i/'.'J'J- 
 
 III I II II II ^^s^fl^^te^sB '^' " '■-''' ' 
 
Columte ®nit)ersltp 
 
 intfjeCitpofi^ctoSorfe 
 
 College of l^\)^iidani anb ^urgconB 
 
 &ibtn fap 
 
 ©r. etitoin ^. Cragin 
 
 1859-1918 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/practiceofmidwifOOgala 
 
THE PRACTICE OF MIDWIFERY 
 
THE PRACTICE 
 OF MIDWIFERY 
 
 BEING THE SEVENTH EDITION OF DR. GALABIN'S 
 
 MANUAL OF MIDWIFERY, GREATLY 
 
 ENLARGED AND EXTENDED 
 
 BY 
 
 ALFRED LEWIS GALABIN 
 
 M.A., M.D. Cantab.; F.R.C.P. Lond. 
 
 LATE FELLOW OF TRINITY COLLEGE, CAMBRIDGE ; CONSULTING OBSTETRIC PHYSICIAN TO GUY's 
 
 HOSPITAL ; LATE PRESIDENT OF THE OBSTETRICAL SOCIETY OF LONDON ; LATE 
 
 EXAMINER IN OBSTETRIC MEDICINE TO THE UNIVERSITIES OF OXFORD, 
 
 CAMBRIDGE, LONDON, AND NEW ZEALAND, AND TO THE ROYAL 
 
 COLLEGES OF PHYSICIANS AND SURGEONS 
 
 GEORGE BLACKER 
 
 M.D., B.S. Lend.; F.R.C.S. Eng. ; F.R.C.P. Lond. 
 
 FELLOW OF UNIVERSITY COLLEGE, LONDON ; OBSTETRIC PHYSICIAN TO UNIVERSITY COLLEGE 
 
 HOSPITAL, AND THE GREAT NORTHERN CENTRAL HOSPITAL ; TEACHER OF PRACTICAL 
 
 MIDWIFERY, UNIVERSITY COLLEGE HOSPITAL MEDICAL SCHOOL ; 
 
 EXAMINER IN OBSTETRIC MEDICINE TO THE ROYAL COLLEGES 
 
 OF PHYSICIANS AND SURGEONS 
 
 ILLUSTRATED WITH 503 ENGRAVINGS 
 
 Many 0/ the New Illustrations specially drawn by T. W. P. Lazvrcnce, M.B., B.S., J^.R.C.S. 
 
 P athologist to University College Hospital, and Curator of the Museum 0/ 
 
 Pathology, University College Hospital Medical School 
 
 lie to |orh 
 THE MACMILLAN COMPANY 
 
BEABBUBY, AGNEW, & CO. LD., PRINTERS, 
 LONDON AND TONBEIDGE 
 
Treface 
 
 'TT^HE present edition of this work has been thoroughly revised, 
 and to a large extent rewritten. The -subjects chiefly 
 requiring revision have been the development of the ovary and 
 of the early ovum, the physiology of the foetus and of the puer- 
 peral state, the mechanism of labour, the lower uterine segment, 
 the pathology of eclampsia, hydatidiform mole, accidental com- 
 plications of pregnancy, narcosis in labour, vaginal and extra- 
 peritoneal Cesarean section, and pubiotomy. 
 
 A new chapter has been added on " Injuries and Diseases of the 
 Foetus." 
 
 One hundred and seventy-four new figures have been added, 
 and many of the others modified or redrawn. Most of the new 
 figures have been drawn specially for the work by Mr. T. W. P. 
 Lawrence, F.E.C.S. Altogether there are nearly three hundred 
 new illustrations. 
 
 The form of the page has been altered, and the additions have 
 rendered it necessary to enlarge the book by some two hundred 
 pages. 
 
 Mnji, 1010. 
 
Table of Contents 
 
 CHAPTEB I. 
 
 Aj^atomy of the Pelvis. 
 
 PAGE 
 
 The pelvis as a whole. — Differences between male and female j)elves. — 
 Inclination of the pelvis. — Articulations of the pelvis. — Changes in 
 pelvic joints during pregnancy. — Mechanical action of the sacrum. — 
 Measurements of the pelvis. — Diameters. — Alterations of diameters 
 by soft parts. — Other measurements. — Axis of the pelvis. — Axes of 
 the several planes. — ^The pelvis in infancy and childhood. — Develop- 
 ment of the pelvis. — Changes in the sacrum. — Changes in the lateral 
 pelvic wall. — Effects of the pressure of the femora. — Effects of sitting. 
 — Effects of muscular action ........ 1 
 
 CHAPTER II. 
 
 Ovulation and Conception. 
 
 Development of the ovaries and ova. — Structure of the ovary. — Relation 
 of menstruation to ovulation. — Character of the menstrual fluid. — 
 Source of the menstrual blood. — Theory of menstruation. — Cycle of 
 menstrual changes. — Maturation of the Graafian follicle. — Period of 
 ruj)ture of the Grraafian follicle. — Eormationof the corpus luteum. — 
 Commencement and duration of menstruation. — Conception. — Period 
 of possible impregnation ......... 34 
 
 CHAPTER III. 
 
 Early Development of the Ovum. 
 
 Maturation of the oocyte. — Fertilisation and segmentation of the 
 ovum. — The decidua. — Further changes in the ovum. — The formation 
 of the mesoderm. — The amnion. — Structure of the amnion. — The 
 li([uor amnii. — The allantcns. — Formation of bloodvessels ... 65 
 
viii Table of Contents. 
 
 CHAPTEE IV. 
 
 The Choeion, Placenta, and Umbilical Coed. 
 
 PAGE 
 
 The chorion. — The placenta. — Varieties of placenta in animals. — Formation 
 of human placenta. — Characters of full-grown placenta. — Functions of 
 the placenta. — The umbilical cord . . . . . . ^ . 92 
 
 CHAPTEE V. 
 
 Development of the Fcetus. 
 
 The fcetus in successive months. — The foetus at full term. — Circulation of 
 the foetus. — Changes in the foetal circulation at birth. — Physiology of 
 tbe foetus 115 
 
 CHAPTEE VI. 
 
 The Anatomy of the Fcetal Head. 
 
 The head as a wbole. — Sutures and fontanelles. — Diameters. — Influence of 
 sex and race on the dimensions of the foetal head. — Ai-ticulation of the 
 foetal head 127 
 
 CHAPTEE VII. 
 
 The Attitude, Presentation, Lie, and Position of the Fcetus 
 
 IN TJtero. 
 
 Attitude. — Presentation and lie. — Causation of head presentation . . 136 
 
 CHAPTEE VIII. 
 
 Changes in the Maternal Organism consequent upon Pregnancy. 
 
 Changes in the uterus. — Uterine vessels. — Uterine lymj)hatics and nerves. 
 — Size of the uterus in the successive months of pregnancy. — Changes 
 in the cervix uteri. — The cervix and lower uterine segment. — Changes 
 in the vagina and other adjacent parts. — Mechanical effects on other 
 parts. — Changes in the breasts. — Diagnostic value of mammary 
 changes. — Changes in the body generally. — Circulation. — Blood 
 pressure — Eespiration. — Puerperal osteoj)hytes. — -Urine. — Nervous 
 system. — Pigmentatiou 145 
 
Table of Contents. ix 
 
 CHAPTEE IX. 
 
 Diagnosis of Pkegnancy. 
 
 PAGE 
 
 Symptomatic signs. — Suppression of menstruation. — Morning sickness. — 
 Mammary clianges. — Physical or direct signs. — Enlargement of the 
 uterus and of the abdomen. — Hegar's sign. — Changes in the cervix 
 uteri and vagina. — Violet coloration of cervix and vagina. — Inter- 
 mittent uterine contractions. — Ballottement. — Foetal movements. — 
 Uterine souffle. — Foetal heart-sounds. — Funic souffle. — Eeca]3itulation 
 of signs in order of date. — Differential diagnosis, — Pseudocyesis. — 
 Diagnosis of life or death of foetus. — Diagnosis between first and 
 subsequent pregnancies ......... 171 
 
 CHAPTEE X. 
 
 The Dxteation and Hygiene of Pregnancy. 
 
 The duration of pregnancy. — Calculation of probable date of delivery. 
 
 — Hygiene of pregnancy . . . . . . . • .195 
 
 CHAPTEE XI. 
 
 Laboue. 
 
 Causes which determine labour. — Nervous mechanism of uterine contrac- 
 tions. — Arrangement of nerve-centres and afferent nerves. — Mode in 
 which the uterus contracts. — Eetraction of the uterus. — Polarity of 
 the uterus. — Cause of the pain in labour. — Effect of the pains on the 
 general sj'stem. — The course of x^artuiition. — Premonitory symptoms. 
 — Spurious pains. — The three stages of labour. — The first stage. — 
 Mode in which the cervix and vagina expand. — Caput succedaneum 
 in the first stage. — Second or expulsive stage ..... 203 
 
 CHAPTEE XII. 
 
 The Mechanism of Laboue. 
 
 General intra-uterine pressure. — Direct uterine pressure. — Auxiliary 
 forces. — Magnitude of the forces. — Eesistances. — Positions of the 
 head in vertex i)resentations. — Movements of the head and of the 
 trunk of the foetus. — Descent.— Flexion. — Internal rotation. — Exten- 
 sion. — Restitution. — External rotation. — Eolations of movements to 
 each other. — Mechanism in occipito-posterior positions. — Mechanisms 
 in unreduced occipito-posterior presentations. — Lateral obliquity. 
 — Moulding of foetal head in vertex positions. — Caput succedaneum. 
 — Diagnosis of cranial positions. — By abdominal palpation. — By 
 vaginal examination. — The third stage. — Mechanism of detachment. — 
 Mechanism of expulsion. — Separation and expulsion of membranes. — 
 Duration of labour 2;j0 
 
X Table of Contents. 
 
 CHAPTBE XIII. 
 
 Management of Normai. Labour. 
 
 PAGE 
 
 Eequisites to be taken by accoucheur. — Antiseptic precautions. — Preliminary 
 preparations. — Position of tbe patient. — Examination. — Management 
 of first stage. — Artificial rupture of membranes. — Management of 
 second stage. — Management of occipito-posterior positions. — Preserva- 
 tion of the perineum. — Expulsion of the trunk. — Ligature of the 
 funis. — Management of the third stage. — Expression of the placenta. 
 — Examination of the j)lacenta. — Examination of perineiim. — Use of 
 the binder. — Use of anesthetics in labour. — Scopolamine morphine 
 narcosis. — Maternal mortality in childbirth. — Foetal mortality . . 290 
 
 CHAPTEE XIV. 
 
 Face Presentations. 
 
 Frequency. — Causation. — Varieties. — Mechanism of labour. — Extension. 
 — Internal rotation.— Flexion. — Eestitution. — External rotation. — 
 Lateral obliquities. — Contrasts between mechanism of face and 
 vertex presentation. — Caput succedaneum. — Moulding of head. — 
 Diagnosis. — Prognosis. — Brow presentation. — Treatment of face 
 presentations. — Management of mento-posterior positions. — Treat- 
 ment of protracted labour. — Treatment of brow presentation . . 321 
 
 CHAPTEE XV. 
 
 Pelvic Presentations. 
 
 .Causation. — Varieties. — Diagnosis.— Mechanism of labour. — Mechanism 
 in dorso-posterior jiositions. — Irregularities of mechanism. — 
 Mechanism in foot or knee presentation. — Moulding of child. — 
 Prognosis. — Management. — Extraction of head ..... 345 
 
 CHAPTEE XVI. 
 
 Multiple PREGNiUS^CY. 
 
 Causation. — Binovular twins. — Uniovular twins. — Acardiac monsters. — 
 Sex of the children. — Course of pregnancy. — Diagnosis. — Presenta- 
 tion. — Labour-.— Management of labour. — Superfoetation . . . 365 
 
Table of Contents. xi 
 
 CHAPTEE XVII. 
 
 Physiology of the Puerperal State. 
 
 PAGE 
 
 Pulse and temperatui'e. — Secretions and excretions. — Involution of uterus. 
 — Changes in mucous membrane. — The placental site. — The cervix 
 uteri and vagina. — The lochia. — Condition of the blood. — Body 
 weight. — After-pains. — Secretion of milk. — Composition of the milk. 
 — Diagnosis of puerperal state. — Diagnosis of parity. — Differences 
 between multiparous and parous uterus. — The new-born infant . . 380 
 
 CHAPTEE XVIII. 
 
 Management of the Puerperal State. 
 
 Cleanliness. — Diet and general management. — Action of bowels. — Lacta- 
 tion. — Management of new-born infant. — Selection of wet-nurse. — 
 Artificial feeding 401 
 
 CHAPTEE XIX. 
 
 Abnormal Pregnancy. 
 
 Ectopic or extra-uterine foetation. — Yaiieties. — Causation. — Pathological 
 anatomy. — Ovarian foetation. — Tubal foetation. — Tubal mole. — Tubal 
 abortion. — Pupture of the tube. — Hsematocele and Hsematoma. — 
 Tubo-ovarian foetation. — Tubo-uterine foetation. — Intra-ligamentous 
 foetation.— Secondary abdominal foetation. — Primary abdominal foeta- 
 tion. — Pregnancy in rudimentary uterine horn. — Symptoms. — Diag- 
 nosis. — Prognosis. — Treatment. — Operation ..... 417 
 
 CHAPTEE XX. 
 
 DiSORDEKS OF PREGNANCY DUE TO EeFLEX ToXIC AND MECHANICAL 
 
 Causes. 
 
 Classification — Nausea and vomiting. — Other digestive disturbances. — 
 •Salivation. — Gingivitis. — Anasmia. — Neuralgia. — Cough, dyspnoea, 
 palpitation, syncope. — Eruptions. — Pruritus. — Chorea. — Hysteria. — 
 Albuminuria. — Eclampsia. — Causation. — Pathology. — Diagnosis. — 
 Treatment. — CEdema. — Varicose veins. — Haemorrhoids . . . 455 
 
 CHAPTEE XXI. 
 
 Abnormalities of the Uterus. 
 
 Congenital malformations. —Displacements. — Anteversion and anteflexion. 
 — Retroversion and retroflexion. — Prolapse of uterus and vagina. — 
 Hernia of uterus 49;j 
 
xii Table of Contents. 
 
 CHAPTEE XXII. 
 
 Diseases of Decidua and Ovum. 
 
 PAGE 
 
 Decidual endometritis. — Anomalies of decidua basalis and placenta. — 
 Anomalies of form and size. — Congestion and inflammation of 
 placenta. — Infarcts. — Calcification. — Syphilis. — Tubercle. — Tumours 
 of placenta. — CEdema. — Carneous mole. — Blighted ovum. — Hydatidi- 
 form mole. — Hydramnios or Hydrops amnii. —Deficiency of liquor 
 amnii. — Anomalies of funis.— Knots. — Coils. — Torsion. — Anomalies 
 and diseases of foetus. — Intra-uterine amputation of limbs. — Con- 
 genital dislocations. — Exomphalos. — Intra-uterine fracture of bones. 
 — Rachitis. — Intra-uterine death. — Retention in utero, maceration, 
 miimmification. — ]\Iissed labour 510 
 
 CHAPTEE XXIII. 
 
 Accidental Complications of Pregnancy. 
 
 Chronic cardiac disease. — ^Acute endocarditis. — Phthisis. — Acute lobar 
 j)neumonia. — Jaundice. — Acute atrophy of liver. — Diabetes. — Pj^elo- 
 nephritis. — Brouchocele. — Htemorrhages. - — Appendicitis. — Ovarian 
 tumours.— Pibroid tumours of uterus. — Surgical operations. — Ague. — 
 Syphilis. — Zymotic diseases. — Yariola. — Scarlatina. — Measles. — 
 Erysipelas. — Enteric, typhus, and relapsing fevers. — Cholei-a . . 551 
 
 CHAPTEE XXIV. 
 
 Premature Expulsion of the Ovum. 
 
 Definition. — Mechanism. - Causation. — Symptoms and course. — Diagnosis. 
 — Prognosis. — Prophylaxis. — Treatment of threatened abortion. — 
 Treatment of inevitable abortion. — Treatment of incomplete abor- 
 tion. — Treatment in later months. — After-treatment .... 566 
 
 CHAPTEE XXV. 
 
 HjEMOREHAGE in PREGNiUS'CY. 
 
 Menstruation in jaregnancy. — Placenta prsevia.^Definition. — Causation. — 
 Varieties. — Prequency. — Pathological anatomy. — Source of the blood. 
 — Cause of bleeding before full term. — Presentation of foetus. — 
 Symptoms and course. — Diagnosis. — Prognosis. — Treatment. — ^Acci- 
 dental haemorrhage. -Causation. — Pathological anatomy. — Symptoms 
 and course. — Diagnosis. — Prognosis. — Treatment .... 590 
 
Table of Contents. xiii 
 
 CHAPTEE XXVI. 
 
 Precipitate and Prolonged Labour. 
 
 PAGE 
 
 Precipitate labour. — Treatment.— Prolonged labour.— General effects.- - 
 Oontinuoti.s action of uterus. — Retraction of uterus.— Effects at the 
 several stages. — Anomalies of expulsive force. — Inertia of uterus. — 
 Irregular and painful contractions. — Inefficiency of auxiliary forces. 
 — Deviation of uterine axis. —Treatment in first stage of labour. — 
 Treatment in second stage. — External pressure. — Oxytocic drugs. — 
 Forceps. —Indications for use of forceps 617 
 
 CHAPTEE XXVII. 
 
 Labour Obstructed by Anomalies of the Soft Parts. 
 
 Trismus uteri. — Causation. — Organic rigidity of cervix. — Diagnosis. — 
 Treatment. — Hydrostatic dilators. — Manual dilatation. — Instru- 
 mental dilators. — Application of forceps. — Incision of cervix.— 
 Version or craniotomy.— Vaginal or abdominal Caesarean section. — 
 Atresia of cervix. — Malposition of os. — Cicatrices and atresia of vagina 
 and vulva. — Eigidity of perineum. — Cancer of cervix uteri and pelvis. 
 — Labour complicated by tumours. — Fibroid tumours. — Ovarian 
 tumours. — Hydatid tumours. — Prolapse of vagina. — Distended 
 bladder. — Vesical calculus. — Vaginal enterocele. — Hsematoma or 
 tbrombus ............ 634 
 
 CHAPTEE XXVIII. 
 
 Labour Obstructed by Anomalies of the Ovum. 
 
 Shoulder, arm, and transverse presentations. — Freqiiency. — Causation. — 
 Varieties. — Diagnosis. — Prognosis. Natural terminations. — Spon- 
 taneous rectification. — Spontaneous version. — Spontaneous evolution. 
 Spontaneous expulsion. — Termination of neglected cases. — Treat- 
 ment. — Version. — ■ Decapitation. — Embryotomy. — Presentation of 
 head or arm with hea'd. — Dorsal displacement of arm. — ^Presentation 
 of hands and feet together. — Presentation of foot with head. — Locked 
 twins.— Foetal monstrosities. — Conjoined twins. — Acardiac monsters. — 
 Anencephalic monsters. — Extroversion of viscera. — Excessive develop- 
 ment of foetus. — General dropsy. — Emphysema. — Congenital hydro- 
 cejihalus. — Ascites, hydrothorax, distension of abdomen. — Congenital 
 encephalocele. — Spina bifida.— Other external tumours. — Anomalies 
 of membranes. — Shortness of funis 063 
 
xiv Table of Contents. 
 
 CHAPTEE XXIX. 
 
 Axo:malies of the Pelvis. 
 
 PAGE 
 
 Enlarged pelvis. — Contracted pelvis. — General forces concerned in the 
 production of pelvic deformities. — Effect of the pelvic inclination. — 
 Effect of standing, walking, &c. — Effect of sitting. — Diagnosis of 
 pelvic contraction. — Pelvimetry. — External meastirements. — Internal 
 measiirements.— Yarieties of contracted pelvis. — Classification. — The 
 generally contracted pelvis. — The infantile pelvis. — The rachitic 
 generally contracted i)elvis. — The masculine pelvis. — The dwarf pelvis 
 — The flattened pelvis and the generally contracted flattened jDelvis. — 
 Caiisation. — The rachitic flattened pelvis. — -The chondrodystrophic 
 pelvis. — Mechanism of labour. — Diagnosis. — -The pelvis of double 
 congenital dislocation of the hips. — The split pelvis.— General effects 
 on pregnancy and labour. — Prognosis. — Treatment. — Choice between 
 forceps and version. — Extraction of after-coming head. — Craniotomy 
 and Cfesarean section. — Symphj-siotomj^ and pubiotomy. — Induction 
 of ijremature labovu- or abortion ........ 697 
 
 CHAPTEE XXX. 
 
 Eare Forms of Pelvic Deformity. 
 
 The triradiate or rostrated malacosteon pelvis. — The triradiate rachitic 
 I)elvis. — Oblique pelvis. — The scoliotic pelvis. — The obHque pelvis from 
 shortening or disease of one leg. — The oblique pelvis of Naegele. — 
 Transversely contracted pelvis. — The pelvis of Eobert. — The kyphotic 
 pelvis. — The high assimilation pelvis. — The bed-ridden pelvis. — The 
 siJondylolisthetic pelvis. — Pelvis deformed by out-growths . . . 763 
 
 CHAPTEE XXXI. 
 
 Induction of PREMATrRE Labour and Artificial Abortion. 
 
 Induction of premature labour. — Indications for the operation. — Methods 
 of operating. — Puncture of membranes. — Introduction of flexible 
 bougie into uterus. — Dilatation of cervix. — Hydrostatic dilators. — The 
 vaginal douche. — Intra-uterine injections. — Yaginal tampons. — 
 Choice of method. — Care of the child. — Induction of artificial abortion. 
 — Indications for operation. — Choice of time. — Mode of operating . 792 
 
 CHAPTEE XXXII. 
 
 Extraction of the Ecetus in Pelvic Presentations. 
 
 Causes of impaction. — Extraction by the feet. — Bringing down the leg in 
 breech presentation. — Digital traction. — The soft fillet. — The blunt 
 hook. — Eorceps. — Bringing down the second leg. — Liberation of the 
 arms. — Delivery of the head. — Injuries to the foetus .... 806 
 
Table of Contents. xv 
 
 CHAPTER XXXIII. 
 
 The Forceps and Vectis. 
 
 PAGE 
 
 The vectis. — The vectis in occipito -posterior i)ositions. — The forcei^s. — 
 " Historjr. — Mechanical action. — Requirements of good forceps. — 
 Varieties. — Disadvantages and advantages of straight forceps. — Axis- 
 traction forcei)s. — Application of torcejis. — Axis traction with long 
 curved forceps. — Leverage action of forceps. — Application of axis- 
 traction forceps. — Forceps in occipito-posteiior presentations. — Forceps 
 in face presentations. — Application of forceps to after-coming 
 head 821 
 
 CHAPTER XXXIV. 
 
 Version. 
 
 Definition. — History.— Cephalic version. — Cephalic version by external 
 method. — Cephalic version by combined external and internal 
 method. — Podalic version. — Bipolar version in head presentation. — • 
 Bipolar version in shoulder presentation. — Internal version in head 
 presentation. — Internal version in shoulder presentation. — Choice of 
 leg to seize. — -Application of noose to prolapsed arm.— Version in 
 impacted shoulder presentation . . . . . . . .861 
 
 CHAPTER XXXV. 
 
 Craniotomy and Embryotomy. 
 
 Indications for operation. — Mortality. — Instruments. — Method of operating. 
 — Methods of extraction. — Craniotomy forceps. — The cephalotribe.— 
 Cranioclasm. — Induction of face presentation. — Version. — The crochet. 
 — Forceps.— Extraction of body. — Perforation of after-coming head. — 
 Embryotomy in pelvic presentations ....... 883 
 
 CHAPTER XXXVI. 
 
 CESAREAN Section, Symphysiotomy, and Pubiotomy. 
 
 Cajsarean section. — History. — Indications for operation. — Time for 
 f)perating. — The operation. — Uterine sutures. — After-treatment. — 
 ]*]xtra-peritoneal Ctesarean section. — Post-mortem Ceesarean section.— 
 I'orro's operation. — Supra- vaginal hysterectomj'. — -Panhysterectomy. — 
 Vaginal Ciosarean section. — SJ'mphysiotomJ^^ — History. — Indications 
 for opoi'utioii . — I'ro]iaTations. — The operation. — Prognosis. — Puljiotomy 908 
 
xvi Table of Contents. 
 
 CHAPTEE XXXVII. 
 
 Accidents during, and after Labour. 
 
 PAGE 
 
 Euptures and lacerations of genital canal. — Eupture of uterus or vaginal 
 involving peritoneum. — Eupture during pregnancy. — Incomplete 
 rupture of uterus. — Perforation of the uterus. — Lacerations of cervix. 
 — Lacerations of the vagina. — Lacerations of the vaginal outlet, 
 vulva, and perineum. — Eupture of the pelvic articulations. — Obstetrical 
 paralysis. — Presentation, prolapse and expression of the funis. — 
 Physometra or tympanites uteri. — Inversion of uterus . . . 934 
 
 CHAPTEE XXXVIII. 
 
 Eetention of the Placenta and Post-partum HiEMORRiiAGE. 
 
 Eetention of the placenta.— Causation. — Inertia. — Adhesion. — Hour-glass 
 contraction. — Prophylaxis. — Treatment. — Post-partum htemorrhage. 
 — Frequency.— Causation.— Symptoms and diagnosis. — Prophylaxis. 
 — Treatment. — Intravenous injection of saline fluid. — Secondary 
 puerperal haemorrhage ......... 973 
 
 CHAPTEE XXXIX. 
 
 Puerperal Fevers. 
 
 Definition. — Organisms in puerperal fever. — Varieties — Causation. — Eela- 
 tions to erysipelas and scarlatina. — Contagious character of different 
 varieties. — Pathological anatomy. — Symptoms and course. — General 
 peritonitis. — Saprtemia. — Vascular or phlebitic septicaemia. — Pyeemia. 
 — Pelvic cellulitis and pelvic peritonitis. — Frequency. — Prognosis. — 
 Prophylaxis. — Prophylaxis in lying-in hospitals. — Treatment. — Treat- 
 ment of pelvic cellulitis and pelvic peritonitis. — Operative measures. — 
 Puerperal tetanus 992 
 
 CHAPTEE XL. 
 
 Phlegmasia Dolens, Thrombosis, Embolism, Sudden Death, 
 Chorion Epithelioma. 
 
 Phlegmasia dolens or peripheral venous thrombosis. — Embolism and 
 thrombosis of pulmonary arteries. — EmboHsm of systemic arteries. — 
 Entrance of air into the veins. — Syncope and shock. —Other causes of 
 sudden death. — Chorion epithelioma or deciduoma malignum . .1048 
 
Table of Contents. xvii 
 
 CHAPTER XLI. 
 
 Puerperal Insanity. 
 
 PAGE 
 Insanity of pregnancy. — Insanity of labour. — Insanity of the puerperal 
 
 period.- — -Insanity of lactation. — Prophylaxis. — Treatment . . . 1070 
 
 CHAPTER XLII. 
 
 Injuries and Diseases of the Fcetus, 
 
 CephalliEematoma. — Other injuries to the head. — Injuries to the bones. — 
 Injuries to nerves. — Cerebral hteniorrhages. — Il£ematoma of the 
 sterno-mastoid. — Asphyxia neonatorum. — Mastitis neonatorum. — 
 Ophthalmia neonatorum. — Tightness of frenum linguae. — Tetanus 
 neonatorum. — Icterus neonatorum. — Septic infections of the new- 
 born 1079 
 
 CHAPTER XLIII. 
 
 Diseases oe the Breast. 
 
 Abnormalities in the quantity of milk. — Deficient secretion of milk. — 
 Polygalactia.— Galactorrhoea. — Dej^ressed nipples. —Excoriations and 
 fissures of nipples.— Mastitis, mammary abscess. — Galactocele . .1103 
 
 INDEX . : 1113 
 
List of Illustrations 
 
 FIGURE 
 
 1. Os Innorainatum ....... 
 
 2. Division between the Ilium, Ischium, and Pubes . 
 
 3. Sacrum and Coccyx ....... 
 
 4. Section of Sacrum and Coccyx ..... 
 0. Female Pelvis, seen from the front .... 
 
 6. Pemale Pelvis, viewed in the Axis of the Brim 
 
 7. Outlet of Pelvis 
 
 8. Male Pelvis, seen from the front ..... 
 
 9. Male Pelvis, viewed in the Axis of the Brim 
 
 10. Pelvis of Chimpanzee ....... 
 
 11. Antero-posterior Section of Pelvis .... 
 
 12. Nutation of Sacrum during Parturition ....... 
 
 13. Antero-posterior Section of Sacrum and Symphysis Pubis to show 
 
 Effect of Walcher's position ........ 
 
 Section through outlet of Pelvis to show Effect of Walcher's position 
 
 Section of Pelvis, parallel to the Brim, passing through the points 
 where the Pelvis rests upon the Heads of the Femora . . . 
 
 Section through Plane of Pelvic Brim ...... 
 
 Section through Plane of greatest dimensions . . . . . 
 
 Section through Plane of least dimensions ...... 
 
 Section of Pelvis, side to side ; perpendicular to Plane of Brim . 
 20. Lateral view of Pelvis from within, showing the inclined Planes of 
 the Ischium ........... 
 
 Diagram to show asymmetry of Pelvic Brim ..... 
 
 Diagram showing Axis and Planes of Pelvis . . . . . . 
 
 Pelvis of Foetus, viewed in the Axis of the Brim . . . . 
 
 Antero-posterior Section of Adult Pelvis, with Foetal Pelvis super- 
 imposed ............ 
 
 25. Diagram to illustrate the Change of Shape in the Pelvis . 
 
 26. Transverse Section through Ovary, Mesosalpinx and Fallopian Tube 
 
 27. Section of Ovary of Human Foetus ....... 
 
 28. Section of Ovary of Foetus of Eight Months 
 
 29. Section of Adult Human Ovary 
 
 30. Section of Ovary of Woman aged Twenty-five Years .... 
 
 31. Section of a portion of Cat's Ovary 
 
 32. Section of Wall of Grraafian Follicle 
 
 33. Section of Graafian Follicle 
 
 34. Human Ovum ........... 
 
 35. (!omposite Drawing of Mucous Membrane of Uterus renKjved hy 
 
 Hysterectomy on first day of Menstruation . . ... 
 
 b2 
 
 14. 
 15. 
 
 16. 
 17. 
 
 18. 
 19. 
 
 21. 
 22. 
 23. 
 24. 
 
 PAGE 
 2 
 
 2 
 3 
 
 3 
 3 
 4 
 4 
 6 
 6 
 7 
 8 
 10 
 
 11 
 12 
 
 13 
 14 
 15 
 16 
 
 17 
 
 18 
 19 
 21 
 24 
 
 25 
 27 
 34 
 35 
 36 
 37 
 38 
 39 
 40 
 41 
 42 
 
 47 
 
XX List of Illustrations. 
 
 FIGURE PAGE 
 
 36. Oblique Section througli Ovary and Tube in situ .... 53 
 
 37. Section of Corpus Luteum of Pregnancy, showing Lutein Cells 
 
 38. Section of Wall of Corpus Luteum ...... 
 
 39. Section of Human Ovary, showing Corpus Luteum at Third Month 
 
 of Gestation 
 
 40. Corpus Luteum at Full Term of Pregnancy 
 
 41. Diagram of the Formation of the Corpus Luteum . 
 
 42. Formation of Polar Bodies in Asterias Grlacialis . 
 
 43. Formation of Second Polar Body of the Mouse 
 
 44. Segmentation of Mammalian Ovum . 
 
 45. Stages in the Fertilisation of the- Egg of the Mouse 
 
 46. Diagram of Fertilisation ..... 
 
 47. Diagram of Embedding of Ovum and Formation of Decidua Capsu- 
 
 laris and Basalis ...... 
 
 48. Pregnant Uterus, showing very Early Ovum embedded in posterior 
 
 wall ........ 
 
 49. Section through centre of Peters' Ovum 
 
 50. Decidual Cells from early Pregnancy 
 
 51. Section of Ovum in situ at beginning of Second Week, showing 
 
 Decidua Capsularis formed ..... 
 
 52. The same Ovum magnified 
 
 53. Membranes in situ, from near margin of Placenta 
 
 54. Section of Decidua Yera at Fourth Month 
 
 55. Transverse Section of Embryonic Area of Sheep . 
 
 56. Embryonic Area of the Eabbit .... 
 
 57. Scheme of Formation of the Amnion 
 
 58. Diagrammatic Transverse Sections to illustrate Cleavage of Mesoderm 
 
 and Formation of Amnion .... 
 
 59. Diagrams to illustrate the Formation of Allantois in some Mam- 
 
 mals ......... 
 
 60. Diagram of Early Ovum to show Origin of Mesoderm 
 6L Embryonic Area in Peters' Ovum .... 
 
 62. Embryo of 2 mm 
 
 63. Section of Spee's Human Ovum .... 
 
 64. Spee's Human Ovum at early part of Second Week . 
 
 65. Sagittal Section of Early Human Ovum 
 
 66. Development of Placenta 
 
 67. Embedding of Early Guinea-pig Ovum 
 
 68. Development of Placenta, diagrammatic 
 
 69. Vertical Section through the Decidua Basalis at the Sixth Week 
 
 70. Very Early Human Ovum, of Age not exceeding Fourteen Days 
 
 71. Diagram of Teacher-Bryce Ovum 
 
 72. Human Ovum of Eighth Week 
 
 73. Diagram of Embedding of Early Htiman Ovum 
 
 74. Section through Placenta of Seven Months in situ 
 
 75. Diagram showing the Mode of Attachment of the Villi tc the Decidua 
 
 76. Chorionic Villi 
 
 77. Sections of Chorionic Villi 
 
 78. Section of fully-formed Placenta, with part of the Uterus 
 
 79. Diagrammatic Section of Placenta 
 
List of Illustrations. xxi 
 
 FIGURE p^jjg 
 
 80. Uterine Surface of Placenta jq^ 
 
 81. Eoetal Surface of Placenta . . . . . . . . . 106 
 
 82. Early Ovum, in the Museum of Guy's Hospital, showing the straight 
 
 direction of the Vessels of the Cord HO 
 
 83. Microscopic Section of Wharton's Jelly HI 
 
 84. Section of Umbilical Cord . . . . . . . ..112 
 
 85. Diagrams illustratmg the Formation of the Umbilical Cord . .11,3 
 
 86. Early Human Ovum iHst^it . . . . . . . . . 116 
 
 87. Series of Embryos . . . ... . . . .117 
 
 88. Diagram of the Foetal Circulation 122 
 
 89. Foetal Skull . 128 
 
 90. Foetal Skull, seen from above, showing anterior and posterior 
 
 Fontanelles . . . . . . . . . . . 129 
 
 91. Foetal Skull, posterior view, showing posterior Fontanelle, Sagittal 
 and Lambdoidal Sutures. . . . . . . . .129 
 
 . . 133 
 
 . 133 
 
 . . 136 
 
 . 137 
 
 . . 138 
 
 . 140 
 
 . . 141 
 
 . 141 
 
 92. Skull of a European Foetus ...... 
 
 93. Skull of a Negro Foetus 
 
 94. Attitude of the Mature Foetus in titer o .... 
 
 95. Normal Attitude of the Foetus in ntero 
 
 96. Attitude of Foetus in ntero with abundant Liquor ximnii 
 
 97. Outline of the Uterus at Full Term .... 
 
 98. Ovoid Form of Foetus at Full Term .... 
 
 99. Adaptation of Foetus to Uterus 
 
 100. Adaptation of Hydrocephalic Foetus . 142 
 
 101. Maladaptation of Foetus and Uterus in Breech Presentation . . 142 
 
 102. Foetus in utero at Fifth Month ........ 1-13 
 
 103. Development of Muscular Fibre Cells of Gravid Uterus . . .146 
 
 104. Drawing of Elastic Fibres in "Wall of Pregnant Uterus . . . 147 
 
 105. External Layer of Muscle Fibres of Uterus 147 
 
 106. Middle Layer of Muscle Fibres of Uterus 147 
 
 107. Internal Layer of Muscle Fibres of Uterus 148 
 
 108. Arteries and Veins of Uterus ......... 149 
 
 109. Sagittal Section of Gravid Uterus of Fourth Month .... 151 
 
 110. Sagittal Section of Pregnant Uterus at Eighteenth Week . . . 152 
 
 111. Level of Fundus Uteri at Different Weeks of Pregnancy . . .153 
 
 112. Sagittal Section of Uterus and Child at end of Pregnancy . . . 154 
 
 113. Diagram of Uterus showing the Segments and the Ring of Bandl . 156 
 
 114. Diagram to illustrate apparent Shortening of Cervix, without any 
 
 Shortening of Cervical Canal ........ 159 
 
 115. Cervix a,t Seventh Month of Pregnancy 160 
 
 116. Head Engaged in Pelvic Brim at Full Term 161 
 
 117. Mammary Changes in the Later Months of Pregnancy, with Forma- 
 
 tion of Secondary Areola . . . . . . . . .164 
 
 118. Method of Bimanual Examination of Uterus 174 
 
 119. Frozen Section of a Uterus at Thirteenth Week of Pregnancy . .175 
 
 120. Coronal Section of a Pregnant Uterus at the Twelfth Weel^ . . . 176 
 
 121. Sagittal Section of a Pregnant Uterus at the Fourth to the Fifth 
 
 Week of Pregnancy . . . . . . . . .177 
 
 122. JJemonstration of Hogar's Sign by Bimanual Examination, the 
 
 Uterus being antevorted ......... 178 
 
xxii List of Illustrations. 
 
 FIGURE PAGE 
 
 123. Demonstration of Hegar's Sign by Bimanual Examination, tlie 
 
 Uterus being retroverted . . . . . . . .179 
 
 124. Diagram stowing the Areas in wbicb the Foetal Heart Sounds are 
 
 heard with greatest intensity . . . . . . . . 187 
 
 125. Mode of measuring the Height of the Fundus Uteri with Callipers . 199 
 
 126. Diagram of Nerves of Uterus 208 
 
 127. Diagram of Curve of Pains of First Stage . . . . . . 210 
 
 128. Diagram showing Shortening and Thickening of Muscle Fibres . 211 
 
 129. Diagram of Dilatation of Cervical Canal in a Primipara . . . 217 
 
 130. Diagram of Dilatation of Cervical Canal in a Multiparoe . . . 218 
 
 131. From a Frozen Section of a Patient who died in Labour, the Head 
 
 having entered the Pelvic Cavity, but the Membranes being yet 
 unruptured . . . . . . . . . . .220 
 
 132. From the same Section as Fig. 131, the Foetus being removed . . 221 
 
 133. Diagram showing separation of Anuiion from the Placenta . . 222 
 
 134. Vertical Section, to illustrate the relations of the Uterus and Vagina 
 
 in the Virgin, the Bladder being nearly empty ..... 224 
 
 135. Tracing of the Uterine Pains during the Exj)ulsive Efforts of the 
 
 Second Stage ........... 226 
 
 136. Appearance of Vertex at Vulval Outlet . . . . . . . 227 
 
 137. Emergence of Foetal Head at Vulval Outlet 228 
 
 138. Diagram of General Intra-uterine Pressure . . . . . . 231 
 
 139. The Cavity of the Uterus, with the Parturient Canal in a state of Full 
 
 Dilatation 232 
 
 140. Sagittal Section of Primipara at beginning of First Stage of Labour . 233 
 
 141. Sagittal Section of Uterus from near end of Second Stage of Labour 234 
 
 142. Section of Litems with Child in situ, towards end of Second Stage of 
 
 Labour ............ 236 
 
 143. Superficial and Deep Muscles of Pelvic Floor seen from below . . 237 
 
 144. Lateral View of Muscles of Pelvic Floor 238 
 
 145. Brim of the Pelvis, and Base of the Foetal Skull in first cranial 
 
 position ............ 240 
 
 146. Brim of the Pelvis, and Base of the Foetal Skull in the second 
 
 position ............ 240 
 
 147. Brim of the Pelvis, and Base of the Fo'tal Skull in the third position 241 
 
 148. Brim of the Pelvis, and Base of the Foetal Skull in the fourth position 241 
 
 149. First Vertex Presentation 242 
 
 150. Second Vertex Presentation ........ 242 
 
 151. Third Vertex Presentation 243 
 
 152. Fourth Vertex Presentation 243 
 
 153. Diagram showing that with the Head completely flexed the Maximum 
 
 Diameter is coincident with the Axis of the Plane of the Pelvis in 
 
 which the Head is lying ......... 245 
 
 154. Line of Section and Shape of Suboccipito-bregmatic and of Occipito- 
 
 frontal Planes 246 
 
 155. Diagram of Head-lever .......... 247 
 
 156. Diagram to illustrate the Mode in which Flexion is produced by the 
 
 Pressure of the Girdle of Contact on the Head .... 248 
 
 157. Diagram to illustrate the Li crease of Flexion by Pressure, after the 
 
 Head has entered the Genital Canal 249 
 
List of Illustrations. xxiii 
 
 158. Outline of the Internal Surface of the left half of the Pelvis, showing 
 
 the path of the Occiput in the first, and in the occipito-anterior 
 termination of the fourth position ....... 249 
 
 159. Diagram of Mechanism of Labour ....... 250 
 
 160. Showing the Genital Tract toward the end of the Second Stage of 
 
 Labour ............ 252 
 
 161. Commencement of Extension, showing position of Foutanelles . . 254 
 
 162. First Stage of Extension 255 
 
 163. Second Stage of Extension ......... 255 
 
 164. Successive Stages of first, or left occipito-anterior, position of Vertex 257 
 
 165. Escape of Head by Flexion in unreduced occipito-posterior position. 
 
 First Stage 258 
 
 166. Escape of Head by Flexion in unreduced occipito-posterior position. 
 
 Second Stage 258 
 
 167. Diagram of Mechanism of Labour in unreduced occipito-posterior 
 
 Presentations ........... 258 
 
 168. Successive Stages of fourth, or left occipito-posterior, j^osition of 
 
 Vertex, when unreduced ......... 259 
 
 169. Plane of Section and Shape of suboccipito-frontal Diameter . . 260 
 
 170. Diagram of Head presenting at Brim in occipito-posterior Presenta- 
 
 tion 261 
 
 171. Section showing Partial Extension of Saline when the Occiput is 
 
 behind 262 
 
 172. Outlet of the Pelvis, showing a slight Naegele- obliquity of the Foetal 
 
 Head, which is passing through the Pelvic Cavity in the first 
 position 263 
 
 173. Outlet of the Pelvis, showing a slight Naegele -obliquity of the Fcetal 
 
 Head, which is passing through the Pelvic Cavity in the third 
 position ............ 264 
 
 174. Foetus from a case of Advanced Pregnancy, showing inclination of 
 
 Head towards Eight Shoulder 264 
 
 175. Diagram to show Synclytism of the Head . . . . . . 265 
 
 176. Diagram of Anterior Parietal Obliquity 266 
 
 177. Diagram of Posterior Parietal Obliquity . . . . . . 267 
 
 178. Moulding of Head in occipito-anterior position of Vertex . . . 268 
 
 179. Moulding of Head in occipito-anterior position of Vertex . . . 269 
 
 180. Usual Moulding of Head in unreduced occipito-posterior position of 
 
 Vertex ............ 270 
 
 181. Usual Moulding of Head in unreduced occipito-posterior ijosition of 
 
 Vertex 270 
 
 182. Diagram showing positions of Centre of Caput Succedaneum in the 
 
 several positions of the Vertex ........ 272 
 
 183. Abdominal Palpation, Manoeuvre No. 1 274 
 
 184. Abdominal Palpation, Manoeuvre No. 2 ...... 275 
 
 185. Abdomijial Palpation, Manoeuvre No. 3 276 
 
 186. Abdominal Palpation, Manoeuvre No. 4 ...... 277 
 
 187. First Vertex position 278 
 
 188. Second Vertex positioii ......... 278 
 
 189. Third Vertex position 279 
 
 190. Fourth Vertex position 279 
 
xxiv List of Illustrations. 
 
 FIGUEE PAGE 
 
 191. Moulding of Bones of Head 280 
 
 192. Sagittal Section showing Placenta in titer o after Birth of Child . . 282 
 
 193. Expulsion of Placenta from Upper Uterine Segment into Lower 
 
 Uterine Segment and Vagina ....... 284 
 
 194. Delivery of Placenta according to Matthews Duncan . . . . 286 
 
 195. Delivery of Placenta according to Schultze ..... 286 
 
 196. Examination of the Os Uteri in the First Stage of Labotu- . . . 296 
 
 197. Supporting the Perineum ......... 303 
 
 198. Expulsion of Shoulders 304 
 
 199. Presentation of the Face at the Pelvic Brim in the second facial position 321 
 
 200. Diagram of the Head completely extended entering the Pelvic Inlet . 322 
 
 201. Diagram of Head-lever in Face Presentation . . ... 323 
 
 202. Diagram to show the Eifect of Obliquity of the Uterus in causing 
 
 Face Presentations .......... 324 
 
 203. Potation of Chin under Pubic Arch in Face Presentation . . . 327 
 
 204. Distension of intact Perineum in Face Presentation . . . 328 
 
 205. Passage of Head under Pubic Arch by a movement of Flexion in Face 
 
 Presentation ........... 329 
 
 206. Arrest of Head, Neck, and Shoulders in Plane of Bi'im in persistent 
 
 mento-posterior Presentation ........ 330 
 
 207. Diagram of Mechanism of Labour in Face Presentation . . . 332 
 
 208. Successive Stages of first, or right mento-posterior, position of Face. 333 
 
 209. Diagram of Mechanism of Labour of second Face Presentation . . 334 
 
 210. Moulding of Head in Face Presentation 335 
 
 211. Moulding of Head in Face Presentation 335 
 
 212. Face Presentation, first and second positions ..... 336 
 
 213. Face Presentation, third and fourth positions . .... 337 
 
 214. Plane of Section and Shape of Mento-vertical Diameter . . . 338 
 
 215. Moulding of Head in Brow Presentation . . . . . . 340 
 
 216. First, or left sacro-anterior, position of the Breech .... 345 
 
 217. Foetus i» ifiero with Breech Presentations . . . . . . 346 
 
 218. Breech Presentation with extended Legs ...... 347 
 
 219. Breech in Pelvis, left sacro-anterior Presentation, seen from below . 349 
 
 220. Breech in Pelvis, right sacro-posterior Presentation, seen from below 350 
 
 221. Passage of Breech under Pubic Arch by a movement of lateral Flexion 351 
 
 222. Passage of the Shoulders in Pelvic Presentation . . . . 352 
 
 223. Diagram of Mechanism of Breech Pi'esentations ..... 353 
 
 224. Passage of the Shoulders in Pelvic Presentation, one Arm extended . 354 
 
 225. Descent of the Head .......... 355 
 
 226. Diagram of Mechanism of Labour in Foot or Ivnee Presentation . 356 
 
 227. Manual Extraction of Head through the Outlet of Soft Parts . .' 360 
 
 228. Shoulder and Jaw Traction 362 
 
 229. Twins in ntero, both presenting by Vertex . . . . . . 366 
 
 230. Diagram of the Ari-angement of the Placentae and Membranes with 
 
 Uniovular Twins .......... 368 
 
 231. Acardiac Acephalic Foetus 369 
 
 232. Section of a Placenta with a Foetus Compressus .... 370 
 
 233. Adaptation of Twins in vtero, both lying transversely . . . . 371 
 
 234. Adaptation of Twins in utero, with one Vertex and one Pelvic Pre- 
 
 sentation ........... 372 
 
List of Illustrations. xxv 
 
 FIGURE PAGE 
 
 235. Adai)tation of Twins in ntero, both pi'esentiug by the Vertex . . 373 
 
 236. Uterus Didelphys • ... 375 
 
 237. Uterus Septus, with Septate Vagina ....... 376 
 
 238. Uterus Subsej^tus .......... 376 
 
 239. Uterus Bicornis Unicollis 377 
 
 240. A Twin Pregnancy 378 
 
 241. Section of a Uterus from a Patient djnugfive mimites after Delivery 384 
 
 242. Section of Uterus on the Third Day of the Piierperium . . . 385 
 
 243. Section of Uterus on the Sixth Day of the Puerperium . . . 386 
 
 244. Section of the Uterus on the Twentj^-sixth Day of the Puerperium . 388 
 
 245. External Views of the Nulliparous and Parous Uterus . . . 397 
 
 246. Sections of the Nulliparous and Parous Uterus 398 
 
 247. Chart showing Involution of Uterus, Average of Thirty-four Cases . 405 
 
 248. Chart showing Involution of Uterus. Saprcemia. Effect of one 
 
 Douche, and clearing out Uterus ....... 405 
 
 249. Hawksley's Milk Steriliser 412 
 
 250. Tubal Pcetation, with the Corpus Luteum in the Ovary of the opposite 
 
 side 419 
 
 251. Ovarian Pregnancy .......... 421 
 
 252. Early Tubal Pregnancy unruptured, situated in Isthmus of Tube . 422 
 
 253. Tubal Eoetation showing intra-mural Site of Ovum outside Lumen of 
 
 Tube 423 
 
 254. A Tubal Mole seen in Section 424 
 
 255. Specimen of Tubal Abortion ......... 425 
 
 256. Tubal Eoetation, Decidua in Uterus partly separated . . . 426 
 
 257. Early Ruptured Ampullary Pregnancy ....... 427 
 
 258. Tubo-uterine or Interstitial Eoetation ...... 430 
 
 259. Intra-ligamentous Eoetation ......... 431 
 
 260. Uterus and Foetus from a Case of (? secondary) Abdominal Eoetation. 432 
 
 261. The Author's Case of Primary Abdominal Eoetation .... 435 
 
 262. Pregnancy in Rudimentary Uterine Horn . . . . . . 436 
 
 263. Foetus retained Twenty Tears in Calcified Broad Ligament Sac . 439 
 
 264. Decidual Cast from Case of Tubal Pregnancy . . . . . 441 
 
 265. Degenerate Villi in Wall of Tube 443 
 
 266. Mikulicz Tampon 452 
 
 267. Kidney of Pregnancy from Patient with Albuminuria . . . 469 
 
 268. Kidney from a Case of Eclampsia ....... 479 
 
 269. Liver from a Patient dying of Eclampsia ...... 480 
 
 270. Position of Uterus with a Pendulous Abdomen . . ... 494 
 
 271. Incarceration of the retroflexed Gravid Uterus with Piupture of the 
 
 Bladder 497 
 
 272. Incomplete Eetroflexion of the Uterus ....... 500 
 
 273. Prolajjse of second degree in unimpregnated Uterus . . . . 505 
 
 274. Prolajjse of third degree in unimpregnated Uterus . . . . 506 
 
 275. Battledore Placenta . . . . . . . . . .512 
 
 276. Placenta Succentuin'ata . . . . . . . . ..513 
 
 277. Placenta Circumvallata ......... 513 
 
 278. Blighted Ovum with irregular thickening of Membranes . . . 5i4 
 
 279. Villi from Syphilitic J'laccnta 516 
 
 280. Tuberous Fleshy M(jle 518 
 
xxvi List of Illustrations. 
 
 FIGURE PAGE 
 
 281. Blighted Ovum, showing Morbid Enlargement of the Umbilical Cord 519 
 
 282. Section of Placental Tissue from an Early Ovum retained Eour 
 
 Months in utero after Death of Embryo ..... 520 
 
 283. A portion of the Section shown in Fig. 282, more highly magnified . 520 
 
 284. Hydatidiform Degeneration of Chorion . . . . . . 523 
 
 285. Commencement of Hydatidiform Degeneration of Chorion . . 523 
 
 286. VniiofMole . / 524 
 
 287. Uterus containing a Yesicular Mole ....... 527 
 
 288. Section of Uterine Wall and Tart of Mole 529 
 
 289. Placenta Yelamentosa 535 
 
 290. Knot of Umbilical Cord 536 
 
 291. Coiling of Cord round Neck of Foetus 537 
 
 292. Torsion of the Cord 538 
 
 293. Spirochaeta Pallida from Blood Smear . . . . . .541 
 
 294. Tibia from a healthj' and syphilitic Foetus . . . . . . 542 
 
 295. Shrunken Foetus after Eetentiou in utero ...... 547 
 
 296. Contents of Cyst, in Dr. Oldham's Case of Missed Labour . . . 548 
 
 297. Usual Mechanism of Abortion in the first Two Months of Pregnancy. 567 
 
 298. Mechanism of Abortion in the Early Months 567 
 
 299. Abnormal Mechanism of Abortion ....... 568 
 
 300. Mechanism of Abortion, Foetus expelled in the intact Amnion . . 568 
 
 301. Foetus expelled entire with the Membranes and Placenta at the 
 
 Seventh Month .......... 573 
 
 302. Ovum expelled in Abortion in Third Month 576 
 
 303. Evacuation of the Uterus in a Case of Early Abortion . . . 583 
 
 304. i^uthor's Uterine Yulsellum 584 
 
 305. Ovum Forceps ........... 585 
 
 306. Irrigating Curette ........... 587 
 
 307. Sim's Cm-ette 587 
 
 308. Placenta Prsevia 592 
 
 309. Diagram of Eeflexal iJevelopmcnt of I'lacenta 593 
 
 310. Central Placenta Prrevia 595 
 
 311. Marginal Placenta Prsevia and Low Implantation of the Placenta . 595 
 
 312. Placenta Prtevia, nndistiirbed by any commencement of Labour . 596 
 
 313. Champetier de Eibes' Bag in situ ........ 604 
 
 314. Half Breech Forming a Plug after Version in a case of Placenta 
 
 Prasvia 606 
 
 315. Section of the Uterus of a Patient who died of internal and external 
 
 Hfemorrhage ........... 609 
 
 316. Section of the Uterus of a Patient dying at the Eighth Month from 
 
 Eclampsia . . . . . . . . . . .611 
 
 317. Section of a Portion of the L^terine Wall and Vagina from a Patient 
 
 dying during Labour .......... 622 
 
 318. Improved Hydrostatic Dilator for Cervix Uteri 637 
 
 319. Champetier de Eibes' Hydrostatic Dilator, with Forceps for introduc- 
 
 tion 639 
 
 320. Frommer's Uterine Dilator 642 
 
 321. Bossi's Uterine Dilator 642 
 
 322. Uterus removed by Wertheim's Operation in a Case of Cancer of the 
 
 Cervix obstructing Delivery ....,.,, 650 
 
List of Illustrations. xxvii 
 
 FIGURE PAGE 
 
 323. Eetroflexion of the Pregnant Uterus at Full Term with a Fibromyoma 
 
 adherent in Douglas' Pouch ........ 655 • 
 
 324. Dermoid Tumour of the Right Ovary obstructing Labour . . . 657 
 
 325. Prolapse of posterior Vaginal Wall with Enterocele . . . . 660 
 
 326. Coronal Section of the Pelvis, showing the usual position of a Hfoma- 
 
 toma of the Vulva 661 
 
 327. Arm Presentation in the dorso-anterior position . . ... 664 
 
 328. Arm Presentation in the abdomino-anterior position .... 666 
 
 329. Commencement of Spontaneous Evolution . . . . . . 670 
 
 330. Spontaneous Evolution arrested ....... 671 
 
 331. Further Progress of Spontaneous Evolution . . . . . . 672 
 
 332. Termination of Spontaneous Evolution ... . . 672 
 
 333. Spontaneous Expulsion .......... 673 
 
 334. Decapitating Hook, with serrated edge . . . . • . . 674 
 
 335. Decapitation 674 
 
 336. Presentation of Head and Hand ....... 677 
 
 337. Dorsal Displacement of Arm ......... 678 
 
 338. Presentation of a Hand and Foot with Funis ..... 679 
 
 339. Locked Twins 680 
 
 340. Thoracopagus Monster 684 
 
 341. Dicephalus Monster 684 
 
 342. Syncephalus Monster 685 
 
 343. Anencephalus Monster .......... 685 
 
 344. Labour impeded by Hydrocejahalus ....... 690 
 
 345. Encephalocele ........... 693 
 
 346. Pelvimeter 701 
 
 347. Measurement of Diagonal Conjugate ....... 705 
 
 348. Diagram for Calculation of True Conjugate ..... 707 
 
 349. Sagittal Section of a Normal Pelvis ....... 712 
 
 350. Sagittal Section of a Small Round Pelvis ...... 712 
 
 351. Infantile Pelvis 713 
 
 352. Section of a Normal Pelvis parallel to and just below the Inlet . . 716 
 
 353. Section of Flattened Rachitic Pelvis parallel to and just below the 
 
 Inlet 717 
 
 354. Sagittal Section of a Rickety Flat Pelvis ...... 717 
 
 355. Upper half of a Section through a Normal and Rachitic Innominate 
 
 Bone . . • 718 
 
 356. Reniform Rachitic Pelvis ......... 719 
 
 357. Skeleton of Rachitic Dwarf with Contracted Pelvis . . . . 720 
 
 358. The Outlet of a Rickety Flat Pelvis 721 
 
 359. Median Section through a Flat Rachitic Pelvis 722 
 
 360. Median Section through a Flat Rachitic Pelvis with marked Bending 
 
 of the Sacrum 723 
 
 361. Figure-of-eight Rachitic Pelvis ........ 724 
 
 362. Chondrodystrophic Pelvis ......... 725 
 
 363. Engagement of Head in Brim of flattened Pelvis, viewed from below 
 
 in the Axis of the Brim 726 
 
 364. The Rhomboid of Michaelis in a Woman with a well-formed Pelvis . 733 
 
 365. Pregnancy with Double Congenital Dislocation of the Hij)S . . . 735 
 
 366. Transverse Section of Fcjetal Skull 743 
 
xxviii List of Illustrations. 
 
 FIGURE PAGE 
 
 367. Transverse Section of Foetal Skull, showing the Alterations produced 
 
 by Yertical Compression ......... 744 
 
 368. Transverse Section of Foetal Skull, showing the Outline of Skull as 
 
 compressed by Extraction after Version ...... 744 
 
 369. Passage of After-coming Head through Eeniform Flattened Pelvis . 744 
 
 370. Munro Kerr's Method of determining the Eelative Size of Foetal 
 
 Head and Pelvis 758 
 
 371. Triradiate Malacosteon Pelvis in Extreme Deformity, viewed in the 
 
 Axis of the Brim ........... 763 
 
 372. The same Malacosteon Pelvis, seen from the Outlet .... 764 
 
 373. Eostrated Malacosteon Pelvis, in Earlier Stage of Deformity . . 765 
 
 374. Eostrated Malacosteon Pelvis, seen from the Outlet .... 766 
 
 375. Pseudo-malacosteon Eachitic Pelvis 767 
 
 376. The Outline of the Pelvic Brim in the principal varieties of Con- 
 
 tracted Pelvis ........... 768 
 
 377. Scoliotic Flattened Pelvis 770 
 
 378. Oblique Pelvis, from Anchylosis of the Hip-joint, and Disuse of Eight 
 
 Leg . . . . . . . . . . . . .771 
 
 379. Oblique Pelvis of Naegele 772 
 
 380. An Oblique Pelvis of Naegele, in which the Distortion is only slight . 773 
 
 381. Oblique Pelvis of Naegele seen from behind . . . . . . 774 
 
 382. Transversely contracted Pelvis of Eobert 777 
 
 383. Figure of Woman with Kyphotic Pelvis . . . . . . 779 
 
 384. Kyphotic Pelvis 780 
 
 385. Pelvis of a Woman who had been bedridden from Infancy iip to the 
 
 Age of 31 784 
 
 386. Figure of Woman with Spondylolisthetic Pelvis .... 785 
 
 387. Spondylolisthetic Pelvis . ." 786 
 
 388. Bony Growth of the Sacrum ........ 787 
 
 389. Sacral Exostosis filling the Pelvis 788 
 
 390. Minor Degree of Deformity from Exostosis of the Cristie of the 
 
 Pubes ............ 788 
 
 391. Cancerous Growths from the Bones of the Pelvis, causing Deformity. 789 
 
 392. Enchondroma of Sacrum obstructing Labour ..... 790 
 
 393. Horrocks' Maieutic 797 
 
 394. Maieutic, fixed on Catheter . 797 
 
 395. Maieutic, distended i)i situ 798 
 
 396. Hearson's Thermostatic Nurse 802 
 
 397. Pinard's Manoeuvre .......... 810 
 
 398. The Blunt Hook 812 
 
 399. Axis-traction Forceps applied to the Breech . . . . . . 814 
 
 400. The Manner in which the Pelvis of the Child should be grasped by 
 
 the two Hands ........... 814 
 
 401. Bringing down extended anterior Arm 816 
 
 402. Shoulder and Jaw Traction 818 
 
 403. The Vectis 821 
 
 404. Short straight Forceps 824 
 
 405. Short cruwed Forceps, with French Lock 824 
 
 406. Long straight Forceps 825 
 
 407. Diagram illustrating the Defects of long straight Forceps . . . 826 
 
List of Illustrations. xxix 
 
 FIGURE PAGE 
 
 408. Simpson's Forceps 828 
 
 409. Barnes' Forceps 828 
 
 410. Long ciirved Forceps . 830 
 
 411. Tarcier's Axis-traction Forceps, withi tlie Traction-handle removed . 832 
 
 412. Upper or right-hand Blade of Tarnier's Axis-traction Forceps . 
 
 Traction Eod detached for cleansing of Hinge .... 833 
 
 413. Traction with Tarnier's Axis-traction Forceps 833 
 
 414. Axis-traction Forceps 834 
 
 415. Axis-traction Forceps with Screw at end of Handles . . . . 835 
 
 416. Diagram showing the Increase in the Conjugate Diameter in 
 
 Walcher's position 838 
 
 417. Introduction of first or lower Blade of Axis-traction Forceps . . 841 
 
 418. Introduction of second or upper Blade of Axis-traction Forceps . 842 
 
 419. Diagram to illustrate Introduction of second or upper Blade of long 
 
 curved Forceps .......... 844 
 
 420. Mode of making Axis-traction with ordinary long curved Forceps . 848 
 
 421. Mode of delivering Head through Vulval Outlet 851 
 
 422. Tarnier's Axis-Traction Forceps 855 
 
 423. The Author's Axis-traction Foi'ceps ....... 856 
 
 424. External Cephalic Version with the Woman in the Trendelenburg 
 
 position ............ 862 
 
 425. First Stage of Bipolar Version 866 
 
 426. Second part of Fii'st Stage of Bipolar Version ..... 867 
 
 427. Second part of First Stage of Bipolar Version, when Head becomes 
 
 extended 868 
 
 428. Second Stage of Bipolar Version ....... 869 
 
 429. Commencement of Third Stage of Bipolar Version . . . . 869 
 
 430. Second part of Third Stage of Bij)olar Version ..... 870 
 
 431. Internal Version in Head Presentation ....... 872 
 
 432. Internal Version in Head Presentation. Seizing the Leg . . . 874 
 
 433. Version by Leg diagonally opposite to presenting Shoulder . . . 876 
 
 434. Internal Version in Transverse Presentation, dorso-anterior position 877 
 
 435. Internal Version in Transverse Presentation. Seizing the lower Foot . 878 
 
 436. Version by the nearer Leg, or that corresponding to the presenting 
 
 Shoulder. Noose placed upon prolapsed Arm .... 879 
 
 437. Internal Version. Leg drawn down into Vagina, Head pushed up to 
 
 Fundus 880 
 
 438. Oldham's Perforator 884 
 
 439. Simpson's Perforator 884 
 
 440. Perforation of Head 886 
 
 441. Craniotomy Forceps with Screw to Handles 888 
 
 442. Eoper's Craniotomy Forceps . . . - 889 
 
 443. Elongation of Head in Conical Form by Extraction with Craniotomy 
 
 Forceps 890 
 
 444. Braxton Hicks' Cephalotribe 892 
 
 445. Head crushed by Cephalotribe • . . 894 
 
 446. Simpson's Splitting Basilyst 896 
 
 .447. Auvard's three-bladed Cephalotribe 896 
 
 448. Craniotomy Forceps .......... 898 
 
 449. Crochet 900 
 
XXX List of Illustrations. 
 
 FIGURE PAGE 
 
 450. Diagram of Mode of applying Sutures in Sanger's Operation . . 909 
 
 451. Diagram of Sutures secured in Sanger's Oj^eration . . . . 910 
 
 452. Application of Sutures in Csesarean Section ..... 910 
 
 453. Sutui'es tied according to Sanger's Method, seen from above . . 911 
 
 454. Author's Method of placing Sutures to unite Abdominal Wall . . 912 
 
 455. Koeberle's Serre-noeud 917 
 
 456. Guarded Pin for fixing Stump of Uterus in Abdominal Wound . 917 
 
 457. Vaginal Csesarean Section . . . . . . . . . 921 
 
 458. Separation of Pubic Bones in Symphysiotomy ..... 924 
 
 459. Symphysiotomy Knife .......... 927 
 
 460. Pinard's Eegistering Separator for Symphysiotomy .... 928 
 
 461 . Bumm's Subcutaneous Method of performing Pubiotomy . . . 930 
 
 462. Gigli's Saw in position for sawing through the Bones . . . 932 
 
 463. Over-distension of the lower Uterine Segment in Transverse Pre- 
 
 sentations ............ 935 
 
 464. Eupture of Cervix and lower Uterine Segment ..... 937 
 
 465. Eupture of Cervix, lower Uterine Segment, and posterior Vaginal 
 
 Fornix 939 
 
 466. Eupture of the lower Uterine Segment with large subperitoneal 
 
 Hcematoma ........... 940 
 
 467. Incomplete Eupture of Perineum . . . . . . . . 951 
 
 468. Complete Eupture of Perineum into Eectum ..... 951 
 
 469. Antero-posterior Section of Perineal Body in I'rimiioaras . . . 952 
 
 470. Hagedorn's Needles 955 
 
 471. Hagedorn's Needle-holder 955 
 
 472. Prolapse of Funis, with the Head in the first position . . . 960 
 
 473. Gum-elastic Catheter, adapted as Funis Eepositoi' 963 
 
 474. Commencing Inversion of the Uterus ...... 965 
 
 475. Complete Inversion of Uterus with Prolapse. The Placenta still 
 
 attached 966 
 
 476. Sagittal Section of Pelvis with complete Inversion of Uterus . . 967 
 
 477. Modified Aveling's Eepositor for Inversion of Uterus . . . . 970 
 
 478. Modified Aveling's Eepositor applied for Eeduction of inverted 
 
 Uterus 971 
 
 479. Uterus with adherent Cotyledon of Placenta from Patient dj'iug of 
 
 ante-partum and post-partum Haemorrhage 974 
 
 480. Eetained Placenta from Hour-glass Contraction of the Uterus . . 976 
 
 481. Eemoval of an adherent Placenta ........ 977 
 
 482. Uterus and Vagina properly and comj^letely plugged with Gauze . 986 
 
 483. Uterus and Vagina improperly plugged with Gauze . . . . 987 
 
 484. Horrocks' Apparatus for Intra-venous Injection .... 989 
 
 485. Diagram of Annual Variation of Puerperal Fever and other Diseases 
 
 for London 1000 
 
 486. Uterus showing Acute Sloughing Endometritis 1006 
 
 487. Uterus from a Case of Acute Septicaemia following criminal 
 
 Abortion, ending fatally on the Sixth Day 1008 
 
 488. Diagram illustrating Spread of Infection from the Cervix and the 
 
 Uterus 1010 
 
 489. Diagam illustrating the Spread of a Septic Thrombo Phlebitis . . 1011 
 
 490. Temperature Chart of a Case of Acute Septicaemia .... 1014 
 
List of Illustrations. xxxi 
 
 FIGURE PAGE 
 
 491. Temperature Chart of a Case of Sapraemia, due to retained Membranes 1019 
 
 492. Diagram of Situation of Thickening in Parametritis . . . . 1024 
 
 493. Diagram of Annual Variation of Pvierperal Fever and other Diseases 
 
 for England and Wales 1025 
 
 494. Uterus with a portion of retained Placenta from a Patient dying of 
 
 Septicaemia . . . . . . . . . . . 1035 
 
 495. Ohorionepithelioma of Uterus with Lutein Cysts in both Ovaries . . 1061 
 
 496. Microscopic Section of Ohorionepithelioma ..... 1063 
 
 497. A Collection of Epithelial Cells lying within a Bloodvessel from a 
 
 Case of Hydatidiform Mole 1064 
 
 498. Chorionepithelioma of Uterus with Secondary Growths in Vagina and 
 
 in Perivaginal Connective Tissue ....... 1067 
 
 499. Spoon-shaped Depression on Foetal Skull . . . . . . 1081 
 
 500. L-shaped Depression on Foetal Skull 1081 
 
 501. Fracture of Parietal Bone in Case of Forceps Delivery . . . . 1082 
 
 502. Schultze's Method. Position of Expiration 1092 
 
 503. Schultze's Method. Position of Inspiration . . . . . . 1092 
 
THE 
 
 Practice of Midwifery 
 
 Chapter I. 
 
 ANATOMY OF THE PELVIS 
 
 The study of the anatomy of the pelvis is of primary importance 
 for the obstetric art, since upon the disproportion of its size to that 
 of the foetus, or abnormaHty of its shape, depends a large propor- 
 tion of the difficulties which are met with in delivery. The pelvis 
 is a structure adapted for fulfilling many functions at once, and its 
 obstetric functions are greatly influenced by the purely mechanical 
 conditions to which it is subjected. It forms (1) a bony ring, by 
 means of which the weight of the body is transmitted to the legs ; 
 (2) an axis for the movements of the legs upon the trunk ; (3) an 
 attachment for many of the most powerful muscles of the trunk 
 and of the legs ; (4) a cavity to contain the pelvic viscera ; and 
 (5) a bony canal for the passage of the child in parturition. The 
 rough external surface, with many prominences to afford leverage, 
 is adapted for the attachment of muscles ; the smooth internal 
 surface is suitable for the passage of the foetus. Owing to the 
 erect posture of women, the contents of the abdomen and pelvis 
 tend to gravitate towards the pelvic outlet. Hence there is a 
 mechanical difficulty, which does not exist in the case of animals, 
 in rendering the structures which close the pelvis strong enough 
 to prevent any undue yielding under pressure. There are two 
 peculiarities in the formation of the bony pelvis which tend to 
 diminish tbis difficulty. First, the considerable inclination which 
 the brim of the pelvis has to the horizon in the standing position 
 has the effect that the major portion of the weight of the abdominal 
 and pelvic viscera rests rather upon the anterior abdominal wall 
 and anterior bony wall of the pelvis, than upon the soft parts 
 which close the pelvis inferiorly. Secondly, owing to the curvature 
 
 M. 1 
 
2 The Practice of Midwifery. 
 
 of the pelvic canal, greater than that of the pelvis of animals, the 
 lower part of the sacrum and coccyx afford some measure of bony 
 
 Fig. 1. — Os innominatum. 
 
 support to the contained viscera, and give a firm attachment to the 
 muscles and other structures which constitute the pelvic floor. 
 As in almost all mammalia, the pelvis is made up of four bones : 
 
 two ossa innominata, the 
 sacrum and the coccyx. Of 
 these, each os innominatum 
 is formed by the union of 
 three principal portions, the 
 ilium, ischium, and puhes. 
 These are separated from 
 each other, generally up to 
 about the age of twenty, by 
 a triradiate or Y-shaped piece 
 of cartilage, having its centre 
 at the acetabulum. In 
 addition to the pelvis proper, 
 the last lumbar vertebra has 
 also to be taken into con- 
 sideration in relation to 
 certain pelvic deformities. 
 The student will be assumed 
 to be fully acquainted with these bones, as described in text-books 
 of anatomy, and those points only which have a special bearing 
 on obstetrics will be here considered. 
 
 Fig. 2. 
 
 - Division between the 
 ischium, and pubes. 
 
 ilium, 
 
Anatomy of the Pelvis. 3 
 
 The Pelvis as a whole. — The formation of the pelvis out of 
 several bones, instead of as a completely ossified ring, serves a 
 triple purpose. 1st. It allows the progressive development which 
 
 Fig. 3. — Sacrum and coccyx. 
 
 Fig. i. — Section of sacrum 
 and coccyx. 
 
 takes place especially about the age of puberty in the female sex. 
 2nd. By allowing a certain degree of yielding of the joints, it 
 diminishes the risk of fracture. 3rd. It diminishes in some degree 
 
 Fig. 5. — Female pelvis, seen from the front. 
 
 the jar transmitted to the trunk and brain from any concussion 
 upon the feet. 
 
 The pelvis is divided into two parts by an irregularly oval ring, 
 somewhat approximating towards a heart-shape, which constitutes 
 the pelvic Jjiiin or inlet and is the part of the bony canal at which 
 
 1—2 
 
4 The Practice of Midwifery. 
 
 deformities most frequently exist, and impediment to the passage 
 of the foetus most frequently occurs. The upper half, or false 
 pelvis, has no direct concern with the mechanism of parturition, 
 
 Fig. 6. — Female pelvis, viewed in the axis of the brim. Antero-posterior 
 or conjugate, transverse, and oblique diameters marked, with measure- 
 ments in inches and centimetres. 
 
 and chiefl}^ interests the obstetrician by the fact that, from 
 varieties in its measurements, inferences may be drawn as to the 
 condition of the true pelvis. The lower half, or true pelvis, includes 
 the brim itself and all the structures below it. The parts requiring 
 
 Fig. 7.— Outlet of pelvis. Antero-posterior and transverse diameters 
 marked, with measurements in inches and centimetres. 
 
 separate consideration are the hrim or inlet, the outlet, and the 
 cavity, or space comprised between inlet and outlet. The brnn is 
 formed by the upper margin of the pubes in front, the ilio-pectineal 
 line of the innominate bone on either side, and the upper ^ and 
 anterior margin and promontory of the sacrum behind. It is to 
 
Anatomy of the Pelvis. 5 
 
 be noted, however, that, although the promontory of the sacrum is 
 usually regarded as formmg part of the brim, it generally, in the 
 normal pelvis, lies slightly above the true plane of the brim. 
 Thus the plane of the brim cuts the front of the sacrum in a line 
 situated at a small but variable distance below the promontory ; 
 and, if the promontory of the sacrum is regarded as forming part 
 of the curve of the brim, that curve does not lie accurately in one 
 plane. The promontory of the sacrum forms a flattened portion 
 in the curve of the brim even in the normal pelvis, but does not 
 actually project inwards. In the commoner varieties of deformity, 
 it does so project inwards, and causes the shape of the brim to 
 resemble an actual heart-shape or kidney-shape. The cavity of 
 the pelvis is bounded by the sacrum and coccyx behind, the pubic 
 bones in front, the inner surface of the innominate bones, with the 
 sacro-sciatic ligaments and the muscles attached to them, at the 
 sides. The outlet is lozenge-shaped, and has the tubera ischii at 
 each side, the rami of the ischia and pubes converging to the lower 
 margin of the symphysis pubis in front, and the sacro-sciatic 
 ligaments converging to the coccyx and lower end of sacrum 
 behind. The pelvic brim is sometimes termed the superior strait, 
 the outlet the inferior strait. 
 
 Differences between Male and Female Pelvis. — There are 
 important differences between the male and female pelvis, the 
 peculiarities of the latter being necessary to qualify it for its 
 functions in parturition. The bones of the female pelvis are 
 thinner and slighter, and the prominences for muscular attach- 
 ment less strongly marked. When looked at from the front, the 
 female pelvis is seen to be shallower, wider, and less funnel-shaped, 
 the outlet being relatively larger in proportion to the inlet. Koughly 
 speaking, the female pelvis forms a short segment of a long cone, 
 while the male pelvis is a long segment of a short cone. As a 
 consequence, both the tubera ischii and the acetabula are much 
 farther apart in the former. The latter circumstance causes 
 woman to have a more undulatory or side-to-side movement in 
 walking than man. The iliac fossae are inclined at about the same 
 angle to the axis of the brim in the two sexes ; but, in consequence 
 of the greater width of the true pelvis, the iliac crests are farther 
 apart in woman, and thus give the greater breadth across the hips 
 to woman's figure. The iliac crests are also more curved, and, 
 in consequence, the iliac fossae more hollowed out. A marked 
 difference is the greater width of the pubic arch, which in woman 
 is usually greater than a right angle, on the average about 96° ; 
 
6 The Practice of Midwifery. 
 
 in man less than a right angle, on the average ahout 75°. The 
 depth of the symphysis pubis is much less in woman, and the 
 sacrum is broader. The obturator foramina are more triangular, 
 
 Fig. 8. — Male pelvis, seen from the front. 
 
 and their vertical diameter less in proportion. The great sacro- 
 sciatic notch is shallower and wider. The dimensions of the brim 
 are manifestly larger, and more especially the magnitude of the 
 transverse in proportion to the antero-posterior diameter. Verneau 
 gives for adult females the following averages : transverse 13"5 cm.. 
 
 Fig. 9. — Male pelvis, viewed in the axis of the brim. 
 
 conjugate 10'6 ; males : transverse 13*0 cm., conjugate 10*4. The 
 shape of the brim also differs somewhat, the male brim approxi- 
 mating more to a cordate, the female to an oval shape. This 
 difference is due to the maximum transverse diameter in the male 
 being placed more posterior to the centre of the brim than the 
 
Anatomy of the Pelvis. 
 
 7 
 
 maximum transverse diameter in the female. Looked at from 
 below, the greater size of the outlet of the female pelvis is still 
 more manifest than that of the inlet. 
 
 These peculiarities in the female pelvis are connected with the 
 presence in it of the female genital organs, and the larger space 
 which they occuj)y. In cases in which the uterus and ovaries are 
 imperfectly developed, the pelvis is not infrequently small, and 
 conversely, in cases of double uterus, the transverse diameter of 
 the pelvis has been found unusually large. There is considerable 
 variety in different individuals in the degree in whioh the 
 characteristics of the female pelvis, especially the large size of 
 the brim, associated with great length 
 of the transverse compared to the 
 antero-posterior diameter, are 
 developed. 
 
 In some women, in whom the 
 pelvis resembles the male type, con- 
 siderable difficulty may be experienced 
 in child-birth. There are also differ- 
 ences between different races. In the 
 most intellectual races the pelvis is 
 most fully developed in area, a differ- 
 ence which must be associated with 
 the greater size of the children's 
 heads. The development is greatest 
 in the Circassian race, and affects 
 especially the transverse diameter. 
 In the more savage races, on the 
 contrary, such as Negroes, Hottentots, 
 Bushmen, and Australian Aborigines, 
 not only is the size somewhat less, 
 
 but the pelvic brim is more round, from relative smallness of 
 the transverse diameter, and thus shows a slightly greater resem- 
 blance to the type of the monkey's pelvis, in which the antero- 
 posterior diameter is greater than the transverse (see Fig. 10). 
 The angle of the pubic arch is also generally not so great. 
 Difficulties in parturition, however, more often occur in the 
 higher races, since the greater size of the pelvis is more than 
 compensated by the greater size and less compressibility of the 
 fcetal head. 
 
 Thus liiggs has shown that while contracted pelves occur in 
 34 per cent, of the black women as compared with 9 per cent, of 
 the white women in Baltimore, owing to the smaller and more 
 
 Fig. 10. — Pelvis of chimpanzee. 
 
8 
 
 The Practice of Midwifery. 
 
 compressible heads of the negro children, artificial delivery is more 
 often required among the latter.^ 
 
 Inclination of the Pelvis.— It was formerly supposed that, in 
 the erect position, the plane of the pelvic brim was only slightly 
 inclined to the horizon, that is, that it was nearly in the position 
 which it assumes when the dry pelvis is placed upon a table, 
 
 Fig. 1 1 . — Antero-posterior section of pelvis. /<j;, horizoutal plane ; axjyh, axis 
 of pelvic brim ; r I. vertical line of body ; c i; conjugata vera ; |; ss, plane 
 of superior strait ; ^; gd, plane of greatest dimensions ; ^ Id, plane of 
 least dimensions ; jj ]} o, plane of pelvic outlet ; m p^, median plane ; 
 in c c, Meyer's normal conjugate. (After Bayer.^) 
 
 resting upon the tip of the coccyx and the tubera ischii. A trace 
 of this error still remains in the term horizontal ramus, applied to 
 the upper ramus of the pubes, whereas in the upright position of 
 the man or woman this ramus is in reality more nearly vertical 
 than horizontal. It was first shown by Naegele that the plane of 
 the brim, in the erect position, approaches more nearly to the 
 vertical than the horizontal, and he estimated the angle which 
 
 1 Eiggs, J. F., .Johns Hopkins Hospital Eeports, 1904, Vol. XII., p. 421. 
 
 2 Bayer, Vorlesungen iiber AUgemeine Geburtshiilfe, 1903, Bd. 1, Heft 2, p. 137. 
 
Anatomy of the Pelvis. 9 
 
 it makes with the horizon at 60° or more. According to the 
 observations of Meyer, it varies, according to the position of the 
 thighs, from 45° to 100°, and in the usual erect posture, is on an 
 average 55°. 
 
 In view of the variations in the inclination of the pelvis in 
 different positions of the body, Meyer has proposed to term the 
 normal conjugate a plane passing through the upper border of 
 the symphysis pubis and the centre of the body of the third sacral 
 vertebra, since this portion of the sacrum moves least in any 
 alteration of the jDOsition of the trunk or of the lower limbs ^ 
 (Fig. 11). Taking the angle of pelvic inclination at 60°, it follows 
 that the height of the promontory of the sacrum above the top of 
 the pubes is, on the average, about 3f inches. A line passing 
 horizontally backwards through the top of the pubes passes below 
 the tip of the sacrum, and intersects the coccyx. The tip of the 
 coccyx is above the level of the ajDex of the pubic arch, and a line 
 joining these two points makes an angle of about 10° with the horizon. 
 
 In the upright position the vertical line through the centre of 
 gravity of the body passes through a point a little behind the 
 promontory of the sacrum. It corresponds with the line v l in 
 Fig. 11. For equilibrium to be maintained, when the body is 
 balanced upon the heads of the femora by the aid of gentle 
 muscular action, this vertical line must lie exactly, or almost 
 exactly, in the vertical plane through the points where the 
 acetabula rest upon the heads of the femora. In standing at ease, 
 however, the inclination of the pelvis is slightly diminished, until 
 the strong ilio-femoral ligaments, or one of them, are put upon the 
 stretch, and relieve the muscles in the duty of maintaining the 
 balance. The vertical line through the centre of gravity then 
 falls somewhat behind the vertical plane passing through the 
 acetabula. 
 
 In pregnancy, or when any abdominal tumour exists, the pelvic 
 inclination is diminished. The centre of gravity of the body in its 
 new position must be brought over the points of support at the 
 heads of the femora, in order to maintain the balance. This is 
 effected partly, it is true, by the woman throwing her shoulders 
 backward, and so altering the curve of the spine, but partly also 
 l)y rotation backward of the whole trunk together upon the heads 
 of the femora. The effect which such rotation through any given 
 angle will have upon the position of the centre of gravity will be 
 greater in proportion to the height of a woman. Hence, in short 
 women, during pregnancy, either the inclination of the pelvis 
 
 ' H. Meyer, Stutik und Mechanik <ler Menschliclieri Kiiocliengeriistes, 1873. 
 
lO 
 
 The Practice of Midwifery. 
 
 is more diminished than in tall women, or, more frequently, the 
 shoulders are more thrown back, and thus the i^regnant condition 
 becomes more manifest. 
 
 Articulations of the Pelvis. — There are certain peculiarities 
 about the pelvic articulations which adapt them for the functions 
 of parturition, and accordingly there is a slight difference between 
 the male and female pelvis as regards these joints. 
 
 Sar.ro-iliac Articulation. — This is formed between the auricular 
 surfaces of the sacrum and ilia, which are each covered by a layer 
 of cartilage, and are closely applied together, but not usually 
 
 directly united. At times the two 
 surfaces are connected by firm 
 transverse fibres, but in the adult 
 woman, and especially in preg- 
 nancy, spaces containing serous 
 fluid exist between them, and a 
 certain small degree of movement 
 is permitted. The nature of this 
 movement is a tilting of the sacrum 
 backward or forward relatively to 
 the pelvis upon a transverse axis 
 passing through the centre of 
 the joint. Thus, by the tilting 
 backwards of the promontory of 
 the sacrum the antero-posterior 
 diameter of the inlet is somewhat 
 increased, and at the same time 
 the anterior wider part of the 
 auricular surface of the sacrum 
 being pressed backwards between 
 the two ilia separates them to a greater degree, and so further 
 increases the dimensions of the pelvic inlet, while conversely by 
 the tilting backward of the lower extremity of the sacrum there is 
 a slight gain of space at the outlet (see Fig. 12). 
 
 The centre of movement is nearer to the promontory than to the 
 tip of the sacrum. Hence the tip describes an arc of a longer circle 
 than the promontory, and the diameter of the outlet is more affected 
 than that of the inlet. It is estimated by Matthews Duncan that, 
 by nutation forward of the promontory, the conjugate diameter of 
 the inlet may be diminished as much as one or even two lines, and 
 that to this diminution corresponds an augmentation of the corre- 
 sponding diameter of the outlet of probably double the amount. 
 
 Fig. 12. — Nutation of sacrum during 
 parturition. 
 
 a h. Symphysis pubis. 
 
 c d. Ordinary position of sacrum. 
 
 o" d". Sacrum in its position of 
 extreme nutation. The tip 
 of the sacrum is carried back- 
 ward, so as to augment the 
 antero-posterior diameter of 
 tiie inferior strait. 
 
 (After Matthews Duncan.) 
 
Anatomy of the Pelvis. 
 
 1 1 
 
 In this way parturition is facilitated in a perceptible degree. At 
 the early stage of labour the woman is naturally inclined to be up 
 and about, or, if in bed, to lie with the thighs extended ; and in 
 these positions the promontory of the sacrum is tilted back, and 
 the pelvic brim gains its greatest dimensions. When, however, 
 the head is passing through the outlet, she instinctively draws up 
 her knees and bends her body over them, while the contraction of 
 the abdominal muscles draws the pubes upward. The effect of 
 this is to tilt the promontory forward and the lower end of the 
 sacrum with the coccyx backward, and so give increased room at 
 the outlet. A similar movement has been described as taking 
 
 Fig. 13. — Antero-posterior section of sacrum and symphysis pubis to show 
 the increase in the conjugate diameter ; in the horizontal position 11 -5 cm. , 
 in Walcher's position ITS cm., as compared with 10'9 cm. in the lithotomy 
 position. (After Klittner.) 
 
 place, in lesser degree, by the assumption of a similar position 
 in defecation. A still greater nutation of the i^romontory of the 
 sacrum backward and increase of the conjugate diameter than 
 that which occurs in the horizontal position is produced by the 
 Walcher position, in which the woman lies on her back, with her 
 buttocks resting on the edge of the table, and her legs hang down 
 vertically without any support. According to Kiittner ^ the con- 
 jugate is increased by the horizontal position "6 cm., and by the 
 Walcher position '9 cm. (about -^ inch), as compared with the 
 lithotomy position (Fig. 13). With these increases correspond 
 diminutions of 1"3 and 1-8 cm. respectively in the antero-posterior 
 diameter of the outlet (Fig. 14). 
 
 1 Kuttner, Hegar's Beitrage, 1898, Vol. I., p. 211. 
 
12 
 
 The Practice of Midwifery. 
 
 In consequence of this, advantage is taken of the Walcher position 
 to facihtate the passage of the head through the brim in cases 
 of contraction of the conjugate diameter. 
 
 Symphysis Pubis. — The fibro-cartilage is thicker in front than 
 behind, and towards the posterior part there is a small fissure, 
 which at time extends throughout the whole of the articulation ; 
 this is better marked in the female than in the male, and appears 
 to be formed by the softening and absorption of the fibro-cartilage. 
 
 Sacro-Cuccygeal Articulation. — The sacrum is joined to the coccyx 
 by a small cartilaginous disc like that uniting the other vertebrae, 
 and occasionally there is a similar disc between the first and second 
 
 IS -6 cm 
 
 Fig. 14. — Section through outlet of pelvis to show the diminution of the 
 antero-posterior diameter of the outlet by 1-3 cm. in the horizontal posi- 
 tion and rS cm. in Walcher's position as compared with the lithotomy 
 position. (After Kiittner.) 
 
 bones of the coccyx. In the adult woman there is a definite cavity 
 in the centre of the intervertebral disc between the sacrum and 
 coccyx, whereby a considerable amount of forward and backward 
 movement is allowed. 
 
 Changes in Pelvic Joints during Pregnancy. — In pregnancy 
 the cartilages and fibrous structures become swollen and softened, 
 and the cavities extended, so that the bones are separated slightly 
 further, and the mobility increased. In some cases this process 
 proceeds to a morbid degree, or persists too long after delivery. 
 Walking may thus be painful or difficult from undue mobility 
 at the joints, especially at the symphysis pubis. In some animals 
 the changes in the joints are of more importance than in woman. 
 
Anatomy of the Pelvis. 
 
 13 
 
 Thus, in guinea-pigs wide separation takes place at the symphysis 
 pubis in delivery, and in the sow tilting of the sacrum materially 
 enlarges the pelvic canal. 
 
 Mechanical Action of the Sacrum. — A vertical transverse 
 section of the pelvis through its points of support has the 
 form of an arch, both in the standing and the sitting position ; 
 these points of support being, in the former case, the acetabula, in 
 the latter, the tubera ischii. There is no mechanical analogy, 
 however, to an arch in architecture, for the opening out of the 
 
 Fig. 15. — Section of pelvis, parallel to the brim, passing through the points 
 where the pelvis rests upon the heads of the femora, a l. Posterior 
 sacro-iliac ligaments. 
 
 arch is not prevented by any lateral support, but partly by the 
 ring of the pelvis being completed at the symphysis pubis, and 
 partly by the strong and wide-spread union of the ilia with the 
 sacrum. Nor has the sacrum any analogy to the keystone of an 
 arch, although, on account of its general resemblance to a wedge, it 
 was formerly compared to one. It has been shown by Matthews 
 Duncan that its action is rather that of a strong transverse beam, 
 which receives the weight of the body at its centre, and transmits 
 it at its extremities to the iha. 
 
 The weight of the body may (by the parallelogram of forces) be 
 considered as made up of two components, one tending to force the 
 
14 The Practice of Midwifery. 
 
 sacrum downward and forward in the plane of the pelvic brim (or 
 in the direction of v c in Fig. 11, p. 8), the other tending to force 
 it backward at right angles to that plane (or in the direction of the 
 long axis of the sacrum in the same figure). Taking the pelvic 
 inclination at 60°, the latter force is exactly half, the former about 
 four-fifths, of the weight of the trunk.^ 
 
 A section through the centre of the sacro-iliac joint parallel to 
 the brim of the pelvis (Fig. 15, p. 13) shows that the sacrum is 
 broader below than above, and that its general shape, therefore, is 
 just the reverse of such a wedge-shape as would be required to 
 counteract the tendency to displacement in the plane of the brim. 
 A main part of the weight is in fact borne by the posterior sacro- 
 
 FiG. 16. — Section through plane of pelvic brim or superior strait. 
 
 iliac ligaments {a h, Fig. 15), by which the sacrum is, as it were, 
 suspended from the posterior crests of the ilia. On looking at the 
 section, however, it will be seen that, near the centre of the joint, 
 there is a space through which the general wedge-shape of the 
 section of the sacrum is reversed. In this way is formed a notch, 
 or what in mechanics is called a "bite," which is of great import- 
 ance in keeping the bones in place. Its efficacy is increased by 
 the fact that the posterior sacro-iliac ligaments slant inwards, from 
 the ilia to the sacrum (a h, Fig. 15), and thus, in proportion to 
 the tension which is put upon them, they draw the ilia more 
 strongly together, and keep the articulating surfaces in closer 
 contact. 
 
 1 The exact proportion is sin. 60° or '866. 
 
Anatomy of the Pelvis. 
 
 ^5 
 
 The general wedge-shape of the sacrum does come into play 
 in preventing its displacement downwards and backwards per- 
 pendicular to the plane of the pelvic brim. The tendency to 
 separation of the ilia, which its pressure in this direction would 
 produce, is counteracted as before by the slanting direction of the 
 posterior sacro-iliac ligaments which draw the bones more power- 
 fully together in proportion to the strength of the displacing force. 
 
 Measurements of the Pelvis. — The dimensions of the canal 
 of the true pelvis may be estimated by drawing any number of 
 imaginary planes at different levels, and ascertaining the diameters 
 
 2~D SAC. FOR. 
 
 O.INT.- 
 
 FlG. 17. — Section through plane of greatest dimensions. 
 
 of each plane. Of these planes the most important are — first, the 
 plane of the brim, or superior strait (Fig. 16) ; secondly, the median 
 plane of the pelvic cavity, passing through the centres of the sacrum, 
 and of the symphysis pubis ; and thirdly, the plane of the outlet, or 
 inferior strait. The median plane intersects the obturator foramen 
 near its upper part, and the greater sciatic foramen a little above 
 its centre, crossing the ischium above the level of its spine. (See 
 Fig. 11, p. 8.) The plane of greatest pelvic dimensions does not 
 quite correspond to the median plane of the pelvis, but passes 
 through the centre of the symphysis pubis, the junction of the 
 second and third sacral vertebrae, and the centre of the acetabula 
 (Fig. 17). 
 
 The plane of the outlet is generally regarded as drawn through 
 the apex of the pubic arch and the tip of the coccyx. Such a plane, 
 however, has no fixed position, but varies with the position of the 
 coccyx ; and, further, except in case of ankylosis of the coccyx, it 
 
1 6 The Practice of Midwifery. 
 
 is the plane of outlet of the fixed bony pelvis, terminating at the 
 lower extremity of the sacrum, which determines the limit of size 
 of the body which can pass out. For the coccyx can be pressed 
 backward until the antero-posterior diameter measured from its tip 
 exceeds that measured from the lower end of the sacrum. More- 
 over, the coccyx being thus movable and virtually endowed with 
 elasticity in virtue of its connection with the perineum and its 
 muscles, any influence which it exercises upon the progress of 
 labour is comparable rather to that exercised by the soft parts of 
 the perineum, and differs totally from the resistance of the rigid 
 portion of the pelvis. Hence it appears preferable to regard the 
 plane of the outlet as that drawn through the apex of the pubic 
 arch and the lower extremity of the sacrum (m n. Fig. 22, p. 21). 
 
 O.INT 
 
 SY 
 
 Fig. 18. — Section through plane of least dimensions. 
 
 Such a plane is inclined about 16° to the horizon, assuming the 
 inclination of the pelvic brim to be 60°, while a plane drawn through 
 the tip of the coccyx is inclined only about 10°, or less, according 
 to the position of that bone. If constructed in this way it corre- 
 sponds nearly to the plane of least pelvic dimensions, passing laterally 
 through the ischial spines (Fig. 18). 
 
 Diameters of the Pelvis. — In each plane three diameters are 
 generally described, the antero-posterior, the oblique, and the 
 transverse (see Fig. 6, p. 4). At the brim the term conjugate is 
 frequently applied to the antero-posterior diameter. The name 
 is taken from that given to the smallest diameter of an ellipse, 
 and should not therefore be extended, as it sometimes is, to the 
 antero-posterior diameters in the cavity and at the outlet, since 
 these are not the smallest in their respective planes. The oblique 
 
Anatomy of the Pelvis. 
 
 17 
 
 diameters at the brim are drawn from a point on the iUo-pectineal 
 line a little in front of the sacro-iliac joint on either side to a point 
 corresponding with the ilio-pectineal eminence. It is to be noted 
 that the right oblique diameter (r o) is that ivliiclL starts from the 
 right sacro-iliac joint, and the left oblique (l 0) that ivhich starts 
 from the left sacro-iliac joint. Some confusion has arisen from the 
 fact that some French authors have used the term in just the 
 opposite sense, naming each oblique diameter from its anterior 
 instead of from its posterior extremity. Taking the average of a 
 
 Fig. 19. — Section of pelvis, side to side ; perpendicular to plane of brim. 
 
 large number of normal pelves, the following may be given as the 
 standard measurements, taking the nearest quarter of an inch : — 
 
 
 Anterc 
 
 -posterioi 
 
 Oblique. 
 
 Transverse. 
 
 
 
 ins. 
 
 cms. 
 
 ins. 
 
 cms. 
 
 ins. 
 
 cms. 
 
 Brim 
 
 . 
 
 4i 
 
 = 11 
 
 4| 
 
 = 12 
 
 ?>l = 
 
 :13 
 
 Cavity . 
 
 . 
 
 4| 
 
 = 12 
 
 (5i) 
 
 = (13) 
 
 4| = 
 
 :12 
 
 Outlet . 
 
 . 
 
 4i 
 
 = 11-5 
 
 m 
 
 = (11-5) 
 
 4i- 
 
 11 
 
 Plane of greatest 
 
 pelvic 
 
 
 
 
 
 
 
 dimensions 
 
 . 
 
 5i 
 
 = 13 
 
 
 — 
 
 5 = 
 
 12-5 
 
 Plane of least 
 
 pelvic 
 
 
 
 
 
 
 
 dimensions 
 
 , 
 
 4* 
 
 = 11-5 
 
 
 . — - 
 
 4 = 
 
 10-1 
 
 The oblique diameters at the cavity and the outlet are enclosed 
 in brackets, as of comparatively little importance, since their length 
 is uncertain, not being measured between bony points. 
 
 The rhomboidal opening presented by the pelvis including the 
 coccyx, when looked at from below (Fig. 7, p. 4), does not lie in 
 one plane, the tuberosities of the ischia being on a lower level than 
 the line joining the apex of the pubic arch to the tip of the coccyx. 
 
 M. 2 
 
i8 
 
 The Practice of Midwifery. 
 
 It may be regarded as made up of two triangles, one side being 
 common to the two, namely, the transverse diameter between the 
 tuberosities of the ischia, the apex of one triangle being the apex 
 of the pubic arch, of the other the tip of the coccyx. 
 The following are average measurements : — 
 
 41=11 
 
 31 = 9 
 
 U~5 = ll'5-12-5 
 
 Between ischial tuberosities 
 Antero-posterior measured to tip of 
 
 coccyx ...... 
 
 This may be increased when the coccyx 
 
 is pushed backward in parturition to 
 
 It will be observed that the transverse diameter is progressively 
 and considerably diminished in passing from the brim towards the 
 
 outlet, the effect of which is obvious 
 on looking at a vertical section of 
 the pelvis from side to side per- 
 l^endicular to the plane of the 
 brim (Fig. 19). The diminution 
 is chiefly due to a slightly marked 
 line of elevation running from the 
 brim at about the position of the 
 ilio-pectineal eminence downward 
 and backward to the ischial spine, 
 at which point the transverse 
 diameter in the plane of least pelvic 
 dimensions is the smallest of all 
 the diameters of the normal pelvis, 
 being only four inches (10-10*5 
 cm.), or very little more. On 
 looking at a lateral view of the 
 pelvis from within (Fig. 20), it will 
 be seen that this line divides the 
 lateral wall into an anterior and 
 posterior j)art. Before and behind this elevated line are two 
 smooth inclined planes, the former looking slightly forward, the 
 latter slightly backward. These are the anterior and posterior 
 inclined ]jlanes of the ischium. This narrowing of the lateral 
 dimensions of the pelvis from above downwards has a considerable 
 influence on the rotations of the foetus in parturition. The view, 
 however, that the inclined planes play an imj)ortant part in bringing 
 about the rotation of the foetal head has been abandoned very 
 largely, and it is probable that any effect they may have is but 
 slight, unless the foetal head fits very tightly in the pelvis. 
 
 Fig. 20. — Lateral view of pelvis from 
 within, showing the inclined 
 planes of the ischium. 
 
Anatomy of the Pelvis. 19 
 
 The antero-posterior diameter becomes considerably increased as 
 it is traced downward from the brim into the cavity of the pelvis, 
 but is diminished again rather suddenly when the inferior strait or 
 plane of outlet of the true rigid pelvis is reached. Beyond this 
 point it is again somewhat increased, owing to the mobility of the 
 coccyx, supposing this bone to be pressed backward to its fullest 
 extent. The diminution which the antero-posterior diameter 
 undergoes at the inferior strait does not, however, alter the general 
 result, namely, that the transverse diameter is the longest at the 
 brim, the oblique in the cavity, and the antero-posterior at the 
 outlet. It will be seen hereafter that this fact is of great import- 
 ance in determining the movement of the foetal head, the longest 
 diameter of which rotates as in a 
 screw, following the longest diameter 
 of the pelvis. 
 
 The right oblique diameter at the 
 brim is, as a rule, slightly longer than 
 the left (Fig. 21). Two causes may 
 contribute to this result : first, the 
 greater use of the right leg, leading 
 to a greater inward pressure at the 
 right acetabulum, and a consequent 
 relative shortening, in development, Fig. 21.— Diagram to show asym- 
 of the left obKque diameter, ending ™*^J7 9j.Pei^\^ brim. ;• 0., 
 
 ^ ' o right obhque diameter ; I. o., 
 
 at that acetabulum; secondly, a left oblique diameter ; r. *-. c, 
 
 congenital asymmetry, which rans iS^^'^S^^B^;;^ 
 
 throughout the vertebral column, 
 
 including the cranial bones, and in virtue of which that column 
 has a slight tendency towards a spiral arrangement instead of 
 being perfectly straight. It is doubtful, however, whether the 
 right leg is generally stronger than the left ; and whether it is not 
 rather the left leg, which corresponds to the right arm, with which 
 it moves synchronously. 
 
 Alterations of Diameters hy Soft Parts. — The diameters as given 
 above are measured in the dry pelvis, and the presence of the soft 
 parts introduces modifications of some importance, especially at the 
 pelvic brim. In general the soft parts diminish each available 
 diameter about ^ inch, except when the uterine wall intervenes 
 between the presenting part and the pelvis, in which case the 
 diminution may be much greater. At the brim, however, the 
 projections of the psoas and iliacus muscles lessen the transverse 
 diameter about \ inch. In the clothed pelvis, therefore, the 
 
 1 Eaycr, luc, cit. p. lijy. 
 
 2—2 
 
20 The Practice of Midwifery. 
 
 oblique diameter at the brim, instead of being smaller than the 
 transverse, is about equal to it. 
 
 Other Measurements. — Besides the diameters already given, there 
 is another which has considerable practical importance, because it 
 can readily be ascertained in the living woman. This is measured 
 from the apex of the pubic arch to the promontory of the 
 sacrum, and is called the diagonal conjugate or sacro-subpubic 
 diameter (e n, Fig. 22, p. 21). In the normal or slightly contracted 
 pelvis it is about two-thirds of an inch longer than the true con- 
 jugate, and therefore measures normally 4'90 inches (12*5 cm.). 
 Another diameter commonly given is the sacro-cotyloid diameter 
 (Fig. 21, p. 19), measured from the promontory of the sacrum 
 to a point corresponding to the acetabulum on each side. It 
 measures normally 3-J inches (9 cm.). The cavity of the pelvis 
 is much deeper posteriorly than anteriorly, the depth from the 
 promontory to the tip of the sacrum being 3f inches (9'5 cm.), 
 or to the tip of the coccyx 4^ inches (11 cm.), while the depth of 
 the symphysis pubis is 1^ inches (4 cm.). 
 
 External Measurements. — The external measurements of the 
 pelvis are only of significance from the fact that inferences may be 
 drawn from varieties in them with regard to the magnitude of 
 internal diameters. The following are average measurements : — 
 
 ills. cms. 
 
 Between antero-superior spines of ilia (Dist. 
 
 Sp. II.) 10-lOi = 25-26 
 
 Between widest part of iliac crests (Dist. Cr. II.) 11-11^ = 27-5-29 
 External conjugate (C. Ext.) between spine of 
 
 last lumbar vertebra and upper border of 
 
 symphysis pubis ...... 7|-8i = 19-21 
 
 Between outer surfaces of great trochanters . 12|-13 = 31-32 
 
 Axis of the Pelvis. — By the axis of the pelvis is meant an 
 imaginary line indicating the course taken by the centre of the 
 fcetal head as it passes through the genital canal. This course 
 not being precisely defined, various modes have been given for 
 drawing the axis of the pelvis. Thus the centre of the head was 
 supposed to move in what was called the circle of Carus, a circle 
 having its centre at the upper margin of the pubes, and a radius 
 equal to half the conjugate diameter of the brim. But the inner 
 surface of the sacrum is almost straight in vertical section so far 
 as the junction of its second and third bones, and the inner surface 
 of the pubes is also nearly straight, diverging only at a small angle 
 from the direction of the surface of the sacrum. The centre of the 
 
Anatomy of the Pelvis. 
 
 21 
 
 head, therefore, in the first part of its course, descends almost in a 
 straight line, as through a cylinder, until it is low enough for the 
 bead to meet the resistance of the curved portion of the sacrum, 
 forming part of the pelvic floor. Its course, therefore, has no 
 
 H 
 
 . R 
 
 Fig, 22. — Diagram showing axis and planes of pelvis. A b c, axis of 
 pelvis ; C D, axis of developed canal of soft parts ; x, anus as distended 
 in parturition ; E F, plane of brim ; K L, mid-plane of cavity ; M N, 
 plane of outlet ; o P, axis of brim ; Q R, axis of mid-plane ; s T, axis 
 of outlet ; H H, horizon ; E N, diagonal conjugate or sacro-subpubic 
 diameter. 
 
 resemblance to the arc of a circle, neither does it resemble a 
 parabola, to which it has been compared, for the two arms of a 
 parabola tend towards directions parallel to each other, if produced 
 far enough. 
 
 The following construction for drawing the pelvic axis will give 
 a line closely approximating to the path of the centre of the foetal 
 
22 The Practice of Midwifery. 
 
 bead. Through the promontory of the sacrum draw a line e f 
 (see Fig. 22, p. 21), not to the absolute summit of the symphysis 
 pubis, but to the nearest point of the symphysis. This line repre- 
 sents the smallest diameter through which the fcetus has to i^ass 
 at the brim, and therefore most rightly deserves the name of the 
 true conjugate diameter. It is sometimes called the obstetric true 
 conjugate diameter, to distinguish it from a line drawn to the 
 absolute summit of the symphysis, as in Fig. 11 (p. 8). The 
 plane passing through e f perpendicular to the plane of the figure 
 is, for practical purposes, the plane of the pelvic brim. Similarly, 
 if M N be drawn from the tip of the sacrum to the nearest point at 
 the bottom of the symphysis i^ubis, m n is the smallest antero- 
 posterior diameter at the inferior strait, and the plane passing 
 through M N perpendicular to the plane of the figure is the plane 
 of the pelvic outlet. 
 
 From the point in front of the pubes where e f and m n meet, 
 let any number of radii be drawn intersecting the pubes and the 
 sacrum, and let a line a b c be drawn, passing through the centres 
 of all those portions of the radii which are intercepted between the 
 inner surfaces of the pubis and sacrum. The line a b c will be the 
 axis of the bony pelvis. The upper half of it, a b, will be almost 
 a straight line, since the upper half of the anterior face of the 
 sacrum is nearly straight. If r l be a radius midway between e f 
 and M N, the plane passing through k l perpendicular to the plane 
 of the figure will be the mid-plane of the pelvic cavity. 
 
 The construction may be completed in the following manner for 
 the variable portion of the genital canal. Suppose the coccyx to be 
 pushed back as in jjarturition, and the soft part of the canal to be 
 dilated to the full expansion reached as the foetal head is passing 
 through it. The curve of the posterior wall of the canal will thus 
 be an arc of a circle having its centre near the lowest point of the 
 symphysis pubis, and the axis of the canal of soft parts, including 
 the coccyx, will be an arc of a circle c d, having the same centre 
 and half the radius. At c there is a point of discontinuity 
 between the axis of the bony pelvis and that of the canal of soft 
 parts. At this point the centre of the head slightly changes its 
 direction of movement on passing the inferior strait, having just 
 previously been compelled to approach nearer to the pubes, on 
 account of the progressive diminution of the antero-posterior 
 diameter. 
 
 Axes of the several Planes of the Pelvis. — It has been 
 usual to regard the axis of each plane as a straight line drawn 
 
Anatomy of the Pelvis. 23 
 
 at right angles to that plane through its centre. Such a line, how- 
 ever, has no practical significance or use. "What we want to know 
 is the direction in which the centre of the head is, or ought to be, 
 advancing, when that centre lies in any given plane of the pelvis. 
 This direction will be given if we define the axis of any plane as 
 the tangent to the curved axis of the pelvis at the point where it 
 cuts that plane. This is the same thing as the straight line joining 
 the centres of two very closely adjacent planes, and it therefore 
 necessarily gives the direction of motion of the centre of the head. 
 As thus defined, the axis coincides with the line drawn at right 
 angles to the plane at the brim, but at other parts, especially 
 towards the inferior strait, this is not precisely so. In Fig. 22, 
 p is the axis of the brim, q e, the axis of the mid-plane, is 
 inclined only slightly to the axis of the brim, on account of 
 the slight curvature of a b, the upper part of the pelvic axis. 
 s T, the axis of the outlet, which indicates the line of movement 
 of the centre of the fcEtal head as it approaches the outlet, differs 
 appreciably from the straight line drawn at right angles to the 
 plane of the outlet, and is nearly coincident with the vertical axis 
 of the woman. 
 
 The Pelvis in Infancy and Childhood. — In infancy the 
 pelvis is very small, even in proportion to the size of the child, 
 and thus the organs afterwards contained in the pelvis are, in the 
 infant, partially in the abdomen. The prominence of the abdomen 
 noticed in early life is thus accounted for. Besides its small size, 
 the pelvis of the infant difi'ers in shape from that of the adult, and 
 departs less widely from the type of pelvis seen in animals (see 
 Fig. 10, p. 7). The iliac fossae are flatter and less spread out, more 
 upright, and their surfaces look more forward. The maximum 
 distance between the iliac crests is hardly greater than that 
 between the antero-superior spines. It has generally been said 
 that the sacrum is narrower in proportion than in the adult pelvis, 
 but Professor Thomson has shown that the reverse is the case, its 
 width in the foetus exceeding the transverse diameter of the brim. 
 The maximum width lies, however, more above the plane of the 
 brim than in the adult; and the wings are less developed in 
 proportion to the body.^ Most writers maintain that the antero- 
 posterior diameter of the brim exceeds the transverse in the fcetal 
 and infantile pelvis, and this is the case with many dried specimens. 
 According to Thomson, however, this is not correct ; and he finds 
 the excess of the transverse diameter to be little less in the fcetal 
 
 J Journal of Anuloriiy and Pliysiology, 1898—99, Vol. XXXIII.. \>. 859. 
 
24 
 
 The Practice of Midwifery. 
 
 than in the adult pelvis. The pelvis is funnel-shaped, becoming 
 smaller towards the outlet in the female sex as well as in the male. 
 The curve of the sacrum, in antero-posterior section, is very slight, 
 and the sacro-vertebral angle is less than in the adult, so that the 
 anterior surface of the sacrum looks more forwards and not so 
 much downwards. The transverse concavity of its anterior surface 
 is greater than in the adult, while it is less deeply sunk between 
 the iliac bones in the direction of the coccyx. The curvature of 
 the ilio-pectineal lines is slighter. The pubic arch forms a more 
 acute angle, and the tubera ischii are relatively nearer together 
 than in the adult. The three portions of the innominate bone, 
 separated by a triradiate or Y-shaped piece of cartilage, having its 
 
 Fig. 23. — Pelvis of foetus viewed in the axis of the brim. 
 
 centre at the acetabulum, are not united into a solid bone till about 
 the twentieth year, an arrangement which permits the prolonged 
 enlargement of the pelvis by growth. It has been said that there 
 is little or no distinction between the male and female pelvis in 
 foetal life and childhood, but, according to Fehling's researches, 
 the distinctions of sex are manifested much earlier than has been 
 supposed, even at the fifth month of foetal life. The special 
 characters of the female pelvis, especially its relatively large size, 
 are not, however, fully manifested until the time of puberty is 
 drawing near. About this time a specially rapid growth takes 
 place in the female, except in those cases in which there is 
 congenital deficiency of uterus and ovaries. This is one of the 
 facts which show that the development of the pelvis depends 
 
Anatomy of the Pelvis. 
 
 25 
 
 largely upon the original forces of growth, and not merely upon 
 mechanical influences. 
 
 Development of the Pelvis. — The changes in shape which the 
 pelvis undergoes during growth are brought about partly by the 
 development of the several bones, and partly by the action of 
 mechanical forces. The characteristic differences of sex depend 
 upon the former, and are already manifest in fcetal life. The latter 
 act equally, or almost equally, upon the two sexes. It is of special 
 
 Fig. 24. — Antero-posterior section of adult pelvis with foetal pelvis (enlarged) 
 si;perimposed to show changes in position of sacrum. Dotted out- 
 line = adult pelvis ; continuous outline = pelvis of fcetus of seventh 
 month. Angle of pelvic brim in adult 60° ; in foetus 84°. 
 
 importance to study carefully the action of these influences in the 
 development of the normal pelvis, for if this be once thoroughly 
 understood, the mode in which all the forms of distorted pelvis 
 result from modifications of these influences will present no difii- 
 culty. The most important mechanical influence is exerted by the 
 weight of the body transmitted through the sacrum, from the effect 
 of which the bones become gradually moulded in the course of 
 years. The pressure and tension of muscles and ligaments have 
 also considerable influence. 
 
 Changes in the Sacrum. — The vertical line through the centre of 
 gravity of the body passes nearly through the promontory of the 
 
26 The Practice of Midwifery. 
 
 sacrum, and therefore in front of the centre of the sacro-ihac jomt 
 (r /, Fig. 11, p. 8). The effect of the weight therefore tends to 
 rotate the iDromontory of the sacrum forward and downward upon a 
 transverse axis through the centre of the sacro-ihac joint. The 
 lower extremity of the bone would be tilted bach in corresponding 
 degree but for the tension of the sacro-sciatic ligaments. The 
 effect of the two forces acting in conjunction is that the curva- 
 ture of the sacrum, in antero-posterior section, is increased, while 
 the sacro-vertebral angle becomes more acute, and the upper part 
 of the anterior surface of the sacrum approaches nearer to the hori- 
 zontal. Besides this, each of the two components of the body-weight, 
 one acting perpendicular to the pelvic brim, the other in the plane 
 of the brim, has an effect upon the sacrum. The first causes it to 
 sink deeper downward and backward between the ilia, so that the 
 j)romontory approximates more nearly than before to the plane of 
 the brim (Fig. 24). The second and larger component causes it to 
 sink slightly towards the centre of the brim, so that the posterior 
 crests of the ilia stand out further behind it. It also, through 
 yielding of the bone, diminishes its curvature in transverse section, 
 and thus flattens that part of the circumference of the brim formed 
 by the sacrum. (See Fig. 25.) This effect is increased if the 
 bone is unduly soft, as from rickets, and the promontory then 
 becomes an actual projection inwards into the brim. 
 
 As regards the changes in the sacrum due to growth, the chief 
 difference noted in the adult pelvis is that the wings of the sacrum 
 have developed more in proportion than the central portion. (Com- 
 pare Figs. 6, p. 4, and 28, p. 24.) It has generally been stated that 
 this development of the sacral wings produces a relative increase of 
 the transverse diameter of the pelvis. According to Thomson, 
 however {be. cit.), the growth of the sacrum as a whole is so much 
 less than that of the ilia, that, notwithstanding the development of 
 the wings, the total transverse width is less in proportion to the 
 brim in the adult than in the foetus. So far as the growth of the 
 sacrum is concerned, therefore, the preponderance of the transverse 
 over the conjugate diameter would tend to diminish. It is probable 
 that it actually does diminish in the earlier years as a result of the 
 more raj)id growth of the ilia, and thus a pelvis in which the trans- 
 verse has not the same preponderance over the conjugate as in the 
 adult is characteristic rather of the child than of the foetus or infant, 
 as was formerly supposed. When the more rapid growth of the 
 wings of the sacrum takes place near the time of puberty, the 
 transverse diameter regains its preponderance, aided by the action 
 of mechanical forces. If any cause prevents the development of the 
 
Anatomy of the Pelvis. 
 
 27 
 
 sacral wings, marked transverse narrowing in the adult pelvis is the 
 result. 
 
 Changes in the Lateral Pelvic Wall. — It has been already- 
 explained that a main part of the weight of the body is suspended 
 from the posterior crests of the ilia by the posterior sacro-iliac 
 ligaments (see pp. 13, 14). Its effect upon the shape of the brim 
 may be studied by examining a section parallel to the brim, through 
 the points of support of the acetabula upon the heads of the femora, 
 a section which passes also nearly through the centre of the 
 sacro-iliac joint and its posterior Hgaments. (See Fig. 15, p. 13, 
 and Fig. 25.) 
 
 The innominate bone (a d ^, Fig. 25), hinged upon the sacro-iliac 
 joint (c), forms a lever, whose fulcrum is the joint c. The posterior 
 
 Fig. 25. — Diagram to illustrate the change of shape in the pelvis. The figures are 
 supposed to be sections parallel to the plane of the brim, passing through the 
 points where the pelvis rests on the heads of the femora, like the actual section 
 shown in Fig. 15, p. 13. 
 
 A. Child's pelvis. B. Mature pelvis reduced to size of child's pelvis. 
 
 a h. Posterior sacro-iliac ligaments. d. Point at which pelvis rests on head 
 
 c. Sacro-iliac articulation. of femur. 
 
 e. Symphysis pubis. 
 P, Q. Components of pressure of head of femur. 
 
 extremity («) of the lever is drawn forwards and inwards through 
 the x^osterior sacro-iliac ligaments {a h) by that component of the 
 body- weight which acts parallel to the brim. The anterior end (e) 
 of the lever would therefore be tilted outward, on an axis perj)en- 
 dicular to the brim passing through the fulcrum c, but that it is 
 held inward by the symphysis pubis. As it is, the bone is gradually 
 moulded and its curvature increased, so as to enlarge the transverse 
 diameter of the pelvis. 
 
 In Fig. 25 is shown diagrammatically the change of shape 
 produced by the body-weight in the advance from infancy to 
 maturity. The actual change, as shown in the figure, is exagge- 
 rated, according to modern views as to the true shape of the infantile 
 pelvis, since the transverse exceeds the conjugate diameter even in 
 infancy. Comparing a with a, it will be seen that in b the sacrum 
 
28 The Practice of Midwifery. 
 
 has become flattened, and has sunk deeper between the ilia. The 
 lateral walls of the pelvis have become more curved, and, in 
 consequence, the transverse diameter has become relatively greater. 
 
 Efects of the Pressure of the Femora. — The tilting outward of the 
 anterior end of the lever is resisted, not only by the completion of 
 the pelvic ring at the symphysis pubis, but by the inward pressure 
 of the heads of the femora at the point d (Fig. 25). So far indeed 
 as this pressure is the reaction to the weight of the body, it acts 
 vertically upwards (p, Fig. 25). This is evident if the equilibrium 
 of the leg is considered. The resistance of the ground, by which 
 the weight of the body is supported, acts vertically upwards. For 
 equilibrium this line of action must coincide with the line in which 
 the weight of the body is transmitted downward to the head of the 
 femur. It therefore tends to thrust the acetabulum d not inward, 
 but outward. For the projection of its direction on the plane of 
 Fig. 25, being a vertical line (p), will fall outside the sacro-iliac 
 joint or fulcrum c. The force p will, therefore, tend to rotate the 
 lower end of the innominate bone, or lever a d e, outward. 
 
 The pressure of the head of the femur has, however, also a 
 horizontal component q, acting inward at the point d. This is due 
 to the horizontal component of the tension of the muscles which 
 slant inward from the femur to the pelvis. It is to be observed also 
 that the perpendicular from the fulcrum c (Fig. 25) on the direction 
 of the force q is much greater than that on the direction of p. The 
 force Q has therefore in this respect a mechanical advantage in 
 leverage over the force p. Inward pressure at the acetabulum is 
 also produced in lying on the side. It would be impossible to 
 calculate d 2Jriori whether on the whole the inward or outward 
 leverage would preponderate. But experience shows that the 
 inward leverage does actually preponderate. This is proved by the 
 fact that, in persons w'ho sit much and stand or walk little, as, for 
 instance, children who suffer severely from rickets, the pelvis 
 becomes relatively wider, from diminished action of the pressure of 
 the femora. It is also proved especially by two rare forms of 
 pelvis. The first is that in which the legs are congenitally absent, 
 but the woman is able to sit upon the tubera ischii. The second 
 is that of the so-called congenital dislocation of both femora, really 
 a malformation, in which no acetabula are developed, but the heads 
 of the femora rest on the outside of the expansions of the ilia. In 
 both these forms of pelvis, the transverse diameter is relatively 
 large, in consequence of the absence of the pressure of the femora 
 at the acetabula. 
 
 Since therefore the tension of the sacro-iliac ligaments (a h, 
 
Anatomy of the Pelvis. 29 
 
 Fig. 25) is resisted both by the inward thrust at d and by the 
 tension at e, the iUum is the portion of the innominate bone which 
 is most strongly acted upon between the counteracting forces, and 
 thus it is at the posterior part of the lateral wall between c and d 
 that the curvature of the brim is most increased. The effect 
 extends also to the crest of the ilium, which gains in this way 
 that curvature owing to which the maximum transverse diameter 
 (Dist. Cr. II.) comes to exceed the distance between the antero- 
 superior spines (Dist. Sp. II.). The inward pressure of the femora 
 is not in itself, without the effect of the junction at the symphysis 
 pubis, sufficient to counteract the tilting outward of the anterior 
 end of the lever, as is proved by the fact that the acetabula do 
 actually become relatively further apart, and the anterior half of 
 the pelvic ring has its share in the moulding produced.^ 
 
 The ilium alone has been regarded as forming the lever, and 
 termed the " sacro-cotyloid beam." All the parts of the innominate 
 bone, however, react upon each other, even though the union 
 between them is only by cartilage, as is proved by the fact, already 
 mentioned, that the development of the curvature of the brim 
 takes place even in the absence of an acetabulum.^ There is 
 another reason why it is mechanically unsound to regard the ilium 
 alone as the lever. For, since there is more or less rigid union 
 between ilium and pubes, the action betweto the two cannot be 
 reduced to a single resultant force, but only to a force and a 
 couple, while the direction of the couple cannot be determined. 
 But at the point e, where the two pubic bones are united, it is 
 obvious from symmetry that the action between the two in the 
 standing position is reduced to a single horizontal force, and that 
 the couple vanishes. 
 
 The leverage action in widening the pelvis being dependent upon 
 the component of the body-weight which acts parallel to the plane 
 of the brim, it follows that the effect is increased with any increase 
 of the inclination of the brim, and the converse. Hence we get a 
 general principle which it is of great importance to remember in all 
 pelvic deformities. Any deformity which increases the inclination oj 
 
 1 For a discussion of the effect of the pressure of the femora, see Champneys, Trans. 
 Obst. Soc. London, 1883, Vol. XXV., p. 70. 
 
 2 Matthews Duncan, in his able discussion of this suVjject, committed one error, when 
 he assumed that the direction of tlie necli of the femur indicates the direction of the 
 resultant pressure of the head of the femur upon the pelvis (Researches in Obstetrics, 
 p. 106). There is no reason why it should indicate this direction, since the force is 
 transmitted just as if the femur formed a straight line, and that it does not do so is 
 proved by the change in the direction of the neck of the femur which sometimes 
 occurs in old age, when its inclination to the vertical becomes more obtuse. This 
 shows that the average diiection of the resultant pressure of the pelvis upon the head 
 of the femur is not in the line of the neck, but more nearly vertical. 
 
30 The Practice of Midwifery. 
 
 the brim, tends to ijroduce a relatively great, and any deformity ivhich 
 dinmiishes it, to produce a relatively small, transverse diameter. 
 
 Effects of Sitting. — In sitting the reactions to the weight of the 
 body act vertically upwards through the tubera ischii. The pro- 
 jections of these vertical lines upon the plane parallel to the brim 
 through the centres of the sacro-iliac joints pass outside those 
 joints, just as the line p does in Fig. 25, p. 27, the tubera ischii 
 being further apart than the sacro-iliac joints. Hence the effect of 
 the pressure tends to rotate the anterior end of the lever formed by 
 the innominate bone outward, and thus increase relatively the 
 transverse diameter of the pelvis. In persons, therefore, who 
 cannot stand or walk during the age of development, but sit a great 
 deal, the pelvis is generally wider than normal. For the body- 
 weight tends to widen the pelvis by leverage, as in standing, 
 although in somewhat less degree, on account of the diminished 
 pelvic inclination ; and this tendency is assisted by the pressure on 
 the tubera ischii, instead of being counteracted in some measure by 
 pressure on the acetabula. On the other hand, the pelvis of a 
 woman bedridden from birth, who never sat or walked, has been 
 described in which the antero-posterior diameter at the brim is 
 considerably greater than the transverse (see Chapter XXX.) ; while 
 the outlet is small, somewhat like that of a male pelvis. 
 
 Again, since the vertical line through the tubera ischii passes 
 outside a line joining the centres of the symphysis pubis and of the 
 sacro-iliac joint, the pressure on the tuber tends to rotate the 
 lower part of the innominate bone outward upon this line as axis. 
 Movement of the whole bone being resisted by the ligaments, the 
 ischia become bent somewhat outwards, and the distances between 
 their tubera relatively wider, as the pelvis grows. The action of 
 the muscles passing from the ischium and from the lower ramus of 
 the pubes to the femur also tends to draw the ischium outwards, 
 and to widen the pubic arch. The same forces which widen the 
 distance between the tubera ischii also counteract the tendency 
 which the tension of the lesser sacro-sciatic ligaments would 
 otherwise have to approximate the spines of the ischia. 
 
 Effects of Muscular Action. — The plane of the abdominal muscles 
 attached to the anterior half of the pelvic ring is inclined backward 
 in reference to the axis of the brim. Of these muscles, the recti 
 are the most powerful. Thus, the traction force exercised by these 
 muscles has a component acting in the plane of the brim and tend- 
 ing to pull the pubes backward toward the sacrum, and thus flatten 
 the pelvic ring from before backward and spread it out laterally. 
 This force aids the effect of the body-weight in promoting the 
 
Anatomy of the Pelvis. 31 
 
 transverse development of the pelvis. It is probably due to the 
 same force that, in intra-uterine rachitis, before the body-weight 
 can have any influence, the characteristic rachitic shape of brim is 
 produced. The psoas and iliacus muscles also tend to draw the 
 superior half of the pelvic ring toward the inferior, and so to flatten 
 the pelvis. 
 
 The change of shape of the iliac fossse, by which they become 
 more curved and more hollow and look more uj)wards than in 
 infancy, is promoted by the traction of the muscles attached to 
 them, especially the glutei and sartorius, as well as by the leverage 
 exercised on the ilia by the posterior sacro-iliac ligaments. 
 
 The doctrine that the weight of the body is the most important 
 of the influences determining the normal development of the adult 
 out of the infantile pelvis, and also the production of certain forms 
 of pelvic deformity, especially of the rachitic pelvis, is supported by 
 Litzmann,^ Matthews Duncan,^ and Schroeder.^ On their authority 
 it has obtained wide acceptance. Ivehrer,* however, has argued 
 that, because many of the changes characteristic of rickets have 
 been found in congenital cases, when the body- weight can have had 
 no influence, the action of the muscles must be the most important 
 element in the case. Fehling ^ also contends against the doctrine 
 of the influence of the body-weight in the normal development, and 
 in the production of the rickety pelvis ; and, as to the formation of 
 the latter, attaches the chief importance to arrest or disturbance of 
 development. 
 
 The view that the tendency of the growth of the bones plays a 
 leading part in the development of the pelvis is supported by the 
 fact, already mentioned, that in the young female child of eight to 
 twelve years of age the pelvic inlet has a somewhat oval form, and 
 the conjugate diameter is longer in relation to the transverse than 
 it is in the fcetus or the adult, no doubt as a result of the more 
 rapid growth of the ilia. 
 
 Breus and Kolisko ^ maintain that the forces of the growth of the 
 bones are all-important, and lay great stress upon the effects 
 produced by inequalities in the rate of growth both of the sacrum 
 and of the component parts of the ilium in the development of 
 
 ' Litzmann, Die Formen des Beckens, Berlin, 1861. 
 
 '■^ M. Duncan, Researches in Obstetrics, EdinVjurgh, 1868. 
 
 " Hchroeder, Lehrbuch der Geburtshiilfe, Bonn, 1882. 7th Aufl. 
 
 * Kehrer, Zur EntvvickelungsKoschichte des Kachitischen Beckens, Arch, filr 
 Gyniik., Band V., Hft. I., p. .55, 1873. 
 
 ^ Fehling, Die Form des Beckens beim Fbtus und Neugeborenen. Arch. fLir 
 Gyniik., Band X., Hft. I., p. ], 1876; iJic Entstchung der Rachitischen Beckens. 
 Arch, fiir Gyniik., Band XI., lift. !., p. 173, 1877. 
 
 « Die Patholugischen Jieckeiiformen, Leipzig, I'JOO, Bd. I., Th. 1, 1904, Th. 2. 
 
32 The Practice of Midwifery. 
 
 the normal and abnormal type of j)elvis. According to them, the 
 more raj)id growth of the ilium in the early years of life tends to 
 produce the oval shape of the pelvic inlet in the young child, 
 the occurrence of which is difficult to explain on the assump- 
 tion that it is due to the action of the body- weight. If this were 
 so, then a progressive flattening of the pelvis should take place 
 from foetal up to adult life, which is not the case, since the action 
 of the body- weight comes into play at a very early period, affects 
 both sexes equally, and continues to act so long as the individual is 
 able to walk of sit. 
 
 We are quite ignorant concerning the nature of the conditions 
 which influence the rate of growth of the different constituent 
 bones of the pelvis, and no satisfactor}^ explanation of them has 
 been given hitherto ; but in any consideration of the evolution 
 of the adult pelvis such inequahties in the rate of growth of the 
 bones at different periods of life cannot be ignored, and must 
 certainly be regarded as a most important factor. 
 
 It must be admitted, therefore, that both the forces of growth 
 and the action of muscles are of much importance, and that 
 MattheW'S Duncan and Schroeder have attached too exclusive an 
 influence to the leverage action of the " sacro-cotyloid beam." 
 But it does not follow that, because in intra-uterine rachitis, when 
 the bones are still more yielding than in rickety children, the 
 action of muscles and other pressures are sufficient to produce 
 many of the usual rachitic changes, the effect of the body-weight 
 is not a very important or even a predominant influence after 
 birth. 
 
 The following are the chief arguments proving the important 
 influence of the body-weight : — 
 
 (1.) That all the changes which the body- weight and the resist- 
 ances it calls out might be expected to produce in the pelvis, do 
 actually occur in the progress from infantile to adult life. These 
 are the changes already described (pp. 25 — 30), namely, relative 
 increase of the transverse diameter, rotation of the sacrum on a 
 transverse axis, with corresponding increase of its curvature in 
 antero-posterior section and diminution of the sacro -vertebral 
 angle, flattening of the sacral curve in transverse section, sinking 
 of the sacrum deeper between the ilia in the direction of the 
 coccyx, separation of the tubera ischii, widening of the pubic 
 arch, and general relative increase of the pelvic outlet. Fehling, 
 indeed, contends that conclusions drawn from dried foetal pelves are 
 unsafe, on account of the change of shape which occurs in drying. 
 He declares that the transverse expansion of the brim is present 
 
Anatomy of the Pelvis. 33 
 
 even at the third month of foetal life, and that sexual differences 
 are plainly seen even at the fifth month. Hence he argues that 
 the traction of the ilio-sacral ligaments is far less important than 
 Matthews Duncan supposed, and that the transverse expansion of 
 the foetal pelvis dejDends upon original growth. Professor Thomson 
 also concludes that the ratio of the transverse to the conjugate is 
 nearly the same in the foetus as in the adult. It may be allowed 
 that Matthews Duncan under-estimated the relative influence of 
 the process of development. But the facts shown by Thomson do 
 not controvert the view of Matthews Duncan with regard to the 
 leverage action of the innominate bone under the influence of the 
 body-weight, but rather confirm it. For since the relative wddth 
 of the sacrum becomes diminished from foetal to adult life, the 
 adult pelvis should be narrower transversely than the foetal so far 
 as regards the effect of growth ; and, in the bedridden pelvis (see 
 Chapter XXX.), this is found to be actually the case. But Thomson's 
 measurements give an average ratio of transverse to conjugate in 
 the foetus of only 1*18 as compared with 1*27 (Verneau) in the 
 adult. Thus actual widening takes place normally, though less 
 than was formerly supposed. 
 
 (2.) That in rachitic softening of the bones all the changes are 
 exaggerated. 
 
 (3.) That in the various forms of pelvic deformity, whenever the 
 pelvic inclination, and therefore also the component of the body- 
 weight acting in the plane of the pelvis, are increased, the conjugate 
 diameter is relatively diminished ; whenever these are diminished 
 (as in the kyphotic pelvis), the conjugate diameter is relatively 
 increased. 
 
 (4.) That in the malacosteon pelvis (see Chapter XXX.), which 
 has originally been normally developed, and which is changed by 
 mechanical influences, the change of shape is obviously due mainly 
 to the body-weight, together with the pressures on the acetabula 
 and tubera ischii. 
 
 (5.) That the formation of the oblique pelvis of Naegele, in which 
 one sacro-iliac articulation is anchylosed (see Chapter XXX.), 
 can only be explained by the leverage of the innominate bone 
 being called into action on one side only, and so producing the 
 usual curvature of the brim on that side only, while the opposite 
 side remains nearly straight. 
 
Chaptef IL 
 
 OVULATION AND CONCEPTION. 
 
 The Development of the Ovaries and Ova. — The genital 
 glands, which develoiD comparatively late, are situated on the mesial 
 aspect of the Wolffian bodies ; the coelomic epithelium in this 
 situation proUferates and forms the so-called germinal epithelium, 
 from which the primitive sex cells are usually considered to be 
 
 s^^-<>'' 
 
 ^. 
 
 
 
 
 ^•?^^#R^--'|:W^ 
 
 ^-■■0-: 
 
 Fig. 26. — Transverse section through ovary, or ; mesosalpinx and 
 Fallopian tube, ft, to show Wolffian tubules, j:;o. Human foetus 
 measuring 14 cm. from vertex to breech. 
 
 derived (Fig. 26). Eecent observations, however, have thrown some 
 doubt on the real site of origin of these cells, for in elasmobranchii 
 they have been found to be formed by the migration of cells from 
 the yolk sac, and in an early human ovum of 4*9 mm. in length 
 Ingalls ^ has described large sex cells as present under the peri- 
 toneum at the root of the mesentery in the region of the first five 
 
 1 N. W. Ingalls, Ai'chiv. fiir Mikrosp., 1907, Vol. LXX., p. 5i7. 
 
Ovulation and Conception. 35 
 
 trunk segments. If further investigations should show these 
 observations to be correct, then the primitive sex cells must be 
 considered as differentiated during the very early division of the 
 fertilised ovum, as is the case in some of the lower classes of the 
 animal kingdom. 
 
 In the further development of the genital gland, the proliferating 
 germinal epithelium, with the exception of a single layer on the 
 surface which persists as the ei)ithelial covering of the ovary, 
 
 
 
 \.">l t 
 
 
 
 
 '■i 
 
 * /,- 
 
 ^■^ 
 
 
 
 Fig. 27. — Section of ovary of human foetus, 14 cm. from vertex to breech, 
 showing ingrowing columns of cells (genital cords) and upgrowth of 
 proliferating stroma. 
 
 grows inwards and eventually forms the primitive ova or oocytes,^ 
 the follicular epithelium, and most probably the interstitial cells of 
 the ovary. At the same time the mesenchyme beneath proliferates, 
 and growing up between the columns of cells, forms the vascular 
 and fibrous stroma of the ovary. The solid ingrowing columns of 
 cells (genital cords) resemble tubules to some extent, and it is easy 
 to see how the erroneous conception of Pfiiiger and others arose 
 that they were tubules with a lumen. 
 
 ' 'J'he human ovum before the ](rocess of maturation and expulsion of the polar 
 globules has J'cndered it ready for fertilisation is, following the nomenclature intro- 
 duced by Boveri, called an oocyte, 
 
 3—2 
 
36 The Practice of Midwifery. 
 
 Waldeyer describes the embedding as taking place by a reciprocal 
 growth upward of processes of the stroma, and downward of 
 branching columns of epithelial cells, which are eventually cut up 
 into clusters (Fig. 27). At a very early stage some of the cells are 
 conspicuous by their large size, and these are the "primordial ova," 
 or oocytes. Each cluster, as a rule, eventually contains one only 
 
 '■^'^:Wf". -^ 
 
 Fig. 28. — Section of ovary of foetus of eight months, showing young 
 Graafian follicles. 
 
 of the oocytes, while the smaller cells remain still small, and, by 
 numerous divisions, arrange themselves around the primordial 
 ovum, to form the epithelium of the Graafian follicle. 
 
 In the early stages of development a cortical zone containing 
 numerous columns of cells, and very little stroma, can be dis- 
 tinguished from a central medullary zone in which the fibrous 
 stroma is much more abundant, and in which the genital cords are 
 ultimately reduced to a few epithelial strands in which ova are no 
 
Ovulation and Conception. 37 
 
 longer recognisable. The greater part of the ovary is formed from 
 the cortical zone. The researches of Winiwarter ^ have shown that 
 the changes occurring in the cells of the cortical zone derived from 
 the germinal ei^ithelium are of a very complex character. Two 
 main types of cells may be recognised, one with a large clear nucleus 
 and distinct nucleolus which does not show any sign of division. 
 These are the young oocytes (Fig, 28). The second type of cells 
 contains a granular nucleus with a coarse nuclear network, is in 
 a state of active division, and forms at first a single layer of low 
 columnar epithelium, and finally by further proliferation a many- 
 celled layer investing the primordial ovum. The secretion of the 
 liquor folliculi leads to the formation of a cavity, and separates the 
 
 
 Fig. 29. — Section of adult human ovary. One follicle just beginning to 
 develop is shown, and four primordial follicles, x 210. 
 
 cells immediately surrounding the oocyte, the so-called discus pro- 
 ligerus or cumulus oophorus, from the remainder of the cells lining 
 the Graafian follicle or the stratum granulosum. 
 
 "While the greater part of the actively dividing cells of the cortical 
 zone undoubtedly form the follicular epithelium, a certain number 
 of them remain grouped together in the spaces between the follicles 
 and become the so-called interstitial cells ^ of the ovary. These 
 cells lately have attracted considerable attention in connection with 
 the internal secretion of the ovary, in the production of which they 
 are held by some writers '^ to play an important part. 
 
 The formation of the oocytes from the young egg cells proceeds 
 
 1 v. Winiwarter, Archives de Biologic, 11)01, Vol. XVII., p. .S3. 
 
 2 J. K. Lane-Claypon, Journ. Obst. and Gyn. Brit. Emp., Vol. XF.. No. 8. p. 20."). 
 =' Limori, Journ. de Phys. et Path. Gc'n., 190-1, Vol. XVI. 
 
38 The Practice of Midwifery. 
 
 during the later months of foetal life, and usually is completed at 
 the time of birth. 
 
 From the mode of origin of the ovary, it follows that it is not 
 covered by the peritoneum in the same sense as the other viscera. 
 The superficial layer of the original germ epithelium is not 
 developed into ovules, but becomes the epithelial covering of the 
 ovary (Fig. 30 ; e, Fig. 31, p. 39). It is continuous with 
 the peritoneal epithelium, but it is j)rismatic, and not flattened. 
 The outer fibrous covering of the ovar}^ the so-called tunica 
 
 
 
 
 
 ,^';.A----U 
 
 
 Fig. 3U. — Section of oA^aiy of woman aged twenty-five years, semi- 
 diagrammatic, showing germinal epithelium, tunica alhuginea, stroma, 
 and Graafian follicles. 
 
 alhufi'inea, is simply a superficial condensed portion of the fibrous 
 stroma of the organ (Fig. 30). It derives its name from its whitish 
 colour, due to its vascularity being less than that of the interior of 
 the organ. Like the rest of the stroma, it contains involuntary 
 muscular fibres, as well as connective tissue. 
 
 All the oocytes which are to be developed in the ovary exist in 
 it at birth, and a far greater number are present than are required 
 for ovulation throughout the whole period of active sexual life. 
 The number at birth has been estimated as high as 100,000. 
 A considerable proportion, however, appear to become atrophied, 
 and disajjpear, so that in adult life, and even at puberty, the 
 
Ovulation and Conception. 39 
 
 At puberty, it is said that about 
 
 number is much smaller 
 30,000 remain. 
 
 Structure of the Ovary. — The ovary is generally described as 
 made up of two portions — a cortical zone, containing the Graafian 
 follicles, and an internal portion, consisting of the fibro-vascular 
 stroma. This distinction, however, exists only in infancy and early 
 childhood, and ceases to be marked before puberty, although the 
 follicles are always chiefly situated near the surface. The stroma 
 is made up of wavy connective tissue, mingled with elastic fibres, 
 and also a considerable quantity of involuntary muscular fibres. 
 
 Fig. 31. — Section of a portion of cat's ovary, e, epithelium ; m g, membrana 
 granulosa ; v, vessel ; o, ovule ; s, connective tissue stroma ; 1, medium- 
 sized follicles ; 2, smaller follicles ; 3, smallest follicles. 
 
 To the action of the latter considerable importance is attached by 
 some authorities as influencing the rupture of the follicles, and the 
 expulsion of the ova. On section of an ovary after puberty, a few 
 follicles are seen which have reached sizes varying from y^g ^P ^o 
 ^ inch, but the great majority are visible only on microscopic 
 examination. 
 
 From the section of a cat's ovary (Fig. 31) it will be seen that 
 the primordial follicles lie close to the surface. As they get some- 
 what larger, they lie deeper in the ovary, but, as they approach 
 maturation, their superficial part again approaches the surface until 
 the covering gives way. The explanation is that, the superficial 
 layer of the ovary being denser than the subjacent stroma (see 
 
40 The Practice of Midwifery. 
 
 Fig. 30), the enlarging follicle at first goes inward in the direction 
 of least resistance. When it has got so large that it can go no 
 further inward, it begins to stretch and thin the overlying layer of 
 stroma, till at length it bursts. In the human ovary follicles of any- 
 thing beyond the smallest size appear less numerous, in proportion 
 to the stroma, than in that of the cat. 
 
 The Graafian follicle, when approaching maturity, is generally 
 described as having two coverings. Of these, the innermost is of 
 most importance. The external connective tissue covering, the theca 
 foUiculi, has two layers— an outer, the tunica externa, or fibrosa, 
 
 Fig. 82. — Wall of Graatian follicle, showing the two layers of the theca 
 
 folliculi. 
 
 and an inner, the tunica interna (Fig. 32). The tunica externa, 
 consisting of highly vascularised connective tissue arranged con- 
 centrically round the follicle, is formed from the stroma of the 
 ovary and the vessels supplying the follicle. The tunica interna, 
 more cellular in structure, is made up of large round or polygonal 
 cells with well-staining nuclei, also derived from the cells of the 
 stroma. These are the so-called lutein cells, and as the follicle 
 increases in size they acquire a granular appearance, due to the 
 accumulation within them of a yellow pigment, and ultimately play 
 an important part in the development of the corpus luteum. The 
 innermost layer is an epithelial lining, called the membrana 
 granulosa, and is made up of cubical cells of granular appearance. 
 
Ovulation and Conception. 
 
 41 
 
 several layers deep (Figs. 32, 33). At one spot on the circum- 
 ference there is a thickening of the epithelium, forming a projection 
 called the discus proligerus or cumulus oophorus, and in this the 
 ovum is embedded (Fig. 33). At an early stage of the development 
 of the follicle its cavity is entirely filled by the oocyte surrounded 
 by several layers of polygonal or cuboidal cells, the nuclei of which 
 stain well. As the follicle approaches maturity a relatively large 
 space forms, filled with clear fluid called the liquor folliculi, which 
 is believed to be formed by degenerative processes occurring in the 
 
 M\ 
 
 ^^j. 
 
 
 Fig. 33. — Graafian follicle, showing membrana granulosa, discus proligerus, 
 tunica interna, and tunica externa. 
 
 cells of the membrana granulosa, or by transudation from the 
 surrounding vessels. 
 
 The ovarian ovum, or oocyte, may be regarded as a greatly 
 developed cell, having its nucleus and nucleolus. Immediately 
 before its discharge from the Graafian follicle it measures about 
 •22 mm. to '32 mm. in diameter. 
 
 Its outer covering, corresponding to the cell-wall, is a tough, 
 elastic, and transparent membrane, called the zona ijellucida. In 
 some of the lower animals there exist openings, to allow the access 
 of the spermatozoa, either in the form of a single aperture, the 
 micropijle, or of numerous minute pores. 
 
 Under the microscope a faint radial striation can often be detected 
 in this membrane, and on this account it is usually termed the 
 zona radiata, or the striated membrane of the ovum. 
 
 These striae are l^elieved to l)e minute pores, and it has been 
 
42 The Practice of Midwifery. 
 
 shown by Heape^ and others that they are occupied by processes of 
 the cells of the corona radiata, the innermost layers of cells of the 
 discus proligerus immediately surrounding the ovum. 
 
 Within the zona radiata a second thin membrane has been 
 described, but its existence is doubtful, and the appearance may be 
 due to the fact that the processes of the cells of the corona radiata 
 are continued through the zona into the protoplasm of the ovum. 
 
 The cavity enclosed by the zona radiata is filled by the egg 
 protoplasm, which contains a number of granules of different sizes. 
 
 Fig. 34. — Human ovum, showing the corona radiata, the zona radiata, the 
 protoplasm and deutoplasm, the germinal vesicle and germinal spot. (Van 
 der Stricht. Bull, de I'Acad. de Med. de Belgique, 1905, 19, p. 303.) 
 
 the yolk or deutoplasm (Fig. 34). The larger granules are found in 
 the centre of the egg, while the smaller granules are arranged round 
 the periphery. Embedded in the protoplasm, usually somewhat 
 excentrically, is the germinal vesicle, about 30 /x to 45 /a in 
 diameter, corresponding to the nucleus of the cell. It is spherical 
 in outline, consists of a nuclear membrane enclosing a clear matrix, 
 and contains one or more nucleoli, the largest of which is termed 
 the germinal spot. 
 
 Occasionally two germinal vesicles are present in the ovum, and 
 two or three ova may at times be found in a single follicle. 
 
 1 Heape, Quart. Journ. Micros. Science, 1886, Vol. XXVI., p. 157. 
 
Ovulation and Conception. 43 
 
 Relation of Menstruation to Ovulation. 
 
 Menstruation consists of a discharge of blood from the mucous 
 membrane of the body of the uterus, accompanied by an increased 
 secretion from the mucous glands of the uterus and vulva. The 
 discharge recurs at intervals which normally are generally from 
 twenty-eight to thirty days. The intervals, however, vary some- 
 what in different women, and in some cases, without any departure 
 from health, they are habitually as short as three weeks or as long 
 as six weeks. The degree of regularity of the intervals also varies 
 in different persons, but any great irregularity generally implies 
 some deviation from perfect health. The intervals are to be 
 reckoned not from the end of the period, but from the beginning 
 of the one to the beginning of the next. 
 
 The duration of the discharge and its amount also vary greatly, 
 both in different women, and in the same woman at different times 
 and in different circumstances. From three to four days is the 
 commonest duration of the flow in this country, but it may last 
 only a few hours, or as long as eight days, without disturbance of 
 health. It generally commences gradually, becomes most profuse 
 about the second or third day, and then gradually diminishes. 
 The total amount of blood normally lost at the period is variously 
 estimated at from two to six ounces, and about three ounces may 
 probably be taken as the average. The quantity is greater in hot 
 climates than in cold ; and it is also increased by luxurious living, 
 and by premature or undue mental stimulation. 
 
 Character of the Menstrual Fluid. — The menstrual blood has 
 usually the peculiarity of not coagulating. This depends upon its 
 becoming mixed with mucus. Thus, when menstrual fluid is 
 retained in consequence of an imperforate hymen or congenital 
 septum, it becomes a thick treacly fluid without clots. If the 
 amount of blood be excessive, or if it be poured out suddenly, clots 
 are formed, the relative proportion of mucus l>eing then insufficient 
 to prevent coagulation. 
 
 On microscopic examination of the menstrual fluid, besides blood 
 and mucous corpuscles, and vaginal epithelium, there is to be seen 
 epithelium from the cavity of the uterus. Not uncommonly, also, 
 shreds can be detected, showing the structure of the mucous mem- 
 brane of the body of the uterus. Sometimes these form thin flat 
 pieces, in which the openings of the uterine glands, and occasionally 
 even the epithelial lining of those glands, may be seen. 
 
 The menstrual fluid has a peculiar odour, depending upon the 
 
44 The Practice of Midwifery. 
 
 mucous secretion mixed with it, and analogous in some measure to 
 that which exists in animals during the period of rut. The fluid 
 very readily decomposes, but apart from decomposition, there is no 
 foundation for the popular prejudice that it has especially injurious 
 properties. The relative proportion of blood to mucus in the 
 menstrual fluid increases from its commencement up to its maximum, 
 and gradually diminishes again towards its close. 
 
 Source of the Menstrual Blood. — It is now universally agreed 
 that the source of the menstrual blood is the mucous membrane 
 lining the body of the uterus, and this alone. It does sometimes 
 happen that, under the influence of the active arterial flux caused 
 by the menstrual nisus, hasmorrhage takes place from the cervix 
 uteri, or even from the vagina or vulva, when there exists an erosion, 
 ulcer, or recent wound in these regions. Again, in cases of reten- 
 tion of menstrual fluid from atresia of the vagina or cervix uteri, 
 the Fallopian tubes have sometimes been found distended with 
 blood as well as the uterus, but shut off by a constriction from the 
 uterine cavity. In these instances the mucous membrane of the 
 Fallopian tubes must have poured out blood during menstruation. 
 All these cases, however, are only instances of an abnormal condi- 
 tion, and in normal menstruation, although the Fallopian tubes 
 take part in the general hypersemia of the genital organs, yet no 
 hsemorrhage occurs from their mucous membrane. 
 
 With regard to the exact mechanism of the escape of the blood 
 from the mucous membrane, there is not yet so much agreement. 
 Theories have been held that the blood transudes through the walls 
 of unbroken capillaries under tbe influence of congestion, or that 
 permanent openings exist from the vessels into the uterine glands, 
 closed merely by muscular contraction through the intermenstrual 
 intervals ; and these theories have not yet been entirely abandoned. 
 But the evidence largely preponderates in favour of the view of 
 which Pouchet and Tyler Smith were the first chief supporters, 
 namely, that at each menstrual period more or less of the surface 
 of the mucous membrane is broken up and cast off", allowing the 
 blood to escape through the torn capillaries. There is no doubt 
 that, in a special morbid condition, the so-called " membranous 
 dysmenorrhoea," a considerable thickness of mucous membrane is 
 separated and thrown off in one or several pieces. It is also a fact, 
 although not so universally recognised, that a certain approxima- 
 tion towards this condition is quite common, especially in women 
 who suffer pain in menstruation from the first outset of that 
 function. In such cases a careful examination of the menstrual 
 
Ovulation and Conception. 45 
 
 fluid frequently reveals shreds which microscopic examination 
 shows to belong to the body of the uterus, and to contain either the 
 apertures for the glands, or sometimes the entire structure of the 
 glands, including the epithelial lining. 
 
 If the uterus of women who have died within about ten days 
 after the cessation of the iast menstrual period be examined, the 
 mucous membrane is found to be generally not more than 2^7 inch 
 to Jo inch in thickness, and it shows no very sharp line of demarca- 
 tion from the muscular wall beneath, the extremities of many of 
 the glands dipping into the muscular layer. If death take place 
 during a period of amenorrhoea, the condition is very similar. If, 
 however, a woman who menstruates normally has died very shortly 
 before the expected onset of a period, the thickness of the mucous 
 membrane is much increased by distension of the vessels and 
 serous exudation into the stroma, being often as much as ^ inch at 
 its thickest part. The stroma cells swell up and become more 
 evident, but their nuclei stain less deeply. The epithelium of the 
 surface and of the glands is swollen ; the cilia become ill defined ; 
 the glands are enlarged and in parts dilated. The capillary net- 
 work near the surface becomes much more evident, and the blood 
 spaces are engorged with blood, while numerous leucocytes are to 
 be seen in the neighbourhood of the vessels and near the surface. 
 There is some differentiation into a compact and spongy layer, 
 owing to the fact that the stroma cells become most swollen near 
 the surface of the mucous membrane. 
 
 In cases of death during menstruation, more or less of the 
 mucous membrane has been found disintegrated and removed ; 
 but on this point the evidence is at present conflicting. The 
 difficulty of settling the question arises from the fact that fatal 
 diseases may gravely alter the normal menstrual changes, a uterine 
 hsemorrhage which is not true menstruation often occurring shortly 
 before death. The softened mucous membrane also easily under- 
 goes jwst-mortem dissolution. Tyler Smith believed that the 
 mucous membrane was completely exfoliated, and described and 
 figured the uterus of a woman who died during menstruation, in 
 which the mucous membrane ceased abruptly at the os internum, 
 that of the body of the uterus l)eing entirely wanting. Sir John 
 Williams also holds that the whole of the tissues generally regarded 
 as mucous membrane is disintegrated and cast off. He described 
 four cases in which he found the mucous membrane entirely absent 
 over part, or the whole, of the body of the uterus, after death 
 during menstruation, but all these were cases of death from acute 
 febrile diseases. 
 
46 The Practice of Midwifery. 
 
 This view has not been supported by any other histologists, and 
 was probably based upon imperfect methods of section-cutting. 
 Leopold records, amongst others, two cases of sudden death by 
 accident during menstruation, and concludes that only a very 
 superficial layer of the mucous membrane is thrown off. Engel- 
 mann denies even so much exfoliation as this. Spiegelberg 
 extirpated an inverted uterus during menstruation, and found 
 the mucous membrane intact, except a partial loss of the most 
 superficial epithelial layer. Wyder records two cases of death 
 from accident on the fourth and eighth days respectively from the 
 commencement of menstruation. He finds a notable loss of 
 thickness of the mucous membrane during menstruation, but no 
 disintegration of its whole thickness. The majority of modern 
 observers, especially Moericke, De Sin^ty, Lohlein, and Gebhard, 
 hold that the exfoliation of mucous membrane is only superficial, 
 and that not even the whole of the surface epithelium is necessarily 
 cast off ; but V. Kahlden and Christ believe that the destruction is 
 always considerable. 
 
 According to Heape, monkeys in India menstruate about every 
 month, in a very similar way to women. In observations made 
 esjDecially upon Semnopithecus entellus, Heape finds exfoliation of 
 the superficial part of the mucous membrane, by which the vessels 
 are laid open. At the onset of menstruation, he finds degeneration 
 of the superficial layer of the mucous membrane. In this layer, 
 congested capillaries break down with extravasation, and red and 
 white cells are swept into the stroma. The extravasated blood 
 collects in lacuna in the stroma, and these lacunae, extending and 
 dissecting, lift the epithelium. All the epithelium, portions of 
 glands, and sometimes whole glands are swept away. The inner 
 surface of the uterus appears ragged, with masses of blood here and 
 there, but the deep layers of the stroma are wholly intact. 
 
 In a case of sudden death of a woman by drowning ten days 
 from the beginning and seven from the end of a period, I found a 
 fully developed mucous membrane, ^inch thick — a thickness which 
 seems to be too great to be consistent with the whole thickness of 
 mucous membrane having been thrown off in menstruation. I have 
 also snipped out a small portion of the surface of an inverted 
 uterus at the end of menstruation, and found a thickness of mucous 
 membrane as much as j\j inch existing. The evidence, therefore, 
 is on the whole in favour of the view that the menstrual bleeding 
 is due to a disintegration of the surface of the mucous membrane 
 reaching to a proportion of its thickness, probably varying in 
 different women, but not to its whole depth. On this view, in 
 
Ovulation and Conception. 47 
 
 those cases in which either small shreds, or more complete pieces, 
 of membrane are found in the menstrual discharge, there is an 
 undue fibrillation or toughness of the exfoliated portion, so that 
 the disintegration is less complete than it should be. The cause 
 of the normal disintegration is probably to be found, partly in 
 some degenerative change in the tissues, partly in extreme pressure 
 in the small vessels of the mucous membrane. Fatty degeneration, 
 
 . U idt'T' 
 
 Fig. 35. — Composite drawing of mucous membrane of uterus removed by 
 hysterectomy on first day of menstruation, hi, extravasated blood ; 
 atr, stroma ; gl, gland ; Is. str, isolated portions of broken-up stroma. 
 
 preceding any actual exfoliation, is described by Sir John Williams, 
 but its existence is denied by Leopold and Wyder.^ 
 
 1 For evidence as to the changes of the mucous membrane in menstruation, reference 
 may be made to the following papers : — Sir John Williams, " On the Structure of the 
 Mucous Membrane of the Uterus and its Periodical Changes," Obstet. Journ. Great 
 Britain, Vols. II., V. ; Leopold, " Die Uterusschleimbaut und die Menstruation," Archiv. 
 fiir Gynalcologie, Bd. XI., 1877, p. Ill ; Wyder, "Beitrage fllr Normalen und Patholo- 
 gischen Ilistologie der Menschlichen Uterusschleimbaut," 7&/<Z., Bd. XIII., 1878, p. 1.5 ; 
 Bland Sutton, Surgical Diseases of the Ovaries and Fallopian Tubes, p. 7 ; Heape, 
 "The Menstruation of Semnopithecus entellus," Phil. Trans., London, 1894 and 1897 ; 
 " Menstruation and Ovulation of Monkeys and the Human Female," Obst. Soc. Lend. 
 Trans., Vol. XL., 1898, p. 101 ; De Sincty, "Eecherches sur la Muqueuse Uterine pendant 
 la Menstruation," Gaz. Mcid. de Paris, No. 7, 1881 ; Lohleiii, " Das Verhalten der Uterus- 
 schleimbaut wiibrend der Menstruation," Gynak. Tagesfragen, H. 2, No. 6 ; Moericke, 
 " Die Utcrus.schleimhaut in Verscheiden Altersperioden und zur Zeit der Menstruation," 
 Zeitschr. f. Geb. u. Gyn. VII. 84—187,1882; Gebhard, " Die Menstruation," Vcit's 
 Handbuch der Gyn. TArA, 1893; Mandl, " Beitrag zur Frage des Verhaltens der 
 Uterusmucosa wahrend der Menstruation," Arch. f. Gyn. Lll. .5.57 — .578, 1896 ; Christ, 
 
48 The Practice of Midwifery. 
 
 In Fig. 35, p. 47, is shown a section of the superficial part of the 
 mucous membrane of a uterus removed by hysterectomy a few hours 
 after the commencement of menstruation. In the menstruating 
 uterus there is marked extravasation of blood into the stroma, 
 partly the result of diapedesis and partly the result of actual 
 rupture of the walls of the capillary vessels (Fig. 35). The blood 
 makes its way towards the free surface of the mucous membrane 
 and either forms small sub-epithelial collections of blood (the sub- 
 epithelial hfematomata of Gebhard), which ultimately burst into 
 the uterine cavity, or the corpuscles escape at many points through 
 small openings between the epithelial cells of the surface mucous 
 membrane, at which before the hciemorrhage occurs, as Tussenbrock^ 
 and Mendes de Leon have pointed out, numerous leucocytes have 
 previousl}^ escaped, giving rise to the ante-menstrual leucorrhoea 
 which normally occurs. 
 
 Haemorrhages also occur into the lumen of the glands, and 
 portions of the mucous membrane are thrown off, in some places 
 consisting merely of the epithelium, in others of small fragments 
 of the stroma and glands. 
 
 The regeneration of the tissues after menstruation ceases is 
 carried out by the formation of new cells from the epithelium of 
 the surface and of the glands, and also by the formation of new 
 stroma cells. This process is attended by well-marked mitosis, and 
 occurs in all parts of the mucous membrane near the surface. 
 
 Theory of Menstruation. — When the ovaries are congenitally 
 entirely absent, no menstruation occurs, and the same result 
 follows if the ovaries are removed in early life. Examples of this 
 are said to exist, or to have existed, in the hedjeras, or guards to 
 the harem, in certain parts of Asia. A stimulus originating in the 
 ovaries is therefore essential to the first establishment of menstrua- 
 tion. It is also essential, in most cases, for its continuance. By 
 the removal of both ovaries, whether enlarged by tinnour or not, 
 an artificial menopause is brought on as a general rule. Not very 
 unfrequently, it is true, either irregular uterine haemorrhage, or even 
 perfectly regular menstruation, continues after the operation. In 
 most instances, however, this is due to some small fragment of 
 ovarian stroma, or a supplementary ovary having been left behind. 
 Thus, in one case of oophorectomy, under the care of Dr. Battey, 
 
 " Das Verhalten der Uterusschleimhaut wahrend der Menstruation." D. I. Giessen, 
 1897 ; V. Kahlden, " Beitrage flir Geb. und Gjnak.," Hegar's Festschrift, 1889 ; 
 Macgregor, Pathology of the Endometium, 1905. 
 
 1 Tnssenbrock and Mendes de Leon, Arch. f. Gynak., Hft. 3, 1894, Vol. XLVII., 
 p. 497. 
 
Ovulation and Conception. 49 
 
 not only menstruation but pregnancy occurred after the operation, 
 though only a minute fragment of stroma was left, and the same 
 result has happened in other similar cases. •■■ 
 
 It is now generally believed that the influence of the ovaries 
 upon menstruation and upon the development and nutrition of the 
 body generally is due to an internal secretion rather than to any 
 reflex influence transmitted through the nerves. This appears to 
 be established by the fact that it has been found, in experiments 
 upon animals, that atrophy of the uterus and vagina rapidly 
 follows upon removal of the ovaries, whereas this does not occur if 
 the ovaries are removed from their normal position and transplanted 
 to other parts of the body.- 
 
 The researches of Heape and others have shown that the 
 menstrual cycle is homologous with the oestrus cycle of the lower 
 animals. The oestrus cycle is divided by Heape into the three 
 periods of pro-oestrum, oestrus, and di-oestrum. In the stage of 
 pro-oestrum, which is homologous to human menstruation, there is 
 congestion of the genitals and increased secretion of mucus, 
 in some of the higher animals slightly tinged with blood, and 
 accompanied by a special odour which attracts the male. In such 
 animals as the stag spermatozoa are secreted by the males only at 
 the corresponding period. The pro-oestrum is succeeded by the 
 oestrus, or the period of sexual desire, during which alone the 
 female will receive the male and impregnation is possible, and this 
 stage is no doubt usually associated with ovulation. The analogy 
 of menstruation with the stage of pro-oestrum is shown by the 
 similarity of the processes taking place in the genital organs, and 
 by the further fact that sexual feeling in the human female is at its 
 height just after menstruation is over or at a period corresponding 
 to the stage of oestrus, although it may exist also during the flow 
 or just before its onset. No doubt, as Teacher and Bryce^ point out, 
 in the lower animals ovulation takes place during oestrus or in the 
 late pro-oestrum, and fertilisation usually follows forthwith. In the 
 human subject, on the other hand, a considerable interval of time 
 may elapse between insemination and ovulation or between 
 insemination and fertilisation. They maintain, however, that the 
 most favourable condition for successful impregnation is the occur- 
 rence of insemination and ovulation simultaneously and the 
 
 1 li. Battey, " Oophorectomy," Transactions of International Medical Congress, 
 1881. 
 
 '^ Knauer, "Die Ovarientransplantation," Arch. f. Gynak., LX., p. 322, 1900; 
 Halban. " Ueber den Einfluss der Ovarien auf die Entwickelung des Genitales," 
 Monats. fiir Geburts und Gyniik., Bd. XII., p. 497, 1900; Heape, loc. c'lt. 
 
 ^ The pjarly Development and Embryology of the Human Ovum, 1908. 
 
 M, 4 
 
50 The Practice of Midwifery. 
 
 occurrence of fertilisation immediately the male and female 
 elements meet as in the lower animals. 
 
 In most cases the first menstruation is believed to mark, or 
 shortly to follow, the first ripening of ova. In some instances, 
 however, ovulation occurs in girls who have never menstruated, as 
 is proved by the fact that pregnancy has sometimes occurred before 
 there has been any appearance of the menstrual flow. It is the 
 general rule that, in connection with each menstrual period, one or 
 more ova are discharged, but exceptions to this rule are not 
 uncommon. The occurrence of ovulation without menstruation is 
 proved by pregnancy taking place during periods of amenorrhoea, 
 and by occasional cases of oophorectomy performed about the 
 middle of an intermenstrual interval, in which a follicle is found 
 apparently just ruptured. That of menstruation without ovulation 
 is shown by instances in which no sign of recent or impending 
 rupture of a follicle has been found when death has taken place, or 
 oophorectomy has been performed, just after, or during, normal 
 menstruation. 
 
 Cycle of Menstrual Changes. — The effects of menstruation are 
 not confined to the uterus and ovaries, nor to the time of the men- 
 strual period, but there is a monthly cycle of nutrition influencing in 
 some degree the whole organism. In susceptible women there is 
 often, for some days before the flow, a fulness with tenderness of 
 the breasts, which begins to pass away as soon as the flow com- 
 mences. This condition appears to indicate a tendency to 
 commencing development in the breasts, coincident with the 
 monthly development of the uterine mucous membrane. Sphyg- 
 mographic observations have shown that the arterial tension is 
 generally somewhat raised above the average before the flow, and 
 sinks to a level rather below the average during, and shortly after, 
 the flow. According to Dr. Stephenson's observations, both the 
 temperature of the body and the excretion of urea also follow a 
 monthly cycle. The curve of temperature is above the mean for 
 about half the month, rising to about half a degree above the mean 
 line ; it crosses and falls below that line about, or shortly before, 
 the time of onset of menstruation, and sinks to a similar depth 
 below it for about a similar interval. The curve indicating the 
 excretion of urea follows a very similar course. There are thus 
 general signs of increased activity of nutritive changes conincident 
 with the time of development of the uterine mucous membrane. 
 
 The cause of the monthly periodicity cannot be explained, but it 
 probably lies in the nervous centres rather than in the ovaries. 
 
Ovulation and Conception. 51 
 
 This view appears to be confirmed by the effect which a nervous 
 shock, such as a fright, or excessive muscular exertion, often has in 
 bringing on menstruation prematurely. The commencing matura- 
 tion of the Graafian follicle is probably the consequence rather than 
 the cause of the same arterial afflux of blood to the uterus and 
 ovaries which causes the development'of the uterine mucous mem- 
 brane. As the maturation proceeds, a reflex stimulus from the 
 ovarian nerves increases the afflux of blood until menstruation is 
 determined. In morbid conditions of the ovary, when maturation 
 of follicles is interfered with, or hastened by undue congestion, 
 menstruation is aj)t to be irregular, or its rhythm to be altered. 
 
 Pfliiger's theory that menstruation was due to the reflex irritation 
 of the nerves of the ovary by the pressure of the growing Graafian 
 follicle has received some support from the experiments of Strass- 
 mann,^ who has succeeded by the injection of various substances, 
 such as gelatine, into the stroma of the ovary, in inducing the 
 signs of " heat " and swelling and hyperemia of the mucous mem- 
 brane of the uterus in bitches. 
 
 That the afflux of blood, however, precedes the onset of menstrua- 
 tion is illustrated by what is observed in the case of soft fibroid 
 tumours. Such tumours often vary perceptibly in size during the 
 menstrual cycle, and it is generally found that the greatest size is 
 reached a little before the onset of the flow, and that a diminution 
 takes place either during its course, or at, or even just before, its 
 onset. 
 
 Active arterial hypersemia continues, however, throughout the 
 menstrual flow, and is one of the factors which determine the 
 amount of blood lost. Thus the increased activity of circulation 
 produced by coitus, or great muscular exertion, increases the 
 amount of flow, and is apt to bring it on again, after it has recently 
 ceased. Congestion extends to the vagina and vulva throughout 
 the i)eriod, and if death occurs during menstruation, the whole 
 vicinity of the uterus and ovaries is found greatly congested. The 
 muscular wall of the uterus is, however, sometimes found j)ale and 
 comparatively bloodless, and this condition is to be explained by the 
 occurrence of muscular contractions. The occasional contractions 
 which are manifest to the hand in the pregnant uterus take place 
 also in the unimpregnated uterus during menstruation, and probably 
 at other times. They serve to expel the product of menstruation, 
 and close up the increased cavity left in the body of the uterus by 
 the exfoliation of mucous membrane. It is possible also that 
 uterine contraction may determine the first rupture of vessels at the 
 
 ' Strassmann, Arch, fiir Gyniik., W.)(j, Vol. LIl., Hft. 1, p. 13-t. 
 
 4—2 
 
52 The Practice of Midwifery. 
 
 onset of menstruation by forcing blood out of the muscular wall 
 into the mucous membrane, and checking its return through the 
 veins. A pale condition of the muscular wall after death during 
 menstruation does not, however, prove that it is continuously 
 bloodless during the flow, but only that the blood has been squeezed 
 out of it by contraction before death, or by rigor mortis. With the 
 expulsive contractions of the fundus is associated some physiological 
 relaxation of the cervix ; but any material dilatation of that canal 
 j)robably only occurs when something bulky, such as membrane, 
 clot, or mass of tenacious mucus, has to be expelled. 
 
 Maturation of the Graafian Follicle. — Before the onset of 
 puberty Graafian follicles are found only in the deeper portions of 
 the cortex, and do not reach the surface of the ovary. When the 
 period for the occurrence of the first ovulation approaches, the 
 Graafian folHcle enlarges, and at first recedes from, but afterwards 
 again approaches, the surface of the ovary (see p. 40). Under the 
 influence of the hyperaemia preceding menstruation there is great 
 enlargement and proliferation of the vessels in the vascular tunic 
 of the follicle which is nearest to maturity. From the increased 
 vascular supjDly follows increased secretion of the liquor follicuU, 
 and the follicle comes to form a prominence on the surface of the 
 ovary. From the eflect of pressure the cells of the tunica fibrosa 
 become sej)arated from one another, and the tunica interna and the 
 tunica albuginea become thinned at the most prominent part. At 
 length rupture occurs, and the ovum, with most of the cells of the 
 membrana granulosa, escapes with the rush of liquor folliculi, aided, 
 as some hold, by the pressure of blood previously efiused into the 
 follicle. The actual ruj)ture, which takes place at a point previously 
 free from vessels, the so-called stigma, is said by Clark ^ to be due 
 to necrotic changes occurring in this area of the wall of the follicle, 
 the result of circulatory changes, and is facilitated by the fact that 
 the ovary has no distinct fibrous capsule, nor true peritoneal cover- 
 ing. At the same time there is, as is generally believed, a kind of 
 erection from active congestion of the Fallopian tube and its 
 fimbriated extremity, so that the latter is more closely applied than 
 usual to the ovary. The experiments of Pinner ^ and Lode,^ who 
 introduced particles of colouring matter and Nematode's eggs into 
 the peritoneal cavity of dogs, have shown that the motion of the 
 cilia lining the fimbriae produces a current of serum towards the 
 
 1 Clark, Johns Hopkins Hospital Reports, 1898, Vol. VII., p. 181. 
 
 2 Pinner, Arch. f. Anat. u. Phys., 1880, p. 241. 
 
 8 Lode, Arch. f. Gynak., 1894, Vol. XLV.,p. 295. 
 
Ovulation and Conception. 
 
 53 
 
 m.o 
 
 orifice of the tube, and no doubt by this means the ovum is guided 
 into it. Much importance has been attached to the grasping of the 
 ovary by the fimbriae of the tube during menstruation (Fig. 36). 
 The fimbriated extremity, however, is not large enough to grasp the 
 whole ovary, and the capacity for erection of the Fallojiian tube 
 appears to have been exaggerated. The current produced by the 
 cilia must, therefore, be of great consequence, and be capable of 
 guiding an ovum toward the tube, even when it has escaped outside 
 the grasp of the fimbriae. The possibility of this is illustrated by 
 the case of batrachians, in which the oviducts are situated at a 
 distance from the ovary, and the 
 ova are discharged, in the first 
 instance, into the peritoneal 
 cavity. In this way also may be 
 explained the cases of so-called 
 external migration in which an 
 ovum escaped from one ovary has 
 been carried into the Fallopian 
 tube of the opposite side, and 
 there arrested.^ 
 
 The disposition of the tube is 
 also such that the action of 
 gravity is favourable to the ovum 
 reaching its orifice. The length 
 of the tube being much greater 
 than the distance from the uterus 
 to the ovary, the tube curls over 
 the ovary in a loop, so that its 
 outer third comes to be outside 
 and below the ovary, the ovarian fimbria which is attached to the 
 ovary running downwards from that organ to the orifice of the 
 tube. The fimbriae, therefore, are in contact with the ovary at or 
 near its most dependent part. It is probable, however, that it is 
 not very rare for an ovum to escape into the peritoneal cavity and 
 not reach the tube. 
 
 Fig. 36. — Oblique section through 
 ovary and tube in situ, ms, meso- 
 salpinx ; 0, ovary ; ^, tube ; or, 
 opening of ovarian bursa ; fe, fim- 
 briated extremity ; to, ovarian 
 bursa ; mo. mesovarium. (Bumm, 
 Grundriss der Geburtshilfe.) 
 
 Period of Rupture of the Graafian Follicle. — When it was 
 supposed that the swelling of the uterine mucous membrane took 
 place daring menstruation and not before its onset, it was 
 believed that the time of rupture of the Graafian follicle was 
 shortly after the end of a period, and that an impending rupture 
 might be precipitated by the increased congestion, and perhaps 
 
 ' See the chaptei' on extra-uterine fcjetation. 
 
54 The Practice of Midwifery. 
 
 the contraction of the muscular fibres in the ovaries, induced 
 by coitus. 
 
 Most observers, however, believe that the disappearance of a fixed 
 oestrus in the human female has resulted in the severance of 
 ovulation from oestrus, so that the discharge of an ovum may take 
 place at irregular and uncertain dates throughout the menstrual 
 cycle. It cannot be denied that this is, at least, a not infrequent 
 occurrence. From the apparent analogy between the supposed 
 exfoliation of mucous membrane in menstruation and the exfolia- 
 tion of the developed mucous membrane, the so-called decidua 
 vera, at the end of pregnancy, the mucous membrane developed 
 for menstruation has been called the menstrual decidua. It has 
 further been supposed by some that the separation of this decidua, 
 and consequent commencement of menstruation, indicates that the 
 ovum belonging to that menstrual period has not only escaped, but 
 has failed to become impregnated. It would follow that the impreg- 
 nated ovum belongs, not to the last menstrual period which occurs, 
 but to the first which fails to appear ; and that the duration of 
 pregnancy, generally reckoned from a few days after the end of 
 the last period, is shorter than has generally been supposed. This 
 is not supported by cases of pregnancy from a single coitus of 
 kno\Yn date. Moreover, there is reason to believe that the ovum 
 may take as much as nine or ten days in passing from the ovary to 
 the uterus. From a very careful study of the data recorded with 
 regard to twelve early human ova, including one described by 
 themselves, the j^oungest human ovum hitherto met with, of the 
 estimated age of thirteen to fourteen days, Teacher and Bryce ^ 
 have come to the conclusion that the fertilisation of these ova must 
 have taken place at very wide intervals during the month, and that 
 ovulation in these cases, probably corresponding more or less 
 closely to fertilisation, must also have taken place at different 
 intervals during the month. Further than this, if their estimation 
 of the ages of these ova is correct, then the embedding of the 
 fertilised ovum, which they reckon probably begins some seven days 
 after fertilisation, occurs quite independently of the menstrual 
 growth of the mucous membrane of the uterus, and may take place 
 at any time during the menstrual cycle, except during the stage of 
 actual destruction. 
 
 They conclude from their study of these early ova that menstrua- 
 tion is not a preparation for the reception of an ovum in the old 
 sense of the words, but that it represents a cyclical process which 
 provides for the maintenance of the endometrium in a suitable 
 
 1 Early Development and Imbedding of the Human Ovum. 1908. 
 
Ovulation and C.'onception. 
 
 55 
 
 condition for the production of the decidua of pregnancy, and that 
 the occurrence of an ovarian pregnancy shows that the ovum 
 is not dependent upon the development of a menstrual decidua 
 for a suitable nidus in which to become embedded. 
 
 Formation of the Corpus luteum.— Even before the rupture 
 of the Graafian follicle the tunica interna becomes thickened by 
 proliferation and enlargement of the cells composing it, and 
 acquires a somewhat granular appearance, due to the presence of 
 
 Fig. 37. — Section of corpus luteum of pregnancy, showing lutein cells. 
 Above is seen the central mass of fibrin ; in the centre the mass of lutein 
 cells, with radiate partitions of connective tissue resulting from the 
 original convolutions ; below the stroma of the ovary. (After Whitridge 
 Williams.) 
 
 minute granules of yellow pigment in the cells. After its rupture 
 the cavity of the follicle fills up with blood-clot, intermingled with 
 which are the remaining cells of the membrana granulosa. It was 
 held by Coste that there is normally no effusion of blood into the 
 follicle, but only a semi-transparent gelatinous material, slightly 
 tinged with blood-pigment. Dalton,^ however, found only one 
 specimen of a corpus luteum of menstruation in which the central 
 clot was absent as compared with nine in which it was present. 
 The cells of the tunica interna, the so-called lutein cells, now 
 
 * '• Report on tljo Corpus Luteum," Ti'ansactions of the American GynecologicEvl 
 Society, Vol. II. 
 
56 The Practice of Midwifery. 
 
 undergo very marked hypertrophy, and their yellow colour becomes 
 more conspicuous. By their excessive proliferation within the 
 confined area of the follicle, they become thrown into folds, which 
 have been compared in appearance to cerebral convolutions. These 
 gradually encroach upon the clot in the centre, which shrinks, 
 becomes decolorised, and eventually remains as only a white 
 stellate area. Between the developing lutein cells a delicate reticular 
 netw^ork can be distinguished, which forms a fine limiting membrane 
 
 
 
 • "-.V -v^-^;- •••Iv- "4: •:•'-.• .-r-i^ :•:. .:• -.■■-/ i. 
 
