frequent. ^Moreover, as the 
 occiput and sinciput descend on the same level, rotation does not take 
 place easily, and the head may remain in the pelvis for hours in posterior 
 position of the occiput without rotating. 
 
 It seems unnecessary, however, to describe these separately as bregma 
 presentations, but rather as vertex presentations with poor flexion. 
 
 Poor flexion of the head in vertex piesentations with the occiput ^os-^ 
 terioi is recognized as one of the causes of long, difficult labor with lack 
 of anterior rotation. 
 
 THE MECHANISM OF BREECH PRESENTATIONS. 
 
 A breech presentation is one in which the pelvic end of the fetal ovoid 
 presents at the cervix. It is a longitudinal presentation. 
 
 A "complete" breech presentation is one in which the fetus retains 
 its normal attitude with the legs and thighs flexed on the abdomen, 
 the feet consequenth' presenting at the cervix with the buttocks (see 
 Fig. 185). This is also called a "full" breech presentation. 
 
 A "frank" breech presentation is one in which the thighs only are 
 flexed, the legs being extended along the abdomen of the fetus (see Fig. 
 186). This is also called a "breech with extended legs." 
 
 A foot or a knee may prolapse, giving rise to the terms "foot" and 
 "knee" presentations, but as prolapse of a lower extremity in nowise 
 changes the mechanism or treatment from that of a normal breech pre- 
 sentation, these terms are of little importance. 
 
 Frequency. — Pinard.^ who quotes the largest series of cases on record, 
 found in 10(),()(K) labors of all kinds 3301 breech presentations, 3.3 per 
 
 ' Loc. cit. 
 
MECHANISM OF BREECH PRESENTATIONS 295 
 
 cent., or about 1 to 30. In labors at term only, however, he found the 
 trequency less, or only about 1 in 60. 
 
 Edgar/ in his 2200 labors, found 82 breech presentations, 3.7 per cent 
 or about 1 to 26. '' 
 
 The findings at the Sloane Hospital correspond more nearly with those 
 ot Ldgar than with those of Pinaid. In 20,000 labors, actually 90 252 
 births, on account of multiple births, there were 835 breech presentations 
 4.12 per cent., or about 1 to 24. In 17,401 labors at term there were 492 
 breech presentations, 2.25 per cent., or 1 to 35. In the 2599 premature 
 labors there were 343 breech presentations, 13.2 per cent., or about 1 
 to /.o. 
 
 beSe'term*""^*^' ''^^^'^' ^^^^ '^'''^'"^ frequency of breech presentations 
 Failure of the "law of accommodation" already mentioned is chiefly 
 responsible for breech presentations. Normally the fetal ovoid best 
 fits the uterme cavity when it lies with the cephalic end downward 
 Any change m shape of the uterine cavity or of the fetal ovoid tends to 
 disturb the workings of this law, and may result in a breech presentation 
 or some other presentation less frequent. 
 
 Thus breech presentations occur more frequently in multigravid^ 
 with lax abdommal and uterine walls; in hydramnios; in deformities 
 ot the uterus with fibroid tumors; and in placenta previa-in all of 
 which conditions_ the normal shape of the uterine cavity is disturbed- 
 also m prematurity; with twins; with monstrosities; and with dead or 
 macerated fetuses-conditions in which the fetal ovoid is abnormal in shape 
 Anything preventing free engagement of the head, such as a deformed 
 ^ T l?"" ci-'f ^^^?^ ^''''^^' ^^''^' ^° P^^^^ce a breech presentation. 
 Hn.n^t«? in presentations mentioned as occurring at the Sloane 
 
 Hospital, 490, or nearly- 60 per cent., were in multigravid^; h^-dramnios 
 IZ^T/ '? 4; fibroids m 8; placenta previa in 5; septate uterus and 
 '^f '?^,f^^^^°^' by which the shape of the uterus was distorted, each 1 
 
 q iV ;''l?-''' ^^ P'' ''^^•' ^.^' ^^'^"^^ ^'^^ premature; in 76, or about 
 9 per cent tu'ins were present; in 63, or 7.5 per cent., the fetus was dead 
 or macerated; and m 5 fetal monstrosities occurred. In 107 or over 12 
 per cent., the pelvis was deformed. 
 
 K.;'^'l!'' tT^"^'" presentations, there are eight possible positions of the 
 breech. These are named from the positions of the sacrum, as has ah-eadv 
 been e-xplained (see page 250;. According to the findings at the Sloane 
 Hospital the fetal back lies much more frequently anterior than posterior 
 In 80/ breech presentations, m which the position was accurateh- deter- 
 7Z' Tl, 7'q s/ero-anterior, while only 91 were sacroposterior posi- 
 tions. The Lb. A positions numbered 399, and the R. S. A. numbered 
 317, showing that the fetal back was more commonly on the left side nf 
 the mother s abdomen.^ The sacroposterior positions^-ere abou teqn lly 
 
 Sr s'r in4'5"' ' ^'^' "^'' ^' ^- ^- ^^^^^ ^^^ P°^^^^^- - 
 
 1 Practice of Obstetrics, 1905, p. 580. 
 
296 THE MECHANISM OF LABOR 
 
 111 comi)lete breech presentations the anteroposterior diameter is 
 greater (although more compressible) than is the transverse or bi tro- 
 chanteric. The positions L. S. A. and U. S. P. results from a selection 
 by this larger diameter, of the larger diameter of the pelvis — the right. 
 This is shown in the series of 807 breech presentations at the Sloane 
 Hospital, in which the L. S. A. and R. S. P. numbered 444, while the 
 K. S. A. and L. S. P. numbered 363. 
 
 In frank breech presentations the anteroposterior diameter is not the 
 longer, and hence this reason for seeking the right oblique diameter of 
 the pelvis does not hold, but the complete breech presentation is much 
 more common than the frank breech — 504, as compared with 331 in the 
 complete series of S3o cases abo\e quoted — therefore the general rule 
 holds. 
 
 Diagnosis. — In a breech presentation abdominal palpation detects 
 the fetal back on one side of the mother's abdomen and the fetal small 
 parts on the other. Palpation of the lower fetal pole immediately arouses 
 attention by the absence of the hard head usually felt there. 
 
 Palpation of the upper fetal pole discloses the hard, round, movable 
 object, which a little experience will enable the obstetrician to recognize 
 at once as the fetal head. 
 
 Auscultation of the fetal heart sounds locates the point of greatest 
 intensity at or above the level of the umbilicus and on the left or right 
 side of the mother's abdomen, according as the fetal back is on the left 
 or the right side. 
 
 Vaginal examination in the early stage of labor detects the absence of 
 the hard, round head, and relatively high position of the presenting part. 
 With the cervix dilated the spines of the sacrum, the tuberosities of the 
 ischiimi and the anus are felt. If the membranes have ruptured and the 
 presenting part has descended into the pelvis the characteristics of the 
 genitals can be detected. In the later stages of labor the presenting 
 part becomes edematous and the breech with its anus may present some 
 of the characteristics of the face with its mouth. 
 
 A careful attention, however, to the following differential features, 
 will usually enable the diagnosis to be made without difficulty. 
 
 Breech vs. Face. 
 
 Head in upper abdomen. Head in lower abdomen. ' 
 
 Anus. Small, no bony ridges. Mouth. Larger, bonj- alveolar ridges. 
 
 Sphincteric action. No sphincteric action. 
 
 Meconium discharged. No meconium discharged. 
 
 Sharp spines of the sacrum. No such projections. 
 
 Among all these differential features the sacnun is the most important. 
 If you feel the sacrum you have a hreech. 
 
 5s'ot infrequently before the vaginal examination has been made there 
 has been a dark discharge on the \'uh'a pad which can be recognized at 
 once as meconium, and, taken with the feel of the hard, round mass in 
 the upper abdomen, serves as a verification of the diagnosis of a breech 
 presentation. 
 
MECHANISM OF BREECH PRESENTATIONS 297 
 
 In a complete breech presentation and in a footling presentation the 
 examining finger may first reach a foot and the question naturally arises, 
 "Is it a foot or a hand?" Attention to the following differential features 
 will often prove of value: 
 
 Foot vs. Hand. 
 
 At right angles to leg. In line -witli arm. 
 
 Toes short and all in straight line. Fingers longer; thumb almost at 
 
 right angles to fingers. 
 Heel felt. No such projection. 
 
 Among these differential features the heel is the most important. If 
 you feel a Jieel you have a foot. 
 
 Mechanism of Breech Presentation L. S. A. and R. S. A. — The mechan- 
 ism of complete and frank breech presentation is practically the same, 
 though the treatment is different, as will be discussed later. 
 
 Engagement. — The back of the fetus is directed toward one iliopectineal 
 eminence, and the bitrochanteric diameter lies in the opposite oblique 
 diameter of the pelvis. Engagement does not take place until late in 
 labor, for although the bony diameter of the breech is small, bitrochan- 
 teric, 8.75 cm., the breech itself is irregular and, until compressed, large. 
 Hence it rides high until well molded. 
 
 Molding. — The soft parts are compressed, and the flexion of the legs 
 and thighs increased. There is no real caput, although there is edema 
 and discoloration of the anterior buttock, or of the scrotum in males. 
 An extremity if prolapsed becomes discolored and swollen. 
 
 Descent. — Labor usualh' is slow, as the breech, soft and irregular, not 
 fitting well into the pelvis, makes a poor dilator for the cervix. The 
 membranes are apt to rupture prematurely because of this irregularity 
 of the breech and the movements of the feet in complete breech presen- 
 tations. 
 
 Internal Rotation. — The anterior or lower buttock first reaches the 
 pelvic floor and rotates anteriorly to the pubic arch. 
 
 Birth of Hips. — The hips are now born in one of three ways: both 
 together, the posterior first followed by the anterior, or the anterior first 
 followed by the posterior. The hips are so small that they can easily 
 be born together, especially in a frank breech. In a complete breech 
 usually the anterior foot prolapses at this tiriie, followed by the birth 
 of the anterior hip. Then the posterior foot and hip follow over the 
 perinemn. 
 
 (This mechanism is rarely observed unassisted at the Sloane Hospital 
 as it is the practise there for the obstetrician to deliver the anterior foot 
 as it appears at the vulva, and thus to favor the birth of the anterior 
 hip first.) (See Treatment). 
 
 As the posterior hip passes over the perineum the body is bent laterally 
 upward, corresponding to the curve of the birth canal. After the birth 
 of the hips these fall downward toward the mother's anus and the body 
 straightens out. The body is rapidly born until the shoulders appear 
 at the pelvic brim, which occurs at about the time when the imibilicus 
 is born. 
 
29S 
 
 THE MECHANISM OF LABOR 
 
 Birth of the Shoulders. — The shoulders enter the pelvis in the same 
 oblique diameter as did the hips. The anterior, being lower in the pelvis, 
 first strikes the pelvie Hoor and rotates to the pubic arch. Again, as in 
 cephalic presentations, the shoulders may be born in one of three ways: 
 anterior first followed by posterior, posterior first followed by anterior, 
 or both together. The tliameter of the shoulders is large, 12.25 cm., so 
 that rarely will both shoulders be born together. Unassisted the anterior 
 will probably be born first, because of the weight of the body dragging 
 it downward. It is said that among savages the mother generally 
 reaches down and lifts the body of her child upward in an attempt to 
 embrace it, thus probably assisting the posterior shoulder out first. 
 The custom among obstetricians is divided. At the Sloane Hospital 
 the body is lifted with the object of first freeing the posterior shoulder 
 
 Fig. 216. — Normal delivery of the after-coming head. Occiput anterior. Head well flexed. 
 
 (see Treatment). The arms are normally born still flexed. Occasionally 
 they become extended, delaying the birth of the head (see Abnormalities 
 of Breech Delivery, page 713). 
 
 Birth of the Head. — This is the critical part of breech deliveries, as the 
 head presents longer diameters than the body unless well flexed. It is 
 difficult to describe the normal mechanism in the birth of the after-coming 
 head, for, except in large pelves or with small fetuses, this mechanism is 
 always assisted by the obstetrician. At the Sloane Hospital, except in 
 the conditions mentioned, the mechanism unassisted is never observed. 
 Indeed, it is the duty of the obstetrician in e^-ery breech delivery to cavse 
 the mechanism most favorable for delivery to occur. (This will be 
 explained fulh' under Treatment.) 
 
 As the shoulders are born the head presents at the brim of the pelvis. 
 Xormally the head is well flexed, asJjecause of uterine pres>ure from 
 
MECHANISM OF BREECH PRESENTATIONS 299 
 
 above, the longer pole of the lever, the sinciput is pushed down (see Fig. 
 216). Consequently it is the suboccipitofrontal diameter, 10.5 cm., which 
 presents. This can enter the pelvis in any diameter, the narrowest diam- 
 eter at the brim being 11 cm. If the shoulders remain as they were 
 born, directly anteroposterior, the head will enter the pelvis directly 
 transversely, L. 0. or R. O. The rotation of the occiput anteriorly or 
 posteriorly is now influenced chiefly by the position oj the body. The 
 weight of the arms and legs being chiefly on the side of the abdomen, 
 causes this to turn downward, and the back to turn upward. The occi- 
 put naturally follows, rotating anteriorly to the pubic arch. The weight 
 of the body falling downward increases the flexion. The occiput catches 
 on the pubic arch and is arrested. The sinciput is pushed onward and 
 up over the perineum, chin, mouth, nose, eyes and forehead successively 
 emerging. And the head is born by continued flexion. 
 
 If the body begins to pronate immediateh* after the birth of the 
 shoulders, the long diameter of the head enters the pelvis, not in the 
 transverse diameter, but in one oblique, and with the continued prona- 
 tion of the body the occiput rotates to the pubic arch. If the head is 
 large or not well flexed, that is, if there is any difficulty in engagement 
 in the transverse diameter, the body will turn, thus bringing the head 
 into the oblique. It is probable that it enters the oblique oftener than 
 in the transverse. It is readily seen how the obstetrician, by causing 
 anterior rotation of the back, can almost surely secure anterior rotation 
 of the occiput. 
 
 Posterior Rotation of the Occiput. — Very rarely the body supinates, 
 and the occiput rotates into the hollow of the sacrum. This occurs either 
 from some manipulation of the body of the child, or because of some » 
 abnormality of the pelvis, by which the occiput is prevented from ^ 
 rotating anteriorly. 
 
 Delivery of the head takes place in one of two ways. If the 
 head is well flexed, uterine pressure from above and the weight of the 
 body dragging from below, forces the sinciput down, so that the chin 
 passes under the pubic arch, and the mouth, nose, eyes, and forehead 
 pass under the pubic arch first (see Fig. 217). The head is born by con- 
 tinued flexion, the back of the child approaching the back of the mother. 
 
 If the head is extended, the long diameter, the mento-occipital, 13.25 
 cm., presents at the outlet. This cannot be born. The chin catches above 
 the pubic arch and is held there while pressure from above forces the 
 occiput down first and pushes it up over the perineum, the occiput, 
 fontanelles, forehead, eyes, nose, mouth, and lastly chin successively 
 appearing over the perineum. The head is born by late extension (see 
 Fig. 218), the abdomen of the child approaching the abdomen of the 
 mother. 
 
 In the first condition it is evident that the obstetrician could be of 
 assistance by niaking traction doTvniward; in the second, by traction 
 upward. 
 
 Summary of Mechanism, L. S. A. — ^The back is directed toward the 
 left iliopectineal eminence. The bitrochanteric diameter is in the left 
 
300 
 
 THE MECHAXISM OF LABOR 
 
 oblique diameter of the pelvis. Engagement occurs late followed by 
 molding. Descent is slow. The left or anterior hip rotates anteriorly 
 
 Fig. 217. — Occiput posterior. Head born by continued flexion 
 
 Fig. 218. — Occiput posterior. Head bom by late extension. 
 
MECHANISM OF BREECH PRESENTATIONS 
 
 301 
 
 to the pubic arch, and the hips are born by lateral flexion to the left 
 (of the child) both together, the anterior first, or the posterior first. 
 The shoulders enter the same diameter as did the hips, the left oblique. 
 The left shoulder rotates anteriorly, and the shoulders are born unassisted 
 anteriorly first, followed by the posterior; if assisted, possibly the pos- 
 terior first; occasionally, if small, both together. The head, well flexed, 
 enters the pelvis in the opposite diameter from that by which the shoulders 
 and hips entered, transversely or in the right oblique, according to the 
 position of the body, and the occiput rotates anteriorly chiefly from 
 the pronation of the body. The occiput catches on the pubic arch and 
 the head is born by flexion. 
 
 Rarely the occiput rotates into the hollow of the sacrum, because of 
 the supination of the body or from some obstacle to forward rotation. 
 Delivery takes place in one of two ways. 
 With good flexion the forehead passes 
 under the pubic arch and the head is 
 born by continued flexion, the back of 
 the child approaching the back of the 
 mother. With the head extended, the 
 chin catches above the pubic arch, and 
 the occiput is pushed forward, the head 
 being born by extension, the abdomen 
 of the child approaching the abdomen of 
 the mother. 
 
 Mechanism of R. S. A. — The back is 
 directed toward the right iliopectineal 
 eminence and the bitrochanteric diameter 
 is in the right oblique diameter of the 
 pelvis. ^Molding and descent occur. 
 The right hip rotates anteriorly. The 
 body is born by lateral flexion to the 
 right (of the child). The shoulders enter 
 the right oblique diameter, and the right 
 shoulder rotates anteriorly. The head 
 enters the pelvis transversely, or in the 
 left oblique diameter, and rotates ante- 
 riorly; occasionally posteriorly. 
 
 Mechanism of R. S. P. and L. S. P. — This is exactly similar to that 
 of the anterior positions. The back is directed to the right or left sacro- 
 iliac joint. The anterior hip and shoulder rotate to the pubic arch, when 
 the conditions are the same as in the original anterior positions. 
 
 The head after a breech delivery is not molded at all. This fact is 
 very noticeable (see Fig. 219). 
 
 (The abnormalities of mechanism in breech deliveries will be con- 
 sidered under Treatment.) 
 
 Prognosis. — Maternal. — The maternal prognosis of breech presenta- 
 tions is excellent, although it should be recognized that the risk of lacera- 
 tion of the perineum is much greater than in vertex presentation, and in 
 
 Fig. 219. 
 
 -Breech delivery, 
 not molded. 
 
 Head 
 
302 THE MECHANISM OF LABOR 
 
 frank breech presentations, especially in primigravidte, even complete 
 lacerations of the perinenin are not very infrequent. 
 
 In the 8:i") breech i)resentations, occurring in 20,000 consecutive labors 
 at the Sloane Hospital, there were 7 deaths, or 0.8 per cent., although none 
 of these deaths were due to the i)resentation. The causes were as follows: 
 
 From sepsis, 2. 
 
 Eclampsia, 2. 
 
 Toxemia of ])regnancy, 2. 
 
 INIalignant endocarditis, 1. 
 
 In 4 cases there occurred a complete laceration of tlie perineum. 
 Fetal Prognosis. — Tlie fetal prognosis in breech presentation is always 
 less favorable than in presentations of the vertex, and for many reasons. 
 Many of the children are premature. Some of the serious complica- 
 tions of ])regnancy and labor requiring artificial delivery, as placenta 
 previa, are associated with breech presentation. Furthermore, abnor- 
 malities of mechanism and delay in the delivery of the head not infre- 
 (jucntly associated with lireech ])resentation add to the fetal risk, 
 esi)ecially in ])rimigravid{T^. 
 
 In the series of s;^5 breech presentations at the Sloane Hospital, there 
 was a complete fetal mortality, including abortions and macerated fetuses, 
 of 302, or 36 per cent., which was <livided as follows: 
 
 Fetal deaths from difficult labor, 48, or 5.7 per cent. 
 
 Prematurity and early fetal death, 230, or 27.5 per cent. 
 
 Other causes, 24, or 2.8 per cent. 
 
 Total, 36 per cent. 
 The conditions grouped under the head of "other causes " mentioned 
 above, will be seen from the following table: 
 
 Accidental hemorrhage 8 
 
 Placenta previa 3 
 
 Eclampsia 2 
 
 Immaturity (twins) 2 
 
 Anomalies 4 
 
 Hemorrhage of newborn 2 
 
 Bronchopnciinionia 2 
 
 Acute infection of liver 1 
 
 ToiixX 24 
 
 It is seen from the abo^•e that while the general fetal mortality was 
 36 })er cent., less than 6 per cent, was due to the delivery itself. 
 
 Treatment. — As the fetal danger is greater in breech than in vertex 
 deliveries and the labors are usually longer and more difficult for the 
 mother, it is usually wise to attempt the conversion of the breech to a 
 vertex presentation before labor. 
 
 In multigravidae with lax abdominal and uterine walls this conversion 
 can often be accomplished with ease by external manipulation alone, 
 i. e., by external version. With the woman on her back and with the 
 abdomen uncovered, the obstetrician gently pushes the fetal head toward 
 the brim of the pelvis, while he })ushes the breech in the opposite direc- 
 tion, as described in the chapter on Version (see page 769). 
 
MECHANISM OF BREECH PRESENTATIONS 303 
 
 If the patient is a primigravida with tense or very fat abdominal 
 wall, or if the fetus is very large and the breech is low in the pelvis, 
 external cephalic version is much more difficult and sometimes without 
 an anesthetic is impossible. Under an anesthetic the version is usually 
 easy and the difficulty consists only in maintaining the corrected presen- 
 tation. If the head is placed well within the brim of the pelvis and there 
 is no abnormality present, the fetus will often stay in cephalic presenta- 
 tion. Disappointments, however, are not uncommon and occasionally 
 a day or two after the change from a breech to a vertex presentation 
 the fetus is again found presenting by the breech. The corrected presen- 
 tation can sometimes be maintained by an abdominal binder, but 
 occasionally all efforts in this direction fail and the presentation is best 
 left as a breech. 
 
 It should be remembered that breech presentations are much juore 
 common in early than in late pregnancy and that many breech presen- 
 tations are spontaneously changed to vertex presentations between the 
 eighth month and term. The close of the eighth month or the beginning 
 of the ninth is the best time to attempt the change of a breech to a vertex 
 presentation by external version. At an earlier period the operation is 
 often unnecessary and at a later period, owing to the growth of the fetus, 
 it is often more difficult. For a breech delivery a table is preferable to 
 a bed and it is advisable to have an assistant to administer the anesthetic 
 and to assist by pressure upon the fundus during the latter part of the 
 delivery, leaving the nurse free to make preparations for the baby, 
 arranging hot and cold tubs for resuscitation if needed, etc. If a table 
 is not available for the delivery the patient during the second stage should 
 lie across the bed with hips near the edge and whether on the table or 
 bed she should be placed in the lithotomy position, with knees supported 
 with leg holders, and draped as for a forceps delivery (see page 758). 
 
 Since the birth of the head is the most critical period of a breech delivery 
 it naturally follows that full dilatation of the cervix is desired, hence 
 care should be taken to preserve the membranes intact if possible until 
 this result is accomplished. Furthermore, as the soft breech is not 
 as good a dilator as the hard fetal head it is advisable (except in cases 
 of frank breech, where on account of threatened impaction it is neces- 
 sary to bring down a foot) not to interfere with the presenting pelvic 
 extremity until it reaches the vulva, lest the size of the dilating body be 
 reduced and the dilatation be imperfect. 
 
 The delivery of a complete breech consists of three parts : The first 
 is from the birth of the foot to the birth of the navel; the second is 
 from the birth of the navel to the birth of the mouth; the third is from 
 the birth of the mouth to the complete birth of the head. The first part 
 should be very slow; the second should be rapid; the third should be 
 rapid or slow, according to the condition of the fetus. 
 
 When the foot appears, usually the anterior, it is gently lifted out and 
 covered with a towel wrung out in hot sterile water. The hot, wet towel 
 has a threefold purpose. It keeps the fetal extremity warm, thus pre- 
 venting the attempt at respiration which the shock of air lower than 
 
304 THE MECHANISM OF LABOR 
 
 bo(l\ temperature tends to cause; it preserves the vitality of the fetus, 
 and it renders the extremity covered with vernix caseosa less slippery 
 in the obstetrician's grasp. The delivery to the birth of the navel should 
 be as slow as i)ossible, in order that the cervix may be fully dilated by 
 the body of the fetus, thus lessening the danger of the passage of the 
 larger head. To this end no traction should be made on the leg. The 
 delivery should be made by uterine effort alone. The leg, however, may 
 be raised gently, thus guiding the hips up over the perineum. Soon the 
 second leg and hip appear and slip over the perineum. The assistant, 
 as the delivery proceeds, should carefully follow down the fundus, press- 
 ing it gently with both hands, and keeping it contracted on the dimin- 
 ishing fetal body. If the uterus be allowed to balloon up, the arms of 
 the fetus may become extended, thus giving rise to what is often a serious 
 complication. The assistant should be especially careful in following 
 down the fundus after the birth of the navel, as this is the time v.hen 
 the arms are more likely to become extended. As more of the body 
 appears, it should be wrapped in the hot, wet towel. Finally, the navel 
 appears and the first part of the delivery is over. The cord should be 
 pulled down in a loop to prevent undue traction on it. The second 
 part of the delivery should be as rapid as possible. Until the birth of 
 the navel the fetus is getting its supply of oxygen through the placenta. 
 After the birth of the navel, however, the cord is almost sure to be 
 pressed upon, and the placenta often begins to separate from the uterine 
 wall. Hence, the fetus is cut off from its supply of oxygen and will die 
 unless delivered quickly. Five minutes is about the limit of time which 
 can elapse from the birth of the navel to the birth of the mouth without 
 the loss of the fetus. Therefore no time is to be lost. The fetus, covered 
 with the hot, wet towel, is firmly grasped by the body above the iliac 
 crests, and traction is made downward until the shoulders appear at the 
 vulva. Then the body of the fetus is raised and the posterior arm, if 
 flexed, appears at the perineum. This may drop out spontaneously. 
 If not, two fingers of the obstetrician's hand — right if the back is to the 
 right, left if the back is to the left — are passed along the fetal back and. 
 o\er the shoulder, hooking down the arm by the elbow. The body is 
 now dejiressed, and the anterior arm may be born spontaneously or 
 easily extracted. If not, the body of the fetus is rotated so that the 
 anterior shoulder becomes posterior or nearly so, when two fingers of 
 the oi)i)osite hand are inserted over this shoulder, again hooking down 
 the elbow. Thus the attempt is made to deliver the arm posteriorly 
 only, the reason being that the muscular perineum gives and admits 
 the fingers easily, while the bony pubic arch does not. This is all 
 the more important if the arms are extended, a condition always pos- 
 sible, and described later (see page 713), when the whole hand must be 
 inserted for a greater distance to bring the arms down. This is only 
 possible j)osteriorly. 
 
 With the birth of the shoulders and arms the back of the fetus is turned 
 upward to bring the occiput anterior. This is most important. The 
 head readily follows the body unless the pelvis is deformed, and it is 
 
MECHANISM OF BREECH PRESENTATIONS 
 
 305 
 
 usually the obstetrician's fault if the body is supinated and the head 
 rotates posteriorly (see also page 299). 
 
 The safest way of delivering the after-coming head, the critical and 
 most difficult part of the delivery, is by the Mauriceau-Smellie-Veit 
 method (see Fig. 220), so called because all three men described it. 
 
 The righti hand is passed under the child's abdomen and the fingers 
 are inserted into the mouth, and with slight traction the head is well 
 flexed. We have seen previously why complete flexion is so important. 
 The body of the fetus straddles the right forearm of the obstetrician. 
 The fingers of the left hand make traction on the shoulders of the fetus, 
 one on each side of the neck. Traction is made downward until the head 
 is felt to slip under the pubic arch. The body of the fetus is now lifted 
 up onto the mother's abdomen, and is supported by the left hand and 
 arm. This brings the mouth of the fetus over the perineum. The right 
 
 Fig. 220. — -Mauriceau-Smellie-Veit method. 
 
 hand is slipped down and guards the perineum, exactly as in vertex 
 deliveries. The second part of the delivery is now over and the fetus 
 is safe, unless the delivery has been too long or difficult. 
 
 The head is delivered over the perineum exactly as in a vertex case. 
 There need be no hurry if the fetus is in good condition, as it will begin 
 to breathe and even to cry as soon as the mouth is born. The perineum 
 can be gradually distended and the delivery made without serious tear- 
 ing. Should the fetus be in a bad condition, this part of the delivery 
 must be hurried regardless of the perineum. Anesthesia can be given 
 
 1 The right hand is used under the child's abdomen, as this is the hand with which the 
 perineum is guarded in vertex deliveries, and the hand under the child is more quickly- 
 slipped down onto the perineum than the hand on the shoulders. In some cases, however, 
 especially in flat pelves, the head comes through the pelvis transversely, and when the face 
 is found to be markedly turned toward the mother's right, it is easier to use the left hand 
 under the abdomen so that it can easily reach the mouth. In Fig. 220 the left hand is 
 represented under the abdomen. 
 20 
 
300 THE MECHANISM OF LABOR 
 
 ■iftor the l)irth of tlie navel if the patient is inclined to resist and to be 
 unrnly. if given after the birth of the mouth it tends to prevent rupture 
 
 of the perineum. • 1 1 ^i 
 
 The placenta follows the birth of the child more quickly than ma 
 
 vertex delivery, as it often begins to separate when the fetus is partly 
 
 born, as was mentioned. , , . 
 
 For the complications of breech delivery and their management see 
 
 page 711. 
 
CHAPTER IX. 
 THE MANAGEMENT OF NORMAL LABOR. 
 
 MANAGEMENT OF THE FIRST STAGE. 
 
 In describing the management of a case of labor something should be 
 said about the summons. The two disagreeable features in the practice 
 of obstetrics are the uncertainty of the summons and the long hours of 
 waiting. I have spoken of the summons as uncertain and I would have 
 every student of obstetrics looking forward to this as a lifework con- 
 sider well what this means. The call to an obstetric case is likely to come 
 just at a time when he least desires it. At night, perhaps when he is 
 all tired out with his day's work; in the daytime, when he has filled 
 every hour of the day with previous engagements. This must be expected 
 not only once, but frequently in the life of the obstetrician. He may have 
 to give up a large part or the whole of his vacation just because an 
 obstetric case does not go into labor at the time expected. These and 
 the long tedious hours of inactivity, waiting at the house of the patient 
 for nature to do her work, are the disagreeable features in the practice of 
 obstetrics and yet no one should engage in this line of work, and no one 
 deserves success in it, who is not willing to give an obstetric call pre- 
 eminence over every other engagement, who is not willing to respond 
 at once to the call of the woman who has entrusted herself to his care 
 and placed her full confidence in him. 
 
 It has always seemed to the author that the fact of a pregnant woman 
 placing herself and her unborn child unreservedly in the care of an 
 obstetrician carried with it greater moral obligation on the part of the 
 latter to be loyal to her in every way than did any other engagement in 
 medicine. 
 
 There may be mentioned another disagreeable feature in the practice 
 of obstetrics, and that is, the liability to criticism. For so many years 
 has labor been considered a normal physiological process which, with 
 proper care, should have no complications for mother or child, that there 
 is a tendency especially among women and their friends to blame the 
 obstetrician if anything unfavorable occurs, no matter how unjust this 
 criticism may be. 
 
 Thus far the unfavorable side of obstetrics has been depicted and it is 
 well to look at this side carefully before selecting it as a specialty. 
 
 There is another side, however, and in the judgment of the author 
 it is the weightier. 
 
 There is no branch of medicine in which the doctor comes so near to 
 the heart of his patient as does the obstetrician, who by his skill, careful 
 
 (307) 
 
308 THE MANAGEMENT OF NORMAL LABOR 
 
 attention and sympathy has carried a woman safely through wliat is 
 l)erhaps the most trying experience of her Hfe. He has safely guarded 
 her confidences early in pregnancy. He has been ready with kindly 
 advice to lessen as far as possible the discomforts of the later months 
 and by his skill and sympathetic encouragement he has safely guarded 
 her through labor. Is it any wonder that the conscientious, skilled 
 obstetrician possesses the respect and affection of his i)atients to a 
 degree which enables him to forget the discomforts of the untimely call, 
 the loss of sleep, and the bodily fatigue. Another pleasant feature of 
 obstetrics is the happy atmosphere of the home of the new arrival. AYith 
 the suffering and anxiety passed and the baby an ever-increasing joy 
 in the household, the sunny atmosphere of the home during the normal 
 puerperium makes the visits of the obstetrician a pleasure. 
 
 From what has been written above it is evident that the obstetrician 
 should respond at once to the needs of his patient. On the other hand, if 
 he has seen his patient frequently during pregnancy and has assured 
 himself of the size of the pelvis and the presentation and position of the 
 child, and furthermore, if at the home of his patient there is a nurse with 
 whose training and skill he is familiar, it is not necessary for the obstet- 
 rician to be called, or to visit his patient during the early part of the 
 first stage of labor. 
 
 The Nurse. — So much depends upon the cleanliness, the skill and the 
 personality of the nurse that a few words concerning her will not be out 
 of place. While formerly the old monthly nurse was the rule and the 
 hospital-trained nurse the exception, with the increase in the number 
 of training schools and opportunities for nurses to become trained in 
 obstetrics, this rule, especially in the higher walks of life, is rapidly coming 
 to be reversed, and the selection of a trained nurse for his patient becomes 
 one of the first duties of the obstetrician. Of the three important features 
 of a nurse, i. e., cleanliness, skill and personality, in the mind of the 
 obstetrician the first two receive chief attention, while it is the last, 
 or the personality of the nurse, which most appeals to the patient and 
 upon which much depends. Admitting that the patient is irritable and 
 unreasonable, admitting that nurse No. 1 is just as skilful as No. 2, 
 it must be remembered that the nurse and patient are to be together 
 most of the time for four or five weeks, and unless the i)ersonality of 
 the nurse is agreeable to the patient some other nurse had better be 
 selected. 
 
 A skilful nurse who is liked by the patient, and who by her tact, 
 encouragement and sympathy can enable her to look forward to her 
 labor without apprehension and endure it cheerfully and bravely when 
 it arrives, is certainly a blessing to the lying-in chamber. 
 
 The selection of the nurse, however, should be left to the obstetrician, 
 and she should be one, if possible, with whose training he is familiar, 
 who has worked with him and who knows his methods. The comfort 
 to the obstetrician of having a nurse upon whom he can thoroughly 
 rely, both for calling him at the proper time in the progress of the labor 
 and at the first indication of impending danger, who is calm in emer- 
 
MANAGEMENT OF THE FIRST STAGE 309 
 
 gencies and quick in i)reparation to meet them, can only be fully appre- 
 ciated by those who have enjoyed this pri\'ilege and then been deprived 
 of it. As a rule the nurse should be at the home of the patient at least a 
 week prior to the calculated date of labor. 
 
 Preparation of the Rooms. — The lying-in chamber should be large and 
 pleasant with plenty of sunlight and easy to ventilate. It is a distinct 
 advantage if it contains an open fireplace. All unnecessary articles of 
 furniture and draperies should be removed and a bare floor with a few 
 rugs is preferable to a carpet. The baby should not be kept in the room 
 with the mother, but should have as a nursery a room adjoining. The 
 reason for this is obvious. If kept in the same room the mother is apt 
 to be awakened by its every cry, while if in an adjoining room it can be 
 attended to by the nurse without disturbing the mother and can be more 
 easily trained to its regular hours and habits, as the trained nurse will 
 readily recognize for which of its cries the baby should be taken up 
 and which should be disregarded. 
 
 This is easily done in an adjoining room, while it might be difficult 
 if the baby was in the same room with the mother. With good modern 
 plumbing and ventilated traps it is a great convenience and perfectly 
 safe to have a bath-room opening out of either the mother's room or 
 the nursery. 
 
 Of course the above conveniences are only possible in the homes of the 
 well-to-do, but the writer believes that it is always well to study ideals 
 and then approximate them as closely as possible. 
 
 The Conduct of the Obstetrician. — Many text-books give minute 
 directions as to the conduct of the obstetrician when called to a case of 
 labor, even suggesting subjects of conversation. It seems to me that this 
 can be summarized in a very few words: Act the part of a gentleman. 
 Your patient has sent for you for a definite purpose, i. e., to aid her in 
 her distress and she does not care to discuss politics or the weather. She 
 is anxious to know if her labor is progressing normally, if she and her 
 child are all right, and she will probably ask you how long her labor will 
 continue. 
 
 To this last question an evasive answer had better be given, but after 
 you have assiu-ed yourself that mother and child are all right and the 
 labor progressing normally, a few words of encouragement and reassur- 
 ance as to her condition will be of great comfort and assistance. 
 
 The Preparation of the Bed. — As soon as the patient has well started 
 in labor the bed should be prepared for the delivery, and fortunate it is 
 for the obstetrician and the nurse that the old-fashioned, low, double 
 bed is rapidly giving place to the higher, individual bed, which with doctor 
 on one side and nurse on the other allows the patient to be cared for 
 with much greater convenience and less fatigue to the back. According 
 to the author's experience, the following arrangement of the bed proves 
 most satisfactory: 
 
 Final Bed. — There is first made up the bed as it is desired for the patient 
 to lie on after the completion of the delivery, called the final bed, /. e., 
 over the mattress, often covered with a washable mattress cover, is spread 
 
310 
 
 THE MANAGEMENT OF NORMAL LABOR 
 
 a freshly laundered sheet, tightly stretched and fokled nnder at the 
 corners (see Fig. 221). 
 
 Across this is i)laced a piece of rubber sheeting, 1x1^ yards, which is 
 to come under the hips of tiie patient. This must be spread smoothly 
 and its ends folded under the mattress so as to avoid all wrinkles for 
 the patient to lie on. Over this is placed a freshly laundered draw- 
 sheet made by folding a sheet lengthwise twice. This covers the piece 
 of rubber sheeting and, like it, is to have its ends folded smoothly under 
 the mattress. This completes the final bed. 0\'er this is now made 
 up the temporary or Jahur bed. 
 
 The Temporary or Labor Bed. — A piece of rubber sheeting 1| x2 yards, 
 large enough to co\er most of the final bed, is spread over the bed 
 already made, smoothly stretched, tucked tighth^ under the mattress or 
 pinned at the corners with safety pins. Over this is placed a freshly- 
 laundered sheet also smoothly stretched. Across the middle of the 
 bed, where the buttocks of the patient are to lie is placed a sterilized 
 
 Fig. 221. — Bed arranged for delivery. 
 
 obstetric pad (30 inches square) made of some absorbent material 
 covered with absorbent gauze. This has the advantage of being com- 
 fortable for the patient, sterile and capable of receiving the discharges 
 of the parturient canal with very little soiling of even the surround- 
 ing temporary bed. The limbs of the patient are covered with sterile 
 stocking-drawers and a sterile towel placed across the abdomen, the 
 night-dress being drawai up to the breasts. 
 
 At the close of the labor, the bed pad, containing the discharges is 
 folded up and slipped from beneath the buttocks. The patient is then 
 turned on her side, the sheet and rubber of the temporary bed are loosened 
 from beneath the mattress and rolled up longitudinally, soiled side in, 
 as far as possible. This exposes about half of the final bed and on to 
 this the patient is now rolled, and the soiled temporary bed is slipped off, 
 leaving the patient lying on the clean final bed, having been subjected 
 to scarcely any exertion and without any lifting on the part of the obstet- 
 rician or nurse. On this final bed and under the hips of the patient 
 
MANAGEMENT OF THE FIRST STAGE 311 
 
 there should now be placed a fresh sterilized bed pad. Where it can easily 
 be so arranged, it is often desirable to deliver the patient upon another 
 bed, or if an obstetric operation is to be performed, upon a table and 
 then at the close of the labor to move her back to her own clean bed 
 which has been prepared for her. 
 
 Preparation of the Patient. — At the onset of labor the patient should 
 be given a thorough soapsuds enema and the lower bowel well emptied. 
 If the membranes haVe not ruptured, she should then receive a full warm 
 bath with free use of \a clean soap, especially about the mons veneris and 
 inner surfaces of the\thighs, followed by a thorough rinsing with fresh 
 water free from soap. For this bath the ordinary bath spoMje, should .f, , 
 not be used, but a freshly laundered wash cloth. Y^-M^mLs )»<lfc«^«**» ^sa^M^i 
 
 If the membranes have ruptured, in order to avoid the possibility of ' 
 infection from the entrance into the amniotic sac of the soiled bath water, 
 attention to the danger of which has been called by Stroganoff,^ Sticher and 
 others, the tub-bath is omitted, and in its place a thorough sponge bath 
 is given by the nurse. The nurse should then clip closely with the scissors 
 the hair of the \ailva, or shave it with a safety razor. In his service at 
 the Sloane Hospital the author uses a safety razor for this purpose, but 
 in his private practice usually employs the method of clipping with 
 scissors. After the nurse has clipped or shaved the vulva she washes 
 it thoroughly from above downward, i. e., from mons veneris to and 
 beyond the anus with sterile cotton swabs and sterile soap and water, 
 including in this cleansing the inner surfaces of the thighs as well. She 
 then washes these parts thoroughly with sterile water and then with lysol 
 solution (0.5 per cent.) and applies a sterile vulva pad; it being desired 
 to keep the vulva covered with a sterile dressing during the labor. 
 
 It will be noticed that no antepartum douche is advised. For many 
 years it has been my custom, both in hospital and in private practice, to 
 omit all antepartum douching for three reasons: 
 
 1. The probability of interference by douching with nature's safe- 
 guards against infection. 
 
 2. The possibility of introducing infection from without into a prac- 
 tically sterUe vaginal canal. 
 
 3. The results of experience showing the morbidity and mortality of 
 patients as low without douches as when douches are given and perhaps 
 lower. 
 
 Of 1990 cases observed by Bretschneider,^ 1018 received a vaginal 
 douche and 972 were not douched. The number of those showing fever 
 in the puerperium was higher by 3.73 per cent, in those douched than 
 in those not douched. 
 
 It is my custom never to allow a nurse to make a vaginal examination, 
 as I prefer to take all responsibility of infection through examination. 
 Nor does it seem to me necessary that a nurse should thus examine, 
 for with a careful study of the patient's pains and inspection of the effect 
 
 1 Centralblatt f. Gyn., February 9, and March 2, 1901. 
 
 2 Klinische Versuche iiber den Einfluss der Scheidenspiilungen wahrend der Geburt auf 
 den Wochenbettsverlauf, Arch. f. Gyn., 1901, Ixiii, 453-471. 
 
312 THE MANAGEMENT OF NORMAL LABOR 
 
 of these pains upon the i)elvic floor she is siiffieiently a])le to report to 
 the ohstetrieian the i)rogress of the labor. 
 
 Preparation of the Obstetrician. — At the present (hiy it is well known 
 that the secret of success in obstetrics is asepsis, or surgical cleanliness 
 on the part of the obstetrican on the one hand, and non-interference 
 \vith nature's methods of asepsis on the other. Personal asepsis on the 
 part of the obstetrician may be secured in several different w^ays, but the 
 three principles which govern the methods most generally employed are: 
 
 1. Thorough scrubbing of the hands and forearms with sterile soap 
 and water. 
 
 2. Disinfection of the hands and forearms. 
 
 3. Covering the clothing with a sterile gown, and the hands wn'th 
 sterile rubber gloves. 
 
 Hand Scrubbing. — This is in all probability the most important step 
 in all methods of securing personal asepsis and w-ith this is included 
 the care and cleanliness of the finger nails. The obstetrician should 
 always endeavor to keep his fingers in as normal a condition as possible 
 with nails short, well rounded and smooth and without "hang nails." 
 The method of cleansing employed by the author is as follows: 
 
 Using a sterile scrubbing brush, not too harsh, the hands and forearms 
 are scrubbed with tincture of green soap and running water for about 
 two minutes, especial attention being paid to the scrubbing of the finger 
 nails. 
 
 With a lemon stick or nail cleaner the finger nails are then carefully 
 cleansed, care being taken not to cause injury in so doing. The scrubbing 
 is then continued for about two minutes and the hands and forearms are 
 then rinsed in plain water. They are next washed with 50 per cent, 
 alcohol to remove all traces of soap and the loosened epidermis and they 
 are then immersed for about a minute in a dish of bichloride (1 to 1000) 
 deep enough to allow immersion to the elbow, and sterile rubber gloves 
 are applied. The gloves may be sterilized either by dry heat in a steam 
 sterilizer or by boiling in plain w^ater. In the former case the hands 
 must be dried with a sterile towel and dusted with sterile talcum powder 
 before the gloves are put on. In the latter case the gloves may be 
 emptied directly from the boiler into the dish of lysol solution or 
 bichloride solution and put on wet. 
 
 In private practice it is very desirable to have in one's obstetric bag 
 two pairs of rubber gloves of which at least one pair is dry sterilized, 
 ready for immediate use at any time. 
 
 After the sterile gloves have been put on it is the custom of the author, 
 both in his service at the Sloane Hospital aid in his private practice, 
 to immerse the gloved hands in lysol solution 0.5 per cent. This serves 
 not only as an additional disinfection, but the lysol solution makes a 
 most admirable lubricant and by the author no other is used either for 
 hands or instruments. 
 
 For covering the clothing of the obstetrician some sort of a sterile 
 gow^n or suit is necessary. The author's preference is to wear a thin, 
 long rubber apron and over this to put on a long sterile gown which is 
 
MANAGEMENT OF THE FIRST STAGE 313 
 
 carried in the obstetric bag, sterilized in a separated sack which is closed 
 with a stitch. 
 
 The Examination at the Bedside. — Before making a vaginal examina- 
 tion, and therefore before thorough sterilization of the hands, the obstet- 
 rician may make the external abdominal examination and obtain such 
 information as is possible from this. The patient should be lying on her 
 back with night-dress dra"«Ti up to the breasts and sheet drawn down to 
 the mons veneris. 
 
 Following the method of abdominal palpation described in Chapter V, 
 the presentation and position of the child are made out and also the 
 amount of engagement of the presenting part. The auscultation of the 
 fetal heart is next in order and this should be done carefully, as the com- 
 parison of subsequent auscultations during labor with this made at the 
 beguining gives valuable information as to the condition of the child 
 and whether or not it is being subjected to too long pressure. The 
 importance of careful observation of the fetal heart during labor has 
 only been duly recognized in recent years, and the author would lay 
 stress upon the value of this procedure in determining when acceleration 
 of the delivery by forceps or otherwise is indicated. 
 
 The fact of excessive or too-prolonged pressure is usuaU}^ indicated 
 by a fetal heart which is not only markedly slowed during the pains, but 
 remains between the pains far below its normal rate as determined by 
 the examination at the begimiing of labor. Any embarrassment felt by 
 the patient at the thought of examination is usually lessened during the 
 abdominal palpation, especially if she is assured during the steps of the 
 examination that the presentation and position are normal and the con- 
 dition of the child is good. 
 
 In this way the patient becomes accustomed to the obstetrician and 
 by the time he is ready for the vaginal examination it gives her little 
 mental shock and, as a rule, little objection is made. 
 
 The Vaginal Examination. — When discussing the preparation of the 
 obstetrician (page 312) it was stated that the secret of success in modern 
 obstetrics lay in (1) asepsis on the part of the obstetrician, and (2) Non- 
 interference wath nature's methods of asepsis. Of late the danger asso- 
 ciated with the vaginal examination has become well recognized and it 
 is seen to depend not only on the first of the conditions mentioned above, 
 but also on the second, i. e., non-interference with nature's methods of 
 asepsis. 
 
 Let us consider for a moment the normal conditions of the parturient 
 canal. The uterine cavity during pregnancy is sterile, this fact having 
 been established by Doderlein, Gonner and others, and accepted by prac- 
 tically all authorities. 
 
 The vagina normally contains large niunbers of bacteria, mostly bacil- 
 lary in character, although at times cocci are found, but according to 
 Kronig, Menge and AYilliams, with the exception of the gonoccoccus, 
 these bacteria are normally non-pathogenic. Hence the vagina of the 
 normal pregnant woman may be considered practically sterile at the 
 time of the onset of labor. The rulvsi on the other hand abounds in 
 
314 THE MANAGEMENT OF NORMAL LABOR 
 
 t)acteriii, both i)atliogenic and uon-patliogenic. During the progress of 
 the labor tlie course of all discharges, mucus, liquor amnii, and blood is 
 outward, tending to flush out and cleanse the ])arturient canal. At the 
 completion of the labor the expulsion of the child, as also that of the 
 placenta and blood, still further tends to wipe out the canal. The con- 
 traction of the uterus and the closure of the uterine vessels, both by this 
 muscular contraction and by the formation of thrombi in their open 
 mouths, tend to prevent the entrance of bacteria into the general cir- 
 culation. These are the factors in nature's prophylaxis against infection. 
 
 Having then a parturient canal practically sterile from fundus to vulva, 
 but non-sterile at the vulva, the dangers of a vaginal examination are 
 apparent. With the large raw surface of the uterine cavity and frequent 
 abrasions and lacerations of the lower canal the soil for inoculation with 
 pathogenic organisms is certainly present and it may readily be seen 
 how even a sterile finger or douche nozzle can carry infection from the 
 non-sterile vulva without to this sterile soil within. 
 
 Accepting these as the normal conditions of a woman in labor, although 
 there are certain rare cases of infection which with our present knowledge 
 we are able to explain in no other way than that they are cases of auto- 
 infection, ?'. e., caused by pathogenic bacteria within the woman; it 
 must be admitted that m ordinary cases of infection the obstetrician is 
 the causative factor, either with dirty fingers or dirty instruments infect- 
 ing the sterile canal, or with sterile fingers or sterile instruments carrying 
 infection from the non-sterile vulva without to the sterile canal wuthin. 
 Realizing from the above the dangers of a vaginal examination, the 
 importance of making them as infrequently as possible, consistent with 
 the knowledge needed is evident, and also the value of substituting the 
 abdominal examination for the vaginal whenever practicable. 
 
 The Frequency of Vaginal Examinations. — In the conduct of an ordinary 
 normal obstetric case at least two vaginal examinations are usually 
 desirable, one as soon after the arrival of the obstetrician as the patient 
 and he can conveniently be prepared for it, and the other immediately 
 after the rupture of the membranes. 
 
 At the first of these examinations the condition of the vagina and 
 pelvic floor is determined, whether or not they are softening and dilating 
 under the influence of the labor; the condition of the bladder and rectum, 
 whether or not either is distended ; the condition of the cervix, the amount 
 of its dilatation and dilatability, and the presentation and position of 
 the child. These last, however, should usually be determined by abdom- 
 inal palpation, and the vaginal examination by feeling the sutures and 
 fontanelles in a vertex presentation, and the sacrum and genitals in a 
 breech presentation, should serve only as a verification of the diagnosis 
 made by external examination. 
 
 This vaginal examination should also determine the amount of mold- 
 ing of the presenting part and whether it is advancing as it should with 
 each pain. 
 
 Lastly, the examiner should note carefully the interior of the pelvis 
 and determine whether the diagnosis of sufficient room made during the 
 
MANAGEMENT OF THE FIRST STAGE 315 
 
 pregnancy is correct. Before making any vaginal examination the \iilva 
 should always be carefully inspected for evidences of \-enereal disease, 
 so that both the physician and nurse may be safe-guarded against infec- 
 tion and if evidences of gonorrhea are present, that additional precautions 
 may be taken in the care of the baby's eyes. 
 
 The value of the second examination immediately following the rup- 
 ture of the membranes lies in the fact that occasionally with the gush of 
 liquor amnii, especially if the presenting part does not accurately fit 
 the pelvis, a loop of cord prolapses and the prompt detection of it not 
 only makes its replacement easier, but may save the life of the child. 
 Furthermore, an examination after the rupture of the membranes enables 
 the obstetrician to more readily verify his diagnosis of presentation and 
 position, if there was doubt before. 
 
 While two vaginal exammations are the average number needed in 
 the conduct of a normal case of labor, yet marked variations naturally 
 occur. In some cases, especially in multigravidae the membranes have 
 ruptured and the presenting part has descended well into the pelvis 
 by the time the obstetrician reaches the patient, so that only one vaginal 
 examination, perhaps not even that, is needed. On the other hand, in 
 many cases of prolonged labor, extending over many hours, several vagi- 
 nal examinations may be indicated at intervals of two to four hours, in 
 order to determine whether it is safe to leave the case to the unaided 
 efforts of nature or resort should be had to one of the obstetrical operations. 
 
 The chief points to remember are these: Vaginal examinations during 
 labor should be made as infrequently as possible consistent with the 
 knowledge needed, and each A'aginal examination should be made with 
 the greatest care to avoid the possibility of infection. 
 
 The Method of Making the Vaginal Examination. — ^After the obstetrician 
 has finished the abdominal palpation of the patient, the nurse should be 
 asked to prepare her for the vaginal examination, while he prepares his 
 hands as described on page 312. Having thoroughly scrubbed and disin- 
 fected his hands and forearms and put on sterile rubber gloves, he is now 
 ready for the examination. In the meantime the nurse has been prepar- 
 ing the patient, who lies on her back with knees flexed. After the nurse 
 has disinfected her oami hands she washes the vulva, previously clipped 
 or shaved, with sterile soap and water, using sterile cotton for this pur- 
 pose, and always washing from mons toward anus, not in the opposite 
 direction. She then bathes the ATdva with lysol solution 0.5 per cent., and 
 drapes the patient with a sterile or freshly laundered sheet, as is shown 
 in Fig. 222. This is sometimes spoken of as the U-sheet, although the U 
 is inverted. We now come to the most important precaution in making 
 the vaginal examination. Realizing that the vagina may be considered 
 practically sterile, and that the vulva in spite of thorough efforts at 
 cleansing and disinfection is probably often not sterile, the object desired 
 is to introduce the sterile gloved fingers mto the vagina without touching 
 the vulva with them. Otherwise, no matter how sterile the fingers are, 
 or how sterile the vagina is, pathogenic bacteria may be wiped off from 
 the vulva and carried hv the fingers, then infected, to the vagina and 
 
316 
 
 THE MANAGEMENT OF NORMAL LABOR 
 
 Fia. 223. — Method of making a vaginal examination. 
 
MANAGEMENT OF THE FIRST STAGE 
 
 317 
 
 nature's efforts to prevent infection be thwarted. The best method of 
 conducting this examination is as follows (see Fig. 223). The labia are 
 well separated with the fingers of one hand, so that the vaginal orifice 
 is exposed. The examining fingers of the other hand are then introduced 
 directly into the vagina without touchmg the labia. It is the custom 
 of the writer before introducing the fingers to immerse the examining 
 hand in lysol solution, 0.5 per cent., and to bathe the vulva with the same 
 solution; this serving as the best lubrication with which he is familiar. 
 
 Fig. 224. — Method of putting on first glove. 
 
 Much stress may well be used on the value of sterile rubber gloves in 
 the conduct of a case of labor, especially by those who are doing general 
 medical and surgical work. For those obliged, for example, to treat 
 sore throats, ulcers of the legs, contagious diseases, or pus cases of any 
 kind, and at the same time attend women in confinement, it is practically 
 the only way in which they may reasonably hope to avoid infection; but 
 in the use of rubber gloves several points should be borne in mmd. 
 Although the gloves fresh from the boiler or sterilizer are sterile, they 
 are easily infected either by the hands in putting on, or by touching 
 non-sterile objects after they are on. For these reasons the hands should 
 be thoroughly cleansed and disinfected as previously described, before 
 
318 
 
 THE MANAGEMENT OF NORMAL LABOR 
 
 starting to i)ut on the gloves, and in putting on the gloves care should be 
 taken not to touch the outside of the glove with the ungloved hand. 
 If the gloves are sterilizefl dry, this can usually be accomplished by 
 ha\ing the wrists of the glove turned back when sterilized, and putting 
 them on as shown in Figs. 224 and 225, not allowing the bare skin to 
 touch the outside of the glove. If the gloves are sterilized by boiling, 
 they may be emptied into the antiseptic solution and put on direct 
 
 Fig. 225. — Method of putting on second glove. 
 
 therefrom. This is facilitated by having the glove filled ^^•ith the solution 
 before inserting the hand. 
 
 After the gloves are on, one should be so trained as to have it ".second 
 nature" to avoid touching any non-sterile object, and if h\ accident any 
 such object is touched, the gIo^■ed hand .should be immediately washed 
 m some such disinfecthig solution as bichloride .solution, 1 to 1000. 
 
 The Stay of the Obstetrician at the Patient's House.— It is easily 
 understood that the busy physician cannot remain at the patient's house 
 
MANAGEMENT OF THE SECOND STAGE 319 
 
 from the beginning to the completion of every labor. On the other hand, 
 it is only fair to the patient that she should be visited and carefully 
 examined by her obstetrician as soon as her labor has well started and 
 that he should remain with her during her second or expulsive stage and 
 for at least an hour after the birth of the child. After a careful examina- 
 tion during the first stage, experience will usually indicate to the physician 
 how long he can safely be absent, engaged m other work, without being 
 needed by the patient, and if there is a well-trained nurse in attendance, 
 and especially if he can communicate with her frequently by telephone, 
 he is often enabled, during the first stage to devote several hours to other 
 work. He should alwaj's hold himself in readiness, however, to come at 
 once to the patient's house on the call of the nurse. During the first 
 stage it is a good rule not to encourage the patient to use her abdominal 
 muscles during uterine contractions as it usually does little good and by 
 forcing the undilated cervix doTMiward it tends to loosen the fascial sup- 
 port of the anterior vaginal wall and favors the development of a cysto- 
 cele. During this first stage, unless it begins at night, the patient should 
 be encouraged to be up and walking about, as engagement of the present- 
 ing part and dilatation of the cervix are favored by the upright position. 
 She should not be allowed, however, to become overfatigued by excessive 
 walking. If the first stage begins at night, the patient, after the examina- 
 tion of the obstetrician, should be advised to get some sleep if possible, 
 so as to save her strength for the demands of the morrow. If the first 
 stage is at all prolonged, it is desirable to give the patient at intervals 
 some easily digested nourishment like chicken-broth or beef-tea, or she 
 may have a cup of coffee and some toast, or a cup of tea if she chooses. 
 Care should be taken, however, to select only such food as will not inter- 
 fere with the administration of the anesthetic during the second stage. 
 During a prolonged first stage, if the patient becomes very tired and 
 nervous and progress seems to be interrupted, nothing appears to be so 
 effectual as to give the patient some rest by the administration of a nerve 
 sedative like chloral or an opiate. This will be mentioned later when 
 discussmg uterine inertia. 
 
 MANAGEMENT OF THE SECOND STAGE. 
 
 Durmg the second stage the patient should usually be in bed or on the 
 delivery table and as the time for delivery approaches, as shoA^ii by the 
 bulging of the pelvic floor and beginning gaping of the vulvar orifice, 
 she and the obstetrician should be prepared for the delivery. 
 
 Posture of the Patient. — The position of the patient during delivery 
 may largely be left to the choice of the obstetrician. In the tenements, 
 where the beds are apt to be dirty, it is sometimes desirable to have 
 the patient in the lateral position, so that the hips may lie at the edge 
 of the bed and the field of operation be surrounded by the sterile towels 
 and coverings brought by the obstetrician (see Fig. 226), thus avoiding 
 contact with the bedding found in the room. This, moreover, is the posi- 
 
 / 
 
320 
 
 THE MANAGEMENT OF NORMAL LABOR 
 
 tioii preferred in England and in many places on the Continent. During 
 the early years of the writer's practice this was the position usually 
 employed. Many years ago, however, the author abandoned it for the 
 dorsal position and for the following reasons: 
 
 It is difficult to keep the patient quiet in the position desired for the 
 lateral posture. One wishes the knees kept flexed, the upper knee (the 
 right) a little more flexed than the lower. During her pains, however, 
 the patient is very apt to extend her legs, perhaps throw herself about 
 and disarrange the sterile coverings with which the obstetric field is 
 surroimded. ^Moreover, for the auscultation of the fetal heart, a very 
 important feature in the proper conduct of a labor, it is usually necessary 
 to turn the patient on to her back, thus changing her position and cover- 
 ings. Furthermore, it is much more difficiilt to follow the progress of the 
 labor by abdominal palpation in the lateral position than in the dorsal. 
 
 Fig. 226. — Patient in lateral position on Kelly pad with limbs covered with sterile 
 stocking-drawers and field of operation surrounded by four sterile towels. Pud and drapery 
 brought by obstetrician. 
 
 For these reasons, both in his service at the Sloane Hospital and in 
 his private practice, the dorsal position is preferred by the author for 
 normal deliveries, and in all obstetrical operations the dorsal position is 
 almost universally employed. 
 
 Draping of the Patient. — As the second stage approaches its close the 
 patient should l)e draped for her delivery. ' The nurse should roll up the 
 patient's night-dress and undervest well under the breasts to prevent 
 soiling. A pair of sterile stocking-drawers should be put on, and the 
 gap between the night-dress and the stocking-drawers should be covered 
 with a sterile towel. Under the patient's hips should be placed a sterile 
 bed pad, already described (see Fig. 227). 
 
 Preparation of the Obstetrician. — As the time for the deli\ery ap- 
 proaches the obstetrician should put on a sterile gown and after a fresh 
 scrubbing and disinfection of his hands and forearms should see that his 
 rubber gloves are sterile, as already indicated. 
 
MANAGEMENT OF THE SECOND STAGE 
 
 321 
 
 Instructions to the Patient. — The second stage of labor is usually 
 greatly facilitated by a few words of instruction given to the patient. 
 She should be told to avoid crying out as far as possible and encouraged 
 to draw in a long breath as a pain approaches, then to hold it and bear 
 down at the acme of each contraction. Lying on her back with knees 
 flexed, she can grasp each side of the mattress or the head of the bed, 
 and can aid her uterine and abdominal muscles by pulling on the mattress 
 or pushing on the head of the bed, or in place of this she can pull on the 
 hands of the nurse whose position is on the opposite side of the bed from 
 the obstetrician, or on a folded sheet attached to the foot of the bed. 
 The patient should be told not to touch the sterile hands of the obstet- 
 rician, nor the sterile towel on her abdomen. To avoid this, in hospital 
 practice, it is often desirable to place about the wrists of the patient 
 a pair of padded wrist bands, which are attached to the table with mobility 
 enough to allow the patient to grasp the sides of the table, if she wishes, 
 
 Fig. 227. — Patient draped for delivery in private practice. 
 
 but without sufficient mobility to allow her to touch the hands of the 
 obstetrician or the abdominal towel. During the second stage of labor, 
 especially as the presenting part approaches the vulva, the suffering of 
 the patient should be relieved and voluntary muscular contraction be 
 controlled by the use of an anesthetic. 
 
 Anesthesia during the Second Stage of Labor. — For the introduction 
 of the use of anesthesia to relieve the suffering of women in labor we are 
 indebted to Sir James Y. Simpson, the discoverer of chloroform. x4.1though 
 ether was previously employed by him for this purpose, he substituted 
 chloroform for it soon after his discovery of this anesthetic^ 
 
 Opinions differ among different obstetricians and in different localities 
 as to the choice of anesthetic for this purpose, some even going to the 
 extreme of doubting the wisdom of allowing any anesthetic during labor 
 unless an obstetrical operation is to be performed. The author firmly 
 believes that the suffering of a woman during the second stage of labor 
 21 
 
322 THE MANAGEMENT OF NORMAL LABOR 
 
 should be relieved by anesthesia and, furthermore, the use of anesthesia 
 enables the obstetrician to largely control the advance of the presenting 
 part at the vulvar outlet and is therefore of great assistance in preserv- 
 ing the integrity of the pelvic floor. The choice of the anesthetic, how- 
 ever, is an important one and should be based chiefly upon the physical 
 condition of the woman. As is shown in the chapter on Toxemia of 
 Pregnancy (see page 435) it is now Avell established that chloroform may 
 produce lesions in the liver resembling those found in the toxemia of 
 pregnancy, with or without eclampsia. It is therefore unjustifiable in 
 cases suffering with the toxemia of pregnancy to use as an anesthetic 
 that which would tend to increase the pathological lesions. For this 
 reason in recent years the author has made it a rule in all cases of toxemia 
 to employ ether rather than chloroform in the second stage of labor and 
 in all operations needing an anesthetic. The question is naturally asked: 
 Why not use ether in all cases of labor, rather than chloroform? The 
 autihor in his service at the Sloane Hospital tried for a time to abandon 
 the use of chloroform during labor and to employ ether as a substitute 
 in all cases. The result was so unsatisfactory to both physicians and 
 nurses that he was obliged to return to the use of chloroform in all cases 
 where evidences of a toxemia were absent. 
 
 The features desired in anesthesia during the second stage of labor are: 
 
 1. Safety. 
 
 2. Rapidity in action. 
 
 3. Rapidity in passing off. 
 
 4. No excitement of patient. 
 
 5. No nausea. 
 
 With the exception of the first there can be no question but that all 
 these features are possessed by chloroform in a much higher degree than 
 by ether. The ease with which the intensity of the suffering is lessened 
 by a whiff or two of chloroform; the rapidity with which the patient 
 passes imder its influence and rapidly emerges from it in time to use her 
 voluntary muscles at the request of the obstetrician; the absence of 
 excitement and struggling under chloroform as compared with its fre- 
 quency under ether; the absence of nausea with chloroform while ether 
 frequently protluces it; these features all argue in favor of chloroform 
 if we can be assured of its safety. 
 
 Regarding the safety of chloroform, it must be admitted that in con- 
 ditions of toxemia it is not as safe as ether. In normal conditions of preg- 
 nane}^, howe\'er, with liver and kidney's healthy, the experience of the 
 author and his associates at the Sloane Hospital in 30,000 deliveries and 
 during many years of private practice seems to indicate that the use of 
 chloroform during the second stage of labor, when carefully administered, 
 a few whiffs at a time during the pains, is relatively free from danger. 
 
 It is freely admitted that harm may be done by too much anesthesia 
 during labor. If too much anesthetic is given the uterine contractions 
 may be lessened in duration and frequency, and if it is continued too 
 long, it favors uterine inertia with its attending dangers — postpartimi 
 hemorrhage and puerperal infection. Furthermore, by this prolonged 
 
MANAGEMENT OF THE SECOND STAGE 323 
 
 anesthesia the Hfe of the child may be endangered or even lost. The 
 effect upon the child of an anesthetic administered to the mother is 
 easily seen in the condition of the child delivered by Cesarean section. 
 It is often quite deeply anesthetized or asphyxiated and may require 
 quite active efforts at resuscitation before it cries and breathes well. 
 
 In the author's method of anesthesia in labor, in cases free from toxemia, 
 a chloroform dropping bottle and Esmarch inhaler is placed in the hands 
 of the nurse who is to use them only under his direction. The use of the 
 chloroform is postponed, if possible, imtil the latter half of the second 
 stage, although occasionally the nervous condition of the patient is such 
 that even at the begimimg of the second stage, without anesthesia, instead 
 of aiding her uterine contractions by voluntary action of her abdominal 
 muscles, she seems to inhibit them and it is fomid that by giving a whiff 
 of chloroform with each pain her nervous system is quieted; she is willing 
 and able to use her abdominal muscles, and her progress in labor is 
 immensely aided. The writer's custom is to have the nurse drop several 
 drops of chloroform on the inhaler and have the patient inhale it after 
 each downward pressure with the abdominal muscles; having her under- 
 stand that if she cries out and does not press do\ATiward she caimot have 
 the relief of the chloroform. In this way she soon learns to make the 
 most of her energies during her pains and rests between them, the inhaler 
 being removed as soon as the uterine contraction has ceased. 
 
 If the chloroform seems to lessen the uterine contractions in frequency 
 or force the nurse is told to withold its use during the next pain. The 
 patient will often ask if her pains are to get worse and worse, and it is 
 always a comfort to her to be assured that as the end approaches she 
 will receive more and more anesthetic and that she will not know when 
 the child is born. 
 
 As suggested here, when the head begins to distend the vulvar orifice 
 more and more anesthetic is given with each pain imtil just as the head 
 passes the ^-ulva the patient is anesthetized to the surgical degree. 
 
 With the birth of the child the use of the anesthetic is discontinued, 
 unless marked lacerations need repair, or for some reason the whole hand 
 has to be introduced into the uterus^ as for the removal of an adherent 
 placenta or blood-clots. It should be borne in mind m this connection 
 that the use of chloroform is not attended with the same freedom from 
 danger after the birth of the child as during the labor. 
 
 Spinal Anesthesia. — For a time it was hoped that the subarachnoidal 
 injection of cocaine or some of its derivatives would prove a safe and 
 reliable method of relieving the suffering of labor. Later experience with 
 it, however, has sho-^-n the method uncertain, some patients not being 
 relieved by it, and in some relief being only of very brief duration. ^lore- 
 over, the after-effects of the method in the shape of headache and nausea 
 are usually very distressing, and what is of more importance, in a series 
 of 1708 cases in which it was used, as reported by Halm.^ there were 
 eight deaths in some of which autopsy showed a meningitis due to infec- 
 
 1 Ueber subarachnoideal cocaininjectioiien nach Bier. Centralbl. f. d. Grenzgebiete der 
 Med. u. Chirurgie, 1901, iv, 304-317 und 340-354. 
 
324 THE MANAGEMENT OF NORMAL LABOR 
 
 tion. For these reasons the method has fallen into disuse and is not to 
 be recommended. 
 
 Scopolamin-morphin ; Scopolamin-narcophin Anesthesia. — The so-called 
 "twilight sleep," or Dammerschlaf. 
 
 During the past year, through the lay press of America, the use of 
 a combination of scopolamin and morphin, or narcophin, to produce 
 a lessening and forgetfulness of the sufferings of childbirth, has been 
 brought into great prominence. 
 
 That a combination of these drugs could be used for this purpose was 
 first brought out by Steinbuchel in 1902. To Kronig and Gauss, of 
 Freiburg, belong the honor, however, of developing the method as it 
 is kno'ttTi today, and they have used it since 1906 at the Freiburg Clinic. 
 Gauss's first paper on the subject appeared in 1906 and contained a report 
 of 500 cases treated with these drugs without injury to mother or child. 
 
 According to Kronig and Gauss the objects sought at the Freiburg 
 Clinic are: 
 
 1. That the woman shall feel the pains of labor to a far lesser degree 
 than normal. 
 
 2. That she shall lose the memory of the pains and the incidents of 
 childbirth. 
 
 The anesthesia is best produced in a darkened, quiet room. As the 
 patients are susceptible to sudden light or noise, at Freiburg they are 
 given dark glasses and their ears are filled with cotton. The drugs used 
 are scopolamin stable and either morphin hydrochloride or narcophin, 
 an opiate closely related to morphin but containing more narcotin. 
 
 The author in his experience with the method has used only the com- 
 bination of scopolamin and narcophin. According to Gauss the first 
 injection should consist of both the scopolamin and the opiate but the 
 subsequent injections should be only of scopolamin. 
 
 The scopolamin is put up commercially in ampoules containing 1 c.c. 
 = 0.0003 gm. or gr. lyii-o- The narcophin should be made up in small 
 quantities of a 3 per cent, solution so that 1 c.c. = 0.03 gm. = gr. ss. If 
 morphin hj^drochloride is used, a solution is made so that 1 c.c. = 0.01 
 gm. or gr. i. 
 
 Technic. — ^The first injection is given when the labor pains become 
 regular and active, i. e., when the interval between uterine contractions 
 is about five minutes. 
 
 The two drugs are injected intramuscularly, usually in the gluteal 
 region and separately, although usually through one insertion of the 
 needle. The fetal heart should be carefully listened to before beginning 
 the anesthesia and every fifteen minutes during the labor. The initial 
 dose of narcophin 0.03 gm. or gr. ss is injected and then through the same 
 needle, without removing it, 1.5 c.c. scopolamin stable = 0.00045 gm. 
 or gr. y-j-g is injected. The second dose consists of scopolamin 0.5 c.c. 
 = 0.00015 gm. or gr. -:^^-^^. The narcophin is not repeated. This 
 second dose is generally given about an hour after the first. About half 
 an hour after the first injection the patient begins to feel drowsy; she 
 easily falls asleep between the pains; the face flushes and the pupils 
 
MANAGEMENT OF THE SECOND STAGE 325 
 
 become dilated. The patient often complains at this early stage of dry- 
 ness of the mouth and may be given water freely. 
 
 Half an hour after the second injection the "memory test" should be 
 applied, and according to Gauss, this test is the criterion of the dosage. 
 The patient is asked how many injections she has had, or if she remembers 
 an object which had been shown her, or some previous event in the labor, 
 etc. If she does not remember the object or the event, the third injection 
 may be deferred for an hour or an hour and a half from the second. 
 A primigravida requires on an average five or six injections and the 
 intervals between them is determined by the memory test. 
 
 Maternal Results. — In about SO per cent, of cases the women do not 
 remember what happened while they were under the influence of the 
 drug. 
 
 In about 90 per cent, their suffering is very greatly relieved. The first 
 stage of labor is made more comfortable and in the author's experience 
 has seemed shorter than normal. 
 
 The second stage is, as admitted by all obstetricians who have used 
 the method, considerably prolonged. Some women are greatly excited 
 by the drugs, makmg it difficult to keep the patient in bed and the sterile 
 drapery in place. The need for forceps delivery, in the interest of the 
 child as well as the mother, is increased by the use of the drugs. 
 
 The w^omen on the day following the delivery seem less exhausted than 
 those with whom this method has not been employed. 
 
 Fetal Results. — That the fetus is affected by the drugs is shown by the 
 fact that when the child is born the pupils are often dilated and the skin 
 is often dry. While many of the children will breathe and cry sponta- 
 neously, a certain number will be born asphyxiated and require active 
 efforts at resuscitation and a certain number will be born in a condition 
 gives a cry, then the respiration slows down and becomes shallow. The 
 which at Freiburg is called oligopnea. The child takes a breath or perhaps 
 heart becomes slow, perhaps 30 or 40 to the minute, and the child 
 becomes cyanotic. After a minute or two the child begins to breathe 
 more regularly and rapidly and the action of the heart improves. In 
 a few moments, in the majority of cases, even if nothing is done to the 
 child, the pulse and respiration become normal. The return to normal 
 is hastened by active measures of resuscitation. Unfortunately in a few 
 instances either as a result of the action of the drugs upon the individual 
 baby, or on account of the prolonged pressure of the second stage, the 
 child at birth is without pulse or respiration and all efforts at resuscita- 
 tion fail. 
 
 Conclusions. — ^After a year's experience with scopolamin-narcophin 
 anesthesia in obstetrics the author has reached the following conclu- 
 sions : 
 
 It is contra-indicated in cases of primary uterine inertia, as it tends to 
 check the labor. 
 
 It is of little value in very short labors, as there is insufficient time for 
 the drugs to act. 
 
 It is inapplicable as a routine procedure in a large teaching institution 
 
326 THE MANAGEMENT OF NORMAL LABOR 
 
 with an active maternity service, as the staff requirements are too 
 great. It is also not suitable as a method for the general practitioner 
 in a private house. In certain selected cases in a hospital there are 
 advantages to the mother in having the suffering and mcidents of the 
 labor obliterated from her memory. 
 
 The danger to the mother from the use of the drugs employed in the 
 so-called "twilight sleep" is not great. 
 
 There is always a certain amount of danger to the child and for this 
 reason the fetal heart should be listened to every fifteen minutes from the 
 first injection till the child is born. This means that the obstetrician 
 or his trained assistant must be in constant attendance during all this 
 time. 
 
 The use of pituitary extract to stimulate, in the second stage, uterine 
 contractions which have been markedly lessened by scopolamin and an 
 opiate has associated with it considerable danger to the child. 
 
 That the advantages of the method in the majority of cases are suffi- 
 cient to counter-balance the disadvantages the author has been unable 
 to convince himself. 
 
 Nitrous Oxide-oxygen Anesthesia. — Following the recent satisfactory use 
 of this anesthesia in surgery its emplo\Taent in obstetrics has of late 
 been considerable. It is early yet to formulate conclusions, but the 
 experience of different obstetricians, including the author, has been such 
 as to warrant a further trial of it. 
 
 Preservation of the Pelvic Floor. — Probably the most frequent injury 
 resulting from childbirth is laceration of some part of the pelvic floor, 
 especially the perinemn, and the importance of this laceration is seen 
 from the fact that nearly every gynecologist has found the operation of 
 perineorrhaphy among those he is most frequently called upon to do. 
 Fortunately for the patient the obstetrician has learned the importance 
 of detection and repair of this mjury immediately following the labor, with 
 the result that fewer women find the need for consulting the gynecologist 
 for obstetrical injuries. For many years it has been said that a very large 
 part of g^iiecology has been due to bad obstetrics. It may be justly 
 stated to the credit of the obstetrician that this donation to gynecology 
 is steadily growing less. ■Minor grades of laceration of the permeum 
 and vaginal wall, especially about the fourchette, are of very common 
 occurrence, even in the hands of good practitioners, and the obstetrician 
 who states that he has delivered a large series of cases without a tear 
 either stamps himself as a poor observer or as one whose veracity needs 
 attention. 
 
 Tears are found much more frequently m primiparse than in multi- 
 parse. Schroeder observed them in 34.5 per cent, of his primiparse and 
 9 per cent, of his mm^iparse; Olshausen in 21.1 per cent, of his primi- 
 parae and 4.7 per cent, of his multiparae. But these figures must have 
 referred to fairly deep tears, as small tears of the fourchette and vagmal 
 wall near it occur m a much larger percentage of cases. 
 
 There is a timidity on the part of some practitioners in acknowledging 
 that a laceration of the perineum has occurred for fear they be criticized 
 
MANAGEMENT OF THE SECOND STAGE 327 
 
 by the patient or her family, and on account of this timidity there has 
 been a tendency to avoid careful inspection of the pelvic floor for lacera- 
 tions, the obstetrician not wishing to find them. Fortunately for the 
 patient, the laity are becoming acquainted with the fact that lacerations 
 of the pelvic floor will occasionally occur in the hands of the best opera- 
 tors and are becoming more inclined to blame not the physician in whose 
 hands the laceration occurred, was detected and repaired, but the one 
 in whose hands it occurred and was neglected. The only course which 
 is safe, both for the satisfaction and the reputation of the obstetrician, 
 is to inspect carefully the pelvic floor after labor and make such repairs 
 as are needed. 
 
 While these small tears are often beyond the control of the obstet- 
 rician the deep tears in a normal labor can be largely prevented and the 
 occurrence of a laceration of the perineum through the sphincter ani in 
 a normal labor usually means either carelessness or lack of skill. 
 
 Etiology of Laceration of the Perineum. — The following may be 
 considered the causes of laceration of the perineum. 
 
 1. Too rapid expulsion of the presenting part. 
 
 2. Faulty mechanism of labor. 
 
 3. Disproportion between presenting part and vulvar outlet. 
 
 4. Abnormal pelvic outlet. 
 
 5. Lack of elasticity in the pelvic floor. 
 
 Too Rapid Expulsion. — This is probably the most frequent cause of 
 laceration, the head under the influence of a powerful uterine contrac- 
 tion, supplemented by vigorous action of the abdominal muscles, being 
 suddenly expelled from the vulva before it has had time to stretch. 
 
 Faulty Mechanism. — In the normal mechanism of labor flexion is 
 maintained imtil the occipital protuberance has descended well under 
 the symphysis so that the posterior extremity of the suboccipital diam- 
 eters lies under the pubic arch as extension occurs, i. e., in such a 
 manner that the suboccipitobregmatic and suboccipitofrontal diameters 
 are thrown across the vulvar orifice. 
 
 If extension occurs too early, so that the occipitobregmatic and occipito- 
 frontal are substituted for the suboccipital diameters, the perineum is 
 exposed to greater tension than normal and laceration is favored. It is 
 readily seen that in brow and face cases and in cases of persistent posterior 
 position of the occiput laceration may often be met with. 
 
 Disproportion. — Sometimes it is necessary to deliver a very large 
 head through a very small vulvar orifice in a primigravida, or through a 
 pelvis so small that a difficult forceps delivery is necessary, or perhaps 
 the hand has to be introduced through an undilated vulva and a version 
 performed. In such cases a perineal laceration is not unusual and is 
 excusable. 
 
 Abnormal Outlet. — In some cases a long, narrow pubic arch or an 
 abnormal inclination of the pelvis may expose the perineum to abnormal 
 tension and laceration occur. 
 
 Lack of Elasticity.— This is most often seen in elderly primigravidse, 
 but occasionally in younger women the perineum is very rigid and 
 
328 THE MAXAOEMENT OF NORMAL LABOR 
 
 unyielding and after stretching to a certain size it will suddenly tear like 
 paper through a couiiiderable portion of its depth. While usually these 
 tears begin in the vaginal wall near the fourchette or in the fourchette 
 itself and extend downward and backward, they sometimes begin in the 
 skin surface of the perineum and extend both upward and downward. 
 
 Prophylaxis. — In considering the causes of laceration of the perineum 
 it was seen that of the five causes given there are, at the time of the labor 
 only two which are under the control of the obstetrician, viz.: 
 {a) The rapidity of expulsion. 
 (6) The mechanism of flexion and extension. 
 
 Prophylaxis then must be directed along these lines. 
 
 For many years the attempt to preserve the pelvic floor was spoken 
 of as support of the perineum. In the light of present knowledge we do 
 
 Fig. 228. — Caput in sight. 
 
 not support the perineum but direct our attention to controlling the 
 rapidity of advance of the head; keeping the head flexed until the occipi- 
 tal protuberance is well under the pubic arch, then keeping the nape of 
 the neck well up against the pubic arch while extension gradually takes 
 place. This control of the rapidity of advance is maintained by the 
 use of anesthesia on the one hand and by external pressure on the other. 
 As the caput appears in sight (see Fig. 228j the patient is given more 
 anesthetic during her pains and as soon as her voluntary pressure is no 
 longer needed she is told to breathe rapidly with mouth open during her 
 pains and not to press down; at the same time the anesthesia is deepened 
 as desired. The obstetrician, standing at the patient's right, with his 
 right arm under her flexed thigh and gloved hand covered with a sterile 
 towel to protect it from the rectum, surrounds the vulvar orifice with his 
 thumb and index-finger (see Fig. 229), while his ring and other fingers. 
 
MANAGEMENT OF THE SECOND STAGE 
 
 329 
 
 placed behind the anus, enable him to control very largely the rapidity 
 of the head's advance. This control is rendered more complete by 
 pressure with the index and middle fingers of the other hand directly 
 on the fetal head showing at vulvar orifice. As soon as possible it is 
 desired to control the extension of the fetal head. Up to this point the 
 head has been advancing with each pain and receding in the intervals. 
 As soon as the occipital protuberance has descended well beneath the 
 pubic arch the head can be held in the position desired first by pressure 
 
 Fig. 229. — Head under control. Patient deeply anesthetized for a few moments. The 
 towel in the photograph has been allowed to slip back to show the position of the anus. 
 In practice the lower gloved hand should be covered with a sterile towel. 
 
 with the right middle finger through the pelvic floor just beneath the 
 forehead, then a little later just beneath the chin of the child. The 
 patient may now be completely anesthetized as the farther advance and 
 extension of the head are entirely within the control of the obstetrician. 
 When the vulvar orifice has been sufficiently dilated he can easily shell 
 out the head in an interval between pains. In these efforts to preserve 
 the perineum and deliver the head many operators formerly recom- 
 mended the introduction of the finger into the rectum. This should be 
 discountenanced as accompanied by danger of infection both to mother 
 
330 THE MANAGEMENT OF NORMAL LABOR 
 
 and child tJirougli the obstetrician's finger. While it is desirable to have 
 the vulvar orifice sufficiently dilated to allow of the birth without lacera- 
 tion, careful observation of women subsequent to their confinement have 
 convinced the author that it is possible to restrain the advance of the 
 head too. long and allow of too much stretching of the vulvar outlet; 
 the tissue in some women being so stretched and relaxed that it does 
 not regain its tone. In many cases it has seemed that it would have been 
 wiser to allow the perineum to tear and then repair it, rather than to 
 allow it to become thus overstretched. Attention may also be called 
 to the fact that if the umbilical cord is coiled about the neck or otherwise 
 compressed, too long detention of the head at the vulvar outlet may 
 result in the loss of the child. The danger can only be foreseen and 
 averted by careful observation of the fetal heart sounds and the early 
 detection of their irregularity. 
 
 Episiotomy, — Some obstetricians believe it is possible to tell when the 
 perineum is to tear badly and prefer to cut the vulvar outlet with knife 
 or scissors in an oblique direction downward and backward on either 
 side, between the anus and the tuber ischii, feeling that if the tension is 
 removed there will be no tear, or if it does occur, the tear will be only a 
 continuation of the incision, and will heal more readily than the irregular 
 tears without incision. The author's experience leads him to advise 
 against this, as in the first place it seems impossible to foretell that an 
 extensive tear is to occur, and secondly, properly repaired tears usually 
 heal w^ithout difficulty. 
 
 Cord about the Child's Neck. — As soon as the head is born the adminis- 
 tration of the anesthetic should cease. The finger of the obstetrician 
 should be passed to the neck of the child to ascertain if the umbilical 
 cord is coiled about it, and should such be found to be the case, the cord 
 should be loosened and slipped over the head of the child, or should this 
 not be possible, it may be loosened so that the child can be born through 
 the loop, or if the cord is too tightly coiled to allow of loosening, it 
 should be tied or clamped twice and cut between the ligatures or clamps. 
 The next step is the birth of the shoulders. 
 
 Delivery of the Shoulders. — After the birth of the head there is 
 usually a few moments' delay before the expulsion of the shoulders 
 and trunk, but if the finger has determined that the cord is not coiled 
 about the neck and the fetal circulation appears normal this slight 
 delay is of little consequence and the next pain usually expels the 
 trunk. The lack of danger in slight delay under these conditions may 
 well be mentioned, lest the cyanotic condition of the child's face lead 
 to too rapid and forcible interference. If the head of the child 
 is supported by the hand of the obstetrician there is a tendency for 
 the posterior shoulder to be born first, as claimed by Lefour, Auvard, 
 Leonet, Edgar and others, while if the head is not supported the anterior 
 shoulder tends to be born first. It is the author's custom, both in his 
 service at the Sloane Hospital and in his private practice, to favor the 
 birth of the anterior shoulder first (see Fig. 230) by retarding the advance 
 of the posterior shoulder and by lowering the hand which supports the 
 
MANAGEMENT OF THE SECOND STAGE 
 
 331 
 
 head and for the following reasons: It is well known that a laceration 
 of the perineum which was only very slight during the birth of the head 
 not infrequently becomes plowed out into an extensive laceration by 
 the posterior shoulder. It therefore seems reasonable that as long as 
 slight tears in the perinemn often occur during the birth of the head 
 extensive tears will be lessened in frequency by keeping the weight of the 
 posterior shoulder off the perineum as much as possible during its 
 birth. If the posterior shoulder is delivered first the weight of the 
 trunk has to be allowed to fall upon the perineum in order to allow the 
 anterior shoulder to be disengaged from behind the symphysis and 
 emere-e beneath it. 
 
 Fig. 230. — Birth of anterior shoulder. 
 
 If the anterior shoulder is delivered first the whole weight of the head 
 and trunk can be raised and kept off the perineum as the posterior shoul- 
 der sweeps over it (see Fig. 231). In this way there is avoided, as far as 
 possible, the tendency of the posterior shoulder to increase by tension 
 any lacerations which have occurred during the birth of the head. 
 
 As said above, the birth of the shoulders usually follows soon upon the 
 birth of the head and without difficulty, especially if uterine contraction 
 is supplemented by pressure upon the fundus by either nurse or assis- 
 tant. Occasionally, however, there is delay in the descent of the shoulders 
 and the condition of the child demands that the birth of the shoulders be 
 expedited. This can usually be accomplished by seizing the sides of the 
 child's head between the two hands, as the obstetrician stands at the 
 
332 
 
 THE MANAOEMEXT OF NORMAL LABOR 
 
 right of the patient, and drawing shghtly downward and outward on the 
 head. It is sometimes necessary, however, to insert the finger into the 
 anterior axilla and secure the delivery by traction. 
 
 It is necessary to call attention to the fact that forcible lateral traction 
 on the head away from the shoulder, as when the advance of the shoulder 
 is obstructed, is not devoid of danger, as it occasionally leads to such 
 stretchmg or laceration of the brachial plexus as to result m paralysis, 
 called the birth palsy of Duchenne or Erb's paralysis. 
 
 This paralysis may also be produced by traction upon the shoulders 
 with fingers over the clavicles in delivering the after-coming head. The 
 lesion usually involves the fifth and sixth cervical nerves and, although 
 
 Fig. 231. — Birth of posterior shoulder. 
 
 the nerves are only slightly injiu-ed, spontaneous recovery may occur 
 within a few weeks; if the fibers are badly torn the paralysis may be 
 permanent and only be prevented by nerve suture. 
 
 As the trunk rapidly follows the birth of the shoulders, the nurse with 
 her hand on the fundus of the uterus should gently follow it in its descent 
 toward the pelvis. Holding the top of the fundus in the palm of her 
 hand she shoidd gently manipulate it mitil she is certain of its feel and 
 then her function should be to guard the fundus, being prepared to 
 knead it firmly -if any marked hemorrhage occurs, but otherwise to use 
 only sufficient pressure and friction to ensure against ballooning of the 
 uterus with blood, but not enough to cause marked discomfort to the 
 
MANAGEMENT OF THE SECOND STAGE 333 
 
 patient. Leaving the contraction of the uterus to the guardianship of 
 the nurse, the obstetrician can turn his attention to the baby. 
 
 Care of the Child. — If the labor has been normal and not unduly pro- 
 longed the child will usually begin to cry almost immediately after its 
 birth, its palor or cyanosis then changing to a ruddy pink hue. This 
 inspiration and cry can often be stimulated by snapping a few drops of 
 cold boric acid solution upon it as the eyes are washed or even by 
 blowing upon it. If it does not begin to breathe within a short time the 
 cord should be ligated and efforts at resuscitation instituted promptly. 
 If the child behaves normally it is laid between the mother's thighs 
 near enough to the mother to avoid traction on the cord and the eyes 
 washed with boric acid solution from inner to outer canthus. The 
 object of this direction is to avoid infection of the lachrymal ducts. The 
 question then arises. Shall the cord be ligated at once? This varies with 
 the circiunstances. 
 
 (a) If the child does not breathe promptly, as indicated above, the 
 cord should be ligated and cut at once and efforts at resuscitation insti- 
 tuted. It is wise under these circmnstances to ligate the cord at quite 
 a little distance from the child so that after the tubbing of it or other 
 manipulations intended to stimulate respiration, the cord can be ligated 
 and cut again at the usual distance from the body and thus the stump 
 of the cord which is to receive the sterile dressing be saved as much 
 as possible from the danger of infection from the tub or manipulations 
 of artificial respiration. 
 
 (b) If the child is vigorous and breathes well immediately after birth 
 there is no great advantage in delaying the ligation of the cord, and this 
 is usually done as soon as the eyes have been washed with the boric acid 
 solution. 
 
 (c) If the child breathes well but is feeble and under weight there are 
 certain advantages in waiting until the pulsations in the cord have nearly 
 ceased before ligating it. It is estimated that the child gains from one 
 to three ounces of blood by this delay of a few moments in the ligation 
 of the cord. The increase of blood to the child is, of course, fetal blood 
 which has been forced into the placenta by the fetal heart. It is regained 
 during this delay in two ways: 
 
 1. By thoracic aspiration produced by the respiration and crying of 
 the child under the stimulation of the atmosphere which is lower in tem- 
 perature than the liquor amnii with which it was previously surrounded. 
 
 2. By placental compression under uterine contraction which forces 
 blood from the placenta along the umbilical vein to the fetus. 
 
 The gain of blood to a feeble child is often of considerable importance, 
 while with a vigorous child it would be of little moment. 
 
 Method of Ligation and Dressing of the Cord. — One of the greatest dangers 
 to which the newborn child is exposed is infection of the navel. 
 
 In order to avoid this the greatest care should be observed in the 
 treatment of the umbilical cord and its stump until the cord is off and 
 the navel thoroughly healed. A few principles should guide us. As 
 it is an established fact that the drier the stump of the umbilical cord 
 
334 
 
 THE MANAGEMENT OF NORMAL LABOR 
 
 can be kept, the sooner the cord separates and the navel heals, it is only 
 rational to ligate the cord at no great distance from the child's abdomen 
 and to have as little fluid as possible in the stump. On the other hand, 
 it occasionally happens that either on account of the first ligature cutting 
 through or for some other reason it is necessary to apply another liga- 
 ture between the first ligature and the child's navel. This necessitates 
 the selection of the site of the first ligature at a sufficient distance from 
 the child's abdomen to allow of the application of another ligature proxi- 
 
 Fig. 232.— First knot. 
 
 Fig. 23.3.— Second knot. 
 
 Fig. 234.— Third knot. 
 
 Fig. 2.35. — Fourth knot. 
 
 mal to it if necessary. A point one inch from the child's abdomen will 
 be sufficient for this purpose. In order to have this stump as small and 
 dry as possible the blood and Wharton's jelly of this portion of the cord 
 is gently stripped toward the placenta before the ligature is placed. 
 
 Before the cord is cut a second ligature is always appliefl on the placen- 
 tal side of the point where the cut is to be made for the following reasons: 
 
 1 . The possibility of a twin pregnancy and a vascular communication 
 between the two placentte must not be lost sight of, although the latter 
 is rare. 
 
MANAGEMENT OF THE SECOND STAGE 335 
 
 2. The retention of the blood in the placenta keeps it a firmer object 
 for the litems to act upon and more easily expel. 
 
 3. It prevents the soiling of the bed or pad upon which the woman 
 is delivered. 
 
 Attention should be called to the fact that the blood which would 
 flow from the distal end of the cord if unligated would not be maternal 
 blood, but fetal blood forced into the placenta by the fetal heart. This 
 distal ligature is usually placed from 1| to 2 inches from the first and 
 the cord cut with sterile scissors, not too sharp, about | inch from the 
 proximal ligature. 
 
 The ligation and the cutting of the cord should be done with sterile 
 hands. The tape, instruments and baby shoidd not be touched by any- 
 thing non-sterile until after the cord dressing has been applied. At 
 the Sloane Hospital the following method of ligating the cord is followed 
 (see Figs. 232, 233, 234, and 235). In applying the first ligature the tape 
 after the first double knot is left with the ends long. After the cutting 
 of the cord the two ends are tied across the end of the umbilical stump, 
 so as to include one of the umbilical arteries, they are then brought 
 around the remainder of the stump and tied in the original groove, thus 
 including the other umbilical artery. Finally, they are brought once 
 more around the stump as a whole and tied in a double knot. This 
 method of ligature has the advantage of ligating the arteries individually 
 as well as collectively and, furthermore, tends to care in the ligature and 
 watchfulness to prevent oozing or secondary bleeding. 
 
 After the ligating and cutting of the cord the baby is anointed from 
 head to feet with some sterile oily substance like sterilized petrolatum, 
 or albolene to remove the vernix caseosa. This is done with sterile hands 
 and the baby is then wiped clean with a sterile towel. The baby is not 
 bathed for six hours after birth and is not put in the tub until the cord 
 is off. In an endeavor to find a method which would keep the cord dry 
 and sterile and favor its rapid separation, the author tried in different 
 series of cases a variety of cord dressings, gauze and cotton alone and 
 also with a variety of different powders; talcum, starch, bismuth, starch 
 and salicylic acid, boric acid, etc. He reached the conclusion that sterile 
 gauze was better than cotton, and that better results were obtained 
 without rather than with the use of powders. For several years the dress- 
 ing used has been sterile gauze in two pieces : One a little square cut on 
 one side to slip around and fold over the cord (see Fig. 236) ; the other 
 a long strip of gauze to wrap about the abdomen of the child and serve 
 as a band to hold the small gauze dressing in place. 
 
 It is well to have on hand a number of cord dressings sterilized and 
 ready for use as shown in Fig. 236 C, the square gauze dressing being 
 rolled within the gauze band and both surrounded by a gauze cover. 
 The cord dressing with gauze band applied to the baby may be seen in 
 Fig. 237. This cord dressing, sterile in itself and applied with sterile 
 hands, is not removed, unless accidentally soiled, until five days have 
 elapsed. If the outer band becomes soiled it may be replaced by a clean 
 one. In a consecutive series of 10,000 cases at the Sloane Hospital the 
 
336 
 
 THE MANAGEMENT OF NORMAL LABOR 
 
 average day of separation of the cord was the eighth. After the cord has 
 separated there is often quite a core or stump which has not entirely 
 healed. The best treatment for the stump is to touch it every day or 
 
 Fig. 236. — Cord dressing: A, small square of gauze to fold around and over cord; B, gauze 
 band to hold small square in'place; C, cord dressing rolled up w-ithin muslin cover. 
 
 Fig. 2.37. — -Cord dressing applied to the baby. 
 
 two with a nitrate of silver stick and then apply a pad of sterile gauze 
 without powder. This treatment should be continued until the stump 
 has retracted and healed. If, after the stimip has retracted out of sight 
 
MANAGEMENT OF THE SECOND STAGE 337 
 
 there is still a little discharge, either that of ordinary granulation or a 
 little bloody oozing at times, the depression of the navel should be 
 cleansed with a little sterile cotton on a sterile wooden toothpick and a 
 little 8 per cent, nitrate of silver solution, or a little powdered alum carried 
 in with another sterile cotton toothpick. If any evidence of infection 
 appears about the navel it should be frequently cleansed with a sterile 
 cotton toothpick and a wet dressing of alum acetate solution kept on. 
 The application of tincture of iodin of half-strength is also of value. 
 
 Treatment of the Baby's Eyes. — The vernix caseosa having been removed 
 and the cord dressing applied, the prophylactic treatment of the eyes is 
 completed by the instillation of some salt of silver. At present the author 
 is using in his service at the Sloane Hospital and in his private practice 
 a 20 per cent, solution of argyrol. 
 
 In order to determine the best silver salt for the prophylactic treatment 
 of the eyes of the newborn a comparative study was made by the author, ' 
 in 1907, of the results obtained by him at the Sloane Hospital by the 
 use in five different series of cases of five different silver solutions: 
 Nitrate of silver, 2 per cent.; nitrate of silver, 1 per cent.; protargol, 
 5 per cent.; argyrol, 10 per cent.; argyrol, 20 per cent. The results were 
 as follows: 
 
 Series I. In 1000 confinements, 2 per cent, nitrate of silver solution: 
 Cases of ophthalmia, 18; eyes lost, none; opacities, none. 
 
 Series 11. In 1000 confinements, 1 per cent, nitrate of silver solution: 
 Cases of ophthalmia, 34; eyes lost, 1; opacities, none. 
 
 Series III. In 2000 confinements, 5 per cent, protargol solution: Cases 
 of ophthalmia, 53; average per thousand, 26+; eyes lost, 1; opacities, 1. 
 
 Series IV. In 2000 confinements, 10 per cent, argyrol solution: Cases 
 of ophthalmia, 34; average per thousand, 17; eyes lost, 1; opacities, 2. 
 
 Series V. In 2000 confinements, 20 per cent, argyrol solution : Cases 
 of ophthalmia, 43; average per thousand, 21+ ; eyes lost, none; opacities, 
 none. 
 
 During the use of the 2 per cent, nitrate of silver solution, the irrita- 
 tion of the eyes with the accompanying edema and discharge, the so-called 
 "silver catarrh," was so great that, not only did it occupy a great deal 
 of our nurses' time in applying compresses and irrigating the babies' 
 eyes, but it seemed to be a source of danger, not only by leaving an 
 irritated eye which might later become infected, but also by causing 
 in our nurseries discharging eyes from which the discharge might be 
 carried by nurses to healthy eyes, and thus infection produced. For 
 this reason, although no eyes were lost in this series, and, as fa?- as known, 
 no opacities produced, the strength of the nitrate of silver solution was 
 reduced from 2 per cent, to 1 per cent. The author has stated above 
 "as far as known" for the reason that in this series of 1000 confinements 
 5 babies were taken from the hospital with ophthalmia miimproved 
 and against advice, in whom the ultimate result is unknown to the writer. 
 
 1 Cragin, The Prophylactic and Curative Treatment of Ophthalmia Neonatorum, Trans. 
 Amer. Gyn. Soc, 1907. 
 22 
 
338 THE MANAGEMENT OF NORMAL LABOR 
 
 In this same series 2 babies died witli ophthalmia uncured. In the 
 second series, with the use of the 1 per cent, nitrate of silver solution, the 
 lessened irritation of the eye seemed a great improvement; but, as shown 
 above, there occurred 34 cases of ophthalmia, nearly twice as many as 
 in the previous series, and, in addition, one eye was lost by perforation 
 of the cornea. It looked as though the lessened irritation had been 
 gained at the expense of protection, and for this reason the use of the 1 
 per cent, nitrate of silver solution was abandoned. At this time the use 
 of protargol came to the author's notice, and in the next series of 2000 
 confinements a 5 per cent, protargol solution was used as a prophylactic 
 measure. The irritation was lessened, but, in this series, although there 
 were fewer cases of ophthalmia than with the use of 1 per cent, nitrate 
 of silver solution, one eye was lost and there was one opacity. 
 
 In the next series of 2000 confinements, 10 per cent, argyrol solution 
 was used with the following results: The number of cases of ophthalmia 
 per thousand was 17, the smallest number in any series of the 8000 cases; 
 there was a complete absence of irritation, and the drug was a safe one 
 for a nurse to apply at frequent intervals in case ophthalmia developed. 
 
 Unfortunately in this series of 2000 confinements, one eye was lost, 
 and two babies left the hospital with a small opacity of one cornea. For 
 this reason it seemed to the author that in spite of the reduction in the 
 number of cases per thousand, the protection was insufficient, and, there- 
 fore, in the next series of 2000 confinements the strength of the argyrol 
 solution as a prophylactic measure was increased to 20 per cent. 
 
 In this series no eyes were lost, there were no opacities of the cornea, 
 and no babies left the hospital with a purulent discharge. For reasons 
 w^hich will be given later, however, the number of cases of ophthalmia 
 was larger than in the preceding series, that is, 21+ per thousand. This 
 series covered a period in which there was an epidemic of so-called " pink 
 eye" in New York City; and, as no gonococci were found in the eyes of 
 the babies during the month, it was thought by the ophthalmologist, 
 who saw some of the cases in consultation, that they were cases of pink 
 eye. On comparison of the results in the five different series it will be 
 seen that Series V, treated with 20 per cent, argyrol, surpasses all the 
 others save Series I, in which 2 per cent, nitrate of silver was used; and 
 when it is noted that in this series five babies left the hospital with 
 ophthalmia uncured, Avhile in Series V no baby left the hospital with a 
 purulent discharge from either eye, it seems to the author that Series 
 \ should receive the preference. 
 
 In addition to this, the freedom in Series V from the silver catarrh, 
 with its demand for cold compresses, frequent irrigations, and frequent 
 attentions from .the nurses, so pronounced in Series I, has proved a great 
 boon to the hospital regime. 
 
 Viewed from the clinical standpoint alone, the method employed in 
 Series V seemed the most satisfactory, but that he might have a reason 
 for the faith which lay within him the author had made for him a series 
 of very careful investigations concerning the bactericidal power of the 
 
MANAGEMENT OF THE SECOND STAGE 
 
 339 
 
 silver salts used in the different series. The tests were made with the 
 Staphylococcus pyogenes aureus, the Streptococcus pyogenes, and the 
 gonococcus and were made in duplicate. The method of procedure was 
 to transfer the cultures to the disinfectant solutions of different strengths 
 for the various times, and then again from them to large tubes of broth 
 holding 50 c.c. each. In this way any chance of the small amount of 
 disinfectant which might still cling to the organisms having any restrain- 
 ing action on the growth was eliminated by the large quantity of broth 
 used. 
 
 In the case of the gonococcus two strains of the organism were secured, 
 one of which was a very sturdy grower. Both of these were used as a 
 check upon each other in the case of argyrol and similar results were 
 obtained in both cases. The gonococcus was cultivated in ascitic broth. 
 
 The times of exposure were from thirty seconds to thirty minutes in 
 the cases of the Streptococcus pyogenes and the gonococcus; and from 
 thirty seconds to twelve minutes, in the case of the Staphylococcus 
 pyogenes aureus. 
 
 In the results which follow the minus signs indicate no growth. The 
 plus signs indicate a growth: 
 
 NITRATE OF SILVER SOLUTIONS. 
 
 Time. 
 
 30 seconds . 
 
 1 minute 
 
 2 minutes 
 
 3 minutes 
 5 minutes 
 
 12 minutes 
 20 minutes 
 30 minutes 
 
 2 per cent. 
 
 Streptococcus 
 1 per cent. 
 
 Ptogexes. 
 i per cent. 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 :s. 
 
 I per cent. V") per cent, ^j-s per cent. 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 Time. 
 
 30 seconds 
 
 1 minute 
 
 2 minutes 
 
 3 minutes 
 5 minutes 
 
 12 minutes 
 
 Staphylococcus Pyogenes Aureus. 
 
 2 per cent. 1 per cent. J per cent. j per cent, 'jio per cent, '/m per cent. 
 
 ++ ++ + + 
 
 -- ++ ++ + + 
 
 -- ++ ++ + + 
 
 -- ++ ++ + + 
 
 -- ++ ++ + + 
 
 ++ ++ + + 
 
 Time. 
 
 30 seconds 
 
 1 minute 
 
 2 minutes 
 
 3 minutes 
 5 minutes 
 
 12 minutes 
 20 minutes 
 30 minutes 
 
 Gonococcus. 
 2 per cent. 1 per cent. 
 
 5 per cent. 
 
 i per cent. 
 
340 
 
 THE MANAGEMENT OF NORMAL LABOR 
 
 Time. 
 30 seconds 
 
 1 minute 
 
 2 minutos 
 '.i minutes 
 5 minutes 
 
 12 minutes 
 20 minutes 
 30 miiuites 
 
 o per cent. 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 PROTARGUL SOLUTIONS. 
 
 Stkeptococcus Pvogenes. 
 2 per cent. 1 per cent. 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 per cent. 
 
 J per cent. 
 
 /ii) per cent 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 Time. 
 30 seconds 
 
 1 minute 
 
 2 minutes 
 
 3 minutes 
 5 minutes 
 
 12 minutes 
 
 o per cent. 
 
 Staphylococcus Pvogenes Aureus. 
 2 per cent. 1 per cent, i per cent, j per cent. 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 percent, '/so per cent. 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + .+ 
 
 + + 
 
 Time. 
 30 seconds 
 
 1 minute 
 
 2 minutes 
 
 3 minutes 
 5 minutes 
 
 12 minutes 
 20 minutes 
 30 minutes 
 
 G )Xoct)CCU.s. 
 5 i)er cent. 2 per cent. 
 
 - - + + 
 
 - - + + 
 
 - - + + 
 
 1 per cent. 
 
 + + 
 + + 
 + + 
 + + 
 + + 
 
 per cent. 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 + + 
 
 ARGYROL SOLUTIONS. 
 
 Stheptococcu.s Pyogenes. 
 
 Time. 
 
 
 
 
 30 per cent. 20 per cent. 
 
 10 per cent. 
 
 
 .' i)er cent. 
 
 1 per cent 
 
 30 seconds ....++ + + 
 
 + + 
 
 
 + + 
 
 + + 
 
 1 minute .... 
 
 + + + + 
 
 + + 
 
 
 + + 
 
 + + 
 
 2 minutes 
 
 + + + + 
 
 + + 
 
 
 + + 
 
 + + 
 
 3 minutes 
 
 + + + + 
 
 + + 
 
 
 + + 
 
 + + 
 
 5 minutes 
 
 + + + + 
 
 + + 
 
 
 + + 
 
 + + 
 
 12 minutes 
 
 + + + + 
 
 + + 
 
 
 + + 
 
 + + 
 
 20 miiuites 
 
 + + + + 
 
 + + 
 
 
 + + 
 
 + + 
 
 30 minutes 
 
 + + + + 
 
 + + 
 
 
 + + 
 
 + + 
 
 Sr.\PHYLococcu.s Pyooe.ntes Aureus. 
 
 
 
 
 Time. 30 per 
 
 cent. 20 per cent. 
 
 10 i)cr cent. 
 
 2 
 
 pi'r cent. 
 
 1 per cent. 
 
 30 seconds ....++ + + 
 
 + + 
 
 
 + + 
 
 + + 
 
 1 mimite ....++ + + 
 
 + + 
 
 
 + + 
 
 + + 
 
 2 minutes . . . + + + + 
 
 + + 
 
 
 + + 
 
 + + 
 
 3 minutes . . . + + + + 
 
 + + 
 
 
 + + 
 
 + + 
 
 5 minutes . . . + + + + 
 
 + + 
 
 
 + + 
 
 + + 
 
 12 miiuites . . . + + + + 
 
 + + 
 
 
 + + 
 
 + + 
 
 
 G0NOCOCCU.S. 
 
 
 
 
 
 Time. 
 
 30 per cent. 20 per cent. 
 
 10 per cent. 
 
 2 per cent. 
 
 30 seconds 
 
 _ _ _ 
 
 - 
 
 + 
 
 + 
 
 + + 
 
 1 minute 
 
 
 
 
 
 
 _ _ _ 
 
 — 
 
 + 
 
 + 
 
 + + 
 
 2 minutes 
 
 
 
 
 
 
 _ _ _ 
 
 — 
 
 + 
 
 + 
 
 + + 
 
 3 minutes 
 
 
 
 
 
 
 _ _ _ 
 
 — 
 
 + 
 
 + 
 
 + + 
 
 5 minutes 
 
 
 
 
 
 
 _ _ _ 
 
 — 
 
 + 
 
 + 
 
 + + 
 
 12 minutes 
 
 
 
 
 
 
 _ _ _ 
 
 — 
 
 + 
 
 + 
 
 + + 
 
 20 minutes 
 
 
 
 
 
 
 _ _ _ 
 
 — 
 
 — 
 
 — 
 
 + + 
 
 30 minutes 
 
 
 
 
 
 
 _ _ _ 
 
 — 
 
 — 
 
 — 
 
 + + 
 
MANAGEMENT OF THE THIRD STAGE 341 
 
 From the foregoing tests it is evident that in the solutions usually 
 employed, argyrol has practically no bactericidal power over the strepto- 
 coccus or staphylococcus; but with the gonococcus, in strengths of 
 20 per cent, and 30 per cent., it is perfectly efficient. These tests also 
 show why the results with the 10 per cent, argyrol were not as good as with 
 the 20 per cent, argyrol. 
 
 So long as a 20 per cent, argyrol solution is efficiently bactericidal 
 with the gonococcus in thirty seconds; so long as the gonococcus is the 
 coccus most feared in the etiology of ophthalmia neonatorum, and so 
 long as the clinical results are practically as good as with the use of 2 
 per cent, nitrate of silver, and better than with 1 per cent, nitrate of 
 silver, and this without the annoyances of silver irritation and staining, 
 the author feels justified in using and advocating the use of argyrol as a 
 prophylactic against ophthalmia neonatorum. The instillation of the 20 
 per cent, argyrol solution is repeated on the third day of the puerperium. 
 After the prophylactic treatment of the eyes, the baby is weighed (one 
 ounce being deducted for the weight of the cord dressing), is wrapped in 
 a blanket mid kept warm with a hot-water bag placed not too near it, 
 w^hile attention is directed to the care of the mother. 
 
 MANAGEMENT OF THE THIRD STAGE. 
 
 Expression of the Placenta. — With the birth of the child the second 
 stage ends and the third or placental stage begins. During this period 
 the fundus of the uterus is guarded by the nurse, who having discon- 
 tinued the use of the anesthetic with the birth of the child's head, 
 follows dowTi the fundus with her hand upon it as the physician delivers 
 the body of the child and then guards the fundus during the period of 
 placental separation while the physician is ligating and cutting the 
 cord, removing the vernix caseosa, applying the cord dressing, washing 
 the baby's eyes, etc. During the placental or third stage the objects 
 desired are the separation of the placenta; the avoidance of excessive 
 hemorrhage; the expulsion of the placenta and the contraction of the 
 uterus. For the securing of these objects time should be allowed for 
 placental separation and during this time the fundus should be carefully 
 guarded by the hand of the nurse. It is important that the obstetrician 
 should ascertain that the nurse has found the fundus with her hand 
 and that she is holding and guarding that rather than the sjTuphysis 
 pubis which the author has known nurses to mistake for it. 
 
 The nurse should hold the fundus in the palm of her hand with suffi- 
 cient manipulation of it to prevent ballooning, but, unless hemorrhage 
 occurs, without force enough to cause distress to the patient, in this 
 way allowing time for the separation of the placenta. The time of wait- 
 ing for placental separation varies in the practice of different practi- 
 tioners from fifteen to thirty minutes. At the Sloane Hospital the 
 routine procedure is to wait twenty minutes from the birth of the child 
 before efforts at expressing the placenta are undertaken. In case a 
 hemorrhage occurs the fundus is manipulated vigorously until either 
 the hemorrhage ceases or the placenta is expressed. 
 
342 
 
 THE MANAGEMENT OF NORMAL LABOR 
 
 At the expiration of the twenty minutes from the birth of the ciiild the 
 obstetrician takes the fundus and expresses the placenta by the Crede 
 method. Standing at the patient's riglit lie seizes the fundus with his 
 left hand, his thumb being in front and fingers behind the fundus, and 
 makes forcible compression of it at the same time that he presses the 
 fundus downward in the axis of the parturient canal (see Figs. 238, 239, 
 and 240). This compression should be carried out during a uterine 
 contraction and there may be several attempts necessar}' before the 
 
 Fig. 238. — Crede method of expressing the placenta. 
 
 placenta is delivered; each attempt at expression, howe^■e^, should be 
 undertaken during a uterine contraction, as downward pressure on an 
 uncontracted uterus will in some cases easily cause inversion. As the 
 placenta emerges from the ^•ulva it is received in the palm of the right 
 hand which supports it as the membranes are trailing out of the vagina. 
 The plan of placental delivery should be expression from above rather 
 than traction from below. 
 
 The membranes should not be twisted, as this is very apt to tear them. 
 Ample time should be given for their separation and then the hand hold- 
 
MANAGEMENT OF THE THIRD STAGE 
 
 343 
 
 ing the placenta may be moved a little up and douai to facilitate the 
 delivery of the membranes. After the birth of the placenta it should be 
 spread out, maternal surface upward, and carefully examined for missing 
 or lacerated cotyledons or evidence that some of the structure of the 
 placenta is lacking. 
 
 It should then be turned over and the fetal surface examined, the 
 amniotic sac being opened to see if sufficient membranes are present to 
 construct a sac large enough to contain the fetus. If a considerable 
 portion of the placenta itself is lacking, the author's practise is to redis- 
 
 FiG. 239. — Crede method. Placenta distending vulva. 
 
 infect one gloved hand or put on a sterile glove and go into the uterus for 
 the missing portion. Also if a large portion of the amnion or chorion is 
 lacking the same method is followed, but if only a small portion of the 
 amnion and chorion is missing this is left to come away with the lochia. 
 
 If a small portion of the membranes is seen to be retained in the 
 cervix and vagina this is carefully removed by the sterile fingers. 
 
 With the complete expulsion of the placenta a dose of the fluidextract 
 of ergot (1 to 2 drams), or some other preparation of ergot is given to main- 
 tain the contraction of the uterus, this tending not only to prevent 
 hemorrhage but infection. 
 
344 
 
 THE MANAGEMENT OF NORMAL LABOR 
 
 No douches, either vaginal or intra-iiterine, should be given save for 
 two indications: (a) To control hemorrhage, (b) To wash away 
 debris which has been loosened by the fingers. After the deliver}^ of 
 the placenta the pelvic floor should be carefully examined for lacera- 
 tions. It is not sufficient simply to inspect the skin surface of the peri- 
 neum and decide from this that no laceration has occurred. The skin 
 surface even to the fourchette may remain intact and yet extensive 
 lacerations may have occurred — lacerations which have involved the 
 fascia binding together the levatores ani, thus producing one of the most 
 important lesions of the pelvic floor. 
 
 Fig. 240. — Ciedc method. Placenta emerging from vulva. 
 
 Not only should the skin surface of the perineum be inspected, but 
 the labia should be separated, and if tears are found in either sulcus these 
 should be sutured as will be discussed later (see page 726). In regard 
 to the immediate repair of lacerations of the cervix, it is the consensus 
 of opinion among obstetricians today that, save for the deep lacerations 
 causing hemorrhage, the wisest course lies in leaving lacerations of the 
 cervix alone during the puerperal weeks. The author is strongly convinced 
 that the necessary manipidation incident to the examination and ex- 
 posure of lacerations of the cervix and the danger of closing the cervical 
 canal so tightly as to interefere with uterine drainage tend so often to 
 the development of infection and subinvolution as to furnish a very strong 
 
GAURDING THE FUNDUS 
 
 345 
 
 argument against the immediate repair of lacerations of the cervix unless 
 marked cervical hemorrhage occurs. 
 
 After the delivery of the placenta and the repair, if necessary, of 
 lesions of the pelvic floor, the vuh'a is cleansed and a drv sterile absorbent 
 
 Fig. 241. — A, breast binder; B, abdominal binder. 
 
 Fig. 242. — Abdominal binder and breast binder applied. 
 
 vulva pad is applied. The mother now should be allowed to rest but 
 the fimdus of the uterus should be held and guarded by the hand of the 
 nurse until it is evident that the uterus will remain well contracted, 
 i. c, at least an hour from the birth of the child. At the expiration of 
 
346 THE MANAGEMENT OF NORMAL LABOR 
 
 this period the abdominal binder may be applied. Tlie abdominal and 
 breast binders as employed at the Sloane Hospital, before and after 
 application are shown in Figs. 241 and 242. 
 
 Abdominal Binder. — The release of the abdominal wall from the ten- 
 sion to which it has been subjected for months leaves it so lax that the 
 woman is inclined to feel uncomfortable unless some abdominal support 
 is applied. For this reason the abdominal binder may be looked upon as 
 a source of comfort at least during the first few days of the puerperium. 
 Furthermore, a snugly fitting binder tends to prevent ballooning of the 
 uterus with its accompanying hemorrhage and thus serves as a factor 
 in safety as well as comfort. 
 
 After the fifth day the choice between continuing the binder and dis- 
 carding it may largely be left to the patient and in hot weather she is 
 usually more comfortable without it after the first week. As soon as the 
 uterus has involuted sufficiently to descend into the pelvis it should be 
 borne in mind that retroversion of it is possible for the reason that the 
 round ligaments have not yet regained their tone and the uterine body is 
 heavier than normal. Such being the case it is important that the binder 
 if worn after the first week should not be applied too tightly and, further- 
 more, the patient should be urged not to lie continuously on her back. 
 She should lie for a time on one side then on the other and as soon as 
 the breasts have lost their sensitiveness, she may lie for a time each 
 day on her abdomen. 
 
 Postpartum Chill. — Very frequently the patient immediately following 
 the completion of the third stage will experience quite a pronounced 
 rigor. This is purely a vasomotor disturbance of little moment and re- 
 quires for its treatment only a warm blanket and a hot-water bag or a 
 warm electric pad applied to the feet. Its occurrence is usually explained 
 by the sudden diminution in heat production due to the cessation of 
 muscular effort and by the heat loss through perspiration, etc. 
 
 If the uterus is well contracted, the lochia moderate in amount, and 
 the pulse slow and strong, the obstetrician can usually leave his patient 
 with safety in about an hour from the birth of the child. The nurse should 
 be instructed to take the temperature, pulse and respiration of the mother 
 every four hours during the daytime for the first few days and after that, 
 if the puerperium seems normal, twice a day will suffice. The tempera- 
 ture of the baby should be taken night and morning. The nurse should 
 also be told to catheterize the patient every eight hours if she is unable 
 to void her urine, to give her a tablet of codein, gr. ss, repeated in two 
 hours if needed for after-pains; to let the baby go to the breast for five 
 minutes after the mother has had a rest and to bathe the baby on the 
 lap at any time after six hours from birth. 
 
 Clothing of the Baby. — After the baby has been bathed on the lap 
 it may be dressed. The advice of the obstetrician is often asked regard- 
 ing the clothing of the expected child and it is important that he should 
 be well informed on this subject, for one of the agreeable pastimes of the 
 expectant mother during her trying months of waiting is the preparation 
 of the clothing for the anticipated child. Of course the obstetrician 
 
CLOTHING OF THE BABY 347 
 
 in his advice regarding dress can only deal with principles. The mother 
 will delight in getting, and the friends m sending, all sorts of dainty make- 
 ups for the head and feet of the baby and with these the obstetrician 
 need not concern himself. There are, however, four principal articles 
 in the clothing of the baby m which the obstetrician is deeply interested, 
 and these articles are shown in the accompanying Fig. 243. They are: 
 
 A C 
 
 Fig. 243. — Clothing of the baby: A, flannel band; B, short flannel shirt; C, long flannel slip; 
 
 D, long muslin slip. 
 
 1. A flannel hand which is to be used from the time the sterile dress- 
 ing of the navel is dispensed with until the baby is four or five months 
 old. This not only gives warmth to the baby's abdomen but furnishes 
 support to the umbilicus, tending to prevent hernia from crjang of the 
 baby, should there be any tendency to umbilical weakness. The band 
 is better sewed with a loose running stitch rather than pinned, and care 
 should be taken that it is applied firmly enough to give a gentle support 
 to the abdomen and not tightly enough to crowd up the stomach and 
 interfere with its digestion. 
 
 2. A short flannel shirt. 
 
348 
 
 THE MANAGEMENT OF NORMAL LABOR 
 
 3. A long Jianncl dip, long enough to come well below the baby's feet 
 so that it can be folded over to keep the feet warm. 
 
 Fig. 244. — Wa.shing of the face and scalp. 
 
 4. A long muslin slip; this may be plain or decorated with sufficient 
 ribbons and embroiderv to satisfv the daintiest of tastes. 
 
 Fig. 24.5. — Bain- in the tub. 
 
 The Baby's Bath. — Until the cord has separated and the na\el has 
 healed the baby is bathed on the lap of the nurse and the navel is kept 
 
THE BABY'S BATH 
 
 349 
 
 I'lii. IMC). — Drying hi\hy on the lap. 
 
 Fig. 247. — Sewing on the band. Weighing the baby. 
 
350 THE MANAGEMENT OF NORMAL LABOR 
 
 dry. With the heahng of the navel, however, the baby is ready for its 
 tub l)ath which should be given daily just before one of its morning 
 
 feedings. O^^r-V ^ .U-C^ a<-n>-M^ ^-.^> 
 
 For this purpose there are needed 'a bath-tub which can be easily 
 cleansed, some clean, pure soap, a thermometer, and either a soft wash- 
 cloth which can be easily laundered and sterilized, or sterile gauze or 
 cotton which can be used and throwji away. The temperature of the 
 water is very important and should range from 98° to 102° F. Xo nurse, 
 even with a thermometer, should ever put a baby in a tub of water with- 
 out first testing the temperature of the water with her hand. The neglect 
 of this simple precaution cost the life, from scalding, of the baby of one 
 of the author's intimate friends. The first step in the bath should be 
 the washing of the face and scalp, and this should be done on the lap 
 of the nurse before the baby is put in the tub (see Fig. 244). For the 
 scalp, clean soap should be used on the wash-cloth. With the face and 
 scalp cleaned, especially in all creases, such as behind the ears, the baby 
 is ready to have its clothing removed and be lifted gently into the tub 
 of water (see Pig. 245), the temperature of which has been carefully tested. 
 After carefully washing all parts of the body, especially in the creases, 
 the baby is lifted onto the lap of the nurse on which is spread a soft towel 
 which is at once folded about the l)al)y so that chilling from exposure 
 is avoided (see Fig. 246). By gently patting the towel about the baby 
 the skin is dried. The creases are then dusted with talcum powder and 
 the baby is ready for the four articles of clothing just described, the 
 band being sewed on (see Fig. 247) rather than pinned. 
 
CHAPTER X. 
 
 CARE OF CHILD IN ABNORMAL CONDITION AT BIRTH. 
 
 The preceding description applies to the care of the child in normal 
 condition. Not infrequently, however, the condition of the child is 
 abnormal at birth either from asphyxia or on account of being premature 
 and of undersize and underweight. 
 
 ASPHYXIA NEONATORUM. 
 
 Differential Diagnosis. — This condition must first be differentiated from 
 apnea which is the normal condition of the fetus in utero as long as it 
 receives sufficient oxygen through the placenta and cord. The apnea 
 may also continue for a short time after the fetus has reached the outside 
 world, provided the placenta is still attached to the uterus and the cord 
 is pulsating. The child does not breathe because it is already sufficiently 
 oxygenated. This is altogether different from asphyxia in which there 
 is insufficient oxygenation. 
 
 Etiology.^ — ^Asphyxia, or insufficient oxygenation of the fetus, may arise 
 from various causes. In the first place anything interfering with the 
 ready flow of fetal blood through the placenta in close proximity to the 
 maternal blood and through the cord to the fetus tends to produce 
 asphjoda. Thus premature separation of the placenta, tonic compres- 
 sion of the placenta by tonic contraction of the uterus, and compres- 
 sion of the cord would all act to lessen the oxygenation of the fetus. 
 Cerebral compression in the fetus with slowing of the fetal heart would 
 lessen oxygenation in another way. The condition of the blood of the 
 mother, as during eclamptic seizures when her oxygenation is insufficient, 
 may cause a lack of oxygenation in the fetal blood. These may all act 
 while the fetus is in utero. On the other hand, the fetal head including 
 the face may be too long delayed in the vagina and from a short cord, or 
 a compressed cord or from a prematurely separated placenta, sufficient 
 oxygenation through placenta and cord is not obtained by the fetus and it 
 suffocates. The same would apply if the placenta was separated and 
 the membranes were unruptured or were tight over the face of the child. 
 
 Again, if the cord has been compressed and the child has made efforts 
 to breathe in utero, the msufflation of liquor amnii, mucus and even meco- 
 nium into the air passages interferes with the entrance of air after birth. 
 
 Finally, in premature infants the nerve and muscular development 
 may be so imperfect that the normal process of respiration cannot be 
 carried on. 
 
 Pathology. — The pathological findings in asphyxia neonatormn vary 
 with the cause of the asphjofia and the rapidity of its development. In 
 
 (351) 
 
352 CARE OF CHILD IN ABNORMAL CONDITION AT BIRTH 
 
 general, more or less atelectasis is found with engorgement of the right 
 heart and pulmonary vessels. There is congestion of the viscera with 
 frequent ecchymoses and depending upon the amount of cerebral com- 
 pression, lesions varying from edema of the brain and its membranes to 
 cerebral hemorrhages of considerable size. If intra-uterine or intra vaginal 
 efforts at respiration have been made the trachea and bronchi may be 
 found filled with mucus, amniotic fluid and even meconium. 
 
 Antepartum Diagnosis. — There are certain evidences of impending intra- 
 uterine asphyxia which are important enough to deserve consideration. 
 The most valuable are the following: 
 
 (a) Change in the fetal heart sounds. 
 
 (6) The passage of liquor amnii stained with fresh meconium in pre- 
 sentations other than breech. 
 
 (c) Tumultuous movements of the fetus. 
 
 (d) JNIarked, persistent umbilical souffle. 
 
 Of these different signs the persistent slowing of the fetal heart beats 
 froms^J3Q^ 14\to 100 or below is the most valuable as indicating undue 
 compression and threatened asphyxia and, as a rule, should be regarded 
 as an indication for hastening the deliver^'. 
 
 The change from a slow fetal heart to one that is ^•ery rapid or 
 irregular is frequently a sign of disturbed fetal circulation and perhaps 
 impending asphjT^ia, but is less to be depended on than the marked 
 slowing of the fetal heart mentioned above. 
 
 The appearance of fresh meconium in the liquor ammi in cases other 
 than breech is a strong evidence of disturbed fetal circulation and threat- 
 ened asphyxia, and especially when associated with slow fetal heart 
 sounds, should be considered as indication for hastening the delivery. 
 
 Not infrequently, just before the death of the child in ntero, the mother 
 notices tumultuous movements of the child; these may indicate asphyxia 
 and attempts at respiration during its death struggle. Taken by them- 
 selves these tumultuous movements are not often a sign of great impor- 
 tance but coupled with very slow heart sounds and the passage of mecon- 
 ium into the liquor amnii, they become a serious indication of asphyxia. 
 
 The same may be said of the persistent umbilical souffle. While 
 alone it is often a sign of little moment, when found associated with 
 other signs of disturbed fetal circulation it may form a sufficiently strong 
 corroborative evidence of threatened asphyxia to indicate hastening of 
 the deli^'ery. 
 
 Clinical Picture. — Clinically there are two types of asphyxia presented 
 by the baby. In one the muscle tone is retained and the child is c>'anotic. 
 This is usually called asphyxia livida. In the other the muscular system, 
 including the sphincters, is relaxed, and the child is pale and the con- 
 dition is called asphyxia pallida. The prognosis of asphyxia livida is 
 usually better than that of asphyxia pallida, although the child is often 
 resuscitated from either condition. The passing of the child from the 
 condition of asphyxia livida to that of asphyxia pallida, as sometimes 
 happens, usually indicates a bad prognosis and the return of muscular 
 contraction in an asphyxia pallida usually means a good prognosis. 
 
ASPHYXIA NEONATORUM 353 
 
 Treatment. — In the treatment of asphyxia neonatorum there are three 
 chief indications: 
 
 1 . To clear the upper air passages. 
 
 2. To perform artificial respiration. 
 
 3. To employ reflex stimulation of respiration. 
 
 These three indications can be met in several ways, but in whatever 
 method that may be selected, it should be borne in mind that an asphyx- 
 iated newborn baby is a delicate structure of low vitality and great care 
 should be taken not to injure its structure or lower its vitality. 
 
 Clearing the Upper Air Passages. — For clearing the upper air pas- 
 sages which may be filled with mucus, liquor amnii, etc., a good method is 
 to hold the baby, wrapped in a sterile towel, with head down and then 
 gently slap its buttocks. This not only allows the obstructing fluid to 
 run out but often stimulates respiration from the slapping. In addition 
 to this, a method often employed at the Sloane Hospital is to use a 
 ''blow-out" so-called, i. e., to have the nurse place a fold of sterile gauze 
 over the mouth of the baby, indenting the gauze over the baby's mouth 
 so as to mark its location. The obstetrician then blows through the 
 gauze into the baby's mouth at the same time holding his hand over its 
 stomach so that it shall not be distended. In this manner, mucus and 
 fluid in the upper air passages are forced out through the baby's nose 
 and are wiped away by the nurse as she draws the gauze along and 
 prepares a fresh surface for another "blow." 
 
 In addition to the methods above mentioned, a catheter or other 
 varieties of suction apparatus may be used for withdrawing mucus from 
 the upper air passages, but are seldom employed by the author. 
 
 Artificial Respiration. — For performing artificial respiration various 
 methods are in common use and all have their place at times. 
 
 Preparation. — One important fact to be emphasized in this connection 
 is that in every labor which is markedly prolonged, or in which the fetal 
 heart sounds have been slowed, and in every operative delivery, the 
 possibility of an asphyxiated baby should be borne in mind and prepara- 
 tions for treating it be made. These preparations consist chiefly in hav- 
 ing at hand two tubs, one containing warm water at a temperature of 
 about 115° F., the other containing cold water with ice to keep it cool. 
 
 Until the reflexes have returned in the baby there is no advantage 
 in trying to stimulate its respiration by cold applications to its skin and 
 there is a distinct disadvantage in the danger of lowering its vitality. 
 Hence at first it is the warm-water tub which is needed and it is the 
 author's custom to keep the baby in the warm water as much as possible 
 while performing artificial respiration upon it. 
 
 If the baby is asphyxiated at birth the cord is tied and cut at a sufli- 
 cient distance from its abdomen to allow of a second ligature, cutting 
 and sterile dressing after the procedures of resuscitation are over. 
 
 With the upper air passages cleared as already described, the baby is 
 
 at once placed in the tub of warm water with its face supported above 
 
 the level of the water. With its vitality thus protected by the heat, 
 
 artificial respiration may be carried on by a modification of Sylvester's 
 
 23 
 
354 CARE OF CHILD IN ABNORMAL CONDITION AT BIRTH 
 
 method as shown in Figs. 248 and 249. With the arms of the baby between 
 the thumbs and forefingers of the obstetrician, while the back of the thorax 
 is supported by his remaining fingers, the operator Hfts the arms and thorax 
 and thus expands the baby's chest (see Fig. 248). In the next move- 
 ment the operator transfers his forefingers to the scapular region and 
 compresses the baby's chest with his thumbs (see Fig. 249). With the 
 alternation of these two movements, 10 to 18 per minute, artificial respira- 
 tion is maintained with very little shock to the baby and often with most 
 gratifying results. As soon as the reflexes return and the baby begins 
 
 Fig. 248. — Modified Sylvester's method. .Artificial inspiration. Baljy in tub of 
 
 warm water. 
 
 to use its diaphragm, respiration may be stimulated by transferring the 
 baby for an instant to the tub of ice-water, immediately returning it to 
 the warm water, so as not to lower its vitality. Dashing a few drops of 
 the ice-water onto the chest of the baby while it is still in the warm water 
 will often suffice to stimulate its respiratory movements. As a rule it is 
 well to keep the baby in the warm tub with occasional short transfers 
 to the cold tub until it cries well. It should then be dried^ its cord tied 
 again at the usual distance from the body, a sterile cord dressing applied, 
 the baby wrapped in a warm blanket and placed in its crib. In every 
 
ASPH YXIA XEONA TOR UM 
 
 355 
 
 case of asphyxia the baby should be carefully watched after resuscitation 
 for any evidence of failing respiration. 
 
 The method just described is the one usually employed by the author 
 in his service at the Sloane Hospital and in his private practice and the 
 preparation of the tubs of hot and cold water is that expected of his 
 nurses. In some cases the baby does not respond to this method of arti- 
 ficial respiration and other well-known methods should be tried, per- 
 haps returning the baby at intervals to the warm tub and the modified 
 Sylvester method just described. 
 
 Fig. 249. — Artificial expiration. Baby in tub of warm water. 
 
 A good method is the Schidtze method, in which the baby is held with 
 the operator's thumbs over the thorax, the index-fingers in the axillae 
 and the remaining fingers over the scapular region. The baby is first 
 swung do^\Ti between the operator's thighs, the operator in the meantime 
 lifting forward the baby's thorax (see Fig. 250). This evidently expands 
 the baby's chest. In the next movement the baby is gently swung over 
 the operator's shoulder, its thorax falling on the thumbs of the operator 
 which thus compress it (see Fig. 251). 
 
 With the alternation of these two movements artificial respiration 
 may be carried on. It is readily seen, however, that in cases of fracture 
 
^oG CARE OF CHILD IN ABNORMAL CONDITION AT BIRTH 
 
 of either of the extremities or the clavicle, the method is not one to be 
 recommended. 
 
 A substitute for the Schultze method suggested by Byrd, in 1870, 
 modified by Dew,' in 1893, and generally known as Dew's method, is de- 
 picted in Figs. 252, 253, 254, and 255. He describes the method as follows: 
 " Grasp the infant with the left hand, allowing the neck to rest between 
 
 Fig. 250. — Schultze method. 
 First motion. 
 
 Fig. 251. — Schultze method. 
 Second motion. 
 
 the thumb and forefinger, the head falling far over backward (see Fig. 
 252) straightening the mouth with the laryn.x and trachea, thereby serv- 
 ing to raise and hokl open the epiglottis. The upper portion of the back 
 and scapulae resthig in the jjalm of the hand, the other three fingers are 
 
 1 Establishing a New Method of Artificial Respiration in Asphyxia Neonatorum, New 
 York Medical Record, vol. xliii, No. 10, pp. 289-292. 
 
ASPHYXIA NEONATORUM 
 
 35- 
 
 inserted in the axilla of the baby's left arm, raising it upward and out- 
 ward. Then with the right hand, if the baby is large and heavy, grasp 
 
 Fig. 252.— Dew method. 
 
 Fig 253. — Dew method. 
 
 Fig. 254. — Dew method. 
 
 Fig. 255. — Dew method. 
 
358 CARE OF CHILD IN ABNORMAL CONDITION AT BIRTH 
 
 the knees in such a way as to hold them with the right knee resting 
 between the thuml) and forefinger, the left between the fore- and middle 
 fingers. This position will allow the back of the thighs to rest in the 
 palm of the operator's hand. If tlie infant is small and light it will be 
 found more convenient and easier to hold it in the same way by the 
 ankles instead of the knees, allowing the calves instead of the thigh to 
 rest in the palm of the hand. 
 
 Fig. 256. — Author's method. 
 
 "The next step is to depress the pelvis and lower extremities so as to 
 allow the abdominal organs to drag the diaphragm downward, and with 
 the left hand to gently bend the dorsal region of the spine backward 
 (see Fig. 253). This enlarges the thoracic cavity and produces inspira- 
 tion. Then, to excite expiration, reverse the movement, bringing the 
 head, shoulders and chest forward, closing the ribs upon each other 
 (see Fig. 254). At the same moment bring forward the thighs, resting 
 them upon the abdomen. 
 
 "The movement arches the lumbar region backward and so bends the 
 
ASPHYXIA NEONATORUM 
 
 359 
 
 (;hild upon itself as to crowd together the contents of the thoracic and 
 abdominal cavities, bringing about a most complete and forcible 
 expiration. 
 
 "By elevating the buttocks and depressing the head and shoulders 
 (see Fig. 255) the expulsion of mucus can be affected, as in the Schultze 
 method." 
 
 
 Fig. 257. — Author's method. 
 
 A method often used by the author in alternation with the modified 
 Sylvester method in the warm tub is that shown in Figs. 256 and 257, 
 in which the baby held as in Fig. 256 is rather rapidly changed to the 
 position of Fig. 257, then returned to Fig. 256. Inspiration is stimulated 
 by the motion from 256 to 257 in two ways: (1) By the reflex stimula- 
 tion of rushing through the air; (2) by the descent of the liver and dia- 
 phragm which expands the chest capacity. The results of this method 
 are often very satisfactorv. 
 
360 CARE OF CHILD IN ABNORMAL CONDITION AT BIRTH 
 
 Reflex Stimulation. — A method of rcflexly .stiinulating respiration is 
 that of Lahorde, wliich consists in rhythmic tractions npon the tongue, 
 either with a forceps or the fingers. This method is based on the principle 
 that traction on the tongue refiexly stimuhites the respiratory centre 
 and the phrenic nerve. 
 
 In desperate cases, any or e\en all of the above methods may be used 
 before deciding the case is hopeless, providing, of course, the fetal heart 
 is still beating. The author has several times succeeded in resuscitating 
 apparently hopeless cases by direct insufflation — the mouth-to-mouth 
 method — with several layers of gauze placed over the mouth of the 
 baby the operator gently blows into the baby's mouth at regular inter- 
 vals, imitating inspiration, and then com- 
 presses the chest with his hand. Not infre- 
 quently the color of the baby under this 
 method will assume its normal condition and 
 ■voluntary respiratory movements begin. 
 
 The physician should never despair so 
 long as the heart continues to beat, even if 
 voluntary respiration does not begin for an 
 hour. 
 
 Occasionally, in cases of asphyxia asso- 
 ciated with fracture of the fetal skull and 
 cerebral hemorrhage, benefit is obtained by 
 operation with the removal of the clot and 
 pressure. Recovery under these conditions, 
 however, is exceptional. 
 
 One of the most valuable methods of re- 
 suscitating asphyxiated babies is by the use 
 of the lungmotor (see Fig. 258) which in 
 the author's experience has proved both 
 efficient and safe. 
 
 The lungmotor consists of two air pumps 
 which operate in unison, yet are not connected 
 in any way as far as the interchange of air is 
 concerned. At no time does the devitalized 
 air come in contact with the fresh air or 
 oxygen. It works by hand — three fingers. 
 An upward movement of the lungmotor fills "inspiration" cylinder 
 with air or oxygen or a mixture of both, according to the setting of the 
 air and oxygen valve. At the same time the "expiration" cylinder fills 
 with the expired air expelled by the lungs of the subject. Conversely 
 the following downward movement of the handle and piston forces the 
 air and oxygen now contained in the "inspiration" cylinder into the 
 lungs of the subject and discharges the expired air of the expiration 
 cylinder into the open. 
 
 To make the lungmotor available for persons of all ages and corre- 
 spondingly varying lung capacities the lungmotor is provided with adjust- 
 ments for different air volumes suitable for newborn, five-year-old, ten- 
 
 FiG. 258. — The lungmotor. 
 
IMMEDIATE CARE AFTER BIRTH OF PREMATURE BABIES 361 
 
 year-old children, fifteen-year-old or small adult, adult average and adult 
 large. This range provides for all sizes of subject. 
 
 The volume notches for size of subject are on the "inspiration" piston 
 rod opposite to each of the sizes of subject, viz.: Newborn, five-year-old, 
 ten-year-old children, fifteen-year-old or small adult, adult average and 
 adult large. The volume notches are engaged by a slide pin on top of 
 the "inspiration" cylinder cover. The slide pin can be swung around 
 the circle over the graduated volume, size and stroke regulating dial, 
 the graduations with plain marks for corresponding ages registering with 
 the notches in the piston rod. 
 
 The treatment of cases of asphyxia neonatorum often has associated 
 with it most grievous disappointment. Not infrequently the obstetrician 
 after strenuous efforts will have his hopes raised and will perhaps believe 
 he has succeeded in saving the child, only to have them dashed to the 
 ground during the next twenty-four to forty-eight hours by the death 
 of the child from atelectasis. On the other hand the permanent successes 
 are frequent enough to reward one for patient persistent eftorts. 
 
 THE IMMEDIATE CARE AFTER BIRTH OF PREMATURE BABIES OR 
 BABIES OF UNDERSIZE OR UNDERWEIGHT. 
 
 One of the great problems in the care of premature babies is the main- 
 tenance of their body heat. The author's experience at the Sloane Hos- 
 pital leads him to believe that while a baby weighing 4| pounds or over 
 will usually do w^ell at the ordinary temperature of the nursery, a baby 
 weighing less than this does much better in a temperature of 85° to 90° F. 
 For this reason it is his custom at the Sloane Hospital to place, for a time 
 at least, a baby weighing 4^ pounds or less in an incubator in which 
 the temperature is maintained at first around 90° F. and then gradually 
 reduced as the baby shows that it can maintain its body heat at a lower 
 incubator temperature. In order to preserve the vitality of these prema- 
 ture babies, as soon as possible after birth they are anointed with steril- 
 ized petrolatum to remove the vernix; a cord dressing is applied; they 
 are wrapped in a warm blanket and then transferred at once to the 
 incubator w^here the incubator clothing is put on. The clothing of the 
 baby while in the incubator does not need to be as much or as heavy as 
 that of the baby in the nursery and the author's experience has led him 
 to adopt as suitable clothing for an incubator baby the following: One 
 short flannel shirt and two napkins. One of the napkins is folded diag- 
 onals^, brought between the thighs and pinned in the usual way. The 
 other napkin is folded lengthwise about the waist and thighs of the baby 
 and pinned with the bottom turned up if desired. A small square of 
 canton flannel is usually placed inside the inner napkin next to the anus 
 to receive the baby's stools. This light, loose clothing allows freedom of 
 motion to the baby and is heavy enough for the warm atmosphere in 
 which it is. The baby in the incubator is handled as little as possible in 
 changing its diapers, it is not bathed and it is weighed only at intervals 
 of several days. Its feeding is discussed in the chapter on Lactation, 
 
3G2 CARE OF CHILD IN ABNORMAL CONDITION AT BIRTH 
 
 see page 408. Suffice it to say here that an incubator baby usually needs 
 human breast milk and usually does best when fed in small amounts 
 with halt'-streniith milk at shorter intervals than a full-term baby is fed. 
 
 Incubators and Their Substitutes. — To the ditierent \arieties of 
 incubators which have been in use for many years, most of which have 
 consisted of an air chamber warmed by a tank of water heated by a gas 
 or other burner, there have been three common objections: 
 
 Insufficient air space. 
 
 Insufficient circulation of air. 
 
 Difficulty in maintenance of a constant temperature. 
 
 11, PILOT LIGHT 
 
 Fig. 259. — Infant incubator. 
 
 Impressed with these objections the author has sought to overcome 
 them by: 
 
 1. Having an incubator built several times larger than those in com- 
 mon use. 
 
 2. IMaintaining a gentle current of filtered air through it, the air enter- 
 ing through a gauze-screened opening below and being sucked out by a 
 small electric fan above. 
 
 3. Maintaining a constant temperature by different series of electric 
 lights which may be turned on or off at will. This incubator (see Fig. 
 259) has been in use, with two of its fellows, at the Sloane Hospital for 
 two years and has clearly demonstrated its superiority over the incuba- 
 tors of the old t^-pe. Babies of greater prematurity and lesser weight have 
 lived and developed in these incubators than any we have been able to 
 save heretofore. 
 
 The mechanical description of the incubator is as follows: It is built 
 entirely of steel finished on the outside in aluminum bronze and painted 
 
IMMEDIATE CARE AFTER BIRTH OF PREMATURE BABIES 363 
 
 on the inside with gray enamel. It consists primarily of the incubator 
 proper which is 84| inches in length, 46| inches in height, and 30| inches 
 in depth. It is supported on legs 30 inches high, making the total height 
 76| inches. In front (see Fig. 259) at each side are two double doors of 
 beveled plate glass set in nickel-plated brass frames. At each end is a 
 beveled plate glass window 24j inches by 20^ inches. In the interior 
 directly behind each set of doors is a basket or cradle, built of nickel- 
 plated brass wire and supported on hooks, in which the infant lies. 
 Beneath each cradle is a tray which contains water for keeping the air 
 moist. The condition of the air is indicated by a hygrometer and its 
 temperature by a thermometer, both of which are visible through the 
 
 Fig. 260. — Incubator heated by a gas burner or an alcohol lamp. 
 
 glass doors. Beneath each tray is a series of violet-colored incandescent 
 lamps which furnish the heat which is distributed by means of a heat 
 disbursor. On the roof of the incubator a small motor with a fan and 
 the necessary resistance is enclosed in a metal chimney leading from the 
 interior. The motor is controlled by a rheostat situated outside of the 
 incubator between the two front windows. The lamps are connected in 
 series of two on each side controlled by snap switches as shown, which in 
 turn are connected with the house current. Directly inside of each door 
 is a small pilot lamp. When the incubator is in operation the air enters 
 through the intakes (No. 6), comes in contact with the heat-disbursing 
 plates and passes throughout the interior. By means of the motor fan 
 a continual gentle current of fresh, warm air is kept circulating through 
 
364 CARE OF CHILD IN ABNORMAL CONDITION AT BIRTH 
 
 the incubator. The degree of heat is regulated by turning on more or less 
 of the snap switches and by ])r(>per regulation of the motor. 
 
 Fig. 261. — Cotton jacket and socks. 
 
 Fig. 262. — Baby in cotton jacket and socks. 
 
CAPUT SUCCEDANEUM AND CEPHALHEMATOMA 365 
 
 Where the house is not wired for electricity an incubator of the old 
 type (see Fig. 260), in which the water tank surrounding the air chamber 
 is heated by a gas burner or an alcohol lamp may be used. The objec- 
 tions of limited air space and poor circulation of air must be recognized, 
 however, and overcome as far as possible. 
 
 Substitutes for Incubators. — In private families where it is impossible 
 to secure an incubator it is often possible by different makeshifts to 
 obtain admirable results without it. In some houses a small room 
 may be chosen and by the regular heating apparatus of the house the 
 temperature may be raised and maintained at or above 80 degrees. 
 
 The author has at times obtained good results by surrounding the 
 baby's crib with folding screens over which blankets are thrown, the 
 temperature of this space being maintained by an electric heater. 
 
 In all of these arrangements of enclosed, heated air spaces, the impor- 
 tance of ventilation from a nearby window should be borne in mind. 
 
 When a baby is taken out of the incubator, which is done for a little 
 while at a time, after the temperature of the incubator has been gradually 
 reduced to approximately that of the nursery, it is an excellent plan to 
 dress the baby something after the manner of the Esquimaux, i. e., in 
 what is called at the Sloane Hospital a cotton jacket and socks (see Figs. 
 261 and 262) which are easily made by stitching a layer of cotton to a 
 gauze backing of the shape shown. These are made in a few moments by 
 the nurse and are very useful in maintaining the baby's body heat. If in 
 this cotton jacket the baby's temperature tends to remain subnormal, 
 additional heat can be supplied by an electric pad or by hot-water bags, 
 great care being taken not to burn the baby. 
 
 In many cases even without an incubator or a superheated room a 
 good result may be obtained, in a baby not too premature, by the use 
 of the cotton jacket and an electric pad. 
 
 CAPUT SUCCEDANEUM AND CEPHALHEMATOMA. 
 
 Caput Succedaneum. — After a long labor the child's head usually 
 presents a swelling over the area which has been surrounded first by the 
 cervical ring and later by the vaginal canal and vulvar orifice. This 
 swelling is called the caput succedaneum and varies in its location on the 
 head according to the presentation and position of the fetus. Thus in 
 an occipito-anterior position of the vertex it is usually found over the 
 right parietal bone if the position was an L. O. A., and over the left 
 parietal bone if it was an R. O. A. The condition consists of an edema 
 of the scalp and is caused by absence of pressure on the head over the 
 area corresponding to the opening in the birth canal, while the walls of 
 the parturient canal firmly compress the rest of the head. It naturally 
 follows that the longer and more difficult the labor is, the greater will be 
 the edema of the exposed portion of the scalp and the size of the caput 
 succedaneum. On the other hand, if the labor has been rapid and easy 
 the caput succedaneum may be absent. If on account of the long tedious 
 labor there has been a marked molding of the fetal head, this molding, 
 
366 CARE OF CHILD IN ABNORMAL CONDITION AT BIRTH 
 
 together with the caput, may cause a disfigurement of the child at birth 
 which may be alarming to the parents and friends. They may be 
 assured, howe^•e^, that this disfigurement is only temporary and that in 
 from twent\-four to fort>-eight hours it will largely have disai)peared. 
 It needs no treatment save cleanliness of the scalp to avoid infection in 
 case there has been an abrasion of the scalp during the delivery. 
 
 Cephalhematoma. — Another swelling which may appear on the child's 
 head during the first week after birth is that of a cephalhematoma. It 
 differs from the caput succedaneum just described in ninnerous particu- 
 lars. While the caput is present and most marked at l)irth and rapidly 
 disappears, the cephalhematoma as a rule does not appear until several 
 
 Fig. 263. — Single cephalhematoma. 
 
 days after birth and then usually increases for several days. The cephal- 
 hematoma consists of an effusion of blood beneath the pericranium and 
 is therefore limited in extent by the sutures surrounding each cranial 
 bone. The caput succedaneum, on the other hand, involving only the 
 tissues of the scalp, may extend right over the sutures and fontanelles. 
 The cephalhematoma is caused by the rupture of a vessel between the 
 pericranium and one of the cranial bones which has received less support- 
 ing pressure during the labor than the rest of the fetal head. It is there- 
 fore due to relative absence of pressure over this area rather than to an 
 excess of pressure. The cephalhematoma may follow a breech delivery 
 as well as a vertex, although more common in the latter. It may be 
 single, as shown in Fig. 26-3 or double, as seen in Fig. 264. ^Yhile more 
 
CAPUT SUCCEDANEUM AND CEPHALHEMATOMA 
 
 367 
 
 common over one of the parietal bones, it may occur over the occipital 
 or one of the frontals. 
 
 Clinical Course. — As stated above, the cephalliematoma usually first 
 appears several clays after the birth of the child. It generally increases in 
 size for several days, remains stationary for a "^'eek or more and then, 
 as a rule, gradually disappears. Unless there has been an abrasion of the 
 scalp over the tumor it does not often become infected and the anxiety 
 of the family can be quieted by the assurance that the swelling is only 
 temporary and that it will probably have disappeared in from six to 
 eight weeks. In the process of absorption of the effused blood and return 
 of the pericranium to the bone a hard ridge of bony spicules can often 
 
 Fig. 264. — Double cephalhematoma. 
 
 be felt around the circumference of the cephalhematoma. As the fingers 
 pass from the surrounding area onto this elevated ridge and then down 
 on to the skull nearer the centre of the cephalhematoma the feel of a 
 depressed fracture of the skull is suggested. If it is remembered that in 
 the process of repair of a cephalhematoma and the reattachment of the 
 pericranium to the skull this elevated ridge of new bone projection is the 
 rule, the diagnosis is usually easy. Furthermore, the time elapsed since 
 the birth of the child and the absence perhaps of any possible trauma 
 during the labor should aid in the exclusion of fracture. 
 
 Treatment. — As the rule is that a cephalhematoma, provided it is not 
 infected, will absorb without treatment, the principle of treatment 
 consists of protection and cleanliness. If any abrasion of the scalp exists 
 
368 CARE OF CHILD IN ABNORMAL CONDITION AT BIRTH 
 
 near tlie cephalhematoma, it is well to disinfect this abrasion with tinc- 
 ture of iodin and then to j^rotect tiic swelling with a dressing of sterile 
 gauze in order to avoid any further abrasion. It is often desirable to 
 surround the swelling with a ring of gauze to prevent friction from the 
 pillow. The question occasionally arises in the case of a large cephal- 
 hematoma: Will the i)rocess of absorption not be hastened by aspira- 
 tion and the withdrawal of the fluid portion of the eft'used l)lood? The 
 author believes that this is not to be recommended, as there is always 
 more or less risk of infection in this procedure, and the avoidance of infec- 
 tion of the effused blood is the object especially desired. 
 
 If infection of the cephalhematoma has occurred it should be treated 
 on general surgical principles of opening and drainage. 
 
CHAPTER XI. 
 
 THE PUERPERIU:\I AND ITS :\L\XAGE:MEXT. 
 
 The piierperium is the term applied to that period immediately 
 following the birth of the child which is required for the return of the 
 uterus and parturient canal to its normal condition. The time usually 
 required is about six weeks, but this varies greatly with the muscle and 
 nerve tone of the individual. In some of the healthy women of the labor- 
 ing class the involution of the uterus is often as well advanced at two 
 weeks as in some in the so-called higher walks of life at four weeks. 
 
 ANATOMICAL AND PHYSIOLOGICAL CHANGES. 
 
 The Uterus. — At the end of pregnancy the uterus measures approxi- 
 mately 12 inches by 9 inches by 8| inches. It weighs about two pounds 
 and has a capacity of about 400 cubic inches. 
 
 At the end of the puerperium it measures approximately 3 inches by 2 
 inches by 1 inch, weighs about Ij ounces, and has a capacity of about 1 
 cubic inch. 
 
 This rapid decrease in size, called involution of the uterus, is well 
 illustrated by Fig. 265, which is a photograph of a uterus taken from a 
 woman who died of pneumonia on the day of her delivery. Although 
 not regaining its normal size until about six weeks after labor, the marked 
 reduction occurring within the first few hours of the puerperium is very 
 striking. The distinction between the upper and lower uterine segments 
 is well marked. The bloodvessels are constricted by the contraction 
 and retraction of the muscular fibers, thus making the upper uterine seg- 
 ment, although thick, appear firm and rather anemic. A good idea of 
 the vascular channels of the pregnant uterus can be obtained by inject- 
 ing a cadaver soon after delivery with formalin and then making a frozen 
 section of the uterus, as was done in Fig. 266. From this it is seen that 
 the uterus is riddled with vascular channels which are closed by the con- 
 traction and retraction of the uterus indicated in the preceding figure. 
 
 As time goes on the muscular fibers atrophy and the uterus decreases 
 rapidly in size so that by the tenth day of a normal puerperimn it has 
 returned to the true pelvis and can no longer be felt above the pubis. 
 
 The Endometrium. — The separation of the placenta and membranes 
 from the uterus taking place in the deeper portion of the spongy layer of 
 the decidua, there remains lining the uterus at the completion of the 
 third stage of a labor more or less of this spongy decidua which has an 
 irregidar surface infiltrated with blood. At the placental site the decidual 
 surface is more jagged, is raised abo^'e the rest of the uterine cavity, and 
 24 " (369) 
 
370 
 
 THE PUERPERIUM AXD ITS MANAGEMENT 
 
 the blood infiltration is greater. The superficial part of the decidual 
 layer undergoes necrosis and is cast off in the lochia while the deeper 
 portion is preserved, becomes transformed into connecti\'e tissue from 
 which, together with the fundi of the utricular glands which are left, a 
 new endometrium is constructed. 
 
 The Cervix. — Immediately after delivery the cervix is widely dilatable, 
 admitting even the cone-shaped hand. It is usually more or less lacerated 
 and shades off" into the vagina in such a Avay as to make its anatomical 
 
 Fig. 265. — Uterus of woman who died on the day of her delivery. 
 
 outlines indistinct. The lips of the cervix are edematous and at the 
 close of labor are often visible at the vuhar orifice. On the second day 
 the cervix has reestablished its anatomical landmarks, although the 
 internal os usually admits the finger at the end of a week and the external 
 OS always remains more patulous than in a nullipara. 
 
 The Vulva. — On the day following delivery the \ulva is still edematous 
 and tender and may be a source of discomfort to the patient. This swell- 
 ing and tenderness rapidly disappears, however, without treatment and 
 
ANATOMICAL AND PHYSIOLOGICAL CHANGES 
 
 371 
 
 is seldom mentioned by the patient after the third day. The lacerations, 
 if repaired under aseptic precautions, usually unite readily and are repre- 
 sented later simply by whitish cicatrices. 
 
 The Vagina. — The vagina after labor is patulous with relaxation 
 of both anterior and posterior walls. The tone rapidly returns to this 
 canal, although it remains a little more patulous than in a nullipara and 
 the nigse are a little less distinct. 
 
 After-pains. — In the first labor "after-pains" or painful contractions 
 of the uterus after the expulsion of the placenta are unusual. These 
 
 Fig. 266. — Frozen section, showing vessels of puerperal uterus 
 
 after-pains are usually due to the accumulation of small blood-clots in 
 the uterine cavity on account of imperfect contraction. They are com- 
 mon in multiparge and often increase with each labor, as each labor seems 
 to diminish the power of the uterus to contract and remain contracted 
 as it does in the first. 
 
 It is especially seen in labors where the uterus has been overdistended, 
 as in hydramnios, multiple preg^iancy, or in very tedious labors where 
 the uterine muscle has become tired out. 
 
 It is always wise for the obstetrician to provide for the relief of these 
 pains before he leaves the house of the patient, otherwise he is very apt 
 
372 
 
 THE PUERPERIUM AND ITS MANAGEMENT 
 
 to be disturbed during the night by a request for such reHef. A tablet 
 of codien, gr. ss, repeated in two hours usually serv^es this purpose well. 
 
 Where the pains are persistent, the use of the ice-bag o\'er the fundus 
 uteri often gives marked relief and maintains the contraction of the 
 uterus. 
 
 Occasionally the uterus will be found to be ballooned with blood-clots 
 and the patient be suffering intensely with after-pains. In such cases 
 if compression of the fundus does not empty the uterus it is sometimes 
 advisable in extreme cases to give a hot intra-uterine douche, or even to 
 clean out the clots Mith the sterile hand, then administer a dose of ergot 
 and apply the ice-bag to the fundus. 
 
 Fig. 267. — Lochia, first day. 
 
 The Lochia. — For two or three weeks after deli\ery there occurs a 
 discharge from the uterovaginal canal which is called the lochia. For 
 the first three or four days the discharge is composed chiefly of blood 
 mixed with decidual cells and epitheliiun from the cervix and vagina. 
 It looks bloody and is called the lochia mhra. It is alkaline in reaction 
 and has the odor of blood or fresh meat. The sources of the blood are 
 the large sinuses of the placental site, the torn vessels of the decidua, and 
 the various tears in the cervix, vagina or vulva. 
 
 For the next three or four days the discharge is lighter in color and 
 serous in character and is called the lochia serosa. 
 
 The disintegration and casting off from the uterine ca\'it\' of any 
 remains of decidua and the granulation of lesions in the parturient canal 
 
\n.rouicAL Ann PnyswwoiCAL changes 
 
 37J 
 
 Fig. 268.-Lochia. third day. 
 
 Fig. 269.— Lochia, tenth day 
 
374 THE PUERPERIUM AND ITS MANAGEMENT 
 
 now give to the lochia a whiter color, so that from about the se\'euth to 
 the fourteenth day, perhaps longer, it is called the lochia alba. 
 
 In some cases the lochia rubra or bloody lochia ])crsists for several 
 weeks. This is usually the result of improj)er involution of the uterus 
 which may arise from lack of nursing, from retained secundines, the 
 presence of fibroid tumors, posterior displacement of the uterus, etc. 
 
 It is more apt to be prolonged in multipara^ than in primipane. The 
 microscopic appearance of the lochia on the first, third and tenth, days 
 may be seen in Figs. 267, 208, and 2()9. 
 
 Odor. — It has already been stated that the odor of the lochia during 
 the first three or four days resembles that of blood or fresh meat. After 
 these first few days, as the mucus of the canal forms a larger proportion 
 of the discharge, the lochia has a peculiar odor of its own which every 
 obstetrician should become familiar with in order to recognize any depar- 
 ture from the normal. The odor of the normal lochia at this time always 
 reminds the author of smoked ham. It is altogether different from the 
 otl'ensive odor which the lochia sometimes assumes when more than the 
 normal amount of organic material is retained in the birth canal and this 
 organic material has been invaded with putrefactive bacteria. 
 
 Bacteria. — Thanks to the labors of Doderlein, Kronig, ^Nlenge, and 
 Williams, it is now established that during the first few days of the puer- 
 perium the normal, uninfected uterine cavity does not contain bacteria. 
 
 After the first few da^■s bacteria are found there but in the normal 
 condition they are not of the pyogenic varieties. ^Moreover, the vaginal 
 discharge during the normal puerperium, although containing numerous 
 harmless bacteria, does not contain p\ogenic organisms, with the excep- 
 tion of gonococci, which may have been present before or during preg- 
 nancy. The reaction of the vagina during pregnancy is acid but during 
 the puerperium is alkaline. 
 
 Amount. — The quantity of lochia varies greatly in different women. 
 In general the amount is greater if the woman does not nurse her child 
 and the resulting stimulation of uterine contractions is absent. 
 
 The amount has been estimated as follows: During the first four 
 days 1 kilogram, or 2| pounds, during the next two days 270 grams, or 
 9 ounces, during the next three days 200 grams, or 7 ounces. The whole 
 amount being about 85 pounds. This estimation, however, is of very 
 little practical value and the frequency' of change of vulvar pads needed 
 and their normal appearance is of much greater importance to the 
 obstetrician. 
 
 The normal amount of lochia should not require change of vulvar pads 
 oftener than every four hours. The appearance of the pads on the 
 first, third and tenth days is shown in Figs. 270, 271, and 272. 
 
 A marked diminution in the amount of the lochia, and especially an 
 absence of lochia before the proper time, should be looked upon with 
 suspicion as being suggestive either of retention or infection. 
 
 Perspiration. — During the first week of the puerperium this function 
 of the skin is greatly increased and for a woman at this time, especially 
 after sleeping, to find herself bathed in perspiration is a very common 
 
ANATOMICAL AND PHYSIOLOGICAL CHANGES 375 
 
 picture. It seems to be one of nature's ways for eliminating waste pro- 
 ducts in the process of general involution incident to the puerperium. 
 It has an important clinical bearing in the fact that a woman with dress 
 wet with perspiration is more subject to chilling and colds when exposed 
 
 Fig. 270. — Vulva pad, first day. 
 
 to draughts, and the chilling of the breasts may cause or increase the 
 congestion of them. 
 
