COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX00040061 > f . ••■.■."'••.■■.' . ' • ■ ••.■'■'•■■ i ■ .' ■ i' : ' *to$b8 '• 3&E8 -''/"'■ •'•;.•.'. /a; •'-• '/.-> *cc*yy TK ? iTH Vi Columbia (HnitJeraitp inttjfCttptOfttiJfork College of ^Jjpstctans; anb burgeons Hifararp rSTra Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/systemofobstetriOOauva A SYSTEM OF OBSTETRICS WITH FIVE HUNDRED AND THIRTY-SEVEN ILLUSTRATIONS; BASED UPON A TRANSLATION FROM THE FRENCH OF AWARD REVISED BY CURTIS M. BEEBE, M. D. CHICAGO. ILL. 1892 J. B. FLINT & COMPANY NEW YORK Ou Copyright, 1892, J. BENTON FLINT. hWUfrtT ft f ««B?Mah mEStVBSt THE MERSHON COMPANY PRESS, RAHWAV, N. J. CONTENTS. PAGE. I. Menstruation and Fecundation, 17 II. Development and Description of the Human ovum. . 27 III. Modification of the Maternal Organism. . . 64 IV. The Parturient Canal 84 V. Presentations and Positions. ... . . . 97 VI. Symptomatology of Pregnancy, 127 VII. The Diagnosis of Pregnancy 158 VIII. Progress and Duration of Pregnancy. — Prognosis.— Hygiene, 164 IX. Accouchement.— Maternal Phenomena. . . . 170 Phenomena of the Appendages 188 X. Mechanism of Accouchejient.— Fetal Phenomena. . 194 XI. Influence of Accouchement on the Mother and on the Child, 214 XII. Management of the Accouchement 224 XIII. Accouchement.— Delivery of the Appendages, . 234 XIV. Post-Partum, 240 XV. Puerperal Pathology. — General Disease. — Eclampsia. 250 XVI. Puerperal Septicemia, 257 XVII. Puerperal Pathology. — Extra Genital Localized Diseases. 269 XVIII. Diseases of the Bony Pelvis 277 XIX. Diseases of the Genital System and its Dependen- cies.— Genital Dystocia. 307 XX. Diseases and Anomalies of the Placenta. . . 324 XXI. Diseases of the Ovuline Envelopes, .... 335 XXII. Diseases and Death of the Fetus.— Fetal Dystocia, 338 XXIII. Multiple Pregnancy, 348 XXIV. Premature Expulsion 359 XXV. Accidents of Accouchement, 368 XXVI. Accidents of the Delivery of Appendages. . . 376 XXVII. Accidents of Post-Partum. 389 XXVIII. The Vectis or the Lever 391 XXIX. Versions 302 XXX. Forceps 402 XXXI. Manual Extraction, 416 XXXII. Induced Expulsion, 420 XXXIII. Embryotomy 423 XXXIV. Hysterotomy. — Cesariax Section 432 TREATISE ON OBSTETRICS. CHAPTER I. MENSTRUATION AND FECUNDATION. Woman's life is divided into three great periods : one, prsegenital ; another, genital; the third, post-genital. The first extends from birth to the first menstruation ; the second, from puberty to the menopause, and the last, from the menopause to the close of life. Only the genital period interests the obstetrician, for it is that portion of woman's life that is consecrated to procreation. In im- posing this role upon woman, nature has established in her a pre- ponderance of the genital system, an idea that Michelet has so well expressed in the words, "Woman is a matrix supplied with organs." This genital system, which dominates the feminine organism, imposes three different states, that successively divide the genital period. For a time there is repose, calm, an intermittent and a regular truce accorded to the economy. Then there is the prepa- ration for fecundation, the period of emission of the ovule, the menstrual state. Sometimes, finally, after the meeting and the union of the two elements, male and female, a being developes in the interior of the uterus, and causes in the gestating woman a series of changes necessary to ensure this new life ; this epoch is designated as the puerperal state. Thus, a state of repose, a men- strual state and a puerperal state occur during the genital life of woman. It is the puerperal state that especially interests the obstetrician. Obstetrics is the study of the puerperal state, pro- vided this term is used to designate the period which extends from impregnation to the end of lactation, or to the end of the third month after delivery when the mother does not nurse her child. Before entering upon the study of pregnancy it will be necessary to consider briefly menstruation and fecundation, which are its pre- liminaries to pregnancy. The term menstruation is applied to the flow of blood, which occurs periodically from the female genital organs. Menstruation comprises two essential phenomena, ovu- lation and a sanguineous flow. Each demands a special study. Ovulation is the liberation by the ovary of a cell, having an important future and to which has been given the name ovule. 18 Menstruation and Fecundation. A word on the ovary and its contents. The ovary, situated in the posterior wing of the broad ligament, is a small gland resembling an almond in form. It measures four centimetres in length, two in height ami one centimetre and a half in its antero-posterior thick- no- : it- weight is eight grammes. Its two surfaces and its superior border being free it floats in the peritoneal cavity. Its inferior border is attached by a ligament to the uterus and to the pavilion of the tube by one of its fimbriae. I shall return to the anatomical relations of the ovary in connection with the subject of fecundation. r^'^P^^ 1 ^^^, FlG. i. — Section of a fragment of the cvary. S S, ovarian stroma: e, epithelium ; I I, Graafian follicles highly developed ; 2 2, non-developed follicles; 3, very small follicles; O, ovule in the Graafian follicle; vv, bloodvessels; 9, cells of the granular membrane. On section, the structure of the ovary is found of a reddish color, rose colored in some parts, a deeper red in others. This is the bulbus portion, a mixture of non-striated mucular fibres, con- nective tissue fibres, arteries, veins, lymphatics and some nerve filaments. This bulbus portion forms almost the whole of the ovary. It is covered by a thin envelope, which scarcely measures a millimetre in thickness. The peripheral portion, called the fibrous tunic by the older writers, is distinguished from the subjacent portion by its pale color, its apparent homogeneousness and by its firmness. This envelope is the fundamental portion of the ovary. It is formed by the accumulation "f <>\ i-;t <•.-., also called ovarian vesicles or Graafian follicles. It i- in the interior of these vesicles that the ovule is found. I lontrary to what is observed in all the other glands of the organ- i-m, the ovary has its cavity at the surface and it is there that the phenomenon of ovulation takes place. To comprehend the phe- nomenon a complete description of the ovisac and its contents is Menstruation and Fecundation. 19 indispensable. The follicle contains an accumulation of other cells, among them one of particular character, the ovule. The ovule is the female primordial element, just as the spermatozoid is the pri- mordial element of the male. The ovule is constituted by the germinative spot, the germinative vesicle, the vitellus and vitelline membrane. The ovule is contained in the interior of the ovarian vesicle surrounded by cells, the whole being enveloped in a common membrane. Altogether these structures form the ovisac. In its conformation the ovule does not differ from ordinary cells. Each ovisac contains an ovule, and each ovary contains, as M. Sappey has demonstrated, approximately 300,000 ovisac, or 600,000 to each woman. Fig. 2. — Schematic representation of the Graafian follicle or ovisac and of its contents, the ovule. Let us follow an ovisac in its menstrual evolution. In its interior the cells assume proliferation and at one point a cavity is formed, that fills with liquid, perhaps the result of the cellular activity. The vesicle enlarges markedly under the influence of the cell pro- liferation and of the accumulation of liquid. It takes on a size that becomes visible to the naked eye at the surface of the ovary. 20 Menstruation and Fecundation. This swelling continues and the vesicle, instead of remaining spherical, takes an ovular form, with the small extremity corre- sponding to the free surface of the ovary. At the moment when the distention hecomes too great, rupture occurs at the most pro- jecting point. This rupture, prepared for by the modifications in the ovisac, is provoked by the congestion of the bulbus portion of the ovary. This congestion occurs under the influence of menstru- ation or any genital excitation, such as that produced by coitus. Fig. 3. — Ovisac preparing to rupture and liberate the ovule. At the moment of dehiscence the ovule is thrown outward. The ovisac, abandoned by the ovary, becomes henceforth useless. Its role is completed. Blood and plastic lymph are effused into its interior. The place of rupture which has given passage to the ovule cicatrizes. The vesicle becomes folded on itself. From the transformations of its contents it takes on the appearance of the corpus liitcinn, disappearing by degrees until reduced to a linear or radiate cicatrix that is more or less depressed. The corpus luteum of menstruation differs from that of pregnancy only by the fact that the iatter, under the influence of the activity impressed on all the genital zone by fecundation, instead of diminishing, enlarges for two or three months and does not undergo regression until after delivery. Thus we understand the phenomena of ovulation, there Menstruation and Fecundation. 21 now remains to be studied the other condition of menstruation, that is, the flow of blood. The periodical hemorrhage that occurs during the genital life of woman generally begins, in France, at fifteen years of wj^ and inates at forty-live. Thus it may be said that the genital life continues about thirty years. But there are observed frequent variations in the period of appearance and of cessation of the menses, variations which depend upon the constitution, upon the temperament, upon the geographical latitude of the country, upon the education, upon the habitual diet, upon the race and upon the social condition of the woman. Various facts of precocious and of late menstruation have been cited. The menstrual flow is repro- duced in general every solar month (thirty to thirty-one days), sometimes oftener ; every lunar month (twenty-eight days), and some women menstruate even every three weeks, others only every five weeks. Finally, there are some in whom the appearance of the flow is capricious and irregular. The duration of the flow is com- monly from three to six days. Some women only menstruate a few hours, others from ten to twelve days. I only give the extreme figures. It is difficult to appreciate the quantity of blood lost at each menstrual period, but a quantity less than fifty grammes or greater than five hundred grammes may be considered as pathological. The blood which flows during the menstrual period has its source in the tubes and in the body of the uterus, rarely in some other portion of the genital organs. Exceptionally the flow may occur from another region, in such cases as have been called menstrual deviation, where the periodical haemorrhage takes place from the lungs, from the intestine, from the mouth, from the nose, from the surface of a wound, from an erectile tumor or from the nipple. I return to the uterus. At each menstruation the uterine mucosa is folded on itself in such a way as to recall the cerebral convolutions. This tumefaction, the consequence of the genital congestion, favors the implantation of the fecundated ovule, which thus becomes grafted on the folds of the mucosa. The mucosa also undergoes other modifications, about which there are so many different opinions that it is impossible to judge of their true nature. Having sufficiently discussed the two essential phenomena of menstruation, there remains the study of their relations. Does the flow of blood depend upon ovulation? Or, on the contrary, does ovulation depend upon the blood-flow? Or, a third hypothesis, are these two factors independent ? Each of these theories has its partisans. Without wishing to enter here into a complete discussion of this difficult question, I shall say that I believe in a certain de- ' gree of independence of ovulation and menstruation. I also believe ' that they are subordinate, one to the other, in such a way that they most often occur together. It is the union of ovulation and of 22 Menstruation and Fecundation. istruation that constitutes menstruation, as the current of air and the contraction of the vocal cords forms the voice. Now there is the same union and the same independence existing between the current of air and the contraction of the vocal cords, as between ovulation and the ilow of blood. Ovulation is the essential phe- nomenon of menstruation and the sanguineous flow the accessory element. One assures fecundation, the other preparation for it. Their union place the woman in the most favorable condition for conception. From this study of menstruation we pass to that of fecundation or conception. Fecundation is the union of two elements, male and female, in the aim of procreation of a new being. Conception is the synonym of fecundation, and only differs from it by a simple shade of meaning; fecundation indicating the union of the two procreative elements, and conception applying better to the state of the woman who has just been fecundated. We have spoken of one element, the ovule. We shall now turn to the spermatozoid. The spermatozoid, wrongly called spermatozoon at the time it was considered animalcule, is composed of a head of ovular form, measuring 5 mm. in its long axis, of a small cylindrical body of- fering almost the same length, and finally an undulating tail which grows successively thinner toward its extremity, and has a length of 45 mm. From the recent studies on the development and the nature of the spermatozoid, it has been proven that it is only a cell of a particular form, the nucleus being represented by the head and the protoplasm by the intermediate segment. The tail is only a simple cilium analogous to that met in other cells of the economy. Under the microscope, in a drop of fresh spermatic fluid, spermatozoids are seen in great number, moving with great rapidity. These displacements are due to a corkscrew movement of the cilium which constitutes the tail of the anatomical element. In a second a spermatozoid covers its length ; it moves at the rate of two to three millimetres a minute. These movements quickly cease as soon as the spermatozoid is placed in an acid medium instead of tin- alkaline fluid in which it normally occurs. The uterine fluid being alkaline, and likewise that of the tube, the spermatozoid pre- serves its n.ovements therein for a certain length of time, to fifteen days, according to Schroeder, and perhaps even more. But if there is endometritis, the uterine secretion becomes acid and the sperma- tozoid is quickly killed. The two elements, male and female, now being understood, we may essay the solution of the problem of fecundation, and to this end we shall note successively : The place of the meeting of these two elements; the approach of these elements, one toward the other ; the difficulties that they must overcome before union. Menstruation and Fecundation. 28 At the moment of ovular dehiscence tin* ovule becomes free at the surface of the ovary, the spermatozoid, for the other part, ia de- posited at the external orifice of the uterus as a consequence of coitus. To meet, the ovule and the spermatozoid must travel through the uterus and the tube. But the approach of these elements toward each other can only he comprehended by a previous study of the parts through which they must pass. We turn, then, to the cavities of the uterus and of the tubes. Head. Intermediate Segment. .Tail. Fig. 4. — Spermatozoid. Fig. 5. — Uterus: body; isthmus; cer- The uterine cavity is subdivided into that of the body and that of the cervix, which are separated by a short canal, the isthmus (Fig. 5). Each of these cavities measure about two and one-half cen- timetres vertically, though in the nulliparous woman the cavity of the cervix exceeds that of the body, and, on the contrary, in the muciparous woman that of the body is relatively greater. The cavity of the body has a triangular aspect, the superior angles being continuous with the tubes, and the inferior with the isthmus. The surfaces are plane and applied one to the other in such a way that the space is virtual or is filled in the normal state with a small quantity of mucus. The cavity of the cervix is fusiform, slightly flattened from before backward. The mucosa that lines its walls is uplifted by the arbor vita, two in number. Each one of these structures is composed of a longitudinal axis, from which arise transverve and ascending branches. The anterior axis begins at the external orifice and is directed obliquely above and to the right ; the posterior axis, placed symmetrically to the origin of the former, followes an oblique path in an analogous direction, that is to the left and toward the internal orifice. The two axes terminate by gradual diminution toward 24 Menstruation and Fecundation. the isthmus, no branches existing at that place. The utility of the arbor vita' is unknown, but it is supposed that they favor the passage of the spermatozoids. The uterine cavity is lined by a mucosa, of one to two millimetres in thickness, continuous above with that of the tube and below with that of the cervix. In the cervical cavity the epithelium is calci- form, and is continued into the interior of the numerous racemose glands of this region. At the summit of the projections of the arbor vitae the epithelium becomes cylindrical and possesses cilia. In the isthmus and in the cavity of the body of the uterus, there is found cylindrical epithelium w r ith cilia, that is prolonged into the interior of the tubular glands (with the exclusion of the cilia), the only variety contained in this region. The tube or oviduct is the canal that establishes communication between the surface of the ovary and the uterine cavity. When the abdominal cavity is opened, and the intestines are removed, there will be seen on each side of the uterus two transverse folds. These are the broad ligaments, the free or the superior border of which is divided into three wings. The anterior contains the round ligament, the median contains the tube, and the posterior is reserved for the ovary and its ligaments, to the number of two, one attaching it to the uterus (ligament of the ovary), the other to the tube (ligament of the tube). The tube presents an average length of twelve centimetres. De- parting from the supero-lateral angle of the uterus it takes a slightly tortuous course toward the lateral wall of the pelvis, terminating a short distance from this wall by expanding into a fringed and mobile pavilion. In the vicinity of the uterus the diameter of the tube is about one millimetre, and this increases more and more toward the pavilion. Its structure comprises a superficial, incom- plete, serous envelope ; a non-striated muscular tunic, composed of a superficial longitudinal layer and a deep circular; finally, the mucosa, which presents numerous longitudinal folds (Fig. 6). The epithelium which lines its cavity has cilia, as in the uterus, and at the free border of the tube it becomes directly continuous with the flattened epithelium of the peritonaeum. This description is sufficient to give us a succinct idea of the canal, which extends from the ovary to the external orifice of the uterus, and which the two elements, male and female, follow in their approach toward each other. But a preliminary question occurs here, that of knowing at what place the meeting of the spermatozoid and ovule usually takesplace. If it is possible to determine this point, we know in advance the path taken by each of these elements. It has been shown from the experiments of Bisehoff and of Nuck, on bitches, that the meeting - place in the external third of the tube. Coste admits the same Menstruation and Fecundation. l~> for the human female; he also believes thai if the meeting takes place aearer the uterus fecundation i- nol possible, for is pene- trating thus far the ovule becomes bo coated with albumen as to become impermeable. Lei us take the ovule at the Burface of the ovary and the Bperma- tozoid at the entrance of the uterus, and follow these elements to tht' point of meeting, in the external third of the tube, studying their mode of progression. We havefour theories : One, of the progression of the spermatozoid by capillary action (Coste, hoiegeois) ; on< , as to the action of the vibratile cilia (Muller) ; another, as to the movement of aspiration made hy the uterus at the end of coition (Biolan, Morgan), and a fourth, a supposition that the sperrnatozoids are capable of inde- pendent migration by virtue of the rapid progression revealed under the microscope. Thus we are in the presence of four theories that render quite plain the progress of the spermatozoid. It has been objected that ciliated cells do not exist in the whole extent of the genital organs ; that aspiration cannot be exerted in a cancerous uterus ; that in certain animals fecundation is possible although the sperrnatozoids are not mobile. These are simple objections of detail which show us that one of these causes may be deficient or absent without impeding fecundation. It appears rational to admit that capillary action, the vibratile cilia, uterine aspiration and the movements of the sperrnatozoids are conjoined in aiding the progress of the male element in the interior of the female genital organs. All these theories are true in part, but no one of them should be admitted to the exclusion of the rest. "With regard to the ovule, the problem to be solved is the manner in which it passes from the surface of the ovary to the external third of the tube. The distance is short and yet the difficulty is great, for the route is not continuous. The surface of the ovary, like the pavilion of the tube, floats in the great peritoneal cavity. The ovule then passes from one to the other, much as a projectile is thrown from one point to another in the atmosphere. Attempts have been made to explain this migration in five different way- : 1. Heller and Rouget believe that, at the moment of dehiscence of an ovisac, the pavilion of the tube, free in the usual state, applies itself on the ovary and exactly encloses it. The ovule is thus en- grossed and gathered into the tube at its issue from the ovisac. 2. Kehrer advances the theory of the projection of the ovule into the pavilion of the tube by an impulse given it from the bursting of the Graaffian follicle. I do not believe in this fantastic theory. 3. The ligament which unites the ovary to the pavilion is slightly hollowed out on its upper surface in the form of a trough ; Henle interprets this anatomical disposition by giving us the opinion that the ovule follows tins from the ovary to the tube. 4. But little 26 Menstruation and Fecundation. satisfied with the explanations given, and discouraged in his vain researches, Kiwisch has advanced the idea that the migration of the ovale is accidental. The peritonaeum thus becomes the tomb of useless ovules. 5. I arrive at the theory of the menstrual lake, that I have reserved for the end, as it appears the most adapted to explain the migration of the ovule. Fig. 6.— Uterus. Tube. Ovary. Fig. 7. — Posterior round ligament. I, ligament of the ovary; 2, ligament of the tube; 3, posterior round ligament, with the three branches external, median, internal. According to Becker, at the moment of dehicence there occurs around the ovary an accumulation- of serum and liquid blood which constitutes a veritable lake. When the ovule leaves the ovisac it floats on this fluid, which, being diverted by the tube into the uterus draws the ovaule with it into the genital canal. But an objection arises at once. If this current draws the ovule from the ovary toward the vulva, how can the spermatozoid, placed under the same influence, pursue a contrary direction? 1 shall remark that the spermatozoid is generally deposited in the feminine genital organs before or after the flow, and that it gains the external third of the tube without undergoing the influence of this current. I know that Development and Description of the Hit/man Ovum. ■>- some conceptions only take place od condition of a coitus during the menstrual period. J jut id options may be explained by admitting that the spermatic fluid, from it- special consistence, remains adherent to the uterine mucosa, or even to the vaginal, and that it accomplishes fecundation after cessation of the menstrual flow. We might also suppose that by the action of the vibratile cilia and the movements of the spermatozoids, the mule element is capable of overcoming the sero-sanguineous current to arrive at the ovule. The ovule and the spermatozoid having met in the external third of the tube, fecundation occurs, the woman has conceived and pregnancy commences. "We are now to study all the transforma- tions of this fecundated ovule, which becomes the embryo, and then the foetus, and all the modifications affecting the material organism under this influence. CHAPTER II. DEVELOPMENT AND DESCRIPTION OF THE HUMAN OVUM. The fecundated ovule in the external third of the tube continues in its course toward the cavity of the body of the uterus, where it arrives in a few days, and where it becomes fixed and develops during the nine months of pregnancy. During this passage the ovule begins its transformation and continues in development after its arrival in the uterus. The modifications to be disclosed begin, then, in the tube, and are achieved after fixation in the uterine cavity. In studying fecundation, we left the ovule surrounded by spermatozoids. "We will then take up the description at the same point. The first transformations to which fecundation gives rise are : 1. The formation of the male nucleus. 2. The fusion of the two nuclei, male and female. 3. Segmentation. 4. The formation of somatopleures and of splanchnopleures. 1. Formation <>f the male nucleus. — Spermatozoids in variable number surround the ovule ami attempt to penetrate the vitelline * I omit some modifications of the ovule previous to fecundation (formation of the amphiaster, emission of polar globules), which are of secondary importance. 28 Development and Description of the Human Oram. membrane in the endeavor to traverse the vitellus to the germi- native spot, which is only the nucleus of the ovule, represented in Fig. 8 by the central black spot. One of these spermatozoids, either because it is endowed with a particular vigor, or because it finds a thin and relatively weak point in the vitelline envelope, buries itself in the surface of the ovule. At its approach the vitellus form a projection to meet it, as if to invite it to enter, and draws it toward the centre. To this momentary projection of the vitellus has been given the name "cone of attraction." The spermatozoid, as indicated in Fig. 9, which represents the successive steps of the penetration, continues to approach the center. Soon the head becomes detached from the intermediary segment and from the tail, the role of which is terminated and which quickly disappear. In the interior of the ovule there are now found two nuclei (Fig. 10) ; one, the larger, is the germinative vesicle — the female nu- cleus of the ovule ; the other, placed between the preceding and the vitelline membrane, is the male nucleus, the former head of the spermatozoid. •2. Fusion of the two nuclei. — The male nucleus becomes sur- rounded by a series of small rays which cover all its surface like bristles (Fig. 11). Continuing its concentric progress, this nucleus arrives in contact with the female nucleus (Fig. 12), with which it becomes fused little by little, furnishing a series of appearances which recall, somewhat, two stars passing over the other as in eclipse. In Figure 13 the eclipse is total, the fusion of the two nuclei complete. The ovule presents the same details as before i midation, the vitelline membrane, the vitellus, the germinative vesicle or nucleus, in winch exists the germinative spot or nucle- olius. But the male nucleus, essentially active, has been added to the female nucleus, which passively awaited it, and has imparted to the ovule a new vitality, the effects of which are quickly per- ceived. 3. Segmentation. — The ovular nucleus is seen to divide and give birth within the vitelline membrane to two distinct cells (Fig. 14). The segmentation continues, in place of two cells, four appear (Fig. 15). Finally, by a series of analogous divisions (Fig. 16) a great number of cells accumulate in the interior of the ovule, contained within the vitelline membrane. We are now at about the eighth day consecutive to fecundation. 1. Formation of somatoplewreB and splanchnopleures. — In the center of this agglomeration of cells is formed a small collection of liquid which by its progressive augmentation pushes back the cells entrically nod packs them into the vicinity of the vitelline wall (Fig. 17'. All these cells, which as a whole constitute the blasto- derm, are divided into three distinct layers (Fig. 18). The ex- ternal, or ectoderm; the middle, or mesoderm, and internal, or Development and Description of the Human Oram. 29 Fig. 8. — Meeting of the spermatozoids and the ovule. Fig. 9. — Penetration of the spermatozoid. Fig. 10. — Ovule, with its two nuclei, FlG. II. — Radiations of the male nucleus, male and female. Fig. 12. — Approach of the two nuclei. Fig. 13. — Fusion of the two nuclei. 30 Development and Description of the Human Ovum. endoderin. The three layers, external, middle and internal, of the blastoderm are also called epiblast, mesoblast and hypoblast re- spectively. Fig. 14. — Segmentation. Fig. 15. — Segmentation. Fig. i 6. — Segmentation. Liquid collection pushing the cells excentrically. Fig. 17. — Peripheral accumulation of the cells. Development and Description of the Human ('mm. 31 This division does not take place posteriorly, where the cells remain packed together, and there they soon are separated by a canal, which becomes the medullary canal, and by a thickening, circular on section, called the dorsal cord or the notochord, which forms the bodies of the vertebra.', that is, the most resistant part of the vertebral column. The section of this dorsal chord and medul- lary canal can be seen in Fig. 19. The same illustration indicates a new transformation of the ovule- The mesoderm, or the middle layer of the blastoderm, is separated into two rows of cells, the external adhering to the ectoderm and the internal to the endoderm. By this separation the three layers now form only two : An external, called the somatopleure. An internal, called the splanchnopleure. The somatopleure forms the envelope and the framework of the body, the splanchnopleure, the viscera. To facilitate the comprehension of the preceding illustration, the two layers, formed by cells composing the splanchnopleure and the somatopleure, will be represented by a unique character as shown in Fig. 20, which is otherwise identical with Fig. 19. These two layers are blended behind in a common mass in which is perceived the dorsal cord and the medullary canal. The somatopleure and the splanchnopleure, which were disposed in a circular manner (Fig. 20), next undergo a strangulation in their middle portion as indicated in Fig. 21. This strangulation divides these two membranes into two distinct regions : One. embryonic (inferior, Fig. 21). The other, extra-embryonic (superior). The embryonic portion is united to the extra-embryonic by the intermediate or constricted region. Xow these three parts have, in the ulterior development of the ovum, different roles to fulfill. The extra-embryonic part will form the envelopes of the ovum and the placenta. The intermediate part will form the cord. The embryonic part will form the fcetus. Let us study successively the development of each of these parts and their constitution after complete formation. I. Extra-embryonic portion of the ovum. — Membranes. — Placenta— Amniotic liquor —The extra-embryonic part of the ovum is formed, as we have seen in Fig. 21, by the extra-embryonic somatopleure and splanchnopleure, separated by a virtual space called the external co?lum (the internal cceluni is an analogous space found at the embryonic part). The real cavitv formed bv the 32 Development and Description of the Human Ovum. extra-embryonic splanchnopleure is called the umbilical vesicle and contains the elements for the nutrition of the ovum until the for- mation of the placenta. This umbilical vesicle corresponds, as to its contents, to the yolk of the eggs of birds. While the wall of the umbilical vesicle, formed by the splanchnopleure, undergoes an atrophy and a progressive retreat, the suprajacent layer, on the contrary, which is only the extra-embryonic somatopleure, takes on a considerable and rapid development to constitute the secondary chorion and the amnion. The layer of the somatopleure, is seen to throw out a series of prolongations, indicated by the successive tracings 1, 2, 3, 4 (Fig. 22). These prolongations meet one another by surrounding the ovule; their reunion quickly occurs at a point opposite to their origin. When this reunion is achieved (Fig. 23), i. e., of the two layers created by this prolongation, one is directly applied to the internal surface of the vitelline membrane over all its extent ; the other, continuing with the intermediate somatopleure, lines a part of the external surface of the umbilical and of the internal surface of the preceding layer; while between them and the embryo exists an actual cavity in which is collected the amniotic fluid. Endoderm. Hypoblast. Internal layer. Mesoderm. Mesoblast. Middle layer. Ectoderm. Epiblast. External layer. Vitelline membrane. FlG. i8. — Formation of the three blastodermic layers. The primary chorion is formed by the vitelline membrane, the surface of which is covered at a certain time with villi. The secondary chorion is created by the addition of the layer of the extra- embryonal somatopleure to the vitelline membrane. These two membranes undergo a true fusion to form the secondary chorion. The membrane which, in Fig. 23, is found under the secondary chorion, is the amnion. In the space which separates them is developed the definitive chorion, as we shall see. Development and Description of the Human Ovum. 33 FlG. 19. — Formation of somatopleure and splanchnopleure. I, splanchnopleure; 2, somatopleure; 3, dorsal cord; 4, medullar} - canal. Fig. 20. — Simplification of Fig. 19. 