 
 
 Fig. 38. — Section of wall o£ corpus luteum, showing the vascular 
 connective tissue septa. 
 
 separating them from the cells of the membrana granulosa, and in the 
 meshes of which the vascular connective tissue septa develop (Fig. 38), 
 and form a series of partitions dividing up the masses of lutein 
 cells, and giving to the whole a somewhat festooned appearance. 
 
 With the almost comj)lete disappearance of the blood-clot the 
 ruptured follicle has become converted into a solid mass of lutein 
 tissue, divided up by connective tissue septa, the whole forming the 
 so-called corpus luteum, or yellow body. Soon degenerative changes 
 make their appearance in the lutein cells, and undergoing hyaline 
 
Ovulation and Conception. 57 
 
 or fatty degeneration, they gradually disappear, and their place is 
 taken by the newly formed connective tissue, which grows in from 
 the surrounding tissue of the ovary, and which ultimately cannot 
 be distinguished from the ovarian stroma. 
 
 At the height of its development the corpus lufceum is con- 
 siderably larger than the Graafian follicle from which it is formed. 
 The ultimate absorption of the lutein cells, especially in elderly 
 women, may take place somewhat imperfectly, while the degenera- 
 tive changes may extend to the newly formed connective tissues, 
 with the result that there is left in the stroma of the ovary a mass 
 of hyaline tissue resembling an old scar, the so-called corpus 
 fibrosum or corpus albicans. In elderly women a number of such 
 bodies may be found in sections of the ovaries. 
 
 The function of the corpus luteum appears to be to replace the 
 ruptured follicle by new connective tissue with the least possible 
 formation of fibrous scar tissue. Clark ^ believes that one of its 
 functions is to maintain unimpaired the circulation through the 
 ovarian stroma. 
 
 According to Fraenkel, the corpus luteum is the glandular organ 
 which forms the internal secretion of the ovary, and is necessary 
 for menstruation and pregnancy. In rabbits, destruction of the 
 corpus luteum prevents the implantation of the ovum. In women, 
 the same operation almost always prevents the next menstruation.^ 
 
 The origin of the lutein cells is a matter upon which there is still 
 
 a good deal of difference of opinion. Two views have been held : 
 
 that they are derived from the cells of the membrana granulosa, and 
 
 that they develop from the cells of the tunica interna, and are 
 
 therefore of connective tissue origin. The majority of observers 
 
 are in favour of the latter view, and there is, it seems, little doubt from 
 
 the recent work of Clark, Lockyer,^ and others, that it is the correct 
 
 one. The fact that at a time when the cells of the tunica interna 
 
 are showing marked signs of proliferation those of the membrana 
 
 granulosa are already exhibiting degenerative changes, as well as 
 
 the fact that even before rupture of the follicle the developing 
 
 lutein cells can be recognised lying outside the membrana granulosa 
 
 and separated from it by a very delicate basement membrane formed 
 
 from the tunica interna, are strong arguments in favour of this 
 
 view. The processes described by Clark as taking place in the 
 
 degeneration of follicles in the interior of the ovary which do not 
 
 rupture bear out his contentions as to the connective tissue origin 
 
 1 Clark, Johns Hopkins Hospital Reports, 1898, Vol. Vn., p. 181. 
 '^ Arch. f. Gyniik., B. 08, H. 2, 1903. 
 
 ■■' Cuthbert Lockyer, Journ. Obst. and Gyn. Brit. Emp., V., January and February, 
 I90r, ; Trans. Ob.st, Hoc. London, 1905, Vol. XLVIT., p. 157, 
 
58 
 
 The Practice of Midwifery. 
 
 of the lutein cells. Stevens^ has shown that the follicles and ova in 
 pre-menstrual life attain maturit}' by a well-marked constant series 
 of changes. The ova never, however, attain the size of those of an 
 adult female, and the mature pre-menstrual Graafian follicle usually 
 
 :) 
 
 y 
 
 Fig. 39. — Section of the human ovary, 
 showuig a corpus luteuin at the 
 third mouth of gestation. 
 
 Fig. 40. — Corpus luteum at the full 
 term of pregnanc3\ 
 
 measures about '8 to 1 mm. in diameter. The disappearance of 
 the follicles is brought about by a series of degenerative changes, 
 during which the ovum appears to be destroyed by phagocytic 
 action on the part of some of the cells of the membrana granulosa, 
 
 while the follicle itself becomes 
 obliterated by the growth into 
 it of a species of granulation 
 tissue which develops from its 
 fibrous tunic. 
 
 When the ovum has not 
 become impregnated, the de- 
 velopment of the corpus luteum 
 has reached its height after 
 about twenty days ; after this 
 it undergoes rapid absorption. 
 The cells gradually disappear, 
 the colour is changed from 
 3^ellow to a whitish tint, the 
 vessels become atrophied, and 
 eventually there remains only 
 the relic of the fibrous tissue 
 which the cells have formed. 
 In the healthy ovary this is 
 scarcelj^ noticeable ; when the ovary is congested or inflamed 
 it has the appearance of a stellate white cicatrix. The diminu- 
 tion is already considerably advanced by the time the next 
 follicle is ready to rupture, though the yellow colour is generally 
 noticeable for two or three months. Such a corpus luteum has 
 
 1 Trans. Obst. 8oc. Lond., Vol. XLV., p. 465. 1908. 
 
 Fig. 41. — Diagram of the formation of the 
 corpus luteum. a, the cavity of the 
 follicle filled with blood ; 5, l\ the clot 
 diminishing in size, while the epithelial 
 lining becomes thickened and convo- 
 luted, and the clot becomes decolorised ; 
 <7, e,f, completion of the process. In 
 / the convolutions have coalesced to 
 form a yellow mass, the decolorised 
 remnant of the clot remaining only as 
 a central stellate cicatrix. (After 
 Dal ton.) 
 
Ovulation and Conception. 59 
 
 been termed a false corpus luteum, but is better named the corpus 
 luteum of menstruation. The corpus luteum of menstruation, 
 when at its greatest development, remains, as a rule, at the stage 
 shown at d, Fig. 41. Some remnant of dark clot can be seen near 
 the centre, or toward the surface of the ovum ; the convolutions of 
 the masses of lutein tissue are distinguishable, not blended into a 
 uniform mass, and they are most developed in the part of the 
 follicle farthest from the surface. 
 
 If pregnancy occurs, a very different course is followed. The 
 maturation and rupture of fresh follicles is then, as a rule, arrested, 
 and, according to Skrobansky,^ this is brought about by the action 
 of the internal secretion of the corpus luteum of pregnancy. In 
 consequence of the hyperpemia due to pregnancy the yellow body 
 reaches a much higher development, and this develoi^ment is more 
 protracted, as also is the diminution. The greatest height is 
 reached about the third month ; the corpus luteum is still marked 
 at the time of delivery, and does not entirely disappear for one or 
 two months after. At the third month it is about two-thirds of an 
 inch in length (Fig. 39, p. 58), and forms a manifest prominence on the 
 surface of the ovary ; at the time of delivery it still averages nearly 
 half an inch in length (Fig. 40, p. 58). The yellow colour is more 
 marked ; at the early stage the convolutions are firmer to the 
 touch, eventually they blend together in a firm mass, their margins 
 being only indicated by bands of connective tissue. The cells reach 
 about g Jq or even -^^ inch in diameter. The corpus luteum can be 
 felt as a manifest firm swelling in the substance of the ovary. This 
 is not generally the case with the corpus luteum of menstruation. 
 In about one-third of the cases a cavity is formed in the substance 
 of the corpus luteum, containing clear fluid, but more frequently 
 the centre is occupied by the stellate decolorised relic of the blood- 
 clot, like that shown in Fig. 41. The formation of a cavity is 
 ascribed by Dalton to a separation and collection of the serum 
 belonging to the original blood-clot. It is rarely, if ever, observed 
 in the corpus luteum of menstruation. 
 
 The corpus luteum of pregnancy formerly had the less appropriate 
 name of the true corpus luteum. The only structure which really 
 deserves the name of false corpus luteum is that which may be 
 formed if a follicle shrinks, and its wall becomes thickened without 
 rupture ever having taken place. This is distinguished from a 
 corpus luteum of pregnancy or menstruation by the absence of the 
 yellow colour, and by the fact that it is not on the surface of the 
 ovary, nor connected with a cicatrix on that surface. 
 
 1 Skrobansky, Arch. f. Mikr, Anat., U)0:?, Vol. LXH., p. GOT. 
 
6o The Practice of Midwifery. 
 
 The corpus luteum has no positive medico-legal value as a proof 
 of pregnancy. For a few cases have been recorded in which the 
 corpus luteum of menstruation has appeared to have all the 
 characters usual in that of pregnancy. This has generally been in 
 instances where there has been some cause for undue congestion, 
 such as the presence of a fibroid tumour or a life of prostitution. 
 On the other hand, there have been cases of pregnancy in which no 
 corpus luteum or none of distinctive character could be found. 
 
 Commencement and Duration of Menstruation.— The first 
 menstruation is the usual sign that the girl has become capable 
 of conception and child-bearing. It is believed to be dependent, as a 
 rule, upon the first ovulation, although, in some cases, ova are 
 discharged previous to any menstruation. According to Fraenkel, 
 it is the corpus luteum arising from ovulation which determines 
 the next menstruation. At the same time occur the changes, 
 physical and mental, which indicate the arrival at the age of 
 puberty. The body of the uterus, hitherto small in relation to 
 the cervix, is developed, the pubes becomes covered with hair, 
 the pelvis acquires the typical female type, and the breasts are 
 developed. At the same time there is a mental change, and the 
 girl becomes more bashful and retiring. Neither the body of the 
 uterus, however, nor the pelvis, at once reach their full capacity for 
 the discharge of their functions ; they do not generally attain their 
 full size till the age of about twenty. The age at which menstruation 
 commences is influenced by climate, race, and mode of life. The 
 influence of climate has been exaggerated. It has generally been 
 stated that in hot climates the age is on an average two or three 
 years earlier than in cold ; but modern observations appear to show 
 that there is no constant difference. 
 
 Luxurious living and early stimulation of the mental faculties 
 tend to bring on menstruation at an earlier age, and thus the 
 children of the rich and dwellers in towns commonly menstruate 
 earlier than the poorer classes in the country. Premature sexual 
 stimulus has a similar effect. Feeble health and poor diet tend to 
 retard the appearance of the flow. There may be a difference 
 between different races living in the same country, and among the 
 Hindoos, whose custom is for marriage to be completed as soon as 
 menstruation appears, the age is peculiarly early. 
 
 The age of appearance of menstruation may vary from 10 to 20 
 without departure from health. In England more than half of the 
 whole number of girls first menstruate between the ages of 14 and 
 17, and more than five-sixths between those of 13 and 19, the 
 
Ovulation and Conception. 6i 
 
 average age being a little above 15J. Normally the discharge recurs 
 at regular intervals, with the exception of periods of pregnancy and 
 lactation, up to the menopause or climacteric period, which is 
 commonly between the ages of 40 and 50, most frequently at about 
 48. Exceptionally menstruation may go on even up to the age of 
 00. The period of active sexual life is thus generally from 30 to 35 
 or 40 years. Those who menstruate early commonly continue to 
 menstruate late, unless any pelvic inflammation has led to atrophy 
 of the ovaries. Eepeated pregnancies tend to prolong the period of 
 sexual activity. Cases occasionally occur in which true menstruation 
 begins in infants, even at the age of two or three, and continues 
 regularly from that time. Such a condition is associated with 
 premature development of the breasts, of the pelvis, and of the 
 sexual emotions. In such a case pregnancy has occurred in the 
 ninth year, and the birth of a living child in the tenth. 
 
 Conception.— Conception is effected by union of the spermatozoa 
 with the ovum. One or more spermatozoa penetrate the zona 
 pellucida, and, on reaching the yolk, become motionless, and lead 
 to certain changes in the nucleus hereafter to be described. The 
 micropyle, or opening through the zona pellucida for the entrance 
 of spermatozoa, though it exists in lower animals, as insects and 
 fishes, has not been detected in mammals. It is believed that the 
 ovum is generally fertilised in the Fallopian tube, probably for the 
 most part in its outer half, and more especially among its fimbrise, 
 the folds of which form a receptacle in which the semen may be 
 retained for some time. This belief is based mainly upon experi- 
 ments on the lower animals, in which the spermatozoa may be 
 found along the whole length of the tube, and on the surface of the 
 ovary, a few hours after coitus. Nuck placed a ligature on one 
 horn of the uterus of a bitch three days after coitus. Some time 
 later two embryos were found in the tube arrested by the ligature. 
 Again, if a bitch be subjected to coitus just after the rut is over, 
 and killed a few hours later, ova and spermatozoa are found along 
 the whole length of the tube, but, in its lower two-thirds, the 
 spermatozoa have not penetrated the vitelline membrane. This is 
 explained by the change which takes place in the ovum as it passes 
 along the tube, owing to the addition to it of an albuminous 
 envelope. The phenomena of extra-uterine foetation show that, 
 in women also, the spermatozoa may reach the peritoneal cavity. 
 The precise mechanism by which the ascent of the spermatozoa is 
 effected is not positively known. A great deal must be attributed 
 to their own power of motion, since, according to Henle, they can 
 
62 The Practice of Midwifery. 
 
 traverse the distance of an inch in 7^ minutes. Many cases of 
 pregnancy with narrow and unruptured hymen have been recorded, 
 and spermatozoa have traversed minute openings in a vaginal 
 septum. I have known a case of jDregnancy where the vagina 
 was contracted up to a rigid tube, only ^ inch in diameter, so that 
 penetration was totally impossible, while urine was constantly 
 trickling through this tube from the bladder. In such instances, 
 the spermatozoa must have made their way by their own activity 
 the whole length of the vagina, as well as of the uterus and 
 Fallopian tube. Besides the movements of the spermatozoa them- 
 selves, the effects of capillary attraction, and of suction exerted in 
 some way into the uterus, have been thought to have an influence 
 on the ascent of the spermatozoa, and both of these may be im- 
 portant elements in the matter in some cases. Modern physio- 
 logists also attach importance to chemiotaxis, by which is meant 
 the attraction or repulsion exercised upon organisms by fluids of 
 different kinds. In the majority of instances, it is sufficient for 
 impregnation that semen is deposited in the vagina ; but there is 
 reason to believe that, in women of ardent temperament at any 
 rate, some portion of it often ascends almost immediately into the 
 cervix. This is the only explanation of the fact that injections of 
 cold water, or various solutions, used immediately after coitus as a 
 prophylactic against pregnancy, not unfrequently fail to secure the 
 desired result, though they are immediately fatal to the spermatozoa 
 wherever they reach the semen. 
 
 Normally there is in coitus as distinct an orgasm of sensation on 
 the j)art of the woman as that which accompanies emission in the 
 man. It is not necessarily associated with ejection of the secretion 
 of any gland, but is accompanied by certain muscular actions. The 
 sexual orgasm is not necessary to conception, for the condition in 
 which it is habitually absent, or what may be called sexual frigidity, 
 is by no means uncommon, being present in some 40 per cent, of all 
 women, and pregnancy frequently occurs notwithstanding. The 
 occurrence of the orgasm at the proper time does, however, favour 
 conception. I have known a lady who was married under twenty, 
 and lived in married life for many years with two husbands in 
 succession. When she had passed the age of forty, she experienced 
 the sexual orgasm in coitus for the first and only time in her life, and 
 from that day dated her first and only pregnancy. 
 
 It is difficult to imagine any mechanism by which the uterus can 
 exercise active suction, although a suction toward the abdominal 
 cavity may sometimes be caused by sudden expansion of the chest 
 during the sexual orgasm, with closure of the glottis. But the 
 
Ovulation and Conception. 63 
 
 most probable explanation is that in such cases mucus is displaced 
 from the cervical canal by pressure due to impact of the penis, and 
 that, in the intervals of pressure, semen ascends to take its place 
 out of the pool of that fluid just deposited in the posterior vaginal 
 fornix. 
 
 Period of Possible Impregnation. — Since the spermatozoa may 
 remain alive in a suitable medium for ten days or more, and the 
 ovum may occupy probably ten days in descending to the uterus, it 
 is obvious that a fruitful coitus may take place almost at any time, 
 and probably at any time, of the menstrual cycle. It has long been 
 believed that the greatest aptitude for conception exists shortly 
 after the end of a menstrual period. Nature seems to give some 
 evidence in favour of this view, since the period of most acute sexual 
 feeling is generally just after the end of menstruation, although this 
 may extend also to the time just preceding the flow. A similar con- 
 clusion may be drawn from a comparison of the duration of pregnancy 
 in cases of single coitus on a known date with its duration as 
 reckoned from the end of the last menstrual period. The former 
 period is, on an average, 272 days,^ the latter 278 days.^ It may be 
 inferred from this that the fruitful coitus probably takes place, on 
 an average, about six days from the end, or ten days from the 
 beginning, of the last menstrual period. Recorded cases seem to 
 show that this is, at any rate, a possible time for fruitful insemination, 
 as, for example, two instances mentioned by Marion Sims, in which 
 pregnancy followed a single known coitus at such a date, and one in 
 which it was the result of intra-uterine injection by him of seminal 
 fluid. Raciborski concluded, arguing, however, from only fifteen 
 cases of a single coitus, that, in rather more than half, the fertile 
 coitus occurred in the two days following menstruation. 
 
 On the other hand, if the doctrine mentioned above were true, 
 that the commencement of menstruation is a sign tbat impregnation 
 of the ovum discharged in connection with that period has failed, it 
 would follow that coitus is least likely to be fruitful just after the 
 end of a period, and most likely to be so a few days before the 
 onset of a period. It is a strong argument against this doctrine 
 
 ^ Lowenhardt's statistics give 272 days (" Die Berechnung und die Dauer der 
 Schwangerschaft," Archiv flir Gyniikologie, III., 1872); Ahlfeld's, 271 (" Beo- 
 bachtungen Liber die Dauer der Schwangerschaft," Monatsschrift flir Geburtshiilfe, 
 XXXIV., 1869); Stadfeldt's, 272 (Annales de Gynecologic, VIII. , 1877, p. 227); 
 Matthews Duncan's, 275 (Fecundity, Fertility, and Sterility, Edinburgh, 1871) ; 
 "Dauer der Schwangerschaft," Fr. v. Winckel, Handbuch der Geburtshiilfe, 1903, 
 p. 648. 
 
 '•^ According to Matthews Duncan. Lowenhardt {op. cit.) reckons 282 days from the 
 fmt day of menstruation, an estimate which closely corresponds witli that of Duncan. 
 
64 The Practice of Midwifery. 
 
 that it would seem a strange anomaly of nature for sexual feeling 
 to be strongest exactly at the time when impregnation is least 
 likely. Some evidence on this question may be derived from the 
 case of the Jews. In the Jewish law, Jewish women are directed to 
 abstain from coitus during menstruation, and for seven days after 
 its cessation.^ Strict observers of the law are said to go beyond 
 what is commanded in Leviticus, and even if the discharge lasts 
 only for an hour or two, to observe five days during which the 
 discharge might last, for the period itself, and add to these seven 
 clear days, making twelve in all, at the least. Less strict observers 
 of the law, however, keep only three days after the cessation of the 
 flow, or merely occupy separate rooms while it actually continues. 
 It is much to be doubted whether, whatever may be laid down 
 in the Priestly Code, a whole nation was ever induced to practise 
 abstinence at the period of most acute sexual feeling. It is 
 probable that, with Jewesses who observe strictly the Levitical 
 law, the fertile coitus is generally shortly before the period, but 
 there are no statistics as to the duration of pregnancy ffom a 
 single known coitus in those who observe the Jewish law. 
 
 If the conclusions drawn by Teacher and Bryce^ are correct as to 
 the age of the early human ova they have studied, then it 
 follows that fertilisation may occur at any time during the inter- 
 menstrual period, although, as we have already mentioned, they 
 think that pregnancy is most likely to occur when insemination and 
 ovulation take place simultaneously, and this no doubt is most 
 probable just after the menstrual period. It is said that some women 
 conceive only when coitus takes place actually during the men- 
 strual flow ; but it is comparatively rarely that this is put to the 
 test. 
 
 ^ See Leviticus xv. 19. 
 - Loe. clt. 
 
Chapter III. 
 
 EARLY DEVELOPMENT OF THE OVUM. 
 
 The details of the development of the ovum belong to embryo- 
 logy, and only so much will be considered here as is necessary in 
 order to understand the formation of the envelopes of the foetus 
 which are of practical importance in midwifery. These are, from 
 
 Fig. 42. — Formation of polar bodies in Asterias glacialis. ps, polar spinale ; 
 ph', first polar body ; pb", second polar body ; n, female pronucleus. 
 (After Hertwig.) 
 
 without inwards, the decidua, the chorion, and the amnion, of 
 which the first belongs to the uterus, the two latter to the ovum. 
 The earlier of the changes now to be described are only inferred 
 to take place from the analogy of what occurs in the lower 
 animals, and some of the earliest have not been observed even in 
 mammals. 
 
 Maturation of the oocyte. — Maturation occurs independently 
 of impregnation, and consists of a series of changes which prepare 
 the egg for fertihsation. The actual process has not been 
 observed in the human ovum, but no doubt it takes place in the 
 same manner as in some of the lower mammals, in which the whole 
 series of changes can be followed. The most important phase in 
 maturation is the formation and throwing off of the so-called polar 
 bodies.^ The germinal vesicle approaches the surface of the ovum, 
 
 ' The polar bodies were so called because it was thought that their presence 
 determined the pole of the egg at which the first segmentation took place after 
 fertilisation of the ovum occurred. 
 
 M. 5 
 
66 The Practice of Midwifery. 
 
 loses its membrane, and becomes somewhat smaller, characteristic 
 mitotic changes occur, and it ultimately undergoes division, so that 
 a portion of it becomes budded off on the surface with a small part 
 of the protoplasm as the first polar body. A repetition of the 
 same process leads to the formation of the second polar body, 
 while the cell remaining now forms the mature ovum (Fig. 42). 
 At times the first polar body undergoes further division. The 
 oocyte after its first division is called an oocyte of the second 
 order, and when it again divides and the second polar body has 
 been thrown off, it is termed the mature ovum, and its nucleus 
 the female pronucleus. The second polar body is considered to 
 be homologous to the mature ovum, capable therefore of becoming 
 
 
 Fig. 43. — Formation of second polar body of the mouse. I. First polar 
 body («) and its nucleus {b) with second polar spindle. II. Second polar 
 body with remains of spindle X 1,200 diameters. (Sobotta.) 
 
 fertilised, and, according to some observers, plays a part in the 
 development of teratomata. 
 
 The nucleus of the somatic cells contains a substance called 
 chromatin, arranged in the form of a network, which during the 
 process of division of the nucleus forms a definite constant number 
 of filaments or rods called chromosomes. It is computed that in 
 the body cells of man the number of chromosomes is twenty-four. 
 In the reproductive cells, both male and female, only half the 
 number of chromosomes normal to the animal is found. 
 
 The reduction in the number of chromosomes is effected during 
 the maturation of the sex cells and the throwing off of the polar 
 bodies, and obviously is necessary to avoid a doubling of the amount 
 of chromatin in the process of fertilisation in each successive 
 generation. By the fusion of the male and female pronucleus the 
 normal number of chromosomes is again constituted in the 
 segmentation nucleus. 
 
Early Development of the Ovum. 
 
 67 
 
 Fertilisation and Segmentation of the Ovum. — The details 
 of the process of fertilisation as described by Sobotta^ and 
 Melissinos^ in the mouse are as follows: — The spermatozoon meets 
 the ovum in the oviduct before the throwing off of the second polar 
 body is completed, and finds its way into the interior by piercing 
 the zona pellucida. The head of the spermatozoon becomes con- 
 verted into a small vesicular nucleus, the male pronucleus, 
 smaller than the germ nucleus. The two nuclei approach one 
 another, and, now of equal size, come to lie side by side. Characteristic 
 changes occur in the nuclear network, and the chromatin becomes 
 divided up into the chromosomes. It has been shown in Ascaris, which 
 has only four chromosomes, that the rods are divided after splitting 
 
 D ^'^-^ E "==^-==^=^ F 
 
 Fig. 44. — Segmentation of mammalian ovum, z.p., zona pellucida ; p. b., polar 
 bodies ; o.c, outer cells'; i.e., inner cells ; s.c, segmentation cavity. 
 
 between the two first blastomeres in such a way that each receives an 
 equal number of maternal and paternal chromosomes (Fig. 46, p. 69). 
 Too much importance cannot be laid on this fact, since the chromatin 
 is the material basis of the hereditary qualities handed on from one 
 generation to another.^ 
 
 The conjugation of the sperm and germ nuclei into the segmenta- 
 tion nucleus is immediately followed by the segmentation of the 
 ovum, the egg dividing into two segments or blastomeres, and, as 
 
 1 Sobotta, Arch. f. Mikr. Anat., 1903, Vol. LXI.. p. 274. 
 
 2 Melissinos, Arch. f. Mikr. Anat., 1907, Vol. LXX., p. .577. 
 
 » The experiments of Boveri, Delage, and others have shown that the eggs of sea- 
 urchins containing no part of the germ nucleus, when fertilised by spermatozoa, will 
 undergo .segmentation and form larvic, and tiiat these eggs also can be made to 
 segment and form larvaj by the action of certain physical and chemical stimuli without 
 the i)resencc of spcrmotozoa. From these experiments we may conclude that the 
 union of the male and female nuclei is not the means by which developmental changes 
 arc initiated, altiiough it is the most important factor in tl)e process. (T. H. Biyce, 
 Quain's Anatomy, 1908, Vol. I., p. 17.) 
 
68 
 
 The Practice of Midwifery. 
 
 V. 
 
 'I 
 
 ■•-\ 
 
 II. 
 
 III. 
 
 ^ 
 
 
 IV. 
 
 VI 
 
 VII. 
 
 Fig. 45.— Stages in the fertilisation of the egg of the mouse. (Sobotta.) I. Entrance 
 of spermatozoon. II. Rotation of sperm head. III. Formation of sperm nucleus, 
 which lies to the left ; the germ nucleus lies to the right. IV. Resolution of 
 ■ nuclei. V. Vesicular stage of nuclei. VI. Enlargement of sperm nucleus and its 
 approach to germ nucleus. VII. First segmentation-spindle with group of 
 paternal chromosomes to left, and of maternal to right. 
 
Early Development of the Ovum. 69 
 
 has been pointed out, each of these receives an equal complement of 
 maternal and paternal chromosomes (Fig. 46). Each of the two 
 primary segments now divides again, and thus a group of four 
 segments is formed, each of which in its turn divides, until a small 
 mass is produced called the mulberry mass or morula. 
 
 At this stage, while the new cells are still enclosed within the zona 
 pellucida, and the whole is but little, if at all, larger than the 
 
 Fig. 46. — Diagram of fertilisation. Paternal chromosomes black, maternal 
 white. (Modified after Boveri. Quain's Anatomy, Vol. I., Embryology, 
 T. H. Bryce.) 
 
 ovum from which it is derived, a distinction between the 
 cells can be perceived, the centre being occupied by larger, 
 more granular cells, the outer layer consisting of smaller, clearer 
 elements. Fluid now accumulates in the centre of the mass, and 
 almost completely separates the outer layer of cells from the inner 
 except at one point. The outer layer proliferating, is converted 
 into the so-called trophobiaet, and plays an important part in the 
 embedding and nourishing of the early ovum, while the central 
 mass forming the formative or embryonic cell mass takes part in 
 
70 
 
 The Practice of Midwifery. 
 
 the formation of the embryo, the yolk-sac, and in man and apes 
 almost certainly the amnion. The ovum at this stage of development 
 is termed the blastocyst. 
 
 In the mouse the zona pellucida persists after the ovum has 
 reached the uterus, and only disappears as it is becoming embedded. 
 The early stages of cleavage of the human ovum have not been 
 seen, the earliest known ovum (Teacher — Bryce) having already 
 advanced beyond the stage of the blastocyst and measuring 
 1-95 X -95 X 1-1 mm. 
 
 Before describing the further changes in the ovum after it has 
 
 Fibrin. 
 
 Fibrin. 
 
 Ovum 
 
 Vessel. - 
 Gland. - 
 
 Fibrin. 
 
 Cavity of 
 Ovum, 
 
 Gland 
 Vessel 
 
 Ovum. 
 
 - Vessel. 
 Gland. 
 
 Fibrin. 
 
 Coeloma 
 Externum. 
 
 Vessel. 
 
 D / I (#r-^ 
 
 Gland. 
 Gland. 
 
 Embryo. 
 Fig. 47. — Diagi-am of embedding of ovum and formation of decidua capsularis 
 and basalis. The uterine vessels are indicated by thinner lines, the 
 glands by thicker lines. (After Peters.) 
 
 reached the uterus, it is well to consider the changes in the uterus 
 itself which result in the formation of the decidua or the outermost 
 of the three envelopes of the ovum. 
 
 The Decidua. — On reaching the uterus the ovum becomes 
 attached as a rule at a point not far from the orifice of the Fallopian 
 tube, most frequently on the posterior wall. The proliferation of 
 the mucous membrane to form the decidua used to be described as 
 commencing from the moment of the fertilisation of the ovum, but 
 it is more probable that it only begins when the ovum becomes . 
 attached, and so exercises its stimulating influence on the 
 surrounding tissue. 
 
Early Development of the Ovum. 71 
 
 It was formerly believed that the ovum on arriving in the 
 uterus was already provided with villi ; that it attached itself by 
 means of these villi to the surface of the uterus; and that the 
 mucous membrane then grew up round it until it completely 
 
 Fig. 48. — Pregnant uterus showing very early ovum embedded in posterior 
 v^all. Site indicated by black dot (Peters, Einbettung des Men- 
 schlichen Eies.) 
 
 covered it in, and shut it off by a septum, the decidua refiexa, from 
 the cavity of the uterus. 
 
 A study of several very early human ova recently described by 
 Leopold,^ Spee,^ Peters,'^ Teacher and Bryce,* and Jung,'"" all of 
 
 ' Utei'us uiid Kind, Leipzig, 1897. 
 
 2 Arch, f . Anat. und Phys. ; Anat. Abtheil., 1896, pp. 1—30, IhUl., 1899, pp. 1.59—170. 
 
 ■^ Ueber die Einbettung des Menschlichen Eies, Wien, 1899. 
 
 '' The Early Development and Imbedding of the Human Ovum, 1908. 
 
 '■ Beitiiigezur Friilie.sten EieinbeLtung beim Menschlichen Weibe, Berlin, 1908. 
 
72 The Practice of Midwifery. 
 
 which are ah'eady completely embedded m the uterme mucous 
 membrane, has shown that the cells of the trophoblast have the 
 
 Gl Ca M Tr 
 
 1 ! \ \ 
 
 U E a 
 
 \ i -% 
 
 1 ■ / 
 
 B L 
 
 Sy 
 
 B 
 
 / 
 
 
 -Sy 
 
 Ir 
 
 Ca 
 
 B L 
 
 /■ 
 
 ^ f^ i> 
 
 Sy 
 
 } U E 
 
 E 
 
 / 
 
 Gl 
 
 M 
 
 Com 
 
 Ca 
 
 GlTr B Ca 
 
 Fia. 49.— Section through centre of Peters' ovum, supposed to have been implanted 
 in the uterus about seven days. 
 
 a — S, aperture of entry ; F, cap of organising fibrin ; E, embryonic area ; M^ mesoblast ; 
 Tr, trophoblast ; Sy, syncytium ; Z>, decidual cells ; Com, compact layer of 
 decidua ; TJ E, uterine epithelium ; B L, blood lacunae ; Ca, capillaries ; Gl, 
 uterine glands. 
 
 power of dissolvmg the maternal tissues, probably by the formation 
 of some enzyme. 
 
 These observations demonstrate that the ovum attaches itself 
 either in the morula or early blastocyst stage, as in the guinea-pig. 
 
Early Development of the Ovum. 73 
 
 to the mucous membrane, immediately burrows into it, and pro- 
 ceeds to develop there, the villi being formed ultimately within the 
 substance of the uterine mucous membrane. The minute aperture 
 of entry is covered at first only by a small soft thrombus which 
 becomes organised into fibrous tissue. The position of the ovum is 
 not marked by any projection above the general surface of the mucous 
 membrane, as seen in Peters' ovum, which was supposed to have 
 been attached about seven days (Fig. 49). The decidua reflexa is at 
 first simply that part of the general mucous membrane or decidua 
 vera which the ovum has undermined, with the minute cicatrix, 
 Eeichert's scar, at its centre. As the ovum grows the glands of 
 the mucous membrane, partly destroyed by the trophoblast and 
 partly pushed aside, become placed concentrically around it (C, D, 
 Fig. 47). As the decidua reflexa or capsularis reaches its greatest 
 development, before coming into contact with the decidua vera, 
 the main part of it is formed by the growth of what was originally 
 the central portion, and gland cavities, with their openings into 
 the cavity of the uterus, are seen only near the margin where 
 it is attached to the uterine wall. The central part of the decidua 
 reflexa, as the ovum is embedded in the stratum compactum alone, 
 resembles the superficial portion of the decidua vera, and contains 
 no glands. 
 
 The mucous membrane, proliferating in consequence of the 
 stimulus of pregnancy, thus forms the decidua. The name decidua 
 is employed, because the membrane is cast off from the uterus at 
 the end of pregnancy. That portion of the developing mucous 
 membrane to which the ovum is attached was called the decidua 
 serotina and forms eventually the site of the placenta, the rest of the 
 mucous membrane lining the uterus was called the decidua vera, and 
 the portion which covers the ovum from the uterine cavity was called 
 the decidua rejiexa. 
 
 The inappropriate names given to the several portions of the 
 decidua originated from a false theory of its origin. The decidua 
 was correctly figured by William Hunter as being the developed 
 mucous membrane. John Hunter, however, believed that it was 
 a layer of coagulable lymph poured out from the surface of the 
 uterus, and this view was long accepted by anatomists. It was 
 supposed that this layer covered the surface of the uterus, 
 including the orifices of the Fallopian tubes, before the ovum had 
 emerged from the tube. The ovum, on arriving at the orifice of 
 the tube, pushed a portion of the layer of lymph before it into 
 the uterus, and this portion was called the decidua reflexa. The 
 portion of the layer which remained undisturbed was the decidua 
 
74 The Practice of Midwifery. 
 
 vera. Finally, it was supposed that a fresh layer of lymph was 
 poured out between the uterine wall and the ovum, and this, as 
 being formed later, was called the decidua serotina (from serus, late). 
 The terms decidua basalis instead of decidua serotina and decidua 
 cai^sidaris instead of decidua refiexa are now coming into general 
 us&. 
 
 Thus, in the early stage of pregnancy, there is a decidual cavity, 
 which is in fact the cavity of the enlarging uterus, the ovum 
 forming a prominence projecting into it. The cavity has three 
 
 Fig. 50. — Decidual cells from early pregnancy. 
 
 openings, the os uteri and the orifices of the two Fallopian tubes. 
 The Fallopian tube, however, from which the ovum descended, is 
 liable soon to be occluded by its growth. The existence of the 
 decidual cavity explains the fact that a sound may be passed into 
 the uterus within the first three months of pregnancy without 
 rupturing the ovum, and sometimes without interruption to the 
 pregnancy, and also the fact that, in some exceptional cases, men- 
 struation may continue during the first three months of pregnancy. 
 The stroma of the decidua is made up of the characteristic 
 decidual cells. These are large round, oval, or polygonal cells with 
 large nuclei. In a section they are epithelioid in appearance ; but, 
 if separated by oedema of the tissue or otherwise, many of them are 
 
Early Development of the Ovum. 
 
 75 
 
 seen to have protoplasmic outgrowths which join similar outgrowths 
 from neighbouring cells (Fig. 50). It is now generally agreed that 
 they arise by hypertrophy of the connective tissue cells of the 
 stroma of the unimpregnated uterus. But it is not always easy to 
 distinguish them in a section from epithelial cells. Thus, at an 
 early stage in the growth of the placenta, groups of cells are seen 
 amongst the villi which used to be regarded as " decidual islands." 
 Many authorities now consider that these belong to the foetal 
 trophoblast, and corresj)ond to the cells of Langhan's layer, or 
 deeper layer of chorionic epithelium, although no direct continuity 
 with Langhan's layer can generally be traced. As a rule, the 
 decidual cells have a smaller nucleus 
 in proportion than the cells of the 
 trophoblast. 
 
 The thickness of the decidua is 
 much greater at the early stage of 
 pregnancy than in the later months, 
 both absolutely and still more in 
 proportion to the bulk of the ovum. 
 The greatest thickness, which may be 
 as much as ^ inch for the decidua vera, 
 is attained by the third month. By 
 that time the decidua capsularis has 
 already been thinned by stretching. 
 The decidua vera and decidua capsu- 
 laris come into contact at the fourth 
 month, and are blended together, the 
 decidual cavity is obliterated, and the 
 ovum occupies the whole of the body of 
 the uterus. From this time the decidua 
 
 caj^sularis becomes gradually stretched into a structureless lamella, 
 which, after the sixth month, cannot generally be detected as a 
 distinct membrane. The decidua vera, at term, is reduced to about 
 j;- inch in thickness, or about one-fifth of the thickness which it 
 had at the third month. 
 
 Decidua Vera. — The decidua vera, in its growth, gradually 
 becomes divided into two layers, a compact layer nearest the 
 surface, and a sjjongi/ or (jlandular layer nearest the muscular wall of 
 the uterus, and forming the greater part of the thickness of the 
 membrane (Fig. 54, p. 78). The compact layer is made up of the 
 characteristic decidual cells, with but little intercellular substance. 
 In the earlier months the ducts of the uterine glands may be 
 seen traversing it, and there are numerous thin-walled vessels. 
 
 Fig. 51. — Section of ovum in situ 
 at beginning of second week, 
 showing decidua capsularis 
 formed. (After Leopold.) 
 
76 
 
 The Practice of Midwifery. 
 
 Leucocytes are seen among the large cells, and numerous lymph 
 spaces are believed to exist, especially around the vessels and the 
 gland-ducts. The surface epithelium gradually loses its elongated 
 cylindrical sha]3e, and becomes cuboid or flattened. This change 
 is considered to be decisive evidence of pregnancy. After the 
 junction of the decidua vera and capsularis (about the third month), 
 surface epithelium is no longer discoverable. 
 
 The spongy layer is made up of proliferating glands with a 
 
 Amnion 
 d embryo 
 
 Maternal 
 
 Decidua 
 capsularis 
 
 Chorionic memiirane 
 
 Chorionic vdh 
 
 Chono decidual 
 apace 
 
 Fig. 52. — The same ovum magnified. 
 
 minimum of interglandular stroma. The cells of the stroma 
 are smaller than those of the compact layer, not so round, but 
 more frequently spindle-shaped, and there is more intercellular 
 substance. The glands at first are lined by typical cylindrical 
 uterine epithelium, but this gradually becomes more cuboidal 
 in shape, and eventually is cast off to a great extent. Toward 
 the end of pregnancy the gland cavities become arranged as large 
 flattened spaces parallel to the uterine wall. These constitute the 
 ampullary layer, which is much thinner than the spongy layer in the 
 early months, and was believed to form the surface of separation 
 
Early Development of the Ovum. 77 
 
 when the decidua is thrown off. Beneath it there is a very thin, 
 deeper and more compact layer of decidual tissue, which remains 
 attached to the muscular wall (Fig. 53). The spaces of the 
 ampullary layer have generally lost their epithelial lining, but 
 some epithelium remains, especially in the ends of the glands, 
 which dip into the deeper compact layer. 
 
 Decidua Refiexa or Cajjsidaris. — Within a few hours after its 
 attachment to the mucous membrane the ovum is believed to be 
 shut off from the uterine cavity by the decidua capsularis. The 
 
 A' 
 
 ci. 
 
 "^V^'^^rrs' •*>- 
 
 — J — ~«*Ssa:i^i>_ 
 
 ^ ^ '^ 
 
 / Sf /C* - 
 
 Fig. 53. — Membranes in situ, from near margin of placenta, r, chorionic 
 villus ; cun, amnion ; ch, chorion ; c.l., compact layer of decidua ; 
 sjJ.l, spongy layer ; m, muscle of uterine wall. 
 
 decidua capsularis usually attains its greatest thickness at about 
 the second month. It is made up of decidual cells, and is covered 
 at first on its exterior by a single layer of cuboidal or flattened, 
 epithelial cells. Near the border where it is attached to the uterus 
 a few gland-ducts may be detected, opening on its outer surface. 
 Its inner surface, in contact with the chorionic villi which are 
 attached to it, is not covered with epithelium, and no gland-ducts 
 open in it. 
 
 Decidua Serotina or liasalis. — The decidua basalis is that portion 
 of the decidua which lies immediately beneath the ovum. It is 
 seen as a separate layer only on the uterine surface of the placenta 
 
78 
 
 The Practice of Midwifery. 
 
 but the whole mass of the placenta is really formed in relation 
 with it. Its structure will be described in conjunction with the 
 development and structure of the placenta. 
 
 In the early stage of pregnancy the growing ovum does 
 not nearly fill the uterine cavit}^, which grows faster than the 
 ovum. Thus there remains a considerable space, the decidual 
 
 f x,-^ 
 
 ^\ ^ 
 
 .> .' ^ i^ 
 
 
 ( )mpact 
 " ucr. 
 
 1 
 
 "^^^ 1 ij cr. 
 
 
 Muscular 
 UwaU. 
 
 Fig. 'A. — Section of decidua vera at fourth month, x 1.3. 
 (After Whitridge Williams.) 
 
 cavity, between the decidua capsularis and decidua vera. (See 
 Fig. 119, p. 175.) 
 
 In an early abortion the openings of the glands may be seen 
 with the naked eye, or more clearly with a lens, on the smooth 
 internal surface of the decidua vera, and the same appearance 
 may be seen when the uterus is opened before the tliird month of 
 pregnancy. No such openings are seen on the decidua capsularis, 
 except at a very early stage, close to its border. Before the full 
 
Early Development of the Ovum. 
 
 79 
 
 term of pregnancy coagulation necrosis of the decidua takes place 
 preparatory to its separation. By the fourth month the decidua 
 reflexa has lost its vascularity, and atrophic changes have already 
 commenced in the decidua vera, the result of the pressure and 
 distension which it undergoes. 
 
 The decidua, as its name implies, is cast off at the end of 
 pregnancy, and there has been a controversy whether the mucous 
 membrane is thrown off completely, so that the muscular wall of 
 the uterus is laid bare. The truth appears to be that more or less 
 of the extremities of the glands is left, with their epithelium, in 
 the deeper compact layer of decidual tissue which remains attached 
 when the decidua is thrown off by detachment through the outer 
 part of the compact layer or its junction with the spongy layer.^ 
 
 
 
 Primitive groove, 
 
 
 Mesoderm . 
 
 
 
 
 
 Amnial fold . ^ 
 
 ^^ 
 
 w 
 
 Ectoderm.^ ^i 
 
 1^ wi 
 
 
 Visceral "m 
 
 ^% MR 
 
 
 mesoderm. ""_># 
 
 1 ^:3Ml%\ 
 
 
 Ectoderm. 
 
 ^ Entoderm . 
 
 , Ccelom. 
 
 Parietal 
 mesoderm . 
 
 Coelom. Coelom. 
 
 Fig. .5.5. — Transverse section of embryonic area of a sheep. (After Bonnet.) 
 
 These form the starting point for the renewal of the glandular 
 tissue ; and the surface epithelium is derived from the epithelium 
 of the gland-tubes like that of the uterus after menstruation. The 
 remnant of decidual tissue remaining attached, is, however, so soft, 
 that it may readily undergo post-mortem disintegration after 
 delivery at full term. A certain portion of the decidua vera comes 
 away attached to the chorion ; the remainder is discharged in pieces 
 with the lochia. A thin layer of the decidua basalis, pierced by the 
 openings of the placental vessels, comes away on the uterine surface 
 of the placenta. 
 
 Further Changes in the Ovum. — There are many gaps in our 
 knowledge of tlie development of the early human ovum, but from 
 the worlv which has 1)eeri carried out by Hubrechfc on Tarsius, one 
 of the lemurs, Selenka and others on some of the apes and monkeys, 
 together with the facts obtained by a study of the numerous early 
 
 * J. G. Webster, Human Placeatation, lliOl. 
 
8o The Practice of Midwifery. 
 
 human ova which have now been described, we are able to trace 
 with a fair degree of certainty the changes which occur in the first 
 stages of the development of the foetus. In the blastocyst, as 
 already mentioned, the outer covering consists of the cells of the 
 trophoblast, and forming a projection into the interior is the for- 
 mative or embryonic cell mass. The first change is the formation of 
 the primitive entoderm by the splitting off from the lower margin 
 of the cell mass of a layer of cells which ultimately form a small sac, 
 the entodermic or yolk-sac, separated by a considerable space from 
 the wall of the trophoblast (Fig. 60, p. 83). In the next phase 
 after the formation of the entoderm a space develops by splitting 
 
 / 
 
 Fig. 56. — Embryonic area of the rabbit showing two stages in the develop- 
 ment of the mesoderm (Kolliker). In A the mesoderm extends on either 
 side of the primitive streak over the posterior part of the embryonic area, 
 and also behind the primitive streak, in B the mesoderm extends over 
 a circular area surrounding the embryonic area, which is trilaminar 
 except in the middle line in front of the primitive streak. 
 
 in the middle of the cells of the cell mass, the so-called amnio- 
 embryonic cavity. The cells forming the floor of this cavity 
 undoubtedly remain as the embryonic ectoderm, while the fate of 
 the cells of the roof is a matter of dispute. In the lemur they 
 disappear, so that the ectoderm comes to the surface and is exposed, 
 but in the higher apes and man in all probability they persist 
 (Bryce), so that the cavity becomes the true amniotic cavity, and the 
 embryonic ectodermic cells never reach the surface. The amnion 
 in man, therefore, from the very first is a closed cavity, and the 
 cells forming its roof are attached to the inner surface of the 
 trophoblast by a solid stalk, the so-called connecting stalk. 
 
 Formation of the Mesoderm. — In order to understand the 
 formation of the amniotic folds in the lower mammals, such as 
 
Early Development of the Ovum. 
 
 8i 
 
 the rabbit, it will be necessary to consider the development of the 
 mesoderm in them before passing on to a consideration of its forma- 
 tion in the human ovum (Fig. 56). At one end of the oval-shaped 
 embryonic area a dark line appears, the primitive streak produced 
 by a thickening of the ectoderm, and from the lateral borders of 
 this newly formed cells are found to be extending into the space 
 between the ectoderm and entoderm, forming the mesoderm. These 
 cells gradually extend all round the blastocyst and also forwards in 
 
 Choi-ion Amalotic sac 
 
 Ventral 
 5 tal K 
 
 E,mbr;yo 
 
 Amniotic 3ft.c 
 
 Amniotic sac 
 
 Fig. 57, — Scheme of formation of the amnion. ^ 
 
 front of the primitive streak by the side of the developing embryonic 
 axis. At this stage commences a cleavage of the mesoderm into 
 two layers, so that the outer layer is comjDosed of the mesoderm 
 with part of the ectoderm, the inner layer of the rest of the 
 mesoderm with the entoderm. The outer layer is called the 
 somatopleure (snq) in Fig. 58), and that part of it which belongs 
 to the region of the embryo forms the body walls. The inner 
 layer is called the splanchnopleure {sj)2^ in Fig. 58), and that part 
 of it which belongs to the region of the embryo forms the wall of 
 the alimentary canal (i, Figs. 58, 59). The cleavage is not 
 
 ' \'oi] Wiiickel, Handbuch der GebuitshUlfe, \WA, Vol. I., Tt. I., p. 272. 
 M. 
 
82 
 
 The Practice of Midwifery. 
 
 confined to the border of the region of the embryo, but eventu- 
 ally extends completely round to the opposite pole of the yolk-sac, 
 
 Fig. 58. — Diagrammatic transverse sections of embryo and ovum in lower 
 mammals to illustrate cleavage of mesoderm and formation of amnion. 
 af. amnial fold ; a, amnion ; ac. amnial cavity ; y, yolk-sac ; v, intestine ; 
 e, epiderm ; m, mesoderm; 11, hypoderm ; sm2), somatopleure ; sjJlJ, 
 splanchnopleure ; ce, cceloma externum ; ci, coeloma internum. The 
 size of the emlaryo in proportion to the ovum is exaggerated in the 
 figures. (See Figs. 49, p. 72, and 64, p. 86.) 
 
 and the yolk-sac thus becomes a free vesicle within the ovum (see 
 Figs. 58, 59). The space between the two layers formed by the 
 cleavage of the mesoderm is called the coelom. The embryo, 
 especially at its head end, now sinks into the interior of the 
 
Early Development of the Ovum. 
 
 83 
 
 blastocyst, and a fold of the somatopleure grows up round it from 
 its cephalic and caudal extremities and from its sides. The embryo 
 thus becomes surrounded with a hollow wall, which grows up 
 
 Fig. 59. — Diagrammatic longitudinal sections to illustrate the formation of 
 the allantois in some of the lower mammals. ;, interior of alimentary- 
 canal ; y, yolk-sac or umbilical vesicle ; 2)}), pleuro-peritoneal space, 
 comprising cceloma internum -and coeloma externum ; a, amnion ; 
 ac, amnial cavity ; al, allantois. 
 
 towards its dorsal surface, most rapidly around the head, and 
 arches over its back, converging until it meets in the centre and 
 covers it in entirely. The fold consists of an outer and inner leaf. 
 
 e^f 
 
 
 ^ 
 
 Vie/ 'f^rc^SV 
 
 
 £ 
 
 \1 ^ 
 
 <^ 
 
 @> 
 
 Fig. (>0, — Diagram of early ovum to show origin of mesoderm, modified after 
 Teacher and Bryce. ?«, mesoderm ; ent, entoderm ; e\n, embryonic cell 
 mass ; am, amniotic cavity ; nt, connecting stalk ; t, trophoblast. 
 
 When it meets over the centre of the back, the double septum 
 between its different parts (c, Fig. 58) is absorbed, and the outer 
 leaf (sometimes called the false amnion) remains as tbe outer 
 surface of the ovum, eventually forming part of the chorion, the 
 
 0—2 
 
84 
 
 The Practice of Midwifery. 
 
 zona pellucida having disappeared. The inner leaf becomes the 
 true amnion (a in c, Fig. 58), and encloses the amnial cavity (ac). 
 The fluid afterwards poured out into the amnial cavity is called the 
 liquor amnii, or amniotic fluid. 
 
 In the lemur, and probably also in man, the mesoderm is 
 developed at an earlier stage and in a somewhat different manner 
 (Fig. 60). The first signs of it are to be found in a mass of cells 
 which take origin from the posterior extremity of the embryonic area, 
 and growing outwards along the amnion stalk, ultimately surround 
 
 Entoderm. 
 
 Mesoderm. 
 
 Part of coelom . 
 
 Trophoblast. 
 Mesoderm. 
 
 Entoderm. 
 
 Amnial cavity. 
 
 Embryonic 
 ectoderm. 
 
 Yolk-sac. 
 
 Mesoderm. 
 
 Pig. 61. — Embryonic area in Peters' ovum, highly magnified. 
 
 the yolk-sac, the amnion, and the inner surface of the trophoblast. 
 A thickened portion of this mesoderm from a very early stage forms 
 a connecting band between the posterior end of the embryonic area 
 and the trophoblast, the so-called connecting stalk (Haftstiel). 
 This connecting stalk is a most important feature in the early 
 development of the human ovum. Not only does the primitive 
 mesoderm form a lining for the trophoblast and the yolk-sac, but, 
 as Teacher and Bryce^ have shown from their study of an early 
 human ovum about thirteen to fourteen days old, it completely fills 
 the blastocyst (Fig. 60). Indeed, they incline to the view that the 
 
 1 The Early Development and Imbedding of the Human Ovum, T. H. Bryce and 
 J. H. Teacher, 1908. 
 
Early Development of the Ovum. 85 
 
 mesoderm arises at even an earlier stage than is here described, 
 and think that it may take origin concurrently with the entoderm 
 from the embryonic cell mass, so that the entoderm from the very 
 first is differentiated into an epithelial layer forming the lining 
 for the yolk-sac and a vascular mesenchyme which gives origin to 
 the vessels of the connecting stalk and chorion, and the blood and 
 bloodvessels of the yolk-sac. The very early development of the 
 mesoderm in point of time in the human ovum is shown by the 
 fact that up to now the primitive streak has not been formed. This 
 
 Fig. 62. — Embryo of 2 mm. about thirteen days old. (After Graf v. Spee, 
 from Volkmann's Entwickelungsgeschichte). y s, yolk-sac ; am, amnion ; 
 n gr, neural groove ; n c, neurenteric canal ; p str, primitive streak ; 
 ah st, abdominal stalk. 
 
 now makes its appearance on the germinal disc, and from its sides 
 a further development of mesoderm takes place. 
 
 On the upper surface of the primitive streak a shallow groove is 
 formed by the upgrowth of two folds of ectoderm, the neural folds, 
 and from the thickened ectoderm of the groove develops the 
 central nervous system. From the portions of the mesoderm lying 
 on either side of the neural folds the primitive mesodermic segments, 
 or proto-vertebrae, of the trunk are developed. 
 
 It will not 1)0 necessary for us to consider the development of the 
 human embryo any further, since the rest of the stages have no 
 immediate bearing on our subject. 
 
86 
 
 The Practice of Midwifery. 
 
 The Amnion.— The amnion is at all times non-vascular, with 
 the possible exception mentioned below. It has a single layer of 
 cuboidal epithelium, corresponding to the epidermis, and looking 
 inward toward the amniotic cavity. Outside this there is a layer of 
 
 Embryonic area. 
 
 Chorion . 
 
 Amnial cavity. 
 Abdominal pedicle 
 
 Chorion. 
 
 Yolk-sac. Allantois. 
 
 Fig. 63. — Section of Spee's human ovum at early part of second week. 
 
 embryonic connective tissue, derived from the mesoderm, in which 
 are seen spindle and stellate cells. 
 
 The amnion is at first separate from the inner surface of the chorion, 
 a semi-liquid gelatinous substance, the mesenchyme, occupying the 
 
 Chorionic villi 
 
 \0X :k^. 
 
 'Embryonic area. 
 
 Amnial cavity. 
 Abdominal pedicle. 
 
 Chorion. 
 
 Constriction betw^een yolk-sac 
 and embryonic area. 
 
 Fig. 64. — Spee's human ovum at early part of second week. 
 
 intervening space {pp Fig. 59). By the middle of pregnancy 
 the amnion comes into close contact with the chorion, only a 
 little gelatinous material remaining between them. The amnion 
 is always easily separable from the chorion, although it adheres 
 to it slightly. Exceptionally, fluid (false liquor amnii) is still 
 found between the two, even at the full term of pregnancy. In 
 such case, after one bag of water (the chorion) has been ruptured 
 
Early Development of the Ovum. 87 
 
 in labour, a second (the amnion) may be found still intact. Some 
 authorities describe vessels as existing in the gelatinous substance 
 between amnion and chorion, and as having a function in the 
 secretion of the liquor amnii. Others describe vasa propria as 
 existing in the amnion in the neighbourhood of the placenta at the 
 early stage of pregnancy, and consider abnormal persistence of 
 these vessels to be one cause of hydrops amnii. 
 
 The Liquor Amnii. — The amnion is at first close to the back of 
 the embryo, but it gradually becomes distended by a fluid, the 
 liquor amnii, until it is brought into contact with the chorion. 
 Eelatively to the foetus the amount of the liquor amnii is much 
 greater in^the earlier months of pregnancy, at which time the 
 tetus floats quite freely in it. Its actual maximum is reached 
 about the seventh or eighth month, after which it is in part 
 absorbed. The average quantity on delivery is from one to two 
 pints, 1300 gr. (Winckel). The amount of fluid varies greatly in 
 different cases. The liquor amnii also varies in specific gravity, 
 1004 — 1025, the average being from 1020 in the earlier months to 
 1010 at the end of pregnancy. It is a yellowish clear or dark flaky 
 fluid, alkaline or neutral in reaction, contains salts, chiefly chlorides 
 and phosphates, some albumen, more in the earlier months than 
 in the later, and urea towards the end of pregnancy. At first it 
 is quite limpid and clear, but becomes somewhat more turbid 
 towards the end of pregnancy from the foetal lanugo, epithelial 
 scales, and vernix caseosa which are shed into it. It does not 
 normally contain bacteria or any of the alvine excretion of the 
 foetus, but occasionally, without any foetal disease, it is found dark 
 and discoloured. 
 
 Origin of the Liquor Amnii. — The liquor amnii is, in considerable 
 part, derived from the maternal vessels and not from the foetus. 
 This is evident from cases in which the embryo has perished at a 
 very early stage, but in which, nevertheless, liquor amnii is found 
 to be present in proportion to the size of the ovum and not to 
 that of the embryo, which in some instances may have entirely 
 disappeared. The process must be one of transudation, chiefly 
 from the maternal vessels of the placenta ; and the fact that the 
 injection of potassium iodide into the maternal circulation is 
 followed by its appearance in the liquor amnii, although it cannot 
 be recovered from foetal kidneys, is in favour of this view. It is 
 possible that the determination of the transudation in the direction 
 of the amnial cavity may be due to a secreting power in the cells 
 lining the amnion ; and this is supported by the evidence of certain 
 observers who have demonstrated changes in the cells of the 
 
88 The Practice of Midwifery. 
 
 amnion suggestive of secretory activity, especially in cases of 
 hydramnion. 
 
 It is probable, however, that the foetal vessels are also an impor- 
 tant source of the liquor amnii, for it exists in oviparous animals. 
 The amnion itself has no vessels, but a system of capillaries is 
 described starting from the umbilical cord and ramifying on the 
 inner surface of the placenta, just under the amnion. These 
 become atrojDhied towards the end of pregnancy, as also do the 
 vessels already described (p. 87) as existing in the mesenchyme 
 between amnion and chorion. Some notable proj)ortion also of 
 the liquor amnii, especially in the later months of pregnancy, may 
 be formed by the urine of the foetus, which is discharged into it. 
 This seems to be proved not only by the presence of urea in the 
 liquor amnii,^ increasing in amount towards the end of pregnancy, 
 but by the fact that, when there is occlusion of the urinary passages 
 of the fcetus, the bladder, ureters, or pelves of the kidneys become 
 distended with urine.^ In such instances the swelling of the foetal 
 abdomen so produced sometimes proves a serious obstacle to 
 delivery, and necessitates embrj^otomy. It is, however, by no 
 means certain that the foetus discharges urine into the liquor amnii 
 in normal conditions ; this may only occur, as Winckel believes, 
 when its life is in danger. The source of the small amount of urea 
 usually found in the liquor amnii would then be the maternal 
 blood. The increased amount of urine secreted by the fcetus 
 towards the end of pregnancy, and the disappearance of the capil- 
 lary system on the surface of the placenta, is considered to explain 
 the change of composition in the liquor amnii in the later months. 
 The proportion of albumen may diminish from about "8 per cent, 
 to "08 per cent., while that of urea, which in the early months 
 amounts only to a trace, may rise to '35 or '4 per cent. 
 
 Uses of the Liquor Amnii. — The liquor amnii provides a fluid 
 medium in which the foetus is suspended, and which protects it 
 both from shocks or pressure from without, and from interference 
 with its circulation by uterine contractions. It also gives space 
 for those muscular movements of the fcetus which are doubtless of 
 importance in exercising its muscles and promoting its growth, and 
 prevents the formation of amniotic adhesions. In labour it is of 
 great service by forming, with the protruding bag of membranes, a 
 
 1 The amount of urea present is often not greater than that usually met with in 
 serous fluids, viz., -03 — '04 per cent. 
 
 2 Joulin, however (Traitd d'Accouchements, p. 308), denies this inference, having 
 collected a number of cases in which there was occlusion of urethra without distension 
 of bladder, and considering that the amount of urea in the liquor amnii is too small to 
 justify the conclusion that the urine is habitually discharged into it, 
 
Early Development of the Ovum. 89 
 
 fluid wedge which dilates the cervix and os uteri. It also protects 
 the child from the pressure of the uterine contractions in the first 
 stage of labour, keeps the placenta in contact with the uterine wall, 
 and after rupture of the membranes lubricates and cleanses the 
 genital canal. The liquor amnii is not supposed to furnish nutri- 
 ment to the fcetus, but the foetus occasionally swallows some of it, 
 as is proved by lanugo and epidermic scales being found in the 
 intestines. Some consider that, in this way, the liquor amnii serves 
 a purpose in providing the fcetus with water. 
 
 The Yolk-sac or Umbilical Vesicle. — The yolk-sac is at first large 
 in comparison to the cavity within the embryo, and for a time the 
 latter derives the greater part of its nourishment from it. As 
 the embryo increases in age it soon becomes developed out of 
 proportion to the size of the yolk-sac. As a result of this a folding 
 in of the embryonic area occurs around its margins, especially 
 anteriorly, where a diverticulum of the yolk-sac is formed, the 
 primitive fore gut. The folding in at the sides and the tail end 
 occurs somewhat later, but is ultimately carried out so that the 
 hind gut is formed, and the connecting stalk, now bent round to 
 the ventral aspect of the embryo, becomes the abdominal stalk 
 (Bauchstiel). The constricted neck of the yolk-sac is termed 
 the vitelline duct, and its expanded extremity is the umbilical 
 vesicle. 
 
 The Allantois. — Before the folds of the amnion have completely 
 met, the formation of the allantois in many of the lower mammals 
 commences by a depression on the inner side of the entoderm, 
 destined to form the lining of the future intestine. This depression 
 carries before it the inner of the two layers into which the meso- 
 derm has become divided, so as to form a projection into the space 
 between the two layers, or the coelom {al in a, b. Fig. 59, p. 83). 
 The allantois thus forms at first a hollow vesicle, its cavity opening 
 into the lower end of the hind gut. The vesicle thus formed, 
 according to the usual description, receives two arteries and two 
 veins, and grows out rapidly between the yolk-sac and the amnion 
 (pj9. Fig. 59), until it reaches the inner surface of the chorion 
 (Fig. 59, A, b). It quickly S23reads over this, and thus performs the 
 important function of conveying to it a vascular supply and con- 
 nective tissue substratum. The expanding allantois with its 
 tubular pedicle has been compared to an umbrella with its handle. 
 In some lower mammals the vesicle formed by the allantois 
 projecting into the coelom serves as a receptacle for the urinary 
 secretion at an early stage of development. In birds, the allantois 
 
90 
 
 The Practice of Midwifery. 
 
 has a considerable development and a prolonged use, as it 
 completely envelops the yolk-sac. 
 
 In man and the monkeys theallantois appears at a comparatively 
 late stage as a hollow diverticulum from the yolk-sac growing into 
 the middle of the mesoderm of the connecting stalk. It is an 
 unimportant structure, and does not vascularise the chorion, which, 
 indeed, it never reaches, and the greater part of it remains merely 
 as a relic. When the umbilical cord is formed the extra-embryonic 
 
 Chorionic villi 
 
 Mesoderm 
 
 Mesoderm- 
 
 -Vessela 
 
 Fig. 65. — Sagittal section of early human ovum 2 mm. in length. (After 
 Graf V. Spee, from Volkmann's Entwickelungsgeschichte). 
 
 portion of the allantois is found embedded in it, while the intra- 
 embryonic portion forms the urinary bladder and urachus. 
 
 Formation of Bloodvessels. — The first appearance of blood- 
 vessels is to be seen on the under-aspect of the yolk-sac, from which 
 they gradually extend until the whole is covered with a vascular 
 network (Fig. 65). In an early human Ovum of about eighteen to 
 nineteen days' development (Eternod^) the two heart tubes, still 
 
 1 Eternod, Anatom. Anzeiger, 1899, Vol. XV., p. 181. 
 
Early Development of the Ovum. 91 
 
 separate from one another, are seen to be portions of a sinus-like 
 vessel which runs back on either side of the notochord to form the 
 primitive aortas and passes as a single trunk bhrough the connect- 
 ing stalk into the chorion. Where this vessel lies near the mouth 
 of the yolk-sac it is joined by a vascular loop surrounding the 
 allantoic tube, the sinus ensiforme, into which the vessels from the 
 yolk-sac pass. It is obvious, therefore, that at a very early stage 
 of development indeed in the human ovum a circulatory system is 
 established between the embryo and the chorion (Bryce), which is 
 of great interest in connection with the functions of the cells of the 
 trophoblast. At a later stage, after the complete establishment of 
 the vitelline circulation, as in an ovum described by His, the heart 
 is present still as a single tube, but showing a division into an 
 auricular, ventricular, and bulbar part, and is joined by three pairs 
 of veins : the vitelline veins from the yolk-sac, the allantoic from 
 the chorion, and the ducts of Cuvier, formed by the union of the 
 cardinal veins, from the body of the embryo. 
 
Chapter IV. 
 THE CHORION, PLACENTA, AND UMBILICAL CORD. 
 
 The Chorion. — When the ovum reaches the uterine cavity it 
 has no doubt attained the stage of an early blastocyst, and measures 
 about '2 mm. in diameter. In the mouse the zona peUucida is still 
 present at this stage, but quickly disappears, and probably in the 
 case of the human ovum it is also present when the ovum first 
 reaches the uterus. The outer epithelial covering of the blastocyst, 
 the trophoblast, -which, as we have seen, has the power of destroying 
 the maternal tissues, is arranged in many layers, and at first is 
 composed of discrete cells. 
 
 The ovum generally becomes attached to the surface of the 
 mucous membrane on the posterior or anterior wall of the uterus 
 
 Mesoblast. 
 
 Trophoblast. 
 
 Bloodspace. 
 
 Syncytium. 
 
 Endothelium. 
 
 Capillary. 
 
 Decidua. 
 
 Uterine wall. 
 
 Fig. 66. — Development of placenta (diagrammatic). (After Peters.) 
 
 near the fundus, most frequently on the posterior, rarely toward 
 the lower part of the cavity. The causes which determine the site 
 of attachment are unknown. As already described (see pp. 72, 73), 
 the ovum quickly buries itself in the mucous membrane, which at 
 once begins to become converted into decidua, and forms the 
 elevation which is the characteristic resting-place of all the four 
 earliest human ova yet described (Fig. 48, p. 71). 
 
The Chorion, Placenta, and Umbilical Cord. 93 
 
 By a process of necrosis followed by solution a large implantation 
 cavity is formed in the decidua, in which the ovum at first lies free. 
 Very rapid proliferation now ensues in the trophoblast, which shows 
 
 a differentiation into a cellular layer, the cyto-trophoblast, imme- 
 diately surrounding the ovum, and a layer of undifferentiated 
 protoplasm, the plasmodi-trophoblast, which throws out numerous 
 buds, and in large part fills up the implantation cavity. The power 
 
 Syncytium. 
 
 Fibrin. 
 Capillar3^ ~ ~ -4' 
 
 Mesoblast. 
 
 Trophoblast. 
 
 Decidua. 
 Fibrin. 
 
 Blood space. 
 Decidua. 
 
 Fig. 68. — Development of placenta (diagrammatic). (After Peters. 
 
 of destroying the maternal tissues resides mainly in the plasmodi- 
 trophoblast. 
 
 As the maternal tissue is dissolved, both bloodvessels and glands 
 are eroded (Figs. 66, 68), and thus spaces are formed, bounded 
 
 ' Graf V. Spec, Zeit.>^chr. f. Morphol., Bd. :-5, 1!)01, s. i:5U. 
 
94 
 
 The Practice of Midwifery. 
 
 partly by decidual tissue and partly by trophoblast, which become 
 filled by maternal blood owing to the erosion of the vessels. Other 
 S]paces are formed by vacuolation in the midst of the plasmodi- 
 trophoblast itself, which eventually communicate with those of the 
 
 =■•..« .•"2 ^--^ 
 
 'o „ » ® 
 
 ^ 1 a o 
 
 • ' !;-#^^ 
 
 Fig. 69. — Vertical section through the decidua basalis at the sixth week, 
 showing the penetration of the villi into the decidua. D, decidua ; 
 V, section of villus embedded in a haemorrhage ; h, haemorrhages; e b, 
 epithelial buds, from other embedded villi, not shown in the section ; 
 a, bud showing section of vessel in its interior. (After Eden.) 
 
 former variety, and become also filled with maternal blood. These 
 sjDaces form the commencement of the maternal blood space of the 
 placenta. The blood in them does not coagulate, but serves to 
 nourish the ovum. 
 
 They are thus, according to the modern view, extra- vascular from 
 the commencement, and not formed by dilatation of the maternal 
 vessels, as was formerly held by many anatomists. 
 A sluggish circulation takes place through them ; 
 and the eroded maternal vessels opening into them 
 become hypertrophied, and eventually form the 
 maternal arteries and veins communicating with 
 the general intervillous blood- space of the placenta, 
 in which the maternal circulation then becomes 
 thoroughly established. 
 The ovum now becomes fixed to the decidua first 
 by strands of plasmodi- trophoblast and then by the chorionic villi 
 (Fig, 71). The implantation cavity at this stage forms a definite 
 space in which the ovum, surrounded by its trophoblastic processes, 
 lies bathed in the maternal blood and attached to the walls of the 
 
 Fig. 70.— Very 
 early human 
 ovum, of date 
 not exceed- 
 ing fourteen 
 days. (After 
 Velpeau.) 
 
The Chorion, Placenta, and Umbilical Cord. 95 
 
 cavity by the tips of the processes. All round the ovum the decidua 
 lining the cavity is in a condition of advanced coagulation necrosis, 
 appearing as a darkly staining zone with no nuclei and studded 
 with leucocytes. 
 
 Soon the irregular masses of trophoblast are penetrated with 
 buds of connective tissue growing out from the mesoderm of the 
 chorion (Fig. 68). These branch and penetrate, like a core, the 
 processes of trophoblast, thus converting them into villi (Fig. 68). 
 
 • * * vp ' ,' *, • t ' * ^ 1 - V ,' ' ^- ' ' , • "■ ■"■ >4®J^ ~ «* * • ' * *'*.* •••* 
 
 '**<i^ ^ . • <} '. *' }■'*' ' ji^' '.'."'' • ' ' ' • ,'t>'- ^ ' I ' • ft * • * 
 
 
 
 i*^ 
 
 * » • * * 
 
 Fig. 71. — Diagram of Teacher-Bryce ovum, 13 to 14 days old. (Modified.) The 
 cavity of the blastocyst completely filled by mesoderm, and imbedded 
 therein are the amnio-embryonic and entodermic vesicles. The cyto-tropho- 
 blast forms the outer covering of the blastocyst, and a network of plasmodi- 
 trophoblast unites it to the walls of the implantation cavity. The necrotic 
 zone of the decidua is seen, and here and there masses of plasmodium 
 invading the capillary vessels in the decidua. Scattered throughout the 
 decidua are small glands and numerous vessels lined by endothelirmi.^ 
 
 As soon as the foetal vessels reach the chorion they begin to spread 
 over the whole surface of it, and penetrate the connective-tissue 
 core of the villi, thus rendering them vascular. The fcetal tropho- 
 blast of the villi becomes arranged in two layers — an inner layer of 
 cells, or Langhans' layer, and an outer layer of undifferentiated 
 protoplasm or syncytium (Figs. 66, 68). Peters thought that the 
 conversion off the surface layer of the epithelium into syncytium 
 was due to the action of the maternal blood, but it is probable that 
 it is developed at even an earlier stage than this, and it is derived 
 from the plasmodi-trophoblast. The villous stems are at first single, 
 
 ' Eai-Iy JJevelopment and Imbedding of the Human Ovum, 1908. 
 
96 
 
 The Practice of Midwifery. 
 
 but they soon become divided up into numerous branches, and in 
 the capillary vessels in their interior nucleated blood corjDuscles can 
 be seen derived from the embryo, and carried to the villi by the 
 allantoic arteries through the abdominal stalk. 
 
 In the first few weeks of pregnancy the whole surface of the 
 ovum becomes surrounded with branching vascular villi, which 
 come into relation with the decidua reflexa as well as the decidua 
 vera. Spaces containing maternal blood thus surround the whole 
 ovum (Fig. 71). As joregnancy advances, the blood supply of 
 the decidua basalis increases, and that of the decidua capsularis 
 diminishes. The villi in relation with the decidua basalis 
 
 multiply rapidly and form the chorion 
 frondosum, which eventually becomes 
 the placenta. Over the rest of the 
 ovum the villi grow less rapidly 
 (Fig. 72), and eventually atrophy, and 
 their vessels disappear. This part of 
 the chorion is then known as the 
 chorion loeve. By the time the decidua 
 capsularis has come in contact with 
 the decidua vera, at some time in the 
 fourth month of pregnancy, the blood 
 spaces of the former have shrunk up 
 and disappeared, and the villi are 
 atrophied and evascular. In a section 
 through the membranes in situ in the 
 later months of pregnancy, a layer of 
 foetal epithelium, several cells deep, is 
 seen outside the connective tissue of 
 the chorion, and in it a few sections of 
 atrophic villi, not containing vessels. Outside this is a layer of 
 fibrin-like material, containing small spaces, which is considered to 
 arise from degeneration of fcetal and decidual cells. It is known 
 as the canalised fibrin, or Nitabuch's fibrin layer, and is believed to 
 indicate the demarcation between foetal and maternal tissue. 
 
 Fig. 72. — Human ovum of eighth 
 week : the growth of villi 
 preponderates at one part ; 
 at other parts the villi are 
 already becoming atrophied. 
 (After Carpenter.) 
 
 The Placenta. — A placenta consists essentially of two vascular 
 structures, one maternal and one foetal, so closely interlocked 
 together that, without any actual communication between the two 
 vascular systems, interchange of gases and of nutritive and 
 excretory material can take place between them. 
 
 Varieties of Placenta in Animals. — In the simpler forms of 
 placenta found in animals, such as the diffused placenta of the 
 
The Chorion, Placenta, and Umbilical Cord. 97 
 
 mare, or the polycotyledonary placenta of ruminants, depressions 
 or crypts more or less complex are formed by the developing 
 maternal mucous membrane, into which are inserted tufts of 
 chorionic villi. These crypts are not the enlarged mouths of the 
 uterine glands, as was formerly supposed by some ; but, on the 
 contrary, the gland-tubes more frequently open on the ridges 
 between the crypts, or on part of the mucosa not in contact with 
 villi. The mode of their formation appears to be, that when one of 
 
 Fig. 73. — Diagram of embedding of early human ovum.i y^j, fibrin cap ; 
 tr\ trophoblast ; em. embryo ; gl. glands ; v. vessels of uterus ; 
 m. muscle of uterine wall ; cIl. early chorion. 
 
 the earliest villi has attached itself to the uterine mucous mem- 
 brane, the membrane grows up into a ridge around it.^ As the 
 villus develops into a tuft, the crypt which is thus formed becomes 
 more and more complex. The crypts have an epithelial lining, and 
 the villi likewise have an epithelial covering. Between the two a 
 small quantity of albuminous fluid can be detected, secreted by the 
 epithelium of the mucous membrane, which thus discharges a kind 
 of glandular function. To this fluid the name of " uterine milk" 
 has been applied, and it is to its absorption by the villi that the 
 
 1 Peters, Verhand. d. Deut. Gesellsch. f. Gynak., 1897, Vol. VH., s. 264. 
 
 2 See Lectui-e.s on the Comparative Anatomy of the Placenta, by Professor Turner, 
 E.linburgh, 1S7G. 
 
 M. 7 
 
98 
 
 The Practice of Midwifery. 
 
 fcetus owes its nourishment. When delivery takes place, the villi 
 are drawn out of the crypts, like fingers out of a glove, and bring 
 away with them either no maternal tissue, or only some of the 
 
 — Foetal vessel. 
 
 Main trunk 
 of chorionic 
 villi. 
 
 Chorionic villi. 
 
 Maternal 
 vessel. 
 
 "Uterine wall. 
 
 Fig 74. — Section through placenta of seven months i« ^i^M. (Af ter Minot.) 
 
 epithelium. No bleeding therefore takes place, as a rule, in 
 parturition. Such forms of placentae are called non-deciduate. 
 
 In deciduate placentae, such as the zonary placentae of carnivora, 
 the interlocking of the two membranes is more complex, so that 
 
The Chorion, Placenta, and Umbilical Cord. 99 
 
 they cannot be separated in parturition. The ridges of maternal 
 mucous membrane not only grow up perpendicular to the surface, 
 but send off partitions or trabeculse at various angles, and the villi 
 are divided into more complicated branching tufts. More or less 
 of the maternal laminae is then torn away in parturition, or on 
 artificial separation of the placenta, remaining in the fissures 
 between the foetal portions of the placenta, and the maternal vessels 
 are thereby ruptured. In some cases a more or less continuous 
 layer of mucous membrane, forming a decidua basalis correspond- 
 ing to that in the human subject, is also brought away in parturition 
 on the uterine surface of the placenta. In this form of placenta, 
 as in the simpler kind, a maternal epithelium covers the laminse or 
 
 Fig. 75. — Diagram of mode of attachment of villi to the decidua, showing 
 proliferation of cells of Langhans' layer, and spreading of syncytium over 
 the surface of the decidua. 
 
 trabeculse of maternal mucous membrane, called decidual processes, 
 and intervenes between the maternal vessels and the villi. Pro- 
 fessor Turner describes an early stage of enlargement of maternal 
 vessels into sinus-like spaces as visible in some parts of the placenta 
 of the cat. In that of the fox, he finds the capillaries dilated to 
 from twice to four times the capacity of the fcetal capillaries, and 
 in that of the sloth he describes a still more remarkable dilatation 
 of vessels, no maternal capillaries at all existing, and all the maternal 
 vessels being of colossal size, as compared with capillaries. 
 
 Developnent of Human Placenta. — According to the modern view, 
 the formation of the placenta in man and monkeys is totally different 
 from its formation in the lower mammals ; since the ovum burrows 
 at once into maternal tissue (see p. 72), and the placenta is formed 
 entirely within the substance of the uterine mucous membrane. 
 
 7—2 
 
lOO 
 
 The Practice of Midwifery. 
 
 The earlier stages have ah-eady been described (pp. 72 — 73). As 
 the decidua basalis develops, its deepest part becomes converted, like 
 the decidua vera, into two layers, a spongy or ampuUary layer con- 
 taining the dilated gland cavities, next to the muscular wall (Fig. 74), 
 and within this a compact layer, constituted by the characteristic 
 decidual cells. A considerable number of the primary villi extend 
 from the chorionic membrane to the compact layer of the decidua, 
 to which their extremities are attached. These are termed fastening 
 villi (Fig. 75), and form the main framework of the placenta. 
 The trophoblast at their extremities sends out processes, composed 
 
 ..*!«»««-- 
 
 w 
 
 Syncytium. #• 
 
 Langhans' layer. 
 
 Stroma 
 
 .»■■>' -•*''*';V-.. 
 
 "••1«t 
 
 — ' Syncytium. 
 
 Langhans' layer. 
 
 -t 
 
 Stroma. 
 
 Syncytium 
 
 
 v.v^^w 
 
 ^'^■^^^^^■m.^^'''' 
 
 Fig. 76, — Chorionic villi, a, at three weeks ; B, at three months ; C, at nine 
 months. (After Whitridge Williams.) 
 
 of proliferating cells of Langhans' layer, which, like the roots of a 
 tree, invade the deeper decidual tissue, the so-called cell nodes or cell 
 columns, and thus unite the placenta firmly to the uterine wall. 
 
 The main mass of the placenta is made up by the prolifera- 
 tion of villi, which project freely into the blood spaces. When 
 teased out they form a mass like very fine seaweed branching 
 from main trunks attached to the chorionic membrane (see 
 Fig. 72, p. 96). 
 
 Only the fastening villi are attached to the decidua basalis, but 
 occasionally the extremity of a terminal villus may be attached by 
 a band to a neighbouring villus. An artery and vein enter each 
 villus. In the longer branches, connecting vessels run between 
 
The Chorion, Placenta, and Umbilical Cord. loi 
 
 the artery and vein, forming a fine capillary network. In the 
 smallest terminal twigs there may be only a single vascular 
 loop. In the later months of pregnancy, the vessels in the ultimate 
 branches of the villi are large in proportion to the size of the villus, 
 and occup}^ nearly its whole substance. By increasing proliferation, 
 the small villi become more numerous in proportion to the large 
 main trunks as pregnancy advances. 
 
 The stroma of the chorion and chorionic villi is a connective tissue 
 of characteristic appearance, but varies according to the stage of 
 pregnancy. In the earlier weeks the cells are stellate and branching 
 and are separated from one another by a considerable amount of 
 mucoid substance (Fig. 76, a). Later they become more spindle- 
 shaped and more closely packed together, so that the stroma has a 
 denser appearance (Fig. 76, c). They are still connected by fine 
 fibrillar processes, which distinguish the f cetal connective tissue from 
 the maternal. 
 
 In the first three months of pregnancy a double layer of 
 epithelium may be demonstrated, covering the villi and all other 
 parts of the chorion. After the mid-term of gestation the deep 
 layer disappears more or less completely. In a full-term placenta 
 even the superficial layer has disappeared from some of the villi, 
 and the foetal capillaries are separated from the maternal blood 
 space only by a delicate layer of connective tissue. 
 
 The outer layer consists of the syncytium, a thin layer of granular 
 multi-nucleated protoplasm, which stains deeply. The deep or 
 Langhans' layer consists of discrete cells, which are large and well 
 defined, with oval nuclei standing with their long axes at right 
 angles to the surface. 
 
 It was formerly supposed by some that the outer layer of 
 epithelium was derived from the mother ; by others that the 
 deep layer belonged to the fcetal mesoderm, and was not really 
 epithelial. It is now generally agreed that both layers are derived 
 from the foetal -epiblast. It is probable that these two varieties 
 of the trophoblast are more or less convertible one into the other. 
 Thus the primary covering of the ovum is cellular, the cyto- 
 trophoblast, and this becomes converted into the plasmodi-tropho- 
 blast or syncytium. A section of an early ovum often shows 
 masses of discrete cells connected with the villi but outside the 
 syncytium, and a continuity between them and Langhans' layer 
 can only occasionally be traced. Intermediate conditions are also 
 seen, in which the separation of the protoplasm into cells is only 
 just discoverable. Again, the processes from the ends of the 
 fastening villi into the deep layer of the decidua consist of discrete 
 
I02 
 
 The Practice of Midwifery. 
 
 cells, derived from Langhans' layer ; but in the later months 
 of pregnancy, and especially in the last month, a section of the 
 decidua basalis shows also, in its superficial portions, fine processes 
 of syncytium mixed up with the decidual cells. 
 
 During the early months of pregnancy the syncytium of the villi 
 shows great activity. Proliferation occurs in localised areas, result- 
 ing in the formation of epithelial buds (Fig. 77), which are the 
 commencement of new villi. The chorionic stroma, followed by 
 the vessels, only enters the bud later (Fig. 77, b), and Langhans' 
 layer of cells takes no part in the formation of buds. This 
 dependence of the proliferation of the villi upon the syncytium 
 is a proof that the S3aicytium is of fcetal and not of maternal 
 origin. 
 
 A section of the placenta in the fourth month, when it is first 
 
 full}' constituted, shows that 
 the main part of it is made 
 up of chorionic villi, having 
 still, in great part, their 
 double epithelial covering. 
 There is a much greater 
 proportion than in the later 
 months of large chorionic 
 trunks, in which the amount 
 of stroma is large in propor- 
 tion to the vessels. There 
 are many processes of syncy- 
 tium or epithelial buds (see 
 Fig. 69, p. 94), which on 
 section look like giant cells lying in the blood sj^aces. There are also 
 masses of large discrete cells. These have been termed " decidual 
 islands," and have been considered to be sections of decidual pro- 
 cesses extending through the whole thickness of the placenta. Many 
 authorities, however, now regard them as masses of trophoblast, 
 corresponding in structure to Langhans' layer, which have not 
 been penetrated by the chorionic connective tissue, and therefore 
 have not been converted into villi. Hence the tendency is now to 
 infer that decidual processes only extend for a very short way 
 into the placenta between its lobes, and that the rest of its frame- 
 work is of fcetal origin. 
 
 As the placenta grows the intervillous blood spaces expand and 
 communicate more and more with each other, until there is one 
 general blood space throughout the entire placenta filled with 
 maternal blood, in which the chorionic villi hang freely. The 
 
 Fig. 77.- 
 
 fiom an 
 
 —A, B, Sections of villi 
 ovum at the sixth week. 
 Ves, vessel ; Up. B, epithelial bud ; st, stioma 
 of villus ; .«Z, superficial laj'erof epithelium. 
 The deep layer is not seen. (After Eden.) 
 
The Chorion, Placenta, and Umbih'cal Cord. 103 
 
 maternal arteries and veins mostly open directly into this through 
 the compact layer of decidua basalis. There are no maternal 
 capillaries in the placenta, and no maternal vessels extend more 
 than a very short way into it, along the decidual processes. In 
 general, the veins open directly by an oblique course (see Fig. 74, 
 p. 98), through the decidua basalis. Some of the arteries open on 
 the decidual processes, which extend a short way into the placenta 
 from the maternal surface. The arteries have a spiral course both 
 through the muscular wall of the uterus and the decidua serotina. 
 The veins are destitute of true valves, but they are often bent 
 
 Fig. 78. — Section of fully-formed placenta, with part of the nterus. 
 a, umbilical cord ; h, h, section of uterus ; c,c, c, branches of the umbilical 
 vessels ; d, d, cuiiing arteries of the uterus. 
 
 acutely upon themselves, forming what is described as a falciform 
 valve. Thus both arteries and veins are closed, after separation 
 of the placenta, by firm contraction and retraction of the uterine 
 muscle. 
 
 Chai'acters of the full-grown Placenta. — The placenta at full 
 term forms a round or slightly oval mass, of spongy consistency. 
 Its greatest diameter is, on the average, from 7 to 8 inches, its 
 greatest thickness about an inch, and its weight about 20 ounces. 
 It is generally inserted on the posterior or anterior wall of the 
 uterus near the fundus, more frequently on the posterior. More 
 rarely it is inserted on one side, and if so, more frequently on the 
 right, seldom absolutely on the fundus. Still more rarely it is 
 
104 
 
 The Practice of Midwifery. 
 
 inserted lower down in the body of the uterus, either approaching 
 to or overlapping the internal os. Such modes of insertion imply 
 respectively the risk or the certainty of haemorrhage before 
 delivery, and will be discussed under the head of placenta praevia. 
 The placenta is never inserted upon any part of the cervix. The 
 fcetal or internal surface of the placenta is smooth, and covered by 
 the amnion, which can be easily peeled off up to the insertion of 
 the funis, or for about half-an-inch on to the funis. The umbilical 
 cord is generally inserted to the foetal surface a little excentrically, 
 and the amnion is reflected over it. Through the amnion large 
 arteries and veins may be seen radiating over the surface from the 
 
 ChAm 
 
 Fig. 79. — Diagrammatic section of placenta. Am, amnion; Ch, chorion; 
 m,muscular wall of uterus; «r, ampullarylaj'er ; V, main trunk of chorionic 
 villi ; L, lacuna containing maternal blood ; s, portions of maternal tissue 
 belonging to decidua basalis (?) ; cj, glandular spaces ; v, vessel. (After 
 Leopold.) 
 
 insertion of the cord (Fig. 81, p. 106). The edges of the placenta 
 are continuous with the chorion and decidua vera. 
 
 The external or maternal surface of the placenta, somewhat 
 convex, is slightly rough, compared with the internal surface, and 
 is also soft and friable. It is covered by a very thin greyish-white 
 layer, not more than ^-^ inch in thickness, formed by the decidua 
 basalis. This is pierced by the openings of the arteries and veins 
 passing between the uterus and the placenta. It may be torn off 
 in places, showing the redder chorionic villi through the gaps. It 
 cannot be stripped off, except in small pieces, owing to the firm 
 attachment to it of the chorionic villi beneath. This external 
 surface is divided by numerous sulci into lobes called cotyledons. 
 The layer of decidua basalis dips down into the sulci, where it 
 
The Chorion, Placenta, and Umbilical Cord. 105 
 
 is continuous with the decidual processes, which extend a short 
 distance into the j)lacenta between its lobes. In general to the 
 centre of each cotyledon corresponds a main branch of an umbilical 
 artery, which suddenly dips down at right angles from the foetal 
 surface, in a main chorionic trunk (such as v. Fig. 79, p. 104). It 
 may be inferred that each cotyledon corresponds to the develop- 
 ment of a primary chorionic villus. It is now considered that the 
 framework of the placenta is made up, not by decidual processes. 
 
 \ 
 
 \ ^^^': 
 
 Fig. 80. — Uterine surface of placenta. 
 
 but by the primary main trunks of villi growing from the chorion 
 and attached ultimately by fastening vilH to the decidua basalis. 
 The uterine arteries generally enter at the intersection of sulci, 
 and open at once, or after a very short course, into the placental 
 blood spaces. In their course through the decidua basalis or, 
 for a short distance, in the decidual processes between the 
 cotyledons, they are destitute of muscular walls, and differ but 
 slightly from veins. The openings for veins are situated on the 
 sulci, or on the surface of lobes. There is also generally described 
 a large sinus, the circular or marginal sinus, into which many of 
 
io6 
 
 The Practice of Midwifery. 
 
 the venous apertui-es open, belonging to the decidua vera, and 
 running round the placenta. This, however, is not constant in its 
 presence, nor does it completely surround the placenta. 
 
 A certain number of the ramifying branches of the chorionic 
 villi run pretty direct toward the decidua basalis, to which they 
 are firmly attached. In this way the two surfaces of the placenta 
 are held together. The main bulk of the tissue is made up by the 
 exuberant growth of the lateral branches which spring from these. 
 The terminal twig of the umbilical artery in each villus bends down 
 
 Fig, 
 
 81. — Foetal siu'face of placenta. Amnion stripped from one half and 
 removed. 
 
 in a loop to become the efferent vein. It is said, however, that the 
 efferent vessel of one terminal villus may become the afferent vessel 
 of another. Numerous capillary networks also exist between arteries 
 and veins in the larger trunks, and anastomoses between the arteries. 
 Near the margin of the placenta are found villi in which there is 
 little or no vascular development, but which retain their solid 
 cellular character. 
 
 If a section be made through the uterus with the placenta in situ, 
 there is seen to be a layer of the decidua basalis just beneath the 
 placenta, in which large flattened spaces are developed. This 
 corresponds to the " areolar or ampullary layer " in the decidua 
 vera, and, like it, forms the surface of separation at full term {ar, 
 
The Chorion, Placenta, and Umbilical Cord. 107 
 
 Fig. 79, p. 104). There is no layer of maternal tissue over the 
 basement chorion from which the main trunks of the chorionic villi 
 spring, but at the margin of the placenta a portion of the decidua 
 basalis can be traced running in beneath the chorion and serving 
 both to attach the placenta to the uterine wall and to close in the 
 intervillous spaces at the circumference. 
 
 Here and there, however, small areas of tissue may be seen on the 
 surface of the chorion or surrounding some tufts of villi, which are 
 regarded by some authorities as consisting of maternal tissue 
 belonging to the decidua serotina, but are almost certainly undiffer- 
 entiated portions of trojDhoblast. 
 
 In a microscopic section the villi are seen to be much more 
 numerous than in the early months, but smaller. The vessels 
 occupy a much larger proportion of their space in comparison with 
 cellular tissue. Their epithelial covering consists only of a thin 
 layer of syncytium, and Langhans' layer has disappeared. Much 
 fewer epithelial buds or processes of syncytium than in the earlier 
 months of pregnancy are seen. Canalised fibrin is seen abundantly 
 beneath the epithelium of the chorionic membrane. It is also 
 visible in a thin layer in many villi, immediately beneath the 
 epithelium, and covers the superficial portions of the compact layer 
 of the decidua basalis. Many of the arteries show signs of 
 obliterative endarteritis tending to the closure of their lumen. 
 
 There are generally some infarcts visible on the uterine surface 
 of the placenta. These are due to the obliteration of the correspond- 
 ing arteries of the chorionic villi, accompanied by atrophy and 
 degeneration of the villi and death of the epithelium. This in its 
 turn is followed by the clotting of the blood in the corresponding 
 intervillous spaces and the formation of fibrin. In this manner 
 numerous grey or placental infarcts are formed throughout the 
 substance of the placenta as full term approaches. They form 
 conical or greyish masses, the base of the cone being on the uterine 
 surface and varying in size from some hardly visible to the naked 
 eye to others several centimetres in diameter. 
 
 Some authorities describe, as occurring in the last month of 
 pregnancy, a spontaneous thrombosis in some of the uterine sinuses 
 beneath the placenta, associated with an encroachment on the 
 sinuses by a proliferation of the lining membrane. This has been 
 thought to have to do with the causation of the onset of labour, but 
 is not yet absolutely proved to be a normal occurrence. 
 
 Functions of the Placenta. — As we have seen in considering 
 the structure of the placenta, the foetal blood circulating in the 
 
io8 The Practice of Midwifery. 
 
 capillaries of the chorionic villi is separated from the maternal 
 blood in the intervillous spaces by the connective tissue of the 
 villus, the endothelial wall of the capillary, in the early months by 
 the two layers of epithelium on the surface of the villus, and in the 
 later months by only one layer or, in some instances, where the 
 capillary lies exposed on the surface of the villus, by its endothelial 
 wall alone. 
 
 It is obvious therefore that gaseous interchanges between the 
 blood of the mother and of the foetus and the passage of fluid 
 substances from the one circulation to the other can take place with 
 great facility. 
 
 In the early stages of development before the circulation through 
 the chorion is established the foetus is no doubt nourished by the 
 cells of the trophoblast. It is possible that they have the power of 
 exercising a selective action, and, according to HerfT, they secrete a 
 substance which has the effect of preventing the coagulation of the 
 blood circulating in the intervillous spaces. That the placenta acts 
 very efficiently in j^romoting the nutrition of the foetus is demon- 
 strated by the marked and continuous increase in its size which 
 takes place during the whole period of intra-uterine life. 
 
 (1) Picspiration. — By the interchange of gases between the foeta 
 and maternal blood, the placenta serves as the respiratory organ of 
 the foetus, and the blood which reaches the placenta through the 
 umbilical arteries darkened with carbonic acid returns oxygenated 
 through the umbilical vein, and, as Zweifel has demonstrated, 
 containing oxyhsemoglobin. 
 
 Since the foetus has but little loss of heat to supply, the amount 
 of oxygen required is probably not very great. Nevertheless, 
 experiments on animals have shown that, if the placental circulation 
 be interrupted, respiratory movements are excited, and the foetus 
 shows signs of asphyxia in a few minutes,^ and the same thing 
 occurs if the funis is compressed in delivery. The foetus is, however, 
 capable of being restored after a longer duration of asphyxia than 
 an air-breathing animal would survive. 
 
 (2) Nutrition. — From the time of its formation, the placenta is 
 the sole organ of nutrition for the foetus, and it is probable that 
 the epithelium of the villi has a selective power in absorbing 
 nutriment. That not only substances in solution, but small 
 particles such as microbes, may pass from one circulation to the 
 other, is proved by the fact that zymotic diseases, such as small- 
 pox, chicken-pox, and scarlet fever, are communicated in some 
 
 1 Zweifel, " Die Respiration des Foetus," Arch. f. Gynaii., [X. and XII. 
 
The Chorion, Placenta, and Umbilical Cord. 109 
 
 cases from the mother to the fcetus ; for it has been shown that 
 the contagimn of siich diseases is particulate. 
 
 In tuberculosis of the mother, the disease is very rarely com- 
 municated to the foetus. Kiiss has, however, shown that in 
 animals tubercle bacilli may pass to the foetus from the mother via 
 the placenta ; and in typhoid fever the bacilli have been found in 
 the tissues of the fcetus in quite a large number of cases.^ In most 
 other zymotic diseases, too, such as pneumonia, relapsing fever, 
 anthrax, cholera, septicasmia, the transmission of the disease has 
 been definitely proved. There is always the probability, however, 
 that in such instances the " barrier action " of the placenta, as its 
 property of arresting the passage of certain substances has been 
 termed, may have been in abeyance owing to the fact that the 
 mother was suffering from the disease in question. There appears 
 to be normally no passage of red corpuscles from the maternal 
 to the foetal circulation, or vice versa. Thus the nucleated red 
 corpuscles of the foetus are not found in the maternal blood at all. 
 At the same time it must be remembered that the analyses made 
 by Varaldo^ of the blood of the umbilical vein and arteries, while 
 furnishing further proof of the nutritive functions of the placenta, 
 also show that there are more white corpuscles in the blood of the 
 vein than in that of the arteries.^ 
 
 If these observations are correct, we must conclude that white 
 cells pass from the mother to the foetus, that some of them are 
 retained in the latter, and that they may serve in their passage as 
 carriers of nutrition. The parasites of malaria have not been 
 proved to pass from the maternal to the foetal circulation, although 
 cases have been recorded in which the foetus has been born with 
 a greatly enlarged spleen. 
 
 In experiments on animals it has been found that minute 
 particles of cinnabar passed from the maternal to the foetal 
 circulation.^ The same has been found in the case of Indian ink, 
 but in these cases there may have been rupture of vessels, and 
 more recent observations have given a negative result. 
 
 It is possible, as has been suggested, that albuminous bodies 
 may pass the placenta as soluble peptones, the epithelium of the 
 villi secreting a peptonising ferment. 
 
 Various chemical substances administered to the mother have 
 
 1 Speier, " Zur Casuistik ties Placentaren Ueberganges der Typhusbacillen von der 
 MuUor auf die Frucht," D. I., Bieslau, 1897; H. T. Hicks and Herbert French, 
 I^aiicct, June 3rd, 1905 ; Kiiss, De VR6T6(lit6 Parasitaire de la Tuberculose Humaine, 
 Paris, 1898. 
 
 2 Varaldo, Arch, di Ostet., 1900, Vol. VIL, p. 72.3. 
 8 Ileitz, Centralbl. f. die Med. Wissensch., 1868. 
 
I lO 
 
 The Practice of Midwifery. 
 
 been detected in the foetal circulation, but it is only those which 
 are highly diffusible, such as chloroform, alcohol, and iodide of 
 potassium, which pass with freedom. Thus opium, or its alkaloids, 
 may be administered to the mother in considerable doses without 
 destroying the foetus, although young infants are highly susceptible 
 to their influence. 
 
 (B) Excretion. — It has been shown ^ that the foetus maintains a 
 temperature of its own slightly (about 0*9° F.) above that of the 
 surrounding parts of the mother, and hence tissue changes must 
 take place in it with some activity. The urea and probably other 
 
 Fig. 82.^Early ovum, of about ten weeks, in the Museum of Guy"s Hospital, 
 showing the straight direction of the vessels of the cord. 
 
 waste products are chiefly got rid of through the placenta, although, 
 to some extent, they are discharged with the foetal urine into the 
 liquor amnii in the later months of pregnancy. Thus urea has 
 been detected in the blood of the placenta, in greater proportion 
 than in other parts of the maternal circulation. Hence the 
 placenta, to some extent, discharges the functions of the kidneys 
 during foetal life. According to Claud Bernard, it has also a 
 glycogenic function, and it still further resembles the adult liver 
 in its power of storing up mineral and microbic poisons. These 
 functions are probably performed by the epithelium of the villi. 
 Whether the placenta furnishes an internal secretion to the foetus, 
 
 1 Warster, " Beitrage zur Tocothermometrie," D. J., Zurich, 1870. 
 
The Chorion, Placenta, and Umbilical Cord. 1 1 1 
 
 or, as some authors have contended, to the mother, is a problem 
 which must be left to the future to decide. 
 
 The Umbilical Cord. — The umbihcal cord, or funis, forms 
 the link between the umbilicus of the child and the foetal portion 
 of the placenta. When fully formed it contains the two umbilical 
 arteries and one vein, originally the left vein, and the remnant of 
 the pedicle of the umbilical vesicle. It is covered by a sheath 
 consisting of modified foetal slcin,^ and the main part of its bulk 
 is made up of a special kind of embryonic connective tissue called 
 Wharton's jelly. This is composed of delicate interlacing fibrillffi, 
 which are processes extending from small stellate cells, and have 
 large interspaces filled with gelatinous muco-albuminoid material 
 
 Fig. 83. — Microscopic section of Wharton's jelly showing stellate cells and 
 interlacing fibrillse. 
 
 (Fig. 83). The cells and fibres tend to arrange themselves in a 
 concentric fashion round the three vessels. Similar tissue occurring 
 in morbid growths receives the name of myxoma. 
 
 The surface is covered with several layers of stratified epithelium 
 resembling the skin of the foetus at the fourth month of intra-uterine 
 life, and continuous with the skin of the foetus, about 1 cm. from 
 the surface of the abdomen. The thickness of the cord is generally 
 about that of the little finger, but varies considerably, according 
 to the amount of Wharton's jelly present. The average length of 
 the cord is about 21 to 22 inches, but it may be as long as 70 inches 
 or as short as 3 inches. In cases of malformation of foetus, with 
 extroversion of abdominal viscera, the cord may be absent altogether, 
 the fa^tus being in contact with the placenta. Excess of length is 
 more frequent than defect. When very long it is liable to form 
 
 ' Foulis, T]-ans. Mcd.-Chir. Soc. Edin., 1900, Vol. XIX. 
 
I 12 
 
 The Practice of Midwifery 
 
 loops roiiucl the neck, limbs, or body of the foetus. Knots may 
 also be formed in it when the fcetus, while small, happens to pass 
 through a loop, but these are rare. If a knot becomes drawn tight, 
 the fcetus may perish from the arrest of circulation. 
 
 17p to the third month the intestine extends a little way into the 
 umbilical cord ; at that time it becomes retracted into the abdomen. 
 The arteries are external to the vein which lies between them 
 (Fig. 84). They have no branches, and have the peculiarity that 
 they increase in diameter from the fcetus towards the placenta, 
 so that the current of blood becomes slower in approaching the 
 placenta. The vessels are peculiar in their structure, since they 
 consist almost entirely of muscle tissue. There is a rudimentary 
 internal coat, but practically no tunica adventitia. No elastic 
 tissue is present, and the muscle fibres are arranged mainly 
 
 longitudinally. The trans- 
 verse diameter of the arteries 
 is about 3 to 5 cm., while that 
 of the veins is from 5'5 to 
 7*5 cm. Both the arteries 
 and the veins contain semi- 
 lunar or circular valves, valves 
 of Hoboken, formed by fold- 
 ings of the vessel walls, which 
 are more numerous in the 
 former than in the latter. 
 
 There are no capillaries in 
 the cord after an early stage 
 of pregnancy, except a few 
 which extend a short distance into it from the skin of the foetus. 
 But vasa propria of the cord have been described as existing at a 
 very early stage of pregnancy, derived from the umbilical arteries. 
 There are no lymphatics, but nerves have been described mainly 
 towards the fcetal end of the cord. 
 
 The pedicle of the umbilical vesicle becomes embedded in the funis, 
 which folds over it from each side, at an early stage of develop- 
 ment. In a microscopic section of the funis the allantois is visible 
 only near the fcetal attachment, as a small duct lined with cuboidal 
 or flattened epitheHum. The section of the pedicle of the umbihcal 
 vesicle may be seen at any part, but more often toward the placental 
 attachment, and presents a similar appearance. 
 
 Spiral Ticist of the Cord. — In early pregnancy, when the cord is 
 short, the arteries run parallel, or nearly so (Fig. 82, p. 110), but at 
 the end of pregnancy there is a spiral twist, which, in about nine 
 
 Fig. 8J. — Section of umbilical cord, 
 arteries ; r, vein ; all, remains 
 allantois. 
 
 of 
 
The Chorion, Placenta, and Umbilical Cord. 113 
 
 cases out of ten, is from right to left, over the anterior surface 
 when regarded from the umbilical end. This implies that the 
 fcetus must have made a corresponding number of revolutions 
 upon its axis. The cause of the twist has not been satisfactorily 
 explained. It is most probably due to the fact that the vessels 
 
 W7ft 
 
 cl 
 
 u.u. 
 
 ^ 
 
 -M-IA 
 
 a/nt 
 
 ^iC.C. 
 
 U/lh 
 
 oA 
 
 Fig. 85. — Diagrams illustrating the formation of the umbilical cord.i 
 am. amnion; ep. epiblast : «.r. umbilical vesicle: sf. ventral and abdo- 
 minal stalk; ch. chorion: «?. allantois. The gradual enclosing of the 
 heart rudiment, the shifting of the ventral stalk on to the abdominal 
 aspect of the embryo, the coalescence of the stalk of the umbilical 
 vesicle with the abdominal stalk containing the chorionic vessels, the 
 ultimate position of the remains of the umbilical vesicle on the surface 
 of the placenta under the amnion, and the derivation of the epithelial 
 covering of the cord from the epiblast are all shown. 
 
 grow faster than the cord, with the result that the latter 
 becomes disposed in a spiral fashion. It has been ascribed to the 
 pressure in the umbilical vessels, to the movements of the fa?tus, 
 to the action of its heart, or the pressure in its vessels. If it be 
 
 Modified from Grosser, Anatomic und Entwicklun'^^geschichte der Eiliiiute u. dor 
 Placenta, 1909. 
 
 M. ft 
 
114 The Practice of Midwifery. 
 
 assumed that the left leg is congenitally stronger than the right, 
 corresponding with the right arm, and that it is used more strongly 
 by the foetus in kicking, the usual direction of the rotations, and of 
 the consequent spiral in the cord, will be accounted for. Nodosities 
 are often seen upon the cord, due to torsion anomalies of the vessels, 
 varicose nodes, or heaping up of Wharton's jelly. 
 
Chapter V. 
 DEVELOPMENT OF THE FCETUS. 
 
 No general description of the development of the foetus will here 
 be given, since this subject belongs rather to works on embryology. 
 But since it is often of practical importance to be able to judge of 
 the age of an ovum or foetus expelled prematurely, the following 
 particulars are given as to the characters to be recognised at each 
 month. It is to be remembered, however, that the measurements 
 of weight and length are only to be taken as approximate guides, 
 since great varieties occur according to the rapidity and vigour of 
 development in different cases. In estimating the age of the foetus 
 towards the latter months of pregnancy, the length of the foetus is 
 of greater value than the weight, not being subject to such wide 
 variations. The months of pregnancy are to be understood as 
 meaning calendar months, here and elsewhere in this work, unless 
 it is otherwise stated. 
 
 First Month. — An ovum has been described, at the beginning of 
 the second week, whose diameter was about ^ inch, and one whose 
 age was estimated at about 12 days and whose diameter was about 
 f inch ; the length of the embryo was one line (Fig. 87, p. 117). 
 At the end of the third week the diameter of the ovum is about 
 f inch, the length of the embryo two lines. The amnion is 
 formed, the embryo is nourished by the umbilical vesicle, it is very 
 much bent upon itself so that the head and the tail almost overlap, 
 and the enlargement of its cephalic extremity is marked. About this 
 time the vessels are reaching the chorion by the umbilical pedicle. 
 At the end of the fourth week, the greatest diameter of the ovum is 
 about I inch (2 cm.) its weight about 40 grains (2*59 gm.). The 
 length of the embryo is about ^inch (1 cm.), measured in a straight 
 line from the head to the most prominent part of the caudal curve. 
 The eyes and ears, the visceral arches, and the mesodermic segments 
 are distinguishable. Four bud-like processes mark the commence- 
 ment of the limbs. The umbilical vesicle is manifest, but smaller 
 than the embryo, and the abdominal stalk and vitelline stalk are 
 close to one another. The amnion closely invests the embryo, and 
 is separated by an interval from the chorion. 
 
 Second Month. — At the end of the second month, the ovum is 
 
 8—3 
 
ii6 
 
 The Practice of Midwifery. 
 
 about 2| inches (6*5 cm.) in its greatest diameter, the embryo 1^ inch 
 (3 cm.) long, measured as before in a straight hne, and its weight 
 about 240 grains (15*4 gm.). The umbilical vesicle is very small, 
 and hangs only by a withered thread. The increased proliferation 
 
 Fig. 86. — Early human ovum in situ, showing the. short thick umbilical cord, 
 the umbilical vesicle, the chorion, amnion, decidua reflexa, and decidua 
 vera.i 
 
 of villi at the site of the future placenta is manifest (see Fig. 72, 
 p. 96). The funis is straight, about 10 mm. in length (see Fig. 82, 
 p. 110), the amnion is considerably distended, and reaches the 
 chorion or nearly so. The umbilical ring is closing, but still 
 
 1 Univ. Coll. Hosp. Med. School Mus., No. 4177a. 
 
Development of the Foetus. 1 1 7 
 
 contains a loop of intestine. The limbs project beyond the body, 
 but the legs are still smaller than the arms. Points of ossification 
 have appeared in the lower jaw and clavicle. The mouth and nose 
 are manifest. The nose is broad and flat, and the nostrils look 
 forwards. The Wolffian bodies have become atrophied, and the 
 kidneys have appeared. The head is nearly as large as the body of 
 the embryo. The back is straighter and the curvature less marked. 
 
 i) 
 
 t'->:,,^ 
 
 Fig. 87. — Series of embryos, from His, of the first and second months of 
 pregnancy, measuring respectively 2'1, 4'2, 7-5, 13'7, 15'5, and 23 mm. in 
 length. 
 
 the tubercle of the tail is still present, but the embryo is now 
 definitely human and may be termed the f^tus (Fig. 87). 
 
 Third Month. — At the end of the third month the ovum is about 
 4 inches long (10 cm.), the amnion fills the whole chorionic vesicle, 
 the placenta is formed, and the rest of the chorion has to a 
 considerable extent lost its villosity. The cord has now become 
 long relatively to the fcjetus, and already shows its spiral twist. 
 Its point of insertion is much nearer to the breech than 
 the head. The foetus is about 3^ inches (8 cm.) long from head 
 to feet, and weighs about 3 ounces (84-9 gm.). The head is 
 separated from the body by the neck, and the oral from the 
 
ii8 The Practice of Midwifery. 
 
 nasal cavity by the palate ; the mouth is also closed by lips. 
 The sexual organs have appeared, but penis and clitoris are 
 scarcely distinguishable. The vitelline coil is withdrawn from the 
 umbilical ring into the abdomen. The limbs are developed, 
 including the fingers and toes, and a first appearance of formation 
 of nails can be detected. Points of ossification have appeared in 
 most of the bones. 
 
 Fourth Month. — At the end of the fourth month the foetus is on 
 an average about 5| inches long (13 cm.), and weighs about 7 J 
 ounces (204 gm.). The sex can now be distinctly recognised. The 
 bones of the skull have partly ossified, but still have very wide 
 fontanelles and sutures. The skin is firm and rose-coloured. The 
 head occupies about one-fourth of the whole body length, and 
 short colourless hair is beginning to appear on it. There is a slight 
 commencement of formation of down on the skin. The legs and 
 arms are of the same length, and movements of the limbs have 
 commenced. These may, however, be detected in a freshly-expelled 
 embryo even before the end of the third month. The umbilicus is 
 close above the pubes. 
 
 Fifth ]\[onth. — The foetus is on an average 9 inches long 
 (22"5 cm.), and weighs about 1 pound (450 gm.). The hair 
 upon the head is better developed, and lanugo or down has appeared 
 over the whole body. The skin begins to be covered with the 
 " vernix caseosa," a white greasy substance made up of the 
 secretion of the cutaneous glands mixed with epithelium. The 
 liquor amnii still exceeds the fcetus in bulk. A foetus born at this 
 time may make vigorous movements at birth, and continue them 
 for some hours. 
 
 Sixth Month. — The foetus is about 12 inches long (30 cm.), and 
 weighs from 2 to 2| pounds (900 — 1,100 gm.). The eyebrows and 
 eyelashes are beginning to form. Deposit of fat in the subcu- 
 taneous cellular tissue is beginning, but only in a small degree, so 
 that the skin still has a wrinkled appearance. There is yellowish 
 material in the small intestine, and there may be a commencing 
 appearance of the darker "meconium " in the large intestine. The 
 hair on the head is longer and less like down. 
 
 Seventh Month.- — The average length is 15 inches (37*5 cm.), and 
 weight from 3 to 4 pounds (or about Ih kilo.). The eyelids are 
 now open, and, in a boy, one testicle is generally descending into 
 the scrotum. The nails are thicker, but do not reach the tips of 
 the fingers. The lanugo is beginning to disappear from the face. 
 It is generally considered that the foetus does not become " viable," 
 or capable of surviving, till the end of the twenty-eighth week, or 
 
Development of the Foetus. 119 
 
 the seventh lunar month. Children born earlier perish after a few 
 hours or days. There is a considerable number of recorded cases, 
 however, in which premature children have survived, whose age 
 at birth was reckoned as less than this both from the dates given 
 by the parents and the appearance of the children themselves.^ 
 
 Eighth Month. — The average length is 16| or 17 inches (40 — 
 42 cm,), the weight 4^ or 5 pounds (2 — 2J kilo.). Owing to greater 
 deposit of fat, the wrinkled appearance of the skin has nearly dis- 
 appeared, and it is now flesh-coloured. Lanugo still covers the 
 body, but is beginning to be thrown off. The scrotum contains at 
 least one testicle, usually the left. Children born at this time are 
 much less active and more somnolent than those which have reached 
 full term. The mortality among them is greater, and they readily 
 perish if not well cared for, although they survive as a rule if 
 carefully tended. 
 
 The Foetus at Full Term.— The average length is 21 inches 
 (50 cm.), and weight 7 pounds (3 — 3 J kilo.). The skin is whiter, 
 not so red as in premature children, the finger-nails project 
 beyond the tips of the fingers, the toe-nails reach the ends of 
 the toes. The hair on the head is from 1 to 2 inches long, and 
 generally dark ; the lanugo has been thrown off for the most part, 
 but is still found on the shoulders. Both testicles can be felt in the 
 scrotum, and in the female the labia majora are in contact, and 
 cover in the labia minora. 
 
 The umbilicus is nearer the centre of the body than in earlier 
 months, being only about three-quarters of an inch below the exact 
 centre. The child, unless asphyxiated, cries vigorously with a loud 
 voice immediately after birth, and actively moves its limbs. 
 Within a few hours it passes urine and meconium. The latter 
 consists of intestinal mucus mixed with epithelium, lanugo, and 
 bile, which gives it a dark brownish-green, or nearly black, colour. 
 
 With regard to the weight of the foetus, variations between 6 
 and 8 pounds are very common. Children are sometimes born at 
 full term, and survive, which weigh less than 5 pounds. As a 
 rule, however, a child which weighs under 5 pounds at full term 
 has little chance of living. If premature, its chances are much 
 l^etter. Weights above 10 pounds (4,530 gm.) are uncommon, and 
 those above 12 (5,400 gm.) very rare. There is, however, a con- 
 siderable number of recorded cases of children weighing from 12 
 up to nearly 18 pounds (8,150 gm.). Such children have generally 
 been still-born ; but Sir Richard Croft is said by Dr. Rigby to have 
 
 I Sec a paper by Ahlfeld, Arch. f. Gymik., VIII., s. I'Jt. 
 
I20 The Practice of Midwifery. 
 
 delivered a living child weighing 15 pounds, and Dr. Waller reports 
 a living child delivered by forceps, and weighing 18 pounds 15 ounces 
 (8,570 gm.).^ The length of the foetus varies much less widely 
 than the weight, but may reach as much as 24| inches (60 — 
 61 cm.), the average being 19^ — 23 J inches (48 — 58 cm.). Dead 
 children, owing to the loss of tone in the muscles, usually measure 
 1"5 — 2 cm. longer than living children of the same age. 
 
 The weight of the ftetus is affected by various circumstances. 
 The stature and bulk of the father and mother naturally have an 
 influence. Males are, on the average, heavier than females, the 
 proportion being about 12 to 11. Children generally increase in 
 weight in successive pregnancies if they do not occur too frequently. 
 This may depend, in a measure, upon the effect of repeated par- 
 turition, but probably in greater degree upon the age of the mother, 
 for it has been found that the heaviest children are born between 
 the ages of 25 and 35. Hence, if there is disproportion between 
 the fcetus and the bony pelvis, later labours are often more difficult 
 than the earlier ones. Beyond the age of 35, or after the ninth 
 pregnane}^ the weight of the children tends again to diminish. 
 
 Legitimate children are heavier than illegitimate as a rule, and 
 it has been shown that if the mother is able to rest during the 
 latter weeks of her pregnancy, the child will' be heavier than if 
 she has to work hard up to the date of her confinement. 
 
 Excessive size of the fcetus may be due to post-maturity ; for 
 very large children, with unusually ossified bones, have been born 
 when labour has not occurred for several weeks, or even over a 
 month, beyond the expected date. 
 
 In 14 to 15 per cent, of all children weighing over 8f pounds 
 (4,000 gm.) the pregnancy has lasted more than 300 days. For 
 two or three days after birth, and before the secretion of milk is 
 fully established, the child loses weight. The number of boys born 
 exceeds that of girls in the proportion of about 106 to 100. In 
 elderly primiparse the disproportion is greater. Between the ages 
 of 30 and 40 it is about 125 to 100 ; between the ages of 40 and 50, 
 about 135 to 100.^ 
 
 According to Haase,^ the following rule gives approximately the 
 length of the embryo, measured from vertex to sole of foot, in 
 centimetres at the end of each of the ten lunar months of gestation. 
 For the first five months square the number of the month to which 
 the pregnancy has advanced. For the second five months multiply 
 
 1 Trans. Obst. Soc. London, 1860, Vol. L, p. 309. 
 
 2 Ahlfeld., Arch. f. Gyn., 1871, IJ. 353—372. 
 8 Charit^-Annalen, II. 686. 
 
Development of the Foetus. 
 
 121 
 
 the number of the month by 5. Hence we get the following 
 table : — 
 
 At the end of the first month - 
 second month 
 
 Length of foetus. 
 
 1x1= 1 centimetre. 
 2X2=4 
 
 third month 
 
 -3x3=9 
 
 fourth month 
 
 - 4 X 4 = 16 
 
 fifth month 
 
 - 5 X 5 = 25 
 
 sixth month 
 
 - 6 X 5 = 30 
 
 seventh month 
 
 - 7 X 5 = 35 
 
 eighth month 
 
 - 8 X 5 = 40 
 
 ninth month 
 
 - 9 X 5 = 45 
 
 tenth month 
 
 - 10 X 5 = 50 
 
 Circulation of the Foetus.— The umbilical vein, which brings 
 the aerated blood from the placenta, divides at the transverse 
 fissure of the liver into two branches. The larger of these unites 
 with the portal vein, and supplies the liver ; the lesser, the ductus 
 venosus, passes directly to the inferior vena cava. Thus the greater 
 part of the aerated blood has to pass through the liver before 
 reaching the general circulation, and this proportion becomes 
 greater towards the latter part of pregnancy. The right auricle 
 receives from the inferior vena cava a mixture of venous blood from 
 the lower parts of the body with aerated blood from the placenta, 
 either direct or after passing through the liver. 
 
 In the earlier months of foetal life, the blood current of the 
 inferior vena cava is directed by the Eustachian valve across the 
 right auricle, through the foramen ovale into the left auricle, and 
 thence to the left ventricle. The venous blood returning from the 
 upper part of the body by the superior vena cava, passes in front 
 of the Eustachian valve, through the right auricle into the right 
 ventricle. Thence it is driven into the pulmonary artery, whence 
 only a small proportion passes to the lungs, while the major part 
 passes through the ductus arteriosus into the aorta beyond the 
 point of origin of the left subclavian artery, and so is distributed 
 to the lower part of the body. 
 
 Thus in the earlier part of foetal life, while the Eustachian valve 
 almost entirely prevents a mixing of the currents in the right 
 auricle, the head, neck, upper extremities, and liver are supj)lied 
 with almost pure aerated blood, the lower part of the body only 
 with venous blood which has already passed through the other part 
 of the circulation. Thus is explained the disproportionately rapid 
 
O A 
 
 5lfH\20/ 
 
 \i tj 
 
 Fig. 88. — Diagram of the foetal circulation. 1, the umbilical cord, consisting 
 of the iimbilical vein and two umbilical arteries, proceeding from the 
 placenta (2) ; 3, the umbilical vein dividing into three branches — two 
 (4, 4) to be distributed to the liver, and one (5) the ductus venosus, which 
 enters the inferior vena cava (6) ; 7, the portal vein, returning the blood 
 from the intestines, and uniting with the right hepatic branch ; 8, the 
 right auricle — the course of the blood is denoted by the arrow proceeding 
 from 8 to 9 ; 9, the left auricle ; 10, the left ventricle — the blood 
 following the arrow to the arch of the aorta (11), to be distributed 
 through the branches given off by the arch to the head and upper 
 extremities ; the arrows (12) represent the return of the blood from the 
 head and upper extremities through the jugular and subclavian veins, to 
 the superior vena cava (14), to the right auricle (8), and in the course of 
 the arrow through the right ventricle (15) to the pulmonary artery (16) ; 
 17, the ductus arteriosus, which appears to be a proper continuation of the 
 pulmonary artery — the offsets at each side are the right and left 
 pulmonary arteries cut off ; the ductus arteriosus joins the descending 
 aorta (18, 18), which divides into the common iliacs, and these into the 
 internal iliacs, which become the umbilical arteries (19), and return the 
 blood along the umbilical cord to the placenta, and the external iliacs (20), 
 which are continued into the lower extremities. The arrows at the 
 termination of these vessels mark the return of the venous blood by the 
 veins to the inferior cava. (After Carpenter.) 
 
Development of the Foetus. 123 
 
 development of the head and upper part of the body and of the 
 liver, more especially in the early part of foetal life. 
 
 A change, however, takes place by about the middle of pregnancy. 
 The Eustachian valve becomes smaller, and the valve of the foramen 
 ovale becomes more developed, so that a portion of the aerated 
 blood entering from the inferior vena cava is retained in the right 
 auricle, and reaches the descending aorta by way of the ductus 
 arteriosus. Hence, in the latter half of pregnancy, the lower part 
 of the body is supplied, no longer with venous, but with mixed 
 blood, while the head and upper limbs are still supplied with com- 
 paratively pure aerated blood. This explains the fact that a 
 relatively more rapid growth of the lower part of the body takes 
 place in the latter half of pregnancy than in the former. 
 
 Changes in the Foetal Circulation at Birth. — As soon as the 
 child is born an immediate change takes place in the circulation. 
 As soon as the first respiratory movements take j)lace, and air 
 enters the lungs, the pulmonary arteries immediately dilate, and a 
 greatly increased stream of blood passes through the lungs, and, 
 returning to the left auricle, raises the pressure in it. At the same 
 time the placenta is detached, the circulation through it soon ceases, 
 and, by the cessation of the current from the umbilical vein, the 
 pressure in the right auricle is lowered. The two causes combined 
 render the pressure in the left auricle greater than that in the 
 right, the valve of the foramen ovale is thereby closed, and blood no 
 longer passes between the auricles. Moreover, as soon as the main 
 stream of blood propelled by the right ventricle begins to pass 
 through the lungs, the pressure in the ductus arteriosus is lowered. 
 The ductus is then gradually diminished by the contractility of its 
 own walls, and, at the end of a few days, is practically closed, 
 though not absolutely obliterated for some time longer. The walls 
 come into contact, and the lumen is obliterated finally by hyper- 
 trophy of the internal coat and the formation of new connective 
 tissue without the formation of any thrombus. A small cavity 
 remains at the aortic end of the duct for a considerable time, the 
 pressure in the aorta being now greater than that in the pulmonary 
 artery. 
 
 The edges of the valve of the foramen ovale also generally become 
 adherent and unite after a few days. The opening may remain 
 ununited, however, for some little time without any blood passing 
 through it. A patent condition of the opening after birth is one of 
 the causes of cyanosis in infants. 
 
 The blood pressure in the descending aorta becoming diminished 
 
124 The Practice of Midwifery. 
 
 when it no longer receives blood through the ductus arteriosus, the 
 umbilical arteries also contract to some extent, thrombi are formed 
 in them, and they become obliterated. The umbilical vein is also 
 closed either by simple contraction or by thrombus. 
 
 It is remarkable with how little disturbance the important changes 
 which transform the circulation of the fcetus in utero to that 
 required for its extra-uterine existence are carried out. 
 
 Physiology of the Fcetus. — Our knowledge of foetal physiology 
 is of the scantiest description, but there are certain facts which 
 have been ascertained, and which throw some light upon the many 
 interesting problems involved. A most interesting feature in con- 
 nection with the foetal heart is its power of continuing to beat for 
 long periods of time after the birth of the foetus and independently 
 of the central nervous system. Thus Neugebauer has recorded a case 
 in which the heart continued to beat in the trunk of a mutilated 
 foetus for more than three hours. Another striking feature is the 
 power of the foetal heart to continue to beat without any attempts 
 at respiration being made by the foetus. Ballantyne records a case, 
 for example, where the heart beat for five hours after birth in such 
 conditions. 
 
 The blood of the foetus is relatively rich in red corpuscles and 
 haemoglobin, and also exhibits some degree of leucocytosis. It con- 
 tains a certain number of nucleated red cells, and it is said that the 
 foetal oxyhEEmoglobin is more difficult to reduce than that of the 
 mother.^ 
 
 Beyond the fact that for its respiration the foetus is dependent 
 upon the integrity of the placental circulation, very little is known 
 of the manner in which this function is carried out, and we are 
 entirely ignorant of the way in which the gaseous interchanges take 
 place between'the maternal and foetal blood. 
 
 The fact already mentioned that the living foetus has a slightly 
 higher temperature in utero than its mother, and the further fact 
 that various products of tissue change have been demonstrated in 
 its tissues, seems to prove that a certain degree of metabolism takes 
 place in its body, and Ballantyne has made the interesting sugges- 
 tion that its metabolism may display some similarity to that of a 
 hibernating animal.^ 
 
 Chemical analyses of the tissues of the foetus and its placenta 
 show that the former stores up in its body during intra-uterine life 
 
 1 G-. Zanier, Arch. Ital. de Biol., 1896, XXV., p. .58. 
 
 2 J. W. Ballantyne, Manual of Ante-natal Pathology, 1902, to which the student 
 should refer for further information on foetal physiology. 
 
Development of the Foetus. 125 
 
 a considerable quantity of iron and fat, the latter, according to 
 Thiemich,^ not derived from the fat in the mother's food. The 
 placenta (see p. 108) is undoubtedly the chief source of nutrition to 
 the foetus, and it seems probable that not only has it the power 
 of storing up certain substances, but that it possesses also the 
 property of initiating chemical changes in the substances passing 
 through it, and further exerting a selective action on those it 
 allows to pass to the foetus, the so-called barrier action of the 
 placenta. In the earliest weeks of development the human ovum 
 is nourished by the cells of the trophoblast, and no doubt to a 
 small extent by absorption from the umbilical vesicle ; the latter is, 
 however, an unimportant structure in man, and, as we have seen, 
 the chorionic circulation becomes established at a very early age 
 (see p. 91). That the foetus swallows some of the liquor amnii 
 is certain, and although the amount of nutrition it may derive 
 from this source is very small, yet it may well obtain its supj)ly of 
 water in this manner. 
 
 The function of excretion, like that of nutrition and respiration, 
 is mainly carried out by means of the placenta, but a certain 
 amount of waste material is contained in the meconium and the 
 foetal urine. 
 
 Of the functions of the other organs of the foetus our knowledge 
 is exceedingly fragmentary, but it would seem that the liver has an 
 important function in foetal life, since its relative weight is so much 
 greater than after birth, and it receives the purest blood from the 
 placenta. 
 
 Sugar is found in the foetus in larger quantities than after birth, 
 and the glycogenic function of the liver is doubtless an important 
 one from the time of its development. The sugar is found, how- 
 ever, even earlier than this ; and, at this stage, the glycogenic 
 function appears to be fulfilled by other tissues, especially by the 
 placenta, while glycogen can be found in most young foetal tissues, 
 viz., muscle and heart. 
 
 About the third month the liver cells begin to assume their 
 characteristic features, and bile to be secreted. Bile has already 
 been mentioned as a constituent of the meconium, to which it gives 
 its characteristic green colour. The gall-bladder is also generally 
 filled at the time of birth. 
 
 The brain cells of the foetus are in a rudimentary condition up to 
 birth. There is, however, a discharge of energy from time to time 
 causing the movements of the limbs. Reflex movements are also 
 provoked by stimulus applied to the surface of the body. They are 
 
 1 Zentralbl. f. Physiol., 18i)'J, XII. 
 
126 The Practice of Midwifery. 
 
 easily excited by pressure through the walls of the abdomen and 
 uterus, and may also be called out by uterine contractions, when the 
 foetus is so placed that contraction causes pressure on any special 
 parts. It must, however, be remembered that fcetal movements 
 may be met with independently of the cerebrum and medulla, since 
 they may occur in anencephalic and acephalic foetuses and at times 
 after craniotomy. 
 
Chapter VL 
 THE ANATOMY OF THE FCETAL HEAD. 
 
 The head of the foetus is the part which, in almost all cases, 
 passes with greatest difficulty through the pelvis ; and the behaviour 
 of the head during its passage must of course depend upon the 
 mutual relations between the head and the j)elvic cavity. In order, 
 therefore, to understand the mechanism of labour it is as necessary 
 to study the anatomy of the foetal head as that of the pelvis. 
 
 The head of the fully-developed foetus forms an irregular ovoid, 
 whose compressibility varies greatly according to the diameter in 
 which the compressing force is applied. In reference to midwifery, 
 the head may be regarded as made up of two parts, the incom- 
 pressible base, including the bones of the face, and the compressible 
 vault or calvarium. The bones of the base of the skull and face 
 are early developed, so that by the time of birth they are practically 
 unyielding in their texture, and for the most part immovably united 
 to each other. In consequence of this the various imj)ortant ganglia 
 and organs of special sensation at the base of the brain are protected 
 from injury, as the head is compressed during labour. The bones 
 which make up the calvarium, on the contrary, instead of being 
 ossified together as in later life, are connected only by membrane, 
 while the bones themselves, in the great majority of cases, are soft 
 and semi-cartilaginous, esj)ecially towards the edges. The individual 
 bones are thus movable, and may be made to overlap each other to 
 a considerable extent. The shape of the head can be altered by 
 moulding, according to the exigencies of the case, not only by this 
 relative movement and overlai^ping of the bones, but still more by 
 actual bending of the bones themselves, more especially of the 
 parietal bones, which are the softest. The effect of the pressure on 
 the head during labour is to diminish the capacity of the whole 
 cranium. This is proved by the rapid increase of the average 
 diameters of the foetal head which takes place during the first two 
 or three days after birth, at a time when the weight of the whole 
 child is actually diminishing. It is brought about mainly by 
 cerebro-spinal fluid being squeezed out of the head into the spinal 
 canal, but, to some extent also, by the blood being similarly 
 squeezed out into the veins of other parts. The brain substance 
 
128 
 
 The Practice of Midwifery. 
 
 of the hemispheres, bemg but Httle developed at the tmie of birth, 
 is able to undergo considerable compression and moulding without 
 permanent injury. As the head becomes compressed, the parietal 
 bones invariably overlap, or tend to overlap, both the frontal and 
 occipital bones. It will be seen hereafter that a knowledge of this 
 fact is of very practical importance in facilitating the diagnosis of 
 the position of the head in vertex presentations. The parietal bone 
 which is anterior in the pelvis generally overlaps the posterior in 
 vertex presentations, because it receives less support from the 
 soft parts. 
 
 The face, as compared with that of the adult, is very small in 
 proportion to the cranium. The lower jaw especially is widely 
 
 different from the adult maxilla, 
 the ramus being short and 
 oblique, so that the toothless 
 maxillfie come into close contact, 
 and both chin and angle of jaw 
 are approximated to the fore- 
 head. Thus the distance from 
 the tip of the chin to the root 
 of the nose measures only from 
 1^ to 1^ inches. 
 
 The Sutures and Fon- 
 tanelles. — The vault of the 
 sliull is made up mainly of four 
 bones, the occipital, the two 
 parietal, and the frontal, which 
 at the time of birth is divided in the median line into two parts. 
 The squamous portions of the temporal bones form such a 
 small proportion of the vault that they scarcely come into con- 
 sideration. The membranous septa between the bones are called 
 sutures, the points at which two or more sutures meet are called 
 fontanelles. Looldng at the head from above (Fig. 90, p. 129), the 
 four sutures which are of chief importance are seen. These are : — 
 1st, the sagittal, which separates the two parietal bones, and divides 
 the vertex longitudinally. It derives its name sagitta, an arrow, 
 from its appearance when the fcetal head is seen from above 
 (Fig. 90). The anterior fontanelle, more pointed in fronc than 
 behind, is regarded as resembhng the head of the arrow, the suture 
 the shaft. 2nd. The frontal suture is a continuation of the 
 sagittal suture forwards, and separates the two halves of the frontal 
 bone. 3rd. The coronal suture separates the frontal from the 
 
 Fig. 89.— Foetal skull, o— /, occipito- 
 frontal diameter ; o — m, occipito- 
 mental ; m — .r, maximum vertico- 
 mental diameter ; s — h, suboccipito- 
 bregmatic ; s — y,suboccipito-frontal. 
 
The Anatomy of the Foetal Head. 129 
 
 parietal bones : it extends transversely and almost vertically across 
 the head, meeting at its extremities the temporal sutures at about 
 the summit of the squamous portions of the temporal bones. 
 It receives its name as marking about the position at which 
 the anterior part of the triumphal crown of the ancients rested. 
 4th. The lamhcloidal suture separates the angular projection of the 
 occipital bone from the posterior borders of the two parietal bones, 
 and receives its name from the resemblance of its shape to that of 
 the Greek letter A. It extends at each side to the posterior angle 
 of the temporal bone. The temporal sutures, separating the inferior 
 concave borders of the parietal bones from the squamous portions 
 of the temporal bones, have no practical obstetric importance. 
 
 Fig. 90. — Foetal head seen from 
 above, showing anterior and 
 posterior fontanelles. 
 
 Fig. 91. — Foetal skull. Posterior 
 view, showing posterior fonta- 
 nelle, sagittal and lambdoidal 
 sutures. 
 
 There are two fontanelles of importance, the anterior and posterior. 
 The anterior, or greater fontanelle, called also the bregma {^piyixa, 
 the top of the head), is formed by the junction of the sagittal, 
 frontal, and coronal sutures. It forms a wide rhomboidal mem- 
 branous space, large enough for the tip of the finger to be laid in it ; 
 its anterior angle running between the divisions of the frontal 
 bone, extends much further than the others (Fig. 90). 
 
 The posterior fontanelle (Fig. 91) is formed by the junction of the 
 sagittal and lambdoidal sutures. It does not form an open mem- 
 branous space like the anterior, unless there is defective ossification, 
 but it is recognised simply as the point of junction of three con- 
 verging sutures, the sagittal and the two branches of the lambdoidal. 
 If in any case it should approximate in size to the anterior, it is 
 easily distinguished from it, if it be remembered that the anterior 
 
 M. 9 
 
130 The Practice of Midwifery. 
 
 fontanelle is formed by the junction oifour sutures at right angles, 
 the posterior by the junction of three sutures, inclined at an angle 
 of about 120° to each other. Occasionally, a false fontanelle 
 is formed by a spot of defective ossification along the course of one 
 of the sutures, generally the sagittal. It is distinguished by the 
 fact that only two lines of suture can be traced from it. Some- 
 times mention is made of temporal fontanelles, at the anterior and 
 posterior extremities of the concave inferior border of each parietal 
 l)one (Fig. 89, p. 128). Of these, the anterior is never of any con- 
 sequence, being covered by the temporal muscle. The posterior 
 temporal might possibly be mistaken for the posterior fontanelle if 
 the head were greatly flexed, and at the same time flexed also 
 laterally, so as to bring its side within reach. It would, however, 
 be readily distinguished by its being easy to feel the ear in its 
 immediate proximity. 
 
 Besides the change of shape of the head which is allowed by the 
 bending and overlapping of the several bones forming the vault of 
 the skull, a further moulding is permitted by the fact that the 
 triangular portion of the occipital bone, W'hich is a component of 
 the vault, is united to the basilar portion, not rigidly, but by a 
 fibro -cartilaginous band. In this way a kind of hinge-joint is 
 formed, allowing the posterior portions of the bone to perform 
 movements of flexion and extension.^ 
 
 The fcetal head often becomes unsymmetrical in consequence of 
 the moulding which it undergoes during labour. A slight degree 
 of deviation from symmetry may, however, be observed in a foetal 
 head which has been removed from the uterus either by Caesarean 
 section, or after the mother's death, and has never undergone the 
 process of labour. This has been ascribed to a natural asymmetry, 
 which arises during development, and is of such a nature that 
 there is a slight tendency to a spiral arrangement throughout the 
 whole spinal column, involving both the head and the pelvis. So 
 far as regards the head, it is generally of such a kind that the 
 right side appears to be slightly displaced downwards and forwards, 
 the left side upwards and backwards, in reference to the vertical 
 axis of the foetus.^ 
 
 Diameters of the Foetal Skull. — In order to judge of the 
 changes of shape of the head, and its relations, both before and 
 after moulding, to the dimensions of the pelvis, it is desirable to 
 
 1 Budin. De la Tete du Foetus au Point de Vue de I'Obstetrique, Paris, 187(5, p. 76. 
 
 2 Stadtfeldt, "On the Physiological Asymmetry of the Head of the Foetus," 
 Obstet. Journ. VII., p, 92. 
 
The Anatomy of the Foetal Head. 131 
 
 have numerical measures of some of the more important diameters 
 of the skull. These have been given very variously, and with a 
 want of exactitude, by different authors. Thus the fronto-occipital 
 diameter is by some made to terminate at the posterior fontanelle, 
 by others at the occipital protuberance. The occipito-mental 
 diameter is, by different authors, regarded as starting from either 
 the one or the other of these points, and is generally spoken of as 
 the largest diameter of the skull. Except in a few exceptional 
 cases, it is nothing of the kind according to either definition. The 
 maximum diameter, in the great majority of cases, runs from the 
 chin to a point on the sagittal suture, somewhat variable in position 
 according to the moulding, but nearer to the posterior than to the 
 anterior fontanelle. It is usually, therefore, a superoccipito-mental 
 diameter. Exceptionally, however (in some cases of face and brow 
 presentation), the maximum diameter terminates at a point between 
 the posterior fontanelle and the occipital protuberance, and is, 
 therefore, a suboccipito-mental diameter. It appears better, there- 
 fore, with Budin,^ to describe a maximum vertico-mental diameter, 
 as distinct from the occipito-mental. Again, the cervico-bregmatic 
 and suboccipito-bregmatic diameters are, by different authors, made 
 to terminate at the centre of the anterior fontanelle, its anterior 
 margin, or a point on the sagittal suture. For these diameters to 
 be of any use in giving information as to the moulding of the head, 
 it is absolutely necessary that they should be measured from points, 
 such as the centres of the fontanelles, which can be accurately 
 determined throughout all stages and varieties of moulding. The 
 important diameters, then, are the following (see Fig. 89, p. 128) : — 
 1st, the maximum vertico-mental (Max.) ; 2nd, the occipito-mental 
 (O.M.), measured from the posterior fontanelle to the chin ; 3rd, 
 the occipito-frontal (O.F.), measured from the posterior fontanelle 
 to the glabella, or root of the nose^ ; 4th, the cervico-bregmatic (C.B.), 
 measured from the centre of the foramen magnum to the centre of 
 the anterior fontanelle, or point of intersection of the coronal with 
 the line of the sagittal and frontal sutures ; 5th, the suboccipito- 
 bregmatic (S-0. B.), measured from the junction of the occipital 
 bone with the back of the neck to the centre of the anterior 
 fontanelle ; 6th, the suboccipito-frontal (S-0. F.), measured from 
 the same point to the prominence of the forehead. All these are 
 measured in the vertical antero-posterior plane. The following are 
 transverse diameters : — 7th, the bi-parietal (Bi-P.), or maximum 
 
 1 Of). f;it., p. 17. 
 
 2 This measurement is moie commonly taken to the occipital protuberance, but in 
 the unmoulded head, its magnitude is about the same in either case. The position of 
 the occipital protuberance cannot be precisely determined in the living infant. 
 
 9—2 
 
132 The Practice of Midwifery. 
 
 transverse, between the two parietal protuberances ; 8th, the bi- 
 temporal (Bi-T.) is measured between the points widest apart on 
 the coronal suture ; 9th, the bi-zygomatic (Bi-Z.), or minimum 
 transverse diameter of the base of the skull, is measured between 
 the two points widest apart on the zygomata ; 10th, the bi-mastoid 
 (Bi-M.), the outside diameter between the mastoid processes at their 
 widest part.-^ Of these diameters the cervico-bregmatic corresponds 
 approximately with the vertical diameter of the skull. The occipito- 
 frontal does not perfectly correspond with an antero-posterior or 
 longitudinal diameter, which should be rather measured from the 
 occipital protuberance than from the posterior fontanelle. In the 
 unmoulded head the two are almost precisely equal, but in the 
 ordinary moulding of vertex presentations the occipito-frontal 
 becomes the larger. Owing to the flexed position of the head, 
 neither the one nor the other is normally ever coincident with the 
 plane of the pelvic brim. 
 
 The following are average measurements for these diameters in 
 the unmoulded head, those in the second column being given to the 
 nearest quarter of an inch, as as to be more easily committed to 
 memory : — 
 
 1. Maximum vertico-mental diameter (Max.) 
 
 2. Occipito-mental (O.M.) . 
 
 3. Occipito-frontal (O.F.) . 
 
 4. Cervico-bregmatic (C.B.) 
 
 5. Suboccipito-bregmatic (S-0. B.) 
 
 6. Suboccipito-frontal (S-0. F.) . 
 
 7. Bi-parietal (Bi-P.) . 
 
 8. Bi-temporal (Bi-T.) 
 
 9. Bi-zygomatic (Bi-Z.) 
 10. Bi-mastoid (Bi-M.) 
 
 The plane of the head corresponding to the suboccipito-bregmatic 
 diameter has a circumference on an average of 12i inches, or 32 cm., 
 that corresponding to the occipito-frontal diameter of 13f inches, 
 or 34cm., and the circumference corresponding to the occipito-mental 
 measures about 14 or 14^- inches, or 35 to 36 cm. 
 
 After even easy labours, with normal vertex presentation, the 
 diameters of the head will, when the child is born, be somewhat 
 different in relative magnitude from those given above, in conse- 
 quence of the pressure which the head has sustained. The most 
 
 1 A fronto-mental diameter is sometimes mentioned, and estimated at about 
 3 25 inches, but this is useless, since there is no definite point from which to measure 
 its upper extremity. 
 
 ins. 
 
 cm. 
 
 (Max.) 5 
 
 or 5 = 12-5 
 
 . 4-85 
 
 „ 4| = 12 
 
 . 4-6 
 
 „ 41 = 11-25 
 
 . 3-8 
 
 „ 3| = 9-5 
 
 . 3-8 
 
 „ 3f = 9-5 
 
 . 4-1 
 
 „ 4 =10 
 
 . 3-7 
 
 „ 3| = 9-5 
 
 . 3-4 
 
 „ 31 = 8-25 
 
 . 3-1 
 
 „ 3 = 7-5 
 
 . 3-0 
 
 „ 3 = 7-5 
 
The Anatomy of the Foetal Head. 133 
 
 marked changes are increase of the maximum vertico-mental 
 diameter, and diminution of almost all the rest, even of the occipito- 
 mental, but especially of the suboccipito-bregmatic and bi-parietal. 
 The nature of the moulding will be explained in the chapter on the 
 mechanism of labour. 
 
 The compressibility of the trunk of the foetus is so marked that 
 the diameters are of little importance. The longest transverse 
 diameter of the shoulders measures about 4-| inches, or 12 cm., and 
 can be reduced by pressure by nearly f inch, or 2 cm., and that of 
 the pelvis, the bis-iliac, about 3J inches, or 8 cm. 
 
 Influence of Sex and Race on the Dimensions of the Foetal 
 Head. — The brain of men being, on the average, somewhat more 
 bulky than that of women, there is a corresponding difference in the 
 
 Fig. 92. — Skull of a European foetus. 
 
 Fig. 93.— Skull of a Negro foetus. 
 
 size of the head of male and female children at birth. The average 
 difference in circumference has been found to be about half an inch, 
 or about one twenty-fifth part of the whole. The bones of the male 
 skull are also generally more firmly ossified at the time of birth. 
 Hence arises greater protraction of labour in the case of males, more 
 frequent necessity for artificial aid, and greater mortality both to 
 mothers and children. Thus, out of more than 47,000 deliveries 
 in the Guy's Hospital Lying-in Charity, the number of children 
 stillborn was, including all presentations, among males 42*8 per 
 1,000, among females 35"6 per 1,000 ; while, in vertex presentations 
 at full term, the numbers were, among males 26'9 per 1,000, 
 among females 21*5 per 1,000 stillborn. A greater number 
 of male children than females also die shortly after birth. The 
 size of the child's head, like its total bulk, increases with the age 
 and repeated pregnancies of the mother, in the mode which has 
 been already mentioned (see p. 120). 
 
134 "The Practice of Midwifery, 
 
 The influence of race is a still more important one than that of 
 sex. The increase of size in the brain which goes with civilisation 
 and intellectual development involves greater pain, difficulty, and 
 risk in parturition, for it requires a corresponding increase of size 
 in the skull, and although ;the pelvis undergoes some corresponding 
 enlargement, yet this does not fully keep up with that of the head. 
 In savage races not only is the head smaller on the whole, but there 
 is relatively less development of the anterior cerebral lobes, and the 
 forehead is, therefore, flatter. The suboccipito-frontal diameter 
 (3, 4, Figs. 92, 93), therefore, and also a diameter passing through 
 the prominence of the forehead parallel to the suboccipito-breg- 
 matic, are much smaller. Labour is, therefore, facilitated in 
 corresponding degree, since this latter diameter, in the living child, 
 has to be taken in conjunction with a portion of the back of the 
 neck, when the head is entering the pelvis well flexed, and thus 
 becomes the largest of all the diameters of the foetus which is ever 
 coincident with the greatest diameters of the pelvic brim or outlet. 
 In explaining the facility of parturition in savage women, it is 
 necessary also to take into account the greater sensibility to 
 pain induced by the mode of life of the civilised and highly 
 cultivated woman, although the difference in the size of the 
 foetal head appears to be the most important element. Even in 
 the same race, the size of the head is greater in the educated 
 classes than in the uneducated, the greater also among inhabit- 
 ants of towns than in agricultural districts. Comparing civilised 
 races with each other, difficult labours are perceptibly more 
 numerous in a race like the Teutonic, in which the type of head 
 is short and round, or brachycephalic, than in one like the Celtic, 
 Scandinavian, or Norman, in which it is more frequently long or 
 dolichocephalic. Some savage races, like the Caribs, and the 
 Macrocephali, a Scythian race mentioned by Hippocrates, have 
 been accustomed to flatten the foreheads of the children by pres- 
 sure in early infancy, and it has been supposed that a hereditary 
 tendency to such a form of head has eventually been acquired in 
 such cases. This, however, would be opposed to the modern 
 doctrine that acquired characters are not inherited. 
 
 Articulation of the Foetal Head. — The articulation of the 
 head with the spinal column, allowing movements of flexion and 
 extension, is situated nearer to the occiput than to the forehead, in 
 the proportion of about one to two. The head, balanced upon its con- 
 dyles, may hence be regarded as a lever, the anterior arm of which 
 
The Anatomy of the Foetal Head. 135 
 
 is longer than the posterior. The importance of this circumstance, 
 in securing flexion of the head, will be seen hereafter (Fig. 153, 
 p. 245). The extensive movements of the head which are possible 
 in the fcetus are due to the extreme flexibility of the cervical portion 
 of the vertebral column. Movements of rotation take place between 
 the atlas and axis, and the head can generally be rotated upon the 
 body through as much as a quarter of a circle without injury to the 
 spinal cord. 
 
Chapter VIL 
 
 THE ATTITUDE, PRESENTATION, LIE, AND 
 POSITION OF THE FCETUS IN UTERO, 
 
 By the attitude of the foetus is meant the relation which the 
 different j)arts of its body have to each other. By the presentation 
 is meant the part of its body which occupies the lower segment 
 of the uterus, lying over the internal os uteri. This must 
 be distinguished from the presenting part, or that part of the 
 foetus which is felt by the finger when passed through the 
 
 Fig. 94. — Attitude of the mature foetus in utero. 
 
 cervical canal. The word lie is used to denote the relation of the 
 long axis of the foetus to the axis of the uterus. Thus the lie 
 may be longitudinal, oblique, or transverse. By the position 
 is meant the relation which some part of the foetus {e.g., the back) 
 has to the front, back, and sides of the uterine walls. Thus the 
 back may be inclined backward or forward, to the right or to 
 the left. Hence for each presentation or lie of the foetus there 
 are varying positions, and it is usual to divide these into four, 
 
Attitude of the Foetus in Utero. 
 
 137 
 
 with reference to two axes or straight lines intersecting the longi- 
 tudinal axis of the uterus at right angles to that axis and to each 
 other, and thus dividing the uterus, or the pelvic brim, into four 
 compartments. The corresponding positions are called the first, 
 second, third, and fourth, and will be described hereafter in 
 reference to each presentation. 
 
 Attitude. — The usual attitude of the foetus is as follows 
 (Fig. 95): — The back is arched, so as to form a convexity backward. 
 
 Fig. 95. — Normal attitude of the fcetus in utero. (Bumm, Grundriss der 
 Geburtshilfe.) 
 
 The head is bent upon the sternum, and is usually inclined 
 to one or other shoulder. The forearms are crossed, or close 
 to each other in front of the chest. The thighs and legs are 
 flexed, so that the knees are near the elbows and the heels near 
 the breech or buttocks, the dorsum of the foot being drawn up 
 toward the leg, and the sole turned somewhat inward. The legs 
 are generally crossed. The umbilical cord generally lies in the 
 space between the arms and legs (Fig. 94). This attitude exists more 
 or less from the early part of pregnancy, but varies somewhat with 
 the amount of liquor amnii. Thus when the liquor amnii is relatively 
 in greater quantity the limbs have greater freedom of movement, 
 
iss 
 
 The Practice of Midwifery. 
 
 and are not so close to the body (Fig. 96). The attitude is due 
 to the tonic action of the flexor muscles, which, as being the 
 stronger, predominate over the extensors. Any persistent deviation 
 from the normal attitude occurs as a rule only in dead children. 
 A tendency toward a similar position of the limbs is seen in the 
 infant even after birth. At the very earliest stage of pregnancy 
 the embryo hangs by the umbilical cord, not touching the walls of 
 
 Fig. 96. — Attitude of foetus wt utero with abundant liquor amnii. (Bumm, 
 modified from Chievitz., A Research on the Topographical 
 Anatomy of the Full Term foetus in sitw, 1899.) 
 
 the ovum, with its back downward, and its cephalic extremity 
 somewhat lower than the other. 
 
 Presentation and Lie. — With regard to its presentation or lie 
 the fcetus in the great majority of cases lies with its head down- 
 ward and with its long axis coincident with that of the uterus, that 
 being the position in which its shape is most conveniently adapted 
 to the shape of the uterine cavity, which is most spacious at the 
 fundus (see Fig. 97, p. 140). At the end of pregnancy the propor- 
 
Presentation of the Foetus in Utero. 139 
 
 tion of cephalic presentations is as much as 96 per cent. In the 
 Guy's Hospital Lying-in-Charity, out of 23,800 children, it was 
 96*9 per cent. It was for a long time believed that up to about the 
 seventh month of pregnancy the fcetus lay with its head uppermost, 
 and that then by an active movement of its own, which was called 
 the culbute, it suddenly reversed its position. It is now established 
 that the head is generally lower than the breech, even from the 
 commencement of pregnancy. In the earlier months frequent 
 changes of jDOsition take place through the foetal movements, and 
 even up to the later months the proportion of head presentations 
 is not so great as at full term. Thus Veit at the seventh month 
 of pregnancy found 56*6 per cent, vertex, 38"4 per cent, breech, and 
 4'8 per cent, transverse presentations. 
 
 According to Churchill, at the seventh month the proportion of 
 head presentations is among living children only 83 per cent., and 
 among dead children only 53 per cent. Dubois gives 88 per cent, 
 as the proportion of head presentations for living children, and 
 only 45 per cent, for dead children, born during the seventh month. 
 
 With the advance of pregnancy the frequency of head presenta- 
 tions markedly increases. Thus Simpson found at the eighth month 
 68 per cent., at the ninth month 76 per cent., and at full term 96 
 per cent, cephalic presentations. 
 
 Collins, in about 16,000 deliveries, found the proportion of head 
 presentations among living children 98'3 per cent., among children 
 born in a putrid state, upwards of 500 in number, only 80 per cent. 
 These figures show also that the proportion of head presentations 
 is much less among dead children than among living at the same 
 period of pregnancy. 
 
 Changes from other presentations into head presentations are 
 more frequent than the converse, and a transverse or oblique is 
 more frequently changed than a breech presentation. Although 
 changes from the head into a breech or transverse presentation are 
 relatively more rare, yet they do not infrequently occur. According 
 to Schroeder, the former occur in 8*3 per cent, of all cases, and a 
 fcetus has been observed to change its position from head to breech 
 and vice versa as many as six times within a few days. The chief 
 causes of such changes are strong movements of the foetus occurring 
 in conjunction with a changed posture of the mother. Valenta, 
 from repeated observations made on nearly 1,000 pregnant women, 
 found that changes of presentation occurred in 42*4 per cent, in the 
 later months of pregnancy.^ Fasbender^ in 418 cases examined 
 
 1 Monatsschrift f. Geburt, 1866. 
 
 2 Beitrage z. Geburtsh. u. Gyn., 1870, Bd. 1, Heft 1, 540. 
 
140 
 
 The Practice of Midwifery. 
 
 during the last two to three months of pregnancy observed changes 
 of position in 88, or 21 per cent., and changes of presentation 
 in 75, or 18 per cent. The presentation becomes progres- 
 sively more stable as the end of pregnancy approaches, more 
 especially in primiparae, in whom the head rests lower in the pelvis, 
 while the firmer abdominal walls prevent much swaying over of the 
 fundus uteri as the position of the body is changed. Schroeder, 
 from observation on 214 primiparae (including four cases of 
 contracted pelvis) during the last three weeks of pregnancy, found 
 
 that changes of presentation took place 
 in 36*4 per cent. The instability of the 
 presentation is much greater when any 
 deformity of the mother exists, especially 
 when there is a contracted pelvis, which 
 keeps the fcetal head entirely above the 
 brim. 
 
 Causation of Head Presentation. — 
 There are three chief causes to which 
 the preponderating frequency of head 
 IDresentation is to be attributed : 1st, the 
 efi'ect of gravity ; 2nd, the adaptation of 
 the shape of the foetus to that of the 
 uterine cavity; and 3rd, the effect of 
 foetal movements excited by pressure 
 when the two shapes do not correspond. 
 Some controversy has taken place as to 
 which of these is the true cause, but the 
 more correct view is to regard them all 
 as having an influence. As the foetus is 
 immersed in fluid not much lighter than 
 itself, the effect of gravity will depend, 
 not upon the position of its centre of gravity when in air, but upon 
 the relative specific gravity of its different parts. Matthews Duncan 
 has shown that the specific gravity of the foetal head is greater than 
 that of the decapitated trunk, and that, when the foetus is immersed 
 in saline fluid of about the same specific gravity as itself, it lies in an 
 oblique position, its head lower than the breech, and the right side 
 lowest owing to the weight of the liver. If allowed to sink, the right 
 shoulder generally touches the bottom first. Within the uterus the 
 foetus is not suspended by the umbilical cord, except at the very 
 earliest stage of pregnancy, but rests on the inclined plane formed 
 by the uterine wall. When the woman is standing upright it rests 
 on the anterior uterine wall, inclined to the horizon at an angle of 
 
 Fig. 97.— Outline of the 
 uterus at full term. 
 
Presentation of the Foetus in Utero. 141 
 
 about 35°, the normal pelvic inclination being somewhat diminished 
 during pregnancy in order to preserve the balance of the body. In 
 these circumstances the usual position of the foetus is almost exactly 
 that which it assumes when immersed in saline fluid. Again, when 
 the woman is lying flat on her back, the fcetus rests on the posterior 
 uterine wall, inclined at an angle of about 55° to the horizon. In 
 this position also gravity favours head presentation, but tends to 
 rotate the back of the foetus towards the mother's back. In the 
 reclining position, when the shoulders are raised, the axis of the 
 uterus is nearly vertical, and the higher specific gravity of the head 
 
 Fig. 98.— Ovoid form of foetus at 
 full term. 
 
 Fig. 99. — Adaptation of foetus 
 to uterus. 
 
 tends still further to keep it over the os. When, however, the 
 woman lies on her side, the fundus uteri drops over by its own 
 weight, and then gravity tends to displace the head from the os. 
 The gravitation theory accounts for head presentations being less 
 usual with dead children, for Matthews Duncan found that where the 
 child had died in utero before labour, the specific gravity of the head 
 was less than in the case of a living child, and the foetus often floated 
 with the head highest in a saline fluid of its own specific gravity. 
 These experiments of Matthews Duncan, however, are taken 
 exception to by Schatz ^ and Whitridge Williams, who have shown 
 that when the fluid in which the foetus is suspended has a specific 
 
 1 Schatz, Arch. f. Gynak., 1904, Heft 3, LXXI., s. 541. 
 
142 
 
 The Practice of Midwifery. 
 
 gravity nearly approximating to that oi: the liquor amnii, or from 
 1,010 to 1,020, the breech tends to sink rather than the head. Seitz,^ 
 too, has found that the specific gravities of the head and of the 
 decapitated trunk are the same, and that the former is not higher 
 than the latter, as Matthews Duncan supposed. 
 
 In cases of hydrocephalus breech presentations occur in 29 per cent, 
 of the cases, or about nine times as frequently as they do with 
 healthy children. This is explained in a measure by the fact that 
 the specific gravity of the hydrocephalic head is probably less than 
 that of the healthy head notwithstanding the increase of its total 
 
 Fig. 100. — Adaptation of hydro- 
 cephalic foetus. 
 
 Fig. 101. — Diagram of maladaptation 
 of foetus and uterus in breech 
 presentation. 
 
 weight. In this case, however, the question of adaptation of shape 
 comes also into play : the enlarged head does not so readily fit into 
 the lower segment of the uterus ; and when the enlargement is very 
 great, the shape of the foetus may be best adapted to that of the 
 uterus when the head is uppermost (see Fig. 100). Another reason 
 for thinking that the effect of gravity is not sufficient by itself to 
 account for all the circumstances is found in the fact that the head 
 presents more frequently than other parts, even when women are 
 constantly lying in bed, and as frequently on the side as on the 
 back. 
 
 A much more important factor in all probability is the adaptation 
 of the shape of the foetus to that of the uterus. In the later 
 
 1 Seitz, von Winckel's Handbuch der Geburtshlilfe, 1904, Vol. 1., p. 1012, Part II. 
 
Presentation of the Foetus in Utero. 
 
 143 
 
 months of pregnancy the shape of the uterine cavity is definitely 
 pyriform, with the hroad end uppermost (see Fig. 97, p. 140), 
 and this is especially the case when its walls become rigid under 
 the influence of the occasional muscular contractions which 
 are constantly taking place throughout pregnancy. The shape of 
 the foetus in its usual attitude is also pyriform, and corresponds to 
 
 ..«*.*>: -^>' 
 
 Fig. 
 
 102. — -Foetus in utero at the fifth month presenting by the breech. 
 (Modified from specimen, Mus., Univ. Coll. Hosp. Med. School.) 
 
 that of the uterus when the head is downwards. When the long 
 axis of the child is transverse or oblique, the pressure of the con- 
 tracting uterine wall tends to press the projecting poles towards the 
 central axis of the uterus, and so convert the presentation into a head 
 or breech. At the same time the pressure thus exerted upon the 
 fcetus is likely to excite reflex movements, which assist in changing 
 the position. In breech presentations (Fig. 101, p. 142), the foetus 
 is not BO well adapted to the uterine cavity as in cephalic, the lower 
 
144 The Practice of Midwifery. 
 
 segment of the body of the uterus being unduly distended. It is 
 not Hkely that the uterine contractions would by themselves change 
 such a presentation, but the foetus is not so stably held in position 
 by the uterine walls as when the head is downwards, and it is probable 
 that the increased pressure on the legs may excite more lively 
 movements than usual, and increase the chances of a change of 
 presentation. Such movements of the lower limbs, too, are likely to 
 produce a greater effect, since they will act against the bones of the 
 pelvis and not against the soft tissues of the fundus uteri. All 
 changes occur more easily when the liquor amnii is relatively 
 abundant, and after the rupture of the membranes it is rare for a 
 change of presentation to occur. That such a thing is a possibility, 
 however, is shown by the occurrence of the so-called spontaneous 
 version in some cases of shoulder presentation. 
 
 When the child is dead the effect of reflex movements is lost, and 
 the long axis of the child has no longer the same tonicity. These 
 influences must be added to that of the changed specific gravity of 
 the head in accounting for the frequency of abnormal presenta- 
 tions with dead children. In the earlier months of pregnancy the 
 uterine cavity is more spherical, and the relative abundance of 
 liquor amnii allows the foetus to lie in it in almost any position (see 
 Fig. 102). An abnormal presentation is also more easily produced, 
 by the gush of liquor amnii on rupture of the membranes, 
 
Chapter VIII. 
 
 CHANGES IN THE MATERNAL ORGANISM CONSE- 
 QUENT UPON PREGNANCY. 
 
 Changes in the Uterus. — From the commencement of preg- 
 nancy an increased nutritive energy is imparted to the sexual 
 apparatus, including the breasts, and to surrounding parts, but 
 more especially, and in enormous degree, to the body of the uterus, 
 which serves as a receptacle for the ovum. The nulliparous 
 uterus weighs about an ounce (30 gms.), that of the woman who 
 has borne children about IJ ounces (45 gms.) ; at the full term of 
 pregnancy it weighs 28 ounces to 2 pounds, or about 1,000 gms., 
 not including the blood contained in its walls, while the foetus is 
 still in its cavity. 
 
 The length of the uterine body is increased from about If inches, 
 or 4 cm., in the nullipara to about 12 inches, or 30 cm. ; its width 
 from If inches, or 3*5 cm., to about 9 inches, or 22"5 cm. ; and its 
 depth from about 1^ inches, or 3 cm., to about 8 inches, or 20 cm. 
 
 The cavity, which in the nulliparous uterus is almost flattened, 
 and has cubical capacity only sufficient to contain a few drops of 
 mucus, is increased at its full development some 519 times (Krause). 
 The following table gives the average dimensions of the uterus as 
 a whole at different months according to Farre and Tanner^ in 
 inches, and according to Waldeyer^ in centimetres : — 
 
 Length. Width. Depth, 
 
 ins. cms. ins. cms. ins. cms. 
 
 End of 3rd month 4^- 5 = 13 4 = 8-8-5 3=8 
 4th 
 5th 
 
 6th „ 8 - 9 = 21-5 6| = 17-5 6 = 16 
 
 10 -11 = 27-30 7^ = 20 61 = 17-5 
 
 11 -12 = 30-32-5 8 = 21-5 7 = 19-5 
 
 7th 
 8th 
 9th 
 
 51- 6 = 13-5 5 4 
 
 6 - 7 = 17 5* 5 
 
 12 -14 = 32-5-37-5 9| = 25-5 8-9 = 21*5-24-5 
 
 This growth affects all the elements of the uterus — the mucous 
 membrane, the muscular walls, the peritoneal covering, the arteries, 
 
 1 Cyclopaedia of Anatomy and rhysiology : article, " Uterus and its Appendages," 
 p. 645. 
 
 2 Waldeyer, Das Beckcu, Bonn, IH'J'.), 
 
 M. 10 
 
146 
 
 The Practice of Midwifery. 
 
 veins, nerves, and lymphatics. The growth of the mucous 
 membrane by which the decidua is formed has ah*eady been 
 described. The increase of the area of the muscular wall is in 
 great measure due to growth rather than distension by the ovum 
 within the first three months of pregnancy, for at this time the 
 uterine cavity is not completely filled by the ovum, and an almost 
 corresponding growth of the uterus takes place in the early part of 
 
 pregnancy in cases of extra-uterine 
 fcetation, when the ovum is not 
 inside the uterine cavity. It is 
 brought about by the general 
 systemic changes induced by the 
 pregnancy itself. 
 
 In the later months distension 
 has more influence, and the mus- 
 cular wall no longer increases in 
 thickness, but becomes somewhat 
 thinner than before. Its thickness 
 at full term varies much in 
 different cases, nnd thus accounts 
 for great varieties in the expulsive 
 power of the uterus. It generally 
 varies from J to f inch (5-10 mm.), 
 except over the placental site, 
 where it is greater. 
 
 A marked change in the tissue 
 of the muscular wall takes j)lace 
 by the development of enormous 
 involuntary muscular fibres, often 
 as much as ten times the length 
 and five times the thickness of 
 those seen in the unimpregnated 
 uterus. These may arise in part 
 by the growth of the original mus- 
 cular fibres, but partly also by the 
 development during the first twenty-six weeks of the embryonic 
 nucleated muscular fibre-cells, having a length not much greater 
 than their thickness, which exist in the unimj)regnated uterus. 
 These are showm at 1, 2, in Fig. 103, and the process of development 
 of the large fibres at 3, 4, 5. The length of the developed fibres 
 is as much as ^q or Jq inch. 
 
 The connective tissue in the wall of the uterus develops with the 
 muscle fibres, and becomes softer and more spongy in texture. 
 
 Fig. 103. — 1,2, Embryonic nucleated 
 muscular fibre-cells of the unim- 
 pregnated uterus. 3, 4, 5, Mus- 
 cular fibre-cells of the gravid 
 uterus in different stages of deve- 
 lopment. 
 
Changes in the Maternal Organism. 147 
 
 There is a considerable increase in the number of yellow elastic 
 fibres, which is most marked between the muscle fibres of the 
 external and middle layers, and around the vessels. In the cervix 
 
 Fig. 104. — Drawing of elastic fibres in the wall of the pregnant uterus 
 showing their marked development under the peritoneum in the outer 
 and middle layers of muscle tissue and around the vessels of the uterine 
 wall. 
 
 there is a similar layer superficially under the epithelium and a 
 deeper layer surrounding the vessels. 
 
 The distribution of muscular fibres in the unimpregnated uterus 
 is confused, so that no definite layer or arrangement can easily be 
 
 Fig. 105. — Diagram of external layer of 
 muscle fibres of pregnant uterus. 
 
 Fig. 106. — Diagram of middle layer of 
 muscle fibres of pregnant uterus. 
 
 made out. At the full term of pregnancy three muscular layers are 
 described, but these are not so definite or so easily separable as the 
 circular and longitudinal layers forming the walls of other hollow 
 viscera, as the intestines. The external layer continuous with the 
 outer longitudinal layer in the wah of the Fallopian tube forms a 
 subserous layer which spreads out over the fundus of the uterus, 
 
 10—2 
 
148 
 
 The Practice of Midwifery. 
 
 passing down as longitudinal bands over its anterior and posterior 
 surfaces, and sends some fibres into the broad ligaments (Fig. 105). 
 The middle layer is the thickest and strongest, especially towards 
 the fundus of the uterus. It consists of fibres which interlace in 
 various directions and surround the uterine arteries. They must 
 therefore diminish the calibre of the arteries by their contraction ; 
 and when the emptying of the uterus allows a more complete 
 retraction of the fibres and shrinking of the uterine wall, they close 
 the canals of the vessels entirely, and so prevent haemorrhage after 
 the separation of the placenta. This layer is continuous with the 
 circular fibres in the wall of the tube, and is reinforced by fibres 
 derived from the round ligaments, the ovarian ligaments, and 
 especially the utero-sacral ligaments (Fig. 106). The fibres from the 
 
 latter, together with the trans- 
 verse bands of the circular 
 fibres derived from the tube, 
 make up the greater part of 
 the middle layer. 
 
 The internal layer is com- 
 paratively thin, and is mainly 
 derived from the internal 
 longitudinal layer in the wall 
 of the tube. The fibres are 
 arranged circularly round the 
 axis of the uterus at its centre 
 and lower part, and at the 
 upper part circularly round 
 the orifices of the Falloj)ian 
 tubes. According to William Hunter, even the internal coat loses 
 its regularity at the placental site, and the fibres are there inter- 
 laced irregularly around the vessels, the effect of which arrange- 
 ment in the arrest of haemorrhage is obvious. A strong circular 
 band of fibres surrounds the internal os uteri, and forms a true 
 sphincter to the uterine cavity, being much stronger and more 
 ready to contract than any other part of the circular fibres 
 (Fig. 107). This sphincter muscle is more manifest clinically 
 than it is on dissection. In the unimpregnated uterus it often 
 leaves its impression as a tight constriction round a laminaria tent 
 used for dilatation ; throughout pregnancy, according to the modern 
 doctrine, it holds its ground, and remains closed for the most part, 
 though it may dilate enough to admit the tip of the finger in the 
 last month or two. Even in labour it may show undue spasmodic 
 rigidity, when it ought to relax. After delivery it is the first part 
 
 Fig. 107. — Diagram of internal layer of 
 muscle fibres of pregnant uterus. 
 
Changes in the Maternal Organism. 149 
 
 to close, while the cervix still remains quite thin and flaccid, and 
 may enclose thereby a retained placenta. 
 
 Uterine Vessels. — The main arteries supplying the uterus 
 become greatly enlarged, and so also do those in the uterine walls, 
 especially at the placental site. The coats of the arteries are 
 hypertrophied and thickened, and a considerable remnant of such 
 thickening appears to remain even after involution, and to furnish 
 
 Fig. 108. — Arteries and veins lof uterus. (After Heitzmann and Hyratl.) 
 
 a character distinguishing the parous from the nulliparous uterus. 
 The arteries ramifying in the uterine walls anastomose freely with 
 each other. As they penetrate deeper into the walls and approach 
 the internal surface, they take a spiral or corkscrew-like course 
 (arteriffi helicinse). This is especially marked in the arteries which 
 convey blood into the placenta, and it has the effect of facilitating 
 the closure of the canals by the contraction of the uterine muscular 
 filn-es. (See Fig. 78, p. 103.) The veins are still more enlarged, 
 and become dilated into a system of sinuses communicating with 
 each other, chiefly towards the internal surface of the uterus,^and 
 
150 The Practice of Midwifery. 
 
 more especially under the placental site (Figs. 78, p. 103; 79, p. 104). 
 Some of these may be large enough to admit the tip of the finger. 
 The veins have no valves, and their walls are not separable from 
 the uterine tissue (Fig. 108). Their course is generally parallel to 
 the surface, and is occasionally bent back suddenly upon itself, 
 producing what has been called a "falciform valve." This arrange- 
 ment allows the vessel to be closed by uterine contraction. In the 
 absence of uterine contraction, it is obvious that haemorrhage may 
 take place from the veins as well as from the arteries, to a very 
 considerable amount. 
 
 Uterine Lymphatics and Nerves. — The abundant lymphatics 
 of the uterus form plexuses of lymjDh-spaces around the glands and 
 vessels of the mucous membrane, and beneath the serous covering 
 of the organ these open into collecting branches at the sides of the 
 uterus, which in their turn open into larger trunks in the broad 
 ligaments. 
 
 This lymphatic system undergoes great enlargement in preg- 
 nancy, and fulfils an imj)ortant function both in the tissue changes 
 attendant upon the rapid growth of the uterus, and still more in its 
 rapid involution after delivery. The great development of lym- 
 phatics also accounts for the proneness to absorption of septic 
 matter which exists after delivery.^ A great controversy formerly 
 took place as to whether or not the nerves of the uterus grew during 
 pregnancy. It is now established that, as might be expected, growth 
 does take place in the nerves, including the so-called " ganglion 
 cervicale uteri," which increases in size from f inch to 2 inches and 
 I inch to 1^ inches, to fit the uterus for the process of labour, in which 
 both reflex action and periodic centric discharge of nervous energy 
 play important parts. Even during pregnancy, the irritability of 
 the uterus is considerably increased. Uterine contractions, gene- 
 rally painless, are readily excited by stimulus, and such contractions 
 take place at intervals even without any stimulus. The contrac- 
 tions are of service in promoting the circulation through the uterine 
 walls by emptying from time to time the large venous sinuses. 
 Their importance as regards the diagnosis of pregnancy will be 
 further explained hereafter. 
 
 Size of the Uterus in the successive months of Pregnancy. — 
 In the first three months the body of the uterus grows more in its 
 
 1 It is maintained by Hoggan (Trans. Obst. Soc. London, 1883, Vol. XXIII., p. 4) that 
 the usual account of the lymphatics of the iiterus is erroneous, that there are no true 
 subserous lymphatics, and that the method of injection, by which such a system is 
 supposed to be demonstrated, is fallacious. He describes only a deep and superficial 
 layer of lymphatics in the mucous membrane, and muscular lymphatics, which 
 occasionally appear under the serous surface. 
 
Changes in the Maternal Organism. 151 
 
 breadth and depth than in its length, and very often at the site of the 
 insertion of the ovum there is a definite bulging of the uterine wall 
 which renders the outline of the uterus irregular in shape. Hence 
 the pyriform shape of the organ, though maintained to some extent 
 throughout the first three months, is gradually lost (Fig. 121, p. 177). 
 By the end of the third month the whole uterus has again become 
 
 Fig. 109. — Sagittal section of gravid uterus of fourth month. (Waldeyer, Das 
 Becken, Fig. 96.) 
 
 globular, the growth of the body being very marked as compared 
 with that of the cervix, and it retains this globular or egg-shaped 
 form up to the sixth month. From the sixth month onwards, 
 the foetus in its usual attitude begins to be accommodated to 
 the shape of the uterus, instead of floating in any position, and 
 to correspond with this necessity, the growth of the long diameter 
 of the uterus again predominates, and the organ again acquires a 
 pear-shaped form, the lower segment generally containing the foetal 
 
152 
 
 The Practice of Midwifery. 
 
 head. In abnormal presentations of the foetus and deformities of 
 the spine or pelvis, the shape of the uterus may be considerably 
 modified. In the first three or four months, the weight of the 
 fundus causes an increase of the normal slight anteversion and 
 anteflexion of the unimpregnated uterus. At the eighth week the 
 uterus is usually about the size of a goose's egg. At the twelfth 
 
 Ob 
 Internutn 
 
 Utero -vesical 
 pouch 
 
 Fig. 110. — Sagittal section of pregnant uterus at eighteenth week. From 
 frozen section. (Webster.) 
 
 week, or the end of the third lunar month, it is the size of a foetal 
 head, and the highest point of the fundus reaches about 6 cm. 
 above the symphysis pubis. At the sixteenth week, or the end of 
 the fourth month, the uterus usually first comes into contact with 
 the abdominal walls, and is readily detected on external examination 
 of the abdomen, although its increased size may be detected on 
 bimanual examination at a very early stage, even as early as the 
 sixth to eighth week. Its upper limit now reaches about 9 cm., 
 one hand's breadth, or rather more, above the symphysis pubis. 
 
Changes in the Maternal Organism. 153 
 
 At the end of the fifth month the fundus reaches to just below the 
 umbilicus, and at the end of the sixth month, or the twenty-fourth 
 week, it is a little above the umbilicus, at the seventh month, or the 
 twenty-eighth week, two to three fingers' breadth above that point, 
 and at the end of the eighth month, or the thirty-second week, 
 about two-thirds of the distance between the umbilicus and the 
 ensiform process. At this period the greatest circumference of the 
 abdomen is approximately 97 cm. At the thirty- sixth week, or 
 
 TT' 
 
 Fig. 111.— Diagram of the level of the fundus uteri at the different weeks of 
 
 pregnancy. 
 
 the termination of the ninth month, the fundus of the uterus 
 reaches its highest point, namely, the line of the ensiform 
 cartilage, and the circumference of the abdomen is now about 
 99 cm. At full term the uterus has sunk a little downwards and 
 forwards, and its highest point is at about the same level as at the 
 thirty-sixth week, while the greatest circumference of the abdomen 
 now measures on an average 100 cm. This descent of the level of 
 the fundus is due to the sinking of the whole uterus more deeply 
 into the pelvis, which occurs normally during the last two weeks of 
 pregnancy (Fig. 111). 
 
 It is obvious that the level of the fundus will tend to vary 
 
154 
 
 The Practice of Midwifery. 
 
 somewhat with the size of the child, the presence of multiple 
 pregnancies, and the degree of laxness of the abdominal walls. 
 
 Owing to the pelvic inclination, the pregnant uterus in the later 
 months, when the woman is standing upright, rests upon the 
 anterior abdominal wall as an inclined plane, its axis being nearly 
 
 Fig. 112. — Sagittal section of uterus and child at end of pregnancy. First 
 stage in progress slight dilatation of internal os is present. Patient died 
 of eclampsia. (Leopold, Altas Uterus und Kind, Plate XIX.) 
 
 coincident with the axis of the pelvic brim, and the abdominal 
 wall supports a greater share of its weight than the pelvis. "When 
 the woman lies on her back the uterus falls backward against the 
 vertebral column, and its axis is inclined posteriorly to the axis 
 of the pelvic brim. (See Fig. 131, p. 220, and Fig. 139, p. 232.) The 
 uterus being flaccid in the absence of contractions, its shaj)e is 
 affected by gravity, and thus, both in the upright and dorsal 
 
Changes in the Maternal Organism. 155 
 
 positions, especially in the latter, it becomes spread out laterally, 
 and its antero-posterior diameter is diminished. The intestines lie 
 chiefly behind and above the uterus, but, in the dorsal position, they 
 come further down in front over its upper margin. The axis 
 of the uterus is rarely central, and, as in the unimpregnated state, 
 it is more frequently inclined toward the right side. This inclina- 
 tion appears to depend partly upon congenital tendency, partly 
 upon the presence of the rectum and sigmoid flexure toward the 
 left side, and partly upon gravity, since most persons, on account 
 of the weight of the liver, prefer to lie more frequently on the 
 right side. The projection of the vertebral column in the middle 
 line increases the tendency of the pregnant uterus to fall to one 
 side or other in the dorsal position. In addition to the inclina- 
 tion, there is in about 80 per cent, of all cases also a slight rotation 
 of the uterus towards the right, so that its anterior surface looks 
 not directly forward, but somewhat to the right. 
 