 Diet. — Regarding the diet of the patient following her delivery opinions 
 differ somewhat from those formerly held, and the idea that a woman 
 should be kept upon a very light and purely fluid diet for several days 
 
 Fig. 271. — Vulva pad, third day. 
 
 after her confinement is rapidly losing ground. Aside from milk, broths 
 and gruels, the author is accustomed to allow eggs and toast even during 
 the first twenty-four hours of the puerperium. Weak tea and coffee 
 are allowable, if the patient is accustomed to them, but cocoa once or 
 twice a day is preferable as tending to stimulate the secretion of the 
 
 Fig. 272. — Vulva pad, tenth day. 
 
 milk. A gruel made from corn meal is also of value in stimulating milk 
 secretion. 
 
 The Bowels. — During the first twenty-four to forty-eight hours of 
 the puerperium there is usually little tendency toward a normal evacua- 
 
376 THE PUERPERIUM AND ITS MANAGEMENT 
 
 tion of the bowels, and for several reasons. They have usually been 
 thoroughly evacuated during the labor; but little nourishment is taken 
 during this period and on account of the sudden decrease in intra-abdomi- 
 nal pressure it requires quite a little time for the intestines to adjust 
 themselves to the greater abdominal room and renew normal peristalsis. 
 
 They should not be allowed to go unmoved longer than forty-eight 
 hours, except perhaps in cases of complete laceration of the sphincter, 
 and if the patient suffers with tympanites she may be relieved by an 
 enema at any time. 
 
 On the third day, i. e., at the end of about forty-eight hours, it is well 
 to move the bowels thoroughly with a saline, and for this purpose it is 
 the author's custom to administer from one-half to one bottle of the 
 liquor magnesii citratis. This is agreeable to most patients and, especially 
 if followed by an enema, is usually effectual both in emptying the bowel 
 and also in relieving the breasts which are apt to be congested at this 
 time. 
 
 The Bladder. — Even if the perineum has been sutured it is wiser 
 to let the patient urinate voluntarily, if she can, rather than to use the 
 catheter. 
 
 It is so easy to start a cystitis by the use of the catheter, even if great 
 care is observed, that the author always prefers to avoid the catheter 
 if possible. If the perineal wound is gently irrigated with some weak 
 antiseptic solution like bichloride (1 to 5000) after each urination no harm 
 seems to result from the flow of the urine over it. It must be borne in 
 mind, however, that many women secrete urine very rapidly after con- 
 finement and that on account of the swelling of the urethra many are 
 unable to void it. For these reasons it is well to instruct the nurse to 
 catheterize the patient every eight hours if she is unable to empty her 
 bladder voluntarily. For this purpose the freshly boiled glass catheter 
 is usually preferable to the soft rubber and should be introduced by sight, 
 not by touch, i. e., after disinfecting the hands the labia should be well 
 separated and held apart by the fingers of the one hand, the vestibule 
 thoroughly cleansed, and the catheter passed directly into the meatus 
 without touching the labia. In some women the secretion of urine is so 
 rapid that the catheter has to be used every six hours for a time, both 
 for the comfort of the patient and to prevent the distention of the bladder 
 interfering with the contraction of the uterus. 
 
 Nursing. — Until the secretion of milk is established in the breasts 
 which is usually on the third day, sometimes on the second in multip- 
 arse, the baby should be put to the breasts only infrequently. 
 
 The author's custom is to have the baby put to the breast as soon as 
 the mother has had a rest and to repeat this every four hours during the 
 da>time, but not at night until the secretion of milk is established. 
 
 During this period the baby should not remain at the breast longer 
 than five minutes at a time, for if allowed to remain longer the nipple 
 is very apt to be made tender and perhaps becomes abraded. That it 
 should be put to the breasts during the colostrum period, however, is 
 important for several reasons. 
 
VISITS OF THE OBSTETRICIAN 377 
 
 1. It stimulates the contraction of the uterus which is much needed 
 at this time. 
 
 2. The colostrum serves as a laxative for the baby and aids in emptying 
 its intestines of meconium in preparation for the milk which is soon to 
 be secreted. 
 
 3. The nursing of the baby upon the breasts tends to stimulate their 
 function and hastens the milk secretion. 
 
 On the occasion of the next visit of the obstetrician he should note the 
 height of the fundus, the amount of the lochia, the temperature and pulse 
 of the mother and w^hether she has been able to urinate or not. 
 
 The condition of the baby should also be noted : its color, its tempera- 
 ture, whether it has taken hold of the nipple well, whether it has urinated 
 or not, and whether its bowels have moved. 
 
 Visits of the Obstetrician. — The number of calls the obstetrician should 
 make upon his patient depends of course upon many different circum- 
 stances — the distance of the patient from the physician, the smoothness 
 of her convalescence, the condition of the baby, etc. The author can 
 give no better rule than to mention his custom in the care of an obstetric 
 case in a large city like New York which is as follows: 
 
 Two visits for the first one or tw^o days; then one visit a day until the 
 end of the second w^eek, followed by a visit every other day until the four 
 weeks have expired. The question naturally arises as to how long an 
 obstetrician should remain in charge of the case. This depends upon 
 whether he is the general family practitioner who has attended the woman 
 in confinement as he would attend her through an attack of pneumonia, 
 or whether he is recognized as an obstetrician, a specialist to whom 
 obstetric cases are referred and who devotes special time and study to 
 this branch. To the visits of the general practitioner there should be no 
 rule of limitation, for after the convalescence of the mother he is needed 
 for the supervision of the baby and perhaps for other medical needs in 
 the family. 
 
 For the specialist, however, there should be a hard-and-fast rule, and the 
 one which has seemed to the author the most satisfactory is to limit the 
 visits to one month and then refer the patient back to the physician by 
 whom she was referred, or, if not referred to him by a physician, to recom- 
 mend her either to a pediatrist or to a general practitioner. It is always 
 a mistake for the obstetrician to remain in charge of a referred case for 
 a moment after his services as obstetrician are needed. It is also a mis- 
 take for the obstetrician to prescribe for any ailment of any other member 
 of the family while attending a referred obstetric case. He will retain 
 the respect and good will of the family physician who referred the case 
 only by performing his services as obstetrician and referring the patient 
 back to him at the end of the obstetric month. 
 
 Furthermore, even if the case comes to the obstetrician independently, 
 without being referred, the most satisfactory rule of practice is to refer 
 the patient to some one else at the end of the obstetric month as after 
 that there is no good "line of demarcation" where the obstetrician can 
 say his services are no longer needed, for the baby may contract some 
 
378 THE PUERPERIUM AND ITS MANAGEMENT 
 
 contagious disease, and to leave the baby when it is ill without oU'ending 
 the mother is a nn)st difficult precedure. As suggested above the only 
 satisfactory rule is the obstetric month for the ohstetricuiu. 
 
 The Obstetrical Fee. — A word here regarding the obstetrical fee may 
 not be amiss. Of course every obstetrician has a method of his own, 
 a method of doing his work, a method of charging, a method of book 
 keei)ing. 
 
 Furthermore he usually has or should have a reason for his method. 
 
 The method of charging, which after many years of active obstetrical 
 work has seemed to the author the most satisfactory, has been to charge 
 an inclusive fee, stated to the family beforehand, which will include the 
 care during confinement and also the visits during the obstetric month. 
 Office or house visits and examinations of the urine during pregnancy 
 are not included in this fee, and if on account of an operative delivery the 
 services of one or more assistants are needed an additional charge is made. 
 
 The author's reason for including in his obstetrical fee the puerperal 
 visits is as follows: The obstetrician's chief aim is, or should be, the 
 welfare of the mother and her child. If everything is not progressing 
 absolutely smoothly it is a great comfort, alike to the patients and obstet- 
 rician, for him to feel that he can make as many visits each day as he 
 wishes to assure himself that conditions are satisfactory, or to attempt 
 to make them so. 
 
 Visits of Friends. — During the first week of the puerperium the quieter 
 a patient can be kej)t the better. This means that visitors outside the 
 immediate members of the family should be excluded — a field for the 
 exercise of great tact on the part of the obstetrician. 
 
 It is usually necessary to allow the mother and perhaps the mother- 
 in-law, scmietimes the father and occasionally the father-in-law to see 
 the patient in the first twenty-four hours, but other members of the 
 family can usually be pacified by being shown the baby. In this connec- 
 tion attention may well be called to the fact that visitors with colds or 
 other infections about them are a source of danger in the nursery and 
 should be excluded. 
 
 It should be remembered that on the day following a confinement a 
 patient often seems stronger than she really is. The contrast to the .suffer- 
 ing of the day or night before, the realization that the dreaded event 
 is over, the joy of the presence of the newborn babe — her own, all con- 
 spire to a condition of exultation which produces a false appearance of 
 both physical and nerve strength in the mother which may be mis- 
 leading. 
 
 She probably feels stronger than she will on the third day when the 
 breasts distend and begin their function of lactation. The strength of 
 the patient should be conserved to meet the future demands and, further- 
 more, excitement from visitors may through vasomotor action favor 
 uterine relaxation. 
 
 Outline of Convalesence. — One of the first questions asked by the 
 patient or her friends is in regard to the duration of her stay in bed or 
 in the house. The author's outline of privileges is as follows: 
 
LACTATION 379 
 
 Any time after the fourth day, if there has been no perineal operation, 
 the patient may sit on the commode long enough to void urine or evacu- 
 ate the bowel. It is better not to try to have a movement of the bowels 
 on the first day of her sitting up on the commode lest she feel faint. 
 
 On the ninth day she may sit up in bed for an hour and on the tenth 
 day she may sit up for an hour in a chair. 
 
 After the tenth day she may add an hour each day to the time she sits 
 up until she has the privilege of sitting as long as she desires, better 
 dividing the time between morning, afternoon, and evening. 
 
 At the end of three weeks she walks about the floor and at the end of 
 four weeks she is allowed downstairs and out for a drive. 
 
 LACTATION. 
 
 One of the most important problems which the obstetrician has to 
 face, next to the mechanical problem of delivery, is the nourishment of 
 the baby he has brought into the world. If the mother has a well- 
 developed breast with a good milk supply the solution of the problem 
 is usually easy, but unfortunately this is often not the case. One of 
 the penalties of modern civilization seems in many instances to be an 
 inability on the part of the mother to supply proper food either in quantity 
 or quality for her child. The exact reason for this is often obscure. 
 
 In some cases the grandmother and the great-grandmother of the 
 child were unwilling to nurse because unwilling to spare sufficient time 
 from their social duties. In other cases the overtaxing of the nervous 
 system by study or social duties at a time when the pelvic organs and 
 breasts should have been developing has left imperfect development in 
 each. Fortunately at the present time the laity are so well educated to 
 the fact of the importance of a good breast of milk for the well-being of 
 the child, and the annoyance and anxiety sometimes associated with 
 artificial feeding, that most mothers are willing, if not anxious, to nurse 
 their child at least for a few months. The ability to nurse a child success- 
 fully is one of the greatest blessings alike to mother, to child, and to 
 obstetrician. It brings mother and child together in every sense of the 
 word as nothing else can or will, and develops a maternal love which 
 those deprived of it do not realize. To the child it usually means peaceful 
 days and nights and a steady gain. To the obstetrician it generally 
 means absence of anxiety as far as the child is concerned. As long as 
 nothing equals a good breast of mother's milk for the nourishment of the 
 child it is important that the obstetrician should understand both the 
 anatomy and the physiology of the breast. 
 
 The Breast. — The anatomy of the breast has already been described 
 (see page 50). It will be sufficient in review simply to mention the fact 
 that its secreting structure consists of from 15 to 20 lobes which in turn 
 are composed of a number of lobules. The canals of the lobules unite 
 to form the excretory ducts of the lobes, called the lactiferous duds, 
 which, 15 to 20 in number, converge toward the nipple on the surface 
 of which thev terminate. 
 
380 
 
 THE PUERPERIUM AND ITS MANAGEMENT 
 
 Colostrum. — During the latter part of pregnancy and the first two or 
 three days of the i)uerperium there can be expressed from the nipple a 
 thin, yellowish fluid called colostrum. The yellow color is usually assigned 
 to the colostrum corpuscles. According to Kiduie it is due to a pigment 
 resembling the coloring matter in the cells of the corpus luteiun. This 
 yellow color may be very slight but usually just before the secretion of 
 the true milk it is very pronounced. The colostrum is composed largely 
 of serum albumen and coagulates on boiling. It contains more protein 
 and more salts than the average woman's milk, but less sugar and less 
 fat as will be seen from the following tables quoted from Holt:^ 
 
 Fig. 273. — Human milk, first day, showing colostrum corpuscles. 
 
 Colostrum. Average woman's milk. 
 
 Fat 2.04 3.50 
 
 Sugar 3.74 7.00 
 
 Protein . 5.71 1.25 
 
 Salts 0.28 0.20 
 
 Water 88.23 88.05 
 
 Colostrum has a specific gravity of 1.030 to 1.040 and is alkaline in 
 reaction. Under the microscope (see Fig. 273) it is seen to consist of 
 large, granular bodies called colostrum corpuscles, and fat droplets of 
 various sizes. 
 
 The colostrum corpuscles are cast off epithelial cells which have under- 
 gone fatty degeneration. 
 
 * Diseases of Infancy and Childhood. 
 
LACTATION 
 
 381 
 
 The appearance in the microscopic field difl'ers greatly from that of 
 the perfect emulsion seen in normal human milk (see Fig. 275). On the 
 third or fourth day in primiparse, often at the close of the second day in 
 multiparse, the breasts become engorged; they feel hot, full and tender 
 to the patient and on palpation they feel larger and firmer, and the 
 distended milk ducts can be easily palpated. The fluid which can be 
 expressed from the nipple has now increased and contains more of the 
 fat droplets of ordinary milk intermingled with the colostrum corpuscles 
 (see Fig. 274). Colostrum has little nutritive value but is supposed to 
 act as a laxative and clear the baby's intestinal canal of meconium and 
 so prepare the way for milk digestion. 
 
 Fig. 274. — Human milk, third day. 
 
 As the days go by the colostrum corpuscles are seen to diminish and 
 the even, perfect emulsion of normal human milk (see Fig. 275) takes 
 the place of the irregular emulsion seen in colostrum. The colostrum 
 corpuscles should have disappeared by the tenth or twelfth day. 
 
 Woman's Milk. — Normal woman's milk is bluish-white in color and 
 is usually, even when freshly drawn, amphoteric to litmus or slightly 
 acid to phenolphthalein. It varies in specific gravity from 1.026 to 1.036, 
 with an average of 1.031 at a temperature of 60° F. Under the micro- 
 scope woman's milk is seen to be composed of numerous round, fat drop- 
 lets of nearly uniform size (see Fig. 275) called milk corpuscles, suspended 
 in a clear fluid. Acetic acid when added to woman's milk causes small 
 flocculi, never the large, firm coagula as seen when it is added to cow's 
 
382 THE PUERPERIUM AND ITS MANAGEMENT 
 
 milk. The composition of average woman's milk is seen in tlie table given 
 al)o\e where it is compared with woman's colostrum. 
 
 Mother's Condition. — As the breasts become engorged and the secretion 
 of milk begins, the woman, especially if she is of a nervous disposition, 
 often shows quite a little general reaction. The breasts are hot and 
 l)ainful, she may have a headache and, especially if she is a primipara, 
 the nursing of the baby on the sensiti^'e nipples may give rise to so much 
 general discomfort that not infrequently a slight rise of temperature 
 accompanies the inception of lactation. 
 
 A temperature of 100° to 100.0° F., which appears on the third or fourth 
 day of the puerperium, w^iile the breasts are engorged as described above, 
 
 Fiu. 275. — Human milk, tenth day. 
 
 and subsides on the following day as the breasts soften and the milk 
 supply is taken care of by the baby, may well be assigned to the condition 
 of the breasts — a breast temperature. 
 
 It must be remembered, however, that this is also the time when infec- 
 tion is apt to show itself by a rise of temperature, and the obstetrician 
 must be careful not to overlook a beginning infection just because the 
 breasts are a little distended. Years ago many cases of infection were 
 assigned to the condition of the breasts and were called "milk fever." 
 As the knowledge of puerperal infection increased and it became known 
 that puerperal infection was wound infection, there arose a tendency 
 to deny the existence of milk fever and to assign all rises of temperature 
 in the puerperium to infection. I'ndoubtedly, as will be considered again 
 
LACTATION 
 
 383 
 
 under Puerperal Infection (see page 823), the pendulum ^\\•ung too far and 
 the fact lias now been established that painful distended breasts, especially 
 in a nervous woman, may give rise to a slight rise of temperature ^\-ithoiit 
 infection. 
 
 The Act of Nursing. — ]\Iost babies when put to the mother's breasts 
 will take hold and will suck as though always accustomed to it. Occa- 
 sionally, however, the situation is markedly different, and either on 
 account of the condition of the nipple, or the character of the milk, or 
 the strength, or vd][ of the baby, it will not nurse. 
 
 Depressed Nipple. — On account of the previous pressure of tight cloth- 
 ing, or the natural conformation of the nipple, or because the breast 
 is so distended and firm, the nipple does not project beyond the level of 
 the breast and there is nothing for the baby to get hold of. In such cases 
 it is necessary either to let the baby nurse for a time through a nipple 
 shield (see Fig. 276j which will draw out the nipple so the baby can grasp 
 it, or to draw it out mechanically with the breast pump, or breast pump 
 and fingers, so as to accomplish the same result. Sometimes the use of 
 the nipple shield for a moment or two will draw it out sufficiently so that 
 the shield may then be discarded 
 and the baby be directly applied 
 to the breast. 
 
 Character of the Milk. — In some 
 instances there is something in the 
 quality of the mother's milk which 
 gives the baby discomfort every 
 time it comes to the mother's 
 breast. Under these conditions the 
 baby soon refuses to nurse and the 
 indication is a careful examination 
 
 of the mother's milk and if possible an improvement in its condition 
 before trying again to have the baby take it. 
 
 The Strength of the Baby. — ^Babies which are premature, or are other- 
 wise enfeebled, may become so exhausted in their endeavors to obtain 
 nourishment from a mother's nipple through which the milk does not 
 come easily that they are unable to obtain sufficient nourishment. 
 When this is the case the baby should not be put to the breast for a 
 time, but the mother's milk should be drawn off artificially and given to 
 the baby in a bottle, or in some cases by a medicine dropper, or even by 
 gavage. 
 
 The Will of the Baby. — It is astonishing how early the baby will develop 
 a will of its own. If it has been fed with sugar solution, or a preparation 
 of milk from a bottle with a nipple through which the fluid flows easily, 
 the baby may so much prefer that method to sucking hard on a breast 
 from which the food does not come readily that it will refuse to take 
 the breast. This situation calls for much patience and tact on the part 
 of the nurse. She must be careful not to overtax the mother by too pro- 
 longed endeavors to make the baby take hold and nurse, for a crying 
 baby, especially her own crying baby, refusing to take the nipple is cer- 
 
 FiG. 276. — The Sloane Hospital nipple shield. 
 
384 THE PUERPERIUM AND ITS. MANAGEMENT 
 
 tainly a nerve-wearing object; on the other hand, it is only by patience, 
 gentleness and perseverance that the baby is persuaded that the mother's 
 breast is the proper source of nourishment and that by a little effort of 
 its own it can satisfy its hvmger. In some cases, if the baby is strong and 
 well, it may be necessary to let the baby skip a feeding and in common 
 parlance "starve the baby to it." This, however, should be done under 
 the supervision of the obstetrician. 
 
 It is often possible to coax the baby to the nipple by expressing a little 
 of the milk from the breast first so as to soften the breast and start the 
 milk flowing more freely, also by taking off the yellow, colostrum fluid 
 first, the subsequent, more normal milk may be more attractive to the 
 baby. 
 
 Furthermore, by leaving the nipple bathed with milk or sugar solution, 
 the baby may be induced to take it. These are some of many methods 
 in the "coaxing" process. As a rule, if the baby for one or two nursings 
 will take the breast normally, the battle is won and no further trouble 
 need be expected. 
 
 Frequency of Nursing. — During the interval between the birth of the 
 child and the establishment of the milk secretion, i. e., for two or some- 
 times three days after birth, the baby should be put to the breast only 
 every four hours and only during the daytime and allowed to remain 
 there only five minutes. The reasons for this have already been stated 
 (see page 376). During this period the amount of fluid needed by 
 the baby is supplied in the shape of a 5 per cent, sugar solution or plain 
 boiled water given at regular intervals, usually between the nursings. 
 With the establishment of the milk secretion regular habits of nursing 
 should be instituted. During the first week of the baby's life it usually 
 needs seven feedings in the twenty-four hours. This means that during 
 this time the baby should be put to the breast every three hours during 
 the daytime. It is desirable to disturb the mother as little as possible 
 during her sleeping hours, although during the first week it may be neces- 
 sary in the interest of the hahy and the comfort of the mother's breasts 
 to have the baby nurse twice between the hours of 10 p.m. and 7 a.m. 
 This should be reduced to once as soon as possible. 
 
 Duration of Nursing.— Babies and breasts vary greatly in the time 
 required to saipply the infant with a proper amount of milk at a single 
 nursing, and this is sometimes best determined by the scales. As a rule, 
 however, a normal baby at a normal breast during the first month will 
 obtain a sufficient amount of nourishment in from eight to twelve minutes. 
 If the milk flows very freely this may have to be reduced to six minutes 
 and the baby may not care to nurse longer. If, on the other hand, the 
 milk flows very slowly and the baby is large and strong, twenty minutes 
 may be allowable. This should be considered the limit of time for a single 
 nursing and is usually not reached until the baby is several months old. 
 
 Care of the Breasts and Nipples. — ^This may usually be summed up in 
 two words, support and cleanliness. 
 
 As the breasts become engorged and heavy, they tend to sag and the 
 ducts, not being so easily emptied, tend to become distended, especially 
 
LACTATION 385 
 
 in the outer and lower quadrants, and distended ducts tend to become 
 inflamed. Hence it is that as a prophylactic measure the breasts should 
 be supported and the breast binder as indicated in Fig. 242 be applied 
 not later than the second day. The breast binder should be worn until 
 the patient is up and about, when she can wear a loose-fitting corset. 
 It should be applied snugly anough to give support but not tightly enough 
 to markedly compress the breast and so diminish the milk supply. 
 
 The nipples should be cleansed with boric acid solution before and 
 after the nursing. The secret of success in the care of the nipples is 
 cleanliness. The liability to trouble with the nipples is lessened if they 
 have been bathed regularly during pregnancy with the borax and alcohol 
 solution recommended on page 153. 
 
 During the interval between nursings the nipples should be protected 
 by a little square of sterile lint on which is spread some sterilized petrola- 
 tum. This prevents the binder from sticking to the nipple and removing 
 some of the epithelium when it is loosened. If the nipple becomes 
 abraded, an astringent application like the glyceritum acidi tannici is 
 very beneficial. 
 
 If an actual crack of the nipple occurs the wisest treatment is the 
 touching of the crack with 8 per cent, solution of nitrate of silver, applied 
 with a thin layer of cotton on a toothpick, and then letting the baby 
 nurse through a shield for a few times. If the crack in the nipple is 
 deep and difficult to heal it is often wise to discontinue the nursing 
 for twelve to twenty-four hours, expressing the milk in the meantime. 
 
 "Caked" Breast. — If the ducts of the breast become distended and 
 inflamed, perhaps from sagging, or insufiicient emptying, or from chilling 
 of the surface, or perhaps from the combination of all three causes, we 
 have a condition sometimes called "caked" breast or threatened mastitis. 
 This condition may be accompanied by a rigor and a rapid rise of tem- 
 perature and pulse, the temperature going perhaps to 103° to 105° F. 
 
 The treatment is usually best summarized as follows: Empty the 
 breasts. Empty the bowels. Apply ice. 
 
 The breasts should be emptied as much as possible by the baby, per- 
 haps letting it nurse twice in succession on that breast rather than in 
 alternation with the other. The breast should be further emptied by 
 gentle massage by the nurse perhaps as often as every two hours, care 
 being taken not to bruise the breast tissue during the manipulation. 
 
 In some cases the breast is so tender that the breast-pump accomplishes 
 the purpose with less discomfort to the patient. 
 
 Emptying the bowels with a saline cathartic like Epsom salts or 
 Rochelle salts is a valuable adjuvant in depletion of the breast. 
 
 The use of the ice-bag on a nursing breast was formerly thought to be 
 a most dangerous procedure, but is now regarded one of the most valuable 
 methods of treating a painful, engorged breast, and may be used freely 
 not only in conditions of inflammation, but in any condition of painful 
 distention. If a condition of actual mastitis exists, all massage and 
 nursing at the breast should be discontinued. The pain is often relieved 
 by enveloping the breast with a cold, wet dressing of alum acetate 
 25 
 
386 
 
 THE PUERPERIUM AND ITS MANAGEMENT 
 
 solution or with ichthyol ointment. As soon as evidences of pus are 
 detected radial incisions and free drainage are distinct indications. In 
 making the incisions in a woman's breast, not only should the future 
 usefulness but the cosmetic effect should be considered. The incisions 
 should be radial so that as few milk ducts as possible are severed. The 
 areola should if possible be avoided so that the pigmented area of the 
 breast may not be disturbed in the cicatrix. The upper quadrants of 
 the breast, especially the upper inner quadrant, should if possible be 
 avoided. 
 
 Axillary Breast Tissue. — Occasionally supernumerary masses of milk 
 ducts occur in the axilla anrl as the breasts become engorged these axillary 
 masses become swollen and painful (see Fig. 277). As a rule they give 
 annoyance onlj^ for three or four days and the application of the ice- 
 bag is the only treatment needed. 
 
 Fig. 277. — Axillary Ijreast tissue. 
 
 Quantity and Quality of Milk. — At the present day it so frequently 
 happens that a woman's milk is unsatisfactory in either quantity or 
 quality that it is important for the obstetrician to ascertain both of 
 these conditions. 
 
 Quantity. — In general there are two varieties of methods for ascer- 
 taining the quantity of woman's milk: 
 
 1. Non-instrumental methods. 
 
 2. Instrumental methods. 
 
 Non-instrumental Methods. — These may be classified as follows: 
 
 (a) By noting the time baby nurses. 
 
 (6) By noting the time baby sleeps. 
 
 (c) By inspection, pali)ation, and expression. 
 
LACTATION 387 
 
 Time Bahy Niirses. — The mother may say ''Oh, yes; I have an abun- 
 dance of milk; my baby nurses for half an hour." This is pretty positive 
 exndence that the quantity is insufficient, otherwise the baby would be 
 satisfied in a much shorter time and could not be induced to nurse longer. 
 
 Time Baby Sleeps. — If the baby goes to sleep immediately after nurs- 
 ing, but in a half to one hom- wakens and seems hungry, it frequently 
 means that the quantity obtained at the last nursing was insufficient. 
 
 Inspection, Palpation, and Expression. — One is often surprised in the 
 character of a woman's breasts. Some buxom-looking women with large 
 breasts have very little gland tissue and secrete very little milk. On the 
 other hand, some thin women with relatively flat breasts, wih secrete 
 an abundance of milk. The fact is that the large breast may be com- 
 posed chiefly of fat and be of very little value as a source of nourishment 
 for the baby, while the thin, small breast may be composed chiefly of 
 gland tissue and may secrete freely. 
 
 These facts can best be ascertained by inspection and palpation of 
 the breasts and then noting the readiness with which milk can be expressed 
 from the nipple. In the satisfactory breast the cord-like ducts can be 
 felt and the milk easily expressed; in the unsatisfactory breast it may 
 be found that the nipple on which the baby has been nursing for several 
 days yields scarcely a drop of milk. Breasts vary greatly as to the 
 amount of milk present between nursings. Some breasts have consider- 
 able milk in them all the time, while in others the milk seems to be 
 secreted just at the time of the nursing, and the nursing from one breast 
 may even cause milk to flow from the nipple of the other breast as well. 
 
 Instet^iextal Methods. — There are two instruments for determining 
 the quantity of a mother's milk which are almost indispensable in the 
 nursery. 
 
 1, The scales. 
 
 2. The thermometer. 
 
 The Scales. — Formerly the chief use of the scales in the nursery was 
 to ascertain the weight of the baby at birth and if the weight was exag- 
 gerated a little it was no disparagement to the scales. Any subsequent 
 weighing of the baby was largely a matter of curiosity to determine if 
 the baby had gained more in a month than the neighbor's baby. 
 
 The use of the scales in the present-day nursery is considered just 
 as much a routine daily procedure as giving the baby its bath. It not 
 only tefls by the steady increase in the weight of the baby that the 
 mother's milk is sufficient in quantity, but is also a strong argument in 
 favor of the quality of the milk being as it should be. Furthermore, by 
 accurately weighing the baby before and after nursing, just the amount 
 of nourishment obtained from the breast can be told. 
 
 The type of scales to be purchased for the nursery is a matter of con- 
 siderable importance. It should embody three principles: 
 
 1. It should have a firm standard. 
 
 2. It should have a capacious scoop or basket. 
 
 3. It should register half-ounces, preferably with an arm along which 
 the weight is passed (see Fig. 278). 
 
388 
 
 THE PUERPERIUM AND ITS MANAGEMENT 
 
 The question of a firm standard is one of great importance, as was once 
 demonstrated in the writer's experience. He had advised the style of 
 scales recommended above, but as the family had in the house a scales 
 
 Fig. 278. — Scales for weighing infants. 
 
 of the butcher type, with dangling scale pan, they thought this would 
 answer and employed this, suspended from the gas fixture to weigh the 
 baby. Everything went well for a few days but one morning during one 
 
 
 
 
 WEEK OF AGE | 
 
 LBS 
 
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 Fig. 279. — Infant's weight chart. 
 
 of the baby's customary jumps and kicks in the scale pan it fell out, 
 striking its head on the floor. Fortunately the baby recovered, but with 
 a misshapen head, the result of its fall. 
 
LACTATION 389 
 
 The average weight of a baby at term, as seen from the records of 5000 
 consecutive full-term labors at the Sloane Hospital, is seven pounds 
 three ounces. During the first three days of the puerperium the baby 
 loses on the average about ten ounces. The reason for this initial loss 
 in the baby's weight lies in the discharge of meconium and urine and the 
 excess of tissue waste over noi^ishment taken during the first few days 
 prior to the establishment of normal lactation. 
 
 "With the inflow of mother's milk the baby begins to gain and under 
 proper conditions gains from half an ounce to one ounce per day. It is 
 expected that a baby on its mother's milk will have regained its birth 
 weight in ten days. A bottle-fed baby not infrequently may require 
 a month to get back its birth weight. 
 
 The normal weight curve of a healthy baby may be seen in Fig. 279. 
 
 The actual amount of milk daily secreted by a woman varies greatly 
 in different individuals, but the following estimates, determined by 
 weighing the baby before and after each nursing, may be considered a 
 fairly accurate average. 
 
 During the first two weeks, beginning with the establishment of lacta- 
 tion, 5x-xx. 
 
 During the second two weeks of the puerperium, §xx-xxx. 
 
 The Thermometer. "While this instrument has for many years been 
 considered necessary in the care of ill babies, the author can well remem- 
 ber when its use in the case of a healthy baby was unheard of. Like 
 the scales it has come to be regarded an important instrument in the 
 proper care of a baby and its routine daily employment a necessity. It 
 is one of the best instruments for determining that the baby in the first 
 few days of its existence is obtaining sufficient nourishment. Although 
 there are many exceptional causes of rise of temperature, the most 
 usual cause of a baby's high temperature in the first two or three days 
 is insufficient nourishment, especially fluid, and this temperature is often 
 spoken of as "inanition fever" or "starvation temperature." 
 
 The frequency of occurrence of this rise of temperature may be learned 
 from the fact that in a consecutive series of 500 babies born at the Sloane 
 Hospital, 135 showed this fever. The highest temperature was usually 
 reached on the third or fourth day and the average duration was three 
 days. 
 
 In about two-thirds of the cases the temperature did not rise above 
 102° F., although in 9 it reached 104° F., and in one 106° F. The descent 
 to normal as soon, as the baby received sufficient nourishment was usually 
 sudden, although occasionally gradual. 
 
 The babies during the inanition fever usually lose weight steadily and 
 do not begin to gain until the temperature reaches normal. In the series 
 of 135 cases at the Sloane Hospital the loss of weight among those with 
 inanition fever was double that of those without fever. In 1 case it 
 amounted to twenty-eight ounces. 
 
 Before this condition was well understood the author met with a very 
 sad experience in the family of a friend which illustrated it. The first 
 baby in this family, nursing from its mother's breast, which was appar- 
 
390 
 
 THE PUERPERIUM AXD ITS MANAGEMENT 
 
 ciitlx funiisliin^ sufficient nourisliinent, but was not, suddenly ran a 
 liiflli temi)eraturt\ tlie skin became dry, the fontanelle dej)ressed. The 
 baby faded Uke a flower and died apparently of exliaustion. 
 
 The second child, a boy, weighed at birth Sj pounds and was apparently 
 \igorous. During the first fort\-eight hours its loss in weight was 5| 
 ounces. During the next twenty-four hours he lost S ounces. His 
 temperature had then gradually risen till it reached 102. S° F.; his lips 
 and skin were dry; the fontanelles depressed and the child apathetic. 
 Smce the experience wath the preceding child the condition of inanition 
 fever hafl become recognized and now on attempting to express milk 
 from the mother's nipples it was found impossible. The child was 
 immediately given water freely and before midnight a wet-nurse with 
 abundant milk supply was secured and by the following morning the 
 baby's temperature was normal and remained so. 
 
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 Fig. 280. — Temperature chart. Inanition fever. 
 
 During the next four days he gained 18 ounces. The temperature 
 chart of this case is shown in Fig. 280. The thermometer showed the 
 danger to which the baby was exposed. 
 
 The rectal temperature of the baby should be taken night and morning 
 for the first ten to fourteen days and once a day after that during the 
 obstetric month. A rise of temperature in the first few days, other condi- 
 tions being normal, should always suggest a lack of fluid nourishment. 
 If the mother's milk secretion is delayed the baby should either be 
 given sugar solution every three hours, or put upon a weak formula of 
 modified milk. 
 
 Mixed Feedings. — Some women, although unable to furnish from the 
 breasts the entire amount of nourishment needed by the baby, can fur- 
 nish a certain amount, whicli agrees perfectly with the baby. Under 
 
LACTATION 391 
 
 these circumstances it is wise to make use of mixed feedings, i. e., supple- 
 ment the mother's milk with a certain number of bottles of modified 
 cow's milk. The method of using supplemental food varies in different 
 cases. Some women, if they are allowed to have an uninterrupted sleep 
 at night by the substitution of a bottle for the breast at night, are able 
 to supply the rest of the nourishment without difficulty. 
 
 With other women the baby needs more frequent supplemental feed- 
 ing and here it is usually the best plan, after determining by weighing 
 the baby before and after nursing, just how much the baby obtains from 
 the breast, to give after each nursing a bottle containing sufficient modi- 
 fied milk to make up the required amount. The method of nursing at 
 the regular intervals and giving a supplemental feeding if needed is 
 usually better than alternately giving the breast and the bottle, as under 
 the less frequent stimulation of the breasts the milk supply rapidly 
 diminishes. 
 
 Quality. — ^Aside from the quantity of the mother's milk, the fault may 
 lie in the quality of the milk supplied to the baby. 
 
 In order to recognize the abnormal character of milk the obstetrician 
 should familiarize himself with the normal constituents. 
 
 Woman's milk contains fats, sugar, protein, salts, and water. 
 
 Fats. — The fats are the chief source of animal heat. Their caloric 
 value being more than double that of the carbohydrates or the protein. 
 
 Thus 1 gram of fat yields 9.3 calories, while 1 gram of either 
 carbohydrate or protein yields only 4.1 calories. The fats are very impor- 
 tant in the normal development of the nervous system and in bone growth. 
 They save nitrogenous waste and increase the body weight. Fat serves 
 an important function in maintaining the proper consistency of the 
 stool. 
 
 Thus even an excess of fat over that needed for absorption is of value 
 when properly digested, but attention must be called to the fact that in 
 some instances the baby has difficulty in digesting fat and even the 
 butter-fat of woman's milk which is much easier to digest than the butter- 
 fat of cow's milk may cause trouble. The fat in woman's milk is in the 
 form of an emulsion of minute globules in an albuminous solution. 
 
 Sugar. — The sugar of woman's milk is in the form of lactose and is in 
 solution. Its proportion is very uniform, and as it too is one of the sources 
 of animal heat, its uniformity is important. The sugar is partly converted 
 into fat and so increases body weight. 
 
 Protein. — This is a constituent of food which is essential to the life 
 and development of the child since it is the only kind of food capable of 
 replacing the nitrogenous waste of the body. It is also essential for the 
 growth of the cells of the body, hence in the infant a relatively large 
 amount is required. The chief forms of protein in woman's milk are 
 casein and lactalbumin. The casein is held in suspension by the calcium 
 phosphate with which it is combined, while the lactalbumin is in solution 
 and resembles the serum albumin of the blood. 
 
 The Mineral Salts. — ^These are more important in early infancy than 
 later in life because essential in the building up of the osseous system of 
 
392 THE PUERPERIUM AND ITS MANAGEMENT 
 
 the body. The most important of the mineral salts are the phosphates 
 of lime and magnesium which are found in abundance in woman's milk. 
 Water. — A large percentage of all animal food is water. It is important 
 in woman's milk for the solution of some of the constituents, as the sugar, 
 the salts and some of the protein and the suspension of the rest of the 
 protem and the fat emulsion. Woman's milk contains such a large per- 
 centage of it, as seen in the table given below, that when the baby is on 
 breast milk as its sole diet, little additional water is required. The 
 amounts of these different ingredients in normal woman's milk may be 
 seen from the following table: 
 
 NORMAL WOMAN'S MILK. 
 
 Fat: In minute globules in permanent emulsion, 3.5 per cent. 
 
 Sugar: As lactose, 7 per cent. 
 
 Protein: The most important forms are casein and lactalbumin, 
 casein held in suspension by calcium phosphate, and lactalbumin in 
 solution, 1.25 per cent. 
 
 Salts: All in solution except calcium phosphate, 0.2 per cent. 
 
 Water: 88.05 per cent. 
 
 Examination of Woman's Milk. — Although for a complete analysis of 
 woman's milk the services of a trained chemist and a laboratory are 
 needed, an approximate clinical examination may be made by the 
 obstetrician by means of the Holt's milk set (see Fig. 281) which consists 
 of a lactometer and a cream gauge. With this set, some litmus paper 
 and a microscope, an approximate clinical examination of a woman's 
 milk can be made. 
 
 The specimen taken for examination should, according to Holt, be either 
 the middle portion of the milk, i. e., after nursing two or three minutes, 
 or better, the entire quantity from one breast, since the composition of 
 the milk will differ greatly according to the time when it is taken. The 
 first milk being slightly richer in protein and much poorer in fat, while 
 the last drawn from the breast is low in protein and high in fat. 
 
 The reaction is tested with litmus paper. 
 
 The specific gravity is taken with the lactometer (P'ig. 281 A) as with 
 an urinometer. Attention may be directed to the fact that the specific 
 gravity is lowered by the fat and raised by the other solids. 
 
 Estimation of Fat. — This is done by the use of the cream gauge 
 (Fig. 281 B), the' results of which, although only approximate, are 
 sufficiently accurate for clinical purposes. 
 
 The tube is filled to the zero mark with fresh milk and then allowed to 
 stand at the temperature of the room for twenty-four hours, when the 
 percentage of cream is read off. The ratio of the cream to the fat is 
 approximately five to three. Thus 5 per cent, of cream means 3 per cent, 
 of fat. 
 
 Sugar. — The percentage of sugar in woman's milk is so nearly constant 
 that it is disregarded in the clinical examinations. 
 
EXAMINATION OF WOMAN'S MILK 
 
 393 
 
 i.oiu 
 
 1,010 
 
 \ 
 
 L_J 
 
 Protein. — ^There is no accurate, simple method for determining the 
 amount of protein in milk, but an approximate idea may be obtained 
 from a knowledge of the specific gravity and the percentage of fat if 
 the sugar and salts are regarded as so nearly constant as not likely to 
 affect the specific gravity. The specific gravity will then vary directly 
 with the proportion of protein and inversely with the proportion of fat. 
 Thus high protein, high specific gravity; high fat, low specific gravity. 
 By this method can be told whether the protein is excessively high or 
 excessively low and is sufficient for practical purposes. 
 
 Effect of Diet on Woman's Milk. — 
 The sugar in woman's milk is but 
 little affected by her diet, but the 
 fat and the protein may be distinctly 
 influenced by it. The fat is increased 
 by a diet rich in fats and carbohy- 
 drates, especially if no exercise is 
 taken. It is decreased by shutting 
 oft* fats and carbohydrates, substi- 
 tuting vegetables therefor and in- 
 creasing the amount of exercise. In 
 general, a low diet lowers the fat. The 
 protein is increased by overeating, 
 especially of meats and vegetables, 
 with little exercise, and decreased by 
 the opposite course. All fluids tend 
 to increase the amount of milk and 
 the alcoholic malt extracts tend to 
 increase both the amount of milk 
 and the amount of fat. Certain 
 gruels, such as cornmeal gruel, have 
 a similar tendency. 
 
 Effect of Menstruation on Woman's 
 Milk. — Although amenorrhea is the 
 rule during lactation, not infre- 
 quently a nursing mother finds that 
 she is menstruating and this menstru- 
 ation once reestablished is apt to con- 
 tinue with more or less regularity 
 during the lactation period. The 
 
 question naturally arises, shall she continue nursing while menstruating? 
 The disturbance produced by menstruation varies greatly in different 
 individuals, but as a rule, even if there was marked dysmenorrhea before 
 pregnancy, after the birth of a child the disturbance is slight and the 
 baby is much less upset by the continuance of nursing from the breast 
 during menstruation than it would be by a change to artificial food. 
 
 Effect of Pregnancy on Woman's Milk. — The milk of a pregnant woman 
 is usually insufficient in quantity for a nursing infant and also is poor 
 in quality. For these reasons and also from the fact that the stimulation 
 
 B 
 
 Fig. 281. — Holt's lactometer and 
 cream gauge for examination of 
 woman's milk. 
 
394 THE PUERPERIUM AXD ITS MAX AGE ME NT 
 
 of the nipple by the suckling of the child tends to the production of a 
 miscarriage, nursing at the breast should be discontinued as soon as the 
 diagnosis of another pregnancy is made. 
 
 Effect of Nervous Impressions on Mother's Milk. — Dairymen hnd that the 
 cow who is i)lacid in disi)osition and is protected from sources of nervous 
 irritation, whether it be from dogs, from the bull, or from human beings, 
 gives the best milk to the growing calf. In like manner the mother 
 who is of a placid temperament and is not annoyed or nervously upset 
 by sources of irritation in the domestic or social world makes the best 
 human cow. 
 
 Some women by nature are unfitted for one of the highest privileges 
 and duties of motherhood — the nursing of their children. Nervous, 
 hysterical, irritable and without control, how could it be expected that 
 such a woman would give good milk? It cannot be expected and they 
 do not give it. 
 
 They may be able to nurse during the obstetric month while they are 
 under the care of the nurse and the obstetrician and are shielded alike 
 from the annoyance of the kitchen and the social world, but as soon as 
 they begin to mingle in society and take up the duties of life, the baby 
 usually suffers from indigestion, worries, does not gain and has to be 
 provided with some other source of nourishment. 
 
 The Wet-nurse. — Realizing that nothing equals good breast milk 
 for the nourishment of the baby it has been natural in the past, when 
 the mother's milk has failed, to turn first to a wet-nurse if one could be 
 found. 
 
 Fortunately, the knowledge of artificial feeding with modified cow's 
 milk has greatly increased, and although at times a wet-nurse is almost 
 indispensable to the life of the baby, she is looked upon at the present 
 day as a last resort, and as a rule only employed in the case of a premature 
 baby or one with whom all forms of cow's milk seem to disagree. 
 
 The reasons for this reluctance in the employment of wet-nurses are 
 obvious. The class of women who have been willing to accept such a 
 position has usually been of a low grade and people of refinement dislike 
 to have them in their households. ^Moreover, the fear of infection of the 
 baby with some constitutional disease, especially s\'philis or tuberculosis, 
 has not been groundless. There are times, however, when the life of the 
 baby hangs in the balance and a mother is willing to waive all feelings 
 of sentiment in the interest of the baby. 
 
 Selection of a Wet-nurse. — The most important thing in the selection 
 of a wet-nurse is that she should be healthy and especially that she 
 should be free from venereal diseases and tuberculosis. 
 
 Syphilis, the most important of these, can usually be detected by 
 means of the Wassermann reaction and the obstetrician, on whom 
 the responsibility usually rests in the selection of a wet-nurse, should 
 never recommend one unless she has been found negative to the Wasser- 
 mann test. The infection of a baby with gonorrhea by an attendant 
 suffering with it is so easy through the medium of the hands, clothing, 
 etc., that detection of it in the proposed wet-nurse is extremely important. 
 
NORMAL WOMAN*S MILK 395 
 
 Much can be learned from the history of the woman and her baby 
 but here, unfortunately, the story of the candidate cannot always be 
 relied upon. A history of marked vaginal discharge and irritable bladder 
 or symptoms of pelvic inflammation on the part of the woman and a 
 history of ophthalmia in the case of the baby should always be looked 
 upon with suspicion, but before gonorrhea can be positively excluded, 
 a physical examination should be made of the woman and a smear taken 
 from any vaginal discharge present. 
 
 In excluding tuberculous infection in the wet-nurse, not only should the 
 lungs be carefully examined, but search should be made for the cicatrices 
 of tuberculous abscesses especially in the neck where tuberculous glands 
 are so common. Having found the woman healthy both on general and 
 local examination the next question concerns her breasts. The object 
 desired is a good, healthy, human cow, with plenty of milk, which flows 
 freely through nipples which are easy for the baby to suckle. Here again 
 inspection, palpation and expression are important, for by them the 
 physical features of the breast and the abundance of the milk can be 
 determined. 
 
 Some wet-nurses with plenty of milk have to be excluded on account 
 of the nipples being so depressed that a baby who is feeble, as is likely to 
 be the condition in the case for which the wet-nurse is required, could not 
 extract it. 
 
 A breast, not too large, with prominent veins, a rather small but promi- 
 nent nipple, from which the milk can be expressed in a stream, presents 
 the most satisfactory picture. 
 
 The quality of the milk secreted by the proposed wet-nurse can be 
 determined in two ways. 
 
 1. By inspection of her baby. 
 
 2. By examination. 
 
 Much can be told from the condition of the baby of the proposed wet- 
 nurse. If it is gaining steadily, sleeps well, appears happy, has normal 
 stools and its skin is free from eruption, its mother's milk is in all proba- 
 bility good. This probability can be made a practical certainty by 
 examination with the milk set as indicated on page 392. 
 
 In the selection of a wet-nurse the obstetrician must not be too particu- 
 lar about the marriage of the candidate. Some of the best wet-nurses are 
 those who, having come from the outlying districts of the old country 
 where the marriage relations are lax and ignorance widespread, find them- 
 selves pregnant on landing on our shores and on leaving the maternity 
 hospitals have no better means of support than that offered by the 
 occupation of wet-nurse. Furthermore, there are certain advantages to 
 the family employing the wet-nurse, in having no husband around to 
 annoy by calling, or to upset the wet-nurse by reports as to the conditions 
 at her home. 
 
 One of the problems which often presents is, what to do with the baby 
 of the wet-nurse. In some instances, rare of course, it is wise to let the 
 wet-nurse bring her baby with her. The feeble baby of the patient may 
 be able to nurse only a little and unless the breasts of the wet-nurse are 
 
396 THE PUERPERIUM AND ITS MANAGEMENT 
 
 well eni])tie(l by the str()n<>; l)al)\' the milk supply rapidly (liiiiinishes. 
 As a rule, liowexer, the hahy of the wet-nurse has to he eared for either 
 in one of the foundlinji; h()sj)itals or hy one of the nurse's friends. 
 
 The diet of the wet-nurse in her new surroundings is a matter of con- 
 siderable importance. What she needs is f^ood, plain, milk-producing 
 food, not the luxuries of the table which would be likely to u})set her 
 digestion. Bread and butter, milk, eggs, cereals, cooked fruits, meat and 
 vegetables, once a day; cocoa, very little tea or coflfee; no alcohol. On 
 this dietary and with careful regulation of her" bowels with some such 
 laxative as cascara or phenolphthalein, and a little regular exercise each 
 day in the open air, the health of the wet-nurse will usually l)e main- 
 tained, and her health often means the health of the baby for whom her 
 services are sought. 
 
 Artificial Feeding. — As already stated the wet-nurse at the present 
 day is seldom necessary, and it may be added she is seldom desired, and 
 a good one is often very difficult to find when desired. From this it 
 follows that when artificial feeding is required cow's milk must usually 
 be accepted as a substitute. Goat's milk, which was formerly much used 
 for this purpose, is now almost never employed. A satisfactory substi- 
 tute for woman's milk must contain the same ingredients. In cow's milk 
 are found the same ingredients, but not in the same proportions. Further- 
 more, it is found that cow's milk differs so in digestibility from woman's 
 milk that when the proportions of the ingredients in cow's milk are made 
 to correspond with those in woman's milk the young baby does not 
 digest the food. However, as stated above, cow's milk contains the 
 ingredients of woman's milk and can be modified to suit the needs of the 
 individual baby. 
 
 The first requisite is to secure a good cow's milk and the first requisite 
 of good cow's milk is that it be clean milk from healthy cows. 
 
 Healthy Cows. — Just as in the selection of a wet-nurse it is considered 
 of the utmost importance that she be healthy, so in the selection of cows 
 for milk for infant feeding it is all essential that they be absolutely 
 healthy. Although the question of venereal diseases does not have to 
 be considered in them, as in wet-nurses, it is necessary to consider seri- 
 ously the question of tuberculosis. Tuberculous cows are not fit to supply 
 milk for anyone, least of all to babies, as young mfants are especially 
 liable to infection from bovine tuberculosis. From this it follows that 
 all cows which have not been subjected to the tuberculin test and proved 
 negative should be excluded from the dairy used for infant feeding. 
 
 Clean Milk. — INIilk to be clean must come from clean cows in clean 
 stables, milked by clean hands into clean utensils. This means that 
 the best milk for infant feeding comes from dairies where the cows are 
 kept with as much care as our best horses, where the stalls are kept clean 
 and well ventilated, wdiere the cows are carefully groomed, where the milk- 
 men during milking wear clean suits and have freshly washed hands, and 
 see that the udders and teats of the cows are clean before taking the milk 
 from them. Milking by electricity eliminates many of the dangers of 
 contamination. 
 
MODIFICATION OF COW'S MILK 397 
 
 The utensils into which the milk is received must have been recently 
 cleansed with hot water or steam and the milk thus received must be 
 cooled rapidly and kept cool until it reaches the consumer, which should 
 not be later than eighteen hours. These conditions are fulfilled in the 
 milk to which the Milk Commission of the County Medical Society of 
 New York allows the brand of "certified" and are observed with special 
 care in the dairies of those milk laboratories like those of the Walker- 
 Gordon Laboratory of New York and Boston, which make a specialty 
 of modifying cow's milk for infant feeding according to prescription by 
 physicians. 
 
 There is one other prerequisite to the license to use the brand "cer- 
 tified" on a bottle of milk; this is that the milk does not contain more 
 than ten thousand bacteria to the cubic centimeter. This condition 
 can only be fulfilled by observing the precautions of cleanliness mentioned 
 above, but the milk from a number of dairies where these precautions are 
 observed does not show more than five thousand bacteria to the c.c. 
 
 Herd Milk Compared to Milk from a Single Cow. — ^The statement is fre- 
 quently heard from a patient's family that they have a fine cow, perhaps 
 a Jersey, and they can have her milk kept just for the baby's food. It 
 is a duty to correct the impression that this is better or even as good as 
 milk from a herd. 
 
 No cow feels equally well on every day, and when not feeling well her 
 milk is not good. In a herd, although there are always some cows not 
 feeling in the best condition, the proportion is usually about the same and 
 as the majority are feeling well and the milk from these is but little 
 influenced by that from those not feeling well, the milk as a whole is much 
 more uniformly good than from a single cow, however good she may be 
 at the best. Moreover, as many babies have a difficulty in digesting 
 milk rich in fat, and milk from a herd composed solely of Jersey cows 
 usually contains a high percentage of fat, a herd composed, aside from 
 Jerseys, of a certain number of cows giving milk with a lower percentage 
 of fat, such as the Holsteins, has a distinct advantage. 
 
 Modification of Cow's Milk. — Having obtained a good, clean milk from 
 healthy cows, the next questions presenting themselves for consideration 
 are the differences between woman's milk and cow's milk and the modifi- 
 cation of the latter for infant feeding. 
 
 Woman's milk and cow's milk, as already stated, contain the same 
 ingredients, but in different proportions, as will be seen from the following 
 comparative table: 
 
 
 Woman's milk, 
 
 Cow's milk 
 
 
 average. 
 
 average. 
 
 Fat . . . 
 
 . 3.50 
 
 4.00 
 
 Sugar . 
 
 . 7.00 
 
 4.50 
 
 Protein 
 
 1.25 
 
 3.50 
 
 Salts . . 
 
 . 0.20 
 
 0.75 
 
 Water . 
 
 . 88.05 
 
 87.25 
 
 It is seen from the above that in cow's milk there is an excess of fat, 
 protein and salts and less sugar than in woman's milk. Moreover, in 
 modifying cow's milk for infant feeding not only must these differences 
 
398 THE PUERPERIUM AXD ITS MANAGEMENT 
 
 be considered, but also the presence of bacteria in cow's milk; its acidity 
 and the fact that the fats and the protein of cow's milk are more difficult 
 for the baby to digest than are those of woman's milk. 
 
 The individual modifications will now be considered. 
 
 Fat. — The amount of fat which a normal baby can digest varies from 
 1 to 4 per cent, and the usual rule of modification is to start a baby on 
 a dilution of cow's milk containing about 1 per cent, of fat and very grad- 
 ually increase it until it is able to digest 4 per cent, of fat which probably 
 will not be for several months. 
 
 Sugar. — ^The modification of cow's milk to correspond with woman's 
 milk, so far as sugar is concerned, consists simply in the addition of 
 sugar of milk until the required percentage is obtained. 
 
 Protein. — ^For a long time protein was considered the ingredient of 
 cow's milk which was the most difficult for the baby to digest. Riper 
 experience showed that the healthy child usually had more difficulty 
 in digesting fat than protein and in certain cases of disordered digestion 
 any of the ingredients of milk may cause trouble. Usually in the first 
 week the baby will easily digest 0.5 per cent, of protein, 1 per cent, at three 
 weeks and 2 per cent, at four months. Protein is important for the 
 nutrition and general development of the child and should not be kept at 
 a low percentage too long. The usual modification of the protein of cow's 
 milk to fit it for infant feeding is simply dilution, although if the baby 
 has difficulty in digesting it the milk can be peptonized. 
 
 Salts. — When cow's milk has been diluted so that the percentage of 
 protein is about right to give the baby, it is found that the amount of 
 total salts approximates that in woman's milk. This is seen in the follow- 
 ing table from Holt: 
 
 Cow's milk 
 Protein . . . .3.50 
 Inorganic salts . . 0.75 
 
 The dilution of the milk which gives a suitable percentage of fat and 
 protein so nearly adjusts the inorganic salts to the baby's needs that 
 they can usually be disregarded in preparing a formula for the baby's 
 food. 
 
 Bacteria. — The presence of bacteria in cow's milk and the fact that 
 there must be a relatively small number in milk suitable for infant feed- 
 ing has already been mentioned. The destruction of these bacteria in 
 modified milk will be discussed later under the head of Pasteurization. 
 
 Reaction. — ^As cow's milk is acid in reaction rather than amphoteric 
 to litmus paper, as is woman's milk, it follows that this excessive acidity 
 must be overcome. This is usually accomplished by adding 5 per cent, 
 of lime-water, or 1 ounce to each 20 ounces of food, although bicarbonate 
 of soda may be used. 
 
 Home Modification. — In the home modification of cow's milk for infant 
 feeding, aside from knowing that the milk is clean from healthy cows and 
 that the milk was cooled at once and kept cool until used, it is important 
 to know the percentage of fat in the milk used. In preparing the food 
 
 DUuted 
 once. 
 
 Diluted 
 twice. 
 
 Diluted 
 3 times. 
 
 Diluted 
 4 times. 
 
 1.75 
 0..37 
 
 1.16 
 0.25 
 
 0.87 
 0.18 
 
 0.70 
 0.15 
 
MODIFICATION OF COWS MILK 399 
 
 for the young baby, milk with considerable cream in it is desired. Cream 
 is but milk in which a large percentage of the fat has accumulated by 
 rising. Thus in the ordinary dairy of the farm where the night's milking 
 is placed in pans and allowed to stand until morning when the cream is 
 skimmed from the top of the pan, the milk as put into the pan has the 
 average composition of: 
 
 Fat, 4 per cent. 
 
 Sugar, 4.5 per cent. 
 
 Protein, 3.5 per cent., but the cream which is skimmed off in the 
 morning has most of the fat in it and its composition is: 
 
 Fat, 16 per cent. 
 
 Sugar, 4.5 per cent. 
 
 Protein, 3.5 per cent. 
 
 In other words, cream is nothing but fat milk. Cream obtained in 
 this way is called gravity cream, as distinguished from cream separated 
 from the milk by a centrifugal machine, which is called centrifugal cream. 
 At the present day most of the cream in the market is centrifugal cream 
 as it can be obtained and delivered twenty-four to thirty-six hours earlier 
 than by the gravity process. 
 
 It is well for the obstetrician to remember, in cases of emergency in 
 the country, that the gravity cream on the top of a pan of milk which 
 has stood for four or more hours is approximately milk with 16 per cent. 
 fat. 
 
 For infant feeding, however, it is the custom to use milk from a quart 
 milk bottle which has been filled at the dairy, cooled at once and kept 
 cool until used. This bottle of milk if kept quiet after filling will in four 
 hours have most of the fat at the top. If it has been transported to a 
 distance it should be allowed to stand for two hours in the refrigerator 
 to allow the cream to separate again. 
 
 As it is often necessary in infant feeding to have milk with different 
 percentages of fat, it is important to know the approximate amount of 
 fat in the milk at different heights in the bottle which has stood for four 
 hours or more, and how milk with different percentages of fat may be 
 obtained. As the cream rises the milk at the top of the bottle contains 
 a very high percentage of fat, perhaps 20 per cent., which rapidly decreases 
 as you descend until at one-eighth of the way down it is only 2 per cent., a 
 quarter of the way down only 1 per cent., and below perhaps only 0.5 per 
 cent. If the bottle is thoroughly shaken the percentage of fat will be that 
 of the average, i. e., 4 per cent. In baby feeding it is found that milk 
 containing 7 per cent, of fat is sufficiently rich, although it is often neces- 
 sary to have a milk with a lower percentage. The problem of the obstet- 
 rician is to obtain milk with 7 per cent, of fat and with percentages lower 
 than this. This is done by taking the top milk down to different levels 
 from a quart bottle which has stood until the cream has risen to the top, 
 thus: 
 
 Sixteen ounces from top of quart bottle 7 per cent. 
 
 Twenty ounces from top of quart bottle 6 " 
 
 Twenty-four ounces from top of quart bottle 5 " 
 
 Whole bottle shaken 4 " 
 
400 THE PUERPERIUM AND ITS MANAGEMENT 
 
 For the feeding of a healthy baby during the first month of its life, 
 and this is the function of the obstetrician, it is found that 7 per cent, 
 milk is usually the most satisfactory, and this is best obtained by dipping 
 as with a Chapin dipper the upper half from a quart bottle of milk in 
 which the cream has risen to the top (in order to prevent running over 
 when inserted the first dipper should be filled with a spoon). The for- 
 mula of this milk averages: 
 
 Fat . . 7 per cent. Sugar 4.5 per cent. Protein . . 3.5 per cent. 
 
 It may also be obtained in an emergency by taking one part of gravity 
 cream standing on a pan of milk which approximately would be: 
 
 and three parts of ordinary milk 
 
 Fat. 
 
 Sugar. 
 
 Protein. 
 
 16 
 
 4.5 
 
 3.5 
 
 ' 4 
 
 4.5 
 
 3.5 
 
 4 
 
 4.5 
 
 3.5 
 
 ^ 4 
 
 4.5 
 
 3.5 
 
 28 
 
 18.0 
 
 14.0 
 
 7 
 
 4.5 
 
 3.5 
 
 which would give as an average 
 
 Having obtained 7 per cent, top milk the next problem is the dilution 
 of this milk to suit the age, but more important, to suit the digestion of 
 the individual baby. No baby's digestion is determined by mathematics, 
 and no milk formula, however carefully worked out, is bound to agree 
 with every baby of the same age and weight. There is one principle, 
 however, which should guide the obstetrician. 
 
 The baby should be started on a food so weak that almost any baby 
 could digest it and then the strength and amount of the food should be 
 gradually increased as the baby shows its ability to digest more, care 
 being taken not to increase so rapidly in either strength or amount as to 
 upset the digestion or cause dilatation of its stomach. A baby whose 
 food is increased too rapidly in either strength or amount is apt to be so 
 upset as to require a considerable period of patient effort on the part 
 of those in charge before the regular gain is established. 
 
 If the baby seems well, sleeps well, has normal stools and gains a little 
 each week it is usually wise to be satisfied rather than to attempt to 
 surpass the neighbor's baby in weight. In preparing the baby's food 
 it is usually most convenient to make the amount 20 ounces or multiples 
 thereof. 
 
 The amount of lime-water needed to produce the required alkalinity 
 is 1 ounce in 20 ounces of food, or 5 per cent., and the amount 
 of milk-sugar which is required to be added is usually 1 ounce in 20 
 ounces of food, or 5 per cent. For these reasons, among others, 20 
 ounces is the amount of food usually first prepared. Now, how many 
 ounces of this 7 per cent, top milk shall be used in this 20 ounces of food? 
 As a rule a healthy baby of average size can easily digest on the second 
 day milk composed of 3 ounces of the 7 per cent, top milk with 1 ounce 
 of milk-sugar and 1 ounce of lime-water and diluent up to 20 ounces. In 
 
MODIFICATION OF COWS MILK 401 
 
 order to understand the percentage of fat, sugar and protein the baby is 
 getting the following formulae should be studied : 
 
 Fat. Sugar. Protein. 
 
 7 per cent, top milk 7 4.5 3.5 
 
 If 1 ounce of this milk is taken and diluted up to 20 ounces the result 
 would be as follows: 
 
 Fat. Sugar. Protein, 
 
 20)7.00 4.50 3.50 
 
 0.35 0.22 0.17 
 
 If 1 ounce of sugar is added to the 20 ounces it would be 5 per cent., 
 and would give 
 
 Fat. Sugar. Protein. 
 
 0.35 0.22 0.17 
 
 5.00 
 
 0.35 5.22 0.17 
 
 This is spoken of as 1 in 20 milk from 7 per cent, top milk. 
 If 3 ounces of 7 per cent, top milk are taken and diluted up to 20 
 ounces the result would be three times the 
 
 Fat. 
 
 Sugar, 
 
 Protein. 
 
 0.35 
 
 0.22 
 
 0.17 
 
 Fat. 
 
 Sugar. 
 
 Protein. 
 
 1.05 
 
 0.66 
 
 0.51 
 
 or 
 
 If 1 ounce of sugar of milk is added to the 20 ounces, or 5 per cent., 
 the result would be 
 
 Fat. Sugar. Protein. 
 
 5.00 
 
 1.05 5.66 0.51 
 
 This is a food which most babies can digest on the second or third day. 
 
 This is called 3 in 20 from 7 per cent, top milk. In the same way by 
 taking 4 ounces of the 7 per cent, top milk and diluting up to 20 ounces 
 and adding 1 ounce, or 5 per cent., of milk-sugar the result would be 
 
 Fat. Sugar. Protein. 
 
 1.4 5.88 0.68 
 
 and would be called 4 in 20 milk from 7 per cent, top milk. 
 Obtained in a similar way 5 in 20 milk would be 
 
 Fat. Sugar. Protein. 
 
 1.75 6.10 0.85 
 
 6 in 20 milk would be . 2.10 6.32 1.02 
 
 7 in 20 milk would be 2.45 6.54 1.19 
 
 As already indicated it is impossible to frame a schedule of strengths 
 of milk which all babies can follow and an average can only be suggested. 
 Usually a healthy baby will be able to digest a 4 in 20 milk by the 
 26 
 
402 THE PUERPERIUM AND ITS MANAGEMENT 
 
 fourth or fifth day; a 5 in 20 or a 6 in 20 milk in the second week and a 
 7 in 20 milk in the fourth week. As a rule the strength of the food is not 
 increased unless the stools show^ that the digestion is good, but the baby 
 is not satisfied. 
 
 The Amount of Food Allowed at Each Feeding.— This as well as the 
 strength of food varies with the individual child and no positive schedule 
 can be given. 
 
 The following schedule is intended merely to suggest the approximate 
 amounts allowable at the different stages: 
 
 First week 1 to l| ounces. 
 
 Second and third weeks 1^ to 3 
 
 Fourth and fifth weeks 25 to 4 
 
 Sixth to ninth week 3 to 5 
 
 Third to fifth month 4 to 6 
 
 Fifth to ninth month 5 to 7 
 
 Ninth to twelfth month 6 to 9 
 
 The Diluent. — The author's experience in feeding babies at the Sloane 
 Hospital leads him to believe that many babies, even during the first 
 month of life, are more comfortable, have more normal stools, and gain 
 faster if the diluent of the top milk is a w^eak barley-water rather than 
 plain water. The barley-water used is made as follows: A table- 
 spoonful of barley flour is added to a quart of water and cooked for 
 twenty minutes. 
 
 Instruction in Food Preparation. — Realizing the difficulty in instructing 
 the laity, especially the ignorant women of a hospital ward service, in 
 percentage feeding, the author has arranged an apparatus which, at a 
 nominal cost, can be placed in the hands of women leaving the hospital, 
 and which will enable them, after having been once shown, to prepare 
 a proper food for their baby, even should they know nothing of percen- 
 tage feeding. This apparatus is called the Sloane Maternity Milk Set, 
 and the description accompanying the set is as follows: 
 
 THE SLOANE MATERNITY MILK SET. 
 
 (Arranged by the Author.) 
 
 The set consists of a measuring glass holding twenty ounces (see Fig. 
 282), and a metal dipper (called the Chapin dipper) holding one fluid 
 ounce (see Fig. 283). 
 
 Directions for Use. — Get a quart bottle of good milk and let it stand on 
 ice or in a cool place for an hour so that the cream will show at the top 
 of the bottle. 
 
 Take sixteen dipperfuls from the top of the bottle, filling the first dipper 
 with a clean spoon and taking the remaining fifteen dipperfuls by dipping 
 carefully from the bottle. 
 
 These sixteen dipperfuls (called top milk) are to be mixed in a clean 
 pitcher and from the milk thus mixed the baby's food is prepared. 
 
 In using this milk set, Avhatever strength of food is desired, the sugar 
 
THE SLOANE MATERNITY MILK SET 
 
 403 
 
 Fig. 282 
 
 Fig. 283 
 
 and the lime-water are always the same : one ounce of milk-sugar (or a half- 
 ounce of granulated sugar) and one ounce (one dipperful) of lime-water. 
 
 The quantity of food made by filling the glass once is always the same 
 — twenty ounces. The strength of the food varies with the number of 
 dipperfuls of top milk used. 
 
 Preparation of the Food. — First. — Into the measuring glass pour milk- 
 sugar up to the line marked 1 ounce milk-sugar, or granulated sugar up 
 to the line marked half-ounce granulated sugar. 
 
 Secoxd. — Add one dipperful of lime-water and mix by shaking the 
 glass. 
 
 Thike. — Add the required number of dipperfuls of top milk according 
 to the age of the baby, as explained below. 
 
 FoFRTH. — Fill the measuring glass up to the line marked 20 ounces 
 of food, with water, either plain or barley-water. 
 
 During the first month it is usually 
 better to use plain boiled water, after that 
 barley-water. 
 
 Strength of Food for Different Months. — 
 First day: Give no milk; put in milk-sugar 
 to mark, then fill with boiled water. 
 
 Second day: Add two dipperfuls of top 
 milk. 
 
 Third day: 
 milk. 
 
 Fourth day 
 milk. 
 
 Fifth to tenth 
 of top milk. 
 
 Tenth to thirtieth day: Add six dipper 
 fuls of top milk. 
 
 One month to two months: Add 
 dipperfuls of top milk. 
 
 Two months to four months: Add eight dipperfuls of top milk. 
 
 Four months to nine months: Add ten dipperfuls of top milk. 
 
 When the baby needs more than 20 ounces in the twenty-four hours, 
 fill the measuring glass twice instead of once before putting the food into 
 the baby's bottle. 
 
 After nine months the food is prepared by shaking the quart bottle of 
 milk when first obtained and using the plain mixed milk. 
 
 After preparing the food put it (especially in hot weather) on the stove 
 and heat it until it simmers. It is then ready to be placed iii the baby's 
 bottles which have been thoroughly washed in hot soapsuds and rinsed. 
 
 The above directions are given for an average healthy baby. A frail 
 baby, or one whose weight is below the average, wUl need to have the 
 strength of food increased more slowly., A very strong, healthy baby may 
 have the strength of the food increased more rapidly. If the stronger 
 food does not seem to agree with the baby decrease the number of dipper- 
 fuls of milk used. 
 
 Add three dipperfuls of top 
 Add four dipperfuls of top 
 day: Add five dipperfuls 
 ipper- 
 seven 
 
 Figs 
 
 282 and 283. — Sloane 
 maternity milk set. 
 
404 
 
 THE PUERPERIUM AND ITS MANAGEMENT 
 
 B>' increasing or decreasing the number of dipperfuls of milk the food 
 can usually be adjusted to the child's digestion. 
 
 Amount of Food at Each Feeding for Different Ages. — First week, 
 1-1 1 ounces. 
 
 Second and third Aveeks, l|-3 ounces. 
 
 Fourth and fifth weeks, 2^-4 ounces. 
 
 Sixth to ninth week, 3-5 ounces. 
 
 Third to fifth month, 4-6 ounces. 
 
 Fifth to ninth month, 5-7 ounces. 
 
 Ninth to twelfth month, 6-9 ounces. 
 
 Bottles. — The milk having been modified to 
 suit the digestion of the baby and the number 
 of feedings and the amount to be given at each 
 having been decided upon, the next question is, 
 what sort of bottles shall be used in giving the 
 food to the baby? The best bottles are those 
 which can be most readily cleaned. Cylindrical 
 bottles so shaped that a straight stick like a 
 lead-pencil can reach each part of the inside (see 
 Fig. 284) meet the indication. 
 
 Bottles which are graduated on the side are a 
 convenience. As many bottles should be used as 
 the baby has feedings in the twenty-four hours, as 
 the food for the twenty-four hours should be made 
 up at once and apportioned to the different bottles, 
 which should be placed in the ice-box until needed. 
 
 Fig. 284 
 
 Fig. 285. — Auticolic uipple. 
 
 The bottles after using should be rinsed with cold water then washed 
 with hot soapsuds and a little brush, and once a day they should be put 
 in cold water and boiled for a half-hour, taken out and stood bottom up 
 until needed. 
 
 Nipples. — The nipple which can be applied directly to the bottle is 
 the best. The nipple connected to the bottle by a small rubber tubing 
 is almost impossible to keep clean and should be discarded. The nipple 
 with a bulbous end called the "anticolic" nipple, as seen in Fig. 285, is 
 a satisfactory one. 
 
 The size of the hole in the nipple is a matter of importance. It should 
 be large enough when the nipple is filled with water and held tip down- 
 
STERILIZATION OF MILK BY PASTEURIZATION 405 
 
 ward to allow the water to escape drop by drop but not large enough to 
 let it run in a stream. The rubber nipples should be washed with cold 
 water, then in hot soapsuds, and once a day boiled or steam sterilized. 
 They should then only be handled with clean hands. 
 
 Destruction of the Bacteria in Milk. — Knowing that cow's milk with 
 the ordinary methods of handling contains enormous numbers of bacteria, 
 and often pathogenic bacteria, it seems natural that the question of their 
 destruction should have forced itself upon the profession. A number 
 of years ago Jacobi, of New York, advocated boiling milk in small bottles 
 for infant feeding. This was still further popularized by Soxhlet, in 1886, 
 and gradually came into general use. This process of heating milk to 
 212° F., and maintaining it for one to one and a half hours, received the 
 name of sterilization and was productive of great good in checking the 
 spread of tuberculosis and diseases which may be carried through the 
 medium of milk, especially at a time prior to the modern endeavors to 
 obtain clean milk through healthy cows, clean stables, clean milkers and 
 clean receptacles. 
 
 It was soon found, however, that sterilized milk had disadvantages, 
 and that even this degree of heat did not make the milk safe for very 
 long, as the spores were not destroyed and at the temperature of the room 
 bacteria would soon develop again. INIoreover, the taste of the milk 
 was altered by sterilization. It was constipating and in a certain number 
 of cases it produced scurvy. This led to experiments along the line of 
 raising the milk to a lesser degree of heat than 212° F. It has been 
 found, chiefly through the work of Freeman of New York, that raising 
 the temperature of milk to 140° F. and maintaining it for forty minutes 
 is sufficient to kill the bacilli of tuberculosis, typhoid fever, diphtheria, 
 and from 98 to 99 per cent, of all other bacteria in milk. In addition, 
 nearly all the objectionable features associated with sterilized milk are 
 eliminated. The spores, however, are not killed and the milk after pas- 
 teurization must be cooled rapidly and kept cool until just before using. 
 As a rule pasteurized milk should not be kept over twenty-four hours. 
 
 Dr. Rowland G. Freeman, of New York, has devised a very simple 
 apparatus for pasteurizing milk for infant feeding, and his instructions 
 for its use are here given : 
 
 INSTRUCTIONS FOR USING DR. FREEMAN'S APPARATUS FOR 
 
 LOW-TEMPERATURE STERILIZATION OF MILK 
 
 BY PASTEURIZATION. 
 
 Pasteurization of milk consists in heating it rapidly to about 140° F., 
 retaining it at that temperature a definite time and then cooling it rapidly 
 to below 60° F. The apparatus is designed to accomplish this purpose. 
 It subjects the milk to a temperature of about 140° F. for 40 minutes. 
 
 The apparatus consists of a pail for water and a receptacle for the 
 bottles of milk. 
 
 The yail is a simple pail with cover. Extending around the pail is a 
 
406 
 
 THE PUERPERWM AND ITS MANAGEMENT 
 
 groove for indicating the level to which the pail is to be filled with water. 
 Inside the pail are three supports (Fig. 286, C) for holding the receptacle. 
 The receptacle for the bottles of milk consists of a number of hollow 
 cylinders fastened together. Surrounding and binding together the group 
 of cylinders is a wire (.4). It is this wire {A) which rests on the support 
 (C) when the milk is being heated (Fig. 286). Below the wire {A) are 
 three short wires (B). These wires (B) rest on supports (C) when the 
 receptacle is raised for cooling (Fig. 287). 
 
 1 . Fill the pail to the level of the groove with water, cover it and put- 
 it on the stove to boil, the receptacle for the bottles having been left out. 
 
 2. Fill the body of each bottle with milk or some modification of milk 
 in proper proportion for feeding; stopper with a wad of cotton batting 
 and ])ut in a refrigerator. If all the bottles which the receptacle holds 
 are not needed, fill the remaining cylinders with cold Avater. Each space 
 in the receptacle must be filled. 
 
 Fig. 286. — Freeman pasteurizer. 
 
 Fig. 287. — Freeman pasteurizer. 
 Receptacle raised for cooling. 
 
 3. When the water in the pail on the stove boils thoroughly, take the 
 bottles of milk from the refrigerator and put them in the spaces for them 
 in the receptacle. 
 
 4. Pour cold water into each of these spaces so as to surround the 
 body of the bottle. 
 
 5. Take the pail of boiling water from the stove and put it on a table 
 or mat. Do not put it on metal or stone. Be sure that the pail is still 
 filled exactly to the level of the groove and that the water is boiling 
 vigorously. 
 
 6. Set the receptacle containing the bottles of milk into the pail of 
 boiling water so that the wire (.4) will rest on the support (C), cover the 
 pail quickly and let it stand one hour. During this period the pail must 
 not be on the stove and the cover must not be removed. 
 
 7. Now uncover the pail and lift the receptacle and turn it so that the 
 wire (B) will rest on the support (C), thus elevating the top of the receptacle 
 above that of the pail. Put the pail, containing the receptacle elevated 
 in this manner, in a basin under a faucet to which a rubber pipe may be 
 attached connecting it with the pail (Fig. 287). The water will overflow 
 
STERILIZATION OF MILK BY PASTEURIZATION 407 
 
 from the pail into the basin. Or the pail may be stood under a pump, 
 fresh cold water being pumped into it every few minutes. 
 
 The above-described method of cooling is the best. When, however, 
 it is not possible to cool the milk in this way, the cooling may be accom- 
 plished by placing the receptacle containing the bottles of milk in iced 
 water, or by simply standing the bottles on wood in a refrigerator. 
 
 8. To warm the milk for use put the bottle containing it in a vessel 
 of cold water on a stove and leave it until it is warm. Use a fresh bottle 
 for each feeding. 
 
 9. Wash the bottles thoroughly after using, and once a day put all the 
 empty bottles in a kettle of cold water on the stove and let this water 
 boil for an hour. The bottles should then be taken out and stood bottom 
 up until used. 
 
 Milk sterilized by this apparatus may be used for food during the 
 following twenty-four hours. 
 
 The pasteurizer is made in two sizes, one holding ten 6-ounce bottles, 
 the other seven 8-ounce bottles. 
 
 Never use 6-ounce bottles in the 8-ounce receptacle. 
 
 Never use 8-ounce bottles in the 6-ounce receptacle. 
 
 Pasteurized Milk or Raw Milk, Which? — There is no denying the fact 
 that if it was certain that the milk was clean in the sense that it came 
 from healthy cows, that the strictest precautions as to cleanliness in the 
 stables, the dairy and among the dairymen had been observed, clean raw 
 milk would be better than pasteurized milk. In the warm weather 
 especially the milk in the cities has required so long a time in transporta- 
 tion (twenty-four to forty-eight hours) and the milk in the country is 
 so apt to come from uncertain dairies that the only safe milk for the 
 baby is pasteurized milk. The importance of heating milk in summer, 
 in order to keep it, has long been recognized by housewives who for 
 years have been in the habit of "scalding" milk, which generally means 
 setting the vessel containing the milk on the back of the range until it 
 "simmers." It is found that milk thus treated has been raised to about 
 the temperature to which so-called pasteurized milk is now raised. 
 
 Furthermore, an investigation of the Health Board of New York City 
 as to the condition of the milk in the tenements, found that the laity had 
 become so well educated as to the importance of heating milk before 
 using it for food for the baby that in a large majority of the families 
 some method of heating the milk was employed before the baby was fed. 
 
 This fact should be borne in mind : If there is any uncertainty about 
 the health of the cows or the hygiene of the dairy, and especially during 
 any epidemic of diphtheria, typhoid or scarlet fever, the only safe milk 
 is that which has been heated. 
 
 Peptonized Milk. — For babies having difficulty in digesting the protein 
 of cow's milk, a partial predigestion by an extract derived from the pan- 
 creas called extractum pancreatis, acting in an alkaline medium, as with 
 bicarbonate of soda added, is often of very great assistance. Many 
 babies who are not gaining on a given formula of milk will often start 
 at once to gain as soon as the milk is peptonized. Moreover, when a baby 
 
40S 
 
 THE PUERPERIUM AND ITS MANAGEMENT 
 
 can (li<i;('st a very weak formula of milk, and for the proper development 
 of the ehild a stronjier formula is desired, this ean often he digested when 
 peptonized. Thus peptonizing the milk until the baby can easily digest 
 the food which is natural for its age and weight has often a distinct 
 advantage. The most convenient method of ])eptonizing the food is by 
 means of the peptonizing tubes, which are on the market, which contain 
 the extractum pancreatis and the alkali in the same tube. One of the 
 tubes should be distributed among the different bottles prepared for the 
 twenty-four hours' food as follows: If there are eight bottles prepared 
 for the eight feedings, twenty minutes before feeding time one of the 
 bottles should be taken from the ice-box, the cotton stopper removed, 
 one-eighth of the contents of the peptonizing tube added to the milk, 
 the stopper replaced and the bottle stood in warm water for the twenty 
 minutes. It is then ready to be given to the baby. 
 
 Laboratory Milk. — Through the initiative of the Walker-Gordon Co. 
 there have been established since 1892-93 in Boston, New York and many 
 other large cities, milk laboratories where physicians can obtain by pre- 
 scription almost any formula of milk for infant feeding. The Walker- 
 Gordon Co. have their own farm where the milk is obtained under most 
 perfect hygienic conditions as regards cows, dairy and dairymen, and the 
 milk is under the constant supervision of a competent bacteriologist. 
 
 At the laboratory they have as available factors with which to fill 
 the different prescriptions: 
 
 Centrifugal cream containing 32 per cent, fat; 
 
 Separated milk from which the fat has been removed; 
 
 A 20 per cent, solution of milk-sugar; 
 
 Lime-water. 
 
 With these different factors a prescription for almost any percentage 
 of fat, sugar and protein can be filled and by using whey the percentage 
 of whey, protein and casein is varied. 
 
 The physician can thus order, as on the blank given below, milk for 
 his baby patient as he would order drugs from a drug-store, and the 
 annoyance of home modification be avoided. 
 
 
 
 Per cent. 
 
 Remarks. 
 
 
 Fat 
 
 Milk-sugar 
 
 
 Number of feedings 
 
 Amount of each feeding. 
 
 
 Protein 
 
 ■ Whey 
 
 Casein 
 
 
 Lime-water . 
 
 Heat to 
 
 ° F. 
 
 Diluent 
 
 
 
 
 Ordered for. 
 
 Date . 
 
 Signature , M.D. 
 
 Every obstetrician, however, should understand and be able to instruct 
 nurses and patients in the home modification of milk. 
 
 The Feeding of Premature Babies. — For the satisfactory feeding of 
 babies under four and a half pounds it is almost necessary to have breast 
 milk. Although great advances have been made in artificial feeding and 
 
THE FEEDING OF PREMATURE BABIES 409 
 
 occasionally a premature baby will live and thrive on modified cow's 
 milk, this experience is exceptional and an endeavor should always be 
 made to secure a wet-nurse if the mother of the premature baby is unable 
 to furnish proper breast milk. 
 
 A great deal of milk will not be required for premature babies, as their 
 stomachs are small and their digestions weak. At the Sloane Hospital 
 it is the custom to feed the incubator babies every two hours during the 
 daytime and less frequently during the night, giving them equal parts 
 of breast milk and 5 per cent, sugar solution, starting with 5ij o| the mix- 
 ture at each feeding and gradually increasing it to an ounce as the baby 
 grows stronger and the interval between feedings is increased. 
 
 The premature baby is at first unable to nurse directly from the breast, 
 hence the milk must be drawn with a breast-pump. If the services of a 
 wet-nurse have been secured it is often advisable to allow her to have her 
 baby with her, as should only the amount needed for the premature baby 
 be taken from her breasts the milk supply will soon diminish and perhaps 
 disappear. Furthermore, it is almost impossible to keep up the milk 
 supply in a breast if the breast-pump alone is used. 
 
 The baby of the wet-nurse, if healthy (it is specially important that it 
 is free from venereal disease), may be used not only to maintain the 
 milk supply of its mother, but by going occasionally to the breasts of 
 the mother of the premature baby develop them so that the wet-nurse 
 can soon be dispensed with. 
 
 At first the premature baby is often unable to suck its food through 
 a rubber nipple and has to be fed by means of a medicine dropper, but 
 as its strength increases, it readily takes the nipple; the diluent of the 
 breast milk is reduced; the interval between feedings is increased to two 
 and a half hours; it is allowed to go to the breast two or three times a 
 day, and finally nurses entirely from the breast and is taken out of the 
 incubator. A similar method of feeding premature babies is followed 
 if their body temperature is maintained by means of the heated rooms, 
 the electric pad or a cotton jacket and hot-water bottles. 
 
 Is the Food Agreeing with the Baby? — ^This question is ever present with 
 the one having the responsibility of the care of the baby during its early 
 life. If the baby seems well and happy, sleeps well, has normal stools 
 and is gaining steadily in weight, the question can be answered in the 
 affirmative. Of all the criteria of the agreement of the food with the 
 baby the stool, which represents the residue of that food, is one of the 
 best. For this reason it is not only important that the practical obstet- 
 rician should be familiar with the characteristics of a normal stool and 
 the various departures from the normal but should watch the baby's 
 stool from day to day and thus keep informed of this expression of its 
 digestion. 
 
 Stools. — During the first two days of life, before the milk is secreted 
 in the mother's breasts, the stools of the baby consist of the black, tarry 
 meconium which has been accumulating during fetal life and which may 
 be seen discharged at the time of birth, especially should the presentation 
 be a breech. 
 
410 THE PUERPERWM AND IT.S MANAGEMENT 
 
 The normal stool of the baby after the milk secretion is well established 
 in the mother's breast is bright yellow in color, smooth in consistency, 
 and without appreciable odor. 
 
 Various departures from this smooth, yellow consistency may occur 
 in the baby's stool without markedly affecting the baby's well-being. 
 Sometimes a change in tiie weather or a little overfatigue of the mother 
 will in some way cause such a change in her milk as to give the baby a 
 a green stool instead of a bright yellow one. This change is not thoroughly 
 understood and it can only be said that it is due to a substitution of bili- 
 verdin for bilirubin. 
 
 Lumps of undigested food usually called "curds" often appear in the 
 stool. Sometimes most of the stool is made up of these small, soft, 
 yellowish-white lumps, often with a little mucus. The lumps are usually 
 composed of fat and indicate an inability on the part of the baby to 
 digest all the fat of its milk. 
 
 Sometimes larger, smooth lumps of a yellowish-brown color appear, 
 fewer and harder than the fat curds just described. These are usually 
 composed chiefly of protein, perhaps coated with fat. This indicates 
 a fault in the digestion of the protein of the food and if they persist 
 may indicate a reduction in the percentage of protein if the baby is 
 artificially fed. 
 
 Loose green or greenish-yellow stools, followed after a time by the 
 appearance of mucus, may be due to an excess of either sugar or fat. 
 Large, dry, clay-colored stools, with a foul odor, are usually due to an 
 excess of fat. 
 
 In studying the stools of a baby the fact should be borne in mind that 
 the stool of a baby at its mother's breast may have a character bad 
 enough to suggest a change in the formula if it was on cow's milk and yet 
 the baby seems in general to be doing well and it is the part of discretion 
 not to make a change. 
 
 Caloric Value of the Food. — Li feeding a baby artificially it is often 
 of value to determine approximately the caloric value of the food it is 
 recei\'ing in order to determine if it is receiving a sufficient number of 
 calories for its weight. A baby at the end of the second week, weighing 
 7 to 8 pounds, usually requires about 300 calories. Suppose now it is 
 taking 8 feedings of 2| ounces each of 6 in 20 from 7 per cent, top milk. 
 That would be 20 ounces of 
 
 Fat. Sugar. Protein. 
 
 2.1 6. .32 1.02 
 
 as 
 
 1 gram of fat gives 9.3 calories. 
 
 1 gram of sugar gives 4.1 calories. 
 
 1 gram of protein gives 4.1 calories. 
 
 The percentage of fat 0.021 X 9.3 (caloric value of fat) = 0.195 calorie 
 in 1 gram of food. 
 
 The percentage of sugar 0.063 X 4.1 (caloric value of sugar) = 0.258 
 calorie in 1 gram of food. 
 
RETRACTION OF THE FORESKIN 411 
 
 The percentage of protein 0.01 X 4.1 (caloric value of protein) = 0.041 
 calorie in 1 gram of food. Total, 0.494. 
 
 1 liter of food = 0.494 X 1000 = 494 calories in 1 liter of food. 
 
 20 ounces = | liter = 328 calories in babies' food. 
 
 Commercial Infants Food. — An enormous number of these are upon the 
 market, some advertized as substitutes for woman's milk and to be used 
 alone, such as Nestle's food, malted milk, etc., and others recommended 
 to be mixed with cow's milk. 
 
 Although some of these foods are of value for a short time, when noth- 
 ing better can be obtained, their prolonged use is very apt to cause dele- 
 terious results, especially rickets and scurvy. Thej' all have the common 
 characteristic of containing a large percentage of carbohydrate usually 
 in the form of sugar and a low percentage of fat. Some of the babies are 
 fat and may look well in pictures, but they are not strong babies, as shown 
 in later infant life. These foods are occasionally of value when it is 
 desired to discontinue milk feeding for a short time, but as a rule if they 
 are to be used they should be substituted for the carbohydrate usually 
 added to cow's milk in its modification, and the lack of fat should be 
 made up by the addition of cream. During the obstetric month there 
 is seldom any excuse for their use. If, however, a woman taking an ocean 
 trip is unable to nurse her baby, they are of marked value. In such a 
 case the author prefers condensed milk, opening a fresh can each day 
 or else having one of the milk laboratories prepare the food for the journey, 
 pasteurizing it and packing it in ice before starting. 
 
 Condensed milk diluted twelve times for a baby under one month of 
 age and from ten to six times for an older baby, has the advantage that 
 it is sterile and the fats and protein of cow's milk are reduced to a degree 
 that almost any baby can digest and do well on for a short time. 
 
 TONGUE-TIE. 
 
 One of the minor operations which the obstetrician often has to perform 
 is that for a tongue-tie which is so pronounced as to interfere with the 
 baby's nursing. If on inspection the frenum is found to extend so far 
 forward as to prevent the projection of the tongue beyond the gum 
 and causes a marked furrow in the tongue on attempts in this direction, 
 the thin anterior portion of the frenum had better be divided. The 
 operation is easily done with sharp, blunt-pointed, sterile scissors, if 
 the opportune moment when the baby elevates the tongue and puts the 
 frenum on the stretch is waited for. 
 
 Two precautions are worthy of mention: 
 
 1. Only the thin anterior portion of the frenum should be cut. 
 
 2. If the baby shows any tendency to the hemorrhagic disease of the 
 newborn the operation had better be postponed until the baby is well. 
 
 RETRACTION OF THE FORESKIN— CIRCUMCISION. 
 
 The retention of smegma within a long, tight foreskin of a male baby 
 leads to an irritation of the penis which not infrequently leads the child 
 
412 THE PUERPERIUM AND ITS MANAGEMENT 
 
 into subsequent bad babits. For tbis reason tlie author advises routine 
 retraction of the foreskin in the second week of infant hfe and repetition 
 of tliis retraction by the mother or nurse often enouji;h to kee]) the parts 
 c4ean and free from retention of smegma. 
 
 In the author's service at the Sh)ane Hospital, where the patient 
 remains, as a rule, thirteen days after confinement, the routine procedure 
 is to retract the foreskin on the seventh and the twelfth days. 
 
 If the foreskin is very long and tight and does not retract easily after 
 one or two retractions, the author in private practice advises circumcision. 
 His preference is to perform the operation at about the end of the third 
 week, by wdiich time the baby has usually regained and passed his birth 
 weight and is able to endure a light anesthesia. The author usually 
 employs 4 sutures of catgut, size 00; one at the frenum, one on the dor- 
 sum and one on either side. After a trial of different methods of dressing 
 the following has been adopted as giving the best results: Powder the 
 glans freely with sterile talcum powder and apply a large square of sterile 
 cotton. Over this apply the diaper as usual. When the diaper becomes 
 wet and soiled, cleanse the parts with boric acid solution; dry them and 
 apply the sterile talcum powder and sterile cotton as before. The prin- 
 ciple of the treatment is to keep the parts clean and dry. Under this 
 procedure the baby seldom loses in weight; often gains as usual in the 
 twenty-four hours following the operation and the wound is completely 
 healed at the end of the obstetric month. Thus far the long, tight fore- 
 skin of the male baby has been under discussion. Of scarcely less impor- 
 tance is the long, tight prepuce of the female baby. Although the irrita- 
 tion is usually not noticed until the child is a little older, the author has 
 seen little girls of six months who were almost constant masturbators 
 when left alone, and were only cured by a "circumcision" similar in detail 
 to that of the male, removing the prepuce thoroughly. 
 
 OPHTHALMIA NEONATORUM. 
 
 The prophylactic treatment of the eyes at birth has already been dis- 
 cussed under the Management of Normal Labor (see page 337). It now 
 remains to consider the actual treatment of ophthalmia if infection of the 
 eye from the birth canal escaped the prophylaxis or if, as more often hap- 
 pens, infection came later from some extraneous source. As seen from 
 the statistics of the Sloane Hospital, it is seldom that after the prophyl- 
 actic treatment with 20 per cent, argyrol solution the gonococcus is 
 found in the smear from the cases of ophthalmia. 
 
 In a series of 10,000 consecutive deliveries at the Sloane Hospital there 
 were 237 babies with a purulent discharge from one or both eyes, giving 
 a frequency of 1 in every 42+ cases. Although smears were taken in 
 all of the cases the gonococcus was found in only 29. 
 
 Day of Onset of the Ophthalmia. — The day of the puerperium on which 
 the purulent discharge appeared is of interest as showing that many 
 cases became infected subsequent to birth. The possibilities of infec- 
 tion of the baby's eyes in a large obstetric service are numerous in spite 
 
HEMORRHAGIC DISEASE OF THE NEWBORN 413 
 
 of all precautions. The mother in handling and nursing the baby may 
 carry infection to the eyes, the baby itself may carry, through its hands, 
 infection to its eyes, or the nurse in attending to several babies may be 
 the medium of infection. 
 
 In the 237 cases in the above series the ophthalmia began : 
 
 On 1st day of puerperium in .... 1 
 
 "2d " " 10 
 
 "3d " " 6 
 
 " 4th " " 3 
 
 " oth " " 13 
 
 " 6th " " 26 
 
 " 7th " " 35 
 
 " 8th " " 41 
 
 " 9th " " 36 
 
 " 10th " " .29 
 
 " 11th " " 20 
 
 " 12th " " 11 
 
 " 13th " " 4 
 
 " 14th " " 1 
 
 " 17th " " 1 
 
 237 
 
 Treatment. — The treatment followed by the author at the Sloane Hos- 
 pital has been frec[uent irrigations of the eye from inner to outer canthus 
 with a saturated solution of boric acid ; the instillation of argyrol, 25 per 
 cent, solution every four hours, and the application of cold boric acid 
 compresses. The frequency of the boric acid irrigations should vary with 
 the severity of the infection and the amount of pus, the object being to 
 keep the eye as free from pus as possible. In the severe cases with rapid 
 accumulation of pus the affected eye or eyes should be irrigated every 
 fifteen to twenty minutes. In a few cases, in addition to the arg\Tol, 
 an occasional instillation of 1 per cent, nitrate of silver solution has been 
 employed. 
 
 Duration of Treatment. — ^The average duration of treatment has been 
 seven and six-tenths days. The shortest was two days and the longest 
 forty-nine days. 
 
 Results. — Of the 237 cases of ophthalmia occurring in 10,000 consecu- 
 tive deliveries 235 left the hospital in good condition with ^"ision unim- 
 paired. One left the hospital against advice and before the treatment 
 was completed. In 2 cases there was an opacity of a part of one cornea. 
 
 HEMORRHAGIC DISEASE OF THE NEWBORN. 
 
 Occasionally during the first week of infant life, and rarely later, 
 spontaneous hemorrhages occur in different parts of the body. These 
 hemorrhages are from the small bloodvessels; have no apparent connec- 
 tion with the delivery and are usually multiple. They may arise from 
 the mucous membrane of the alimentary canal, the blood appearing 
 either in the vomitus or in the stool; they may come from the navel; 
 they may appear subcutaneously in different parts of the body; there 
 may be a hemorrhage in the conjunctivae; behind the eye; from the 
 
414 THE PUERPERIUM AND ITS MANAGEMENT 
 
 penis; into the meninges or in any viscus. The amount of blood lost at 
 any one time is usually not great, but there is apt to be a continuous 
 oozing for several hours, perhaps days. 
 
 Frequency and Etiology. — The frequency of the disease seems to be 
 rather greater in hospital than in private practice. In a consecutive 
 series of 4000 deliveries at the Sloane Hospital there were 18 cases of 
 hemorrhage in the newborn, a frequency of 1 in 222+. Of these IS cases, 
 14 were normal deliveries, 2 were breech and 2 were forceps deliveries, 
 1 being a high forceps and 1 a median. As to the time of onset of the 
 hemorrhage, in all but 3 it occurred in the first week. In 5 it occurred 
 on the second day; in 6 on the third day; in 1 on the fourth day; 1 on 
 the fifth day; 1 on the sixth day; 1 on the seventh day; 1 on the eighth 
 da>- ; 1 on the fifteenth day ; and 1 on the nineteenth day. From this it 
 will be seen that the second and third flay are the most frequent times 
 of its occurrence and that it seldom appears after the first week. 
 
 The frequency of the source of the bleeding is of interest. Among the 
 18 cases, in 2 the hemorrhage came from the nose; in 3 from the mouth; 
 in 10 from the stomach; in 6 from the intestine; in 3 from the navel; 
 in 2 from the penis; in 2 it was cerebral; and in 2 it was subcutaneous. 
 Of the 18 mothers, G were primiparse and 12 multiparte. But little 
 is known concerning the exact etiology of the condition. In some cases 
 the mother is syphilitic. One of the mothers in the author's series of 18 
 gave a positive Wassermann reaction. In some cases the mother is anemic 
 and toxemic, l)ut it is a significant fact that all the mothers of this series 
 left the hospital in good condition. 
 
 Duration of the Disease. — The disease is usually of short duration and 
 the child which is to recover usually turns the corner within forty-eight 
 hours. A baby may ha\'e only one small hemorrhage, and then being able 
 to assimilate its food, its resistance and coagulating power of its blood 
 improves and no further bleeding occurs. On the other hand the hemor- 
 rhage may continue and increase in spite of treatment and the baby die. 
 The general condition of the baby usually shows considerable prostra- 
 tion and there is a loss of weight. The temperature usually rises as the 
 weight falls. 
 
 Fetal Mortality. — This varies markedly with the treatment and its 
 promptness of administration. In this series of 18 cases all but 1 were 
 treated with human blood serum. This 1 was a mild case and recovered 
 without it. Among the 17 treated with the serum there were 6 deaths, 
 the mother of 1 of the cases being distinctly syphilitic. 
 
 Treatment. — In the past various therapeutic remedies have been used 
 for this condition among which adrenalin, the lactate of calcium and 
 solutions of gelatin have been the most popular. The results from this 
 medical treatment were far from satisfactory. In 18 recorded cases at 
 the Lying-in Hospital, New York, as reported by Welch, there were 17 
 deaths. In 1910 Welch^ reported his use of human blood serum in 
 cases of hemorrhage of the newborn, having used it in 12 cases and 
 
 1 Normal Human Blood Serum as a Curative Agent in Hemophilia Neonatorum, The 
 American Journal of the Medical Sciences, June, 1910. 
 
HEMORRHAGIC DISEASE OF THE NEWBORN 415 
 
 succeeding in checking the bleeding in each case. At this time the 
 author in his service at the Sloane Hospital was using rabbit serum for 
 the same purpose, but although his results were better than with the 
 drugs previously employed, they were not as good as those of Welch with 
 human serum and the use of rabbit serum was abandoned and human 
 serum adopted in its place. 
 
 Dosage. — The blood is drawn into a sterile flask and allowed to coagu- 
 late. As soon as the serum has separated it may be withdrawn and 
 injected. Even in mild cases it is well to inject subcutaneously about 
 30 c.c. (10 to 15 c.c. at a time) during the first twenty-four hours. If the 
 case is a severe one this amount may be increased and given at shorter 
 intervals with safety and advantage. It is usually injected under the 
 skin of the back and is rapidly absorbed. The treatment should be con- 
 tinued until the bleeding ceases. Of late it has been found that if the 
 case is an urgent one it is not necessary to wait for the serum to separate, 
 but some of the Avhole blood may be taken from the mother's vein and 
 injected immediately beneath the skin of the baby's back. The author 
 has several times recently made use of this method with advantage. 
 
PART in. 
 PATHOLOGICAL PREGNANCY. 
 
 CHAPTER XII. 
 TOXEMIA OF PREGNANCY. 
 
 While in the majority of cases pregnancy pursues a normal physio- 
 logical course, disturbances of metabolism and faulty elimination with 
 associated pathological lesions are very frequent and present various 
 symptomatic pictures referred now to the stomach, now to the nervous 
 system and again to the liver, the kidney, the skin or the vascular sys- 
 tem. These varied symptom groups are collected by the practical obstet- 
 rician under the general term of toxemia of pregnancy and the puerperium, 
 which includes not only the pernicious vomiting of pregnancy but the 
 headache^ high-tension pulse, albuminuria, disturbances of vision, certain 
 skin eruptions, the nervous symptoms indicating a threatened eclampsia, 
 and even the eclamptic seizure itself. 
 
 The exact etiology of this toxemia is still unknown, but whatever it 
 may prove eventually to be, it is generally agreed that the symptoms 
 and pathological changes of the toxemia of pregnancy and the puerperium 
 are caused by some toxin or toxins circulating through the system and 
 that with this there is associated some fault in the elimination of the 
 products of metabolism. 
 
 PERNICIOUS VOMITING OF PREGNANCY OR HYPEREMESIS 
 GRAVIDARUM. 
 
 About one-half of all pregnant women suffer with more or less nausea, 
 and occasional vomiting during the early months of their pregnancy 
 especially in the morning. This usually begins in the early part of the 
 second month and ceases spontaneously in the latter part of the third or 
 early part of the fourth month. While some of this vomiting in the 
 early months may be toxemic in origin, and that occurring in the latter 
 months of pregnancy almost always is, there is a form of vomiting occur- 
 ring in the early months of pregnancy, often spoken of as "morning 
 sickness," which may be looked upon as reflex or neurotic and almost 
 a physiological accompaniment of pregnancy. This nausea and vomiting, 
 although most often occurring in the morning, may vary greatly in 
 different people, both in its time of occurrence and in its duration. In 
 27 (417) 
 
418 TOXEMIA OF PREGNANCY 
 
 some women it appears only at night and in others it may last throughout 
 the whole pregnancy instead of being confined to the early months. The 
 reflex or neurotic character of the vomiting can sometimes be demon- 
 strated by causing it to disappear by correcting a malposition of the 
 uterus, by prescribing a simple placebo, or by some other form of mental 
 suggestion. This form of vomiting is looked upon as extremely annoying, 
 and perhaps interfering with the mother's nutrition, but not ks a serious 
 condition. 
 
 On the other hand, thanks to the labors of Ewing, Stone, Williams, and 
 others, there is now recognized a distinct pathological vomiting called 
 "l)ernicious vomiting of pregnancy" or "hyperemesis gravidarum" with 
 definite ])athological lesions. 
 
 This vomiting is toxemic in origin and the condition of the patient 
 may become extremely critical and may even terminate fatally. The 
 trouble may begin as an ordinary morning sickness, but the complete 
 picture of the pernicious vomiting of pregnancy includes an emaciated 
 patient with flushed face, dry lips and tongue, with a sweetish odor to 
 the breath, a feeble pulse usually increased in frequency, temperature 
 usually a little subnormal until near the end, when as the toxemia increases 
 the temperature usually rises. There is inability to retain anything on 
 the stomach, frequent retching, perhaps vomiting of blood or coffee- 
 ground material, and the patient is often jaundiced. 
 
 To this clinical picture there are added definite changes in the urine 
 and distinct lesions in the liver and kidneys. 
 
 Changes in the Urine.— In this toxemic vomiting the urine is diminished 
 111 amount. It may contain but little albumin, perhaps a few casts. It 
 often shows acetone, diacetic acid, /3-oxybutyric acid and indican. It 
 ma\' contain blood, perhaps leucin and ty rosin. As pointed out by 
 Williams, in 1906, the nitrogen ratios in the urine of toxemic vomiting 
 differ markedly from the normal, showing a disturbance of proteid metab- 
 olism with faulty oxidation. The percentage of ammonia nitrogen is 
 increased, while that of urea nitrogen is diminished. 
 
 In order to interpret the abnormal it is necessary to understand the 
 normal nitrogen output, and for this reason the author placed in bed 
 for nine days at the Sloane Hospital for Women two normal pregnant 
 women in their last month of pregnancy. Their diet was solely milk 
 and water, the same diet which our toxemic patients would be likely 
 to receive and the nitrogen ratios in the twenty-four-hour specimens 
 of the women were determined by a professional chemist for each of the 
 nine days with the following results: 
 In one the average for the nine days was: 
 
 A.,,r„«„:„ .,;*..„ TT • Amido-acid and undetermined 
 
 Ammonia nitrogen. Urea nitrogen. nitrogen. 
 
 4., 37 per cent. * 84.63 per cent. 5.78 per cent. 
 
 In the other: 
 
 »„„„■■, ^^ . Amido-acid and undetermined 
 
 Ammonia nitrogen. Urea nitrogen. nitrogen. 
 
 5.95 per cent. 81.9 per cent. 7.09 per cent. 
 
PERNICIOUS VOMITING OF PREGNANCY 419 
 
 This makes the average for the two patients for the nine days: 
 
 Amido-aeid and undetermined 
 Ammonia nitrogen. Urea nitrogen. nitrogen. 
 
 5.16 per cent. 83.26 per cent. 6.43 per cent. 
 
 These figures may be regarded as fairly accurately representing the 
 normal nitrogen ratios of normal pregnant women on milk-and-water 
 diet in the last month of pregnancy. 
 
 In the experience of the author the cases of pernicious vomiting have 
 shown, as a rule, a high ammonia nitrogen and a low urea nitrogen and 
 as the patient has become worse the percentage of ammonia nitrogen 
 has increased and that of urea nitrogen decreased. Furthermore, as the 
 patient has improved the opposite condition has prevailed, viz., the 
 ammonia nitrogen has decreased, while the urea nitrogen has increased. 
 This is shown by the urinary findings in the following case occurring at 
 the Sloane Hospital for Women: Mrs. A., aged nineteen years, admitted 
 to the hospital February 8, 1912. In June, 1910, and again in January, 
 1911, she had been obliged to have a pregnancy interrupted at about the 
 third month on account of hyperemesis. Her last menstruation before 
 admission to the hospital occurred on December 20, 1911. Since the 
 middle of January she had been suffering with nausea and vomiting and 
 for the week preceding admission she had not been able to retain anything 
 on her stomach. In spite of colon irrigations, rectal feeding, etc., her 
 condition steadily grew worse, and on February 13 her urea nitrogen was 
 40.7 per cent, of total nitrogen, and her ammonia nitrogen was 23.8 
 per cent, of total nitrogen. 
 
 Her uterus was emptied on February 14 and she began at once to 
 improve. Her stomach on the following day was able to retain food and 
 on February 17 her urea nitrogen was 45.7 per cent, and her ammonia 
 nitrogen was 11.4 per cent. On February 28 her urea nitrogen was 68.4 
 per cent, and her ammonia nitrogen was 4.37 per cent., and she was 
 discharged cured. 
 
 The degree in which these urinary changes are present in a given case 
 of pernicious vomiting and the fact of their increasing or decreasing under 
 treatment will often prove, when studied in connection with the clinical 
 picture, of great value in determining the gravity of the situation and 
 the prognosis. It should be stated, however, that occasionally a careful 
 study of the clinical picture of the patient will show an improvement 
 before the laboratory findings, and will justify the obstetrician in refrain- 
 ing from emptying the uterus even if the urinary report does not show 
 improvement. 
 
 On the other hand, failure to recognize the condition of severe pernicious 
 vomiting of pregnancy and allowing the patient to go unrelieved until 
 she becomes jaundiced, has hemorrhages from the mucosa of the alimen- 
 tary canal or into the skin, and until she has a rapid, feeble pulse and a 
 rising temperature, often results in the loss of the patient, the procedure 
 of terminating the pregnancy having been postponed too long. This 
 danger can best be impressed upon the obstetrician by a study of the 
 
420 
 
 TOXEMIA OF PREGNANCY 
 
 pathological lesions of the condition. As these lesions are found chiefly 
 in the liver a section of a normal liver will be shown first for comparison 
 
 Fig. 288.— Normal liver. X 100. 
 
 Fig. 289. — Liver of pernicious vomiting. Diffuse fatty degeneration. 
 
PERNICIOUS VOMITING OF PREGNANCY 421 
 
 (see Fig. 288). The chief pathological lesion found in the pernicious 
 vomiting of pregnancy is a fatty and hydropic degeneration of the Uver 
 which is apt to be diffuse, as is shown in Figs. 289 and 290, but in some 
 cases is zonal and goes on to necrosis. This zonal necrosis when present 
 is more apt to be central, or between the centre and the periphery of the 
 lobule (see Fig. 291) rather than at the periphery, although often the 
 fatty degeneration is most marked at the periphery. In this fatty 
 degeneration and autolysis of the liver, although hemorrhage from the 
 alimentary canal is not uncommon, there seems to be little tendency to 
 hemorrhage into the liver itself as is so often seen in eclampsia. In some 
 cases, especially if the condition has existed for a considerable time, the 
 lesion is practically identical with that of acute yellow atrophy (see Fig. 
 292). 
 
 Fig. 290. — Liver of pernicious vomiting. X 500. High power of Fig. 289. 
 
 The kidneys in cases of pernicious vomiting show more or less degenera- 
 tion of the epithelium of the convoluted tubules. 
 
 Treatment. — At the onset the condition should be looked upon as a 
 toxemia associated with faulty protein metabolism and with a tendency 
 to pathological lesions in liver and kidneys, especially the former. With 
 this as a working hypothesis treatment should consist in reducing the 
 ingestion of protein food; in favoring elimination especially through 
 the bowels and kidneys and if improvement is not soon manifest the uterus 
 should be emptied before the liver changes become severe. 
 
 As regards diet, if any food can be retained by the stomach, meats 
 should be avoided and milk, either plain, diluted milk or some of the 
 
422 
 
 TOXEMIA OF PREGNANCY 
 
 Fic. 291. — Pernicious vomiting of pregnancy. Necrosis between centre and periphery of 
 
 liver lobule. 
 
 Fig. 292. — Liver of pernicious vomiting. Acute yellow atrophy. 
 
PERNICIOUS VOMITING OF PREGNANCY . 423 
 
 milk preparations as matzoon, koumiss, etc., and cereals may be 
 administered. If the stomach rejects all food, attempts at mouth feed- 
 ing should be abandoned and the patient's nutrition maintained, if pos- 
 sible, by nutrient enemata, as for instance, of peptonized milk. 
 
 The use of sodium bicarbonate in the treatment of the toxemia of preg- 
 nancy depends upon its antiketogenic property, that is, upon its ability 
 to inhibit the production or at least to neutralize the effects of acetone 
 bodies consisting of acetone, diacetic acid and |3-oxybutyric acid. For 
 whatever be the primary cause of the toxemia of pregnancy, recent 
 investigations of the urine have shown that clinically these states are 
 frequently accompanied by acidosis, or the overproduction of the 
 above-named acid bodies. The organism defends itself against the 
 necessarily deleterious effect of these bodies by neutralizing them first 
 with the fixed alkalies of the body (sodium, potassium, etc.), and later 
 by increased formation and excretion of ammonia. This explains why 
 the urinary ammonia serves as a fair index of the degree of acidosis 
 present. Neither of the methods of self-defense, however, can be con- 
 tinued indefinitely or be looked upon as harmless to the body. The with- 
 drawal of the fixed alkalies interferes with the functions of the protoplasm 
 of the cells by diminishing their normal alkaline or neutral reaction, 
 while the excretion of ammonia interferes with the urea metabolism. The 
 addition of sodium bicarbonate gives the body additional alkali both for 
 neutralization of the acids formed and for their mobilization, that is, for 
 their excretion through the kidneys without much damage to these organs ; 
 it thus spares both the fixed alkalies of the body and the normal urea 
 metabolism. As the acids are continuously produced, the administra- 
 tion of the alkali must be prolonged and the quantity sufficient for each 
 individual case, the reaction of the urine and the amount of ammonia 
 in the urine serving as index of the conditions. In cases of extreme 
 acidosis the intravenous administration of an alkali, sodium carbonate 
 or bicarbonate, should be considered just as in the parallel condition of 
 acidosis and coma in the course of diabetes. 
 
 Of all remedial measures the author knows of none which have served 
 him as well as colon irrigations with soda solution once or twice daily, 
 serving the triple purpose of removing toxins from the intestine, and 
 furnishing fluid and an alkali to the system. During the period of treat- 
 ment by colon irrigations and nutrient enemata, however, the urinary 
 findings, especially the nitrogen ratios and also the clinical picture of 
 the patient, should be carefully studied and if within a few days improve- 
 ment is not evident, the uterus should be emptied; a procedure which 
 if not too long delayed is usually followed by a rapid convalescence. 
 It is seldom safe to attempt to maintain the nutrition of a patient suffer- 
 ing from toxemic vomiting by nutrient enemata alone for more than a 
 week. The patient needs fluid both for body tissues and for purposes 
 of elimination and if any water can be retained by the mouth it is a dis- 
 tinct advantage to allow it. 
 
 If emptying of the uterus becomes necessary, the anesthetic used, for 
 reasons which will be discussed later, should be ether rather than chloro- 
 form. 
 
424 
 
 TOXEMIA OF PREGNANCY 
 
 THREATENED ECLAMPSIA AND ECLAMPSIA. 
 
 Etiology. — The generally accepted view today is that in each of these 
 two conditions there is a toxemia, but that in eclampsia in addition to 
 the toxemic condition there is added a convulsion. 
 
 In other words the toxemia is generally not called eclampsia unless 
 an explosion in the shape of a convulsion has occurred and yet this is 
 only an incident in the condition of toxemia and a woman may escape 
 a convulsion simply because her increasing toxemia is recognized, her 
 diet is restricted, elimination is favored and her blood-pressure reduced, 
 or because labor intervenes and, as usually happens, the toxemia then 
 
 Fig. 293. — Liver of eclamptic patient. Hepatic type. 
 
 rapidly lessens. Such being the case, threatened eclampsia and eclampsia 
 may properly be considered under the same heading. 
 
 Pathology. — Our knowledge of the pathology of eclampsia is of com- 
 paratively recent date, but thanks to the work of Jurgens, Schmorl, Wil- 
 liams, Ewing, and others, the lesions are now well recognized. The 
 changes are mainly those of congestion, hemorrhage, parenchymatous 
 degeneration and necrosis. The liver and kidneys are the organs chiefly 
 involved, the lesions varying with the clinical type. Thus, in those cases 
 characterized by vomiting, jaundice, a tendency to hemorrhage, with 
 little edema and slight albuminuria, the liver is the organ most involved, 
 as seen in Figs. 293, 294, and 295, which represent the liver and kidney of 
 the same patient. Here the liver is markedly involved and the kidney 
 
THREATENED ECLAMPSIA AND ECLAMPSIA 
 
 425 
 
 Fig. 294. — Liver of eclampsia. Hepatic type. High power of Fig. 293. X 500. 
 Taken at periphery of lobule. 
 
 Fig. 295. — Kidney of eclamptic patient whose liver is shown in Figs. 293 and 294. 
 
426 
 
 TOXEMIA OF PREGXANCY 
 
 but little involved. The history of this case was briefly as follows: Mrs. 
 ]\I., aged nineteen years, twelve hours after a normal labor at the Sloane 
 Hospital for Women, suddenly turned in bed, called out "What's that?" 
 had a convulsion, went from bad to worse; on the fifth day vomited blood; 
 died on the sixth day. Her urine showed only a trace of albumin at any 
 time, with a few hyaline, epithelial and granular casts. Her liver showed 
 marked necrosis at the centre of the lobules (see Fig. 293), a zone of fatty 
 and hydropic degeneration near the periphery (see Fig. 294), and a tew 
 normal liver cells at the periphery along the portal vessels. 
 
 On the other hand, in the cases characterized by headache, high-ten- 
 sion pulse, marked disturbance of the nervous system, marked albumin- 
 
 FlG, 
 
 'Mi 
 
 296. — Liver of another eclamptic patient. 
 
 uria and edema, the kidney changes are more marked, as is seen in Figs. 
 29(), 297, and 298, which represent the liver and kidney, respectively, 
 of the same patient. Here the liver changes are slight while the kidney 
 changes are very pronounced. The history of this case was briefly as 
 follows: She was brought to the Sloane Hospital in coma at 0.30 p.m., 
 having had three convulsions before admission. Her urine became solid 
 on boiling and showed numerous casts. An elastic bag was introduced 
 on admission and she was delivered about midnight. She had five con- 
 vulsions between the time of her admission and delivery and two after 
 delivery. She died on the third day. The kidneys (see Fig. 29S) showed 
 a chronic diffuse nephritis with the formation of new connective tissue; 
 
THREATENED ECLAMPSIA AND ECLAMPSIA 427 
 
 Fig. 297.— Liver of eclampsia. Nephritic type; high power of Fig. 296. X 500. 
 Taken at periphery of lobule. 
 
 Fig. 298.— Kidney of eclamptic patient whose liver is shown in Figs. 296 and 297. 
 
428 
 
 TOXEMIA OF PREGNANCY 
 
 the tubules were dilated and the epithelium largely degenerated; an 
 acute exacerbation of a chronic process. 
 
 Many border-line cases present themselves in which both the liver 
 and the kidneys are involved, yet in every large maternity service these 
 two distinct clinical types — the liver type and the kidney type — are 
 often seen. 
 
 The lesions in the liver vary from congestion with granular and fatty 
 degeneration to necrosis with almost complete dissolution of the liver 
 parenchyma. This necrosis begins at the centre of the lobule and extends 
 toward the periphery, leaving only a mass of granular detritus surround- 
 ing the central \ein, the nuclei and cell contents disappearing with only 
 a reticular network in the place of the liver cells. Thromboses with 
 
 Fig. 299. — Liver of eclampsia, hemorrhagic type. 
 
 hemorrhage occur throughout the lobule more often at the periphery 
 (see Fig. 299). The organ may be swollen or diminished in size, according 
 to the change in the parenchyma. It usually presents a yellowish color 
 and may have hemorrhages under the capsule. The kidneys are swollen, 
 the cortex thickened and pale, the markings less distinct than normal and 
 the capsule not adherent. Microscopically the cells of the cortical tubules 
 are swollen, in many places disintegrating. The vessels are injected and 
 the tubules contain much granular material. Other changes found are 
 moderate fatty degeneration of the heart, and edema, congestion and 
 hemorrhages in the brain. The body often shows edema, subcutaneous 
 hemorrhages, and jaundice. The above are the pathological changes in 
 the severe grades of toxemia of pregnancy and the puerperium. 
 
THREATENED ECLAMPSIA AND ECLAMPSIA 429 
 
 Symptoms. — Of the greatest importance to every student and practi- 
 tioner of obstetrics today is the early recognition of the symptoms of the 
 toxemia of pregnancy, as it is chiefly by the recognition and treatment of 
 these early symptoms that the more severe grades of toxemia and those 
 threatening eclampsia with its dire results can be avoided. 
 
 The condition of toxemia is a most insidious one and its early signs 
 and symptoms often so closely resemble the harmless mechanical results 
 of the pressure of the large, heavy uterus, with its contents, that they 
 frequently escape the detection of all save the most careful observers. 
 
 Edema. — It is true that in the latter half of pregnancy it is not at all 
 unusual, as a result of the mechanical pressure above, to have a certain 
 amount of edema of the feet and legs. It is true that on account of the 
 condition of the blood in pregnancy it is not unusual to have a change 
 in the expression of the face and perhaps a little swellmg of the fingers 
 so that the rings fit more tightly than normal. This is all true, but these 
 may be the symptoms of a beginning toxemia and nothing but a careful 
 and frequent examination of the urine will determine whether these signs 
 and symptoms are of no moment, or whether they indicate grave condi- 
 tions which must be treated promptly and thoroughly. 
 
 The Urine. — In the toxemia of pregnancy, even in the severe grades 
 threatening eclampsia, the m-ine varies greatly in different patients, 
 depending largely upon whether the lesion involves chiefly the liver or 
 the kidneys. 
 
 The quantit}' of the urine is sometimes greatly diminished, even to 
 eight or ten ounces in the twenty-four hours, and the first evidence of 
 improvement in the patient may be an increase in the amount of urine 
 pa,ssed. iVfter a convulsion the urine may be almost suppressed and what 
 is passed be of a distinctly smoky color. The amount of urea excreted 
 may vary greatly in different patients, depending largely upon the diet 
 taken. Two patients under the observation of the author passed only 
 seventy-five grains of urea a day throughout their whole pregnancy. 
 These patients were on a diet from which red meats were excluded, but 
 never presented signs of more than the mildest grade of toxemia. 
 
 The amount of albumin in the urine of a patient suffering from toxemia 
 varies greatly. In about 10 per cent, of the cases there is none save the 
 merest trace of albumin in the urine until after the first convulsion, while 
 in others it is found in variable amounts even to a degree in which the 
 urine nearly solidifies on boiling. After a convulsion it is the rule for the 
 urine to contain a large amount of albumin even if it showed little if any 
 before. The large amounts of albumin in the urine of toxemic patients 
 are found especially in those in whom the kidneys are the organs chiefly 
 involved and in those suffering with a chronic nephritis to which the 
 pregnancy has added an acute exacerbation. 
 
 In the severe grades of toxemia, and especially in eclampsia, the urine 
 contains numerous casts, hyaline, granular, and epithelial. 
 
 High Blood-pressnre. — Another evidence of beginning toxemia and 
 one the importance of which is receiving more and more recognition is 
 a rising blood-pressure. The blood-pressure in pregnancy varies in dif- 
 
430 TOXEMIA OF PREGNANCY 
 
 ferent women, as is stated on page 155, but the average is about 113 mm. 
 In a beginning toxemia the blood-pressure rises until in an eclamptic 
 seizure or in the posteclamptic coma it may register well above 200. 
 The highest blood-pressure met with by the author in a patient who did 
 not have a convulsion was 232, but this is an exceptional experience. A 
 safe rule is to look with suspicion upon any blood-pressure in pregnancy 
 above 140 and to consider that usually it is below 125. The importance 
 of the blood-pressure as an indication of toxemia emphasizes the need of 
 the frequent use of the sphygmomanometer. 
 
 Headache. — The occurrence of frequent headaches in pregnancy should 
 always be looked upon as a probable indication of a toxemia and as one 
 of the proofs that they have a toxic origin may be mentioned the fact 
 that the treatment most likely to give relief is that along the line of 
 elimination, colon irrigations, etc. 
 
 Nausea and ]'()mitin(j. — In the early months of pregnancy it has been 
 shown that vomiting is often of toxemic origin and in the type called 
 pernicious vomiting such is always the case. In the latter months of 
 pregnancy even more uniformly than earlier, vomiting should always 
 be looked upon as toxemic and an eclamptic seizure not infrequently 
 begins with a severe headache and vomiting soon to be followed by a 
 convulsion. 
 
 Nervous System. — In the severe grades of toxemia, especially that 
 threatening eclampsia, the nervous system usually show^s changes from 
 the normal equilibrium. The patient may be restless, irritable and suffer 
 fjom insomnia, or on the other hand she may be dull, apathetic, sleepy, 
 and stupid. 
 
 The Eyes. — Not infrequently one of the early manifestations of tox- 
 emia is a disturbance of vision, perhaps a blurring of the vision or the 
 appearance of spots before the eyes, musc?e volitantes. Occasionally 
 the ophthalmologist is first consulted for improvement of the vision and 
 he diagnoses the hemorrhagic retinitis resulting from the toxemia. The 
 seriousness of the result of the eye lesions depend upon the extent and 
 location of the hemorrhages. If small and located outside the field of 
 vision they may be entirely recovered from, but if centrally located the 
 vision may be permanently impaired. 
 
 Hemorrhages into the retina should always be looked upon as one of 
 the serious symptoms of toxemia. In some cases presenting ocular symp- 
 toms, no lesion can be demonstrated and the symptoms rapidly disap- 
 pear with the toxemia. In some instances the patient complains of ring- 
 ing in the ears (tinnitus aurium) as one of the symptoms of her toxemia. 
 The symptoms of the toxemia of pregnancy, which may or may not lead 
 to a convulsion have now l)een described and will be recapitulated as 
 follows: Edema; increasing urinary changes (albumin, casts, disturbed 
 nitrogen partition, etc.); high blood-pressure; headache; vomiting; 
 disturbed nervous system; disturbed vision. 
 
 Frequency. — An idea of the frequency of the occurrence of eclampsia 
 or toxemia with convulsions may be gained from the fact that in 20,000 
 consecutive deliveries at the Sloane Hospital for Women there were 251 
 
THREATENED ECLAMPSIA AND ECLAMPSIA 431' 
 
 cases of eclampsia, i. e., it occurred in 1.2 per cent, of cases, or 1 in 79. 
 Of these 251 cases, 168 occurred in primigravidse and 83 in multigravidfe. 
 In 154 it occurred before term and in 97 at term. 200 showed premonitory 
 symptoms, 51 showed no premonitory symptoms; 249 showed albumin 
 in the urine, while 2 showed none. In 200 casts were found in the urine 
 while in 51 no casts were found. The eclamptic seizure may occur either 
 before, during or after labor. In the 251 cases mentioned above, the 
 first convulsion was antepartum in 159, intrapartum in 40, and post- 
 partum in 52, i. e., eclampsia during pregnancy is the most common 
 occurrence. Anything increasing the congestion or the demand for 
 elimination favors toxemia and eclampsia. Hence the greater frequency 
 of toxemia in multiple as compared with single pregnancy. Eclampsia 
 is not confined to normal pregnancy, but has even been reported 'as 
 occurring in ectopic gestation. 
 
 Type. — Of the 251 cases of eclampsia there were 24 showing hemor- 
 rhages, i. e., 9.6 per cent, were of the hemorrhagic type. 
 
 As a rule careful and frequent observation of the condition of the 
 urine, the blood-pressure and the general condition of the patient will 
 tell whether there is an increasing toxemia, threatening eclampsia or not. 
 In 51 of the 251 cases mentioned above, however, there were no premoni- 
 tory symptoms save a mild albuminuria, and in 2 even this was absent. 
 It must be admitted that in rare instances even if the urine is examined 
 every week fulminating cases of eclampsia will arise as out of a clear sky. 
 This, however, is extremely exceptional under careful observation. 
 
 Eclamptic Seizure. — Either with or without premonitory constitu- 
 tional symptoms of a toxemia the convulsion itself usually presents the 
 following picture: The eyes stare, the lids twitch, the pupils are first 
 contracted, later dilated. The eyes are insensible to light, the eye-balls 
 are rolled upward, and to one side. The face becomes cyanotic, the jaws 
 jerk rapidly, the tongue is bitten if protruded. 
 
 Between the clonic spasms there is a tonic spasm of the different muscles 
 of the body in which the arms are flexed, the thumbs flexed into the 
 palms and the fingers are bent over them. Respiration is arrested by con- 
 tractions of the muscles of the thorax and the diaphragm. There is a 
 rigidity of the entire body and limbs with loss of Sensation and conscious- 
 ness. After a period of alternating tonic and clonic spasms lasting from 
 one to five minutes the patient passes into a coma in which respira- 
 tion returns, at first irregular and stertorous, then more natural; at the 
 same time sensation and consciousness gradually return. The convul- 
 sion, including the period of coma, often lasts half an hour and then the 
 patient may completely recover consciousness or pass directly from one 
 convulsive seizure to another, the number depending upon the degree 
 of the toxemia and the promptness of the treatment. It is exceptional 
 for a patient to have only one convulsion. In one of the author's cases 
 which recovered the patient had 31 convulsions. As many as 80 convul- 
 sions have occurred in one case. 
 
 DifEerential Diagnosis. — It is only natural that a convulsion occurring 
 during pregnancy or the puerperium should suggest eclampsia, and as a 
 
432 TOXEMIA OF PREGNANCY 
 
 rule this is justified, yet this conclusion is not always warranted. The 
 convulsion may be an expression of epilepsy or hysteria and attention 
 may well be called to a few of the differential features as shown in the 
 
 following tables: 
 
 Eclampsia rs.— Epilepsy. 
 
 Patient not subject to convulsions. Patient subject to con\-ulsions. 
 
 Urine usually shows albumin. Urine usually free from albumin. 
 
 Edema common. No edema. 
 
 Prodromic symptoms of toxemia. No prodromic symptoms save aura. 
 
 Rising temperature. No rise of temperature. 
 
 EcL.VMPSiA vs. Hysteria. 
 
 Patient unconscious. Patient not unconscious. 
 
 Coma present. No coma. 
 
 Urine scanty and albuminous. Urine abundant, without albumin. 
 
 Muscular contractions more marked. Muscular contractions less marked. 
 
 Treatment. — Prophylaxis. — ^Following in the line of preventive medicine, 
 the keynote of our profession today, the most important treatment of 
 toxemia is prophylaxis and comprises such observation and care of the 
 pregnant patient as will lessen the chances of toxemia on the one hand, 
 and will lead to the early detection and prompt treatment of the con- 
 dition if it develops. As has already been indicated under the ^Nlanage- 
 ment of Normal Pregnancy (see page 150) overburdening the system with 
 protein metabolism is avoided by regulation of the diet and elimination 
 is favored by regulation of the bowels and large draughts of water. 
 
 In order to detect the early evidences of a toxemia in pregnancy the 
 urine must be examined regularly, at least as often as every two weeks, 
 even if the patient is feeling perfectly well, and the examination should 
 not simply be for albumin and casts but should include as well the tests 
 for faults in metabolism, especially protein metabolism. If evidences 
 of a toxemia are found the examinations of the urine should be made 
 more frequently, even as often as every few days. 
 
 It is not sufficient that the patient should send specimens of her urine 
 to the obstetrician every two weeks. She should be seen by him person- 
 ally. Her blood-pressure should be taken regularly. He should examine 
 for edema and should question her as to headaches, vision, digestion, etc. 
 
 In this way only can the obstetrician inform himself of the inception 
 of toxemia and escape responsibility in the occurrence of eclampsia. 
 
 The Treatment of Toxemia Threatening Eclampsia. — If the condition of 
 toxemia has once developed the obstetrician may well be guided in its 
 treatment by the following five principles : 
 
 1. The products of metabolism requiring elimination should be reduced. 
 
 2. Elimination of metabolic products should be favored. 
 
 3. High blood-pressure should be reduced. 
 
 4. If the toxemia of the patient, as shown by the urine, blood-pressure 
 and general condition does not markedly improve under the preceding 
 principles of treatment, or if an eclamptic seizure occurs, the uterus 
 should be emptied. 
 
 5. In all methods of treatment that should be avoided which will 
 either reduce the resistance of the patient or seriously damage any of her 
 organs. 
 
THREATENED ECLAMPSIA AND ECLAMPSIA 433 
 
 Let us now consider these principles more in detail. 
 
 1. In reducing the products of metabolism requiring elimination the 
 obstetrician is brought face to face with the problem of diet for the 
 toxemic patient. As protein metabolism is that most often at fault, it 
 is generally agreed that red meats should be avoided in all forms of 
 toxemia of pregnane}^ and the puerperium. Although in mild degrees 
 of toxemia chicken and fish may be allowed, in severe forms of the 
 condition an exclusive milk diet with large draughts of water is the diet 
 of choice, to which are added chicken-broth, cereals, fruits and green 
 vegetables, as the toxemia diminishes. As a prophylactic measure it is 
 our custom, during the last month of a normal pregnancy, to allow the 
 ingestion of red meat only two or three times a week. 
 
 Fig. 300. — Apparatus for, and method of, giving colon irrigations. 
 
 2. In favoring the elimination of products of metabolism the three 
 avenues, the skin, the urinary tract and the intestinal tract should 
 receive careful attention. Thus elimination through the skin by sweat- 
 ing, induced either by the hot-air bath or the hot, wet pack, is a most 
 useful measure in the treatment of toxemia. Elimination through the 
 urinary tract, favored by the ingestion of large amounts of water, and 
 elimination through the intestinal tract, favored by calomel and saline or 
 other laxatives, and especially by colon irrigations with saline or soda solu- 
 tion, are methods which are considered routine procedures in the treat- 
 ment of this condition. At the Sloane Hospital colon irrigations are 
 given with two tubes (see Fig. 300), and nine gallons of fluid are used, 
 28 
 
434 TOXEMIA OF PREGNANCY 
 
 3. In the reduction of blood-pressure, while venesection is tiie choice 
 of many obstetricians, and was formerly quite extensively employed 
 by the author, its use has now been largely superseded at the Sloane 
 Hospital by veratrum viride, nitroglycerin and chloral, and with better 
 results. 
 
 Our method of using these drugs in toxemia threatening eclampsia is 
 as follows : Chloral (30 grains) is administered per rectum as an initial 
 dose, and then repeated in doses of from 20 to 30 grains every four 
 to six hours, according to the restlessness of the patient. Nitro- 
 glycerin, gr. -V to Y^-Q, every two to four hours is given hypodermi- 
 cally. If, under the use of the larger doses of these drugs, the tension 
 still remains high, we depend on the use of veratrum viride rather than 
 venesection. 
 
 The preparation used has been Squibb's fluidextract of veratrum and 
 the dose employed has scarcely ever exceeded 5 minims. Our rule is to 
 give 5 minims hypodermically and watch the effect. As the frequency 
 is usually reduced with the tension, it is our custom to be largely guided 
 in repetition of the dose and in the size of the dose by the frequency of 
 the pulse, although the reduction in the tension is the object desired. 
 
 If at the expiration of from one to two hours the pulse has not been 
 reduced in frequency to 100 or below, and the tension correspondingly 
 reduced, a second hypodermic injection of veratrum, 1 to 3 minims is 
 given. The tension of the pulse is then controlled, if not kept low by the 
 continued use of the nitroglycerin, by repeated doses of veratrum, 1 to 3 
 minims, every four hours. 
 
 4. To repeat the fourth principle stated earlier in the book, if the 
 toxemia of the patient, as shown by the urine, blood-pressure, and general 
 condition, does not markedly improve under the preceding principles of 
 treatment, or if an eclamptic seizure occurs, the uterus should be emptied. 
 At the Sloane Hospital some years ago a series of patients was treated^ 
 on the palliative plan, favoring elimination without emptying the uterus, 
 but the mortality was so much greater than when the fetus and its toxins 
 were eliminated from the uterus and the system, that for the past ten 
 years the rule has been, given an eclamptic seizure or a toxemia so severe 
 as to strongly threaten eclampsia in spite of treatment, proceed to empty 
 the uterus. 
 
 In carrying out this rule the fifth principle of treatment deserves marked 
 emphasis and will be restated here, hi all methods of treatment that 
 should be avoided which tvill either reduce the resistance of the patient or 
 seriously damage any of her organs. 
 
 This principle has an important bearing on the method of emptying the 
 uterus. Having decided that the fetus should be removed from the 
 uterus, the next questions are: How? and When? If the cervix is soft 
 and dilatable and the patient has had one or more convulsions, our ow n 
 preference is manual dilatation and delivery, usually by version. 
 
 If, on the other hand, the cervix is long and rigid, we believe that the 
 patient is better off, even if delivered several hours later, to have her 
 cervix softened and dilated by the preliminary use of the elastic bag or 
 
THREATENED ECLAMPSIA AND ECLAMPSIA 435 
 
 bags, rather than to be delivered by an immediate accouchement force, 
 which leaves her in marked shock and with cervix deeply lacerated, per- 
 haps to the vaginal junction. Our observation leads us to believe that 
 pronomiced shock and deep lacerations lessen both the resistance of the 
 patient and her chances of recovery. In the cases of long, rigid cervix, 
 which do not readily dilate under the use of the elastic bag, the so-called 
 vaginal Cesarean section has a distinct and valuable field of usefulness. 
 In a restricted class of cases future experience may prove the abdominal 
 Cesarean section to be the operation of choice. 
 
 Now the question arises as to the use of an anesthetic in toxemia and 
 diu-ing the eclamptic seizure. For many years it was our custom at the 
 Sloane Hospital to administer chloroform to every patient suffering with 
 eclampsia and to give it to the patient each time she had a convulsion. 
 This was done with the idea that the conM.ilsions were in themselves 
 an element of grave danger to the patient and that they were controlled 
 by the chloroform. Fm-thermore, if the uterus had to be emptied for 
 the toxemia of pregnancy, showm in the early months by pernicious 
 vomiting, or in the later months by eclampsia, chloroform was the 
 anesthetic usually employed. Riper experience has led us in the first 
 place to question whether chloroform has very much eftect in controlling 
 the convulsions, and secondly, whether in the light of our present knowl- 
 edge concerning the effect of chloroform, its use in toxemia and eclampsia 
 conforms to our fifth principle of treatment recommended above, viz.: 
 Harmful remedies should be avoided. Recent studies of the pathological 
 changes produced by delayed chloroform poisoning in man and cliloro- 
 form anesthesia in dogs have shown a marked similarity to those of 
 eclampsia. These studies were exhaustive and include the work of 
 Lengemann, Osterhag, Stiles and ^McDonald, Stassman and others, 
 together with the more recent work of Howland and "Whipple. The 
 similarity of the lesions in the liver is shown in Figs. 301, 302, and 303, 
 which represent delayed chloroform poisoning in man, cliloroform anes- 
 thesia of a dog, and eclampsia. The most striking result of these studies 
 was the extent of the degeneration and necrosis found in the li\'er and 
 kidney after chloroform anesthesia of short duration. 
 
 It has been found in experiments on dogs that characteristic lesions 
 are regularly produced, varying in degree with the duration and depth 
 of anesthesia and also with idiosyncrasy. Thus after thirty minutes to 
 one hour anesthesia with chloroform the centres of the lobules of the 
 liver show congestion with granular and fatty degeneration, the inner- 
 most cells being necrotic, their nuclei not taking the stain and the proto- 
 plasm being deeply stained pink T\-ith eosm. With more prolonged 
 action the changes approach those fomid in delayed chloroform poison- 
 ing m man. The liver appears yellow and fatty with scattered hemor- 
 rhages. The cells about the centres of the lobules are entirely necrotic, 
 a granular mass remaining. Outside of this is an area of cells which 
 have undergone hyaline and fatty degeneration, vdih normal cells at the 
 periphery. In some cases the liver cells have almost entirely disappeared 
 with onh- a few scattered living cells in the portal spaces. In the kidney 
 
43G 
 
 TOXEMIA OF PREGNANCY 
 
 Fig. 301. — Delayed chloroform poisoiiiug in man. 
 
 Fig. 302. — Liver of dog. One hour chloroform anesthesia. 
 
THREATENED ECLAMPSIA AND ECLAMPSIA 
 
 437 
 
 Fig. ,303. — Liver of eclamptic patient. Hepatic type. 
 
 Fig. 304. — Kidney of dog. Delayed poi.soning after seven and one-half hours chloroform 
 
 anesthesia. 
 
438 TOXEMIA OF PREGNANCY 
 
 clili)rot'orin ant'sthosia causes a marked congestion with a cloudy swelliui;' 
 and occasionally heniorrhao-es into the parenchyma (see Fig. 3()0- 
 
 The cells of the tubules are swollen and granular, occluding most of 
 the lumen; in other phices they have disa])i)eared entirely. Fatty 
 degeneration is present and in many cases pronounced. The heart muscle 
 may be pale and show fat droplets in its fibers. Hemorrhages occur 
 throughout the body, particularly in the serous membranes and in the 
 intestinal and stomach mucosa. 
 
 Rowland and others were able, almost at will, by continuing the 
 anesthesia, to produce delayed chloroform poisoning in dogs, with symp- 
 toms and lesions corresponding in detail with those of delayed chloroform 
 poisoning in man. Thus we find in these three conditions, eclampsia, 
 delayed chloroform poisoning in man, and chloroform anesthesia in 
 animals, many similarities. Pathologically there is central necrosis, 
 parenchymatous and fatty degeneration in the liver; congestion, paren- 
 chymatous and fatty degeneration in the tubules of the kidney and a 
 tendency to hemorrhages throughout the body. Clinically, in delayed 
 chloroform poisoning, and in eclampsia, there are vomiting, jaundice, 
 delirium, convulsions, and coma. With these facts before us, showing 
 that chloroform acts as a poison to the liver and kidney, it certainly 
 seems that its use in the toxemia of pregnancy and eclampsia would 
 still further impair these organs already damaged. 
 
 In turning to ether as a substitute when anesthesia is required in 
 toxemia and eclampsia, the question naturally arises: Does ether pro- 
 duce lesions in the liver and kidney similar to chloroform? Some work 
 had already been done along this line, notably by Bandler, Lengeman and 
 Leflfman, and it was partly to confirm scattered observations on this 
 subject that a further study of ether anesthesia was undertaken by Dr. 
 Edward T. Hull,^ then Pathologist to the Sloane Hospital, and the author. 
 
 In our experiments six mongrel dogs of medium size w^ere given ether 
 by inhalation from an open cone. They were killed with ether forty- 
 eight hours after the last anesthesia and autopsied at once. Tissues 
 were fixed with Midler's fluid and 10 per cent, liquor formaldehyd, 
 equal parts, and stained with hematoxylin and eosin. Fat was stained 
 with Altman's fluid, Scharlac R. as control. Sufficient ether was given 
 to produce complete muscular relaxation with loss of corneal reflex. 
 
 Dog 1. Given ether for three successive hours. 
 
 Dogs 2 and 3. Given ether two hours each on two successive days. 
 
 Dog 4. Given ether for two and a half hours on two successive days. 
 
 Dog 5. Given ether for three hours on two successive days. 
 
 Dog 6. Given ether for two and a half hours on three successive days. 
 
 With dogs 3, 4, and 6 a section of liver and kidney was taken at the 
 beginning of the first anesthesia for control. The dogs all took the anes- 
 thesia well and appeared bright and active throughout the experiments 
 with the exception of dog 3. This dog required artificial respiration 
 
 1 Cragin and Hull, The Treatment of Eclampsia Including a Comparison of the Dangers 
 of Chloroform and Ether in this Condition, Jour. Amer. Med. Assoc, January 7, 1911, 
 Ivi, 5-11. 
 
THREATENED ECLAMPSIA AND ECLAMPSIA 
 
 439 
 
 twice, had a slight cough on the first day, which became more marked 
 on the following days. It showed no pneumonia on autopsy. 
 
 In none of these animals could any necrosis in any of the parenchyma 
 be found. In the lungs occasional small areas of a deeper red than the 
 surrounding substance, containing an increase in amount of blood on 
 section, showed congestion. The heart muscle in each dog was found 
 to be of normal color, striations distinct, no apparent increase in fat. 
 
 There were no hemorrhages in the mucosa of the stomach and intes- 
 tmes. 
 
 The livers were of a good color throughout, the vessels in a few places 
 standmg out a brighter red than the surrounding structure. The yellow 
 
 Fig. 305. — Liver of doj 
 
 Four and one-half hours ether anesthesia. 
 
 appearance was entirely lacking, and the cells throughout preserved their 
 outlines with contents intact (see Fig. 305). There was no suggestion 
 of necrosis at any point. The protoplasm was somewhat granular and 
 small droplets of fat were found in the cells about the central veins and 
 in the portal spaces. This fat was only slightly in excess of that in the 
 controls. 
 
 The kidneys were of normal size, capsule not adherent, cortex not 
 thickened, markings distinct. ^Microscopically the cells of the tubules 
 were well preserved throughout, their outlines were distinct, the nuclei 
 staining sharply, the protoplasm granular, the tubules containing in 
 some places some granular material. Fat globules were present in a few 
 of the straight tubules and in the lining cells. This condition seemed no 
 
440 
 
 TOXEMIA OF PREGNANCY 
 
 more than is normally found and no more marked than in the controls 
 taken. The condition is well shown in Fig. 30(). 
 
 No pathological changes could be found in any of the sections of pan- 
 creas and spleen. These facts seem to demonstrate that in animals, at least, 
 ether produces practically little effect on the liver and kidneys as com- 
 pared with the very marked changes in these organs produced by chloro- 
 form, and while it may be argued that this comparison has been demon- 
 strated only in animals, the similarity between the lesions of delayed 
 chloroform poisoning in man and chloroform anesthesia in animals makes 
 it appear more than probable that reasoning as to the effect of ether on 
 the liver and kidney of man, from the lesions produced by ether in 
 animals, is entirely justified. 
 
 Fig. 306. — Kidnej- of dog. Five hours ether anesthesia. 
 
 Impressed with the above facts the author, in his service at the Sloane 
 hospital, has abandoned entirely the use of chloroform in all cases of 
 toxemia of pregnancy or eclampsia, either for operative procedure or 
 for the control of convulsions, and has employed ether in these conditions, 
 whenever an anesthetic was required. 
 
 During this period since the abandonment of chloroform, aside from 
 numerous cases of toxemia, there have been seventy-one cases of true 
 eclampsia, i. e., toxemia with con^•ulsions varying in number from one 
 to thirty-one. In the treatment of these patients no attempt has been 
 made to control the convulsions by means of the anesthetic. This end 
 has been sought through lowering the blood-pressure and quieting the 
 nervous system by the use of veratrum, chloral, and nitroglycerin. 
 
THREATENED ECLAMPSIA AND ECLAMPSIA 441 
 
 Ether has been used whenever an anesthetic has been required durmg 
 delivery. Former experiences with attempts to control the convulsions 
 by chloroform proved that it was practically impossible. Recent experi- 
 ences without attempts to control convulsions by an anesthetic have 
 given'results which compare favorably with those of the former method. 
 
 In these 71 cases of eclampsia (occurring in 8000 deliveries) treated 
 without chloroform there have been 8 deaths, a mortality of 11.2 per cent. 
 In the 251 cases of eclampsia in the 20,000 deliveries prior to the aban- 
 donment of chloroform in toxemia and eclampsia there were 71 deaths, 
 a mortality of 28 per cent. Not only has the treatment of eclampsia 
 without chloroform given a lower mortality, but it has also seemed that 
 others having toxemia were perhaps spared eclamptic seizures by the 
 avoidance of the use of chloroform and the further damaging of the 
 already damaged liver. This would seem to be shown by the fact that 
 while in the 20,000 deliveries in which chloroform was used in all cases 
 there ^^-ere 251 cases of eclampsia; in the SOOO deliveries in which ether 
 was used in all toxemic cases there were only 71 cases of eclampsia. 
 
 Another question presenting itself was whether chloral hydrate, a 
 drug we were using extensively in eclampsia both to lower blood-pressure 
 and quiet the nervous system, had like cliloroform, which it somewhat 
 resembled chemically and in name, a deleterious effect upon the liver 
 and kidneys. At the author's suggestion, Dr. J. Gardner Hopkins,^ 
 at that time Pathologist to the Sloane Hospital, undertook a series of 
 experiments to solve this problem. In these experiments it was attempted 
 to produce the severest effects possible from chloral hydrate, and doses 
 were given sufficient to produce surgical anesthesia. To do this large 
 amounts of chloral had to be used and a number of dogs died without 
 recovering from the anesthesia. A sufficient number recovered, however, 
 from which to study the condition of the liver and kidneys after a lapse 
 of one or two days, the time at which the lesions from cliloroform are most 
 severe. In the series of twenty-six dogs poisoned in various ways by 
 chloral, only six were found whose livers showed definite pathological 
 changes. These changes consisted in the appearance of fat in the liver 
 cells. None of the livers showed necrosis of the cells about the central 
 veins — the lesion characteristic of chloroform poisoning and eclampsia. 
 The kidneys showed no histological changes produced by the chloral. 
 
 As a result of these experiments one may therefore feel justified in 
 continuing the use of chloral in eclampsia without fear that in reasonable 
 doses it is likely to do harm to either liver or kidneys. 
 
 Prognosis. — The prognosis of the toxemia of pregnancy depends upon 
 the extent of the visceral lesions, especially those of the liver and kidneys, 
 and these depend largely upon the period at which the condition is recog- 
 nized and treated. Most of the maternal deaths occur in those whose 
 urine has not been regularly and frequently examined and whose general 
 condition has not been constantly watched for early evidences of a 
 toxemia such as headache, vomiting, high blood-pressure, edema, etc. 
 
 1 A Study of Experimental Poisoning with Chloral Hydrate with References to its Effect 
 on the Liver and Kidneys, Amer. Jour. Obstet., April, 1912, vol. xxv. No. 4. 
 
442 TOXEMIA OF PREGNANCY 
 
 It imist 1)0 admitted, however, that in a certain number of cases after 
 exposure to cold or indiscretion in diet, the echimptic seizure will be so 
 fulminating and with so little warning as to be beyond human knowledge 
 to foresee or prevent. As indicated above also the prognosis depends a 
 good deal upon the treatment, although the results in different hospitals 
 will depend largely upon the type of patients received, i. e., whether the 
 service is composed largely of emergency ambulance cases, brought to 
 the hospital as a last resort after gross neglect of the patient at home, 
 or whether the service is a waiting service with patients kept under care- 
 ful observation. Our present maternal mortality at the Sloane Hospital, 
 where the service is partly an emergency and partly a waiting one, is 
 about 11 per cent., i. e., in the last 71 cases of eclampsia occurring in 
 8000 consecutive deliveries there were 8 deaths, a mortality of 11.2 per 
 cent. 
 
 In the 251 cases of eclampsia in the 20,000 consecutive deliveries at 
 the Sloane Hospital there were 71 maternal deaths, or 28.3 per cent. 
 Of these 251 cases 
 
 159 were antepartum with 55 deaths, or 34.5 per cent. 
 40 were intrapartum with 11 deaths, or 27.5 per cent. 
 52 were postpartum with 5 deaths, or 9.6 per cent. 
 
 No one can watch the rapidity with which the toxic symptoms usually 
 disappear after the uterus is emptied, without being impressed with 
 the benefit of this procedure, whether induced by nature or by art. A 
 glance at the above statistics shows that while occasionally eclampsia 
 occurs postpartum, its mortality is relatively low and the prognosis 
 therefore hopeful. 
 
 Fetal Mortality. — In the 251 cases of eclampsia occurring in the 20,000 
 consecutive deliveries there were 151 fetal deaths, or 60.15 per cent.; of 
 these 151, 35 were prior to the period of viability, 89 were stillbirths and 
 27 died subsequent to birth, making 116 fetal deaths in 216 viable fetuses, 
 a fetal mortality of 53.9 per cent. 
 
 There are several conditions affecting the life of the fetus in the toxemia 
 of pregnancy which deserve consideration. In the first place the fetus 
 shares the mother's toxemia, and for a given period of gestation is less 
 well developed and has less vitality than in a normal pregnancy. In the 
 second place one of the common accidents of a toxemia of pregnancy is 
 an accidental hemorrhage which, separating more or less of the placenta 
 from the uterine wall, greatly endangers fetal life. Again, a sufficient 
 number of fetuses have been born in a spastic state to indicate that a 
 fetus may have an intra-uterine convulsion and life become extinct at 
 that time. Finally, in the interests of the mother, pregnancy is usually 
 interrupted on the occurrence of a convulsion, however premature the 
 gestation may be, and the artificial delivery coupled with the prematurity 
 naturally gives a high fetal mortality. 
 
 One of the problems facing the obstetrician in the toxemia of preg- 
 nancy is whether, aside from the mother's interests, which usually should 
 stand paramount, the fetus has a better chance of life and development 
 
THREATENED ECLAMPSIA AND ECLAMPSIA 4^4:3 
 
 by remaining longer in iifcro or by being brought into the \\'orld. The 
 risks of the fetus becoming more toxic or of an accidental hemorrhage 
 occurring at any time are so great that often the fetal chances are better 
 from an interruption of pregnancy than from its longer continuance. 
 
 The subject of a subsequent pregnancy, after an eclampsia and a 
 pregnancy in a patient known to have a chronic nephritis, now deserves 
 consideration. Many women have a fulminating attack of toxemia 
 with eclampsia are delivered and, while perhaps the urine diu-ing the 
 attack nearly solidified on boiling, it rapidly clears so that in from two 
 to four weeks it becomes normal and remains so. These cases under 
 proper supervision and careful regimen are often able to go through 
 subsequent pregnancies without further kidney trouble. 
 
 On the other hand, a certain number of cases of toxemia with or with- 
 out eclamptic seizures, continue to show urinary changes for a long 
 time after apparent recovery from the toxemia. There is, perhaps, a 
 continuous albuminuria for several months and after that if the patient 
 gets overfatigued or catches cold a little albuminuria returns. More- 
 over, a few casts are frequently present and the patient shows that her 
 kidneys have ne^'er quite recovered from the results of the toxemia. A 
 subsequent pregnancy in these cases is always a serious matter. With 
 proper care, avoiding foods rich in proteids and keeping the avenues of 
 elimination active, they may be carried safely through their pregnancy, 
 but they are always a source of anxiety to the obstetrician, as in many 
 of them a toxemia develops in the latter half of pregnancy which may 
 require induction of labor to control. In both of these post-toxemic 
 classes of women the wisest plan is to advise them not to become pregnant 
 until the urine has been free from albumin for at least a year. 
 
 If a woman has a chronic diffuse nephritis and marries, the danger of 
 pregnancy should be explained to her and she should be advised to avoid 
 it. If pregnancy ensues the blood-pressure and urine should be under 
 most careful observation so that if necessary the pregnancy may be 
 interrupted before the kidney lesion becomes too serious. 
 
CHAPTER XIII. 
 
 LOCAL AND GENERAL AFFECTIONS AND DISEASES 
 COMPLICATING PREGNANCY. 
 
 Varicosities and Hematoma of the Vulva. — As a result of the pressure 
 of the pregnant uterus upon the ]>el\ic veins, varicosities in the lower 
 extremities and at the pelvic outlet are common. These varicosities are 
 naturally greater in vertex presentations than in breech presentations, 
 where the pressure of the hard head is absent. They are also more 
 common in multiple pregnancy than in a single pregnancy. ^ aricosities 
 are also greater in cases which have had a previous varicose condition of 
 the veins at the beginning of pregnancy. The results of the pelvic press- 
 ure are seen in varicosities of the vulva, varicosities of the legs and 
 thighs and in hemorrhoids. 
 
 A'aricosities of the \uha are seen and felt as irregular worm-like masses 
 in either labium, increasing in size on standing and straining, giving to 
 the woman the feeling of fulness, weight and perhaps burning, occasion- 
 ally reaching such a size as to interfere with walking. The importance 
 of the condition of course rests on the possibility of their rupture either 
 into the tissue of the vuha forming a hematoma of the vulva, or exter- 
 nally, with marked hemorrhage. The natural tendency of the \'aricosities 
 is to steadily increase as pregnancy advances and the intrapelvic pressure 
 increases, and with the veins of the bulbs of the vestibule enormously dis- 
 tended it requires but little increase in the tension to cause their rupture, 
 as from a fall astride a hard object, a blow, a kick, or the straining of 
 labor, or e^■en the straining at stool. 
 
 Hematoma. — The result of the rupture of a varicocele (jf the vulva 
 is soon seen in a rapidly developing tumor of the vulva, which as a rule 
 soon assumes on its inner aspect the bluish discoloration characteristic 
 of ecchymoses. If the skin of the vulva is unbroken the hemorrhage 
 occurring into a confined space usually soon ceases spontaneously, but 
 if from any trauma the skin of the vulva is broken, the hemorrhage may 
 be so severe as to endanger the life of the woman. The size of the dis- 
 tendedlabium may become so great as to form a tumor causing dystocia, 
 as will be referred to again under that head. 
 
 Treatment. — Prophylactic. — The object sought in treating this con- 
 dition is first to prevent as far as possible the increase in size of the 
 varicosities by reducing the amount of pressure from above and giving 
 suj)port to the dilated veins below. Although it is impossible to entirely 
 remove the pressure from above until the termination of the pregnancy, 
 something can be accomplished by having the patient wear a long, well- 
 fitting corset, which comes well beneath the abdominal tumor and sup- 
 (444) 
 
VARICOSITIES OF THE LEGS AND THIGHS 445 
 
 ports it, in fact lifts it from the pelvic veins. Another measure of relief 
 is to make sure that the lower bowel is kept empty so as to avoid the 
 pressure of any fecal column. 
 
 The best support to the dilated veins of the vulva is usually obtained 
 by having the patient, when she is on her feet, wear a firm, soft vulva pad 
 or napkin. Furthermore, every woman suffering with marked dilatation 
 of the veins of the vulva should be warned of the possibility of their 
 rupture and be instructed that in case this occurs, she should lie down 
 at once and apply pressure, assuring her that if she will do this and 
 summon her physician, nothing serious will happen before his arrival. 
 If the skin of the vulva is unbroken the best treatment is rest in the hori- 
 zontal position with an ice-bag applied to the vulva. If the skin is broken 
 it is often advisable for the obstetric surgeon to incise the hematoma, 
 turn out the clots, introduce a purse-string suture around the bleeding 
 surface and pack the remaining cavity with gauze. This last is the 
 treatment recommended when the vulvar hematoma serves as a cause 
 of dystocia, as will be seen later. 
 
 ~Wi 
 
 ^^K' "^^■■HHH 
 
 l^p r....,.»:,,.,.,,.«....... 
 
 
 J^^^^^^^^^^t^ -V 
 
 ^^^^^^^^HHjHp " 
 
 u 
 
 
 i^^^^^^^K' 4I 
 
 Fig. 307. — Varicosities of the thighs in pregnancy. 
 
 Varicosities of the Legs and Thighs.— With the tendency among 
 non-pregnant woman to have varicose veins on the leg or thigh as great 
 as it is, it is easy to understand why, in pregnancy with pressure upon 
 the pelvic veins from the pregnant uterus and the frequency of constipa- 
 tion, these varicosities are common. A marked case is shown in Fig. 
 307. In order to avoid marked permanent dilatation of the veins of the 
 lower extremities with the accompanying discomforts, it is always wise 
 to support the dilated veins with an elastic stocking or well-fitting ban- 
 dage. Occasionally a group of dilated veins, as in the calf or in the 
 popliteal space, becomes inflamed and extremely tender during preg- 
 nancy. This antepartum phlebitis is treated in the same way as that 
 of the postpartum variety with rest in the horizontal position, the appli- 
 cation of an ice-bag and later support. 
 
446 AFFECTIONS AXD DISEASES COMPLICATING PREGNANCY 
 
 Hemorrhoids. — Another result of obstructed venous circulation from 
 pelvic i)ressure in pre^^nancy is seen in the frequent occurrence of hemor- 
 rhoids, which may add greatly to the discomfort of the patient. The 
 majority of women are constipated during pregnancy and this con.stipa- 
 tion, together with the pressure of the pregnant uterus, naturally jiredis- 
 poses to a dilatation of the hemorrhoidal veins. 
 
 Treatment. — The treatment is prophylactic and j)alliative, seldom radi- 
 cal during pregnancy. The prophylactic treatment, consists in keeping 
 the bowels moving regularly each day and in taking the pressure off 
 from the pelvic veins as much as possible by the use of a well-fitting 
 corset or an abdominal bandage. 
 
 The palliative treatment usually employed by the author is as follows: 
 After each stool have the patient bathe the anus with cold water. After 
 drying the parts have her apply with toilet paper some of the following 
 ointment, carrying a little of it into the bowel. 
 
 I^ — Ichthyol 5ij 
 
 Ointment of tannic acid ... ov 
 
 Lanolin . . oJ 
 
 If the hemorrhoids are acutely inflamed, rest in bed with local ap])lica- 
 tions of cold witch hazel reduces the inflammation and gi^■es marked 
 relief. It is seldom advisable to remove the hemorrhoids by operation 
 during pregnancy. 
 
 Edema of the Vulva. — This may be of three different varieties. It 
 may be (a) systemic, (b) mechanical or (c) the result of local inflam- 
 mation. 
 
 (a) Systemic. — An edema of any part of the body in pregnancy may be 
 an expression of a toxemia with deficient kidney function. Hence the 
 appearance of edema of the vulva should always indicate first of all an 
 examination of the urine. Should this be found abnormal the condition 
 should be looked upon as systemic and the treatment indicated is that 
 of toxemia. If the urine is found normal, grave anxiety ceases and it 
 can be concluded that the condition is local. 
 
 (h) Mechanical. — A common result of the intrapelvic pressure in preg- 
 nancy is edema of the vulva and lower extremities. With the urine 
 normal, this may usually be looked upon as of little consequence save 
 discomfort. This edema of the vulva may be either unilateral or bilateral 
 (see Fig. 308). It may be so pronounced as to cause considerable 
 discomfort and under these circumstances it may be wise to put the 
 patient to bed for a time. The horizontal position with the use of hot 
 applications will usually reduce the edema markedly. In a few cases 
 it is well, after carefully disinfecting the skin of the vulva, to prick it in 
 several places with a sterile needle and allow the serum to drain away. 
 
 After this slight operation the vulva must be kept carefully covered 
 with a sterile dressing on account of the danger of infection. 
 
 (c) The Result of Local Infection. — Occasionally an edema of the vulva 
 may be caused by a local infection and inflammation, as a gonorrheal 
 vaginitis and ^'ulvitis, a chancroid, or an abscess of one of the vulvo- 
 
GONORRHEAL INFECTION 
 
 447 
 
 vaginal glands. A careful inspection and a smear will usually establish 
 the diagnosis and the treatment is that of an infection. 
 
 Edema of the lower extremities will be considered here as it is so inti- 
 mately associated with edema of the vulva. As with the latter condition 
 it may be of very serious import or of very little consequence. It may be 
 one of the early symptoms of a serious toxemia or it may be purely 
 mechanical. 
 
 Examination of the urine tells the story, hence the importance of 
 instructing all pregnant patients to report the presence of any edema. 
 If examination of the urine shows it to be normal, they can safely be 
 informed that the swelling is simply from pressure. 
 
 Fig. 308. — Edema of the vulva in pregnancy. 
 
 Gonorrheal Infection. — Gonorrheal infection of the vulva, urethra, 
 vagina and cervix will be discussed together, as in practice they are 
 usually found associated. 
 
 While it is possible for the woman to infect herself by using an infected 
 towel or napkin, the usual source is sexual intercourse with an infected 
 man. 
 
 To the shame of the husband be it said that the lessened frequency of 
 intercourse usually practised during pregnancy is regarded by some a 
 sufficient excuse for his seeking gratification outside, with the natural 
 result of an infection which he communicates to his wife on his return. 
 
 The danger of puerperal infection at her delivery, to say nothing of 
 added discomforts during pregnancy, and the risk of ophthalmia in the 
 case of the child, make this infection a very serious one. 
 
448 AFFECTIONS AND DISEASES COMPLICATING PREGNANCY 
 
 Diagnosis. — A gonorrheal infection during pregnancy, with its asso- 
 ciated, increased vascularity, usually presents a very acute picture. The 
 edema, the purulent discharge, gluing the hairs of the vulva together; 
 the presence of pus in the urethra, perhaps in Skene's ducts; the inflamed 
 openings of the ducts of the vulvo^•aginal glands; the frequent mic- 
 turition and tenesmus; all suggest the diagnosis of infection by the 
 gonococcus and a smear will verify it. 
 
 Treatment. — The importance of curing the condition if possible, before 
 the onset of labor, indicates active local treatment. In the author's 
 experience, daily douches by the patient of bichloride solution (1 to 5000) 
 and daily applications by the obstetrician of 25 per cent, argyrol solution 
 to cervix, vagina, urethra, and all crypts within the vulva have given the 
 best results. 
 
 At the time of the- labor a careful irrigation of the vagina with 0.5 per 
 cent, lysol solution lessens the danger of infection of the baby's eyes, but 
 as soon as it is born its eyes should be thoroughly irrigated with a satu- 
 rated solution of boric acid and 25 per cent, solution of argyrol or 1 per 
 cent, solution nitrate of silver instilled. ]\Iy own preference is for 25 
 per cent, solution of argyrol repeated every four hours for the first three 
 days of the baby's life. 
 