1, chorial villi; 2, vitelline membrane: 3, somatopleure; 4, splanchnopleure. From the embryo, between the somatopleure and the splanchno- pleure, in the pelvic region, is developed a hollow bud, which pro- gressively enlarges separating the two limiting membranes, this is 34 A velopment and Description of the Human Ovum. the allantois. Its embryonic part becomes the bladder and the urachus and its extra-embryonic part forms the third chorion (or definitive) and the placenta. Fig. 24 shows the first steps of the development of the allantois. Fig. 25 defines a more advanced stage. The allantois progressively invades the space which separates the secondary chorion from the amnion. It may be compared to an umbrella, the handle forming the cord and the spread portion extending more and more to envelope the embryo as in 1, 2, 3, 4 (Fig. 25). We are now at about thet wenty-fifth day consecutive to the fecundation. ^Chorial villi. Vitelline membrane. Somatopleure. Splanchnopleure. Extra-embryonic part External coelom. Intermediate part of the ovum. Embryonic part of the ovum Som-topleure. Splanchnopleure. — Internal coelom. Fig 21. — Strangulation of the ovum. At the end of the first month the allantois is at the height of its development. It has carried with it, over all the internal surface of the secondary chorion, vascular ramifications, which are prolonged into the villi. The umbilical vesicle, after the absorption of its contents for the development of the ovule, progressively atrophies. I luring all the second month the enveloping membranes change but little, they undergo a development as a whole, all their surface is covered by vascular villi, so that the shaggy ends of these structures can be easily seen by floating the ovum in water. During the third month, the villi which cover the surface of the ovum atrophy except at the point where the ovum adheres to the uterus and there they take on a remarkable development. This hypertrophied region, where all the life of the allantois seems local- ized, becomes the placenta ; over all the rest of its extent the allantois atrophies, as indicated in Fig. 26. Development and lh- script ion of the Human Ovum. 35 Outside the placenta] zone the aUantois is entirely united to the secondary chorion, as indicated in a limited region of Pig. 26; thus is formed the tertiary or definitive chorion. Thus it is Si en that the primary chorion is formed by the vitelline membrane, the secondary by the extra-embryonic somatopleure ; the tertiary by the aUantois. Fig. 22. — Prolongations of the extra- embryonic somatopleure. The umbilical vesicle continues to atrophy. This atrophy is complete at the end of the third month, and at this moment nutrition by the placenta is definitely substituted. Consequently at this time the embryo becomes the foetus ; that is, at the end of the third month, or at the commencement of the fourth, the reign of the aUantois, i. e., the placenta, replaces that of the umbilical vesicle. Tins vesicle atrophies so completely that it is difficult to find traces of it in the ovum at term. The ovum during the evolution that we have now to follow, is en- closed and protected by the uterine mucosa, which takes a special evolution transforming it into a new membrane called the decidua, thus designated because it is destined to being cast off at the same time with the ovum. The preceding description has given us a summary of the for- mation of the placenta, of the chorion, of the amnion, of the decidua 36 Development and Description of the Human Ovum. and of the amniotic fluid ; we have now to study the details, which will initiate us more intimately into the constitution of these dif- ferent parts, by taking as a type the ovum nearly arrived at term. But before beginning this detailed description, it is indispensable to embrace at a glance the general configuration of the ovum enclosed by the uterus. The schematic section represented by Fig. 27 permits us to easily grasp this as a whole. Fig. 23. — Formation of the amnion and secondary chorin. I, vitelline membrane or primitive chorion : 2, umbilical vesicle; 3, secondary chorion; 4, amnion; 5, amni- otic cavity containing the amniotic liquid. Here there is seen, in passing from the uterus to the foetus : 1. The uterine wall, thin in the inferior segment at the cervix. 2. The uterine mucosa (partially transformed into the clecidua), considerably thickened at the placenta and divided in the rest of it extent into two layers, one applied directly on the ovum (ovuline decidua), the other to the inner surface of the uterus (uterine de- ci lua) ; the latter is continuous interiorly with the cervical mucosa. "We shall study later the formation of these membranes. 3. The chorion, considerably hypertrophied in one region to con- stitute the placenta, and atrophied, on the contrary, in the rest of its extent, where it is enclosed between the ovuline decidua and the amnion. Development and Ih-script'um of the Human Ovum. 37 4. The amnion, which is the most internal membrane. 5. The amniotic fluid, which fills the cavity of the amnion, and in which tioats the fcetus connected to the placenta hy the cord. Fig. 24. — Formation of the allantoic bud. 1, progression of the allantoic bud; 2, allantoic bud. We shall study these different parts in the following order: I. Placenta. II. Chorion. III. Amnion. IV. Decidual membranes. V. Liquor amnii. I. Placenta. — The placenta, forming the union between the maternal and fcetal circulations, is a fleshy and vascular disc, termi- nating by one of its surfaces in the cord, the other adhering to the internal wall of the uterus. Its weight is about five hundred grammes, nearly that of the liquor amnii, so that the foetal append- ages represent approximately a kilogramme. Dimensions: twenty centimetres in diameter or a little less ; three centimetres in thick- ness toward the center, pressively thin toward the edge. To under- stand this organ completely it is necessary to study: 1. Its foetal surface; 2. Its uterine surface; 3. Its circumference: 4. It- structure; 5. Its physiology. 1. The foetal surface, in contact with the liquor amnii, is smooth 38 Development and Description of the Human Ovum. in all its extent, for it is covered by the amnion, winch can easily be detached. It is grooved by the vessels formed by the expansion of funicular arteries and veins. FlG. 25. — Development of the allantois. 1, secondary chorion (the two membranes being united in one). The insertion of the cord may occur in four different regions (Fig. 29) : 1. At the center of the placenta (central insertion). 2. Between the center and the periphery (lateral insertion). 3. At the margin of the placenta (marginal insertion). 4. On the membranes (velamentous insertion). Their relative frequency is as follows : Central and lateral insertion (equally frequent) 95 per 100. Marginal insertion 4 per 100. Velamentous insertion 1 per 100. In cases of velamentous insertion, which may occur up to twenty centimetres from the placental margin, the vessels may ramify in the membranes (Benekiser), or, on the contrary, they may pursue isolated courses up to the placenta before dividing (Lobstein). 2. The uterine swrface is unequally projecting and flocculent, and divided into lobes or cotyledons by a number of more or less marked Development and Description of the Human Ovum. 39 grooves. These Lobes, to the number of ten, fourteen, or more, are divided into Lobules, which are composed by a grouping of villi. It is by this surface that the placenta is adherenl to the uterus. To state this insertion exactly, it is important to divide the internal Burface of the uterus by two parallel plans AB, CD (Fig. 81) pass- ing one at eight centimetres below the fundus of the uterus, the other at eight centimetres from the internal orifice. According to a series of measurements that I have math-, it results that the distance which separates the two planes AB ami CD, hy following the uterine wall, is about sixteen centimetres. Fig. 26. — Formation of the placenta and tertiary or definite chorion. I, remains of the umbilical vesicle; 2, tertiary or definite chorion; 3, placental villi; 4, placenta; 5, allantois. Every placenta which by any part of its surface is inserted below the plane CD, that is to say which encroaches on the uterine circle blended with plane CD, is an inferior polar placenta, or a placenta prcevia. Likewise, every placenta which by any portion of its extent is in- serted above the plane AB is a superior polar placenta. Every placenta inserted between these two planes may be called 40 Development and Description of the Human Ovum. equatorial, for its center coincides with the equator of the uterus, but this variety is rare, the diameter of the placenta being usually greater than sixteen centimetres and thus encroaching on one of the polar circles. From the statistics of forty-eight cases I ha^e found : Inferior polar placenta in one-third of the cases. Superior polar placenta in two-thirds of the cases. Equatorial placenta, exceptionally. The inferior polar placenta, or placenta prsevia, gives rise to a series of accidents which will be studied later. Frr,. 27. — Ovum definitely formed. 1, remains of the umbilical vesicle; 2, maternal placenta; 3, fcetal placenta; 4, cord; 5, amnion; 6, chorion; 7, ovuline decidua; 8, decidua and uterine mucosa; 9, uterine wall. 3. The circumference of the placenta is constituted by the union of the membranes with this organ. This placental margin, regular in a rounded or oval placenta, becomes more or less tortuous when Development and De$<-ri]>tion of the Human Chum. 41 FlG. 28. — Foetal surface of the placenta, with amnion partly uplifted. Fig. 29. Fig. 30. — Uterine surface of the placenta. 42 Development and Description of the Human Ovum. the form departs from the normal type. Thus we are led to say a few words on the different forms of placenta in simple pregnancy : A. Sometimes the placenta is unilobed, the most frequent form. B. Sometimes it is multilobed, but not having the lobes entirely separated. C. Sometimes it is multilobed, with the lobes so distinct that there appear to be several placentas. Fig. 31. As examples of these varieties we have under A. Unilobed placenta. Fig. 32. 1. Circular form (Fig. 32). Development and Description of tlis Human Ovum. 43 2. Oval form (Fig. 33). Fig. 33. Fig. 34. 3. Irregular form (Fig. 34). 44 Development and Description of the Human Ovum. B. United multilobed placenta. Fig. 35. 1. Two equal lobes (Fig. 35). Fig. 36. 2. Two unequal lobes (Fig. 36). Development and Description oj the Human Ovum. i.~> Fig 37. 3. There exist more than two lobes (Fig. 37). C. Placenta with separate lobes. Fig 38. (a). Two equal lobes (Fig. 38). 46 Development and Description of the Human Ovum. Fig. 39. (b). Two unequal lobes (Fig. 39). Fig. 40. (c). More than two lobes (Fig. 40). 4. Structure. — Let us take a perpendicular section of the uterine Avail, the placenta, and the cord, as represented in the schematic illustration of Fig. 41. We then find, from the superficies toward the center : 1. Beneath the peritoneum (which is not given in the illustration) the muscular wall. 2. Beneath the uterine mucosa, transformed into the maternal placenta containing a series of lacunar spaces, the remains of the glandular culs-de-sac more or less modified and terminating super- ficially in a series of villi. 3. The foetal placenta, shaggy on the uterine side, by virtue of its rich mass of villi interlacing with those of the maternal placenta; smooth on the foetal side, where it is in contact with the amnion. Development and Description of th Human Ovu in. 47 4. Finallj, ibe umbilical cord. Through all these tissue, i> found a vascular network, tin- details of which I shall give alter having explained at greater length these different part-. \rcular venous sinus (maternal placenta). Vein of maternal placenta. bmus. Funicular artery. Funicular vein. An isolated villus. Sinus. Villus of foetal placenta. Villus of maternal placenta. Maternal placenta. Glandular opening. Amnion. — Chorion. Ovuline decidua. Uterine decidua. Fig. 41. — Schema representing the structure of the placenta. A. Maternal placenta. — The uterine mucosa, transformed in the placental region, is divided into two parts, separated by the more or less regular line of the glandular lacuna?. It is at this place that separation occurs at delivery, the eccentric part remaining adherent to the uterus to constitute the new mucosa, the other portion, the decidual, follows the placenta. When we examine the uterine 48 Development and Description of the Human Ovum. surface of a recently-expelled placenta, it is the portion corre- sponding to this series of lacuna? that meets our eyes. The part near the fcetal placenta terminates in series of villi, somewhat projecting and ramifying. In a vascular point of view, these villi are of two kinds, as will be seen in Fig. 41. In one variety the artery is continuous with the vein after having formedd a more or less rich vascular network. In another the artery opens directly by one or two orifices into spaces called sinuses. From these villi arise other veins. In this way the blood returns into the venous system and enters the uterine sinuses directly or by the interme- diate circular sinus which exist around the placenta. B. Foetal placenta. — The framework of the fcetal placenta is formed, like that of the maternal, of connective tissue, with fusi- form and star-shaped cells. It is adherent by its fcetal surface to the chorion, of which it is only the expansion, and is united to the maternal placenta by a series of rich and luxurious villi. The villi are of two kinds : one absolutely free, floating without adhesions in the sinuses, the other terminating by the extremity in the maternal placenta. These villi are furnished with vessels in the form of a capillary network with an apparent artery and an afferent vein. From the preceding description it is seen that the union of the two placentas, fcetal and maternal, occurs through the intermediate villi. Some of the maternal and fcetal villi are in contact, and some are separated by the blood of the sinus which surrounds them like an atmosphere. The blood of these sinuses is exclusively maternal. There is no direct communication between the blood of the mother and that of the foetus, but a simple mediate contact, through the flattened epithelium which forms a continuous layer at the surface of the villi, and through the walls of the vessels. The physiological changes which we have now to study occur through the medium of this barrier. 5. PJiysiology. — In the placenta, the foetal and the maternal blood being in mediate contact, the foetal blood is relieved of its carbonic acid and absorbs oxygen, just as this occurs in the lungs of an adult. Thus a veritable respiration takes place at this point. Besides this, the nutritive elements contained in the maternal blood are absorbed by the foetal blood, so that the placenta plays a double role, respiratory and nutritive, taking the place, for the foetus, of the lungs and of the digestive tract. Aside from the i mri nal constituents carried by the maternal blood, there may be abnormal elements, such as the different medicaments and divers microbes. The iodide and chlorate of potash and salycilic acid ingested by the mother during labor are found after birth in the foetal organism. The same is true of potassium nitrate, of yellow prussiate of potash, of bromide of potassium and sulphate of quinine, but their passage is slower. Chloroform also passes from the Development and Description of tht Human Ovum. A'.' mother to the foetus, but without danger to the child. Solid elements may pass through the placenta. The transmissi microbes has been recently established. The majority of the pathogenetic microbes traverse the pla ;enta but with unequal facility. However, the placenta ie not a simple filter, it also possesses the power of producing sugar ; the glucogenic function identical with that pertaining to the adult liver. The placenta not only serves the foetus as a digestive tube and lung, but also t the part of the hepatic gland. II. The Chorion. — This simple name is given to the tertiary or definitive chorion. Situated between the decidua, which covers its external surface, ami the amnion, which lines its internal surface, it is more adherent to the first than to the second. The adhesion with the decidua is immediate, that with the amnion is mediate and occurs through an intermediate glutinous substance, the reticulated magma. This disposition explains why the amnion is so easily detached from the chorion during labor, while detach- ment of the chorion from the decidua is rarely observed : and why the liquor amnii, transuding through the amnion, so easily accumu- lates ] etween this membrane and the chorion. The chorion is composed of a stroma of connective tissue. It- external surface is covered, by a layer of pavement cells, with which it is in contact with the decidua. Rich in vessels at the second month of gestation, it is completely deprived of them after the complete and definitive formation of the placenta ; however, ex- ceptionally these vessels may persist. III. Amnion. — The amnion is the most internal membrane of the ovum. After having covered all the internal surface of the ovum it is continued on the placenta and then to the cord, which it surrounds like a sheath, terminating at the umbilicus, where the cutaneous covering of the fcetus begins. The amnion i- composed of two layers : an external, containing connective tissue with some non-striated muscular fibres, and an internal, or epithelial, directly in contact with the liquor amnii. Vessels are wanting, except in the vicinity of the placenta, where during the first months of pi g nancy are met the vasa propria which secrete the amniotic liquor, and the abnormal persistence of which would be one of the causes of hydramnios. IV. Decidual Membranes. — The decidual membranes being formed at the expense of the uterine mucosa, are then of maternal origin. I shall describe them here, however, becau>e their union with the ovum is so intimate, and because, as their name indicates, they are cast off with it. The decidual membranes are three in number. 50 Development and Description of the Human Ovum. the uteroplacental, the uterine, and the ovuline. How are these decidual membranes formed ? On the arrival of the ovum in the uterine cavity it lodges in the mucous folds as indicated in Fig. 42. The two projections of the mucosa, which limit the fold in which the ovule reposes, take on a rapid development and surround the ovule more and more (Fig. 43). Soon they enclose it com- pletely, as in Fig. 41. At this moment there exist three distinct parts : The first is formed by the union between the ovum and the uterine wall; this is the utero-placental decidua, formerly called the serotrine decidua. The second lines the uterine wall and only undergoes slight modifications ; this is the uterine or true decidua. The third directly covers ths ovum, by means of the development already described ; this is the ovuline decidua or decidua rejiexa. Fig. 42. Fig. 43. Fig. 44. Enclosure of the ovum by the uterine mucosa. Fig. 45. — Disposition of the deciduas in relation to the ovum and uterine wall. I, fjlacenta; 2, uterine wall ; 3, uterine decidua; 4, ovuline decidua; 5, ovum. These three decidual membranes being known, let us follow their evolution. During the first three months of pregnancy, the ovuline Development and Description of the Human Oram. 51 and the uterine deciduas are separated by a Bpace, which permits the passage of the spermatozoids to the tube and a second fecun- dation after the first. These tacts will be Btudied later under super-fecundation. With the second three months the conditions change, the ovuline and the uterine deciduas are in contact and quickly contract intimate adhesions in such a manner (Fig. 45) that the uterine wall is fused with the ovum ; thus, at this moment, super-fecundation becomes impossible unless a double uterus exists. It is likewise understood why abortion during the second three month- is so often accompanied by the retention of membranes and especially of the decidua. Uterine muscle. — Glandular culs-de-sac. Spindle-shaped cells. Round cells. Chorion. Amnion. Robin. , Sinety. Friedlander. Fig. 46. — Section of the internal wall and of the membranes. During the last three months, separation from the ovum and from the uterine wall is progressive. As for the placenta separation occurs at the moment of delivery at the level of the glandular culs- de-sac. As to the membranes, opinions differ. To comprehend the place where separation occurs, let us follow (Fig. 46) the different layers met in going from the uterus to the liquor amnii. Beneath the peritonseum, not represented in the illustration, is found the uterine muscle, then the mucosa and the united deciduas in three layers : the first lamina strewn with glandular culs-de-sac, the second composed of elongated cells, the third of round cells. 52 Development and Description of the Human Ovum. Concentrically are the chorion and the amnion. Now, the sepa- ration occurs : According to Robin, at the union of the muscle with the mucosa, which thus is cast off as a whole, leaving the uterine wall naked. According to Sinety, at the level of the glandular culs-de-sac. the same as the placenta. According to Friedlander, in the middle of the layer of elongated cells. Fig. 47. — Evolution of the ovuline and uterine deciduas. 1, glandular culs de- sac; 2, placenta; 3, uterine wall; 4, ovum; 5, uterine decidua; 6, membrane of new formation covering the non-decidous mucosa; 7, non decidous uterine mucosa; 8, ovuline decidua; 9, cervix; 10, mucosa of the cervix. With regard to the decidua, the opinion of Sinety appears the most admissible. For the membranes as for the placenta separation occurs at the level of the glandular culs-de-sac, the superficial portion of the uterine decidua remaining adherent to the ovuline decidua (Fig. 47) and thus only this superficial portion is cast off with the foetus. At the moment of term, the detachment, which commences in the vicinity of the internal orifice, and gains the fundus by degrees, is usually complete or at least very extended. Development and Description of the Human Ovum. V. Liquor Amnii. — The amniotic fluid appears a little afterthe formation of the amnion. At four months and a half it- weight is equal to that of the I'm tn~. A.t term it amounts, on the to half a litre. However, there are very extensive variations. But when the quantity exceeds a litre there results the pathological state known as hydramnios, a question belonging to puerperal pathology. Clear and transparent in the 1 eginning of pregna Blightly yellow at the end, in the pathological state it may become greenish or red. This liquid, in which is found some • proceeding from the epidermis of the foetus, from the renal and from the amniotic epithelium, contains chiefly chloride of sodium, lactate of Bodium and albumin. The origin of the liquor amnii is not yet definitely settled. Some suppose that it proceeds from the mother, by filtration through the membranes into the amniotic cavity. Others believe it to proceed from the ovum, arising from the annexes, from the vasa propriaof Junghluth, from the cord, or from the foetus itself by lenal and cutaneous secretions. Physiology. — The uses of the amniotic liquid are multiple. By its presence it creates a veritable liquid atmosphere for the foetus. If the uterine wall was applied on the foetus, funicular circulation would certainly be impossible. During labor, the liquor amnii accumulating in the bag of waters, favors the opening of the genital canal. II. Intermediate portion of the ovurn.— The cord. — The umbilical cord is the flexible stem which joins the placenta to the foetus. We have already seen its formation. Fig. 48. — Straight cord. Fig. 49. — Twisted cord. External conformation. — Smooth and whitish at its superfV the cord sometimes represents a plain stem (Fk r . 48), sometii. on the contrary, a stem twisted on itself, and this tortion may be directed from right to left (Fig. 49), or from left to right. Some- times on the same cord a torsion in an inverse direction is noted at the two extremities. The relative frequency of the different varieties of funicular torsion (the spiral will be described by follow- ing the cord from below upward 1 may be indicated by the following figures : 54 Development and Description of the Human Ovum. Sinistro-torsion, 72 per 100. Dextro-torsion, 25 per 100. Double torsion, 1 per 100. No torsion, 2 per 100. The torsion of the cord is due to the disposition of the vessels, which will be studied later. Fig. 50. — Circular nodosity. Fig. 51. — Sessile and pedunculated nodosities. I, pedunculated nodosity; 2, sessile nodosity. The usual length is fifty centimetres at term. Variations : maxi- mum, one metre, seventy-eight centimetres (Neugebauer) ; mini- mum, total absence, where the umbilicus is adherent to the placenta. The size is nearly that of the little finger. Variations : maximum, seven centimetres and one-half in circumference (Bell) ; minimum, the size of a goose quill (Scanzoni). Much more marked restrictions may exist and compromise the circulation. On the cord are often found nodules, that may be circular (Fig. 50), sessile or peduncu- lated (Fig. 51). The contents of these nodules may be gelatinous (Wharton's jelly), arterial (vascular loop), or vercaS (venous loop or venous dilatation). With these nodules, or simple swellings of the cord, there must not be confused the true knots, which will be studied under pathology. The insertion of the cord takes place for one part at the umbilicus and for the other part at the internal surface of the placenta. The latter insertion has been fully described. Interior con formation. — When the cord is cut transversely, it is found composed (Fig. 52) of a continuous amniotic envelope, filled Development and Description of the Human Owm. .,., and distended by Wharton's jelly. En this substance are contained three vessels, a large vein and two small arteries. The relative disposition of these vessels is variable. The arteries and the \< in may pursue a parallel course without a trace of twi-tiii'_ r (Fig. 58). The vein may be twisted around the arteries (Fig. 54) in a spiral form. The two arteries may twist around the vein (Fig. 55). Finally, the twisting of the three vessels may be simultaneous ami reciprocal (Fig. 56). Furicubr artery. Funicular vein. Wharton's jelly. Amnion. Fig. 52. — Transverse section of the cord. As anomalies, I may note the absence of one artery, or the presence of a third. Exceptionally, there may be two or three veins. Fir,. 53. Fig. 54 Fig. 5: Fig. 56. In the interior of the vesseis are found incomplete semilunar valves, which sometimes become circular, like a diaphragm. The physiological role of these valves is not well known, and beside, must be of slight importance, since the obstruction they produce is incomplete. They may play a certain part in the production of the 56 Development and Description of the Human Orum. funicular souffle. The existence of fine vessels in the cord, the rasa propria (Paige), has been note:l; the existence of lymphatics and nerves has not been proven. Physiology. — The cord serves to unite the mother and the foetus, through the intermediate placenta. The blood carried to the pla- centa by the umbilical arteries is returned to the fcetus by the umbilical vein, after having undergone respiratory and nutritive modifications in the placenta. Contrary to the usual purposes of these vessels, it will be observed that here the arteries carry the dark blood and the vein the red blood. III. Embryonic portion of the ovum. — The foetus at term. — There is no positive sign that will permit us to affirm that the fcetus is at term ; thus we are obliged, for this determination, to use a series of points which, as a whole, afford some certainty. The points are : 1. The information furnished by the mother, on the subject of the probable duration of the pregnancy, at the moment of delivery (last menstruation, a single coitus, first movements of the fcetus . 2. The weight of the child, which is, on the average, three kilo- grammes, attaining quite often three thousand five hundred grammes, but the variations from greater to less may be considerable — max- imum nine thousand grammes (Eiembault) ; minimum, one thousand three hundred grammes (Blot) . It must al so be understood that this inferior limit is somewhat arbitrary, in the default of exact knowledge of the date of conception. 3. The length of the foetus, measured from head to foot, is generally fifty centimetres — equal to that of the umbilical cord. Variations of five centimetres, more or less, are not rare. 4. The development of the nails and hair is too variable to be taken into serious consideration. In general, in the fcetus at term, the nails exceed the extremity of the finger. The hair presents a length of two to three centimetres, or even more, and the fine down which covers all the hairy regions appears more developed before term than at term. 5. In the male infant the testicles have descended into the scrotum, but this descent sometimes occurs before term, and does not always exist at term. G. The ossification of the skull, the only bones that can easily be explored in the living child, is too variable in its degree to afford clear information. In the dead fcetus there may be recognized in a section of the inferior part of the femur a point of ossification that Beclard considers a positive sign of the maturity of the fcetus. The researches of Hecker and of Hartman have shown, however, that it sometimes exists before term, and that it may be wanting Development and Description oj the Human Ovum. 57 ;it term. No one of these signs is positive, then, but their recog- nition permits an approximate valuation, generally sufficient to d( termine it' the child is at lull term. Form and topography. — The general form of the foetus, rolled up in the cavity of the uterus, is ovoid i Fig. 58), th< large extremity corresponding to the breech and the small to the head. This is the .atic ovoid. Fig. 57. — Beclard's point cf ossification. Fig. 5S. — Somatic ovoid. The somatic ovoid may he divided into two secondary ovoids : Cephalic (head), cormic (trunk). These are united by the neck. The topography of the cormic ovoid needs no special consider- ation ; the foetal trunk is identical, with smaller dimensions, with that of the adult; it is an adult in miniature. This is not true with regard to the cephalic ovoid. In exploring the head of the new-born, the union of the bones which compose it is found. These are real solutions of continuity (sutures and fonta- nelles) that are of considerable importance in obstetrics, for a knowledge of them permits diagnostication of the situation and the relations of the cephalic extremity which presents during delivery. The sutures are the lines of union of two contiguous bones and the fontanelles are the confluents formed by the meeting of two or more sutures. The fontanelles are two, principal or median; and two, secondary or lateral. The two median fontanelles are : 1. The lambda, or the posterior fontanelle (small fontanelle), at the union of the occipital and the two parietal bones, a virtual fonta- nelle, for the 1 Mines do not leave a free space at this point. •2. The bregma, or anterior fontanelle (great fontanelle), at the union of the parietal and the frontal bones, a real fontanelle, con- stituted by a large fibrous space, having the form of a lozenge, the 58 Development and Description of the Human Ovum. frontal borders being more prolonged than the parietal. This fonta- nelle generally closes two or three months after birth. The two secondary, or lateral, are : 1. Asterion, at the union of the occipital, the parietal 'and the temporal bones, a virtual fontanelle. 2. The pterion, at the union of the frontal, the parietal and the temporal bones and the great wing of the spenoid, likewise a virtual fontaneDe and only of slight importance. Fig. 59. — View of the upper part of the head. Finally, there exist, as anomalies and consequently as accessory, two other median fontanelles : 1. The obelion, a lozenge-shaped space, at one or two centimetres in advance of the lambda on the biparietal suture. 2. The glabella, a fibrous median space, of oval form, sometimes found on the bifrontal suture at about two centimetres from the root of the nose. Fig. 60. — Lateral view of the head. The sutures are named from the bones which enter into their for- mation. These we find : 1. The biparietal suture, which, beginning at the occiput, is Development and Description of tin Human Ovum. 59 continuous, after traversing the I regma, with the bifrontal Buture. These two Buturee together are designated as the sagittal Buture. 