 Changes in the Cervix Uteri. — It was formerly believed 
 that, during the later months of pregnancy, the cervix uteri was 
 gradually spread out from above downward, and thus formed the 
 lower segment of the pear-shaped uterine cavity. It is now 
 established that such spreading out is really a part of the process 
 of labour, and that, in the great majority of cases, it does not take 
 place until either a few days before active labour, when it may be 
 effected by painless uterine contractions, or, more frequently, until 
 the commencement of definite labour pains. In very exceptional 
 cases, however, generally those of primiparge, the cervix may be 
 expanded, so that the bag of membranes rests upon the external 
 OS, for some weeks before actual labour. Much more frequently, 
 especially in multiparee, there is partial dilatation of the internal os 
 in the last four to six weeks of pregnancy, sufiicient to let the finger 
 pass through and feel the foetus presenting, but in these cases the 
 cervix still remains a separate cavity, unoccupied by the bag of 
 membranes. 
 
 The Cervix and Lower Uterine Segment. — The question of 
 the exact relationship of the lower uterine segment to the cervix is 
 one which has excited a great deal of controversy, and is by no 
 means settled even at the present time. There are three main 
 views held as to the nature and mode of origin of the lower uterine 
 segment. The first, which has the su[)port of Bandl, Bayer, and 
 Kiistner, is that the upper part of the cervical canal becomes 
 enormously dilated in the later months of pregnancy, and forms. 
 
156 
 
 The Practice of Midwifery. 
 
 together with a part of the body of the uterus, the lower uterine 
 segment. The second view, which is supported by Bumm and 
 Blumreich, is that there is no lower uterine segment at all, and that 
 the part of the uterus which has been described as such is in reality 
 the greatly thinned and distended cervix. The third view, accepted 
 amongst others by Leopold, Yon Franque, Waldeyer, Yarnier, and 
 Barbour, is that the cervix remains undilated up to the commence- 
 ment of labour, except in some extremely rare cases, that it takes 
 
 ut jS. 
 
 _J r^ 
 
 L if -ut J 
 
 Fig. 11.3. — Diagram of uterus showing the segments and the ring of Bandl. 
 u. ut. s., upper uterine segment ; r. B., ring of Bandl ; I. ut. s., lower 
 uterine segment ; i. o.. internal os ; e. o., external os. 
 
 no part in the formation of the cavity of the uterus, and no part in 
 the development of the lower uterine segment, and that the latter is 
 formed from the body of the uterus alone. The following meaning 
 of the terms used by different authors must be clearly understood. 
 Miiller's ring is the upper orifice of the cervical canal in the later 
 months of pregnancy, and is usually considered as identical with 
 the internal os. By Bandl's ring is meant a projecting ridge felt 
 during labour either on the internal surface of the uterus or 
 through the abdomen on its outer surface as a ridge with a 
 
Changes in the Maternal Organism. 157 
 
 depression below it, and situated at a varying distance above the 
 symphysis pubis. According to those who support the view of 
 Bandl as to the origin of the lower uterine segment, and by Bumm 
 and Blumreich, the ring of Bandl is held to be situated at the level 
 of the internal os. If, on the other hand, we accept the third view, 
 that the cervix takes no part at all in the formation of the lower 
 uterine segment, then the ring of Bandl represents the line of 
 union between the thickened contractile portion of the body of the 
 uterus, or the upper segment, and the thinned distensile portion of 
 the uterus, or the lower segment, and on this view of its nature it 
 has also been termed the retraction or contraction rincr. 
 
 O 
 
 It would seem at first sight as if there should not be any 
 difficulty in determining by the examination of microscopical 
 sections whether the lower segment is derived from the body of the 
 uterus or from the cervix. Unfortunately in many instances this is 
 impossible, owing to the bad state of preservation of the tissues. 
 
 Further, there is some difficulty in deciding whether the internal os 
 should be defined as the point where the mucous membrane changes 
 its character, or as that where the strongest ring of sphincter muscle 
 is situated. The latter definition appears preferable, since it is the 
 only one applicable to the infantile uterus, in which the arbor vitaB 
 of the cervical mucous membrane extends some way into the body 
 of the uterus. Adopting this definition, the evidence greatly 
 preponderates that, setting aside the very exceptional cases of 
 primiparse noted above, the upper limit of the cervical canal in the 
 later months of pregnancy is the true clinical internal os, possessing 
 its powerful ring of sphincter muscle, although it may be true that 
 the characters of cervical mucous membrane may occasionally 
 extend higher up, or, as Kiistner has shown, the formation of 
 decidua may extend some distance down the cervix. 
 
 If an examination be made at the first onset of hemorrhage in 
 the case of a placenta preevia, it may often be observed that the 
 upper orifice of the cervical canal is as yet but slightly dilated, and 
 that the placenta is, in some places, attached to the lower portion 
 of the uterine body up to the very edge of the orifice. This con- 
 dition is seen in the frozen section of placenta praevia (Chap. XXY.). 
 Specimens have also been described, notably by Matthews Duncan, 
 Angus Macdonald, and Miiller, in which, at the end of pregnancy, 
 the membranes were found attached down to the very edge of the 
 same orifice, at which orifice also the cervical mucous membrane 
 apj)eared to begin. 
 
 Bandl detected characters of cervical mucous membrane above 
 the limit of the apparent internal os, which closes the cervical 
 
158 The Practice of Midwifery. 
 
 canal above toward the end of pregnancy. He believed that in the 
 later months the upper part of the cervical canal became enor- 
 mously dilated, so that the true internal os lay at a point above the 
 symphysis pubis, and concluded that the muscular ring forming 
 the internal os was gradually shifted upwards during the last few 
 weeks of pregnancy in reference to the limit of the cervical mucous 
 membrane, so that it became expanded and incorporated with the 
 muscle of the lower uterine segment. In this way he accounted for 
 the high position of the internal os in Braune's frozen sections 
 (Fig. 132, p. 221), Experience shows that, if a woman dies during or 
 shortly after labour, the uterus post mortem frequently shows no 
 sharp line of demarcation between the thickened and the thinned 
 segment, nor any projecting ridge, but only a gradual transition ; 
 and thus the inward projection of the ring is mainly a clinical 
 phenomenon, dependent upon active muscular action. 
 
 A further difficulty is introduced by the moulding of the uterus 
 upon the foetus, which occurs during the second stage of labour, 
 and which leads to the formation of projections on the inner surface 
 of the uterus which have in some instances been wrongly interpreted 
 as the ring of Bandl. The preponderance of evidence appears to 
 be in favour of the view that the lower uterine segment is formed 
 wholly from the body of the uterus, and it may be defined as that 
 part of the uterus which must be converted into a canal so as to 
 allow the foetus to pass. It forms rather less than a fourth of the 
 total cavity of the uterus, and, owing to its distension, its muscle 
 contracts less efficiently than that of the rest of the uterus during 
 labour. As a general rule it further represents that part of the 
 uterine wall from which the membranes are stripped off in the 
 formation of the bag of membranes (Barbour). The retraction ring, 
 or the ring of Bandl, forms the lower boundary of the retracted 
 area of the uterine musculature. Whether the retraction ring 
 forms at the internal os, as it may do in some rare cases, or higher 
 up, as is usually the case, will depend upon the contractile efficiency 
 of the uterine muscle.^ 
 
 Softening. — From the commencement of pregnancy, a softening 
 begins in the texture of the cervix, owing to congestion and the 
 effusion of serum in its substance. As early as the end of the 
 first month, a softening of the superficial tissue just at the tip of 
 
 1 Eeference may be made to the following papers : — Duncan, Researches in Obstetrics, 
 pp. 243—273 ; Macdonald, Edin. Med. Journ., April, 1877 ; Bandl, Ueber das Verbal ten 
 des Uterus und Cervix in der Schvvangerschaft, Stuttgart, 1876 ; also Archiv fiir 
 Gynak., XII., p. 334 ; Kustner, Ibid., XII., p. 303 ; Miiller, Ibid., XIII., p. 150, and 
 XIV., p. 184 ; Sanger, Ihid., p. 389 ; Hart, Atlas of Female Pelvic Anatomy, pp. 63 — • 
 77 ; Barbour, Brit. Med. Journ., 1890, p. 1002, and " Atlas on the Anatomy of Labour 
 as exhibited in Frozen Sections," 3rd ed., 1896 ; Dittel, Diel Dehuungszone des 
 
Changes in the Maternal Organism. 159 
 
 the cervix may be detected. From this part the softening spreads 
 both more deeply into the tissue and upwards towards the uterus. 
 Towards the end of pregnancy the softening is sometimes so 
 extreme, that an inexperienced person may find it difficult to 
 distinguish the cervix from the vagina. By the fourth month 
 the softening is generally sufficiently advanced to be characteristic, 
 although in some cases of multiparas, where there has been a 
 previous induration of the cervix, the 
 softening is much later in making itself 
 manifest. If, however, a woman is sup- 
 posed to be in the later months of 
 pregnancy, and the cervix is found to be 
 unsoftened, and projecting into the 
 vagina as in the unimpregnated state, 
 there is a very strong presumption that 
 the supposed pregnancy does not exist, 
 or is not intra-uterine. On the other 
 hand, very marked softening may exist 
 without any pregnancy, as in some 
 exceptional cases of fibroid tumours. 
 The absence of softening is thus of more 
 decisive value as a negative, than its 
 presence as a positive sign. 
 
 Apparent Shortening. ■ — Besides this 
 softening, there is an apparent shorten- 
 ing of the cervix, as felt on vaginal 
 examination, and it was upon this 
 shortening that the old theory about the 
 cervical cavity being taken up into that 
 of the uterus was largely based. If, 
 however, an opportunity occurs of ex- 
 amining the length of the cervical canal, 
 either after death, or from the external 
 OS being patulous enough to allow the 
 finger to be passed into it, it is almost always found that the 
 canal is lengthened rather than shortened, as compared with that 
 of the unimpregnated uterus, its average length being 3*5 cm. 
 The apparent shortening depends upon two causes. The first is 
 
 Schwangeren und Kreissenden Uterus, Leipzic, 1898 ; Von Franque, Cervix und 
 unteres Uterinsegnient, Stuttgart, 1897; Untersuchungen und Erorterungen zur 
 Cervixfrage, Wilrzburg, 1899 ; H. Bayer, " Morphologie der Gebarmutter," Freund, 
 Gynakologische Klinik, Strassburg, 1885 ; G. Leopold Atlas Uterus und Kind, Leipzic, 
 1897 ; W. Waldeyer, Medianschritt einen Hochschwangeren, Bonn, 1866 ; A Pinard 
 and A. Varnier, Sltudes d'Anatomie Obstetrical, Paris, 1892 ; Bumm and Blumreich, 
 Zeitsch. f. Geb. u. Gyn. B. 58, 1906. 
 
 Fig. 114. — Diagram to illus- 
 trate how there may be 
 apparent shortening of the 
 cervix, as seen and felt 
 from the vagina, without 
 any shortening of the cer- 
 vical canal. The upper 
 figure, A, shows the cervix 
 at about the third month, 
 the lower, b, at about the 
 eighth month of pregnancy, 
 u, cavity of uterus ; V, 
 vagina ; B, bladder. 
 
i6o 
 
 The Practice of Midwifery. 
 
 the thickening and extension of the uterine wall, coupled 
 with the loosening of the vaginal tissue adjoining, and a traction 
 upwards exercised by the enlarging uterus upon the cervix as it 
 rises higher into the abdomen. In consequence of this, the pro- 
 jection of the lip of the cervix into the vagina may become less, 
 without any diminution of its distance from the cavity of the uterus 
 (see Fig. 114). This is especially marked as regards the anterior lip 
 of the cervix, because the prominence of the uterine wall in front, 
 due to its expansion, is generally increased by a bulging outward, 
 due to the pressure of the foetal head resting in that situation, and 
 thus the angle between the anterior lip and the vaginal wall tends 
 
 Fig. 115. — Condition of the cervix with the head above the pelvic brim at the 
 seventh month of pregnancy. (Bumm. ) 
 
 to become effaced. The second cause is the alteration in the direc- 
 tion of the cervical canal. This is generally somewhat flexed 
 forward, even in the unimpregnated uterus. As pregnancy advances, 
 it generally becomes more and more inclined forward in reference 
 to the axis of the uterus, so that the two meet at an angle at the 
 internal os(Fig. 114). By this means, the lips of the cervix may 
 become approximated to the uterine cavity, although the length of the 
 cervical canal is actually being increased, as shown in Fig. 116. 
 Towards the end of pregnancy, the cervix uteri becomes more 
 difficult to reach, since it is drawn upward by the uterus rising 
 into the abdomen, and frequently, in addition, is tilted backward 
 toward the sacrum, in consequence of the fundus falling forward 
 through its own weight. 
 
Changes in the Maternal Organism. i6i 
 
 The cervical glands secrete a thicker mucus than usual during 
 pregnancy, and this usually forms a tenacious white mucous plug, 
 filling up the cervical canal. In parous women, if there is a 
 previously existing eversion of the mucous membrane from lacera- 
 tion of the cervix in a former labour, giving the appearance of a 
 so-called erosion, the hyperfcrophied papillae, or villous prominences, 
 become much more enlarged, florid, and soft. The external os 
 generally becomes more patulous than in the unimpregnated state, 
 but this change is more marked in multiparse, in whom the os 
 is wider to begin with. In first pregnancies the os is generally 
 
 Fig. 116. — Head engaged in the pelvic brim at full term, showing the apparent 
 shortening of the cervix and obliteration of the anterior vaginal fornix. 
 (Bumm.) 
 
 closed to the finger up to nearly the end of pregnancy (Fig. 116). 
 In multiparse the finger may generally be passed into the cervix 
 in the later months, if not through the internal os. 
 
 Changes in Vagina and other adjacent Parts. The mucous 
 membrane and muscular walls of the vagina become hypertrophied, 
 and its secretion increased. From about the third to the fourth 
 month the anterior vaginal wall feels stretched, from the commenc- 
 ing ascent of the uterus, as well as turgid. In the later months 
 there is so much hypertrophy and relaxation of the mucous 
 membrane that, notwithstanding the lengthening of the vagina, it 
 tends to hang in folds, which appear at the vulva, the prominence 
 covering the urethra being often especially marked. The mucous 
 
 M. 11 
 
1 62 The Practice of Midwifery. 
 
 membrane of the vulva also becomes turgid and relaxed, the 
 secretion of the follicles increased, the veins enlarged, and often 
 varicose, the vaginal outlet wider. The projection of the pelvic 
 floor beyond the outlet of the bony pelvis is, in consequence, 
 notably increased. The round ligaments are much increased in 
 thickness as well as in length, in consequence of the hypertrophy 
 of the muscular fibres contained in them. Owing to the elevation 
 of the fundus they become inclined at a much greater angle to the 
 pelvic brim than in the unimpregnated state. Their action is to 
 draw the fundus downwards and forwards in reference to the axis 
 of the brim. According to Leopold, when the points of insertion of 
 the round and ovarian ligaments are relatively close together and 
 on the anterior wall of the uterus the placenta is probably 
 situated on the posterior wall, while when they are farther apart 
 and on the lateral aspects of the uterus the placenta is most likely 
 to be situated on the anterior wall. The broad ligaments grow, 
 rather than become unfolded, and the direction of their ujDper 
 margins becomes very oblique. Owing to the expansion upwards 
 of the fundus uteri, the insertion of the round and ovarian liga- 
 ments is no longer nearly at the level of the summit of the uterus, 
 but toward the lower part of its upper third. The Fallopian tubes 
 are increased in length and diameter, and their direction becomes 
 nearly perpendicular to the pelvic brim. The position of the 
 ovaries, which also share in the general hypertrophy of the pelvic 
 organs, thus comes to be comparatively low down in reference to 
 the body of the uterus, and near to its walls. The formation of 
 the corpus luteum in the ovary has been described already (p. 55). 
 Further maturation of follicles is almost invariably arrested during 
 pregnancy, but this question will be further discussed under the 
 head of superfoetation. Whether ovulation accompanies or not 
 the menstruation which sometimes occurs during the first few 
 months of pregnancy, has not been demonstrated. Probably in all 
 cases of normal pregnancy there is an over-production of lutein 
 cells in the ovary and a formation of atretic follicles. The 
 whole cellular tissue of the pelvis partakes in the same growth 
 and relaxation as the broad ligaments, and the nutritive changes 
 affect even the pelvic joints, as already described (see p. 12) ; 
 increased deposit of external fat also takes place about the pelvis 
 and loins. 
 
 Mechanical Effects on other Parts. — Mechanical effects arise 
 partly from the direct pressure of the enlarged uterus, partly from 
 the increased intra-abdominal pressure caused by its presence. 
 
Changes in the Maternal Organism. 163 
 
 The degree of the latter depends upon the tightness of the 
 abdominal walls, which is generally much greater in first preg- 
 nancies. The capacity of the bladder is diminished, chiefly by 
 direct pressure of the uteras. Hence there is a more frequent need 
 for micturition ; and sometimes, in addition, urine is involuntarily 
 expelled, especially in the upright position. Constipation is often 
 troublesome, and is to be ascribed not so much to direct i3res8ure 
 upon the rectum as to general interference with the freedom of 
 peristaltic movement of intestines. Sometimes the pressure on the 
 veins causes oedema of the feet and legs, and in some cases also of 
 the vulva ; but this oedema is not often considerable in degree 
 unless there is some additional cause, such as disorder of the 
 kidneys. When there is any tendency to imperfection of venous 
 circulation, the veins of the lower extremities and vulva often 
 become varicose, and this varicosity may become very severe in 
 degree. It is relieved, to a great extent, by a recumbent posture. 
 In the abdominal walls a certain amount of growth and relaxation 
 as well as stretching occurs. The umbilical depression becomes 
 gradually obliterated, is flat with the surface of the abdomen 
 usually at the end of the seventh month, and in the last months 
 generally forms a soft prominence. In women whose tissues are 
 wanting in tone, the recti are sometimes separated from each other 
 in their middle and upper thirds — a condition which may remain 
 permanent after delivery. 
 
 From the end of the fifth month of pregnancy skin -cracks, or 
 cutaneous strice, are generally formed from the effect of tension. 
 They are caused by a more or less complete disruption of the deeper 
 connective tissue layer, especially of the elastic fibres of the skin, 
 and therefore run at right angles to the direction of greatest tension. 
 They are chiefly seen at the sides of the abdomen towards the lower 
 part, running parallel to Poupart's ligament or to the linea alba, or 
 tending to curve round the umbilicus. They may be formed also 
 upon the breasts, buttocks, and thighs. Schultze found them on the 
 thighs in 36 per cent, of all multiparse examined and in 6 per cent, 
 of men. Although they have been called lince gravidarum, they are 
 not peculiar to pregnancy, but may occur from any kind of disten- 
 sion, even from the rapid growth of fat. In only twenty-eight of 
 492 cases of pregnancy observed by Hecker were they absent. 
 They have the appearance of short spindle-shaped lines, generally 
 about half an inch to an inch in length. While the tension lasts, 
 they are reddish or bluish ; after delivery they remain as opaque 
 white lines. Sometimes they become the special seat of cedema, 
 or of distension of lymphatics, in consequence of the diminution 
 
 11—2 
 
164 
 
 The Practice of Midwifery. 
 
 over their area of the uniform support afforded by the elasticity 
 of the skin.^ 
 
 Changes in the Breasts. — Almost from the very outset of preg- 
 nancy there may be a sense of fulness and tenderness in the 
 breasts, sometimes with darting pains referred to the nipples or 
 glands. These may be regarded as the continuation and develop- 
 ment of the similar symptoms sometimes felt by sensitive women 
 before the onset of menstruation. By the second month actual 
 enlargement of the breasts may become noticeable, and it grows 
 
 Fig. ]17. — Mammary changes in later months of pregnancy, 
 with secondary areola. 
 
 gradually more manifest as pregnancy advances. The enlargement 
 is mainly in the glandular tissue itself, though the connective tissue 
 and fat also take part in it. Hence the breast has a knotty feel, 
 due to irregular thickenings in the gland tissue radiating from the 
 nipple. In the later months enlarged blue veins may be seen under 
 the surface of the skin. In an enlargement due to fat there is not 
 the same knotty feel, and the vascular supply is not altered. 
 
 More characteristic signs are found in the nipples and areolae. 
 The nipples, unless when flattened through pressure by the stays, 
 become more prominent and more susceptible to erection. They 
 are often covered with minute branny scales, due to the drying of 
 
 1 See Busey, "The Cicatrices of Pregnancy," Trans. Am. Gyntec. Soc, Vol. IV.; 
 "Duncan, "Phlegmasia Dolens with Lymphatic Varix," Trans. Obst. Soc. London, 
 1881, Vol. XXIII., p. 132. 
 
Changes in the Maternal Organism. 165 
 
 the small quantity of secretion which oozes from them. The 
 areolae become enlarged and darkened by pigment. This change, 
 however, varies very greatly according to the complexion of the 
 woman. In dark brunettes the areolae may become almost black, 
 in blondes the deposit of pigment may be hardly noticeable. The 
 glandular tubercles of the areola (Montgomery's glands), resembling 
 miniature nipples, ten to twenty in number, become enlarged and 
 prominent, and the whole areola moist, and slightly elevated above 
 the skin. The tubercles may have an excretory duct from which 
 a little milky or mucoid fluid exudes. In the later months there 
 is developed in dark women around the outer part of the areola 
 what was described by Montgomery as the secondary areola. The 
 appearance is that of white spots on a darker ground, and is usually 
 compared to that of colour discharged by a shower of drops of 
 water falling on a tinted ground. The secondary areola may begin 
 to be visible in some cases as early as the fifth month, and its 
 presence affords a strong presumption of pregnancy (see Fig. 117). 
 Towards the end of pregnancy the breasts droop somewhat, and the 
 nipples become directed downward, so as to be better adapted for 
 the infant to seize. 
 
 It is possible in many cases as early as the third month to 
 squeeze a drop of secretion from the breasts by dexterously com- 
 pressing them from the base toward the nipple. As pregnancy 
 advances this becomes increasingly easy. The product formed by 
 the mammary gland at this stage of its evolution is not milk, but 
 a mucoid fluid,^ and accordingly the drop so squeezed out is quite 
 clear and transparent. Later on in pregnancy some opaque white 
 material is generally seen, mixed with the clear mucoid fluid. On 
 microscopic examination this is found to consist of the so-called 
 " colostrum corpuscles," similar to those found in the first secretion 
 after delivery. While mucoid fluid may be found in conditions of 
 irritation of uterus or ovaries, or in spurious pregnancy, colostrum 
 is an almost, if not absolutely, certain proof of pregnancy, uterine 
 or extra-uterine. 
 
 Diagnostic Value of Mammary Changes. — Changes in the breasts 
 similar to the early stages of those associated with pregnancy not 
 infrequently occur in connection with various uterine and ovarian 
 tumours, and especially with the so-called " pseudo-cyesis," or 
 imaginary pregnancy, found mostly in women whose menstruation 
 is becoming irregular with the approach of the menopause. 
 Mammary changes also sometimes occur when women have reason 
 to' expect pregnancy, as shortly after marriage, or after illicit 
 
 ' See Creightoii, " I'liysiology and Pathology of the Breast," p. 49. 
 
1 66 The Practice of Midwifery. 
 
 intercourse. After a previous pregnancy they are of little 
 diagnostic value, for the alteration in the areolae remains in some 
 degree permanent, and a little secretion may sometimes be still 
 found in the breasts for a long time after lactation has ceased, or 
 even when nothing more than a miscarriage has taken place. In 
 the case of a young woman suspected of pregnancy, the examination 
 of the breasts is of very great though not of decisive value. It has 
 the special advantage that it may often be more readily secured 
 than the opportunity for vaginal examination, and may indicate the 
 necessity for further investigation. Some excuse may be found to 
 look at the breasts, even if we wish to avoid giving any hint of our 
 suspicions to the woman herself. In the absence of very marked 
 changes, the point especially to be sought for is to obtain a drop of 
 secretion, since this sign is independent of varieties of complexion. 
 It is a sign also which often can be found at quite an early stage, 
 before other signs exist, except such as may be overlooked by any 
 but a practised observer. The secondary areola is strong evidence 
 when it is visible, but it does not appear until the stage when 
 positive proof may be obtained by the examination and auscultation 
 of the uterus. In women who become pregnant again while 
 suckling a previous child, the sign of pregnancy is to be found 
 rather in suppression of the milk than in increased mammary 
 activity. 
 
 Changes in the BoD3fT?ENEKALLY. 
 
 Circulation. — In some animals, at any rate, the total amount of 
 blood in the body during pregnancy is increased, and it may be 
 assumed that the same holds good for the human female ; and, as 
 it is not found that the pulse is more rapid in pregnant women, the 
 cavities of the heart must be dilated so as to propel more blood at 
 each stroke, if the circulation is to be as active as before. This is 
 found actually to take place. With the dilatation is associated 
 hypertrophy, which appears to be not merely compensatory to the 
 dilatation, but to go so far as actually to improve the circulation. 
 Thus women who are subject to chilblains at other times may be 
 exempt from them during pregnancy. 
 
 The increase in the area of cardiac dulness, which is usually 
 present, and which might be assumed to prove the existence of 
 hypertrophy of the heart, is in reality due to a displacement 
 upwards of the organ as a result of the presence of the pregnant 
 uterus in the abdomen. A good deal of difference of opinion still 
 exists as to whether there is any real increase in the size of the 
 heart during pregnancy, but the researches of Dreysel, Miiller, and 
 
Changes in the Maternal Organism. 167 
 
 others, appear to demonstrate an actual increase in the weight of 
 the organ, and we may conchide, therefore, that probably both 
 hypertrophy and dilatation do take place. In women in a normal 
 state of health the changes in the blood are unimportant. The red 
 corpuscles and the haemoglobin remain unaffected, the specific 
 gravity is normal, but there is a slight diminution in the alkalinity 
 of the blood, and a marked degree of leucocytosis. The chief 
 increase is in the polymorpho-nuclear leucocytes. According to 
 Zangemeister, the freezing point is lowered, and the albuminous 
 content is diminished. 
 
 The frequent cases in which impoverishment of the blood is 
 marked must be regarded as deviations from health. They depend 
 for the most part either upon the impairment of digestion which 
 often occurs, or upon a want of that increased supply of nourishing 
 food which pregnancy calls for. 
 
 In these cases important changes take place in the quality of 
 the blood. It becomes richer in fibrin and in white corpuscles, 
 poorer in red corpuscles, and also, especially as regards the liquor 
 sanguinis, in albumen. The average diminution of red corpuscles 
 is about 11 per cent. ; the average diminution of haemoglobin 
 somewhat greater, about 13 per cent. 
 
 Blood Pressure. — The blood pressure is raised during pregnancy, 
 and most observers are agreed that this rise occurs mainly during 
 the second half of pregnancy, and that there is little or no alteration 
 in the blood pressure during the early months. 
 
 The pressure is at its highest towards the end of gestation, and 
 during the second stage of labour there is a further marked rise. 
 Immediately after delivery a fall occurs to below the normal, and 
 this continues until the placenta has been expelled, when the 
 pressure again rises a little. As a rule, however, it remains 
 subnormal until about the fifth day of the puerperium, after which 
 it attains gradually the normal mean. 
 
 It is exceedingly likely that this rise of blood pressure is due to 
 some altered condition of the blood, and that it may be regarded as 
 in some way associated with the hypertrophy of the thyroid gland 
 which takes place during pregnancy, and, as related to the increased 
 metabolic activity of the mother's tissues, the result of the presence 
 of the growing foetus in utero. 
 
 Respiration. — As might be expected, there is an increased con- 
 sumption of oxygen and an increased discharge of carbonic acid 
 through the lungs in pi:egnancy — an increase which has been 
 
1 68 The Practice of Midwifery. 
 
 estimated as high as 25 per cent. There is no great difference in the 
 size of the chest, for the space lost by diminution of depth is made 
 up for by increase of breadth at the base of the thorax. Freedom of 
 respiration is, however, interfered with, since the presence of the 
 pregnant uterus limits the descent of the diaphragm in inspiration. 
 Thus there is a tendency to shortness of breath towards the end of 
 pregnancy. Provision is indeed to some extent made by nature for 
 this liability, since it is presumed to be with a reference to the 
 contingency of pregnancy that in women respiration is habitually 
 thoracic rather than abdominal, while in men it is the reverse. 
 
 Puerperal Osteophytes. — In nearly half of the whole number 
 of pregnant women calcareous plates are formed after the fifth 
 month on the interior of the skull in the neighbourhood of the 
 vessels between the dura mater and the bone, and these have been 
 called osteophytes by Rokitansky. They consist chiefly of carbonate 
 of lime with a large proportion of organic matter. They form 
 irregular plates about ^ inch in average thickness, connected more 
 intimately with the bone than the dura mater. 
 
 Hanau-"^ has pointed out their relationship to the formation of 
 osteoid tissue in other parts of the body, and is inclined to attribute 
 their presence to a slight degree of osteomalacia. 
 
 Urine. — The quantity of urine is increased, probably in conse- 
 quence of the increased arterial pressure, since the increase is found 
 to be in the water rather than the solid constituents. The occur- 
 rence of albuminuria will be considered among the disorders of 
 pregnancy. Occasionally a very small quantity of sugar is found 
 in the urine in the later months, not, however, so frequently as in 
 women who are suckling. When it occurs it is attributed to the 
 resorption of sugar from milk secreted in the breasts, although 
 alimentary glycosuria may undoubtedly be met with, and the 
 experiments of Lanz^ appear to show that the power of assimilating 
 the sugar contained in the food is below the normal in pregnant 
 women. 
 
 The amount of the nitrogen excreted as urea is in healthy women 
 about the normal, but the proportion of that excreted as ammonia 
 to the whole is slightly increased. The total amount of solids is 
 rather below the normal, and this is brought about by a diminution 
 in the amounts of uric acid, creatin, creatinin, phosphates, and 
 
 1 Hanau, Fortschritt, d. Med., 1892, No. 7. 
 
 2 Wien. Med. Presse, 1895, No. 49. 
 
Changes in the Maternal Organism. 169 
 
 sulphates excreted, while, on the other hand, the amount of chlorides 
 excreted is increased. 
 
 A definite storing up of nitrogen in the body of the mother 
 occurs, no doubt, in connection with the growth and metabolism of 
 the foetus. This is seen mainly in the later months of pregnancy, 
 and is more marked in multiparge than in nulliparse. The experi- 
 ments of Hagemann^ and others have demonstrated that in bitches 
 during pregnancy there is an increased excretion of nitrogen in the 
 early months of pregnancy, and that an amount more than sufficient 
 for the requirements of the foetus is retained in the body of the 
 animal in the later months. 
 
 A peculiar deposit called kyesteine, first described by Nauche, is 
 often found in the urine of pregnant women, if allowed to stand six 
 or seven days protected from dust. It is a product of decomposition, 
 and is of no value as a sign of pregnancy, since it is not always 
 present in pregnant women, and may be found under other 
 conditions, and in the male sex. 
 
 A slight degree of acetonuria, not exceeding the normal physio- 
 logical limit, can be demonstrated in almost all pregnant women, 
 but the view that its presence is a sign of the death of the foetus in 
 utero has been shown to be untenable. 
 
 According to Fischel, small quantities of peptone can be recog- 
 nised in the urine during pregnancy as well as in the puerperium ; 
 the significance of this is unknown, and, indeed, other observers 
 have thrown some doubt on the correctness of Fischel's^ conclusions. 
 
 Nervous System. — The irritability of the nervous centres to 
 reflex stimuli becomes increased, probably as part of the physio- 
 logical process by which they are prepared for the discharge of 
 nervous energy in parturition. By deviations from this normal 
 process arise numerous reflex disturbances. The most frequent of 
 these are disturbances of digestion, especially nausea and vomiting. 
 Craving for food is naturally more frequent, in consequence of the 
 increased demands upon the organism. This is sometimes con- 
 verted into longings for unusual and even unpleasant articles of 
 food, and thus the unnatural longings of pregnancy have become 
 popularly known. The temper may be changed, so that an amiable 
 woman becomes irritable and peevish, or sometimes, it is said, the 
 opposite change may occur. Other frequent nervous disturbances 
 are hysteria, neuralgia, fainting or dizziness, and perversions of 
 special senses. Eruptions such as acne or eczema probably depend 
 
 ' Aichiv. f. Anat. u. Phys,, Phys. Abth., 1890, Hft. 516, p. 577. 
 ■^ Fischol, Zcritralbl. f. Gyniik,, 1889, No. 27, p. 473. 
 
lyo The Practice of Midwifery. 
 
 also mainly upon nervous influence. All these changes are depar- 
 tures from a strictly normal condition, and will be further considered 
 among the disorders of pregnancy. 
 
 Pigmentation. — There is a tendency to pigmentation in other 
 parts beside the areolae of the breasts, and in individual instances, 
 chiefly in dark women, this may be strongly marked. Most women 
 show more or less of dark rings under the eyes. The abdomen, 
 axillae and pubes become darker, and a special dark band is formed 
 along the linea alba from the ensiform cartilage to the pubes, 
 surrounding the umbilicus and forming the umbilical areola. This 
 dark band, however, becomes much more marked after delivery. 
 In rare cases the face is disfigured by irregular patches of a dirty 
 yellow or brownish pigment, the so-called chloasma uterinum; they 
 are met with more especially on the forehead, the bridge of the 
 nose, and the upper lip. It may be in origin either a physiological 
 or a sympathetic pigmentary disturbance. 
 
Chapter IX* 
 DIAGNOSIS OF PREGNANCY, 
 
 It is of obvious importance for every medical man, whatever 
 may be his branch of practice, to acquire skill in the diagnosis of 
 pregnancy, since almost all medical and surgical diseases are liable 
 to be modified by the occurrence of that state. Moreover, not only 
 may it be of extreme importance to the patient to obtain a correct 
 opinion, but the result will inevitably make manifest to all con- 
 cerned the medical man's skill, or want of skill, in the diagnosis. 
 He will naturally incur ridicule if he is found to have overlooked or 
 mistaken an advanced pregnancy, and may find the result still 
 more unpleasant if he erroneously accuses of pregnancy a virtuous 
 unmarried woman. 
 
 The signs of pregnancy may be divided into the probable or 
 symptomatic signs, dej)ending upon the changes induced in the 
 maternal organism, and the physical or direct signs afforded by 
 the growth of the uterus and the ovum. Of these, the former are 
 sufficient only to indicate the probability of pregnancy, while many 
 of the latter furnish the ground for an absolute diagnosis. 
 
 Symptomatic Signs of Pregnancy. 
 
 Suppression of Menstruation. — The cessation of menstruation 
 is commonly the first sign which leads a woman to suspect herself 
 to be pregnant. Its significance as an indication of probable 
 pregnancy is most when the woman appears perfectly healthy, 
 without any anaemia or chlorosis, and when previous menstruation 
 has been regular and not too scanty. A short period of amenorrhcea 
 is not so significant as a longer one. The amenorrhcea is valuable 
 as a corroborative sign when its duration corresponds with the 
 indications given by more direct signs, such as the enlargement of 
 the uterus. Irregular hemorrhages during pregnancy (really due 
 to a threatened abortion) may be mistaken for menstruation. A 
 more genuine menstruation may occur within the first three months 
 of pregnancy, while there is still a space between the decidua vera 
 and the decidua reflexa, the decidual cavity. Cases have been even 
 reported in which menstruation has continued throughout the whole 
 
172 The Practice of Midwifery. 
 
 of pregnancy, although it is extremely rare for such a thing to 
 occur at regular intervals. In such a case the blood probably comes 
 from the decidua in the lower uterine segment in the early months, 
 and from the cervix uteri in the later months of pregnancy. 
 Cazeaux ^ has recorded the case of a woman twenty-four years of age 
 who menstruated during her pregnancies only and at no other 
 time. If, however, a woman who imagines herself pregnant men- 
 struates regularly, however scantily, there is a strong presumption 
 that the pregnancy is not genuine. It is to be remembered, on 
 the other hand, that suppression of menstruation may occur from 
 various emotional and other causes without marked disturbance of 
 health. Temporary cessation of menstruation sometimes occurs 
 shortly after marriage without any pregnancy, and the same thing 
 may happen after illicit intercourse. 
 
 The occurrence of pregnancy during the amenorrhoea of lactation 
 is not common. According to Eemfry ^ it occurs in only 6 per cent., 
 while of women who menstruate regularly while suckling it occurs 
 in 60 per cent, during lactation. Pregnancy may also commence 
 in the midst of periods of amenorrhoea arising from other causes, 
 and sometimes even in the case of women who have never men- 
 struated at all. Special care is, therefore, required not to overlook 
 a pregnancy of shorter duration than would correspond to the date 
 of the amenorrhoea. The medical man must also be prepared for 
 possible deception on the part of the woman. Women who wish to 
 conceal pregnancy may deny the suppression of the menses, and 
 may even artificially stain their linen to simulate menstruation. If 
 they confess the amenorrhoea, they may give it an incorrect date, 
 generally a more recent one than the true. 
 
 Morning Sickness. — Nausea and vomiting are symptoms which 
 often call attention to the probability of pregnancy, especially if 
 they occur without apparent ill-health, or are associated with 
 amenorrhoea, or with obvious enlargement of the abdomen. The 
 nausea or vomiting of pregnancy most frequently occurs when the 
 woman first rises in the morning, and is met with in about two- 
 thirds of all pregnant women. Often there is nausea without actual 
 vomiting, or accomj)anied merely by retching, and perhaps the 
 bringing up of some glairy fluid. These symptoms commonly 
 begin about the beginning of the second month, and are relieved or 
 mitigated at the end of the fourth month.^ They may, however, 
 
 1 Cazeaux. Traite Theor. et Prat, de I'Art des Accouchements, Paris, 1862. 
 
 2 L. Remfry, Trans. Obst. Soc. London, 1897, Vol. XXXVIll., p. 22. 
 
 3 A. Giles, Ihid., 1894, Vol. XXXIII., p. 303. 
 
Diagnosis of Pregnancy. 173 
 
 commence very soon after conception, and may also continue through 
 the later months of pregnancy. The severer forms of vomiting will 
 be considered among the disorders of pregnancy. 
 
 Mammary Changes. — The changes in the breast and their 
 diagnostic value have already been described (pp. 164 — 166). In 
 every doubtful or suspected case of pregnancy the breasts should 
 be observed, and it is often convenient to make this the first step in 
 the examination of the patient. 
 
 Physical or Direct Signs of Pregnancy. 
 
 Enlargement of the Uterus and of the Abdomen. — For 
 examination of the abdomen, the patient should lie on her back on 
 a flat couch, with a small pillow under her head, but not under the 
 shoulders. The thighs should be flexed and somewhat separated, 
 so as to obtain the greatest possible relaxation of the abdominal 
 muscles. The stays, and everything tied round the waist, should 
 be unfastened, and the skirts slipped down so as to uncover the 
 abdomen, keeping the pubes covered. It is generally of advantage 
 to have the skin actually uncovered, to allow ocular inspection of 
 the state of the umbilicus, and of any pigmentation which may 
 exist, but the palpation and auscultation may be carried out, if 
 necessary, through a thin chemise spread fiat over the surface. If 
 the abdominal muscles are rigid, the patient should be directed to 
 look up to the ceiling, letting her head rest easily back upon the 
 pillow, and her attention should be distracted by conversation 
 while the pressure of the hand gradually overcomes the muscular 
 resistance. 
 
 By palpation and percussion the position and dimensions of the 
 enlargement formed by the pregnant uterus, if such exists, are 
 made out. 
 
 Within the first two months of pregnancy the abdomen may 
 become somewhat flatter than before, from the uterus sinking 
 lower into the pelvis through its increased weight. By the third 
 month there begins to be some enlargement in the lower part of 
 the abdomen. It is generally in the fourth month that it first 
 becomes possible to feel the enlarged uterus in the hypogastric region 
 by external examination only. 
 
 The size and position of the uterus in the different months of 
 pregnancy have already been described (p. 153). In the earlier 
 months the consistence of the uterus, except when in a state of 
 contraction, is soft and elastic, so that in this respect it is liable to 
 
174 
 
 The Practice of Midwifery. 
 
 be mistaken rather for an ovarian cyst or fibro-cystic tumour than 
 for an ordinary fibroid tumour of the uterus. Later on, its con- 
 sistence becomes quite characteristic, and is sufficient to afford a 
 certain diagnosis of pregnancy. The hand receives the impression 
 of a soHd body — the foetus, floating in liquid — the liquor amnii. 
 Near the end of pregnancy, the actual parts of the foetus, the 
 head, the back, limbs, and breech, may be made out by palpation. 
 Sometimes, when the liquor amnii is abundant, especially about 
 the sixth or seventh month, a fluid thrill may be felt through it, 
 resembling that which may be observed in a simple ovarian cyst. 
 
 Fig. 118. — Method of bimanual examination of uterus. 
 
 To estimate the enlargement of the uterus in the early months 
 the bimanual examination is necessary. To gain the full benefit of 
 this, the bladder must be empty, and in a case of any doubt, it is 
 important to secure this condition by passing a catheter. If a 
 patient is very nervous, and the abdominal muscles very rigid, it 
 may in rare cases be necessary, if it is important to make a diagnosis 
 at once, to administer an anaesthetic in order to obtain a satisfactory 
 result. The patient is still to be in the dorsal position, as for 
 examination of the abdomen. The physician, standing at the right 
 side of his patient, passes his right hand beneath the thigh and intro- 
 duces the index finger, anointed with an antiseptic lubricant, 
 into the vagina, the remaining fingers being bent well back upon 
 
Diagnosis of Pregnancy. 175 
 
 the palm. The fingers of the left hand, without any intervening 
 garment, are pressed deeply into the abdomen, not too close to the 
 
 Fig. 119.— Frozen section of a uterus at thirteenth week of pregnancy from a 
 patient dying of heart disease. The large amount of decidua in the lower 
 uterine segment, and the decidual cavity are well seen. There are minute 
 hjemorrhages into the placenta, decidua capsularis, and decidua vera.i 
 
 pubes, and endeavour to get behind the fundus and bring it forward 
 into anteversion, so that the body of the uterus is grasped between 
 
 ' Blacker, Trans. Obst. Soc. Lond., Vol. 42, p. 235, 1900. 
 
176 
 
 The Practice of Midwifery. 
 
 the two hands, as shown in Fig. 118. If there is any difficulty 
 about doing this, the finger in the vagina may faciHtate the 
 manipulation by first pushing the cervix backw^ards as far as 
 possible. If the cervix is beginning to ascend, as it does in the 
 course of the third and fourth months, and is therefore difficult to 
 reach, the middle, as well as index finger, may be introduced into 
 the vagina, and an additional reach of about a quarter of an inch 
 thus obtained. 
 
 When grasped in this way between the two hands, the uterus 
 
 Fig. 120. — Coronal section of a pregnant uterus at the twelfth week of 
 pregnancy, with asymmetrical enlargement of the fundus simulating an 
 extra uterine gestation. A well-marked groove was present between the 
 two halves of the uterus. The dotted outline shows the shape of the 
 uterus six weeks later. (After Piskaiek.) 
 
 in very early pregnancy feels more anteflexed and more anteverted 
 than usual, and the increased breadth of the body and tendency to 
 a globular shape may be made out. On account of its elasticity, 
 the pregnant uterus has the peculiar character that its outline is 
 not so easily defined as that of a uterine enlargement of similar 
 size due to hyperplasia or fibroid tumour. On this account, it 
 may be missed by an uniDractised observer, but to a skilled person, 
 this very quality is the most characteristic of pregnancy. If an 
 occasional hardening, due to the intermittent uterine contractions 
 which will be mentioned hereafter, can be detected, the diagnosis 
 
Diag-nosis of Pregnancy. 
 
 177 
 
 is still further confirmed. The uterus, if unimpregnated, can be 
 rolled between the fingers, and the absence of enlargement posi- 
 tively made out. Other kinds of enlargement, due to hyperplasia 
 or tumour, are generally distinguished, not only by their greater 
 hardness, but by being associated, not with amenorrhcea, but 
 frequently with menorrhagia. 
 
 Hegar's Sign. — Another special character of the uterus in 
 early pregnancy, to be discovered on bimanual examination, is 
 known as Hegar's sign of pregnancy. This consists of a change 
 in consistency of that part of 
 the uterus which is just above 
 the cervix, and below the 
 expanded portion of the body. 
 This segment becomes soft, 
 thin, yielding, and compres- 
 sible, while the cervix below 
 and fundus above are com- 
 paratively firm, the former 
 being harder and the latter 
 more elastic. The compres- 
 sible part corresponds to the 
 portion of the body of the 
 uterus below the ovum 
 occupied only by soft spongy 
 decidua (Fig. 119). In ex- 
 treme cases the continuity 
 between cervix and fundus 
 becomes obscured, and the 
 impression is given of a 
 separation between them. In 
 some instances this has led to an erroneous diagnosis of extra- 
 uterine pregnancy : a hypertrophied cervix being mistaken for the 
 whole uterus, and the fundus, flexed to one side, for an extra-uterine 
 sac (Fig. 120). This compressibility of the lower uterine segment 
 is present, according to Dickenson, in two-thirds of all cases. A 
 definite bulging of the uterine wall at the site of the attachment of 
 the ovum is also very characteristic : it can be felt more readily 
 when the implantation of the ovum is on the anterior wall of the 
 uterus ; but it may be felt posteriorly or at the sides of the uterus 
 in the region of the tubes (Fig. 121). 
 
 Fia. 121. — Sagittal section of a pregnant 
 uterus at the fourth to the fifth week of 
 pregnancy. The bulging of the anterior 
 wall is well marked, and the relatively 
 increased resistance of the posterior 
 wall and the compressibility of the 
 lower uterine segment (Hegar's sign) 
 are shown diagrammatically. (After 
 Piska ek.)i 
 
 1 I'iskaijek UeVjer Ausladungcn umschricbener Geblirmutter abschnitte. 
 1899. 
 
 M. 12 
 
 Wien. 
 
178 
 
 The Practice of Midwifery. 
 
 In a certain number of early pregnancies the portion of the wall 
 of the uterus corresponding to the site of the ovum forms an elastic 
 bulging mass, while the remainder of the uterine wall is hard, 
 resistant, and distinct in outline. Not uncommonlj'- the two 
 portions are separated from one another by a definitely recognisable 
 furrow or ridge. 
 
 Another sign of early pregnancy, to which Sellheim in particular 
 has drawn attention, is the possibility of wrinkling or folding up 
 by manipulation the outer layer of muscle tissue in the wall of the 
 uterus, especially on its posterior surface. This is due to the marked 
 
 Fig. 122. — Demonstration of Hegar's sign by bimanual examination, 
 the uterus being anteverted. 
 
 softening of the muscle layers and to the increased mobility of the 
 outer layers upon the inner, which are firmly attached to the ovum. 
 
 These signs are of most value from the sixth to the eighth or 
 tenth week of j)regnancy. 
 
 In order to recognise them, the best mode of examination is 
 that shown in Fig, 122, the external hand being placed behind the 
 fundus so as to bring the uterus into anteversion, and the internal 
 finger being placed in front of the cervix. Sometimes, however, 
 this cannot be done without the administration of an anaesthetic, 
 when the uterus is retroverted. Then the external hand may be 
 placed in front of the fundus, which is pushed back, and the 
 vaginal finger behind the cervix (Fig. 123). Another plan is to 
 
Diagnosis of Pregnancy. 
 
 179 
 
 place the index finger in the rectum and the thumb in the vagina, 
 while the external fingers are pressed in as shown in Fig. 123. 
 
 If the elastic enlargement of the fundus above described can be 
 ascertained, especially if Hegar's sign be present, if it agrees in 
 size with the duration of amenorrhoea, and if in addition, in a 
 nulliparous woman, a little mucoid secretion can be squeezed from 
 the breasts, a practically certain diagnosis of pregnancy may be 
 made even within the first two or three months. The medical 
 man will, however, do well not to commit his credit by an absolutely 
 positive opinion until he obtains the more certain signs of the foetal 
 
 Fig. 123.- 
 
 -Demonstration of Hegar's sign by bimanual examination, 
 the uterus being retro verted. 
 
 heart-sounds, foetal movements, or ballottement. This method of 
 diagnosing pregnancy by the bimanual examination of the uterus 
 depends greatly upon the tactus eriulitus gained by practice, and it 
 frequently happens that the inexperienced overlook a pregnancy of 
 as much as three months' standing, or even longer. The student 
 should therefore lose no opportunity of- becoming familiar with the 
 feel of the uterus in the early stage of pregnancy. The only con- 
 dition in which this method of examination fails to afford a good 
 result, is when the fundus uteri is partially retroverted or 
 retroflexed, so that it is impossible to get the fingers of the external 
 hand sufficiently behind the uterus to bring it forward into a position 
 of anteversion, and when the abdominal walls are also rigid or 
 
 12—2 
 
i8o The Practice of Midwifery. 
 
 loaded with fat. Even then, the administration of an anaesthetic 
 would generally overcome the difficulty. 
 
 Changes in the Cervix Uteri and Vagina. — The diagnostic 
 value of the changes in the cervix and vagina has already been 
 described (pp. 155 — 161). It is especially important to ascertain 
 whether the degree of change discovered corresponds to the date 
 of pregnancy as estimated by the size of the uterus, determined by 
 bimanual or abdominal examination. Towards the end of pregnancy 
 in multipara, the finger may often be passed through the cervix 
 into the uterus, and feel the membranes and presenting part of the 
 foetus. If there is a difficulty in reaching the cervix sufficiently to 
 observe its softening and apparent shortening after the third or 
 fourth month of pregnancy, when it rises to a greater distance from 
 the vulva, it is a good plan to make the patient turn on to her left 
 side, if the examination is being made with the right hand. It is 
 then possible to retract the perineum more thoroughly, and thus to 
 reach to a higher level in tlie hollow of the sacrum. 
 
 Violet Coloration of Cervix and Vagina. — Besides the 
 changes in the cervix itself, the enlarged uterine arteries may be felt 
 pulsating in the lateral fornices. These, however, may be found 
 also in the case of periuterine inliamuiation, as well as in that of 
 tumours, especially hbroid tumours of the uterus. A sign of more 
 importance is to be found in the violet coloration of the cervix uteri, 
 vagina, and vulva. The colour differs from that produced by active 
 congestion or inflammation of the mucous membrane by its bluer 
 tint, due to its being the effect of venous obstruction, the result of 
 pressure. The blue tint is first to be recognised in the cervix itself, 
 and hence it is sometimes an assistance to diagnosis, within the first 
 three months of pregnancy, to examine the cervix, with a Ferguson's 
 speculum. A similar appearance, however, may result from the 
 pressure of a tumour. 
 
 Intermittent Uterine Contractions. — Throughout pregnancy 
 gentle painless contractions of the uterus take place at intervals 
 by discharge of centric nervous force, and similar contractions may 
 often be excited by manipulation of the uterus. That they do not, 
 however, solely depend upon external stimulus, is proved by the 
 fact that the uterus may sometimes be found tense when the hand 
 is first laid upon it. The tense condition generally lasts for a minute 
 or two, resembling in its duration a labour pain. It may be 
 possible to detect the alternate contraction and relaxation of the 
 
Diag-nosis of Pregnancy. i8i 
 
 uterus as soon as it comes into contact with the abdominal wall, 
 and it becomes more and more easy to do so as pregnancy advances. 
 It may often, however, be necessary to watch the case for some 
 time, and make repeated examinations, before a decisive result is 
 obtained. In the intervals of relaxation the uterus lies flaccid 
 under the action of gravity, its outline is indistinct, and the foetus, 
 if large, can be easily felt through its walls. During a contraction 
 it resumes more or less its true pyriform shape, so that it becomes 
 more prominent in front, its boundaries become definite, and the 
 tenseness of its surface prevents the parts of the foetus from being 
 distinctly felt. If this sign is obtained in a strongly marked 
 degree, it is proved not only that pregnancy of some sort exists, 
 but that it is intra-uterine. In the case of a soft fibroid tumour, 
 variations of density may take place owing to uterine contractions, 
 but these are never so strongly marked as the more characteristic 
 changes which may be observed in a pregnant uterus. Similar 
 changes might conceivably occur in a distended bladder, but have 
 not been observed in it, andit seems that the bladder, when over- 
 distended, loses its contractile power. The j)regnant uterus, when 
 in an irritable state, sometimes remains continuously in a partially 
 contracted and tense condition, and it may then be impossible to 
 detect alterations of tenseness in its walls. The failure, therefore, 
 after repeated attempts, to detect contractions, does not prove that 
 any given swelling is not the uterus, although, if the presumed 
 pregnancy is at an advanced stage, it should always excite suspicion 
 on this point. 
 
 There are two cases in which this sign is of special value. The 
 first is when an irregular tumour exists, and there is doubt whether 
 a part or the whole of it is formed by the pregnant uterus. If the 
 hardening of contraction extends over the whole mass, it is proved 
 that the whole of it, however irregular, consists of the uterus. The 
 second case is that of an excess of liquor amnii, when the foetus is 
 too small to give signs of its life, and the pregnant uterus may be 
 mistaken for an ovarian cyst, and is liable even to be tap]3ed under 
 such a mistaken diagnosis. 
 
 Ballottement. — By ballottement {hallotter, to toss up like a ball) 
 is meant the sensation imparted to the fingers when they are placed 
 beneath or at the sides of the foetus, and, as it were, toss it up or 
 about in the liquor amnii. There are two kinds of ballottement, 
 internal and external, of which the internal is the most valuable as 
 a sign of pregnancy. Internal ballottement is obtained in the 
 following manner : The woman is placed in the dorsal position, the 
 
1 82 The Practice of Midwifery. 
 
 index finger, or two fingers, of one hand are introduced into the 
 vagina, while the fundus is pressed down by the other hand or by an 
 assistant. The uterus is brought into the most favourable position 
 if the woman takes a deep breath, and then holds her breath for a 
 moment. The finger in the vagina, with its tij) resting just in front 
 of the cervix, then gives a sudden but gentle push or jerk upwards. 
 The hard foetal head, which is usually resting at this spot, is felt to 
 recede from the finger, and after a moment's interval, to return with 
 a gentle tap. This constitutes the complete sign of ballottement 
 {choc en retour, ballottement double), but sufficiently characteristic 
 evidence may often be obtained even if a distinct return-tap cannot 
 be made out, provided that the hard body can be felt to recede, and, 
 after a moment or two, to have returned to its former position. If 
 the foetal head does not rest in front of the cervix when the woman 
 is horizontal, it may often be made to do so, and to give the sign of 
 ballottement, if she is placed in a reclining position, with the 
 shoulders and head raised but supported by pillows, so that the axis 
 of the uterus is nearly vertical, or its upper extremity inclined 
 somewhat forward. If this also fails, the finger may be introduced 
 into the vagina as the woman stands uj^right. If any other part 
 than the head is presenting, internal ballottement cannot so easily 
 be obtained. Ballottement is chiefly available from the end of the 
 fourth to the seventh month, and is most marked about the middle 
 of that period. It may sometimes be obtained in the latter half of 
 the fourth month, earlier than it is possible to detect the foetal 
 heart-sounds, and it is at this early stage that this sign is most 
 valuable. In the last two months of pregnancy, the quantity of 
 liquor, amnii becomes relatively too small to allow the foetus to be 
 tossed up, but the hard foetal head, if presenting, may be felt 
 through the uterine wall by the finger placed in front of the cervix, 
 and may be moved by it to some extent. 
 
 Internal ballottement is a positive sign of pregnancy, though not 
 of the life of the foetus, if detected by a skilled observer. An in- 
 experienced person might possibly mistake an anteflexed fundus 
 uteri, especially if associated with ascites, for the foetal head ; but 
 the anteflexed fundus would not give the distinct return-tap upon 
 the finger after tossing ujd which makes the sign of ballottement 
 complete. 
 
 External ballottement is obtained in the following manner : The 
 woman is placed in the dorsal position, with the abdomen exposed 
 or only lightly covered ; one hand is placed on either side of the 
 uterus, and by a light quick movement of the fingers one or other 
 part of the foetal body may be made to recede and often to impinge 
 
Diagnosis of Pregnancy. 183 
 
 upon the opposite hand. In some instances only an irregular mass 
 may be felt which can be moved to and fro. This sign can be 
 best obtained when the breech is presenting and the head is at the 
 fundus. External ballottement can be made out to some degree as 
 soon as the uterus is in contact with the anterior abdominal wall, 
 and it is a very characteristic sign of pregnancy when definitely 
 present. It may be obtained also in the following manner, and this 
 method is particularly useful in cases of hydramnics where the 
 excess of liquor amnii may obscure the parts of the foetus. The 
 patient is placed in the lateral or semi-prone position, so that the 
 uterus rests against the couch, or overhangs its edge. One hand is 
 placed above the uterus to steady it, while the fingers of the other 
 are laid flat beneath the uterus at any point where a firm portion of 
 the,foetus can be felt, and give it a jerk upwards, as in the case of 
 internal ballottement. 
 
 Foetal Movements. — Foetal movements probably commence at 
 a very early stage in the development of the muscular system of 
 the embryo. They are generally first felt by the mother about the 
 eighteenth to the twentieth week, but the time when this occurs is 
 very variable. The first feeling of the foetal movements, which is 
 known by the name of quickening, is supposed to depend upon the 
 uterus having risen sufficiently into the abdomen to come into 
 contact with the abdominal walls. The unaccustomed sensation, 
 when first felt, especially in first pregnancies, often gives rise to 
 a feeling of faintness, or other disagreeable nervous symptoms. 
 As pregnancy advances, the motions become more and more 
 manifest ; in the later months they may often be seen as well 
 as felt, and can readily be excited by stimulating the foetus with 
 pressure through the abdominal wall. Foetal movements may 
 be heard on auscultation before they are recognised by the 
 mother, and before the foetal heart is audible. The sound at first 
 is a faint thud, later in pregnancy louder thuds or taps may be 
 heard, and sometimes loud scratching or rubbing noises, as the 
 foetal extremities scrape against the interior of the uterus. They 
 occur in some patients with extreme frequency. When pregnancy 
 is somewhat advanced, an impulse against the stethoscope may 
 often be felt accompanying the sound. The movements may 
 sometimes be felt from the abdomen by the physician before the 
 mother feels them, and at an earlier stage still, before the uterus 
 has come into contact with the abdomen, they may sometimes 
 be felt from the vagina, or on bimanual examination. Move- 
 ments may be felt in this way from the vagina as early as the 
 
184 The Practice of Midwifery. 
 
 beginning of the fourth month, and may be heard on auscultating 
 the abdomen about the middle of the fourth month. 
 
 Recognition of foetal movements is of great value in diagnosis, 
 for it proves not only pregnancy, but the presence of a living foetus, 
 and often it does this when the foetal heart cannot be heard. The 
 subjective sign of quickening is of little or no value, for some- 
 times women fail to perceive the movements up to quite a late 
 period of pregnancy. More frequently, even women who have 
 borne several children mistake intestinal movements for those of 
 a foetus, and on this ground become firmly convinced that they 
 are pregnant. Even the physician will find a faint sound of 
 foetal movement more difficult to be certain about than the sound 
 of the foetal heart, and must take care not to mistake for it either 
 movements of the abdominal muscles or those of the intestines. 
 
 « 
 
 The sign is greatly confirmed if the movements can be felt as well 
 as heard. There is one case in which the recognition of foetal 
 movements by feeling from the vagina is of special value. This is 
 when pregnancy is complicated by an abdominal tumour, which may 
 prevent the fundus uteri from coming into contact with the abdominal 
 walls up to a much later period than usual, so that the usual signs, 
 on auscultating the abdomen, are entirely absent, and even the en- 
 largement of the fundus uteri may be obscured by the presence of 
 the tumour. 
 
 Uterine Souffle. — The uterine souffle is a soft blowing murmur, 
 synchronous with the maternal pulse and present in about 99 per 
 cent, of all pregnant women. It is generally heard on one or both 
 sides of the uterus, rather low down, over the position of the 
 uterine arteries, but sometimes it is audible over a considerable i^art 
 of the fundus. It was formerly called the placental souffle, from 
 the belief that it had its origin in the placenta. This is disproved 
 by the fact that it may be heard for some days after delivery, with 
 diminishing intensity, and that a similar souffle may be heard in 
 some cases of uterine tumour. It is now generally agreed that the 
 uterine souffle has its origin in the large arterial branches 
 approaching the uterus from the broad ligaments and entering the 
 uterine walls. No certain inference can be derived from it as to 
 the position of the placenta. The arteries, however, are most 
 developed in the neighbourhood of the placenta, and if the souffle 
 is heard widely over the fundus in front, there is a certain presump- 
 tion in favour of the placenta being attached in front. The 
 converse inference must not be drawn from the absence of a souffle 
 in front. The souffle is physically explained, partly by the presence 
 
Diagnosis of Pregnancy. 185 
 
 of many large arterial branches having tortuous courses, and 
 partly by the deteriorated quality of the blood in some women in 
 pregnancy, which renders it more prone to generate a murmur, as 
 in the case of the arterial and venous murmurs of anaemia. The 
 soufSe is loudest when the blood deterioration is greater than usual. 
 In some such cases the murmur can be distinguished as being 
 double, the second and fainter element corresj)onding to the dicrotic 
 wave of the pulse. The uterine souffle differs slightly from the 
 murmur produced by pressure on a large artery in that it swells 
 and dies away more gradually, and is generally softer. This 
 probably is due to its being produced in a number of arterial 
 branches of various sizes. It has been comj)ared to the puffing of 
 the engine of a goods-train going slowly, and heard from a distance. 
 The uterine souffle of pregnancy has also the special character that 
 it is very variable at different times in the same person. This 
 character appears to depend mainly upon the effect of contractions 
 of the uterus, and partly also upon changes in its position. As a 
 uterine contraction comes on, the souffle becomes raised in pitch, 
 and thereby often for a time louder, sometimes even almost 
 whistling in tone. As the contraction reaches its height, it becomes 
 fainter, and may be even suppressed, resuming its original quality 
 as the pain passes off. The souffle may sometimes be modified to 
 some extent by pressure with the stethoscope, and has been felt 
 occasionally as a thrill by the finger. 
 
 The uterine souffle may be heard towards the end of the fourth 
 month, and therefore generally earlier than the fcetal heart-sounds, 
 some say even as early as the eighth or ninth week. In the early 
 months it must be sought for by placing the stethoscope close above 
 the pubes at either side, and pressing it deep down to reach the 
 sides of the uterus. The souffle is of considerable value in the 
 diagnosis of jDregnancy, especially in the earlier months, when the 
 foetal heart cannot be detected. It is true that it may be heard in 
 uterine tumours, but these are rarely associated with amenorrhoea. 
 Moreover, a tumour equal in size to a uterus pregnant less than 
 four and a half months rarely gives a souffle. If the souffle is found 
 to have marked variations of quality and loudness, tlie presumption 
 of pregnancy is increased, for tumours are not subject to such 
 marked contraction as the pregnant uterus. A souffle may be heard 
 in extra-uterine pregnancy, but not so constantly as in normal 
 pregnancy; and, if heard, it would not be so likely to vary in quality. 
 
 Fcetal Heart- Sounds. — The foetal heart-sound is double, like 
 that of a heart in after-life, but the distinction in quality between 
 
1 86 The Practice of Midwifery. 
 
 the two sounds is not so marked. When the heart is heard only 
 faintly, the first sound alone may be audible. The quality of the 
 sound has been compared to that of a watch (not a lever watch) 
 ticking underneath a pillow. The student can, however, best learn 
 it by listening to the heart of an infant soon after birth. The rate 
 generally varies between 120 and 160 in the minute. It has often 
 been stated that the rate is most rapid when the heart-sounds first 
 begin to be heard, while the foetus is still very small, and that it 
 diminishes in rapidity with the advance in pregnancy. In reahty, 
 however, there is no marked progressive change. The rapidity of 
 the heart is much increased, sometimes as much as twenty beats 
 in the minute, by active fcetal movements. It varies also to some 
 extent in accordance with the condition of the mother. When the 
 maternal pulse is rapid on account of fever, the rate of the foetal 
 heart may be increased also, although not in anything like the same 
 proportion: As in the case of the adult heart, an elevation of the 
 blood-pressure makes the heart's rapidity less. In the case of the 
 foetus, the blood-pressure is chiefly liable to be affected by pressure 
 upon the funis and placenta. Thus, during a labour pain, the foetal 
 heart becomes slower, and resumes its former rapidity when the 
 pain is over. During a head-last delivery, when the funis is 
 pressed upon, the foetal pulse-rate, as observed in the funis, may 
 become very slow, and a sudden and great increase of rapidity 
 may then sometimes be noticed the instant the head is liberated. 
 The foetal heart-rate also becomes slower as the vitality of the 
 foetus is becoming exhausted by prolonged pressure in delivery ; and 
 thus, in protracted labour, as the mother's pulse becomes gradually 
 more rapid, the foetal heart becomes gradually slower. The 
 pressure on the funis and placenta leads also to diminished 
 oxygenation of the foetal blood, and so to stimulation of the vagus, 
 and further slowing of the foetal heart. This change of rapidity 
 affords a valuable sign of danger to the child's life. In these cases 
 the heart only gradually returns, after delivery, to its former 
 rapidity or nearly so. The foetal heart-sounds can generally be 
 detected for the first time in the course of the fifth month of 
 pregnancy, mostly from the eighteenth to the twentieth week. 
 In unusually favourable circumstances, they may be heard as 
 early as the fifteenth or sixteenth week, and they become 
 progressively louder as pregnancy advances. 
 
 The fcetal heart-sounds are by far the most valuable of all the 
 signs of pregnancy. If they are recognised, it is proved that 
 pregnancy exists with a living foetus, and the only possible further 
 doubt that could arise is whether the pregnancy is normal or extra- 
 
Diagnosis of Pregnancy. 187 
 
 uterine. If, then, the presumed pregnancy has reached the fifth 
 month, it is well to make the listening for the foetal heart one of the 
 early steps of the examination. If it is detected, only a confirmation 
 of the pregnancy being intra-uterine is required, and this is to be 
 found in the changes of the cervix, the characters of the uterine 
 tumour, audits alternate contraction and relaxation. To listen for the 
 foetal heart, perfect quiet in the room must be secured, and any 
 ticking clock should be stopped. The stethoscope should be pressed 
 
 o o 
 
 I y i 
 
 Fig. 124. — Diagram showing the areas in which the foetal heart sounds are 
 heard with greatest intensity in vertex and breech presentations. The 
 upper circles indicate the area of maximum intensity in the first and 
 second breech presentation, the inner of the lower two circles in the first 
 and second vertex, and the outer in the third and fourth. The two latter 
 circles are a little too far forwards. 
 
 gently upon the abdomen by resting the ear upon it, and should 
 not be held by the fingers, or allowed to touch the clothes. Some 
 prefer a binaural stethoscope, as intensifying sound, but I have 
 often found it fail to reveal the foetal heart when an ordinary 
 wooden stethoscope succeeds, probably because muscular sounds 
 are more liable to create confusion in the binaural. The foetal 
 heart should always be counted, and it should be noted whether 
 the rate remains tolerably constant in successive quarters of a 
 minute. If it cannot be counted, the sign must be regarded as 
 unco^rtain. 
 
1 88 The Practice of Midwifery. 
 
 The heart-sounds are transmitted best through the back of the 
 foetus when tbe foetus is in its usual attitude. In the early months 
 the fcetal heart-sounds are most readily heard in the middle line 
 between the symphysis and the umbilicus. However, toward the 
 latter part of pregnancy, if the foetus is lying in the first position, 
 with its back towards the left side, as it is in the great majority of 
 cases (see Fig. 124, p. 187), the likeliest place to hear the foetal 
 heart is about half-way between the umbilicus and the centre of 
 Poupart's ligament on the left side. If it is lying in the second 
 position, with its back toXvards the right side, the heart is heard best 
 in the corresponding position on the right side. When the foetus 
 is presenting by the breech, the foetal heart is heard best relatively 
 higher up, at the level of or even above the umbilicus, in proportion 
 to the size of the uterus (Fig. 124). In face i^resentations, it is 
 heard through the thorax better than through the back. In any other 
 than a face presentation, when the back of the foetus is lying back- 
 ward, and the limbs with a good deal of liquor amnii intervene 
 between its trunk and the surface of the uterus, the foetal heart is 
 heard less distinctly, and sometimes not heard at all. If, therefore, 
 it is not heard at the first attempt, repeated trials should be made 
 on different occasions, and it must not be assumed that the child 
 is necessarily dead, if the foetal heart appears for a time to have 
 disappeared. In order to catch.the foetal heart-sounds at an early 
 stage of pregnancy, a great deal depends upon the observer's ear 
 being practised in distinguishing them. It is therefore desirable, 
 even for those who are skilled in auscultation in general, to take 
 opportunities of practising this form of it in particular. In normal 
 conditions the sounds are heard usually over an area of a circle 
 with a radius of some 5 to 6 cm., but when they are faint they are 
 audible only over a very limited portion of the abdomen. If, there- 
 fore, they are not at first detected, the attempt should not be given 
 up until the whole surface of the uterus has been explored. 
 
 In a few instances it has been found possible to palpate the foetal 
 heart directly through the abdominal wall of the mother. 
 
 The chief fallacy which is likely to occur is the mistaking the 
 woman's heart-sounds, which may sometimes be heard in a similar 
 situation, esj^ecially when a tumour is present, for those of a foetus. 
 If the mother's pulse is slow, while the foetal heart has its usual 
 rapidity, counting the two is sufficient to distinguish between 
 them. If, however, the woman's pulse is rapid, 120 or more, 
 great care is required. The radial artery should be felt while 
 the ear rests upon the stethoscope. If the sounds heard are 
 really those of a foetal heart, it will be found that the two will not 
 
Diagnosis of Pregnancy. 189 
 
 continue exactly synchronous for long together, even though their 
 rates are about the same, but one or the other will fall behind. 
 Another test, which should be used in addition in any case of 
 doubt, is to trace the sounds towards the woman's heart. Foetal 
 heart-sounds will then be lost, but the woman's heart-sounds will 
 become gradually intensified. 
 
 Variation of Rate of Heart according to Sex and Size of Foetus. — It 
 has been found that the average rate of heart is more rapid in 
 girls than in boys. The average for all children is about 132 per 
 minute. If the rate much exceeds this, say amounts to 140 or 
 more, there is a certain presumption in favour of the child being a 
 girl ; if it falls much below it, say is only 124 or less, in favour of 
 its being a boy. The observation is only of value if made before 
 labour has begun, in the last two months of pregnancy, and while 
 the foetus is quiet. The rapidity of tlie heart, however, varies 
 ©onsiderably in the same children at different times without any 
 obvious cause, and hence the method is extremely uncertain. 
 Predictions in individual cases would not come true in more than 
 two cases out of three at the most. There have been also 
 observations tending to show that the rate of the heart is slower the 
 larger the child ; and it has been inferred by some that boys have 
 slower pulse-rates only because they are generally larger than girls. 
 The fact that there is no marked change in the heart's rapidity 
 from the time when it is first heard, when the foetus is quite small, 
 would seem to be rather against this view. At the sixteenth week 
 I have found the rapidity to be not greater than 140 per minute. 
 
 Funic Souffle. — Occasionally a blowing murmur is heard as 
 well as the double foetal heart-sound. Sometimes this replaces 
 the foetal heart- sounds altogether, but more frequently the clear 
 heart-sounds are heard at one spot, the murmur at another not far 
 off. Such a murmur is occasionally a cardiac bruit, but is generally 
 produced in the funis, at some j)oint where it is subjected to 
 pressure or twisted. It is very variable in the same jDcrsons, 
 According to some, it may be heard in as many as 12 or even 
 15 per cent, of cases at the end of pregnancy. 
 
 As the funic soufHe is produced usually by pressure on the cord 
 when it persists throughout the whole course of labour, and 
 especially when it increases in intensity, it forms an important 
 warning of impending danger to the life of the foetus. According to 
 Von Winckel, some 76'5 per cent, of the children are still-born in 
 these conditions. 
 
 Special forms of stethoscope have been made to auscultate the 
 
iQo The Practice of Midwifery. 
 
 uterus through the vagina ; and by means of these, the foetal 
 movements, the uterme souffle, and possibly the foetal heart-sounds, 
 may be heard somewhat earlier. These are not likely, however, 
 to come into general use. 
 
 Recapitulation of Signs in Order of Date.— A brief re- 
 capitulation of the more important signs of pregnancy in the order 
 of their occurrence may here be of use. Suppression of menses 
 generally dates from the commencement. Pain, tenderness, and 
 slight swelling of the breasts may begin from the very first. 
 Morning sickness may also begin from the first, but more 
 commonly in the second month. Within a very few weeks, 
 the time varying according to the skill of the observer, elastic 
 enlargement of the fundus uteri may be made out bimanually, 
 and Hegar's sign may be distinguished. From the beginning 
 of the second month (in primiparse) softening begins at the tip of 
 the cervix, and gradually increases. In the second or third month 
 some violet coloration of the cervix, as seen by speculum, may 
 commence. By the beginning of the third month some mucoid 
 secretion may be squeezed from the breasts. In the third month 
 foetal movements may possibly be felt from the vagina or bi- 
 manually. From the beginning or middle of the fourth month 
 they may be heard from the abdomen ; and from the end of the 
 fourth month they may also be felt externally. In the fourth 
 month the changes of softening and apparent shortening in the 
 cervix are generally characteristic, and the cervix begins to ascend 
 higher. Sometimes, by the middle of the fourth month, or, at any 
 rate, at the end of it, ballottement may be obtained. Towards the 
 end of the fourth month, and sometimes even earlier, the uterine 
 souffle may be heard. Alternate contractions and relaxations of the 
 uterus may be made out generally during the fifth month. The 
 foetal heart is generally first heard during the fifth month, from the 
 eighteenth to the twentieth week, but sometimes before the end of 
 the fourth month. In the fifth month also, the secondary areola 
 sometimes begins to be visible round the nipples. From this time 
 onward all the signs become progressively more manifest except 
 ballottement, which fails in the last two or three months. In 
 the last two months, in multiparge, the finger may sometimes be 
 passed through the cervix, and feel the presenting part. 
 
 Differential Diagnosis of Pregnancy. — A diagnosis of 
 pregnancy must be based on the recognition of the physical or 
 direct signs of that state and it is therefore unnecessary to go 
 
Diagnosis of Pregnancy. 191 
 
 through all the conditions which might possibly be mistaken foi- 
 pregnancy, since in all of them these direct signs will be absent. 
 In a case of doubt the order of investigation should be to ascertain, 
 first, that some tumour is present in the abdomen ; secondly, that 
 it is the enlarged uterus ; and thirdly, that the enlargement is due 
 to pregnancy. It is chiefly within the first four months, and 
 especially the first three months, that some uncertainty may exist, 
 but a month or two's delay will then always solve the question. 
 Within the first four months, the enlargement of the uterus due 
 to pregnancy has to be distinguished from that due to fibroid 
 tumour or subinvolution and cbronic metritis, and the distinction 
 may generally be made by the peculiar elasticity, and indefinite 
 outline, so characteristic of the pregnant uterus. It is to be 
 remembered, however, that a dead ovum may be retained for 
 months within the uterus, and that the uterus in such a case may 
 become hard. The nature of the case will then generally be 
 indicated by the history, especially by the absence of menstruation, 
 but sometimes can only be cleared up by exploration of the cavity 
 of the uterus. (See Chapter XXII.) The tumour formed by 
 hcematometra, or distension of the uterus with retained menstrual 
 secretion, may resemble the pregnant uterus, though generally it is 
 more tense. In this case there will be a history of spasmodic pain 
 recurring every month ; and either the patient will be a girl who 
 has never menstruated externally, or there will have been some 
 cause, such as an operation on the cervix, to produce occlusion of 
 that canal. Moreover, the impervious state of the vagina or cervix 
 may be detected on examination. The most difficult cases for 
 diagnosis are those in which pregnancy is comj)licated with a 
 uterine or ovarian tumour. In these the tumour may obscure some 
 of the usual jjositive signs ; and not only has the fact of pregnancy 
 to be made out, but they have to be distinguished from cases of 
 extra-uterine pregnancy, which also generally produces an irregular 
 mass in the abdomen. In these cases the likelihood of mistaking a 
 retroverted gravid uterus for a periuterine hsematocele must be 
 borne in mind especially, and the utmost pains must be taken to 
 ascertain how much of the tumour consists of the uterus, and 
 whether there is a fcetus inside or outside the uterine cavity. The 
 diagnosis of j)regnancy with excess of liquor amnii from an ovarian 
 cyst, often a difficult one to make, will be considered under the 
 head of hydrops amnii. 
 
 Pseudocyesis, or spurious Pregnancy.- — A case in which a 
 diagnosis is often called for, Ijut in which it is not difficult to make, 
 
192 The Practice of Midwifery. 
 
 if any care is used, is that of imaginary or spurious pregnancy, to 
 which the term pseudocyesis has been applied. En this condition 
 many of the more superficial signs of pregnancy may exist, 
 suppression of menstruation, mammary changes with presence of 
 secretion, prominence of abdomen, and supposed foetal movements. 
 It may occur at any time of life in women who desire or expect 
 that they may become pregnant. It is most frequent, however, at 
 the approach of the menopause, when menstraation is arrested, or 
 perhaps has only become very scanty, and there is at the same time 
 a deposit of fat in the abdominal walls and flatulent distension 
 of the intestines. The prominence of the abdomen may be due 
 simply to these causes, but often it is produced also in part by the 
 attitude assumed, the convexity forwards of the lumbar spine being 
 increased, and the shoulders thrown back. The mental condition 
 has much to do with the production of this state, which is more 
 frequently found in hysterical women. It may vary from a not 
 unnatural mistake, dispelled at once by a medical opinion, through 
 all degrees up to an almost insane delusion, proof against assurances, 
 which may persist for more than the natural nine months of preg- 
 nancy. In more rare cases, in addition to the spurious pregnancy, 
 there is a spurious labour when the expected time of delivery has 
 arrived, and labour pains seem to come on, and recur for some time 
 at regular intervals. This generally happens to a woman whose 
 medical attendant has accepted her own account of her condition 
 without investigation. 
 
 Spurious pregnancy is easily recognised on examination. There 
 is no complete dulness in the abdomen, though there may be 
 diminished resonance from deposit of fat. The os is found unaltered, 
 and there is no uterine tumour to be felt on bimanual examination. 
 The apparent tumour produced by arching of the spine and tension 
 of the muscles is, if necessary, dispelled at once on the adminis- 
 tration of an anesthetic. The formality of this proceeding, coupled 
 with a consultation, is often of great use in convincing the patient, 
 or at any rate her friends, that no pregnancy exists. 
 
 Diagnosis of the Life or Death of the Fcetus. — The indications 
 of the life of the fcetus to be relied on are the fcetal heart-sounds 
 and fcetal movements. If, after being manifest, these can no 
 longer be discovered on repeated examinations by a competent 
 person, its death may be inferred. Some weight, but not an abso- 
 lute one, may be attached to the sensation of movements by the 
 mother. In the earlier months of pregnancy, before movements or 
 heart-sounds are distinguishable, the foetus may be inferred to be 
 
Diagnosis of Pregnancy. 193 
 
 dead if the enlargement of the uterus be observed to have become 
 arrested, and there has been a recession in the development of the 
 breasts. Sometimes, but not always, the mother's health becomes 
 impaired in such a case. In some cases, especially when at least 
 the half-term of pregnancy has been reached, the death of the 
 foetus j)roduces an increased secretion of colostrum or milk, similar 
 to that which occurs after its expulsion. This is shortly followed 
 by recession of the breasts. Generally, after death of the ovum, 
 reflex symptoms of pregnancy, such as vomiting, diminish or 
 disappear. But, in some instances, vomiting and general malaise 
 commence only on the death of the ovum. A sense of coldness in 
 the situation of the uterus is given as a sign of death of the ovum, 
 but is not much to be relied upon. The dead ovum cannot of 
 course become colder than the maternal tissues surrounding it, 
 although it ceases to impart warmth to them. 
 
 It has been suggested to place a thermometer in the vagina and 
 then in the cervix, and if the temperature of the two cavities is 
 found to be the same, there is a considerable probability that the 
 foetus is dead. 
 
 Considerable and persistent haemorrhage from the uterus does 
 not necessarily imply the death of the foetus ; an offensive 
 uterine discharge generally does so. If the finger can be passed 
 through the os, and feel the cranial bones loosened in the scalp, the 
 death of the foetus is assured. 
 
 Diagnosis between first and subsequent Pregnancies. — 
 
 The most valuable distinction between first and subsequent preg- 
 nancies is to be found in the condition of the hymen. The effect 
 of coitus is generally to tear notches in the edge of the hymen. 
 These do not, however, extend completely down to the base of 
 attachment of the hymen, which forms the lower limit of the 
 vagina. In a nulliparous woman, therefore, the hymen can always 
 be easily traced, its attachment being continuous, its free border 
 more or less broken up. If the two index fingers be inserted 
 between the hymen and the fourchette, and separated a little 
 laterally, the fossa navicularis, or boat-shaped depression thus 
 produced, can be made out. On the other hand, the effect of 
 parturition in a primipara, either at full term, or in the later months 
 of pregnancy, is to produce an inevitable laceration of the vaginal 
 outlet, formed by the hymeneal attachment, this being the narrowest 
 and least dilatable part of the canal formed by the soft parts. The 
 laceration consists of one, or more frequently several, longitudinal 
 rents, extending completely to the base of the hymeneal attachment 
 M. 13 
 
194 The Practice of Midwifery. 
 
 and separating the component parts of the hymen. In a parous^ 
 woman, therefore, the hymen either remains only in the form of 
 several detached prominences of mucous membrane, the caruncidce 
 myrtiformes, or, at any rate, there are one or more well-marked 
 spaces, or cicatricial bands separating its torn fragments. The fossa 
 navicularis no longer exists as a depression ; but the mucous mem- 
 brane forming it has become flush with the posterior vaginal wall. 
 The essential part of the process concerned in the production of 
 carunculffi myrtiformes is the sloughing of intermediate portions of 
 hymen, which only occurs after the bruising of labour. The only 
 thing which could possibly simulate the effects of labour is the 
 delivery of a large tumour through the vagina. 
 
 There are many other signs whose presence affords more or less 
 positive evidence of a previous pregnancy, though their absence 
 does not prove that a former parturition may not have occurred, 
 especially at an interval of a considerable number of years, or before 
 the full term of pregnancy. The most decisive of these are the 
 existence of old lacerations of the perineum, either destroying the 
 fourchette only or extending more deeply, and alterations in the 
 cervix. Generally in parous women the os uteri is converted from 
 a round or oval opening into a transverse slit, from slight notches 
 at each side having been produced by laceration in parturition ; 
 and from the same cause the cervix becomes broader at the end and 
 less tapering. It also softens less early in a subsequent pregnancy. 
 Not infrequently there is more obvious evidence of previous 
 parturition in the presence of the deeper lacerations produced 
 in labour. These are most frequently bilateral, usually deepest 
 on the left side, and they are often accompanied by eversion 
 of the anterior and posterior lips of the cervix. Sometimes 
 they are unilateral, triradiate, or still more irregular. Other 
 signs are the result of distension in previous pregnancies. The 
 abdominal walls, instead of being tense, are often lax, so that 
 they can be raised in a fold between the fingers, and allow the 
 uterus and parts of the foetus to be more readily explored. The 
 breasts are flaccid and drooping instead of being firm and tense. 
 Besides the reddish or bluish skin-cracks on the side of the abdo- 
 men and the breasts, which appear only in the later months of 
 pregnancy under the influence of actual tension, other old, silvery 
 white skin-cracks {linece albicantes) may be detected, before the skin 
 is actually put on the stretch. 
 
 ^ I.e., a woman who has borne one or more children. 
 
Chapter X, 
 THE DURATION AND HYGIENE OF PREGNANCY. 
 
 The Duration of Pregnancy. — It is never possil)le, in the human 
 subject, to determine the exact date of conception. It is only in 
 very exceptional cases that the date of fruitful coitus is known, and 
 even when this is the case, it is possible that conception may not 
 occur for several days, possibly even as much as ten or fourteen 
 days afterwards, the spermatozoa meanwhile retaining their 
 vitality. In general, the only date we have to reckon from is that 
 of the last menstruation, and this is sufl&ciently accurate for most 
 purposes, since, as we have already mentioned, the most favourable 
 time for impregnation is when menstruation and ovulation coincide, 
 and insemination occurs just before or after menstruation. 
 
 In the case of domestic animals, where there is generally only a 
 single coitus, and that at a period of ovulation, more exact obser- 
 vations are possible. The result is to show that there are con- 
 siderable variations in the duration of pregnancy dating from the 
 coitus, greater even than are supposed to occur in the case of 
 women. Not only do some deliveries occur considerably before 
 the average date at which the great majority take place, a result 
 which might be due to premature labour, but a few occur con- 
 siderably after it, and thus appear to prove an unusual protraction 
 of gestation in some individual cases. Thus in cows the average 
 duration of pregnancy is about 282 days. Oat of 140 cows observed 
 by Tessier, 121 calved between the 269th and 290th day, but five 
 calved between the 290th and 308th day. Again, in mares the 
 average duration is about 348 days. Out of 102 mares observed by 
 Lord Spencer, 72 foaled between the 340th and 360th day, but 21 
 foaled at various times from the 360th to the 377 th day, and 
 one on the 394th day. From analogy it may be expected, that, in 
 the human subject also, pregnancy may in exceptional cases be 
 protracted longer than usual, and the child probably in consequence 
 attain an unusual size. 
 
 The calculation of the average duration of pregnancy from a 
 single coitus is open to considerable uncertainty, since many of the 
 cases are those of unmarried women whose statements on the 
 subject are open to suspicion. Matthews Duncan collected 
 
 13—2 
 
196 The Practice of Midwifery. 
 
 46 cases, and calculated an average of 275 days. Other authors 
 give other estimates, generally lower than this, and varying from 
 268 to 276 days.^ The question of the duration of pregnancy from 
 the fertile coitus is chiefly of interest in reference to the medico- 
 legal question, whether a child is to be regarded as possibly 
 legitimate or not, when born at an interval longer than usual after 
 the last possible date of coitus with the husband. The laws of 
 Scotland, France, and Austria, allow a possible limit of 300 days, 
 that of Prussia one of 302 days. In England and America no 
 absolute limit is laid down, but each case must be judged on its 
 merits. In America a very liberal view has been taken, and 
 legitimacy has been allowed after intervals of 313 and 317 days. 
 No case of protraction beyond 300 days from a single known coitus 
 has, however, been scientifically established. Of James Eeid's cases 
 the longest was 293, and Leishman relates the case of a married 
 lady, in which the interval was 295 days, and the child weighed 
 12 lb. 3 oz. Of cases in which the minimum duration of pregnancy 
 was supposed to be fixed by the death or departure of the husband, 
 one recorded by Mr. Hewitt gives 308 days, one by Sir James 
 Simpson 313 days, and two by Dr. Murphy 314 and 324 days 
 respectively. The last, at least, is reasonably open to doubt, but 
 there is some reason to think that pregnancy may possibly be 
 sometimes prolonged to the equivalent of ten menstrual periods 
 instead of nine, or to about 308 days. For cases have been 
 recorded in which labour pains have come on at the expected time, 
 but have passed off again, and have not recurred until four weeks 
 later, while the child, when born, has been of unusual size and 
 weight. In any medico-legal case, the fact of a child having been 
 of unusual size at birth would be evidence in favour of the possi- 
 bility of the pregnancy having been unusually protracted, although 
 it is also possible that the child might be unusually small at full 
 term, and therefore not larger than usual when born at a later 
 period. Ballantyne records the case of an anencephalic foetus, 
 which must have been either 1^ or 2^ months post-mature, and 
 which weighed 9 lb. although anencephalic, and showed other 
 signs of post-maturity ; ^ that is, it was not only large, but apart 
 from the deformity exceptionally well developed. 
 
 1 See Montgomery, Signs of Pregnancy, 2ncl ed., pp. 493 et seq. ; Duncan, 
 Fecundity, Fertility, and Sterility, 1871, p. 457; Ahlfeld, " Beobachtungen liber die 
 Dauer der Schwangerschaft," Mon. f. Geb., 1869, XXXIV.; Lowenhardt, "Die 
 Berechnung und die Dauer der Schwangerschaft," Arch. f. Gyn., 1872, III. ; 
 V. Winckel, Samml. Klin. Vortr., N. F., No. 285, 1900, Gyniik. No. 84; Issmer, 
 Archiv. f. Gynak., 1887, Hft. 2, XXX., p. 277, 1889, Hft. 2, XXXV., p. 310; Filth, 
 Zentrbl. f. Gynak., 1902, No. 39. 
 
 2 Journ. of Obst. and Gyn. Brit. Emp., Dec, 1902. 
 
The Duration and Hygiene of Pregnancy. 197 
 
 The actual duration of pregnancy is dependent upon a number 
 of different factors, such as the sex and size of the child, the con- 
 stitution and strength of the mother, whether she is a married or a 
 single woman, the number of pregnancies she has had, and the 
 amount of rest she is able to take during the latter months of her 
 pregnancy. 
 
 As a general rule, when the size of the child exceeds the normal, 
 the duration of the pregnancy does so also. Thus the average 
 length of the pregnancy for children weighing more than 4,000 
 grammes, or 8*8 lb., is 286 days counting from the last menstrual 
 period, and 275 days reckoning from a single coitus. Of 245 such 
 children, in 12"2 per cent, the pregnancy lasted more than 302 
 days from the last menstrual period, and in 4 of 118 more 
 than 302 days from a single coitus. At the same time it must 
 be remembered that pregnancy may be prolonged with a child of 
 average size. Thus in 3'2 per cent, of children weighing less 
 than 4,000 grammes, or 8*8 lb., the pregnancy lasted more than 
 302 days. 
 
 Cases are recorded of very considerable apparent protraction of 
 pregnancy from the date of the last menstrual period. It is not 
 wonderful that this should be the case, since it is an undoubted 
 fact that conception may occur during a period of amenorrboea, 
 and such cases prove nothing as to real prolongation of gestation. 
 It is possible that cases of apparent protraction for two or three 
 weeks may dei)end upon conception having occurred just before the 
 first menstrual period which failed to appear. The following table 
 gives the result of 650 cases in which the foetus was apparently 
 mature, observed by Merriman and James Eeid, the duration being 
 calculated from the last day of menstruation : — 
 
 28 were delivered in the 37th week — 253 to 259 days. 
 
 64 
 
 
 38th , 
 
 260 to 266 „ 
 
 102 
 
 
 39th , 
 
 267 to 273 „ 
 
 177 
 
 
 40th , 
 
 274 to 280 „ 
 
 140 
 
 
 41st , 
 
 281 to 287 „ 
 
 81 
 
 
 42nd , 
 
 288 to 294 „ 
 
 39 
 
 
 43rd , 
 
 295 to 301 „ 
 
 13 
 
 
 44th , 
 
 302 to 308 „ 
 
 6 
 
 
 45th , 
 
 309 to 315 „ 
 
 Calculation of probable Date of Delivery. — The most con- 
 venient practical rule for calculating the date of delivery is based 
 upon the fact that 278 days is the average time from the termination 
 of the last menstrual period, taking the mean of the observations 
 
198 
 
 The Practice of Midwifery. 
 
 of different authors. Hence we get the following table for calculating 
 the date of delivery : — 
 
 days. 
 
 
 
 
 Average duration, 278 days. 
 
 From Jan. 
 
 1 to Oct. 1 
 
 = 273 (274) days— Add 5 (4) 
 
 „ Feb. 
 
 1 to Nov. 1 
 
 = 273 (274) 
 
 
 , 5(4) 
 
 
 , Mar. 
 
 1 to Dec. 1 
 
 = 275 
 
 
 „ 3 
 
 
 , Apr. 
 
 1 to Jan. 1 
 
 = 275 
 
 
 , 3 
 
 
 , May 
 
 1 to Feb. 1 
 
 = 276 
 
 
 , 2 
 
 
 , June 
 
 1 to Mar. 1 
 
 = 273 (274) 
 
 !> ! 
 
 , 5 (4) 
 
 
 , July 
 
 1 to Apr. 1 
 
 = 274 (275) 
 
 
 , 4 (3) 
 
 
 , Aug. 
 
 1 to May 1 
 
 = 273 (274) 
 
 
 , 5 (4) 
 
 
 , Sept. 
 
 1 to June 1 
 
 = 273 (274) 
 
 
 , 5 (4) 
 
 
 , Oct. 
 
 1 to July 1 
 
 = 273 (274) 
 
 
 , 5(4) 
 
 
 , Nov. 
 
 1 to Aug. 1 
 
 = 273 (274) 
 
 
 „ 5 (4) 
 
 
 , Dec. 
 
 1 to Sept. 1 
 
 = 274 (275) 
 
 
 , 4(3) 
 
 In the above table the figures in brackets are to be used in leap- 
 year in place of the others. The mode of using it may be explained 
 by examples. Suppose the last menstrual period ended on Jan. 10, 
 then Oct. 10 will be 273 days (or in leap year 274 days) ; add 5 
 days (or in leap-year 4 days) to make up the average interval of 
 278 days ; this will give Oct. 15 as the most probable date for 
 delivery, which is likely to take place within about a week on one 
 side or the other of that date. Again, suppose the last menstrual 
 period ended on March 29, then Dec. 29 will be 275 days ; add 3 
 days to make up the average interval of 278 days, this will give 
 Jan. 1 as the most probable date for delivery. 
 
 The following rule, which may be easily remembered, will give 
 the same results as the above table within one day, which is a 
 difference of little consequence, where exact determination is 
 impossible. Take the date of the end of last menstruation ; from 
 this reckon nine calendar months forward, or what is equivalent to 
 the same thing, three months back ; if the end of February is 
 included in the nine months add 5 days (in leap-year 4 days), if 
 not, add 3 days. Thus, suppose Feb. 10 the last day of menstrua- 
 tion ; reckon nine months forward to Nov. 10, and add 5 days, 
 this will give Nov. 15 as the most probable date of delivery. This 
 rule is exactly correct for nine months out of the twelve ; for the 
 remaining three it gives an error of only one day. If it be pre- 
 ferred to reckon from the first day of menstruation instead of the 
 last, or if the record of the former day only be preserved, the 
 average duration may be reckoned at 282 days instead of 278, and 
 the same rule applied, with the addition of four days extra. 
 
The Duration and Hygiene of Pregnancy. 199 
 
 In confirmation of the calculation derived from the date of last 
 menstruation, the date of quickening, which is on the average at 
 about the seventeenth week in a multipara, although it may not 
 occur until the twentieth week in a primipara, may be inquired for, 
 but it varies so much in different women that no very positive 
 inference can be deduced from it. Still, it is valuable as a confirma- 
 tion, if it agrees with the result obtained from the date of last 
 menstruation, while, if there is a very wide discrepancy, this may 
 lead to the detection of cases in which either there is menstruation 
 
 Fia. 125. — Mode of measuring the height of the fundus uteri above the 
 symphysis pubes with callipers. 
 
 for a period or two after conception, or in which conception occurs 
 during a period of amenorrhoea. If, therefore, the date of quickening 
 is very widely apart from what is supposed to be the seventeenth 
 week, it is well to estimate the size of the uterus by abdominal 
 examination. This should be done in any case where it is of 
 importance to have a correct estimate of the date of pregnancy, as 
 when premature labour is to be induced in cases of pelvic contrac- 
 tion. The position of the fundus uteri at the several months has 
 been already described (see p. 153). The estimate may be made 
 best in the middle months of pregnancy, from the fourth to the 
 seventh, and it must Ije remembered that the height generally 
 assigned to the fundus uteri at the fifth and sixth months is too 
 
200 The Practice of Midwifery. 
 
 low, and that the fundus generally reaches the level of the umbilicus 
 at the end of the twentieth week or soon after. The distance of the 
 umbilicus from the pelvis, however, varies in different cases, and 
 there are two methods which give a more accurate result, the first 
 that of measuring the height of the fundus uteri above the pubes ; 
 the second that of measuring the length of the foetus itself, as it lies 
 within the uterus. For the first method, the position of the fundus 
 is made out by palpation and percussion, and the distance from the 
 point so determined to the pubes is measured by callipers (Fig. 125). 
 In order to ascertain the length of the foetus i)i utero, one arm of 
 the callipers is introduced into the vagina, and placed upon the 
 lowest point of the head, the uterine wall intervening ; the other 
 arm is placed on the outside of the abdomen on the highest part of 
 the breech. 
 
 For results of value to be obtained from the method of estimating 
 the height of the fundus uteri, it is necessary to take into account 
 the size and attitude of the child, the amount of liquor amnii, the 
 thickness of the abdominal wall, and the degree of engagement of 
 the head in the pelvic brim. The other method is available when- 
 ever the long axis of the foetus can be brought into such a position 
 that it can be measured by the callij)ers. 
 
 Height of fundus Length of foetus Height of fundus circumference 
 
 Week of uteri above pubes nieasured iu uten above pubes of the abdomen 
 
 pregnancy. measured by ^ measured by (Schrader). 
 
 callipers. i^tru. tape (Spiegelberg). *■ ' 
 
 ins. cm. ins. cm. ins. cm. ins. cm. 
 
 40 10=2.5 9i = 24-5 13i = 23 40=100 
 
 38 92 = 24 93 = 24 13 =22-5 
 
 36 9i = 23 9i = 23 123 = 21-5 39*= 99 
 
 34 9'' = 225 8| = 22 12=20 
 
 32 83 = 21-5 8i=20o 11| = 19 38*= 97 
 
 30 8| = 20-5 8=20 11 =17-5 
 
 28 74=19-5 73=19 10? = 16-5 373= 94 
 
 26 7^ = 18 7| = 18 I 
 
 24 63=16-5 — [ 10-5 
 
 22 6 =15 — ) 
 
 20 08=13-5 
 
 18 43=11-5 
 
 16 4" = 10 
 
 The figures in the first two columns of the table are mainly 
 taken from those of Sutugin/ which do not differ greatly from 
 the results obtained by Ahlfeld.^ The height of the fundus uteri 
 above the pubes may also be estimated by a tape measure ; 
 but this does not give so accurate a result as measurement by 
 callipers. The average measurements taken by this method, 
 
 ^ " On the Means of ascertaining the Length of Gestation," &c., Obstet. Journ. of 
 Great Britain and Ireland, 1875, Vol. Ill 
 
 2 " Bestimmungen der Grosse und des Alters der Frucht," Arcli. fiir Gynak., Bd. 2, 
 p. 252. 
 
The Duration and Hygiene of Pregnancy. 201 
 
 according to Spiegelberg,^ are given in the third column of the 
 table. The figures in the lower part of the first column, from the 
 twenty-sixth to the sixteenth week, are based upon my own observa- 
 tion, the averages given by Sutugin being taken from only one or 
 two cases. The measurement of the circumference of the abdo- 
 men is also of some value in determining the duration of pregnancy. 
 According to all three authors, the height of the fundus, in the 
 horizontal position of the woman, continues to increase progressively 
 even in the last few weeks of pregnancy, and the sinking of the 
 fundus in the last two or three weeks, so often spoken of, exists 
 only in the standing position. The method of measuring the foetus 
 itself, instead of the height of the fundus, is preferable, especially 
 in cases of pelvic contraction, when the foetal head cannot descend 
 into the pelvis, and the fundus is therefore unduly elevated.^ 
 
 Hygiene of Pregnancy. — Pregnancy being a natural physiolo- 
 gical condition, the ordinary mode of life, provided it is a healthy one, 
 should not be too much departed from. In normal circumstances, 
 an increased supply of nourishing food is generally required, but it 
 should be given in the most digestible form, and the patient should 
 be warned against an excess of meat in the diet. It is of great 
 importance to keep up a reasonable amount of exercise in the open 
 air, to preserve the muscular system in good tone. Women of the 
 labouring class, who work in the open air throughout pregnancy, 
 pass through their confinements with much greater ease than those 
 who lead sedentary lives. It is reasonable to expect that women 
 who spend a great part of the day in bed, or on a sofa, will be 
 ill prepared for the severe muscular effort required in labour. On 
 the other hand, excessive fatigue, strains, and the lifting or carrying 
 heavy weights are to be avoided. Women should be protected as 
 far as possible from any fright, mental shock, mental distress, or 
 undue excitement. Constipation is to be guarded against by diet 
 as far as possible, but violent purgatives should be avoided. Baths 
 may be used according to the ordinary custom, and the genitals 
 should be frequently washed with warm water ; but some degree of 
 caution is required as to vaginal injections. They may be used if 
 there is leucorrhoea, but they should neither be very hot nor very 
 
 ^ Lchrbuch der Geburtshiilfe, 2nd ed., p. 111. 
 
 '^ Ahlfeld gives the following useful formula for determining the age of the foetus 
 
 from its length in utero : — ^= ^—^ = age in months and weeks, a being the 
 
 (22 X 2) - 2 42 _, 
 
 lengLli of the ffjetus in uteru in centimetres; thus p = -g- =: 8|, or q^ 
 
 months. 
 
202 The Practice of Midwifery. 
 
 cold, and the injection should not be made with much force. It is 
 not usual to abstain from marital intercourse during pregnancy, 
 although in this respect the lower animals set an example to the 
 human race. Coitus is, however, a frequent cause of abortion, and 
 much moderation is desirable, especially during the first four 
 months. If a woman has aborted before, or if there are symptoms 
 of threatened abortion, abstinence during at least the earlier part 
 of pregnancy should be advised. 
 
 The dress should be such as to avoid all undue pressure. Garters 
 should be discarded, as tending to promote varicose dilatation of the 
 veins. Stays, if worn, should be made to expand. It is better, 
 however, to use no stays, but have each skirt of petticoat or dress 
 attached to a bodice, so as to hang from the shoulders. In multi- 
 parse, if there is a jDendulous abdomen, from laxity of the abdominal 
 walls, involving a tendency to anteversion of the uterus, an 
 abdominal belt should be worn. Great care should be taken that 
 the stays do not press upon the nipples and flatten them. If the 
 nipples are already flattened, a guard may be worn over them, and 
 this may tend to promote their development, but they should not 
 be actively drawn out. The nipples may be prepared for lactation 
 by anointing them each night with some pure lanoline and washing 
 them daily with spirit and water, or with a solution of boric acid in 
 50 per cent, alcohol. This care is especially desirable in primiparae, 
 or if there have been sore nipples in a previous lactation. 
 
 The special disorders of pregnancy will be considered hereafter. 
 The general principle is to exhort women to endure the minor 
 inconveniences as unavoidable for the time, and specially to avoid 
 any unnecessary activity in treatment. 
 
 It is advisable to test the urine for albumen from time to time, 
 say once a month in the earlier months, and once a week in the last 
 two months of pregnancy. 
 
 It is also advisable to make a preliminary abdominal examination 
 at least a month before full term, in order to estimate the position 
 and size of the foetus, and the dimensions of the pelvis. External 
 pelvic measurements should be taken, if not already known ; but it 
 is only exceptionally necessary to make a vaginal examination. 
 
 If any vaginal examination is made within the last month of 
 pregnancy, antiseptic precautions should be observed as carefully as 
 at the time of labour. Coitus during the last month should be 
 discouraged. Puerperal septicaemia has been attributed to contagion 
 conveyed in this way to the vagina. 
 
Chapter XI, 
 LABOUR. 
 
 Labour has to be regarded in two aspects, first as a series of 
 vital actions to effect delivery^ secondly as a mechanical process, 
 the course of which depends upon the motor forces which act, and 
 the resistances which are called into play by the relations of the 
 passenger to the passages through which it has to pass. The 
 physiological and clinical ]3henomena of labour will here be first 
 considered. 
 
 Causes which determine Labour. — The reason why labour 
 comes on so regularly at a definite time is not fully understood. 
 Among the more important of the causes which have been assigned 
 for its occurrence are the following : — 
 
 (1) Increased irritability of the uterine muscle ; 
 
 (2) The increased growth of the ovum ; 
 
 (3) The occurrence of coagulation necrosis in the cells of the 
 decidua and in the epithelium of the chorionic villi ; 
 
 (4) The occurrence of thrombosis in the veins of the placental 
 sinuses ; 
 
 (5) Increased venosity of the foetal blood and a deficiency of 
 oxygen in the utero-placental vessels ; 
 
 (6) The accumulation of toxic materials derived from the foetus 
 in the mother's blood ; 
 
 (7) Alterations in the maternal metabolism associated with the 
 menstrual periodicity and attaining their maximum at the end of 
 pregnancy ; 
 
 (8) Gradual diminution of the power of the growing ovum to 
 exert an inhibitory action upon the uterine contractions ; 
 
 The irritability of the uterus, no doubt, increases progressively 
 throughout pregnancy, and it is thought that, although ovulation 
 is suspended, the menstrual nisus does to some extent continue, 
 and that the uterine contractions which are periodically taking 
 place become more active at the times when menstruation would 
 have occurred. Accordingly abortion or miscarriage is more likely to 
 occur at such a time. It is only necessary for the ordinary uterine 
 contractions to be intensified up to the point at which they begin 
 
204 The Practice of Midwifery. 
 
 to cause some dilatation of the internal os and pressure of the 
 membranes against it ; and then the reflex mechanism is started by 
 which the process of labour thenceforth goes on automatically. It 
 appears that the uterine irritability and the stimulus reach a 
 sufficient intensity to bring this about generally at the time when 
 the tenth menstrual period would have occurred. It remains, how- 
 ever, to explain why this should happen at the tenth menstrual 
 period and not at any other. It cannot be due simply to the 
 magnitude of the uterine contents having reached a certain point, 
 for, when there is an excessive secretion of liquor amnii, a more 
 extreme distension may be produced in the earlier months of 
 pregnancy without bringing on labour. In many cases of twin 
 pregnancy, also, any given degree of uterine distension would be 
 reached at an earlier stage. 
 
 In connection with the explanation of the onset of labour, the 
 following facts have also to be explained : (1) In extra-uterine 
 foetation, if the foetus lives up to the end of the ninth month, there 
 is a kind of false labour at that time, a decidual membrane is 
 expelled from the uterus, and the foetus dies about the same time. 
 (2) When one fcetus dies in the case of twins it is frequently retained 
 within the uterus until the other has reached maturity, and is then 
 expelled with it. (3) An ovum sometimes perishes in the earlier 
 part of pregnancy, but is retained within the uterus for months, 
 and sometimes is only expelled at the end of the ninth month. One 
 of the most important theories is that originally proposed by Sir 
 James Simpson, that when the fcetus approaches maturity, a 
 change, namely, fatty degeneration, as he thought, takes place in 
 the decidua, preparing it for separation from the uterus, and some- 
 what analogous to the change in the stalk of a fruit, causing its 
 separation from the tree when the fruit is ripe. In consequence of 
 the coagulation necrosis which actually does occur in the cells of 
 the decidua and in the epithelium of the chorionic villi, the ovum 
 is supposed to begin to act like a foreign body, irritating the uterine 
 nerves, and sending a reflex stimulus to the nervous centres by 
 which uterine contractions are excited. This view would explain 
 the causation of false labour in cases of extra-uterine pregnancy, 
 and perhaps also the death of the extra-uterine foetus at full term, 
 since an analogous change may take place in the extra-uterine 
 placenta.^ If the thrombosis in the uterine veins of the placental 
 
 1 According to Leopold, " Studien liber die 8chleimhaut des Uterus," Arch. f. 
 Gynak. XL, p. 49, fatty degeneration of the decidua before labour is not a constant 
 occurrence, but there is always a change in the layer where separation is to take place, 
 consisting of a thinning of the trabeculse which hold together the network of spaces 
 existing at that level of the decidua. 
 
Labour. 205 
 
 site, described by some, is a normal occurrence, tbis will aid in 
 bringing on labour, by producing some obstruction to the blood 
 current through the placenta, and so leading to increased venosity 
 of the foetal blood and a deficiency of oxygen in the utero-placental 
 vessels. It is well known that lack of aerated blood, such as occurs 
 in asphyxia, tends to produce uterine contraction and expulsion of 
 the foetus. 
 
 Spiegelberg proposes the theory that about full term some change 
 takes place in the nutritive requirements of the foetus, so that it 
 needs some substance not supplied through the placenta, and dies 
 if it does not obtain it ; that, on the other hand, it no longer requires 
 some substance hitherto supplied to it, that this substance accumu- 
 lates in the maternal blood, acts as a chemical irritant to the 
 nervous centres, and so induces uterine contractions. 
 
 Schaeffer ^ propounds the theory that the effect of the increasing 
 distension of the uterus in tending to cause uterine contractions is 
 inhibited by some body circulating in the mother's blood and derived 
 from the cells of the syncytium, the so-called syncytiotoxine, and 
 that the action of such a body is evidenced by the changes occurring 
 in the maternal blood during pregnancy. 
 
 These changes he describes as essentially a diminution in the 
 number of the red blood corpuscles, a diminution of their resisting 
 power to the action of the hemolytic body, and a diminution in 
 the amount of haemoglobin they contain. In the later months of 
 pregnancy as a result of these changes the inhibitory action on the 
 nerve centres becomes lessened, the distension of the uterus calls 
 forth more marked uterine contractions, and these in their turn, 
 pressing the lower pole of the ovum against the tissues of the lower 
 uterine segment, set up the reflex contractions which eventuate in 
 the onset of true labour. The changes in the blood described 
 probably do occur, but whether they are due to some body derived 
 from the syncytium is pure hypothesis for which there is no certain 
 proof. This view offers some explanation of the occurrence other- 
 wise difficult to explain, that even when the foetus dies in the early 
 months labour often does not ensue for some time. This is 
 suj^posed to be due to the fact that in some of these cases the 
 syncytium continues to show signs of growth after the death of the 
 fcetus, and so continues to secrete the substance which exercises an 
 iuhibitoiy action upon the uterine contractions. 
 
 It appears prol;able that one of the most important elements of 
 the causation may be a periodicity inherent, in some inexplicable 
 manner, in the nervous centres associated with some change in the 
 
 1 Schaeffer, Zentrbl. f. Gyiiiik., 1901, No. 50, p. 1375. 
 
2o6 The Practice of Midwifery. 
 
 maternal metabolism, and no more to be accounted for than the 
 menstrual periodicity of twenty-eight days, which itself also appears 
 to have its seat in the nervous centres and to be associated with 
 certain changes in the body metabolism, as evidenced by the 
 occurrence of attacks of diarrhoea, migraine, vertigo, diminution in 
 the hfemolytic resistance of the red blood corpuscles, changes in the 
 composition of the blood, and a fall in the blood pressure, which 
 have been shown to occur at these periods in certain women. 
 
 The essential element in the process by which the foetus is 
 expelled consists in the contractions of the uterus ; the auxiliary 
 force supplied by the voluntary muscles is only a minor factor. 
 This is proved by the fact that, in cases of paraplegia, where the 
 abdominal muscles are paralysed, labour may be completed in a 
 natural manner, while, on the other hand, in uterine inertia, where 
 the pains are absent, no voluntary effort can make the labour 
 progress. 
 
 Nervous Mechanism of Uterine Contractions. — The uterus 
 is quite independent of any direct control of volition. Contractions 
 may go on rhythmically when a woman is perfectl}^ insensible from 
 apoplexy, from the coma of puerperal convulsions, or the narcosis 
 of anaesthetics. It is, however, much under the indirect influence 
 of emotions. The accoucheur often finds disagreeable evidence of 
 this fact when, in the case of a sensitive woman, his entry into the 
 room is sufficient to banish the pains, which just before were 
 recurring regularly. If he takes his leave in impatience, the pains 
 are apt to return, and the child to be born quickly in his absence. 
 Again, it is found greatly to conduce to the favourable progress of 
 labour to keep up the woman's courage and hopeful anticipation of 
 its conclusion. The effect of mental shocks or sudden frights in 
 bringing on premature uterine contractions is well known. In 
 protracted labour also, the effect on the woman's mind of prepara- 
 tions for the application of forceps sometimes acts as such a stimulus 
 to the pains that artificial assistance becomes needless. After 
 delivery not only will suckling induce a sympathetic contraction of 
 the uterus, but the maternal emotions induced by seeing the infant 
 have the same effect. In these cases a stimulus, or in some cases 
 even an inhibitory action, must be transmitted from the brain to the 
 centres in the spinal cord. 
 
 The chief causes of uterine contraction are two : first, periodic 
 centric discharge of nervous energy ; secondly, reflex stimulus. 
 The centric discharges of energy are manifested throughout preg- 
 nancy by the periodic gentle uterine contractions, alternating with 
 
Labour. 207 
 
 relaxation. The tendency to periodic discharge is preserved during 
 labour, when, though receiving a more or less constant afferent 
 impulse from the nerves of the uterus and vagina, the spinal 
 centres send out their stimulus to the uterus only at intervals. The 
 centric discharge is capable of being excited by certain substances 
 circulating in the blood, such as ergot and other drugs, or an excess 
 of carbonic acid. It is probably also excited by some morbid 
 material in the blood when premature labour is brought on by some 
 zymotic disease, more especially small-pox, or by any very serious 
 illness of the mother. 
 
 Eeflex stimulus may act upon the uterus in two ways, either when 
 it is applied to sensitive cerebro-spinal nerves, or to sympathetic 
 nerves. As instances of the first we have the uterine contractions 
 excited by suckling, or other stimulus applied to the breasts, or by 
 the sudden application of cold to any part of the surface of the 
 body. In labour the pressure of the head upon the vagina and 
 perineum, external pressure upon the perineum, or the introduction 
 of the hand into the vagina to make an examination, have a similar 
 effect in exciting pains. Of reflex stimulus excited by irritation 
 applied to sympathetic nerves, and unaccompanied by pain, we find 
 the chief instance in the nerves of the uterus itself. If the ovum 
 is dead it acts like a foreign body, and generally soon excites the 
 uterus to expel it, although in exceptional cases it may be retained 
 for months. It acts in a similar way as a foreign body if the 
 membranes are separated from the uterine wall over a considerable 
 surface, or if the liquor amnii is allowed to escape and let the 
 uterine wall come into close contact with the foetus. Again, the 
 mode of inducing labour by passing up a bougie between the mem- 
 branes and the uterine wall and leaving it there is an instance of 
 reflex stimulus applied through sympathetic nerves. Further, the 
 irritation caused by the dilating pressure of the bag of membranes 
 or the fcetal head upon the cervix and on the ganglion cervicale is 
 the chief element in the mechanism by which labour goes on 
 automatically when once started. 
 
 Arrangement of Nerve Centres and Afferent Nerves. — 
 Experiments on animals appear to show that two centres for uterine 
 contraction exist in the spinal cord, one in the medulla oblongata 
 and one in the lumbar portion of the cord, and also that the 
 separated uterus has in some degree a power of rhythmic action, 
 in virtue of the nerve centres contained in it. The centre in the 
 medulla must be the centre for reflex stimuli transmitted by the 
 cerebro-spinal nerves of the upper part of the body, and this centre 
 
208 
 
 The Practice of Midwifery. 
 
 appears to be excited to action by the presence of an undue amount 
 of carbonic acid in the blood. The centre in the lumbar part of the 
 cord appears to be that more immediately governing the uterus. 
 Stimuli are transmitted to it through the cord from the centre in 
 
 Fig. 126. — Diagram of nerves of uterus. j)hr., phrenic ; vag., vagus ; spl., 
 splanchnic ; hoI. pl.^ solar plexus ; r. g., renal ganglion ; or. g., ovarian 
 ganglion ; i. m. g., inferior aortic plexus ; liy. pi., hypogastric plexus ; 
 s. i., sacral nerves; s. sy. 1, 2, 3, 4, sacral sympathetic ganglia; c. g., 
 cervical ganglion ; ut., uterus ; M., bladder ; v., vagina. 
 
 the medulla, and indirectly, in the case of emotions, from the brain. 
 The act of parturition is partly automatic and partly reflex, and 
 direct communication with the brain is not essential to co-ordinate 
 uterine action ; on the other hand, direct communication between 
 the uterus and the lumbar enlargement of the cord through the 
 medium of the sympathetic chain between the first and third 
 
Labour. 209 
 
 lumbar ganglia is essential to regular contraction and retraction of 
 the uterus. It seems also probable that the uterus is able auto- 
 matically to expel its contents as far as the relaxed portion of the 
 genital canal even when deprived absolutely of any spinal influence, 
 the spinal reflexes being then necessarily absent (Amand Eouth^). 
 The nerves carrying the stimulus to the uterus belong to the 
 sympathetic system, but these derive filaments from the spinal cord 
 through the lumbar and sacral nerves which join the sympathetic 
 plexuses. The body of the uterus is supplied chiefly from the 
 inferior aortic plexus, a central plexus lying upon the bifurcation of 
 the aorta, which receives branches from the lumbar ganglia of the 
 sympathetic as well as from the spinal nerves, and is connected with 
 the ovarian (spermatic) plexus (Fig. 126) . Lower down the inferior 
 aortic plexus divides into two hypogastric plexuses, one at each 
 side, which supply the rectum and the vagina, and also send 
 branches to the lower part of the body of the uterus and the cervix. 
 Branches from the hyj)ogastric plexus, together with other branches 
 from the second, third, and fourth sacral nerves, and from the 
 lower lumbar and upper sacral ganglia of the sympathetic, unite 
 to form what has been variously regarded as a ganglion, or a 
 plexus including many ganglia, and has been called the ganglion 
 cervicale uteri, or the fundamental plexus of the uterus (Pissemski^). 
 According to Jastreboff,^ there are really two groups of ganglia, 
 the anterior or utero-vesical ganglia, supplying not only the cervix, 
 but the body of the uterus and bladder, and the posterior or recto- 
 vaginal ganglia, supplying mainly the rectum and vagina, and 
 sending branches to the broad ligaments. These grou^js of ganglia 
 are situated behind and at the side of the u]3per part of the vagina. 
 Kniipffer ^ also describes two smaller ganglia lying on either side of 
 the cervix, the paracervical ganglia. In pregnancy these ganglia 
 undergo marked hypertrophy, and form a considerable mass 
 surrounding the cervix. 
 
 Mode in which the Uterus contracts. — The intermittent 
 character of the pains in labour has an important practical advan- 
 tage both for the mother and foetus. The relaxation of the pressure 
 on the soft parts allows their circulation to go on freely between 
 the pains, and so diminishes the risk of damage to them from pro- 
 longed pressure. The intervals of rest also allow both the nervous 
 centres and the general system of the mother to recover energy. 
 
 1 Kouth, Trans. Obst. Soc. London, 1897, Vol. LIX., p. 191. 
 
 2 Pissemski, Monatsschr. f. Gcb. u. Gyn., 1903, Vol. XVII,, p. 3. 
 
 " " On the Ganglion Cervicale Uteri." Trans. Obst. Soc., London, 1881, Vol. XXIII., 
 p. 273. 
 
 Kniipffer, (Jrsache des Geburteintrittes., Dissert., Dorput, 1892. 
 M. 14 
 
2IO The Practice of Midwifery. 
 
 As regards the foetus, its life would be imperilled by the diminution 
 of the circulation through the uterus and placenta produced by 
 uterine contraction, if the pains were continuous. Thus, when in 
 over-protracted labour the uterus gets into a state of continuous 
 tetanic contraction, the life of the child is generally lost, and the 
 exhaustion of the mother soon becomes very grave. 
 
 The contraction of the uterus, like that of other organs having 
 unstriped muscular fibres, is not only involuntary, but peristaltic. 
 The peristaltic action is not, however, of a very obvious kind, as is 
 j)roved by the very different accounts which have been given of it. 
 It has often been said that the contraction begins at the cervix, 
 spreads thence to the fundus, and finally returns to the cervix 
 again. The truth appears to be, that it begins at the fundus and 
 spreads to the cervix. The pressure of the contracting wall on 
 the liquor amnii would naturally cause bulging of the bag of 
 membranes and apparent recession of the presenting part at the 
 commencement of a pain, the membranes being unruptured, a 
 
 I I I I I T 
 
 • | I I I I I r 
 
 Fig. 127. — Diagram of curve taken with the tocodynamometer of pains of first 
 
 stage of labour.i 
 
 circumstance which has been given as a reason for supposing that 
 contraction begins at the cervix. The time occuj)ied by the wave 
 of contraction in spreading over the uterus is, however, very small 
 as compared with the whole duration of a pain, and therefore the 
 mechanical effect is that of a continuous and not of a peristaltic 
 contraction. In the case of those animals wheie several foetuses 
 are contained in one horn of the uterus, each fcetus in turn is 
 conveyed to the vagina by a true peristaltic action, and the direc- 
 tion of the wave of contraction is then from the fundus to the 
 cervix. 
 
 The uterine contractions follow a certain rhythm, but this rhythm 
 varies in the course of labour. Each pain has a period of increase, 
 a period of greatest intensity, and a period of decline. Then 
 follows a period of relaxation, considerably longer than the whole 
 pain (Fig. 127). As labour advances and the uterine cavity becomes 
 smaller by the progress of the foetus, the uterine walls necessarily 
 become thicker. The pains then become more vigorous, especially 
 if there is considerable resistance, and at the same time the rhythm 
 
 1 Schatz. Arch. f. Gynak., Vol. III., Table II., Curve II. 
 
Labour. 
 
 21 I 
 
 is altered. The intervals become less in proportion, and in each 
 pain the period of greatest intensity is prolonged while the periods 
 of increase and decline become relatively less. If the uterine 
 muscles and nervous centres are well nourished, the intensity of the 
 pains is increased in proportion to the resistance encountered, so 
 long as the woman does not 
 become exhausted. 
 
 V 
 
 Retraction of the Uterus. — 
 
 The progressive diminution in 
 the capacity of the uterine cavity 
 which takes place during the 
 second stage of labour, and to a 
 very marked degree indeed after 
 the birth of the child, is due not 
 only to the contractions of the 
 uterine muscle, but also to the 
 property it possesses of retrac- 
 tion. Each successive contrac- 
 tion of the uterine musculature 
 is followed by some permanent 
 shortening of the individual 
 muscle fibres ; and in this 
 manner their action, for example, 
 in expelling the child is ren- 
 dered continuous and lasting. 
 As the second stage progresses 
 the uterine wall becomes 
 markedly thicker, and this is 
 due to the retraction of the 
 muscle, which leads to a re- 
 arrangement of the fibres so 
 that they become placed to a 
 greater degree side by side, 
 
 and at the same time become shorter and thicker, and so cause a 
 considerable degree of compression of the arteries and veins which 
 lie between them (Fig. 128). The power of retraction which the uterus 
 exhibits in common with other hollow viscera, such as the bladder, 
 is of the greatest importance therefore in maintaining the progress 
 made by each successive contraction in the expulsion of the foetus, 
 in the separation of the placenta, and, most important of all, in pre- 
 Yeni'mg ])OHtj)art'uiiL haemorrhage by the compression and obliteration 
 of the vessels in the uterine wall which it brings about. In cases 
 
 14—2 
 
 Fig. 128. — Diagram showing sliorten- 
 ing and thickening of uterine muscle 
 fibres, and obliteration of lumen 
 of arteries and veins, e.g., the result 
 of retraction. On left, non-con- 
 tracted muscle fibres of pregnant 
 uterus ; on right, same area repre- 
 sented contracted and retracted. 
 
212 The Practice of Midwifery. 
 
 of obstructed labour in which retraction occurs to an excessive 
 degree the Une of demarcation between the contracted and retracted 
 upper uterine segment and the distended lower uterine segment is 
 shown by the marked formation of the so-called retraction ring, a 
 sign clinically of the utmost importance. 
 
 Polarity of the Uterus. — The circular muscular fibres of the 
 cervix do not contract in conjunction with the rest of the muscular 
 wall ; but, on the contrary, there is a nervous correlation between 
 them of such a kind that, with contraction of the body of the uterus, 
 and especially with regular, rhythmical, intermittent, expulsive 
 contractions, such as occur in labour, there is associated a physio- 
 logical yielding of the sphincter muscles of the cervix, including 
 both internal and external os. Conversely, when the body of the 
 uterus is inactive, the circular fibres of the cervix are generally in 
 action, and mechanical dilatation of the cervix tends to excite con- 
 traction in the body of the uterus. These facts were made the 
 basis of rather a fanciful description by Reil,^ who held that in the 
 uterus contraction and expansion are forces naturally in equipoise, 
 but capable of polar divergence. His view was, that in the unim- 
 pregnated uterus there is no divergence of the forces, contraction 
 predominating ; that in pregnancy expansion retreats to one pole, 
 the fundus, and contraction to the other pole, the cervix ; but that, 
 on the onset of labour, contraction leaps over, as in an overcharged 
 jar, from the cervix to the fundus, and expansion retreats to the 
 cervix ; while, after delivery, the forces again come into equipoise, 
 with a preponderance of contraction. 
 
 The term "polarity of the uterus" is a convenient one, as a 
 concise expression of the facts, but, in reality, the explanation of 
 the phenomena seems to be a simple one, and to show no real 
 analogy to electric polarity. The nervous correlation by which 
 the action of the detrusor muscle is associated with physiological 
 yielding, not merely passive stretching, of the sphincter muscle 
 which retains the contents of the cavity is shared by the uterus 
 with other hollow viscera, such as the rectum and bladder, and in 
 all cases the arrangement subserves the same obvious purpose. In 
 the case of the uterus the physiological yielding and relaxation in 
 labour appear to affect not only the cervix, but the muscular wall 
 of the vagina. In all the cases spasm of the sphincter is apt to be 
 associated with inactivity of the expulsive muscle. In the uterus, 
 however, there seems to be a further nervous correlation. In order 
 
 1 See Eeil, Archiv. f . Physiologie, 1807, VII., p. 415; and Charapneys' "Notes on 
 Uterine Polarity," Obstet. Journ., 1880, VII. 
 
Labour. 213 
 
 to make labour go on automatically when once started, it is arranged 
 that the stretching of the cervix by the bag of membranes or the 
 foetus should cause by reflex action expulsive contraction of the 
 body. The same tendency is shown by the uterus, to some extent, 
 at other times, even when unimpregnated. Thus in cases of 
 haemorrhage, with laxity of the fundus and a narrow cervix, 
 mechanical dilatation of the cervix will sometimes arrest the 
 hseraorrhage by stimulating the body of the uterus to contract and 
 close the vessels. Similarly at any stage of pregnancy mechanical 
 dilatation of the cervix will generally set up expulsive i^ains. 
 Whether or not it be called polarity, this relation between the body 
 and the cervix is frequently exemplified ; and when from any 
 nervous aberration, whether of local or general origin, there is an 
 abnormal condition of the one, the condition of the other is usually 
 modified in the converse direction. Thus, when there is a spasmodic 
 contraction or "trismus" of the os or cervix uteri, there is almost 
 always a deficiency in rhythmical and regular expulsive pains. If 
 the OS can be dilated, the pains will generally come on regularly, 
 and conversely, if rhythmical pains can be excited, physiological 
 yielding of the os and cervix will generally take place. It is pro- 
 bable that in the gentle uterine contractions, which take place 
 apart from labour, and are not expulsive in their functions, the 
 strong sphincter fibres which surround the internal os contract 
 with the rest of the body of the uterus, and prevent any tendency 
 to dilatation. Sometimes this may be observed to take place even 
 in labour, when there is a tendency to spasm of the cervix, associ- 
 ated with deficiency of expulsive j^ains, especially when the liquor 
 amnii has escaped prematurely. The effect of a pain may then be 
 actually somewhat to close up the internal or external os, instead 
 of to dilate it further. 
 
 Cause of the Pain in Labour. — The severe pain which almost 
 invariably accompanies labour is chiefly twofold in its origin. 
 First, there is the pain produced in the uterine muscle itself during 
 its contraction. This is analogous to the pain of colic, and is 
 probably due to the compression of the nerve filaments. This 
 kind of pain is felt mainly in the abdomen, over the surface of the 
 uterus. Secondly, there is the pain produced by the stretching of 
 the soft parts, the pressure upon them, and also by the strain upon 
 the uterine ligaments and attachments, when the uterine contrac- 
 tion meets with much resistance. In the early stage of labour this 
 kind of pain is due to the stretching of the cervix, and especially of 
 the margin of the external os. The pain so produced is generally 
 
214 The Practice of Midwifery. 
 
 a dull, aching pain, and is felt chiefly over the upper part of the 
 sacrum. As the foetus advances, pain is produced by stretching of 
 the vagina, and especially of the perineum and vaginal outlet. 
 This is often of a violent tearing character, and very intense, 
 especially in primiparae, since the genital passage becomes more 
 and more sensitive towards its outlet, and in primiparae stretching 
 never suffices, and some laceration of the vaginal outlet, at the site 
 of the hymen, is inevitable. In the later stage of labour there is 
 often also pain running down the thighs, and violent cramps in the 
 thighs and legs, due to pressure upon the sacral plexus. The inten- 
 sity of the pain in labour varies very greatly in different persons, in 
 some degree of accordance with the amount of resistance experienced, 
 but more especially in proportion to the nervous susceptibility of 
 the patient. This applies especially to the pain produced by the 
 contraction of the uterine muscle itself. This in some cases is 
 agonising, while in others it is very easily endurable. In very 
 exceptional cases labour is gone through without any sensation 
 which could be considered as amounting to pain, and labour has 
 even commenced during sleep and been completed without the 
 mother being awakened. In such cases there must have been 
 gradual and easy dilatation, and so little resistance, that a very 
 slight force, perhaps one not much exceeding the weight of the 
 child, has been sufficient to effect delivery. 
 
 Effect of the Pains on the General System. — During a 
 pain the pulse becomes gradually accelerated till the pain reaches 
 its height ; as the pain subsides the pulse falls again, and in the 
 interval of rest returns to its former rate. The acceleration 
 at each pain may be as much as from 20 to 24 beats per minute. 
 If labour is prolonged, there is also progressive acceleration of the 
 minimum pulse-rate. The converse effect on the fcBtus of diminu- 
 tion of the heart-rate, both during a pain, and progressively in 
 prolonged labour, has been already described (see p. 186). 
 
 A rise in the maternal blood pressure occurs during the first 
 stage of labour, becomes more marked with the increase in the 
 intensity of the pains during the second stage, and reaches its 
 highest point at the moment of the birth of the child. Immediately 
 after this the blood pressure sinks to a marked degree, and reaches 
 its minimum with the expulsion of the placenta. On the comple- 
 tion of delivery it gradually rises, but it does not as a rule reach the 
 normal level until about the fifth day of the puerperium. 
 
 There is some elevation of temperature also in labour. Normally 
 it is but slight, but, in protracted labour, it may amount to as much 
 
Labour. 215 
 
 as two or three degrees Fahrenheit. The respiratory rate is also 
 somewhat quickened. 
 
 In sensitive women who feel the labour pains very acutely, labour 
 may give rise to extreme nervous disturbance. Vomiting is 
 frequent, hysterical manifestations are not uncommon, and some- 
 times at the stage of most acute pain, when the head is passing the 
 vulva, the woman loses all control over herself, and becomes 
 scarcely responsible for her actions. Rigors sometimes occur, 
 without any notable elevation of temperature, especially about the 
 time of full dilatation of the os, and the body is not infrequently 
 bathed in jperspiration. 
 
 The Course of Parturition. 
 
 Premonitory Symptoms.— For a week or two before delivery, 
 the uterus generally sinks deeper into the pelvis, while the fundus, 
 in the upright position of the woman, falls more forward, and thus 
 becomes lower. Symptoms of pressure on the chest and epigastric 
 region are thereby generally relieved. From the increased pelvic 
 pressure, there is often frequent micturition, some increase of 
 difficulty in walking, and the vaginal secretion becomes more 
 abundant. There is often also irritability of the rectum at this 
 time ; and this, when it occurs, has the advantage of freeing the 
 pelvis from any collection of faeces. Exceptionally in primiparae, 
 as already described (see p. 155), the internal os becomes expanded 
 by painless contractions, so that the bag of membranes rests upon 
 the external os, but in the great majority of cases the cavity of the 
 cervix remains distinct from that of the uterus until the definite 
 commencement of labour. In some cases, especially in pluriparae, 
 no premonitory signs at all are noticed, and labour begins quite 
 suddenly. In others, besides the symptoms already mentioned, the 
 uterine contractions which occur throughout pregnancy increase in 
 degree, and eventually become manifest to the woman herself, 
 although they are manifest earlier on examination by another 
 person. Such slight pains may recur for a few hours every 
 evening for several successive days, and occasionally may pass off 
 altogether for some time before merging into actual labour. 
 
 Spurious Pains. — The name of spurious or false labour pains 
 is given to pains which often occur during the stage preliminary to 
 labour, and which are distressing to the woman, and sometimes 
 lead her to send for her medical attendant, in the belief that labour 
 is actually in progress. They consist of painful uterine contrac- 
 tions which are generally partial and irregular, and are, at any 
 
2i6 The Practice of Midwifery. 
 
 rate, unaccompanied by any physiological yielding of the cervix. 
 They are distinguished by the fact that they produce no dilatation 
 of the OS, and are not accompanied by the copious lubricating 
 secretion from the cervix, which is poured out in actual labour, 
 and by the absence of any show, or blood in the vaginal discharge, 
 such as occurs when labour has really commenced, and is produced 
 by the sej)aration of the membranes from the lower uterine 
 segment. Such spurious pains are often set up by some local 
 irritation, such as digestive disturbance, or accumulation of faeces, 
 and are then relieved by an aperient or enema. 
 
 The Three Stages of Labour, — It is usual to divide labour into 
 three stages. The first stage is that of the dilatation of the cervical 
 canal and external os ; the second or expulsive stage comprises the 
 period from the full dilatation of the cervix up to the complete 
 expulsion of the foetus ; the third stage is that of the delivery of 
 the placenta. 
 
 The First Stage. — There are three elements in the mechanism of 
 dilatation of the cervix and external os : first, the mechanical 
 stretching by the bag of membranes, or part of the fcetus projecting 
 into the cervix ; secondly, the contraction of the longitudinal fibres 
 of the uterus, which draw the cervix open; and thirdly, the 
 physiological relaxation of the circular fibres, which has already 
 been described (see p. 212) as taking place in conjunction with the 
 contraction of the body of the uterus. It follows from the principles 
 of mechanics that the effect of any given pressure within the bag 
 of membranes in producing a tension of the edge, either of the 
 internal or external os, is directly proportional to the diameter of 
 the OS, and therefore vanishes when the os is very small. Hence, 
 if the OS is closed to begin with, some dilatation by the stretching 
 influence of the longitudinal fibres must take place before the 
 mechanism of dilatation by the bag of membranes, or parts of the 
 foetus, can come into play. 
 
 This is what actually does occur : the contraction of the longi- 
 tudinal fibres of the uterine wall draws open the internal os, causes 
 a slight degree of separation of the membranes in its immediate 
 neighbourhood, and so enables this portion of the membranes to 
 bulge into the dilated upper extremity of the cervical canal. The 
 mechanical action of the dilating part, as it is pressed into the 
 cervix, is that of a wedge : a fluid and uniform wedge in the case 
 of the bag of membranes ; a solid and irregular wedge in the case 
 of the head or other part of the fcetus. It follows that the effect 
 produced by the wedge varies according to the acuteness of its 
 
Labour. 
 
 217 
 
 angle at the points where it is in contact with the edge of the os.^ 
 It will hence be readily understood why it is that, when the 
 membranes are ruptured, either naturally or artificially, before the 
 OS is large enough to allow the head to project much through it, 
 the head forms an extremely bad dilator as compared with the bag 
 of membranes. For it either cannot project into the os at all, or 
 projects so little as to form an extremely blunt wedge instead of an 
 acute one. 
 
 The commencement of actual labour is often very indefinite. 
 The preliminary pains, which have been already mentioned, 
 become more marked, though still at first slight and at long 
 intervals. Generally there takes place also a discharge of mucus, 
 tinged with blood. This depends upon separation of the membranes 
 from the uterus near the internal os, or upon rupture of small 
 
 Fig. 129. — Diagram of dilatation of cervical canal in a primipara. The 
 internal os dilates first, and the external os remains almost closed until 
 the whole canal has become obliterated. 
 
 vessels at the edge of the os, and it therefore indicates that the 
 pains are beginning to be effective in producing dilatation. It is 
 well known to nurses under the name of the " show," as a sign that 
 labour is really commencing. It does not, however, invariably take 
 place. 
 
 The internal os is the first to yield to the effect of the pains, and 
 the cervix becomes expanded so as to form one cavity with the 
 body, and allow the bag of membranes with the presenting part to 
 rest upon the external os, before the external os itself undergoes any 
 notable dilatation (Fig. 129). This implies that a sufficient portion of 
 the bag of membranes must have been detached from the lower 
 
 ' In mathematical language, the tension produced on the edge of the os by any- 
 given pressure within the membranes is directly proportional, not only to the diameter 
 of the OS, but to the sine of the angle which the tangent to the projecting bag of mem- 
 branes (or to the head when tliat is acting as dilator), at the point where it touches 
 the edge of the os, makes with the plane of the os. It follows that the dilating force 
 vanishes when there is no projection, and becomes greater the more complete is the 
 projection. It follows, also, that it becomes progi'cssively more and more effective in 
 proportion to the degree of dilatation which has already been produced. 
 
2l8 
 
 The Practice of Midwifery. 
 
 part of the body of the uterus to allow the bag to project into the 
 cervix, and eventually through the external os. The pressure of 
 this detached portion of the ovum, acting as a solid body, serves as 
 a constant stimulus to the uterus to further contraction, and 
 generally thus ensures the speedy expulsion of the fcetus, although 
 in some exceptional cases, as already mentioned (see p. 155), this 
 state of things continues for some days, or even weeks, before active 
 labour. To this constant stimulus to further contraction is added 
 the intermittent stimulus of pressure on the cervical ganglia and 
 nerves produced by the pains themselves. This stage will generally 
 have been reached before the medical attendant is summoned. If 
 an examination be then made during a pain, before the os is much 
 dilated, the edge of the os will be felt, especially in primiparpe, as a 
 thin, tense, almost membranous ring, with the tense bag of 
 
 Fig. 130. — Diagram of dilatation of the cervical canal in a multiparje. The 
 dilatation of the internal os is accompanied by a dilatation of the 
 cervical canal as a whole. 
 
 membranes projecting more or less into it, so that it is difficult to 
 feel the presenting part until the pain has passed off. After a time, 
 as the OS begins gradually to yield to successive pains, its edge 
 becomes softer, thicker, and more tumid, and this change is a sign 
 that dilatation will thenceforth proceed more rapidly. In parous 
 women the edge of the os is often found soft and thick when first 
 examined. 
 
 The relaxation of the circular fibres and the occurrence of the 
 marked softening of the cervix which is so characteristic of preg- 
 nancy renders the dilatation a permanent one until the contents of 
 the uterus have been expelled. In primiparge the dilatation of the 
 external os definitely follows that of the cervical canal ; in multipara 
 the two processes often go on to a certain extent 2^ari passu, the 
 external os dilating before the canal has been entirely obliterated 
 (Figs. 129, and 130). 
 
 The amount of suffering experienced during the first stage of 
 labour varies very much in different persons. As a rule the woman 
 
Labour. 219 
 
 is able to be up and about. As the dilatation advances the pains 
 recur at progressively shorter intervals, but each pain is short 
 compared with the pains of the expulsive stage, not usually exceed- 
 ing a minute in length. As a general rule the pain consists of 
 uterine contraction only, and the muscles of expiration are not 
 called into play as auxiliaries. The woman may cry out freely from 
 the severity of the pain, and there is no involuntary holding of the 
 breath for expulsive effort. Towards the end of the first stage the 
 pains often recur more frequently than the more prolonged and 
 vigorous pains of the expulsive stage, and to women of a susceptible 
 nervous temperament they may be more distressing, partly because 
 the woman does not feel that progress is being made. When the 
 pains are frequent the pulse may become more rapid, sometimes 
 reaching 100, but falls again after the membranes are ruptured, 
 and there are longer intermissions between the pains. Unless the 
 first stage has been very long protracted, and provided that the 
 membranes are not ruptured, this increase of rapidity in the pulse 
 is not of much moment, and has not the same significance as a 
 rapid pulse in the expulsive stage. As the os is dilating, a copious 
 lubricating secretion is poured out by the mucous glands of the 
 cervix, and the vaginal walls become relaxed and dilatable. The 
 presence of this secretion in abundance is a very important practical 
 sign to the accoucheur that the labour is likely to be completed 
 rapidly. It is of value not only from its own mechanical effect, but 
 as an indication that the vagina as well as the cervix is passing into 
 a suitable condition of preparedness. Like the lubricating secretion 
 poured out in coitus, it is greatly under the influence of the nervous 
 system. It is liable to be deficient when there is a tendency to 
 spasm of the cervix, or a deficiency of rhythmical pains, also when 
 there is any source of irritation either from any abnormal condition 
 of the genital passages, or from unduly frequent examination at an 
 early stage of labour. It is also more lik&ly to be deficient if labour 
 is premature, especially if induced artificially. 
 
 The bag of membranes, which at first bulges at the external os 
 only in the form of a watch-glass (Fig. 196, p. 296), protrudes more 
 and more as the first stage advances, and eventually may form a 
 sausage-shaped swelling in the vagina (see Fig. 131, p. 220), and 
 even protrude externally at the vulva. When the mechanism of 
 nature is carried out to the greatest perfection, the membranes have 
 just such a strength that, when the os is fully dilated to the width 
 of the expanded vagina, and not till then, the pressure of the liquor 
 amnii is raised by the increasing pains up to a point sufficient to 
 rupture them. The rupture generally takes place at the bulging 
 
220 
 
 The Practice of Midwifery. 
 
 part ; the liquor amnii in front of the head then flows away, and a 
 portion also of the rest. The head, however, being pressed down 
 into the cervix, fills it up like a ball valve and retains a certain 
 part of the liquor amnii. A portion of this is retained until after 
 
 Fig. 131. — From a frozen section of a patient who died in labour, the head 
 having entered the pelvic cavity, but the membranes being yet unrup- 
 tured. L, liver ; S, stomach ; Pa, pancreas ; D, duodenum ; «, aorta ; 
 PI, placenta ; oi, os internum (.') or retraction ring {!) ; Bl, bladder ; 
 oe, OS externum ; «, urethra ; M, bag of membranes ; i2, rectum. (After 
 C. Braune.) 
 
 the birth of the foetus, but generally a little flows away at the com- 
 mencement of each successive pain, the uterine pressure beginning 
 to affect the liquor amnii before it has pressed the head into firm 
 contact with the whole border of the os uteri, or of that part of the 
 genital canal which it is entering. Thus the longer labour is pro- 
 tracted the more closely does the uterine wall come into contact 
 
Labour. 
 
 221 
 
 with the foetus. If any other part of the foetus than the head or 
 breech presents, almost the whole of the liquor amnii flows away 
 immediately. The same result happens, if from contraction of the 
 pelvis the head is arrested above the brim and so prevented from 
 descending into and filling up the os. 
 
 Fig. 132. — From the same section as Fig. 131, the foetus being removed. 
 PI, placenta ; ot, cavity of uterus ; oi, os internum (.') or retraction 
 ring (?) ; C, cavity of cervix, the ridge indicated at C is considered by 
 many authorities to be the internal os ; oe, os externum ; V, vagina. 
 Note position of bladder and of the peritoneum. 
 
 The termination of the first stage must be defined as being 
 marked, not by the rupture of the membranes, but by the complete 
 dilatation of the os, or at any rate by its dilatation to such a point 
 that it offers no obstacle to the advance of the presenting part. 
 "When the rupture of the membranes, either by nature or by art, 
 just coincides with such dilatation, it marks the transition from 
 the first to the second stage. The cervix uteri is then converted 
 
222 
 
 The Practice of Midwifery. 
 
 into a continuous tube with the vagina (see Fig. 132, p. 221), the 
 vaginal portion of the cervix merely remaining as a flaccid border 
 resting flat against the dilated vagina (oe, Fig. 132). 
 
 More frequently there is no very well-defined boundary between 
 the first and second stages. The membranes give way, or are 
 ruptured artificially, before dilatation of the os is quite complete. 
 The pains then acquire the character of those of the second stage, 
 and the head begins to advance, while there is still a rim of the 
 
 cervix overlapping the greater 
 diameter of the head, and 
 forming a part of the obstacle 
 to its progress. The effect 
 often is that this rim of the 
 cervix is carried down, to some 
 extent, with the head towards 
 the vaginal outlet. If the 
 membranes rupture still earlier, 
 before much dilatation of the 
 OS has been eflected, the first 
 stage is liable to be much pro- 
 tracted, and the child's life 
 runs a greater risk. This 
 occurs more frequently in 
 primiparae, in whom the os 
 presents a greater resistance 
 to dilatation. So long as the 
 membranes are intact, and 
 there is sufficient liquor amnii 
 present, the head is not pressed 
 down at all into the os before 
 its full dilatation, but, on the 
 contrary, recedes during a pain. 
 The child being thus only subjected to the equable pressure of the 
 liquor amnii on all sides, its circulation is not likely to be seriously 
 interfered with. 
 
 When the membranes are unusually tough and are not ruptured 
 artificially, the bag of membranes may be expelled quite outside the 
 vulva, and even the head may pass through the vulva within the 
 unruptured membranes. The membranes then generally rupture 
 about the situation of the neck, after the birth of the head. The 
 child is popularly said to be born with a caul, and to the so-called 
 caul peculiarly lucky properties have been superstitiously attributed. 
 When the bag of membranes is thus carried down in front of the 
 
 Fig. 133. — Diagram showing how the 
 amnion is partly separated from the 
 placenta when it presents unruptured 
 in the vagina or at the vulva. 
 Amnion = inner dotted line. 
 
Labour. 223 
 
 head, the amnion is usually torn away from the placenta. In most 
 cases the amnion alone forms the caul, the chorion having ruptured 
 at the usual place, and remaining attached to the placenta, but some- 
 times the caul is formed of both membranes (Fig. 133). Still more 
 rarely the whole ovum may be expelled entire, and the child will 
 then be suffocated if the membranes are not ruptured artificially. 
 The uterus acts at a great disadvantage in propelling the fa3tus 
 while the membranes are entire, not only because the body to pass 
 through the passages is larger, but because it does not itself gain 
 strength through the diminution of its cavity, and consequent 
 thickening of its walls, on the escape of the liquor amnii. Such 
 an event, therefore, is only likely to happen when the child is 
 small relatively to the pelvis, and the quantity of liquor amnii 
 also comparatively small. Occasionally a certain amount of water 
 escapes early in labour, and a bag of membranes is nevertheless 
 afterwards found presenting. This generally depends on the 
 membranes having been ruptured not at the os, but higher up 
 within the uterus, so that after the escape of a portion of the liquor 
 amnii, the opening is more or less closed by the pressure of the 
 presenting part. More rarely there is fluid between the chorion 
 and amnion, and two bags of membranes may then be ruptured in 
 succession. Occasionally also fluid is said to be secreted between 
 the chorion and the uterine wall, probably in some remnant of the 
 decidual cavity, and to be expelled with the early pains. 
 
 Mode in ivhich the cervix and vagina expand. — The soft parts 
 which close the pelvic cavity below and form the pelvic floor, as 
 seen in antero-posterior section, may be regarded as made up of 
 two triangles, the anterior and posterior pelvic triangles.^ The 
 apex of the anterior triangle is at the cervix uteri, its base at the 
 pubes. The apex of the posterior triangle is at the edge of the 
 perineum, its base is formed by the lower part of the sacrum and 
 the coccyx. The two triangles are separated by the vagina, which 
 forms a transverse slit, the weakest part of the pelvic floor, and 
 allows one triangle to slide upon the other to some extent (see 
 Fig. 134, p. 224). Of the two the anterior triangle is the most 
 movable, since its base only is fixed, and its apex moves up and 
 down with the cervix uteri. The lower side of the posterior 
 triangle has its mobility limited by its close connection with the 
 lower end of the rectum, which is held in place by strong muscles, 
 the levator ani and others. 
 
 The mode in which the vagina expands in labour is shown by 
 Braune's frozen sections (Figs. 131, 132, pp. 220, 221). The anterior 
 
 1 See Hart, ALlas of Female Pelvic Anatomy, pp. 57 — 67. 
 
224 
 
 The Practice of Midwifery. 
 
 pelvic triangle is drawn upwards, while the posterior pelvic triangle 
 is pushed downward by the advancing head. The two triangles 
 thus open to let the foetus pass like double swing doors, which 
 swing open in opposite directions, and thus convert the vagina 
 into a wide canal. 
 
 The tension produced by the contraction of the longitudinal 
 fibres of the uterus necessarily exercises an upward traction upon 
 the cervix to which they are attached. The anterior pelvic triangle 
 
 Fig. 134. — Vertical section of pelvis in the virgin. 1, body of uterus ; 2, its 
 cavity ; 3, the vaginal portion ; 4, canal of cervix ; 5, lower lip of os ex- 
 ternum, forming apex of anterior triangle ; 6, vagina ; 7, hymen, forming 
 apex of posterior triangle ; 8,fourchette ; 9, fossa navicularis ; 10, urethra; 
 11, bladder, empty and relaxed ; 12, rectum ; 13, anus ; 14, recto-vaginal 
 septum ; 15, perineum ; 16, vesico-uterine fossa of peritoneum ; 17, pouch 
 of Douglas ; 18, os pubis ; 19, labium minus ; 20, labium majus. 
 
 is free to yield to this traction and is accordingly drawn upward, 
 so that the upper part of the bladder is elevated above the pubes 
 (see Fig. 131, p. 220), and the peritoneum is stripped off it. Before 
 the commencement of labour, the whole of the bladder, when 
 empty, is below the level of the top of the pubes. When the anterior 
 triangle has been drawn upward, the lower part of the bladder 
 lies behind the pubes, flattened by pressure of the presenting 
 part. The urine, if any, is contained in the upper part above 
 the level of the top of the pubes. The anterior margin of the os 
 externum {oe, Fig. 132, p. 221) becomes higher in reference to the 
 plane of the brim than the posterior margin. The anterior margin 
 
Labour. 225 
 
 of the OS internum or retraction ring, whichever be the correct 
 interpretation (oi, Fig. 132), is also elevated as much as 1*8 inches 
 higher above the plane of the brim than the posterior margin. If 
 the ridge indicated at C be the true internal os, its anterior margin 
 lies above the pelvic brim, while its posterior margin is below it, 
 opposite the centre of the second piece of the sacrum. The longi- 
 tudinal tension has also the effect that the cervix and lower uterine 
 segment are elongated as well as expanded laterally, and their walls 
 are thereby the more thinned.-^ Since the posterior pelvic triangle 
 cannot be drawn upwards as a whole, but, on the contrary, is driven 
 downwards by the advancing head (see Fig. 131, p. 220), the posterior 
 wall of the uterus, especially of the cervix, is more thinned than 
 the anterior. Hence arises the greater liability to rupture at the 
 posterior wall. In proportion as the wall of the uterus below 
 the retraction ring becomes thinned by stretching, longitudinal 
 and transverse, so the wall above it becomes thickened by retraction 
 or shrinking, chiefly longitudinal. 
 
 Caput Succedaneum in the First Stage. — If the membranes 
 are ruptured before the os is fully dilated, and especially if the 
 dilatation is long deferred and the pains active, an effusion of 
 serum takes place beneath that part of the scalp, or other 
 presenting part of the foetus, which projects into the os, and so 
 is unsupported, in consequence of the pressure to which all the 
 rest of the foetus is subjected. In addition to the serum a small 
 quantity of blood may also be effused. The swelling thus produced 
 is called the caput succedaneum, and it may form a prominence 
 elevated for half an inch or more above the surface of the cranial 
 bones. It renders the shape of the head more sharply conical, 
 and thus better adapted for the wedge-like action of dilating the 
 
 1 The ridge marked oi was regarded by Braune as the internal os, partly on account 
 of the large vein at that level seen in the section. This would agree with the view of 
 Baudl (see p. 155) as regards the internal os and retraction ring. But the majority of 
 authorities now regard it as the retraction ring. Its existence as a ridge projecting 
 Inwards may, however, be due to its coinciding with the depression between the head 
 and body of the foetus, as is seen in Fig. 131. On the anterior wall of the uterus, where 
 the coincidence does not exist, the ridge is not seen on the section of the wall. In a 
 frozen section by Barbour showing the second stage of labour, the head lying slightly 
 lower than in Fig. LSI, the upper part of the bladder is in about the same position, but 
 the peritoneum is stripped off only the front of it, the utero- vesical reflection of perito- 
 neum lying at the level of the top of the pubes. This is in favour of the view that the 
 ridge marked at 6' indicates the position of the internal os. It is not certain that the 
 great elevation of the I'etraction ring or os internum above the level of the brim shown 
 in Fig. IP)] is to be regarded as a usual occurrence in normal labour. It is true that the 
 pelvis is not contracted, but the membranes are still intact although theos is fully ex- 
 panded, and the second stage of labour so far advanced, that the head is resting on the 
 pelvic outlet. Tjabour may have been prolonged, thercfoi'e, in consequence of the 
 failure of the membranes to rupture earlier. 
 
 M. 15 
 
226 
 
 The Practice of Midwifery. 
 
 cervix. It therefore tends to compensate, in some small degree, 
 for the loss of the bag of membranes as a dilator. The position of 
 the caput succedaneum as regards the foetus will be considered 
 hereafter in reference to the mechanism of labour. 
 
 Second or Expulsive Stage. — As soon as the membranes 
 are ruptured, if the os has reached the stage of full dilatation, or 
 nearly so, the character of the pains is completely altered. This 
 arises from two causes : first, because the cavity of the uterus is 
 diminished, and its walls thereby rendered thicker and their 
 muscular power stronger; secondly, because there is an increase 
 of reflex stimulus, from the walls of the uterus coming into contact 
 with the fcetus, and the cervix and vagina being pressed upon by 
 
 Fig. 135. — Tracing of the uterine pains during the expulsive efforts of the 
 second stage, showing the effect of the contractions of the abdominal 
 muscles, superimposed upon the contractions of the uterus.^ 
 
 the hard head instead of the elastic bag of membranes. Immedi- 
 ately after the rupture of the membranes, the uterus, contracting 
 round the foetus, appears to take a rest for a short time. Then 
 the pains recur, and are now much more powerful and prolonged, 
 each pain lasting sometimes a minute and a half, or two minutes, 
 instead of less than a minute. At first the pains are often at 
 longer intervals than those of the latter part of the first stage, 
 and the pulse, in consequence, becomes quieter between the pains. 
 As labour advances they become again more frequent, and as the 
 head begins to press upon and pass through the vulva, pains often 
 come in quick succession, with hardly any perceptible interval, 
 until the head is born. In the expulsive stage, not only are the 
 uterine contractions more powerful, but the woman now instinctively 
 aids them by the expiratory muscles, which act as they do in 
 defecation. These bearing-down efforts, though they are made 
 instinctively, are to some extent under the control of the will. In 
 
 1 Schatz. Arch. f. Gynak, Vol. III., Table III., Curve XL, 1872. 
 
Labour. 
 
 227 
 
 order to fix the pelvis and the chest, the woman involuntarily 
 places her feet against some support, such as the foot of the bed, 
 and clutches something with her hands, such as a long towel tied 
 to the foot of the bed. A deep breath is first taken, and then the 
 glottis is closed, and all the expiratory muscles put into strong 
 action. The abdominal pressure so produced, besides its own direct 
 mechanical effect, probably stimulates the uterus to more vigorous 
 contraction (Fig. 135). In consequence of this action of the auxiliary 
 muscles, the character of the cry is altered in the expulsive stage. 
 There is no longer any loud crying-out during the height of a pain. 
 
 Fig. 136. — Appearance of the vertex at the vulval outlet. 
 
 but instead of this the breath is held, and the silence is broken 
 only by short deep expiratory groans in the intervals between the 
 bearing-down efforts. As the pain is passing off, or when it is just 
 commencing, there may still be loud crying-out. 
 
 Although the contractions of the uterus are more violent in the 
 second stage, they are often less distressing than the pains of the 
 first stage. The woman herself feels the presence of a solid body 
 to be expelled, her attention is taken up by the semi- voluntary 
 efforts which she makes to expel it, and her patience is no longer 
 tried by the feeling that no progress is being made. The action 
 of the respiratory muscles must be regarded as reflex although 
 partially under the control of the will. For the bearing-down 
 
 15—2 
 
228 
 
 The Practice of Midwifery. 
 
 efforts may take place to some extent mider chloroform narcosis, if 
 not too deep, or in the coma following puerperal convulsions. The 
 auxiliary forces can only act with a closed glottis, and the action 
 of the glottis has been well compared to that of a safety-valve. As 
 the head approaches the outlet of the vagina, which is the most 
 sensitive part of the canal, and where there is most risk of lacera- 
 tion, the pain becomes so intense at the height of a contraction, if 
 a rupture is threatened, that the woman opens her glottis to cry 
 out. The effect is immediately to take off a part of the expulsive 
 force, and so diminish the risk of rupture. Such an outcry generally 
 takes place when the head is just on the point of passing, and the 
 
 SS- 
 
 FiG. 137. — Emergence of foetal head at vulval outlet. 2<S^, second sacral ver- 
 tebra : B, bladder ; B, rectum ; a, anus ; /, fourchette ; u?; urethra. (After 
 Schroeder.) 
 
 perineum and vaginal outlet are at their greatest strain. Besides 
 the safety-valve action of the glottis, which takes place automati- 
 cally, the accoucheur may also utilise it to some extent to regulate 
 the course of labour. If the pains are ineffective, and the bearing- 
 down efforts weak, he may exhort the woman to hold her breath, 
 and make stronger efforts ; if, on the other hand, the pains are 
 violent and a rupture of the perineum is threatened, he may tell 
 her to cry out, and not to hold her breath. 
 
 Under the influence of the pains of the second stage, the head 
 advances intermittently, receding somewhat in the intervals of 
 the pains in consequence of the elasticity of the soft parts. A 
 caput succedaneum is formed more frequently in the expulsive 
 stage than in the first stage, and it now occupies that j)art of the 
 
Labour. 229 
 
 head which loolis in the direction of its motion, and is unsupported 
 by either cervix or vaginal walls, being due as before to the 
 effect of pressure upon all the rest of the foetus. By the pressure 
 of the head as it descends, the rectum is emptied of any fgeces 
 which it may contain. As the head begins to press upon and 
 distend the perineal body, the perineum bulges outward, and at the 
 same time it is elongated and its anterior margin carried forward. 
 The rectum is flattened by the head ; the anus itself is carried 
 forward, lengthening the space between it and the coccyx, and, as 
 the apex of the head protrudes through the vulva, the stretching 
 of the perineum drags apart the margin of the anus, and the anus 
 opens to the size of an inch or more in the shape of a D, the 
 anterior wall of the rectum resting upon it (see Fig. 136, p. 227). 
 Tearing of the mucous membrane covering the anterior wall of the 
 rectum not uncommonly occurs, and may give rise to smart bleed- 
 ing. Eventually the edge of the perineum, stretched almost as thin 
 as a membrane, forms a ring round the apex of the head, if it has 
 not been lacerated in a previous labour. The perineum may be so 
 thin toward its anterior part, that the sutures of the head can be 
 felt through it (Fig. 137, p. 228). Before this can take place in a 
 primipara, the inevitable laceration at the posterior part of the 
 vaginal outlet, marked by the insertion of the hymen, must have 
 already occurred. By alternate advance and recession of the head, 
 the thin margin of the perineum is gradually stretched. Sometimes 
 the head is arrested at the end of a pain, with the thin ring still 
 stretched over it and intact, but no longer recedes. This has been 
 called the stage of " crowning," and when it occurs, may generally 
 be taken as a sign that the head will pass without any serious 
 laceration of perineum. As soon as the greatest diameter of the 
 head has passed, the elastic and contractile forces of the vagina 
 assist its further progress, and the edge of the perineum quickly 
 slips over it. Slight laceration of the fourchette at this time is very 
 common, but not inevitable. The body is sometimes expelled^^by 
 the same pain, and generally by, at any rate, the following one, 
 which occurs after a short interval of rest, and is followed by a gush 
 of pent-up liquor amnii, at times mingled with some blood which 
 indicates partial detachment of the placenta. Thus terminates the 
 second stage of labour. The description of the third stage will be 
 deferred till after the consideration of the mechanism of the second 
 staf'e. 
 
Chapter XII. 
 THE MECHANISM OF LABOUR. 
 
 The manner in which the foetal head passes through the genital 
 canal depends upon the propulsive forces which act upon it, and 
 the resistance which it meets. In order, therefore, to understand 
 the mechanism of labour in head presentations, and the various 
 movements of the head during its passage, it is necessary, in the 
 first place, to study the forces which act upon the fcetus, and the 
 direction of action of each. 
 
 The propulsive force produced by a uterine contraction is made 
 uj) of two parts — (1) the general intra-uterine jiressure, (2) the direct 
 uterine pressure upon the fcetus. 
 
 General Intra-uterine Pressure. — The contracting walls of the 
 uterus pressing upon the bag of membranes in its cavity, filled with 
 liquor amnii, cause a j^ressure in that fluid which, in general, is 
 uniform throughout every part of it, with the exception of the 
 variation at different levels, due to the weight of the fluid itself. So 
 long as the cervix uteri is closed no propulsive force is thus pro- 
 duced. As soon as the cervix begins to be opened, the pressure in 
 the liquor amnii causes the bag of membranes to bulge through the 
 OS. A resultant propulsive force is then produced which tends to 
 force the ovum as a whole forwards through the cervix, but has no 
 action upon the foetus. Its direction may be inferred from the 
 consideration that it would be neutralised if there were no unsup- 
 ported part of the bag of membranes, that is to say, if there were 
 an equal pressure acting over every part of the membranes which 
 bulge into the os. The force must therefore be equal and opposite 
 to that which would be the resultant of such a uniform pressure 
 over the bulging membranes ; in other words, it acts in the central 
 axis of the os uteri and perpendicular to its plane. If the mem- 
 branes still remain unruptured after the os uteri is fully dilated, as 
 in such a case as that shown in Fig. 131, p. 220, we must conceive 
 the place of the os uteri to be taken by that circle of the vagina 
 where the bag of membranes ceases to be pressed upon by the 
 vaginal walls, and becomes unsupported (Fig. 131). 
 
 After the rupture of the membranes, the head usually fills up the 
 
The Mechanism of Labour. 
 
 231 
 
 cervix uteri or vagina like a ball valve, and a considerable propor- 
 tion of the liquor amnii is retained within the cavity of the uterus, 
 although a small quantity of it generally continues to escape at 
 the commencement of each pain throughout the course of labour. 
 The general intra-uterine pressure then acts on the upper surface 
 of the head, while that part which projects into the os uteri or 
 vagina is unsupported. The force acting on the head from this 
 cause is equivalent to a fluid pressure equal to that of the liquor 
 amnii acting on the upper surface 
 
 of the head, including that part . ----^ 
 
 which is articulated to the trunk. 
 The reason of this is that the 
 trunk would be in equilibrium, 
 as far as regards the liquor 
 amnii, if a surface of similar 
 fluid pressure were substituted 
 for the area of junction with the 
 head ; and therefore the effect 
 of the fluid pressure transmitted 
 from the trunk to the head is the 
 same as if the trunk were 
 removed and the fluid acted 
 directly on the head. Thus 
 results a propulsive force, acting 
 no longer upon the whole ovum, 
 but upon the head. It is not 
 transmitted to the head through 
 the condyles, but, in analogy 
 with the former case, its direc- 
 tion is perpendicular to that 
 circle of the head where the 
 
 head ceases to be pressed upon by the cervix or vagina, as the case 
 may be, and lies in the central axis of that circle. 
 
 In general there is free communication between the liquor amnii 
 within the uterus and that in the bulging bag of membranes in 
 front of the head, sometimes called the " fore-waters." During a 
 pain the bulging of the membranes is increased and the head 
 appears to recede. So long as this is the case, the general intra- 
 uterine pressure does not exercise any propulsive force upon the 
 ffx'tus until after rupture of the membranes. There is one excep- 
 tion, liowever, to this rule. Sometimes, when the liquor amnii is 
 scanty, and the expulsive stage of labour progresses with the 
 membranes still unruptured, as shown in Fig. 131, p. 220, the head. 
 
 FiGr. 138. — Diagram of general intra- 
 uterine pressure showing bulging of 
 bag of membranes through the os. 
 
232 
 
 The Practice of Midwifery. 
 
 may fit so tightly in the genital canal as to shut off the fore-waters 
 from the liquor amnii within the uterus. The increased intra- 
 uterine pressure due to a pain is then not transmitted to the 
 fore-waters and exercises a propulsive force on the foetus, due to 
 the excess of the intra-uterine pressure over that of the fore-waters. 
 It is to be noted that in Barbour's frozen section, representing 
 the second stage of labour, the head near the outlet, liquor amnii 
 
 Fig. 139. — Diagram of the parturient canal in a state of full dilatation. 
 
 intervenes between the breech and the fundus uteri. The chief 
 force at work is therefore the general intra-uterine pressure. 
 
 Direct Uterine Pressure. — Besides the pressure transmitted 
 through the liquor amnii, the uterine walls exercise direct pressure 
 on the body and limbs of the foetus where they come in contact, 
 and thus produce a force which is transmitted to the head through 
 the foetal spine and the occipital condyles. If the uterus were to 
 contract like a uniform bag, it would tend, during a pain, to 
 assume a spherical shape, the sphere being that form which has 
 
The Mechanism of Labour. 
 
 233 
 
 the smallest surface for a given amount of cubic contents. This is 
 not found to be the case. When uncontracted, the uterus lies 
 like a more or less flaccid bag moulded upon the surrounding 
 structures ; but, when it contracts, it tends to assume a certain 
 definite form, dependent upon its natural shape, and the relative 
 strength of its muscular fibres. Hence, by German authors, this 
 direct uterine pressure upon the foetus is called the " form-restitu- 
 tion force." During a pain a transverse section of the uterus, 
 
 Fig. 140. — Sagittal section of primipara at beginning of first stage of labour. 
 Commencing dilatation of cervical canal. Note shape of uterus and 
 level of fundus as compared with Fig. 141.1 
 
 which, when the woman is lying on her back, is much flattened 
 antero-posteriorly from the effect of gravity, becomes more nearly 
 circular. The longitudinal diameter of the uterus is found to be not 
 shortened, but actually lengthened, during a pain, while the antero- 
 posterior diameter is shortened relatively to the transverse. This 
 proves that the action of the circular fibres is relatively so powerful 
 that the axis of the ffXitus is straightened by the pain, notwithstanding 
 the pressure on the l)reech (Fig. 141). Actually, owing to the extension 
 
 ' l,fo|,(.l(|, uterus mill Kind, Plate XVlll. 
 
234 
 
 The Practice of Midwifery. 
 
 of the head and of the spine of the foetus, its length from the vertex 
 to the breech is usually increased from about 10 inches (25 cm.) to 
 14 inches (35 cm.) (see Fig. 141). And thus is explained the fact that 
 the pressure on the breech, due to the action of the longitudinal fibres, 
 is able to transmit a force through the spine to the head without 
 loss, notwithstanding the pliant nature of the foetal axis, that axis 
 
 Fig. 141. — Sagittal section in outline of Barbour's uterus from near end of 
 second stage of labour. Note shape of uterus and level of fundus as 
 compared with Fig. 140. 
 
 being supported on all sides by the circular fibres and so prevented 
 from bending. 
 
 The direction of the force resulting from the direct uterine 
 pressure on the foetus is. approximately parallel to the axis of the 
 uterus. The direction of the axis of the uterus during labour is 
 generally considered to be normally nearly coincident with the axis 
 of the pelvic brim, but varies to some extent either in consequence of 
 the common deviation of the fundus uteri toward the right side, or in 
 accordance with the position of the woman (Fig. 140). In the absence 
 of a pain, while the woman is lying on her back, the fundus uteri is 
 inclined backward in reference to the axis of the brim, a position 
 
The Mechanism of Labour. 235 
 
 which is seen also in the frozen corpse (Fig. 131, p. 220) ; but during 
 a pain, in the second stage of labour, the fundus becomes more or 
 less thrown forward, in consequence of the descent of the diaphragm 
 produced by the preliminary deep inspiration, and by the drag pro- 
 duced by the contracting round ligaments. When the woman 
 stands upright, on the other hand, the fundus is apt to be inclined 
 forward in reference to the axis of the brim, if the abdominal walls 
 are lax. On the whole, the average direction of the axis of the 
 uterus may be regarded as being slightly inclined posteriorly in 
 reference to the axis of the brim (see Fig. 139, p. 232). This 
 implies a corresponding inclination of the force due to direct uterine 
 pressure. Fig. 139 is diagrammatic, since the whole parturient 
 canal is not dilated thus at the same time, the fundus having 
 begun to descend by retraction before the vulval outlet is fully 
 dilated by the advancing head. 
 
 Auxiliary Forces. — In the expulsive stage of labour, when the 
 auxiliary muscles come to the aid of the uterus, the first step is 
 that, at the onset of a pain, the woman takes a deep breath and 
 then closes the glottis, thus fixing the diaphragm. This descent of 
 the diaphragm depresses somewhat the fundus uteri, and thus 
 brings the uterine axis more nearly into coincidence with the axis 
 of the brim. The glottis remaining closed, the expiratory muscles 
 of the abdomen and chest compress the abdominal contents, just 
 as in defecation or micturition, while the diaphragm remains passive. 
 The abdominal pressure thus produced acts over every part of the 
 outside of the uterus except those which are below the level of the 
 stratum of cellular tissue in the pelvis forming the floor of the 
 abdominal cavity. The part of the uterus thus pressed upon 
 coincides nearly with that part of the muscle which is actively con- 
 tracting. The effect of the auxiliary muscles is therefore to add to 
 each of the resultant forces already mentioned, namely, the general 
 intra-uterine pressure, and the direct uterine pressure on the fcetus. 
 It has also another influence of great practical value, namely, that 
 it tends to press the uterus downwards, as a whole, towards the 
 pelvis. This takes off the tension placed by the uterine contrac- 
 tions on that lower distensible uterine segment which intervenes 
 between the strong retracting or thickening part of the muscle (see 
 p. 15G), and the attachment of the uterus to the pelvis, and which 
 accordingly is the part of the uterus most liable to rupture. Thus 
 the tendency to rupture of the uterus is resisted by an efficient 
 action of the auxiliary muscles, and is more likely to occur if the 
 aljdominal walls are weakened by fat or over-distension. 
 
236 
 
 The Practice of Midwifery. 
 
 In a protracted labour, as the liquor amnii gradually escapes 
 more and more completely, the uterine walls come into closer 
 contact with the foetus, and thus the relative importance of the 
 general intra-uterine pressure becomes progressively less, and that 
 of the direct uterine pressure on the foetus progressively greater. 
 This will happen the more rapidly if any deformity of the pelvis 
 prevents the head descending into it sufficiently to act effectively 
 
 Fig. 142. — Section of uterus with child i/i situ, towards the end of the second 
 stage of labour. The membranes have ruptured, the head lying between 
 the right oblique, and the conjugate diameter is at the vulva, and there 
 is a well-marked caput succedaneum. There is some undoing of the 
 flexion of the spinal column, and there is a space between the arms and 
 the legs.i 
 
 as a ball-valve. It will be observed that the force exerted by the 
 general intra-uterine pressure on the head is always perpendicular 
 to that circle of the soft parts which the head is at the moment 
 entering, and therefore acts always at the greatest possible advan- 
 tage. That produced by the direct uterine pressure acts nearly in 
 the axis of the brim until the head is so far advanced that the trunk 
 meets the inclined pelvic floor (see Fig. 137, p. 228). It then 
 
 1 From Barbour, Atlas of the Anatomy of Labour, Plate XXII. 
 
The Mechanism of Labour. 
 
 237 
 
 becomes inclined more forward, but still does not act so strictly in 
 the direction in which the head is advancing as the other force. It 
 is therefore an advantage if, in the later stage of labour, a consider- 
 able quantity of liquor amnii is still retained. 
 
 Magnitude of the Forces acting in Labour. — The force exerted 
 by the uterus is of much greater magnitude and importance than 
 that produced by the auxiliary muscles. This is proved by the 
 fact that, if pains are absent, no voluntary effort is effective in for- 
 warding labour. Matthews Duncan^ ascertained experimentally the 
 force necessary to rupture the membranes, and found it to vary 
 
 Fig. 143. — Superficial and deep muscles of pelvic floor seen from below. 
 
 from 4^ to 36 lb., the average being 15 lb. He inferred that the 
 minimum force necessary to complete labour does not much exceed 
 that which ruptures the membranes, and believed that the force 
 naturally expended does not often exceed 50 lb. Schatz^ endeavoured 
 to measure the force directly by manometer, and found that in 
 normal conditions during the pains the intra-uterine pressure was 
 indicated by a column of mercury 80 mm. in height, represent- 
 ing a force of some 8 to 9 kilos., 18 to 20 lb., or in some cases by a 
 column 200 mm. high or a force of 25 to 30 kilos., 55 to 66 lb. 
 
 The natural rupture of the membranes at a certain time, which 
 normally should correspond to the completion of the first stage, 
 
 ' Ilesea relies in OVjstetrics, p. 299. 
 
 - Scliatz, Verliandlunj(en d. Deutschen Gesell. f. Oyii., 1X95, VL, |i. 5;5I. 
 
238 
 
 The Practice of Midwifery. 
 
 depends upon two factors, first the increase in size of the os uteri, 
 and, secondly, the progressive increase in the force of the pains. 
 Supposing the pressure of the Hquor amnii to remain constant, the 
 effect of that pressure in producing tension, and therefore tendency 
 to rupture, of the enclosing membrane, is proportional to the radius 
 of that sphere which corresponds incurvature to the projecting bag 
 of membranes at any point. While the os is still small, the pro- 
 truding membranes form a segment of a small sphere, but as the 
 OS enlarges, the corresponding sphere also enlarges, and with it the 
 strain upon the membranes, even apart from any increased vigour 
 in the pains. 
 
 Fig. 144. — Lateral view of muscles of pelvic floor. (After Farabeuf and 
 Varnier, Introduction al'etude clinique et a la Pratique des accouchements.) 
 
 Resistances. — The movements of the head and other parts of the 
 foetus in passing through the pelvis are determined by the directions 
 of the resistances they encounter. It has already been explained 
 (see p. 18) that the pelvis is so shaped that it corresponds, in a 
 degree, to a female screw. The largest diameter gradually changes 
 from a transverse to an antero-posterior direction, as it is traced 
 from above downwards, and the anterior and posterior inclined 
 planes of the ischium are so arranged that the left anterior and 
 right posterior quarters of the pelvis combine to form a portion of 
 a screw with a turn from left to right ; the right anterior and left 
 posterior quarters another portion of screw with the opposite turn, 
 namely from right to left. When the head reaches the floor of the 
 pelvis it meets an inclined plane sloping forwards, formed, first, by 
 the lower part of the sacrum, secondly by the coccyx with the 
 muscles attached to it, thirdly by the soft parts between the coccyx 
 
The Mechanism of Labour. 239 
 
 and the anus, together with the recto-vaginal septum which lies 
 flattened against them, and finally by the perineal body. This 
 inclined plane, as it exists in a multipara when the vaginal canal is 
 as yet only partially dilated, is well seen in the section from a 
 frozen body, shown in Fig. 131, p. 220. In a primipara, the perineal 
 body extends much further forward, and its position, when fully 
 distended by the advancing head, is shown in Fig. 139, p. 232. 
 
 The movement of the presenting part, as it approaches the 
 outlet of the soft parts, is much affected by the shape of the 
 strong muscle which virtually forms the sphincter of the vagina, 
 namely the anterior portion of the levator ani (Fig. 143). The 
 main attachments of this important muscle, which, together 
 with the coccygeus muscle and the pelvic fascia, makes up the 
 pelvic floor, are as follows. Arising from the posterior surface 
 of the pubes from the white line on the obturator fascia, and 
 from the ischial spine, it passes back, surrounding the vagina 
 and the rectum, to be attached to the side of the coccyx, to the 
 raphe between that bone and the anus, to the sides of the rectum 
 and vagina, and to the perineal body. Hence, when the pelvic 
 floor, driven down before the advancing foetus, is bulged outward, 
 and the anterior portion of the levator ani stretched open, this 
 muscle being attached most firmly anteriorly and posteriorly and 
 comparatively free at the sides, takes the form of an ellipse, with 
 its long diameter antero-posterior. In easy labours, when the 
 presenting part does not fit tightly to the bony pelvis, the shape of 
 this elliptic opening has more to do than that of the pelvis with 
 the rotation of the long diameters of the presenting part into the 
 antero-posterior diameter of the outlet. 
 
 Positions of the Head in Vertex Presentations. 
 
 The head, as it enters the brim, may occupy almost any diameter 
 of the pelvis. The simplest classification is that adopted by 
 British authors, according to which the pelvis is divided into four 
 quadrants by antero-posterior and transverse lines, and four 
 positions of the head are described according to the quadrant in 
 which the occiput lies. For any other presenting part there will 
 also be four corresponding positions. Again, it is usual with 
 British authors to name the right oblique diameter of the pelvis 
 that diameter which passes through the right sacro-iliac articu- 
 lation, and the left oblique that which passes through the left 
 sacro-iliac articulation. It must be borne in mind, that by some 
 Continental writers exactly the reverse usage is adopted. 
 
240 
 
 The Practice of Midwifery. 
 
 The four following are the positions of the foetal head : — 
 First or left occijnto-anterior (L. 0. A.). — The long diameter of 
 the head approximates toward the right oblique diameter of the 
 
 Fia. 145.— Brim of the pelvis, and base of the foetal skull in the 
 first cranial position. 
 
 pelvis. The occiput points toward the left foramen ovale ; the 
 forehead toward the right sacro-iliac articulation. 
 
 Second or right occipito-anterior {R. 0. A.). — The long diameter of 
 the head approximates toward the left oblique diameter of the 
 pelvis. The occiput points toward the right foramen ovale ; the 
 forehead toward the left sacro-iliac articulation. 
 
 Third or right occijnto-posterior {R. 0. P.). — The long diameter 
 
 Fig. 146. — Brim of the pelvis, and base of the foetal skull in the second position. 
 
 of the head approximates toward the right oblique diameter of the 
 pelvis. The occiput points toward the right sacro-iliac articulation ; 
 the forehead toward the left foramen ovale. 
 