 As regards the treatment of the parturient canal after the birth of 
 the child, the best plan in the writer's judgment is to avoid all postpartum 
 douches on account of the danger of carrying the infection higher, and to 
 be content with especial care in maintaining the cleanliness of the vulva. 
 
 The possibility of puerperal infection with a complicating salpingitis 
 or oophoritis should always be borne in mind, but this danger is not 
 lessened by postpartum douches, but rather increased. 
 
 Abscess of Vulvovaginal Gland. — A great many chaste women as a 
 result of a simple catarrlial inflammation of the vulva near the opening 
 of one of the vulvovaginal or Bartholin's glands, have a cyst in either 
 labium. The most common cause of an al)scess of this gland is a gonor- 
 rheal infection rather than a simple catarrhal inflammation or trauma. 
 However, not infrequently an abrasion of a cyst of this gland leads to an 
 infection of it with the ordinary pathogenic organisms found about the 
 vulva, as the colon bacilli, staphylococci, etc., and an abscess results 
 without the presence of gonococci. 
 
 Treatment. — As it is very desirable to eliminate as far as possible all 
 sources of infection about the parturient canal before the onset of labor, 
 the best treatment of an abscess of the vulvovaginal gland complicating 
 pregnancy is incision as soon as the diagnosis is made, so that the abscess 
 cavity will either be healed or at least granulating before labor. The 
 redness, edema and tenderness of the labium usually enables the diag- 
 nosis of abscess, from a cyst of Bartholin's gland, to be made without 
 difficulty. 
 
 Pruritus Vulvae. — The increased secretion of the vagina and vulva, 
 common in pregnancy, especially in the obese, often gives rise to a 
 pruritus, perhaps even to an eczema of the vulva, which may be very 
 distressing and interfere with sleep. 
 
PROLAPSE OF THE VAGINAL WALLS 449 
 
 Treatment. — The first step in the treatment of the pruritus is to ascer- 
 tain whether the source of the irritation is from above, as from a vagina] 
 discharge or a septic or diabetic urine, or from without, as from parasites 
 or filth. 
 
 If an irritating urine is present this should receive its appropriate treat- 
 ment and the same may be said of parasites or filth. If the itching is 
 due to a simple, though increased vaginal leucorrhea, as a rule on account 
 of the risk of carrying infection into the vagina or lessening nature's 
 safeguards against infection, douching should not be advised. If, under 
 exceptional circumstances a douche is used, one containing borax, a 
 tablespoonful, and alum, a teaspoonful, in two quarts of warm water is to 
 be preferred. 
 
 The author's ordinary procedure is to direct the patient to bathe the 
 vulva frequently, i. e.,2 or 3 times in the twenty-four hours with carbolic 
 solution (1 to 100). This usually affords great relief. If, either as a result 
 of the itching and scratching, or as a result of a constitutional dyscrasia, 
 an eczema of the vulva is present, the following ointment is of value: 
 
 3 — ^Acidi salicylici gr. xv 
 
 Zinci oxidi, 
 
 Pulv. amyli aa 5iiss 
 
 Petrolati SJ 
 
 M. Sig. apply locally. 
 
 To this ointment, as the process becomes less acute, the oil of cade, 5 j> 
 is added. 
 
 Pruritus vulvse is sometimes only a part of a general pruritus resulting 
 from a toxemia, a gouty diathesis, or a neurasthenia and in these the 
 general condition needs treatment as well as the local. 
 
 Pointed Condylomata or Venereal Warts. — These are usually of gonor- 
 rheal origin, but occasionally develop as a result of irritation, due to 
 the increased secretion of the parts in pregnancy even in chaste indi- 
 viduals. As the result of the marked vascularity of the vagina and vulva 
 these pointed condylomata usually grow very luxuriantly, but unless 
 they show a tendency to slough it is usually better to postpone their 
 removal until after delivery. As sloughing would interfere with an aseptic 
 technic removal is indicated in this condition, although they bleed 
 more in removal during the pregnant than in the non-pregnant state. 
 
 As a rule cleanliness and the use of a dessicating powder, as calomel, 
 starch, talcum, etc., singly or combined, serves the purpose well. 
 
 Prolapse of the Vaginal Walls. — If the patient has previously been 
 the subject of a cystocele or rectocele, these conditions are usually much 
 aggravated by the weight and pressure of the pregnant uterus and by the 
 constipation which so often accompanies pregnancy. Occasionally in 
 primigravidse this weight and pressure combined with straining at stool 
 are sufficient to originate this prolapse of the vaginal walls. 
 
 Cystocele. — Of the two vaginal walls the prolapse of the anterior 
 wall together with the bladder attached to it is the more important. 
 This cystocele sometimes produces such a pouch filled with urine as 
 29 
 
450 AFFECTIONS AXD DISEASES COMPLICATING PREGNANCY 
 
 practically to fill the vagina and even project from it. The patient suffers 
 with the feeling of weight and pressure in the vagina with retention of 
 urine and vesical tenesmus. The best treatment in this pronounced type 
 of case is to catheterize the patient, putting her in the knee-chest posi- 
 tion, if necessary, to relieve the pressure of the presenting part upon the 
 bladder. To avoid a recurrence of the trouble it is usually wise to support 
 the abdomen with a well-fitting, long corset and have the patient assume 
 the knee-chest position for a few moments night and morning. In a few 
 cases it is necessary to hold up the vaginal wall with a ring pessary, 
 although the author dislikes very much to have any foreign body in the 
 vagina during the last month of pregnancy lest it interfere with nature's 
 safeguard against infection. 
 
 Prolapse of the Pregnant Uterus. — \Mien a prolapsed uterus becomes 
 pregnant, although at first the trouble is increased by the extra weight 
 of the organ, as the pregnancy advances the rule is that the uterus gradu- 
 ally rises into the abdomen and the woman does not suffer again from her 
 prolapse until after delivery. 
 
 On the other hand in exceptional cases the prolapse increases during 
 the pregnancy or even originates during the pregnancy from lack of 
 support in the pelvic floor and increased pressure from above. This 
 prolapse may increase to such an extent as to interfere with micturition 
 and defecation, to make standing and walking impossible, and even to 
 the extent of incarceration outside the pelvic outlet, a condition which 
 if unreduced almost inevitably leads to abortion. The diagnosis is 
 usually easy, although unless the height of the fundus is carefully noted, 
 an hypertrophy of the cervix, with a rectocele and cystocele might be 
 taken for a prolapse of the uterus as a whole. 
 
 Treatment. — The treatment in cases where the cervix is outside the 
 vulva consists first in putting the woman to bed and keeping the uterus 
 in place in the hope that as the uterus enlarges its increased size and 
 that of the fetus will prevent the recurrence. In some cases rest in the 
 horizontal position will accomplish this. In other cases elevation of the 
 foot of the bed is indicated, and in still other cases some vaginal support 
 as a pessary or tampon is necessary, although it must be remembered 
 that any tamponade of the vagina in pregnancy favors its interruption. 
 
 In some cases the tendency to a recurrence of the prolapse is so great 
 that during the last weeks of the pregnancy the patient has to be kept in 
 bed most of the time, allowing her up for a period of a few hours with 
 the support of a firm T bandage. 
 
 Retroversion and Sacculation of the Uterus. — These conditions are 
 also discussed under Dystocia and will not be considered here. 
 
 Bands and Septa in the Vagina. — These may have considerable in- 
 fluence upon labor, but as a rule have no effect during pregnancy, hence 
 they Avill he discussed under the head of Dystocia from the Soft Parts. 
 
 Carcinoma of the Cervix. — Occasionally a malignant disease of the 
 cervix complicating pregnancy is met with. In such cases, as always in 
 pregnancy, the life of the mother should receive first consideration. The 
 pregnancy should be interrupted promptly if the case is operable and 
 
SALPINGITIS 451 
 
 the uterus and pelvic glands should be removed. If the child is viable, 
 a Cesarean section just preceding the hysterectomy is usually the method 
 of choice. 
 
 Fibromyomata. — Fibromyomata complicating pregnancy are discussed 
 under Dystocia (see page 630). Suffice it to say here that unless they 
 are pedunculated and so situated as to be likely to cause dystocia they 
 are not, as a rule, to be interfered with during pregnancy. 
 
 Salpingitis. — As a rule salpingitis is bilateral and causes sterility, for 
 even if the content of the tube has become sterile the fimbriated extremi- 
 ties are usually occluded, rendering the union of the ovum and spermato- 
 zoon impossible. 
 
 Occasionally, however, a salpingitis is unilateral and pregnancy through 
 the healthy tube is possible, or infection and impregnation may occur 
 at about the same time. Hence it is possible to have a pregnancy com- 
 plicated by either a chronic or an acute salpingitis and as a result of 
 the stretching, pressure and trauma of pregnancy and labor a chronic 
 salpingitis may undergo an exacerbation, so that a pyosalpinx may 
 complicate pregnancy or the puerperium. 
 
 Symptoms. — The symptoms of a salpingitis complicating a pregnancy 
 vary with the chronicity of the inflammation. If the process is old and 
 the tubal content sterile the only symptom usually present is pain 
 caused by the stretching of the old adhesions about it. Occasionally 
 there may be added the symptoms of a threatened abortion on account 
 of the normal expansion of the uterus being interfered with by old adhe- 
 sions binding uterus and tubes in the pelvis. If the process is acute or 
 an acute exacerbation of a chronic salpingitis there are present the rise 
 of temperature and pulse, the pain and tenderness, the nausea, the bladder 
 irritability, the tympanites, etc., usually associated with an acute salpin- 
 gitis with pelvic peritonitis. 
 
 If a pus sac has formed this may project itself against the abdominal 
 wall or bulge into the vaginal fornix. If the abscess sac by traction of 
 the growing uterus or the trauma of labor is ruptured there may be added 
 the symptoms and signs of a spreading peritonitis. 
 
 Diagnosis. — The positive diagnosis of a salpingitis of the right side com- 
 plicating a pregnancy is sometimes difficult. The symptoms and even 
 the physical signs may resemble those of appendicitis. In fact, both con- 
 ditions may be present, either one having been the seat of the original 
 focus of inflammation, which then spread to the other. If only a salpin- 
 gitis is present the diagnosis can usually be made by the history of 
 previous pelvic inflammation, the feeling of an elongated, tender mass 
 extending to the horn of the uterus; this elongated, tender mass felt 
 through the vagina usually lying lower than an inflamed appendix. If 
 the salpingitis is of gonorrheal origin evidences of this infection will 
 usually be visible in Skene's ducts or the ducts of the vulvovaginal 
 glands. The temperature, pulse and blood count may be similar in both 
 salpingitis and appendicitis. Gastric disturbances are more marked in 
 appendicitis than in salpingitis. The rigidity of the right rectus is more 
 marked, as a rule, in appendicitis than in right-sided salpingitis, but as men- 
 
452 AFFECTIONS AND DISEASES COMPLICATING PREGNANCY 
 
 tioned in the discussion of appendicitis, rigidity of the recti muscles are 
 often less evident as diagnostic features in pregnancy on account of the 
 enlarging uterus occupying the lower part of the abdomen. If the sal- 
 pingitis is left-sided the elongated tender mass reaching to the left horn 
 of the uterus and felt in the left vaginal fornix, especially when coupled 
 with the history of previous pelvic inflammation, usually makes the 
 diagnosis easy. 
 
 Treatment. — The treatment of a salpingitis during pregnancy and the 
 puerperium should in general be conservative. During pregnancy rest 
 with the application of an ice-bag over the affected tube, together with 
 proper diet, moving the bowels by enemata, etc., is usually all that is 
 required. 
 
 If a pus sac forms this should be evacuated and drained early so that 
 if possible the sinus will have healed before the onset of labor in order 
 to lessen the risk of infection. If there is doubt whether the condition 
 is a salpingitis or an appendicitis, the abdomen should be opened (prefer- 
 ably along the outer border of the rectus muscle) and the pus sac re- 
 moved. 
 
 During the puerperium, if an acute salpingitis or an acute exacerbation 
 of a chronic salpingitis develops, a certain amount of time should be 
 given to palliative treatment, as rest, ice-bag, etc. But if in spite of this 
 treatment, the condition as shown by temperature and size of tumor 
 mass seems to be getting worse, operation should be performed and the 
 pus sac removed if possible, otherwise drained. 
 
 Ovarian Tumors. — These are discussed in the chapter on Dystocia (see 
 page 639) , but it may be stated here that unless the tumor is very small 
 the best procedure is usually to remove it early in pregnancy wdth the 
 hope that the pregnancy will not be interrupted. In this way not only 
 is the risk of dystocia from it avoided, but the risk of a twist in its pedicle 
 and the risk of sloughing and infection. 
 
 DISEASES OF THE SKIN IN PREGNANCY. 
 
 Excessive Pigmentation. — While a certain increase in pigmentation 
 of the skin is characteristic of pregnancy, especially the primary and 
 secondary areolae of the breasts and the darkening of the linea alba, in 
 some instances there is such a deposit of pigment upon the face as to be 
 distinctly disfiguring (see Fig. 109). The deposit is chiefly upon the 
 forehead and cheeks, while the eyelids remain of a much lighter color. 
 
 This gives a peculiar mask-like appearance which so alters the expres- 
 sion of the patient that she usually desires to avoid observation. She and 
 her husband are often mentally distressed lest the disfigurement be per- 
 manent, but she can be reassured that it will rapidly lessen after delivery 
 and will soon not be noticeable. It must be admitted, however, that it 
 is likely to recur with each pregnancy, and there is a little tendency for 
 the skin to remain of a slightly darker hue. Treatment of the condition 
 has thus far been very unsatisfactory. 
 
DISEASES OF THE SKIN IN PREGNANCY 453 
 
 Pruritus. — The local pruritus vulvse has already been studied. A 
 general pruritus as a result of a toxemia or general neurasthenia is not 
 at all uncommon in pregnancy, and often a source of great discomfort 
 to the patient, preventing sleep and increasing her neurosis, which in 
 turn increases the pruritus. 
 
 Treatment. — ^The general principles which should govern the treatment 
 are methods favoring elimination, nerve sedatives and general tonics. 
 As in the majority of cases the cause is toxemic, the bowels should be 
 moved freely with a saline laxative, the diet should be of a variety most 
 easily digested, and the secretion of urine should be stimulated by drinking 
 freely of water. For temporary relief a soda bath, adding a handful of 
 bicarbonate of soda to the tub, will often ^ive marked relief. Building up 
 the general system with plenty of fresh air, with the administration of 
 iron and arsenic, will, as a rule, greatly assist the local treatment. 
 
 Herpes Gestationis. — ^A^ery frequently in pregnancy, as a result of a 
 toxemia, various skin lesions appear which have been grouped under the 
 general term of "herpes gestationis" although the same lesions may 
 occur in the non-pregnant and would be better described by the terms 
 erythema multiforme or dermatitis herpetiformis. The lesions vary from 
 a smooth erythema without infiltration to hardened papules, vesicles 
 and even bullae on a red, infiltrated base. 
 
 Symptoms. — ^The local symptoms are those of burning and itching. At 
 different times the eruption may occur on the thighs, the trunk, the fore- 
 arms, or even be general. The eruption may resemble measles and scarlet 
 fever, but the absence of the constitutional symptoms of these infectious 
 diseases, the fact that the eruption does not involve the mucous mem- 
 branes, and that the temperature, if at all elevated, is ver}^ slight, usually 
 enables the diagnosis to be easily made. Although the condition usually 
 rapidly improves after delivery, it is very rarely severe enough to justify 
 interruption of pregnancy unless this is indicated from other evidences 
 of the toxemia. 
 
 Treatment. — The treatment indicated is first of all that of the toxemia 
 by the usual methods of assisting elimination, followed by general tonics. 
 For the relief of the local irritation soda baths, Lassar's paste, carbolic 
 solution, etc., may be tried. 
 
 Impetigo Herpetiformis. — One of the rare skin affections occasionally 
 complicating pregnancy is impetigo herpetiformis. Attention was called 
 to it and its high mortality by Hebra in 1872. The eruption usually 
 begins on the inner side of the thighs or in the anogenital region, and may 
 spread over the trunk involving the mucous membranes as well. The 
 lesion appears as groups of pustules which spread peripherally. These 
 groups often coalesce, become covered with large crusts, which then fall 
 off leaving perhaps large, bleeding, reddened areas. The centres of these 
 areas often show efforts at healing while the process is spreading at the 
 periphery. 
 
 Symptoms. — The mucous membrane of the mouth may be affected 
 early. The general condition of the patient is depressed, usually but not 
 always accompanied by a rise of temperature and pulse, sometimes with 
 
454 AFFECTIONS AND DISEASES COMPLICATING PREGNANCY 
 
 rigors. In about 75 per cent, of the cases, the disease has proved fatal. 
 The disease is regarded as of toxemic origin, although sometimes 
 associated with infection. 
 
 Treatment. — Treatment has been of very little avail, but with our 
 present knowledge of the disease should be directed toward the support- 
 ing of the patient and favoring elimination. The ammoniated mercury 
 ointment, found so useful in treating impetigo in children, may well be 
 tried as a local application. 
 
 Fibroma MoUuscum. — Fibroma molluscum may occur in pregnancy 
 as in the non-pregnant state. Brickner^ has described such a case and 
 states that fibroma molluscum gravidarum differs in no way histologi- 
 cally from the disease when found in males or in non-pregnant women. 
 The disease is found chiefly about the neck and under the breasts. It 
 is most apt to appear in the latter half of pregnancy. While it might be 
 thought the fibromata mollusca might be confused with warts or verrucse, 
 the shape, consistency and peculiar pedunculation suffice to distinguish 
 them. 
 
 The prognosis is absolutely good, the lesions gradually disappearing 
 spontaneously a few months after delivery. If the growths are annoying, 
 they may be snipped off with a sharp, curved scissors. 
 
 Other Skin Diseases. — A woman who is pregnant is liable to the skin 
 afi'ections. to which the non-pregnant woman is subject and on account 
 of the tendency to toxemia in pregnancy all skin diseases which are of 
 toxemic origin are favored by it, and if present at its onset are usually 
 aggravated as pregnancy advances. 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 Hysteria. — The nervous system of most pregnant women is in a state 
 of less stable equilibrium than in the non-pregnant state. It requires 
 less to upset this equilibrium ; the result of the upset is more pronounced 
 and the restoration of the normal equilibrium is more difficult. From this 
 it follows that if a woman is predisposed to hysterical manifestations 
 when not pregnant, she is much more prone to them when pregnant. 
 Many factors seem involved in bringing this about. The existence of the 
 pregnancy with possible interference with other plans may be a disap- 
 pointment. The physical dread of labor and the mental dread of the 
 responsibility of maternity may darken the horizon. Furthermore, the 
 effect of a toxemia or faulty metabolism, seen so markedly in epilepsy 
 in the non-pregnant, may be evident here in an hysterical outburst. 
 Suffice it to say that hysteria in pregnant women is common; that it 
 does not usually interfere with the progress of the pregnancy or effect 
 the physical or mental development of the child. 
 
 Treatment. — The treatment consists chieflv in forbearance on the part 
 of the husband, the family and the obstetrician; moral suasion and the 
 use of such nerve sedatives as the bromides, valerian, etc. 
 
 1 Amor. Jour. Obstct., 1900, liii, No. 2, 191-199. 
 
DISEASES OF THE NERVOUS SYSTEM 455 
 
 Neuralgia. — In pregnancy neuralgia in different parts of the body is 
 extremely common and may be looked upon as arising from one or both 
 of two causes: (a) pressure, (b) a toxemia. 
 
 Pressure. — Neuralgic pains in the sacral region and extending down the 
 thighs, resulting from the pressure of the pregnant uterus upon the sacral 
 nerves and those leaving the pelvis, are easily to be understood. They 
 usually increase wdth the growth of the fetus and cannot be entirely 
 relieved until the pressure is relieved by the delivery. The best that can 
 be done is usually to lift the uterus as much as possible by having the 
 patient wear a well-fitting corset or abdominal belt. Some relief can 
 often be given by having her assume the knee-chest position several times 
 a day, thus allowing the uterus to be lifted by gravity from the pelvic 
 nerves. It is the writer's custom to tell patients assuming the knee- 
 chest position to remain in that position long enough to draw six long 
 breaths. Another result of the pressure of the pregnant uterus is seen 
 in the frequency with which cramps of the muscles of the lower extremi- 
 ties occur. Cramps in the muscles of the foot or of the leg are often very 
 distressing to the patient, especially when she is in bed with shoes and 
 clothing removed. Firm extension of the foot on the leg will usually 
 relieve the cramp promptly. 
 
 Toxemia. — Neuralgia in the upper part of the body of the pregnant 
 woman is also common and can best be explained by some fault in metab- 
 olism with a resulting toxemia. Certain it is that as a result of faulty 
 digestion and metabolism the teeth more readily undergo caries in preg- 
 nancy, and neuralgia not infrequently results from this caries. The 
 treatment consists in improving metabolism, favoring elimination by the 
 bowels, kidneys, etc., and by proper attention to the teeth. 
 
 Neuritis. — Occasionally in pregnancy the patient not only suffers 
 from neuralgic pains, but one or more regions show paralysis, muscular 
 atrophy and the reaction of degeneration — a true neuritis, with the 
 usual symptoms of tenderness and shooting pains. As already indicated, 
 this may either be localized in a single area or be multiple. As it often 
 occurs in areas where the afferent nerves are not subjected to pressure, 
 it is assigned to a general dyscrasia, a toxemia, as its cause. This is 
 made more probable from its frequent association with other symptoms 
 of toxemia. It usually disappears gradually after delivery. The treat- 
 ment is that usually employed in neuritis. 
 
 Rarely is it severe enough to justify interruption of the pregnancy, 
 although occasionally this justification presents itself. 
 
 Chorea. — If a patient who has previously suffered from chorea becomes 
 pregnant there is a strong tendency for it to recur. Moreover, chorea 
 occasionally occurs for the first time during pregnancy, and may assume 
 a very severe type, interfering with sleep and the taking of nourishment. 
 The severe type is associated with fever, mania and a high mortality. 
 In a series of 438 cases of chorea complicating pregnancy, collected by 
 Buist, Schrock, French and Hicks, there was a mortality of 16.5 per cent. 
 In the mil/d types of chorea recurring in pregnancy the cause may be the 
 same as that of the original attack as anemia, rheumatism, a nerve shock, 
 
456 AFFECTIONS AND DISEASES COMPLICATING PREGNANCY 
 
 etc., the tendency being aggravated pcrhai)s by the unstable e(iiiiUbrnim 
 of the nervous system in pregnancy. 
 
 On the other hand the severe tvpe of chorea occurring for the first time 
 in pregnancy, characterized by the occurrence of fever during hfe, and 
 the autopsy findings of an acute endocarditis, is usually assigned to a 
 toxemia. In some cases of a severe type the Streptococcus viridans has 
 been found. Chorea usually appears in the first half of pregnancy and 
 has a tendency to persist until after delivery, when as a rule it disappears 
 spontaneously. The severe types of the disease often cause premature 
 delivery. 
 
 Treatment. — In the mild forms of the disease arsenic, iron, rest, fresh 
 air and proper attention to the diet and elimination will suffice to carry 
 the woman safely through her pregnancy. If in spite of this treatment 
 the condition persists and shows a tendency to increase,, the pregnancy 
 should be interrupted. 
 
 Insanity Complicating Pregnancy and the Puerperium. Insanity 
 During Pregnancy. — Even in a normal pregnancy it has been shown 
 that the mental state of the woman is in unstable equilibrium and that 
 in patients of the neurotic type it requires very little to unbalance 
 this equilibrium, and cause them to exhibit hysterical manifestations 
 and other psychoses. This disturbed mental equilibrium in a certain 
 proportion of cases, about 1 to 1000, amounts to a real insanity. 
 
 Etiology. — Heredity and the tendency to recurrence are very marked 
 factors in the etiology of the insanity of pregnancy. If there exists the 
 family taint of insanity, or if the patient herself has ever been mentally 
 unbalanced, the exaggeration of all psychoses, which pregnancy natur- 
 ally tends to bring about, often acts to cause an outbreak or a recurrence. 
 Occasionally it occurs without any known hereditary taint or previous 
 marked psychosis in the patient. It may show itself at any time after 
 the third month of pregnancy and is especially common in the unmarried 
 and in those who are not desirous of pregnancy. It may follow a marked 
 nerve shock of any description. Its onset is often very insidious and may 
 be considered simply the depression or the irritability which frequently 
 goes with pregnancy until some insane act suddenly opens the eyes of 
 the obstetrician and the family. 
 
 It is most often found associated with some form of toxemia and this 
 possibility should always be borne in mind when considering the treat- 
 ment of the condition. 
 
 Relative Frequency. — Alienists in charge of asylums usually assign to 
 maternity and its associated conditions about 15 per cent, of the cases of 
 insanity among their female patients. Abt divides this percentage as follows : 
 
 Insanity of pregnancy, 2 per cent. 
 
 Insanity of the puerperium, 9 per cent. 
 
 Insanity of lactation, 4 per cent. 
 
 Varieties. — Insanity complicating pregnancy may present one of two 
 general types: (1) A melancholia. (2) A mania. 
 
 Melancholia. — The mental depression experienced at times by a great 
 many pregnant women otherwise normal may be exaggerated to such 
 
DISEASES OF THE NERVOUS SYSTEM 457 
 
 a degree as to amount to a typical melancholia with perhaps suicidal 
 tendencies. It may assume a religious phase and the patient be over- 
 whelmed with her sense of sin and unworthiness. 
 
 Mania. — On the other hand the mind of the patient may be in a state 
 of intense activity and excitement with occasional violent outbreaks. 
 Varied hallucinations may be present and in her periods of excitement 
 and violence she may injure herself or those about her. In the author's 
 experience melancholia during pregnancy has been much more common 
 than mania. 
 
 Diagnosis. — ^The dividing line between the natural psychoses of preg- 
 nancy and insanity is often difficult to fix, especially is this true in patients 
 who are anxious to have their pregnancy interrupted and for that reason 
 are willing to appear mentally unsound. The only safe course for the 
 obstetrician in these circumstances is to share the responsibility and 
 associate with himself an alienist, that they together may observe the 
 case and decide upon the treatment. 
 
 Treatment. — ^The first step in the treatment of the insanity of preg- 
 nancy is to safeguard the patient against injuring herself or others. 
 She should not be left alone for a moment night or day, and for this 
 reason two nurses are needed, sometimes even four. Considering the 
 fact that quite a large percentage of the cases are of toxemic origin the 
 bowels should be freely moved, the diet should be carefully regulated 
 to meet the needs of the individual and elimination favored by large 
 draughts of water, etc. If the patient is poorly nourished her nutrition 
 should be increased if possible, and if she refuses to eat nourishment should 
 be introduced, by moral suasion if possible, otherwise by the stomach- 
 tube. She should be given sleep and for this purpose the milder hypnotics 
 like the bromides, chloral, veronal, etc., may be tried first, but where 
 the patient is very excitable the author has succeeded best with hyoscin 
 hydrobromate, gr. ywo ^- 4 h., supplemented if necessary with a hypo- 
 dermic injection of morphin. 
 
 The question of induction of labor naturally presents itself. As a rule 
 the insanity of pregnancy usually disappears spontaneously shortly after 
 delivery. For this reason, if under treatment for toxemia and with 
 nerve sedatives the mental condition does not clear and especially if 
 true suicidal tendencies develop, in the opinion of the author the uterus 
 should be emptied. 
 
 Asylum Treatment. — ^For insanity complicating pregnancy the stigma 
 resting upon one committed to an institution is so great that it is 
 desirable, if the patient can be properly nursed at home or in a general 
 hospital, not to commit her to an asylum unless the interruption of 
 pregnancy has failed to restore the mental balance. 
 
 Puerperal Insanity. — This may appear as a continuation and exag- 
 geration of the psychoses manifest during the pregnancy, or may develop 
 suddenly at any time during the puerperium, i. e., durmg the first month 
 following the delivery. It may seem to develop with the agony of a 
 severe second stage of labor and continue into the puerperium, but in 
 the author's experience it has developed most often in the second week 
 
458 AFFECTIONS AND DISEASES COMPLICATING PREGNANCY 
 
 of the puerperium. In addition to this period of development a certain 
 number of cases seem to arise after the puerperium proper in women 
 overtaxed by the drain upon the system from nursinji; their child; this 
 form bein<j called insanity of Uiciation. 
 
 Etiology. — As in insanity complicatino; pregnancy, puerperal insanity 
 may arise as the result of a toxemia, and not a few cases, subjects of an 
 eclamptic seizure, have to pass through a period of puerperal insanity. 
 Moreover, puerperal insanity in a considerable })roportion of cases is so 
 closely related to an infection that puerperal infection must be looked 
 upon as an important factor in the etiology. Sudden grief or mental 
 shock, as the loss of the child in a person with delicate mental balance, 
 not infrequently serves as an inciting cause. 
 
 The same varieties of insanity, /. e., melancholia and mania, are present 
 in puerperal insanity as are seen in that complicating pregnancy. In 
 the insanity of lactation the melancholic type is more common than 
 mania. 
 
 Prognosis. — The insanity associated with maternity, whether it be that 
 of pregnancy, the puerperium, or lactation, usually has a good prognosis, 
 and it may be said that the more acute the onset and the more violent 
 the symptoms the better the prognosis. As a rule the patient recovers 
 in from two weeks to six months, but although some patients will pass 
 through a subsequent pregnancy without mental disturbance, it must 
 be borne in mind that there is always a tendency to recurrence with the 
 repetition of the pregnancy. 
 
 As already stated, the prognosis of insanity associated with maternity 
 is usually good, yet the author will never forget the impression made 
 upon him when called to an institution for the insane to operate for 
 hemorrhoids upon an inmate who, a brilliant young woman, in her first 
 confinement twent}' years ago had been afflicted with insanity from which 
 she had never recovered. 
 
 Treatment. — The same safeguarding of the patient by constant attend- 
 ance as recommended in the treatment of the insanity of pregnancy is 
 imperative here and even more so, as another factor — the child — has 
 entered the problem, and the danger of the mother in an unguarded 
 moment doing injury to her child is so great that, as a rule, the child should 
 be taken from the breast and not allowed to nurse. In a few cases the 
 secretion of the milk may be maintained by expression or by drawing it 
 off with a breast-pump in the hope that the mental aberration will be of 
 very short duration and that the baby may then be returned to the breast. 
 The same methods of securing sleep and maintaining nutrition may be 
 followed here as in treating the insanity of pregnancy. In the insanity 
 of the puerperium the difficulty and the expense of maintaining for a 
 sufficient time in her own home the proper safeguards and nursing of 
 the patient and the child make resort to commitment to an asylum more 
 often advisable or necessary. In the insanity of lactation the cessation 
 of nursing, the general upbuilding of the mother, both nervously and 
 physically, and the safeguarding of both mother and child are the prin- 
 ciples of treatment to be observed. 
 
CARDIAC DISEASE IN PREGNANCY 459 
 
 Epilepsy. — One of the important questions of the day is that of eugenic 
 marriages, and efforts are wisely being made to prevent the marriage of 
 the unfit. 
 
 Certain it is that children should not be brought into the world by 
 epileptic parents. These children are usually feeble, poorly nourished 
 and frequently die of congenital epilepsy. Fortunately epileptics are 
 frequently sterile, so that congenital epilepsy is rare. As a rule epilepsy 
 has very little effect on pregnancy and during it convulsions are rather 
 less frequent than usual. During the puerperium, however, there seems 
 to be a tendency to an increased frequency. An epileptic seizure is often 
 confused with eclampsia but the absence of urinary changes and the his- 
 tory of previous attacks usually enables the diagnosis to be made. 
 
 Treatment. — Epilepsy during pregnancy and the puerperium should 
 be treated as in the non-pregnant state. Careful diet, attention to 
 elimination by the bowels and the bromides generally serve the purpose. 
 On account of the risk of the mother injuring the baby during an epileptic 
 seizure and because the drain of the nursing and the stimulation of the 
 breasts seem to favor an increase in the number of epileptic seizures, it 
 is usually unwise to allow an epileptic mother to nurse her child. 
 
 Hemiplegia. — On account of the frequency of toxemia in pregnancy 
 and the tendency to hemorrhages in toxemia a cerebral hemorrhage with 
 a resulting hemiplegia is not a very rare complication of pregnancy and 
 the puerperium. 
 
 Although the prognosis depends upon the size and location of the 
 hemorrhage, as a rule it is good and the woman rapidly regains power 
 after delivery. The hemiplegia has little effect upon the labor itself. 
 Thrombophlebitis, one of the common results of puerperal infection, 
 and occasionally complicating pregnancy, may give rise to a cerebral 
 embolus with various paralyses, depending upon the area from which the 
 circulation is excluded. 
 
 Paraplegia. — Paraplegia is a rare complication of pregnancy, being 
 usually due to a spinal lesion independent of the pregnant state. A 
 few cases have been reported as being associated with a toxemia. The 
 labor in cases of paraplegia is usually normal and accompanied by less 
 pain than usual. 
 
 DISEASES OF THE BONES AND JOINTS. 
 
 These will be discussed under the head of deformities of the pelvis 
 resulting therefrom (see p. 665). 
 
 CARDIAC DISEASE IN PREGNANCY. 
 
 The condition and behavior of the normal heart in pregnancy has 
 already been discussed under the Physiology of Pregnancy (see page 134) . 
 Chronic cardiac disease with resulting valvular lesions is associated with 
 pregnancy in a certain proportion of cases. According to Fellner and 
 Vinay the frequency of this association is about 2 per cent. 
 
460 AFFECTIONS AND DISEASES COMPLICATING PREGNANCY 
 
 Occasionally hearts which in the non-pregnant state present no abnor- 
 mal sounds, gi\e distinct murmurs in the latter part of pregnancy, 
 showing that valves which may be competent for the ordinary demands 
 upon the heart are not equal to the increased demand of pregnancy. 
 The usual lesion is chronic endocarditis, existing prior to pregnancy, 
 although the pregnancy may be the cause of an exacerbation of it, and 
 rarely an acute endocarditis may arise during the pregnancy. Less com- 
 mon lesions of the heart complicating pregnancy and the puerperium, 
 especially the latter, are myocarditis and fatty degeneration. The 
 myocarditis is most often the result of puerperal infection, while the 
 fatty degeneration may follow a severe toxemia or be the result of a 
 prolonged chloroform anesthesia. 
 
 The mitral lesions are much more frequent than the aortic and for- 
 tunately mitral insufficiency is much more frequent than mitral stenosis. 
 
 Prognosis. — Of all the complications of pregnancy there is none in which 
 the prognosis is more uncertain than a serious cardiac lesion, especially 
 a mitral stenosis. Young, otherwise healthy women, with a mitral 
 insufficiency well compensated, will, judging from the author's experience, 
 usually pass through pregnancy and the puerperium with very little if 
 any trouble. With a mitral stenosis the prognosis is much more grave, 
 but in all cardiac diseases complicating pregnancy the prognosis depends 
 largely upon whether any lack of compensation has existed prior to the 
 pregnancy. 
 
 If compensation has failed in the non-pregnant state, this failure 
 is very apt to recur and increase during pregnancy, when the demands 
 upon the heart are so much greater. This is especially true in the case 
 of a mitral stenosis. Moreover, while a diseased heart may pass safely 
 through a normal pregnancy and labor, it is poorly fitted to endure the 
 common complications of either, as a toxemia, a long tedious labor, 
 a severe hemorrhage or infection. Moreover, the heart which tends to 
 lose compensation in a normal single pregnancy and labor has this ten- 
 dency exaggerated if the pregnancy is multiple. Again, a patient suffer- 
 ing with an endocarditis may pass safely through her pregnancy and per- 
 haps her labor and then suddenly die of a pulmonary or cerebral embolism. 
 
 According to Fellner, in about 20 per cent, of cases of serious cardiac 
 lesion, abortion or premature labor results. This may be caused by 
 accidental hemorrhage, by placental changes, or by the death of the fetus 
 from insufficient oxidation of the fetal blood. 
 
 Treatment. — ]Much depends upon the care of the patient during her 
 pregnancy, and if she is willing to cooperate with her obstetrician, many 
 cases may be carried safely through maternity which otherwise would 
 be lost. The following are the chief principles of treatment: 
 
 1. Relieve the work of the heart as much as possible. 
 
 2. Watch for lack of compensation. 
 
 3. Use cardiac tonics, as digitalis, when indicated. 
 
 4. In a few cases interrupt the pregnancy. 
 
 Relief of Cardiac Work. — This implies the avoidance of all violent exer- 
 cise durmg pregnancy, the relief of pelvic pressure by careful attention 
 
CARDIAC DISEASE IN PREGNANCY 461 
 
 to the bowels, and the proper support of the abdomen and enlarging 
 uterus. The amount of rest required by the patient depends largely upon 
 the gravity of the lesion and the completeness of the compensation. The 
 author has succeeded in carrying some patients with marked mitral 
 stenosis safely through pregnancy and labor, even after symptoms of 
 lack of compensation, by keeping them extremely quiet during most of 
 the pregnancy, having them spend a large part of their time in bed, 
 varjang the monotony by moving them in a wheel-chair to a porch for 
 fresh air and diversion and then to a couch or reclining chair for the 
 remainder of the day. When the time of labor has arrived, in order to 
 relieve the work of the heart as much as possible, violent muscular strain, 
 such as the powerful expulsive efforts of the second stage, should be 
 avoided by the employment of ether anesthesia and the early use of the 
 forceps, or by breech extraction if the presentation is that of a breech. 
 
 Watch for Lack of Compensation. — This is usually evidenced by irregu- 
 larity and increased frequency of the pulse, by cyanosis of the lips and 
 fingers, by pulmonary congestion and edema with dyspnea, perhaps with 
 a hacking cough. The patient is often restless, cannot sleep lying down, 
 and digestion is often impaired. These symptoms and signs should always 
 be watched for, and to a certain extent anticipated by treatment. 
 
 The Use of Cardiac Tonics. — The drug which usually serves best to 
 prevent lack of compensation and to deal with it when present is digitalis. 
 Strychnin is also valuable, but the use of digitalis in small doses for 
 several weeks at a time, and then repeated after an interval of one to 
 three weeks in cases threatened with failing compensation, usually works 
 well. 
 
 During labor, when the strain upon the heart is great and when collapse 
 is threatened, some rapidly acting cardiac stimulant should be given. 
 The delivery of a patient suffering with a severe cardiac lesion should 
 be surrounded with every safeguard for dealing with sudden cardiac 
 failure or pulmonary congestion : the usual cardiac tonics, oxygen, plenty 
 of assistants to watch the case, etc. 
 
 For the dyspnea and restlessness often associated with cardiac disease, 
 codein or small doses of morphin may be used with advantage. 
 
 Interru'ption of Pregnancy. — If a woman with a poorly compensated 
 heart contemplates marriage she should have explained to her and her 
 fiance the danger of pregnancy in her condition. 
 
 The question of interruption of pregnancy depends chiefly on that of 
 compensation of the heart. If compensation is good and the patient 
 is willing to be careful and obey orders, interruption of the pregnancy is 
 unnecessary. On the other hand, if the patient shows increasing failure 
 of compensation, interruption of the pregnancy may be the only proced- 
 ure which will save her life. The time of this interruption may not be 
 an easy problem to solve. 
 
 If compensation fails early in pregnancy the decision is usually easy, 
 and emptying the uterus with the least shock to the patient, usually 
 with a preliminary gauze packing of cervical canal and vagina for twelve 
 to twenty-four hours, is the procedure indicated. If the period of gesta- 
 
462 AFFECTIOXS AND DISEASES COMPLICATIXG PREGNANCY 
 
 tion is about six months, and the cervix is long and rigid, the difficulty 
 of emptying the uterus at this period is sometimes so great that it is 
 wiser to wait until a little later when there is a chance of saving the 
 child and the cervix is shorter and softer. 
 
 PULMONARY AFFECTIONS COMPLICATING PREGNANCY. 
 
 Dyspnea. — The difficulty in breathing often experienced in pregnancy 
 may be of two varieties — mechanical or neurotic. 
 
 Mechanical. — In the latter months of pregnancy, as the uterus enlarges 
 and occupies a large part of the abdomen, the descent of the diaphragm 
 and therefore the expansion of the lungs is interfered with and on exercise, 
 such as going up stairs, hill climbing, etc., the patient experiences more 
 or less dyspnea. 
 
 In a normal single pregnancy this usually is of little consequence, but 
 in cases where the abdominal distention is unusually great, as in mul- 
 tiple pregnancy, hydramnios, pregnancy associated with a tumor, etc., 
 the dyspnea may be very annoying, requiring the patient to sleep with 
 several pillows. 
 
 Neurotic or Spasmodic. — Occasionally in pregnancy, especially in neu- 
 rotic individuals, there occurs a form of dyspnea, which from its evanes- 
 cent character and the absence of any lesion to be detected between the 
 attacks is usually called neurotic, spasmodic dyspnea, and is best treated 
 by nerve sedatives. 
 
 Before diagnosing a dyspnea of pregnancy neurotic, however, care must 
 be taken not to overlook a toxemia which with its accompanying contrac- 
 tion of the arterioles may be the cause of the dyspnea. In other words, 
 no dyspnea should be called neurotic unless lesions of the kidneys, heart, 
 etc., can be excluded. 
 
 Emphysema. — Patients suffering with emphysema prior to pregnancy 
 usually have their symptoms much exaggerated by pregnancy. This 
 exaggeration may arise both from the mechanical interference with the 
 normal action of the diaphragm and from the neurotic tendencies which 
 pregnancy so often brings out. 
 
 Emphysema from interference with the normal oxygenation of the fetal 
 blood and the resulting accumulation of carbon dioxide occasionally 
 stimulates the uterus to contract and causes a premature expulsion of the 
 ovum or fetus. On the other hand, the symptoms sometimes become so 
 distressing that in the interest of the mother it is necessary to interrupt 
 the pregnancy. 
 
 Asthma. — Women who are subject to asthmatic attacks are very 
 likely to have these attacks increased in frequency and severity when 
 they become pregnant. ]\I()re()ver, some women will suffer from asthma 
 during pregnancy who have never before been troubled with it. This 
 variety seems to be due to the pregnancy itself and usually persists more 
 or less until delivery when, as a rule, it disappears. The treatment of 
 asthma complicating pregnancy is the same as that in the non-pregnant 
 state. Change to a clear, dry atmosphere usually gives the patient relief. 
 
PULMONARY AFFECTIONS COMPLICATING PREGNANCY 463 
 
 Reflex Cough of Pregnancy. — Some women without demonstrable 
 lesions of the throat or respiratory tract will suffer with an irritable 
 cough which is annoying and very persistent, in spite of the usual 
 methods of treatment. Spraying the throat with astringent lotions will 
 sometimes give relief, but in many cases it resists all treatment but 
 disappears rapidly after delivery. 
 
 Hemoptysis. — Hemorrhage from the respiratory tract occasionally 
 occurs during pregnancy without demonstrable lesions or subsequent 
 lung involvement. It often seems associated with an overacting heart 
 in neurotic women and sometimes seems to be of the nature of a vicarious 
 menstruation. In the absence of pulmonary lesion no treatment is 
 required save reassurance, rest, and nerve sedatives. 
 
 Tuberculosis Complicating Pregnancy. — This question may well be 
 studied under two heads: (1) The effect of pregnancy upon tuberculosis. 
 (2) The eft'ect of tuberculosis upon pregnancy. 
 
 The Effect of Pregnancy upon Tuberculosis. — Varying with the site and 
 type of the tuberculous lesion present, most observers are agreed that the 
 effect of pregnancy upon tuberculosis is a deleterious one. This harmful 
 effect is least pronounced in the chronic process called "fibroid phthisis." 
 It is most pronounced in tuberculosis of the larynx. Patients with 
 latent tuberculosis in the sense of having in certain lymphatic glands of 
 the body tuberculous foci which have for years remained localized, may, 
 with the occurrence of pregnancy, have this tuberculous process extend to 
 the lungs and even become general. Patients, moreover, with an arrested 
 pulmonary tuberculosis not infrequently have, with the occurrence of 
 pregnancy, a lighting up of this process with an active extension as the 
 pregnancy advances. Again, a tuberculous pregnant woman, especially 
 one with a fibroid phthisis, may pass through pregnancy with apparently 
 little exacerbation of her tuberculous process, and then in her puerperium, 
 perhaps as a result of the strain of the labor and the anesthetic, develop 
 a rapid extension of the disease, perhaps causing her death in a short 
 time from an acute general tuberculosis. 
 
 The reason for the deleterious effect of pregnancy upon tuberculosis 
 seems clearly to be the reduced vitality of the woman resulting from 
 the increased demand of pregnancy upon her blood, the increased 
 tax upon her different organs, and the drain upon her system, resulting 
 from the different complications of pregnancy and labor as toxemia, 
 especially that form characterized by hyperemesis, hemorrhage, infection, 
 etc. In a few cases, especially in those suffering with fibroid phthisis, 
 the tuberculous patient seems for a time to improve during the pregnancy. 
 This may be due to the increased nutrition often seen in normal pregnancy, 
 or in exceptional cases to an increased expansion of the upper portions 
 of the lung; the lower portions being compressed by the upward pressure 
 of the enlarging uterus upon the diaphragm. 
 
 That a tuberculous woman, however, should have her tuberculosis 
 improved by pregnancy is not a result to be counted upon or expected. 
 
 The Effect of Tuberculosis upon Pregnancy. — The association of preg- 
 nancy with tuberculosis is so commonly seen that any tendency of the 
 
464 AFFECTIONS AND DISEASES COMPLICATING PREGNANCY 
 
 disease to cause sterility, which by some is supposed to exist, must be 
 a very slight one. Nor does the disease commonly cause an interruption 
 of pregnancy. In a few advanced cases, however, on account of insuffi- 
 cient oxygenation, or on account of a tuberculous change in the placenta, 
 premature labor occurs. 
 
 As a rule tuberculous women have poorly nourished, feeble children, 
 born with what might be called a tuberculous tendency or a soil suitable 
 for the growth of the tubercle bacillus. On the other hand the author 
 has occasionally delivered tuberculous women of large, healthy-looking 
 babies who apparently had every prospect of future well-being. 
 
 A sufficient number of cases are now on record to demonstrate that 
 tuberculosis may at times be transplanted directly from mother to fetus. 
 
 Birch-Hirschfeld,^ in 1891, demonstrated tuberculosis in the fetus 
 itself. Sitzenfrey,^ in 1909, was able to demonstrate tubercle bacilli in 
 the blood of two children in a series of twenty-six born of tuberculous 
 women. 
 
 Through the investigation of Schmol, Novak and others, the tuber- 
 culosis of the placenta has been shown to be a common lesion in tuber- 
 culous women ; the frequency varying in different series of cases from 50 
 to 70 per cent. 
 
 Friedman,^ by experiments on animals, was able to demonstrate the 
 possibility of fetal tuberculosis by the introduction of tubercle bacilli 
 along with the spermatozoa. The possibility of congenital tuberculosis 
 in the human fetus must therefore be considered established and yet 
 in spite of a not infrequent involvement of the placenta in tuberculous 
 women, the birth of healthy children is so common that congenital tuber- 
 culosis must be considered the exception rather than the rule. It is 
 easy to understand that a child born with a soil suitable for the growth 
 of tubercle bacilli and living with one or more tuberculous parents easily 
 becomes infected, even if it did not have congenital tuberculosis. 
 
 Treatment. — The desirability of eugenic marriages in the interest 
 both of the family and the State is so well established at present that 
 there can be no question as to the advice to be given to a patient in active 
 tuberculosis. For her own sake, for the sake of her husband-to-be, and 
 for the sake of her possible child or children, she should not marry. 
 Her chances of recovery would be lessened by a pregnancy. She is likely 
 to infect her husband; she is likely to infect her child either before or after 
 birth. 
 
 If a candidate for matrimony has a healed tuberculosis she may consult 
 neither her physician nor an obstetrician as to the wisdom of marriage, 
 but if opportunity arises she should be advised of the danger of maternity 
 in her condition and that there is a possibility that her tuberculous 
 process, now quiescent and local, may be rendered active and general 
 by a pregnancy. 
 
 1 Arbeiten d. Pathol. Inst, zu Leipzig, Jena, 1891, p. 428. 
 
 2 Die Lehre von den Kongenitalen Tuberculose, etc., Berlin, 1909, clxxxi, 150-179. 
 
 3 Exp. Beitrage z. Frage Kongenitaler Tuberkelbazillen iibertragung, etc., Virchow's 
 Archiv, 1905. 
 
PULMONARY AFFECTIONS COMPLICATING PREGNANCY 465 
 
 The problem often confronting the obstetrician is what advice should 
 be given to a tuberculous pregnant woman? This depends a good deal 
 upon the state of the tuberculosis and the period of pregnancy, especially 
 the former. 
 
 In the first place the author believes firmly that a woman in the early 
 months of pregnancy, in active tuberculosis, with temperature, cough, 
 etc., should have her pregnancy interrupted whether the tuberculosis is 
 laryngeal or pulmonary. She needs every ounce of her vitality to com- 
 bat her tuberculosis. A continuance of her pregnancy is almost certain 
 to stimulate the development and spread of the tuberculous process; to 
 lower her vitality and greatly lessen her chances of recovery. Even if 
 the patient seems to be enduring her pregnancy with slight exacerbation 
 of her tuberculous symptoms, so many women thus afflicted go down 
 rapidly after confinement that the position taken above seems justified. 
 
 With regard to laryngeal tuberculosis, this procedure has received 
 general endorsement, and the plan of emptying the uterus in the early 
 months of every pregnancy complicated by an active tuberculosis is 
 rapidly gaining ground. Trembley, of Saranac Lake, so intimately 
 associated with tuberculosis, shares this view. The obstetrician should 
 be prepared at all times for an emergency tracheotomy with patients 
 suffering with a laryngeal tuberculosis. If the patient with active tuber- 
 culosis first presents herself to the obstetrician in the latter months of 
 pregnancy the course to be followed must be determined by the conditions 
 in the individual case. If the tuberculosis seems to be increasing and the 
 patient losing ground the pregnancy should be interrupted on the ground 
 that in pregnancy the life and future health of the mother should take 
 precedence over that of the child. Moreover, if the period of viability 
 of the child has been reached the interruption of the pregnancy may 
 even be to its advantage, rather than to allow it to go to term with the 
 risk of its becoming infected from the placenta. If the child has not 
 yet reached its period of viability, but is near it, it may be advisable to 
 postpone for a time the induction of the labor, meanwhile, by fresh 
 air and other hygienic measures endeavoring to improve the general 
 condition of the mother. 
 
 If the woman is in the last stages of a tuberculosis it is a debatable 
 question whether to empty the uterus or not, as the mere procedure of 
 the interruption may hasten the departure of the woman and the decision 
 must be determined largely by the conditions present in the individual 
 case, the strength of the mother, and the development of the child. 
 
 When the patient presents herself pregnant, but with an arrested 
 tuberculosis, the problem is a different one. If the arrest has been a 
 recent one and the pregnancy is in its early stages the author believes 
 that it should be interrupted. If, on the other hand, the tuberculous 
 process has been arrested for years and the patient is willing to surround 
 her life with all safeguards such as proper climate, sleeping out of doors, 
 etc., the continuance of the pregnancy may be allowed under careful 
 supervision. At the time of her labor, effort should be made to save her 
 strength as much as possible, to use as little anesthesia as possible, an4 
 30 
 
466 AFFECTIONS AND DISEASES COMPLICATING PREGNANCY 
 
 to avoid any unnecessary blood loss. She should be informed of the 
 danger of frequent repetition of pregnancy and should be advised against 
 it. She should in the interests of both herself and her child not be allowed 
 to nurse. 
 
 If emptying of the uterus is indicated in the early months, as in a 
 pregnancy complicated by an active tuberculosis, the procedure here, 
 as at term, should be carried out with the least shock to the woman 
 and the least anesthesia possible. The best plan, after two months of 
 gestation, is usually to perform the operation in two stages, first packing 
 the cervical canal and vagina firmly with bismuth gauze or a weak 
 iodoform gauze, and then at the end of twelve to twenty-four hours, after 
 the cervix has become softened and dilated, emptying the uterus with 
 the sterile, gloved finger, curette, and looped sponge holder. 
 
 One phase of the tuberculous woman's condition after confinement 
 deserves mention. I'sually her chart will show a temperature which 
 is naturally regarded as tuberculous and yet the possibility of a sapremia 
 in a tuberculous woman must not be overlooked. Not infrequently the 
 tone of her uterus is below normal and blood-clots and lochia are often 
 retained Avith putrefactive changes. In a number of cases seen by the 
 author the temperature of a tuberculous woman in the puerperium 
 came to normal after a gentle intra-uterine douche had washed away 
 decomposing organic material. 
 
 Pneumonia Complicating Pregnancy. — Pneumonia during pregnancy 
 is a serious complication viewed from the standpoint of either the pneu- 
 monia or the pregnancy, as each handicaps the other. The mechanical 
 interference with full lung expansion in pregnancy, especially during the 
 later months, greatly adds to the dyspnea of the pneumonia and the 
 consolidation of a portion of one or both lungs interferes with the normal 
 oxygenation of both mother and fetus. Interruption of the pregnancy is 
 a common result of this insufficient oxygenation as well as of the infec- 
 tion itself, with its high temperature, death of the fetus, etc. A number 
 of cases are on record by Carbonelli, Netter and others in which pneu- 
 mococci were found in the fetal organs. The frequency of this interrup- 
 tion of the pregnancy increases as the pregnancy approaches term, thus, 
 as generally considered, pneumonia interrupts the pregnancy in about 40 
 per cent, of the cases during the first half and in about 60 per cent, during 
 the second half. According to Vinay about 60 per cent, of these prema- 
 ture children die from the prematurity and the pneumococcus infection. 
 
 The maternal mortality of pneumonia in pregnancy is high. In Ricau's^ 
 series of 43 cases, 12 died; a mortality of 28 per cent. 
 
 Pneumonia Complicating the Puerperium. — This may be due to several 
 causes: It may be the result of the anesthetic used during the delivery; 
 it may be the continuance of a pneumococcus infection from jjregnancy 
 into the puerperium; it may arise as a fresh pneuuKX-occus infection 
 during the puerperium, or it may complicate a puerperal infection either 
 as a result of a septic embolus or as a hypostatic congestion from enfeebled 
 
 1 Th^se de Paris. 1874. 
 
PULMONARY AFFECTIONS COMPLICATING PREGNANCY 467 
 
 circulation. The mortality of pneumonia in the puerperium is greater 
 than of that occurring during the pregnancy. If labor intervenes in the 
 course of a pneumonia all observers are agreed that the strain of the 
 labor upon the already overtaxed heart lessens the chances of recovery. 
 If the pneumonia complicates a puerperal infection it is usually regarded 
 as a terminal infection with a very grave prognosis. 
 
 Treatment. — The treatment of pneumonia complicating pregnancy 
 should be medical rather than obstetrical. At first thought it might seem 
 that, as the fetal mortality is so high and the dyspnea is mechanically 
 increased by the continuance of the pregnancy, the best plan would be 
 to interrupt the pregnancy, disregarding the life of the child. The results 
 of this treatment, however, do not seem to justify the procedure. In 
 the series of cases collected by Vinay the maternal mortality was 68 
 per cent, when the pregnancy was interrupted, and only 15 per cent, 
 when it was not interrupted. The additional shock to the woman arising 
 from the induction of the labor or the emptying of the uterus seems to 
 turn the tide against her. The best plan seems to be to quiet uterine 
 activity by the application of the ice-bag to the fundus and the adminis- 
 tration of a mild opiate as codein, which also tends to quiet the hacking 
 cough and then to follow the usual treatment of pneumonia. If labor 
 intervenes care should be taken to lessen the shock of the delivery as 
 much as possible and to stimulate the heart to meet the demand upon it. 
 
 Whether the labor should be left to nature or expedited instrumen- 
 tally depends entirely upon the progress made by nature. The use of 
 oxygen in pneumonia complicating pregnancy is often of great value. 
 The treatment of a pneumonia complicating the puerperium depends 
 upon whether the infection is primarily pulmonary when the ordinary 
 treatment of pneumonia is indicated or whether it is secondary to a 
 pelvic infection. In the latter case the general treatment of puerperal 
 infection coupled with careful cardiac stimulation is the plan to be 
 followed. 
 
 With the general hydremic condition of the blood in pregnancy and 
 the unusual demands upon the heart, pulmonary edema is a common 
 accompaniment of a pneumonia complicating pregnancy and the puer- 
 perium. It should be constantly watched for and combated with dry 
 cups, oxygen, and cardiac stimulants. 
 
 Pulmonary Embolism Complicating Pregnancy and the Puerperium. — 
 Pulmonary embolism is a very rare complication of pregnancy and yet 
 as a thrombophlebitis of the pelvic or crural veins occasionally occurs 
 in pregnancy it must be considered possible for a portion of the thrombus 
 to separate and be carried to the right heart and the pulmonary arteries, 
 the result depending upon the size and niunber of the pulmonary arteries 
 occluded. A few cases of sudden death from this accident have been 
 reported by Barnes^ and others. 
 
 Pulmonary embolism complicating labor, and especially the puerperium, 
 is unfortunately much more common. It is one of the most tragic events 
 
 1 On the Thrombosis and EmboUa of Lj-ing-in "Women, Trans. Lond. Obstet. Soc, 1863, 
 iv, 30-53. 
 
468 AFFECTIONS AND DISEASES COMPLICATING PREGNANCY 
 
 which the obstetrician ever has to face. Its suddenness, often when 
 the i)atient is apparently convalescing smoothly, causes such a shock 
 alike to the family and the obstetrician that it is almost overwhelming. 
 
 The obstetrician looks about for its cause and wonders if it could have 
 been foreseen or prevented, and his search is usually in vain. While it 
 usually follows a low grade of infection with a certain amount of thrombo- 
 phlebitis of the pelvic veins, hundreds of cases are seen with as much or 
 greater thrombophlebitis without pulmonary embolism and occasionally 
 it occurs in the course of a puerperium, which has apparently been per- 
 fectly normal and afebrile. While it may occur during or immediately 
 following the labor, it usually occurs in the second or third week of the 
 puerperium. It usually occurs without warning, although the author 
 remembers one case who complained of cardiac oppression about twenty 
 minutes before the acute dyspnea and symptoms of collapse appeared. 
 While in rare cases it may develop as a primary thrombus in the right 
 heart itself, it is usually an embolism which is secondary to a thrombo- 
 phlebitis of the pelvic or crural veins. 
 
 The result depends upon the extent of occlusion of the pulmonary 
 artery or arteries. In some cases the main pulmonary artery is completely 
 plugged, the patient passes into a sudden cyanotic pallor with intense 
 dyspnea and precordial distress, the pulse disappears at the wrist and 
 in a very few moments the patient is dead. In other cases the patient 
 experiences a sudden pain in one side of her chest, she has dyspnea and 
 perhaps a little cyanosis and after a few hours she begins gradually to 
 recover. On the following day there are often the physical signs of a 
 localized pleurisy with a slight rise of temperature. Although this embolic 
 process may repeat itself at the end of a week or more, the author's 
 experience has been that if the patient did not die within an hour or so 
 from the initial embolism, she has recovered in spite of one or more 
 recurrences in what were apparently small pulmonary arteries. 
 
 Treatment. — Prophylactic treatment consists chiefly in strict asepsis 
 to avoid as far as possible the occurrence of a thrombophlebitis. Pul- 
 monary embolism has occurred w^hether patients after labor have been 
 allowed to sit up early or late. It would seem rational to the author, 
 however, not to allow a puerperal patient to sit up until the uterus is 
 well involuted and the uterine sinuses small. 
 
 In the tragic fulminating type of pulmonary embolism death usually 
 occurs so soon that, as a rule, all that can be done is to administer cardiac 
 stimulants and oxygen if it is at hand. If the pulmonary artery plugged 
 is a small one and the patient recovers from this embolus, the chief treat- 
 ment is rest in order to avoid a recurrence. As a rule a patient should 
 be kept in bed for two weeks after the signs and symptoms of the embolus 
 have disappeared. The patient is often relieved of the distress of the 
 localized pleurisy in the region of the embolus by strapping the chest. 
 
 Air Embolism. — In spite of the fact that air can be pumped freely 
 into the \eins of certain animals without causing serious symptoms, as 
 shown by Hare, Fitzpatrick, and others, there nevertheless remain on 
 record certain cases in which death has followed the injection of air into 
 
DISEASES OF THE BLOOD COMPLICATING PREGNANCY 469 
 
 the liuman uterus for the purpose of inducing an abortion or for other 
 reasons. On the other hand, in many of the cases in recent years, which 
 at autopsy have shown air bubbles in the veins, it has been possible as 
 demonstrated by Dobbin to prove infection by the Bacillus aerogenes 
 capsulatus, so that death from injection of air into the pelvic veins of 
 women must be considered very unusual. 
 
 DISEASES OF THE BLOOD COMPLICATING PREGNANCY AND THE 
 
 PUERPERIUM. 
 
 As already stated when discussing the physiology of pregnancy (see 
 page 132) the blood of the normal healthy pregnant woman does not 
 differ markedly from that of the non-pregnant state. There is, however, 
 a moderate hydremia and a moderate leukocytosis and many women 
 enter pregnancy in a condition far from normal. 
 
 Simple Anemia. — ]\Iany have been anemic for years, some become 
 pregnant again while already reduced by lactation or frequent child- 
 bearing. Hence, simple anemia is a common accompaniment of preg- 
 nancy, and when it is considered that the maternal blood is the source 
 of fetal nourishment and growth, and is at the same time the recipient 
 of the effete fetal material, it is easy to understand why many preg- 
 nant women are anemic, have low blood-pressure, and need iron tonics, 
 fresh air, etc., during pregnancy and need safeguarding against hemor- 
 rhage, which these anemic women bear badly, during labor. 
 
 Pernicious Anemia. — Although a rare complication of pregnancy, occa- 
 sionally as the result of a prolonged simple anemia during the pregnancy, 
 a severe toxemia or a severe postpartum hemorrhage, the patient is 
 found in a state of progressive anemia which microscopic examination 
 of the blood shows to be a true pernicious anemia. The literature of this 
 subject will be found reviewed by Findley.^ 
 
 Symptoms. — The clinical picture is that usually found in pernicious 
 anemia. The extreme yellowish pallor, with dyspnea and progressively 
 increasing weakness; edema of the extremities, etc. It is more often 
 found complicating the puerperium than pregnancy, although the exact 
 etiology is obscure. 
 
 The red blood cells are decreased in number. They are often irregular 
 in shape and some are nucleated. The hemoglobin is actually decreased 
 in amount, although relatively increased. 
 
 Prognosis. — The prognosis is usually bad, and although the patient 
 may greatly improve under treatment, the disease usually progresses to 
 a fatal issue. 
 
 Treatment. — The medical treatment which has proved of great value 
 is the administration of arsenic — Fowler's solution — in increasing doses. 
 Of late the transfusion of human blood has been employed with marked 
 success in some cases. If the positive diagnosis is made early in preg- 
 nancy the induction of abortion is certainly justifiable in some cases. 
 
 1 Pernicious Anemia and Pregnancy, Amer. Jour. Obstet., 1908, Iviii, 51-57. 
 
470 AFFECTIONS AND DISEASES COMPLICATING PREGNANCY 
 
 In conjunction with the above treatment everything should be done to 
 build up the nutrition and general system of the patient. 
 
 The tendency to hemorrhages found in pernicious anemia not infre- 
 quently leads to accidental liemorrhage with j)remature separation of the 
 placenta and death of the fetus. 
 
 Leukemia. — Although in a few rare instances leukemia is found 
 complicating pregnancy, the connection between the two is very vague. 
 If the disease existed prior to the pregnancy it is aggravated by the 
 latter condition. The diagnosis is suggested by the profound anemia 
 and the enlarged spleen but is only rendered positive by the differential 
 blood count. According to Sanger^ the fetal blood does not show these 
 changes. 
 
 Prognosis. — The prognosis is usually bad. 
 
 Treatment. — Induction of abortion, if the diagnosis is made early in 
 pregnancy, is justifiable, but its value is problematical. 
 
 Hemophilia. — A true hemophilia is a rare complication of pregnancy 
 and the puerperium. A tendency to hemorrhage from the different 
 mucous membranes, from the alimentary canal, from the uterus, subcu- 
 taneously, etc., is often seen in the toxemia complicating pregnancy and 
 the puerperium and hence it is usually wise to consider the hemophilia 
 of pregnancy and the puerperium as of toxemic origin. 
 
 CHRONIC INFECTIOUS DISEASES. 
 
 Syphilis. — One of the most important diseases complicating pregnancy 
 is syphilis, as three factors in the situation are concerned: the father, 
 the mother, and the child. 
 
 Paternal Syphilis. — As a rule, even with the low moral standard of 
 some syphilitics, a man in the active stage of syphilis with visible genital 
 lesions does not marry. Occasionally, however, this has taken place and 
 the woman has been infected with this dread disease on her wedding 
 night and impregnated at the same time. The more common occur- 
 rence has been that the man's genital lesions have healed and before 
 the days of the Wassermann reaction he has supposed himself cured and 
 has married only to find to his great distress later that he has infected 
 both his wife and his child. 
 
 The effect of syphilis upon the mother and child depends largely 
 upon the stage of the disease at the time of the impregnation. More- 
 over, pregnancy itself has a marked influence upon the disease. 
 
 Syphilis as Influenced by Pregnancy .^ — If a woman becomes infected with 
 syphilis at the time of, or soon after, impregnation, the local lesions as a 
 result of the increased vascularity of the parts become much more severe 
 than in the non-pregnant state. When the woman is not pregnant the 
 initial lesion of syphilis is usually small and inconspicuous and is often 
 overlooked. During pregnancy, however, the initial lesion is large, 
 
 1 Uebcr Leukiiniie bei Schwangerschaft, etc., Archiv f. Gyn., 1888, xxxiii, 161-210. 
 
SYPHILIS AND PREGNANCY 471 
 
 softer, and shows a tendency to ulcerate. The flat condylomata are 
 also larger, have more of a tendency to spread and also frequently slough. 
 Papules show a tendency to become pustules, and the whole disease 
 presents a more virulent picture than in the non-pregnant condition. 
 The constitutional symptoms of the infection are also more pronounced, 
 with fever more common and neuralgic pains throughout the body 
 more severe. 
 
 Influence of Syphilis upon Pregnancy. — A large number of syphilitic 
 women as seen in hospitals and dispensaries have suffered from an infec- 
 tion of both gonorrhea and syphilis and as a result of their gonorrheal 
 infection the fimbriated ends of their tubes have been closed and preg- 
 nancy rendered impossible. Hence, quite a number of syphilitic women 
 are sterile. If pregnancy does occur, the effect of syphilis upon it depends 
 largely upon the stage of the disease. If the woman is already syphilitic 
 or is infected at the time of impregnation, abortion or premature labor 
 usually results. 
 
 If a woman becomes infected with syphilis during pregnancy, the 
 effect upon the pregnancy depends largely upon the period at which the 
 infection occurs. If it occurs in the early part of pregnancy, abortion or 
 premature labor with death of the fetus is the rule, while if the infection 
 occurs in the latter part of pregnancy the child may go to term and be 
 born apparently healthy. In more than 50 per cent, of these cases 
 (Finger), howe^'er, the child shows a positive Wassermann reaction, and 
 sooner or later exhibits manifestations of the disease. The method of 
 transmission of s}'philis from the father to the ovum has been shrouded 
 with a good deal of mystery. It was for a long time supposed that the 
 infection was carried by the spermatozoa, but since the discovery of the 
 Spirocheta pallida as the infecting organism of syphilis and the fact has 
 been established that the spirocheta is three times as long as the head 
 of the spermatozoon (Bab), it is evident that the spermatozoa cannot 
 be the means of transfer. Two other possibilities exist: 
 
 1. That the spirochetse are carried by the spermatic fluid along with 
 the spermatozoa. 
 
 2. That the mother's blood is first infected and the spirochetse are 
 carried to the ovum by her infected blood. 
 
 It is probable that both of these avenues are utilized by the spirochetse. 
 For many years it has been kno\\Ti that a syphilitic child, infected from 
 its father, could be born of a mother apparently free from the disease and 
 could nurse that mother without infecting her. This is known as Colles's 
 law. The Wassermann reaction has thrown much light upon this con- 
 dition and it is now kno^\Ti, by finding that these women give a positive 
 Wassermann reaction, that the reason they do not become infected by 
 their syphilitic child is that they are already syphilitic themselves, the 
 infecting organisms having passed from the fetus through the placenta 
 to the maternal blood or perhaps, as suggested by W'illiams, they have 
 been infected by syphilitic chorionic villi circulating in the maternal 
 blood. The changes produced by syphilis in the placenta have been 
 discussed elsewhere (see page 109). 
 
472 AFFECTIONS AND DISEASES COMPLICATING PREGNANCY 
 
 Evidences of Syphilis in the Fetus. — The usual result of syphilis in either 
 parent is a stillbirth, the fetus bein^j undersized, poorly nourished and 
 macerated. Occasionally, however, the child is born alive, but presenting 
 the characteristic lesions of the disease which should be familiar to every 
 obstetrician both on account of the danger of infection and the impor- 
 tance of prompt treatment both of the child and the mother. The 
 characteristic a])pearances are well shown in Figs. 309 and 'MO, which 
 are photographs of a case occurring in the author's service at the Sloane 
 Hospital; the following illustrations of placenta and cord (Figs. 311 to 314) 
 being taken from the same case. The skin is dry and of a grayish hue. 
 
 Fig. 309. — Congem|al syphilis. 
 Syphilitic bulifie on hands and feet. 
 
 Fig. .310. — Congenital syphOis 
 of feet. 
 
 Bullie on soles 
 
 The bullte on the palms of the hands and soles of the feet are very charac- 
 teristic. The subcutaneous fat of the body is largely lacking. ]\Iucous 
 patches in the mouth and pharynx, and ulcerations about the anus are 
 common, and these visible lesions may be considered the typical evidences 
 of fetal syphilis. In rare instances, especially if both jjarents were free 
 from syphilis at the time of conception, and the infection was acquired 
 in the latter half of pregnancy, the child may appear healthy at birth 
 (Profeta's law). In the majority of cases, however, these children will 
 give a positive Wassermann reaction and in a few months will exhibit 
 the characteristic lesions of the disease and may readily infect any wet- 
 nurse to whom they may be given to nurse. 
 
SYPHILIS AXD PREGNANCY 
 
 473 
 
 Characteristic changes are present in the knigs, the abdominal viscera, 
 and the long bones. 
 
 n?<«^ '-^^^..j 
 
 Fig. 311. — Sj'philitic placenta. The large vessel shows an obliterating endarteritis with 
 small round-celled infiltration of its wall. A small vessel is nearly occluded. Many of the 
 chorionic \-illi are thickened, showing a decreased number of bloodvessels in their stroma. 
 There is round-celled infiltration of the stroma. 
 
 Fig. 312. — Syphilitic umbilical cord. Low power. Thickening of the coats of the vessel 
 walls and infiltration with small round cells. 
 
474 AFFECTIONS AND DISEASES COMPLICATING PREGNANCY 
 
 Fig. 313. — High-power view of portion of the wall of one of the arteries, marked with a square 
 in preceding figure, showing very marked round-celled infiltration, especially of the media. 
 
 Fig. 314. — Section of skin of feet, showing spiroehetae. 
 
SYPHILIS AXD PREGNANCY 475 
 
 The lungs may be the seat of gummata or the alveoH may be filled 
 with degenerated epitheliiun or be compressed by the formation of new 
 connective tissue with round-cell infiltration. The lungs as a whole are 
 large and heavy. 
 
 The liver is markedly increased in size and weight, weighing three or 
 four times its normal amount. This increase in size is brought about by 
 an increase in the interstitial connective tissue with here and there areas 
 of round-cell infiltration. 
 
 Similar changes are found in the spleen, pancreas, and kidneys. The 
 spleen as well as the liver is increased greatly in size. 
 
 Diagnosis. — The diagnosis of s^^^hilis complicating pregnancy is some- 
 times obscure, but should always be suggested by a history of repeated 
 miscarriages or premature labors, and evidences of the disease should 
 then be searched for in lesions of the skin, adenopathy', and the Wasser- 
 mann test. 
 
 Treatment. — ProphyL-\ctic. — Marriage. — Certainly the question of 
 eugenics finds no richer field of usefulness than in the prevention of 
 marriage when either the prospective husband or wife are sj^hilitic. 
 The future health of the other and the life of the possible child depend 
 upon it. The question naturally arises, Can a man or woman who has 
 had s\T)hilis ever marry with a clear conscience? This question may 
 certainly be answered in the affirmative. The number of instances in 
 which the disease has been cured and perfectly healthy children have 
 been born and have remained healthy is sufficiently large to justify this 
 answer. One fact, however, should be impressed upon all candidates 
 for matrimony who have been syphilitic. They should not marry until 
 all signs of the disease have disappeared and the repeated Wassermann 
 test is negative. 
 
 CuKATR'E. — If pregnancy exists and either father or mother are found 
 to be syphilitic, the mother (to say nothing of the father) should at once 
 be placed upon active syphilitic treatment, not only for her sake, but 
 for that of her child. She should be given salvarsan and the usual syphili- 
 tic treatment. The transmissability through the placenta of the drugs 
 usually employed in the treatment of syphilis enables one to treat the 
 fetus as well as the mother. The author in several instances of tertiary 
 s\^hilis in the mother has succeeded in carrying the pregnancy to a suc- 
 cessful termination after several premature deliveries by the continuous 
 use during the pregnancy of small doses of the protiodide of mercury. 
 The child when born, even if showing syphilitic lesions, may nurse its 
 mother with safety to her for the reason already mentioned. There is the 
 gravest danger, however, in allowing the child of a sj'philitic father or 
 mother to nurse any other woman, and this should never be allowed even 
 if it seems perfectly healthy and shows no syphilitic lesions at birth. 
 The. lesions may appear within a few weeks or months and the wet-nurse 
 became infected from the child. ^Moreover, the mother of a s^3)hilitic 
 child should never be allowed to nurse any other child even if she herself 
 presents no evidences of syphilis. As already stated, she is actually 
 syphilitic and may infect a healthy baby through her milk. It is evident 
 
476 AFFECTIONS AND DISEASES COMPLICATING PREGNANCY 
 
 from the above that botli mother and child at the time of its })irth ma>' 
 appear perfectly liealthy and yet each be siifi"erin<;- from hitent syphiHs 
 and the mother be capable of infecting a healthy baby and the child a 
 healthy woman. From this it follows that the greatest safety in selecting 
 a wet-nurse lies in first subjecting her to a Wassermann test. 
 
 Malaria in Pregnancy and the Puerperium. — The effect of malaria 
 upon a pregnancy depends largely upon the severity of the infection. 
 In the ordinary type of malarial infection as seen in the northern part 
 of the United States, there is very little tendency for the pregnancy to 
 be interrui:)ted, but in tropical climates where the fever is high and pro- 
 longed, and the rigors severe, premature labor is common. Edmonds' 
 found this to be the case in Africa. In persons who have suffered with 
 a malarial infection, pregnancy, labor and the puerperium seem to have 
 a tendency to cause a recurrence of the attack. According to Bonfils,^ 
 Legeois'' and others, malaria predisposes to puerperal hemorrhages. 
 The fetus occasionally presents evidences of malarial infection at birth, 
 i. e., enlarged spleen, pigmentation, etc., and according to Bodenhauser^ 
 and Economos^ the plasmodium is found in the fetus. Williams, however, 
 after very careful search in a series of 15 cases, in which the plasmodium 
 was found in the mothers, was unable to find it in the babies. 
 
 Diagnosis. — From the natural tendency of human nature to avoid 
 criticism there has been an inclination among general practitioners to 
 call puerperal infection malaria. The fact that many rises of tempera- 
 ture after confinement subsided under the use of (not because of) quinine 
 only served to confirm them in this practice. Since the discovery of the 
 Plasmodium and the spread of the knowledge that its presence was the 
 criterion of malarial infection, this unscientific confusion of puerperal 
 infection and malaria is rapidly disappearing, and at the present time 
 the diagnosis of malaria in the puerperium is not justified unless the 
 ])lasmodium is found. 
 
 Treatment. — Malaria in pregnancy and the puerperium should be 
 treated as in the non-pregnant state and quinine administered freely. It 
 should be borne in mind, however, that if the pregnant patient does not 
 have malaria, large doses of quinine are apt to bring on labor. 
 
 ACUTE INFECTIOUS DISEASES. 
 
 Scarlet Fever. — This is an unusual complication of pregnancy and the 
 puerperium, not because pregnancy estal)lishes an immunity, but because 
 scarlet fever in the adult is unusual. As will be shown when discussing 
 the relation between contagious diseases and puerperal infection (see 
 page 813), scarlet fever may attack a pregnant or parturient patient and 
 run its course without especially affecting the puerperiimi or being affected 
 by it. 
 
 1 Malaria and Pregnancy, Brit. Med. Jour., April 29, 1899. 
 
 2 Paludisme et Puerperalite, Ann. de Gynec, 1886, xx, 14-125. 
 
 ' Arch, do Tocologie, January, 1891. * New York Med. Jour., 1893. 
 
 6 Soc. d'Obstet. de Paris, February 25, 1907. 
 
ACUTE INFECTIOUS DISEASES 477 
 
 Undoubtedly confusion has arisen in the past from the fact that in 
 pregnancy as the result of a toxemia and in the puerperium as the result 
 of infection, a rash may appear which resembles scarlet fever. For this 
 reason the older statistics of scarlet fever complicating pregnancy should 
 be accepted with caution, and with our present knowledge of both con- 
 ditions the rational view seems to be (1) that a scarlet fever complicating 
 pregnancy, if of a very severe type, with high temperature, may cause 
 an abortion or premature labor, but that an ordinary course of scarlet 
 fever does not interfere with the normal course of pregnancy; (2) that 
 the danger arising from scarlet fever complicating pregnancy and the 
 puerperium comes from the complications not infrequently associated 
 with scarlet fever, i. e., the kidney and cardiac lesions and the strepto- 
 coccic infections. 
 
 It is readily seen that the kidney lesion of scarlet fever added to a 
 kidney lesion of pregnancy increases the gravity of the prognosis. More- 
 over, if the puerperal patient, with the large, raw surface of the parturient 
 canal, has a scarlet fever with a complicating streptococcus infection 
 of the middle ear or elsewhere, the risk of puerperal infection is 
 increased. 
 
 The possibility of transmission of scarlet fever from the mother to the 
 child seems well established by the cases reported by Leale,^ Saffin^ and 
 others. 
 
 Measles. — On account of the relative infrequency of measles in the 
 adult, it is an unusual complication of pregnancy and the puerper- 
 ium. The danger of this association lies in the high temperature, the 
 complicating pulmonary affection, and the increased risk of puerperal 
 infection. Measles during pregnancy is very apt to cause abortion or 
 premature labor, different observers in small series of cases reporting 
 interruption of the pregnancy in from 55 to 81 per cent. (Fellner,^ Klotz*). 
 This is probably caused by the high temperature and the coughing. 
 Although the complicating streptococcic infections of measles are usually 
 less frequent than in scarlet fever, still the literature of the subject indi- 
 cates a high mortality from puerperal infection; this may be accounted 
 for in part by the relatively large number of incomplete abortions. 
 Pneumonia also is a frequent and dangerous complication. 
 
 Smallpox. — Under the custom of general vaccination in this country, 
 smallpox is a very rare complication of pregnancy. When it does occur 
 it is a very serious complication both for the mother and child. It is 
 very apt to lead to abortion or premature labor with death of the child. 
 
 The maternal mortality, according to Vinay,^ is 36 per cent. The 
 hemorrhagic type is usually fatal to both mother and child. In the dis- 
 crete variety the pregnancy may not be interrupted at the time, but the 
 disease is apt to be transmitted to the fetus which may or may not be 
 killed by it. One of the author's cases was admitted in labor to the Sloane 
 Hospital shortly after her discharge from a smallpox hospital. The 
 
 1 Medical News, 1884, p. 636. ^ ^gw York Medical Record, April 24, 1886, 
 
 5 Innere Krankheiten, Vienna, 1903. ■* Archiv f. Gyn., Band xxix, S. 448. 
 
 5 Vaccinia et Variola au cours de la Grossesse, Lyon Med., March 25, 1900, 
 
478 AFFECTIONS AND DISEASES COMPLICATING PREGNANCY 
 
 child, a stillbirth, was almost as distinctly pock-marked as the mother, 
 showing that it too had suffered with the same disease. 
 
 On account of the pustular eruption of the woman the risk of infection 
 of the parturient canal during any examination or manipulation is 
 greatly increased. Hence, the need of the greatest care and the wisdom 
 of making as few examinations as possible. 
 
 Treatment. — If the pregnant woman has been exposed to smallpox, 
 she should be ^■accinated at once, the same as in the non-pregnant state, 
 with a view of protecting both the mother and the fetus. According to 
 Kollock^ the children of women who were vaccinated or had smallpox 
 during pregnancy are immime to vaccination and smallpox later. The 
 majority of authorities, however, do not accept this view of protection, 
 and many cases are recorded which show its absence. Certainly the 
 child should be vaccinated without regard to any possible im- 
 munity. 
 
 Typhoid Fever. — This is a serious complication of pregnancy alike 
 for mother and fetus on account of the long duration of the disease and 
 the reduction of the mother's vitality on the one hand and the risk of 
 the interruption of the pregnancy and the death of the child on the other. 
 About 50 per cent, of the pregnancies complicated by typhoid fever are 
 interrupted. This depends largely upon the severity of the infection, 
 the height of the temperature, etc. F. W. Lynch, in Professor Williams's 
 clinic at Baltimore, demonstrated the typhoid bacilli in the organs of 
 the fetus of a woman who aborted while suffering from typhoid fever 
 and this observation has been frequently confirmed, so that the passage 
 of the bacilli and their toxins through the placenta to the fetus must be 
 considered important factors in the death and expulsion of the fetus. 
 In the author's experience, pregnant patients suffering with a moderate 
 degree of typhoid infection with temperature not over 104° F. have not 
 aborted, while those suffering with a severe infection with temperature 
 frequently reaching 105° F. or over have aborted. 
 
 Treatment. — The treatment of typhoid fever complicating pregnancy 
 is the same as that in the non-pregnant state, including cold bathing, 
 suitable diet, cardiac stimulation where needed, etc. In addition to 
 this, the employment of the ice-bag on the abdomen over the fundus 
 uteri has seemed to the author very valuable in preventing uterine 
 contractions and the interruption of the pregnancy. 
 
 Cholera. — According to most authorities, cholera is one of the most 
 serious complications of pregnanc>' ever met with. Schultz,- who in 1894 
 studied carefull\- its effect upon menstruation, pregnancy and the puer- 
 perium, found that jjregnancy was interrupted in 54 per cent, of cases 
 and that the maternal mortality- was 57 per cent. Accidental hemor- 
 rhages are common during the pregnancy, as are changes in the placenta 
 and decidua, which Slavjansky has described as characteristic. Accord- 
 ing to Ballantyne, Ti/zoni, Cantani, and others, the disease is directly 
 
 • Amer. Jour. Obstet., 1889, p. 1079. 
 
 2 Ueber der Einfluss der Cholera auf Menstruation, Schwaugcrschaft Geburtsh. u. Wochen- 
 bett, Zentralblatt f. Gyn., 1894, xviii, 1138. 
 
DISEASES OF THE ORGANS OF SPECIAL SENSE 479 
 
 transmitted to the fetus in idem. The treatment is the same as in the 
 non-pregnant state. 
 
 Other Infectious Diseases. — Anthrax, tetanus, yellow fever, and 
 certain other infectious diseases are so rare as complications of obstetrics 
 that students are referred to general medical works for their study. 
 
 DISEASES OF THE ORGANS OF SPECIAL SENSE. 
 
 AfEections of the Eyes Complicating Pregnancy. — Disturbances of 
 vision during pregnancy are of great importance as possible indications 
 of grave danger either to the life of the woman or to her future vision. 
 The condition most frequently associated with disturbed vision in preg- 
 nancy is a disease of the kidneys, the lesion in the eye being the so-called 
 ''albuminuric retinitis" with white patches of exudate and hemorrhages. 
 Moreover, a true optic neuritis is not infrequently found associated with 
 the toxemia of pregnancy. If the woman's general condition is much 
 reduced b}" the nausea and vomiting of pregnancy, any muscular asthen- 
 opia previously existing is naturally aggravated. One of the unusual 
 ocular complications of pregnancy and the puerperium, especially as a 
 result of the labor, is a detachment of the retina. With the tendency 
 to a lack of stability of the nervous system seen in many women during 
 pregnancy, the possibility of an hysterical amaurosis must always be con- 
 sidered. During the puerperium it is a common experience to find a certain 
 amount of eye weakness, and that a woman in the first week or two after 
 confinement is unable to read or focus the eyes for any length of time on 
 a given object without more or less eye strain and headache. This is 
 especially true if she has suffered from profuse hemorrhages or a 
 toxemia. 
 
 Diagnosis. — ^AVhile recognizing the possibility of a disturbed vision in 
 pregnancy and the puerperium being an hysterical manifestation, this 
 should be the last diagnosis made. Visiial disturbances in pregnancy 
 should always first suggest a toxemia and should indicate a careful exami- 
 nation of the urine. Moreover, if the vision is markedly blurred, an 
 ophthalmoscopic examination of the eye should be made to determine 
 the existence and extent of the eye lesion. 
 
 Prognosis. ^The prognosis of eye lesions in pregnancy is usually better 
 than in the non-pregnant state, but this depends upon the location of 
 the lesion and whether the pregnancy is interrupted early or not. If the 
 hemorrhages are not over the macula and the pregnancy is terminated 
 promptly, the prognosis of restoration of vision is good. On the other 
 hand, if the hemorrhage is over the macula, or if the optic nerve is 
 involved, especially if the eye signals of danger are not heeded and preg- 
 nancy is allowed to continue and the toxemia increase, a permanent 
 impairment of vision is probable. It must also be borne in mind that 
 any serious eye lesion is apt. to be made worse by a subsequent preg- 
 nancy. The chances of recovery of perfect vision after detachment of 
 the retina during pregnancy, labor, or the puerperium seem, from the 
 cases reported, to be better than in the non-pregnant state. 
 
480 AFFECTIONS AND DISEASES COMPLICATING PREGNANCY 
 
 Treatment. — This depends upon the eye lesion, the presence or absence 
 of a toxemia, and its degree if present. If, as is usually the case, a toxemia 
 is present, the first indication is to treat this in the usual way, favoring 
 elimination, lowering blood-pressure, etc., and in this connection the 
 importance of careful and frequent observation of the blood-pressure, 
 when ocular symptoms complicate pregnancy, should be emphasized. 
 The important question for every obstetrician in charge of these cases 
 to answer is naturally this: Shall pregnancy be allowed to continue? 
 While it is difficult to formulate a hard-and-fast rule in these cases and 
 the decision to interrupt the pregnancy should usually be concurred in 
 by a competent ophthalmologist, it may be said in general that retinal 
 hemorrhages usually indicate a grave toxemia and that the life, future 
 health and future vision of the woman are usually best safeguarded by 
 an interruption of the pregnancy. Usually the vision improves rapidly 
 after delivery but a certain amount of permanent impairment is not 
 uncommon. 
 
 Affections of the Ears Complicating Pregnancy. — Aside from a ringing 
 in the ears and certain nervous disturbances of hearing which may or 
 may not be due to a toxemia present, it is the experience of most aurists 
 and obstetricians that chronic deafness is made worse by pregnancy and 
 that while the deafness usuall.y improves after the delivery (especially 
 if the woman does not nurse her child) the hearing does not return to 
 that enjoyed before the beginning of pregnancy. ^Moreover, each subse- 
 quent pregnancy usually results in a still further impairment with a 
 lessened return to the previous hearing. Lactation from the tax upon 
 the woman's strength and general vitality seems to have an especially 
 deleterious eflfect. 
 
 Treatment. — Patients suffering with chronic deafness will sometimes 
 consult their obstetrician as to the effect of pregnancy upon their hearing, 
 and it is only fair that they should be informed that it will probably be 
 made worse. The problem more often presented, however, is the question 
 of the justification of interruption of the pregnancy on account of an 
 increasing deafness. This is often a difficult question to answer, as in it 
 is involved the question of justification of marriage unless they were 
 willing to run the risk of an increasing deafness. Moreover, in man\' 
 cases the deafness will increase whether they become pregnant or not, 
 although probably not so rapidly. In general it may be said that deaf- 
 ness, as a rule, is not a justification for the interruption of pregnancy and 
 in a long obstetrical experience the author has only once felt justified 
 in doing it. In this instance there were two' sisters under his care. One 
 showed an increasing deafness in each of three pregnancies and after the 
 third was almost totally deaf. The other had showed an increasing 
 deafness in her two previous pregnancies, the hearing after each delivery 
 failing to return to that enjoyed at the beginning of the pregnancy. She 
 was now pregnant the third time and the husband was extremely averse 
 to having what little hearing she had impaired. After a careful study 
 of her sister's experience and with the concurrence of two well-known 
 aurists, the pregnancy was interrupted by the author. 
 
DISORDERS OF THE ALIMEXTARY CAXAL .481 
 
 Affections of the Nose Complicating Pregnancy. — An increased sen- 
 sibility of tlie olfactory nerves during pregnancy is so common as to be 
 regarded as physiological. Peculiarities in the sense of smell, such as 
 distaste for the odors of certain foods, are often not only very marked, 
 but distressing, causing nausea. The nasal mucosa, especially of the 
 lower turbinates and the septum, is in a condition of distinct hyperemia 
 in pregnancy and this readily accounts for the tendency to epistaxis 
 which is often seen. The epistaxis in some cases seems to be in the nature 
 of a vicarious menstruation and occasionally appears on the date which 
 would have been the menstrual period. In the other instances it is the 
 result of the tendency to hemorrhage from the different mucous mem- 
 branes associated with a toxemia. In the cases where the epistaxis 
 resembles a vicarious menstruation, the bleeding is usually not profuse 
 and little treatment is needed. On the other hand, the epistaxis of a 
 toxemia is sometimes so profuse that packing of the nares is necessary. 
 It is of course extremely desirable to have any suppurative process in 
 nose, throat, or ears cured if possible before the onset of labor, for fear 
 that by the hands or the clothing infection might be carried to the 
 parturient canal during labor or the puerperium. 
 
 DISORDERS OF THE ALIMENTARY CANAL. 
 
 The Mouth. — The Teeth. — So common is the tendency to caries of 
 the teeth in pregnancy that it undoubtedly gave rise to the old saying, 
 "For every child a tooth." Certain it is that women suffering with 
 carious teeth at the beginning of pregnancy find their cavities increase 
 rapidly in size as the pregnancy advances and those without cavities 
 at the onset of pregnancy often find them developed. It is probably due 
 in most cases to the disturbed secretions of the digestive tract incident 
 to pregnancy. In some cases the dental caries resembles the mild form 
 of osteomalacia. As a result of the dental caries, toothache and facial 
 neuralgia are common and a suppurating tooth root may well be the 
 source of infection of the parturient canal, the means of conveyance 
 being the hands or the handkerchief. 
 
 Treatment. — Great care should be taken of the teeth during pregnancy, 
 especially in the way of cleanliness. Xot only should they be carefully 
 brushed with, for instance, a good tooth paste or powder, but an alkaline 
 mouth wash like the milk of magnesia should be used frequently. In 
 addition to this the woman should consult her dentist at intervals during 
 her pregnancy so that her teeth may be kept under observation by him 
 and cavities filled while they are small. ]\Iajor work on the teeth during 
 pregnancy should be avoided, if possible, on account of the danger of 
 nerve shock and abortion. Under nitrous oxide, however, a tooth may 
 be extracted if necessary with relatively little danger. It should be 
 borne in mind that a toothache or facial neuralgia may be a neurosis 
 of pregnancy rather than the result of dental caries. 
 
 Gingivitis. — Xot infrequently the gums during pregnancy become 
 swollen, soft and spongy, and bleed easily during the brushing or even 
 31 
 
482 AFFECTIONS AND DISEASES COMPLICATING PREGNANCY 
 
 on slight touch. This is best treated by careful cleansing of the mouth 
 with one of the good astringent, antiseptic mouth washes, of which 
 there are a number on the market. At the same time the digestion, 
 elimination, and general upbuilding of the patient should receive careful 
 attention. 
 
 Ptyalism. — While a slight increase in the secretion of saliva is quite 
 common in the early part of pregnancy, occasionally the secretion is so 
 markedly increased as to be distinctly pathological. It may run from 
 the mouth almost constantly day and night, interfering greatly with the 
 patient's comfort, preventing sleep, etc. In one of the author's patients 
 the amount varied between one and two pints in the twenty-four hours. 
 The ptyalism is usually limited to the first half of pregnancy, but in a 
 patient of the author's it continued until the delivery and then rapidly 
 disappeared. 
 
 In mild cases it may be the result of a reflex irritation of the sym- 
 pathetic nervous system — a pure neurosis, but in cases of the severe 
 type it seems to be one of the expressions of a toxemia, other toxic 
 symptoms being usually present. 
 
 Treatment. — The methods of treatment which usually prove most 
 efficacious are : 
 
 1. Local astringent mouth washes. 
 
 2. The administration of atropin. 
 
 "^ 3. The treatment of any toxemia present by careful attention to diet 
 and elimination. 
 
 It must be admitted, however, that some cases seem rebellious to all 
 forms of treatment, and the condition persists until the delivery. 
 
 Gastric Indigestion. — The physiological or neurotic vomiting of 
 pregnancy and also the toxemic or pernicious vomiting have already 
 been discussed under the Physiology and Toxemia of Pregnancy (see 
 pages 131 and 417). Not infrequently, however, the pregnant patient 
 suiTers with what appears to be a pure gastric indigestion with "heart- 
 l)urn" and for this she seeks relief. 
 
 Treatment. — The remedies which usually prove most satisfactory are 
 either bicarbonate of soda or some preparation of magnesia. The bicar- 
 bonate of soda may either be given in five-grain powders every three or 
 four hours, or, as is often more convenient, in the form of soda mint 
 tablets, in which the peppermint is sometimes of value. The magnesia 
 may either be given in the form of the milk of magnesia, 5j, q- 3-4 h., 
 or some patients prefer to have with them a lump of solid magnesia 
 (magnesii carbonas) from which at intervals they take a small bite. For 
 the digestion giving distress after meals, a tablet containing rhubarb, 
 ipecac and soda, as for instance, rhubarb powd., gr. ij, sodii liicarb., 
 gr. V, ipecac, pulv. gr. |, olei menth. pip., q. s., taken before eating is 
 often of value. In all cases the diet of the patient should be carefully 
 attended to. 
 
 Constipation and Intestinal Indigestion. — The constipation which is 
 so extremely connnon in women at all times and especially common in 
 pregnancy, has already been discussed under Management of Normal 
 
DISORDERS OF THE ALIMENTARY CANAL 483 
 
 Pregnancy (see page 152). Not infrequently the pregnant patient suffers 
 with an intestinal indigestion with fermentation of the intestinal contents 
 and distress from the gas. 
 
 Treatment. — In the treatment of this condition, in addition to regulating 
 the movement of the bowels, the administration of an intestinal disin- 
 fectant is of value. A formula which has often given satisfaction is as 
 follows : 
 
 I^ — Sodii phenolsulphonatis Bss 
 
 Tr. nucis vomicae 3ij 
 
 Glycerini gj 
 
 AquEe q. s. ad. Svj 
 
 M. Sig. — Dessertspoonful in water before eating. 
 
 A number of the drugs belonging in the class of coal-tar derivatives 
 are used with benefit in this condition. Aside from the distress caused 
 by intestinal gas. in pregnancy, the patient sometimes suffers from the 
 pain caused by adhesions resulting from a previous operation. This is 
 usually most pronounced during the early months, while the uterus is 
 rising from the pelvis. Not much can be accomplished by treatment of 
 this condition save the assurance that the adhesions, as a rule, gradually 
 stretch and the symptoms lessen as the pregnancy advances. 
 
 Gastroptosis, Enteroptosis, and Movable Kidneys. — These conditions 
 are so common among thin women that they are commonly met with, 
 in the early part of pregnancy and the obstetrician finds many of his 
 patients coming to him wearing different varieties of abdominal belts 
 and corsets for the support of the prolapsed organs. During pregnancy 
 the natural result as the uterus rises in the abdomen is that it has a 
 tendency to elevate the prolapsed organs and take the place of the 
 mechanical support so that, as a rule, a woman suffering with one or 
 other of these conditions is usually relieved by the pregnancy. If she 
 gains considerably in flesh during the pregnancy, as is not uncommon, 
 the improvement may be permanent, but if not, the former prolapsed 
 condition of the abdominal organs tends to recur after the puerperium. 
 
 Appendicitis Complicating Pregnancy. — There is no evidence to prove 
 that initial attacks of appendicitis are predisposed to by pregnancy or 
 that they occur with greater frequency than in the non-pregnant state. 
 It must be conceded, however, that from the traction on adhesions 
 about a chronically inflamed appendix in the changing size of the uterus 
 during pregnancy and the puerperium, and from the inevitable trauma 
 of labor, recurrent attacks are favored and if in the appendix or its neigh- 
 borhood there is a pus sac, this sac may be ruptured with the develop- 
 ment of a suppurative peritonitis. Certainly attacks of appendicitis 
 complicating a pregnancy, especially among those with a history of 
 previous attacks, are not rare. ReuvalV in 1908, collected 253 cases. 
 The diagnosis of appendicitis during pregnancy and the puerperium 
 often presents greater difficulties than in the non-pregnant state, and it 
 is often overlooked. A pregnant patient often suffers with pain in the 
 
 1 Mitteilungen aus der Gyn. Klin, des Prof. D. Otto Engstrom, Berlin, 1908, Band vii, 
 Heft 3. 
 
484 AFFECTIONS AND DISEASES COMPLICATING PREGNANCY 
 
 lower part of the abdomen from pressure of the enlarging uterus and 
 from traction on adhesions resulting from previous pelvic inflammation. 
 As will be referred to under the subject of Pyelitis (see page 601) the 
 right ureter is the one most frequently enlarged and tender, and pressure 
 of the pregnant uterus upon it often presents some of the symptoms of 
 appendicitis. Moreover, in the latter third of pregnancy, when the 
 abdominal wall below the umbilicus is rendered tense by the enlarged 
 uterus, it is more difficult to make out the rigidity of the rectus or 
 the muscular spasm upon which considerable reliance is placed in the 
 diagnosis of appendicitis in the non-pregnant. 
 
 During the puerperium there are several conditions of the right tube 
 and ovary which may resemble in part, at least, an ajjpendicitis, such as 
 a twist in the right appendage, a suppurative inflammation, etc. Occa- 
 sionally also a small tumor on the right side of the uterus or involving 
 the right ovary may become inflamed and resemble an appendicitis. 
 Finally, even the tender uterine body in puerperal infection may at 
 times suggest appendicitis. The only safe rule is to always think of the 
 possibility of an appendicitis if the woman complains of pain in the 
 region of the appendix, with an increase in temperature and pulse and 
 with nausea; then examine carefully the urine, palpate the pelvic organs 
 and the kidneys, take a careful blood count, and usually with a careful 
 study of the history and the blood count, and exclusion of inflammation 
 of the pelvic organs and the urinary tract, a correct diagnosis will he 
 made. 
 
 Prognosis. — This is somewhat less favorable than in the non-pregnant, 
 for the reason that with the dilated vessels and blood changes of preg- 
 nancy thrombophlebitis is more common, and the operation itself is 
 more difficult in technic. The appendix in the latter half of preg- 
 nancy is more difficult to reach, a longer incision may be necessary, and 
 if the appendix has ruptured and drainage is necessary, this is often more 
 difficult to secure. In cases of perforative appendicitis, not infrequently 
 an abortion or premature labor results and adds to the gravity of the 
 situation. 
 
 Treatment. — Prophylactic. — Realizing the higher mortality of appendi- 
 citis in pregnancy as compared with the non-pregnant state, the best advice 
 to give a married woman with a history of previous attacks of appendicitis, 
 is to have her appendix removed before she becomes pregnant. 
 
 Curative. — If a woman is seized with an attack of appendicitis in the 
 early half of pregnancy she should be treated by operation the same as 
 in the non-pregnant state. Here the prognosis differs but little from that 
 in those not pregnant and, as a rule, the course of pregnancy is not 
 interrupted. In the latter half of pregnancy the problem is a little 
 different. On account of the increased difficulty of the operation, the 
 wiser plan, if from the temperature, pulse and blood count the inflamma- 
 tion seems catarrhal rather than suppurative or gangrenous, is to treat 
 the condition palliatively with rest, ice-bags, etc., with the hope that the 
 operation can safely be postponed until after the puerperium. If, on 
 the other hand, the appendicitis gives evidence of being suppurative, 
 
AFFECTIONS OF THE LIVER AND GALL-BLADDER 485 
 
 it should be treated on general surgical principles, care being taken to 
 interfere with the pregnant uterus as little as possible. The author 
 does not favor the suggestion of emptying the uterus either from below 
 or by abdominal Cesarean section as a preliminary step in dealing with 
 the appendix. 
 
 Ileus. — Obstruction of the intestines during pregnancy can arise 
 from the same causes as in those not pregnant and the only reason for 
 discussing the subject in a work on obstetrics rests in the fact that the 
 traction of the enlarging uterus upon a portion of intestine held fast by 
 inflammatory adhesions may bring about an angulation of it and a nar- 
 rowing of the lumen sujQBcient to cause partial or even complete obstruc- 
 tion. ]Moreover, the pressure of the enlarged uterus may still further 
 diminish the lumen which has been reduced by angulation. The condi- 
 tion demands the same surgical attention as in the non-pregnant, but the 
 operator is always handicapped by the presence of the large uterus. 
 
 AFFECTIONS OF THE LIVER AND GALL-BLADDER. 
 
 Jaundice. — The serious lesions of the liver resulting from the toxemia 
 of pregnancy in which the liver may undergo the pathological changes 
 of acute yellow atrophy and have jaundice as one of the symptoms have 
 already been discussed under Toxemia (see page 421). In addition to 
 this a simple catarrhal jaundice occasionally occurs in pregnancy as in 
 the non-pregnant. This, in itself, is usually of little importance, its 
 interest lying in the fact that while in most instances jaundice compli- 
 cating pregnancy is an indication of serious trouble, either a severe 
 toxemia, a gall-stone obstruction, or a chloroform poisoning, it may 
 mean a simple, catarrhal inflammation, which subsides readily under 
 restricted diet, and a few doses of calomel or phosphate of soda. Jaun- 
 dice in pregnancy, however, should never be considered a simple matter 
 until the serious lesions above mentioned can be excluded. 
 
 Gall-stones. — As gall-stones occur quite frequently in women it is 
 natural that with the pressure of the pregnant uterus, and the trauma 
 of labor, attacks of gall-stone colic and cholecystitis should occasionally 
 be met with in pregnancy and the puerperium. Peterson,^ in 1910, 
 made a study of the condition, collecting 25 cases complicating pregnancy 
 and 10 cases complicating the puerperium. 
 
 In the 25 cases where the pregnancy was complicated by gall-stones, 
 the period of gestation when the attack first appeared was recorded in 
 20 cases as follows : 
 
 Attacks prior to pregnancy 2 cases. 
 
 First appearance during first month 2 cases. 
 
 3 cases. 
 
 2 cases. 
 
 1 case. 
 
 7 cases. 
 
 1 case. 
 
 1 case. 
 
 1 case. 
 
 1 Gall-stones during Pregnancy, Trans. Amer. Gyn. Soc, 1910, xxxv, 84-120 
 
 
 ' second 
 
 
 third 
 
 
 ' fourth 
 
 
 fifth 
 
 
 ' seventh 
 
 
 ' eighth 
 
 
 ' labor 
 
486 AFFECTIONS AND DISEASES COMPLICATING PREGNANCY 
 
 In the 10 cases complicating the piierperiimi tlie time of onset was 
 recorded in 9 cases as follows: 
 
 First appearance during labor 1 case. 
 
 " " first week of puerperium 5 cases. 
 
 " " ninth day " 1 case. 
 
 " " tenth day " 1 case. 
 
 " " third week " 1 case. 
 
 \Yhile it is desirable to postpone operation during pregnancy and the 
 puerperium if possible, urgent indications for operation should be dealt 
 with as in the non-pregnant state, even at the risk of induction of 
 premature labor. 
 
 DISEASES OF THE URINARY TRACT. 
 
 Nephritis. — The lesions of the kidneys in toxemia and the subject 
 of ])regnancy in women suffering with chronic nei)hritis have already 
 been studied in the chapter on Toxemia of Pregnancy (see pages 424-443). 
 
 Lactosuria and Glycosuria. — Diabetes. — For many years it has been 
 known that the api)lication of Fehling's test will demonstrate sugar in 
 the urine of a certain number of pregnant women. This number varies 
 in the experience of different observers from 1 to o per cent. In the 
 majority of cases the sugar is lactose and not glucose, and the profession 
 is indebted to Prof. J. Whitridge Williams,' of Baltimore, for a clear 
 exposition of the difference in clinical significance of a lactosuria which 
 is largely concerned with the function of lactation and is of little moment, 
 and a glycosuria which is of serious import. The lactosuria which 
 appears in early pregnancy, at the beginning of mammary engorgement, 
 and again in the first week of the puerperium, as the function of lactation 
 establishes itself, may be looked upon as a physiological rather than 
 a pathological occurrence. On the other hand, a glycosuria may occur 
 in pregnancy either because the patient had diabetes before she became 
 pregnant, or it may originate in the pregnancy as the result of faulty 
 metabolism or from some unknown cause associated with the pregnancy 
 itself. This glycosuria originating in pregnancy is usually temporary 
 in character aufl subsides on restricting carbohydrate diet, or at any 
 rate at the end of pregnancy. It may, however, recur in each subsequent 
 pregnancy, and there is ground for believing that in a few cases it becomes 
 the starting-point of a true diabetes. 
 
 Diagnosis. — From the above it is evident that the differentiation 
 between a lactosuria and a glycosuria is an important one and that the 
 obstetrician should not be satisfied to rely on Fehling's test alone. Fur- 
 thermore, it is important to note whether the glycosuria is constant or 
 only temporary in its occurrence and whether the amount increases or 
 not as pregnancy advances. 
 
 Prognosis. — It has been shown that the prognosis of a lactosuria is 
 altogether favorable and need cause no anxiet}'. Furthermore, the prog- 
 
 1 The Clinical Significance of Glycosuria in Pregnant Women, Amer. ,Jour. Med. Sci., 
 January, 1909. 
 
AFFECTIONS OF THE URIXARY TRACT 487 
 
 nosis of a transient glycosuria is usually favorable, but if it tends to recur 
 and persist longer and longer it should be looked upon with suspicion 
 as the possible forerunner of diabetes. In contrast with the preceding 
 pictures is that of a woman becoming pregnant while suffering with real 
 diabetes, i. e., with the excretion of glucose in the urine for long periods 
 of time with a marked increase in the amount of the urine and with the 
 constitutional symptoms of diabetes. This is a rare but very serious 
 complication. That it does occur is shown by the fact that in 1882 
 Mathews Duncan^ collected from the literature 22 cases, and in 1909 
 Williams collected 66. Its seriousness is proved by the experience of 
 every obstetrician. The maternal mortality averages about 50 per cent. 
 Any severe shock during pregnancy or the shock and trauma of labor 
 may eventuate in coma and death. Offergeld,- in a series of 60 cases, 
 found that 30 per cent, died in coma and in about 50 per cent, the disease 
 had proved fatal within two and a half years. Graefe,^ found 7 out of 26 
 cases complicated with hydramnios and in 5 of these glucose was found 
 in the liquor amnii. 
 
 The tendenc>' to gangrene after the trauma of labor is found as after 
 trauma or operation in the non-pregnant suffering with diabetes. Patients 
 in whom the diabetes seems latent or quiescent before pregnancy often 
 have all the symptoms aggravated with the occurrence and advancement 
 of pregnancy and if a toxemia arises, whether the lesion is more pro- 
 nounced in the liver or in the kidney, the toxemia and the diabetes each 
 act unfavorably upon the other. 
 
 The fetal mortality is even higher than the maternal. In about 50 
 per cent, the fetus dies in utero and is expelled by abortion or premature 
 labor and in about 10 per cent, more the child dies within the first year. 
 
 Treatment. — This depends chiefly upon the diagnosis. Cases of lacto- 
 suria usually require no treatment. If a woman has a true diabetes with 
 a constant glycosuria, urine increased in amount and with the constitu- 
 tional symptoms, emaciation, thirst, etc., she should be advised against 
 pregnancy, and if pregnancy ensues it should be interrupted. If a woman 
 previously healthy develops a glycosuria in pregnancy she should be 
 placed upon diabetic diet, her digestion and elimination carefully super- 
 vised, and the amount of glucose carefully determined by frequent exami- 
 nations of the urine. If it shows a marked tendency to become constant 
 and increase and the constitutional symptoms of diabetes begin to present 
 themselves, the pregnancy should be interrupted, as with the high fetal 
 mortality inevitably associated with diabetes it is not fair to expose the 
 mother to the risk of true diabetes. 
 
 Mechanical Disturbances of the Urinary Tract. — It has already been 
 stated that a patient suffering with movable kidney may be mechanically 
 relieved by the occurrence and development of pregnancy, the enlarging 
 uterus tending to hold the movable kidney in place. On the other hand, 
 
 1 On Puerperal Diabetes, Trans. London Obstet. Soc, 1882, xxiv, 256-285. 
 
 2 Archiv f. Gyn., Band Ixxxvi, Heft 1, 160. 
 
 3 Die Einwirkung des Diabetes Mellitus, etc., Graefe's Sammlung Zwangloser Abhand- 
 lungen, 1897, Band ii. Heft 5. 
 
488 AFFECTIONS AND DISEASES COMPLICATING PREGNANCY 
 
 the weight of the heavy uterus upou the bladder ofteu gives rise to 
 anuoying symptoms, especially if the presenting part lies low in the 
 pelvis. Frequency of micturition is very common and this may interfere 
 with sleep and add further irritation to a nervous system already in 
 unstable equilibrium. Furthermore, in the same way that the pelvic 
 pressure may interfere with the venous return in the rectal circulation 
 and cause hemorrhoids which perhaps will bleed, so may this same press- 
 ure interfere with the venous return of the bladder and perhaps cause 
 hematuria. Mechanical support of the uterus is indicated for relief in 
 both cases. 
 
 DISEASES OF THE DECIDUA. 
 
 As the decidua of pregnancy is nothing but the endometrium of the 
 non-pregnant which has undergone certain hypertrophic changes to fit 
 it for the lodgement and nutrition of the ovum, it is natural that affec- 
 tions similar to those of the endometrium, should be found in the decidua. 
 Recent knowledge has determined that many of the conditions formerly 
 grouped under the term "endometritis" are not inflammatory,-, but 
 tro])hic, and that in many cases the hyperplastic endometrium removed 
 in a curettage is the result of the proximity of the menstrual period, still, 
 three conditions of the non-pregnant endometrium are recognized: 
 
 1. A hyperplasia. 
 
 2. An atrophy. 
 
 3. A bacterial inflammation. 
 
 These same three conditions are found affecting the decidua of preg- 
 nancy. 
 
 Hyperplasia of the Decidua. — This hyperplasia may be general, affect- 
 ing both the interstitial and the glandular structure of the decidua, or it 
 may affect chiefly either the interstitial or the glandular structure. 
 
 Diffuse Hyperplasia. — After the first three months of a normal preg- 
 nancy the decidua, save at the placental site, becomes thinner and thinner 
 as the pregnancy advances. Instead of this, the decidua in some cases 
 continues the general hyperplastic process started in early pregnancy. 
 Into this thickened decidua in which both the interstitial and glandular 
 portions are hypertrophied, hemorrhages frequently take place which 
 maj^ separate the fetal membranes from the uterine wall, or may even 
 break through the membranes into the amniotic sac. The usual result 
 is the death and expulsion of the embryo, either on account of the hemor- 
 rhages interfering with fetal oxygenation or because the nutrition for the 
 fetus was diverted to the decidua. If the fetus dies early it may become 
 almost, if not quite, absorbed, and the thickened decidua be cast of? as 
 a thickened sac lined with amnion — a fleshy mole. On the other hand, 
 the hyperplasia may be gradual and less in amount and the fetus may 
 rarely reach the period of viability, although usually poorly nourished. 
 At the time of the abortion or labor there is apt to be more or less 
 retention of this thickened decidua with the tendency to postpartum 
 hemorrhage, sepsis, and subinvolution. 
 
DISEASES OF THE DECIDUA 489 
 
 Interstitial Hyperplasia. — Instead of the hyperplasia bemg general, it 
 may affect chiefly the interstitial structure of the decidua and be more 
 or less localized, causing projections or polypoid masses on its inner sur- 
 face between the openings of the utricular glands. The decidual cells, 
 including their nuclei, are very much enlarged. This is the Endometritis 
 decidua tuberosa, or Polyposa of Yirchow.^ 
 
 Glandular Hyperplasia. — The glandular portion of the decidua is occa- 
 sionally the chief seat of the hyperplasia, the glands secreting an abnormal 
 amount of clear, pale yellow fluid, which may either trickle away from 
 the uterus and vagina almost continuously, or be stored up for a time 
 between the decidua parietalis and decidua capsularis and then be dis- 
 charged with a sudden gush, at times amounting to a pint or more in 
 quantity. This discharge of fluid in pregnancy has long been known as 
 "hydrorrhea gravidarum." x\ccording to Van der Hoeven,^ the fluid 
 differs from liquor amnii in having a lower specific gravity and no albu- 
 minous materials or urinary elements. Another condition occasionally 
 occurring in pregnancy and confused with it is the rupture of the mem- 
 branes high up above the cervix, allowing the liquor amnii with all its 
 chemical and physical characteristics to trickle away from the uterus 
 and vagina. As a rule the rupture of the membranes in the lower uterine 
 segment usually leads to the induction of labor within thirty-six hours. 
 In a series of cases collected from the literature by INIeyer-Ruegg,^ 
 instances were reported where labor had not intervened for a period 
 varying from one to three months and on delivery examination showed 
 that the membranes had contracted about the fetus. 
 
 Endometritis Decidua Cystica. — Occasionally in glandular hyperplasia 
 of the decidua, the openings of the glands become occluded and small 
 retention cysts develop on the surface of the decidua. This condition 
 was described by Breus,^ in 1882, and called by him endometritis decidua 
 cystica. 
 
 Atrophy of the Decidua. — In rare instances, as described by Hegar^ 
 and others, any one of the different uterine deciduse (parietalis, basalis, 
 capsularis) instead of undergoing hyperplasia may atrophy, with the 
 result that the embryo obtains neither sufficient lodgement, support nor 
 nutrition. Its etiolog}^ is obscure. It usually causes the death and expul- 
 sion of the ovum. If the decidua capsularis (reflexa) is the one to atrophy 
 it allows the embryo to descend as the decidua stretches until it lies just 
 over or within the cervix — the cervical pregnancy of Rokitansky. 
 
 Bacterial Inflammation of the Decidua. — x4cute inflammation of the 
 decidua may exist as the result of bacterial infection and present the 
 typical pathological lesions: swelling, infiltration with leukocytes, and 
 necrosis with a purulent exudate. It usually arises from a gonorrheal 
 
 1 Endometritis decidua tuberosa, Die Krankhaften Geschwiilste, 1864, ii, 478-480. 
 
 2 Hydrorrhea Gravidarum, Monatssch. f. Geb. u. Gyn., 1899, x, 329-337. 
 
 3 Eihautberstung ohne Unterbrechung der Schwangerschaft, Zeitschr. T. Geb. u. Gyn., 
 1904, li, 419-468. 
 
 ^ Ueber Cystose Degeneration der Decidua Vera, Archiv f. Gyn., 1882, xix, 483-489. 
 5 Kysten-bildung in der Decidua, Monatsschr. f. Geburtsh., 1863, xxi. Supplement 
 Heft 11. 
 
490 AFFECTIONS AND DISEASES COMPLICATING PREGNANCY 
 
 infection or from non-ase])tic attempts at indnction of a])ortion; ii\ the 
 latter instance i;i\'in<i; tlie si<>;ns and syni])tonis of i)ueri)eral sepsis. Acute 
 inflannnation of the decidna may also arise in the course of the exanthe- 
 mata and other infectious diseases, the bacteria of the general disease 
 being carried to the lining of the uterus. The diagnosis would be made 
 only from s\ini)toms of a threatened abortion and evidence of uterine 
 infection. Occasionally in the post])artum study of the placenta of a 
 tuberculous patient a tuberculous inflammation of the decidua with 
 characteristic cheesy nodules is found. 
 
 Hemorrhage. — In the course of the various changes in the decidua which 
 have been described it is not unusual to have more or less hemorrhage 
 occur either into the substance of the decidua or between the different 
 deciduse or between the decidua and the uterine wall. The ovum which 
 is usually separated from the uterus and cast off as a result of these 
 hemorrhages is often surrounded with blood-clots in various stages of 
 organization giving the different varieties of bloody mole. 
 
 Treatment. — The treatment of the different changes in the decidua 
 wdiich may complicate a ])regnancy, save that of syphilis, usually has 
 to be postponed until after the uterus is emptied. Syphilitic changes 
 should be dealt with by constitutional treatment of syphilis as soon as 
 it is suspected. In the treatment of the other changes in the decidua 
 two principles should guide one. 
 
 1. Make sure that the uterus is thoroughly and aseptically emptied 
 at the time of the labor or abortion. 
 
 2. If an endometritis remains after the puerperium, treat that 
 according to the conditions present; by a curettage if necessary. 
 
CHAPTER XIV. 
 DISEASES OF THE FETAL MEMBRANES. 
 
 DISEASES OF THE CHORION. 
 
 Hydatidifonn or Vesicular Mole. — This is a disease of the chorion 
 in which the terminal villi are converted over a larger or smaller area 
 into translucent vesicles varying in size from that of a grain of sand to 
 cystic masses the size of a grape or even larger (see Fig. 315). In general 
 
 Fig. 315. — Hj-datidiform mole. 
 
 appearance they resemble somewhat a bunch of Malagar grapes, but 
 differ in that many of the vesicles are attached to each other rather 
 than to the branches of the parent stem. The condition was described 
 by Aetius, of Amida, in the sixth century, but for many years no true 
 knowledge of the condition existed, and many false ideas prevailed as, 
 
 (491) 
 
492 DISEASES OF THE FETAL MEMBRANES 
 
 for instance, that each Acsicle was a separate ovum. Hydatid cysts of 
 the liver were known, and for many years this vesicular disease of the 
 chorion was considered to have some relation to the disease which was 
 occasionally found in the liver. 
 
 The first correct explanation of the condition was apparently given 
 by Virchow\^ He described the vesicles as degenerated chorionic villi, 
 and so we consider them today. 
 
 Frequency.^ — In the Charite Hospital in Berlin, in a series of 2130 
 pregnancies, hydatidiform mole occurred once in 532 cases, while 
 Madame Boivin, of Paris, found it only once in 2130 pregnancies. 
 Hydatidiform mole is more common in multigravidse than in primigravidse. 
 In the last 10,000 cases admitted to the obstetric division of the Sloane 
 Hospital there were 3 cases of hydatidiform mole. In several instances 
 reported hydatidiform mole has recurred in subsequent pregnancies. 
 
 Etiology. — The etiology of the condition is still obscure. Some author- 
 ities (Mrchow, Veit) believe the condition is due to a disease of the 
 endometrium and in support of this view may be mentioned the fact of 
 recurrence of the disease in successive pregnancies. Furthermore, Aichel,^ 
 in 1901, claimed that by mechanically interfering with the circulation 
 of the placental site in pregnant dogs he had succeeded experimentally 
 in producing hydatidiform mole in 7 out of 13 cases. Other authorities 
 (INIarchand, Durante, Van der Hoeven) consider the disease of ovular 
 origin and the changes in the endometrium secondary. In support of 
 this view may be mentioned instances of twin pregnancy in which one 
 fetus is normal with normal placenta and the other ovum is an hydatidi- 
 form mole. Another argument favoring the view of ovular origin is the 
 fact that in many cases all traces of the fetus have disappeared, showing 
 that the mole developed very early in pregnancy before the ovum was 
 likely to have become very deeply imbedded in decidua or to have 
 received very much nourishment from it. While the arguments in favor 
 of the ovular origin seem rather stronger than those of the endometritic, 
 it has to be admitted that at present the exact etiology is unknown. 
 
 Pathology. — The vesicular degeneration of the chorion usually begins in 
 early pregnancy and usually involves the whole chorion. As a rule the 
 fetus dies and is absorbed so that no trace of it is foimd. Occasionally, 
 however, the disease apparently begins later in the pregnancy and is 
 less in extent, so that the nutrition of the fetus is not markedly interfered 
 with, and it may be born alive with one portion of the placenta showing 
 vesicular degeneration. This occurrence of a living fetus with a placenta 
 partially degenerated into vesicles makes it seem probable that the fetal 
 death usually occurring in early pregnancy is the result of chorionic 
 degeneration rather than its cause, as has been suggested by some. 
 Hydatidiform mole is not confined to uterine pregnancies, but has also 
 been found in cases of ectopic gestation. On microscopic examination 
 changes are found both in the stroma of the villi and in the epithelial 
 
 1 Myxoma der Placenta, Die Krankhaften Geschwiilste, 1863, i, 405-414. 
 
 2 Ueber die Blasenmole, eine experimentelle Studie, Verh. der Deutsch. Ges. f. Geb. u. 
 Gyn., 1901. 
 
DISEASES OF THE CHORION 
 
 493 
 
 covering, more marked, however, in the latter. In the stroma the change, 
 according to Marchand,^ ig chiefly an edema, although as the process 
 advances the bloodvessels of the terminal villi disappear, the stroma cells 
 become necrotic and do not stain well. The changes in the syncytium 
 and in Langhans's layer of cells is most marked. They both proliferate 
 irregularly and luxuriantly. In each layer along with the proliferation, 
 occurs a certain amount of degeneration and necrosis, producing numerous 
 vacuoles. One characteristic of these two epithelial layers in an hydatidi- 
 form mole is their tendency to erode and penetrate. The Langhans's 
 layer in places penetrates the syncytium; they both penetrate Nitabuch's 
 
 Fig. 316. — Hydatidiform mole perforating the uterine wall. (Bumm.) 
 
 fibrin layer, the natural outer boundary of the ovum; they burrow into 
 the decidua and in some cases they not only penetrate but even per- 
 forate the uterine musculature, so that the vesicles may be found project- 
 ing through the uterine wall (see Fig. 316). These perforating moles are 
 not necessarily malignant but easily lead to rupture of the uterus and 
 severe hemorrhage during labor, abortion or surgical manipulation for 
 emptying the uterus. The so-called syncytial wandering cells which 
 are found in the regenerating endometrium and occasionally in the 
 
 ' Ueber den Bau der Blasenmole, Zeitschr. f, Geb. u. Gyn., 1895, xxxii, 206-216. 
 
494 DISEASES OF THE FETAL MEMBRANES 
 
 musculature near it after a normal pregnancy are usually more abundant 
 in the case of an hydatidiform mole. A few- degenerated chorionic villi 
 are occasionally found to have penetrated the wall of one of the uterine 
 veins and found their way into the lumen along which they may be 
 carried by the blood current. Along with the local disease of the chorion 
 there may be associated the usual complications of pregnancy, such as 
 the various phases of toxemia, pernicious vomiting, with its liver necrosis, 
 nephritis, etc. The breasts show the usual changes of pregnancy. 
 
 Occasionally associated with an hydatidiform mole are found multi- 
 locular lutein cysts of the ovaries. This association is not constant, 
 but is frequent enough to arouse speculation as to a possible etiological 
 connection. FriinkeP claims that at least 100 cases of this complication 
 are on record. These cysts, according to Frankel, are multilocular, but 
 each seems to project from the surface of the ovary, rather than lie 
 as daughter cysts, as in the ordinary cystadenoma. They average 
 about the size of a grape, although occasionally the combined cystic 
 mass may reach the size of an orange. They are filled with clear fluid 
 and their walls are lined with one or more layers of lutein cells. In a few 
 of the cases reported (Frankel) retrogression has been noticed in the 
 cysts after the uterus was emptied of the hydatidiform mole. Although 
 these lutein cysts have been noted as involving one or both ovaries 
 by numerous observers (Marchand, Stoeckel, Runge, Jatfe), their etio- 
 logical relation to the hydatidiform mole has never been thoroughly 
 established. 
 
 Prognosis. — E\ery obstetrician of large experience has met with cases 
 of hydatidiform mole in which the uterus was emptied and in which 
 there was no recurrence of the mole, although the woman subsequently 
 bore children. The author has recently delivered a patient of her third 
 living child, although her first pregnancy resulted in an hydatidiform 
 mole. Hence it must be recognized that a certain type of hydatidiform 
 mole is non-malignant. On the other hand, about 50 per cent, of the 
 cases of chorio-epithelioma (Eiermann) which, although in a few cases 
 presenting a low grade of malignancy, usually is the most tragically 
 malignant disease to which woman is subject, are preceded by an hydatidi- 
 form mole. This gives at least presumpti\'e evidence that there is some 
 connection between hydatidiform mole and chorio-epithelioma. More- 
 over, the fact that cases of hydatidiform mole occur which penetrate and 
 even perforate the uterine wall (see Fig. 316), shows that, even if per- 
 manent recovery follows removal of the uterus in these cases, hydatidi- 
 form mole may be at least destructive. Moreover, the fact that in a 
 few cases of hydatidiform mole, at varying intervals after the expulsion 
 of the mole, metastases of vesicular, degenerated villi are found in the 
 vagina or vulva, shows that, even if there is no recurrence after removal 
 of these metastases, there is certainly a resemblance in some cases between 
 the behavior of hydatidiform mole and chorio-epithelioma. Finally, 
 it must be agreed that between the non-malignant hydatidiform mole 
 
 1 Die Histologic der Blascnmole und ihre Beziehungen zu den maligiien von den Chorion 
 Zotten ausgehcnden Utcrustunioren, Zeitschr. f. Geb. u. Gyn., Band xli, S. 520. 
 
DISEASES OF THE CHORIOX 495 
 
 on the one hand and the rapidly malignant chorio-epithelioma on the 
 other, there are certain types of hydatidiform mole which occupy a 
 transitional ground. Furthermore, pathologists are agreed that at 
 present they are unable to determine microscopically which hydatidiform 
 mole is to prove absolutely benign and which is to assume a destructive 
 type. 
 
 Signs and Symptoms. — One of the first signs of an hydatidiform mole 
 is an enlargement of the uterus beyond the size expected at that period 
 of pregnancy. Coupled with this is the inability of the obstetrician to 
 hear the fetal heart and the inability of the woman to feel fetal move- 
 ments, although the uterus is larger than the size at which both of these 
 are usually- detected. Thus at three or four months the uterus may be 
 at the level of the umbilicus and yet neither fetal heart or fetal movements 
 be capable of detection. One of the characteristics of an hydatidiform 
 mole is an irregular hemorrhage or serosanguineous discharge, which 
 may occur at any time and usually continues at varying intervals until 
 the mole is removed by nature or by the obstetrician. 
 
 Diagnosis. — In the discharge there occasionally appear some of the 
 characteristic vesicles of the mole. From these the diagnosis is eas.y, 
 but as this sign is often absent the diagnosis in many cases has to be 
 made from the excessive size of the uterus, its boggy feel and the absence 
 of fetal heart sounds and fetal movements. In some cases without hemor- 
 rhage it may be almost impossible to diagnose an hydatidiform mole from 
 a dead fetus with hydramnios until the uterus is explored. 
 
 Treatment. — As soon as the diagnosis is made the uterus should be 
 emptied both on account of the risk of the groT\i:h perforating the uterus 
 and causing its rupture, with severe, perhaps fatal, hemorrhage, and 
 also on account of the risk of the development of a chorio-epithelioma 
 with all its dire consequences. In emptying the uterus the greatest care 
 should be observed lest, in the manipulation, the uterine wall, weakened 
 by the inroads of the growth, give way. After the dilatation of the cervix 
 the gloved finger is the safest instrument to be used in the removal of 
 the grov^i:!! and after its removal or expulsion the uterine cavit}' should 
 be carefully palpated to make sure that it is empty. It is usually wise 
 to pack the uterine cavity with gauze after removing an hydatidiform 
 mole to provide against hemorrhage. 
 
 A patient after the removal of an hydatidiform mole should be watched 
 for several months with great care and any intermenstrual hemorrhage 
 should be looked upon as suggestive of chorio-epithelioma. A curettage 
 should be promptly performed; the curettings carefully examined and if 
 chorio-epithelioma is found a radical hysterectomy should be performed 
 with the hope that the disease is localized. 
 
 Chorio-epithelioma. — One of the most tragic results of a pregnancy, 
 terminating either as an abortion or a full-term labor, is the development 
 of a rapidly fatal malignant groT\i:h composed of both layers of the chorio- 
 nic epithelium — the syncytium and Langhans's layer and called a cliorio- 
 epitheJioma (see Fig. 317). This growth may show itself during the first 
 week after an abortion or full-term labor, or may not appear for a nmuber 
 
496 
 
 DISEASES OF THE FETAL MEMBRANES 
 
 of months. In about 50 per cent, of the cases as already stated, it has 
 been preceded by the growth of an h\'datidiform mole and in a few cases 
 it has been found developed before the uterus was emptied either of the 
 embryo or the mole. The literature of the subject appears to begin with 
 the paper of Stinger/ who in 1892, reported the autopsy of a case which 
 died seven months after an abortion at the eighth week. In this case 
 there were soft, reddish tumors in the uterine wall and metastases in the 
 
 A 
 
 / 
 
 
 r / 
 B 
 
 Fig. 317. — Chorio-epithelioma, showing involvement of uterus, vagina and broad liga- 
 ments: A, primary growth; B, metastases in broad ligament; C, metastases in vagina. 
 
 lungs, one of the ribs, the diaphragm and in the right iliac fossa. Sanger 
 considered the cells found in these tumors as of decidual origin and the 
 growth a sarcoma deciduocellulare. This view was generally accepted 
 until Marchand,^ in 1895, and again in 1898, published the results of 
 
 • Deciduoma Malignum, Verhandl. d. deutschen. Gcsellsch. f. Gyn., 1892, iv, 333. 
 
 2 Ueber die sogcnannten "decidualen" Geschwiilste, etc., Monatssehr. f. Geb. u. Gyn., 
 1895, i, 419-438, 513-560; Ueber das Maligna Chorion EpitheHom, nebst Mittheilung 2 
 neuer Fiille, Zeitschr. f. Geb. u. Gyn., 1898, xxxix, 173-258. 
 
a 
 I 
 
 
 
 't. 
 
 
 
 u 
 
CHORIO-EPITHELIOMA 497 
 
 his experience and studies which proved that the growths were of epithehal 
 origin, were fetal rather than maternal, and that both layers of the 
 chorionic epithelium were found in them. He gave to the growth the 
 name oi chorio-epithelioiiia, and his views regarding its pathologv have 
 held until the present. 
 
 Frequency.— Since the publication of Sanger's first case in 189'^ the 
 reports of similar cases have been numerous and frequent, so that con- 
 siderable literature has accumulated. Two cases presented themselves 
 m the author s service at the Sloane Hospital within a few months 
 Jrig. ob and Plate M represent the pathological findings in one of 
 them. 
 
 Etiology.— The cause of chorio-epithelioma is unknown save for the 
 
 tact that, as already stated, in about one-half the cases it is preceded bv 
 
 . an hydatidiform mole. It seems to have the tendencv to proliferate and 
 
 burrow, which is characteristic of certain hydatidiform moles turned 
 
 Pathology.— The primary growth is usually located in the uterine cavitv 
 at the p acental site. It is a soft vascular, purplish mass, somewhat resem- 
 blmg^a hematoma. Although this is the usual site it is not universallv 
 so. Cases ot ectopic gestation have been followed bv a chorio-epithe- 
 lioma with Its primary focus in the tube (Davidson, WiUiams) Other 
 cases are on record where the primary growth was in the vagina and 
 the uterus seemed free from the disease; the chorionic epithelium which 
 may be transplanted in a normal pregnancy, in this case having under- 
 gone a mahgnant change. Chorio-epithelioma has been found associated 
 with certain teratomata of the testicle and the ovary (Schlagenhaiifer 
 Risel Pick and others). Here it seems to have arisen from the undifferen- 
 tiated fetal ectoderm m the teratoma. The growth, as a rule, rapidlv 
 erodes and penetrates the venous channels and hence metastases^ ar'e 
 recjuent and occur early. The most frequent site of these metastases 
 
 nv vlr-f"l'f ^""" ^^!'' ^^^ ^}''\ ^" '^'' °^^j°^^^^^ °f ^^«^« become 
 imoliedif the case is to prove fatal. The next most frequent site of 
 
 metastasis is m the vagma and the diagnosis of a uterine chorio-epithe- 
 lioma can often be confirmed by finding in the vagina a purplish hemor- 
 dischar r°' ^'""^'^ """^ ■ ' ""''"^ '' ''^''^^^^' accompanied by a foul 
 
 Other sites of metastasis are in the liver, kidneys, spleen, the con- 
 nective tissue of the broad ligament, the bones, and the brain. Lutein 
 cystomata of the ovaries are at times found associated with chorio- 
 epithehomata as they are with hydatidiform moles, but as in the latter 
 case no etio ogical connection has been established. Microscopicallv 
 chorio-epithehomata show blood spaces surrounded bv masses of svncvt- 
 mm and proliferated Langhans's cells. According to Marchand and Risel 
 the growth may be either typical or atypical. In the former the cells' 
 resemb e those of the chorionic epithelium of early pregnancv, while in 
 the latter the growth more nearly resembles a sarcoma, the infiltration 
 being more diffuse and consisting of irregular groups of less clearly 
 defined syncytial and Langhans's cells. ^ 
 
498 DISEASES OF THE FETAL MEMBRANES 
 
 Clinical Picture.— ('lu)ri()-cj)itlu'li()nia iiia\ follow any pregnancy, at any 
 age and whatever the period of its termination. Its existence should 
 always be suggested if after a labor, abortion or expulsion of any hydat- 
 idiform mole the woman has a hemorrhage which tends to persist and 
 which is associated with a cachexia, an enlargement of the uterus and a 
 foul discharge. This suspicion is rendered still more probable if a soft, 
 hemorrhagic growth is found in the vagina. The clinical picture will 
 perhaps be rendered clearer by the history of one of the author's cases. 
 
 A German woman, aged thirty-three years; married; admitted on 
 September 11, 1911, with the following history: 
 
 Family history of no significance. 
 
 Menstrual hidory began at the age of sixteen years, irregular in type, 
 flowing every three to four weeks for four or five days, with a rather 
 profuse discharge of blood, preceded by severe pain. 
 
 Marital History. — The patient had been married for the last eleven 
 years and had been jiregnant three times; one miscarriage four years 
 ago, necessitating a curettage; one full-term child; and a six month's 
 miscarriage eight weeks before admission. 
 
 Present History. — From the second to the sixth month of her last 
 pregnancy the patient had repeated small hemorrhages until at the end 
 of the sixth month she gave birth to a fetus, which is said to have lived 
 one day. From this time up to the day of admission, a period of eight 
 weeks, the patient continued to have a bloody vaginal discharge. She 
 was not under observation during this time and received no medical 
 treatment. The flow was said to have been profuse and almost without 
 intermission. Clots were frequently passed. The patient became pro- 
 gressively weaker. There was loss of appetite, strength and flesh. During 
 the last few weeks there were frequent attacks of faintness and actual 
 loss of consciousness. She complained of a continuous pain in the left 
 loin and back, constantly growing worse. During the last two weeks 
 there was a cough with blood-tinged sputum. The bowels were con- 
 stipated, but of bladder symptoms there were none. 
 
 The {physical examination presented the following points of interest: 
 The patient was of a sallow, lemon color, ob^'iously anemic and showing 
 evidence of recent loss of flesh. She was scarcely able to w^alk. The 
 heart action was rapid, the sounds of poor quality, but no murmurs 
 were present. Examination of the lungs revealed over the right lower 
 lobe many fine, subcrepitant rales. Breath sounds were diminished, 
 but there was no impairment of resonance. Otherwise the lungs seemed 
 normal. The abdomen was flabby, with recent strise, and the muscle 
 tone poor. The fundus uteri could be felt four fingers' breadth below the 
 umbilicus. Vaginal examination showed the perineum to be relaxed 
 and there was a moderately profuse serosanguinous discharge. On the 
 right side of the posterior vaginal wall was a tumor the size of a hickory 
 nut, bluish in color, irregular in outline and firm in consistency. The 
 cervix was soft and easily admitted the examining finger, revealing to 
 it a spongy, friable mass in the cavity of the uterus which bled freely. 
 The uterus was large, as indicated, and not freely movable. 
 
DISEASES OF THE CHORION 499 
 
 On admission the temperature was 101.2°, pulse 120, and the 
 respirations 38. 
 The blood count: 
 
 Red blood cells 2,972,000 
 
 White blood cells 18,000 
 
 Polynuclear leukocytes 80 per cent. 
 
 Lymphocytes 20 per cent. 
 
 Hemoglobin 50 per cent. 
 
 The urine was acid, 1032, a trace of albumin, no sugar. Microscopic 
 examination showed a moderate number of red blood cells, epithelial 
 cells, and urates. 
 
 Diagnosis. — Chorio-epithelioma. 
 
 Operation was not considered advisable because of the presence of 
 metastases in the vagina and lung, and because of the presumption that 
 they existed in uterosacral and broad ligaments as indicated by the lack 
 of mobility of the uterus. The general condition of the patient as well 
 was so poor as to render her a bad operative risk. 
 
 The patient lived for twenty-three days after admission, running a 
 typical septic temperature, ranging from normal to 105.8° F. The pulse- 
 rate averaged about 130, often reaching 160. During the last four days 
 the temperature was subnormal. Examination of the lungs from time 
 to time showed an extension of the signs first noted in the right lower 
 lobe, until fine subcrepitant rales could be heard all over both lungs. 
 
 Another tumor mass appeared in the vagina similar to, though smaller 
 than, the one originally observed, which meanwhile had ulcerated. The 
 cough and bloody expectoration became aggravated and the serosan- 
 guinous vaginal discharge continued to the end. 
 
 An abstract of the pathologist's report of the autopsy findings is 
 given below : 
 
 " Anatomical Diagnosis. — Chorio-epithelioma of the uterus with exten- 
 sion into the uterosacral ligaments. Metastases in the vagina, lungs and 
 liver. 
 
 "Lungs (see Plate VI) studded with nodules varying from 0.5 to 3 
 cm. in diameter. Some are pale but most are deep, dusky red. They 
 show deep umbilication and two seem to have penetrated the pleura. 
 On section they form irregular masses through the lung tissue and there 
 is much hemorrhage into their substance, and the centres of some of the 
 larger nodules are softened. The bronchial lymph nodes are not invaded. 
 
 "Uterus (see Fig. 317) moderately enlarged. The cavity is lined 
 with a layer of deep red, necrotic tissue, 3 to 4 mm. thick, which extends 
 into a large necrotic mass, 4 cm. in diameter in the left uterine wall (A). 
 It has perforated the muscle posteriorly and become adherent. The 
 centre is semifluid and exceedingly foul. It extends out into the lower 
 portion of the left broad ligament (B), and there is a nodular tumor about 
 2 cm. in diameter in the right uterosacral region (B), which is deep red 
 but not broken down. There are 3 nodules in the vaginal wall, 1 cm. 
 in diameter, two of which are ulcerated on the surface and necrotic^in 
 the centre; the third is well preserved (C, C, C). 
 
500 DISEASES OF THE FETAL MEMBRANES 
 
 "Liver much enlarged, reddish-yellow in color. In the right lobe 
 are two small, deep red nodules." 
 
 Sections cut from the primary growth showed microscopically an 
 invasion of the uterine musculature by groups of large multinuclear 
 cells (syncytial masses). The metastatic nodules in lungs and liver 
 showed a similar in\'asion by the cells of the new growth. Both primary 
 and secondary foci were characterized by hemorrhagic areas. 
 
 Diagnosis. — This, although perhaps suggested by the history, is usually 
 not positively made till either curettings from the uterus or a portion 
 of the vaginal growth is subjected to a microscopic examination. It 
 is especially important to emphasize here the value of subjecting to 
 microscopic examination the curettings of every case which has recently 
 been pregnant unless the tissue removed is evidently normal chorion. 
 
 Treatment. — AVhen once the diagnosis has been made, the only hope 
 from treatment lies in the early radical removal of the uterus, tubes, 
 ovaries, and upper part of the ^■agina. Even then operation is hopeless 
 if the lungs and other organs are involved in metastases. Hence the 
 woman should be carefully examined for evidences of general metastases 
 and if these are found operation should not be performed. Although 
 cases occur in which these growths are found in the vagina and not in 
 the uterus, the author does not believe it rational to simply remove the 
 vaginal growths and run the risk of leaving behind a uterine growth 
 which may not be apparent. 
 
 During the year 1915 the author has operated upon two cases of 
 chorio-e])ithelioma, each preceded by an hydatidiform mole. In both 
 cases the disease was limited to the uterus and both made good 
 recoveries after a complete hysterectomy. 
 
 DISEASES OF THE AMNION. 
 
 Abnormal Amount of Liquor Amnii. — The amount of liquor amnii in a 
 given case may either be above or below that usually present. An exces- 
 sive amount is spoken of as hydramnins, polyhydramnins, dropsy of the 
 amnion, etc. An amount below the normal is called oligohydramnios. 
 
 Hydramnios. — The amount of liquor amnii varies greatly in individual 
 cases which are regarded normal. Thus a variation of from one to two 
 pints is not considered abnormal. On the other hand the amount is 
 sometimes enormous, in rare cases reaching several gallons. The first 
 question then is what shall be considered a dividing line between the 
 normal and the abnormal. This must be more or less arbitrary, but in 
 general any case having an amount of liquor amnii over two quarts is 
 considered one of hydramnios. 
 
 Frequency. — Cases of slight excess of liquor amnii are relatively common, 
 while those with marked excess producing distinct symjjtoms are rare. 
 In a series of 20,000 consecutive deliveries at the Sloane Hospital there 
 were recorded 113 cases of hydramnios, or a frequency of 1 in 177. 
 
 It is more common in multigravida? than in primigravida^. In this 
 series of 113 cases, 81 were multigravidie and 32 primigravida". It is 
 
DISEASES OF THE AMNION 501 
 
 more common in multiple than in single pregnancy, thus in this series 
 of 113 cases there were 23 women with multiple pregnancy: 20 sets of 
 twins and 3 sets of triplets. This of course is a much greater frequency 
 than is normal for multiple pregnancy. 
 
 Etiology. — Although the exact etiology is more or less obscure, three 
 general sources are usually accepted as possible. Thus the source of the 
 fluid may be (1) fetal, (2) maternal, (3) amniotic. 
 
 Fetal Sources.— The conditions of the fetus which furnish the most 
 satisfactory explanation of the excessive amount of liquor amnii are 
 lesions in the umbilical cord or in the fetus itself, causing obstruction to 
 the return flow of blood with increased blood-pressure in the umbilical 
 vein. The lesion in the cord may be an obstruction due to a tight knot 
 or the pressure of a tumor, etc. The cause of the obstruction on the other 
 hand may be within the fetus and may consist of a cirrhosis or syphilitic 
 disease of the liver. Not infrequently the obstruction to the circulation 
 is due to some abnormality of the fetal heart. If for any reason there is 
 some obstruction to the circulation in the placenta there naturally 
 results an hypertrophy of the heart and for a time it may be equal to 
 the task required of it. Later on it becomes insufficient; an edema of 
 the placenta and an increase of the liquor amnii may follow. A heart 
 with a congenital malformation still more readily becomes unequal to 
 its task and congestion, edema and transudation naturally follow. Under 
 normal conditions the fetal kidneys are regarded as taking little part in 
 the production of the liquor amnii. When, however, the fetal heart 
 becomes hypertrophied, more fluid is forced through the kidneys; a 
 greater urinary secretion is produced and in some cases at least this 
 increased urinary secretion seems a marked factor in the production of 
 the hydramnios. This method of production of hydramnios seems to 
 find its illustration in certain cases of uniovular twins in which one of 
 the amniotic sacs is in the condition of hydramnios. Autopsy on the 
 affected twin in several instances of this complication has shown an hyper- 
 trophy of both heart and kidneys as though one fetus receiving more 
 blood than the other had thrown more work on the heart, which became 
 hypertrophied and forced more blood through the kidneys. The heart 
 later became unequal to its task and congestion followed. This con- 
 dition has been carefully studied by Schatz,^ Wilson,^ ^Yerth■■^ and others. 
 The amount of liquor amnii surrounding the other fetus may be either 
 normal or diminished in amount. In quite a large percentage of cases, 
 fetal deformities such as spina bifida, anencephalous monster, hare-lip, 
 exstrophy of the bladder, the different varieties of talipes, etc., are found 
 associated with hydramnios. An excessive cutaneous transudation of 
 fluid associated with cardiac hypertrophy in the fetus has been looked 
 upon as an occasional etiological factor. 
 
 1 Eine besondere Art von einseitiger Polyhydramnie, etc., Archiv f. Gyn., 1882, xix, 
 329-369. 
 
 2 Hydramnion in Cases of Uni Oval, or Homologous Twins, Trans. London Obstet. Soc, 
 1899, xli, 235-272. 
 
 3 Einseitiges Hj'dramnion mit Oligohydramnie der zweiten Frucht, Archiv f. Gyn., 1882, 
 XX, 353-377. 
 
502 DISEASES OF THE FETAL MEMBRANES 
 
 Maternal Sources. — In a few cases lesions of the maternal heart, liver 
 or kidneys with evidences of obstruction in the maternal circulation 
 are associated in such a way with hydramnios as to appear to be related 
 as cause and effect. 
 
 Amniotic Source.— In some rare cases an actual inflammation of the 
 amnion seems to exist which causes an increased secretion, resulting in 
 hydramnios. 
 
 Symptoms. — The symptoms arising from hydramnios are largely 
 mechanical, resulting from the abnormal intra-abdominal pressure. 
 These symptoms vary of course, according to whether the hydramnios 
 is acute or chronic. In the chronic form, which is much more common 
 than the acute, the symptoms closely resemble those of multiple preg- 
 nancy. There is more tendency to edema of the lower extremities and 
 the vulva than is normal; more tendency to renal disturbance; more 
 dyspnea and gastric disturbance. If this increase in pressure, however, 
 has taken place gradually, the system seems to be able to accommodate 
 itself to it so that the patient may be able to go to term without an extreme 
 degree of suffering. In the acute hydramnios, on the other hand, the 
 picture is different. Beginning usually between the fourth and the sixth 
 month the uterus distends rapidly. The uterine and abdominal walls 
 soon become tense and tender. The patient in well-marked cases suffers 
 with dyspnea, perhaps cyanosis. She may have to sleep bolstered up 
 in bed, gastric digestion is often mechanically interfered with, and her 
 heart becomes overburdened. The lower extremities and perhaps the 
 vulva become edematous. The kidneys often become involved and in 
 not a few cases, unless nature interi;"upts the pregnancy, this interruption 
 has to be brought about by the obstetrician in order to save the life of 
 the woman. Owing to the amount of distention of the uterus and the 
 tenseness of the uterine and abdominal walls it is often impossible to 
 accurately map out the fetus, and it is often difficult to hear the fetal 
 heart or hearts, hence it is not an unusual surprise at the delivery to 
 fiiid a twin pregnancy. The fetus in these cases is usually poorly nour- 
 ished and, as stated above, it not infrequently presents some malforma- 
 tion, hence its loss if pregnancy has to be interrupted early in order to 
 save the mother is not so great. 
 
 Diagnosis. — The condition from which hydramnios most often has to 
 be diagnosed is multiple pregnancy. If these two conditions exist inde- 
 pendently and present their typical signs and symptoms the diagnosis 
 is usually easy. The hydramnios presents the tense, distended uterus 
 and abdominal wall with its accompanying dyspnea and pressure symp- 
 toms with indistinct fetal parts and heart sounds. The multiple preg- 
 nancy, on the other hand, presents its multiple fetal extremities and its 
 multiple heart sounds with less dyspnea and less edema or other pressure 
 symptoms because the growth of the abdominal tumor has been more 
 gradual and the system has had opportunity to adjust itself to the 
 increased pressure. The difficulty in diagnosis lies in the fact that mul- 
 tiple pregnancy is often associated with hydramnios, and with the tense 
 uterine wall of hydramnios in many cases it is impossible to determine 
 
DISEASES OF THE AMNION 503 
 
 multiple fetal parts or fetal hearts, and accurate diagnosis becomes almost 
 impossible. In a few cases it is necessary to differentiate between hydram- 
 nios and extra-uterine abdominal fluid, encysted or free. In general the 
 diagnosis is made by first determining the presence or absence of preg- 
 nancy and for this the consideration of the menstrual history; the con- 
 dition of the breasts; the appearance of the vagina and cervix; the feel 
 of the cervix and lower uterine segment; the shape of the abdominal 
 tumor as determined by a bimanual examination and the presence or 
 absence of the positive signs of pregnancy usually answers. If the exist- 
 ence of pregnancy is once determined it is usually easy to differentiate 
 hydramnios from extra-uterine collections of fluid. Occasionalh', how- 
 ever, pregnancy coexists with ascites or a large ovarian cyst, which may 
 severely tax the diagnostic powers of the obstetrician. However, the 
 effect of position in changing the percussion note in ascites and a careful 
 study of the relation of the ovarian cyst to the uterine body will usually 
 enable him to arrive at a correct diagnosis. 
 
 Treatment. — In the chronic form of hydramnios it is seldom that 
 active treatment is indicated. Realizing the excessive intra-abdominal 
 pressure, the patient should be kept quiet and elimination should be 
 favored; the stomach, liver and kidneys should be taxed as little as 
 possible by restricting nitrogenous diet and giving small quantities at 
 shorter intervals than usual. The author has never been able to accom- 
 plish enough in withholding such fluid as the patient wishes to quench 
 her thirst to make it worth while. The obstetrician should be con- 
 stantly on the alert for renal complications. 
 
 In the acute hydramnios with marked dyspnea and serious embarrass- 
 ment of circulation the interruption of the pregnancy is indicated, 
 whatever its stage. As already stated, this interruption often takes 
 place spontaneously, but if not, labor should be induced. On account 
 of the risk of the sudden gush of the liquor amnii causing prolapse of the 
 cord and malpresentation of the child, and the sudden emptying of the 
 uterus predisposing to postpartum hem^orrhage, the membranes should 
 be punctured through the cervical canal and the liquor amnii be allowed 
 to drain off slowdy. 
 
 Prognosis. — In chronic hydramnios the prognosis for both mother and 
 child is usually good under careful observation. 
 
 In acute hydramnios the prognosis for the mother is usually good, 
 provided she is not suffering from a severe constitutional disease and 
 provided she is carefully watched and the pregnancy is interrupted before 
 the pressure becomes too great. The prognosis for the child in acute 
 hydramnios is always uncertain for the reason that it is often premature, 
 usually poorly nourished, and not infrequently malformed. 
 
 Oligohydramnios. — ^In a few rare cases the liquor amnii instead of 
 being abnormally increased in amount is abnormally decreased, so that 
 the fluid surrounding the fetus is insufficient for its protection and 
 development. This is called oligohydramnios . Most authorities state 
 its frequency as about once in four thousand cases. It is met with not 
 only in single uterine pregnancies, but in multiple pregnancies and in 
 
504 
 
 DISEASES OF THE FETAL MEMBRANES 
 
 advanced cases of ectopic gestation. Little is known of the etiology of 
 the condition. In a case reported by Strassmann,* in 1894, there was 
 an absence of both kidneys, and in a case reported by Jagcrard,'- in the 
 same year, there was an absence of one kidney and a cystic degeneration 
 of the other. These cases suggest the possibility of the absence of kidney 
 function being the cause of the oligohydramnios in some cases. The 
 presence of this etiological factor, however, is by no means uniform. In 
 some cases of oligohydramnios the fetal skin has been found thick and 
 dry, with very little secretion, but whether this was the result or one of 
 
 Fig. 318. — Intra-uterine amputation, healed at hirth. 
 
 the causes of the oligohydramnios, has never been settled. The results 
 of oligohydramnios are most serious when it occurs in the early part of 
 pregnancy, as with insufficient fluid to separate the amnion from the 
 fetus, adhesions form between the two and numerous fetal malformations 
 occur. Faults of fusion in the midline, different forms of talipes, intra- 
 uterine amputations by the bands of adhesions, interference with the 
 nutrition and distortion of the fetus from pressure are among the results 
 
 ' Zeitschrift f. Geburtsh. u. Gynak.. 1894, Band xx\-iii, Heft 1, 181. 
 - Amer. Jour. Obstet., 1894, xxix, 432-446. 
 
DISEASES OF THE AMNION 505 
 
 found in oligohydramnios. In some cases the fetal circulation is so 
 interfered with as to kill the fetus and cause its expulsion. In some 
 cases of twin pregnancy one amniotic sac has an abundance, perhaps 
 even an excess, of liquor amnii, while the other sac has hardly any, and 
 the fetus in this sac is malformed, perhaps even compressed to a fetus 
 papyraceous. Oligohydramnios occurring late in pregnancy is usually 
 less disastrous than when it occurs early, but even here abnormal compres- 
 sion and various minor deformities are often seen. The same may be 
 said regarding advanced cases of ectopic gestation where there is little 
 fluid in the amniotic sac. 
 
 Intra-uterine Amputations. — Intra-uterine amputations have already 
 been referred to. It is readily understood that the amniotic bands of 
 adhesion, by encircling any portion of the upper or lower extremities, 
 may, by interfering with its circulation, cause sloughing and even ampu- 
 tation. Children are occasionally born in w^hich such an amputation 
 has occurred from this cause and the stump has healed (Fig. 318). Not 
 infrequently the delivery is premature, but if the pregnancy goes to term 
 and firm adhesions have formed between the placenta and the fetus, 
 the labor is apt to be tedious and distressing and there is always the 
 risk of a premature separation of the placenta with danger alike to 
 mother and child. 
 
CHAPTER XV. 
 ABORTION. 
 
 The arrest of gestation and expnlsion of the ovum prior to the period 
 of viability of the child is called by the medical profession abortion. 
 
 This term, however, has been so long associated with the criminal 
 operation that it is distasteful to patients, who speak of the occurrence 
 as a miscarriage, and it is always wise for the physician in the presence 
 of his patient to use this latter expression. 
 
 The twenty-eighth week or the completion of the seventh month of 
 gestation is generally accepted as the period of viability, for although 
 by means of an incubator the life of a child of less than seven months' 
 gestation has occasionally been saved, this result is so exceptional that 
 it is not to be expected and little hope of it should be given. Interrup- 
 tion of pregnancy then, prior to the completion of the seventh month, 
 may be called abortion or miscarriage, and between the seventh month 
 and term, premature labor. 
 
 Frequency. — In 1000 consecutive patients in the author's private prac- 
 tice who have been pregnant, 371 have had one or more miscarriages. 
 This shows the extreme frequency of the occurrence, i. e., a little more 
 often than 1 in 3 (although it is impossible to tell how many of these 
 were induced). In this 1000 cases 53 miscarried in their first pregnancy. 
 
 Etiology. — In studying the etiology of abortion the following factors 
 may be recognized: (a) Traumatism, (6) maternal causes, (c) fetal 
 causes, (d) paternal causes. 
 
 A. Traumatism. — Under this heading may be placed all forms of 
 violence, as blows, falls, lifting heavy weights, excessive action of the 
 abdominal muscles, as in severe vomiting, coughing or sneezing, exces- 
 sive or violent intercourse, the introduction of instruments, etc. All 
 these probably act by causing hemorrhage into the decidua or between 
 the decidua and the uterine wall thus separating more or less of the ovum 
 from its attachment. 
 
 B. Maternal Causes. — Here may be mentioned: 
 
 1. Causes acting through the nervous system, as mental shock; reflex 
 irritation, as from nursing a child while again pregnant; nervous diseases, 
 as chorea, epilepsy, etc. 
 
 2. Causes Acting through the Blood. — One of the most frequent 
 causes of abortion is a condition or group of conditions in the mother 
 which is called a toxemia. The nature of this toxemia is not known 
 at present, and it can only be said that products of metabolism which 
 should be oxidized, rendered innocuous- and eliminated, probably cir- 
 culate in the blood in a harmful form. 
 
 (506) 
 
ETIOLOGY OF ABORTION 507 
 
 Also acting through the blood of the mother is syphilis with its accom- 
 panying disease of the decidua, and this disease should always be thought 
 of in searching for the etiology of repeated miscarriages in a given case. 
 
 High fevers^ especially with a temperature above 105° F., predispose 
 to a miscarriage. This is often seen in typhoid fever through which, if 
 the course is a mild one and the temperature relatively low, the preg- 
 nant patient will often pass without interruption of the pregnancy, while 
 on the other hand, if the course is severe and the temperature high, 
 abortion is common. 
 
 Malarial fever also predisposes to abortion, and in all probability some 
 of the cases of abortion assigned to the administration of quinine have 
 been due to the malarial infection for which the quinine was given. 
 
 Acting through the blood of the mother as causes of abortion may 
 also be mentioned poisonous drugs, as mercury, phosphorous, lead, ergot, 
 etc.; poisonous gases, as coal gas, or a lack of elimination of carbon 
 dioxide gas, in diseased conditions of the heart and lungs, and lastly, an 
 impoverished condition of the blood itself as in extreme anemia, will 
 sometimes produce an abortion. 
 
 .3. Local Causes. — Probably the most common cause of abortion or 
 miscarriage is an endometritis which interferes with the formation of a 
 healthy decidua and normal attachment of the ovum. The causes of the 
 endometritis may be varied, but it is the endometritis itself which stands 
 in direct etiological relation with the separation of the ovum. 
 
 A posterior displacement of the uterus is one of the common causes of 
 abortion and in the judgment of the author this forms the chief argument 
 in favor of bimanual examination of a patient early in pregnancy. The 
 displacement may cause the abortion in one of two ways : either through 
 the endometritis resulting from the chronic congestion produced by the 
 retroversion or retroflexion, or if the uterus is fixed by adhesions and 
 incarcerated beneath the promontory of the sacrum, as the growth con- 
 tinues something has to give way and the uterus relieves its tension by 
 emptying itself in the direction of least resistance, i. e., through the 
 cervical canal. 
 
 Abortion is sometimes produced by adhesions outside of the uterus 
 interfering with its normal expansion; by lacerations of the cervix, which 
 give too little support at the outlet of the uterus and also expose it to 
 constant irritation and perhaps endometritis. 
 
 Tumors of the uterus, especially fibromyomata, will sometimes cause 
 an abortion, although many times a patient, whose uterus is studded 
 with fibroids, will pass through pregnancy without the slightest tendency 
 to abort. 
 
 When abortion is produced by a fibromyoma it is probably caused 
 either by the encroachment of the tumor upon the cavity of the uterus 
 or by the endometritis which accompanies it. 
 
 In placenta previa abortion and premature labor are well known to be 
 common. - .« 
 
 C. Fetal Causes. — Under thi? heading may be grouped any disease 
 of the fetus or fetal membranes destroving the life of the fetus. While 
 
508 ABORTION 
 
 a dead fetus may sometimes be retained within the cavity of the uterus 
 for weeks, months, or even years, as a rule the uterus soon regards it as 
 a foreign body and expels it in from one to four weeks. Among the 
 causes of fetal death may be mentioned hemorrhage into the placenta, 
 degeneration of the chorion, extreme torsion of the cord with stenosis 
 of its vessels, etc. 
 
 D. Paternal Causes. — The one chief cause of abortion assignable to 
 the father is syphilis, producing from syphilitic spermatozoa syphilitic 
 changes in the placenta and fetus. In addition to syphilis, constitutional 
 exhaustion from alcoholic or venereal excesses, from tuberculosis or 
 other wasting diseases, by producing unhealthy spermatozoa seems to 
 predispose to abortion. 
 
 The occurrence of an abortion often seems in itself a predisposing 
 cause of a recurrence. 
 
 The above-mentioned causes, save traumatism, are largely predisposing 
 in character, and with one or more of these predisposing causes present 
 it is evident that a very slight traumatism might serve as an exciting 
 cause. Classified according to etiology, abortion may be looked upon 
 as either accidental or intentional, these terms being self-explanatory. 
 Intentional abortion may be either criminal or medical, the latter 
 expression being used to cover those interruptions of pregnancy which 
 are demanded for the life and health of the mother and which are per- 
 formed by the medical attendant after careful and conscientious study 
 of the case. 
 
 Symptoms. — Classified according to symptoms, abortion may be either 
 threatened or inevitable. The symptoms of threatened abortion are 
 hemorrhage and perhaps pain. Usually the first evidence of any tendency 
 to abort or miscarry is a bloody discharge from the vagina. This may 
 be accompanied or soon followed by slight recurring pains. However, a 
 woman may have a slight bloody flow for a number of days and with it 
 occasional recurrent pains which under proper treatment may subside, 
 the patient go to term and be delivered of a healthy child. These symp- 
 toms then (hemorrhage and pain) may be only those of a threatened 
 abortion, but if in addition to the hemorrhage and pain there is found 
 on examination a dilatation of the cervix and a beginning protrusion of 
 the ovum the abortion becomes inevitable. There may also be certain 
 prodromal symptoms of general malaise and increase in the vaginal 
 mucus, and an increased frequency of micturation. 
 
 Pathology. — Whatever the etiology of an abortion the pathological 
 result is usually an effusion of more or less blood into the decidua or 
 between the decidua and the uterine wall (see Plate VII). In a threat- 
 ened abortion (Plate VII, Fig. 1) this may be slight and not enough to 
 separate any material portion of the chorion or placenta from the uterine 
 wall. In an inevitable abortion, on the other hand (Plate VII, Fig. 2), 
 more and more of the ovum is separated until, under the influence of the 
 uterine contractions, either the entire ovum is expelled from the uterus 
 as in complete abortion (see Fig. 319), or the embryo is expelled, leaving 
 behind more or less of its membranes and the decidua as in an incomplete 
 
PLATE VII 
 
 FIO. 1 
 
 Threatened Abortion. 
 
 FIG. 2 
 
 Inevitable Abortion. 
 
PATHOLOGY OF ABORTION 
 
 509 
 
 abortion, or the entire ovum is retained for a time within the cavity of 
 
 the uterus as a mole. , . . ; ^ u 4.u 
 
 Classified according to pathology then, abortion is comvlete when the 
 entire ovum is expelled from the uterus; incomplete, when a part ot the 
 ovum is retained. 
 
 Fig. 319. — Complete abortion. 
 
 In a complete abortion, which takes place soon after the occurrence 
 of the hemorrhage and uterine contractions which caused its separation, 
 the embryo will be found enclosed in its sac of amnion and chorion with 
 the luxuriant chorionic villi surrounded by more or less of the decidua and 
 covered with more or less blood. In some early cases, as in Fig. 319, the 
 ovum is enclosed in a practically complete triangular decidual sac In 
 this case the patient, a private patient of the author's, menstruated last 
 
510 
 
 ABORTION 
 
 on October 5, 1900, and the ovum in the deci(kial sac was discharged 
 December 17, 1900. 
 