2. The occipito-parietal Buture, also called the lamdoid, on account of its analogy with the Greek letter of the same name. 3. Tlu' Eronto-parietal sutuiv, which cuts the Bagittal perpendicn? larly and terminates laterally in the pterion. 4. The temporo-parietal suture unites the squamous portion of the temporal to the parietal. UT >* C C. I P Fig. 6i. — Cephalic planisphere. The other sutures present only a secondary importance and do not merit especial mention. In the track of these sutures, in par- ticular the biparietal suture toward its posterior portion, there exi~t some separate hones, more or less disfiguring the topography and interfering with the diagnosis. 60 Development and Description of the Human ^uro. Diameters. — If the two foetal ovoids were regular, it would be suf- ficient to take the length and the width to recognize the exact dimensions, but their irregularities necessitate the determination of a certain number of diameters, with which the physician should be familiar if he wishes to comprehend the mechanism and the diffi- culties of delivery. Let us study successively the two ovoids, the cephalic and the corinie. A. The cephalic ovoid.— The foetal head is composed of two parts that are essentially different : One forms an irregular plane, a solid osseous mass, extending from the occiput to the face, this is the base of the cranium. The other constitutes a case enclosing the brain and surmounting the base, with which it is continuous by its base, this is the vault of the cranium. The vault is of predominant importance in normal delivery and in dystocia, when perforation and crushing are not necessary but when the cerebral substance must be evacuated to reduce the head ; the base, on the contrary, opposes the obstacle to delivery. Thus is seen the different roles of these two portions of the head and the necessity of measuring their principal diameters. The vault of the cranium, that is, the intact head, has three principal diameters : 1. The mento-maximum, extending from the point of the chin to the most distant point of the sagittal suture, at some millimetres in front of the lambda. 2. The biparietal, joining the two parietal protuberances. 3. The bitemporal, extending from one pterion to the other. The base of the cranium has also three principal diameters : 1. The inio-nasal, which extends from the inion to the root of the nose. 2. The bimalar, uniting the two malar tuberosities. 3. The biosteric, extending from the asterion to that of the oppo- site side. Aside from these diameters, which are to a certain extent static, there are others, of an importance only comprehended after the study of the mechanism of delivery, which may be called dynamic. I will only simply mention them here, returning later to their study apropos of parturition. These are : 1. The suboccipito-bregmatic, extending from the union of the occiput and the neck to the center of the bregma. 2. The suboccipito-maximum, from the same posterior point to the most distant part of the bifrontal suture. :!. The Bubmento-bregmatic, from the union of the chin and the neck to the center of the bregma. I. Submento-maximum, from the same anterior point to the most distant part of the sagittal suture. Inj.nn at and 1 1' •rijitifii n/' tl/r Jliimnii drum. 61 The ilimei t these different din meters nre as follows: Static diauirtcrg. — MR wii|^»rn$xin*m, \y/ z centimetres, rlnionasafe* ■)£ centimetres. 5 centimetres. y^ centimetres, centimetres. by z centimetres. Dynamic diameters, — SuboccijJftb-bregmatic, g]/ 2 centimetres. Suboccipito-maximum, 10^ centimetres. Suhmento-hregmatic, <) l / 2 centimetres. Submento-maximum n centimetres. For the Inst, 1(H could be admitted, but it is important to know that it is greater than the Buboccipito-maximum, and we would thru have a series of figures easily retained, 6£, 11, HI, Ul, 10$, 11J, 18J, from 6 to 18, with the exception of 12, by adding a half to each. The mento-maximum and the inio-nasal, as well as the dynamic diameters, are antero-posterior, the others are transverse. B. Thr ennui <■ <>n nd. — The trunk of the foetus, much more irregular and more reducible than the head, also presents several diameters, which are, on account of its compressibility, only of secondary importance. I will only note : 1. The bitrochanteric, uniting the two trochanters. 2. The pubo-sacral, extending from the upper part of the sacral promoting to the middle of the anterior surface of the pubes. 8. The bisacromial, from the acromion of one side to that of the opposite side. 4. The sterno-dorsal, a horizontal line from the middle of the sternum to the corresponding spinous apophysis. The diameters measure on the average : Pubo-sacral, 6 centimetres. Bitrochanteric, 9 centimetres. Sterno-dorsal, 9 centimetres. Bisacromial, 12 centimetres. Figures 6, 9, 12 are easily retained. According to these dimensions one would be led to believe that the thorax forms the large extremity of the cormic ovoid and the breech the smaller portion, but the two diameters of the breech are much less reducible than those of the thorax and the addition to the pelvis cf the lower limbs folded on themselves considerably increases the volume of this foetal part and renders it really larger than the thoracic. Physiology. — A. Circulation. — The foetus presents two distinct circulations during its sojourn in the uterine cavity. The first (embryonic), depending on the umbilical vesicle \ the second (foetal), developing with the allantoid vesicle and replacing the preceding, this is the placental circulation. 62 Development and Description of the Human Oram. The foetal circulation (Fig. 62) differs from the definitive in two essential points: 1. By the existence of a funicular placental territory, which brings the fcetal blood in contact with the maternal. Placenla Fig. 62. — Sehema of the foetal circulation. 2. By the communication of the aortic with pulmonary circulation in two ways : a, through the foramen ovale (Fig. 62 B), which con- nects the two auricles; b, the ductus arteriosus, uniting the pul- monary artery and the aorta. These communications, which are Development and Description oj the Human (hum. 03 destined fco disappear at birth, permit the blood to make the com- plete round of the circulation without passing through the Lungs, and these structures remain rudimentary tiuring intrauterine life. B. Respiration. — This function comprises three successive pro- cesses: 1. The oxygenation of the blood, accompanied by the elimination of carbonic acid. ^. The transportation of oxygen to the different tissues of the organism by the intermediatory circu- lation. :>. The deoxygenation of the blood, with combustion as its result. The last two processes are only present in the foetus to a small degree. The first process is essentially different from that of the adult by occurring in the placenta instead of in the lung. In passing through the placenta the foetal blood absorbs oxygen from the maternal circulation and discharges its carbonic acid. Every cause of arrest of the placental circulation, of partial or total sup- pression of the function of the placenta, leads to asphyxia of the foetus. C. Nutrition. — The nutrition of the foetus is carried on both by the blood and liquor amnii. In the placenta the blood is charged with the nutritive elements contained in the maternal circulation, for the placenta permits the nitration of solid, liquid and gaseous elements. The nutritive role of the amniotic liquid is not so well established as that of the blood. It possesses nutritive qualities for it contains albumin and salts. It is swallowed by the foetus, for experiments on animals by freezing have shown the existence of ice extending from the amniotic liquid through the mouth and oesophagus to the stomach. Examination of the meconium under the microscope has also shown the existence of numerous hairs from the skin, which could only be drawn in with the liquor amnii. But nutrition exists in monstrosities in which the mouth is absent and also in the early months of intrauterine life when deglutition is im- possible, so that if the liquor amnii fulfills any nutritive purpose at all it is very slight compared with that of the placenta. D. Secretions. — The skin furnishes the vernix caseosa which at the moment of birth covers the foetus like an irregular false membrane. The intestine secretes the meconium, a mixture of bile, cellular debris and different elements found in the liquor amnii. Except under special conditions, the meconium is only expelled after birth. The kidneys also act during pregnancy. The urine accumulates in the bladder, and then passes into the liquor amnii. Obliteration of one of the ureters produces hydronephrosis, and that of the urethra, retention of urine with distention of the bladder — a proof of the existence of micturition during infra-uterine life. E. Innervation and motility. — Sensibility and motility exist in the foetus, every excitation conveyed to it is interpreted by movements. It is also probable that during intra-uterine life there are alternatives of sleeping and waking. 64 Modifications of the Maternal Organism. CHAPTER III. MODIFICATIONS OF THE MATERNAL ORGANISM. We have studied the ovum during its development in the uterine cavity, it is now important to study the parallel modifications which occur in the maternal organism. These modifications are not localized, as might be supposed, in the genital system, but involve the whole economy. It will then be necessary to successively examine all the systems. I shall begin with the genital apparatus as the one most directly interested. I. Genital system and vicinity. — Some special anatomical consider- ations are necessary to a proper understanding of this subject. The uterus is the organ in which the ovum is developed during normal pregnancy. Situated in the pelvic cavity, with the rectum behind and the bladder in front, it unites the vagina to the tubes. The general form of the uterus is that of a pear, the large ex- tremity constituting the body, the small the cervix. The body and the cervix are united by a thinner part, the isthmus. In the normal state the axis of the uterus is rectilinear, that is, the body and the cervix have the same direction. This uterine axis is nearly identical with that of the superior strait and is perpendicular to that of the vagina. However, the axis of the uterus is perpendicular to that of the vagina only when there is a certain degree of repletion of the bladder. But, after the evacuation of the urine, ante-devi- ation occurs. Thus the uterus lies on a cushion of water and fol- lows its variations. The uterus is held in its normal position by by the support given to it by the pelvic floor. The longitudinal dimension of the uterus is six centimetres and a half, which is divided as follows : Cervix, 0,025 Isthmus, 0,005 Body, cavity, .... 0,025 Thickness of the wall, - - 0,010 0,065 These dimensions represent the average as applied to all uteri. It should not be forgotten, however, that in the nulliparous woman the cavity of the cervix is greater, and in the multiparous that of the body. Weight: forty grammes. The uterus is covered by the peritoneum in the greatest part of its extent except over the three regions shown in Fig. 65. This Modifications of t)u Maternal Organism, 65 membrane separates it from the bladder in front, from the in- testines above and from the rectum behind. The fundus of the uterus is situated about three centimetres above the horizontal plane passing through the superior portion of the symphysis pubis. I have already described the interior of the uterus under head of menstruation audit is sufficient to say here that the external orifice is rounded and sometimes punctiform in the nulliparous woman, that it is transversely elongated after a first parturition, and that, in consequence of multiple lacerations, it may have a stellate or an irregular appearance. Uterine mucosa. Cavity of the body. Isthmus. Arbor vitae. Branches of arbor vitas. Vaginal cul-de-sac. Vagina. Fig. 63. — Vertical and transverse section of the uterus. The uterus is composed of an important muscular coat, ineom= pletely covered by a serous membrane, and lined on its interior by a mucous covering that we have already studied. The muscular tunic is exclusively composed of non-striated fibres. It differs in the body, in the isthmus and in the cervix. Body. — Fig. 67 schematically represents this structure. In the center, forming the framework, is a plexiform layer formed by inter- lacing muscular fibres with the meshes occupied by the arteries and the veins which dilate during pregnancy to form veritable sinus -. Above this plexiform layer is the superficial muscular layer com- prising an antero-posterior loop, which, commencing at the isthmus in front, follows the median line of the uterus to terminate behind at a corresponding point. Then there comes a series of transvi - fibres, which are prolonged in part into the broad ligaments. Be- neath is the deep muscular layer, also comprising two arrangements Modifications of the Maternal Organism. Fig. 64. — Anteroposterior and median section of the female pelvis. Fig. 65. — Profile view of the uterus. Fig. 66. — Relations of the cervix (Schroeder). Modifications of the Maternal Organism. 67 of fibres; one transverse, forming a series of irregular rings, the others in the form of a X. This series of fibres in the form of a Z are directly in contact with the mucosa. Deep layer, transverse fibres, Fibers in Z, vertical part Fibers in Z, inclined part Superficial layer, vertical fibres. Superficial layer, transverse fibres. Plexiform or middle layer. Fig. 67. — Transverse section of the uterus, at the level of the body (schema). Isthmus. — In the isthmus we only find transverse or slightly oblique fibres, that is, the plexiform layer does not reach here, hut only the superficial loop fibres and those in the form of a Z. Cervix. — The same is true of the cervix, but there is, however, difference between the isthmus and the cervix, as in the latter the connective tissue element predominates while in the isthmus the muscular fibres are more abundant. These anatomical considerations permit us to pass to the study of the modifications of the uterus under the influence of pregnancy. These modifications are of three kinds: A. Macroscopic. B. Microscopic. C. Physiological. A. Macroscopic modifications, — The body containing the ovum and the cervix opposing its egress, assume a physiological role essentially different. The modifications of these two parts of the 68 Modifications of the Maternal Organism. uterus are completely dissimilar, from which, arises the necessity of studying them separately. 1. Modifications of the body. — Volume. — I shall only speak of the vertical diameter, which measures fourteen centimetres at the third mouth (not including the cervix) ; twenty-one in the sixth month, and thirty-five in the ninth month. Fig. 68. Uterus empty (profile view). Fig. 69. First three months of pregnancy (uterus rounded). Fig. 70. Second three months of pregnancy. Fig. 71. Third three months of pregnancy. Fig. 72. First three months. Uterus in pelvis (front view). Fig. 73. Second three months. Uterus in abdomen. Fig. 74. Third three months, Abdominal-pelvic situation. Cajiacity. — The capacity of two to three cuhic centimetres in an empty state is increased to four or five litres. Form. — The uterus hecomes rounded during the first three months ot pregnancy, while increasing in volume. During the second three months, the uterus especially increases in its postero-superior part, in the region indicated in Fig. 70, by a series of small projections, in such a manner that the openings of the tubes are carried below and a little forward. During the last three months it is especially the antero-inf erior part which develops, in such a way that the cervix is thrown backward. The general form of the uterus at term is, as before pregnancy, that of an ovoid with the small ex- tremity downward. Modifications oj tht Maternal Organism. 69 Situation. — During the first three months of gestation the uterus is developed in the interior of the pelvic excavation. The fundus passes tho superior strait and encroaches on the abdominal cavity (Fig. 71). In the second three months the uterus, becoming too large for the pelvic cavity, ascends into the abdominal cavity above the superior straight (Fig. 78). Umbilicus, middle of pregnancy. Fig. 75. — Gradual elevation of the uterus in the abdominal cavity. During the last three months the situation of the uterus varies in the primiparse and in the multiparas. In the .primiparse, early descent of the uterus into the pelvic excavation, with engagement of the festal part, takes place, especially during the last two months l Fig. 74). In the multipara- the lax abdominal Avail allows sufficient room for the distention of the uterus, and engagement only occurs during the last fifteen days of pregnancy, sometimes even later. The relation of the fundus of the uterus to the abdominal wall (Fig. 75) is interesting to determine, for it serves as a mark from which an approximate estimation of the date of the pregnancy 70 Modifications of the Maternal Organism. may be made. Unfortunately, great variations exist. However, it may be said in a general way that : During the fourth month the uterus is a little below the um- bilicus; during the fifth, at the level of the umbilicus.; during the sixth, a little above the umbilicus ; during the seventh, three fingers' breadth above the umbilicus ; during the eighth, six fingers' breadth above the umbilicus, and during the ninth month, nine fingers' breadth above. Orientation. — The uterus presents three principal axes, an antero- posterior, a vertical, and a transverse. Now, during pregnancy, it may undergo various deviations by turning on these axes. 1 Antero-posterior axis. — Lateral inclination. — I suppose this axis passing in the vicinity of the cervix. Movements of the uterus around this fictitious line incline its fundus to the right or to the left. From the statistics of one hundred cases I have deduced the following : Right inclination, 55 per 100. Left inclination, 5 per 100. No inclination, 40 per 100. Fig. 76. — Median uterus, symmetrical Fig. 77. — Apparent inclination of the development of the two halves of the uterus, asymmetrical development of the organ. of the two halves of the organ. Various causes have been invoked to explain this lateral incli- nation of the uterus; among them are : Decubitus, preponderant usage of the right or of the left arm, the situation of the placenta, the relative length of the round ligaments, the anatomical dispo- sition of the mesentary, and vesical or rectal repletion. But none of these explanations are satisfactory, and it seems the mode cf development of the uterus, either symmetrical or asymmetrical, affords a better account of these lateral deviations. The sym- metrical development of the two halves of the organ gives a uterus which appears median (Fig. 76), while asymmetrical development imposes a right (Fig. 77) or a left inclination. Thus the inclination of the uterus is apparent and not real. If real inclination occur, it is consecutive to the preceding. Modifications of the Maternal Organism. 71 2. Vertical axis. — Rotation is the movement round the vertical axis. The anterior Burface of the uterus is generally inclined to- ward the Bide where the organ is most developed. This rotation is important with regard to a Casarian operation, for if the direction is not corrected there is danger of wounding some important vessels. Fig. 7S. — Normal gravid abdomen. Fig. 79. — Pendulous gravid abdomen. 3. Transverse axis. — Antero-posterior inclination. — I suppose this axis passing through the union of the body and cervix. During the first three months, rarely later, the body of the uterus may in- cline backward, thus constituting retroversion of the gravid uterus, which we shall study further on. During the latter part of preg- nancy this posterior deviation is impossible, on account of the size of the uterus, but anteversion may occur with a very lax abdominal wall (Fig. 79). Weight. — Thickness. — The weight of the uterus attains about a kilogramme at term (not including the foetus). The thickness of the uterus is, normally, rive millimetres. Opinions on this subject differ greatly. Some authorities say it is thinner, some that it is thicker, and some that it remains the same during pregnancy, and. all have autopsies to bear them out. These different obser- vations demonstrate the inconsistency of its thickness. There exists in general a notable difference between the superior segment and the inferior, the latter being relatively very thin. Points of the uterus which have supported a prolonged compression, like that of the foetal head, are diminished in thickness. The surface of the insertion of the placenta is hypertrophied, on the contrary. 2. Modifications of the cervix. — The cervix is modified in its form, in its situation, in its volume and in its consistence. The effaee- ment, that is, the disappearance of the cervix which precedes the 72 Modifications of the Maternal Organism. opening of the external orifice, although sometimes occurring during pregnancy, will be studied with accouchement. Fig. 80. Type norm&f Fig. Si- Fig. 82. Fig. 83. a, uterine circle (Bandl's ring) limit between the supero- lateral and inferior segments; b, internal orifice; c, external orifice. Form. — Outside the modifications of form caused by effacement there may be found, aside from the normal type often persisting in the primiparse, one of the three principal forms represented in the adjoined schema (Figs. 80, 81, 82 and 83). These modifications ;i re due to the degree of the relative dilatation of the two orifices of the uterus. Situation. — The cervix naturally follows the body in its evolutions. During the first three months the cervix is found in its natural position, often a little approached to the perinaeum. During the ■ml three months the cervix follows the uterus in its ascent and becomes less accessible to vaginal touch. During the last three month- it- situation differs in the primipara from that in the multi- para. In consequence of the progressive engagement during the Modifications of the Maternal Organism. 73 last three months in the primipara, the cervix descends and is also usually deviated to the left and a little haekward. Rarely the cervix is median or to the right. In the multipara, engagement takes place later, and the situation of the cervix varies with degree of the uterine descent. With regard to cervical deviations, they are the same as in the primiparee. FlGS. 84 and 85. — Folds of the vagina during pregnancy. Fig. S6. — Ligaments of the uterus seen from above. Volume. — Hypertrophy of the cervix is generally admitted, under the influence of pregnancy, in such a manner that its length is doubled ; from twenty-five millimetres it is increased to five centi- metres. We shall return to this apropos of effacement. 74 Modifications of the Maternal Organism. Consistence. — The cervix progressively diminishes in consistence during pregnancy. This softening does not occur as a whole, but from the external orifice toward the internal, fallowing progressive invasion like that of an epithelioma. This softening is sometimes so great that the examining linger can scarcely perceive the cervix in the midst of the vaginal tissues. Attempts have been made to base a diagnosis of the date of pregnancy on the extent of the soften- ing of the cervix, but, even in a first pregnancy, the variations are too great to allow us to accord this sign any such degree of precision. This modification is probably due to a serous infiltration and to microscopic changes occurring in the cervix. It is to be noted that all the tissues of the genital zone, and in particular those of the vulva, undergo an analogous softening, though less in degree, and equally accompanied by hypertrophy. B. Microscopic modifications. — In studying the development of the ovum we have seen the modifications of the uterine mucosa which con- stitute the decidua. Only the mucous membrane of the body and of the isthmus undergo this transformation. In the cervix the mucosa, out- side of functional superactivity and epithelial proliferation, does not present any change. The cervical glands secrete a viscous liquid of such great consistence that it forms a veritable obdurator, a gelatinous plug which is cast out at the beginning of labor. The mus- cular fibres undergo modifications of hypertrophy and multipli- cation both in the body and in the cervix cf the uterus, but less in degree in the latter. The peritonaeum is hypertrophied and enlarged to accommodate the increase in the surface of the uterus. The afferent arteries of the uterus take on considerable development, sufficient to assure a complete supply of blood to the organ. The veins undergo a parallel development, forming true sinuses in the muscular wall. There is an analogous increase in the size of the lymphatics. The nerves also appear hypertrophied. C. Physiologiccd modifications. — The uterus is essentially a mus- cular organ and like all the other viscera it is connected with the central nervous system by the centrifugal and the centripetal nerves. The presence of nerves creates two properties, sensibility and irri- tability. As a muscular organ the uterus possesses extensibility, retractility and contractility. These five physiological properties are more or less modified by the puerperal state : 1. The sensibility of the uterus, body and cervix, is obscure. In the normal state the uterine surface can be attacked without causing acute pain. On the contrary, in the pathological state this suscepti- bility is capable of arising quickly. Under the influence of uterine contraction during labor the pain becomes severe, as much in the cervix as in the body. This difference in the results produced by Modifications of the Maternal Organism. lij contact and by contraction justifies the special nature attributed to uterine sensibility. 2. The uterus is irritable, that is to say that an excitation arising in any sensitive zone is transmitted to the uterus reilexly and causes a contraction. The majority of the methods employed to cause ahortion act by bringing this property of the uterus into play. 8. Extensibility permits the uterus to distend progressively with the development of the product of conception. Without it pregnancy would be impossible. During gestation the body of the uterus undergoes extension ; at the moment of labor the cervix and the inferior segment are extended in turn. 4. Retractility is opposed to extensibility. By this property the uterus has a tendency to diminish in volume, like a rubber balloon. Retractility is only the effect of the tonicity possessed by the uterus in common with all other muscles. Pathological exaggeration of retractility produces uterine tetanus and its absence creates uterine inertia. 5. Contractility is constituted by the momentary contraction of the uterus as a whole. It results in a diminution of the capacity of the organ or in a tendency to this diminution. In an empty state of the uterus contractions are painless and are not felt except in pathological conditions, such as pseudo membranous dysmenor- rhoea. During pregnancy they are also painless, and if they are perceived at all it is as a passing hardness of the abdomen. On the contrary, contractions become painful during labor. II. Vagina. — Vulva. — Perinceum. — These structures undergo two principal modifications, hypertrophy and softening, occurring in common with the same changes in the uterus, thus preparing a favorable condition for the exit of the child. A. Vagina. — The vagina increases in all its dimensions. Its elongation facilitates, in the second three months of pregnancy, the ascension of the uterus. When, during the last three months, the uterus descends again the vagina, is folded on itself (Figs. 84 and 49). The vascular system undergoes an equal development, having the double effect of modifying the coloration of the vagina and of making the arterial pulsations perceptible in some cases (vaginal pulse of Osiander). B. Vulva. — Besides hypertrophy and a certain degree of softening the vulva undergoes two other important modifications. A pigmen- tation analogous to that of the breast cr of the face and a violaceous coloration, more marked on as the vagina is approached. C. Perinceum. — The perina?um, participating in the softening and in the hypertrophy of the tissues of the genital zone, acquires under 76 Modifications of the Maternal Organism. the influence of pregnancy a great suppleness permitting stretching at the moment of accouchement. Like the vulva, it often becomes the seat of pigmentation, especially in brunettes. Fig. 87. — Ligaments of the uterus, profile view. A, insertion of the broad ligaments; B, utero-sacral ligament; C, utero-vesical ligament. III. Appendages of the uterus. — I shall study the modifications of the ligaments with the enclosed vessels, by describing the modifi- cations impressed on them by pregnancy. A. Ligaments. — During pregnancy all the ligaments undergo a notable hypertrophy with a certain degree of softening, as in all the organs of the genital zone. The suppleness acquired by the utero- sacral ligaments permit the ascension of the cervix during the second three months of pregnancy. With regard to the broad ligaments, the contraction of their muscular fibres play, according to the demonstrations of Thevenot and Budin, an important role in the engagement of the uterus and of the foetal part. Their contraction, Bynergetic with the pressure exercised by the abdominal wall, causes the foetus to descend into the excavation; their relaxation permits the ascension of the uterus. The tube and the ovary, contained in the broad ligament, par- ticipate in the general hypertrophy of the genital system. The ovary in particular, which has furnished the fecundated vesicle, times acquires the volume of a small walnut. Budin has justly insisted on the pain which is often caused by palpation of the ovaries during pregnancy. B. Bloodvessels. — The adjoined plate brings these structures to Modifications of the Maternal Organism. 77 memory sufficiently without necessitating further description. All these vessels, especially the veins, assume a considerable develop- ment during gestation. VEP VEINS. ARTERIES. Fig. 88. — Bloodvessels of the genital system. AA, aorta; R, renal artery ; AUO, utero-ovarian artery; AIG, left primary iliac artery; AP, puerperal artery; AU, uterine artery; All, internal iliac artery; AIE, external iliac artery; AEP, epi- gastric arteries; ALR, artery of the round ligament; AV, vaginal artery; OV, ovary; TR, tube; V, vagina; UT, uterus. Veins: corresponding deviationi on the opposite side. C. Lymphatics. — The role of the lymphatics is small in the physi- ological state, but is more important in cases of puerperal septi- cemia. The uterine lymphatics pass to a series of glands grouped in the pelvis, as indicated in Figure 89. IV. Articulations of the pelvis. — The three articulations which es- pecially fix the attention are the two sacro-iliac symphyses and the symphysis pubis. As a whole, they may be considered as three breaks in the pelvic ring which give it greater flexibility. This 78 Modifications of the Maternal Organism. appears to be their special use. Under the influence of pregnancy the peripheral ligaments of these articulation relax, and the intra- articular ligaments undergo a certain degree of softening with hypertrophy. These modifications cause a slight separation of the articular surfaces. - _ Guerin's retro-pubic glands. Satellite glands of the uterus. Uterus. Lateral pelvic glands. Sacral glands. — Lymphatic glands of the pelvis. V. Abdominal wall. — The umbilicus seems deeper during the first three months of pregnancy, as if the urachus exercised traction at this point. Beginning with the second three months the umbilicus is progressively flattened and often becomes projecting in the last three months. These three periods of the changes in the umbilicus have only a theoretical interest. Fig. 90 — Linese alblcantes of pregnancy. The abdominal integument, distended by the enlarging uterus, presents a series of subepidermic cracks, forming small plaques of cicatricial appearance. These are the linene albicantes of preg- nancy. These vibices particularly occur in the subumbilical Modifications oj tht Maternal Organism. 79 region and parallel to the fold of the groin. They may also invade the whole extent of the al domen, i om< tin es even the buttocks and upper part of the thighs. By anomaly, they are exclusively situated in one of these two regions. They are rosy or bluish when recent; in multipara those dating from a previous pregnancy have ;i pearly reflex. They diminish in extent after pregnancy, but never dis- appear entirely. In five cases out of one hundred they are wanting. These subcutaneous ruptures are not exclusively observed during pregnancy; they may le produced by any cause of abdominal detention. Fig. 91. — Nipple. True and secondary areolae. Tubercles of Montgomery. 