 Fourth or left occipito-posterior (L. 0. P.). — The long diameter of 
 the head approximates toward the left oblique diameter of the 
 
The Mechanism of Labour. 
 
 241 
 
 pelvis. The occiput points toward the left sacro-iliac articulation ; 
 the forehead toward the right foramen ovale. 
 
 It is not meant that in these positions the long diameter of the 
 head lies precisely in any oblique diameter of the pelvis,. for, as a 
 
 Fig. 1J:7. — Brim of the pelvis, and base of the fcetal skull in the third position. 
 
 rule, it is more nearly transverse than antero-posterior, but only 
 that it approximates more nearly to that oblique diameter than to 
 any other. If the long diameter of the head is exactly transverse, 
 it is regarded as being on the boundary between the first and 
 fourth ; or between the second and third positions ; if it is exactly 
 
 Fig. 148. — Brim of the pelvis, and base of the foetal skull in the fourth position. 
 
 antero-posterior (which can only happen in a transversely con- 
 tracted brim), it is regarded as being on the boundary between 
 the first and second or between the third and fourth. 
 
 These four positions of the vertex, or of any other presenting 
 part, such as the face or breech, can at once be deduced if the 
 following two facts are remembered — first, that the back of the 
 child looks forward in the first and second positions, backward in 
 
 M. 16 
 
242 
 
 The Practice of Midwifery. 
 
 the third and fourth ; secondly, that its antero-posterior diameter 
 lies in the right oblique diameter of the pelvis in the first and 
 third positions, in the left oblique diameter in the second and 
 fourth. It should also be remembered that the back of the child 
 is to the mother's left in the first and fourth, to her right in the 
 second and third positions. 
 
 It has been mentioned (see p. 18), that, at the pelvic brim, the 
 transverse diameter is the largest. The reason why the long 
 diameter of the head generally enters the pelvis somewhat 
 
 Fig. 149. — First vertex presentation, left FiG. 150.— Second vertex presentation, right 
 occipito anterior. Head markedly flexed. occipito anterior. Plead markedly flexed. 
 
 obliquely, and not in the transverse diameter, is twofold. First, 
 the psoas and iliacus muscles so reduce the transverse diameter 
 at the brim that, in the pelvis clothed with its soft parts, the 
 transverse diameter is not greater than the oblique. Secondly, 
 the initial position of the head is greatly influenced by the position 
 of the body of the child before the onset of labour. The child 
 generally lies in the uterus with its back directed somewhat 
 forward. The main reason for this is that the posterior wall of 
 the uterus is rendered somewhat convex inwardly by the projec- 
 tion of the lumbar vertebrse of the mother (see Fig. 131, p. 220, 
 and Fig. 139, p. 232). The foetus is therefore better accommodated 
 
The Mechanism of Labour. 
 
 243 
 
 to the shape of the uterus when the fcetal spine is turned away 
 from the spine of the mother. 
 
 If the conjugate diameter of the pelvic brim is contracted, 
 while the transverse is relatively large, the long diameter of the 
 head enters the brim almost exactly in the transverse diameter. 
 In the much more rare cases in which the pelvis is contracted 
 transversely at the brim, to such an extent that its antero- 
 posterior diameter is the largest, the long diameter of the head 
 may enter the brim nearly in that antero-posterior diameter, 
 
 Fig. 151. — Third vertex presentation, riglit 
 occipito posterior. Flexion of head not so 
 marked as in occipito anterior presenta- 
 tion. 
 
 Fig-. 152. — Fourth vertex presentation, left 
 occipito posterior. Flexion of head not so 
 marked as in occipito anterior presenta- 
 tion.i 
 
 provided that there is insufficient room for it in the other 
 diameters. 
 
 The proportion of cases in which the vertex presents is more 
 than 96 per cent. In about 24,000 deliveries in Guy's Hospital 
 Lying-in Charity it was 96"9 per cent. As to the relative frequency 
 of the different positions of the vertex, very various estimates 
 are given. Without any doubt the first position is much the 
 commonest, and its frequency is variously given as from 65 to 80 
 per cent, of vertex presentations. Almost all authorities also agree 
 that the fourth position is much the rarest, and, according to the 
 
 1 The four figures, 149, 1.50, 151, 152, all from Farabeiif and Varnier, Pratique des 
 Accouchements, Figs. 31, '62, 33 and 34, 
 
 16—2 
 
244 The Practice of Midwifery. 
 
 highest estimate, its frequency is less than 5 per cent., or about 
 2*6 per cent. The chief difference of opinion is as to the relative 
 frequency of second and third positions. The cause of the dis- 
 crepancy is partly, that third positions generally change into second, 
 and that the case may be observed for the first time either before 
 or after the change ; part,]y that, when the back of the foetus is 
 toward the right, the long axis of the head is often so nearly 
 transverse that it is difficult to say whether the position should be 
 called second or third. 
 
 It was taught by Naegele that, in 99 per cent, of all cases, the 
 long diameter of the head lay at first in the right oblique diameter 
 of the pelvis, and that second positions, as well as fourth, were 
 excessively rare. The opinion of many modern authorities is 
 rather that primary second positions are about as common as 
 third, so that the frequency of each may be taken as about 
 15 per cent. 
 
 The chief reason why the long diameter of the head so 
 frequently lies in the right oblique diameter of the pelvis is that 
 the left oblique diameter of the pelvis and lower part of abdomen 
 is partially occupied by the rectum and sigmoid flexure, with their 
 contents, and so affords less space. Another cause also contributes 
 to the great frequency of the first or left occipito-anterior position. 
 The pregnant uterus generall}^ not only has a natural obliquity 
 toward the right side, but is rotated somewhat on its axis, so that 
 its front looks toAvard the right, and its left side is foremost. The 
 left and anterior portion of the uterus therefore occupies the most 
 dependent position when the woman is standing upright. The 
 foetus, lying in its usual attitude, with the limbs flexed, is most 
 readily accommodated to the shape of the uterus when its antero- 
 posterior diameter nearly corres^Donds with the transverse, or 
 greatest, diameter of the uterine cavity. Its back is most frequently 
 directed forward, and not backward, partly from the effect of the 
 accommodation of the shape of the uterus to the position of the 
 maternal spine, which has been already mentioned (see p. 242), 
 and partly from the effect of the higher specific gravity of the 
 spinal column of the foetus when the woman is standing upright. 
 Hence it follows that the back of the child is generally directed to 
 the left side, and somewhat forward. 
 
 Movements of the Head and of the Trunk of the Fcetus. 
 
 It has already been explained that the curved axis of the pelvis 
 (Fig. 22, p. 21) is a line drawn to represent, as nearly as possible, 
 
The Mechanism of Labour. 
 
 245 
 
 the path described by the centre of the foetal head in passing 
 through the genital canal. While the centre of the head, and in 
 its turn the trunk of the fcetus, is passing along the curve, the 
 head and the body make certain rotations on various axes, which 
 it is important to study, in order to understand the mechanism of 
 labour, and its modifications under various circumstances. The 
 mechanism will first be described for the case in which the head 
 
 Fig. 153. — Diagram showing that with the head completely flexed the maxi- 
 mum vertico mental diameter is nearly coincident with the axis of the 
 plane of the pelvis in which the centre of the head is lying. (After 
 Kaltenbach Zeitsch f. Geb. u. Gyn., Bk. XXI.) 
 
 lies in the left occipito-anterior, or first, position (L. 0. A.). The 
 most important of these movements are enumerated as follows : — 
 
 /Flexion. 
 
 Internal Eotation. 
 DESCENTi Extension. 
 
 Restitution. 
 ^External Rotation. 
 
 Flexion. — While the meriibranes are still unruptured, and 
 before any expulsive force has begun to act upon the foetus, the 
 head lies over the os uteri in a variable position, occasionally 
 
246 
 
 The Practice of Midwifery. 
 
 partly extended, but, as a study of frozen sections has shown, as a 
 rule completely flexed with the chin resting on the sternum. 
 
 If the liquor amnii is abundant, especially in a multipara, and the 
 head is not engaged in the pelvic brim, the position may be inter- 
 mediate between flexion and extension. The two fontanelles are 
 then nearly on the same level, the anterior being perhaps somewhat 
 
 OCCIPUT 
 
 SINCIPUT 
 
 Fig. 154. — Line of section and shape of suboccipito-bregmaticandof occipito- 
 frontal planes. (From lead tape tracings by Edgar, Practice of Obstetrics, 
 1904, p. 467.) 
 
 the lowest, owing to the shape of the head. Both fontanelles 
 can be reached with about the same readiness, and the sagittal 
 suture between them crosses the centre of the presenting part. 
 When, however, the head is already engaged in the pelvic brim, as 
 in most primiparse, or is so large as to fit tightly into the lower 
 segment of the uterus, the liquor amnii in that part being 
 comparatively scanty, the head is already considerably flexed 
 before the rupture of the membranes, in order to adapt it to the 
 containing cavity. As soon as the membranes are ruptured, and 
 
The Mechanism of Labour. 
 
 247 
 
 the head begms to meet with resistance, either from the cervix 
 uteri, or other part of the genital canal, a movement of flexion of 
 the chin upon the sternum begins, if flexion is not already complete, 
 associated with the onward movement of the centre of the head 
 through the pelvic brim. By this movement, which is really a 
 movement of accommodation, a mechanical advantage is gained, for, 
 when flexion is complete, the greatest diameter of the head which 
 has to pass any plane of the pelvis is no longer the longitudinal or 
 occipito-frontal {of, Fig. 89 , p. 128), but either the suboccipito- 
 bregmatic {sh, Fig. 89, p. 128), or one nearly approximating to it. 
 The length of the occipito-frontal diameter being about 4*6 inches 
 (11*25 cm.), with a circumference of 13| inches, 
 and that of the suboccipito-bregmatic only 
 3'8 inches (9*5 cm.), with a circumference of 
 ] 2f inches, there is thus a gain of about three- 
 quarters of an inch in the diameter, or of one 
 inch in the circumference, even without any 
 moulding of the head (Fig. 154). Also the 
 maximum diameter of the whole head {mx, 
 Fig. 89), instead of lying at all across the 
 pelvis, becomes, when flexion is comj)lete, 
 nearly coincident with the axis of the plane in 
 which the centre of the head is lying (Fig. 153). 
 Cause of Flexion. — The cause of flexion, 
 when it does occur, is twofold. The first 
 cause depends upon the position of the occipital 
 condyles nearer to the occiput than to the 
 forehead, the second upon the irregular 
 shape of the head. The first cause is the 
 simplest, and in general the most important, 
 is illustrated by Fig. 155. Suppose a c to 
 
 Fig. 
 
 155. — Diagram of 
 head lever. 
 
 Its mode of action 
 be a line drawn 
 parallel to the axis of the uterus and passing through the occipital 
 condyles. This will be the direction of the propulsive force, so 
 far as this depends on the direct uterine pressure on the fcetus (see 
 p. 232). The head, in entering any part of the genital canal, will 
 be resisted most at the two extremities of its longest or antero- 
 posterior diameter, f (Fig. 155), and the resistances at and f may 
 be considered equal. The head may then be regarded as a lever, 
 balanced about the point c, where the line of propulsive force cuts 
 F, by the resistances at and f. Since the anterior arm f c of 
 the lever is longer than the posterior arm o c, the resistance to the 
 forehead will have the mechanical advantage, and the forehead 
 will be retarded more than the occiput. When labour is difficult 
 
248 The Practice of Midwifery. 
 
 and prolonged, so that most of the hquor amnii drains away, and 
 the du'ect uterine pressure is the chief force at work, the move- 
 ment of flexion so produced will generally go on until it is stopped 
 by the chin being pressed firmly against the sternum, or the arm 
 of the foetus, which is often forced down under the chin by the 
 expulsive force (see Fig. 131, p. 220). In easy rapid labour, when 
 the general intra-uterine pressure is the chief force in action, 
 flexion remains more moderate, not perhaps exceeding that which 
 exists in utero. In general, advance and flexion take place together, 
 but it is possible for flexion to occur before advance, if the head is 
 about to enter a strait of the pelvis which is too small to receive it 
 while unflexed. For, during a pain, the occiput may be pushed 
 
 V 
 
 bIM / 
 ! ')< c 
 
 G\/\ 
 
 Fig. 156. — Diagram to illustrate the mode in which flexion is produced by 
 the pressure of the girdle of contact on the head. 
 
 slightly downwards, and, during the interval, the head as a whole 
 pushed as much backwards by the resistance of the elastic soft 
 parts, and the forehead so elevated. In this way the occiput may 
 be slightly dejDressed, and the forehead slightly elevated alternately 
 until sufficient flexion has been produced to allow the head to 
 advance as a whole into the narrow part, whether constituted by 
 the bony pelvis, the cervix, or soft parts elsewhere. 
 
 The second cause of flexion comes into play even if there is no 
 force transmitted through the condyles, the only propelling force 
 being the general fluid pressure, transmitted to the foetus through 
 the liquor amnii. -^ It arises from the relation between the shaj^e 
 of the head and the pressure exercised upon it at the girdle of 
 
 1 See Lahs., " Die Theorie der Geburt," Bonn, 1887. 
 
The Mechanism of Labour. 
 
 249 
 
 Fig. 157. — Diagram to illustrate 
 the increase of flexion by pres- 
 sure after the head has entered 
 the genital canal. 
 
 contact either with the os uteri, or the yet imperfectly expanded 
 
 soft parts elsewhere. The head, looked at from the side, is seen to 
 
 form an unequal wedge, the slope at 
 
 the occipital end being steeper than 
 
 at the frontal (see Fig. 89, p. 128, 
 
 and Fig. 156). Fig. 156 represents 
 
 the head, the still imperfectly ex- 
 panded OS uteri forming the girdle of 
 
 contact. The resultant of the 
 
 general fluid pressure acts perpen- 
 dicularly through the centre of the 
 
 OS, in the line f g. The pressures 
 
 at the girdle of contact (disregarding 
 
 friction) act perpendicularly to the 
 
 surface, that is, at the ends of the 
 
 longest diameter engaged (a b), they 
 
 act along the lines a h, b h. Their 
 
 resultant must act through the point h where these lines meet, and 
 
 it must act perpendicularly to the plane of the os, if the head as a 
 
 whole is not being pushed toward the forehead, or toward the 
 
 occiput, that is to say, it acts in the 
 line D E parallel to f g. We have 
 then two equal forces acting in 
 opposite directions, but not in the 
 same straight line. This forms 
 what in mechanics is called a 
 couple, and it will cause the occiput 
 to descend and the forehead to 
 rise until the tangents at a and b 
 are equally inclined to f g, in which 
 case the point h and also the point 
 c will lie upon f g. If friction is 
 taken into account, it will some- 
 what limit the effect produced, so 
 that the angles which the tangents 
 at A and b make with the plane of 
 the OS will not become perfectly 
 equal, but it will not alter its 
 general character. It will be 
 
 observed that flexion, produced by this cause, need not go so far as 
 
 to bring the chin into contact with the sternum. 
 
 A second effect of the pressure of the girdle of contact is produced 
 
 during the intervals of the pains, when a partial flexion has already 
 
 Fig. 158. — Outline of the internal 
 surface of the left half of the 
 pelvis. The two curved lines 
 mark the path of the occiput in 
 the first, and in the occipito- 
 anterior termination of the 
 fourth position. 
 
250 
 
 The Practice of Midwifery. 
 
 occurred. Fig. 157 represents a head in such a position engaged 
 in a cyhndrical elastic canal. The pressures at a and b during 
 the intervals of propelling force will act perpendicularly to the 
 
 1^4 
 
 -t/.i 
 
 V^.i 
 
 Fig. 159. — Diagram of mechanism of labour illustrating the movements of 
 head and shoulders in their passage through the pelvis. Outline = pelvis 
 looked at from above and behind ; arrow = occipito frontal diameter of 
 head ; arrov^r head = occiput ; —\ = bis-acromial diameter of shoulders ; 
 short limb = right shoulder ; i. v. -i, L.O.P. head entering pelvis, occ. fr. 
 diam. in left oblique diam., bis-acrom. diam. of shoulders in rt. obi. diam. 
 of pelvis ; ii., internal rotation forwards of occiput through J- of circle ; 
 iii., further internal rotation of occiput through ^ of circle and conversion 
 into V. i. L.O.A. ; iv., v. i. L.O.A. occ. fr. diam. in rt. obi. bis-acrom. diam. of 
 shoulders in left obi. of pelvis ; v., internal rotation of occiput through 
 I of circle to front ; vi., birth of head by movement of extension, occiput 
 leading, showing twist of head on shoulders ; vii., restitution, occiput 
 rotating back towards original position to undo twist ; viii., external 
 rotation of occiput with internal rotation of right shoulder to the front ; 
 ix., birth of shoulders, right shoulder leading. 
 
 surface in the direction of the arrows. They will thus, as shown 
 in the figure, form a pair of equal forces, or " couple," tending to 
 rotate the head on a transverse axis, so as to increase its flexion. 
 This kind of pressure will be exercised even by the lower segment 
 of the uterus and before the onset of labour, but especially after the 
 
The Mechanism of Labour. 251 
 
 rupture of the membranes. Together with the general tendency of 
 flexor to preponderate over extensor muscles, it is the cause of the 
 flexion existing in utero. 
 
 The effect of flexion is that, instead of the examining finger 
 touching a point near the middle of the sagittal suture, the 
 posterior fontanelle becomes progressively more within reach, and 
 the anterior fontanelle relatively higher. When flexion is complete 
 the posterior fontanelle may be nearly at the centre of the present- 
 ing part and of the caput succedaneum, while the anterior fontanelle 
 may be out of reach, especially when the head is much elongated 
 by moulding. 
 
 Internal Rotation.— By the movement of internal rotation the 
 long diameter of the head changes from a position not far from 
 the transverse diameter of the pelvis into the antero-posterior or 
 nearly so. In this rotatory movement, therefore, the head describes 
 rather more than one- eighth of a circle. It emerges beneath the 
 pubes with the sagittal suture directed almost, but not quite, in an 
 antero-posterior direction (see Fig. 137, p. 228, and Fig. 161). 
 This is called a short internal rotation in contradistinction to the 
 long internal rotation which occurs in occipito-posterior positions. 
 
 Causes of Internal Flotation. — Internal rotation is due, in the 
 first place, to a screw-like mechanism, the longest diameter of the 
 head accommodating itself to the longest diameter of the pelvis, 
 which progressively changes from a transverse to an antero-posterior 
 direction. In some cases of contracted pelvis where the head fits 
 the pelvis tightly the anterior inclined plane of the ischium may 
 help in directing the occiput forwards, and the posterior inclined 
 plane of the ischium, coming into play at a higher level, may help 
 in directing the forehead backwards. It is ]3robable, however, that 
 in most instances the rotation of the head is brought about by some 
 other agency than the inclined planes of the pelvis. As soon as the 
 head has descended into the cavity of the pelvis the action of the 
 sloping posterior and lateral walls of the pelvic floor must be taken 
 into account. These together form a sloping gutter which tends to 
 direct any body coming into contact with it downwards and forwards 
 into the free space under the pubes formed by the vaginal outlet. 
 
 The forecomiug part of the head, in the case of the vertex the 
 occiput, is directed forwards by these sloping walls, and rotates 
 towards the free space under the pubes, in the direction of least 
 resistance. This movement takes place quite independently of the 
 screw-like form of the l)ony pelvic walls, and occurs both in 
 occipito-aiiterior and occipito-posterior presentations. The action 
 
252 
 
 The Practice of Midwifery. 
 
 of the sloping gutter of the pelvic floor is aided by the shape of the 
 opening in the levator ani muscle through which the head has to 
 pass, which has the form of an ellipse with its long diameter 
 directed antero -posteriorly. 
 
 Some writers, in view of the difficulty of explaining the forward 
 rotation of the forehead in cases of unreduced occipito-posterior 
 
 Fig. T 60.— Section showing the genital tract towards the close of the second 
 stage of labour. The fundus is at the level of the first lumbar vertebra. 
 The retraction ring is well marked ; the anterior vaginal wall is its usual 
 length, 2 inches, while the posterior vaginal is greatly stretched and 
 measures 7 inches ; the placenta is not separated, and the anus and 
 perineum are stretched. (Vide, Fig. 142, p. 236, Barbour.) 
 
 presentations, maintain that the rotation forwards of the forecoming 
 part of the head is in reality due to a rotation of the body of the 
 child. Owing to the projection forwards of the lumbar spine of the 
 mother, there is a tendency for the spine of the child to turn away 
 from the spine of the mother (see p. 244), and as during a con- 
 traction the uterus becomes flattened antero-posteriorly, if the back 
 of the fcetus is placed obliquely, the uterine contractions will tend 
 to rotate it to the front. During a uterine contraction the trunk 
 
The Mechanism of Labour. 253 
 
 and the head of the foetus may be considered as forming one body, 
 and therefore any rotation forwards of the back will be accompanied 
 by a similar rotation of the occiput. If this is the explanation of 
 the rotation of the forecoming part forwards, then we must hold 
 with Schrceder that the rotation of the shoulders does not take 
 place to so complete a degree as that of the head, and that the 
 com]3lete rotation of the latter, although initiated in this manner, 
 is completed by other accessory causes. 
 
 Sellheim has lately put forward the view that the rotations of the 
 foetus in its passage through the birth canal can be explained on 
 purely mechanical grounds. He maintains that if a body capable 
 of being bent in different directions with varying degrees of facility 
 is pushed through a curved cylindrical canal, it will pass with the 
 greatest ease when its most bendable flexures correspond to the 
 most marked curves of the cylinder. 
 
 In the case of the foetus, in the normal attitude of flexion it 
 maintains in utero, the movement which can take place most 
 readily is extension of the head on the trunk. Hence during its 
 passage through the pelvic canal its body, following this law, rotates 
 in such a manner as to bring the back of the neck into contact with 
 the under-aspect of the pubes, and also to permit of extension of the 
 head taking place with the greatest facility. 
 
 In the case of a face presentation the movement of flexion of the 
 head is the one which can occur most readily, and therefore rotation 
 takes place in such a manner as to bring the chin under the pubes, 
 and so to permit of flexion of the head on the trunk. 
 
 Extension. — Flexion is maintained until the head meets the 
 resistance of the inclined plane looking forward formed by the 
 soft parts which constitute the pelvic floor (see Fig. 132, p. 221). 
 The reverse movement of extension then commences (see Fig. 161). 
 The chin becomes separated from the sternum ; the head moves 
 almost as if it were rotating about a transverse axis passing through 
 a point somewhere in the symphysis pubis (except that the movement 
 of internal rotation around a quite different axis is generally also 
 still proceeding). The forehead moves faster than the occiput, 
 having to go along the outside of the curve while the occiput moves 
 along the inside; but no point on the head is arrested, and the 
 posterior fontanelle is nearly in the centre of the part which first 
 protrudes through a vulva not previously lacerated (see Figs. 136, 
 p. 227; and 162). Eventually, as the head escapes through the 
 vulva, the occiput becomes turned somewhat upward in front of the 
 pubes (see Figs. 162, 163, 164 (4)). Meanwhile the perineum and 
 
254 
 
 The Practice of Midwifery. 
 
 the soft parts behind the anus become greatly stretched, the anus 
 itself expanded, and the anterior margin of the perineum drawn 
 forward (see Fig. 22, p. 21, and Figs. 161, 162,. 163). The ring 
 formed by the vulval outlet is at its greatest tension when the 
 forehead is just passing the fourchette, and the girdle of contact 
 formed by it then encircles the head nearly in the plane of the 
 suboccipito-frontal diameter {sy, Fig. 89, p. 128). If the promi- 
 nence of the forehead has once passed without rupture, the perineum 
 slips quickly over the face, and, as soon as the chin is released, the 
 extension of the head is diminished. 
 
 Cause of Extension. — Extension is caused by the resistance of the 
 
 inclined plane of elastic soft 
 parts looking forward, which 
 forms the pelvic floor, acting in 
 conjunction with the propelling 
 force of the uterus, the direction 
 of which is not far removed from 
 the axis of the brim, except in 
 those cases in which so much 
 liquor amnii is retained that the 
 main force at work is still the 
 general intra-uterine pressure. 
 This inclined plane is well 
 shown in the frozen sections 
 (Figs. 131, p. 220, and 132, 
 p. 221). Although the membranes 
 are there unruptured, the second 
 stage is shown so far advanced 
 that the head is just beginning to 
 press on the pelvic floor. Further 
 advance in the direction of the axis of the brim is prevented by the 
 resistance of the sloping floor, and the forecoming part of the head 
 which meets the resistance is directed forward. The resistance of 
 the pubes to the aftercoming part of the head and the attachment 
 of the head to the neck prevent the head moving forwards as a 
 whole, and the occiput, its forecoming part, can, therefore, only go 
 forward by a movement of extension. If the front of the child is 
 directed forwards, as in face presentations, or unreduced occipito- 
 posterior positions of the vertex, precisely the same mechanism 
 produces flexion, as will be seen hereafter, and if the head escapes 
 with its long diameter directed laterally, as happens in rare cases 
 only, it produces lateral flexion of the head toward the anterior 
 shoulder. 
 
 Fig. 161. — Commencement of extension, 
 showing position of fontanelles. 
 
The Mechanism of Labour. 
 
 255 
 
 Restitution. — In most cases the shoulders only partially follow 
 the internal rotation of the head. The head then, immediately on 
 its escaj)e from the vulva, turns back towards the direction it 
 originally occupied, so as to accommodate itself to the position of the 
 shoulders. The term restitution is usually applied to this move- 
 ment, which is followed as the shoulders rotate on their passage 
 through the pelvis by the movement of external rotation of the 
 head (Fig. 159, vii.). " 
 
 External Rotation. — After it has emerged from beneath the 
 pubic arch and escaped from the perineum, the head, after under- 
 
 FiG. 162. — First stage of extension. 
 
 Fig. 163. — Second stage of extension. 
 
 going the movement of restitution, rotates back again still further 
 toward the direction which it occupied at first, the face becoming 
 turned toward the right thigh of the mother. This is due to the 
 effect of the screw-like mechanism of the pelvis and canal of soft 
 parts on the shoulders and body of the child. The long diameter 
 of the shoulders is from side to side, and, like the long diameter of 
 the head, it accommodates itself to the longest diameter of the 
 pelvis as it descends, turning from the oblique into the antero- 
 posterior. Occupying at first the left oblique diameter of the pelvis, 
 the right shoulder anterior, it turns into the antero-posterior at 
 the outlet, the right shoulder escaping under the pubic arch, the 
 left shoulder sliding over the perineum. The elliptic shape of 
 the opening of the levator ani supplements the efl'ect of the pelvic 
 
256 The Practice of Midwifery. 
 
 pressure on the shoulders as it does that upon the head. The 
 rotation of the shoulders is thus opposite in direction to the 
 previous rotation of the head. Occasionally it happens that 
 the head has rotated completely into the antero-posterior, and the 
 shoulders, following the rotation of the head, completely into the 
 transverse diameter of the pelvis. In this case the rotation of the 
 shoulders is as likely to go on in the same direction as to be 
 reversed. If it does so, the left shoulder comes out under the pubic 
 arch, and the face turns toward the mother's left thigh. 
 
 Relation of Movements to each other. — It will be observed 
 that the first and third of these movements, flexion and extension, 
 are the reverse of each other, and so also are the second and fifth, 
 internal rotation and external rotation. The movements do not, 
 however, take place separately and successively, but generally two 
 of them are going on together, in conjunction with the descent of 
 the centre of the head. Thus with the descent of the head through 
 the main part of the bony pelvis are combined flexion and internal 
 rotation. As soon as the head meets the inclined plane of the 
 pelvic floor, or rather as soon as the effect of the resistance of this 
 inclined plane preponderates over the forces tending to produce 
 flexion, flexion ceases and extension begins. Descent, internal 
 rotation and extension then go on together until the head escaj)es 
 from the perineum. At this point external rotation is substituted 
 for its opposite, internal rotation. When, by the elasticity of the 
 soft parts, the head is pushed back in the interval of pains, not 
 only descent, but the other movements, are generally reversed for 
 the time, more especially internal rotation. Thus the head recedes, 
 as well as advances, by a screw-like movement. The successive 
 stages, for the first position, are shown in Fig. 164, p. 257. 
 
 In the second, or right occipito -anterior position of the vertex, 
 the mechanism is precisely the same as in the first or left occipito- 
 anterior, except that left is substituted for right, and the directions 
 of internal and external rotation are reversed. In the frozen section. 
 Fig. ]31, p. 220, the foetus is seen to be in the second position. The 
 head is beginning to press upon the inclined plane of the pelvic 
 floor, and the force which transforms flexion into extension is thus 
 beginning to act. Internal rotation is not yet complete. 
 
 Mechanism in Occipito-posterior Positions. — SujDpose the 
 head to be in the third or right occiijito-posterior i^osition, flexion 
 takes place as in occipito-anterior positions, and for the same reason. 
 With internal rotation the mechanism is different. The head being 
 
The Mechanism of Labour. 
 
 ■SI 
 
 well flexed, the occiput comes down much in advance of the forehead, 
 and is the first to meet the resistance of the inclined plane of the 
 pelvic floor, which pushes it forward. At the same time there is 
 free space under the puhic arch, and the occiput, therefore, usually 
 turns away from the resisting plane until it is directed nearly 
 forwards, and escapes under the pubic arch. As soon as the occiput 
 has begun to be directed anteriorly, the elliptic opening of the levator 
 ani aids in completing the rotation, as in primary occipito-anterior 
 
 Fig. 164. — Successive stages of first, or left occipito-anterior, position of vertex. 
 
 positions. The position is thus converted into the second or right 
 occipito-anterior, and the movements of extension, restitution and 
 external rotation take place just as if the head had been originally 
 in that position. The internal rotation in occipito-posterior 
 positions therefore takes place through nearly three-eighths of 
 a circle, instead of only a little more than one-eighth (see Fig. 158, 
 p. 249), and is called a long rotation. 
 
 Sometimes this rotation begins before the true floor of the pelvis 
 is reached, and the inclined plane which causes it is then that 
 formed by the recto-vaginal septum. Whether the rotation occurs 
 early or late, the resistance which causes it is that of the soft parts, 
 
 M. 17 
 
258 
 
 The Practice of Midwifery. 
 
 Fig. 165. — Escape of head by flexion 
 in unreduced occipito-posterior 
 position, first stage. 
 
 Fig. 166. — Escape of head by flexion 
 in unreduced occipito-posterior 
 position, second stage. 
 
 a^.3 
 
 Fig. 167. — Diagram of mechanism of labour in unreduced occipito-posterior. 
 (For general explanation, see Fig. 1.59.) i., R.O.P., V. 3., occ. fr. diam. rt. 
 obliq., bis-acrom. diam. left obliq. ; ii., rotation of forehead though J circle 
 forwards ; iii., birth of head by movement of flexion, forehead leading ; 
 iv., restitution, rotation of forehead towards original direction ; v., external 
 rotation with rotation of anterior left shoulder forwards ; vi., birth of 
 shoulders, left shoulder leading. 
 
The Mechanism of Labour. 
 
 259 
 
 and not of the planes of the ischia, or any part of the bony pelvis. 
 The screw-like mechanism of the bony pelvis would rather deter- 
 mine a rotation of the occiput backwards, since the occiput is 
 originally behind the spine of the ischium. This is further proved 
 by experiment, for it has been shown that if, in the corpse of a 
 woman who has died during or just after delivery, a foetus be 
 placed in an occipito-posterior position, after the uterus has been 
 opened, and pushed through from above, the rotation takes place in 
 
 Fig. 168. — Successive stages of fourth, or left occipito-posterior, position of 
 the vertex, when unreduced. 
 
 the natural way if the soft parts are intact, but not if they are 
 lacerated, or greatly over-distended in repetition of the experiment. 
 In the fourth or left occipito-posterior position of the vertex, the 
 mechanism is precisely the same. The occiput usually first rotates 
 to the left and then forwards. The position is thus converted into 
 the first or left occipito-anterior, and extension and external rotation 
 take place as if the head had been in that position originally. 
 
 Mechanism in Unreduced Occipito-posterior Positions. — In 
 some cases the rotation forwards of the occiput fails, but probably 
 in not more than about one-tenth of the whole. In these cases, as 
 
 17—2 
 
26o 
 
 The Practice of Midwifery. 
 
 the flexion of tlie head is generally deficient, the forehead forms the 
 forecoming part, and coming first into contact with the sloping 
 gutter of the pelvic floor, is directed by the usual mechanism to the 
 front by rotating through one eighth of a circle, the occiput conse- 
 quently rotating back into the hollow of the sacrum. In this 
 position the head reaches the pelvic floor. The resistance of the 
 
 inclined plane, pushing forward 
 the forecoming part of the head, 
 then causes a movement not of 
 extension, but of flexion (see 
 Figs. 165, 166, 168), and by this 
 movement of flexion the head 
 escapes, the forehead passing 
 beneath the pubic arch, while the 
 occiput passes over the perineum. 
 The occiput, in this case, has to 
 go along the outside of the curve, 
 and therefore moves faster than 
 the forehead. The anterior fon- 
 tanelle is then often nearly in the 
 centre of the presenting part, as 
 the head is reaching the vulval 
 outlet. This mode of escape of the 
 head involves a serious mechanical 
 disadvantage. (Compare Figs. 165, 
 166, with Figs. 161, 162, 163.) 
 Instead of the suboccipito-breg- 
 matic, measuring only 3| inches 
 (9*5 cm.), and finally the sub- 
 occipito-frontal diameter, either 
 the occipito-frontal, measuring 4| 
 inches (11-25 cm.), or a diameter 
 not far removed from it, is opposed 
 to the antero- posterior diameter 
 of the outlet of the genital canal. With a normal size of foetus 
 and of maternal passages, the head cannot generally so pass, except 
 by rupture of the perineum, until it has been so moulded by 
 pressure as greatly to diminish the occipito-frontal diameter. 
 Even after such moulding, difficulty often occurs, the risk of 
 rupture of perineum is always increased, and artificial delivery is not 
 infrequently called for. 
 
 The chief cause of failure of the usual rotation of the occiput 
 forward is deficient flexion of the head, whether this be due to 
 
 SINCIPUT 
 
 Fig. 169. — Line of section and shape 
 of suboccipito frontal diameter. 
 (From Edgar, lead tape tracing, 
 Practice of Obstetrics, Fig. 549.) 
 
The Mechanism of Labour. 
 
 261 
 
 contraction of the conjugate diameter of the pelvis, or any other 
 reason. For the reason why the occiput tarns forward is, as 
 already mentioned, that, coming in advance, it is the first part to 
 meet the inclined plane of soft parts. If, however, the occiput and 
 forehead are descending on the same level, there is no reason why 
 the occiput should be pushed forward any more than the fore- 
 head. Even if the flexion is merely less marked than usual, 
 the excess of the pressure forwards on the occiput over that on the 
 forehead may be insufficient to overcome the resistance of friction. 
 The resistance to rotation due to friction will of course be greater the 
 more tightly the head is fitted in the pelvis. Hence a large size 
 of the foetal head in proportion to 
 the pelvis may be one of the 
 causes which contribute towards 
 the occiput remaining posterior. 
 Another cause may be descent of 
 the head low in the pelvis still 
 covered by an incompletely-dilated 
 OS uteri. For the rim of the os 
 uteri, by retarding the occiput, 
 which should escape first, tends to 
 prevent complete flexion. 
 
 In about one-half of the cases 
 of unreduced occipito - posterior 
 presentations the child is prema- 
 ture or undeveloped, and no doubt 
 in such conditions the small size 
 of the head enables it to pass 
 through the pelvis almost in the 
 same position as that in which it 
 entered it. In dorso-posterior positions of the trunk the projection 
 of the lumbar spine of the mother may play a part in producing 
 some extension of the head on the trunk of the foetus, and in 
 occipito-posterior presentations the head enters the pelvic brim less 
 readily as a rule than in occipito-anterior presentations, and thus 
 some degree of extension may be set up (Fig. 171). 
 
 Movements of restitution and external rotation take place in 
 unreduced occipito-posterior positions, as well as in other cases. 
 The face turns generally to the side toward which it originally 
 looked; to the left in the third position, to the right in the fourth 
 position. This rotation is due, as before, to the untwisting of the 
 head on the shoulders, and to the movement of the shoulders in 
 descending through the outlet of the genital canal. 
 
 Fig. 170 
 
 ing 
 
 -Diagram of head present- 
 at brim, with occiput 
 posterior showing longest trans- 
 verse diameter, the bi-parietal 
 occupying a diameter of the 
 brim less than the longest 
 oblique diameter. In occipito- 
 anterior presentations the bi- 
 parietal diameter occupies the 
 oblique diameter. (Herman, 
 Difficult Labour, Fig. 6.) 
 
262 The Practice of Midwifery. 
 
 The successive stages of an unreduced occipito-posterior position 
 are shown in Fig. 168, p. 259. 
 
 Lateral Obliquity of the Foetal Head. — In the older works on 
 midwifery, besides the five movements of flexion, internal rotation, 
 extension, restitution, and external rotation, a sixth movement or 
 condition called obliquity was described. By this was meant a 
 
 Fia. 171. — Section showing partial extension of spine when the occiput is 
 behind. (Modified from Varnier, Pratique des Accouchements, Fig. 172.) 
 
 kind of lateral or bi-parietal obliquity of the head, which, for 
 distinction, is called the Naegele-obliquity, because it was first 
 described by Naegele.^ The Naegele-obliquity means a rotation of 
 the head on its antero -posterior axis, so that the anterior parietal 
 bone {i.e., in the first position, the right parietal bone) lies most 
 deeply in reference to the plane of the brim, the middle of the 
 
 1 Two other obliquities of the foetal head at the brim have sometimes been spoken 
 of :— Koederer's obliquity, by which is meant the chin flexion ; and Solayres' obliquity, 
 by which is meant the entrance of the long diameter of the head in an oblique diameter 
 of the pelvis. 
 
The Mechanism of Labour. 
 
 263 
 
 sagittal suture is nearer to the promontory of the sacrum than to 
 the top of the symphysis pubis, and the anterior parietal tuber is 
 in advance of the posterior. For this reason it is often called 
 anterior parietal obliquity. By this is implied, assuming the axis 
 of the child to be perpendicular to the brim, a lateral flexion of the 
 child's head toward its j^osterior shoulder, the left shoulder in the 
 first and fourth positions, the right shoulder in the second and 
 third (Fig. 174). If Naegele-obliquity exists before the os is fully 
 dilated, and the os itself is centrally situated in reference to the 
 axis of the brim, the sagittal 
 suture will divide the os into 
 two unequal parts, the anterior 
 being the largest. In Figs. 172, 
 173, is shown a slight Naegele- 
 obliquity, still persisting as the 
 head is approaching the outlet 
 of the bony pelvis in the first 
 and third positions respectively. 
 It is to be observed that, even 
 without any Naegele-obliquity, 
 the '.^anterior parietal bone 
 always, when the head is at the 
 brim or in the cavity of the 
 pelvis, lies most deeply in 
 reference to the horizon, though 
 not in reference to the plane of 
 the brim, simply in consequence 
 of the oblique position of the 
 long diameter of the head, and 
 the inclination of the brim 
 itself to the horizon. 
 
 Two among the reasons given by Naegele for inferring the lateral 
 or bi-parietal obliquity of the head were the following. First that 
 the examining finger, when introduced, touches the right parietal 
 bone (in the first position) in the vicinity of the tuber, and not a 
 point in the sagittal suture. This, however, is simply the result of 
 the head lying in the oljlique diameter of the brim, and the inclina- 
 tion of the outlet of the pelvis to the inlet. A second reason was 
 that the caput succedaneum formed before complete dilatation of 
 the OS is situated upon the right parietal bone, near its upper edge, 
 and not centrally over the sagittal suture. This, however, may be 
 explained, as it has been by Matthews Duncan, without assuming 
 any lateral obliquity, on the ground that the caput succedaneum 
 
 Fia. 172. — Ou 1 I I I 'is, showing a 
 
 slight Naegele-obliquity of the foetal 
 head, which is passing through the 
 pelvic cavity in the first position. The 
 asterisli marks the presenting point. 
 (After Tyler Smith.) 
 
264 
 
 The Practice of Midwifery. 
 
 will be thickest where the head is least supported. The thickest 
 part will therefore be, not necessarily in the centre of the os uteri, 
 but rather in the direction of the axis of the undilated vagina, while 
 in other parts within the circle of the os uteri, where partial support 
 is received from the posterior vaginal wall, the swelling may be so 
 inconsiderable as not to attract notice. These two points therefore 
 do not prove any Naegele-obliquity, and its existence is only to be 
 inferred when it can be made out that the centre of the sagittal 
 suture is nearer to the promontory of the sacrum than to the top of 
 
 Fig. 173. — Outlet of the pelvis, showing a 
 slight Naegele-obliquity of the foetal 
 head, which is passing through the 
 pelvic cavity in the third position. The 
 asterisk marks the presenting point. 
 (After Tyler Smith.) 
 
 Fig. 174.- — Foetus from case of 
 advanced pregnancy, showing 
 inclination of head towards 
 right shoulder. (Webster, Text 
 Book of Obstetrics, Fig. 113.) 
 
 the symphysis pubis, or that an os uteri situated centrally around 
 the axis of the brim is divided unequally by the sagittal suture, the 
 anterior segment being the larger. 
 
 It is now generally held that the Naegele-obliquity is not a 
 regular occurrence in normal labour, and it is quite certain that it 
 does not occur in such a uniform and marked way as to make it 
 deserve to be ranked with the five important movements of flexion, 
 internal rotation, extension, restitution, and external rotation. In 
 the case of contraction of the conjugate diameter, however, the 
 Naegele-obliquity is often marked, and the cause of its occurrence 
 in general will be discussed when the mechanism of labour in a 
 
The Mechanism of Labour. 
 
 265 
 
 pelvis contracted in its conjugate character is described. Even, 
 however, when the pelvis can hardly be called contracted, whenever 
 the head passes with difficulty, and has prominent and firmly 
 ossified parietal tubera, so that the bi-parietal diameter is greater 
 than the oblique diameters slightly inclined to it, some degree of 
 Naegele-obliquity is common throughout the earlier part of the 
 passage of the head through the pelvis. It has then the mechanical 
 advantage that the large bi-parietal diameter of the head is never 
 opposed to any diameter of the pelvis, but one parietal tuber, the 
 anterior, always passes a little in advance of the other. 
 
 Fig. 175. — Diagram to show synclytism of the head. 
 
 Whether or not any Naegele-obliquity exists in the earlier part of 
 the passage of the head, there is almost invariably, in the later part 
 of the passage through the canal of soft parts, a lateral or bi- 
 parietal obliquity of the opposite kind, by which the head is flexed 
 towards the anterior shoulder (i.e., the right shoulder, in the first 
 position) instead of the posterior. For the occiput is not usually 
 ever rotated quite completely to the front, and moreover the head 
 meets the inclined plane of soft parts (see Fig. 131, p. 220) before 
 even the full amount of internal rotation, which does occur, is 
 finished. The inclined plane then, its resistance being directed 
 forward — while it pushes the occiput towards the child's back (in 
 occipito-anterior positions), and so causes extension — must at the 
 
266 
 
 The Practice of Midwifery. 
 
 same time push it towards the anterior shoulder, and so cause 
 lateral flexion. 
 
 Supposing that there is no Naegele-obliquity while the head is 
 passing through the upper part of the pelvis, this lateral flexion 
 might conceivably take place rapidly enough to keep the two 
 parietal tubera on the same level in reference to each successive 
 plane of the genital canal of soft parts, a condition called by 
 German authors the synclitic movement of the head (Fig. 175). In 
 
 Fig. 176. — Diagram of anterior parietal obliquity. 
 
 point of fact, however, just as the extension of the head is not rapid 
 enough to prevent the presenting point moving progressively forward, 
 relatively to the head, toward the posterior fontanelle, as the head 
 approaches the outlet, so the lateral flexion is not rapid enough to 
 keep the parietal tubera on the same level in reference to the 
 successive planes of the genital canal. The anterior parietal tuber 
 therefore almost always passes each plane toward the outlet of the 
 canal somewhat in advance of the posterior, even when there is no 
 Naegele-obliquity in the upper part of the canal. When the 
 Naegele-obliquity does exist at first, this advanced position of 
 
The Mechanism of Labour. 
 
 267 
 
 the anterior tuber will be the more marked, because the left lateral 
 flexion will have first to be obliterated, before the right lateral 
 flexion can be produced. 
 
 Similarly, in unreduced occipito-posterior positions, a lateral 
 flexion of the head toward the anterior shoulder will accompany the 
 movement of chin-flexion by which it escapes under the pubic arch. 
 Some authors maintain that anterior parietal obliquity, or Naegele's 
 obliquity, is most likely to obtain in the case of primiparse in whom 
 
 Fig. 1 77. — Diagram of posterior parietal obliquity. 
 
 the tense abdominal walls press the uterus backwards, so that its 
 long axis is behind that of the pelvic inlet, while the opposite con- 
 dition of posterior parietal obliquity, where the head enters the brim 
 obliquely, so that the posterior parietal bone is at a lower level than 
 the anterior, is most generally seen in multipara with lax abdominal 
 walls and a tendency to a pendulous abdomen (Figs. 176, 177). 
 
 These varieties of lateral obliquity, like the Naegele-obliquity, are 
 not of sufficient importance to be ranked on a level with the five 
 main rotations as already enumerated. 
 
268 The Practice of Midwifery. 
 
 Moulding of the Foetal Head in Vertex Positions. — Two 
 changes in the head are produced by the pressure on it during 
 labour — first, a general diminution of its size ; and secondly, an 
 alteration in its shape, by which the diameters most compressed 
 are specially diminished, a compensatory increase taking place in 
 certain other diameters. The general diminution of the head is 
 produced partly by some of the blood being squeezed out of the 
 head into the rest of the body, and partly by some of the cerebro- 
 spinal fluid being squeezed out of the cerebral ventricles into the 
 spinal canal. Its occurrence is proved by the rapid increase which 
 takes place in the average diameters of the head during a day or 
 
 Fig. 178. — Moulding of head in occipito-anterior position of vertex. 
 
 two after birth, a period during which the whole weight of the child 
 is somewhat diminishing. The diminution is rendered possible, 
 first by the obliteration of any interval between the bones which 
 existed along the sutures, and secondly by the overlapping of the 
 bones. This overlapping takes place in a regular way, in con- 
 sequence of the anatomical relations of the bones. Both the frontal 
 and occipital bones pass beneath the parietal bones, thus allowing a 
 diminution in the antero -posterior diameter of the head. The 
 parietal bones also overlap, and almost invariably the posterior 
 parietal bone, which is subjected to most pressure, passes beneath 
 the anterior. The movement of the occipital bone is rendered 
 possible by a cartilaginous interval between the posterior and the 
 basilar portion, so that the posterior portion is capable of a kind of 
 hinge movement on the other. 
 
The Mechanism of Labour. 269 
 
 The moulding in shape of the foetal skull in oceipito-anterior 
 positions, and also in occipito-posterior positions which end by 
 rotation of the occiput forward, is shown in Fig. 179. The con- 
 tinuous outline is the unmoulded head ; the dotted outline indicates 
 the shape after moulding. The points f, b, o in the figure indicate 
 definite points, namely, the root of the nose, and the centres of the 
 anterior and posterior fontanelles, and the diameters are measured 
 to these definite points (see p. 131). The chief diminution is in the 
 suboccipito-bregmatic (s.o. — b) and suboccipito-frontal diameters, 
 
 
 X 
 
 ^ 
 
 X 
 
 ' ~~r 
 
 / 
 
 1 
 
 /^-^^ 
 
 1 
 
 i^TG. 179. — Moulding of head in oceipito-anterior position of vertex. (Aftei 
 Budin.) The continuous outline shows the shape of the head before, the 
 dotted outline after, moulding. 
 
 which are successively opposed to the antero-posterior diameter at 
 the outlet. The fronto-occipital diameter, r o, is also diminished, 
 and even the mento-occipital diameter, m o (measured to the 
 posterior fontanelle), is somewhat diminished, instead of being 
 increased, as might at first sight be expected, from the outward 
 appearance of the moulded head. The chief compensatory increase 
 is in the maximum oblique or vertico-mental diameter (m — x), 
 which, when the head is well flexed, lies almost in the axis of the 
 genital canal at the point where the centre of the head is placed. 
 In the unmoulded head the posterior extremity of this is much 
 nearer to the posterior than to the anterior fontanelle (see x, 
 Fig. 89, p. VAH), )jut after moulding it runs to a point not far from 
 
270 
 
 The Practice of Midwifery. 
 
 the centre of the sagittal suture (x, Fig. 179). It will be ob- 
 served that the change of shape takes place not so much by the 
 
 so 
 
 Fig. 180. — Usual moulding of head in unreduced occipito-posterior position 
 of vertex. The continuous outline shows the shape of the head before, 
 the dotted outline after, moulding. 
 
 Fig. 181. — Usual moulding of head in unreduced occipito-posterior position 
 
 of vertex. 
 
 movement of the bones upon each other as by the bending of the 
 thinner parts of the bones, more especially of the parietal bones, 
 the curvature of which is greatly altered. 
 
The Mechanism of Labour. 271 
 
 Besides the moulding visible in the antero-posterior section, the 
 head also becomes flattened from side to side, the bi-parietal 
 diameter being especially diminished. The head viewed from the 
 front or from the back immediately after delivery has also an 
 unsymmetrical appearance. This is due to the posterior parietal 
 bone, which has sustained the greatest pressure, being more 
 flattened, and the anterior parietal bone, which has been directed 
 toward the free space of the vagina, having become more convex. 
 Besides the asymmetry due to pressure, there is also a natural 
 asymmetry in the foetal head, which has already been mentioned 
 (see p. 130). After the effect of moulding has passed off, as it 
 generally does in a few days, or a week at the utmost, this natural 
 asymmetry may become appreciable. 
 
 When, in an unreduced occipito-posterior position, the head is 
 delivered without assistance in the usual way, the forehead passing 
 under the pubic arch while the occiput sweeps over the perineum, 
 the moulding in the antero-posterior section is very different, and is 
 represented in Figs. 180, 181. Here the fronto-occipital and mento- 
 occipital diameters are much more shortened than in the usual 
 position, and the compensatory increase takes place not in the 
 maximum oblique or vertico-mental diameter (m — x, Fig. 89, p. 128), 
 but in the suboccipito-bregmatic diameter (s.o. — b), which in the 
 other case is so much diminished, and in the vertical or cervico- 
 bregmatic diameter. Sometimes, however, in unreduced occipito- 
 posterior positions, the head is delivered in quite a different way. 
 Extreme flexion takes place at quite a late stage, so that eventually 
 the occiput escapes over the edge of the perineum, while the fore- 
 head is still high up behind the pubes. As a rule, this occurs only 
 with a dead child, with which a more excessive moulding of the 
 head is possible, and it is sometimes promoted by delivery with 
 forceps. The kind of moulding is then an exaggeration of that 
 which occurs in occipito -anterior deliveries, as shown in Fig. 179. 
 The elongation of the head along the maximum diameter, m — x, is 
 excessive, the head is extremely flattened by the pressure against 
 the pubes, so that there is an almost uniform slope from the face 
 up to the parietal bones, and the back of the head forms an almost 
 vertical line with the neck. Fig. 180 is drawn from measurements 
 taken by the author, so as to correspond with Budin's figures. 
 The figure given by Budin for the moulding in occipito-posterior 
 positions,^ and also that of Tarnier and Chantreuil,^ represents the 
 
 1 De la Tete du Foetus au Point de Vue de robstdtrique, Paris, 187(i, PI. XVIII. 
 
 2 Tarnier et Cliantreuil, Traitc'i de PArt des Accouchements, Paris, 1882, Vol. I., 
 p. (582. 
 
272 
 
 The Practice of Midwifery. 
 
 exceptional case just mentioned, and not the usual condition for a 
 child spontaneously delivered alive. Figures, however, are given by 
 Barnes ^ and Spiegelberg ^ which show the same general shape of 
 the head as Fig. 180. 
 
 Caput Succedaneum. — In addition to the changes in the bony 
 
 cranium, the appearance of the 
 head is altered by the formation of 
 the cajDut succedaneum. The cause 
 of its production has been already 
 mentioned (see p. 225). If a caput 
 succedaneum is formed at the early 
 stage of labour, the head being in 
 the first position, its centre is near 
 the border of the anterior parietal 
 bone near the centre of the sagittal 
 suture (1'4, Fig. 182). The reason 
 why it is not centrally situated 
 over the sagittal suture, even 
 though there be no lateral obliquity 
 of the head, is because the anterior 
 part of the os uteri, looking toward 
 the yet imperfectly dilated vagina, 
 is less supported than the posterior. 
 As the head becomes more flexed 
 in advancing, the centre of the 
 caput succedaneum (in occipito- 
 anterior positions) gradually 
 advances nearer to the posterior 
 fontanelle. It is in this later stage 
 of labour that the most marked 
 caput succedaneum is generally 
 formed, and it may then project an 
 inch or more from the level of the 
 cranial bones. In Fig. 182, 1*4, 
 l'4fe, 1-46, show the successive positions in the first position of the 
 head, or fourth position after rotation, 2'3, 2'3h, 2-3& in the second 
 position, or third position after rotation. The same points will be 
 approximately the successive presenting points of the head in the 
 two positions, if, with Matthews Duncan, we define the presenting 
 
 Fig. 182. — Diagram showing posi- 
 tions of centre of caput succeda- 
 neum in the several positions of 
 the vertex. 
 
 1'4, lib, 1-4&. Successive posi- 
 tions of centre of caput succeda- 
 neum in first position of the vertex, 
 and in fourth position after rota- 
 tion. 
 
 2-3, 23b, 2-3b. Successive posi- 
 tions of centre of caput succeda- 
 neum in second position of vertex, 
 and in third position after rota- 
 tion. 
 
 3a. Position of centre of caput 
 succedaneum in unreduced third 
 position of vertex. 
 
 ia. Position of centre of caput 
 succedaneum in unreduced fourth 
 position of vertex. (After Tyler 
 Smith.) 
 
 1 " On the Varieties of Form imparted to the Foetal Head," Trans. Obst. Soc. London, 
 1866, Vol. VII., p. 171. 
 
 2 Lehrbuch der Geburtshiilfe, p. 1.50. 
 
The Mechanism of Labour. 273 
 
 point as that point on the surface of the head through which the 
 curved axis of the developed genital canal passes. If, however, we 
 take Tyler Smith's definition, which seems a preferable one, that the 
 presenting point is that point of the head which is most centrally 
 situated in the os uteri, the vagina, and the ostium vaginae in the 
 successive stages of labour, then in the first stage, before full dilata- 
 tion of the OS, the presenting point will be a point on the sagittal 
 suture, provided that the os is central in reference to the axis of 
 the brim, and there is no Naegele-obliquity of the head. 
 
 In unreduced occipito-posterior positions the centre of the caput 
 succedaneum advances forward toward the anterior fontanelle as 
 the head descends, instead of approximating to the posterior 
 fontanelle. Thus in some cases the anterior fontanelle may be 
 almost in the midst of the caput succedaneum. In Fig. 182, 1*4, 
 4a indicate the successive positions in the fourth position of the 
 head, 2"3, 3a in the third position. 
 
 The position of the caput succedaneum will, after the birth of 
 the child, in many cases show in what position the head has been 
 delivered. Both the size of the caput succedaneum and the extent 
 of the moulding of the cranium depend upon the amount of 
 pressure to which the head has been subjected, in conjunction with 
 the duration of labour. 
 
 The caput succedaneum is formed by effusion of serum into the 
 cellular tissue of the scalp, with occasionally slight extravasations 
 of blood at various points. It is at its maximum at the time 
 of delivery, and progressively diminishes from that time. Its 
 diagnosis from cephalhematoma, formed by rupture of a consider- 
 able vessel, will be considered under the head of that affection. 
 
 Diagnosis of Cranial Positions. 
 
 By Abdominal Palpation. — The position of the fcetus may 
 generally be diagnosed by inspection and palpation of the abdomen ; 
 and it is advisable to make this the first step in the examination 
 of the parturient woman. The patient should be placed in the 
 dorsal position, and the examination should be made in the absence 
 of a pain. 
 
 (1.) The examiner stands at whichever side of the patient is 
 convenient, facing her head. By inspection and palpation of the 
 shape of the uterus, he ascertains whether the long axis of the 
 child is longitudinal, oblique, or transverse in relation to the axis 
 of the uterus, and also defines the upper limit of the fundus of the 
 uterus (Fig. 183). 
 
 M. 18 
 
274 
 
 The Practice of Midwifery. 
 
 (2.) Having found that the long axis is longitudinal, he places 
 the palms of his two hands at each side of the fundus, and ascer- 
 tains which foetal pole occupies it. The breech gives the sensation 
 of a large, irregularly shaped, nodular body ; the head that of a 
 smaller, round, hard, and more movable body, separated from the 
 rest of the body by the groove of the neck (Fig. 184). 
 
 (3.) The next step is to determine the direction of the back of 
 the child. The examiner places his fingers on either side of the 
 
 
 Fig. 183. — Abdominal palpation. Manoeuvre No. 1. 
 
 abdomen and makes gentle but deep pressure. On one side he 
 feels the back as a firm, uniform, resistant mass, without any 
 marked projections. On the other he feels the limbs, especially 
 the knees or feet, as multiple nodules. These will be movable 
 in the liquor amnii, if the membranes are still unruptured, and 
 may be making active motions. In fat women, or when a large 
 quantity of liquor amnii is present, the diagnosis is facilitated if 
 one hand makes deep pressure while the other is palpating. The 
 position where the foetal heart is best heard will give confirmatory 
 evidence, for this position is on the side toward which the back is 
 directed, except in the case of face presentation. Having 
 
The Mechanism of Labour. 275 
 
 differentiated the back, the examiner next ascertains if it is 
 directed forward, backward, or transversely. If the direction is 
 backward, the Hmbs will be felt over a wider area of the front of 
 the uterus than usual, the back over a less wide area, and the 
 foetal heart is likely to be less plainly audible than usual (Fig. 185). 
 (4.) The examiner grasps the lower part of the uterus, just 
 above the symphysis pubis, between the fingers and thumb of one 
 hand, or between the fingers of his two hands. If the lie of the 
 
 Fig. 184.^ — Abdominal palpation. Manceuvre No. 2. 
 
 child is cephalic, he can thus ascertain whether the head is engaged 
 in the pelvis or not. If it is not engaged, it is felt as a round, 
 hard, movable body. The next step is then to determine the 
 attitude of the head. If palpation shows that the greatest cephalic 
 prominence is on the same side as the limbs, the presentation is 
 vertex. If the reverse is the case, the presentation is face. In the 
 latter case, the diagnosis is confirmed by the foetal heart being 
 most plainly audible on the same side as that on which the limbs 
 are felt (Fig. 185). 
 
 (5.) If the head is found to be engaged in the pelvis, the examiner 
 turns so as to face the patient's feet. With three or four fingers of 
 
 18—2 
 
276 The Practice of Midwifery. 
 
 each hand he makes deep pressure downward at each side of the 
 lower segment of the uterus, in the direction of the axis of the 
 pelvic brim. He finds that one hand is arrested sooner than the 
 other by a hard, round body, the head, while the other hand 
 descends deeper into the pelvis. In vertex presentations the 
 prominence of the head is on the same side as the limbs, in face 
 presentation on the opposite side. The depth at which the 
 
 1 I 
 \ 
 
 
 
 Fig. 185. — Abdominal palpation. Maneeuvre No. ,S, " Cephalic grip." 
 
 prominence is felt indicates the degree of descent of the head into 
 the pelvis. If the head has descended deeply, the anterior shoulder 
 may often be detected by this method of palpation(Fig. 186). 
 
 (6.) In cases of obstructed labour the retraction ring may be 
 felt, especially during a pain, as a transverse depression running 
 across the front of the uterus, and forming the lower limit of the 
 firm, thick, contracting segment of the uterus, which hardens 
 during the pain. 
 
 (7.) The round ligaments may be palpated in the neighbourhood 
 
The Mechanism of Labour. 277 
 
 of the internal inguinal ring. If they converge towards the 
 uterus, according to Palm and Leopold/ the placenta is usually 
 situated on the posterior wall of the uterus. If they are parallel 
 or diverging, it is usually on the anterior wall. This is due to the 
 fact that the uterine wall to which the placenta is attached becomes 
 more developed than the other. The degree of contraction of the 
 ligaments during a pain is an indication of the intensity of con- 
 traction of the uterus generally. 
 
 / 
 
 ; 1 
 
 s 
 
 \ 
 
 \ 
 
 %j ; 
 
 \ 
 
 \ 
 
 ! 
 
 " ■'- .1'-:'.'. 
 
 Fig-. 186. — Abdominal palpation. Manoeuvre No. 4. 
 
 By these methods of abdominal palpation it is possible to 
 diagnose the presentation, and to conduct labours in the majority 
 of cases without any vaginal examination at all. Some authorities 
 advise that this should be done, in order to avoid the risk of septic 
 organisms being carried by the examining finger into the vagina. 
 The drawbacks are that the stage of dilatation of the os cannot 
 then be ascertained, nor the progress of dilatation ; and any 
 
 ' I'alm, " IJebcr dio Diafj-nose dcs Placentarsitzcs in dcr SchwaiiKerschaEt," Zeitsch. 
 f. Geb. und Oyn., IH'.KJ, XX.V. 817—350; liCopold, "Die Diagnose des riaceniar- 
 Kitzes in dor Scliwangerschaft nnd wiihrend dei Geburt," Arbeitcn aus des Dresdener 
 Fiauenklinik, 181).',, IF. 151 — IGf;. 
 
278 
 
 The Practice of Midwifery. 
 
 obstruction to labour due to the condition of the cervix or vagina, 
 or a prolapsed funis, would remain undiscovered to a late stage. 
 Moreover, those not very dexterous in abdominal palpation might 
 miss the diagnosis of occipito-posterior positions or even of face 
 presentation. Although it is impossible theoretically absolutely 
 to sterilise the hands, it is found practically that a thorough use 
 of efficient antiseptics is a sufficient safeguard in ordinary circum- 
 stances against the conveyance of sepsis. Whenever it is necessary 
 to introduce the hand into the interior of the uterus, during or 
 after labour, sterilised rubber gloves should, however, be worn. 
 
 Fig. 188. — Second vertex position, patient 
 in usual obstetric position. 
 
 Fig. 187. — First vertex position, showing 
 relations of posterior fontanelle and 
 sagittal suture. (Figs. 187, 188, 189 
 and 190 from Eden, Manual of Mid- 
 wifery, modified from Eibemont- 
 Dessaignes and Lepage, Precis 
 d'Obstetrique.) 
 
 In all cases, too, where the practitioner has under his care, at 
 the time he is attending a confinement, a septic case of any 
 description, he should wear sterilised rubber gloves as a pre- 
 cautionary measure, even when making vaginal examinations. 
 
 By Vaginal Examination. — Even before rupture of the mem- 
 branes, or dilatation of the os, the round mass of the head, and its 
 separation from the body at the neck, can generally be made out 
 on bimanual examination between the internal and external hand 
 through the uterine wall, the patient being placed in the dorsal 
 position. Examination through the os uteri, to determine the 
 presentation and position, must be made in the interval of pains. 
 
The Mechanism of Labour. 
 
 279 
 
 while the membranes are lax. The head is distinguished by its 
 hardness and uniform outline. Sometimes the yielding portions of 
 the bones, on being impressed with the tip of the finger, bend 
 under the pressure with a parchment-like crackle, which can be 
 both felt and heard. After the rupture of the membranes, the 
 accoucheur may often determine with certainty that the head is 
 presenting by feeling the hair on the scalp. 
 
 The sutures and fontanelles can generally be made out before 
 rupture of the membranes, but more easily after the liquor amnii 
 
 Fig. 189. — Third vertex position. Head 
 flexed. 
 
 Fig. 190. — Fourth vertex position. Head 
 partly extended, showing anterior 
 and posterior fontanelles and sagittal 
 suture. 
 
 has escaped, and when the head is no longer covered by the mem- 
 branes. While the os is still small, it is probable that all which 
 can be detected will be a single suture, the sagittal, crossing it 
 generally in the right oblique diameter, approximating nearer to 
 the transverse than the antero-posterior. This will prove that 
 the head lies either in the first or third position, and if the 
 direction of the back is made out by abdominal examination, it is 
 easy to decide which of these two the position is. Similarly, if 
 there is a suture running in the left oblique diameter, the head 
 must be in the second or fourth position. The fontanelles at this 
 early stage will probably be about equidistant from the centre of 
 the 08, covered by the uterine wall. The anterior is distinguished 
 by its large size, and the four sutures at right angles meeting in 
 it ; the posterior by its small size, not forming any actual space, 
 
28o 
 
 The Practice of Midwifery. 
 
 and the three sutures meetmg in it. If either fontanelle or both 
 can be reached, the position of the head is deterrained by vaginal 
 examination alone. The direction of the posterior fontanelle will, 
 of course, give the direction of the occiput. 
 
 When the os is more dilated, and the head has descended lower 
 and become flexed (in occipito- anterior positions), the posterior 
 fontanelle is generally reached easily, while the anterior is reached 
 with more difficulty, by tracing the sagittal suture (see Fig. 187, 
 p. 278). This change in the facility of reaching the two fontanelles 
 results from the internal rotation of the head, when that has 
 
 progressed, even though there 
 should be no increase of 
 flexion. In cases of some- 
 what difficult labour, when 
 flexion is very great, and the 
 head large and much elon- 
 gated, the posterior fontanelle 
 may become very nearly the 
 presenting point. The fon- 
 tanelle may be obscured by 
 being nearly in the centre of 
 the caput succedaneum. 
 Nothing is then readily made 
 out except the three con- 
 verging sutures. When the 
 case is seen for the first time 
 at this stage, the diagnosis of 
 the position of the head is 
 not quite so easy, from the 
 difficulty of telling which is 
 the occipital bone. The anterior fontanelle may be reached by 
 passing, if necessary, half the hand into the vagina — the right 
 hand, if the patient is lying in the usual left lateral position, or the 
 left hand, corresponding to the curve of the genital canal, if any 
 difficulty is experienced. In some cases also the anterior ear can 
 be reached without much difficulty, especially when Naegele- 
 obliquity exists. There is, however, a simple and easy mode of 
 determining the point, depending upon the laws of the moulding of 
 the head, according to which the occipital always passes beneath 
 the parietal bones. If it can be ascertained that one of the three 
 bones has a tendency to become depressed beneath the other two, 
 the bone is certainly the occipital bone, and the direction of the 
 occiput is tlins determined. 
 
 Fig. 
 
 — Moulding of head showing 
 posterior parietal bone depressed beneath 
 anterior, and occipital bone beneath both 
 parietals. (Kiberaont-Dessaignes and 
 Lepage, Precis d'Obstetrique, Fig. 225.) 
 
The Mechanism of Labour. 281 
 
 Again, in occipito-posterior positions, as the head descends in 
 •the pelvis, the anterior fontanelle may be nearly in the centre of 
 the presenting part, and the posterior fontanelle may be difficult 
 to reach. Then, in a similar way, if it can be ascertained that 
 two of the bones tend to be depressed under the other two, these 
 are determined as being the two segments of the frontal bone, and 
 the position of the head is thus shown. 
 
 A criterion is given for distinguishing occipito-posterior from 
 occipito-anterior positions even before the opening of the os. This 
 is that, in occipito-posterior positions, the anterior segment of the 
 uterine wall as felt from the vagina does not descend so low behind 
 the pubes as in occipito-anterior, because the forehead does not 
 generally lie so deeply as the occiput in reference to the plane of 
 the brim. This criterion is not, however, always decisive, since, 
 in occipito-posterior positions, the forehead often lies lower than 
 usual in comparison with the occiput. 
 
 The Third Stage. — As soon as the child is expelled, the woman 
 generally has a feeling of intense relief and comfort, after the agony 
 and exertion she has gone through. More rarely she may feel 
 exhausted or faint, or a rigor may occur. 
 
 The natural course of the third stage of labour, or expulsion of 
 the placenta, is rarely seen, since it is usually shortened by art. 
 It appears that, in general, the placenta is detached, partially at 
 any rate, almost immediately after the birth of the child. For, 
 in a multipara, and where there is no obvious laceration of 
 perineum or vagina, the first appearance of blood commonly 
 indicates that some separation of placenta has occurred. Such 
 appearance of blood may usually be noticed very quickly after the 
 expulsion of the child. Moreover, Lemser examined with the 
 entire hand in 168 cases immediately after the birth of the child. 
 He found that in 71 per cent, the lower edge of the placenta could 
 be felt lying in the os uteri directly the hand was introduced, and 
 in 94 per cent, within nine seconds after delivery of the foetus. 
 On the other hand, in the uterus removed by Porro's operation, 
 the placenta is, in most cases, found completely attached. The 
 vigour of the contraction and retraction of the uterus must, how- 
 ever, be impaired by the incision in the anterior wall, as well as by 
 the effect of the anaesthetic given to full surgical degree. The 
 Porro uterus cannot therefore be assumed to represent the normal 
 condition. 
 
 Mechanism of Detachment. — There has been much controversy as 
 to the mechanism both of the detachment and the expulsion of 
 
282 
 
 The Practice of Midwifery. 
 
 the placenta, and the matter is not yet fully settled. One cause 
 is almost universally acknowledged to be a valid one, and by some 
 is regarded as being the only one, namely, the shrinking of the 
 placental site in the retraction of the uterus. On this subject some 
 facts may be deduced from mechanical considerations. For, 
 consider the condition of the placenta when shrinking of the 
 placental site has occurred a little short of that necessary to cause 
 
 Fig. 192. — Sagittal section showing placenta hi utero after birth of child. 
 Note thinness of wall of uterus at placental site, and folding of flaccid 
 lower uterine segment. No separation of placenta has taken place. 
 (Modified after Pestalozza, Anatomia dell 'Utero Umano : Vallardi, 
 Milano.) 
 
 detachment. First, suppose the form of the uterus globular ; the 
 effect of shrinking will then be independent of any detrusion. Any 
 section through the uterine wall and the placenta will form an arc 
 of a circle ; and detrusion cannot commence until the placenta has 
 been separated. The uterine surface of the placenta will be com- 
 pressed towards the centre of its area, owing to its attachment to 
 the shrunken placental site. This compression toward the centre 
 will decrease from the uterine to the foetal surface, which is free. 
 Hence any small element of area on the uterine surface of the 
 
The Mechanism of Labour. 283 
 
 placenta at the centre will be subject to no radial tension. Any 
 other small element of area will be subject to radial tension because 
 it will be drawn toward the centre by its attachment to the uterine 
 wall, and drawn outward by its connection with the corresponding 
 areas of the substance and foetal surface of the placenta, which have 
 not been drawn so much inward toward the centre. At the same 
 time the shrinking of the j)lacental site will be resisted by the attached 
 placenta, and will therefore be less than that of a corresponding 
 area elsewhere in the uterus. The radial tension will increase from 
 the centre toward the circumference, because the obliquity of lines 
 joining corresponding areas of uterine and fcetal surfaces will 
 increase, the foetal surface being less drawn in toward the centre 
 than the uterine. Moreover, while any element of area away from 
 the border is supported on all sides by other elements of area, an 
 element of area on the border is unsupported on the outside. For 
 both reasons, separation must begin at the circumference, and 
 spread inward toward the centre, unless the placenta is more firmly 
 adherent at the circumference than at other parts, and there is no 
 evidence that it is so as a general rule. This reasoning is in 
 accordance with the result of experiments made by sticking a disc 
 to an elastic surface, and then letting the surface retract. 
 
 The mechanism is somewhat modified if the retracted uterus is 
 not globular, but tends to adopt its natural form of a flattened 
 pear-shape. This it does in the Porro uterus, and probably also 
 in normal conditions, to some extent at any rate. In this case, if 
 the placenta is situated on the anterior or posterior wall, reaching 
 to the sides and summit of the uterus in its retracted shape, the 
 sides may be so pressed inward by the uterine contraction as to 
 do away with the outward radial tensions in a lateral direction. 
 Similarly the top of the placenta may be so pressed down by the 
 fundus uteri as to do away with the upward radial tensions in its 
 upper half. But if so, the placenta having been already compressed 
 as much as it can be, the same force will be transmitted to the 
 lower half, and will there increase all the downward radial tensions, 
 so that separation will commence at the lower border, from the effect 
 of detrusion in addition to retraction. There can be nothing in the 
 contraction of the uterus in any case to diminish the downward 
 radial tensions. If, on the other hand, detrusion acts, when the 
 placenta has not been compressed to the maximum degree or nearly 
 so, the downward pressure may separate the top of the placenta 
 first, the placenta not being able to transmit the force like a rigid 
 body to its lower margin. It appears probable, therefore, that 
 shrinking of the placental site and detrusion are the main forces 
 
284 
 
 The Practice of Midwifery. 
 
 concerned in the detachment of the placenta at its commencement, 
 and that in most cases separation commences at the lower margin. 
 Any morbid adhesion at any part of the placenta would, of com'se, 
 modify the commencement of separation. 
 
 When separation has once commenced, some blood is poured out. 
 
 Fig. 193. — Expulsion of placenta from upper segment into lower uterine 
 segment and vagina. The fundus uteri is elevated, the lower segment 
 elongated, and the cord has descended. (From specimen in Univ. Coll. 
 Hosp. Med. School Museum.) 
 
 in the interval of pains, between the separated surfaces, and must 
 tend to aid the further separation, if the membranes are still 
 sufficiently attached to prevent its flowing away at the sides. 
 Schultze considers the formation of this retro-placental haemafcoma 
 to be the main cause of separation. Matthews Duncan, on the 
 other hand, considered that it had no place in the normal mecha- 
 nism. Probably it comes into play in cases when the placenta is 
 
The Mechanism of Labour. 285 
 
 attached to the fundus of the uterus, and plays the greater part, 
 the less active and contmuous is the uterine contraction during the 
 third stage of labour. Some have attached importance to the 
 diminution of intra-uterine pressure after delivery. The firmly 
 adherent j)lacenta of the Porro uterus appears to disprove this as 
 a cause. 
 
 Mechanism of ExpiUsion. — It was formerly thought that the 
 placenta came down like an inverted umbrella, with its foetal surface 
 near the insertion of the funis foremost, as shown in Fig. 195, p. 286. 
 This necessarily implies that the placenta and upper part of bag of 
 membranes are first inverted by a considerable effusion of blood 
 behind them, and that the uterus afterwards contracts on this 
 effusion of blood, and drives out the placenta by its means (see 
 Fig. 193), According to Matthews Duncan, however, the normal 
 process is that the placenta is folded or rolled together by the 
 contracting uterus on an axis corresponding to the long axis of the 
 uterus, and that it presents at the os uteri by a point on its foetal 
 surface very near its lower margin, the lower margin having been 
 somewhat inverted by the traction of the membranes which the 
 placenta has to drag after it (Fig. 194, p. 286). As it passes 
 through the vagina, the placenta usually becomes further inverted 
 by the traction of the membranes, which have still partially to be 
 peeled off the uterine wall, and drawn out of the uterine cavity. 
 When, however, the uterus acts well, and the vagina is contractile, 
 the placenta may jDresent even at the vulva by a point on or near 
 its edge, and come out rolled on a longitudinal axis, with its uterine 
 surface outermost. In this mode of expulsion, effusion of blood 
 behind placenta and membranes is not necessary to the mechanism, 
 and Matthews Duncan regarded the ideally perfect expulsion as 
 almost unaccompanied by blood. 
 
 More recently, other authorities have advocated the correctness 
 of the old view. The point is of practical importance, because the 
 modern principle that traction should never be made upon the cord 
 is mainly based upon the idea that such traction interferes with 
 the normal mechanism of delivery. There is no doubt that, if 
 traction is made, the placenta is drawn down in the shape shown 
 in Fig. 193. 
 
 Champneys,^ in 70 cases, marked the spot on the placenta which 
 first presented at the os uteri. In the great majority of cases (all 
 but lOj this spot was on the foetal surface within two inches from 
 the lower edge. In 16 cases it was on the lower edge, or amnion 
 
 ' •• .M'-ctiiiiiisin of the 'I'liinl Stii;,'e ol' riabour," Trans, Obst. Soc. London, Vol. XXIX. 
 l>p. 117 arifl lol. 
 
286 
 
 The Practice of Midwifery. 
 
 below the lower edge ; in 23 cases it was on the placenta within 
 one inch of the lower edge. In two cases only the uterine surface 
 of the placenta presented. It was found also that the presenting 
 part varied with the position of the placenta. The higher the 
 placenta, the higher the presenting point, and vice versa. 
 
 These results indicate a partial and progressive inversion of the 
 placenta and membranes and a mode of delivery intermediate 
 between that described by Schultze and that described by Matthews 
 Duncan. In Champneys' cases, however, the woman lay on her 
 side, and no stimulation was used to the uterus during the third 
 stage of labour. It is probable that the mechanism is not ideally 
 perfect under these circumstances. So far as can be inferred from 
 
 Fig. 19-1. — Delivery of placenta accord- 
 ing to Matthews Duncan. 
 
 Fig. 195. — Delivery of placenta accord- 
 ing to Schultze. 
 
 the customs which exist among savage tribes, the primary position 
 for labour is not that of lying, but rather squatting as for defecation. 
 The delivery of the placenta is assisted by pressure by the woman's 
 own hands, or by the aid of her friends, and she may even stand up 
 to squeeze the abdomen in the third stage of labour. At any rate, 
 the frequency with which the intervention of the accoucheur is 
 called for in the third stage shows that, under our present civilised 
 conditions, its mechanism is often not entirely natural. 
 
 My own observations, in cases in which the uterus is stimulated 
 in the usual way by the hand after delivery of the child, lead me 
 to support Matthews Duncan's view so far as to say that the main 
 folding of the placenta, when it passes the os uteri, is generally on 
 a longitudinal axis, though the presenting point is often further 
 from the edge than is represented in Fig. 194. It is easily shown 
 by experiment that the placenta will pass through a much smaller 
 
The Mechanism of Labour. 287 
 
 ring when thus folded than when the insertion of the funis comes 
 first. 
 
 It is obvious that, the more the expulsion is effected by effusion 
 of blood, the more nearly the mechanism approximates to Schultze's 
 view ; the more it is due to uterine contraction, the more nearly 
 it approximates to Matthews Duncan's view. It will generally be 
 agreed that the latter is preferable. The conclusion is that the 
 usual mode of expulsion is intermediate, to a variable extent, 
 between the two mechanisms ; but approaches rather to that 
 described by Matthews Duncan when the placenta is attached to 
 the anterior or posterior walls of the uterus, and the more nearly 
 so, the more judicious is the management of the third stage, and 
 the more vigorous the uterine action, while, on the other hand, it 
 approaches to that described by Schultze when the attachment of 
 the placenta is at the fundus of the uterus, and the uterine con- 
 tractions are less active and continuous during the third stage of 
 labour. 
 
 Separation and Expulsion oj Membranes. — It has already been 
 explained (see p. 217) that the membranes are separated from the 
 lower segment of the uterus by its dilatation to form a canal for 
 the foetus, and that this separation is necessary for the formation 
 of the bulging bag of membranes. By the retraction of the 
 uterus, after delivery, the chorion is partially but not entirely 
 detached, the line of separation passing through the ampullary 
 layer of the decidua {see p. 106), so that the superficial layer of 
 the decidua comes away with the chorion. The chorion is thrown 
 into fine wrinkles, being detached along the ridges of the wrinkles, 
 but remaining attached along the furrows. When the placenta is 
 detached, the blood which escapes thereupon tends to detach also 
 the membranes in the vicinity of the placenta. It does not, how- 
 ever, separate the whole bag of membranes, partly because its 
 quantity is insufficient, partly because it begins to escape externally 
 as soon as it has cleared a way for itself to the os uteri. Then, 
 when the placenta is expelled by the contraction of the uterus, it 
 drags after it the membranes, completing their separation from 
 above downwards, and usually inverting the bag of membranes. 
 When there is sufficient effusion of blood behind the placenta to 
 invert it, as in Fig. 195, this blood, driven down by the uterus, aids 
 in the inversion, detachment, and expulsion of the bag of membranes. 
 By the time the placenta and membranes escape from the vulva the 
 membranes are inverted, the foetal surface of the amnion being 
 external, and the placenta is often inverted also. If delivery of 
 the placenta is aided by gentle traction on the edg§ whiQh presents 
 
288 The Practice of Midwifery. 
 
 in the vagina, it generally comes down with the uterine surface 
 outermost. 
 
 The large arteries and veins passing to the placenta are of 
 course torn across as soon as detachment occurs, and some bleeding 
 takes place from their open mouths. This is the source of the 
 retro-placental hematoma, when such is produced. But, unless 
 " there is uterine inertia, the open mouths are quickly closed by 
 further retraction of the placental site, the muscular fibres of the 
 middle coat of the uterus interlacing irregularly around the 
 vessels. After a time, the exact duration of which is unknown, 
 permanent closure is secured by the formation of thrombi in the 
 vessels beyond the constricted part, just as thrombi are formed 
 in any other vessels the current through which is arrested by 
 pressure or ligature. Champneys estimates the amount of blood 
 escaping as six ounces before the delivery of the placenta, and six 
 ounces enclosed in the placenta and membranes. As in his 
 observations the uterus was unstimulated during the third stage 
 of labour, the woman lying on her left side, the average quantity, 
 when the uterus contracts well, is probably less, amounting to some 
 400 to 500 gms. 
 
 Occasionally the placenta is expelled into the vagina, or even 
 externally, by the same pain which expels the foetus. More 
 frequently there is a rest for a variable time — perhaps for from 
 twenty minutes to an hour, or even longer, in the absence of 
 external stimulus. During this time the uterus may be felt 
 moderately hard, and still reaching up to some height in the 
 abdomen, generally about up to the umbilicus. At this period, as 
 well as at other times, rhythmic contractions, though not very 
 marked, take place in addition to tlie tonic contraction, and 
 therefore the uterus varies in hardness. After a time the con- 
 tractions again become stronger, and are felt as pains, although 
 slight as compared with those of the expulsive stage. With these 
 pains a little blood may be expelled, and hence they have been 
 called " dolores cruenti." They have the effect of gradually 
 completing the detachment of the placenta, if that is not com- 
 pleted just after the birth of the child, or by subsequent effusion 
 of blood behind the placenta, and at length of expelling it from 
 the body of the uterus in the manner already described, so that 
 it lies partly in the flaccid relaxed cervix and partly in the vagina. 
 Its expulsion externally, in the absence of assistance, is effected 
 by the expiratory muscles, aided by the muscular walls of the 
 vagina and cervix. 
 
 After delivery of the placenta, the uterus may be felt in the 
 
The Mechanism of Labour. 289 
 
 hypogasti'ium as a comparatively small firm ball, varying, however, 
 considerably in size in different women. The average level of the 
 fundus may be taken as rather more than five inches above the 
 pubes, and more than half-way from pubes towards umbilicus ; but, 
 when the uterus is large or rests unusually high above the pelvis, 
 it may reach even up to the umbilicus or somewhat higher ; and 
 its height may be as much as seven or eight inches above the pubes. . 
 Khythmic contractions, in addition to the tonic contraction, con- 
 tinue to take place in it, although not necessarily felt by the woman 
 as pains. In all cases, therefore, it varies in hardness, and this 
 variation must not be considered as indicating a risk of haemorrhage, 
 unless either the relaxation is too great in the intervals, or gushes 
 of blood take place with the contractions, or between them. 
 
 Duration of Labour. — Very wide differences are found between 
 the duration of labour in different women, depending partly upon 
 the vigour of the expulsive forces, partly upon the presentation of 
 the foetus, the relation between the size of the fcetus and the canal 
 of the bony pelvis and the soft parts, as well as upon the dilatability 
 of these latter. The first stage generally occupies at least three or 
 four times as long as the second, and in multiparse the second stage 
 may be completed by a very few pains. In primiparse the length 
 both of the first and of the second stage is very much greater : that 
 of the first, from the greater rigidity of the cervix ; that of the 
 expulsive stage, from the resistance offered first by the orifice of the 
 vagina, formed by the ring of hymen so far as it still exists, which 
 must inevitably be more or less lacerated, and, secondly, by the 
 perineum, which has never before undergone dilatation. 
 
 The average duration of labour, reckoning from the first manifest 
 pains, may be taken as being about fifteen hours in primiparse, and 
 seven or eight hours in multiparse. In primiparse beyond the age 
 of thirty-five years, the duration of labour is greater, and, on an 
 average, exceeds twenty-four hours. 
 
 A greater number of labours take place during the night than 
 during the day ; the hours during which most commence being 
 those from 9 to 12 p.m., and those during which most are terminated 
 those from midnight to 3 a.m. 
 
 M. 19 
 
Chapter XIIL 
 
 MANAGEMENT OF NORMAL LABOUR. 
 
 It is a well-known rule that the accoucheur should always attend 
 promptly to the first summons from a lying-in woman. It may be 
 that she has deferred sending till the last moment, or labour may 
 be extremely rapid. In such a case, if from any delay of the 
 attendant the child is born before his arrival, the mother's life may 
 be lost from j^ost-jKirtum haemorrhage, or the child's in a case of 
 pelvic presentation. Again, the favourable moment for interference 
 in a case of abnormal presentation may be lost. If, on the other 
 hand, the patient has sent unnecessarily early, the attendant, after 
 ascertaining the exact state of affairs, and the probable duration of 
 the labour, may confidently leave her for a time. 
 
 Requisites to be taken by the Accoucheur. — The attendant 
 should be provided with a stethoscope, a catheter (either a glass 
 female catheter or a No. 10 or No. 12 gum-elastic male catheter), 
 bottles containing chloroform, ether, solution of chloral, tincture of 
 opium or Battley's liquor opii sedativus, liquor ergotse ammoniatus, 
 or some preparation of ergot for hypodermic injection, such as 
 ergotinine citrate or ernutine, a vaginal douche for use with an 
 ordinary jug, a hypodermic syringe with tablets for hypodermic injec- 
 tion, a Schimmelbusch's mask or Junker's chloroform inhaler, and 
 either a small elastic catheter (No. 6) suitable for passing into the 
 infant's larynx, or a special mucus evacuator. These may be 
 carried in a leather bag fitted with a removable sterilisable linen 
 lining with pockets for the bottles. There should also be in the 
 bag a Budin's intra-uterine tube, a perineum needle, silkworm gut 
 or horsehair for stitching the perineum, and iodoform gauze for 
 plugging the uterus. A pair of axis traction midwifery forceps 
 should also be carried, and the few instruments necessary for intra- 
 venous transfusion or plugging the uterus, viz., a glass cannula, a 
 scalpel, scissors, aneurism needle, two pairs of Spencer Wells' 
 forceps, a pair of dissecting forceps, together with a vulsellum and 
 a pair of intra-uterine or ovum forceps. A pair of thin rubber 
 gloves should never be omitted, and these, as well as all the 
 
Management of Normal Labour. 291 
 
 other instruments, should be carried in Hnen bags which can be 
 washed and steriHsed. 
 
 There should be provided in the room hot and cold water, 
 thread for tying the funis, an abdominal binder, absorbent wool, 
 and a supply of diapers, or, by preference, sterilised pads of cotton 
 wool covered with gauze. 
 
 Certain antiseptics must either be carried in the obstetric bag, or 
 provided beforehand at the house. These are alcohol, 70 to 80 per 
 cent., perchloride or biniodide of mercury for disinfection of hands 
 and non-metallic instruments, and either lysol, carbolic acid, or 
 formalin for metallic instruments. Perchloride and biniodide of 
 mercury may be carried either in tabloids or in solution. If 
 tabloids are used they should be tested with the water of the district 
 in dilute solution, to make sure that no precipitate is formed by the 
 hardness of the water. They should contain no powdery colouring 
 matter, which would mask the slight milkiness caused by precipita- 
 tion. A concentrated solution can be made according to the 
 following formula : — E. Hydrarg. Perchlor. gr. xx.. Acid : Hydro- 
 chlor. dil. 5ss., Glycerini 5i., Aq. ad ji. The acid increases the 
 efficacy of the mercury in the presence of albuminous matter. A 
 concentrated solution of mercuric iodide may be made according to 
 the following formula : — Pi. Hydrarg. lodid. Eubr. gr. xx., Potass. 
 lodid. gr. XV., Aq. 51. Tabloids are also made of it, which dissolve 
 readily. Pure carbolic acid may be carried, liquefied by 10 per cent. 
 of water. 
 
 Antiseptic Precautions. — The reports of the Registrar-General 
 show that the mortality due to puerperal septicaemia throughout 
 Great Britain considerably exceeds that due to all the difficulties 
 and accidents of labour. Hence the most important thing of all, 
 in the conduct of normal labour, is to take precautions against the 
 occurrence of septicaemia. Of late years, by the improvement of 
 antiseptic measures, and especially by the use of perchloride of 
 mercury as an antiseptic, lying-in hospitals have been converted 
 from the most dangerous places of all for delivery into the safest. 
 There is therefore strong reason for believing that a universal 
 adoption of stringent antiseptic precautions would considerably 
 diminish the present mortality from puerperal septicaemia. 
 
 I may so far here anticipate the subject of puerperal fever as to 
 state the following facts. It is excessively difficult absolutely to 
 sterilise the vagina by any antiseptic treatment, but the microbes 
 or germs ordinarily present in it do no harm unless substances 
 capable of decomposition, such as placenta, are retained. On the 
 
 19—2 
 
292 The Practice of Midwifery. 
 
 other hand, if septic microbes, and especially if virulent microbes, 
 are introduced, such as may be carried from puerperal or any other 
 form of septicaemia, or from phlegmonous erysipelas, they may 
 cause fatal septicaemia after perfectly normal labour. The most 
 important element of antisepsis therefore consists in preventing 
 the introduction of virulent germs into the genital canal, and this 
 can be done without the risk of injurious effects which may attend 
 the injection of poisonous antiseptics. 
 
 The use of antiseptics does not supersede, but supplements, 
 ordinary cleanliness. Both accoucheur and nurse should keep 
 their nails short, wear no rings, and scrub their hands and arms 
 for ten minutes before touching the genitals. The hands should 
 then be disinfected by scrubbing in alcohol, 70 to 80 per cent., 
 and then in a solution of biniodide or perchloride of mercury, 1 in 
 1,000. A basin of the same solution should be kept by the bed- 
 side, that the hand may again be dipped in from time to time. 
 For the first disinfection, a solution of biniodide of mercury in 
 spirit, 1 in 500, is also most effective. The nurse must use the same 
 precautions before each washing of the genitals after labour. If a 
 catheter is used, it should be a glass one, sterilised by boiling. If a 
 solution of 1 in 1,000 is found to roughen the hands too much, one 
 of 1 in 2,000 may be used. Forceps and other steel instruments, 
 after thorough cleansing and sterilisation in boiling water, are best 
 disinfected by a solution of lysol 1 in 50, of formalin 5ss. ad Oi., or 
 of carbolic acid of a strength of at least 1 in 40. It must be 
 remembered that soap is incompatible with most antiseptics, except 
 lysol or carbolic acid, and destroys their efficacy ; also that a very 
 small quantity of carbolic acid precipitates the sublimate solution. 
 Lysol, being alkaline, has in itself a considerable cleansing as well 
 as antiseptic power, and may be used, with advantage, for the 
 hands, before their immersion in mercurial solution. Biniodide of 
 mercury may be used instead of the perchloride, and is even more 
 efficacious, though somewhat more expensive. 
 
 It is most important that the practitioner attending midwifery 
 cases should soil his hands as little as possible with infectious 
 materials, and therefore whenever he is attending any septic cases 
 he should wear rubber gloves. In these circumstances he should 
 also always put on a pair of sterilised rubber gloves before making 
 any vaginal examination, that is to say in all instances where his 
 hands have come in contact with any infectious material, such as 
 the discharge from a suppurating wound. The external genitals 
 should be washed by the nurse with soap and water at the outset 
 of labour, the hair cut short with scissors, and then the parts 
 
Management of Normal Labour. 293 
 
 carefully cleansed with an antiseptic solution, since pathogenic 
 organisms are said to be commonly present in the vulval secretion 
 though not in the vaginal. Lysol 1 in 100, which is valuable for 
 its cleansing quality, may be used first, and then perchloride of 
 mercury 1 in 1,000, which is less irritating to skin and mucous 
 membrane than the alkaline lysol. 
 
 In a normal case it is neither necessary nor advantageous to give 
 a vaginal douche before labour, but if any purulent vaginal dis- 
 charge is present, and especially if there is any suspicion of its 
 being of gonorrhceal origin, a douche should always be given in the 
 early stages of labour. This may be a solution of perchloride or 
 biniodide of mercury 1 in 1,000, or lysol 1 in 100. 
 
 After delivery, if any intra-uterine manipulation has been 
 carried out, or if there is any other reason for doing so, such as 
 haemorrhage, an intra-uterine douche of perchloride or biniodide of 
 mercury may be given of the strength of 1 in 4,000, or, better still, 
 of lysol 1 in 100, or of tincture of iodine 5ii. to the pint, or of 
 chinosol 1 in 400. The douche should be given at a temperature 
 of 105° to 110° F., or if for the arrest of haemorrhage at a 
 temperature of 118° to 120° F. 
 
 The occasional appearance of poisonous symptoms after the use 
 of mercury has generally followed the repeated use of the solution 
 rather than a single douche. But it must be remembered that 
 immediately after delivery is the time when there is the greatest 
 possible extent of absorbent surface. If, therefore, a mercurial 
 douche is used at that time, special care must be taken to ensure 
 that it flows freely away, that the uterus is well contracted at the 
 time, and that no excess of it remains in the vagina or cervix. On 
 the whole, it is better never to use any preparation of mercury for 
 an intra-uterine douche, but to use instead a solution of lysol. 
 
 The external parts should be washed from time to time during 
 the progress of labour, especially if it be prolonged, with pledgets 
 of wool soaked in whatever antiseptic lotion is being employed, and 
 it is well to keep, as far as possible, a sterile pad of wool or one 
 soaked in an antiseptic lotion applied to the genitalia until the head 
 is engaged in the vulva. 
 
 Another antiseptic precaution is to thoroughly clear out the 
 rectum at the commencement of labour, and so avoid the extrusion 
 of faeces by the pressure of the advancing head. This is best 
 carried out by the administration of a copious enema when pains 
 commence. But if there is any tendency to constipation, a daily 
 action of the bowels should be secured by an aperient at the time 
 when labour is expected. 
 
294 The Practice of Midwifery. 
 
 It is improbable that sewer-gas can actually originate puerperal 
 septicaemia. But it may be a predisposing cause by depressing the 
 health of the patient. Care should be taken therefore beforehand 
 that the drains of the house are in good order, and that there is no 
 concealed water-closet in bedroom or dressing-room, nor any 
 untrapped waste-pipe in or near the rooms. 
 
 The antiseptic precautions required during the puerperal period 
 will be considered later, and the special precautions necessary in 
 lying-in hospitals will be discussed under the head of puerperal 
 septiccBmia (Chapter XXXIX.). 
 
 Preliminary Preparations. — The room should be as airy as 
 possible and also quiet. The bed should be firm, and a feather 
 bed is especially to be avoided. The bedding and bed should be 
 protected by a waterproof sheet, and a draw-sheet, folded in several 
 thicknesses, should be placed under the hips, so that it can be 
 readily removed when soiled. Special lying-in sheets are made, 
 stuffed with sublimate wood-wool. These have the advantage over 
 the simple draw-sheet, since they are capable of absorbing a 
 considerable quantity of liquor amnii or other discharge. With the 
 lower classes it is usual to wear till the labour is completed an old 
 suit of the ordinary dress, including stays, which interfere with 
 abdominal examination. It is preferable for the patient to be in 
 her night-dress, over which she may wear a dressing-gown in the 
 earlier stages of labour. It is a good plan for her also to wear 
 underneath the night-dress a special petticoat, fastened loosely 
 round the waist. The night-dress can then be tucked up and kept 
 clean during delivery, and when the labour is over, the soiled 
 petticoat can be easily slipped off, and the necessity for changing 
 the night-dress avoided. With the poorer classes the attendant 
 should insist that no more persons than necessary are in the room, 
 since, especially among the Irish, the neighbours are fond of 
 gathering in the lying-in room. 
 
 Position of the Patient. — In this country it is usual for the 
 woman to lie on her left side, with the hips brought near the edge 
 of the bed, during the later stage of labour, or for an examination. 
 On the Continent and in America the dorsal position is the usual 
 one. Each position has its own advantages, but on the whole 
 those of the lateral position predominate. In point of delicacy it 
 has the superiority ; it allows forceps or other instruments to be 
 used with less exposure and less disturbance to the patient ; and it 
 tends to correct the common right obliquity of the uterus. 
 
Management of Normal Labour. 295 
 
 Moreover, during the passage of the head over the perineum, the 
 pressure on the perineum is not increased by the weight of the 
 child, as it is in the dorsal position, and hence the risk of laceration 
 is somewhat less in the lateral position. On the other hand, the 
 dorsal position tends somewhat to accelerate labour during the 
 earlier part of the passage of the head through the pelvis. Not 
 only does the weight of the child give direct assistance to the 
 expulsive force, but, by pressing the presenting part more firmly 
 upon the os uteri or vagina, it stimulates the contractions of the 
 uterus in a reflex manner. This is especially useful in cases of 
 uterine inertia. 
 
 It may be advantageous to vary the position of the patient from 
 time to time during the progress of the labour to suit varying 
 conditions, and at the third stage the patient should, as a rule, be 
 placed upon her back. 
 
 Examination of the Patient. — The first object is to ascertain 
 whether the presentation and the maternal passages are normal. 
 The entrance of the accoucheur, however, is apt to put a stop to 
 the pains for a time, and he should, therefore, be careful to avoid 
 startling the nerves of the patient. It is well to sit down quietly 
 for a while, ask a few questions about the time when the pains 
 commenced, their frequency, character, and situation, whether any 
 " show " has been seen, whether the waters have broken, whether 
 the bowels have acted freely, and also to feel the patient's pulse. 
 He should also inquire (if he has not previously ascertained) 
 about the character of former labours, the state of health during 
 pregnancy, and whether the patient has reached the full term. 
 He should see that his hands are warm before making any examina- 
 tion. For this purpose the antiseptic solution for disinfecting the 
 hands should be used hot. 
 
 It is desirable to make an abdominal examination in order to 
 ascertain by palpation whether the uterus and foetus are naturally 
 placed, and also to make sure, either by feeling movements or 
 hearing the foetal heart, that the foetus is alive. The successive 
 stages of abdominal palpation have already been described. 
 Abdominal examination is more troublesome than vaginal when 
 the ordinary dress is worn, but the student should be careful to use 
 all opportunities both of practising auscultation of the foetal 
 heart and acquiring skill in making out the parts of the foetus 
 and its position by abdominal palpation. He should not scruple, 
 therefore, to have the abdomen fully exposed. 
 
 It is usual and preferable to commence the vaginal examination 
 
296 
 
 The Practice of Midwifery. 
 
 during a pain, and hence arises the common phrase of " taking a 
 pain." Her attention being distracted by the pain, the patient 
 does not notice so much the inconvenience of the introduction of 
 the examining finger. The index finger of the right hand, anointed 
 with an antiseptic lubricant, such as lanocylhn, or glycerine con- 
 taining perchloride of mercury 1 in 1,000, is generally used for 
 examination in the position shown in Fig. 196. 
 
 The vulvar orifice should be opened with the fingers of the left 
 
 Fig. 196. — Exaraination of the os uteri in the first stage of labour. 
 
 hand, and the examining finger passed directly into the vagina as 
 far as possible without coming into contact with the external 
 genitalia. 
 
 The condition of the vagina may first be noted, especially as to 
 its freedom from any obstruction or contraction, the relaxation of 
 the mucous membrane, and the amount of lubricating secretion 
 present. An abundant secretion of slimy mucus is generally a 
 safe indication that labour has set in in earnest, and that the pains 
 and dilatation of the os will progress in a satisfactory manner. 
 For the physiological relaxation of the cervix, generally associated 
 with good expulsive pains, is usually attended also by a copious 
 
Management of Normal Labour. 297 
 
 secretion from the cervical glands, which are greatly under the 
 influence of the nervous system. 
 
 The next point is to make out the size of the os uteri, and the 
 condition of its edges. The inexperienced student must be careful 
 definitely to feel its margin, and not to overlook a very small os, 
 and mistake a thin uterine wall stretched over the presenting part 
 for the bag of membranes. If the os is still small, it may lie so far 
 back in the hollow sacrum as to be difficult to reach. In such a 
 case the accoucheur should see that the bladder is empty, since a 
 full bladder displaces the cervix much farther back, and should 
 place the patient on her back, introducing two fingers of the right 
 hand into the vagina, and pressing the fundus downward and back- 
 ward with the left hand placed on the abdomen. Another plan, but 
 not such a good one, is to place the patient transversely on the bed, 
 still lying on her left side, and introduce two fingers of the left 
 hand into the vagina, the flexor surfaces directed towards the 
 anterior pelvic wall. Examination while the pain still continues 
 will best reveal the condition of the os, and the effect of the pain 
 upon the os, the bag of membranes, and the presenting part. A 
 thin hard margin to the os generally denotes that dilatation will be 
 slow, or that the stage of it is early ; if the edge is soft and thick, 
 it is likely to yield much more quickly. 
 
 To make out the presenting part, if the membranes are still 
 intact, it is necessary to continue the examination during the 
 interval between the pains. No attempt to explore it should be 
 made while the bag of membranes is tense, lest the membranes 
 should be ruj^tured prematurely. If the os is still small it is 
 sufficient for the accoucheur to satisfy himself that the head is 
 presenting, without making out its exact position by feeling the 
 fontanelles. To do this, however, it is not sufficient to feel the 
 presenting part through the uterine wall, but the finger must be 
 passed in through the os to touch it. If, on passing the external 
 OS, the finger finds a cervical canal still existing, so that the bag 
 of membranes or presenting part does not rest upon the external 
 OS, but only upon the internal os, or upper orifice of the canal, it 
 is generally a sign that the labour will not soon be over. For the 
 internal os and cervical canal have to be dilated before dilatation 
 of the external os begins, and this process is indeed often completed 
 during the few days before active labour, while there are still no 
 well-marked pains. 
 
 If a bag of membranes only is felt, and no presenting part can 
 be reached, special care is necessary to ascertain whether there is 
 any abnormal presentation, especially a shoulder presentation or 
 
298 The Practice of Midwifery. 
 
 transverse position of the child. In this investigation, examination 
 of the abdomen should on no account be omitted. In some cases 
 the failure to feel any presenting part may arise simply from the 
 liquor amnii being very abundant, and the head resting far forward 
 above the symphysis pubis, not engaged in the pelvis. In such 
 a case the head may be reached by pressing the finger far forward 
 within the os, while the patient lies on her back, and the 
 external hand presses the head down from above. If one or two 
 fingers fail to reach any presenting part, the dilatation of the os 
 having made some progress, the half-hand or whole hand should 
 be introduced into the vagina for the purpose, an anaesthetic being 
 given, if necessary. 
 
 If the presenting part has not descended into the pelvis when 
 the first examination is made, and particularly if no guidance is to 
 be obtained from the history of previous labours, the size of the 
 pelvis should be explored by the finger. More especially, the 
 accoucheur should test whether the promontory of the sacrum can 
 be reached too easily, and, if it can, he should measure the 
 diagonal conjugate diameter (see Chapter XXIX.). He should also 
 judge whether there is less space than usual on either or both 
 sides of the pelvis, and note also the size of the cavity and outlet. 
 Next, it is well to examine whether any fseces can be felt in the 
 rectum ; and if any are found, to have an enema administered, if 
 labour is not too far advanced, or too rapidly advancing. A 
 collection of faeces in the rectum may materially delay the progress 
 of labour before it is expelled before the advancing head. Even a 
 small quantity of faeces interferes with perfect antisepsis. 
 
 As to the probable duration of labour, the medical attendant 
 may form an opinion for his own guidance from the size and 
 dilatability of the os, the amount of mucus present, and the size 
 of the pelvis. He should avoid risking his credit by making any 
 positive prophecy as to time to the patient or her friends, but 
 should content himself with assuring her that all is going well, and 
 that the duration of labour will depend upon the pains. As to 
 whether or not it is necessary for him to remain continuously in 
 attendance, he will judge partly by the state of the os, partly by 
 the vigour and frequency of the pains, taking also into account 
 whether the patient is a primipara or a multipara. In any case of 
 doubt, he should wait for at least half an hour or an hour, to 
 watch the rate of progress. Sometimes a patient may send for 
 her attendant when suffering only from false pains, that is to say, 
 irregular and painful contractions of the uterus, which do not 
 dilate the os. False pains generally recur at very irregular 
 
Management of Normal Labour. 299 
 
 intervals, not with the more or less rhythmic regularity of true 
 pains. But we can positively distinguish them only by making 
 a vaginal examination, and finding that they do not produce 
 dilatation of the os, or cause protrusion of the bag of membranes. 
 False pains commonly depend on some irritation in the alimentary 
 canal, and are best treated by a mild aperient combined with a 
 sedative, such as hyoscyamus. 
 
 Management of the First Stage — During the first stage the 
 patient should not be kept too much in one position. It is 
 generally better that she should be up, occasionally walking about, 
 and occasionally resting in a chair. If the first stage is tedious, 
 the lateral position is especially to be avoided, because, in that 
 position, the weight of the ovum is taken off from the os and cervix, 
 and the reflex stimulus is thereby diminished. If she lies down, 
 the patient should rather lie on her back. At this stage, she 
 should be enjoined not to weary herself with bearing-down efforts, 
 which at present are useless, and her strength should be kept up 
 by a sufficient amount of light nourishment. With the lower 
 classes it is often necessary to discourage the use of alcohol. 
 During the dilatation stage examinations should only be made if 
 absolutely necessary. Asa general rule, in the conduct of a case of 
 normal labour only two internal examinations should be made, one 
 during the first stage and another immediately after the rupture 
 of the membranes, because the presentation may be changed with 
 the rush of liquor amnii, or the funis may become prolapsed. 
 Frequent examinations before the stage is reached at which the 
 abundant secretion of mucus begins are apt to irritate the cervix 
 and vagina, and increase the dryness of the canal. 
 
 If the attendant remains during a prolonged first stage, he 
 should remember not to stay too continuously in the room, but 
 give the patient opportunities to empty her bladder. Occasionally 
 difficulty of micturition arises from the pressure of the head on 
 the neck of the bladder or urethra, and the use of the catheter 
 may be necessary. A distended bladder may be a cause of pro- 
 longation of labour, from its interfering with the effective action 
 of the auxiliary muscles. With the elongation of the cervix and 
 distensible lower segment of the uterus, the upper part of the 
 bladder is carried upward above the level of the pubes (see 
 Fig. 131, p. 220). Hence, if an abdominal examination be made, 
 the bladder, if at all distended, is readily felt as an elastic rounded 
 swelling in front of the lower portion of the uterus. For emptying 
 the bladder a full-sized male gum elastic catheter (No. 10 or 
 
300 The Practice of Midwifery. 
 
 No. 12) is generally preferable to the short glass female catheter, 
 since the urethra may be lengthened and distorted by the dis- 
 placement of the bladder upwards, and the pressure of the head ; 
 and it is not sufficient to reach the flattened lower portion of the 
 bladder in order to evacuate the urine. The swollen meatus is 
 also apt to be displaced further forward than its usual position. 
 Difficulty sometimes arises in getting the point of the catheter past 
 the head. One or two fingers should then be passed into the 
 vagina, and, by pressure forwards through the urethral wall, the 
 point of the catheter should be guided up to and past the point of 
 compression. If necessary, the head should be pushed somewhat 
 backward in the interval of a pain, to give the catheter room 
 to pass. 
 
 Artificial Rupture of Membranes. — When the dilatation of the 
 OS is complete, labour is accelerated by artificial rupture of the 
 membranes (see p. 226). The risk is also by this means averted 
 that the amnion may be separated from the chorion by too far an 
 advance of the bag of membranes in front of the head, and that the 
 chorion may consequently be left behind in utero. The experienced 
 practitioner may often with advantage rupture the membranes 
 rather before the os is fully dilated to the size of the vagina or 
 that of the greatest diameter of the head, but not before it is large 
 enough for the head to enter it sufficiently to form a dilator not 
 less efficient than the bag of membranes. If the membranes are 
 ruptured prematurely, the os is apt to remain rigid, and a labour, 
 which had been progressing favourably up to that point, may pass 
 into an inactive stage. The inexperienced student should rather 
 incline to the alternative of leaving the membranes too long intact 
 than to that of rupturing them too early. The bag of membranes 
 may generally be ruptured by pushing the tip of the forefinger 
 through it when rendered tense by a pain. If the membranes are 
 too tough to allow this, they should be gradually scratched through 
 with the finger nail, while still tense. If this still fails, they may 
 be ruptured by pressing upon them with some pointed instrument. 
 A catheter stylet, or uterine sound, is preferable to the traditional 
 hairpin, often used for this purpose, and care must be taken to 
 sterilise whatever instrument is used. Sometimes there may be so 
 little bulging of the bag that it is difficult to judge whether the 
 membranes are ruptured or not. This may be due to scantiness of 
 liquor amnii, or to the membranes being inelastic and remaining 
 adherent near the margin of the os. In such a case the distinction 
 may be made by the contrast of the smooth surface of the membranes 
 
Management of Normal Labour. 301 
 
 with the roughness due to the hair on the scalp. Sometimes, by 
 sweeping round the forefinger an inch or two within the margin of 
 the OS, the membranes may be separated, and the bulging bag 
 allowed to form. In rupturing the membranes artifiicially, especially 
 if liquor amnii appears abundant, it is a good plan to place a bed- 
 pan or bed-bath under the patient, to prevent her getting wetted. 
 Otherwise, the excess of fluid should be mopped up with napkins, 
 and the draw-sheet shifted to a dry place. 
 
 Management of the Second Stage. — Toward the end of the first 
 stage the patient should lie down in the left lateral position. To 
 aid the expulsive pains, it is usual to tie a round towel to the foot 
 of the bed, so that, by pulling upon it during the pain, the patient 
 may gain some assistance in fixing her chest for the action of the 
 auxiliary muscles. Women often like also to be able to rest their 
 feet against the foot of the bed. As soon as the membranes are 
 ruptured the exact position of the head should be made out by the 
 sutures and fontanelles, if this has not been done previously, so that, 
 in case of occipito-posterior positions, the management presently to 
 be described may be carried out. In general, women instinctively 
 hold their breath, and bring the auxiliary muscles into action during 
 the expulsive pains. Sometimes, however, especially in the case 
 of sensitive women who feel the pains acutely, their efficacy is 
 diminished by lack of closure of the glottis. In such a case, the 
 woman must be repeatedly exhorted not to cry out in the pain, but 
 to hold her breath and bear down. The giving a little chloroform 
 during the pain, short of anaesthesia, may assist towards this object. 
 The patient need not be kept rigidly in the lateral position. If the 
 uterus is inert during the earlier part of the passage of the head, it 
 is of advantage to place her on her back, and so increase the reflex 
 stimulus due to pressure of the head. 
 
 Management of Occipito-posterior Positions.— If a diagnosis 
 of the position of the head is made in occipito-posterior positions, 
 it is almost always possible to secure by manipulation that rotation 
 of the occiput forwards which fails in about 4 per cent, of the cases 
 left to nature. It has already been explained that failure of rota- 
 tion is always due to insufficient flexion (see p. 260). Hence the 
 effort should be to promote flexion rather than to attempt the more 
 difficult task of directly rotating the head. This is to be done by 
 pressing on the forehead with one or two fingers during the pains, 
 and endeavouring at the same time somewhat to aid its rotation 
 backwards. The physician may also, if he can readily accomplish 
 
302 The Practice of Midwifery. 
 
 it in the intervals between the pains, pass two fingers over the 
 occiput and endeavour to draw it downwards and forwards. It 
 must, however, be borne in mind in these cases that rotation 
 forwards often occurs very late in the course of labour, and prema- 
 ture interference is to be deprecated. If the attempt to promote 
 flexion fail, then the case may be either treated by the application 
 of forceps or vectis or the hand passed into the vagina, the head seized 
 between the fingers and thumb, and the occiput manually rotated 
 to the front. In order to facilitate this manoeuvre, the head should 
 be flexed and pushed up out of the pelvic cavity. At the same 
 time, by abdominal manipulation, an attempt should be made to 
 rotate the shoulders, so as to render the rotation forwards of the 
 occiput a permanent one. This method succeeds in the great 
 majority of the cases. Rotation cannot however be expected to 
 occur, and it is therefore useless to attempt to promote it, until the 
 OS is sufficiently dilated to allow the occiput to pass over its margin, 
 and meet the resistance of the pelvic floor. The treatment of 
 protracted labour in occipito-posterior positions by the aid of the 
 vectis or force]3S will be considered in the chapter on the use of 
 those instruments (ChajDter XXXIII.). 
 
 Preservation of the Perineum. — When the head begins to press 
 upon the perineum, the physician has a much more important duty 
 to perform than in the earlier stages of its passage ; and by skilful 
 management he can do very much to avert laceration, more especi- 
 ally in the case of iDrimiparse, with whom the risk of such laceration 
 is much greater. The plan formerly recommended was to " support 
 the perineum," that is to say, to press with the palm of the hand 
 upon the perineum when stretched over the advancing head, and so 
 check that advance. It is now generally agreed that such pressure 
 on the perineum is a stimulus to increased uterine action, and so, 
 when pains are violent, may actually bring about the accident which 
 it is desired to avoid. In other cases again, the plan of prolonged 
 pressure led to quite an unnecessary delay in the j)assage of the head. 
 
 The causes which chiefly tend to rupture of the perineum, and 
 which are capable of being modified by art, are two : — first, and 
 chiefly, the head being forced through the outlet by vigorous pains 
 before the perineum has had time to dilate in the natural manner 
 under the influence of repeated jDains ; secondly, the fact that the 
 uterine force transmitted to the condyles does not act in the axis 
 of the outlet of soft parts (see Fig. 22, p. 21, and Fig. 181, p. 220), 
 but is inclined at an angle toward its posterior wall, so as to cause 
 special pressure upon the perineum. 
 
Management of Normal Labour. 303 
 
 Hence there are two great aims to be carried out in trying to 
 avoid rupture, first, to delay the too rapid advance of the head ; 
 and secondly, to press it forward toward the pubic arch, and so 
 equalise the pressure on the ring of the vulval outlet. To do this 
 both hands should be employed, and in all cases the physician 
 should determine by visual insj)ection the degree of tension which 
 the perineum is undergoing. The fingers of the left hand passed 
 between the thighs from the front may be placed on the occiput to 
 check its advance when the tension becomes too great. At the same 
 
 \ 
 
 s. 
 
 Fig. 197. — Supporting the perineum and checking the advance of the head in 
 the manner described. 
 
 time the right hand is spread out flat behind the perineum, so that 
 the index fingers and thumb press on the frontal protuberances a 
 little anterior to the sacro-sciatic ligaments on each side, and direct 
 the head forward, without exercising any pressure on the sensitive 
 central portion of the perineum where the strain is greatest. 
 Thus both hands act together in checking advance when necessary, 
 while the right hand keeps the head forward against the pubic arch. 
 At the same time that he employs pressure the physician may 
 exercise some control over the " safety-valve " action of the glottis 
 by telling the patient to cry out, and to cease bearing down, when 
 tension Ijecomes dangerous. If the patient is devoid of self-control, 
 
304 
 
 The Practice of Midwifery. 
 
 and the pains tumultuous, there is a better chance of avoiding 
 laceration if chloroform is administered. 
 
 In primiparse there is an inevitable laceration of the entrance of 
 the vagina proper, marked by the remnant of the hymen, and from 
 this point the laceration may run upward and downward, extending 
 through to the skin. But in general lacerations reaching the 
 cutaneous surface of the perineum run from before backward, com- 
 mencing at the fourchette, after the inevitable laceration has 
 already occurred, if the patient be a primipara. It is to the 
 
 Fig. 198. — Expulsion of shoulders. (Modified from Bumm, Grundriss der 
 Geburtshilfe, Fig. 215.) 
 
 anterior edge of the perineum, therefore, that attention must be 
 most closely directed. 
 
 It is not uncommon, however, to see the superficial layers of the 
 epidermis cracking and giving way before the deeper layers. By 
 pressure in front of the sacro-sciatic ligaments, or by pressure on 
 the fundus uteri, it is often possible to squeeze out the head in the 
 interval of pains, and this plan is a good one when the pains are 
 difficult to control. 
 
 The treatment required for a distinctly pathological rigidity of 
 the perineum will be considered in Chapter XXVII. 
 
 Expulsion of the Trunk. — As the head is passing through the 
 vulva, the patient's right thigh should be raised by the nurse, to 
 allow the occiput to pass forward in front of the pubes. The head 
 
Management of Normal Labour. 305 
 
 should be received upon the right hand, and by it guided forward 
 close to the thighs, as the trunk is expelled. 
 
 As soon as the head has passed the vulva, the physician should 
 see if the funis is round the neck, and if it is, he should, as quickly 
 as possible, slip the loop over the head. If he cannot do this he 
 should try to slip it over the shoulders. If this also fails the funis 
 may be rendered so short that it checks the further advance of the 
 child, and the child will then be in danger of asphyxia from the 
 funis being drawn tight, and the circulation through it stopped. 
 If, therefore, the funis is found to be tight, and cannot be released, 
 it should be cut with scissors, the child quickly extracted, and 
 the ]3roximal end of the funis held between the finger and thumb to 
 prevent bleeding, until the child is born, when a ligature can be 
 placed round it. 
 
 The trunk is generally expelled by the pain following that which 
 expels the head. As a rule, it is sufficient to wait quietly for the 
 occurrence of the pain. In normal labour there is no danger to the 
 child at this stage, even if the body is not expelled for several 
 pains, the placental circulation being still intact. Moreover, if not 
 already partially asphyxiated, the child is generally able to breathe 
 at this stage, if it requires to do so. If, however, the child has 
 already been imperilled by prolonged labour, and especially after a 
 difficult forceps delivery, it may be sacrificed by prolonged delay 
 after the birth of the head. Increasing lividity of the face shows 
 the child to be alive. But, if it becomes extreme, and especially if 
 it is accompanied by convulsive twitchings, it is an indication for 
 accelerating delivery. The uterus may then be stimulated by 
 friction, the woman told to bear down, and j)ressure brought to bear 
 on the breech of the child through the abdomen. If the delay is 
 very long, and the sooner if the child appears to be very large in 
 proportion to the genital canal, the head may be grasped between 
 the hands, avoiding the face, and gentle traction, not enough to 
 endanger the spinal cord, may be made upon the neck during a pain. 
 The anterior shoulder should be delivered first from under the pubes 
 and then the posterior over the perineum. If there is still difficulty 
 in delivering the shoulders, then as soon as the posterior axilla can 
 be reached the index finger may be hooked into it, and traction 
 made upon it in addition to that on the head, care being taken not 
 to use force enough to injure the brachial nerves. 
 
 After tlie shoulders have passed, the expulsion of tbe body of 
 
 the child should be left entirely to nature, since, if the uterus be 
 
 emptied artificially, it is more likely to remain flaccid, and permit 
 
 haemorrhage. In all cases the left hand should be placed upon the 
 
 M. 20 
 
3o6 The Practice of Midwifery. 
 
 abdomen, follow down the fundus as it diminishes in size, and make 
 sure that it remains contracted. This is an important measure as 
 a safeguard against haemorrhage. If the uterus expels the child 
 vigorously it is likely to remain contracted. 
 
 If the child breathes and cries freely, it should be laid near the 
 mother's thighs, in such a position that it does not hurt her by 
 kicking against the vulva. If the presence of mucus in the mouth 
 is shown by any rattling respirations, it should be wiped out with a 
 handkerchief. 
 
 As soon as the head appears, the eyes and their neighbourhood 
 should be wiped clean from mucus with a piece of absorbent cotton 
 soaked in a saturated solution of boracic lotion or in a 1 in 4,000 
 perchloride or biniodide of mercury solution. If any purulent or 
 muco-purulent discharge has been noticed, or if there is any 
 reason to suspect the existence of gonorrhoea, a few drops of a 
 solution of perchloride of mercury, 1 in 2,000, should be dropped 
 into the eyes. The ophthalmia neonatorum, which is often a source 
 of permanent blindness, may thus be averted. A solution of nitrate 
 of silver, 2 j)er cent., may also be used, and statistics appear to show 
 that it is the most trustworthy germicide for the purpose ; but it 
 has the drawback that it is apt itself to set up a slight inflammation. 
 To avoid this the use of sojDhol 5 per cent., argyrol 25 to 50 per 
 cent., protargol 10 to 20 per cent, solutions has been suggested 
 (see Chap. XLII.). Other microbes than the gonococcus may set 
 up less severe forms of ophthalmia neonatorum. 
 
 Ligature of the Funis. — It was formerly recommended to 
 tie the funis as soon as the child cries or breathes freely. The 
 experiments of Budin,^ however, have shown that the opposite 
 practice is desirable. If the funis is left untied, circulation in the 
 vein generally ceases within four to five minutes, and the pulsation 
 in the arteries within eight to ten minutes, the cessation passing 
 from the placental end towards the child. If the funis is not cut 
 till about a minute after pulsation has ceased, there is hardly any 
 bleeding from the placental end. If, however, it is tied early, a 
 considerable quantity of blood escapes, the amount of which was 
 found by Budin to be on the average about three ounces (88 gms.) 
 greater than in the former case. It may be inferred that this 
 amount of blood is transferred from the placenta to the child during 
 the few minutes after birth, partly from the thoracic aspiration 
 during inspiration, partly from the effect of the pressure of the 
 
 1 Budin, " A quel moment doit-on op^rer la ligature du cordon ombilical ? " Progres 
 Medicalo, 1876. 
 
Management of Normal Labour. 307 
 
 uterus on the placenta ; and that it serves to supply the extra 
 amount of blood required to fill the pulmonary circulation at the 
 time when the lungs take the place of the placenta as organs of 
 respiration. Hence we get the startling result that to tie the funis 
 immediately is equivalent to bleeding the child to the amount of 
 three ounces (90 gms.), a bleeding which would correspond to 
 one of about sixty ounces in an adult. The conclusions arrived at 
 from the amount of blood which escapes from the placenta have 
 been confirmed by observations on the increase of the weight of 
 the child during the few minutes after birth. General experience 
 shows that the children are more vigorous after late ligation of the 
 funis, suffer less loss of weight in the few dajys after delivery, and 
 more quickly begin to gain weight again. Some have alleged that 
 they are more liable to an apparent jaundice, which has been 
 thought to be really due to disintegration of over-abundant blood- 
 corpuscles. The observations of Schmidt, however, show that 
 exactly the opposite is the case.-^ 
 
 It may be inferred that the extra amount of blood is an 
 advantage to the child, especially as it gains very little nourish- 
 ment from its mother during the first two days. If, therefore, 
 there is no necessity for haste on account of the condition of the 
 mother, or in order to resuscitate an asphyxiate 1 child, the funis 
 should not be tied until the pulsations, near its placental end, 
 have stopped for a minute or more, or, at any rate, till five 
 minutes have elapsed since the birth, if the pulsations continue 
 longer. In the majority of cases the pulsation ceases within three 
 or four minutes, but sometimes it continues as long as fifteen 
 minutes or more. Such prolonged pulsation may occasionally be 
 an indication of adherent placenta. 
 
 The material commonly prepared by the nurse for tying the cord 
 consists of several strands of strong thread, tied together at both 
 ends, but a narrow tape sterilised by boiling or by immersion in an 
 antiseptic solution, such as perchloride of mercury 1 in 1,000, is 
 preferable. The knot should be tightened gradually and firmly, in 
 order to compress the elastic gelatinous material uf the cord, 
 especially in cases in which this is unusually abundant, otherwise 
 bleeding may occur after an interval. When the funis is very thick, 
 it should always be looked at after a while to make sure that the 
 ligature is safe. The ligature may be placed as close to the 
 umbilicus as one inch, or even half an inch, provided that there is 
 no umbilical hernia. The funis is then cut with scissors about half 
 
 ' Schmidt Archiv f. (iyn., 1894, Vol. XLV., lift. 2, p. 28.3. 
 
 20—2 
 
3o8 The Practice of Midwifery. 
 
 an inch beyond the ligature, care being taken that no injury is done 
 to the limbs of the infant. It is quite unnecessary to place a second 
 ligature on the placental side if the plan has been adopted of waiting 
 for the cessation of pulsation, as only a few drops of blood will 
 escape. The oidy case in which the second ligature ought to be 
 used is that in which the hand placed on the uterus finds it still so 
 large that it may have within it a twin foetus. The object in this 
 case is to prevent any loss of blood to the second foetus, in case there 
 should be a single placenta and inosculation of the foetal vessels. 
 
 The methods advocated by some obstetricians of cauterising the 
 cut end of the cord or of treating the cord by crushing are not 
 necessary, nor indeed are they practicable in ordinary practice. 
 
 Management of the Third Stage of Labour. — In ordinary cases 
 of labour, a correct management of the third stage is the most 
 important of r.ll the duties of the physician ; and it is at this stage 
 that erroneous practice is still most frequent. Only a few years 
 ago, the method taught in most text-books was to wait for a certain 
 interval after delivery for contraction of the uterus, and then to pass 
 the fingers into the vagina and trace up the cord, feeling for its 
 insertion into the placenta. If the insertion could be felt, the cord 
 was to be wound round the fingers of one hand, so as to give a 
 purchase for pulling, while the fingers of the other hand in the 
 vagina were placed on the cord, so as to direct the traction at first 
 backward in the axis of the pelvic inlet. In practice, it has not 
 been uncommon to remove, or attempt to remove, the placenta by 
 traction on the funis, even when the insertion of the latter could 
 not be felt, the placenta being still wholly in the uterus. The objec- 
 tion to this method is, that any traction whatever on the funis pulls 
 away the centi-e of the placenta from the uterine wall, and so creates 
 a vacuum which must be filled up either by blood poured out from 
 the uterine wall, or, less frequently, by entrance of air from outside. 
 Moreover, by drawing down the placenta like an inverted umbrella, 
 it interferes with the natural mechanism of its expulsion (see Figs. 
 194, 195, p. 286), and renders its bulk greater for passing through 
 the cervix and vagina. Practitioners who adopt the correct mode of 
 management of the placenta, and are unremitting in their vigilance, 
 are almost exempt from the grave accidents of j^ost-partuni 
 haemorrhage, and, moreover, save their patients not only from 
 the inconvenience of after-pains, excited by the formation and 
 retention of clots within the uterus, but also from the grave 
 dangers of septic intoxication or septic infection so Hkely to follow 
 the retention of any portion of the placenta or membranes in utero. 
 
Management of Normal Labour. 309 
 
 Expression of the Placenta. — The correct mode of aiding the 
 delivery of the placenta, when aid is required, is that of external 
 pressure. This method is often spoken of as the method of 
 Crede, although Cred6 only revived a mode of treatment previously 
 known, though not generally practised. During the birth of the 
 body of the child the physician is to follow down with his hand the 
 contracting uterus, and by pressure, and, if necessary, gentle 
 friction, stimulate it to maintain its retraction after the child is 
 born. After the birth of the child, if the fundus uteri can be felt 
 as a firm rounded mass it is left alone. If it appears flaccid, it is 
 gently kneaded until firm contraction is induced. It is not desirable, 
 by forcible pressure, to attempt to completely expel the placenta 
 with the same pain which expels the child, or immediately after- 
 wards. For if the uterus be completely emptied before thrombi 
 have had time to form in the vessels, it is more apt to relax again 
 quickly, not being stimulated by the presence of the placenta 
 within, and so to allow haemorrhage to take place. 
 
 Provided that there is no abnormal haemorrhage, the physician 
 at short intervals places his hand upon the uterus, to make sure 
 that it does not become flaccid and dilate. Kneading the uterus 
 is called for only when undue relaxation does occur. If his 
 attention is otherwise occupied for any considerable time, as in 
 resuscitating a child born asphyxiated, he directs the nurse to 
 keep a hand on the uterus. At this stage it is best for the 
 patient to lie on her back. Gravity then aids the descent of the 
 placenta, and tends to counteract any collection of blood within the 
 uterus. The position is also most convenient for expression of the 
 placenta. 
 
 Expression of the placenta may be carried out as soon as there 
 is evidence that it has been expelled out of the upper contracting 
 segment of the uterus into the dilated cervix and vagina. This i? 
 indicated by the fact that the fundus is noticed to rise up about 
 an inch and a half above the position which it previously occupied, 
 while it becomes reduced in circumference, remaining as firm or 
 firmer than before, and the distended lower uterine segment con- 
 taining the placenta causes a distinct bulging above the pubes. In 
 the majority of cases this occurs within twenty minutes to half an hour 
 after the birth of the child. An additional indication may be 
 obtained, if, as soon as the child is born, the funis is drawn down 
 very gently, and a sterilised thread is tied round it where it passes 
 over t?ie margin of the vulva. Descent of the placenta is then 
 indicated by a further descent of the thread externally. As soon as 
 evidence of the descent of the placenta is thus obtained, the uterus 
 
3IO The Practice of Midwifery. 
 
 should be grasped by one or both hands, the fingers being placed 
 behind it and the thumbs in front, stimulated by pressure and 
 kneading to contract if flaccid, and then at the height of the 
 contraction pressed firmly downward in the axis of the pelvic 
 brim. By this means the placenta is squeezed out. As it 
 passes through the vulva it should be grasped by the hand and 
 rotated, so as to twist up the membranes into a kind of cord, which 
 is to be withdrawn very gradually, so as to avoid its tearing. If it 
 is felt to begin to tear, it should be seized by the fingers at a higher 
 point and so extracted. 
 
 In this expression, the contractile upper segment of the uterus 
 acts simply as a piston, by means of which the pressure of the 
 external hand is transmitted to the i)lacenta lying in the relaxed 
 lower segment and vagina. It is necessary for it to be contracted 
 and not flaccid, both in order that it may be rigid enough to 
 transmit the force, and to avoid the risk of its being inverted by 
 the external pressure. 
 
 If there is no descent of the placenta at the end of half an hour 
 after the birth of the child, it is advisable to stimulate the uterus 
 to expel it. Uterine contractions will be * recurring by this time. 
 These are to be stimulated by pressure and kneading of the fundus. 
 As soon as an active contraction is called forth by these means, so 
 that the fundus becomes quite hard under the hand, the fundus is 
 grasped by both hands, and concentric compression made upon it, 
 at the same time that it is pressed downwards in the direction of 
 its axis. The size of the uterine body is felt to diminish under 
 the hand if the placenta is by this means expelled from it. Con- 
 tinued downward pressure in the pelvic axis will then squeeze the 
 placenta out through the vulva. 
 
 If this method does not succeed with the first pain, it should be 
 repeated with successive pains, until the placenta is gradually 
 detached. An unusual delay in expulsion may mean that the 
 placenta is more adherent than usual to the uterine wall ; but the 
 difiiculty will often be overcome if patience be exercised. It is 
 advisable to wait as much as two hours, unless there is undue 
 haemorrhage, before introducing the hand into the uterus to 
 se]3arate the placenta, because this procedure, even with careful 
 antiseptic precautions, involves some degree of risk of carrying 
 microbes to the placental site. If, however, the lower margin of 
 the placenta can be felt in the vagina by a hand carefully sterilised, 
 or covered by a sterilised glove, there is no harm in seizing 
 that between the thumb and two fingers, and aiding the pressure 
 from above, during the uterine contraction, with gentle traction 
 
Management of Normal Labour. 311 
 
 upon it, care being taken not to use force enough to tear its lacerable 
 substance. 
 
 If rather free haemorrhage occurs from the vagina with the early 
 pains of the third stage, more active stimulation should be used 
 by pressure and gentle kneading of the fundus ; and the expression 
 of the placenta should be commenced earlier. 
 
 Ahlfeld recommends the expectant plan as preferable to early 
 expression of the placenta in normal cases. No pressure or 
 massage is to be applied to the fundus. After delivery and 
 separation of the child, any lacerations which bleed are to be 
 stitched. Dry sheets are to be placed under the patient, and she 
 is to be well covered up with bed-clothes. A draw-sheet is placed, 
 and about every five minutes the amount of blood passing is noted, 
 and the draw-sheet shifted to a dry place. The pulse is also to be 
 watched, so that any serious intra-uterine bleeding would be 
 revealed by acceleration of the pulse. Only after an interval of 
 from one and a half to two hours, unless abnormal haemorrhage 
 occurs, is the expression of the placenta to be commenced ; the 
 bladder having been emptied by catheter meanwhile. The advan- 
 tages claimed by Ahlfeld for this plan are that the average amount 
 of blood lost is less, that both primary and secondary post-jjcirtum 
 haemorrhage are less common, and that artificial extraction is rarely 
 called for. It is obvious that this method favours the separation 
 of the placenta by retro-placental haematoma, which Ahlfeld regards 
 as the normal mechanism ; and that active expulsion of the 
 placenta, with a minimum effusion of blood, would more rarely 
 occur when it is employed. The long waiting required will render 
 the method one unlikely to be adopted as a general rule. 
 
 Examination of the Placenta. — The bag of membranes will 
 generally have become inverted, and will require re-inversion to 
 bring the uterine surface outermost. The first step is to examine 
 the uterine surface of the placenta, and make sure that it is com- 
 plete, especially along the margin, and that no part is left behind 
 in the uterus. Any adherent clots should first be washed away 
 from the surface. If the cotyledons are partially separated, the 
 placenta should be spread out flat, or with the uterine surface some- 
 what concave, and then it will be possible to see whether the parts 
 all fit together, and none is missing. In this examination, any 
 infarcts or hardened, degenerated, or calcareous patches on the 
 surface will be noted. 
 
 The next step is to see that the whole of the two layers of mem- 
 branes, amnion and chorion, are present. They are most easily 
 
312 The Practice of Midwifery. 
 
 separated at the edges if placenta and membranes are placed in a 
 basin of water. The chorion is outermost and continuous with 
 the edge of the placenta. The amnion can be stripped up to the 
 insertion oi the funis. The experienced accoucheur will judge at 
 a glance that none of the chorion is deficient, by the whole of the 
 membranes having a rough outer surface, due to the portion 
 of decidua remaining attached to the chorion. The amnion is 
 smooth on both sides, thinner but stronger than the chorion. 
 There should be sufficient membranes present to have enclosed 
 the foetus, allowance being made for the shrinking due to their 
 elasticity. Except in the case of placenta prsevia, where the 
 membranes have been ruptured at the edge of the placenta, there 
 should be a border of them all round, but deeper at one part than 
 another. 
 
 It is to be noted that the chorion is more likely than the amnion 
 to be left behind in the uterus, wholly or partially. The amnion 
 is not likely to be left behind when the chorion comes away ; but it 
 may be torn away from the edge of the placenta and separated from 
 the chorion, when it has been carried down as a caul, or as a bag 
 descending far in advance of the head. When the amnion has been 
 torn away, special care is necessary to make sure that none of the 
 chorion has been left behind. 
 
 If a placenta succenturiata had been left behind in the uterus, 
 the fact would be revealed by a corresponding deficiency in the 
 chorion, and by the torn ends of the vessels which supj)lied it, 
 passing from the edge of the main placenta, or separately from a 
 velamentous insertion of the funis. 
 
 If any portion of the placenta or any large portion of the chorion 
 appears to be absent, the hand covered with a sterilised rubber 
 glove must be introduced into the uterus, and it must be found 
 and removed at once. Small pieces of the chorion may be left to 
 come away by themselves. In such case, if any offensive dis- 
 charge occurs, or febrile symptoms arise, the uterus must be at 
 once explored. 
 
 Examination of the Perineum. — After the delivery of the 
 placenta a careful examination should be made as to whether there 
 is any laceration of perineum, so that any rent may be immediately 
 sewn up. Visual examination is better than digital ; and, if there 
 is any doubt, a good light must be obtained for the inspection. 
 Many lacerations remain unobserved for want of a visual 
 examination. The mode of treating any laceration will be here- 
 after described. 
 
Management of Normal Labour. 313 
 
 Use of the Binder.— The object of the binder is not to serve 
 as a prophylactic against haemorrhage, for which purpose it is 
 worse than useless, but simply to supply that support to the 
 abdominal viscera which is taken away by the sudden diminution 
 of tension. The binder should never be applied until at least 
 half an hour has elapsed since the birth of the child, and a 
 sufficient continuous contraction of the uterus has been secured. 
 Up to that time the physician should keep his hand on the 
 uterus, observing its conditions, kneading it if it becomes large 
 and soft, or haemorrhage occurs, but remembering that a certain 
 alteration of hardness and softness is the physiological law. If 
 there is any excess of sanguineous discharge, or if the contraction 
 of the uterus is unsatisfactory, he must continue this observation 
 for a longer time, until he is certain that there is no longer risk 
 of haemorrhage. The pulse at this time will generally have fallen 
 down to, or even below, its normal level, and an unusually rapid 
 pulse, such as one of 100 or more per minute, unless accounted 
 for by the severity of the labour, or other known cause, must be 
 taken as indicating a risk of haemorrhage. As a greater security 
 against haemorrhage, it is recommended by some to give after 
 delivery of the placenta, as a routine practice, a dose of ergot, 
 about a drachm of the liquid extract, or the liquor secalis 
 ammoniatus. In the case of a strong healthy woman, whose 
 uterus has been acting vigorously, this seems unnecessary, but it 
 should always be given to a weakly patient, or when there has 
 been any indication of uterine inertia or tendency to haemorrhage. 
 Its use in such cases, by preventing the formation of clots, tends 
 to avert after-pains, as well as haemorrhage. According to 
 Herman's ^ observations, the use of the binder makes no difference 
 as regards the subsequent size of the abdomen. But if a lady, 
 in future years, is not quite satisfied with her figure, she will be 
 apt to lay the blame on an accoucheur who omitted the use of the 
 binder. It is possible that its use is in reality some safeguard 
 against persistent flaccidity of the abdominal wall and consequent 
 pendulous abdomen. 
 
 In applying the binder the soiled linen and napkins should first 
 be removed, and the draw-sheet shifted, the patient being disturbed 
 as little as possible. The binder should be wide enough to reach 
 from the ensiforrn cartilage to the pubes, and long enough to over- 
 lap across the abdomen only. One end is rolled up to pass it 
 beneath the patient, and care must be taken that it is spread out 
 
 ' lleruian, TrariH. Obst. Soc. London, 1890, Vol. XXXU., p. 108. 
 
314 " The Practice of Midwifery. 
 
 evenly, and low enough down over the hips. The nearer end is 
 then laid over the abdomen, and held at its lower margin with the 
 left hand, while the right hand draws the further end smoothly 
 over it. The two layers are then held together, at the desired 
 tension, by the left hand, while the right hand fixes them with 
 large safety-pins going from below upward. The first pin is 
 placed close to the lower margin of the binder, which should pass 
 below the level of the great trochanter ; the second a little below 
 the level of the crest of the ilium ; the third above the level of 
 the crest of the ilium. These three pins are sufficient, but a 
 fourth may be placed higher up. It is a good plan to place a 
 folded towel under the line of pins, not as a pad, but to make it 
 easier to avoid pricking the skin in inserting the pins. A thin 
 layer of cotton wool wrapped in gauze or muslin may be used for 
 the same object. A pad is sometimes placed underneath the 
 binder, with the idea of compressing the fundus. This generally 
 pushes the fundus on one side, and it is very doubtful whether 
 it is of any use in maintaining contraction. If any pad at all is 
 used, the best is a small saucer, wrapped in a napkin, and placed 
 with its concave surface over the fundus, so that it does not get 
 displaced. 
 
 After the application of the binder the mother should be left 
 perfectly quiet to rest, and, if possible, to sleep. An opiate is not 
 necessary, as a general rule, but some light nourishment, such 
 as an egg beaten up with hot milk, or beef tea, may be given with 
 advantage. 
 
 Use of Anaesthetics in Labour. — In the great majority of 
 cases of labour where an anaesthetic is required chloroform is the 
 one to be chosen. Even when it is necessary to give it to the full 
 surgical extent, as in obstetric operations, it does not appear to 
 involve the same increased risk, as compared with other ansesthetics, 
 such as ether, which it does in ordinary cases. The explanation of 
 this is probably to be found in the physiological hypertrophy of the 
 heart which occurs during pregnancy, in the stimulation of heart 
 and lungs which occurs during each labour pain, even when the 
 patient is pretty deeply angesthetised, and perhaps also to some 
 extent in the high abdominal pressure due to tlie presence of the 
 pregnant uterus. All these causes diminish the risk of sudden 
 anaemia of the brain. If vomiting occurs, and food is present in 
 the stomach, it is of course necessary, whatever be the anaesthetic 
 used, to see that the patient does not get suffocated through the 
 vomited matter obstructing the larynx. If given to the partial 
 
Manag'ement of Normal Labour. 315 
 
 extent which alone is ever necessary in normal labour, chloroform 
 may be regarded as entirely free from risk. Ether is more dis- 
 agreeable to the patient than chloroform, and has not the same 
 satisfactory effect of deadening pain when given in partial degree. 
 Most of the objections formerly made to the use of chloroform in 
 normal labour have not now to be considered ; and, as a rule, it 
 may always be given whenever the pains are felt acutely, or the 
 patient is desirous to take it. Its use is a distinct advantage, 
 putting aside the question of relief of pain, in those cases in which 
 the pains are too violent, or occur at too short intervals. There 
 are, however, two drawbacks to its use : first, that it tends to 
 diminish the vigour of the pains, and so is apt somewhat to increase 
 the duration of labour ; secondly, that it increases the risk of j^ost- 
 partwn hsemorrbage in patients predisposed to that accident. These 
 disadvantages may be avoided to a great extent by not giving the 
 chloroform too freely. When, however, there is manifest inertia 
 of the uterus or a history of post-partum haemorrhage on former 
 occasions, it is better to avoid it entirely, or give it only in infini- 
 tesimal degree. Thus, when a patient is very anxious to take 
 chloroform, and its effect appears undesirable, a very little 
 chloroform may be mixed with eau-de-Cologne. 
 
 Anodynes in the First Stage of Labour. — As a rule chloroform 
 should not be given until the pains of the expulsive stage begin. 
 If the pains of the first stage are very distressing to the patient, 
 and especially if at the same time the os is rigid and slow in 
 yielding, either chloral or some preparation of opium, such as 
 Battley's liquor opii sedativus, may be given. The effect is often 
 not only to diminish pain, but to lessen spasmodic rigidity of the 
 OS, and allow the patient to recruit her strength by some sleep in 
 the intervals of the pains. Chloral is generally preferable to 
 opium. Two doses of fifteen grains may be given with from half 
 an hour to an hour's interval, and the dose repeated, if necessary, 
 after one or two hours. If there is sickness, and the medicine 
 cannot be retained, a moderate hypodermic injection of acetate of 
 morphia (a sixth or a quarter of a grain) may be administered. 
 In some cases, however, of muscular rigidity of the os, especially 
 when the uterus is active, and the membranes have ruptured pre- 
 maturely, chloroform is found to be far more efficacious than chloral, 
 and in such instances it may be desirable to give it, even in the 
 first stage of lal)our. 
 
 Chloroform in the Second Stage. — The chloroform is to be given in 
 such a way as only to dull sensibility, and not to produce com- 
 plete anaesthesia, or entirely abolish self-control. For this purpose 
 
3i6 The Practice of Midwifery. 
 
 it may be sufficient to place the inhaler over the face only during 
 the pains, allowing the patient to come round in the intervals. 
 The chloroform may be dropped on any simple form of inhaler 
 (such as Skinner's), or on some absorbent cotton wool placed at the 
 bottom of a tumbler. If more convenient, the patient may be 
 allowed to hold the inhaler herself, provided the physician makes 
 sure that she is actively holding it, not allowing it to rest passively 
 over or near the face. Junker's inhaler is a very good one for 
 administering the chloroform. The patient may herself hold the 
 mouthpiece, while the physician with his left hand works the 
 bellows, without having to lean over the patient, and has his right 
 hand free. This inhaler economises greatly the quantity of chloro- 
 form used, and is safer than any other for the administration of 
 chloroform to the surgical degree. As the chloroform is given 
 more gradually with this inhaler, it must be continued to some 
 extent during the intervals, as well as during the pains, sufficiently 
 to render the patient somnolent in the intervals, and only partially 
 conscious during the pains. Just as the head is about to pass the 
 vulva, if the pains come on with increased vigour the administra- 
 tion may be pushed more nearly to the point of complete 
 anaesthesia. 
 
 "When anaesthesia to the surgical degree is required, as for 
 obstetric o]3erations, it is desirable to have another person for 
 administering the anaesthetic, who may give his whole attention 
 to that duty. It is frequently convenient to be able to apply 
 forceps without the necessity for having an assistant. In such 
 case, if chloroform, be given, it should only be to a degree short 
 of abolishing the patient's self-control, otherwise the partial 
 anaesthesia renders the operation much more difficult. As an 
 anaesthetic for obstetric operations chloroform has the advantage 
 over ether that it more completely relaxes the uterus, when given 
 to the full extent. This is especially of advantage in the opera- 
 tion of version. Ether, however, is to be preferred, if an anaesthetic 
 is indispensable, in cases in which the patient is greatly exhausted 
 and the pulse feeble, as, for instance, after severe ante-partum 
 haemorrhage. 
 
 In the third stage the administration of chloroform involves a 
 risk of relaxation of the uterus and consequent haemorrhage. It 
 should not therefore be given at this stage, unless it is required 
 for the removal of an adherent placenta. 
 
 Spinal ancesthesia. — The plan of inducing anaesthesia by injection 
 of a solution of an analgesic into the subarachnoid space has been 
 practised in a considerable number of surgical operations, more 
 
Management of Normal Labour. 317 
 
 especially on the Continent and in America. The same method 
 has been extended to the production of analgesia in normal labour, 
 and in the performance of obstetric operations. 
 
 The injection is made, with strict antiseptic precautions, between 
 the laminse of the twelfth dorsal and first lumbar or of the fourth 
 and fifth lumbar vertebrse. The needle should be four inches lone, 
 and is best made of platinum, with an iridium point. It is inserted 
 immediately above the spinous process of the first lumbar or 
 1 centimetre below and outside the spinous process of the fourth 
 lumbar vertebra, the patient being placed, if possible, in the sitting 
 posture, with the back well arched forwards. It is directed 
 vertically downwards and slightly inwards, and will enter the 
 interval between the laminae of the twelfth dorsal and first lumbar 
 or of the fourth and fifth lumbar vertebrae, and penetrate the sub- 
 arachnoid space, as is shown by the escape of clear cerebro-spinal 
 fluid through the needle. 
 
 A few drops of cerebro-spinal fluid are first withdrawn, and then 
 the syringe is attached to the needle, and 1 cc. of a solution of 
 tropacocaine 5 to 8 per cent., 1 cc. of a 5 per cent, solution of 
 stovaine with a 5 per cent, solution of glucose, or 1 cc. of a solution 
 containing 10 eg. of stovaine and 1 mg. of neutral strychnine 
 sulphate very slowly injected. 
 
 The needle is now withdrawn and the puncture sealed by 
 collodion. The analgesia commences almost immediately and is 
 usually complete in from five to ten minutes. The drawbacks to 
 the method are that the duration of the analgesia is uncertain and 
 comparatively short, varying from thirty minutes up to three 
 hours or more, but being on the average a little over an hour. 
 The injections may be repeated ; but in some cases in which f grain 
 of cocaine has been used, alarming symptoms of cardiac and general 
 collapse have occurred. 
 
 Lindenstern records 500 cases. In 13 the method failed, in seven 
 there was marked collapse, in 34 vomiting occurred during the 
 operation and in 54 after the operation, and in 100 of the cases 
 more or less severe headache followed. The latter appears to 
 depend upon a febrile reaction, since a second puncture, made 
 in cases of severe headache, has shown the cerebro-spinal fluid to 
 be turbid, and to contain many polynuclear leucocytes. 
 
 If cocaine is used it appears in a considerable proportion of cases 
 to stimulate uterine contraction. The method is therefore not 
 suitable when it is desired to relax the uterus for the performance 
 of an obstetric operation, such as turning. On the other hand, 
 artificial delivery has often l)een found necessary after the injection, 
 
3i8 The Practice of Midwifery. 
 
 and this is attributed to the paralysis of the abdominal muscles 
 produced by the analgesia. 
 
 It thus appears that the inconveniences of the method exceed 
 in general those of chloroform, and it is obvious that any failure 
 of perfect antisepsis would involve a serious risk. Hahn ^ collected 
 eight deaths in 1,708 recorded cases, in some of which lesion of 
 the cerebral or spinal meninges were found at the necro^Dsy. Since 
 then 5,350 cases have been recorded with five deaths. Hardruin^ 
 mentions fifteen cases of death from spinal anaesthesia as coming 
 under his observation, and a large number of cases in which 
 serious complications occurred. On the other hand, Jonnesco has 
 recorded recently 1,015 cases of spinal analgesia without a death, 
 and in 623 of these cases he has used stovaine and strychnine, 
 and maintains that this combination prevents all the dangers which 
 may follow the use of stovaine alone. He considers spinal analgesia 
 absolutely safe, and free from all drawbacks and dangers. 
 
 Scopolamine Morphine Narcosis. — This method has been 
 strongly advocated by von Kronig.^ He injects during labour 200 
 to 6^5 grain scopolamine with J grain morphine and repeats the 
 scopolamine at intervals depending upon the result obtained. In 
 successful cases the patient passes into a condition of " Dammer- 
 schlaf " or twilight sleep, and after a successful sleep of this kind 
 the patient awakes quite happy and declaring that she has felt 
 nothing. The dosage is determined by the test of the patient's 
 consciousness. It is sufficient if the interruption of her mental 
 associations is so complete that sensation disappears with sufficient 
 rapidity from the memory. According to von Kronig the duration 
 of the labour is not increased, the risk to the mother is practically 
 7iil, and there is no evidence of any increased risk to the children. 
 A. Bertins^ from an experience of 400 cases urges caution in the 
 use of this method. In 36 per cent, of the cases no analgesia 
 resulted, while in 38 cases the regularity of the uterine contractions 
 was lessened, leading to delay or suspension of the j)ains, and to 
 the death of the foetus through prolonged labour and weakening of 
 muscular power. No doubt in cases where the patient can be kept 
 
 1 Hahn, " Ueber subarachnoideale Cocaininjectionen nach Bier," Centralbl. f. d. 
 Grenzgebiete der Med. u. Chir., 1901, IV. 304—317 and 340—354. 
 
 2 A. E. Barker, Brit. Med. Journ., 1908, Vol. II. ; Lindenstern, Beitrag z. Klin. 
 Chir. Tubingen, January, 1908 ; P. Hardruin, Archiv gen. de Chinargie, August, 1908 ; 
 Therapeutic Gazette, August, 1907 ; Jonnesco, Brit. Med. Journ., November 13, 1909, 
 p. 1396. 
 
 8 Von Kronig, Deutsch. Med. Wochsch., June, 1908. 
 
 ^ A. Bertins, Journ. Americ. Med. Assoc. January 11, 1908. 
 
Manag-ement of Normal Labour. 319 
 
 under skilled observation the method may be of value, but it is 
 hardly suited for ordinary practice. 
 
 Maternal Mortality in Childbirth. — Statistics relating to this 
 subject are in this country extremely scanty, and it is difficult to 
 arrive at any exact conclusions. From hospital statistics Matthews 
 Duncan^ estimated the death-rate as about 1 in 120. Among the 
 105,749 confinements of married women occurring during the three 
 years 1894 — 1896 in New South Wales there were 714 deaths, or a 
 death-rate of 1 in 148. From the data collected by Coghlan in 
 connection with these figures it appears that the risk to the mother 
 is greater at the first birth than at any subsequent one up to the 
 ninth, the minimum risk being met with at the fourth. The risk 
 attendant on a first birth is at a minimum at the ages of twenty- 
 two or twenty-three years, when it is 0"0068. as compared with 
 0*028 at the age of thirty-nine. 
 
 The risk for unmarried women in childbirth is greater at every 
 age than in the married, the disproportion in the risk being 
 greatest at the lower ages. In Saxony during the years 1883 — 1890 
 for every 10,000 children born there died 66*6 mothers, or a 
 mortality rate of 1 in 166. 
 
 During the ten years 1894 — 1903 in the Rotunda Hospital, 
 Dublin, of 15,205 labours in the intern maternity department 
 56 mothers died, or 0*36 per cent.^ During the same time of 
 14,818 cases in the extern department 38 mothers died, or 0*25 per 
 cent. ; a total death-rate of 94, or 0*27 per cent., in 30,023 confine- 
 ments. In the same ten years in England and Ireland of 
 10,290,289 confinements there died 50,877 women, or a death-rate 
 of 0'49 per cent. 
 
 Fcetal Mortality. — Of 2,060,657 children born in Germany 
 during the year 1900, 64,518 in all, including premature births, 
 were born dead, or 3*1 per cent. In the ten years 1893 to 1902 
 in Hamburg there were registered 236,050 births. Of these 223,390 
 were vertex presentations with a death-rate of 2 per cent. ; 885 face 
 presentations with a death-rate of 13 per cent. ; 7,066 breech 
 presentations with a death-rate of 22 per cent. ; and 1,640 trans- 
 verse presentations with a death-rate of 38*9 per cent. The foetal 
 
 1 Matthews Duncan, On the Mortality of Childbed and Maternity Hospitals, Edin., 
 1870; Schultze, von Winckel, Handbuch der Geburtshtilfe, Vol. II., Part 3, s. 1683 ; 
 Still Births in England and other Countries, Government Return, 1893 ; Report on 
 the Decline of the liirth Rate and Mortality of Infants in New South Wales, Sydney, 
 1904. 
 
 2 Jellett, Manual oi Midwifery, 19U5, p. 297. 
 
320 The Practice of Midwifery. 
 
 death-rate in lying-in hospitals, owing to the large percentage of 
 primiparae, and the number of complicated cases admitted, is con- 
 siderably above that for the country as a whole ; thus in the Charite 
 Hospital, Berlin, between 1884 and 1901 the foetal death-rate was 
 6*5 per cent. 
 
 In 10,803 births at the Kotunda Hospital 605 infants were 
 born dead, or 1 in 17*8 = 5*8 per cent., while 248 died in the 
 hospital, making a total number born dead or dying in hospital of 
 853,-1 in 12-5 = 8 per cent. 
 
 There is a higher percentage mortality among boys than girls, 
 and the death-rate of illegitimate is higher than tbat of legitimate 
 children. 
 
 The proportion of children dying during birth to those dying 
 during pregnancy is difficult to estimate, but in the three years 
 1899—1901, of 121,183, or 3*15 per cent., children born dead in 
 Prussia, 2*6 per cent, died during birth, and 0"5 per cent, were 
 dead before labour set in. 
 
Chapter XIV. 
 FACE PRESENTATIONS. 
 
 Although labour with face presentation cannot be regarded as 
 normal, yet, in the great majority of cases, it is completed naturally. 
 The mechanism of labour in face presentation has great analogy to 
 
 Fig. 199. — Presentation of the face at the pelvic brim in a position 
 intermediate between second and third. 
 
 that in the vertex presentation, and should therefore be considered 
 in close relation with it. 
 
 In face presentation, the head, instead of being flexed upon the 
 sternum, is extended, so that the occiput is reflected upon the back, 
 and the face and forehead form the presenting part (see Fig. 199). 
 The consequence is that the chest is thrown forward against the 
 uterine wall, and the back is separated from it. In face presenta- 
 tion, the action of the lever formed by the diameter of the head 
 which is thrown across the pelvis (see p. 247), acted on by the 
 resistance at its two extremities, is reversed. The fulcrum of the 
 lever is now formed by the point C (Fig. 201), where the line of 
 force, acting through the condyles, cuts the fronto-mental diameter, 
 
 M. 21 
 
322 
 
 The Practice of Midwifery. 
 
 F M. This fulcrum is now nearer, not to the posterior, but to the 
 anterior end of the lever (compare Fig. 201 with Fig. 155, p. 247). 
 The posterior arm of the lever is therefore the longest, and has the 
 mechanical advantage. The head therefore, instead of tending to 
 become flexed, becomes more and more extended, until the chin 
 becomes the most advanced point. 
 
 It follows that there must be some intermediate position of 
 partial extension in which the two arms of the lever are equal, and 
 their action balanced. From this position, if ever so little flexion 
 occurs, the anterior arm of the lever gets the advantage, flexion 
 
 Fig. 200. — Diagram of the head completely extended entering the pelvic inlet 
 with its vertico-mental diameter corresnonding to the axis of the pelvis. 
 (After Kaltenbach, Zeitsch. f. Geburts. n. Gyn., Vol. XXI.) 
 
 progresses, and ordinary vertex presentation results ; if ever so 
 little further extension occurs, the posterior arm of the lever gets 
 the advantage, extension goes on, and face presentation is produced. 
 This immediate position is called broiv presentation, the prominence 
 of the forehead being the presenting point, and the anterior 
 fontanelle and the root of the nose within reach at about equal dis- 
 tances in opposite directions. As it is thus a position of unstable 
 equilibrium, the head could never pass through the pelvis in brow 
 presentation, even if there were room for it so to pass. Generally 
 there is not room, the vertico-mental, or longest diameter of the 
 head, being thrown across the pelvis. The head may, however, be 
 arrested in a position of a brow j)resentation, though even this is 
 very rare ; and when this haj)pens, there is considerable difficulty 
 
Face Presentations. 
 
 323 
 
 in effecting delivery. As a general rule, brow presentations are 
 converted, not into vertex, but into face presentations. For there 
 must have been some cause leading to the partial extension, and 
 this will generally go on to j)roduce complete extension, the head- 
 lever no longer tending to counteract it. It is thus evident that all 
 cases of face presentation, except those existing during pregnancy, 
 must have passed through the stage of brow presentation, in their 
 deviation from the normal condition. 
 
 The rarer variety of primary face presentations in which the 
 extension of the head is undoubtedly present 
 before the onset of labour, as, for example, in 
 a case of congenital enlargement of the thyroid 
 gland, must be distinguished from secondary, 
 in which the extension of the head occurs after 
 the commencement of labour. 
 
 Frequency of Face Presentation. — The 
 
 frequency of face presentation is variously 
 estimated by different authors. The statistics 
 of the Guy's Hospital Lying-in Charity (out of 
 49,145 cases) give "33 per cent., or 1 in 303 ; 
 Churchill (out of nearly 250,000 cases collected) 
 gives the frequency as 1 in 231 ; Collins, for 
 the Piotunda at Dublin, as only 1 in 497 ; 
 Pinard, for the Maternite at Paris (out of 
 81,711 cases), as 1 in 225 ; Spiegelberg, from 
 German statistics, as 1 in 324. It appears, 
 therefore, that no uniform difference is pro- 
 duced by the dorsal position in labour generally 
 adopted on the Continent. 
 
 Fig. 201. — Diagram of 
 head-lever in face 
 presentation. 
 
 A C, axis of expul- 
 sive force passing 
 through condyles. 
 
 F M, frontal-men- 
 tal diameter of head. 
 
 C, fulcrum of lever. 
 
 Causation. — One of the causes which may tend to produce face 
 presentation is the peculiar shape of the child's head, namely, what 
 is called the dolicho-cephalic shape, in which the occiput projects 
 more than usual, and the posterior arm of the head-lever is there- 
 fore not so much as usual exceeded in length by the anterior in its 
 normal position (see Fig. 155, p. 247). There is no doubt that this 
 cause will tend to facilitate face presentations, if it exists, but it is not 
 positively decided whether it is, in point of fact, a cause commonly 
 in operation. Budin,'- measuring the shape of heads born in face 
 presentations, found that, after the moulding of labour had passed 
 off, they were not dolicho-cephalic. Hecker,^ on the contrary, who 
 
 ' " Do la Tete du F«;tus au point de vue de FObstetrique." 
 ''■ " Ueber die Schadelform bei Gesichtslagen." 
 
 21—2 
 
324 
 
 The Practice of Midwifery. 
 
 attaches much hnportance to this shape of the child's head, has 
 reported instances in which the elongation of the occiput did 
 persist after delivery. It is clear, however, that this cause is not 
 sufficient by itself, as the anterior arm of the lever is always longer 
 than the posterior. 
 
 Some forms of foetal monstrosity produce a face presentation 
 during pregnancy, persisting in labour. The chief of these are 
 the anencephalic foetus, and the foetus deformed by tumour of the 
 thyroid gland. 
 
 Any accidental cause leading to a partial extension may produce 
 
 Fig. 202. — Diagram to show the effect of obliquity of the uterus in causing face 
 
 presentations. 
 
 face presentation, since the resistances will complete the extension, 
 if once it has passed beyond the neutral point of unstable equi- 
 librium (or brow presentation). Such a partial extension may 
 arise from a sudden gush of profuse liquor amnii, which is present 
 in 30 per cent, of all the cases, or from an oblique position of the 
 child in the uterus at the time when the membranes rupture. 
 This is more likely to happen when the child is dead, for then there 
 is not the tonicity of flexor muscles which maintains the chin-flexion, 
 as well as flexion of limbs, in the usual attitude of the foetus. Even 
 a want of tone of flexor muscles in a living child may promote it. 
 Face presentation is promoted by disproportion between the 
 
Face Presentations. 325 
 
 head and the pelvis, which occurs in some 28 to 30 per cent, of the 
 cases, for i£ the head is detained above the brim, displacement is 
 more readily produced by any cause. A particular form of pelvic 
 deformity may actually cause it, namely, the generally flattened or 
 elliptic pelvis,^ not specially contracted in the conjugate diameter. 
 The chief resistance may then be at the ends of the bi-parietal 
 diameter, especially if the head has prominent and firmly ossified 
 parietal tubera, instead of at the ends of the long antero-posterior 
 diameter, or that opposed to the conjugate of the pelvis, which is 
 generally nearly the bi-temporal diameter. In such case, the 
 resultant of the resistances may fall posterior to the condyles 
 instead of in front of them, and then more or less extension will be 
 produced, the descent of occiput being more resisted than that of 
 the front part of the head. 
 
 A cause of face presentation which is now generally considered 
 to be one of the most important is obliquity of the uterus, and 
 therefore of the propelling force, and this is a cause which may be 
 combined with any of the others. For suppose the fundus uteri 
 to be inclined to the right side, and the child to be lying with its 
 back toward the right, that is, in the second or third position. 
 The propelling force is then inclined toward the left, and therefore 
 tends to push the condyles in that direction, or toward the face of 
 the child. The head is thus pressed against the left pelvic wall, 
 and the reaction of the pelvic wall forms a force tending to push 
 in the opposite direction (that is, toward the right side of the 
 pelvis, and toward the occiput of the child) either the forecoming 
 part of the head, if the head is not fully engaged in the pelvis, 
 or the centre of the head, if it is engaged. In either case, there 
 is thus produced what in mechanics is called a " couple," that is a 
 pair of equal forces acting in opiDosite directions, but in parallel, 
 not in the same straight lines (Fig. 202).^ The tendency of this 
 pair of forces is not to move the centre of the head, but to rotate 
 it on a transverse axis, so as to produce extension. If the obliquity 
 of the propelling force is considerable, this effect may overcome 
 the forces tending to produce flexion, and so lead to fa,ce presenta- 
 tion. Similarly, an obliquity of the uterus toward the left side 
 tends to produce extension when the back of the child lies toward 
 the left, that is, in the first and fourth positions. 
 
 1 See Chapter XXIX. 
 
 2 Each of the forces forming the couple is equal to the component of the propelling 
 force resolved (by the piirallelogram of forces) perpendicularly to the axis of tlie pelvis. 
 The oblique propelling force, together with the reaction of the lateral pelvic wall, is 
 equivalent to a force acting in tiie axis of the pelvis, tending to produce onward move- 
 ment, and the couple, tending to produce rotation on a transverse axis, that is, 
 extension. 
 
326 The Practice of Midwifery. 
 
 Statistics afford some evidence that this cause is actually in 
 operation. For in vertex presentation left dorsal positions pre- 
 dominate in the proj)ortion of about three to one, but in face 
 presentations only in the j)roportion of about four to three. It 
 must be inferred that a face presentation is much more easily 
 developed out of a vertex when the back of the child lies to the 
 right. This is explained by the usual obliquity of the fundus uteri 
 toward the right side. 
 
 A sudden reversal of the lateral obliquity of the uterus will 
 have a much greater effect than a persistent obliquity. Suppose 
 the woman to be lying on the left side, and the fundus uteri 
 to be inclined toward the left in consequence, the child lying 
 in the second j^osition, with its face to the left. If the jDosition 
 of the child's head corres^Donds to that of its trunk, lying in the 
 axis of the uterus, the occiput will then be tilted to the right, 
 and the face will be more inclined over the brim than usual. 
 Suppose that she then turns to the right side, causing a right 
 lateral obliquity of the uterus and of the trunk of the foetus, 
 and that a pain comes on at that moment. The foetal head will 
 probably not at once accommodate itself to the position of the 
 trunk, and will be in a position of partial extension ; while the 
 uterine contraction will produce a pair of forces tending to cause 
 further extension. 
 
 An anterior or posterior obliquity of the uterus acts in a similar 
 way to a lateral obliquity. A posterior obliquity of the uterus, in 
 reference to the axis of the brim, which in some degree is probably 
 a normal condition (see p. 235), tends to cause extension in occii^ito- 
 posterior positions (third and fourth), an anterior obliquity (such as 
 occurs from pendulous abdomen) in occipito-anterior positions (first 
 and second). Here again we find that third and fourth positions 
 are relatively commoner in face than in vertex presentations, while 
 posterior obliquity of the uterus is more usual than anterior, and 
 thus the theory of causation by obliquity of propelling force is again 
 confirmed. This view is strengthened by the fact that face presen- 
 tations recur in the same patient in about 8 per cent, of the cases.^ 
 
 Varieties of Face Presentations.— In face, as in vertex presen- 
 tation, there are four positions, each of which is developed out of 
 the corresponding position of the vertex by extension of the head. 
 It is usual to name them from the position of the chin {e.g., left 
 mento-anterior). 
 
 The four following will then be the positions of the face : — 
 First or Right Mento-jJosterior, R. M. P. — The long diameter of 
 1 Wullstein, Die Gesichtslage, I. Dissert., Berlin, 1891. 
 
Face Presentations. 
 
 327 
 
 the head approximates towards the right oblique diameter of the 
 pelvis. The chin points toward the right sacro-ihac articulation, 
 the forehead toward the left foramen ovale. 
 
 Second or Left Mento-posterior, L. M. P. — The long diameter of 
 the head approximates toward the left oblique diameter of the 
 pelvis. The chin points toward the left sacro-iliac articulation, 
 the forehead toward the right foramen ovale. 
 
 Third or Left Mento-anterior, L. M. A. — The long diameter of the 
 head approximates toward the right oblique diameter of the pelvis. 
 The chin points toward the left foramen ovale, the forehead 
 toward the right sacro-iliac articulation. 
 
 Fourth or Right Mento-anterior, K. M. A. — The long diameter of 
 the head approximates toward the left oblique diameter of the 
 
 Fig. 203.— Rotation of chin under pubic arch in face presentation. 
 
 pelvis. The chin points toward the right foramen ovale, the fore- 
 head toward the left sacro-iliac articulation. 
 
 As in the vertex positions, the first and third and the second and 
 fourth are the reverse of each other. The first position is still the 
 commonest, but only in slight proportion. The fourth is relatively 
 not so rare as in vertex presentations. The reason for the differences 
 has already been explained. 
 
 In comparing any position with the corresponding position of 
 the vertex, it must be noted that the words right and left, anterior 
 and posterior, are reversed, because the face position is named by 
 its anterior extremity, the vertex by its posterior. Thus the first 
 vertex position, or left occipito-anterior, becomes by extension the 
 first face position, or right mento-posterior. It will be seen shortly, 
 
328 
 
 The Practice of Midwifery. 
 
 however, that the right mento-posterior position of the face corre- 
 sponds mechanically to the right occipito-posterior or third position 
 of the vertex, the chin being the most prominent part of the one, 
 the vertex of the other. Similarly for the other three positions. 
 
 Mechanism of Labour in Face Presentation. 
 
 The mechanism of the passage of the head will first be described 
 for the case in which the face lies in the first or right mento- 
 posterior position. As in the case of the vertex, five principal 
 subsidiary movements take place in conjunction with the movement 
 
 "^-v. 
 
 Fig. 204. — Distension of intact perineum in face presentation. Tlie elongation 
 of occiput produced by protracted labour is also shown. B. Bladder. 
 2 S. Second sacral vertebra. R. Rectum, a. Anus. /. Fourchette. 
 m: Orifice of urethra. (After Schroeder.) 
 
 of descent of the centre of the head along the curved axis of the 
 pelvis. These are enumerated as follows : — 
 
 Extension. 
 Internal Kotation. 
 Descent -i Flexion. 
 
 Eestitution. 
 ^ External Rotation. 
 
 Extension.— It has already been explained that the posterior 
 arm of the head-lever, instead of the anterior, is now the longest. 
 The resistances therefore produce progressive extension instead of 
 
Face Presentations. 
 
 329 
 
 flexion, the resistance to the forehead having the mechanical 
 advantage over that to the chin, until the chin becomes the most 
 advanced point, and extension is at last checked by the occiput 
 being compressed against the back (see Fig. 201, p. 823). Not only 
 the action of the head-lever, but the shape of the presenting part, is 
 the reverse of that in vertex presentations. The anterior extremity, 
 the chin, instead of the posterior, is now the most jDrominent and 
 projecting part, the forehead being more gradually rounded. Hence 
 the chin in face presentation corresponds mechanically to the occiput 
 in vertex presentation. When the face is lying over a not quite 
 fully expanded os uteri, this shape of the presenting part also 
 
 Fig. 205. — Passage of the head under the pubic arch by a movement of flexion 
 in face presentation. 
 
 favours extension, just as the shape of the vertex favours flexion in 
 vertex presentations (see pp. 248, 249). 
 
 Internal Rotation. — The chin, descending in advance of the 
 forehead, is the first to meet the resistance of the inclined plane 
 formed by the soft parts at the posterior part of the pelvic floor 
 (see Fig. 132, p. 221), and by it is pushed forward into the free 
 space under the pubic arch, just as the occiput is usually pushed 
 forward in occipito-posterior positions. The chin then comes to 
 be directed almost exactly forward, as shown in Figs. 204, 205. 
 Thus the internal rotation takes place through nearly three-eighths 
 of a circle. The first position of the face corresponds mechanically 
 to the third position of the vertex, and is converted into the fourth 
 
330 
 
 The Practice of Midwifery. 
 
 position of the face by a loufi rotation, just as the third of the 
 vertex is converted into the second. Like the occiput in occipito- 
 posterior positions, the chin may be rotated forward either early or 
 late, but more frequently late. Early rotation, when it occurs, is 
 due to the pressure of the upper part of the elastic pelvic floor. 
 When extension is incomplete, rotation is more likely to be delayed ; 
 and for a time, in the earlier part of its descent, the chin may be 
 rotated somewhat backward, in consequence of the screw-like 
 
 Fig. 206. — Arrest of head, neck, and shoulders in plane of brim in persistent 
 mento-posterior presentation. 
 
 shape of the bony pelvis, the posterior inclined plane of the 
 ischium directing the chin backward, if the presenting part fits 
 tightly. 
 
 It hardly ever happens that the chin remains posterior like the 
 occiput in unreduced occipito-posterior positions. It is scarcely 
 possible for the head to be delivered spontaneously in this way, 
 unless it is excessively small in relation to the genital canal, or the 
 perineum extremely deficient, because, in order that the chin might 
 escape over the anterior margin of the perineum, it would be 
 
Face Presentations. 331 
 
 necessary for the neck and shoulders of the fcetus to enter the cavity 
 of the pelvis at the same time as the head, which in a normal-sized 
 pelvis is impossible unless the child is very small. Sometimes, 
 however, a small head may be delivered artificially in this position, 
 the chin being hooked over the perineum. Sometimes the rotation 
 only occurs just as the face passes the outlet, and the chin may 
 then escape almost in a lateral position, the internal rotation being 
 incomjjlete. 
 
 The mechanism of the second position of the face corresponds 
 exactly to that of the first, right and left being interchanged. In 
 the third position the chin has only to rotate through about one- 
 eighth of a circle, until it is directed nearly forward, and the 
 mechanism corresj)onds to that of the first position of the vertex, 
 a short rotation occurring in each case. In this case, the inclined 
 plane of the pelvic floor guides the chin forward in the earlier part 
 of the descent of the head. The mechanism of the fourth position 
 corresponds to that of the third, right and left being inter- 
 changed. It is equivalent mechanically to the second position of 
 the vertex. 
 
 Flexion. — The fore-coming part of the head is pushed forward 
 as soon as it meets the inclined plane at the floor of the pelvis. 
 The after-coming part of tlie head is prevented from moving 
 forward by the resistance of the pubes, and by its attachment to 
 the neck. Hence, since the front of the child is now directed 
 forward, the chin either having rotated forward, or being anterior 
 from the first, a movement of flexion is produced, as at the 
 termination of unreduced occipito-posterior positions of the vertex 
 (see p. 260). The chin escapes under the pubic arch, while first the 
 forehead and then the bregma and occiput pass over the perineum 
 (Fig. 205, p. 329). The forehead moves faster than the chin, 
 having to go along the outside of the curve, while the chin moves 
 along the inside, but the chin is not arrested. The greatest 
 diameter of the foetus opposed to any antero-posterior diameter of 
 the genital canal is one which passes through the posterior part of 
 the head behind the anterior fontanelle, since in this the thickness 
 of the neck has to be included (see Fig. 204, p. 328). 
 
 Restitution. — As in vertex presentations, as soon as the head is 
 released the face generally turns again towards the side which it 
 originally occupied to accommodate itself to the position of the 
 slioulders. 
 
332 
 
 The Practice of Midwifery. 
 
 External Rotation. — As the shoulders rotate m then- passage 
 through the pelvis, and their bis -acromial or transverse diameter 
 turns into the antero-posterior diameter of the pelvic outlet, the 
 
 r.mii 
 
 Fig. 207. — Diagram of mechanism of labour in face presentation. (For 
 
 explanation of general scheme of diagram, see Fig. 159.) < = fronto- 
 
 mental diameter of face, semicircle = chin ; \— = bis-acromial 
 diameter of shoulders ; short limb = right shoulder ; i., r.m.p. , first face, 
 fr. ment. diam. in rt. obliq. diam., bis-acr. diam. in left oblique ; 
 ii., internal rotation of chin through \ of circle forwards ; iii., further 
 rotation of chin, and conversion into fourth face presentation ; iv., chin 
 rotated under symphysis pubis ; v., face born by movement of exten- 
 sion, chin leading: vi., restitution, movement of chin toM^ards original 
 direction; vii., external rotation of face with internal rotation of 
 shoulders ; viii., birth of shoulders, right shoulder leading. 
 
 rotation of the face takes place still further in conformity with the 
 rotation of the shoulders, so that in the first and fourth presenta- 
 tions it looks towards the right thigh, and in the second and third 
 towards the left thigh, of the mother. 
 
Face Presentations. 
 
 333 
 
 Lateral Obliquities in Face Presentation. — Lateral or Naegele- 
 obliquity of the head is not so often observed in face as in vertex 
 presentation, because the large bi-parietal diameter is now situated 
 nearer to the after-coming than to the fore-coming part of the 
 head. It may, however, occur in some cases where labour is 
 difficult, or the pelvis contracted, especially when posterior obliquity 
 of the uterus, in reference to the axis of the brim, exists, and the 
 anterior side of the face then becomes deepest in reference to the 
 
 Fig. 208. — Successive stages of first, or right mento-posterior, position of face. 
 
 plane of the brim. In the later stage, the chin-flexion of the head, 
 on approaching the outlet, is accompanied by some lateral flexion 
 toward the anterior shoulder, just as the extension of the head is, 
 in vertex presentations, toward the outlet of the canal of soft parts 
 (see p. 265), and for the same reason. 
 
 Contrasts between the Mechanism of Face and Vertex 
 Presentations. — It will thus be seen that while the mechanism of 
 delivery in face and vertex presentations is closely analogous in many 
 respects, it is contrasted in the following particulars : — In face 
 
334 
 
 The Practice of Midwifery. 
 
 presentation extension takes the place of flexion in the earlier stage, 
 and flexion takes the place of extension in the later stage. In 
 vertex presentations, the commoner positions, the occipito-anterior, 
 are the more favourable, a short rotation only being required ; in 
 face presentations, the commoner positions, the mento-posterior, 
 
 ^'m.-il. 
 
 Fig. 209. — Diagram of mechanism of labour of second face presentation, 
 showing its conversion into the third face, and the mechanism of the 
 latter. (Symbols as in Fig. 207.) 
 
 are the less favourable, a long internal rotation being required. In 
 vertex presentations, the first and second positions remain un- 
 changed ; the third and fourth are generally converted into the 
 second and first respectively. In face presentations, the first and 
 second positions are almost invariably converted into the fourth and 
 third respectively ; the third and fourth remain unchanged. 
 
 Descent is accompanied by extension and internal rotation till 
 
Face Presentations. 
 
 335 
 
 the chin is beginning to approach the pubic arch. Then flexion is 
 substituted for extension ; and descent, internal rotation, and flexion 
 
 Fig. 210. — Moulding of head in face presentation. The continuous outline 
 shows the head before moulding. (After Budin.) 
 
 Fig. 211. — Moulding of head in face presentation. The continuous outline 
 shows the head before, the dotted line after, moulding. F 0, fronto-occi- 
 pital diameter ; M 0, mento-occipital ; SO — B, sub-occipito-bregmatic, 
 (After Budin.) 
 
 go on together till the head has escaped at the vulva. Then 
 external rotation is substituted for its opposite, internal rotation. 
 The successive stages of a mento-posterior position are shown in 
 Fig. 208 (p. 333). 
 
33^ 
 
 The Practice of Midwifery. 
 