 Often in a practically complete abortion a little of the decidiia is left 
 behind, as often occurs in a normal labor at term, but as it usually comes 
 away in the lochia without symptoms, the retention of only a little decidua 
 and nothing else is usually not regarded sufficient to place it in the class 
 of incomplete abortion. 
 
 Fig. 320. — Fetus only expelled; membranes retained. 
 
 In the incomplete abortion the fetus alone may be expelled and the 
 membranes, amnion, chorion and decidua all be retained, as in Fig. 320, 
 or especially in early abortions the ovum may be covered only by amnion 
 (Fig. 321), or by amnion and chorion with its luxuriant villi, so that 
 the specimen obtained may be a little vesicle covered with the shaggy 
 chorionic villi (see Fig. 322). 
 
 In quite a large percentage of cases the ovum is retained within the 
 uterus for a considerable time after the death of the fetus. Under these 
 circumstances the blood effusion which havS gradually surrounded the 
 
PATHOLOGY OF ABORTION 
 
 511 
 
 ovum coagulates and there is formed a blood-clot whose centre consists 
 of a more or less degenerate ovum. This structure is spoken of as a mole 
 and is called a sanguineous or bloody mole, when the encapsulating blood- 
 clot is relatively fresh and retains its blood-red color (see Fig. 323), and 
 a carneous or fleshy vwle, when from the deposit of fibrin the encapsu- 
 
 FiG. 321. — Fetus covered only with amnion. 
 
 lating blood-clot has lost its original appearance and consistency and 
 has become more fleshy in character. 
 
 If a section is made through one of these moles after its discharge from 
 the uterus there is usually found in its centre a small cavity lined with a 
 smooth membrane (the amnion) and, depending upon the development 
 
512 
 
 ABORTION 
 
 of the ovum and the age of the mole, there may be found liangin<i; from 
 one point of the membrane either a small umbilieal cord and partially 
 degenerated fetus or perhaps only a remnant of an umbilical cord, the 
 fetus having been absorbed. 
 
 In all moles the fetus is smaller than would be expected from the 
 menstrual history, showing that the death of the fetus occurred a con- 
 siderable time before its expulsion from the uterus. 
 
 Fig. 322. — Ovum with amnion and chorion expelled. 
 
 A complete absorption of the fetus can only take place in the early 
 weeks of development. If it is retained in the uterus after it has reached 
 any considerable size it usually macerates and decomposes, becoming a 
 serious menace to maternal life. Rarely, however, it undergoes a drying 
 process called mummificaiion. In twin pregnancy one of the twins 
 sometimes thrives at the expense of the other and the unfortunate twin 
 becomes compressed and thinned out and is only found at term as a 
 fetus papyraceous or parchment-like fetus (see Fig. 324), in the mem- 
 brane of what might at first be thought a single pregnancy. 
 
TREATMENT OF ABORTION 
 
 513 
 
 Very rarely in intra-uterine pregnancy, but much more often in ectopic 
 gestation, a fetus is retained until it is converted by the deposition of 
 lime salts into a relatively innocuous litJwpedion. 
 
 Treatment. — Prophylaxis. — The most important factor in the prophyl- 
 actic treatment of abortion is the education of patients in the moral 
 and legal wTong as well as the danger of induced abortion. Many women, 
 remarkably conscientious in perhaps almost every other action, seem to 
 lose all sense of right and wrong when possessed of the desire to rid them- 
 selves of the product of conception. They vrill often state that all their 
 friends get relief and they are going to have it. ]Many satisfy themselves 
 
 Fig. 323. — Sanguineous mole. 
 
 with the idea that very early in pregnancy there is little form to the 
 ovum and it amounts to nothing. There are two good methods of edu- 
 cation of the laity in this matter — one is to show them either a specimen 
 or a photograph of a fetus of two or three months' development and to 
 tell them that there is certainly life in the fetus and that the destruction 
 of that life is a crime, both morally and legally, just as the taking of the 
 life of the child a year after it is born would be a crime. ]Many a woman, 
 when this phase of the subject has been presented to her, has been 
 persuaded to abandon her determination to terminate her pregnancy. 
 Another method which is often useful is to instruct the patient in the 
 33 
 
514 
 
 ABORTION 
 
 dangers of induced abortion and to assure her that no reputable member 
 of the profession will have anything to do with carrying out her desire 
 and that she cannot afford to risk her life in the hands of disreputable 
 men whose hands and instruments would, like their work, probably be 
 unclean. 
 
 The education of patients along these two lines of moral responsibility 
 and dangers of induced abortion has saved the life of many an unborn 
 fetus. 
 
 Fig. 324. — Fetus papyraceous in membranes of full-term fetus. 
 
 Unfortunately for the unborn race, some of the modern abortionists 
 have learned to do the criminal act in the same aseptic, scientific manner 
 which is employed by the conscientious surgeon when the uterus has to 
 be emptied in orfler to save the life of the mother, in this way making 
 detection of the abortionists' crime more difficult. 
 
 Before leaving the subject of the prophylactic treatment of abortion 
 it is fitting that something be said regarding the position of the physician 
 toward the persuasion of his patients to interrui:)t their pregnancy for 
 other than medical reasons. I will not call it a temjjtation, as no man 
 should allow the persuasion to so influence him as to become a temptation. 
 
PLATE VIII 
 
 Vagina and Cervical Canal Packed with Gauze. 
 
TREATMENT OF ABORTION 515 
 
 Many a case will present itself which will arouse his sympathies and 
 make him wish with all his heart that his patient had not become pregnant 
 at just this apparently the most inopportune time for her, but there is 
 only one position for the reputable conscientious physician to take, i. e., 
 that save for distinct medical reasons with which a fellow practitioner 
 concurs, he will have nothing to do with the induction of abortion, even 
 if the patient making the plea is the wealthiest and most influential in 
 his practice. 
 
 Treatment of Threatened Abortion. — On the occurrence of any uterine 
 hemorrhage with or without pain the patient should be at once put to 
 bed, her mental excitement quieted as much as possible by words of 
 encouragement and her uterine irritability quieted by an opiate. In 
 order to get a rapid effect the author's custom is to first administer 
 a hypodermic injection of morphin (gr. \-\) and then continue the 
 influence of the opiate by giving codein (gr. ss) every two hours for 
 two or three doses. If no pain appears the codein can then be dis- 
 continued, only to be resumed at intervals of about four hours if pain 
 recurs. The patient should lie quietly on the back and should receive 
 only light, non-stimulating nourishment, better cool than hot. The 
 application of an ice-bag just above the symphysis often quiets uterine 
 irritability. After a day or two if neither pain nor hemorrhage recurs 
 the fluidextract of viburnum may be substituted for the opiate, but the 
 patient should be kept oiT her feet for a number of days after all hemor- 
 rhage and pain have ceased. 
 ^ Treatment of Inevitable Abortion. — As soon as it is evident that to the 
 symptoms of hemorrhage and pain, which may belong only to a threat- 
 ened abortion, there is added a beginning dilatation of the cervix and a 
 protrusion of the ovum into the cervical canal, the picture changes from 
 that of a threatened to one of inevitable abortion and the object then 
 desired is the speedy, complete emptying of the uterus with as little 
 hemorrhage and pain as possible. If the cervix is dilating rapidly and 
 everything progressing favorably the best treatment is to leave the 
 patient alone and allow the uterus to empty itself as completely as 
 possible. It is extremely important, however, that everything passed 
 from the vagina should be preserved for careful examination to deter- 
 mine whether or not the ovum has been completely expelled. Under 
 two months the ovum is often so completely expelled that the uterus 
 may be considered empty, but after this period of gestation an incomplete 
 abortion becomes the rule. 
 
 If the cervix is slow in dilating and the hemorrhage is profuse, one of 
 the best methods of treatment is to pack the cervical canal and the 
 vagina with a long strip of iodoform gauze (see Plate A^III). This 
 tends to check the hemorrhage by confining it between the decidua and 
 the uterine wall, and occurring in this confined space the hemorrhage 
 tends to separate the ovum more and more completely from the uterine 
 wall at the same time that the gauze tends to soften and dilate the cer- 
 vical canal. Often, if the gauze is removed at the end of eight to twelve 
 hours, the cervix is found dilated and the ovum lying free in the canal. 
 
516 ABORTION 
 
 If the cervix is well dilated or easily dilatable and the ovum is not steadily 
 advancing, the discomfort of the woman and the amount of blood loss 
 may be markedly lessened by putting the patient under an anesthetic 
 and with the finger or fingers of the sterile gloved hand sweeping around 
 the cavity of the uterus and removing the ovum, blood-clots, etc. After 
 this procedure it is well to irrigate the cavity of the uterus with some 
 sterile solution like normal saline solution to remove all debris and then 
 follpw it with an intra-uterine tamponade of a weak iodoform or bismuth 
 gauze. The use of the gauze tamponade has the advantage not only of 
 controlling hemorrhage but in the withdrawal of the gauze the uterine 
 cavity is wiped clean of retained portions of decidua if there be any. 
 Iodoform or bismuth gauze is better than plain gauze, as the latter 
 remains sweet in the uterus but a short time. Attention has already been 
 called to the fact that the specimen passed from the uterus should be 
 saved and carefully examined to see if it is complete. This is usually 
 best determined by floating the specimen in water. It is exceptional 
 that the ovum is cast oflF with the deciduse complete, as shown in Fig. 319, 
 and especially rare is this occurrence after the second month. Even if 
 the amnion and chorion are complete it is common to find patches of 
 decidua absent. If the cast-off ovum is surrounded by the complete 
 deciduse, of course the abortion is complete and no intra-uterine inter- 
 ference is indicated. If only small patches of decidua parietalis are absent 
 from the specimen when carefully examined, it may be regarded as prac- 
 tically complete and so treated, the uterine cavity being left alone. 
 
 Treatment of Incomplete Abortion.- — The question now arises, What is 
 the best treatment when only a part of the ovum has been discharged, 
 the remainder being retained within the cavity of the uterus? Often it 
 is only the fetus which is discharged, the amnion, chorion and decidua 
 being retained. 
 
 This is especially common in and after the third month. All degrees 
 of incompleteness, however, occur — from the fetus alone to the fetus 
 surrounded by the amnion, chorion and most of the decidua. The earlier 
 the abortion, the more likely is it to be complete; while the more mature 
 the placenta, the more likely is the fetus to be the only part to be dis- 
 charged. Even in the early weeks, if only the ovum is discharged (see 
 Fig. 322), enough decidua maybe retained to cause continued hemorrhage. 
 
 In an abortion which is known to be incomplete there is only one rule 
 which should be followed in treatment: The uterus should be emptied 
 with the least injury and with the greatest cleanliness. The best instrument 
 for emptying a uterus when the cervix is well dilated or easily dilatable 
 is the aseptic finger or fingers. If one, or preferably two, fingers can be 
 introduced into the uterine cavity, with the assistance of the other hand 
 on the abdomen depressing the abdominal and uterine walls in apposi- 
 tion to the intra-uterine fingers, every part of the uterine cavity can be 
 palpated and the presence of secundines detected and removed. The 
 uterine cavity is then irrigated to wash away loosened debris and the 
 intra-uterine tamponade used. There are many incomplete abortions, 
 however, in which the cervical canal is not sufficiently dilated or easily 
 
TREATMENT OF ABORTION 
 
 517 
 
 dilatable to admit the finger. In such instances some substitute for the 
 finger must be used. The two instruments* which in the author's exper- 
 ience have proved most valuable are seen in Fig. 325. A blunt, firm 
 curette and a sponge holder. The loop of the curette is flat on one sur- 
 face and the shank is rigid enough to give all the scraping power needed, 
 while the loop is large enough to make perforation of the uterus unlikely. 
 The sponge holder is made with halves separable so that one-half may be 
 used as a curette if desired. The general plan in the use of these two 
 instruments is to separate the membranes from the uterine wall with 
 
 Fig. 325. — Sponge holder and curette. 
 
 the curette and then remove them from the uterine cavity with the sponge 
 holder. In using the curette but little force should be employed and that 
 little should be in the direction toward the operator, the instrument 
 being ver^ gently introduced until the fundus of the uterus is reached 
 and then all scraping done in the withdrawal. The contact of the curette 
 with the fundus is more easily detected if the latter is steadied and gently 
 depressed by the hands of an assistant or nurse. Each side and cornu 
 of the uterus should in turn be gone over by the curette but always 
 with the thought of doing as little injury as possible to the uterine wall. 
 
518 
 
 ABORTION 
 
 111 onltT to use tlu' two instruincnts shown above, three other instriiiiients 
 are usually needed as adjuvants (see Fig. 32(3). 
 
 1. A volsella to hold the cervix. 
 
 2. A perineal retractor, one st\le of which is here represented. 
 
 3. A glove stretcher dilator. 
 
 Following the use of the curette and sjjonge holder some sort of a 
 iloul)le-current catheter is needed for washing away debris, and for this 
 
 Fig. .326. — Volsella, perineal retractor and dilator. 
 
 purpose the Bozenian-Fritsch instrument shown in Fig. 327 answers 
 well. 
 
 If an intra-uterine tamponade is indicated, the packing forceps 
 shown in Fig. 327 for introducing gauze is very useful. 
 
 The advantage gained by the introduction of the finger or fingers 
 and palpation of the uterine cavity to determine that it is empty is well 
 illustrated by 2 cases which have come under the author's observation. 
 
 In the first case the uterus was carefully curetted after an incomplete 
 abortion and was supposed to be left empty. On about the tenth day 
 
TREATMENT OF ABORTION 
 
 519 
 
 afterward she passed the whole placenta which at the time of the curet- 
 tage had been firmly adherent to the uterine wall and allowed the curette 
 to pass over its amniotic surface and escaped detection. A finger intro- 
 duced into the cavity of the uterus would certainly have not allowed this 
 oversight. 
 
 This experience occurred early in the professional career of the author 
 and taught him a lesson never to be forgotten. 
 
 Fig. 327. — Packing forceps and double-current catheter. 
 
 The second case was sent to the author's hospital ward by a very able 
 practitioner who said that he had carefully curetted and emptied the 
 uterus but that the woman was not properly situated at home for con- 
 valescence and requested that she be admitted to the hospital for care 
 during her recovery. The following morning she passed the fetus 
 enveloped in a complete amnion and chorion. 
 
 The fetus in its sac had evidently been attached to the fundus of the 
 uterus and the curette had passed all around it without interfering with 
 
520 ABORTION 
 
 its attachment. A finger introduced into the uterine cavity would have 
 detected its presence. 
 
 The question arises: What should be done if the obstetrician is called 
 to attend a case of abortion in which the patient is said to have passed 
 the ovum but the specimen was not saved? Two alternatives present 
 themselves: The first is to keep the patient in bed and await develop- 
 ments, and consider the abortion complete if all bleeding ceases within 
 a week and no rise of temperature occurs. The second is to consider the 
 abortion incomplete so long as evidence to the contrary is lacking and 
 treat the case as an incomplete abortion. In an abortion of less than 
 two months' gestation the author believes the first alternative good 
 practice. But when the period of gestation is more than two months, 
 provided the dilatation of the cervix and evidence of blood lost are 
 sufficient to convince him that the abortion was certainly of the inevit- 
 able type, he believes the second alternative the correct .procedure and 
 that the patient should be anesthetized, her uterus explored and either 
 demonstrated to be empty or made so at once. 
 
 In this connection it may be well to caution the physician not to be 
 deceived by the statements of women anxious to have abortion per- 
 formed. 
 
 Treatment of Neglected Abortion. — Under this heading is included cases 
 of incomplete abortion which give rise either to continued bleeding- 
 metrorrhagia^or to evidence of infection from decomposition of the 
 retained secundines. In each the indication is the same — to clean the 
 uterus as gently as possible. The need for gentleness is especially great 
 in the infected cases, as the uterine w^all is extremely soft and perforation 
 of it by the curette is very easy. 
 
 After-treatment. — One of the most important results of abortion, espe- 
 cially induced abortion, has been the subinvolution and endometritis" 
 arising from the neglect of the precautions which are recognized as neces- 
 sary at term and generally observed. Many women remain quiet but a 
 few days following a miscarriage, and even if they escape the dangers 
 arising from an incomplete abortion, often suffer for years from the 
 subinvolution, displacement and endometritis which might have been 
 avoided by proper care. 
 
 Patients after abortion, just as reasonably as after childbirth at term, 
 should be kept in bed until the uterus has had a chance to involute. 
 It is the author's custom to keep them in bed at least a week and not 
 allow them to go out of the house for at least two weeks. Attention should 
 be called to the fact that after abortion, as after labor at term, there is 
 often a tendency of the uterus to retrovert and patients should not be 
 allowed to go about until it is determined either that the uterus has 
 remained in normal position or it has been replaced and supported with a 
 pessary if it was retro verted. 
 
 Treatment of Habitual Abortio?i. — No matter how anxious a woman 
 may be at certain periods of her life to get rid of the product of her con- 
 ception, there often comes a time when her greatest desire is to bear a 
 child, but whether or not the previous abortions have been induced, the 
 
TREATMENT OF ABORTION 521 
 
 occurrence of one miscarriage after another tends to reproduce this 
 result in subsequent pregnancies and so bring about the miscarriage 
 habit, or the condition of habitual abortion. The etiology is largely 
 based on the pathological changes in the uterus, namely, the subinvolu- 
 tion and endometritis resulting in the formation of unhealthy deciduse. 
 Back of this may lie a constitutional dyscrasia such as syphilis, and this 
 should always be sought for and treated if found in a case suffering 
 from' habitual abortion. 
 
 It must be recognized that the successful treatment of habitual abor- 
 tion is often extremely difficult and attempts in this direction often meet 
 with disappointment. In the first place the pelvic organs should be 
 gotten into as normal a condition as possible before pregnancy is allowed. 
 At least a year and perhaps more than that time should elapse between 
 the last miscarriage and a subsequent pregnancy in order to allow the 
 subinvolution to subside. If the endometritis persists a curettage will 
 often give the quickest and most effective result. If the cervix shows 
 extensive lacerations, they should be repaired. When, after a suitable 
 interval, pregnancy has again occurred, certain precautions should be 
 taken. In the first place all sexual intercourse must be interdicted. 
 Furthermore, in well-marked cases, the patient should remain in bed 
 each month on the days which would naturally be those of menstrua- 
 tion. If there is the slightest suspicion of syphilitic infection it should 
 receive constitutional treatment. The urine should be carefully watched 
 for evidences of a toxemia and the avenues of elimination be kept in 
 functional activity. 
 
 Between the times which would normally be the menstrual periods the 
 patient may be allowed a little more liberty, but in those whose tendency 
 to abort is very great it may be necessary to keep them off their feet 
 during a large part of the time until after the period of their former 
 miscarriages has passed. The author's custom is to allow the patient 
 out of bed a few hours each day during the weeks which would not be 
 her menstrual weeks, but she should avoid stair climbing and all rough 
 motoring and should simply seek fresh air without fatigue. If once the 
 pregnancy can be safely brought to term the so-called habit is usually 
 broken and little trouble experienced in the future. 
 
 MAT 
 
CHAPTER XVI. 
 
 ECTOPIC GESTATION. PREGNAN( Y IN MALFORMED 
 
 UTERI. 
 
 ECTOPIC GESTATION. 
 
 The normal situation for an impregnated ovum to lodge and develop 
 is within the cavity of the uterus. A pregnancy located anywhere else, 
 as being out of place, is called ectopic gestation. This term covers not 
 only those conditions which are strictly extra-uterine but also a preg- 
 nancy in the interstitial ])ortion of the tube which while ectopic is not 
 outside of the uterus. 
 
 The first clearly recorded case of ectopic gestation is one described in 
 the eleventh century by Albucasis/ an Arabian physician, who observed 
 parts of a fetus working their way through the abdominal wall. During 
 the seventeenth century more exact descriptions are given and different 
 varieties are mentioned. In 1614 Mercerus"^ performed an autopsy 
 upon a woman who had died of a ruptured ectopic gestation of two 
 months, probably tubal or tuboovarian, although regarded by him as 
 ovarian. During the seventeenth century the distinction between primary 
 and secondary abdominal gestation was clearly made. 
 
 Frequency. — For centuries ectopic gestation was considered one of 
 the rarest of accidents to which woman was liable, but since March 3, 
 1883, when Lawson Tait, of Birmingham, England, performed his first 
 successful operation upon a case of ruptured ectopic gestation, literature 
 has abounded in reports of cases of this condition and every busy gyne- 
 cologist is called upon to operate upon several of these cases each year. 
 Some idea of the frequency of the condition may be gained from the 
 fact that Formad, of Philadelphia, in 3500 general autopsies, found 35 
 ectopic gestations. In one series of 500 abdominal sections performed 
 by the author for different pelvic conditions there were 38 cases of ectopic 
 gestation. In assigning credit for our knowledge of this condition it 
 is only just to state that to Lawson Tait and his views regarding the 
 etiology and treatment of pehic hematocele we owe most of our present 
 practical knowledge of the subject. 
 
 Varieties. — In 1752 Bohmer adopted a classification of ectopic gesta- 
 tion which may well be accepted today, viz., tubal, ovarian, ahdominaL 
 
 For many years the existence of an ovarian pregnancy was subject to 
 grave doubt, but in the last decade the carefully recorded cases of Van 
 Tussenbrook, of Amsterdam, Thompson, of Portland, Webster, of Chicago 
 (2 cases), Davis, of Philadelphia, and others lea^'e no doubt that true 
 
 1 De Chirurgia, cura J. Channing, Oxon, 1778. 
 - Anthropographia et Osteologia, Parisiis, 1626. 
 
 (522) 
 
ECTOPIC GESTATION 
 
 523 
 
 ovarian pregnancy does exist as a variety of ectopic gestation, although 
 very rare. A case of ovarian pregnancy operated upon by the author is 
 shown in Figs. 328, 329, 330, and 331 . That primary abdominal pregnancy 
 can occur in the sense that an ovum free in the abdominal cavity is met 
 and fertilized by a spermatozoon and there develops, is extremely diffi- 
 cult to believe when the marked absorptive power of the peritoneum 
 is considered. On the other hand, many instances are recorded where 
 the fetus, after partial development within the tube, or between the 
 folds of the broad ligament, has escaped secondarily into the abdominal 
 
 Ovary containing blood-clot 
 
 Left tube overlying a parovarian cyst 
 
 Fig. 328. — Ovarian pregnancy, seen from above. 
 
 cavity and continued its existence, although in these cases the placenta 
 has usually maintained its attachment either within the tube or between 
 the folds of the ligament. These are cases of secondary abdominal 
 gestation. 
 
 The ovarian and abdominal varieties of this condition are so rare 
 that for practical purposes ectopic gestation may ordinarily be looked 
 upon as primarily tubal. 
 
 It may be situated in different portions of the tube and receive different 
 names, as for instance: 
 
 In the interstitial portion called tuho-uterine or interstitial. This 
 variety is rare, constituting only about 3 per cent, of cases. 
 
524 ECTOPIC GESTATION— PREGNANCY IN MALFORMED UTERI 
 
 In the tube proper, called trve tubal. In this variety the gestation may 
 lie in any one of. the three sites: the isthmus, the ampulla, or in the 
 fimbriated extremity. 
 
 It may lie between the tube and the ovary, called tubooMrian. 
 
 Secondary varieties of ectopic gestation are those resulting from dis- 
 placement of the ovum after its primary lodgement. 
 
 This displacement may take place either into the abdominal cavity by 
 abortion through the fimbriated extremity of the tube, constituting a 
 
 Fig. 329. — Ovarian pregnancy, seen from below and without. 
 
 secondary abdominal pregnancy, or down through the floor of the tube, 
 constituting an intraligamentous pregnancy, perhaps escaping thence by 
 rupture of the broad ligament folds into the abdominal cavity, constitut- 
 ing also a secondary abdominal pregnancy. In a few cases of interstitial 
 pregnancy the ovum seems to have been discharged into the uterine 
 cavity, becoming an intra-uterine pregnancy. 
 
 In summing up the varieties of ectopic gestation the following may 
 be recognized: 
 
ECTOPIC GESTATION 
 
 525 
 
 Primary Ectopic Gestation: 
 
 Tubo-uterine or interstitial. 
 [ Isthmial. 
 
 True tubal \ Ampullar. 
 
 [ Infundibular. 
 
 Tuboovarian. 
 
 Ovarian 
 Secondary Ectopic Gestation: 
 
 Abdominal. 
 
 Intraligamentous. 
 
526 ECTOPIC GESTATION— PREGNANCY IN MALFORMED UTERI 
 
 Etiology. — In studying tlie causes of ectopic gestation the normal 
 site of impregnation must first he considered. In animals, spermatozoa 
 have heen found in the tube and in the pelvic cavity surrounding the 
 ovary in from two and three-quarter to twenty hours after intercourse. 
 An autopsy, performed sixteen hours after death, upon a girl who died 
 of coal-gas poisoning immediately after intercourse-showed spermatozoa 
 in the tube. It is known that the ovum requires several days to pass 
 along the tul)e from o\ar\' to uterus. 
 
 
 
 Fig. 331. — Ovmiiiu pregnancy. Vifw of chorionic villi shown in Fig. 33U, under liiglier 
 
 magnification. X 75. 
 
 It therefore follows that the normal meeting-place of ovum and 
 spermatozoon is in the tube, and it is generally recognized that the tube 
 is the normal site of impregnation and that the ordinary forms of ectopic 
 gestation result from some hindrance to the advance of the impregnated 
 ovum along the tube toward the uterus and the partial development of 
 the ovum at the point of detention. 
 
 In the case of ovarian pregnancy the ovum is impregnated before it 
 leaves the ovary and undergoes partial development there. Conditions 
 causing delay in the j)rogress of the ovimi along the tube may be 
 situated : 
 
ECTOPIC GESTATION 527 
 
 1. In the lumen of the tube. 
 
 2. In the wall of the tube. 
 
 3. Outside the wall of the tube. 
 
 4. In the ovum itself. 
 
 Conditions in the Lumen of the Tube. — Here may be mentioned many 
 hindrances to the advance of the o\'um such as diverticula; strictures; 
 inflammation of the mucosa resulting in damaged cili?e; polypi, and in 
 rare cases even a previous ectopic gestation, as in the case reported by 
 Coe/ in which at the time of operation for ruptured ectopic gestation 
 on the right side the remains of an ectopic gestation, which had occurred 
 twelve years previously, was found obstructing the proximal end of the 
 same tube. 
 
 Conditions in the Wall of the Tube. — The thickening of the tubal wall 
 resulting from a previous salpingitis interferes with the normal peris- 
 taltic action and probably favors the arrest of the fertilized ovum within 
 the tube. 
 
 Conditions Outside the Wall of the Tube. — Pelvic tumors, especially 
 fibromyomata of the uterus may so compress the tube as to narrow the 
 lumen and arrest the ovum. Adhesions between the tube and adjacent 
 structures may by their traction cause angulation of the tube and thus 
 bring about an obstruction to the passage of the ovum to the uterus. 
 
 Condition of the Ovum Itself. — The passage of the ovum toward the 
 uterus may be so slow or over so circuitous a route that its development 
 reaches a size which is too large to pass through the lumen of the tube. 
 This is seen especially in twin ectopic gestation and in external migration 
 of the ovum. 
 
 External migration of the ovum is quite common in ectopic gestation. 
 J. W. ^Yilliams being able to demonstrate it in 5 out of 30 cases. 
 
 In the case of H. C. Coe, already referred to, the proximal portion of 
 the right tube was entirely blocked by a lithopedion, while external to 
 this was a ruptured gestation sac, the ovum having come from the left 
 ovary and been impregnated by spermatozoa passing through the left 
 tube, as the right ovary was small, atrophic and surrounded by adhesions, 
 while the left ovary contained a recent corpus luteum. 
 
 In a case of the author's, on operation a ruptured ectopic gestation 
 was found in the left tube, although eleven years before he had removed 
 the left ovary for a dermoid cyst. This must have been a case of external 
 migration of the ovum, which had come from the right ovary, passecf 
 around the uterus and entered the distal end of the left tube. 
 
 Kelly reports an interesting case from which he had removed a diseased 
 left ovary and right tube, leaving a normal right ovary and left tube, and 
 who fifteen months later gave birth to a child at term and who seventeen 
 months after delivery was obliged to have the left tube removed for 
 ruptured ectopic gestation. 
 
 One of the most recent theories of the etiology of ectopic gestation, 
 and one which furnishes a most plausible explanation, in some cases at 
 
 1 New York Medical Record, May 27, 1S93. 
 
528 ECTOPIC GE ST A'T I ON— PREGNANCY IN MALFORMED UTERI 
 
 least, is that of Otto V. Hiiffman,i of the Long Island College. It is what 
 he calls the anomalous-embedding-area theory. While searching for 
 some confirmation of the inflammation or ol3striiction theories in a 
 very remarkable specimen of tnbular pregnancy removed at necropsy, 
 he found two supernumerary, but rudimentary. Fallopian tubes, one 
 attached to each of the fully developed tubes. Inasmuch as there was 
 no evidence of obstruction or inflammation having caused the tubular 
 pregnancy, he inferred that, early in the embryological development of 
 this individual there was a duplication of the Miillerian ducts and that, 
 with the subsidence in the growth of one pair, those portions which should 
 
 Fig. 332. — Dr. Childs's case of twin ectopic gestation. (Jour. Am. Med. Assoc, Ucccnibor 
 28, 1907.) A, amniotic sac; C, ruptured segment lying free from the remainder of the tube 
 except for a slight peritoneal attachment. 
 
 have formed a second uterus, with all the factors that determine an 
 implantation area, became lodged as "rests" in the walls of the fully 
 developed tubes, and that one of these "rests" of embedding tissue 
 permitted the ovum to embed at the abnormal site. With this as his 
 working hypothesis, he carefully examined 68 specimens of ectopic preg- 
 nancy and found malformations of the tube or ovary in 54 per cent, 
 of them. This result, in face of the difficulty of examining torn and 
 very often incomplete material, along with the fact that the lower 
 
 1 Ectopic Pregnancy Associated with Anomalous Fallopian Tubes, Surg., Gynec. and 
 Obst., May, 1913; A Theory of the Cause of Ectopic Pregnancy, Jour. Amer. Med. Assoc, 
 December, 1913, p. 2130. 
 
ECTOPIC GESTATION 
 
 529 
 
 mammals are known to have definite embedding or placentation areas 
 scattered throughout their uteri, seemed to him to justify th£ theory of 
 anomalous embedding areas being the cause of ectopic pregnancy, and 
 he pointed out that all other theories had lost sight of the essential mutual 
 
 Fig. 333 
 
 1 — 
 
 Fig. 334 
 
 Figs. 333 and 334. — Combined ectopic and intra-uterine gestation; operation five months 
 after miscarriage. Fig. 333, tube and ovarj' removed at operation; 1, gestation sac containing 
 amnion and gi\dng chorionic villi under the microscope; 2, fimbriated extremity; 3, ovary. 
 Fig. 334, fetus contained -within its membranes, passed from the uterus on the day following 
 the operation. (American Text-book of Gynecology.) 
 
 relation of the ovum and the embedding site which obtains in the normal 
 physiology of embedding. While as yet embedding tissue cannot be 
 identified morphologically, such specialized tissue is known to exist in 
 scattered areas in the long double uteri of the lower mammals — scattered 
 presumably to prevent all the ova from embedding at the upper ends of 
 34 
 
530 ECTOPIC GESTATION— PREGNANCY IN MALFORMED UTERI 
 
 the uteri and to get a proper distribution of the Htter; this makes Huff- 
 man's theory quite plausible. 
 
 Multiple and Repeated Ectopic Gestation. — Ectopic gestation like intra- 
 gestation may be single or multiple. There may be found two embryos 
 in the same tube, usually called twin tubal pregnancy, as illustrated by 
 the case of Dr. Charles G. Child, Jr., of New York, of which Fig. 332 is 
 a photograph. On the other hand, there may be one embryo in each tube, 
 called bilateral tubal pregnancy. 
 
 Dr. L. P. McCalla,^ of Boise, Idaho, has collected from the literature 
 25 cases of the former (twin-tubal pregnancy) and together with one 
 of his own 37 cases of the latter (bilateral tubal pregnancy). 
 
 Ectopic gestation may occur simultaneously with intra-uterine gesta- 
 tion, as is illustrated by the case of the author's (see Figs. 333 and 334), 
 in which he operated for the ruptured ectopic gestation one evening 
 and the patient passed the intra-uterine embryo enveloped in its mem- 
 branes on the following day. 
 
 Ectopic gestation may be repeated in the same tube, as illustrated in 
 the case of Dr. H. C. Coe, already referred to, in which the lithopedion 
 resulting from the former ectopic gestation obstructed the passage along 
 the tube of the ovum of the second. 
 
 Ectopic gestation may occur in one tube at one time and in the opposite 
 tube subsequently, as is illustrated by the author's case upon whom he 
 operated February 25, 1905, for ectopic gestation with ruptured right 
 tube and who subsequently (September 6, 1906) required operation for 
 an ectopic gestation in the left tube. Before each operation the patient 
 passed from the uterus a complete decidual sac; Fig. 335 being a photo- 
 graph of the one passed just prior to the operation in 1905. 
 
 In the author's service at the Sloane Hospital during the last three 
 and a half years, 35 cases of ectopic gestation have been operated upon, 
 among which there were 6 cases which had previously been operated 
 upon for ectopic gestation. In 5 of these cases the second ectopic gesta- 
 tion sac was on the opposite side from the first, while in 1 case it 
 occurred for the second time on the same side, the tube not having been 
 removed at the first operation. 
 
 For a long time it was thought that a previous history of sterility, 
 showing difficulty in impregnation, was an important feature of ectopic 
 gestation. 
 
 In a recent analysis, however, by Frank^ of 80 cases occurring at Mount 
 Sinai Hospital, New York, only 12 of the entire series had never been 
 previously pregnant, and 6 of these acquired their ectopic gestation dur- 
 ing the first six months. It will thus be seen that sterility plays a very 
 imimportant part in the condition. 
 
 The occurrence of ectopic gestation in the first pregnancy in 12 out of 
 SO cases reported as above by Frank, and in 3 out of 43 cases reported 
 by Doderlein, shows the relative infrequency of ectopic gestation in the 
 first pregnancy. 
 
 ' Surgery, Gynecology and Obstetrics, March, 1909, p. 248. 
 -' Amer. Jour. Obst., 1909, vol. lix, No. 2. 
 
ECTOPIC GESTATION 
 
 531 
 
 Pathology. — Changes in the Uterus. — The uterus enlarges both its walls 
 and cavity along w'ith the development of the ectopic gestation but to 
 a lesser degree than at a corresponding period of intra-uterine pregnancy. 
 The degree of uterine enlargement, moreover, varies directly with the 
 proximity of the gestation sac to the uterine wall. As, for instance, it is 
 much greater in an interstitial pregnancy than in a tuboovarian gesta- 
 tion. The softened feel of the uterus so characteristic of normal intra- 
 uterine pregnancy is present in ectopic gestation, but to a very limited 
 extent. Within the cavity of the uterus in a case of ectopic gestation 
 there is formed a decidua corresponding to the decidua parietalis of a 
 normal intra-uterine pregnancy, but as there is no ovum lodged upon it, 
 
 y 
 
 I 
 
 r.\ 
 
 
 .y-fe?vf 
 
 Fig. .335. — Decidual cast; ectopic gestation. 
 
 there is no decidua capsularis (reflex), and no decidua basalis. It is 
 rough and shaggy on its outer surface where it adheres to the uterine 
 wall, relatively smooth but wrinkled on its inner surface (see Fig. 336). 
 This decidua is seen in sitii in Fig. 337, which is a photograph of a speci- 
 men removed by the author on account of fibromyomata at the time of 
 operation for the ruptured gestation sac. 
 
 This decidua is usually cast off in small fragments between the eighth 
 and twelfth week, often near the time of tubal rupture or abortion, but 
 occasionally it is cast off en masse, as seen in Fig. 335, already referred to. 
 The microscopic appearance of this decidua is shown in Fig. 338. 
 
 This discharge of the decidua is accompanied by more or less bleeding. 
 
532 ECTOPIC GESTATIOX—PREGXANCl^ IX MALFORMED UTERI 
 
 Changes in the Fallopian Tube. — Occasionally when the pregnancy is 
 normal and intra-nterine, decidual cells are found in the Fallopian tubes 
 
 Fig. 336. — Decidua expelled from the uterus in a case of ectopic gestation: A, rotated 
 so as to show the shaggy uterine side; B, shows the free surface. Author's specimen. 
 (American Text-book of Gj-necolog}\) 
 
 Fig. 337. — Decidua iti situ; fibroid uterus removed at time of operation for ruptured ectopic 
 gestation. (American Text-book of Gynecology.) 
 
 (Lange, Mandel). In ectopic gestation this is ahvays the case and there 
 is formed a more or less incomplete decidual membrane which as the 
 ovum lodges and develops becomes differentiated into a pseudodecidua 
 
ECTOPIC GESTATION 
 
 533 
 
 capsularis and decidiia basalis corresponding to what normally develops 
 in the uterus after the lodgement of the ovum. As might be expected, 
 however, neither of these decidual coverings are as complete in the tube 
 as in the uterine cavity and when it is considered that the decidual lining 
 serves practically as a protection to the maternal tissue against the in- 
 roads of the chorionic villi, with their trophoblastic covering, it is readily 
 understood that in the tube with an imperfect and scanty decidual mem- 
 brane the fetal ^'illi easily erode and invade the tubal wall, opening 
 maternal vessels and weakening the tubal wall which when compared 
 with the uterine wall is little suited to accommodate a growing embryo. 
 In a normal intra-uterine pregnancy, along with the growth of the 
 
 Fig. 338. — Photomicrograph of a section of decidua in a case of ectopic gestation, showing 
 the large decidual cells. (American Text-book of Gynecology.) 
 
 embryo and fetus there occurs a progressive h\'pertrophy and hyperplasia 
 of the muscular structure of the uterine wall. 
 
 In a tubal pregnancy during the early weeks of gestation a similar 
 change occurs in the muscular structure of the tubal wall, but this hyper- 
 trophy and hyperplasia soon cease and after the first few weeks the 
 muscle fibers are found separated and the gestation sac composed largely 
 of connective tissue. The thickness of the gestation sac varies in different 
 portions. In some places it is thickened by hemorrhages into the sub- 
 stance of the wall, and by inflammatory deposit upon the exterior. In 
 other places it is thinned by stretching of the tubal wall coincident with 
 the growth of the ovum or by the occurrence of an intratubal hemorrhage. 
 
534 ECTOPIC GESTATION— PREGNANCY IN MALFORMED UTERI 
 
 The fetal troi^hoblast in its eroding action may open np the decidua 
 capsnhiris and set free the ovnni into the hnnen of the tube and force 
 it along this canal and out of the fimbriated extremity by the pressure 
 of the hemorrhage coming from the eroded maternal vessels. 
 
 On the other hand the fetal villi may penetrate and even perforate 
 the muscle wall and peritoneal covering of the tube, thus making an 
 avenue of escape. The most usual process of tubal rupture is the yielding 
 of the tubal wall under the increased tension of a sudden hemorrhage 
 within it, due to the opening of a large maternal vessel. 
 
 Directions of Escaye from the l\ihe.- — The ovum in tubal gestation 
 may excape from the tube in four different directions in the following 
 order of frequency: 
 
 Outward, by tubal abortion through fimbriated extremity (see Fig. 339). 
 
 Uyimrd, hy rupture into the peritoneal cavity (see Fig. 340). 
 
 r' t' 
 
 o vap-"^ 
 
 Fig. 339. — Tubal abortion. 
 
 Downward, by rupture between the folds of the broad ligament (see 
 Fig. 341). 
 
 Inward, by extension of an interstitial pregnancy into the cavity of 
 the uterus — rare. 
 
 Tvhal Abortion. — The escape of the impregnated ovum through the 
 fimbriated extremity of the tube into the peritoneal cavity is regarded 
 by practically all observers today as much the most frequent termination 
 of tubal gestation: The percentage generally accepted is about 75 per 
 cent, tubal abortions to 25 per cent, tubal ruptures. These percentages 
 vary greatly in the records of different hospitals. Thus in a series of 60 
 cases of tubal pregnancy reported by Newell/ of Boston, there were 22 
 tubal abortions and 22 tubal ruptures, but in 14 cases the pregnant tube 
 was removed before rupture or abortion had occurred. In a series of 80 
 consecutive cases of ectopic gestation occurring at the Mount Sinai 
 
 1 International Clinics, vol. iv, 15th series. 
 
ECTOPIC GESTATION 
 
 535 
 
 Hospital, New York, and reported by Frank,^ there were 42 tubal rup- 
 tures and only 20 tubal abortions; but there were 11 hematoceles and 4 
 pregnant tubes removed before rupture or abortion. In a series of 289 
 cases collected from literature by J. W. Williams there were 22 per cent, 
 tubal ruptures. 
 
 In forming an estimate of the frequency of tubal abortion it must be 
 remembered that in many cases of this condition the ovum has undoubt- 
 edly been entirely expelled from the tube, the hemorrhage has ceased 
 and the patient has recovered without operation, or an hematocele has 
 formed which has been drained through the vagina without opportunity 
 to examine the tube and determine whether it was a rupture or abortion. 
 
 Fig. 340 
 
 Fig. 341 
 
 A tubal abortion usually occurs before the fimbriatedjextr^ity is 
 closed, {. e., during the first twojaootJba^jaLthe^geslHionr^t may, how- 
 ever, occur later if the fimbriated extremity is not firmly closed. 
 
 It is easily seen that the probability of a tubal abortion is greatest 
 when the ovum is implanted near the fimbriated extremity and this 
 probability decreases as the site of implantation approaches the cornu 
 of the uterus. If lodged in the isthmus of the tube — that straight, nar- 
 row portion just outside the cornu of the uterus — as the lumen is small 
 and does not easily distend, the ovum makes room for itself by erosion 
 of the tubal wall which easily leads to rupture, rather than tubal 
 abortion. 
 
 In the ordinary conditions of tubal abortion with the ovum lodged 
 either in the ampulla or in the fimbriated extremity, the inroads of the 
 trophoblast cause a hemorrhage which ruptures the decidua capsularis, 
 
 1 Amer. Jour. Obst., 1909, vol. lix, No. 2. 
 
53(3 ECTOPIC GESTATION— PREGNANCY IN MALFORMED UTERI 
 
 usually destroys the life of the ovum, and usually, but not always expels 
 it more or less t'()m])l('tely from the tube. Three outcomes are therefore 
 possible. 
 
 1. The ovum may remain for a longer or shorter period in the tube as 
 a tubal mole. 
 
 2. It may be completely expelled from the tube, giving a complete 
 tubal abortion. 
 
 3. It may be only partially expelled from the tube, giving an incom- 
 plete tubal a})ortion. 
 
 If the tubal abortion is complete and the tube left empty, the hemor- 
 rhage from the tube into the peritoneal cavity, although it may be 
 profuse at the time, soon ceases. This is analogous with the outcome 
 of a complete uterine abortion. It should be remembered, however, 
 that in the process of expelling the ovum, before the abortion becomes 
 complete the hemorrhage may be so profuse as nearly to exsanguinate 
 the patient, as has occurred in the author's experience. 
 
 On the other hand, as in an incomplete uterine abortion, so long as 
 the tubal abortion is incomplete subsequent hemorrhages are to be 
 expected. According to Wormser, the incomplete tubal abortions are 
 ten times as frequent as the complete. In a few cases, with the fimbriated 
 extremity closed, the hemorrhage setting free the ovum within the tube 
 may so disorganize and destroy it that only an hematosalpinx results 
 which is gradually absorbed, as is sometimes the case with a pelvic 
 hematocele resulting from a complete tubal abortion. 
 
 Tjihal Rupture. — As a result of the inroads of the chorionic villi with 
 their trophoblastic covering, the vessels of the tubal wall which have 
 become enlarged during the pregnancy are opened, and the weakened 
 tubal wall, unable to withstand the tension caused by the hemorrhage 
 gives way, allowing more or less of the ovum to escape either upward into 
 the peritoneal cavity (see Fig. 342) or downward between the folds of 
 the broad ligament. 
 
 The former, intraperitoneal rupture is much more common and more 
 serious than the latter, as in the former the open vessels may continue 
 to pour forth blood into the peritoneal cavity, while in the latter the 
 hemorrhage takes place into a confined space which is extraperitoneal. 
 
 The escape of the ovum from the tube by tubal rupture occurs in about 
 25 per cent, of cases. The site of this rupture is usually in that portion 
 of the tube corresponding to the decidua basalis where the invasion of 
 the trophoblast has been the deepest. As in a tubal abortion the escape 
 from the tube at the time of the hemorrhage may be either complete or 
 incomplete. In the incomplete escape the ovum may plug the opening 
 for a time until subsequent hemorrhage resulting from further inroads 
 of the chorion villi forces it out of the tube. 
 
 Escape of the ovum into the cavity of the uterus occurs only in that 
 form of ectopic gestation called interstitial or tvho-uterine pregnancy, 
 where the ovum has lodged or partly developed in the interstitial portion 
 of the tube. This variety of ectopic gestation is one of the rarest and 
 in its termination may present either the most favorable or the gravest 
 
ECTOPIC GESTATION 537 
 
 outcome of all. In its most favorable termination it is simply forced 
 gradually from the interstitial (intramural) portion of the tube into the 
 uterine cavity and continues its development as a normal intra-uterine 
 pregnancy. The diagnosis of this condition and outcome is almost 
 impossible to accurately determine, as it is extremely difficult to differ- 
 entiate it from a pregnancy in which the impregnated ovum has lodged 
 and developed in the horn of the uterine cavity and which gives in the 
 early months a very asymmetrical uterus, but which later presents a 
 uterus of normal shape. Instead of this favorable termination of an 
 interstitial pregnancy the opposite is the more common. Surrounded 
 as it is by the muscular structure of the uterine wall it is easy to under- 
 
 FiG. 342. — Tubal rupture: A, ruptured tube; B, uterine end of tube; C, fimbriated extremity. 
 
 stand that here a growing embryo can be much more easily accommo- 
 dated and for a much longer time than in any other portion of the tube, 
 and instead of a rupture of the sac occurring before the twelfth week, as 
 most often occurs in every other variety of tubal pregnancy, here rupture 
 does not usually take place until four to six months, but when the rup- 
 ture does occur the event is apt to be much more rapidly fatal on account 
 of the larger sinuses which have developed in the decidua basalis and the 
 surrounding uterine tissue. 
 
 Exciting Causes of Tubal Rupture or Abortion. — In our study of the 
 pathology of ectopic gestation we have learned that the real causes of 
 escape of the ovum from the tube are (1) the erosion of the tubal ivall by 
 
538 ECTOPIC GESTATION— PREGNANCY IN MALFORMED UTERI 
 
 the chorionic villi with their trophoblastic covering, (2) tJie hemorrhage 
 from the nioternal vessels opened by this trophoblastic erosion. 
 
 On the one hand we have a weakening of the capsule surronnding the 
 ovum, and on the other an increase in the tension within it. A yielding 
 is the natural result. This result may occur without the intervention of 
 any outside exciting causes, as is illustrated by the fact that occasionally 
 in ectopic gestation a tubal rupture or abortion A^ill occur when the 
 patient is lying quietly asleep in bed. On the other hand it is easily under- 
 stood that when the predisposing causes are present in the tube, any 
 exciting cause increasing intra-abdominal pressure may determine the 
 event. In several of the author's cases the history was obtained that 
 the rupture or abortion followed speedily upon sexual intercourse. In 
 other cases a gynecological examination; straining at stool; lifting a 
 weight; some traumatism; or the arrival of the period of menstrual 
 congestion has seemed to be the exciting cause which determined the 
 rupture or abortion. 
 
 In studying the different varieties of tubal pregnancy we have learned 
 that the escape of the ovum from the tube by abortion or rupture takes 
 place at different times according to the site of lodgement in the tube. 
 
 Tubal abortion usually occurs before the closure of the fimbriated 
 extremity, which ordinarily takes place at about eight weeks of tubal 
 gestation. It must be remembered, however, that if the ovum lodges 
 and develops in the tube near the fimbriated extremity it may keep this 
 extremity open for a longer period. Tubal rupture occurs latest (four 
 to six months) in the interstitial variety of ectopic gestation because the 
 surrounding muscular wall is thicker and more easily adapted to the 
 growing embryo. 
 
 On the other hand tubal rupture occurs earliest (4 to 6 weeks) in 
 the isthmial variety of ectopic gestation where the ovum lodges in the 
 straight narrow portion of the tube just beyond the interstitial portion. 
 
 The lumen is small, not easily distensible, and the trophoblast soon 
 erodes the wall to form a bed for the oAum and this erosion soon leads to 
 rupture. 
 
 When the ovum is lodged in the ampulla of the tube it finds a larger 
 lumen and a more distensible wall and rupture does not usually occur 
 until the gestation has advanced to from eight to twelve weeks. Before 
 leaving the discussion of the period of tubal rupture or abortion atten- 
 tion should be called to the fact that in rare instances the life of the 
 embryo ceases and in the condition of a mole or lithopedion it is retained 
 in the tube for months or even years without the occurrence of either 
 abortion or rupture. 
 
 Moreover, with the ovum partly within and partly without the tube, 
 fetal life in exceptional cases may continue until the completion of the 
 full period of gestation. This will be referred to later under the heading 
 of Advanced Ectopic Gestation. 
 
 Changes in the Ovum. — So long as the life of the ectopic ovum continues 
 it develops along normal lines just as though resting in its normal bed 
 in the uterine cavitv. 
 
ECTOPIC GESTATION 
 
 539 
 
 The Placenta. — In ectopic gestation the placenta differs from that in 
 normal intra-uterine pregnancy only in the imperfect formation of the 
 decidua. The amnion and chorion which constitute the fetal portion are 
 well developed, but with the scanty and imperfect decidual formation 
 it is easy to understand the incompleteness of the maternal portion. 
 
 The escape of the ovum from the tube either by abortion or rupture 
 usually terminates the life of the embryo. In fact it may be said that 
 the rupture of the pseudodecidua capsularis, setting the ovum free in the 
 lumen of the tube, also accomplishes, as a rule, the same result. 
 
 In either case, whether retained in the tube or expelled from it by 
 abortion or rupture, a hemorrhage usually "accompanies the change of 
 
 ■^^•^^^^«m 
 
 Fig. 343. — Ectopic gestation, showing blood-clot and chorionic villi in the tube. 
 
 lodgement and if the ovum is small it will be found surrounded with a 
 blood-clot producing a tubal mole (see Fig. 343), or a blighted ovum 
 (see Fig. 344) in the interior of which are found chorionic villi and 
 usually a small amniotic cavity. 
 
 x\s stated above, the escape of the ovum from the tube by either abor- 
 tion or rupture usually marks the death of the ovum, and this applies 
 whether the escape is into the peritoneal cavity or between the folds of 
 the broad ligament. Exceptions to this rule will be mentioned later. If 
 discharged into the peritoneal cavity, the ovum with its accompanying 
 hemorrhage gravitates to the pouch of Douglas, and if the women sur- 
 vive the hemorrhage and shock the blood forms a pelvic hematocele, 
 
540 ECTOPIC GESTATION— PREGNANCY IN MALFORMED UTERI 
 
 becoming roofed in by the coils of intestine which float above it and 
 become adherent to each otlier. If tlie ovum is not further advanced 
 than two months of gestation and the hemorrhage not too great in amount 
 both ovum and effused blood may be entirely absorbed. The absorptive 
 power of the peritoneum is so great that in some cases much older ova 
 than two months and enormous hematoceles are absorbed. The prox- 
 imity of the rectum, however, and the ready soil of the blood-clot makes 
 infection of the hematocele and blighted ovum easy, hence a suppurating 
 hematocele is not an vmcommon result of an ectopic gestation which has 
 not been operated u]ion and while a fetus which has advanced lieyond 
 
 Fig. 344. — Blighted ovum discharged by rupture of tube. 
 
 the fourth month may remain quiescent in the abdomen for months or 
 years, being changed to a lithopedion or undergoing a mummification, 
 still suppuration of the sac and soft parts of the fetus may be expected 
 at any time with the accompanying effort on the part of nature to expel 
 the fetal skeleton through the rectum, the bladder, or even through the 
 abdominal wall, as w'as described by Albucasis in the eleventh century. 
 In some cases of advanced ectopic gestation the fetus has been found 
 alive in the peritoneal cavity surrounded only by the fetal envelopes, 
 and attempts have been made to explain its location by the theory that 
 after the discharge of the ovum from the tube into the peritoneal cavity 
 
ECTOPIC GESTATION 541 
 
 it engrafted itself afresh upon the peritoneum and there developed. 
 This theory the author has never been able to accept as either rational 
 or borne out by the findings in cases of advanced ectopic gestation oper- 
 ated on by him. AYhen it is considered how uniformly fetal death fol- 
 lows complete separation of the chorion from its attachment in a uterine 
 pregnancy, it is impossible to believe that any other result would follow 
 this separation in a tubal pregnancy. This will be referred to again 
 when discussing advanced ectopic gestation, but for the present it is 
 sufficient to state that when an o^iim is completely discharged from a 
 tube into the cavity, either by abortion or rupture, three outcomes are 
 possible if the patient survives the hemorrhage and shock: 
 
 1. If small it may be completely absorbed. 
 
 2. It may suppurate. 
 
 3. It ma.y mummify or be changed to a lithopedion. 
 Intraligamentous Rupture. — ^^Vhen the rupture occurs in the floor of 
 
 the tube and the ovum is discharged with hemorrhage down between 
 the folds of the broad ligament a dift'erent condition prevails. The blood 
 is effused into a confined space and the hemorrhage is usually checked 
 by the pressure produced by the tension of the distended ligament. Thus 
 producing a broad ligament hematoma. Rarely the folds of the broad 
 ligament yield under the excessive tension and a secondary rupture 
 occurs from the broad ligament into the peritoneal cavity and we then 
 have conditions resembling those found in the intraperitoneal abortion 
 or rupture. 
 
 When the ovum is discharged between the folds of the broad ligament 
 the rule is, as in the intraperitoneal rupture, that fetal life ceases; if small 
 the o\Tim may be absorbed, although the absorptive power of connective 
 tissue is less than that of the peritoneal cavity and suppuration of the 
 pelvic hematoma resulting from an intraligamentous rupture is not un- 
 common. The continuation of fetal life in an intraligamentous rupture 
 will be studied later. 
 
 Symptoms. — The SATnptoms of ectopic gestation may well be studied 
 under two groups: 
 
 1. Those occurring before tubal rupture or abortion. 
 
 2. Those occurring at the time of tubal rupture or abortion. 
 Before Tubal Rupture or Abortion. — Prior to the occurrence of the 
 
 hemorrhage which determines the escape of the 0M.mi from the tube 
 the symptoms may either be absent altogether or extremely few. The 
 patient may feel absolutely well and have no idea that she is pregnant, 
 or she may have the usual symptoms of early pregnancy but be entirely 
 ignorant that anything is abnormal, least of all that she is carrying 
 within her abdomen the possibility of one of the most serious experiences 
 to which woman is liable. 
 
 Occasionally, however, a woman will suffer with a vague feeling of 
 discomfort, or an indefinite pain on one side of the pelvis and will seek 
 her physician to ascertain its cause. Often under these circumstances 
 and occasionally in the early routine examination of a patient supposedly 
 pregnant it is possible to diagnose the presence of ectopic gestation 
 
542 ECTOPIC GESTATIOX—PREGXAXCY IX MALFORMED UTERI 
 
 prior to the period of tubal rupture or abortion. In all probability the 
 presence of vague pains in the region of the gestation sac often means 
 the occurrence of small hemorrhages insufficient in amount to cause 
 rupture of the sac. 
 
 Before tubal rupture or abortion, a rule which the author has found 
 of great j)ractical value in diagnosing ectopic gestation is as follows: 
 // a pregnant patient ha^ a mass at the side of the litems, ahcays think of 
 the possibility of ectopic gestation. Having obtained a history of possible 
 pregnancy, with a uterus somewhat softened and congested and an 
 elongated mass at the side of the uterus with vessels about it pulsating 
 distinctly, the diagnosis of an unruptured ectopic gestation can often 
 be made correctly in spite of the fact that a tube or ovary, the seat of 
 chronic inflammation, may lead to many errors. 
 
 .1^ the Time of Tubal Rupture or Abortion. — The clinical picture of a 
 patient at the time of tubal rupture or abortion is a typical one and 
 should be impressed upon the mind of e\ery practising physician and 
 surgeon. 
 
 The sudden sharp abdominal pain causing the patient to "double up," 
 as the expression is; the feeling of faintness; the pallor; the rapid and 
 feeble pulse; the rapid respiration; the air hunger; the cold perspira- 
 tion; the nausea and the subnormal temperature — these all point to 
 the true condition present, viz., shock and internal hemorrhage. 
 
 A rule which the author has found of great practical value is as follows: 
 7/ a married woman, living with her hvsband, has a sudden sharp abdom- 
 inal pain with symptoms of collapse, always think of ectopic gestation. 
 
 Diagnosis. — To establish a diagnosis of ectopic gestation there must 
 be added to this clinical picture the patient's history and the physical signs. 
 
 Patient's History. — The most important feature in this history is the 
 question of possible pregnancy, and for this the obstetrician naturally 
 looks to the irregularity of her menstruation. While many instances 
 have occurred in which a patient has suffered from a tubal rupture or 
 abortion, although her last menstruation was normal in time of occurrence, 
 amount and duration, this is exceptional and the rule is that at the last 
 menstrual period either the menstruation was skipped or it was abnormal 
 either in time of occurrence, amount or duration. Often instead of the 
 normal free flow at the regular time there is only a spotting of the 
 napkins followed later by a more or less irregular brownish discharge 
 containing shreds. 
 
 Nausea, vomiting, a feeling of fulness in the breasts and the usual 
 subjective symptoms of pregnancy may be present and the patient thinks 
 she is progressing favorabh- in a normal pregnancy when, to the surprise 
 of everyone, she is suddenly seized with a severe, sharp pain on one side 
 of her abdomen with the faintness, nausea, rapid pulse and respiration 
 and the other features of the clinical picture described above. 
 
 L sually about this time the menorrhagia appears and may continue 
 for several weeks, being due to the separation of the uterine decidua. 
 
 As shreds are usually passed with the discharge the patient often 
 thinks she has had a miscarriage and that her troubles will soon be over. 
 
ECTOPIC GESTATION 543 
 
 Following this attack of pain, symptoms of pelvic peritonitis often 
 present themselves. These may subside and the patient be around as 
 usual when she is suddenly seized with another attack of sharp pain, 
 syncope, etc., perhaps even worse than before. The decidual membrane 
 (see Fig. 335), while usually passed in fragments, is sometimes discharged 
 en masse, as in the author's case here illustrated, and when found is of 
 great aid in diagnosis. 
 
 The history of a period of previous sterility was formerly considered 
 of marked value in diagnosis, but as already stated, this is now looked 
 upon as of little importance. 
 
 The following features in the history may be considered most worthy 
 of note : 
 
 1. Amenorrhea, or some departure from the normal menstruation. 
 
 2. Symptoms of pregnancy. 
 
 3. The occurrence of sudden, sharp pain with syncope. 
 
 4. An irregular metrorrhagia. 
 
 Physical Signs. — Before the occurrence of tubal rupture or abortion the 
 physical signs, as already indicated, are those of an enlarged tube with 
 perhaps the additional signs of increased vascularity and congestion due 
 to pregnancy. The uterus may feel a little larger and softer than normal 
 with cervix a little patulous, and sometimes the arterial pulsation on the 
 side of the pelvis corresponding to the site of the gestation sac is rather 
 abnormally distinct. The breasts in a primigravida may show sufficient 
 engorgement and stimulation to be of value in diagnosis, although in a 
 multigravida the breast changes are seldom of much importance. 
 
 At the time of tubal rupture or abortion the physical signs will depend 
 very largely upon whether the ovum has escaped into the peritoneal 
 cavity or down between the folds of the broad ligament, i. e., whether the 
 escape is intraperitoneal or extraperitoneal. If intraperitoneal, there 
 may be scarcely any physical signs to be detected. If the tube has emptied 
 itself either by rupture or abortion, as may happen if the event occurs 
 early in the gestation, the condition is that of a movable uterus, a col- 
 lapsed tube and a larger or smaller amount of free blood in the pelvis. 
 Somewhere in this free blood and usually in the pouch of Douglas is the 
 early ovum, as indicated in Fig. 345. 
 
 On considering the conditions it is easy to understand how few physical 
 signs may be present. The increase in size of the uterus may be so slight ■ 
 as not to be palpable, especially if the amount of free blood in the abdom- 
 inal cavity is large. The question then resolves itself into the physical 
 signs of free blood in the pelvis. The skilled fingers will sometimes diag- 
 nose the condition of the vague feeling of fulness in the vaginal fornices 
 and the lessened distinctness with which the pelvic organs are palpated. 
 Moreover, with the effusion of blood in the pelvis there occurs a floating 
 upward of the intestines which causes more or less distention of the 
 abdomen. 
 
 Sufficient has now been said to show that the physical signs present 
 at the time of tubal abortion or intraperitoneal rupture may be very 
 meagre and the diagnosis must be made largely from the history of the 
 
544 ECTOPIC GEST AT lOX— PREGNANCY IX MALFORMED UTERI 
 
 case and the general condition of anemia and shock in wliich the patient 
 is found. 
 
 If tlie ovum has escaped with hemorrhage (h)wn hetween the folds of 
 the broad ligament, the conditions are difi'erent and distinct physical 
 signs are present. We have now an encapsulated hemorrhage giving 
 a distinct mass at the side of the uterus, bulging down on one side, and 
 lichind the cervix, pushing the uterus upward, forward and toward the 
 opposite side and opening up the folds of peritoneum which forms the 
 broad ligament so that the mass may be felt above Poupart's ligament. 
 If the gestation sac occurred on the left side of the pelvis the peritoneum 
 
 Ruptured 
 tube 
 
 Ovum 
 
 Fig. .345. — Ovum surrounded by blood-clot, discharged by rupture of the tube. 
 
 is lifted from the rectum v.hich is more or less surrounded by the hemor- 
 rhage, so that a finger introduced into the canal detects the stricture-like 
 feel caused by the attachment of the tense peritoneum to its second 
 portion. 
 
 Subsequent to Tubal Rupture or Abortion. — If the patient is examined 
 several days after intraperitoneal rupture or abortion the conditions 
 have changed; the blood has clotted and has become encapsulated by 
 the adhesion of the coils of intestine which floated above it and we now 
 have a i)elvic hematocele with distinct physical signs. The bimanual 
 examination detects a boggy mass behind and to one side of the uterus 
 and this boggy mass taken in connection with the history of some of the 
 
ECTOPIC GESTATION 545 
 
 symptoms of pregnancy; an irregular metrorrhagia; the occurrence of 
 an attack of sudden, sharp pain and evidences of shock and internal 
 hemorrhage will usually enable every careful observer to make the cor- 
 rect diagnosis. 
 
 The blood examination showing a diminution of hemoglobin and the 
 number of red cells and a slight leukocytosis has often proved of value. 
 
 Differential Diagnosis. — The condition for which ectopic gestation is 
 most often mistaken, alike by the patient and her medical attendant, is 
 an early miscarriage. In each there are symptoms of pregnancy, hemor- 
 rhage, pain and the passing of something from the uterus. It is not 
 strange that the two conditions are confused, and it is here that the rule 
 already given, if a pregnant patient has a mass at the side of the uterus, 
 always think of the possibility of ectopic gestation, so often proves of 
 value. 
 
 As an illustration of the frequency of this error it may be stated that 
 many a patient has been curetted for the supposed retained secundines 
 of a miscarriage and only portions of decidua obtained which showed 
 under the microscope no chorionic villi. In endeavoring to differentiate 
 between a miscarriage and ectopic gestation the following differential 
 features may be of value: 
 
 Miscarriage vs. — Ectopic Gestation. 
 
 Uterus larger, cervix more patulous. Uterus smaller, cervix less patulous. 
 
 No mass felt at side of, or behind, the uterus. Perhaps mass felt at the side of, or behind, 
 
 the uterus. 
 
 No tenderness or distention of the abdomen. Both may be present. 
 
 No evidences of shock and internal hemor- Both present if tubal rupture or abortion 
 
 rhage. has occurred. 
 
 Mass discharged from the uterus shows Mass shows only decidual cells, no chorionic 
 
 chorionic villi. villi. 
 
 Another condition sometimes confused with ectopic gestation is a tube 
 distended with either serum or pus, especially the latter. The physical 
 signs of the two conditions prior to rupture often closely resemble one 
 another and just as the rupture of an ectopic gestation sac is followed 
 by symptoms of shock and then peritonitis, so may the rupture or leakage 
 of a pus tube be followed by similar symptoms. The chief feature in 
 their differentiation rests in the differences in their clinical history. 
 
 In the case of ectopic gestation there is perhaps obtainable the symp- 
 toms of pregnancy, while in the other there is the history of previous 
 pelvic inflammation. 
 
 Subsequent to the rupture the following differences can usually be 
 noted : 
 
 Ruptured Ectopic Gestation vs. Ruptured Pyosalpinx. 
 
 Frequency of pulse greater. Temperature Frequency of pulse less. Temperature 
 
 at first subnormal; later rises slightly. rises steadily and markedly. 
 
 Patient shows loss of blood. Patient does not show blood loss. 
 
 Pain of shorter duration (septic symptoms Pain of longer duration. Signs of sepsis 
 
 usually not present). soon present. 
 
 Blood examination shows anemia. Blood examination does not show anemia. 
 
 Leukocytosis greater. 
 
 35 
 
546 ECTOPIC GESTATION— PREGNANCY IN MALFORMED UTERI 
 
 The condition called membranous dysmenorrhea is one which may 
 be confused with ectopic gestation when the decidua is discharged en 
 masse or in large pieces as in each case there is an absence of chorionic 
 villi, but the history of frequent recurrence of a discharge of membrane 
 at a menstrual period with the absence of any- 
 mass at the side of the uterus and the absence 
 of symptoms of pregnancy will usually enable 
 one to diagnose that variety of dysmenorrhea 
 called membranous. It is perfectly possible, 
 however, that some of the cases diagnosed as 
 membranous dysmenorrhea which occurred only 
 once were cases of tubal abortion in which the 
 decidua was expelled and the early ovum after 
 discharge into the peritoneal cavity was ab- 
 sorbed without operation and without a correct 
 diagnosis. 
 
 A menstrual cast from a case of membranous 
 
 dysmenorrhea is shown in Fig. 346, which may 
 
 be compared with that of ectopic gestation shown 
 
 in Fig. 347. 
 
 The menstrual cast is never more than 4 x 2.5 cm., while the decidual 
 
 cast of ectopic gestation may be as large as 8 x 4 cm. The menstrual 
 
 cast is thinner and more fragile than that of ectopic gestation. The 
 
 difference in appearance under the microscope is shown in Figs. 348 and 
 
 Fig. 346. — Menstrual 
 cast expelled from a case 
 of membranous dysmenor- 
 rhea in a virgin. 
 
 Fig. 347. — Decidual cast expelled from a case of ectopic pregnancy before operation. 
 It is split open to show the inner surface which is smooth; it has the grooves which are also 
 characteristic of decidua. 
 
 349 which are photomicrographs of a decidua of pregnancy and a men- 
 strual decidua. In the decidua of pregnancy the cells are larger, the 
 nuclei are well defined, dense, and homogeneous. In the menstrual 
 decidua the cells are smaller, the nuclei are less dense and are pyknotic. 
 
ECTOPIC GESTATION 
 
 547 
 
 It may seem strange, at first thought, that a fibromyoma of the uterus 
 and an ectopic gestation should ever be confused, yet this has occurred 
 in a number of instances where the patient presented the symptoms of 
 early pregnancy and examination detected a mass at the horn of the 
 uterus. If the patient has not previously been examined and the pres- 
 ence or absence of a fibroid determined, it is easy to understand why 
 several questions should arise: 
 
 Fig. 348. — Decidua compacta from a case of early (uterine) abortion. X 500. Note 
 the larger cells with dense, homogeneous, well-defined nuclei. 
 
 Is it a normal pregnancy and a fibromyoma ? Is it an ectopic gestation 
 either interstitial or isthmial? Is it an ectopic gestation of the ampullar 
 variety in which a hemorrhage has occurred into the tube and the preg- 
 nant tube and ovary have become adherent to the side of the uterus? 
 Is it a combined intra-uterine and ectopic gestation? 
 
 Many of these questions it may be impossible to answer positively 
 until the occurrence of a sudden, sharp pain with symptoms of shock and 
 internal hemorrhage mark the case as one of tubal rupture or abortion, 
 whatever else may be present. 
 
 Each case must be studied by itself, and perhaps the growth of the mass 
 
548 ECTOPIC GESTATION— PREGNANCY IN MALFORMED UTERI 
 
 watched for a time, but certain features of a fibromyoma which differ 
 from those of pregnancy must always })e borne in mind: the slow growth; 
 the firm circumscribed character; the insensitiveness; the tendency to 
 cause menorrhagia rather than amenorrhea, and finall>' the frequency 
 with which one fibromyoma is found accompanied by others in the 
 same uterus. 
 
 1 lii ^ *■ 
 
 
 
 Fig. 349. — Stroma cells of endometrium removed from a virgin the day before the men- 
 strual flow was due. X 500. Note the size of the cells in comparison with the decidual 
 cells in Fig. 348. Also compare the nuclei; here they are not so dense and are pyknotic. 
 
 Where both fibromyoma and an ectopic gestation coexist, as in the 
 author's case (see Fig. 337), the diagnosis may be exceedingly difficult 
 prior to tubal rupture or abortion. 
 
 The diagnosis of interstitial ectopic gestation prior to rupture of the 
 sac is one which should be made w^ith great care and, as a rule, only after 
 several examinations at repeated intervals, for the reason that in many 
 cases of intra-uterine pregnancy the ovum is lodged in one horn of the 
 uterine cavity and in its early development gives to the uterus an asym- 
 metrical shape which might easily be mistaken for an interstitial ectopic 
 gestation. 
 
ECTOPIC GESTATION 549 
 
 If time is allowed and the development of the ovum followed, the 
 uterus is seen to gradually assume its symmetrical shape and the preg- 
 nancy is seen to be normal and intra-uterine. An early and rash diag- 
 nosis of interstitial ectopic gestation might have led to a needless and 
 embarrassing operation. The diagnosis of combined intra-uterine and 
 ectopic gestation is seldom made until the symptoms and physical signs 
 of the other are seen to continue after the ovum has been discharged 
 either from the tube or from the uterus. In the author's case (see 
 Figs. 333 and 334) he did not suspect the presence of the intra-uterine 
 pregnancy at the time of the operation for the ruptured ectopic gestation 
 and was only made aware of its presence when the ovum was passed 
 from the uterus on the following morning. 
 
 Advanced Ectopic Gestation. — As already stated, the life of the ovum 
 usually ceases at the time of its discharge from the tube, whether its dis- 
 charge is by tubal rupture or tubal abortion and whether the discharge is 
 intraperitoneal or extraperitoneal, i. e., between the folds of the broad 
 ligament. In a few instances, however, probably for the reason that the 
 original placental attachment was but little disturbed, fetal life con- 
 tinues and may go to term or even beyond it and the child may reach 
 perfect development. On the other hand, fetal life may cease at any 
 period between the time of the primary tubal rupture or abortion and 
 term, on account of a separation of more of the placenta, perhaps by 
 secondary rupture of the sac and accompanying hemorrhage, than is 
 needed for fetal life and development. Several varieties of advanced 
 ectopic gestation may present themselves. According to. the author's 
 experience the most common variety is the intraligamentous, in which the 
 rupture of the tube has occurred in its floor where it was uncovered by 
 peritoneum. Of the 6 cases of advanced ectopic gestation operated on 
 by the author, 4 were of this variety, although this is a much greater 
 frequency than is given by most authors. 
 
 The folds of the broad ligament are opened out and lifted up; the 
 uterus is pushed upward, forward and to the opposite side and in this 
 extraperitoneal space the life of the fetus may continue to full develop- 
 ment. This life and development depends upon the non-disturbance 
 of a sufficient area of the placenta to provide for the needs of the fetus. 
 
 As the growth of the fetus continues the maternal portion of the ges- 
 tation sac formed by the folds of the broad ligament may rupture with 
 the escape of the fetus into the abdominal cavity. This event may be 
 accompanied by more or less separation of the placenta and with suffi- 
 cient hemorrhage to kill both mother and child, or the placental separation 
 and hemorrhage may be slight and fetal life may continue in the abdom- 
 inal cavity, although the placenta still remains attached in the cavity 
 formed partly by tubal wall and partly by distended broad ligament. 
 
 This forms one variety of abdominal pregnancy, being secondary to an 
 intraligamentous pregnancy. In most of these cases the fetus is still 
 surrounded by its amnion and chorion laive reinforced by adherent coils 
 of intestine. In some cases, however, it has been impossible to identify 
 these membranes, and this has given rise to the probable erroneous 
 
550 ECTOPIC GESTATION— PREGNANCY IN MALFORMED UTERI 
 
 idea of a primary abdominal pregnancy. At tlie present time most 
 authorities agree that a primary abdominal pregnancy in the sense of an 
 ovum being discliarged into the peritoneal cavity, forming an attach- 
 ment to any portion of the peritoneum and developing there, does not 
 occur. 
 
 In another variety of advanced ectopic gestation the fetal sac has 
 been gradually extended from the tube either through the fimbriated 
 extremity, as occurred in one of the autlior's cases, or through a rupture 
 through the wall of the tube which did not greatly disturb the placental 
 attachment. 
 
 As the fetus is gradually extruded from the tube into the peritoneal 
 cavity surrounded by its amnion and chorion, the fetal sac is reinforced 
 by the coils of intestine which surround it and become adherent to it, and 
 into which the chorionic villi may imbed themselves. This constitutes 
 the tnho-ahdominal variety of advanced ectopic gestation, the placenta 
 being still retained more or less within the cavity of the tube while the 
 rest of the ovum lies within the abdominal cavity. Here again a second- 
 ary rupture may extrude the fetus into the abdominal cavity. From 
 consideration of the above it will be seen that the location and attach- 
 ment of the placenta in cases of advanced ectopic gestation depend 
 largely upon the site of its attachment in the tube at the time of the 
 escape of the ovum. 
 
 In the intraligamentous pregnancy, if the placenta was attached 
 chiefly to the roof of the tube at the time of rupture, it would lie above 
 the fetus as pregnancy advanced, and being raised by the growing fetus 
 the placenta might be brought in contact with, and form adhesions to, 
 the viscera of the abdomen. If the placenta was attached to the side 
 or the floor of the tube at the time of the rupture, the villi of its per- 
 iphery might spread over the floor of the pelvis and attach themselves to 
 the large vessels found there. In the tubo-abdominal variety the ex- 
 panding periphery of the placenta may attach its villi to the intestines 
 and any viscus with which they come in contact, thus forming very inti- 
 mate adhesions and making removal by operation very difficult. At one 
 time it was thought that the placenta in certain instances at least con- 
 tinued its growth after the death of the fetus. At the present day the 
 apparent increase in the size of the placenta which occasionally occurs 
 after the death of the fetus is understood as caused by a hemorrhage 
 into its substance or between it and its site of attachment due to the 
 inroads of the trophoblastic covering of its villi. The symptoms of 
 advanced ectoyic gestation vary greatly in different cases. In some cases 
 the escape from the tube is so gradual that the woman has few symp- 
 toms at this time; thinks they are simply the discomforts to be expected 
 in pregnancy, and by the time she is seen by the obstetrician may have 
 forgotten all about them. This was the condition in one of the author's 
 cases who came to the hospital just before term expecting a normal 
 confinement. On close questioning she recalled the fact that at about 
 the third month she had an attack like "inflammation of the bowels," 
 and thought she had a miscarriage but later felt life and it had been very 
 
ECTOPIC GESTATION 551 
 
 distinct, so distinct in fact that the fetal movements had annoyed her 
 greatly. As a rule, if the woman and the fetus survive its escape from 
 the tube, the T\'oman passes through a period of pelvic inflammation 
 depending in extent upon the amount of hemorrhage accompanying the 
 tubal rupture. At about this time the decidua is discharged from the 
 uterus with more or less metrorrhagia, so that it is not unnatural that a 
 miscarriage with inflammation following should be the diagnosis of the 
 laity. 
 
 After this period of pelvic inflammation is passed the pregnancy may 
 progress normally to term or the woman may pass through another 
 stormy period, perhaps fatal to both herself and the fetus, due to a second- 
 ary rupture of the gestation sac into the peritoneal cavity. 
 
 At or near term uterine contractions, called spurious labor, occur and 
 this spurious labor is a time of great danger alike to the mother and the 
 fetus. To the mother for the reason that the uterine contractions have 
 in a number of instances caused a rupture of the gestation sac resulting 
 in maternal death. To the child because even without rupture of the 
 gestation sac the uterine contractions may so interfere with the placental 
 circulation as to kill the fetus. This occurred in one of the author's 
 cases in which, although the fetus was alive when he was sent for to 
 operate, in the twenty-four hours intervening before he could reach the 
 case the uterine contractions had so interfered with the placental circula- 
 tion as to kill the fetus. 
 
 The diagnosis of advanced ectopic gestation is one which is often over- 
 looked and in many cases is difficult. The three features which stand 
 out as guide-posts to the diagnosis are : 
 
 1. The history of an occurrence somewhat resembling a miscarriage 
 followed by pelvic inflammation in the course of what otherwise seemed a 
 normal pregnancy. 
 
 2. The physical signs of a fetus lying nearer than normal to the 
 abdominal wall, with fetal movements very distinct and easily palpable, 
 as though just beneath the skin. 
 
 3. Finding the uterus small, empty and separate from the gestation 
 sac. 
 
 The author is free to admit that in two of his cases he was unable 
 to make the positive diagnosis of ectopic gestation until he had anes- 
 thetized the woman and introduced his finger into the cervical canal and 
 thus proved the uterus empty. The reasons for the difficulties in diag- 
 nosis are obvious. The landmarks of the pelvic organs are largely 
 obscured by inflammatory adhesions binding them together. The uterus 
 is often closely incorporated with the gestation sac and seems practi- 
 cally a part of it. 
 
 Thus it is that the correct diagnosis is sometimes overlooked until 
 spurious labor calls attention to the fact that the conditions are abnormal. 
 
 Treatment of Ectopic Gestation. — In discussing the treatment of ectopic 
 gestation the author prefers to divide the subject into two periods:— ^ 
 
 (a) Early ectopic gestation (under six months). 
 
 (b) Advanced ectopic gestation. 
 
552 ECTOPIC GESTATION— PREGNAA'CY IN MALFORMED UTERI 
 
 The reason for incliidin<i; gestation as late as the sixth month in the 
 period of early ectopic gestation is that, in the author's judgement, up 
 to this time the life of the fetus should be disregarded and therefore the 
 same principles of treatment apply. 
 
 Treatment of Early Ectopic Gestation. — This again may be 
 considered under three heads: 
 
 (a) Prior to tubal rupture or abortion. 
 
 (b) At the time of tubal rupture or abortion. 
 
 (c) Subsequent to tubal rupture or abortion. 
 
 Prior to Tubal Rupture or Abortion. — As soon as the diagnosis of 
 unruptured ectopic gestation is positively made there can be but one 
 wise indication, i. e., removal of the pregnant tube by operation. 
 
 Methods Formerly in Vogue. — Attempts to kill the fetus by electricity 
 or by the injection of morphin or other substances in the hope that 
 the pregnancy will l)e arrested and operation avoided have now been 
 abandoned as uncertain, unsafe, and unjustifiable. 
 
 Even after the death of the fetus, as long as the tube is not emptied, 
 hemorrhages into it may occur, causing rupture of the tube with all its 
 possible dangers. Furthermore, it can never be told when tubal rupture 
 or abortion is to occur or whether this occurrence is to have a fatal issue 
 or not. These accidents may occur during the course of treatment which 
 seeks to kill the fetus. The only safe rule to follow is to save the woman 
 the risks accompanying tubal rupture and abortion by removing the 
 pregnant tube. As a rule this operation is better done by the abdominal 
 than by the ^■aginal route, as by the former, with the pehic organs in 
 good view, such conservative work as may be necessary to leave them in 
 good condition for the future may be done. The risk in the operation 
 for removal of an unruptured tube in the hands of one accustomed to 
 abdominal work is very slight and is as nothing compared to that to 
 which the woman is exposed if left to the possible dangers of tubal rupture 
 or abortion. 
 
 At the Time of Tubal Rupture or Abortion. — The condition is that of 
 a woman suffering from internal hemorrhage and shock, and the iatter 
 is largely dependent upon the former. If the tube has ruptured the 
 hemorrhage may continue until the death of the woman. If tubal abor- 
 tion has occurred and is complete the hemorrhage may cease without 
 fatal issue, but if incomplete, and as already stated, according to Wormser 
 the incomplete tubal abortions are ten times as frequent as the complete, 
 the hemorrhage may continue or be repeated until the woman is exsan- 
 guinated. For these reasons the author has adopted for his own guidance 
 the following rule: 
 
 If the patient is seen at the time of tubal rupture or abortion, operate 
 and check the hemorrhage as soon as careful preparations for the opera- 
 tions can be made, unless the patient is in such extreme collapse that the 
 operation in itself would probably prove fatal. In this case watch the 
 patient carefully, noting the condition ot the pulse at short intervals, 
 to see if the patient is impro\ing or losing ground. If improving, wait 
 and operate when the patient is in better condition. If losing ground, 
 
ECTOPIC GESTATION 553 
 
 operate rapidly, seeking to check the hemorrhage with as Httle manipu- 
 lation as possible, perhaps having an assistant infuse the patient during 
 the operation, and leaving considerable warm salt solution in the abdomen 
 when closing it. Regarding the details of the operation for ruptured 
 ectopic gestation something may well be said. At the time of tubal 
 rupture or abortion the operation is much better done from above than 
 from below. The bleeding-point is much more easily found and secured 
 through the abdominal incision than through the vaginal route and for 
 the subsequent steps of the operation: removing the gestation sac, blood- 
 clots, etc., the abdominal route is certainly preferable. 
 
 In making the abdominal incision, passing through the fascia and ap- 
 proaching the peritoneum, the latter usually appears darker than normal 
 and bulging. "With the nicking of the peritoneum the blood usually gushes 
 out and if any doubts of diagnosis existed before, they are now dissipated. 
 
 In planning the operation for ruptured ectopic gestation it is well to bear 
 in mind the fact that the field of the lesion, and therefore the field of the 
 operation, is supplied by two arteries (see Fig. 31), the ovarian coming 
 in at the upper part of the broad ligament and the uterine entering the 
 broad ligament at its lower portion, then coursing up along the side of 
 the uterus to anastomose with the ovarian artery near the uterine cornu. 
 The hemorrhage in the patient before us must come from one or both of 
 these arteries, hence a ligature or clamp about the tube near the horn of 
 the uterus and another about the upper portion of the infundibulopelvic 
 ligament just distal to the fimbriated extremity of the tube will control 
 the ordinary sources of bleeding. 
 
 The reason for calling attention to these vessels rests in the fact that 
 often the abdomen is full of blood ; the pelvic field is completely obscured 
 by it, and unless the operator has distinctly in mind what he has to do, 
 much valuable time may be wasted in sponging away blood which has 
 already been lost without checking its source. 
 
 First determine on which side the gestation sac lies, seize the broad 
 ligament and tube near the horn of the uterus on that side and draw it 
 into view. The compression with the thumb and finger at this point 
 will, in a large number of cases, check the hemorrhage, as the bleeding at 
 the point of rupture is apt to come from the uterine end of the tube. iVt 
 any rate the situation is now under control; the ligatures can be placed 
 as desired and the hemorrhage is checked. As a rule the affected tube 
 should be removed as a probable source of future trouble even if the 
 case is one of abortion rather than rupture. Some operators (^Martin, 
 Prochownich and others) advocate leaving the tube in certain cases of 
 tubal abortion even if it has to be incised to remove the product of 
 conception. The removal of the tube is, in the opinion of the author, 
 a much safer procedure. 
 
 The removal of the blood-clots should now receive attention. After 
 scooping out the larger ones with the hand, the remainder can best be 
 flushed out with warm salt solution, it being borne in mind that it is not 
 necessary to remove every small clot and that more harm may be done 
 by prolonging the operation than benefit derived from removing the clot. 
 
554 ECTOPIC GESTATION— PREGNANCY IN MALFORMED UTERI 
 
 The warm salt solution will often stimulate the patient and if the opera- 
 tion is (lone quickly, carefully and with as little handlino; of the intestines 
 as possible, cases which seemed almost hopeless will often stand the 
 oj)eration well and begin to rally as soon as the hemorrhage is checked 
 and the blood-clots removed. 
 
 \Yhen operating at the time of tubal rupture or abortion the abdominal 
 wound should be closed without drainage. The field of operation is a 
 clean one. The blood-clots are aseptic and the risks of infection are less 
 without than with drainage. 
 
 In the interstitial variety of ectopic gestation, as has already been said, 
 the pregnancy advances further before rupture, the muscular wall about 
 the ovum is thicker and more vascular and its rupture is naturally 
 attended by more hemorrhage and shock. It can easily be seen that 
 this is the variety of ectopic gestation most likely to be rapidly fatal at 
 the time of rupture. The first steps of the operation are the same as 
 those indicated above: Open the abdomen, seize with thumb and fingers 
 the broad ligament and the tube near the horn of the uterus on the side 
 occupied by the gestation sac and draw it into view. While in this variety 
 it may occasionally be possible to excise the aft'ected uterine cornu and 
 leave the uterus, in the majority of cases it is safer to remove the uterus. 
 The peritoneal cavity is then cleansed of blood-clots and products of 
 gestation and the abdominal wound closed. 
 
 In the above description of the treatment at the time of tubal rupture 
 or abortion the conditions considered have been those of intraperitoneal 
 escape of the ovum. Occasionally, as previously indicated, the rupture 
 takes place through the floor of the tube down between the folds of the 
 broad ligament. In this variety of intraligamentous rupture of early 
 ectopic gestation an exception may be made to the rule — operate at the 
 time of rupture. If the diagnosis is clear and the hemorrhage evidently 
 extraperitoneal and encapsulated, pushing the uterus upward, forward 
 and to the opposite side, operation may be postponed while the patient 
 is kept under close observation. The two indications for operation 
 which should be constantly kept in mind are repeated hemorrhage 
 and suppuration. Often the pelvic hematoma produced by the intra- 
 ligamentous rupture will be gradually absorbed and no other treatment 
 needed save rest in bed and the ice-bag upon the lower abdomen during 
 the first few hours following the rupture. Occasionally, however, due 
 to the erosion of the trophoblastic layer of the chorion, new vessels are 
 opened and fresh hemorrhage occurs to the extent sometimes of causing 
 rupture through the broad ligament fold into the peritoneal cavity. In 
 these instances of recurrent hemorrhage in an intraligamentous rupture 
 it is wiser to open the abdomen and seek the source of bleeding from 
 above rather than to attempt to deal with it through a vaginal 
 incision. 
 
 Another termination of an intraligamentous rupture is that of suppura- 
 tion of the hematoma. Although the blood-clots are aseptic at the time 
 of the formation of the hematoma, the close proximity of the rectum 
 makes infection easy and not at all infrequent. It is here m the treat- 
 
ECTOPIC GESTATION 555 
 
 ment of a suppurating intraligamentous hematoma that the vaginal 
 incision and drainage is the operation of choice. 
 
 Treatment of Early Ectopic Gestation Siibsegnen t to T ub al Ruptu re or 
 Ahortio7i. — It not infrequently happens that th ^obstetric surgeony first 
 sees the case of ectopic gestation several days or weeks after the escape 
 of the ovum from the tube either intraperitoneally or extraperitoneally. 
 
 If the escape has been intraperitoneal and the physical signs of a pelvic 
 hematocele with the boggy feel of blood-clots behind and to the side of 
 the uterus are detected, operation and removal of the blood- clots, gesta- 
 tion products and probably the tube is, as a rule, the indication, for it is 
 usually impossible to tell whether the tube is emptied or whether villi 
 still remaining are to erode and open other vessels with hemorrhage 
 which may be disastrous. Here again, unless the hematocele has sup- 
 purated, the abdominal operation is preferred to the vaginal. If suppura- 
 tion has occurred vaginal incision and drainage are indicated. If the 
 rupture was intraligamentous and not seen until some time subsequent 
 to its occurrence, the same rules hold for observation or operation as 
 already given when discussing the treatment of ectopic gestation at the 
 time of intraligamentous rupture, viz., operate only if hemorrhages recur 
 or the hematoma suppurates. Before leaving the subject of the treatment 
 of the early ectopic gestation the question may well be asked : Is it never 
 safe to leave a case of tubal abortion without operation? Undoubtedly 
 many patients have suffered from tubal abortion in which the tube 
 emptied itself completely and recovery followed without operation. It 
 is never safe to make this prognosis. If the patient is seen near the 
 time of the occurrence of the tubal abortion, the difficulties in the way of 
 determining that the tube is empty are so great that the author believes 
 it unsafe to advise non-interference. On the other hand, in a few cases 
 not seen until a considerable time has elapsed since the tubal abortion, 
 in which the history has shown no recurrence of the hemorrhage since 
 the first, and in which the tube has felt to him empty and the hemato- 
 cele firm and diminishing in size, he has advised non-interference without 
 regret. 
 
 Treatment of Advanced Ectopic Gestation. — When the ectopic 
 gestation has advanced to a development of six months a different phase 
 of the subject is presented. Two lives come into consideration: the fetal 
 as well as the maternal. Up to this period of fetal development, although 
 admitting that this period is arbitrarily selected, the author believes 
 the fetal life should be disregarded. Now as pregnancy reaches six 
 months of advancement and the fetus begins to make its presence more 
 evident, two questions present themselves: 
 
 1. Is the fetus worth saving if pregnancy continues till the child is 
 viable and is delivered alive? 
 
 2. Is the maternal risk greatly increased by allowing the gestation to 
 continue from six to eight and a half months? 
 
 In answering the first question the author's experience is of value. 
 It has been his fortune to operate upon 6 cases of advanced ectopic 
 gestation. In 3 the child was alive at the time of operation and all 
 
556 ECTOPIC GESTATION— PREGNAXCY IX MALFORMED UTERI 
 
 3 of the children left the hospital in good condition with their mothers 
 at the ex])iration of their period of convalescence. 
 
 In one of the li\"ino; children there was a congenital dislocation of the hip, 
 yet otherwise the child was healthy. In another of the living children, 
 one foot was everted, the other inverted at time of birth, but at three 
 months under non-operative orthopedic treatment the feet and legs were 
 practically straight (see Fig. 350). The remaining 4 children seemed 
 perfectly formed. These children seemed certainly worth saving, provided 
 the risk to the mother was not greatly increased thereby. 
 
 It is generally recognized that at about term spurious labor is apt to 
 intervene and this spurious labor in a number of instances has caused 
 
 Fig. 350. — Full-term child; ectopic gestation. 
 
 rupture of the ge.station sac and maternal death. However, the author's 
 experience and study of the literature would seem to teach that if this 
 time of spurious labor is anticipated and the gestation terminated at 
 eight and one-half months, the risk to the mother has been but little 
 increased by this wait of two and a half months. It therefore seems 
 justifiable in dealing with cases of ectopic gestation which have advanced 
 to six months or later to give the life of the child consideration, and 
 endeavor to secure a viable child by allowing the pregnancy to approach 
 term but, realizing the danger of spurious labor to both mother anrl child, 
 avoid this risk by operating at about eight and a half months. Another 
 apparent advantage in avoiding the last two weeks of gestation rests 
 
ECTOPIC GESTATION 557 
 
 in the fact that in the last two weeks the relative amount of liquor amnii 
 seems lessened and the fetus is subjected to more pressure. 
 
 Operation for Advanced Ectoinc Gestation. — The crux of the whole 
 matter in dealing by operation with cases of advanced ectopic gestation 
 lies in the management of the placenta. In the intraligamentous variety 
 the placenta is often spread out over the whole side of the pelvic floor and 
 firmly adherent to the pelvic vessels, and in the intraperitoneal variety 
 the placenta may be just as firmly adherent to the intestines and practi- 
 calh' any of the abdominal viscera. To separate from its bed a placenta 
 thus firmly adherent, with the fetal circulation of it active until the cord is 
 tied, and with the chorionic villi imbedded as they often are, may mean 
 so profuse a hemorrhage as to cause the loss of the patient on the table. 
 For this reason it is found wiser, save in those exceptional cases where 
 careful examination of the sac shows that the vessels supplying it can 
 be hgated and the sac removed entire, to remove the fetus only and leave 
 the placenta to separate gradually and come away. 
 
 In a large number of cases of advanced ectopic gestation, as already 
 stated, the rupture occurs downward through the floor of the tube and 
 the development is intraligamentous. 
 
 In these cases the peritoneum is lifted from the floor of the pelvis and 
 even from the abdominal wall, so that an abdominal incision at the outer 
 border of the rectus muscle will sometimes open into the gestation sac 
 without opening the general peritoneal ca^'ity. If the placenta has to 
 be left to come away piecemeal it is a distinct advantage to have the 
 peritoneum unopened, hence the author's custom is to make a lateral 
 rather than a median incision. Having reached the sac, the wisest plan 
 is first to examine its surrovnidings carefully to determine whether the 
 attachment of the placenta is such that the vessels supplying the sac 
 can be ligated and the sac safely removed. If the gestation is of the 
 tubo-abdominal variety this can often be done, as in one of the author's 
 cases, and the abdominal wound closed and the period of convalescence 
 greatly shortened. 
 
 On the other hand, the decision to attempt to remove the sac must 
 be carefully made, as once the removal is started it is often necessary to 
 complete it even at the risk of great loss of blood. Under ordinary 
 circumstances the safest plan of treatment is to incise the gestation sac; 
 remove the child; stitch the sac to the abdominal wound and pack the 
 sac with a weak iodoform gauze. This packing can be changed every 
 second or third day and the separation of the placenta aided with the 
 finger. A sinus will persist for a time after the separation of the placenta, 
 but in all of the author's cases the sinus closed in a reasonably short 
 time. Catgut should be the ligature and suture material employed, as 
 otherwise the sinus would probably persist longer. 
 
 In the above discussion of treatment by operation it has been under- 
 stood that the fetus was alive at the time of operation. If the fetus 
 has been dead for a month or more and the sac not infected, the operation 
 is simpler for the reason that the placenta separates much more easily 
 and there is not the danger of profuse hemorrhage from the site of the 
 
558 ECTOPIC GESTATION— PREGNANCY IN MALFORMED UTERI 
 
 placental attachment. In fact, the rule is to remove the placenta as 
 distinguished from the case with a living fetus, where the rule is to 
 leave it. 
 
 The question now presents itself: Given a case of advanced ectopic 
 gestation in which the fetus has just died, is it wiser to operate at once or 
 later? Eealizing that the placenta can be removed more easily and 
 safely a few weeks later, it is usually wise to postpone the operation from 
 four to six weeks to allow for some obliteration of the maternal blood 
 spaces about the chorionic villi of the placenta. During this time, how- 
 ever, the woman should be under careful observation, and if any evi- 
 dence of infection occurs, as shown by her temperature or pulse, prompt 
 operation is indicated. 
 
 With a living fetus, and also with a dead fetus, if the gestation sac is 
 .not infected, the abdominal operation is the method of choice. 
 
 On the other hand, if the gestation sac has suppurated the vaginal 
 operation allowing for the removal of the gestation products and drain- 
 age is preferable. In removing the gestation sac in the abdominal opera- 
 tion it is sometimes found, especially in the intraligamentous variety, 
 that the uteru,s is so incorporated with the sac that the operation is best 
 completed with a hysterectomy. 
 
 PREGNANCY IN MALFORMED UTERI. 
 
 When considering the varieties of malformation of the uterus which 
 would cause trouble during pregnancy, it must be remembered that 
 malformations of the uterus and vagina are dependent chiefly upon some 
 fault in the normal development and fusion of the ducts of INIiiller. In 
 the normal course of development the upper portions of the ducts of 
 Miiller, although separate, converge, forming the Fallopian tubes; the 
 middle portions fuse and the partitions between them disappear, forming 
 the uterus, while their lower portions by a similar fusion and absorption 
 of partition form the vagina. Any interruption in this normal fusion 
 and development may leave more or less of a double canal in the uterus 
 or in the vagina, and depending on the equality or inequality in the 
 development of the two halves, there may result either a symmetrical 
 double uterus and vagina or one-half may be well developed while the 
 other presents all grades of development from zero to perfection. 
 
 As pregnancy in malformed uteri is only being considered, those rare 
 conditions of absence of the uterus and rudimentary uterus in which the 
 latter organ is represented only by a band of connective tissue posterior 
 to the bladder need not be discussed. For pregnancy to exist at least one 
 of the ducts of INIiiller must have developed sufficiently to form a service- 
 able half of a double uterus and vagina. 
 
 The varieties of malformation then which concern the obstetrician are: 
 
 1. The uterus unicornis (see Fig. 351), in which only one duct of Miiller 
 is developed. 
 
PREGNANCY IN MALFORMED UTERI 
 
 559 
 
 2. The uterus bicornis in its various forms (see Figs. 352, 353, and 354), 
 in which both ducts are equally developed but there is a fault in the 
 normal fusion and absorption. 
 
 Fig. 351. — Uterus unicornis: LH, left horn; LT, left tube; Lo, left ovary; RH, right 
 horn; RT, right tube; Ro, right ovary; RLr, right round ligament; LLr, left round ligament. 
 
 (Mann.) 
 
 3. The uterus bicornis in which one duct is imperfectly developed and 
 has no communication with the vagina (see Fig. 355). 
 
 4. The uterus didelphys (see Fig. 356) in which the two halves are 
 separate throughout. 
 
 Fig. 352. — Uterus bicornis. 
 
 5. The uterus septus (see Fig. 357) in which the exterior of the uterus 
 feels normal but the partition between the middle portions of the ducts 
 of Miiller has never absorbed. 
 
500 ECTOPIC GESTATION— PREGNANCY IN MALFORMED UTERI 
 
 G. The uterus bipartitus (see Fig. 358) in which both uterus and vagina 
 are doulile and lie side by side as separate tubes. And lastly 
 
 7. The double vagina in which the fusion, absorption and develop- 
 ment of the ducts of Miiller are normal until the vagina is reached, but 
 
 Fig. .35-3. — Uterus cordiformis: a, indented fundus; h, b, tubes; c, c, round ligaments; 
 d, central longitudinal ridge on posterior wall of uterine cavity; e, e, lateral ridges of same; 
 /, internal os; g, g, cervix. (Hirst.) 
 
 Fig. 354. — Uterus incudiformis. (Hirst.) 
 
 Fig. 35.5. — Uterus bicoruis unicollis with rudimentary horn. (Kehrcr.) 
 
 here a partition is left dividing the vagina throughout more or less of 
 its strength. 
 
 ^Yhile all of these malformations may cause confusion in diagnosis 
 both in pregnancy and in labor, and several of them may cause com- 
 
PREGNANCY IN MALFORMED UTERI 
 
 561 
 
 Fig. 356. — Double uterus (uterus didelphys) : a, right cavity; b, left cavity; c, right 
 ovary; d, right round ligament; e, left round ligament; /, left tube;;?, left vaginal portion; 
 h, right vaginal portion; i, right vagina; /, left vagina; k, partition between the two vaginse. 
 (Mann.) 
 
 Fig. 357. — Uterus septus duplex (natural size), completely double uterus, and incom- 
 pletely double vagina of a girl, aged twenty-two years: a, a, tubes; b, b, fundus of the double 
 uterus; c, c, c, partition of uterus; d, d, cavities of the uterine bodies; e, e, internal orifices; 
 /, /, external walls ofjthe two necks; g, g, external orifices; h, h, vaginal canals; ^, partition 
 which divided the upper third of the vagina into two halves. (Mann.) 
 36 
 
502 ECTOPIC GESTATION— PREGNANCY IN MALFORMED UTERI 
 
 plications of labor which will be discussed later, the only variety which 
 is likely to cause pathological pregnancy and deserves to be studied in 
 connection with the preceding section on ectopic gestation is that in 
 which one of the ducts of Miiller is rudimentary and, although its Fallo- 
 pian tube and uterine body are patent, has no communication with 
 either the cervical canal or vagina (see Fig. 355). Here by external 
 migration of the ovum from the opposite ovary, or by external migra- 
 tion of spermatozoa from the opposite tube impregnating an ovum 
 
 Fig. 358. — Uterus bicoruis duplex: o, a, double entrance to vagina; b, meatus urinarius; 
 c, clitoris; d, urethra; e, e, double vagina; /, /, external orifices of uterus; (j, g, double cervix; 
 h, h, bodies and horns of uterus; i, i, ovaries; k, k, tubes; I, I, round ligaments; ni, m, broad 
 ligaments. (Hirst.) 
 
 from the ovary of the affected side, a pregnancy may start in this rudi- 
 mentary horn. As there is no communication with the cervical canal 
 or vagina, the natural result is rupture with all the dangers of fatal 
 intraperitoneal hemorrhage which is associated with interstitial ectopic 
 gestation. This rupture usually occurs during the first four months. 
 Occasionally the fetus is retained for an indefinite period in the rudimen- 
 tary liorn as a lithopedion, or is eliminated by suppuration. 
 
 Treatment. — If the diagnosis is made prior to rupture of the sac abdom- 
 inal section should be performed and the pregnant rudimentary horn 
 removed. Unfortunately, however, in such cases, as in that of interstitial 
 
PREGNANCY IN MALFORMED UTERI 563 
 
 ectopic gestation, the first intimation of the condition is often at the time 
 of rupture, with its chnical picture of internal hemorrhage and collapse. 
 The treatment indicated is removal of the pregnant horn or hysterectomy, 
 depending upon the conditions found at operation. 
 
 Pregnancy in a uterus unicornis and in a uterus bicornis with both horns 
 having a communication with the cervical canal and vagina usually 
 progresses normally, but there are several interesting features of preg- 
 nancy in the different forms of double uterus which deserves consid- 
 eration. 
 
 The unimpregnated half undergoes a sympathetic hypertrophy and 
 develops a decidua as does the other. If the unimpregnated half has a 
 communication with the cervical canal and vagina, this decidua may be 
 discharged with a metrorrhagia presenting the clinical picture of a mis- 
 carriage as happened in a case seen by the author in consultation. 
 
 Under these circumstances the continuation of pregnancy after a sup- 
 posed miscarriage may lead to considerable surprise. 
 
 In the case above referred to there occurred at irregular intervals 
 during the pregnancy a moderate bloody discharge, apparently a men- 
 struation from the unimpregnated half of the uterus. 
 
 Pregnancy in a uterus bicornis may give rise to various doubts in 
 diagnosis as to the contents of each horn and the diagnosis perhaps 
 absolutely cleared only at the termination of labor. In one of the author's 
 cases the placenta was situated in one horn and the fetus in the other; 
 the horn containing the placenta presenting much the feel of a soft 
 fibromyoma. In rare instances of twin pregnancy in a uterus bicornis 
 one twin has been found in each horn. Dystocia arising from different 
 forms of malformed uteri is discussed under the head of Dystocia (see 
 page 625). 
 
CHAPTER XVII. 
 HEISIORRHAGE. 
 
 One of the most important complications of pregnancy, labor and the 
 puerperium is hemorrhage, and it will be discussed as occurring in each 
 of these three periods. 
 
 Etiology. — Hemorrhage during and immediately following lal)or may 
 result from laceration of some portion of the parturient canal, but the 
 chief factor in obstetric hemorrhage is the placenta, the hemorrhage 
 resulting from the opening of the uteroplacental vessels and insufficient 
 uterine contractions to close the uterine sinuses. 
 
 Varieties. — Mewing hemorrhage as either antepartum, intrapartum 
 or postpartum, the following classification will be adopted, based on its 
 etiology. 
 
 Hemorrhage, 
 axtepartum from ixtrapartum from postpartum. 
 
 1. Al^normally situated 1. Abnormally situated 1. The so-called postpar- 
 
 placcnta. placenta. tiun hemorrhage. 
 
 2. Normally situated pla- 2. Normally situated pla- 2. Puerperal hemorrhages. 
 
 cent a. cent a. 
 
 3. .\bnormally situated .3. Lacerations. 
 
 placenta and fetus 
 (ectopic gestation). 
 
 In studying ante])artiun hemorrhage or that occurring during i)reg- 
 nancy, the first variety presenting itself for consideration is that from 
 an abnormally situated placenta, and the first example of this to be 
 studied is placenta previa. 
 
 PLACENTA PREVIA. 
 
 Placenta pre\ia is a ])lacenta situated wholly or in part in the lower 
 uterine segment, that part of the uterus which dilates as labor advances. 
 
 Varieties. — Several ^■a^ieties of placenta previa are recognized accord- 
 ing to the situation of the placenta in the lower uterine segment, thus 
 placenta previa may be complete or incomplete. 
 
 A complete placenta previa is one in which the j)lacenta completely 
 covers the internal os (see Fig. 359). 
 
 An incomplete placenta previa is one in which the placenta does not 
 completely cover the internal os. 
 
 It may be partial, overlapping the internal os (see Fig. 360), marginal, 
 just reaching the internal os (see Fig. 361), or lateral, lying in the lower 
 uterine segment, but not reaching the internal os (see Fig. 362). 
 (564) 
 
PLACENTA PREVIA 565 
 
 Frequency. — The frequency of placenta previa is much greater in a 
 maternity hospital than in private practice for the reason that many 
 cases, which if normal would have been treated at home, are sent to the 
 hospital on account of the complication. Moreover, the statements by 
 different authors regarding the frequency of the condition vary greatly, 
 Tarnier giving the frequency as once in 207 cases, and W. Miiller as 
 once in 1078 cases. 
 
 Fig. 359. — Complete placenta previa. Fig. .360. — Partial placenta previa. 
 
 According to the author's experience placenta previa in an active 
 hospital maternity service occurs with greater frequency than is repre- 
 sented even by Tarnier's figures, and in private practice once in 500 cases 
 represents the frequency more closely than do the figures of Miiller. 
 
 In 25,000 consecutive deliveries at the Sloane Hospital there were 
 223 cases of placenta previa, giving a frequency of once in 112 cases. 
 
 Fig. 361. — Marginal placenta previa. Fig. 362. — Lateral placenta previa. 
 
 The frequency of the complete variety is much less than of the incom- 
 plete. In 174 cases occurring in 20,000 consecutive deliveries at the 
 Sloane Hospital there were 39 cases of complete placenta previa and 
 135 of the incomplete variety. 
 
 Etiology. — Although little is known concerning the exact etiology of 
 placenta previa, the conditions which seem to favor it are multiparity and 
 anything causing an enlargement or abnormal shape of the uterus with 
 an hypertrophy of the endometrium. 
 
566 HEMORRHAGE 
 
 It is much more common in multigravirhie than in primigravidse. 
 In 174 cases of placenta previa occurring at the Sloane Hospital there 
 were 148 multigravidse and only 20 primigra\ida\ 
 
 The condition is apparently favored by a subinvolution of the uterus 
 resulting from numerous pregnancies and especially from frequent 
 pregnancies. 
 
 It also seems to be favored by the presence of fibromyomata in the 
 uterus enlarging and distorting it. The connection between these 
 conditions and placenta previa seems to be through the resulting endo- 
 metritis preventing the normal embedding and vascularization of the 
 ovum. 
 
 The view formerly accepted was that the ovum either primarily lodged 
 in the lower part of the uterine cavity and developed there or that in 
 a threatened abortion it loosened its primary attachment which was 
 higher up and secondarily formed an attachment and developed lower 
 do\ATi. 
 
 More recent views are those of Hofmeier and Kaltenbach, and that 
 of Strassmann. According to Hofmeier and Kaltenbach the placenta, 
 instead of developing wholly from the chorion and decidua basalis 
 (serotina), developed in part from a portion of the chorion in apposition 
 with the decidua capsularis (reflexa) ; this reflexa placenta as pregnancy 
 advances extending toward or over the internal os. 
 
 According to Strassmann, in placenta previa, on account of a defi- 
 cient vascularization of the decidua basalis resulting from a previous 
 endometritis, the placenta spreads over a larger area of uterine surface 
 to provide proper circulation and nutrition, and in doing so occasionally 
 reaches or overlaps the uterine os, this extension being favored by the 
 cleavage of the decidua parietalis (vera). 
 
 Aiiomalies of the Placenta. — In placenta previa placental anomalies 
 are common. Thus the placenta is often of irregular shape. It may 
 be much more extensive than normal, as suggested by Strassmann. 
 Placentae succenturiatse are not uncommon. The pkcenta may be 
 composed of two separate lobes with one on either side of the internal 
 OS. Furthermore, a part at least of the placenta may be abnormally 
 adherent. 
 
 Anomalies of the Umbilical Cord. — The insertion of the umbilical cord 
 in placenta previa is often marginal or velamentous, and prolapse of the 
 cord is common. 
 
 Anomalies of Presentation and Position. — The presence of the placenta 
 in the lower uterine segment interferes with the normal descent of the 
 presenting part into the pelvis, thus favoring abnormalities of presenta- 
 tion and position. In the 174 cases of placenta previa in 20,000 consecu- 
 tive deliveries at the Sloane Hospital there were 54 presentations other 
 than vertex. 
 
 Symptoms. — The chief symptom of placenta previa is hemorrhage, 
 a flow usually of bright red blood coming suddenly and without pain, 
 unless the patient is in labor, often when the patient is perfectly quiet, 
 perhaps even asleep. The hemorrhage in placenta previa has been 
 
PLACENTA PREVIA 5S7 
 
 called "unavoidable," to distinguish it from "accidental" hemorrhage 
 where the placenta is normally situated. 
 
 The first bleeding may occur at any time from the formation of the 
 placenta at the third month until the onset of labor; the most usual time, 
 however, is after the sixth month. The first hemorrhage may or may 
 not be profuse, this depending as a rule upon the nearness of approach 
 to the complete variety of placenta previa. The first hemorrhage is 
 usually not fatal, but after a little time ceases spontaneously, only to 
 recur at any moment and with a severity which cannot be foretold. 
 Exceptions to this general rule occasionally occur: If the placenta previa 
 is of the incomplete, especially of the lateral variety, no hemorrhage 
 may appear until the labor, and perhaps even then the hemorrhage will 
 not be sufficient to attract attention, as with the rupture of the mem- 
 branes the presenting part may so compress the placenta against the 
 uterine wall as to check any abnormal bleeding. 
 
 On the other hand, there will always remain impressed upon the author's 
 memory a case of complete placenta previa which gave no hemorrhage 
 at all during pregnancy, but in which at the outset of labor there occurred 
 a hemorrhage so profuse as to cause the woman to faint and to so exsan- 
 guinate her that her life was saved with great difficulty. Thus far has 
 been described what might be called intermittent hemorrhages, but 
 occasionally, instead of a profuse flow there may be a more or less con- 
 tinuous dribble which gradually brings about a pronounced anemia of 
 the patient, and leaves her in a poor condition for the grave -hemorrhage 
 which may occur unexpectedly and suddenly take her life. 
 
 The question naturally arises: Are the time of occurrence of the first 
 hemorrhage and the amount of this hemorrhage any criteria of the variety 
 of the placenta previa? In general it may be said that the earlier in 
 pregnancy the first hemorrhage occurs and the more profuse it is, the 
 more likely is the condition to be one of complete placenta previa. 
 Attention, however, has already been directed to the fact that numerous 
 exceptions occur^ 
 
 Cause of the Hemorrhage. — In a normal pregnancy, especially in its 
 latter part, there is a gradual thinning out and retraction of the cervix 
 and lower portion of the uterus constituting the lower uterine segment 
 (see page 210), as distinguished from the upper uterine segment, which 
 is the normal site of attachment of the placenta. 
 
 This retraction and thinning is brought about chiefly by the intermit- 
 tent uterine contractions which go on through pregnancy, as described by 
 Braxton Hicks, and are usually painless, but in some patients are asso- 
 ciated with considerable discomfort. In the normal arrangement the 
 placental attachment is not disturbed until after the birth of the child, 
 when the upper uterine wall contracts away from the placental surface 
 and by this contraction closes its bleeding sinuses at the same time. 
 In placenta previa the conditions are quite different. The placenta is 
 attached to the lower uterine segment which must retract away from it as 
 pregnancy advances and labor approaches. The lower uterine segment 
 has little power of muscular contraction and the separation may occur at 
 
568 HEMORRHAGE 
 
 a time when even this Httle poAver is not in action. \Yhile in the early 
 months the phicenta and tlie lower nterine segment may keep pace in 
 their growth, there soon comes a time when the decidna will stand no 
 further tension and the slightest increase may cause a separation of 
 the placenta along the decidual layer, thus opening up the decidual 
 vessels. This increase of tension may arise from various causes: a mis- 
 step, straining at stool, sexual intercourse, a vaginal examination, or it 
 may come from the extra congestion of the would-be menstrual period, 
 or as a result simply of the normal intermittent uterine contractions 
 which always accompany pregnancy. The hemorrhage as seen from the 
 above explanation is maternal, from the uterine sinuses, as the chorionic 
 villi are usually not injured, and if the fetus is killed by the hemorrhage 
 it is usually on account of the fact that the resulting separation of the 
 placenta shuts ofl' the fetal oxygenation and nutrition, rather than on 
 account of a fetal hemorrhage. The amount of hemorrhage likely 
 to occur in labor with a placenta previa cannot be predicted from the 
 amount of blood lost and the frequency of the hemorrhages in preg- 
 nancy; usually, however, the greater the bleeding in pregnancy, the more 
 probability of serious hemorrhage in labor. 
 
 In a placenta previa the hemorrhage occurring during labor is usually 
 more profuse during the interval between uterine contractions, as while 
 the uterus is contracting it forces the presenting part downward and by 
 its pressure lessens the bleeding. Occasionally, however, the hemor- 
 rhage seems to be increased by the contraction, on account of forcing out 
 of the uterus and Aagina, blood already lost in pre\ious separation of new 
 areas of placenta. 
 
 After the birth of a child in a placenta previa the conditions differ 
 from those found in a normal labor. There is not the same natural 
 power of complete separation of the placenta, and during nature's 
 attempts the hemorrhage may be quite profuse, especially when con- 
 sidered in connection with the fact that the woman has perhaps already 
 lost considerable blood. 
 
 For this reason, and also for the reason that the placenta is often 
 adherent in portions, it is often wise to remove the placenta manually 
 and pack the uterus with gauze, as will be discussed under Treatment. 
 
 This abnormal situation of the placenta in the lower uterine segment 
 in front of the child is usually regarded as favoring premature delivery, 
 perhaps by premature rupture of the membranes. In the 174 cases 
 mentioned above, 95 were delivered prematurely, although in many the 
 premature labor was induced as a part of the treatment. 
 
 Diagnosis. — The occurrence of a hemorrhage in pregnancy after the 
 period of placenta formation should always suggest the possibility of a 
 placenta previa, and it should be considered a probability unless it can 
 be excluded. It may be an "accidental" hemorrhage, i. e., a hemorrhage 
 from a normally situated placenta, but that is usually associated with 
 urinary changes and other signs and symptoms of a toxemia, as will be 
 discussed later (see page 575). 
 
 In the absence of evidences of a toxemia it is probably a placenta previa. 
 
PLACENTA PREVIA 569 
 
 There are certain physical signs of a placenta previa which should 
 assist in the diagnosis. They are usually all present in the complete 
 variety and diminish in the incomplete with the distance of the placenta 
 from the internal os until in the lateral variety they may be almost 
 absent. These physical signs are as follows: 
 
 On account of the increased vascularity of the region the cervix in 
 a placenta previa is usually softer and more dilatable than normal. 
 
 In the later months it is often partly dilated. The violet discoloration 
 of the cervix and vaginal fornix and the vascular pulsation of the lower 
 uterine segment are usually greater than normal. 
 
 The presenting part lies high and between it and the examining finger 
 can often be detected the boggy mass of the placenta, making less dis- 
 tinct the landmarks of the presenting part. If the finger is introduced 
 through the cervical canal the placenta or its edge can usually be felt 
 in all save the lateral variety. Objection has been raised by some to the 
 introduction of the finger lest it should induce premature labor, but so 
 important is the diagnosis of placenta previa if present, and so likely is 
 placenta previa or some other indication for induction of labor to be 
 present if a hemorrhage occurs in pregnancy, that the procedure is per- 
 fectly justifiable. Hence the rule which the author gives his students: 
 that if one is in doubt as to the presence of a placenta previa, introduce 
 the finger into the cervical canal, under anesthesia if necessary, and 
 palpate for the placenta. Quite a number of cases of placenta previa 
 of the incomplete variety escape diagnosis until after expulsion of the 
 placenta and membranes, their careful examination showing then the 
 opening in the membranes close to the placenta. 
 
 Prognosis. — The mortality of placenta previa, both maternal and fetal, 
 depends largely upon the variety and the treatment undertaken by the 
 obstetrician. 
 
 The prognosis in the complete variety is naturally much more grave 
 than in the incomplete. 
 
 In a combined series of 1400 cases reported by Ohlshausen, Stra^smann, 
 Schauta and Gussero, without regard to the variety of the placenta previa, 
 there was a maternal mortality of 8 per cent. The prognosis for thq^ 
 child is always grave and for the following reasons: In the first place 
 it is usually premature, malpresentation and malposition are common; 
 prolapse of the cord is common and finally artificial delivery is usually 
 resorted to in the interest of the mother. 
 
 In general the total infant mortality of placenta previa may be given 
 as about 60 per cent, or, if non-viable infants are excluded, about 35 
 per cent. 
 
 It has already been stated that the maternal mortality depends greatly 
 upon the method instituted by the obstetrician. If the seriousness of 
 the situation is recognized and the pregnancy is terminated promptly 
 the figures given will fairly accurately represent the maternal and the 
 fetal mortality. If, on the other hand, the method pursued is to watch 
 and wait with the hope that there will be no more hemorrhage, the mor- 
 tality will be much higher. 
 
570 HEMORRHAGE 
 
 The first question of importance in any method of treatment is the 
 maternal mortahty. In a series of 5000 consecutive dehveries at the 
 Sloane Hospital, since the use of the elastic bags has been the routine 
 treatment of placenta previa, there have been 49 cases of this condition, 
 14 of the complete and 35 of the incomolete variety. 
 
 In these 49 cases there were 4 deaths or 8.1 per cent., but of these 
 4 that died, 1 died of infection following a Cesarean section, the placenta 
 previa being associated with a flat pelvis and 1 died of toxemia, leaving 
 only 2 deaths, or 4 per cent, from uncomplicated placenta previa, and of 
 these 2, 1 lived only thirty minutes after reaching the hospital, being 
 nearly moribund and with child dead on admission. 
 
 Of the 4 that died, 2 were those of complete placenta previa and two 
 incomplete (one partial and one lateral), the latter dying of secondary 
 conditions, infection, and toxemia. The maternal mortality then from 
 treatment of complete placenta previa by means of the extra-ovular 
 elastic bag was 2 in 14, or 14.2 per cent. 
 
 As regards the infant mortality in the 49 cases mentioned above, 32 
 children were delivered alive, 8 died subsequently, 6 from prematurity 
 and 2 from other causes, and 17 were stillbirths. This gives a total 
 infant mortality of 25 in 49, or 51 per cent. 
 
 In the 49 cases there were 10 in whom the pregnancy had advanced 
 less than seven months, and in 1 case the child was dead when the mother 
 entered the hospital. This left only 38 cases in which saving the life of 
 the child could be considered possible and of these 38, 29 children were 
 delivered alive and 24 left the hospital alive, so that G3.1 per cent, 
 of the children viable on admission of the mother left the hospital alive. 
 
 Treatment. — When once the diagnosis of placenta previa is definitely 
 made there is in private practice only one safe rule of treatment, i. e., 
 proceed to empty the uterus. The first hemorrhage is not usually, 
 although occasionally, fatal. The second may be. The first should 
 therefore be considered the red flag, or signal of danger ahead, and the 
 only method should be adopted which will free the woman from danger. 
 In dealing with a case of placenta previa two problems present them- 
 selves before the actual delivery of the child: 
 
 1. The control of the hemorrhage. 
 
 2. The dilatation of the cervix. 
 
 These two problems are solved by the use of the Voorhees modifica- 
 tion of the Champetier de Ribes bag, as is shown in Figs. 363 and 364. 
 
 The use of the elastic bag. is extra-ovular, i. c, outside the membranes, 
 which are kept intact. The presence of the bag softens and dilates the 
 cervix and at the same time by pressure on the bleeding surface controls 
 the hemorrhage. With the usual antiseptic and aseptic precautions one 
 of the larger sizes of bag is introduced within the cervical canal and 
 distended with fluid (0.5 per cent, lysol solution). 
 
 In the ordinary employment of the Voorhees bag for the induction 
 of labor there is objection to the largest bag, lest it displace the presenting 
 part and cause a malpresentation or a prolapse of the cord. In placenta 
 previa this objection does not hold, as the presenting part usually lies 
 
PLACENTA PREVIA 
 
 571 
 
 high on account of the placenta and the dehvery is usually completed 
 by a version. 
 
 For this reason the largest bag is employed which can easily be intro- 
 duced. There are many advantages in the large-sized bag. It is an 
 advantage to have as few introductions as possible, both because every 
 manipulation favors more bleeding, and adds to the risk of infection, 
 and because each manipulation adds to the discomfort and shock of the 
 patient who may have been considerably reduced by hemorrhages. 
 Furthermore, when once the large-sized bag has passed the cervix it is 
 usually an easy matter to complete the dilatation manually and then a 
 version can be performed, or if it is a breech presentation a foot can be 
 pulled down and the child extracted. 
 
 As stated above the use of the bag is extra-ovular and the membranes 
 are kept intact until the bag passes the cervix and good dilatation is 
 obtained. This method is preferred b}' the author to the intra-ovular 
 
 Fig. 363 
 
 Fig. 364 
 
 use of the bag, where the amniotic sac is ruptured and the bag placed 
 within, chiefly in the interest of the child, but with little, if any detriment 
 to the interests of the mother. 
 
 If the membranes are ruptured and the dilating bag placed within the 
 amniotic sac, the version which follows has to be performed in a uterus 
 largely emptied of fluid and with greater danger to the child and greater 
 danger of rupture of the uterus. Furthermore, experience proves that 
 the presence of the dilating bag beneath the edge of the placenta in an 
 incomplete placenta previa (see Fig. 363) usually checks the hemorrhage 
 without dissecting the placenta to any great extent from the uterine 
 wall, and in the complete variety it has seemed to cause less maternal 
 blood loss when used beneath the placenta (see Fig. 364) than when the 
 placenta has been bored through and the bag placed above the placenta 
 in the amniotic sac. It has been argued that the presence of the bag 
 beneath the placenta in a complete placenta previa, as shown in Fig. 364, 
 
572 HEMORRHAGE 
 
 would separate so much of the placenta from the uterine wall that the 
 fetal circulation and oxygenation would be interfered with and the child 
 be lost. Experience seems to show that this interference with the utero- 
 placental circulation is not greater than in other methods employed per 
 vaginam and that the fetal mortality is satisfactorily low. 
 
 Before the introduction of the elastic bag it was the custom to pack 
 the cer\ical canal with gauze to soften and dilate it, then further dilate 
 the cervix manually until a bipolar version could be done, when the leg 
 and half-breech would be brought down to serve as a tampon and dilator. 
 This method was a useful one, but gave a higher fetal mortality from sub- 
 jecting the child to longer pressure than the jiresent employment of the 
 elastic bag which secures a greater dilatation of the cervix before the 
 version. 
 
 Furthermore, the cervix in placenta previa is apt to tear rather easily, 
 and an accouchment force without the use of the elastic bag has in not 
 a few instances started a tear which in the performance of the ^'ersion 
 became a rupture of the uterus. In cases of emergency and where the 
 elastic bags are not at hand, packing the cervical canal with gauze and 
 performing a Braxton Hicks's or bipolar version and pulling down one 
 foot, or if it is a breech presenting, simply pulling down one foot will 
 often meet the indications; but a long experience with the bags has con- 
 vinced the author of their superiority in the treatment of placenta previa 
 where the placenta lies wholly or in part over the internal os. 
 
 Is it always necessary to do a version in placenta previa? No. 
 
 The fact that some cases are not diagnosed until after the labor, shows 
 that some cases gi\'e little hemorrhage, the descending head serving as 
 a tampon controlling bleeding. This gives an indication of treatment 
 in certain cases of vertex presentation where the finger detects a lateral 
 or marginal placenta previa. In many cases with little hemorrhage, 
 the mere rupture of the membranes, allowing the head to come down 
 on the placenta, will meet the indications and the case may then be left 
 to nature. 
 
 In some cases the cervix is so well dilated when first seen that no 
 preliminary employment of the elastic bag is needed, and after a little 
 preliminary dilatation with the fingers the patient may be delivered by 
 the forceps or by version. 
 
 On the other hand, cases of placenta previa, especially primigravidse, 
 occasionally present themselves, in which the cervix is so long and rigid 
 that the elastic bag, even one of the smallest size, cannot be introduced 
 without preliminary dilatation. This can usually be done by means of 
 a glove stretcher dilator, but must be done with great care on account 
 of the risk of cervical laceration, already mentioned. In these cases of 
 rigid cervix complicating placenta pre\ia there has been a tendency of 
 late to recommend the employment of abdominal Cesarean section. 
 
 The author is free to admit that exceptionally a case will present itself 
 in which the placenta previa is central or complete, with cervix long, 
 with little dilatation and with hemorrhage profuse. Here it is that 
 abdominal Cesarean section may be the procedure of choice. It should 
 
PLACENTA PREVIA 573 
 
 be borne in mind, however, that when once a patient has been deUvered 
 by Cesarean section, the uterine wall with its cicatrix is not in as good 
 condition for subsequent labor on account of possible yielding of the 
 uterine cicatrix favoring rupture. For this reason, and also from the 
 fact that for the ordinary conditions found in placenta previa the treat- 
 ment by employment of the elastic bags has been so satisfactory in his 
 experience, the author reserves abdominal Cesarean section in placenta 
 previa for exceptional cases of the complete variety with cervix undilated 
 and hemorrhage profuse. 
 
 As regards the employment of vaginal Cesarean section or vaginal 
 hysterotomy in placenta previa, in spite of its enthusiastic advocacy by 
 Doderlein, who reports 34 consecutive cases with one maternal death, 
 the operation has few adherents in this country or in England or France. 
 In Germany a few obstetricians employ it in exceptional cases, but its 
 general use is not to be recommended. 
 
 Before leaving the different methods of delivery in placenta previa 
 something should be said regarding the technic of version after 
 dilatation of the cervix by means of the large-sized elastic bag. In 
 some cases the placenta lies wholly or in part over the internal os. 
 If the fingers can reach the edge of the placenta, this should be sought 
 and the fingers made to enter the amniotic sac around the placental edge. 
 If the edge cannot be felt, the fingers should bore through the placenta, 
 seize the foot and extract. 
 
 Even after the child has been delivered, the woman with placenta 
 previa is not out of danger. As already stated, the placenta is often more 
 or less adherent in places and its site of attachment being where there is 
 little contractile power of the uterus, nature is often incapable of thor- 
 oughly separating the placenta and until the placenta is thoroughly 
 separated and cast oft' there is likelihood of hemorrhage. 
 
 Furthermore, even after the uterus is entirely emptied the dilated 
 sinuses in the lower uterine segment often bleed more than when these 
 sinuses at the placental site are situated in the upper uterine segment. 
 For these reasons it is well as a routine procedure after emptying the 
 uterus in a placenta previa to pack the uterine cavity with gauze to 
 prevent further loss of blood. The gauze for intra-uterine packing is 
 better impregnated with bismuth than plain, as plain gauze does not 
 remain sweet in the uterine cavity for the twenty-four hours usually 
 desired, and a woman who has been the subject of a placenta previa, 
 who has lost considerable blood, and whose sinuses in the lower uterine 
 segment contain large thrombi very easily becomes infected. In fact 
 it is a very common thing for a patient with placenta previa to run a 
 little temperature after delivery, even if the delivery has been conducted 
 with the strictest precautions. 
 
 At the beginning of the discussion of the treatment of placenta previa 
 the statement was made that when once the diagnosis was definitely 
 made there was in private practice only onp safe rule of treatment, i. e., 
 proceed to empty the uterus. It might be further added that in the treat- 
 ment of placenta previa the mother's life should always receive first 
 
574 HEMORRHAGE 
 
 consideration and the child's second. The child being usually premature 
 and the fetal mortality always relatively high. 
 
 In a hospital service with patients surrounded by nurses and with 
 several doctors in the building and instruments and dressings near at 
 hand this rule of ])roceeding to empty the uterus in the incomplete 
 variety of placenta previa may be modified somewhat if the child is near 
 the period of viability and a few weeks more of pregnancy would be 
 likely to secure a living child. Even in a hospital service this should 
 only be done in the lateral or marginal varieties of placenta previa, 
 and where the ^■ertex presents, so that the rupture of the membranes 
 would in all probability allow the head to come down and sufficiently 
 tampon the bleeding surface. If, under these conditions the patient is 
 kept constantly in bed and under close observation, the little risk may 
 sometimes be justifiable. The question now arises. Are there conditions 
 which would ever justify such temporizing in private practice? The 
 author has occasionally made use of the following plan which is applicable 
 in a large city like New York, but not in the country. 
 
 In a case of lateral or marginal placenta previa where the placenta 
 at the most only reaches the internal os, with a night and day nurse in 
 attendance and with sterile gauze packing, speculum and dressing forceps 
 at the bedside, and a telephone connection in the house, he has arranged 
 with several of his medical friends, thoroughly informed as to the con- 
 dition of the patient, to answer a call to her house if they should receive 
 a summons. In this way the patient was reasonably certain of obtaining 
 medical aid at short notice, even if her attending obstetrician could not 
 be obtained. This method has succeeded in sa^'ing the lives of some 
 children which otherwise it would have seemed necessarv to sacrifice. 
 
 HEMORRHAGE WITH A NORMALLY SITUATED PLACENTA. 
 
 It has been shown that with placenta previa, an abnormally situated 
 placenta, hemorrhage may occur either antepartum or intrapartum. It 
 will now be seen that hemorrhage may occur either antepartum or intra- 
 partum with a normally situated placenta. 
 
 Hemorrhage with a normally situated placenta may be one of two 
 varieties: 
 
 1. There may occur one or more hemorrhages into the substance of 
 the placenta, the condition being spoken t)f as "placental apoplexy." 
 
 2. Hemorrhage may occur between the placenta and the uterine wall 
 from premature separation of a normally situated placenta, this being 
 called "accidental hemorrhage." 
 
 ACCIDENTAL HEMORRHAGE. 
 
 The premature separation of a normally situated placenta may occur 
 either during pregnancy or during labor, it being very much more 
 frequent in the former than in the latter. 
 
 Some idea of the frequency of accidental hemorrhage may be gained 
 
ACCIDENTAL HEMORRHAGE 
 
 575 
 
 from the fact that in the 20,000 consecutive dehveries at the Sloane 
 Hospital, 212 cases, or a frequency of 1 in 94, a little more than 1 per 
 cent., were considered cases of this condition. Cases simply showing 
 a few blood-clots or with a history of slight bleedings in pregnancy were 
 not included. 
 
 Varieties. — Premature separation of a normally situated placenta may 
 be complete, as indicated by the term (see Fig. 365), or incomplete in which 
 only a portion is separated; this separation occurring at its centre; its 
 periphery, or anywhere between (see Figs. 366 and 367). 
 
 The hemorrhage resulting from this separation may be external or 
 concealed. The former being about three times as frequent as the latter. 
 
 In the series of 212 cases just quoted there were 159 cases with external 
 hemorrhage and 53 with the hemorrhage concealed. 
 
 Fig. 365 
 
 Fig. 366 
 
 Fig. 367 
 
 Fig. 365. — Complete premature separation of normalh' situated placenta. 
 
 Fig. 366. — Incomplete separation of normal^' situated placenta. External hemorrhage. 
 
 Fig. 367. — Incomplete separation of normally situated placenta. Concealed hemorrhage. 
 
 The most usual occurrence is that the margin of the placenta becomes 
 separated and the hemorrhage works its way down between the mem- 
 branes and the uterine wall (see Fig. 366) until it escapes externally. On 
 the other hand, it may be concealed in several ways: 
 
 1. The centre only of the placenta may be detached. 
 
 2. The hemorrhage may dissect upward rather than downward. 
 
 3. The hemorrhage may rarely break through into the amniotic sac. 
 
 4. The cervica canal may be plugged b}' blood-clots, the membranes 
 or the presenting part, so that no blood escapes externally. 
 
 Etiology. — The predominating factor in the etiology of premature 
 separation of a normally situated placenta is a toxemia with a diseased 
 decidua favoring the occurrence of the hemorrhage which is the imme- 
 diate cause of the separation. The same tendency to the occurrence of 
 hemorrhage in the toxemia of pregnancy which is seen in the liver, the 
 kidneys, the retina, the mucosa of the alimentary canal and the skin, is 
 shown here in the decidua of the uterus. The same condition of premature 
 separation of the placenta in the early months of its formation is seen 
 
576 HEMORRHAGE 
 
 in the repeated miscarriages of the third and fourth months in women who 
 suffer from a toxemia every time they become jjregnant. 
 
 So frequent is the association of a toxemia with "accidental hemor- 
 rhage" that, as already suggested during the discussion of placenta previa, 
 if a pregnant jiatient has a hemorrhage and at the same time shows 
 the urinary changes or other evidences of a well-marked toxemia, the 
 probable diagnosis is an "accidental hemorrhage" rather than a placenta 
 previa. 
 
 Certain constitutional diseases also cause premature separation of 
 a normally situated placenta by producing a diseased decidua with the 
 tendency to hemorrhage. Among such diseases may be mentioned 
 syphilis, smallpox, scarlet fever, etc. Any overdistention of the uterus, 
 as by hydramnios or multiple pregnancy, seems to predispose to a 
 looser attachment of the placenta than normal, and hence to favor its 
 premature separation. 
 
 Multiparity favors this occurrence, as is shown by the fact that in the 
 series of 212 cases already mentioned there were 139 multigravidse and 
 only 73 primigravidse. 
 
 A short cord, either actually short or shortened by being wound about 
 some portion of the fetus, may by traction on the placenta, as the child 
 descends, cause a premature separation of the placenta with death of the 
 fetus. 
 
 A sufficient number of cases of "accidental hemorrhage" following a 
 traumatism, as a severe blow or violent muscular efl'ort, have been 
 reported to show that these cannot be disregarded as possible causes of 
 premature separation of the placenta, and finally the instrument of the 
 abortionist introduced between the fetal membranes and the uterine 
 wall may mechanically separate the placenta and accomplish his dire 
 purpose. 
 
 Symptoms and Signs. — The symptoms of a premature separation of a 
 normally situated placenta in the early months of pregnancy are usually 
 simply those of a threatened abortion, i. e., hemorrhage with or without 
 pain. 
 
 The lesion is practically identical with that of an abortion as it is the 
 separation of the chorion from the uterine wall. The discharge of blood, 
 usually external, may be either bright or dark, scanty or profuse. 
 
 It is usually rather scanty in amount at first and is often not very 
 bright. Later in pregnancy, especially near term or during labor, the 
 symptoms are more or less pronounced, depending upon the degree of 
 separation of the placenta. 
 
 A complete premature separation of a normally situated placenta near 
 term presents to the obstetrician one of the greatest problems with 
 which he has to deal and sometimes furnishes him an experience which 
 ever after remains indelibly impressed upon his mind. 
 
 The picture may be something as follows: A patient with albuminuria 
 and other evidences of a toxemia begins to have pain in the abdomen 
 with or without a discharge of blood from the vagina. The pain is 
 not the intermittent type of labor pains, but is more or less constant. 
 
ACCIDENTAL HEMORRHAGE 577 
 
 The patient feels faint and shows anemia. Her pulse becomes poor, 
 and she is evidently in shock. The uterine wall feels tense, perhaps bulg- 
 ing on one side over the placental site and the uterus as a whole has 
 increased greatly in size. The fetal parts are less easy to make out than 
 at the previous examination, and the fetal heart beat can probably not 
 be detected. If this premature separation occurs during labor the regular 
 labor pains cease. The continuous stretching pain of the uterus distend- 
 ing with blood appears in their place and the woman rather rapidly pre- 
 sents the picture of shock and internal hemorrhage with pallor, a feeble 
 pulse, etc. 
 
 The usual picture of accidental hemorrhage is a combination of toxemia 
 with that of shock and internal hemorrhage. There is often a little exter- 
 nal bleeding, but our worst cases are usually those of complete separation 
 of the placenta with concealed hemorrhage. 
 
 Diagnosis. — If external bleeding accompanies premature separation of 
 a normally situated placenta near term the condition must be diagnosed 
 first from placenta previa. A few of the differential features are here 
 presented. 
 
 Premature Separation of Placenta vs. Placenta Previa. 
 
 Toxemia usually present. Toxemia usually not present. 
 
 Pain usually continuous. Without pain unless in labor. 
 
 No placenta felt through cervix. Perhaps placenta felt. 
 
 Uterine wall in continuous tension. Uterine wall relaxes. 
 
 Uterus rapidly increases in size. Uterus does not increase in size. 
 
 Evidences of shock and hemorrhage. Only evidences of hemorrhage. 
 
 Fetal death more common. Fetal death less common. 
 Perhaps bulging of uterus at placental site. No such bulging of uterus. 
 
 The symptoms may resemble those of rupture of the uterus. In both 
 there are hemorrhage, shock, and perhaps marked pain. 
 Some of the differential features are as follows : 
 
 Premature Separation of Placenta vs. Rupture of Uterus. 
 
 Occurs in pi'egnancy or early in labor. Usually occurs late in protracted and diflS- 
 
 cult labor. 
 
 Toxemia usually present. Toxemia usually not present. 
 
 Membranes usually unruptured. Membranes usually ruptured. 
 
 Upper uterine segment distended and tense. Upper uterine segment smaller and con- 
 tracted. 
 
 Presenting part does not recede. Presenting part recedes. 
 
 If the "accidental hemorrhage" is concealed the diagnosis should 
 always be suggested by the large, tense uterus, with constant pain and 
 evidences of shock and internal hemorrhage, especially in a patient 
 suffering with the toxemia of pregnancy. 
 
 Prognosis. — Accidental hemorrhage in the latter months of pregnancy 
 or in labor is often one of the most serious complications of obstetrics and 
 always has a high maternal and fetal mortality. The maternal mortality, 
 as reported by different observers, is usually given as from 30 to 50 per 
 cent., and the fetal mortality as from 85 to 95 per cent. 
 37 
 
578 HEMORRHAGE 
 
 In the series of 212 cases at the Sloane Hospital there were 12 maternal 
 deaths, giving a total maternal mortality of 5.7 per cent. 
 
 In these 212 cases the hemorrhage was of the external variety in 159, 
 with 8 deaths, giving a mortality of 5.03 per cent., ^ and of the concealed 
 variety in 53 with 4 deaths, giving a mortality of 7.5 per cent. 
 
 In the 212 cases there were 122 fetal deaths, giving a total fetal mor- 
 tality of 57.5 per cent.; of these 122 fetal deaths, 22 were abortions i. e., 
 non-viable. Hence, in the series of 212 cases there were 190 viable 
 fetuses and of these 100 were lost, a mortality of 52.6 per cent. 
 
 The reasons for the high maternal and fetal mortality in accidental 
 hemorrhage are obvious. The patient at the time of the accident is 
 usually in poor condition on account of the toxemia. She is then reduced 
 to a condition of shock, and in this shock, in order to save her from fatal 
 hemorrhage, she is subjected to an artificial delivery. 
 
 The high fetal mortality is a natural result of the toxemia of the mother, 
 the premature separation of the placenta, the artificial delivery and the 
 prematurity of the fetus. In the above series of 212 cases, 120. or more 
 than half, were premature. 
 
 Treatment. — The treatment varies with the period of pregnancy and 
 the severity of the condition. In the earlier months of pregnancy soon 
 after the formation of the placenta, and while the uterus is still small, 
 a slight accidental hemorrhage may occur with a separation of the 
 placenta so slight as not to interfere with the life and development of 
 the fetus. Such a condition under rest and symptomatic treatment will 
 often be recovered from, and at the delivery of the placenta the former 
 occurrence of the accidental hemorrhage will be evidenced simply by the 
 white placental infarct. 
 
 IMoreover, even a more extensive separation of the placenta, when the 
 uterus is small, as in the first half of pregnancy, usually subjects the 
 mother to relatively little risk from hemorrhage or shock. In well-marked 
 cases near term, however, where the s^Tiiptoms of shock and internal 
 hemorrhage are distinct, no temporizing methods will answer, the woman 
 is in grave danger and only prompt and intelligent treatment will save 
 her and even that may fail. 
 
 The indication is to empty her uterus without adding more than is 
 absolutely necessary to her shock. The one barrier to this accomplish- 
 ment is the condition of the cervix and it is often this condition of the 
 cervix which marks the difference between success and failure in the 
 treatment of cases of complete premature separation of a normally 
 situated placenta. 
 
 If the cervix is dilated or dilatable the uterus can be easily and promptly 
 emptied and packed with gauze and the woman rescued from her danger. 
 
 On the other hand, if the cervix is long and rigid, with the woman 
 toxic and suftering from severe shock and hemorrhage, the obstetrician 
 is face to face with a problem which he would gladly escape. Realizing 
 that the object desired as the first step toward emptying the uterus is 
 the dilatation of the cervix, the best method is usually to introduce an 
 elastic bag into the cervical canal at once. The patient's shock and general 
 
ACCIDENTAL HEMORRHAGE 579 
 
 condition can then be treated by stimulation, infusion, or direct trans- 
 fusion, as conditions indicate, while the cervix is softening and dilating 
 under the influence of the elastic bag. 
 
 After sufficient softening and dilatation the cervix can be dilated 
 manually and the fetus delivered by version or forceps as seem best 
 under the circumstances. 
 
 In the cases of complete separation of the placenta the fetal life is so 
 often destroyed before delivery that it is considered perfectly justifiable 
 in these grave cases to disregard the life of the fetus, and if the mother 
 can be more easily and quickly delivered by a craniotomy, to perform it 
 in her interest. 
 
 In the cases of long, rigid cervix which do not dilate readily under the 
 use of the elastic bag, the vaginal Cesarean section has a limited but 
 valuable field of usefulness. The abdominal Cesarean section also in 
 certain rare cases may be the operation of choice. It should be remem- 
 bered, however, that these patients are usually in shock and in poor 
 condition for surgical operation and the procedure which adds least to 
 their shock will usually give the best results. 
 
 Even after the uterus is emptied, the patient is not out of danger, as 
 the author has learned to his sorrow. These uteri which have been 
 markedly dilated, and in women who have lost considerable blood, tend 
 to relax after delivery and add a postpartum to an accidental hemorrhage. 
 
 As a prophylactic procedure, it is always well after the uterus is emptied, 
 to pack its cavity with gauze and have the fundus carefully guarded for 
 at least an hour. 
 
 Ergot should be used as a routine procedure. The extract of pituitary 
 gland will probably prove useful in such cases. 
 
 In addition to these drugs the ordinary methods for overcoming shock 
 and toxemia, if present, are indicated. 
 
 It has been shown that an antepartum hemorrhage may occur either 
 with an abnormally situated placenta (placenta previa) or with a nor- 
 mally situated placenta (accidental hemorrhage). 
 
 It may also occur with an abnormally situated placenta and fetus, i. e., 
 with an ectopic gestation, due to the separation of the uterine decidua 
 (see page 531). 
 
 Intrapartum hemorrhage has been shown to occur either with placenta 
 previa or with a separation of a normally situated placenta (accidental 
 hemorrhage). It may also arise from laceration of any portion of the 
 parturient canal from fundus to vulva. The only lacerations likely to 
 cause serious hemorrhage during labor are: 
 
 1 . Lacerations of the cervix. 
 
 2. Rupture of the uterus. 
 
 Lacerations of the Cervix. — It is not often that a laceration of the 
 cervix will cause serious hemorrhage during labor, but the author was 
 called to one case in consultation in which the attending obstetrician 
 in dilating manually a long, rigid cervix during a tedious labor, met with 
 a hemorrhage from laceration of the circular artery which nearly exsan- 
 guinated the woman. In such an emergency it is sometimes necessary 
 
580 HEMORRHAGE 
 
 to put a suture of catgut around the bleeding vessel, although in most 
 instances it is sufficient to pack the cervical canal and vagina with gauze 
 until the presenting part comes down and by its pressure controls the 
 bleeding. The laceration most likely to prove serious during labor is a 
 rupture of the uterus. 
 
 Rupture of the Uterus. — A solution of continuity in the uterine wall 
 other than a laceration of the cervix, may occur during pregnancy, labor, 
 or the ])uerperium. Its occurrence, however, during pregnancy and the 
 puerperium is so exceptional that the expression — rupture of the uterus 
 - — is usually interpreted as a complication of labor. 
 
 Etiology." — Rupture of the uterus is predisposed to by anything weaken- 
 ing the uterine wall, as a fatty degeneration of its muscle fibres; a separa- 
 tion of its muscle fibres, as by the presence of a fibromyoma; an inroading 
 of its wall as by an hydatidiform mole; an overdistention of its wall; a 
 cicatrix in its wall, as from a previous laceration or operation; a necrosis 
 of its wall, as from prolonged pressure, or a septic infection which markedly 
 softens its wall. ^Moreover, uterine rupture is predisposed to by multi- 
 parity and by abnormal presentations. In 30 cases of rupture of the 
 uterus occurring at the Sloane Hospital 23 were in multigravidje and 7 
 in primigra\idje, and among the 30 there were 11 abnormal presentations. 
 
 Rupture of the uterus during pregnancy usually occurs as a result of 
 an abnormal pregnancy, as an interstitial pregnancy or an hydatidiform 
 mole which gradually inroads the uterine wall until it perforates it. 
 
 lvui)ture of the uterus during the puerperium usually occurs as a result 
 of necrosis following prolonged pressure, a septic uterus, or of a currettage 
 in a septic uterus. 
 
 When a portion of the lower uterine segment is unduly compressed 
 between the presenting part and a sharp promontory of the sacrum or 
 an exostosis of the pelvis the part thus compressed may slough out, 
 leaving a small opening through the uterus. The same result may 
 occur with a normal pelvis if a fetal head, too large to pass the canal, is 
 allowed to press too long against the lower uterine segment. 
 
 A more common cause of postpartiun rupture of the uterus is perhaps 
 a currettage of a septic uterus in which the operator, not perceiving that 
 he has passed the boundary of the decidua, continues the use of the 
 curette until it has gone entirely through the uterine wall. 
 
 While a weakening of the uterine wall by fatty degeneration, cicatrices 
 and tiunors undoubtedly serves as a predisposing factor, the one cause 
 of rupture of the uterus which stands out above everything else is over- 
 distention : tension of the lower uterine segment, produced by the uterus 
 working too long against an obstacle to the birth of the child. We are 
 indebted to Bandl for our knowledge of the behavior of the uterus in 
 prolonged labor. 
 
 The upper uterine segment, as described on page 211, is the active por- 
 tion and contracts and retracts while the lower portion dilates to allow 
 the i)assage of the child. The lower edge of this upper uterine segment, 
 called the contraction ring or ring of Bandl, at the beginning of labor lies 
 at about the level of the pelvic brim and nearly corresponds on the 
 
ACCIDENTAL HEMORRHAGE 581 
 
 uterus with the attachment of the peritoneum to it. If an obstacle to 
 the dehvery of the child exists, whether the dystocia is due to an obstruc- 
 tion in the bony pelvis or soft parts of the canal, or whether it is due 
 to an abnormal size or presentation of the child, this upper, active uterine 
 segment retracts and thickens until the contraction ring, ^^^hich can be 
 distinctly felt, approaches nearer and nearer to the level of the umbilicus. 
 The lower uterine segment on the other hand, especially if the cervix is 
 caught beneath the presenting part, becomes thinner and thinner until 
 it can stand no further tension without yielding. 
 
 Uteri, the seat of an old cicatrix in the upper uterine segment, as from 
 a previous Cesarean section, will often show^ this cicatrix as the part 
 of least resistance and the yielding of the wall will occur here, but in 
 uteri without cicatrices it is in the lower uterine segment which is the 
 yielding, tliinning portion. 
 
 With a portion of the uterus stretched to its limit, its rupture may 
 occur in one of two ways: 
 
 1. It may occur spontaneously. 
 
 2. It may occur through intervention. 
 
 There is no doubt that a uterus will occasionally rupture spontaneously 
 if left too long working against an obstacle to delivery; the thinned out 
 uterine wall finally yielding under the influence of uterine contractions 
 alone. 
 
 JNIuch more commonly, however, rupture occurs as the result of inter- 
 vention by the obstetrician, and the one fact in this connection above 
 all others which the student of obstetrics should have impressed upon 
 his mind, is that a tonic uterus with upper uterine segment contracted 
 and retracted, with the ring of Bandl near the umbilicus and the lower 
 uterine segment thinned out, is just the uterus to rupture if it is 
 subjected to any more tension within it, as by a version or any 
 intra-uterine manipulation. 
 
 ]Moreover, a rupture of the uterus often occurs as an extension of one 
 or more of the lacerations of the cervix produced in the course of an 
 accouchement force. This is especially true in the case of a placenta 
 previa, where the lower uterine segment is rendered more friable by the 
 dilated sinuses and where the obstetrician in order to save the mother 
 from further loss of blood is anxious to complete the delivery as soon as 
 he reasonably can. It has also occurred a number of times in the course 
 of an accouchement force in cases of eclampsia with long, rigid cervix, 
 where the cervix w^as torn rather than stretched, and where the cervical 
 tear made by the hand became a uterine tear when the version and 
 extraction were performed. 
 
 Frequency. — Fortunately rupture of the uterus is a rare accident and 
 it will become still more rare when the dangers of version in a tonic uterus 
 and a very rapid accouchement force, with a long, rigid cervix are more 
 generally understood. 
 
 The frequency of rupture of the uterus is variously stated by different 
 observers, but is usually given as about 1 in 1000 cases. Statistics in 
 private practice are often misleading, as autopsies after confinement in 
 
582 HEMORRHAGE 
 
 private practice are few and the death resulting from uterine rupture 
 has not infrequently been assigned to shock, postpartum hemorrhage, or 
 sepsis. 
 
 It is in maternit}' hospitals where accurate records are kept that reli- 
 able statistics are obtained, yet in these unusual accidents a very large 
 service is necessary for valuable conclusions as to their frequency. 
 
 In a series of 20,000 consecutive deliveries at the Sloane Hospital 
 there were 30 cases of rupture of the uterus treated; 15 of these occurred 
 outside of the hospital and were admitted with this complication. 
 
 If all cases at the hospital were considered it w^ould make a frequency 
 of 1 in 666f cases. If only those occurring in the hospital were counted 
 the frequency would be 1 in 1333^ cases. 
 
 Varieties. — The most practical classification of cases of rupture of the 
 uterus is to consider them as examples either of complete or incomplete 
 rupture. 
 
 A complete rupture of the uterus is one in which the rent extends through 
 the uterine wall and opens the peritoneal cavity. 
 
 An incomplete rupture is one in which the rent does not open the peri- 
 toneal cavity. In the series of 30 cases treated at the Sloane Hospital, 
 16 were of the complete and 14 of the incomplete variety. 
 
 Pathology. — The tear in the uterus may be either longitudinal or 
 transverse, or a combination of the two. It may involve the anterior, 
 the posterior or either of the lateral walls. As the occiput more often 
 lies to the mother's left, it is the lower uterine segment on the left side 
 which is usually subjected to the greatest amount of tension and hence 
 the rupture is most often found on the left side. A rupture starting with 
 a laceration of the cervix is apt to be more or less longitudinal, while a 
 spontaneous rupture in a uterus not subjected to a previous Cesarean 
 section is apt to be transverse and to involve either the anterior or pos- 
 terior uterine wall. 
 
 Spontaneous rupture in a case previously subjected to a Cesarean 
 section naturally takes the direction of the uterine cicatrix. 
 
 In one case brought to the author's service the uterus was nearly sepa- 
 rated from the vaginal portion of the cervix by a transverse rupture. 
 
 The edges of the uterus are usually ragged and irregular. If the rupture 
 is incomplete and occurs as an extension of a laceration of the vaginal 
 portion of the cervix it often goes into the broad ligament and the hemor- 
 rhage opens out its folds and strips the peritoneum from the anterior or 
 posterior surface of the uterus, especially the former. In this subperi- 
 toneal space may be found more or less of the placenta and fetus together 
 with blood-clots. On the other hand, neither the fetus nor the placenta 
 may have passed through ,the rent and the condition be only detected 
 by a postpartum examination. 
 
 The hemorrhage taking place into this subperitoneal space may cease 
 spontaneously, unless the uterine artery has been torn, and form a large 
 pelvic hematoma which may be absorbed, or by a recurrence of the 
 hemorrhage may break through into the peritoneal cavity, or the pelvic 
 hematoma may become infected, subjecting the patient to the dangers 
 
ACCIDENTAL HEMORRHAGE 583 
 
 of a pelvic abscess. If the rupture of the uterus lacerates the uterine 
 artery, even the incomplete variety of the accident may prove fatal from 
 hemorrhage. The complete variety of rupture is apt to prove fatal from 
 septic peritonitis, even if the women survive the initial hemorrhage. 
 
 Symptoms. — A spontaneous rupture of the uterus during pregnancy 
 usually presents the symptoms of a ruptured ectopic gestation (see page 
 542). and will not be further discussed here. The symptoms of rupture 
 of the uterus occurring during labor usually follow those of a protracted 
 labor with membranes ruptured and with little advance. At the time 
 of the rupture the woman usually has a sharp abdominal pain, the regular 
 labor pains cease and she presents the picture of shock and internal 
 hemorrhage; especially is the condition of shock usually pronounced, 
 with pallor, rapid, feeble pulse, etc. 
 
 This is the rule, and yet some patients will be very deceptive in their 
 clinical picture. There may be very little external hemorrhage and the 
 shock may for a time be slight, so that the obstetrician is surprised to 
 find on examination that the woman has a rupture. This condition of 
 relative well-being is more apt to be associated with the incomplete 
 rather than the complete variety of uterine rupture. 
 
 Whenever a woman immediately following delivery presents the clini- 
 cal picture of pronounced shock without hemorrhage enough to account 
 for it, the possibility of rupture of the uterus should always be thought 
 of. The hemorrhage may be slight and may be largely internal rather 
 than external. The physical signs vary with the individual case and the 
 conditions existing. If the fetus and placenta have largely escaped into 
 the abdominal cavity, abdominal palpation will often detect the con- 
 tracted empty uterine body riding upon an irregular mass, which occupies 
 the lower portion of the abdominal cavity. The abdomen itself is 
 usually distended. Vaginal examination will detect under these circum- 
 stances a recession of the presenting part and the fingers introduced 
 into the cervical canal will pass into the rent. 
 
 If the uterine rupture is only diagnosed after the delivery the obstet- 
 rician may be surprised to find that his fingers pass through a rent into 
 the peritoneal cavity and that he distinctly feels intestine, or that in the 
 incomplete variety of rupture, his fingers pass up along the uterus without 
 feeling intestine and that with his other hand on the abdomen he can 
 easily approximate them with only the abdominal wall and peritoneum 
 between them. 
 
 Prognosis. — The mortality of rupture of the uterus, both maternal 
 and fetal, is high. The mother is exposed to the immediate risk of severe 
 hemorrhage and shock and to the later risk of infection. The child is 
 exposed to the risk of the protracted labor which usually precedes the 
 rupture and then to the risk of asphj'xia from separation of the placenta 
 from the uterine wall. The maternal and fetal mortality usually each 
 approximates 85 per cent. 
 
 In the 30 cases of rupture of the uterus occurring in 20,000 consec- 
 utive deliveries at the Sloane Hospital, the maternal mortality was 26, 
 or 86f per cent. 
 
584 HEMORRHAGE 
 
 In this same series the fetal inortahty was 24, or SO per cent. 
 
 The maternal mortality is less in the incomplete than in the com]>lete 
 variety of rupture. In this series of 'M) cases, 10 were of the complete 
 variety and 14 of the incomplete. In the 16 complete ruptures the 
 mortality was 15, or 93.7 per cent., while in the 14 incomplete ruptures 
 the mortality was 11, or 78.5 per cent. 
 
 The 26 maternal deaths of this series at the Sloane Hospital were 
 assigned as follows: Hemorrhage and shock, 15; sepsis, 9; eclampsia 
 and not due to rupture, 2. Many of these cases were nearly moribund 
 or profoundly septic on admission. 
 
 If the woman dies as a result of the hemorrhage and shock the death 
 usually occurs within twenty-four hours, while death from infection may 
 be postponed several days. 
 
 Women who have recovered from a rupture of the uterus seem rather 
 prone to a recurrence of the accident in a subsequent labor as reported 
 by Peham and IMikhine. 
 
 Treatment. — The most important and most hopeful treatment of rup- 
 ture of the uterus is prophylaxis. It is through the general recognition 
 of the danger of rupture, if a version is attempted in a tonic uterus, that 
 this accident will be avoided. Furthermore, if the danger of a rapid 
 mechanical dilatation of a long, rigid cervix without previous prepara- 
 tion by softening is recognized, there will be fewer cases of extension of 
 cervical tears into the lower uterine segment. 
 
 Prophylactic treatment implies a careful study of each individual 
 obstetric case during pregnancy and labor, so that the relative size of the 
 child and birth canal together with the presentation will be known before 
 labor begins. Moreover, during the labor any delay in its progress and 
 any marked thinning of the lower uterine segment should be looked 
 upon with suspicion and the obstetrician be in readiness to aid nature 
 whenever it is needed, and before the integrity of the uterine wall is 
 endangered. 
 
 If rupture of the uterus has actually occurred the treatment indicated 
 depends upon: 
 
 1. The variety of the rupture — complete or incomplete. 
 
 2. The amount of shock. 
 
 In the first place the fact should be established by careful examination 
 whether the rupture has opened the peritoneal cavity or not. 
 
 If the rupture has been proved to be incomplete the uterus should be 
 emptied if not already empty; its cavity and the cavity created by the 
 rent should be firmly packed with sterile (better bismuth or weak iodo- 
 form) gauze and the woman then treated symptomatically. The use of 
 ergot, saline infusion and cardiac stimulation are the usual indications. 
 
 If, on the other hand, examination discloses a complete rupture, the 
 first problem may be that of dealing with the fetus and placenta if still 
 undelivered. If they are still in the uterus or uterus and vagina, as a 
 rule they should be delivered -per vias naturales, reducing the size of the 
 fetus by craniotomy or embryotomy if necessary to facilitate delivery. 
 
 The next indication is usually to open the abdomen, remove the blood- 
 
POSTPARTUM HEMORRHAGE 585 
 
 clots, the fetus and the placenta, if they have escaped from the uterus 
 mto the abdominal cavity, and then deal ^^•ith the rent according to the 
 conditions found. If the rent is small and the edges not very ragged 
 the best procedure is to suture the rent, cleanse the abdominal cavity 
 and close it. If, on the other hand, the tear in the uterus is extensive 
 and the edges irregular and ragged, the best plan is to complete the 
 operation by a hysterectomy. 
 
 The question now arises, Is the amount of shock ever a contra-indica- 
 tion to the abdominal operation even in a complete rupture? The best 
 answer to this question is an affirmative one. There are cases in which 
 the woman is in extreme shock in which the hemorrhage is not very 
 active and in which the probability is great that if subjected to an 
 abdominal operation at once she would be lost upon the table. Under 
 such circumstances as these the best treatment is to pack the uterus and 
 rent firmly with gauze to prevent any further hemorrhage and then 
 endeavor to overcome the shock of the woman. Not infrequently at 
 the end of twelve to twenty-four hours the woman has rallied suffi- 
 ciently to enable her to endure an abdominal operation and then the 
 intra-abdominal problems can be dealt with as above. 
 
 As to the treatment of a perforation of the uterine wall caused by a 
 pressure necrosis, whether the opening be anterior into the bladder or 
 posterior into the peritoneum or rectum, it may be said that better 
 results are usually obtained by leaving the patient alone with the hope 
 that nature will clean and close the fistula, rather than by operation. 
 
 If the perforation of the uterus has been caused by a curette, it is 
 usually the wisest plan to open the abdomen and deal with the uterine 
 rent according to the conditions found, either suturing the rent if the 
 uterus is not infected or performing hysterectomy if the rent is large and 
 ragged and the organ septic. A number of cases of perforation of the 
 non-pregnant uterus with sound or curette have been reported in which 
 the abdomen was not opened and yet the woman recovered. In the 
 pregnant or recently pregnant uterus, however, the conditions for which 
 a curette would be likely to be used are so often septic and the risk of 
 carrying septic material into the peritoneal cavity by the perforation is 
 so great, that abdominal section is usually the best method of dealing 
 with perforations of the pregnant uterus. 
 
 If a loop of intestine has prolapsed into a ruptured or perforated uterus 
 the indication is to open the abdomen and, aside from either suturing 
 the rent in the uterus or performing hysterectomy, to deal with the 
 loop of intestine according to its vitality, cleansing and leaving, or 
 
 resecting it. 
 
 * 
 
 POSTPARTUM HEMORRHAGE. 
 
 This term is usually applied to a hemorrhage occurring within twenty- 
 four hours from the birth of the child and is usually called primary if it 
 occurs T\dthin the first hour before the abdominal binder is applied and 
 secondary if it occurs later. For convenience in description, in histories 
 
586 HEMORRHAGE 
 
 of patients, it is the custom to divide hemorrhage into three different 
 degrees (arbitrary of course) according to the amount lost. 
 
 Thus hemorrhage of the first degree, sixteen to twenty-four ounces. 
 
 Hemorrhage of the second degree, twenty-four to thirty-two ounces. 
 
 Hemorrhage of the third degree, thirty-two ounces or over. 
 
 Frequency. — An idea of the frequency of occurrence of postpartum 
 hemorrhage will be gained from the records of 20,000 consecutive deliv- 
 eries at the Sloane Hospital. In this series not only was the occurrence 
 of postpartum hemorrhage recorded, but the different degrees of hemor- 
 rhage were noted. Of course the personal equation of the observer enters 
 largely into the record of blood lost in each case, and yet the series is 
 large enough to furnish a reliable average. 
 
 In the 20,000 deliveries there were 2118 cases in which a blood loss of 
 sixteen ounces or more was recorded. This gave a frequency of 10.5 per cent. 
 
 This frequency varied greatly in the different thousands, from 21.6 
 per cent, in the fourth thousand to 1.9 per cent, in the nineteenth 
 thousand. The average frequency of occurrence of the different degrees 
 of hemorrhage was first degree, 6.4 per cent.; second degree, 2.6 per cent.; 
 third degree, 1.5 per cent, of cases. 
 
 Etiology. — For a proper understanding of the etiology of postpartum 
 hemorrhage, nature's provision for the control of bleeding after the 
 separation and expulsion of the placenta must first be considered. 
 
 1. The dilated uterine sinuses are surrounded by muscle fibers and 
 bundles, some longitudinal and some circular, the contraction and retrac- 
 tion of which have a tendency to close the lumina of the vessels. 
 
 2. The increased coagulability of the blood in the latter part of preg- 
 nancy and in labor with the leukocytosis and the diapedesis of the 
 leukocytes into the connective tissue surrounding the uterine sinuses, 
 favors thrombosis in these vessels. 
 
 3. The slowing of the current of blood through these sinuses still 
 further favors the process of coagulation and thrombosis. All three are 
 normally in action in the control of hemorrhage after a normal labor. 
 