6. Breasts. — We will only touch here upon the question of the superficial changes of the nipple, the areola, and of the contiguous integument. The nipple increases in size, becoming erectile and sensitive, even hypera?sthetic and painful. Around the nipple there are two zones of unequal coloration, the most eccentric being the least deeply colored. The first is the true areola, existing before pregnancy and becoming more pigmented under its influence. The hypertrophy of Mongomery's tubercles and the pigmentation are the two principal characters of the areola during gestation. The other, the secondary areola, is a pigmentation of gravid origin, and forms a circle surrounding the first. The subcutaneous venous plexus becomes very apparent. By compressing the nipple toward the end of pregnancy some drops of colostrum often exude. The colostrum sometimes flows spontaneously. II. Kei-vous system. — A. Central. — The sensitiveness of the preg- nant woman is usually exaggerated. The intelligence i- also affected, so that a naturally vivacious woman becomes dull when pregnant. Exceptionally, a contrary modification has been noted. Various perversions in the form of morbid desires are to be noted. Alterations of the will are also often present and border on insanity in some cases. 80 Modifications of the Maternal Organism. B. Peripheral. — Pregnancy predisposes to diverse neuralgias, and in particular to odontalgia, especially in women whose dental system presents a previous physiological inferiority. III. Respiratory system. — The development of the uterus causes an increase in the transverse diameter of the thorax, and on the contrary a diminution of the antero-posterior and of the vertical. The general capacity of the thorax is diminished, producing a certain obstruction to respiration, that is increased by the globular poverty of the blood, another effect of pregnancy that we shall soon explain. This double cause exposes the pregnant woman to breath- lessness. IY. Circulatory system. — Blood. — There are three principal modi- fications of the blood, namely, serous plethora, globular anaemia (except as to the leucocytes), and diminution of the solid principles (except fibrin). The quantity of water composing the blood is notably increased, so that the total mass of the sanguineous liquid is greater during pregnancy. There is then a plethora, but a serous plethora or hydremia. From the exaggeration of the vas- cular tension there arises in the capillaries a quantity of serum, causing a generalized swelling of the tissues. This swelling should not be confounded with a certain degree of adipose tissue which is a frequent result of pregnancy as we shall see later. Besides the general infiltration of the tissues the augmentation of the total amount of blood has two other effects : predisposition to haemorrhages and obstruction of the functions of certain organs, in particular, of the heart (hypertrophy, dilatation) and of the kidney (congestion, nephritis, albuminuria). The greater vascular tension produces more energetic pulsation on the part of the arteries and a tendency to dilatation on the part of the veins, frequently terminating in the production of varices. V. Urinary system. — In the kidney we find congestion and ob- struction due to the general modifications of the circulation and to the compression exercised by the voluminous uterus. From this arises a predisposition to nephritis and disturbances of secretion, which will be studied with the urine. Compression of the ureter is possible, especially when the en- gagement is deep, leading to arrest of the flow of urine and the production of eclampsia. In its development the uterus obstructs the bladder more or less by its expansion, and causes changes in the form and in the situ- ation of the urinary reservoir. During the first three months of pr< ^nancy the conditions are not notably changed. During the 3< eond three months, the bladder is considerably relieved from Modifications of the Maternal Organism. 81 pressure by the ascent of the uterus. During the third three months, and also during labor following the degree of the fceto- uterine engagement, the bladder takes different forms (Figs. 92, 93, 94). The urethra follows, in part, the changes of the bladder. Fig Q2 — B'ndder in the form of a crescent. Ve, bladder; U, uterus ; R, rectum : V a, vagina. The urine undergoes three principal modifications, an augmen- tation in the quantity of water, diminution of the solid elements (except the chlorides), and appearance of new elements (kiestine, albumin, glycose). The augmentation of the liquid portion is only relative, for the total quantity of urine is nearly the same during the pregnant state as in the normal condition. The diminution of the solid elements comprises the phosphates, sulphates, urea, uric acid, creatine and creatinine. The chlorides alone are increased. Under m the term kiestine has been designated a special substance which appears on the surface of the urine of pregnant women. The presence of albumen is relatively rare ; I shall return to this subject under albuminuria. Apropos of glycosuria, authorities are not in accord. I reserve this subject for the chapter on diabetes. VT. Cutaneous and osseous systems. — Besides the different situa- tions already noted, gravid pigmentation may occur in various other parts, notably on the face. The nutrition of the nails may be 82 Modifications of the Maternal Organism. Fig. 93. — Bladder in the form of a slipper. Fig. 94. — Bladder in the form of a horn. Modifications of the Maternal Organism. 33 disturbed, causing a diminution in their thickness. The skeleton undergoes modifications in its general attitude and in its nutrition. In consequence of the development of the abdomen, the woman to maintain her equilibrium is obliged to throw the upper part of the hotly backward. The puerperal Btate also seems to excite oss< development, as under its influence there has been noted on the internal surface of the cranium, and more rarely on the internal Burface of the pelvis, the production of osteophytes in the form of plaques which arise with pregnancy and disappear with it. VII. Digestive system and appendages. — The liver undergoes an augmentation in volume and a fatty degeneration especially marked in the centre of the hepatic lobule. With regard to the digestive -y-tem, it is subjected to very important modifications which react in a marked manner on the nutrition. Gestation is capable of disturbing more or less deeply each one of the four acts of nutrition. 1. Absorption. — Sometimes the appetite is excited under the influence of pregnancy, digestion is more easily accomplished and absorption seems thus favored. But usually an opposite modifi- cation is seen, so that a retardation of absorption can be consideied the rule during gestation. Other causes contribute to the retar- dation of absorption, such as vomiting and diarrhoea. •2. Assimilation is generally lessened under the influence of pregnancy, and this exercises a most unfavorable action on scrof- ulosis and anaemia. Scrofula already exercises an unfavorable action on nutrition and pregnancy; by exaggerating this nutritive di-turbance pregnancy hastens the evolution of tuberculosis. Aside from scrofulosis, the anaemia resulting from gestation sometimes becomes so marked that it constitutes a grave disease. 3. Disassimilation. — If this process is complete, only three waste products result, that is, urea, carbonic acid and water. But if disassimilation is incomplete, different products arise among which I shall note uric acid, lactic acid, sugar and fat. The excess of these products in the blood, or in the eliminative organ (urinary or biliary passages), produces the different diseases indicated by the following table : Excess of lactic acid causes i f> h ™ m ^ s ™> I Osteomalacia. r- c ■ j f Gout, Lxcess of uric acid causes < T . . ' , (. L nnary gravel. Excess of fat causes f Obesity. \ Biliary lithiasis. Excess of sugar causes - 1 / ^,^ C3emi ?" _. , I Glycosuria, Diabetes. Now, pregnancy favors the development of the different diseases by retarding the disassimUative stage of nutrition. 4. Elimination occurs through the skin, the intestine (comprising 84 The Parturient Canal. its tributary glands, the liver in particular), the lungs and the kidneys. We have seen that the analysis of the gravid urine shows a diminution of the solid elements (except the chlorides). Benal elimination is lessened then, and it is probable that the same is true with regard to the pulmonary, cutaneous and intestinal elimi- nation. When this retardation of elimination becomes too marked, it terminates in a pathological state, eclampsia. CHAPTER IV. THE PARTURIENT CANAL. The parturient canal is a narrowed and irregular region through which the foetus must pass at the moment of delivery. This canal is constituted by an osseous region, which forms its framework, the bony pelvis, and is completed by the soft parts below, which as a whole may be called the soft pelvis or perineum. I. Bony pelvis. — The pelvis is formed by the two iliac bones, adherent at the symphysis pubis, and reunited posteriorly by the intermediate sacrum with its inferior appendix, the coccyx. This sketch allows us to note four articulations, the symphysis pubis in front, the two sacro-iliac symphyses, one on each side of the sacrum, and finally the sacro-coccygeal articulation. The pelvic ring, in- terposed between the vertebral column and the lower members, plays an important physiological part. In its description I shall confine myself exclusively to the obstetrical side of the question. External conformation. — The exterior of the pelvis interests the obstetrician but little ; however, as in certain vices of conforma- tion the measurement of some external diameters furnishes useful knowledge, I shall indicate four of these : 1. The sacro-pubic, from the spinous process of the first sacral vertebra to the anterior and median part of the symphysis pubis, twenty centimetres. 2. The bispinous, separating the two anterior superior iliac spines, twenty-four centimetres. 3. The bis-iliac, uniting the two most distant points of the iliac crests, twenty-eight centimetres. 4. The bitrochanteric, from the great trochanter of one side to that of the other, thirty-two centimetres. Tht Parturient Canal. -- Internal conformation. — In it- interior tlie pelvis presents two absolutely distinct regions, separated by a retraction that consti- tutes the linea-ilio-pectinea completed behind by the promontory, and to which is given the term superior strait. Above this is found the great or false pelvis ; below it is the true pelvis. Fig. 95.— False pelvis covered by the soft parts. A, aorta: A I PG, left primary iliac artery; A I EG, left external iliac artery; M P, psoas muscle; CM A, section of the muscles of the abdominal wall; GT, great trochanter; MI, iliac muscle; M CL, quadratus-lumborum muscle; V C I, inferior vena cava; VI PG, left primary iliac vein; A S V, sacro- vertebral nn^'le; 1 1.8, insertion of sacro-sciatic ligaments; MO E, external obturator muscle; A I P, inferior arch of the pubes. The false pelvis forms an incomplete funnel, constituted by the iliac wings laterally, and the spinal column behind. The ilio-psoas muscles, by filling the iliac fossa?, offer a support to the gravid uterus when it inclines to one side. But the true pelvis is essentially the obstetrical part of the pelvis. It is limited above by the superior strait, already defined, and below by the inferior strait (point of the coccyx, inferior part of the saco-sciatic ligaments, ischium, ischio-pubic rami, inferior part of the pulic symphysis). Between these two straits is found the pelvic excavation. At the inferior part of the excavation a contracted portion, the median strait, divides it into two unequal parts : one, superior, the great excavation; one, inferior, the small excavation. The median strait is of considerable importance in obstetrics. It constitutes the limit between the bony pelvis and the muscular pelvis; above it, the foetus passes through a bony canal; below it, through a muscular canal. Above it lies pelvic dystocia: below it 86 The Parturient Canal. (except in obstacles furnished by the ischium and coccyx) we have perinseo- vulvar dystocia. For complete recognition of the true pelvis it is necessary to de- scribe successively : a. The superior strait. (•. The great excavation. c. The median strait. d. The lesser excavation. e. The inferior strait. a. Superior strait. — Formed by the promontory, projecting part of the wings of the sacrum, innominate line of the ilium, ilio-pectineal eminence, pectineal surface, pubic spine, superior part of the pubis and of the symphysis pubis. Diameters. — 1. Antero-posterior or sacro-pubic, eleven centimetres. 2. Ttco oblique; the left from the right sacro-iliac symphysis to the left ilio-pectineal eminence ; the right from the left sacro-iliac symphysis to the right ilio-pectineal eminence. These two diame- ters are equal and measure twelve centimetres. 3. A transverse, uniting transversely the two most distant points of the innominate line, fourteen centimetres. b. The great excavation, or the Excavation, properly so-called. — Formed by the sacral concavity, the great sciatic notch, the os- seous surface extending from the ischium to the iliac wing, the obturator foramen, the posterior surface of the pubis and of the symphysis pubis. Fig. 96. — Pelvis : diameters of the superior strait. Dianu tere. — 1. An antero-posterior, from the median part of the third sacral vertebra to the middle of the posterior inter-line of the symphysis pubis, twelve centimetres. The Parturient ( 'anal. < 2. Two oblique: the left, better called the cacal, from the middle of the right sciatic notch to the middle of the left obturator foramen ; the right, better the rectal, follows an opposite direction; both measure twelve centimetres. However, the two extremities of tl diameters, corresponding to soft parts, are easily extended to thirteen centimetres, and even more. 3. A transverse: from a point corresponding to the base of one cotyloid cavity to that of the other, twelve centimetres. c. The median strait. — Formed by : the inferior part of the sacrum, the inferior border of the lesser sacro-sciatic ligament, the sciatic Bpine, a line from this spine to the inferior part of the pubic symphysis. FlG. 97. — Pelvis: diameters of the excavation. Diameters. — 1. An antero-posterior, from the inferior and median part of the sacrum to the inferior part of the symphysis pubis, twelve centi- metres. •1. Two oblique: a caeal, from the middle of the right lesser sacro- sciatic ligament to the middle of the ischio-pubic border and of the left obdurator foramen ; a rectal, identical in the opposite direction. Both measure eleven centimetres. 3. A transverse: extending from the sciatic spine of one side to that of the opposite, ten centimetres. '/. e. Lesser excavation and inferior strait. — I unite these two regions in one description. Their importance is only secondary in relation to the preceding. The inferior strait, according to classical de- scriptions, is constituted by the point of the coccyx, the inferior border of the great sacro-sciatic ligament, the ischium, the ischio- pubic rami and the inferior part of the symphysis pubis. Xow I shall remark : 1. That the great sacro-sciatic ligament does not extend to the point of the coccyx, but from the base of this bone to the ischium, so that the inferior strait is without limit in this region. 88 The Parturient Canal. 2. That the coccyx, from its mobility, plays the role of a soft part, its point consequently cannot serve to limit a fixed osseous strait, this would only be possible in ankylosis of the articulation of this bone with the sacrum, a pathological condition and relatively rare. Fig. 98. — Pelvis: diameters of the median strait. 3. That the line uniting the ischiatic bones is found much above that going from the point of the coccyx to the inferior part of the symphysis pubis, and that for this reason these parts cannot con- tribute to the formation of a single plane. 4. That the cocey-perimeal muscle by its insertion rises above the inferior strait and removes almost all its importance, in an obstetrical point of view. These different reasons argue for the acceptance of the median strait as the real limit of the excavation interiorly. It conforms better to the reality to consider the inferior strait, not as a true strait, but as a simple osseous tripod, formed by the two ischiatic bones and the coccyx, these three projections being separated by three deep notches, the pubic in front, the sacro-sciatic laterally. It is comprehended then that a displacement (of the ischiatic bones) and a fixation (coccyx) may become a cause of dystocia. Thus it is well to know that in the normal state the distance which separates the two ischiatic tuberosities is eleven centimetres, and that which usually extends from the point of the coccyx to the inferior part of the symphysis pubis is nine centimetres, but is very extensible. Placing in relation the dimensions of corresponding diameters we have : Diameters. Transverse. Oblique. Antero-posterior Superior strait '3 12 11 Excavation 12 12 12 Median strait 10 II 12 The I'uriiirii nt < 'mini . 39 It will be seen then, by recalling thai in the excavation the oblique diameters present a notable extensibility, that the great dimensions of the pelvis are : Transverse at the superior strait. Oblique in the excavation. Antero-po8terior at the median strait. We can now, from these figures, foresee the situation of the fetal head in its descent through the osseous canal. The head will place its greatest dimension, that is, the occipito-mental diameter, so that its position will lie : Transverse at the superior strait. Oblique in the excavation. Direct at the median strait. II. Soft pelvis. — Perinmim. — The pelvic skeleton constitutes one of the most important muscular centers. Of these muscles some descend from the thorax to an insertion on its upper border; others are inserted on its external surface ; finally, the last, which interest us more especially, are fixed to the internal surface of the pelvis, lining its walls and closing its inferior opening. Let us follow the latter muscles from the superior toward the inferior part of the pelvis. Above the superior strait, tilling the iliac fossae, are the psoas muscles, which we have already had in question. Below the superior strait, after having raised the pelvic aponeurosis, which forms a fibrous mass solidly closing the pelvis below, is found a most important muscular plane, lining the pelvis and also closing it below. The muscles thus uncovered (Fig. 99) are posteriorly the pyramidals ; laterally and in front, the internal obturators, and finally, in the center of this large space is found the coccy-perinseal elevator, which it would be more simple to call the levator perinaei. The internal obturator passes, from its insertion around the obturator foramen, between the sciatic spine and the ischium to become fixed in the great trochanter. The pyramidahs, from its origin on the anterior and lateral surfaces of the sacrum, passes out through the great sacro-sciatic notch to become fixed on the great trochanter also. The coccy-perinaeal elevator, or simply the perineal, forms a trough, a hammock, transversely in the pelvis, attached laterally to the sciatic spine, to the pubis and to a fibrinous intersection which unites these two points. Posteriorly it is attached to the coccyx and to the inferior part of the sacrum while it is free in front and is limited by the posterior vaginal wall. It is on this hammock that the organs of the pelvis rest. This hammock supports the fcetal head, which depresses it in its passage to the vulvar orifice. The levator possesses several fasciculi which by their union con- stitute one muscle. The first fasciculus, the ischio-coccygeal, 90 The Parturient Canal. extends from the sciatic spine to the lateral parts of the coccyx. The second fasciculus, the coccygeal, arising from the fibrous inter- section between the sciatic spine and the pubis, has its fibres con- verging toward the point of the coccyx. The third fasciculus, the ano-vulvar, particularly resisting, arises in front at the' inferior and posterior part of the pubis and forms a fan interlacing with the fibres of the opposite side, between the coccyx and anus for one part and the rectum and vagina for the other part; some fibres terminating on the lateral portions of the rectum and vagina. Rectum (anus.) Ischium coccy- geal fasciculus. Pyramidal. Sacrum. FlG. 99 — Pelvic diaphragm. Internal obturators. Pyramidial muscles. Coccy-perinseal elevator. Examined as a whole, the fibres of this levator may be divided into three fans on each side, disposed in opposed directions : a sciatic fan, with the point at the sciatic spine and the base at the lateral border of the coccyx; a coccygeal fan, with the point at the extremity of the coccyx and the base at the fibrous intersection join- ing the sciatic spine and the pubis, and a pubic fan, with the point at the pubis and the base on the coccy-vulvar median line. The coccyx is thus included in the muscle and forms a de- pendent portion. This bone, being mobile at its articulation with the sacrum, follows the fibres in their different movements. Thus, when the foetal part distends the muscular mass the coccyx is pushed backward with the muscular fibres. This bone, a hard part in the static state, should be considered as a soft part in the dynamic state. This pushing back of the coccyx makes a portion of the amplification of the perinaeum. It marks the beginning of the period of expulsion. It is the first obstacle met by the foetal part at the beginning of this period. But this obstacle will usually be easily overcome, unless there is ankylosis of the sacrococcygeal articu- lation. There then exists a veritable cause of dystocia. The anterior portion of the levator perinsei, the part in contact with the posterior vaginal wall, may also become a cause of dystocia. Tin Parturient ( 'anal. 9] Budin, who has particularly studied this cause of dystocia, has clearly established the fact thai this anterior portion oi the Levator may be an obstacle to exploration, to coitus, ami to delivery. £ a Bulbusvestibuli Ischio-cavern- ous muscle. Oe^ptransverse External sphincter of the anus. Fig. ioo. — Schema representing the superficial muscles of the perinreum. Thus constituted the levator perinsei is to the abdominal cavity (at the inferior pelvic opening) what the diaphragm is to the inferior thoracic opening. The perineal elevator is covered and completed superficially by a series of muscles, which must be described in brief. Of these muscles, one surrounds the termination of the 92 The Parturient Canal. intestine ; this is the external sphincter of the anus. The others are disposed around the vulva. They are: 1. The constrictor of the vulva, a muscular ring enveloping the vaginal bulbs. Its contraction produces inferior vaginismus. •2. The superficial transverse muscle, a muscular band thrown from one ischium to the other. 3. The deep transverse muscle, a simple muscular vestige pass- ing from the ischio-pubic ramus to the corresponding bulb of the vagina. 4. The ischio-cavernous muscle, enveloping, along the ischio- pelvic rami, the root of the cavernous bodies. 5. Wilson's muscle, composed of some muscular fibres passing from the internal surface of the pubis to the urethra. Fig. ioi . — Antero-posterior section of the muscles and aponeuroses of the perinaeum (Schema). MW, Wilson's muscles; T P, deep transverse; CV, vulvar constrictor; T S, superficial transverse; R C P, coccy-peritonseal elevator; S A, anal sphincter (external sphincter]. Thus we have two muscular planes constituting the perinseum : A deep plane, consisting of the perineal elevator, which is, conse- quently, the pelvic diaphragm ; a superficial plane, represented by the muscles subjacent to the skin. Through these tissues pass vessels and nerves. Thus comprised, the perinaBum gives passage to three important organs, the rectum behind, the urethra in front and the vagina in the middle. To terminate the study of the geni- tal canal there remain for description the vagina and its appendage, the vulva. The Partwrient Canal. 98 The vapina is a canal of cylindrical form, inserted byita superior emity on the cervix, forming the culs-de-sac, and continai its inferior extremity with the \ nlva at the level of the hymen. Its length is ten centimetres, measured to the posterior cul-de-sac. Its externa] Burface is in relation to the surrounding viscera, the rectum behind, the bladder in front; and inferiorly, muscular relations with the pelvic floor. Thus the vagina forma a largo and spacious cavity in the vicinity of the uterus and becomes narrowed at the vulva. Praputium clitoridis. Clitoris. Labia majora. Labia minora. . Urethral tubercleand ^ urethra. Vaginal orifice. Hymen. Fossa naviculars. Perinaeum. Anus. / Mons veneris. Labia majora. Orifice of Bartholin's Iw S 5 ~ "iSfc " gland. Fourchette. Fig. 102. — Virginal vulva. In exploring the internal surface of the vagina, by separating the two walls, it is found to have a rosy tint, in the normal state ; a violaceous during pregnancy. On both the anterior and posterior walls exists a longitudinal projection called the vaginal column (anterior and posterior). The vagina is composed of three coats : an external, composed of connective tissue and elastic fibres ; a middle, of non-striated mus- cular tissue, of which the eccentric fibres are longitudinal, and the concentric circular, an internal, mucous, totally deprived of glands but rich in papillae that are covered by stratified pavement epithe- lium. 94 The Parturient Canal. The vulva is composed of three successive and concentric planes : First plane. — Mons veneris, labia majora, perinceum. — The labia majora form two vertical folds, blending above with the mons veneris, and becoming effaced below on the perinseum. In the center of the oval thus formed are found the other vulvar parts. The external surface of the labia is cutaneous and covered with hair ; the internal surface is smooth, normally moist and the two labia are often in contact. This contact is destroyed by the separation of the thighs. Second plane. — Pr&putium clitoridis, nymphce, fourchette. — The nymphse are two folds analogous with and parallel to the labia majora, but much more thin. Above they separate to enclose the clitoris. Of the two folds formed by this separation, one forms the prepuce of the clitoris, the other forms the frsenum. Below, the nymphfe diminish, and are united by a small fold called the fourchette. Vagina. ■**-. ^____^---r Post-navicular commissure. V Navicular fossa. ^- ^ Anterior navicular commissure \ _>»^^ •• Ano-vulvar perinaeum. Fig. 103. — Perineo-vulvar profile. Third plane. — Vestibule, meatus urinarius and its tubercle, vagina and hymen. — In the space circumscribed by the base of the nymphse is found an elliptical surface that can be considered as divided into two equal parts by a transverse line. Above this line is the vestibule, below it is the vaginal orifice. The vestibule presents the urethral tubercle with the meatus urinarius. The vaginal orifice, below this, is more or less protected by the hymen, or the carunculse which represent its remains. The fossa navicularis is a small depression situated between the fourchette and the hymen or its debris. Laterally the fossa navicularis is lost on the sides of the vulva ; anteriorly and posteriorly it is limited by the anterior and posterior navicular commissures (Fig. 103). The vulva is separated from the vagina by the hymen. The intact hymen may pic -cut various conformations (Figs. 104 to 111). At the first coitus the hymen is usually ruptured, leaving the hymeneal carunculse (Fig. 112). After accouchement, these ruptures become deep and by isolated cicatrization form the carunculse myrtiformes (Fig. 113). In rare cases the hymen may remain intact after coitus, and even after parturition. In exceptional cases, pregnancy has been noted with an imperforate hymen. Tin Parturient Canal. '.'.", Resume of the parturient canal. — Planes and axes. — The parturient canal, consisting, as has been seen, of an osseous passage and of a Boft passage, is somewhat modified in it- 08S< ous portion by the presence of soft parts which retract the different diameters of the pelvis, but which, nevertheless, do not alter the general form. Fig. 104. — Crescent hymen. Fig. 105. — Hymen with a small diaphragm. F;g. 106. — Hymen with a large diaphragm. Fig. 107. — Cleft hymen. Fig. 10S. — Fringed hymen. FlG. 109. — Hymen with double slit. FlG. 1 10. — Hymen with a double orifice. Fig. in. — Cubiform hvmen. Fig. 112. — Hymeneal caruncul.-e. Fl 3. 1 13. — Caruncula: myrtiformes. The plane of the superior strait, with the woman in the erect position, forms an angle of sixty degrees with the horizontal. The plane of the inferior strait is more closely approached to the hori- zontal, but without coinciding with it. This difference of inclination is due to the unequal bight of the pelvic walls, winch, in front 96 The Parturient Canal. (pubis) measure five centimeters, and behind (sacrum) ten cent metres. The axis of the superior strait, that is the perpendicular to the center of its plane, passes from the umbilicus toward the middle of the coccyx. That of the median strait extends from a point situated a little in advance of the promontory toward the anus. The direction of the axis of the pseudo inferior strait is quite variable on account of the mobility of the coccyx. The direction of these axes is very important in practice, for they indicate the direction in which the tractions on the foetus should be made. Fig. 114.. — Fish-hook curve of the parturient canal. The general axis of the parturient canal, from the superior strait to the vulva, is not an arc of a circle, as described by Carus, nor an angle, as maintained by Fabbri, but rather a fish-hook, as Tarnier has indicated, that is, rectilinear in the osseous portion and curved in the arc of a circle in the soft parts (Fig. 114). This curve is of the greatest interest to the obstetrician, as will be seen later. Presentations and Positions. 07 CHAPTER V. PRESENTATIONS AND POSITIONS. Presentations. — The foetus, enclosed in the uterine cavity, is separated from the exterior by the parturient canal, which it must traverse at the moment of labor. For this exit, it may he placed in different ways, presenting to the genital opening so many different regions of the body. The symptoms furnished by foetal exploration and the mechanism of delivery, will necessarily vary according to these different cases. The necessity of a classification of the foetal presentations is thus imposed on obstetricians. Eolled up in the uterine cavity, the child is generally flexed. This general flexion is accomplished by a series of partial flexions. Thus, the head is flexed on the trunk, the forearms on the arms, the hands on the forearms, the thighs on the trunk, the legs on the thighs, the feet on the legs— flexion everywhere. In this attitude, which singularly favors the reduction of the foetal mass, the child offers the form of an ovoid, the large extremity corresponding to the breech and the small extremity to the head. This is the somatic ovoid. The somatic ovoid (Fig. 115) is divided, as explained before, into the cephalic ovoid and the cormic ovoid. Fig. 115. — Somatic ovoid formed by the union of the two ovoids, cephalic and cormic. The cephalic ovoid, though smaller than the cormic ovoid, is le-s reducible. Its great axis extends from the chin to the sagittal suture, a little in advance of the lambda. Considered in its trans- verse dimensions, it presents a series of points serving as marks of 98 Presentations and Positions. other diameters ; these are the biparietal, bifrontal, bimalar and biasteric. The cormic ovoid, more or less deformed by the addition of the superior and the inferior members, presents its great diameter from the breech to the summit of the thorax. It also offers transverse diameters, such as the bisacromial and bitrochanteric. These two ovoids are united by the neck. Fig. i i 6. — Vertex presentation. Fig 117. — Face presentation Fig. 118. — Brow presentation. Fig. 119. — Breech presentation. Fig. 120. — Thorax presentation. The foetus presents at the genital canal, usually by the cephalic Presentations and Positions. 99 ovoid, sometimes by the cormic ovoid. But every ovum, to pass through the parturient canal, may open it by the large or by the 1 extremity, or, again, transversely. Theoretically, there are, then, three presentations for every ovoid : large end, small end, and transversely. The Bame is true with regard to each of the fcetal ovoids. Fig. 121. — Abdomen (lumbar) presentation. The cephalic ovoid may, in fact, present : 1. Sometimes by its large extremity (vertex) (Fig. 116). 2. Sometimes by its small extremity (face) (Fig. 117). 3. Sometimes transversely (brow) (Fig. 118). The cormic ovoid also may present : 1. Sometimes by its large extremity (breech) (Fig. 119). 2. Sometimes by its small extremity (thorax or shoulder) (Fig. 120). _ 3. Sometimes transversely (loins or abdomen) (Fig. 121). We have then six presentations : Cephalic ovoid. Cormic ovoid. 1. Vertex. I. Breech. 2. Face. 2. Thorax (shoulder). 