 Caput Succedaneum in Face Presentation. — The swelling 
 upon the presenting part is often very considerable in face presenta- 
 tion, labour being generally more protracted than in vertex pre- 
 sentation. The features thus become excessively distorted, the lips 
 being enormously swollen, and the eyelids also swollen so much that 
 the eyes are closed at birth. There may be also effusion of blood 
 in the conjunctivae. While the chin is posterior, the centre of the 
 caput succedaneum formed is near the eye ; in mento-anterior 
 positions, or after rotation of the chin forward, it is at the lower 
 
 Fig. 212. — Face presentation; «, first position; 5, second position. 
 (Farabeuf and Varnier.) The arrow indicates the line of forward 
 rotation. Patient in usual obstetric position. 
 
 part of the cheek near the angle of the mouth, 
 features passes off in a few days. 
 
 The swelling of the 
 
 Moulding of the Head in Face Presentation. — The moulding 
 of the head in face presentation is shown in Fig. 211, taken from 
 Budin's measurements. The convexity of the frontal and occipital 
 bones is increased, while the parietal bones are flattened, so that 
 the curvature of the sagittal suture is diminished. The squamous 
 portion of the occipital bone is rotated backward, so that the 
 occipital protuberance becomes unusually prominent. The chief 
 diminution is in the vertical or cervico-bregmatic, and in the sub- 
 occipito-bregmatic diameters (s.o. — b) ; the compensatory increase 
 is chiefly in the fronto-occipital diameter (f o), but there is slight 
 increase also of the mento-occipital (m o). Fig. 204 (p. 328) also 
 
Face Presentations. 
 
 337 
 
 shows the relation which the moulding of the head has to the 
 pressure of the genital canal. The prominence at the anterior part 
 of the forehead (shown in Fig. 210), generally seen after face pre- 
 sentation, does not seem easy to account for, except on the view 
 that it is formed when the case is going through the stage of brow 
 presentation, at which time the forehead is the most unsuj^ported 
 part. The extension of the head of the foetus on the trunk some- 
 times persists for several days after birth. 
 
 Diagnosis. — The face may be distinguished from the vertex, even 
 before the rupture of the membranes, by the unevenness of the 
 
 Fig. 21.3. — Face presentation; a, third position; &, fourth position. 
 (Farabeuf and Varnier.) The arrow indicates the line of forward 
 rotation. Patient in usual obstetric position. 
 
 features, compared with the uniform hardness of the cranial bones. 
 As a rule, however, a face presentation is not fully developed until 
 the membranes have ruptured, and the resistance comes into play. 
 Whenever there is even a suspicion that the face is presenting, the 
 utmost care and gentleness must be used in vaginal examination, to 
 avoid the risk of injuring the eyes. The diagnosis of face presenta- 
 tion by abdominal palpation has already been described (p. 273). 
 When the head is high up, and the chin directed backwards, the 
 back of the head, and the depression between it and the child's 
 back, may be made out a little above the brim towards one side of 
 the front of the pelvis, especially if bimanual examination is 
 employed. The fcetal heart will be heard most distinctly on the 
 M. 22 
 
338 
 
 The Practice of Midwifery. 
 
 same side as that on which the limbs are felt, instead of on the 
 opposite side, as in vertex presentations (see p. 275). Cases of face 
 presentations have been recorded in which the pulsations of the 
 foetal heart have been felt through the mother's abdomen.^ 
 
 The only other part which might possibly be mistaken for the face 
 on vaginal examination is the breech. The distinctive points to be 
 
 sought for on the face are the 
 root of the nose, the openings 
 of the nostrils, the hard, 
 toothless, alveolar ridges in 
 the mouth, and the chin. In 
 the breech, the anus, grasping 
 the finger with its sphincter, 
 the bony prominences of the 
 sacrum, and the presence of 
 thick meconium, undiluted 
 with liquor amnii, are dis- 
 tinctive. 
 
 Prognosis in Face Pre- 
 sentation. — The prolongation 
 of labour common in face 
 presentation renders the prog- 
 nosis much more unfavour- 
 able for the child than in 
 vertex presentation. Thus, 
 in 166 cases of face presenta- 
 tion in the Guy's Hospital 
 Lying-in Charity, the propor- 
 tion of children still-born was 
 ^^^^ 8'4 per cent. In vertex pre- 
 
 FlG.2U-Lmeof section and shape of the ggntations during the same 
 mento-vertical plane. (Edgar, from _ . . 
 
 lead-tape tracings, Practice of Obstetrics, time, the proportion of children 
 
 ^^' '-^ still-born (including premature 
 
 children) was only 2-7 per cent. Out of these 166 cases of face 
 presentation, artificial delivery was found necessary in seven. One 
 child was delivered by version, four by forceps, two by the cepha- 
 lotribe. All of the mothers recovered. It is generally considered, 
 however, that in face presentation the prognosis for the mother is 
 also somewhat more unfavourable than in vertex presentation, but 
 the difference is not nearly so great as in the case of the child. 
 
 1 Fischel, Prag. Med. Wochsenschr., 1881, No. 12 ; Duval, Johns Hopkins Hospital 
 Bulletin, October, 1897, p. 207. 
 
Face Presentations. 339 
 
 In reference both to mothers and children, it is to be remembered 
 that the pelvis is more often contracted in face than in vertex 
 presentation. According to Hecker/ the maternal mortality is 
 3'7 per cent., and the foetal 8'7 per cent. 
 
 Brow Presentation. — It has already been mentioned that 
 brow presentation constitutes the position of unstable equilibrium, 
 in which the two arms of the head-lever exactly balance each 
 other, so that the propulsive force has no tendency to produce 
 either flexion or extension (see p. 323). The prominence of the 
 forehead forms the centre of the presenting part, and the anterior 
 fontanelle can generally be reached in one direction, the nose or 
 even the chin in the other. The large mento-occipital, or even 
 the maximum vertico-mental (see p. 132) diameter of the head, is 
 thrown almost exactly across the pelvis. This is generally too 
 large for the pelvis to admit, and hence it is usually only when 
 the head has not yet fully entered the brim that brow presenta- 
 tion is observed. In the unstable equilibrium of brow presentation, 
 if there is the slightest variation either in the degree of flexion of 
 the head or in the inclination of the propulsive force, the tendency 
 either to extension or flexion will begin to predominate. Hence 
 the head can never possibly pass through the genital canal in a 
 position of brow presentation, even if the pelvis is large enough to 
 admit the maximum vertico-mental diameter of the head. Almost 
 always the change is into face presentation, since the cause, what- 
 ever it may be, which has already produced undue extension, 
 generally goes on to produce complete extension into face pre- 
 sentation. I have known a case, however, in which the presentation 
 was partially converted into a face, and the chin rotated forward. 
 The vertex then came down, and the head was delivered in the 
 occipito-posterior position of the vertex. But though the head 
 never passes through the pelvis in a position of brow presentation, 
 it is sometimes, although rarely, arrested in that position, any 
 slight advantage which one or other arm of the head-lever may gain 
 at any time not being sufficient to overcome friction and move the 
 head. 
 
 Disproportion between the child and the pelvis, dorsal dis- 
 placement of the arm, premature rupture of the membranes followed 
 by the contraction of the uterus tightly round the trunk of the 
 taitu.8, are some of the conditions likely to lead to a persistence of 
 a brow presentation. 
 
 1 V. Hecker, " Statistiches aus der GebLirtenstalt Miinclien," Archivf. G^'niilc, 1882, 
 Bd. 20, s. 378. 
 
 22—2 
 
340 The Practice of Midwifery. 
 
 If a brow presentation remains unconverted, the prognosis is grave 
 both for the mother and the child, the maternal mortality being as 
 high as 5 per cent., and that of the children 20 to 30 per cent. 
 
 Out of 49,145 deliveries in the Guy's Hospital Lying-in Charity 
 brow presentation was observed in thirty cases. Of these twenty- 
 five were delivered spontaneously, the presentation being generally 
 converted into a face ; three children were delivered by version, 
 two by forceps. Thus the proportion of brow presentation was 1 
 in 1,638. 
 
 Moulding of the Head in Brow Presentation. — The general 
 character of the moulding produced in brow presentation is an 
 
 r 
 
 Fig. 215. — Moulding of head in brow presentation. 
 
 exaggeration of that seen in face presentation (Fig. 210, p. 335). 
 In brow presentation the whole of the forehead becomes more 
 convex and prominent, instead of merely its anterior part. The 
 flattening of the parietal bones along the line of the sagittal suture 
 is carried much further than that shown in Fig. 210, and so also 
 is the prominence and convexity near the occipital protuberance. 
 A large caput succedaneum is generally formed, having its centre 
 near the prominence of the forehead. 
 
 Treatment of Face Presentations. — The first point to be 
 regarded is to keep the membranes intact as long as possible. 
 The reason for this is, first, that the face does not form so good 
 a dilator of the soft parts as the vertex ; and, secondly, that it is 
 more liable than the vertex to injurious results from pressure. 
 
Face Presentations. 341 
 
 Most frequently, however, face presentation is only discovered after 
 rupture of the membranes. 
 
 In the latter stage, the general principle is to leave the case 
 as much as possible to nature, and to be content to allow the 
 labour to be more protracted than in vertex presentation. It 
 was formerly recommended either to perform version, or to 
 attempt to convert the face into a vertex presentation. To the 
 latter plan it is a great objection that if the attempt only 
 partially succeeds, as is very probable, the head is brought into 
 the more unfavourable position of brow presentation. That 
 interference is generally quite unnecessary is proved by the 
 statistics of the Guy's Hospital Lying-in Charity already quoted, 
 in which nearly 96 per cent, of the cases were terminated 
 naturally. This is a larger proportion than, in the present day, 
 is generally allowed to be terminated without assistance in vertex 
 presentation. 
 
 Before the rupture of the membranes, indeed, an attempt may 
 safely be made to rectify the position of the child by external 
 manipulation, if its exact position can be positively made out, and 
 especially if the occiput can be felt above the brim. In face 
 presentation the chest is thrown forward against the uterine wall, 
 while the shoulders are separated from it, at the opposite side of 
 the uterus, by a space posterior to the child. The method to adopt, 
 therefore, is to press with the fingers of one hand through the 
 abdominal and uterine walls upon the chest, directing it towards 
 the back of the child, and somewhat upwards as regards the uterine 
 axis, until the shoulders and back are brought against the uterine 
 wall, and the head thereby necessarily flexed. At the same time, 
 the other hand makes counter-pressure uj)on the occiput, felt above 
 the brim, directing it toward the front of the child and downward. 
 Schatz ^ recommends the counter-pressure to be made upon the 
 breech, directing it toward the front of the child, but such pressure 
 would, if anything, tend to lower the chin rather than to raise it. 
 This method of replacement is likely to be j^i'acticable only if the 
 chin is directed forward or to one side, not if it is directed much 
 backward, because then the surface of the uterus corresponding to 
 the chest of the child cannot be reached. 
 
 In these circumstances it has been recommended by Thorn and 
 others to introduce the hand into the uterus and, by pressure first 
 on the forehead and then on the face, to attempt to convert the 
 presentation into an occiput, the other hand being employed to 
 press on the occiput through the abdomen, and an assistant at the 
 
 '^ "Die Urnwandlung von Gesichtslage," Arcli. i'iir (Jjnak., B. V., p. 313. 
 
342 The Practice of Midwifery. 
 
 same time making pressure on the child's chest.-"- When we 
 remember, however, the very high percentage of natural deliveries 
 in face presentations we shall be very loth to interfere. 
 
 Management of Mento-posterior Positions. — The management 
 of mento-posterior positions precisely corresponds mechanically to 
 that of occipito-posterior positions of the vertex. If the rotation 
 forward of the chin does not readily take place, it is to be aided 
 indirectly by promoting extension, just as the rotation of the 
 occiput forward is aided by promoting flexion. This is to be done 
 chiefly by pressing the forehead upward and somewhat backward 
 during a pain. From time to time also, the chin may be drawn 
 downward and somewhat forward by two fingers hooked over it 
 in the interval of pains. 
 
 Extension may also be favoured by placing the woman on her 
 left side, in the first and fourth positions, when the child's back is 
 toward the left, and on her riglit side, in the second and third 
 positions, when the back is toward the right. For suppose the 
 child in the second or left mento-posterior position of the face 
 (see Fig. 199, p. 321), and the woman placed on her right side. 
 The breech tends to fall over toward the right, and the expulsive 
 force therefore becomes directed somewhat obliquely toward the 
 anterior end of the head-lever, and toward the left side of the 
 mother. Thus the anterior arm of the head-lever is shortened, 
 and the posterior increased. This increases the mechanical advan- 
 tage which the resistance to the forehead has over the resistance 
 to the chin (see Fig. 201, p. 323). Another plan may be tried 
 before recourse is had to instrumental delivery. The whole hand 
 is introduced into the vagina, the fingers on one side of the face, 
 the thumb on the other. The head is thus grasped and the chin 
 rotated to the front under an anaesthetic. If this method fail, an 
 attempt may be made to rotate the chin to the front with the help 
 of the vectis (see Chap. XXXIII.). 
 
 Treatment of Protracted Labour in Face Presentation. — If the 
 chin is directed forward, forceps may be applied without hesitation 
 if there is indication for their use. If, however, the chin is directed 
 backward or to one side, there is the disadvantage that one blade 
 is apt to compress the larynx or trachea, and the child's life is then 
 likely to be sacrificed. Under these circumstances, therefore, more 
 patience should be exercised than in vertex presentations. The 
 foetal heart should be carefully watched, and on the first appearance 
 
 1 Thorn, Zeitschr. f. Geb. u. Gyniik., 1895, Bd. 31, s. 1. 
 
Face Presentations. 343 
 
 of any danger to the life of the mother or of the child artificial aid 
 should be given. If the head is sufficiently high in the pelvis, 
 an attempt may be made to convert the presentation into a vertex, 
 after the method recommended by Thorn, or rotation of the chin 
 forwards may be carried out either manually or by the use of the 
 vectis. When the head is high up, the uterus not firmly con- 
 tracted, and especially when there is any contraction of the 
 conjugate diameter of the pelvis, version may be preferred. 
 Otherwise extraction by forceps, preferably by axis traction forceps, 
 should be tried, and if this does not succeed, then as a last resource 
 craniotomy must be performed. 
 
 Some operators have practised pubiotomy or symphysiotomy 
 in these cases, but since the life of the child has generally been 
 endangered by attempts at delivery, such a procedure could hardly 
 ever be justifiable. 
 
 Of 75 cases of mento-posterior presentations collected by Reed, 
 eight of the mothers died and 30 of the children. In 29 of these cases 
 rotation was effected either manually or after the application of the 
 forceps, in 14 the presentation was successfully converted into 
 a vertex, and in 31 the child was delivered with the chin remaining 
 posterior by the use of the forceps. In 14 of the cases, however, all 
 other means failed and craniotomy had to be performed. 
 
 Treatment of Brow Presentation. — Since by far the greater 
 number of brow presentations end spontaneously by conversion 
 into face presentation, the physician may exercise a fair amount 
 of patience, to see what nature will do, so long as the mother's 
 condition is satisfactory and the foetal heart beating naturally. 
 As in the case of face presentation, extension will be aided if the 
 woman is placed on that side toward which the hack of the child 
 is directed; for the breech will fall over toward that side, the 
 propelling force will be directed somewhat obliquely toward the 
 front of the child, and so the anterior arm of the head-lever 
 (see Fig. 201, p. 323) will be shortened, and the posterior arm 
 lengthened. 
 
 The conversion will fail only when the advance of the head is 
 arrested. When it is so arrested,sufficient time should be allowed 
 for the head to become moulded, and then extraction by forceps 
 may be tried. As in face presentations, the most favourable case 
 for their use is that in which the chin is directed forward. In 
 some cases it may l^e possible to convert the case into one of vertex, 
 or of face presentation, by drawing down the occiput or the chin 
 by fingers or vectis, or by Thorn's method ; or if the head is high 
 
344 The Practice of Midwifery. 
 
 up, and the uterus not firmly contracted, version maybe performed. 
 Failing success by one or other of these means, the only resource 
 is craniotomy. 
 
 Of 191 cases of brow presentation collected by Heinricius, 45, or 
 23'5 per cent., of the children were born dead.^ 
 
 1 Reed, Amer. Journ. Obstet., 1905, Vol. LI., p. 615 ; Heinricius. Archiv. d'Obstetr. 
 et Gynec, 1885. 
 
Chapter XV* 
 
 PELVIC PRESENTATIONS. 
 
 In pelvic presentations the long axis of the child lies nearly in 
 the axis of the uterus, as in head presentations, but the head is 
 directed upwards instead of downwards. The primary form of 
 pelvic presentations, and that which is more frequently observed, 
 is breech presentation. In this the attitude of the child is generally 
 the same as in vertex presentation, all the limbs being flexed, and 
 
 Fig. 216. — First, or left sacro-anterior, position of the breech. 
 
 the feet close to the breech, or buttocks, which form the presenting 
 part, {Complete hreech) (see Fig. 216). It is much more common, 
 however, than in vertex presentation for the legs to be more or less 
 extended on the thighs, because there is not so much space for the 
 legs in addition to the breech in the lower segment of the uterus as 
 there is at the fundus. (See Fig. 218, p. 347.) Sometimes one or 
 both thighs become extended on the trunk after rupture of the 
 membranes, or when the bag of membranes is bulging through the 
 OS; either from the gush of liquor amnii, or from active movement 
 of the child. In this way is developed out of breech presentation a 
 
346 
 
 The Practice of Midwifery. 
 
 presentation of one or both knees (very rare), of one or both feet, 
 or of a knee and a foot. {Incomi^lete breech). This extension of thigh 
 is more likely to occur when the breech does not so fully occupy 
 the lower segment of the uterus, and when the liquor amnii is 
 relatively abundant. Hence foot or knee presentations, compared 
 with breech presentations, are relatively more frequent with pre- 
 mature children and twins. When the long axis of the child is 
 
 Fig. 217. — Foetus in utero with breech presentation. From a frozen section. 
 (Modified from Waldejer.) 
 
 oblique in the uterus, the breech being lower, one or both feet may 
 present at the os before rupture of the membranes, and the hands 
 may then sometimes be felt also. The frequency of pelvic presen- 
 tation is estimated at from 1 in 60 to 1 in 45 for mature children, 
 and at about 1 in 30 including all cases. Breech presentations form 
 about 60 or 65 per cent, of all pelvic presentations. The statistics 
 of Guy's Hospital Lying-in Charity give — pelvic presentations 1 in 
 38, breech presentations 1 in 58, foot or knee presentations 1 in 121, 
 
Pelvic Presentations. 347 
 
 breech presentations forming about 68 per cent, of all pelvic 
 presentations. 
 
 Causation of Pelvic Presentation. — The causation may depend 
 on anything which leads to the failure of the forces which generally 
 produce head presentation (see p. 140). Since the adaptation of the 
 child to the shape of the uterus is progressively greater as pregnancy 
 advances, pelvic presentation is commoner with premature children. 
 It is also commoner with multiple pregnancies, in cases of placenta 
 prsevia, with hydrocephalic children (see Fig. 100, p. 142), with 
 excess of liquor amnii, with premature and dead children, with 
 
 Fig. 218. — Breech presentation with extended legs. 
 
 tumours of the uterus, or with contraction of the pelvis, which 
 prevents the fixation of the head in its normal position. In the 
 case of dead children the effect is chiefly due to the failure of active 
 movements, which aid in adapting the position to the shape of the 
 uterus (see p. 142), but the less relative specific gravity of the head 
 in dead children has also been considered to have an influence. 
 Pelvic presentation is also promoted by laxity of the walls of 
 the uterus or abdomen, and is therefore relatively commoner in 
 multiparse. 
 
 Varieties of Breech Presentation. — There are four positions 
 in breech presentations, corresponding to the four positions of the 
 vertex. The dorso-anterior positions are the commoner, like the 
 
348 The Practice of Midwifery. 
 
 occipito -anterior positions of the vertex, and, like them also, 
 differ in the mechanism of their delivery from the dorso-posterior. 
 There is one difference, namely, that in the case of the breech, the 
 transverse or bis-iliac diameter, and not the antero-posterior, is the 
 longest, and tends to adapt itself to the longest diameter of the 
 pelvis. 
 
 First or left sacro-anterior (L. S. A.). — The sacrum looks toward 
 the left foramen ovale ; the bis-iliac diameter approximates toward 
 the left oblique diameter of the pelvis. 
 
 Second or right sacro-anterior {R. S. A.). — The sacrum looks 
 toward the right foramen ovale ; the bis-iliac diameter approximates 
 toward the right oblique diameter of the pelvis. 
 
 Third or right sacro-posterior {R. S. P.). — The sacrum looks 
 toward the right sacro-iliac articulation ; the bis-iliac diameter 
 approximates toward the left oblique diameter of the pelvis. 
 
 Fourth or left sacro-posterior (L. >S'. P.). — The sacrum looks 
 toward the left sacro-iliac articulation ; the bis-iliac diameter 
 approximates toward the right oblique diameter of the pelvis. 
 
 In each of these positions, assuming the position of the head to 
 be adapted to that of the trunk, the front and back of the head 
 look in the same directions as in the corresponding positions of the 
 vertex or face. The first position of the breech, as of the vertex, 
 is the commonest. This is due to the same cause. Owing to the 
 usual right torsion of the uterus (see p. 244), the large transverse 
 diameter of the uterus approximates toward the right oblique 
 diameter of the pelvis, and the large antero-posterior diameter of 
 the whole ovum most readily accommodates itself to this, the back 
 turning away from the prominent lumbo-sacral curve of the mother, 
 and so becoming anterior. This frequency of the first position in 
 breech presentation is a proof that the position depends at least as 
 much upon the accommodation of the whole ovum as upon that of 
 the presenting part in the i^elvis, since the long diameter of the 
 presenting part now occupies the left oblique diameter of the pelvis, 
 which is encroached upon by the rectum and sigmoid flexure. 
 Foot or knee presentation may arise out of any of the varieties of 
 breech presentation 
 
 Diagnosis. — On abdominal examination the round, smooth 
 mass of the head may be made out at the upper part of the uterus. 
 Unless the legs are extended, the fundus uteri is less broad than 
 usual, the lower segment broader. The foetal heart is heard most 
 distinctly higher up than in vertex presentation, generally about 
 the level of the umbilicus. A sign is given for diagnosing extension 
 
Pelvic Presentations. 
 
 349 
 
 of the legs before the onset of labour, namely, that, in this case, the 
 foetal heart is heard lower down than is usual in pelvic presentation, 
 because the breech, not being enlarged by the addition of the legs, 
 is able to lie lower in the pelvis. The bag of membranes is apt to 
 be large and descend low, while the presenting i3art still remains 
 high. In foot presentations the bag is especially elongated. 
 
 Fig. 219. 
 
 -Breech in pelvis, left sacro-anterior presentation, seen from below. 
 Pelvis in usual left obstetric position. 
 
 Before rupture of the membranes, the double contour of the 
 buttocks and the prominences along the sacrum may be felt ; and 
 sometimes the feet may be felt near the breech. When the 
 membranes rupture the liquor amnii escapes gradually, but more 
 completely than in vertex presentations, the flow not being stopped 
 by the action of the head as a ball-valve. The pains after rupture 
 are apt to be more frequent than in vertex presentations, the 
 complete escape of liquor amnii allowing the uterine wall to come 
 into closer contact with the foetus. After rupture of the membranes 
 
350 
 
 The Practice of Midwifery. 
 
 in breech presentation, the os uteri, on vaginal examination, is 
 found to be occupied by two smooth elastic swellings, the buttocks, 
 on which no tangible hair, like that on the scalp, can be felt. The 
 cleft between the buttocks can be traced backwards to the coccyx and 
 sacrum — the spinous processes of the latter are very characteristic — 
 and in its course can be felt the anus, which, in a living child, 
 
 Fig. 220. — Breech in pelvis, right sacro-posterior presentation, seen from 
 below. Pelvis in usual left obstetric position. 
 
 contracts on the finger if an attempt be made at introduction. Thick 
 tenacious meconium comes away on the finger, unlike that mixed 
 with liquor amnii, which may be expelled in head presentations 
 when the child has undergone severe pressure. The genitals may 
 also be recognised, and in the male the scrotum, which becomes 
 much swollen, is a marked feature. The differential diagnosis of 
 the breech from the face, the only part likely to be mistaken for it, 
 has been already mentioned (see p. 338). 
 
 The knee is distinguished from the elbow by being broader, and 
 
Pelvic Presentations. 
 
 351 
 
 having, besides the patella, two tuberosities with a slight depression 
 between them in place of the sharp projection of the olecranon. 
 In case of the slightest doubt, after rupture of the membranes, the 
 diagnosis should be verified by bringing down the foot. The foot is 
 liable to be confused with the hand when, before rupture of the 
 membranes, it is only just reached with the tip of the finger. The 
 following are the characteristic differences. The toes form an even 
 line and are not very movable, while the fingers are more irregular 
 and divergent. The great toe lies close to the other toes, while 
 
 Fig. 221. — Passage of breech under pubic arch by a movement of lateral 
 flexion (second position) . 
 
 the thumb is inclined at an angle to the hand, and is opposed to 
 the other digits. The hand of a living child will often grasp the 
 examining finger. The most unmistakable point of all about the 
 foot is the jDrojection of the heel, with the malleoli above it. This 
 is most easily felt with absolute certainty by catching the foot 
 between two fingers, or between the fingers and thumb, as may 
 usually be done without rupturing the membranes if they are still 
 intact, and still more easily after the escape of the liquor amnii. 
 In case of doubt whether foot or hand is presenting, as it is 
 important to make the diagnosis early, it is desirable, if necessary, 
 to introduce half, or- even the whole hand into the vagina, in order 
 to reach high enough to seize the foot in this way. By this 
 
352 
 
 The Practice of Midwifery. 
 
 method it is easy to avoid any risk of mistake between the heel and 
 the elbow, which may be confused if touched only with the tip of 
 the finger. - 
 
 Mechanism of Labour in Breech Presentation. — The bis-iliac 
 diameter of the breech enters the pelvis, as already mentioned, 
 nearly in one of its oblique diameters. There is no movement 
 corresponding to flexion in vertex presentation. As the breech 
 descends an internal rotation occurs, similar to the internal rotation 
 
 Fig. 222. — Passage of the shoulders in pelvic presentation (first position). 
 
 of head presentations, the bis-iliac diameter turning nearly into 
 the antero-posterior diameter at the outlet (see Fig. 221). Thus, 
 in the first position of the breech, the sacrum turns from the left 
 foramen ovale toward the left side of the pelvis, and the left hip 
 comes under the pubic arch. This internal rotation is not generally 
 so complete as in head presentations, especially when space is 
 ample, the breech being less firm and incompressible than the 
 head. 
 
 Corresponding to the extension in occipito-anterior positions of 
 the vertex is a lateral flexion of the breech on the trunk, due to 
 the inclined plane of the soft parts of the pelvic floor pushing the 
 forecoming part of the breech forward while the trunk is held 
 
Pelvic Presentations. 
 
 353 
 
 backward by the resistance of the pubes (see Fig, 221). The 
 anterior buttock thus comes under the pubic arch, while the 
 posterior buttock distends the perineum. Combined with this 
 
 :S/./ 
 
 sa. 
 
 Fig-. 223. — Diagram of mechanism of breech presentations. (For general 
 
 scheme of diagram, see Fig. 159.) CP = antero-posterior 
 
 diameter of pelvis ; (/) = sacrum ; 1| = transverse diameter of 
 
 hips ; II = right hip ; i., first breech, left sacro. anterior ; ii., rotation 
 of anterior left hip forwards ; iii., birth of hips by lateral flexion, anterior 
 leading; iv., descent of shoulders and after-coming head (for symbols, 
 see Fig. 159) ; v., rotation of anterior left shoulder to front ; vi., birth 
 of shoulders, left leading ; vii., rotation forwards of occiput of after- 
 coming head; viii., further rotation of occiput to front ; ix., birth of head 
 flexed with occiput anterior. 
 
 lateral flexion is a slight posterior flexion of the breech on the 
 trunk in dorso-anterior positions, and anterior flexion in dorso- 
 posterior positions. These are analogous to the lateral flexion 
 of the head toward the anterior shoulder near the outlet of the 
 M. 23 
 
354 
 
 The Practice of Midwifery. 
 
 genital canal in head presentations, and. are due to a similar cause. 
 The anterior buttock is the first to appear at the vulva, and 
 the first to be delivered, provided that the perineum is intact 
 (see Fig. 221). When the perineum is deficient, the posterior 
 buttock may be the first to escape.^ 
 
 After the buttocks have escaped from the vulva, there is a slight 
 movement of restitution in the reverse direction to the internal 
 rotation, the breech returning toward the oblique diameter which 
 it originally occupied, so as to accommodate itself to the position 
 of the shoulders, which are entering the pelvis in the oblique 
 
 diameter. This is not so 
 marked as in head presenta- 
 tion. The feet escape close to 
 the buttocks, unless the legs 
 are extended, the thighs are 
 delivered soon after, and the 
 abdomen descends. Provided 
 no traction has been made 
 upon the child, the arms 
 generally emerge, folded upon 
 the chest, before the shoulders 
 As the shoulders approach the 
 outlet, the bis-acromial dia- 
 meter, like the bis-iliac, turns 
 nearly into the antero-pos- 
 terior diameter of the outlet 
 (Fig. 224). 
 
 The head enters the pelvis 
 in the right oblique or nearly 
 in the transverse diameter, 
 and is maintained in a position of flexion by the pressure of the 
 uterus upon it so long as no traction is made upon the child. 
 As in head-first deliveries, the long diameter of the head turns 
 nearly into the antero-posterior diameter of the outlet, so that 
 the occiput escapes under the pubic arch (Fig. 225). As soon as 
 the head has been expelled out of the powerfully contracting 
 body of the uterus into the distended cervix and vagina, the 
 expulsive force necessarily acts at a great disadvantage (see 
 Fig. 225, p. 354). The only force which then comes into play is 
 that of the auxiliary muscles and the feeble contractile powers of 
 
 Fig. 22i. — Passage of the shoulders in 
 pelvic presentation, one arm extended 
 (second position). 
 
 1 It is sometimes stated that the rule is for the posterior buttock to be born first, 
 but this only occurs when there is deficiency of the posterior wall of the genital canal 
 from former rupture of the perineum. 
 
Pelvic Presentations. 
 
 355 
 
 the vagina and cervix. Hence the head is apt to be delayed at 
 this stage, and the foetus to die from asphyxia. But generally 
 expulsion is effected chiefly by the action of the abdominal muscles, 
 strongly stimulated by the presence of the large hard head in the 
 vagina. If delivery thus takes place naturally, flexion of the chin 
 is maintained to the last, the chin and face emerging first, and 
 the occiput last. In the second position of the breech, the 
 mechanism is precisely tbe same 
 as in the first, right and left 
 being interchanged. 
 
 Mechanism in Dorso-pos- 
 terior Positions of the Breech. 
 
 — Suppose the child to be in the 
 third position of the breech, the 
 sacrum looking toward the right 
 sacro-iliac synchondrosis. The 
 sacrum in tbis case rotates 
 forward instead of backward, so 
 that the right or anterior buttock 
 rotates forward under the pubic 
 arch. The buttocks are then 
 delivered by lateral flexion in 
 the same way as in sacro-anterior 
 positions. If the bis-iliac dia- 
 meter has rotated completely 
 into the antero-posfcerior dia- 
 meter of the j)elvis, the external 
 
 rotation of the breech is generally continued on in the same 
 direction as the internal rotation, and not reversed. The bis- 
 acromial diameter of the shoulders thus enters the brim in the 
 right oblique diameter instead of following the bis-iliac in the left 
 oblique. The long diameter of the head enters the brim with the 
 occiput somewhat forward, and labour is completed as in the 
 second position of the breech. The only explanation which can be 
 given for this is the general tendency of the spine of the child to 
 rotate forward away from the spine of the mother. Sometimes, 
 however, especially if the internal rotation of the breech has been 
 incomplete, there is an external rotation in the reverse direction, 
 and the bis-acromial diameter enters the brim in the left oblique, 
 rotating into the antero-posterior, or nearly so, as it descends. 
 The head then enters the brim with the occiput directed laterally 
 or a little backward. As it descends the occiput almost always 
 
 23—2 
 
 Fig. 225.— Descent of the head. 
 
356 
 
 The Practice of Midwifery. 
 
 ^1. ^.s.a 
 
 Fig. 226. — Diagram of mechanism of labour in foot or knee presentation. 
 
 1|-^ = transverse diameter of hips with foot or knee presenting (for 
 
 other symbols, vide Figs. 159, and 223). The diagram shows the rotation 
 of the posterior hip to the front, in this case the right hip and the 
 accompanying rotation of the shoulders and head. 
 
Pelvic Presentations. 357 
 
 rotates forwards under the pubic arch. The cause of this move- 
 ment is that the neck, which is attached to the posterior part of the 
 head, meeting the resistance of the inchned plane of the pelvic 
 floor, turns away from it into the free space under the pubic arch. 
 
 Irregularities of Mechanism. — In rare cases of dorso-posterior 
 position, the occiput remains j)osterior, turning somewhat toward 
 the hollow of the sacrum. This is most likely to happen when 
 space is ample, so that little or no internal rotation of the buttocks 
 or shoulders occurs, and the back continues to look toward the 
 sacrum during the passage of the trunk. The head may then 
 still be delivered in a position of flexion, the chin and face first 
 escaping under the pubes, and the occiput finally passing over 
 the perineum. Cases have been recorded of a much more rare 
 occurrence, namely, that the head becomes extended into a posi- 
 tion like that of face presentation, the face looking upward toward 
 the abdomen, while the occiput is pressed down upon the back. 
 The occiput is then said to emerge first over the perineum, while 
 the chin is delayed behind the pubes, and the face is born last. 
 But, in such a position, the head is arrested, unless very small in 
 proportion to the pelvis. 
 
 Mechanism in Foot or Knee Presentation. — If one thigh 
 only is extended, the extended thigh forms the most advanced 
 part of the foetus, is the first to meet the resistance of the inclined 
 plane of the pelvic floor, and therefore, according to the universal 
 rule, turns forward away from the resistance into the free space 
 under the pubic arch. Therefore the buttock corresponding to 
 the extended thigh becomes eventually anterior. The delivery of 
 the body and head is the same as in breech presentations (Fig. 226). 
 
 Moulding of the Child in Pelvic Presentation. — The 
 
 cedematous swelling, corresponding to the caput succedaneum, 
 occupies mainly the anterior buttock, and includes the genitals, 
 especially the scrotum in a male. The absence of any caput 
 succedaneum on the head is notable. The shape of the head 
 is little altered, bat it becomes somewhat more rounded than the 
 head before moulding, the vertical, or cervico-l^regmatic diameter 
 being relatively increased. This is due to the pressure of the 
 genital canal on the front, back, and sides being more continuous 
 than the uterine pressure on the top of the head. 
 
358 The Practice of Midwifery. 
 
 Prognosis. — The prognosis is slightly more unfavourable for 
 the mother than in vertex presentations, since artij&cial delivery 
 of the child has not infrequently to be undertaken ; Hecker/ taking 
 all cases, estimates the maternal mortality at 2'07 per cent. The 
 first stage of labour is generally more tedious, since the breech 
 is not so well shaped a dilator as the head, and, from its softness, 
 does not stimulate the nerves of the cervix so powerfull}^ The 
 passage of the head is also apt to be delayed, the breech not being 
 large enough to dilate the passages sufficiently to allow it to pass 
 with ease, and tearing of the soft parts is likely to ensue. If one 
 foot or knee present, and, still more, if both do so, the likelihood 
 of delay is greater, the fore-coming part of the foetus being then 
 a more inefficient dilator than the breech. 
 
 In this way arises the great danger to the child's life in pelvic 
 presentations. One cause of this is pressure on the funis. This 
 begins in some measure as soon as the umbilicus is entering the 
 brim, that is, when the buttocks are passing the vulva (see Fig. 
 221, p. 351), but is much greater when the trunk is born, and the 
 funis is compressed between the hard head and the pelvis. A still 
 more important cause is, that by the shrinking of the uterus on the 
 expulsion of the main part of the bulk of the foetus the placental 
 circulation is more or less arrested by compression of the uterine 
 arteries, and the j)lacenta may even be partially detached. This 
 is especially the case when the head is completely expelled out 
 of the body of the uterus into the cervix and vagina (see Fig. 225, 
 p. 355). 
 
 Premature attempts at respiration are also very likely to occur 
 leading to the aspiration of mucus or liquor amnii into the child's 
 air passages.^ A comparatively short delay at this stage is therefore 
 inevitably fatal to the child. 
 
 Spencer^ has shown that injuries to the thoracic and abdominal 
 viscera are very common in breech presentations, while injuries 
 to the sternomastoid muscles and the nerves in the neck are very 
 liable to follow forcible traction on the after-coming head. 
 
 The proportion of children still-born varies very much according 
 to the skill of the accoucheur, and therefore is very differently 
 estimated by different authors. Churchill gives the mortality as 
 1 in 3^, Von Winckel 1 in 5, Dubois as 1 in 11. The statistics of 
 the Guy's Hospital Lying-in Charity, where the labours are attended 
 by students, and where the child is often born before the arrival 
 of the accoucheur, give a still higher mortality than that estimated 
 
 1 Hecker, loc. cit., p. 255. 
 
 2 Spencer, Trans. Obst. Soc. London, 1891, Vol. XXXIII. , p. 203. 
 
Pelvic Presentations. 359 
 
 by Churchill, namely, 1 in 3'0 for breech presentation, and 1 in 
 2" 3 for foot or knee presentation, out of 49,145 deliveries. 
 
 In the years 1896—1906 at the Basle KliniV among 10,842 
 births there were 368 breech presentations. Of the mothers 
 8, or 2'17 per cent., died, and 28, or 7'6 j)er cent., of the children. 
 The foetal mortality among the primiparse was 1 in 7, and among 
 the multiparaB 1 in 12. 
 
 Management of Pelvic Presentations. — In all cases where a 
 breech presentation is recognised before the onset of labour an 
 attempt should be made to convert it into a vertex presentation by 
 the performance of external cephalic version. Pollock^ has shown 
 that this procedure is rendered much easier and more certain if 
 the patient be placed in the Trendelenburg position. The risks to 
 the mother and the child are much less in a vertex than in a 
 breech presentation, and even if the attempt at version fails no 
 harm ensues. 
 
 The first and most essential point in the management of pelvic 
 presentations during labour is to abstain from premature interfer- 
 ence with nature. In the first instance the membranes must be 
 kept intact as long as possible, in order to get the greatest possible 
 dilatation of the soft parts by their means, since the breech forms 
 an inefficient dilator to prepare the way for the larger- sized head 
 which has to follow it. In presentation of one or both feet, this 
 necessity is still greater, since the half-breech, or both legs together, 
 form a still worse dilator than the breech. 
 
 After rupture of the membranes, it is still necessary to leave 
 matters to nature as long as possible. The midwife or inex- 
 perienced student may be tempted by the facility for traction 
 which is offered by the body or legs of the child, especially if the 
 labour proves tedious. But if any traction is made prematurely, 
 two evil results follow. First, the arms, instead of remaining 
 folded on the breast and slipping out before the head, are retarded 
 by friction. They then slip up by the sides of the head, and 
 become jammed with the head in the pelvis, thus frequently 
 causing the loss of the child's life. Secondly, the tractile force 
 being transmitted through the neck, the anterior arm of the head- 
 lever is the longest ; the resistance which it meets has therefore 
 the mechanical advantage over that experienced by the posterior 
 or occipital arm, and the head becomes extended. In this way the 
 maximum vertico-mental diameter of the head may be thrown 
 
 1 iHiaelowitz, Inauf,'. Diss., Basle, IDOf). 
 
 2 Pollock, Trans. Obst. Soc. London, IDOfJ, Vol. XLVIH., p. iH'J 
 
36o 
 
 The Practice of Midwifery. 
 
 across the pelvic brim, or nearly so, and find the space insufficient 
 for its passage. 
 
 The first pressure upon the funis, and consequent risk to the 
 child, begins when the umbilicus enters the pelvic brim, or about 
 the time when the breech is passing the vulva, but it becomes 
 much'greater when the child is born as far as the umbilicus. It is 
 just before this time that the first duty of the attendant commences. 
 As soon as he can easily reach the umbilicus by passing a finger 
 
 Fig. 227. — Manual extraction of head through the outlet of soft parts. 
 
 just within the vagina, he should draw a loop of the cord gently 
 downward. The object of this is twofold — first, to prevent the 
 cord undergoing any longitudinal stretching as the child advances, 
 and consequent interference with the circulation through its spiral 
 vessels ; secondly, to enable him to watch the foetal pulsations in 
 the cord, and so judge of any danger to the foetus. The loop 
 of cord should also be guided to that part of the pelvis where 
 there is most room for it, generally opposite the sacro-iliac 
 synchondrosis. 
 
 From this time the delivery may be accelerated so far as this 
 
Pelvic Presentations. 361 
 
 can be done by encouraging the patient to bear down, and by 
 pressure from above on the fundus. But still there must be no 
 further interference, unless there are signs that the child is in 
 imminent peril. The most significant of these are inspiratory 
 efYorts, made while the mouth and nose are still retained within 
 the passages. These are evidence that the child is becoming 
 suffocated. Failure, or great retardation, of the pulsation of the 
 funis is also an indication that it is necessary to have recourse to 
 extraction. 
 
 As the breech and body of the child are passing the vulva the 
 physician should, with his right hand, support the body, and carry 
 it forward between the mother's thighs towards her abdomen, thus 
 aiding the lateral flexion of its body (see p. 351). At the same 
 time he should assist the expulsion by pressing with his left hand 
 upon the fundus uteri. Such external pressure is of special value, 
 because, while aiding the expulsive force, it also promotes the 
 flexion of the head, and tends to keep the arms in their natural 
 position across the chest. In most cases it will prevent the necessity 
 for having recourse to artificial extraction. After the arms have 
 appeared, and when the head is reaching the vulva, it is better to 
 hand over to the nurse, or other assistant, the duty of pressing 
 upon the fundus, and spread out the left hand behind the perineum 
 in front of the sacro-sciatic ligaments, in the same position as that 
 described at p. 303 for the case of the fore-coming head. By 
 pressure in this situation, the finger and thumb keep the head 
 forward under the pabic arch, and so tend to avert rupture of the 
 perineum, while at the same time, by pressure upon the forehead 
 at the final stage of expulsion, they may assist the exit of the head. 
 
 Extraction of the Head. — "When the after-coming head is expelled 
 out of the strong contractile body of the uterus into the dilated 
 cervix and vagina (see Fig. 225), the natural forces act upon it at a 
 very great disadvantage. For the only expelling forces are now 
 the weak contractile powers of the cervix and vagina and the action 
 of the auxiliary muscles. Hence at this stage sufficient delay to 
 cause the death of the child is apt to be produced, if the case is left 
 to nature. As soon, therefore, as the arms have escaped, the head 
 should be extracted if it does not immediately follow. 
 
 At this stage the resistance is due only to the soft parts of the 
 vaginal and vulval outlet, and is usually not considerable. There 
 is, however, one mechanical difficulty in artificial extraction. The 
 force of traction, acting through the spinal column, is applied to the 
 head at a point nearer to its posterior than to its anterior extremity. 
 Hence, if traction is made in the axis of that plane of the genital 
 
362 
 
 The Practice of Midwifery. 
 
 canal in which the centre of the head lies (see Fig. 22, p. 21)," the 
 occiput is drawn down more than the forehead, the head becomes 
 extended, a larger diameter of it is thrown across the genital canal, 
 and in consequence the resistance is greatly increased, and the 
 perineum is endangered. 
 
 Hence the object to be attained is to make traction in such a 
 way as to avoid causing extension, and secure the descent of the 
 chin. There are three means available for attaining this end : the 
 application of forceps, the so-called Prague method of delivery, and 
 
 Fig. 228. — Shoulder and jaw traction. (Mauriceau-Smellie-Veit Method.) 
 
 traction on the shoulders of the child with the introduction of the 
 finger into the mouth of the child so as to promote flexion of the 
 head, shoulder traction with a jaw hold. 
 
 The application of forceps is undoubtedly the safest and one of the 
 most effective methods of delivering the after-coming head, and in 
 all cases of breech presentation they should be ready at hand in 
 case they may be wanted. If, however, the forceps are not 
 immediately available, one of the two other methods may be 
 employed. In applying the Prague method the j^roceeding is as 
 follows : — Wrap the legs and feet of the child in a napkin and seize 
 them with the right hand. Hook the left hand over the back of the 
 
Pelvic Presentations. 363 
 
 neck, as shown in Fig. 227. Then carry the legs forward in a 
 direction almost, but not quite, at right angles to the pubes, as 
 indicated in the figure. Make traction in this direction with the 
 right hand. Aid the traction with the left hand, but use this hand 
 chiefly to steady the head, and prevent its escaping with too sudden 
 a jerk. 
 
 The exj^lanation of the success of this method is as follows : The 
 forward direction of the traction causes a pressure of the pubes 
 against the occiput. This force, combined with the component of 
 the tractile force resolved perpendicularly to the pubes, and acting 
 through the condyles, forms a "couple," or pair of equal and 
 opposite forces not acting in the same straight line, which tends to 
 cause descent of the chin and ascent of the occiput. This method 
 is equally applicable when the occiput looks backwards, the feet of 
 the child being carried up over the mother's abdomen and traction 
 being made with the other hand on the shoulders. In this case the 
 head is born with the occiput leading, the face emerging last, and, as 
 a result, the perineum is very likely to be torn. 
 
 In a parous woman this method will almost always instantly 
 release the head when once it has reached the pelvic floor. The 
 only difficulty likely to occur is in a primipara, to whom, with 
 a forecoming head, rupture of the perineum would be likely to 
 occur. In such a case a considerable amount of force may have to 
 be employed, and this is likely to lead not only to rupture of the 
 mother's perineum, but also to injury to the tissues of the child's 
 neck, especially the sternomastoid muscles. In these circumstances, 
 while an assistant, if one be available, makes traction on the child's 
 legs, pressure should be made on the fundus uteri with one hand, 
 and the other should be applied just in front of the sacro-sciatic 
 ligaments in an attempt to squeeze the head out through the 
 vulva. In a really difficult case, however, where there is marked 
 rigidity of the soft parts or possibly some contraction of the bony 
 outlet of the pelvis, shoulder traction with a jaw grip must be 
 resorted to. In this, the so-called Mauriceau-Smellie-Veit manoeuvre, 
 the index finger of the left hand is passed into the vagina and 
 placed far back on the edge of the inferior maxilla of the fcetus. 
 At the same time the first and second fingers of the right hand are 
 applied to the child's shoulders. Traction is then made on the 
 shoulders, aided by the pressure of an assistant's hand on the fundus 
 of the uterus, while the finger in the mouth aids in the traction 
 and at the same time keeps the head in a flexed position. This is 
 a very effective manoeuvre both in causing flexion, and in adding 
 to the tractile force without increasing the tension upon the neck. 
 
364 The Practice of Midwifery. 
 
 but it is rarely required to overcome resistance due only to the soft 
 parts. An alternative and very useful method is the introduction 
 of the index finger of the left hand into the mouth of the foetus to 
 produce flexion while traction is made on its legs with the right 
 hand, and the descent of the head aided, if necessary, by pressure 
 made on it through the abdomen by an assistant. 
 
Chapter XVI. 
 
 MULTIPLE PREGNANCY. 
 
 By multiple pregnancy is meant the simultaneous development 
 of more than one embryo. The case of chief practical importance 
 is that of twin pregnancy, which occurs, taking an average for 
 different countries, about once in eighty cases. Triplets are found 
 only about once in 6,400 pregnancies (80^).^ It is extremely rare to 
 find a greater number of embryos than three, quadruplets 
 occurring about once in 512,000 births (80^), and quintuplets, of 
 which there are a few on record, once in 40,960,000 (80*). In 1888 
 Vassalli recorded a case in which six foetuses, two female and four 
 male, were expelled at the fourth month of pregnancy. 
 
 Causation. — The proportion of twin pregnancies varies in 
 different countries, and it may be inferred that the variation 
 depends upon difference of race. On the whole, multiple pregnancy 
 appears to be commonest among the most fertile races. Thus in 
 Ireland the proportion is about 1 in 60, in England only about 
 1 in 110. The highest rate is met with in Dublin, 1 in 57, and 
 the lowest in Naples, 1 in 158. Individual women occasionally 
 show a tendency to rej^eated twin pregnancy, and there is evidence 
 that this tendency may be hereditary, although this does not appear 
 to apply to uniovular twins. Such constitutional or hereditary 
 tendency shows itself, as a rule, on the mother's side, but there is 
 some reason for believing that the father may also have an 
 influence, for an unusual number of twin pregnancies have some- 
 times occurred in the families of brothers, or in those of the same 
 husband by different wives. Von WinckeP has recorded a case in 
 which the paternal influence was shown in three generations, twins 
 being born six times in nine births. According to the statistics 
 collected by Matthews Duncan,^ the tendency to production of 
 twins increases with successive pregnancies, with the exception of 
 the first pregnancy, at which it is greatest of all ; and the later in 
 life women are married, the more likely are twins to be born at the 
 
 ' Hellin, Die Ursache der Multiparitiit, Mlinchen, 1895. 
 
 2 Strassmann ; Von Winckel, Handbuch der Geburtshiilfe, 1904, Vol. I., Part 2. 
 p. 743. 
 8 Matthews Duncan, On Fecundity, Fertility, and Sterility. Edinburgh, 1866. 
 
366 
 
 The Practice of Midwifery. 
 
 first delivery. It has generally been considered that the tendency 
 to produce twins is associated with unusual fertility and an atavistic 
 tendency, but Matthews Duncan,^ from observations on animals, 
 infers that the birth of twins may be a stage on the way toward 
 sterility. 
 
 Twin pregnancy may be either of the binovular or the uniovular 
 variety. 
 
 Binovular Twins. — Two or more ova may become fertilised 
 at the same time, and an excess of Graafian follicles in the ovary 
 
 Fig-. 229. — Twins in utero, both presenting by vertex. 
 
 appears to predispose to this. These may proceed either from 
 the same or different ovaries, and, in some cases, may both 
 escape from the same Graafian follicle. The possibility of two ova 
 being thus fertilised at the same time is proved by the finding, in 
 some cases, of two corpora lutea equally developed, and by the 
 occasional occurrence of simultaneous pregnancy on the two sides 
 of a double uterus, also by that of twin pregnancy with one foetus 
 in the uterus and one extra-uterine. It is probable that both ova 
 may be fertilised at the same coitus, but this is not always the 
 case. This occurrence is called swperfecundation, and is supported 
 
 1 Matthews Duncan, On Sterility in Woman, London, ISS-l. 
 
Multiple Pregnancy. 367 
 
 by the fact that sometimes children of different colours have been 
 born, one white and one mulatto, or one mulatto and one negro. It 
 must be remembered, however, that of the two children of a negress 
 by a white father one may be quite dark at the time of birth and 
 the other quite light, and to prove superfecundation in the human 
 subject it would be necessary for two foetuses to be born of the 
 same mother presenting the definite characteristics of two different 
 races. In the case of animals, it is known that different foetuses in 
 the same litter may have different fathers. 
 
 When the twins arise from two different ova, each will be enclosed 
 in its own amnion and chorion, and generally, in the first instance, 
 its own decidua reflexa, although if the two foetuses are implanted 
 very close to one another in the uterus only one decidua reflexa 
 may be formed. When the growing ova come into contact, and a 
 partition between them is formed by the union of their walls, the 
 decidua reflexa may soon become thinned and lost in the partition. 
 Only four layers, instead of six, are then traceable in the partition, 
 two of chorion and two of amnion. The placentae may be entirely 
 separate, or they may be joined at their borders or united by a 
 membranous portion, but there is no vascular communication 
 between them. From the fact that two distinct bags of membranes 
 are most frequently found (in about 85 per cent, of all cases), it 
 appears that this variety of twin pregnancy is the commonest. 
 
 Uniovular Twins. — An ovum may have a double germinal 
 vesicle, and an embryo be developed from each. Such ova are met 
 with not uncommonly. In this case the placenta and chorion are 
 common to the two, but the amniotic sacs are separate. Tlie 
 septum between them may, however, break down or be absorbed, 
 and the embryos may thus come to be contained in a single bag 
 of membranes. In this variety, there is frequently more or less 
 vascular communication in the placenta between the two embryos. 
 A single chorionic cavity occurs in about 14 to 15*5 per cent, of 
 twin pregnancies. 
 
 When we remember that this view necessitates the extrusion of 
 two polar bodies, the formation of two female j)ronuclei, and the 
 entrance of two spermatozoa, it is obvious that it presents many 
 difficulties, and they are not lessened by the fact that the develop- 
 ment of two blastodermic vesicles may lead to the formation of two 
 chorions, and it is necessary to imagine that these coalesce so as to 
 give rise to the single chorion existing with uniovular twins. It is 
 much simpler and more probable to hold the view that a single 
 blastodermic vesicle may give rise to two embryonic areas. If the 
 
368 
 
 The Practice of Midwifery. 
 
 two embryonic areas remain completely separate uniovular twins 
 develop, whereas if they are in close proximity and become united 
 they give rise to one or other of the varieties of double monsters. 
 In the latter case only a single amniotic cavity is developed from 
 the first. It is possible that the same may be the case in some 
 instances, when the embryos are completely separated, especially if 
 
 Fig. 230. — Diagrams of the arrangement of the placentae and membranes with unioYular 
 twins ; a, with double amnion ; h, with single amnion. 
 
 I - ' • = decidua. 
 
 = separate amnions. 
 
 = single amnion. 
 
 ^^ = placenta,. 
 
 'ft^^f^f&Z = communicating areas of placentae, 
 (From V. Winckel, Handb. der Geburtshlilfe, Vol. I., Pt. II,, Plate V.) 
 
 the separation does not extend fully to the abdominal pedicle. In 
 this variety also there is a single placenta, and generally vascular 
 communication between the embryos. In some cases the funis is 
 single near its placental insertion, bat contains a double set of 
 vessels, and bifurcates on aj)proaching the foetuses, thus indicating 
 that the cleavage of the area germinativa did not extend throughout 
 the abdominal pedicle, and some authorities believe that, in all 
 
Multiple Pregnancy. 
 
 3^9 
 
 such cases, an amniotic septum existed originally, but has been 
 broken down. But it is uncertain, when there is a common chorion 
 and separate amniotic cavities, whether the twins originated from a 
 double yolk, or from cleavage of the area germinativa. Sobotta 
 believes that the latter is always the explanation, considering that 
 it is impossible for a second spermatozoon to enter the ovum and 
 unite with a second female pronucleus.^ 
 
 In only about 0*25 per cent. (1 in 389) of all cases the twins 
 are found in a single amniotic cavity (Ahlfeld).^ It is said that 
 twins contained in the same amniotic cavity show, in after-life, a 
 much closer resemblance to 
 each other than ordinary 
 twins. 
 
 Uniovular twins are more 
 often of the male than of 
 the female sex, the mothers 
 are apt to be young or rela- 
 tively old, death of the foetus 
 or malformations are com- 
 moner than with binovular 
 tv/ins, and heredity appears 
 to play no part in their pro- 
 duction. 
 
 In triplets, it appears that 
 most frequently two are 
 developed from the same 
 ovum, and the third from a 
 second ovum. 
 
 Fig. 231. — Acardiac, acephalic foetus. 
 
 Acardiac Monsters. — 
 When two embryos are con- 
 tained within a common chorion, the abdominal' pedicle of one may 
 remain partially blended with, or be in close vicinity to, the 
 abdominal pedicle of the other. In such twins developed from a 
 single ovum with a single placenta, there is always a vascular com- 
 munication in the placental vessels, usually arterial, less commonly 
 venous, between the two embryos. 
 
 When the vascular communication of the vessels in the placenta 
 is free, and one foetus is stronger than the other, the weaker foetus 
 is apt to be converted into what is called an acardiac monster in 
 
 1 KoVjotta, "Neueie AnschauunKcn liber die Entstehung der Doppelbilduiigen," 
 Wiirzbuiger Abharidlungeri 11)01, Hd. L. Hft. 4. 
 
 - Ahlfeld, Zeitschr. f. Gob. u. Gyn., 1902, Bd. 47, p. 230. 
 
 M. 
 
 24 
 
370 
 
 The Practice of Midwifery. 
 
 the following way. Blood from the arteries of the foetus having 
 the stronger heart reaches the arteries of the weaker foetus, and, 
 by virtue of its greater tension, causes the blood to flow back to 
 the heart, thus reversing the direction of the current.-^ The heart 
 of the weaker foetus, being no longer of use, becomes atrophied. 
 From its imperfect blood supply, the foetus is very imperfectly 
 developed, and generally only the lower parts of the body are 
 developed at all, since the blood, arriving at the iliac arteries, has 
 readiest access to these. The trunk and upi^er parts are represented 
 by a mere mass of flesh (see Fig. 231). In rare cases there is a 
 partial development of the head and upper limbs. An acardiac 
 foetus is thus generally also acephalic. It must be distinguished 
 from the anencephalic foetus, in which the base of the skull is 
 developed, and which has nothing to do with twin pregnancy. 
 
 Fig. 232. — Section of a placenta wilh a ftehis conijjressus. (Univ. Coll. 
 Hosp. Med. School Mus.) 
 
 Sex of the Children — Double monsters are invariably of the 
 same sex, and it is probable that the same law is generally true of 
 all twins developed from a single ovum. A case has occurred in 
 the Guy's Hospital Lying-in Charity of twins of opposite sexes 
 contained apparently in the same bag of membranes. A case also 
 has been recorded of a healthy female twin associated with a male 
 acephalic foetus^ which must have arisen by cleavage of the 
 embryonic area. ^Yhen we remember how difiicult it often is to 
 determine the exact arrangement of the membranes in some of 
 these cases, and further that there may be difficulty even in recog- 
 nising the sex of a new-born child, especially if it be deformed, 
 the apparent exceptions to this law may be explicable in one or 
 other of these ways. The statistics of the Guy's Hospital Lying-in 
 Charity give 38 per cent, as the proportion of cases in which both 
 children were males, 34 per cent, in which there was one of each 
 sex, 28 per cent, in which both were females. According to German 
 statistics collected by Veit, however, it is most frequent to find one 
 child of each sex, viz., in 35 to 38 per cent, of the cases. 
 
 1 Ballantyne, Antenatal Pathology : The Embryo, 1904, p. 625. 
 
 2 Dickinson, Med.-Chir. Trans., 1863, Vol. XLVI., p. 141. 
 
Multiple Pregnancy. 371 
 
 Course of Pregnancy in Multiple Gestation Twins, and 
 
 still more triplets, are, as a rule, smaller and weaker than ordinary 
 children, and the mortality among them is greater ; they seldom 
 attain the same degree of development either in length or weight 
 as a single foetus, but, as a rule, the males are heavier than the 
 females. In the ease of triplets, it is rare for all three to survive, 
 and in two-thirds of the cases labour occurs prematurely. The 
 uterus and abdomen, however, become more distended than in 
 
 Fig. 233. — Adaptation of twins i>i utero both lying transversely. 
 
 ordinary pregnancy, and this condition is apt to lead to premature 
 labour. This is often an additional reason for the small size of 
 twins at birth. Besides the ordinary risks during pregnancy, a twin 
 or triplet has to incur the struggle for existence with the other 
 fcetus or fcetuses, and if one is less favourably jDlaced for obtaining 
 nutriment, it is either smaller and weaker, or may perish altogether. 
 Thus it is not uncommon for one twin to be much larger than the 
 other at birth. When one twin dies during pregnancy it is 
 frequently retained until full term, and then expelled with the 
 other. Being excluded from the air, it does not become putrid, but 
 
 24—2 
 
372 
 
 The Practice of Midwifery. 
 
 shrinks up, and becomes mummified. To such a blighted foetus, 
 when flattened between the other bag of membranes and the uterine 
 wall, the name of foetus papyraceus or fa'tus compressus has been 
 given. More rarely, the dead ovum, perishing at an early stage, 
 degenerates into a mole, either carneous or vesicular. In other 
 cases, the dead foetus acts as a foreign body, and sets up uterine 
 action. Then either the dead ovum alone may be expelled, provided 
 the bags of membranes and placenta are quite separate, or both 
 may be expelled. 
 
 Unioval twin pregnancy, the twins having a common chorion and 
 
 two amniotic cavities, appears to be 
 a cause of hydramnios, the hydra- 
 mnios affecting the larger. It has 
 been suggested that the heart of the 
 stronger twin becomes hypertrophied, 
 through getting a larger share of 
 nutriment from the placenta, and 
 causes an increased secretion of urine. 
 But it does not seem to be explained 
 why this secretion should be greater 
 than in normal pregnancy. 
 
 Multiple pregnancies undoubtedly 
 expose the mother to a greater degree 
 of suffering from the disorders of 
 j)regnancy. Thus there is likely to be 
 greater pressure on the bladder and 
 rectum, morning vomiting is increased, 
 respiration is more difficult, and there 
 is a greater tendency to the occur- 
 rence of albuminuria and of eclampsia. 
 
 Fig. 23d. — Adaptation of twins in 
 utero with one vertex and one 
 pelvic presentation. 
 
 Diagnosis. — A suspicion of twin pregnancy may be excited by 
 unusual size of the abdomen and uteras, but no certain inference 
 can be drawn from it. If the foetuses lie side by side they may be 
 mapped out separately by palpation, and a definite groove may be 
 felt separating them. Special attention should be devoted to 
 discovering whether two heads can be felt. The diagnosis is con- 
 firmed by distinguishing two foetal hearts, of different rapidity, 
 heard at two distant points, the sound being lost in the intervening 
 space. By listening with a binaural stethoscope, fitted with 
 separate tube for each ear-piece, it may be possible positively to 
 determine that the two hearts are asynchronous. 
 
 In some cases a large number of limbs can be detected. When 
 
Multiple Pregnancy. 
 
 375 
 
 During this period of waiting care must be taken to listen to the 
 heart of the second child from time to time, since after the birth of the 
 first occasionally a considerable degree of separation of the placenta 
 takes place, and thus the life of the second child may be endangered. 
 If labour is premature by a considerable interval, and a second 
 child is enclosed in a half of a double uterus whose orifice is 
 undilated, it may be advisable to leave it, the first placenta having 
 come away, on the chance that it may be retained some time longer. 
 If, however, the second bag of membranes presents, this chance* is 
 
 Fig. 236.— Uterus Didelphys. 
 
 too remote to justify postponement of the puncture of the 
 membranes. 
 
 If the uterus is inert in the second labour it should be stimulated 
 by external pressure, which may generally be sufficiently exerted 
 by a binder. In some cases, on this account, delivery by forceps is 
 called for. There is a special liability to post-partum haemorrhage 
 after twin pregnancy, partly on account of the excessive size of the 
 placental site, partly because the uterus is apt to be inert after its 
 over-distension. Special care must be taken, therefore, by keeping 
 up pressure on the uterus, to guard against the risk of post-partum 
 ha;morrhage, and it is well to give a dose of ergot after delivery of 
 the placenta — say one drachm of the liquid extract. The physician 
 should also watch the patient longer than usual, before leaving the 
 house. 
 
 Any abnormal presentation must be treated in the usual way. 
 The difficultieH which may arise from both children descending into 
 
376 
 
 The Practice of Midwifery. 
 
 the pelvis together, and becoming interlocked, will be considered in 
 Chapter XXVIII. 
 
 Superfcetation. — It has already been mentioned that by super- 
 fecundation is meant the fertilisation at a second coitus of another 
 
 Fig. 237. — Uterus septus, with septate vagina. 
 
 Fig. 238. — Uterus subseptus. 
 
 ovum belonging to the same period of ovulation. By superfa'tation 
 is meant the fertilisation of a second ovum belonging to another 
 period of ovulation after the iirst ovum has been developing for a 
 month or more. That ovulation may occur during pregnancy is 
 proved by the observations of Ldwenthal, Slavjansky, Martin, and 
 others. 
 
 In extra-uterine pregnancy there is positive evidence that it does 
 occur, for a five months' foetus has been found in the abdomen, and 
 
Multiple Pregnancy. 
 
 377 
 
 a three months' foetus in the uterus. In this case the intra-uterine 
 foetus would be the better situated for getting nutriment, and its 
 inferior development could not be due to failure in this respect. If 
 ovulation occurs up to the time when, at about the fourth month, 
 the decidua vera and refiexa come into contact, and the decidual 
 cavity is obliterated, there is no a priori impossibility in a second 
 ovum becoming implanted upon the developing mucous membrane. 
 
 In the case of a double uterus, whether uterus didelphys, uterus 
 septus or subseptus, or uterus bicornis (see Figs. 236 — 239), there 
 would be no obstacle to the production of super foetation if ovulation 
 ever occurred during pregnancy. When pregnancy exists in one 
 side of such a uterus, a decidua is generally developed on the other 
 side also. Unless this change 
 in the mucous membrane 
 prevented the implantation of 
 the ovum, superfoetation' need 
 not be limited to the first 
 three months of pregnancy, 
 but might occur much later. 
 In some cases of apparent 
 superfoetation the existence 
 of a double uterus has actually 
 been verified. It may have 
 existed in others also without 
 being detected, for if the 
 septum is limited to the body 
 of the uterus, and the os is single, it is not always possible to dis- 
 cover the condition during life, except by dilatation of the uterus. 
 
 Most of the cases, however, which have been adduced as evidence 
 of superfoetation are explicable in other ways. If twins are born 
 together of apparently very unequal development, this may be due 
 simply to one twin having failed to obtain an equal share of nutri- 
 ment, as already described (see p. 370). If the less developed 
 embryo is not alive, it is almost certain that it is simply a case of 
 blighted ovum retained without decomj)osition. The cases which 
 are chiefly relied upon for proving superfoetation are those in which 
 two children, both of which survived, have been born with an 
 interval of some weeks or months between them.^ Even of these, 
 however, most may be explained by supposing that the more 
 developed foetus of twins was born prematurely, and that the other 
 was retained either in a single or double uterus until it became 
 
 Fig. 239. — Uterus Bicornis Unicollis. 
 
 1 For a case of this kind, in which the uterus was double, see a pajicr by Dr. Ross, 
 Lancet, August, 1871. 
 
378 
 
 The Practice of Midwifery. 
 
 fully developed. The strongest evidence in favour of superfcetation 
 is derived from one or two well-established eases in which viable 
 children have been born at an interval of about four months} 
 These. can apparently only be explained by the supposition either 
 that the first child was premature within the limits of viability, and 
 that the second was due to superfcetation within the first three 
 
 Fig. 24:0. — A twin pregnancy. One foetus has attained the age of 3 — 4 
 months, the second is much smaller. There are two placentae and two 
 sets of membranes. (Univ. Coll. Hosp. Med. School Mus.) 
 
 months of j)regnancy, or else that (the first child being born at full 
 term) superfcetation had taken place at a later period of pregnancy, 
 an occurrence which would be possible only with a double uterus. 
 
 Many so-called cases of superfcetation are valueless as proofs of 
 the occurrence of this condition, because those who described them 
 have failed to recognise the difficulty of comparing the develox)ment 
 
 1 Dr. Bonnar, "A Critical Enquiry regarding Superfcetation, with Cases," Ediu, 
 Med. Journ., January, 186.5. 
 
Multiple Pregnancy. 379 
 
 of two children not born at the same time, except with the assist- 
 ance of a very accurate record of their appearances, weights, and 
 measurements. 
 
 A case observed by Dr. Tyler Smith ^ affords some evidence in 
 favour of superfoetation. A woman miscarried at the end of the 
 fifth month, and some hoars afterwards a small clot was discharged, 
 enclosing a perfectly fresh and healthy ovum of about one month. 
 The patient had menstruated regularly during the time she had been 
 pregnant, and was unwell three weeks before she aborted. There 
 were no signs of a double uterus. This case is specially interesting 
 from the coincidence of menstruation during pregnancy with 
 supposed superfoetation, but it is open to the possible doubt that 
 the ovum, though apparently fresh, might have been retained after 
 death without decomposition. 
 
 The conclusion is that in many instances superfoetation has been 
 assumed without sufficient ground, but that in very rare cases there 
 is as strong evidence of its occurrence as the nature of the case 
 permits. Whether in any of these there was a normal uterus is 
 not absolutely certain. 
 
 1 Manual of Obstetrics, p. 172. 
 
Chapter XVIL 
 PHYSIOLOGY OF THE PUERPERAL STATE. 
 
 By the puerperal state is meant the condition of the woman 
 during the time when she is recovering from the effects of labour, 
 and the pelvic organs are returning, so far as they do return, to 
 their former condition. This extends over a period of as much as 
 six weeks in normal cases, and is apt to be extended longer when 
 any disturbance occurs. Though the puerperal state must be 
 regarded as, in the main, physiological, yet it borders very closely 
 on the pathological, and morbid processes very readily arise in it. 
 The tearing across of vessels, formation of thrombi in them, and 
 rapid cell production from the surface of the uterine mucous 
 membrane are different from anything else which occurs under 
 normal conditions. In a large proportion of women, moreover, 
 including all primiparse, there are actual traumatic lesions to be 
 recovered from, consisting of more or less bruising and laceration 
 of the vaginal outlet and vulva, not unfrequently also of the cervix 
 and adjoining cellular tissue. 
 
 The exertion of labour is normally followed by a sense of extreme 
 relief and calm. If, however, labour has been severe, there may 
 be signs of nervous exhaustion. There may be a slight rigor, due 
 to actual chill from the cessation of muscular activity, coupled 
 with the cooling of the skin by perspiration. This is soon relieved 
 by warm clothing. Eefreshing sleep generally soon follows, and 
 does much to restore the patient. 
 
 Pulse and Temperature. — After natural delivery the pulse 
 falls to a normal rate and often to one somewhat below the normal, 
 sometimes as low as 50 or even lower. Sometimes the rate is still 
 further diminished on the second or third day, and a frequency even 
 as low as 30 ^ has been noted. Frequently the pulse regains its usual 
 rate about the third to fifth day, but it may remain low as long as a 
 week ; such retardation of pulse may be taken as a sign that all is 
 going well. Like the temperature, the pulse of lying-in women is 
 
 1 Knapp ; von "Winckel, Handbuch der Geburtshiilfe, Vol. II., Part 1, p. 145. 
 
Physiology of the Puerperal State. 381 
 
 readily affected by slight causes, whether emotional or constitu- 
 tional disturbances, but not to so great an extent. So long as the 
 disturbance is slight, the temperature is a more delicate indication 
 than the pulse. 
 
 The causation of this slowing of the pulse is somewhat complex. 
 It has been attributed to the fall in blood pressure, the diminution 
 in the vascular area due to the cutting out of the placental circula- 
 tion, the rest in bed, reflex stimulation of the vagus with inhibition 
 of its accelerator fibres, and to the j)resence in the blood of various 
 bodies associated with the processes of involution. 
 
 Temperature is often raised a degree or two during the latter 
 part of labour, if at all severe or protracted, and remains elevated 
 for a short time afterwards. Soon it sinks to the normal level, and 
 generally somewhat below it. Throughout the puerperal state, 
 and especially for the first ten or fourteen days, the temperature 
 very easily becomes elevated from any slight cause, readily rising- 
 even as high as 101° or 102°. Such cause may be local inflamma- 
 tion due to laceration of perineum or cervix, mental emotion or 
 shock, irritation of breasts accompanying the secretion of milk, 
 or slight septic absorption at some exposed surface, which does not 
 go on to produce more serious symptoms. Even constipation, or 
 slight imprudence in diet, appears to be capable of causing a rise 
 of temperature. All these causes act more readily on highly 
 neurotic subjects. A rise of temperature about the third day 
 accompanying the secretion of milk has even been considered by 
 many authorities to be a normal occurrence. It does not appear, 
 however, that any notable rise of temperature should be regarded 
 as necessary, or absolutely normal ; and the elevation about the 
 third day is probably due, much more often than was formerly 
 supposed, to a slight septic or traumatic disturbance. The so-called 
 " milk-fever " is not therefore to be regarded as a physiological 
 occurrence. In normal cases, if temperatures are taken only 
 twice a day, it is exceptional to observe a rise of temperature of 
 more than about one degree. Thus of women after normal labours 
 attended in Guy's Hospital Lying-in Charity, on whom observations 
 on temperature were made, a reading above 100° F. at any time 
 was noted in only 12 per cent, even before the introduction of 
 perchloride of mercury as an antiseptic, and no special tendency 
 to elevation about the third day was observable.^ On the other 
 hand, in lying-in hospitals, even when free from any apparent 
 unfavourable influence, a considerable rise of temperature was 
 
 1 Guy's Hosp. Reports, Vol. XVII. 
 
382 The Practice of Midwifery. 
 
 more common previous to the recent perfection of antisepsis, by 
 which pyrexia after delivery has been, to a great extent, banished.^ 
 
 Hence a rise of temperature of more than two degrees should 
 always rouse some anxiety, and be an indication for very careful 
 watching of the patient. But in the absence of corresponding 
 elevation of pulse, or other unfavourable signs, it often proves 
 transient, and does not necessarily mean danger. It is only to be 
 attributed to the secretion of milk when it accompanies some local 
 discomfort, or fulness in the breasts, and subsides as soon as the 
 flow of milk becomes free and normal. 
 
 For the purposes of comparison a standard of so-called morbidity 
 has been adopted in many lying-in hospitals, viz., if the temperature 
 rises above 100° F. on two occasions between the second and the 
 eighth day, the puerperium is considered to be abnormal, and the 
 case is included in the morbidity tables. 
 
 The first day is excluded because transient rises of temperature 
 during the first twenty-four hours are not uncommon and of little 
 imjDortance. 
 
 Secretions and Excretions. — The skin is generally moist so 
 long as the patient remains in bed, and sweating is readily excited. 
 The bowels are sluggish. The secretion of urine is very copious 
 during the first two or three days of the puerperium ; it diminishes 
 about the fourth day and rises again at about the normal amount 
 about the end of the first week, after which it remains practically 
 normal. 
 
 Immediately after delivery, in nearly 50 per cent, of the cases, 
 the urine contains a trace of albumen, possibly due to the strain of 
 a labour. On microscopic examination epithelium cells, red blood 
 corpuscles, and occasionally hyaline casts can be detected, but both 
 these and the albumen have, as a rule, disappeared in normal cases 
 by the end of the first twenty-four hours. Taking into account the 
 light diet and the rest in bed, the excretion of urea is copious, the 
 average amount between the third and fifth day being from 26*5 to 
 30 gms., or approximately the normal amount. 
 
 Peptones are constantly found in the urine, and are attributed to 
 the processes of involution occurring in the muscle fibres of the 
 uterus. The amount excreted increases up to the fourth day, and 
 they disappear about the twelfth day. The quantity present 
 appears to bear some relation to the number of leucocytes in the 
 
 1 Dr. E. S. Tait, " Observations on Puerperal Temperatures," Trans. Obst. Soc, 
 London, 1884, Vol. XXVI., p. 8. 
 
Physiology of the Puerperal State. 383 
 
 blood, and cannot be, as was supposed formerly, attributed to the 
 presence iji utero of a dead and macerated foetus. 
 
 Acetone, on the other hand, which is also found at times in the 
 urine, is said to be specially frequent with such a condition of the 
 foetus. The amount of phosphates and sulphates excreted is at a 
 maximum on the first day of the puerperium ; after this it diminishes, 
 and about the fifth day rises again slightly. The excretion of 
 chlorides is somewhat increased. A slight degree of glycosuria is 
 common, and may be regarded as physiological.-^ It is noted 
 especially when the milk is first secreted. It disappears afterwards 
 if the consumption balances the secretion of milk, but appears 
 again if the breasts become over-full, or the consumption of the 
 milk is checked. It appears, therefore, to be due to resorption of 
 milk-sugar from the secreted milk, or else to elimination of sugar, 
 formed with a view to the lacteal secretion, but not utiHsed. The 
 form of sugar present is said to be lactose, not glucose. This 
 would seem to prove the origin of the sugar to be resorption from 
 the breasts. 
 
 There is commonly some difficulty in micturition for the first few 
 days, due partly to the mere effect of position, partly to the efl:ect 
 of pressure upon the neck of the bladder and the urethra, and partly 
 to slight injuries to the vulva and urethra occurring during labour. 
 Necessity for the use of the catheter is, however, exceptional. 
 
 Involution of the Uterus. — Ehythmical contractions of the 
 uterus continue after the ex]3ulsion of the placenta, and are more 
 or less perceptible for some days afterwards, becoming gradually 
 less marked as the uterus diminishes in size. In the intervals of 
 the active contractions, a certain amount of muscular tonicity 
 normally persists. When the contractions cause a painful sensa- 
 tion to the woman, they are called " after-pains." The rapid 
 diminution in the size of the uterus is closely associated with the 
 lessened flow of blood through it. This lessened flow depends 
 mainly upon two causes : first, the removal of the stimulus caused 
 by the presence of the growing ovum ; secondly, the compression 
 of the vessels produced by the retraction and closure of the emptied 
 uterus and the maintenance of a tonic contraction of its walls. 
 The process of reduction in size goes on most actively for the first 
 week after delivery. After this it continues with diminishing 
 rapidity, and is not complete until from six to eight weeks have 
 passed, 
 
 ' IJe Slrif^ty, " Recherches sur I'Uiinc pendant la Lactation," Gaz. M6el. de Paris, 
 187;i 
 
384 
 
 The Practice of Midwifery. 
 
 Immediately after delivery the uterus occupies the greater part 
 of the pelvic cavity, and is somewhat anteverted and flattened from 
 
 
 1 pS'Oi*''-', 
 
 .h: 
 
 Fig. 241. — Section of the uterus from a patient dying five minutes after 
 delivery. The thickness of the retracted uterine walls, the collapsed 
 lower uterine segment, and the flattening of the cervix against the^ 
 posterior vaginal wall are well shown. (Webster, Pelvic Anatomy, 
 Plate II.) 
 
 before backward. On section a distinction can be made out clearly 
 between the upper uterine segment, the lower segment, and the 
 cervix. The well-marked ring which can be felt through the 
 
Physiology of the Puerperal State. 385 
 
 cervical canal is, as Webster ^ has pointed out, the lower edge of the 
 retraction ring, and not the internal os. The uterus is, as a whole, 
 symmetrically placed in the pelvis, and is not rotated. 
 
 ot 'i^j,-^^-'^,-,. 
 
 Fig. 242. — Section of uterus on the third day of the puerperium. The slight 
 diminution in size of the uterus is to be noted. The flaccid condition 
 of the lower uterine segment has disappeared. |(Webster, Pelvic 
 Anatomy, Plate VII.) 
 
 Owing to the loosening of the attachments of the uterus to the 
 vagina and other structures, it is capable of a considerable degree 
 of movement, and this is well shown in the marked displacement 
 
 1 Webster, Researches in Female Pelvic Anatomy, 1892. 
 
 M. 25 
 
386 
 
 The Practice of Midwifery. 
 
 which may occur as the result of over-distension of the bladder. 
 After the first day the distinction between the three portions of the 
 uterus disappears. 
 
 The dimensions of the uterus immediately after delivery are as 
 
 Fig. 243. — Section of uterus uii sixth day of puerperiiim. The uterus is now 
 below the level of the pelvic brim. (Webster, Pelvic Anatomy, 
 Plate XII.) 
 
 follows : length, 15 cm. (6 inches) ; breadth, 11 — 12 cm. (4f inches) ; 
 depth, 7 — 8*5 cm. (3f inches); thickness of the walls, 3h — 5 cm. 
 (If — '2 inches). At this period the sound passes into the uterine 
 cavity about 11*5 cm. (4| inches), on the tenth day about 10*5 cm. 
 (4^ inches), at the end of the fifteenth day 9"8 cm. (3f inches), at 
 
Physiology of the Puerperal State. 387 
 
 the end of the fourth week 8 cm. (S^ inches), and at the end of the 
 sixth week 7 cm. (2f inches). Webster has shown that, owing to 
 the extreme folding of the lower uterine segment and cervix which 
 is usually present, attempts to measure the length of the uterine 
 cavity with the sound are likely to lead to inaccurate results. From 
 a study of frozen sections he finds the cavity of the uterus to 
 measure 6^ inches (15'5 cm.) at the beginning of the puerperium, 
 and 4f inches (11"5 cm.) on the sixth day. The uterus weighs 
 about 1 kilo, immediately after delivery (35 ounces), at the 
 end of the first week ^ kilo. (17 ounces), at the end of the 
 fortnight J kilo. (11 ounces), and at the end of the third week 
 ^ kilo. (9 ounces). By the end of the seventh week it has 
 regained its normal weight of 50 — 60 grms. (2 ounces). Immedi- 
 ately after delivery the height of the fundus above the pubes is 
 on an average between 5 and 6 inches (12 — 15 cm.), but varies 
 much in different cases. It may be as much as 7 or 8 inches 
 (17"5 — 20 cm.). A few hours after delivery, even up to twelve hours, 
 the fundus generally appears to be higher than before. This is 
 attributed to the filling of the bladder and rectum, which elevate 
 the uterus out of the pelvis. A diminished intensity of the tonic 
 contraction of the uterine wall and a recovery of the tone of the 
 vaginal walls may also contribute to the effect. 
 
 Frozen sections appear to show that there is very little change 
 in the uterus during the first four days of the puerperium, after 
 which as involution proceeds a gradual diminution in size occurs, 
 and at the end of a week the fundus is about three inches (7'5 cm.) 
 above the pubes, the descent of the fundus taking place at about the 
 rate of 1 cm. a day. At the end of two weeks the fundus is 
 still as much as 1^ inches above the pubes, but soon after this 
 it becomes difficult to feel it by external examination alone. 
 
 The mechanism of the process of involution is that the enormously 
 hypertrophied muscle fibres of the pregnant uterus undergo a 
 gradual diminution in size. Some of the older observers described 
 a complete destruction of the muscle fibres with fatty degeneration, 
 but this has not been confirmed by more recent observa- 
 tions. Sanger has made a careful study of the changes occurring 
 in the fibres, and describes a gradual diminution in their breadth 
 and length to such a degree that at the end of involution the fibre 
 is actually shorter than it is in the normal non-pregnant uterus. 
 The fibres have under the microscope a slightly granular and 
 hyaline appearance, which is probably due rather to a process of 
 albuminoid degeneration than to fatty degeneration. The proto- 
 plasm of the fibres, no doubt, is in large part oxidised without the 
 
 25—2 
 
388 
 
 The Practice of Midwifery. 
 
 occurrence of any fatty change. Helme, from a study of the process 
 in the uterus of the rabbit, regards the change as a process of 
 
 Fig. 2i4. — Section of the uterus upon the twenty-sixth day of the puerperium. 
 The uterus is now entirely an intrapelvic organ. (Varnier, Pratique des 
 Accouchements, Fig. 323.) 
 
 peptonisation of the protoplasm with absorption of the soluble 
 material by the circulation and resulting diminution in size of the 
 fibres. Hyaline and granular degeneration also affects the con- 
 nective tissue. He found no evidence of the formation of any new 
 
Physiology of the Puerperal State. 389 
 
 fibres. As we have seen, peptonuria is fairly constant in the puer- 
 perium. Other observers have described a discharge of glycogen from 
 the uterus and a rapid absorption of water during the first twenty- 
 four hours after delivery. It is probable that the process of 
 autolysis, due to the action of intracellular ferments, plays an 
 important part in the changes in the protoplasm of the muscle cells 
 associated with involution. The proper performance of involution 
 depends upon a due action of the absorbent system, as well as upon 
 the diminution of the blood supply. It is apt to be interfered with 
 by any constitutional condition which impairs this, as well as by 
 any cause which prevents the proper contraction of the circulation. 
 According to Sanger,^ three conditions are necessary : increased 
 oxidation, ansemia of the muscle fibres, and continuous retraction 
 and contraction. 
 
 The arteries which have been so greatly increased in size during 
 pregnancy become diminished by the contraction of their calibre. 
 Their walls, however, remain thicker than in the unimpregnated 
 uterus, a diminution in the lumen from obliterative endarteritis 
 occurs, and this change is a permanent one. Thus, in a section of 
 the parous uterus after involution, the arteries, which are apparently 
 more numerous than in the nulliparous organ, project beyond 
 the surrounding surface, present thick yellowish white walls, more 
 opaque than the tissues around, and their canals remain patent. 
 
 The obliteration of the large venous sinuses of the placental site 
 takes place in the following manner : After delivery, thrombi are 
 formed in them.^ Then j)roliferation of the lining membrane 
 takes place ; it undergoes hyaline degeneration, and forms a glassy- 
 looking transparent substance, thrown into folds, reminding one of 
 the appearance presented by a corpus luteum. This folded layer, 
 in some cases, completely closes the channel. In others the centre 
 is occupied by the remains of the thrombus, which has become 
 organised, apparently by the growth into connective tissue cells 
 either of the leucocytes contained in it, or of wandering nuclei 
 from the tissues. These changes are most fully developed at the 
 end of four weeks. But even up to the end of twelve months the 
 convoluted appearance may still be discernible. It may therefore 
 be of great importance as medico-legal evidence of a previous 
 pregnancy.'^ 
 
 1 Siinger, lieitriiKe zui; I'iith. Anat. u. Klin. Med. von Wagner's Schulern, 1S87, 
 p. 134. 
 
 - According to some authorities, thrombosis of the sinuses begins a month or so 
 before delivery, IjiiL it is probaVjlc tliat this is a morbid, not a normal, process. 
 
 " " Changes in the Uterus resulting from Gestation," by Sir J. Williams, Trans, 
 Obst. Soc. London, 1878, Vol. XX., p. 172. 
 
390 The Practice of Midwifery. 
 
 Changes in the Mucous Membrane. — The portion of the 
 decidua vera superficial to the ampullary layer (see Fig. 53, p. 77) 
 normally comes away as a layer blended with the chorion. The 
 remainder, covered with a layer of blood and fibrin, remains attached 
 for a time to the interior of the uterus. Gradually the superficial 
 part of it, consisting mainly of the ampullary layer itself, with some- 
 times portions of the upper cellular layer still remaining attached, 
 breaks up, becomes necrotic, undergoes fatty degeneration, and is 
 discharged in shreds with the lochia. The muscular wall of the 
 uterus is never entirely laid bare, for the deepest layer of mucous 
 membrane remains attached, including the dilated extremities of 
 the glands. The interglandular part of the mucous membrane is 
 reconstituted by proliferation of the connective tissue cells. The 
 cylindrical epithelium lining the new glands, and that which 
 eventually covers the mucous surface, is probably derived from 
 the epithelium which remained at the deepest portion of the old 
 glands, and which undergoes marked proliferation, mitotic figures 
 being very numerous. The new epithelium is fully formed by the 
 middle of the fourth week of the puerperium. 
 
 The Placental Site. — The portion of mucous membrane left 
 over the placental site is thinner than elsewhere, so that the 
 muscular wall is more nearly exposed. The regeneration of 
 mucous membrane takes place more slowly over this surface, 
 and the involution of the uterine substance is also slower at the 
 placental site. Hence, about a week or ten days after delivery, 
 the placental site forms a prominence with uneven surface, convex 
 toward the uterine cavity. This, in some cases, it might be 
 possible at first sight to mistake for a new growth in the uterine 
 wall, or portion of adherent placenta. It remains readily recog- 
 nisable until the sixth week after delivery, and finally disappears 
 during the course of the third month. 
 
 The Cervix Uteri and Vagina. — The internal os takes part 
 in the contraction of the uterine body on the expulsion of the 
 placenta. Contraction is indeed specially marked at this part, so 
 that the internal os can be felt from the inside as a definite 
 ring. It remains, however, for a time large enough to admit one 
 or two fingers. The cervix does not take part in the contrac- 
 tion, and continues for a considerable time thin, soft, and flaccid, 
 having a length of about three inches or more. Its edges are 
 frequently irregular from laceration, and sometimes the lacera- 
 tion extends as deeply as the vaginal reflexion. When the 
 laceration is deep, it is most frequently either on the left side, 
 
Physiology of the Puerperal State. 391 
 
 or bilateral, the cleft on the left side being the deeper. The 
 reason of this appears to be that the occiput is most commonly 
 directed toward the left side, and, escaping first from the ring 
 of the cervix, is most likely to cause laceration of it. The internal 
 OS may remain patent enough to admit the finger for a week or 
 more, but usually ceases to be so after ten days, and is quite 
 reformed by the third week. The cervical canal remains patulous 
 for a longer time, and its involution is not complete till the 
 end of six or seven weeks. Involution of the vagina occupies about 
 the same time as that of the uterus. After a first delivery its 
 outlet remains permanently wider than before, as the clefts which 
 have been torn in it do not entirely unite again, but heal up by 
 granulation. The vaginal rugae reappear about the third week. 
 
 The Lochia — A discharge takes place for the first two or three 
 weeks after delivery, called the lochia, or lochial discharge. It 
 arises from the internal surface of the body of the uterus, with the 
 addition of the secretion of the cervix and vagina. At first the 
 discharge is almost pure blood. With it may be passed large 
 clots, especially if the uterus is not well contracted, so that blood 
 is poured out more freely, and space and time allowed for it to 
 coagulate within the uterus. For the first three days blood still 
 predominates, but is mixed with serous exudation, leucocytes, 
 epithelial cells, shreds of decidua, and fatty and granular cells 
 derived from the degenerating decidua. Clots, generally small, 
 may still be passed from time to time. After the third or fourth 
 day, the proportion of blood diminishes, and that of serous fluid 
 increases. The colour of the discharge, hitherto dark red (lochia 
 rubra or cruenta), now becomes paler {lochia serosa). The propor- 
 tion of blood corpuscles progressively diminishes, and that of the 
 other constituents, especially the leucocytes, increases. About the 
 ninth day the colour becomes yellowish grey, or slightly greenish, 
 from a small quantity of blood being still present {lochia alba, 
 green -waters). The constituents at this time are chiefly leucocytes, 
 granular cells, fat, epithelial cells, and cholesterine crystals. From 
 this time the discharge gradually diminishes until it merges into 
 the character of the non-puerperal secretion. 
 
 The reaction of the lochia is alkaline or neutral at first, while 
 the discharge is abundant. After a few days, as the quantity 
 diminishes, it becomes acid in the vagina, the usual reaction of the 
 vaginal secretion preponderating. The discharge has a peculiar, 
 disagreeable smell, from the secretion of the glands. It very 
 readily ]>ecomes decomposed upon the napkins, but, within the 
 
392 The Practice of Midwifery. 
 
 vagina, it has not normally the odour of decomposition. If such 
 an odour is observed, it indicates the probability of some clots or 
 placenta being retained, unless due to septic infection conveyed 
 from without. It has been found that, after the first day or two, 
 the lochial fluid has a toxic influence, if injected into the tissues 
 of animals, and that this becomes during the first week greater 
 the greater the interval after delivery.^ It is probable that 
 normally, before this deleterious quality is developed, any breaches 
 of surface in the genital canal become covered with granulations, 
 and so protected from absorbing readily. Normally micro- 
 organisms are not present in the uterus. In the discharge from 
 the vagina, saprophytes abound, but the most modern observa- 
 tions appear to show that pyogenic organisms are normally not 
 present.- Cocci, however, are present in greater proportion than 
 in pregnancy, during which condition bacilli preponderate. 
 
 The quantity of the lochial discharge varies much in different 
 women, like that of the menstrual flow, and is apt to be more 
 abundant with those who habitually menstruate profusely. It is 
 also influenced by the age of the patient, being more abundant in 
 young women, the management of the third stage of labour, and 
 the taking of alcohol. Generally the quantity is greater if the 
 woman does not suckle, the stimulus to uterine contraction being 
 lost. After the red colour has ceased, it is apt to return about the 
 fourteenth to twentieth day, especially if the woman gets about 
 too soon or exerts herself too much, no doubt as a result of the 
 dislodgment of small thrombi. 
 
 The total amount of the lochial discharge is from 500 to 1,000 
 gms. (17 — 35 ounces).^ Giles^ estimates the amount, however, as 
 less than 20 ounces. 
 
 In women who do not suckle the periods return as a rule six to 
 eight weeks after their confinement, and in those who do suckle 
 on the cessation of lactation. 
 
 Condition of the Blood. — During the puerperal state the blood 
 exhibits a diminution in the number of red corpuscles and in the 
 amount of haemoglobin during the first two days, a result probably 
 due to the hsemorrhage at delivery and the lochial discharge. At 
 the end of ten days the deviations from the normal as to leucocy- 
 tosis, diminution of red corpuscles, and diminution of hgemoglobin 
 
 1 Kehrer, Arch. fur. Gynak., 1877, Bd. 1], H. 2, p. 348. 
 
 2 Kronig, Bacteriologie des Genitalkanales der Schwangeren, Kreissenden, imd 
 Puerperalen Frau, Leipzig, 1897. 
 
 3 Bumm, Grundriss zur Studium der Geburtshilfe. 
 
 ■* Giles, Trans. Obst. Soc. London, 1893, Vol. XXXV., p. 190 ; Fehling, Wochenbett., 
 p. 18. 
 
Physiology of the Puerperal State. 393 
 
 are reduced, on the average, to less than a third of their amount at 
 the time of delivery. The reduction of the leucocytosis is most 
 rapid during the first three or four days. Thus, on the fifth day, 
 the average count of leucocytes per cubic millimetre is about 
 12,000 as compared with about 21,000 at delivery. The normal 
 count, for healthy young women, is variously estimated at from 
 7,500 to 9,000.^ In using the method of examination of the blood 
 as an aid to the diagnosis of septicaemia, it is important to bear in 
 mind both the normal leucocytosis and its normal rapid diminution. 
 
 Body Weight. — A definite loss in body weight occurs during 
 the puerperium. According to von Winckel, this amounts to about 
 6'8 per cent, of the total body weight, and is mainly due to the 
 lochial discharge and to the milk. It is greater in multiparas and 
 in suckling women. 
 
 After-pains. — The intermittent contractions of the uterus, 
 which continue after delivery, serve to expel any clots which may 
 be retained within the uterus, and assist in diminishing its blood 
 supply. They occur normally in all cases, but are only termed 
 after-pains when they cause a i^ainful sensation, either in conse- 
 quence of the vigour of the contractions or of undue sensitiveness 
 of the uterus. Such after-pains are most marked for the first day 
 after delivery, but they may jpersist, with diminishing severity, for 
 four or five days. They are generally excited by the presence of 
 some clots or shreds within the uterus, but their intensity varies 
 also with the nervous sensibility of the patient, so that, in this 
 respect, they are in some measure analogous to the pain of 
 dysmenorrhcea. They are scarcely noticed when a good continuous 
 uterine contraction is secured from the first, and no clots are 
 formed within the uterus. Thus in primiparge they are absent, 
 as a rule, and are most marked in women who have had many 
 children, or when the uterus has been over-distended, as by twin 
 pregnancy. They are more marked when pains have been feeble 
 during delivery than when they have been violent. After-pains 
 are excited in a reflex manner, as uterine contraction always is, 
 by suckling the infant. 
 
 After-i^ains are thus salutary, in a measure, in that they cause 
 the expulsion of clots. But it is still better to avoid them by 
 preventing the formation of clots. The best prophylactic is to 
 make sure that the uterus is emptied of clots at the completion of 
 
 1 Sec Henderson, " Obsoivations on the Maternal lilood at Term and during the 
 I'lierperiuin," .iourn, of Obstet. and Oyn. lirit. Eiiif)., February, 1!)02, Vol. I., p. ICS. 
 
394 The Practice of Midwifery. 
 
 the third stage of labour, and that a good contraction is maintained 
 afterwards, 
 
 Affcer-pains are distinguished by their intermittent character, 
 and by the absence of tenderness or constitutional disturbance. 
 The fundus uteri may also be felt to harden with the pain. 
 
 Secretion of Milk. — The evolution of the breasts during 
 pregnancy has been already described (see p. 164). The typical 
 appearance of a section of the mammary gland, as generally shown 
 in figures, in which each acinus is regularly lined with a mosaic of 
 polyhedral granular cells, exists only when the function of lactation 
 is in full exercise. Before evolution, and during its earlier stages, 
 the acinus is filled irregularly with cells, whose character varies 
 according to the stage of evolution. By the time of delivery the 
 cells have become large, round, containing a nucleus and fat 
 particles, often vacuolated, and regularly arranged round the wall 
 of the acinus,^ which contains also some mucoid fluid. 
 
 The small quantity of secretion for the first two days after 
 delivery is called colostrum, and does not differ materially from the 
 fluid which may be squeezed from the breasts before delivery. It 
 is a clear, somewhat slimy, mucoid fluid, containing yellowish 
 ojDaque dots and streaks. These dots and streaks are made up of 
 the colostrum corpuscles, large nucleated cells, granular with fat 
 particles. The colostrum corpuscles are polynuclear leucocytes, 
 which find their way into the acini of the breast, take up fat 
 corpuscles, and pass out into the lymphatics and capillaries. 
 
 Milk corpuscles also are already j)resent. Besides having the 
 colostrum corjDuscles, colostrum differs from milk in containing 
 much less casein, but more globulin and lactalbumen ; a precipitate 
 is therefore formed on boiling it. Colostrum has a laxative effect 
 on the infant. If therefore the child is put early to the breast, 
 there is no need to give it the castor oil which many nurses are 
 fond of administering. 
 
 About the third day the breasts become full, congested, sensitive, 
 and often somewhat knotty. The thin bluish milk now appears 
 in abundance, and takes the place of the colostrum. For a while 
 some colostrum corpuscles may still be seen on microscopic 
 examination, but the milk corpuscles, minute round fat globules, 
 now become the predominant constituent. These are formed 
 within the secreting cells, from which they find their way into the 
 interior of the acini. 
 
 It has already been explained that the so-called " milk-fever," 
 
 1 Physiology and Pathology^ of the Breast, by Dr. C. Creighton. 
 
Physiology of the Puerperal State. 395 
 
 to which the synonyms of " ephemera " or " weid " have been 
 given, is not to be regarded as a physiological occurrence, and that 
 a rise of temperature about the third day is often due to some 
 transient septic or traumatic disturbance. Febrile disturbance 
 may, however, be produced about this time by irritation and 
 tension, or a slight degree of inflammation, in the breasts, especially 
 if suckling is difficult at first on account of an undeveloped or 
 flattened condition of the nipples. "When it occurs it is to be 
 regarded as the constitutional disturbance set up by a local 
 cause. 
 
 Composition of the Milk. — The casein is formed by the 
 gland epithelium from the albumen of the blood. The milk-sugar 
 or lactose, as well as the fat in the form of milk globules, is also 
 formed in the gland. The minute oil globules are believed to be 
 kept in emulsion by the dissolved casein forming a film around 
 them. The average proportion of the solid ingredients in human 
 milk is as follows : — Fat, 2"4 per cent. ; casein, 1'9 per cent. ; 
 milk-sugar, 6"3 per cent. ; salts, 0'34 per cent. ; a trace of the 
 lactalbumen, present in the colostrum, still remains, about 0*4 per 
 cent. Hence a precipitate of slight flocculi is formed on boiling 
 milk. The proportion of butter may, however, vary between 2*4 
 and 7 per cent. ; of casein, between 1"9 and 4 per cent. ; of milk-sugar, 
 between 3'5 and 6 per cent. The proportion of fat increases up to 
 the end of the first month and then diminishes, while the proportion 
 of sugar increases for the first three months. 
 
 The quantity of milk, in women who are able to nurse well, 
 increases uj) to about six or seven months, after which it diminishes. 
 This is an indication that it is desirable, at this time, to begin to 
 give the infant other food in addition. As time goes on the 
 relative proportion of casein becomes greater, that of butter and 
 milk-sugar less. In feeble women the milk often diminishes or 
 disappears after three or four weeks, either because the supj)ly to 
 the system derived from the involution of the uterus then fails, or 
 because the woman is not strong enough to produce milk in addition 
 to the expenditure of energy in being up and about. 
 
 Diagnosis of the Puerperal State. — The woman has the 
 general appearance of having passed through some illness, especially 
 if delivery Ijas been concealed. The abdomen is often slightly full, 
 but lax, and the skin wrinkled. Skin cracks (linese gravidarum), 
 red or white, are generally present. Pigmentation is usually 
 visilde in various parts, and especially in the form of a central dark 
 
396 The Practice of Midwifery, 
 
 line from ensiform cartilage to pubes. This becomes much more 
 marked during the first few days after delivery than it is during 
 jjregnancy. The breasts are full, generally contain colostrum or 
 milk, and show the other changes associated with pregnancy and 
 lactation. The fundus uteri can usually be felt above the pubes 
 up to about the fourteenth day. For a much longer time its large 
 size can be detected on bimanual examination. The vagina is lax 
 and gaping, and often shows lacerations, especially at the border of 
 the perineum ; the hymen, if any of it remains, is torn completely 
 to its base. The cervix is soft and patulous ; its edges often show 
 lacerations or bruising. The internal os is smaller, but may be 
 large enough to admit the finger into the uterus. The lochial 
 discharge will generally be present, its character depending upon 
 the interval since delivery. The characteristic softness of the 
 tissues in the puerperal state, especially of the cervix, vagina, and 
 perineum, is absent in pathological conditions, or after operations 
 within the pelvis. 
 
 Diagnosis by these signs will rarely be difficult within ten or four- 
 teen days after delivery. In case of doubt, toward the end, or after 
 the end, of that period, observation of the progressive diminution 
 in size of the uterus may be of value. An apjDroximate estimate 
 may be formed of the date of delivery by the height of the fundus 
 uteri above the pubes, by the character of the lochia, of the secretion 
 in the breasts, whether colostrum or milk, by the condition of any 
 lacerations, whether granulating or cicatrised, and by the degree of 
 relaxation of cervix and vagina. 
 
 Diagnosis of Parity. — To diagnose, after a considerable 
 interval, whether a living woman has borne children, is often 
 difficult. The most reliable signs are to be found in the conditions 
 of the vaginal outlet and hymen. From the eftect of coitus, the 
 hymen only becomes notched at its edges, while the whole circuit 
 of its vaginal attachment may still be traced as intact. After 
 parturition, in some cases, it is broken up into sections, separated 
 from each other by smooth patches of mucous membrane, the 
 result of lacerations reaching completely down to the vaginal wall. 
 In others, the hymen is only represented by projecting tags of 
 mucous membrane here and there, the so-called carunculse myrti- 
 formes ; while in others again, in which the broken-up fragments 
 have sloughed away after labour, no trace of it remains. This 
 characteristic condition of the hymen in the parous woman is 
 produced, not merely by its more extensive laceration, but by the 
 sloughing of some intermediate portions from the eftect of bruising 
 
Physiology of the Puerperal State. 397 
 
 and pressure. The only thing which could possibly simulate the 
 effect of parity in a nulliparous woman is the delivery of a large 
 tumour, such as a fibroid, through the vagina. Deficiency of the 
 perineum, indicating a former rupture, is a valuable sign when it 
 exists. 
 
 The presence of white lines on the abdomen (lineae gravidarum), 
 indicating old skin cracks, justifies only a suspicion of a previous 
 pregnancy, for these may result from distension by a tumour, or 
 even merely by fat. 
 
 Changes in the Cervix. — Changes in the cervix are significant when 
 observed, but their absence proves little or nothing, since, when no 
 
 '\ 
 
 Fig. 245. — External views of the nullipai'ous and parous uterus. 
 
 laceration occurs, the cervix may return almost completely to its 
 former condition. As a rule, in the nulliparous uterus, the os is 
 oval, smooth, and comparatively small. In the parous uterus it is 
 a wider lateral cleft, dividing the cervix more or less into an 
 anterior and posterior lip. If there is a deep lateral cleft on one or 
 both sides, especially if the anterior and posterior lips are rolled 
 apart, and so altered by hyperplasia that they offer some resistance 
 when an attempt is made to draw them together, the evidence is 
 still stronger. These conditions of the cervix may be recognised 
 by digital touch alone, and the conclusion may also be confirmed 
 by examination through the speculum. A Sim's speculum should 
 be used, and given to an assistant to hold. To demonstrate any 
 eversion of the cervix, the physician should take a Sim's sharp 
 tenaculum hook in each hand, fix one in each lip of the cervix, 
 
398 
 
 The Practice of Midwifery. 
 
 crossing the shanks, and draw the two Hps together, thus rolling 
 inward any intra-cervical mucous membrane which has become 
 everted. 
 
 Differences between Nullijjarous and Parous Uterus. — It may be of 
 critical medico-legal importance, in identifying a dead body, to 
 determine whether the woman has borne children or not. To 
 decide this point, the examination of the uterus is most im- 
 portant, and such examination may be possible when external 
 parts are defaced by decomposition. As a rule the parous uterus 
 is larger than the nulliparous, and its walls thicker. No decisive 
 importance must, however, be attached to this sign, since a 
 
 / 
 
 V 
 
 Fig. 246. — Sections of the nulliparous and parous uterus. 
 
 nulliparous uterus may be hypertropi)ied, and a parous uterus may 
 undergo super-involution until its walls become extremely thin. 
 The most ready distinction is to be found in the shape of the 
 organ. In the nulliparous uterus, the top of the fundus externally, 
 as seen from the front or back, is almost level, scarcely rising 
 above the line of the broad ligaments ; in the parous uterus, it is 
 markedly convex, rising considerably above that line (Fig. 245, 
 p. 397). Again, if a longitudinal section is made from side to side, 
 passing through the cavity, in the nulliparous uterus, the walls of 
 the body are seen to be convex inward, leaving but a small cavity ; 
 in the parous uterus they are concave inward, leaving a much 
 larger cavity (Fig. 246). 
 
 The convoluted margins of the old sinuses of the placental site, 
 if observed, afford absolute evidence. These are distinguishable 
 
Physiology of the Puerperal State. 399 
 
 for some months, and, according to Sir J. Williams (see p. 389), so 
 long as twelve months. Pigmentation at the placental site may 
 also be observed. The thickened appearance of the arteries in the 
 uterine wall is a permanent condition (see p. 389). 
 
 Most, if not all, of these signs, with the exception of the con- 
 voluted walls of the sinuses, might possibly be simulated after 
 the growth of a large fibroid tumour, and its delivery through the 
 genital passages. The eversion of the lips of the cervix may result 
 from a bilateral incision, sometimes made with the view of curing 
 dysmenorrhoea. 
 
 The New-born Infant. 
 
 The change of circulation which takes place immediately after 
 birth has already been described (see p. 123). After birth, the left 
 ventricle being now distended by blood at a higher pressure, and 
 having harder work to do, quickly becomes larger and thicker, in 
 proportion to the right, than it was during foetal life. 
 
 The rectum soon becomes active, and expels the meconium, which 
 is sterile at birth, but rapidly becomes infected during the first few 
 days of life with numerous organisms partly through the mouth and 
 partly through the anus. In two or three days the motions assume 
 the ordinary faecal appearance, becoming yellow instead of green. 
 The bowels normally act at intervals of a few hours, the motions 
 being soft, of about the colour and consistency of mustard. The 
 'urine is copious after the first few days of life, owing to the liquid 
 character of the food, and has a specific gravity of 1005 to 1008. 
 The amount of urea excreted in the urine increases rapidly from 
 •06 — '11 grammes on the first day to "8 grammes on the seventh day.^ 
 During the first four days of life the urine also constantly 
 contains a small quantity of albumen. ^ 
 
 Up to the third or fourth day, when it obtains for the first time 
 an ample supply of milk, the child loses weight. It regains its 
 original weight at the end of about a week, and from that time 
 increases progressively. The temporary loss may be as much as 
 seven or eight ounces, and is certainly dependent upon the 
 insufficient supply of food during the first few days of life. 
 
 The remnant of the umbilical cord dries up from the extremity 
 toward the umbilicus, undergoing aseptic necrosis, and a line of 
 demarcation is formed close to the edge of the skin, at which it is 
 separated generally on the fourth or fifth day, sometimes later. A 
 
 ' Housing, Zeitschr. f. Geb. u. Gyn., 1895, Bd. 33, p. 3(i. 
 ^ (j'/Mvny and Keller, Des Kindcscrnahrung, 1902. 
 
400 The Practice of Midwifery. 
 
 granulating surface is left, which cicatrises in a few days. The 
 caput succedaneum generally disappears after a day or two, and in 
 a few days, or within two weeks at the utmost, the head returns to 
 the original shape, from which it had been altered by the moulding 
 produced in delivery. 
 
 For a week or more the skin is red and superficially congested ; 
 and desquamation of the cuticle, generally in fine flakes, begins 
 about the sixth to seventh day, and continues for one to three 
 weeks. Within the same time, the mammary glands, both of boys 
 and girls, are apt to become red and swollen, and may produce a 
 mucoid secretion containing colostrum bodies and milk globules, 
 and rich in albumen and salts. This condition is to be regarded 
 as forming a part of the cutaneous hyperfemia. The slight 
 inflammation passes off in a few days, unless the glands are 
 irritated by manipulation. 
 
 When the hypersemic redness of the skin is beginning to pass off, 
 toward the end of the first week, sometimes as early as the second 
 or third day, the skin often becomes coloured yellow by jaundice, 
 or apparent jaundice, and the conjunctivae partake of the same tint. 
 Generally the appearance of the faeces is unaltered, the urine is not 
 pigmented, and the infant does not appear to suffer much in health. 
 The yellow colour usually subsides and disappears after about a 
 week. There has been some doubt whether this condition is true 
 jaundice or not. 
 
 There are probably three varieties of icterus neonatorum to be 
 distinguished : the so-called simple or idiopathic jaundice ; that' 
 which follows umbilical infection with sepsis, or is associated with 
 such a condition as syphilitic or interstitial hepatitis ; and, lastly, 
 the jaundice associated with hsemoglobinuria neonatorum, of which 
 the exact nature is uncertain.^ 
 
 It is probable that idiopathic jaundice may be set up in some way 
 not fully explained, in connection with the sudden change at birth 
 in the circulation through the liver, leading to slowing of the 
 portal circulation.^ But the slighter forms of apparent jaundice, in 
 which faeces and urine are unaffected, are ascribed by some writers 
 to changes in the blood. It is supposed that a surplus of red 
 corpuscles is broken up in the circulation, and that colouring matter 
 derived from heematoidin transudes into the tissues. The yellow 
 tint, when manifested in this slighter form, generally passes off 
 without treatment within about a week. 
 
 1 Ballantyne, Antenatal Pathology : The Foetus, 1902, p. 67. 
 
 2 The diminution of pressure in the capillaries of the liver would at any rate diminish 
 the resistance to the passage of secreted bile into the circulation. 
 
Chapter XVIIL 
 
 MANAGEMENT OF THE PUERPERAL STATE. 
 
 In the 'management of the puerperal state, the most essential 
 points are to secure for the lying-in woman rest, both bodily and 
 mental, for a sufficient period, and to prevent the entrance of any 
 septic poison by the most careful regard for surgical cleanliness 
 and hygiene. The susceptible condition of the nervous system 
 which exists during pregnancy continues, and is even more marked, 
 during the puerperal state. It is important, therefore, to see that 
 the patient is not excited by the visits of friends, or by too many 
 persons in the room ; and to protect her, as far as possible, from 
 any source of painful emotion. 
 
 Cleanliness. — All soiled linen and sheets should be removed 
 after delivery, and not kept in the room. The diapers used to 
 absorb the lochial discharge should be changed frequently, before 
 they become offensive to smell. Antiseptic wood-wool diapers, or 
 the " ladies' sanitary towels " stuffed with absorbent cotton, are 
 preferable to the ordinary diapers, since the latter may not have 
 been perfectly purified in the wash. Sterilised pads of cotton wool 
 wrapped in sterile or antiseptic gauze, secured by a T-bandage, are 
 best of all, and should be used at any rate in hospital practice. 
 Linen and sheets must be changed whenever they become soiled. 
 A fire in the room is useful, for the sake of ventilation, when the 
 weather is not warm enough to allow a window to be kept open. 
 Care should be taken that the lying-in room is not exposed to foul 
 air from a water-closet, or to access of sewer gas, or other septic 
 exhalations. The room should be aired occasionally, if the window 
 is not open, care being taken to protect the patient from draught. 
 For this purpose the window may be opened for a minute or two. 
 several times a day, even in winter, the patient's head being covered 
 meanwhile with a shawl. It is better not to darken the room, 
 except when the patient finds the light trying, for light is healthful 
 both to mother and infant. The external genitals should be washed 
 several times a day with an antiseptic, such as perchloride of 
 mercury 1 in 2,000, or lysol in 1 per cent, solution. For this 
 purpose sponges should not l>e used, Ijut tampons of absorbent 
 
 M. 26 
 
402 The Practice of Midwifery. 
 
 cotton, which are afterwards destroyed, and in all cases the cleansing 
 should be done from before backwards. 
 
 After labour in a normal case the genital canal may be regarded 
 as free from all pathogenic organisms, and it should be the constant 
 endeavour of the nurse to keep it so. No manipulation of any kind 
 must be carried out by the nurse about the genitalia without a 
 preliminary scrubbing of her hands with soap and water and soak- 
 ing them for a sufficient length of time in an efficient antiseptic 
 solution. 
 
 The triumph of antisepsis in lying-in hospitals was at first 
 obtained by the routine use of mercurial douches 1 in 2,000 during 
 the puerperal period, in addition to the employment of mercury 
 as an antiseptic for hands. The recent tendency in them, however, 
 is to discard douches in normal cases ; but other precautions have 
 been substituted. Thus at the Maternity Hospital of New York 
 douches of cyllin emulsion 1 per cent, are used before delivery. 
 The genitals are washed with the same after delivery, and an 
 occlusion bandage is then applied containing a pad wrung out of 
 the same cyllin emulsion. This is changed every two hours, or 
 whenever the i>atient passes urine. 
 
 In private practice, routine douches in normal cases have been 
 almost completely abandoned, since, if the nurse is not very careful in 
 her antisepsis, septic infection may be introduced by means of the 
 douche. They may be called for if the lochial discharge becomes 
 offensive. The antiseptic should be an efficient one, not too diluted ; 
 and, as an additional security, the water should in all cases be 
 sterilised by boiling. If used at all, the irrigation should be used regu- 
 larly at least twice a day. Otherwise the vaginal tube may rub off 
 some granulations, and leave a spot more prone to the absorption of 
 the septic material allowed afterwards to form. 
 
 For use in private practice, a solution of chinosol 1 in 400 to 600 
 appears to be an efficient non-j)oisonous antiseptic. Iodide or 
 perchloride of mercury 1 in 4,000 may, however, be used without 
 risk of producing poisonous effects, provided that the nurse is 
 skilled and that care is taken that no excess remains in the vagina. 
 The iodide is reputed more highly antiseptic and less poisonous 
 than the perchloride, but it more often causes irritation to the 
 vagina. Cyllin 1 in 200 to 400, lysol 1 per cent., and tincture of 
 iodine 5i. — ij. ad Oj., are also good antiseptics. 
 
 The syringing may be carried out by a douche can or by an 
 irrigator, a round bed -pan, or, better still, a " ladies' bed-bath," 
 being placed under the patient's hips. The douche can should be 
 placed but a few feet above the level of the patient's body, and to 
 
Management of the Puerperal State. 403 
 
 avoid the entrance of air into the vagina a Httle of the fluid should 
 be allowed to run through the vaginal tube before it is introduced. 
 Great care must be taken to cleanse efficiently the vulva })efore the 
 douche is given. The vaginal tube should be of glass, and should 
 be sterilised by boiling, or immersion in perchloride of mercury 
 1 in 1,000. 
 
 Diet and General Management — Immediately after labom% it 
 is a good plan to give some liquid nourishment, such as beef-tea, 
 or an egg beaten up in hot milk. After the baby has been washed 
 and dressed, and soiled linen removed, the patient should be allowed 
 to sleep. If labour has been unusually severe, and the patient is 
 restless, an opiate may be given, but it is preferable not to give one 
 as a general rule. If after-pains are unusually troublesome, a few 
 half-drachm doses of ergot repeated every four hours with or without 
 a mild anodyne,^ rather than opium or morjDhia, are generally 
 sufficient to meet the case. It was formerly the custom to keep 
 lying-in patients on low diet, with the idea that such a regimen was 
 antiphlogistic. It is now agreed that the better they are nourished 
 the more likely they are to resist disease. Frequently women do 
 not care for meat, or for much solid food, for the first two or three 
 days, and, in that case, there is no advantage in pressing the 
 appetite. They should then have nourishing food in a digestible 
 form, a fair allowance of milk in some shape, as well as soup or beef- 
 tea, tea or coffee with toast or bread-and-butter, eggs, or milk gruel, 
 according to taste. There is, however, no harm in giving fish, 
 chicken, or digestible meat even before the third day, if the patient 
 likes it, and in the absence of any rise of temperature or constitu- 
 tional disturbance of any kind. After this time, in the absence of 
 febrile disturbance, she may take ordinary simple diet in reasonable 
 quantity, allowance being made for the fact of her being quiet in 
 bed, and, on the other hand, for the material required for lactation. 
 In the absence of lactation, less ample diet is required. 
 
 The physician should visit the patient within twelve hours after 
 delivery, and daily for the first week. He should note pulse and 
 temperature at each visit, unless there is a nurse who is able to 
 record these night and morning. The first signal of any disturb- 
 ance will often be given by a rise of temperature. At the first 
 visit he should inquire whether urine has been passed, and, if the 
 quantity passed is very little, he should make sure, by abdominal 
 palpation, whether there is any distension of bladder. In case of 
 
 ' The following is a useful formula : — Potass. Bromicl., gr. x. ; Tirict. Hyoscyaini, ss. ; 
 Sp. Carnphora!, rr^ xv. ; Mucilag. Aeaciie, 5j. ; Aq., ad Jj. ; to be taken occasionally, 
 
 26—2 
 
404 The Practice of Midwifery. 
 
 retention, the catheter must be used at least twice a day. To 
 prevent the setting up of cystitis by carrying septic matter into the 
 bladder, the patient should be placed in the left lateral position, 
 the lochia should, just before the introduction of the catheter, be 
 washed away from the vulva by an antiseptic solution, such as 
 mercuric iodide 1 in 4,000, and the catheter, washed in a solution 
 of perchloride or iodide of mercury 1 in 1,000, and anointed with 
 an antiseptic lubricant, such as lano-cyllin or perchloride of 
 mercury 1 in 1,000 glycerine, should be passed into the urethra by 
 sight, A glass catheter, which can be sterilised by boiling water, 
 is the safest to use, care being taken to push it only just far enough 
 into the bladder to allow the urine to flow. For the first twelve 
 hours at any rate, the urine must be passed in a horizontal position 
 over a bed-pan, and this position is often a chief cause of the 
 difficulty. After that time, if there is no excessive sanguineous 
 discharge, the patient may, if necessary; be allowed to kneel up to 
 pass her urine, or to sit up on the bed-bath, or turn over on to her 
 face. For it is always desirable to avoid the use of a catheter if 
 possible. She should be encouraged to vary her position in bed 
 from time to time. If she lies constantly on her back, the lochial 
 discharge is dammed up in the vagina by the perineum ; if she is 
 always on one side, it may be retained in the uterus, the fundus 
 bagging over to the dependent side. The kneeling up to pass 
 urine, after the time has passed when it would cause risk of 
 haemorrhage, has the advantage that it assists the escape of the 
 discharge. With the same object, after the first day or two, if 
 the patient is doing well, she may be supported in a sitting 
 position to take her meals. She should also be in the sitting 
 posture, or have the shoulders supported by pillows, to give the 
 infant the breast. These expedients are more called for when the 
 plan of vaginal irrigation is not employed. So long as the patient 
 is doing well, it is not desirable to make vaginal examinations. If 
 there is occasion for doing so, the hand must be well washed with 
 soap and water and then disinfected in the usual manner with 
 spirit and a solution of perchloride of mercury 1 in 1,000. 
 
 To obtain early warning of any septic or inflammatory mischief, 
 it is desirable not only to keep a record of temperature, taken at 
 least twice a day, but to record the progress of involution, as indi- 
 cated by the height of the fundus above the symphysis pubis. 
 Bladder and, if possible, rectum should be empty when the obser- 
 vation is taken. A convenient mode^ is to record the height of 
 
 1 " Notes on the Variation in the Height of the Fundus Uteri during the Puer- 
 perium," Stevens and Griffith, Trans. Obst. Soc. London, 1895, Vol. XXXVII., p. 2i6. 
 
Management of the Puerperal wState. 405 
 
 the fundus on the temperature chart, taking the line representing 
 each degree of temperature above lOO'^ as representing also each 
 inch above the i3ubes. Examples of this are shown in Figs. 247, 248. 
 
 M'EM'EM-EM-EM-EM-EM- EM-EM- EM- E M- EM-EM- E.M-E 
 
 99° 
 NORMAL 
 
 Fig. 247. — Chart showing involution of uterus. Average of thirty-four cases. 
 (After Stevens and Griffith.) 
 
 Fig. 248. — Chart showing involution of uteius. Saprsemia. Effect of one douche, 
 and clearing out uterus. (After Stevens and Griffith.) 
 
 Fig, 247 shows the curve obtained from an average of thirty-four 
 cases ; Fig. 248 illustrates the effect of saprremia in checking in- 
 volution, and the result of one douche and clearing out uterus. 
 
 If possible, the patient should keep her bed for ten days, or for a 
 longer time, if the discharge is still sanguineous, and she should 
 
4o6 The Practice of Midwifery. 
 
 return to it, if getting up brings on again a red discharge. On first 
 leaving it, she should spend much of her time reclining on a sofa, 
 and should not return completely to her ordinary mode of life, or 
 undertake severe exertion, till the end of six weeks, at which time 
 involution ought to be fairly complete. In the case of a primipara, 
 when there has been much laceration, or bursting of soft parts, it is 
 often desirable for the recumbent position to be maintained, for the 
 most part, for three or even four weeks. 
 
 Action of the Bowels. — It is usual to secure an action of the 
 bowels on the second or third day, and it is not desirable to leave 
 them confined longer than this. If the patient does not dislike it, 
 and the nurse is skilful, a copious enema of soap and water avoids 
 the necessity of an aperient. Otherwise a mild laxative may be 
 given. The traditional castor-oil is often disliked. If not, it may 
 be given in a dose of two to four drachms. Or its place may be 
 taken by the compound liquorice powder, or tamar indien, or the 
 following pill: — Ext. Aloes Socot., gr. f ; Ext. Nucis Vomicae, gr. ss.; 
 Ext. Hyoscyami, gr. iij.; Pulv. Glycyrrhiz., q.s. 
 
 Lactation. — Not only does the infant thrive better when suckled 
 than when fed artificially, but it is most important for the mother 
 herself to suckle at least until the completion of involution, that 
 she may not lose the stimulus to tbe contraction and involution of 
 the uterus associated with the performance of tbat function. Even 
 if the milk is deficient in quantity or poor in quality, she should at 
 least partially nurse her infant for the first four or six weeks, if no 
 longer. The chief causes which should prevent this are entire 
 absence of milk, or nipples which are useless for suckling either 
 from flattening, want of development, or cracks which render 
 suckling too painful, or the occurrence of acute mastitis. Lactation 
 should not be continued after the puerperal period, either if the 
 milk is poor in quality, so that the child does not thrive upon it, or 
 if the mother's health is so delicate that injury to her from it is to 
 be feared, especially if she has a tendency to phthisis, or belongs 
 to a strongly phthisical family. Suckling must be prohibited if the 
 mother is suffering from any acute illness, and in certain cases of 
 mal-development, such as cleft palate or hare-lip, the child may be 
 unable to suck. 
 
 The child should be put to the breast for the first time within 
 twelve hours after delivery, when the mother has had some sleep. 
 For the first two days suckling should be repeated only two or 
 three times a day. As soon as the milk is freely secreted, about 
 
Management of the Puerperal State. 407 
 
 the third day, the infant should be accustomed to take the breast at 
 regular intervals of about two hours, a httle later at three hours' 
 interval, and afterwards four hours. During the night it may be 
 allowed to sleep as long as it will, so that, if possible, the mother 
 may not be disturbed more than once. Eight or nine feedings at 
 first in the twenty-four hours are usually sufficient. No other 
 food is generally necessary before the secretion of milk, but if the 
 infant appears hungry, a few teaspoonfuls of water and sugar or 
 milk and water, one of the former to three or four parts of the 
 latter, may be given ; or, if sterilised, cows' milk may be given 
 undiluted. 
 
 The duration of each feeding may vary from five to twenty minutes, 
 according to the strength of the child and the ease with which it can 
 obtain the milk. About ten minutes is an average. If the milk 
 is vomited or curds appear in the stools, it is generally a sign that 
 the child is taking more than it requires or can digest. 
 
 The child should be weighed at least twice a week. It should 
 regain its birth weight in ten days, and afterwards gain about five 
 ounces a week for the first two or three months. 
 
 The child should lie in a bassinette, and not in the bed with its 
 mother. It should never be allowed to go to sleep with the nipj)le 
 in its mouth. After suckling, the nipples should be washed, 
 carefully dried, and anointed with glycerine of borax. This does 
 much to prevent their becoming cracked. The child's mouth should 
 also be washed out with a piece of linen rag dijDped in clean boiled 
 water. By this means the production of thrush, by the growth of 
 a fungus, o'idium albicans, in the mouth, is prevented. It is a good 
 plan to wash the nipples before the suckling as well as afterc 
 Both breasts should be used at each time of nursing, that the 
 tension may be equally relieved, if both are tense ; otherwise they 
 may be used alternately. Primiparse may require instruction in the 
 mode of supporting the infant on the arm in a nearly horizontal 
 position, and adjusting the nipple, so that the nostrils are not 
 obstructed by pressing against the breast, but are free for breathing. 
 It may be necessary for the mother to press down the areola by one 
 finger placed above, the other below it, especially if the breast is 
 tense or the nipple flattened. 
 
 The breast may become knotty and painful, when the milk is first 
 secreted, from the secretion not escaping freely through the ducts. 
 Gentle friction in the direction of the nipple is then useful, and, if 
 the infant is not able to suck strongly, it may be desirable to draw 
 a little milk with a breast glass, fitted with elastic tube and mouth- 
 piece. If, however, suckling is not intended, and the milk is to be 
 
4o8 The Practice of Midwifery. 
 
 suppressed, all friction or drawing of the breasts should be avoided. 
 The breasts should be supported, if swollen and tender, and gentle 
 pressure made upon them. This may be done by covering each 
 breast with a thin layer of cotton wool, and compressing it with two 
 large handkerchiefs, one tied above the opposite shoulder, the other 
 below the opposite armpit ; or both breasts may be supported and 
 gently compressed by a carefully adjusted bandage, the nipples 
 being left free, or a muslin binder padded with wool may be applied 
 round the chest. This is often the most comfortable support. At the 
 same time the woman should drink little, and the bowels should be 
 kept acting freely by a saline laxative, such as sulphate of magnesia. 
 If necessary, belladonna may be used for its local influence in 
 checking the secretion of milk, or may be given internally. The 
 best method is to smear the breasts with glycerine of belladonna ^ 
 or to apply an evaporating lotion containing belladonna.^ Iodide of 
 potassium, which has a specific action in checking the gland activity, 
 may also be given in twenty-grain doses, three or four times 
 repeated. 
 
 If the mother's milk is insufficient in quantity, 1,000 to 1,200 
 grammes, 35 to 42 ounces — being the average amount secreted daily, 
 she should suckle at longer intervals, and the breast should be supple- 
 mented by cows' milk suitably diluted, or sterilised, and given by 
 the bottle. This plan is much better for the infant than an 
 entirely artificial diet, although with the lower classes it is often 
 necessary to combat a prejudice against " mixing the milks." If, 
 on the contrary, the milk is excessive, the mother should drink 
 less liquid, and the bowels should be kept acting freely. It is 
 rarely necessary to draw off the excess with a breast-glass, as the 
 milk usually runs away spontaneously. 
 
 The only mode of maintaining or increasing the secretion of milk 
 is to give a diet with plenty of liquid, and a reasonable abundance 
 of nitrogenous food, especially meat, fish, and vegetable food 
 containing much nitrogen, such as lentils, beans, or peas. A 
 moderate quantity of stout or beer is advantageous if it does not 
 disagree. The so-called galactagogues (such as castor-oil leaves 
 locally apj)lied) are not to be relied upon. Pilocarpine in small 
 doses is reputed to be the most efficient. 
 
 Management of the New-born Infant. — As soon after delivery 
 as the nurse's attention is no longer required for the mother, she 
 washes and dresses the child, which has meanwhile been covered up 
 
 1 Ext. Belladonnse, gr. Ix. ; Glycerini, §j. 
 
 2 Lin. BelladonDfe, 3iv. ; Lin. Aconiti, 3ij. ; Spt. Vini Eectif., 3iv. ; Aq. RosfB, Jx, 
 
Management of the Puerperal State. 409 
 
 in a piece of flannel. Before or affcer the bath the medical attendant 
 should carefully examine the baby so as to make sure that it has no 
 defect or malformation such as supernumerary digits, imperforate 
 anus, or cleft palate. To bathe it, the nurse places the baby in a 
 warm bath, and washes it all over with soap and water. First of 
 all the eyes, and their neighbourhood, which have already been 
 wiped clean from mucus, should be carefully cleansed by means of 
 a piece of soft linen rag dipped in clean water or, better, boric acid 
 lotion. If the vernix caseosa be unusually adherent, it may be 
 softened by smearing cold cream or olive oil over it, but too much 
 friction in removing it should be avoided. The mode of treating 
 the funis traditional with nurses is to wrap it in a piece of linen in 
 which a hole has been burnt, through which to pass the funis, and 
 to change the piece of linen daily. It is preferable to wrap it in a 
 piece of absorbent gauze, several layers together, or in absorbent 
 cotton, after dusting it with boric acid powder. The funis is then 
 turned upward on the abdomen, and kept in place by a binder, which 
 should not be too tight. After the funis has dropped off, a small 
 flat pad of dry linen or boric lint should be j)laced over the umbilicus 
 until it has completely cicatrised. 
 
 The clothing of the infant should be warm, but not tight enough 
 to compress thorax or abdomen, or interfere with the movement of 
 the limbs. A diaper folded in a triangular shape is used. The 
 anterior corner is brought up between the thighs over the abdomen, 
 and kept in place by tbe lateral corners tied across it ; no pins 
 should be used about the baby. To prevent excoriation of the skin, 
 it is of great importance to change the diaj^ers as soon as they are 
 wetted or soiled, and to cleanse and dry the buttocks. The child 
 will generally give notice by crying when it has passed any evacua- 
 tions. The child should be washed in a warm bath every day, and, 
 after the first few weeks, morning and evening. The flexures should 
 be thoroughly dried after washing, and dusted with pure starch 
 powder. For the comfort of the mother it is desirable to accustom 
 the infant, from the first, to go to sleep, laid quietly in its cradle, 
 without nursing or rocking to sleep. 
 
 Selection of a Wet-nurse.— When a mother is unable or 
 unwilling to nurse, nourishment by a wet-nurse is undoubtedly 
 more favourable for the child than bottle-feeding, as ordinarily 
 carried out. With a patient of the upper classes, therefore, this 
 alternative may be recommended ; but the necessity for it is, to, a 
 great extent, done away with where humanised milk, or the specially 
 prepared " modified milk," can be procured. 
 
4IO 
 
 The Practice of Midwifery. 
 
 The wet-nurse should have the appearance of good health, and 
 be free from any sign or suspicion of syphilis, scrofula, or tuber- 
 culosis. She should also have sound, well-developed nipples, 
 well-developed breasts, not too fat, and the milk should flow from 
 them easily. The best age is between 20 and 35. It is preferable 
 that the age of her infant should not be too far removed from that 
 of the one to be nursed, but it should be older rather than younger. 
 The best test of the quality of her milk is the condition of her own 
 infant. This should also be inspected most carefully, especially 
 about the buttocks, to make sure that there is no eruption or other 
 sign suggesting any possibility of syphilitic taint. If the milk is 
 specially examined, it should have a specific gravity of about 1030, 
 give a percentage of cream as much as 3 per cent, by lactometer, 
 and under the microscope show abundant milk globules, no colos- 
 trum corpuscles. If the infant, after fair trial, does not thrive with 
 one wet-nurse, it may be necessary to change her for another. 
 
 The diet of the wet-nurse and amount of exercise taken should 
 be, as far as possible, what she has been accustomed to. If she 
 is put upon an unnecessarily rich diet, and leads a more inactive 
 life than before, the milk is apt to fail. Two meals of meat in the 
 day, and about a pint of stout or beer, if she is accustomed to take 
 alcohol, may be given. 
 
 Artificial Feeding. — A large part of the mortality of hand-fed 
 children in the lower classes is due to the fact that farinaceous 
 food is frequently given within the first few months, at a time 
 when, from the imj)erfect development of the salivary glands, the 
 infant has little or no power of digesting starch. In general, only 
 milk should be given for the first six months. Goats' milk and 
 asses' milk both have an advantage over cows' milk in a closer 
 resemblance to human milk. In general, however, cows' milk will 
 be the only substitute available. The object, of course, is to make 
 the substitute resemble human milk as closely as possible. The 
 following table gives the average percentage of constituents in 
 each : — 
 
 
 Hnman. 
 
 Cows'. 
 
 Goats'. 
 
 Asses'. 
 
 Water 
 
 87-0 
 
 85-7 
 
 86-3 
 
 89-3 
 
 Solids 
 
 12-9 
 
 14-3 
 
 13-7 
 
 10-7 
 
 Casein 
 
 1-9 
 
 4-8 
 
 3-4 
 
 1-09 
 
 Lactalbumen 
 
 0-4 
 
 0-57 
 
 1-3 
 
 0-7 
 
 Fat 
 
 4-0 
 
 4-3 
 
 4-3 
 
 3-0 
 
 Lactose .... 
 
 6-3 
 
 4-03 
 
 4-0 
 
 5-5 
 
 Salts 
 
 0-34 
 
 0-5 
 
 0-62 
 
 0-42 
 
Management of the Puerperal State. 411 
 
 The proportions in human milk, however, vary considerably, 
 especially that of proteids. Thus the percentage of proteids given 
 by different authorities varies as widely as from 1*5 to 3*9. More 
 observations are required on the relative proportion of caseinogen 
 and lactalbumen in human milk. The proteid coagulable by acid 
 is present in cows' milk in great excess as compared with the 
 uncoagulable proteid, while in human milk there is also more 
 coagulable than non-coagulable proteid, but not to the same 
 excess. 
 
 Human milk is alkaline in reaction and usually sterile ; cows' 
 milk when it reaches the consumer is generally acid, and contains 
 many organisms. The percentage of nutrient materials is about 
 12"9 in human milk and 14"3 in cows' milk. If water equal 
 to two-thirds of the milk be added to cows' milk, the j^roportion of 
 proteids will be about right, but the milk will be poor in cream and 
 sugar. This defect can, however, be readily remedied by the addition 
 of sugar of milk and cream. The chief difficulty, however, is in the 
 digestion of the casein, and arises from the fact that the casein of 
 cows' milk coagulates in larger, firmer curds, which are more diffi- 
 cult of digestion than the flocculi of human milk. Practically, 
 therefore, it is necessary to add an equal part of water, provided 
 that the milk has not been previously watered, for infants under 
 three months, and two parts of water for infants under one month, 
 together with twenty to thirty drops of nursery cream, if it can be 
 obtained pure from a reliable source, and one teaspoonful of sugar 
 of milk to each feed. The digestion of the casein is the chief point 
 to be attended to. If undigested curds are vomited or seen in the 
 faeces, the milk must be more diluted. It is a common mistake, 
 however, with nurses to dilute the milk too much and too long, 
 After three months the proportion of water may generally be 
 reduced to half the milk, after four to one-third, and from the fifth 
 or sixth onward the milk may be given undiluted. 
 
 The water for dilution should be boiled. It is still better to use 
 very thin barley water or decoction of arrowroot (53. ad Oj.) ; this 
 prevents the curds formed from being so large. This plan may, 
 therefore, be adopted, if undigested curds are seen. It is preferable 
 to sterilise the milk itself by heating it to the boiling point, and 
 then cooling it rapidly, or, better, by heating it in a proper milk 
 steriliser. This is the more desirable in towns where the milk 
 cannot be got perfectly fresh. 
 
 According to the researches of Budin, it is best, if the milk is 
 efficiently sterilised, to give it undiluted. It is found that, with 
 sterilised milk, hard curds are not formed in the stomach, and 
 
412 
 
 The Practice of Midwifery. 
 
 experiments show that the infants gam weight more rapidly on 
 undikited than on diUited milk. A convenient form of milk steriliser 
 is shown in Fig. 249. The boiling pan holds seven bottles, each 
 containing a measure of food, and fitted with a valvular cap, which 
 allows steam to escape, but prevents the entrance of air. The water 
 is to be kept at the boiling point for forty minutes. A supply suffi- 
 cient for twenty-four hours is thus prepared. When the food is 
 required, a bottle is heated in the food warmer, till the thermometer 
 marks 100°. The rubber cap is then taken off and replaced by a 
 soft rubber nipple, and the bottle is at once given to the child. 
 Milk sterilised in this way is found not to have suffered the 
 
 diminution of digestibility which is 
 noticed in boiled milk. 
 
 Another plan is not absolutely to 
 sterilise, but to " pasteurise," the 
 milk, by keeping it for at least 
 twenty minutes at a temperature of 
 150° to 160°. Hawksley's steriliser 
 may be used in this way, and the 
 same object is more easily attained 
 by Aymard's steriliser. The chief 
 advantages of pasteurisation are that 
 chemically the milk is not seriously 
 changed, the taste and smell are 
 unaltered, any pathogenic organisms 
 present are destroyed, fermentation 
 is stopped, and the risk of the 
 transmission of infectious disease 
 is abolished.^ 
 
 Sterilisation of milk does not 
 obviate the necessity that the milk should be as fresh and uncon- 
 taminated as jDOSsible before sterilisation. Scurvy sometimes 
 occurs in infants fed on sterilised or peptonised milk, and may 
 be due, as some authorities maintain, to the presence of bacterial 
 toxins in the milk before sterilisation, or to the destruction of 
 the antiscorbutic element in fresh milk by its pe^Dtonisation or 
 sterilisation. 
 
 The proper proportion of sugar to add is about sixty grains to 
 four ounces of diluted milk. Milk sugar is of course the best, but 
 in the absence of it, ordinary white sugar may be added. Practi- 
 cally a small lump may be dissolved in each bottle of milk. The 
 
 Fig. 249.— Hawksleys Milk 
 Steriliser. 
 
 1 Cautley, The Feeding of Infants, p. 199 
 
Management of the Puerperal State. 413 
 
 milk should be given warm, at a temperature of about 98"^ F. A 
 young infant will not require more than from one to two ounces 
 at a time. If cream be added it must be quite fresh and contain no 
 preservatives. It is possible now to obtain nursery cream of good 
 quality and proper consistence from any of the large dairy com- 
 panies. In hot weather both the cream and the milk should be 
 either pasteurised or raised to the boiling point, " scalded," as 
 soon as they are received ; and when the milk has been boiled 
 care must be taken to keep it in a tightly sealed-up vessel in a 
 cool place. 
 
 It is often recommended that the milk should be from one cow. 
 On the other hand, it is stated that the cow is liable to periods 
 of heat even during lactation, and that then the milk is apt to 
 disagree, whereas the effect is not noticed when the milk of a dairy 
 is all mixed. In towns it obviously requires much faith to believe 
 that milk from one cow is really obtained. 
 
 Condensed milk, diluted with water, has the advantage that the 
 casein does not clot in such large curds as that of fresh milk. It 
 sometimes agrees better therefore for a time when the infant does 
 not digest the casein. It has a great disadvantage, however, of 
 containing much too large a proportion of sugar. Its prolonged 
 use seems inadvisable on this account, and, though fattening, 
 it appears to tend towards the production of rickets. Unsweetened 
 condensed milk, which may now be obtained, is preferable, but 
 will only keep about a day after the opening of the tin. With 
 this a little sugar should be added at the time of use. It is still 
 commoner with condensed than with fresh milk to make the 
 mixture too weak. Four parts of water to one of milk make it 
 equal in strength to fresh milk, not reckonin;^ the added sugar. 
 For the infant's use, therefore, not more than about nine or ten 
 parts of water should generally be added, except for the first three 
 or four weeks, when it may be necessary to add as much as fourteen 
 or fifteen parts. 
 
 " Humanised milk " is now made by some of the dairy companies 
 from cows' milk, by the addition of cream, freshly prepared whey, 
 and milk sugar. This may be used with advantage, where it can 
 be obtained, and is generally sent out sterilised, or it can be 
 sterilised in the same way as ordinary milk, in the milk steriliser. 
 If pure cows' milk can be obtained, a close approximation to human 
 milk will be given by the following plan. Add to the milk two- 
 thirds its bulk of water, and to each four ounces of the mixture 
 add sixty grains of milk sugar, and two teaspoonfuls of cream. 
 The whole is then to be heated in the steriliser. The liest cream 
 
414 
 
 The Practice of Midwifery. 
 
 is that obtained in the centrifugal separator, not by skimming, so 
 that it may be supplied fresher. 
 
 An improvement in infant feeding is the introduction of milk 
 laboratories, the first of which was instituted at Boston, U.S.A., 
 at the suggestion of Dr. Eotch, under the name of the Walker- 
 Gordon Laboratory. In these the cows' milk is standardised, 
 and milk is prepared for each individual infant with the exact 
 proportions prescribed by the physician, and sent out sterilised. 
 The following is an example of such a prescription : — 
 
 Proteids. ...... 1 '5 per cent. 
 
 Fat 3 
 
 Sugar ....... 6 „ 
 
 Number of feedings .... 8 
 
 Amount for each feeding . . .4 ounces. 
 Heat to 170° F., 30 minutes. 
 
 The following table shows the average amount recommended to 
 be given to a healthy infant : — 
 
 
 
 Percentages. 
 
 
 
 
 Weeks of Life. 
 
 
 
 
 Amount 
 fed in ozs. 
 
 Daily Quantity 
 in ozs. 
 
 
 
 
 
 Proteids. 
 
 Fat. 
 
 Sugar. 
 
 
 
 First .... 
 
 0-75 
 
 2-00 
 
 4-50 
 
 H 
 
 4—15 
 
 Second 
 
 
 
 1-00 
 
 2-50 
 
 5-50 
 
 If 
 
 15—20 
 
 Third . 
 
 
 
 1-00 
 
 3-00 
 
 6-00 
 
 2 
 
 20—24 
 
 Fourth 
 
 
 
 TOO 
 
 3-00 
 
 6-00 
 
 9i 
 
 24—30 
 
 Eighth 
 
 
 
 1-25 
 
 3-50 
 
 6-50 
 
 H 
 
 26—34 
 
 Twelfth 
 
 
 
 1-2.5 
 
 3-50 
 
 6 -.50 
 
 at 
 
 30—36 
 
 Sixteenth . 
 
 
 
 l-oO 
 
 3-75 
 
 6-50 
 
 H 
 
 34—38 
 
 Twenty-fourth 
 
 
 
 1-75 
 
 3-75 
 
 6-50 
 
 H 
 
 36 40 
 
 Thirty-second 
 
 
 
 1-75 
 
 4-00 
 
 7-00 
 
 6 
 
 38—42 
 
 Fortieth 
 
 
 
 2-00 
 
 4-00 
 
 6-50 
 
 61 
 
 38—41 
 
 Forty-eighth 
 
 
 
 2-50 
 
 4-00 
 
 6-50 
 
 ^i 
 
 40—45 
 
 This modified milk may now be obtained from nearly all the 
 large dairy companies in London or in other large cities. It has 
 the disadvantage of being somewhat expensive. When the mother's 
 milk causes colic it will often be advantageous to wean the infant 
 and use the modified milk. 
 
 Indications, according to which the proteids, fat, and sugar are 
 to be varied, may be obtained from the condition of the infant. 
 Excess of proteids is shown by undigested curds in the motions. 
 This condition is also a frequent cause of colic. Sometimes there 
 is diarrhcea, but more frequently constipation. Excess of fat is 
 indicated by frequent vomiting. It is sometimes shown by frequent 
 motions, which are nearly normal in appearance. In some cases 
 
Management of the Puerperal State. 415 
 
 they contain small round lumps of fat, somewhat resembling 
 casein. The most constant indication that too little fat is given 
 is constipation with hard, dry motions. If too little sugar is given 
 the gain of weight is apt to be too slow. Excess of sugar may be 
 shown by colic, or thin, green, acid motions. If the gain in weight 
 is unsatisfactory, and there is no sign of indigestion, all the 
 ingredients should be increased. 
 
 In many cases, especially if the baby is at all delicate or prema- 
 ture, the best i)lan is to feed it on peptonised milk, prepared with 
 Fairchild's peptonising powders or peptogenic milk powders. By 
 this means all difficulties are avoided. The peptonised milk can be 
 given either pure or diluted with an equal quantity of water, and 
 when the child is ten days old or a little older and gaining weight plain 
 boiled or sterilised milk can be substituted by slow degrees for the 
 peptonised, a teaspoonful at a time. By this means even the most 
 delicate babies can be reared successfully on cows' milk. In all 
 cases where any other food than boiled fresh milk is being used, 
 such as peptonised or sterilised milk, or one of the patent milk 
 foods, a little raw meat juice or orange juice should be given to 
 the baby daily after the first two or three weeks of life. 
 
 The only farinaceous food allowable for young infants are those 
 manufactured on the principle of Liebig's food, in which the starch 
 is, to a considerable extent, already converted into glucose by the 
 action of malt. If the infant will not thrive on milk, and a wet- 
 nurse is not available, such a food may be tried. Even this, 
 however, does not answer so well before the third month as it does 
 after that time, when the salivary glands are beginning to be active. 
 Infant foods are prepared on this principle by Allen & Hanbury, 
 Loflund, Mellin, Benger, Horlick, and others. 
 
 In bottle-feeding the most scrupulous cleanliness is of essential 
 importance. The food, unless sterilised as described above, should 
 be prepared fresh each time of feeding ; bottle and nipple should 
 be most carefully cleansed and kept in water when not in use ; and 
 that form of feeding-bottle should be chosen in which the tube is 
 dispensed with entirely, and the nipple fitted immediately to the 
 neck of the bottle. If the milk cannot be obtained frequently 
 fresh, to each bottle of milk may be added a grain or two of 
 bicarbonate of soda, to correct any acid reaction ; or, if the infant 
 has any tendency to diarrhoea, a little lime-water. The addition of 
 citrate of soda in the proportion of one or two grains to each ounce of 
 milk given is a valuable help, since it has the property of retarding 
 the coagulation of the proteid and increasing its digestibility. 
 Regularity of meals must be observed as with breast-feeding. The 
 
4i6 The Practice of Midwifery. 
 
 infant should always be nursed while it is feeding. The nurse must 
 never be allowed to let the bottle remain in the cradle with the 
 infant to soothe it to sleep. 
 
 When the child is seven months old, one of the farinaceous foods 
 which contain all the ingredients of wheat, not merely starch, 
 should be given in addition to the milk. From this time it is well 
 to give also some gravy, or beef-tea, with a little bread. 
 
Chapter XIX. 
 ABNORMAL PREGNANCY. 
 
 Ectopic or Extra-uterine Fcetation. 
 
 Under the head of abnormal pregnancy may be included all 
 cases of what is commonly spoken of as extra-uterine fcetation, but 
 may receive the more widely inclusive term of " ectopic " fcetation. 
 By this is meant the arrest of the ovum at some jDoint before it has 
 reached the cavity of the uterus. Closely allied with this is the 
 development of the ovum in one horn of a double uterus, when 
 that horn is so rudimentary that pregnancy cannot go on in a 
 normal course. 
 
 Varieties. — The ovum may either escape altogether into the 
 peritoneal cavity, and become implanted there, or it may become 
 arrested anywhere in its course between the Graafian follicle and 
 the uterine cavity, and may or may not afterwards escape by rupture 
 from its original situation. Hence we have the following varieties 
 of ectopic fcetation : (1) ovarian ; (2) primary abdominal ; (3) tubo- 
 ovarian, or tubo-abdominal, when the ovum is contained in a sac 
 formed between the pavilion of the tube and the ovary, or a portion 
 of the peritoneum ; (4) tubal ; (5) tubo-uterine or interstitial, when 
 the ovum is arrested in that part of the tube which passes through 
 the uterine wall ; (6) secondary abdominal, when the ovum partially 
 escapes by rupture of the sac ; (7) intra-ligamentous or extra- 
 peritoneal, when the sac formed by the tube ruptures into the 
 broad ligament, and the ovum develops between the layers of the 
 broad ligament. To these varieties of extra-uterine fcetation must 
 be added : (8) pregnancy in an abnormal uterus, generally the 
 rudimentary horn of a uterus unicornis. 
 
 Causation. — In some instances obstacles are discovered which 
 may have impeded the course of the ovum, such as a small polypus ^ 
 at the mouth of the Fallopian tube, or a fibroid tumour. It is 
 probable that in some cases the obstacle may consist in a twisting 
 of the tube due to peritoneal adhesions, or to a constriction or 
 
 1 Vassner, Monats. f. Gyoiik., Bd. 17, p. 881. 
 M. 27 
 
4i8 The Practice of Midwifery. 
 
 atresia of the tube, which the semen can pass, but not the ovum. 
 Such conditions, however, cannot usually be verified by autopsy as 
 having existed prior to impregnation, on account of the great 
 alterations produced by the inflammation set up by the presence of 
 the extra-uterine sac, and indeed are not usually present. 
 
 One morbid condition has been found in the remaining parts of 
 both tubes in cases of tubal foetation, namely, a chronic catarrhal 
 salpingitis, with some loss of epithelium. This might promote 
 tubal foetation in two ways. If the epithelium were entirely lost at 
 some spot, the ovum might adhere more readily, as it is supposed 
 to do to the endometrium after the superficial exfoliation of 
 menstruation, or the loss of epithelium may lead to the failure of 
 the current set up by the action of the ciliae by which the ovum 
 normally is carried into the uterine cavity. Salpingitis further 
 may cause irregular adhesion of the plicae of the tube, and in this 
 way culs-de-sac may be formed in which the ovum may be caught. 
 These diverticula, which by some writers are considered of congenital 
 origin, are no doubt usually the result of salpingitis, although, in 
 view of the fact that the ovum embeds itself in the wall of the tube 
 as it does in the uterus, it is probable that in many cases where the 
 ovum has been supposed to be lying in a diverticulum it has in 
 reality only been embedded in the tubal wall. 
 
 Another theory of causation has been jDropounded by Webster, 
 namely, that the fault lies in a congenital abnormality of the 
 mucous membrane of the tube, which renders it susceptible to be 
 stimulated by the presence of an ovum to produce decidual tissue, 
 a peculiarity which ought to be limited to the mucous membrane of 
 the uterus. 
 
 Freund and Taylor ^ are inclined to regard congenital want of 
 development of the tubes, together with an infantile condition of 
 the uterus and sterility, as a possible cause. 
 
 In a very large number of cases of extra-uterine gestation nothing 
 abnormal can be detected in the tubes, and Bland Sutton ^ main- 
 tains that this variety of j)regnancy occurs as often, if not more 
 often, in a healthy as in a diseased or imperfectly developed 
 tube. 
 
 Clinical observation, however, tends to confirm the view that the 
 cause is often some acquired morbid condition hindering normal 
 pregnancy, and probably also altering the character of the tubal 
 mucous membrane. For the subjects of ectopic foetation are 
 rarely very young, generally over thirty years old ; and, in many 
 
 1 Taylor, Extra-uterine Pregnane^-, London, 1899, p. 24. 
 
 2 Bland Sutton, Surgical Diseases of the Ovaries, London, 1896, p. 245. 
 
Abnormal Pregnancy. 
 
 419 
 
 cases, they have either lived for years in sterile marriage, or a 
 good many years have elapsed since the last pregnancy. If the cause 
 of extra-uterine pregnancy were always a congenital abnormality it 
 might be expected that it would generally occur in a first pregnancy. 
 Extra-uterine pregnancy soon after marriage is not, however, so 
 rare as has sometimes been supposed, and I have met with a case 
 in which, after operation for ruptured tubal fcetation, a second 
 normal child was born within a year from marriage. 
 
 It has been suggested that intense mental emotion or shock may 
 set up contractions of the tubes by which an early ovum may be 
 arrested in its passage down the tube and may continue to develop 
 there. Various conditions of the ovum itself have also been cited 
 as possible causes, the shedding of the zona pellucida before it 
 
 Fig. 250. — Tubal foetation, with the corpus hiteum in the ovary of the opposite 
 side. The decidua is partly detached from the uterine cavity. 
 
 reaches the uterine cavity, its over-development either causing an 
 actual physical difficulty in its passage through the tube or leading 
 to its becoming prematurely embedded before it has reached the 
 uterine mucosa. 
 
 There is another curious mode of origin which appears to occur 
 in women who have not shown any degree of sterility; namely, the 
 interference of one ovum- with another on their way to the uterus. 
 According to Dr. Parry's^ statistics — twin pregnancies are at least 
 four times as common in extra-uterine as in normal fcetation : a 
 proportion which proves that some causal relation must exist. It 
 has been thought that the second ovum may be obstructed by the 
 first in reaching or passing along the tube. These statistics have, 
 however, been questioned on the ground that cases are included as 
 twin pregnancies in which the intra-uterine has followed on an old 
 
 1 i'arry, Extra-uterine Pregnancy. 
 
 27—2 
 
420 The Practice of Midwifery. 
 
 extra-uterine pregnancy, with the foetus still retained in the 
 abdomen. 
 
 Tubal pregnancy may occur in either tube, in a nullipara or a 
 multipara, in the first or any subsequent pregnancy, and may be 
 repeated in the same patient. Multiple pregnancies in the tubes 
 have been described as well as simultaneous intra-uterine and extra- 
 uterine pregnancy and the development of both blood and hyda- 
 tidiform moles. Chorion epithelioma has also been described, 
 and even the occurrence of eclampsia, in cases of advanced tubal 
 fcetation. 
 
 Some cases of tubal fcetation give evidence of transperitoneal 
 migration of the ovum, or of the spermatozoa, from one side to 
 the other. By the former, those cases are explained in which 
 the corpus luteum is found on one side and the ovum in the 
 opposite Fallopian tube (see Fig. 250) ; by the latter, those in 
 which ovum and corpus luteum are on the same side, but the 
 portion of tube between ovum and uterus rudimentary, or evidently 
 long impervious. The wandering of the spermatozoa across the 
 peritoneal cavity by their own movements is not surprising. Nor 
 is that of an ovum, if it be remembered that probably many ova 
 fail to reach the Fallopian tube, and that some of these may 
 happen to come within reach of the current of serum produced by 
 ciliary action toward the orifice of the opposite tube. In very 
 rare cases, it has been thought to be proved that the ovum reached 
 the uterus and ascended the tube of the opposite side. 
 
 Pathological Anatomy — The pathological anatomy and usual 
 course vary in difi'erent varieties. 
 
 Ovarian Foetation. — Until quite recently some authorities denied 
 the possibility of ovarian fcetation. Several recent cases, however, 
 have demonstrated an early embryo in a sac within the ovary, and 
 the evidence is now admitted as convincing. Ovarian foetation is 
 very much rarer than tubal ; but now that its possibility is estab- 
 lished, it is probable that some cases in which the pregnancy was 
 too advanced for absolute demonstration were really ovarian. It 
 is not improbable that the condition known as blood-cyst of the 
 ovary may sometimes be due to foetation, as in the case described 
 by Kelly and Mcllroy. It is probable, however, that some cases 
 which were regarded as ovarian, from the position of the sac 
 being similar to that of an ovarian tumour, without any peritoneal 
 adhesions, were really intra-ligamentous, with the ovary spread out 
 on the wall of the sac. Cases of advanced pregnancy are not 
 decisive, since the tube is not found intact at that stage. The 
 
Abnormal Pregnancy. 
 
 421 
 
 following case, reported by Van Tussenbroeck/ appears to satisfy 
 the most stringent criteria of proof. The patient, aged 31, mother 
 of five children, having had no menstruation for six weeks, had 
 suddenly signs of internal haemorrhage, and the diagnosis of 
 ruptured extra-uterine foetation was made. Abdominal section being 
 performed, a large quantity of clot and blood was found in the 
 peritoneal cavity. The left annexa were normal; the right tube 
 was normal and free from adhesions, the right ovary was capped 
 
 Villi 
 
 Lutein 
 cell layer 
 
 Hilum w'i'i\ u'.i 
 of ovary \\U\"-''- 
 
 Ovarian tissue 
 Fig. 251. — Ovarian pregnancy. (From Eden. Von Tassenbroeck's case).i 
 
 by a small tumour the size of a walnut, covered with coagulated 
 blood. The tumour was not adherent to the tube or other organs. 
 This tumour was found to be a foetal sac, containing a small embryo, 
 with a relatively thick funis attached to the wall of the sac ; at its 
 centre was an opening with fringe-like projections, and on its deep 
 aspect there was a large corpus luteum. The fcetal placenta had 
 a structure identical with the normal; there were two layers of 
 epithelium over the villi, and the syncytium was typical. 
 
 > Annales de Gyn. et d'Obstet., IKiti). Vol. LTI., p. 'y'M. 
 
422 The Practice of Midwifery. 
 
 A number of otlier cases have now been recorded in which a 
 detailed and careful examination has proved the existence of an 
 ovarian pregnancy ; among these are the cases of Thompson, 
 Mendes de Leon, Franz, Kelly and Mcllroy, Mikolitsch, Freund 
 and Thome, Munro Kerr and Teacher.^ An early case of ovarian 
 gestation has also been reported by Anning and Littlewood, the ovum 
 being about fourteen days old, and a doubtful case in which the 
 ovum had nearly reached the fourth month of development by Croft. 
 
 From a study of these cases, it appears probable that in 
 ovarian foetation the Graafian follicle ruptures without escape of 
 the ovum so as to allow the spermatozoon access to the ovum and 
 its fertilisation in situ. The development of the ovum may then 
 take place within the follicle, the opening becoming closed, or it may 
 
 Fig. 252. — Early tubal s^estation unruptured, situated in isthmus of tube. 
 (Univ. Coll.''Hosp. Med. School Mus., Spec. 4218E.) 
 
 burrow its way out, as in Van Tussenbroeck's case, into the vascular 
 tissue lying external to the lutein tissue and there develop, as in 
 the case described by INIunro Kerr and Teacher. The vascularity 
 of this tissue markedly favours the development of the ovum. 
 There is no formation of any structure resembling decidua. The 
 nutrition of the ovum is carried on by the epithelium of the 
 chorionic villi, which are bathed in maternal blood, lying in spaces 
 in the ovarian stroma. As the ovum continues to grow gradual 
 absorption of the ovarian stroma takes place, and the sac finally 
 ruptures. If the ovum continues to grow after the rupture of the 
 sac the latter is composed of the fcetal membranes only with the 
 ovary or some portion of it attached to the wall of the sac. In 
 the majority of cases ovarian j)regnancy leads to rupture and 
 haemorrhage before the third or fourth month, generally within 
 the first eight weeks, and it is doubtful if it can ever go on to full 
 term, like an abdominal pregnancy. 
 
 The ovum, like that of tubal foetation, is often converted into a 
 
 1 Early Development and Embryology of the Human Ovum, Bryce and Teacher, 
 Glasgow, 1908, p. 67. 
 
Abnormal Pregnancy. 423 
 
 blood mole, as in Mikolitsch's case ; and rupture may take place 
 after this conversion as well as before. 
 
 Tubal Foetation. — Tubal foetation is the commonest of all the 
 varieties of extra-uterine gestation. The ovum may become im- 
 planted either in the ampullary or isthmal portion of the tube, 
 most commonly in the former. It may be attached to one of the 
 folds of the mucous membrane or at the bottom of one of the 
 intervening depressions, thus constituting the columnar and inter- 
 columnar varieties of Werth. Wherever it is situated, the young 
 ovum quickly embeds itself in the wall of the tube, burrowing 
 
 Blood clot. 
 
 ;'?<^„_ .-: , Lumen of tube. 
 
 / 
 
 "^'-/■^ 
 
 
 w 
 
 Trophoblast. Villus. 
 
 Fig 253. — Tuball foetation showing intra-mural site of ovum outside lumen of tube. 
 (Filth, Archiv fiir Gyn., Bd. 63, Taf. 3, Fig. 3.) 
 
 into the muscular layer, so that it acquires really an intra- 
 muscular site. This is effected by the activity of the cells of the 
 trophoblast in the same way as in the uterus, and is associated 
 with swelling, fibrinous degeneration, and final breaking down of 
 the muscle cells which lie in contact with the fcetal elements. In 
 this manner an implantation cavity is formed within which the 
 ovum lies. 
 
 Decidual cells are formed in some measure, especially in the 
 neighbouring plicse of the tube, and round the borders of the 
 ovum ; but there is no compact layer of decidua like that in the 
 uterus to afi'ord attachment to the villi and limit their penetration. 
 
 The amount of decidual formation, varies very largely in difi'erent 
 
424 The Practice of Midwifery. 
 
 cases, and appears at times to be entirely wanting. It has, however, 
 been described by Whitridge WilUams and others in the non-pregnant 
 tube of the opposite side. If situated in the ampullary portion of 
 the tube, the developing ovum may bulge into the lumen covered 
 by a capsule which not uncommonly contains some muscle fibres, 
 and which rei^resents the decidua capsularis, the so-called capsular 
 membrane. With the continued growth of the ovum the lumen of 
 the tube may become entirely obliterated, and the sac of the ovum 
 may become fused with its opposite wall. In cases of isthmal 
 pregnancy, where the lumen of the tube is smaller, this bulging 
 does not as a rule occur, the ovum continuing its development in 
 the tissues of the wall, the lumen being obliterated and pushed 
 
 Fig. 254. — A tubal mole in section, sliowing amniotic cavity. 
 
 aside. In most cases the continued growth of the ovum quickly 
 leads to destruction and disappearance of the decidua capsularis. 
 
 The vascularity of the tube becomes very markedly increased, 
 and at first there is some slight hypertrophy of the muscle cells. 
 These ultimately are replaced by connective tissue cells to a con- 
 siderable extent. The peritoneum becomes somewhat thickened, 
 and adhesions are often present round the tubes as the result of 
 the peritonitis which is set up. 
 
 The development of the intervillous circulation is brought about 
 in the same manner as in the case of an intra-uterine pregnancy, 
 the maternal vessels being opened up and their walls invaded by 
 the cells of Langhans' layer. In some instances the invading cells 
 seem to undergo proliferation inside the lumen of the vessels, 
 and this may be the explanation of some of the cases of so-called 
 deportation of the chorionic villi. 
 
 In consequence of its intra-mural site, it is clear that the developing 
 
Abnormal Pregnancy. 425 
 
 ovum in the course of time may burst either through the wall of the 
 tube into the peritoneal cavity or rarely between the layers of 
 the broad ligament, or may burst into the lumen of the tube. 
 The destruction or erosion of the wall of the tube or of the sac 
 of the ovum is brought about in two ways : firstly, by the action of 
 the epithelium of the villi, which erodes the muscular wall or 
 renders it very thin ; and secondly, by the occurrence of haemor- 
 rhages into the chorio-decidual sj^ace. Such hsemorrhages are very 
 likely to occur from comparatively slight causes, owing to the very 
 frail union which exists between the foetal and maternal tissues in 
 these cases. 
 
 Fig. 255. — Specimen of tubal abortion. The fimbriated extremity greatly 
 distended by a clot. (From Kelley, Operative Gynecology, 1906, Vol. [I., 
 Fig. 647.) 
 
 Tubal Mole. — In a considerable proportion of tubal pregnancies 
 the ovum dies at an early period of its development. In some cases 
 it is absorbed, and all trace of it disappears ; in others it forms a 
 hsematosalpinx. In others again the occurrence of hsemorrhages 
 into the chorio-decidual space is followed by the formation of a 
 blood or so-called tubal mole, followed or preceded by the death of 
 the embryo. The development of such a tubal mole is no doubt the 
 usual accompaniment or precursor of the bursting of the ovum into 
 the lumen of the tube, the so-called internal rupture. In the 
 majority of cases the abdominal end of the tube becomes closed 
 about the eighth week of a tubal pregnancy. 
 
 Tubal Abortion.— When the abdominal ostium remains patent 
 the mole lying in the cavity of the tube sets up contractions 
 
426 
 
 The Practice of Midwifery. 
 
 of the tubal muscle by which it maybe partially or wholly extruded 
 into the peritoneal cavity. When the extrusion is complete it is 
 usually accompanied by a considerable quantity of blood. 
 
 The symptoms produced are generally those of diffuse intra- 
 peritoneal hsemorrhage, which may be as severe as in the case of 
 rupture of the tube, but is usually less so, the haemorrhage being 
 limited by contraction of the gravid tube, which soon resumes an 
 almost entirely normal appearance, to the naked eye. 
 
 If the mole is only partially extruded, or if, in cases where it is still 
 present, the embryo alone is expelled, the hsemorrhage usually 
 continues, leading to the production of a hematocele of varying size. 
 
 According to Martin, two-thirds of the cases of tubal fcetation end 
 in tubal abortion. The reason appears to be that, owing to the 
 deficient formation of decidua, the trophoblast quickly opens up 
 
 Fig. 256. — Tubal ftetation. Decidua in uterus partly separated. 
 
 larger maternal vessels than in uterine pregnancy. The pressure 
 of the blood then separates the attachment of the ovum, and it 
 bursts into the lumen of the tube. 
 
 In a certain number of cases the placenta appears to continue for 
 some time a kind of vegetative growth, so that a mass of considerable 
 size, made up of villi and blood clot, may be found, without any 
 embryo. The possibility of such an occurrence is, however, denied 
 by Wiiit ridge Williams and Berry Hart. 
 
 The mass of clot may contain only a few traces of degenerate 
 chorionic villi. In other cases none are found, and it is difficult to 
 decide between tubal fcetation and hematosalpinx. But if a rounded 
 mass of clot is found in one tube, the other tube being undilated, 
 there is a probability in favour of tubal fcetation. 
 
 Rupture of the Tube. — Eupture of the tube may be brought 
 about as the result of several causes. No doubt in many cases the 
 
Abnormal Pregnancy. 
 
 427 
 
 wall of the tube is destroyed — eroded — by the action of the tropho- 
 blast or by the growing villi, and finally perforated. In other 
 instances the final factor is the occurrence of hsemorrhage into the 
 tube, resulting in its over-distension when the abdominal ostium is 
 closed, and again the contractions of the tubal muscle may play a 
 part in producing both tubal abortion and rupture. 
 
 The rupture of a tubal pregnancy may follow directly any form of 
 muscular exertion, it is not uncommonly caused by sexual inter- 
 course, and it may even be directly due to examination of the 
 pelvis. In a case under my care a mass on the right side of the 
 uterus was found to collapse during bimanual examination under an 
 anaesthetic. Two days later a definite lump could be felt in 
 
 *>«')* } 
 
 ^A 
 
 ^'i--K^M 
 
 Fig. 257. — Early ruptured ampullary pregnancy. The ovum is seen almost 
 surrounded by villi. The ovary presents a corpus lutem, and the 
 fimbriated end of the tube is partly closed. 
 
 Douglas' pouch, and on removal this was found to be a blood mole 
 two and a half inches in diameter. There was no free blood 
 in the peritoneal cavity.^ 
 
 The rupture takes place usually at from two to eight weeks' 
 growth, within the period of the erosive activity of the tropho- 
 blast ; more rarely in the third month : a few cases are on record 
 in which a tubal foetation has gone on till the later months, or 
 even till full term. This is only possible when the muscular wall 
 of the tube undergoes great hypertrophy, as it sometimes does 
 also in cases of pyosalpinx or hydrosalpinx, becoming a quarter of 
 an inch thick or more. The growing sac then separates the layers 
 of the );road ligament, and comes to have a pedicle somewhat like 
 
 ' fialabin, Trans. 01)81, Soc. London, 1005, Vol. XLYU., p. 332. 
 
428 The Practice of Midwifery, 
 
 that of an ovarian tumour formed by the stretched-out base of the 
 broad ligament. Its position is therefore not unlike that of an 
 intra-ligamentous pregnancy, except that it does not generally 
 descend so deeply into the pelvis. In a case recorded by Heinricius ^ 
 the left Fallopian tube was found post mortem to be enormously 
 distended, and to contain two full-term children, one completely 
 disintegrated, the other well preserved. The history pointed to the 
 first conception having occurred six years, the second about one 
 year before death. 
 
 When situated in the isthmus of the tube a tubal fcetation 
 commonly ruptures very early, even as early as the second week ; if 
 the ovum is in the ampulla of the tube, rupture is commonly later, 
 as from six to eight weeks, and abortion is more likely to occur. 
 
 The embryo alone, or the whole ovum, may escape from the sac, or 
 the whole may remain within it. In rare cases false membranes 
 form a new sac around the escaped embryo, and pregnancy goes on. 
 The usual result of rupture of the tube is diffuse intra-peritoneal 
 haemorrhage. If the patient does not die from the effect of 
 haemorrhage some peritonitis is set up by the effused blood. 
 After a time the blood clots, and the clots may be shut in by 
 peritoneal adhesions, and form masses, mainly behind the uterus. 
 Eventually the fluid part of the blood becomes absorbed, and in 
 time the clots, unless septic infection reaches them from adjacent 
 bowel. The ordinary form of retro-uterine hfematocele, in which 
 the uterus is displaced forward and upward, is not usually a sequel 
 of diffuse intra-peritoneal haemorrhage, but results from more 
 gradual bleeding, associated with tubal mole or tubal abortion. 
 
 Hematocele and Hfematoma. — Modern evidence has shown that 
 pelvic hsematocele is due in the great majority of cases to extra- 
 uterine foetation. The limitation of the blood effusion to the pelvis 
 implies gradual and rather j)rolonged bleeding. In most cases the 
 first blood effused sets up some plastic peritonitis, and the blood 
 becomes shut in by adherent intestines. As the bleeding goes on the 
 limited space is dilated, and the uterus is pushed forward and 
 generally upward, so that the cervix lies behind the toj) of the 
 symphysis pubis, and the fundus may be felt superficially under the 
 abdominal wall, above the pubes. The top of the mass may often be 
 felt on abdominal examination rising behind and above the level 
 of the fundus, sometimes as high as the umbilicus. Hsematocele 
 may result from rupture of the tube by a very small aperture, so 
 that the bleeding is gradual. But it is most frequently due to bleeding 
 
 1 Heinricius, Arch, f, Gynak,, B. 4, H. 1. 
 
Abnormal Pregnancy. 429 
 
 from a tubal mole, escaping through the open end of the tube. The 
 term perituhal hcematocele is given to a special form, in which the 
 bleeding is still more gradual than in the usual one. The slowly 
 exuding blood becomes enclosed in a thin cap of lymph attached to 
 the edges of the tubal orifice, and this is gradually distended as the 
 blood effusion increases, while its thickness is increased by additional 
 deposit of lymph. Thus a blood-containing pseudo-cyst is formed, 
 enclosing the end of the tube, which is not necessarily, although 
 generally, adherent to any other structures. If the effusion takes 
 place through a minute rupture at the side of the tube, the term 
 paratuhal hcematocele is employed. 
 
 If the rupture and haemorrhage takes place into the cellular 
 tissue of the broad ligament, and not into the peritoneal cavity, 
 the result is a pelvic licematoma. The mass thus formed is rarely 
 so large as a hsematocele, being in an enclosed space from the 
 first, but it may rupture secondarily into the peritoneal cavity. 
 A hsematoma generally lies to one side of and somewhat behind 
 the uterus, and pushes the uterus over toward the opposite side 
 of the pelvis. In some cases, however, it strips up the peritoneum 
 from the pouch of Douglas and from the back of the uterus, 
 extending even over to the opposite broad ligament. In such 
 cases it may attain to a large size, and be difficult or impossible 
 to distinguish from a large hsematocele. The ordinary course 
 both of hsematoma and hsematocele is to be very slowly absorbed. 
 Sometimes, however, especially when of very large size, they may 
 suppurate, being generally infected by organisms from the bowel. 
 
 In iuho-ovarian foetation, the ovum is arrested at the pavilion of 
 the tube, which is already adherent, or which becomes adherent, to 
 the ovary, and thus forms the foetal sac. The course appears to 
 resemble that of abdominal fcetation. 
 
 In tubo-ahdominal foetation, the ovum is attached to the pavilion 
 of the tube, and the sac is completed by adhesion of the pavilion, 
 after implantation of the ovum, to some portion of the peritoneum. 
 
 In tubo-uterine, or interstitial, fwtation (Fig. 258), where the ovum 
 is arrested in the uterine portion of the tube, the sac as it enlarges 
 most frequently projects outwardly at the angle of the uterus, 
 becomes thinned at that point, and rujDtures before the fourth 
 month. No undoubtedly authentic case of interstitial pregnancy 
 has been recorded which has progressed beyond the sixth month. 
 
 In a case described by Eooswinkel a living child was extracted 
 from the abdomen at full term, but in this instance the interstitial 
 pregnancy had burst into the abdominal cavity at the fourth month, 
 forming a secondary abdominal foetation. 
 
430 
 
 The Practice of Midwifery. 
 
 If the sac is near the uterine cavity, it may bulge into that cavity, 
 and then a part of the ovam may escape, or be extracted, through 
 the natural passage.-^ The sac in this form of fcetation lies outside 
 the lumen of the tube, as in ordinary tubal fcetation. Eupture com- 
 monly occurs later than in tubal fcetation, in the third or fourth 
 month. 
 
 In some cases of interstitial fcetation, the ovum has been thought 
 to have been developed in an abnormal tube running in the wall of 
 
 Fig. 258. — Tubo-uterine, or interstitial, fcetation. (From a specimen in the 
 museum of Guy's Hospital.) 
 
 the uterus, and communicating with the Fallopian tube.^ Such a 
 tube might be the Wolffian duct or a portion of the Miillerian duct 
 not blended with the duct of the other side, and may open into the 
 uterus anywhere between the uj)per angle and the external os. The 
 uterus would be really a more or less complete uterus unicornis, 
 although externally it might appear normal. 
 
 Intra-ligamentous Fcetation. — This is a rare variety of tubal gesta- 
 tion, only one case having occurred in 197 examples of extra- 
 uterine gestation recorded by Martin and Werth. The primary 
 
 1 Braxton Hicks, Trans. Obst. Soc. London, 1867. Vol. IX., p. 57. 
 
 2 Leopold, Archiv f. Gynak., 1878, Bd. 13, Hft. 3, p. 355. 
 
Abnormal Pregnancy. 
 
 431 
 
 implantation of the ovnm is in the tube, and as the early placenta 
 grows it perforates the wall of the tube and acquires an attach- 
 ment to the cellular tissue of the mesosalpinx. Owing to the 
 extreme vascularity of this tissue, no doubt in the great majority 
 of cases the pregnancy comes to an end as the result of 
 hfemorrhage into the intervillous spaces, with or without the 
 formation of a hgematoma. If the ovum continues to develoj) 
 it does so in a sac in the cellular tissue between the layers of 
 the broad ligament. The wall of the sac may be thick, with a 
 
 Fig. 259. — Sagittal lateral section of pelvis, with intra-llgamentous foetation in 
 right broad ligament. A, amnion ; A.C., amnial cavity ; fI, placenta ; B.L., broad 
 ligament; P, peritoneum; F, fcetus ; CA, chorion ; R, rectum; L.A., levator 
 ani ; P.T., paraproctal tissue ; O.I., obturator internus. (After Berry Hart.) 
 
 considerable layer of involuntary muscular fibre over its surface, 
 or it may be thin. The attachment of the placenta becomes 
 extended from its primary site in the tube to the cellular tissue 
 lining the sac. It may occupy any part of the sac, sometimes its 
 upper portion, near the original position, of the Falloj^ian tube 
 (Fig. 259), sometimes its lower portion, beneath the fcetus, where 
 it becomes attached deeply to the cellular tissue at the base of the 
 broad ligament. As the ovum grows, it may peel the peritoneum 
 either posteriorly off the back of the uterus and the other broad 
 ligament (posterior intra-ligamentary foetation), or it may extend 
 anteriorly and peel the peritoneum first off the psoas and iliacus 
 
432 
 
 The Practice of Midwifery. 
 
 muscle, commencing at the interior face of the broad ligament, and 
 finally of! the anterior abdominal wall from below upward (anterior 
 intra-ligamentary foetation). In other cases, but more rarely, the 
 broad ligament is drawn out and a kind of pedicle formed from it, 
 like that of an ovarian tumour. Much more frequently the sac 
 burrows deeply into the broad ligament, and is widely attached to 
 the cellular tissue of the pelvis, as shown in Fig. 259, so that it is 
 difficult or impossible, if an operation is performed, to make a 
 pedicle, and remove the whole sac. 
 
 As a synonym to intra-ligamentous foetation, the terms sub- 
 peritoneo-pelvic and subperitoneo-aldominal foetation are sometimes 
 
 Fig. 260.- 
 
 -Uterus and foetus from a case of (.-' secondary) abdominal foetation. 
 The placenta is connected with right broad ligament. 
 
 used, the former when the pelvic peritoneum only is stripped up, 
 the latter when the peritoneum is stripped up above the level of the 
 pelvic brim. 
 
 As Werth contends, it is possible that a number of the supposed 
 cases of intra-ligamentary gestation are in reality pseudo-ligamentary, 
 being examples of tubal gestation developing behind and beneath 
 the broad ligament. In such cases the ovary is found spread out 
 on the anterior surface of the tumour. 
 
 In a true intra-ligamentary gestation the fcetus may go on 
 developing up to full term, or may die from imperfect nutrition, 
 without any further rupture, at any time during the course of 
 pregnancy, generally within the last two months. In some cases, 
 the peritoneum remains free from inflammation throughout; in 
 others, peritonitis is set up, and the peritoneal surface of the sac 
 becomes adherent to pelvis, intestines, or abdominal wall. 
 
Abnormal Pregnancy. 433 
 
 In other cases, again, secondary mpture into the peritoneal cavity 
 occurs, generally in the third or fourth month. If the ovum dies, 
 the patient may die from haemorrhage, if not saved by abdominal 
 section, or may survive with the formation of a hsematocele. 
 If it continues to live, secondary abdominal fcetation is the result. 
 