 Of these three, the contraction and retraction of the musculature of 
 the uterine wall are the most important. In fact it is upon the normal 
 contraction and retraction of the uterus after labor that the safety of the 
 woman depends. In general, postpartum hemorrhage may be looked 
 upon as due to one or other of two causes: 
 
 1. A failure of the uterus to normally contract and retract. 
 
 2. A laceration of the parturient canal opening a vessel or vessels of 
 importance. 
 
 Failure of the uterus to normally contract and retract, or relaxation of 
 the uterus may be due to several causes, both predisposing and exciting. 
 
 Predis'posing Causes. — In general, multiparity favors relaxation of the 
 uterus, postpartum hemorrhage occurring about twice as often in mul- 
 tipara? as in primiparte. An overtired muscle, as after a protracted labor; 
 an overstretched muscle, as in multiple pregnancy or hydramnios; a 
 poorly developed muscle; a muscle weakened by disease or bad hygiene; 
 a too rapidly emptied muscle; a muscle with defective innervation: All 
 
POSTPARTUM HEMORRHAGE ^ 587 
 
 these conditions may be considered as predisposing to a relaxation of the 
 uterine muscle. 
 
 Another cause which deserves emphasis is prolonged anesthesia which 
 often leaves the uterus wdth poor contractile power. Furthermore, cer- 
 tain general conditions of the woman such as pulmonary, cardiac, or 
 hepatic disease, by interfering with the normal balance of circulation, 
 tend to bring about the same condition. Certain conditions of the 
 blood, as anemia or toxemia, are often associated with uterine relaxation. 
 The presence of a tumor, as a fibromyoma in the uterine wall, and the 
 presence of anything in the uterine cavity, whether it be a tumor, a por- 
 tion of the placenta or a blood-clot, interferes with normal contraction 
 of the uterus and so predisposes to hemorrhage. Postpartum hemor- 
 rhage is common after placenta previa, as the dilated uterine sinuses are 
 then situated in the lower segment, which has little contractile power. 
 
 The interference with a normal uterine contraction may be outside the 
 uterus and may be due to a distended bladder or rectum. It may be 
 due to adhesions between the uterus and the neighboring viscera or 
 between the uterus and the abdominal wall. It may be due to conditions 
 of the nervous system, as mental excitement, grief, anger, etc. 
 
 Foremost among the exciting causes of postpartimi hemorrhage stands 
 a mismanagement of the second and third stages of labor. An improper 
 employment of Crede's expression of the placenta, either too early, too 
 rapid or too forcible favors improper uterine contraction and hemor- 
 rhage. 
 
 Diagnosis. — The first question in postpartum hemorrhage is the 
 diagnosis of its existence and its source. The hemorrhage, of course, 
 usually appears externally, and it is then easy for any observer to tell 
 that the woman is bleeding. On the other hand, the uterus may relax 
 and concealed blood accumulate within it until the woman is nearly 
 exsanguinated. In other words, the woman may nearly bleed herself 
 to death into her o^mi uterus, the hemorrhage being concealed and the 
 patient simply presentijig the constitutional symptoms of hemorrhage. 
 
 This concealed pastpartum hemorrhage with an unruptured uterus will 
 not occur if the fundus is carefully guarded in the third stage, and dur- 
 ing the hour following. The criterion of this concealed hemorrhage is 
 the feel of the fundus. If the fundus is firm and well contracted and no 
 bleeding appears externally the woman is not suffering from postpartum 
 hemorrhage. 
 
 On the other hand, it may be difficult at first to locate the fundus, 
 which may be like a lax bag, but soon a little friction identifies it and a 
 little compression expels large masses of blood-clot and fluid blood and 
 the fundus then resumes its normal consistency and normal postpartum 
 size. 
 
 If the woman is bleeding externally the question is, What is the source 
 of the hemorrhage? The diagnosis is made by the condition of the fundus. 
 If the fundus is not firm and compression of it expels clots and fluid 
 blood, the source of the hemorrhage is the relaxed uterine body. But 
 if the fundus is firm and well contracted and the bleeding still continues. 
 
588 HEMORRHAGE 
 
 the source oi the hemorrhage is a laceration of tJie lower parturient canal, 
 the cervix, va<j;ina, or vuh'a. 
 
 Physical Signs and Symptoms. TJie first e\i(icnce of postpartum 
 hemorrhage is usually a freer discharge of blood than normal from the 
 vulva outlet detected while cleansing the i)erineum prior to the applica- 
 tion of the vulva pads, or it may be the too-rapid soaking of the vulva 
 pads with blood. The sign which deserves especial emphasis because 
 the one sought at once on seeing or being told that the woman is 
 bleeding is a relaxed fundus. The condition has been described when 
 discussing the diagnosis. 
 
 The constitutional symptoms of severe postpartum hemorrhage if 
 once seen can never be forgotten. The pallor; rapid and feeble pulse; 
 the restlessness; air hunger; the patient wishing the windows open and 
 asking to be fanned; the pinched face; dry lips and tongue, and thin, 
 peaked nose. 
 
 This is the picture of hemorrhage. It is astonishing how much blood 
 some women can lose without showing marked symptoms of its loss and 
 how rapidly they will recover if the hemorrhage is checked and yet after 
 repeated hemorrhages a small additional blood loss in some women will 
 l)rove fatal. 
 
 Treatment. — The most important feature in the treatment of post- 
 partum hemorrhage is prophylaxis. This means a proper hygiene during 
 pregnancy with plenty of fresh air, with suitable food and exercise. It 
 also means intelligent conduct of the different stages of labor, especially 
 the second and third. In the second stage the woman should not be 
 allowed to go too long unaided lest the uterus become overtired and 
 relax later. She should not be given too much anesthetic, especially if 
 chloroform is used. 
 
 The proper management of the third or placental stage is perhaps 
 the most important of all. Sufficient time under ordinary circumstances 
 should be given for the uterus to contract upon the placenta or away from 
 it and so complete the separation and expulsion of both placenta and 
 membranes. 
 
 The rule followed at the Sloane Hospital is to allow twenty minutes for 
 this process. Occasionally a portion of the placenta becomes separated 
 in advance of the rest, perhaps because the remainder is abnormally 
 adherent or because there is a divided placenta; at any rate, the surface 
 from which the separation occurred may bleed quite profusely as regular 
 uterine contraction is prevented by the portion of the placenta still 
 attached. Under these circumstances the indication is usually to empty 
 the uterus without waiting for the twenty minutes to elapse. 
 
 In the expression of the placenta by Crede's method, the most impor- 
 tant precaution is to attempt the expression only during a contraction 
 of the uterus. Strong, downward compression of a relaxed uterine bofly 
 tends to cause an inversion of the uterus thus favoring the occurrence of 
 a hemorrhage rather than preventing it. 
 
 To avoid hemorrhage from retained secundines the placenta and mem- 
 branes should be carefully examined after expulsion, arid if any large 
 
POSTPARTUM HEMORRHAGE 589 
 
 portion is missing it should be removed manually with the gloved hand. 
 Attention has already been called to the fact that to ensure the uterus 
 maintaining its normal postpartum contraction, its fundus should be 
 carefully guarded for an hour after the delivery of the child. In the 
 active treatment of postpartum hemorrhage the first step is to seize 
 the fundus through the abdominal wall and if it is not found well con- 
 tracted, to manipulate it until it contracts firmly and the uterus expels 
 its contents, as it is the form of postpartum hemorrhage with relaxed 
 uterus, which one is most frequently called upon to treat. This will 
 be considered first, leaving the hemorrhage from laceration of the lower 
 parturient canal with contracted fundus until later. 
 
 Having stimulated the uterus to contract and having made sure 
 that it is empty, even by the introduction of the gloved hand if neces- 
 sary, the next problem is to maintain this contraction. While the hand 
 is in the uterine cavity the uterus usually contracts well, and especially 
 if the other hand upon the abdomen is compressing the fundus, according 
 to the method of Gooch, the bleeding usually ceases. This same result 
 can usually be brought about by Breisky's method of uterine compression, 
 by which the uterus is compressed between the fingers of the two hands, 
 one making upward pressure in the anterior fornix and the other on the 
 abdominal w^all making downward pressure upon the uterine fundus. 
 These, however, are only temporary procedures. 
 
 For maintaining uterine contractions we have three general methods, 
 any or all of which may be wisely made use of. They are: 
 
 1 . The use of drugs. 
 
 2. The douche. 
 
 3. Intra-uterine gauze tamponade. 
 
 Drugs. — As a rule some preparation of ergot, as the fluidextract Sij, 
 has been given by the mouth immediately following the expulsion of the 
 placenta. At any time after a half -hour one-half this dose may be 
 repeated, or better, a corresponding hypodermic dose of aseptic ergot 
 may be given. The extract of the pituitary gland often proves most 
 useful under these circumstances. 
 
 The Douche. — If a sterile douche bag, tube and nozzle are at hand, 
 as should always be the case, a hot intra-uterine douche of a temperature 
 116° to 120° F. may be given wath advantage. As a rule a sterile normal 
 salt solution is the best, although the douche may be made more astrin- 
 gent by using 2 to 4 per cent, acetic acid solution, or hot iodin solution 
 may be used, adding iodin to sterile water until it assmnes a wine color. 
 If, with the employment of the hot douche, prepared in one of the ways 
 just mentioned, the uterus does not maintain its contraction and the 
 hemorrhage cease, the best procedure is an intra-uterine tamponade. 
 
 Gauze Tamponade. — Although plain sterile gauze may be used for an 
 intra-uterine tamponade, it does not remain sweet long in the parturient 
 canal, where the blood and mucus with which it becomes soaked soon 
 impart to it a disagreeable odor. For this reason at the Sloane Hospital 
 it is the custom for all intra-uterine and vaginal packing to use a bismuth 
 gauze (bismuth subcarbonate, 1 ounce; glycerin, 1 ounce; water, 1 pint); 
 
590 HEMORRHAGE 
 
 the gauze is soaked in this, then drietl and steriHzed), or a o per cent, 
 iodoform gauze. The bismuth gauze usually remains sweet for twenty- 
 four hours and does not carry with it the characteristic disagreeable 
 odor of iodoform. 
 
 In the use of any gauze, as an intra-uterine tamponade, great care 
 must be taken that the gauze does not become infected during its intro- 
 duction. 
 
 The best plan is always to carry in one's obstetric outfit glass tubes 
 containing strip gauze pre})ared for intra-uterine packing in case of need. 
 When introducing it into the uterus, the tube of gauze is held by the 
 nurse above the pubes, the perineum is retracted with a speculum, the 
 cervix is pulled do\\Ti with a vulsellum and as the labia are separated 
 the gauze is passed with a long forceps, as for instance, a loop-ended 
 sponge holder, into the cavity of the uterus, clear to the fundus. It is 
 important that the gauze reach the fundus so as to leave no space in the 
 upper part of the uterine cavity, where the blood may accumulate and 
 balloon the uterus. For this reason it is well to have a hand on the fundus 
 as the gauze is carried carefully upward until it meets with resistance. 
 That part of the gauze is then released and a portion seized lower down ; 
 this is passed upward and so on until the cavity of the uterus and then 
 the vaginal canal are filled. 
 
 Conditions sometimes arise, as in extreme emergencies, where the 
 speculum and vulsellum are not to be had. Under these circumstances 
 an intra-uterine tamponade can be done with any long forceps like the 
 sponge holder. The perineum can be depressed with the back of the 
 gloved left hand introduced into the vagina and along the palm of this 
 hand, which also separates the \Tilva, the gauze can be passed into the 
 uterus as before. 
 
 In other emergencies the sterile gauze may either be lacking or be in 
 insufficient quantity and yet the woman is bleeding profusely. Any 
 freshly laundered material like a sheet may be torn up and used for the 
 tamponade. It may be argued that the sheet is not sterile and there is 
 risk of infection. That is all true, but the woman is bleeding profusely 
 and the danger of death from hemorrhage is greater than that from 
 infection from freshly laundered sheets, which probably do not contain 
 pathogenic organisms of marked virulence. The lesser risk must be 
 chosen. The amount of gauze needed to control some cases of post- 
 partmu hemorrhage is considerable. In one case, whose life the author 
 probably saved through the intra-uterine tamponade, he used twenty 
 yards of strip packing a,nd two towels before the hemorrhage ceased. 
 The intra-uterine tamponade is usually removed at the end of twenty-four 
 hours. Having checked the hemorrhage the problem then presented is 
 the treatment of the general condition of the patient. 
 
 The i»dications depend largely upon the condition of the pulse. If 
 this is fair, keeping the patient quiet, surrounded with hot blankets, wdth 
 head low, perhaps with the foot of the bed elevated and the restlessness 
 relieved by a small dose of morphin will meet the indications. In 
 extreme cases, where the pulse is very feeble or impalpable at the wrist, 
 other measures must be resorted to. The amount of blood loss should 
 
POSTPARTUM HEMORRHAGE 591 
 
 in part at least be replaced by an intravenous saline infusion or by sub- 
 cutaneous h^^podermoclysis. 
 
 The limbs of the patient should be bandaged to maintain as much of 
 the blood of the body as possible in the trunk. Cardiac stimulants should 
 be administered and of these strychnin is one of the best. The uterine 
 fundus should be carefully guarded to prevent further hemorrhage and 
 some recommend the compression of the abdominal aorta. The question 
 of cardiac stimulation in uterine hemorrhage is one demanding careful 
 judgment. The uterus may not bleed if the vascular tension is low, 
 while if the tension is greatly increased by cardiac stimulation the thrombi 
 may become loosened and hemorrhage recur. The knowledge of experi- 
 ence is a most valuable asset in these decisions and can only be gained 
 by considering the dangers of too low blood-pressure on the one hand and 
 too high blood-pressure on the other and then endeavoring in each case 
 to take the middle ground. 
 
 The women in these cases of postpartum hemorrhage are thirsty from 
 loss of blood, and allowing them to drink freely of water as soon as the 
 stomach will retain it and the frequent administration of a saline enema 
 will, as a rule, not only relieve the thirst, but improve the quality of the 
 pulse. 
 
 Laceration of the Lower Parturient Canal. — Thus far we have been 
 considering postpartum hemorrhage with relaxed uterine body. In some 
 cases examination of the fundus shows it well contracted, yet bright 
 red blood is trickling freely over the perineum. This means that there 
 is some laceration of the lower parturient canal. It may be at the vesti- 
 bule or in the vagina, but is probably in the cervix. 
 
 The source of this bleeding should be sought and if it is at all pronounced 
 it should be checked by suture. If it comes from the cervix, a vulsella 
 in its anterior lip, or in the absence of a vulsella, a stitch placed in the 
 anterior lip, will draw the cervix into view, especially if the perineum 
 is retracted with a speculum (see Fig. 368). The laceration can then be 
 repaired. Care should be taken on the one hand to place the first stitch 
 high enough to include the upper angle of the tear and on the other hand 
 care should be taken that the last stitch does not close the cervical canal 
 so tightly as to interfere with drainage and so favor infection. These 
 lacerations are usually best sutured with chromicized catgut, which 
 holds the tissues in apposition until union is complete, but does not have 
 to be removed. 
 
 Inversion of the Uterus. — One of the complications of delivery occa- 
 sionally associated with postpartum hemorrhage, although fortunately 
 a rare occurrence, is an inversion of the uterus. A condition in which, in 
 its complete form, the uterus is turned wrong side out and upside down. 
 The inversion, however, instead of being complete (as sho-^^i in Plate 
 IX, dra^Ti from a photograph of a case seen in consultation by the 
 author), may be incomplete and consist simph' of a downward cupping 
 of the fundus. The frequency is usually stated as about once in 200,000 
 cases, although most consulting obstetricians of large experience have 
 seen several cases. It seems to be much more common in primiparse 
 
592 
 
 HEMORRHAGE 
 
 than in multipara\ It usually occurs in the third stage of labor, but has 
 been reported as occurring as late as the second week. These late cases 
 may have been o\erlooked earlier. It may recur after replacement, as 
 reported by Fisher, on the third day. 
 
 Etiology. — The conditions necessary for the occurrence of an inversion 
 of the uterus after labor are a relaxation of the fundus and a dilatation 
 of the cer\"ix. ^^ ith these conditions present it may occur in one of three 
 ways. 
 
 1 . It may be pushed down from above. 
 
 2. It may be pulled down from below. 
 
 3. It may fall down spontaneously. 
 
 Fig. 36S. — Showing a recent cervical tear. (Bunim.) 
 
 The most usual cause of an inversion of the uterus is the improj)er 
 application of Crede's method of expression of the placenta. This should 
 only be practised while the uterus is contracted. If the fundus is relaxed 
 it is a relatively easy matter to indent it, and when once an indentation 
 has occurred it is a still easier matter to continue this indentation into 
 an incomplete inversion of the uterus. In the cases which have occurred 
 and been seen by the author this has been the etiology. 
 
 It must ])e admitted that with a placenta adherent to a relaxed fundus, 
 traction on the cord which used to be practised by ignorant midwives 
 could produce inversion. This has not been met with in my experience. 
 
 A number of obser^■e^s have reported cases of spontaneous inversion 
 
PLATE IX 
 
 Complete Inversion of Uterus. 
 
POSTPARTUM HEMORRHAGE 593 
 
 of the uterus, in which a relaxed fundus fell down within a dilated cervix 
 under the influence of the contraction of the abdominal muscles or the 
 weight of an adherent placenta. This, however, must be a rare occur- 
 rence, and it is wiser to consider an inversion of the uterus as usually the 
 result of mismanagement on the part of the obstetrician. 
 
 In g^Tiecology one occasionally meets with a case in which a submucous 
 fibroid attached to the fundus of the uterus has been gradually expelled 
 through the cendx which it has slowly dilated and has drawn the fundus 
 after it, producing an inversion of the fundus. This, however, is a gradual 
 process, has little connection ■v^'ith the acute inversion of obstetrics, and 
 will not further concern us here. 
 
 Signs and Symptoms. — The diagnosis of inversion of the uterus .after 
 delivery is usually made by noting the absence or cupping of the fundus 
 above, by the presence of a mass below, usually mth the placenta adherent 
 to it and by evidences of shock and hemorrhage presented by the patient. 
 The symptom of shock in the complete variety of inversion of the uterus 
 is quite pronounced and usually leads one to seek the cause. The amount 
 of hemorrhage varies in different cases, but in those seen by the author 
 it has been greater in the incomplete variety where the placenta had been 
 expelled, but in the process a portion of the uterus had been carried down 
 toward the cervix, preventing normal contraction of the uterine body. 
 In the case illustrated in Plate IX, where the inversion was complete 
 and the placenta was adherent to the inverted fundus, there was rela- 
 tively little hemorrhage, shock being the pronounced symptom. The 
 physical signs were characteristic. The fundus could not be felt through 
 the abdominal wall, but protruding from the vulva was a mass covered 
 by the placenta with amniotic surface outward. 
 
 Progrnosis. — This depends upon its recognition and prompt treatment. 
 If the condition is recognized at once, replacement is usually easy and the 
 prognosis favorable. Neglected cases have a high mortality from sepsis, 
 hemorrhage, etc. In a series of 54 cases reported by Winckle there were 
 12 deaths. Hirst reports 6 cases "^-ith no deaths. 
 
 In 35,000 consecutive deliveries at the Sloane Hospital only 1 case 
 of complete inversion of the uterus occurred. This is pictured in 
 Plate IX, and had a favorable termination. 
 
 Treatment. — Inversion of the uterus is so often the result of mismanage- 
 ment of the third stage of labor that the prophylactic treatment is most 
 important, especially the precaution — Do not attempt Credes expression of 
 the placenta icith a relaxed fundus. Another precaution which it hardly 
 seems necessary at the present day to state is: Do not attempt delivery 
 of the placenta by traction on the cord. Certain cases of partial inversion 
 of the uterus will reduce themselves as the uterus contracts. 
 
 In the active treatment of inversion, the indication is the replacement 
 of the fundus as soon as possible, before the cervLx has contracted firmly 
 and strangulation is threatened. The method varies according as to 
 whether the placenta is still attached or whether it has been separated 
 and expelled. In order to have the mass to be replaced as small as pos- 
 sible, the better plan is usually to remove the placenta manually before 
 38 
 
594 HEMORRHAGE 
 
 attempting reduction of the fundus. After the placenta has been removed, 
 if the inversion is incomplete, the obstetrician with one hand working 
 within the cavity of the uterus and the other through the abdominal 
 wall, can usually by so-called "taxis" restore the original shape of the 
 uterus. If the inversion is complete, the problem is to carry back through 
 the cervical ring the larger uterine body. The plan of procedure is to 
 try to replace first the part which came through last, i. e., by working 
 with the fingers on one side of the uterine mass near the cervix, try to 
 carry back through the cervical ring a part of the lower uterine segment. 
 If once a start is made and a portion of the uterus is replaced, the rest of 
 the uterus usually follows easily. 
 
 With the inversion replaced the next problem is its maintenance. For 
 this purpose it is advisable to pack the uterus with gauze. The above 
 treatment is applicable to cases seen and diagnosed immediately after 
 the occurrence of the accident. If the diagnosis is delayed or the con- 
 dition is neglected, the cervix will contract firmly, and the inverted 
 uterus tend to slough with the danger of septic peritonitis. Sometimes 
 the inversion becomes chronic without sloughing or infection, but this 
 belongs within the realm of gynecology and will not be further discussed 
 here. Inversion found, however, at any time during the obstetric month, 
 does demand our consideration, and the first method to be tried is that 
 of taxis with the woman under anesthesia similar to the method already 
 described for the acute cases. If taxis fails, several operative procedures 
 are at command. These consist in dividing the cervical ring posteriorly 
 (Hirst), anteriorly (Peterson), or both anteriorly and posteriorly together 
 with the lower uterine segment (Spindli). 
 
 After replacement of the uterus these incisions are of course sutured. 
 
 Puerperal Hemorrhages. — Under this term are included all profuse 
 hemorrhages from the parturient canal occurring at any time from the 
 end of the first twenty-four hours till the end of the obstetric month. 
 
 Etiology. — The cause of puerperal hemorrhages may be either without 
 or within the uterus. The causes acting from without the uterus usually 
 do so either by causing a sudden relaxation of the organ, as some strong 
 emotion, grief, anger, fear, etc., or by interfering with uterine contraction 
 as overdistention of the bladder or rectum, especially the former. The 
 ()^'erdistention of these viscera often acts by causing version or flexion 
 with congestion and retention of blood-clots. 
 
 Causes acting from within the uterus may be either within the uterine 
 wall or within the uterine cavity, and both act by interfering with normal 
 uterine contractions. Those within the uterine wall are chiefly fibro- 
 myomata. 
 
 The most common cause of puerperal hemorrhages is something within 
 the uterine cavity, as retained portions of placenta, a placenta succen- 
 turiata, blood-clots, polypi, etc. Unless a uterus is empty it cannot con- 
 tract firmly and hemorrhage is a natural sequel. Portions.of the placenta 
 and blood-clots usually undergo putrefacti\e changes and occasion a rise 
 of temperature and other evidences of infection. Occasionally, h()we\er, 
 a portion of placenta is so firmly adherent to the uterus that it retains its 
 
PUERPERAL HEMORRHAGES 595 
 
 vitality, becomes more or less pedunculated, blood is deposited about it 
 and becomes organized and a so-called placental polypus is formed, which 
 is nourished as is a fibroid polypus through the vessels of its pedicle. 
 This placental polypus may remain in the uterine cavity for months, 
 causing hemorrhages, but without infection. 
 
 Treatment. — Causes of puerperal hemorrhages acting from without 
 the uterus, such as sudden strong emotions, overdistended bladder and 
 rectum should be eliminated h\ keeping the patient quiet and by proper 
 attention to her avenues of elimination. 
 
 Since the most common cause of puerperal hemorrhages is something 
 abnormal within the uterine cavity, this should be explored under anes- 
 thesia and emptied. This can usually be done with the fingers, aided if 
 necessary by a loop-ended sponge-holder, which can be used both as a 
 firm, blunt curette and as a placenta forceps. If the uterine cavity is 
 then freed from all debris with a gentle douche of sterile salt solution, 
 and the patient is kept quiet until involution is complete, the hemor- 
 rhage is not likely to recur. 
 
 Involution in these cases is usually aided by the administration of 
 ergot. If the hemorrhages are caused by the presence of fibromyomata 
 in the uterine wall, the indication is usually to hasten involution by the 
 administration of ergot and the application of the ice-bag to the abdo- 
 men over the fundus and to leave the decision as to the treatment of 
 the fibroid until the puerperium is passed. Occasionally fibromyomata 
 in the uterine wall not only cause puerperal hemorrhage, but as a result 
 of disturbed circulation due to the labor, undergo degenerative changes, 
 become infected and demand removal or hysterectomy even during the 
 puerperium. 
 
CHAPTER XVIII. 
 PYELITIS COMPLICATING PREGNANCY. 
 
 During the last few years it has become recognized that inflammation 
 of the pelvis of the kidney is a not infrequent complication of pregnancy 
 and the puerperium and produces symptoms which in the past have led 
 to many errors of diagnosis. 
 
 The literature of the subject prior to 1904 is very meager and mostly 
 in French, but since that date many articles have appeared reporting 
 individual cases so that now the list of recorded cases is large and steadily 
 increasing. 
 
 The condition Avas first recognized and described in 1S41 by Rayer, 
 whose Traite dc maladies des Riens, vol. iii, p. 112 et 241, contains 
 a chapter on Rapports de la pyelite et de la grossesse. 
 
 He evidently recognized pregnancy as a cause of renal distention 
 and inflammation but contrary to the present accepted view, considered 
 the pyelitis as secondary to a cystitis. 
 
 That pyelitis is not a rare complication of pregnancy and the puer- 
 perium is evidenced by the fact that from 1900 to 1910 in his service at 
 the Sloane Hospital and in his private consulting practice in New York 
 and its suburbs, the writer met with 23 cases, 17 occurring during 
 pregnancy and G during the puerperium. 
 
 Etiology. — Reblaub, at the surgical congress in 1892, first gave the true 
 etiology and pathology, i. e., ureteral compression and infection. 
 
 As early as 1877 Chamberlain^ called attention to the fact that in preg- 
 nancy the kidney is congested and the ureter dilated and for this reason 
 is more liable to infection. 
 
 The fact of frequent ureteral dilatation in pregnancy has been verified 
 at autopsy by many observers, among whom may be mentioned Stadfeld, 
 Olshausen, Loelein and others. 
 
 Stadfeld, in 16 autopsies on pregnant women, found the ureter dilated 
 on one or both sides in 9. 
 
 Olshausen, in 34 autopsies on pregnant women, found dilated ureter 
 in 25 cases. 
 
 L'reteral compression and consequent dilatation is much more apt to 
 occur on the right side than on the left. In the 25 cases in Avhich 
 Olshausen found dilated ureters, the dilatation was bilateral in 13, and 
 unilateral in 12, and of these 12 there were 10 right-sided and 2 left. 
 
 This is of importance in connection with the marked predominance 
 of right-sided pyelitis in pregnancy as compared with the left. The 
 accompanying drawing (Plate X) from an autopsy on one of the author's 
 
 1 Amer. Jour. Obstet., 1877, p. 177. 
 (596) 
 
PLATE X 
 
 Dilatation of Riglit Ureter in Patient Recently Pregnant. 
 
ETIOLOGY 597 
 
 cases, dying soon after confinement, without pyelitis, demonstrates the 
 condition of right ureteral dilatation. 
 
 Experiments on animals by Halbertsma and others have shown that 
 the urine is excreted under low pressure. Halbertsma^ showed that the 
 weight of 5 grams compressing the ureter of a dog over a surface of 
 8 mm. is sufficient to hold back a column of urine 400 mm. in height. 
 
 Ludwig demonstrated that the pressure in the renal pelvis normally 
 does not exceed 10 mm. of mercury. It requires, therefore, but little 
 compression of the ureter to retard the current and favor ureteral 
 dilatation. 
 
 To explain the greater frequency of dilatation of the right ureter over 
 the left, many suggestions have been made : 
 
 1. The rotation of the uterus on its long axis from left to right, forward, 
 places the uterus and its contents more in the right oblique diameter of 
 the pelvis than in the left and thus exerts more pressure upon the right 
 ureter than on the left. As to the causes of this rotation of the uterus, 
 it may be mentioned that as the uterus rises out of the pelvis it is deflected 
 from the median line by the promontory of the sacrum and therefore 
 lies in one or other oblique diameter. The presence of the rectum on the 
 left side of the pelvis naturally favors deflection to the opposite side. 
 Also, as the uterus rises into the abdomen the sigmoid flexure of the colon, 
 often distended, tends to lie behind the left side of the uterus and still 
 further favors the right obliquity of that organ. According to Guy on, 
 uterine and ovarian tumors, wdien movable, tend to be displaced to the right. 
 
 2. The greater prominence of the right over the left common iliac 
 artery at the brim of the pelvis exposes the right ureter to greater press- 
 ure between the uterus and the iliac artery of that side. 
 
 3. In the later months of pregnancy the greater frequency of the fetal 
 head in the right oblique diameter of the pelvis increases the frequency 
 of pressure upon the right ureter. 
 
 4. The pregnant uterus as it grows tends to displace the ureters to the 
 sides of the pelvis against which it compresses them. As the uterus 
 usually develops more to the right than to the left, the compression 
 is usually greater on that side. 
 
 On account of the greater tone in the uterine and abdominal walls 
 in primigravidpe, it would naturalh' be expected that more ureteral 
 compression, and hence more cases of pyelitis would occur in primi- 
 gravidse than in multigravidse, and that was borne out in the experience 
 of the author, there being among the 17 antepartum cases 11 primigravidse 
 and 6 multigravidse. 
 
 It has been noted that anything tending to increase the size of the 
 pelvic contents, i. e., twins, hydramnios, uterine or ovarian tumors 
 associated with pregnancy, favors the tendency to ureteral compression 
 and dilatation. 
 
 Injection of the Urinary Tract Above the Point of Compression. — From 
 the frequency with which the Bacillus typhosus appears in the urine of 
 
 1 Volkmann's Samm. klin. Vprtrag, Januarj', 1882, N. 212. 
 
598 PYELITIS COMPLICATIXG PREGXANCY 
 
 typhoid fever patient.s and from experiments on animals it would seem 
 that in many infeetive processes, provided the urinary tract is unob- 
 structed, ortjanisms may i)e eliminated 1).\ the urine without ai)precial)le 
 injury to the renal tract. 
 
 On the other hand, the experiments on animals by Reblaub and Bonneau 
 show that after an aseptic ligature of the ureter the injection of either 
 streptococci or colon bacilli into a distant part of the body can produce a 
 pyonephrosis. 
 
 From the above it seems evident that a renal tract, in which there is 
 compression of the ureter or ureters, is much more liable to infection 
 than one which is unimpeded. 
 
 In pregnancy we have on the one hand a urinary tract which is com- 
 pressed, as shown by the frequency of dilated ureters in that condition, 
 and on the other hand we have a larger amount of toxic material than 
 normal to be eliminated. Hence the frequency of pyelitis. 
 
 In most cases of pyelitis complicating ])regnancy and the puerperium 
 the disease is primarily right-sided, although if the attack is severe and 
 prolonged the left kidney is occasionally involved secondarily. 
 
 In the writer's 23 cases all but 1 were primarily right-sided and in 
 none was the involvement of the left kidney marked. 
 
 As bearing on this subject the case reported by Kouwer is one of 
 interest. 1 In Case I of his series the obliquity of the uterus at seven 
 months was distinctly to the left, and here the pyelitis was primarily 
 left-sided. When the position of the uterus was corrected the symptoms 
 of the pyelitis suddenly disappeared. In a series of 62 reported cases 
 the left side was primarily infected but six times. In a few cases it has 
 been bilateral. 
 
 The infecting organism in the pyelitis of pregnancy is usually the colon 
 bacillus, and often a diarrhea or intestinal disturbance has preceded the 
 attack. 
 
 Mnay, on the other hand, found in one of his cases the streptococcus, 
 and in a case reported by Lop the gonococcus was found. 
 
 The period of pregnancy at which pyelitis is most likely to occur is, 
 judging from the author's cases, between five and eight months. In the 
 17 cases of the author's in which the pyelitis appeared during pregnancy, 
 it occurred at five months in 7; at six months in 3; at seven months in 
 3; at eight months in 2. In 2 cases it appeared near term. 
 
 In a case referred to by Kendirdjy- it occurred at two and a half 
 months. 
 
 Clinical Course. — Although occasionally the onset of the disease is 
 insidious, with scarcely any rise of temperature and slight pain, and the 
 condition is discovered accidentally by examination of the urine, as a 
 rule the onset is sudden and marked, presenting the following symptoms: 
 Pain in the right lumbar region; a rise of temperature often accompanied 
 by a rigor; irritability of the bladder. 
 
 1 Pyelonephritis en zwangerschap Niederl. Tijdschr. v Geneesk., Amsterdam, 1904, 2 r., 
 xl, d. 2, 539-549. 
 
 - Gazette de hopitaiix civils et niilitares, 1904, xxvii. 
 
CLINICAL COURSE 
 
 599 
 
 Pain in the Right Luinhar Region. — Although very rarely the left 
 kidney is the organ chiefly involved and near it the pain is located, 
 and although occasionally the pain seems to be general over the abdomen, 
 the typical picture of pyelitis is pain and tenderness in the region of the 
 right kidney. This pain is sometimes very severe and agonizing, some- 
 times only elicited by palpation or motion. The pain often follows the 
 course of the ureter from kidney to bladder. It is often intermittent. 
 
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 -Typical case of pyelitis. Pregnancy seven months advanced, 
 puerperjum at term. 
 
 Normal 
 
 Rise of Temperature. — Most cases show a rise of temperature ranging 
 from 102° to 104° F., often accompanied by one or more rigors. In mild 
 cases, under appropriate treatment of the condition, the temperature 
 subsides in from four to seven days, but in more severe types there are 
 recurrences which may extend the temperature over several weeks. The 
 accompanying temperature chart of one of the author's cases illustrates 
 an average (see Fig. 369). 
 
600 PYELITIS COMPLICATIXC PREGNANCY 
 
 If the kidney .substance l)ect)nies invohed tlie temperature continues 
 higher and rigors are more frequent and pronounced. 
 
 The pain over the ki(hiey and rise of temperature, with or without 
 rigors, are usually synchronous and correspond with the obstruction of 
 the ureter and retention of purulent urine above the region of obstruction. 
 
 With the overcoming of the obstruction and establishment of a free 
 flow from kidney to bladder the pain and temperature usually subside. 
 
 During the height of pain and temperature the urine may show no pus, 
 but with the subsidence of the pain and temperature pus cells usually 
 appear. 
 
 llecurrences of the pyelitis with rise of temperature, pain and other 
 evidences of the condition may appear after several weeks of apparent 
 health. 
 
 Irritability of the Bladder. — Among the early symptoms of pyelitis in 
 pregnancy are frequent and painful micturition, perhaps misleading to 
 the diagnosis of cystitis. 
 
 In some cases the micturition, although frequent, is accompanied by 
 little pain. If the pyelitis is severe and the discharge of pus profuse the 
 inflammation may descend along right ureter to the bladder, and thence 
 up along left ureter to the left kidney, the cystitis in this case being 
 secondary to the pyelitis. AYhile in a cystitis arising during pregnancy 
 or the puerperium from many different sources of infection, the inflam- 
 mation may extend upward along the ureters and produce pyelitis the 
 typical pyelitis of pregnancy, in the opinion of the author and most 
 French authorities, is a descending infection and involves the bladder 
 only secondarily. 
 
 It is but fair to state in this connection, however, that Opitz and 
 many Germans regard the infection as ascending even if no cystitis is 
 present.^ 
 
 The urine is acid, sp. gr. 1.008 to 1.012, at first may contain only a trace 
 of albumin and perhaps a few casts, to be soon followed by pus cells, 
 renal epithelium, and l)acteria. The pus cells, as stated above, are usually 
 more abundant as the pain and temperature subside. The urine after 
 filtration often shows no albumin. The urine often contains pus cells 
 for a month or more after the constitutional symptoms have subsided. 
 In one of the author's cases the urine did not become absolutely free from 
 pus until the baby Avas nine months old. 
 
 The general condition of the patient, provided the pyelitis is unilateral, 
 continues good for a considerable time in spite of the high temperature. 
 The pulse, although rapid during the height of the temperature, soon 
 falls below 100. 
 
 If the disease becomes bilateral the general condition of the patient 
 begins to deteriorate, as sho^Ti by emaciation, pallor, loss of strength, and 
 appetite. 
 
 Diagnosis. — The diagnosis of the condition, although extremely impor- 
 tant, has until recently been largely overlooked. IMany cases of pyelitis 
 
 1 Zeitschrift fur Geburtshulfe und Gynakologie, Bd. xv, S. 209. 
 
DIAGNOSIS 601 
 
 in pregnancy have undoubtedly been mistaken for appendicitis, typhoid 
 fever, cystitis, or salpingitis. 
 
 In many cases the diagnosis is easy if the possibility of the condition 
 is borne in mind. Pain and tenderness in the region of the kidney, a rise 
 of temperature, an irritable bladder and an acid urine containing pus 
 may point at once to the diagnosis of pyelitis. On the other hand it 
 must be remembered that palpation of the abdominal viscera of a woman 
 pregnant from five to eight months is not an easy matter, and these other 
 diseases often give symptoms which closely resemble those of pyelitis. 
 
 In two of the author's cases the point of greatest tenderness corre- 
 sponded closely with the McBurney point, and it was only by a careful 
 examination of the urine that the correct diagnosis was made. It has 
 seemed to the author in studying his series of cases, that the leukocyte 
 count in the cases of pyelitis resembling appendicitis was lower than 
 would be expected in an appendicitis case correspondingly ill. The reason 
 for the point of tenderness corresponding closely with the McBurney 
 point seemed to be that pressure at this point forced the uterus back 
 against the inflamed ureter and this increased the pain. 
 
 One of the author's cases presented symptoms which at first suggested 
 typhoid fever. She had an irregular fever for several days, with an occa- 
 sional epistaxis. For three days prior to his visit she had complained of 
 pain in the right lumbar region. The diagnosis was made b}' finding the 
 Widal test negative and the urine acid, with pus cells, renal epithelium, 
 bacteria, and a trace of albumin. Her epistaxis was probably explained 
 by the amenorrhea of pregnancy. 
 
 The symptoms of pyelitis in the early stages often resemble those of 
 a cystitis, but the acidity of the urine, the location of the pain in pyelitis 
 being usually in the region of the kidney and ureter hence higher than 
 is the rule in cystitis; the higher temperature; the less vesical tenesmus 
 in pyelitis and the fact that in pyelitis 150 to 200 c.c. of boric acid solu- 
 tion can usually be injected into the bladder with very little discomfort 
 to the patient, usually distinguishes the condition from a cystitis. It 
 has already been stated that a cystitis may arise as a secondary result 
 of the pyelitis. 
 
 The differential diagnosis between pyelitis and salpingitis can usually 
 be made by the history, a bimanual examination, and the careful examina- 
 tion of the urine. 
 
 It will thus be seen that the diagnosis of pyelitis complicating preg- 
 nancy can usually be made if there is remembered the possibility of its 
 occurrence; the cardinal symptoms, viz., pain in region of the kidney 
 (usually the right), a rise of temperature and bladder irritation, and by 
 a careful examination of the urine, chemical, microscopic, and bacterio- 
 logical. 
 
 Cystoscopy and ureteral catheterization are sometimes of aid in 
 diagnosis. 
 
 In the case of Price,^ a catheter introduced into the right ureter passed 
 
 1 Med. Record, 1904, xxvi, 379-385. 
 
602 PYELITIS COMPLICATING PREGNANCY 
 
 but a short distaiur and l)ucklcd. It passed easily into tlie left ureter. 
 The cystoscope showed diseoloration about the right ureteral orifiee. 
 In this ease al)()rti()u was induced and a month later a catheter passed 
 alon<i; the right ureter without difficulty. 
 
 Pyelitis conii)licating the puerperium may arise either as a descending 
 infection like the pyelitis of pregnancy, or as an ascending infection 
 secondary to a cystitis. Arising in either of these two ways it is often 
 mistaken for uterine infection and the uterus subjected to many useless 
 indignities. The usual rules of diagnosis as applied to pyelitis complicat- 
 ing pregnancy will usually solve the problem in the puerperium. 
 
 Prognosis. — The prognosis in pyelitis complicating pregnancy varies 
 greatly. If there has been no previous disease of the kidney and the 
 attack is mild and unilateral the prognosis is usually good. 
 
 Fig. .370. — Kidney removed from case whose temperature chart is shown in Fig. 371. 
 
 ^Yhen the disease is bilateral and severe there is always a possibility 
 of its extending to the kidney substance, perhaps producing multiple 
 abscesses and demanding nephrectomy, as occurred in one of the author's 
 cases (see Figs. 370 and 371). 
 
 As a rule the urine shows evidence of the disease for several weeks 
 after the subsidence of the constitutional symptoms. The possibility 
 of a recurrence of the attack during the same pregnancy or during the 
 puerperium should be borne in mind. This has occurred in the author's 
 experience. 
 
 The condition may also recur in subsequent pregnancies, as reported 
 by Vinay, who has seen it recur in three successive pregnancies. Cases 
 are reported in which several months after childbirth and after apparent 
 general recovery pyelonephritis occurred which demanded nephrectomy. 
 
TREATMENT 603 
 
 The above represents the dark side of the picture and is exceptionaL 
 
 The rule is that the attack is mild; under appropriate treatment lasts 
 but a few days; the patient goes to term and enjoys a normal puerperium. 
 
 It is possible that a pregnant as well as a non-pregnant patient may 
 have a pyelitis resulting from a calculus or from a tubercular inflamma- 
 tion, but these do not belong in the class now under discussion. 
 
 Treatment. — In the vast majority of cases the medical treatment of 
 rest in bed, drinking large quantities of water, fluid diet and a urinary 
 antiseptic meets the indications and is followed by the recovery of the 
 patient. Often within forty-eight hours after beginning the treatment 
 the temperature and pulse return to normal and the patient feels com- 
 paratively comfortable, although the urine still shows pus. The urinary 
 antiseptic which has given the author the greatest satisfaction is urotropin 
 given in the dose of gr. v four times a day. The pain in some cases is 
 very intense, and although this is somewhat relieved by an ice-bag over 
 the kidney, it is usually necessary to administer some preparation of 
 opium. The cause of the pain is the damming back of the purulent urine 
 in the kidney and ureter, hence the pain is often most acute before pus 
 appears in the urine. 
 
 The rigor and the rise of temperature belong with the pain in this 
 period of obstructed ureter. With the overcoming of the obstruction by 
 the flushing treatment above mentioned, the pain and temperature 
 subside and pus appears in the urine, or if present before, usually shows 
 an increase. The giving way of the obstruction in the ureter under the 
 influence of increased fluid pressure above may be only temporary, and 
 recurrences of the retention with pain, fever and rigor are frequent, 
 the purulent urine each time accumulating until its pressure is suffi- 
 cient to overcome the resistance of the obstruction in the ureter, when a 
 discharge takes place into the bladder with a subsidence of the acute 
 symptoms. 
 
 In one of the author's cases this occurred at a regular interval of forty- 
 eight hours for a number of days, so that the rigor and high temperature 
 every other day with normal temperature and pulse on the intervening 
 day gave a strong resemblance to malarial infection. 
 
 In many reported cases the injection of 150 to 200 c.c. of boric acid solu- 
 tion into the bladder, as recommended by Pasteau, has seemed to stimu- 
 late increased secretion in the kidney with the overcoming of the obstruc- 
 tion and a relief of the symptoms. SippeP advises relief of pressure on 
 the inflamed kidney and ureter by having the patient lie on the opposite 
 side. He reports marked relief from this mode of treatment. 
 
 As the cause of the obstruction and infection of the urinary tract is 
 the advancing pregnancy, the question naturally arises: Should not the 
 pregnancy be terminated? In answering this question many phases of 
 the subject have to be considered. 
 
 Most of the cases recover under medical treatment and the pregnancy 
 goes to term and terminates in a normal labor and puerperium. 
 
 1 Zentralblatt fiir Gynakologie, 1905, No. 37. 
 
604 
 
 PYELITIS COMPLICATING PREGNANCY 
 
 On the other hiuul, oecasioiuilly, us oecurred in one of the author's cases, 
 the pyelitis increases in severity until it alone induces the labor. 
 
 In most cases tlie pyelitis rapidly inii)rove^ after the uterus is emptied 
 and the pressure removed. On the other hand, in some the pyelitis first 
 appears at term or in the puerperium. In a few cases the pyelitis extends 
 to the renal substance and becomes a suppurative pyelonephritis, as 
 occurred in the fifth case which came under the author's observation, 
 whose temperature chart appears in Fig. 371. 
 
 DAY OF 
 DISEASE 
 
 1 
 
 2 
 
 3 
 
 4 
 
 5 
 
 6 
 
 7 
 
 8 
 
 9 
 
 10 
 
 11 
 
 12 
 
 13 
 
 14 
 
 15 
 
 16 
 
 41- — 
 105° 
 
 E 
 
 — 
 
 E 
 
 zz 
 
 
 — 
 
 
 
 E 
 
 — 
 
 E 
 
 — 
 
 1 
 
 
 1 
 
 = 
 
 E 
 
 = 
 
 E 
 
 = 
 
 
 
 E 
 
 - 
 
 
 zz 
 
 
 13: 
 
 E 
 
 = 
 
 E 
 
 = 
 
 4.0''104- 
 
 103- 
 
 39°-^ 
 102A 
 
 
 E 
 
 ZZ 
 
 
 
 1 
 
 E 
 
 E 
 
 E 
 
 1 
 
 — 
 
 E 
 
 E 
 
 
 E 
 
 E 
 
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 — 
 
 E 
 
 
 
 
 E 
 
 E 
 
 ^ 
 
 S 
 
 
 
 1 
 
 li. 
 
 E 
 
 Zx 
 
 100- 
 
 C. F. 
 
 —140- 
 130- 
 120- 
 
 uj no- 
 lo 
 
 -I 
 
 2 100- 
 
 90- 
 
 80- 
 
 70- 
 
 E 
 
 1 
 
 i 
 
 1 
 
 £ 
 
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 ^ 
 
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 ^ 
 
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 ^ 
 
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 5 
 
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 5 
 
 5 
 
 ^ 
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 £ 
 
 ^ 
 
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 Fig. 371.- 
 
 -Case of suppurative pyelonephritis resulting from pyelitis, 
 shown in Fig. 370. 
 
 The kidney is 
 
 Judging from the writer's experience, this extension to the kidney sub- 
 stance is more likely to occur when the pyelitis begins near '.erm or in 
 the puerperium. 
 
 In some cases the passage of the ureteral catheter has seemed to 
 overcome the obstruction in the ureter and to favor drainage from the 
 kidney. The injection of 20 per cent, argyrol solution through the 
 ureteral catheter has been strongly recommended by some. It must 
 always be borne in mind, however, that any trauma of the urinary tract 
 favors a further spread of the colon bacillus infection. 
 
TREATMENT 605 
 
 Considering all these facts the author believes: 
 
 1. That interruption of the pregnancy before the period of viability 
 of the child is very seldom indicated. In only 2 of his 17 cases was 
 premature labor induced. 
 
 2. That when the pyelitis occurs between the fifth and seventh month 
 in a kidney previously healthy, a favorable prognosis under medical 
 treatment is justified for both mother and child. 
 
 On the other hand, realizing that the condition usually improves rapidly 
 after emptying the uterus and that the pyelitis, if it continues, sometimes 
 extends and becomes a suppurative pyelonephritis demanding nephrot- 
 omy or nephrectomy, it must be felt that if the fetus has reached the 
 age of viability, and in spite of medical and eliminative treatment, the 
 pyelitis fails to improve, interruption of the pregnancy is not only 
 justified, but demanded. 
 
 Disappointments in this disease are not uncommon. Occasionally, 
 after a subsidence of all subjective symptoms for a week or perhaps 
 several weeks, and after one has congratulated himself that the medical 
 treatment was all that was needed, the patient will have a recurrence 
 of all the acute symptoms, perhaps with greater severity than before, 
 and necessitate obstetrical or surgical intervention. In these cases of 
 recurring or long-continued pyelitis the use of a colon bacillus vaccine, 
 preferably an autogenous vaccine, has proved of great value. 
 
 In the severe types of the disease occurring during pregnancy and 
 failing to respond to medical treatment, the question naturally arises: 
 Shall the kidney be operated upon, or shall the uterus be emptied? The 
 author believes that the latter procedure should usually be tried first, 
 especially if there is a considerable amount of pus in the urine and the 
 lesion seems to be chiefly in the pelvis of the kidney. In these cases 
 the release of pressure upon the ureter, brought about by emptying the 
 uterus, favors better drainage from the kidney and as a rule the condition 
 rapidly improves. 
 
 On the other hand, in some cases there is very little involvement of the 
 pelvis of the kidney, but the colon bacillus infection goes right to the 
 substance of the kidney and here operation upon the kidney rather than 
 the uterus is indicated. This is illustrated by the following case occurring 
 in the author's service: 
 
 Mrs. L., a primigravida, aged twenty-four years, was admitted to the 
 Sloane Hospital, November 12, 1914. Her last menstrual period began 
 May 20, 1914. Four days before admission she was seized with a sudden 
 attack of pain in her right side. This pain continued until admission to 
 the hospital. It was increased by deep breathing or by any movement 
 of the body. It seemed to shoot down toward the right groin. She 
 suffered with frequent and painful micturition, and on the night preced- 
 ing her admission to the hospital she had a rigor with temperature 103° F. 
 
 On admission to the hospital a catheterized specimen of the urine 
 showed no pus and a culture showed no organisms. The urine on the 
 fourth day after admission showed pus cells and 10 per cent, albumin. 
 The patient then seemed to be improving under urotropin and forced 
 
606 
 
 PYELITIS COMPLICATING PREGNANCY 
 
 fluids. From that time on, however, she became steadily worse, on tlie 
 tenth and eleventh days having a rigor with a rise of temperaUire to 105° 
 F. or over, as seen from the accompanying chart (see Fig. 372). It was 
 then decided to remo\e the right kidney, which was done by the author 
 on the following day. The kidney is shown in Figs. 373 and 374. It 
 showed miiltij^le small abscesses scattered through the substance of the 
 cortex. A culture taken from these abscesses showed a pure culture of 
 colon bacilli. 
 
 DAY OF 
 MONTH 
 
 3 4 
 
 9 ' 10 I 11 12 13 U 15 Iti 17 IS I'.l 
 
 12 13 14 15 lli 17 IN I'.l 20 2r 22 23 24 ' 25 2(5 27 2S 2!» 30 1 
 
 Fig. 372. — Opeiative chart. Mrs. L. iSiippurative pyelonephriti?. 
 
 The patient made an easy recovery from her operation and her preg- 
 nancy continjued without disturbance until January 7, 1915, when she 
 came back to the hospital suffering with a p>elitis of the left kidney. 
 She went into spontaneous labor on January 12, and was delivered after 
 a short labor. Her course during the puerperium is shown in Fig. 375. 
 Her pyelitis of the left kidney subsided on the seventh day, recurred 
 between the fourteenth and sixteenth days and then disappeared. When 
 seen five months later the urine was normal and the j^atieiit in good 
 condition. The continuation of the high temperature with rigors and 
 pain and tenderness in the region of the kidney after the uterus has been 
 emptied, or the recurrence of these symptoms perhaps months after the 
 
Fig. 373. — Kidney of Mrs. L., showing suppurative pyelonephritis. 
 
 Fig. 374. — Kidney of Mrs. L., laid open, showing suppurative pyelonephritis. 
 
608 
 
 PYELITIS COMPLICATING PREGNANCY 
 
 delivery and in s\nte of medical treatment, including vaccines, usually 
 indicates operation upon the kidney either nephrotomy or nephrectomy. 
 The obstetrician is often asked, by patients who have had a pyelitis 
 in their previous pregnancy, if this is likely to recur, if they become 
 pregnant again, or is it safe for them to become i)regnant again. Before 
 answering this question it is well to bear in mind the fact that so long as 
 there is any trace of the trouble in the urine there is very apt to be an 
 exacerbation of it if the patient becomes pregnant. 
 
 DAY OF 
 H EPP. 
 
 1 
 
 
 jj_| 2 1 3 
 
 4 
 
 5 
 
 6 
 
 7 
 
 8 
 
 9 
 
 10 
 
 11 12 
 
 13 U 
 
 15 
 
 16 
 
 17 
 
 18 19I2O 
 
 
 DAY OF 
 
 MONTH 
 
 m 
 
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 7 S 
 
 Jt 
 
 10 11 
 
 12 
 
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 15 
 
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 IS 
 
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 20 
 
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 21 
 
 22 23 
 
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 27 28 
 
 m 
 
 29 30 '31 
 
 1 i 1 ; 1 
 
 
 100 
 
 7 
 
 C. F./ 
 / 
 
 140 
 
 v/o 
 
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 rr 
 
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 DEFEC. 
 
 0|N|0|^ 
 
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 d|njD 
 
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 T|u- 
 
 JD N D 
 
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 Fig. 375. — Puerperal chart. Mrs. L. Pyelitis of remaining kidney. 
 
 It has been known to recur in three successive pregnancies, as reported 
 by Vinay anrl mentioned above. On the other hand, if the urine has 
 been free from all evidence of pyelitis for a year or more, the author 
 believes the chances of a recurrence in a subsequent pregnancy are small. 
 The only 1 of his 23 cases known to have become pregnant again passed 
 through her second pregnancy, labor and the puerperium without any 
 trouble in the urinary tract. 
 
 In conclusion, I would state that patients who have had a pyelitis com- 
 plicating pregnancy or the puerperium should be strongly advised not 
 to become pregnant again until all traces of the disease have disappeared. 
 In one of the author's cases this required nearly a year. 
 
PART IV. 
 PATHOLOGICAL LABOR. 
 
 CHAPTER XIX. 
 ABN0R:\IAL labor from anomalies IX FORCES. 
 
 In normal labor the active forces of expulsion and the passive forces 
 of resistance are so nicely balanced as to insure a gradual dilatation of 
 the parturient canal, a moderate molding of the presenting part and 
 an intermittent but progressive ad- 
 vance of the fetus without injury to 
 mother or child. This balance be- 
 tween expulsive and resistant forces, 
 however, is easily disturbed, and this 
 disturbance may arise from a relative 
 deficiency or excess in either the 
 power of expulsion or the force of 
 resistance. 
 
 The expulsive forces consist of the 
 muscular power of the uterine body 
 and of the abdominal wall. The 
 resistant forces comprise the bony 
 pelvis (hard parts), and the cervix, 
 vagina and pelvic floor (soft parts). 
 This may be illustrated by the accom- 
 panying Fig. 376, in which the expul- 
 sive forces are represented above the 
 line A-B and the resistant forces 
 
 below. Even if both the expulsive forces and the resistant forces are 
 normal, the fetus from its size, attitude, presentation or position may 
 disturb the normal process of the labor and thus cause dystocia. 
 
 Abnormal labor then may arise from: 
 
 A. Anomalies in the forces. 
 
 B. Anomalies in the passages. 
 
 C. Anomalies in the fetus. 
 
 Ahnorvial labor from anomalies in the forces concerns both the forces 
 of expulsion and resistance, either of which may be deficient or relatively 
 in excess. 
 
 39 (609) 
 
 Fig. 376. — Diagram illustrating expul- 
 sive and resistant forces. 
 
GIO ABNORMAL LABOR FROM ANOMALIES IN FORCES 
 
 DEFICIENCY IN THE EXPULSIVE FORCES. 
 
 As the expulsive forces comprise the contractions both of the uterus 
 and the abdominal wall they will be studied separately. 
 
 Uterine Inertia. — Instead of normal uterine contractions recurring at 
 gradually shortening intervals and with increasing force, and causing a 
 progressive dilatation of the cervix with advance of the presenting part, 
 the contractions— "pains" — may become less and less frequent and less 
 and less efficient, although perhaps distressing and the labor be unduly 
 prolonged. This prolonged, inefficient labor due to lack of power in the 
 uterine contractions is called uterine inertia. This uterine inertia may 
 be caused by the condition of the muscle itself, without obstruction to 
 the birth of the child, and is then called primary inertia, or it may be 
 due to exhaustion caused by an excessive amount of work thrown upon 
 the uterus by more or less obstruction in the parturient canal. It is then 
 called secondary inertia. It should be stated in this connection, however, 
 that there are certain border-line cases which are difficult to classify as 
 either primary or secondary inertia and partake of the characters of 
 each. Thus the resistance presented by a rigid cervix may be sufficient 
 to exhaust the uterine contractions of one uterus, while its dilatation 
 would be an easy task for another. 
 
 Primary Uterine Inertia.^ — Primary uterine inertia may be due to various 
 causes, as for instance: 
 
 (a) Defective development of the uterine muscle. This being but a 
 local manifestation of defective muscular development throughout the 
 body. 
 
 (6) Overdistention of the uterine muscle, as from multiple pregnancy, 
 hydramnios, etc. 
 
 (c) Congenital malformation of the uterus interfering with normal 
 contractions. 
 
 {d) Distortion of the uterine muscle by fibroid growths. 
 
 {e) Weakening of the uterine muscle b}' disease. 
 
 (/) Defecti^"e innervation of the uterine muscle. 
 
 These different factors deserve separate consideration as they are far 
 from having an equal influence. 
 
 Although undoubtedly defective muscular development affects the 
 power of uterine contraction, it is often found that the lessened muscular 
 resistance in the pelvic floor so nearly offsets the lessened uterine tone 
 that the labor progresses normally. 
 
 So often has the author seen delicate "hot-house" looking young women 
 with scarcely anj' muscular development pass through an easy, normal 
 labor, that he has learned to look forward to their labor with much less 
 anxiety than in the case of certain robust, athletic women whose uterine 
 muscle is undoubtedly of excellent tone, but whose pelvic floor is as rigid 
 as their legs or arms. 
 
 That overdistention of the uterus interferes with its tone and tendency 
 to contract both during and after labor is a fact familiar to every obstet- 
 rician and can easily- be understood by students. 
 
DEFICIENCY IN THE EXPULSIVE FORCES 611 
 
 From the author's experience he can recall a number of instances in 
 which the congenital malformation of the uterus or the presence of fibroid 
 tumors in the uterine wall have been associated with long, tedious labors, 
 followed by relaxation of the uterus and postpartum hemorrhage. 
 
 The weakening of the uterine muscle by disease does not often appear 
 as a factor in uterine inertia, although it is usually included among 
 the causes of this condition. Patients are often seen pass through normal 
 labor, although emaciated by prolonged phthisis or typhoid fever, and 
 this is probably explained as above that the muscular resistance of the 
 pelvic floor is lessened at the same time as the expulsive power of the 
 uterine muscle. 
 
 The question of defective innervation of the uterine muscle causing 
 uterine inertia is an interesting one, although difficult to prove. Certain 
 it is that outside influences like the arrival of the physician, or some 
 unexpected news, will often inhibit uterine contractions for a time. 
 Furthermore, the intensity of the pain in women, unaccustomed to suffer- 
 ing, and nervously unable to bear it, will often seem to send an inhibitory 
 influence to the centre, presiding over uterine contractions, lessening 
 their force or prolonging the interval between them. For these reasons 
 it is the nervous, hysterical woman with poor nerve control, in whose 
 confinement uterine inertia should be anticipated. In this connection 
 attention may well be called to the fact that if the bladder is distended, 
 the pressure upon it during a uterine contraction may cause such acute 
 pain as to inhibit normal uterine action. 
 
 The clinical picture of primary uterine inertia is familiar to every 
 obstetrician. The uterine contractions, although perhaps starting with 
 the normal intervals, do not continue as they should, but, instead of 
 recurring with increased frequency and force, perhaps grow less and 
 less frequent and gradually diminish in effectiveness. An examination 
 of the cervix at this time will often show but little dilatation in spite of 
 the fact that the woman has been in labor for hours and her pains have 
 been more and more distressing. She is just the one to think that she 
 has had a terrible experience by the time the first stage is half completed. 
 It is only fair to state in this connection, however, that the ability to 
 endure pain varies greatly in different women and depends very largely 
 upon the nervous organization of the individual. It is not unusual to 
 meet with the type of calm, phlegmatic women, who think a little pain 
 is nothing and who pass through the discomfort of the first stage with 
 hardly a murmur, but at the present day, with our high-tension mode 
 of life and with women whose nervous systems are at equally high ten- 
 sion, it is more their misfortune than their fault that the nagging, ineffec- 
 tive pains of the first stage seem more than they can stand. 
 
 Secondary Inertia.- — The conditions present in secondary uterine inertia 
 are different: The contractions began normally and continued with 
 increasing force and frequency until the uterine muscle became tired out. 
 This is what might be expected of any muscle of which the work demanded 
 is more than it is equal to. The uterus is tired and the woman herself 
 is tired, both nervously and physically. This fatigue of the uterus may 
 
612 ABNORMAL LABOR FROM ANOMALIES IN FORCES 
 
 come early or late, depending upon the endurance of the uterus and the 
 amount of work to be done. The endurance of the uterus, like that of 
 the woman herself, seems to depend both on the muscle tone and general 
 nerve control. The amount of work demanded may be greater than 
 normal on account of some slight obstruction in the canal, perhaps due 
 to excessive rigidity of the cervix, or to absence of the aid of the fluid 
 wedge, caused by early rupture of the membranes; it may be due to an 
 abnormal presentation, or position of the child, or the presence of a 
 tumor, or lastly, it may be due to an impassable contraction of the pelvis. 
 
 The result of both primary and secondary uterine inertia is prolonged 
 labor, and this prolongation varies greatly in importance according to 
 whether the membranes are ruptured or not and whether the patient is 
 in the first or second stage. If the membranes are unruptured and the 
 woman is in good general condition the first stage of la])or may often be 
 prolonged for hours, perhaps even davs, without danger to mother or 
 child. 
 
 On the other hand, if the membranes are ruptured, the author's 
 experience teaches that the prolongation of the labor beyond forty-eight 
 hours is associated with danger alike to the child and the mother. To 
 the child from interference with its placental circulation; to the mother 
 from increased risk of infection. For this reason it is his custom at the 
 Sloane Hospital not to allow a woman to go more than twenty-four hours 
 with ruptured membranes before efforts are made to excite uterine 
 contractions. 
 
 Although, as stated above, prolongation of labor in the first stage may 
 be safely allowed to continue for many hours if the membranes are 
 unruptured, and even with ruptured membranes may continue twenty- 
 four to forty-eight hours without causing anxiety, when the labor enters 
 the second stage there should be constant progress, and in the author's 
 practice the interruption of progress in the second stage of labor resulting 
 in no advance for from one to two hours is considered an indication for 
 interference. 
 
 Treatment.- — Prophylaxis. — On considering the etiology of uterine 
 inertia it is easy to see the importance of having the woman approach 
 her labor in the best possible condition of body and nervous system. 
 Hence the reasons for advising during pregnancy regular (not violent) 
 exercise, plenty of fresh air, long hours of sleep, and freedom from 
 sources of nerve irritation as far as possible. If unable to take active 
 exercise during the latter part of pregnancy, passive exercise in the 
 shape of massage will often do much toward keeping the woman in good 
 general condition. If there is a history of previous uterine inertia or if 
 for any reason this is anticipated, the administration of strychnin 
 sulphate, gr. 3^77, three times a day for three or four weeks previous to 
 the labor will often prove serviceable. If the woman is anemic, some 
 preparation of iron is indicated. 
 
 During Labor. — In the treatment of all forms of uterine inertia one of 
 the first essentials is an accurate diagnosis of the conditions present. Are 
 the presentation and position normal? Is the relative size of child and par- 
 
DEFICIENCY IN THE EXPULSIVE FORCES 613 
 
 turient canal such that dehvery j^er vias naturales is possible? Too often 
 there are seen in consultation cases which have had feeble, ineffectual 
 pains most of the day or most of the night, and in which a careful exami- 
 nation reveals an occipitoposterior position in which a manual rotation 
 of the head and a proper application of the forceps would have termi- 
 nated the labor hours before, with markedly less suffering to the mother 
 and greater safety to the child. It is certainly time to recognize the fact 
 that posterior positions of the occiput are often associated with feeble, 
 ineffectual uterine contractions. The diagnosis in this condition can 
 often be suspected at least from the description of the case: "many hours 
 of labor with ineffectual pains and no advance." Again, too often there 
 are seen neglected cases of uterine inertia in which the relation between 
 the child and the parturient canal is such as to render delivery through 
 the natural passages impossible, and yet the uterus has been allowed to 
 work away for hours at this impossible problem until the organ itself 
 has become exhausted, the child's life endangered and the operation 
 of Cesarean section which hours before would have easily saved the 
 child with little risk to the mother, now has associated with it a relatively 
 high mortality. ^Yith an accurate diagnosis made of the conditions 
 present, and with abnormalities in position and size excluded, the question 
 may well be asked : Does the patient need reassurance, rest or stimulating 
 drugs ? 
 
 If the inertia is of the primary variety and largely dependent upon 
 the nervous apprehension of the woman, much can often be accomplished 
 by the moral support of the obstetrician in assuring her that everything 
 is all right and in urging her to endure the pains as bravely as she can. 
 If the inertia seems to be due to the fact that the acuteness of the 
 pain acts as an inhibitory impulse, preventing normal uterine contrac- 
 tions, the administration of morphin sulphate, gr. \, hypodermically, or 
 chloral hydrate, gr. xx-xxx, in warm water or milk per rectum will often 
 remove the inhibition and after a little rest greatly improve the uterine 
 contractions. If the inhibitory impulse comes from a distended bladder, 
 increasing the distress of each uterine contraction, the bladder should be 
 emptied. 
 
 When the inertia is distinctly secondary and due to exhaustion, unless 
 the obstacle to the advance of the presenting part is unsurmountable, 
 the indication is certainly rest. A woman is often seen tired out, nervous 
 and discouraged, feeling that she has done all she can, yet has accom- 
 plished little; and that the end is far off. If this woman is reassured, is 
 told that she is only tired and needs rest and is then given morphin or 
 chloral as indicated above, is allowed to secure a little rest and is then 
 given some easily digested nourishment like hot broth, the whole picture 
 often changes. She will usually resume her labor with new courage, 
 the pains will be stronger and the labor will progress normally to its 
 termination. 
 
 Where intrapartum stimulation of uterine contractions by the use of 
 drugs is indicated, three drugs should be considered: strychnin, quinine, 
 and pituitary extract. The use of ergot, formerly in vogue for uterine 
 
614 ABNORMAL LABOR FROM ANOMALIES IN FORCES 
 
 inertia should l)e absolutely abandoned until after the child is born and 
 the placenta expelled . The contractions of the uterus produced by ergot 
 are tonic in character and both interfere with the normal progress of 
 labor and endanger the life of the child. The employment of strychnin 
 and quinine during labor for stimulatuig uterine contractions is often 
 serviceable and usually safe. The contractions under the use of these 
 drugs are intermittent, resembling those of normal labor, and do not 
 endanger the child. The method usually followed by the author is to 
 give strych. sulph., gr. ^q, and quinine sulph., gr. v, every four hours alter- 
 nately. In patients especially susceptible to quinine, disagreeable symp- 
 toms, such as ringing in the ears, etc., may be produced early and the 
 discomfort of her labor be increased by the drug. In these cases it should 
 be discontinued at once. 
 
 Fituitary Extract. — Since 1909 the use of pituitary extract obtained 
 from the posterior lobe of the gland has become quite extensive for the 
 relief of both primary and secondary inertia, and experience with it has 
 now been sufficiently large to demonstrate both its value and its dangers, 
 and to indicate the conditions under which its employment is likely to 
 be followed by success and under wdiich by failure. The drug is best put 
 up in ampoules, each containing 1 c.c. representing 0.1 grain of the fresh 
 posterior lobe of the pituitary body. It should be administered intra- 
 muscularly, preferably in the gluteal region under strict aseptic precau- 
 tions. Its effect is usually evident in about five minutes and lasts about 
 twenty minutes. The dose of 1 c.c. may be given twice or three times 
 at intervals of half an hour. While admitting great advantages in the 
 use of the drug under proper conditions, the dangers will first be empha- 
 sized. Under full doses the uterine contractions are sometimes so stormy 
 and so tonic as to endanger the life of the child by asphyxia and the life 
 of the mother by rupture of the uterus, several instances of which have 
 been reported. Experience with the drug has demonstrated the fact that 
 as a means of inducing labor it is uncertain and unsatisfactory; that for 
 uterine inertia in the first stage of labor or until the cervix is either dilated 
 or dilatable, pituitary extract is unsafe. 
 
 On the other hand, when the resistance of the cervix is obliterated and 
 the bony pelvis is not contracted, the drug is a valuable one and will 
 often obviate the need of delivery by the forceps or will change the type 
 of the forceps operation demanded from the high operation to the medium 
 or the low. The author's rule in the use of pituitary extract for uterine 
 inertia is not to administer it unless conditions are such that if necessary 
 he could artificially deliver the child within a few moments if the uterine 
 contractions under the influence of the drug became too stormy and 
 prolonged. Chloroform, as a rule, will relax these tonic contractions of 
 the uterus and should always be at hand. An intramuscular injection 
 of pituitary extract at the beginning of a Cesarean section is often of 
 value as a substitute for ergot to prevent relaxation of the uterus after 
 the child is extracted. 
 
 A careful consideration of uterine inertia demonstrates the fact that 
 there are two main classes in which cases may be grouped: 
 
DEFICIENCY IN THE EXPULSIVE FORCES 615 
 
 1. Those cases of inertia in which reassurance^ rest and the stimulating 
 drugs, such as strychnin, quinine and pituitary extract, will accomplish 
 the desired result. 
 
 2. Those cases which cannot be relieved by the above-mentioned 
 methods and which require artificial delivery. 
 
 The first class has already been sufiiciently considered. It now remains 
 to consider the second class and to answer the question, Under what 
 conditions should uterine inertia be treated b}^ artificial delivery? In 
 general this question may be answered as follows: When either fetal 
 life or maternal convalescence is endangered. 
 
 Fetal Danger. — It would seem that by this time the importance of 
 carefully noting the rapidit}^ and quality of the fetal heart sounds during 
 labor would be generally recognized, and this simple precaution be uni- 
 formly and frequently observed, yet among general physicians who 
 practice obstetrics this is not the case. 
 
 There is no criterion of the fetal well-being which equals the character 
 of the fetal heart sounds, yet this criterion is often neglected. 
 
 The need of frequent observations of the fetal heart sounds is in the 
 author's judgment one of the deciding arguments in favor of the dorsal 
 position of the woman. in labor rather than the lateral position. 
 
 The lateral position requires frequent changes to the dorsal for proper 
 auscultation, and this means frequent disarrangement of the sterile 
 drapery. The dorsal position needs no such change. 
 
 The excuse of many who neglect auscultation of the fetal heart during 
 the second stage of labor is that after they have put on their rubber 
 gloves they cannot handle the stethoscope without unsterilizing their 
 gloves. 
 
 If the obstetrician has with a stethoscope carefully auscultated the 
 fetal heart during the first stage of labor, it is not necessary for him to 
 use the stethoscope during the second stage when his hands are sterile- 
 gloved. For many years the writer has carefully and frequently auscul- 
 tated the fetal heart in the second stage of labor by raising with gloved 
 hands the sterile towel usually kept on the patient's abdomen, and, 
 having the nurse pull down the night-dress so as to cover the abdomen, 
 with ear applied to the night-dress he has auscultated as desired; the 
 nurse has then folded back the night-dress, he has replaced the sterile 
 towel which he has been holding with sterile hands and this process has 
 been repeated as often as necessary. 
 
 The importance of frequent auscultation of the fetal heart during 
 the second stage of labor may well be considered as great. It furnishes 
 the chief criterion of the well-being or danger of the child, and in uterine 
 inertia if on auscultation the fetal heart is found markedly slowed and 
 especially if with this lessened rate there is associated a well-marked 
 irregularity, fetal danger is established and artificial delivery is indi- 
 cated. 
 
 This does not necessarily mean that forceps delivery or version must 
 be undertaken at once, or still less that one of the cutting operations 
 for delivery in dystocia should be performed. It simply means that the 
 
616 ABNORMAL LABOR FROM ANOMALIES IN FORCES 
 
 labor should bo expedited in the best way under the existing circum- 
 stances. If the cervix is still undilat(>d and there is no dystocia from the 
 hard parts, the use of the elastic bag until the labor can be more easily 
 terminated by nature or the forceps, may be the best procedure. 
 
 Every obstetrician realizes that with normal relations in size between 
 fetus and pelvis the key to the situation lies in the dilatation of the cervix. 
 With that undilated he must wait. With the cervix dilated the situa- 
 tion is under his control and he can terminate the labor mechanically 
 if he wishes. In the conical elastic bag of Champetier de Ribes, modi- 
 fied by Dr. James D. Voorhees, of New York, and illustrated in Fig. 432, 
 the obstetrician has an instrument which, in uterine inertia, whether 
 primary or secondary, with membranes intact or ruptured (and espe- 
 cially in the latter), serves a most useful purpose. The use of these bags 
 for the induction of premature labor will be discussed later (see page 739), 
 but in uterine inertia they meet the indication in dilating the cervix 
 before the internal os is obliterated better than anything else known to 
 the author. They do it evenly, w^ith elastic pressure and in a conical 
 shape resembling closely the conical fluid wedge of the bulging bag of 
 waters used by nature in dilating this canal. 
 
 Moreover, the elastic bag not only has the dilating power which would 
 be given it if the tube attached to the apex of the cone were pulled upon, 
 but the presence of the conical bag in the cervical canal causes reflex 
 muscular contractions of the uterine body and thus calls forth the vis a 
 tergo which was lacking. W' ith the uterine contractions forcing the uterine 
 contents down upon the base of the bag, aided if necessary by occasional 
 traction upon the tube attached to its apex, the internal os is gradually 
 dilated and the cervix retracted. If one bag is not sufficient by its 
 stimulating and dilating power to bring about the continuance of the 
 labor to a successful issue, the next size may be used. The general rule 
 being to use first the largest size which can be easily introduced, i. e., 
 No. 1, 2, or 3, it being understood that the fewer the manipulations of 
 the parts, the less the discomfort to the woman and the less risk of 
 infection. 
 
 It is seldom wise in a vertex case to use bag No. 4, as there is danger 
 of displacing the presenting part and allowing prolapse of the cord. 
 
 If the internal os has disappeared it is almost impossible to place the 
 elastic bag in the cervix without displacing the presenting part, but 
 under slight anesthesia the cervical ring may be dilated by introducing 
 and separating two or more fingers or two fingers and the thumb of one 
 hand (Harris) or one or two fingers of each hand (Edgar). 
 
 With this accomplished the labor which previously had reached a 
 stand-still is often seen to progress steadily to a successful termination. 
 
 Even with internal os obliterated, manual dilatation must be performed 
 gradually and with care, for the tissue of the cervix varies greatly in 
 elasticity in different cases and the author reraem})ers seeing in consulta- 
 tion a case in which this dilatation produced a laceration of the cervix 
 causing so severe an intrapartum hemorrhage as nearly to exsanguinate 
 the patient. Careful, gradual, manual dilatation of the cervix, however, 
 
DEFICIENCY IN THE EXPULSIVE FORCES 617 
 
 in cases of uterine inertia with internal os obliterated, is a procedure of 
 extreme value. 
 
 If the examination discloses the fact that a posterior position of the 
 occiput is the cause of the delay and the embarrassment of the fetal 
 circulation, artificial rotation and delivery are indicated. 
 
 In the presence of a slow, irregular fetal heart, a dystocia of the hard 
 parts, too great to be dealt with by forceps or version, indicates a 
 Cesarean section, unless this operation is contra-indicated by the feeble 
 condition of the fetal heart or the too-long delayed decision to deliver 
 artificially and the great probability that the woman is already infected. 
 
 Uterine inertia associated with fetal heart sounds indicating danger to 
 fetal life is one of the first types of inertia indicating artificial delivery. 
 
 Uterine Inertia Endangering Maternal Convalescence. — If the membranes 
 have ruptured, prolonged pressure of the child against the uterine wall 
 or against the vagina or bladder, even if the pressure is not accompanied 
 by uterine contractions powerful enough to accomplish any advance 
 of the presenting part, may endanger maternal convalescence by post- 
 partum hemorrhage, by infection, by necrosis, or by an increased 
 mortality of any operation resorted to for delivery. 
 
 In a certain class of women, with nervous system of unstable eciuili- 
 brium, the nerve and muscle tone seem only equal to the task of dilating 
 the cervix, perhaps not that. The immediate result is an exhausted 
 woman, perhaps an hysterical woman, with labor only partly completed. 
 If these patients are allowed to continue in their ineftective labor, the 
 remote result may be a nervous and physical ^^Teck for a year or two 
 after the birth of the child. In a certain number of these cases, simple 
 measures such as rest, reassurance, food, strychnin or quinine may 
 overcome the difficulty, but in a larger number these measures fail. 
 
 This class and this condition usually indicates artificial delivery, 
 usually by forceps, occasionally by version. 
 
 * This class has in recent months, through tlie use of pituitary extract, 
 been somewhat reduced in the number of those needing artificial delivery, 
 but there still remain a large number who should not be allowed to con- 
 tinue longer in labor for the two reasons already suggested: 
 
 1. The effect upon the maternal soft parts. 
 
 2. The effect upon the nervous system. 
 
 It would be extremely valuable if one could definitely outline the 
 exact condition of the maternal soft parts which should always be taken 
 as the indication for artificial assistance to nature's eft'orts at delivery, 
 but this is almost impossible, as each case has to be studied by itself. 
 In general, the dryness and beginning edema of the cervix and vagina 
 may be taken as an indication that the circulation and nutrition of the 
 soft parts are being interfered with, and if, with membranes ruptured 
 and labor well under way, no progress has been made for an hour in 
 either dilatation or advance of the presenting part, and the simple 
 measures of rest, food, and stimulating drugs have proved unavailing, 
 artificial mechanical assistance is indicated. 
 
 The exact type of mechanical assistance to be chosen depends, as 
 
filS ABNORMAL LABOR FROM ANOMALIES IN FORCES 
 
 already suggested, upon the diagnosis of the conditions present. If the 
 (lehiy is caused l)>" too great resistance in the bony canal and a disprojjor- 
 tion between it and the fetal head, it is time for Cesarean section rather 
 than later after frequent manipulations have increased the danger of the 
 operation. If the inertia is due to too great resistance in the cervix, it 
 is time to make use of the \aluable assistance of the elastic bag both in 
 dilating the cervix and stimulating the contractions of the fundus. 
 
 If the presenting part has descended to the pehic floor and the resis- 
 tance here has proved too great for the overworked uterus to overcome, 
 it is time for the use of the forceps before the maternal soft parts and the 
 fetal brain receive an undue amount of pressure. 
 
 While discussing, as an indication for artificial delivery, the effect 
 of uterine inertia upon the nervous system of the mother in convales- 
 cence, it must not be thought that this indication is often found separate 
 from the two already studied, i. e., fetal danger and danger to the maternal 
 soft parts. In fact two, if not three, of these indications are usually found 
 associated. The nervously exhausted woman, perhaps hysterical in 
 labor and neurasthenic for months afterward; the tired uterus which 
 tends to relax, bleed and become infected after labor; and the fetal heart 
 slowed and irregular from undue pressure, these three conditions are so 
 often found combined as to present a familiar picture to e\'ery consulting 
 obstetrician. The author's plea is for studied, skilled, artificial assistance 
 in delivery before the mother and child are exposed to these dangers. 
 
 There is one condition not usually classed as uterine inertia to which 
 the writer would like to call attention. It is the long delay which some- 
 times intervenes between rupture of the membranes and the uterine 
 contractions of the first stage of labor. 
 
 Patients sometimes present themselves at the hospital with the history 
 that their membranes ruptured three, four, or even five days before their 
 labor ])ains began. An nnfortiuiate experience several years ago in which 
 the fetal heart ceased before the labor was completed, and a study of the 
 temperature charts of a number of these cases, convinced the author 
 that in many particulars they resemble cases of uterine inertia during 
 actual labor; that there is fetal danger from interference wuth fetal 
 circulation from prolonged pressure, and that maternal morbidity is 
 common from sapremia if not from bacteremia. 
 
 For these reasons. the writer has made it a rule in recent years, both at 
 the Sloane Hospital and in his private practice, to introduce an elastic 
 bag (Voorhees) into the cervix if uterine contractions have not started 
 at the end of twenty-four hours from the time of the rupture of the 
 membranes. 
 
 The elastic bag, as a rule, not only brings on uterine contractions, but 
 lessens the further escape of the liquor amnii, and the results, both fetal 
 and maternal, have seemed to justify the procedure. 
 
 Before leaving the treatment of uterine inertia, attention should be 
 be called to the fact that friction and manipulation of the fundus of the 
 uterus through the abdominal wall will often arouse uterine contraction 
 and keep the uterus at its work as will nothing else. 
 
DEFICIENCY IN THE EXPULSIVE FORCES 619 
 
 Abdominal Wall Inertia. — ^While in the first stage of labor it is uterine 
 inertia, or deficiency in the expulsive force of the uterus, which has most 
 to do with prolonged labor, in the second stage, in the absence of 
 mechanical obstacles to delivery, it is often a deficiency in the expulsive 
 force of the abdominal muscles, or abdominal wall inertia, which is at 
 fault. 
 
 Etiology.- — The causes of inertia of the abdominal muscles are various; 
 most often it is due to overdistention in previous pregnancies or it may 
 be due to exceptional conditions in the present pregnancy, as twins, 
 hydramnios, etc. It may be but a part of a poor general muscular devel- 
 opment and here wasting diseases such as tuberculosis and typhoid 
 exert a marked influence. 
 
 Abdominal wall inertia may be largely the result of inhibiting impulses, 
 started by the acuteness of the pains. Thus, certain women in whom 
 the sense of pain is very acute will cry out with each pain and make 
 no attempt to use their abdominal muscles, in fact seem to check the 
 tendency of the abdominal wall to contract. This action is best seen 
 by dulling the acuteness of the pain with a little anesthesia when 
 involuntarily the patient will bring her abdominal muscles into action 
 and greatly facilitate the progress of the labor. 
 
 Another cause of inertia of the abdominal wall is ignorance on the 
 part of the patient, especially a primigravida. If she is told at the 
 outset of each pain, to hold her breath and strain downward as though 
 having a constipated movement of the bowels, she soon learns to use her 
 abdominal muscles to the best advantage and the improvement in the 
 progress of the labor is often remarkable. 
 
 There is one cause of inertia which is both abdominal and uterine, 
 viz., that due to pendulous abdomen. The condition, as will be shown 
 later (see page 620), is usually caused by a laxity and stretching of the 
 abdominal wall, and as a rule, is present only in multigravidse. The uterus 
 falls forward as the pregnancy advances; the abdominal wall has little 
 tone and the resultant of the uterine and abdominal wall contraction is 
 upward and backward (see Fig. 377, arrow A) rather than downward 
 in the normal direction of the parturient canal (arrow B). The uterine 
 muscle soon tires in action and uterine inertia is added to inertia of the 
 abdominal wall which might be said to be present throughout the 
 pregnancy. 
 
 Treatment. — Naturally this depends largely upon the cause in the 
 individual case. If after confinement the abdominal wall of a patient 
 is found markedly relaxed with recti separated, marked benefit is derived 
 from a combination of exercise and support. 
 
 The practise night and morning, when wearing only the night-clothes 
 or a loose wrapper, of exercises which bring in play and develop the 
 abdominal muscles, will do much toward restoring the tone of the abdom- 
 inal wall; furthermore, the wearing during the daytime of a properly 
 fitting corset so adjusted as to give support to the lower part of the 
 abdomen and thus lessen the tendency of all the abdominal viscera to 
 sag, will prove of marked aid in the efforts to restore tone. 
 
620 
 
 ABNORMAL LABOR FROM ANOMALIES IN FORCES 
 
 As indicated above, if the abdominal wall inertia is due to the inhibi- 
 tory impulses produced by the acuteness of the pain, a few whiffs of 
 anesthetic gi\en with each i)ain and instruction to the patient to press 
 down when she has a pain will usually meet the indication. 
 
 If during pregnancy the abdominal wall shows a tendency to become 
 pendulous, it should be supported by a proi)erly fitting corset or abdominal 
 
 bandage which will support the ab- 
 domen and maintain the uterus in 
 the long axis of the body. It is a 
 mistake to think that it is nearer 
 nature and therefore better for a 
 woman during pregnancy to go 
 about without any abdominal sup- 
 port. As the abdominal wall dis- 
 tends, especially in multigravidse, 
 the uterus becomes more lax and 
 the fetus is less likely to engage 
 normally in the brim of the pelvis 
 and at the proper time. 
 
 If the case of pendulous abdo- 
 men is seen in labor, the abdom- 
 inal wall and uterus must be 
 supported in the axis of the 
 body either by an abdominal 
 bandage which is often difficult 
 to retain in place, or by the 
 obstetrician or nurse keeping up 
 pressure with the hands upon 
 the abdomen and fundus of the 
 uterus while the patient lies upon 
 her back. In a case of the author's 
 he was obliged to spend the whole 
 day pressing with his hands upon 
 the abdomen of his patient and 
 stimulating the fundus of her 
 uterus, in order to keep the fetus 
 in the normal axis of the parturient 
 o-,-, -D , , , , -iu • canal and overcome the tendency 
 
 377. — Pendulous abdomen with mis- i i • i u • 
 
 directed force causing inertia. tO abdomuial Wall mcrtia. 
 
 Fig. 
 
 RELATIVE EXCESS IN THE EXPULSIVE FORCES. 
 
 Precipitate Labor. — Labor in order to be normal in mechanism and 
 duration presupposes a certain amount of resistance in the cervix and 
 pelvic floor which requires time to overcome, during which process there 
 is usually ample opportunity for the patient, nurse and obstetrician to 
 make necessary preparation for the delivery and then have several hours 
 of tedious waiting. In rare cases, however, especially in multigravidse, 
 
RELATIVE EXCESS IN THE EXPULSIVE FORCES 621 
 
 the labor is terminated with very few pains, with scarcely any warning 
 and without opportunity to secure a nurse or physician, perhaps without 
 time for the patient to reach the bed. It is then called i^recipitate labor. 
 This is, as a rule, brought about by one of three conditions: 
 
 1. Relatively strong expulsive powers. 
 
 2. Relatively weak resistance. 
 
 3. Small body to be expelled. 
 
 In some women with normal tone of uterine and abdominal walls 
 the power of expulsion inherent in these two sources of power is very 
 great and a considerable resistance in cervix, vagina, and pelvic floor is 
 easily overcome. 
 
 If such a woman with a large pelvis should be badly lacerated in 
 cervix and pelvic floor and without having her lacerations repaired 
 should again become pregnant and go to term, provided she retained 
 her previous tone in uterine and abdominal walls, her labor would natu- 
 rally be greatly shortened. It might be short enough to give no time for 
 preparation and be called precipitate. Moreover, if with conditions 
 favoring a rapid labor, such as strong expulsive powers, large roomy 
 pelvis, with badly lacerated cervix and pelvic floor, labor should come 
 on prematurely and the child be very small, it is easy to see why labor 
 should be still more likely to be precipitate than if the child were of full 
 size at full term. 
 
 In a justomajor pelvis or a congenital split pelvis the resistance from 
 the bony parts is practically eliminated, but in certain women with 
 practically normal pelves the cervix and pelvic floor dilate so rapidly 
 that the labor is completed with three or four pains. 
 
 In many of these cases the preliminary softening and dilatation of 
 the cervix has been going on for days or weeks without the knowledge 
 of the patient, who thought it only a continuance of the discomforts 
 of pregnancy, perhaps confusing it with the intermittent uterine 
 contractions of pregnancy (Braxton Hicks's sign) which in some give 
 distress. 
 
 Suddenly, perhaps with rupture of the membranes, expulsive pains 
 come on and the labor is over. 
 
 Prognosis. — The danger to the mother is usually slight. Lacerations 
 of the perineum is the most common result, although this is not as fre- 
 quent or extensive as might be expected. If the placenta is firmly 
 adherent, inversion of the uterus from traction upon the cord may result 
 and cause postpartum hemorrhage, which may also come from premature 
 detachment of a placenta not abnormally adherent. Serious syncope 
 from sudden lessening of intra-abdominal pressure, although possible, 
 seldom occurs. 
 
 The greatest danger is usually fetal, from the child falling upon the 
 hard floor or the ground, or from rupture of the cord and hemorrhage 
 therefrom, or from being deposited in the basin of a water-closet, etc. 
 
 In other words the fetal dangers are those naturally arising from the 
 expulsion of the child while the mother is standing or sitting, rather than 
 lying in bed. 
 
G22 ABNORMAL LABOR FROM ANOMALIES IN FORCES 
 
 Treatment. — If the precipitate labor occurs in a primigravida it comes 
 as a surprise and there is no opportunity for treatment, prophyhictic 
 or otherwise. If such an experience, however, has once occurred, much 
 can be done to prevent its recurrence in a subsequent labor. 
 
 The patient, during the last weeks of pregnancy, should take no 
 violent exercise. She should ride rather than walk, shoidd be careful 
 about straining at stool, etc. A nurse should be in attendance during 
 the last weeks of pregnancy and at the first intimation of labor the patient 
 should go to bed and retain the horizontal position, preferably on the 
 side. She should be told not to bear down with her pains. With each 
 uterine contraction, the nurse, until the arrival of the obstetrician, should 
 administer a little anesthesia with one hand, while with the other covered 
 with a sterile towel she makes pressure against the pelvic floor. 
 
 Irregular Contractions of the Uterus. — As already stated, the use of 
 ergot to stimidate uterine contractions is unsafe while the fetus is still 
 in utero for the reason that the contractions, while often increased in 
 force, tend to become tonic or tetanic, without the intervening periods 
 of relaxation which are essential to the maintenance of placental and 
 fetal circulation; thus endangering the life of the fetus at the same time 
 that it interferes with the normal process of labor. The use of ergot is 
 equally to be condemned while the placenta is still in utero. 
 
 When the author was a student it was the custom to advise the 
 administration of ergot as soon as the child was born and before the 
 expulsion of the placenta. Acting under this advice, in his first obstetric 
 case, he administered ergot immediately after the birth of the child and 
 there followed an experience never to be forgotten by him. 
 
 The uterus became irregularly contracted in the shape of an hour- 
 glass, with a portion of the placenta included in the grasp of the contract- 
 ing ring, while the remainder of the placenta lay above the ring in a 
 relaxed portion of the uterus. As usually happens in hour-glass contrac- 
 tions of the uterus, a profuse hemorrhage soon complicated the situation. 
 
 This case is given as an illustration of the fact that irregular contrac- 
 tions of the uterus sometimes occur, dividing its cavity into compart- 
 ments. This constricting ring is usually situated at the junction of the 
 upper and lower uterine segments, i. c, is the ring of Bandl, but in some 
 cases forms just below the foreign body (placenta) which lies within 
 the cavity; the position of the cavity above the constricting ring being 
 sometimes relaxed and at other times contracted. It has been stated 
 that an abnormally adherent placenta resulting from a previous endo- 
 metritis will sometimes cause a similar hour-glass contraction, but with 
 this combination of cause and effect the author has had no experience. 
 
 Treatment. — The treatment of these cases of irregular or hour-glass 
 contraction consists in relaxing the uterus by the administration of anes- 
 thesia, chloroform or ether, manual dilatation of the constricting ring, 
 and removal of the placenta. This method was followed with success 
 in the case mentioned above, but the lesson that ergot should never be 
 given in a case of labor until after the placenta was expelled, was 
 impressed in a most forcible manner. 
 
EXCESS IN RESISTANT FORCES 623 
 
 Tetanic Contraction of the Uterus. — Occasionally the uterus, espe- 
 cially when there is an obstacle to delivery, assumes a condition of tetanic 
 contraction, sometimes called tonic spasm of the uterus or "tonic uterus." 
 The contractions at first may be normal with intermissions of relaxation, 
 then as the obstruction fails to be overcome, they become more and more 
 vigorous and finally assimie a condition of continuous contraction, pre- 
 venting all progress and exposing the child to danger from interference 
 with the placental circulation. This contraction usually involves the 
 whole of the upper uterine segment, as stated by Veit, although the 
 firmness in the feel of its lower edge — the ring of Bandl — has caused 
 certain French observers (Cheron, Budin and others) to locate the con- 
 traction here. 
 
 If this condition of tetanic contraction of the uterus is caused by an 
 obstruction to the advance of the presenting part, the upper uterine 
 segment becomes more and more contracted and retracted, while the 
 lower uterine segment thins. The importance, therefore, of this tetanic 
 contraction as leading to possible rupture of the uterus, either sponta- 
 neously, or if a version is attempted, cannot be too strongly emphasized. 
 
 In the rare cases where the uterus assumes this tetanic condition with- 
 out obstruction to delivery, the spasmodic contraction should be relaxed 
 by the administration of anesthesia and delivery hastened in the interests 
 of both mother and child. This same rule of relaxation by anesthesia 
 and hastening of the termination of the labor also applies where there 
 is obstruction to the delivery, even if this termination of the labor requires 
 Cesarean section or craniotomy. 
 
 EXCESS IS RESISTANT TORCES. 
 
 Regarding the resistant forces as composed of the bony pelvis, the 
 cervix, the vagina and the pelvic floor, excess in their resistance to the 
 normal progress of labor, and therefore prolonged labor, may be caused 
 by abnormalities in any one of them. 
 
 These may be studied then either under the head of anomalies of the 
 forces or anomalies of the passages. While it is well to call attention to 
 them as factors in the forces of labor, it seems wise to study their 
 abnormalities under the head of anomalies in the passages. (See next 
 chapter.) 
 
CHAPTER XX. 
 
 ABXOiniAL LABOR FR0:M ANOMALIES IX THE PASSAGES. 
 
 The passages concerned in the mechanism of labor consist of both 
 soft parts and hard parts. The soft parts include the uterus, the vagina 
 and the \ulva, while the hard parts comprise the bony pelvis. The soft 
 parts will be first considered. 
 
 ABNORMAL LABOR FROM ANOMALIES OF THE SOFT PARTS OF 
 
 THE PARTURIENT CANAL. DISPLACEMENTS OF THE 
 
 UTERUS. 
 
 Pendulous Abdomen. — The marked anterior displacement of the preg- 
 nant uterus with a corresponding downward protrusion of the anterior 
 abdominal wall, called pendulous abdomen, is, as a rule, caused by one 
 of the three following conditions and usually in this order of frequency: 
 
 1 . Lack of tone in uterine and abdominal walls. 
 
 2. Contraction of the pelvic brim. 
 
 3. Shortening of the abdominal cavity with lumbar lordosis. 
 
 Lack of Tone in Uterine and Abdominal Walls. — In a primigravida the 
 muscle tone of uterus and abdominal wall usually keeps the fetus closely 
 applied to the peh'ic brim and well within the abdominal cavity. Hence 
 it is that in her first pregnancy a woman usualh' discloses her condition 
 less than in her subsequent pregnancies. After several pregnancies have 
 occurred with short intervals, the uterine and abdominal walls become 
 stretched, lose their tone and have less power to retain the fetus within 
 the normal lines of the abdomen. This lack of tone, together with the 
 tendency to an increased size of child with successive pregnancies, favors 
 an increasing protrusion of the abdomen and uterus forward and down- 
 ward, sometimes reaching a position of 30° to the horizon. 
 
 If unaccompanied by abnormalities in spine and pelvis this variety 
 of pendulous abdomen is of little importance save as a possible source 
 of discomfort during pregnancy and a cause for delay in labor. 
 
 Treatment. — During pregnancy the condition is most relieved by sup- 
 porting the abdomen and uterus by a well-fitting corset or abdominal 
 binder. During labor the force of uterine contraction in this condition 
 is naturally misdirected upward and backward (as indicated by arrow A 
 in Fig. 377) rather than downward in the direction indicated by arrow B. 
 
 The malposition of the uterus sometimes so interferes with labor that 
 in order to secure and maintain engagement and descent of the presenting 
 part it is necessary during most of the labor to support the abdominal 
 wall and uterus with an abdominal binder or the hands of the obstetrician, 
 or even with both. 
 (624) 
 
ANOMALIES OF SOFT PARTS OF PARTURIENT CANAL 625 
 
 Contraction of the Pelvic Brim. — ^^Yhene^'e^ there is present a marked 
 condition of pendulous abdomen, especially in a primigravida, it should 
 always be suspected that there may be a contraction of the pelvic brim, 
 or at least a disproportion between child and passage. It may be only 
 the result of an atonic condition of uterine and abdominal walls, but 
 attention has already been called to the fact that a contracted pelvic 
 brim, interfering with normal fetal engagement, favors malpresentation 
 and perhaps pendulous abdomen. 
 
 Treatment. — ^The method of dealing with the condition depends upon 
 the degree of pelvic deformity and is considered on page 652. It is of 
 the utmost importance that the fact should be borne in mind that a pen- 
 dulous abdomen, while sometimes of minor consequence, may be asso- 
 ciated with a condition of the pelvis needing the highest skill in the 
 delivery. 
 
 Shortening of the Abdominal Cavity with Lumbar Lordosis. — The condition 
 of lumbar lordosis with descent of the thorax, reducing the longitudinal 
 and anteroposterior diameter of the abdomen will be considered under 
 deformity of the pelvis associated with disease of the spinal column 
 (see page 678). 
 
 As pregnancy advances in this condition, finding insufficient room 
 within the normal confines of the abdomen the uterus of necessity enlarges 
 forward and produces perhaps a marked condition of pendulous abdomen. 
 Here then is a serious pathological condition of spine and pelvis associated 
 with a protruding and pendulous abdomen, the abdominal shape being 
 the clinical picture which should arouse the suspicion of the obstetrician 
 as to the possible malformation of the parturient canal. The treatment 
 of course depends upon the degree of this malformation. 
 
 Malformations of the Uterus. — ^The different varieties of malforma- 
 tion of the uterus aft'ect pregnancy and labor in dift'erent ways. Thus 
 the most common cause of sterility or delayed pregnane}' is the undevel- 
 oped uterus, for the treatment of which artificial dilatation and general 
 upbuilding offers the greatest hope of cure. The variety of uterine mal- 
 formation most likely to give rise to confusion of diagnosis during preg- 
 nancy and dystocia during labor is some form of double uterus varying 
 from the uterus bicornis to the uterus didelphys. 
 
 The possible difficulty in diagnosis during pregnancy is illustrated by 
 a case of the author's, in which, with a uterus bicornis, the child rested 
 in one horn and the placenta was attached in the other. On abdominal 
 examination three possibilities presented themselves: 
 
 1. Pregnancy associated with a soft fibroid. 
 
 2. Pregnancy associated with an adherent ovarian cyst. 
 
 3. Pregnancy in a uterus bicornis. 
 
 All three of these possibilities were considered, but the author must 
 admit that a positive diagnosis was not made until the child was born. 
 The difiiculty in this case was increased by the fact that he had no oppor- 
 tunity to examine the case until she was well along in pregnancy. 
 
 Another difficulty in diagnosis associated with malformation of the 
 uterus is that of the existence of pregnancy in one-half of a double uterus 
 40 
 
626 ABNORMAL LABOR FROM AN&MALIES IN PASSAGES 
 
 where tliere are two cervices as well as two uterine bodies and menstrua- 
 tion may continue for a time from the unimpregnated half. Often it is 
 necessary to delay a positiAe diagnosis for a few months until more 
 positive symptoms are present. 
 
 The malformation of the uterus most likely to cause dystocia is a 
 uterus didelphys or a duplication approachuig it. 
 
 The unimpregnated half enlarges in sympathy- with the pregnant side 
 of the uterus and this enlarged unimpregnated half may by its bulk so 
 obstruct the parturient canal as to cause marked dystocia. Furthermore, 
 in attempts to overcome the dystocia, complications may arise as occurred 
 in a case of the author's in which a separation occurred between the 
 pregnant and unimpregnated portions with the practical result of a 
 ruptured uterus. 
 
 Sacculation of the Uterus. — Abnormalities in pregnancy and labor 
 may result frt)m immobile displacements of the uterus, both posterior 
 
 and anterior, in either case resulting, as 
 pregnancy advances, in a distention or 
 sacculation of the wall of the uterus 
 opposite to that fixed. 
 
 Retroversion of the Pregnant Uterus. 
 — A pregnant retroverted uterus, as a 
 rule, follows one of three courses and in 
 the following order of frequency: 
 
 1 . It corrects its malposition as preg- 
 nancy advances. 
 
 2. A miscarriage occurs. 
 
 3. The uterus becomes incarcer- 
 ated with sacculation of the anterior 
 wall. 
 
 A great many pregnant, retroverted 
 uteri rise out of the pelvis as preg- 
 nancy advances, and although there is a 
 tendency for the retroversion to recur 
 during the puerperium, still no further complications arise during the 
 pregnancy and no dystocia occurs as a result of the retroversion. 
 
 On the other hand, many of the miscarriages of early pregnancy occur 
 as a result of a neglected retroversion of the uterus in which the fundus, 
 being more or less fixed in the hollow of the sacrum, does not easily 
 rise and develop to accommodate the growing ovum, and as something 
 has to yield, the direction of least resistance is outward through the 
 cervical canal, and a miscarriage results. For this reason the author has 
 emphasized the importance of early examination of pregnant women 
 for the detection and correction, if present, of a retroversion. 
 
 Anterior Sacculation.- — Another result of pregnancy in a retroverted 
 uterus is incarceration with sacculation of its anterior wall. 
 
 If for any reason the pregnant, retroverted uterus neither corrects its 
 malposition nor aborts, the posterior wall being fixed in the pelvis (see 
 Fig. 378), the anterior wall alone can dilate to accommodate the growing 
 
 Fig. 378. 
 
 -Anterior sacculation of 
 the uterus. 
 
ANOMALIES OF SOFT PARTS OF PARTURIENT CANAL 627 
 
 fetus. This distention of the anterior uterine wall is called sacculation, 
 and the condition as a whole with its accompanying symptoms of rectal 
 pressure and vesical retention or irritation is spoken of as incarceration 
 of the pregnant uterus. 
 
 Symptoms. — Usually the first and most marked symptom is difficulty 
 in urination. This may amount to absolute retention with intense suffer- 
 ing until the condition is relieved by the use of the catheter. The reten- 
 tion may be followed after a time by a more or less constant dribble of 
 urine from the overdistended bladder. Unless the condition is soon 
 relieved a cystitis develops which may go on to necrosis of the bladder, 
 perhaps even to rupture of that organ. The discomfort of retention may 
 be followed by bloody and purulent urine with portions of necrotic mem- 
 brane. If rupture of the bladder occurs there are added the symptoms 
 of peritonitis. 
 
 In the early stages of the condition, along with the disturbances of 
 bladder function, may go symptoms of rectal and sacral pressure, with 
 constipation, pains down the thighs, backache, etc. Reflex symptoms 
 of nausea and vomiting may also be present. 
 
 Physical Signs. — On bimanual examination of an incarcerated, retro- 
 verted, pregnant uterus, the vaginal fingers detect a soft, bulging 
 mass in the posterior fornix and the cervix displaced high up behind 
 the symphysis, perhaps even above it. The soft, bulging mass is 
 seen to be continuous with the cervix and to be the hypertrophied 
 posterior uterine wall. 
 
 The abdominal hand detects the fact that the anterior uterine wall 
 is distended and thinned as compared with the posterior, and that by 
 its sacculation the growing fetus is accommodated. It is usually impos- 
 sible to map out the uterus accurately until the bladder has been emptied. 
 
 Diagnosis. — There are two conditions which are most likely to be con- 
 fused with an incarcerated pregnant uterus: 
 
 1. A soft fibroid low down on the posterior wall of the pregnant uterus. 
 
 2. An ovarian cyst low down behind a pregnant uterus. 
 
 Both of these conditions can usually be diagnosed from an incarcerated, 
 pregnant uterus by the fact that in each the cervix occupies a more 
 nearly normal position in the vagina rather than a position high up behind 
 the pubes. Furthermore, in each there is an absence of the intimate 
 connection between the bulging mass and the cervix. In some instances 
 a soft fibroid attached just above the cervix and filling the pouch of 
 Douglas may present marked difficulties in diagnosis. The previous 
 history in each case is often of great assistance. 
 
 Treatment. — ^This may well be considered as (a) prophylactic and (6) 
 curatiw. 
 
 Prophylactic. — While the majority of retroverted pregnant uteri will 
 correct their malposition as pregnancy advances, this should never 
 be taken for granted, and one of the first things to be determined in 
 pregnancy is whether or not the uterus is in normal position and enlarg- 
 ing normally. If the uterus is found retroverted and movable its 
 position should be corrected at once and maintained by a well-fitting 
 
628 ABNORMAL LABOR FROM ANOMALIES IX PASSAGES 
 
 pessary until the uterus is large enough to retain its position in front of 
 the sacrum. This usually occurs in the third or fourth month, and the 
 pessary can then be removed. 
 
 If on the first examination the retroverted pregnant uterus appears to 
 be fixed in the pelvis, care should be taken that too vigorous manipula- 
 tions do not induce a miscarriage, but with the woman in the knee-chest 
 position, or in Sims's position, gentle efforts at replacement may be made 
 by pushing the posterior uterine wall gently upward with the vaginal 
 fingers, perhaps at the same time pushing the cervix gently backward. 
 
 Sometimes a retroversion, which at first seemed fixed, can be corrected 
 in this manner at a single sitting. In other cases little is accomplished 
 at first, but several gentle manipulations of this kind at intervals of 
 several days aided by the natural gro^\i:h of the pregnant uterus and its 
 tendency to correct any malposition, will often accomplish the desired 
 result. As soon as the fundus of the uterus has been raised to the neigh- 
 borhood of the promontory of the sacrum, the amount gained can be 
 maintained by the use of a pessary and the completion of the replacement 
 will often be found easy at a subsequent sitting, perhaps even found 
 accomplished by nature. 
 
 Curative. — ^Vhen incarceration of the pregnant uterus in the hollow 
 of the sacrum with sacculation of the anterior uterine wall has already 
 occurred and the accompanying bladder disturbances, retention, irrita- 
 tion, etc., are present, the situation becomes more acute and relief is 
 imperative. In the first place the blaflder must be emptied by catheter 
 and care should be taken by the internal administration of a urinary 
 antiseptic like urotropin to avoid the development of a cystitis. If a 
 cystitis has already developed, in addition to the employment of the 
 urotropin, bladder irrigations may be of ^■alue. 
 
 With the bladder emptied, similar efforts at replacement by manipula- 
 tions, as already described, should be employed, and after a few sittings 
 will usually succeed. In the meantime it is well to keep the Avoman in 
 bed, under close observation, and with most careful attention to the 
 cleanliness of her bladder and its periodical emptying. 
 
 If these manipulations fail and the situation becomes at all acute, 
 the best treatment usually consists in opening the abdomen and manually 
 freeing the adhesions, if present, and replacing the malplaced uterus as 
 recommended by ]Mann,^ in 1898. Occasionally this condition of anterior 
 sacculation of the uterus with parturient canal obstructed by thickened 
 posterior uterine Avail is met Avith at full term. Here deliAcry is usually 
 best accomplished by a Cesarean section. 
 
 Posterior Sacculation. — In the same Avay that a fixation of the fundus 
 and posterior wall of the pregnant uterus in tlie holloAV of the sacrum and 
 a restriction in its expansion leads to a sacculation of its anterior Avail, 
 so a fixation of the fundus of the uterus to the anterior abdominal Avail 
 and a restriction in the expansion of the anterior uterine Avail in preg- 
 nancy may lead to a sacculation of the posterior uterine Avail. This 
 
 1 The Surgical Treatment of Irreducible Retroflexion of the GraA-id Uterus, Trans. 
 Amor. Gyn. Soc, 1898, xxiii, 135-140. 
 
ANOMALIES OF SOFT PAETS OF PARTURIENT CANAL 629 
 
 anterior fixation of the uterus is usually the result of a gynecological 
 operation. For many years a popular operation for the correction of 
 retroversion of the uterus was the fixation of the fundus uteri to the 
 anterior abdominal wall (see Fig. 379) and called ventrofixation. It was 
 found, however, that although many women after these operations 
 would pass through pregnancy and labor without dystocia, it depended 
 largely upon the amount of stretching in the adhesions formed between 
 the fundus and the anterior abdominal wall. If these adhesions stretched 
 so that they became simply thin bands or guys which allowed normal 
 expansion of the uterus in pregnancy, little, if any, trouble resulted. On 
 the other hand, if the fundus remained firmly fixed to the anterior abdom- 
 inal wall, only that portion of the uterus could expand to accommodate 
 the growing fetus which lay above and behind the point of fixation 
 (see Fig. 379). This resulted in a 
 distention or sacculation of the pos- 
 terior uterine wall, while the anterior 
 wall became hypertrophied and in 
 its restricted space formed a muscu- 
 lar tumor obstructing the parturient 
 canal and often requiring Cesarean 
 section for the delivery. This 
 happened six times in the author's 
 experience. It has been advised to 
 open the abdomen and free the adhe- 
 sions and then leave the case to nature, 
 but the author believes Cesarean 
 section a preferable procedure. 
 
 Diagnosis. — The exact condition is 
 usually determined by the history 
 of a previous abdominal operation, 
 by finding the cervix displaced far 
 back, near and perhaps above the 
 promontory of the sacrum, and the 
 parturient canal blocked by a firm tumor which extends from the dis- 
 placed cervix to the anterior abdominal wall. 
 
 Realizing the danger of a ventrofixation in a woman likely to become 
 pregnant, different operators have attempted to avoid the complication 
 by substituting for the firm fixation a loose suspension of the uterus by 
 adhesive bands to the anterior abdominal wall, following the method of 
 Kelly, who sutured the fundus to the parietal peritoneum and subperi- 
 toneal tissue rather than to the fascia of the anterior abdominal wall. 
 It was thought for a time that this would obviate the dangers of the 
 dystocia resulting from the ventrofixation. In this connection, however, 
 the experience of the author^ is of interest. 
 
 In (October, 1902, a very able New York surgeon, realizing the obstet- 
 rical dangers of a ventrofixation performed with great care a ventro- 
 
 1 Cragin, Ventrosuspension an Unsafe Operation for Posterior Displacement of the 
 Uterus during the Child-bearing Age, Trans. Amer. Gyn. Soc, 1908, xxxiii, 322-327. 
 
 Fig. 379. — Posterior sacculation of the 
 uterus from ventrofixation. 
 
630 ABNORMAL LABOR FROM ANOMALIES IN PASSAGES 
 
 suspension for retro\ersion of the uterus in the case of ^Irs. S., aged 
 twenty-six years. She was much benefited by the operation and in 
 March, 1903, she became pregnant. On December 5, 1903, she was 
 delivered by the autlior after a very easy and ra})id labor lasting only 
 two and a half hours. In June, 1907, she became pregnant again and 
 on the eve of March 2(), 1908, the author was again called to deliver 
 her. On examination the following conditions were found. The cervix 
 was high up posteriorly and with difficulty reached. The child lay 
 t^ans^•ersely and the anterior uterine wall formed a muscular tumor 
 obstructing the parturient canal as has so often l^een found after a 
 ventrofixation. In other words, the ventrosuspension which in 1903 
 allowed an easy delivery had, in the meantime, become a ventrofixation 
 with obstruction requiring a Cesarean section which was performed at 
 the Sloane Hospital, :\Iarch 27, 190S. 
 
 From this it is seen that a ventrosuspension may become a ventro- 
 fixation, and that both ventrofixation and ventrosuspension are unsafe 
 operations for women during the child-bearing age. 
 
 Tumors of the Uterus. Fibromyomata. — The most common form of 
 uterine tumor causing abnormality in labor is a fibromyoma, a so-called 
 fibroid of the uterus. Considering the frequency of fibroids in women 
 (according to Bayle they occur in 20 per cent, of all women over thirty- 
 five), it is only natural that they should often be found associated with 
 pregnancy, and this notwithstanding the fact that to a certain extent 
 fibroids predispose to sterility. 
 
 In a consecutive series of 20,000 labors at the Sloane Hospital there 
 were 89 cases with fibroids large enough to be noted, i. e., frequency of 
 1 in 224+ or 0.45 per cent. Pinard,^ in a consecutive series of 13,915 
 labors, reported 84 cases with fibroids, or a frequency of 0.6 per 
 cent. 
 
 In the author's series of 89 cases there were only 11 which required 
 special treatment because of the fibroid itself and 4 in which the fibroid 
 caused actual obstruction to delivery. Hence it is seen that, although 
 the association of fibromyomata with pregnancy is relatively a frequent 
 one, disturbance by them of the normal course of labor is unusual. 
 
 In many cases the existence of the tumor is first noted while holding 
 the fundus of the uterus during or just after the third stage of a normal 
 labor. 
 
 So much depends upon the variety of the fibroid tumor which com- 
 plicates pregnancy that the relative frequency of the different varieties 
 is of interest. In the series of 89 cases at the Sloane Hospital 41 were 
 subperitoneal, 36 were interstitial, 2 w^ere submucous, 7 were subperi- 
 toneal and interstitial combined, 3 were interstitial, subperitoneal and 
 submucous combined. 
 
 Before taking up the possible complications of delivery arising from 
 fibroids it is well to study the changes which take place during pregnancy 
 and the puerperium. 
 
 1 Fibromes et Grossesse, Annales de Gyn. et d'Obst., 1901, \\\ 165-167. 
 
FIBROMYOMATA COMPLICATING PREGNANCY AND LABOR 631 
 
 Changes in Fibroids. — Physiological Changes. — During pregnancy a 
 fibroid, as a rule, increases in size. In some cases this increase is so marked 
 that a tumor which cannot be detected before pregnancy reaches the 
 size of a lemon or an orange at the time of delivery. This increase in 
 size is brought about in one of three ways: by hypertrophy; by hyper- 
 plasia of all its elements; by edema. 
 
 The tumors also change their position. This is seen especially in tumors 
 situated in the lower zone of the uterus or attached to the cervix, and it 
 is fortunate that change in position occurs, for otherwise many more 
 cases of labor obstructed by fibroids would be met with. One of the 
 most interesting provisions of nature is seen in the gradual elevation of 
 a fibroid situated low in the pelvis and threatening marked obstruction 
 to the parturient canal. 
 
 Many a case in which it has seemed that Cesarean section would be 
 the only possible method of delivering a living child has demonstrated 
 nature's power of dealing with the problem by the gradual rising of the 
 tumor in the pelvis until it lies above the brim and ceases to cause any 
 obstruction to the parturient canal. 
 
 The ascent of the tumor is brought about in three ways: (a) by the 
 increase in size of the tumor, (b) by the increase in size of the uterus, (c) 
 by the retraction of the cervix in preparation for delivery. 
 
 Any tumor or organ in the pelvis, as it increases in size and finds the 
 pelvic cavity cramped for its accommodation, tends to rise out of the 
 pelvis. This is seen in the case of an enlarging ovarian cys't, an enlarging 
 uterus, a distended bladder, etc. The increase in size of the uterus with 
 its corresponding elevation of the site of attachment of the fibroid natu- 
 rally tends to raise the tumor. Furthermore, as the cervix is retracted 
 into the lower uterine segment and the lower segment into the upper, 
 there is a tendency to remove from its obstructing position the very 
 class of fibroids which is most likely to cause difficulty, i. e., those 
 attached to the lower portion of the uterus. 
 
 Hence it is that no one should feel assured of the absolute necessity 
 of Cesarean section for the delivery of a case complicated by a pelvic 
 fibroid until it is seen that the tumor is neither removed by nature nor 
 can be pushed out of the way by the fingers of the obstetrician. 
 
 The above changes in size and position may be regarded as 
 physiological and natural to pregnancy. Another physiological 
 change belongs to the puerperium, and that is an involution or decrease 
 in size. 
 
 In some fibromyomata, especially those approaching myomata in 
 structure, an involution of the tumor will accompany the involution of 
 the uterus,, even to the extent, in exceptional cases, that the examining 
 finger will be unable to detect it. 
 
 This is illustrated by a case seen by the author in consultation with 
 Dr. W. A. Valentine, of New York, in which at the first labor there was 
 a fibroid tumor about the size of a child's head and there occurred a 
 most profuse postpartum hemorrhage. At the end of a few months 
 this tumor had become reduced to the size of a lemon. During her 
 
G32 ABNORMAL LABOR FROM ANOMALIES IN PASSAGES 
 
 second pregnancy the tumor increased but little in si/e and ])ro(luced 
 no complications in the labor. 
 
 When seen by the author a few mouths alter delivery, he was unable 
 to detect the tumor. 
 
 There are other changes in fibroids (•omi)licatiug ])regnancy and the 
 puerperium which can only be looked ui)on as i)athological. 
 
 Pathological Changes. — These are due, as a rule, to one of three 
 causes: 
 
 1. Disturbed nutritiou. 
 
 2. Traumatism. 
 
 3. Infection. 
 
 Disturbed Nutrition. — This is brought about by some interference 
 with the normal circulation of the tumor and may be caused by some 
 change in the vessel walls, as a sclerosis, a stasis of the blood current, 
 or a thrombosis. These changes are especially apt to occur in the puer- 
 perium when retrograde changes in the uterus are taking place. Another 
 interference with circulation producing nutritional changes results from 
 a twist in the pedicle of the tumor which may reach such a degree as to 
 shut off all circulation from the tumor and cause its necrosis or gangrene. 
 This accident is also more likely to occur during the puerperium, as with 
 the uterus emptied and reduced in size, the tumor has more room to 
 move about and produce a twist in its pedicle. 
 
 Traumatism. — The influence of traumatism in lowering the vitality of 
 a tumor or an organ and thus making it more susceptible to the entrance 
 of infective organisms is well known. In labor a fibroid tumor, if of the 
 submucous or subperitoneal ^•a^iety, especially the former, is liable to 
 a considerable traumatism. This is less likely to occur if the tumor is 
 interstitial. In the puerperium perhaps a tumor will be found which has 
 been exposed to the changes resulting from disturbed nutrition and also 
 to traumatism. 
 
 Infection. — A tumor with vitality thus lowered as a result of pressure 
 during pregnancy, traumatism during labor, and disturbed nutrition 
 during the puerperium, is naturally liable to infection, especially in 
 the puerperium, hence it is that a woman whose pregnancy is compli- 
 cated with a fibroid is not out of all danger when the labor is passed, for 
 the tumor may become infected with the various pathogenic organisms 
 which threaten a woman in confinement and undergo suppuration. The 
 most common of these infective organisms are the streptococcus, the 
 staphylococcus, the colon bacillus, and the gonococcus. 
 
 As far as the tumor itself is concerned it may undergo the following 
 changes as a result of its complicating a pregnancy and labor: 
 
 It may become edematous. 
 
 It may undergo a fatty or myxomatous degeneration. 
 
 It may become necrotic or even gangrenous. 
 
 It may suppurate. 
 The EfEect of Fibroids on Pregnancy and Labor. — The Effect on 
 Pregnancy. — Sterility. — A woman ■s\dth a fibromyoma in her uterus 
 is less likely to become pregnant than one with a normal uterus. About 
 
FIBROMYOMATA COMPLICATING PREGNANCY AND LABOR 633 
 
 twenty-five per cent, of women with fibroids are sterile, and even if not 
 absolutely sterile, women with fibroids are apt to have pregnancy delayed. 
 
 The sterility depends upon the location and size of the tumor, the 
 condition of the endometrium, and the condition of the tubes and ovaries. 
 
 A submucous tumor, even if small, is more apt to interfere with preg- 
 nancy than one of the subperitoneal variety. As a rule, however, the 
 larger the tumor the larger the percentage of sterility. 
 
 Goetze, at the Greifswald Clinic, found 13.6 per cent, of sterility in 
 women with small fibroids, but 50 per cent, in those with tumors larger 
 than a child's head. 
 
 The sterility based upon the location and size of the tumor depends 
 upon the condition of the endometrium. Thus, with a submucous 
 fibroid there is more endometritis than with one which is subperitoneal. 
 Moreover, a large fibroid usually encroaches more or less upon the cavity 
 of the uterus and the endometrium covering the projecting portion of 
 the tumor is usually either hypertrophic or atrophic, not normal. 
 
 The tubes and ovaries of women suffering with fibromyomata are usually 
 hypertrophied and congested and seem to share in the causation of sterility. 
 
 Abortion and Premature Labor. — In the experience of most obstetricians, 
 pregnancy complicated with a fibromyoma has a tendency to premature 
 interruption, either as an abortion or premature labor. This, like the 
 sterility, is largely dependent upon the condition of the endometrium. 
 
 The presence of a hyperplastic endometritis with its tendency to an 
 accidental hemorrhage greatly favors interruption of the pregnancy. 
 
 In the author's series of 89 cases there were 22 with premature labor. 
 
 Pressure Symptoms. — In the case of large fibromyomata complicating 
 pregnancy, the pressure from the large tumor combined with the large 
 uterus in the latter months may produce great discomfort to the woman. 
 Moreover, the pressure below upon the rectum, ureters and renal vessels 
 and the pressure upward upon the diaphragm may so embarrass ehmina- 
 tion and respiration as to demand serious consideration. We have thus 
 f-ar studied the possible complications of pregnancy resulting from the 
 presence of fibromyomata. It should be borne in mind, however, that, as 
 a rule, unless the tumor is of considerable size, the pregnancy progresses 
 normally and in many instances the tumor is not detected until after 
 the child is born. 
 
 Effect of Labor. — Fibromyomata complicating pregnancy maj- influ- 
 ence labor in three different ways. The tumor may: 
 
 1. Interfere with normal uterine contractions. 
 
 2. Cause abnormal presentations. 
 
 3. Cause obstruction. 
 
 4. Interfere with normal separation of placenta. 
 
 Interference with Uterine Contractions. — Tumors of the interstitial 
 and submucous type, seldom those of the subperitoneal type, show the 
 interference with uterine contractions by uterine inertia. This tends to 
 give as a result a slow tedious labor and postpartum hemorrhage. 
 Although the expected frequently does not happen, it is hemorrhage 
 from inability of the uterus to firmly contract and close the bleeding 
 
634 ABNORMAL LABOR FROM ANOMALIES IN PASSAGES 
 
 vessels which is the compHcation most expected. In the author's series 
 of 89 cases there were 21 cases of postpartum hemorrliage. 
 
 A tumor in the uterine wall separating the muscular fibers or a tumor 
 in the uterine cavity naturally prevents the normal action of the uterine 
 musculature. 
 
 Malprescntatiuns. — A tibromyoma, if of considerable size and situated 
 low down in the uterus, is apt to occupy a portion of the pelvic brim and 
 may prevent a normal vertex presentation. The t^'pes of fibromyomata 
 most likely to cause this malpresentation are the subperitoneal or the 
 interstitial. A submucous tumor large enough to cause obstruction 
 would probably be associated with sterility. In the author's series of 
 89 cases of fibroids complicating pregnancy there were 78 cases of vertex 
 presentation and 11 with presentation other than vertex — 12.35 per 
 cent, of malpresentations. 
 
 Olshausen,^ in cases collected from the literature, found 47 per cent, 
 of malpresentations. 
 
 As a result of interference with the normal entrance of the head into 
 the pelvic brim prolapse of the cord must be looked upon as one of the 
 possible results of fibroids complicating pregnancy and labor. 
 
 Fibromyomata Ohstruding Labor. — Considering the frequency of the 
 association of fibromyomata with pregnancy, it is interesting to note how 
 seldom the tumor itself actually necessitates operative delivery. 
 
 In a series of 89 cases at the Sloane Hospital there were only 1 1 which 
 needed special treatment and in 2 this consisted in simply pushing up 
 the tumor out of the pelvis. In the remaining 9 the following operations 
 were performed: 
 
 Hysterectomy, 4. 
 
 Myomectomy, 2. 
 
 Cesarean section, 1. 
 
 Cesarean section and hysterectomy, 1. 
 
 Craniotomy, 1. 
 
 Adherent Placenta. — ^The normal separation of the placenta in a case 
 of labor complicated with fibroids is often lacking. This may be caused 
 in two ways: 
 
 1. On account of the absence of normal endometrium at the site of 
 lodgement of the ovum an abnormal decidua basalis (serotina) is devel- 
 oped. 
 
 2. The interference of the tumor with normal uterine contractions 
 lessens the expulsive power of the uterus. 
 
 In the series of 89 cases above referred to there were 25 cases of retained 
 secundines. 
 
 Effect ox Puerperium. — ^The presence of a fibromyoma in the uterus 
 of a woman just delivered tends to increase both the after-pains and the 
 amount and duration of the lochia. These two results follow from 
 interference with the normal uterine contractions. Of more consequence, 
 however, is the danger of degeneration and infection of the tumors which 
 
 ' Myom und Schwangerschaft, Veit's Handbuch der Gyn., 1897, xi, 765, 814. 
 
FIBROMYOMATA COMPLICATING PREGNANCY AND LABOR 635 
 
 are favored by the lowered vitality and traumatism incident to the preg- 
 nancy and labor. This degeneration and infection of the tumor may 
 take place as a localized process entirely independent of the ordinary 
 uterine infection, and in case a tumor becomes tender and painful with 
 an increase in temperature and pulse this should be suspected. 
 
 Occasionally the acute process w^ill subside under the use of the ice- 
 bag, but it usually indicates operative interference. 
 
 Diagnosis. — The combination of fibromyomata and pregnancy is often 
 a difficult one to diagnose. On the one hand, the irregular shape of the 
 uterus may be thought to be due to the asymmetrical development of 
 the pregnant uterus, and on the other hand, the enlargement may be 
 assigned to the growth of the tumor. Irregular bleeding which may 
 occur in early pregnancy as a result of the presence of the tumor may be 
 mistaken for menstruation. 
 
 The diagnosis is usually made by noting that the growth is more rapid 
 than that of a fibromyoma, that areas of softening such as are expected 
 in pregnancy appear in the uterine body, and that the cervix gradually 
 assumes the characteristic of the pregnant condition. 
 
 The author has seen cases of myomata, especially those of the sub- 
 mucous type, in which with abdomen open, the feel and appearance of 
 the uterus so resembled pregnancy that this condition could not be 
 positively excluded until the uterus was incised. As a rule amenorrhea 
 and the usual symptoms of pregnancy are present to assist in the diag- 
 nosis even w^hen this condition is complicated with fibromyomata. 
 
 Mortality. — The prognosis of pregnancy and labor complicated by the 
 presence of fibromyomata in the uterus varies with the size and location 
 of the tumor, the surroundings of the patient, and the judgment and 
 skill of the obstetrician in charge of the case. 
 
 3. A small fibroid located subperitoneally has little effect upon pregnancy 
 and labor and can usually be disregarded. Attention should be called 
 to the fact, however, that fibroids are frequently multiple and often 
 while only one can be felt, there may be one or more in the uterine wall 
 which may interfere more or less with uterine contractions. This inter- 
 ference is usually not enough to cause anxiety. On the other hand, a 
 tumor large enough to cause obstruction or one which undergoes necrotic 
 changes presents one of the serious problems of obstetrics. As regards 
 the surroundings of a patient with these complications, the low mor- 
 tality of the present day depends largely upon having these patients either 
 in a well-equipped hospital with all modern provisions for maintaining 
 asepsis, or else providing in the patient's home a temporary equipment 
 which will answer the same purpose. i\.s regards the judgment and skill 
 of the obstetrician, there is no complication of obstetrics in which greater 
 conservatism is indicated than in the association of fibromyomata with 
 pregnancy and labor, for the reason that save in exceptional instances 
 nature is equal to the solution of the problem. A few observations on 
 this subject may be of value: In the first place fibromyomata sometimes 
 cause abortion, or artificial abortion may in rare instances be indicated 
 in this complication. 
 
036 ABNORMAL LABOR FROM ANOMALIES IN PASSAGES 
 
 The complete emptying of the uterus in an al)ortion compHcated by 
 fibroids is a mucli more serious operation than with a normal uterus. 
 The tortuous canal, the adherence of the membranes, and the tendency 
 to hemorrhage, all unite to make the technic more difficult. In some 
 cases the hemorrhage can only be checked b\' a hysterectomy. Further- 
 more, if the tumor is of the submuc-ous, and sometimes e\en of the inter- 
 stitial variety, the operation may so injure the capsule of the tumor that 
 necrosis and infection fol'ows. While conservatism has been advocated, 
 as a general rule in the treatment of the complication under considera- 
 tion, if the tumor undergoes necrosis, only prompt, radical work in the 
 shape of myomectomy or hysterectomy will keep the mortality low. 
 
 Maternal Mortality. — In the 89 cases of fibromyomata occurring in 
 20,000 consecutive labors at the Sloane Hospital there were 3 maternal 
 deaths, i. e., 3.3 per cent. Of these 3 deaths, 1 occurred from toxemia of 
 pregnancy, 1 from nephritis, and 1 from sepsis from sloughing of the 
 tumor. 
 
 Pinard, in his series of 84 cases, reported a maternal mortality of 3.G 
 per cent. 
 
 Fetal Mortality. — Aside from the fetal mortality resulting from abor- 
 tion and premature labor," there is always danger to the fetus from the 
 endometritis favoring accidental hemorrhage; from prolapse of the cord 
 when the tumor interferes with normal engagement of the presenting 
 part; from toxemia when the tumor is large enough to interfere by its 
 pressure with elimination, and from the operative delivery when the 
 tumor causes obstruction. 
 
 In the author's series of 89 cases there were 31 fetal deaths; 4 from 
 abortion, IS stillbirths, and 9 subsequently, but before the mothers left 
 the hospital. This gave a fetal mortality of 34.8 per cent. 
 
 Treatment. — In discussing the treatment of fibromyomata complicat- 
 ing pregnancy and labor, it is only right to antedate this condition 
 and consider the case of an unmarried woman who is contemplating 
 matrimony. 
 
 What advice should be given her? This depends largely upon the size 
 of the tumor. The first question which naturally presents itself is this: 
 Should a woman with a fibromyoma of the uterus marry ? This question 
 has been asked of the author a number of times, and he has each time 
 answered it in the affirmative and has never regretted it. 
 
 Other questions presenting themselves may be these : Should anything 
 be done to the tumor before marriage? Is childbirth possible? What 
 will be the effect of pregnancy upon the tumor? The answers to these 
 questions depend largely upon the size and location of the tumor 
 or tumors. If the tumor is subperitoneal, is small and is causing no 
 symptoms, the author believes that the woman should be allowed to 
 marry and that she is fortunate if she is ignorant of the existence of the 
 growth. 
 
 If the tumor is of large size and is causing symptoms, either hemor- 
 rhage, pain or other pressure symptoms, or is seen to be increasing in 
 size, the problem is a difficult one. In the solution of it several factors 
 
FIBROMYOMATA COMPLICATING PREGNANCY AND LABOR 637 
 
 should be borne in mind, when considering matrimony. In the first 
 place, while fibromyomata have a certain degree of sterility, still preg- 
 nancy is possible, and during the pregnancy the tumor will probably 
 increase in size. 
 
 With these facts in mind the author believes that if the tumor is large 
 enough to cause symptoms and is either subperitoneal or submucous 
 and can be removed without hysterectomy, this should be done before 
 marriage. 
 
 The next question is : What should be done if the tumor is large enough 
 to produce symptoms, yet is so situated that it cannot be removed 
 without removing the body of the uterus? The author believes that 
 here the best treatment is supravaginal hysterectomy before marriage, 
 leaving at the operation, the ovaries, tubes, and cervix. This allows the 
 woman to ovulate and retain the benefits of the ovarian function. It 
 also retains the normal condition of the vagina. In fact it retains the 
 conditions for normal marital relations. Of course the woman will 
 be unable to become a mother, and the would-be husband should be 
 informed of this before marriage, but the presence of the tumor in all 
 probability robbed her of the blessing of maternity long before the opera- 
 tion and she is in much better condition for matrimony after operation 
 than before. 
 
 In the consideration of the management of the case of a w^oman who 
 is already pregnant when first seen by the obstetrician, one of the first 
 questions which may arise is this: Shall the tumor receive any treat- 
 ment during pregnancy? This cjuestion the author believes should be 
 answered in the negative unless the tumor obstructs the parturient 
 canal, or necrosis of the tumor is threatened. If the tumor is situated 
 in the cervical canal and is pedunculated, it should be removed with 
 the hope that the pregnane}' will not be interfered with. If the tumor 
 is subperitoneal and threatens obstruction, a condition is presented 
 which may tax the judgment of the obstetrician to the utmost. While 
 a few cases may well be treated by myomectomy during pregnancy, 
 the author believes this to be very exceptional and in general not good 
 practice. Fig. 380 is the photograph of a tumor attached to the fundus 
 and threatening obstruction. It was removed by the author by myo- 
 mectomy when the woman was two months pregnant, the pregnancy 
 not being interrupted. In the majority of cases the tumor will either be 
 pulled up out of the way by nature as the pregnancy advances, or can be 
 pushed out of the way by the gentle manipulation of the obstetrician. 
 Furthermore, during pregnancy is not a favorable time to operate upon 
 the uterus, as the risk of hemorrhage and infection is greater and the 
 tendency to abortion too great to be lightly overlooked. 
 
 In the majority of cases the pregnant uterus containing one or more 
 fibroids should be left alone until nature has demonstrated in her 
 labor that she is unable to remove the obstruction and complete the 
 delivery. In many cases during the labor itself the tumor will be seen 
 to rise and cease to obstruct. The waiting observation of the obstet- 
 rician, however, should be intelligent and it should ever be borne in mind 
 
638 ABNORMAL LABOR FROM ANOMALIES IN PASSAGES 
 
 that long-continued and forcible pressure upon the tumor fa\'ors necrosis 
 and infection and endangers the mother more than a timely clean 
 operation. 
 
 If early in the first stage of labor the parturient canal is foimd to be 
 distinctly obstructed liy the tumor, the best treatment is usually a 
 Cesarean section followed l)y a myomectomy or h>sterectomy, as the 
 conditions indicate. 
 
 A variety of problems may be presented to the obstetrician by the com- 
 plication of pregnancy by fibroids of large size. One may be the advis- 
 ability of operating during pregnancy and removing uterus and fetus 
 
 ■**fi8»* 
 
 '» •>* 
 
 \ 
 
 > 
 
 Fig. 380. — Fibroinxoina rcmuxed from luiidu.-? of two iiiuuths prcguaut ultTu? 
 
 not interrupted. 
 
 ricguancy 
 
 before its viability, \yhile instances ma>- arise where the pressure of 
 the growing uterus and tumor is such as to endanger the life of the mother 
 and disregard of the life of the fetus is justifiable, in general it may be 
 said that the difference in mortality between a simple Cesarean section 
 and one followed })y hysterectomy is so slight in a clean case, that the 
 best procedure in skilled hands and with modern equipment is to let 
 the pregnancy go to term, deliver by Cesarean section, and then deal 
 with the tumor according to the conditions found. 
 
 4. Another problem may present itself: In the case of an early preg- 
 nancy complicated by a fibromyoma which has never caused symptoms, 
 
OVARIAN TUMORS COMPLICATING PREGNANCY AND LABOR 639 
 
 is it justifiable to empt}^ the uterus to avoid the probable growth of the 
 tumor? 
 
 While conditions may arise in which such a procedure is justifiable, 
 it is usually very exceptional, and the author has usually advised against 
 it, both on moral grounds and for the reason that the induction of abor- 
 tion in the case of a fibroid uterus is an operation of greater danger than 
 is usually supposed. As regards the question of operation upon fibro- 
 myomata during the puerperium, it may be said that unless the circula- 
 tion of the tumor is suddenly obstructed, as by a twist of the pedicle, or 
 the tumor becomes necrotic or infected, the puerperium is not a good 
 time for operation. It is much better to wait until involution in the 
 uterus and the tumor is complete, when the ease of operation will be 
 increased and the risk diminished. Moreover, in some cases the need 
 for operation will be found to have disappeared. 
 
 A twist in the pedicle of a fibromyomata with acute symptoms from 
 its strangulation and inflammation indicates operation at once, whether 
 it occurs during pregnancy or the puerperium. Furthermore, the oc- 
 currence of necrosis or suppuration of the tumor as a result of the labor 
 demands speedy radical operation. 
 
 Carcinoma of the Uterus. — Occasionally a neglected carcinoma of the 
 cervix will so infiltrate the surrounding tissue as to cause marked obstruc- 
 tion to delivery. In one case of the author's this obstruction was so 
 extreme and the danger of hemorrhage from laceration of the cancerous 
 tissue, if craniotomy was attempted, was so great that in spite of the 
 child being dead Cesarean section was performed. 
 
 Ovarian Tumors. — ^Tumors of the ovary present a serious complication 
 in pregnancy and labor, not only on account of possible dystocia, but also 
 on account of possible changes taking place in the tumor itself. 
 
 Although solid tumors of the ovary occasionally occur, McKerron^ 
 finding in the literature 5 fibromata in a series of 107 cases of ovarian 
 tumor complicating pregnancy, it is the cystic tumor, either the cyst- 
 adenoma or the dermoid, which is most often found complicating preg- 
 nancy and labor. 
 
 Diagnosis. — An ovarian cyst is usually diagnosed by its elastic feel, its 
 spherical or multilocular shape, its relation to the uterus, and the history 
 of the patient. In this connection attention should be drawn to the fact 
 that a tense cyst, or one under pressure, may lose its elastic feel and be 
 mistaken for a solid tumor. The natural position for a small ovarian 
 tumor is first at the side of the uterus, then in the pouch of Douglas, then 
 as its size becomes too great for the pouch of Douglas, unless it has formed 
 adhesions there, it naturally rises into the abdomen. If it has formed 
 adhesions in the pouch of Douglas, or has become incarcerated there, 
 or if it is an intraligamentous cyst, it retains its position and is more 
 likely to cause dystocia. A dermoid cyst, from its greater weight and 
 greater tendency to form adhesions, is more likely to be found low in the 
 pelvis. A knowledge of the behavior of these different varieties and 
 
 1 The Obstruction of Labor by Ovarian Tumors in the Pelvis, Trans. London Obst. Soc. , 
 1897, xxxix, 334-382. 
 
040 ABNORMAL LABOR FROM ANOMALIES IN PASSAGES 
 
 conditions of ovarian cysts greatly assists in the diagnosis of an ()\arian 
 tumor complicating pregnancy. 
 
 Occasionally an ovarian cyst will simulate ])regnancy. The author 
 once saw in consultation an inmate of an institution for the feeble- 
 minded who presented many of the symptoms of pregnancy and was 
 suspected of being in that condition as a result of rape by one of the 
 orderlies of the institution. The girl had an enlarged abdomen, darkened 
 areolae, fluid in the breasts and amenorrhea. Careful examination, how- 
 ever, detected a small uterus, separate from a large ovarian cyst, which 
 was later verified by an operation. The changes in the breasts were 
 due to the ovarian stimulation from the growth of the tumor and the 
 amenorrhea was due to her anemia. 
 
 Effect on Pregnancy. — Most obstetricians agree that abortion and 
 premature labor are more common in a pregnancy associated with an 
 ovarian cyst. Remy,^ in a series of 321 pregnancies complicated by 
 ovarian tumors collected from the literature, found abortion or premature 
 labor reported in 17 per cent. The complication, however, most to be 
 dreaded in pregnancy is some change in the cyst itself, as a strangulation 
 from a twist in its pedicle. The change in the shape and size of the uterus 
 usually necessitates a change in the position of the tumor with the risks 
 of a twist in its pedicle, if it is a pedunculated tumor. This, however, is 
 less likely to occur in pregnancy than in the puerperium. 
 
 Effect of Labor. — An ovarian tumor may or may not cause dystocia, 
 according to its relation to the parturient canal. If small and situated 
 above the pelvis it is not likely to interfere with the labor, but if situated 
 in the pouch of Douglas, or if intraligamentous and lying low in the 
 pelvis, it may cause most marked obstruction. 
 
 Although the tumor may not interefere with the labor, if it lies above 
 the pelvis the labor often so interferes with its circulation and vitality 
 as to cause future trouble. 
 
 Effect on the Puerperium. — The fact that the labor has been com- 
 pleted does not necessarily signify that the danger from a complicating 
 ovarian tumor is over. The tumor may have been bruised during the 
 labor with the consequent lowering of vitality and greater risk of infection, 
 or following the labor, with the increased room for changing its position 
 the tumor may become twisted on its pedicle with the acute symptoms 
 belonging to that condition. 
 
 If it is known that a woman has an ovarian tumor, the puerperium 
 shoidd be carefully watched and the occurrence of acute pain, \'omiting 
 and symptoms of peritoneal irritation with tenderness over the tumor 
 and a rise of temperature and pulse should be taken as evidence that the 
 circulation of the tumor has become obstructed and an abdominal 
 operation should be performed promptly with removal of the tumor. 
 
 Treatment. — An ovarian tumor complicating pregnancy in its early 
 half should be removed. It is admitted that in 15 to 20 per cent, of the 
 cases the operation is followed by abortion or premature labor, but these 
 
 ' De La Giosscssc coinpli(iuee dc Kj'ste ovariquc, Paris, 1S86. 
 
OVARIAN TUMORS COMPLICATING PREGNANCY AND LABOR G41 
 
 results are not unusual in the complication of pregnancy by an ovarian 
 tumor even without the operation for its removal. The route to be 
 followed in the operation depends upon the size and the location of the 
 tumor. 
 
 In general the abdominal route is preferable, but in two instances, one 
 with a cystadenoma and the other with a dermoid cyst, the author has 
 removed the tumor per vaginam without interference with the course of 
 pregnancy. 
 
 The above general rule the author believes applies, unless the tumor 
 is so small as to be disregarded, until the pregnancy is six months 
 advanced. 
 
 Fig. 381. — Oyaiian tumor obstructing th6 parturient canal. (Bumm.) 
 
 During the last three months the question of operation is a debatable 
 one and usually it is better to keep the patient under careful observa- 
 tion and postpone the operation until after -the labor, unless the latter is 
 obstructed by the tumor, or the circulation and nutrition are disturbed. 
 The reason for this view is based upon the fact that during the latter 
 part of pregnancy the operation is often difficult, especially if the tumor 
 lies behind the uterus (Fig. 381), the incision often has to be a long one 
 and the inevitable manipulation favors premature delivery. When the 
 labor is obstructed by the tumor the question arises : Shall it be tapped 
 or shall it be removed? It is admitted that if the cyst content is thin, 
 clear fluid, as obtains in some ovarian and parovarian cysts, the cyst 
 can be emptied and the labor terminated without an abdominal opera- 
 tion. Years ago the author treated cases in that way, but the difficulty 
 on the one hand in determining that the cyst content is clear and rela- 
 41 
 
642 ABNORMAL LABOR FROM ANOMALIES IN PASSAGES 
 
 lively harmless and the danger on the other, of infecting the peritoneum 
 if the tumor is a dermoid, or the cyst fluid infected, has led to the abandon- 
 ment of this method and most operators are agreed that the best procedure 
 is the removal of the tumor if operative skill is at hand or ol)tainable. 
 As a rule, if an ovarian tumor obstructs the labor, the best procedure is 
 the combination of an ovariotomy with a Cesarean section. 
 ' To remove an ovarian tumor by abdominal incision during a labor 
 and then allow the sutured incision to be subjected to the strain incident 
 to the completion of the labor by nature, does not appeal to the author 
 as good practice. Furthermore, in his experience the ovarian tumors 
 causing obstruction are usually situated behind the uterus and are much 
 easier reached and better treated after the uterus has been emptied. 
 
 The author's preference is usually to perform a Cesarean section and 
 follow it by the ovarian operation. 
 
 The indication for operation upon an ovarian tumor during the puer- 
 perium is based upon the condition of the tumor itself. If as a result of 
 the labor it becomes inflamed or infected, or if a twist of its pedicle 
 occurs, the tumor should be removed at once, otherwise it may be left 
 until the woman has regained her strength and her uterus has involuted. 
 
 Dystocia from Kidney. — Although obstruction to labor arising from 
 the kidney or kidneys is a rare complication, still in 6 instances the author 
 has met with obstruction of the parturient canal from a congenitally 
 displaced kidney. In the first instance, in a case seen in consultation 
 with the late Dr. T. Gaillard Thomas and Dr. H. ]Mc]M. Painter, of New 
 York, the patient was at term, and filling the pelvis posteriorly and to 
 the left side was a congenitally displaced kidney in the condition of 
 hydronephrosis. 
 
 This was removed by the author^ per vaginam. The operation was 
 followed within twelve hours by uterine contractions and the child was 
 born normally on the following day. A few years later he attended this 
 woman in a labor which was absolutely normal. 
 
 In the other 5 instances of labor obstructed by congenitally displaced 
 kidneys both kidneys, lay in the pelvis, and in each case Cesarean section 
 was performed without disturbing the kidneys. These 5 instances 
 occurred in the same patient. 
 
 Calculi in the Bladder.- — Occasionally, as reported by Love,^ a calculus 
 in the bladder may obstruct labor from its size and position. In Dr. 
 Love's case the calculus became so wedged between the presenting part 
 and the Del vis that the child had to be delivered by Cesarean section. 
 As a rule the best procedure is to relieve the obstruction by removing 
 the calculus. 
 
 Cancer of the Rectum.^ — As in cancer of the cervix so in cancer of the 
 rectum, the connective tissue in the pelvis may become so infiltrated by 
 the disease as to produce an unyielding mass impassable for the child 
 without great danger of extensive laceration and hemorrhage. 
 
 1 Congenital Peh-ic Kidney Obstructing the Parturient Canal, Amer. Jour. Obst., 1898, 
 xxx^-iii, 36-41. 
 
 2 Trans. Alumni Soc. Sloane Mat. Hosp., I'JIO, pp. 1 and 2. 
 
DYSTOCIA FROM CONDITIONS OF THE CERVIX 643 
 
 In cases of this kind, in spite of the fact that the woman has but a 
 short time to live, if the obstruction is marked. Cesarean section is the 
 best method of delivery. It may be noted, however, that the mortality 
 from Cesarean section in this class of cases is high. 
 
 Aside from the causes of obstruction already mentioned, other tumors, 
 malignant or benign, will occasionally occlude more or less the parturient 
 canal and require either their removal or Cesarean section. 
 
 Dystocia from Conditions of the Cervix. 
 
 Atresia of the Cervix. — Occasionally on vaginal examination to deter- 
 mine the amount of cervical dilatation no cervix and no os uteri will 
 be detected, but a thin muscular diaphragm will stretch across the 
 vaginal vault, separating the presenting part from the examining 
 fingers. 
 
 This is often confusing in diagnosis, as the usual landmarks are obscured. 
 Of course there was an opening present when impregnation occurred, and 
 the present atresia is the result of inflammation of the cervical canal 
 which has taken place since. Sometimes this atresia has followed a 
 previous amputation of the cervix, but more often the atresia is the 
 result of an inflammation of the canal of a cervix which has been retracted 
 and flattened out in nature's eftort to find and dilate the opening. Some- 
 times the atresia is only apparent and there is present a very small and 
 very rigid external os. 
 
 It is interesting to observe that in some of these cases of atresia of 
 the cervix the labor will continue for hours without progress so long as 
 the atresia is complete, but as soon as a small opening is made, complete 
 dilatation is accomplished within a very short time and the labor pro- 
 gresses rapidly. 
 
 Diagnosis. — If the possibility of this condition is borne in mind the 
 diagnosis usually presents little difficulty. Generally, if a careful examina- 
 tion be made, the representative of the cervix and the place where the 
 external os should be can be felt. 
 
 Treatment. — Having made the diagnosis of the condition the treatment 
 is usually easy. It consists simply in making, with some sterile instru- 
 ment, an artificial opening where the external os should be. Sometimes 
 the sterile-gloved finger will suffice to make the opening, but often a 
 sharper, firmer instrument will be necessary. 
 
 Stenosis of the Cervix. — Aside from an atresia of the cervix, dystocia 
 may arise from a narrowing or an excessive rigidity of the cervical canal. 
 This may be the result of lack of development, of previous operation, of 
 traumatism, or ulceration with cicatrization. 
 
 From Faulty Development. — The same cases which on account of lack 
 of development in the uterus suffer from dysmenorrhea during girlhood 
 and perhaps from sterility after marriage, and which present on examina- 
 tion an anteflexed uterus, perhaps with an elongated cervix, often exhibit 
 in labor a stenosis of the cervix and a delay in dilatation amounting to 
 dystocia. This condition is really the result of lack of development, and 
 
644 ABXORMAL LABOR FROM AXOMALIES IX PASSAGES 
 
 the mechanical dihitation of the cervix ^A•hich enables them to become 
 pregnant may be looked upon as an aid to the further development of the 
 uterus. 
 
 When the stenosis of the cervical canal is overcome by one labor the 
 subsequent labors usually progress normally. In elderly primigravidse 
 is occasionally met a rigidity of the cervix which from its difficulty in 
 dilatation resembles the stenosis of the cervix just described. 
 
 From Previous Operation. — Every gynecologist should attend a certain 
 number of deli\eries in women upon whom he has performed the opera- 
 tion of trachelorrhaphy. In this way onh' can he properly appreciate the 
 importance of leaving in his operations for lacerated cervix, in women 
 who are likely to have other children, sufficient cer\ical tissue and a 
 cervical canal sufficiently large for a relatively normal dilatation. It is 
 one of the trying experiences of the obstetrician to meet in labor a cervix 
 which has been previously repaired, perhaps with a beautiful cosmetic 
 result, but with a rigidity from lack of surrounding tissue which can 
 only be overcome by unnecessary hours of labor, or perhaps by mechan- 
 ical dilatation which leaves a cervix in a worse state of laceration than 
 that for which the original operation was performed. It is better in a 
 trachelorrhaphy, in women during the child-bearing age, to leave an 
 external os rather luiduly patulous than to suture it too tightly. Atten- 
 tion has already been called to the fact that as a result of a previous am- 
 putation of the cervix a certain amount of dystocia may residt from a 
 cicatricial os. As a rule, however, this does not occur. 
 
 From Traumatism. — Occasionally a difficult instrumental delivery is 
 accompanied by so much traumatism and followed by so much slough- 
 ing and cicatrization that a subsequent dystocia results from the stenosis 
 and rigidity thus produced. 
 
 From Ulceration. — The extensive use of caustics, either chemical caus- 
 tics or the actual cautery, and diseases which are characterized by ulcera- 
 tion with subsequent cicatrization when the disease is cured, as for 
 instance syphilis, may result in a cicatricial condition of the cervix 
 causing dystocia, which can only be overcome by mechanical dilatation. 
 
 Treatment. — When labor is prolonged on account of a stenosed or 
 excessively rigid cervix, two general methods of treatment are at the 
 command of the obstetrician: (a) medicinal, (b) mechanical. 
 
 Medicinal Treatment. — A woman whose first stage has been unduly 
 prolonged and whose cervix for reasons under discussion is still undilated, 
 is usually tired out both physically and mentally and needs rest. Chloral 
 (grs. xx) per rectum or a hypodermic injection of morphin sulph. 
 (gr. \-\), ANill often give the needed rest of two or three hours, and if a 
 little hot broth or some easily digested food is then administered and 
 encouragement given, the patient will often renew her labor with increased 
 vigor and rapidly complete her first stage. 
 
 If the uterine muscle shows inertia and appears to be unequal to 
 the task of dilating the cervix, two drugs are of value: quinine and 
 strychnin. 
 
 The administration of ciuinine sulph. fgr. v, q. 4 h.) and strychnin 
 
DYSTOCIA FROM CONDITIONS OF THE CERVIX 645 
 
 sulpli. (gr. ^-^ q. 4 li.), alternating ^Yith each other, will stimulate the 
 rhythmical contractions of the uterus better than any other medication 
 known to the author. 
 
 Some obstetricians favor repeated vaginal douches of hot lysol solu- 
 tion (0.5 per cent.) for their softening effect upon the cervix and vagina. 
 
 It must be borne in mind, however, that the introduction of a douche 
 nozzle, or any other foreign substance into the vagina during labor, 
 increases the risk of infection. The use of pituitary extract before the 
 cervix is dilated is neither safe nor wise. 
 
 Mechanical Treatment.- — If in spite of rest of the patient and medicinal 
 stimulation of the uterine muscle, the cervix still resists dilatation, there 
 is nothing quite equal to the use of the elastic bag, as described on page 
 616. The presence of the bag in the cervical canal not only softens and 
 dilates the cervix, but stimulates uterine contractions and has proved 
 itself a method of such great value that, save for giving the patient 
 rest, medicinal methods of dealing with a stenosed or rigid cervix in labor 
 have fallen more and more into disuse and the elastic bags are, as a 
 rule, promptly resorted to. 
 
 After the cervix has been softened and partially dilated by nature or 
 by the use of the elastic bag, its further dilatation, if nature is unequal 
 to the task, may be accomplished by gentle and gradual stretching with 
 the gloved fingers. This must be done carefully, as in some instances 
 extensive laceration and profuse hemorrhage have resulted. 
 
 Septa of Cervix. — Referring to the development of the uterus (see 
 page 47), it is seen that it is formed by a union of the two ducts of Miiller 
 which lie side by side, and that in the normal development the partition 
 formed by the two approximated walls is absorbed, leaving a single canal 
 for the uterine body and cervix. Sometimes, as a result of faulty devel- 
 opment, there is an arrest in the absorption of this partition and a band 
 is left running anteroposteriorly for a variable height across the cervical 
 canal. The dystocia arising from this band is seldom of any consequence, 
 as although it can sometimes be felt running anteroposteriorly across the 
 presenting part, it usually stretches easily, as nature selects one opening 
 or the other, or it can be cut, or slipped to one side by the obstet- 
 rician. 
 
 Another variety of septum in the cervical canal sometimes results 
 from faulty union in a trachelorrhaphy. The union at the site of one 
 or more sutures may fail, and instead of leaving only one os uteri, the 
 operation may result in two openings, with a septum between which in 
 a subsequent labor may resemble that found from faulty development. 
 It is treated in the same way. Sometimes, as a result of extensive lacera- 
 tion, sloughing and cicatrization, similar bands or septa may result. 
 
 Edema of the Anterior Lip, — Occasionally before the dilatation of the 
 cervix is complete the anterior lip is caught between the fetal head and 
 the anterior pelvic wall and becomes quite edematous. While usually 
 this disappears as the dilatation progresses, this process can often be 
 facilitated by upward pressure upon it with the gloved fingers between 
 and during two or three uterine contractions. The pushing downward 
 
646 ABNORMAL LABOR FROM ANOMALIES IN PASSAGES 
 
 and forward of the undilated cervix by the advancing head tends to 
 loosen the attachments of the anterior vaginal wall and favor cystocele; 
 hence the desirability of lessening this if possible. 
 
 Dystocia from Conditions of the Vagina or Vulva. 
 
 Atresia. — Complete atresia of the vagina is usually a congenital con- 
 dition and is, of course, a barrier to pregnancy. Its association with the 
 absence or imperfect development of the other pelvic organs and the 
 treatment of the condition will be found discussed in works on gynecology. 
 
 Stenosis of the Vagina. — The most important form of vaginal stenosis 
 is congenital in origin and occurs as a perforated diaphragm stretched 
 across the ^'agina at about the junction of its upper one-third with 
 the lower two-thirds. The first feel to the examining fingers is that of 
 a blind vaginal fornix, but careful examination usually detects a small 
 opening in the diaphragm and above it a cervix. 
 
 When first found in labor it may suggest the necessity for a Cesarean 
 section, but although a number of instances of this condition have 
 occurred in the author's experience, in each instance, as the cervix dilated 
 and allowed the presenting part to come down upon the diaphragm, its 
 opening dilated rapidly, like a thinned-out cervix, and labor progressed 
 favorably. 
 
 If dystocia arose from this diaphragm, a small crucial incision could 
 be made in it and the opening mechanically dilated with the elastic bag. 
 
 Cicatricial stenosis of the vagina sometimes arises from injuries or 
 from extensive inflammation with ulceration. At the time of labor the 
 narrowed canal usually softens and dilates sufficiently for the child to 
 pass, but if dystocia arises from it, the dilatation ma}- be facilitated by 
 the use of the elastic bag, or in rare instances multiple incisions may be 
 advisable. 
 
 Septa in the Vagina. — In the same way that an arrest in the process 
 of absorption of the partition between the canals of the two ducts of 
 Midler may leave an anteroposterior septum in the cervix, so the same 
 arrest may leave a double vagina to a greater or less height. As a rule 
 the septum is more apt to be present below and absent above, near the 
 cervix. It may be only a narrow band or it may be a partition and reach 
 almost, if not quite, to the cervix. The septa are usually anteroposterior, 
 but occasionally are transverse or oblique. It is not often that vaginal 
 septa cause dystocia as, if it is a double vagina, nature usually selects 
 one-half and sufficiently dilates it, or if it is only a narrow band, it is 
 usually slipped to one side by nature or can easily be so slipped or ligated 
 and cut by. the obstetrician. These bands are not very vascular. One 
 case in the author's experience proved of marked interest. A patient 
 with a vaginal septum reaching nearly to the cervix was in labor with a 
 breech presentation. After the rupture of the membranes one foot and 
 a loop of cord came dowai to the vulva in one half-vagina and the 
 other foot in the other half-\agina. Rapid incision of the whole 
 vaginal septum saved the life of the child. 
 
ANOMALIES OF SOFT PARTS OF PARTURIENT CANAL 647 
 
 N i^n annoying result of labor in connection with a double vagina has 
 occurred twice in the author's experience. The woman after getting up 
 from her confinement and going about complained of the sagging and 
 protrusion of the relaxed vaginal septum, causing annoyance as she 
 walked. Relief was given by excision of the remains of the septum in one 
 case and excision of the complete septum with a Hegar's perineorrhaphy 
 in the other. 
 
 Septa will occasionally be found in the vagina as a result of lacerations 
 and the miion of raw surfaces not anatomically belongmg together. 
 Thus a band may stretch between cervix and vagina or across the 
 vagina, etc. These have little importance in labor. 
 
 A double vagina, with the septum extending the whole length of the 
 vagina, accompanied by a double uterus occasionally leads to an amusing 
 confusion in diagnosis. Different members of the house staff at the Sloane 
 Hospital once examined such a case and while one man reported the cervix 
 almost completely dilated, the other reported no dilatation. One had 
 examined one vagina, the other, the other one. 
 
 Tumors in the Vagina. — Cysts, fibromata, malignant masses and hema- 
 tomata are the most common forms of vaginal tumor causing dystocia. 
 
 If large enough to seriously obstruct the canal these growths should 
 if possible be removed. In hematomata the best treatment consists in 
 incision of the tumor, turning out the clots and packing with sufficient 
 gauze to control the hemorrhage. 
 
 If the mass cannot be removed, as in cases of inoperable carcinoma. 
 Cesarean section may be the best method of delivery. 
 
 Rigid Vulvar Orifice. — ^In some elderly primigravidse, especially those 
 who on accomit of vaginismus, or for some other reason have had only 
 infrequent intercourse, also in athletic women who through horseback 
 riding or other forms of exercise have highly developed the muscles of 
 the pelvic floor, the vulvar orifice is so rigid as to cause distinct dystocia 
 from tardy dilatation. 
 
 A rigid vulvar orifice sometimes also results from cicatrices arising 
 from traumatism of the vulva, or from extensive inflammation with 
 ulceration. 
 
 It often happens in cases of rigid vulvar orifice that dilatation needs to 
 be facilitated, both to lessen the suffering of the woman and conserve her 
 strength, and also in the interest of the child whose welfare, as shown by 
 the fetal heart sounds, would be endangered by a longer continuation of 
 pressure. The dilatation in such cases may weU be facilitated by gradual 
 stretching with gloved fingers or by the use of a large-sized elastic bag. 
 
 Hematoma of the Vulva. — Not infrequently as a result of straining 
 during the labor or of traumatism in efforts at delivery, a hematoma of 
 the vulva is formed which narrows the vulvar orifice and so causes 
 dystocia. 
 
 The treatment, as in hematoma of the vagina, consists in incision, turn- 
 ing out the clots and packing with sufficient gauze to control the bleeding. 
 
 Edema of the Vulva. — This condition (see Fig. 382) may be the result 
 of general or local causes. It may arise as a part of a general edema 
 
(')4S ABNORMAL LABOR FROM ANOMALIES IN PASSAGES 
 
 due to nephritis, or as a result of i)ressure of the eliild, eitlier (hiring 
 preguaney or during the eourse of a long, dry labor. Although edema 
 of the vulva does uot usually- eause marked dystocia, it does greatly 
 predispose to lacerations of the vulva and perineum and in some cases 
 so lowers the vitality of the tissue that sloughing results. 
 
 Edema of the vuha occurring during pregnancy will often subside 
 if the patient is put to bed and kept oft" her feet for a few days. 
 
 Treatment. — Pricking the edematous tissue witli sterile needles and 
 covering the parts with a sterile dressing will often rapidly relieve the 
 condition. 
 
 Fig. 382. — Edema of the \-ulva. 
 
 / 
 
 ANOMALIES OF THE HARD PARTS OF THE PARTURIENT CANAL. 
 
 The most serious forms of abnormal labor are associated with anomalies 
 of the hard parts and will now be considered under the head of 
 
 Deformities of the Pelvis. 
 
 A pelvis is considered deformed when it is so abnormal in either size, 
 shape or articulation as to interfere with the mechanism or progress 
 of normal labor. This definition does not exclude the possil)ility of un- 
 aided delivery, for many cases of markedly deformed pelvis have easy 
 deliveries, either because the available birth canal is ample in size, or 
 
ANOMALIES OF HARD PARTS OF PARTURIENT CANAL 649 
 
 because the child is small. In 1770 cases of deformed pelvis at the 
 Sloane Hospital 815, or about 4(3 per cent., delivered themselves 
 normally at term. 
 
 Frequency. — Since the time of Heinrich von Deventer,^ who in 1701 first 
 described deformities of the nelvis from the obstetrical standpoint, our 
 knowledge of this subject has gradually developed, but it is only in recent 
 years, since routine pelvimetry became the rule in the care of pregnant 
 women, that an accurate idea as to the frequency and variety of pelvic 
 deformity has been obtained. 
 
 The frequency of pelvic deformity varies greatly in different countries 
 and in different races in the same country. 
 
 At the Sloane Hospital for Women, in 20,000 consecutive deliveries 
 there were 1770 cases with deformed pelvis, or 8.8 per cent., but as stated 
 above, of these 1770 cases, 815, or 46 per cent, delivered themselves 
 normally at term; and, moreover, in the remaining 955, 371, or 20 per 
 cent., were delivered prematurely, leaving only 584, or 33 per cent., of the 
 deformed pelves which caused d}' stocia at term. At the Sloane Hospital 
 justomajor pelves are not classified as deformed pelves, or the frequency 
 of 8.8 per cent, would doubtless be increased. At the Sloane Hospital 
 rachitic pelves are not classified by themselves but are included with 
 the simple flat, the justominor and the justominor flat, hence the fre- 
 quency of each of these varieties is doubtless somewhat increased. 
 
 It must be understood that in assigning a given case to the class of 
 deformed pelves, trouble will arise when the departure from the normal 
 measurements is slight and the labor presents little difficulty. 
 
 There will always be a large number of these border-line cases which 
 one observer would place on one side of the line and another on the other. 
 
 In studying abnormal pelves we must constantly have before us the 
 normal pelvis and its measurements, and carefully note any marked 
 departure from this normal. 
 
 For all practical purposes the normal pelvic measurements may be 
 regarded as follows: 
 
 EXTERNAL MEASUREMENTS. 
 
 DIAMETERS OF THE INLET. 
 
 Interspinous 26 cm. 
 
 Intercristal 28 cm. 
 