3. Brow. 3. Abdomen (loins). The vertex and the breech are identical ; they represent the large extremity : one the cephalic ovoid ; the other the cormic ovoid. The face and the thorax are analogous, they represent the two small extremities. The analogy is the same for the brow and the lumbo- abdominal region ; the ovoids are placed transversely. Of the six presentations, each comprise one of the zones of the two fcetal ovoids limited by the following planes : For the cephalic ovoid, two planes perpendicular to the long axis of the head, passing, one through the root of the nose, the other through the posterior angle of the bregma. For the cormic ovoid, two planes, also per- pendicular to the long axis, and passing, one through the summit of the iliac crests, the other through the point of the zyphoid ap- pendix (Fig. 122'. 100 Presentations and Positions. Relative frequency of these different presentations Vertex, Face, - - Brow, - - Breech, Thorax, Abdomen, 19 out of 20 parturitions. 1 " 250 1 " 300 I " 30 1 " 125 1 " 1000 " (Relatively too high) The following proportions may also be adopted. Out of one thousand parturitions there exist : Vertex, Face, - - Brow, - - Breech Thorax, - Abdomen, 956 deliveries. 4 3 30 6 1 " (I recall again that 1 to 1000 for the abdomen is relatively too high.) Occipito - mental J j.j" p- ace portion. 1 m ; Br0 ^ Pelvi-cervical portion. I. Breech. II. (Shoulder) Thorax. III. Back and abdomen. Fig. 122. — Schema of presentable zones. Each of these six presentations has four varieties. These varieties are of secondary importance to the cephalic ovoid, and only indicate a simple inclination of the foetal part which presents. A simple enumeration will be sufficient : I. Vertex. — Variety, Occipital (exaggerated flexion). Frontal (flexion little marked). Right parietal (right parietal quite accessible). Left parietal (left parietal quite accessible). Presentations and Positions. lul II. Face. — Variety, III. Brow. — Variety, (Mental (extension). I (extension not marked). Right malar (right malar quite accessible). Left malar (left malar quite accessible). (Parietal (tendency to flexion). Facial (tendency to extension). Right temporal (right temporal quite accessible). [ Left temporal (left temporal quite accesiblej. For the cormic ovoid, on the contrary, these varieties are im- portant, for they lead to practical consequences that will be studied later. FiG. 123. — Complete breech. I. Breech. — 1. Complete variety. — The inferior limbs are flexed and close to the pelvis. This is the type for presentation of the breech (Fig. 123). 2. Incomplete variety. — Thighs. — The pelvic members are raised up along the anterior plane of the foetus (Fig. 124). 3. Incomplete variety. — Knees. — The thighs are extended, but the legs flexed on the thighs, so that the knees constitute the lowest foetal part (Fig. 125). 4. Incomplete variety. — Feet. — The inferior limbs are extended, and the feet descend first (Fig. 126). II. Thorax — 1. Variety of the right shoulder (that is, the region of the right shoulder presents.) 2. Left shoulder. 3. Back (thoracic portion). 4. Sternum. 102 Presentations and Positions. Thus one of the four surfaces of the thorax presents (anterior, posterior, right or left lateral). Fig. 124. — Incomplete breech, thigh variety. III. Abdomen. — 1. Variety of the right flank. 2. Left flank. 3. Lumbar regions. 4. Umbilicus. FlG. 125. — Incomplete breech, knee varrety. Thus, as for the thorax, the variety is constituted by the region of the abdomen (anterior, posterior, right or left lateral) presenting. ntations and Positions. 103 I present the following table, placing the figures relative to each presentation and their varieties, which indicate the frequency. Fig. 126. — Incomplete breech, foot variety. I. Vertex, 956 per 1000. f Occipital, ... v • J Frontal, - variety, -, Right Parieta i > [ Left parietal, - (?) - (?) - (?) - (?) II. Face, 4 per 1000. f Mental, ... ,. J Frontal, ... Variety, j Right makr> . . |^ Left malar, • (?) - (?) - (?) - (?) Ill . Brow, 4 per 1000. f Parietal, v - J Facial, .... | Right temporal, [ Left temporal, - (?) " (?) - (?) - (?) IV. Breech, 30 per 1,000. f Complete, ... v . | Incomplete, thighs, j Incomplete, knees, [ Incomplete, feet, 450 per 1000 300 " " 5 " " 245 " « V. Thorax, 6 per 1000. f Risiht shoulder, v . j Left shoulder, vanety, j g^ .... 500 per 1000 495 " '• -> i< (< [ Sternum, 2 " " VI. Abdomen, 1 per 1000. f Right flank, - Variety \ Left flank ' . ' " " - ' | Lumbar regions, [ Umbilicus, • (?) • (?) - (?) - (?) 104 Presentations and Positions. Causes of the presentations. — Accommodation, or adaptation of the contained foetus to the containing uterus, regulates the situation of the child during pregnancy. The laws of this accommodation are two in number and may be formulated thus : First law (uterine law). — Every contractile containing body adapts to its own form and dimensions its contents even inert, provided it is sufficiently resisting (that is, accommodation can be made with a fcetus recently dead). Second laic (fcetal law). — Every living contents, endowed with active movements, adapts its forms and dimensions to those of a containing body even inert, provided it is sufficiently resisting. Now, these two essential conditions of accommodation wiU be re- united : with a firm and contractile uterus ; with a vigorous and moving fcetus. The general form of the fcetus is, as we have seen, that of an ovoid, with the large extremity corresponding to the breech, the small extremity to the head. The general form of the uterus is that of an ovoid, with the large extremity corresponding to the fundus, the small extremity to the inferior segment. Accom- modation brings the breech of the fcetus to the fundus of the uterus and the head in the inferior segment. We now know why the fcetus normally presents by the vertex. Let us review the various causes which modify this physiological state and cause other presentations. We shall need to examine successively the pelvis, the uterus, the ovuline appendages and the accidental causes, such as traumatism. 1. Pelvis. — In the normal state, with a presentation of the vertex, the head during the latter part of pregnancy engages in the pelvic excavation. This engagement, by fixing the foetal part, assures the preservation of the presentation. But when any cause (contraction of the pelvis, pelvic tumor) renders difficult or impossible the passage of the superior strait, the head remains mobile and the fcetus, not being fixed, is exposed to mutations of presentation. 2. Uterus. — Normal accommodation in presentation of the vertex supposes a uterus sufficiently resisting and of an ovoid form with the small extremity inferior. Any exaggerated flexibility of the uterus, or any alteration of its normal form, becomes a cause of vicious presentations. By this mechanism act : Excessive multiparity; by causing a relaxation of the uterine wall, and of the abdominal wall which sustains it. The foetus re- mains mobile to the moment of delivery, and in one of its evolutions may become fixed in a vicious presentation. Lateral and anterior inclinations of the uterus ; these inclinations, whether real or apparent, involve the foetus in their deviation, so that its axis no longer corresponds with that of the pelvis. The result is seen in vicious presentations. Presentations hould be limited. 128 Symptomatology of Pregnancy. From menstruation, on the contrary, may be deduced signs of great value. Every arrest of menstruation in a healthy woman, normally regular, should bring to mind the possibility of the existence of pregnancy Conception may take place at any period of the inter-menstrual period or during the menstrual flow, but in the majority of cases it occurs during the ten days following the end of menstruation. From this moment of conception the menstrual flow doi'S not appear. There are, however, exceptions, and some women continue to menstruate during pregnancy. It has been objected that menstruation during pregnancy is modified in duration, quantity or quality. But, practically, the woman reports a periodical flow of the same abundance and quantity as before pregnancy. There is then nothing to show that this flow of blood differs from normal menstruation. It is just to conclud that this woman is menstruating but it must not be deduced that the uterus is empty. Conclusion: If the cessation of menstruation is one of the best signs of the be- ginning of pregnancy, we must not base an affirmation of the vacuity of the uterus on its persistence. The development of the abdomen is only perceived by the woman at the end of a certain stage of pregnancy (two months and some- times even more). Soon after conception, some women perceive a certain flattening of the abdomen. The development of the ab- domen, generally perceived clearly at the end of the fourth month, rarely progresses with regularity. All other tilings being equal, the development of the abdomen is as much more considerable as the number of pregnancies becomes greater — a fact explained by the increasing laxity of the abdominal walls. We shall ignore the exact date at which the first movements of the child are perceived, but we know that they are generally felt at the beginning of the fourth month. In general, it is at four months and a half that these movements are perceived, sometimes later. Some pregnant women never feel them. The descent of the uterus resulting from engagement causes pelvic obstruction (frequent urging to urination, exaggeration of the con- stipation) and a thoracic relief (easier respiration). At the same time the abdomen seems to diminish in volume. Women usually can give quite exact information on these different symptoms. 2. Inspection. — The inspection of the abdomen and of the ex- ternal genital organs reveals a series of modifications, that have already been discussed and which I only recall here. On the side of the abdominal wall, besides the distention produced by the in- crease in the size of the uterus, are noted the linear albicantes, es- pecially numerous in the subumbilical region, and the brownish Symptomatology of Pregnancy. 129 pigmentation along the linea alba. The external genital org besides oedema and varices, undergo a hypertrophy which give them a swollen aspect. The vestibule and th • vulvo- vaginal orii a violaceous coloration thai is also found i a the vagina and cervix by using a Bpeculum. This coloration sometimes aids the diag- nosis of pregnancy, bui it is nol pathognomonic. Besides this, there is found sometimes in brunettes a diffuse pigmentation of the vulva, especially marked on the labia majora. 3. Palpation. — Percussion is a variety of palpation but while it occupies a considerable place in medicine, its part is of slight importance in obstetrics. Percussion can only serve to give infor- mation as to the height of the uterus and on the contents of normal or pathological organs situated around or in front of the uterus. I shall not insist on these secoudary ideas hut pass at once to pal- pation itself. For palpation the woman should be disrobed, preserving no garment that will obstruct abdominal palpation. Save in rare ex- ceptions the horizontal decubitus is indispensable, the head a little elevated, the limbs extended and slightly separated from each other, the arms stretched along the body, all the muscles being relaxed as much as possible. The obstetrician should have warm huids, for a cold contact predisposes to muscular contraction. The physician places himself to the right of the patient and proceeds with extreme slowness. , The palpation consists of three portions: (A). Prauterine, in which the abdominal wall and the organs around the uterus are explored ; (B) The uterine, where the walls of the uterus arc- examined ; (C) The infra-uterine, in which the contents of the uterus are in question, that is the ovum itself in the case of pregnancy. Let us examine each of these in succession : A. Prteuterine. — The thickness of the abdominal wall will he appreciated by pinching it up in front of the uterus. Pra^uterine palpation affords information as to the presence of intestinal loop- in front of the uterus, on the degree of distention of the bladder, when this reservoir exceeds the superior strait. In this pra?uterine exploration, the fingers will often feel the round ligaments, forming a cord quite clearly perceptible during pregnancy, especially when it is the seat of varices, and sometimes one of the ovaries. In this exploration will be recognized the tumors developing at the expense of the abdominal organs. B. Uterine. — By following the contour of the uterus, its height above the symphysis or above the umbilicus will lie determined, an important observation in determining the date of the pregnancy, and its inclination to one side or the other of the abdomen will be recognized. Supple in a normal state, the uterine wall becomes 130 Symptomatology of Pregnane}/. resistant during contraction. In cases of excessive softness of the uterus, this contraction hecomes necessary to afford a clear contour of the organ and to reveal the peculiarities of its conformation. By palpation the approximate thickness of the uterine wall can he determined. This is especially to be appreciated by the degree of the distance of the foetal part. Some uterine walls appear so thin by the superficiality of the foetus as to give the impression of an extra-uterine pregnancy. Uterine exploration also affords infor- mation on the existence of malformations and on the presence of fibroids. The latter, when of small size, may be mistaken for foetal parts, but their immobility and their preception during uterine contraction will avoid an error of diagnosis. C. Intro-uterine. — We arrive at the exploration of the uterine contents, which constitutes the third and the most important portion of palpation. In palpation of the ovum, many of the sen- sations imparted by the foetus are exact, many of those given by the appendages (placenta, cord, amniotic liquid) are vague. In exceptional cases it is possible that a special doughiness may sepa- rate the fingers from the fcetal plane, this supposes a placenta at this point. I have never felt such a sensation. When the abdomi- nal wall is very thin the fingers may meet a cord surrounding the fcetal trunk. The liquor amnii in normal quantity gives a fluctu- ation as a whole analogous to that obtained at the surface of a large abscess. The foetus, however, is the principal aim of our explo- ration, and the hands, separated from it by the utero-abdominal wall, should become familiar with it. Before going further in this study, it is important to note two important signs that are to be considered as positive signs of pregnancy. I speak of passive move- ments and of active movements of the foetus. The first attest the presence of a foetus and the second indicate that the child is living. The first -is furnished by preference by the foetal head, the second by the thoracic members and especially by the pelvis. 1. Passive movements. — Usually designated as balottement these movements are produced in the following conditions (I suppose the foetal head at the fundus of the uterus, two or three fingers are applied mediately at its point of contact) : a. A sudden concussion is .iven to the fcetal head by depressing the abdominal wall; the fingers receive the sensation of a distant flying body — single sen- sation (of departure), h. Often, the hand being left in place, at tlif end of a few seconds the head returns to its first position and imparts a shock to the fingers — double sensation (of departure and of return), c. If the two hands are applied to the lateral extrem- ities of the head, the fcetal head pushed suddenly by one hand gives a sensation of departure, comes against the other hand, a second sensation of shock, and then returns to its first position, giving a Symptomatology of Pregnancy, 181 third shock treble Bensation (of departure, of Bhock. and of return). Such are the varieties of balottement, I add abdominal, for we will later that there exists a vaginal. Balottement constitutes a positive sign of pregnancy, on one con- dition, which is that the tumor giving this sensation must be intra- uterine. This condition is, in fact, indispensable, for it sometimes happens thai abdominal tumors may float in an ascitic fluid. I have met two cases of abdominal tumors producing ballottement, but these tumors are never intra-uterine. Every intra-uterine tumor which imparts the sensation of ballottement, indicates, then, with certainty, the presence of a foetus. 2. Active movements. — By applying the hands for some time on the abdominal wall there are felt slight shocks produced by the feet i if the foetus uplifting the utero-abdominal wall, more rarely by other foetal parts. These movements are often perceptible to vision. Besides these slight shocks the hand sometimes perceives a more extended movement, caused by the displacement of the foetus as a whole. These movements, easily perceptible to the mother, are often a cause of error on her part on account of the possible con- fusion with other analogous sensations ; but it is not the same when they are perceptible to the physician. A shock clearly perceived by the obstetrician at the surface of a tumor of the abdomen, with- out the interposition of the intestine between this tumor and the abdominal wall, indicates the positive presence of a living foetus. Active movements, perceived by the obstetrician, are, then, a positive sign, but on condition of the absence of the intestine, for contractions of this organ may sometimes simulate foetal move- ments. Now, percussion easily detects the presence of the intestine by its sonorousness. Muscular contractions of the abdomen can not simulate fcetal movements, for the surface of their production is too large. I add in conclusion that these active movements to constitute a positive sign must be dearly perceived. Having studied the active and passive movements of the foetus, let us pass in review the details of the peculiarities of fcetal palpation. The head is distinguished by its hardness, its rounded form and its mobility, in the absence of engagement in the pelvis. The last character is absent when the head is fixed in the pelvic ring, but the other characters are sufficient then for its recognition. In case of doubt, the groove constituted by the neck will be a valuable mark to distinguish the head from the breech. The breech is regular at one side (buttocks), irregular at the other (pelvic members). It appears larger than the head, when it is complete (thighs flexed and close to the body), less in size, on the contrary, when it is incomplete. Exceptionally it furnishes the sensation of ballottement. 132 Symptomatology of Pregnancy. The thorax and the abdomen are not more often accessible than the back of the foetus, and are simply revealed by a certain resist- ance to the exploring hand. Sometimes the crest of the spinous apophyses can be felt. The shoulder will be recognized by the pro- jection it forms in the vicinity of the cephalic extremity. AVith regard to the pelvic or thoracic limbs, outside of the active movements by which they are so frequently manifested, they appear in the form of a tumor, cylindrical or rounded, easily displaced. Epigastrium. Hypochondrium. Iliac fossa. Hypogastrium.. Fig. 163. — Schematic division of the uterus into different regions. With this knowledge of each fcetal part, we can begin the study of the diagnosis of the presentations and positions by the aid of pal- pation. The first fcetal part that should be sought, on account of the clearness of the sensations which it furnishes, is the head. When the situation of the head can be exactly stated, fcetal pal- pation is three-quarters completed. Let us then take up the search for the cephalic ovoid. Fig. 163 shows the different regions of the uterus, each corresponding to an analogous region of the abdomen. Besides the umbilicus, which is the central and median region, the head may occupy : 1. The hypogastrium. 2. The iliac fossa (right or left). 3. The flank (right or left). 4. The hypochondrium (right or left). 5. The epigastrium. 1. The head in the hypogastrium (mobile or engaged). — This situation is much the most frequent, for the hypogastrium leads to the partu- rient canal and vertex presentations are the rule. The head, at the Symptomatology of Pregnancy. L88 hypogastrium, may be found in two \< . y different conditions, mobile above the superior strait, or fixed iii the parturienl canal. When the head is mobile at the level of the superior Btrait, more or Less approached to it, presentation exists, for the fceta] part is ,-it thr entrance to the genital canal, but it may be easily modified, either spontaneously or artificially. When, on the contrary, the head has penetrated into the pelvis, the presentation, without he- coming absolutely definite, takes a stability much more marked. Mel die at the superior strait, the head may engage by the vertex, face or brow. Thus it is impossble to exactly state in advance whichone of these presentations will become definitive at the moment of engagement. The obstetrician must then be contented to say in such eases, presentation 6f the cephalic ovoid. But when the head has penetrated into the excavation, mutations of presentations are rare, so that at this moment, save some restrictions, an exact diag- nosis becomes possible. Fig. 164 — Search for the head in the hypogastrium. Let us examine these different cases. To seek the head in the hypogastrium, the hands are applied as in Fig. 164. At about rive centimetres above the superior strait, one seeks, by approaching the extremities of the fingers of the two hands, to grasp the body which may lie interposed between them. If the head is found at this level its characters are revealed and it will he more or less 134 Symptomatology of Pregnancy. mobile. If the head is riot met in this first exploration the extrem- ities of the fingers are depressed a little ; the superior strait is then sought and, at need, even the excavation. If the head is at this level we find : A. Presentation of the vertex. B. Presentation of the brow. C. Presentation of the face. (The last two exist at the moment of labor). Fig. 165. — Search for the engaged head in presentation of the vertex (Pinard). A. Presentation of the vertex. — On one side the hand finds with difficulty the resisting plane furnished by the head ; on the other it is quickly arrested by a projecting tumor, clearly appreciable (Fig. 165). The part of the head difficult to find is the occiput, the other projecting, easily explored, is the forehead. According as the pro- jection is more or less marked, the exploring hand will note whether the forehead is turned posteriorly, transversely or anteriorly. This simple exploration, made with precision, permits the recog- nition of both the presentation and the position. Exploration of the trunk, which will be explained later, will complete this diagnosis. B. Brow presentation. — On one side is a voluminous tumor, more projecting than the forehead in vertex presentation and here con- stituted by the occiput (Fig. 166). On the other side is an unequal tumor 'jiving sensation of an incomplete clearness. This is the in- ferior part of the face and neck. C. Face presentation. — On one side is a projection, relatively large, seemingly constituting by itself all the foetal head; this is Symptomatology of Pregnancy. IBS the occipito-parietal projection, the same as found in brow presen- tations but exaggerated by the extension of the head (Fig. 107). Fig. 166. — Brow presentation with head engaged. Fig. 167. — Face presentation with head slightly engaged. 136 Symptomatology of Pregnancy. This projection is separated from the trunk by a very clear de- pression. On the opposed side the face is explored with difficulty, though in cases of rnento-anterior the inferior maxillary constitutes at this point a sort of horseshoe. If we compare the three presentations of the cephalic ovoid, we see that palpation of the head gives a projection much- more marked on one side than on the other. Projecting side of the head. — Vertex. — Frontal region. — Marked projection. Brow.— Occipital region. — More marked projection. Face.— Occipito-parietal region. — Very large projection. Retreating side of the head. — Vertex. — Occipital region. — Smooth. Brow. — Face and neck. — Uneven. Face. — Contour of inferior maxillary. — Uneven. Fig. 168. — Thorax presentation; variety; left shoulder. In proportion as the head descends into the parturient canal, ex- ploration becomes more difficult. Finally, at a given moment during labor, the head becomes no longer accessible to palpation. After having recognized and determined the situation of the head, it is necessary to explore the breech and the back to complete tin- palpation. The breech is found in one or the other hypo- chondrium, in general in that which corresponds to the brow (with vertex presentation), rarely on the median line at the epigastrium. The buck, according as we have to do with a vertex, a brow, or a face -entation, will be found more or less approached to the uterine Symptomatology of Pregnancy. L87 wall. Palpation of the Bhoulder may aid in completing a doubtful or difficult diagnosis in Borne cases. FlG. 169. — Presentation nul (breech and head in the flanks). Fig. 170. — Abdomen presentation (breech in the iliac fossa and head in the flank). •2. The head in the iliac fossce (right or left) .—The head is recognized by its usual characteristics. The breech is generally situated in the flank or in the hypochondrium of the opposite side. According to the situation of the back, that is to say of the vertebral column, we have, when it looks forward or backward, presentation of the thorax, shoulder variety, right. or left (Fig. 168); when it looks 138 Sinnpiomatology of Pregnancy. upward or downward, presentation of the thorax, sternal or dorsal variety. The diagnosis of the presentation will, in general, he possible by palpation, from the exact determination of the head and that of the hack. Back to the front, smooth plane. Back to the rear, small parts of the foetus. Where this last point is diffi- cult to elucidate in a clear manner, we may arrive by palpation at an exact statement of the presentation without being able to affirm the variety. 3. The head in the flank (right or left).— When the head is in one of the flanks, it can be recognized by palpation from its usual char- acters. The breech is found in the opposite flank or in the neighboring iliac fossa. In the first case there is no presentation, for the trunk is distant from the opening of the genital canal (Fig. 169). To constitute a presentation a very marked flexion of the foetus would be necessary, so that the child will lie in the inferior segment of the uterus, as in a hammock. Then we would have a presentation of the abdomen (Fig. 170). In the second case (Fig. 171), the breech being in the iliac fossa, if its position is maintained at the moment of labor, we would also have, and more markedly than above, a presentation of the ab- domen. But at this moment the breech generally descends into the superior strait, then into the excavation, and presentation of the breech is thus constituted in place of that of the abdomen. 4. The head is in the hypochondrium (right or left) or in the epi- gastrium. — When the head is at the fundus of the uterus, either at the epigastrium or in one or the other hypogastrium, the breech is found at the entrance to the parturient canal, that is, there exists a presentation of the breech. The head most often occupies the hypochondrium toward which is turned the anterior plane, or the sternum of the foetus, the same as the breech in presentations of the vertex. The complete breech does not engage in the excavation during pregnancy. This is not so with regard to the breech in the incom- plete variety of the buttocks, that is found below the superior strait during the ninth month, and might be mistaken for the vertex in a rapid examination. Palpation, of the head in the fundus of the uterus, of the breech in the hypogastrium or engaged in the excavation, and finally, of the back, placed to the right or to the left, permits us to state actlythe foetal situation, and to determine the presentation as well as the position. By palpation we can also recognize whether the breech is com- plete or incomplete variety, the volume of the foetal part being more siderable in the first case, and the feet being sometimes per- ceptible in the vicinity of the head in the second. Symptomatology of Pregnancy. 189 Palpation also affords exact information on the diagnosis of twin pregnancies, on the death of the foetus, and as to different patho- logical states. Borne words on the difficulties of palpation and we shall have finished with this method of exploration. These difficulties may be met at each one of the thr< e portions thai have been discussed. Fig. 171. — Complete breech presentation R S I A. 1. Prceuterine. — Fatty infiltration of the abdominal wall makes the sensation obscure in obese women. Exaggerated sensitiveness of the abdominal wall may obstruct palpation to such a point that in cases where precision of diagnosis is indispensable it is neces- sary to have recourse to anaesthesia. Uterine anteversion may render fcetal palpation very difficult. In this case the fundus of the uterus must be pushed as far backward as possible. 2. Uterine. — Tumors of the uterine wall (multiple fibroid.-), rigidity of this wall in primiparae, or in hydramnios of twin preg- nancy, obstruct the hand in exploration of the foetus. This may also occur from too frequent contractions of the uterus during pregnancy and especially during labor. 3. Intra-wterine. — An excess of the amniotic liquid, twin pregnancy and death of the fcetus are causes of difficulty that experience alone can surmount. 4. Auscultation. — From experience it has been learned that by applying the ear to the abdominal wall of a woman toward the term of pregnancy, there can be heard four varieties ofsounds : 140 Symptomatology of Pregnancy. Mother. y Foetus. A. A maternal souffle, ... B. A foetal double pulsation, C. Fceto-funicular souffle, D. Sounds of foetal movements, - - ) Before beginning the study of these sounds, some preliminary words on the mode of practicing obstetrical auscultation will be useful. Preliminaries. — The woman should be placed in the same position as for palpation (or better left in this position), since digital ex- ploration and auscultation generally follow palpation. The ac- coucheur remains likewise on the right side of the woman, but may change sides to complete his examination. Auscultation is either immediate or mediate : Immediate, when the ear is directly (or better, with the linen or the chemise inter- vening) applied to the abdomen. Mediate, when a stethoscope is interposed between the ear and the abdomen. This last method is generally preferred, as less offensive to the woman's modesty and as furnishing clearer and more exact results. Figs. 174, 175. — Bell of obstetrical stethoscope. The choice of a stethoscope is not a matter of indifference ; those employed for the thorax are not so favorable for, obstetrical auscul- tation. The essential condition of a good obstetrical stethoscope is that it shall have a large bell, for example, like that represented in Figs. 17-4 and 175. With these preliminaries we may proceed to the study of the different puerperal sounds. A. Maternal souffle. — The maternal souffle presents several im- portant characteristics : It is intermittent and synchronous with the pulse of the woman. If the uterus is auscultated at the same time that the finger explores the radial artery, at the moment the pulse is felt at the wrist the Symptomatology of Pregnancy. ill ear hears a sound which occupies a duration of one-quarter, one- third, or one-half of a cardiac revolution. Uterine Contraction. Maternal Souffle. FlG. 176. — Evolution of the maternal souffle during uterine contraction. Its timbre is variable; sometimes acute, sometimes grave, some- times musical. It may be situated at any point of the uterine sur- face, but is heard most often over the sides, or at the border of the insertion of the broad ligaments. Its site is sometimes single, sometimes double, sometimes multiple. When following uterine contraction, it undergoes an augmentation of intensity, then sinks below normal, to resume its first intensity when the contraction is ended. These variations are put in schema form in Fig. 176. This souffle appears generally at the beginning of the second three months of pregnancy, augments up to the commencement of the third three months, when it attains its apogee, and decreases from this time (Fig. 177). 1. Aorto-iliac theory (Hans, Bouillard). — The souffle is pro- duced in the aorta and in the iliacs compressed by the uterus. If tins were so it would he impossible to find the souffle at any point of the uterine surface, notably above the pubis where it is often met. 2. Epigastric theory (Kiovisch, Glenard). — These two authors have localized the maternal souffle in the epigastric arteries. The objection made to the preceding theory applies equally to this and demonstrates its untruth. Glenard has, besides, abandoned his theory, placing in the puerperal artery that which had formerly been attributed to the epigastric ; the puerperal artery being a de- pendent of the uterus, this author is thus ranged in the uterine theory, which will be exposed later. 3. Placental theory (Laennec, Monod). — The possibility of having two or three distinct spots where the maternal souffle can be heard invalidates this theory. 4. Uterine theory (P. Dubois). — This is the generally admitted theory, localizing in the vessels of the uterus the origin of the ma- ternal bruit or souffle; thus it is often called the uterine souffle. But, though in accord on the principle, authors differ as to what variety of vessels is involved. The schema Fig. 179 represents the succession of uterine vessels showing the divisions, and the authors cited have been placed opposite the variety of bloodvessels ad- vanced as a cause. 