 The survival of the foetus must depend to a large extent on the 
 position of the placenta. If this is situated at the upper part of the 
 sac above the foetus, it can hardly escape some damage when the 
 sac ruptures ; on the other hand, when it is situated at the bottom 
 of the sac below the foetus rupture may occur without any disturbance 
 of its attachments, and in such a case, provided that the membranes 
 are intact, the foetus may continue to develop as a secondary 
 abdominal foetation. 
 
 Secondary Abdominal Fc3etation. — This variety of extra-uterine 
 pregnancy may be the sequel of a tubal or of an intra-ligamentary 
 foetation. In the first case it is possible occasionally for the 
 developing ovum to escape through the abdominal end of the tube 
 into the peritoneal cavity and to continue its development, as, for 
 example, in a few cases of tubo-ovarian or tubo-abdominal preg- 
 nancy. In some cases the ovum may even survive rupture of the 
 tube and continue to grow. In such instances no doubt the tube 
 gives way by a process of slow erosion rather than of rupture, 
 and the foetus enclosed in its membranes gradually escapes through 
 the opening thus formed into the peritoneal cavity. When a 
 secondary abdominal foetation is the result of the rupture of an 
 intra-ligamentary foetation the ovum, as already mentioned, is most 
 likely to survive if the placenta is situated below it and has already 
 acquired a firm attachment to the cellular tissue. The broad 
 ligament then continues to form the placental site just as the tube 
 does in the first variety.^ 
 
 Generally more or less chronic peritonitis continues during the 
 course of pregnancy, and the foetus becomes enclosed in an adven- 
 titious sac of lymph. Sometimes there is no peritonitis, and the 
 foetus is found enclosed merely in its membranes, amnion and 
 chorion, or amnion only. Or, again, the membranes may rupture, 
 and the foetus be quite free among the intestines, the liquor amnii 
 being absorbed by the peritoneum. The placenta often forms an 
 elastic mass, toward one side, separate from the foetus, and simu- 
 lating an ovarian tumour. Pregnancy may go on to full term, or 
 
 1 Leopold's researches on animals have shown that young foetuses when introduced 
 into the peritoneal cavity are rapidly destroyed when the peritoneum is healthy by the 
 action of phagocytes. Archiv f. Gynak., 1880, Bd. 18, Hft. 1, S. 53. 
 
 M. 28 
 
434 
 
 The Practice of Midwifery. 
 
 the foetus may die from imperfect nutrition or from pressure at any 
 time during the course of j)regnancy. The presence of muscular 
 fibres makes it more Hkely than in most other forms that the 
 placenta should become detached by contractions of the sac when 
 false labour occurs. 
 
 Primary Ahdominal Foetaiion. — The possibility of this is still 
 doubted, but there is no d priori reason against it, now that the 
 possibility of ovarian foetation is universally admitted, and its 
 
 Left Fallopian 
 tube. 
 
 Eight Fallopian 
 tube. 
 
 Left ovary. 
 
 Adhesion of 
 
 capsularis to 
 
 back of uterus. 
 
 Capsularis. 
 
 Right ovary. 
 
 Deepest por- 
 tion of placen- 
 tal site. 
 
 Placental site. 
 
 Eectum. 
 Fig. 2(il. — The author's case of primary abdominal foetation. 
 
 occurrence has shown that " the ovum is capable of embedding 
 itself in any patch of connective tissue which is sufficiently large to 
 accommodate it, and sufficiently vascular to meet the demands of its 
 nutrition " (Teacher^). It is, however, almost impossible to prove 
 in any given case, because there is a possibility that the ovum may 
 have been aborted from the tube at a very early stage, and after- 
 wards have implanted itself upon the peritoneum. Cases of this 
 kind have been recorded in lower animals, in which the original 
 
 1 The Early Development and Embryology of the Human Ovum, 1908 (see p. 49). 
 
Abnormal Pregnancy. 435 
 
 site within the tube was discovered on microscopic section. A 
 similar case in woman is recorded by Tuholski.^ If, however, the 
 ovum damaged by separation can attach itself to the peritoneum, 
 it seems still more likely that a fresh ovum can do so. Presumably 
 the peritoneal epithelium normally prevents attachment of the ovum, 
 and such attachment can only occur if the peritoneum is previously 
 damaged. 
 
 Most of the cases of so-called primary abdominal gestation are 
 no doubt instances of the continued growth of an ovum after its 
 extrusion from the tube or from between the layers of the broad 
 ligament. 
 
 The following case appears open to no other interj)retation than 
 primary abdominal foetation. Eupture of an extra-uterine foetation 
 took place at seven weeks' gestation, and the patient died after 
 operation from unexpected syncope, having a damaged heart, 
 although hsemorrhage had not been very extreme. The embryo was 
 found, and measured f inch in length. Both tubes were free and 
 pervious, the fimbrise normal, and showed no sign of any recent 
 dilatation. The fcetal sac appeared to be subperitoneal, lying at 
 the bottom of the pouch of Douglas. Its attachment was two inches 
 away from the nearest ovary. The wall covering in the sac was 
 somewhat adherent to the back of the uterus and broad ligaments 
 (see Fig. 261), but was free above, there being no intestinal adhesion. 
 It had a smooth outer surface which microscopically resembled in 
 structure the peritoneal surface of the broad ligament. This sac 
 wall (Fig. 261) can only be explained as being a decidua reflexa or 
 capsularis, derived from the peritoneal surface. 
 
 This specimen was examined by a committee of the Obstetrical 
 Society of London,^ who reported that it was probably a case of 
 primary abdominal foetation, the committee considering that there 
 was a possibility that the ovum might have been at first implanted 
 in the tube, and afterwards transplanted after abortion to the pouch 
 of Douglas. But now that it has become known that the decidua 
 capsularis is formed by the ovum burrowing at once into the maternal 
 surface before the formation of villi, the presence of a decidua 
 capsularis seems as conclusive proof as the case allows that the 
 abdominal implantation was primary. 
 
 Witthauer records a case of primary abdominal pregnancy.^ 
 After two months' amenorrhoea, the patient had symptoms of 
 internal haemorrhage. A fd'tal sac of the size of a hen's egg was 
 
 ' Aiiier. Gyii. and Obstet. Journ., December, 1901. 
 
 '^ Tnins. Obst. Soc. London, 1896, Vol. XXXVIII., p. 88. 
 
 » Zentralbl. f. Gynak., Jan, 31, 1903, No. 5, p. 136. 
 
 28—2 
 
43^ The Practice of Midwifery. 
 
 found in the lower end of the omentum. Chorionic villi were 
 detected in it, and the ovum was surrounded by blood which 
 separated it from the omental tissue. Both tubes — not, however, 
 cut in serial sections — and ovaries appeared normal. Nowhere could 
 any union be discovered between the cells of the trophoblast or the 
 epithelium of the chorionic villi and the tissues of the omentum, 
 and this makes it probable that the case was in reality one of 
 secondary im23lantation, like most of the others described. 
 
 Pregnancy in a rudiinentari/ uterine horn (Fig. 262) may either 
 lead to rupture in the early months — this occurred in the fourth or 
 fifth month in twenty-four out of forty-five cases of rupture collected 
 
 Fig. 262. — Pregnancy in rudimentary uterine horn, a, junction of rudimentary 
 horn with uterus ; *, point of origin of round and ovarian ligaments and Fallo- 
 pian tube, toward outer part of ectopic sac ; c, uterus unicornis dexter. 
 
 by Werth — or the foetus may go on developing to full term, as 
 hapj)ened in 26 per cent, of his cases. ^ 
 
 In the latter case, the pregnancy may be marked by no abnormal 
 symptoms, until full term arrives, or some peritonitis may occur in 
 the course of pregnancy. In one such case, that of a primipara, 
 I removed the whole tumour unopened after full term, tied the base 
 like an ovarian tumour, after separating extensive adhesions, and 
 the patient recovered as quickly as from an ovariotomy. Within a 
 year she had had a second child, developed in the remaining half of 
 the uterus, and normally delivered. 
 
 In only 19 j)er cent, of the cases did the band of tissue uniting 
 the two horns contain any trace of lumen, and therefore most of these 
 cases must have been examples of external migration of the sper- 
 matozoon. A microscopic examination is, however, always neces- 
 sary to prove the absence of any canal, and this has often not been 
 
 1 Werth ; Von Winckel, Handbuch der Geburtshiilfe, Bd. 2, T. 2, p. 978. 
 
Abnormal Pregnancy. 437 
 
 carried out. The mortality when rupture does occur is high : 
 thirty-one patients out of forty-eight died almost at once after the 
 occurrence of the rupture. Whether the pregnancy continues to 
 full term or rupture occurs depends no doubt upon the degree of 
 development of the muscular tissue of the rudimentary horn. 
 
 The diagnosis of this condition is usually not made until an 
 operation is undertaken, but it has been made in a few cases even 
 before operation. 
 
 Pregnancy in a rudimentary horn is distinguished from tubal 
 pregnancy by the fact that, in the former, the origin of the round 
 and ovarian ligaments lies to the outside of the sac, in the latter, on 
 the inside (Fig. 262). 
 
 In cases of multiple pregnancy and tubal gestation three possible 
 conditions may be present : the two foetuses may be in the same 
 tube, there may be one foetus in each tube, or there may be a 
 simultaneous intra-uterine and extra-uterine pregnancy. When both 
 foetuses are in the same tube they are most commonly contained in 
 the same foetal sac, and this condition has been seen both in the 
 early and the later months of pregnancy. The cases in which there 
 is a foetus in both tubes have so far been met with only in the 
 early months of pregnancy. 
 
 Of the cases in which one foetus has been in the uterus and one 
 extra-uterine, a considerable proportion has gone on to full term 
 without producing grave symptoms, and the extra-uterine tumour 
 has been discovered only in labour or after delivery. In some the 
 extra-uterine sac has ruptured, or haemorrhage has taken place 
 internally.-^ 
 
 Neugebauer ^ has collected 171 cases of this kind. Of these no 
 less than fifty-four of the intra-uterine foetuses were carried to full 
 term, and forty- nine were born alive, while of the extra-uterine 
 foetuses thirty-two went to full term, but only four were born alive. 
 In twenty-eight cases both children reached full term, and all three 
 in one case of triplets. Of the patients operated upon some 19 per 
 cent, died, while of those not operated upon the maternal mortality 
 was nearly 50 per cent. 
 
 In all forms of ectopic foetation, the uterus becomes considerably 
 enlarged, and a decidua forms in it. In tubal foetation, the uterine 
 enlargement is greater the nearer the sac is to the uterus. The 
 increase in the size of the uterus continues usually for the first three 
 
 1 As in a case reconlcd by the authfd-, 'J'raiis. Obst. Soc. London, 1881, VoJ. XXHI., 
 p. 141. 
 
 ''' Neugc))auer, Zur Leliro der Zwilliiigsschwangcrschaft niit heterotopem Sitz dei' 
 Friichte, Leipzig, i;i07. 
 
438 The Practice of Midwifery. 
 
 months ; and during the fourth month, if previous interruption of 
 the pregnancy has not occurred, the uterus commences to diminish 
 in size. The increase in size is due to hypertrophy of the muscle 
 tissue, increased vascularity, and the formation of the decidua. 
 The latter at the height of its develoj)ment is about ^ to 1 cm. in 
 thickness. Its structure is that of the decidua of pregnancy, and it 
 presents two layers, a compact and a spongy layer. The degree of 
 development and the date of its formation varies in different cases, 
 and does not seem to follow any definite law. The decidua is 
 detached and expelled on the death of the ovum or sometimes 
 during the course of the pregnancy, either as a whole (see Fig. 264) 
 or in fragments. In the early months progressive enlargement of 
 the uterine cavity is an important evidence of continued life of the 
 foetus. 
 
 When pregnancy goes on to the later months, the child is 
 occasionally well formed, but more often it is smaller and less 
 nourished than in uterine pregnancy, and deformities, the result of 
 pressure, are common, occurring in at least 50 percent, of all cases.-"- 
 They aft'ect in the order of frequency the head, the pelvis and lower 
 extremities and the upper extremities of the fcetiis. If the foetus 
 dies before full term, the contents of the sac may become decomposed, 
 or suppuration may occur in it. The patient may then suffer from 
 septic absorption. The decomposition in the sac, notwithstanding 
 the exclusion of air, is probably to be attributed to organisms 
 making their way in from the blood or from the intestines, which 
 are usually in close vicinity. More rarely the sac may rupture into 
 the peritoneal cavity, or haemorrhage may occur from partial detach- 
 ment of the placenta, the blood either making its way iuto the sac, or, 
 if there is no adventitious sac, reaching the general peritoneal cavity. 
 
 When full term is reached, if the child is alive up to that time, 
 a kind of sham labour often takes place ; uterine contractions, 
 accompanied by action of the auxiliary muscles of labour, occur, 
 and separate and expel the uterine decidua. This leads to a 
 sanguineous discharge lasting several days. The child dies within 
 a few days from the onset of this sham labour. In other cases 
 the decidua is expelled before the full term, especially if the child 
 has died previously. It is but rarely that rupture of the sac is 
 caused by the sham labour, but some haemorrhage may take place 
 into it. In most cases, after death of the child decomposition takes 
 place in the contents of the sac, causing inflammation and suppura- 
 tion, either at once or after some interval. The contents may then 
 
 1 Von Winckel, Uber die Missbildungen von Ektopisch Entwickelten Fiiichten, 
 Wiesbaden, 1902. 
 
Abnormal Pregnancy. 
 
 439 
 
 escape either externally, by the rectum, the vagina, or the bladder. 
 Ut these the external opening is most favourable, that into the 
 
 rectum the commonest. The process of evacuation may be pro- 
 longed even for years, if not assisted artificially, the bones coming 
 away piecemeal. Eventually the patient may recover. 
 
440 The Practice of Midwifery. 
 
 In other cases decomposition does not take place, but the fluid 
 in the sac is absorbed, the membranes become closely applied to 
 the body of the foetus, and the latter becomes mummified, the soft 
 parts being converted into a greasy pulp, or gradually changed into 
 adipocere.^ The sac and fcetal membranes may become calcified 
 from deposit of lime, the so-called lithokelyphos, a process which 
 aids in isolating the foetus and rendering it innocuous. In some 
 cases the foetus itself becomes more or less calcified, and is then 
 called a " lithopsedion." Generally only the integument is actually 
 calcified, the deposit of lime commencing in the vernix caseosa, but a 
 similar deposit may take place in the internal organs also.^ A 
 mummified or calcified foetus may be retained for many years (in 
 one case as long as fifty-seven years), and other pregnancies may 
 occur and go on to a normal issue. In one instance I removed the 
 calcified sac with a lithopEedion from a patient in whom extra-uterine 
 pregnancy going to full term had been diagnosed twenty years 
 before. At the end of twenty years, abdominal section became 
 necessary on account of the development of an ovarian tumour on 
 the other side; and the old foetal sac w^as removed entire. The sac 
 was of stony hardness, and had to be sawn open after removal with 
 the whole of the broad ligament. The foetus was calcified externally ; 
 its brain was intact but soft, and the ventricles of the brain retained 
 their shape. Inflammation of the sac is, however, liable to occur at 
 any time. 
 
 Symptoms. — In cases of tubal pregnancy, when ruj^ture occurs 
 early, the first thing which may indicate that there is anything 
 amiss is that the patient, who often considers herself in good health, 
 has a sudden attack of agonising abdominal pain with collapse and 
 signs of internal haemorrhage. There may or may not have been 
 amenorrhoea and morning vomiting or other signs of early 
 pregnancy. The intra-peritoneal haemorrhage is often accompanied 
 by severe vomiting. The temperature at first is normal or sub- 
 normal, but after a day or two becomes elevated from peritoneal 
 inflammation or from the absorption of fibrin ferment by the 
 peritoneum. If rupture is deferred beyond six or eight weeks, 
 general symptoms of pregnancy usually exist, and attacks of acute 
 spasmodic pain, partly due to contractions of the tube and partly to 
 intra-mural haemorrhages, tend to occur. Generally there is 
 
 1 Adipocere is a soft waxy substance composed mainly of ammonium margarate with 
 an admixture of potassium and calcium mai'garate. 
 
 2 " Note on tiie so-called Lithopsedion," by Dr. E. Barnes, Trans. Obst. Soc. London, 
 Vol. XXIll., p. 170; Kuchenmeister, " Uber Lithopadion," Arch. f. Gynak., 1881, 
 Bd. 17, Hft. 2, s. 153. 
 
Abnormal Pregnancy. 
 
 441 
 
 amenorrhoea, but irregular discharges of blood are apt to take 
 place, especially m conjunction with the attacks of spasmodic 
 pain. Even the continuance of regular menstruation is not a 
 disproof of tubal foetation. In many cases, the commencement 
 of uterine haemorrhage indicates death of the ovum and the 
 commencement of formation of a tubal mole. If no intra-peri- 
 toneal hgemorrhage or tubal abortion occurs, a sanguineous dis- 
 charge generally goes on for weeks, sometimes for two or three 
 months. The uterine haomorrhage generally implies separation 
 of the uterine decidua ; and this may be expelled at once, or after 
 some interval. Sometimes, in place of amenorrhoea, there is a 
 slight continuous sanguineous dis- 
 charge from the commencement of 
 pregnancy. I have met with one 
 case in which the commencement of 
 extra-uterine foetation during lacta- 
 tion was marked not by the cessation, 
 but by the reappearance, of regular 
 menstruation. In some cases rupture 
 occurs by a small opening. There 
 may then be milder attacks of abdo- 
 minal pain with symptoms of shock 
 due to repeated small haemorrhages, 
 followed perhaps by a more marked 
 attack of pain due to a severe intra- 
 peritoneal bleeding. 
 
 It must be remembered that in 
 the great majority of cases rupture 
 of the tube does not occur, and in 
 such the classical clinical picture 
 
 of a ruptured tubal gestation is not seen. Tubal abortion is 
 marked by signs of internal haemorrhage, preceded or accom- 
 panied by spasmodic pains in one groin. The symptoms are 
 generally not so extreme as in rupture of a tubal foetation, but 
 may be so severe that the one condition cannot be distinguished 
 from the other till the abdomen is opened. The most characteristic 
 signs of an early tubal pregnancy, and those most commonly 
 present, are — amenorrhoea, one period at least having been missed ; 
 irregular haemorrhage from t,he uterus, the discharge slight in 
 amount, resembling that of a long-continued period ; repeated 
 attacks of pelvic pain, often associated with nausea and faintness ; 
 and the occasional — in al>out 25 to BO per cent, of the cases — 
 passage of shreds or even a complete uterine decidua. 
 
 Fig. 264. — Decidual cast from case 
 of tubal pregnancy. 
 
442 The Practice of Midwifery. 
 
 In abdominal, or intra-ligamentous, pregnancy the general signs 
 of pregnancy, including amenorrhcea, are generally present. 
 Sometimes nothing abnormal is noted till full term, or the death 
 of the foetus, when a false labour, and expulsion of decidua from 
 the uterus, followed by a kind of lochial discharge, supervene. 
 More frequently unusual abdominal pain is felt, especially on 
 movement of the foetus ; and in abdominal pregnancy attacks of 
 peritonitis usually occur ; or the whole of pregnancy may be a 
 course of subacute peritonitis. In intra-ligamentous pregnancy 
 there are often j)ressure symptoms, especially if the sac descends 
 low into the jDolvis. If the sac is on the left side, more or less 
 intestinal obstruction may be produced by the sigmoid flexure being 
 distended over it. After death of the foetus there are frequently 
 the constitutional signs of inflammation of the sac, peritonitis, and 
 septic absorption. There may be previously irregular bleeding and 
 exj)ulsion of a uterine decidua, but not so frequently as in tubal 
 foetation. 
 
 Diagnosis. — A tubal foetation may be suspected if there are 
 general signs of early pregnancy, accompanied by attacks of 
 spasmodic pain, and irregular haemorrhage, and if a tumour of 
 corresponding size is felt at one side of or behind the uterus. 
 Probably in most cases of tubal foetation, while the ovum is alive, 
 there is no symptom beyond amenorrhoea ; and symptoms only 
 commence when abortion or rupture occurs, or when the ovum dies 
 and a tubal mole begins to form. Thus, when a successful operation 
 has been performed for an unruptured tubal foetation, the condition 
 is generally that of a tubal mole. 
 
 If tubal abortion has occurred, and a pelvic hgematocele has 
 formed, a soft, boggy, tender mass can be detected in the pelvic 
 cavity usually behind and to one side of the uterus. The degree of 
 displacement of the uterus gives a clue to the size of the tumour, 
 which is often somewhat indefinite in outline, although at times it 
 can be felt reaching above the pelvic brim with a convex upper 
 border. 
 
 In cases in which the ovum continues to live after the first eight 
 weeks, ballottement may possibly be discoverable somewhat earlier 
 than in normal pregnancy, as in a case recorded by Thomas, of New 
 York. If a swelling is detected at the side of the uterus, not yet 
 advanced enough to give signs of foetal life, and if a manifest souffle 
 is heard over the swelling, there is a strong presumption in favour 
 of extra-uterine foetation. The cervix uteri, in the early months, 
 will probably resemble that of ordinary pregnancy, and the uterus 
 
Abnormal Pregnancy. 443 
 
 will be enlarged, but not so globular as in uterine pregnancy. Its 
 position varies, but generally it is pushed to one side and forward, 
 the sac lying rather behind it. If there is a strong presumption in 
 favour of extra-uterine pregnancy, sufficient to make it justifiable 
 to run the risk of inducing abortion, the diagnosis may be con- 
 firmed by passing the sound into the uterus, and making out that 
 it is empty. A sudden severe attack of faintness and collapse, with 
 signs of internal haemorrhage, commencing with sharp pelvic pains, 
 
 V 
 
 
 
 Fig. 265. — Degenerate villi in blood clot in wall of tube from case of 
 tubal pregnancy . 
 
 will justify a probable diagnosis of ruptured tubal foetation, especially 
 if menstruation has been arrested for a few weeks. A small lump 
 at one side of the uterus may perhaps be discoverable only if an 
 anaesthetic is given for the examination. The discharge of a decidua 
 from the uterus without any ovum or chorionic villi is a very 
 strong confirmation of a diagnosis of extra-uterine foetation. 'J'his 
 occurrence affords a strong presumption, if not absolute proof, of the 
 death of the ovum. If it is afterwards found that the length of the 
 uterine cavity, measured by the sound, diminishes instead of 
 increasing, the death of the ovum is confirmed. Again, if the 
 
444 The Practice of Midwifery. 
 
 cavity of the uterus is found to be little or not at all increased, 
 there is a presumption that the ovum has been dead for some 
 weeks, and that the uterus has become involuted, assuming that 
 the diagnosis of extra-uterhie foetation is established on other 
 grounds. 
 
 In the later months, when the foetation will generally be of the 
 abdominal or intra-ligamentous variety, the presence of a living 
 foetus would be ascertained by auscultation and palpation. A 
 souffle like the uterine souffle may be heard, but not so constantly 
 as in normal pregnancy. The difficulty will now be to distinguish 
 between extra-uterine and uterine pregnancy. The apparently 
 superficial position of the foetus is an unreliable sign, for this may 
 simply result from thinness of the uterine wall. In the later 
 months the cervix will generally be less softened than in normal 
 pregnancy, but in some cases the softening is so considerable that 
 this distinction fails. The enlargement of the uterus does not con- 
 tinue to increase beyond three or four months. The diagnosis may 
 be made absolute, if the uterus can be made out as separate from 
 the sac containing the foetus. On the other hand, if marked changes 
 of firmness and laxity are manifest in the sac containing the foetus, 
 the sac is almost certainl}^ the uterus. As before, if the case is very 
 critical, diagnosis may be comi^leted by use of the sound. Not 
 infrequently the cervix becomes patent enough to allow the finger 
 to jDass and ascertain the emptiness of the uterus, especially about 
 the time of the exjDulsion of the decidua. In intra-ligamentous 
 pregnancy, the placenta may sometimes be made out to be at the 
 top of the sac, and some part of the foetus may be felt low down in 
 the pelvis, with no placenta intervening. The uterus will be more 
 or less pushed over to one side, though the sac may extend in 
 front of or behind it. Abdominal foetation may sometimes be dis- 
 tinguished from intra-ligamentous by the placenta forming an 
 elastic fluctuating tumour distinct from the foetus, and by more 
 marked signs of peritonitis during the course of the pregnancy. 
 The parts of the foetus may also, in some cases, be felt more 
 superficially, and pain will be produced when they are handled. 
 
 In the case of combined extra-uterine and uterine pregnancy, 
 diagnosis from pregnancy complicated by a tumour is very difficult, 
 and can only be made by recognising foetal life in both tumours. 
 
 If the patient is only seen after the death of the foetus, the 
 distinction will have to be made between extra-uterine foetation and 
 an ovarian or uterine tumour, and must depend chiefly uj)on a 
 history of pregnancy, not ending in delivery, and the recognition of 
 parts of the foetus, especially the head, by palpation, abdominal or 
 
Abnormal Pregnancy. 445 
 
 bimanual. Since histories are often unreliable, it may be 
 impossible to make an absolute diagnosis, except by exploratory 
 incision. 
 
 If, when abdominal section is performed in the later months, a 
 free peritoneal cavity is opened, and the sac is found to be also 
 covered by peritoneum, the pregnancy must be either intra-liga- 
 mentous or advanced tubal. The latter can only be distinguished 
 by the presence of a more definite muscular wall, below, as well as 
 above, and continuous with the wall of the Fallopian tube. 
 
 Tubo-uterine foetation is distinguished from tubal by the absence 
 of any portion of tube between the sac and the uterus, and by the 
 origin of the round ligament being outside the sac. In pregnancy 
 in a rudimentary horn, the origin of the round ligament is also out- 
 side the sac, but the sac is not continuous with the uterus. 
 
 Prognosis. — Extra-uterine foetation is almost always fatal to the 
 child, and very dangerous to the mother. The mortality of cases 
 in which tubal foetation was positively ascertained was formerly a 
 very high one (97 per cent., Puech). Of late, however, a consider- 
 able number of cases has been saved by abdominal section, mostly 
 after rupture of the sac ; and, in some cases, when a diagnosis has 
 been made in the first few weeks of pregnancy, before rupture. In 
 most of these, however, the tube appears to have contained a tubal 
 mole, and not a living ovum. 
 
 Among 114 cases recorded by SideP and Werth^ operated upon 
 for profuse intra-peritoneal haemorrhage there were sixteen deaths, 
 or 14 per cent. Of thirty-one recorded cases of interstitial pregnancy 
 treated by operation four died. 
 
 It is now recognised that a large proportion of cases of tubal 
 foetation end in recovery, without operation, by tubal abortion or the 
 formation of a tubal mole, hsematocele, or hsematoma. Champneys^ 
 records seventy-five cases treated in St. Bartholomew's Hospital, 
 and diagnosed as extra-uterine foetation, in which operations were 
 only performed on account of some urgent indication. The 
 mortality of the whole was 9*3 per cent. Nine primary abdominal 
 sections were performed with a mortality of 22*2 per cent., and 
 seventeen secondary abdominal sections with a mortality of 29"4 
 per cent. No operations during the life of the foetus were 
 included. 
 
 In 291 cases of tubal abortion with the formation of a pelvic 
 
 ' Sidel, Inaug. Diss., Berlin, 1903. 
 
 2 Werth ; Von Winckel, Handbuch der Geburtshulfc, Vol. II., Bd. 2, s. 93. 
 
 " Champneys, Journ. OVjstet. and Gyn. Brit. Emp., Vol. I., 1902, p. 585. 
 
44^ The Practice of Midwifery. 
 
 hsematocele treated expectantly by Fehling/ Zweifel,^ and Thorn,^ 
 there were no deaths. 
 
 On the other hand, the results of operative treatment are almost 
 equally good. Thus out of 284 cases operated upon there were only 
 six deaths. The question is not, however, one which can be decided 
 by statistics alone. A good deal will depend upon the class of the 
 patient, the length of time she can afford for getting well, and the 
 nature of the hsematocele. 
 
 In intra-ligamentous or abdominal foetation, reaching the later 
 months, the mortality is still very high. According to Harris,* the 
 result of twenty-seven cases of abdominal section for advanced 
 extra-uterine pregnancy with a living child up to 1887 was a mor- 
 tality of 93 per cent. : of 145 additional cases up to 1897 a mortality 
 of 31 per cent., thus showing the improvement due to the advance 
 of surgery. 
 
 Better results than these, however, have been recorded. Thus 
 Sittner^ from 1887 to 1900 collected forty-eight cases with a 
 living fcetus in which total extirpation of the sac was carried out 
 with a maternal mortality of 12'5 per cent., and thirty-five cases 
 where the placenta was left in situ with a maternal mortality of 
 42*8 per cent., while during the j^ears 1896 to 1900 alone the 
 mortality in the former class was only 5*5 per cent, and in the 
 latter 33*3 per cent. 
 
 Treatment. — If there are signs of diffuse intra-^Deritoneal 
 hfemorrhage and a suspicion of extra-uterine foetation, the treat- 
 ment is to perform abdominal section at once, and remove the foetal 
 sac if one is found. Within the first eight weeks of pregnancy 
 there are generally no adhesions, and the operation is an easy one. 
 If the patient is extremely collapsed from hasmorrhage and the pulse 
 bad, strychnine should be given subcutaneously before operation, 
 and rej)eated in case of need during the operation. An ample 
 supply of sterilised normal saline solution (chloride of sodium, 
 gr. Ix. adOj.) should be prepared and an assistant be ready to inject 
 it into a vein in the arm, as soon as the bleeding vessels have been 
 secured, in the manner described in Chapter XXXVIII. It is 
 better, if possible, to secure the vessels before the transfusion, 
 otherwise the increase of vascular pressure increases the bleeding. 
 
 1 Fehling, Zeitschr, f. Geburt, u. G-yri., 1898, Bd. 38, ss. 67—100. 
 
 2 V. Scanzoni, Arch. f. Gyn., 1902, Bd. 6.5, s. 562. 
 
 3 Thorn, Miinch. Med. Wochenschr., 1903, No. 21, p. 893. 
 
 ^ Amer. Journ. of Obstet., 1887, XX. 1154—1167 ; Monatschr. f. Geb. uud Gynak., 
 1897, VI. 137—156. 
 5 Sittner, Zentralblatt f. Gynak., 1903, No. 2, p. 33. 
 
Abnormal Pregnancy. 447 
 
 But, if the patient is in imminent danger of dying from the 
 hsemorrhage, the injection may be commenced immediately before 
 or simultaneously with the operation. 
 
 Even if the signs are those of only moderate internal haemorrhage, 
 it is better to perform abdominal section, provided that the patient 
 is seen within two or three days from their occurrence. For a first 
 moderate bleeding may be followed by a more copious one. And, 
 if the blood is left to be absorbed, it is more likely that peritoneal 
 adhesions will be set up and future sterility result, than if the blood 
 is evacuated and the gravid tube removed. There is also the risk, 
 if the haemorrhage is at all considerable, that the clot may become 
 septic, from its vicinity to the intestine, and thus set up extensive 
 inflammation, and require secondary operation. 
 
 Oi^eration for Diffuse Hemorrhage. — If blood is found in the 
 peritoneal cavity, the first step should be to find which tube con- 
 tains the foetal sac, and to draw it up into the incision. A pair of 
 pressure forceps is then placed temporarily on the infundibulo- 
 pelvic ligament, securing the ovarian artery, and another close to 
 the angle of the uterus to secure the communicating branch of the 
 uterine artery. The broad ligament is secured by ligatures, and 
 the tube with sac removed, the ovary being left if possible. The 
 abdominal cavity is then cleared of blood, and may be washed out 
 with sterilised saline solution (gr. Ix. ad Oj.), while, if the patient is 
 ansemic from loss of blood, but not so extremely so as to require 
 intra-venous transfusion, it is well to leave a quart of this solution 
 in the peritoneal cavity. Its absorption is promoted if the foot of 
 the bed is raised upon blocks about a foot. The fluid then gravitates 
 toward the i^art of the peritoneum near the diaphragm, where 
 absorption is more active. An enema of saline solution after the 
 operation is also useful. 
 
 If a probable diagnosis of early tubal foetation is made before 
 symptoms of haemorrhage bave occurred, and a lump is felt in the 
 position of the Fallopian tube, it is advisable to make an exploratory 
 abdominal section if it is doubtful whether the ovum is dead or 
 alive, or if there is reason to think that it is only just dead. For 
 serious haemorrhage may occur even after the death of the ovum. 
 If, however, it is probable, on account of long-continued sangui- 
 neous discharge, or from evidence that the uterus has become 
 involuted, that tlie ovum has been dead for a considerable time, it 
 may be sufficient to keep the patient completely at rest for many 
 weeks, in the hope that the tubal mole may shrink and become 
 absorbed. The rest should be prolonged as long as there is any 
 sanguineous discharge and for at least a week or two longer. The 
 
448 The Practice of Midwifery. 
 
 surgeon should be prepared to perform an abdominal section at 
 once, in case of symptoms of haemorrhage appearing. 
 
 If there have been symptoms of haemorrhage, and the physical 
 signs of pelvic haematocele or haematoma have appeared, it may 
 be presumed that the ovum is dead, and that the bleeding is 
 gradual and limited by adhesions or cellular tissue. The question 
 of operation must then be decided by the circumstances of each 
 case. As a general rule, if there is a presumption that the embryo 
 is so small that it can readily become dissolved, that is to 
 say, if, as is usually the case, it has not reached two months' 
 development, it is better to wait so long as matters are quiescent, 
 keeping the patient at rest in bed. The blood will generally even- 
 tually become absorbed. If the swelling begins to diminish, the 
 patient is likely to get well without operation ; if further increase 
 occurs, an operation will generally be necessary. 
 
 If there is reason to believe that the foetus has lived beyond two 
 months, an operation is advisable, for the probability is that the 
 foetus will, sooner or later, break down and become septic. It is 
 not, however, always possible to determine the point without an 
 exploratory incision. In a doubtful case, examination of the 
 pelvis with the X-rays and a screen, or a skiagraph of the pelvis, 
 may demonstrate the presence or absence of a fcetus with developed 
 bones, and its size. As regards the choice of operation, if there is 
 evidence of commencing sepsis, the swelling should be evacuated at 
 once from the vagina. The same mode of access is generally 
 advisable if operation is decided on because the swellingundergoes 
 increase, or fails for a long time to show signs of diminution, or is 
 very excessive in size, unless there are symptoms of fresh rupture 
 or haemorrhage into the general peritoneal cavity. In case of doubt 
 as to the nature of the tumour, or whether such fresh rupture has 
 occurred, it is often useful to make an exploratory abdominal 
 incision first. If the pelvis is then found to be completely covered 
 in by adhesions, or if the swelling proves to be a hgematoma in the 
 broad ligament, the blood should be evacuated through the vagina, 
 and the abdominal incision closed. In the case of hsematoma, the 
 abdominal incision is useful to guide the direction of the vaginal 
 evacuation, so that it avoids the peritoneum. In a case of 
 hsematoma of the broad ligament, the absorption appears often to 
 be slower than that of an intra-peritoneal effusion, and the course 
 of the case is shortened by vaginal evacuation. 
 
 Operation of Vaginal Evacuation. — The patient is placed in the 
 lithotomy or exaggerated lithotomy position, and the legs secured 
 by leg rests or Clover's crutch. After shaving of the pubes and 
 
Abnormal Pregnancy. 449 
 
 disinfection of the vulva and vagina, the cervix is drawn down- 
 ward and forward by vulsella. An incision is made with scissors 
 through the posterior vaginal fornix in the direction of the most 
 prominent or softest part of the swelling, but inside the course of 
 the ureter. Fine pointed forceps are pushed into the swelling, 
 and the opening enlarged by separation of the blades, and then 
 by the fingers until two fingers can be introduced. Clots are then 
 scooped out by the fingers and the cavity washed out with sterilised 
 normal saline solution, or with an antiseptic such as a solution 
 of chinosol 1 in 400, if the contents are septic. Finally the cavity 
 is plugged with iodoform gauze. The gauze is to be changed at 
 about two days' interval, and the opening from the vagina kept 
 open by its means until the cavity has closed up. Thevenard ^ 
 has recorded fifty-three cases treated by posterior colpotomy with- 
 out a death. 
 
 Treatment after the Early Months. — If there is evidence that the 
 ovum is growing, or that the fcetus is alive, after the second, and 
 especially after the third month, it generally means that the fceta- 
 tion is converted into a ligamentous or secondary abdominal 
 pregnancy. The risk either of operating during the life of the 
 foetus or of waiting is then very much greater than if the ovum 
 is dead. Unless the whole gestation sac can be removed, the 
 attempt to remove the placenta is likely to cause fatal haemorrhage, 
 the placental site being unable to contract and close the vessels. 
 If the placenta is left untouched, there is not always a sufficiently 
 firm sac which can be isolated from the general peritoneal cavity. 
 The placenta has to decompose and come away. If rapid decom- 
 position occurs, there is a current of maternal blood passing 
 amongst decomposing villi, and almost inevitable saprsemia or 
 septicsemia as the result (see Chapter XXXIX.). The decomposition 
 is also likely to lead to early separation of placenta and haemor- 
 rhage. Even late decomposition of the placenta produces more or 
 less septic absorption, and haemorrhage occasionally takes place 
 on separation, even as late as several weeks after the removal or 
 death of the foetus. 
 
 In deciding on treatment no regard should be paid to the life 
 of the foetus, for the foetus is generally more or less deformed by 
 pressure or lack of adequate nutrition, and rarely lives for more 
 than a short time, even if delivered alive by operation at full term. 
 
 In general, it is advisable to perform abdominal section as soon 
 as the diagnosis is made, because the less advanced is the preg- 
 nancy, the greater is the probability that it will be possible to 
 
 1 These do I'aris, 1890. 
 
 M. 29 
 
450 The Practice of Midwifery. 
 
 remove the foetal sac entire, or at any rate the placental site. If 
 this can be done, and the vessels suj)plying the placenta secured, 
 the risk of the operation may be reduced to a small one. 
 
 The decision is a more doubtful one, if the pregnancy has 
 reached, or is close upon, full term, or if there is evidence that 
 the foetus is on the point of perishing. Some have then considered 
 it advisable to wait from four to six or eight weeks after the death 
 of the child, provided that no symptoms of sepsis arise. For the 
 risk of the ojDeration is much less after the maternal circulation 
 through the placenta has ceased : provided that a septic condition 
 has not supervened. 
 
 Similarly, if the foetus is already dead, and matters are quiescent, 
 it may be advisable to wait for a similar jDeriod after its death, but, 
 if more than that time has already elapsed, to operate at once. If 
 any symptoms of commencing sepsis or decomposition in the sac 
 appear, operation should be undertaken at once, before the patient's 
 general condition becomes too unfavourable. 
 
 Dunning^ collected twenty-five recorded cases in which the 
 primary operation was performed during the viability of the foetus, 
 with a maternal mortality of 40 j)er cent., and thirty-three cases in 
 which the secondary operation was performed after the death of 
 the foetus, with a maternal mortality of 42"3 per cent., a greater 
 one than that of 38'8 per cent, given in the earlier statistics of 
 Parry, of thirty-six cases treated by secondary operation. He 
 concluded that, in the majority of cases, the operation should be 
 undertaken while the child is still living. Harris' statistics of 145 
 cases of primary operation during the life of the foetus, including 
 the months before viability, give a still better result of the primary 
 operation, namely a mortality of 31 per cent. The figures given by 
 Sittner, already quoted (see p. 446), of forty-eight cases operated 
 upon with total removal of the sac and a maternal mortality of 
 only 12*6 per cent., show that the correct principle is to operate as 
 soon as the diagnosis is made, and in all cases if possible to remove 
 the sac and placenta entire. But it must be remembered that, in 
 reckoning this mortality, cases are not included in which it was 
 found impossible to remove the sac with the placenta, and that the 
 total mortality of Sittner's eighty-three cases of operation with a 
 living foetus (1887—1900) is 25*3 per cent. 
 
 Operation in the Later Months. — In the primary operation, the 
 first essential is to avoid wounding the placenta until the vessels 
 supplying it have been secured. The site for commencing the 
 incision should therefore be toward the upper part of the abdomen, 
 
 1 Amer. Journ. of Obstet., November, 1899, Vol. XL., p. 592. 
 
Abnormal Pregnancy. 45 1 
 
 or where some foetal part is felt so superficially that there cannot 
 be placenta over it. If such a site cannot be found in the median 
 line of the abdomen, the incision may be made anywhere else. 
 
 The most favourable chance for removing the whole sac is when 
 the foetation is intra-ligamentous, especially if the placenta is 
 situated at the top of the sac. If the child is not viable, it is 
 better to remove the sac unopened, if possible. Occasionally the 
 sac may have formed a kind of pedicle like an ovarian tumour, by 
 drawing out the broad ligament, which can be tied without 
 difficulty. More frequently it descends deeply into the pelvis. 
 Its complete removal may then require the removal of the uterus. 
 The ovarian artery on the affected side may be tied first, then that 
 on the opposite side. Next the peritoneum is divided transversely 
 in front of the uterus and stripped down with the bladder. Then 
 the uterine artery on the unaffected side is tied, the broad ligament 
 is divided, the uterus is cut across- near the internal os, and lastly 
 the uterine artery of the affected side is tied below the sac and the 
 sac removed. The peritoneal edges are afterwards united by 
 sutures, and, if this can be done, the abdomen may be closed 
 without drainage. The steps of the operation are similar to those 
 in hysterectomy for a fibroid tumour extending into one broad 
 ligament.^ If it is difficult to secure the uterine artery on the 
 affected side, or if the bleeding is not arrested, it may be advisable 
 to tie the anterior branch of the internal iliac artery, or, if this 
 cannot be separated, its main trunk, at the pelvic brim. 
 
 If the child is viable, the sac must be incised at some spot where 
 its parts are felt superficially and show that there is no placenta. 
 The funis is tied at once on the foetal side and the child removed. 
 The placental end may be left untied. The gestation sac is then 
 treated in the way already described. 
 
 If the sac, with the placenta at the bottom of it, descends so 
 deeply into the pelvic cellular tissue that it is judged impossible 
 to remove it entire, the placenta should be left untouched, the sac 
 stitched to the abdominal wound, a wide orifice being left, and 
 plugged with iodoform gauze. The plug must be renewed from 
 time to time. A similar treatment may be adopted if the first 
 incision opens the sac without opening the general peritoneal 
 cavity. At a later stage, if decomposition has begun, or haemor- 
 rhage occurs from partial separation, it may be advisable to detach 
 the placenta completely and renew the plug tightly. 
 
 If the pregnancy turns out to be abdominal, it may happen that 
 
 ^ For a description and figures of the operation see the author's " Diseases of 
 WomeT;." 
 
 29—2 
 
452 
 
 The Practice of Midwifery. 
 
 the general peritoneal cavity is shut off by a firm adventitious sac 
 of false membrane, and is not opened by the incision. In that 
 case it may be advisable to leave the placenta untouched and plug 
 the sac in the manner already described. As a general rule, the 
 adventitious sac will be imperfect, or not strong enough to isolate 
 the general j)eritoneal cavity securely. It will then be even more 
 important than in the case of intra-ligamentous pregnancy to 
 remove the placental site entire. This will generally consist of a 
 sac in the broad ligament into which the primary rupture of the 
 tubal foetation occurred. It can usually be removed unless the 
 
 Fig. 266. — Mikulicz tampon. 
 
 placenta has spread on to surrounding parts which cannot be 
 removed, such as intestine or pelvic wall. If the placental site 
 cannot be removed entire, and there is no sac which can be stitched 
 to the abdominal incision, the only plan is to leave the placenta 
 untouched and to fill the pelvis with a large Mikulicz tampon, a 
 gauze bag with thread attached to the bottom, filled with strips of 
 iodoform or sterilised gauze (Fig. 266), by which the intestines are 
 held back and a large opening into the pelvis maintained. The 
 strips of gauze filling the bag are renewed at intervals, so as to keep 
 the intestines out of the pelvis until the placenta has broken down 
 and come away. 
 
 Drainage may also be required on account of bleeding from 
 
Abnormal Pregnancy. 453 
 
 adhesions which cannot be satisfactorily arrested. If extensive 
 pressure is required, the Mikulicz tampon should be used. Other- 
 wise the best plan is to open the posterior vaginal fornix from the 
 pouch of Douglas, upon the blades of a pair of forceps pushed up 
 by an assistant from below. A strip of iodoform gauze is passed 
 from above into the vagina, about an inch being left within the peri- 
 toneal cavity. The strip is removed at the end of two or three 
 days. 
 
 In the secondary operation the procedure is the same if no sepsis 
 has occurred, and it is equally important to remove the whole sac, 
 or placental site, entire if possible. If sepsis or decomposition has 
 taken place in the sac, the object is to evacuate the sac without 
 contaminating the general peritoneal cavity. If a month or more 
 has elapsed since the death of the foetus, it will most likely be 
 possible at once to peel off the placenta without very serious 
 haemorrhage, and plug the sac with iodoform gauze, its edges 
 having been stitched to the abdominal wound, if the general 
 peritoneal cavity has been opened at all. The attempt to separate 
 the placenta should be begun cautiously from the edge, since the 
 date after the death of the foetus at which the maternal circulation 
 in the placenta ceases is very uncertain. 
 
 If the placenta is left untouched, it generally begins to separate 
 in about a week. Loose pieces may be removed piecemeal, but, if 
 bleeding occurs on the separation, it is better to pull off the whole 
 and arrest the bleeding by plugging with gauze, aided if necessary 
 by external pressure by an abdominal belt. When the gauze is 
 changed, the sac may be washed out with an antiseptic solution, 
 such as chinosol 1 in 400, or tinct. iodi 5j. ad Oj. 
 
 If the placenta is wounded or detached at the operation, or has 
 become detached before, the best chance of arresting bleeding is to 
 place quickly one or more thin Doyen clamp forceps to compress 
 the base of the sac. The ovarian and uterine arteries, or if neces- 
 sary the internal iliac artery on the affected side, may then be 
 sought for and tied, and the placenta removed. If haemorrhage 
 cannot be completely arrested, a Mikulicz tampon may be used, 
 filling the pelvis, and compressing the bleeding site. 
 
 In a case of doubtful diagnosis, when the patient is first seen 
 some months or more after the full term of the supposed pregnancy, 
 the right treatment, as a rule, is to clear up the diagnosis by 
 exploratory incision. The foetus or the tumour, as the case maybe, 
 can then generally be removed. 
 
 When the sac has suppurated, and bones begin to escape either 
 externally, or through some internal cavity, as the rectum, vagina, 
 
454 The Practice of Midwifery. 
 
 or bladder, Nature should be aided in the evacuation. So far as 
 possible the opening should be enlarged by stretching rather than 
 cutting. For this purpose, tents will sometimes be found useful. 
 An anaesthetic being given, the bones may then be extracted by 
 finger or forceps. 
 
 In some cases, an extra-uterine foetus, at or near full term, has 
 been successfully removed through the vagina. This operation 
 should only be undertaken when the sac bulges toward the vagina, 
 and when some foetal part can be felt at the accessible portion of it. 
 This will give some security that the placenta is not situated there. 
 In the absence of such evidence, it is very likely to be found so 
 placed. Here, again, the most favourable case is that of intra- 
 ligamentous pregnancy, when the j)lacenta will probably be at the 
 top of the sac. The sac may be opened by the knife of the benzoline 
 or galvano-cautery to diminish the risk of hemorrhage. This 
 method will not, however, avail to do so, if the placenta is the part 
 first encountered. The placenta should be left untouched. It may 
 be necessary to extract the foetus by forceps or craniotomy. The 
 sac should be plugged with iodoform gauze in the first instance, and 
 afterwards regularly washed out with antiseptics, and it may be 
 useful to insert a large drainage-tube into it. In some cases the 
 vaginal method of removal may be chosen when a previous 
 abdominal incision appears to show this to be the best plan, the 
 placenta lying at the toj) of the sac, and some part of the foetus 
 presenting low in the pelvis. 
 
Chapter XX. 
 
 DISORDERS OF PREGNANCY DUE TO REFLEX 
 TOXIC AND MECHANICAL CAUSES. 
 
 The disorders of pregnancy may be divided into four classes : — 
 (1.) Those arising from reflex nervous influence, associated with the 
 changes in the nervous centres induced by pregnancy, and the 
 increased tissue metabolism which it causes, with the possible 
 accumulation in the mother's blood of various excretory products 
 the result of such metabolism. (2.) Those which result from 
 mechanical effects. (3.) Morbid conditions of the uterus and ovum. 
 (4.) Diseases independent of pregnancy, but of such a nature that 
 the disease is influenced by the pregnancy, or the course of pregnancy 
 by the disease. In some cases, such as puerperal convulsions, 
 the disease may have a complex causation, depending upon more 
 than one of the above causes. 
 
 Many of the disturbances which come under the first class are 
 exaggerations of those reflex symptoms of pregnancy which may be 
 regarded as normal, or scarcely morbid. They depend not only 
 upon the presence of a certain source of irritation in the pregnant 
 uterus, but upon the increased irritability of the nervous centres 
 which is associated with pregnancy. This increased irritability 
 itself may be regarded as physiological, when within due limits, but 
 in persons of highly excitable neurotic temperament it may become 
 excessive, and may take a morbid form, such as hysterical manifes- 
 tations, neuralgia, vomiting, or convulsions. 
 
 In other cases the so-called auto-intoxication of pregnancy may 
 play a part ; that is, a condition supposed to be induced in the 
 mother by the undue accumulation in her body of the waste products 
 of her tissue metabolism and that of the foetus. It is assumed that 
 in certain conditions, as the result of some failure of the proper 
 excretory functions of the liver and the kidneys, such bodies may be 
 retained and accumulate in the mother's blood. Their exact nature 
 is not quite certain, but there appears to be some evidence in favour 
 of the view that they are the products of proteid disintegration. 
 
 Nausea and Vomiting. — The well-known morning sickness, 
 which is generally ^chiefly observed in the second, third, and fourth 
 
456 The Practice of Midwifery. 
 
 months, and passes off in the later months, affecting one-third to 
 one-half of all pregnant women, has been already described among 
 the signs of pregnancy. But in some rare cases the neurosis takes 
 a much more severe form. The vomiting may not be limited to the 
 morning, but occur at all times in the day, and it may persist in 
 the later months of pregnancy. In extreme cases all food taken 
 may be quickly rejected. There may be, in addition, such a 
 continual feeling of nausea that all appetite is destroyed. 
 
 Causation. — The disorder is to be regarded as one of the reflex 
 neuroses associated with the increased irritability of nervous centres. 
 The special source of irritation appears to be the stretching of the 
 fibres of the uterus in consequence of its growth. Thus vomiting 
 is more marked in primiparse, in whom the resistance to expansion 
 may be presumed greater ; and it has sometimes been found to be 
 excessive in cases where there has been an unusually rapid expan- 
 sion, such as those of twin pregnancy, hydrops amnii, or vesicular 
 mole. Again, vomiting is sometimes found to cease when the 
 foetus dies, although it is retained for a time within the uterus. 
 The cause cannot, however, be passive distension by the ovum, 
 since the ovum does not completely fill the uterus in the months 
 during which vomiting is most marked. Women who suffer 
 severely in this way are generally those of highly susceptible 
 neurotic temperament. Frequently they have j)reviously suffered 
 from some uterine disturbance, such as dysmenorrhoea. The 
 neurosis may be aggravated by any morbid condition of the uterus 
 which would render the uterine nerves more susceptible to irritation, 
 whether this be j)revious endometritis or metritis, inflammation of 
 cervix, grave displacement, such as retroversion or retroflexion, or 
 any other condition. For instance, vomiting is sometimes relieved 
 upon the replacement of a retroverted gravid uterus- But such a 
 case is exceptional, both among instances of retroversion of the 
 gravid uterus, and among those of vomiting of pregnancy. It has 
 been alleged that the paroxysms of vomiting are, in some cases at 
 any rate, coincident with the uterine contractions which occur 
 during pregnancy. This would agree with the fact that women who 
 suffer from spasmodic dysmenorrhcea are specially liable to vomiting. 
 It is to be noted, however, that as the contractions become more 
 marked toward the later months of jDregnancy, the vomiting 
 diminishes. 
 
 In some instances painful emotion or sudden mental shock is the 
 starting-point of a very severe kind of vomiting. It has been 
 suggested that some forms of acquired or congenital malformations 
 of the stomach may also play a predisposing part. In other cases 
 
Disorders of Pregnancy. 457 
 
 the tendency to vomiting due to various stomach disorders, especi- 
 ally the dyspepsia produced by alcoholism, or Bright's disease, is 
 added to the effect of pregnancy, and greatly aggravates it. 
 
 In some rare cases in which the vomiting of pregnancy terminates 
 fatally necrotic changes in the cells of the centre of the liver 
 lobules (Whitridge Williams) and of the secretory tubules of the 
 kidney, similar in type to those which are found in eclampsia, have 
 been described as discovered post mortem. On this ground it has 
 been supposed that such fatal cases of vomiting are altogether 
 different in their nature and causation from the milder degree of 
 the vomiting of pregnancy. It may be, however, that even in such 
 cases the same causation may form some element in the case ; but 
 that there is, in addition, a toxic condition of the blood, the 
 toxaemia of pregnancy ; and that this determines the fatal result. 
 
 Symptoms and Course. — In some cases, although the vomiting is 
 excessively distressing, yet the general nutrition does not seem to 
 suffer much. This is especially the case when the vomiting is not 
 continued throughout the whole day. In more severe cases symp- 
 toms of starvation appear. The patient becomes emaciated and 
 weak, the tongue glazed and irritable, the urine scanty, the breath 
 foetid, and often there is a want of sleep. In the later stages 
 elevation of temperature or delirium may occur. In some cases the 
 urine becomes albuminous ; and, according to Whitridge Williams, 
 the proportion of the total nitrogen excreted as ammonia, which 
 normally should amount to about 4 or 5 per cent., may rise to 
 as much as 20, 30, or even 40 per cent. It is quite possible, how- 
 ever, that the true explanation of this alteration in the relative 
 quantities of ammonia and urea may be the accompanying 
 condition of starvation of the patient in a case of pernicious 
 vomiting, and no correct deduction can be drawn as to the nature 
 of the vomiting or its causation from the ammonia coefficient of 
 the urine alone. The depravation of the blood and general weakness 
 predispose to septicaemia, which is liable to arise after either spon- 
 taneous or induced abortion. Spontaneous abortion is apt to be 
 deferred until the patient is almost moribund, and does not then 
 save her life. If it occurs before symptoms are very grave, she 
 generally quickly recovers. 
 
 Prognosis. — Cases which endanger life are very rare in comparison 
 with the number of women who suffer, but they are not absolutely 
 so excessively uncommon. McClintock collected nearly 50 fatal 
 cases ; Gueniot 4f5 ; It. Barnes had himself seen 9. When the 
 pulse rises above 120, when delirium occurs, and haematemesis or 
 diarrhoea supervenes at a severe stage, the danger is great. 
 
458 The Practice of Midwifery. 
 
 Treatment. — In mild cases, in which simply the ordinary morning 
 sickness is unusually troublesome, it is important that the patient 
 should take a little food before getting up. This relieves the 
 exhaustion which may promote the instability of the nerve centres, 
 and gives the stomach occupation in a right direction. 
 
 Constipation, when it exists, should be treated. When there is 
 a foul tongue, a dose of calomel occasionally is of service, and 
 bismuth with bicarbonate of soda, or bicarbonate of potash with 
 calumba and hydrocyanic acid may be given before food. Often an 
 acid with a vegetable bitter after food ^ assists digestion and relieves 
 vomiting. If any special lesion, such as granular inflammation of 
 the cervix, exists, the effect of local treatment to it should be tried. 
 Thus occasional painting of the cervix with concentrated tincture 
 of iodine is often beneficial. Retroversion or retroflexion of the 
 gravid uterus should be remedied, whether there is vomiting or not. 
 Drugs innumerable have been recommended, and not uncommonly 
 all are found to fail. Among these may be mentioned effervescing 
 mixtures with hydrocyanic acid, pepsin oringluvin after meals, oxalate 
 of cerium, which may be given in doses of from five to ten grains, 
 creosote, tincture of nux vomica, vinum ipecacuanhfe in doses of one 
 minim every hour or every two hours, tincture of iodine in minim 
 doses, comj)ound pyroxylic spirit in five-minim doses, caffeine, 
 nitrite of amyl by inhalation. Among the most likely to be useful 
 are remedies which are found to be of value in sea-sickness, such as 
 bromide of potassium in full doses, and nitro-glycerine in tablets, 
 containing each ^ho gi'ain. Iced champagne with milk is some- 
 times retained, but if there is any suspicion of tendency to 
 alcoholism, recourse to alcohol as a remedy should be checked, 
 since it aggravates the complaint. 
 
 In severe cases position and diet should be specially attended to. 
 The patient should be kept recumbent, and liquid nourishment 
 should be given at short intervals, only a spoonful at a time. Iced 
 milk with soda-water or barley-water, or meat jelly, may be tried. 
 Brand's essence of beef is often retained when milk is rejected. 
 Barff 's kreochyle is also valuable. Being pej)tonised, it is quickly 
 absorbed, even when nothing can be retained long in the stomach. 
 Peptonised milk or other forms of predigested food may also be 
 tried. If there is much exhaustion somatose or Peptone Cornells is 
 valuable. Fifteen minims of tincture of opium, given by rectum, 
 or a small subcutaneous injection of morphia and atropia, are often 
 useful ; but, with a patient susceptible to morphia, this may rather 
 do harm. Sulphate of atropia, ^q grain, given by subcutaneous 
 
 1 Acid Nitro-hydrochlor. Dil. TTLsv. ; Tinct. Gentian. Co. 3j- ; Aq. ad Jj. 
 
Disorders of Pregnancy. 459 
 
 injection, sometimes appears to be of more use than any other 
 remedy. In other cases minute doses of morphia given by the 
 mouth, and repeated whenever vomited, prove of great use. 
 Counter-irritation over the stomach sometimes does good, and 
 some recommend Chapman's spinal ice-bag, applied to the cervical 
 vertebrae. The patient should not be allowed to become much 
 emaciated before recourse is had to nutrient enemata. These 
 should either consist of artificially digested food, or pancreatic 
 extract should be added to them to procure digestion in the 
 rectum.^ 
 
 On the hypothesis that, in the pernicious form of vomiting, the 
 cause is a toxin resulting from defective metabolism, treatment by 
 thyroid extract has been suggested, and favourable results have been 
 reported. This appears worthy of trial, especially if albuminuria 
 is present. Good results, too, may be obtained by the transfusion 
 of saline fluid subcutaneously or by the bowel. 
 
 The most radical treatment is of course the induction of abortion. 
 But before having recourse to this, if danger is not too extreme, it 
 is often worth while to try the plan recommended by the late 
 Dr. Copeman, of Norwich, namely, dilatation of the cervical canal. 
 If the cervical canal is already somewhat patulous, this may be 
 effected by pressing the index-finger into it ; if not, metallic bougies 
 may be passed into the canal, but not farther than just up to the 
 internal os. This remedy must be regarded as an empirical one. 
 The only rational explanation of it is, that the uterine tension acts 
 especially on the nerves about the internal os, and that its effect is 
 diminished by partial dilatation of that orifice. Since any effectual 
 dilatation of the cervix has a strong tendency to bring on abortion, 
 this treatment should only be adopted when the case is serious 
 enough to justify such a risk ; and it should therefore be preceded 
 by a consultation. 
 
 Abortion should be induced only when the mother's life is 
 endangered. It is often necessary to tesist the desire of the 
 patient herself, who may be greatly wearied by the vomiting, and 
 perhaps may prefer not to have a living child. If, however, the 
 pulse, the tongue, and the degree of emaciation denote danger, 
 interference should not be put off too long ; otherwise it may fail to 
 save life, and the patient may sink from exhaustion or septicaemia 
 shortly after the abortion is completed. It is, of course, an absolute 
 
 1 Mix equal parts of hot thick water-gruel and cold milk. Add Benger's Liquor 
 I'ancreaticus 3j.i and bicarbonate of soda, gr. v. to "^iv. of the mixture, with which 
 an egg may also be beaten up. If these enemata are not retained, use solid peptone 
 suppositories. 
 
460 The Practice of Midwifery. 
 
 rule that, for the protection of the medical man himself, a consul- 
 tation should be held before this step is decided uj)on. If the 
 operation is not undertaken too late, cessation of the vomiting 
 generally soon follows, and may be attained even before the uterus 
 is completely emptied. The method of procedure in inducing 
 abortion will be described in Chapter XXXI. 
 
 Other Digestive Disturbances. — Besides vomiting, other forms 
 of digestive disturbance, such as pyrosis, heartburn, and flatulence, 
 are common. Occasionally diarrhoea is set up, and this may call 
 for treatment, especially on account of its tendency to lead to 
 abortion or premature labour. The more common tendency is to 
 constipation, which is partly due to the enlarged uterus mechani- 
 cally interfering with intestinal movements. Laxatives will be 
 required, especially if the patient suffers from varicose veins, or 
 swelling of the feet, conditions which are aggravated by constipa- 
 tion. The pill recommended at p. 406 may be taken at night when 
 required, or a moderate dose of the compound liquorice powder, 
 or a small dose of saline. Sometimes enemata are found preferable 
 to aj)erients. 
 
 Salivation. — Salivation is a somewhat rare complication, probably 
 of nervous, but possibly of toxic, origin. Sometimes it is not only 
 very annoying to the patient, but exhausting by its profusion. It 
 may be combined with vomiting, and, like vomiting, it is generally 
 most marked in the second, third, and fourth months. It is apt to 
 resist remedies. Astringent mouth washes, tannin lozenges, and 
 the like, may be tried ; also iodide of potassium, for its influence 
 upon gland activity, or belladonna, for its special effect on the 
 salivary glands. Subcutaneous injections of atropin near the 
 glands have been recommended. 
 
 By those who believe that salivation is another manifestation 
 of toxic' poisoning a pure milk diet with intestinal antiseptics is 
 advocated. 
 
 Gingivitis. — Congestion and hypertrophy of the gums occurs in 
 some 50 to 60 per cent, of pregnant women, both primiparae and 
 multiparee. The condition is one of simple hyperplasia, but may 
 in rare cases become very marked and give rise to a good deal of 
 discomfort and bleeding. The use of an antiseptic astringent 
 mouth wash is indicated, and at times the treatment of the 
 hyper trophied tissues with the cautery. 
 
Disorders of Pregnancy. 461 
 
 Anaemia. — ^In the poorly developed and ill nourished a certain degree 
 of anaemia is the rule in pregnancy, especially when the children follow 
 one another in rapid succession, or if nutrition is interfered with 
 by vomiting and other digestive disturbances. Anaemic bruits 
 are heard in the heart and arteries, and the uterine souffle becomes 
 unusually loud. The number of red corpuscles and the proportion 
 of albumen in the blood diminish, while the number of white 
 corpuscles and the amount of fibrin and water increase. The 
 watery condition of the blood may lead to oedema, in the absence 
 of any albuminuria. This oedema extends to face and upper parts 
 of the body, but is much more marked in parts where the effect of 
 pressure on the veins is also operative, that is to say, in the legs 
 and vulva. In rare cases the anaemia assumes the character of 
 "progressive pernicious anaemia," and tends to a fatal result. 
 Examination of the blood then shows marked diminution in the 
 number of the red cells and the presence of numerous irregular and 
 nucleated red corpuscles. A very large proportion of such cases 
 have ended in death, even when pregnancy has been brought to a 
 premature close spontaneously or artificially. 
 
 Treatment. — The first principle in treatment is to improve the 
 general condition by nutritious and easily digestible diet, especially 
 meat, when it can be taken. When practicable, the digestive 
 powers should also be stimulated by a due amount of fresh air and 
 gentle exercise. Any oral sepsis should receive special attention. 
 Iron should be given without hesitation ; reduced iron, if the vege- 
 table salts are not easily tolerated. In cases in which iron fails 
 to do good, arsenic, manganese, or phosphorus in addition has been 
 recommended. In rare and extreme cases, induction of abortion 
 or premature labour may be called for. When the anaemia appears 
 to have the progressive or pernicious character, this step should 
 not be too long deferred. 
 
 Neuralgia. — Neuralgic pain is common in pregnancy, and may 
 be regarded as partly a reflex neurosis, partly the result of anaemia 
 or impaired nutrition, or the result of the presence of toxic sub- 
 stances from tissue metabolism in the blood. In the case of tooth- 
 ache, it often results from the fact that caries of the teeth is more 
 liable to occur during pregnancy. Besides faceache, the most 
 common neuralgias are headache and mammary and intercostal 
 pain. 
 
 Treatment. — In the case of carious teeth, extraction or stopping, 
 according to circumstances, should not be deferred on account of 
 the pregnancy. For simple neuralgia, iron and quinine are the 
 
462 The Practice of Midwifery. 
 
 most valuable drugs. The latter may often be given in large 
 doses. Opium and morphia should be avoided as far as possible. 
 For the immediate relief of toothache or facial neuralgia, tincture 
 of gelsemium may be given in doses of ten or fifteen minims. 
 Outward applications, such as linimentam aconiti, are often useful. 
 
 Cough, Dyspnoea, Palpitation, and Syncope. — Cough in 
 pregnancy is frequently of a spasmodic and reflex character, like 
 that which occurs in hysterical subjects. Dyspnoea and palpita- 
 tion, in the absence of any cardiac affection, may be partly reflex, 
 and partly the result of anaemia. Dyspnoea in the later months 
 generally depends in part upon the downward movement of the 
 diaphragm being limited, although the actual capacity of the chest 
 is now known not to be diminished in pregnancy. Syncope in 
 pregnancy often does not mean actual failure of the heart, but is 
 rather of the nature of the apparent fainting which is closely allied 
 to hysteria. There is a semi-unconscious condition, which may 
 last for a considerable time, but no grave alteration of the pulse. 
 
 Treatment. — If drugs are required for the cough, antispasmodics, 
 such as belladonna and bromide of potassium, should be given. 
 For the other neuroses above mentioned, good diet and tonic 
 treatment, especially iron, are the chief remedies. If there is 
 dyspnoea care should be taken that the clothing is loose enough. 
 For attacks of " fainting," alcohol should be avoided, but ether or 
 aromatic spirit of ammonia may be given. Anti-hysterical remedies, 
 such as valerian, may also be tried. 
 
 Eruptions. — Various eruptions appear occasionally to have a 
 causal relation with pregnancy, as they do sometimes with disturb- 
 ances of uterus and ovaries apart from pregnancy. The chief of 
 these are acne, eczema, herpes, and urticaria. A special title of 
 " herpes gestationis " has been given to an eruption of groups of 
 vesicles on the limbs and buttocks,^ which often recurs in successive 
 pregnancies. A more severe form of this, becoming pustular, 
 probably of septic origin, and in several cases ending fatally, 
 "impetigo herpetiformis," has been described by Hebra.^ The 
 treatment of these eruptions must be conducted on general 
 principles. 
 
 Pruritus. — In rare cases general pruritus of the skin exists 
 as a neurosis. Pruritus of the vulva is comparatively common. 
 It is promoted by the local venous congestion, but most frequently 
 
 1 Bulkley, Amer. Journ. of Obstet., Vol. VI. 
 
 2 Wien. Med, Woch., 1872, No. 48. 
 
Disorders of Pregnancy. 463 
 
 has a starting point, either in some eczema of the part affected, 
 or in the irritation of an acrid leucorrhceal discharge from cervix 
 or vagina. 
 
 Treatment. — In pruritus of the vulva, any source of leucorrhcea 
 should be treated, and the syringe used frequently to wash away 
 the discharge. The bowels should be kept acting freely. As 
 lotions to be applied directly to the affected surface, solution of 
 borax (gr. x. ad 5].), the liq. plumbi subacetatis dil., solution of 
 carbolic acid (gr. ij. to iv. ad 5]'.), and especially one of perchloride 
 of mercury (gr. ij. ad 3]',) may be tried. Glycerine (5J. ad 5].), 
 and hydrochlorate of morphia (gr. ij. ad 3J.), or dilute hydrocyanic 
 acid (5SS. ad 3J.), or a combination of the two, may also be added 
 for greater sedative effect. When the irritating effect of leucorrhcea 
 seems to be the chief cause of trouble, the vulva may be pro- 
 tected with vaseline to which acetate of lead (gr. xxx. ad §j.) and 
 hydrochlorate of morphia (gr. x. ad 5J.) may be added. An 
 ointment of cocain, creosote, and conium often gives relief. 
 
 Chorea. — Chorea is not a common complication of pregnancy, 
 but, after the age of childhood, it is relatively much commoner in 
 conj unction with pregnancy than apart from it, so that there is no 
 doubt that pregnancy is a strong predisposing cause. Hence the 
 occurrence of chorea in a young woman should always raise the 
 question whether pregnancy exists. Not only does pregnancy 
 predispose to chorea, but the very grave or fatal cases of chorea 
 recorded have been frequently those associated with pregnancy ; 
 and, in general, with this complication, the disease is much more 
 likely to prove very severe as regards the violence of the motions, 
 to lead to bodily wasting or paresis, and to be accompanied with 
 mental disturbance, leading on, in some cases, even to mania. It 
 is therefore to be regarded much more seriously than the ordinary 
 chorea of children. 
 
 The immediate and essential cause of the chorea of pregnancy, 
 as of chorea in general, is not yet fully ascertained. But it cannot 
 be doubted that pregnancy promotes the disease in two ways, first, 
 as a cause of reflex irritation, and secondly, by impoverishment of 
 the blood. The element of mental emotion, well known as an 
 occasional starting point of chorea, is also added in some cases, as 
 when an unmarried girl has become pregnant. Those who suffer 
 from chorea in pregnancy are generally young primiparge (59 per cent, 
 of Buist's cases), who have either suffered from the disease as 
 children, or have a hereditary tendency to neuroses. The 
 associations with rheumatism, with a systolic cardiac bruit, and 
 
464 The Practice of Midwifery. 
 
 with vegetations on the cardiac valves, found in fatal cases, have 
 been noticed in the case of the chorea of pregnancy, as in that of 
 ordinary chorea. 
 
 The disease usually commences in the first half of pregnancy, 
 about the third or fourth month; occasionally it ceases during the 
 course of the pregnancy, but more commonly it continues until 
 the onset of labour. 
 
 Prognosis. — Spiegelberg^ gives the mortality as 23 out of 84^ 
 cases, or 27 per cent. ; but it must be remembered that slight 
 cases are not so likely to have been recorded as the severe. 
 Schrock^ has collected 154 cases with a mortality of 22 per cent. ; 
 Buist^ 255 cases with a mortality of 17'5 per cent.; Barnes^ 56 
 cases with a mortality of 30 per cent. ; Wall and Andrews ^ 40 cases 
 treated at the London Hospital with a mortality of 12" 5 per cent. 
 Of 29 consecutive cases at Guy's Hospital 3 died. French ' 
 and Hicks lay great stress upon the prognostic importance of fever, 
 and maintain that, if no other cause can be found for the fever, 
 the outlook is very grave. When severe, the disease has a tendency 
 to« produce abortion or premature labour. In many instances 
 recovery has quickly followed, but, in a notable proportion, delivery 
 has only occurred at an extreme stage, and death has followed 
 shortly after. Death of the foetus often occurs, and is a cause of 
 the occurrence of premature labour. In Buist's cases, spon- 
 taneous abortion or premature labour occurred in 17*6 per cent. ; 
 in Barnes' cases, in 32 per cent. ; in Wall and Andrews' cases, in 
 only 12'5 per cent., but in another 10 per cent, of these abortion 
 was induced. 
 
 Treatment. — Chorea during pregnancy is less influenced than 
 usual by drugs. The most important point is to maintain nutri- 
 tion and use tonic treatment, especially iron and arsenic. When 
 movements are very violent, direct sedatives may be called for, 
 such as chloral, chloralamide, or even inhalation of chloroform. 
 When danger is indicated by great emaciation, rapid pulse, and 
 high temperature, when there is notable muscular paresis, or 
 mental disturbance so great as to threaten mania, it is justifiable 
 to induce artificial abortion without waiting till it is too late to cure. 
 
 At the same time it must be remembered that the results from 
 
 1 Lehrbuch der Geburtshiilfe. 
 
 2 Eighty of these are taken from Schwechten's dissertation, " Ueber Chorea 
 Gravidarum," Halle, 1876. 
 
 3 Ueber Chorea Gravidarum, I. D. Konigsberg, 1898. 
 
 ^ "Chorea Gravidarum," Trans. Obst. Soc, Edinburgh, 1892. 
 s Trans. Obst. Soc, London, 1869, Vol. X., p. U7. 
 
 6 Journ. of Obst. and Gyn. Brit. Emp., June, 1903, Vol. III., No. 6, p. 5-10. 
 
 7 French and Hicks, Practitioner, August, 1906. 
 
Disorders of Pregnancy. 465 
 
 the induction of abortion are not at all good. Thus induced abortion 
 and induced premature labour was followed by death in no less than 
 43 per cent, of the cases in Buist's series. This mode of treat- 
 ment is very seldom needed, and it is indeed doubtful if it has 
 much influence in saving the life of the patient. 
 
 Hysteria.— In patients subject to hysterical manifestations, 
 these are often increased during pregnancy, and more especially 
 at the time of labour, under the influence of pain. 
 
 The Insanity of pregnancy will be considered in conjunction 
 with puerperal insanity, the latter being the more common affection. 
 
 Albuminueia and Puerperal Convulsions, or Eclampsia. 
 
 The occurrence of albuminuria during j)regnancy has been 
 specially considered in reference to its connection with puerperal 
 convulsions. It was first pointed out by Lever in 1842 ^ that, 
 in the great majority of cases of puerperal convulsions, albumen in 
 considerable quantity is present in the urine. The view that such 
 convulsions are ursemic in character then generally gained accept- 
 ance. Of late, however, some observers have endeavoured to show 
 that albuminuria in pregnant and parturient women is compara- 
 tively common, while eclampsia is very rare, and hence have 
 depreciated the importance of the albuminuria as indicating the 
 probable imminence of convulsions. The importance of urgemia in 
 the causation of eclampsia has also been controverted, on the 
 ground that convulsions sometimes occur without albuminuria, 
 and that, in other cases, the albuminuria only appears after the 
 convulsions, the urine before the fits, or after the first fit, being 
 free from albumen. 
 
 Albuminuria. — The pathology of the albuminuria will be 
 considered in the first instance, and that of the convulsions 
 afterwards. 
 
 Causation. — Several different theories have been propounded as 
 to the causation of the albuminuria. These are not necessarily to 
 be regarded as rival explanations, for, while some of them seem to 
 be inadequate taken by themselves, it is probable that, in many 
 cases, two or more causes combine to influence the kidneys. 
 
 1. The first assigned cause is pressure upon the renal veins 
 from the gravid uterus, producing some venous congestion in the 
 
 1 Guy's Hosp. Reports, 1842. 
 
 M. 30 
 
466 The Practice of Midwifery. 
 
 kidneys. It is not a sufficient cause by itself. It is true that 
 albuminuria may be produced by pressure of an ovarian tumour. 
 But this does not occur till the tension is greater than is usual in 
 pregnancy, and the albuminuria is generally a passive transudation 
 only, disappearing when pressure is taken off, while there is 
 abundant evidence that, in the marked albuminuria of pregnancy, 
 there are actual changes in the kidneys. Albuminuria may also 
 occur in the early months, before pressure on the renal veins can 
 exist. 
 
 2. The second cause is also a mechanical one, namely, the 
 pressure of the uterus upon the ureters. In consequence of this, 
 the kidneys will have to secrete against a higher pressure than 
 usual, and may find their task therefore more difficult. This cause 
 may operate while the uterus is still mainly in the pelvis. There 
 is some direct evidence that this is a vera causa, for out of 32 fatal 
 cases of eclampsia Lohlein found that in 8, or 25 per cent., dilata- 
 tion of one or both ureters was recorded at the autopsy. Herzfeld, 
 in 463 cases of eclampsia, found dilatation of both ureters in 22 per 
 cent.^ 
 
 A further argument adduced for the conclusion that mechanical 
 pressure in one or both of these modes is often an element in the 
 case is the fact that albuminuria and eclampsia are much commoner 
 in primiparae, in whom the tension of the abdominal walls is greater. 
 Thus from 60 to 80 per cent, of all cases of eclampsia occur in 
 primiparae. There is, however, as we shall see, another possible 
 explanation of this fact. Moreover, twin pregnancy and hydramnios 
 are also predisposing causes. Twin pregnancy has been noted in 
 from 5 to 8 per cent, among cases of eclampsia,^ whilst among all 
 labours its proportion is only from "9 to 1*5 per cent. 
 
 3. The third cause is the increased work thrown u]3on the kidneys 
 during pregnancy by their having to excrete the waste products 
 resulting from the increased tissue metabolism of the mother and 
 that of the foetus. Although the bulk of the latter is small in pro- 
 portion to the body, yet activity of growth must be accompanied by 
 active formation of waste products, and, if the kidneys are naturally 
 weak, and barely equal to their work before, this addition may 
 just disturb the balance, especially when added to mechanical 
 causes of embarrassment. Evidence in favour of the operation of 
 this cause is the fact that both albuminuria and eclampsia have 
 
 1 Zentralbl. f. Gyn., 1901, No. 40. 
 
 2 Cassamajor, "Contribution a I'Etude de TEclampsie Puerperale d'apres une 
 Statistique de la Clinique de 1872—1892," D.I., Paris, 1892; Olshausen, " Ueber 
 Eklampsie," Volkroann's Sammlung, 1891, No. 39. 
 
Disorders of Pregnancy. 467 
 
 been found to subside after the death of the foetus and before its 
 expulsion. 
 
 If, on account of any disturbance in the function of the liver or 
 other blood glands, metabolism is imperfect, intermediate products 
 may result more toxic than the normal ultimate products. Such 
 toxins circulating in the blood may cause further damage to the 
 glands at fault as well as to the kidneys. This in its turn will lead 
 to a further retention of them in the mother's tissues, resulting in 
 a condition of so-called auto-intoxication. In favour of this view is 
 the fact that degenerative changes are found in the liver cells as 
 well as in the kidneys. 
 
 4. The fourth cause is the increased arterial tension which is 
 usual in pregnancy. Considerable disturbances of the kidney 
 circulation probably also occur during labour pains. Possibly this 
 is the explanation of the greater frequency with which foreign 
 observers have discovered a slight degree of albuminuria during 
 labour compared with that noted in the ninth month of preg- 
 nancy (see below). Such albumen, when only present in very 
 small quantity, and without any general oedema or constitutional 
 symptoms, is probably only a passive transudation. 
 
 5. The fifth possible cause is one suggested by Tyler Smith, 
 namely, a reflex nervous influence starting from the pregnant 
 uterus as a source of irritation, and disturbing the circulation or 
 secretion of the kidneys, as those of the salivary and thyroid 
 glands are in some cases disturbed. This it is difficult or 
 impossible to verify, but it does not seem an improbable cause, 
 since there is a close nervous connection between the kidneys and 
 pelvic organs, as is often shown by the sudden copious secretion 
 of urine in hysterical women. 
 
 6. A theory of the causation of the form of albuminuria associated 
 with eclampsia is that it is dependent upon a special form of micro- 
 organism. Blanc ^ made culture of a micrococcus from the kidneys 
 of eclamptic patients, and stated that the product, if injected 
 into rabbits, gave rise not only to albuminuria, but directly to 
 convulsions. Gerdes^ found a bacillus which he regarded as the 
 cause of eclampsia in the blood and in various organs, but most 
 in the placenta. Other observers, however, consider this to be 
 only the proteus vulgaris and to be of post-mortem origin. 
 Lermovitsch "^ found a round or oval organism in the blood of 
 44 eclamptic patients, cultures of which, injected into guinea- 
 
 1 Zeitschr. t Geb. und Gyniik., XXXIII., p.'i). 
 
 2 Deutsch. Med. Wochenschr. , 1892, XVIIJ., p. 26, 
 8 Lermovitsch, Zentral?jl. f. Gyniik. , 1899, No. 46. 
 
 30- 
 
468 The Practice of Midwifery. 
 
 pigs and rabbits, caused haemorrhagic endometritis, anaemia, and 
 tetanic spasms. Most observers have found that no specific 
 organisms can be cultivated from either the blood or the urine, 
 and this theory is therefore probably erroneous. 
 
 7. The most recent theory is that the toxaemia which produces 
 both the changes in the kidneys and the eclampsia is the result 
 of the action of certain ferments in the placenta, the toxins from 
 which pass into the general circulation and set up chemical changes 
 in other organs of the body. On this ground the early emptying 
 of the uterus is advocated as a remedy. 
 
 Frequency of Albuminuria. — Eather contradictory accounts have 
 been given as to the frequency with which albuminuria exists in 
 pregnant women, without any other morbid sign appearing. Some 
 foreign observers make it appear to be a common occurrence. Thus 
 Blot, Litzmann, Petit, and Hypolitte have published observations 
 in which they found albumen in the urine of more than 20 per 
 cent, of women during or just after labour. During the ninth 
 month, before the onset of labour, albumen was found in about 
 14 per cent. 
 
 On the other hand, albuminuria, which can be detected in the 
 ordinary way by heat and nitric acid, does not seem so common 
 in this country. Out of 200 cases in the Guy's Hospital Charity, 
 in which the urine was tested about the time of labour, albumen 
 was found in only four, and two of these appeared to be cases of 
 chronic Bright's disease. The explanation may lie in the fact, 
 that the foreign observers used more delicate tests, and so recorded 
 very slight traces of albumen. Such a degree of albuminuria 
 stands widely apart from that usually associated with eclampsia, 
 for in that albumen is generally present in large proportion. 
 According to Little, however, in 1,000 jD^egnant women whose 
 urine was examined in the Johns Hopkins Hospital, a considerable 
 proportion of albumen, together with tube-casts, was recorded in 
 7*3 per cent, of the cases. 
 
 It is of course to be borne in mind that, if albumen be found 
 in urine passed in the ordinary way, the observation must be 
 confirmed by testing some which has been withdrawn by catheter ; 
 otherwise the albumen may be due to some admixture of vaginal 
 secretion. It is probable that slight traces of albumen are often 
 due, not to any kidney affection, but to a slight catarrh of the 
 bladder, which is not uncommon in pregnancy. In other cases, 
 especially if occurring quite at the end of pregnancy, or during 
 labour only, they may result from slight mechanical transudation 
 under pressure without any nephritis. 
 
Disorders of Pregnancy. 
 
 469 
 
 In considering the albuminuria of pregnancy three separate 
 conditions must be recognised. The presence of the albumen may 
 be due to the fact that a woman who is the subject of chronic 
 Blight's disease becomes pregnant, it may appear in the urine in 
 the early months of pregnancy and be associated with the so-called 
 kidney of pregnancy, or it may appear for the first time late in 
 pregnancy or during labour in association with the onset of an 
 attack of eclampsia. 
 
 Chronic Bright's disease is usually aggravated by the occurrence 
 
 Pig. 267. — Kidney of pregnancy from a patient with albuminuria and 
 hydatidiform mole dying from hfemorrhage. Cloudy swelling and 
 coagulation necrosis of the epithelium of the convoluted tubules is 
 present (see Fig. 286). 
 
 of pregnancy, but, as a rule, the patient does not develop eclampsia, 
 and the case runs a course similar to that of an ordinary instance 
 of this disease. 
 
 The second class of case, in which the albumen appears usually 
 about the middle of the pregnancy, presents much the same 
 symptoms as those of an ordinary case of acute kidney disease. In 
 most instances the patients have previously been perfectly healthy, 
 and the albuminuria is accompanied by oedema and the presence of 
 renal tube casts and blood in the urine, a condition which by some 
 authors is called the chronic renal disease of pregnancy. This 
 
470 The Practice of Midwifery. 
 
 variety of kidney disease rarely leads to the development of 
 eclampsia, but not uncommonly there is a history of an attack of 
 eclami)sia in a previous pregnancy.-^ 
 
 Herman^ has shown that in the albuminuria of pregnancy three 
 different types of kidney may be met with : first, kidneys showing 
 disease such as may occur apart from pregnancy ; secondly, 
 conditions very closely resembling those of ordinary acute nephritis ; 
 thirdly, kidneys presenting macroscopically but little change, but on 
 microscopic examination showing evidence of acute degenerative 
 processes, the typical kidneys of eclampsia (see p. 480). 
 
 As French and others have pointed out, a very close comparison can 
 be drawn between the kidney changes occurring in cases of scarlet 
 fever and those occurring during pregnancy. Just as there are 
 cases of scarlatinal nephritis in which cedema is entirely absent, 
 and uraemia is the first symptom to attract attention, while in other 
 cases cedema without ursemia is a marked feature, so in cases of 
 the albuminuria of pregnancy oedema may be marked without the 
 occurrence of eclampsia, and, on the other hand, eclampsia may occur 
 suddenly with little or no oedema. 
 
 The changes in the kidneys, too, in the two cases, are very com- 
 parable, and may vary from slight congestion to the most acute 
 degenerative processes afl'ecting large areas of the kidney substance. 
 We may therefore conclude that the difference is one of degree only 
 between the cases in which albuminuria occurs early in pregnancy, 
 with a good deal of oedema, and those in which eclampsia occurs 
 late in pregnancy, with little or no oedema. 
 
 A recent nejjhritis, the result of pregnancy, is said to be 
 distinguished from a chronic Bright's disease, upon which pregnancy 
 has supervened, in the relative proportion of serum albumen and 
 paraglobulin in the urine. In chronic Bright's disease, the greater 
 portion of the precipitate consists of serum albumen, in eclamptic 
 patients, of paraglobulin.^ 
 
 Symptoms and Course. — The nephritis associated with eclampsia 
 appears in the majority of cases to be a quite recent attack. 
 Usually only a slight amount of general oedema, which com- 
 monly has escaped notice, precedes the convulsive attack. In 
 49 per cent, of French's cases there was no oedema at all, and 
 
 1 French, Goulstonian Lectures, Brit. Med. Journ., May, 1908. 
 
 2 Herman, AUbutt's Syst. Med., 1899, Vol. VII., p. 810. 
 
 s Treat the urine with a saturated solution of magnesium sulphate, and filter. This 
 precipitates the paraglobulin only, which remains upon the filter. The serum albumen 
 in the filtrate is precipitated by heat. The residue on the filter is dissolved in warm 
 distilled water, and precipitated again by heat. The relative quantities can thus be 
 compared. See Maguire, Lancet, 1886, Vol. IL, d. 524 ; Ralfe, Diseases of Kidneys, 
 p. 107. 
 
Disorders of Pregnancy. 471 
 
 in 35 per cent, there was only slight oedema of the face and ankles. 
 But women who have had eclampsia in their first pregnancy 
 sometimes have a recurrence or increase of albuminuria in 
 successive pregnancies, and the tendency of the nephritis of 
 pregnancy, when thus chronic or repeated, seems to be towards the 
 production of the granular kidney of interstitial nephritis. The 
 affection of the eyes which is common in such cases confirms this 
 conclusion. Eetinal haemorrhages and white spots of retinitis are 
 seen, similar to those usually associated with chronic interstitial 
 nephritis. Pre-existing Bright's disease is generally aggravated by 
 pregnancy. Frequently the extent of the oedema indicates that the 
 interstitial nephritis, if any, which exists, is complicated by more or 
 less acute tubal nephritis. The oedema is also aggravated by the 
 tendency to hydremia usual in pregnancy, and also by the effect of 
 pressure. Hence it sometimes becomes very extreme in the lower 
 limbs, vulva, and lower part of abdomen. A very marked oedema 
 of the vulva usually means albuminuria, and not merely the 
 effect of pressure. 
 
 The milder symptoms usual in the nephritis of pregnancy are 
 headache, sleeplessness, dizziness, and vomiting. There is an 
 unusual proneness to the diseases of the puerperal state, such as 
 septicaemia, cellulitis, and mania, and probably also to jjost-partum 
 haemorrhage. 
 
 Besides eclampsia and impairment of sight, the nephritis of 
 pregnancy involves another danger, namely, that of paralysis. 
 Paraplegia, hemiplegia, and facial paralysis are apt to occur in 
 pregnancy, paraplegia being the commonest ; and, in a large 
 proportion of cases, they are associated with albuminuria. Deaf- 
 ness, or injury to other special nerves, may arise in the same way. 
 As in the case of the retina, the cause may probably be either 
 local haemorrhages or inflammatory deposits. In most cases 
 recovery or improvement takes place after delivery. 
 
 The more chronic form of Bright's disease does not so irequently 
 lead to eclampsia as the recent and usually unobserved attack. 
 Seyfert records that out of over 70 cases in which women suffering 
 from Bright's disease became pregnant, only 2 had convul- 
 sions. Hofmeier records that out of 46 cases of the more chronic 
 form of nephritis in pregnancy, one-third of the patients had 
 convulsions. 
 
 The fact that chronic Bright's disease in pregnancy, as a rule, 
 does not produce convulsions may be explained by two considera- 
 tions. First, the degree of albuminuria is not a measure of the 
 impairment of the excretory power of the kidney, and in chronic 
 
472 The Practice of Midwifery. 
 
 nephritis a certain compensatory balance of excretory power may 
 have been attained. Secondly,- in chronic disease, the nerve- 
 centres may be supposed to have become, in some measure, tolerant 
 of the influence of the toxins in the blood. Thus when, after 
 eclampsia in a first pregnancy, albuminuria recurs in subsequent 
 pregnancies, the eclampsia does not recur in more than 3 per cent, 
 of the cases. 
 
 It cannot be a correct explanation that the albuminuria is 
 the consequence of the convulsions. For, in most cases, the 
 albuminuria certainly precedes in point of time. And, again, 
 albuminuria is not usually the result of ordinary epileptic fits, 
 nor even of those cases somewhat resembling eclampsia, in which a 
 series of epileptiform convulsions, in rapid succession, leads to 
 a fatal result. The venous congestion produced by the convulsions 
 must, however, tend to increase the embarrassment of the kidneys. 
 
 In the chronic nephritis of pregnancy there is a great tendency 
 to abortion, which appears generally the result of the prior death 
 of the foetus, or to premature labour with a still-born child. In 
 many cases this is associated with the occurrence of haemorrhages 
 into the placenta or between the membranes and the uterine wall 
 and the formation of numerous large white infarcts. I have 
 known cases in which eclampsia has occurred at the first preg- 
 nancy, the albumen has disappeared or greatly diminished in 
 the intervals of pregnancy, but a series of pregnancies have 
 followed, each terminated by the death and subsequent expulsion 
 of the foetus, the albuminuria, accompanied by affection of the eyes, 
 having recurred with each pregnancy. The only explanation 
 possible appears to be either that the foetus perishes from insuffi- 
 cient nutrition, or that it is directly killed by a poison present in 
 the blood. The frequent death of a child in eclampsia, where the 
 nephritis present is usually a recent attack, is in favour of the latter 
 explanation. 
 
 Treatment. — Very slight traces of albumen, in the absence of any 
 symptoms, appear to be of little significance, especially if observed 
 only in the ninth month, or during or just after actual labour. If, 
 however, the proportion of albumen is considerable, if casts are 
 present, or if there is general oedema or other constitutional 
 symptoms, treatment is called for. The bowels should be kept 
 acting freely, both with a view to keeping down arterial tension, 
 and with the hope of carrying off some waste products by that 
 channel. The kidneys should also be flushed as much as possible, 
 to prevent impairment of excretory power by the choking of the 
 tubes with epithelium. The best diuretic for this purpose is water, 
 
Disorders of Pregnancy. 473 
 
 but salines, such as acetate of potash, may also be given. In recent 
 and acute attacks of nephritis advantage has been derived from a diet 
 which gives the kidney as little work as possible in excreting 
 nitrogenous material. This indication is best fulfilled by a diet 
 consisting of milk, not more than three pints in the day, and 
 starchy material, such as cornflour, sago, arrowroot, etc., alone. 
 The patient should also be kept in bed, both for the avoidance of 
 chills, and for the effect of rest in diminishing waste products. 
 In chronic cases, according to the modern view, it is better not to 
 restrict the diet too much, but to give a fair amount of meat. It 
 seems desirable, however, to be sparing in the use of beef-tea or 
 meat extracts. Iron should be given in the more chronic cases 
 when there is anaemia. Turkish baths may be used to stimulate 
 the action of the skin. When albuminuria comes on first in the 
 later months in a primipara, especially if urine is scanty, albumen 
 copious, and there is headache or affection of vision, watch must 
 be kept for the outbreak of convulsions, and the eyes carefully 
 examined with the ophthalmoscope. 
 
 Full doses of bromide of potassium may be given as a 
 prophylactic, and chloral may be added if premonitory signs are 
 very marked. 
 
 For cases in which the albuminuria ap]3ears to be due to the 
 toxaemia of pregnancy, and not chronic Bright' s disease, treatment 
 by thyroid extract has been suggested by Nicholson,^ on the theory 
 that the toxaemia is due to defective metabolism, and that the 
 thyroid extract stimulates metabolism. At any rate, the thyroid 
 treatment tends to lower arterial pressure, which is generally ex- 
 cessive in albuminuria. It is advisable to watch daily the amount 
 of urine secreted, and the amount of urea, especially in primiparae, 
 and when the albuminuria is attributed to the toxaemia of 
 pregnancy. 
 
 If there is much oedema towards the end of pregnancy, or if the 
 proportion of albumen is large, and increases notwithstanding 
 treatment, premature labour should be induced. This is especially 
 desirable in the case of a primipara, and still more if there are 
 premonitory symptoms of eclampsia, such as headache or vomit- 
 ing ; if albuminuric retinitis is present ; or if the urine is scanty, 
 or the elimination of urea very defective. There is a better chance 
 of escaping eclampsia if labour is brought on than if the kidney 
 disease is left to become aggravated. It is justifiable even to induce 
 abortion, after a consultation, if grave symptoms are present, 
 
 1 Jouni. of Obst. and Gyri. Brit. Emp., July, 1902, Vol. II., p. 40. 
 
474 The Practice of Midwifery. 
 
 especially serious damage to the retina, or paralysis, or a threaten- 
 ing of eclampsia. 
 
 Eclampsia. — Puerperal convulsions, or eclampsia, are to be 
 distinguished from hysterical convulsions, and from convulsions 
 set up by lesions of the brain on a large scale, such as cerebral 
 ha;morrhage. The disease is also distinct from true epileptic fits, 
 occurring casually in pregnancy, labour, or the puerperal state. 
 The epileptic tendenc}'-, however, appears sometimes to predispose 
 to actual eclampsia. 
 
 Clinical History and Symjjtoms. — Sometimes the attack comes on 
 without any premonitory signs having been observed, the patient 
 having been about, and apparently in perfect health. More 
 frequently there are premonitory signs, especially severe headache, 
 lasting for at any rate some hours, and sometimes accompanied by 
 flashes of light, or other affection of the eyes. Other premonitory 
 signs sometimes observed are nausea and vomiting, severe epigastric 
 pain, vertigo, and dimness of sight. Sometimes not only oedema of 
 the lower parts, but some puftiness of the face, has been noticed for 
 a few days or for a week or two. Marked cedema of the vulva is 
 generally a sign of nephritis. The onset of the convulsions may 
 occur either during pregnancy, sometimes as early as the sixteenth 
 week, but generally in the eighth or ninth month, during labour, 
 or after delivery. 
 
 The individual convulsion resembles an epileptic convulsion, 
 except that the epileptic cry never occurs. Sometimes a definite 
 tonic stage is observed, lasting not more than a few seconds. The 
 face turns suddenly pale, the features are drawn and rigid, the 
 head generally drawn to one side, the eyes turned up showing the 
 whites, the muscles rigid, the thumbs turned into the palms of 
 the hands, respiration arrested. Then twitching begins at the 
 face and eyes, and extends to more violent jerking movements of 
 the head and neck, and of tlie limbs. The face becomes livid and 
 horribly distorted, the veins distended from interference with 
 respiration, the tongue is protruded and often bitten, the breath 
 escapes with a hissing sound, and is accompanied with foam 
 from the mouth. At this stage the arteries may be seen 
 beating violently, the passage of blood through the lungs being 
 obstructed. 
 
 In other cases no clear distinction between tonic and clonic stage 
 can be made out, especially when the fits succeed each other in 
 quick succession. The fits begin with twitching of the face and 
 eyeballs, and tonic and clonic spasms of the muscles of the limbs 
 
Disorders of Pregnancy. 475 
 
 seem to alternate. In the tonic spasms, the back may be arched, 
 as in opisthotonos. 
 
 During the convulsions there is complete insensibility, and the 
 pupils do not act to light. Urine and faeces may be passed. The 
 clonic stage of convulsion may last from half a minute to two 
 minutes, most frequently not longer than one minute. 
 
 The convulsion is followed, for a short time, by a partial degree 
 of coma, with stertorous breathing. After a first attack, conscious- 
 ness is soon recovered, but the patient is more or less confused, 
 having no remembrance of what has occurred, and sometimes falls 
 into a heavy sleep. The special character of the convulsions of 
 eclampsia is that they recur. In mild cases there may be only a 
 few fits at long intervals, and consciousness may always return 
 in the intervals. In severe cases the convulsions recur with 
 increasing frequency, and in some instances more than 100 have 
 occurred. Sometimes they follow in such quick succession as to 
 appear almost continuous. When several convulsions have 
 occurred at short intervals, coma, more or less complete, persists 
 in the intervals. Breathing is stertorous, the face congested and 
 swollen, the tongue often swollen and bleeding. The patient is 
 generally unconscious, unable to understand when spoken to, or 
 to answer, and remembers nothing afterwards of her condition. 
 Keflex sensibility, however, is shown if she is touched, or when 
 labour pains occur. During the intervals there is often a 
 certain amount of muscular rigidity with restlessness, more 
 marked when a paroxysm is approaching. The sensibility of 
 the pupils to light is diminished. They may be dilated or con- 
 tracted, but generally are contracted shortly before and during a 
 paroxysm. 
 
 Convulsions may be induced by external stimuli, especially by 
 vaginal examinations. Frequently they are excited by a labour 
 pain. The pain is first manifested by the groaning restlessness, 
 and bearing down of the patient, the uterus may be felt to harden, 
 and then the convulsion comes on. The converse relation may also 
 exist, and the paroxysm may induce a prolonged tetanic con- 
 traction of the uterus, lasting several minutes longer than an 
 ordinary labour pain.^ This may be one cause of the frequent 
 death of the foetus, by arresting or greatly diminishing the circula- 
 tion through the placenta. If the eclamptic attack comes on 
 during pregnancy, it has a strong tendency to cause expulsion of 
 
 ^ " On the liehaviour of the Uterus in Puerperal Eclampsia," by Dr. Braxton Hicks, 
 Trans. Obst. Hoc. London, 188.'5, Vol. XXV., p. 118. Spiegelberg, however, states it as 
 his experience that the uterus is never observed to take part in the paroxysm. 
 
47^ The Practice of Midwifery. 
 
 the foetus. If the attack is sufficiently severe and prolonged, labour 
 is sure to come on sooner or later. If the convulsions come on 
 during labour, the pains of the second stage generally progress 
 with vigour, and sometimes the child is rapidly expelled. This 
 tendency may be due in part to the asphyxia produced by the con- 
 vulsions, for asphyxia is well known to cause the uterus to expel its 
 contents. Frequently the child is still-born. Among the causes 
 tending to its death are the interference with the mother's respira- 
 tion, and the prolonged tetanic contractions of the uterus, when 
 these occur. But in some instances of mild eclampsia during 
 pregnancy, which passed off without bringing on labour, but were 
 associated with copious albumen in the urine, I have found that 
 the child died at the time of the convulsions, but was expelled 
 only after some days and weeks. This is evidence in favour of the 
 view that, as in the case of the nephritis of pregnancy without 
 eclampsia, a poison circulating in the mother's blood has an 
 injurious effect upon the foetus. 
 
 From the effect of repeated convulsions, the pulse becomes rapid 
 and sometimes small. The rate may rise as high as from 120 to 
 140. From sphygmographic tracings taken during the eclamptic 
 state, I have found that the pulse is not a dicrotic pulse of low 
 tension, like the ordinary rapid pulse of fever, but one of abnor- 
 mally high tension, like that observed in Bright's disease. The 
 temperature also rises in a marked degree from the effect of the 
 convulsions. In cases not actively treated, when many paroxysms 
 occur at short intervals, it may rise to a very unusual height, such 
 as 108° or 109°.-^ Any very considerable rise of temperature 
 indicates great danger. The use of chloroform, of morphia, or of 
 venesection, however, appears to interfere with the rise of tem- 
 perature. If the convulsions are arrested, or occur at longer 
 intervals, the temperature falls again even though the coma con- 
 tinues. This rise of temperature is contrasted with the state of 
 things in ordinary cases of urtemia without convulsions, for then 
 the temperature tends to become sub-normal. A similar rise of 
 temperature takes place when a fatal result follows, in either sex, 
 from a series of epileptiform convulsions, much resembling 
 eclampsia, but apart from pregnancy, and not associated with any 
 albuminuria or nephritis. This effect on temperature appears to 
 be evidence that the comatose state of the eclamptic patient 
 indicates actual injury to the nerve-centres caused by the eclamptic 
 explosions, an injury which is apt to lead on to a fatal result- 
 
 1 See cases recorded by Bourneville, Etudes Cliniques et Thermom^triques sur les 
 Maladies du Systeme Nerveux, and by the author, Brit. Med. Journ., May 22, 1875. 
 
Disorders of Pregnancy. 477 
 
 Pyrexia also occurs apart from a rapid succession of convulsions, 
 or at a later stage, and then probably implies the presence of some 
 septic element. 
 
 Causation and Pathological Anatomy. — Eclampsia is not of very 
 common occurrence. Its frequency, however, aj)pears to vary in 
 different countries and at different times and places, as does that of 
 puerperal septicaemia (see Chapter XXXIX.). According to 
 Cassamayor, in Tarnier's clinic in Paris there was 1 case of 
 eclampsia to every 47 labours in 1872, as compared with 1 to 730 
 in 1882, and 1 to 130 in 1891. In the Guy's Hospital Charity it 
 occurred once in 842 deliveries, and fatal cases amounted 
 to 1 in 3,368 deliveries. In New York City, from 1867 to 
 1875, fatal cases amounted to 1 in about 700 deliveries. ■*■ 
 In the thirteen years 1892 — 1905 there were 70 cases of 
 eclampsia in 47,924 deliveries at the Ptotunda Hospital, or 1 in 
 694.^ The general estimate for Europe is about 1 case in 600 
 deliveries. A marked circumstance in relation to the causation is 
 the special liability of primiparge to the disease. In the Guy's 
 Charity 60 per cent, of the cases were in primiparse. Other 
 statistics give a proportion of from 70 to 85 per cent. Multiple 
 pregnancies undoubtedly appear to be a predisposing cause, and 
 eclampsia has been met with in six cases of hydatidiform mole, 
 where no foetus was present. 
 
 Urine. — In the great majority of the cases the urine is found to 
 be albuminous. The proportion of albumen is usually large. 
 Often it occupies a third or a quarter of the bulk of the urine 
 after settling, and sometimes the urine becomes nearly solid on 
 heating. The urine is not only albuminous, but frequently also 
 scanty, and sometimes almost suppressed. Often it is turbid and 
 smoky-looking from containing blood. Sometimes the quantity of 
 blood is sufficient to colour it red. Pienal epithelium can generally 
 be detected by the microscope, and not uncommonly hyaline, 
 granular, and fatty casts. It has been found by Herman that in 
 eclampsia there is a marked diminution in the quantity of urea 
 excreted. Helonin^ has studied the relation between the total 
 nitrogen of the urine and the amount eliminated as urea in the 
 albuminuria of pregnancy and eclampsia. He concludes that in 
 normal urine from 80 to 90 per cent, is so eliminated, but in these 
 diseased conditions a much smaller proportion. At the same time 
 
 ' Lusk, Science and Art of Midwifeiy, p. 526. 
 
 2 De la Haipc, Journ. Oljst. and Gyn. Brit. Emp., lilOfJ, Vol. IX., p. 102. 
 " " Contribution a I'Etude du Diagnostic de I'Hepato-toxhemie Gravidique," 
 Th^se, Paris, 1899. 
 
478 The Practice of Midwifery. 
 
 it must be remembered that the nitrogenous intake in these patients 
 is often very small. 
 
 The quantity of urea increases again in patients who recover, but 
 not in cases which end fatally. There is thus evidence of retention 
 of products which the kidneys should secrete. It does not follow 
 that the urea itself causes the convulsions ; but it is more likely to 
 be some substance, a product of the disintegration of protein, which 
 occurs in much smaller quantity, but is more poisonous. If the 
 patient recovers, the quantity of albumen generally rapidly lessens 
 after delivery, and it may have entirely vanished in two or three 
 days. Usually, however, it does not entirely disappear for some 
 weeks. In some cases a small proportion of albumen remains for 
 many months afterwards, but yet eventually disappears, and does 
 not necessarily recur in future pregnancies. In other cases the 
 albuminuria remains permanent. Of 77 cases investigated by 
 Koblanck, in 5, or 6*5 per cent., chronic nephritis developed. 
 
 In general, therefore, it may be said that the albuminuria is not 
 a passive transudation, but an evidence of nephritis. 
 
 Some authorities have considered that the importance of 
 albuminuria in connection with eclampsia has been overrated, and 
 that urgemic eclampsia is only one out of several common varieties. 
 Therefore, since the albuminuria was first discovered in the Guy's 
 Charity, it may be of interest to record that out of all cases in that 
 charity during the forty years up to 1875 in which the urine was 
 examined, it was free from albumen throughout in only two. In 
 one of these the convulsions were produced by arachnitis, as verified 
 by an autopsy; in the other they followed severe post-partum 
 haemorrhage, in a girl who had been seduced. The total number of 
 cases in which the presence of albuminuria is recorded is 41, 
 and there were several others in which the urine was suppressed, 
 general oedema was present, and there was no doubt of the 
 existence of nephritis. 
 
 The association with albuminuria is thus so general as to prove 
 absolutely that a causal relation exists. Either, therefore, the 
 eclampsia results from the nephritis, or the albuminuria from the 
 eclampsia, or both are the result of a common cause. 
 
 An important point in connection with the quantitative analysis of 
 the urine is the estimate of the total quantity of nitrogen excreted, 
 normally amounting to about 15*8 grammes, of which the urea 
 accounts for 87'7, and the ammonia for 3"3 per cent. In eclampsia 
 a much higher proportion is excreted in the form of ammonia salts, 
 while the proportion excreted as urea is markedly diminished. 
 Besides the nitrogen excreted in the form of urea, ammonia, uric 
 
Disorders of Pregnancy. 479 
 
 acid, and creatinine, there is a certain amount present chiefly in 
 the form of amino-acids, the so-called undetermined nitrogen, and 
 the amount of this, too, in cases of eclampsia has been shown by 
 Ewing and Wolf ^ to bear a higher proportion than the normal to 
 the total quantity excreted. 
 
 It is very important to remember, in drawing any clinical 
 conclusion from the analysis of the urine, that the highest ammonia 
 coefficient is seen in cases of prolonged fasting, and that a high 
 ammonia coefficient may have no pathological significance at all 
 if the nitrogen intake is low. 
 
 ZweifeP puts forward the view that the increased excretion of 
 ammonia is due to increased acidity of the blood, and ascribes it 
 to the presence of lactic acid, which he regards as a disintegration 
 product of protein. Further investigations, however, lend no 
 support to his view that lactic acid is the cause of eclamptic con- 
 vulsions ; indeed, they tend rather to show that it is either the 
 result of the excessive muscular contractions or of a failure of the 
 liver to convert ammonia into urea. 
 
 Chemical analyses of the blood, urine, liver, and placenta have 
 shown that these organs contain in eclampsia considerable quantities 
 of the products of protein disintegration, and it seems probable 
 that in this disease a process of autolysis of the tissues of these 
 organs takes place to a considerable degree. 
 
 Examination of the blood has shown that its alkalinity is 
 sometimes diminished, and that there is a marked increase in 
 the amount of fibrinogen present, and a great increase in the 
 number of white corpuscles. 
 
 Pathological Anatomy : Kidney. — In fatal cases of eclampsia, 
 generally only an early stage of tubal nephritis has been found, 
 and some observers have not detected anything more than con- 
 gestion, Schmorl,^ however, has shown that renal changes are 
 present in 99 per cent, of all cases. His investigations confirm 
 those of other observers, and have demonstrated that the change, 
 affecting chiefly the epithelium of the convoluted tubules, is of a 
 degenerative character, and consists in cloudy swelling, fatty 
 degeneration, and coagulation necrosis of the protoplasm of the 
 cells. The glomeruli, as a rule, are unaffected, though fibrinous 
 thrombi are present in their capillaries. The kidneys are att'ected 
 unequally, and healthy and diseased patches may be seen lying side 
 
 1 Ewing and Wolf, Amer. Journ. Obstet., 1907, Vol. LV.. No. 3, p. 289. 
 
 2 Zweifel, Zentralbl. f. GynJik., 1909, No. 26, p. 897 ; Aroh. f. Gynak., 1904, Bd. 72, 
 p. r,72; Dieiist, Zentralbl. f. Gyniik., 1905, No. 12, p. .353; Arch. f. Gyniik., 1908, 
 Bd. HC, p. 314. 
 
 » Schmorl, Zentralbl. f. Gynak., 190.5, No. .5, p. 129. 
 
480 The Practice of Midwifery. 
 
 by side (see Fig. i568). It is interesting to note that Angus 
 Macdonald, arguing from the autopsies of two cases, considered the 
 renal condition to be a degeneration rather than an inflammation, 
 the epitheHal cells in some tubes being converted into a colloid 
 material, which plugs both these and other tubes. ^ 
 
 Liver. — Of recent years much attention has been directed to 
 lesions of the liver, of the nature of a thrombotic hepatitis, with 
 degeneration of the liver cells. By some, especially by French 
 authorities, these are considered to be primary, and to be of more 
 importance than the renal changes. They thus regard the disease 
 as a toxaemia of hepatic origin. In a small proportion of cases 
 there is jaundice as a complication, and these cases are generally 
 fatal. Schmorl found the liver affected in 71 of his 73 cases. 
 The changes have been studied in great detail by Konstantinowitsch, ^ 
 who has shown that the earliest change is degeneration of the liver 
 cells at the periphery of the lobule, followed by thrombosis of the 
 capillaries secondary to changes in their endothelium and 
 haemorrhages into the liver substance. These changes are followed 
 by necrosis of the liver cells in the areas of thrombosis and this 
 in its turn by further thrombosis in the interlobular vessels and 
 the formation of still larger areas of necrotic liver tissue. He lays 
 considerable stress on the characteristic primary limitation of the 
 change to the periphery of the lobules. 
 
 Brain. — In about 90 per cent, of the cases thrombosis of the 
 capillaries, together with areas of necrosis and hsemorrhages, 
 is found both in the cortex and in the medulla. 
 
 Heart. — In the same way in about 60 per cent, of the cases 
 degenerative changes in the muscle fibres occur, together with areas 
 of necrosis and interstitial haemorrhages. 
 
 Placenta. — The formation of white infarcts in the placenta and 
 their frequency in cases of albuminuria have already been pointed 
 out. In cases of eclampsia other changes have been described, 
 consisting of large haemorrhages and marked proliferation and 
 degeneration of the syncytium. 
 
 One of the most characteristic features of cases of eclampsia is 
 the occurrence of thrombi in the capillary vessels of almost all the 
 organs of the body. 
 
 Causation. — A consideration of the chemical and pathological 
 changes described in the urine, the blood, and the organs, shows 
 that the most characteristic changes met with in eclampsia are as 
 follows : marked degenerative processes in the cells of the kidneys 
 
 1 Obstet. Journ., 1878, Vol. VI. 
 
 2 Ziegler's Beitrage, 1907, No, 40, Hf t. 3, p. 483. 
 
Disorders of Pregnancy. 481 
 
 and the liver, together with evidence of a disturbance of tissue meta- 
 bolism, the accumulation of the products of protein disintegration in 
 the tissues and in the urine, and changes in the blood, associated 
 with increased coagulability and the formation of numerous 
 thrombi throughout the body. 
 
 Probably the most important, as it is the most striking, of these 
 changes, is the evidence of the presence of the products of protein 
 disintegration in the urine and the tissues. Such evidence is 
 
 I 
 
 V 
 
 X 
 
 ^ 
 
 ° J 
 
 Fig. 268. — Kidney from a case of eclampsia, showing cloudy swelling and 
 coagulation necrosis of the epitheliam of the convoluted tubules. The 
 glomeruli are^unafEected. 
 
 furnished by the presence of abnormal organic and inorganic fatty 
 acids in the liver and the urine, and the presence of lactic acid, 
 together with the large proportion of undetermined nitrogen and the 
 large ammonia coefficient found in the urine in cases of eclampsia. 
 The most probable explanation of the presence of these substances 
 is that they are the results of the autolysis of the cells of various 
 organs, especially those of the liver, and that the result of these 
 destructive changes is the saturation of the tissues of the body with 
 the products of protein disintegration, leading to a condition of 
 M. 31 
 
482 
 
 The Practice of Midwifery. 
 
 toxaemia, or auto-intoxication, which is the essential factor in the 
 production of eclampsia. 
 
 Since autolysis, due as it is to the action of the intracellular 
 ferments upon the protoplasm of the cell, does not usually occur in 
 living tissues, it is necessary, if we are to accept this view of the 
 causation of eclampsia, to find some primary cause to explain the 
 occurrence of such autolytic changes. 
 
 Fig. 269. — Liver from a patient dying of eclampsia, showing necrosis of the 
 liver cells at the periphery of several lobules, with thrombosis of the 
 interlobular vessels. Complete necrosis of the whole of one lobule is 
 also shown at the upper left hand corner of the figure. 
 
 What is the nature and what is the origin of the body which 
 initiates the series of changes leading to the profound disturbance 
 of tissue metabolism and the marked tissue necrosis so characteristic 
 of eclampsia? No doubt the poison which causes the auto-intoxica- 
 tion of eclampsia is the same as that which is responsible for the 
 so-called toxaemia of jiregnancy. At one time it was supposed to 
 be derived from the foetus, but the fact that eclampsia may occur 
 without the presence of a foetus in cases of hydatidiform mole 
 proves this theory to be erroneous. 
 
 The possibility of a foetal origin being excluded, it was natural 
 that the placenta should be regarded as a possible source of the 
 poison, and this view was greatly encouraged by the discovery by 
 
Disorders of Pregnancy. 483 
 
 Schmorl of the presence of placental cells in the vessels of the 
 lungs in nearly all cases of eclampsia. They have since been shown 
 to occur in other conditions than eclampsia, and indeed in normal 
 pregnancy. This observation, however, may be said to have 
 originated the placental theory of eclampsia. 
 
 Veit^ put forward the view that these placental cells were toxic to 
 the mother ; and that, while in normal circumstances they were 
 rendered harmless by the action of certain anti-bodies which he 
 termed syncytiolysins, when in excess they produced albuminuria 
 and eclampsia. Ascoli supported the same theory, but thought 
 that the anti-bodies were the toxic agents, and not the cells. 
 
 Further investigations have failed to confirm the results obtained 
 by Veit and other workers, and have thrown grave doubts upon the 
 whole theory, which probably is erroneous. 
 
 Experiments carried out by the injection of placental extracts 
 into animals have shown that such substances have a highly toxic 
 effect, and that this is mainly due to the nucleo-proteid they 
 contain causing widespread capillary thrombosis. The importance 
 of this observation is considerable when we remember what a large 
 part capillary thrombosis plays in the pathology of eclampsia. 
 
 The placenta has further been shown to be an organ very rich in 
 ferments, and the process of autolysis takes place in it with great 
 activity after death. Indeed, some observers have maintained that 
 autolysis may take place in it during life, that in eclampsia there 
 is hyperactivity of the placental ferments, and that the passage of 
 these ferments and the products of the autolysis of the placental 
 tissues into the blood may be the primary morbid change leading 
 to eclampsia. 
 
 The view which most observers hold at the present time as to the 
 nature of eclampsia is that it is an auto-intoxication of the body due 
 to the presence in the tissues of the products of protein disintegra- 
 tion, and that the production of these toxic substances is due to 
 a special activity of the intracellular ferments leading to autolytic 
 changes in various organs. Further than this, the placental theory 
 supposes that there is a passage of ferments and products of 
 autolytic changes from the placenta into the body generally, 
 resulting in a widespread thrombosis and the increased activity of 
 the autolytic ferments of other organs with an excessive formation 
 of toxic bodies, and the condition of toxic poisoning characteristic 
 of ecbtmpsia. 
 
 The differences, clinical and pathological, which exist between 
 the various diseases — acute yellow atrophy, the pernicious vomiting 
 
 1 Scholten and Volt, Zentralbl. f. Gyruik., 1902, No. 7, p. J«!J; i;»04, No. 1, p. 1. 
 
 31—2 
 
484 The Practice of Midwifery. 
 
 01 pregnancy, ursemia, and eclampsia — all no doubt examples of 
 auto-intoxication, may well be explained by variations in the nature 
 and chemical composition of the different toxic bodies which are the 
 essential factors in their causation, while the part played by the 
 placenta in the production of eclamptic convulsions may be a 
 possible explanation of the differences which exist between this 
 disease and ursemia. 
 
 In the great majority of cases, the presence in the blood of these 
 toxic bodies, which are retained owing to impaired excretory powers 
 in the kidneys, is the essential element in the causation.^ It is not, 
 however, the sole cause, but with it are combined the increased 
 irritability of the nerve centres in pregnancy, and the presence of a 
 cause of reflex irritation in the pregnant uterus, and often in actual 
 labour pains. That reflex irritation is a cause actually operating is 
 proved by the fact that more than half of the cases commence 
 during actual labour, that a paroxysm may be excited by vaginal 
 examination or the introduction of the hand to operate, and that 
 the convulsions frequently subside after delivery. The combination 
 of the effect of a poison in the blood and of reflex irritation may be 
 illustrated from physiological experiments. It is possible to give 
 such a dose of strychnia to a frog that it remains free from convul- 
 sions, and recovers, if left perfectly quiet. By touching it, however, 
 spasms are excited, and these, if repeated, will kill the frog. It is 
 not, therefore, wonderful that in pregnant women convulsions may 
 be the result of a recent acute nephritis, whereas in ordinary 
 Bright's disease they only occur in a late stage of ursemia. 
 
 The immediate mechanism by which the convulsions are pro- 
 duced is uncertain. They may be caused, like the spasms produced 
 by strychnia, by the direct action of the poison on the nerve-centres. 
 Since convulsions sometimes occur in animals bled to death, it has 
 been supposed by some that the immediate antecedent is ansemia 
 of the brain, caused by spasm of the arteries. Another theory of 
 the production of cerebral ansemia, the Traube-Eosenstein theory, 
 has been rather widely circulated. It was suggested by Traube for 
 ordinary uraemic convulsions, and has been adapted by Eosenstein 
 to the case of puerperal eclampsia. The theory is, that there is 
 
 1 Further than this, Bradford's experiments have shown that when the available 
 kidney substance is diminished beyond a certain amount, roughly speaking one quarter 
 of the total kidney weight, the protein tissues undergo rapid disintegration with the 
 formation of abnormal quantities of extractives. In eclampsia the destruction of the 
 kidney substance must often amount to a considerable portion of the whole kidney 
 (Bradford, Proc. Roy. Soc, 1892). 
 
 For an excellent review of recent work on eclampsia, with a full bibliography, to 
 which the authors desire to acknowledge their indebtedness, see Eardley Holland, 
 Journ. Obst, and Gyn. Brit. Emp., 1909, Vol. XVI., Nos. 4, 5, 6. 
 
Disorders of Pregnancy, 485 
 
 excessive arterial pressure, combined with watery blood ; that this 
 produces transudation from the vessels, and thence cedema of the 
 brain, by which the vessels are in their turn compressed, being 
 enclosed within the skull, and so anaemia of the brain is produced, 
 and consequent convulsions. If this theory were true, since the 
 same cause of oedema would operate all over the body, the tendency 
 to ursemic or puerperal convulsions ought to be proportional to the 
 tendency to general oedema. This is not the fact, for ordinary 
 urgemic convulsions are most frequent in the case of contracted 
 granular kidney, when there is little or no general oedema ; and 
 general oedema is generally not very marked in puerperal 
 eclampsia. 
 
 Diagnosis. — ^The diagnosis from hysterical ursemic and epileptic 
 convulsions generally is easy. In convulsions set up by some gross 
 cerebral lesion, such as cerebral haemorrhage, there will generally 
 be accompanying paralysis, such as hemiplegia, and the coma will 
 come on more suddenly. 
 
 Prognosis. — The prognosis is grave. The mortality is now 
 reckoned at from 20 to 25 per cent., and it was greater before the 
 introduction of the treatment by inhalation of chloroform. Herz- 
 feld, however, recently collected 463 cases with a mortality of 17 
 per cent. Hirst^ records 86 cases with a total mortality of 27'4 per 
 cent., 33"8 per cent, of the primiparae and 14*25 per cent, of the 
 multiparae dying. 
 
 About 50 per cent, of the children are lost. The danger is 
 greater the earlier the convulsions begin, and the more frequently 
 they occur, although recovery has been recorded after the occurrence 
 of over 200 fits.^ The early onset of coma, the presence of complete 
 anuria, and a continuous high temperature are signs of bad prog- 
 nostic omen. 
 
 On the other hand, the excretion of an increasing quantity of pale 
 urine, and an increase in the percentage of urea present are good 
 signs. 
 
 In the Guy's Charity, the mortality was 50 per cent, in cases 
 which began before the onset of labour, 25 per cent, in those which 
 began during labour, and only 8 per cent, in those which began 
 after delivery, the total mortality being 25 per cent, up to 1875. In 
 the ten years 1875 — 1885, however, the mortality was only 9 per 
 cent. Lohlein's ^ statistics give a mortality of 40'5 per cent, out of 
 83 cases which began before the onset of labour. Death most 
 
 1 Hirst, Therap. Gaz., I'hiladelpliia, April, ]!)07, p. 220. 
 
 2 Engelmaiiii, Zeiitralbl. f. Gyniik., 1907, No. 1 1 , p. HOC. 
 8 Zeitschr. f. Geburtsh. u. G yuaek., B. 4, H. 2. 
 
486 ThePractice of Midwifery. 
 
 frequently results from the coma, with exhaustion ; sometimes it 
 occurs in a paroxysm. There is also a predisposition to puerperal 
 disorders, such as septicaemia, oedema of the lungs, pneumonia, 
 puerperal insanity, and, it is said, to post-partinn haemorrhage. 
 
 Treatment. — Prophylactic treatment, for cases in which albu- 
 minuria has been discovered, has been already considered under 
 the head of albuminuria. When one or more convulsions have 
 occurred, the first treatment should be to give an active purgative. 
 This lowers arterial tension, without weakening so much as vene- 
 section, it may possibly carry off some poisonous material from the 
 blood through the bowel, and it may sometimes remove one of the 
 sources of reflex irritation in the shape of an accumulation in 
 the bowels. When the patient is conscious, any hydragogue 
 purgative, such as the Pulvis Jalapae Co., may be used. If she is 
 comatose, the best plan is to jDlace two drops of croton oil at the 
 back of the tongue, or the stomacli may be washed out and one or 
 two ounces of a saturated solution of magnesium sulphate intro- 
 duced into it. The chief aim in the treatment of these cases is to 
 arrest the convulsions, to eliminate the toxins from the patient's 
 body as completely as possible, and, as a further measure when 
 necessary, to remove the probable source of the poison and an 
 undoubted cause of reflex irritation by emptying the uterus. 
 
 It is of great importance to check or limit the number of convul- 
 sions, since a rapid succession of them generally leads to a fatal 
 result. The most effective means for this end are the subcutaneous 
 injection of morphia and the administration of chloroform. The 
 morjDhia must be given in full doses. Half a grain may be injected at 
 first, and afterwards one-third of a grain at about six hours interval. 
 The effect of the drug on the pupil must be watched, and not more 
 than two grains given in the twenty-four hours, although as much as 
 12 grains have been administered in four days. De la Harpe^ records 
 71 cases treated at the Kotunda Hospital by the administration of 
 morphia with 12 deaths, or a mortality of 16'9 per .cent. In 
 cases where the patient is deeply comatose morphia must be given 
 with caution, and some authorities maintain that it is best given 
 by the rectum in the form of suppositories. 
 
 Chloroform should be administered until the morphia has had 
 time to act, or if it fails to check the convulsions, or if any obstetric 
 interference is called for. It has a great influence in preventing 
 the recurrence of the fits, and it allows any necessary manipulation 
 to be carried out without the probability of exciting a paroxysm. 
 When the administration is commenced during the consecutive 
 
 1 Journ. Obst. and Gyn. Brit. Emp., 1906, Vol. IX., No. 2, p. 102. 
 
Disorders of Pregnancy. 4S7 
 
 coma, this condition is generally ameliorated. The arterial tension 
 is lowered, and the pulse at the same time becomes slower, restless- 
 ness is diminished, contraction of the pupils passes off, and usually 
 the breathing becomes less stertorous, and the venous congestion 
 of the face diminishes. Chloroform should always be administered 
 when fits continue to recur frequently, or when there is material 
 elevation of temperature. At first the patient may be brought 
 pretty fully under the influence of the drug, but afterwards it may 
 be given only from time to time, and in partial degree. Any 
 premonitory signs of a paroxysm, such as increased muscular rest- 
 lessness, more rapid breathing, or contraction of the pupils, are 
 indications for giving more of the chloroform, and so, a fortiori, is 
 the recurrence of a fit. When chloroform is given judiciously, in 
 this partial degree, the administration may be continued for hours 
 together without danger. Next to morphia and chloroform, the 
 most valuable drugs are chloral and bromide of potassium. These 
 are most suitable for mild cases, such as those which commence 
 after delivery usually prove to be, and for those in which it is 
 either impossible to carry out the prolonged administration of 
 chloroform, or it is thought unsafe to continue it longer. Thirty 
 grains of chloral, with the same quantity of bromide of potassium, 
 may be given either by mouth or by enema in one or two doses. 
 Some American authorities praise tincture of veratrum viride, 
 given subcutaneously in doses of 10 to 20 minims, so as to keep the 
 pulse rate down to 60 per minute and reduce its tension. Mirto^ 
 has recorded a series of 61 cases treated with veratrum viride with 
 5 deaths, or a total mortality of 8*04 per cent. 
 
 Treatment by thyroid extract has been suggested,^ and favourable 
 results reported. The evidence does not, however, appear con- 
 clusive at present, since the morphia treatment was employed at 
 the same time. It is advised to give five-grain tabloids every three 
 or four hours, until symptoms of thyroidism appear in the form of 
 flushing of skin, perspiration, accelerated pulse, and increased 
 secretion of urine. In urgent cases, when coma is present, the 
 drug may be given per rectum or even subcutaneously. 
 
 While an attempt is being made to control the convulsions by 
 one or other of the means described, further treatment should be 
 carried out with a view to eliminating or at any rate diluting the 
 toxic bodies which are present in the blood and tissues of the 
 eclamptic patient. The most rapid and effectual method of doing 
 
 ^ Anniili di Ostet. c. (linecol., December, 1905. 
 
 2 Nichoi.Hoii, " 'I'ljyroid Extract in EclarnpHia," Journ. of Obst. and Gyn., July, 
 iy02, Vol. il., p. 40. 
 
488 The Practice of Midwifery. 
 
 this is undoubtedly to practise venesection followed by the intro- 
 duction of normal saline solution either into a vein, by the rectum, 
 or subcutaneously. This mode of treatment is especially applicable 
 to plethoric patients. At the same time that saline transfusion is 
 being practised hot air or hot baths should be given in order to 
 promote the action of the skin. Hot air baths should, however, 
 not be given without the simultaneous administration of consider- 
 able quantities of fluid by the mouth or by transfusion, since it is 
 possible that the free elimination of fluid through the skin may 
 lead to a concentration of the poison unless it is replaced by the 
 free administration of fluids by the mouth or subcutaneously.^ If 
 free purgation can be set up it is of advantage, but often purgatives 
 administered by the mouth are not absorbed, and reliance must be 
 placed upon large enemata. 
 
 The large bowel should be well flushed out with copious enemata of 
 soap and water until faecal matter is no longer passed, and it is a good 
 plan to leave about one pint of normal saline solution in the bowel. 
 In cases where the secretion of urine is scanty, the application of 
 large fomentations or dry cupping over the kidney region may be 
 tried. 
 
 When the secretion of urine is exceedingly scanty, and other 
 means, including the emptying of the uterus, have failed to arrest 
 the convulsions, and especially in cases occurring after delivery, 
 the operation of decapsulation of the kidneys has been suggested 
 and practised with varying success.^ The object of the operation is 
 to relieve the increased tension in the kidneys which is supposed to 
 be present and to interfere with their functions. The mortality of 
 the operation is high, 37 per cent, or more,^ and further experience 
 is required to determine whether this procedure is likely to have 
 any permanent place in obstetric practice. 
 
 In cases where the fits continue in spite of treatment and labour 
 has not commenced, the great question is whether to induce labour 
 or not. In mild cases, in which only one or two or three fits occur 
 at wide intervals, and leave no notable coma, it may be sufiicient to 
 give purgatives, chloral, and bromide of potassium, and put the 
 patient on a milk diet, watching carefully the proportion of albumen 
 in the urine. But if the case is at all severe — and it is to be 
 remembered that cases commencing before labour are much the 
 most dangerous of all — it appears advisable to empty the uterus, 
 provided that no means which increase the patient's danger are 
 
 1 Leopold, Zentralbl. f. Gynak., 1907, No. 32, p. 572. 
 
 2 Gauss, Zentralbl. f. Gynak., 1907, No. 19, p. 521. 
 
 8 Pfannenstiel, Miinchener Med. VVochenschr., 1908, JSTo. 36, p. 1903. 
 
Disorders of Pregnancy. 489 
 
 employed in doing so, since, in the majority of cases, the kidneys 
 rapidly improve after delivery. Herman has, indeed, adduced 
 statistics to show that no advantage is gained by doing so ; but those 
 collected by Zweifel^ show a mortality of 28*5 per cent, under 
 expectant, and one of only 11*2 per cent, under active treatment. 
 Indeed, if we accept the view that the primary cause of eclampsia 
 is to be found in the contents of the uterus, and if at the same time 
 we admit that the presence of the fcetus in utero undoubtedly acts 
 as a source of reflex irritation, then the emptying of the uterus when 
 the convulsions cannot be controlled by other means seems a rational 
 mode of treatment. It is, at any rate, a method of treatment which 
 at the present day is practised by many obstetricians of note whose 
 views must carry great weight.^ Indeed, Bumm suggests that the 
 rapid delivery of every patient on the occurrence of the first fit would 
 be followed by a lowering of the maternal mortality to 5 per cent. 
 
 The first principle is to carry out no manipulation except with the 
 aid of chloroform, for fear of setting up a convulsion. The best 
 mode of inducing labour is to puncture the membranes. This at 
 once takes off some of the reflex irritation by diminishing the tension 
 of the uterus. In some cases I have found this suffice to stop the fits, 
 while labour has not come on for a day or so. If the fits continue, 
 and labour does not progress, it should be accelerated by dilatation 
 of the cervix. If the internal os is expanded and the cervical canal 
 obliterated, the external os may be rapidly dilated, either digitally, 
 if it is yielding, or by Bossi's dilator (see Chapter XXVII.), the 
 patient being placed fully under the influence of chloroform. If 
 the cervical canal is still intact, a more gradual mode of dilatation is 
 generally preferable, to avoid the risk of laceration, and that of 
 septic infection to which eclamptic patients are specially liable. A 
 Champetier de Eibes' bag (see Chapter XXVII.) may be applied ; 
 and if satisfactory pains do not soon come on, a weight may be 
 attached to the bag to increase its dilating power. Meanwhile 
 morj)hia should be given, or the partial administration of chloroform 
 should be continued. 
 
 The patient being already in labour, the general principle is to 
 accelerate the labour, if it does not proceed rapidly, so far as this 
 can be done without any violent interference, chloroform being 
 always given during manipulations, even the passing of a catheter. 
 The second stage is often rapid and tumultuous, but the first stage 
 is apt to be protracted. If the labour progresses satisfactorily, and 
 
 1 " Zur Behandluiig der Eklampsie," Zentralbl. f. Gynak., 1895. 
 
 2 Buinm, Miincherier Med. Wochciischr., 11)03, No. 21, and 1907, No. 47 ; Liepmann, 
 Miinchener Med. Wochenschr., 1906, No. 25. 
 
490 The Practice of Midwifery. 
 
 the fits are controlled by treatment, no interference with it is needed. 
 Otherwise the cervix may be dilated, as already described. In 
 urgent cases bipolar version may be performed as soon as the os will 
 admit two fingers, pro\dded that the membranes are then intact, and 
 delivery accelerated, if need be, by gentle traction on the leg. Other- 
 wise forceps may be applied as soon as the os is dilated enough 
 to allow their easy application. In rare cases craniotomy may be 
 called for, especially if there is evidence that the child is dead. Of 
 late Cesarean section has been performed, mostly in German3% in a 
 considerable number of cases in which rapid delivery could not 
 otherwise be effected. The mortality, however, has been very high 
 (58*9 per cent, in 56 cases collected by Hillman and Stevens 
 and 55 per cent, in 34 cases collected by Hammerschlag^), and 
 it has not, therefore, yet been proved that this treatment is advis- 
 able. Vaginal Csesarean section would seem a better procedure 
 (see Chapter XXXVL), but it has not been shown that even this is 
 preferable to gradual dilatation of the cervix. Diihrssen,^ however, 
 maintains that it is, and has collected 112 cases of vaginal Csesarean 
 section for eclampsia with 17 deaths, or a mortality of 15 per 
 cent., while ZweifeF has had only 1 death from pneumonia in 
 33 cases treated by this method. 
 
 In the convulsions, care should be taken to prevent the tongue 
 being bitten, as far as possible. This may be done either by placing 
 a soft folded handkerchief between the jaws, so as to depress the 
 tongue, or by keeping a piece of cork or indiarubber between the 
 molar teeth. 
 
 While a patient is comatose, either before or after delivery, no 
 attempt should be made to feed by the mouth. For many patients 
 die with the complication of broncho-pneumonia, which may be set 
 up by liquid food getting into the bronchi when a patient cannot 
 swallow j)roperly. The patient should be kej)t on her side as far as 
 possible, so as to avoid the continual swallowing of the mucus which 
 is secreted. 
 
 A watch should be kept upon the temperature, since a con- 
 siderable elevation of it is of the gravest prognosis. If it rises 
 to a very high point, as above 104°, cold should be applied to 
 the head, or, if necessary, to the whole body, till it is reduced. 
 This may be effected by an ice-water cap or, if necessary, by 
 cold sponging. The very high temperatures, however, are rarely 
 observed when the fits are kept in check by morphia or chloroform, 
 
 1 Zentralbl. f. Gynak., i:)04, No. 36, p. 1069. 
 
 2 Diihrssen : Von Winckd, Handbucb der Gebuitshiilfe, 1906, Bd. 3, Th. 1, p. 663. 
 
 3 Zv/eifel, Zentralbl. f. Gynak., 1905, No. 26, p. 806. 
 
Disorders of Pregnancy. 491 
 
 or when venesection is employed, even though the result may- 
 be fatal. 
 
 If there are any signs of failure of the heart hypodermic injections 
 of digitalin or camphor should be given. In some cases where 
 cyanosis is very marked, and the respiration is much impeded, 
 clearing the mouth and nose of mucus, artificial respiration, and 
 cardiac massage and the administration of oxygen may be 
 required. 
 
 After delivery, if the patient is to recover, the interval between 
 the fits becomes longer, and the temperature falls, although coma 
 may sometimes continue for a day or two. Morphia or chloroform 
 may still be given, if fits recur frequently, otherwise this is the most 
 favourable time for the action of chloral with bromide of potassium, 
 and it is especially in this class of cases that nephrotomy and 
 decapsulation of the kidneys has been suggested. 
 
 Other Disorders produced by Mechanical Causes. 
 
 CEdema. — Qj^dema of the lower limbs, and sometimes of the 
 vulva, is a common result of the pressure of the gravid uterus. 
 The tendency to cedema is increased if there be anaemia in addition. 
 The condition is not of much consequence, so long as it is certain 
 that it is not due, in part, to nephritis. 
 
 Treatment, — Avoidance of standing and frequent or occasional 
 rest in the horizontal position should be enjoined. The bowels 
 should be kept acting regularly, to prevent an increase of pressure 
 on the veins by a loaded rectum or a sigmoid flexure, but violent 
 or hydragogue purgatives should be avoided, as tending to in- 
 crease anaemia. If anaemia is present, iron may be given with 
 advantage. 
 
 Varicose Veins. — Varix of the veins of the legs, thighs, and 
 sometimes of the vulva and vagina, is also a result of pressure, 
 especially in multiparas, when the veins have been subject to 
 repeated distension from the same cause. The increased volume 
 of the blood may have some influence in the causation as well as 
 the local pressure. Sometimes thrombosis and phlebitis occur in 
 the distended veins, especially those of the leg. Instances are on 
 record of fatal haemorrhage from spontaneous rujoture of a vein 
 in the leg, or laceration by violence of a varicose vein of the vulva. 
 If a vein is ruptured beneath the mucous membrane, lueinatoiia of 
 the vulva is produced. This will be considered hereafter. 
 
49^ The Practice of Midwifery. 
 
 Treatment. — Varicose veins in general should be treated by 
 keeping up the legs as much as possible, administration of 
 laxatives, and the use of elastic stockings or bandages for the 
 legs. If phlebitis occurs, the recumbent position must be main- 
 tained, and anodyne lotions applied. In the case of rupture of a 
 vein, firm local pressure will arrest the bleeding. If there is a 
 very superficial and localised varix of the vulva, where pressure is 
 not available, excision of the veins in the earlier stage of pregnancy 
 may be desirable. 
 
 Hsemorrhoids. — The passive congestion from pressure on the 
 rectal veins, added to the active congestion which prevails 
 throughout the pelvis, in consequence of the stimulus of the 
 pregnant uterus, tends to the production of haemorrhoids. The 
 tendency is often greatly increased by the constipation which is so 
 common in pregnancy. The f£ecal accumulation compresses the 
 hsemorrhoidal veins ; violent straining further increases the venous 
 tension, and may set up inflammation in the haemorrhoids. A 
 similar effect may be produced from violent straining in diarrhoea, 
 or from the action of too strong purgatives. Internal haemorrhoids 
 are liable to bleed in pregnancy, sometimes to a serious extent. 
 External haemorrhoids, which are the commoner, often become 
 inflamed, and cause much pain in defecation. 
 
 Treatment. — The general treatment is to give gentle laxatives, 
 but avoid any violent purgatives. The laxatives most suitable 
 for use in pregnancy have already been mentioned (see p. 406). 
 Aloes, in small doses, is sometimes useful, although in large doses 
 it is especially to be avoided, on account of its special action upon 
 the rectum. If the piles are external, the patient should avoid 
 using any paper after defecation, but instead of this take a vessel 
 of water and a small sponge to the closet, and ^wash with the 
 sponge. The water may be hot if the piles are inflamed, other- 
 wise cold. For inflamed external piles, an ointment consisting of 
 equal parts Ung. Zinci Oxidi, Ung. Plumbi Acetat., Ung. Hydrarg. 
 Nitrat. Dilut., may be used. The distilled extract of hamamelis 
 (Pond's extract or hazeline) may be used externally undiluted, may 
 be applied by means of a piece of unpurified sheep's wool soaked in 
 the lotion and introduced just within the anus, or may be injected 
 into the rectum, diluted with two parts of water, by means of the 
 ordinary glycerine injection syringe, holding two drachms. Opera- 
 tions on the haemorrhoids during pregnancy will generally only be 
 advisable if there is serious haemorrhage, which cannot otherwise 
 be checked. 
 
Chapter XXI. 
 ABNORMALITIES OF THE UTERUS. 
 
 Congenital Malformations of Uterus and Vagina. — The case 
 of pregnancy in a rudimentary uterine horn, leading to rupture, 
 has been already described (see p. 436). When the uterus consists 
 of one developed half only (uterus unicornis), and pregnancy occurs 
 in it, the course of pregnancy and labour is usually normal. Several 
 varieties occur of double uterus or vagina. Both vagina and uterus 
 may be double (see Figs. 236, 237, pp. 375, 376), the vagina maybe 
 single and whole uterus double, the uterus may have a single cervix 
 and double body (see Fig. 238, p. 376), or the body may be only par- 
 tially divided. In all these conditions pregnancy is possible on one 
 or both sides, and generally goes on to a normal termination.^ The 
 possibility of superfcetation in a double uterus has already been 
 considered (see p. 376). Labour may be retarded when the uterus 
 is double, from weakness of the muscular wall, from deviation of the 
 uterine axis, or from the other side forming an obstruction. In 
 one case I have known the head of the child to get into the second 
 half of a double uterus {uterus bicornis unicollis), and form a mass 
 in the pelvis, preventing the progress of labour, and necessitating 
 Csesarean section, which was successfully performed. I have found 
 the placenta retained, and very difficult to reach, at the extremity 
 of a long diverging horn. From a similar cause, j^ost-jMi'tum 
 haemorrhage may occur. In cases where the uterus is only partially 
 divided (uterus cordiformis), transverse presentations are especially 
 frequent. When the body of the uterus is double, and one side 
 pregnant, a decidua is formed on the unimpregnated side, and is 
 generally expelled after delivery. This may be the only sign which 
 calls attention to the fact of some abnormality existing. The exact 
 character of the abnormality is best made out just after delivery, 
 when the exterior of the uterus can be easily manipulated through 
 the relaxed abdominal walls, and the finger can l)e introduced into 
 the interior. 
 
 ' Giles, Trans. Obst. Soc, London, 190.5, Vol. XXXVII., p. .SOI. 
 
494 
 
 The Practice of Midwifery. 
 
 DISPLACEMENTS OF THE UTEEUS AND VAGINA. 
 
 Anteversion and Anteflexion. — In the early months of preg- 
 nancy there is usually some increase in the normal anteflexion of 
 the uterus, and its anteversion in reference to the axis of the brim, 
 the bladder being empty or nearly empty, in consequence of the 
 increased weight of the fundus. Sometimes these conditions are 
 exaggerated, especially when the uterus has been anteverted or 
 anteflexed before impregnation. Generally the symptoms are slight, 
 but some irritability of bladder or rectum may result from pressure 
 
 Fig. 270. — Figure showing position of uterus with a pendulous abdomen. 
 
 of the fundus upon the former, and of the cervix upon the latter. 
 It was considered by Dr. Graily Hewitt, that anteflexion in early 
 pregnancy is the chief cause of vomiting, and has a strong tendency 
 to lead to abortion, but these conclusions have not been generally 
 accepted. It is not possible for the fundus to become incarcerated 
 in anteflexion as it does in retroflexion, unless some other morbid 
 condition, such as a fibroid tumour, co-exists. As the uterus 
 enlarges, the fundus rises out of the pelvis, above the level of the 
 pubea. 
 
 In the later months of pregnancy, anteversion, generally com- 
 bined with anteflexion, appears in a different form, and leads to the 
 condition known as pendulous belly. It is generally due to the 
 
Abnormalities of the Uterus. 495 
 
 laxity of the abdominal walls in multiparse. The heavy fundus 
 hangs forward over the pubes, so that the front of the fundus may 
 be at a lower level than the centre of the uterus. In extreme cases 
 the recti are widely separated, so that the fundus forms a kind of 
 hernia, covered only with skin, fascia, and connective tissue. This 
 disj)lacement is promoted by contraction of the pelvis — and this is 
 its most common cause in primiparse — sufficient to prevent the head 
 from lying in the pelvic cavity, by any deformity which diminishes 
 the space between the pelvis and the ribs, so that there is not room 
 for the axis of the uterus to lie in its usual position, and by lordosis 
 of the lumbar vertebrae, which pushes the posterior wall of the 
 uterus forward. 
 
 When the displacement is considerable, there is difficulty in 
 walking, dragging pain from the stretching, sometimes irritability 
 of the bladder from the pressure uj)on it, sometimes oedema at the 
 lower part of the abdominal wall. There is a tendency to abnormal 
 presentations of the foetus from the altered influence of gravity, and 
 in very marked cases dilatation of the cervix during labour takes 
 place very slowly or may even be wanting entirely.-^ 
 
 Treatment. — Little or no treatment is usually required for ante- 
 version or anteflexion in the early months. Moderate rest in the 
 dorsal position may be emjDloyed, and, if necessary, a hypogastric 
 belt may be worn when the fundus has begun to rise above the 
 pubes. Ante version pessaries are not to be recommended in 
 pregnancy. For the displacement in the later months, a firm 
 abdominal belt should be worn, carrying the fundus backward and 
 upward. 
 
 In cases of anteversion and anteflexion, where the uterus is more 
 or less fixed as the result of the operations of vaginal fixation, 
 ventral suspension, or ventral fixation, complications may arise both 
 during pregnancy and labour. These are especially likely to occur 
 when the uterus is firmly attached to the bladder or to the anterior 
 abdominal wall. During pregnancy the patient may complain of 
 pain due to the stretching of the adhesions, and as the ovum grows 
 the uterus may develop entirely at the expense of its posterior wall, 
 the anterior remaining undeveloped ; at the same time upward 
 displacement of the cervix may take place to an excessive degree, 
 and when labour sets in dilatation of the cervical canal may not 
 occur at all or very imperfectly. In such circumstances there will 
 be a considerable risk of the occurrence of rupture of the uterus. 
 Attempts have been made to avoid any such complications by 
 practising, in patients who are likely to become pregnant, ventral 
 
 1 li, V. J'.iauii Fornwald, Zentralbl. f. Gyniik., 1898, No. 19, s. 489. 
 
49^ The Practice of Midwifery. 
 
 suspension rather tlian ventral fixation or by passing the attaching 
 sutures through the lower uterine segment only. As Whitridge 
 Williams, however, has shown, difficulty may arise even when the 
 operation of ventral suspension has been carried out by competent 
 surgeons. Thus he has recorded two cases in which Cesarean 
 section was required and one in which craniotomy was performed for 
 dystocia occurring in patients upon whom this operation had been 
 performed. He further collected thirty-six cases where Cesarean 
 section was required, and three cases of craniotomy in patients 
 suffering from dystocia the result of one or other of these operations. 
 Ventral fixation or ventral suspension therefore should not be 
 performed in patients who are likely to become pregnant. 
 
 Retroflexion and Retroversion. — These are by far the 
 gravest displacements of the pregnant uterus. In the great 
 majority of cases the version and flexion are combined. A per- 
 fectly straight retroverted gravid uterus is hardly found, except 
 in the rare cases in which the displacement is produced suddenly 
 by violence or strain. In some cases, however, the version, and 
 in others the flexion, is the prominent element. Eetroflexion 
 entirely without retroversion rarel}^ if ever, occurs, for the cervix 
 is almost always tilted forward more or less. Retroversion with 
 retroflexion, in its complete form, cannot exist beyond about the 
 end of the fourth or the middle of the fifth month of pregnancy, 
 for, after that, the fundus is too large to be contained in the pelvis. 
 
 Causation. — This displacement arises as a rule out of a previous 
 displacement of an unimpregnated uterus. In the great majority 
 of cases, the displacement has become gradually aggravated in 
 consequence of the growth of the uterus. Before pregnancy the 
 uterus has been either retroverted, or, more frequently, in the 
 commoner condition of retroflexion combined with retroversion. 
 In either case there has been more or less of that partial prolapse 
 which is the almost invariable antecedent and accompaniment of 
 retroversion. Pregnancy having occurred, the growing fundus 
 begins to press upon surrounding parts. In a considerable pro- 
 portion of cases of this kind the uterus eventually rights itself 
 spontaneously, and the fundus rises out of the hollow of the 
 sacrum into the abdomen. The mechanism by which this happens 
 appears to depend upon the fact that the state of the pregnant 
 uterus is, to some extent, plastic, and yields gradually to continuous 
 pressure, while at the same time the cervix forms a fixed point under 
 the symphysis pubis. Thus, being pressed upon on all sides in the 
 pelvis, as it enlarges, it expands in the direction of least pressure, 
 
Abnormalities of the Uterus. 
 
 497 
 
 that is, toward the pelvic brim, until at length the fundus is able 
 to get above the promontory of the sacrum. 
 
 If this spontaneous rectification does not occur, just the reverse 
 generally happens, and the displacement becomes aggravated, the 
 element of retroversion more especially being increased, so that 
 the cervix is tilted more and more forward and upward, stretching 
 the anterior vaginal wall and the urethra. This is due to the 
 
 Fig. 271. — Incarceration of the retroflexed gravid uterus with rupture of the 
 bladder from over-distension. (Univ. Coll. Hosp. Med. School Mus., 
 Spec. No. 4251.) 
 
 fact that the presence of the enlarged displaced fundus excites 
 bearing- down efforts by which it is forced lower and lower, and 
 the cervix thereby tilted forward and upward. Sometimes the 
 fundus comes low enough actually to rest upon the perineum, 
 and it has even been known to distend the anus. Toward the 
 end of the third month the uterus begins to be so large that 
 the fundus, lying from the first in the hollow of the sacrum, is 
 detained under the sacral promontory, and is unable to rise above 
 it, since the antero-posterior diameter of the pelvic brim is less 
 M. 32 
 
498 The Practice of Midwifery. 
 
 than that of the pelvic cavity (see p. 17). In this way arises 
 incarceration of the retroverted gravid uterus. Its pressure on 
 surrounding parts grows greater ; the cervix is pushed more and 
 more forward and upward, since the fundus cannot rise, and 
 eventually a stage is reached at which the pressure of the cervix 
 on the neck of the bladder, generally combined with the 
 stretching upward of the urethra, causes retention of urine 
 (Fig. 271). " • 
 
 Though this gradual mode of origin is the rule, in rate cases 
 the displacement arises suddenly. Either a fall on the back, or a 
 sudden muscular strain or bearing-down effort, forces the fundus 
 down into the hollow of the sacrum. If this happens toward the 
 end of the third, or in the fourth month of pregnancy, the fundus 
 will be so large that it cannot easily rise again, and then the 
 symptoms of incarceration come on suddenly or rapidly. Even 
 this sudden mode of origin, however, implies a previous partial 
 displacement. The fundus must have been inclined more back- 
 wards than normal, though not in the hollow of the sacrum, 
 otherwise the abdominal pressure would have acted on its 
 posterior, not on its anterior surface, and would only have brought 
 it into increased anteversion. Such inclination of the fundus 
 backward would be greater if the bladder happened to be full at the 
 time when the sudden strain or fall took place. 
 
 Diirhrssen maintains that cases of incarceration of the retroverted 
 gravid uterus are most commonly due to a sudden fall or blow, and 
 that in these cases the symptoms do not appear so early as in cases 
 of retroflexion. As the cervix points almost directly upwards the 
 lower uterine segment is able to grow and expand in the direction 
 of the pelvic inlet. This continues until the stretching of the 
 vaginal walls which occurs reaches its maximum, and then the 
 cervix begins to press upon the bladder, and so causes the reten- 
 tion of urine. In these cases the bladder may become almost 
 divided into two separate pouches by the projection of the cervix 
 into it. 
 
 Results.— 'Ha.tnve' 8 readiest mode of relief is the occurrence of 
 abortion. This may happen before the uterus is large enough to 
 cause incarceration. Thus, if a series of abortions before the end 
 of the third month has occurred, without any apparent cause, and 
 an examination of the woman is made, the cause is sometimes 
 revealed in retroflexion of the uterus, and future pregnancies pro- 
 ceed normally, when the displacement has been rectified. When 
 the uterus is incarcerated, and pressure becomes severe, the 
 tendency to abortion is possibly increased. 
 
Abnormalities of the Uterus. 499 
 
 Herman/ however, has collected 115 cases of which only five 
 aborted, or 1 in 25. 
 
 After abortion, the flexion of the uterus is apt to interfere with 
 the complete evacuation of the ovum, unless the evacuation is 
 artificially completed. From retention of a portion of ovum may 
 arise saprsemia, or possibly even septicsemia. 
 
 As soon as retention of urine is produced, grave danger arises if 
 the case is not promptly treated. The bladder becomes greatly 
 distended, often rising above the level of the umbilicus. Some- 
 times it has been mistaken for an ovarian tumour. Eventually 
 the tension is somewhat relieved by some of the urine dribbling 
 away (so-called imracloxical incontinence). The retained urine 
 soon decomposes, and sets up cystitis. When drawn off, it may 
 be found bloody and intensely foetid and ammoniacal. Sometimes 
 the inflammation of the bladder is so severe as to cause sloughing 
 of part, or even of the whole thickness, of its wall. Casts consisting 
 of mucous membrane, or mucous membrane and muscle tissue, or 
 even in very rare cases of the whole thickness of the bladder wall 
 have been expelled. The pressure extends backward to the kidneys, 
 and may set up albuminuria and uraemia. The septic inflammation 
 may also extend backward to the kidneys, and lead to septic 
 nephritis and the so-called " surgical kidney." Karely the bladder 
 ruptures, or gives way by ulceration,^ and rarely, also, peritonitis 
 arises. The most frequent cause of a fatal result is the inflam- 
 mation of bladder and kidneys. A case has also been recorded 
 in which pressure on the colon caused ulceration and gangrene of 
 the gut.^ 
 
 Even when the stage of incarceration has been reached, a natural 
 termination is possible, without the occurrence of abortion, provided 
 the dangers arising from retention of urine are averted by the 
 catheter being used whenever required. The plastic uterus gradu- 
 ally accommodates itself by expanding upwards in the direction of 
 the pelvic brim, the only direction in which expansion is possible, 
 until it has reached a sufficient size to allow the major part of the 
 foetus to rise out of the pelvis into the abdomen. It appears that, 
 during this process, the fundus uteri gradually rises into the 
 abdomen, escaping past the promontory of the sacrum by gradual 
 growth rather than sudden movement, and that, at any rate in 
 most such cases, the uterus thus eventually rights itself, although 
 for some time, and perhaps even to full term, a bulging pouch, 
 
 1 Herman, Brit. Med. Jouin., 1904, Vol. I., p. 877. 
 
 2 Haultaiii, Kdin. Med. .louni., June, 18!)0, Vol. XXXV., p. 1122. 
 
 « Treub, quoted by Dienat, Deutsch. Med. Wochenschr., April 2Uth, 1905, p. ()23. 
 
 32—2 
 
500 
 
 The Practice of Midwifery. 
 
 consisting of the lower portion of the jDosterior uterine wall, may 
 still be felt in the pelvis behind the cervix. 
 
 E. Barnes describes an incomplete retrofiexion, or sacculation of 
 the uterus, as persisting in some cases to full term, the uterus being 
 converted into two pouches, a pelvic pouch containing the head or 
 breech, and an abdominal pouch containing the bulk of the foetus, 
 the cervix remaining displaced forwards and upwards above the 
 symphysis pubis (Fig. 272). He considers that this condition is 
 
 Fig. 272.— Gradual development of anterior wall of uterus in a case of 
 incomplete retroflexion of the uterus. 
 
 developed out of a retroflexion in the early months by a pouch-like 
 diverticulum being formed from the upper surface — that is, the 
 original anterior wall— of the uterus, which eventually becomes the 
 abdominal pouch, receiving the greater bulk of the fcetus. In 
 most cases this condition comes under observation only when labour 
 comes on, and its progress is arrested on account of the displaced 
 position of the os. 
 
 Symptoms. — For the first month or two there may be little or 
 no symptom, but generally there is an increase of the symptoms 
 previously associated with the retroflexion, especially bearing-down 
 
Abnormalities of the Uterus. 501 
 
 pain in the pelvis, chiefly towards the back, and pain and difficulty 
 in defecation ; usually constipation is marked ; sometimes there is 
 leucorrhoea, sometimes irritability of bladder. . Then, generally 
 before the end of the third month, or early in the fourth month, 
 retention of urine is produced. This generally happens the later, 
 the greater is the amount of room in the pelvis. Often it begins 
 rather suddenly, perhaj)s in consequence of some strain or bear- 
 ing-down effort. The distress then quickly becomes considerable ; 
 the symptoms of pelvic pressure are increased, but the most acute 
 pain is due to the condition of the bladder. Eeflex symptoms are 
 excited by the presence of the displaced fundus like a foreign body 
 pressing upon the rectum. These chiefly take the form of bearing- 
 down efforts, by which the mischief is aggravated. Sometimes 
 interference with the bowels and partial obstruction lead to 
 nausea and vomiting. Later constitutional disturbance with 
 pyrexia is produced by the decomposition of the urine, the inflam- 
 mation of the bladder, and finally the damage to the kidneys, 
 which may lead to ursemic symptoms. Pain indicative of peritonitis 
 is rare, but pain from distension and inflammation of bladder, with 
 pelvic pressure, may be severe and agonising without the existence 
 of any peritonitis. 
 
 When the retroversion is suddenly produced as the result of a 
 fall or strain, the acute symptoms of pressure come on suddenly, 
 and there may be in addition the symptoms of shock, pallor, rapid 
 feeble pulse, sometimes nausea and vomiting. 
 
 Diagnosis. — The most characteristic and constant symptom is 
 that of retention of urine combined with amenorrhoea of about 
 three months. In any case of retention of urine, where pregnancy 
 is possible, inquiry should be made about the state of menses, and 
 the likelihood of retroversion of the gravid uterus be borne in 
 mind. It must, of course, be remembered that haemorrhage may 
 occur if abortion is threatened, but, if pregnancy exists, there will 
 generally have been some amenorrhoea. Sometimes the complaint 
 made is not of retention, but of inability to hold the urine, this 
 condition being due to the dribbling away of the urine from the 
 distended bladder. 
 
 The abdomen may probably be found occupied by the distended 
 bladder. The nature of this swelling will be cleared up by the 
 use of the catheter, and an examination of the breasts will lead to a 
 suspicion of pregnancy. On vaginal examination, after the bladder 
 has been emptied, the rounded swelling behind the cervix formed 
 by the pregnant fundus will have to be distinguished from other 
 swellings which may be situated there. It will be larger than in 
 
502 The Practice of Midwifery. 
 
 the case of retroflexion of the un impregnated fundus. The occur- 
 rence of amenorrhoea, changes in the breasts, and other signs of 
 pregnancy, will help the diagnosis. Less will be felt of the fundus 
 uteri from the hypogastrium than should be felt in correspondence 
 with the date of pregnancy ; and on bimanual examination, the 
 complete absence of the fundus from its normal position in front 
 may be made out. The continuity of the swelling behind with the 
 cervix, and the conjoint movement of the two, may also generally 
 be ascertained. 
 
 The case of a tumour behind the uterus will generally be dis- 
 tinguished by the condition of the cervix. In retroflexion of the 
 gravid uterus, there is almost always some retroversion also ; the 
 cervix is tilted more or less forward and displaced upward as well 
 as forward, so as to put the anterior vaginal wall and urethra on a 
 stretch. When the uterus is pushed forward by a tumour behind, 
 the cervix is generally lower down, and looks more nearly in its 
 normal direction. Of these two signs, the direction of the cervix 
 is the more important, for the cervix may be drawn upward in the 
 case of fibroid or ovarian tumour. In the case of tumour, the 
 fundus may also be made out, on bimanual examination, as lying 
 in front. The tumours most likely to lead to error, when found 
 behind the cervix, are small ovarian or fibroid tumours, or the sac 
 of an extra-uterine foetation, the last being especially likely to cause 
 a mistake. Eetro-uterine hfematocele and inflammatory swellings 
 have also to be distinguished. 
 
 In some cases the retroflexed pregnant fundus may be detected 
 as varjdng in hardness, in consequence of the rhythmical con- 
 traction of the uterus during pregnancy. The softening of the 
 cervix will often aid in distinguishing the case from one of a 
 tumour displacing the unimpregnated uterus. Sometimes the 
 diagnosis can be at once completed by restoring the fundus to 
 its place. 
 
 In a case of sacculation or j)artial retroflexion of the uterus the 
 diagnosis may be difficult owing to the extremely oedematous and 
 thickened condition of the sacculated portion. 
 
 Treatment. — In the early stage, before incarceration has taken 
 place or retention of urine has been produced, it is generally easy 
 to replace the uterus. The patient should be placed in the semi- 
 prone position. First the finger in the posterior cul-de-sac of the 
 vagina pushes the fundus upward as far as it can reach ; next the 
 finger is transferred to the cervix and carries the cervix well back- 
 ward into the cavity of the sacrum. By this means the fundus 
 will be brought still further forward. Either a full-sized Hodge's 
 
Abnormalities of the Uterus. 503 
 
 pessary or an elastic ring^ pessary should then be introduced. 
 The object is to maintain or complete the restoration of the 
 uterus rather by holding the cervix backward than by directly 
 pushing the fundus upward. This is easier in the case of the 
 pregnant, than in that of the unimpregnated uterus, partly because 
 the organ is larger, and partly because it has a natural tendency 
 to straighten itself in pregnancy when opposing forces do not 
 prevent this. 
 
 If incarceration and retention of urine have already been pro- 
 duced, the first thing is to empty the bladder, and the rectum also 
 by enema, if there is any collection of faeces. A soft rubber 
 catheter should be employed, or if this does not succeed a No. 8 
 male gum elastic catheter may be tried. After this, if the 
 symptoms have been acute and are now relieved, and if there is no 
 immediate threatening of abortion, it is often a good plan to keep 
 the patient in bed for a day or two, and continuously in the 
 semi-prone position, the bladder being emptied regularly, to see 
 whether spontaneous restoration will occur. If not, the attempt 
 should be made to restore the uterus, or this plan may even 
 be adopted at the outset. I have hardly ever found this treat- 
 ment by immediate reduction either fail to succeed, or lead to any 
 inconvenient result. It requires, however, some dexterity in 
 manipulation. 
 
 Great assistance is derived from the knee-elbow position. The 
 patient is made to kneel on a flat couch so that her chest, as nearly 
 as possible, touches the surface of the couch, and the thighs are 
 perfectly vertical. This position makes the brim of the pelvis 
 look almost vertically downward. When the labia are separated, 
 air enters the vagina and distends it into a wide cavity, and the 
 contents of the pelvis are drawn toward the abdomen, not only by 
 their own gravity, but, in a measure, by that of the abdominal 
 contents, which produces a negative pressure (i.e., a pressure less 
 than that of the atmosphere) in the portion of the abdomen now 
 most elevated. 
 
 In an easy case the uterus is restored from the vagina with least 
 discomfort to the patient. Two fingers are introduced into the 
 posterior cul-de-sac, and placed upon the fundus as far back as 
 possible. The fundus is then pushed toward the abdomen as far 
 as the fingers will reach, not directly upward, but toward the side 
 to which the fundus is already inclined in order to avoid the pro- 
 montory of the sacrum. This will generally be toward the right 
 
 1 'J'he best form of ring pessary is that made of watch-spring covered with iiidiarubbcr, 
 the diameter of the section of the rubber being not less than about half an inch. 
 
504 The Practice of Midwifery. 
 
 side. Meanwhile counter-pressure may be made upon the cervix, 
 or opposite pole of the uterus, by the other hand placed on the 
 abdominal wall just above the pubes, or the cervix may be drawn 
 down by a vulsellum, care being taken not to tear the tissue softened 
 by the pregnancy. As soon as the fundus has receded to the full 
 length of the fingers, the fingers should be transferred to the cervix, 
 and carry this fully back into the hollow of the sacrum, before the 
 patient is allowed to lie down upon her side. If the fundus has 
 been fully restored, it will generally remain in position ; if only 
 partially, the displacement recurs at once, or after a short time. 
 
 Restoration by Rectum.— li pressure from the vagina does not 
 easily succeed, pressure from the rectum should be tried. This 
 allows the fingers to reach further back and more completely to 
 the fundus, and so affords a greater leverage. The fingers can also 
 thus reach higher in the pelvis, especially when the vagina is not 
 lax. One or two fingers should be passed into the rectum, the 
 knee-elbow position being used as before, and the manipulation 
 carried out in precisely the same way as from the vagina. Some 
 prefer to give an anresthetic and place the patient in the semi-prone 
 position. With a nervous patient, this plan may be adopted ; 
 otherwise I have found the advantage of the anaesthetic to be less 
 than that of the knee-elbow position. But in any case, if the 
 attempt fails, the patient should be placed under anaesthesia, and 
 taxis again tried, either in the semi-prone or the dorsal position, 
 whichever is found most convenient. No undue force must be 
 used, and in any case where signs'of sloughing of the bladder wall 
 are present forcible efi'orts at replacement must be avoided. After 
 the replacement, the patient should be kept in bed for a day or two, 
 and an opiate given, lest abortion should come on afterwards. 
 
 Elastic Pressure. — If digital rej)lacement fails, the method of 
 gradual pressure should be tried. This is best efl'ected by the 
 introduction of a ring pessary as large as possible into the vagina, 
 as suggested by Sinclair,^ and this alone is often sufficient to over- 
 come the displacement. Or an air-ball pessary may be placed in the 
 vagina, as far back toward the fundus as possible, and its inflation 
 increased from time to time by means of the air-pump with which 
 it is fitted, unless there are grave constitutional symptoms, since 
 spontaneous restoration practically always occurs if the bladder be 
 kept emptied. If there are, it may be advisable to induce abortion. 
 If possible, a sound or stylet should be passed through the os, so as 
 to rupture the membranes. If this proves impossible, as is most 
 likely in cases of pure retroversion, owing to the extreme displace- 
 
 1 Sinclair, Trans. Obst. Soc. London, 1900, Vol. XLII., p. 338. 
 
Abnormalities of the Uterus. 
 
 505 
 
 ment of the os, it has been recommended to draw off the liquor 
 amnii by puncturing from the vagina with an aspirator needle, but 
 I have never known this to be necessary. The uterus will right 
 itself to a considerable extent at any rate, as it expels its contents. 
 
 Abdominal Section. — An alternative is to perform abdominal 
 section, separate any adhesions which may exist, and restore the 
 uterus to position. This procedure has been carried out success- 
 fully in a number of cases, but will rarely be necessary if the other 
 means are properly tried, and should only be resorted to as a last 
 resource, unless there is evidence of the presence of adhesions or of 
 serious damage to the bladder. 
 
 The treatment of the partial retroflexion, real or supposed, 
 continuing up to labour at full 
 term, will be considered hereafter 
 (Chapter XXVIL). 
 
 The use of any pessary intro- 
 duced in the early months 
 should generally be continued 
 up to about the end of the fourth 
 month. After that time the 
 fundus uteri becomes too large 
 to descend again into the pelvis, 
 and the pessary should therefore 
 be removed. 
 
 Fig. 27;^. — Prolapse of second degree in 
 unimpregnated uterus. 
 
 Prolapse of the Uterus and 
 Vagina. — Prolapse of the uterus 
 may be real in the early months 
 of pregnancy, or ifc may be apparent, being really elongation of the 
 cervix ; or again there may be that condition which in apparent 
 procidentia^ of the unimpregnated uterus is the commonest, namely, 
 an elongation of the supra-vaginal cervix combined with descent of 
 the whole uterus (see Fig. 273). Prolapse of the uterus is not very 
 common in pregnancy, considering the frequency with which it 
 occurs apart from pregnancy. For the prolapse is to some extent a 
 hindrance to pregnancy, and pregnancy, when it does occur, has a 
 tendency eventually to cure the prolapse. The uterus, as it 
 enlarges, generally rises out of the pelvis, and eventually rests 
 upon the brim. 
 
 Causation. — All forms of prolapse of uterus and vagina, as might 
 be expected, occur chiefly in women who have been pregnant before. 
 Prolapse of the pregnant uterus in the great majority of cases 
 
 1 The term " procidentia" is used when the cervix descends outside the vulva. 
 
5o6 
 
 The Practice of Midwifery. 
 
 arises out of prolapse existing before pregnancy. In very rare 
 instances, however, prolapse may be produced suddenly within 
 the first two or three months of pregnancy by a fall or violent 
 strain, just as it may in the case of the unimpregnated uterus. 
 When a prolapsed uterus becomes pregnant, the descent may at 
 first be increased in consequence of the increased weight. It has 
 already been explained that descent is almost always associated 
 with some degree of retroversion or retroflexion. The case now to 
 be considered is that in which the descent is the main element of 
 the displacement. If the case has been before pregnancy one of 
 prolapse of the second degree (called also procidentia) , in which the 
 cervix descends outside the vulva, but the fundus uteri remains 
 
 within the body, it will almost 
 certainly have been associated 
 with more or less elongation of 
 the supra-vaginal cervix, the 
 result of tension (Fig. 273). 
 During the first two or three 
 months of pregnancy, the cervix 
 may still come down outside, the 
 fundus remaining in the pelvis 
 more or less retroverted or 
 retroflexed. The congestion and 
 strangulation of the cervix will 
 then be greater than usual in 
 consequence of the hypersemia 
 of pregnancy. As pregnancy 
 goes on, the fundus almost 
 always rises up out of the 
 pelvis, and draws up the cervix after it. Hence in the later 
 months of pregnancy, although the cervix may be lower than 
 usual in consequence of its elongation, it hardly ever comes out- 
 side. Earely the fundus becomes detained beneath the promontory 
 of the sacrum, the retroflexion increases as pregnancy goes on, and 
 the case becomes essentially one of retroflexion of the gravid 
 uterus. 
 
 When the prolapse is mainly apparent, and not real, the con- 
 dition is generally one of hypertrophic elongation, not solely or 
 mainly of the supra-vaginal, but of the intra-vaginal portion of the 
 cervix. This also arises out of a similar condition existing before 
 pregnancy. There is then usually some descent in addition, which 
 is due to the weight of the enlarged cervix, and allows the cervix to 
 be protruded externally. As the uterus rises out of the pelvis, any 
 
 Fig. 27i. — Prolapse of third degree in 
 unimpregnated uterus. 
 
Abnormalities of the Uterus. 507 
 
 descent of the body of the uterus is remedied, and there is a 
 tendency also to draw the cervix upward. But sometimes the cervix 
 itself is more or less constantly gripped and retained outside the 
 vulva, and then the traction increases the elongation of the cervix 
 instead of remedying its malposition. Its hypertrophy also is 
 increased, in consequence of the hypersemia of pregnancy. Almost 
 all cases in which the cervix uteri appears externally in the later 
 months of pregnancy after the fifth month are to be explained 
 in this way. 
 
 It is possible for early pregnancy to exist with Ti^rolapse of the 
 third degree, in which not merely the cervix, but the whole uterus, 
 is outside the body in a position of retroflexion (Fig. 274). 
 
 The enlarging mass then soon becomes strangulated by the 
 vulva, and abortion follows if the uterus is not reduced. Cases 
 have been reported in which this state of things has been supposed 
 to continue as long as the fifth or even the sixth month. But 
 it is probable that in these cases the fundus was really in the 
 pelvis, inside the vulva (as in Fig. 273, p. 505), although the 
 vagina may have been completely inverted over the procident 
 cervix. 
 
 Apparent prolapse, due to hyperplasia of the cervix, may lead 
 to obstruction in labour in consequence of the difficulty in the 
 dilatation of the elongated and hypertrophied cervix. This will be 
 considered hereafter. 
 
 Prolapse of the vagina alone commonly affects the anterior wall 
 only. The posterior wall may also be prolapsed either with or 
 without the anterior wall, generally after damage to the perineum 
 in former deliveries. Prolapse of the anterior wall is often a 
 sequel of an original prolapse both of uterus and anterior vaginal 
 wall, after the uterus has been drawn up, owing to its increased 
 size. The evolution of the vaginal walls in pregnancy tends to 
 aggravate the condition. In labour the prolapsed vaginal wall, 
 driven before the head, may become swollen, and form an obstacle 
 to progress. It may even slough from the effect of prolonged 
 pressure. 
 
 Symptoms. — The symptoms of prolapse in the unimpregnated 
 state are generally increased in the early months of pregnancy, 
 in consequence of the increased weight and congestion. Irrita- 
 bility of bladder, from the accompanying cystocele, is often 
 troublesome. If the cervix remains external it is apt to become 
 deeply congested, irritated, inflamed, or ulcerated from friction. 
 This condition of the cervix may lead to abortion. A prolapsed 
 vagina may become much swollen in labour, and form an obstacle 
 
5o8 The Practice of Midwifery. 
 
 to the advance of the head. In general, after the fourth month, as 
 the cervix is drawn upward by the enlarging uterus, the symptoms 
 of prolapse are considerably relieved, except in those cases of 
 elongation of the vaginal cervix, in which the os may remain 
 external to the vulva. 
 
 Treatment. — If there is any notable prolapse of the uterus itself 
 within the first few months of pregnancy, it should be supported 
 by an elastic ring, or full-sized Hodge's pessary. This may 
 generally be removed about the end of the fourth month. In 
 troublesome cases, and more especially if any ulceration of the 
 exposed cervix has been produced, rest in the horizontal position 
 is a great aid to the treatment. If a pessary is not, at first, readily 
 tolerated on account of tenderness of the uterus or vagina, the 
 uterus may be supported by a tampon of absorbent cotton, soaked 
 in a solution of alum thirty grains, boric acid four grains, to an 
 ounce of glycerine, and having a tape tied round it for withdrawal. 
 This should be changed every day. If the cervix uteri is found 
 external to the vulva, its reduction must be the first step in treat- 
 ment. In reducing it, care should be taken not to convert the 
 prolapse into a retroflexion by pushing up the cervix only, and 
 leaving the fundus low down in the hollow of the sacrum. The 
 fundus should first be pushed up from the posterior cul-de-sac of 
 the vagina, or from the rectum. If there is any difficulty in doing 
 this, the semi-prone, or the knee-elbow position will often facilitate 
 it, as described for the case of retroflexion of the gravid uterus 
 (see p. 504). 
 
 Prolapse of the anterior vaginal wall in the early months is apt to 
 be associated with some descent of the uterus, and may then call 
 for the use of a pessary. In the later months it is to be treated 
 chiefly by rest and mild astringents in the form of lotion, or dis- 
 solved in glycerine and applied by tampon, which may be kept in 
 place, if necessary, by a perineal band. Sometimes, even at this 
 stage, a large elastic ring pessary is of use, its anterior portion 
 holding up the vaginal wall behind the pubes. In labour, if the 
 prolapsed and swollen vagina wall is driven down in advance of the 
 head, it should be gradually drawn back over it by the fingers. In 
 prolapse of the posterior vaginal wall, pessaries are not generally of 
 service, and the treatment must be confined to rest and the use of 
 astringents. 
 
 Apparent prolapse, due to elongation of the vaginal cervix, can 
 receive benefit from a pessary only when it is associated with some 
 actual descent of the uterus, as may be the case in the early months. 
 In the later months all that can be done is to prescribe rest and 
 
Abnormalities of the Uterus. 509 
 
 prevent irritation of the cervix by friction. The treatment of 
 difficulty in parturition, arising from the hypertrophied cervix, will 
 be considered hereafter. In all cases of prolapse, of whatever 
 variety, attention should be paid to the regulation of the bowels, 
 that the displacement may not be aggravated by straining. 
 
 Hernia of the Uterus. — In the later months the fundus uteri 
 may protrude into the sac of an umbilical hernia if greatly distended, 
 or into a ventral hernia, due to stretching of the cicatrix of an 
 abdominal section, especially one in which a pedicle of uterine or 
 ovarian tumour has been fixed. A sort of hernia may also arise 
 simply from separation of the recti muscles. In these cases the use 
 of an abdominal belt during pregnancy is sufficient treatment, and 
 birth generally takes place naturally or with the aid of forceps. 
 
 In a case recorded by Eosner^ the gravid uterus was incarcerated 
 in a ventral hernia, and Cesarean section followed by removal of the 
 uterus was performed. 
 
 In very rare cases the uterus has been found in the sac of an 
 inguinal or femoral hernia, and in still rarer pregnancy has occurred 
 in such a uterus.^ The diagnosis would be made by recognising 
 the characters of the pregnant uterus in the sac, the absence of the 
 uterus from its usual position, and the displacement of cervix and 
 vagina towards the sac. Such cases have generally ended in spon- 
 taneous abortion. If the uterus cannot be returned, abortion should 
 be induced in the early months by passing a sound or stylet through 
 the OS. Later, an operation as for strangulated hernia may possibly 
 become necessary. If possible the uterus should not be incised, but 
 returned after incision of the neck of the sac, either with or without 
 evacuation of the liquor amnii. If this prove impossible the uterus 
 must be emptied and returned, or if any signs of sepsis are present 
 hysterectomy should be performed. 
 
 1 Rosner, Zentralbl. f. Gynak., 1904, No. 48, p. 1486. 
 
 2 Spiegelberg, Lehrbuch der Geburtshiilfe, 2nd ed., English translatioD, 1887, Vol. I., 
 p, 382, 
 
Chapter XXIL 
 DISEASES OF DECIDUA AND OVUM. 
 
 Decidual Endometritis. — Inflammation of the decidua arising 
 from endometritis existing before pregnancy may or may not be 
 associated with the presence of organisms in the affected tissues. 
 In the latter case it may be due to gonorrhoea, tubercle, syphilis, or 
 to any of the septic or saprophytic organisms. The inflammation 
 may affect the decidua vera, basalis, or capsularis, or any one or two 
 of these divisions. The whole of the mucous membrane may be 
 involved, or only portions, leading to the development of the special 
 variety known as endometritis polyposa. On microscopical 
 examination are found enlargement of the decidual cells, infiltration 
 of the tissues with collections of small round cells, and hypertrophy 
 and hyperplasia of the glands. In the most marked forms 
 haemorrhages may occur, and may be the exciting causes of an 
 abortion. In some cases, more especially in those due to the action 
 of various organisms, marked degenerative changes occur in the 
 deciduae. The fibrin layer of Nitabuch is well marked, and local 
 areas of necrosis occur which are composed mainly of degenerate 
 decidual cells. Another characteristic feature is the occurrence of 
 thrombosis in the sinuses of the decidua basalis which contain 
 masses of large well-staining cells, " syncytial wander cells," 
 derived from the syncytium of the chorionic villi.-^ 
 
 Ultimately there may be an excessive formation of connective 
 tissue leading to abnormal attachment of the decidua to the 
 uterine wall, interfering with the formation of the ampullary layer, 
 and so causing adhesions of the placenta to the uterus, a condition 
 which is apt to occur in successive pregnancies. In a later stage 
 atrophic changes may also be met with, the glandular layer then is 
 absent altogether, only a few remains of the decidua basalis being 
 found, and the chorionic villi, surrounded by some fibrous connective 
 tissue,become attached directly to the m uscle tissue. The muscle tissue, 
 often thinner than normal, takes the place of the decidua basalis, and 
 Nitabuch's fibrin layer is formed in it, and numerous syncytial 
 wander cells are seen scattered among the muscle fibres. The 
 
 1 V. Franque, Zeitsch. f. Geb. u. Gyn., 1897, Bd. 37, no. 11, s. 277. 
 
Diseases of Decidua and Ovum. 511 
 
 causation of this condition has been attributed to acute inflammation 
 in the puerperium or a previous chronic interstitial endometritis. 
 