 Left oblique 22 cm. 
 
 Right oblique 22+ cm. 
 
 External conjugate 20 cm. 
 
 DIAMETERS OF THE OUTLET. 
 
 Anteroposterior 9.50 cm.-ll ..50 cm. 
 
 Transverse 11 cm. 
 
 INTERNAL MEASUREMENTS. 
 
 DIAMETERS OF THE BRIM. 
 
 Anteroposterior (true conjugate) 11 cm. 
 
 Oblique 12 cm. 
 
 Transverse 13 cm. 
 
 DIAMETfeRS OF THE CAVITY. 
 
 Each 12 cm. 
 
 ^ Operationes chirurgicffi no^'nm lumen exhibentes obstetricanibus, 1701. 
 
650 ABNORMAL LABOR FROM ANOMALIES IN PASSAGES 
 
 Varieties of Deformed Pelvis. — Tn his teaching the autlior has adopted 
 the following classification, based on the etiology of the condition and 
 similar to that of Schauta:^ 
 
 1. Anomalies resulting from faulty development: 
 
 (a) Simple fiat, non-rachitic pelvis. 
 
 (6) Generally, equally contracted (justominor) pelvis. 
 
 (c) Generally, contracted flat (justominor flat) pelvis. 
 
 (d) Funnel-shaped or masculine pelvis. 
 
 (e) Obliquely contracted (Naegele) pelvis. 
 
 (/) Double obliquely contracted (Robert) pelvis. 
 (g) Generally, equally enlarged (justomajor) pelvis.^ 
 (h) Split pelvis. 
 
 2. Anomalies resulting from disease of the pelvic bones or traumatism: 
 
 (a) Rachitic pelvis. 
 
 (6) Osteomalacic pelvis. 
 
 (c) New growths. 
 
 (d) Caries, necrosis, atrophy. 
 
 (e) Fracture. 
 
 3. Anomalies in the articulations of the pelvic bones: 
 
 (a) Abnormally firm union (synostosis). 
 
 1. Of the symphysis. 
 
 2. Of one or both sacro-iliac joints. 
 
 3. Of the sacrum with the coccyx. 
 (h) Abnormally loose union. 
 
 4. Anomalies resulting from diseases of the superimposed skeleton: 
 
 (a) Spondylolisthesis. 
 
 (b) Kyphosis. 
 
 (c) Scoliosis. 
 
 (d) Kyphoscoliosis. 
 
 (e) Lordosis. 
 
 5. Anomalies resulting from abnormalities of the subjacent skeleton: 
 
 (a) Coxitis. 
 
 (b) Dislocation of the femur or femora. 
 
 (c) Absence or deformity of one or both lower extremities. 
 
 Deformities of the Pelvis Resulting from Faulty 
 Development. 
 
 In studying the development of the normal pelvis it is seen that its 
 peculiar shape is the result of a number of different forces, viz.: 
 (a) The growth of the individual pelvic bones. 
 
 (6) Traction exerted on these growing bones by muscles and liga- 
 ments. 
 
 (c) Pressure downward upon these growing bones by the superim- 
 
 posed trunk. 
 
 (d) Pressure upward througli the fem'ora. 
 
 1 Die Beckenanomalien, Miiller's handbuch der Geb., 1889, p. IL 
 
 2 At the Sloane Hospital justomajor pelves are not included among deformed pelves. 
 
ANOMALIES OF HARD PARTS OF PARTURIENT CANAL 651 
 
 The final shape of the pelvis is the resultant of these different forces. 
 If any of these, forces are deficient or in excess the normal equilibrium is 
 disturbed and the pelvis fails to assume its normal shape and size. 
 
 Even if the forces of traction, pressure and counter-pressure are nor- 
 mal, if they are brought to bear upon bones smaller than normal, even 
 though healthy, deformity may result. The same forces acting upon bones 
 softened by disease may cause even greater deformity. 
 
 Viewed clinically, pelves may be contracted in the following diameters: 
 (a) The anteroposterior. 
 (6) The oblique, 
 (c) The transverse. 
 {d) All diameters. 
 
 The Simple Flat, Non-rachitic Pelvis. — ^In this variety of pehdc 
 deformity there is a shortening of the anteroposterior diameters of the 
 pelvic canal while the transverse diameters remain practically normal. 
 
 Frequency.— This is one of the most common forms of pelvic deformity; 
 Michaelis^ finding it in 43 per cen t, of the 72 cases of contracted pelvis 
 described by him. 
 
 At the Sloane Hospital, among the 1770 deformed pelves occurring 
 in 20,000 consecutive deliveries, the simple flat pelvis was found in 1129, 
 or 63.7 per cent. Of the 1170 deformed pelves among the whites there 
 were 869 of the simple flat variety, or 75 per cent., while of the 600 
 among the blacks there were 280, or 43.2 per cent. 
 
 J.W.Williams of Baltimore, found it in 32 per cent, of ah contracted 
 pelves in white women as compared with 2 per cent, in colored. 
 
 It is found among the upper classes as well as the lower; in the well- 
 nourished and apparently well-developed as also in those subjected 
 to privation. But little is known of its etiology, and the lifting and 
 carrying heavy weights which formerly were emphasized as causative 
 factors now receive little consideration in this country. It seems to be 
 a congenital condition, as not infrequently a fetus or child at birth will 
 present a pelvis of this shape. In some families it seems to be hereditary, 
 and mother and daughter have pelves of similar contraction. 
 
 Characteristics.- — In the simple flat pelvis the sacrum is set forward 
 as a whole without rotation on its transverse axis, as occurs in the flat 
 rachitic pelvis. This shortens the conjugate diameter throughout the 
 whole length of the pelvic canal, leaving the other diameters undisturbed. 
 Although the sacrum is set forward- as a whole the practical obstruction 
 to labor is most marked at the superior strait. Not infrequently in this 
 type of pelvic deformity there is a double promontory caused by the 
 projection of one of the lower intervertebral articulations of the sacrum 
 (see Fig. 383 j. In this case the conjugate should be measured from the 
 lower promontory. The amount of contraction in a simple flat pelvis is 
 moderate, seldom reaching 2 cm. 
 
 Diagnosis. — Unless there is the history of a previous difficult labor , 
 the simple flat pelvis is easily overlooked, as it may occur in those pre- 
 
 1 Das enge Becken, Leipzig, ISol. 
 
052 ABNORMAL LABOR FROM ANOMALIES IN PASSAGES 
 
 senting the picture of perfect health aiul (levelopmeut. It is only by 
 the practise of careful pehimetrv as a routine procedure that this error 
 is avoided. IIo\ve\er, if the pelvis of each obstetric patient is carefully 
 measured, the diagncsis of a simple flat pehis is usually made with ease. 
 The external conjugate is found shortened, perhaps measures . 18 cm . 
 instead of the normal 20 cm., and on internal examination the sacrum 
 from promontory to coccyx is more readily felt than normal, while the 
 lateral walls feel at their usual distance. The pelvis is a- symme- 
 trical one and therefore does not interfere with locomotion. When dis- 
 cussing pehimetry attention was called to the fact that occasionally the 
 
 external conjugate gives little idea 
 of the available internal conjugate. 
 So long as a simple flat pelvis 
 is occasionally found in well-nour- 
 ished patients' with otherwise large 
 pelves, and so long as the external 
 conjugate occasionally fails to indi- 
 cate an internal shortening, sur- 
 prises are bound at times to come 
 unless the promontory of the sac- 
 rum is always felt for with the 
 ^'aginal fingers. Even then, in 
 some pelves the promontory may 
 be so high up that an undue 
 })rominence of it cannot be felt, 
 especially in the latter part of 
 pregnancy when a thorough ex- 
 amination is more difficult. 
 
 The simple fiat peh'is may be 
 confused with aflat rachitic pelvis, 
 but as in diagnosing the justo- 
 minor pelvis, so here the rachitic 
 pelvis is distinguished by the 
 disturbance of the normal rela- 
 tions between anterior superior spines and crests. j_n the rachitic peli:is 
 t he inter s pinous diameter is equal to, or greater than , the in tercristah 
 
 Pregnancy and Labor in the Simple Flat Pelvis. — On account of the 
 anteroposterior contraction at the brim of the pelvis there is often a 
 failure of the prese nting part to_eiiter_the brim during the last weeks of 
 • gestation,, and consequently abnormal prominence of the abdomen, some 
 degree of pendulous abdomen, and various malpresentations are com- 
 mon. As the presenting part does not readily enter and fill the brim 
 of the pelvis, p^oln pse of the coid is a frequent complication. 
 
 The first stage of labor is usualh' protracted both on account of the 
 
 <^sloj mess of the jiead ijDLjeugagiiLg_and the slowness of tji£, cervix-JB-dilat- 
 
 ing. As the head does not readily descend to press upon the cervix its 
 
 dilatation is accomplished by a retraction of the cervix over the head 
 
 aided by the projecting bag of waters, if the membranes are unruptured. 
 
 Fig. 383. — Simple flat pelvis with double 
 IJi'omontory. (Buinni.) 
 
ANOMALIES OF HARD PARTS OF PARTURIENT CANAL 653 
 
 Often, however, the membranes rupture early and this still more retards 
 the dilatation of the cervix. As a rule the head enters the pelvis trans- 
 versely and partly extended, so that the anterior fontanelle may be 
 easily felt instead of being high up and out of reach, as in the justominor 
 pelvis. There is an exaggeration of the lateral obliquity, the sagittal 
 suture usually approaching the sacral promontory. 
 
 That part of the fetal head encountering the most resistance is the 
 last to enter, hence usually the anterior parietal bone enters first and 
 overlaps the posterior. On the child's head after birth can often be 
 found a depression where the posterior parietal bone rested against the 
 promontory, this depression lying usually near the sagittal suture between 
 the anterior fontanelle and the parietal eminence. Occasionally the 
 lateral obliquity takes the opposite direction; the anterior parietal bone 
 impinging on the pubes and the posterior parietal bone being the first to 
 enter the pelvis. 
 
 Although the anteroposterior diameter of the pelvic canal is short- 
 ened throughout, it is at the brim that t hejd£La^iiLJJi£,labQr-ia-JiLo^t 
 marked and usually after the head has passed the narrowing at the brim 
 the labor progresses favorably and often unaided to its termination. Not 
 infrequently, however, so much time and effort has been consumed in 
 securing engagement of the head that the natural forces are exhausted 
 and the delivery has to be completed by the forceps or version. 
 
 The Generally, Equally Contracted or Justominor Pelvis. — Frequsncy. 
 — This is one of the most frequent varieties of deformed pelvis found in 
 large cities like New York, especially in girls, such as shop-girls, who 
 have worked hard with insufficient fresh air and nourishment. At the 
 Sloane Hospital for Women it occurred as follows: In 20,000 consecu- 
 tive deliveries there were found 1770 deformed pelves, of which 224, or 12 
 per cent., were justominor. Of the 1770 deformed pelves, 1170 occurred 
 among whites and 600 among blacks. Of the 1170 among the whites 
 only 85, or 7.2 per cent., were justominor, while of the 600 among the 
 blacks 139, or 23 per cent., were justominor. Edgar,^ of New York, found 
 this deformity in 2.5 per cent., of all his cases. Williams,^ of Baltimore, 
 found it in one-third of the contracted pelves in white women and two- 
 thirds of those occurring in black women. Miiller,'' of Germany, found it 
 in 37 per cent, of his cases of contracted pelvis, and Richelet,^ of France, 
 in 28 per cent. 
 
 It is the pelvis to be expected in small women, but occasionally it is 
 found in large women who are apparently well developed and of per- 
 fect stature. It is a symmetrical pelvis, hence does not interfere with 
 walking or other exercise and, save for careful, routine pelvimetry, would 
 be likely to be overlooked until the time of labor. 
 
 Characteristics. — In the justominor pelvis all the diameters are re- 
 duced, but so reduced as to maintain the symmetry of the pelvis and 
 
 1 The Practice of Obstetrics, 1907. 2 Obstetrics, 1908. 
 
 ' Zur Frequenz u. Aetiologie des Allg. verengten Beckens, Archiv f. Gyn., 1880, xvi, 
 155-173. 
 
 ^ Du Bassin generalement retreci, etc.. These de Paris, 1896. 
 
654 ABNORMAL LABOR FROM ANOMALIES IN PASSAGES 
 
 yet the shortening of the different diameters may not be actually uni- 
 form, as the reduction in the size of the brim may be a little less than 
 that of the outlet, or vice versa. The sacrum in a justominor pelvis is 
 set a little higher and farther back than normal and the promontory is 
 not tilted forward. This explains why in ])elvimetry in this type of pelvis 
 the external conjugate is often found relatively longer, and therefore 
 more nearly normal, than the other diameters. It also explains why, in 
 taking the diagonal conjugate in a justominor pelvis, it is harder to 
 reach the promontory of the sacrum than would be expected from the 
 size of the pelvis. The posterosuperior iliac spines are relatively farther 
 apart than normal on account of the retroplacement of the sacrum, and 
 the transverse concavity of the sacrum is often found increased. 
 
 The bones of the pelvis as a whole are usually, but by no means always, 
 a little lighter than normal. The shortening of the anteroposterior 
 diameter in a justominor pelvis usually varies between 1 and 2 cm. and 
 seldom gives a conjugate of less than 9 cm. 
 
 Diagnosis. — As already seen, the diagnosis of a justominor pelvis prior 
 to labor is only made by careful pelvimetry. 
 
 As the external conjugate is less reduced than the other measurements 
 taken in external peh'imetry, it is to the oblique diameters that we look 
 for our diagnosis of a justominor pelvis. The oblique diameters of a 
 normal pelvis are regarded as approximately 22 cm., the right oblique 
 being a trifle longer than the left. At the Sloane Hospital, although 
 admitting that the classification is more or less arbitrary, it is the 
 author's custom to allow a variation of approximately 2 cm. on either 
 side of this normal average of 22 cm. for the oblique diameters before 
 transferring the case from the class of normal to that of abnormal pelves. 
 
 Thus, between the measurements of 20 cm. and 24 cm. in the oblique 
 diameters, other things being equal, the pehis may be considered nor- 
 mal, with the variation allowed to different individuals, the same 
 as is allowed in the sizes of heads, hands and feet which may vary greatlj' 
 and yet be considered normal. 
 
 On the other hand, a symmetrical, uniformly contracted pelvis whose 
 oblique diameters measure 20 cm. or less is called a justominor pelvis. 
 
 Furthermore, as will be studied later, a symmetrical pelvis uniformly 
 enlarged, whose oblique diameters measure 24 cm. or over, is called a 
 justomajor pelvis. 
 
 The justominor pelvis might easily be confused with a rachitic pelvis, 
 but is differentiated from it by one characteristic feature, viz., in the 
 justominor pelvis the normal relation between the interspinous and 
 intercristal diameters is maintained, and the latter is greater than the 
 former. In the rachitic pelvis, however, as will be studied later, this 
 relation is disturbed, and the interspinous diameter is equal to, or greater 
 than, the intercristal. 
 
 Labor in a Generally Contracted (Justominor) Pelvis. — As all the diam- 
 eters of the pelvis are contracted, it is readily seen that with a normal- 
 sized child the labor is likely to be prolonged. 
 
 The fetal head can onlv enter the brim in marked flexion and this 
 
ANOMALIES OF HARD PARTS OF PARTURIENT CANAL 655 
 
 flexion with additional molding must continue until the pelvic floor 
 is reached. This means that the posterior fontanelle will, as a rule, 
 be easily felt, while the anterior fontanelle will be high up, out of reach. 
 
 The posterior fontanelle, moreover, will be small and show the over- 
 lapping of the parietal bones. The caput usually becomes marked 
 before the labor is completed. Another reason for the prolongation of 
 the labor, aside from the reduction in size of the canal throughout its 
 length is that, associated with this increase in the resistant forces, there 
 is often a decrease in the expulsive force in the uterus and abdominal wall 
 on account of poor physical development of the individual. 
 
 In the justominor pelvis, as stated above, the contraction in the 
 different diameters continues from brim to outlet, hence the difficulties in 
 the labor and causes of its prolongation are not passed when the head 
 reaches the cavity of the pelvis, as often happens in the case of a simple 
 flat pelvis just described. 
 
 Generally Contracted, Flat (Non-rachitic) Pelvis. — This type of pelvis 
 combines the features of the two preceding: the justominor and the 
 simple flat pelvis, i. e., all the diameters are below normal, but the con- 
 jugate is relatively less than any of the others. This pelvis has many 
 of the features of the rachitic but differs from it in the following par- 
 ticulars : 
 
 1. The anterior half of the pelvis is not markedly broadened, i. e., 
 the normal relation between the interspinous and intercristal diameters 
 is not disturbed. 
 
 2. The sacrum is relatively retroplaced rather than anteplaced. The 
 sacrum is small and is considerably higher than in the normal pelvis. 
 Although nearer the symphysis than in the normal pelvis, it is placed 
 farther back between the innominate bones than normal. 
 
 According to Litzman, the closer proximity of the sacrum to the sym- 
 physis and resulting flattening of the pelvis is due to a shortening of 
 the innominate bones. The promontory is high and hence the diagonal 
 conjugate is relatively increased and the promontory is not prominent. 
 
 Frequency. — This type of pelvis is met with quite frequently in New 
 York. In the 1770 cases of deformed pelvis occurring in 20,000 consecu- 
 tive deliveries at the Sloane Hospital, 354, or 20 per cent., were justo- 
 minor flat. A.mong the 1170 whites in this series there were 148, or 12.6 
 per cent., justominor flat pelves, while in the 600 blacks there were 206, 
 or 34.3 per cent. 
 
 It is a congenital deformity due to some hereditary influence or an 
 arrested development in fetal or infant life. It is claimed by some that 
 it is due to premature walking or long standing in early childhood. 
 
 Diagnosis. — ^This can only be made by careful pelvimetry, both exter- 
 nal and internal. The patient may appear perfectly well and strong and 
 know of no reason why she should not bear children normally and easily, 
 but accurate pelvimetry will show that the diameters of the pelvis are 
 all reduced, and the internal conjugate more than the others. 
 
 The ease with which the lateral pelvic walls can be palpated is also 
 worthy of note and is of value in verifying the diagnosis. 
 
V 
 
 656 ABNORMAL LABOR FROM ANOMALIES IN PASSAGES 
 
 Labor in the Generally Contracted Flat Pelvis.- — It can easily be seen 
 that labor in this type of pehis combines the difficulties of the two 
 preceding. It is more difficult than in the justominor pelvis because 
 it is flat, and it is more difficult than in the simple flat pelvis because 
 it is justominor, i. e., the compensating room in the sides of the pelvic 
 cavity usually present in the simple flat pelvis is absent on account of 
 the shortening of the oblique diameters. The entire pelvis is below 
 normal in size. * 
 
 The Narrow, Funnel-shaped Pelvis. — This type of pelvis is contracted 
 at the outlet, either trans\'ersely or in both its transverse and antero- 
 posterior diameters. While most marked examples of the funnel-shaped 
 pehis are found associated with a lumbar kyphosis, which will be dis- 
 cussed later, a narrow, funnel-shaped pelvis is occasionally met with, due 
 to faulty development without associated abnormalities in the spinal 
 column. The depth of the pelvis is greater than normal on account of 
 the increased length of the sacrum, greater dej^th of the lateral walls, 
 and greater height of the symphysis. 
 
 The sacrum is narrow, straighter than normal, and placed far back 
 between the ilia. 
 
 Frequency. — Although formerly considered very rare, since systematic 
 examination of the outlet of the pelvis has become a routine procedure 
 in many hospitals, it is found quite frequently. Schauta estimated 5.9 
 per cent, of funnel-shaped pelves in 5000 cases, and Williams,^ in a con- 
 secutive series of 2215 full-term labors, found 135 typical funnel pelves, 
 or an occurrence of fi.l per cent. 
 
 In the series of 2215 labors reported by Williams, there were 1313 
 white and 902 black women, and of these 135 funnel pelves 77, or 5.87 per 
 cent., occurred in the white, as compared with 58, or 6.43 per cent., 
 occurring in the black women. 
 
 In this same series of 1313 white women, in addition to the 77 funnel 
 pelves, he found 98 examples of the difl'erent ^'arieties of contraction of 
 the pelvic outlet, as compared with 58 funnel pelves and 312 outlet 
 contractions in the 902 black women. 
 
 This would indicate that in the white race the funnel pelvis is of rela- 
 tively greater frequency than in the colored, constituting 44 per cent, 
 of the abnormal pelves in this series of 1313 white women, as compared 
 with 15.23 per cent, of the abnormal pelves in the 902 black women. 
 
 Etiology. — ^The exact cause of this variety of deformity is unknown. 
 It has usually been assigned to a continuation of the infantile type, and 
 has often been found in those who on account of anterior poliomyelitis 
 or other reasons have been unable to walk. 
 
 Williams believes that the great majority of outlet contractions are 
 associated with assimilation of the last lumbar vertebra with the sacrum, 
 causing the sacrum to consist of six vertebrse instead of five, and in a 
 number of his cases he has been able to palpate six sacral vertebrae 
 through the vagina. 
 
 ■ The Funtiol Pelvis, Amor. Jour. Obst., .July, 1011, Ixiv, No. 403, p. lOfi. 
 
ANOMALIES OF HARD PARTS OF PARTURIENT CANAL 657 
 
 Diagnosis, — This is made by a comparison of the measurements of the 
 outlet with those of the inlet of the pelvis. Whether the inlet is normal, 
 above normal or abnormally small, the outlet is always smaller than 
 would naturally correspond with these measurements. Furthermore, 
 on vaginal examination and palpation the pelvic walls are felt to con- 
 verge toward the outlet and the pubic arch feels narrow. To Williams, 
 of Baltimore, the profession is indebted for emphasizing the importance 
 of carefully measuring, or at any rate palpating the outlet of the pelvis 
 and thus avoiding the serious embarrassment of meeting unexpectedly 
 with serious dystocia at the outlet of a pelvis whose inlet seemed normal. 
 
 Practically, a pelvis may be considered a funnel pelvis when either 
 the transverse or the anteroposterior diameters of the outlet are reduced, 
 the former from 11 cm. to 8 cm. or less and the latter from 11.50 cm. to 
 9 cm. or less. Ankylosis of the sacrococcygeal joint with coccyx forward 
 presents a similar condition, but this is usually overcome by fracture 
 during delivery. 
 
 Labor in the Narrow, Funnel-shaped Pelvis.-^As would naturally be 
 supposed, the difficulties in the labor occur not at the inlet, which may 
 be as large as or even larger than normal, but at the outlet of the 
 pelvis. 
 
 Here malpositions of the head are common, such as posterior positions 
 of the occiput; oblique or transverse positions of the head, and imperfect 
 flexion. Moreover, the expulsive forces are often deficient at this critical 
 time, the greater part of the fetus lying in the lower uterine segment 
 and the vagina, while the upper uterine segment is contracted, retracted, 
 empty, and powerless. 
 
 The length of the anteroposterior diameter of the outlet of the pelvis 
 is by no means a criterion of the space available for the passage of the 
 fetal head, as the pubic arch is often so narrow that the head cannot 
 enter it. In fact in many cases the only space available for the passage 
 of the fetal head is that between the tuberosities of the ischia and the 
 coccyx, this latter of course allowing some retroplacement. 
 
 Klein,^ in- 1896, pointed out the fact that the prognosis of labor depends 
 not so much upon the absolute size of the transverse diameter of the 
 outlet as upon its relation to the distance between the centre of the 
 transverse diameter and the anterior surface of the tip of the sacrum 
 (not coccyx). This distance he calls the "posterior sagittal diameter" 
 (see Fig. 384), and gives as the normal diameters of the pelvic outlet: 
 transverse, 11 cm.; anterior sagittal, 6 cm.; posterior sagittal, 9.95 cm. 
 Although a transverse diameter of 8 cm. at the pelvic outlet may well 
 be looked upon as a danger signal, still it by no means follows that 
 this diameter will be associated wdth marked dystocia, as the posterior 
 sagittal diameter may give ample room for the fetal head, as indicated 
 in Fig. 385. AATiile a wider transverse diameter with a shorter posterior 
 sagittal (see Fig. 386) may require Cesarean section for delivery of a 
 living child. This crowding of the fetal head toward the posterior part 
 
 1 Die Geburtshlilfliche Bedeutung der verengerungen des Beckenausgangs. Volkmann's 
 Samml. klin. Vortrage, 1896, N. F., No. 169. 
 42 
 
658 
 
 ABNORMAL LABOR FROM ANOMALIES IN PASSAGES 
 
 of the pelvic outlet in a funnel pelvis tends to severe lacerations of the 
 pelvic floor, even if delivery through the natural passage is possible. . 
 
 Fig. 384. — Normal diameters of the pelvic outlet. 
 
 Fig. 385. — Marked shortening of the transverse diameter, but ample room furnished by 
 
 the posterior sagittal. 
 
 Fig. 386. — Wider transverse diameter, but passage of head impossible on account of 
 shortened posterior sagittal diameter. 
 
 The dangers of the funnel-shaped pelvis are many and concern both 
 the mother and the fetus. Aside from the danger of extensive lacerations 
 
ANOMALIES OF HARD PARTS OF PARTURIENT CANAL 659 
 
 of the mother, the long pressure of the soft parts against the bony pro- 
 jections of the pelvic outlet, especially if the correct diagnosis has been 
 overlooked and the case neglected, tends to sloughing and fistulse and 
 the forcible extraction of the child in these neglected cases tends to 
 injury of the pelvic articulations. 
 
 The fetal dangers naturally depend upon the degree of pelvic deform- 
 ity, the time of diagnosis, and tjie method of deliver3\ If neglected and 
 left too long upon the floor of the pelvis the life of the fetus is lost from 
 interference with the placental circulation. 
 
 If dragged through the narrow outlet by brute force the child is usually 
 lost from cranial and cerebral injuries. 
 
 The method of delivery indicated varies with the degree of contraction 
 in the individual case. In the lower grades of contraction delivery may 
 take place unaided or by an easy forceps operation, while in the high 
 degrees of contraction delivery of a living child may onlj' be possible 
 through a pubiotomy or Cesarean section. The safety of mother and 
 child requires that a transverse diameter of the pelvis contracted to 
 8 cm. or less should be looked upon with suspicion and the labor watched 
 for early indications for operative interference. 
 
 Imperfect Development of One Sacral Ala. Obliquely Contracted 
 Pelvis of Naegele.— This tj^^e of deformed pelvis was first described by 
 Naegele^ who, in 1839, published a monograph based upon 35 cases. 
 The condition is a rare one. In the series of 1770 deformed pelves occur- 
 ring in 20,000 consecutive deliveries at the Sloane Hospital there were 
 18 obliquely contracted pelves, or 1 per cent. In the 1170 whites of 
 this series there were 13, or 1.1 per cent. In the 600 blacks there were 
 5, or 0.8 per cent. 
 
 Characteristics. — ^The pelvis of Naegele is an asymmetrical one whether 
 viewed from above or below, from in front or behind. The posterior 
 portion of the innominate bone on the affected side lies in close apposition 
 with the sacrum and in such a way that that side of the pelvic cavity is 
 flattened out. 
 
 The sacrum is asymmetrical, much narrowed on the affected side and 
 is turned so as to look toward this side (see Fig. 387). The promontory 
 is deflected toward the diseased side of the pelvis. The symphysis pubis 
 is deflected toward the sound side, but its external surface faces a little 
 toward the affected side rather than directly forward. The iliopectineal 
 line on the affected side is markedly straightened, while on the opposite 
 side its curvature is increased. 
 
 This gives to the pelvic brim the shape of an irregular oval with long 
 diameter between the sacro-iliac joint on the affected side and the ilio- 
 pectineal eminence on the sound side. The internal oblique diameter 
 from sacro-iliac joint of sound side to iliopectineal eminence of affected 
 side is usually markedly shortened. 
 
 The internal conjugate diameters, both diagonal and true, are directed 
 obliquely and are usually somewhat lengthened. The pubic arch is 
 
 1 Das Schriig vereagte Becken, Mainz, 1839. ' ' 
 
660 
 
 ABNORMAL LABOR FROM ANOMALIES IN PASSAGES 
 
 irregularly contracted as the rami of ischium and pubes are pushed inward 
 toward the sound side of the pelvis. The acetabulum of the affected side 
 
 Fig. 387. — Naegele pehds, supeiior ^'iew. (Naegelc.) 
 
 looks more anteriorly than normal, while on the opposite side it looks 
 almost directly outward. The iliac fossa of the sound side is directed 
 nearly forward, while on the affected side it is directed inward. 
 
 Fig. .388. — Naegele pelvi.-;, posterior view. (Naegele.) 
 
 On looking into the'cavity of the pelvis from above, if the deformity 
 is Avell marked it is seen that the great sacrosciatic notch on the affected 
 
ANOMALIES OF HARD PARTS OF PARTURIENT CANAL 6G1 
 
 side is almost obliterated and the tuberosity of the ischium lies nearly 
 in apposition with the sacrum and projects into the pelvic canal. 
 
 When viewed from behind (see Fig. 38S), the posterior superior iliac 
 spine of the affected side is seen to lie in close apposition with the spines 
 of the sacrum and the obliteration of the great sacrosciatic notch on that 
 side is seen in marked contrast to that of the opposite side. 
 
 Etiology. — The characteristic shape of the Naegele pelvis depends 
 upon the imperfect development or absence of the alse of the sacral 
 vertebrae on one side. Usually, but not always, there is a synostosis of 
 the sacrum and the innominate bone on this side. The origin of this 
 deformity has been the subject of much discussion, some claiming the 
 view expressed above that the synostosis was only secondary to a 
 primarj^ sacral defect; others claiming that the primary lesion was an 
 inflammation which caused an ankylosis and subsequent deformity. 
 The view generally accepted today is the one first expressed, i. e., that 
 there is first a defect in development: an absence of the bony nuclei 
 in the alee on one side of the sacrum. The reasons for this belief are 
 numerous. There is no history of inflammation. The alee are lacking 
 not only in the sacral vertebrae which enter into the formation of the 
 sacro-iliac joint, but along the whole length of the sacrum. If there was 
 a primary ankylosis the subsequent displacement upward and backward 
 would be impossible. 
 
 As a result of the lack of development in the sacral alee the innominate 
 bone tends to slide past the normal site of the sacro-iliac joint and to 
 come in contact with the bodies of the sacral vertebrae. 
 
 This tendency existing in infant life is greatly exaggerated when the 
 child begins to walk and more and more pressure is transmitted from the 
 femur up through the poorly arched innominate bone of the affected side. 
 The friction and irritation caused by this abnormal mobility usually 
 results in inflammation, atrophy, and ankylosis of the joint. 
 
 Diagnosis. — ^As patients with an obliquely contracted pelvis may have 
 no limp in their gait, unless careful pelvimetry is carried out as a routine 
 procedure in every case of pregnancy, the condition may be entirely 
 overlooked until labor is well advanced. There is usually little difficulty, 
 how^ever, in making the diagnosis if the ordinary pelvic measurements 
 are carefully taken, especially the oblique diameters, and th^ pelvic 
 cavity is carefully palpated. If the deformity is marked, the right and 
 left oblique diameters, measured externaUy, while normally differing by 
 only a fraction of 1 cm., will be found in a Naegele pelvis to be markedly 
 unequal. This should attract attention to an abnormality. 
 
 This asymmetry may then be verified by measuring from the last 
 lumbar spine to the anterior superior spine on either side. Furthermore, 
 the palpation of the pelvic cavity, bringing out the facts that one side 
 of the pelvis — the diseased side — is flattened out and lies nearer the 
 median line than the other; that the pubic arch does not lie opposite 
 the middle of the sacrum but toward the sound side; that the spine of 
 the ischium lies close to the sacrum on the diseased side, these palpation 
 findings taken in conjunction with the inequality of the external oblique 
 
662 ABNORMAL LABOR FROM ANOMALIES IN PASSAGES 
 
 diameters should enable the diagnosis of a Naegele pelvis to he made. 
 For purposes of classification a difference of 2 cm. in the oblique diameters 
 is sufficient to place a pelvis in the class of obliquely contracted. 
 
 Influence on Labor. — The mechanism of labor in a Naegele pelvis is 
 similar to that in a generally contracted pelvis. The only portion of the 
 pelvic cavity available for parturition is the sound side, and through 
 this sound side, if the child is small and uterine contractions strong, the 
 head in extreme flexion may pass. If the child presents by the breech, 
 the delay in the delivery of the after-coming head is apt to give a high 
 fetal mortality. 
 
 The maternal mortality of labor in this variety of pelvic deformity 
 depends upon the degree of contraction, the time of diagnosis, and the 
 method of deli^•ery. The prognosis may always })e considered grave. 
 
 Litzman, in a series of 41 cases, lost 79 per cent, of the mothers in the 
 first labor, and only 15 per cent, of the labors ended spontaneously. 
 
 Fig. 380. — Transversely contracted Robert pelvis. (Robert.) 
 
 The results of Litzman, however, occurred in 1853, and do not represent 
 the present-day methods of early accurate pelvimetry' and improved 
 technic in operative delivery. 
 
 Method of Delivery. — .Spontaneous labor should only be waited for in 
 cases where the sound half of the pelvis seems roomy, and careful com- 
 parison of the relative size of head and pelvis gives a favorable prognosis. 
 In cases with marked contraction and in doubtful cases, unless a short 
 test of labor justifies hope in the powers of nature, the best result will 
 come from an early resort to Cesarean section. Induction of premature 
 labor would only be indicated in very minor degrees of contraction and 
 is seldom to be recommended. 
 
 The Double Obliquely Contracted Pelvis. The Transversely Con- 
 tracted Pelvis or the Robert Pelvis. — This variety of pelvic deformity 
 was first described by Robert^ in 1842. 
 
 1 Beschreibung eines im hochsten Grade querver^ngten Beckens, U. S. W., Karlsruhe 
 u. Freiburg, 1842. 
 
ANOMALIES OF HARD PARTS OF PARTURIENT CANAL 663 
 
 Characteristics. — In the Robert pelvis (see Fig. 389) the imperfect 
 development of the sacral alse, which in the Naegele pelvis involves only 
 one side, is bilateral. This gives a pelvis which is markedly contracted 
 transversely and is often spoken of as the double, obliquely contracted, 
 or double Naegele pelvis. 
 
 The sacral alse are usually both absent and the innominate bones and 
 the imperfectly developed sacrum ankylosed. The ankylosis, however, 
 is not uniformly present and one of the sacral else may be slightly devel- 
 oped, giving a slight asymmetry to the pelvis. 
 
 The Robert pelvis is markedly contracted in its transverse diameters. 
 The sacrum is extremely narrow and the posterosuperior iliac spines 
 and the spines and tuberosities of the ischia are brought close together. 
 The anterior surface of the sacrum is apt to be convex in both directions, 
 and the sacrum as a whole has a slight anterior displacement, but the 
 shortening of the anteroposterior diameter is so slight in comparison with 
 the transverse that it seems practically normal. 
 
 The Robert pelvis is one of the rarest of the pelvic deformities. In 
 the series of 20,000 consecutive deliveries at the Sloane Hospital no case 
 of Robert pelvis was found. 
 
 Diagnosis. — ^As a rule the condition is recognized without difficulty, 
 as the transverse diameters of the pelvis measured externally are all 
 markedly shortened, while the external conjugate remains nearly normal. 
 The pubic arch is distinctly narrowed and internal examination shows the 
 sides of the pelvis approximated. 
 
 Influence on Labor. — The degree of contraction in the typical Robert 
 pelvis is such that delivery per vias naturales is impossible, and as induc- 
 tion of premature labor is impracticable, Cesarean section is the only 
 rational method of delivery if the child is alive. 
 
 The Generally, Equally Enlarged Pelvis. Justomajor Pelvis. — A 
 pelvis in which all the measurements are far in excess of the normal, 
 although preserving their normal relations. Although an arbitrary 
 classification, it is the custom, as already stated, at the Sloane Hospital 
 to call equally enlarged pelves whose oblique diameters measure 24 cm. 
 or over, justomajor pelves. 
 
 Frequency. — ^These abnormally large pelves are frequently found in 
 women of gigantic stature and occasionally in women of medium size. 
 
 If careful pelvimetry is followed in every obstetric case a much larger 
 number of justomajor pelves will be found than is generally supposed. 
 
 Diagnosis. — ^The condition is readily determined by pelvimetry and 
 noting that not a few but all the diameters of the pelvis are enlarged 
 and the relative proportions are maintained. 
 
 Influence on Labor. — Under ordinary circumstances the labor is little 
 influenced by an equally enlarged pelvis, except for the fact that there 
 is no obstruction from a narrowing of the bony canal. 
 
 The women of gigantic stature often have large children and especially 
 in first labors, these, as well as medium-sized women with abnormally 
 large pelves, usually present normal, easy labors. Occasionally, however, 
 in multigravidse with justomajor pelves and with pelvic floor lacerated 
 
004 ABNORMAL LABOR FROM ANOMALIES IN PASSAGES 
 
 or badly stretched, the i:)re(|;iiaiit uterus hes low in the pelvis with unusual 
 pressure upon rectum, bladder and pelvic veins, resulting in various 
 discomforts to the woman, such as constipation, frecjuent micturition, 
 edema of the vulva and lower extremities, and difficult locomotion. 
 
 JMoreover, the labor in these cases may be precipitate with little 
 mechanism and with an increase of existing lacerations. 
 
 The Split Pelvis. — This is due to a defect in the development of the 
 lower i)ortion of the trunk in front and not only is there an absence of 
 union of the pubic bones at the symphysis (see Fig. 390), but there are 
 usually other malformations present, such as exstrophy of the bladder, 
 spina bifida, etc. The space between the ends of the pubic bones is usually 
 filled Avith fibrous tissue which is more or less yielding, and the pressure 
 upward through the femora forces the innominate bones outward and 
 upward, approximating the posterior superior spines of the ilium and 
 projecting the sacrum forward. 
 
 Fig. 390. — Split pelvis. (Breus and Kolisko.) 
 
 Frequency and Influence on Labor. — The split pelvis is one of the rarest 
 of pelvic deformities encountered as a complication of pregnancy and 
 labor, although there are a few^ cases on record. The reason for the 
 rarity is obviously not only the rarity of the malformation, but the fact 
 that such women with exstrophy of the bladder and other faults in devel- 
 opment are not as likely to be attractive to the opposite sex. 
 
 Labor in the split pelvis has many of the characteristics of that in 
 the justomajor pelvis. It is usually fairly rapid and easy, although the 
 absence of the resistant anterior pelvic wall usually interferes with the 
 normal mechanism in flexion and rotation. After the labor there has 
 resulted in some cases a prolapse of the pelvic organs. 
 
ANOMALIES OF HARD PARTS OF PARTURIENT CANAL 665 
 
 Pelvic Anomalies Resulting from Disease of the Pelvic Bones. 
 
 The Rachitic Pelvis. — Frequency. — The disease which is most often the 
 cause of pelvic deformity in this country, especially among the colored 
 race, is rachitis — rickets. In the white race it is of infrequent occur- 
 rence, but in the colored race not only in the South, but in the large 
 cities like New York, it is common. 
 
 Williams, at the Johns Hopkins Hospital, found 6 per cent, of the 
 deformed pelves occurring in white women, and 22 per cent, of those in 
 colored women were rachitic in origin. In the dispensaries of Vienna, 
 Berlin and other parts of Europe, pelves deformed by rachitis are 
 frequently seen. 
 
 Etiology. — Rachitis is a disease of malnutrition, and when the difficulty 
 experienced by the colored population of a city like New York in securing 
 airy, healthful tenements within their means is considered, it is not 
 difficult to understand the result. 
 
 The colored tenements are usually poorly lighted, poorly ventilated, 
 and overcrowded, and if with this is coupled insufficient food of improper 
 quality, it is not surprising to see in them children presenting all the 
 evidences of the disease in question. 
 
 Furthermore, the white race is not exempt nor need it be confined to 
 the tenements, for in the early days of enthusiasm over laboratory 
 methods of infant feeding and milk sterilization, here and there in a 
 palatial residence a child could be found presenting the early symptoms 
 of rachitis produced by improper nourishment. Fortunately our knowl- 
 edge of artificial feeding has increased and the dangers just alluded to 
 have been recognized and are usually avoided. 
 
 Pathology. — Before discussing the type of deformity produced in the 
 pelvis by rachitis, it would be well to consider briefly the pathology of 
 the disease itself. In the normal growth and development of healthy 
 bone two chief processes are going on: 
 
 1. At the periphery a proliferation of cells intended for bone structure. 
 
 2. An associated calcification of these cells. 
 These processes are seen in Fig. 391. 
 
 In rachitis these processes are markedly disturbed (see Fig. 392). 
 The proliferation of cells at the periphery goes on more rapidly than is 
 normal, while the calcification of these cells is less than normal. It is 
 estimated that in rachitic bone the deposit of inorganic salts is only one- 
 third that in normal bone. This gives a pelvis which is pliable and yields 
 more readily to the forces to which it is subjected, viz.: 
 
 Pressure from above. 
 
 Counter-pressure from below. 
 
 Traction by muscles and ligaments. 
 
 The condition of the bone in rachitis differs entirely from that in 
 osteomalacia, as in the former calcification has never taken place while 
 in the latter calcification w^as previously complete, but was followed by 
 softening. Furthermore, the lack of calcification and softening in rachitis 
 is more marked at the epiphyses of the long bones, although it does occur 
 
660 ABNORMAL LABOR FROM ANOMALIES IN PASSAGES 
 
 to a less extent under the periosteum of the long and flat bones. In 
 osteomalacia the softening is more uniform throughout the bone substance. 
 Rachitis may be fetal, i. e., develop in utero, and at birth the infant 
 presents abnormalities produced by muscular action upon the softened 
 bones; or more commonly it develops during early childhood, and depend- 
 ing upon the age at which calcification finally takes place, the bones in 
 general and the pelvis in particular, vn[\ present different abnormalities. 
 
 a ' 
 
 id 
 
 ^ 
 
 Fig. 391. — Section tlu'ough oiiitication zone of noriual bone; a, hyaline carlilage; h, zone 
 of beginning cartilage proliferation; c, columns of cartilage cells; d, columns of hypertrophic 
 cartilage; e, zone of temporarj- calcification; /, zone of primary medullary spaces; g, zone 
 of primary bone formation; h, fully developed spongy bone; t, bloodvessels; A;, layer of 
 osteoblasts. (Ziegler.) 
 
 It is readily understood that the pelvis of a child suffering from rickets 
 in which ossification took place before the child stood, walked, or worked, 
 will be less deformed than one in which the disease was in active progress 
 during the teens of the child when both at work and at play the pressure 
 upon the pliable pelvis from above and below and through muscles and 
 ligaments was continued for years with steadily increasing deformity. 
 
ANOMALIES OF HARD PARTS OF PARTURIENT CANAL 667 
 
 Fig. 392. Bone in rickets. Longitudinal section of a rib at the junction of the costal 
 
 cartilage hi a severe case of rickets (slightly magnified). C, costal cartilage; B, bone; 
 A proliferating cartilage zone which is much widened. Between the hypertrophied car- 
 tilage cell-columns (a) making up this proliferating zone are seen medullary spaces (b) 
 containing bloodvessels. In this zone He masses of bone (c) not calcified. The calcification 
 zone is almost wanting, only scattered islands (d) of calcified cartilage cells being seen. 
 Beyond this proliferating zone (A) is a layer of bony tissue (£) made of up small bands, of 
 which only a few have a nucleus containing lime (e). These nuclei appear black. The bony 
 bands differ both in form and arrangement from those of normal ossification. Between 
 the bony masses are medullary spaces which appear light in the illustration. At (g) the 
 beginning of cartilage proliferation is seen. Above this zone the cartilage is normal. (From 
 Karg and Schmorl.) 
 
608 
 
 ABNORMAL LABOR FROM ANOMALIES IX PASSAGES 
 
 III considering tlie effect of rachitis u])on a peKis. it should l)e reniein- 
 l)ered that calcification eventually takes place in a rachitic ])elvis and in 
 obstetrics the obstetrician has to deal with the crystali/ed result of 
 damage done to a i)eKis which was yielding at a time during the develop- 
 mental j)erio(l of youth when it should have been firm. 
 
 Varieties. — Depending upon the extent of the disease, its duration, 
 and the age of the individual at which the process ceased, the following 
 varieties of pelvic deformity are produced by rachitis: 
 
 1. Flat, generally contracted rachitic. 
 
 2. Simjile flat rachitic. 
 
 3. Generally equally contracted rachitic. 
 
 4. Pseudo-osteomalacie. 
 
 By comparing these varieties with the deformities arising from faulty 
 development (see page 050) it will be seen that the first three are the 
 same, although in a different order of frequency. 
 
 Fig. 393. — Sharp bend in posterior pehdc wall of rachitic pelvis. (Bumm.) 
 
 The Flat, Generally Contracted Rachitic Pelvis. — This is the 
 most common form of pelvic deformity found in women who in early 
 life have been afflicted with rachitis and may be looked upon as the 
 typical rachitic pelvis. The arrested development due to the malnutri- 
 tion and presence of disease easily explains the general reduction in the 
 size of the pehis. The typical shape of the rachitic pelvis will be under- 
 stood if its mode of production is studied. 
 
 Characteristics.— The sacrum is pushed downward and forward between 
 the iliac bones and is rotated on its transverse axis mainly by the pressure 
 of the trunk upon it, but partly by the downward ])ull of the psoas muscles 
 
ANOMALIES OF HARD PARTS OF PARTURIENT CANAL 669 
 
 upon the spinal column and the upward pull of the erector spinse muscles 
 upon the posterior surface of the sacrum. This would naturally tend to 
 throw the tip of the sacrum and the coccyx directly backward. The 
 attachment of the sacrosciatic ligaments and the pelvic muscles to the 
 lower part of the sacrum and cocc}x, however, prevent this backward 
 movement of the posterior pelvic wall as a whole and pulling the lower 
 portion forward cause a sharp bend in it, usually near the third or fourth, 
 sometimes the fifth, sacral vertebra (see Fig. 393). 
 
 In its longitudinal axis the sacrum shows a lessening of its anterior 
 vertical concavity above (in some cases there may even be a vertical 
 convexity) and an increase below. In some cases the body of the first 
 sacral vertebra projects more than the others and forms a false promon- 
 tory. By the forward movement of the bodies of the sacral vertebrae 
 the transverse concavity of the anterior surface is diminished, and in 
 some cases the anterior surface of the sacrum may indeed be convex 
 from side to side. 
 
 Fig. 394. — Anterior divergence of the innominate bones; rachitic pelvis. (Bumm.) 
 
 By the pull of the strong sacro-iliac ligaments, together with the weight 
 of the trunk upon the sacrum, the posterosuperior iliac spines are drawn 
 downward, inward, and forward. This tends to throw the anterior half 
 of the innominate bones outward (see Fig. 394). 
 
 Although this is prevented in part by the symphysis pubis and Pou- 
 part's ligaments, still the ilia are thrown somewhat outward, so that the 
 distance between the anterior superior iliac spines becomes little less than, 
 equal to, or even greater than, the distance between the iliac crests. This is 
 the practical criterion of a rachitic pelvis. 
 
 A further result of the pulling inward and forward of the posterior 
 portion of the innominate bones is to produce in them an abnormal 
 anteroposterior curvature; the point of greatest curvature being found 
 on the iliopectineal line just in front of the sacro-iliac joints and posterior 
 to the median transverse line of the pelvic inlet. On account of this 
 flexion of the innominate bones the transverse diameter of a rachitic 
 pelvis is relatively increased, but, as the pelvis is usually below normal 
 in size, its transverse diameter rarely exceeds, if indeed it actually equals, 
 the normal. 
 
 Furthermore, the projection forward of the sacrum (see Fig. 394) 
 
G7() ABNORMAL LABOR FROM ANOMALIES IN PASSAGES 
 
 prevents this transverse diameter from being accessible to the fetal head 
 by crowding it forward to where the transverse diameter is narrower. 
 The anteroposterior flexion of the innominate bones has a further effect 
 of throwing the acetabula forward so that the pressure from below upward 
 through the femora is exerted more anteroposterior! y than in the normal 
 pelvis. 
 
 The resistance at the symphysis pubis to the outward rotaticn of the 
 innominate bones has the tendency to bend the ends of the pubic bones 
 inward toward the pelvic canal. 
 
 The projection of the sacrum forward and of the symphysis backward 
 gives the pelvic inlet in a well-marked rachitic pelvis the shape of the 
 figure 8, and it is sometimes called "the figure-of-eight pelvis." 
 
 According to the degree of inbending of the symphysis pubis in a rachitic 
 pelvis, the shape of the inlet may be cordiform, reniform, or that of the 
 figure eight. Through the traction of the adductor and rotator muscles 
 of the thighs upon the tuberosities of the ischia (increased in rachitis 
 on account of the anterior position of the acetabula and the bowing of 
 the femora), the tuberosities are pulled outward and forward so that the 
 pubic arch is greatly widened and the transverse diameter of the outlet 
 is increased. This result is also favored when, on account of the disease, 
 walking of the child is long delayed and much of the time is spent in the 
 sitting posture, thus bringing the weight and pressure of the trunk upon 
 the tubera ischii without the counter-pressure from below through the 
 femora. 
 
 We have then, in a typical rachitic pelvis usually one which is smaller 
 than normal and with bones thinner and more delicate than would be 
 found in a woman always healthy. Occasionally, however, the bones 
 are thicker and heavier than usual. 
 
 On account of the rotation forward of the sacrum and the lordosis 
 which so often accompanies it, the anterior inclination of the pelvis is 
 increased and the external genitals are displaced backward. The iliac 
 fossse look more anteriorly than in the normal pelvis; the pelvic cavity 
 is shallow; the inlet is narrowed, especially in its conjugate, and the 
 outlet is relatively, if not actually, enlarged by the widening of the pubic 
 arch and separation of the tuberosities of the ischia. 
 
 Diagnosis. — As far as the pelvis itself is concerned, its rachitic character 
 is determined by one criterion. The distance between the anterosuperior 
 spines of the ilia approximates or exceeds the distance between the iliac 
 crests. In connection with this, to complete the picture, must be taken 
 the patient's early history and her present bone condition. 
 
 If her early history can be obtained it will usually be found that she 
 was late in beginning to walk, perhaps three or four years of age, and 
 that she was also late in teething. Her present condition is one of small 
 stature, with short, thick, curved extremities, the tibiae especially showing 
 curved, sharp anterior borders (Fig. 395). The joints are enlarged and 
 as the patient walks, her bow-legged condition is easily seen. Her brow 
 is low and broad and her nose is flat, she often has the so-called " chicken 
 breast." This is the picture of a rachitic patient. 
 
ANOMALIES OF HARD PARTS OF PARTURIENT CANAL 671 
 
 Influence on Labor. — On considering the shape and size of the typical 
 rachitic pelvis, its influence upon labor is readily understood. Most of 
 the difficulty arises at the inlet of the pelvis and if this is passed the 
 labor usually proceeds easily. The mechanism of labor resembles some- 
 what that described in the simple, flat pelvis, from faulty development, 
 but in the rachitic pelvis the narrowing of the conjugate at the brim is 
 greater than in the simple flat, because the sacrum is rotated forward on 
 its transverse axis instead of being carried forward as a whole. As a 
 result of this the promontory is more 
 prominent and the obstruction usually 
 greater. On the other hand, the rachitic 
 pelvis has a cavity which is more shallow 
 and more roomy and an outlet which is 
 larger than in the simple flat. Hence 
 the labor in a rachitic pelvis, when once 
 the brim plane is passed, is easier than in 
 the simple flat, and much easier than in 
 the generally equally contracted flat pelvis 
 arising from faulty development. 
 
 The Simple Flat, Rachitic Pelvis. — 
 Here we have a condition in which only 
 the conjugate diameter is reduced, the 
 transverse diameter remaining unaltered. 
 This is a less common form of the rachitic 
 pelvis than the flat, generally contracted 
 rachitic just considered, and represents 
 either less malnutrition and a lesser degree 
 of disease or else a shorter course, and a 
 completed ossification before the deform- 
 ing forces could exert great influence. 
 The diagnosis is made by careful pelvim- 
 etry determining a disturbance of the 
 normal relation between the interspinous 
 and intercristal diameters and by a care- 
 ful study of the history of the case. Its 
 influence upon the labor depends entirely 
 upon the degree of flattening. 
 
 The Generally Equally Contracted, 
 Rachitic Pelvis. — This is a rare type of 
 
 rachitic pelvis and represents chiefly the result of malnutrition in a 
 patient who has been afflicted with rachitis, the disease beginning 
 and reaching its termination before the child sat up or walked, hence 
 before the pelvis was subjected to much pressure. 
 
 The diameters of the pelvic inlet are equally shortened and the diag- 
 nosis is made by general evidences of a past rachitis and sometimes by 
 changes in the sacrum and separation of the tuberosities of the ischia. 
 This is the only type of rachitic pelvis in which the normal relation 
 between the interspinous and intercristal diameters may be unchanged. 
 
 Fig. 395. — Rachitic patient, 
 showing bow-legs and tibiae with 
 sharp, curved anterior borders. 
 
G72 ABNORMAL LABOR FROM ANOMALIES IX PASSAGES 
 
 The influence ui)()n labor closely resembles that of a generally equally 
 contracted pelvis from faulty development, save that in the pelvis con- 
 tracted from rachitis, the labor is easier after the brim plane has been 
 passed, on account of the lessened depth of the pelvis and the widening 
 of the pubic arch. 
 
 The Pseudo-osteomalacic, Rachitic Pelvis. — Here the rachitis 
 has progressed to an extreme degree and through a long ])eriod during 
 which, while the disease was in active progress, not only have efl'orts 
 at walking been made, but the weight of the trunk possibly exaggerated 
 by carrying heavy burdens has been added. The sacrum sinks far down 
 into the pelvic canal and is sharpl\" cur\ed from above downward 
 anteriorly. The acetabula are pressed inward upon the pelvic canal 
 (see Fig. 396) and the anteroposterior flexion of the innominate bones 
 is extreme. 
 
 When the disease has rim its course, the pelvis is firmly set in markedly 
 distorted shape. The differential diagnosis between the pseudo-osteo- 
 
 FiG. 396. — Pseudo-osteomalacic pel\ns. (Xaegele.) 
 
 malacic pelvis of rachitis and the pelvis of true osteomalacia is made 
 by applying the usual criterion of rachitis, /. e., the disturbed relation 
 between the interspinous and intercristal diameters; by determining the 
 fact that ossification occurred for the first time after the disease was 
 arrested, and by finding evidences of rachitis in other parts of the ix)dy. 
 
 Furthermore, osteomalacia has certain peculiarities of its own which 
 usually enable one to recognize it. These will be studied later. 
 
 The Osteomalacic Pelvis. — The disease causing the most marked 
 l)elvic deformities encountered by the obstetrician is known as osteo- 
 malacia, malocosteon, or mollities ossium. 
 
 It is characterized by a general softening of the bone tissue in difi'erent 
 portions of the skeleton, complete normal ossification having previously 
 taken place, thus differing from rachitis, in which ossification does not 
 become comj^lete until after the termination of the disease. 
 
 Frequency and Etiology. — In America the disease is a rare one, less than 
 a score of cases having been reported. At the Sloane Hospital in 20,000 
 consecutive labors onlv 1 case of osteomalacia was found. In Ger- 
 
ANOMALIES OF HARD PARTS OF PARTURIENT CANAL 673 
 
 many, Switzerland and Italy, however, it has been quite common. The 
 disease and its effect upon the pelvis were well known to Stein and Kilian 
 in the early part of the last century, and in 1861 Litzman had collected 
 from the literature a series of 131 cases. It occurs much more commonly 
 in women, and especially in pregnant or puerperal women, than in men. 
 
 In the 131 cases collected by Litzman there were 120 women and 
 only 11 men, and of the 120 women, 85 were pregnant or puerperal. 
 
 Although little is known of the true etiology of oesteomalacia, it seems 
 to be due to unsanitary modes of life, lack of cleanliness, poor food, etc. ; 
 and in proportion to the improved sanitation in different parts of the 
 world, the disease and its results have gradually disappeared. 
 
 The disease is essentially one of adult life, seldom occurring in chil- 
 dren, thus differing again from rachitis. It usually effects women in the 
 active child-bearing age, and especially those who have borne several 
 children. 
 
 Pathology. — Although the disease may aft'ect any portion of the skele- 
 ton, it is especially apt to involve the pelvis and often the vertebree and 
 ribs. The exact pathological changes have not been definitely settled. 
 
 The view generally accepted for years held that the condition was 
 simply a decalcification of the bone resulting from lactic acid, or some 
 similar acid circulating in the blood. Fehling,^ in 1888, advanced the 
 theory that the disease was a trophoneurosis due to some abnormal 
 conditions in the ovaries. 
 
 Although the improvement in the disease, which often follows oophor- 
 ectomy, would seem to associate osteomalacia in some way with the 
 ovarian function, the exact etiology and pathology have never been 
 settled. 
 
 The bone in a marked state of the disease is very soft and spongy and 
 on section shows distinct areolation. Themarrow spaces are dilated, the 
 vascularity is increased and the normal ossification absent. 
 
 The pelvis in this softened state is unable to resist the pressure of 
 the trunk above, the counter-pressure from below, and the traction of the 
 various muscles and ligaments, and actually collapses. 
 
 Distortion of the Pelvis. — The changes in the shape of the pelvis vary 
 with the extent of the disease, but will be best understood by considering 
 the typical shape in a well-marked example of the disease. 
 
 Under the influence of the body weight the pliable sacrum is rotated 
 on its transverse axis and the promontory driven far down into the pelvic 
 canal, an exaggeration of that seen in the rachitic pelvis. 
 
 The apex of the sacrum and the coccyx are at the same time pulled 
 markedly forward by the ligaments and muscles attached to them, thus 
 causing a marked anterior flexion in the sacrum at its lower third. 
 
 The force from below, upward and inward through the femora pushes 
 the lateral walls of the pelvis inward (see Fig. 397) so that in extreme 
 cases they nearly close the canal. This pushing in of the lateral walls 
 forces the pubic rami forward giving a beak-shaped projection at the 
 
 1 Ueber Kastration bei Osteomalacie, Verl. d. deutschen Gesellsch. f. Gj-n., 1888, ii, 
 311-318. 
 43 
 
674 
 
 ABNORMAL LABOR FROM ANOMALIES IN PASSAGES 
 
 symphysis, hence the name "beak-shaped pelvis" sometimes appHed 
 to one deformed by osteomalacia. The tuberosities and rami of the 
 ischia are also approximated so that in extreme cases the pubic arch is 
 reduced to a mere slit. 
 
 In a few cases where the patient is unable to stand, long sitting upon 
 the softened pelvis will cause a moderate eversion of the tubera ischii. 
 Thus as a result of osteomalacia the pelvic canal may be distorted into 
 various shapes by the folding in upon it of the pelvic walls, this distortion 
 in some cases amounting almost to obliteration. 
 
 Furthermore, when the softening process involves the vertebrae as well 
 as the pelvis, the weight of the trunk often forces the lumbar vertebrae 
 downward and forward into the pelvic brim, thus still further tending 
 to close the canal. 
 
 Fig. 397. — Osteomalacic pelvis. (Bunini.) 
 
 Clinical Picture. — The history of a patient suffering from osteomalacia 
 is of practical importance. The patient while pregnant first notices 
 rheumatoid pains in various parts of the body, perhaps with cramps in 
 certain muscles of the thighs and difficulty in walking. A little later 
 she finds that her spine, ribs and especially her pelvis are sensitive to 
 pressure. These discomforts continue until her child is born and if, as 
 is often the case, she has had previous children, this labor, as compared 
 with the others, is more difficult. After the birth of the child, her 
 symptoms gradually disappear, although walking may be difficult for 
 a considerable time. At her next pregnancy the symptoms return with 
 increased severity. 
 
 The rheumatoid pains are more intense and walking is very difficult 
 on account of the approximation of the thighs caused by the collapse of 
 the pelvis. She has to turn through nearly a half-circle in order to bring 
 one foot in front of the other. The anterior wall of the pelvis is especially 
 tender on pressure. Walking now becomes impossible and she is obliged 
 
ANOMALIES OF HARD PARTS OF PARTURIENT CANAL 675 
 
 to spend the remainder of her pregnancy in bed. The pelvis in the 
 meantime has become more contracted, so that labor has to be terminated 
 by craniotomy or Cesarean section. After the labor the symptoms 
 again gradually disappear, but she finds that she has lost several inches 
 in height. This results from the bending and compression of the bones 
 of the spinal column with their descent into the brim of the pelvis. This 
 loss in stature sometimes amounts to a foot or more. 
 
 Diagnosis.^ — The condition of osteomalacia can, as a rule, be readily 
 determined by the history of the case, and a physical examination of 
 the pelvis. 
 
 History. — Rheumatoid pains beginning during the pregnancy; inability 
 to walk, loss in stature. 
 
 Physical Examination.- — Pelvis tender on pressure; pliable, distorted 
 with peculiar, beak-like process in front; depressed lateral walls; sharp 
 anterior flexion of sacrum; marked narrowing of the pubic arch; approxi- 
 mation of coccyx and tubera ischii. 
 
 Influence on Labor. — ^The deformity of the pelvis, produced by osteo- 
 malacia, is a most serious one and, except in a very mild type of the 
 disease, requires Cesarean section for the delivery of a living child. 
 
 Treatment. — This may be considered under two heads: (a) Prophyl- 
 actic. (6.) Curative. 
 
 Prophylactic. — As the disease seems to be largely the result of poor 
 sanitation and poor nutrition, much can be done in the way of preven- 
 tion by attending to these conditions. The effect of improved sani- 
 tation in reduction of the frequency of osteomalacia has already been 
 referred to. 
 
 Curative.- — If a patient presents the early symptoms of the disease 
 every effort should be made to improve her general nutrition by nourish- 
 ing food, sleeping out of doors, the administration of tonics containing 
 the phosphates, etc.- 
 
 The treatment which has thus far proved the most efficient is a complete 
 hysterectomy. Although the reason of it is not understood, the fact 
 seems to have been demonstrated that the cessation of the function of 
 ovulation and the so-called "internal secretion" of the ovary is usually 
 associated with a marked improvement in the condition, if not a cure of 
 the disease. 
 
 New Growths of the Pelvis. — The most common forms of pelvic 
 tumors are exostoses, bony projections which may occur near the sacro- 
 iliac joints, upon the anterior surface of the sacrum near the promon- 
 tory, behind the symphysis pubis, or perhaps along the course of the 
 iliopectineal line. 
 
 They may be associated with multiple exostoses in different parts 
 of the body and are not infrequently found in patients the subject of 
 rachitis. 
 
 The bony outgrowths are usually not large and cause trouble, not so 
 much from their size as from the sharpness of their projection, exposing 
 the maternal soft parts to the risk of contusion or perforation. 
 
 The author met with one case in which a sharp pelvic exostosis, by 
 
G70 ABNORMAL LABOR FROM ANOMALIES IN PASSAGES 
 
 ])ressure (luring the labor and subsequent sloughing, produced as eom- 
 jjlete a perforation of the uterus as could have been made by a carpenter's 
 punch. The forefinger was easily passed through it. 
 
 V^arious other tumors may arise from the bony pelvis and cause partial 
 or complete obstruction to labor; among them may l)e mentioned 
 cnchondromaia, which are considered the most frequent variety; fibro- 
 mata, osteosarcomata, and carcinomata. 
 
 The author has met with 2 cases of osteosarcoma obstructing the 
 l)arturient canal. These tumors sometimes become cystic and assume 
 rapid growth. 
 
 Tumors of the pelvis are usually inoperable, and their influence upon 
 labor, except in the case of small exostoses, depends largely upon their 
 size. Cesarean section is the method by which the labor must usually 
 be completed in order to obtain a living child. 
 
 Caries, Necrosis, Atrophy. — Deformity of the pelvis from this cause 
 is especially seen in the cases of tuberculosis of the sacro-iliac joint. 
 If, as is usually the case in tuberculous bone disease, this occurs in early 
 life, the loss of bone substance followed by ankylosis when the process 
 heals, leads to a lack of de\elo]:)ment of the afl'ected side of the pelvis, 
 and there results an obliquely contracted pelvis similar to that of Naegele. 
 It usually presents much less deformity and has less influence in causing 
 dystocia than the true Naegele pelvis, due to the faulty development in, 
 or absence of, the sacral ahe on one side. It naturally follows that the 
 later in life the tuberculous caries and ankylosis occur the less will be 
 the pelvic deformity and dystocia. 
 
 Fracture of the Pelvis. — Except in the case of the coccyx, fracture of 
 the pelvic bones is usually associated with injuries so severe that recovery 
 therefrom is rare. Hence for the obstetrician to meet with a pelvis 
 deformed by a previous fracture is unusual. Such experiences, however, 
 do occur. 
 
 The portion of the pelvis most often found the seat of fracture is the 
 anterior wall, i. e., the pubes. The least frequent is the sacrum. 
 
 The deformity of the pelvic canal depends upon the location of the 
 fracture, and may be due to the following conditions: 
 
 (a) The distortion of the pelvic walls at the point of union, the apposi- 
 tion of the bones being imperfect. 
 
 (6) Excessive callus. This is especially found if mobility of the bones 
 at the seat of fracture persisted for a considerable time, the excessive 
 callus later becoming ossified and causing marked deformity. 
 
 (c) Ankylosis of joint nearest the fracture. Fracture of one of the 
 ala? of the sacrum may cause in union an ankylosis of the sacro-iliac 
 joint on that side, with a lack of development or an atrophy of that half 
 of the pelvis and a result resembling in shape and effect the oblicpiely 
 contracted pelvis of Naegele. 
 
 In fracture of the acetabulum, the result of hip-joint disease, the head 
 of the femur may project into the i)elvic ca\'ity and narrow it to that 
 extent. 
 
 Fracture of the pubes causes an irregular distortion of the pelvic inlet. 
 
ANOMALIES OF HARD PARTS OF PARTURIENT CANAL 677 
 
 especially if the accident occurred early in life and development of the 
 affected side was markedly interfered with. 
 
 Fracture of the loiver part of the sacrum and coccyx is followed by a 
 dislocation of the lower fragment forward. This often unites at such 
 an angle as to cause a sharp projection into the pelvic canal and a con- 
 siderable dystocia. 
 
 Fracture of the coccyx is quite a common accident in skating, the 
 feet sliding from beneath one and the patient suddenly assuming the 
 sitting posture upon the ice. The coccyx may be fractured at this time, 
 and although the accident may be followed for a considerable time by 
 pain on long sitting, especially on a hard seat, the pain and tenderness, 
 as a rule, gradually disappear and there only remains an angulated condi- 
 tion of the coccyx which may or may not cause dystocia at a future 
 labor. 
 
 Occasionally the fractured coccyx is a source of annoyance for years, 
 the periosteum becoming inflamed and thickened and giving rise to both 
 local and reflex disturbances. This will be found discussed under the 
 head of coccygodynia in different works on gynecology. 
 
 In cases of dystocia, caused by a narrow outlet, the coccyx will occasion- 
 ally be fractured, or a separation between two of its vertebrae occur, 
 especially during an instrumental delivery. It is most likely to occur if 
 there has been a previous fracture from some accident. It must not 
 be thought that this fracture will only occur in a forceps delivery. In 
 one case the author attended in three consecutive labors. In the first 
 and second deliveries which were rather difficult forceps operations, the 
 snap of the coccyx was felt and heard as traction was being exerted on 
 the instrument. In the third labor the patient was able to deliver her- 
 self without the use of instruments, but in the course of the natural 
 labor, just as the head passed the pelvic outlet, the snap of the coccyx 
 was distinctly heard. 
 
 The convalescence from fracture of the coccyx during labor is similar 
 to that from a fall in the non-pregnant. It is usually necessary for com- 
 fort that the patient use an air-cushion for a month or more when sitting 
 for any length of time. 
 
 It may be stated that the refracture of the coccyx may be considered 
 a happy outcome, as it is one of the simplest means of overcoming the 
 difficulty. The reason that a fractured coccyx does not easily unite 
 firmly is the fact that each act of defecation brings in play the muscles 
 attached to it and thus prevents the immobility necessary for the best 
 union. 
 
 Anomalies in the Articulations of the Pelvic Bones. 
 
 Abnormally Firm Union. — Synostosis, or abnormally firm union of the 
 pelvic bones, may develop in any of the pelvic joints, but is most often 
 found at the symphysis pubis and usually occurs in early life. Although 
 this limits the slight mobility in this joint normally found in pregnancy 
 and labor, if no other pelvic abnormality is present it is of little impor- 
 
078 ABNORMAL LABOR FROM ANOMALIES IN PASSAGES 
 
 tauoe. At a time when symphyseotomy was more popular and more 
 often performed than now, it was an annoyance to find that the separa- 
 tion of the symphysis required a saw instead of a knife, as expected. Now 
 that pubiotomy has supphmted symphyseotomy whenever any division 
 of the anterior pelvic wall is determined upon, a saw is always provided 
 and the synostosis of the symphysis does not enter into consideration. 
 
 Synostosis at the Sacro-iliac Joint. — Tlie effect of synostosis at this 
 joint has already been considered under two phases: (1) From faulty 
 development with absence of the sacral ala? on one side, as in the Naegele 
 pelvis, or on both sides, as in the Robert pelvis. (2) As a result of caries 
 and necrosis in tuberculous disease of the sacro-iliac joint. 
 
 In all cases, except where the synostosis is bilateral, as in the Robert 
 pelvis, the abnormally firm union at the sacro-iliac joint is, as a rule, 
 associated with atrophy and lack of development, giving an obliquely 
 contracted pelvis with the dystocia common to the pelvis of Naegele. 
 
 Synostosis at the Sacrococcygeal Joint. — The firm, bony union of the 
 lower coccygeal vertebrse normally takes place during the latter half of 
 the child-bearing age of women, but the joints between the sacrum and 
 coccyx and between the first and second coccygeal vertebrae normally 
 retain their mobility until the child-bearing age is over, thus allowing 
 in labor a recession of the coccyx and an increase of the conjugate at the 
 outlet amounting to about 2 cm. Occasionally, as a result of injury in 
 youth or of premature calcification in later life, this joint becomes anky- 
 losed, giving rise to a dystocia similar to that discussed imder Fracture 
 of the Coccyx, and usually dealt with in the same way, i. e., by fracture 
 either in natural or instrumental delivery. 
 
 Abnormally Loose Union. — During pregnancy there is developed in 
 women as in certain animals a physiological softening and relaxation 
 of the pelvic articulations in preparation for labor. 
 
 This relaxation is sometimes increased beyond the normal so that 
 walking is difficult and painful. The increased mobility is usually due 
 to an abnormal development of synovial fluid within the joint, but could 
 be the result of inflammation, suppuration, etc. 
 
 A marked increase of fluid within the joint makes rupture of the 
 joint more likely in a severe instrumental delivery. 
 
 The pain and difficulty in standing and walking are often a great 
 annoyance to the patient who demands relief. The condition osteomalacia 
 must be thought of, although rare. With this excluded the patient's 
 anxieties should be quieted and relief given, as far as possible, by a well- 
 fitting corset or abdominal binder which will hold the pelvic bones in 
 good apposition at the symphysis pubis and the sacro-iliac joints. 
 
 Anomalies of the Pelvis from Disease of the Spinal Column. 
 
 Spondylolisthesis.— The spondylolisthetic pelvis (see Fig. 398), named 
 and described by Kilian,^ in 1853, and sometimes called Kilian's pelvis, 
 
 ' Dc spondylolisthesi gravissimiE pclvangustise causa nuper detecta, Bonn, 185.3. 
 
ANOMALIES OF HARD PARTS OF PARTURIENT CANAL 679 
 
 is one in which, as the translation from the Greek (vertebrae slipping) 
 indicates, the last lumbar vertebra has become displaced downward on 
 to the anterior surface of the sacrum. 
 
 Varying with the extent of the disease, the lower anterior edge of the 
 body of the last lumbar vertebra projects beyond the anterior surface 
 of the sacrum, or the lower surface of this last lumbar vertebra has slid 
 down so as to lie entirely on the anterior surface of the upper portion of 
 the sacrum, to which it is firmly united perhaps by bony union. 
 
 Along with this dislocation of the body of the last lumbar vertebra 
 there follows a marked lordosis of the lumbar spine so that the fourth, 
 the third and, in extreme cases, even the second lumbar vertebra has 
 rolled down into the pelvic brim, shortening the stature of the woman and 
 
 narrowing the conjugate of the 
 pelvic inlet by the mass of the 
 prolapsed lumbar spine. 
 
 Although we owe the name and 
 the first accurate description to 
 Kilian, it is to the long and pains- 
 taking work of Neugebauer, 
 covering a number of years, that 
 we owe most of our knowledge 
 
 Fig. 
 
 398. — Vertical section through spondylo- 
 listhetic pelvis. (Kilian.) 
 
 Fig. 399. — Last lumbar vertebra of 
 spondylolisthesis (a), contrasted with a 
 normal fifth lumbar vertebra. (Neuge- 
 bauer.) 
 
 of the exact pathological condition and to his may be added the name 
 of Lane who, in 1885, published the results of his studies of the changes 
 produced by pressure in the lower part of the spinal column and called 
 attention to the fact that the carrying of heavy burdens was an important 
 etiological factor in the production of spondylolisthesis. 
 
 It is only the body of the last lumbar vertebra which is displaced down- 
 ward and forward, the inferior articular processes retaining their normal 
 relation with the superior articular processes of the first sacral vertebra 
 and the arch and the laminae, as a rule, maintaining a patent spinal canal 
 so that the cord is uninjured. The displacement of the last lumbar 
 vertebra is due then to a stretching and bending of the interarticular 
 segment (see Fig. 399). After a time, as a result of friction and pressure, 
 this interarticukr segment may present a transverse fracture. 
 
 Moreover, the pressure and friction of this lumbar vertebra against 
 
680 
 
 ABNORMAL LABOR FROM AXOMALIES IX PASSAGES 
 
 the anterior surface of the sacruiii may also cause more or less attrition 
 here, followed l)y ankylosis. 
 
 The descent of the lumbar vertebra' into the pelvis pushes the base 
 of the sacrum backward, and elevates the symphysis and anterior portion 
 of the pelvis. This diminishes the amount of the pelvic incHnation. In 
 fact, in extreme cases the pelvic inclination may be entirely obliterated. 
 
 Etiology. — The exact etiology of spondylolisthesis lias never been 
 determined. 
 
 Neugebauer assigned it to an imperfect development of the inter- 
 articular segment of the last lumbar \ertebra or to its fracture with 
 stretching of the fibrous union. Lane, on the other hand, having seen 
 several examples of it among coal-heavers, laid stress on the carrying of 
 heavy weights as a cause of the deformity. It is reasonable to suppose 
 
 Fig. 4(A). — ]ilL■i:^ky's case of spondylolisthesis. (Hirst.) 
 
 that both factors enter into the etiological problem, and that in certain 
 cases both are concerned in the result. If a lumbar vertebra was faulty 
 in the development of its interarticular portion, it certainly would be 
 more likely to be stretched and displaced under the influence of a heavy 
 weight than one normally developed. 
 
 Frequency. — The condition is a rare one but Neugebauer, in 1893, 
 collected from the literature 115 cases; ^Yilliams, in 1899, collected 7 
 more, and added 1 of his own. Hirst, in 1909, reported 1 more, making 
 124 cases on record, 6.5 per cent, of which were males. 
 
 General Appearance. — The front view of a woman, the victim of spondy- 
 lolisthesis (see Fig. 400), shortened in stature, as regards her trunk, her 
 thorax approximated to her pelvis, as though her ribs fitted within the 
 crests of the ilia, is striking. Her external generative organs are tilted 
 upward so that the vulva is directed more forward than normal. A deep 
 
ANOMALIES OF HARD PARTS OF PARTURIENT CANAL 681 
 
 crease is sometimes seen extending across the abdomen above the s}'m- 
 physis. Viewed from behind, as a result of the lordosis of the lower lumbar 
 spine, the posterior superior iliac spines and the iliac crests stand out 
 prominently with a furrow over the spinous processes of the lumbar 
 vertebra?. The buttocks are flattened, giving the gluteal region a heart- 
 shaped appearance. 
 
 Viewed from the side, the woman shows the hollow back incident to 
 the lordosis, and in some cases the spine of the last lumbar vertebra stands 
 out very prominently. The abdomen is more or less pendulous, even 
 in the non-pregnant state, and in pregnancy this of course is greatly 
 exaggerated. 
 
 This is easily explained in the non-pregnant state by the shortened 
 abdomen, and the exaggeration during the latter part of pregnancy by 
 the failure of the presenting part to engage on account of the obstructed 
 pelvic inlet is easily understood. 
 
 Diagnosis. — This can usually be made by careful attention to the 
 woman's history; her general appearance and careful pelvimetry, both 
 external and internal. It may be possible to obtain from her a history 
 of serious injury which might have associated with it a vertebral fracture, 
 or she may give a history of severe labor and burden carrying. Her 
 general appearance of shortened trunk and abdomen with relatively 
 long legs is certainly suggestive. Her gait is peculiar. Her toes are not 
 turned outward, but one foot is swung around the other and her foot- 
 prints lie nearly in a straight line. She has difficulty in balancing herself 
 and tries to overcome the forward tendency of her body by carrying her 
 shoulders far back. She is unable to carry any w^eight in front of her. 
 Pelvimetry shows that under the pressure of the trunk upon the anterior 
 surface of the sacrum instead of its base, the promontory is rotated back- 
 ward on its transverse axis, thus narrowing the conjugate at the outlet. 
 Furthermore, this retroplacement of the base of the sacrum, in con- 
 junction with the abnormal strain thrown upon the iliofemoral ligaments, 
 causes an outward rotation of the innominate bones at the brim. The 
 result, as far as the pelvic bones themselves are concerned, is a funnel- 
 shaped pelvis. At the inlet the transverse diameters between spines and 
 crests are increased, but the external conjugate, if taken just below the 
 last lumbar spine, is usually diminished, although if taken from the base 
 of the sacrum it would be increased, as this is throwai backward. The 
 transverse and conjugate diameters at the outlet are diminished and the 
 pubic arch is narrowed. 
 
 On internal examination the conjugate is seen to be narrowed. This 
 is not the true conjugate, but the distance between the symphysis and 
 the body of one of the lumbar vertebrae which lies in front of the sacrum. 
 
 This is spoken of as the "false" or "effective" or "available" conju- 
 gate of the spondylolisthetic pelvis and should be measured to the nearest 
 lumbar vertebrie, which is usually the fourth, although rarely the third, 
 and still more rarely the second. The fact that the bony projection in 
 the pelvis is a lumbar vertebra rather than a sacral, is determined by the 
 absence of transverse processes, and the fact that the iliopectineal line 
 
682 ABNORMAL LABOR FROM ANOMALIES IN PASSAGES 
 
 seems to be continued behind the projection rather than ahnig its anterior 
 surface. 
 
 The downward displacement of the lumbar spine carries with it the 
 large vessels of the lower abdomen, so that the common iliac arteries 
 and even the bifurcation of the aorta can sometimes be felt on vaginal 
 examination. 
 
 Influence on Labor. — ^In mild cases the influence of spondylolisthesis on 
 labor is similar to that of the simple flat pelvis, with the addition of a 
 slight contraction of the outlet. From this low degree of deformity in 
 which nature may perhaps deliver herself unaided, to the severe type of 
 the disease in which the pelvic inlet is nearly filled with lumbar vertebrae 
 and the outlet greatly contracted, all degrees of dystocia present them- 
 selves. In general it may be said that when the "available" conjugate 
 is less than 8 cm., Cesarean section is usually the method of choice in 
 the interest of both mother and child. 
 
 Prognosis. — The statistics of mortality in spondylolisthesis in former 
 years, before the present perfection of the technic of Cesarean section, 
 should not be taken as representing the prognosis of today, when more 
 careful pelvimetry and early resort to, Cesarean section, before the 
 woman is exliausted or infected, is the rule. In marked cases of spondylo- 
 listhesis the prognosis is that of Cesarean section. It is in the lesser 
 grades, where delivery through the natural passages is problematical, 
 that most of the bad results are obtained. In this connection a few facts 
 may well be considered. 
 
 A woman with spondylolisthesis in her first labor may succeed in 
 delivering herself unaided, yet in a subsequent labor, as the disease is 
 progressive, the dystocia may be so extreme as to require Cesarean 
 section for the delivery of a living child. 
 
 Furthermore, even in mild grades of spondylolisthesis, the dystocia is 
 more marked with the same grade of inlet measurements than in rachitis, 
 for the reason that in the latter the pelvis is more shallow, and the outlet 
 is expanded rather than contracted. 
 
 Kyphosis. — Kyphosis, or hunch-back, due to caries of the spinal column, 
 produces a deformity of the pehis by giving an abnormal direction to the 
 pressure exerted by the trunk upon the base of the sacrum. 
 
 The honor of first accurately describing the condition is properl}^ 
 given to Breisky^ who, in 1865, published an article on "The Influence of 
 Kyphosis on the Shape of the Pelvis." This honor, however, should 
 be shared in part with others, especially Rokitansky, Litzmann, and 
 Neugebauer, who had previously recognized it. 
 
 Characteristics. — The amount of pelvic deformity in kyphosis depends 
 upon the situation of the "hump" and, as a rule, the nearer this approaches 
 the sacrum the greater the deformity. 
 
 If the hump is situated high enough in the dorsal region (see Figs. 
 401 and 402), the compensating lordosis which is usually present may be 
 sufficient to maintain the normal position of the centre of gravity and no 
 
 ' Ueber deu Einfluss der Kyphose auf die Beckengestalt, Zeitschr. der Gesellsch. der 
 Aerzte in Wien, 1865, vol. i. 
 
ANOMALIES OF HARD PARTS OF PARTURIENT CANAL 683 
 
 Fig. 401 
 
 Fi.^ 40-' 
 
 Figs 401 and 402.-Kyphosis in dorsal region. Mother and second child whose weight at 
 birth was 8 pounds 15 ounces. Labor spontaneous; duration five and a half hours. 
 
fiS4 
 
 ABNORMAL LABOR FROM AXOMALTES IX PASSAGES 
 
 pehic deformity results. If, lioweNer, the kypliosis is situated at the 
 jmictiou of the dorsal and lumbar portions of the si)inal column (see 
 Fig. 40^)), or esjH'cially if it is in the lumhosaeral region (see Fig. 404) 
 this is impossible and the characteristic deformity results. The pressure 
 of the trunk comes on the anterior surface of the sacrum. The sacrum 
 is rotated on its transverse axis, so that its base is displaced backward and 
 its apex forward, just the opposite of what occurs in rachitis. The entire 
 sacrum is narrowed from side to side and elongated. 
 
 Fig. 403. 
 
 -Kyphosis at junction of dorsal and 
 lumbar regions. 
 
 Fig. 404. — Kyphosis in lumbar 
 region. 
 
 ^^ ith the posterior displacement of the sacral base there occurs a 
 rotation of the innominate bones on their anteroposterior axis, so that 
 the iliac crests are separated, the flaring of the fossae is increased, and the 
 tuberosities of the ischia are apprf)ximated. There then results a funnel- 
 shaped pelvis with enlarged inlet and contracted outlet. 
 
 The body in kyphosis bends forward and in order to maintain the 
 normal equilibrium the knees of the patient are flexed (see F'ig. 404). 
 The pelvic inclination is diminished. When the kyphosis occurs at the 
 lumbosacral junction there is usually caries of the sacrum as well as of 
 
ANOMALIES OF HARD PARTS OF PARTURIENT CANAL 685 
 
 the lumbar vertebra and ankylosis taking place here gi^es a most marked 
 deformity resulting from kyphosis. There is no opportunity for a com- 
 pensating lordosis below. The spine above bends far forward and the 
 backward displacement of the base of the sacrum and forward displace- 
 ment of its tip give the extreme funnel-shaped kyphotic pelvis. This 
 bending downward of the lumbar spine into the pelvic inlet gives an 
 obstruction at the brim somewhat analogous to that of spondylolisthesis, 
 and was described by Herrgott as spondylolizema. It is distinguished 
 from it, however, in occurring as a result of caries rather than from faulty 
 development or fracture. 
 
 The dipping do^raward of the lumbar spine into the brim of the pelvis 
 may practically occlude the pelvic inlet as far as the entrance of the child 
 is concerned and this condition was described by Fehling,^ iii 1S72, as 
 "pelvis obtecta" (see Fig. 405). 
 
 Fig. 405. — Pehds obtecta. (Fehling.) 
 
 Frequency. — The relative frequency with which one sees hump-backed 
 women on the streets of any large city suggests the probability of any 
 obstetrician in active practice having to deal with labor in a pelvis 
 deformed by this condition. At the Sloane Hospital for Women in 20,000 
 consecutive labors there were 15 kyphotic pelves, or 1 in 1333. 
 
 This is a greater frequency than found by Klien^ in his statistical 
 studies (1 in 6016), but his figures were thought by him to make the 
 condition more infrequent than actually occurred. 
 
 Influence on Pregnancy and Labor. — On account of the shortened spine 
 and sinking of the thorax, the abdomen is shortened and its capacity 
 diminished. This leads to a pendulous abdomen, and not infrequently 
 to malpresentation and malposition of the child, as transverse presenta- 
 tion and occipitoposterior position, which are common. 
 
 Furthermore, when, in the latter part of pregnancy, to the contracted 
 thorax, so often seen in the hump-backed, there is added marked upward 
 
 1 Pelvis Obtecta, Archiv f. Gyn., 1872, iv, 1-.33. 
 
 2 Die Geburt beim kyphotischen Becken, Archiv f. Gyn., 1896, i, 1-12S. 
 
68(3 ABNORMAL LABOR FROM ANOMALIES IN PASSAGES 
 
 pressure of the diaphragm from the enlarging uterus, dyspnea may be 
 a distressing symptom. The "hump" itself, on account of the increased 
 abdominal and pelvic weight, may become sensitive and disturb the 
 patient's sleep. 
 
 Prognosis. — The marked picture of deformity presented by many of 
 these women, the subject of kyphosis, with their shortened stature, 
 greatly humped back, contracted chest and pendulous abdomen may at 
 first suggest the thought that nothing short of a Cesarean section will 
 deliver such women; and yet it is remarkable how many will deliver 
 themselves or can be delivered b\' forceps or version (see Figs. 401 
 and 402). 
 
 In the 15 cases of kyphosis occurring in 20,000 consecutive deliveries 
 at the Sloane Hospital, the methods of delivery were as follows: normal, 
 3; by forceps, 8; by version, 2; by Cesarean section, 2, In this group 
 of 15 cases there was no maternal mortality. The fetal mortality was 
 3; 1 stillbirth and 2 early deaths, all premature. The stillbirth was in 
 a delivery by forceps; the 2 early deaths occurred in children delivered 
 by version. 
 
 Unless the kyphosis occurs at the lumbosacral junction when the 
 prolapsed vertebra may present the obstruction similar to that seen in 
 spondylolisthesis, the difficulty in labor in a kyphotic pelvis is usually 
 not encountered until the floor of the pelvis is reached. 
 
 The difficulties then are usually those of the funnel pelvis and must 
 be dealt with in the same w^ay. A transverse diameter of 8 cm. at the 
 pelvic outlet may be taken as the practical dividing point between a 
 delivery which may be expected to be accomplished through the natural 
 passages, either spontaneously or by the use of the forceps, and a delivery 
 whose successful termination may require either induction of premature 
 labor or Cesarean section, or some operation like pubiotomy which 
 enlarges the pelvic outlet. In pelves contracted at the outlet the author 
 believes that version is not a good method of delivery, as on account of 
 the delay in delivering the after-coming head, the child is not infrequently 
 lost. 
 
 Surprises frequently occur and many cases with a transverse diameter 
 of 8 cm. by marked molding of the fetal head under the influence of 
 strong pains will deliver themselves, but to regard the abo\-e diameter 
 mth suspicion may be looked upon as a good practical working rule. 
 
 The author's experience leads him to believe that a transverse diameter 
 of 7 cm. or less at the outlet should be regarded as an indication for 
 Cesarean section. 
 
 Scoliosis. — ^A certain amount of lateral curvature of the spine is fre- 
 quently seen in young women who habitually sit in an improper atti- 
 tude at the table or desk, especially during their developmental period. 
 This, however, is usually slight, is situated at the upper part of the spinal 
 column and is usually compensated for by a similar curve in the opposite 
 direction lower down and has, as a rule, little if any effect upon the shape 
 of the pelvis. 
 
 When the lateral curxature is situated in the lumbar region, it is[usually 
 
ANOMALIES OF HARD PARTS OF PARTURIENT CANAL 687 
 
 associated with a pelvis contracted in one of its oblique diameters, but 
 usually not sufficient to cause dystocia. 
 
 Marked scoliosis, however, is usually of rachitic origin and is charac- 
 terized by a typical deformity of the pelvis properly called scoliorachitic 
 (see Fig. 406). 
 
 The innominate bone toward which the convexity of the lumbar spine 
 is directed receives the greater part of the weight of the trunk from above 
 and upward pressure through the femur, and under this unequal pressure 
 one side of the pelvis is pushed inward, giving an oblique contraction. 
 
 The innominate bone on the affected side is pushed upward, inward 
 and backward, displacing the acetabulum anteriorly and pushing the 
 
 Fig. 406. — Scoliorachitic pelvis. (Tarnier.j 
 
 symphysis to the opposite side. In this condition there are present the 
 results of rachitis as well as those of the spinal curvature, henqe there is 
 usually more or less contraction of the inlet due to the rotation of the 
 sacrum on its transverse axis and an enlargement of the outlet due to an 
 e version of the tubera ischii. 
 
 Thus, while the pelvis is obliquely contracted and occasionally anky- 
 losis occurs at the sacro-iliac joint on the affected side, it differs from 
 the obliquely contracted pelvis of Naegele in that in the scoliorachitic 
 pelvis the outlet is enlarged, while in the Naegele pelvis it is contracted. 
 
 Diagnosis. — The condition is usually detected without difficulty by 
 inspection of the spinal curvature and by careful pelvimetry. If unnoticed 
 before, the spinal curvature when at all marked is usually detected when 
 
688 
 
 ABNORMAL LABOR FROM ANOMALIES IN PASSAGES 
 
 the lumbosacral region is exposed for measuring the oblique diameters 
 in the course of routine pelvimetry. The pelvimeter shows a marked 
 difference in the two oblique diameters and careful palpation, both 
 internal and external shows the characteristics of an obliquely contracted 
 pelvis, the curve of the pelvic cavity on the affected side more or less 
 flattened, the symphysis displaced to the opposite side, but in this case, 
 on account of the rachitic origin, the pubic arch and pelvic outlet enlarged. 
 
 Fig. 407. — Kyphoscoliosis. 
 
 Influence on Labor. — x\lthough minor grades of scoliosis may exist 
 without affecting the pelvis enough to cause dystocia, in the typical 
 scoliorachitic pelvis only one oblique diameter is available for the long 
 diameters of the presenting part, and the amount of dystocia depends upon 
 the amount of contraction in this diameter. After the inlet is passed, 
 the labor usually progresses favorably on account of the expanded outlet. 
 
 As a rule the dystocia is not so extreme that it cannot be overcome by 
 the use of the forceps. 
 
 Kyphoscoliosis. — The kyphoscoliotic pelvis (see Fig. 407) combines 
 the features of the two pelvic deformities just described. The disease 
 
ANOMALIES OF HARD PARTS OF PARTURIENT CANAL 689 
 
 is usually rachitic in origin, and rachitic kyphosis being usually situated 
 high in the dorsal region may be largely compensated for by a lumbar 
 lordosis. The exact type of pelvic deformity will depend upon which of 
 the two conditions, the kyphosis or the scoliosis, predominates. As a 
 rule, however, the contraction of the inlet usually found in the typical 
 scoliotic pelvis is lessened by the kyphosis and the contraction of the 
 outlet usually associated with kyphosis is lessened by the scoliosis. 
 
 Diagnosis. — The diagnosis is made by general inspection, careful pelvim- 
 etry, and pelvic palpation. All degrees of dystocia may be met with 
 and must be dealt with according to the amount of pelvic contraction. 
 
 Lordosis. — Lordosis, or anterior curvature of the 
 
 spinal column associated with other spinal or pelvic 
 disease, is not at all uncommon and has frequently 
 been referred to in our study of pelvic deformities. 
 As a primary condition and unconnected with spinal 
 and pelvic disease it is very rare. Hirst, however, 
 in his text-book of Obstetrics, describes and pic- 
 tures a case of his (see Fig. 408) resulting from 
 paralysis of the spinal muscles and calls attention 
 to the increased pelvic inclination and possible diffi- 
 culties in coition and parturition. The engagement 
 of the presenting part may be seriously interfered 
 with, although there are not a sufficient number of 
 cases on record to give much practical experience 
 with this condition. 
 
 Anomalies Resulting from Abnormalities of 
 THE Subjacent Skeleton. 
 
 For the development and maintenance of the 
 normal shape of the pelvis it is necessary to have 
 an equal amount of force transmitted to the pelvis 
 through each femur, whether it be simultaneously, 
 as in standing, or alternately, as in walking or 
 running. tp .^„ t ^ • 
 
 '=> IIP'- ... Fici- 408. — Lordosis 
 
 in studymg the deformities of the pelvis, it is from paralysis of spinal 
 seen that whenever this force is unequal on the muscles. (Hirst.) 
 two sides, there is apt to result an oblique contrac- 
 tion of the pelvis, more marked if it is exerted during early childhood 
 while the pelvis is in its formative period. This inequality of force is 
 seen in any lameness in which on account of pain or weakness in one of 
 the lower limbs the weight of the body is transferred as soon as possible 
 to the other. This application of an abnormal amount of force to the 
 sound side of the pelvis usually results in pushing it upward, inward, and 
 backward. 
 
 A certain amount of pelvic distortion sometimes results from bilateral 
 lameness, but is usually of little importance in obstetrics. 
 
 The most common causes of unilateral lameness causing pelvic deformity 
 44 
 
690 ABNORMAL LABOR FROM ANOMALIES IN PASSAGES 
 
 are coxitis, dislocation of the femur, and deformity or absence of one of 
 the lower extremities. 
 
 Fig. 409.— Coxalgic pelvis before patient has walked. (Redrawn from Williams.) 
 
 Coxitis. — The coxalgic pelvis, or one resulting from hip-joint disease, 
 is an obliquely contracted pelvis, but its exact shape depends upon the 
 age of the individual at which the disease was an active process (see 
 Figs. 409 and 410). 
 
 Fig. 410. — Coxalgic pelvis after patient has walked. (Redrawn from '\\illiams.) 
 
 If the disease is active before the child begins to walk, or if the 
 child is confined to the bed for a long time, there is a lack of development 
 on the affected side, so that the whole innominate bone of that side is 
 smaller than normal, the sacral ala of that side is underdeveloped, and 
 
ANOMALIES OF HARD PARTS OF PARTURIENT CANAL 691 
 
 often there is an ankylosis of the sacro-ihac joint locating the deformity, 
 chiefly on the affected side. 
 
 On the other hand, if the disease develops later, the pelvic deformity 
 may be most marked on the healthy side and result from the weight 
 of the body being thrown chiefly onto the healthy limb and the greater 
 pressure on the sound side of the pelvis pushing this innominate bone 
 upward, inward, and backward, and thus causing the deformity on the 
 healthy side. 
 
 In both cases, however, there is seen to be an oblique contraction. 
 At the same time the pelvis is usually tilted, being higher on the healthy 
 side. The dystocia is usually less in this latter variety than in the former, 
 where the lack of development is more marked. 
 
 Diagnosis.- — The presence of a coxalgic pelvis is usually suggested 
 by the lameness of the patient and is verified by pelvimetry and careful 
 external and internal palpation of the pelvis and hip-joints. The fixation 
 of the thigh often proves a distinct annoyance in delivery by forceps, and 
 for that reason version is sometimes preferred. 
 
 Influence on Labor.— The effect of the coxalgic pelvis on labor is that 
 of an obliquely contracted pelvis. Of the two varieties of coxalgic 
 deformity, that which results from the disease occurring in very early 
 life gives the most marked deformity and may be similar to that of the 
 Naegele pelvis. As a rule, however, the amount of pelvic deformity is 
 not sufficient to require Cesarean section and the dystocia can usually 
 be overcome by the use of forceps or version. 
 
 Dislocation of the Femur or Femora. — The dislocation of the head 
 of the femur may be congenital or acquired in youth and never reduced. 
 Furthermore, the condition may be unilateral or bilateral, usually the 
 former. Whether the dislocation is unilateral or bilateral, the pelvic 
 deformity is usually not sufficient to cause marked dystocia. 
 
 In unilateral dislocation the shape of the pelvis depends upon the 
 direction taken by the head of the femur. If it is displaced upward and 
 backward, as is usually the case, the corresponding leg is shortened and 
 the greater weight is thro^^^l on the leg of the sound side, with a tendency 
 to push that side of the pelvis upward, inward, and backward, and to tilt 
 that side of the pelvis upward. If the displacement of the head of the 
 femur is forward, there is a tendency to push the anterior wall of that 
 side of the pelvis inward. In both of these instances there results more 
 or less oblique contraction of the pelvis. If there is a congenital disloca- 
 tion of the heads of both femora upward and backward onto the iliac 
 bones there occurs an interesting change in the shape of the pelvis, 
 although usually not sufficient to cause dystocia. The sacrum is rotated 
 forward with absence of pressure through the femora on the lateral walls 
 of the pelvis and by the pull of the muscles attached to pelvis and femora, 
 the ischia are separated, especially at their tuberosities. There results 
 a pelvis moderately flattened, but with transverse diameter increased, 
 especially at the outlet, and with cavity shallow. On inspection and 
 palpation the trochanters are found more prominent, the buttocks are 
 broader and on side view the patient shows a distinctly hollow back. 
 
692 ABNORMAL LABOR FROM ANOMALIES IN PASSAGES 
 
 On account of the imperfection of the false acetabula, there is apt to 
 be more or less waddling in the gait. 
 
 Absence or Deformity of One or Both Lower Extremities. — ^In the 
 absence of one lower extremity the weight of the body is of necessity 
 upon the sound leg, this has the effect, previously noted, of pushing the 
 sound side of the pelvis upward, inward, and backward, and giving as a 
 result an obliquely contracted pelvis, usually, however, not sufficient to 
 cause marked dystocia. 
 
 The result produced by the absence of one lower extremity may be 
 produced in a lesser degree by any deformity of one lower extremity which, 
 although doing some work, is unable to do its full share. 
 
 This applies to the atrophied limb of anterior poliomyelitis, but in 
 this case there may be added the faulty development of the pelvis on the 
 affected side. Even here, however, marked dystocia is unusual. 
 
 In the absence of both lower extremities the patient is obliged to spend 
 much of the time in the sitting posture giving the so-called "sitz pelvis " 
 in which the tuberosities of the ischia are everted, the pelvis made more 
 shallow, and the crests of the ilia approximated. 
 
 In bilateral club-foot a change in the pelvis has been noted as a result 
 of the absence of spring, as compared with that of the normal person who 
 possesses a normal arch of the foot and walks with more or less flexion 
 of the knees. The resulting pelvis is one with contracted outlet and 
 increased inclination, but usually of very little obstetric importance. 
 
 INFLUENCE OF CONTRACTED PELVIS ON PREGNANCY. 
 
 While studying the different varieties of deformity of the pelvis it 
 may be well to consider the influence of a contracted pelvis on pregnancy 
 and labor as contrasted with these processes in a normal parturient canal. 
 
 As regards pregnancy, it is in contraction of the pelvic inlet that depar- 
 tures from the normal are especially seen. In the early months, while 
 the uterus is in the pelvis, a contracted inlet is inclined to interfere with 
 the normal rising of the uterus in its growth. If there has been a previous 
 tendency to retroversion, this tendency is exaggerated, and to this the 
 tendency to incarceration is added, with its associated symptoms of 
 vesical retention and rectal pressure. 
 
 With these tendencies overcome and the pregnancy advanced to the 
 later months there are certain distinct characteristics of pregnancy asso- 
 ciated with a pelvis contracted at the inlet. 
 
 As the fetus approaches maturity and the head becomes too large to 
 enter the brim of the pelvis, the uterus as a whole becomes lifted out of 
 the pelvis and more protrusion of the uterine and abdominal walls results. 
 This forward protrusion is most marked when the abdomen is shortened 
 by disease of the spinal column, but is present to a certain extent even 
 with normal spinal column when the inlet is contracted. Moreover, if 
 the patient is a multigravida, with uterine and abdominal walls previously 
 stretched, this forward protrusion is favored, giving a pendulous abdomen 
 with a tendency to faulty presentations, prolapse of the cord, etc, . 
 
INFLUENCE OF CONTRACTED PELVIS ON PREGNANCY 693 
 
 Pendulous Abdomen. — On account of lack of support in the anterior 
 abdominal wall, even with a normal pelvis, the uterus sometimes falls 
 far forward and has to be assisted in the engagement of the presenting part. 
 
 If the pelvic inlet is contracted, a pendulous abdomen is much more 
 common and the uterus, instead of being inclined at an angle of 35 
 degrees to the horizon, may lie horizontally or may fall far forward 
 and downward so that the fundus lies below the level of the cervix. 
 
 Faulty Presentations. — In a contracted inlet, especially with a narrow 
 conjugate, the head being prevented from engaging, is apt to slide into 
 one of the iliac fossae giving rise to a transverse or shoulder presenta- 
 tion. A lesser degree of the lateral displacement of the presenting part 
 will give an oblique presentation. The contracted inlet, preventing the 
 ready entrance of the vertex and normal flexion, may favor extension 
 of the head and result in a brow or face presentation. 
 
 Prolapse of the Cord. — In any case in which the presenting part does 
 not readily engage and accurately fit the pelvic inlet, a loop of cord is 
 apt to slip down in advance, hence it is in deformed pelves that prolapse 
 of the cord is so common. This is of much less consequence during preg- 
 nancy and before the rupture of the membranes, than during labor and 
 after the membranes have ruptured, but it is important at any time that 
 the possibility of prolapse of the cord in connection with a contracted 
 pelvis should be thought of, watched for, and if detected, replaced as 
 soon as possible. 
 
 Influence on Labor. — There are certain general characteristics of labor 
 in a contracted pelvis which should be considered before the means for 
 dealing with the dystocia are studied. 
 
 In the first place, when the amount of pelvic contraction is not too great 
 to permit of delivery through the natural passages, much depends upon 
 the race, the character of the pains, and the size and moldability of the 
 fetal head. 
 
 Race. — It is the experience of practically all obstetricians who have 
 to deal with labor in both black and white women, that with a given 
 amount of pelvic contraction, about twice as many black women as white 
 will succeed in delivering themselves. This is largely due to the smaller 
 size and greater moldability of the head of the colored child, as will be 
 considered later. 
 
 Character of the Pains. — In obstetrics nothing is more difficult to 
 prognosticate than the character and efficiency of the pains of a primi- 
 gravida. A pelvic canal, known by careful pelvimetry and palpation to 
 be perfectly passable for a given head under normal strong uterine con- 
 tractions, becomes absolutely impassable without artificial aid in the 
 case of a woman who becomes nervously exhausted in the first stage of 
 labor, and becoming discouraged and losing self-control, will not or can- 
 not use her voluntary muscles in the second stage. On the other hand, 
 a woman with placid disposition, good physique, cheerful, hopeful and 
 helpful to the last, will make the most and best of her pains, will mold 
 the fetal head and deliver her child perhaps unaided. In some multi- 
 gravidse, however, stretching and weakening of the uterine and abdom- 
 
094 ABNORMAL LABOR FROM ANOMALIES IN PASSAGES 
 
 inal walls, due to a previous difficult labor, make a certain amount of 
 uterine inertia inevitable, in spite of the will of the woman. 
 
 Size and Moldahiliti/ of ihe Fetal Head. — The difficulty in accurately 
 determining the size of the fetal head and the advances made in this 
 direction have already been discussed (see page 189). Another uncertain 
 factor in the problem is its moldability. Reference has already been 
 made to heads of colored children and to the fact that their smaller size 
 and greater moldability will often enable them to pass a narrowed 
 canal which in the case of the white child might be impassable. ^Nlore- 
 over, the heads of certain white children with thin cranial bones, wide 
 sutures and large fontanelles, perhaps premature, will mold with great 
 ease and will pass through a canal which for a hard unmoldable head 
 would be impossible. Another characteristic of labor in a contracted 
 pelvis is the disturbance in the normal process of dilatation of the cervix. 
 Instead of the head lying low in the pelvis and in close contact with a 
 partially retracted cervix in the first stage of labor, in a pelvis with con- 
 tracted inlet the head usually lies high. The force of the uterine contrac- 
 tion acts on the entire column of liquor amnii, and the amniotic sac 
 forced down into the cervical canal usually ruptures prematurely, before 
 the cervix is dilated and retracted, and the labor has to continue without 
 the ball-valve action of the head to hold back a large part of the liquor 
 amnii and to immediately aid with its solid wedge in the rapid dilatation 
 of the cervix. After the premature rupture of the membranes in a pelvis 
 with contracted inlet, the first stage is apt to be tedious, as it has to be 
 accomplished by a gradual molding of the head and retraction of the 
 cervix under uterine contractions which may not be efficient. 
 
 Prognosis. — The dangers of labor in a contracted pelvis may be either 
 maternal or fetal. 
 
 The Matermd Dangers. — These vary indefinitely with the surround- 
 ings and care of the patient and whether she is under careful observation 
 and skilled care in a well-regulated maternity hospital or whether she 
 is under the care of a man who never practises pelvimetry and seldom 
 examines his cases until they are in labor. 
 
 At the Sloane Hospital, in a consecutive series of 20,000 deliveries 
 there were 1770 cases of deformed pelvis, and in this series 35 mothers 
 were lost, making a maternal mortality of 1.9 per cent. This is only 
 slightly above the total maternal mortality of the hospital, which is 
 1.09 per cent. Williams, in a series of 278 cases of labor with contracted 
 pelvis, reports a maternal mortality of 2.88 per cent. 
 
 Maternal mortality and morbidity resulting from labor in a contracted 
 pelvis are easy to understand, when it is considered first of all that, as 
 a rule, the membranes rupture early and the labor is prolonged. It is 
 the common experience of obstetricians that a long, dry labor, with its 
 accompanying lowered vitality of the soft parts of the parturient canal 
 and tendency- to putrefaction in the amniotic sac, predisposes to infection 
 in any labor, especially if, as in a contracted pelvis, the labor has to be 
 terminated by artificial measures. Hence infection may be looked upon 
 asoneof the chief dangers to themotherfrom labor with a contracted pelvis. 
 
INFLUENCE OF CONTRACTED PELVIS ON LABOR 695 
 
 Another danger which should always be thought of, is rwpture of the 
 uterus. In pelves of moderate contraction, especially in primigravidse, 
 it is a common rule, and within limitations a good one, to wait and see 
 what nature can do toward accomplishing the delivery. During this 
 period of waiting and observation, however, the fact must not be lost 
 sight of that the uterus, working against an obstacle which may be too 
 great for it to overcome, is gradually thinning its lower segment, and if 
 this process is allowed to continue too long, either spontaneous rupture 
 may occur, or the operative interference necessary for the termination 
 of the labor may cause a rupture. The great danger of causing a rupture 
 by version or attempted version, in a tonic uterus, where the liquor 
 amnii has drained away and the uterus has contracted on the child, is 
 discussed elsewhere (see page 710). 
 
 Another danger to which the mother is subjected in labor with con- 
 tracted pelvis is sloughing and fistidoe. 
 
 Fortunately for parturient women the dangers of long pressure of the 
 fetal head upon the soft parts of the pelvic canal and neighboring organs 
 have become well known, and by avoidance their results, such as vesico- 
 vaginal and rectovaginal fistulse, are much less commonly seen than 
 formerly. 
 
 As a rule it is the presenting fetal head, which by long compression of 
 the soft parts between itself and the hard, bony pelvis, causes the slough 
 and subsequent fistula. The fetal body is usually too soft and compres- 
 sible to cause this result and the after-coming head usually does not 
 remain long enough in the pelvis. 
 
 Emphasis upon the liability of long pressure to cause fistulse by slough- 
 ing does not exclude the possibility of the production of fistulse by the 
 forceps in delivery. 
 
 One more maternal danger from labor in a contracted pelvis will be 
 mentioned, and that is hemorrhage. The long, tedious labor is very apt 
 to result in an exhausted uterus as well as an exhausted mother, and an 
 exhausted uterus does not readily contract or maintain its contraction 
 after labor. This means a tendency to postpartum hemorrhage with 
 its own immediate dangers and the subsequent liability to infection from 
 lowered vitality, retained blood-clots, etc. 
 
 Fetal Bangers. — In the 1770 cases of labor in contracted pelvis at the 
 Sloane Hospital there were 225 stillbirths; 129 died subsequently 
 before the mothers left the hospital, and there were 37 abortions. This 
 gave a total infant mortality, excluding the abortions, of 20 per cent. 
 It is only fair to state, however, that during the first half of this series. 
 Cesarean section was scarcely ever performed and craniotomy was the 
 rule when the forceps or version failed. Williams, in his series of 278 
 cases, reports an infant mortality of 12.96 per cent. 
 
 Some of the causes of this fetal mortality will now be considered. 
 For a long time it has been held that as long as the membranes remain 
 unruptured, labor may continue indefinitely in the first stage with scarcely 
 any danger to the child. The writer desires to call attention to the fact 
 that there are many exceptions to this rule, and that he has many times 
 
G96 ABXORMAL LABOR FROM ANOMALIES IX PASSAGES 
 
 met with, cases in wliicli, although the membranes were unruptured, he 
 has foimd, on dehvery by Cesarean section, a decided caput formed, the 
 meconium in the Hquor amnii and the fetal heart showing an undue 
 amount of embarrassment from compression. 
 
 The only way to determine that the continuence of the first stage is 
 not endangering the life of the fetus is to listen frequently to the fetal 
 heart and to watch carefully for changes in its frequency and rh\-thm. 
 
 While a long continuation of the first stage is not without danger to 
 the fetus, its risk is slight as compared to that of a prolonged second stage 
 with which most of the fetal dangers are associated. Among these may 
 be mentioned: 
 
 (a) Asphyxia. — The long, dry labor with perhaps a uterus in tonic 
 contraction exposes the fetus to risk of asph^-xia from compression of 
 placenta and cord even when the cord is in normal position. ^Yhen the 
 cord is prolapsed, as so often happens in contraction of the pelvic inlet, 
 this danger is greatly increased. 
 
 (h) Cerebral Compression. — If a child after delivery by the forceps 
 shows signs of cerebral compression, the use of the instrument is often 
 blamed for the result, while the opposite may be the truth, and the 
 delay in the use of the instrument, allowing the fetal head to remain 
 subject to severe pressure for too long a period, may have been the real 
 cause of the trouble. One not infrequently sees the result of cerebral 
 compression after a so-called "normal labor," /. e., one terminated by 
 nature, but where the pressure was too prolonged. It must be recognized 
 that in labor in a contracted pelvis the child is exposed to danger of 
 cerebral compression both by the labor itself, if it is difficult and markedly 
 prolonged, and also by the use of the forceps, if this operation is difficult. 
 
 (c) Sloughing Areas on the Fetal Scalp. — The prolonged pressure of 
 the fetal head against some bony projection in a contracted pelvis may 
 show its result after birth in either a distinct groove in the child's head 
 where the bony prominence rested, or a lowered vitality in the scalp 
 at that point with subsequent sloughing which may both lower the 
 general vitality of the child and serve as an avenue of infection. 
 
 AMiat has been said regarding the pressure of the bony projection in 
 the pelvic canal on the fetal head may also apply to undue and unskilful 
 pressure of the forceps blade on the fetal head which may not only result 
 in sloughing of the fetal scalp but even in fracture of the fetal skull. 
 
 (d) Malpresentation and Malposition. — As the fetal mortality is 
 increased by malpresentation and malposition, and as these are both 
 more common in contracted than in normal pelves, it naturally follows 
 that they should be thought of when explaining the fetal mortality in 
 labor associated with deformity of the pelvis. 
 
 Finally, to the fetal dangers already enumerated should be added the 
 dangers of 
 
 (e) Artificial delivery, and when one considers that in our series of 
 1770 cases with deformed pelvis there were only 815, or 46.4 per cent., 
 with normal labors, it is e\ident that in many instances the fetal danger 
 from the forceps and version must be included among those associated 
 with labor in a contracted pelvis. 
 
CHAPTER XXI. 
 
 ABNORMAL LABOR FROM ANOMALIES OF THE FETUS AND 
 IN PRESENTATION. 
 
 ABNORMAL LABOR FROM ANOMALIES OF THE FETUS. 
 
 Overgrowth of Fetus. — It is readily understood that a pelvis of a 
 given size might allow an easy delivery in the case of a small child, while 
 it would be almost impassable to an abnormally large child. It is seen 
 then that for a normal labor much depends upon the size of the child. 
 
 Much ignorance exists among the laity regarding the actual weight 
 of children at birth. This is due first to the fact that there seems to be 
 a widespread tendency to exaggerate the weight of a new arrival and to 
 take especial pride if the child is unusually large, and secondly, to the 
 fact that it is the custom to weigh the child in one or more blankets, and 
 among the laity the weight of the wrappings is not accurately deducted. 
 Hence it is not unusual for the proud father to announce that he has a 
 boy weighing all the way from 12 to 15 pounds. 
 
 At the Sloane Hospital the net weight of a child at birth is accurately 
 taken and recorded in the delivery room, and as soon as the baby reaches 
 the nursery it is weighed again, and thus the actual weight is attested 
 by two observers. 
 
 In a series of 25,000 consecutive deliveries at the Sloane Hospital, the 
 largest normally formed child weighed twelve pounds three ounces. A 
 few monsters weighed more than this, but these do not belong in a series 
 of normally formed children. 
 
 To determine the average weight of a child at term without regard 
 to sex. a consecutive series of 5000 children was taken, excluding all 
 whose length was less than 48 cm. The average weight was 7 pounds 
 3 ounces. In this series of 5000 cases there were 2577 boys with an 
 average weight of 7 pounds 4.1 ounces, and 2423 girls with an average 
 weight of 7 pounds 1.9 ounces. Thus the average actual weight was 
 less than 71 pounds, and the boys averaged only about 2 ounces more 
 than the girls. 
 
 While a normal pelvis will allow the easy passage of a 75-pound child, 
 an 11-pound child may give marked dystocia. The causes of unusual size 
 on the part of the child will now be considered. In the first place the 
 overgrowth may be due to: 
 
 Prolongation of Pregnancy. — It has already been stated under Duration 
 of Pregnancy (see page 157) that while the average duration of pregnancy 
 is regarded as about 273 days from intercourse, it may vary from 231 
 to 329 days, and this variation occurs in an^'mals as well as women. 
 
 (697) 
 
698 ABNORMAL LABOR FROM ANOMALIES OF THE FETUS 
 
 Moreover, it is proNed in many cases, hy the al)normal si/e and nnusnal 
 development of the eliild, tliat the preti;nancy has been abnormahy pro- 
 longed. In some instances there is even a history of an attempt on the 
 part of nature to start the labor at the usual time, but for some reason 
 the symptoms of labor ceased (missed labor) and only recurred weeks 
 later. 
 
 The question of ])roloiigation of pregnancy is one of medicolegal as 
 well as obstetrical importance, and concerns the legitimacy of children 
 born more than 280 days after the death of the husband, or after his 
 last possible opportunity for intercourse. 
 
 The law regarding this varies in different countries. In France and 
 Austria legitimacy cannot be ciuestioned unless the pregnancy has 
 exceeded 300 days. In England and America no exact period is fixed 
 and each case is decided on its own merits. 
 
 It is admitted then by practically all obstetricians that j^regnancy 
 may be abnormally prolonged and that this prolongation may give rise 
 to such overgrowth of the fetus as to cause marked dystocia. The dystocia 
 resulting from overgrowth of the child concerns chiefly the fetal head 
 and shoulders. 
 
 The Head. — The head in the overde\'eloped fetus is not only larger but 
 harder and less moldable and for both of these reasons the mechanical 
 problem of delivery is rendered more difficult. 
 
 The Shoulders. — The shoulders, moreover, are apt to be broader than 
 normal and this may become an important factor in the dystocia. 
 
 Oversize of One or Both Parents. — An important question in taking the 
 history of every obstetrical case, especially if the woman is small, concerns 
 the size of her husband. If the patient herself is large she may have a 
 large pelvis, but at any rate her pelvis should be carefully measured, as 
 a large woman often has a large child. Of greater importance is the 
 size of the husband, for this usually means a large child and the jjossible 
 dystocia resulting from the union of a small wife with a large husband is 
 readily seen. 
 
 Elderly Primigravidse. — Sometimes elderly primigra\'idiTe have large chil- 
 dren, and this increased size of the fetus c()U])led with the tendency to 
 uterine inertia and abnormal resistance in the soft parts often means 
 dystocia. 
 
 Multiparity. — Unless the children are born very close to each other 
 there is a tendency' for each succeeding child \\\) to the third or fourth 
 at least, to be a little larger than the ])receding, so that a woman, 
 although able to gi\-e birth to her first or second child, may fail in her 
 third or fourth. 
 
 Treatment of Overgrowth of Fetus. — This concerns first the prolongation 
 of pregnancy. Mistakes are so frequent in calculating the exact date of 
 a confinement that the obstetrician must be cautious in deciding that 
 the pregnancy has really been abnormally prolonged. Impregnation, 
 instead of occurring just after the last menstruation, may have occurred 
 just prior to the next, which did not appear, and this would account for 
 an error of three weeks in calculation. As a rule, however, the period 
 
Abnormal lAbor from anomalies of the fetus 609 
 
 immediately following an impregnation, while usually greatly diminished, 
 is not entirely checked, and this scanty or irregular menstruation may 
 assist us in the diagnosis. 
 
 The author's rule is, never to allow a woman to go more than two 
 weeks beyond the calculated date of confinement, without frequent, 
 careful comparison of the size of the fetus with that of the pelvic canal; 
 and if the child is apparently a little large for the pelvic canal, to consider 
 that an indication for the induction of labor. 
 
 In a woman whose menstruation has been previously regular and who 
 has not been separated from her husband, three weeks may be considered 
 the limit beyond which it is not wise to allow a prolonged pregnancy to 
 continue. 
 
 In all cases of overgrowth of the child the only safe management 
 consists in frequent palpation of the child's head and its comparison 
 with the pelvic brim and the consideration of a justified suspicion of 
 disproportion as an indication for induction of labor. 
 
 Some women have, as a rule, unusually large children or children w^ith 
 prematurely ossified heads, and hence in spite of normal pelves have 
 more or less dystocia. This may be impossible to determine in the first 
 pregnancy, but experience gained in the first labor is often of the greatest 
 value in subsequent pregnancies, and should lead to the most careful 
 observation of the relative size of child and pelvis and the induction 
 of premature labor if found indicated by threatened disproportion. 
 
 If the disproportion from overgrowth of the child is first ascertained 
 in labor and through nature's inability to accomplish the delivery, the 
 obstetrician is often face to face with a serious problem. With a normal 
 pelvis one is loath to perform either Cesarean section or pubiotomy, 
 especially in the first labor; and if forceps or version fails, it may be too 
 late to perform one of the major operations with the low mortality which 
 it is recognized should belong to them. 
 
 Malformations of the Fetus. — Before taking up the individual fetal 
 malformations it will be found desirable to note carefully the following 
 etymological key, arranged by Dr. J. Clifton Edgar, of New York, 
 which the author has found of great value in explaining the nomen- 
 clature : 
 
 Etymological Key .—Prefixes : a- or an-, "absence of"; syn- or sym-, 
 "fusion" or "blending of two symmetrical structures"; mono-, "single" 
 "undivided"; di-, "two"; tri-, "three"; anti-, "opposed" or "oppo- 
 site"; tetra-, "four"; epi-, "above"; hypo-, "below"; ectro-, "abor- 
 tive", "defective," "rudimentary"; schisto-, "cleft"; micro-, "small"; 
 hemi-, "half." Suffixes: -pagus, "united," "connected"; -schistos, 
 "cleft." Parts of body: -cephalus, "head"; -cormus, "trunk"; -pygus, 
 "breech"; -melus, "limb" ("extremity"); -thorns, "chest"; -notos, 
 "back"; -prosopos, "face"; -crania, "skull"; -rachis, "spine"; -lecanus, 
 " pelvis" ; -ischio, "seat-bone"; -pus, "foot," "leg"; -brachius, "arm"; 
 -ophthalmos, -opos, "eye"; -otos, "ear". 
 
 Only the more common fetal malformations and those likely to cause 
 d^'stocia will be considered in this w^ork. 
 
roo 
 
 ABNORMAL LABOR FROM ANOMALIES OF THE FETUS 
 
 Hydrocephalus. — Tliis is one of the commonest forms of fetal malforma- 
 tion causing dystocia. At the Sloane Hospital for Women, in 20,000 
 labors there were 14 cases of hydrocephalus. 
 
 In hydrocephalus the cerebral A'entricles are distended with fluid 
 and the whole head more or -less enlarged (see Fig. 411). In well-marked 
 cases the cranial bones are imperfectly developed, are thin, pliable and 
 separated by wide sutures and large fontanelles. As the fluid increases 
 in the ventricles the brain substance becomes thinned and crowded 
 toward the cranium initil it becomes onh' a sac containing the cerebral 
 fluid. 
 
 Fig. 411. — Frozen section of hydrocephalic head: .4, inner wall of right ventricle and 
 falx cerebri; B, choroid plexus; C, cerebellum; D, dilated left ventricle; E, optic tract; F, 
 frontal lobe. 
 
 While as a factor in causing dystocia only antepartum hydrocephalus 
 is considered, still it may be mentioned that one of the disappointments 
 of the obstetrician is to meet with the gradual development of a hydro- 
 cephalus in a child which at birth showed no evidence of the condition 
 save perhaps the fact that it was not strong and well developed. In 
 the author's experience this has occurred most frequently in premature 
 babies and has appeared within the first two or three weeks after birth. 
 
 Diagnosis. — Unless the fetal head is very much enlarged so that 
 fluctuation and perhaps a peculiar crackling sensation of the fetal skull 
 can be detected on palpation of the woman's abdomen, the diagnosis is 
 
ABNORMAL LABOR FROM ANOMALIES OF THE FETUS 701 
 
 usually not made until after several hours of strong, second-stage pains, 
 with a normal pelvis and vertex presentation, it is found that the present- 
 ing part does not advance. If the presentation is a breech, the diagnosis 
 is usually not made until it is found that there is an obstacle to the extrac- 
 tion of the after-coming head. In both these instances careful palpation, 
 with the hand inserted into the vagina if necessary, will usually detect 
 the large head, the thin pliable bones, the large fontanelles and broad 
 sutures. Certain possible errors of diagnosis are worthy of mention. 
 
 In the first place the hydrocephalus may be in its early stages, the 
 ventricles may be full and somewhat distended, but the fetal head instead 
 of being markedly enlarged, with thin bones, broad sutures and large 
 fontanelles, may be but little enlarged, yet on account of the distended 
 tense ventricles, may be almost incompressible. Such a fetal head is 
 easily confused with an ordinary large head or a prematurely ossified 
 head. 
 
 Another condition may lead one into error: The head may lie high in 
 the pelvis and a parietal bone present in such a way that no sutures or 
 fontanelles can be felt without inserting the hand into the vagina. 
 
 On account of the difficulty in many cases in detecting a slight lumbar 
 obstruction to the entrance of the head into the pelvic brim, the lack 
 of engagement, when no sutures or fontanelles are palpable, may easily 
 be assigned to a lumbar obstruction requiring Cesarean section. It 
 is not well to make a vaginal examination with the whole hand upon 
 cases to be subjected to Cesarean section on account of the added risk 
 of infection, hence the one criterion of hydrocephalus which would 
 determine the condition is omitted. The author once fell into this error 
 and was chagrined to deliver by Cesarean section a hydrocephalic child. 
 
 In very rare cases the sutures and fontanelles are so widened and 
 enlarged that under the pressure of very severe uterine contractions a 
 rupture of one of the sutures or fontanelles may occur with an escape 
 of the intra-cranial fluid and a collapse of the fetal head, followed by a 
 spontaneous delivery. This is so extremely rare during any duration 
 of the second stage, which is safe for the mother, that it is never to be 
 expected. 
 
 Prognosis. — The maternal prognosis of fetal hydrocephalus depends 
 chiefly upon the care received by the mother. An early recognition of 
 the condition by the obstetrician and an early reduction in the size of the 
 fetal head usually saves the mother from danger. On the other hand, 
 the neglect of a woman in labor with a hydrocephalic fetus exposes her 
 to the risk of ruptured uterus, and repeated trials of delivery by forceps, 
 with the tendency of the blades to slip, exposes her to the risks of exten- 
 sive lacerations and subsequent infection. The fetal prognosis is abso- 
 lutely bad, and fortunate it is for all concerned if fetal life ceases at birth 
 rather than continues to become a hopeless imbecile. 
 
 Treatment. — It may be said that the most important factor in the 
 treatment of hydrocephalus is the diagnosis. As soon as the diagnosis 
 is positively made, the life of the child may be disregarded, for even if 
 it is born alive, its life is usually very short, and it is a comfort neither 
 
702 ABXORMAL LABOR FROM AXOMALIES OF THE FETUS 
 
 to its parents nor to tlu-ir friends. For these reasons the mother's welfare 
 should alone he considered. This usually demands reduction in the size 
 of the fetal head. An exception to this rule may ohtain in the instance 
 where, for the descent of jjroperty or the fulfillment of other conditions, 
 
 it is very imj)ortant that a livinoj child 
 should be born, even if it lives only 
 for a few moments. 
 
 The ordinary active treatment, a.s 
 has been indicated consists in the 
 reduction in size of the fetal head. 
 This is accomplished by perforation 
 through one of the sutures or fonta- 
 nelles. This perforation may be done 
 both in breech and in vertex presen- 
 tations with a strong pair of sharp- 
 ]jointed scisst)rs. However, in vertex 
 cases especially, it is best done by 
 such an instrument as the perfor- 
 ator of the Tarnier basiotribe, to 
 which the crushing blades may be 
 a])])lied, and the delivery facilitated 
 by craniotomy if necessary. It is 
 important for the moral effect upon 
 the parents and friends that the 
 child whose head has been perforated 
 should not be born alive, hence it is 
 desirable that the perforator should 
 be passed to the medulla and moved 
 about freely. As a rule there is 
 little difficulty in reaching the head 
 sufficiently to perforate, but if in a 
 breech presentation this is found to 
 be extremely difficult, the method 
 of puncturing the spinal canal and 
 passing a catheter along it into the 
 cranial cavity, as recommended by 
 Van Huevel, may be followed. 
 
 Anencephalous Monster. — In contra- 
 distinction to hydrocephalus, with 
 its large fetal head, there may occur a monster lacking a large part 
 of the brain sulxstance and skull and presenting a small head which is 
 mostly face. It is seen by a glance at Fig. 412 that the head in this 
 condition is not likely to cause dystocia, but often these cases have large 
 trunks and the delivery of the shoulders is not infrequently difficult. 
 
 Diagnosis. — The \aginal feel of an anencephalous monster with a 
 cephalic presentation is often at first confusing. However, the pro- 
 trusion of the eye-balls and perhaps of the tongue, when the presentation 
 is a face, which it commonly is, and the absence of the cranial xault and 
 
 Fig. 412. — -Anencephalous monster. 
 
Xiphopagus. (Hirst and Piersol.) 
 
ABXORMAL LABOR FROM AXOMALIES OF THE FETUS 703 
 
 the feeling of the sella turcica Avhen the presentation is a vertex, will 
 often enable the correct diagnosis to be made. 
 
 Prognosis. — ^The maternal prognosis usually differs but little from^ that 
 of a normal labor if the patient is in the hands of a skilled obstetrician, 
 as the dystocia is usually not marked. 
 
 The fetal prognosis is fortunately absolutely bad and the child, if born 
 alive, usually dies within a few moments. Twice in the author's experience 
 one of these monsters has lived for about a day. 
 
 Treatment— If artificial delivery of an anencephalic monster is indi- 
 cated, a version with breech extraction is the best procedure, provided 
 
 Fig. 413. — Pygopagus. 
 
 version is not contra-mdicated by a tonic condition of the uterus. The 
 after-coming head naturally presents little difficulty. 
 
 If marked dystocia arises from the breadth of the shoulders, it can be 
 overcome by section of one of the clavicles. As a rule, however, the 
 delivery of an anencephalic monster either occurs spontaneously or can 
 be terminated by a version and breech extraction. 
 
 Double Monsters. — ^^Yhile great varieties of duplication are found in 
 different monsters, for practical purposes three classes of double monsters 
 may be distinguished. 
 
704 ABNORMAL LABOR FROM ANOMALIES OF THE FETUS 
 
 1. Monsters with separate bodies joined loosely by the front or back 
 
 of trunk, xiphopagus (see Plate XI) or pygopagus (see Fig. 413). 
 
 The Siamese twins were an example of xiphopagus, and the Hungarian 
 sisters of pygopagus. 
 
 2, Monsters with duplication of upper part of bod^• — dicephahis (see 
 Plate XII). 
 
 Fig. 414. — Tetrapus. 
 
 3. Monsters with duplication of lower part of bodv — tetrapus (see 
 Fig. 414). 
 
 Diagnosis. — Although multiple pregnancy is often suspected,, the diag- 
 nosis of a double monster is usually not made until the hand is intro- 
 duced to ascertain the cause of the protracted labor. 
 
PLATE XII 
 
 Dieephalie Monster. 
 
 Photograph presented to the author by Drs. Hupp and Quimby. 
 
ABNORMAL LABOR FROM ANOMALIES OF THE FETUS 705 
 
 Mechanism. — It can hardly be said there is a regular definite mechanism 
 in the delivery of double monsters, but the principle which seems to 
 guide nature in accomplishing the desired result is worthy of great 
 admiration. By advancing first a part of one duplicate and then a part 
 of the other, by the molding of each, and the fitting of one into the 
 other, spontaneous delivery is often accomplished in a wonderful way. 
 
 Fortunately premature labor is common in these conditions, hence 
 each half of the double monster is apt to be smaller than in a full-term, 
 single pregnancy. Nature can often be assisted in her task of delivery, 
 by pushing up one part and allowing the other to advance. In double- 
 headed monsters this method is often of value. It occasionally happens, 
 however, that the advance of one head is blocked by the impaction of 
 the other, and in such a case, craniotomy or amputation of the first head 
 is the procedure of choice. The monster can then usually be delivered 
 by forceps or version. 
 
 Dystocia from Enlargement of the Fetal Body. — Occasionally the 
 fetal abdomen is found of such a size that natural delivery is impos- 
 sible. This abdominal enlargement is usually the result of one or more 
 of the following conditions: Ascites; tumors of the kidneys or liver; a 
 markedly distended bladder. 
 
 Occasionally, as a result of obstruction of the circulation through the 
 fetal liver, the abdomen becomes immensely distended with ascitic fluid, 
 making delivery impossible without first tapping and drawing off the 
 fluid. At times associated with this condition, or independent of it, 
 there occurs an obstruction of the superficial lymphatics of the body 
 causing a marked edema of the subcutaneous tissue of the fetus with 
 great enlargement of its trunk. 
 
 One of the most common causes of abdominal enlargement causing 
 dystocia of fetal origin is a congenital cyst of one or both kidneys. These 
 cysts often grow rapidly and to an immense size, often making the 
 abdomen the largest part of the fetus and naturally causing marked 
 dystocia. 
 
 Tumors of the liver and other viscera are occasionally found as the 
 cause of the abdominal enlargement causing dystocia of fetal origin. 
 
 In the case of atresia of the lower urinary tract, the fetal bladder may 
 become so distended as to fill and distend the whole abdomen. 
 
 Diagnosis. — As a rule the diagnosis of dystocia arising from conditions 
 of the fetal abdomen or trunk is not made until after the birth of the 
 head. Delay then naturally leads to investigation, even the introduction 
 of the hand into the uterus, and the true cause of the dystocia is found. 
 In the treatment of the condition the life of the fetus receives but little 
 consideration, as the condition is usually incompatible with the future 
 health of the fetus, and the usual indication is to open the abdomen of 
 the child and reduce its bulk so as to aflow delivery through the natural 
 passages. 
 
 External Tumors of the Fetus. — Aside from tumors of the abdomen 
 mentioned above, certain external tumors of the fetus occasionally 
 occur and give rise to dystocia, or at any rate to confusion in diagnosis. 
 45 
 
70G ABNORMAL LABOR FROM ANOMALIES OF THE FETUS 
 
 Exani])les of these are a myxoma, or a lym])liaii^ioma of the neck 
 preventing flexion; a teratoma of the sacrum, an encephalocele, or an 
 
 Fig. 415. — Case of hydrencephaloccle. (Microcophalus.) 
 
 hydrencephalocele (see Fig. 415 and Plate XIII) or a meningocele 
 (see Fig. 416). 
 
 In many of these fetal tumors, if dystocia is present, it is often over- 
 come by following the principle of nature in the delivery of double 
 monsters, /. c, the propulsion of first one part and then another. Bear- 
 
 FiG. 41G. — Spina l)ifitla. Meningocele. 
 
 ing this in mind, the obstetrician may push U]) the obstructing object, 
 and thus facilitate deliverv. 
 
X 
 
 < 
 
 Oh 
 
 o 
 
 
 
 ft 
 
 o 
 
 fl 
 
 0) 
 
 >. 
 
 I 
 
 m 
 
 ft 
 
 o 
 
 
 o 
 
DYSTOCIA ARISIXG FROM PRESEXTATIOXS OF THE FETUS 707 
 
 Cases of encephalocele rarely give rise to dystocia, as they are situated 
 chiefly in the occipital or frontal regions, usually the former, and are 
 expelled either before or after the head. Moreover, the cranial bones 
 about the opening are usually softer and more yielding than normal. 
 The case, of which Figs. 415 and Plate XIII are drawings, occurred in 
 the author's service at the Sloane Hospital and was delivered easily. 
 
 The case of meningocele, of which Fig. 416 is a photograph of the 
 specimen, was seen by the author in consultation with Dr. Brooks, of 
 Greenwich, Conn., and presented an interesting complication. The 
 child was normally delivered, but during the birth the large meningeal 
 sac was ruptured and bled quite profusely. The author excised the sac 
 and approximated the muscles over the lumbar opening. The child 
 made a good recovery and is now fourteen years old and in good health 
 save for a slight lack of control over bladder and bowel. 
 
 Fig. 417. — Transverse or shoulder presentation. (Bumm.) 
 
 DYSTOCIA ARISING FROM ABNORMAL PRESENTATIONS OF 
 
 THE FETUS. 
 
 Transverse Presentations. — In these presentations the long axis of 
 the fetus, instead of corresponding with that of the mother, crosses it at 
 an angle which approaches a right angle (see Fig. 417). Under the 
 term transverse presentation are included presentations of any portion 
 of the fetal trunk, but as all transverse presentations usually change to 
 a shoulder presentation as labor advances, a transverse presentation is 
 often called a shoulder -preseniation. 
 
 Varieties. — Transverse presentations are classified according to the 
 positions of the fetal back and head. Thus the fetal back may be anterior 
 
708 ABNORMAL LABOR FROM ANOMALIES OF THE FETUS 
 
 or posterior and the fetal head may lie to the left or to the right, hence 
 four positions of a transverse presentation are possible: 
 Left dorso-anterior 
 
 Left dorsoposterior 
 
 with head to the left. 
 
 Right dorso-antenor ] -,1,1, i j. ^u • u^. 
 T-> . 1 , 1 ^ . > with head to the right. 
 
 Right dorsoposterior j 
 
 Frequency. — Li a series of 20,000 consecutive deliveries at the Sloane 
 Hospital there were 181 cases of transverse presentation. Li other words, 
 transverse presentations occurred once in every 111 cases. As to the 
 frequency of the different positions, dorso-anterior positions were much 
 more frequent than dorsoposterior, and the fetal head was found more 
 frequently on the right side than on the left. Thus, of the 181 cases of 
 this series, 123 were dorso-anterior while only 50 were dorsoposterior. 
 In 102 the head was on the right and in 71 on the left side of the mother. 
 In 8 cases the position of the child was not specified in the history. 
 
 Etiology. — The etiological factors leading to a transverse presentation 
 may usually be grouped under three heads: 
 
 1. Abnormal Mohility of Fetus. — ^This is seen in multigravidje with 
 lax uterine and abdominal walls. In the author's series of 181 cases, 
 there were 144 multigravidse and only 37 primigravidse. 
 
 Ilydramnios with excessive mobility of the fetus favors transverse 
 presentations. 
 
 Prematurity with a small, freely movable fetus is often associated with 
 a transverse presentation. In the above series of 181 cases 87 cases were 
 premature. 
 
 2. Disproportion between Presenting Part and Parturient Canal, or 
 Conditions Preventing Cephalic or Pelvic Engagement. — This is especially 
 seen in cases of deformed pelvis, monstrosities, placenta previa, etc. 
 In the author's series of 181 transverse presentations there were 48 cases 
 of deformed pelvis. 
 
 3. Abnormalities in the Position and Shape of the Uterus. — Examples 
 of these are seen in cases of pendulous abdomen, uterus bicornis, and in 
 uteri deformed by fibromyomata. 
 
 Diagnosis. — The diagnosis can often be made by inspection of the 
 woman's abdomen and can easily be determined by abdominal and 
 vaginal palpation. 
 
 On inspection the longest diameter of the uterus is seen to be the 
 transverse. 
 
 On abdominal palpation the fetal head is found in one flank and the 
 breech in the other. 
 
 On vaginal examination the first thing noticed is usually the absence 
 of the head, and it may be possible to detect the spine of the scapula, 
 or the clavicle and in some cases the ribs. 
 
 If the membranes are ruptured and the arm prolapsed the diagnosis 
 is usually easy, although the differential points between the hand and 
 foot, mentioned on page 297 may be of value. 
 
 Prognosis. — As the termination of a transverse presentation by natural 
 labor is extremely rare, the prognosis for both mother and child depends 
 
DYSTOCIA ARISING FROM PRESENTATIONS OF THE FETUS 
 
 109 
 
 largely upon the treatment adopted. If the diagnosis is made and the 
 position corrected early the prognosis is good. The longer the case 
 goes untreated, the worse the prognosis. 
 
 Mechanism.— As a rule no mechanism of labor in a transverse presen- 
 tation is to be expected. 
 
 As contractions of the uterus occur, the usual result, in a case untreated, 
 is an impaction of the shoulder, with a marked dilatation of the lower 
 uterine segment; a retraction of the upper uterine segment; death of 
 the fetus from long pressure; perhaps death of the ipother from rupture 
 of the uterus, or exhaustion and sepsis. There are two possible ways in 
 which nature in rare cases succeed in delivering the child unaided: 
 (a) Spontaneous version. 
 (6) Spontaneous evolution. 
 
 Spontaneous Version. — Occasionally under the influence of the first 
 few pains of labor, a transverse presentation, which has persisted for a 
 
 Fig. 418. — Spontaneous evolution. (Bumm.) 
 
 considerable time during pregnancy, will be converted into a longitudinal 
 presentation. This may be brought about by the uterine contractions 
 themselves and is more apt to occur in multigravidee with lax uterine and 
 abdominal walls, with plenty of room for the child to move, with cervix 
 undilated, membranes intact, shoulder not engaged, uterine contractions 
 strong and child alive. This process is called spontaneous version. 
 
 Syontaneons Evolution. — Under certain conditions, as in premature 
 labors \\dth a fetus small or macerated, with a pelvis of large size and 
 uterine contractions strong, nature sometimes succeeds in crowding 
 one part of the fetus past the other and delivering the child (see Fig. 
 418). Thus the breech may be crowded past the shoulder and delivered 
 ■first, the rest of the body following as in a breech presentation; or still 
 more rarely, with the shoulder leading, the fetus may be folded on itself 
 and expelled as one mass (see Fig. 419). These processes, called spon- 
 taneous evolution, are never to be expected with a full-term living child, 
 in fact spontaneous evolution almost never occurs save with a small, 
 dead child, a large pelvis, and strong uterine contractions. 
 
710 ABNORMAL LABOR FROM ANOMALIES OF THE FETUS 
 
 Treatment. — The treatment of a transverse presentation ma}- be 
 summed up in one word — version. 
 
 If the diagnosis is made })efore labor, external version should be tried. 
 As a rule external eei)halic version should be attempted, but if the 
 obstetrician does not succeed in causing the head to present, and the 
 breech is much nearer the pelvic inlet, he should be satisfied with an 
 
 Fig. 419. — Spontaneous evolution. (Bunim.) 
 
 external pelvic version. If the case is first seen after the membranes have 
 ruptured and the shoulder has presented, the treatment indicated is an 
 internal podalic version, unless version is contra-indicated by a tonic con- 
 dition of the uterus. Attention has already been directed to the danger 
 of version in a tonic uterus (see page 623), and this danger shonld be 
 emphasized here, as in the neglected transverse presentations with 
 shoulder impacted, the lower uterine segment is usually thinned and any 
 attempt at version is likely to be followed by a rupture of the uterus. 
 
DYSTOCIA ARISING FROM PRESENTATIONS OF THE FETUS 711 
 
 While version is the treatment indicated, if the case is seen soon after the 
 rupture of the membranes and before the uterus has become tonic, if 
 the case has been neglected, the shoulder has become impacted and the 
 child is dead or dying, decapitation is the operation of choice. Cesarean 
 section is usually contra-indicated in neglected transverse presentations, 
 both on account of the danger of infection and also for the reason that the 
 vitality of the child has, as a rule, already been reduced. It is often 
 necessary to completely anesthetize the woman before determining that 
 the uterus is too tonic to admit of a safe version. 
 
 Abnormalities of Breech Presentation. — Breech Extraction. — A breech 
 presentation may present abnormalities of mechanism leading to marked 
 dystocia. These abnormalities arise chiefly from the faulty position of 
 the legs or the arms. 
 
 Breech Presentation with Extended Legs or a "Frank Breech." — This 
 condition has already been described in the chapter on Mechanism of 
 Labor (page 247) (see Fig. 420) . Many cases of breech presentation with 
 extended legs, if the fetus is small and the pelvis large, will deliver them- 
 selves spontaneousl}'. On the other hand, if the fetus is large the exten- 
 sion of the legs may produce so great a wedge with the base formed by 
 the fetal trunk and legs that labor is unduly prolonged and perhaps 
 obstructed. In all such cases the indication is to break up the wedge by 
 pulling down one foot. As the longer this is delayed after the rupture of 
 the membranes, the harder the procedure becomes, it naturally follows 
 that the question as to whether in a frank breech presentation one foot 
 should be brought down early in the second stage is an important one. 
 The author's rule is to bring down a foot in every case of frank breech 
 presentation unless the patient is a multigravida with relatively small 
 fetus and plenty of room, or a primigravida with a small fetus. 
 
 Technic. — One of the first essentials in the technic of bringing down 
 a foot in a frank breech is sufficient dilatation of the cervix to allow 
 of the passage of the obstetrician's hand. Hence, if the cervix is not 
 already dilated, the dilatation should be increased manually until the 
 hand easily passes. The hand selected should be that whose palm corre- 
 sponds to the abdomen of the fetus as in a podalic version. Passing 
 the hand along the anterior thigh of the fetus until the popliteal space is 
 reached, pressure is made here forcing the knee away from the midline 
 of the fetal abdomen and toward the fetal back. This usually tends to 
 flex the leg so that the obstetrician's forefinger, or fore- and middle fingers 
 may easily be slipped over the knee and down the leg to the foot. The 
 foot is then brought down into the vagina, leaving the other leg extended 
 to serve with the fetal trunk as a good dilator of the parturient canal. 
 With a foot and leg of the fetus drawn down into the vagina the obstetri- 
 cian has in them the tractor needed in case nature is unable to continue 
 the expulsion of the fetus unaided. It must be borne in mind, however, 
 that in every breech delivery, whether it be that of a normal complete 
 breech, or the extraction after a podalic version, or the extraction of a 
 frank breech, it is desirable to have as much of the delivery as possible 
 brought about by uterine contractions aided by the downward pressure of 
 
712 ABNORMAL LABOR FROM ANOMALIES OF THE FETUS 
 
 an assistant or nurse upon the fundus. In other words, progress if possible 
 should come through downward pressure from above rather than through 
 downward traction from below. The pressure of an assistant or nurse 
 upon the fundus tends both to maintain flexion of the fetal head and 
 to prevent extension of the arms by the side of the head. In most cases 
 of frank breech presentation with the patient under anesthesia it is pos- 
 sible to gently introduce the hand into the uterus, seize a foot as described 
 above, and draw it down into the vagina, thus breaking up the wedge. 
 
 Fig. 420. — Frank breech presentation. 
 
 Some authors speak of the necessity of using the blunt hook or a fillet 
 in the fetal groin as a tractor for the imjjacted breech. Such has never 
 been the author's experience, as he has always been fortunate enough to 
 be able to deliver the breech by bringing down a foot and using that as a 
 tractor or else by insertion of his fingers in one or both fetal groins and 
 exerting traction there, aided by the pressure of an assistant upon the 
 uterine fundus. The author would be very loath to use a blunt hook 
 for this purpose on account of the danger to the soft parts of the fetus 
 and perhaps fracture. The danger of the slipping of the blunt hook and 
 
DYSTOCIA ARISING FROM PRESENTATIONS OF THE FETUS 713 
 
 injuring the soft parts of the mother should be borne in mind here as 
 well as in its use upon a dead child in the course of a craniotomy. The 
 fillet, although less dangerous than the blunt hook, can do considerable 
 damage to the soft parts. The author, in his more than twenty-five years 
 of obstetric experience, has never found it necessary to apply the forceps 
 to an impacted breech. He can imagine a condition in which this would 
 be justifiable, but he would prefer under these circumstances application 
 of the blades over the trochanters rather than the oblique application, 
 with one blade over the sacrum and one over the thigh, as recommended 
 by some. 
 
 Abnormalities from Position of the Arms. — The criterion of a successful 
 breech delivery often depends upon the position of the fetal arms. In a 
 complete breech presentation with normal mechanism, as already described 
 (page 297), the thighs and legs are flexed, bringing the feet near the 
 
 Fig. 421. — Breech delivery with extended arms. Reaching for bend of elbow. 
 
 buttocks and near the cervix; the arms are flexed and folded on the chest 
 so that soon after the birth of the navel the elbows come within easy 
 reach of the obstetrician so that the forearms can be extended and 
 delivered with little difficulty. 
 
 Two abnormalities in the position of the arms may greatly complicate 
 a breech delivery : 
 
 1. One or both arms may be extended by the side of the fetal head 
 (Fig. 421). 
 
 2. One arm may lie behind the fetal neck — the nuchal hitch, as it is 
 called (Fig. 423). 
 
 Etiology. — The most common cause of extension of the fetal arms is 
 traction on one or both legs of the fetus from below, as in a podalic ver- 
 sion or in a hastened breech extraction. This complication is especially 
 apt to occur if constant pressure is not exerted on the uterine fundus 
 and flexion of the fetal head maintained. This pressure from above 
 
714 
 
 ABXORMAL LABOR FROM AXOMALIES OF THE FETUS 
 
 tends to kvv\) tho iiorinal attitude of the fetus as far as head and arms are- 
 coneerned. The most common cause of the nuchal hitch is a rotation 
 of the fetal trunk c()nil)ined with traction from below. 
 
 Tri'dfiiicttf. — When considering the treatment of a hreech i)resentation 
 with extende(^l arms attention should lie directed to the yrophylaxis 
 and the importance in every breech delivery of having an assistant or 
 nurse exert firm downward pressure upon .the fundus uteri while the 
 obstetrician is exerting traction from below. The object of this fundal 
 pressure is to prevent the complication of extended arms. 
 
 Active Treatment. — If the fetus is of full size there is not room in an 
 average pelvis for the head to pass with the arms extended by its side, 
 and unless the complication can be relieved in about five minutes the 
 fetal life is usually lost. As the parts are more yielding posteriorly than 
 anteriorly, it is the posterior arm which is first sought and brought down 
 
 Fig. 422. — Breech delivery with extended arms. With finger in bend of elbow, making 
 arm sweep across face and down along chest. 
 
 (Fig. 421). Rotating the fetal body so that the posterior shoulder lies 
 in the hollow of the sacrum, the obstetrician's hand is passed along the 
 back of the fetus, over the shoulder and down the arm to the elbow. 
 Traction should not be exerted until the elbow is reached, as otherwise 
 the humerus is easily fractured. With a finger or fingers in the bend of 
 the fetal elbow the arm, as a rule, is easily made to sweep across the 
 face and down across the chest (Fig. 422). With one arm delivered the 
 fetal body is rotated so as to brmg the other arm posterior. The obstetri- 
 cian now changes the hand holding the feet of the fetus and with his free 
 hand passed up along the fetal back and over the shoulder to the bend 
 of the elbow he brings down the other arm. 
 
 Breech Delivery Complicated by a Nuchal Hitch. — The object desired 
 in this condition is first to get the arm which lies behind the fetal neck 
 to slide forward to the side of the head, when the same procedure as has 
 just been described for bringing down an arm may be employed. This 
 
DYSTOCIA ARISING FROM PRESENTATIONS OF THE FETUS 715 
 
 desired object is usually brought about by rotating the body and with 
 it the head of the fetus away from the side on which the obstructing 
 elbow lies. This tends to cause the fetal arm to slide to the side of the 
 
 Fig. 423. — Nuchal hitch; arm behind neck. 
 
 head. Thus in Fig. 423, if the fetal trunk was rotated from left to right 
 forward, the hand and forearm would slip along to the right side of the 
 head and then the obstetrician could deliver that arm as already described. 
 
 Fig. 424. — Mauriceau-Smellie-Veit method. 
 
 This rotation is facilitated by pushing the fetus up slightly before begin- 
 ning the rotation. The fetal head in these different complications of 
 breech presentation is usually best delivered by the Mauriceau-Smellie- 
 
716 ABNORMAL LABOR FROM ANOMALIES OF THE FETUS 
 
 Veit method (Fig. 424), as already described on page 305. With a warm, 
 wet towel over the lower part of the fetal trunk, the fetus lies on the 
 forearm of the obstetrician. Flexion is maintained by one or two fingers 
 in the mouth of the fetus while traction is exerted on the shoulders by 
 two fingers of the other hand on either side of the neck. By maintaining 
 flexion of the head the child's mouth, nose, eyes and forehead advance 
 over the perineum, the body of the child being raised and made to ap- 
 proach the abdomen of the mother. In cases of contracted conjugate or 
 of relati^•ely large head difficulty may be met with in extracting the fetal 
 head. This difficulty is still further increased if the cervix is not suffi- 
 ciently dilated and emphasizes the importance of making sure that the 
 cervix is well dilated before beginning the extraction. 
 
 If the conjugate of the pelvis is shortened, in other words, if the case 
 in hand is a simple flat pelvis, it will often be found of value to so rotate 
 the fetal body that the long diameter of the head as it enters the brim 
 lies transversely. It is also an advantage to crowd the occiput as near 
 the lateral wall of the pelvis as possible so as to have the bitemporal diam- 
 eter opposite the narrowest part of the brim. Furthermore, if marked 
 flexion of the head in this transverse position is brought about by the 
 fingers in the fetal mouth, the bitemporal diameter is made to enter the 
 brim before the biparietal which is larger. This gives the advantage of 
 the smaller end of the wedge which is of value. 
 
 It is not often that the forceps are needed in the delivery of the after- 
 coming head. Occasionally, however, they are of great assistance in 
 delivering the child within the required time. If needed they are applied 
 to the sides of the child's head along the occipitomental diameter, after 
 raising the child's body. When studying the mechanism of breech 
 presentation (see page 300), attention was called to the fact that occasion- 
 ally the occiput rotated to the hollow of the sacrum and that the head 
 could then be born by continued flexion or by extension. In the hands 
 of the skilled obstetrician these occipitoposterior positions are usually 
 rotated to occipito-anterior positions and delivered as such. Neglected 
 cases and cases associated with certain unusual deformities of the pelvis 
 may necessitate delivery of persistent occipitoposterior positions as such. 
 
 Compound Presentation. — A compound presentation is the presenta- 
 tion of two or more parts of the fetus at the same time, as for instance 
 the head and a hand; the breech and a hand; the head and a foot; a 
 transverse with two hands, or a transverse with a hand and a foot, etc. 
 
 Etiology. — A compound presentation is usually associated with some 
 disproportion between the presenting part and the pelvic brim, so that 
 the presenting part does not readily engage and leaves room at its side 
 for another fetal part to slip into the pelvis. This complication is there- 
 fore predisposed to by a contracted pelvis or by a head of abnormal 
 size; it is also predisposed to by a lack of conformity of the presenting 
 part to the brim of the pelvis, as in a malposition of the fetus; by a dis- 
 placed uterus; by multiple pregnancy, or by hydramnios. It is sometimes 
 brought about mechanically by an unsuccessful attempt at podalic ver- 
 sion in a transverse presentation with prolapsed arm, a foot being brought 
 
DYSTOCIA ARISIXG FROM PRESEXTATIOXS OF THE FETUS 717 
 
 down but. on account of the tonic condition of the uterus, tlie prolapsed 
 arm still remaining in the vagina. 
 
 Frequency. — In a series of 20,000 consecutive labors at the Sloane 
 Hospital there were 84 compound presentations, i. e., this complication 
 occurred on an average once in every 238 cases. It is more common in 
 multigravidse than in primigravidse, as shown from the fact that among 
 the 84 cases there were 54 multigravidte and only 30 primigravidte ; 43 
 of the 84 cases went into labor prematureh". 
 
 The frequency of the different varieties of compound presentation is 
 of interest. In the above series of 84 cases the following frequency' of 
 combination was noted: 
 
 Head with hand in 48 cases. 
 
 Breech with hand in 13 cases. 
 
 Head with foot in 10 cases. 
 
 Compound transverse^ in 7 cases. 
 
 Head with hand and foot in 6 cases. 
 Treatment. — If the diagnosis is made before rupture of the membranes 
 some authorities recommend placing the woman on the side opposite to 
 that of the prolapsed extremity in the hope that the prolapsed extremity 
 will be withdra^^Ti. Thus, if the right hand lies by the side of the present- 
 ing head, place the woman on her left side. The author is free to admit 
 that he has never been able to accomplish much by this treatment by 
 posture. The general principle of treatment which he has found most 
 useful in his experience has been first to endeavor to push up out of the 
 way the undesired part and then to favor the descent of the mam pre- 
 senting part. Failing either in replacing or in keeping replaced the 
 undesired part he has generally considered version indicated unless the 
 procedure has been contra-indicated by the tonic condition of the uterus 
 or the firm engagement of the presenting parts. Often if the head pre- 
 sents together with one or more extremities and the head is engaged, 
 the best procedure is the application of the forceps to the head, being 
 careful not to include the prolapsed extremity in the grasp of the 
 instrument, and delivery without regard to the prolapsed extremity or 
 extremities. The methods of treatment followed in the author's series 
 of 84 cases are of interest as showing the variety of indications and 
 their results: 26 cases were delivered icithout a version and of these 18 
 were delivered spontaneously, 3 by breech extraction, 3 by forceps, 1 
 by craniotomy and 1 by Cesarean section. Fifty-eight were delivered hy 
 a version more or less complete. After the ^'ersion 38 of these cases 
 delivered themselves normally, 18 were delivered by breech extraction 
 and 2 by the forceps. In 32 cases the version was only partial, consisting 
 of little more than the reposition of the prolapsed extremity. 
 
 Mortality. — ^The maternal mortality in this series of 84 cases was 2.3 
 per cent. ; 1 mother being lost from toxemia of pregnancy and 1 from a 
 rupture of the uterus. The fetal mortality among those A'iable at the time 
 of delivery was 18.9 per cent. 
 
 1 A transverse vrith a prolapsed hand is not considered a compound presentation at the 
 Sloane Hospital, but a transverse with two hands or a hand and a foot is so considered. 
 
CHAPTER XXII. 
 PROLAPSE OF THE UMBILICAL CORD. 
 
 TiiK descent of the umbilical cord into the pelvis in ad\ance of the 
 presentinjj part is called a prolai)se of the cord. If diaj2;n()sed ])efore 
 rupture of the membranes it is sometimes spoken of as presentation of 
 the cord. 
 
 Frequency. — Different observers have stated the frequency of prolapse 
 of the cord with very marked differences varying from 1 in 65 to 1 in 
 1897 cases. 
 
 In 20,000 consecuti\-e deliveries at the Sloane Hospital prolapse of 
 the cord occurred in 269, a frequency of 1 in 74 cases, or L3 per cent. 
 It is therefore approximately correct to consider the frequency about 
 1 per cent. 
 
 Etiology. — The chief cause of prolapse of the cord is some lack of 
 adaptation of the presenting part to the inlet of the pelvis. With the 
 normal adaptation of the presenting part to the lower uterine segment 
 and the brim of the pelvis there is no room for a loop of cord to descend 
 in front of it. In a malpresentation, however, as in a transverse presen- 
 tation, or in a deformed pelvis with pelvic inlet too small to allow the 
 entrance of a normal-sized head, the presenting part does not fit the 
 brim and there is room for a loop of cord to descend. With this etio- 
 logical principle understood, it is easy to note associated causes. Thus, 
 }3rolapse of the cord is favored by marked displacements of the uterus; 
 deformities of the uterus as by fibromyomata; hydramnios in which a 
 sudden, profuse gush of liquor amnii, especially if the membranes rup- 
 tured in the sitting or erect position, might wash down a loop of cord; 
 an abnormally long cord; a low insertion of the cord as in placenta 
 previa; multiparity; multiple pregnancy and prematurity. 
 
 The effect of some of these causes may be seen in the author's series 
 at the Sloane Hospital. In the 269 cases, 184 were multigravidse and 
 only 85 primigravidse. There were 91 premature deliveries. 
 
 In the 269 cases there were 16(5 whose presentation was not with 
 occiput anterior. There were 67 with deformed pehis and 67 with abnor- 
 mality of the cord or placenta. 
 
 Diagnosis. — If the fetus is alive the diagnosis of a prolapsed cord either 
 before or after rupture of the membranes is usually easy for a careful 
 observer: its cord-like shape; its ])ulsati()n; its characteristic twist, all 
 make clear the condition. It should be remembered, h()we\er, that the 
 the cord may either present as a loop with the two limbs in apposition or 
 it may stretch across the cervical canal ))eneath the ])resenting ])art which 
 '(718) 
 
PROLAPSE OF THE UMBILICAL CORD 719 
 
 lies between the limbs of the loop. The prolapsed cord may- even lie 
 outside the vulva and still be pulsating. 
 
 After pulsation in the cord has ceased, diagnosis of its prolapse may 
 present difficulties to the beginner. The author was once called to a 
 suburb of New York to operate upon a supposed rupture of the uterus 
 with prolapse of the intestine through the rent and cervix. On examining 
 the case he found a prolapsed cord of a dead fetus. The absence of 
 mesentery as well as the characteristics of the cord made the diagnosis 
 clear. It is possible on superficial examination to mistake for a prolapsed 
 cord of a dead fetus, part of a foot or a hand in the vagina, the edematous 
 lip of a lacerated cervix, etc. The reverse of this is also true. 
 
 Prognosis. — ^The maternal mortality depends upon the abnormality 
 associated with the prolapse of the cord and upon the operation to which 
 the patient is subjected in the attempt to save the life of the fetus. The 
 mere existence of a prolapsed cord, although subjecting the fetus to 
 grave danger, would, with a normal-sized fetus and pelvis, ordinarily 
 cause little danger to the mother if left alone, although in rare cases the 
 prolapse of the cord might so shorten it as to cause a premature separation 
 of the placenta. 
 
 In the series of 269 cases at the Sloane Hospital there were 11 maternal 
 deaths, a mortality of 4 per cent. Of the 11 cases, 5 died of the toxemia 
 of pregnancy; 3 from sepsis; 1 from ruptured uterus; 1 from placenta 
 previa and 1 from abdominal operation for complicating ovarian cyst. 
 It should be remembered that many of these were neglected cases and 
 that in 85, or nearly one-third, there was no pulsation in the cord when 
 first seen. 
 
 The fetal mortality from prolapse of the cord is always high from 
 asphyxia due to the compression of the cord between the pelvis and the 
 presenting part. It is usually over 50 per cent. 
 
 As the fetal head is much harder and more closely fills the pelvic canal 
 than does the breech, the fetal mortality from prolapse of the cord with 
 a vertex presentation is about twice as high as with a breech presen- 
 tation. 
 
 In the above series of 269 cases the fetal mortality was 157, or 58.3 
 per cent., although as said above, in 85 no pulsation could be detected 
 when first seen at the hospital. Of the 157 fetuses, 29 were premature 
 and might be considered abortions. Ninety-seven were stillbirths and 
 31 died subsequently. 
 
 Treatment. — In the treatment of prolapse of the cord, prophylaxis 
 deserves first consideration. Remembering that in malpresentations, 
 deformed pelves and in hydramnios, prolapse of the cord is common, 
 great care should be taken that these cases are not in sitting or 
 standing positions when the membranes are likely to rupture, and that 
 if possible the membranes should be kept intact until the cervix is well 
 dilated. 
 
 Furthermore, as the prognosis is worse the longer the prolapse exists, 
 in all cases, as soon as the membranes rupture, an examination should 
 be made to ascertain the presence or absence of the prolapse. 
 
720 PROLAPSE OF THE UMBILICAL CORD 
 
 If the prolapse has actually occurred there are two indications in its 
 treatment : 
 
 1. To replace the cord. 
 
 2. To maintain the reposition. 
 
 For the reposition the best plan is usually to place the woman in the 
 knee-chest position under anesthesia (some prefer the Trendelenburg 
 position) and then with the whole hand in the vagina and as many fingers 
 in the cervical canal as will pass, to carry up the prolapsed cord on the 
 tips of the fingers with as little compression as possible and place it 
 above some projecting portion of the presenting part if it is a vertex and 
 then withdraw the hand gently. If the cervix is not sufficiently dilated 
 for this procedure and the membranes are unruptured, they should be 
 kept intact if possible until the cervix is dilated, and for this purpose the 
 introduction of the Voorhees elastic bag answers well. 
 
 During all procedures for the reposition of a prolapsed cord and the 
 maintaining of it in the correct position, the woman should be kept as 
 much as possible with elevated hips. While she can be kept for a short 
 time in the knee-chest position, this soon becomes very tiresome, and the 
 Trendelenburg posture, or the exaggerated lateral prone position, with 
 the woman on the side corresponding with the fetal back and with a 
 pillow beneath her hips, may be substituted. 
 
 With the cervix dilated and the cord replaced manually it is often 
 well in a vertex presentation to rupture the membranes and secure the 
 engagement of the head by pressure from above or by the use of the 
 forceps. 
 
 With the rupture of the membranes, if the cord remains replaced and 
 the head descends, the delivery may be left to nature or expedited with 
 the forceps, depending upon the condition of the fetal heart which should 
 be auscultated every few moments. If in a vertex presentation with the 
 rupture of the membranes the prolapse recurs, or if the membranes are 
 ruptured when the case is first seen, and it is impossible to replace 
 the cord and maintain the reposition, the best procedure is usually to 
 dilate the cervix manually if necessary and perform a podalic version, 
 provided version is not contra-indicated by a tonic uterus. If version 
 is contra-indicated, the cord should be placed where its compression 
 is likely to be least, as opposite one of the sacro-iliac joints, and then 
 the child deli\'ered by the forceps as rapidly as is consistent with the 
 safety of the mother. 
 