142 Symptomatology of Pregnancy. A physical law proves that a sonorous sound is produced when a fluid circulating in a tuhe passes from a narrow region into an en- largement ; this law demonstrates that P. Dubois is correct in sup- posing that the maternal souffle arises at a moment when the blood empties from the capillaries into the sinuses. Besides, it is not impossible that the other uterine vessels compressed accidentally by the stethoscope, by a tumor, by a foetal part, or by any analo- gous cause, may be equally the source of a maternal bruit. The maternal souffle, then, takes origin in any point of the uterine bloodvessels, but preferably at the union of the capillaries with the sinuses. z no is ^{smancjy » ?ua3o/[' J Uj & DUVN3T) B. A foetal double jndsation. — When practicing auscultation of the fcetal heart, the sounds of which have been compared to the remote ticking of a watch, there is heard (Fig. 180) : 1. A first sound, tolerably strong. 2. A short silence. Symptomatology of Pregnancy. 143 3. A second sound, more dull. 4. A long Bilence. The t'a-tul heart beats on the average one hundred and forty times a minute; one will hear, the double sound in question one hundred and forty times a minute. The number <>f pulsations being about seventy in the adult, it will he seen that the} are double this number in the fu-tus. Fig iSo. — Foetal heart sounds. The number of foetal pulsations may present quite extensive variations : Physiological limits -J ^ V Maximum, 160. mum. 120. , . . ... . f Progressive diminution, ioo, 90, 60, etc., to fcetal death. Pathological limits | Augmentation to 190, 200, in cases of intense fever of the mother. Uterine co-traction Fcetal heart sounds. / Fig. 181. — Evolution of fcetal heart sounds during uterine contraaion. During uterine contraction, the frequency is exaggerated moment- arily at the beginning, then diminishes sometimes to such a degree that the ear perceives no sound. The obstetrician should not forget this peculiarity, which may lead to a belief that the condition of the foetus is serious, when there is only a passing modification. Fig. 181, in schematizing the variations of the fcetal heart sounds during uterine contraction, shows the analogy with that taking place in the maternal bruit. During the first three months of pregnancy, it has never been possible to hear the fcetal heart sounds. Exceptionally they can be perceived during the fourth month, but more often during the first half of the fifth month ; it is in general, however, at about the middle of pregnancy that they become distinctly perceptible; their clearness progresses to the end of gestation as in the schema, Fig. 18*2, which sums up what we have said. The perception of the the fcetal heart sounds permits us to affirm the existence of pregnancy and that the 'foetus lives. However, this sign may be attached to certain causes of error ; thus the maternal cardiac pulsation transmitted to the abdomen may be mistaken for 144 Symptomatology of Pregnancy. the foetal heart sounds. To avoid this confusion it is sufficient to explore the maternal pulse while auscultating the mother; the syn- chronism indicates the maternal origin of the sounds. From this comes the very important precept : Never auscultate the fcetus without taking the maternal pulse at the same time. In difficult cases, the obstetrician who fears a confusion with the throb of Ms own arteries (arteries of the head, in particular the temporal) will avoid all source of error by taking his own pulse simultaneously. <*. »*J ■3 C3 <_ *i o ca o CM< ' 1 C3 CO CO > W 1 CJ P 1 C5 ' oo Ct 6 3 -J 1 These causes of error, it is seen, are very easy to avoid, and hence the exellence of the fcetal heart sounds as a positive sign of preg- nancy. The perception of these sounds permits, besides, a watch over the life of the fcetus, and during labor furnishes the physician important knowledge as to the necessity of prompt intervention when a life is in danger. It has been pretended also that by the aid of auscultation one could recognize during pregnancy the sex of the fcetus. In 1859 Frankenhauser advanced the following relation : More than one Symptomatology of Pregnancy. 1 1." hundred and forty-four pulsations to the minute, a girl; less than one hundred and forty- four pulsations, a boy. Taking up this question again in 1879 Danzats modified the preceding con- clusion. More than one hundred and forty-four pulsation- to the minute, a girl ; less than one hundred and thirty-five, a boy. Dan- zats created thus between one hundred and forty-four and one hun- dred and thirty-live pulsations a neutral zone where diagnosis impossible. From the researches of Budin and Chaignot, made the same year, it resulted that these figures had no utility in practice, and that it is necessary to renounce all ideas of diagnosti- cating the sex of the child during pregnancy by auscultation or by any of the other means proposed to this end. Finally, fatal auscultation permits us to verify the diagnosis of the presentation a ml position made by palpation, and this study will terminate the subject of fcetal heart sounds. The sounds of the fcetal heart are heard within a zone more or less extended on the abdominal wall, a zone which represents a circle of ten to fifteen centimetres diameter. In proportion as the ear or stetlioscoi* :- approached to the center of tins circle, the sound becomes clearer and stronger. This region, where the heart sounds are particularly clear, is called the focus of auscultation. This focus is usually single ; however, as will be seen later in a simple pregnancy, it may lie double, as in the case of twins. The foci of auscultation will vary with the situation of the fcetal heart ; that is, each presentation and position will have its special focus. Let us study these different foci by commencing with the presentation of the cephalic ovoid. 1. Vertex. — I will suppose the vertex engaged in the excavation (we will see later that the height of the focus of auscultation varies with the degree of engagement). I use as a diagram a series of lines which take the umbilicus as a starting point and dispose themselves in a fan shape to the different points of the pelvis, as follows (id. both sides) : Antero-superior iliac spine. Superior ilio-umbilical line. Anteroinferior iliac spine. Inferior ilio-umbilical line. Ilio-pectineal eminence. ' Umhilico-pectineal line. Pubic spine. Umbilico-pubic line. Total: eight lines. It is on the paths of these eight lines that we find the foci of auscultation of the eight positions of the vertex. Schema 183 represents the site of the different foci of auscultation at the point where each one interrupts a line ; the name of the position is given at the side. It will be remarked that for LOP there exists two foci. This the only position where this peculiarity exists. The line on which is seated the left focus is found above the left superior ilio-umbilical (supplementary line). In proportion as the back of the foetus turns 146 Symptomatology of Pregnancy. posteriorly the right focus becomes more and more clear, and, on the contrary, it is that of the left that becomes louder when the back is directed forward, approaching LOT. To reconstruct tliis schema from memory it is sufficient to recall that the focus of L A (the line of which is expressly accentuated) is found on the left inferior ilio-umbilical line. Fig. 183. — Vertex. Foci of Auscultation. Stethoscopic Fan. Foetal Part Superior Strait 2 EXCA V ATI ON 3 Medir/v. Strait VUL+t++*mtHHtVA Fig. 184. — Height of foci of Ausculation varying according to the degree cf engagement of the fcetal part. (The inferior lines indicate the height of the fcetal part which presents and the superior analogous lines the height of the foci of auscul- tation which corresponds to them.) What has been said applies to cases where the vertex is engaged in the excavation. But what is the site of the different foci when engagement has not taken place or when, on the contrary, the head Symptomatology of Pregnancy. 117 has arrived at the vulva ? Fig. 18 i responds to this question ; it is destined to show the relative height of the foci of auscultation, fol- lowing the degree of engagement of the foetal part; the upper black line corresponds to the foetal part free. These different heights being known it is sufficient to return to Fig. L88 and transport, parallel to itself, each of the foci, either up- ward or downward, according to the degree of engagement; thus we will have the successive positions occupied by the foci during the successive descent of the head. Examples : In L T, head mobile above the superior strait, the focus will be in A. In S, head fixed at superior strait, the focus will be in B. In P, head at the vulva, the focus will be in C (Fig. 185). Fig. 185. — Vertex. Variations in the height of f< cus of auscultation according to the degree of engagement ot the fcelal part. 2. Face. — I proceed likewise for the determination of the foci in the positions of the presentation of the face, supposing that labor is advanced so that the fcetal part is in the excavation. The stetho- scopic fan is given in Fig. 186. The mnemotechnic mark here is the L M A line, the same as L A for the vertex. The E M P is here analogous to L P as to a double focus, for the cardiac region of the foetus is equally distant, right and left, from the abdominal wall. Although this double focus has not been described, it is probable that it exists and for my part I have been able to recognize it in a similar case. With regard to the height of these different foci, according to the degree of engagement, I return to what has been said of the vertex. Fig. 184 applies as well to presentations of the face as to those of the vertex. 3. Forehead. — The different foci of auscultation in presentation of the forehead are not sufficiently known to allow me to touch 148 Symptomatology of Pregnancy. upon their description. They demand new study. Each presen- tation of the forehead being intermediate between a presentation of the vertex and of the face, one can take a point situated on the middle of a line reuniting the two foci of corresponding presentations and approximately fix the site of the one sought. A%t. Fig. i 86 — Face. Foci of auscultation, ;5tethoscopic fan. 4. Breech. — I suppose the breech engaged in the excavation, the foci are disposed in a fan (Fig. 187) analogous to those of the face and vertex. For Pi S P I have marked two foci of auscultation which exist probably as in L P or Pi M P, but this fact has not been verified. The line L S A is that from which the fan can be reconstructed from memory. With regard to the height of the foci, I will repeat that which has been given for the vertex and face, for since the researches of M. Eibemont, it has been shown that in a foetus doubled on itself, as it is in the uterine cavity, the heart is equally distant from the vertex and from the breech ; the height of the focus of auscultation will be the same for the vertex and for the breech with equal degrees of engagement. Presentation of the breech being very rarely accompanied by engagement during preg- nancy, it will be understood that the foci of auscultation will be found in parallel circumstances above the umbilicus. 5. Thorax. — Shoulder presentations, other than the varieties of the right or left shoulder, being rare, we have only at present de- termined the foci for these two varieties, and in their two most usual positions, that is, the right and the left acromio-iliac trans- verse, B A T and L AT. ('.. Abdomen. — The great rarity of these presentations has not yet permitted us to determine the foci of auscultation. Ii . • - i < 1 o - tin- engagement of the fVetal part, there are other causes which may produce variation in the situation of the foci of auscul- tation, such as lateral inclination of the uterus, or, again, anterior Symptomatology of Pregnancy. 1 c.i inclination, which, for example, notably lowers the focus in L T, when it is pronounced. All these variations are complications, bul tin- physician should never forget their possibility, in order i<> k< ep in mind certain apparent anomalies, the details of which are too extended to produce here. The knowledge of the preceding foci as described is not sufficient alone for diagnosis of presentation and position, but it permits us, diagnosis being firsi made by palpation, to obtain verifications by the aid of the ear, and enables the assurance that the focus is placed in the situation indie at i d for the supposed presentation and position. A focus placed in another region puts one on the track of an error committed and leads to the necessary rectification. **'*• Fig. 1S7. — Breech. Foci of auscultation. Stethoscopic fr.n. C. Fceto-funicular sovffle. — At the same time with the fcetal heart sounds, there is sometimes beard a blowing sound, usually single, exceptionally double. This souffle differs essentially from that previously studied (maternal souffle), and is easily distinguished from it, for tbe first is synchronous with the pulsations of the mother, tbe second, with tbe fcetal pulsations. The fceto-funicular souffle recognizes, as its name indicates, a double origin: Either the foetus, cardiac (heart) souffle: or the cord, funicular (vessels) souffle. The cardiac souffle of the foetus is due either to a lesion of tbe valvular orifices, as in adults ; to an in- sufficient permeability of the foramen ovale; or, with a normal heart, to modifications in the blood, producing sounds analogous to those which are designated under the name anaemic in the adult, and the pathology of which is still unknown. The funicular souffle, exceptionally caused by the semilunar folds which exist in tbe umbilical vessels, is generally due to compression of tbe cord, either between the back of tbe child and the uterine wall, or by circular constrictions. Cbarrier, in making of this souffle a sure sign of circular constriction of tbe cord, has heen 150 Symptomatology of Pregnancy. much too positive, and is unwise in proposing premature artificial labor in' such cases to save the life of the child. We do not possess exact and sufficient symptoms to enable us to recognize the different varieties of fcetal cardiac souffle, so that all the ambition of the obstetrician should be confined to distinguishing a foetal souffle from a funicular souffle, and yet this diagnosis is not always possible. The cardiac souffle has its maximum of intensity at the focus of auscultation of the fcetal heart, and, on the contrary, the funicular souffle has its maximum of intensity situated at a different point, in the region of the cord. This sign is that which will better permit the differentiation ; those distinctions which are based on the intensity or the variability of the murmur furnish only an incomplete security. The fceto-funicular souffle has, in the point of view of the existence of pregnancy, the same semeiological value as the fcetal heart sounds — it indicates the presence of a living foetus, but its importance is very small com- pared with the existence of the fcetal heart sounds, so clear and easy to find. D. Sounds of fatal movements. — In practicing auscultation during a certain time there is perceived sometimes a rustling, analogous to that produced by the two hands applied on the ear when a slight movement is given to the outer one. Sometimes a shock is heard, sudden and dull, like that obtained when striking with one finger on the hand covering as before the pavilion of the ear. Occasionally these shocks take a peculiar regularity, as if the foetus pulsated slowly in the interior of the ovular cavity (rhythmic movements). The rustlings are due to the displacements of the foetus in totality ; the shocks, to movements of small fcetal parts which strike the uterine wall ; the cause of the rhythmic movements is ignored, besides they have no special semeiological value. The sounds of foetal movements commence with the movements themselves, that is, at the beginning of the fourth month of pregnancy, but they are not clearly per- ceptible until about the middle of the fourth month. Like the foetal heart sounds, they constitute a positive sign of the existence and the life of the foetus. However, it is important not to confuse them with intestinal sounds, nor with the shocks which abdominal muscular contractions may give to the stethoscope. These causes of error can only be avoided in the second half of pregnancy, when the perception of the foetal shock had become clear and distinct ; but at this time this symptom, which would be important if unique, generally loses its advantages by the appearance of other signs of pregnancy more easily appreciated. 5. Digital examinaiton. —The uterus is directly accessible by the vagina, indirectly by the rectum and bladder, in such a way Symptomatology of Pregnancy. 151 that the finger penetrating into these different cavities may famish valuable information on the gestating organ and its contei I exploration is dependent upon the -< use of touch. It U then only a variety of palpation. One is internal, the other is external. In these internal explorations the fingers are in contact with the mucous membrane, in palpation they are in contact with the integument. Digital examination can be made : 1. By the urethra and bladder — vesical touch. 2. By the anus and rectum — rectal touch. 3. By the vulva and the vagina— vaginal touch. I shall be brief as to the first two and shall dwell, on the con- trary, on the last. 1. Vesical touch requires a previous dilatation of the urethra, an operation which prevents its use in pregnancy. 2. Rectal touch, practiced after a previous evacuation of fecal materials, gives information on the volume of the uterus, on the 1 exact situation of tumors placed behind it and on some other points of secondary importance. It should be resorted to when vaginal examination is difficult or impossible on account of some obstacle, such as vaginismus, retraction or cicatricial obliteration of the vagina, intact or too narrow hymen. But the^e conditions are ex- ceptions and in the great majority of cases vaginal touch will be used. Fig iSq — Dorsal position. 3. Vaginal touch may be performed with the woman in the upright position or lying dowm. The upright position permits a rapid and summary examination, but very incomplete. The horizontal position is the only one which allows a conscientious and satisfactory exami- nation and, except in rare cases, it should always be used. The woman should be placed in the same position as for pal- pation, or rather left in this position, since one generally practices digital examination after palpation and auscultation, there is simply ne< ded a slightly more marked separation of the thighs (with slight flexion and the elevation of the buttocks with the aid of a cushion dorsal position) (Fig. 189). Such is the French position. In Eng- land the woman is placed on the left side, the thighs flexed at a right angle on the trunk, the upper one a little more than the 152 Symptomatology of Pregnancy, lower (lateral position) (Fig. 190). Exceptionally, and in certain pathological conditions, the woman is placed on the knees and elbows (genu-pectoral position) (Fig. 191). Fig. 190. — Lateral position. Let us suppose the woman in the dorsal position and proceed to digital examination. Exploration may be made with either hand, by preference with the right, the most used ; in this case the phy- sician places himself at the woman's right. It is important for tins to place the woman in her bed so that her right side is easily accessible. Fig. 191. — Genu-pectoral position. Digital examination or touch may be : Unidigital: practiced with the index finger, the other fingers being flexed and folded in the hollow of the hand (Fig. 192). Bidigitcd: index and middle finger (Fig. 193). The introduction of two fingers gives greater length, the middle finger permitting deeper penetration, and may be used in muciparous women with- out inconvenience. In a primiparous women this simultaneous introduction is often painful and should be avoided. Man mil . the whole hand can be made to penetrate into the geni- tal organs, usually to explore the contents of the uterus, in case of vicious presentation for example. The hand, disposed as in Fig. 194, can scarcely ever be introduced without anaesthesia. While one hand practices vaginal touch, the other should always Symptomatology of Pregnancy. 153 be placed on the abdomen, combining and completing the explo- ration. The finger that is introduced into the genital organs should be aseptic and covered with an oily Bubstance to permit an easy gliding (vaseline, oil, cold cream, cerate, etc.). Fig. 192. — Unidigital touch. Fig. 193. — Bidigital touch. Fig. 194. — Manual touch. Vaginal touch is executed, like palpation, by a series of examin- ations : 1. Vulvar. 2. Vaginal. 3. Uterine. 4. Periuterine. 5. Pelvic. The pelvic exploration is only a variety of the periuterine, but I separate them for the clearness of description. We shall study first digital examination on the non-pregnant woman, to note the changes caused progressively by the develop- ment of the ovum. A. Vaginal touch in the non-pregnant woman. — 1. Vulvar. — The vulva being easily accessible to vision, the obstetrician will derive more information from exploration of the region by the eye than by the finger. There are two orifices that it is necessary to become familiar with by touch, the urethral for catheterism and the vaginal which conducts the finger toward the cervix. Explo- ration is commenced by search for the vaginal orifice. For this the finger will be held vertically, direct along the inner surface of the 154 Symptomatology of Pregnancy. thigh, until in contact with the vulvo-perinseal region where the vulvar opening is detected. At this moment the finger is generally in contact with the perinseum and by ascending a little the vaginal orifice is reached. To determine the situation of the urethral orifice, the finger, after having found the vaginal orifice, explores the vestibule from below upward and meets a small opening, which with a little experience can be easily recognized. 2. Vaginal. — The finger in passing through the vagina passes successively the vulvo-vaginal orifice and the muscular ring con- stituted by the coccy-perimeal levator. Continuing on its way the finger following, sometimes the anterior wall, sometimes the pos- terior wall, sometimes the right or left lateral wall, arrives in the corresponding culs-de-sac which surround the cervix. I only note in passing the importance of seeking carefully for double vaginas, which often pass unnoticed. 3. Uterine. — To attain the cervix in difficult cases, it is necessary, the buttocks of the patient being elevated : a. To depress the elbow to the plane of the bed, thus giving the finger a proper direction. b. To separate successively the labia majora and minora of each side, in such a way as to insinuate the hand between them ; by this manoeuvre one can easily penetrate a finger's breadth farther. "When the cervix is examined, the anterior, lateral and posterior surface of the uterus can be explored, by successively depressing each cul-de-sac, while the abdominal hand affords a support from above downward in an umbilico-coccygeal direction. 4. Periuterine. — By depressing the vaginal wall, circularly from the posterior to the anterior cul-de-sac, the finger meets : The rectum. • The ovary ") The tube >• Broad ligament. The round ligament J The bladder, ureter, urethra. The exploration of the ovary, of the tube, and especially of the round ligament and the ureter demands great experience, and some- times the most experienced finger can not perceive them. The direction in which the finger leaving the uterus will meet the dif- ferent organs is indicated by Fig. 195. These different organs are more easily found when they become the seat of a pathological change and it is also in such circumstances that their exploration becomes useful. 5. Pelvic. — By strongly depressing the vagina and the contiguous sofl tissues, one can, without actual pain to the woman, explore the pelvic will and even arrive at the superior strait and at the sacro- vertebral angle. The great importance of this examination will be comprehended in the study of the pathological pelvis. Symptomatology of Pregnancy. ill. i'M i und nr;thr... 155 • Round ligament. •Tube. >. s Ovary. „ Rectum. Fig. 195. — Periuterine touch. B. Vaginal touch during 1 pregnancy. — We shall follow the different steps indicated above, noting the modifications caused by conception. 1. Vidvular. — There is no important change outside the hypertro- phy of its elements. k 2. Vaginal. — I simply recall the circular fold which is sometimes formed at an advanced period of pregnancy. The finger often finds small projections in the vaginal wall, a little larger than the head of a pin. These are the result of granular vaginitis, a frequent affection of pregnancy, manifested as a blennorrhagic vaginitis by a yellowish leucorrhcea, but absolutely distinct with regard to. its nature and it is not venereal, although it relates to microbes. • 3 Uterine. — At an advanced period of pregnancy, when the cervix is completely softened and its consistency identical with that of the vagina, even a practiced finger may meet actual difficulty in cervical exploration. To find the cervix in difficult cases it is necessary to follow the vaginal fundus in different directions ; in this series of successive explorations the finger will meet the organ and recognize its orifice. The finger permits us to verify the modifications of the cervix and of the body of the uterus (hypertrophy and softening). The soften- ing of the cervix and the augmentation of the volume of the body of the uterus are, at the beginning of pregnancy in the absence of positive symptoms which do not exist at this period, valuable indices for diagnosis. Toward the middle of pregnancy appears the ballottement, called vaginal in distinction from abdominal. When the finger placed in the cervix, or in one of the culs-de-sac (preferably in the anterior), impresses a slight push from below upward, it has the sensation of 156 Symptomatology of Pregnancy. a hard bod}' which retreats and, at the end of some seconds, strikes upon the finger in resuming its first position. This sensation of retreat and return is balottement. It is generally produced by the head of the foetus, exceptionally by the breech, sometimes by another foetal part. Very exceptionally ballottement may be per- ceived at the beginning of the second three months of pregnancy. In general it is only felt after four months and a half, and it becomes especially clear during the seventh month; during the ninth month it is met no longer unless there is hydramnios, for the foetus becomes too heavy and too closely surrounded to retreat before the pressure of the finger (Fig. 196). Vaginal ballottement. I Nul.» • Fig. 196. — Vaginal ballottement. Is vaginal ballottement a positive sign of pregnancy ? An analo- gous ballottement may be produced by a large vesical calculus, or by the body of the uterus in anteflection and very mobile on the cervix, or again by some periuterine tumor. Like all other positive signs, vaginal ballottement has then its sources of error, but these are avoided if, as in abdominal, all ballottement is eliminated that is not produced by an intra-uterine tumor. Vaginal ballottement produced by an intra-uterine body is, then, a positive sign of pregnancy. By this restriction the above-mentioned sources of error will be avoided, i. e., those belonging to periuterine or uterine tumors, for none of them are intra-uterine. But it is asked, How may we be assured that the tumor is intra- uterine "? This is decided by attentive exploration of the inferior segment of the uterus, and in doubtful cases, by waiting a con- traction by which we may be assured that the tumor explored is contained in the uterus. There may be doubtful cases where the obstetrician may be unable to decide, but this is no reason for eliminating ballottement from the positive signs, for with such reasoning there would remain no positive signs, not even the sounds of the fcetal heart, which are sometimes too vague to be affirmative. Digital examination also permits, at a sufficiently advanced period of pregnancy, recognition of the characters of the foetal part which presents. When this relates to the vertex there is a smooth, even, hard tumor, usually engaged in the excavation. When there is presentation of the brow, the tumor is also smooth but not engaged. In a face presentation, the tumor is somewhat unequal, with a Symptomatology of Pregnancy. l.~< smooth forehead and regular at the Bide. There is no engagement ivciy exceptional during pregnancy). The breech La recognized by tumor, less bard than the head and less equal, accompanied by small parts and not engaged when the breech is complete, often engaged on the contrary, when it is incomplete. With a presen- tation of the thorax or abdomen the fetal partis usually inaccessible during pregnancy. In many cases the details of the foetal presentation can be felt through the uterine segment and to this I shall return apropos of examination during labor, when the cervix is open. In some cases of great permability of the cervix, the exploring finger arrives at a foetal part simply covered by the membranes, and clearly recognizes the presence of a child by noting a hand, a foot, an osseous suture, a fontanelle or the ocular globe. The clear perception of a fcetal part by vaginal touch is a positive sign of pregnancy, but it is of service only in relatively rare cases. 4, .">. Periuterine mid pelvic. — The bladder and the uterus may also be explored by the finger during pregnancy, although the bladder often ascends above the pubes. With regard to the broad liga- ments and the organs they contain, their ascension with the uterus renders them inaccessible to vaginal examination. I only mention the examination of the pelvis, in which pregnancy causes no modi- fication perceptible to touch in the normal state. (The pathological modifications will be stated under puerperal pathology.) 158 The Diagnosis ot Pregnancy. CHAPTER VII. THE DIAGNOSIS OF PREGNANCY. The various signs or 'pregnancy which we shall now study in detail are divided into two categories : 1. The first, dependent on the mother, are called probable or pre- sumptive signs, for if they afford a suspicion of pregnancy and render it probable, they do not authorize its affirmation. 2. The second, dependent on the foetus, are termed positive signs, for then presence places pregnancy beyond doubt. I shall only recall these various signs, as we are now familiar with them and as their value has been discussed in describing them. A. Probable or maternal signs. 1. Genital system and vicinity. Uterus. — Suppression of the menses. Progressive increase in size. Special softness of the body and of the cervix. Intermittent contractions. Existence of the maternal souffle. Vagina. — Vaginal pulse. Violaceous coloration. Vulva. — Hypertrophy. Violaceous coloration. Abdominal wall. — Increase in size of the abdomen. Linaer albicantes. Pigmentation along the linea alba. Umbilicus : Depression, then flattening, sometimes projections. Breasts. — Increase in size. Projection and exaggerated sensitiveness of nipples. Flow of colostrum. Hypertrophy of Montgomery's tubercules. Pigmentation of the areolse, and formation of the secondary areola. Linear albicantes. 2. Nervous system. Modifications of the senses of the intellect and of the will (abnormal desires). 3. Respiratory system. Dyspnoea. Modification of the quantity of carbonic acid exhaled. The Diagnosis of Pregnancy. 159 4. Circulatory system. Globular anamia and serous plethora. • Cardiac hypertrophy. Peripheral venous dilatation (varices). • 5. Urinary system. Diminution of the solid elements of the urine. Frequency of albuminuria and of glycosuria. Frequency of disturbances of micturition. 6. Cutaneous system. Pigmentary collections. 7. Digestive system. Modifications of the appetite. Vomiting. Retardation of the different nutritive processes ; ab- sorption, assimilation, disassimilation, elimi- nation, with different diseases resulting. B. Positive or foetal signs (Six). Two obtained by palpation. 1. Passive movements or abdominal ballottement. 2. Active movements. Two by auscultation. 3. Fcetal heart sounds (or fceto-funicular souffle). 4. Fcetal movements. Two by digital examination. 5. Passive movements or vaginal ballottement. 6. Detection of a foetal part. I recall that these positive signs to be actually considered as such must unite certain indispensable conditions, which are: 1. Clearness. — When our sensations are not sufficiently exact, con- clusions should be suspended. 2. Certain peculiarities. a. For abdominal ballottement. — The tumor which gives the sen- sation of ballottement must be intra-uterine. J). For the active movement perceived by palpation. — There must be no interposition of intestine between the uterus and the abdominal wall. c. For the foetal heart sounds. — There must be no synchronism with the maternal pulse d. For audition of the foetal movements. — The woman must be absolutely quiet and contract no muscle of the abdominal wall. e. For vaginal ballottement. — The tumor affording ballottement must be intra-uterine. /. For detection of a fcetal part. — The fcetal part explored must exactly recall a region of the child easily appreciated. 