 Endometritis affecting the decidua basalis is of course the most 
 important as regards its influence on the life of the ovum. A con- 
 siderable amount of change in the decidua vera is not incompatible 
 with the continuance of pregnancy, but it may excite the uterus to 
 expel the ovum, especially when hsemorrhage has occurred into the 
 tissue. 
 
 To a special form of endometritis, affecting chiefly the decidua 
 vera, but sometimes also the decidua capsularis, the term endometritis 
 decidualis tuberosa, or endometritis decidualis j^olyposa, has been 
 given. In this the free surface of the decidua becomes elevated in 
 the form of bosses, or polypoid projections. These are due chiefly 
 to local proliferation of cells and fibroid tissue, but the swelling 
 may be increased by infiltration of blood into the tissue. Over the 
 bosses, or polypoid projections, the orifices of the glands are 
 generally obliterated by the cell-growths, but in the intervening 
 parts of the decidua they remain visible. 
 
 Symptoms. — Pain referred to the uterus, or tenderness of the 
 uterine walls during pregnancy, may arise from endometritis 
 decidualis, but symptoms may be altogether absent. 
 
 Catarrhal Decidual Endometritis or Hydrorrhoea gravidarum. — In 
 some cases a discharge takes place during pregnancy of a thin 
 watery or muco-purulent fluid. This may begin in the third or 
 fourth month, but is more abundant in the later months of preg- 
 nancy. It is attributed to hypertrophy of the glands of the decidua, 
 persistence of the ducts, and excessive secretion from them. Small 
 cysts may be present forming the so-called endometritis cystica. 
 Sometimes the discharge takes place continuously, or frequently in 
 small quantities. In other cases, if its exit is obstructed by a plug 
 of tenacious mucus in the os, or adhesion between the decidua vera 
 and reflexa, it may be retained until a considerable quantity is 
 accumulated, and then be discharged in a sudden gush. Such a 
 flow is liable to be mistaken for the escape of the liquor amnii, or of 
 the fluid which sometimes collects between the amnion and chorion. 
 From both of these it is distinguished by the fact that the discharge 
 generally takes place more than once, and from escape of the liquor 
 amnii by the fact that pregnancy continues uninterrupted. In 
 some cases, however, uterine action may be set up, and premature 
 labour follow. Ahlfeld^ has recorded a case in which as much as 
 500 cc. was evacuated. Paul Bar and others maintain that this 
 escape of fluid is often really due to the rupture of the membranes 
 
 I [lolzapfel, Hegar's Beitrage, 1903, Bd. 8, s. 1. 
 
512 
 
 The Practice of Midwifery. 
 
 without the supervention of labour, and Meyer Euegg has collected 
 fifteen cases in which periods of fifteen to 120 days have elapsed 
 between the escape of the liquor amnii and the occurrence of labour. 
 
 In such a case the foetus can either continue to develop within the 
 amniotic cavity or may escape through the tear and continue its 
 development outside the membranes, the so-called exochorial 
 development of the foetus. In the latter case the membranes 
 retract and lose their elasticity, the opening through which the 
 foetus escaped contracting round the cord. No treatment is of any 
 avail, except the use of sedatives and rest if premature labour 
 should appear to be threatened. 
 
 Acute endometritis or acute metritis in pregnancy may arise in the 
 course of acute zymotic diseases. Apart from such a cause they 
 are hardly ever observed unless as the result of some complication, 
 such as the presence of a tumour, or the incarceration of a retro- 
 verted uterus ; or, when septic, from a traumatic cause, such as the 
 attempt to induce abortion. 
 
 Anomalies and Diseases of the Degidua Basalis and Placenta. 
 
 Anomalies of Form and Size. — The cord may be attached to 
 the edge, instead of, as usual, near to the centre of the placenta. 
 
 This variety is called the 
 battledore placenta (Fig. 275). 
 The cord may reach the 
 membranes a little distance 
 from the edge of the pla- 
 centa, the vessels dividing 
 into branches before arriv- 
 ing at the placenta, and the 
 branches running in the 
 membranes. This consti- 
 tutes the placenta velamen- 
 tosa (Fig. 289, p. 535). It is 
 the result of the abdominal 
 pedicle having been attached 
 to the decidua reflexa instead 
 of the decidua serotina. In 
 such a case, the cord will readily tear away from the placenta, if 
 any traction is made upon it. In rare cases there are detached 
 masses of placental tissue apart from the main placenta, and due to 
 development of isolated patches of chorionic villi. These are called 
 placentce succentiiriatce (Fig. 276) . They are of considerable practical 
 
 Fig. 275. — Battledore placenta. 
 
Diseases of Decidua and Ovum. 
 
 513 
 
 importance, because they may easily remain behind in the uterus 
 
 undetected, and give rise either to secondary j^ost-partum heemor- 
 
 rhage or to decomposition and septic absorption. The vessels 
 
 supplying them may run from the 
 
 edge of the main placenta, or may be 
 
 separate branches in a velamentous 
 
 insertion of the funis. Their torn 
 
 ends would be the chief indication 
 
 of a separate lobe having been left 
 
 behind. 
 
 In some instances the secondary 
 portions are so large as to constitute 
 a placenta consisting of two equal 
 portions, a placenta cliniidiata, or 
 even a placenta tripartita, or tliree- 
 lobed placenta. A placenta marginata 
 presents a grey-white band running 
 all round the placenta at the margin, 
 and due to the formation of a collar 
 of white infarction at the junction of 
 the decidua reflexa and decidua 
 basalis. The term placenta circum- 
 vallata is applied to the placenta when the chorion is folded over 
 at the margin, and a collar-like thickening is thus formed on 
 
 ^-^vlffS- 
 
 FiGr. 276. — Placenta succenturiata. 
 
 Fig. 277. — Placenta circumvallata. 
 
 the fcetal aspect with its rim directed towards the centre. Some- 
 times the placenta is thinner than usual, and spread over a larger 
 surface of the uterus. Such a placenta is called placenta 
 membranacea. Both of the last two conditions probably result 
 M. 33 
 
SH 
 
 The Practice of Midwifery. 
 
 from a reflexal development of placenta (see Chapter XXV.). 
 This again may be the consequence of the imperfect development 
 of the normal part of the placenta, due to previous endometritis. 
 In other cases there appears to be actually excessive development 
 of the placenta. Sometimes this is associated with an excessively 
 large fcetus, sometimes with hydrops amnii. Sometimes also it 
 api^ears to be a kind of comj)ensatory hypertrophy, when, for some 
 reason, the fcetus has a difficulty in obtaining nutriment enough. 
 The j)lacenta sometimes appears to be unusually small, without any 
 obvious ill effect upon the fcetus. It has already been mentioned 
 that in multiple pregnancy, if one or more placentae are less 
 
 Fig. 278. — Blighted ovum with irregular thickening of membranes. 
 
 favourably placed, or insufficient in extent, the corresponding foetus 
 is apt to perish. 
 
 Congestion of the Placenta and Placentitis. — Congestion of 
 the decidua basalis and maternal portion of the placenta may 
 arise from j)assive obstruction in the maternal vascular system, as, 
 for instance, from cardiac or renal disease, or it may be the result 
 of inflammation of the endometrium. In either case it may lead 
 to haemorrhage, and formation of thrombus, and this may cause the 
 death of the embryo, or excite the uterus to expel the ovum. In 
 the fully formed placenta, permeated by the maternal blood spaces, 
 congestion on the maternal side can exist only in the form of 
 excessive blood pressure. This also may lead to the formation of 
 
Diseases of Decidua and Ovum. 515 
 
 thrombus, for if the blood escapes into any space which it does not 
 naturally occupy, and in which the current stagnates, clotting takes 
 place. 
 
 The study of inflammation in the placenta is a difficult one, and 
 much that has been written upon the subject is erroneous. Inflam- 
 mation may occur in the decidua basalis and maternal portion of 
 the placenta, as well as in the decidua vera and capsularis. 
 
 Thrombosis in the maternal blood spaces of the incipient 
 placenta is also apt to be produced, and is attributed to primary 
 thrombosis in the sinuses of the decidua basalis or uterus.-^ The 
 blood spaces become distended, and elevated into irregular pro- 
 tuberances on the foetal surface of the placenta, formed by clot. 
 The embryo perishes in consequence, and remains very small in 
 proportion to the size of the placenta (Fig. 278). 
 
 Infarcts. — The commonest abnormality seen in the placenta con- 
 sists of white infarcts. These form generally conical whitish or 
 yellowish firm masses, with the base of the cone on the maternal 
 surface of the placenta, and result from obliteration of a branch of 
 a chorionic artery. Microscopic infarcts are present in all 
 placentae at full term, and have been well described by Whifcridge 
 Williams.^ 
 
 If they are unusually numerous or large they indicate premature 
 degenerative changes and senility of the placenta and are of 
 importance. The primary change is obliterative endarteritis in 
 one of the arteries of a villus, leading to coagulation necrosis 
 affecting the cells of Langhans' layer and then those of the 
 syncytium. This is followed by the clotting of the maternal blood 
 in contact with the villus, death of the tissues of the latter, and the 
 formation of a homogeneous whitish or yellowish mass, the white 
 infarct. In this the remains of the villi, more or less degenerated, 
 can be recognised. 
 
 Eed infarcts are less commonly seen, and occur most frequently 
 on the maternal surface of the placenta. Their frequent association 
 with chronic nephritis and death of the fcetus renders them of 
 importance clinically. 
 
 It is possible that in some cases the formation of infarcts may be 
 the result of inflammation of the maternal tissues spreading to the 
 cells of the villi. 
 
 For the majority of infarcts, and especially for those occurring in 
 
 1 See Bcny ilart, -''J'tiberose J<'le.sliy Mole," Jouin. of Obst. luid Gyn., May, 1902, 
 Vol. I., p. 479. 
 
 2 Whitridge Winiams, Arner. Jouin. Obst., 1900, Vol. XLI., pp. 775—801. 
 
 38—2 
 
5i6 
 
 The Practice of Midwifery. 
 
 the decidua basalis and the intervillous spaces, the cause is to be 
 found in inflammatory changes in the decidua, while those 
 primarily of chorionic origin and arising mainly in the last months 
 of pregnancy no doubt are secondary to atrophy and shedding of the 
 epithelium of the chorionic villi. 
 
 Calcification. — In many cases calcareous deposits are found on 
 the maternal surface of the placenta in the decidua basalis. They 
 appear to be due in general to calcification occurring in infarcts 
 
 d^ 
 
 
 ■^ 
 
 Fig. 279. — Villi from specimen of syphilitic placenta. The enlargement of 
 the villi, the degenerative changes in the stroma, and the obliteration of 
 some of the vessels of the villi are shovs^n. 
 
 and old clots, are often associated with adhesion of the placenta, and 
 are indicative of old age and degeneration. Calcareous deposits in 
 the foetal tissues in proliferating and degenerating areas of the 
 adventitia of the chorionic vessels have also been described. 
 
 Syphilis of the Placenta. — The most characteristic change in 
 the syphilitic placenta is its increase in weight relatively to that of 
 the fcetus. Thus the relation between the weight of the two is often 
 1 — 3 in place of the normal 1 — 55. The placenta is jDale and 
 mottled with yellowish-white patches, its consistence is often soft 
 and friable, while the cord may be oedematous, and the amount of 
 liquor amnii is often excessive. Examination of the teased-out 
 
Diseases of Decidua and Ovum. 517 
 
 chorionic villi shows even to the naked eye that they are shorter 
 and thicker than in the normal placenta. Under the microscope it 
 can be seen that the villi are increased in size and are placed more 
 closely together, the intervillous spaces being to a large extent 
 obliterated. The stroma of the villi contains a very large number 
 of round cells, and the vessels present evidence of periarteritis and 
 endarteritis, leading in some instances to their complete occlusion, 
 with consequent degeneration of the stroma (see Fig. 279). Here 
 and there proliferation of the cells of the syncytium on the surface 
 of the villi is taking place, and owing to the manner in which the 
 villi are packed together, ifc appears in places as if there was 
 actually inclusion of syncytial cells in the stroma of the villi. 
 Gummata occasionally, but rarely, occur. The spirochseta pallida 
 can be demonstrated readily in the villi, but are rarely found in the 
 maternal decidua. 
 
 Tubercle of the placenta has been observed in conjunction with 
 phthisis of the mother, but is very rare. 
 
 No doubt most of these cases begin as a tuberculous endometritis 
 from which the intervillous spaces are infected secondarily, with 
 subsequent destruction of the epithelium of the villi, opening up of 
 the blood-vessels, and finally invasion of the fcetal blood by tubercle 
 bacilli. Cases have been described in which the primary site 
 appeared to be the chorionic villi.-"^ 
 
 Tumours of the Placenta.— All tumours of the placenta are 
 in reality derived from the chorionic villi, and almost all have the 
 structure of chorioangiomata. They are of very rare occurrence 
 and are usually single. The tumours are covered on the surface 
 with a layer of epithelium derived from the cells of Langhans' layer 
 or the syncytium, and beneath this there is a thin connective tissue. 
 The interior of the tumour is made up almost entirely of a number 
 of dilated vessels derived from the vessels of the villi and set in a 
 sparse connective tissue stroma. Tumours of a fibrous or fibro- 
 myxomatous structure, in continuity with the chorionic villi, have 
 also been observed. 
 
 Cysts of the placenta are sometimes seen, usually on the foetal 
 surface of the placenta near the centre. They are most frequently 
 formed by cystic degeneration of the cells of Langhans' layer, but 
 may occur in old infarcts or blood clots. 
 
 1 Schmoii and Kockel. Zioglers Beitriigc z. Path. Auat., 1891, Bd. 10, lift. 2, 
 s. 313. 
 
5i8 The Practice of Midwifery. 
 
 CEdema of the Placenta.— In some cases the placenta is found 
 unusually large, heavy, pale in appearance ; and the fluid which 
 oozes from it is not pure blood, but semi- serous in character. The 
 placenta still remains unusually large and heavy, even after drain- 
 ing. There has thus been actual hypertrophy of the villi, in 
 compensation for the impairment of their function. 
 
 QEdema of the placenta may arise from a fault either on the 
 maternal or the fcetal side. Thus it has been observed in con- 
 junction with general oedema from albuminuria, or with ascites 
 arising from hepatic obstruction on the mother's part. In other 
 
 Fig. 280.— Tuberous fleshy mole, blood being effused in masses under the 
 foetal surface of the membranes. 
 
 cases, it is associated with hydramnios or oedema of the foetus, and 
 then appears to be dependent on some anomaly causing obstruc- 
 tion in the foetal circulation. The blood circulating in the maternal 
 blood spaces may also be too watery, if the cause of the affection 
 is albuminuria or anaemia on the mother's side. (Edema of the 
 placenta is apt to lead to imperfect development or death of the 
 foetus, and to premature labour. 
 
 Thrombosis : Carneous Mole or Blood Mole — Thrombosis 
 of the placenta, leading to distension of portions of the maternal 
 blood space with clot, may result either from inflammation or 
 degeneration of the maternal or foetal portions of the placenta and 
 
Diseases of Decidua and Ovum. 
 
 519 
 
 especially from thrombosis of the maternal vessels (see p. 515). It 
 may also arise from partial detachment of the chorion or placenta 
 from the uterine wall as the result of uterine contractions set up 
 by violence, emotion, or other exciting cause of abortion. This 
 is apt to lead to the death of the embryo, which may entirely 
 disappear if it has only advanced to a very early stage of develop- 
 ment, or may remain of very small size in comparison to the size 
 of the whole ovum (Fig. 280). The amnial cavity may then shrink 
 up, or the amnion may be ruptured from the increased pressure, 
 and the liquor amnii escape. The foetal and maternal membranes, 
 infiltrated with clotted blood, or having isolated masses of clot in 
 their substance, then form a firm, 
 fleshy mass, called a carneous ov fleshy 
 mole. This may be retained in the 
 uterus for some weeks or months, 
 but is eventually expelled, usually 
 not later than the fifth month. In 
 other cases, the amnial cavity 
 remains patent, though the main 
 part of the mass retained in utero is 
 formed by the thickened membranes 
 (Fig. 281). The term "mole" (from 
 mold, a shapeless mass) is properly 
 applicable only where there is no 
 embryo. But it is often applied to 
 an ovum with thickened infiltrated 
 membranes, even though an amnial 
 cavity and small embryo may be 
 present, as in Figs. 280, 281. 
 
 The situation where blood is effused may be in the substance 
 of the chorion or decidua, or between them and the uterine wall, 
 into the chorio-decidual space. Frequently clot is found partly 
 infiltrated among the villi, and partly in rounded masses under the 
 chorion and amnion, which form prominences toward the amnial 
 cavity (Fig. 280, the tuberous fleshy mole of Berry Hart^). Another 
 frequent situation for blood to be effused, and to form clots, is 
 the decidual cavity. It rarely breaks through into the amnial 
 cavity. 
 
 The firm substance eventually expelled may have, at first sight, 
 very little resemblance to an ordinary ovum. Not only may an 
 early embryo have Ijeen dissolved, and the liquor amnii absorbed, 
 Ijut the amnion may have been ruptured, from the pressure of the 
 
 ' I'.eriy Ilmt, Journ. (Jbst. uiid Cyii. I'.iit. Kmp., May, 1!J02, Vol. I., p. 479. 
 
 Fig. 281. — Blighted ovum, showing 
 morbid enlargement of the 
 umbilical cord. 
 
520 
 
 The Practice of Midwifery. 
 
 Fig. 282. — Section of placental tissue from an early ovum retained four months 
 in utero after death of embryo, r, villus ; si', syncytium covering villus ; 
 sj), syncytium proliferating in branching processes. x 120. (From a 
 photograph.) 
 
 Fig. 283. — A portion of the section shown in Fig. 282 more highly magnified. The 
 letters signify the same as in Fig. 282. x 2i0. (From a photograph.) 
 
Diseases of Decidua and Ovum. 521 
 
 extravasation, or as a result of an early hydramnion, and the 
 embryo may have escaped unobserved. The chorionic villi, retain- 
 ing their attachment to the uterus, may continue to grow to some 
 extent, so that their bulk is large in comparison with the embryo, 
 if this can still be detected, A large portion of the mass, however, 
 generally consists of compressed clot, which may have become 
 decolorised. The nature of the carneous mole may always be 
 determined by recognition of the chorionic villi on microscopic 
 examination. They can generally be seen most easily if a small 
 portion of the mass is teased out on a slide and examined with a 
 low power. They may, however, also be seen in section, generally 
 embedded in the midst of fibrin, if sections be cut of the whole 
 mass. When a section is examined in this way it is often evident 
 that there has been, relatively, excessive proliferation of the 
 cellular substance of the chorion, with deficient development of its 
 vessels. 
 
 Blighted Ovum. — In other cases, again, the embryo perishes from 
 some cause or other, whether this be some morbid condition in 
 itself, the funis (see Fig. 281), the membranes (see Fig. 280, p. 518), 
 or the maternal organism. The blighted ovum with relatively 
 slight, or without any, thickening of the membranes, may then 
 sometimes be retained in a similar way for weeks or even months 
 before it is expelled. Generally it is expelled after two or three 
 months at the outside ; but in some cases it has been retained up 
 to what would have been the full term of pregnancy, and then 
 expelled. The term missed abortion is sometimes applied to such 
 retention of a dead ovum, on the analogy of " missed labour," the 
 term used when a dead fcetus is retained in the uterus after full 
 term. In general the microscopic appearance of a section of 
 carneous mole or blighted ovum shows more or less degenerated 
 villi, mixed up with clot. In some cases, however, a vegetative life 
 appears to continue for weeks or months, associated even with 
 active proliferation of the syncytium covering the villi, as shown 
 in Figs. 282, 283. In this way the absence of decomposition, 
 even after the ovum has been broken up for a long time, is 
 accounted for. 
 
 While there is no doubt that chorionic villi may remain per- 
 fectly fresh in appearance and free from decomposition for weeks 
 after the death of the embryo, while in contact with maternal 
 blood, it has been a disputed point whether they can continue to 
 grow under these circumstances. There seems to be no reason, 
 however, why they should not be nourished by the maternal blood, 
 without any footal circulation through them ; and, in hydatidiform 
 
522 The Practice of Midwifery. 
 
 degeneration, there is no doubt that they are so nourished. In 
 favour of the view that chorionic tissue may grow after death of the 
 embryo is the fact that, in a bhghted ovum, there is often found a 
 relatively considerable mass of placental tissue with a very minute 
 embryo (see Figs. 278, 280), or without any embryo in the closed 
 amuial cavity. And the appearance of active proliferation of the 
 syncytium four months after death of the embryo, shown in 
 Figs. 282, 283, appears to amount to a demonstration. 
 
 Symptoms and Diagnosis of Carneous Mole or Blighted Ovum. — 
 When the ovum has perished, the general signs of pregnancy, 
 especially the evolution of the breasts, subside. Vomiting of preg- 
 nancy is also frequently arrested or diminished. When the liquor 
 amnii has escaped or been absorbed, and a carneous mole has been 
 formed, examination of the uterus bimanually may show it to be 
 firmer than is usual in pregnancy, on account of the more solid 
 character of its contents. It must be remembered, however, that 
 firmness, as detected at any particular moment, may be due to 
 contraction of the uterus, and not to solid material within it. 
 When the embryo has been dead for some time, the size of the 
 uterus will be less than it should be in accordance with the date of 
 pregnancy, and the size remains stationary, instead of progressing 
 with the advance of pregnancy. This is the most reliable sign of 
 all ; and, in case of doubt .whether the ovum is still alive, it is 
 desirable, when symptoms are not too serious, to wait until time 
 enough has elapsed for it to be manifested. It should not be 
 forgotten that pregnancy sometimes commences in a period of 
 amenorrhoea, and that, on this account, the jDregnancy may be 
 supposed to be further advanced than it really is. During the 
 retention of the carneous mole, or blighted ovum, there is no proper 
 menstruation. Either amenorrhoea may persist, or there may be 
 a continuous or irregular sanguineous discharge. Sometimes the 
 colour of the discharge, instead of being that of bright blood, is 
 brownish, from the breaking up of clot. 
 
 Treatment. — In some cases the retention of a dead ovum appears 
 not to affect the health perceptibly. The case may then be left 
 to nature, in the exjDectation that the contents of the uterus will 
 be expelled within a few weeks, and delay is specially indicated, 
 if there be any doubt about the diagnosis. If there is a general 
 appearance of cachexia, or other sign that the health is suffering, 
 if there is haemorrhage or offensive discharge, or if the retention is 
 long protracted, the uterus should be emptied. A few full doses of 
 ergot may first be tried, and the sound may be passed into the 
 uterus. If these means do not bring about expulsion, the os may 
 
Diseases of Decidua and Ovum. 
 
 523 
 
 be dilated with a laminaria tent. This may be followed up, if 
 necessary, by dilatation with Hegar's dilators, under anaesthesia, 
 and digital evacuation of the uterus as described in Chapter XXIV. 
 
 Hydatidiform Degeneration of the Chorion. Vesicular or 
 Hydatidiform Mole. — In this disease the villi of the chorion 
 
 undergo proliferation with cystic degeneration, so that portions 
 of them become converted into cysts filled with a fluid containing 
 mucin, 0*29 per cent., as well as albumen, 0'61 per cent., and 
 
 Fig. 284. — Hydatidiform degeneration 
 of chorion. 
 
 Fig. 285. — Commencement of hydati- 
 diform degeneration of chorion. 
 
 resembling closely that of a serous transudation. The vesicles may 
 be of any size up to about lialf an inch, or even more. The general 
 appearance produced is shown in Fig. 284. It has been compared 
 to that of a bunch of grapes, but the mode of attachment of the 
 cysts is essentially different. Instead of being attached by stalks 
 to branches of a main stem, each cyst is attached by a pedicle to 
 another cyst, that again to another, and the final pedicle not to a 
 main stem, but to the convex surface of a membrane, the chorion. 
 The formation of the individual vesicles is due to the fact that the 
 proliferation of cells with degeneration does not aftect the villi 
 uniformly throughout, ]mi takes place at detached centres (Fig. 284). 
 
524 
 
 The Practice of Midwifery. 
 
 The altered portion of the villus grows into the vesicle ; the inter- 
 vening parts which remain normal, or comparatively normal, form 
 the connecting pedicles. 
 
 The microscopical appearances of a hydatidiform mole are as 
 follows : in the small and young cysts the stroma is composed of a 
 firbillary substance presenting a swollen appearance and containing 
 some spindle-shaped connective tissue cells with well-preserved nuclei. 
 In the larger cysts the ground substance has practically disappeared, 
 and is limited to a thin layer of fibrous tissue lining the covering 
 epithelium. The homogeneous mass replacing it, the result of 
 
 Fig. 286." 
 
 -Villi of mole, r, with proliferation of the walls of Langhans' 
 layer, c.l., and some traces of syncytium. i 
 
 dropsical degeneration of the tissues, contains the remains of a few 
 degenerate cell masses and a few leucocytes. The blood-vessels 
 have disappeared, and their remains can only be seen in the stalks 
 of the cysts. 
 
 Very characteristic changes occur in the epithelium on the 
 surface, consisting of marked proliferation of the cells of Langhans' 
 layer and of the syncytium and of the formation of vacuolar spaces 
 in the masses of syncytium. 
 
 The proliferating chorionic epithelium leads to an almost total 
 
 1 See Proc. Eoy. Soc. Med. London, March, 1909, Obstetrical Section 
 
Diseases of Decidua and Ovum. 525 
 
 destruction of the decidua with which it is in contact, and collections 
 of separated syncytial cells can be recognised lying embedded 
 among the muscle fibres or contained in the vessels of the uterine 
 wall often weeks after the expulsion of the mole. 
 
 In the majority of cases, the degeneration commences within 
 the first two months of pregnancy, before the placenta is fully 
 differentiated, and it then usually affects the whole of the convex 
 surface of the chorion. The embryo may have disappeared 
 altogether, or may be found in a blighted condition, if it has 
 reached a somewhat later stage of development. When the 
 hydatidiform change commences after the formation of the placenta, 
 it generally affects only the placental site. In the great majority 
 of cases, the foetus perishes before or after the formation of the 
 mole has begun, but in some instances, in which only a few 
 lobes of the placenta have become degenerated, or in which the 
 degeneration, though more widely spread, is only partial, a healthy 
 foetus has been found in combination with a vesicular mole. 
 
 Occasionally signs of commencing hydatidiform degeneration 
 can be recognised in the placenta of an ordinary early abortion. 
 Not infrequently a twin foetus is associated with a vesicular mole. 
 In some cases the tendency to active proliferation of the diseased 
 villi is shown by their invading the uterine wall. They appear to 
 reach the uterine sinuses by growing into them from the maternal 
 blood spaces, as the normal villi sometimes do. But they sometimes 
 penetrate much more deeply into the uterine wall than normal villi 
 ever do, and may reach quite close to the peritoneal surface. In 
 some cases the uterine wall becomes broken down, in consequence 
 of the pressure produced by their proliferation ; the muscle fibres 
 become destroyed and rarefied and replaced by the diseased mass, 
 the so-called malignant mole. If this process reaches near to the 
 outer surface, peritonitis may be set up, or even rupture of the 
 uterus may occur. This tendency to a semi-malignant proliferation 
 must be associated with the occurrence of deciduoma malignum so 
 far more frequently as a sequence of vesicular mole than of an 
 ordinary delivery or abortion. 
 
 Occasionally secondary metastatic growths are met with in the 
 vagina associated with what appears to be an ordinary hydatidiform 
 mole i7i liter o. 
 
 No certain histological characters are at present known by which 
 it is possible to recognise a malignant mole, although the deep 
 penetration of the villi and the presence of numerous masses of 
 syncytial cells in the muscle tissue are suspicious characters. 
 
 A vesicular mole sometimes grows to so great a size as to enlarge 
 
526 The Practice of Midwifery. 
 
 the uterus as much as pregnancy at full term. More frequently 
 the uterus is not enlarged beyond its size at the fifth or sixth 
 month of pregnancy. 
 
 Causation. — The causation of the degeneration is not fully 
 understood. The formation of the vesicular mole has sometimes 
 been repeated in the same woman, and hence it is inferred that the 
 condition of the mother may have something to do with it. Thus 
 inflammation of the decidua may be a predisposing cause, and this 
 condition has actually been found in conjunction with the vesicular 
 mole. Again, Bright's disease, ansemia, or chlorosis in the mother 
 has appeared, in some instances, to be the predisposing cause. 
 The two main theories as to its causation are that it is due to 
 some primary affection of the ovum or that it is due to pathological 
 changes in the decidua and interference with its blood supply. If 
 some defect on the part of the ovum is the cause, it is possible that 
 this may be derived either from the mother or from the father. 
 
 According to some authorities, the frequent association of cysts of 
 the corpora lutea is an important etiological factor. They are 
 usually accompanied by an excessive formation and dissemination 
 of lutein cells in the stroma of the ovary, and those writers who 
 regard the corpus luteum as a body with an internal secretion pre- 
 siding over the early nutrition and embedding of the ovum regard 
 the excess of lutein tissue as the cause of the hydatidiform degene- 
 ration. It is more likely, however, that the same cause which leads 
 to the proliferation of the chorionic epithelium produces the 
 excessive proliferation of the lutein cells in the ovary. A more 
 probable explanation of the origin of a vesicular mole is that which 
 assigns it to changes in the decidua, which at first is often thickened 
 and exhibits well-marked inflammatory processes. The efiect which 
 the age, multiparity, and certain diseases of the mother appear to 
 have and the fact that a woman may have a hydatidiform mole in 
 several successive pregnancies is evidence in favour of the decidual 
 origin. The changes in the decidua may be associated with some 
 fault of development in the foetal portion of the ovum. This is the 
 readiest way of explaining those cases in which there are twin ova, 
 of which one is developed normally, while the other undergoes 
 vesicular degeneration. 
 
 As it arises from the chorionic villi, the vesicular mole is neces- 
 sarily in all cases the product of conception ; it does not, however, 
 necessarily imply a recent conception, for the diseased structure 
 may be retained for some time within the uterus, and afterwards 
 grow to a considerable size. 
 
 In some cases a foetus has been born at full term, and a vesicular 
 
Diseases of Decidua and Ovum. 
 
 527 
 
 mole has been expelled some months later, when no second con- 
 ception has been thought possible. This may be explained either 
 on the ground that there was a twin ovum which had undergone 
 degeneration, or that a portion only of the vilU of the first ovum 
 
 Fig. 287. — Uterus containing a vesicular mole.i (Univ. Coll. Hosp. Med. 
 School Mus.) 
 
 had undergone this change, and had been retained in consequence 
 of the close connection which they form with the uterine wall. 
 In other cases again a vesicular mole has been expelled first, and 
 a living ffjotus some months after. These again may have been 
 
 1 See I'roo. Uoy. Soc. Med. London, March, 1909, Obstetricnl Section. 
 
528 The Practice of Midwifery. 
 
 instances of twin pregnancy. It does not appear that a piece of 
 normal placenta retained in the uterus at the expulsion of the foetus 
 can afterwards undergo the vesicular degeneration. Some have 
 maintained the theory that the origin of the vesicular degeneration 
 is the previous death of the foetus. This seems to be disproved by 
 the cases, which are fairly numerous, in which a living foetus has 
 been associated with partial vesicular change. When the degenera- 
 tion of the placenta is general the foetus must inevitably perish as 
 a secondary result. It has been suggested that the way in which 
 the death of the embryo acts in causing a vesicular mole is that the 
 influence of the foetal thyroid in causing embryonic tissue to develop 
 into normal connective tissue is removed. In a case of partial 
 vesicular degeneration of the chorion, diffused throughout the whole 
 placenta, which I met with, associated with a living foetus at five 
 months, the foetal thyroid was specially examined from this point 
 of view, and reported on by a committee of the Obstetrical Society 
 of London.^ The thyroid was found to be quite healthy and 
 normally developed. 
 
 The condition is a rare one, being met with about once in 2,000 
 pregnancies, but has been met with in an extra-uterine gestation. 
 
 Symptoms and Course. — At first the symptoms may not differ 
 from those of ordinary pregnancy. After two or three months the 
 enlargement of the uterus and of the abdomen is often more rapid 
 than in normal pregnancy, but this is not invariably the case. When 
 it is so, constitutional disturbance may be set up by the unusual 
 tension, and uterine contractions, threatening abortion, may be 
 excited. Frequently the first thing which attracts attention is a 
 sanguineous discharge, which usually sets in between the end of the 
 first and the third month of pregnancy. This may consist either 
 of pure blood, or of a more watery fluid, compared to red-currant 
 juice, due to the rupture of some of the vesicles. Sometimes 
 clusters of vesicles come away with the discharge, and the com- 
 parison is then to white currants floating in red-currant juice. The 
 haemorrhage may greatly exhaust the patient, or even lead to a 
 fatal result. Eventually, usually at the fourth or fifth month, the 
 uterus may either expel the great mass of the mole, leaving other 
 more adherent portions behind, or it may completely empty itself. In 
 the former case, very considerable haemorrhage may occur or recur ; 
 in the latter, involution of the uterus takes place as after abortion or 
 delivery. Sometimes the case simulates one of accidental haemor- 
 rhage, if bleeding has taken place, the uterus is much distended, 
 and clot only can be felt on passing the finger through the cervix. 
 
 1 Trans. Obst. Soc, London, 1903, Vol. XLV., p. 101. 
 
Diseases of Decidua and Ovum. 
 
 529 
 
 It must be remembered that the lower segment may be occupied by 
 clot, and the mole lie above. 
 
 Diagnosis. — An absolutely certain diagnosis can only be made 
 when some of the vesicles are discovered in the discharge, or the 
 mole is felt by the finger passed through the cervix. A probable 
 diagnosis may be based upon the following points : the size of the 
 uterus not agreeing with the duration of pregnancy, especially a 
 too rapid increase of size ; presence of haemorrhage or " currant- 
 juice" discharge; and absence of any tangible parts of the foetus, 
 
 Fio. 288. — Section of uterine wall and part of mole, showing : muscle 
 fibres, m ; small celled infiltration in spongy layer and deepest part of 
 compact layer of decidua, s.ci. ; the fibrin layer of Nitabuch, ni ; the 
 cell layer of proliferating epithelium of mole, c.l.^ 
 
 of any ballottement, or signs of foetal life, when the uterus has 
 reached a size at which these ought to be discoverable in normal 
 pregnancy. The uterus often has a peculiar doughy feel, but does 
 not fluctuate as in a case of hydramnios, and is markedly tender 
 on palpation. In partial degeneration of the placenta with a living 
 foetus a certain diagnosis is practically impossible. 
 
 Pror/nosis. — The result is generally favourable, if adequate treat- 
 ment is undertaken early enough. The danger chiefly depends 
 upon the amount of blood lost and the risk of the recurrence of the 
 
 ' Sey Proc. Hoy. Sjc. Med., London, iMarch, lyo'J, Obstetrical Section. 
 
 M. 84 
 
530 The Practice of Midwifery. 
 
 bleeding. There is a risk also of septicaemia and other post-jyartum 
 disturbances, to which the loss of blood and the operative inter- 
 ference -which is so often necessary renders the patient more liable. 
 The rarer cases, in which the growth deeply penetrates the uterine 
 wall in a quasi-malignant manner, are always dangerous, since they 
 involve the risk of peritonitis or rupture of the uterus. 
 
 Chorion-epithelioma (see Chapter XL.) has been observed after 
 vesicular moles in a very much larger proportion of cases than after 
 normal pregnancy or abortion. Thus, of the first ninety cases 
 recorded, forty -nine followed a vesicular mole, which is a very rare 
 disease. 
 
 Treatment. — When a positive diagnosis has been made by in- 
 spection of some of the vesicles the uterus should be evacuated 
 as soon as possible. The only exception to this rule is the rare 
 case in which the presence of a living foetus is detected in addition 
 to the mole. If the haemorrhage is not serious the physician may 
 then defer interference in the hope of saving the foetus. If the 
 diagnosis is only probable, the decision in favour of evacuating 
 the uterus or otherwise must depend upon the amount of haemor- 
 rhage, and its effect upon the patient's condition. It is to be remem- 
 bered that the vesicular mole is a very much rarer condition than 
 ordinary pregnancy with haemorrhage, due to threatened abortion. 
 
 If the OS is dilated, and the expulsion of the mole has commenced, 
 the evacuation of the uterus may be assisted by manipulation. If 
 not, supposing that evacuation is resolved upon, the cervix must 
 be dilated first by a tent if necessary, and afterwards by Hegar's 
 dilators (see Chapter XXIV.), or may be plugged with gauze, or 
 hydrostatic dilators may be employed if the uterus is very large, 
 until it will admit two or three fingers. The patient should be 
 placed under an anaesthetic for the evacuation. A full dose of ergot 
 may be administered a little before, or ergotin may be injected 
 subcutaneously at the time of operating, in order to gain the assist- 
 ance of the uterus in expelling the mass and diminish haemorrhage. 
 
 The patient is placed in the dorsal position for the operation, 
 and, according to circumstances, either the whole hand or the half- 
 hand, not including the thumb, is passed into the vagina. The 
 bladder is to be emptied previously, and the other hand, placed 
 upon the abdomen, presses down the fundus upon the fingers in 
 the vagina. In general it is sufficient to pass two fingers into the 
 uterus to scoop out the vesicular mass. After the lower part is 
 removed, the contracting fundus, aided by the external pressure, 
 brings more and more within reach of the fingers, until the interior 
 of the fundus is reached, and the whole cavity evacuated. If, 
 
Diseases of Decidua and Ovum. 531 
 
 however, the uterus is very greatly enlarged and the cervix wide, 
 four fingers or the whole hand may be passed into its cavity. In 
 other cases again, in which the vagina is narrow, the evacuation 
 may be effected without more than two fingers being passed into 
 the vagina, the uterus, toward the end of the process, being pushed 
 down close to the outlet in a position somewhat of anteversion. I 
 have known the lower part of the uterus to be filled with a mass of 
 clot ; so that it was only after the evacuation of a large part of this 
 that the vesicular mole could be reached, and the diagnosis 
 positively completed. 
 
 If the vesicles are not easily detached from the uterine wall, 
 care must be taken not to use too much force in detaching them. 
 Otherwise, in a case in which the growth has invaded and eroded 
 the uterine wall, a rupture reaching the peritoneal surface might 
 be produced. The operator should carry the separation only so 
 far as he can effect it with the pulp of the fingers, not using the 
 nails. If vesicles are left embedded in the uterine wall, they will 
 probably be destroyed by pressure, if the cavity is once thoroughly 
 evacuated, and a firm contraction secured. After the operation, 
 a course of ergot should be given to assist involution. If it has 
 not proved possible thoroughly to clear the cavity, or if an offensive 
 discharge from it appears, the uterus should be periodically washed 
 out with an antiseptic solution.^ If hsemorrhage persists, the 
 cavity of the uterus should be explored after an interval (curetted 
 and the scrapings examined microscopically), while the possibility 
 of chorion-epithelioma following must be borne in mind. 
 
 Hydramnios, or Hydrops Amnii. — The quantity of liquor 
 amnii varies considerably in different cases. When it is so much 
 in excess as to cause constitutional disturbance to the patient, the 
 condition is called Hydramnios. 
 
 In some cases the amount of fluid in the uterus is very great, as 
 much as thirty to sixty pints having been met with. In most cases 
 the accumulation of the fluid takes place gradually, but in a few 
 cases, eight of 623 observed by Lion, it occurs rapidly.^ 
 
 The accumulation may occur quite in the early months of 
 pregnancy, and no doubt inlays some part in the production of the 
 so-called hsematomatous mole. 
 
 Causation. — In some cases, hydramnios has been observed in 
 conjunction with certain morbid conditions in the mother, such as 
 
 1 Solution of perchloride of mercury (1 in 4,000) ; Tinct. lodi, 3ij, ad aq. Oj : or 
 lysol, 1 per cent., may be used. 
 
 ^ Lion, Ai'chiv de Tocol et Gyn., ]8y7. Bd 23. 
 
 34—2 
 
532 The Practice of Midwifery. 
 
 leucaemia, chronic anfemia, nephritis, and grave heart disease, 
 which ajDpear to have something to do with the causation. In 
 general, however, the fault is rather on the foetal side. This is 
 shown by the fact that hydramnios is specially frequent in twin 
 pregnancy, but, as a rule, only one of the ova is affected in this 
 way. Again, in a large proportion of cases (about 75 per cent, 
 according to McClintock), the foetus has been found to be 
 of the female sex. The foetus is rarely quite perfectly 
 developed or well nourished, and in a considerable proportion of 
 cases is born dead or dies soon after delivery. This may be 
 due in part to the premature delivery which is common in such 
 eases. A considerable number, however, of the foetuses (15 
 per cent, according to McClintock) are dead and macerated before 
 delivery. 
 
 In about 50 j)er cent, of the cases the placenta is found in 
 some way anomalous, either unusually large or oedematous, the 
 result of some interruption to the placental circulation. The 
 causation, therefore, probably varies in different cases. (1) It may 
 result from an inflammation of the amnion itself, the effect of 
 which is sometimes shown by adhesions of the amnion to the 
 foetus, or bands traversing the amnial cavity. The cells lining 
 the amnion, altered by inflammation, may determine an exces- 
 sive transudation tow^ard the amnial cavity. (2) In the common 
 cases in which hydramnios is associated with some fcetal deformity, 
 as in 19 of 23 cases recorded by Ahlfeld, the deformity is probably 
 generally the primary cause. Thus in extroversion of the viscera 
 the vessels are less covered than usual, and allow more ready 
 transudation. In abnormalities of the circulatory system, there is 
 generally some obstruction, and excessive pressure in the placental 
 vessels, stenosis or thrombosis of the umbilical vein, or torsion of 
 the cord. Cirrhosis of the foetal liver, syphilitic or non-syphilitic 
 valvular disease of the heart, and stenosis of the aorta, pulmonary 
 artery, or ductus arteriosus are among the pathological changes 
 which have been recorded. (3) When hydramnios is associated 
 with twin pregnancy, the twins are frequently developed from one 
 ovum, having a single chorion, the placenta being single ; the 
 vessels of the twins communicating, about one-twentieth to one- 
 fifth of the whole placenta being common to the two. The 
 hydramnios is explained on the ground that such twins have often 
 some deformity, or, at any rate, abnormality in the placental 
 circulation. For example, the umbilical cord of the affected twin 
 may be velamentous. According to Wilson,^ the following is the 
 
 1 Trans. Obst. Soc. London, 1899, Vol. XLL, p. 235. 
 
Diseases of Decidua and Ovum. 533 
 
 explanation of the hydramnios in these cases. The twin whose 
 vessels run a shorter or more direct course obtains an undue share 
 of blood from the placenta. In consequence it grows faster than 
 the other, and its heart becomes hyj)ertrophied. This leads in 
 some way to an increased uptake of fluid in the placenta. The 
 kidneys also become hyper trophied, and there is increased exudation 
 certainly from the kidneys, and probably also from the skin and 
 the portions of placenta belonging to the affected foetus. The 
 result is hydramnios of the larger twin rapidly produced about the 
 fourth or fifth month, and ending usually in premature delivery 
 before the end of the seventh month. The smaller twin has a 
 normal or deficient quantity of liquor amnii, and its heart is 
 sometimes found to be thin. Kiistner^ maintains that there is 
 generally some obstruction in the placental circulation of one twin 
 which leads to increased work on the part of its heart and resulting 
 cardiac hypertrophy. The increased cardiac action in its turn leads 
 to a gradual extension of its placental territory, and so to its better 
 nutrition. Finally, the hypertrophied heart is unable to meet the 
 demands upon it, it begins to fail, and thus result venous stasis, hyjjer- 
 trophy and later atrophy of the liver, dropsy, and hydramnios. Wilson 
 found that, out of 101 cases of hydramnios, 46 occurred in twins, 
 and 4 in triplets. Of the 46 twin cases, at least 2'2 appear to have 
 been of the unioval variety, although twins developed from different 
 ova are seven times as common as unioval twins. (4) The rarest 
 form seems to be that due to disease of the mother, such as syphilis 
 or antemia. In this case there may be general dropsy of the 
 placenta, as well as hydramnios. 
 
 Symptoms and ■ Course. — The symptoms are the effect of the 
 mechanical pressure due to the rapid increase in size of the 
 uterus. This increase generally does not become manifest before 
 the fifth month, but it may go on so rapidly that the uterus is 
 soon much larger than it usually is at the full term of pregnancy. 
 The symptoms are then similar to those produced by a large ovarian 
 tumour. There is pain from tension and the weight of the 
 abdominal contents, dyspnoea and palpitation from interference with 
 the diaphragm, and disturbed digestion, also from the effect of 
 pressure. The urine is often scanty, and when tension is very 
 great, it may become albuminous. There is often oedema of feet 
 and legs, and this may extend to the vulva and lower part of 
 abdomen. Often spontaneous relief is afforded by the occurrence 
 of premature labour. The first stage of labour is apt to be tedious 
 
 1 Kustner, Arch. f. Gyn., 1870, Bd. 10, s. 134, Hft. 1, 1883, Bd. 21, s. 1, Hffc. 1 ; 
 Werth, Arch. f. Gyn,, 1882, Bd. 20, s. 353, Hft. 3. 
 
534 The Practice of Midwifery. 
 
 from the over-distension of the uterus. From the same cause, 
 there is a greater proneness than usual to post-partiim haemorrhage, 
 as there is in the case of twins. 
 
 Diagnosis. — There may be difficulty in diagnosis when the 
 collection of fluid is very great, and the foetus small or dead, so 
 that the foetal heart and movements cannot be detected. I have 
 met with several cases in which the uterus had been tapped in the 
 belief that it was an ovarian cyst, not always with the result of 
 bringing on labour. The softened state of cervix and expansion of 
 lower segment of uterus, as felt j^er vaginam, combined with a 
 history of amenorrhoea, will generally prove pregnancy. Frequently 
 also, although the distended uterus may give a fluid wave or 
 thrill as distinct as that to be detected in an ovarian cyst, the 
 firm body of the foetus may be felt on dipping for it with the 
 fingers in the midst of the fluid mass, especially if the patient be 
 placed upon the side or in the knee-elbow position. The difficulty 
 which sometimes arises is that of distinguishing between hydram- 
 nios and an ovarian cyst complicating pregnancy. For although 
 the body of the pregnant uterus may generally be made out as 
 separate from the ovarian cyst, this may not be possible if disten- 
 sion is extreme. The most valuable distinction of all is to be found 
 in the fact that, notwithstanding the over-distension of the uterus, 
 the intermittent uterine contractions, a most important sign of 
 pregnancy (see p. 180), may still generally be detected in it, 
 especially if excited by manipulation. A hardening of the wall of 
 the tumour is thus produced, and if it can be made certain that 
 the hardening extends to the whole tumour, it is proved that the 
 whole of it is uterus. Another useful distinction may often be 
 found in the fact that, when the uterus is so distended as to simulate 
 a large ovarian cyst, there is generally some yielding of the cervix, 
 more than exists normally at the fifth or sixth month of pregnancy, 
 so that the finger may be pressed into it far enough to reach the 
 membranes. 
 
 In minor cases of hydramnios, the distinction has to be made 
 from twin pregnancy. This may be done by obtaining the positive 
 signs of the existence of twins (see p. 372), in the one case, or by 
 noting the altered consistency of the uterus from the excess of fluid 
 within it in the other, and the fact that, in the case of hydramnios 
 of one of twins, the fluid thrill is not transmitted to all parts of 
 the uterus when the sac of the healthy foetus is palpable as well as 
 that of the hydramniotic foetus. 
 
 Treatment.— In mild cases, all that can be done is to prescribe 
 rest, and the support of the uterus by an abdominal belt. If serious 
 
Diseases of Decidua and Ovum. 
 
 535 
 
 This 
 
 constitutional disturbance is caused, labour must be induced, 
 was necessary in 20 per cent, of Wilson's cases. 
 
 It is desirable, if possible, to wait until the child is viable. 
 Sometimes, however, it is necessary to interfere before this, and 
 there need be less reluctance to do so from the fact that, in such a 
 case, there is little chance of a healthy child surviving. 
 
 The foetal mortality is about 25 per cent, in chronic cases, and 
 much higher than this in acute cases. The danger to the mother 
 results from the over-distension of the uterus, the resulting risk 
 
 Fig. 289. — Placenta velamentosa. 
 
 of i)ost-imrtum hgemorrhage, and the necessity for operative 
 interference. 
 
 If there is a hope of saving the child^ the induction of labour 
 may be commenced by passing an elastic bougie into the uterus in 
 the mode hereafter to be described (see Chapter XXXI.), or by 
 introducing a small dilating bag. If not, there is no object in 
 keeping the membranes intact. The membranes may then be 
 ruptured by passing a sound or stylet through the cervix. In the 
 first stage of labour, when it comes on spontaneously, it will often 
 be necessary to stimulate the over-distended uterus to contraction 
 by rupturing the membranes early and evacuating the liquor 
 amnii, if this has not already been done. After delivery, a dose of 
 ergot should be given, and special care taken to guard against post- 
 partum hgemorrhage. 
 
536 
 
 The Practice of Midwifery. 
 
 Deficiency of Liquor Amnii. — Deficiency of liquor amnii in 
 the later months may lead to protraction of the first stage of 
 labour, the fluid being insufficient to form a properly bulging bag 
 of membranes. 
 
 As the amniotic cavity is formed within a solid mass of cells, 
 if it does not develop properly, adhesions may exist between the 
 cells of the amnion and those of the embryonic plate of the foetus, 
 and as growth proceeds these may become drawn out and form 
 amniotic bands, which play an important part in the production of 
 foetal deformities and intra-uterine amputation of 
 limbs. 
 
 Anomalies of the Funis. — Velamentous Inser- 
 tion. — A completely central insertion of the cord 
 is not at all common, occurring in only 3 per 
 cent, of all placentfe. In 56 per cent, it is 
 excentrically situated, in 31 per cent, near the 
 edge of the placenta, and actually at the margin 
 in some 5 per cent. The most important 
 anomaly in the insertion of the cord is that in 
 which it has its attachment, and breaks up into 
 its constituent vessels on tbe membranes some 
 distance from the edge of the placenta, the so- 
 called placenta relamentosa. This occurs in 
 about '5 per cent, of placentae, and is especially 
 frequent in cases of placenta prsevia and with 
 multiple pregnancies. The most probable ex- 
 planation of this anomaly is that put forward 
 by V. Franque,^ viz., that in some cases the 
 decidua reflexa is as vascular as, or even more 
 vascular than, the neighbouring part of the 
 decidua basalis, and in these conditions the 
 vessels in the abdominal stalk may have a free vascular connection 
 with the decidua reflexa, and in this position the umbilical cord may 
 ultimately develop. When this is the case the umbilical vessels will 
 have primarily an attachment to a portion of the decidua which 
 finally becomes applied to the chorion. The vessels of a i^lacenta 
 velamentosa may be torn or j)ressed upon during labour, and some 
 18 per cent, of the children in these cases are born asphyxiated. 
 
 Knots. — A knot in the funis is produced by the foetus passing 
 through a loop in it. This occurs either in the early months of 
 
 1 V. Franque, Zeitschrift f. Geb. u. Gyn., 1894, Bd. 28, ss. 293—348. 
 
 Fig. 290.— Knot of 
 umbilical cord. 
 
Diseases of Decidua and Ovum. 
 
 537 
 
 ■ pregnancy or only in labour. It is favoured by the funis being 
 unusually long, so that a loop is readily formed towards the lower 
 part of the uterus. Complex knots may be produced if the foetus 
 passes twice or more through the loop. In general, the knot is not 
 drawn so tight as to obstruct the circulation, and it has then little 
 practical effect. If the knot is formed only in labour, generally no 
 mark remains upon the funis when it 
 is undone. If it is of longer standing, 
 the gelatinous substance of the cord 
 is found to have disappeared at the 
 points exposed to pressure. In rare 
 cases, the knot becomes drawn so tight 
 that the fcetus perishes, generally in 
 the earlier months of pregnancy. 
 
 Coils. — The funis may be coiled 
 once, twice, or oftener, round the 
 neck of the foetus, or round the limbs. 
 A coil round the neck may be regarded 
 as the first stage toward the formation 
 of a knot in the cord, the head only, 
 and not the whole fcetus, having passed 
 through the loop. Coils, like knots, 
 are most likely to be formed when 
 the funis is longer than usual. Coils 
 round the neck generally come into 
 practical operation only during labour. 
 They then shorten the length of funis 
 available, and so may cause obstruc- 
 tion to labour, or detachment of the 
 placenta. These difficulties in labour 
 will be considered hereafter (see 
 Chapter XXVIII.). They may also 
 cause death of the foetus by strangula- 
 tion, when put on the stretch with the advance of labour. In rare 
 cases, a coil or coils round the neck become so tight in the course 
 of pregnancy as to destroy the fcetus. Sometimes even the head 
 is nearly amputated by the constriction. It is believed that intra- 
 uterine amputation of limbs also may sometimes be produced by 
 constriction through a coil of funis, but it is probably due much 
 more frequently to a band resulting from amnial adhesions.-^ 
 
 Fig. 291. — Coiling of cord round 
 neck of foetus. 
 
 1 V. Fraii<|u<^, Zeilsehriffc f. Geb. u. Gyn,, 1894, Hd. 28, ss, 29.S— 8-18. 
 
538 The Practice of Midwifery. 
 
 Torsion. — It has already been explained that the vessels of the 
 funis, originally straight, become gradually twisted as pregnancy 
 advances, from the rotations of the fcetus in one direction prepon- 
 derating over those in the other direction. The same cause acting 
 in a more sudden or rapid manner, may cause actual torsion of the 
 whole funis to such an extent that the calibre of the vessels is more 
 or less obstructed. The torsion is generally most marked near 
 the umbilicus, Wharton's jelly being thinner at that part, and 
 
 ^ 
 
 /^'S^ 
 
 ^o^^^- 
 
 Fig. 292.— Torsion of the cord. (Univ. Coll. Hosp. Med. School Mus.) 
 
 the resistance of the funis being, therefore, less. The torsion 
 may affect the whole cord or only a circumscribed part of it, 
 and in the latter case it is possible for the cord to be twisted 
 entirely through. This only occurs, however, with dead or 
 macerated foetuses. 
 
 It may be produced either after the death of the foetus or during 
 its life. In the former case, it must be due solely to rotations 
 produced by movements of the mother and external pressures. It 
 will take place more readily from the fact that the firmness of the 
 funis, and its consequent resistance to torsion, is diminished by 
 death. Torsion of the funis during the life of the fcetus may be 
 due both to fcetal movements, and to maternal movements and 
 
Diseases of Decidua and Ovum. 539 
 
 pressures, probably for the most part to the former. By causing 
 obstruction of the vessels it may lead to the death of the foetus. 
 In individual cases, it is difficult to determine whether the torsion 
 is the consequence or the cause of the death of the fcetus. In a 
 considerable proportion of the cases there is evidence that it 
 occurred after the death of the foetus, first because the degree of 
 torsion is much greater than would be sufficient to kill the fcetus, 
 and secondly, because other sufficient cause of its death, such as 
 the presence of syphilis, is discovered. On the other hand, the 
 facts that it is commoner with male than with female children, that 
 the twisting of the cord cannot be undone, and that children are 
 not infrequently born alive' with marked torsion of the cord, are 
 in favour of its ante-mortem occurrence. 
 
 Anomalies and Diseases of the Fcetus. 
 
 The foetus is subject to innumerable faults of development, and 
 to a considerable number of diseases. For these, the reader is 
 referred to works on malformations, and on diseases of children.^ 
 Space will allow here only a brief reference to a very few conditions 
 which have a special obstetric interest. 
 
 Intra-uterine Amputation of Limbs. — Limbs occasionally 
 present the appearance of having been amputated, the stump 
 having healed over, with what appear to be the rudiments of fingers 
 or toes attached to the end of it. At one time the view was held 
 that these were the result of amputation by constriction by the 
 umbilical cord, but this is certainly not the case, and more recent 
 observations tend to show that they are either the result of mal- 
 development or of pressure by amniotic bands due to imperfect 
 formation of the amniotic cavity and acting at a very early stage 
 in the development of the embryo. 
 
 Congenital dislocations, so called, affect most frequently the 
 hip-joint, and, next to that, the shoulder. In most cases, at any 
 rate, the condition is really due to a fault of development rather 
 than to dislocation, the articular cavities being formed in an 
 abnormal position or undeveloped, while the actual dislocation may 
 take place in some instances during the act of birth. 
 
 1 See Forstcr, Misbildungen der Menschen, 1801 ; Ahlfeld, Die Misbildungen der 
 Menschen, mit Atlas, 1880; Noble Smith, The Surgery of Deformities; Baliantyne, 
 Antenatal I'athology and Hygiene : The Foetus, 1902, The Embryo, li)04 ; Taruffi, 
 Storia della Teratologia, Bologna, 1881 — 1894. 
 
540 The Practice of Midwifery. 
 
 Intra-uterine Fracture of Bones.— Apart from the fracture 
 of bones which may arise in difficult labour, whether completed 
 naturally or artificially, cases of intra-uterine fracture have also 
 been observed. The limbs, as being the parts most exposed, are 
 chiefly affected, and more especially the thighs. Cases have 
 been recorded in which as many as thirty to a hundred fractures 
 have been met with, affecting almost all the bones. ^ 
 
 Possibly such cases are to be explained as instances of excessive 
 fragility of the bones and excessive foetal movements or externa 
 violence. Other cases, however, accompanied as they often are by 
 malformations of other parts of the body and the presence of scars 
 over the sites of the fractures, can only be explained by supposing 
 that they are the results of mal-developments having their origin 
 in amniotic adhesions or bands the result of faulty develoj^ment 
 from formation of the amniotic cavity. Dislocation is apt to be 
 added to the fractures, from the effect of the traction of muscles 
 acting upon the separated fragments. In other cases, separation of 
 the bones results, not from actual fracture, but from failure of 
 union between different centres of ossification or separation of 
 epiphyses, sometimes the result of inflammation. This may result 
 from syi^hilis, as well as from rachitis. 
 
 Anencephalus. — In this abnormality the brain is absent, and 
 the head consists only of the face and base of the skull, the bones 
 forming the vault being rudimentary. It is developed either from 
 the bursting of a hydrocephalus or as a result of amniotic pressure 
 or amniotic bands. It is difficult to regard the first cause as an 
 important one when we remember that in these cases as a rule the base 
 of the skull remains convex and the fact that the eyes are occasion- 
 ally perfectly formed. It is probable that cases of complete absence 
 of the cranium are due to amniotic pressure, while those of partial 
 anencex3haly are the result of amniotic adhesions interfering with 
 the due development of the parts.^ The body is usually well 
 developed, and the shoulders broad. The child may live for a few 
 hours or even for several days after delivery, for sixteen in one 
 recorded case.^ 
 
 Deficient Closure of Abdominal ^A/'alls, or Exomphalos. — In 
 
 the early stage of foetal existence a portion of the intestine normally 
 projects outside the abdomen at the umbilicus. Sometimes there 
 
 .1 Linck, Archiv f. Gyn.. 1887, Vol. XXX., s. 261, Hft. 2 ; Chaussier, Bull. Fac. de 
 Med. de Paris, 1813, Vol. III., p. 301. 
 
 2 Ballantyne, Antenatal Pathology : The Embryo, 1904, p. 348. 
 
 3 Ross, Trans, Obst. Soc. London, 1868, Vol. IX.. p. 31. 
 
Diseases of Decidua and Ovum. 541 
 
 is a failure in the natural process by which this portion of intestine 
 is drawn into the abdominal cavity and the abdominal walls are 
 closed in. A kind of hernial sac then exists at the time of birth, 
 generally covered only by amnion, as the peritoneum is usually 
 wanting. The size of the sac varies greatly ; sometimes it contains 
 only some coils of intestine, frequently a part of the liver also. 
 Sometimes nearly the whole of the abdominal contents, including 
 the stomach, liver, spleen, and even the heart and lungs when the 
 deficiency involves the thorax, are outside the body. The funis is 
 generally attached towards the summit, or near the lower part, of 
 the protuberant mass, and the vessels, often only a single artery 
 and vein, divide and spread out over the amnion. Sometimes the 
 funis is abnormally short or 
 even absent. The condition 
 is often combined with mal- 
 formations in other parts of # 
 the body. 
 
 When the extruded mass of 
 viscera is large, it may form i y 
 
 the presenting part, and it ,/ .r- 
 
 may then give rise to some -" 
 
 difficulty in diagnosis. The -v^/^ 
 
 child will generally be inca- 
 pable of surviving. 
 
 Eetroflexion of the spine 
 and absence of certain of the ^m. 293.-Spirochaeta pallida from blood 
 
 . smear. One red corpuscle is shown. 
 
 lumbar vertebrae is very 
 
 common, the foetus being in a position of marked opisthotonos. 
 
 Postnatal life as a rule is very short. 
 
 Hydrocephalus, Spinabifida, Meningocele, Encephalocele, and 
 Tumours — These conditions will be described in Chapter XXVIII. 
 under the head of obstructions to labour. 
 
 Syphilis. — Syphilis in the fcetus may be inherited from the 
 mother, from the father and the mother, or from the father, the 
 mother either developing secondary symptoms, or showing no signs 
 of the disease and yet being immune and not capable of infection 
 from her syphilitic child. It may also be derived from the mother 
 if she be infected with syphilis between probably the end of the 
 first and the end of the seventh month of pregnancy. Syphilis is 
 the commonest cause of repeated abortions and miscarriages, and 
 may kill the foetus either by the affections of the placenta which have 
 
542 
 
 The Practice of Midwifery. 
 
 already been described or by its direct effect upon the foetus itself. 
 It is often associated with hydramnios. 
 
 When the foetus has perished before birth it is often macerated 
 and wasted, and may or may not show definite evidence of 
 syphilis. 
 
 Even when born alive it may be puny and ill nourished, even 
 although it shows no signs of syphilis at birth. It may, however, 
 exhibit various congenital malformations. In other cases the signs 
 
 Fig. 29i.- 
 
 -Tibia from a healthy and from a syphilitic foetus. The thickening 
 of the epiphysial line in the latter is to be noted. 
 
 of syphilis may be present at birth or may develop, as is usually 
 the case, about the end of the first month. 
 
 The most characteristic eruption of the skin at birth is pem- 
 phigus, affecting especially the palms of the hands and feet, but 
 sometimes other i3arts of the body also. This may lead to detach- 
 ment of large flakes of skin even in the living foetus. It is, however, 
 a rare condition, occurring in only some 2 per cent, of syphilitic 
 foetuses. 
 
 Syphilis in the foetus is peculiar in presenting no primary stage, 
 and shows itself chiefly in the general nutrition, the skin, the 
 viscera, and the bones. Copper-coloured stains, condylomata, 
 
Diseases of Decidua and Ovum. 543 
 
 mucous patches, and erosions and cracks around the mouth are 
 the symptoms usually developing about the end of the first month 
 of life. The viscera chiefly affected are the spleen, liver, and lungs. 
 
 The changes in them are chiefly of two kinds, which may 
 be found together or separately. These are interstitial deposits 
 of cellular or fibroid tissue causing enlargement with elastic 
 induration of the organ, and gummata in the form of granules or 
 small patches. Thus in the liver there may be either " miliary 
 gummata " compared to semolina grains, or more rarely gummata 
 of larger size. Sometimes the gummata break down into small 
 abscesses. Peritonitis, usually secondary to visceral lesions, is 
 common. One of the most constant of all the manifestations of 
 syphilis in the foetus is said to be an inflammation in the long 
 bones of the limbs. The so-called osteochondritis of Wegner, at 
 the junction of the cartilage of the ej)iphysis with the bone, exces- 
 sive proliferation of the cartilage cells, takes place, with resulting 
 compression of the blood-vessels, so that the proliferating cells 
 degenerate and undergo fatty changes. Hence a yellowish or 
 orange-coloured line is seen at the junction of the epiphysis 
 much thicker than the normal white line in this situation. This 
 change is most characteristically seen at the lower epiphysis of the 
 humerus and of the radius and the upper of the tibia. 
 
 In some cases the degenerative changes may go on to softening, 
 and in this softened tissue suppuration may occur if it becomes 
 infected with pyogenic organisms. 
 
 Treatment. — When either parent shows signs of syphilis ; when 
 previous abortions have occurred, attributable to syphilis ; or when 
 the previous child has suffered from congenital syphilis, the mother 
 should be treated during pregnancy with the view that the drug 
 may reach also the foetal circulation. Perchloride of mercury may 
 be given three times a day after meals in doses of -^ to -^2 gi'ain, 
 combined with a little hydrochloric acid and syrup. 
 
 Congenital Rachitis. — In rare cases the foetus is affected by a 
 disease closely resembling, and apparently identical with, the 
 rachitis of children. There is great deficiency of earthy material 
 and abnormal softness of all the bones, and the limbs are stunted, 
 thickened and bent. The abdomen is swollen and the liver 
 enlarged. At the epij^hyses of the long bones and of the ribs there 
 is thickening which, according to Spiegelberg, is due to an exces- 
 sive proliferation of the cells engaged in the formation of bone, 
 identical with that which occurs in ordinary rachitis. Depaul, 
 however, contends that the disease is not the same as the rachitis 
 
544 The Practice of Midwifery. 
 
 of children. The general changes of shape in the bones are 
 similar to those produced by ordinary rachitis. The stunted and 
 thickened aj)j)earance of the limbs, however, is much more marked, 
 and the head is unduly large in proportion to the body and limbs. 
 Sometimes the cranial bones are imperfectly ossified, exhibiting 
 well-marked craniotabes, and sometimes there is hydrocephalus. 
 There may be fractures of the bones (see p. 540), which are some- 
 times found united, or partially united, at the time of birth. Since 
 the weight of the body cannot come into play, the changes of shape 
 in the skeleton, including a flattening of the pelvis in its antero- 
 posterior diameter, and widening of the pubic arch, must be due 
 to the traction and pressure of muscles and ligaments combined 
 with external pressure. The bones in early fcetal life will have 
 less power of resisting these forces than those of a child similarly 
 affected. 
 
 The causation of intra-uterine rachitis is obscure, since, in the 
 recorded cases, malnutrition on the mother's part was not apparent. 
 The disease is especially liable to occur in twin pregnancy. One 
 foetus only has been found affected, when the placentae were 
 separate ; and both foetuses when there was a single conjoint 
 placenta. This is evidence in favour of the view of Spiegelberg, 
 that the cause is not so much any malnutrition in the mother, as 
 some unknown condition in the placenta. 
 
 According to Ballantyne, foetal bone diseases may be arranged 
 in a series of types, at one extreme being a disease resembhng 
 infantile rachitis, probably coming on in the later months of preg- 
 nancy, at the other the disease which has been described as 
 achondroplasia or chondrodystrophia foetalis. The chief character 
 of this is shortness of the limbs, due to the diaphyses of the long 
 bones being only one-half or one-third their normal length, while 
 the epiphyses are normal in size or increased. The disease is not 
 incompatible with postnatal life, and its effects on the pelvis will be 
 described in Chapter XXIX. 
 
 Intra-uterine Death of the FcEtus. — The foetus may die from 
 numberless causes, from any disease or morbid state either of 
 itself or of the placenta or membranes, from faults of development, 
 probably even from mere inherent deficiency of vitality, from any 
 cause preventing an adequate supply of nutriment, from poisons 
 transmitted from the mother, either those of zymotic diseases or 
 mineral poisons, such as lead or arsenic, and from external injuries. 
 There is evidence also that a febrile condition in the mother may 
 of itself destroy the foetus, apart from the presence of any poison. 
 
Diseases of Decidua and Ovum. 545 
 
 When the mother is affected by fever, the pulse and temperature 
 of the foetus rise in Hke proportion, the temperature of the fcetus 
 being always nearly a degree above that of the mother. Experi- 
 ments on animals have shown that artificial elevation of temperature 
 destroys the foetus before the mother dies, and that a temperature 
 so produced in the mother as high as 106° is always fatal to the 
 foetus. Danger to the foetus may be considered to have begun 
 when the temperature has reached 104°. No doubt in the great 
 majority of instances foetal asphyxia, either acute or chronic, is the 
 immediate cause of foetal death. 
 
 Diseases of the foetus such as pleurisy, pneumonia, or endocarditis 
 may also occur, apparently from transmission either of microbic 
 infection or of toxins from the mother. These may lead to its 
 death either before or shortly after birth. 
 
 Sometimes the foetus dies without any obvious cause, and in 
 some instances this occurrence has been repeated at about the 
 same time of pregnancy in a number of successive pregnancies, or 
 every alternate pregnancy. When a macerated foetus is exiDelled, 
 evidence of syphilis may be found in the majority of cases, on a 
 careful examination of it, especially in regard to the epiphyses of 
 the long bones of the limbs. In the case of repeated death of the 
 foetus at about the same time of pregnancy, syphilis appears also to 
 be the most usual cause. In some instances, however, such a 
 result has been attributed to malnutrition of the mother, or to 
 disease of the placenta not due to syphilis, but to some other cause, 
 such as pre-existing endometritis. It has been recommended in 
 cases in which the foetus has repeatedly died in the later months of 
 pregnancy to induce premature labour a little before the time at 
 which death generally occurs. If the suspected cause be syphilis, 
 this proceeding offers little hope of success, since the foetus would 
 probably already have grave visceral lesions. A better plan is to 
 give a course of mercurial treatment to both parents in the interval 
 of pregnancy, and to the mother during pregnancy. If, however, 
 the probability of syphilis be excluded, and, more especially, if 
 examination of the foetus on a previous occasion has shown it to be 
 in itself healthy, the plan of inducing labour some time after the 
 seventh month may be adopted. 
 
 Retention of dead Foetus in Utero ; Maceration, Mummi- 
 fication. — As a rule the death of the embryo or foetus is followed 
 by the expulsion of the ovum in from two days up to two or three 
 weeks. For degenerative changes in the placenta and membranes 
 follow the foetal death ; the ovum begins to act like a foreign body 
 
 M. 35 
 
546 The Practice of Midwifery. 
 
 and excites the uterus to exjDel it. There is an exception to this 
 rule in the case of twin or triplet pregnancy. In this case, if one 
 ovum dies, it is more usual for the blighted ovum to be retained 
 until the birth of the living child, especially if the placentae are 
 conjoined, or united at their borders. This is probably to be 
 exjDlained on the ground that the degenerated placenta occupies a 
 relatively small part of the interior uterine surface (a condition 
 usually the actual cause of the death of the ovum), while the main 
 part of that surface remains still in contact with living and growing 
 membranes. In some cases even of single pregnancy, a blighted 
 ovum or dead foetus may be retained for months within the uterus, 
 especially if its death has taken place in the earlier part of preg- 
 nancy. The cause probably is either that the uterine irritability 
 is less than usual, or that the placenta remains closely attached to 
 the uterine wall, and so maintains a certain degree of vitality. Or 
 these two causes may be in operation together. In the great 
 majority of cases, uterine pains come on at what would have been 
 the full term of pregnancy, if not before, and the ovum is then 
 expelled. Much more frequently, a macerated foetus is expelled 
 before the end of the seventh month. An early foetus may become 
 entirely dissolved in the liquor amnii and all traces of it 
 disappear. 
 
 Maceration is the most usual and typical change which follows 
 the death of the fcetus. This is a slow moist decomposition, but 
 not putrefaction, in the jDresence of the liquor amnii, but with the 
 exclusion of air. The cuticle generally becomes loosened, detached 
 in large pieces, or raised in blebs. The cutis and deeper tissues 
 are stained brownish-red from infiltration with blood pigment. 
 Fatty degeneration in the tissues and deposition of fat crystals take 
 place, especially near the surface. The attachment of the bones, 
 especially of the cranial bones, is loosened. The tissues become 
 soft and lacerable, and the whole body is somewhat swollen and 
 loses its tonicity, so that it may be squeezed into almost any shape. 
 The presentation, in consequence, is very apt to be an abnormal 
 one. The brain is converted into a soft diffluent mass, and the 
 viscera eventually lose their anatomical characters. The tissues 
 are generally oedematous, and turbid sero-sanguineous fluid collects 
 in the serous cavities and in all the tissues. The liquor amnii 
 becomes turbid and greenish or brownish, and has a sickly dis- 
 agreeable smell, not, however, that of putrefaction. The funis is 
 soft, smooth, and lacerable, and is stained brownish-red, like the 
 cutis. The placenta is pale, yellowish, and friable, showing fibrous 
 degeneration and fatty changes, but the difficulty of exchiding 
 
Diseases of Decidua and Ovum. 
 
 547 
 
 ante-mortem changes must always be remembered. If the mem- 
 branes become ruptured, and air and germs obtain an entry, 
 putrefaction generally takes place quickly within a few days. 
 
 Mummification is a term applied to a drier form of change in the 
 fcetus. It occurs especially in twin pregnancy, when the ovum has 
 become blighted, and is to be ascribed partly to the gradual death 
 of the fcetus from deficient blood supply, partly to the effect of 
 pressure. The tissues are here found shrunken instead of 
 oedematous. The skin lies almost immediately on the bones, only 
 scanty muscles intervening, and the areolar tissue seems to have 
 disappeared (Fig. 295). The placenta is pale, small, and tough. 
 The liquor amnii is absorbed, and the foetus is closely enveloped 
 by the membranes. The tissues also are 
 comparatively tough, and the foetus looks as 
 if it had been shrivelled up by being kept 
 in spirit. The foetus is generally found 
 squeezed up or flattened, and, in the latter 
 case, has been termed "foetus jiapyraceus " 
 or " compressus.'" A similar result may 
 sometimes happen in single pregnancy if 
 the foetus dies gradually from such a cause 
 as torsion or stenosis of the funis, the liquor 
 amnii being scanty. Possibly also it may 
 occur if the liquor amnii escapes by a small 
 opening, without entry of air, and the 
 placenta retains some vitality by adhesion 
 to the uterine wall. 
 
 Symptoms and Diagnosis of the Death of 
 the Foetus. — The breasts are arrested in 
 
 their development, become flaccid, and soon shrink. In the later 
 months, however, the sign of the death of the foetus may be a 
 temporary secretion of colostrum or milk, like that which follows 
 its expulsion, followed later by recession of the breasts. When 
 ultimately the dead foetus is expelled, as a rule no mammary 
 changes occur. Other reflex symptoms, such as nausea and 
 vomiting, which depend ujjon the growth of the uterus, often 
 cease, while the mother may complain of a feeling of general 
 malaise, epigastric pain, a feeling of weight in the abdomen, or 
 irritability of bladder or rectum. The enlargement of the abdomen 
 and uterus ceases, except in the case of vesicular mole. The symp- 
 toms and signs which are found in the earlier months of pregnancy 
 in the case of a blighted ovum or carneous mole have already been 
 described (sec p. 522). Sometimes a subjective feeling of coldness 
 
 35—2 
 
 Fig. 295.— Shrunken foetus 
 after retention in utero. 
 
548 
 
 The Practice of Midwifery. 
 
 in the site of the uterus is given as a sign of death of the foetus, 
 especially when pregnancy is somewhat more advanced. This is 
 not much to be relied upon. The ovum cannot of course become 
 colder than surrounding parts, although it ceases to be a source of 
 heat. 
 
 In the later months, the mere apparent cessation of fcetal move- 
 ments must not be taken as evidence of the child's death, for it 
 may frequently remain quiet for a considerable time. Nor is 
 reliance to be placed upon failure to hear the foetal heart upon a 
 
 Fig. 296. — Contents of cyst, in Dr. Oldham's case of missed labour. 
 
 particular occasion. If, however, toward the end of pregnancy a 
 sldlled observer has previously heard the foetal heart easily, and 
 afterwards fails to hear it on repeated trials, while movements also 
 can no longer be detected, the presumption of the death of the foetus 
 is considerable. In general, before making a positive diagnosis, it 
 is desirable to wait until arrest in the enlargement of the 
 uterus and recession in the development of the breasts become 
 manifest. 
 
 Treatment. — The treatment in the earlier months of pregnancy 
 has already been described (see p. 522). In the later months, when 
 the diagnosis has been made absolute by sufficient lapse of time, 
 and especially if there is any sanguineous or offensive discharge, 
 
Diseases of Decidua and Ovum. 549 
 
 the membranes may be punctured, and tents or hydrostatic dilators 
 used afterwards, if required. 
 
 Missed Labour. ^The term " missed labour " has been applied 
 to cases in which, with or without the occurrence of labour pains or 
 of a false labour, the feet us has died and then has been retained for 
 weeks or even months in iitero. The condition must be distin- 
 guished carefully from cases of extra-uterine gestation or of preg- 
 nancy in the undeveloped cornu of a unicornate uterus. The 
 foetus usually undergoes maceration or mummification, or may be 
 converted into adipocere, but if the membranes rupture and in- 
 fection occurs, suppuration of the uterine contents may take place. 
 
 In the classical case of Dr. Oldham,^ who first introduced the 
 term, the foetus became disorganised, and converted into a mass of 
 bones and adipocerous matter (see Fig. 296), portions of which 
 were discharged or removed through the os uteri for the course of 
 three months from the date of the fall term of pregnancy. The 
 woman then died, and the mass was found in an imperfect cyst 
 formed by the abdominal parietes and the posterior uterine wall, 
 the anterior uterine wall having been apparently worn through. 
 This case is therefore open to the interpretation that an extra- 
 uterine sac may have ruptured into the uterus, although Dr. Oldham 
 recorded that he felt the foetus in utero during life. In a case 
 reported by the author,^ which had at first been diagnosed as one of 
 missed labour, a watery discharge escaped through the cervix uteri, 
 two months after the date of full term. After dilatation by a tent, 
 the foetus was felt presenting by the finger passed through the cervix 
 at an opening resembling the internal os. The woman died, and 
 the foetus was found to be in an extra-uterine sac which had formed 
 an opening just at the convexity of the bend in a retroflexed uterine 
 canal. 
 
 A sufficient number of cases have now been recorded and verified 
 by operation to make it certain that the condition of missed labour 
 does occur. ^ While the retained placenta may undergo some 
 increase in size from degenerative changes after death of the foetus, 
 no definite proof has so far been produced that it can grow in the 
 true sense of the term. 
 
 The symptoms of this condition are those due to the death of the 
 fa'tus, and the diagnosis may be extremely difficult, esj^ecially if the 
 foetus has been dead some time and the liquor amnii has all become 
 
 1 Proc. I'ath. Soc, ]Mr,-i7, First Seswion, p. 103. 
 
 2 Trans. Obst. Soc. r.oridon, 187.o, Vol. XVII. , p. 170. 
 
 8 V. Franque, Zeitschr. f. Geb. u. Gyn., 18!)7, \id. 37, s. 277. 
 
550 The Practice of Midwifery. 
 
 absorbed. If septic infection and suppuration occur the patient 
 runs a considerable risk of general septicaemia. 
 
 The treatment of missed labour, if in any case it is established 
 that the fcetus is certainly in the uterus, is to dilate the cervix by 
 laminaria tents and hydrostatic dilators, and to empty the uterus 
 with the patient under an anaesthetic, the portions of the fcetus 
 being removed by the fingers, or by whatever forceps are found most 
 conveniently to grasp them. 
 
Chapter XXIIL 
 
 ACCIDENTAL COMPLICATIONS OF PREGNANCY. 
 
 The following are diseases which occur independently of preg- 
 nancy, but which are of such a nature that they have a special 
 influence on pregnancy, or pregnancy upon them. 
 
 Chronic Cardiac Diseases. — The physiological changes in the 
 heart which result from pregnancy have already been explained. 
 The increased volume of the blood and increased arterial tension 
 cause some dilatation, especially of the left ventricle. This leads to 
 compensatory hypertrophy, which may proceed as far as actually 
 to improve the circulation (see p. 166). When, however, chronic 
 valvular disease exists, the case is different. A degree of com- 
 pensation by hypertrophy may then have been attained, sufficient 
 to maintain the circulation under ordinary circumstances. But 
 when a further dilatation and increase of tension is produced by 
 pregnancy, the powers of nutrition may be unable to resjDond by 
 producing a further compensation by hypertrophy. This is rendered 
 more probable by the fact that a certain degree of anaemia is not 
 uncommon in pregnancy, and that this anaemia may be carried 
 to a pathological degree, especially when vomiting or other diges- 
 tive disturbances occur. The embarrassment of the lungs, and 
 consequent tendency to inflammatory changes in them, which 
 result from the cardiac disease, are also increased by the inter- 
 ference with respiration due to the abdominal distension. A still 
 further strain is placed upon the diseased heart by the process 
 of labour. This is proved by the fact that, in many recorded cases, 
 patients who have survived pregnancy and parturition have 
 succumbed within two or three weeks after delivery. During the 
 labour itself, the heart's action often becomes very irregular, and 
 the patient cyanotic. 
 
 When the heart disease is at all grave, pregnancy therefore 
 proves a very serious complication. Out of 31 cases collected by 
 Angus Macdonald,^ 17, or 55 per cent., proved fatal. Many of 
 
 1 The Bearing of Chronic Disease of the Heart upon Pregnancy, Parturition, and 
 Childbed, London, 1878. 
 
552 The Practice of Midwifery. 
 
 these cases, however, were specially severe. Abortion or premature 
 labour frequently comes on spontaneously, when symptoms are 
 grave, and this occurrence, in several cases, anticipated the execu- 
 tion of the physician's resolve to induce labour. According to 
 Macdonald, cases of mitral regurgitation prove the least grave, 
 those of mitral contraction the most grave. This is probably 
 explained hj the fact that, in the latter case, the tension which 
 generally produces dilatation and hypertrophy of the left ventricle is 
 all expended upon the left auricle, and thence thrown back upon 
 the lungs and right heart. In aortic regurgitation, the symptoms 
 were severe, but were generally relieved after delivery, if the 
 patient had passed safely through that stage. 
 
 The prognosis depends rather upon the condition of the heart 
 muscle than upon the nature of the valvular lesion. If the heart 
 muscle is healthy and compensation present the danger is small, 
 whereas if the heart muscle is degenerated and compensation want- 
 ing the danger is very considerable. The maternal mortality in all 
 cases is about 12 to 14 per cent. 
 
 The fatal result is generally due to over-distension of the right 
 side of the heart and cardiac paralysis, or to cardiac failure the 
 result of extensive degenerative changes in the heart muscle. 
 
 Prophylaxis. — In all cases of chronic heart disease which jDro- 
 duce any marked symptoms, such as dyspnoea, palpitation, oedema, 
 or notable alteration of jnilse, the ph^^sician should advise the 
 patient not to marry, if his opinion is asked. 
 
 Treatment. — The general management of the cardiac condition, 
 and treatment by drugs, are the same as when there is no 
 pregnancy. All exciting causes of pulmonary complications should 
 be especially avoided. In labour, early assistance by forceps or 
 version should be given, and bearing-down efforts of the patient 
 restrained as much as possible. A sandbag should be placed upon 
 the abdomen or an abdominal bandage used to lessen the risk 
 from the sudden fall in the blood pressure following on the birth 
 of the child. 
 
 Anaesthesia may usually be employed without any increase of 
 danger. Cases undoubtedly occur from time to time in which, in 
 order to lessen the strain on a heart which shows signs of yielding, 
 the induction of abortion or of premature labour should be carried 
 out. The physician should, however, warn the patient and her 
 friends that the immediate sequel of labour, whether spontaneous 
 or induced, may be aggravation of symptoms, since it must always 
 be remembered that the risk of death following upon delivery may 
 be greater for a time than it is during pregnancy. Macdonald 
 
Accidental Complications of Pregnancy. 553 
 
 held that premature labour should seldom or never be recom- 
 mended, because it is likely to do greater harm than good, by 
 disturbing the action of the heart and the condition of the lungs. 
 
 Acute Endocarditis. — Acute endocarditis may occur in preg- 
 nancy as at other times, and is a very fatal complication. Not 
 infrequently it happens that, in consequence of extra strain in 
 pregnancy, fresh valvular inflammation supervenes upon chronic 
 disease. This may take either the ordinary plastic or the ulcerative 
 form. Embolism is then apt to occur, and in this way aj)oplexy 
 and paralysis may be produced. 
 
 Phthisis. — The opinion has been held by many that pregnancy 
 acts as a prophylactic against phthisis in those predisposed to that 
 disease. There is no evidence, however, that this is really the 
 case in general. It may be true in some of those cases in which 
 pregnancy appears to improve the general health, but it probably 
 more frequently occurs that impairment of health, from some of 
 the disturbances of pregnancy, favours the onset of the disease. 
 The fact that the susceptibility to phthisis of unmarried women is 
 rapidly diminished after thirty years of age, while that of married 
 women maintains its intensity between twenty-five and forty years 
 of age, that is during the child-bearing period, seems to show that 
 pregnancy has a deleterious effect upon those disposed to phthisis. 
 To this there are many exceptions. The puerperal state and lactation 
 have a much more decidedly unfavourable influence. As a rule, 
 abortion or premature labour occurs spontaneously only when the 
 condition of the mother is becoming extreme, or when her blood is 
 insufficiently aerated. In the later stages of phthisis amenorrhoea 
 results, and pregnancy is not likely to occur, but in the earlier or 
 quiescent stages of the chronic form of the disease this is not the 
 case. Phthisical women should be advised not to marry, both on 
 account of the increased risk to themselves, the probably phthisical 
 predisposition of their children, and the possible communication 
 of contagion to their husbands. The first child is often well 
 nourished, but subsequent children are very likely to be feeble and 
 delicate. Labour, in phthisical women, should receive early assist- 
 ance by the use of forceps. Artificial induction of abortion has 
 been performed on account of phthisis. But the general opinion 
 is that the influence of the pregnancy upon the phthisis is so 
 uncertain that, as a rule at any rate, this operation is not justi- 
 fiable. The same conclusion will apply even to the induction of 
 premature labour. 
 
554 The Practice of Midwifery. 
 
 Acute Lobar Pneumonia. — Pneumonia, which in other respects 
 has a close analogy to zymotic diseases, shows this character also 
 in its relation to pregnancy. Pregnancy seems to afford a certain 
 protection against its onset, but, when it does occur, its severity 
 and danger are increased. The gravity of the disease is greater, 
 the further advanced is the pregnancy, and if it occurs after the 
 sixth month about 50 per cent, of the mothers die. This may 
 partly be explained by the interference of the distended abdomen 
 with the descent of the diaphragm and freedom of respiration, 
 although the capacity of the chest is not actually diminished, as 
 was formerly supposed. Pneumonia leads to abortion in about one- 
 third and to premature labour in about two-thirds of the cases. 
 This may be due to imperfect oxj-genation of blood, to the general 
 effect of the acute disease on the mother's system, or to the death 
 of the foetus produced by the high temperature (see p. 545). In 
 the latter case, delivery may be delayed until the acute stage has 
 subsided. Premature labour, either induced or spontaneous, renders 
 the prognosis much more unfavourable. As will be explained in 
 the chapter on puerperal fevers, there is some evidence that 
 pneumonia, existnig before delivery, may merge into puerperal 
 septicaemia, the pneumococcus behaving as a septic microbe. 
 
 Treatment. — Premature labour should on no account be induced, 
 but the onset of labour should be averted if possible. If labour 
 does come on near full term, early aid should be given by forceps, 
 if called for. Digitalis is often useful to maintain the vigour 
 of the heart, and generally stimulant treatment is likely to be 
 called for. 
 
 Jaundice. — Jaundice is a rare affection in pregnancy, but has 
 great interest from the tendency which exists for apparently simj)le 
 jaundice to develop into the fatal disease, acute yellow atrophy of 
 the liver. Sometimes such a development takes place only after 
 delivery. Of seven cases of jaundice in pregnancy met with by 
 Sj)iegelberg,^ two were cases of acute yellow atrophy. 
 
 Simple Jaundice. — Simple jaundice may run an ordinary course 
 during p>regnancy. As a rule, it does not lead to abortion or pre- 
 mature labour, but this result does sometimes happen. The foetus 
 and liquor amnii are sometimes, but not always, stained yellow 
 with bile pigment. 
 
 Acute Atrophy of the Liver.— Of 164 cases of acute atrophy 
 of the liver, 66 occurred in pregnant women. The disease may 
 
 1 Spiegelberg, Lehrbuch der Geburtshiilfe, English translation, 1887, Vol. I., p. 357. 
 
Accidental Complications of Pregnancy. 555 
 
 occur as early as the sixth week of pregnancy, but is commoner 
 towards the later months. It generally begins like simple jaundice ; 
 then grave constitutional symptoms supervene, elevation of pulse 
 and temperature, headache, severe and repeated vomiting, 
 haemorrhages, delirium, coma, and death usually within a week 
 from the onset of the attack. A diminution in the size of the 
 liver may be detected. 
 
 Pathological Anatomy. — The liver-cells are, in great measure, 
 destroyed by parenchymatous degeneration. The degenerative 
 changes usually begin in the periphery of the lobule, but in some 
 cases, and constantly in those cases occurring as a sequel to the 
 toxaemic vomiting of pregnancy, the change begins in the centre of 
 the lobule. There is also degeneration of the muscles, especially of 
 that of the heart. Degeneration of the kidney-cells has also been 
 described in some cases. Abortion or premature labour often 
 comes on, and the foetus and liquor amnii are found stained with 
 bile pigment. The presence of crystals of leucin and ty rosin in the 
 urine, which is scanty, high-coloured, and of high specific gravity, 
 is characteristic. There is also an alteration in the relation between 
 the ratios of urea and ammonia in the urine, the percentage of the 
 latter, which normally is about 5 per cent., rising to as much as 
 12 to 37 per cent. The most probable explanation of this is that 
 the ammonia is carried out of the body in combination with organic 
 acids, and therefore cannot be turned into urea, of which less is 
 excreted. 
 
 Causation. — It is generally believed that the disease is due to 
 some form of toxaemia, but the exact mode of origin of the poison 
 is obscure. In some cases severe mental shock or mental distress 
 appears to be an exciting cause. According to Spiegelberg, the 
 symptoms of acute atrophy are often preceded by haemorrhage from 
 the uterus or other parts, which may have a depressing influence. 
 In very rare instances an apparent epidemic of acute atrophy of the 
 liver in pregnant women has been recorded. Of 44 recent cases of 
 acute yellow atrophy no less than 9 in pregnant women occurred 
 in districts in which epidemic attacks of jaundice appear relatively 
 common. 
 
 There are three main views as to the nature of this disease : that 
 it is a primary disease of the liver, that it is a general disease with 
 secondary involvement of the liver, and that it is a rare form of 
 infective disease. The resemblance between cases of acute yellow 
 atrophy and cases of malignant jaundice is extremely close, and 
 there can be no doubt but that they are both due to some virulent 
 organic poison of unknown nature acting especially upon the liver. 
 
55^ The Practice of Midwifery. 
 
 Pregnancy would aid in the production of such poison, since both 
 the kidneys and the liver are then apt to have their functions 
 deranged because of the increased work thrown upon them, and the 
 interference with the circulation. The Jaundice is due to a catarrhal 
 condition of the finest bile ducts, and is no doubt produced by the 
 excretion in the bile of the poison which damages the liver-cells. 
 The condition of the liver in acute atrophy is similar to that 
 produced by phosphorus poisoning, but in the latter condition the 
 liver is usually enlarged and not atrophied, and the percentage of 
 fat is much higher, from 3 to 30 per cent., as compared with the 
 normal 5 per cent, found in acute yellow atrophy.^ 
 
 Treatment. — Simple jaundice in pregnancy may be treated in the 
 ordinary way. Moderate use of purgatives and diuretics is desirable. 
 Acute atroj)hy when once developed is almost hopeless, although 
 cases of recovery have been recorded even in pregnancy.^ Saline 
 transfusion may be employed and intestinal antiseptics given, while 
 the administration of sodium bicarbonate is indicated in view of 
 the high percentage of ammonia in the urine and the fact that the 
 autolysis of the liver is favoured by the acid reaction of the tissues. 
 If in simple jaundice haemorrhages occur, or the urine is albuminous 
 or deficient in urea, or there are any other grave constitutional 
 symptoms, such as coma or mental aff"ection, indicating a danger 
 that acute atrophy may supervene, the question of induction of 
 premature labour or abortion should be considered. 
 
 Diabetes. — Diabetes is another disease affected by pregnancy. It 
 is to be remembered that physiological glycosuria occurs in the 
 puerperal woman, and it appears proved that a certain number of 
 pregnant women have glycosuria not due to the resorption of 
 lactose. Cases have been recorded in which diabetes has recurred 
 in successive pregnancies, and has been absent during the intervals, 
 as is sometimes the case with albuminuria. Not infrequently 
 23regnancy occurs in a diabetic patient, and runs its course undis- 
 turbed ; but generally the diabetes is aggravated, and the complica- 
 tion is of grave import both to mother and child. Of cases collected 
 by Matthews Duncan,^ namely, 22 pregnancies in 15 mothers, 4 
 ended fatally during the puerperal period, premature labour having 
 been induced in one of these. Hydramnios was frequent, and in 
 one case sugar was found in the liquor amnii. In 7 out of 19 cases 
 the child died during the pregnancy, after reaching viable age, and 
 in 2 more it died a few hours after birth. 
 
 1 W. Hunter, Clifford AUbutt's System of Med., Vol. IV., Part 1, p. 115. 
 
 2 Creed and Scott Skirving, Austral. Med. Gaz., 1888-89, Vol. VIII., p. 259. 
 8 Trans. Obst. Soc. London, 1882, Vol. XXIV., p. 256. 
 
Accidental Complications of Pregnancy. 557 
 
 Of 19 cases collected by Stengel/ of whom 16 were multiparas, 
 ten of the mothers died either at the time of labour or within a 
 few weeks. 
 
 Treatment should be the same as if the patient were not preg- 
 nant, but the labour should not be allowed to continue too long. 
 
 Pyelonephritis of Pregnancy. — In a small number of cases of 
 pregnancy a condition of pyelonephritis develops about the fourth 
 or fifth month which rapidly clears up after the birth of the child, 
 and appears to be dependent directly upon the presence of the 
 foetus in utero. Dilatation of one or of both ureters commonly is 
 present, most frequently of the. right one, and as a rule there is no 
 antecedent cystitis. The dilatation of the ureter, which is usually 
 situated about one inch from its entrance into the bladder, has been 
 assumed to be due to the pressure of the foetal head, but this cause 
 obviously cannot come into play as early as the middle of pregnancy, 
 and it is possibly due to some constriction of the ureter, swollen as 
 a result of the pregnancy as it passes through the ureteral canal in 
 the cellular tissue at the base of the broad ligament. The chief 
 feature of the disease is the presence of pus in the urine without 
 cystitis, accompanied by fever and pain in the loins or in the back. 
 In the majority of cases the organism present is the bacillus coli. 
 The infection occurs probably by the blood stream, possibly by the 
 lymphatics. As a rule the patient recovers with treatment during 
 the iDregnancy, or the condition clears up after delivery. Only very 
 exceptionally is there any question of the induction of premature 
 labour. 
 
 Bronchocele. — Cases have been observed in which abronchocele 
 has occurred for the first time or increased during pregnancy. It is 
 a question how far the causation depends upon the increased vascular 
 tension of pregnancy, and how far upon a reflex nervous influence. 
 A temporary increase of the swelling of the thyroid is apt to be 
 produced by the straining of labour ; but the enlargement generally 
 subsides to a great extent, though not altogether, after delivery, 
 while great improvement or recovery may result in a case of 
 exophthalmic goitre from pregnancy. 
 
 Heemorrhages. — Women who are liable to haemorrhages have 
 this liability increased by the increased vascular tension of preg- 
 nancy. In some cases, also, the deteriorated quality of the blood 
 may have an influence. Thus haemoptysis occasionally occurs 
 
 1 Univ. of Pcnnsylv. Med. Bulletin, October, 1903. 
 
558 The Practice of Midwifery. 
 
 during pregnancy; and in that condition it has not the same 
 significance as at other times in indicating the probable existence 
 of phthisis. Again, epistaxis and bleeding from the alimentary 
 canal, especially from the rectum and stomach, are not uncommon. 
 Cerebral haemorrhage, producing paralysis, sometimes occurs, but 
 this is more especially associated with albuminuria. Distended 
 varices sometimes rupture on the surface, and pelvic hematocele, 
 from rupture of a vessel near the uterus, has occasionally been 
 recorded. 
 
 Appendicitiso— Although pregnancy cannot be said to predispose 
 to an attack of appendicitis, yet a previously existing attack is 
 likely to be greatly aggravated during pregnancy, and very serious 
 symptoms may arise, while the danger of the condition is certainly 
 increased. 
 
 The congestion of the pelvic organs and the frequency of severe 
 constipation would appear to favour the occurrence of suppuration. 
 The synii^toms will be the same as those of an attack occurring 
 apart from pregnancy, but the diagnosis may be extremely difficult, 
 and the attack is very likely to be regarded as one of pelvic peritonitis 
 or of pyelonephritis, while in the puerperium a perforative peritonitis 
 may be thought to be due to septic infection. Eecent observations 
 tend to show that abortion or premature labour does not occur as 
 frequently as might be anticij)ated, but during labour or after 
 delivery the rupture of an encapsuled collection of pus may be 
 brought about by the contraction or the shrinking of the uterus. 
 At the same time, in some cases, the presence of the enlarged 
 uterus helps to shut in a collection of pus. 
 
 In all cases in which an acute attack occurs in the early months 
 of pregnancy an operation should be performed. In the later 
 months the question is a more difficult one to decide, and the 
 danger of the complication is much greater. Even at this period 
 of pregnancy, however, in view of the great risk the patient runs 
 during labour and the puerperium, operative interference is indicated, 
 and on the whole it appears best not to induce labour, as has been 
 recommended by some writers, before operating. As a general rule 
 the case should be treated as if the patient were not pregnant. 
 
 Oyarian Tumours — Ovarian tumours of small size may not 
 interfere with the course of pregnancy or parturition, provided they 
 do not occupy the pelvis. If the tumour is of considerable size, 
 the complication is a serious one. The tension may become so 
 great before the end of pregnancy, that vital functions are interfered 
 
Accidental Complications of Pregnancy. 559 
 
 with. Other dangers also exist, the tumour may rupture under the 
 influence of pressure, or the presence of the enlarged uterus may 
 cause twisting of the pedicle, or interference with its circulation, 
 with resulting necrotic and inflammatory changes in the tumour. 
 The obstruction to labour which an ovarian tumour occupying 
 the pelvis may cause will be considered hereafter (see 
 Chapter XXVIII.). 
 
 Treatment. — In cases where an ovarian tumour is found to 
 complicate pregnancy as a general rule ovariotomy should be per- 
 formed without delay. The risk of the operation is very small. 
 Thus McKerron^ records 299 ovariotomies during pregnancy with a 
 mortality of only 3"3 per cent., and in 219 cases collected by 
 Graefe,^ operated upon since 1902, the maternal mortality was only 
 0'47 per cent., and the pregnancy continued uninterruptedly in 
 84 per cent. The only exception to the rule of immediate operation 
 might be the case where it was thought advisable in the later 
 months of pregnancy to wait until the child was certainly viable, but 
 in such a case it must always be borne in mind that the presence of 
 the large uterus may prove a serious obstacle to the operation. 
 
 Fibroid Tumours of the Uterus. — Although fibroid tumours 
 of the uterus are often associated with sterility, yet pregnancy may 
 occur, especially if the tumours are subperitoneal. The tumours 
 then generally increase in size with the growth of the uterus, and 
 may in some cases undergo atrophy with the involution of the 
 uterus. A difficulty of diagnosis may arise during pregnancy, and 
 the suspicion may be raised of the presence of extra-uterine foeta- 
 tion on account of the irregularity of the tumour containiDg the 
 foetus. In other cases the fibroid tumour becomes so softened 
 during pregnancy as to render its recognition difficult, or it may be 
 mistaken for an ovarian tumour. When the fibroids are external, 
 pregnancy and parturition are often undisturbed ; when they are in 
 the wall of the uterus, there is a tendency to malpresentations of 
 the foetus, inertia of the uterus, and to post-partum haemorrhage. 
 
 In cases where the fibroid tumour is attached to the posterior 
 wall it may become impacted in Douglas' pouch and cause incarcera- 
 tion of the uterus, and in the case of a pedunculated subserous fibroid 
 torsion of the pedicle may occur with acute symptoms. At times 
 during the progress of the pregnancy the tumours are the seat of 
 much pain, but in the great majority of cases this passes off with 
 rest in bed. 
 
 1 K. G. McKeiTon, rre^'iancy, Labour, and Childbed with Ovariau Tumour, 1903. 
 
 2 Graefc, Zeitschr. f. Gob. u. Gyn., 1905, Bd. 50, p. 499. 
 
560 The Practice of Midwifery. 
 
 Diagnosis. — This may be easy or difficult. Small tumours may 
 be mistaken for fcetal parts, or, if very soft, not recognised at all. 
 In the case of multiple fibroid tumours causing considerable and 
 general enlargement of the uterus, the recognition of an early 
 jDregnancy may be almost impossible, and a correct diagnosis often 
 only can be made by watching the growth of the tumour and 
 waiting for the signs of fcetal life. In a large number of cases 
 uteri have been removed and then found to contain a fcetus. Soft 
 subserous tumours may be mistaken for a dermoid ovarian cyst, 
 and this mistake is especially likely to occur if the pedicle becomes 
 twisted. Eepeated examinations should be made at different times, 
 and in all cases of doubt the patient should be watched and the 
 signs of pregnancy carefully looked for. 
 
 Treatment. — Interference during pregnancy is very rarely 
 required, and should only be carried out if serious symptoms 
 arise from the pressure of the tumour or from degenerative or 
 inflammatory changes occurring in it. 
 
 The induction of abortion or premature labour should not be 
 practised, and whenever possible the case should be allowed to go 
 to full term, and then whatever treatment may be necessary 
 carried out (see Chapter XXVIL). 
 
 Surgical Operations. — The effect of a surgical operation in 
 pregnancy varies greatly according to the susceptibility of the 
 woman to reflex influence. In one case the extraction of a tooth 
 may bring on labour; in another ovariotomy, or amputation of 
 the thigh, may produce no such result. But after serious opera- 
 tions abortion or premature labour follows in a considerable 
 proportion of cases (according to Cohnstein's statistics, in 45'5 per 
 cent.). The tendency appears to be greater in the third and fourth 
 and in the last two months, less in the middle months. The cause 
 may be reflex influence, or, less frequently, the fever following the 
 operation. Operations on the vagina or in the neighbourhood of 
 the uterus are more likely to interrupt pregnancy. Such operations 
 are also likely to be attended with considerable haemorrhage. Preg- 
 nancy does not appear to be unfavourable to the recovery of the 
 patient, but the puerperal state is so. It is therefore unfavourable 
 if premature labour follows very quickly upon a severe operation. 
 
 It is better to defer ox)erations not of an urgent character until 
 after delivery, unless the condition for which the operation is 
 required is aggravated by pregnancy, or is likely to cause difficulty 
 in delivery. So far as possible, no serious operation should be 
 performed during the puerperal period. 
 
Accidental Complications of Pregnancy. 561 
 
 Ague.- — The relation of malarial fever to pregnancy is, in some 
 degree, similar to that of zymotic diseases. It is met with but 
 rarely, but when it does occur it is aggravated. Latent malarial 
 infection may also become again active during pregnancy. This is 
 more likely to happen in the puerperal state, at which time fever, 
 ascribed to malaria, is relatively common in malarial districts. 
 At this time also, the character of the fever is modified; instead 
 of being intermittent, it becomes remittent, and the paroxysms 
 become irregular. Malarial fever not uncommonly leads to abor- 
 tion or premature delivery. In some cases there has been evidence 
 of its communication to the fcetus, which may die before, or soon 
 after, delivery ; but in fifteen cases recorded by Whitridge Williams^ 
 in no instance did the foetus show signs of the disease, although in 
 all cases its blood was carefully examined. 
 
 Syphilis. — The effects of syphilis upon the fcetus and the 
 placenta have already been described. Syphilis may be inherited 
 from either parent, or both, even if the disease exists only in a 
 latent condition. In the case of untreated syphilis, syphilitic 
 children may be procreated for ten years or more, the intensity of 
 the infection diminishing with the lapse of time. 
 
 If a pregnant woman acquires syphilis, the local manifestations 
 in the neighbourhood of the genital organs are more severe than 
 usual, in consequence of the hyperaemia of those parts. The con- 
 stitutional disease is generally mild. A woman impregnated by a 
 husband who has latent syphilis, may acquire the disease for the 
 first time from the foetus. In this case the symptoms are very 
 mild, and only those manifestations which are generally late ones 
 may be shown. Some authorities deny the communication of 
 syphilis from the foetus to the mother, and vice versa. But what is 
 known as Colles' law is admitted as a general rule, although 
 exceptions have been recorded. This is, that a woman is never 
 infected by nursing her own child suffering from hereditary 
 syphilis, though another woman is likely to be so, and though she 
 may never have shown signs of the disease. It is not certain 
 whether this implies that all such mothers have had symptoms so 
 slight that they have been overlooked, or whether the mother receives 
 from the fcetus a modified form of the disease so that there are no 
 noticeable symptoms, or that the mother absorbs from the foetus 
 some antitoxin and so acquires for herself immunity either partial 
 or complete. But in any case it proves that the syphilitic poison 
 
 1 W. WilliiirriH, CJbMtctrics, li>08, p. 485. 
 
 M. 30 
 
562 The Practice of Midwifery. 
 
 affects the mother. In other cases again a syphihtic mother 
 bears an a^Dparently healthy child, which is however immune to 
 syhilis, cannot be infected by its mother, and whose blood gives a 
 jDOsitive result with Wasserman's reaction. When a pregnant 
 woman acquires syphilis, the foetus may have symptoms similar to 
 those of the hereditary disease. It is probable, if the infection takes 
 place after the seventh month of pregnancy, that the foetus generally 
 escapes. But Hutchinson^ has recorded cases in which the mother 
 was infected within the last few weeks of pregnancy, and in which 
 the child, after birth, had symptoms like the ordinary hereditary 
 disease. 
 
 Treatment. — If syphilis is acquired during j^regnancy, mercurial 
 treatment throughout the remainder of pregnancy is of importance 
 for the sake of the child, as well as for that of the mother. The 
 formula given at p. 578 may be used. 
 
 Tetanus. — Tetanus during pregnancy has been observed chiefly 
 in the earlier months, and pregnant women appear to have an 
 increased liability to the disease, at any rate during the first half 
 of pregnancy. It has generally followed some minor operation, or 
 some manipulation in connection with the induction of abortion. 
 The gravity of the disease is the same as that of puerperal 
 tetanus. 
 
 Tetany. — Tetany is a disease which, when it occurs, usually 
 develops in the later months of pregnancy and may last during 
 lactation. The prognosis is almost invariably favourable, but a 
 fatal result has been recorded. It may recur in successive preg- 
 nancies. Tetany is especially likely to occur during the spring in 
 epidemics in certain localities, and is a disease of extremely local 
 distribution. Thus it is very rare in London, but not uncommon in 
 Vienna and Heidelberg. 
 
 Zymotic Diseases. 
 
 Any zymotic disease may occur during pregnancy. But in 
 general the pregnant woman appears to be less liable than others 
 to the outbreak of a zymotic disease, while, on the other hand, the 
 puerjDeral woman is much more liable. This rule does not, how- 
 ever, ap]3ly equally to all diseases. It is most marked in the case 
 of scarlatina, and probably least marked in that of small-pox. 
 Any severe zymotic disease is rendered more grave by pregnancy, 
 
 1 Medical Times and Gazette, 1878. 
 
Accidental Complications of Pregnancy. 563 
 
 especially in the later months, but still more so by the puerperal 
 state. Most zymotic diseases are apt to lead to premature labour 
 or abortion. There are three elements which may tend toward 
 this result : first, the death of the fcetus from the high tempera- 
 ture ; secondly, the effect of the severity of the disease upon the 
 mother ; thirdly, the effect on the mother of the special zymotic 
 poison concerned. That the third element is actually operative 
 is proved by the special tendency of small-pox to produce pre- 
 mature labour, even when it runs a mild course, and when the 
 child is born alive. The mode of operation is, in some cases, the 
 production of haemorrhage in the uterus or placenta. The puerperal 
 state being much more unfavourable than that of pregnancy, the 
 longer abortion or premature labour is deferred the better it is 
 for the mother. Labour should not therefore be induced in any 
 case, although, in small-pox, when the child is viable, induction 
 might give it a better chance of surviving. 
 
 Variola — Small-pox has been observed in pregnancy oftener 
 than most zymotic diseases. Confluent or unmodified small-pox 
 is very dangerous to the mother, and proves fatal in the majority 
 of cases. It tends to assume the haemorrhagic form, and specially 
 to cause uterine haemorrhage. In almost all cases it leads to 
 abortion or premature labour and the death of the foetus. Modi- 
 fied or discrete small-pox generally runs a favourable course, but 
 even this leads to abortion or premature labour in most cases, 
 although not so constantly as the more severe disease. 
 
 In a certain proportion of cases, but not invariably, the foetus is 
 affected by the disease in utero. Sometimes it is born with 
 pustules upon it. In other cases, when it is delivered at a later 
 stage the scars of pustules are visible. When premature labour 
 occurs early in the disease, the child may become affected a few 
 days after delivery. Sometimes, although not apparently affected, 
 the child dies shortly after birth. In other cases, the child, which 
 has shown no trace of the disease, is found to be insusceptible to 
 vaccination. Cases even have been recorded in which it has been 
 supposed that the child was affected by the disease in utero, or very 
 shortly after birth, during epidemics of small-pox, although the 
 mother did not suffer from it, or in which one of twins in utero took 
 the disease from the mother while the other escaped. 
 
 Vaccination during pregnancy appears to run its course as usual. 
 In an epidemic of small-pox, therefore, pregnant women, who have 
 not Ijeen revaccinated, should undergo that operation. Vaccina- 
 tion should not Ije performed very shortly after delivery, since 
 
 86—2 
 
564 The Practice of Midwifery. 
 
 even a very slight zymotic poison may then have an unfavourable 
 influence. 
 
 Scarlatina. — Scarlatina is very rare during pregnancy, especially 
 as compared with its frequency during the few days after delivery. 
 According to some, the incubation may be prolonged for weeks and 
 months during pregnancy, and the outbreak only take place after 
 delivery (see section on Scarlatina in Chapter XXXIX.). Mild 
 cases of scarlatina may run a favourable course. If the fever is 
 high, abortion or premature labour generally follows, and then the 
 danger is greatly increased, as in ordinary puerperal scarlatina. 
 It has been inferred that the disease may be conveyed to the foetus 
 in utero, because the child, at or shortly after birth, has sometimes 
 shown desquamation of the skin or other sequelse of the disease. 
 
 Measles. — Measles rarely occurs in pregnancy. Usually the 
 disease runs an ordinary and mild course. But cases have been 
 recorded in which it has been unusually severe, tending towards a 
 hsemorrhagic type, or complicated by pneumonia. In such cases 
 premature labour or abortion frequently follows. The child has 
 been born with the eruption of measles. 
 
 Erysipelas. — Erysipelas is not very common in pregnancy. It 
 does not seem to prove specially dangerous, unless premature 
 labour is the consequence. There is then a serious risk, since the 
 streptococcus of erysipelas is very closely allied to, if indeed it is 
 not the same as, the streptococcus pyogenes of septicaemia; but 
 this may be averted if, by strict antiseptic precautions, conveyance 
 of the microbes to the vagina can be prevented. The risk is much 
 increased if the erysipelas is in the vicinity of the genital canal. 
 Even in cases of erysipelas limited to the head and face, the foetus 
 at the time of birth has been affected both by cutaneous erysipelas 
 and by septicaemia or pyaemia. It is possible, therefore, for septic 
 poison to be transmitted to the genital canal through the blood (see 
 Chapter XXXIX.). 
 
 Enteric, Typhus, and Relapsing Fevers. — All these diseases 
 are rare during pregnancy, especially in the later months. Enteric 
 fever leads to premature labour or abortion in the majority of cases. 
 The interruption of pregnancy generally follows at the time when 
 temperature ranges the highest, and the prognosis is rendered more 
 grave in consequence, although as a rule the delivery occurs quite 
 normally. Severe haemorrhage is apt to follow after abortion in 
 
Accidental Complications of Pregnancy. 565 
 
 the earlier months, and it has been thought that the prognosis of 
 the disease is on this account more grave at that time than in the 
 later months. Transmission of enteric fever to the foetus has been 
 proved by the finding of bacilli in it after death. Eelapsing fever, 
 according to Murchison and Zuelzer,^ leads to interruption of preg- 
 nancy in almost every case. Weber,^ however, at St. Petersburg 
 found this happen in only 28 out of 63 cases. Typhus fever is less 
 apt to lead to premature labour or abortion than either of the other 
 two, and its course is not so much modified by pregnancy as that of 
 many zymotic diseases. 
 
 Cholera. — It does not appear that jDregnancy affords any notable 
 protection against cholera. Accounts differ as to whether the 
 mortality of the disease is increased by the complication. It is 
 said to be both more frequent and more fatal in the later months. 
 Interruption of pregnancy follows in a considerable proportion of 
 cases, and in others it is probably only prevented by the early fatal 
 termination. Haemorrhage into the uterus is apt to occur, and is 
 one of the causes of abortion. 
 
 1 Monatschr. f. Geburtshiilfe, Vol. XXX. 
 
 2 Berlin. Klin. Wochenschr. , Vol. VII. 
 
Chapter XXIV. 
 PREMATURE EXPULSION OF THE OVUM. 
 
 The term abortion or miscarriage is applied to premature expul- 
 sion of the ovum when this occurs before the time when the child 
 becomes viable, or capable of possibly surviving. After that 
 date, the term premature labour is used. The point of demarcation 
 between the two may be taken as the end of the sixth calendar 
 month, or about 183 days, although there is practically but little 
 chance of the child being reared, if born before the end of the 
 twenty-eighth week, or 196 days. A distinction is sometimes made 
 between abortion and miscarriage, the term abortion being used in 
 the first two or three months of pregnancy, before the placenta is 
 formed, and the term miscarriage from the time when the placenta 
 is formed up to the date when the child is regarded as viable. It is 
 better, however, to consider the terms abortion and miscarriage as 
 sjmonjans, since no distinct boundary between the two can be assigned, 
 and women themselves generally prefer the word miscarriage to the 
 word abortion. 
 
 Premature expulsion of the ovum is one of the commonest of the 
 morbid occurrences of pregnancy. On an average, every woman 
 who has borne children and reached the limit of the child-bearing 
 age has had at least one abortion or premature labour. The pro- 
 portion of abortions to full-term deliveries has been estimated as 
 being as much as one to five, and multiparas, as might be expected, 
 are more subject to them than primiparse. 
 
 The attachment of the ovum to the uterine wall is less firm in the 
 early months of pregnancy before the complete formation of the 
 placenta. Hence it is within the first four months of pregnancy, 
 and especially in the third month, that abortions are most common. 
 Within the first few weeks of pregnancy many abortions pass 
 altogether unrecognised, or only suspected. A woman goes a few 
 days, or two or three weeks, beyond the expected time of menstrua- 
 tion ; then haemorrhage occurs, resembling a menstrual period rather 
 more profuse than usual, and an ovum may escape unobserved. If 
 shreds of decidua are detected, these show only a slightly greater 
 development than the shreds of menstrual decidua sometimes passed 
 in menstruation without any conception. It is therefore impossible 
 
Premature Expulsion of the Ovum. 567 
 
 to estimate accurately the relative frequency of abortions within the 
 first two months. Abortions positively diagnosed occur most fre- 
 quently between the sixth and the sixteenth week. This fact may 
 be explained not only from early abortions being often undetected, 
 but partly also on the ground that some causes of abortion, such as 
 retroflexion or fibroid tumour of the uterus, only begin to 
 operate. when the ovum and uterus have reached a certain size, and 
 that the various diseases of the embryo or membranes which may 
 lead to abortion require a certain time for their development before 
 
 Fig. 297. — Usual mechanism o£ abortion FiG-. 298.— Mechanism of abortion in the 
 within the first two months of preg- early months, with inversion of the 
 
 nancy. decidua vera. 
 
 the embryo is destroyed, or the membranes so much altered as to 
 excite the uterus to expulsion. 
 
 Mechanism of Abortion. — Within the first two months of preg- 
 nancy the ovum is most frequently expelled entire together with 
 the decidua vera, decidua capsularis, and the rudimentary placenta 
 (see Fig. 297). The whole ovum is either expelled surrounded by the 
 decidua vera, or it becomes separated at the placental site and is 
 extruded first, dragging after it the decidua vera, which is thus 
 stripped off the uterine wall and is inverted, the mechanism 
 reHCTnbh"ng that of Schultze's method of separation of the 
 
568 
 
 The Practice of Midwifery. 
 
 placenta (see Fig. 298). In other cases the decidua reflexa or capsu- 
 laris is ruptured, and the ovum, surrounded by the amnion and the 
 rudimentary chorion, is expelled, leaving behind in utero the greater 
 part of the decidua basalis undergoing development into the placenta 
 and the decidua vera and- capsularis (see Fig. 299). These subse- 
 quently come away as a whole or broken up into fragments. 
 
 In the course of the third month, the ovum may either be 
 
 Fig. 299. — Mechanism of abortion in 
 cases where the greater part of the 
 decidua basalis, together with the 
 decidua vera and capsularis, is left 
 in idero. 
 
 Fig. 300. — Mechanism of abortion, the 
 foetus expelled in the intact amnion. 
 
 ruptured in its expulsion or not, according to circumstances, 
 rupture becoming more probable as the month proceeds. If 
 rupture takes place, retention of the incipient placenta is more 
 likely to occur. It is possible, however, for the amnion containing 
 the embryo to be expelled entire, the umbilical cord breaking off at 
 its attachment to the surface of the placenta and the latter, together 
 with the chorion, being retained in utero. In other cases again the 
 embryo enclosed in the amnion and the chorion may come away 
 
Premature Expulsion of the Ovum. 569 
 
 entire, leaving a part of the placenta in utero. After the end of the 
 third month, the amnion is usually ruptured from the effect of the 
 uterine contractions, and the liquor amnii escapes. Then the 
 embryo is expelled first, and the placenta is discharged afterwards, 
 as in labour at full term. 
 
 The later the stage of pregnancy reached, the more nearly does 
 the process resemble that of ordinary labour. In the middle months 
 of pregnancy, after the placenta has been formed, but before the 
 formation of that layer of open meshwork which facilitates its 
 separation from the uterine wall (see p. 79), the separation of the 
 placenta is much more difficult, and the uterine action is often 
 insufficient to effect it completely. Hence either the whole or a 
 portion of the placenta is liable to be retained for a longer or 
 shorter period, especially if attached in one of the tubal angles of the 
 uterus, unless removed artificially. It is from the tenth, and more 
 especially from the twelfth, up to about the twentieth week that this 
 specially close union exists between the placenta and the uterine 
 wall, and hence an abortion within these limits of time is more 
 likely to lead to grave results than either before or after. 
 
 Cervical Abortion. — In primiparse the external os often 
 presents a good deal of rigidity, and after the separated ovum has 
 been expelled into the dilated cervical canal it may be retained 
 there for some time behind a partly dilated external os, the 
 uterine contractions no longer having any effect upon it, forming 
 the so-called cervical abortion. 
 
 Causation. — The uterine contractions, which expel the ovum 
 prematurely, are excited either by a cause acting directly upon the 
 nervous centres, or one which calls out reflex action, or by a com- 
 bination of the two. Both the excitability of the nerve centres 
 and the tendency to congestion of the uterus are greatest at the 
 epochs which would have been menstrual periods if pregnancy had 
 not occurred, and hence abortion is especially likely to happen at 
 these dates. Different women also vary immensely in the ease 
 with which abortion can be excited. The difference depends chiefly 
 upon the degree of irritability of the nervous system, but, to some 
 extent also, upon the firmness of attachment of the ovum to the 
 uterus. Thus cases are on record in which women have fallen 
 out of windows from a height sufficient to fracture their limbs, 
 and pregnancy has been undisturbed. Ovariotomy and various 
 operations upon the cervix uteri have been performed, nitric acid 
 has been applied to the interior of the uterus in the early weeks 
 
570 The Practice of Midwifery. 
 
 of pregnancy, without abortion following. Pregnancy has even 
 established and maintained itself until discovered, notwithstanding 
 the wearing of an intra-uterine stem. On the other hand, with 
 some women, any slight mental or physical disturbance, even the 
 seeing a mouse or a sj)ider, appears to be sufficient to cause 
 abortion. Frequently both a predisposing and an exciting cause 
 can be assigned ; and, in the presence of a predisposing cause, the 
 exciting cause may be of the most trivial character. 
 
 When once the uterine contractions have caused dilatation of 
 the cervix uteri to a certain extent, and have pressed down the 
 ovum sufficiently to bulge into it, the process of abortion goes on 
 automatically, like that of labour, and resembles labour on a small 
 scale. The reflex irritation caused by pressure of the partially 
 detached ovum upon the cervix, keeps up the rhythmical discharge 
 of energy from the nerve centres. 
 
 The most important classification of the causes of abortion is 
 the division into those causes which affect the ovum or uterus and 
 those which act directly upon the mother. In the former class are 
 comprised most of the morbid conditions which have already been 
 described among the diseases of pregnancy. The subdivisions of 
 this class are the following : — 
 
 (1) Primary morhid conditions of the Joetus, especially those leading 
 to its death. — If the foetus dies from any cause, its death is followed 
 by degenerative changes in the chorion or placenta, which no 
 longer continues in such active vital connection with the uterine 
 wall. The ovum then begins to act as a foreign body, and sooner 
 or later excites the uterus to expel it. The production of extra- 
 vasations of blood between the ovum and the uterine wall is often 
 an intermediate step. As already mentioned, the expulsion generally 
 takes place within a few weeks. Disease or malnutrition of the 
 foetus, even without causing its death, may also be associated with 
 similar changes in the membranes, and lead in the same way to 
 abortion. Among the causes leading to the death or malnutrition 
 of the foetus must be reckoned imperfect fertility on the part of 
 either or both parents. Conception followed by abortion may thus 
 be a stage on the way to complete sterility. Syphilis is one of the 
 most frequent and important causes leading to abortion through 
 death of the foetus, as well as through disease of the foetal mem- 
 branes, and it often produces this effect in successive pregnancies. 
 In the case, therefore, of repeated abortions, without other manifest 
 cause, special inquiry should always be made for any history or sign 
 of syphilis in either parent. If none such can be found, a diagnosis 
 may sometimes be made by examination of the foetus (see p. 541). 
 
Premature Expulsion of the Ovum. 571 
 
 (2) Primary morbid conditions of the amnion, chorion or decidua 
 (see pp. 510 — 550). — These may either first cause the death of the 
 foetus, or may directly lead to abortion by irritating the uterus. 
 Those morbid conditions which lead to haemorrhage, and consequent 
 separation of chorion or placenta, are of special importance. 
 Haemorrhages into and white infarcts of the placenta are also 
 frequent causes. Besides morbid conditions produced by disease, 
 separation of placenta and haemorrhage often arise from mechanical 
 causes, especially in cases of placenta praevia. Among these may 
 be mentioned shocks, blows, excessive coitus, the use of instruments 
 for the induction of criminal abortion, violent muscular exertion, 
 and even the effect of coughing, vomiting, or straining at stool. 
 
 (3) Morbid conditions of the uterus. — These may be displacement, 
 especially retroversion and retroflexion (see p. 496), inflammation 
 of the whole substance of the uterus, the presence of fibroid or other 
 tumours, or fixation by peritoneal adhesions. 
 
 Causes affecting the mother directly form the second main class. 
 Certain drugs, called oxtyocics, have more or less power of exciting 
 contractions of the uterus, and by this means may cause abortion. 
 Those most efficacious appear to be ergot, and quinine in large 
 doses (ten grains or more). Digitalis in large doses has perhaps a 
 similar effect. Savin and cantharides have also been taken 
 criminally with this object, and have sometimes had the desired 
 effect. All these drugs are very uncertain in their action, unless 
 there is a predisposition to abort. When ergotism is produced by 
 the poisonous effects of ergot of rye, eaten in bread, abortion may 
 result. 
 
 All acute febrile diseases tend to cause abortion. The poison 
 of certain zymotic diseases has, however, a special tendency to 
 produce this effect, apart from the degree of fever, apparently by its 
 influence on the nerve centres. Of these, small-pox and pneumonia 
 are marked examples. With this effect of a zymotic poison may 
 be compared the similar effect of other poisons, such as lead, 
 excess of carbonic acid in the blood from asphyxia, whether due to 
 mechanical cause or heart or lung diseases, and the poison which 
 exists in the blood in renal disease. In the last case abortion or 
 premature labour may be produced directly, as well as through 
 death of the ffjetus. Of mineral poisons, lead has been most 
 frequently noted as a cause of abortion, generally through its 
 leading to the death of the fcetus. It appears to be capable of 
 producing this result even by acting in a remote way through the 
 father. For it has been recorded that, when workmen have suffered 
 from lead poisoning, their wives have been specially liable to abort. 
 
572 The Practice of Midwifery. 
 
 Apart from any special poison, expulsion of the ovum is apt to 
 occur in any very grave disease of the mother, especially as a fatal 
 issue is approaching. It happens also sometimes from extreme 
 malnutrition, as in times of famine, or in excessive vomiting of 
 pregnancy. Other general states of the system, such as heart 
 disease, or cirrhosis of liver, may act by producing hyperemia of 
 the decidua and consequent extravasation of blood. 
 
 Causes acting through the Nervous System. — Abortion is often 
 produced by some sudden or violent emotion, such as fright, grief, 
 anxiety, shock, hearing bad news, or seeing some startling sight. 
 Such emotional causes are sj^ecially operative either as exciting 
 causes, when there is already some predisposing cause at work, or 
 in women of highly sensitive and neurotic disposition. Other 
 causes produce a reflex effect through the impressions upon 
 peripheral nerves. Thus continuing to suckle an infant after 
 pregnancy has recurred may lead to abortion, suckling having a 
 well-known tendency to set up uterine contractions. In the same 
 way is to be explained the occasional effect of severe pain, such 
 as toothache, of violent purgatives, of any surgical operation, such 
 as even the extraction of a tooth, but more especially of operations 
 in the neighbourhood of the uterus, of vaginal syringing, or 
 distension of the vagina by a plug or india-rubber dilator. 
 
 It has been sujDposed that in some cases a habit of aborting at 
 about the same date in successive pregnancies has become estab- 
 lished. There seems to be no positive proof of the possibility of 
 this, and it is probable that in most such cases there has been 
 some persistent cause, such as syphilis, or endometritis, or uterine 
 displacement, which would naturally lead to abortion at about the 
 same date of pregnancy. 
 
 Examination of the ovum will sometimes reveal the cause of the 
 abortion in the shape of degenerative changes in the chorion or 
 decidua, or signs of syphilis in the fcetus. 
 
 In the early months the commonest causes of abortion may be 
 said to be endometritis and retroversion of the uterus, and in the 
 later months syphilis and chronic Bright's disease. 
 
 Symptoms and Course of Abortion. — The earliest symptom 
 of abortion is usually uterine haemorrhage. For if the starting- 
 point of the process is uterine contraction, the contraction leads 
 to a partial detachment of the ovum, and consequent rupture of 
 vessels, before the escape of the liquor amnii, and generally before 
 the contraction is manifestly felt as pain. If, on the other hand, 
 the starting-point is extravasation of blood into the foetal 
 
Premature Expulsion of the Ovum. 573 
 
 membranes, some of the blood generally breaks through into the 
 decidual cavity, and escapes externally through the cervix. The 
 bleeding may at first be slight and intermittent, but is increased 
 in quantity when uterine contractions become active, and the ovum 
 begins to be more completely sejDarated, and forced down into the 
 cervix. Clots of considerable size are generally passed before the 
 ovum itself is expelled. The bleeding may continue, continuous or 
 intermittent, for some days before the pains come on. In rare 
 cases it may last even for weeks before ending in abortion. Loss 
 of blood is generally greater after the second month, when the 
 cervix has to be dilated to a considerable size before the ovum can 
 
 Fig. 301. — Foetus expelled entire with the membrane and placenta at the 7th month. 
 (Univ. Coll. Hosp. Med. School Mus.) 
 
 pass. It may then be sufficient to cause syncope, and reduce the 
 patient to extreme anaemia, but rarely proves fatal. This is especially 
 likely to occur when the uterus contains a hydatidiform mole, 
 or when degenerative changes or fibromyomata are present in its 
 walls. 
 
 Within the first two months the pains of expulsion may not be 
 very different from those of dysmenorrhoea. The later the stage 
 of pregnancy, the more do the pains resemble those of labour at 
 term. Cases of abortion commencing with intermittent pains, 
 due to uterine contraction, and leading to haemorrhage only in the 
 later stage, are rarer than those in which the hemorrhage is the 
 first symptom. They are generally cases which occur somewhat 
 
574 The Practice of Midwifery. 
 
 later in pregnancy ; within the first two months, haemorrhage 
 almost always occurs at the commencement. In premature labour, 
 or in abortion when pregnancy has nearly reached the sixth month, 
 there is not necessarily any haemorrhage before the birth of the 
 foetus, unless the starting-point of the premature expulsion has 
 been extravasation of blood. 
 
 Incomplete Abortion. — Occasionally, even when the amnion is 
 expelled intact, the incipient placenta remains attached to the 
 uterus. This happens much more frequently when the amnion is 
 ruptured, and the embryo escapes first. If the attachment of the 
 placenta is too firm for the subsequent uterine contractions to 
 break it down, the cervix may close up again, and the uterus 
 become quiescent. Generally contractions recur, and the mass is 
 exj)elled, after a few hours, or within two or three days, but 
 sometimes it is retained for weeks, or even months. In other 
 cases the main mass of the placenta is expelled immediately or 
 shortly after the embryo, but some portion of it is more adherent, 
 and remains in utcro. 
 
 The result of incomplete abortion varies according to the firm- 
 ness of attachment of the placenta to the uterus. If there is close 
 attachment over nearly the whole surface, decomposition may be 
 averted. There is then generally but slight htemorrhage in the 
 first stage of the abortion. Usually some haemorrhage occurs, 
 either continuously or at intervals, so long as there is placenta 
 retained. In rare cases, when the attachment is very general, there 
 is none at all for a considerable time, and it may even be supposed 
 that pregnancy is continuing. Eventually, often at the date of a 
 menstrual epoch, active uterine contractions come on, separate 
 more of the placenta, and then there is increased haemorrhage until 
 the whole is either expelled or artificially removed. 
 
 More frequently, the union of the placenta is not close enough 
 to preserve its vitality, decomposition occurs, and in a day or two 
 offensive discharge begins. The placenta is generally expelled 
 after a time piecemeal, when the firmness of adhesion has been 
 broken down by putrefaction. The decomj)osition is much 
 promoted if the finger has been introduced in futile attempts to 
 remove the placenta, and air thereby admitted to the uterus. 
 Sometimes a mass of placental tissue hangs only by a small band 
 of adhesions, and is forced down into the cervix uteri, or through 
 the cervix into the vagina, the body of the uterus contracting up 
 into small bulk. The projecting portion of tissue then most 
 readily becomes putrid. In other cases, again, the portion of 
 placenta, while taking a polypoid form, retains some vitality or is 
 
Premature Expulsion of the Ovum. 575, 
 
 preserved from decomposition by being retained within the uterus 
 without free access of air or saprophytic microbes, and often 
 becomes coated with fibrin, as well as infiltrated with clot. Such 
 a structure has been called a placental 'polypus or fibrinous x>olypus. 
 In rare cases the patient recovers without any placental mass ever 
 making its appearance. The placenta must, in such eases, have 
 broken down in shreds. 
 
 When decomposition of the placenta occurs, the patient is exposed 
 to the risk of septic intoxication and septic infection, as in the case 
 of retention of portions of placenta after full- term delivery. The 
 disease, however, is not usually so severe, and rarely leads to a 
 fatal result, although sometimes death does occur. Frequently 
 rigors come on within two or three days after the initial stage of 
 the abortion, followed by high temperature, quick pulse, and other 
 constitutional symptoms. Pelvic peritonitis or pelvic cellulitis 
 not uncommonly follows, more especially the former, and often 
 - the foundation is laid for chronic uterine malady. As in cases 
 following full-term delivery, the disease may either be simply 
 septic intoxication, that is, poisonous effects from the absorption of 
 chemical products of decomposition, or septic infection proper, in 
 which there is, in addition, the multiplication of septic organisms 
 in the blood or tissues (see Chapter XXXIX.). In most cases the 
 symptoms subside quickly after removal of the putrid material, 
 and hence it may be presumed that septic intoxication only is at 
 any rate the m.ain element in the case. Yery severe cases, however, 
 may resemble the gravest forms of puerperal septicaemia, and be 
 marked by diarrhoea, vomiting, severe headache, great abdominal 
 distension, and other signs of general septic peritonitis. Such 
 cases occur especially after the criminal induction of abortion, in 
 which septic microbes may have been introduced to the uterus. 
 
 Diagnosis. — In the diagnosis of an abortion the first thing to 
 determine is the existence of pregnancy. Pregnancy existing, the 
 occurrence either of uterine haemorrhage, or of pains due to 
 rhythmical uterine contractions, is invariably a sign of threatening 
 abortion. The chief difficulty often is to determine whether preg- 
 nancy does exist, especially if irregular haemorrhage has continued 
 for some time. The diagnosis of pregnancy must be made by the 
 ordinary physical signs of that condition, especially, in the early 
 months, by the estimation bimanually of the size, shape, and con- 
 sistency of the uterus (see Chapter IX.). A vaginal examination 
 should always be made, the hand being first disinfected as in the 
 case of labour, and, if the os is found dilated, and a part of the 
 ovum presenting there, or expelled into the vagina, the diagnosis 
 
576 
 
 The Practice of Midwifery. 
 
 will be undoubted, not only of threatened, but of inevitable or 
 partially completed abortion. The only thing likely to be mistaken 
 for an ovum is a soft polypus, or soft fibroid tumour, the lower 
 segment only of which can be reached by the finger. If the 
 w^hole can be reached, a polypus will be distinguished by having 
 a iDedicle, which cannot be separated by the finger, while an ovum, 
 or portion of ovum, is readily detached. 
 
 If a substance has been passed j^e?- vaginam, examination of this 
 will determine whether an abortion has occurred or not, and 
 whether the whole of the ovum has been expelled. In the absence 
 of an embryo, chorionic villi should be sought for, to decide the 
 fact of abortion. They may be seen most readily if the blood is 
 
 Fig. 302. — Ovum expelled in abortion in third month ; dr, decidua refiexa, the 
 front portion removed to show interior of ovum ; dr, decidua vera, showing 
 orifices of uterine glands ; c, chorion commencing to form placenta. 
 
 Washed away, and the mass floated out in water. A small portion 
 of anything which resembles villi should then be spread out upon 
 a slide and examined with a low microscopic power. If decidua 
 only can be detected, it must be remembered that a decidua of con- 
 siderable thickness, even intact enough to form a cast of the whole 
 uterus, is sometimes passed in membranous dysmenorrhoea, and 
 that a decidua with cells like those of normal pregnancy is formed 
 and often passed in extra-uterine foetation. 
 
 Generally the decidua reflexa comes away, covering the ovum, and 
 may bring away with it a portion of the decidua vera, attached to 
 its border (Fig. 302). Special care should be taken to make sure 
 that the embryonic placenta is not left behind. 
 
Premature Expulsion of the Ovum. 577 
 
 If the substance passed has not been kept for examination, doubt 
 may exist whether a part or the whole of the ovum is still retained 
 in the uterus, and if so, whether it is still continuing to develop or 
 is dead. The continuance of the pregnancy can often only be 
 determined by noting the size of the uterus and ascertaining at a 
 subsequent examination if it has increased in size to a degree 
 proportionate to the interval of time which has elapsed. 
 
 If the whole still remains, this will generally be revealed by the 
 size of the fundus uteri, estimated bimanually. If a part only is 
 retained, the sanguineous discharge will be excessive in amount, 
 with the passage of clots, or protracted, or will recur from time to 
 time. The cervix uteri also is more likely to continue patulous if 
 any considerable piece of ovum remains within, and uterine con- 
 tractions will recur, while it will close up and uterine contractions 
 will cease if the whole has been evacuated. Offensive discharge 
 generally indicates some placenta retained and decomposing. 
 
 Prognosis. — A fatal result from abortion is comparatively rare, 
 but does occur occasionally, sometimes from hgemorrhage, more 
 frequently from the effect of septic infection. It is estimated by 
 Lusk, from the statistics of deaths in New York City, that deaths 
 from all causes after abortion are nearly as numerous in proportion 
 as deaths from metria after delivery at full term, if it be correct to 
 reckon one abortion to every eight to ten full-term deliveries. I 
 have known abortion in the third month not only end fatally, but 
 form the starting-point of a series of cases of fatal puerperal 
 septicaemia in the practice of the medical attendant. Death, 
 however, is very rare, if abortion is treated efficiently from the 
 outset. Abortion very frequently leaves behind it chronic uterine 
 disease, chronic congestion and hypertrophy of the mucous mem- 
 brane, so-called endometritis jjosi ahortum, associated with 
 subinvolution of the uterus. Several causes tend to this result. 
 First, there is frequently some already existing morbid state of the 
 uterus, the cause of the abortion ; secondly, women often disregard 
 an abortion, and omit to take sufficient rest and care afterwards ; 
 and, thirdly, the natural stimulus of lactation in promoting the 
 contraction and thereby the involution of the uterus is wanting. 
 
 I'he danger of criminal abortion is very much greater than that 
 of spontaneous abortion. This is to be explained partly because 
 instruments are often used by unskilled persons when the object 
 is criminal, partly because the healthy ovum has a closer and 
 more vascular connection with the uterine wall, so that its separa- 
 tion is more likely to be incomplete, or to be attended with profuse 
 
578 The Practice of Midwifery. 
 
 bleeding. Of cases of criminal abortion which have been made 
 public, the women have died in not less than half. It must, 
 however, of course be remembered that the death of the woman 
 is generally the circumstance which leads to investigation and 
 detection, and that many other cases remain undetected. 
 
 Prophylactic Treatment. — When any evidence of syphilis in 
 either parent has been discovered a prolonged course of mercury^ 
 should be given to both parents in the intervals of pregnancy, and 
 to the mother throughout pregnancy. In the case of retroflexion 
 or retroversion of the uterus the displacement should be corrected, 
 and a pessary should be worn up to about the middle of the fourth 
 month. 
 
 With women who have already shown a predisposition to abortion, 
 and with neurotic and excitable subjects generally, special care 
 should be taken to avoid all exciting causes, bodily or mental. The 
 care should be greatest for the first four months, and especially at 
 the first two or three menstrual epochs, at which times it is often 
 prudent to keep the woman in bed for a few days, while in cases 
 of habitual abortion without obvious cause it may be necessary to 
 keep the patient in bed until she quickens or even longer. The 
 exciting causes most to be guarded against are mental excitement 
 or alarm and undue muscular exertion. In some cases even 
 travelling and riding in a carriage have to be given up. Strong 
 purgatives and the use of vaginal syringing either too vigorously 
 or with too hot or cold water should also be avoided. Though it is 
 not usual with the human race to give up coitus during pregnancy, 
 some women who are especially prone to abort only go to the full 
 term if they occupy a separate room from their husbands during 
 pregnancy, or at any rate for the first four months. 
 
 When repeated abortion occurs apart from syphilis or displace- 
 ment of the uterus, or exciting causes, the most probable explanation 
 is a chronic endometritis. For this the most effectual treatment 
 is often curetting the endometrium after dilatation. 
 
 Treatment of Threatened Abortion. — So long as haemorrhage 
 is not very severe, while there is no proof of escape of the liquor 
 amnii, and the cervix is not dilated so as to allow the ovum to be 
 felt presenting, abortion may be regarded as only threatened and 
 not inevitable, and an effort made to avert it. This is rarely, 
 however, successful if both haemorrhage and rhythmical pains are 
 
 i The following formula may be used : — Liq. Hydiarg. Perchlor. nj Ixxx. ; Acidi 
 Hydrochlor. dil. m x. ; Syrupi 3j. ; Aq. ad. 3J. ; ter quotidie. 
 
Premature Expulsion of the Ovum. 579 
 
 present ; if only one of these symptoms exists, the attempt is much 
 more hopeful. In all cases of threatened abortion the first necessity 
 is to direct that the patient should be kept completely at rest in 
 bed and that any solid substances passed should be saved for 
 examination. If haemorrhage is at all considerable the bed-pan 
 should be used. The patient should not leave her bed, or be lifted 
 up from the horizontal position for any purpose, and should avoid 
 all movement as far as possible. Diet should be light. Alcohol 
 and very hot or cold liquids should be avoided. If retroversion or 
 retroflexion of the uterus is detected on vaginal examination the 
 uterus should be restored, if possible, by gentle manipulation, in 
 the manner previously described (see p. 502). In general it is 
 better to wait till the symptoms have been quieted by rest and 
 sedatives before introducing a pessary. 
 
 The drug most to be relied on to check the action of the uterus 
 is opium. A subcutaneous injection of morphia may be given to 
 start with ; or Battley's liquor opii sedativus or nepenthe may be 
 given in twenty-minim doses for two or three doses, and after- 
 wards in ten-minim doses every four hours. If the abortion does 
 not become inevitable, the opiate must be continued until all 
 symptoms have completely subsided, and the patient should still 
 be kept in bed for a week or ten days afterwards. Purgatives 
 should be specially avoided, and the bowels should be relieved, 
 if necessary, by enema ; or, when symptoms are subsiding, by 
 gentle laxatives. An American preparation, the liquid extract of 
 Viburnum prunifolium, has been recommended as having a special 
 influence in averting uterine contractions. It is given in drachm 
 doses. Bromide of potassium is also sometimes useful in addition 
 to opium, or when opium is not well tolerated. When haemorrhage 
 persists for many days or weeks consecutively without the occurrence 
 of active contractions, and is sufficient in quantity to necessitate 
 further treatment, ergot may be given in small doses, such as 
 ten or fifteen minims of the liquid extract, in combination with 
 opium. With this treatment there is a certain risk that the 
 uterus may be excited to expel its contents, but frequently the 
 ergot in such doses induces only gentle tonic contraction of the 
 uterus. As the drug also tends to contract the arteries and 
 diminish the force of the heart, it may then be successful in 
 bringing about arrest of haemorrhage without the occurrence 
 of abortion. 
 
 Treatment of Inevitable Abortion. — Abortion may be regarded 
 as inevitable, if the ovum is felt presenting through the dilated 
 
 37—2 
 
580 The Practice of Midwifery, 
 
 OS, if the liquor amnii has, without doubt, escaped, or if the 
 haemorrhage is very excessive. If any considerable clots have 
 ])een expelled through the cervix uteri, the abortion almost always 
 proves inevitable, but the pregnancy has been known to continue 
 notwithstanding. Assuming that the abortion is inevitable, it 
 is to be remembered that the process is to a certain extent a 
 natural one, resembling labour on a small scale, and that inter- 
 ference is necessary only when haemorrhage is excessive, or the 
 evacuation of the uterus incomplete. Within the first eight or 
 ten weeks of pregnancy it is especially desirable to avoid premature 
 or needless manipulation, since this is likely to lead to rupture of 
 the ovum, which otherwise may be expelled intact. After the 
 fourth month, also, the process of abortion approximates more and 
 more to that of delivery ; there may be little or no haemorrhage 
 before the birth of the foetus, and, if so, no interference is required 
 at that stage. 
 
 In the early months haemorrhage is rarely very excessive, pro- 
 vided that the ovum is expelled entire, as the ovum itself, in such 
 cases, forms a plug when pressed down into the cervix. The ovum 
 need not then be removed by the finger unless the whole of it is 
 felt as having descended into the vagina, or at any rate into the 
 expanded cervix. If portions of the decidua vera remain attached 
 to the uterine wall, after the expulsion of the intact ovum, they 
 need not be sought for by the finger, but may be left to break up 
 and come away in the discharges. When the liquor amnii escapes, 
 especially in the third or fourth month of pregnancy, there may 
 be considerable haemorrhage either before or after the expulsion 
 of the embryo. In this case the treatment to be adopted varies 
 according to the condition of the cervix. If the cervix is undi- 
 lated, and the ovum out of reach, the choice lies between plugging 
 the vagina, or introducing a laminaria or tupelo tent into the cervix 
 and adding a vaginal plug. Plugging the vagina is generally 
 preferable, since materials for the purpose are always at hand, and 
 the risk attendant on the use of tents is thus avoided. The plug 
 not only arrests the bleeding, if properly applied, but acts as a 
 stimulus to uterine contraction, so that the ovum often is found 
 lying behind it, when the plug is removed. 
 
 Method of plugging the Vagina. — The vulva having been 
 carefully cleansed, a vaginal douche should be given of lysol 1 per 
 cent, or some other antiseptic lotion. The best material to use is 
 sterilised iodoform gauze in long strips. In the absence of this 
 rather broad strips of lint or linen about a foot long may be taken, 
 
Premature Expulsion of the Ovum. 581 
 
 sterilised by boiling, and either moistened with some antiseptic 
 such as cyllin or lysol *5 per cent, solution, perchloride of mercury 
 1 in 3,000, iodised glycerine, or else dusted with iodoform. Strip 
 after strip is then packed in through a Sim's sjieculum until the 
 whole vagina is firmly plugged. The plug should not be left in 
 more than about six hours unless it be iodoform gauze, in which 
 case it may be left in twelve or even eighteen hours, after which 
 time it may be reapplied if necessary, and the vagina should be 
 again irrigated with an antiseptic lotion on its removal. 
 
 In conjunction with the use of a vaginal plug, a full dose of ergot 
 may be given in a case of abortion with considerable haemorrhage. 
 The most effectual and rapid method is to give a subcutaneous 
 injection of ergotin or ernutin, passing the syringe deeply into 
 the gluteal muscles. Failing this, one or two drachms of the 
 liquid extract, or liquor ergotae ammoniatus, may be given by 
 mouth. 
 
 If the ovum is not expelled after two aj)plications of the vaginal 
 plug, nor the os sufficiently dilated to allow it to be extracted, the 
 cervix should be dilated under anaesthesia with Hegar's metal 
 dilators. 
 
 Method of using Hegar's Dilators. — The vagina being first dis- 
 infected, the patient is anaesthetised and placed in the lithotomy 
 position, a Sim's or Auvard's speculum passed, and the cervix seized 
 and drawn down by a vulsellum. A size of dilator which will quite 
 easily pass is first used. Then successive sizes are passed, up to 
 about No. 20, when the cervix will be large enough to admit the 
 finger. When there is much resistance, it may be necessary to 
 spend one, two, or three minutes in the introduction of each. 
 
 Method of using Tents. — Laminaria or tupelo tents sterilised by 
 being kept in a saturated solution of iodoform and ether, or in an 
 alcoholic solution of perchloride of mercury 1 in 1,000, should be 
 used. Laminaria tents have the greater power ; tupelo tents 
 expand more quickly. Either may be smeared with salicylic 
 cream^ or iodoform and vaseline, and mounted upon a Barnes' tent 
 introducer. The introducer with the tent may then be passed like 
 the uterine sound, without the use of a speculum, the patient lying 
 in the left lateral position ; or Sim's speculum may be used, the 
 cervix being drawn forward and fixed with a vulsellum. In case of 
 difficulty the latter method should be chosen. If the cervix is 
 small, a single tent only is used ; if it is already somewhat dilated, 
 several are placed side by side. The ends should project through 
 
 1 Salicylic acid, I part ; vaseline, 8 parts. 
 
5^2 The Practice of Midwifery. 
 
 the external os. In the present case, the vagina should be 
 moderately jjlugged below the tents, to keep them m position, and 
 aid in arresting haemorrhage. Laminaria tents should not be left 
 more than about eight hours, tupelo tents not more than three or 
 four hours. On their removal, an antiseptic douche should be 
 again used. If dilatation is still insufficient, it should be com- 
 pleted with Hegar's dilators under an anaesthetic. 
 
 Method of evacuating the Uterus. — If the os is dilated enough to 
 allow the ovum to pass, or, in the case of an early abortion, to 
 admit the finger, the uterus should be emptied at once, if the 
 haemorrhage is so considerable as to require interference. The 
 manipulation now to be described is also to be carried out in 
 precisely the same way, if there is occasion to remove the placenta 
 after escape of the embryo. Unless pregnancy has been far 
 advanced the index finger only is to be introduced into the uterus. 
 The great principle to be followed is, if possible, to bring down the 
 uterus within reach of the finger by external pressure rather than 
 to force the finger up to the uterus. The first essential is that the 
 bladder should be emptied, and it is generally well to make quite 
 certain of this by passing the catheter. An anaesthetic greatly 
 facilitates the operation. In its absence, as much relaxation as 
 possible of the abdominal muscles must be secured. For this 
 j)uri3ose, the head should be supported by a low pillow only, the 
 shoulders low, the thighs flexed. The left hand is then pressed 
 deej)ly into the abdomen, not too near the pubes, so as to get behind 
 the uterus, and bring the fundus forward close behind the uf)per 
 margin of the symphysis pubis. It is of the utmost importance that 
 the uterus should always be brought into this position, as in this 
 way alone is it possible to reach the fundus of the uterus when the 
 pregnancy is at all advanced. If the uterus can once be got into 
 this position, it is generally possible to evacuate it without intro- 
 ducing more than a single finger into the vagina, and to get the 
 finger quite up to the fundus by the time that the evacuation is 
 complete. In introducing the finger, the cervix is drawn somewhat 
 forward by the tip of the finger hooked into it, while the fundus is 
 pressed downward by the external hand. 
 
 If possible, the finger is passed behind and above the ovum or 
 placenta. The flexor surface of the finger then sweeps the retained 
 mass so far as possible as a whole downward into the vagina. If it 
 is impossible at first to reach above the retained ovum, what is 
 within reach may be removed first. Then the uterus contracts up, 
 as it is emptied, with the aid of external pressure, and brings the 
 remainder within reach. The finger should not be finally withdrawn 
 
Premature Expulsion of the Ovum. 583 
 
 until the cavity is to a great extent closed up, otherwise bleeding 
 may occur, and clots be formed within it. In closing up, the cavity 
 tends to resume the flattened form it has in the unimpregnated 
 uterus. The right index finger, sweeping across from the left to 
 the right cornu, can then finally make sure that nothing remains 
 attached to its walls. 
 
 When the uterus has once fully retracted there is hardly ever any 
 
 Fig. 30.S. — Evacuation of the uterus in a case of early abortion. 
 
 hgemorrhage beyond the ordinary discharge, analogous to the 
 lochial discharge. It hardly ever happens, therefore, that any 
 styptic is required to arrest bleeding. If contraction fails and 
 serious bleeding does occur, an intra-uterine douche of sterile 
 water, lysol solution 1 per cent., or any other weak antiseptic 
 lotion at a temperature of 115'^ to 118° F., should be employed, or 
 if this fails to arrest the bleeding the uterus should be plugged with 
 antiseptic gauze as tightly as possible. In the case of an early 
 
584 
 
 The Practice of Midwifery. 
 
 abortion this is an easy and certain method of arresting the 
 bleeding. 
 
 There are two causes which are apt to render it difficult to get 
 the uterus into the requisite position of anteflexion — first, rigidity 
 of the abdominal muscles, or thickness of abdominal walls ; and, 
 secondly, a niore or less retroverted or retroflexed position of the 
 uterus. The difficulty is greatest when the two are combined, for 
 then the external hand cannot get behind the fundus without being 
 pressed in very deeply, and this the abdominal walls will not allow. 
 Several expedients may be used to overcome the difficulty. Kigidity 
 of muscles is most completely overcome by an anaesthetic, and in 
 all cases it is better to administer one. When 
 the muscles are once fully relaxed by this 
 means, there is rarely any difficulty. 
 
 There are other means, however, which 
 often suffice, without the use of an anaesthetic. 
 If the woman has had children previously, 
 it will frequently be possible to pass the half- 
 hand (excluding the thumb) or even the whole 
 hand into the vagina. The index finger can 
 then be passed into the cervix, and used like 
 a rej)ositor, as in restoration of the uterus by 
 the sound, so as to bring the uterus forward 
 into anteversion, and enable the external hand 
 to command the fundus. If the half-hand 
 cannot be passed into the vagina, it may be 
 possible, by the use of a vulsellum, such as 
 that shown in Fig. 304, to get the index finger 
 far enough into the cervix to act as a repositor. 
 The tenaculum is fixed firmly into the anterior 
 lip, and the cervix is drawn forward while the finger is passed into it. 
 The tenaculum may then be given to an assistant, to keep up the 
 traction, while the left hand is transferred to the abdomen, and the 
 uterus brought into the position already described. It is better to 
 make counter-pressure with the external hand, rather than counter- 
 traction with the tenaculum, during the evacuation and passage of 
 the finger up to the fundus, otherwise the cervix may possibly be 
 lacerated by the tenaculum. When an offensive discharge is 
 present, it is better, if possible, to avoid the use of the tenaculum, 
 for fear that the punctures might afford a site for septic 
 absorption. 
 
 Various ovum forceps have been devised to remove ovum or 
 placenta, but the finger is a far better instrument than any. If the 
 
 Fig. 30i.— Author's 
 uterine vulsellum. 
 
Premature Expulsion of the Ovum. 585 
 
 placenta is adherent, it has generally to be removed in pieces. 
 Even though adherent or indurated, placental tissue is always soft 
 enough to be gradually broken up and detached from the uterine 
 wall by the pulp of the finger without use of the nail. As any piece 
 is detached, it is hooked between the finger and the uterine wall, 
 and drawn out of the uterus. The finger is then again introduced, 
 and so on till the whole is removed. As the uterus is emptied, it 
 generally contracts up upon the finger, diminishing 
 its cavity, and so facilitating the evacuation. The 
 operator should never desist until he has com- 
 pletely reached the fundus with his finger, and 
 made sure that all placenta is removed, leaving 
 nothing more than roughness, or slight shreds, at 
 the placental site. For if some of the placenta is 
 left, after entry of air has been facilitated by inser- 
 tion of the finger, there may be more decomposition, 
 and worse results than if no interference at all had 
 been undertaken. 
 
 The only use to which ovum forceps should ever 
 be applied is to draw out of the uterus pieces which 
 have already been detached or nearly detached, if 
 this cannot be done easily by the finger alone. 
 The cervix may have contracted up, so as barely 
 to allow the finger to pass, while the body of the 
 uterus remains comparatively large and globular. 
 It is then difficult to hook a loose piece out of the 
 wider cavity into the cervix already filled by the 
 finger. The piece may then be grasped by forceps, 
 guided up to it by the finger. Forceps for this 
 purpose should be somewhat curved to suit the 
 genital canal : the blades should be not more than 
 half an inch wide, and should have transverse 
 ridges, interlocking with each other, so as to give 
 a firm grasp (see Fig. 305). 
 
 Fig. 305.— Ovum 
 forceps. 
 
 Treatment of Incomplete Abortion. — If the foetus has 
 escaped and the placenta or decidua remains behind, it is of 
 the greatest importance to effect an early and complete evacuation 
 of the uterus. Though this principle is generally accepted by all 
 good authorities, it is not yet universally carried out in practice. 
 Digital extraction of the placenta is necessarily unpleasant to the 
 patient ; and, if she is intolerant of manipulation, and reluctant to 
 take an anajsthetic, there is a temptation to leave the case to nature — 
 
586 The Practice of Midwifery. 
 
 at any rate, until decomposition occurs, or constitutional disturbance 
 arises. It is true that the patient generally recovers, if this practice 
 be adopted, and that the placenta is usually expelled after a few days. 
 The disadvantages, however, are many. There is some risk of even 
 fatal septicaemia. The jolacenta, if adherent, is generally not 
 expelled till softening by decomposition has begun, and fragments 
 of it are apt even then to be retained, and to cause persistent or 
 recurrent haemorrhage. The patient generally goes through a stage 
 of febrile disturbance, due to some degree of septic absorption, and 
 often accompanied by some metritis, pelvic peritonitis, or cellulitis. 
 As a result of this, the natural involution of the uterus is retarded 
 by the active hyperaemia kept up by the inflammation, and chronic 
 uterine trouble is apt to remain afterwards. 
 
 Immediate emptying of the uterus must be the invariable rule in 
 all cases where the haemorrhage is excessive, the temperature at all 
 raised, or the discharge in the least degree offensive. If none of 
 these indications are present, the length of time for which the 
 placenta may be left must depend upon the circumstances of the 
 case. If the patient is tolerant, and the uterus can be easily cleared 
 out without an anaesthetic, it is well not to wait more than an hour 
 after the passage of the foetus. The cervix is then sure to be large 
 enough to let the finger pass easily, whereas later on it may have 
 closed up again more or less. If an anaesthetic is required, there 
 should be an assistant to administer it ; for the operation must be 
 carried out verj' deliberately and carefully, and an imperfect 
 evacuation is often worse than no interference at all. Meanwhile 
 the placenta should not be allowed to remain more than about 
 twelve, or, at the outside, twenty-four hours. If the assistance of 
 an expert in obstetrics is available for the operation, it is often of 
 advantage. If there is haemorrhage, the vagina may be plugged 
 meanwhile, care being taken either to use iodoform gauze or to 
 moisten the strips of sterilised lint with some antiseptic — lysol, 
 •5 per cent. ; perchloride of mercury, 1 in 3,000; or cyllin, '5 per 
 cent. — and not to leave the plug more than twelve hours at the 
 utmost. On removal the placenta will sometimes be found lying 
 above the plug. The less the haemorrhage, the greater is the pro- 
 bability that the j)lacenta is firmly adherent, and not likely to be 
 expelled by nature. The operation is to be carried out according 
 to the method already described. 
 
 It may happen that the case is only seen at a later stage, when 
 the placenta has been already retained for days, or when doubt 
 exists whether it has come away or not. Or again, haemorrhage 
 may be persisting or recurrent at a considerable interval, even for 
 
Premature Expulsion of the Ovum. 587 
 
 weeks, after the commencement of the abortion. The presence of 
 an offensive discharge, or the large size of the body of the uterus 
 felt bimanually, will be a sign that the uterus is certainly not 
 emptied. In any case the principle of treatment is the same as in 
 the former instance, namely, to exj)lore completely the uterine 
 cavity up to the fundus, and make sure that it is entirely emptied. 
 The course of action to be adopted 
 will depend upon the condition of 
 the cervix. If any considerable 
 portion of the placenta remains, 
 especially when there is enough to 
 cause an offensive discharge, the 
 cervix will generally remain open 
 enough to allow the finger to be 
 passed through with steady pres- 
 sure, an anaesthetic being given if 
 required. If the cervix has closed 
 up too much for this, as is often 
 the case if only minute fragments of 
 placenta remain, or if the haemor- 
 rhage is due not to retained pla- 
 centa, but to a granular or villous 
 condition of the uterine mucous 
 membrane remaining after the abor- 
 tion, it must first be dilated. This 
 is a case in which rapid dilatation 
 with Hegar's dilators should be 
 carried out. 
 
 If any adherent placenta is found, 
 the finger will generally suffice to 
 detach it. If not, a curette may 
 be used for the purpose. If there 
 is evidence of sepsis, or decomposed 
 material is present, the blunt irri- 
 gating curette (Fig. 306) may be 
 employed, so that all debris detached 
 
 is at once washed away by an antiseptic solution. Lysol 1 per 
 cent., tinct. iodi 5j. ad Oj., or iodide of mercury 1 in 4,000, in boiled 
 water, may be used for the purpose. If no placenta is found, but 
 only a roughened, softened, or villous condition of mucous mem- 
 brane as a source of hgemorrhage, the surface should be scraped 
 with the sharp steel curette (Fig. 307), and iodised phenol applied 
 afterwards on a sound or Playfair's probe wrapped in absorbent 
 
 Fig. 306.— Iirl^ 
 ing curette. 
 
 Fig. 307.— Sim's 
 curette with 
 metal liandle. 
 
588 The Practice of Midwifery. 
 
 cotton wool. The curette will also remove any small fragments of 
 ovum or decidua which may remain adherent. Some authorities 
 advise plugging the uterine cavity with iodoform gauze after 
 curetting. In the absence of sepsis this is unnecessary, but it is 
 advisable if there is evidence of septic endometritis. Sterilised 
 moist iodoform gauze, 10 per cent., is the best for the purpose. If 
 plugging is employed, no caustic should be used to the endometrium. 
 
 If severe febrile symjDtoms arise within a few days after an 
 abortion, and there is not evidence that the uterus has been com- 
 pletely emptied, it may be presumed that there is septic absorption 
 from some portion of ovum retained in the uterine cavity. There 
 will sometimes be an offensive discharge to indicate this, but not 
 always. There may be decomposing matter in the uteras, and no 
 indication of it in the vagina, especially if vaginal syringing has 
 been employed. The uterus should be explored and emptied as 
 early as possible after the outset of the septic symptoms. If the 
 patient is seen only at a late stage, if there is a local swelling of 
 pelvic cellulitis or peritonitis to account for the febrile attack, if 
 the cervix has closed up and uterine discharge ceased, and it is 
 thought that the decomj^osing material has come away, it may be 
 desirable not to interfere actively. In case of doubt, the curette 
 may be used for diagnosis, to decide whether any pieces of ovum 
 still remain. 
 
 If the contents of the uterus have been found offensive, the 
 interior should be washed out with an antiseptic. A solution of lysol, 
 1 per cent., or of iodine, 1 — 2 drachms to the pint, may be used. The 
 best j)lan is to employ an ordinary douche with a long rubber tube 
 attached to one or other form of metal or glass intra-uterine tube, 
 of which Budin's is one of the best. Care must be taken to avoid 
 the entrance of air by allowing the solution to flow through the tube 
 and cannula before and while it is being introduced into the 
 uterus. 
 
 The so-called placental or fibrinous polypus (see p. 575) may 
 offer some obstacle to detachment by the finger, if the pedicle is 
 small, on account of its slippery character. In such a case it may 
 be removed with a pair of ovum forceps and the remains of the 
 pedicle detached with a curette. 
 
 Treatment of Abortion in the later months.^ — In the fifth and 
 sixth months interference for arrest of haemorrhage is much 
 more rarely required before the birth of the foetus. After delivery, 
 contraction of the uterus must be secured, as in labour at term, by 
 
Premature Expulsion of the Ovum. 589 
 
 external pressure, as a safeguard against haemorrhage. An attempt 
 may be made to effect the expulsion of the placenta by the method 
 of expression (see p. 309). Failing this, it will generally be neces- 
 sary for its removal to introduce the half or whole hand into the 
 vagina, and two fingers or the half-hand into the uterus. If the 
 placenta is attached on the right side of the uterus, it is most easy 
 to detach it by introducing the right hand, a.nd conversely, so that 
 the tips of the fingers may detach the upper border of the placenta 
 first. 
 
 After-treatment. — Patients are commonly inclined to make too 
 light of an abortion, and to get about too soon. This it one of the 
 reasons why chronic uterine disease is so often a sequel. As a rule 
 confinement to bed as long as after labour at term, or at any rate 
 until all sanguineous discharge has ceased, is desirable. After a 
 severe abortion in the third or fourth month with difficult extrac- 
 tion of the placenta, still more prolonged rest is often called for. 
 Care should be maintained for some weeks more, with a view to 
 preventing the subinvolution of the uterus which is apt to remain. 
 Involution may be assisted by a course for some weeks of the liquid 
 extract of ergot in half-drachm doses, or two or three grains of 
 ergotin in pill three times a day. A grain or two of sulphate of 
 quinine may often be added with advantage, or iron if there is 
 anaemia after haemorrhage. 
 
Chaptef XXV. 
 
 HEMORRHAGE IN PREGNANCY. 
 
 The consideration of hfemorrhage in the earlier months of 
 pregnancy resolves itself almost entirely into the consideration of 
 threatened abortion, Avhich has already been discussed. For the 
 causes tending to h?emoirhage tend also to excite premature 
 expulsion of the ovum ; and the haemorrhage itself, by separating 
 the placenta, or leading to the formation of clots which irritate the 
 uterus, increases this tendency. Placenta previa, so important a 
 cause of haemorrhage toward the end of pregnancy, may also be a 
 cause of it in the months which follow the differentiation of the 
 placenta. No doubt even before this, an incorrect implantation 
 of the ovum may have the same effect, though such a cause will 
 generally escape recognition. Placenta praevia is, however, only 
 the cause of a relatively small proportion of the cases of haemorrhage 
 occurring in the early and middle months. In persistent or re- 
 current haemorrhage in the fourth or fifth month, without obvious 
 exciting cause of abortion, placenta praevia is not found in more 
 than one-fifth of the cases. Some authorities, however, hold that 
 a development of part of the placenta on the decidua reflexa is a 
 more frequent source of haemorrhage and abortion in the early 
 months than has generally been supposed. 
 
 Menstruation in Pregnancy. — That the menstrual nisus does 
 to a certain degree persist during pregnancy is shown by the 
 special liability to abortion at what would have been menstrual 
 periods, as well as by the presumed onset of labour at the tenth 
 epoch after the last menstruation. Ovulation, however, during 
 pregnancy is an occurrence of extreme rarity. It is probable 
 that in many cases in which women themselves give a history 
 of menstruation in pregnancy, the bleeding has not been suffi- 
 ciently regular in its occurrence to entitle it to this description, 
 but has been really a bleeding indicating a threatened abortion. 
 Menstruation in pregnancy is occasionally met with, but is 
 extremely rare, so that, in any case of doubtful pregnancy, the 
 persistence of menstruation, however scanty, is a strong pre- 
 sumption against the pregnancy existing. The occurrence of one 
 
Haemorrhage in Pregnancy. 591 
 
 menstruation, or apparent menstruation, after conception, is not, 
 however, so very uncommon. It is much more rare for it to be 
 repeated two, three, four, or five times, and still far more so for it 
 to continue up to, or nearly up to, full term. 
 
 Up to the fourth month there is a decidual cavity, between the 
 decidua vera and refiexa, and it is therefore possible for menstrua- 
 tion to take place from the surface of the mucous membrane. It 
 is not positively known whether in the menstruation of pregnancy 
 any exfoliation of the surface takes place, as in ordinary menstrua- 
 tion, but this can hardly occur to any extent without involving also 
 the separation of the decidua basalis. 
 
 Women who menstruate in j^regnancy rarely have a perfectly 
 healthy uterus. Sometimes they have suffered previously from 
 menorrhagia. Frequently they are multiparse, and have erosion 
 or granular inflammation of the cervix from the effect of previous 
 parturition. It is believed that, in many cases, this inflamed cervix 
 is the site of the bleeding. If the blood comes from the body of the 
 uterus, probably exfoliation or rupture of superficial vessels is only 
 slight. After the fourth month, if menstruation continues, either 
 the blood must come from the cervix, or there must be, in fact, a 
 threatening of abortion at each month. A double uterus has not 
 been found to exist in recorded cases of menstruation in the later 
 months, and would not account for the occurrence if it did exist, 
 for the decidua formed in the unimpregnated side is generally 
 retained until after parturition. Menstruation in pregnancy must 
 therefore be regarded as a morbid occurrence, and women who so 
 menstruate should take special care to rest at the periods, as being 
 liable to the risk of abortion. 
 
 HAEMORRHAGE IN THE LATER MoNTHS OF FreGNANCY, PlACENTA 
 
 Previa, Accidental HiBMORRHAGB. 
 
 It has been usual to divide haemorrhage in the later months of 
 pregnancy, and before parturition, into two classes, " unavoidable 
 haemorrhage," that is, hsemorrhage due to placenta prsevia, or 
 implantation of the placenta so low down in the uterus that it must 
 become detached in the dilatation of the cervix, and " accidental 
 bajmorrhage," or hsemorrhage due to partial separation of a 
 normally situated placenta. 
 
 Placenta Pr;rvia. 
 
 Definition. — In placenta praevia, the placenta, instead of being 
 attached near the fundus, is situated low down in the body of the 
 
592 
 
 The Practice of Midwifery. 
 
 uterus, and is found in the later months either approximating to 
 or overlapping the internal os, so that a part of its insertion is on 
 the lower segment of the uterine body which has to be stretched 
 to allow the fcetus to pass. In Fig. 308, it is evident that 
 dilatation of the os to the size indicated by the dotted lines inevitably 
 detaches the lower part of the placenta, whether it stops just short 
 of the internal os or overlaps it. When it was believed, as formerly, 
 that a large part of the cavity of the cervix was taken up into the 
 
 Fig. 308. — Placenta piaevia. Two varieties of insertion are indicated : one in 
 which the placenta overlaps considerably the internal os, and would 
 appear as a complete placenta prsevia when the os was partially dilated ; 
 one in which it is attached just short of the internal os, and would appear 
 as partial placenta preevia, when the os was partially dilated. 
 
 cavity of the body of the uterus with the advance of pregnancy, it 
 was thought that the placenta might be attached to the internal 
 surface of the cervix. The phrase which has more recently been 
 used of attachment of the placenta to the " cervical zone " of the 
 uterus has also led sometimes to misconception. It must be clearly 
 borne in mind, therefore, that only the body of the uterus can give 
 attachment to the ovum, and that the mucous membrane of the 
 cervix is not adapted to this purpose. Although the theory of the 
 expansion of the upper part of the cervix has again been revived of 
 late (see p. 158), there is no doubt that, in placenta prsevia covering 
 
Haemorrhage in Pregnancy. 
 
 593 
 
 the internal os uteri (see Fig. 308, p. 592) at any rate, the internal 
 OS remains undilated up to the time that haemorrhage first occurs. 
 
 Causation. — The position of the placenta, when it is found to 
 be prsevia in the later months of pregnancy, may result either 
 from the ovum having been originally attached in the lower 
 segment of the body of the uterus, or from part of the placenta 
 having been developed upon the decidua reflexa on the lower side 
 of the ovum, or from both these conditions combined. Both have 
 been demonstrated as existing in the earlier months of pregnancy. 
 
 Now that it is known that the ovum burrows at once into the 
 
 Placenta 
 
 Internal os 
 
 Keflexal 
 placenta 
 
 Decidual 
 cavity 
 
 Bladder 
 
 Fig. 309. — Diagram of reflexal development of placenta at three months' 
 pregnancy, which vs^onld lead to placenta praevia overlapping the internal 
 OS in the later months. 
 
 mucous membrane on its attachment, it is evident that a placenta 
 covering the internal os before dilatation can only be due to a 
 reflexal development of placenta, since the ovum must have been 
 originally on one side or other of the os. It is probable that 
 both causes act together in producing a complete placenta prsevia. 
 For, if the ovum is attached near to the internal os, the expansion 
 of the decidua basalis will be impossible in the direction of the 
 cervical canal, and the necessary placental space may in conse- 
 quence be obtained by its development on the decidua reflexa,^ 
 which eventually becomes adherent to the uterine wall so as to 
 overlap the internal os. In such a case the reflexal portion of the 
 placenta is but imperfectly attached to the decidua vera, and 
 
 1 Hofmeier, Verhandlungea der Dcutschen Gcsellsch., 18'J7, p. 204. 
 M. 38 
 
594 The Practice of Midwifery. 
 
 therefore the separation of the two can occur without much 
 haemorrhage taking place. 
 
 Placenta prgevia is comparatively rare in primiparse and relatively 
 common in women who have had a number of children, especially 
 if the pregnancies have followed in rapid succession. It may be 
 inferred that it depends upon some morbid condition of the uterus 
 previous to conception, and this conclusion is often confirmed by the 
 previous history of patients in whom this condition is found. It is 
 probable that the chief element in causation is a dilatation of the 
 cavity of the uterus, due to subinvolution, hypertrophy, or 
 endometritis. The effect of this is likely to be that the ovum, 
 instead of being arrested at once by the mucous membrane nearly 
 filling up the cavity when it reaches the uterus from the Fallopian 
 tube, is liable to fall down to a lower part of the uterus before it 
 becomes attached. It is possible also that an inflammatory condi- 
 tion of the mucous membrane rendering the implantation of the 
 ovum less easy, or atrophy leading to imperfect vascularisation and 
 nutrition of the decidua, may have some influence in the matter. 
 
 Some authorities have ascribed j)lacenta praevia entirely to 
 reflexal development of the placenta. The possibility of a very low 
 attachment to the ovum, however, is demonstrated by a case, 
 figured by Hunter,^ of an abortion of four weeks, in which there is 
 a complete decidual cast of the uterus, with an ovum implanted at 
 its lowest extremity. 
 
 The difficulty of explaining the central attachment of the ovum 
 over the internal os has been overcome by the suggestion that the 
 developing ovum when it reaches the uterus is larger than the 
 opening of the internal os, and that very speedily after implantation 
 in that situation the two walls of the canal coalesce, and further 
 embedding of the ovum takes place in relation to both. 
 
 A placenta praevia is often found thinner and more widespread 
 than usual. The explanation may be either that a more extended 
 placenta has a greater chance of overlapping the zone of detach- 
 ment, or that the reflexal portion of the placenta, to which there is 
 less free access of blood, has to be more widespread to compensate 
 for this defect. The latter j)rinciple holds true to some extent at 
 any rate, for there is generally a special thinness around the 
 position of the internal os, and in that part of the placenta which is 
 on the opposite side of the internal os to the main mass. 
 
 Another explanation has been put forward by Strassmann^ who 
 
 1 Anat. Uteri Humani Grav., 1851, PI. XXXIV., Figs. 1 and 2. 
 
 2 Strassmann, Zeitschr. f. Geb. u. Gyn., 1901. Bd. 41, s. 529 ; Archiv f. Gynak., 
 1902, Bd. 67, Hft. 1, s. 112. 
 
Haemorrhage in Pregnancy. 
 
 595 
 
 considers it is due to a deficient vascularisation of the decidua, the 
 sequel of old chronic endometritis. 
 
 The facts now known with regard to the embedding of the early- 
 ovum and the splitting of the decidua vera to form the decidua 
 capsularis offer another and very probable explanation of the 
 development of at any rate some cases of placenta prsevia. If, for 
 example, with a rather low or " vicious insertion " of the placenta, 
 as it has been called, such splitting of the decidua takes place to an 
 
 Fig. 310. — Central placenta prasvia. 
 
 Fig. 311. — Marginal placenta prsevia and 
 a low implantation of the placenta in 
 lower uterine segment. 
 
 excessive degree, the decidua basalis may well have an extended 
 attachment to the lower uterine segment and so lead to the 
 formation of a placenta prsevia. It is probable indeed that a 
 primary low implantation of the ovum with an excessive splitting 
 of the decidua is the real explanation of the majority of these 
 cases. 
 
 Varieties. — It has been usual to divide placenta prsevia into 
 three varieties, complete, or central, when the whole of the os is 
 
 38—2 
 
596 
 
 The Practice of Midwifery. 
 
 covered by placenta j^a-i'tial, the commonest variety, when it is only 
 partially covered ; and marginal, when the placenta just reaches 
 the edge 6t the os. The true view ^of the relation of placenta 
 preevia to the internal os being adopted, these varieties have no 
 longer any strict accuracy. The varieties are still retained, but 
 are judged of according to the relation of the placenta to the 
 internal os when an examination is made, partial dilatation of the 
 
 Fig. 312. — Placenta previa, undisturbed by any commencement of labour. 
 The placenta just covers the internal os ; the cervical canal is intact. 
 (After Ahlfeld.) 
 
 OS having taken place. The classification of any given case may 
 therefore vary according to the stage of dilatation reached. Many 
 cases in which the placenta overlapped the undilated os will appear 
 as cases of only partial placenta praevia at the later stage ; and 
 many again in which it only approached the os and did not overlap 
 it at all will likewise appear, at the same stage, as cases of partial 
 j)lacenta prgevia, only somewhat less in degree. Further, the edge 
 of the placenta may reach withm the zone of necessary detachment 
 and yet never overlap the internal os at all, even when dilated. In 
 
Haemorrhage in Pregnancy. 597 
 
 such cases the placenta would be detected only if the finger were 
 passed within the uterus. It is only when the placenta approxi- 
 mates more or less toward a central position that it continues to 
 appear as a complete placenta prsevia throughout the whole 
 dilatation stage. 
 
 A more exact classification may be made of placenta prsevia as it 
 exists before any dilatation of the internal os has begun. There 
 are then only two varieties, one in which the placenta only 
 approximates to the internal os, but does not overlap it, and one 
 in which it overlaps it. The first is called marginal placenta 
 prsevia ; the second must be called complete placenta prsevia ; even 
 if only the edge of the placenta overlaps the os (Fig. 312). 
 
 Frequency. — The frequency of placenta prsevia has been 
 variously estimated at from 1 in 573 (Johnson and Sinclair : 
 Dublin) to 1 in 1,564 deliveries (Schwarz : Germany). In the 
 Guy's Hospital Lying-in Charity, in 49,845 deliveries, the propor- 
 tion was 1 in 534. Only about 4*4 per cent, of the patients were 
 primiparse. 
 