 If the presentation which is complicated by a prolapse of the cord is 
 a breech and the cervix is well dilated the indication is to pull doAvn one 
 foot and hasten the extraction. If the cervix is not well dilated, a large- 
 sized elastic bag should be introduced so that when this passes the cervix 
 the labor can easily be terminated rapidly. In this case as in a vertex 
 presentation the fetal heart should be auscultated frequently, as this 
 alone gives the criterion of the fetal condition, which serves as a guide 
 to treatment. 
 
 If the fetal heart has ceased to pulsate, the method of delivery should 
 be selected which will expose the mother to the least risk, either leaving 
 
PROLAPSE OF THE UMBILICAL CORD 
 
 721 
 
 the case to nature or expediting by forceps or version. It is seldom 
 that any other instrument than the hand is needed for the reposition of 
 a prolapsed cord. If such an instrument is needed, one of the best can 
 be improvised by running a loop of tape through a gum elastic catheter 
 (see Fig. 425). The loop of tape emerging from the eye of the catheter 
 
 Fig. 425 
 
 Fig. 426 
 
 Fig. 427 
 
 can be passed around the loop of cord and then hooked over the end of 
 the catheter. So long as the catheter is passed in the upward direction 
 (see Fig. 426) the tape carries the loop of cord. When the catheter is 
 drawai downward the tape slips off the end and the umbilical cord is 
 released (see Fig. 427). 
 
 46 
 
PART y. 
 OBSTETRIC SURGERY. 
 
 CHAPTER XXIII. 
 INJURIES TO THE PARTURIENT CANAL. 
 
 Laceration of the Cervix. — Slight lacerations of the cervix are common 
 accompaniments of a first labor, even of one called normal, but these 
 slight lacerations usually heal readily if cleanliness is observed, and only 
 leave small cicatrices which usually distinguish the parous women from 
 the nullipara. The slight lacerations may be unilateral, bilateral or 
 stellate, thus superficially dividing the ring of cervix about the external 
 OS. The result may be a slightly patulous condition of the cervical 
 opening, but unless infection has occurred the slight lacerations are 
 unimportant and require no treatment. 
 
 Extensive lacerations of the cervix, on the other hand, may be of marked 
 importance, both at the time of delivery and subsequently. These 
 lacerations, like the slight ones just described, may be unilateral, bilateral 
 or stellate, and in rare cases may even be transverse. Cases are reported 
 by Boudereau, Edgar and others in which the cervix has been com- 
 pletely torn off from the rest of the uterus. 
 
 The deep lacerations are usually longitudinal and either unilateral 
 or bilateral. The longitudinal lacerations may extend upward and 
 become a part of a rupture of the lower uterine segment, or even open 
 the peritoneal cavity. It may extend downward and involve the vagina, 
 perhaps opening the rectum. 
 
 Etiology. — Laceration is predisposed to by an abnormal rigidit}' of the 
 cervix; a disproportion between the presenting part and the parturient 
 canal; a premature rupture of the membranes and a rapid artificial 
 delivery. 
 
 The long, narrow, rigid cervix of the poorly developed uterus dilates 
 slowly and often tears in spontaneous labors and is usually torn if, as 
 so frequently happens, the woman has to be delivered by the forceps. It 
 is this very rigid cervix, especially in elderly primigravidse, which has 
 usually furnished the cases of circular detachment of the cervix from the 
 rest of the uterus. As a rule in precipitate labors the cervix dilates easily 
 and rapidly; in fact, may have been partially dilated for several weeks 
 prior to the onset of labor, and in these cases laceration is unusual. 
 
 (723) 
 
724 INJURIES TO THE PARTURIENT CANAL 
 
 It is in tlie tedious labors, especially with premature rupture of the 
 membranes where the cervix becomes edematous, that laceration is 
 common. 
 
 It, moreover, is especially common where the labor has to be terminated 
 artificially, as by a difficult forceps operation or a version. 
 
 The operation of accouchement force is usually associated with more 
 or less laceration, and if the cervix is long and rigid the tearing is often 
 deep. When the head is delivered either in the course of a version or 
 a forceps delivery the laceration is apt to be deepened. 
 
 Symptoms and Diagnosis.— In the majority of cases there are no symp- 
 toms during the puerj)erium from laceration of the cervix and the diag- 
 nosis is made by the vaginal examination at the end of the obstetric 
 month which detects the irregular shape of the cervix. There may, how- 
 ever, be one pronounced symptom of the laceration immediately after 
 the birth of the child, and continuing after the expulsion of the placenta, 
 and that is hemorrhage. 
 
 As a rule the pressure of the presenting part prevents bleeding until 
 after the child is born and then it must be distinguished from ordinary 
 postpartum hemorrhage with relaxed fundus. 
 
 The condition of the fundus is the usual criterion. Hemorrhage, 
 associated with a firm, well-contracted fundus, usually means laceration 
 of the parturient canal, and the site is determined by inspection. If no 
 bleeding is seen to come from the perineum, lower vagina or anterior 
 portion of the vulva, the cervix can be pulled down with a vulsella and 
 inspected as shown in Fig. 428. 
 
 Treatment. — The question of immediate repair of a lacerated cervix 
 has during the last few years been the subject of much discussion. 
 Obstetricians are pretty well agreed that save for the one indication — 
 hemorrhage — a lacerated cervix had better not be repaired immediately 
 after labor. 
 
 The reasons for this conclusion are numerous. In the first i)lace, if 
 the delivery has been conducted in an aseptic manner, many of the 
 lacerations will heal in such a way as to be the cause of no further trouble. 
 
 Furthermore, the condition of the parts immediately after labor is a 
 poor one for repair. The parts are edematous and the landmarks more 
 or less obscured. It is difficult to tell how small to make the os, and 
 because of these difficulties, in many cases the cervix has been closed 
 too tightly, the retention of the lochia has occurred and sepsis has 
 resulted. 
 
 It may be asked, so long as it is always recommended to rei)air a 
 laceration of the perineum immediately. Why should not a laceration of 
 the cervix be repaired at once? The conditions are different in the two 
 cases and the differences depend chiefly upon two things — drainage 
 and the amount of handling. The ordinary repair of a lacerated i)eri- 
 neum interferes little with drainage from the uterus. The repair of a 
 lacerated cervix, in which the closure is too tight, may interfere with or 
 even obstruct uterine drainage. 
 
 Furthermore, the drawing down of the cervix and the amount of 
 
LACERATIONS OF THE VAGINA 
 
 725 
 
 manipulation necessary in its repair exposes the woman to a risk of infec- 
 tion much greater than that associated with a perineorrhaphy. 
 
 On the other hand, a laceration of the cervix causing hemorrhage indi- 
 cates operation. While it is a fact that if the vessel in the cervix which 
 is bleeding is a small one, the packing of the uterine cavity, the cervical 
 canal and the vagina firmly with gauze will in many cases check the 
 hemorrhage, in most cases this is an uncertain procedure, and the 
 better plan is to expose the cervix as shown in Fig. 428 and suture 
 the tear or tears with chromicized catgut, being careful to insert the first 
 suture at the upper angle of the tear which is usually the source of the 
 bleeding, and bearing in mind the danger of leaving too narrow a cervical 
 canal. 
 
 Fig. 428. — Showing a recent cervical tear. (Bumm.) 
 
 The use of an absorbable suture like chromicized catgut, which holds 
 the tissues in apposition until union is complete, but does not subject the 
 patient to the annoyance of removal, is a distinct advantage, as can be 
 readily appreciated by all who have tried both the absorbable and the 
 non-absorbable suture. 
 
 Lacerations of the Vagina. — The most common site of a vaginal 
 laceration is in the lower portion of the canal, and it is usually associated 
 withja laceration of the perineum, the tear being, as a rule, longitudinal and 
 extending either in the median line or on one or both sides of the vagina. 
 If the vaginal tear is bilateral, the two sides of the tear are often of 
 unequal length with a tongue of intact mucosa between them. 
 
726 INJURIES TO THE PARTURIENT CANAL 
 
 These lower vaginal tears, aside from being caused l)y the same condi- 
 tions which produce lacerations of the perineum, are often caused by 
 the tips of the forceps blades, especially if the handles are elevated, and 
 thus the tips depressed too soon. 
 
 The next most frequent site of a vaginal tear is in the upper part of 
 the canal, and is usually an extension of a cervical tear. These tears may 
 be either longitudinal or transverse, in some cases separating the vagina 
 from the cervix for a considerable distance. These vaginal tears may 
 be slight and of little consequence, or they may be extensive, going 
 through into either the bladder or the rectum. The openings into the 
 bladder and rectum, however, wdiich occasionally follow delivery are 
 usually the result of long pressure from the presenting part with slough- 
 ing; the fistulae resulting from pressure necrosis rather than from 
 tearing. 
 
 Lacerations of the middle portion of the vagina are unusual but occa- 
 sionally occur either from unskilled use of the forceps or rarely in an 
 unaided labor. 
 
 Treatment. — Lacerations of the lower portion of the vagina should 
 always be searched for when examining for lacerations of the perineum 
 and should be sutured. 
 
 Lacerations in the upper portion of the vagina, like lacerations of the 
 cervix, should, as a rule, be left alone unless hemorrhage occurs, and 
 usually union takes place. Frequently even fistula? of bladder or rectum 
 will close spontaneously, but if not they should be closed by operation 
 later. The obstetric month is usually not the best time for these 
 operations. 
 
 Lacerations of the Perineum and Vulva. — In spite of all care on the 
 part of the obstetrician laceration of the perineum will occasionally occur. 
 Li the hands of the skilled obstetrician the lacerations will be relatively 
 few and not extensive, but in some cases the condition of the tissue is 
 such that it will not sufficiently stretch and a laceration occurs. It was 
 formerly considered a marked reflection upon an obstetrician's ability 
 or care if a laceration occurred, and consequently there was a temptation 
 not to examine carefully, but if no laceration appeared externally, to 
 state the absence of laceration and receive the credit. Unfortunately 
 the tears within the vuh'a which involve the fascia, binding together 
 the levatores ani muscles, are often more serious than the external 
 tears and not infrequently a woman who was told that she had no lacera- 
 tion, would find on examination by a gynecologist after months of 
 discomfort, that she had had an internal laceration which had not been 
 recognized by her obstetrician, and then his early credit was changed 
 to later and more lasting blame. 
 
 The laity have gradually become educated to the fact that lacera- 
 tions of the perineum will occasionally occur in the best of hands and 
 the obstetrician to be blamed is usually not the one in whose hands the 
 laceration occurs, provided he properly repairs it, but the one who, hav- 
 ing had a laceration, does not examine carefully and ascertain the fact, 
 but neglects it. 
 
LACERATIONS OF THE PERINEUM AND VULVA 727 
 
 Lacerations of the perineum vary greatly in extent and character. 
 In a primipara there is often a slight tear of the fourchette perhaps a 
 centimeter in length, but if this involves only mucosa and neither muscle 
 nor fascia, it is of little consequence and will heal sufficiently spon- 
 taneously. 
 
 In general two varieties of laceration of the perineum are recognized: 
 the complete and the incomplete. The complete laceration passes 
 through the sphincter ani, while in the incomplete laceration the 
 sphincter is not involved. 
 
 The complete laceration is fortunately rare and is excusable only in 
 very trying cases, as for instance, a breech presentation with extended 
 legs. In this case the laceration is often produced by the operator's 
 arm. The incomplete laceration, as already stated,, is common. It may 
 be a median tear extending from the fourchette downward toward the 
 anus and upward in the median line of the vagina, or it may be a 
 lateral tear extending upward on one or both sides of the vagina, as 
 already mentioned under Lacerations of the Vagina. In rare cases the 
 tear has been central, the fetal head passing through the centre of the 
 perineum between the rectum and vagina. 
 
 A type of laceration often overlooked until months after labor is the 
 submucous laceration, in which the lesion is in the submucous tissue 
 and the result is a very lax perineum and vulvar outlet often associated 
 with a rectocele and cystocele. The excessively relaxed vulva sometimes 
 arises as a result of efforts to prevent visible laceration of the perineum, 
 the head in the second stage of labor being held back until the perineum 
 and vulva have become so overstretched that, although no visible lacera- 
 tion occurs, the pelvic floor never regains its tone. These are cases in 
 which the after-result to the patient would have been better with a 
 repaired laceration than with no visible laceration but no tone. 
 
 Treatment. — Prophylactic. — 'No discussion of the treatment of lacera- 
 tion of the perineum is complete without consideration of the prophyl- 
 axis, i. e., the method of preserving the integrity of the pelvic floor 
 during the birth of the child. This is included in the proper manage- 
 ment of the second stage of labor and consists of the following endeavors 
 on the part of the obstetrician: 
 
 L To control the advance of the presenting part so that it will be 
 gradual and the dilatation will be gradual and complete. 
 
 2. To keep the shortest diameter of the presenting part across the 
 parturient canal. This in a vertex presentation implies keeping the 
 head well flexed until the suboccipitobregmatic diameter has passed 
 the pelvic outlet before extension is allowed. 
 
 3. To deliver the presenting part gradually in the interval between 
 uterine contractions, the patient's expulsive efforts being controlled by 
 anesthesia. 
 
 Oyeratim. — If a laceration of the perineum has occurred, the indica- 
 tion in all cases save those in which the woman is in very grave shock 
 is its immediate repair. If strict cleanliness is observed the tissues usually 
 unite readily and the woman is not only saved the mental and physical 
 
728 INJURIES TO THE PARTURIENT CANAL 
 
 distress of subsequent operation, but the increasing discomfort of the 
 relaxed ])elvic floor which finally compels her to consent to this procedure. 
 
 The method varies according as the laceration is incomplete or com- 
 plete. As the former is so much more common than the latter, it will be 
 discussed first. 
 
 The problem is to bring in apposition the parts which were in apposi- 
 tion when the laceration occurred. In order to ascertain just the extent 
 and location of the tear or tears, it is necessary to have a good light 
 and to separate the labia well with the fingers of one hand and with the 
 other to sponge with sterile gauze or cotton any bleeding surface. 
 
 It is important in the first place to see the upper angle of the lacera- 
 tion, for unless this is sutured the closure of the lower portion only leaves 
 a pocket above in which the lochia accumulates and the woman is exposed 
 to the risk of infection. The parts immediately after labor are benumbed 
 from the stretching and pressure and often no anesthetic is required for 
 the suturing. If anesthesia is required, it should be borne in mind that 
 even in a woman with normal liver and kidneys, chloroform after the 
 straining of the labor is over is not as safe as during the labor, and not 
 as safe as ether. Not infrequently a slight superficial laceration can be 
 repaired before the placenta is expelled and while its separation is being 
 waited for. For any extensive laceration, howe^'er, it is better to wait 
 until the placenta is expelled and ergot has been given. While it is a 
 great convenience to have an assistant administer the anesthetic, circum- 
 stances very frequently arise where it is desirable to avoid the formality 
 of an operation, and usually when the laceration is incomplete, the 
 obstetrician and his nurse should be able to do all that is necessary for 
 a successful repair. With the patient across the bed, or on a table, to 
 secure a good view of the field of operation, with the knees supported 
 with a leg-holder as shown in Fig. 457 and with the hips on a Kelly pad 
 or rubber sheet leading to a drainage tub, the nurse with one hand 
 can guard the fundus to prevent relaxation, and with the other can 
 administer the anesthetic. 
 
 In suturing the tears in the vaginal sulci, the repair of which is very 
 important for the future tone of the pelvic floor, it is well to introduce 
 the needle in the vaginal mucosa on one side of the tear, direct it slightly 
 toward the operator, have it emerge at the bottom of the tear, reintro- 
 duce it near the point of exit, direct it slightly from the operator, and 
 have it emerge on the vaginal mucosa opposite its point of entrance. 
 Introduce each succeeding suture in the lateral sulcus or sulci in the 
 same manner. 
 
 After repairing the lateral tears there remains only the laceration 
 at the fourchette and the skin perineum to be sutured. The most 
 important stitch here is the so-called crown stitch which brings together 
 the parts at the fourchette, the remaining sutures being merely super- 
 ficial. In private practice the best suture material for the repair of 
 incomplete lacerations of the perineum, as for repair of lacerations of 
 the cervix, is 20-day chromicized catgut, which holds the tissue in apposi- 
 tion long enough for firm union, yet does not subject the patient to the 
 annoyance of having the stitches removed. In a hospital-ward service. 
 
COMPLETE LACERATIOX OF THE PERINEUM 
 
 '29 
 
 for purposes of economy it is sometimes advisable to suture tears in the 
 vagina and about the vestibule with plain catgut, and for repair of the 
 perineal body and skin to use silkworm-gut sutures. 
 
 If the laceration has extended into the bulb of the vestibule and is 
 causing considerable bleeding, the best plan is to surromid the bleeding 
 area with a purse-string suture, which passes in and out of the surround- 
 ing tissue. AYhen this is drawn up and tied it usually so constricts the 
 bleeding area as to check all hemorrhage. 
 
 In certain difficult cases., as with impacted breech with extended legs 
 in an elderly primigravida, a complete laceration of the perineum will 
 occasionallv occur in the effort of the obstetrician to deliver a living 
 
 Fig. 429. — Denudation for secondary iLpair of complete laceration of perineum. 
 
 child. In 20,000 consecutive deliveries at the Sloane Hospital there 
 were 17 complete lacerations, or 1 in 1176. 
 
 ^^ hen this accident has occurred it is usually advisable to attempt 
 its repair at once, although it may not in every case be absolutely suc- 
 cessful, the distress to the woman from an ununited sphincter with lack 
 of control of feces and gas being so great that every safe effort should 
 be made to save her from this annoyance. In some cases of complete 
 laceration of the perineum, nature by filling in the gap between the ends 
 of the sphincter with cicatricial tissue, will give the woman partial con- 
 trol, although, as a rule, the result is so imperfect as to be very unsatis- 
 factory and not to be relied upon. Certainly the indication is to repair 
 by operation. 
 
730 
 
 IXJIRIES TO THE PARTURIEST (A SAL 
 
 In a complete laceration of the perineum it i> u>ually a(hisal)le to 
 secure the services of an assistant to administer the anesthetic, so that 
 the nurse will be left free to assist the operator. The operation which 
 has given the author the greatest satisfaction in the repair of complete 
 lacerations is based upon the principle advocated by Xoble. of Georgia, 
 by which the anterior rectal wall is drawn down far enough to keep the 
 rectal contents away from the perineal wounrl. 
 
 The technic can perhaps be best understood by referring to the 
 illustrations of the secondary repair of complete lacerations as performed 
 by the author (see Figs. 429, 430. and 431). In the immediate repair the 
 tissues are eflematous and the landmarks are somewhat obscured, but the 
 
 Fig. 430. — Repair of complete laceration of perineum. Drawing down anterior rectal wall. 
 
 ends of the sphincter are not as much retracted. On the other hand, in 
 the secondary operation, the original raw surface must be restored by 
 denudation and the ends of the sphincter freed and brought forward. In 
 both operations the anterior wall of the rectal tube .should be freed and 
 drawn downward, with an artery clamp applied to it, until the ends of the 
 sphincter ani can be united over it as shown in Figs. 429 and 430. The 
 ends of the sphincter are united by chromicized catgut, two stay sutures of 
 silkworm gut being introducerl from the skin surface through the sphincter 
 at a little distance from the sutured ends to serve as a kind of splint and 
 additional support. When these are tied (see Fig. 431 ) there is left for 
 repair only what would correspond to an incomplete laceration of the peri- 
 
COMPLETE LACERATION OF THE PERINEUM 731 
 
 neum which may be repaired in the usual way. The bowels should be kept 
 constipated for three full days and then moved with great care and with- 
 out straining. The author's usual method is to keep the patient on broths 
 during the first three days following the operation, avoiding milk which 
 is apt to cause a constipated stool. On the night of the third day a 
 laxative pill is given, and on the morning of the fourth day through a 
 catheter an enema of olive oil, §iv, is carefully given and allowed to 
 remain and soften the stool. A teaspoonful of Rochelle or Epsom salts 
 is then given by mouth every hour, until the bowels move or until eight 
 doses have been taken. If necessary a soapsuds enema is then adminis- 
 tered through a catheter to start the movement, the patient being 
 
 Fig. 4.31. — Repair of complete laceration of perineum. Sutures introduced. 
 
 cautioned against straining. After the first movement the bowels may 
 be moved each day. The silkworm-gut sutures should be removed at 
 the end of about ten days. 
 
 In considering the different procedures available for dealing with 
 dystocia the author wishes first to present the three non-cutting opera- 
 tions : 
 
 1. Induction of premature labor. See Chapter XXIV. 
 
 2. The use of the forceps. See Chapter XXV, page 745. 
 
 3. Version. See Chapter XXVI, page 768. 
 
 The operations involving the use of the knife will be considered in 
 Chapter XXVII, page 776. 
 
CHAPTER XXIV. 
 INDUCTION OF ABORTION AND PREMATURE LABOR. 
 
 The course of pregnancy may be artificially interrupted in the interest 
 of either the mother or the child, or both. 
 
 If the pregnancy is interrupted before the child is viable, /. c, before 
 it is capable of life and growth outside of the uterus, the procedure is 
 called inchwticm of abortion. 
 
 If the interruption is brought about after the child is ^'iable, it is called 
 induction of 'premature labor. 
 
 The period of viability of the child is therefore the di\i(ling line 
 between them. The procedures of induction of abortion and induction 
 of premature labor are so closely related that they will both be con- 
 sidered in the same chapter. There is, however, one marked difference 
 between them. Induction of abortion is performed solely in the interest 
 of the mother, and the life of the fetus is disregarded. Induction of pre- 
 mature labor, on the other hand, usually carries with it the assumption 
 that the fetus is capable of existence outside of the uterus and the opera- 
 tion is performed in the interests of both mother and child; the excep- 
 tion being induction of premature labor when the child is dead, late in 
 pregnancy. 
 
 INDUCTION OF ABORTION. 
 
 ^Yllen the further continuance of gestation would seriously endanger 
 the life or future health of the mother, it is justifiable to induce al)ortion 
 in the interest of the mother. 
 
 Indications. — The indication may be maternal or fetal. 
 
 Maternal. — These may be general or local. 
 
 (ieneral Indications. — The most common maternal indication for 
 induction of abortion is some form of to.vemia. It may show itself in 
 the form of pernicious vomiting with evidently a liver lesion, marked 
 acidosis, etc., or it may assume the form of a progressively increasing 
 kidney disturbance with marked albuminuria, high-tension pulse, head- 
 ache, edema, etc. Certain it is that a toxemia, increasing in spite of 
 treatment, is the most common indication justifying induction of abortion. 
 
 The indication may arise from advanced yuhnonary or cardiac disease. 
 When discussing tuberculosis and cardiac disease complicating pregnancy 
 (see pages 459 and 463) the author made his position clear, that in an 
 active tuberculosis he believed that pregnancy should not be allowed 
 to continue. Also, that in certain cases of cardiac disease, especially in 
 cases of mitral stenosis where failure of compensation had been present 
 before pregnancy started, interruption of the pregnancy was justifial)le. 
 ( 732 ) 
 
INDUCTION OF ABORTION 733 
 
 The indication for induction of abortion may lie in the nervous system 
 of the mother as a chorea, mania, or melancholia. It is well known that 
 a woman who has been subject to attacks of chorea has a tendency to 
 a recurrence of it in pregnancy. The chorea in some cases assumes such 
 a severe form as to cause an abortion, and in other cases in the interests 
 of the mother it is necessary to induce an abortion. The question of 
 mania and melancholia complicating a pregnancy and serving as an 
 indication for its interruption is a very important one. 
 
 The disappointment at finding herself pregnant is sometimes so great 
 in a woman that for the time being it may assume the character of a 
 melancholia. In the majority of these cases, moral suasion and sym- 
 pathy on the part of the friends and will-power and common-sense on 
 the part of the woman herself will enable her to adjust herself to the 
 circumstances and the pregnancy continues without further trouble. 
 Occasionally, however, a true melancholia or mania, even with homicidal 
 tendencies, develops and unless this soon subsides under treatment 
 directed toward a toxemia and with nerve sedatives, the future men- 
 tality of the woman demands an interruption of the pregnancy. One 
 of the difficult problems is sometimes to determine whether the mental 
 condition is feigned or real. If the abnormal mental condition is real 
 and distinctly pathological, especially if it shows a homicidal tendency, 
 the pregnancy should be interrupted. 
 
 Certain blood conditions of the mother, such as a pernicious anemia, 
 in which pregnancy seems to be hastening the fatal termination, justify 
 induction of abortion. 
 
 In general it may be said that when the condition of the mother is 
 such that her life, future health, or reason, are seriously endangered 
 by a continuance of a pregnancy, that pregnancy should be inter- 
 rupted. 
 
 Local Indications. — Certain local, pathological conditions in the 
 mother occasionally justify the interruption of a pregnancy. 
 
 If a woman has a carcinoma of the uterus in the operable stage, so 
 important is it that the disease should be removed early and radically, 
 that the presence of a pregnancy should be disregarded entirely. If the 
 carcinoma is in the inoperable stage and the pregnancy near term, the 
 life of the fetus deserves consideration. 
 
 When Cesarean section carried with it a high mortality, there were 
 many local conditions in a woman's pelvic organs or the parturient canal 
 which were considered justifiable indications for induction of abortion. 
 Thus, if a woman had a pelvis too contracted to allow of delivery of a 
 child by forceps or a version, it was formerly considered justifiable to 
 interrupt the pregnancy. If a woman had a fibroid tumor which was 
 likely to grow during pregnancy and perhaps require a Cesarean section 
 with a hysterectomy or a myomectomy, it was formerly considered 
 justifiable to interrupt the pregnancy. With the present low mortality 
 of Cesarean section, even when coupled with a hysterectomy or myo- 
 mectomy, it is today usually not considered justifiable to interrupt a 
 pregnancy under these circumstances unless the general condition of 
 
734 INDUCTION OF ABORTION AND PREMATURE LABOR 
 
 the woman is such as to make her an unsafe surgical risk for any 
 abdominal ojjeration. 
 
 Fetal Indications. — Certain grave conditions of the fetal membranes 
 or the placenta indicate induction of abortion. Among these may be 
 mentionefl : 
 
 Hydatidiform mole. 
 
 Acute hydramnios. 
 
 Placenta previa. 
 
 Premature separation of a normally situated placenta — accidental 
 hemorrhage. 
 
 These are all discussed elsewhere, but it is a well-established fact 
 that in the case of a hydatidiform mole the early emptying of the 
 uterus is the best procedure, not only for the immediate welfare of 
 the woman, but to save her from uterine perforation and the possible 
 development of chorio-epithelioma. In acute hydramnios, placenta 
 previa and "accidental hemorrhage," while the treatment varies with 
 the variety and degree of the condition present, the generally accepted 
 treatment for the severe types of all three complications is that of 
 emptying the uterus. 
 
 Fetal Death. — While fetal death is often the result of maternal causes, 
 it may be looked upon as of itself an occasional indication for induction 
 of abortion. As a rule the fetus after its death in utero plays the part 
 of a foreign body, upon which the uterus soon contracts and before 
 long expels. In the meantime, if the amniotic sac is intact, the uterine 
 contents are usually sterile, and no harm results even if the fetus, her- 
 metically sealed, has been retained in utero for several weeks. Occa- 
 sionally, however, the uterus does not expel the dead ovum, bacteria 
 gain an entrance to it, and a sapremia, perhaps even a septicemia, 
 follows. If the death of the fetus is suspected, the woman's temperature 
 and pulse, and her elimination should be carefully watched so that the 
 first evidences of bacterial invasion may be noted and the uterus then 
 be emptied promptly. The difficulty lies in the fact that from the fourth 
 to the fifth month it may be very hard to determine positively whether 
 the fetus is alive or dead. Hence, in case of any doubt, and in the 
 absence of any signs of bacterial invasion, it is usually wise to wait and 
 see if nature will not either demonstrate that the fetus is alive, or expel 
 it if dead. In the meantime the obstetrician should be constantly on 
 the alert for any evidences of infection. 
 
 Induction of abortion save in emergencies should not he resorted to with- 
 out the advice and support of a medical colleague. 
 
 Methods of Induction of Abortion. — IMany methods have been ad- 
 vocated, tried and abandoned as dangerous, too slow or ineffectual. 
 Among these may be mentioned the use of drugs, as ergot, rue, savine, 
 parsley, tansy, pennyroyal, etc. Pituitary extract, lately introduced, 
 has also been found unsuitable for this purpose. The use of electricity, 
 tamponade of the vagina, and the use of cervical tents are other examples 
 of ob.solete methods. 
 
INDUCTION OF ABORTION 735 
 
 The two methods which at the present day may be regarded as the 
 best are : 
 
 1. A mechanical dilatation of the cervix with a glove-stretcher dilator, 
 followed at the same sitting with a cleaning out of the uterus with 
 curette, ovum forceps (for this purpose there is nothing better than the 
 looped sponge-holder) and a double-current catheter. The value of the 
 use of the gloved finger in the cavity of the uterus to determine that it 
 is empty has already been mentioned (see page 518). 
 
 2. The same method as the abo\-e preceded by a preparatory softening 
 and dilatation of the cervix by tamponade of the cervical canal and the 
 vagina with gauze. 
 
 The choice between the two methods depends upon the duration of 
 the pregnancy and the softness and dilatability of the cervix. 
 
 During the first two months of pregnancy, while the uterus and the 
 ovum are small, the first method by which the uterus is emptied at a 
 single sitting is the method of choice. After the second month, unless 
 the cervix is unusually soft and dilatable, the second method with its 
 preparatory softening and dilatation of the cervix is to be recommended. 
 
 Technic. — In the first method the technic is largely that of an 
 ordinary curettage and requires the same preparation of instruments, 
 hands and field of operation, with sterile draping of the vulva, thighs, 
 etc. There are, however, certain dift'erences between this operation and 
 an ordinary curettage, depending on the fact that the patient is pregnant 
 and the uterine wall is softer and more easily penetrated than in the 
 non-pregnant state. For this reason it is extremely important that little 
 force be used in all intra-uterme manipulations and for most of the work 
 a stiff, blunt curette should be used rather than a sharp one, and what 
 little pressure is employed in the use of the instrument should be 
 employed in coming toward the operator rather than in going from him. 
 The author does not think it necessary that the careful man should 
 make the rule never to use a sharp curette in this operation, as often, 
 after he has supposedly cleaned out the uterus with his blunt curette, 
 he is in the habit of very gently going over the uterine cavity wdth a 
 sharp curette to loosen any decidua which may have escaped the blunt 
 instrument. If it is possible to introduce one or two fingers into the 
 uterine cavity, it is of the greatest advantage to do so, as by depressing, 
 with the hand on the abdomen, one part of the uterus after another 
 toward the finger within it, all parts of the uterine cavity may be explored 
 and any foreign substance detected. After irrigating the uterine cavity 
 with saline solution in order to wash out all loosened debris, it is well 
 to pack the uterus and vagina with gauze, either a bismuth gauze or a 
 weak iodoform gauze, which will remain sweet longer than plain gauze, 
 and leave it for twenty-four hours. The advantage of the gauze tam- 
 ponade is that it not only prevents excessive bleeding, but on its with- 
 drawal on the following day it wipes off from the inner surface of the 
 uterine wall any secundines which may have escaped the curette on the 
 day before. 
 
 In the second method the procedure is carried out in two sittings. 
 
736 IXDUCTIOX OF ABORTION AND PREMATURE LABOR 
 
 At the first sitting, with sterile hands, instruments and field of operation, 
 a speculum is introduced, the cervix is seized with a bullet forceps or 
 a volsella, steadied and dilated. The cervical canal and the vagina are 
 then firmly packed with bismuth or weak iodoform gauze and left for 
 about twenty-four hours. At the end of that time the cervix, which at 
 the first sitting was found long and rigid, will often be found softened, 
 shortened and easily dilatable. In fact the operation of emptying the 
 uterus, which the day before would have been very difficult, is often 
 found a very easy one, the cervix readily admitting one or more fingers 
 and either with or without the use of the curette and sponge-holder, easily 
 allowing rapid emptying of the uterus. In this second method, as in the 
 first, after irrigating the uterus, preferably with hot sterile salt solution, 
 it is desirable to pack the uterus and vagina with bismuth or weak 
 iodoform gauze, not only for controlling hemorrhage, but for wiping out 
 the cavitv of the uterus when withdrawing the gauze. 
 
 INDUCTION OF PREMATURE LABOR. 
 
 General Indications. — "When the continuance of the gestation to full 
 term would expose either mother or child to serious danger which might 
 be diminished or avoided by the arrest of the pregnancy at any time after 
 the period of viability of the child, the induction of premature labor is 
 indicated. The indications for the induction of premature labor may 
 be either fetal or maternal. 
 
 Fetal Indications. — The indications arising from the fetus may usually 
 be placed in one of the three following groups: 
 
 1. Habitual oversize or premature ossification of the fetal skull. 
 
 2. Habitual death of the fetus during the last days or weeks of 
 pregnancy. 
 
 3. Fetal death. 
 
 A glance at the above group demonstrates at once that with the 
 exception of the last, the fetal indications for induction of premature 
 labor are more apt to be recognized in subsequent pregnancies rather 
 than in the first. Occasionally, when a large man, as a member of a foot- 
 ball squad, or of a crew, marries a very petite young lady, a child too 
 large for her pelvis is suspected and careful observation with pelvimetry 
 and cephalometry practised throughout the latter half of the pregnancy 
 confirms this suspicion, and recognizes the indication for premature 
 labor. As a rule, however, it is the history of previous dystocia with 
 subsequent fetal findings that determines the fetal indication for inter- 
 ruption of the pregnancy. 
 
 Occasionally, for reasons difficult to state, probably in most cases an 
 obscure toxemia, the fetus suddenly dies in utero a week or two before 
 term. In one of the author's cases this occurred twice at about the same 
 period of pregnancy: two weeks before term. In these cases induction 
 of premature labor a little prior to the time at which the fetus has died 
 in previous pregnancies is distinctly indicated. In the author's case 
 
INDUCTION OF PREMATURE LABOR 737 
 
 just referred to, induction of labor three weeks ahead of term in the 
 third pregnancy succeeded in obtaining a living child. 
 
 As in the case of a dead fetus in the early months, so in the latter 
 months of pregnancy. The presence of the dead fetus usually stimu- 
 lates the uterus to contract and expel it. In a few cases in which the 
 death and retention of the fetus has been determined and the mother's 
 health seems to be affected by it, induction of premature labor is indicated. 
 
 Maternal Indications. — The indications arising from the mother may 
 relate to her 'parturient canal, the placenta, or her general system. 
 
 Parturient Canal. — One of the common indications for induction of 
 premature labor is a contracted pelvis and consequently narrowed 
 parturient canal. The diameter of the fetal skull most likely to cause 
 difficulty in delivery is the biparietal. According to the investigations 
 of Budin, Tarnier and others, this diameter which at term averages 
 9.25 cm., at eight months averages 8.25 cm., and at seven months, 7 cm. 
 These facts make rational the induction of premature labor in con- 
 tracted pelves and indicate approximately the amount of prematurity 
 needed for different degrees of contraction. In general, it may be 
 stated that in the interests of the child it is desirable to have the preg- 
 nancy approach as near term as possible without subjecting either child 
 or the mother to too much trauma in the delivery. As a fetus under 
 eight months has little vitality to withstand trauma in delivery, it is 
 seldom desirable to induce a labor for contracted pelvis under eight 
 months of gestation and, indeed, eight months and a week are much to 
 be preferred. 
 
 The Placenta. — ^The indications for induction of premature labor in 
 placenta previa and in accidental hemorrhage will be found discussed 
 under these headings. It may be stated here that while the indications 
 vary with the variety of these complications, it is well established that 
 in complete placenta previa and in a complete separation of a normally 
 situated placenta — "accidental hemorrhage" — induction of premature 
 labor is indicated. 
 
 Conditions of the General System. — As in the early months of preg- 
 nancy, prior to the viability of the child, certain grave systemic affec- 
 tions indicate induction of abortion, so in the later months do they 
 indicate induction of premature labor. Moreover, here as in the early 
 months toxemia stands foremost in the frequency of its occurrence as an 
 indication for induction of premature labor. The form of toxemia most 
 often seen in the later months is that threatening eclampsia rather than 
 pernicious vomiting, although either the liver or the kidney may be the 
 organ chiefly involved. It must be borne in mind also that if the mother 
 is toxic the child may be poisoned by remaining in the uterus and be 
 exposed to greater danger by a continuation of the pregnancy than by 
 its interruption. This is evidenced by the frequent occurrence of fetal 
 death due to the toxemia of the mother prior to the onset of labor. 
 
 Advanced cardiac disease may indicate induction of premature labor 
 in the hope that the labor will be easier if the child is smaller, and con- 
 sequently less strain will be thrown upon the overtaxed heart. More- 
 47 
 
738 INDUCTION OF ABORTION AND PREMATURE LABOR 
 
 over, there is always the hope that with the pregnancy over, the heart 
 will resume its compensation. 
 
 Various other constitutional affections, as of the nervous system, 
 blood, etc., which are aggravated by the pregnancy and give hope of 
 marked improvement after the pregnancy is terminated, justify induc- 
 tion of premature labor as soon as the fetus has reached a period when 
 there is every prospect that it will sur^'ive if brought into the world. 
 
 Prognosis. — The prognosis for the mother depends largely upon the 
 indication for the operation. If the indication is a contracted parturient 
 canal, the prognosis for the mother under the modern aseptic methods 
 is good. If, however, the indication for the interruption of the pregnancy 
 is some grave, systemic disease, the maternal prognosis depends largely 
 upon her general condition. 
 
 The prognosis for the child depends largely upon its weight and devel- 
 opment and whether or not it is suffering from a toxemia resulting from 
 the same condition in the mother. Two facts are worthy of mention : 
 
 1 , It is the maturity of the child rather than its size and weight which 
 determines its resistance. 
 
 2. A toxic baby has much less resistance than one which is not toxic- 
 There is absolutely no foundation for the wide-spread belief that a 
 
 se^'en months' fetus has more chance of survival than one at eight months. 
 Of course the nearer to term the pregnancy reaches, other things being 
 equal and the mother not toxic, the better the chance of survival of the 
 fetus. 
 
 Methods of Inducing Premature Labor. — The use of various drugs 
 for induction of premature labor, as for induction of abortion, has been 
 found either inefficient or unsafe, and are of interest simply as matter 
 of ancient history. The use of castor oil which in full doses will sometimes 
 incite labor if the woman is at term, is practically of no value in inducing 
 premature labor. 
 
 The intra-uterine injection of from one to two ounces of sterilized 
 glycerin between the membranes and the uterine wall was suggested 
 by Pelzer, of Germany, as a means of induction of premature labor, and 
 several years ago was quite extensively tried in this country. Pelzer 
 explained its action in three ways: 
 
 1 . By mechanical separation of the membranes. 
 
 2. By direct irritation of the uterine mucosa as of the rectal mucosa 
 when used in an enema or suppository, 
 
 3. By the affinity of glycerin for water, some of the liquor amnii 
 was drawn through the membranes with more or less collapse of the 
 amniotic sac. 
 
 Very soon after the introduction of this method of Pelzer, cases began 
 to be reported in which renal irritation with hematuria, albuminuria, 
 etc., followed the intra-uterine injection of glycerin, and on account of 
 this danger and the danger of injecting air into the uterine sinuses the 
 method rapidly fell into disuse. 
 
 There are four methods of induction of premature labor which at 
 the present time deserve consideration : 
 
INDUCTION OF PREMATURE LABOR 
 
 739 
 
 1. Dilatation of the cervix with an elastic bag. 
 
 2. The intra-uterine introduction of a bougie — the Kraiise method. 
 
 3. The tamponade of the vagina. 
 
 4. Puncture of the membranes. 
 
 Of these four methods the last two are employed simply as adjuvants 
 of the first two. 
 
 Dilatation of the Cervix with an Elastic Bag. — This is the author's 
 choice among the methods just mentioned and is the method generally 
 
 Fig. 432. — Voorhees's modification of, Champetier de Ribes's bags. 
 
 employed at the Sloane Hospital. It has the great advantage over 
 the second method in that it does not usually rupture the membranes 
 and follows nature's plan of dilating the cervix by elastic pressure. Its 
 presence in the cervical canal stimulates uterine contractions and the 
 conical shape of the bag furnishes a fluid wedge which imitates nature's 
 method. 
 
 The bags used by the author are those of Champetier de Ribes as 
 modified by Dr. James D. Voorhees, of New York. They are of four 
 sizes,, as shown in Fig. 432. 
 
r40 
 
 INDUCTION OF ABORTION AND PREMATURE LABOR 
 
 Except in cases with a long, rigid cervix, it usually is unnecessary to 
 use bag No. 1, as No. 2 can be introduced at the first sitting, some- 
 times even No. 3. As the largest size, bag No. 4, sometimes displaces 
 the presenting part, allowing the possibility of a prolapse of the cord, 
 the author floes not use bag No. 4 unless the presentation is either a 
 breech or a l)reech presentation is desired, as in a placenta previa. 
 
 In the introduction of the bags the vulva should be cleansed and 
 draped as for any operative delivery. Unless the patient is nervous and 
 
 Fig. 433 
 
 Fig. 434 
 
 Figs. 433 and 434. — Looped sponge-holder. 
 
 apprehensive, or the cervical canal very small, no anesthetic is required. 
 The introduction of the bag is facilitated by the lubricating effect of a 
 lysol vaginal douche, 0.5 per cent., although this is not a necessity. 
 
 The instruments required for this operation are a forceps for holding 
 and introducing the bag after it has been folded up; for this a looped 
 sponge-holder answers nicely (see Figs. 433 and 434) . A syringe for distend- 
 ing the bag after it is in place, and here may be used eitlier a metal piston 
 syringe, or a soft-ru})ber bulb syringe (see Figs. 435 and 430), (in i)rivate 
 practice the latter is easier to carry in the obstetrical bag and answers 
 
INDUCTION OF PREMATURE LABOR 
 
 741 
 
 nicely) ; an artery clamp to compress the end of the tuhe after the bag is 
 filled, and a pair of scissors to cut the tape with which the end of the tube 
 is tied, so as to remove the clamp. 
 
 If the cervical canal is very small and rigid it may be necessary to 
 dilate the cervix with a glove-stretcher dilator, as a preliminary step to 
 the introduction of the bag. In such a case an anesthetic should be 
 employed. In private practice with only one assistant, and she the 
 nurse,"^it is well to have the patient lying across the bed with douche pan 
 under her hips and knees elevated. The advantage of the douche pan 
 
 Fig. 435 
 
 Fig. 436 
 
 Fig. 435 and 436. — Syringes used for distending elastic bags. 
 
 is that it not only allows the operator to cleanse the vulva, and if desired 
 give a vaginal douche, but elevates the hips and facilitates manipula- 
 tions. In a hospital the natural position would be on the table in the 
 lithotomy position and with a Kelly pad under her hips. The vulva 
 should be surrounded with sterile towels. 
 
 Having folded the bag into as small a compass as possible, it is seized 
 with forceps (see Fig. 437) and with the two fingers of the left hand in 
 the vagina to depress the perineum and serve as a guide, the forceps 
 containing the bag is passed by the right hand along the vaginal fingers 
 into the cervix until the bag passes the internal os. The forceps is 
 
742 INDUCTION OF ABORTION AND PREMATURE LABOR 
 
 then withdrawn, the syringe adjusted to the tube of the bag whieh is 
 outside the vulva and the l)ag is distended with some sterile fluid; prefer- 
 ably 0.5 per cent, lysol solution, while the vaginal fingers are kept in posi- 
 tion, to make sure that the bag does not slip from the cervix while being 
 filled. The tube is then clamped with an artery clamp just above the 
 nozzle of the syringe and the syringe withdrawn. The tube is tied with 
 narrow tape above the clamp; the clamp withdrawn; the tube folded 
 upon itself and placed in the vagina and a sterile dressing applied to the 
 
 Fig. 437. — Bag in grasp of forceps. 
 
 Fig. 438.— Distended bag. 
 
 vulva. The appearance of the distended bag is shown in Fig. 438. As 
 a rule the labor pains start in from two to four hours after the introduc- 
 tion of the bag. Some uteri, however, seem very insensitive to mechan- 
 ical stimuli and occasionally a bag will remain within the cervical canal 
 for twenty-four hours w^ith scarcely any uterine contractions resulting. 
 This does not mean, however, that nothing has been accomplished, as 
 the presence of the bag usually softens and to a certain extent dilates 
 the cervix even without evident uterine contractions, so that at the end 
 of twenty-four hours the bag can be withdrawn and the next size larger 
 
INDUCTION OF PREMATURE LABOR 743 
 
 introduced. The rule is that when bag No. 3 has been expelled or with- 
 drawn labor is sufficiently under way to need no further stimulation. 
 Occasionally, however, further stimulation is needed, as will be referred 
 to when discussing the second method of induction of premature labor. 
 
 The Introduction of a Bougie. — The Krause Method. — Until recent years 
 the method most generally employed for induction of labor was the 
 introduction of a catheter or bougie between the membranes and the 
 uterine wall. The bougie without an eye near the tip is much better 
 than a catheter with the eye, as with the latter there is a direct channel 
 for air and bacteria from without to the cavity of the uterus. 
 
 If the bougie is sterile and with sterile hands is introduced with all 
 aseptic precautions, there is little maternal risk in this method, but it 
 is open to one great objection. It is very apt to cause a rupture of the 
 membranes with the first few uterine contractions and with the draining 
 away of the liquor amnii there results a dry labor with greater direct 
 pressure upon the fetus, greater delay in the dilatation of the cervix, 
 and the usual disadvantage of a dry labor. Furthermore, in some cases 
 the presence of the bougie for twenty-four to thirty-six hours fails to 
 excite uterine contractions. For these reasons the author prefers not to 
 use a bougie as the initial means of inducing labor, but to reserve its use 
 for cases in which after bag No. 3 has been used and has been expelled 
 or withdrawn, uterine contractions have ceased and further uterine 
 stimulation is needed. With a cervix sufficiently dilated to allow bag No. 
 3 to pass, even if the membranes do rupture from the presence of the 
 bougie, it will do little harm. From the descent of the presenting part 
 it may still further aid the bougie in stimulating uterine contractions 
 and thus aid the labor. 
 
 Technic. — The bougie (see Fig. 439) should be of the so-called gum- 
 elastic variety, and of a size a little smaller than a common lead-pencil. 
 As the bougie sometimes bends on introduction it is always well to have 
 on hand a sterilized stilet with which to maintain its shape if necessar}'^ 
 (see Fig. 440). With hands covered with sterile gloves and vulva and 
 vagina prepared for operation, two fingers of the left hand are passed 
 along the vagina to the cervix. The sterilized bougie, with or without 
 its stilet, held in the right hand, is then passed along the fingers of the 
 left hand to and within the cervix, thence gently inserted as near the 
 fundus as it will go without the use of force, letting it take the path of 
 least resistance. After the bougie has been introduced, it is well to pack 
 the vagina with bismuth or weak iodoform gauze, not only to hold the 
 bougie in place, but to gain whatever uterine stimulation may arise 
 from vaginal tamponade. If at the end of twenty^our hours uterine 
 contractions have not started,, it is usually wise to withdraw the gauze 
 and the bougie and either insert another bougie or an elastic bag. 
 
 Tamponade of the Vagina. — Occasionally the tamponade of the vagina 
 with gauze will bring on uterine contractions. This is more apt to be 
 true in the early months of pregnancy, especially if the cervical canal as 
 well as the vagina is tamponed. In times past this tamponade of the 
 vagina has been recommended as a means of inducing labor. Its uncer- 
 
744 INDUCTION OF ABORTION AND PREMATURE LABOR 
 
 taiiity in time aiul effectiveness, however, has been so great that at the 
 present day it is never used b\' itself for this purpose, but is often used 
 as an adjuvant, as after the intnxhiction of a bougie where as alread}' 
 indicated, it serves a double purj)ose of holding in the bougie and stinui- 
 lating uterine contractions. 
 
 Puncture of the Membranes. — It has to be admitted that puncture of 
 the membranes with draining away of the liquor amnii is usually followed 
 after a longer or shorter interval by uterine contractions and beginning 
 labor. It is not a method to be recommended for induction of premature 
 
 ^ 
 
 Fig. 439.— Bougie. Fig. 440.— Stilet. 
 
 labor under ordinary circumstances, as it is very uncertain in time, and 
 results in a dry labor Mith all its disadvantages and dangers. As an 
 adjuvant to other methods, howe^•er, it is often of marked value. Thus, 
 when the cervix has been sufficiently dilated to allow a No. 3 Voorhees 
 bag to pass, the puncture of the membranes may start afresh uterine 
 contractions which were becoming less and less. Furthermore, in a 
 placenta previa of the lateral type with a vertex presentation and with 
 the woman bleeding, a puncture of the membranes will often allow the 
 head to descend and control the bleeding by pressure as well as stimulate 
 uterine contractions and the progress of the labor. 
 
CHAPTER XXV. 
 FORCEPS. - 
 
 Historical Sketch. — The obstetric forceps has been of such service in 
 the cause of humanity that a brief review of the history of the instru- 
 ment is both interesting and instructive. ^ 
 
 Probably the first mention of the use of the forceps for the dehvery of 
 a hving child is found in the writings of Avicenna, an Arabian physician, 
 who was born a.d. 980, and died a.d. 1037. His writings passed through 
 several translations into Latin, the common language of science at that 
 time, the translation by Benedictus Rinius, of Venice, being published in 
 1555.^ In this translation there is one chapter describing the delivery 
 of a living child by means of the forceps and another chapter giving 
 directions for the extraction of a dead child. 
 
 Subsequent writers also mention the use of the forceps, but just who 
 first devised the instrument has never been thoroughly established. 
 
 Jacobus Ruoif, a native of Zurich, published, in 1524, a treatise on 
 obstetrics, in which he described a long and a short forceps, which he 
 had invented, stating that his instrument had no teeth on it and that 
 the child could easily be delivered by his forceps if it could be applied 
 to the head. The forceps of these early writers were crude instruments 
 with blades not separable, and therefore could only be introduced together 
 and then adjusted to the head. From the middle of the sixteenth to the 
 middle of the seventeenth century but little progress was made either 
 in the construction or use of the forceps. This brings the history to the 
 Chamberlen family, whose different members so improved the construc- 
 tion of the instrument and so perfected its use that by many writers the 
 invention of the forceps has been incorrectly credited to them. 
 
 This famous family was originally resident in Paris. The founder of 
 the English branch of the family was William Chamberlen, probably 
 a surgeon, who being obliged to leave Paris on account of his religious 
 beliefs, went to England in 1569. 
 
 William Chamberlen was evidently fond of the name "Peter," for 
 having two sons he called them both by that name. Both of these sons, 
 Peter the elder and Peter the younger, practised medicine in London 
 and became successful, especially in midwifery. Peter the elder died in 
 1631, and Peter the younger in 1626, leaving a son also named Peter who 
 was called Doctor Peter, to distinguish him from his father and from 
 his uncle. Doctor Peter was the first member of the family to obtain 
 the degree of M.D., receiving it from Padua in 1619, and later from 
 
 1 Avicennge, Liber Canonis de Medicinis Cordial ibus et Canticala Benedicto Rinio Veneto- 
 Venetiis, 1555, liber III, fen. xxl, tract 11, cap. 26, p. 390. 
 
 (745 J 
 
746 
 
 FORCEPS 
 
 Oxford and Cambridge.^ He had a large obstetric practice and died in 
 1683 at Woodham, ]\Iortimer Plall, in Essex, leaving several sons, one 
 of whom named Hugh, was destined to play a prominent part historically 
 in spreading the knowledge of the obstetric forceps. 
 
 Hugh Chamberlen was born in 1630. He was an accoucheur and a 
 man of considerable ability, although it is doubtful whether he ever 
 obtained the degree of M.D. In 1670 he visited Paris and became 
 acquainted with the famous obstetrician Mauriceau, to whom he tried 
 to sell the family secret, claiming that by it he could deliver the most 
 difficult case in a few moments. As a test case Mauriceau gave him a 
 rhachitic dwarf. After three hours of vigorous effort he was obliged to 
 acknowledge his failure and the woman died undelivered twenty-four 
 hours later with uterus badly lacerated. Chamberlen returned to Eng- 
 land and lived there several years, but either on account of his unpopular 
 political views or certain financial difficulties, he was obliged to leave 
 
 Fig. 441. — Chamberlen forceps. 
 
 England and moved to Amsterdam, where he spent the remainder of 
 his days. 
 
 While living in Amsterdam he sold his so-called family secret to Room- 
 huysen, an obstetrician, who soon disposed of it to the Medico-Phar- 
 maceutical College of Amsterdam. This college soon secured the sole 
 right to license physicians to practise in Holland and would grant this 
 license only to those who would take the course in obstetrics, pay a 
 special fee, and under pledge of secrecy receive the knowledge of the 
 Chamberlen instrument. This went on until about the middle of the 
 eighteenth century, when it is said two public-spirited citizens of Hol- 
 land, Vischer and Van der Poll, disgusted that what was claimed to be 
 such a boon to humanity should remain a secret, took the medical course, 
 paid the fee for the secret and published it. It proved to be only one 
 blade of the forceps. Whether this was all Hugh Chamberlen disposed 
 
 1 Partridge, History of the Obstetric Forceps, Amer. Jour. Obst., li, 765. 
 
HISTORICAL SKETCH 
 
 747 
 
 of, or whether the college held back part of the secret is not clear. Any 
 doubt existing concerning the association of the forceps with the Cham- 
 berlen family was cleared up by the finding, in 1813; in a trunk in the old 
 Chamberlen house at Essex, formerly occupied by Doctor Peter, four 
 pairs of forceps (see Fig. 441) which had evidently been used by different 
 members of the Chamberlen family and which represented different 
 stages of development in the instrument. They difi^ered from the forceps 
 previously described by Ruoff by having separate blades. 
 
 Fig. 442 
 
 Fig. 443 
 
 Figs. 442 and 443. — Chamberlen forceps. 
 
 The differences in the shape of the blades showed progressive improve- 
 ment and the fact that the lock had been found insufficient is evidenced 
 by the reinforcement by wrapping as shown in the middle two pairs. 
 All the forceps were short forceps with only a cephalic curve and therefore 
 adapted only to low work. The lateral and anteroposterior view of the 
 perfected Chamberlen forceps is shown in Figs. 442 and 443. The credit 
 of introducing the forceps into general use in England belongs to William 
 Giffard, whose book entitled Cases in Midwifery, published by a 
 
748 
 
 FORCEPS 
 
 friend in 1734, shortly after his death, contained a description of 225 
 cases seen by him durinof the years of 1724-1731, in many of wliich 
 he used the forceps. The l)()()k also contains an ilhistration of Ins 
 instrument. 
 
 The next marked improvement in the obstetric forceps appeared about 
 the middle of the eighteenth century, when Levret, in France in 1747, 
 and Smellie in England in 1751, working independently of each other, 
 added a pelvic curve (as seen in Figs. 444 to 447). The Smellie forceps is 
 
 Fig. 444 
 
 Fig. 445 
 
 Figs. 444 and 445. — Levret forceps. 
 
 a shorter forceps than the Levret, has less of a pelvic curve and by Smellie 
 was often covered with leather to prevent slipping. From these two 
 types of forceps, the Smellie, with the English lock and the Ivcvret with 
 the French lock, have descended the long forceps of the present day. 
 
 From the Smellie forceps come the Simpson, the P^lliot and the Tucker- 
 McLane (see Figs. 448 to 453) . From the Levret forceps comes the Hodge 
 forceps, and it was evidently a modification of the Levret forceps to 
 which Tarnier, in 1877, added the traction rods (see Figs. 454 and 455) 
 
HISTORICAL SKETCH 749 
 
 and enunciated the principle of axis traction which has proved of great 
 vahie in high forceps deHvery. - 
 
 From the preceding historical description of the forceps it is seen 
 that there are three chief varieties of the forceps: 
 
 1. The short forceps, illustrated by the Chamberlen and the Smellie 
 forceps. 
 
 2. The long forceps, illustrated by the Levret, the Elliot and the 
 Tucker-]\IcLane. 
 
 3. The axis-traction forceps, illustrated by the Tarnier. 
 
 Fig. 446 Fig. 447 
 
 ( 
 
 f > 
 
 \ 
 
 Figs. 446 and 447. — Smellie forceps. 
 
 It will be noted that there are two varieties of lock, the English lock, 
 in which one blade fits over and into the other, as seen in the Smellie, 
 the Simpson, the Elliot and the Tucker-McLane, and the French lock, 
 in which the blades are held together by a thumb-screw, as is seen in the 
 Levret forceps and in the axis-traction instrument of Tarnier. 
 
 Comparison of the different instruments also shows two varieties of 
 blade: the fenestrated blade, as seen in the Levret, the Tarnier and 
 
750 FORCEPS 
 
 the Elliot forceps and the solid blade, as seen in tlie Sniellie and the 
 Tucker-McLane. 
 
 The relative value of the fenestrated and solid blade will be discussed 
 later. 
 
 The Function of the Forceps. — The chief functions of the obstetric 
 forceps are two: (1) As a tractor. (2) As a rotator. While it is well 
 recognized that other subsidiary actions are, or may be, associated with 
 
 Fig. 448 Fig. 449 
 
 Figs. 448 ami 449. — .Simpsoa forceps. 
 
 the use of the forceps, such as compression, leverage and uterine stimnla- 
 tion, it is u.sually traction and occasionally rotation which are the functions 
 sought. 
 
 Some compression is inevitably associated with every forceps delivery, 
 but it occurs because it is unavoidable in drawing a head through a 
 canal which has to dilate from within outward rather than because com- 
 pression is desired. A slight amount of leverage from side to side is 
 sometimes employed in very difficult deliveries, but is much less employed 
 than formerly and is seldom to be advised. While e^•erv obstetrician 
 
CHOICE OF A FORCEPS 
 
 751 
 
 realizes that traction upon the forceps almost always stimulates uterine 
 contraction, no one thinks of using the instrument solely for that purpose. 
 
 While formerly the use of the forceps as a rotator was decried as too 
 dangerous, the skilled obstetrician of the present day aims at cephalic 
 application of the forceps, and in his delivery of the head with the cephalic 
 application makes frequent use of the power of rotation. 
 
 Choice of a Forceps. — In considering the choice of a forceps for gen- 
 eral use two facts at once become evident: (1) That a so-called long 
 
 Fig. 450 
 
 Fig. 451 
 
 Figs. 450 and 451. — Elliot forceps. 
 
 forceps will do all the w^ork of which a short forceps is capable and will 
 also do its own work, and that there is therefore no reason for the 
 obstetrician to add to the weight of his obstetric bag by carrying a 
 short forceps. (2) That the axis-traction forceps is a complicated instru- 
 ment and rather cumbersonae for simple forceps operations. A skilled 
 obstetrician can do good work with any of the modern long forceps such 
 as the Simpson, the Elliot or the Tucker-McLane and in general will 
 do his best work with the instrument with which he is most familiar. 
 
ro'i 
 
 FORCEPS 
 
 For many years the author used the Simpson forceps in his work and 
 was satisfied with it, but as time went on he began to appreciate that 
 the shoulder in the shanks of the Simpson forceps exposed the tissues 
 of the vulva to greater tension than was necessary and often it was 
 convenient to have a longer instrument. The two simple long forceps 
 which at the present day rival each other in popularity, are the Elliot 
 and the Tucker-^IcLane, and the rivalry depends upon the question: 
 Shall the blade be fenestrated or solid? At the Sloane Hospital and in 
 
 Fig. 452 
 
 Fig. 453 
 
 Figs. 452 and 453. — Tucker-McLane forceps. 
 
 his private practice the author uses and prefers for all ordinary forceps 
 work the Tucker-McLane instrument with the solid blade for the follow- 
 ing reasons: As stated above the skilled obstetrician of today always 
 aims to apply the forceps blades to the sides of the child's head, i. e., 
 a cephalic application. In order to achieve this result it is desirable to 
 have a blade which will introduce easily and will slide around the cir- 
 cumference of the pelvic canal. A solid blade, on account of its lessened 
 tendency to catch upon any projecting object, will do this more easily 
 
CHOICE OF A FORCEPS 
 
 753 
 
 than a fenestrated blade. Furthermore, the blade which will slip off 
 easily when desired, is a great advantage, and that the solid blade will 
 do this more readily than the fenestrated is known by everyone who 
 has used both. The question is, Will the solid blade slip when undesired 
 
 Fig. 454. — Tarnier axis-traction forceps. Traction handle separated. 
 
 more readily than the fenestrated? This question has exceptionally 
 to be answered in the affirmative. It is an undeniable fact that a fenes- 
 trated blade which has been applied firmly to the head and into the 
 fenestra of which the tissues of the scalp have protruded will hold a 
 little more firmly than the solid blade which presses evenly upon the 
 
 Fig. 455. — Tarnier axis-traction forceps. Traction handle attached. 
 
 outer surface of the scalp. On the other hand, if the application of the 
 forceps is as it should be, and the relation between passage and passenger 
 is suitable for forceps delivery, slipping of the solid blade is an accident 
 of the rarest occurrence. Furthermore, the smooth, solid blade.is a little 
 
 48 
 
754 FORCEPS 
 
 less likely to mar the features of the child than is the fenestrated blade. 
 In certain cases of difficult forceps delivery the principle of axis traction 
 advocated by Tarnier and best exemplified in his forceps (see Figs. 454 
 and 455) is extremely valuable, and if one is to practice obstetrics at all 
 extensively he should carry in his obstetric bag two varieties of forceps, 
 one long, plain forceps, and one axis-traction forceps. The author's 
 preference is for a Tucker-McLane and a Tarnier forceps, and these are 
 the two carried in his obstetric bag. 
 
 With these two instruments the obstetrician is provided for all cases 
 suitable for forceps delivery. If for any reason the delivery is extremely 
 difficult and the Tucker-McLane forceps with its solid blades show a 
 tendency to slip (a very rare occurrence), the Tarnier instrument com- 
 bines both the fenestrated blade and the traction rods, thus meeting all 
 indications. 
 
 Indications for Forceps Delivery. — Insufficient Expulsive Power. — One 
 of the most frequent indications for forceps delivery is a lack of expul- 
 sive power either uterine, abdominal, or both, to overcome the resistance 
 of the parturient canal. This resistance may come either from a dispro- 
 portion between passenger and passage or from a malposition of the 
 presenting part. 
 
 The strength of the patient may have been exhausted in dilating a 
 rigid cervix during the first stage, so that little is left for the second. 
 Or, during the second stage, strength which would have sufficed for the 
 delivery of a normal position may have been spent in the vain endeavor 
 to rotate an occipitoposterior. 
 
 Insufficient Progress. — An illustration of this is seen in cases where in 
 the interest of either mother or child it is advisable to terminate the 
 labor speedily, as for instance, eclampsia of the mother or rapidly failing 
 fetal heart. 
 
 Frequency. — This varies largely with the class of patients with which 
 the obstetrician has to deal. Occasionally it is said by those practising 
 in the country that they have practised obstetrics all their lives and 
 have found it necessary to use the forceps in only a few cases. This can 
 only mean one of two things, either that the patients under discussion 
 were very normal women, or that the lives of many children were lost 
 which might have been saved by the skilful use of the forceps. 
 
 At the Sloane Hospital, in 20,000 consecutive labors, forceps delivery 
 was resorted to in 2468 cases, i. e., 12.3 per cent., or approximately 1 to 8. 
 
 In 500 consecutive cases in the author's private practice, in New York 
 City, forceps delivery was resorted to 113 times, i. e., 22.6 per cent., or 
 ap])roximately 1 to 4. 
 
 Contra-indications. — Forceps delivery should be considered contra- 
 indicated in the following conditions: 
 
 1. Where a disproportion between child and parturient canal renders 
 delivery per vias naturales mechanically impossible. 
 
 2. Where the presentation or position makes delivery impossible. 
 
 3. Undilatable cervix. 
 
 4. Unruptured membranes. 
 
DANGERS IN THE USE OF THE FORCEPS 755 
 
 Some of these contra-indications may be removed and then the forceps 
 be properly indicated. Thus a malpresentation or position may be 
 corrected. An imdilatable cervix may be softened or rendered dilatable 
 by the elastic bag or other means. The membranes should always be 
 ruptured before the application of the forceps. 
 
 Dangers in the Use of the Forceps. — These may be either (a) maternal 
 or (b) fetal. 
 
 Maternal Dangers. — The maternal dangers consist chiefly in (1) lacera- 
 tions, (2) fractures, and (3) sloughing. 
 
 Lacerations. — Lacerations of the pelvic floor will occasionally occur 
 with the best of obstetricians, whether the patient is delivered by nature 
 or by the use of the forceps, and at times this laceration is favored by 
 leaving the woman too long in the second stage of labor, until the vulva 
 has become edematous before applying the forceps; in other words, by 
 the neglect of the forceps rather than by the use of the instrument. 
 On the other hand, there are certain dangers of laceration by the forceps 
 which should be recognized and avoided. Among them may be men- 
 tioned: (a) the sudden slipping of the instrument with consequent 
 laceration of the parturient canal on account of an improper application 
 of the instrument; (6) the too rapid extraction of the head, w^ithout 
 giving time for dilatation of the canal; (c) premature elevation of the 
 handles of the instrument as the head approaches the pelvic floor; thus 
 allowing the ends of the blades to project beyond the head and tear the 
 posterior vaginal wall, perhaps even into the rectum. 
 
 Fractures. — The time for brute force in the use of the forceps has 
 passed. The author has had under his care a patient in whose previous 
 labor, the family physician, a large, powerful man, on finding that he 
 was unable to deliver her with the forceps by his own strength, called in 
 a colleague, who with arms around his waist, pulled upon the attending 
 physician while he pulled upon the forceps. Is it any wonder that in 
 such cases separation of the symphysis or fracture of the coccyx occurs? 
 Straining of one or both of the sacro-iliac joints is also a not unusual 
 result of such improper force. 
 
 In this connection it may be well to mention that in certain cases in 
 which the coccyx has been previously fractured by a fall and has united 
 at an angle, a refracture may occur either under the proper use of the 
 forceps or even by the unaided efforts of nature. In one of the author's 
 cases this occurred in her first and second confinements, which were for- 
 ceps deliveries, and in her third confinement, which was otherwise 
 normal, the coccyx was heard to snap under the normal expulsive powers 
 of nature. 
 
 Sloughing. — Under the influence of too long and too powerful traction 
 upon the forceps, especially if this traction is not intermittent, the soft 
 parts may be so compressed against the bony pelvis as to lose their vitality 
 and sloughing occur. This was formerly the cause of many of the cases 
 of vesicovaginal fistula. Since the proper use of the forceps has been 
 better understood and the instrument has been used before the woman 
 has been left too long in the second stage, fistulse have become less and 
 less frequent. 
 
756 FORCEPS 
 
 From the above it is seen that sloughing may occur either from neglect 
 to use the forceps at the proper time, or from too forcible or too continuous 
 traction upon the instrument when used. 
 
 Fetal Dangers. — The dangers to the fetus in a forceps delivery are 
 three: Compression, fracture, and laceration. 
 
 Compression. — A too long and too forcible extraction of a child through 
 a parturient canal too .small for the fetal head in question may cause 
 a cerebral compression and hemorrhage and result either in fetal death 
 at the time of delivery or soon after, or in cerebral impairment, perhaps 
 idiocy, later in life. On the other hand, a case left too long in need of 
 forceps delivery may have just as serious compression and with just as 
 serious consequences. This is the Scilla and Charybdis between which 
 the skilful obstetrician endeavors to safely steer the fetal bark. 
 
 Frachire. — Fracture of the fetal skull is possible, but usually occurs 
 either from an improper application of the forceps or from an attempt 
 to deliver a head too large for the given canal. 
 
 Lacerations. — Lacerations of the fetal scalp, face, or neck usually 
 occur from one or more of the following causes: 1. From an improper 
 application of the forceps to the child's head. The instrument is con- 
 structed to be applied to the sides of the child's head, i. e., along the 
 occipitomental diameter. If it grasps the head with one blade over an 
 eye and the other over the occiput, or if one blade reaches down on the 
 neck and the other over the forehead, the forceps is apt to slip and 
 lacerati(ms occur. 
 
 2. If traction is made upon the force])s before the blades are properly 
 locked, the blades are not parallel and the edge of one at least is apt 
 to cut into the tissues of the scalp. 
 
 3. Slipping of the forceps from any cau.se usually produces lacera- 
 tions of the fetal scalp or face. 
 
 Varieties of Forceps Operations. — For purposes of description and 
 record, three varieties of forceps operations are recognized: 
 
 1. The high-forceps operation, when the instrument is applied to a 
 head of which the greatest biparietal diameter has not passed the brim 
 plane. This head may be floating or engaged. 
 
 2. The medium-forceps operation, when the head lies in the cavity of 
 the pelvis, i. e., when the greatest biparietal diameter has passed the 
 brim plane. 
 
 3. The low-forceps operation, when the head lies on the pelvic floor, 
 i. e., when the greatest biparietal diameter has passed the plane of the 
 bony outlet. In this case the caput is usually in sight. 
 
 The frequency of the indication for the ditterent varieties of forceps 
 operation may be seen from the following statistics of the Sloane 
 Hospital. 
 
 In the 2468 forceps operations occuring in 20,000 consecutive deliveries 
 there were: 
 
 1778 low operations 8.90 per cent., or 1 to 11 
 
 472 medium operations 2.30 per cent., or 1 to 43 
 
 218 high operations 1 .09 per cent., or 1 to 92 
 
TECH NIC OF THE FORCEPS OPERATION 
 
 757 
 
 Of the 1778 low-forceps operations, 1453 were performed in primi- 
 gravidse, or 81.7 per cent., and 325 were performed in multigravidse, or 
 18.3 per cent. Of the 472 medium- 
 forceps operations, 324 were per- 
 formed in primigravidfe, or 68.6 
 per cent., and 148 were performed 
 in multigravidae, or 31.4 per cent. 
 
 Of the 218 high-forceps opera- 
 tions, 87 were performed in primi- 
 gravidse, or 40 per cent., and 131 
 were performed in multigravidee, 
 or 60 per cent. 
 
 Technic of the Forceps Opera- 
 tion. — Position of the Patient. — 
 In America it is generally agreed 
 that whether a normal delivery is 
 conducted with the patient on her 
 back or on her side, in an obstetric 
 operation like a forceps delivery, 
 there is only one position for the 
 patient, i. e., the so-called lith- 
 otomy position; the patient lying 
 on her back, at the edge of the 
 bed or table, with knees elevated and held in this position by some 
 variety of leg-holder. In a hospital the feet are usually held in canvas 
 stirrups attached to metal uprights at the foot of the table, but in 
 
 Fig. 456.— Robb's leg-holder. 
 
 Fig. 457. — Robb's leg-holder in position. 
 
 private practice a canvas leg-holder, usually called Robb's leg-holder (see 
 Fig. 456), which will pass over one shoulder and then about each knee 
 
758 
 
 FORCEPS 
 
 (see Fig. 4n7), will, on accomit of its light weight and small compass, 
 generally be found most convenient. 
 
 In cases of emergency a folded or twisted sheet may be used for this 
 purpose, but it is wiser to carry a canvas leg-holder in one's obstetric 
 l)ag. The dorsal position has the further advantage that the fetal heart 
 can l)e watched by an assistant during the forceps delivery, and after 
 the delivery of the child, the fundus may be held and if necessary 
 manipulated without change of posture. 
 
 
 Fig. 458 
 
 Preparation of the Patient. — Before the use of the forceps the vulva 
 should ])e closely clipped or shaved if this has not been ])reviously 
 attended to. The bladder should be emptied either voluntarily or by 
 catheter, not only because all the available space in the pelvis is desired 
 for ease of extraction, but also because severe traction and pressure 
 against a distended bladder would endanger that viscus. Furthermore, 
 if a distended portion of the bladder is caught in front of the head, 
 traction upon the latter would tend to loosen the bladder from its pubic 
 
TECH NIC OF THE FORCEPS OPERATION 759 
 
 attachments and favor cystocele. It is taken for granted that the 
 rectnm has been emptied by enema earlier in the labor, but it is fitting 
 that attention should be directed to the fact that the rectum as well as 
 the bladder should be emptied in all forceps operations. 
 
 After emptying the bladder, the vulva and inner surfaces of the thighs 
 should be thoroughly scrubbed with sterile soap and water, disinfected 
 and properly draped, especial care being taken to cover the rectum and 
 to leave exposed only the vulvar field; the surroundings of this field 
 being covered with sterile stocking-drawers and sterile towels or sheets 
 (see Fig. 458). 
 
 The patient should be anesthetized until she is thoroughly under 
 control. The author was once called upon to operate upon a case of 
 ruptured uterus in a woman, who being only partially anesthetized, 
 pushed over her obstetrician, after he applied the forceps, raised herself 
 upon the bed and sat down upon the handles of the instruments as they 
 projected from the vulva, thus causing an incomplete rupture of the uterus. 
 
 Application of the Forceps. — Before discussing the details of the dif- 
 ferent forceps operations, the meaning of the term "application" should 
 be made clear. Two different methods of applying the forceps for the 
 delivery of a child are possible: 
 
 1. The two blades may be introduced, one to one side of the pelvis 
 and the other to the other side, and then locked, grasping any part of the 
 fetal head which lies between them. This was for many years the method 
 used in England and has been generally known as the English method, 
 or the pelvic application. This method considers only the sides of the 
 pelvis in the introduction of the forceps and regards the fetal head chiefly 
 as a foreign body to be extracted from it. 
 
 2. In the medium- and low-forceps operation the long diameter of the 
 head usually, but by no means always, lies in the anteroposterior diam- 
 eter of the outlet and the blades introduced one on each side of the pelvis 
 would under these circumstances be applied to the sides of the child's 
 head but without regard to whether the occiput was anterior or posterior. 
 
 The application sought today by all skilled obstetricians is the cephalic 
 application, sometimes called the "continental method," as distinguished 
 from the English. In this application of the forceps, the blades are 
 applied to the sides of the child's head whatever its position in the 
 pelvis. This method presupposes an accurate diagnosis of the position 
 of the child before the use of the instrument. 
 
 The cephalic application of the forceps is not only more scientific 
 in favoring the natural mechanism of labor, but it brings the pressure of 
 the instrument upon that diameter of the fetal head which is least liable 
 to injury from it. 
 
 The steps of the operation may be regarded as follows: 
 
 1. Diagnosis of the presentation and position. 
 
 2. Introduction of the blades. 
 
 3. Locking of the blades. 
 
 4. Traction. 
 
 5. Removal. 
 
7()0 FORCEPS 
 
 Diagnosis of the Presentation and Position of the Child. — So important 
 is it that the obstetrician should know just the problem with which he 
 has to deal, that the author would lay stress upon the need for an accu- 
 rate diagnosis of the presentation and position of the child and the 
 relative size of the pelvis before attempting the introduction of the 
 forceps. 
 
 The reasons for this are obvious: If it is a breech presentation the 
 forceps is rarely indicated, at least until after the birth of the shoulders. 
 If it is a \ertex presentation with an occipitoposterior position, the 
 forceps is usually not to be introduced until at least partial manual 
 rotation of the head has been accomplished. If the pelvis is too small 
 for delivery 2^^^ ^"o-? naturales the forceps should not be used at all. 
 For these reasons an accurate diagnosis of the conditions present should 
 first be made. If necessary for this purpose even the whole hand shoidd 
 be introduced into the vagina for palpation of the sutures and fontanelles. 
 Many obstetricians feel for and identify the posterior ear as a means of 
 diagnosis of position, but this is, as a rule, unnecessary as the sutures and 
 fontanelles usually furnish the desired information. 
 
 Methods of Introduction of the Blades. — Two methods of introduction 
 of the forceps blades are possible, (a) The lateral, (b) The posterior. 
 The lateral introdiiction consists in passing the left blade to the left side 
 of the pelvis and the right blade to the right side of the pelvis and then 
 adjusting the blades to the sides of the child's head. 
 
 The posterior introduction consists in passing the left blade along the 
 middle of the posterior vaginal wall with the concavity of the blade 
 upward, then passing the right blade held in the right hand, with its 
 convexity sliding along the concavity of the left blade, until the handles 
 are even, then rotating both blades simultaneously until they rest upon 
 the sides of the fetal head. 
 
 For normal cases, with occiput anterior, the lateral method of intro- 
 duction is preferable. The posterior introduction in these cases is both 
 more diflRcidt and more likely to do harm. In fact the posterior intro- 
 duction in its complete form has never been satisfactory to the author, 
 but in cases with occiput posterior the combination of the posterior 
 and lateral introduction has proved of very great value. In these cases, 
 after manual rotation of the occiput as nearly forward as is possible, 
 the blade corresponding to the side on which the occiput has lain is 
 introduced in the median line posteriorly and rotated around to the 
 side of the fetal head, thus holding and increasing the rotation accom- 
 plished by the hand. 
 
 The other blade is then introduced laterally so as to avoid rotating 
 the head in the opposite direction, and is applied to the opposite side 
 of the fetal head. If the position was an L. O. P., after manual rota- 
 tion forward of the fetal head, the left blade would be the one to intro- 
 duce first and posteriorly and after its rotation to the side of the fetal 
 head the right blade would be introduced laterally to the right side of 
 the pelvis. Its shank and handle lying anteriorly to those of the left 
 blade, the two would lock naturally. If the position was an R. O. P., 
 
TECH NIC OF THE FORCEPS OPERATION 761 
 
 after manual rotation forward of the fetal head, the right blade would 
 be the one to introduce first and posteriorly and after its rotation to the 
 side of the fetal head, the left blade would be introduced laterally to the 
 left side of the pelvis. The shank and handle of the left blade will now 
 lie anterior to those of the right, and the two blades will not lock until 
 the handle of the left blade has been carried underneath that of the right. 
 
 With a little adjustment of the two blades they will now lock with 
 ease. 
 
 Technic of Introduction of the Forceps Blades. — In all methods of 
 introduction of the forceps blades, save in the cases where the head is 
 distending the vulvar outlet, the fingers of one hand should be introduced 
 into the vagina far enough to feel the cervix or to ascertain that the 
 cervix had receded out of reach, the function of these vaginal fingers 
 being to guide the forceps blade into the cervical canal. 
 
 In the lateral method of introduction the left blade is usually the 
 first to be introduced and the fingers of the right hand are introduced 
 into the vagina to serve as a guiding groove along which the left blade 
 is to pass into the cervical canal and on to the side of the fetal head. 
 
 In holding the left blade for introduction, the handle is taken lightly 
 between the thumb, fore- and middle fingers of the left hand and is raised 
 and held well to the right above the pubes so that the curve of the con- 
 cavity of the blade will correspond to the convexity of that side of the 
 fetal head; the blade is then passed along the concavity of the vaginal 
 fingers which insure its entrance into the cervical canal, rather than 
 passing to the outer side of the cervix, and is then made to pass gently 
 to the side of the fetal head. As this is done the handle is gently depressed, 
 carried to the median line and allowed to rest on the edge of the perineum. 
 
 The fingers of the left hand are then introduced into the vagina as a 
 guide for the right blade to the cervical canal, the handle of the right 
 blade being held lightly in the fingers of the right hand as was the left 
 handle in the left hand; at first held high and to the left above the 
 pubes, then gradually depressed and carried to the median line until it 
 rests upon the left blade just introduced. The shanks of the two blades 
 are now adjusted until they lock easily. 
 
 When the first blade is introduced posteriorly the handle of the instru- 
 ment may be held lightly in the grasp of the whole hand; first elevated 
 in the median line then gradually depressed as the concavity of the 
 blade slides along the convexity of the head. 
 
 Loching of the Forceps Blades. — ^AYhen the blades are properly applied 
 to the sides of the fetal head they should lock without difficulty, and it 
 is extremely important that the obstetrician should see that the blades 
 are carefully locked before any traction is exerted. With blades locked, 
 the upper and lower edges of the two blades lie in two parallel planes 
 and are not likely to cut the scalp when traction is made upon the 
 handles. If the blades, on the other hand, are not completely locked 
 when traction is exerted, the edges of the two blades do not lie in parallel 
 planes, and the lower edge of one or both blades is apt to cut the scalp or 
 the cheek. 
 
762 FORCEPS 
 
 Traction. — After the locking of tlie forceps blades traction is in order, 
 hut at first should he only tentative with one hand on the handles of 
 the instrument, while the fingers of the other hand are kept against the 
 fetal head to make sure that the head aihances with the traction and 
 that the blades are not slipj)ing from the head. In the exercise of trac- 
 tion upon the forceps two principles should always be observed: 
 
 1. The traction should always be in the axis of the parturient canal, 
 this varying with the height of the head in the pelvis. 
 
 2. The traction should be intermittent, thus imitating nature in her 
 intermittent uterine contractions and allowing opportunity for the 
 reestablishment both of the fetal circulation and the circulation of the 
 soft parts of the parturient canal. In addition to regular intermission 
 in the traction it is advisable also to intermit in the pressure of the 
 blades upon the fetal head by separating the handles of the instruments 
 between the tractions. Great care should be taken, however, to see that 
 the blades are carefully locked again before traction is renewed, as other- 
 wise cutting of the scalp or cheek, as already mentioned, is apt to occur. 
 
 Removal of the Blades. — As soon as the head has been brought suffi- 
 ciently low in the parturient canal to allow its further delivery to be 
 under the control of the hands of the obstetrician, the blades should be 
 removed for two reasons: 
 
 1. Even the thin blades of the forceps occupy a certain amount of 
 room, and their absence diminishes the tension to which the vulvar outlet 
 is subjected. 
 
 2. The head can usually be delivered more gradually and under more 
 perfect control by the hands than by the forceps, and hence laceration 
 is avoided by removal of the blades before the complete delivery of the 
 head. 
 
 The ease with which the solid blade is removed, as compared with the 
 fenestrated, is easily demonstrated at this time. 
 
 Forceps Delivery in Occipitoposterior Positions of the Vertex.— As 
 already indicated in discussing the introduction of the forceps blades, 
 the ideal method of forceps delivery in occipitoposterior positions is 
 to apply the instrument to the sides of the child's head after manual 
 rotation has brought the occiput in front of the transverse diameter of 
 the pelvis. 
 
 Thus in an R. O. P. position, rotate manually to an R. O. A., introduce 
 the right blade first in the median line posteriorly and slide it around 
 the right side of the pelvis until it lies on the right side of the child's 
 head ; then introduce the left blade to the left side of the pelvis and apply 
 it to the left side of the child's head and adjust the handles so that the 
 left lies below the right; then lock the blades and begin traction.' 
 
 In certain cases, however, where it is impossible to rotate the head 
 manually, the double application of the forceps may be necessary. 
 
 Double Application of the Forceps. Scanzoni's Maneuver. — In this 
 method of forceps delivery in occipitoposterior positions, the blades are 
 applied to the sides of the fetal head with occiput still posterior and 
 the concavity of the pelvic curve of the instrument anterior. 
 
DELIVERY BY MEANS OF THE AXIS-TRACTION FORCEPS 763 
 
 The head is brought down to the floor of the pelvis and the rotation 
 of the occiput forward is then favored by gentle manipulation with the 
 instrument as follows: Flexion of the head is favored by upward trac- 
 tion on the forceps; the handles are then turned slowly and gently to 
 the side opposite to the occiput and then allowed to fall slowly downward 
 and backward. This brings about the rotation of the occiput forward, 
 but leaves the forceps with the convexity of the pelvic curve anterior, 
 i. e., the forceps is reversed. The instrument is now withdrawn, reapplied 
 as in an occipito-anterior position and the delivery completed. 
 
 Delivery by Means of the Axis-traction Forceps. — In many cases of 
 the high-forceps operation, and occasionally in the median operation, 
 delivery is difficult on account of the difficulty of exerting traction 
 in the axis of the superior strait, which if continued downward would 
 pass through the lower part of the sacrum. The presence of the coccyx 
 and the perineum rendering impossible sufficient depression of the 
 handles of the forceps to exert traction in this direction, much of the 
 traction force is wasted by drawing the head against the symphysis pubis 
 rather than downward in the axis of the parturient canal. 
 
 Fig. 459. — Pajot's maneuver. 
 
 This defect in the ordinary forceps was recognized nearly a century 
 before Tarnier, in 1877, devised the instrument which bears his name, 
 and two suggestions were made for overcoming the difficulty: one by 
 Saxtorph, was to attach tapes or traction strings to the fenestree of the 
 blades and make traction upon these as well as upon the handles of the 
 instrument. The other, usually called Pajot's maneuver (see Fig. 459) 
 was to make strong downward pressure with one hand near the lock of 
 the instrument, while the other made traction on the handles. 
 
 The most perfect instrument for carrying out the principle of axis 
 traction is that of Tarnier (seen in Figs. 454 and 455). It consists of the 
 long French instrument, with French lock and fenestrated blades, and 
 in the shank of each blade near the fenestra an adjustable traction rod 
 is inserted, which when not in use is snapped over a pin lower down on 
 the shank. When about to be used, the traction rods are freed from the 
 holding pins and fitted into a common handle and cross-bar, which has 
 nearly a universal joint. The ordinary handles of the instrument are 
 not employed for traction, while the traction rods are in use, but serve 
 
764 FORCEPS 
 
 to indicate the direction in which traction sliould be made. Traction 
 is exerted on the cross-bar handle in such a direction as will keep the 
 traction rods nearly parallel to the shanks of the blades and about 1 cm. 
 below them. When this simple rule is followed the traction is made in 
 the axis of the parturient canal; is accompanied by the least friction, and 
 is most effective. While the ordinary handles are not used for traction 
 in the high operation with this instrument, the\' are useful for two 
 purposes: (1) They serve as a guide to the direction for traction, and 
 (2) they are often useful in favoring rotation of the head while traction 
 is made on the traction rods. While some obstetricians use this instru- 
 ment for all forceps operations, without the traction rods for low and 
 median operations, and with the traction rods for the high operation, 
 the author regards the instrument as too complicated and cumbersome 
 for the low and ordinary medium operations, and prefers for this work 
 the Tucker-McLane forceps seen in Figs. 452 and 453, reserving the axis- 
 traction instrument for the difficult high operations. 
 
 Technic of Delivery with the Axis-traction Forceps. — Whether the trac- 
 tion rods of the axis-traction forceps are to be used or not, the blades 
 are introduced singly with traction rods snapped over the holding pins 
 and without the handle and cross-bar. Each blade is introduced in a 
 manner already described for the simple instrument, the left blade being 
 the one usually introduced first. After introduction of the blades their 
 shanks are adjusted and locked with the thumb-screw of the French 
 lock. 
 
 The compression screw lying on the anterior surface of the shanks 
 just in front of the handles should, in the judgment of the author, be used 
 only to maintain the amount of pressure of the blade upon the head, 
 which is given by the obstetrician when the blades are locked, not for 
 the purpose of increasing this compression as the delivery proceeds. The 
 blades having been introduced and locked, the traction rods, if to be used, 
 are unsnapped from their holding pins and the cross-bar handle adjusted 
 to them. 
 
 Traction is now exerted upon the cross-bar in such a way that the 
 traction rods are parallel to, and just below, the regular handles, until 
 the head has been brought sufficiently low to be easily controlled by the 
 hand upon the perineal surface. The cross-bar handle should then be 
 disconnected; the traction rods snapped upon the holding pins; the 
 lock unscrewed and the blades removed from the head. 
 
 Forceps Delivery in Face Presentation. — It is well recognized that 
 with a normal pelvis and a full-sized fetus, delivery of the head in face 
 presentation with chin persistently posterior is impossible, hence the use 
 of the forceps solely as a tractor in this presentation and position is inap- 
 plicable. In a few exceptional cases, however, in skilled hands, the forceps 
 may be used to favor rotation of the chin to the front, this motion of 
 rotation being combined w^th traction and thus an otherwise impossible 
 delivery per mas naiurales is accomplished. 
 
 With the face in a transverse position, or especially in a mento-anterior 
 position, the indications for the use of the forceps are practically the 
 
FORCEPS DELIVERY IN FACE PRESENTATION 
 
 765 
 
 same as in a vertex presentation with head lying transversely or in an 
 occipito-anterior position, viz., insufficient expulsive power, or insuffi- 
 cient progress. In both cases the blades are applied to the sides of the 
 fetal head along the occipitomental diameter (see Figs. 460 and 461), 
 but while in vertex cases the application desired is one with the pelvic 
 
 Fig. 460. — Forceps application. Vertex presentation. 
 
 curve of the forceps directed toward the back of the fetal neck, in face 
 cases the application desired is one with pelvic curve directed toward 
 the front of the fetal neck. In vertex cases it is the occiput which lies 
 nearer the lock, while in face cases it is the chin. In vertex cases flexion 
 is the motion desired until the presenting part has engaged under the 
 symphysis, while in face cases extention is the motion desired. 
 
 Fig. 461. — Forceps application. Face presentation. 
 
 If either the occiput or the chin lies in the transverse diameter of the 
 pelvis, rotation to the anteroposterior diameter is desired. 
 
 In a forceps delivery of a face presentation, with chin anterior, the 
 blades are applied to the sides of the head and traction is made in a down- 
 ward direction until the chin emerges from beneath the symphysis; 
 
76G FORCEPS 
 
 the handles are then elevated and traction exerted in an npward direction, 
 the nose, eyes and forehead sweepin<2; in turn over the fourchette. 
 
 The Use of Forceps in a Breech Presentation. — In a complete breech 
 presentation, where the feet lie near the breech, the forceps is practically 
 never indicated for the delivery of the breech itself, as one or other foot 
 can be })rought down and the foot and leg used as a tractor. 
 
 In the frank breech, with legs extended, this statement also usually 
 applies, although the hand of the obstetrician may have to be intro- 
 duced nearly to the fundus uteri to reach the foot. In very rare cases, 
 however, when the frank breech is impacted in the pelvis, and the uterus 
 so contracted that the introduction of the hand would be accompanied 
 b}^ the da,nger of uterine rupture, the use of the forceps ma>' be indi- 
 cated as a means of delivery. In such instances it must be borne in mind 
 that the trochanters are the parts of the breech best suited for the 
 application of the forceps. 
 
 With one blade applied to one trochanter and the other to the other 
 one, traction may be exerted which will accomplish the delivery of the 
 breech without injury to the child. 
 
 Forceps Delivery of the After-coming Head. — The Mauriceau-Smellie- 
 \>it method of delivering the head, with the two fingers of one hand in 
 the fetal mouth to maintain flexion, and the fingers of the other hand 
 on the fetal shoulders to exert traction (see Fig. 424), will usually succeed 
 in delivering the after-coming head without the use of any instrument. 
 In rare instances, however, where the obstetrician is unable to complete 
 the delivery within the time necessary to secure a living child, the forceps 
 serves a most useful purpose. In these conditions, with the occiput 
 anterior, the body of the child is raised by an assistant or nurse and the 
 blades of the instrument are applied underneath the body, to the sides 
 of the child's head, along the occipitomental diameter, the chin being 
 near the shanks of the forceps and the pelvic curve of the instrument 
 being directed toward the back of the child's neck. With the patient 
 in the lithotomy position, traction is made forward and upward, the 
 mouth, nose, eyes and forehead sweeping over the fourchette as the back 
 of the child approaches the mother's abdomen. 
 
 In the rare cases where, in the attempted delivery of the after-coming 
 head, the obstetrician has not succeeded in rotating the occiput to the 
 front, some recommend the introduction of the blades above the child's 
 body, the concavity of the pelvic curve being directed to the front of 
 the child's neck. In such cases traction would be made downward and 
 backward as the back of the child approaches the back of the mother. 
 
 Mortality of Forceps Operation. — Maternal. — In the author's series 
 of 2468 forceps operations there were 30 maternal deaths, or a maternal 
 mortality of 1.2 per cent. It should be remembered, however, that 
 ])ractically all of the deaths were caused l)y the condition of the mother 
 before the instrument was introduced. Furthermore, the general 
 maternal mortality of the Sloane Hospital, in a consecutive series of 
 20,000 deliveries, was 1.09 per cent., so that the increased mortality 
 in forceps operations was not great. 
 
MORTALITY OF FORCEPS OPERATION 7G7 
 
 Fetal Mortality. — The fetal mortality is seen to vary with the type of 
 operation. Thus in the 1778 low-forceps operations there were 180 
 fetal deaths, or a fetal mortality of approximately 10 per cent. In the 
 472 medium operations there were 94 fetal deaths, a mortality of 19.2 
 per cent. In the 218 high-forceps operations there were 84 fetal deaths, 
 a mortality of 38.5 per cent. The total fetal mortality in the 2468 
 forceps operations of all types was 358, or 14.5 per cent. This total 
 mortality includes not only stillbirths, but death of the children from 
 any cause while the mother remained in the hospital. The stillbirths 
 in forceps operations of different types were markedly less. Thus in 
 the 1778 low-forceps operations the stillbirths were 4 per cent.; in the 
 472 medium-forceps operations the stillbirths were 8.5 per cent.; in the 
 218 high-forceps operations the stillbirths were 26.2 per cent. Total 
 stillbirths were 6.9 per cent. 
 
CHAPTER XXVI. 
 VERSION. 
 
 Version is the substitution of some other part of the fetus for that 
 which presents at the superior strait. By version a transverse or an 
 obhque presentation is changed into one which is longitudinal, or one 
 pole of the fetus is substituted for the other. 
 
 Version is classified either according to the part which is made to 
 present or according to the method b}' which the change is brought 
 about. According to the former classification, version is cephalic 
 when the head is made to present; jjelvic when the breech is made to 
 present; podaJic when the feet are made to present. Classified according 
 to method, version is called external when the manipulations are per- 
 formed externally through the abdominal wall; it is called combined 
 or bipolar or Braxton Hicks version when one or two fingers of one 
 hand are introduced through the cervix, while the other hand assists 
 in the manipulation by working from without through the abdominal 
 wall. It is called internal version when one hand is introduced into the 
 cavity of the uterus. The difference between internal version and 
 combined or bipolar version, as performed today, depends chiefly upon 
 the amount of the hand introduced into the uterus, as in both cases the 
 other hand assists by manipulations through the abdominal wall. In 
 internal version the whole hand is in the uterine cavitj', while in com- 
 bined version only the fingers are in the uterus, the rest of the hand 
 being in the vagina. 
 
 Indications. — The indications for the performance of version are 
 numerous and vary with the variety, but in general they may be stated 
 as follows: 
 
 1 . To Exchange a Less Favorable Presentation for One More Favorable 
 for Delivery. — As, for instance, to change a transverse to a longitudinal 
 presentation. 
 
 2. To Secure a Speedy Delivery. — As, for instance, in eclampsia. 
 
 3. To Accomplish Delivery in a Flat Pelvis. — The employment of version 
 for this purpose is based on the fact that as the biparietal diameter of 
 the fetal skull measures 9.25 cm. and the bimastoid diameter measures 
 only 7.5 cm., the vault of the fetal head is broader than its base. Hence, 
 if the fetus is delivered by the breech, the smaller end of the cephalic 
 wedge is first brought through the pelvic canal and delivery through a 
 flat pelvis is thus facilitated. 
 
 4. To Furnish a Uterine Tamponade by Partial Breech Extraction.^This 
 is especially employed in a placenta previa to prevent hemorrhage by 
 pressure upon the placental site. 
 
 ( 768 ) 
 
METHODS OF VERSION 769 
 
 5. To Lessen Pressure upon the Cord in Certain Cases of Prolapse of the 
 Cord. — ^As, for instance, where maintenance of replacement is impossible. 
 
 In studying the above group of indications it will be seen that, save 
 perhaps in the first, it is podalic version which is indicated and best 
 meets the situation. 
 
 METHODS OF VERSION. 
 
 External Version.— As already stated, in external version all manipu- 
 lations are conducted externally; i. e., the hands of the obstetrician work 
 through the abdominal wall of the patient, pushing out of the pelvic 
 brim the portion of the fetus undesired there and pushing down the 
 fetal part which it is desired to have present. 
 
 Conditions. — For the successful accomplishment of external version the 
 following conditions must, as a rule, be present: 
 The liquor amnii present. 
 The fetus freely movable. 
 The uterine and abdominal walls relaxed. 
 The abdominal wall not too fat. 
 
 Indications.- — ^As a rule external version is only indicated during preg- 
 nancy or very early in labor. It finds its chief indications in a breech 
 presentation which it is desired to change to a vertex and in an oblique 
 or transverse presentation which it is desired if possible to change to a 
 vertex, or failing in that, to a breech presentation. 
 
 Technic. — With bowels and bladder empty, the patient should lie 
 on the back with thighs flexed and abdomen bared and as thoroughly 
 relaxed as possible. The exact presentation and position of the fetus 
 should be carefully determined and then the pole of the fetus which it 
 is desired to have present should be gently pressed with one hand toward 
 the pelvic brim, while with the other hand the undesired pole is gently 
 moved away from the brim in the opposite direction (see Fig. 462) . 
 
 In a breech presentation the author usually prefers to turn the fetus 
 as indicated by the arrows, maintaining flexion. In a few instances it 
 may be easier to turn in the opposite direction. 
 
 In a transverse or shoulder presentation the manipulations may be 
 conducted with the obstetrician standing either above or below the 
 pelvis of the patient (see Figs. 463 and 464). The author usually prefers 
 the former. 
 
 It is the experience of most obstetricians that while in many cases, 
 as for instance, in breech presentations with lax abdominal walls it is 
 easy to perform the version, it is extremely difficult to maintain the 
 result, and one is often disappointed at the end of a day or two to find 
 again a breech presentation. The use of a pad on the side of head and 
 breech toward which they tend to move and a snug abdominal binder 
 will sometimes maintain the corrected presentation, and as soon in the 
 course of the labor as the cervix is sufficiently dilated to justify rupture 
 of the membranes, the escape of the liquor amnii and contraction of 
 the uterus will prevent the return of the malpresentation. So long as 
 there is very little risk in attempting the correction of a malpresentation 
 49 
 
770 
 
 VERSION 
 
 by external version it is i)erfectly justifiable to try it even if disappoint- 
 ments are common. 
 
 Combined or Bipolar Version. — In this method which was perfected 
 and popularized by Braxton Hicks and occasionally called by his name, 
 one hand in the vagina with two fingers in the cervix works on one pole 
 of the fetus, while the other hand externally works through the abdominal 
 wall on the other pole of the fetus. 
 
 Fig. 4G2. — External version in a breech presentation. 
 
 Conditions. — For this method of version the liquor amnii must be 
 present or only recently drained away. The fetus must be movable. 
 The cervix must be sufficiently dilated to admit one or two fingers. The 
 abdominal and uterine walls must be relaxed. 
 
 Indications. — The chief indication for combined or bipolar version in 
 its complete form is a placenta previa in which, before the cervix is suffi- 
 ciently dilated to admit the hand it is desired to pull down one leg and 
 thigh to serve as a uterine tamponade to control hemorrhage. 
 
 Technic. — AVith the patient in the lithotomy position under anes- 
 thesia, with the bowels and bladder empty and the vulva aseptically 
 
METHODS OF VERSION 
 
 771 
 
 prepared, the sterile gloved hand, folded in cone shape, is gently passed 
 between the separated labia into the vagina as far as the cervix. Two 
 fingers of this hand are then passed through the cervix and work on the 
 lower portion of the fetus while the other hand on the abdomen works 
 on the upper portion (see Fig. 465). If it is a podalic version which is 
 desired, as is usually the case in a placenta previa, the steps of the opera- 
 tion mav be outlined as follows : 
 
 Fig. 463. — External version in a transverse presentation. Obstetrician above the pelvis. 
 
 1. Displacement of the presenting part which is undesired. 
 
 2. Downward pressure upon the part desired in the pelvis, i. e., one 
 of the lower extremities. 
 
 3. Rupture of the membranes. 
 
 4. Traction on the lower extremity from within while elevation of the 
 head is assisted by the other hand from without. 
 
 The above might be called a typical complete version by the com- 
 bined or bipolar method. It is also frequently indicated in transverse 
 cases in which it is not necessary to go far to reach and bring down the 
 
VERSION 
 
 part desired. In eiddition to this the obstetrician often makes use of a 
 method which might be called a partial version })y the combined or 
 bipolar method; /. e., with one hand in the vagina and two fingers in 
 the cervical canal, while the other hand works through the abdominal 
 wall, he changes the position of the presenting part so as to facilitate 
 delivery. As instances of this may be mentioned the partial rotation 
 of the. head from an occipitoposterior to an occipito-anterior position; 
 the flexing of a poorly flexed head, etc. 
 
 Fig. 464. — External version in a transverse presentation. Obstetrician below the pelvis. 
 
 Advantages of Combined Version. — 1. It can be performed before the 
 cervix is sufficiently dilated to allow of the passage of the hand. 
 
 2. If strict asepsis and reasonable care observed the operation carries 
 with it scarcely any danger to either mother or child. 
 
 Disadvantages. — The chief disadvantage lies in the fact that two fingers 
 working in the cervical canal have but a limited control over the fetal 
 parts which come within reach. 
 
METHODS OF VERSION 
 
 773 
 
 Internal Version. — In this method the whole hand is passed into the 
 uterine cavity (see Fig. 466) and works on the part desired while the 
 other hand assists externally through the abdominal wall. In internal 
 version the part desired to be brought down through the cervical canal 
 is usually a foot, hence internal version is usually synonymous with 
 podalic version. Podalic version is frequently performed in placenta 
 previa by the combined method, but this is about the only condition 
 in which the podalic version is not postponed until the cervix is suffi- 
 ciently dilated to admit the hand. Even in placenta previa it is the 
 author's custom to perform internal podalic version after mechanical 
 dilatation with the elastic bag rather than version by the combined 
 method. 
 
 Fig. 465. — Combined or bipolar version. 
 
 Conditions. — The conditions under which an internal version is a 
 suitable procedure are extremely important to recognize. They are as 
 follows: . 
 
 1. The cervix must be dilated, or dilatable enough to allow of the 
 passage of the obstetrician's hand. 
 
 2. The uterus must not be so firmly contracted as to make rupture 
 liable. 
 
 The last condition will be emphasized when discussing the contra- 
 indications to version. 
 
 Technic. — The first step is to determine as far as possible by external 
 palpation the exact presentation and position of the fetus. The patient 
 
774 
 
 VERSION 
 
 should then bo anesthetized and catheterized if she has not recently 
 emptied her bhidder. She should be placed in the lithotomy position 
 with vulva shaved, disinfected and surrounded with sterile drapery. 
 The liands and forearms of the obstetrician should be carefully scrubbed 
 and disinfected and, of course, sterile gloves should be worn. 
 Two (piestions now present themselves: 
 
 1. ^Yhich hand shall be introduced? 
 
 2. Which foot shall be brought down? 
 
 The hand introduced should be that whose palm naturally comes in 
 apposition to the abdomen of the fetus. Thus, in a vertex presenta- 
 
 FiG. 466. — Internal version. 
 
 tion, if the fetal back lies to the left, the left hand of the obstetrician 
 should be introduced, and vice versa. 
 
 The anterior foot, i. e., the one lying nearest to the anterior uterine 
 wall, should be first brought down for several reasons: 
 
 1. It is usually a simpler mechanism, and the version is more apt to 
 occur in one plane. 
 
 2. It is more apt to bring the fetal back to the front. 
 
 3. Being a simpler mechanism, it is less apt to displace the arms to 
 the back of the neck. 
 
 Having selected the hand to be introduced, the obstetrician folds it 
 in conical shape and passes it gently into the vagina ])etween the labia 
 
METHODS OF VERSION 775 
 
 which are carefully separated by the fingers of the other hand. Having 
 reached the cervix, if this is not sufficiently dilated to allow of the pas- 
 sage of the closed fist, the cervical canal should be gently dilated until 
 the closed fist will easily pass up and down through it. It must be remem- 
 bered that it is the after-coming head which is likely to cause most diffi- 
 culty in delivery, hence a complete dilatation of the cervix is desired. 
 In this connection it may be mentioned that it is of advantage that 
 each obstetrician should compare the size of his closed fist with that 
 of the fetal head, so that he may estimate the amount of dilatation 
 when his fist will pass through the cervical canal. If the membranes 
 are unruptured and no loops of cord are felt in the lower uterine segment, 
 they may be ruptured soon after passing the cervix. If loops of cord 
 are felt, it is well to go higher before rupturing the membranes. As a 
 rule only one foot should be seized, and this by inserting the thumb over 
 the instep with the forefinger just above the heel. The characteristics 
 of a foot as compared to a hand have already been mentioned (see page 
 297). If a uterine contraction comes on, no attempt at version should 
 be made until the contraction passes off. During a period of uterine 
 relaxation the seized foot may be brought down through the cervical 
 canal, while the other hand of the obstetrician from without the abdomen 
 lifts up the head and favors the version. The half-breech as it comes 
 through the cervix still further dilates it and prepares the way for the 
 after-coming head. After the half-breech has passed the vulvar outlet 
 and the other foot has been delivered, the further conduct of the case is 
 that of ordinary breech extraction (see page 711). 
 
 In a transverse or shoulder presentation, not infrequently an arm 
 is found prolapsed through the cervix into the vagina. Under such cir- 
 cumstances it is sometimes an advantage to put a sterile bandage as a 
 fillet around the wrist of the prolapsed arm and have it loosely held by 
 an. assistant during the version, so that extension of the arm by the side 
 of the head or behind the neck will be avoided. 
 
 In transverse presentations the seizure of the anterior foot, i. e., the 
 one nearer the anterior uterine wall, is the method of choice. 
 
 Contra-indications. — One of the most important phases of internal 
 podalic version is its contra-indications. A neglect of these has cost the 
 life of many a woman from rupture of the uterus, hence the necessity of 
 their careful consideration. 
 
 Internal podalic version is contra-indicated: 
 
 1. When the uterus is in tonic contraction, i. e., when the liquor 
 amnii is drained away and the uterus is contracted on the child, with 
 little relaxation. In this condition the lower uterine segment is usually 
 thinned out; the upper segment is elevated, and the lower segment will 
 not endure without rupture the additional tension incident to the version. 
 
 2. When the pelvis is too small for the delivery of a breech presen- 
 tation. In general it may be stated that a true conjugate of less than 
 8 cm. is too small for the safe delivery of the after-coming head of a 
 full-sized child, hence with a pelvis of this size internal podalic version 
 should not be attempted. 
 
CHAPTER XXVII. 
 DELIVERY BY METHODS DISTINCTLY SURGICAL. 
 
 SYMPHYSEOTOMY AND PUBIOTOMY. 
 
 For many years it has been known that on account of the mobility 
 at the sacro-iliac joints and the fact that these joints converge from 
 above downward, if the anterior pelvic wall is divided, the end of the 
 innominate bones will swing downward and outward, enlarging the 
 pelvic canal. The enlargement is greater in the transverse and oblique 
 diameters than it is in the anteroposterior, although the space is 
 increased by the gap between the ends of the pubic bones. 
 
 There have been in use in obstetrics two methods of division of the 
 anterior pelvic wall for enlarging the parturient canal. In one the 
 division has been made through the joint at the symphysis (see Fig. 467) 
 
 Fig. 467. — Division of the anterior pelvic wall in symphyseotomy and pubiotomy. 
 
 and is called symphyseotomy; in the other the division has been made 
 through the pubic bone itself, usually the left, and is called pubiotomy. 
 As symphyseotomy was first introduced, it will be first considered. 
 
 Symphyseotomy. — This operation was first performed on a living sub- 
 ject by Sigault,^ in 1777, who succeeded by it in delivering a woman with 
 a rachitic pelvis, of a living child after four successive stillbirths. The 
 mother survived, although she had a permanent urinary fistula, and had 
 difficulty in walking. Although for a time the operation was performed 
 with considerable enthusiasm, the complications were found to be so 
 numerous and the mortality so high that it soon fell into disfavor. In 
 
 ' Discours sur les avantages de la section de la symphyse dans les acconchemens, etc., 
 Paris, 1779. 
 
 ( 776 ) 
 
SYMPHYSEOTOMY AND PUBIOTOMY 777 
 
 1866 the operation was revived by Morisani, of Naples, who was able 
 to reduce the mortality to 20 per cent. Spinelli, in 1891, reintroduced 
 the operation in France and it soon became a popular operation with 
 Pinard at the Baudelocque Clinic. The first operation in this country 
 was performed by Jewett, in 1892, and during the succeeding five years 
 nearly every obstetrician with a hospital service performed a few opera- 
 tions. The operation, however, on account of the uncertainty of obtain- 
 ing a living child, the tedious convalescence, perhaps permanent 
 disability of the mother, and its high mortality, gradually fell into disuse 
 and is now practically obsolete. 
 
 Technic. — In general there have been three methods of operating: 
 
 1. The Italian or suprapubic method. 
 
 2. The French or open method. 
 
 3. The American or Ayer's method. 
 
 The Italian or Suprapuhic MetJwd. — In this method, which was the 
 one followed by jNIorisani, a short incision is made in the median line 
 just above the pubis, sufficiently large to admit the index-finger between 
 the symphysis and the peritoneum. The peritoneum and bladder are 
 pushed away from the sjTuphysis and along the finger thus introduced 
 a blunt-pointed, curved knife is passed and the symphysis divided from 
 behind forward and from below upward. The original knife w^as quite 
 a heavy instrument, and was called a Galbiati knife, although subse- 
 quently a blunt-pointed, curved bistoury was often used. 
 
 The French or Open Method. — In this method, which was the one 
 followed by Pinard at the Baudelocque Clinic, an incision is made along 
 the front of the symphysis and the joint divided from before backward 
 under direct inspection. The incision begins just above the symphysis 
 and stops just above the clitoris, which is pulled a little to one side to 
 avoid wounding it. 
 
 The American Subcutaneous or Ayer's^ Method. — In this a small 
 incision is made a little above the subpubic arch, and under the elevated 
 clitoris a narrow tenotomy knife is passed with the point close to the 
 joint up to within one-half inch of the top, separating the overlying 
 soft tissues from the joint; a probe-pointed bistoury is substituted 
 for the tenotomy knife, and under the guidance of a finger in the vagina 
 the symphysis is divided from above downward and from before back- 
 ward. 
 
 In all these methods of operating it is customary to catheterize the 
 bladder and with the catheter to hold the urethra to one side while 
 dividing the symphysis. 
 
 Result of Dividing the Symphysis. — It is often found that even after 
 the division of the sjrtnphysis the pubic bones are held in apposition by 
 the strong subpubic ligament. When this is divided, however, the 
 ends of the bones separate from 3 to 6 cm. If this separation is allowed 
 to exceed 6 cm. it is usually found that the sacro-iliac joints are strained 
 and may cause distressing sjTiiptoms afterward. It is generally regarded 
 
 1 Amer. Jour. Obst., July, 1897, xxxvi, 1-15. 
 
778 DELIVERY BY METHOD!^ DISTINCTLY SVBCICAL 
 
 that a st>i)arati()n of cm. at the symphysis increases the conjugate 
 diameter of the pelvis about 12 mm., the other diameters of the pelvis 
 being correspondingly increased. In order to prevent the separation 
 of the pubic bones beyond the safe limit of 6 cm., the trochanters during 
 the operation should be supported by an assistant on each side of the 
 patient. 
 
 In a few instances the symphysis is found so calcified that the division 
 has to be made with a chain-saw rather than with a bistoury. 
 
 Steps of the Operation. — After thorough aseptic preparation of the field 
 of operation, the symphysis is divided by one of the methods already 
 described. The author in his operations usually preferred the Italian 
 method. After the division of the symphysis and while the trochanters 
 are still supported by assistants, the child should be delivered by forceps 
 or version, although some obstetricians have advocated leaving the 
 case to nature after division of the symphysis. After delivery of the 
 child and expulsion of the placenta the ends of the pubic bones are 
 approximated, great care being taken that the bladder is not caught 
 between the ends of the bones. The soft parts over the joint are sutured ; 
 a sterile dressing is applied, and over this dressing broad strips of rubber 
 adhesive plaster, extending around the pelvis. In order to supplement 
 the action of the adhesive straps in holding the pubic bones in apposition 
 it has been customary to keep the patient in a hammock-bed or a Brad- 
 ford frame for about three weeks. 
 
 Indications. — For a time the indications for s\'mphyseotomy were 
 thought to be furnished by those contractions of the pelvis which are 
 now regarded as relative indications for Cesarean section, i. e., conju- 
 gate diameters varying from 9 cm. to 7 cm. At the present day, however, 
 s^Tnphyseotomy is scarcely ever performed, either a Cesarean section 
 or rarely a pubiotomy being preferred. 
 
 Prognosis. — The great drawbacks to the operation of symphyseotomy 
 are its high maternal mortality and morbidity and its high fetal mor- 
 tality. In spite of all care the position of the wound, the close approxi- 
 mation of the thighs, and the constrained position of the patient make 
 cleanliness difficult to maintain and drainage poor. These conditions 
 readily lead to infection and phlebitis is not uncommon. ^Moreover, 
 vaginal tears and tears extending into the bladder are relatively frequent. 
 The convalescence is tedious and even after the patient is out of bed 
 the mobility at the symphysis is often such as to cause a waddling gait 
 for several months. The union at the symphysis after symphyseotomy 
 is fibrous rather than bony, and this occasionally leads to a slight per- 
 manent enlargement of the pelvis favorable for subsequent deliveries, 
 but often associated with a mobility which causes fatigue on severe 
 exertion. A great drawback to the operation, aside from the high 
 maternal morbidity and mortality is the difficulty in determining whether 
 a living child can be extracted after the operation and the high fetal 
 mortality resulting. At the International Congress in Amsterdam in 
 1899, Barnes presented statistics giving the maternal mortality of 
 symphyseotomy as 10.8 per cent., and the fetal mortality as 14. ."i per 
 
PUBIOTOMY 
 
 779 
 
 cent. Although these percentages have more recently been lowered by 
 individual operators, the operation is not one to be recommended. 
 
 Pubiotomy. — In this operation, which is called also hebosteotomy, 
 the anterior wall of the pelvis is divided by an incision, not through the 
 symphysis, but through one of the pubic bones, usually the left, at a 
 little distance from the symphysis. The advantages claimed for pubi- 
 otomy over symphyseotomy are : 
 
 1. That the incision being through bone rather than cartilage, will 
 heal more readily and with less risk of infection. 
 
 2. That the lateral incision does not deprive the urethra and bladder 
 of their natural supports as does the median operation. 
 
 Fig. 468. — Pubiotomy, showing incision made and needle passed. 
 
 These arguments were strongly presented by Gigli,^ in 1894, and he 
 invented the flexible saw which bears his name and by which most of 
 these operations are performed. - Although the operation was suggested 
 by Gigli, it was performed by Bonard, Calderini, Van de Velde and others 
 before him. Furthermore, the open operation of Gigli was soon 
 improved by Doderlein and Bumm, who in 1904 and 1906 respectively, 
 made the operation more or less subcutaneous. Doderlein's method 
 consists in making a short transverse incision just above the upper 
 margin of the pubic bone, extending about 2.5 cm. inward from the 
 pubic spine. A finger is then passed in separating the tissues from the 
 posterior surface of the bone (see Fig. 468) and along the finger a strong 
 needle, resembling an aneurysm needle, is passed until the lower edge 
 
 ' Taglio lateralizzato del pube, sua vantaggi, sua tecnica, Ann. di os. e gin, 1894, No. 10. 
 
780 
 
 DELIVERY BY METHODS DISTINCTLY SURGICAL 
 
 of the how is reached. It is then curxed sharply forward and over its 
 projecting {)oint in the hibium niajus a small incision is made. The 
 point of the needle is then made to emerge and into its eye is hooked the 
 end of the flexible saw which is withdrawn with the needle through the 
 upper opening. The upper handle is then attached and (see Fig. 469) 
 the saw is ready for work. In using the saw care should be taken to 
 keep the line of the saw between the two handles as straight as possible, 
 as in this way the saw is less likely to break. The sawing should be con- 
 tinued until the bone is completely severed and the saw moves freely 
 beneath the skin. As the saw is withdrawn there is usually quite free 
 bleeding, but this, as a rule, soon ceases on gauze pressure. As soon as 
 the bone is severed a slight gaping occurs and as traction is made on the 
 child the separation of the ends of the bones increases. As in symphyse- 
 otomy, 6 cm. should be considered the limit of safe separation and any 
 
 Fig. 469. — Pubiotoniy. Flexible saw in place. 
 
 further separation should be avoided by pressure upon the trochanters 
 by assistants. 
 
 In Bumm's method the operation is made still more subcutaneous: 
 The needle is made to enter the upper part of the labium majus, is carried 
 up behind the pubic bone, under the guidance of a finger in the vagina, 
 and is made to emerge through the skin just above the upper margin 
 of the pubic bone, between the spine and the symphysis. The saw is 
 then hooked into the eye of the needle and drawn into place from above 
 downward. The strongest advocate of pubiotomy in this country has 
 been Professor J. Whitridge Williams, of Johns Hopkins University, 
 and his results have certainly been brilliant. Up to January, 1912, 
 he, together with his assistants had performed 38 successful pubiotomies 
 upon 36 patients, 2 women having been operated on twice. The method 
 followed by Williams has been that of Doderlein (see Figs. 468 and 469) 
 
PUBIOTOMY 781 
 
 and is the one usually followed in this country. As in symphyseotomy a 
 long strip of rubber plaster is passed around the pelvis over the sterile 
 dressing and the patient is kept in a Bradford frame for two weeks. 
 Williams allows his patients to try to walk on the second or third day 
 after getting up. 
 
 Indications and Contra-indications. — The indication for pubiotomy, 
 like that for s\TQphyseotomy, is a moderate disproportion between head 
 and pelvis, with mother and fetus in good condition, as for instance, in 
 a simple flat pelvis a conjugate varying from 7 to 8.5 cm., and in a 
 justominor flat, a conjugate varying from 7.5 to 9 cm., depending upon 
 the size of the fetal head. Fully as important as the indication for 
 pubiotomy are its contra-indications: 
 
 1. Pubiotomy should not be selected when the pelvis is too small to 
 allow of the passage of the head after division of the pubic bone and 
 separation of the ends for a distance of 6 cm. This is naturally difficult 
 in some cases to determine. 
 
 2. Pubiotomy should not be done when the mother is infected. 
 
 3. Pubiotomy should not be performed when the vitality of the 
 fetus is low or its life very uncertain. 
 
 The second and third contra-indications to pubiotomy bring the opera- 
 tion into competition with abdominal Cesarean section. When first 
 introduced, it was thought that pubiotomy might find a field when the 
 time for an abdominal Cesarean section had passed, as when the woman 
 had been in labor for hours and perhaps after frequent attempts at 
 delivery and maternal infection was feared. Most operators have 
 reached the conclusion, however, that under these circumstances pubi- 
 otomy is contra-indicated as well as Cesarean section. 
 
 Prognosis. — In the hands of the best operators the maternal mortality 
 of pubiotomy has been reduced below 2 per cent. ; thus, Doderlein, in 
 1910, collected 321 pubiotomies, performed in seven German clinics 
 ■up to that year, with a mortality of only 5.8 per cent. The lowest fetal 
 mortality in the hands of the best operators ranges between 4 and 8 
 per cent. This brings the lowest maternal mortality of pubiotomy 
 about on a par with the lowest maternal mortality of Cesarean section, 
 but the lowest fetal mortality, 4 to 8 per cent., is still much higher than 
 the fetal mortality of Cesarean section, which is practically 7iil in similar 
 cases. Moreover, when comparing pubiotomy with Cesarean section, 
 the common complications and morbidity must be considered as well 
 as the mortality. 
 
 Objections to Pubiotomy.- — The hemorrhage occurring during a pubi- 
 omy is usually venous and easily controlled by pressure, but at times 
 it is profuse, and may be difficult to check. The vaginal tears, even after 
 dilatation of the cervix, are sometimes quite extensive and need repair. 
 Injuries of the bladder, either by direct tear or from pressure and necrosis, 
 are not uncommon. Thrombophlebitis is a rather common complication 
 of the convalescence. The above complications studied in connection 
 with the uncertainty of securing a living child by the operation, make 
 one hesitate to recommend the operation. 
 
782 
 
 DELIVERY BY METHODS DISTINCTLY SURGICAL 
 
 CERVICAL INCISIONS AND VAGINAL CESAREAN SECTION. 
 
 In order to avoid the deep, irregular cervical tears which are apt 
 to follow a rapid delivery through a rigid, undilated cervix, Diihrssen,^ 
 in 1890, recommended that deep incisions be made in the vaginal portion 
 of the cervix. These incisions were made in either the anterior or the 
 posterior halves of the cervix, or both, but the lateral portions were 
 avoided. They were carried to the vaginal junction and caused an 
 immediate enlargement of the cervical canal. They were sutured after 
 
 Fig. 470. — Lines of incision in anterior vaginal wall. 
 
 the completion of the labor. This method of enlarging the canal has met 
 with little favor in this countr\', as it was soon found that the incisions 
 did not reach high enough to remove the resistance at the internal 
 OS, and that extensive lacerations which were often difficult to suture 
 were apt to follow. Furthermore, hemorrhages sometimes occurred 
 which were difficult to control. For these reasons most obstetricians in 
 
 ' Uchor (Ion Werth der tiefen Cervix unci Srheiden Damn M.M. Einsehnitte in der Geburt- 
 shiilfe, Archiv f. Gyn., 1S90, xxxvii. 27 66; Transactions of the American Gynecological 
 Society, 1906, xxxi, 116-127; Der \'aginale Kaiserschnitt, Berlin, 1S96. 
 
CERVICAL INCISIONS AND VAGINAL CESAREAN SECTION 783 
 
 recent years, when they have used "Diihrssen's incisions," have Hmited 
 their employment to cases in which the cervix has become obhterated, 
 but the OS has continued rigid. Even here the author beheves that 
 gradual dilatation, either with the fingers or with an elastic bag, is prefer- 
 able. However, he admits that a clean cut is preferable to a ragged 
 laceration, and in rare instances, where in the interest of either mother 
 or child it is necessary to hurry the delivery, a cervical incision may be 
 of value. In these instances one or tM'o incisions will often answer as 
 well as more and time is saved in suturing. 
 
 Fig. 471. — Separating vaginal flaps from uterus and bladder. 
 
 Realizing that incision of the vaginal portion of the cervix did not 
 enlarge the canal sufficiently for immediate delivery, Diihrssen devised 
 the operation which, in 1895, he described under the name of "anterior 
 vaginal hysterotomy," and in 1896 called vaginal Cesarean section. 
 
 The operation consists of an incision through the cervix, either anteriorly 
 or both anteriorly and posteriorly, extending high enough into the lower 
 uterine segment to furnish a sufficient enlargement of the uterine canal 
 
784 
 
 DELIVERY BY METHODS DISTINCTLY SURGICAL 
 
 for the delivery of the child. This operation necessitates a separation 
 of the bladder and the anterior fold of peritoneum from the lower uterine 
 segment. 
 
 Technic. — The patient is placed in the lithotomy position; the 
 bladder is emptied; the vulva is shaved and it, together with the vagina, 
 is aseptically prepared. The field of operation is aseptically draped as 
 for any vaginal or perineal operation. Two volsella forceps are applied 
 to the anterior lip of the cervix, one on each side of the median line, and 
 
 i»C5^*- 
 
 Fig. 472. — Division of cervix and lower 
 uterine segment. 
 
 Fig. 473. — Separation of uterine incision, 
 showing bulging membranes. 
 
 the cervix is brought down into view^ (see Fig. 470) . An inverted T-shaped 
 incision is made in the anterior vaginal w^all, the horizontal part of the 
 incision being made at the cervicovaginal junction, and the longitudinal 
 incision beginning about an inch posterior to the meatus. The triangular 
 vaginal flaps thus outlined are then separated from the uterus and the 
 bladder, partly by dissection and partly by pressure with a gauze sponge 
 (see Fig. 471). The next step in the operation is to separate the bladder 
 from the uterus and to raise it so as to expose the lower uterine segment. 
 This separation is done chiefly by pressure with a gauze sponge. Then 
 
VAGIXAL CESAREAN SECTION 
 
 785 
 
 follows a division of the lower uterine segment in the median line (see 
 Figs. 472 and 473). If sufficient room is not furnished by this anterior 
 incision alone, as is apt to be the case after the eighth month, a trans- 
 verse incision should be made at the cervico vaginal junction posteriorly, 
 and the rectimi and peritoneum pushed away from the uterus. The 
 posterior lip of the cervix is then divided in the median line as far up 
 as may be necessary (see Figs. 474 and 475). The delivery is then 
 accomplished by either version or the forceps, the former being usually 
 the preferable operation. If the posterior incision has been made, it is 
 
 Fig. 474. — Division of posterior lip of ceri,-is. 
 
 usually wise to suture this before suturing the anterior incision. The 
 incisions in the uterus are sutured before those of the vaginal walls (see 
 Figs. 476 and 477). Catgut is used throughout and the endometrium is 
 avoided. 
 
 Indications. — The chief indication for vaginal Cesarean section is an 
 eclampsia in which the cervix is long and rigid, the child not large, 
 and the condition of the mother such that a speedy delivery seems 
 imperative, i. e., that the time required for a dilatation by means of an 
 elastic bag would greatly endanger the welfare of the mother or child, 
 50 
 
rsG 
 
 DELIVERY BY METHODS DISTINCTLY SURGICAL 
 
 or both. In yent'ral the indications for vaginal Cesarean section may 
 he stated as conditions in which a speedy delivery is urgently demanded, 
 and in which the obstacle to the delivery lies solely in the undilated 
 cervix. Thus in certain cases of premature separation of the placenta, 
 or in certain cases of cardiac disease, etc., the operation has a valuable 
 field of usefulness. It is contra-indicated in a contracted pelvis with 
 dystocia therefrom, as it does not enlarge the bony canal. It is per- 
 
 FiG. 475. — .Sepaiaticju of anterior and posturior uterine incisions, sliowing Ijulgiug 
 
 membianes. 
 
 formed by some in placenta previa, but as the cervix is usually soft in 
 this condition, the author prefers either dilatation with an elastic bag 
 or an abdominal Cesarean section to the vaginal operation. 
 
 Disadvantages. — The operation of vaginal Cesarean section must not 
 l)e considered a simple operation, which can easily be performed by the 
 general practitioner who has not had experience in vaginal operations. 
 It may be a difficult operation. The cervix may not readily pull down 
 so as to expose the lower uterine segment (as shown in Fig. 472). This 
 
VAGINAL CESAREAN SECTION 
 
 787 
 
 may require making the upper part of the uterine incision by the sense 
 of touch rather than sight. During the dehvery the uterine incision 
 may be extended by tearing, and a hemorrhage occur which it is difficult 
 to check. In most cases the uterus after dehvery can be pulled down 
 so that with suitable retractors the upper limit of the incision or tear 
 can be seen and sutured, but in some cases this is not easy. Occasionally, 
 in spite of all care, the bladder is injured in the delivery and a vesico- 
 vaginal fistula results. The author believes that while the operation 
 is a valuable addition to our different methods of rapid delivery, it is 
 
 Fici. 476. — Suture of uterine aud ^•aginal 
 incisions. 
 
 Fig. 477. — Operation conipk-tud. 
 
 not one to be lightly undertaken, especially by a novice. For a full de- 
 scription of the operation and results the reader is referred to Diihrssen's 
 article in Winckel's Handbuch der Gehurtshillfe, 1905. 
 
 CESAREAN SECTION. 
 
 The operation by which the fetus is delivered through the uterine 
 and abdominal walls by an incision through each is called a Cesarean 
 section.. 
 
788 DELIVERY BY METHODS DISTINCTLY SURGICAL 
 
 The origin of this term has been surrounded with a great deal of 
 obscurity and been the subject of much discussion. Many have thought 
 that Juhus Caesar was deHvered in this way and that the operation 
 derived its name from him. Careful investigation, however, has found 
 no authority for this view. 
 
 Two other views which are more credible are: (1) That the operation 
 derived its name in some way from the Latin verb caedere, to cut, or (2) 
 that the Roman law, requiring the abdomen of a pregnant woman 
 dying near term to be opened and the child removed, enacted under 
 Xuma Pompilius, anfl called "lex regia," came to be called under the 
 Caesars or other emperors, the Cesarean law. It would then be an 
 easv step to transfer the name Cesarean from the law to the operation 
 itself. 
 
 History. — Although postmortem Cesarean section, /. e., removal of 
 the child through the uterine and abdominal walls of a woman soon after 
 l^er death, had undoubtedly been performed many times, even before 
 the Christian era, the first reported attempt to perform Cesarean sec- 
 tion on a living woman was that of Jacob Xufer, a Swiss swinegelder, 
 who, in 1500, successfully operated on his own wife after the midwives 
 and barbers who were in attendance had failed to deliver her. A study 
 of the details of this case seem to indicate that it was not a true Cesarean 
 section, but the removal from the abdomen of a fetus in a case of advanced 
 ectopic gestation. The first authentic case of the Cesarean section 
 was pr()ba]:)ly that of Trautman, of \Vittenl)erg, who performed the 
 operation in 1610. After this the operation was occasionally done, but 
 always with a high mortality, as the uterus was not sutured and aseptic 
 methods were unknown. Even as late as 1876 more than 50 per cent, 
 of the women died from hemorrhage or infection. In 1876 a distinct 
 advance was made and the mortality of the operation lowered by the 
 suggestion of Porro, who recommended, after the removal of the child, 
 constriction of the cervix; amputation of the body of the uterus and 
 stitching the cervical stump in the lower angle of the abdominal wound. 
 This prevented hemorrhage and the leakage of lochia into the abdominal 
 cavity and lessened the risk of infection. This soon became the popular 
 method of performing the operation and held its own until 1882, when 
 Sanger, by the introduction of the practise of suturing the incision in 
 the uterus, established the operation on a permanent basis. 
 
 The Sanger method of suturing and leaving the body of the uterus 
 was soon found to have so many advantages over the Porro operation, 
 with its sloughing stump and slow healing, that the Porro operation soon 
 fell into disuse save in cases where tumors were present in the uterus. 
 ^^ ith the development of the technic of supravaginal hysterectomy 
 for fibromyomata, in which dropping the cervical stump into the pelvic 
 cavity proved to be the best procedure, this operation soon took the 
 place of the Porro operation when a hysterectomy was indicated in the 
 course of a Cesarean section 
 
 ^^ ith the improvement in surgical technic, asepsis and suture 
 material, the mortalitv of Cesarean section toda^ in clean cases is less 
 
CESAREAN SECTION 789 
 
 than 3 per cent., but the operation itself is practically that recom- 
 mended by Sanger in 1882. 
 
 Indications. — The indications for the performance of Cesarean section 
 are either positive or relative. 
 
 A positive indication is present when the parturient canal for any 
 reason is so narrowed that the child cannot be delivered through it with 
 safety to the mother. 
 
 A relative indication exists when, even if the child could be delivered 
 through the natural passages. Cesarean section offers greater safety to 
 both mother and child. 
 
 Positive indications are most often presented by the pelvis itself, 
 but may be caused by tumors, by certain fixed malpositions of the 
 uterus, as in ventrofixation, or vaginal fixation, etc. x\s far as the pelvis 
 itself is concerned, a full-term child of average size cannot be delivered 
 alive through a pelvis with a conjugate diameter of less than 7 cm. Hence 
 a pelvis of 7 cm. or less in its conjugate is considered a positive indication 
 for a Cesarean section. As a dead child cannot be delivered by crani- 
 otomy through a conjugate of less than 5 cm., this measurement of con- 
 jugate is considered a positive indication for Cesarean section, even 
 when the child is dead. 
 
 A transverse diameter of 7 cm. at the pelvic outlet is usually regarded 
 a positive indication for Cesarean section, but this depends upon the 
 length of the posterior sagittal diameter (see page 657) and a transverse 
 diameter of 7 cm. at the outlet may present only a relative indication 
 for the operation. 
 
 Relative Indications. — The mortality and morbidity of Cesarean sec- 
 tion have been so reduced in recent years by improvement in technic 
 and early operation that many conditions which years ago would not 
 have been thought of as belonging in the class in which Cesarean sec- 
 tion would be justified, are now considered as presenting relative indica- 
 tions for this procedure. 
 
 As far as the pelvis is concerned, a conjugate of 8.5 cm. in a simple 
 flat and 9 cm. in a justominor flat pelvis may with every justice present 
 a relative indication for Cesarean section. On the other hand, a pelvic 
 canal may be roomy enough for the birth of a small child and yet present 
 a relative indication for Cesarean section with a larger child. From 
 this it occasionally happens that a woman may be delivered naturally 
 or with the aid of the forceps in her first labor and yet be best delivered 
 by Cesarean section in her second labor, when the child is larger. 
 
 Occasionally cases of eclampsia with a long, rigid cervix and cases 
 of central placenta previa with rigid cervix and profuse hemorrhage 
 present relative indications for Cesarean section. The same may be 
 said of certain cases of accidental hemorrhage with a long, rigid cervix. 
 In the author's opinion, however, these indications in eclampsia and 
 placenta previa are very exceptional and, as a rule, he prefers to dilate the 
 cervix with an elastic bag and deliver through the natural passages. 
 It should always be remembered when considering" the indications for 
 Cesarean section, that usually the uterine cicatrix is not as strong as the 
 
700 DELIVERY BY METHODS DISTIXCTLY SVEGICAL 
 
 uncut uterine wall, and tliat if a woman is once subjected to a Cesarean 
 section, there is always more or less risk of thinning of the uterine cicatrix 
 or even rupture of the uterus in subsequent labors, if they are at all 
 difficult or prolonged. Hence, if a woman has once been dehvered by 
 Cesarean section, it is usually, though not ahvays, wiser to follow this 
 procedure in subsequent labors, imless they are very easy. 
 
 An idea of the relative frequency of the different indications for 
 Cesarean section may be gained by the following list of indications in 
 a series of 150 Cesarean sections performed by the author at the Sloane 
 HospitaL The operation was performed on account of: 
 
 Contracted pelvis 116 
 
 Fibromyomata 8 
 
 Ventral fixation 6 
 
 Vaginal fixation 2 
 
 Dermoid cyst 4 
 
 Ovarian cystadenoma 3 
 
 Congenital displaced kidnej's (.5 times in same patient) 5 
 
 Carcinoma of cervix "1 
 
 Double uterus, one-half obstructing 1 
 
 Abnormally large child 1 
 
 Weakened walls from pre\nous Cesarean section 2 
 
 Toxemia, long rigid cervix 1 
 
 150 
 
 ^Yhen studying the relative indications for Cesarean section, certain 
 general facts must be considered. There are naturally many border-line 
 cases in which before labor it is impossible to tell whether the patient 
 will be able to deliver herself unaided or by the use of the forceps, or 
 not. So much depends upon the character of her uterine contractions 
 and upon the moldability of the fetal head, that nothing but the test 
 of labor will determine it. Realizing that if a Cesarean section is per- 
 formed in the first labor, the uterine cicatrix will probably be a source 
 of anxiety in each subsequent pregnancy and very likely another Cesar- 
 ean section will be considered advisable, the author is strongly of the 
 opinion that in all border-line cases the woman in her first pregnancy 
 should be given a test labor of several hours to see if she is not able either 
 to deliver herself naturally, or at least to bring the presenting part within 
 the range of a median- or low-forceps operation. Every obstetrician has 
 occasionally met with surprises in this direction, and even after pre- 
 parations for a Cesarean section, the operation has been found unneces- 
 sary. In spite of the low mortality of Cesarean section at the present 
 day, it is an ordeal more or less dreaded by both husliand and wife, and 
 if it can once be demonstrated that natural labor is possible, a great 
 dread, which otherwise would shadow each pregnancy, is lifted from the 
 family. Hence the advantage of a test labor of moderate length to deter- 
 mine whether or not Cesarean section is really necessary. On the other 
 hand, as will be seen when studying the mortality of the operation, 
 this is increased by a long labor, by rupture of the membranes, and by 
 frequent examinations. Hence, if a Cesarean section is likely to be neces- 
 sary, great care should be taken in the test labor to avoid causes of 
 increased mortality. The chief object sought in a Cesarean section 
 
CESAREAN SECTION 791 
 
 which is relatively indicated, is a living cliikl vith the least danger and 
 damage to the mother. To attain this end both mother and child must 
 be in good condition at the time of operation. To perform a Cesarean 
 section and deliver a defective child or one whose vitality has been so 
 reduced by the prolonged pressure of a long labor or so injured by 
 attempts at forceps delivery that it survives but a few hours, is a great 
 disappointment to everybody. On the other hand, to deliver by 
 Cesarean section a child which lives while the mother is lost from 
 infection because the operation was postponed too long and the risks 
 were multiplied by repeated examinations and long labor after rupture 
 of the membranes, is bad obstetrics. A Cesarean section is indicated 
 only when mother and child are in good condition; either are, or can be, 
 placed in good surroundings, preferably in a well-appointed hospital, 
 and in cases in which examinations have been few^ and under the strictest 
 aseptic precautions. If, during pregnancy, it has been determined that 
 a Cesarean section is indicated, it is desirable that no vaginal examina- 
 tions be made near the time of operation. In this way one source of 
 infection is avoided. 
 
 Time of Operation. — ^While it is an advantage, on account of drainage 
 of lochia, to have the cervix dilated at the time of the operation, it is not 
 necessary to wait for the onset of labor in setting the time for a Cesarean 
 section. It is desirable to have the pregnancy at term and the child as 
 vigorous as possible^ but the advantages of complete preparations, good 
 light and assistants, all of which may be obtained if the hour for the 
 operation is elective, more than outweigh the advantages of a cervix 
 dilated by labor, which may begin unexpectedly and demand prepara- 
 tions and assistants which are those of emergency. If there has been 
 no labor and the cervical canal is not sufficiently dilated for drainage, 
 this dilatation may be accomplished by passing the finger down through 
 the cervix from above, while the hand is in the uterus. The author 
 has been impressed with the fact that the cervix does not have to be as 
 much dilated as he formerly supposed, and that after a Cesarean sec- 
 tion the lochia often seems less than after a normal, delivery and he has 
 explained it by the possibility that the decidua in many cases is more 
 completely wiped off with the gauze sponges used in the course of a 
 Cesarean section than is cast off in a normal labor. 
 
 Technic. — The preparation of the patient and the selection and 
 preparation of instrmnents should be the same as for any abdominal 
 hysterectomy. While, as a rule, the Sanger operation, in which the uterus 
 is not removed, is the operation of choice, the decision may be reached 
 in the course of the operation that the interests of the mother are best 
 served by a hysterectomy, hence one should be prepared for it. Aside 
 from the operator and the anesthetist, three assistants are needed : One 
 to help at wound, one to hand instruments, and one to receive and care 
 for the baby. The baby is more or less anesthetized by the anesthesia 
 of the mother, hence the anesthesia should be skilfully administered, 
 and the mother kept under its influence as short a time as possible before 
 the deliverv of the child. 
 
792 
 
 DELIVERY BY METHODS DISTINCTLY SURGICAL 
 
 Tilt' Iiiri.sloN. — 111 the iiKMlern Cesarean section the incision, hotii in 
 the ah(h)iniiial and uterine walls, is just lon^' enou^li to achnit of the 
 (lehvery of tiie fetal head. As a rule 10 cm., or 4 inches, suffices; the 
 choice of the site of the incision varies somewhat with different operators. 
 Some prefer an incision entirely above the umbilicus, while others prefer 
 one whose midpoint is opposite the umbilicus. The author prefers the 
 latter incision for several reasons: 
 
 1. With the lower incision the uterus is less likely to slip away from 
 the abdominal wound as the child is extracted. This is important, as 
 
 cleanliness of the abdominal cavity is se- 
 cured by keeping the uterus in close appo- 
 sition to the abdominal wound. 
 
 2. If the Cesarean section is to be com- 
 pleted with a hysterectomy, it is more 
 easily performed through the lower incision. 
 8. If, on account of previous infection 
 of the uterine cavity, infection of the 
 uterine wall should occur, a readier exit 
 for pus through the abdominal wound and 
 an easier through-and-through drainage are 
 secured in the lower incision than in the 
 higher. 
 
 4. The incision whose midpoint lies 
 opposite the umbilicus is high enough to 
 bring the uterine incision in the upper or 
 contractile segment of the uterus, and that 
 is what is sought. 
 
 One of the ad\'antages claimed by the 
 advocates of the high incision is that there 
 is less risk in it of adhesion between the 
 uterus and the abdominal cicatrix. In the 
 experience of the author, however, whether 
 the incision is made wholly above the 
 umbilicus, or with its centre opposite the umbilicus, the uterus at the 
 end of a week is found well below the abdominal incision, so that per- 
 manent adhesion of the uterus to the abdominal cicatrix is not to be 
 feared. 
 
 During the author's earlier work, the abdominal incision was carried 
 to the left of the umbilicus, but on account of the usual rotation of the 
 uterus from left to right forward, and the tendency of the uterine incision 
 to approximate the left uterine cornu and tube, he has made it a rule 
 during recent years to carry the incision to the right of the umbilicus 
 (see Fig. 478). In this way the uterine incision has been brought nearer 
 the median line. \Yith the short incision the uterus is not lifted out of 
 the abdomen until after the child has been extracted and the question 
 naturally arises, How shall the abdominal cavity be protected during 
 the extraction of the child? The author tried w^alling off the intestines 
 and protecting the peritoneal cavity with pads and having his assistant 
 
 Fig. 478. — Cesarean section. Site 
 of abdominal incision. 
 
CESAREAN SECTION 793 
 
 with hands on each side of the abdomen keep the uterus pressed firmly 
 against the abdominal wall from the first stroke of the knife until, follow- 
 ing the delivery of the child, the uterus is lifted out of the abdomen. 
 This latter method has given the author the most satisfaction and is the 
 method he has followed for several years. The pads are apt to become 
 displaced as the uterus is emptied, and have seemed not only to have 
 given less protection to the peritoneal cavity than the other method, 
 but to have favored subsequent adhesions. 
 
 Hoiv Shall Uterine Bleeding be Controlledf — For a time it was thought 
 necessary to have an assistant firmly hold each broad ligament, thus 
 compressing the ovarian and uterine arteries. This method has long 
 been abandoned in favor of stimulation of uterine contraction by gentle 
 manipulation of the fundus with the hand, by pouring over the uterus 
 hot saline solution and by the hypodermic injection of aseptic ergot. 
 Recently there has been a tendency to substitute pituitary extract for 
 ergot. Every Cesarean section operator becomes impressed with the 
 fact that uteri which show a tendency to relax and bleed when held 
 outside of the abdomen, contract well and cease bleeding when sutured 
 and replaced within the abdominal cavity. Hence too much time should 
 not be spent in endeavoring to make the uterus contract outside of the 
 abdomen, but either the suturing should be pushed and the organ replaced, 
 or if the tendency to relax is too great, the uterus should be replaced and 
 sutured in situ. 
 
 Shall gauze be left in the uterus with end leading into the vagina, for 
 the purpose of favoring uterine contraction and drainage? In the 
 author's earlier cases gauze was emploj'ed, but in his last 100 cases it 
 has been used only five times. It was found to be unnecessary, and from 
 the difficulty experienced in keeping it in place while suturing it proved 
 to be annoying. 
 
 Material and Method of Suture. — Catgut has been the only suture 
 material employed in either the uterine or the abdominal wound in all 
 save the first half-dozen of the author's cases. 
 
 The uterus is sutured Avith three tiers of continuous plain catgut 
 suture; one approximating the middle muscular layer, one passing 
 through peritoneal coat and outer half of muscle wall, and one closing 
 the peritoneum over the previous sutures (see Figs. 479, 480, and 
 481). 
 
 The abdominal wall is sutured' with three, sometimes four, tiers of 
 continuous catgut sutures : 
 
 1. The peritoneum is closed with plain catgut. 
 
 2. The fascia is approximated with chromicized catgut. 
 
 3. The fat, if abundant, with plain catgut. 
 
 4. The skin with subcuticular suture of plain catgut. 
 
 Duration of the Operation. — In the author's series of 150 Cesarean 
 sections the average time from the first cut till the delivery of the child 
 was 38 seconds. The longest delivery consumed 3 minutes; the shortest 
 delivery consumed 9 seconds; 35 were delivered in 20 seconds or less. 
 In the 150 cases, including 17 hysterectomies, the average time of the 
 
794 
 
 DELIVERY BY METHODS DISTINCTLY SURGICAL 
 
 coinpk'lcd operation was '1>>\ iiiiimtcs. 'I'lir longest operation was com- 
 pleted by hysterectomy, coiisimiiii<!; (12 mimites. 
 
 Tlie shortest Sanger Cesarean section consumed 14:^ minutes in its 
 completion. 44ie shortest Cesarean section coni])leted hy hysterectomy 
 consumed '.V.\ minutes. Tliere were S;] Sanger Cesarean sections which 
 consumed not more than oO mhuites in the completion of the operation. 
 
 Fig. 479 
 
 Fig. 480 
 
 Fig. 481 
 
 Figs. 479, 480, and 481. — Steps in suturing the uterine incision. 
 
 The question is often asked, What is the advantage of a quick opera- 
 tion in the performance of a Cesarean section? Why is a 14f minutes 
 completed operation better than one consuming an hour? All surgeons 
 realize that any operation in which careful technic is sacrificed to time 
 is faulty in the extreme. However, in a Cesarean section, a careful 
 technic coupled with a short time, is preferable to a careful technic 
 coupled with a long time for these reasons: From the first cut in the 
 uterus until the uterine incision is closed and the uterus replaced in the 
 
CESAREAN SECTION 795 
 
 abdominal cavity, the woman is losing blood from the nterine sinnses. 
 The loss of blood means lessened resistance to infection and a slo^^'e^ 
 convalescence. Hence, if performed with the same care, a short Cesarean 
 section is better for the w^oman than a long one. 
 
 Subsequent Care. — The subsequent care of a patient upon whom a 
 Cesarean section has been performed is smiilar to that of any abdominal 
 section. By the third day the baby may be applied to the mother's 
 breasts regularly and nursing be continued thereafter. The author's 
 custom has been to keep the patient in bed for two weeks and allow her 
 to leave the hospital in about three weeks. 
 
 Mortality. — The paramount question in every procedure for the 
 delivery of a pregnant woman is the maternal mortality. In the series 
 of 150 Cesarean sections performed by the author there were 10 maternal 
 deaths, or a maternal mortality of 6.66 per cent. 
 
 It must be remembered, however, that this series included all kinds 
 of cases as they were brought to the hospital, some already infected. 
 Among this series there were 143 clean non-toxic cases, and among these 
 the mortality was 2.09 per cent. In the last 40 cases of the series there 
 were no deaths. As experience with Cesarean section has widened, it 
 has become well established that the maternal mortality increases with 
 the number of hours the woman has been in labor, the number of hours 
 her membranes have been ruptured, and with the number of vaginal 
 examinations. With membranes unruptured, or only recently ruptured, 
 and only one vaginal examination, and that under strict aseptic precau- 
 tions, the maternal mortality should be less than 3 per cent. 
 
 If the woman has been in labor with ruptured membranes for many 
 hours and attempts have been made with forceps -or version by men of 
 uncertain asepsis to deliver her, Cesarean section is contra-indicated. 
 In these cases the mortality is from 10 to 25 per cent., and the fetal 
 vitality is uncertain. The causes of maternal death in the author's 
 series of 150 cases were as follows: 
 
 Extensive carcinoma of cervix, mother in last stages of disease, child macer- 
 ated, death from shock "within twenty-four hours 1 
 
 Pulmonary embolus, fourth and thirtieth day 2 
 
 Intestinal obstruction, autopsj' showing no infection 1 
 
 Toxemia (1) with degeneration of liver, (2) with urine solid on boiling; death 
 
 within twenty-four hours 2 
 
 Postpartum hemorrhage; death in three hours 1 
 
 Sepsis, fourth day, seventeenth day, and thirtieth day 3 
 
 10 
 
 Fetal Mortality. — If the fetus is alive at the beginning of a Cesarean 
 section and its vitality has not been impaired by attempts at delivery 
 through the natural passages, the fetal mortality is practically 7iil. 
 
 It is the most certain method of delivering a living child which exists. 
 
 Repeated Cesarean Sections. — The danger of repeated Cesarean sec- 
 tions in the same patient differs but little from that of the original, 
 provided the operation in subsequent pregnancies is performed promptly. 
 The author has performed Cesarean section four times on one of his 
 
790 DELIVERY BY METHODS DISTINCTLY SURGICAL 
 
 patients and five times on anotlier, and in each the convalescence and 
 snbsequent results were all that could ])e desired. On the other hand, 
 to allow a woman who has had one or more previous Cesarean sections 
 to remain long in a subsequent labor would expose her to the risk of a 
 thinned uterine cicatrix and perhaps a uterine rupture, as has been 
 reported by several operators. 
 
 EXTRAPERITONEAL CESAREAN SECTION. 
 
 In order to avoid the high mortality of the classical Cesarean section 
 when performed upon a patient already infected, different obstetric 
 surgeons in recent years have revived old proposals of incising the 
 abdominal wall, pushing upward and backward the peritoneum, open- 
 ing the uterus and delivering the child extraperitoneally. 
 
 As already stated, the idea is not a new one. Jorg, in 1S07, had sug- 
 gested such a procedure through a transverse incision, and this proposal 
 had been modified by Ritgen and the operation performed by him, 
 although unsuccessfully, in 1820. 
 
 Thomas, 1 of New York, in 1S70, not only suggested but successfully 
 operated through a lateral incision parallel to Poupart's ligament, an 
 operation he called gastro-elytrotomy or laparo-elytrotomy. In the 
 hands of seven different operators this operation had a mortality of 
 50 per cent. With the improvement in the technic and results of 
 the Sanger Cesarean section, however, these extraperitoneal methods 
 fell into disuse and it was not until revived by Frank, of Cologne, in 1907, 
 and modified by Latzo, Sellheim, Doderlein and others that extraperi- 
 toneal Cesarean section became popular. Furthermore, it may be 
 stated that this popularity has been much more wide-spread in Germany 
 than in America. 
 
 It is interesting to note that the development of the operation has 
 followed the two lines suggested by the early proposers; thus, the opera- 
 tion through a transverse incision has been developed by Frank, Latzo, 
 and Sellheim, while the operation through a lateral incision — the gastro- 
 elytrotomy of Thomas — has been developed by Doderlein and Diihrssen. 
 
 Technic. — The technic of the operation has ^'aried as it iias been 
 developed by the different operators: Thus Frank, by a transverse inci- 
 sion above the pubes, opened the peritoneal cavity, separated the utero- 
 vesical fold from the bladder and the lower part of the uterus, stitched 
 this fold to the parietal peritoneum, opened the uterus transversely 
 and delivered or allowed nature to deliver the child through this open- 
 ing, closing the wounds in clean cases and draining through the cervix 
 and vagina in infected cases. This has been called the transperitoneal 
 operation. The technic of the operation as modified by Latzo and 
 Sellheim consists in making a Pfannenstiel incision; separating the 
 bladder and peritoneum from one side of the anterior surface of the 
 uterus; lifting up the peritoneum and incising the lower uterine segment 
 
 ' Gastro-elytrotomy, a substitute for the Cesarean section, Amer. Jour. Obst., 1.S71, iii, 
 125-139. 
 
EXTRAPERITONEAL CESAREAN SECTION 
 
 797 
 
 longitudinally. In clean cases the uterine and abdominal wounds are 
 closed after the removal of the placenta, while in infected cases Sell- 
 heim unites the edges of the uterine and abdominal incisions and drains 
 with gauze, allowing the uterine fistula to close later. In the lateral 
 operation, as developed by Doderlein^ and Diihrssen, and practised by 
 them both as late as 1911, the patient was placed in the Trendelenburg 
 posture and an incision made parallel to Poupart's ligament, from near 
 the anterior superior spine to a point just above the symphysis. The 
 fibers of the external and internal oblique muscles were separated with 
 as little cutting as possible; the epigastric vessels were divided between 
 double ligatures and the rectus muscle was drawn inward with a retractor. 
 The fingers working in the subperitoneal connective tissue lifted up the 
 
 A 
 
 \ 
 
 \ 
 
 l,^^!^ 
 
 \ 
 
 ■ "'"\^ 
 
 X^ 
 
 \ 
 i 
 •1 
 
 
 A 
 
 Fig. 482. — Extraperitoneal Cesarean section. (Doderlein.) 
 
 peritoneum from the lateral aspect of the lower uterine segment, which 
 was then incised and the child delivered usually by the forceps. In 1912 
 Doderlein^ abandoned the inguinal incision as possessing no advantages 
 over the longitudinal and the disadvantage of more limited space. The 
 operation as performed by Doderlein, through a longitudinal incision 
 representing one of the best technics of extraperitoneal Cesarean 
 section, is here given in more or less detail. The patient during the 
 early part of the operation is placed in the Trendelenburg posture, a 
 position Doderlein considers important for the success of the operation. 
 An incision is made from the symphysis to a hand's breadth below^ the 
 
 1 Monatsschrift f. Geburtshlilfe und Gyn., 1911, Band xxxiii, Heft 1. 
 
 2 Operative Gynakologie, Seiten 888-896. 
 
798 DELIVERY BY METHODS DISTINCTLY SURGICAL 
 
 umbilicus, a little to the left of the median line (see Fig. 482). The 
 incision -with gentle strokes of the knife is carried down to the subperi- 
 toneal tissue, care being necessary to avoid wounding of the peritoneum 
 on account of the stretching and thinning of the abdominal wall during 
 the pregnancy. The next step is to expose the lateral border of the* 
 bladder and the covering fold of peritoneum. For the purpose of iden- 
 tification it is sometimes advisable to have the bladder partially filled 
 during the early part of the operation and then emptied. The bladder 
 is now gently pushed forward and toward the median line, while the 
 peritoneum is elevated from the lower part of the abdominal wall and 
 the lower part of the uterus (see Fig. 483), care being taken not to disturb 
 the lower attachments of the bladder or the ureter, lest sloughing occur, 
 as happened in one of Doderlein's cases. A longitudinal incision is then 
 
 Fig. 483. — Extraperitoneal Cesarean section. (Dodcrlein.) 
 
 made in the lower uterine segment, avoiding the peritoneum above and 
 the ureter below (see Fig. 484). The patient's position is then changed 
 from one with elevated pelvis to one with lowered pelvis (see Fig. 485), 
 and the chikl extracted, usually with forceps, occasionally by version 
 and breech extraction. The placenta is then expressed, or if indicated 
 on account of hemorrhage, is manually extracted. The patient is then 
 placed in the Trendelenburg posture again and the wounds in the uterus 
 and abdominal wall sutured (see Fig. 486), with or without drainage 
 from above or below, according to the probability of infection before 
 operation. In Doderlein's clinic 58 cases have been operated on by this 
 method. In 53 the indication for the operation was a contracted pelvis; 
 in 2, eclampsia; and in '.], stenosis or rigidity of the soft parts. In the 
 58 cases the maternal mortality was 3, or 5.1 per cent.; the fetal mor- 
 tality was 8, or 13.8 per cent. 
 
EXTRAPERITONEAL CESAREAN SECTION 
 
 799 
 
 Fig. 484. — Showing incision in lower uterine segment. (Doderlein and Kronig.) 
 
 Fig. 485. — Extraction of child. Woman with pelvis lowered ; shoulders raised. 
 (Doderlein and Kronig.) 
 
800 
 
 DELIVERY BY METHODS DISTIXCTLY SURGICAL 
 
 Relative Value of Extraperitoneal and the Sanger Cesarean Section. — 
 In spite of the improved tecliiiic and lowered mortality of Sellheim 
 and Doderlein, the author believes that the classical operation of Sanger 
 is a better operation in clean cases and that in infected cases the supe- 
 riority of the extraperitoneal Cesarean section over the Sanger incision 
 followed by a hysterectomy after the removal of the child is still to be 
 proved. In the first place the Sanger Cesarean section is a simpler opera- 
 tion, without the risk of injury to the bladder and ureter, which is asso- 
 ciated with the extraperitoneal operation. Furthermore, the liability in 
 the extraperitoneal operation of accidentally opening the peritoneal cavity 
 in the blunt dissection in the subperitoneal connecti\"e tissue, V)etween the 
 bladder and the uterus, with the possibility of its infection is certainly 
 
 Fig. 486. — Suturing uterine incision, f Doderlein and Kronig.) 
 
 an unfavorable feature of the operation. Both the maternal and the 
 fetal mortality of the Sanger Cesarean section at the Sloane Hospital 
 are lower than those of the extraperitoneal Cesarean section as reptjrted 
 from Germany, hence the author feels justified in preferring the former. 
 
 POSTMORTEM CESAREAN SECTION. 
 
 It is not often that the opportunity arises to deliver a living child 
 after the death of the mother, yet it is an established fact that the child 
 will sometimes live from twenty to thirty minutes after the heart action 
 and respiration of the mother have ceased. The length of time the child 
 remains alive varies with the cause of death, of the mother. Thus the 
 child will, as a rule, live longer if the mother's death was sudden than if 
 
CRANIOTOMY AND EMBRYOTOMY 801~ 
 
 she had a lingering death in which heart and respiration had been faihng 
 for hours. If the child is near term and alive at the time of the mother's 
 death, three alternatives present themselves: 
 
 1. Leave the mother undelivered. 
 
 2. Deliver by Cesarean section. 
 
 3. Deliver through the natural passages. 
 
 The decision to leave the woman undelivered must be governed 
 largely by the wishes of the family. The author feels that if the family 
 wish the body untouched, it is the duty of the obstetrician to acquiesce. 
 
 The choice between delivery by Cesarean section and through the 
 natural passages depends upon the dilatation of parturient canal. 
 
 If the woman was in labor and the parts well dilated, delivery from 
 below by forceps or version offers a fair chance of saving the baby and 
 seems less of a shock to the family. On the other hand, if the cervix 
 is not dilated, there is a much better chance of saving the baby by 
 Cesarean section, as any knife at hand may be used for the operation. 
 The author has had one successful case of postmortem Cesarean section. 
 
 Postmortem Delivery. — In connection with postmortem Cesarean 
 section should be mentioned spontaneous postmortem delivery. Occa- 
 sionally a woman who has been buried undelivered has for some reason, 
 perhaps for medicolegal purposes, been disinterred and the child has 
 been found in the casket between the thighs of the mother. This delivery 
 is usually brought about by the formation and pressure of gases in the 
 intestines or in the intestines and uterus resulting from the process of 
 putrefaction. Some authorities have laid stress on the contraction of the 
 abdominal and uterine muscles in rigor mortis, aiding in this expulsion. 
 
 CRANIOTOMY AND EMBRYOTOMY. 
 
 The reduction in the size of the fetal head by some cutting or crushing 
 operation is called craniotomy. The reduction in the size of the fetal 
 body by some similar procedure is called embryotomy. As the head 
 usually presents, or at any rate usually offers the greatest obstacle to 
 delivery, it is the operation of craniotomy which is much more fre- 
 quently indicated than an embryotomy, and hence craniotomy will be 
 first considered. 
 
 Craniotomy. — ^In this operation the head is perforated, crushed, and 
 extracted. 
 
 Indications. — In spite of the advances in obstetric surgery and the 
 lessened indications for craniotomy, it is still a proper procedure in 
 certain cases, and in the interest of the mother may serve a most useful 
 purpose. The usual indication for craniotomy is delayed labor with a 
 dead fetus. If the mother can be saved any additional risk and suffering 
 by reducing the size of the head of a fetus already dead, this operation 
 is not only justifiable but in most cases advisable. Craniotomy upon 
 a living child is only justifiable in exceptional circumstances. There are 
 circumstances, however, in which the interests of the mother make the 
 procedure justifiable. The following are examples: 
 51 
 
S02 
 
 DELIVERY BY METHODS DISTINCTLY SURGICAL 
 
 In cases of protracted labor, where frequent, unsuccessful attempts 
 to deliver the fetus have been made and the fetal vitality as shown by 
 the heart sounds is very low, craniotomy is indicated both because the 
 chances of the child sur\-iving any surgical delivery are small, and 
 because the maternal risk of a surgical delivery like Cesarean section 
 would be great. 
 
 If the woman's condition is desperate when first seen, as in an acci- 
 dental hemorrhage with a complete separation of the placenta, and a 
 
 1 
 
 Fig. 487. — Taraier's basiotribe. 
 
 Fig. 488.— Blunt hook. 
 
 craniotomy offers the prospect of less shock to the mother than any 
 other procedure, craniotomy is indicated. 
 
 In hydrocephalus craniotomy finds a positive indication. 
 
 Finally, if the obstetrician in charge is without the experience or skill 
 needed in the performance of a Cesarean section, and is so situated that 
 he cannot obtain the required skill, craniotomy is indicated in the interest 
 of tlie mother, if he is unable to deliver the child by forceps or version. 
 
 Instruments Needed. — For a craniotomy upon a cephalic presentation, 
 a perforator, a crusher and a tractor are needed. These powers are all 
 combined in Tarnier's basiotribe (see Fig. 487), which is the instrument 
 
CRANIOTOMY AND EMBRYOTOMY 
 
 803 
 
 preferred by the author. The instrument consists of a central perforator 
 and two blades resembling long forceps blades which introduce like 
 forceps blades on opposite sides of the fetal head and then adjust, the 
 left blade to a pin on the perforator and the right to a pin on the left 
 blade. The screw as shown in the figure furnishes the crushing power, 
 and with the perforator in place and the fenestrated blades pressed into 
 the fetal skull, the instrument has such a hold upon the fetus that it 
 may be used for powerful traction. If there is difficulty in delivering 
 
 Fig. 489. — Smellie's scissors. 
 
 Fig. 490. — Craniotomy forceps. 
 
 the shoulders, the blunt hook shown in Fig. 488, introduced into one 
 axilla, will often prove serviceable. For a craniotomy upon the after- 
 coming head a crushing instrument is usually not needed, as after 
 perforation, which is usually done behind an ear, or through the foramen 
 magnum, traction on the fetal body usually forces out the brain substance 
 and causes the skull to collapse. In this case a smaller perforator is 
 often useful and the Smellie's scissors (see Fig. 489) answers nicely. In 
 rare cases if a good application has not been secured with the Tarnier 
 basiotribe, and the instrument slips, it may be difficult to reapply, and 
 an instrument is needed with which a firm hold can be obtained upon 
 
804 
 
 DELIVERY BY METHODS DISTINCTLY SURGICAL 
 
 the fetal skull. The craniotomy forceps (shown in Fig. 490) is a useful 
 instrument for this purpose, one blade being applied without and one 
 within the skull. This instrument may also be used to break off, by 
 twisting, a portion of the fetal skull and so reduce the bulk of the head 
 to be extracted. 
 
 Technic. — The patient should be anesthetized both for the relief of 
 suffering and to spare her the mental shock of seeing, or even knowing, 
 that her fetus is being mutilated. The lithotomy position; the aseptic 
 preparation and draping should be the same as for a forceps delivery. 
 In a cephalic presentation two fingers of the left hand should be intro- 
 
 FiG. -191.- 
 
 -P('rf(jrator in skull. 
 blades applied. 
 
 Lateral 
 
 Fig. 492. — Skull cru.shcd with crushiiifj 
 screw. 
 
 duced, and a fontanelle or suture located. Along the two fingers the 
 perforator of the Tarnier basiotribe should be passed and made to 
 enter the skull through a suture or fontanelle, as being easier points of 
 entry than through one of the cranial bones. If the fetal head has not 
 engaged, it should be pushed down and steadied by an assistant until 
 the perforator has entered. Having entered the skull the perforator 
 should be passed to the medulla and moved about so as to make sure 
 that the mutilated fetus is not born alive. The lateral blades of the 
 basiotribe should then be introduced as forceps blades, and applied to 
 the sides of the fetal head (see Fig. 491). The crushing screw should 
 
CRANIOTOMY AND EMBRYOTOMY 805 
 
 then be adjusted and screwed down (see Fig. 492). As the screw is turned 
 the brain substance pours out of the vagina, showing the compression 
 of the fetal skull. When the screw has reached its limit, the instrument 
 as a whole, with its firm grasp upon the skull, may be used as a tractor 
 and the child delivered. 
 