160 The Diagnosis of Pregnancy. With these signs in view let us examine the possibilities of the diagnosis of pregnancy at different periods in its development. I shall especially have in mind normal (physiological) pregnancy, and shall close with some considerations on the difficulties that different pathological states may surround the diagnosis A. Normal pregnancy. — Pregnancy lasts nine months, which may be divided into three parts, and the diagnosis varies according as we have to consider the first, the second, or the third three months. First three months. — During this time no positive sign appears and we are then forced to hold to probable signs. Among these there are three especially which should, on account of their relative importance, fix the attention of the obstetrician and which are like a diagnostic tripod at this period, the other signs only constituting adjuvants. These are : 1. The modifications of the breasts (development of the gland, of the tubercles of Montgomery, pigmentation of the areola, presence of colostrum.) 2. The cessation of the menses. 3. The increase in volume and the softening of the uterus. If we are consulted by a woman: (1) who can afford exact infor- mation on the modifications of the breasts ; (2) whose menstruation, habitually regular, has been suddenly arrested without appreciable pathological cause, and (3) finally, when palpation permits us to state clearly the increase in size and the softening of the uterus, we can be almost sure of the existence of pregnancy. The association of these three signs of probability is almost equivalent to a positive sign; I say almost, for the existence of pregnancy should never be affirmed before meeting one or more of the positive signs. The other probable signs may be grouped around the preceding three and by their number and clearness may diminish the chances of error. But one, or even two, of these three probable signs may be more or less absent, obscuring the diagnosis. On the other hand, each of these three signs may be the consequence of pathological states clearly distinct from pregnancy. I shall only mention these different causes of error, not having space for a complete differ- ential diagnosis. 1. Modifications of the breasts (development of the gland, presence of the colostrum, and pigmentation and development of Montgomery's tubercles). — The last two signs are of a very different appreciation. It is necessary to have known the areola;, and to have preserved an ct memory to appreciate the changes. Simple extemporaneous observation cannot be sufficient, except in rare instances. The Diagnosis of Pregnancy. 161 The augmentation of volume is also produced under the influence of adipose deposit, in cast's where the dinultani elopment of the ahdomen may also Lead to a Buppo itii a of pregnancy. With regard to the presence of colostrum, it has actual im- portance only in the primiparse, for in women who have had children, and especially those who have nursed children, then- may be, for a long time after weaning and in particular at the menstrual period, some drops of colostrum in the nipple. In the primiparaa this sign becomes of influence in the diagnosis of possible pregnancy, but it is necessary to guard against making it a positive sign, for colostrum is sometimes met after prolonged genital excitation- or in consequence of some uterine affections, even in virgins. 2. Cessation oj the menses.— The different causes of amenorrhea, including pregnancy, may be arranged as follows: A. Extra-genital causes. 1. General diseases. a. Acute.— Typhoid fever, etc., causing a simple passing amenorrhea. b. Chronic. — Chlorosis ; phthisis; poisoning; anaemia, from deprivation or unsanitary surrounding. In fact, any debilitating cause may produce amenorrhea. 2. Localized Diseases. a. Acute. — Any acute disease is capable of causing a mo- mentary amenorrhea. A sudden impression, an emotion, the action of cold, an indigestion, the use of exciting drinks, certain medicaments (opium), bleed- ing, act the same. b. Chronic— Prolonged suppuration, etc. Am cause of de- 1 .ilitation. Intestinal worms, by reflex reaction, cause amenorrhea. B. Genital causes. 1. Genital diseases. All diseases of the uterus and of the contiguous organs are capable, to different degrees, of causing a more or less prolonged amenorrhea. Excess of coition or the first coition, may act in the same way. 2. Physiological causes. Pregnancy, lactation, menopause. 3. Genital malformation. Absence or atrophy of the ovaries or of the uterus. ■4. Genital mutilations. Ablation of the ovaries or of the uterus. Cicatricial occlusion of the genital canal. 162 The Diagnosis of Pregnancy. 3. Augmentation of the volume of the uterus. — The different causes capable of producing an increase in the volume of the uterus are : I. Principal causes that may simulate an increase in the size of the uterus and that may produce errors : a. — Ovaries: cysts, cancer. b. — Broad ligaments : cysts, phlegmon, salpingitis. c. — Bectuni : cancer. d. — Bladder : retention of urine, cancer. e. — Peritonaeum : pelvic peritonitis, extra-uterine pregnancy, hematocele. /. — Pelvis : osteo-sarcoma. g. — Tympanites, adipose, ascites, and all abdominal tumors causing an increase in the size of the abdomen. II. Cause of augmentation in the volume of the uterus : a. — Menstrual congestion. b — Metritis. c. — Simple hypertrophy. d. — Haematometra, physometra. e. — Mucous, fibroid, or papillary polypi. /. — Hydatid or dermoid cysts. g. — Fibroids (very frequent). h. — Sarcoma (very rare). i. — Cancer. j. — Normal or pathological pregnancy. Second three months. — The first part of pregnancy is characterized by the absence of the positive signs and the last by their presence. In the second three months, intermediate between these two periods, these signs appear : Sometimes, and rarely, at the beginning (fourth month). Sometimes, and generally, in the middle of this period (fifth month). Sometimes, exceptionally late, toward its termination (sixth month) . Now, before the appearance of these positive signs the diagnosis presents under the same condition as in the first three months and we may relate it to the explanations given above. After their ap- pearance the diagnosis is much simplified and will be established as in the third and last three months which we now study. Third three months. — The existence of the positive signs generally renders diagnosis easy during this period. These signs are, as given : Palpation. 1. Abdominal ballottement. 2. Active movements of the foetus. Auscultation. 3. Foetal heart sounds. 4. Active movements of the foetus. The Diagnosis of Pregnancy. 1G3 Digital examination. ;">. Vaginal ballottement. o remarked that among these signs, there arc three which -imply indicate the presence of the foetus, and three which permit us to say that it is living. These are: a. Sinn* of the presence of the foetus. 1. Abdominal ballottement. 2. Vaginal ballottement. 3. Detection of a foetal part. b. Signs oj the life oj the foetus. 1. Palpation of active movements. 2. Audition of fcetal heart sounds. 3. Audition of active movements. These signs have already been studied in detail and I shall not return to them. B. Pathological pregnancy. — Numerous pathological states may complicate pregnancy and obscure its diagnosis. They will be studied in that part which is reserved for puerperal pathology. I shall simply enumerate the principal conditions. These different complications are, passing from the periphery of the uterus toward the foetus : 1. The various abdominal tumors; cysts of the ovary, hydrone- phrosis, ascites, and extra-uterine pregnancy. 2. Malformations of the uterus,- double uterus. 3. Diseases of the ovuline appendages,- hydatiform moles, hydram- nios, 4. Death of the foetus, multiple pregnancy (2 to 5), monstrosities. 5. Finally, the persistence of the menses during pregnancy. To complete this chapter there remain to be spoken of, the age of the pregnancy, that is, the probable date of delivery (discussed under the duration of pregnancy), the volume of the foetus and its situation in the uterus, and finally, the question relative to the probable sex of the child, so often asked of the accoucheur. Ahlfeld has attempted measurements to determine the dimensions of the foetus, but his results are of little practical value. To appre- ciate the volume of the child the obstetrician is reduced to an approximate estimation based on the knowledge derived from pal- pation. We have seen the mode of determining the situation of the foetus during pregnancy, by palpation, auscultation and digital exami- nation, and it is useless to review this subject. With regard to the diagnosis of the sex of the child, a question nearly allied to that of procreation of the sexes at will, we are no 164 Progress and Duration of Pregnancy. more advanced than in the time of Mauriceau, who thus expressed himself on this subject : "We can have no positive knowledge of the sex of the child which is in its mother's abdomen, and no knowledge of the means of begetting a boy rather than a girl." CHAPTER VIII. PROGRESS AND DURATION OF PREGNANCY. PROGNOSIS.-HYGIENE. A. Progress. — During the first three months the uterus, although but little developed, is the source of painful disturbances explained by reflex action — nausea and vomiting and the syncope. During the second three months these disturbances usually dis- appear. In the last three months the uterus becomes voluminous and attains the upper portion of the abdominal cavity, interrupting the action of the stomach and especially of the diaphragm. Below, it slowly invades the pelvis, disturbing the functions of the rectum and bladder. Finally, its size opposes the free circulation of the pelvis and lower limbs. B Duration. — To appreciate the average duration of preg- nancy, it is necessary to know exactly the moment of conception, that is, of the meeting of the male and female elements — spermatozoid and ovule. Unfortunately, our ignorance on this point is complete. In the most favorable circumstances, where there has been a single sexual connection affording exact infor- mation as to the moment when the spermatic fluid was deposited in the female genital organs, we are still at a loss as to the epoch of conception, for the spermatozoids, according to Schroeder, may preserve their fecundating properties for] fifteen days (perhaps more) before meeting the ovule. These fifteen days make exact calculation impossible. This vagueness enveloping the moment of conception naturally reacts on the fixation of the duration of pregnancy. How shall we decide on the duration of a state when we are ignorant as to its commencement ? To discuss the length of pregnancy and to attempt to fix it within one or two days is to take a perfectly useless trouble. However, it seems that we can admit, as an approximate and a provisory figure, nine solar months, or two hundred and seventy-five days. By leaving a contingent ten days, five before and five after, Progress and Duration of Pregnancy. 165 we have the probable duration oi pregnancy oscillating bel two bundred and seventy and two hundred and eighty days. I figures, 1 repeat, only indicate the probabilities. Tim- in pr< - of this uncertainty we are justly astonished to s< e authors dilate at great length on the study of prolonged pregnancies. Thi> id< prolonged pregnancy has taken its source from various categories of observations : The first comprised the cases where the duration between the lasi menstruation and delivery has been greater than the usual time. I can cite a case where this duration was three hundred and thirty-five •lays, and cases of this kind are far from being rare. But in such cases it is wrong to suppose conception near the end of the last menstruation, since this can not be proven, and the negative can be supposed as well as the affirmative. The same is true of the second category of facts, where pregnancy has been the consequence of a single coitus, or of sexual relations taking place within a short interval of time. The possibility of a contingent fifteen days, during which the sperm atozoids may live in the female genitalia makes cases of prolonged pregnancy, founded on this class of facts, still contestable. A third category of facts comprehends those where the volume of the fcetus is greater than the average, and corresponds to a prolonged duration between the last menstruation, or a single coition and delivery. But as we have seen women delivered at the usual time of pregnancy of a very large fcetus (4000 grammes and more), we can suppose from this that in the other case the duration of preg- nancy has been normal. Finally, in a fourth class, we shall rank those furnished la- veterinary obstetrics. But in all these observations the prolongation of pregnancy remains doubtful, on account of the impossibility of determining the exact date of conception. There is nothing, then, permitting the affirmation of prolonged pregnancy, but it must also be added that there is no proof that obliges us to deny its possibility. It is not sufficient to know the approximate duration of preg- nancy, it is equally necessary to be able to predict the probable date of delivery. This determination will be based on the following signs : 1. Signs furnished by interrogation. a. Signs of the commencement : 1. Last menstruation. 2. Single coition. 3. Appearance of sympathetic phenomena. b. Sign in the middle period : 4. First movements of the foetus. c. Sign toward the end : 5. Phenomena of descent of the uterus. 166 Progress and Duration of Pregnancy. 2. Signs furnished by direct examination. 6. Volume of the uterus and of the foetus. 7. Engagement of the foetal part. 8. Modifications of the cervix. 1. Last menstruation. — The time which most often separates the iast menstruation from delivery is two hundred and seventy-five to two hundred and eighty-two days, with a minimum of two hundred and forty-six days and a maximum of three hundred and twenty- eight days. 2. Single coitus. — Delivery generally takes place at the end of two hundred and seventy-five days, that is, nine months after the fecun- dating coitus, with a possible deviation between two hundred and forty-two to three hundred and seventeen days. The special sen- sations felt by some women can only exceptionally be taken into consideration. 3. Appearance of sympathetic phenomena. — It is rare that these phenomena (vomiting, syncope, development of varices, etc.) in- dicate the exact beginning of pregnancy, for in most cases they only appear some time after conception. However, some women, taught by a previous pregnancy, can sometimes recognize the beginning of pregnancy in this way. 4. First movements of the foetus. — The first movements of the foetus are most often perceived in the course of the fifth month. Rarely they occur before this, but they have been observed in the course of the fourth month. It is equally rare for them to appear for the first time during the last four months. Exceptionally women feel no foetal movements all through gestation although the foetus is per- fectly healthy. Few women can state exactly the precise date of the first foetal movements. When this moment is known, we shall be right in supposing that delivery will take place in about four months and a half, but this diagnostic point is very variable, for there may be a deviation of a month and even more. 5. Phenomena of descent. — In the majority of cases the descent of the uterus appears nul, or we cannot determine it from the infor- mation furnished by the woman. The phenomenon of descent in the multiparas, when it exists, indicates that pregnancy is within the last fifteen days of its termination, but this is only simple proba- bility. In the primiparous woman its importance is nul. 6. Volume of the uterus and foetus. — The volume of the uterus during pregnancy is too difficult to appreciate exactly, so that it yields scarcely any information as to the date of delivery. The height of the uterus in relation to the abdominal wall, however, in Bpite of the error to which it is exposed, furnishes valuable indices. In the relation we have: V< lurth month. — Fundus of the uterus a little below the umbilicus. Progress and Duration of Pregnancy. L67 Fifth month. — At the Level of the umbilicus. Sixth month. —Fundus a little above the umbilicus. mth month. — Three fingers' breadth above the umbilicus. Eighth month.— Six fingers' breadth above the umbilicus. Ninth month. — Nine fingers 1 breadth above the umbilicus. 7. Engagement of the foetal part. — Though the information fur- nished by the engagement of the foetus is quite vague, we can Buppo3e, however, that in a primipara, with a deep engagement, delivery will occur in about a month, and in a multipara, with a deep engagement, delivery will not be later than fifteen days. But these figures are approximate. 8. Modifications of the cervix. — On the supposition that the cervix is effaced during the latter part of pregnancy, we would have the right to diagnosticate the date of delivery from the length of the cervical part of the uterus. But as, save in exception, it is known to-day that effacement often occurs during labor, such reasoning cannot be admitted. With regard to the softening of the cervix, it is too variable in its progress, especially in multipara 3 , to constitute a important element of diagnosis. C. Prognosis. — "We can say, without exaggeration," writes Sacombe,* "from experience and observation, that pregnancy far from being a disease is, if I may express myself, a certificate of life for nine months that nature gives to the pregnant woman." To-day we believe, on the contrary, that the prognosis of the majority of diseases is aggravated by pregnancy. We shall see later, apropos of puerperal pathology, the influence of the different pathological states on pregnancy. With regard to the prognosis of the gestation itself, and especially of delivery, it depends upon divers circumstances, among which must he cited: 1. The conformation of the pelvis. 2. The situation of the foetus (presentation and position). 3. The composition of the urine (albuminuria). From these comes the extreme importance of exact inquiry on these three points during the course of pregnancy. D. Hygiene of pregnancy. — 1. Digestive system. — Except in serious digestive disturbances, alimentation should not be modified during pregnancy. Women, usually constipated, are more so during pregnancy and need laxatives or enemas to avoid intestinal accumulation and violent efforts of defecation. Slight purgatives are without objection but drastic remedies should lie avoided. If diarrhoea occurs it should be combatted by the usual means. * Elements de la Science of Accouchements, 1801, p. 93. 168 Progress and Duration of Pregnancy. 2. Breasts. — The clothes should not compress the mammary glands, so as to allow their physiological development. Apropos of lactation we shall see the special care to be given the nipples, which demand preparation, a veritable education in view of this physio- logical function. 3. Sexual relations. — The physician is often consulted for advice as to the continuance of sexual relations during pregnancy. In cases of irritable uterus and in women predisposed to abortion, all sexual relations should be interdicted during pregnancy, especially at a time corresponding to menstruation. It will even be wise to prescribe separate beds for the husband and wife, the vicinity of the husband often causing a genital excitement that is unfavorable to the calm required by the uterus for its normal development. 4. Medicaments and operations. — Any drug given in a tonic dose is capable of producing abortion. Eemedies prescribed during pregnancy, then, should be given in relatively small doses. There are some exceptions, however, for example, mercury in syphilis, and sulphate of quinine in malaria, where an energetic action is necessary. Can a pregnant woman undergo, without inconvenience, a surgical operation? This question should be viewed from two standpoints : 1. Does pregnancy interfere with the consequences of an oper- ation? The answer is negative for the majority of cases. Gestation does not appear to interrupt cicatrization nor predispose to com- plications. 2. May the operation interrupt the course of pregnancy ? Every operation exposes to abortion, and this danger increases as the genital zone is approached. But very often intervention interesting the uterus itself (amputation of the cervix, ablation of fibroids de- veloped in the uterine wall) have not been followed by any unfor- tunate result. Besides the danger of abortion is not in relation with the gravity of the operation, as some women continue their gestation in spite of an ovariotomy, while others abort after the extraction of a tooth. In the presence of this variability of results it is prudent to perform during pregnancy only operations of necessity. 3. Professions. — Certain professions are unfavorable to the normal evolution of pregnancy. Some are exposed to poisoning, such as workers in lead, caoutchouc (sulphide of carbon), tobacco, others to excessive fatigue, as laundresses, shop girls, sewing-machine oper- ators, etc. 4. Clothing. — All tight clothing should be proscribed. The corset should be as loose as possible. In women predisposed to varices or (.edema of the lower limbs the garters should be replaced by suspend- ing the stockings by bands attached to the corset. The use of im- proper shoes should be avoided. In nulliparous women the relaxation tress and Duration <•> Pregnancy. l»i'.' nf the abdomen may be greatly relieved by the ase of a hypo- ric belt on condition that it is large and embraces t!. two- thirds of the abdomen. 5. Exercise and voyages. — Souk- women, naturally indolent, profit in their pregnant state by confining themselves to an repose. This practice is deplorable, daily exercise i-> necessary. On the contrary we mnst restrain the imprudent who, in spite of their condition, continue their former habits, going to balls, theal etc. Carriage riding is generally favorable. It is wise to dissuade from horsemanship. According to Irwin, sea voyages predis] - to menorrhagias, while Engelman states that railway journey- pro- duce delay of the menses. This would be an interesting difference if clearly established. However, in the majority of cases normal pregnancy is not interrupted by these factors, even prolonged. But in women disposed to abortion prudence should be advised. 6. Toilrt. — Women often inquire if they can continue the use of cold water for their ablutions, the same as before pregnancy. With ird to this no change of habit is necessary. Hot foot-baths should be avoided. Sea bathing is not objectionable, but fatigue should lie avoided. Hot baths are favorable, on condition of being Bhort mot over a quarter hour) and being taken at 30" to 35 c C. The vulvar toilet is hygienic, but vaginal injections should be proscribed before the last fifteen days of pregnancy. These in- jections may be necessary, however, in some cases, where there exists a vaginitis, for example. During the last fifteen day- it is well, in an antiseptic point of view, to advise a daily injection of a bichloride of mercury solution 1 1-4000). 170 Accouchement.— Maternal Phenomena. CHAPTER IX. ACCOUCHEMENT.— MATERNAL PHENOMENA. Accouchement is the expulsion of the ovum from the maternal organism, whether the ovum be in the uterus, as in the normal state, or outside it, as in extra-uterine pregnancy. According to the period at which this takes place accouchement receives various de- nominations : 1. During the first six months — abortion. 2. During the last three months — premature accouchement. 3. At normal term — accouchement at term. 4. After normal term — delayed accouchement. Accouchement is generally made in two stages : First stage, expulsion of the foetus. Second stage, expulsion of the appendages. There are then two successive deliveries : 1. Foetal expulsion or accouchement properly so-called. 2. Accouchement of the annexes or delivery. Foetal accouchement. — The term accouchement employed alone will be applied exclusively to the fcetal expulsion, as opposed to delivery, that will be reserved to designate the expulsion of the appendages. Labor is almost synonymous with accouchement; however, this word applies more particularly to the modifications of the genital organs which prepare for the expulsion (uterine contraction, opening of the parturient canal, etc.). Considered according to its difficulties accouchment is called : 1. Normal, physiological, entocic, when the foetus presents by the vertex and when no difficulties arise. 2. Abnormal, pathological, dystocic, in contrary conditions. Or again : 1. Spontaneous, when it is left to the forces of nature alone. 2. . 1 rtificial, if intervention is necessary. However, a slight inter- vention, for example that which consists in aiding the rotation of the head with the finger, is not considered as constituting an arti- ficial accouchement. Besides, these limits are arbitrary. Maternal phenomena. — The contraction of the uterus and its ssory, that of the abdominal wall, causes the successive opening AccoucJiement. — -Maternal Pht mum na. 171 of the cervix, of the vagina, and of the vulva. Contraction is theo the cause and the opening the effect. We Bhall study these two phenomena ; one etiological, the other the result. A. Uterine contractions. — The uterine contraction presents th ntial characteristics, it is painful, intermittent and involuntary. Painful. — The pain is the dominant character of the uterine con- traction to such an extent that, in common language, these two words are taken (wrongly) as synonyms. It establishes the dif- ference between the uterine contractions of pregnancy and those of labor. The woman Buffers only at the moment when labor com- mences. Its intensity is quite variable. Some women are delivered with- out a trace of pain. Others suffer so dreadfully that they prefer to die and even seek death. The character of the pains varies according to the peiiod of labor. a. Period of dilatation of the cervix. 1. Initial pains. — Slight pains in the hypogastrium, in the flanks and especially in the lumbar region. 2. Preparatory pains. — Sharper than the preceding; occupying the same situation and sometimes radiating along the thighs, in the track of the crural nerve. b. Period of expulsion. 1. Expulsive pains. — The pain takes a new character, because the woman at each contraction feels the need of bearing down. Each pain is accompanied then by a more or less energetic effort in this direction. The radiations along the lower limbs are still frequent but occupy by preference the course of the sciatic. 2. Conquassant pains. — These are the terminal expulsive pains, of accrued intensity, from the excessive dilatation of the vulva at the moment of the passage of the fcetal head. The cause of the pain during uterine contractions has been the subject of long discussions. But it is known that the pathological or energetic contraction of every organ provided with smooth mus- cular fibres produces a pain designated as colic. Now. the pains of accouchement are only uterine colic. All the uterus is painful during uterine contraction, thus, at this moment compression of the abdomen and palpation are painful to the woman. Digital examination is equally painful when the ringer drags on the external orifice of the uterus. Generally the pain disappears in the interval of the contractions. However, when the contractions are very fre- quent or very energetic, as at the end of labor, it is not rare to see them almost continuous, with exacerbation at the moment of muscular activity. In the early part of labor, during the initial contraction.-, the 172 Accouchement. — Maternal Phenomena. patient, who is walking to and fro, stops, supports herself on a chair and inclines forward. She becomes quiet, the face contracts, some oscillations show the mute suffering, then the calm returns ami the patient is momentarily free. Later the pains, becoming more intense, elicit cries, clamorous complaints, mixed with words of despair. These cries are more and more marked as dilatation progresses. During expulsion efforts complicating the situation modify the nature of the cries and permit a practiced ear to easily recognize this last period of labor. Intermittent. — Initial pains, repeated every twenty minutes, duration thirty seconds.* Preparatory pains, repeated every ten minutes, duration sixty seconds. Expulsive pains, repeated every five minutes, duration ninety seconds. Conquassant, almost continuous. The intermittent character of the contractions permit repose for the uterus and the re-establishment of the foetal circulation, which is more or less disturbed during uterine systole. A prolonged con- traction, that is, uterine tetanus, causes death of the foetus by the arrest of its circulation. Involuntary. — As in all the unstriated muscular structures, the contractions of the .uterus are independent of the will. However, some conditions are capable of reflex action, of modifying the in- tensity or the frequence of the contractions. Thus they are seen to diminish under the influence of an emotion or in the presence of a person disagreeable to the patient. In opposition to the uterine contractions, those of the abdominal walls are essentially voluntary, and some women can retard or ad- vance delivery by regulating their intensity. . Some words on the results of uterine contraction. The uterus by contracting diminishes the vertical and antero-posterior. We have seen the influence of the contraction on the foetal circulation. The number of maternal pulsations is, on the contrary, increased throughout its duration (Fig. 197). When the bag of waters is ruptured, there is a slight flow of the liquor amnii at the beginning and the end of the contraction. The force of the uterine contraction varies from one to twenty kilogrammes, and can be fixed at an average of ten kilogrammes. The assistance of the abdominal con- traction is capable of increasing this force to three and even to four times the power (thirty to forty kilogrammes). B. Abdominal contractions. — The contraction of the abdominal ♦These figures only represent the average, they are subject to great variation. Accouchement. — Maternal Phenomena. 1 7:> muscles, that is, the expulsive effort, follows at an advanced period of Labor, usually when the dilatation of the uterine orifice is com- plete and when the foetal part is supported on the perinseum. It commences a little after the beginning of the uterine contraction and ceases a little before its termination. The expulsive effort is not always single during a uterine contraction, three, four or five efforts may be observed. The abdominal contraction depends upon the will, but the need of bearing down is so imperiously impressed on the woman that she cannot restrain from it. The expulsive effort may exist without uterine contraction, and take place some- times under the direction of the accoucheur to terminate a very much advanced expulsion. Uterine contractions. Maternal pulsations. Fcetal pulsations.' / — FlG. 197. — Influence of uterine contraction on the fcetal and maternal pulsations. C. Vaginal contractions. — The vagina, endowed with an unstriated muscular coat, is contractile, but the contractions of this canal are so feeble that their role seems almost nul in accouchement and very rudimentary in delivery itself. II. Opening of the cervix, of the vagina and of the vulva. — The two canals which must successively open and allow the passage of the foetus are : The cervix uteri, to which must be added the inferior segment of the uterus. The vagina, terminated by the vulva and sustained by the peri- neum. Let us study these two successive openings : A. Dilatation of the cervix. — At term, the uterus is constricted by three parts (Fig. 198). An upper thick part, called the superior segment of the uterus (divided by some authors into median and superior segments). A thin intermediate portion, separated from the preceding by the uterine circle (or Bandl's ring). This is the inferior segment of the uterus. An inferior portion is comprised between the external and the internal orifice constitutes the cervix. The superior segment is formed by the body of the uterus, the cervix remains as it was before pregnancy, but with regard to the origin of the inferior segment there are three theories. The first, that of Brandl and Braune, attribute its formation exclusively to the cervix. The uterine circle would be the internal orifice and the 174 Accouchement. — Maternal Phenomena. effacernent of the cervix would constitute the inferior segment. The second theory is also from Bandl, who, modifying his first views admits that the inferior segment is formed in part by the cervix and in part by the body of the uterus. Finally, Waldeyer and Hof meier have sustained a third theory, according to which the inferior segment is formed exclusively by the body of the uterus. Uterine circle. Internal orifice. External orifice. Fig. 198. — Uterus at the beginning of accouchement. I believe it can be demonstrated that no one of these explanations is satisfactory. The uterus in the normal state and before con- ception is composed, in fact, of three parts : The body ; the isthmus ; the cervix. Now, at the end of pregnancy, the body con- stitutes the superior segment of the uterus. The isthmus, the inferior segment. The cervix remains intact. The schemas 199, 200 and 201 present a resume of my idea. Body. Cervix. Fir;. 199. — Uterus at the beginning of pregnancy. The inferior segment is at this period of pregnancy formed by the body. Thus understanding the inferior segment and the cervix, we may study the effect of the uterine contractions in dilating these parts Accouchement. — Maternal Phenomena. 175 for the passage of the foetus. Lei lie suppose a section of the inferior part of the gravid uterus (Figs. 202 to 208). Sup. segment Inf. segment Cervix Fig. 200. — Uterus at the end of pregnancy. The inferior segment is formed by the isthmus. Sup. seg. Inf. segment. ,r Cervix effaced. ^.»— *"" Fig. 201. — Uterus during labor. The inferior segment is at this moment (labor) formed by the isthmus and cervix. Figs. 202 to 208. — Effacement of the cervix and dilatation of the external orifice. (Fig. 202, cervix not effaced; Fig. 203, cervix being effaced; Fig. 204. cervix being effaced: Fig. 205, cervix efface'! : Fig. 206, dilatation of external orifice; Fig. 207, dilatation of external orifice; Fig. 20S, dilatation of external orifice.) 170 Accouchement. — Maternal Phenomena. The point a is the section of the uterine circle. The point h is the section of the internal orifice. The point c is- the section of the external orifice. The line rib represents the wall of the inferior segment. The line ch represents the wall of the cervix. The point (I marks the section of an orifice of new formation (Muller's orifice). Now the opening as in figures 202 to 205 is called effacement. While that occurring in figures 205 to 208 is called dilatation (of the external orifice). Effacement, then, is the disappearance of the cervix, its fusion with the body of the uterus, or better, the fusion of the cavity of the cervix with that of the body of the uterus. Dilatation is the opening of a simple diaphragm, which, after effacement, separates the uterine cavity from the vaginal cavity. But there is no advantage in thus limiting the word dilatation, and it is better to apply it also to the opening of the internal orifice and to the cervical cavity as well as to that of the external orifice. When there have been indicated the length of the cervix (that is, the degree of effacement), the degree of dilatation of the external orifice, of the cervical cavity (if it exist) and of the internal orifice (if still remaining), the explanation is sufficiently clear. When it opens progressively under the influence of the internal contraction, the external orifice is : Sometimes circular. Sometimes oval. Sometimes irregular (cicatrices — cancer). The thickness of the cervix varies according to the parity : In the primipara there is a marked thinning; the edge of the orifice gives a sensation analogous to that felt in touching the frsenum of the tongue. In the multipara, on the contrary, the contour of the cervix is thick, analogous to the lips slightly drawn over the teeth by their intrinsic muscles. The rapidity of the dilatation of the external orifice varies with parity (about ten hours in the primipara, five hours in the multi- para), with the vigor of the uterine contraction, with the state of the softening of the cervix, with the presentation, with the state of the pelvis, etc. It progresses more rapidly in proportion as it advances. Its progression is generally regular; however, it is not rare to observe an arrest during a half hour, an hour, or even more. This interruption may be renewed several times. Some- times the external orifice after dilatation to the extent of two to three finger's breadth may even reform. The pregnancy resumes its normal course to a reappearance of labor after a variable time. This has been designated as retrocession of labor. During dilatation of the external orifice various complications may occur. Among these I shall mention oedema and lacerations. Accouchenu nt. — Matt rnal l'h> norm na. 177 (EdiDiit is sometimes generalized ;u ouiid the cervix, as often ob- served in some easi - of prolonged labor. In the multipara i| invades and thickens the free border of the orifici Fig. 209). In the primipara it respects the frei border, which preserves it- char- acteristic thinness i Fig. •21m. Sometimes it is localized to a portion of the cervix, almost always to the anterior lip, as observed by preference in the occipito-posterior positions on acconnl of the com- pression exercised by the forehead ;iL r ;tin.-t the pubes. ^HSP V "' Fig. 209. — CEdema of the cervix in the multipara. M P* Fig. 210. — CEdema of the cervix in the primipara. Lacerations. — The foetal part pushed too violently by the utero- abdominal contraction, sometimes produces true tears which are shown (Fig. 211) : Fig 211.— Laceiations of the cervix. I. Sometimes as a simple slit, most frequently to the left, on account of the most frequent situation of the occiput to this side. II. Sometimes as a strip ; the path of this laceration leaves the orifice and curves parallel to the periphery of the cervix. 178 Accouchement. — Maternal Phenomena. III. Sometimes as a button-hole, without affecting external os. IV. Sometimes as a circular button-hole, which detaches all the inferior portion of the cervix, separating it and leaving it as though set in a socket. Fig. 212. Dilatation of one finger's breadth. Fig. 213. Dilatation of two finger's breadth. Fig. 214. Dilatation of three finger's breadth. Fig. 215. Dilatation of four finger's breadth. Fig. 216. Dilatation of five finger's breadth or palm of the hand. Fig. 217. Dilatation of six finger's breadth or complete. Fig. 21S. — Perinseal ampliation during accouchement. The degree of dilatation of the external cervix is estimated by the sense of touch. The older authors expressed the degrees of dilatation in comparison with the size of various pieces of money, . iccouchcment.— Maternal Phenomena. 179 then with th.it of the palm of the hand and finally as complete. Borne modern authors, particularly Jiudiu, have proposed esti- mation iii centimetres. But pieces of money vary in different countries and the metric system has not been universally adopted so that it is preferable to estimate the degrees of dilatation in finger breadths (Figs. 212-217). Dilatation is called complete when the periphery of the external orifice is in contact with the pelvic ring. It is called sufficient when it permits the passage of the foetus. This last condition is relative to the volume of the child. In the diagnosis of the degree of dila- tation, it is necessary to keep in mind some causes of error. These are: A circular vaginal fold. Folds of the scalp. Large hag of water. Thinning of the cervico-uterine segment. Deviation of the uterine orifice. It is sufficient to know these, to be able to avoid error. B. Opening of the vagina and vulva. — The vagina, of which the vulva may be considered the external orifice, opposes by itself only a feeble insistence to the progression of the fcetal part. The hymen alone, in some primipara 1 , is capable of causing an obstacle of some importance. But the vagina lies on the perimeum, which, especially in the primiparse, opposes a serious resistance to the exit of the foetus. From this arises the necessity, for the vagina as for the cervix, of a veritable labor before permitting accouchement. For the description of the vagino-vulvar dilatation, I shall suppose a presentation of the vertex, the most common. The uterus contracts and aided by bearing-down it pushes the cephalic extremity into the vaginal canal, which has a direction perpendicular to the uterine axis. In this way the fcetal head, forced parallel to the uterine axis, tends to gouge into the perineum (Fig. 218). The perineum, essentially contractile and retractile, reacts against this pushing from the uterus, and the effect of these two forces combined is to direct the fcetal part toward the vulvar orifice. The perinsemn constitutes a sort of door, swinging one way, flexible, with the sacro-coccygeal articulation representing the hinge, and the inferior part of the vulvar orifice the free side. This door opens under the fcetal pressure, first in its posterior part, or coccy- anal, then in its anterier part, or ano-vulvar. 1. Coccy-anal ampliation. — The head presses first on the coccyx, which it pushes backward. But the coccyx, solidly maintained on each side by the fibers of the perinseal levator, opposes a serious obstacle to the passage of the head. 2. Ano-vulvar ampliation. — The progression continues. The anus opens by degrees (Fig. 219). The head at this moment appears at the vulva then retreats in the interval between the contractions. At each new effort the head advances a little more and dilates the 180 Accouchement. — Maternal Phenomena. vulvovaginal orifice. Finally, by a swinging movement the bead issues distending tbe perinseum to the maximum and dragging it forward. As soon as tbe most voluminous part of tbe foetal region has passed, tbe perinaeum, which lias been drawn out, retreats un- covering tbe fcetal part. Tbe first part of accouchement is com- pleted, one of tbe ovoids has made its exit and the other escapes by an analogous mechanism. The perinaeal opening has been dilated by the first ovoid, so that the passage of the second is made with a relative facility. Fig. 218. — Perinseal ampliation during accouchement. Fig. 219. — Perineo-vulvar ampliation. Opening of the anus. During this ampliation the perineum undergoes an enormous transverse distention, and especially antero-posterior, so that the distance wbicb extends from the inferior extremity of the sacrum Accouchement. — Maternal Phenomena. 181 to the fourchette approximately arrives at twenty centimetre-, four for the an. is and about eij_ r ht tor the retro-anal (comprising the coccyx i part and eight tor the ante-anal part. Even this distance may be exceeded. FlG. 220. — Perineal profile. Perineal lacerations. Different degrees. One of the most frequent complications of accouchement is con- stituted by wounds of the vulva and of the perimeurn. We might Bay these wounds are the rule, for out of one hundred cases I only found the vulva intact in five. Leaving to one side the eccliymoses, which compose the first degree of vulvar traumatisms, we can divide wounds of this region into three categories : 1. Those which affect the inferior or posterior part of the vulva. 2. Those which occupy the latero-posterior regions. 3. Finally, the complex wounds — mixed wounds combining the two preceding. 1. Inferior and posterior wounds. — Wounds of the inferior or pos- terior part of the vulva are those which are usually designated as lacerations of the perinaeum. They may be marginal (Fig. 220) or central 1 Fig. 221). 2. Latero-superior wounds. — As in posterior wounds it is necessary to establish here the distinction between marginal and central laceration. The marginal lacerations extend outward from the vulvo- vaginal orifice or its vicinity and are directed toward the free border of the labia minora which they may attain (Figs. 222 to 225). The central lacerations produce a veritable perforation of the labia minora, analogous to the central laceration of the perimeurn (Fig. 226). 3. Compter wounds. — Complex wounds are constituted by the association of the two preceding varieties. I shall not return to then- description. The number of wounds which may affect the vulva is variable. They may even amount to eight as I have seeu (Fig. 227). 182 Aceoueiiement. — Maternal Phenomena. Prognosis. — Vulvar lacerations expose to two important accidents : for one part, to hemorrhage at the moment of accouchement, es- pecially when an artery, a dilated vein (varices) or a vascular organ like the clitoris, is affected ; for the other part, during post-partum, to haemorrhage. Wounds well cared for reunite, at the perineum most often by first intention, at the latero-superior part of the vulva, by first intention in some cases, in others, and more often, by second intention. Vulva. Central laceration. Fig. 221. — Central laceration of the perineum (J. Y. Simpson). Treatment. — The treatment of vulvar lacerations is preventive and curative. A. Preventive treatment. — 1. Perinao-vulvar dilatation. — Formerly a series of manoeuvres were practiced to hasten the opening of the vulva and of the cervix, but these have been justly abandoned, for Accouchement. — Maternal Phenomena. L88 their influence is more unfavorable than salutary. Others have advised various methods, such as drawing back the perinaeum with two fingers, or using three fingers in the form of a cone, to afford a prsefoetal dilatation. Fig. 222. — Two lacerations. FlG. 223. — Three lacerations. Fig. 224. — Three lacerations, one of Fig. 225. — Three lacerations, one of which affects the free border of the right which affects the free border of the left labia minora. labia minora ariil another the fourchette. •2. Perineeo-wlvar support. — In the double aim of moderating the rapidity of the foetal exit and of giving the foetus the direction de- manding the least distention of the maternal parts, it is important to support the perinasum. For this the hands will lie placed dif- ferently according to the position taken by the woman during labor. 184 Accouchement. — Maternal Phenomena. Fig. 226. — Perforation of the left labia Fig. 227. — Complex wounds of the minora (black point). vulva (8). In the dorsal position, the buttocks are uplifted by means of a cushion, in such a way as to permit easy inspection of the genital organs. The legs are flexed and the thighs widely separated. The physician placed to the right of the woman, passes the right hand under her right thigh and applies it on the perimeum (Fig. 228), taking care not to cover the fourchette, so that the eye can follow its modifications. The other hand is placed on the fcetal head to maintain it. The fcetal part is thus solidly held by the accoucheur, directly by the upper hand, mediately through the perinseum by the lower one. Its exit is thus regulated at will. In the lateral position the woman is placed so that the buttocks correspond to the edge of the bed and the thighs are flexed, making almost a right angle with the trunk. The upper thigh should be a little more flexed than the lower and between them will be placed a pillow rolled on itself, or any cushion, to keep the limbs separated. The right hand (Fig. 229) supports the perimeuni, as in the dorsal position, the other passed around the upper thigh supports the head. 3. Episiotomy. — To avoid extended tears of the perinseum vulvar incisions have been proposed. The different procedures advised are united in the schema of Figure 230. Ritgeii. — A series of radial incisions. Eichelberg. — One or two large latero-inferior incisions. Michaelis. — Posterior incision. Tarnier and Chantreuil. — Incision of Michaelis completed in- feriorly, either on a single side (in L), or on both sides (in a re- versed Y). AfcoiK-lniit, at. — Maternal Phenorm na. 185 Fig. 22$.— Dorsal or French position. £r Fig. 229. — Lateral or English position. 186 Accouchement. — Maternal Phenomena. These incisions can be made with the scissors or with a blunt- pointed bistoury. > \ / ETchelberg \ \5 | \ I Fig. 230. — Different procedures of episiotomy. Ritgen's procedure is insufficient. That of Eicheiberg has, it is said, the disadvantage of often wounding the duct of Bartholin's gland, and of causing section of nervous filaments that remain pain- ful after cicatrization. Michaelis' procedure, completed at need by the incisions advised by Tarnier and Chantreuil, appears inferior to that of Eicheiberg and I believe the disadvantages of the latter have been exaggerated. B. Curative treatment. — When the perineal lacerations are of small extent, not exceeding half of the vulvo-anal portion, they often cicatrize by first intention, provided the lower limbs are tied together at the knees for two or three days. To keep the two lips of the wound together the employment of serre-fines has been advised. But applied on the perinseum they are easily displaced, cause painful dragging and are, in a word, in- ferior to sutures. Perineorrhaphy should be performed every time the perineal laceration is of much extent, and especially if it is complicated. As a contra-indication has been given a too marked contusion after a laborious accouchement, but it is always better to attempt an immediate perineorrhaphy, being prepared to see it fail in unfavor- able cases. Leaving aside the latero- superior wounds, which rarely claim attention, the therapeutics of lacerations will be as follows : Accouchement. — Maternal Phenonu na. 187 1. Laceration of the first degree (limited to the fourchette), do treatment necessary. 2. Laceration of the second degree (from the fourchette to the anus) (Fig. 281). a. Slight laceration. Simple fixation of the lower limbs together for one to three days. No sutures unless the patient is unruly or the nurse inexperienced. b. Extended laceration. Superposed sutures, one centimeter apart. Fig. 231. — Serre-fine. Sfc£M£KT CBRyjDL YAJGINA Fig. 232. — Genital passage. 3. Laceration of the third degree (or complicated) : a deep and extended suture, a series of sutures as in the preceding case. At need, buried suture of the recto-vaginal septum. In the case of central laceration of the perinaeum, we also have recourse to sutures, uniting the separated surfaces in all their extent. Arrived at the close of this study of the maternal phenomena, let us take the whole at a glance. The schema of Fig. 232 represents the canal through which the foetus must pass from the fundus of the uteras. The thick part expels the foetus by its contraction, its role is essentially active ; the thin part, on the contrary, is a long irregular sphincter which, both active and passive, opens and dilates to allow the passage of the uterine contents. Accouchement is only the struggle between the thick part and the thin part of the genital organs. Delivery (extended to the expulsion of all the ovum) is the victory of the thick segment over the thin segment ; it is the denouement of the struggle which lasts a variable time. 188 Accouche mo it. — Phenomena of the Appendages. ACCOUCHEMENT.— PHENOMENA OF THE APPENDAGES. A. Bag ofivaters. — The bag of waters is constituted by that part of the ovuline membranes left bare by the dilatation of the uterine orifice. It is necessary to avoid, as too often occurs, the use of the term ovuline membranes as a synonym for bag of waters, for the latter represents only a part of these membranes. Its formation is caused by the dilatation of the cervix. The bag of waters may present any one of the various forms of the schema in Fig. 233. In the first variety (flat) there is only a thin layer of liquid interposed between the foetal part and the membranes. In the projecting variety we have, according to the degree : (a) the hemispherical form ; (&) the cylindrical form ; (c) the piriform variety. Fig. 233. — Different varities of the bag of waters. The bag of waters is smooth when it is formed by a portion of the membranes distant from the placenta, but it becomes more and more unequal as it approaches the placental disc. These inequal- ities may serve as a guide to the probable situation of the placenta. Sometimes it happens that the finger, passed over the membrane, perceives in their thickness pulsations synchronous with the fcetal Accouchement. — Phenomena of the Appendages. 189 pulsations. This 3ign reveals the presence of vessele passing to an accessory or erratic cotyledon or to a velamentous insertion of the cord. The membranes are permeable, so that the surface of the bag of waters always presents a marked humidity. This permeability plays an important part in the formation of "the show." At a given moment the membranes rupture, the amniotic liquid is liberated, the ovum is open. By studying the mode of rupture of the membranes we shall see at the same time the constitution of the bag of waters. The membranes may rupture in two totally dif- ferent ways, successively, or as a whole. Successive rupture takes place as follows : The cervix opening and giving passage to the foetus, the portion of the membranes which descends first and constitutes the hag of waters undergo. notable distention, much more marked than the rest of the ovuline envelopes. The decidua, the most superficial, soon ruptures leaving uncovered a part of the chorion. The chorion and the amnion, pushed as a whole by the liquor amnii, protrude through the open- in g formed by the rupture of the decidua. The pushing continues, the projection increases and a new rupture follows, but contrary to what might be thought, on account of the elasticity of the chorion compared with the resistance of the amnion, it is the chorion which ruptures first. This is because its adhesion to the decidua prevents its descent or gliding on this membrane ; all its ampliation at the has of waters is made exclusively by its elasticity and not by gliding. For the amnion, on the contrary, though of little marked elasticity, gliding is easy on account of its feeble adhesion to the chorion, so that it descends without difficulty. Thus a rupture of the chorion before the amnion will be comprehended. The amnion remaining alone, to constitute the bag of water, con- tinues to glide. The bag descends, pushed by the amniotic liquid and the fcetal part. This gliding of the amnion produces the de- tachment that is easily found by examination of the appendages after delivery. When this gliding is interrupted by any cause, compression between the foetal part and the uterine wall, adhesion, placenta inserted in the inferior segment, too great thinness of the membrane itself, or finally under the influence of intervention by the accoucheur, rupture takes place as for the chorion and decidua, the ovum is opened, the amniotic liquid flows away, and the fcetus passes through tins opening by enlarging it. Aside from this successive rupture, there exists rupture as a whole, at once. The three membranes are ruptured at the same place. Their union remains intimate, they all three succumb at once. According to the results I have obtained, the rupture as a whole takes place in 40 per cent of cases ; successive rupture takes place in 54 per cent of cases. Successive is then the most frequent. 190 Accouchement. — Phenomena of the Appendages. The situation of the rupture is variable and may occur in different places (Fig. 234, 12 3). Fig. 234. — Different places of rupture of the membranes. In relation to accouchement the rupture may occur : Before labor — premature rupture. During labor — 1. During the dilatation of the cervix (precocious rupture) ; 2. at complete dilatation (tempestive rupture) ; 3. during expulsion (late rupture). After labor — delayed rupture. Premature rupture takes place fifteen days, a month, sometimes even more, before accouchement. I have seen a case where it occurred fifty days before labor, which was at the beginning of the ninth month. Eetarded rupture, that is, after the ovum has been expelled as a whole and at term is quite exceptional (four to five cases). In ex- pulsion before term, it is never frequent. I have put in parenthesis the terms "precocious, tempestive and late rupture" for I do not admit these distinctions based on the erroneous opinion that the bag of waters should rupture at complete dilatation in the physiological state. It is probable, save some exceptions, that the rupture of the bag of waters is as much more favorable to accouchement as it is late. Its integrity presents a double advantage. The risks to the fcetus are less when the ovum is complete. With regard to the mother, it is certain that the bag of waters, forming an advance guard for the fcetal part, favors the dilatation of the cervix and the ampli- ation of the perimeum and of the vulva. This cushion of waters, spreading humidity before it, exercises a soft pressure which the maternal tissues obey better than the rude compression exercised by the foetal part. Accouchement. — Phenomena of the Appendages. 191 Whatever may be the moment o\ accouchement when rupture occurs, it takes place, sometimes silently, sometimes with a noise. The difference depends upon the quantity of water, which may be free to flow at the moment of rupture. The diagnosis of the rupture of the hag of waters, generally easy, may be of excessive difficulty sometimes. Whenever intervention is necessary, and notably the application of the forceps, this diag- nosis, however, is indispensable. In cases of a premature flow of the liquor amnii, the knowledge of the rupture of the ovum is the basis of a prognosis. For the answer to this question we have three elements : 1. The shrinkage of the abdomen. 2. The flow of liquid. 3. Digital examination. 1. The shrinkage of the abdomen. — The rupture of the ovum, some- times causing the evacuation of a large quantity of liquid, may diminish the abdomen so markedly that the patient, and even the accoucheur, will perceive it. However, this sign is too vague to constitute more than an adjuvant. 2. The flow of liquid. — "When liquid, of the same color as the liquor amnii flows troni the vagina, after having eliminated the possibility of an involuntary or unconscious micturition, we may question whether this is the show or the pure amniotic liquid. Differential signs : THE SHOW. LIQUOR AMNII. Stiffening the linen. Not stiffening, or only a little. Mucus, thick. Liquid, not stringy. Sometimes sanguinolent. Of normal color, or tinted by the meco- nium, or again reddish, red, or deep red (maceration). Beginning slow; progressive and contin- Beginning sudden, flowing in jets and uous flow. intermittent. It may occur that the liquor amnii has actually escaped, and yet in digital examination one may still feel a bag of waters more or less filled with liquid. There exist in this case three causes of error. The first is the existence of an amnio-chorial sac (Fig. 235). Now if this sac exists in front of the fcetal part it may be ruptured by the finger or spontaneously. The liquor amnii flows away and yet on examination there is met (Fig. 236) the intact amnion. In the second place, the rupture may have been complete, but the cervix retracting after the flow covers the opening in the membranes (Fig. 237 1. In the third place, the rupture of the membranes, com- plete, while remaining outside, the uterine orifice is obstructed by the approach of the fcetal part, which prevents the ulterior flow of liquid (Fig. 238), and again to touch there appears a bag of waters. 3. Digital examination. — The diagnosis of the integrity of the bag of waters is really difficult only in presentations of the vertex, for 192 Accouchement. — Phenomena of the Appendages. in the other presentations the volume of the sac and the inequalities of the fcetal part scarcely permit hesitation. An experienced finger can sometimes recognize the hair of the fcetus and diagnosticate the absence of rupture. During contraction the sac becomes smooth and tense. The fcetal scalp, on the contrary, becomes wrinkled. Amnion Chorion OeciduA Uterus Fig. 235. — Chorio-amniotic sac. By uplifting the fcetal head in the interval between contractions, if a flow of the liquor amnii is observed, there is evident proof of the rupture of the ovum. Finally in some cases the speculum has been introduced, but this mode of investigation is little used. The persistence with which I have sought to establish the diagnosis of the rupture, or of the integrity of the bag of waters is not superflu- ous, for the hydrocephalic head has been perforated at the bregma in the belief that the operator was puncturing the membranes. Foetus. / Amnion. Chorion. Uterus. »«w»w Fig. 236. Fig. 237. Fig. 238. P.upture cf chorion, with Rupture of the membrane above Opening of the rupture, ob- amnion intact. the uterine orifice. tructed by the approach of the foetal part. The elements of prognosis that can be drawn from the bag of waters depend upon its volume and upon the period of rupture. A flat bag of waters is a favorable augury ; projecting, it predicts dys- tocia. All things being equal, the later the rupture of the bag of waters the better is the prognosis for the mother and for the child. The rale should be to leave the rupture to nature. But if, to follow Accouchement. — Phenomena of the Appendages. 198 some -pedal indication (placenta prsevia, hydramnios, Bpecial rigidity of the membranes), artificial rapture becomes aecessary, the membranes may be opened with the finger nail, which sometimes presents difficulties, or with a carefully disinfected instrument (Fig. 289). Efthe bag of waters is large, the rupture should be made in the interval of the contractions and the hand should moderate the flow of liquid by closing the vulva, as a too violent escape favors the procidence of a limb or of the cord. Fig. 239. — Membrane perforater of whalebone, with ivory point. B. The show. — The ovuline membranes, when they are no longer reinforced by the uterine wall, are easily permeable for the liquor amnii, especially when the intra-ovuline pressure is augmented by the contractions of labor. Thus when accouchement commences, in proportion as dilatation of the cervix proceeds, the liquor amnii filtering through the membranes escapes along the vagina and from the vulva mixing with the mucus in its passage. The mixture of liquids constitutes "the show," which is, then, part ovuline and part maternal. The show is glutinous, gelatinous, due to the mixture with the cervical mucus and to the secretion of the cervical glands. This consistency favors the passage of the fcetus through the parturient canal. In general the show is of a citron color, sometimes streaked with blood. Its appearance is an indication of the onset of accouchement. With a dry vagina one can be sure, save in a pathological state, that labor has not commenced. 194 Mechanism of Accouchement. — Foetal Phenomena. CHAPTER X. MECHANISM OF ACCOUCHEMENT.— FCETAL PHENOMENA. Whatever the presentation may be, except that of the abdomen where accouchement is impossible, the exit of the foetus takes place in six stages : First stage — diminution. Second stage — engagement. Third stage — internal rotation. Fourth stage — disengagement of the first ovoid. Fifth stage — external rotation. Sixth stage — disengagement of the second ovoid. We shall examine for each presentation the details of each of these stages. Presentation of the "Vertex. — I shall take as the type the vertex presentation in L I A, the most frequent position, and I shall speak later of the mechanism in the other positions. 1. Diminution. — The diminution of the head is made by moulding and by inclination of the dystocic diameters (flexion and lateral in- clination). The moulding, resulting in the deformation of the head to be studied under plastic phenomena, is brought about by the over-lapping of the bones or by their depression. This variety of diminution is only of small importance in presentations of the vertex. The inclination of the dystocic diameters, on the contrary, takes a considerable part, it occurs by flexion and lateral inclination. Flexion, by directing the chin towards the thorax, approaches to the genital axis the occipito-mental diameter (13^), the longest of the head. A moderate flexion substitutes the occipitofrontal diameter (11-0 for the occipito-mental and a very marked flexion, the suboccipito-bregmatic (9^) for the occipito-mental (Figs. 240, 241 and 242). By each of these degrees of flexion there is gained two centimetres ; the difference in the circumference belonging to each of these diameters is relatively much more important. The flexion becomes more and more marked in proportion as the head descends into the bony pelvis. This flexion is the normal attitude of the head in relation to the trunk and the pressure of the vertebral column during the uterine contraction only exaggerates it. Flexion is appreciated in digital examination by the relative height of the bregma and lambda. Easy access of the bregma indicates want of Mechanism of Accouchement. — Foetal Phenomena. 195 flexion. In proportion as the lambda approaches the center of the parturient canal the head is flexed. The lateral inclination favors the passage of the trans' diameters of the head, in particular of the biparietal. It occurs amund one of the anteroposterior diameters of the head as a pivot while flexion takes place around a transverse diameter passing in the vicinity of the occipital foramen. With regard to lateral incli- nation it is necessary to understand two terms, cynclitism and asyn- clitism. A synclitic head is that where the two parietal protu- berances are found in the same pelvic plane, at the superior or the median straits, or at any region of the excavation. An asynclitic head is that where the two parietal protuberances are on different planes. Synclitism maintains the sagittal suture in the center of the pelvis. Asynclism inclines it to one side. Synclitism is un- favorable to engagement of the transverse diameters of the head and asynclitism is favorable. Fig. 240. Presentation of the occipito- mental diameter, 13); centimetres. Fig. 241. Presentation of the occipito- frontal diameter, n}4 centimetres. Fig. 242. Presentation of the suboccipito- bregmatic, g% centimetres. Now does the head, in its pelvic passage, descend by synclitism or by asynclitism ? According to Duncan, whose opinion seems to me to be correct, the head is synclitic at the superior strait and in the superior part of the excavation, asynclitic in the inferior part of the excavation and at the inferior strait. 2. En