 Craniotomy upon the after-coming head is usually indicated in a 
 breech extraction in which there has been so great difficult}' in the 
 extraction and so great delay in the delivery that the fetus has died 
 before the head has been delivered. The critical condition of the mother 
 may also indicate craniotomy to secure a speedy delivery. Here, as 
 indicated above, only a perfora,tion is, as a rule, needed, and this is accom- 
 plished by inserting the perforator behind the ear or into the foramen 
 magnum. It is often a convenience to have an assistant or nurse pull 
 down on the legs of the fetus while the obstetrician passes the perforator, 
 guiding it by the fingers of the other hand. Having churned up the 
 fetal brain with the perforator, the obstetrician then completes the 
 delivery of the head by the Smellie-Veit method. The compression of 
 the perforated head by the parturient canal, as the fetus is extracted, 
 forces out the brain substance and so reduces the cephalic bulk. 
 
 Prognosis. — If the conjugate diameter of the mother's pet\'is is 7 cm., 
 or over, the fetal head engaged and the mother not infected, there is 
 very little maternal risk in the operation. On the other hand, if the 
 conjugate diameter is as small as 5.5 cm. or less, a Cesarean section 
 is safer, unless the mother is already infected. If the mother is already 
 infected, or is in a critical condition before the operation is undertaken, 
 the prognosis is naturally grave. 
 
 In 20,000 consecutive labors at the Sloane Hospital there were 188 
 craniotomies; 1 to 106 
 
 Primigravidse 103 
 
 Multigravidse 85 
 
 Condition of fetus at time of operation: 
 
 Dead . 149 
 
 Non-\iable ........ 32 
 
 fHydrocephalic 3 
 
 Alive and viable 7 \ Failing fetal heart 1 
 
 [in fair condition but mother in extremis 3 
 
 188 
 
 Critical condition of the mother . . . ." 134 
 
 Operation on fore-coming head 92 
 
 Operation on after-coming head 96 
 
 Maternal mortahty (none due to operation save perhaps 1 from shock). 
 
 Maternal deaths 50 —26.5 per cent. 
 
 Eclampsia 18 
 
 Toxemia of pregnancy 8 
 
 Chronic nephritis 1 
 
 Sepsis 15 
 
 Rupture of uterus 3 
 
 Accidental hemorrhage 2 
 
 Endocarditis 1 
 
 Malignant endocarditis 1 
 
 Shock 1 
 
806 
 
 DELIVERY BY METHODS DISTINCTLY SURGICAL 
 
 Embryotomy. — This consists in reducing the bulk of the fetal body 
 or in severing it from the head. The operation receives difterent names 
 according to the procedure. Thus, separating the head from the trunk 
 is called decapiialiou. Opening the thorax or the abdomen and with- 
 drawing the viscera is called evisceration. Division of the clavicle to 
 reduce an excessive size of the shoulders is called a cleidotomy. 
 
 Instruments Needed. — For the different operations included imder the 
 term enihryoUnuii, a strong, blunt-pointed, curved scissors (Fig. 493) 
 
 r 
 
 Fig. 493. — Strong, blunt-pointed, curved 
 scissors. 
 
 Fig. 494. — Braun's sharp-edged, 
 blunt-pointed hook. 
 
 will usually answer the purpose. For a decapitation the sharp-edged, 
 blunt-pointed, Braun's hook (Fig. 494), will sometimes be preferable, 
 but the obstetrician should be able to do all of these operations with 
 the scissors. 
 
 Indications. — The chief indication for a decapitation is an impacted 
 shoulder presentation, where version is contra-indicated on account 
 of the danger of rupture of the uterus. If the neck cannot be reached 
 evisceration is then usually indicated. 
 
CRANIOTOMY AND EMBRYOTOMY 807 
 
 Technic. — With the patient in the hthotomy position and with the 
 usual aseptic preparation and draping, the different varieties of embry- 
 otomy are performed as f ohows : 
 
 Decapitation. — In a case of impacted shoulder presentation with a 
 tonic uterus and the fetal neck within reach, the indication as stated 
 above is a decapitation. With the fingers of one hand inserted along 
 the vagina as a guide, the sharp-edged, blunt-pointed, Braun's hook is 
 passed along them and hooked over the fetal neck. Partly by a pulling 
 and partly by a twisting motion, this hook is made to sever the head 
 from the body while the vaginal fingers guard the maternal soft parts 
 from injury from the hook. The same operation of decapitation may be 
 performed by the heavy, blunt scissors shown in Fig. 493, which are 
 guided by the vaginal fingers to the neck and are then used to separate 
 the head from the trunk. After decapitation, the head is pushed up out 
 of the way, and the child extracted by the arm, or a podalic version is 
 performed. This is followed by the delivery of the severed head. If the 
 shoulder presentation is so impacted that the fetal neck cannot be 
 reached, it is usually necessary to reduce the bulk of the trunk by evis- 
 ceration. Using the same scissors shown in Fig. 493, and passing them 
 along the vaginal fingers to the thorax, this is entered by the section of 
 two or more ribs; the diaphragm is then opened through the thorax, so 
 that the obstetrician's hand can be passed into the fetal abdomen. 
 Working partly with the hand and partly with the scissors, one viscus 
 after another can be removed until the trunk will so collapse as to render 
 podalic version an easy and safe procedure, even with a tonic uterus. 
 When with a cephalic presentation of a dead child the labor is obstructed 
 on account of excessive size 'of the shoulders, this excessive bulk can be 
 reduced by section of one or both clavicles by the strong scissors men- 
 tioned above. The section of the clavicles allows the shoulders to fold 
 inward and thus greatly shortens the bisachromial diameter. In an 
 impacted shoulder presentation with a dead child and a deformed pelvis 
 the author has occasionally found it necessary with the scissors not only 
 to divide the clavicle, but also to separate the scapula from the thorax 
 and remove one arm with scapula and part of the clavicle before he could 
 deliver the child. Enough has been written to show that with the scissors 
 the obstetrician can reduce the fetal bulk as may be necessary in the 
 different forms of embryotomy. 
 
PART YI. 
 PATHOLOGICAL PUEEPERIUM. 
 
 CHAPTER XXVIII. 
 PUERPERAL INFECTION. 
 
 Puerperal infection is the term used to cover the various local and 
 general pathological conditions resulting from the invasion of the par- 
 turient canal during labor or the puerperium by various pathogenic 
 organisms. 
 
 Puerperal infection was for centuries shrouded in mystery. It was 
 regarded as the result of retention of the lochia; as a metastasis of the 
 milk; as a specific fever; as an interposition of divine providence, etc. 
 
 It was not until about the middle of the last century that correct 
 views regarding the etiology of puerperal infection were obtained and 
 published. The two men to whom we probably owe most for this knowl- 
 edge were Oliver Wendell Holmes, of this country, who in 1843 pub- 
 lished a paper on "The Contagiousness of Puerperal Fever," and Ignaz 
 Phillipp Semmelweiss, an assistant in the ]\Iaternity Department of 
 the General Hospital of Vienna, who in 1847 was impressed with the 
 frightful mortality among the women in certain wards attended by the 
 medical students as compared with the mortality in other wards attended 
 by midwives and among patients delivered outside the hospital. He 
 set about finding the cause of the terrible death-rate and conceiving the 
 idea that it was due to the fact that students, coming directly from the 
 autopsy room to maternity work, carried infective material from the 
 autopsy table to the parturient women whom they examined, made 
 them wash their hands in chlorin water before this examination. Under 
 this regime the mortality fell at once from over 10 per cent, to 1 per 
 cent., and Semmelweiss became convinced that puerperal infection 
 was wound infection, and from that time until he lost his reason as a 
 result of ridicule and opposition, he spent a large part of his time and 
 strength in -endeavoring to impress these views upon the medical world.. 
 It was not, however, until after the introduction of antiseptic methods 
 in surgery by Lister and the bacteriological study of Pasteur that the 
 profession at large began to accept the fact that puerperal infection was 
 like general wound infection, and could be largely prevented. 
 
 Etiology.- — In order to understand the etiology of puerperal infection 
 and the safeguards with which nature surrounds the parturient canal 
 one must consider the normal bacteriology of the vagina and then the 
 
 (809) 
 
810 PUERPERAL INFECTION 
 
 microorganisms which usually cause infection. As a result of the careful 
 bacteriological work of Kronig and Mengc in 1897, and of Williams in 
 1898, and Bergland in 19l)(), each obtaining the vaginal secretion for 
 examination by means of a small glass tube which could be introduced 
 into the vagina without touching the labia or the hymen, it has been 
 demonstrated that the vagina of the normal, pregnant woman does not 
 contain the ordinary pyogenic cocci and, furthermore, that the vagina 
 has certain bactericidal properties, so that cultures of streptococci and 
 staphylococci introduced within it disappear in from twelve to twenty 
 hours. The l)actericidal power of the vagina is probably due in part 
 to its acid reaction, which is probably produced by a number of different 
 bacteria with which it abounds from birth, among them being the vaginal 
 bacillus of Doderlein. It is probably also due in part to phagocytosis 
 and the germicidal power of the normal mucus and epithelium. 
 
 The acid reaction of the vagina explains also why the gonococcus 
 withstands the bactericidal power of this canal to which the strepto- 
 coccus and the staphylococcus succumb, because the gonococcus lives 
 and thrives in an acid medium. 
 
 The practical obstetrician may then consider the vagina of the normal 
 pregnant woman as sterile, and that even if pathogenic organisms have 
 been introduced they, with the exception of the gonococcus, have disap- 
 peared if the woman has no fever and the vagina has been left untouched 
 for a few days. 
 
 On the other hand, the vvdva abounds in pyogenic organisms: the 
 colon bacillus from the neighboring rectum; the staphylococcus found 
 anj'^vhere on the skin, and frequently the streptococcus and other pyo- 
 genic organisms. 
 
 We have then, as a rule, a sterile vagina within and a non-sterile 
 vulva without. 
 
 The various pathogenic organisms at the threshold of the vagina will 
 first be considered a little more in detail and then the means of transfer 
 from without inward. 
 
 The Streptococcus. — The most virulent types of puerperal infection 
 are usually the result of the invasion of the parturient canal by the 
 Streptococcus pyogenes. For a time the infection may remain localized, 
 but there is always a tendency for it to spread by the bloodvessels and 
 lymphatics until the pelvic organs, the peritoneum and perhaps the 
 general system are involved. 
 
 The Staphylococcus. — Although invasion by the staphylococcus is 
 usually considered to result in a less virulent type of infection than by 
 the streptococcus, it is often a serious infection by itself and not infre- 
 quently is found combined with the streptococcus. The Staphylococcus 
 aureus is the variety usually found. 
 
 The Gonococcus. — This organism which thrives in an acid medium, 
 is often found in the cervical canal, Skene's ducts and Bartholin's ducts, 
 and has recently, through the work of Taussig and Stone and MacDonald, 
 come to be regarded as the cause of a considerable number of rises of 
 temperature in the puerperium. As a rule the gonococcus infection has 
 
ETIOLOGY OF PUERPERAL INFECTION 811 
 
 a tendency to localize itself and the result not be fatal, but occasionally, 
 especially in a mixed infection, it gives rise to a fatal septicemia. 
 
 The Bacillus Coli Communis. — When one considers the proximity of 
 the rectum to the vaginal orifice, especially if the perineum has been 
 lacerated and the vulva is gaping, it is easy to understand the possibility 
 of infection by the colon bacillus. The author once lost a case of symphy- 
 seotomy in which a bacteriological examination showed almost a pure 
 culture of colon bacilli. This was a case which on account of her weight 
 and the strapping of the hips, combined with loose bowels, it was very 
 difficult for the nurse to keep clean. 
 
 The Bacillus aerogenes capsulatus or the gas bacillus of Welch, has 
 occasionally been the organism found in puerperal infection, as reported 
 by Welch, in 1900, who at that time reviewed the literature of the sub- 
 ject. Other series have been reported. In the series reported by Little, 
 in 1905, from the Obstetrical Department of the Johns Hopkins Hos- 
 pital, only one presented a pure culture of the gas bacillus, the others 
 being associated with other bacteria, especially the streptococcus. 
 
 As the gas bacillus usually exists as a saphrophyte upon dead tissue 
 and, as a rule, does not invade the deep tissues, the prognosis is good when 
 it is the only organism present, but when the infection is mixed, the gas 
 bacillus being associated with the streptococcus, the prognosis is grave. 
 
 The Klebs-Loeffler Bacillus. — For many years the grayish slough often 
 seen in the lower portion of the parturient canal, as on lacerations of the 
 perineum and cervix in puerperal infection, was spoken of as diphtheritic, 
 and regarded as an expression of infection with diphtheria. When 
 bacteriology definitely settled the organism of diphtheria and the grayish 
 sloughs of puerperal infection were found, as a rule, not to contain it, 
 the pendulum swung so far as to cause the claim to be made that true 
 diphtheria of the vagina did not occur. 
 
 This claim is too radical, as proved by a case of the author's, in which 
 the Klebs-Loeffler bacillus was isolated from the vagina of a patient and 
 at the same time other members of the family had the usual evidences 
 of diphtheria in the throat. Of course a true diphtheritic membrane in 
 the vagina indicates treatment with antitoxin just as plainly as though 
 it was located on the tonsils or fauces. 
 
 Bacillus Typhosus. — Certain long cases of puerperal infection sometimes 
 present a resemblance both in the general appearance of the patient and 
 in the temperature chart to typhoid fever, but the only safe rule to 
 follow is to consider a fever after confinement as due to puerperal infec- 
 tion rather than typhoid fever, unless the Widal reaction or a positive 
 typhoid culture is obtained. Occasionally a surprise in this direction 
 will occur, but it is extremely rare. 
 
 Other pathogenic organisms are occasionally found associated with 
 puerperal fever, but not with sufficient frequency to merit mention here. 
 
 The Carriers of Infection. — With the vulva swarming with bacteria 
 the question of etiology in puerperal infection concerns itself chiefly 
 with the means of transfer, or the carriers of these pathogenic organisms 
 from the vulva without to the vagina and upper parturient canal within 
 
812 PUERPERAL INFECTION 
 
 and above. Although the reaction of the vagina during pregnancy is 
 acid and the canal possesses certain bactericidal power, as already stated, 
 after delivery this is changed, the reaction becomes alkaline, numerous 
 abrasions in the vagina and cervix usually exist, even if small, and the 
 uterine cavity presents a large, raw surface, all presenting an excellent 
 culture field for bacteria if once they pass the vaginal orifice. The means 
 of transfer is unfortunately easy. Anything, no matter how clean in 
 itself, rubbing past the labia and entering the vagina, easily carries the 
 infecting organisms from the former and inoculates the latter. The 
 importance of this may well be emphasized. No matter how clean 
 the fingers or how sterile the gloves, if they are introduced into the 
 vagina without separating the labia, they may wipe off infective material 
 from the vulva and infect the vagina. It follows from this that the 
 only safe method of making a vaginal examination is by a careful sepa- 
 ration of the labia, during the introduction of the examining fingers. 
 
 If infection of the vagina and parturient canal can thus be carried by 
 the introduction of a clean object, how much greater the danger from 
 one which is not clean. 
 
 It is now well established that the usual causes of puerperal infection 
 are the unclean fingers and instruments of the surgically unclean obstet- 
 rician, and the service which Semmelweiss rendered to parturient women 
 and to the world was in teaching the medical profession the danger of 
 unclean hands in obstetrics. Of course other objects, like dirty douche 
 tips, may carry infection to the vagina. Sexual intercourse just before 
 the admission of the patient in labor has more than once in the author's 
 hospital service been traced as the source of infection. For many years 
 bad air, such as air impregnated with sewer gas and bad general sur- 
 roundings, were held responsible for puerperal infection. It is now 
 known that these have little effect save perhaps in lowering the vitality 
 and general resistance of the patient, and the good results obtained in 
 the out-patient services of maternity hospitals show that in the most 
 squalid and wretched homes, a woman can have a safe delivery and 
 normal convalescence provided the obstetrician's hands, instruments and 
 technic are strictly clean. 
 
 Is Auto-infection Possible? — So thoroughly are the profession and the 
 laity at the present day educated to the fact that most cases of puerperal 
 infection are due to some fault in the technic of the obstetrician, 
 either in the cleanliness of his hands or instruments, or in his conduct 
 of the delivery, that it well behooves one to ask the question. Can 
 puerperal infection occur without its being the obstetrician's fault? 
 Before answering this question let us consider some of the conditions 
 which favor infection. In the first place anything lowering the vitality 
 of the woman as a whole, and of the parturient canal in particular, favors 
 the development of puerperal infection. Thus a poor general condition; 
 a long, dry labor with prolonged pressure; the occurrence of a hemor- 
 rhage; the occurrence of lacerations; these all present a lowered vitality 
 with a lessened resistance to the entry and development of pathogenic 
 bacteria. So common, at any rate, is a slight rise of temperature seen 
 
ETIOLOGY OF PUERPERAL INFECTION 813 
 
 ill cases who have had marked hemorrhage, that it comes to be rather 
 expected. 
 
 Most obstetricians are agreed today that cases of puerperal infection 
 occasionally occur in which the obstetrician is not in the slightest degree 
 responsible for the condition : 
 
 A toxic woman may have an accidental hemorrhage. The uterus of a 
 woman whose vitality is reduced by hemorrhage does not contract well, 
 and in spite of precautions small clots may be retained. This may give 
 rise to a sapremia, and if the woman is carrying pathogenic germs in any 
 part of her parturient canal, as in cervix, Skene's ducts, or Bartholin's 
 ducts, the sapremia may be followed by a septicemia, without the obstet- 
 rician being in any way responsible for it. Again, a woman may have 
 a normal temperature and pulse for a week, or later yet a stenosis at 
 the internal os, perhaps produced by a flexion, either anterior or pos- 
 terior, may cause a retention of lochia with a sapremia, which may be 
 the starting-point of a septicemia, as in the preceding case. In these 
 senses auto-infection is occasionally possible. 
 
 With infection of the parturient canal apparently so easy, the wonder 
 is not that the calamity occasionally occurs, but that at the present 
 day it occurs so seldom. The natural provisions against infection are 
 important and deserve recognition. In the first place there is the general 
 resistance of the normal, healthy tissue to the invasion of bacteria and 
 the provision for their destruction by phagocytosis if invasion is 
 attempted. Moreover, the discharge of fluids, liquor amnii and blood, 
 is downward and tends to cleanse the parturient canal by flushing. 
 Again, the birth of the child tends to wipe out the canal as it descends. 
 Furthermore, the chorion and placenta remain, as a rule, attached to 
 the uterine wall until the child is born, thus serving as a protection to 
 the uterine sinuses and when the placenta and membranes finally sepa- 
 rate and are expelled, they, too, wipe the walls of the lower portion of 
 the canal, and finally the discharge of lochia is downward and outward, 
 tending still further to cleanse it. 
 
 Relation between Contagious Diseases and Puerperal Infection. — Puer- 
 peral infection has not infrequently occurred in the practice of the 
 general physician who attended cases of scarlet fever, measles, etc., and 
 at the same time was doing obstetric work. The question naturally 
 arises, What is the connection between these contagious diseases and 
 puerperal infection? At the present day it is established that scarlet 
 fever and measles do not in themselves produce puerperal infection. 
 In fact the scarlet fever and the measles themselves may be carried to 
 the pregnant or puerperal patient and yet she does not develop puerperal 
 infection. 
 
 In the winter of 1910-1911, a season when there was a large amount of 
 scarlet fever in New York, 1 1 patients in the Sloane Hospital developed 
 scarlet fever, 9 were postpartum cases and 2 antepartum cases. They 
 all passed through the regular course of the disease, and recovered with- 
 out either having puerperal infection themselves or giving it to the 
 others in the hopsital. 
 
814 PUERPERAL INFECTION 
 
 The danger lies in the fact that scarlet fever and measles, especially 
 the former, are frequently complicated by streptococcus infections and 
 these streptococci which are the cause of the most virulent types of 
 puerperal infection may be carried by the hand of the obstetrician to 
 his parturient patients. 
 
 The danger of attending erysipelas and obstetric cases at the same 
 time has been known for years, and the explanation is easy when it is 
 considered that the streptococcus peculiar to erysipelas, the strepto- 
 coccus of Fehleisen, is practically identical with the streptococcus found 
 in the grave cases of puerperal infection. In these cases the medium of 
 transfer is usually the hands of the physician and in the same way these 
 same hands may be the cause of infection if from dressing ulcers of the 
 legs, examining throats, etc., i. e., the everj-day work of the general 
 practitioner, they pass to examining women in labor. The use of sterile 
 rubber gloves, enabling him to have sterile hands after his general work, 
 has proved a great boon to physicians with conscience, and to their 
 pregnant patients, but unless it is absolutely necessary, no physician, 
 even with the protection of sterile gown, and rubber gloves, should 
 attend such cases as erysipelas, diphtheria, etc., and do obstetric work 
 at the same time. 
 
 Some men seem to carry infection with them in spite of precautions. 
 This is seen in the record of certain internes in a hospital service where 
 the services change every few months. The experience of Dr. Rutter 
 of Philadelphia, which has been quoted in most text-books for years, 
 is so instructive that it is worthy of repetition. Dr. Rutter's obstetric 
 work was followed by an almost continuous series of puerperal infection, 
 while his fellow practitioners had little if any. Discouraged by the 
 results of his work he decided to take a long vacation. On his return, 
 however, the same scourge of puerperal infection pursued him and at 
 his death the cause of it all was clear when it was found that he had 
 suffered during life with an ozena which had constantly contaminated 
 his handkerchiefs and his hands. This was before the routine use of 
 sterile rubber gloves in obstetrics. 
 
 Varieties.^ — Puerperal infection may well be classified as either a 
 toxemia or a bacteremia and described as follows: 
 
 1. A Toxemia. — Due to the absorption of: (a) The products of putre- 
 factive bacteria, often called a sapremia (Figs. 495, 496, and 497). (b) 
 The toxins of distinctive pathogenic bacteria. 
 
 2. A Bacteremia. — In which bacteria circulate in the blood, called also 
 septicemia (Fig. 498). 
 
 The distinction between these two classes is clear. In the latter, 
 the bacteria are in the general system. In the former they are localized 
 and do not circulate. 
 
 It must be borne in mind, how^ever, that in actual practice the two 
 classes are not infrequently mingled, the sapremia ser\ing as a port of 
 entry for a bacteremia, so that when a case is first seen it may be impos- 
 sible to tell whether the infection is to result in a bacteremia or not. 
 
 There is one type of bacteremia which presents a distinct clinical 
 picture and has long been called by a distinctive term pyemia. 
 
FREQUENCY OF PUERPERAL INFECTION 
 
 815 
 
 This is especially apt to occur in cases in which one of the lesions is 
 a thrombophlebitis, and in which , portions of the septic thrombus or 
 colonies of bacteria becoming detached, are carried to previously unin- 
 fected tissue. This is sometimes called mestastatic bacteremia and pre- 
 sents the clinical picture of recurrent, wide excursions of temperature 
 with repeated rigors, as one new organ or tissue after another is involved. 
 
 Fig. 495. — Sapremia from retained secundines. 
 
 Fig. 496. — Sapremia from retained lochia 
 due to an anteflexion. 
 
 Fig. 497. — Sapremia from retained lochia 
 due to a retroflexion. 
 
 Frequency. — Statistics regarding puerperal infection at the present 
 day are so difficult to obtain that the records of puerperal infection in 
 20,000 consecutive deliveries at the Sloane Hospital, where any rise of 
 temperature in the puerperium above 100.6° F. is considered fever, are 
 given. It should be remembered that many of the cases were brought 
 
816 
 
 PUERPERAL INFECTION 
 
 to the hospital after l)eiiig long in labor, after unsuccessful efforts at 
 delivery had been made, and that many were already infected. 
 
 In the 20,000 deliveries there was fever, i. e., temperature above 100.6° F. 
 in 2155, or 10.7 per cent. 
 
 Of this number, 1288 were primigravidse, 867 were multigravidae, and 
 372 were premature deliveries (under eight and a half months). 
 
 Variety of Infection. — Of the 2155 cases of infection, 253 were bacter- 
 emia and 1902 were sapremia. 
 
 Thus, in 20,000 consecutive deliveries, .including ambulance cases, 
 there were 253 cases of bacteremia, or 1.25 per cent.; and 1902 cases of 
 sapremia, or 9.5 per cent. 
 
 Fig. 498. — Bacteremia with site of invasion in vagina, at cervix or placental site. 
 
 The use of rubber gloves was introduced at the beginning of the 
 seventeenth thousand, so that in this series of 20,000 deliveries, 16,000 
 were delivered without gloves and 4000 with gloves. 
 
 In the 16,000 cases delivered without gloves, there were: 181 cases 
 of bacteremia, or 1.1 per cent., and 1525 cases of sapremia, or 9.5 
 per cent. 
 
 In the 4000 cases delivered with gloves there were 34 cases of bacter- 
 emia, or 0.35 per cent., and 377 cases of sapremia, or 9.4 per cent. 
 
 The number of cases of bacteremia was greatly reduced by the use 
 of rubber gloves, while the number of cases of sapremia remained practi- 
 cally unchanged. 
 
 Maternal Mortality. — In the 2155 cases of infection occurring in 20,000 
 deliveries there were 54 maternal deaths, a mortality from infection of 
 
LESIONS AND PHYSICAL SIGNS OF PUERPERAL INFECTION 817 
 
 0.27 per cent., and a percentage of mortality among the 2155 cases of 
 2.5 per cent. 
 
 Among the 253 cases of bactejemia there were 54 deaths, or 21.3 
 per cent. 
 
 Among the 1902 cases of sapremia there were no deaths from infection, 
 but 2 died from necrosis of the hver, a mortaUty of 0.1 per cent. 
 
 The Site of Infection. — Any portion of the parturient canal may serve 
 as the site of invasion by pathogenic bacteria (see Fig. 498). The entry 
 may be in some small laceration in the vulva or vagina. It may be 
 higher up in a laceration of the cervix, but the usual site of the lesion in 
 puerperal infection and the usual avenue of entrance is the endometrium, 
 and especially at the placental site. Here is a large, bleeding surface 
 with a considerable amount of torn tissue and large sinuses filled 
 immediately after labor with soft thrombi. These are conditions 
 furnishing a good soil for the growth and development of pathogenic 
 bacteria. 
 
 Pathological Lesions and Physical Signs. — The pathological changes 
 in puerperal infection vary greatly as to whether the case is one of a 
 toxemia (sapremia) resulting from the invasion by putrefactive bacteria 
 of organic material left in the uterus, or whether it is a bacteremia with 
 pathogenic organisms circulating in the blood. 
 
 In a sapremia, inspection of the vulva, vagina and cervix shows a 
 normal condition of this portion of the parturient canal, with any abra- 
 sions, which may have been produced by the labor, healthy and without 
 exudate; the lochia usually not diminished, sometimes profuse and 
 often with an odor which is distinctly offensive. This offensive odor is 
 usually most marked when the bacteria present are those of putrefaction 
 or the colon bacilli. 
 
 On the other hand, the parturient canal in the early days of a sexeve 
 bacteremia presents a decidedly different picture; an inspection of the 
 vulva, vagina and cervix often discloses the fact that any abrasion along 
 the canal produced by the labor is covered with a grayish superficial 
 slough, somewhat resembling the membrane of diphtheria and formerly, 
 before the etiological relation between the Klebs-LoefHer bacillus and 
 true diphtheria was understood, called "diphtheritic." The lochia in 
 a case of bacteremia is usually diminished, may even be absent, and 
 unless there is associated with it a sapremia, it is often free from odor. 
 The uterus is subinvoluted and the grayish superficial necrosis seen upon 
 the cervix may extend over the whole interior of the uterus, so that 
 the endometriiun becomes a grayish or greenish-gray, necrotic membrane. 
 Beneath the necrotic membrane invaded with bacteria and in inverse 
 proportion to the virulence of the bacteria and the rapidity of the 
 invasion, is found in the uterine musculature a zone of leukocyte infiltra- 
 tion, sometimes spoken of as the "protective zone," which as this term 
 implies, seems to serve as a barrier against the further invasion of the 
 system of the woman by the advancing host of bacteria. 
 
 This protective zone is thickest when the resistance of the woman's 
 tissues is greatest and the invasion least virulent and slow. It is least in 
 52 
 
818 PUERPERAL INFECTION 
 
 evidence when the invading bacteria are of the highest virulence, as the 
 streptococci, and the invasion most rapid. 
 
 The most common lesion of puerperal infection is therefore an endo- 
 metritis associated with a subinvokition of the uterus and more or less 
 infiltration of leukocytes just beneath the endometrium, especially at 
 the placental site. Thus we see nature endeavors to localize puerperal 
 infection within the parturient canal and in this she is often successful, 
 especially if the invading bacteria are of low virulence. 
 
 Unfortunately, on account of the virulence of the invading organisms, 
 their great number, the rapidity of their invasion and the low resistance 
 of the tissue of the parturient canal, especially the uterine wall, the 
 protective or reaction zone of leukocytes is in not a few cases incapable 
 of limiting the infection to the endometrium, and the bacteria spread to 
 the uterine wall, the cellular tissue outside of it, the tubes, ovaries, 
 peritoneum and perhaps to almost any organ and tissue in the body. 
 There are two a\enues along which the invading organisms traNcl from 
 the parturient canal to the neighboring or distant tissues: (o) The 
 lymphatics and {b) the veins. 
 
 Although both of these channels may be occupied by bacteria in cer- 
 tain cases of puerperal infection, the two types of infection are fairly 
 distinct, and as in the severest forms the lymphatics, are the avenues 
 followed, this variety will be studied first. 
 
 From the infected necrotic surface of the placental site, or from a 
 lesion in the cervix, the invading organisms may extend along the lym- 
 phatics into the uterine wall and give rise to various degrees of metritis, 
 in some instances resulting only in small aggregations of leukocytes 
 which may eventually be absorbed; in other instances resulting in 
 multiple abscesses with which the uterine body may be riddled. Extend- 
 ing along these uterine lymphatics, which are very abundant just 
 beneath the peritoneum, the bacteria may traA-el to the peritoneum itself 
 and give rise to a peritoniti.^t, which is usually the chief lesion found in 
 rapidly fatal cases of puerperal infection due to streptococcus invasion, 
 the peritoneal cavity on being opened showing a thin seropurulent fluid, 
 with little fibrin and little localization of the infection. 
 
 Cellulitis or Parametritis. — Instead of passing along the lymphatics 
 from the uterine canal directly to the peritoneum covering the upper 
 portion of the uterine body, the organisms may travel from some lesion 
 of the vulva, vagina, cervix or lower uterine segment, through the 
 lymphatics to the subperitoneal cellular tissue surrounding the uterus, 
 i. e., in the broad ligaments at the side, the uterovesical ligaments in 
 front, and the uterosacral ligaments behind the uterus, setting up a 
 cellulitis which resembles that of the hand and forearm following an 
 infected wound of the finger acquired in operating or dissecting. 
 
 There is the same inflammatory edema which may occupy more or 
 less space at the side of the uterus, giving the feel of a hard mass fixing 
 the organ, perhaps pushing it to the opposite side. In extreme cases 
 it may involve the cellular tissue on both sides of the uterus, extending 
 between it and the bladder in front and surrounding the rectum behind. 
 
LESIONS AND PHYSICAL SIGNS OF PUERPERAL INFECTION 819 
 
 In rare cases this involvement of the cellular tissue through lymphatic 
 infection may extend down along the vessels of the thigh and secondarily 
 cause a phlebitis or so-called phlegmasia alba dolens, differing from the 
 ordinary form which is due to a phlebitis, starting with an infected 
 thrombus within the vein. 
 
 The result of cellulitis at the side of the uterus varies with the extent 
 and virulence of the infection. In some cases the exudate, although 
 abundant enough to fix the uterus in the pelvis and present almost a 
 board-like feel to the vaginal fornix, will absorb and leave only slight 
 cicatricial tissue behind. In other cases the exudate will break down 
 into an abscess, which will point in the groin above Poupart's ligament, 
 or burrow down in the posterior or lateral fornix of the vagina or down 
 along the urethra to the vulva. In some instances, if neglected, it will 
 rupture into the rectum behind or the bladder in front, not to mention 
 the vagina or other directions toward which it was pointing. 
 
 Salpingitis. — Inflammation of the tubes in puerperal infection may 
 occur in one of three ways : 
 
 1. In a few cases it occurs as a result of extension of the infection from 
 the endometrium along the mucosa of the tube. 
 
 2. More frequently salpingitis results from extension of the infection 
 through the lymphatics of the broad ligament to the wall of the tube. 
 
 3. Not infrequently salpingitis occurs from infection of the mucosa of 
 the outer portion of the tube from a peritonitis which has resulted from 
 lymphatic infection from the uterus. 
 
 Abdominal section in these cases often shows the fimbriated extremity 
 of these tubes patent and one can express seropurulent fluid from them. 
 
 Oophoritis. — The invading organisms may extend along the lymphatics 
 of the broad ligaments to the hilum of the ovary setting up an oophoritis 
 with or without suppuration, or in the same way that a salpingitis may 
 arise secondarily to a peritonitis, so a Graafian follicle may be infected 
 with the exudate of an infected peritoneum. 
 
 Thrombophlebitis. — At the placental site hemorrhage is checked, after 
 the expulsion of the placenta, by contraction of the uterine musculature 
 about the uterine sinuses and by the formation of thrombi within them. 
 . Localized uninfected thrombosis is therefore a physiological process in 
 every parturition. It is easily understood, however, that these thrombi 
 furnish an excellent medium for the development and spread of infection, 
 when once infective organisms are brought to them. The area in which 
 the thrombi are infected may be a limited one, the process not extending 
 beyond the uterine wall, and recovery rapidly take place. On the other 
 hand, the infected thrombi may be associated with an inflammation of 
 the vein — a thrombophlebitis which extends to almost all the veins of 
 the pelvis, perhaps reaching upward to their junction with the inferior 
 vena cava and extending downward to one or both femoral veins, causing 
 the usual form of phlegmasia alba dolens. 
 
 These infected thrombi may soften, break down and be carried to 
 almost any part of the body as the liver, lungs, spleen, the heart, the 
 different joints, etc. This is the pathological condition in that form of 
 
820 PUERPERAL INFECTION 
 
 puerperal infection called pyemia, in which repeated rigors with sudden 
 rises of temperature, indicate extension of portions of thrombi or colonies 
 of bacteria to organs or tissues, as distinguished from the lymphatic 
 variety of infection already described. The thrombophlebitic form is 
 usually less often fatal and less rapid when it is fatal. The evidences of 
 infection in the uterus will often almost disappear and that organ undergo 
 a fair amount of involution and still the patient continue her rigors and 
 wide excursions of temperature from repeated extensions of portions of 
 infected thrombi, perhaps from secondary foci. The lungs are frequently 
 the seat of these septic emboli and a sudden pain in the chest and the 
 signs of a localized pleurisy mark the event. Not infreciuently the 
 different joints of the body are involved in this embolic process and 
 the writer remembers distinctly one of his patients in whom almost all 
 the joints of her body were involved, including those of the fingers and 
 even one temperomaxillary articidation. These multiple foci of infec- 
 tion do not necessarily mean that the case is to prove fatal, as not infre- 
 quently they gradually lose their \irulence and complete recovery ensues, 
 as in the author's case just referred to. The process is often a long one, 
 and the patient may die of exhaustion, associated with the frequent 
 rigors and protracted fever for weeks or even months, but the farther 
 removed the patient is from the date of confinement and infection, the 
 greater the chance of the infection losing its virulence and the patient 
 recovering. The possibility of an embolus plugging one of the large 
 pulmonary arteries and causing sudden death must always be considered. 
 
 The lodgement of a portion of an infected thrombus in any tissue or 
 organ may lead to the formation of an abscess which indicates surgical 
 interference, and until this pus can be reached and evacuated the tem- 
 perature will continue. ^Moreover, this may be only one of many foci 
 of pus. and the hope that the evacuation of this will cause an end of the 
 fever may be false. 
 
 Phlegmasia Alba Dolens. — The fact that the lower extremity or extre- 
 mities after confinement occasionally became swollen, painful, white 
 and hard; that this was usually associated with fever, and that the 
 secretion of milk was sometimes diminished, led the ancients to explain 
 the condition as a metastasis of the milk and to call it " milk-leg." These 
 views are now known to be erroneous, yet considerable confusion still 
 surrounds the condition. 
 
 It is now known that it is not necessarily associated with parturition, 
 that pelvic operations, especially hysterectomies, are not infrequently 
 followed by a so-called "milk-leg. " 
 
 ^Moreover, its occurrence is not limited to the female sex, as many 
 men recover from an attack of typhoid fever with one or both lower 
 extremities in this condition. 
 
 Varieties. — Two varieties may well be recognized: (a) The ])rimary, 
 and {b) the secondary. In each variety a thrombophlebitis is the under- 
 lying cause. 
 
 In the first or usual variety the thrombophlebitis is the primary con- 
 dition. In the second or unusual form the thrombophlebitis is secondary 
 
ESIONS AND PHYSICAL SIGNS OF PUERPERAL INFECTION 821 
 
 to a pelvic cellulitis, the result of infection carried from the parturient 
 canal by the lymphatics to the cellular tissue of the pelvis, thence to 
 • the cellular tissue of the thigh, thence to the crural vein. In the first 
 or primary variety, the swelling begins at the foot and extends upward 
 as the return blood flow is empeded. In the second variety the swelling 
 begins in the thigh and the foot only becomes swollen after the inflam- 
 mation of the cellular tissue has reached the vein. 
 
 Etiology. — ^The origin of the second or cellulitic variety has already 
 been discussed when studying the spread of infection through the lym- 
 phatics to the cellular tissue of the pelvis. The etiology of the usual or 
 primary variety of "milk-leg" has been somewhat obscured by the 
 fact that it has often followed an operation or confinement from which 
 the convalescence for the first and perhaps the second week has been 
 afebrile, and thus it has been difficult to assign it to infection. Hence 
 it has been assigned to the stasis of blood in the pelvic veins from the 
 pressure of the pregnant uterus, to the recumbent posture after confine- 
 ment or operation, to the condition of the blood in pregnancy, etc. 
 
 The author believes that the ordinary condition of "milk-leg" should 
 be looked upon and called a thrombophlebitis, and that in most, if not 
 all cases, it is due to an infection; this infection in most cases being 
 due to organisms of low virulence, perhaps even in some cases to sapro- 
 phytic organisms. In this belief he has been confirmed by his experience 
 in many cases of which the following is a good example : 
 
 A primipara, on the evening of the twentieth day of a normal, afebrile 
 puerperium, had a slight rigor, and a rise of temperature to 101° F. 
 The next morning she complained of pain in her left groin and palpation 
 elicited tenderness along the left femoral vein. That day the foot, leg 
 and thigh became swollen and she ran the typical course of a thrombo- 
 phlebitis. On the evening following the onset of the rise of temperature 
 the nurse found on the vulva pad a small piece of membrane about the 
 size of a thumb nail, which was distinctly foul in odor. The foul piece 
 of membrane explained to the author the thrombophlebitis which other- 
 wise, on account of her twenty days of afebrile puerperium, he would 
 have been unable to explain. In this case the membranes had been 
 unusually adherent, he had been obliged to remove them manually and 
 had done so as thoroughly as possible, but evidently this little piece had 
 resisted his efforts. It had been so firmly adherent as to retain its vitality 
 during the first and second week of the puerperium and only during 
 the latter part of the third week had it fallen a prey to the saprophytes 
 and become necrotic. 
 
 Clinical Picture. — The ordinary thrombophlebitis of the puerperium, 
 as a rule, occurs during the second or third week after confinement, 
 and not during the first week, although occasional exceptions occur. 
 It may be localized, involving a group of dilated veins in the calf or in 
 the popliteal space, but, as a rule, involves the large branches of the 
 femoral or the femoral vein itself. The attack is usually ushered in with 
 chilly sensations and a rise of temperature (100° to 101° F.), although 
 both of these may be slight. There is usually pain in the groin or in the 
 
822 PUERPERAL INFECTION 
 
 iiroul) of dilated veins to he iiivoK cd. before any swelling of the limb can 
 be detected. Within a few hours, however, the foot, leg and thigh become 
 swollen in this order and with varying <k'grees, de])ending ui)on the size 
 of the vein or veins occluded. Paljiation will usually detect the hardened, 
 tender vessel whose course is often outlined by the redness of the skin 
 over it. The affected limb usually feels extremely heavy and helpless 
 to the patient, while to the observer it looks whitish, perhaps mottled 
 in places and on palpation the skin feels tense. The limb is painful and 
 the most comfortable position is usually that of outward rotation with 
 knee flexed. 
 
 The rise of temperature and pulse usually continue for about a 
 week. 
 
 The tenderness ar.d swelling gradually subside, but instead of the 
 convalescence being completed in four weeks, as is the rule in the normal 
 puerperium, it is often postponed two or three weeks by this complica- 
 tion, and the patient for a year or longer may be annoyed by swelling 
 of the affected limb on standing or much walking. In fact, in some 
 instances the venous return in the affected limb never becomes normal. 
 Moreover, one of the disappointments in thrombophlebitis of the lower 
 extremities is that sometimes, just as the condition seems to be sub- 
 siding in one limb and the temperature and pulse have reached normal, 
 the other limb becomes affected, and the period of discomfort has to be 
 repeated with the corresponding interference with venous return. 
 
 Prognosis. — In the ordinary form of thrombophlebitis of the thigh 
 or leg, or both, coming on in the second or third week of the puerperium, 
 the prognosis is usually good. The convalescence may be tedious and 
 the leg swell, on standing, for many months, and as already stated, 
 both limbs may be in^•olved, yet a hopeful prognosis can usually be 
 given. The possibility of a pulmonary embolus must always be thought 
 of, although in an active obstetric experience of over twenty-five years it 
 has never been the author's misfortune to meet with this accident in a 
 case of thrombophlebitis of the thigh or leg. He has lost a number of 
 cases from pulmonary emboli following operation or delivery, but they 
 have always occurred in cases without evident thrombophlebitis of the 
 thigh or leg. In a series of 20,000 consecutive deliveries at the Sloane 
 Hospital there were 95 cases of phlebitis, and among this number the 
 only death from pulmonary embolus was one who started to leave the 
 hospital contrary to advice and dropped dead in the hall. 
 
 Diagnosis of Puerperal Infection. — If a woman after delivery has a 
 rise of temperature, always suspect infection. It may not be a uterine 
 infection; it may not be an infection in which the obstetrician is at all 
 at fault; yet until the contrary can be proved, the only safe rule is for 
 the obstetrician in his own mind Che need not impart this information 
 to the family) to regard the temperature as evidence of infection, and 
 yet for his own peace of mind he should endeavor to exclude it. Not 
 infrequently in the first twelve hours following a long, dry labor, the 
 patient will have a slight rise of temperature, perhaps between 100° F., 
 and 101° F., corresponding to that following a surgical operation in 
 
DIAGNOSIS OF PUERPERAL INFECTION 823 
 
 which there has been considerable bruising of tissue. This for lack of a 
 better term is usually called " reactionary" temperature, and is character- 
 ized by the fact that within twenty-four hours the temperature falls 
 to normal and remains there. 
 
 Milk Fever. — For many years, on account of the fact that associated 
 with the temperature of puerperal infection there was a diminution of 
 the milk secretion, the condition was considered in some way due to a 
 metastasis of the milk and the fever was called "milk fever." With 
 clearer views regarding the etiology of puerperal infection the old view 
 of its being due to the milk was abandoned. Xo one with a large 
 experience in hospital and private obstetrics, however, can overlook the 
 fact that in certain women, especially nervous primiparse with sensitive 
 breasts and sensitive nipples, the first engorgement of the breasts is 
 not infrequently accompanied by a slight rise of temperature 100° F. to 
 101° F., which subsides as soon as the breasts soften and lactation is 
 well established. 
 
 Bowels. — Not infrequently the intestinal canal of the parturient woman 
 is far from empty and she is suifering from an intestinal auto-intoxica- 
 tion which may cause a slight rise of temperature, subsiding as the 
 intestinal canal is emptied. A fall of temperature to normal will often 
 be noted after a saline or other cathartic has acted well on the third or 
 fourth day, and the result may be due to one or all three of the following 
 actions: The cathartic relieves the congestion of the breasts; it empties 
 the intestinal canal and in the act of moving the bowels the uterus is 
 more or less compressed and expulsion of lochia or clots is favored. 
 
 Pyelitis. — One of the unusual complications of the puerperium, yet 
 far less rare than formerly supposed, is a pyelitis usually the result of a 
 colon bacillus infection, as was discussed in Chapter XVIII. This usually 
 causes a rise of temperature which would be confused with that of 
 uterine infection, unless the possibility of its occurrence be kept in mind, 
 and by finding the acid, purulent urine and the enlarged tender kidney, 
 its presence be verified. 
 
 Appendicitis ; Twist in the Fallopian Tube or in the Pedicle of an Ovarian 
 Cyst or Fibromyoma ; Sloughing of an Ovarian or Uterine Tumor, etc. — The 
 fact that a woman has recently been delivered does not signify that she 
 is exempt from abdominal lesions or complications from which she 
 might suffer were she in the non-puerperal condition. In fact, she is 
 distinctly more liable to the complications mentioned above on account 
 of the change in relations and the trauma incident to the delivery. Thus, 
 a chronic appendicitis as a result of the trauma of labor may become 
 acute, give a rise of temperature, and require operation in the first few 
 days of the puerperium, as occurred in a case operated on by the author 
 on the third day. 
 
 The sudden decrease in the size of the uterus, with the increased room 
 in the abdomen and pelvis, favors a twist in the Fallopian tube or in the 
 pedicle of any ovarian or pendunculated uterine tumor. Furthermore, 
 the trauma of labor not infrequently causes sloughing in an ovarian 
 dermoid or a uterine fibroid, and these as well as other abdominal and 
 
824 PUERPERAL INFECTION 
 
 peh ic complications cause a rise of temi)tTature which might lead one 
 to (liaijnose uterine infection unless careful diagnosis was always sought. 
 
 Having excluded the breasts, the bowels, the kidneys and affections 
 of other abdominal or pelvic organs as the cause of the temperature in 
 the case at hand, the obstetrician is forced to revert to his first suspicion, 
 that there is infection of the parturient canal. The question now pre- 
 senting is: Is she suffering from a sapremia or a bacteremia? 
 
 In an ordinary sapremia there is organic decomposing material within 
 the uterus. It may be there in the form of a portion of the placenta or 
 blood-clots, which should have been expelled at the time of labor, but 
 were not, or it may be there in the form of lochia, which should have 
 drained away, but was prevented by a stenosis of the internal os caused 
 by a flexion of the uterus usually anterior, sometimes posterior, not 
 infrequently a return of an anteflexion which existed before pregnancy 
 occurred. 
 
 This anteflexion of the uterus with retained lochia and rise of tempera- 
 ture is often found to occur when the patient is first allowed to sit out 
 of. bed. These cases of sapremia are those in which the lochia usually 
 has an odor as a result of the action of the saprophytes or the colon 
 bacilli, and inspection of the vulva, perineum, etc., shows no necrotic 
 membrane. 
 
 In a bacteremia, on the other hand, there may be no decomposing 
 placenta or blood-clots in the uterus, which may be empty, save for a 
 grayish, necrotic membrane lining its cavity and covering any abrasion 
 on cervix, vagina, and vulva. The infecting organisms in this case, 
 overcoming the protective zone of leukocytes, have passed through the 
 wall of the parturient canal into the general system. The lochia is 
 usually scant, perhaps absent, and is often without offensive odor. 
 
 Symptoms. — As already indicated, the one predominent symptom of 
 puerperal infection is a rise of temperature usually occurring on the third 
 or fourth day of the puerperium, perhaps ushered in with a rigor or with 
 chilly sensations. 
 
 This may be given as the general rule, yet marked variations occur. 
 In some cases of bacteremia such virulent streptococci are introduced 
 during the labor that the temperature rises immediately afterward and 
 remains high until death or through a long, tedious convalescence. On 
 the other hand, the infection with rise of temperature may start as a 
 sapremia as late as the third day, and this in turn be the starting-point 
 of a long bacteremia. 
 
 The temperature, as a rule, is higher in the evening than in the morning, 
 and usually takes two or three days to reach its highest point. In the 
 pyemic variety of infection the rigors are frequently repeated and the 
 rises and falls of temperature are very sudden and pronounced, a normal 
 temperature, a rigor and a temperature of 105°, all occurring perhaps 
 within a space of two or three hours. 
 
 In a sapremia the pulse, as a rule, is slow, usually below 100 unless the 
 condition is grave. On the other hand, in a bacteremia the pulse soon 
 rises to 120, and if the infection is severe and prolonged, often ranges 
 
TREATMENT OF PUERPERAL INFECTION 825 
 
 between 120 and 140 for weeks. The nteriis is usually subinvoluted and 
 tender. The character of the lochia has already been described, being 
 usually foul and abundant in a sapremia; scanty or absent and often 
 without odor in a bacteremia. 
 
 Inspection of lesions along the parturient canal in a bacteremia shows 
 the membranous covering due to superficial necrosis. The condition of 
 the abdomen in a bacteremia depends upon whether the infection has 
 spread by the lymphatics to the peritoneum or not. If the peritoneum 
 is not involved, the abdomen may be soft, not distended, and not tender, 
 although the patient may suffer with a septic diarrhea. If the infection 
 has spread to the peritoneum, it may be localized about the uterus and 
 appendages as a pelvic peritonitis secondary to a salpingitis, or a 
 cellulitis, and in this condition recovery may take place either with 
 or without surgical interference. 
 
 On the other hand, the peritonitis may be general, with tense, distended 
 abdomen, vomiting, rapid pulse, and evidences of great physical depres- 
 sion, although the patient may retain consciousness till the end. The 
 temperature in these cases of general peritonitis varies greatly. It usually 
 remains high throughout, but occasionally the temperature continues 
 low, and the rapid, thready pulse, the dry, brown tongue, and physical 
 depression show the gravity of the case. 
 
 As indicated above, the prognosis of a general peritonitis resulting 
 from puerperal infection is usually fatal, whether they are subjected to 
 operation or not. As a rule the symptoms of general peritonitis do not 
 present themselves until the third or fourth day, and the fatal issue 
 usually occurs within a week or ten da}'s. Occasionally the general 
 peritonitis arises from an extension of a localized peritonitis or from 
 rupture of a localized collection of pus, as in the broad ligament or tube, 
 and here the symptoms of peritonitis develop later. 
 
 The appetite and digestion in cases of bacteremia are often markedly 
 impaired and add to the difficulty of supporting the patient. 
 
 In the pyemic variety of infection the sweating after the rigors is 
 often very profuse, and adds to the weakness and depression of the 
 patient. 
 
 The amount of pain in puerperal infection varies greatly. It is often 
 greatest when the process is localized in the pelvis with the development 
 of a salpingitis or a cellulitis, which fills more or less of the pelvis with 
 exudate, and then breaks down into an abscess. In these cases they 
 often suffer, not only with the pain of the localized peritonitis, but from 
 the pressure upon the nerves leaving the pelvis and from interference 
 with the functions of the bladder and bowel. On the other hand, many 
 cases of general peritonitis which evidently are desperately ill and 
 approaching a fatal issue may say that they feel very comfortable. Many 
 cases of bacteremia, even those which eventually recover, present a 
 mild delirium during the height of the fever. 
 
 Treatment. — Prophylaxis. — The greatest dread of every obstetrician, 
 is the occurrence of puerperal infection in his practice. Furthermore, 
 this dread is intensified by the education of the laity to the belief that 
 
826 PUERPERAL JXFECTIOX 
 
 if infection occurs, the obstetrician or tlic nurse, especially the former, 
 is at fault. 
 
 Tins Ix-licf nui\ he unjust, hut it exists, and the knowledge of it inten- 
 sifies the anxious days and sleepless nights of the obstetrician who is 
 unfortunate enough to have a patient whom he has delivered become 
 infected. 
 
 Such being the case, it is evident that prophylaxis against infection is 
 the most important factor in the treatment. The use of sterile gloves 
 in the conduct of a delivery has already been referred to and may well 
 be emphasized here. No practitioner at the present day can afford 
 to deliver a case without all the precautions known by the laity to be 
 considered valuable as prophylactic measures against infection. Sterile 
 rubber gloves are among those precautions so recognized, and if a case 
 of infection occurs and gloves have not been worn, the obstetrician is 
 naturally, and probably justly, criticised. Furthermore, if all known 
 precautions have been used and infection does occur, the profession as 
 a whole will stand by the unfortunate obstetrician. Without them he 
 forfeits the support of the laity and the profession as well. 
 
 The use of sterile gloves, however, must not blind the obstetrician to 
 the need of strictest cleanliness of his hands within the gloves, of his 
 person, of the nurse, the field of operation, and the drapery of this field. 
 
 The hands should be scrubbed and disinfected as thoroughly as though 
 the gloves were not to be worn, and in putting on the gloves their exterior 
 must not touch the ungloved hand. Furthermore, the outside of the 
 gloves must not touch anything unsterile, else their sterility is destroyed. 
 
 The precautions to be used in the conduct of a delivery with the 
 preparation of the patient's vulva and draping of the surrounding field 
 have all been described in the chapter discussing the management of 
 normal labor (page 311), and will now only be referred to. The reasons 
 for avoiding the antepartum douche as not only unnecessary, but not 
 devoid of danger, were there set forth. The prophylactic measures which 
 the author would here summarize and emphasize are as follows: 
 
 During her pregnancy keep the patient in the best possible physical 
 condition, with plenty of fresh air and moderate exercise. Favor her 
 elimination by liberal draughts of water and keep her bowels free, so as 
 to avoid auto-intoxication. Have the confinement chamber well lighted 
 and well aired. Have the nurse wear a freshly laundered suit, and prepare 
 herself, including the scrubbing and disinfection of hands and forearms, 
 as for a surgical operation. Let the obstetrician by external palpation 
 and auscultation inform himself as thoroughly as possible as to the con- 
 dition of the fetus and its relation to the parturient canal, so that 
 internal examinations may be as few as possible. Then with the hands 
 and forearms of the obstetrician scrubbed and disinfected, his person cov- 
 ered with a sterile gown and his hands with sterile gloves, let him surround 
 the prepared vulva with sterile drapery, preferably with sterile stocking- 
 drawers covering legs and thighs and a sterile towel on the abdomen. 
 Lastly, let him remember that the only way to make a vaginal examina- 
 tion with the least risk of carrying infection from the vulva without to 
 
TREATMENT OF PUERPERAL INFECTION 827 
 
 the sterile vagina within, is to separate the labia with the fingers of one 
 hand and carry the. examining fingers directly into the vagina without 
 touching the vulva. 
 
 During the second stage of labor keep the vulva covered with a wet 
 bichloride towel to avoid contact with the patient's fingers or other non- 
 sterile objects. In the conduct of the third stage, wait twenty minutes 
 before expressing the placenta, thus allowing time for the uterus to con- 
 tract and the placenta to separate. After expressing the placenta and 
 membranes, examine carefully for any missing portions, and if any part 
 of the placenta or any large portion of the membranes is missing, making 
 certain that the forearm is thoroughly clean and the glove sterile, go 
 into the uterus carefully with gloved hand and remove the missing 
 secundines. Use a postpartum douche only for hemorrhage or for special 
 indications, as for washing out debris or clots. Repair all perineal tears 
 of 1 cm. or over. Do not examine for cervical lacerations or repair 
 them unless cervical hemorrhage occurs or uterine rupture is suspected. 
 Keep the vulva covered with sterile dressings at least during the first 
 week of the puerperium. Have the nurse exercise the greatest care of 
 the vulva during the voiding of the urine and movement of the bowels. 
 The details of these different procedures will be found in the chapter 
 concerning the management of normal labor. 
 
 Curative Treatment. — Opinions differ considerably regarding the 
 details of the treatment of puerperal infection, although the majority 
 are agreed that conservatism should be the keynote of the treatment. 
 It is well established, on the one hand, that nature with her leukocytes 
 and tissue resistance is often able to limit and overcome the invasion 
 of the infective organisms. On the other hand it is proved by accumulat- 
 ing experience of recent years that misguided attempts, by currettage 
 and other surgical procedures, to rid the parturient canal of its infection, 
 have many times broken down nature's barriers and have made general 
 an infection and inflammation which otherwise would have continued 
 local. The conclusion to be drawn from this experience should be that 
 every effort should be directed toward aiding nature in her resistance 
 to the infecting bacteria and in favoring their elimination, and every 
 care should be taken not to handicap her by lowering the resistance of 
 the tissues or opening new avenues of infection. 
 
 In the first place, on the occurrence of a rise of temperature after 
 delivery, the question should be asked. Is the temperature possibly due 
 to something outside the parturient canal? Are the breasts distended? 
 Are the bowels constipated? Is the urine normal? Do not feel at the 
 first rise of temperature that the parturient canal must be invaded, 
 although note at once the size of the uterus and the amount and character 
 of the lochia. 
 
 If there is any suspicion of distended breasts, endeavor to empty them 
 by massage, extra nursing or breast-pump, and move the bowels well, 
 preferably with a saline. If the involution of the uterus seems tardy, 
 put an ice-bag on the fundus. It will do no harm to wait until the 
 following day to watch the effect of these procedures upon the temperature. 
 
828 PUERPERAL INFECTION 
 
 In the iiieantinic, if the locliia is scant, ck'\ ation of the head of tlie hod 
 will often favor th(> drainaije from the ntenis. If the nrine contains ])ns 
 and either kidney, especially the ri<;ht, is enlaru-ed and tender, the treat- 
 ment of pyelitis is indicated (see page ()()3). 
 
 On the following day, if the temperatnre is again high and the breasts, 
 bowels and kidneys have been excluded as factors in its causation, the 
 parturient canal must be considered the source of the trouble. If every 
 precaution of cleanliness of obstetrician, nurse, vulva and dressings 
 has been observed, the patient is probably suffering from a sapremia 
 from the retention of blood-clots, lochia, or some adherent secundines 
 which w'ere accidentally overlooked at the delivery, and the temperature is 
 due to the action of sai)rophitic organisms on this retained organic material. 
 
 On account of the risk of carrying infection from the vagina into the 
 uterus by a vaginal douche during the first few days of the puerperium, 
 it is the custom at the Sloane Hospital to postpone vaginal douching 
 until the first five days of the puerperium have passed, during this period 
 relying upon posture and the use of an ice-bag upon the fundus to favor 
 drainage from, and contraction of, the uterus. At the end of five days, 
 if the elevation of temperature still continues, our practice is, with 
 strictest precautions as to hands, douche can, douche nozzle, vulva, 
 etc., to give, once or twice a day, a hot (110° F.) vaginal douche of two 
 quarts of sterile saline solution, hoping thereby to stimulate the uterus 
 to expel its contents. 
 
 After one or two days, if the temperature has not come down and 
 remained low under the use of the vaginal douches, w^e prefer to give 
 one intra-uterine sterile saline douche, using a speculum and one sterile 
 douche nozzle to wash out the vagina, and another sterile double-current 
 douche nozzle passed directly into the cervical canal without touching 
 vulva or vaginal w^alls to w'ash out the uterus, being careful to pass the 
 nozzle very gently, so as not to injure the uterine wall, but allow the 
 saline solution to wash away any loose debris. 
 
 If nothing comes away with the douche and the uterine cavity seems 
 empty, the uterus is thereafter left alone and all attention directed to 
 the general condition of the patient. On the other hand, if considerable 
 debris comes aw^ay with the douche solution and the uterine cavity seems 
 large, we believe it good practice, wdth the sterile-gloved finger and the 
 patient under anesthesia if necessary, to gently explore the cavity of 
 the uterus, removing any retained blood-clots or secundines with the 
 least possible trauma to the uterine wall, realizing that any trauma may 
 lessen nature's resistance to infective organisms and may be the means 
 of converting a local into a general infection. A few facts based on 
 experience deserve consideration. 
 
 No good and possible harm results from a uterine douche when the 
 douche fluid returns clear. 
 
 All intra-uterine douches should be given with the greatest gentleness 
 in puerperal infection lest a sapremia be converted into a bacteremia. 
 
 In a sapremia an intra-uterine douche is usually of great value when 
 carefully given. 
 
TREATMENT OF PUERPERAL INFECTION 829 
 
 In a bacteremia it is capable of doing harm. Hence when used it 
 should be given with the hope that the condition is a sapremia, but in a 
 way which would do the least harm if the condition should prove to be 
 one of bacteremia. 
 
 The question often presenting itself to the consulting obstetrician 
 when called to see a case of puerperal infection is: Should the uterus be 
 explored or douched, or left alone? Each case should be decided upon 
 its own merits. In many instances the attending physician has already 
 entered the uterus with douche nozzle or curette, or both, and here the 
 best procedure is usually to leave the uterus absolutely alone, to favor 
 drainage by posture and treat the general condition of the patient. On 
 the other hand, if the uterus is large and the lochia free and foul, a gentle 
 exploration with the gloved finger to make sure that the uterus is empty, 
 is believed by the author to be good practice. 
 
 When discussing the diagnosis of puerperal infection, attention was 
 called to a variety of sapremia caused by a stenosis of the uterine canal 
 at the internal os, the result of a flexion of the uterus either anteriorly 
 or posteriorly (see Figs. 496 and 497) . This flexion occurring before the 
 lochia has ceased, causes its retention, with the resulting sapremia. 
 
 In many instances, as in those occurring when the patient first sits up, 
 the tension of the retained lochia overcomes the resistance of the stenosis, 
 drainage is again established, and the temperature returns to normal 
 and no treatment is needed. In other cases a hot vaginal saline douche 
 is needed to stimulate the uterus to expel its lochia. In a few cases an 
 intra-uterine douche both for the dilatation accompanying the introduc- 
 tion of the nozzle and for the irrigation of the uterine cavity gives the 
 best results. 
 
 Having made certain that the uterine cavity is free from decomposing 
 material the next problem is to aid nature in resisting further invasion 
 of the infecting organisms and in overcoming those already present. 
 A careful blood count is of considerable assistance in determining the 
 degree of the infection present and the resistance of the patient. 
 
 A blood culture is of interest scientifically, but in the author's experi- 
 ence it has never proved of great practical value, as in many cases of 
 known bacteremia the laboratory report of the blood culture has been 
 negative, and in other cases the treatment had to be instituted before 
 the report could be obtained. 
 
 The experience gained in, the treatment of tuberculosis by fresh air 
 has wisely guided obstetricians of late in the treatment of puerperal 
 infection, and every well-appointed maternity hospital has its roof 
 garden to which the bed of the septic patient may be moved and kept 
 most of the time. Following these lines in private practice, opening 
 wide the windows and allowing plenty of light and air have become 
 routine procedures in the treatment of puerperal infection. Realizing 
 that anything which will improve the general condition of the patient 
 and will increase her tissue resistance will favor convalescence, nourish- 
 ing, easily digested food is distinctly indicated. The heart is often 
 subjected to a long, tedious strain and the use of cardiac stimulants. 
 
830 PUERPERAL INFECTION 
 
 he^'innin^f with small doses, is usually indicated in bacteremia in antici- 
 pation of a cardiac weakness. 
 
 Alcohol is especially well borne in this condition, and it together with 
 strychnin and digitalis forms a trio any one or all of which may be used 
 to great advantage in maintaining the strength of the circulation. 
 
 For the relief of the patient when the fever is high, cold sponging is 
 of marked value and will often promote sleep and conserve the strength 
 of the patient. The coal-tar antipyretics are not to be recommended, 
 as they all tend to depress the heart, a result the opposite of what is 
 desired. 
 
 Saline enemata, left to be absorbed and furnish saline solution to the 
 body tissues often seem of value. Bosc has claimed marked benefit 
 from subcutaneous injections of saline solution. 
 
 Occasionally the patient suffers from a septic diarrhea which becomes 
 exhausting and needs control. A moderate dose of castor oil, or a saline 
 followed h\ the use of bismuth with or without opium, usually gives 
 the best results. If the infection has extended beyond the uterus, but 
 is localized, as in the cellular tissue of the pelvis, or in the Fallopian 
 tubes, the best treatment seems to be the expectant, keeping the patient 
 quiet with an ice-bag over the abdomen, emptying the bowels with 
 enemata, and watching constantly the physical signs and the tempera- 
 ture chart for evidences of pus formation, when incision will be indicated. 
 If symptoms of general peritonitis arise, the case is usually hopeless, 
 although this will be referred to again under the surgical treatment. 
 The intravenous use of .silver in the form of a colloidal salt — collargol — 
 introduced by Oede, in ISQo, met with an enthusiastic reception, but 
 soon lost favor. The silver ointment, called Oede's ointment, has been 
 extensively used by the author, and although he has never seen any 
 harm result from its use, its benefit was very doubtful. In a few cases 
 it has seemed to increase the resistance of the patient, and in two cases 
 the rigors which had been daily, ceased at once on beginning its use. 
 Whether this was due to the ungentum Crede, as appeared, he was unable 
 from this small series to prove. In this connection attention may well 
 be directed to the fact that it is extremely difficult to determine in 
 puerperal infection whether a sudden improvement in the symptoms of 
 the patient is due to the remedy used or not. The course of the flisease 
 is often one of marked surprises, and without treatment the picture of 
 a patient with high temperature and apparently seriously ill may within 
 twenty-four hours change to one rapidly convalescing. 
 
 The discovery by ^Nlarmorek in 1895, of an antistreptococcic serum 
 naturally raised the hopes of obstetricians that at last a means for deal- 
 ing successfully with puerperal infection had been found. They were 
 doomed to disap})ointment, however, and after a careful study of the 
 literature of rei)orted cases treated with it, a committee of the American 
 Gynecological Society, in 1899, was obliged to re])()rt that there was no 
 evidence in favor of its therapeutic value. 
 
 During the last few years the author has .several times used a polyv- 
 alent serum prepared by the New York Board of Health under the 
 
TREATMENT OF PUERPERAL INFECTION 831 
 
 direction of Prof. ^Yilliam H. Park. This serum is obtained from horses 
 which have been injected with about fifteen to twenty different strains 
 of streptococci from different cases of puerperal fever. The horses 
 are treated for about six months and then bled and the serum concen- 
 trated. He regrets to say that he has been unable to see any marked 
 benefit to the patient from either the subcutaneous or intravenous use 
 of the serum, but when gauze soaked in the serum has been applied to a 
 sloughing wound of the parturient canal, the wound has cleaned and 
 healing has progressed more rapidly than would ordinarily be expected. 
 
 Experimental work with antistreptococcic sera has shown that the serum 
 does not neutralize the toxins nor act directly upon the bacteria as do 
 the antidiphtheritic and antitetanic sera, but simply favors phagocytosis, 
 or in other words, increases the opsonic index of the patient. Hence the 
 antistreptococcic serum would theoretically have more prophylactic 
 than curative power. The use of sera up to the present time, however, 
 has resulted in so little, if any, benefit to the patient, that until a more 
 valuable one is discovered the author does not fell like recommending them. 
 
 The success of Sir Almroth \Yright in the treatment of staphylococcus 
 and gonococcus infections with bacterial vaccines raised the hope that 
 a successful method of treating puerperal infection was near at hand, 
 but in 1910 a committee of the American Gynecological Society, com- 
 posed of Williams (chairman), Xewell and the author, after careful 
 study of the literature of reported cases, reached the conclusion that in 
 acute general infection, the t^pe of puerperal infection in which help is 
 most needed, little is to be expected from bacterial vaccines. A few, 
 however, still have faith in their use even in acute infections, but the 
 majority of the profession have abandoned them in these conditions. 
 The most hopeful field in puerperal infection for the use of bacterial 
 vaccines is in the staphylococcus or gonorrheal infections and in the 
 colon bacillus infection of the kidneys. 
 
 As a rule autogenous vaccines, i. e., those made from the patient 
 herself, are considered preferable to stock vaccines. 
 
 Surgical Treatment. — In recent years there has been much discussion 
 regarding the value of surgery in the treatment of puerperal infection. 
 
 In this discussion three different phases and results of infection must 
 be considered. 
 
 1. A localized collection of pus. 
 
 2. A bacteremia. ■ 
 
 3. A thrombophlebitis. 
 
 And three t}^es of operation must be discussed: 
 
 1. Incision and dramage of an abscess. 
 
 2. Hysterectomy. 
 
 3. Ligation and excision of thrombosed pelvic veins. 
 
 Localized Collections of Pns. — ^The profession are well agreed that where 
 the infection has spread through the lymphatics to the subperitoneal, 
 cellular tissue of the pelvis, with the formation of an abscess, this abscess 
 should be opened and drained, and in the carrying out of this procedure, 
 practical experience has demonstrated certain facts. 
 
832 PUERPERAL INFECTION 
 
 It is always wise not to be in too much of a hurry to incise masses of 
 exudate in the pelvis. Many of them absorb without breaking down 
 into pus, and incision is unnecessary. Incision into these hard masses, 
 before softening has indicated the shortest route to the pus focus, is 
 attended with greater risk to the pelvic viscera, and may open fresh 
 tissue with new avenues for the spread of infection. 
 
 If the collection of pus can be reached by a vaginal incision, that is 
 the jireferable route both for drainage and for the comfort of the patient. 
 
 When softening and the sense of fluctuation are detected, incision is 
 indicated at once. Distinct pus may not be found. It may only be a 
 septic, serous exudate, yet the drainage of this collection aids nature in 
 getting rid of the infection and absorbing the exudate. As to the location 
 of the vaginal incision, the author always prefers the median line behind 
 the cervix. From this opening, with the finger or a blunt-pointed scis- 
 sors, any pus collection in the pouch of Douglas or in either broad liga- 
 ment can be reached. Occasionally the cellular tissue between the 
 uterus and the bladder becomes infected and leads to a pus collection 
 which burrows down alongside of the urethra. This collection may 
 be best reached by an incision in the anterolateral vaginal wall or even 
 in one labium. 
 
 Occasionally the exudate and pus collection lifts up the folds of the 
 broad ligament on one side or the other, so that fluctuation is detected 
 just above Poupart's ligament. These collections are most satisfactorily 
 treated by a posterior vaginal incision, but in some cases it is advisable 
 to incise both above and below and establish through-and-through 
 drainage. 
 
 If the collection of pus is in one of the Fallopian tubes or in one of the 
 ovaries, two questions present themselves: Should operation be per- 
 formed at once or postponed? If the pus tube or ovarian abscess is not 
 in contact with the vaginal fornix, the operation, if performed, would 
 have to be abdominal, and there are several objections to an abdominal 
 operation for a pus collection in the first fortnight of puerperal infection, 
 unless it is imperative. The infective organisms are still virulent. The 
 uterus is still large and it is harder to reach either tube or ovary through 
 a small incision. The operation may rupture the sac and spread the 
 infection which before was localized. Later the tubal or ovarian sac 
 may prolapse to the pouch of Douglas, become adherent to the vaginal 
 fornix and as a temporary procedure, to enable the patient to recover 
 from her infection, the pus sac may be evacuated through the vagina, 
 leaving the more radical abdominal operation until later, when the 
 woman is in better condition and the infective organisms less virulent, 
 and it may be stated here that not infrequently no subsequent abdominal 
 operation is needed. 
 
 On the other hand, if the pus collection in tube or ovary remains high 
 and the infection seems to be increasing, the best procedure is an imme- 
 diate abdominal operation, being guided l)y the same general considera- 
 tions as those wdiich govern in operating in a case of acute suppurative 
 appendicitis, i. c, a woman profoundly septic endures a severe abdominal 
 
TREATMENT OF PUERPERAL INFECTION 833 
 
 operation badly. The best results follow a quick operation with the least 
 possible trauma, the rule being to get in quickly, remove the infective 
 focus and get out quickly. The general surgical principles of elevation 
 of the trunk for pelvic drainage, saline solution per rectum by repeated 
 enemata or by the drop method, etc., should be applied. 
 
 Hysterectomy. — The question of whether a hysterectomy will benefit 
 a patient suffering from puerperal infection is a most important one. 
 The author's view is that in a bacteremia it is not indicated. To be of 
 value it would have to be performed so early that it would be impossible 
 to tell whether the patient would recover without it or not, and without 
 doubt some of the cases reported as cures by this operation have recovered 
 in spite of the operation, rather than because of it, and some who have 
 died would have recovered if not operated upon. Furthermore, if this 
 treatment came into general use it is natural to believe that the mor- 
 tality of the operation would be greater than that of the bacteremia, 
 to say nothing of the unsexed condition of the patient on her recovery. 
 
 When performed as a last resort after the infection has spread beyond 
 the uterus, the operation is worse than useless, as it is impossible by it 
 to get beyond the infection and by the additional shock to a woman in 
 poor surgical condition the end is hastened. 
 
 Is hysterectomy ever indicated in puerperal infection? This question 
 the author would answer in the affirmative and as follows: When the 
 focus is located in the uterus, the removal of the uterus may be the means 
 of saving the patient's life. This condition may arise under varied 
 circumstances. The indication may arise as a prophylactic measure in 
 the course of a Cesarean section, in a case where the membranes have 
 been long ruptured, there have been many examinations, with uncertain 
 aseptic technic, and where at the operation the amniotic sac arouses 
 suspicion of a sapremia. 
 
 It may also be indicated as a prophylactic measure in a case of rupture 
 of the uterus with niuch trauma and where infection is reasonably feared. 
 A fibromyoma of the uterus, as a result of the traiuna of the labor, may 
 undergo sloughing, and while in some cases a submucous or a subperitoneal 
 tumor may be removed and the uterus left, in the majority of cases, a 
 sloughing, infected, fibromyoma complicating the puerperium indicates 
 a hysterectomy. 
 
 We come now to a class of cases of puerperal infection in which one 
 or more abscesses have developed in the uterine wall. These are cases 
 in which nature has been able to localize more or less the infection, and 
 a certain number of the cases will recover if the uterus is removed. 
 
 These conditions are usually not present, at least not diagnosed 
 early in the puerperium, usually not until after the tenth day, and the 
 later in the puerperimn the operation, the better the prognosis, as the 
 organisms have probably lost some of their virulence and the patient 
 may have increased her resistance. The mortality of these operations 
 is always high. 
 
 In 5 cases the author lost 3; and yet they are almost hopeless without 
 operation. Sampson reports good results from opening the abdominal 
 53 
 
834 PUERPERAL INFECTION 
 
 cavity, incising the abscess in the uterus and draining through the abtlom- 
 inal incision. Of course the feasibiUty of this method depends upon 
 the number and location of the abscesses. In the author's cases the 
 abscesses were multiple and hysterectomy seemed the only rational 
 procedure. The difficulty lies in the diagnosis of the condition, but a 
 tender nodule or irregularity in the uterine wall should always suggest 
 it. The author's rule is never to perform a hysterectomy for puerperal 
 infection unless he can detect evidences of localization of infection in 
 the uterus or unless, in operating for localized infection close to the 
 uterus, hysterectomy seems the only way of securing satisfactory drain- 
 age, as for instance, where both appendages are the seat of pus collec- 
 tions, are adherent and have to be removed, and a hysterectomy would 
 not only remove an organ which might be a source of trouble and of no 
 use in the future, but would secure free downward drainage for a ragged 
 infected area. 
 
 Ligation and Excision of Thrombosed Pelvic Veins. — Stimulated by the 
 success achieved by the aurists in the ligation and excision of the lateral 
 sinus in cases of mastoiditis, complicated by a thrombophlebitis of the 
 neighboring veins, obstetricians naturally directed their minds to the 
 possibility of curing cases of puerperal infection complicated by thrombo- 
 
 -/^>...-'-:^;;^vv-- 
 
 Fig. 499. — Case of l.'Mj_tLiLiiu:i '\\itli fij\er fur -ixtj -fijur da^ s. liuL-uVLiy without operation. 
 
 phlebitis of the pelvic veins by their ligation and removal, and many 
 operations are now on record in which this procedure has been tried. 
 Among the pioneers in this line of work may be mentioned Freund, 
 Trendelenburg, Williams, Vineburg and others. At present the opera- 
 tion is still sub ju dice and the obstetric profession seems loath to adopt 
 it, save as a very exceptional procedure. The difficulty in diagnosing 
 the condition, the fact that many recover without operation and that 
 many are likely to be killed by the operation, who would have recovered 
 without it, are large factors in deterring one from performing it. 
 
 The author would sum up his views regarding radical surgical inter- 
 vention in puerperal infection as follows: He does not believe in operat- 
 ing unless he can distinctly detect a localized result of the infection with 
 probable pus collection. In general suppurative peritonitis the result 
 of puerperal infection, although he has opened the abdomen and drained 
 a nimiber of cases, he has never succeeded in saving one. Nevertheless, 
 as the case is usually fatal without operation, in the hope that the case 
 might be one of multiple foci of localized peritonitis, rather than a general 
 involvement of the peritoneum, he would feel that under certain 
 conditions abdominal exploration was indicated. 
 
 To students and ])ractitioners tempted to radical operation for puer- 
 peral infection, the author would like to present for constant consid- 
 
TREATMENT OF PUERPERAL INFECTION 835 
 
 eration the following chart (see Fig. 499) of one of his patients, already 
 referred to as having almost all her joints involved, and who had a tem- 
 perature for sixty-four days, but who finally recovered completely without 
 operation. 
 
 ]\Iany of these desperately ill patients will recover if one leaves them 
 alone, aiding but not handicapping nature in her efforts. Furthermore, 
 it may be borne in mind that as the distance from the confinement 
 increases, the. virulence of the infecting organisms, as a rule, decreases. 
 In the meantime the obstetrician should be constantly on the watch for 
 indications for surgical intervention. 
 
CHAPTER XXIX. 
 
 INFANT MORTALITY. 
 
 Stillbirths. — So much time and thought is being devoted at the 
 present time to the prevention of infant mortality that it is of interest 
 to see what the infant mortaHty associated with labor and the puerperium 
 in a well-regulated hospital, like the Sloane Hospital for "Women, really 
 is. ¥oT this purpose the record of 10,000 births from ^Nlarch 12, 1908, 
 to October 30, 1913, has been carefully analyzed with the results given 
 below. The early cases in this series antedated the routine subjection 
 of every mother having a stillbirth to the Wassermann test, hence the 
 number of stillbirths assigned to syphilis is probably not as large as 
 will be found in the next 10,000 births at the Sloane Hospital. 
 
 ANALYSIS OF 10,000 BIRTHS. 
 
 March 12, 1908, to October 30, 1913. 
 
 Number of stillbirths' 449 
 
 Number of abortions^ 231 
 
 Number of living births 9320 
 
 Total number of births 10,000 
 
 CAUSES OF DEATHS IN INFANTS BORN ALIVE. 
 
 
 
 Number of deaths 
 
 in hospital. 
 
 
 Cause of death. 
 
 Premature 
 births. 
 
 At term. 
 
 Total deaths. 
 
 
 Under Over 
 
 thirteen thirteen 
 
 days. days. 
 
 Under Over 
 
 thirteen thirteen 
 
 days. days. 
 
 Under ' Over 
 
 thirteen thirteen 
 
 days. days. 
 
 Deaths 
 at all 
 ages. 
 
 Accidents of labor 
 
 Congenital syphilis 
 
 Congenital weakness .... 
 Congenital malformations . 
 Miscellaneous 
 
 1 
 
 10 
 
 136 
 
 2 
 10 
 
 3 
 23 
 
 11 
 
 32 
 3 
 9 
 9 
 
 81 
 
 2 
 3 
 3 
 4 
 47 
 
 33 
 13 
 145 
 11 
 91 
 
 2 
 6 
 
 26 
 4 
 
 58 
 
 35 
 19 
 
 171 
 15 
 
 149 
 
 Grand total 
 
 159 
 
 37 
 
 134 
 
 59 
 
 293 
 
 96 
 
 389 
 
 ' Stillbirth — from twenty-seven weeks of pregnancy to term. Any -v-iable fetus in which 
 respiration was not established whether heart action persisted or not. 
 
 - Abortion — during first twenty-six weeks of pregnancy. Any non-viable fetus. 
 
 Day of birth is counted as first day of puerperium: thus, thirteenth day of puerperium 
 is really twelfth daj' postpartum. 
 (836) 
 
INFANT MORTALITY 
 
 837 
 
 MISCELLANEOUS CAUSES OF DEATH AND AGE AT DEATH IN DAYS OF 
 INFANTS BORN PRE]\L4TURELY AND AT TERM. 
 
 Causes of death. 
 
 Under,lto2:2 to3:3to6 
 1 day. I days, days.! days. 
 
 Asphyxia of the 
 newborn : 
 Premature . 
 At term 
 
 Total . . 
 
 Atelectasis: 
 Premature . 
 At term 
 
 Total . . 
 
 Hemorrhage of the 
 newborn : 
 Premature . 
 At term 
 
 Total 
 
 x.„». • ' Total .,, 
 
 n^rri '7 to 13 13 to 20 20 to 27 1 week „f/' I Grand 
 ^-elk <i^ys. days. days. to 1 °"if ; total. 
 ^®®'^- ' month. *S®^-' 
 
 8 
 
 
 
 
 ^ 
 
 
 
 
 3 
 
 1 
 
 
 
 14 
 
 7 
 
 6 
 
 i 
 
 17 
 
 4 
 
 28 
 
 32 
 
 11 
 
 Total . . 
 
 
 
 8 
 
 8 
 
 2 
 
 1 
 
 
 3 
 
 
 11 
 
 Sepsis of the 
 newborn: 
 Premature . 
 At term 
 
 
 1 
 
 .. ; 2 
 
 2 
 
 6 
 
 3 
 
 2 
 
 11 
 
 
 13 
 
 Total . . 
 
 
 2 
 
 2 
 
 6 
 
 3 
 
 2 
 
 11 ..13 
 
 Pneumonia:' 
 Premature . 
 At term 
 
 2 
 
 1 2 
 
 1 8 
 
 3 
 
 11 
 
 3 
 14 
 
 7 
 26 
 
 i 
 
 1 
 10 2 ! 15 
 
 41 2 1 54 
 
 Total . . 
 
 2 
 
 .. ! 2 10 
 
 14 
 
 17 
 
 33 
 
 1 
 
 51 4 69 
 
 Digestive disturb- 
 
 
 
 
 
 
 
 
 
 
 ances: 
 Premature . 
 At term . . 
 
 
 ::;::' :: 
 
 
 
 "2 
 
 'i 
 
 3 
 
 1 
 
 1 
 3 
 
 Total . . 
 
 
 1 
 ■ ■ 1 ■ " 
 
 
 
 2 
 
 1 
 
 3 
 
 1 . 4 
 
 Erysipelas : 
 Premature . 
 At term 
 
 
 
 
 
 1 
 
 1 
 
 
 1 
 1 
 
 
 1 
 1 
 
 Total . . 
 
 
 
 
 
 2 
 
 
 2 
 
 • ! 2 
 
 Accidental deaths 
 (overlying) : 
 Premature . 
 At term 
 
 1 
 
 
 • ^ 
 
 2 
 
 
 
 
 
 
 2 
 
 Total . . 
 
 1 
 
 1 
 
 2 
 
 
 
 
 
 
 2 
 
 Undetermined : 
 Premature . 
 At term 
 
 2 
 
 2 3 
 
 7 
 
 
 1 
 
 
 1 
 
 
 8 
 
 Total . . 
 
 2 .. 2 3 
 
 7 
 
 
 1 1 .. 
 
 1 
 
 
 8 
 
 1 with pneumonia are classed 5 deaths from congestion of lungs (1 at eight hours, 2 at four days, 1 at 
 thirteen days, 1 at sixteen days) and 1 death from empyema (at eleven days). 
 
838 
 
 INFANT MORTALITY 
 
 *5 » 
 
 
 
 oo 
 
 
 c o 
 
 o 
 
 oo 
 
 o 
 
 -<o 
 
 
 
 c 
 
 00 
 
 ercen 
 fdcatl 
 foral 
 ages. 
 
 
 o 
 
 00 
 
 OC<5 
 
 
 00 
 
 o 
 
 CO 
 
 ot- 
 
 00 
 CO 
 
 d«5 
 
 00 
 
 CO 
 
 c 
 
 
 dd 
 o-j< 
 
 fk o 
 
 
 
 
 
 
 
 
 
 
 
 
 
 05 eo 
 
 Total 
 deaths 
 at all 
 ages in 
 hospital. 
 
 -^55 
 
 s 
 
 eo;o 
 
 2 
 
 §2 
 
 t^ 
 
 Neo 
 
 1(5 
 
 -HOO 
 <N(N 
 
 01 
 
 CO 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ii-. 
 
 -J5 00 
 
 e-i 
 
 1M<N 
 
 i< 
 
 ■>}<t^ 
 
 "^f 
 
 (Nt- 
 
 t^ 
 
 (N-3< 
 
 
 
 
 
 (Nt- 
 
 erce 
 
 nder 
 day 
 
 
 - 
 
 OC^ 
 
 "S< 
 
 
 OS 
 
 ^«D 
 
 CO 
 
 ^g 
 
 CO 
 
 I 
 
 lO'* 
 
 Ph O 3 
 
 
 
 
 
 
 
 
 
 
 
 
 
 CO 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 * t, 5 
 
 
 
 
 CO 
 
 <oa> 
 
 lO 
 
 MO) 
 
 i-i 
 
 <=>=! 
 
 r-l 
 
 
 <23I 
 
 o o5 & 
 
 W 
 
 eo 
 
 
 
 CO 
 
 •* 
 
 
 rH 
 
 rHOO 
 
 OS 
 
 <N 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 3 
 
 
 
 
 
 
 
 
 
 
 
 
 
 a.a 0)05 . 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 8g&o>. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 it-^t^-^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Pf 
 
 Number f 
 between . 
 7 to 13 7 
 days. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ^ . 
 
 ■* 
 
 ■*(N 
 
 CO 
 
 •CO 
 
 CO 
 
 
 CO 
 
 CO 
 
 
 
 "5 
 
 e><co 
 
 Per cent. 
 
 of deaths 
 
 under 1 
 
 week. 
 
 
 CO 
 
 COO 
 
 CO 
 
 oo 
 
 •* 
 ■* 
 
 •*o 
 
 CO 
 CO 
 
 coo 
 
 •^ 
 ■* 
 
 
 
 d 
 
 00 rH 
 
 w 
 
 
 
 
 
 o 
 
 
 
 
 
 
 
 -H 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 * ir,-^ 
 
 
 CO 
 
 oco 
 
 o 
 
 Mt^ 
 
 o 
 
 (N -n 
 
 00 
 
 OCQ 
 
 on 
 
 t- 
 
 t-o 
 
 
 
 
 
 
 !N 
 
 N 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 M 
 
 
 1 ^^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Per cent. 
 
 of deaths 
 
 between 
 
 3 to 6 
 
 days. 
 
 
 
 
 
 
 
 1 t- e 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Numbe 
 
 betwee 
 
 3 to 6 
 
 days. 
 
 
 c^ 
 
 fH rH 
 
 M 
 
 -^C<1 
 
 CO 
 
 C<IC^ 
 
 T)< 
 
 MC^ 
 
 ^ 
 
 10 
 
 (0 05 
 
 
 
 
 
 
 
 
 
 C^ 
 
 01 
 
 
 
 
 Per cent. 
 
 of deaths 
 
 between 
 
 2 to 3 
 
 days. 
 
 
 
 
 
 
 
 1 b, a 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 Numbe 
 
 betwee 
 
 2 to 3 
 
 days. 
 
 •CO 
 
 CO 
 
 -^ ; 
 
 -• 
 
 0<N 
 
 IN 
 
 :^ 
 
 "< 
 
 rHlO 
 
 
 
 CO 
 
 IN 
 
 2;: 1 
 
 Per cent. 
 
 of deaths 
 
 between 
 
 1 to 2 
 
 days. 
 
 
 
 
 
 
 
 1- ►. c 
 
 
 
 
 
 
 
 
 
 
 
 
 
 umbe 
 etwee 
 1 to 2 
 days. 
 
 •CO 
 
 CO 
 
 T-l . 
 
 - 
 
 <o^ 
 
 t- 
 
 
 
 ^to 
 
 t» 
 
 00 
 
 000 
 
 2;.o 
 
 
 
 
 
 
 
 
 
 
 
 
 
 cent, 
 leaths 
 dcr 1 
 lay. 
 
 oo 
 
 cm 
 
 O 
 
 05O 
 (NO 
 
 CO 
 
 OO 
 
 on 
 
 •t- 
 
 oi 
 
 (31 "O 
 
 ■-Ht- 
 
 00 
 
 
 
 d 
 
 t-co 
 
 rHOO 
 
 n 
 
 
 
 
 a 
 
 o 
 
 
 
 ■* 
 
 
 
 
 t^(N 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 fc^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 3 CT3 
 
 
 lO 
 
 COM 
 
 lO 
 
 U5IN 
 
 w 
 
 • co 
 
 CO 
 
 (N<3l 
 
 i-H 
 
 iH 
 
 tHO 
 
 
 
 
 
 O 
 
 a> 
 
 
 
 "^ 
 
 (N 
 
 ■* 
 
 OTjt 
 
 \ZS 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 s • ■ 
 
 
 
 
 
 
 
 
 Xi 
 
 'C 
 
 
 .2 
 
 
 a 
 
 
 -,13 
 
 
 
 
 
 
 o 
 
 .a 
 
 o! 
 
 
 J2 
 
 
 
 
 6 • • 
 
 o 
 
 3 
 
 
 
 
 "3 
 
 • • i 
 
 
 <— " 
 
 
 
 
 
 
 
 
 
 
 
 
 
 O 
 
 o 
 
 ih 
 
 
 
 
 
 
 
 
 
 
 
 
 ?> 
 
 ■35 = 
 
 "3 
 
 ■35 = 
 
 -3 
 
 ■323 
 
 ■3 
 
 3 ^ 
 
 "3 
 
 •a 
 
 c 
 
 3 S 
 <3 E 
 
 3 
 C3 
 
 m 
 
 o 
 
 
 o 
 
 II! 
 
 c 
 
 3 S fi 
 
 H 
 
 l^P- 
 
 
 
 
 
 ^ 
 
 
 
 u(i,< 
 
 
 
 
 -£,< 
 
 
 .2&<< 
 
 
 
 e^< 
 
INFANT MORTALITY 
 
 839 
 
 MISCELLANEOUS CAUSES OF DEATH AMONG BABIES BORN PREMATURELY 
 
 AND AT TERM. 
 
 Causes of death. 
 
 Number of deaths. 
 
 In pre- 
 matures 
 
 At term. Total 
 
 Asphyxia of the newborn 
 
 Atelectasis 
 
 Hemorrhage of the newborn . 
 Sepsis of the newborn 
 
 Pneumonia 
 
 Empyema 
 
 Congestion of lungs 
 Digestive disturbances 
 
 Erysipelas 
 
 Accidental deaths (overlying) 
 Undetermined 
 
 Total 
 
 Total deaths from pulmonary causes (asphyxia of the newborn, 
 atelectasis, empyema, pneumonia, and congestion of lungs) 
 
 15 
 
 21 
 
 19 
 
 28 
 
 11 
 
 13 
 
 48 
 
 1 
 
 5 
 
 3 
 
 1 
 
 2 
 
 128 
 
 90 
 
 8 
 
 32 
 
 11 
 
 13 
 
 63 
 
 1 
 
 5 
 
 4 
 
 2 
 
 2 
 
 149 
 
 109 
 
INDEX. 
 
 Abdomen, pendulous, 624 
 
 influence of, on pregnancy, 693 
 Abdominal binder, 346 
 
 cavity, shortening of, 625 
 palpation in breech presentations, 296 
 in L. O. A. position, 255 
 in L. O. P. position, 267 
 in L. M. A. position, 281 
 in R. M. A. position, 281 
 in R. O. A. position, 256 
 in R. O. P. position, 267 
 pregnancy, 523, 525, 549 
 wall, inertia of, 619 
 
 lack of tone in, 624 
 Abortion, 506. See Miscarriage, 
 accidental, 508 
 after-treatment of, 520 
 complete, 508 
 criminal, 508 
 due to fibroids, 633 
 etiology of, 506 
 frequency of, 506 
 habitual, treatment of, 520 
 incomplete, 508 
 
 treatment of, 516 
 induction of, 732 
 
 fetal indications for, 734 
 maternal indications for, 732 
 methods of, 734 
 technic of, 735 
 inevitable, 508 
 
 treatment of, 515 
 intentional, 508 
 medical, 508 
 
 neglected, treatment of, 520 
 pathology of, 508 
 prophylaxis of, 513 
 symptoms of, 508 
 threatened, 508 
 
 treatment of, 515 
 treatment of, 513 
 tubal, 534 
 Abscess in puerperal infection, 831 
 Accidental abortion, 508 
 
 hemorrhage, 574. See Hemorrhage, 
 accidental. 
 After-coming head, 714 
 delivery of, 305 
 forceps, 766 
 After-pains, 371 
 
 Air-embolism complicating pregnancy, 
 468 
 
 Albuminuric retinitis, 479 
 
 Alimentary canal, disorders of, during 
 
 pregnancy, 481 
 Allantois, 88, 97 
 Amnion, 88, 92 
 
 diseases of, 500 
 dropsy of, 500 
 Ampulla of breast, 51 
 Amputations, intra-uterine, 505 
 Anal fascia, 33 
 Anemia complicating pregnancy, 469 
 
 puerperium, 469 
 Anencephalus, 702 
 Anesthesia during second stage of labor, 
 
 321 
 Anesthetics, use of, in eclampsia and 
 
 toxemia, 435 
 Antepartum examination, 169 
 Anticolic nipple, 404 
 Appendicitis complicating pregnancy, 483 
 
 in puerperal infection, 823 
 Appetite during pregnancy, 132 
 Areola of breast, 51 
 primary, 127 
 secondary, 131 
 Argyrol for child's eyes, 337 
 Armamentarium, obstetrician's, 165 
 Arms, extended, in breech presentations, 
 
 715 
 Articulations, changes in, during preg- 
 nancy, 139 
 of fetal skull, 237 
 pelvic, abnormally firm, 677 
 loose, 678 
 Artificial feeding, 396 
 
 respiration, methods of, 353 
 Ascites diagnosed from pregnancy, 147 
 Asphyxia livida, 352 
 neonatorum, 351 
 
 antepartum diagnosis of, 352 
 clinical picture of, 352 
 differential diagnosis of, 351 
 etiology of, 351 
 treatment of, 353 
 pallida, 352 
 Asthma during pregnancy, 462 
 Atresia of cervix uteri, 643 
 
 of vagina, 646 
 Attitude of fetus, 243 
 Auscultation of fetal heart, 181 
 in breech presentations, 296 
 in L. M. A. position, 281 
 in L. O. A. position, 257 
 in L. O. P. position, 267 
 
 (841) 
 
842 
 
 INDEX 
 
 Ausciilt;it ion ill R. M. A. i)()sitii>ii, 2S1 
 
 in R. C). A. position, 257 
 
 in R. (). P. position, 2(57 
 Auto-infoftion, possibility of, 812 
 Auto-intoxicatioM, intestinal, in puerperal 
 
 infection, S'l'-\ 
 Axillary breast tissue, 3S(i 
 Axis-traction forceps, 748, 758, 7()3, 764 
 
 B 
 
 Babies, premature, immediate care of, 
 361 
 
 undersized, immediate care of, 361 
 Baby, bath of, 348 
 
 clothing of, 346 
 Bacillus aerogenes capsulatus in puerperal 
 infection, 811 
 
 coli communis in puerperal infection, 
 811 
 
 Klebs-Loeffler, in puerperal infection, 
 811 
 
 typhosus in puerperal infection, 811 
 Bacteremia in puerperal infection, 814, 816 
 Bacteria in lochia, 374 
 
 in milk, 398 
 
 destruction of, 405 
 Ballottement, 143 
 Bartholin's glands, 22 
 Bath of baby, 348 
 Bathing during pregnancy, 151 
 Bed, pre]iaration of, for labor, 309 
 Bimanual examination during pregnancy, 
 
 184 
 Binder, abdominal, 346 
 
 breast, 385 
 Birth, changes in circulation at, 114 
 Bladder, 26 
 
 calculi in, obstructing labor, 642 
 
 care of, during pregnancy, 136 
 in puerperium, 376 
 Blood during pregnancy, 132 
 Blood-pressure during pregnancy, 133, 
 135, 155 
 
 in eclampsia, 429 
 Bones, changes in, during pregnancy, 139 
 Bottles for milk, 404 
 Bowels during puerperium, 375 
 
 in puerperal infection, 823 
 
 regulation of, during pregnancy, 152 
 Braxton Hicks's method of version, 770 
 Breasts, 50, 379 
 
 axillary tissue of, 386 
 
 ampulla, 51 
 
 areola, 51, 127, 131 
 
 arterial supply, 53 
 
 binder for, 385 
 
 caked, 385 
 
 care of, 384 
 
 changes in, during pregnancy, 127 
 
 during pregnancy, 153 
 
 galactophorous ducts, 51 
 
 lactiferous ducts, 51 
 
 lymphatics of, 53 
 
 Montgomery's tubercles, 51 
 
 Breasts, nerve supply of, 53 
 nipple, 51 
 sinus, 51 
 
 supernumerary, 52 
 sj'mptoms of pregnancy, 141 
 Breech presentations, 247 
 
 abnormalities of, 711 
 birth of head in, 298 
 of hips in, 297 
 of shoulders in, 298 
 complete, 247, 294 
 descent in, 297 
 diagnosis of, 296 
 engagement in, 297 
 extended arms in, 713 
 frank, 247, 294, 711 
 forceps delivery in, 766 
 frequencj^ of, 294 
 incomplete, 247, 294 
 internal rotation in, 297 
 mechanism of, 247, 297, 299, 301 
 molding in, 297 
 normal, 247, 294 
 positions in, 250 
 posterior rotation of occiput in, 
 
 299 
 prog-nosis of, 301 
 treatment of, 302 
 with arms abnormally placed, 
 
 713 
 with extended legs, 247, 294, 711 
 with nuchal hitch, 714 
 Bregma presentations, 294 
 Broad ligaments of uterus, 39 
 Brow presentations, diagnosis of, 291 
 mechanism of, 290, 291 
 prognosis of, 293 
 treatment of, 293 
 Bulbi vestibuli, 22 
 Bulbocavernosus muscle, 35 
 Bulbs of vestibule, 22 
 Byrd's method of artificial respiration, 
 356 
 
 Caked breasts, 385 
 
 Calculi, vesical, obstructing labor, 642 
 
 Caloric value of food, 410 
 
 Canal of Nuck, 39 
 
 Cancer. *See Carcinoma. 
 
 of rectum, dystocia due to, 642 
 
 of uterus complicating pregnane}^ 639 
 
 Caput succedaneum, 365 
 
 Carcinoma of cervix complicating preg- 
 nancy, 450 
 
 Cardiac disease during pregnancy, 459 
 
 Carriers of infection in puerperal infection, 
 811 
 
 Carunculae myrtiformes, 22 
 
 Catheterization during puerperium, 376 
 
 Cellulitis in puerperal infection, 818 
 
 Celom, origin of, 76 
 
 Cephalhematoma, 366 
 
 Cephalometry, 189, 190 
 
 Certified milk, 397 
 
INDEX 
 
 843 
 
 Cervix uteri, at end of pregnancy, 231 
 atresia of, 643 
 
 carcinoma of, complicating preg- 
 nancy, 450 
 changes in, diu-ing pregnane}^, 
 125, 141, 142 
 in puerperium, 370 
 conditions causing dj'stocia, 643 
 edema of anterior lip, 645 
 incisions in, to aid labor, 782 
 lacerations of, 579, 723 
 septa of, 645 
 stenosis of, 643 
 Cesarean section, 787 
 
 extraperitoneal, 796 
 
 compared with Sanger's 
 
 operation, 800 
 technic of, 796 
 history of, 788 
 indications for, 789 
 mortaUty of, 795 
 Porro's operation for, 788 
 postmortem, 800 
 repeated, 795 
 Sanger's method of, 788 
 subsequent care of patient in, 
 
 795 
 technic of, 791 
 time of operation, 791 
 vaginal, 783 
 
 disadvantages of, 786 
 indications for, 785 
 technic of, 784 
 Chamberlen forceps, 746, 747 
 Child, care of, in abnormal conditions, 351 
 at birth, 333 
 length of, at birth, 240 
 Chloral hydrate, use of, in eclampsia and 
 
 toxemia, 441 
 Chloroform, effects of, in eclampsia and 
 toxemia, 435 
 use of, in labor, 322 
 Cholera comphcating pregnane}-, 478 
 Chorea in pregnancy, 45 
 Chorio-epithehoma, 495 
 clinical picture of, 498 
 diagnosis of, 500 
 etiology of, 497 
 frequency of, 497 
 pathologj' of, 497 
 treatment of, 500 
 Chorion, 88, 90, 97, 98 
 diseases of, 491 
 frondosima, 99 
 villi, 100 
 Circular artery, 46 
 Circulation, changes in, at birth, 114 
 
 during pregnane}-, 132 
 Circumcision, 411 
 
 Civilization, relation of, to labor, 5 
 Cleavage, 67 
 Chtoris, 19 
 Clothing of baby, 346 
 Coccygeus muscle, 32 
 Colostrum, 131, 380 
 Columns of Morgagni, 29 
 
 Columns of rectum, 29 
 Compound presentation, 716 
 etiolog}- of, 716 
 frequency of, 717 
 mortalit}' of, 717 
 treatment of, 717 
 Condylomata complicating pregnane}-, 
 
 449 
 Confinement, date of expected, 157 
 Constipation dm-ing pregnancy, 152, 482 
 Constrictor vaginse muscle, 35 
 Contagious diseases, relation of, to puer- 
 peral infection, 813 
 Contracted pelves, 648, 692. See Pelves, 
 
 deformed. 
 Convalescence, 379 
 
 Cord, prolapse of. See Prolapse of cord. 
 Corpus luteum, 61 
 Cough, reflex, of pregnancy, 463 
 Cow's milk, 396 
 
 bacteria in, 398 
 
 certified, 397 
 
 compared with woman's milk, 
 
 397 
 from herd, 397 
 from single cow, 397 
 home modification of, 398 
 modification of, 397, 398 
 Coxalgic pelvis, 690 
 Coxitis, 690 
 Cragin's method of artificial respiration, 
 
 359 
 Craniotomy, 801 
 
 indications for, 801 
 instruments needed in, 802 
 prognosis of, 805 
 technic of, 804 
 Cream, 399 
 
 centrifugal, 399 
 gravity, 399 
 Crede's method of expressing placenta, 
 
 217, 342 
 Criminal abortion, 508 
 Crypts of Morgagni, 29 
 Cyanosis neonatorum, 116 
 Cystocele complicating pregnancy, 449 
 
 DiNIMERSCHLAF, 324 
 
 Date of expected confinement, 157 
 Decapitation of fetus, 807 
 Decidua, 97, 98 
 
 atrophy of, 489 
 
 bacterial inflammation of, 489 
 
 basalis, 98 
 
 capsularis, 105 
 
 diseases of, 488 
 
 hemorrhage of, 490 
 
 hyperplasia of, 488, 489 
 
 parietalis, 105 
 
 reflexa, 105 
 Deformed pelves, 648. See Pelves, 
 
 deformed. 
 Delivery, postmortem, 801 
 
844 
 
 INDEX 
 
 Delivery, surgical methods of, 771) 
 Dew's method of artific^ial respiration, 357 
 Diabetes during pregnancy, 486 
 Diagonal conjugate, measurements of, 
 
 185 
 Diameters, cephalic, 2;5S 
 of fetal heail, 238 
 of j)elvis, 170, 17(1 
 Diet diu-ing pregnancy, 150 
 puerperium, 375 
 effect of, on mother's milk, 393 
 Digestion during pregnancy, 131 
 Double monsters, 703 
 
 diagnosis of, 704 
 mechanism of labor, 705 
 obliquely contracted ])elvis of Robert, 
 662. See Pelves, deforii^ed. 
 Douches in puerperal infection, 828 
 
 vaginal, during pregnancy, 153 
 Douglas, pouch of, 28, 38 
 Draping of patient for second stage of 
 
 labor, 320 
 Dress during pregnancy, 150 
 Drink during pregnancy, 150 
 Dropsy of amnion, 500 
 Dry labor, 209 
 Duct of Gartner, 45 
 
 of Miiller, 47 
 Diihrssen's incisions, 783 
 Dysmenorrhea, membranous, diagnosed 
 
 from ectopic gestation, 546 
 Dystocia from conditions of cervix uteri, 
 643 
 of vagina, 646 
 of vulva, (546 
 from kidney affections, 642 
 
 Ear, affections of, complicating pregnancy, 
 
 480 
 Eclampsia, 424 
 
 anesthetics in, 435 
 
 blood-pressure in, 429 
 
 diagnosed from epilepsy, 432 
 from hysteria, 432 
 
 differential diagnosis of, 431 
 
 edema in, 429 
 
 etiology of, 24 
 
 eyes in, 430 
 
 frequency of, 430 
 
 liver in, 424 
 
 mortality of, fetal, 42 
 
 nausea in, 430 
 
 nervous system in, 430 
 
 pathology of, 424 
 
 prognosis of, 441 
 
 prophylaxis of, 432 
 
 seizure in, 431 
 
 symptoms of, 429 
 
 threatened, 424 
 treatment of, 432 
 types of, 431 
 urine in, 429 
 vomiting in, 430 
 
 Eclamptic seizure, 431 
 Ectoderm, derivatives of, 79 
 Ectojnc gestation, 522 
 
 abdominal, 523, 525, 549 
 advanced, 549, 551 
 
 diagnosis of, 549, 551 
 operation for, 557 
 treatment of, 555 
 bilateral tubal, 530 
 tliagnosed from membranous 
 dysmenorrhea, 546 
 from miscarriage, 545 
 from rupturecl i)yosalpinx, 
 545 
 diagnosis of, 542 
 
 differential, 545 
 etiology of, 526 
 frequency of, 522 
 interstitial, 523, 525 
 intraligamentous, 525, 549 
 multiple, 530 
 
 operation for advanced, 557 
 ovarian, 522, 524 
 pathology of, 531 
 
 changes in Fallopian tube, 
 532 
 in ovum, 538 
 in uterus,. 531 
 ])hysical signs of, before tubal 
 rupture or abortion, 
 543 
 subsequent to tubal 
 rupture or abortion, 
 544 
 placenta in, 539 
 primary, 525 
 repeated, 530 
 secondary", 525 
 symptoms of, 541 
 
 at time of tubal rupture or 
 
 abortion, 542 
 before tubal rupture or 
 abortion, 541 
 treatment of, 552 
 
 advanced, 555, 557 
 early, 552 
 
 at time of tubal rupture 
 
 or abortion, 552 
 prior to tubal rupture 
 
 or abortion, 552 
 subsequent to tubal 
 rupture or abortion, 
 555 
 tubal, 523, 524, 525 
 bilateral, 530 
 twin, 530 
 tubo-abdominal, 550 
 tubo-ovarian, 524, 525 
 tubo-uterine, 523, 525 
 twin tubal, 530 
 varieties, 522 
 Edema of anterior lip of cervix uteri, 645 
 of lower extremities, complicating 
 
 pregnancy, 447 
 in pregnancy, 429 
 of vulva, 647 
 
INDEX 
 
 845 
 
 Edema of vulva, complicating pregnane}-, 
 
 Elliot forceps, 748, 751 
 Embolism, air, complicating pregnancy, 
 468 
 pulmonarj', complicating pregnancv, 
 467 
 puerperium, 467 
 Embrj'o, age of. 119 
 
 external form of, 116 
 length of, 119 
 Embryology', 54 
 Embryotomy, 806 
 
 indications for, 806 
 instritments needed in^ 806 
 technic of, 807 
 Emphysema during pregnancy, 462 
 Enceplialocele, 707 
 Endometritis decidua cj-stica, 489 
 poh'posa, 489 
 - tuberosa, 489 
 Endometrium, 39 
 
 changes in, in puerperium, 369 
 Enteroptosis, dui-ing pregnancy, 483 
 Entoderm, derivatives of, SO 
 Epilepsy diagnosed from eclampsia, 432 
 
 dui-ing pregnancy, 459 
 Episiotomy, 330 
 Epistaxis dm-mg pregnancy, 481 
 Epoophoron, 44 
 Erector cUtoridis muscle, 35 
 Ether, use of, in eclampsia and toxemia, 
 
 438 
 Evolution, spontaneous, 709 
 Examination, ahtepartmn, 169 
 
 dm^ing pregnane}-, 156, 158, 169 
 bimanual, 184 
 vaginal, 184 
 of patient at bedside, vaginal, 313 
 Exercise diu-ing pregnane}-, 151 
 Expulsive forceps, deficiency in, 610 
 Extended arms in breech presentations, 
 
 713 
 Extraperitoneal Cesarean section, 796 
 Extra-uterine pregnancy, 522. See Ec- 
 topic gestation. 
 Eyes, affections of, compUcating preg- 
 nancy, . 479 
 of child, treatment of, 337 
 
 Face presentations, 247 
 
 diagnosed from breech presenta- 
 tions, 296 
 
 etiolog}- of. 279 
 
 forceps delivery m, 764 
 
 mechanism of. 278. 281 
 
 positions in, 249, 280 
 Fallopian tubes. 40 
 
 ampulla of, 41 
 
 arterial supply of, 46 
 
 changes in. m ectopic gestation, 
 532 
 
 development of, 47 
 
 Fallopian tubes, fimbriated extremitv of, 
 41 
 infundibulimi of, 41 
 interstitial portion of, 40 
 isthmus of, 41 
 mucous coat of, 41 
 muscular coat of, 41 
 nerve supply of, 47 
 serous coat of, 41 
 twist in, in puerperal infection, 
 823 
 Fascia, 33 
 
 Fat in modified milk, 398 
 in woman's milk, 391 
 
 . estimation of, 392 
 Feeding, artificial, 396 
 mixed, 390 
 
 of prematm-e infants, 408 
 Femur, dislocation of, aft'ecting labor, 691 
 Fertilization, 65 
 Fetal head, 234 
 
 articulations of, 237 
 cncumferences of, 239 
 cranium of, 235 
 diameters of, 238 
 extension of, 238 
 face of, 235 
 fontanehes of, 236 
 measurements of, 189, 190 
 moldmg of, 240 
 motions of, 238 
 sutiu'es of, 235 
 heart, auscultation of, 181 
 
 in breech presentations, 296 
 in L. ]M. A. position, 281 
 in L. 0. A. position, 257 
 in L. O. P. position, 267 
 in R. M. A. position, 281 
 in E,. O. A. position, 257 
 in R. 0. P. position, 267 
 heart soimds dm-ing pregnancy, 144 
 membranes, 88 
 
 diseases of, 491 
 in man, 9 1 
 movements during pregnancy, 144 
 ovoid, 243 
 
 skuU. See Fetal head. 
 Fetus, 234 
 
 anomalies of, causing abnormal labor, 
 
 697 
 attitude of, 243 
 auscultation of heart of, 181 
 decapitation of, 807 
 external tumors of, 705 
 heart soimds of, 182 
 ; length of, 240 
 
 I location of back and small parts of, 
 
 I 1" 
 
 I malformations of, 699 
 
 overgi'Owi:h of, 697 
 
 dystocia from, 705 
 
 treatment of, 698 
 palpation of, 180, 181 
 papyraceous, 512 
 positions of, 177, 248 
 presentations of, 177, 244 
 
846 
 
 INDEX 
 
 Fetus, presentations of, anterior fonta- 
 nelle, 29-1 __ 
 
 breech, 2-47, 711 
 
 bregma, 24(i. 2oO, 294 
 
 brow, 2-4(), 250, 291 
 
 cephalic, 244 
 
 compound, 248, 716 
 
 face, 247 
 
 faulty, influence on pregnancy, 
 693 
 
 elbow, 248 
 
 foot, 247 
 
 hand, 248 
 
 knee, 247 
 
 longitudinal, 244 
 
 oblique, 244 
 
 pelvic, 244 
 
 shoulder, 248, 707 
 
 transverse, 244, 247, 707 
 
 in twin pregnancy, 196 
 
 vertex, 245 
 sjTjhilis in, evidences of, 472 
 vascular system of, 111 
 
 changes in, at birth, 114 
 Fibroids. See Fibromyoma. 
 abortion due to, 633 
 changes in, 631, 632 
 complicating labor, 630 
 diagnosis of, 035 
 eflfects of, on labor, 633 
 
 on pregnancy, 632 
 
 on puerperiiun, 634 
 mortality, 635 
 treatment, 636 
 Fibroma molluscum in pregnancy, 454 
 Fibromyoma. Sec Fibroids, 
 complicating labor, 630 
 
 pregnancy, 451 
 diagnosed from pregnancy, 145 
 in puerperal infection, 823 
 Floor, pelvic, 31 
 Fontanelles of fetal skull, 236 
 Food, caloric value of, 410 
 commercial, 411 
 does it agree with infant, 409 
 . preparation, instruction in, 402 
 Forceps, 745 
 
 application of, 759 
 
 cephalic, 759 
 
 Continental methoil, 759 
 
 double, 702 
 
 English method, 759 
 
 opI VIC T tO 
 axis-traction, 748, 753, 763, 764 
 choice of, 751 
 contra-indications, 754 
 dangers in use of, 755, 756 
 double application of, 762 
 frequency, 754 
 function, 750 
 historical .sketcli of, 745 
 indications for, 754 
 introduction of blades, 7()0, 761 
 locking of blades, 762 
 mortality in use of, 766 
 position of patient, 757 
 
 Forceps, preparation of patient, 758 
 removal of blades, 762 
 steps of operation, 759 
 technic of operation, 757 
 traction by, 762 
 
 use of, for after-coming head, 766 
 in breech presentations, 766 
 in face presentations, 764 
 in occipitoposterior positions of 
 vertex, 762 
 varieties of operations, 756 
 high, 756 
 low, 756 
 medium, 756 
 Foreskin, retraction of, 411 
 Fossa navicularis, 18 
 Fourchette, 18 
 Frank breech, 247, 294, 711 
 Freeman's apparatus for sterilization of 
 
 milk by pasteurization, 405 
 Fresh air diu"ing pregnancy, 152 
 
 Gal.\ctophorous ducts, 51 
 Gall-bladder, affections of, during preg- 
 nancy, 485 
 Gall-stones, complicating pregnancy, 
 485 
 
 puerperium, 486 
 Gartner, duct of, 45 
 Gastric indigestion during pregnancy, 
 
 482 
 Gastroptosis during pregnancy, 483 
 Generalh^ contracted pelvis, 655. See 
 
 Pelves, deformed. 
 Generative organs, anatomy of, 17 
 
 arterial supply of, 45 
 
 external, 18 
 
 internal, 36 
 
 h-mphatics of, 46 
 
 nerves of, 47 
 
 veins of, 46 
 Genital ridge, 44 
 Germ cells, 54 
 
 development of, 58, 74 
 Germ layers, cleavage of, 67 
 
 derivatives of, 79 
 
 development of, 74 
 
 formation of, 67 
 
 in man, 73 
 Germinal epithelium, 44 
 Gestation, ectopic, 522. See Ectopic 
 
 gestation. 
 Gingivitis during pregnancy, 481 
 Glands of Bartholin, 22 
 
 vulvovaginal, 22 
 Gloves, use of, in labor, 317 
 Glycosuria during pregnancy, 486 
 Goitre chuing i)regnancy, 136 
 Gonococcus in i)uerperal infection, 810 
 Gonorrheal infection complicating preg- 
 nancy, 447 
 Graafian follicle, 55 
 
INDEX 
 
 847 
 
 H 
 
 Habitual abortion, treatment of, 520 
 Hand presentation diagnosed from breech, 
 297 
 scrubbing of, 312 
 Head, after-coming, 714 
 delivery of, 305 
 Headache in pregnancy, 430 
 Heart during pregnancy, 134 
 
 disease during pregnancy, 459 
 Hebosteotomy, 779. See Pubiotomy. 
 Hegar's sign of pregnancy, 143 
 Hematoma complicating pregnancy, 444 
 
 of vulva, 647 
 Hemiplegia during pregnancy, 459 
 Hemophilia complicating pregnancy, 470 
 
 puerperium, 470 
 Hemoptysis during pregnancy, 463 
 Hemorrhage, 564 
 accidental, 574 
 complete, 575 
 concealed, 575 
 diagnosis of 577 
 
 differential, 577 
 etiology of, 575 
 external, 575 
 incomplete, 575 
 prognosis of, 577 
 signs of, 576 
 symptoms of, 576 
 treatment of, 578 
 varieties of, 575 
 antepartum, 564 
 decidual, 490 
 intrapartum, 564 
 in placenta previa, 566, 567 
 postpartum, 564, 585 
 diagnosis of, 587 
 etiology of, 586 
 frequency of, 586 
 signs of, 588 
 symptoms of, 588 
 treatment of, 588 
 puerperal, 594 
 
 etiology of, 594 
 treatment of, 595 
 with a normally situated placenta, 
 574 _ 
 Hemorrhagic disease of newborn, 413 
 Hemorrhoids complicating pregnancy, 446 
 Herpes gestationis, 453 
 History of patient during pregnancy, 156, 
 
 158 
 Hodge forceps, 748 
 Houston, valves of, 29 
 Hydatid of Morgagni, 41 
 Hydatidiform mole, 491 
 etiology of, 492 
 diagnosis of, 495 
 frequency of, 492 
 pathology of, 492 
 prognosis of, 494 
 
 signs of, 495 ; 
 
 symptoms of, 495 
 treatment of, 495 | 
 
 Hydramnios, 500 
 
 diagnosis of, 502 
 
 etiology of, 501 
 
 frequency of, 500 
 
 prognosis of, 503 
 
 symptoms of, 502 
 
 treatment of, 503 
 Hydrocephalus, 700 
 Hymen, 22 
 
 varieties of, 22 
 Hyperemesis "gravidarum, 417. See 
 
 Toxemia of pregnancy. 
 Hysterectomy in puerperal infection, 833 
 Hysteria diagnosed from eclampsia, 432 
 
 in pregnancy, 454 
 
 Ileus complicating pregnancy, 485 
 Impetigo herpetiformis in pregnancy, 
 
 453 
 Inanition fever, 389 
 
 Incisions in cervix uteri to aid labor, 
 782 
 Diihrssen's, 783 
 Incomplete abortion, 508, 516 
 Incubators, 362 
 
 substitutes for, 365 
 Indigestion during pregnancy, 482 
 Induction of abortion, 732 
 Inertia, abdominal, 619 
 
 uterine, 610. See Uterine inertia. 
 Inevitable abortion, 508, 515 
 Infant mortality, 836 
 
 statistics of, 837, 839 
 Infection, puerperal, 809. See Puerperal 
 
 infection. 
 Infectious diseases complicating preg- 
 nancy, 470, 476, 479 
 Infundibulopelvic hgament of uterus, 40 
 Insanity during pregnancy, 456 
 puerperium, 457 
 of lactation," 458 
 Interlocking of twins, 198, 199 
 Internal rotation of fetal head during 
 
 delivery, cause of, 261 
 Interstitial pregnancy, 523, 525 
 Intestinal auto-intoxication in puerperal 
 infection, 823 
 indigestion during pregnancy, 482 
 obstruction during pregnancy, 485 
 Intraligamentous pregnancy, 525, 549 
 
 rupture of Fallopian tube, 541 
 Intra-uterine amputations, 505 
 Inversion of uterus. 591 
 etiology of, 592 
 prognosis of, 593 
 signs of, 593 
 symptoms of, 593 
 treatment of, 593 
 Ischiocavernosus muscle, 35 
 Ischiococcygeus muscle, 31, 32 
 Ischiorectal fascia, 33 
 fossa, 33 
 
848 
 
 INDEX 
 
 Jaundice during pregnancy, 485 
 Justomajor pelvis, 663. See Pelves, de- 
 formed. 
 Justominor pelvis, 653. See Pelves, 
 deformed. 
 
 IviDXEV.s during pregnancy7l34 
 dystocia due to lesions of, 642 
 
 Kilian's pelvis, 678 
 
 Ivlebs-Loeffler bacillus in puerperal infec- 
 tion. 811 
 
 Ivrause's method of inducing premature 
 labor, 743 
 
 Kyphoscoliotic pelvis, 688. See Pelves, 
 deformed . 
 
 Kyphotic pelvis, 682. See Pelves, de- 
 formed. 
 
 L.\Bi.^ majora, IS 
 minora, 19 
 lu-ethral, 28 
 Labor, abnormal, from anomalies of fetus 
 in presentation, 697 
 in forces, 609 
 in passages, 624 
 in absence or deformity of lower 
 
 extremity, 692 
 anesthesia in, 321 
 bed, preparation of, for, 309, 310 
 cause of onset, 205, 207 
 characteristics of commencement of, 
 
 207 
 chill after, 346 
 
 civilization, relation of, to, 205 
 in coxalgic pelvis, 691 
 in dislocation of femur, 691 
 in double obliquely- contracted pelvis 
 
 of Robert, 663 
 draping of patient for second stage of, 
 
 320 
 flry, 209 
 
 effect of fibroids on, 633 
 exciting causes of, 207 
 false pains in, 207 
 first stage of, 209 
 
 duration of, 210 
 management of, 307 
 in fiat, generally contracted, rachitic 
 
 pelvis, 671 
 in generally contracted, flat, non- 
 rachitic pelvis, 656 
 influence of contracted pelvis on, 693 
 in justomajor pelvis, 663 
 in justominor jjelvis, 654 
 in kyphotic pelvis, 685 
 management of, 307 
 first stage, 307 
 second stage, 319 
 third stage, 341 
 
 Labor, mechanism of, 219. .See Mechan- 
 ism of labor, 
 in narrow, funnel-shaped pelvis, 657 
 normal, 204 
 in obliquely contracted pelvis of 
 
 Xaegele, 662 
 in osteomalacic pelvis, 675 
 pains, 207, 209 
 pathological, 609 
 physiology- of, 204 
 precipitate, 620. Sec Precipitate 
 
 labor, 
 preservation of pelvic floor dm"ing, 
 
 326 
 propelling forces of, 241, 242 
 record of, 160 
 in scoliotic pelvis, 688 
 second stage of, 213 
 
 management of, 319 
 separation of placenta in, 216 
 in simple flat, non-rachitic pelvis, 652 
 spinal anesthesia in, 323 
 in split pelvis, 664 
 in spondj-lolisthetic pelvis, 682 
 stages of, 208 
 third stage of, 215 
 
 management of, 341 
 in triplet pregnancy, 203 
 in twin pregnane^', 197, 199 
 uterine contractions in, 241 
 uterus, changes in, during, 206, 210, 
 213, 215 
 Laboratorj' milk, 408 
 Laborde's method of reflex stimulation 
 
 of respiration, 360 
 Laceration of cervix, 579, 723 
 diagnosis of, 724 
 etiologj' of, 723 
 symptoms of, 724 
 treatment of, 724 
 of lower parturient canal, 591 
 of permeum, 726 
 of vagina, 725 
 of \Tjlva, 726 
 Lactation, 379 
 
 irtsanity of, 458 
 Lactiferous ducts, 51 
 Lactosuria during pregnancy, 486 
 Legs and thighs, varicosities of, complicat- 
 ing pregnancv, 445 
 Length of child at birth, 240 
 Leucorrhea during pregnancy, 153 
 Leukemia complicating pregnancy, 470 
 
 puerperium, 470 
 Leukocytes during pregnancy, 132 
 Levator ani muscle, 31 
 Le^Tet forceps, 748 
 Ligament, triangular, 33 
 Lime-water in modified milk, 400 
 Liquor amnii, abnormal amount of, 500 
 
 escape of, 209, 213 
 Lithopedion, 513 
 
 Liver, affections of, during pregnancy, 485 
 during pregnancy, 1.34 
 in eclampsia, 424 
 in toxemia of pregnancy. 421 
 
INDEX 
 
 849 
 
 Lochia, 372 
 alba, 373 
 bacteria in, 374 
 rubra, 372 
 serosa, 372 
 Lordosis, lumbar, 625 
 Lordotic pelvis, 689. See Pelves, de- 
 formed. 
 Lower extremity, absence of, affecting- 
 labor, 692 
 deformity of, affecting labor, 692 
 edema of, complicating preg- 
 nancy, 447 
 Lungmotor, 360 
 
 Lungs, affections of, during pregnancy, 
 462 
 
 M 
 
 Malaria during pregnancy, 476 
 
 puerperium, 476 
 Male and female pelvis contrasted, 228 
 MaKormed uterus, pregnancy in, 558 
 
 treatment of, 562 
 Mammary gland. See Breast. 
 Mania during pregnancy, 457 
 Marital relations during pregnancy, 152 
 Mauriceau-Smellie-Veit method, 305 
 Measles complicating pregnane}'', 477 
 Meatus lu'inarius, 22 
 Mechanism of labor, 219 
 
 in breech presentations, 294 
 in bregma presentations, 294 
 in brow presentations, 290 
 in face presentations, 278 
 in vertex presentations, 251 
 Medical abortion, 508 
 Melancholia during pregnancy, 456 
 Membranes, arrangement of, in twin 
 pregnancy, 195 
 in triplet pregnancy, 201 
 diseases of, 491 
 Membranous dysmenorrhea diagnosed 
 
 from ectopic gestation, 546 
 Meningocele, 707 
 Menopause, 86 
 Menstrual cycle, 80 
 
 periodicitj^, relation of, to labor, 206 
 Menstruation, 80 
 cessation of, 86 
 
 during pregnancy, 140 
 changes in body dm-ing, 85 
 during pregnancy, 126 
 effect of, on mother's milk, 393 
 first appearance of, 85 
 periodicity, 85 
 relation of, to ovulation, 86 
 type of, 85 
 Mental condition during pregnancy, 153 
 Mento-anterior positions, birth of shoul- 
 ders and body, 285 
 descent, 283 
 diagnosis, 281 
 engagement, 281 
 extension, 283 
 external rotation, 285 
 54 
 
 Mento-anterior positions, flexion, 284 
 internal rotation, 284 
 mechanism of, 281 
 molding of, 281 
 restitution of, 285 
 Mentoposterior positions, diagnosis of, 
 287 
 mechanism of, 287, 288 
 prognosis of, 289 
 treatment of, 289 
 Mesoderm, changes in, 76 
 
 derivatives of, SO 
 Mesodermic somites, 78 
 Metamerism, 78 
 
 Metritis diagnosed from pregnancy, 145 
 Milk, bottles for, 404 
 certified, 397 
 cow's, 396 
 
 bacteria in, 398 
 
 destruction of, 405 
 certified, 397 
 compared with woman's milk, 
 
 397 
 from herd, 397 
 from single cow, 397 
 home modification of, 398 
 modification of, 397, 398 
 fever, 382 
 formulae, 400 
 laboratory, 408 
 modified, 402 
 
 amount allowed at each feeding, 
 
 402, 404 
 composition of, 398 
 diluent of, 402 
 lime-water in, 400 
 preparation of, 403 
 pasteurized or raw, 407 
 peptonized, 407 
 secretion of, 376 
 set, Sloane maternity, 402 
 woman's, 381, 392 
 character of, 383 
 compared with cow's milk, 397 
 effect of diet on, 393 
 
 of menstruation on, 393 
 
 of nervous impressions on, 
 
 394 
 of pregnancy on, 393 
 quality of, 391 
 quantity of, 386 
 Milk-leg, 820 
 
 in puerperal infection, 823 
 Miscarriage, 506. See Abortion. 
 
 diagnosed from ectopic gestation, 545 
 Mixed feedings, 390 
 Molding of fetal head, 240 
 Mole, 511 
 
 bloody, 511 
 
 carneous, 511 
 
 fleshy, 511 
 
 hydatidiform, 491. See Hydatidi- 
 
 form mole, 
 sanguineous, 511 
 
 vesicular, 491. See Hydatidiform 
 mole. 
 
850 
 
 INDEX 
 
 Mons veneris, IS 
 Monsters, 700 
 
 ;inencei)h:ilous, 702 
 (loublo, 703 
 
 diajjnosis of, 704 
 nie(;hanisni of labor of, 705 
 hydrocephalous, 700 
 Montgomery's tubercles or glands, 51 
 Morbus ceruleus, 116 
 Morgagni, columns of, 29 
 crypts of, 29 
 hydatid of, 41 
 Mortality, infant, 836 
 
 statistics of, 837, 839 
 Mouth, disorders of, during pregnancy, 
 
 481 
 Movable kidngy during pregnancy, 483 
 Midler, duct of, 47 
 Multigravida, indications of, 148 
 Multiple pregnancy, 191 
 ectopic, 530 
 etiology of, 191 
 frequency of, 191 
 triplets, 200 
 
 coiu'se of pregnancy in, 201 
 etiology of, 200 
 labor in, 203 
 mortality in, 203 
 placenta; and membranes 
 in, 201 
 twin, 191 
 
 course of pregnancy in 197 
 diagnosis of, 196 
 hemorrhage in, 199 
 interlocking in, 198 
 labor in, 197 
 management of, 199 
 mortality in, 200 
 placentae and membranes 
 
 in, 195 
 presentations in, 196 
 sex in, 196 
 Mummification, 512 
 
 N 
 
 Nabothian follicles, 39 
 
 Naegele, obliquely contracted pelvis of, 
 
 659 ' 
 
 Nausea during pregnancy, 131, 141, 150 
 Nephritis during pregnancy, 486 
 Nervous impressions, effect of, on mother's 
 milk, 394 
 
 system during pregnancy, 133 
 Neuralgia during pregnancy, 134, 455 
 Neuritis during pregnancy, 455 
 Nipple, 51 
 
 anticolic, 404 
 
 care of, 384 
 
 cracked, 385 
 
 depressed, 383 
 
 erection of, 131 
 
 for feeding bottles, 404 
 Nitrate of silver for child's eyes, 337 
 Nitrous oxide oxygen anesthesia, 326 
 
 Nose, affections of, complicating preg- 
 nancy, 481 
 Nuchal hitch, 713, 714 
 Nuck, canal of, 39 
 Nurse, selection of, 308 
 
 wet, 394 
 Nvu-sing, act of, 383 
 
 duration of, 384 
 
 frec}uency of, 384 
 
 of infant, 376 
 Nutrition during pregnancy, 131 
 Nymplue, 19 
 
 Obliquely contracted pelvis of Naegele, 
 659. See Pelves, deformed, 
 double, of Robert, 662. See 
 Pelves, deformed. 
 Obstetric fee, 378 
 month, 378 
 outfit for patient, 168 
 records, 158, 160, 162 
 Obstetrician, armamentariinn of, 165 
 preparation of, 312, 320 
 visits of, during puerperium, 377 
 Obstetrics, 17 
 
 Obturator internus muscle', 30 
 Occipito-anterior position, 257 
 
 birth of body and hips, 265 
 
 of shoulders, 263 
 descent in, 259 
 diagnosis of, 253 
 dilatation of cervix in, 259 
 engagement in, 258 
 extension in, 262 
 external rotation in, 262 
 flexion in, 259 
 internal rotation in, 260 
 lateral inclination in, 259 
 mechanism in, 253, 257, 265 
 molding in, 258 
 restitution in, 262 
 Occipitoposterior positions, left, diagnosis 
 of, 266 
 etiology of, 266 
 frequency of, 266 
 mechanism of, 266, 268, 276 
 prognosis of, 276 
 persistent, causes of, 275 
 forceps in, 762 
 mechanism of, 269 
 treatment of, 277, 762 
 right, diagnosis of, 266 
 etiology of, 266 
 frequency of, 266 
 mechanism of, 266, 268, 275 
 prognosis of, 276 
 Oligohydramnios, 503 
 Oocytes, 59 
 Oogonia, 59 
 
 Oophoritis in puerperal infection, 819 
 Ophthalmia neonatorum, 337, 412 
 
 treatment of, 413 
 Organ of Rosemiiller, 44 
 
INDEX 
 
 851 
 
 Osteomalacic pelvis, 672. See Pelves, de- Pelves, 
 
 formed. 
 Ovarian artery, 46 ! 
 
 cyst, diagnosed from pregnancy, 146 
 
 in puerperal infection, 823 
 pregnancy, 522, 524 
 tumor, complicating labor, 639 
 treatment of, 640 
 pregnancy, 452, 639 
 treatment of, 640 
 diagnosed from pregnancy, 146 
 effect of, on labor, 640 
 on pregnancy, 640 
 on puerperium, 640 
 in puerperal infection, 823 
 Ovaries, 41 
 
 arterial supply of, 46 
 cortex of, 43 
 Mlum of, 41 
 medulla of, 43 
 ■nerve supply of, 47 
 tunica albuginea of, 43 
 Oviducts. See Fallopian tubes. 
 Ovoid, fetal, 243 
 Ovula of Naboth, 39 
 Ovulation, 61 
 
 relation of, to menstruation, 86 
 Ovum, 54 
 
 changes in, in ectopic gestation, 538 
 fertilization of, 65 
 implantation of, 97 
 maturation of, 60 
 segmentation of, 67 
 
 Pajot's maneuver, 763 
 
 Parametritis in puerperal infection, 818 
 
 Paraplegia during pregnancy, 459 
 
 Paroophoron, 45 
 
 Parovarium, 44 
 
 Parturient canal, 219, 230 
 
 injuries to, 723 
 Pasteurization of milk, 405 
 Pasteurized milk, 407 
 Patient, preparation of, 311 
 Pelves, deformed, 648 
 
 contracted, influence of, on labor, 
 693 
 on pregnancy, 692 
 prognosis of, 694 
 coxalgic, 690 
 
 diagnosis of, 691 
 influence of, on labor, 691 
 double obliquely contracted, of 
 Robert, 662 
 characteristic, 
 
 663 
 diagnosis of, 
 
 663 
 influence of, on 
 labor, 663 
 due to anomalies from disease in 
 pelvic articulations, 
 677 
 
 deformed, due to anomalies from 
 disease of spinal 
 column, 678 
 of subjacent skeleton, 
 689 
 disease of pelvic bones, 665 
 faulty development, 650 
 frequency of, 649 
 generally contracted, flat, non- 
 rachitic, 655 
 diagnosis of, 
 
 655 
 frequency of, 
 
 655 
 labor in, 656 
 justomajor, 663 
 
 diagnosis of, 663 
 frequency of, 663 
 influence of, on labor, 663 
 justominor, 653 
 
 characteristics of, 653 
 diagnosis of, 654 
 frequency of, 653 
 labor in, 654 
 kyphoscoliotic, 688 
 diagnosis of, 687 
 influence of, on labor, 688 
 kyphotic, 682 
 
 characteristics, 682 
 frequency of, 685 
 influence on labor, 685 
 on pregnancy, 685 
 prognosis, 686 
 lordotic, 689 
 
 narrow, funnel-shaped, 656 
 diagnosis of, 6)7 
 etiology of, 656 
 frequency of, 656 
 labor in, 657 
 obliquely contracted, of Naegele, 
 659 
 characteristics of, 
 
 659 
 diagnosis of, 661 
 etiology of, 661 
 influence of, on 
 
 labor, 662 
 method of delivery 
 in, 662 
 osteomalacic, 672 
 
 clinical picture of, 674 
 diagnosis of, 675 
 distortion in, 673 
 etiology of, 672 
 frequency of, 672 
 influence of, on labor, 675 
 pathology of, 673 
 treatment of, 675 
 rachitic, 665 
 
 equally contracted, 671 
 etiology of, 665 
 flat, 671 
 
 generally contracted, 
 671 
 frequency of, 665 
 pathology of, 665 
 
852 
 
 INDEX 
 
 Pelves, deformed, iticliitic, pseudo-ostco- 
 malaeie, ()72 
 varieties of, 668 
 scoliotic, 686 
 
 diagnosis of, 687 
 influence of, on labor, 688 
 simple flat, non-raehitic, 651 
 
 characteristics of, 
 diagnosis of, 651 
 frequenc}' of, 651 
 labor in, 652 
 pregnancy in, 652 
 split, 664 
 
 frequenc}^ of, 664 
 influence of, on labor, 664 
 spondylolisthetic, 678 
 appearance of, 680 
 diagnosis of, 681 
 etiology of, 680 
 frequency of, 680 
 influence of, on labor, 682 
 prognosis of, 682 
 transversely contracted, of 
 Robert, 662 
 characteristics of, 
 
 663 
 diagnosis of, 663 
 influence of, on 
 labor, 663 
 varieties of, 650 
 male and female, contrasted, 228 
 Pelvic articulations, 227 
 
 abnormalities of, 677, 678 
 brim, contraction of, 625 
 fascia, 33 
 floor, 31 
 
 preservation of, 326 
 organs. See Generative organs, 
 veins, ligation and excision of, in 
 puerperal infection, 834 
 Pelvimeters, 186 
 Pelvimetry, 170, 185 ' 
 
 value of external, 176 
 Pelvis, articulations of, 227 
 
 abnormalities of, 677, 678 
 atrophy of, 676 
 axes of, 225 
 caries of, 676 
 cavity of, 224 
 coxalgic, 690 
 deformities of, 648. See Pelves, 
 
 deformed, 
 diameters of, 170, 176 
 differentiation of male and female, 228 
 double obliquely (contracted, of 
 
 Robert, 662 
 exostoses on, 675 
 false, 221 
 fascia of, 33 
 floor of, 31 
 fracture of, 676 
 
 generally contracted, flat, non-rachi- 
 tic, 655 
 equally enlarged, 663 
 inclination of, 225 
 inlet of, 221 
 
 Pelvis, justomajor, 663 
 justominor, 653 
 kyphoscoliotic, 688 
 ky])lu)tic, 682 
 lining of, 230 
 lordotic, 689 
 
 male and female, compared, 228 
 measurements of, 170, 649. Sec 
 
 Pelvimetry, 
 narrow, funnel-shaped, 656 
 necrosis of, 676 
 new growths on, 675 
 obliquely contracted, of Naegele, 659 
 osteomalacic, 672 
 outlet of, 225 
 planes of, 225 
 rachitic, 665 
 
 flat, generally contracted, 668 
 generally equally contracted, 671 
 pseudo-osteomalacic, 672 
 simple flat, 671 
 scoliotic, 686 
 split, 664 
 
 spondylolisthetic, 678 
 true, 222 
 Pendulous abdomen, 624 
 
 influence of, on pregnancy, 693 
 Peptonized milk, 407 
 Perineal body, 35 
 Perineorrhaphy, 727 
 Perineum, lacerated, 726 
 etiologv of, 327 
 prophylaxis of, 328, 727 
 treatment of, 727 
 Pernicious vomiting of pregnane}-, 417. 
 
 See Toxemia of pregnancy. 
 Perspiration during i5ueri)eriiun, 374 
 Phlegmasia alba dolens, 820 
 
 clinical pic-ture of, 821 
 etiology of, 821 
 prognosis of, 822 
 Pigmentation during pregnancy, 127, 137 
 
 excessive, 452 
 Pituitary extract in uterine inertia, 614 
 Placenta, 90, 106 
 
 abnormalities of, 107 
 arrangement of, in triplet pregnancy, 
 201 
 in twin pregnancy, 195 
 bijjartita, 107 
 
 changes in, during latter part of preg- 
 nancy, 206 
 Crede's method of expressing, 217, 
 
 342 
 degenerations of, 109 
 diseases of, 109 
 duplex, 107 
 
 in ectopic gestation, 539 
 expression of, 341 
 
 Crede's method, 217, 342 
 fenestrata, 107 
 fimctions of, 106 
 inflammation of, 109 
 membranacea, 107 
 multiple, 107 
 neoplasms of, 110 
 
INDEX 
 
 853 
 
 Placenta, pathology of, 107 
 
 premature separation of, 574. See 
 
 Accidental hemorrhage, 
 previa, 564 
 
 cause of hemorrhage in, 567 
 complete, 54 
 
 diagnosed from accidental hem- 
 orrhage, 577 
 from premature separation, 
 577 
 diagnosis of, 568 
 etiology of, 565 
 frequency of, 565 
 incomplete, 564 
 lateral, 564 
 marginal, 564 
 partial, 564 
 prognosis of, 569 
 symptoms of, 566 
 treatment of, 570 
 varieties of, 564 
 separation of, in normal labor, 216 
 succenturiata, 107 
 syphilis of, 109 
 at term, 106 
 triplex, 107 
 tuberculosis of, 110 
 varieties of, 90 
 Placentae, arrangement of, in triplet preg- 
 nancy, 201 
 in twin pregnancy, 195 
 Placentitis, 109 
 Pneumonia complicating pregnancy, 466 
 
 puerperium, 466 
 Polyhydramnios, 500 
 Polymastia, 52 
 Porro's Cesarean section, 788 
 Position of fetus, 177, 248 
 
 in face presentations, 249 
 in vertex presentations, 249 
 Postmortem Cesarean section, 800 
 
 delivery, 801 
 Postpartum chill, 346 
 
 hemorrhage, 564, 585. See Hemor- 
 rhage, postpartum. 
 Posture during pregnancy, 139 
 
 of patient during second stage of 
 labor, 319 
 Pouch of Douglas, 28, 38 
 
 recto-uterine, 28 
 Precipitate labor, 620 
 
 prognosis of, 621 
 treatment of, 622 
 Pregnancy, abdominal, 523, 525, 549 
 air-embolism complicating, 468 
 alimentary canal, disorders of, during, 
 
 481 
 anemia complicating, 469 
 appendicitis complicating, 483 
 appetite during, 132 
 articulations, changes in, during, 139 
 ascites diagnosed from, 147 
 asthma during, 462 
 bathing during, 151 
 bimanual examination in, 184 
 bladder during, 136 
 
 Pregnancy, blood during, 132 
 
 blood-pressure during, 133, 135, 155, 
 
 429 
 bones, changes in, during, 139 
 bowels, regulation of, during, 152 
 breasts during, 153 
 
 changes in, 127 
 symptoms, 141 
 carcinoma of cervix complicating, 450 
 
 of uterus complicating, 639 
 cardiac disease during, 459 
 cervix uteri at end of, 231 
 
 changes in during, 125, 141, 142 
 changes in internal organism due to, 
 123 
 
 uterus, due to, 123, 125, 126 
 
 vagina, due to, 126 
 cholera complicating, 478 
 chorea during, 455 
 circulation during, 132 
 condylomata complicating, 449 
 constipation during, 151, 482 
 cystocele complicating, 449 
 decidual diseases during, 488 
 diabetes during, 486 
 diagnosis of, 145 
 
 differential, 145 
 diet during, 150 
 digestion during, 131 
 diseases complicating, 444, 454 
 dress during, 150 
 drink during, 150 
 douches during, 153 
 duration of, 156 
 dyspnea during, 462 
 ear affections complicating, 480 
 eclampsia of, 424. See Eclampsia, 
 ectopic, 522. See Ectopic gestation, 
 edema in, 429 
 
 of lower extremities, 447 
 
 of vulva, 446 ' 
 effect of, on mother's milk, 393 
 emphysema during, 462 
 enteroptosis during, 483 
 epilepsy during, 459 
 epistaxis complicating, 481 
 excessive pigmentation during, 452 
 extra-uterine, 522. See Ectopic ges- 
 tation, 
 eyes during, 430, 479 
 fibroma molluscum in, 454 
 fibromyomata complicating, 451, 632 
 gall-bladder affections during, 485 
 gall-stones complicating, 485 
 gastric indigestion during, 482 
 gastroptosis during, 483 
 gingivitis during, 481 
 glycosuria during, 486 
 goitre during, 136 
 gonorrheal infection complicating, 
 
 447 
 headache during, 430 
 heart during, 134 
 Hegar's sign, 143 
 
 hematoma of vulva complicating, 444 
 hemiplegia during, 459 
 
854 
 
 INDEX 
 
 Pregnancy, hemophilia complicating, -170 
 hemoptj'sis during, 4G3 
 hemorrhoids complicating, 446 
 herpes in, 453 
 hyperemesis of, 417 
 hysteria in, 454 
 ileus complicating, 485 
 impetigo herpetiformis in, 453 
 indigestion during, 482 
 infectious diseases complicating, 470, 
 
 476, 479 
 influence of contracted pelvis on, 692 
 
 of faulty presentations on, 693 
 
 of fibroids on, 632 
 
 of kyphotic pelvis on, 685 
 
 of prolapsed cord on, 693 
 insanity' during, 456 
 intestinal indigestion during, 482 
 intraligamentous, 525, 549 
 jaundice during, 485 
 kidneys during, 134, 483 
 lactosuria during, 486 
 leucorrhea during, 153 
 leukemia complicating, 470 
 liver dming, 134,_421, 424, 485 
 malaria during, 476 
 in malformed uterus, 558 
 management of normal, 149 
 mania during, 457 
 measles complicating, 477 
 melancholia during, 456 
 menstruation during, 126 
 mouth, disorders of, during, 481 
 movable kidney during, 483 
 multiple, 191. See Multiple preg- 
 nancy, 
 nausea dming, 131, 150, 430 
 nephi-itis dm-ing, 486 
 nervous diseases in, 454 
 
 system in, 133, 430 
 neuralgia in, 134, 455 
 neuritis during, 455 
 normal, management of, 149 
 nose, affections of, compUcating, 481 
 nutrition during, 131 
 ovarian tumors complicating, 452 
 paraplegia during, 459 
 pathologj' of, 417 
 patient, directions for, 156 
 
 observation of, 155 
 pernicious vomiting of, 417 
 physiology of, 123 
 pigmentation during, 127, 137, 452 
 pneumonia complicating, 466 
 postm-e during, 139 
 prolongation of, 697 
 ptj-alism during, 482 
 pulmonary affections during, 462 
 
 embolism complicating, 467 
 pruritus complicating, 453 
 
 ^1^lvae complicating, 448 
 pveUtis complicating, 596. See Pye- 
 litis, 
 record of history and examination, 
 
 158 
 rectmn in, 136 
 
 Pregnancy, reflex cough of, 463 
 respii'ation during, 133 
 salpingitis compUcating, 451 
 scarlet fever complicating, 476 
 signs of, 140 
 in simple flat pelvis, 652 
 skin, diseases of, during, 452, 454 
 
 during, 136 
 smallpox complicating, 477 
 special senses, disturbances of, during, 
 
 479 
 spleen during, 134 
 spurious, 146 
 striae during, 137 
 symptoms of, 140 
 syphilis compUcating, 470 
 influence of, on, 471 
 influenced by, 470 
 teeth, disorders of, dm-ing, 481 
 threatened eclampsia dvu-ing, 424 
 thj-roid gland dm'ing, 135 
 toxemia of, 417. See Toxemia of 
 
 pregnancy, and Eclampsia, 
 tuberculosis complicating, 463 
 tubo-abdominal, 550 
 twin, 191. See Multiple pregnancy, 
 tj-phoid fever complicatmg, 478 
 urinarj' tract, diseases of, during, 486, 
 
 487 
 urine during, 134, 429 
 vaginal douches during, 153 
 examination during, 184 
 prolapse during, 449 
 varicosities complicating, 444, 445 
 venereal warts complicating, 449 
 visual disturbances during, 479 
 vomiting during, 131, 417, 430 
 vulvovaginal abscess complicating, 
 
 448 
 weight during, 131 
 Premature babies, immediate care of, 361 
 births, death statistics of, 839 
 labor due to fibroids, 633 
 induction of, 736 
 
 by dilating cervix with elas- 
 tic bag, 739 
 by introduction of bougie, 
 
 743 
 by puncture of membranes, 
 
 744 
 by tamponade of vagina, 
 
 743 
 indications for, 736, 737 
 methods of, 738 
 prognosis of, 738 
 Presentations of fetus, 177, 244 
 Presenting part, 244 
 Primigravida, indications of, 148 
 Prolapse of cord, 718 
 
 diagnosis of, 718 
 etiology of, 718 
 frec}uency of, 718 
 influence of, on ]:)regnanc3', 693 
 prognosis of, 719 
 treatment of,' 719 
 of pregnant uterus, 450 
 
INDEX 
 
 855 
 
 Protein in modified milk, 398 
 in woman's milk, 391 
 estimation of, 393 
 Pruritus in pregnancy, 453 
 
 vulvse, complicating pregnancy, 448 
 Pseudocyesi^, 146 
 Ptyalism during pregnancy, 482 
 Puberty, age of, 85 
 Pubiotomy, 779 
 
 contra-indication to, 781 
 indications for, 781 
 objections to, 781 
 prognosis of, 781 
 Pubococcygeus muscle, 31 
 Puborectalis muscle, 31 
 Pudendum, 18 
 Puerperal hemorrhages, 594 
 etiology of, 594 
 treatment of, 595 
 infection, 809 
 
 abscess in, 831 
 appendicitis in, 823 
 auto-infection in, 812 
 auto-intoxication in, 823 
 bacillus aerogenes capsulatus in, 
 811 
 coli communis in, 811 
 Klebs-Loeflfler, in, 811 
 typhosus in, 811 
 bacteremia in, 814, 816 
 bowels in, 823 
 carriers of infection in, 811 
 cellulitis in, 818 
 contagious diseases, relation of, 
 
 to, 813 
 diagnosis of, 822 
 douches in, 828 
 etiology of, 809 
 frequency of, 815 
 mortality of, 816 
 pathological lesions in, 817 
 physical signs, 817 
 prophylaxis, 825 
 pyelitis in, 823 
 pyemia in, 814 
 sapremia in, 814 
 septicemia, 814, 816 
 site of infection, 817 
 surgical treatment, 831 
 symptoms of, 824 
 toxemia in, 814 
 treatment of, 825, 827 
 varieties of, 814, 816 
 insanity, 457 
 osteophytes, 139 
 Puerperium, 369 
 
 anemia comphcating, 469 
 bladder, care of, during, 376 
 bowels during, 375 
 catheterization during, 376 
 cervix uteri, changes in, during, 370 
 diet during, 375 
 fibroids, effect of, on, 634 
 gall-stones complicating, 486 
 hemophilia complicating, 470 
 insanity during, 457 
 
 Puerperimn, leukemia complicating, 469 
 management of, 369 
 pathology of, 809 
 pneumonia complicating, 466 
 pulmonary embolism complicating, 
 
 467 
 record of, 162 
 Pulmonary affections during pregnancy, 
 462 
 embolism complicating pregnancy, 
 467 
 puerperium, 467 
 Pyelitis complicating pregnancy, 596 
 clinical course of, 598 
 diagnosis of, 600 
 etiology of, 596 
 prognosis of, 602 
 treatment of, 603 
 in puerperal infection, 823 
 Pyemia in puerperal infection, 814 
 Pyosalpinx, ruptured, diagnosed from 
 
 ectopic gestation, 545 
 Pyriformis muscle, 30, 33 
 
 Quickening, 144 
 
 R 
 
 Rachitic pelvis, 665. See Pelves, de- 
 formed. 
 Record of pregnancy, 158 
 Recto-uterine pouch, 28, 38 
 Rectum, 28 
 
 cancer of, dystocia due to, 642 
 
 columns of, 29 
 
 during pregnancy, 136 
 
 sphincters of, 29 
 
 valves of, 29 
 Reflex cough of pregnancy, 463 
 Respiration during pregnancy, 133 
 
 methods of artificial, 353 
 Retinitis, albuminm-ic, 479 
 Retraction of foreskin, 411 
 Rhomboid of Michaelis, 171 
 Robert, contracted pelvis of, 662 
 Room, preparation of, 309 
 Round ligaments of uterus, 39 
 
 S 
 
 Sacrococcygeal articulation, 228 
 Sacro-iliac articulation, 227 
 Salivation during pregnancy, 141 
 Salpingitis complicating pregnancy, 451 
 
 in puerperal infection, 819 
 Salts in modified milk, 398 
 
 in woman's milk, 391 
 Sanger's method of Cesarean section, 788 
 compared with extraperitoneal 
 operation, 800 
 Sapremia in puerperal infection, 814, 816 
 
856 
 
 INDEX 
 
 Scales for weighing infants, 387 
 Scanzoni's maneuver, 702 
 Scarlet fever complicating pregnancy, 470 
 Schultze's method of artificial respiration, 
 
 355, 350 
 Scoliotic pelvis, GSO. See Pelves, deformed. 
 Scopolamin-morphin anesthesia, 324 
 Scopolamin-narcophin anesthesia, 324 
 Segmentation, 07 
 Seizure, eclainptic, 431 
 Semilunar valves of rectum, 29 
 Septa of cervix uteri, 045 
 
 of vagina, 040 
 Septicemia in puerperal infection, 814 
 Shortening of abdominal cavity, 025 
 Shoulders, delivery of, 330 
 Show, the, 208 
 
 Silver nitrate for child's eyes, 337 
 Simpson forceps, 748, 750 
 Skene's glands, 28 
 
 Skin, diseases of, during pregnancy, 452, 
 454 
 
 during pregnancy, 130 
 Sloane maternity mifk set, 402 
 Small])ox complicating pregnane}^, 477 
 Smell ie forceps, 748, 749 
 Somites, mesodermic, 78 
 Special senses, disturbances of, during 
 
 pregnancy, 479 
 Spermatocytes, 59 
 Spermatogonia, 59 
 Spermatozoon, 57 
 
 maturation of, 03 
 Spermovium, 05 
 Sphincters of rectum, 29 
 Spinal anesthesia, 323 
 Spleen during pregnancj% 134 
 Split pelvis, 004. See Deformed pelves. 
 Spondylolisthetic ))elvis, 078. See De- 
 formed pelves. 
 Spontaneous evolution, 709 
 
 version, 709 
 Spurious pregnancy, 140 
 Staphylococcus in puerperal infection, 
 
 810 
 Starvation temperature, 389 
 Stenosis of cervix uteri, 043 
 
 of vagina, 040 
 Sterility due to fibroids, 032 
 Sterilization of milk, 405 
 Stillbirths, 830 
 
 statistics of, 837, 839 
 Stools of infants, 409 
 Streptococcus in puerperal infection, 810 
 Striae during pregnancy, 137 
 Subinvolution diagnosed from pregnancy, 
 
 145 
 Sugar in modified milk, 398 
 
 in woman's milk, 391 
 Summons, obstetrical, 307 
 Superfecundation, 192 ♦ 
 
 Superfetation, 192 
 Sutures of fetal skull, 235 
 Sylvester's method of artificial respiration, 
 
 353 
 Symphyseotomy, 770 
 
 Symphyseotomy, Americ.m subcutaneous 
 method, 777 
 
 Ayer's method, 777 
 
 French method, 777 
 
 indications for, 778 
 
 Italian method, 777 
 
 open method, 777 
 
 l)rognosis of, 778 
 
 result of, 777 
 
 steps of operation, 778 
 
 suprapubic method, 777 
 
 technic of, 777 
 Synclitism, 259 
 Synostosis, pelvic, 077 
 
 sacrococcygeal, 078 
 
 sacro-iliac, 078 
 Syphilis as influenced by pregnancy, 470 
 
 complicating pregnancy, 470 
 
 diagnosis of, 475 
 
 evidence of, in fetus, 472 
 
 influence of, on pregnancy, 47 1 
 
 l)aternal, 470 
 
 of placenta, 109 
 
 treatment of, 475 
 
 Tarnier axis-traction forceps, 748, 753, 
 
 703 
 Teeth during pregnancy, 139, 150 
 
 disorders of, 481 
 Temperature, starvation, 389 
 Thermometer, 389 
 
 Thighs, varicosities of, comj)licating preg- 
 nancy, 445 
 Threatened abortion, 508, 515 
 Thrombophlebitis in puerj)eral infection, 
 
 819 
 Thyroid gland during pregnancy, 135 
 Tongue-tie, 411 
 
 Toxemia of pregnancy, 417. See Eclampsia, 
 anesthetics in, use of, 435 
 liver in, 421, 424 
 symptoms of, 429 
 treatment of, 421, 432 
 urine in, 418 
 in puerperal infection, 814, 817 
 Transverse presentations, 707 
 diagnosis of, 708 
 etiology of, 708 
 frequency of, 708 
 mechanism of, 709 
 prognosis of, 708 
 treatment of, 710 
 varieties of, 707 
 Transversus perinei muscle, 35 
 Traveling during pregnancy, 151 
 Triangular ligament, 33 
 Triplets, 200 
 
 course of pregnancy. 201 
 etiology of, 200 
 labor, 203 
 membranes in, 201 
 mortality of, 203 
 placentae in, 201 
 
INDEX 
 
 857 
 
 Tubal abortion, 534 
 cause of, 537 
 rupture in, 536 
 pregnancy, 523, 524, 525 
 Tubercles of Montgomery, 128 
 Tuberculosis complicating pregnancy, 4bd 
 efTect of, on pregnancy, 463 
 of placenta, 110 
 Tubo-abdominal pregnancy, 550 
 Tubo-ovarian ligament, 43 
 
 pregnancy, 524, 525 _ 
 
 Tubo-uterine pregnancy, o26, oJt) 
 Tucker-McLane forceps, 748, 752 
 Tumors of uterus complicatmg labor, b6U 
 Twilight sleep, 324 
 Twin tubal pregnancy, 530 
 Twins, 191. See Multiple pregnancy, 
 collision of, 198, 199 
 course of pregnancy, 197 
 diagnosis of, 196 
 hemorrhage in, 199 
 interlocking of, 198, 199 
 labor in, 197 
 
 management of labor in, 199 
 membranes in, 195 
 placentge in, 195 
 presentation of, 196 
 sex of, 196 
 Typhoid fever complicating pregnancy 
 478 
 
 Umbilical cord, 88, 110 
 
 about child's neck. 111, 330 
 anomalies of, 111 
 dressing of, 333 
 method of hgating, 333 
 prolapse of, 718. See Prolapse 
 of cord. 
 Undersized babies, immediate care of, 361 
 Urethra, 27 
 
 Urinary tract, diseases of, during preg- 
 nancy, 486, 487 
 Urine during pregnancy, 154 
 in eclampsia, 429 
 in toxemia of pregnancy, 418 
 Uterine artery, 46 
 
 canal at end of pregnancy, 231 
 distention, relation of labor to, 206 
 inertia, 610 
 
 endangering maternal convales- 
 cence, 617 
 fetal dangers, 615 
 primary, 610 
 secondary, 611 
 treatment of. 612 
 mucous membrane, changes in, after 
 
 impregnation, 90 
 tumor in puerperal infection, 823 
 Uterosacral hgaments, 40 
 Uterovesical hgaments, 40 
 
 pouch, 38 
 Uterus, 36 
 
 arterial supply of, 45 
 bicornis, 48, 559 
 
 Uter 
 
 us bipartitus, 560 
 broad ligaments of, 39 
 carcinoma of, complicating labor, 639 
 cavity of, 38 
 cervix of, 36 
 
 changes in, during pregnancy, 123, 
 125, 142 
 in ectopic gestation, 531 
 in first stage of labor, 210 
 prior to labor, 206 
 in puerperium, 369 
 in second stage of labor, 213 
 in third stage of labor, 215 
 coats of, 38 
 cornua of, 37 
 development of, 47 
 didelphys, 48, 559 
 external os, 37 
 
 fibromyoma of, complicating preg- 
 nancy, 630, 631, 632 
 fundus of, 37 
 
 height of, during pregnancy, 16o 
 incarceration of pregnant, 627 
 infravaginal portion, 36 
 infundibulopelvic ligament, 40 
 internal os, 38 
 inversion of, 591 
 etiology of, 592 
 prognosis of, 593 
 signs of, 593 
 symptoms of, 593 
 treatment of, 593 
 irregular contractions of, 622 
 isthmus of, 36 
 lack of tone in, 624 
 ligaments of, 39 
 lymphatics of, 46 
 malformations of, 48 
 
 causing dystocia, 625 
 pregnancy in, 558 
 treatment, 562 
 mucous membrane of, 39 
 
 relation of, to menstruation, 
 81 
 muscular coat, 39 
 nerve supply of, 47 
 peritoneal pouches of, 38 
 position of, in pregnancy, 126 
 prolapse of, in pregnamcy, 450 
 retroversion of, in pregnancy, 626 
 round ligaments of, 39 
 rupture of, 580_ 
 complete, 582 
 
 diagnosed from premature sepa- 
 ration of placenta, 577 
 etiology of, 580 
 frequency of, 581 
 incomplete, 582 
 pathology of, 582 
 prognosis of, 583 
 symptoms of, 583 
 treatment of, 584 
 varieties of, 582 
 sacculation of, in pregnancy, 626, 628 
 septus, 50, 559 
 serous coat of, 38 
 
858 
 
 INDEX 
 
 Uterus, supravaginal portion of, 36 
 tetanic contraction of, 623 
 tumors of, complicating labor, 630 
 unicornis, 50, 558 
 uterosacral ligaments, 40 
 utricular glands, 39 
 veins of, 46 
 
 Vagina, 24 
 
 arterial supply of, 45 
 
 atresia of, 646 
 
 changes in, during px'egnancy, 126 
 
 puerperium, 371 
 conditions of, causing dystocia. 646 
 development of, 47 
 double. 560 
 
 during pregnancy, 141, 153 
 dystocia due to conditions of, 646 
 at end of pregnancy, 233 
 laceration of, 725 
 
 treatment of, 726 
 lymphatics of, 46 
 septa in, 646 
 stenosis of, 646 
 tumors in, 647 
 veins of, 46 
 Vaginal Cesarean section, 783 
 disadvantages of, 786 
 indications of, 785 
 technic of, 784 
 douches during pregnancy, 153 
 examination, at beginning of labor, 
 313 
 in breech presentations, 296 
 during pregnancy, 184 
 frequency of, 314 
 in L. M. A. position, 281 
 in L. O. A. position, 257 
 in L. O. P. position, 267 
 in R. M. A. position, 281 
 in R. O. A. position, 257 
 in R. O. P. position, 267 
 method of making, 315 
 walls, prolapse of, complicating preg- 
 nancy, 449 
 Valves of rectum, 29 
 
 Varicosities of legs and thighs complicat- 
 ing pregnancy, 445 
 of vulva complicating pregnancy, 444 
 Venereal warts comphcating pregnancy, 
 
 449 
 Version, 768 
 bipolar, 770 
 
 Braxton Hicks's method, 770 
 cephalic, 768 
 
 Version, combined, 770 
 external, 769 
 indications for, 768 
 internal, 773 
 methods of, 769 
 pelvic, 768 
 podalic, 768 
 spontaneous, 709 
 Vesical calculi, obstructing labor, 642 
 Vesicular mole, 491. See Hydatidiform 
 
 mole. 
 Vertex presentations, 245 
 
 mechanism of labor in, 251 
 positions in, 249 
 Vestibule, 22 
 
 bulbs of, 22 
 Visits of friends during puerperium, 378 
 
 of obstetrician, 377 
 Visual disturbances during pregnancy, 479 
 Vomiting, during pregnane}^ 131, 141 
 
 pernicious, 417. See Toxemia of 
 pregnancy. 
 Voorhees's bag, 616, 739 
 Vulva, 18 
 
 changes in, during puerperium, 370 
 conditions of, causing dystocia, 646 
 during pregnancy, 153 
 edema of, 647 
 
 complicating pregnancy. 446 
 hematoma of, complicating preg- 
 nancy, 444 
 lacerations of, 726 
 
 varicosities of, comjjlicating preg- 
 nancy, 444 
 Vulvovaginal glands, 22 
 
 abscess of, complicating pregnancy, 
 448 
 
 W 
 
 Weight chart, 388 
 
 gain in, during pregnancy, 131 
 Wet-nurse", 394 
 Wharton's jelly. 111 
 Wolffian body, 44 
 
 duct, 44 
 
 ridge, 44 
 
 Yolk sac, 88, 90 
 
 ZYGOsrs, 67 
 

 
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