 Pathological Anatomy. — The lower segment of the uterus may 
 be regarded as nearly equivalent to a hemisphere in shape, the 
 undilated internal os being at the centre of the curved surface. In 
 its dilatation for the passage of the child this hemisphere has to be 
 converted into a cylinder equal in capacity to the circumference of 
 the hemisphere. Hence each ring of the hemisphere has to be 
 stretched, the stretching rapidly increasing in degree as the os is 
 approached. It is therefore easy to understand that, when the 
 attachment of the placenta overlaps any ring of the uterus which 
 is stretched at all considerably, the placenta cannot follow the 
 stretching but becomes detached, and so causes inevitable 
 haemorrhage in the first stage of labour. If the foetal head, as 
 presented to the genital canal, be taken as about 3^ inches in 
 average diameter, and the lower segment of the uterus therefore 
 compared to a hemisphere having the same diameter, it will be 
 found the zone of the uterus liable to stretching extends about 
 2?^ inches from the original position of the internal os, the distance 
 being measured from the os along the chord, or nearly 3 inches, 
 if measured along the arc. There is a narrow zone, at the upper 
 part of this dilatable zone, in which the stretching is only slight, 
 and the placenta may be able to yield to it without detachment. 
 Any slight degree, however, of those causes liable to cause detach- 
 ment of a normally situated placenta, such as shocks or l)lows, will 
 
598 The Practice of Midwifery. - 
 
 be apt, during the first stage of labour, to cause detachment and 
 bleeding very easily, the placenta being already on the strain. 
 Speaking roughly, it may be estimated that a zone reaching to 
 about 2 inches from the undilated internal os, measuring along 
 the arc, is the zone of necessary detachment, and that above this 
 there is another zone measuring about an inch or a little more in 
 width, which is the zone of possible detachment, or dangerous 
 insertion. If the placental attachment overlaps the first zone, 
 hsemorrhage in labour is unavoidable ; if it overlaps only the 
 second, haemorrhage may occur from slight causes. Above these 
 zones is the area of safe attachment, so far as concerns the effect 
 of dilatation. The placenta is in fact detached by the same 
 mechanism which normally detaches the chorion from the 
 uterine wall near the lower pole of the ovum, and allows the bag 
 of membranes to advance into the cervix and begin the dilatation 
 of the internal os. Such tendency to advance of the presenting 
 pole of the ovum adds to the effect of the transverse stretching of 
 the placental site in causing detachment of the placenta, especially 
 when the placenta praevia is complete. 
 
 Source of the Blood. — The blood comes mainly from the arteries 
 and veins in the uterine wall separated from the placenta, but to 
 some extent also from the separated placental surface, especially 
 from the margin which, at any moment, has just been separated. 
 It might perhaps have been expected that the blood, constantly 
 entering the maternal blood-spaces which permeate the whole 
 placenta, would continuously pour out through the open mouths 
 of the vessels on the separated surface. Sir James Simpson, 
 indeed, maintained that this was the main source of bleeding. 
 Any such continuous loss from the placenta is, however, prevented 
 by thrombosis taking place in the detached portion. Arterial 
 bleeding from the uterine wall is, to a certain extent, kept in 
 check by that very stretching of the uterine wall which separates 
 the placenta. A patient, therefore, hardly ever bleeds to death 
 with the rapidity sometimes seen in bleeding from the placental 
 site in post-jjarUim haemorrhage. 
 
 Cause of Bleeding before Fidl Term. — The cause of the unavoid- 
 able haemorrhage in the first stage of labour is obvious enough, but 
 there have been various theories to account for the haemorrhage 
 often beginning in pregnancy, especially during the last two or 
 three months. When it was believed that the cervix was taken 
 up into the cavity of the uterus in the course of j)regnancy, such 
 expansion of the cervix from above was believed to separate the 
 placenta ; but then there was no explanation why the haemorrhage 
 
Haemorrhage in Pregnancy. 599 
 
 did not always begin before labour. Barnes has supposed that 
 detachment is caused by excess of the growth of the placenta over 
 that of the corresponding part of the lower uterine segment, which 
 is not adapted for its attachment. Matthews Duncan has supposed 
 that the causes are similar to those of accidental haemorrhage, 
 only that they act with greater facility when the placenta is 
 prsBvia. The real main reason appears to be that, although the 
 cervix is not usually taken up into the cavity of the uterus long 
 before the onset of labour, yet a slight temporary or permanent 
 dilatation of the internal os is very common in the last two 
 months of pregnancy. It is probably due to the occasional 
 uterine contractions which do not cause any feeling of pain (see 
 p. 180). Thus, in multiparse, it is not uncommon, in the last 
 month or two, to be able to pass the finger through the internal 
 OS, and feel the head presenting. And any, even the slightest, 
 commencement of such dilatation of the small internal os must 
 cause detachment of the placenta at its edges, when it overlaps 
 the internal os. Again, it is probable that the placenta when 
 attached over the internal os is more liable to detachment from 
 coitus or other mechanical causes than when normally situated. 
 For shocks and jars are communicated more directly to the cervix 
 than to the fundus of the pregnant uterus, and moreover, in the 
 upright position of the woman intra-vascular pressure is greater 
 at the placenta when this is praevia. In this case the haemorrhage 
 would be truly analogous to " accidental haemorrhage," only pro- 
 duced with greater facility. 
 
 Besides its frequent thinness in the vicinity of the os, the 
 placenta often shows old thrombosis in the part abnormally 
 situated, if there has been partial detachment some time before 
 labour, and consequent degeneration of the villi. The lower 
 segment of the uterus is thicker than usual in consequence of the 
 increased blood supply attracted to it through the placental 
 attachment. This extra thickness sometimes offers an impediment 
 to the easy dilatation of the cervix. Thus some of the most 
 remarkable cases of the so-called " trismus " of the uterus, or 
 spasmodic rigidity of the cervix, forming a grave obstacle to delivery, 
 have been cases of placenta praevia. 
 
 Presentation of Foetus. — In placenta praevia the frequency of 
 abnormal presentation is very much greater than the average. 
 According to Miiller's statistics,^ the proportion of vertex presenta- 
 tions is only 67 per cent, instead of nearly 97 per cent., the normal 
 
 ' Placenta Praevia, Rtultgait, 1877. 
 
6oo The Practice of Midwifery. 
 
 proportion ; while pelvic presentations form 9"3 per cent, (com- 
 pared with the normal 2*4 per cent.), and shoulder or transverse 
 presentations, 23 per cent, (compared with the normal 0*4 per 
 cent.). This result is partly due to the frequency of premature 
 labour, but it appears to show that placenta previa forms an 
 obstacle to the axis or the child lying in the axis of the uterus. The 
 bulk of the placenta itself, which prevents the head lying so low in 
 the pelvis in the lower segment of the uterus, is probably the 
 principal cause, and it may be that a greater relative expansion of 
 the lower segment of the uterus has also some influence. Prolapse 
 of the funis is also relatively much more frequent in placenta 
 prsevia, as might be expected from the greater vicinity to the os 
 uteri of its outer attachment. 
 
 Symptoms and Course. — Although placenta prsevia may be 
 a cause of abortion in the early months, yet cases positively 
 recognised as of this nature commonly cause symptoms only 
 within the last three months of pregnancy. The characteristic 
 symptom is sudden and unexpected bleeding from the uterus, 
 without adequate cause. Sometimes it is induced by moderate 
 exertion, such as standing or walking, but it may come on when 
 the patient is in bed or asleep. The cases of early haemorrhage 
 (seventh or eighth month) are generally those in which the 
 placenta overlaj)s the undilated internal os. If the margin of 
 the placenta reaches, or is in the close vicinity of the os, bleeding 
 may begin rather later ; if the placental attachment only encroaches 
 moderately upon the zone of unavoidable detachment, bleeding 
 generally only begins either with the stage of painless dilatation 
 of the internal os premonitory of labour, or after manifest labour 
 pains have begun. The first bleeding may be so violent as to 
 cause extreme ansemia, and even quickly cause death. This is 
 more apt to be the case when it occurs at or near full term. The 
 bleeding which occurs earlier in pregnancy, unaccompanied by any 
 pain, is generally not so severe at first, and may cease after a 
 short time. It recurs from time to time, either on slight exertion 
 or without any cause, and when the first stage of labour begins 
 it is apt to be very copious. Premature labour often comes on, 
 either after the first, or, more frequently, with subsequent 
 haemorrhages. In other cases there is no such violent haemorrhage, 
 but continuous oozing goes on for days or weeks. 
 
 If left to nature, the case may end in death from haemorrhage 
 before delivery. If, however, the uterus acts vigorously, a natural 
 limit is put to the bleeding, especially when the dilated os is only 
 
Haemorrhage in Pregnancy. 60 1 
 
 partially covered by placenta and the membranes ruptured, so that 
 there is no obstacle to the rapid descent of the fcetus. The advancing 
 head presses the placenta firmly against the uterine wall, and thus 
 forms a plug. If the membranes remain unruptured, the dilating 
 lower uterine segment tends to become still further separated from 
 the placenta, which cannot follow it, and severe bleeding may con- 
 tinue. The tendency to hgemorrhage is less when once the placenta 
 is separated so far as separation is inevitable, but it may still go on 
 from the placental site, if the uterus is not active enough to cause 
 pressure upon this. If the attachment is nearly central, the 
 placenta may be detached entirely by uterine action and expelled 
 before the foetus. The result may be favourable, if the uterus is 
 acting strongly ; and the child even has been born alive. In the 
 Guy's Hospital Lying-in Charity, however, the two cases of placenta 
 praevia in which this incident occurred were both fatal through 
 hsemorrhage. 
 
 Rare cases of placenta prsevia are observed in which hardly any 
 appreciable haemorrhage occurs throughout the entire course. 
 These are cases in which the separation only begins with labour, 
 and in which the uterus is active throughout. Other rare cases 
 again have been recorded, in which there is absolutely no haemor- 
 rhage at the time of labour itself. In these instances, the placenta 
 must have been separated at an earlier period so far as needful, and 
 thrombosis have taken place in the vessels. 
 
 The labour pains in placenta praevia are frequently feeble, 
 partly, in many cases, from the labour being premature, partly 
 from the patient's exhaustion through the haemorrhage. As 
 already mentioned, the cervix uteri sometimes proves unusually 
 rigid, notwithstanding the tendency of the haemorrhage to relax 
 it. Post-partum haemorrhage also is liable to occur, probably in 
 consequence of the same condition of exhaustion, and soon tells 
 seriously on the already anaemic patient. 
 
 Diagnosis, — ^In the last three months, and especially within 
 the last two months of pregnancy, placenta praevia is always the 
 most probable explanation, if sudden and considerable haemorrhage 
 comes on without sufficient exciting cause, especially in the 
 absence of pain, and the probability is increased if similar attacks 
 of hgemorrhage are repeated. On vaginal examination, if haemor- 
 rhage has been only slight or moderate, the internal os may not 
 be permeable to the finger. There is then no absolutely certain 
 means of physical diagnosis, but the uterus round the cervix may 
 feel unduly thick, and the hard outline of the head will not be 
 
6o2 The Practice of Midwifery. 
 
 tangible through it, nor will ballottement be obtainable, at any 
 rate where placenta is situated. There is no certainty in any 
 auscultatory signs, such as finding the uterine soufSe lower down 
 in the groins than usual. Vaginal stethoscopy has been proposed, 
 but could only be of use to those who had practised it much in 
 normal cases. If haemorrhage is very considerable, the internal 
 OS will probably allow the finger to pass on a little pressure, even 
 if not already more dilated. If the os lies high up, the half-hand, 
 or if necessary the whole hand, should be passed into the vagina 
 in order to assure the diagnosis. When the finger can once be 
 passed through the cervix diagnosis is easy. The spongy mass of 
 the placenta could only be mistaken for clot or for a hydatidiform 
 mole. Clot is easily removable by the finger, is less firm and 
 spongy, while the placenta will be found continuous with the 
 membranes if these can be reached. It must be remembered 
 that, if only just overlapping the original internal os, the edge of 
 the placenta is often much thinner and more membranous than 
 usual. Unless the insertion is very nearly central, it will generally 
 not be difficult, passing the hand into the vagina, to reach the 
 edge of the placenta in some direction, find there the membranes, 
 and through them make out what the presentation of the foetus 
 is. If the membranes cannot at first be reached, the direction o£ 
 the nearest edge of the placenta will generally be indicated either 
 by that part of the placenta which is thinnest, or by that which is 
 most separated. Usually the two indications coincide. 
 
 Prognosis. — Placenta prsevia is one of the gravest complica- 
 tions of the puerperal state for the mother, and the prognosis is 
 still graver for the child. For the mother, besides the immediate 
 risk of haemorrhage, there is that of septicaemia after labour. This 
 is due partly to the increased tendency to absorption from 
 emptiness of the vessels, partly to the low position of the placental 
 site, more exposed to the locbial discharge flowing over it, partly 
 to the manual interference and manipulation of the placental site 
 which may have been found necessary, or to retention of portions 
 of the placenta and to the tearing of the lower uterine segment 
 or cervix which is so likely to occur. For the child the main 
 danger is that of asphyxia from loss of maternal blood and 
 separation of a great part of placenta. There is also often that 
 of immaturity, or malposition, or the increased risk involved 
 by version. Koblanck reported a mortality of 3'8 per cent, in 
 467 cases in the Frauenklinik in Berlin. In 178 cases treated by 
 bipolar version by eleven different operators, the mortality was 
 
Haemorrhage in Pregnancy. 603 
 
 4"5 per cent. ; but in 93 cases thus treated by three operators, 
 Hofmeier, Behm, and Lomer/ it was only 1 per cent. The 
 mortahty to the children is generally about 60 per cent. Kiistner,^ 
 however, who employs Champetier de Eibes' bag extensively, 
 reports a mortality of only 35 per cent. It is readily understood 
 that the result to the mother depends largely upon the skilfulness 
 of the treatment, and the speed with which medical assistance is 
 obtained. The danger is greater the earlier the bleeding com- 
 mences, the less it is accompanied by uterine action, the more 
 nearly central is the placental insertion, and the greater the anaemia 
 which is brought about before actual labour. 
 
 Treatment. — A patient having placenta prsevia is never safe 
 until delivery is completed ; and the chief danger is that of violent 
 haemorrhage occurring in the absence of medical assistance. The 
 general principles of treatment are to bring on labour quickly, to 
 shorten the process of delivery so far as this can be done without 
 any forcible interference, which would incur the risk of laceration 
 or bruising, and meanwhile to limit the amount of haemorrhage by 
 securing some form of pressure upon the placental site. 
 
 Induction of Labour. — As a rule it is desirable to induce labour 
 as soon as a positive diagnosis can be made. The only exception 
 to this is the case when pregnancy has not reached the seventh 
 month, when haemorrhage is very slight, and when medical assist- 
 ance can be obtained at short notice. It may then be desirable 
 to attempt to prolong the pregnancy up to seven months in the 
 interest of the child, if there is anxiety to save it. It is to be 
 remembered, however, that the chance of this is somewhat remote 
 in a case in which haemorrhage begins so early, since the placenta 
 then probably overlaps the internal os. If it be decided to tempo- 
 rise, the patient should be kept completely in bed, and opium or 
 morphia administered so long as any bleeding occurs. A nurse 
 may be instructed to plug the vagina in case of any sudden 
 bleeding. 
 
 If it be decided to induce labour, the cervix not being yet 
 permeable to the finger, a hot vaginal douche may first be 
 employed, and then one or more tupelo tents placed in the cervix, 
 and the vagina plugged beneath them in the manner already 
 described (see p. 581). In five or six hours tents and plugs should 
 be removed, and a vaginal douche used with lysol 1 per cent. 
 
 1 "On Combined Turning in the Treatment of Placenta Prasvia," Amer. Journ. of 
 Obst., 1884, XVn., pp. 12:^:^—1260. 
 
 2 " Ucbcr Placenta Pncvia," Verb. d. Deutschcn Gcsell. f. Gyn., 1897, p. 277. 
 
6o4 
 
 The Practice of Midwifery. 
 
 solution. If the cervix is not yet permeable to two fingers, it will 
 probably be possible to introduce the smallest hydrostatic dilator, 
 and so continue the dilatation. 
 
 Plugging the Vagina and Cervix. — If, at the onset of haemorrhage, 
 the cervix is found too small to admit the finger to make a positive 
 diagnosis, or if, while allowing the placenta to be felt, it is still 
 too small to allow two fingers to pass, plugging the vagina is a 
 valuable resource, and one which can always be carried out with 
 
 Fig. 313. — Champetier de Kibes' bag wi situ, in a case of placenta prjevia. 
 
 the materials at hand. It used to be considered permissible in 
 placenta praevia and not in accidental haemorrhage, from the idea 
 that, in the former case, the plug actually compresses the bleeding 
 site. It is doubtful, however, whether this is always really the 
 case ; and the most valuable effect is that of stimulating the uterus 
 by reflex action. The plugging is dangerous rather than useful 
 unless two points are specially regarded : first, that antisepsis is 
 maintained ; and, secondly, that the plugging is mechanically 
 efficient, and really fills and distends the vagina. The plug may be 
 either of sterilised iodoform or other antiseptic gauze, or else of 
 
Haemorrhage in Pregnancy. 605 
 
 plain gauze or cotton wool sterilised by boiling, and soaked in a 
 somewhat dilute antiseptic, such as chinosol 1 in 500 or lysol 1 in 
 100 parts of boiled water. If gauze is used, a rather thin strip 
 "should be taken, and with the aid of a Sim's speculum packed all 
 round the cervix, before the os is covered. The vagina should then 
 be filled to its utmost capacity down to its outlet ; and finally a 
 perineal pad placed over it, upon which firm pressure is made 
 by a 7" bandage fixed to a tight abdominal binder. If cotton wool 
 is used, the pieces should be taken one by one, squeezed free from 
 superfluous moistare, and compressed into a small compass before 
 insertion. The plug should not be left more than about twelve 
 hours. For if clots are allowed to remain and become decomposed 
 above the plug, symptoms of septic absorption may commence 
 even before delivery, and end in puerperal septicaemia afterwards. 
 
 Use of Hydrostatic Dilators. — If a hydrostatic dilator can be 
 introduced into the cervix, it is preferable to a vaginal plug, for it 
 dilates the cervix more rapidly, and stimulates uterine action more 
 powerfully. It will often be possible to introduce the smallest size 
 when the cervix admits one finger, if the improved form of Barnes' 
 dilator, described in Chapter XXVII., be used. The cervix will 
 then probably be dilated enough within an hour to allow of bipolar 
 version. Champetier de Eibes' dilating bag (see Chapter XXVII.) 
 may also be used, introduced into the amniotic cavity after 
 rupture of the membranes,^ and, from its large size and conical 
 shape, will form a still more efficient haemostatic, by compressing 
 the placenta, while it is impossible for it to be expelled until the 
 OS is dilated, and thus it affords a greater security against haemor- 
 rhage. But, for the introduction of this, the os must be large 
 enough to admit two fingers, and the labour therefore advanced 
 enough for bipolar version. If the bag does not completely arrest 
 haemorrhage a weight of 2 lb. may be attached to the neck of it 
 by a string and hung on a pulley over the edge of the bed. 
 
 Hydrostatic dilators are also useful when the membranes are 
 already ruptured and haemorrhage continues, in order to secure a 
 sufiicient dilatation of the cervix to allow internal version or the 
 application of forceps. 
 
 Rupture of the Membranes. — This method is applicable to cases 
 of partial placenta praevia, especially those in which haemorrhage 
 is not great, and active labour pains have already commenced. It 
 may be adopted more safely when dilatation of the os has made 
 some progress, so that it may be followed up soon, if necessary, 
 
 1 Blacker, Tniris. Obst. Koc. London, 1«97, Vol. XXXIX., p. 138. 
 
6o6 
 
 The Practice of Midwifery. 
 
 either by the application of forceps, or version by the internal 
 method. In suitable cases it has the advantage that the chance 
 for the child's life is greater than if version is performed. The 
 uterus may act vigorously as soon as the liquor amnii has escaped, 
 press the placenta against its wall, and rapidly complete delivery, 
 
 or, if it does not, forceps may be 
 applied, or Champetier de Ribes' 
 dilator used if the os is not yet 
 large enough for forceps. 
 
 Digital Separation of Pla- 
 centa. — If the placenta remains 
 partially attached round the 
 whole circuit of the os, the pro- 
 cess of dilatation is retarded 
 by the attachment. The total 
 amount of haemorrhage also 
 appears to be less when the de- 
 tachment is rapid, than when it 
 takes place slowly in successive 
 portions, for thrombosis quickly 
 occurs in the part which has 
 been separated. There is often 
 an advantage, therefore, in com- 
 plete placenta prsevia, in aiding 
 the detachment by sweeping 
 round the finger inside the os. 
 
 Performance of Version. — The 
 traditional treatment for pla- 
 centa prsevia is the performance 
 ^, x^ of version; and the employment 
 
 ^^"•^^ of the method of bipolar version 
 
 Fig. 314.— Half breech forming a plug after renders it possible to adopt this 
 version, in a case of placenta prajvia. treatment at an early stage, 
 
 (Modified from Plates XXIV. and . ,, *^ ^. 
 
 XXVI. Leopold, Uterus und Kind.) namely, as soon as ttie cervix 
 
 will admit two fingers. The 
 majority of cases of placenta prsevia in the Guy's Hospital Lying-in 
 Charity have been treated in this manner. In most cases of placenta 
 prsevia bipolar version is available when the patient is first seen. 
 
 The performance of version is by far the most effectual means 
 of arresting hsemorrhage in placenta prsevia. When one leg is 
 brought down the half-breech forms a plug in the lower segment 
 of the 'uterus, and presses the placenta against the uterine wall, 
 so that there is hardly ever any haemorrhage of consequence after- 
 
Haemorrhage in Pregnancy. 607 
 
 wards. At the same time the greater part of the liquor amnii 
 ■will have escaped, and the uterus will be stimulated by complete 
 contact with the trunk and head of the foetus. There is no 
 necessity to hasten delivery by any forcible traction of the leg, 
 a proceeding which might cause laceration of the cervix and 
 subsequent septic absorption, or even additional bleeding from the 
 torn cervix. 
 
 It is of the utmost importance to allow the child after version to 
 be delivered by the natural forces, since any attempt at forcible 
 delivery is almost certain to be followed by laceration of the cervix 
 or lower uterine segment and the danger of severe post-partum 
 hsemorrhage and subsequent septic infection. The danger of such 
 lacerations is especially great in placenta prsevia, because of the 
 rigidity of the portion of the uterine wall to which the placenta is 
 attached. 
 
 The method of performing bipolar version will be described in 
 Chapter XXXIV. In this case, if the os is wholly covered by 
 placenta, the hand is passed up, on the side where separation is 
 greatest, between the placenta and the uterine wall till the mem- 
 branes are reached. In the case of a very central placental inser- 
 tion, it may be necessary, before performing the actual version, to 
 rupture the membranes along the edge of the placenta, .to draw 
 that edge down towards the centre of the os, and then proceed 
 with the version as rapidly as possible. If the cervix is already 
 dilated enough to allow the whole hand to pass, the operator may 
 turn by the internal method if he finds it easier. 
 
 Unless the alternative of using Champetier de Eibes' bag is 
 adopted, in order to give a better chance of life to the child, 
 version should be performed in all cases of complete placenta 
 prgevia, and in cases even of partial placenta prsevia if haemorrhage 
 is serious. The more placenta there is over the os, and the less 
 active the uterus, the greater is the indication for version. If 
 version is likely to be called for, it is better not to puncture the 
 membranes till the operator is ready to j)erform it, because other- 
 wise it probably cannot afterwards be carried out by the bipolar 
 method. 
 
 The chief drawback to version in placenta prsevia is that it 
 increases the risk to the child, which is likely to be ah'eady 
 enfeebled by partial asphyxia owing to the placental detachment 
 and uterine haemorrhage. On this account, when the child is alive 
 and near full term, the placenta prsevia is partial, the haemorrhage 
 moderate, and the uterus beginning to act, preference may be given 
 to rupture of the membranes followed by the introduction of 
 
6o8 The Practice of Midwifery. 
 
 Champetier de Kibes' bag, and delivery by forceps or version when 
 the cervix is sufficiently dilated. 
 
 Application of Forceps. — If the membranes have been ruptured, 
 if the OS is sufficiently dilated, the placenta not too much in the 
 way, if labour is not progressing fast, and some haemorrhage 
 continues, the best mode to complete delivery is to put on forceps, 
 drawing the placenta down to one side. The main advantage of 
 this treatment, as compared with version, is that the chance of 
 saving the child is greater. 
 
 Csesarean section, both vaginal and abdominal, has been recom- 
 mended for placenta praevia. The former operation is only 
 mentioned to be condemned. Cases may very rarely be met with 
 of placenta previa complicated, for example, by the presence of 
 fibroid tumours^ in the uterus, or in an elderly primipara with 
 extreme rigidity of the cervix, in which the performance of a 
 Caesarean section will in suitable surroundings entail no greater 
 danger to the mother than version or the employment of a hydro- 
 static dilator, and in which the danger for the child certainly will 
 be lessened by such an operation. In such circumstances, and in 
 such circumstances only, Caesarean section would be justifiable. 
 
 In the management of the third stage of labour great care must 
 be taken to avoid the occurrence of post-partum haemorrhage, and 
 the placenta, which is often torn, must be examined with special 
 attention to ensure that no part of it has been retained. 
 
 HiEMOEEHAGE FEOM SePAEATION OF A NOEMALLY SITUATED 
 
 Placenta, oe Accidental H^moeehagb. 
 
 Causation. — Accidental haemorrhage rarely happens to primi- 
 parae, and is most common in debilitated women, and those who 
 have had many children. This is an indication that there is 
 generally some morbid condition of the uterus, such as chronic 
 endometritis, of varying origin, or placenta, as a predisposing cause. 
 Such predisposing causes are similar to those which cause 
 haemorrhage and abortion in the earlier months, namely, all 
 diseased conditions of the placenta which cause undue vascular 
 tension, or weakness of the vessels or of the placental attachment. 
 In some cases albuminuria has been recorded. Generally there is, 
 in addition, some exciting cause. This may be direct violence to 
 the abdomen, or a fall or shock, or excessive muscular exertion, 
 such as lifting weights. Sometimes there is only an emotional 
 cause, which probably acts by exciting violent or irregular con- 
 
 1 Munro Kerr, Lancet, October 30, 1909, p. 1282. 
 
Haemorrhage in Pregnancy. 
 
 609 
 
 tractions of the uterus. In comparatively rare cases there is no 
 obvious exciting cause. In some instances a shght effusion of blood 
 under the placenta, due to some diseased placental condition, may 
 excite irregular uterine con- 
 traction leading to further 
 separation of the placenta and 
 haemorrhage. 
 
 Pathological Anatomy. — 
 From partial detachment of 
 the placenta, blood is poured 
 out between the placenta and 
 the uterus. In most cases 
 this blood, or some part of it, 
 reaches the edge of the pla- 
 centa, separates also the mem- 
 branes, and escapes at the os 
 uteri. Frequently a consider- 
 able amount of clot remains 
 behind within the uterus, 
 behind the placenta, or be- 
 tween the membranes and 
 the uterine wall. The placenta 
 may be hollowed out, so as to 
 present a concave surface out- 
 ward, if the clot lies mainly 
 behind it. A comparatively 
 rare variety is concealed acci- 
 dental hcemorrhage, in which 
 no blood, or scarcely any, 
 makes its appearance exter- 
 nally. Of 82 cases recorded 
 by Colclough 6 were of this 
 character, and 41 of 200 col- 
 lected by Holmes. 
 
 If the placenta remains 
 attached at its margin at all 
 parts, a considerable amount 
 
 of blood may be poured out behind it, without any at all reaching 
 the exterior. Or the blood may be retained near the fundus, between 
 the membranes and the uterus, the uterus not acting strongly, and 
 
 Fig. 315. — Section of the uterus of a patient 
 who died of internal and external liEemor- 
 rhage when SJ months pregnant, with 
 premature separation of the placenta from 
 shortness of the cord which is coiled round 
 the child 's neck. The placenta is separated 
 entirely, the membranes ruptured artifi- 
 cially, and the liquor amnii has escaped. i 
 
 I'inaid et Varnicr, Etudes d'Anatomie Obstetrical, 18!)2. 
 
 81) 
 
6io The Practice of Midwifery. 
 
 the chorion remaining undetached in the lower segment of the 
 uterus. The uterus may be distended by the blood and clots effused, 
 especially in the concealed variety of accidental haemorrhage. In 
 some cases the distension has even been sufficient to rupture the 
 uterus. In general the amnion is not ruptured, and no blood finds 
 its way into the amnial cavity. Sometimes, however, rupture does 
 occur from the placenta or elsewhere, and one variety of concealed 
 accidental haemorrhage may thus arise, the blood passing into the 
 amnial cavity instead of escaping externally. In the majority of 
 cases accidental haemorrhage occurs before there is any sign of 
 labour, but sometimes the bleeding commences in the early stage 
 of labour, or at any rate becomes manifest first at that time. It 
 has already been explained, in the description of placenta praevia 
 (see p. 599), that, in a certain number of cases ranked as acci- 
 dental haemorrhage, there is a predisposing cause for separation in 
 the placenta being attached low down in the uterus, not within the 
 zone of unavoidable detachment, but in the intermediate or dan- 
 gerous zone, where the placenta is put to some slight strain in 
 dilatation of the cervix, and receives shocks communicated through 
 the cervix more directly than when implanted near the fundus 
 uteri. 
 
 Symptoms and Course. — The symptoms are those produced 
 by haemorrhage, sometimes accompanied by pain from distension 
 of the uterus. The majority of the cases are comparatively mild, 
 but in the severe cases the anaemia and prostration are apt to be 
 greater even than in placenta praevia, since the placenta may be 
 sej)arated more suddenly and widely. Symptoms of collapse, with 
 failure of pulse, are most marked of all in the cases of concealed 
 accidental haemorrhage. The jDatient may die from haemorrhage 
 undelivered. As in placenta j)raevia, post-partum haemorrhage is 
 also more liable to occur than usual, on account of the patient's 
 exhaustion, and death shortly after delivery is not uncommon. 
 
 Diagnosis. — When blood and clots appear externally, the dis- 
 tinction has to be made from placenta praevia. A probable diagnosis 
 may be made when there has been a blow, fall, or other exciting cause 
 for accidental haemorrhage. Even in the absence of external 
 exciting cause, serious haemorrhage usually occurs more suddenly 
 than in placenta praevia, without previous slighter haemorrhages. 
 A positive diagnosis is made when the cervix is open enough to 
 admit the finger, and no placenta is found within reach. If the 
 cervix is undilated, there is a jDresumption against placenta praevia 
 
Haemorrhage in Pregnancy. 
 
 6ii 
 
 if the head can be felt normally from the vagina through the 
 uterine wall. Examination of the membranes after delivery will 
 generally show whether the placental insertion encroached upon 
 the dangerous zone. Assuming that the membranes were punctured 
 or gave way near the centre of the os uteri, the aperture in the 
 membranes will be found to be nearer than usual to the margin of 
 
 Fig. 316. — Section of uterus from patient dying at 8th month of eclampsia. 
 There is a large intro-placental hsematemia about half the area of the 
 placenta being separated from its site. Partial separation of the mem- 
 branes is seen in the lower uterine segment. (Winter. i) 
 
 the placenta at some part, if the placental insertion has been lower 
 down in the uterus than usual. 
 
 Concealed accidental hsemorrhage may be difficult to diagnose, if 
 no blood whatever escapes externally. The chief signs to judge by 
 are sudden collapse and faintness, feeble rapid pulse, some- 
 times vomiting, accompanied by general appearance of anaemia, and 
 
 1 Zwel Medlanschnitte durch Gebarende, Berlin, 189ii. 
 
 39—2 
 
6i2 The Practice of Midwifery. 
 
 great tenderness of the uterus. The uterus on palpation will be 
 more uniformly tense than usual, not much varying in firmness by 
 rhythmical contraction, and the foetal parts as a rule cannot be felt, 
 and the foetal heart sounds often cannot be heard. Sometimes it 
 may be recognised as increased in size from the effusion into it, 
 especially if full term is not yet nearly reached, as, for instance, at the 
 sixth month. The collapse may be out of all proportion to the 
 amount of blood effused, and is in part due to the shock caused by 
 the sudden over-distension of the uterus. Concealed accidental 
 hasmorrhage has to be distinguished from rupture of the uterus, but 
 rupture is not likely to occur to a normal uterus (except from great 
 direct violence) before the onset of labour, or even before escape 
 of the liquor amnii. In cases of accidental haemorrhage, mainly of 
 a concealed character, there is often a slight escape of blood per 
 i-aginam, which reveals the real nature of the case. Other cases, 
 more frequent than those of concealed haemorrhage, are of mixed 
 character. There is considerable external haemorrhage, but the 
 uterus also shows signs of over-distension by clot or blood. 
 
 Prognosis. — The milder cases nearly always do well, but in the 
 graver ones the risk of death directly from haemorrhage is even 
 greater than in placenta praevia. Out of 49,145 deliveries in the 
 Guy's Hosj^ital Lying-in Charity there were 105 cases of accidental 
 haemorrhage reported as compared with 92 of placenta praevia 
 but probably many slighter cases are not included in the statistics. 
 There were 12 deaths from haemorrhage reported as compared with 
 8 directly due to haemorrhage in placenta praevia, or 11'4 per 
 cent. Of the more serious cases, the children were still-born in 
 about 60 per cent. The risk to the child is therefore not much less 
 than in placenta praevia, and in severe cases it is probably greater. 
 Johnston and Sinclair recorded only 4 deaths of mothers in 81 
 cases at the Eotunda Hospital, or 4*9 per cent. The cases of 
 concealed accidental haemorrhage are relatively rare; there was only 
 1 in the 105 cases above mentioned in the Guy's Hospital Charity. 
 A considerable number, however, has been recorded, and Goodell^ 
 in 1870 collected 106. In these, the mortality to the mothers was 
 nearly 51 per cent. ; to the children 94 per cent. In 200 additional 
 cases collected by Holmes- in 1901, the mortality to the mothers 
 was 32*2 per cent, to the children 85*8 per cent. Concealed 
 accidental haemorrhage is therefore much more dangerous to both 
 
 1 Amer. Journ. Obst., 1869-70, Vol. II., p. 281. 
 
 2 "Ablatio PlacentjB," Amer. Journ. Obst., 1901, Vol. XLIV., p. 753. 
 
Haemorrhage in Pregnancy. 613 
 
 mother and child than accidental haemorrhage in general. The 
 reason probably is partly that the element of shock through disten- 
 sion of the uterus is superadded, and partly that the very fact of the 
 uterus allowing such distension proves that its walls are feeble, or 
 not prone to contract. 
 
 Treatment. — In considering the treatment of cases of accidental 
 haemorrhage it must be remembered that in the severe cases the 
 foetal mortality will always be very high, and therefore but little 
 regard should be paid to preserving the life of the child. It must 
 also be borne in mind that the object of most of the methods of 
 treatment employed is to set up uterine contractions, and so to 
 cause constriction of the bleeding vessels and arrest of the 
 haemorrhage. When it is impossible to evoke uterine contractions, 
 then the same result is sought to be obtained by mechanical 
 pressure, as, for example, in plugging the vagina and applying an 
 abdominal binder, or by direct ligation of the vessels, as in 
 Caesarean section. 
 
 In slight cases occurring during pregnancy it will be sufficient to 
 keep the patient in bed and to administer an opiate. In more 
 severe cases, where it is necessary to adopt active measures to arrest 
 the haemorrhage, the treatment will depend upon the conditions 
 present. If the patient is in labour, uterine contractions occurring 
 and fairly well marked, if she is not collapsed and the cervix soft 
 and partly dilated, the membranes may be ruptured. Ergot should 
 be given at the same time, eitber a hypodermic injection of 
 ergotin or ernutin, or a drachm of the liquid extract, repeated if 
 necessary. It is advisable also to give a hypodermic injection of 
 strychnine. The membranes should be ruptured with a sound or a 
 catheter stylet. If the abdominal pressure is slight, very little 
 liquor amnii may escape till the uterus contracts. But the operator 
 should not be satisfied till he sees enough fluid to convince him 
 that the membranes are really ruptured. After the puncture of the 
 membranes, the uterus should be stimulated by external pressure 
 and friction, or by a binder. The patient should be kept in bed, 
 and the position should be the dorsal position rather than the 
 lateral, to promote the stimulating pressure upon the cervix, and 
 prevent blood collecting at the fundus. Frequently, after the escape 
 of the liquor amnii, the uterus acts well, and haemorrhage is 
 arrested. If pains are feeble from exhaustion, or bleeding con- 
 tinues, labour should be accelerated by forceps if the os is dilated 
 enough, and the head can be easily reached. If the child is dead, 
 craniotomy, followed ])y extraction with the cephalotribe, will some- 
 
6 14 The Practice of Midwifery. 
 
 times enable the labour to be completed more rapidly, with a less 
 complete dilatation of the os. Care must be taken not to empty 
 the uterus too rapidly, and to keep the fundus well stimulated 
 by external pressure at the final stage of delivery. 
 
 If the haemorrhage is severe, and either external or partly 
 external and internal, there is always a danger that the uterus may 
 not contract if the membranes are ruptured. In such a case when 
 the cervix is undilated, the cervical canal not obliterated, and 
 uterine contractions absent, and especially if the patient is collapsed, 
 it is better treatment to plug the vagina so long as the membranes 
 are unruptured. 
 
 In the first edition of the present work, published in 1886, plug- 
 ging the vagina was recommended for the treatment of accidental 
 haemorrhage when the cervix was undilated and labour had not 
 commenced. The same treatment was advocated by Spiegelberg, 
 and had been recommended as early as 1776. Most authorities, 
 however, considered that it was dangerous, on the ground that fatal 
 bleeding might take place into the uterus behind the plug. The 
 fact that concealed accidental haemorrhage proves much more 
 dangerous than ordinary accidental haemorrhage, was thought to be 
 a strong confirmation of this view. In concealed accidental 
 haemorrhage, however, the element of danger lies, not in the blood 
 being unable to escape, but in the uterus being so inert that it 
 allows itself to be distended without expelling the blood. 
 
 More recently, Smyly has introduced into the practice of the 
 Rotunda Hospital, Dublin, the treatment of plugging the vagina, 
 combined with a tight abdominal binder and pressure from a 
 perineal pad, for those cases of accidental haemorrhage in which the 
 OS uteri is undilated or little dilated, and labour pains are absent or 
 slight. Experience appears to justify this treatment, which is 
 now generally accepted. It is found that after a few hours the 
 patient rallies, if much collapsed, and that good labour pains 
 come on. 
 
 Colclough^ records forty-three cases treated at the Rotunda 
 Hospital by plugging, with two deaths (or 4'6 per cent.), one from 
 rupture of uterus. The plugging must be carried out in the 
 manner described for the case of placenta praevia (see p. 604), and 
 it must be remembered that the treatment is a dangerous one in 
 unskilful hands, if either the plugging is not effective, or antisepsis 
 not fully maintained. It is available only when the membranes are 
 unruptured. 
 
 * " Accidental HEemorrhage," Journ. of Obst, and Gyn. Brit. Emp., August, 1902, 
 Vol. II., No. 2, p. 153. 
 
Haemorrhage in Pregnancy. 615 
 
 According to the Eotunda practice, the plugs are left for twenty- 
 four hours, unless there is haemorrhage through them, or they 
 commence to bulge from the onset of labour pains. If there is 
 hsemorrhage, it is regarded as a sign that the plugging has not been 
 efficiently done, and the plugs are reapplied. At the end of twenty- 
 four hours they are removed, the vagina is douched, and, if labour 
 pains have not come on, the plugs are reinserted. In only three 
 cases out of thirty-six (Colclough) was delivery postponed over 
 twenty-four hours from the application of the plug. 
 
 It is thus proved that plugging the vagina is a good treatment, 
 but it is not yet finally demonstrated that it is better than the other 
 method. The statistics given above may be compared with those 
 of eighty-one cases of accidental haemorrhage out of 13,748 
 deliveries recorded by Sinclair and Johnston.^ These were treated 
 at the Rotunda Hospital by early puncture of membranes, with 
 acceleration of labour by forceps or version. In one case only the 
 vagina was plugged by a sponge. There were four deaths (4*9 per 
 cent.), in two only of which death was due directly to hsemorrhage. 
 
 The statistics of the results of treatment by plugging are very 
 slightly better than those of the old method, not more than might 
 be expected from the effect of modern improvements in antiseptic 
 midwifery. The above sets of statistics are strictly comparable, 
 both being from the Rotunda Hospital. More extensive statistics 
 are required to decide the question. 
 
 If the bleeding is severe, the membranes are ruptured, and the 
 liquor amnii has escaped, there is much greater risk of fresh haemor- 
 rhage taking place into the uterine cavity behind a plug than while 
 the membranes are intact. It is not therefore advisable to plug the 
 vagina in such a case. If the cervical canal is intact, but will 
 admit two fingers, a Champetier de Ribes' bag should be intro- 
 duced, and a weight of 2 lb. attached to it by a string and hung 
 over the edge of the bed. Care must be taken to watch the con- 
 dition of the fundus, to see that no progressive distension is going 
 on. The bag itself by its bulk takes the place to a great extent of 
 the liquor amnii in filling the uterine cavity, and it is a very 
 powerful stimulus to uterine contraction, having a superiority in 
 this respect over a vaginal plug. If the cervix will not admit two 
 fingers, it must be dilated until it will do so either digitally or with 
 Rossi's or other instrumental dilator (see Chapter XXVII.), before 
 the Champetier de Ribes' bag is applied. 
 
 The case is one of extreme difficulty and danger if the Champetier 
 
 1 Practical Midwifery, Dublin, 18.'58, 
 
6i6 The Practice of Midwifery. 
 
 de Eibes' bag fails to cause uterine contractions and dilatation of 
 the cervix, and to arrest the hgemorrhage. It has been proposed in 
 such conditions to carry out forcible dilatation of the cervix with 
 Bossi's or some similar mechanical dilator or by rajjid manual 
 dilatation, and to deliver either by the application of forceps, by 
 version, or, as the child is practically always dead, after craniotomy 
 or embryotomy. The results of this method of accouchement force 
 are, however, exceedingly bad, and it cannot be recommended. It is, 
 nevertheless, the onl}^ resource when the patient is so situated as 
 not to allow of the performance of Csesarean section, either vaginal 
 or abdominal. Such cases as these present one of the most difficult 
 problems in obstetrics, and the maternal mortality, whatever the 
 treatment, will always be very high. 
 
 Cases of severe concealed internal haemorrhage are both very 
 dangerous and very difficult to treat, dangerous because of the 
 marked shock and collapse usually associated with them, and 
 difficult to treat because the uterine muscle as a rule is so paralysed 
 that all attempts to set up uterine contractions are futile. If the 
 method of plugging the vagina, together with the use of a tight 
 abdominal binder, acts purely by mechanically compressing the 
 uterus, as Colclough maintains, then it would appear to be a suitable 
 method of treating these cases. Smyly, however, and others of the 
 Dublin school, do not recommend it, but prefer Csesarean section. 
 The latter operation, followed by removal of the uterus by supra- 
 vaginal amputation, would certainly appear to be the best method 
 of treatment. In this way alone is it possible to deliver the patient 
 rapidly and at the same time to arrest the haemorrhage with 
 certaint}'. 
 
 Abdominal Ceesarean section, which has been j^erformed success- 
 fully in this class of case, is preferable to vaginal, although the 
 latter is strongly recommended by Diihrssen^ and others. 
 
 When accidental haemorrhage has occurred, special care must be 
 taken in the third stage of labour to avoid jjost-partum haemorrhage. 
 
 1 Diihrssen ; V. W^inckel, Handbuch der Geburtshiilfe, Vol. III., Th. 1, s. 595. 
 
Chapter XXVI. 
 PRECIPITATE AND PROLONGED LABOUR, 
 
 Precipitate Labour. 
 
 Labour may be precij)itate when the expulsive force is unusually 
 powerful in proportion to the resistance to be overcome. Excess 
 in the force of the pains has to be considered, not absolutely in 
 itself, but in relation to the resistance and the strength of the 
 resisting tissues. Thus precipitate labour may take place when 
 the expulsive force is normal, if there is unusually small resistance 
 from large relative size of the pelvis and softness or dilatability of 
 soft parts. It may also happen with normal resistance if the 
 expulsive force is excited to excessive action by undue reflex irrita- 
 bility, and again with resistance above the normal, and a still 
 greater excess of irritability. 
 
 Precipitate labour depending on smallness of resistance, though 
 described as an abnormality, has rarely any ill effect. In such a 
 case the passage of the child may take place in a few minutes. 
 The chief risks to be feared, therefore, are the inconvenience of 
 delivery taking place suddenly and unexpectedly, and the danger 
 to the child from its being born in some unusual position. In such 
 cases the child has been expelled into the pan of a water-closet. 
 Still more frequently it has been born when the mother was stand- 
 ing upright, and fallen upon the floor, breaking the funis. Even 
 then the injury suffered by the child has generally not been so 
 severe as might be expected, for the fall is broken by the resistance 
 of the funis, and when the funis is thus violently torn across, 
 bleeding generally does not take place from the severed end. There 
 appears to be a somewhat greater risk of the uterus becoming 
 relaxed after delivery, and allowing haemorrhage, when it has not 
 been called fully into activity by a reasonable amount of resistance. 
 Even this result, however, is exceptional, and more usually the 
 uterus contracts well after rapid labour. 
 
 The risks are greater when, with a normal or an excessive 
 resistance, the expulsive force is excited to undue degree by un- 
 usual reflex irritability, or by injudicious administration of 
 oxytocics, such as ergot. There may be excess of intensity in the 
 action of the uterus itself, or of the auxiliary muscles, or of both 
 
6i8 The Practice of Midwifery. 
 
 together. Or again, the usual intervals of rest between the pains 
 may fail, and the pains may follow each other in stormy succession, 
 almost without intermission, especially as the final stage of labour 
 approaches. The chief danger of excessive intensity in the 
 expulsive force is that of laceration either of the cervix or perineum, 
 the soft parts having no time to dilate under the influence of 
 repeated and moderate pains. Sometimes even rupture of the 
 uterus involving the peritoneum may occur, though no bony obstruc- 
 tion exists. If there is moderate pelvic obstruction fracture of 
 the cranial bones of the child may be produced. From excessive 
 straining in bearing down, emphysema of the neck, face, and chest 
 is sometimes produced, from rupture of some air vesicles in the lung. 
 
 When pains come on in rapid stormy succession, they are 
 generally also intense in degree, and a similar danger of laceration 
 exists. There is also danger of the child becoming asphyxiated 
 from the pressure upon it not being relieved by intermissions. 
 Intense mental excitement is sometimes produced by the rapid 
 succession of agonising pains, and this may even amount to 
 temporary mania, so that a patient is not responsible for her 
 actions. 
 
 In some cases, following the rapid emptying of the uterus and the 
 sudden fall in the intra-abdominal pressure, a syncopal attack 
 may occur. 
 
 Treatment. — If precipitate labour from deficient resistance is 
 anticipated, the only treatment necessary is to keep the patient 
 continually recumbent in the lateral position from the commence- 
 ment of pains, and to be careful to secure adequate uterine con- 
 traction after delivery. If the expulsive force is excessive, and 
 threatens laceration, it is also well to keep the patient in the 
 lateral or, still better, the semi-prone position, so that the pressure 
 on soft parts may not be assisted by gravity. Over-action of the 
 auxiliary muscles may be kept in check to a considerable extent 
 by voluntary control. The patient should not have any support 
 to hold to by the hands, or press against with the feet, and should 
 be exhorted not to hold her breath, but to cry out during the 
 height of a pain. The most effective remedy, however, for ex- 
 cessive action both of the uterus and auxiliary muscles is the 
 administration of chloroform. By this means the pains may be 
 moderated to any desired extent. Failing chloroform, a sub- 
 cutaneous injection of morphia may be given, but it is not so 
 efi"ective. Chloroform will equally moderate an unduly rapid suc- 
 cession of pains, and abolish the nervous excitement therefrom 
 
Precipitate and Prolonged Labour. 619 
 
 resulting. When the obstacle lies at the vaginal outlet and peri- 
 neum, especially in primiparte, and excessive or rapidly following 
 pains threaten laceration, the perineum may often be saved by 
 delaying the advance of the head in the manner previously 
 described (see page 302). This is greatly facilitated if the patient is 
 under chloroform, since otherwise she is likely to lose self-control 
 at the height of a pain, and throw herself into such a position that 
 the physician is powerless. 
 
 Prolonged Labour. 
 
 Labour may be prolonged by an absolute inefficiency in the 
 expulsive force, or by an insuperable resistance in the pelvis or 
 soft parts. In the majority of cases of prolonged labour, however, 
 there is only a relative disproportion between the force and the 
 resistance. The resistance is greater than normal, and the force, 
 either from the first {primary inertia), or when the patient is 
 beginning to get exhausted from her efforts {secondary inertia), is 
 insufficient to overcome it within a moderate time. In primiparae, 
 even the resistance of the vaginal outlet and perineum not uncom- 
 monly is sufficient to produce this effect, the pains, which at first 
 may have been satisfactory, becoming inefficient after a time. 
 
 GeneralEffectsof Protracted Labour. — Undue prolongation of 
 labour always increases the risk to the mother, even when the pro- 
 longation is only in the first stage, at which it is of comparatively 
 slight consequence. There is a certain similarity in the symptoms 
 which arise in prolonged labour, whatever the cause of prolongation. 
 They depend in some degree upon the continuous pressure exerted 
 by the foetus, but to a much greater extent upon the effect upon the 
 nervous system of the fruitless efforts of the uterus. If the delay 
 depends only upon feeble pains {'primary inertia), and especially 
 when this is the case in the first stage of labour before rupture of 
 the membranes, a very long time may elapse before serious efforts 
 become manifest. The more vigorous are the fruitless efforts of a 
 strongly acting uterus to overcome an obstacle, the more quickly 
 do the grave constitutional effects of exhaustion appear {secondary 
 inertia). The first marked effect is upon the pulse, which, instead 
 of being only moderately accelerated during the pains, as by 
 muscular exertion of any other kind, gradually rises above the rate 
 of 100 per minute, and eventually to a rate of 120 or more. In 
 cases of obstructed labour the patient becomes anxious, distressed 
 and restless, the copious lubricating secretion from the cervix and 
 
620 The Practice of Midwifery. 
 
 vulva fails, and the parts become dry and hot, often swollen. 
 Eventually even a slough may form at the part most exposed to 
 pressure. The tongue becomes coated, and finally dry and black. 
 The temperature rises, and nausea and vomiting are often marked. 
 Eventually, within a limited number of hours, the patient would 
 sink from exhaustion, the pulse becoming progressively feebler and 
 more rapid. Of these symptoms the earlier, and especially the 
 acceleration of the pulse, should always be a sufficient indication 
 for interference, and the more formidable ones should never be 
 allowed to arise. 
 
 Tetanic Contraction or Continuous Action of the Uterus. — The 
 effect upon the uterus itself is one of the utmost importance to 
 recognise. For a considerable time a strongly acting uterus is 
 stimulated by resistance to more vigorous pains. Eventually, 
 however, if it is unable to overcome the obstacle, that is in obstructed 
 labour, and no rupture occurs, the pains appear to become feebler 
 and cease. The uterus, however, does not usually become lax, but 
 gets into a state of continuous or tetanic contraction, unbroken by 
 any rhythmical pains, so that it feels firm and hard when the hand 
 is placed upon the abdomen. The useless energy expended in such 
 tetanic contraction still further exhausts the nervous system. It 
 has moreover the efi'ect that, i£ all the liquor amnii has escaped, 
 the parts of the uterine wall in contact with projections of the foetus 
 are subjected to prolonged pressure, while those parts which corre- 
 spond to dejDressions and are so relieved from pressure, become 
 intensely congested. 
 
 "While a strongly acting uterus will fall at length into this state 
 of tetanic action, if the obstacle is insuperable, a feebly acting 
 uterus may do so at a much earlier period. Thus in many cases 
 which were formerly regarded as simply " powerless labour," the 
 condition is really one of continuous action of the uterus. Cases 
 of true inertia alone, either primary or secondary, are distinguished 
 by the softness and laxity of the uterus, and by the fact that the 
 pulse is only slightly accelerated, whereas in continuous action it 
 is always markedly so. As a rule, it is only in the second stage of 
 labour, and after the rupture of the membranes, that tetanic con- 
 traction of the uterus is apt to come on. In very exceptional cases, 
 however, it may do so even in the first stage, when there is an 
 insuperable obstacle to dilatation of the os, such as cancer or 
 cicatricial closure. In some such cases, continuous action may 
 even supervene without any vigorous rhythmical pains ever having 
 been apparent. Any degree of this continuous action or "tetany " 
 of the uterus, associated with cessation of rhythmical pains, should 
 
Precipitate and Prolonged Labour. 621 
 
 be an immediate indication for affording assistance. It is an 
 absolute contra-indication to the administration of any oxytocic, as 
 ergot. 
 
 Retraction of the Uterus. — Besides the constitutional symptoms, 
 protracted labour, unless due to primary or secondary inertia of the 
 uterus, tends to produce a certain local effect. The effect of 
 repeated pains, if they are unable to cause advance of the foetus, is 
 to stretch gradually more and more the cervix together with the 
 adjoining lower segment of the uterus. In corresponding degree 
 the strong muscular portion of the upper segment of the uterus 
 retracts,^ shrinks, and becomes thicker, while, by gradual escape of 
 the liquor amnii, it more closely grasps the foetus. The consequence 
 is that both the internal os uteri and the retraction ring or line of 
 demarcation between the retractile and extensible portions of the 
 body of the uterus (the so-called ring of Bandl, according to some 
 authorities) travel gradually upward. One of these, generally 
 regarded as being the retraction ring, may sometimes, after pro- 
 tracted labour, be felt on external examination as a transverse line 
 of depression across the abdomen, some distance above the pubes. 
 If such a line is detected at a considerable height above the pubes, 
 it is an indication both that interference is required, and that the 
 case has advanced too far for version. When retraction has pro- 
 ceeded beyond a certain point, the power of the uterus is practically 
 lost, notwithstanding the thickening of its walls produced, as the 
 muscular fibres, having already shortened themselves to a con- 
 siderable extent, are no longer able to contract with any degree of 
 force. 
 
 Eetraction is generally the sequel of active expulsive pains ; but if 
 the uterus is emptied artificially in the absence of pains it may 
 occur without them, the uterus gradually closing up its cavity. 
 The force of retraction increases with time, and offers a powerful 
 resistance to dilatation when it has been established a considerable 
 time. 
 
 The extensile zone, as it is stretched, eventually undergoes 
 dangerous thinning. This may lead at last to rupture, com- 
 mencing in the thinned portion, but extending perhaps beyond its 
 limits. The internal os uteri may travel so far upward as to pass 
 above the head of the foetus, even when this is prevented from 
 descending far into the brim. It may then contract somewhat 
 around the neck, being the part of the uterus which has the 
 strongest circular muscular fibres. If version is attempted in this 
 
 1 "Retraction" means the contiactioa and shortening of the uterine muscle, not 
 followed by relaxation. 
 
622 
 
 /, 
 
 The Practice of Midwifery. 
 
 state of affairs there is great danger of laceration, 
 since, to elevate the head, it is necessary to push 
 it past a constricting ring. In the frozen section 
 (Fig. 131, p. 220) if the ridge marked at o i is 
 really the internal os, as held by Braune, its 
 position appears to indicate protraction of labour, 
 though the membranes are intact. As a rule the 
 excessive retraction of the muscular portion of 
 the uterus occurs only after rupture of the mem- 
 branes, when the advance of tlie foetus is ob- 
 structed. In rare cases it may happen even in 
 the first stage, when pains of fair strength have 
 been long continued, but some j)owerf ul resistance 
 to dilatation of the external os exists. When this 
 is so, protraction even of the first stage becomes 
 serious. 
 
 Effects produced at the Several Stages of Lahour. 
 — The first stage of labour, before escape of the 
 liquor amnii, may be protracted, sometimes even 
 for several days, without very serious effect to 
 either mother or child, both being protected from 
 undue pressure by the equable support of the 
 liquor amnii. If protraction is only due to uterine 
 inertia at this stage, the patient suffers little 
 more than the eflect of fatigue and loss of sleep. 
 If it is due to rigidity or other morbid condition 
 of the cervix, the constitutional effects of pro- 
 tracted labour come on sooner or later. Pro- 
 tracted labour in the first stage, after premature 
 rupture of the membranes, is much more serious. 
 The life of the child is endangered by prolonged 
 pressure, the greater part of the liquor amnii 
 gradually draining away. The futile efforts of 
 the uterus also at length bring on the symp- 
 toms of nervous exhaustion already described. 
 
 Fig. 317. — Section of a portion of the uterine wall and vagina 
 from a patient who died during labour. The thickened 
 iipper uterine segment, Bandl's ring forming a thickening 
 on the uterine wall, and the greatly stretched and dis- 
 tended lower uterine segment measuring eight inches in 
 length, are shown. A small part of the placenta is seen 
 attached at the upper end of the section. i 
 
 1 Univ. Coll. Hosp. Med. School Mus. No. 4,252. 
 
Precipitate and Prolonged Labour. 623 
 
 Much longer delay can, however, be tolerated with impunity at 
 this stage than later on, both by mother and child. The child 
 suffers less because there is less powerful reflex stimulus to uterine 
 action than when the head is resting upon the vagina or perineum, 
 the mother for the same reason, and also because the vaginal 
 tissues are not yet endangered by pressure of the head, lying 
 deeply in the pelvis. In pelvic and face presentations, labour, 
 especially in its earlier stage, is naturally more protracted, and less 
 harm than usual results, particularly in pelvic presentations, since 
 the shaj)e of the presenting part causes less pressure. 
 
 Protraction of the second stage, after the external os uteri is 
 completely retracted over the head, is the most serious of all, and 
 produces grave symj)toms within a very few hours. Sloughing is 
 especially likely to occur at the anterior vaginal wall, if delay is 
 allowed to continue very long, and to be followed by vesico-vaginal 
 fistula. Delay at this stage is also most likely to prove fatal to the 
 child through asphyxia. It is in these circumstances that the 
 modern practice of giving much more frequent assistance by 
 forceps than was usual in former days is both most beneficial, and, 
 at the same time, free from any difficulty or danger. 
 
 Anomalies of the Expulsive Fokce. 
 
 Inertia of the Uterus. — Feebleness of uterine action may be 
 either due to deficient nerve force dependent upon some constitu- 
 tional debility, or to faulty development, weakness, or degenerative 
 changes of the uterine muscle. The latter condition is itself 
 generally dependent upon the constitutional state. Inertia may 
 therefore result from any exhausting disease, from constitutional 
 debility, from any cause of malnutrition, such as vomiting, or from 
 residence in a hot climate. As might be expected, it is more 
 common among women of the upper classes, not accustomed to 
 much muscular exertion, than among women used to hard work. 
 On the other hand, it is common among the poor who are unable to 
 get sufficient nourishment, especially if resident in towns, and 
 leading sedentary lives. If pregnancy occurs in very young girls, 
 the uterus is apt to be insufficiently developed. This may also 
 occur if women much beyond the usual age become pregnant for 
 the first time, but is not then so usual. A distended bladder or 
 loaded rectum often interferes with the development or continuance 
 of effective rhythmical pains. The influence appears to act to a great 
 extent through the nervous system, though it is also partly 
 mechanical, especially in the case of a distended bladder, which is 
 
624 The Practice of Midwifery. 
 
 a direct impediment to the action of the auxiliary forces. Excess of 
 liquor amnii or twin pregnancy also tends to produce inertia, the 
 over-distended and therefore thinned uterine wall being naturally 
 more feeble in its contraction. 
 
 The so-called " polarity of the uterus," or correlation between 
 the condition of the body of the uterus and that of the cervix, 
 according to which a quiescent state of the body of the uterus is 
 associated with muscular tonicity of the cervix, and active 
 expulsive pains with physiological relaxation of the circular 
 muscular fibres of the cervix, has already been explained (see 
 pp. 210, 211). 
 
 In consequence of this correlation it happens that, in the first 
 stage of labour, inertia of the uterus, or a tendency to tonic con- 
 traction instead of active rhythmical pains, is apt to be brought 
 about if the natural mechanism of dilatation of the cervix does not 
 act satisfactorily. The cause may be a want of the natural pro- 
 jection of the bag of membranes, either from deficiency of liquor 
 amnii, inelasticity of membranes, or their adhesion around the os, 
 or again it may be premature rupture of the membranes, rigidity 
 of the cervix from some previous morbid state, or spasm of it set up 
 by over-frequent examinations or any other cause. 
 
 There may also be a secondary inertia in the second stage of 
 labour, when some obstruction exists, such as the rigidity of soft 
 parts in a primipara, and a weak uterus, easily wearied by its 
 efforts, falls into a state of laxity when it fails to overcome the 
 obstruction. The term inertia should not, however, be applied to 
 the more dangerous condition of continuous action or tetanic 
 contraction (see p. 620) supervening upon obstructed labour. 
 
 Irregular and Painful Uterine Contractions. — The amount 
 of pain produced by uterine contraction is by no means propor- 
 tional to its mechanical power, which must be estimated by its effect 
 upon the bag of membranes, or presenting part. Not uncommonly 
 contractions are excessively painful at the same time that they are 
 inefficient. This character in the pains may last throughout the 
 whole labour, and in such case it may depend either upon the 
 neurotic over-sensitive character of the nervous system, or upon 
 some inflammatory or other morbid condition of the walls of the 
 uterus. Women who have previously suffered from dysmenorrhoea 
 mainly of the neuralgic or neurotic type are liable to be affected in 
 this way. The excessively painful character of the contractions 
 seems itself directly to impair their efficiency, especially by its 
 interference with bearing-down efforts. 
 
Precipitate and Prolonged Labour. 625 
 
 There is another kind of excessive painfulness in the uterine 
 action, depending upon the nature of the contraction itself, which 
 is irregular and cramp-like, affecting the uterus unequally, and so 
 producing little or no effect upon the os uteri or presenting part. 
 A part of the distress occasioned by such pains is the consciousness 
 of the patient herself that they are useless. Irregular contractions 
 occur especially in the first stage of labour. Women of over- 
 sensitive nervous system are more prone to them, as they are to 
 the merely over-painful contractions. They are liable to be set 
 up by any source of reflex irritation acting upon the nervous 
 system, such as indigestion, or a loaded rectum. One variety 
 constitutes the well-known " spurious pains " coming on before 
 the real onset of labour, and producing no effect upon the cervix. 
 These are generally dispelled by an aperient. Irregular contrac- 
 tion may also be set up in the first stage, when there is something 
 to interfere with dilatation of the cervix, such as morbid adhesion 
 of the membranes around the os, or rigidity of the cervix ; some- 
 times also even in the second stage, when the uterus finds itself 
 unequal to resistance with which it meets. 
 
 Inefficiency in the Auxiliary Forces.— Although the action 
 of the uterus is the most important part in labour, yet, when the 
 resistance is somewhat greater than usual, a deficient action of the 
 auxiliary muscles may be of considerable consequence, partly from 
 the fact that the bearing-down efforts act as a stimulus also to the 
 uterus itself. This deficiency occurs when there is any affection 
 of heart or lungs, which prevents the patient holding her breath in 
 order to fix the diaphragm and bear down ; when the abdominal 
 walls have been overstretched by previous pregnancies, or by any 
 other cause ; and when ascitic fluid, or tumours of any kind, are 
 present in the abdomen. The auxiliary forces may also be feeble 
 from muscular weakness, or when the patient is so deficient in self- 
 control and so unable to bear pain that she persists in crying out 
 even in the pains of the expulsive stage, and will not hold her 
 breath to bear down. 
 
 Deviation of the Uterine Axis.— There is generally some 
 obliquity of the uterus toward the right side, but in some cases 
 lateral obliquity is excessive. A more important and common 
 deviation is anteversion of the uterus, depending upon undue laxity 
 in the abdominal walls, found chiefly in women who have had 
 many previous pregnancies. The fundus may then hang forward 
 and even downward over the pubes, so that the presenting part is 
 
 M. 40 
 
626 The Practice of Midwifery. 
 
 directed backward against the sacrum or lumbar vertebrae instead 
 of toward the pelvis. Deviation of the uterine axis is of com- 
 paratively little consequence until the membranes are ruptured. 
 After this, the efficacy of the force in causing advance of the foetus 
 is reduced in proportion to the cosine of the angle of deviation. 
 Additional pressure, both useless and injurious, is called out, equal 
 to the product of the force and the sine of the same angle. In this 
 ■way, in anteversion of the uterus, if a sudden pain occurs when the 
 patient is upright, it may even cause rupture of the vagina or cervix 
 at its posterior part, without the existence of any considerable 
 obstruction. 
 
 Treatment in the First Stage of Labour. — The main remedies 
 for uterine inertia in the first stage, while the membranes are 
 intact, are time and patience. Investigation should first be made 
 as to the presence of any source of reflex disturbance capable of 
 removal. Thus the effect of a copious enema is often very satis- 
 factory. Beyond this, the chief jDoints to be attended to are to 
 keep up the strength of the patient by a sufficient amount of food, 
 and to secure her a reasonable amount of sleep. For this purpose 
 a dose of opium or chloral may be administered. Pains often 
 diminish from the effect of fatigue, and, after a sleep, return with 
 renewed vigour. In the intervals the patient should be up and 
 moving about as much as possible, not continually reclining. 
 When she lies, the dorsal position should be preferred, so as to 
 secure the greatest pressure upon the cervix. If the contractions 
 are irregular and unusually painful as well as inefficient, chloral 
 should be administered in the mode already described (see p. 315). 
 In the case either of spasmodic irregular pains, or of great pro- 
 traction of the first stage, especially if the bulging of the bag of 
 membranes is not satisfactory, it is well to make sure that the 
 membranes are separated from the uterine wall for some distance 
 within the os. If any adhesion exists, artificial separation will 
 often considerably accelerate labour. To do this, two joints or 
 the whole length of the index finger should be passed within the 
 OS and swept round in a circle. In multiparse, when the vagina is 
 capacious, the half or whole hand may be passed into the vagina 
 to carry this out. Otherwise the patient should be placed on her 
 back, the fundus pushed somewhat backward, and the cervix 
 drawn forward by the index finger hooked into it, until it is near 
 enough for the finger to sweep round the anterior segment. If 
 the posterior segment cannot be reached by the finger, a large 
 gum elastic catheter guided by a strong stylet having only a slight 
 
Precipitate and Prolonged Labour. 627 
 
 curve, both sterilised by boiling water, may be used for this part, 
 care being taken not to rupture the membranes. 
 
 If the OS is soft and dilatable in a case of inertia, and especially 
 if it is suspected that the liquor amnii is excessive, it often 
 accelerates matters to puncture the membranes rather before full 
 dilatation of the os has been reached. Nothing, however, calls for 
 more judgment and experience than the decision when this can be 
 done with advantage. If the membranes are ruptured prematurely 
 in an unsuitable case, the os may become rigid from spasm, lubri- 
 cating secretion may fail, and the case be much more protracted, 
 and the patient suffer much more, than she would otherwise have 
 done. 
 
 If there is rigidity of the os as well as inertia, so long protrac- 
 tion must not be allowed. Artificial dilatation must be undertaken 
 if the pulse becomes much accelerated, or if retraction of the 
 uterus becomes manifested by a transverse line of depression being 
 felt on external palpation. If the liquor amnii has escaped, it is 
 still more necessary not to allow too long delay ; but here also 
 acceleration of the pulse will be the most valuable guide. The 
 mode of interference will be described in the section on morbid 
 conditions of the cervix (Chapter XXVII.). 
 
 Treatment in the Second Stage of Labour. — If pains are 
 inefficient in the second stage, care should be taken to correct any 
 deviation of the uterine axis, especially anteversion. If anteversion 
 exists, the fundus should be supported by a firm binder, and the 
 patient should lie on her back. The dorsal position has the 
 advantage in all cases of inertia, at any rate until the head is 
 passing the vulva ; for gravity then aids the advance of the child, 
 and increases the pressure on soft parts and thereby reflex stimulus. 
 Examinations may also be made with advantage more frequently 
 than under ordinary circumstances, provided that there is no dry- 
 ness or swelling of the soft parts ; for the pressure of one or two 
 fingers in the vagina, and, still more, the pressure on the perineum 
 of the remaining fingers folded back, tend to increase the reflex 
 stimulus to the uterus. 
 
 In all cases of marked inertia the use of chloroform should 
 be avoided if possible, or it should be administered very spar- 
 ingly, not only because it tends to prolong labour in such 
 cases, Init because there is then increased risk of post-partum 
 haemorrhage. 
 
 External Pressure. — A valuable mode of stimulation is the use of 
 external pressure. This has been employed from time immemorial 
 
 40—2 
 
628 The Practice of Midwifery. 
 
 by various savage races, often by very rough and rude methods. 
 When resistance is . slight the direct effect of pressure may cause 
 advance of the foetus, even in the absence of a pain, but the chief 
 vahie of the method is its stimulating effect upon the uterus. It 
 may be carried out when the patient is in the lateral position, but 
 more conveniently when she lies on her back. Two hands are laid 
 upon the fundus uteri, and, as soon as the first hardening of the 
 uterus at the beginning of a pain is felt, it is stimulated by friction. 
 At the height of the pain steady pressure is made downward and 
 backward in the uterine axis. Some patients are more tolerant 
 than others of this pressure, and it must not be carried so far as to 
 give great pain. The same process is repeated with each succeeding 
 pain. Even in the absence of pain, friction and kneading with 
 moderate pressure may be used at intervals of a few minutes, in 
 the hope of exciting pains. The plan is only to be adopted when 
 primarj^ inertia is the sole cause of delay, not when there is 
 exhaustion, continuous action of the uterus, or any serious 
 obstruction to delivery. 
 
 Oxytocic Drugs. — Of the various drugs rejDuted to cause uterine 
 contraction, only two are deserving of consideration here, namely, 
 ergot and quinine. In former days when the application of forceps 
 was regarded as an operation very rarely to be undertaken, ergot 
 was used much more frequently than now. There are several dis- 
 advantages in its use. It frequently not only intensifies the pains, 
 but brings on a tonic contraction of the uterus in the intervals, 
 which greatly increases the risk of the child dying from asphyxia. 
 When exhaustion is approaching, it may simply bring on the state 
 of continuous action, without increasing the rhythmical pains at all. 
 Children stillborn from prolonged labour are therefore more 
 frequent in the practice of those who use ergot frequently, and, 
 moreover, the use of the drug involves the risk of inducing that 
 condition of continuous uterine action which is now well recognised 
 as highly dangerous to the mother. If used before full dilatation 
 of the OS and its retraction over the head, ergot may cause 
 spasmodic rigidity ; if used injudiciously, when any obstruction 
 exists, it may cause rupture of the uterus. The only case in 
 which ergot may be used with safety is when it is quite 
 certain that inertia is the only fault, and that no obstruction 
 exists. To secure this condition, the patient must be a parous 
 woman, who has had no difficulty in previous confinements, 
 the uterus must be quite lax in the intervals of pains, the pelvis 
 of good size, the os fully retracted over the head, the head easily 
 movable, and with no considerable caput succedaneum, the 
 
Precipitate and Prolonged Labour. 629 
 
 foetal heart unimpaired in force and frequency, and the mother's 
 pulse quiet. 
 
 Quinine, given in a full dose of 6 to 10 grains, also has a 
 stimulating effect upon the uterus, and is less likely to induce 
 continuous action instead of expulsive pains. In general, therefore, 
 it may be used in jDreference to ergot, when uterine inertia is the 
 cause of delay. If ergot is used, it may be given in doses of 30 to 
 60 grains of the powder, made into fresh infusion with boiling 
 water, or 30 to 60 minims of the liquid extract. The effect of any 
 oxytocic drug generally becomes manifested within twenty minutes 
 or half an hour. If any has been administered, the condition of the 
 patient should be carefully watched, as well as the foetal heart, and 
 the physician should be prepared to aid delivery with forceps, 
 within a moderate time, if the effect of the drug is not satisfactory 
 or sufficient. 
 
 In general, ergot should be reserved for the purpose of 
 acting upon the uterus after delivery, at which time its pro- 
 perty of inducing tonic contraction is of special value to avert 
 the risk of haemorrhage. When, however, uterine inertia through- 
 out the course of labour has been so marked as to indicate 
 a risk of post-partum haemorrhage, or when a patient has had 
 serious flooding in former deliveries, a dose of ergot may with 
 advantage be given before delivery, in two conditions — first. Just 
 as the head reaches the perineum, when there is no prospect 
 of obstruction at that stage ; secondly, just before the application 
 of forceps, when it has been decided to terminate labour by their 
 means. 
 
 Application of Forceps. — In the great majority of cases of pro- 
 longed labour, the cause lies not merely in uterine inertia, but in 
 some degree of extra resistance, due either to slight disproportion 
 between the foetal head and the pelvis, or rigidity of the soft parts, 
 such as is especially frequent in primiparse. In these circum- 
 stances, the administration of ergot is analogous to applying a 
 spur to the already overtaxed uterus, and is liable to end in a still 
 more complete exhaustion. It is now generally agreed that it is a 
 more scientific plan to supplement the insufficient expulsive force 
 by the vis a fronte exerted by means of forceps. Even if the only 
 fault is inertia, there is no harm in extraction by forceps, provided 
 care is taken to secure due contraction of the uterus after 
 delivery, and so avoid post-partum haemorrhage. It is not now a 
 question of the high forceps ojDeration, in cases in which there is 
 an obstruction preventing the head descending into the pelvis, or 
 of the application of forceps when delay is due to the failure of 
 
630 The Practice of Midwifery. 
 
 the cervix to dilate. In both these conditions application of the 
 forceps is a much more serious matter, only to be undertaken for 
 grave reason. But when the head has entered the cavity of the 
 pelvis so as to be easily grasped by the forceps, and the cervix is 
 either completely retracted over the head, or so far dilated that it 
 no longer offers an obstacle to delivery, extraction by forceps is both 
 easy and practically almost free from risk. 
 
 Indications for Use of Forceps. — Kecourse should be had to forceps 
 long before any of the graver symptoms of protracted labour, 
 which were before enumerated (see p. 623), have appeared. Ac- 
 celeration of the pulse is the most valuable practical indication 
 of the necessity for interference. The minimum j)ulse-rate, taken 
 in the intervals of pains, is the rate which must be taken as a 
 guide. It is to be remembered that some persons have habitually 
 a rapid pulse, especially those suffering from any heart affection, 
 or from alcoholism. These cases will generally be distinguished 
 by the pulse having been rapid from the very outset of labour. 
 It must also be remembered that a rising pulse may be the effect 
 of alcohol given during labour by injudicious friends. Setting 
 apart these cases, it may be said, as a general rule, that when the 
 pulse has risen from a moderate rate to exceed 100 per minute in 
 the second stage of labour, between the pains, the os being dilated, 
 artificial assistance is desirable. One case must be excepted, 
 namely, that in which, toward the end of labour, vigorous pains 
 come on in rapid succession. These are often accompanied by a 
 pulse rising to a high rate, simply from the absence of intermissions. 
 In this case instrumental interference is superfluous, if any progress 
 is being made, for the labour is likely soon to be completed by 
 nature. 
 
 Even before the pulse rises sufficiently to indicate a necessity 
 for interference, forceps may be applied with advantage, if, after 
 complete retraction of the cervix, the head is detained for any long 
 time, more than two hours or so, in the vagina, or resting on the 
 perineum, and little or no progress is being made. Longer time 
 should of course be allowed for this stage in primiparae than in 
 parous women, since in the former longer time is naturally required 
 for the dilatation by successive pains of the vaginal outlet and 
 perineum, and laceration is more likely to occur if this time is 
 shortened. If the head fits so tightly in the pelvis that it does not 
 recede, and cannot easily be pushed back, in the interval of pains, 
 and if moreover the caput succedaneum is large and increasing, 
 these conditions form additional indications in favour of interfering 
 without waiting long for constitutional symptoms, since they denote 
 
Precipitate and Prolonged Labour. 631 
 
 that both the foetal head and maternal soft parts are subjected to 
 serious pressure. 
 
 It cannot be doubted that, by the modern practice of having 
 recourse to forceps without great reluctance, both maternal lives are 
 saved, and the lives of children which would have been stillborn from 
 prolonged pressure. In the present day, however, there is probably 
 little need to urge the expediency of a frequent use of forceps, but 
 it is necessary rather to caution against the risk of carrying the 
 frequency of their use too far ; for practitioners are naturally often 
 exposed to the temptation to apply forceps early, in order to save 
 their own time. In this view it must be remembered that the 
 cases which try the patience most are often those in which the 
 delay is due to difficulty in the complete dilatation and retrac- 
 tion of the cervix. Although, when the head is in the vagina, 
 forceps may as a rule be applied, even unnecessarily, with 
 impunity, this is not the case when the cervix is not fully 
 dilated. There is then a risk of cervical laceration, which not 
 only involves an increased chance of septic absorption, but the 
 prospect that the patient may suffer for years afterwards from the 
 cervical inflammation consequent upon laceration with ectropion. 
 
 Some authorities, in urging a frequent use of forceps, have based 
 their recommendation upon the very large saving of foetal life said 
 to be attained thereby. It does not appear, however, that there 
 are any trustworthy statistics proving that any such large saving 
 can be obtained. Of the total number of still-births, a large 
 proportion are in cases of premature, macerated, or syphilitic 
 children, or the result of malpresentation. The number of these 
 may vary so much in different localities, or in different classes of 
 society, that any inference from the statistics of individual jpracti- 
 tioners as to the still-births due to protracted labour, or saved by 
 the early use of forceps, becomes difficult. 
 
 Under these circumstances it is of interest to compare the results 
 obtained in two adjoining districts, among populations of a similar 
 character, namely, the Lying-in Charities of Guy's and St. Thomas's 
 Hospitals. Some years ago forceps were used more than ten times 
 as often in the St. Thomas's Charity as they were in the Guy's 
 Charity. Thus, for 12 years (1863—1875), in the Guy's Charity, 
 the forceps-rate was 5*1 per 1,000 (about 1 in 200 deliveries) ; the 
 corresponding rate of still-births in vertex presentations, 2*7 per 
 cent. In the St. Thomas's Charity, in 1874, the forceps-rate was 
 54*2 per 1,000 (about 1 in 18 deliveries) ; the corresponding rate 
 of still-births in vertex presentations, 2*8 per cent. In 1875, the 
 forceps-rate was 61*8 jjer 1,000 (about 1 in 16 deliveries); the 
 
632 The Practice of Midwifery. 
 
 corresponding rate of still-births in vertex presentations, 2*8 per 
 cent. In the above ratios of still-births, premature and macerated 
 children are included. It therefore appears that, though no one 
 would probably now recommend for private practice so sparing a 
 use of forceps as only one forceps-case in 200 deliveries, yet with 
 this a slightly better ratio of still-births was attained than that in 
 the St. Thomas's Charity with a use of forceps ten or twelve times 
 as frequent. No patient died in the St. Thomas's Charity in these 
 years after the use of forceps, so the practice there was at any rate 
 apparently innocuous to the mothers, if it did not diminish the 
 ratio of still-births. 
 
 A similar inference may be drawn from the statistics of the 
 Rotunda Hospital, Dublin. The patients may be presumed to have 
 been of a similar class at different times, but the forceps-rate 
 varied very widely under different masters. Under Dr. Shekleton 
 (1847 — 1854), the forceps-rate was 16'5 per 1,000 ; the total ratio 
 of still-births, 6'9 per cent. Under Dr. G. Johnston (1871—1875), 
 the forceps-rate was 116*4 per 1,000 ; the total ratio of still-births, 
 6*1 per cent. Excluding premature and putrid children. Dr. 
 Shelileton's ratio of still-births was 2*7 per cent. ; Dr. Johnston's 
 (1868 — 1875), 2-2 per cent,, with an average forceps-rate of 96*4 
 per 1,000. This gives an apparent gain by frequent use of forceps 
 of one-half per cent. But the greater part of this is probably due 
 to the substitution of forceps delivery for craniotomy, Dr. Johnston 
 having introduced the long curved forceps in place of the straight 
 forceps previously used at the Eotunda Hospital. Thus Dr. 
 Shekleton had 0'79 per cent, craniotomy cases, Dr. Johnston only 
 0-35 per cent. If the difference between these be subtracted, only a 
 difference of "06 per cent, in the ratio of still-births remains in 
 favour of the frequent use of forceps. 
 
 Neither do statistics show positively any saving of maternal 
 mortality by a forceps-rate much greater than about 1 in 200. At 
 the Eotunda Hospital, under Dr. Shekleton, with a forceps-rate of 
 16-5 per 1,000, maternal mortality was IS'O per 1,000 ; under Dr. 
 Johnston, with a forceps-rate of 96-4 per 1,000, mortality was 22-0 
 per 1,000. The latter high mortality was mainly due to puerperal 
 septicaemia, and cannot fairly be taken as telling conclusively against 
 a frequent use of forceps. In the Guy's Charity (1863—1875), with 
 a forceps-rate of 5-1 per 1,000, mortality was 4*4 per 1,000. In the 
 St. Thomas's Charity, in 1874, with a forceps-rate of 54*2 per 1,090, 
 mortality was 7*4 per 1,000; in 1875, with a forceps-rate of 61-8 per 
 1,000, mortality was 3'4 per 1,000; giving a mean mortality for 
 the two years of 5*4 per 1,000. 
 
Precipitate and Prolonged Labour. 633 
 
 A moderately frequent use of forceps, in cases where interference 
 is not absolutely required, can therefore only justly be recom- 
 mended on the ground that it shortens the patient's suffering, does 
 not increase her danger, saves the practitioner's time, and effects a 
 slight saving in the rate of still-births. This saving is so slight as 
 to suggest that delivery by forceps must in itself involve some 
 increased risk to the child, counterbalancing in some measure the 
 advantages gained by shortening the labour. 
 
 No positive general rules can be laid down as to the frequency 
 with which it is desirable to use forceps, since much depends upon 
 the race of the patients, their position in life, and other circum- 
 stances. The results of the St. Thomas's Charity above quoted 
 appear to show that a forceps -rate as high as 1 in 16 or 1 in 18 
 deliveries does not endanger the mothers, but wider statistics on 
 this point are to be desired.^ 
 
 In 20,604 labours during the years 1883 — 1902 recorded by 
 V. Winckel,^ forceps were applied 635 times, a forceps-rate of 30*8 
 per 1,000. In three-fourths of the cases the indication for the 
 use of the forceps was afforded by interference with the foetal 
 circulation, while in 20 per cent, the indication lay in some condi- 
 tion of the mother, such as swelling of the soft parts, thinning of 
 the lower uterine segment, or a general affection, such as eclampsia, 
 necessitating assistance. 
 
 In about 10 per cent, of the cases, the indication for the employ- 
 ment of the forceps was afforded by both the mother and the child. 
 The maternal mortality was 3*1 per 1,000, and the morbidity was 
 11"1 per cent., while the foetal mortality was 9"8 per cent. 
 
 In the Eotunda Hospital during the years 1896 — 1903, among 
 431 forceps cases in 11,098 labours, or a forceps-rate of 38 per 1,000, 
 there were no maternal deaths, but a fcetal death-rate of 13'9 per 
 cent.^ 
 
 J See papers by the author : " EfEects of a Frequent Use of Forceps upon the 
 Fcetal and Maternal Mortality," Obstet. Journ., 1877, Vol. V. ; " Foetal Mortality in 
 Obstetric Practice," Obstet. Journ., 1878, Vol. VI. 
 
 2 V. Winckel, " Uber die Anzeigen flir die Zangenoperation," Deutsche Klinik, 1902, 
 Vol. IX., pp. 483—500. 
 
 3 Jellett, Manual of Midwifery, 190.5. p. 1001. 
 
Chapter XXVIL 
 
 LABOUR OBSTRUCTED BY ANOMALIES OF THE 
 
 SOFT PARTS. 
 
 Spasmodic Contraction of the Cervix Uteri — Trismus Uteri. 
 — The strongest circular muscular fibres of the uterus are those of 
 the cervix. The action of these is especially marked at two points, 
 the internal and the external os, especially the former, which forms 
 the main sphincter of the uterine cavity, both in the unimpregnated 
 and pregnant condition. In normal labour at full term, the 
 internal os becomes dilated, either before manifest pains set in, or 
 ■with the earlier pains. It is therefore chiefly spasmodic rigidity of 
 the external os which is observed as a cause of delay in the first 
 stage of labour. In premature labour, however, and more 
 especially when labour is induced prematurely, as in the case 
 of placenta praevia, eclampsia, or pelvic contraction, spasm of the 
 internal os is not uncommonly manifested. This is not so likely to 
 hajjpen when, as in cases of pelvic contraction, there is time to 
 induce labour by a gradual method, imitating as closely as possible 
 the natural process. It is much more frequent when, as in the 
 case of eclampsia, the process has to be made a rapid one on account 
 of the mother's condition. When spasm of the internal os does 
 occur, it is apt to cause more resistance than that of the external 
 OS, since the muscular fibres are more powerful, and extend over a 
 wider space. 
 
 Causation. — It has been already described how physiological 
 relaxation of the cervix is normally associated with active expulsive 
 pains (see p. 210). Minor degrees of spasmodic contraction are 
 therefore very common as a cause of delay in the first stage of 
 labour in association with ineffective jDains. The extreme form of 
 spasmodic rigidity, which has been called " trismus uteri," and 
 which has sometimes persisted as an obstruction until the efi^ects 
 of the delay upon the patient have been very serious, is a very 
 rare condition. The cause of spasm of the cervix may sometimes 
 be simply inertia of the body of the uterus. More frequently 
 there is some source of reflex irritation causing both one and the 
 
Labour Obstructed by Anomalies of Soft Parts. 635 
 
 other, and to this women of a sensitive neurotic disposition are 
 specially liable. 
 
 Thus there may be a loaded rectum or a full bladder, or pre- 
 mature rupture of the membranes, interfering with the normal 
 mechanism of dilatation, or the cause may be too frequent digital 
 examination at an early stage of labour, or premature and 
 ineffective attempts at operative interference. Again, the cause 
 may be extreme painfulness in the uterine contractions, due to 
 the patient's over-sensitiveness to pain, or some previous inflam- 
 matory condition of the uterine walls. Injudicious administration 
 of ergot in the first stage of labour may have the same effect ; and 
 so may malposition of the foetus, such as shoulder presentation, 
 when, after rupture of the membranes, it prevents the presenting 
 part descending into the cervix to continue the dilatation. 
 
 Often it is difficult or impossible to determine how much of the 
 resistance is due to mere rigidity of tissue, how much to muscular 
 spasm. It is probable that undue organic rigidity is often the 
 cause of superadded spasm, irritation being produced by delay in 
 the first stage. If the os suddenly softens, and begins to dilate 
 quickly, with the accession of expulsive pains, it is proved that the 
 previous resistance was of spasmodic nature. 
 
 Spasm of the internal os is generally due to interference with, or 
 curtailment of, the natural stage of preliminary gradual dilatation. 
 When there is any source of irritation to the uterus, such as pro- 
 longed labour from obstruction, the internal os may contract around 
 the neck, above the head. It may also contract around the body, 
 or neck, after delivery of the breech, in pelvic presentations, or 
 after version. After delivery a similar contraction may incarcerate 
 the placenta. 
 
 The very severe and persistent sj)asm of the cervix, which has 
 been called "trismus uteri," has been sometimes noted in cases of 
 placenta prsevia. The organic change in the uterine wall near the 
 internal os, due to the placental implantation, is then probably 
 concerned in the result. It has also occurred in some cases in 
 which the membranes have been injudiciously ruptured artificially 
 in a protracted first stage. 
 
 Organic rigidity of the cervix may be due to inflammatory 
 conditions or the presence of new growths. Comparative rigidity 
 of the cervical tissue is a natural condition in primiparae, and is 
 the cause of the greater length of the first stage which is usual 
 with them. In parous women, it is usually the result of fibrous 
 induration and hyperplasia of the cervical tissue preceding 
 
636 The Practice of Midwifery. 
 
 pregnancy. The starting-point of this has often been bruising in a 
 former delivery, or laceration followed by eversion. Even in 
 primiparffi there may be fibroid induration resulting from cervical 
 endometritis or chronic engorgement, and rigidity of the cervix is 
 more likely to exist if pregnancy occurs for the first time late in 
 life. There is a special form of cervical hyperplasia and fibroid 
 rigidity depending upon procidentia of the uterus (or prolapse of 
 the second degree) previous to j)regnancy. This may be of two 
 forms, either elongation with hyperplasia chiefly of the supra- 
 vaginal cervix, which is consecutive to descent of the cervix external 
 to the vulva,^ or the same condition of the vaginal cervix, which is 
 usually primar}^, and a cause of uterine descent. With such hyper- 
 plasia of cervix, the rigidity may involve the whole length, including 
 the internal os. In rare cases it is difficult to overcome. Thus I 
 have been compelled from this cause to deliver with the cephalotribe 
 in labour premature at the sixth month. With rigidity may be 
 associated oedema of the hypertrophied cervix, whereby the 
 obstruction is increased. 
 
 In rare cases failure of dilatation may depend, not upon any 
 widespread induration, but on primary smallness of the external 
 OS, associated with some rigidity of its edge. Since the resistance 
 of the rim of the os to dilatation is inversely proportioned to its 
 diameter (see p. 217), it is evident that a very minate os will offer 
 great resistance to expansion by the longitudinal muscular fibres, 
 and will entirely jDrevent any projection of the bag of membranes 
 into it to form a dilator. In one such case, after labour pains had 
 lasted for a week, I found the os with difficulty to be detected. 
 First a small catheter, then the little finger, and next the index and 
 middle fingers were got into it in quick succession. Sj)ontaneous 
 dilatation then went on rapidly, and labour was completed within a 
 very few hours ; but the child was still-born, apparently from the 
 effect of the prolonged first-stage uterine contractions. 
 
 Diagnosis. — When the os has a thin, hard, undilatable edge, it 
 may be expected that the dilatation stage will be prolonged. This 
 condition is commonest in primiparee, and probably depends more 
 upon initial rigidity of tissue than upon spasm. In other cases the 
 edge of the os is found rigid, although thick, especially in parous 
 women, who have had hyperplasia of the cervix. It may be inferred 
 with probability that spasm is an important element in the case 
 when the pains are inefi'ective in producing tension of the bag of 
 membranes, or pressure upon the os of the presenting part after 
 
 ^ For a discussion of the causation of this elongation with hyperplasia, see the 
 author's " Diseases of Women." 
 
Labour Obstructed by Anomalies of Soft Parts. 637 
 
 the membranes have ruptured, especially if they are at the same 
 time irregular or unusually distressing. Deficiency in the natural 
 lubricating secretion, which is regulated by nerve influence, supports 
 the same conclusion. Hyperplasia of the cervix in parous women 
 may be revealed by its irregularity, and may be associated with a 
 history of uterine symptoms before pregnancy. 
 
 Treatment. — In general, treatment has to be decided upon with- 
 out absolute knowledge how much of the resistance is due to spasm, 
 and how much to organic rigidity. 
 For moderate rigidity in the early 
 stage, with the membranes unruptured, 
 and so long as no serious constitu- 
 tional disturbance is produced, time 
 and patience are the best remedies, as 
 for deficiency of the pains. Inter- 
 ference by any manipulation at too 
 early a stage runs the risk of making 
 matters worse by increasing the irri- 
 tation. The plan previously mentioned 
 (see p. 626) of making sure that the 
 membranes are not adherent around 
 the OS, may, however, be carried out. 
 There is one safe treatment which may 
 be adopted without fear, namely, the 
 use at intervals of the vaginal douche 
 with a large supply of hot water, 
 which should have been sterilised by 
 boiling, at a temperature of 105° to 
 110° F. This is advantageous in 
 stimulating the pains, • as well as in 
 relaxing the os. For the latter 
 purpose a hot hip-bath, or, better, 
 
 whole bath may also be used, but is often not so conveniently 
 available. If contractions are unduly painful chloral should 
 be administered as already described (see p. 315), and often has 
 the effect of making the pains more regular and effective. For 
 an extreme degree of this condition, however, especially when 
 the membranes have ruptured prematurely, and the os remains 
 rigid, notwithstanding frequent pains, chloroform is far more 
 effective than chloral, and also has the advantage that the effect 
 passes oft' more quickly when the desired result is sufficiently 
 attained. 
 
 Fig. 318. — Improved hydrostatic 
 dilator for cervix uteri. 
 a h, tube into which the in- 
 troducer is passed, closed 
 at the upper end b. 
 The dotted outline shows the 
 shape of the bag when 
 expanded. For intro- 
 duction, the corners c d 
 are folded inwards. 
 
638 The Practice of Midwifery. 
 
 Artificial Dilatation. — Artificial dilatation should be undertaken 
 if there is long protraction of the first stage after rupture of the 
 membranes, and even before the rupture of the membranes, if the 
 general condition of the patient calls for it, or if there is evidence 
 of undue retraction of the uterus. It is to be remembered, however, 
 that in the first stage, when pains are frequent, the pulse is often 
 more accelerated without serious import than in the second stage, 
 when intermissions are longer. 
 
 Hydrostatic Diltitors. — The chief means of artificial dilatation, in 
 the earlier stage, are the use of hydrostatic dilators and manual 
 dilatation. Of these the former method is usually to be preferred 
 when practicable, since it imitates more closely the natural mode 
 of dilatation by the fluid wedge of the liquor amnii. 
 
 A modified hydrostatic dilator, much easier to introduce than the 
 original form of Dr. Barnes, is shown in Fig. 318, p. 637. The 
 corners are doubled inward when the bag is in the undilated state, 
 so that the upper end of it is conical and slips easily through the 
 OS, and the introducer passes through the centre of the bag. One 
 of the thick metallic bougies, used for dilatation of the cervix uteri, 
 answers best as an introducer, but the ordinary uterine sound may 
 be used. The tube attached to the bag should have a stop-cock. 
 The bags are made of several sizes, to be used at difierent stages of 
 dilatation. For sterilisation the bag may be dipped for a minute 
 or so in boiling water, and then immersed in an efficient antiseptic, 
 as formalin 53. ad Oj., or iodide of mercury 1 in 500. For intro- 
 duction of the bag the patient may be placed in the left lateral 
 position, the left hand or half-hand passed into the vagina — if the 
 vagina is capacious enough — and one or two fingers placed just 
 within the posterior margin of the os. The bag is then guided up 
 the flexor surface of the fingers, and passed up between the 
 presenting part and the posterior uterine wall till it is nearly 
 half-way through the cervix. 
 
 The lower end of the tube by which the bag is filled should be 
 so adjusted as to fit on to the nozzle of the Higginson's syringe. 
 Before any bag is introduced it is well to measure by trial how 
 many syringefuls of water it will hold without over-stretching the 
 india-rubber. If this be not known, the bag is apt to be over- 
 stretched, and possibly may burst, letting the water escape into 
 the uterus. As soon as the bag is in place, the same number of 
 syringefuls of warm sterilised water is to be pumped in, or any- 
 thing short of this number which will make the lower part of the 
 bag sufiiciently tense. If possible the lower end of the bag should 
 be kept well backwards, so that the posterior vaginal wall may 
 
Labour Obstructed by Anomalies of Soft Parts. 639 
 
 support it, and prevent its being so easily squeezed out into the 
 vagina by the uterine action. The bag when in place, as well as 
 being a mechanical dilator of the cervix, is a powerful stimulant to 
 expulsive pains when these are deficient. The position of the bag 
 should be noted from time to time, and it should not generally be 
 left in place more than about an hour without removal, to note 
 the progress made. If the bag is expelled by the uterus wholly 
 
 Fig. 319. — Champetier de Ribes' hydrostatic dilator, with forceps for introduction. 
 
 into the vagina, it will frequently be found that it has already done 
 its work, and that a larger size can be introduced. The only 
 drawback to the use of the hydrostatic dilator is that, by pushing 
 up the head, especially after escape of the liquor amnii, it may 
 l)0ssibly promote displacement of the head from the brim, and 
 descent of the hand, arm, or shoulder. On the removal of any 
 bag, therefore, it should be noted whether the presentation remains 
 undisturbed. If the head has been pushed to one side, it can 
 
640 The Practice of Midwifery. 
 
 generally be replaced easily by external or bimanual manipulation 
 (see Chapter XXXIV.). 
 
 Another form of hydrostatic dilator has been introduced by 
 Champetier de Eibes, Fig. 319, p. 639. This embodies two prin- 
 ciples : (1) the bag is made of inelastic material ; (2) it is about 
 the size of a foetal head, and therefore, when fully distended, cannot 
 be expelled without dilating the cervix sufficiently. This can be 
 introduced if the index and middle fingers can be passed as far as 
 their first articulation. After sterilisation by boiling, all air is to 
 be expelled from the bag. It is then folded and placed between the 
 blades of the forceps, the distal end of the bag projecting some 
 centimetres beyond the end of the forceps, and all freely lubricated 
 with lanocyllin, or glycerine containing perchloride of mercury 
 1 in 1,000. The tips of two fingers being inserted within the 
 cervix, the bag is passed in between them. First one finger and 
 then the other is withdrawn and the bag is passed on till it 
 penetrates 10 — 12 centimetres (4 — 4f inches) within the internal 
 OS. The bag is then filled by an assistant with 1 -per cent, carbolic 
 solution, while the operator with one hand holds the forceps, with 
 the other feels what is going on at the level of the internal os. 
 Meanwhile the forceps are opened, but not removed until the bag 
 is dilated to such a size as will not admit of its descent. A syringe 
 of about 6 ounces capacity is used for filling the bag. According to 
 the inventor, to fill the bag completely, and give it a circumference 
 of 33 cm. (13 inches), 640 grammes (22'4 ounces) must be injected ; 
 if 540 grammes (18'9 ounces) be injected, the circumference will be 
 27 cm. (10'6 inches) ; if 440 grammes (15"4 ounces) be injected, the 
 circumference will be 22 cm. (8'7 inches). When the bag is filled 
 the operator ties a tape round the tube, so as not to be entirely 
 dependent upon the stop-cock. An antiseptic vaginal douche is 
 then given, and repeated frequently during the course of labour. 
 
 If there is urgent need to accelerate delivery, as in cases of 
 eclampsia or haemorrhage, a weight of 2 lb. may be tied to the 
 neck of the bag and hung on a pulley over the edge of the bed. 
 
 The advantages which this bag presents over any variety of 
 Barnes's bags are that it does not lose its shape, as it is inelastic, 
 produces complete dilatation of the cervix, does not tend to slip 
 out, and is easy to introduce. Its main disadvantage is its tendency 
 to displace the presenting part, and in some cases its large size may 
 make it difficult to find room for it within the uterus. This 
 difficulty may in some cases be overcome by rupturing the 
 membranes. I have used similar bags made of a smaller size, which 
 allow introduction through a smaller os uteri. 
 
Labour Obstructed by Anomalies of Soft Parts. 641 
 
 Manual Dilatation. — There are certain cases in which the hydro- 
 static dilators are inapplicable, namely, when, after rupture of 
 the membranes, the head is pressed so firmly down upon the 
 OS that the bag cannot be introduced without too great force, and 
 also when the uterus is acting so powerfully that the bag is 
 squeezed out immediately after introduction. It is chiefly in the 
 latter stages of dilatation that these difficulties are likely to arise. 
 Under these circumstances, or when hydrostatic dilators are not 
 at hand, manual dilatation is very efficacious, and it is even pre- 
 ferred by some authorities under all conditions, because the dilator 
 itself is sentient, and can estimate the degree of tension exercised. 
 The left hand may be used, the patient being in the left lateral 
 position, or either hand when she lies on the back. The left hand 
 is introduced into the vagina, and two fingers are hooked into the 
 OS, drawing it somewliat forward. The tips of the fingers are then 
 gradually introduced in the form of a cone, until four fingers can 
 be passed in side by side. When the os has reached this size, 
 dilatation can still be carried on by separating the fingers, but this 
 soon fatigues the muscles. Dilatation can be carried on longer 
 and more steadily if the whole hand is now introduced into the 
 vagina, and the wedge which it forms enlarged by addition of the 
 thumb, until the os will admit the full breadth of the hand. For 
 this manipulation, chloroform is not generally indispensable, but 
 it may be used with advantage if the resistance is probably due to 
 spasm of the os, or if the patient is over-sensitive to pain. When 
 the OS is large enough to admit the width of the hand, the pre- 
 senting part will generally be able to enter it deeply and complete 
 the dilatation through the natural powers. Even in this latest 
 stage, however, digital manipulation may assist, if the anterior lip 
 of the cervix is driven down deeply in the pelvis, in front of the 
 head. During each pain the fingers may be placed on the margin 
 of the OS nearest to the posterior fontanelle, so as to retract it 
 until it slips over the occiput, which is naturally the part of the 
 head to emerge first. 
 
 Instrumental Dilators. — A very powerful and efficient four- 
 bladed dilator has been introduced by Bossi (Fig. 321). When 
 the OS is quite small, or the cervical canal unobliterated, the 
 blades are used without the sheaths. If only the external os has 
 to be dealt with, and some dilatation is already attained, the 
 sheaths tend to prevent the ends of the blades slipping out. In 
 urgent cases, dilatation may be effected within half an hour. But 
 it is advisable for the operator to allow ample time, watching the 
 expansion attained, as shown by the indicator, and testing the 
 
 M. 41 
 
642 
 
 The Practice of Midwifery. 
 
 tension of the edge of the os by the finger. Otherwise the dilator 
 may cause a commencement of laceration, which is increased by the 
 advancing head. On an average, at least three minutes should be 
 allowed for each centimetre as registered by the indicator, and the 
 operator should keep his watch before him. For the earlier stages 
 
 # 
 
 Fig. 320.— Frommer's dilator. 
 
 Fig. 321.— Bossi"s dilator. 
 
 more time should be allowed, since the addition of a centimetre 
 then means a greater proportionate increase. 
 
 In a modified form of dilator, that of Frommer, the blades are 
 eight instead of four. This makes the tension on the edge of the 
 OS somewhat more uniform. The disadvantages are that there is 
 no option of using sheaths for the blades, and that, at the earlier 
 
Labour Obstructed by Anomalies of Soft Parts. 643 
 
 stages of dilatation, the finger cannot be passed between the blades 
 to test the tension of the edge of the os. 
 
 Considerable care should be exercised in the use of these dilators, 
 as there is great danger if the dilatation is carried out rapidly of 
 causing severe tears of the cervix. As a general rule their use 
 should be restricted to cases where the internal os has already 
 undergone some degree of dilatation, and the cervical canal is 
 partly taken up.^ 
 
 ApiMcation oj Forcejjs. — After dilatation has been carried as far 
 as is possible by hydrostatic dilators or manual dilatation, the 
 means most available for hastening delivery, if necessary, especially 
 in the absence of Bossi's or Frommer's dilator, is the aj)plication 
 of forceps. This means, however, should never be adopted merely 
 to shorten the patient's suffering, or save the practitioner's time, 
 but only when the rising pulse or other general symptoms due to 
 protracted labour indicate the necessity for interference. Even then 
 it is well first to employ full manual dilatation with the aid of 
 chloroform, and then wait a short time to see what nature will effect. 
 It will then be found to be only very rarely that the use of forceps 
 is called for on account of the resistance of the os alone. The case 
 has carefully to be distinguished in which, on account of dispro- 
 portion between the fcetus and the pelvis, the head is prevented 
 from fully entering the os as a dilator, though the os itself is 
 dilatable. A comparatively early application of forceps is then 
 desirable. 
 
 The contrary practice, namely, the comparatively frequent use 
 of forceps before full dilatation of the os, has been recommended 
 by some authorities, especially by Dr. G. Johnston, as master of 
 the Eotunda Hospital, Dublin. Dr. Johnston invented a special 
 form of forceps with narrow blades, in order to be able to pass 
 them through a comparatively undilated os. In his last four years 
 of office, with a total forceps-rate of 116*4 per 1,000, he applied 
 forceps in more than one-fourth of the cases (or at the rate of more 
 than 29 per 1,000, a rate about six times as great as the total 
 forceps-rate in the Guy's Hospital Lying-in Charity, 1863 — 1875) 
 before fall dilatation of the os. Of these, the head was at or above 
 the brim in considerably more than half, and, in more than a third, 
 the OS was less than two-fifths dilated. As already mentioned (see 
 p. 632), Dr. Johnston's results do not show any material gain in 
 the rate of still-births, and they certainly do not show that such a 
 practice is safe for the mothers, even in such skilled hands as his. 
 The maternal death-rate (1871—1875) was 19-3 per 1,000, a very 
 
 1 Blacker, Trans. Med. Soc. London, 190(5, Vol. XXIX., p. 170. 
 
 41—2 
 
644 The Practice of Midwifery. 
 
 high one. This may, indeed, have been due to the septic risks in 
 a lying-in hospital, before the introduction of the latest improve- 
 ments in antiseptic midwifery. But in 88 cases, during the three 
 years, 1872 — 1874, in which forceps were applied before full 
 dilatation of the os, simply on account of premature rupture of 
 the membranes — excluding all cases of complication, such as 
 eclampsia, haemorrhage, or prolapse of funis, and excluding also 
 cases of disproportion- — there were four deaths, i.e., a death-rate 
 of 46"6 per 1,000. It would hardly have been anticipated that 
 the increased risk from premature rupture of the membranes, 
 without any other difficulty or complication, would have led 
 to so great a mortality, if the cases had been left to nature, 
 or treated merely by other modes of dilatation. Again, taking 
 into consideration the whole number of forceps cases, the forceps- 
 rate, which under Dr. Shekleton (1847—1854) was 16-5 per 1,000, 
 rose under Dr. Johnston (1871—1875) to 116'4 per 1,000. But 
 the mortality after use of forceps per 1,000 deliveries rose from 
 0*43 to 6'2, or in more than double the proportion. Again, the 
 deaths per 1,000 in the forceps cases themselves were under Dr. 
 Johnston (1871 — 1875) 54*4, while under Dr. Shekleton, although 
 the use of forceps was reserved for much more extreme cases, they 
 were only 35*7. 
 
 The conclusion therefore remains undisturbed that forceps should 
 never be applied until the os allows the easy application of the 
 ordinary form of instrument. The os can always be expanded up 
 to this point by manual dilatation, or by Bossi's dilator, which 
 has to a great extent obviated the need for using forceps as a 
 dilator of the cervix. Whenever forceps are applied when the head 
 is still within the uterus, and a rim of the cervix remains over the 
 head, whether the cause of delay lies in the cervix or in any other 
 condition, extraction should be carried out with extreme care and 
 slowness, in order to give the cervix time to yield, and avoid as far 
 as possible the risk of laceration. 
 
 Incision of the Cervix. — It is not desirable to incise the cervix so 
 long as there is hope of overcoming the difficulty by dilatation, 
 since incisions, like spontaneous lacerations, by laying open the 
 cellular tissues, expose to the risk of septic absorption, and the 
 incisions are apt to be extended by laceration. If, however, other 
 means fail, and the condition of the patient demands interference, 
 the edge of the cervix may be incised at three or four places, to 
 not more than half an inch in depth. The incisions may be made 
 with Kuchenmeister's scissors (designed for incising the unimpreg- 
 nated cervix), or with ordinary scissors, or with a blunt-pointed 
 
Labour Obstructed by Anomalies of Soft Parts. 645 
 
 bistoury, having only about half an inch of cutting edge exposed 
 and guided up to the resisting edge by the finger. The method of 
 incision is most applicable when the difficulty is due to organic 
 induration or cicatricial tissue, not extending far beyond the edge 
 of the cervix. 
 
 Version or Craniotomy . — It will only be in extremely rare cases 
 that the resistance of the os leads to such grave risks to the mother 
 as to justify sacrifice of the child, or even the increased danger 
 to it involved by version. When the mother is in great danger 
 from other causes, as from eclampsia, and the os will not yield, or 
 when there are very strong grounds for believing the child to be 
 already dead, either version or craniotomy, according to the 
 condition of the uterus, may be called for. 
 
 Vaginal or Abdominal C cesarean Section. — In extreme cases, where 
 incisions of the cervix are required, it will often be better practice 
 to carry out at once vaginal Csesarean section and delivery of the 
 child. At any rate, in the early months of pregnancy this is 
 probably the best method of dealing with very extreme degrees of 
 rigidity of the cervix, and in the later months it may in a few 
 instances be necessary to perform abdominal Caesarean section for 
 rigidity of the cervix, especially that due to cicatricial contraction. 
 
 Atresia of the Cervix. — The cervix must of course have been 
 permeable for pregnancy to occur. In some cases, however, no 
 opening has been discoverable at the onset of labour. Adhesion of 
 inflammatory granulations may have been formed after conception, 
 sometimes as a result of the too vigorous application of caustics in 
 the treatment of cervical inflammation, or of attempts to procure 
 abortion. Care must be taken to reach every part of the vagina 
 and cervix, before it is assumed that there is no opening, lest the 
 case be really one of malposition of the os. 
 
 Treatment. — When labour pains have commenced, a puncture 
 or incision must be made at the site of the os, or at the centre of 
 the lower segment of the uterus, if the site cannot be discovered. 
 Dilatation is then to be carried on by metallic bougies, dressing 
 forceps, fingers, hydrostatic bags, or other convenient means, until 
 there is space for the bag of membranes to bulge into the opening 
 and continue the dilatation. 
 
 Malposition of the Os. — It has already been mentioned that 
 the result of retroversion in the early months is supposed to be, in 
 some cases, the displacement of the os forward at full term, so that 
 it lies out of reach, or nearly so, behind, and even above, the 
 
646 The Practice of Midwifery. 
 
 sj'mphysis pubis (see p. 502). Other authorities attribute the same 
 condition to a sacciform development of the posterior uterine wall. 
 Similarly the os may be displaced backward, opposite the promon- 
 tory of the sacrum. Displacement of the os backward may also 
 result from a previous vaginal hysteropexy. "Whatever the cause 
 be of this condition, the result is the same. The os is unfavourably 
 placed for dilatation by the muscular j&bres, or for projection of the 
 bag of membranes into it. The presenting part cannot enter it at 
 all, for it lies in the cul-de-sac which forms the lower extremity 
 of the uterus. Especially if the liquor amnii has escaped does 
 the mechanism of dilatation fail altogether, and labour may be 
 indefinitely prolonged. 
 
 Treatment. — If a hydrostatic dilator can be introduced into 
 the OS, this means may be emj^loyed. As the os becomes dilated, 
 it wmII tend to approximate toward the axis of the uterus. In 
 general the best plan is to hook the finger into the lower margin of 
 the displaced os, and to stretch it by drawing it toward the central 
 axis of the pelvis. Chloroform should be administered, if necessary, 
 and a hydrostatic dilator may be used at a later stage. If the 
 head lies in the lower cul-de-sac, and cannot be got to enter the 
 OS when fair dilatation has been attained, delivery by version may 
 be necessary. Cesarean section has been performed for displace- 
 ment of the OS uteri. But it is probable that patience, with more 
 gradual treatment, as above described, involves a less risk to the 
 patient, and will always ensure a favourable result. 
 
 Cicatrices and Atresia of the Vagina and Vulva. — 
 Cicatrices of the vagina are most frequently the result of sloughing 
 after protracted labour in former pregnancies. Some of the most 
 severe forms aiise in conjunction with vesico-vaginal or recto- 
 vaginal fistulffi. Cicatrices may also result from syphilitic deposits, 
 or from local injuries or operations apart from parturition. 
 Sometimes there is an almost complete atresia from a congenital 
 transverse vaginal septum above the level of the hymen, or the 
 hymen itself may have a small orifice, and may have been so 
 tough as not to yield in coitus. Cicatrices which involve deeply 
 the surrounding cellular tissue are serious in their effects. They 
 may be so resisting that the fcetus cannot pass without such 
 lacerations as to lay open cellular tissue extensively, and involve 
 the risk of subsequent sejDtic absorption. Similarly, existing 
 fistulse may be increased in extent. 
 
 Treatment. — If there is any congenital septum, the aperture 
 should be dilated by bougies, tents, or hydrostatic dilators. Or, 
 
Labour Obstructed by Anomalies of Soft Parts. 647 
 
 if thin, the septum may be incised. In the case of cicatrices, fair 
 time should be allowed to see the effect of the natural forces, and 
 the softening associated with parturition. If the cicatrices form an 
 almost complete vaginal atresia, the dilatation may be commenced 
 with laminaria tents. If necessary, the most resisting transverse 
 bands should be incised with scissors or a blunt-pointed bistoury. 
 The tissues may then be further stretched with the fingers, or the 
 head allowed to continue the stretching. In some cases, extraction 
 by forceps or after craniotomy may be required, cicatricial bands 
 being divided further, as may be necessary, during the extraction. 
 It will be better treatment to perform Caesarean section^ if the 
 cicatricial tissue fills up the pelvis, or if its incision is likely to 
 injure the bladder or the rectum. Sj)encer^ has recorded a case of 
 this kind in which he performed a Porro-Ceesarean section for com- 
 plete atresia of the vagina following on supra-vaginal amputation of 
 the cervix for cancer. 
 
 EiGiDiTY OF THE Perineum. — Piigidity of the vaginal outlet and 
 perineum is a very frequent cause of delay in the latter part of 
 the second stage of labour in primiparae, especially if the uterus is 
 then becoming fatigued. Both the difficulty and the risk of rupture 
 are increased if the pubic arch is narrower than usual, so that the 
 head is thrown more backward upon the perineum. Difficulty 
 may arise even in subsequent labours, if the perineum has been 
 repaired after rupture on a previous occasion, if cicatricial tissue 
 has remained after previous rupture, or if the child is larger than 
 former children have been. 
 
 Treatment. — Digital manij)ulations are often of value in aiding 
 the dilatation of the perineum and avoiding rupture. While the 
 head is retarded during a pain, in the mode already described 
 (p. 303), if there appears to be danger of rupture, the index and 
 middle fingers may be used to retract the perineum and gradually 
 stretch it in the intervals of pains. This can be carried out more 
 effectually if chloroform is being administered during the labour. 
 Hot fomentations, frequently renewed, may also be used when the 
 head begins to distend the outlet. Within moderate limits, delay 
 at this stage is conservative, giving the structures time to stretch 
 under the influence of successive pains, and it is often desirable, 
 while observing the tension placed upon the perineum, rather to 
 delay the advance of the head than to hasten it. If delay is too 
 great, or constitutional symptoms are arising, delivery must be 
 effected by forceps. Though it is probable that, in actual practice, 
 
 1 See a case by the author, Trans. Obst. Soc. London, 1876, Vol. XVIII., p. 152. 
 
 2 Spencer, Trans. Obst. Soc. London, 1896, Vol. XXXVUI., p. 413. 
 
648 The Practice of Midwifery. 
 
 perineal rupture is more frequently caused than avoided by the 
 use of forceps, yet this will not be the case if forceps are not 
 applied prematurely, and the extraction is made with sufficient 
 patience and slowness. For the force is not, like the natural 
 expulsive force, inclined backwards in reference to the axis of the 
 outlet, so as to press needlessly upon the perineum, and it may 
 be made more gradual than the effect of the pains of the final 
 stage of delivery. When there appears to be great risk of rupture, 
 the extraction should be made by continuous steady traction in 
 the interval of pains, the finger being kept all the while upon the 
 edge of the perineum, to estimate its tension. Unless the patient's 
 self-control can be thoroughly relied upon, it is well to keep her 
 pretty fully under the influence of chloroform, that she may not 
 make a sudden movement. The plan recommended by some, 
 namely, to jDerform cpisciotomy, that is, to make two lateral inci- 
 sions in the edge of the perineum, in order to avoid a central 
 laceration, is not generally desirable. For it is never possible to be 
 certain when, and to what extent, a laceration is inevitable. And 
 the clean-cut laceration itself will almost invariably unite, if 
 properly closed by sutures. In rare cases only, in which a lacera- 
 tion through the sphincter ani appears to be otherwise inevitable, 
 this operation is advantageous. 
 
 Cancer of the Cervix Uteri and Pelvis. — About once in 2,000 
 cases of pregnancy^ conception occurs notwithstanding the existence 
 of cancer of the cervix uteri in its earlier stage. When this is the 
 case, the stimulus of pregnancy generally, but not in all cases, 
 causes a rapid growth of the cancer, so that when full term is 
 reached, the disease may have reached to a very formidable extent, 
 even involving the whole circuit of the cervix, and extensively 
 infiltrating the cellular tissue around. In other cases cancer of 
 the vagina, or cancer commencing elsewhere in the pelvis, as from 
 the rectum, forms such a mass in the cellular tissue that the 
 passage of the foetus, even after embryotomy, becomes difficult or 
 impossible. 
 
 Results. — In some cases, relief is brought by nature through 
 the occurrence of spontaneous abortion or premature labour. If 
 pregnancy goes on to the later months, the complication is very 
 formidable. The difficulty in parturition depends not only upon 
 the extent of the growth, but still more upon its hardness. A 
 certain amount of the softening of parturition may take place even 
 in the diseased cervix : spontaneous lacerations may give increased 
 
 1 Sarwey, Veil, Handbuch der Gynakologie, 1899, Vol. III., Part 2, p. 489. 
 
Labour Obstructed by Anomalies of Soft Parts. 649 
 
 space, and sometimes even unassisted delivery takes place with less 
 difficulty than had been anticipated. If some part of the cervix 
 remains free, it is generally possible to get sufficient dilatation to 
 deliver the fcetus by some means, and, even when the whole circuit 
 is involved, this sometimes proves possible, provided that there is 
 not too much infiltration of the cellular tissue around with hard 
 growth, and that the growth itself does not form too large a mass 
 to allow the foetus to pass. 
 
 The danger, however, is by no means over with delivery. 
 Decomposition and inflammation or sloughing of the bruised 
 cancerous tissue is apt to follow, and the most frequent cause of 
 death is septicaemia set up in this manner. When the whole circuit 
 of the cervix is so involved in the disease that no commencement 
 of dilatation can occur spontaneously, the uterus sometimes passes 
 into the state of continuous action without the occurrence of any 
 distinct rhythmical pains. The pulse rises therewith, and the 
 general condition becomes serious. In other very rare cases, 
 when the uterus has remained quiescent, the fcetus has died, and 
 been retained within the uterus beyond full term, thus constituting 
 one form of the so-called " missed labour " (see p. 549). Some- 
 times before any onset of labour a condition of severe constitutional 
 irritation, with elevation of pulse and temperature, and dry tongue, 
 supervenes. This appears to be due to septic absorption from the 
 cancerous discharge, and to be liable to be induced by any 
 interference with the cervix, even by repeated digital examination. 
 Some patients die undelivered from the effects of the disease, or 
 after an abortive attempt at labour, or after fruitless attempts to 
 deliver them. In others rupture of the uterus occurs (11 out of 
 180, Herman). 
 
 Prognosis. — Excluding cases in which abortion occurs, the 
 mortality within the puerperal period in recorded cases is about 
 43'3 per cent.-"^ Even in cases in which labour terminates naturally 
 without assistance, it is over 30 per cent. The mortality of the 
 children is also very considerable, being about 38 per cent. This 
 is not solely due to the effects of protracted labour, but partly to 
 the tendency of the disease to bring on labour prematurely, and to 
 the feeble vitality of the children, or their death in utero before 
 labour ; also the consequences of the disease. 
 
 Treatment. — This is a case in which the interests of the mother 
 have to be balanced against those of the child. Accordingly some 
 
 1 Sarwey, loc. cit. 
 
650 
 
 The Practice of Midwifery. 
 
 authorities, considering that the mother must die before very long 
 in any case, have considered that special regard ought to be paid to 
 the life of the child. In this country it will be generally considered 
 that the physician has not the right to sacrifice even a probable 
 temporary prolongation of the mother's life for the sake of the 
 
 Fig. 322. — Uterus removed by Wertheim's operation after the child had been 
 delivered by Cesarean section in a case of cancer of the cervix obstruct- 
 ing delivery. The patient had been thirty-six hours in labour, and 
 attempts to deliver with forceps had failed. The incision in the uterus is 
 represented as sewn up to show the method of suturing in Osesarean 
 section.^ 
 
 unborn infant, especially since the preservation of a motherless 
 infant is not always an unmixed advantage. It is only when the 
 chances of the mother are very evenly balanced in the choice 
 between two modes of treatment, as between craniotomy and 
 Caesarean section, when delivery is likely to be very difficult, that 
 
 1 Univ. Coll. Hosp. Med. School Mus. Gray, quoted by Lockyer, Brit. Med. 
 Journ., October 9, 1909, p. 104i. 
 
Labour Obstructed by Anomalies of Soft Parts. 651 
 
 the consideration of the child's life may justly have some weight, 
 especially if the parents are anxious for its preservation. 
 
 As a general rule the decision is one which must be made by the 
 woman or her husband when all the facts of the case have been 
 laid before them. 
 
 In discussing the treatment of this condition it will be best to 
 consider first those cases in which the cancer is operable in the 
 usual sense of the term, that is to say, there is a reasonable prospect 
 by operation of complete extirpation of the growth. In such cases 
 there can be no question that the patient should be operated upon 
 without delay, and that the life of the child should not be con- 
 sidered. The only exception to this rule would be that of a patient 
 in the later months of pregnancy, who, for the sake of obtaining 
 possibly a living child, elected to run the risk of waiting a few 
 weeks before being operated upon. 
 
 In the early months of pregnancy there is a choice between the 
 induction of abortion with subsequent extirpation of the uterus or 
 immediate hysterectomy without preliminary emptying of the 
 uterus. 
 
 The period immediately following an abortion, like the puerperal 
 period, is an unfavourable time for operations ; hence the former 
 alternative may involve a delay of two or three weeks at least in 
 the removal of the cancer. 
 
 Undoubtedly the best operation in the early months of pregnancy 
 is complete extirpation of the whole uterus by the vagina or by the 
 abdomen. 
 
 In the later months the abdominal method should always be 
 chosen for hysterectomy. The modern success of total abdominal 
 hysterectomy^ in the case of cancer of the cervix or body of the 
 uterus justifies this operation in preference to vaginal hysterectomy 
 following the induction of abortion, even though the disease may 
 have reached the vagina, provided it has not spread so far into the 
 broad ligaments as to prevent the whole of it being removed. 
 Abdominal section is performed, and,, if the child is viable, it is first 
 removed by Csesarean section. The details of the operation are 
 similar to that of panhysterectomy following Csesarean section at 
 term, and are described in Chapter XXXVI. 
 
 In the present case it is necessary to divide the vaginal walls as 
 low down as possible so as to give a wide margin of healthy tissue.^ 
 Wertheim's method of performing the operation should be followed 
 
 1 For statistics of recorded cases, see Herman, " The Treatment of Pregnancy com- 
 plicated by Cancerous Disease of ihe Genital Canal," Obstet. Trans., Vol. XX., 1878, 
 p. 191. Vide also Sarwey, loc. cit. 
 
 '^ Wertheim, Brit. Med. Journ., September 23, 1905, p. 689. 
 
652 The Practice of Midwifery. 
 
 so as to avoid the risk of infection and of implantation of cancer 
 cells on the cut surfaces. An alternative is to perform Diihrssen's 
 vaginal Caesarean section (see Chapter XXXVL), and then remove 
 the uterus by vaginal hysterectomy. The abdominal operation 
 allows search to be made for cancerous glands, and a more free 
 removal of the broad ligaments. The vaginal operation causes 
 less shock. 
 
 In inoperable cases, if it is decided not to consider the life of the 
 child, abortion may be induced in the early months, if the patient 
 comes then under observation, and the disease is too advanced for 
 extirpation. The reason for this is not only that the risks after 
 abortion are much less than after labour in the later months, but 
 that the possible stimulus of pregnancy to the advance of the 
 disease is thus abolished. 
 
 Abortion may be induced by puncture of the membranes, if this 
 is practicable. If not, the cervix may be first dilated by a lamiuaria 
 tent. In the first three or four months this will generally be 
 necessary. Antiseptic precautions must be used with special 
 strictness, on account of the risk of sepsis caused by pressure of a 
 tent upon cancerous tissue. 
 
 During labour coming on spontaneously, in cases in which 
 the growth does not admit of extirpation, fair time should be 
 allowed to nature to see what dilatation and softening of the cervix 
 will take place before further interference is undertaken. Hydro- 
 static dilators have sometimes been used to stretch the cervix, but 
 not with very favourable results. It seems that their prolonged 
 pressure is more likely to cause inflammation of the growth or 
 septic absorption than are lacerations or incisions. 
 
 Incision of the Cervix. — In cases which end favourably by the 
 natural powers, the yielding often takes place by spontaneous 
 laceration. This may be imitated by artificial incisions with 
 advantage, the main mass of the growth being first removed by 
 the curette or cautery, and the general results of cases so treated 
 have been good. Hemorrhage either from lacerations or incisions 
 has not generally been very formidable. It may be arrested if 
 necessary by swabbing with a solution of perchloride or subsulphate 
 of iron. The method of incision is applicable chiefly when the 
 disease is mainly in the cervix itself, not so much when there is a 
 large hard mass in the cellular tissue outside. In one case of 
 cancer involving the whole cervix, I incised in several directions up 
 to the vaginal reflection, and then removed the intervening portions 
 by the galvanic ecraseur. Delivery followed very rapidly by the 
 natural powers, the child being alive. 
 
Labour Obstructed by Anomalies of Soft Parts. 653 
 
 If necessary the incisions may be made according to the method 
 of the so-called vaginal Csesarean section (see Chapter XXXVL), 
 the bladder being first stripped up from the front of the uterus as 
 in vaginal hysterectomy, and the peritoneum of the pouch of Douglas 
 from the back. Sagittal incisions are then made in the centre of 
 the anterior and posterior walls. 
 
 Forceps and Version. — Delivery by forceps or version may be 
 combined, if necessary, with the method of incisions, especially if 
 the pains are not strong. Of the two, forceps give rather a more 
 favourable chance to the child. Version, especially by the bipolar 
 method, can be performed when the os is too small for aiDplication 
 of forceps to be desirable, and the half-breech then forms an 
 efficient wedge-shaped dilator. In 9 cases delivered by forceps there 
 were 4 deaths ; in 14 deliveries by version 8 deaths (Herman). 
 
 Craniotomy and Cesarean Section. — Before the introduction of 
 Sanger's method of Csesarean section, craniotomy and Csesarean 
 section both gave a very high mortality, one of from 70 to 80 per 
 cent., with not very much to choose between them. With the 
 improved method of Csesarean section the results are improved, but 
 not nearly equal to those obtained in cases of pelvic contraction, 
 partly on account of the septic material produced by the cancer, 
 partly on account of the depressed constitutional condition of the 
 patient. Where the whole, or nearly the whole, circuit of the os is 
 diseased, or much of the cellular tissue infiltrated, C^esarean section 
 gives the best chance for the child and is the least dangerous 
 method of delivery for the mother when undertaken as a primary 
 choice. Perhaps the best method in this case is to perform the old- 
 fashioned Porro operation, with external treatment of the pedicle 
 (see Chapter XXXVL), by which the uterine cavity is isolated from 
 the peritoneum and its neighbourhood.^ The mortality of these 
 operations, if undertaken during labour, whether the uterus be 
 removed or not, is undoubtedly very high, 54 to 60 per cent.,^ but 
 it should be much less if they are performed during pregnancy 
 before labour has come on. In such cases the growth, either 
 previously or at the same time, should be curetted and cauterised. 
 If attempts have already been made to extract by forceps or by 
 version, craniotomy is generally preferable. 
 
 Labour Complicated by Tumours. 
 
 FiBROMYOMATA, OR FiBRoiD TuMOURs OF THE Uterus. — Con- 
 sidering the frequency of fibroid tumours, it is comparatively rare 
 
 1 Bpcncer, Trans. Obst. Soc. London, 1904, Vol. XLVl., p. 355. 
 
 2 Sarwey, loc. cit. 
 
654 The Practice of Midwifery. 
 
 for them when of large size to be met with as a compHcation of 
 labour ; in 13,814 pregnancies Meheut records 85 cases, or 0*62 per 
 cent. In general, fibroid tumom's appear to be associated with 
 sterility — that is, sterile women tend to develop fibroid tumours. 
 No doubt the presence of fibroid tumours plays a part in the pro- 
 duction of relative sterility, for women wdth these tumours seldom 
 have more than one or two children, but it is doubtful if they are 
 really an etiological factor in the production of absolute sterility. 
 As a rule, the sterility antedates the time at which the presence of a 
 fibroid tumour causes any symptoms. The tumours may have some 
 effect in producing abortion or premature labour, but not so fre- 
 quently as has been supposed. The dangers to which a fibroid tumour 
 complicating labour may lead are inefficient or irregular contrac- 
 tions of the uterus, ante-partum, or more frequently i)ost-imrtum, 
 haemorrhage — the latter depending upon the failure of the uterus 
 to contract — obstruction to the passage of the foetus when the 
 tumour occupies the pelvis, rupture of the uterus from the com- 
 bined effect of the obstruction and partial atrophy or weakness of 
 the uterine muscle, subsequent inflammation or sloughing of the 
 growth from the effect of bruising or pressure, with consequent 
 risk of septicaemia, and very rarely inversion of the uterus. Uterine 
 contractions are apt to be unusually painful. A fibroid tumour 
 also appears to predispose to malpresentations and placenta praevia, 
 and may then render version or other treatment difficult, if the 
 fibroid occupies the lower part of the uterus. 
 
 If the fibroids are corporeal and subserous, especially if pedun- 
 culated, generally labour is but little disturbed, unless their size 
 is so great as to interfere with the action of auxiliary muscles. If 
 they are interstitial, or submucous, the chief risk of haemorrhage 
 occurs, since the due contraction of the uterus is then apt to fail. 
 If a fibroid obstructs labour by occujDying the pelvis, it generally lies 
 behind the cervix (see Fig. 323). It may then be either a corporeal 
 sub-peritoneal fibroid which has dropped down into the j)elvis, or a 
 sub-peritoneal outgrowth from the cervix. The latter is much the 
 more serious, since it cannot be pushed up out of the pelvis. Labour 
 may also be obstructed by a large fibroid polypus, coming down in 
 advance of the presenting part, by a submucous fibroid in the 
 lower part of the uterus or cervix, or by a general fibroid elongation 
 and enlargement of the cervix, generally of the anterior lip. Fibroids 
 generally enlarge with the stimulus of pregnancy, and they may at 
 the same time become soft from oedema or cystic formation. In 
 such case the growth may be difficult to distinguish from an 
 ovarian tumour. 
 
Labour Obstructed by Anomalies of Soft Parts. 655 
 
 Treatment. — If the fibroids are corporeal, and do not occupy the 
 pelvis, all that is generally necessary is to take special pains to 
 secure due contraction of the uterus in the third stage of labour and 
 afterwards. It is well to give a dose of ergot after delivery. If a 
 subserous fibroid occupies the pelvis, so as to obstruct the passage 
 of the fcetus, the first effort should be to push it up out of the 
 pelvis. By this means the necessity for Csesarean section may 
 
 Fig. 323. — Diagrammatic drawing of case of retroflexion of the uterus at full 
 term caused by a fibromyoma adherent in Douglas' pouch, treated by 
 Cassarean section and total abdominal hysterectomy. The posterior wall is 
 much thicker than the anterior, and the fibroid is attached to the posterior 
 wall at the fundus uteri.i 
 
 sometimes be averted. The attempt may first be made with the 
 patient in the knee-elbow position, with the fingers in the vagina, 
 or, if that fails, in the rectum. If this also fails, an ansesthetic 
 should be administered, and the attempt rej)eated with the patient 
 in the semi-prone position. It is sometimes of service to introduce 
 two fingers or even the half-hand into the rectum. If a fibroid 
 tumour occupies the lower segment of the uterus so as to obstruct 
 the passage of the fa^us, and cannot be pushed up above the brim, 
 
 1 Univ. 0(j11. Hosi). Med. School Mas. See Spencer, Proc. Obsfc. Sect. Koy. See. 
 Mod., Vol. II., p. 74. 
 
656 The Practice of Midwifery. 
 
 it is well to let labour come on and progress to some extent, short 
 of the rupture of the membranes. For in some cases, with com- 
 mencing dilatation of the os, the tumour becomes elevated unex- 
 pectedly above the brim, and delivery becomes easy in cases in 
 which Cesarean section had appeared inevitable. 
 
 If this does not occur, and in cases in which it is recognised from 
 the first that the fibroid is cervical, and cannot be elevated out of 
 the way, Csesarean section should be selected as a first choice. In 
 general this should be followed by removal of the uterus, either by 
 supra-vaginal hysterectomy or panhysterectomy according to the 
 position of the tumour. In this way the tumour is cured, and the 
 risk is little, if at all, increased. In some cases, in which there is 
 single tumour with a narrow neck, the tumour may be removed by 
 myomectomy and the uterus preserved. 
 
 If the case is only seen when the membranes have already been 
 long ruptured, it may be preferable to deliver by craniotomy, 
 followed by the use of the cephalotribe, provided that the tumour 
 leaves room enough in the pelvis to allow it without great risk. 
 For this purpose there should be a space measuring at least 
 2| inches in its smallest diameter, and 4 inches in the diameter 
 bisecting the former at right angles. 
 
 If a case comes under observation before full term, a trial should 
 be made whether the tumour can be pushed up out of the pelvis. 
 If this is not the case, it is generally advisable to let the patient go 
 on to full term, and then perform Caesarean section and hysterectomy 
 if required. If the patient refuses this alternative, it may be 
 justifiable to induce abortion, but this may involve serious risk if 
 the tumour interferes with the removal of the placenta. In some 
 cases, in which the tumour is very large and pressure symptoms 
 arise during pregnancy, hysterectomy may be called for before 
 full term. In all cases whenever possible operation should be 
 postponed till the child is viable. Care must be taken not to 
 mistake the sac of an extra-uterine pregnancy, which generally lies 
 behind the uterus, for a fibroid or ovarian tumour complicating 
 uterine pregnancy. 
 
 Enucleation. — In the case of a submucous fibroid presenting 
 at the lower part of the uterus below the foetus, enucleation 
 of the fibroid before delivery may be the best treatment, if 
 delivery is likely to be otherwise very difiicult. If there is any 
 constriction at the lower margin of attachment, forming a demarca- 
 tion between the tumour and the uterine wall, this may generally 
 be efl'ected. The mucous membrane may be incised with scissors 
 along the lower margin of attachment, and the tumour then 
 
Labour Obstructed by Anomalies of Soft Parts. 657 
 
 enucleated as a whole, or, if necessary, after morcellation. A sagittal 
 incision may be made through the anterior or posterior lip of the 
 cervix, as in vaginal Caesarean section. Traction upon the tumour, 
 by means of strong tenaculum forceps fixed into it, will assist the 
 operation. It is necessary for the safety of this operation that there 
 should be a sufficient thickness of 
 uterine wall covering the tumour 
 outside. 
 
 If fibroid enlargement of the an- 
 terior lip is likely to cause much 
 obstruction, it may be amputated 
 before delivery. A fibroid polypus is 
 a much less formidable complication. 
 It can easily be removed with 
 scissors, before delivery. If a polypus 
 is detected only after delivery, it 
 should still be at once removed, lest 
 sloughing should occur, and con- 
 sequent septic absorption. 
 
 OvAEiAN Tumours. — An ovarian 
 tumour in the abdomen does not 
 generally interfere with labour further 
 than by making the pains less effec- 
 tive. Delivery by forceps may be 
 called for on this account. If an 
 ovarian tumour lies in the pelvis 
 behind the cervix, it is liable to 
 obstruct delivery like a fibroid in the 
 same position (Fig. 324). It is still 
 more likely than a fibroid, in con- 
 sequence of the pressure to which it 
 is subjected, to undergo inflammatory or necrotic processes after- 
 wards, or to rupture into the peritoneal cavity. Of 263 recorded 
 cases collected by McKerron,^ 56, or 30"5 per cent., ended fatally. 
 
 Treatment. — The ideal and undoubtedly the best treatment for 
 ovarian tumours in the pelvis obstructing labour is immediate 
 ovariotomy. If the conditions are impossible for carrying out this 
 operation, then an attempt may be made to push the tumour up out 
 of the pelvis, great care being taken and no undue force being 
 employed. If this manoeuvre fails, then the tumour should be 
 
 Fig. 324. — Diagrammatic drawing 
 of a dermoid tumour of the 
 right ovary obstructing labour. 
 Ovariotomy was performed 
 during labour, and delivery 
 effected by forceps. (Univ. 
 Coll. Hosp. Med. School 
 Mus.)i 
 
 ' Sec Spencer. Trans. Obst. Soc. London, 1898, Vol. XL., p. U. 
 
 '■^ McKerron, Pregnancy, Labour, antl Childbed with Ovarian Tumour, UJ08, p. 1G9. 
 
 M. 42 
 
658 The Practice of Midwifery. 
 
 punctured through the vagina, if it appears to consist mainly of a 
 single cyst. For the puncture an aspirator may be used, with not 
 too small a needle, lest the fluid prove to be thick and tenacious. 
 The vagina should first be syringed with an antiseptic solution, 
 and the aspirator needle sterilised by heat. If simple puncture fails 
 to get rid of the obstruction, or if the physical signs suggest that 
 the tumour is semi-solid or a dermoid, it should be incised, and 
 the cyst cavity packed with gauze. In all cases, whether the 
 tumour be pushed up, punctured, or incised, as soon as possible 
 after delivery the remains of it should be removed by abdominal 
 ovariotomy. 
 
 If the tumour is solid or semi-solid, and the obstruction cannot 
 be got rid of by incision, it must be removed either by the abdomen 
 or by the vagina before the child is delivered. In performing 
 ovariotomy in these cases a long incision should be made and the 
 uterus turned out of the abdomen. The ovarian tumour is then 
 removed, the uterus replaced, and labour left to be completed 
 naturally. In cases in which the ovarian tumour partly occupies 
 the abdomen, it may be possible to perform ovariotomy without 
 turning out the uterus. Cfesarean section should not be practised 
 unless it is found impossible to remove the tumour without first 
 emptying the uterus. As a general rule, abdominal ovariotomy 
 should be performed, and not vaginal ; but in a few cases it may 
 be found possible after its incision to remove the tumour by the 
 vaginal route. 
 
 Hydatid tumours of the pelvis are of rare occurrence in Britain, 
 but may possibly form an obstruction to labour like an ovarian 
 tumour.^ The nature of the tumour could hardly be diagnosed 
 before puncture, unless from the presence of a similar tumour in 
 connection with the liver, or in other parts. The obstruction caused 
 by the tumour will generally be overcome by puncture. 
 
 Congenital abnormality of kidney, in which the kidney is 
 situated centrally in the lumbar region, has been recorded as a 
 cause of obstruction to labour, and rupture of the uterus. 
 
 Prolapse of the Vagina.— When the vagina has been prolapsed 
 before pregnancy or during pregnancy, the hypertrophied tissue, 
 especially the anterior vaginal wall, may be pushed down in front 
 of the head, become oedematous from pressure, and cause a certain 
 amount of obstruction. Sometimes a pouch of the bladder, forming 
 a cystocele, descends with the vagina. If this contains urine, a 
 tense swelling, causing increased obstruction, may be formed. 
 
 ' Blacker, Journ. Obst. aud Gyn. Brit. Emp., November, 1908, p. 33fi. 
 
Labour Obstructed by Anomalies of Soft Parts. 659 
 
 The treatment is to empty the bladder by catheter, and retract 
 the prolapsed mucous membrane with the fingers as the head is 
 passing. 
 
 Distended Bladder. — Eetention of urine, from pressure of the 
 presenting part on the neck of the bladder, is not uncommon in 
 labour. The top of the bladder rises in the abdomen with the 
 lengthening of the cervix and upward travelling of the internal os 
 uteri. If the abdomen be examined, therefore, a distended bladder 
 is always easily recognised as an elastic fluctuating swelling in 
 front of the lower part of the uterus. Its effect in rendering pains 
 ineffective has already been considered (see p. 623). In passing a 
 catheter it must be remembered that the meatus is often displaced 
 forward by swelling and descent of the vaginal wall, and the urethra 
 lengthened by stretching. The urine, moreover, is contained only 
 in the upper part of the bladder. It is preferable, therefore, to 
 use not a short female catheter, but an elastic male catheter. If 
 the catheter is arrested at the point where the head rests against 
 the pubes, the head should be pushed up in an interval between 
 pains, and the tip of the catheter guided forward by the finger in 
 the vagina so as to pass the head. 
 
 Vesical Calculus. — Calculus is very rare in women, and still 
 rarer as a complication of labour. Cases have, however, been 
 recorded in which a calculus has become impacted between the 
 descending head and the pubes, or fixed at the entrance of the 
 urethra, and formed an obstacle to labour.^ The diagnosis, if any 
 doubt existed, would be at once decided by the use of the bladder 
 sound. 
 
 Treatment, — The calculus should, if possible, be pushed out of 
 the way above the pubes. The elevation of the bladder in labour 
 will generally facilitate this. If it does not otherwise succeed, the 
 attempt should be repeated in the knee-elbow position, the head 
 being pushed backward. If the calculus is firmly impacted and 
 cannot be pushed up, it may be extracted after rapid dilatation of 
 the urethra, if small. If it is large, vaginal lithotomy may be 
 performed, if necessary, by a longitudinal incision, and the wound 
 closed by sutures when delivery is completed. 
 
 Vaginal Enterocele. — Prolapse of the posterior vaginal wall, 
 independent of pregnancy, is often accompanied by rectocele. 
 Much more rarely some portion of the small intestine, omentum, 
 
 1 Hmellie's Treatise of Midwifery, Vol. II., p. 100, case 60 ; Hugenberger, Petersburg 
 Med. Zeitsch., 1875, Bd. .5. 
 
 42—2 
 
66o 
 
 The Practice of Midwifery. 
 
 or some part of the large intestine, as the sigmoid flexure, descends 
 into the pouch of Douglas, which is always drawn down into the 
 swelling (Fig. 325). Thus a kind of vaginal hernia is formed. In 
 rare cases, such an enterocele may be pushed down in front of the 
 head in labour, and its return prevented by the pressure. Such a 
 swelling will be resonant, wdth gurgling on pressure. The diagnosis 
 will be made certain by combined vaginal and rectal examination. 
 The treatment is to return the hernia by pressure, with the aid, if 
 necessary, of the knee-elbow position, the head being pushed 
 backw^ard. If this does not succeed, the attempt may be made 
 with the aid of chloroform, the patient being in the semi-prone 
 position. This also failing, delivery may be hastened with forceps. 
 
 HEMATOMA, OR Thrombus OF THE Vagina AND VuLVA. — Thrombus 
 
 of the vagina or vulva arises 
 from rupture of veins or capil- 
 lary vessels. It rarely occurs in 
 pregnancy, unless from the effect 
 of violence, more frequently in 
 actual labour or after delivery. 
 The predisposing causes are, first 
 the vascular distension of preg- 
 nancy, next the obstacle to 
 venous return from pressure of 
 the presenting part, and finally 
 the increased venous pressure 
 due to the bearing-down efforts. 
 The actual tearing of the vessels 
 is due to the bruising and drag- 
 ging of the tissues by the 
 presenting part, to operative interference, or to some external 
 violence, such as a fall or blow. In some cases a tense swelling is 
 produced large and hard enough to form an obstacle to delivery. In 
 others the swelling is comparatively small, or only becomes manifest 
 after delivery. The surface may rupture from tension or be lacerated 
 in delivery, and then profuse haemorrhage may occur, even to such 
 an extent as to prove fatal. Afterwards there is danger of septi- 
 caemia from breaking down of the effused clot, especially if exposed 
 to the air. Most frequently the effusion commences close to the 
 vaginal outlet on one side, and, limited by the attachment of the 
 pelvic fascia, extends some little way up the vagina and outwards 
 toward the labia. Occasionally the blood, tearing through the 
 attachment of the fascia, extends up in the cellular tissue surrounding 
 
 Fig. 325. — Prolapse of posterior vaginal 
 wall with enterocele. 
 
Labour Obstructed by Anomalies of Soft Parts. 66 1 
 
 the vagina, on to the iliac fossae, even up to the neighbourhood 
 of the kidneys, or along the anterior abdominal wall. Still more 
 rarely instances have been recorded of subperitoneal hsematomata 
 affecting not the lower part of the vagina, but beginning in the 
 tissues round the cervix and simulating the effusions of blood met 
 with in some cases of incomplete rupture of the lower uterine 
 segment.^ 
 
 In hsematoma of the vulva or vagina, the swelling generally 
 increases rapidly and is accompanied by acute tearing pain in the 
 
 Fig. 326. — Coronal section of the pelvis (diagramraatic), showing the usual 
 anatomical situation of a hsematoma of the vulva, and of a subperitoneal 
 hematoma, and the manner in which the extension of the first 
 upwards, and of the second downwards, is prevented by the attachment 
 of the pelvic fascia to the vaginal walls. 
 
 part affected, and extending to the thigh. Marked symptoms of 
 anfemia may appear at the same time. If the lesion is caused by 
 the head itself, the effusion may be kept in check by pressure, and 
 only increases more gradually after delivery is completed. The 
 swelling is tense but fluctuating, while the blood remains fluid, the 
 surface dark blue and translucent. As clot forms the swelling 
 becomes harder. The vagina may be so much narrowed as to 
 impede the escape of the lochia. The surface may give way only 
 after an interval of some days, and then there is danger of recurrent 
 haemorrhage. The suppuration which follows rupture or artificial 
 
 ' W. Williams, Trans. Am. Gyii. Hoc, 1904, Vol. XXIX., p. 186. 
 
662 The Practice of Midwifery. 
 
 opening may lead to necrosis of tissue round, or burrowing abscesses, 
 as well as to septicaemia. In favourable cases resolution occurs 
 without rupture. 
 
 Thrombus of vagina or vulva does not occur more than once in 
 2,000 or 3,000 deliveries. As a cause of obstruction to labour, it 
 is very much more rare even than this. When the effusion is 
 extensive, the prognosis is a rather serious one. In 50 cases 
 collected by Von Winckel ^ there were 6 deaths, or 12 per cent., and 
 other authorities have given a much more unfavourable estimate 
 than this. In the favourable circumstances, however, attending the 
 treatment of such cases at the present time, the results will be much 
 better. 
 
 Treatment. — If the commencing formation of a thrombus in 
 labour is detected early, the foetus should be extracted with forceps 
 as quickly as possible, since the relief of venous obstruction is the 
 best means to stop the bleeding. If the swelling is so large as to 
 prevent delivery, it must be first incised. The bleeding may be 
 stopped by j)lugging with antiseptic gauze or by drawing the head 
 quickly down upon the opening. Bleeding after delivery must be 
 stopped in the same way. Dangerous bleeding may be kept in 
 check by pressure with the finger alone, while the gauze is being 
 obtained. Eecurrent bleeding is to be treated in a similar 
 manner. 
 
 If the delivery is over, and the thrombus is not ruj)tured, it 
 should be left unopened if possible. The thrombus should only be 
 incised if the surface is becoming sloughy, if there are signs of 
 suppuration in it, or general signs of septic absor^Dtion attributed 
 to its presence, or again if the swelling is so enormous that there 
 is no hope of its absorption. Even a delay of a few days in opening 
 is an advantage, for there is then less risk of recurrent haemorrhage. 
 If an opening is made, it should be fairly free, and at a prominent 
 yet dependent part, generally at the inner side of the labium 
 majus. All blood clot should be removed, the cavity irrigated with 
 a weak antiseptic lotion, and plugged with antisej)tic gauze. Any 
 sloughy and loose bits of tissue should be removed. 
 
 ^ Pathologie unci Therapie des Wochenbettes, English translation, Chadwick, 1876, 
 p. 148. 
 
Chapter XXVIII. 
 
 LABOUR OBSTRUCTED BY ANOMALIES OF THE 
 
 OVUM, 
 
 Shoulder, Arm, and Transverse Presentations. 
 
 Although the term " transverse presentation " or " crossbirth " 
 is frequently used, it is very rare for the long axis of the foetus to 
 lie transversely in the uterus, either in pregnancy or at the onset 
 of labour. Almost the only case in which the foetus actually lies 
 transversely is that in which the abdomen is so contracted from 
 above downwards in consequence of spinal deformity that there is 
 more room for the axis of the foetus in a transverse than in its usual 
 position. The shape of the uterus then accommodates itself to the 
 necessity of the case. In the cases often called " transverse 
 presentations," the axis of the foetus for the most part really lies 
 obliquely in the first instance, the head lower than the breech. 
 The head is then displaced to one side of the brim instead of 
 descending into it, and the shoulder becomes usually at first 
 the presenting part. As the shoulder is pressed more deeply 
 into the brim, the head is deflected more and more upwards, 
 and the long axis of the child becomes more nearly transverse 
 than at first. After the rupture of the membranes the lower arm 
 is prolapsed in about 50 per cent, of the cases, the upper in 
 4*2 per cent., and so becomes the presenting part (Fig. 327, p. 664), 
 but the mechanism is not essentially different, whether the shoulder 
 or arm presents. More rarely other parts of the foetus present, 
 such as the back, or the abdomen, the foetus in the latter case being 
 in a position of excessive extension or opisthotonos, instead of the 
 usual position of flexion. These presentations occur chiefly with a 
 j)remature or macerated foetus, which is apt to become doubled up 
 in various positions. They have a tendency to become converted 
 into shoulder presentations. In rare cases the so-called compound 
 presentations occur, such as hands and feet together, or feet with 
 head. In these cases the axis of the foetus may have considerable 
 oljliqiiity or be nearly transverse, or it may be much doubled ui)on 
 itself. The presentation of feet with head impHes that the legs are 
 extended upon the thighs instead of being flexed as usual. 
 
664 
 
 The Practice of Midwifery. 
 
 In all these presentations the foetus is moulded into such a shape 
 that it forms a wedge with the base uppermost, the dimensions of 
 the base being as a rule so large that it cannot possibly pass 
 through the pelvis. In the case of shoulder or arm presentation 
 the base of the wedge is formed by the diameter of the head in 
 addition to that of the thorax. As a rule, therefore, delivery is 
 impossible, except by artificial means. 
 
 Frequency. — The frequency of shoulder or transverse presenta- 
 tion in its different varieties has been estimated at from 1 in 130 to 
 1 in 250 cases. In the Guy's Hospital Charity it was 1 in 354, in 
 
 49,588 births. Pinard 
 records 804 in 100,000 
 cases, or 1 in 125, Koutier^ 
 1 in 127. 
 
 Causation. — All abnor- 
 mal, and especially oblique 
 and transverse, positions of 
 the foetus are relatively 
 common in pregnancy before 
 full term, and tend to 
 become rectified by the 
 mutual adaptation of the 
 uterus and the foetus, as 
 previously described (see 
 p. 143). Immaturity of the 
 foetus is therefore an impor- 
 tant cause of shoulder 
 presentations, as 25 per cent, of all transverse presentations are met 
 with in premature births. Another, accounting for about 10 per 
 cent, of the cases, is death or maceration of the foetus, for then the 
 tonicity by which it maintains its axis, and the muscular movements 
 by which adaptations are aided, both fail. In the development of 
 shoulder presentations out of a slightly oblique position of the long 
 axis, contraction of the pelvic brim, especially contraction of the 
 conjugate diameter, plays an imj)ortant part. For if the foetal head 
 is unable easily to enter the brim, it is more likely to be deflected 
 to one side toward the iliac fossa. If, on the other hand, it can lie 
 deeply in the pelvis before the onset of labour, its displacement is 
 unlikely. Thus women who have a contracted pelvis are liable to 
 
 1 Routier, De la Termiaaison Spontanfe de I'Accouchement dans la Presentation de 
 I'Epaule, 1893. 
 
 Fig. 327. — Arm presentation in the dorso- 
 anlerior position. 
 
Labour Obstructed by Anomalies of Ovum. 665 
 
 have shoulder presentations recurring in successive labours. In 
 conjunction with pelvic contraction sufficient to keep the head 
 above the brim, obliquity of the uterus is an imj)ortant cause. The 
 uterine force being oblique tends to push the head toward the 
 opposite iliac fossa. Thus the head lies more frequently in the 
 left iliac fossa, and this fact is probably explained by the fundus 
 uteri being generally oblique toward the right. 
 
 Other causes are those which act by interfering with the natural 
 adaptation of the fcetus to the shape of the uterus through uterine 
 contractions. These are laxity or weakness of the uterine muscle, 
 excess of liquor amnii, twin pregnancy, and want of space in the 
 abdomen due to spinal deformity. Laxity of the uterine muscle 
 may be one reason for shoulder presentation being relatively 
 common in multiparse, 90 to 92 per cent, of the cases occurring in 
 them as compared with 8 to 10 per cent, in primiparae. Other 
 reasons are that the uterus is more often oblique or anteverted, 
 from diminished tone of abdominal walls, and that the head does 
 not generally lie so low in the pelvis before labour, on account of 
 the condition of the cervix. "When liquor amnii is excessive, the 
 uterine action has little effect in producing adaptation during preg- 
 nancy. If the fluid escapes gradually on rupture of the membranes, 
 rectification may then be effected. If it escapes suddenly, the foetus 
 may become fixed in any abnormal position. In twin pregnancy, 
 not only is the force of adaptation almost abolished, but one foetus 
 may displace the other by pressure. In placenta prsevia also there 
 is a greater tendency to sboulder presentation, when the mass of 
 the placenta prevents the head from resting so low in the uterus 
 during pregiiancy. 
 
 In 19 per cent, of cases of fibromyomata of the uterus transverse 
 presentations are found, and they appear to be especially common 
 with some forms of maldevelopment of the uterus. Thus Vogel^ 
 records nine cases of uterus arcuatus among eighty-six transverse 
 presentations, and in 29 per cent, of all cases of this deformity of 
 the uterus transverse presentations occur. 
 
 Varieties. — Shoulder and transverse presentations are divided 
 into two main varieties : dorso-anterior, in which the back of the 
 child is directed forward (see Fig, 327), and abdomino-anterior, 
 in which the abdomen is directed forward (see Fig. 328, p. 666). 
 Each of these again is divided into two varieties, according as the 
 head lies in the right or the left iliac fossa. In most cases the 
 back is not directed precisely backward or forward, but somewhat 
 
 1 Vogel, Zeitschr. f. Gcb. u. Uyn., 1900, Bd. 43, p. 312. 
 
666 
 
 The Practice of Midwifery. 
 
 obliquely, as in the cranial positions out of which the shoulder 
 presentations are developed. The relative frequency of the varieties 
 of shoulder presentation is in accordance with that of the different 
 positions of the vertex. Thus dorso-anterior positions are more 
 frequent than dorso-posterior, occurring in three-fifths of all cases. 
 The uterus being usually rotated somewhat to the right, the trans- 
 verse or broadest diameter of the shoulders generally lies nearly in 
 the right oblique diameter of the pelvis, rather than exactly 
 transversely. Hence the head generally lies somewhat more 
 forward in the iliac fossa if it goes toward the left side than if it 
 
 goes toward the right, being 
 displaced laterally in refer- 
 ence to the shoulders. Pro- 
 lapse of the funis is relatively 
 common, the umbilicus being 
 brought lower than normal, 
 and the os not so well filled 
 as by the head. 
 
 Fig. 328. — Arm presentation in the 
 abdomino-anterior position. 
 
 Diagnosis. — In the early 
 stage of labour, the present- 
 ing part lies higher than 
 usual, and may on that 
 account be difiicult to reach 
 or to make out; the bag of 
 membranes forms a longer 
 and less wide prominence 
 than usual ; and the labour 
 often comes on slowly and 
 insidiously, the os having 
 less stimulus from pressure. After the rupture of the membranes, 
 the pains may even appear to subside. This sometimes has the 
 unfortunate result that the accoucheur is not sent for betimes. 
 
 Transverse or oblique positions of the foetus can always be easily 
 made out on abdominal palpation, provided that the uterus is lax 
 and the abdominal walls not excessively thick from fat ; and 
 frequently the position can be easily changed by external pressure 
 only.- Instead of one broad firm portion of the foetus — the breech, 
 being felt toward the fundus, two firm portions — the breech and the 
 head, are felt, and these are displaced toward opposite sides. The 
 head generally lies in one or other iliac fossa. In all cases, there- 
 fore, in which the presentation cannot be made out on vaginal 
 examination, or in which shoulder presentation is suspected, a 
 
Labour Obstructed by Anomalies of Ovum. 667 
 
 careful abdominal examination should be made. If the membranes 
 have been ruptured for some time, and the uterus has closed 
 tightly round the foetus, it is more difficult to make out the head 
 distinctly through the hard uterine wall, especially if it lies rather 
 backward. 
 
 It is of the greatest importance to make an early diagnosis in 
 shoulder presentation, so that, if possible, the position may be 
 rectified before the rupture of the membranes, and that, at any rate, 
 this rectification may be carried out before the uterus has become 
 closely contracted round the child, and version thus rendered 
 difficult. If, therefore, the presentation cannot be made out with 
 complete certainty by one or two fingers, the half-hand or whole 
 hand should be introduced into the vagina so as to reach high in 
 the pelvis and settle any doubt. The examination should be made 
 only in the absence of a pain and when the membranes are quite 
 lax, lest these should be ruptured prematurely. If pains are 
 frequent and vigorous, it is well to administer chloroform for the 
 purpose. Otherwise the reflex stimulus caused by the hand may 
 excite a violent pain which ru]3tures the membranes. 
 
 The shoulder can hardly be mistaken for anything else except 
 the breech, a mistake which I have known to be made with disas- 
 trous results. The distinctive points about the shoulder are the 
 borders of the axilla, especially the ribs below it, and the intercostal 
 spaces, the "grid of the ribs," which are quite characteristic. The 
 spine of the scapula and the clavicle will also be felt. On the other 
 hand, the breech is positively diagnosed by the sacral spines and 
 the anus. If the examining finger be placed in the axilla it will be 
 found to be closed in the direction of the head and open in the 
 direction of the trunk and breech. Indeed, the former can often be 
 reached by the examining hand. The positions of the clavicle and 
 spine of the scapula will show whether the back is directed forward 
 or backward. 
 
 The elbow is distinguished from the knee by its being less 
 broad, and having the sharp projection of the olecranon. As this 
 distinction is not always quite easy, it is well if the slightest 
 doubt exists, and the membranes are already ruptured, to bring 
 down the hand or foot, which can quite readily be distinguished. 
 The measure is entirely free from any disadvantage in both cases. 
 
 The hand is distinguished from the foot by the length and 
 mobility of the fingers, which often grasp the examining finger, 
 and still more by the thumb, separated from the fingers, and the 
 absence of the prominence of the heel. The most characteristic 
 points about the foot are the projection of the heel and the 
 
668 The Practice of Midwifery. 
 
 malleoli of the ankle. To distinguish whether right hand or left 
 is presenting, place the fingers on the flexor surface of the hand 
 as in shaking hands. If then the thumb is directed in the same 
 way as the thumb of the examining hand, as it would be in 
 shaking hands, the hand is the same, right or left, as the examin- 
 ing hand. The position of the foetus may also be determined 
 from that of the arm when j)rolaj)sed in the vagina in the follow- 
 ing way. Draw the arm gently downward, and hold it in a 
 position of moderate (not excessive) supination. The palm of the 
 hand will then look towards the abdomen, and the thumb towards 
 the head (see Fig. 328). Any one may readily test the appli- 
 cability of this rule by stretching out his own hand in a position of 
 supination. 
 
 In cases where the anterior or the posterior surfaces of the 
 trunk present, considerable difficulty may be met with in coming to 
 a correct diagnosis, and in all doubtful cases an anaesthetic should 
 be administered, the whole hand introduced with great care, and 
 a certain diagnosis of the position made. 
 
 Prognosis. — The prognosis will depend upon the stage at which 
 the malposition is detected and the skill of the treatment. 
 Churchill estimated the mortality of the mothers as being as high 
 as 1 in 9, and that of the children as 1 in 2. In the Guy's 
 Hospital Lying-in Charity, in 49,588 births, there were 140 shoulder 
 or transverse presentations, and among these three deaths, two 
 from septicaemia, one from rupture of the uterus before assistance 
 arrived. Seventy per cent, of the children were still-born, includ- 
 ing the premature children. 
 
 In transverse presentations treated skilfully the maternal 
 mortality should not exceed 2 to 3 per cent., while that of the children 
 will vary between 10 and 30 per cent. 
 
 Natural Terminations. — Although, in the majority of cases, 
 it is impossible for delivery to take place by the natural forces, yet 
 to this rule there are the following exceptions. 
 
 Spontaneous Rectification. — A change by which the oblique 
 j)Osition of the foetus is converted into a normal one, with the 
 head presenting, is common during pregnancy, and may occur 
 even during labour. As a general rule, but not invariably, it is 
 necessary for its occurrence that the membranes should remain 
 unbroken. The force which brings the head towards the uterine 
 axis is the effect of the contraction of the circular muscular fibres. 
 It has already been explained that the uterus, in contracting, no 
 
Labour Obstructed by Anomalies of Ovum. 669 
 
 longer acts like a shapeless bag, but tends to assume its own 
 pear-shaped form ; and the relatively great strength of the con- 
 traction of the circular fibres is shown by the fact that normally 
 the foetal axis is lengthened, not shortened, during the pains (see 
 p. 233). Spontaneous rectification is promoted if the patient 
 lies on the side opposite to that towards which the breech is deflected. 
 For then the breech gravitates towards the middle line ; and there- 
 fore tends to bring the opposite fcetal pole — the head, also towards 
 the middle line. Eectification is more likely to happen with a 
 living child, for then the foetal axis has greater tonicity, and also 
 the movements of the child promote adaptation. The relative 
 frequency of spontaneous rectification cannot be estimated, for it 
 may often have occurred in the first stage of labour, before an 
 examination is made. In the Guy's Charity, out of 77 cases of 
 shoulder and transverse presentations in the twelve years 1863 — 
 1875, spontaneous rectification occurred in two, after rupture of 
 the membranes and prolapse of the arm, the head coming down 
 by the side of the arm, and the child being expelled without 
 assistance. 
 
 Spontaneous Version. — In spontaneous version the long axis of 
 the foetus is not brought into coincidence with the uterine axis by 
 the shortest way, but is changed into a nearly reversed position. 
 The breech is brought down towards the mother's pelvis, the 
 shoulder recedes in the direction of the head. Eventually the head 
 ascends towards the fundus, the breech becomes the presenting part, 
 and the case is terminated like one of pelvic presentation. Unlike 
 spontaneous rectification, spontaneous version generally occurs 
 aftei' the rupture of the membranes. As a rule, however, it 
 implies that the shoulder has not descended very low into the 
 pelvis, and that the uterus has not closed so tightly round the 
 child as to prevent its having a fair mobility. In some recorded 
 cases, however, it has occurred several hours after rupture of the 
 membranes. 
 
 Spontaneous version is not so easily explained as spontaneous 
 rectification, for the usual forces of adaptation would tend to pro- 
 duce the latter change only. For its production a vigorous but 
 unequal contraction of the uterus appears to be the essential. 
 The pressure of the breech stimulates that part of the uterus which 
 covers it, especially the longitudinal fibres, to contract powerfully. 
 The breech is thus forced down towards the pelvis, and at the same 
 time a comparative laxity of the part of the uterus covering the 
 head allows the head to rise, and the presenting shoulder to move 
 in the direction of the head. As soon as the head has once risen 
 
670 
 
 The Practice of Midwifery. 
 
 above the level of the breech, the usual forces of adaptation will 
 tend to complete the version, to bring the axis of the foetus into 
 coincidence with that of the uterus, and to make the breech the 
 presenting part. It is clear that, for the descent of the breech to 
 cause ascent of the head, the axis of the foetus must have a 
 certain degree of tonicity. Hence as a rule spontaneous version 
 takes place with a living child only. It is possible also that the 
 movements of the legs may have something to do in evoking the 
 powerful unequal contraction which causes descent of the breech. 
 By some authorities, what has been called spontaneous rectification 
 is included as a variety under the title of spontaneous version, but 
 
 the mechanism of the two pro- 
 cesses is opposite in character. 
 In the Guy's Hospital Charity 
 spontaneous version occurred 
 in 4 cases out of 77, living 
 children being born by the 
 breech. 
 
 Spontaneous Evolution. — In 
 spontaneous evolution the head 
 remains fixed in its original 
 position without elevation, and 
 a rotation of the foetus takes 
 place about the point where 
 the neck is jammed against the 
 pubes, aided by a doubling up 
 of the body. The presenting 
 arm with the shoulder is first 
 Fig. 329.-Commencemeut of spontaneous ^y.[^Q^ deeply into the pelvis. 
 
 Then more and more of the 
 thorax is driven down beside and below the shoulder, the body 
 becoming doubled upon itself. Some rotation of the longest 
 diameter of the doubled foetus into the antero-posterior diameter 
 of the pelvis occurs at this time (Fig. 329), the prolapsed arm 
 coming under the pubic arch, the breech into the hollow of the 
 sacrum, the head remaining above the symphysis pubis. The 
 side presents first at the vulva behind the prolapsed arm, then, 
 the shoulder remaining fixed, the breech is forced lower and 
 lower until it is expelled, followed by the legs (Fig. 331, p. 672). 
 Then comes the thorax with prolapsed arm, and finally the head, 
 with the upper arm generally lying behind it (Fig. 332, p. 672), 
 For spontaneous evolution to be j)ossible the child must be 
 premature, or moderately small relatively to the pelvis, and the 
 
Labour Obstructed by Anomalies of Ovum. 671 
 
 pains vigorous. While spontaneous version generally requires 
 the child to be alive, in spontaneous evolution it is almost 
 invariably dead, first because the doubling up of the body is 
 greatly facilitated by the loss of tonicity which follows its death, 
 and secondly because the child could hardly survive in such 
 a position the enormous pressure required to cause the doubling 
 up and expulsion. Out of 77 
 cases in Guy's Hospital 
 Charity, spontaneous evolu- 
 tion occurred in 6. Three 
 of the children were prema- 
 ture, two were twin children, 
 and one was decomposed. 
 In two other cases spon- 
 taneous evolution appeared 
 to have commenced, and 
 was completed by artificial 
 extraction. The eight chil- 
 dren were all still-born. It 
 is, of course, possible that 
 evolution might eventually 
 occur in a larger proportion 
 of cases, if version were not 
 performed. 
 
 Spontaneous evolution 
 may be arrested, or the 
 patient may die from exhaus- 
 tion before it is completed, 
 as in the case shown in 
 Fig. 330. Even after spon- 
 taneous evolution living chil- 
 dren are occasionally born. 
 Thus Diclcshoorn^ collected 
 16 cases from the literature, 
 including one of his own in which the child weighed 2,880 
 grammes, or about 6 lb. 5 oz. The majority of the children, 
 however, were poorly developed, and soon died. 
 
 S2>ontaneoiis Expiihion, or evolutio corpore conduplicato. — This is 
 a much rarer event than the ordinary spontaneous evolution, and 
 requires a still greater capacity of the pelvis in proportion to the 
 
 Fig. 330. — Spontaneous evolution arrested. 
 (From a frozen section. Chiara.^) 
 
 1 Dickshooni, Ned. Tijdschr. voor Geneeskunde, 1902, Bd. 2, No. 12. 
 
 2 Chiara, La Kvohv/Aom spontanea sorpresa in atto mediante congelazione, Milan, 
 
 1878. 
 
672 
 
 The Practice of Midwifery. 
 
 size of the fcetus. The capacity is, however, required only in 
 one direction, and hence a contracted conjugate diameter is not 
 necessarily an absolute obstacle. The mechanism is similar to 
 that of spontaneous evolution up to the stage at which the doubled 
 side has descended into the pelvis, and the head is doubled back 
 upon the abdomen (Fig. 330, p. 671). Then, instead of remaining 
 above the brim, the head enters the pelvis, pressed deeply into the 
 abdomen, and the two pass together (Fig. 333, p. 673). The 
 presenting shoulder emerges, following the arm, then head and 
 abdomen together, the head in advance of the breech, and finally 
 
 Fig. 331. — Further progress of 
 spontaneous evolution. 
 
 Fig. 332. 
 
 -Termination of spontaneous 
 evolution. 
 
 the legs. This kind of evolution is promoted by traction upon 
 the arm, the presenting shoulder here coming in advance. It 
 occurs only with a dead fcetus, and generally one either premature 
 or macerated. No instance of it occurred in 23,811 births in the 
 Guy's Hospital Charity. In the case of abortions, before the child 
 is viable, it is not so uncommon. 
 
 Termination of Neglected Cases. — After the rupture of the mem- 
 branes, nearly the whole of the liquor amnii soon drains away, the 
 presenting part not filling up the os closely. The uterus then 
 contracts closely around the foetus. Pains continuing, provided 
 that the case is not terminated in any of the ways already described, 
 retraction of the contractile portions of the uterus occurs (see 
 
Labour Obstructed by Anomalies of Ovum. 673 
 
 p. 628), associated with great stretching of the cervix and lower 
 
 distensible zone of the uterine body. This is apt to lead to rupture 
 
 in the thinner portions of the uterus, or in the vagina. Spontaneous 
 
 rupture occurs very infrequently in these cases, about once in 300 
 
 instances, but rupture of the uterus, the result of attempts at 
 
 version, is very liable to occur in transverse presentations.^ If 
 
 rupture does not take place, the uterus eventually passes into the 
 
 state of tetanic contraction, 
 
 and the other grave symptoms 
 
 of obstructed labour supervene 
 
 (see p. 623), The patient 
 
 finally sinks from exhaustion, 
 
 or, if the uterus is inactive, 
 
 from peritonitis and septic 
 
 absorption after the death of 
 
 the foetus. In some instances 
 
 decomposition occurs in the 
 
 contents of the uterus after 
 
 rupture of the membranes, 
 
 with the development of a 
 
 physometra. 
 
 Treatment. — If the patient 
 is seen, as she should be, about 
 six weeks before full term in 
 all cases of pregnancy, it will 
 be often possible to correct by 
 external manipulation an 
 oblique presentation. When 
 she is seen for the first time 
 after the onset of labour the 
 treatment consists in rectifica- 
 tion of the position of the foetus 
 
 by version, so as to bring either the head or the pelvis to present. 
 This will be described in full in Chapter XXXIV. The version 
 is to be carried out in the mode which implies the least possible 
 interference ; if possible, before the rupture of the membranes, by 
 external manipulation only ; otherwise by bipolar version ; if this 
 also fails, as will generally be the case when the membranes have 
 been ruptured some time, by the ordinary internal version. In all 
 cases after version the birth of the child should be left to the 
 
 1 Ivanotf, Annalcs de Gyn6cologic, 1904, pp. 44'.», 513, 58!) ; Merz, Arch. f. Gyn., 
 1894, Bfl. 45, Hft. 2, p. 383 ; Kleinwachter, Arch. f. Gyn., 1871, Bd. 2, Hft. 1, p. 111. 
 
 M. 43 
 
 Fig. 833. — Spontaneous expulsion. 
 Kleinwachter.) 
 
 (After 
 
674 
 
 The Practice of Midwifery. 
 
 natural forces unless there is some definite indication for rapid 
 delivery. 
 
 Decapitation. — It is only in very rare and long-neglected cases 
 that version will fail, in moderately skilful hands, if chloroform be 
 given to the full surgical degree, and if the small blunt hook or 
 noose be employed, if required, to make traction upon the knee 
 or foot (see Chapter XXXIV.). I have never met with a case in 
 
 Fig. 334.— Decapitating 
 hook, with serrated 
 edge. 
 
 Fig. 335. — Decapitation. 
 
 which the knee or foot could not be reached. But it does some- 
 times happen, when the uterus is very firmly contracted around 
 the child, as, for instance, when the liquor amnii has escaped for 
 several days, that the foetus cannot be got to revolve by any safe 
 degree of traction upon the leg. It may even happen, with a 
 decomposed foetus, that the leg may separate, and come away. By 
 far the best resource, if the neck can be reached, is then decapita- 
 tion. Also, if there is strong evidence that the child is dead, 
 decapitation may be performed in preference to exerting great force 
 in attempting to effect version, lest rupture of the uterus should 
 
Labour Obstructed by Anomalies of Ovum. 675 
 
 result. More especially, if the shoulder is driven down low in the 
 vagina, the arm protruding externally, no attempt should be made 
 at version, for the child is then certain to be dead, and version 
 would be dangerous. The best instrument to decapitate with is a 
 semi-circular hook, with a serrated edge (Fig. 334). Other modes 
 of operating have been recommended, such as cutting upwards 
 with blunt-pointed scissors, the neck being fixed with a blunt 
 hook, or the use of a sharp hook, semi-circular or sickle-shaped. 
 Scissors are apt to wound the soft parts, or operator's fingers, and 
 the operation with them is tedious and difficult. A sharp hook is 
 apt to become blunted against the vertebrae, and then fail to divide 
 the spinal column. With a serrated hook delivery can always be 
 effected in a few minutes, if the hook is once placed over the neck. 
 It is essential, however, that the teeth should be sufficiently fine, 
 and slanted in one direction like those of a saw. 
 
 The following, then, is the method to be adopted in decapita- 
 tions : — Bring the shoulder as low as possible by careful traction 
 upon the prolapsed arm. The neck can then generally be reached 
 by the left hand passed into the vagina. Carry the decapitator, 
 protected by the flexor surface of the fingers, up in front of the 
 neck, passing it along the arm, the point directed toward the head, 
 until it reaches the level of the neck. Then turn its point backward, 
 and pass it over the neck ; make quite certain that it is in right 
 position by feeling the point behind the neck (Fig. 835). Now draw 
 the decapitator firmly downward, at the same time that its handle 
 is swayed backward and forward as widely as the vaginal outlet 
 will allow. In this way the neck is quickly cut through. As soon 
 as the vertebrae are divided, note from time to time with the fingers 
 the direction the plane of section is taking, and see that it does not 
 slope too much backward into the shoulder, instead of cutting off 
 the head. It may be necessary to incline the handle of the decapi- 
 tator somewhat in the direction of the head, if this lies very high 
 up. Take care that the last piece of tissue is not divided too 
 quickly, lest the decapitator injure the maternal soft parts in its 
 sudden release. 
 
 While the tissues of the neck are being sawn through one or 
 two fingers of the left hand should be placed upon the under- 
 aspect of the neck, so as to hold it firmly in position, and by 
 making counter-pressure minimise the risk of rupturing the lower 
 uterine segment during the operation. 
 
 The reason why the point of the decapitator should be turned 
 backward is to avoid injury to the bladder. Owing to the direction 
 of the vulval outlet, the handle must be inclined forward. There 
 
 43—2 
 
676 The Practice of Midwifery. 
 
 is therefore less risk of injuring the rectum by cutting downward 
 and forward than there would be of injuring the bladder, if the 
 point were turned toward the pubes, 
 
 By decapitation, the obstructing wedge is broken up, and the 
 body of the foetus is easily withdrawn by traction upon the pro- 
 lapsed arm. It remains only to deal with the head. If the uterus 
 then contracts strongly, the head may be dehvered spontaneously 
 or by expression. The uterus, however, acts at a disadvantage 
 upon so small a body, and will probably be in a state of continuous 
 action from protracted labour ; otherwise decapitation would not have 
 been necessary. In this case it will be necessary to deliver the 
 head artificially. If, as is usually the case, there are no projecting 
 vertebrse at the stump of the neck, the best way is to hook the 
 finger in the mouth, or the thumb in the mouth and the fingers 
 over the base of the skull, and bring the head down in face pre- 
 sentation. If there is much resistance to its passage, a small 
 blunt hook or crochet may be substituted for the finger. If, how- 
 ever, there is a sharp or rough projection of the vertebrae at the 
 neck, this would be turned sideways, and might cause injury to the 
 cervix or vagina, if the head were brought down in face presenta- 
 tion. It is then better, if possible, to seize the stump of the neck 
 with craniotomy forceps of a simple form and bring the head down 
 like an aftercoming head. Forceps may also be employed for 
 extraction. In the case of pelvic contraction it may be necessary 
 to perforate the head, while counter-pressure is made by an assistant 
 over the uterus, and afterwards extract it with the cephalotribe or 
 by other means (see Chapter XXXV.). 
 
 Embryotomy. — Version having been found impossible, the only 
 ease in which the neck cannot be reached for decapitation is that 
 in which there is already a tendency to spontaneous evolution, the 
 shoulder and side descending very low into the pelvis and filling it 
 up, while the neck remains high up (Fig. 330, p. 671). In this 
 case the best plan is to assist evolution, either by hooking the 
 fingers over the breech, if evolution has proceeded far enough for 
 this to be possible, or, if not, by first inserting a small blunt hook 
 or crochet into the thorax or abdomen, and drawing these down in 
 succession. No space is to be gained by evacuation of the contents 
 of the thorax, and but little in general by the evacuation of those of 
 the abdomen. It is of little use, therefore, to jperforate the thorax ; 
 but the abdomen may be perforated with advantage, if delivery is 
 found difiicult, especially if it has become at all distended after the 
 death and decomposition of the foetus. If the evolution cannot be 
 otherwise completed, the spinal column can be divided with strong 
 
Labour Obstructed by Anomalies of Ovum. 677 
 
 scissors, and the two halves of the trunk extracted separately by 
 means of the cephalotribe. 
 
 The same operation of dividing the spinal column, or sjyondy- 
 lotomy, has been recommended by Prof. A. R. Simpson, as an 
 alternative to decapitation. It is stated that version is thereby 
 rendered practicable. The operation is, however, not nearly so 
 easy as decapitation performed in the method above described, 
 nor is the subsequent delivery so easy as that after decapitation. 
 
 Fig-. 336. — Presentation of head and hand. (Braune's Atlas of Topographical 
 Anatomy, PI. XXX.) 
 
 Pkesentation of Hand or Arm with Head. — Presentations 
 of either hand or arm with head, or the prolapse of either by the 
 side of the head, like the descent of the knee or foot in pelvic 
 presentation, imply a departure from the normal attitude of the 
 foetus. They are, therefore, promoted by the death of the foetus, 
 which destroys the tonicity of muscle by which it maintains its 
 usual attitude, and also by its immaturity. Other causes are 
 excess of liquor amnii ; smallness of the head in reference to the 
 pelvis, allowing room for the hand by the side of the head ; and 
 irregularity of the pelvis, especially contraction of the conjugate 
 
678 
 
 The Practice of Midwifery. 
 
 diameter, which prevents the head from accm-ately fitting into 
 and fining up the pelvic brim. The hand may either be felt at 
 the side of the head before ruptm'e of the membranes, or it may 
 be swept down in the sudden escape of a large amount of liquor 
 amnii. Sometimes, again, the hand does not at first present with 
 the head, but is expressed by the side of it, when there are strong 
 pains, and the head does not fill up the brim on account of 
 
 deformity. This is most likely to 
 happen when the child is dead. 
 
 Obstruction is only produced when 
 there is not room enough for the hand 
 and head together. It is more likely 
 to occur the more the hand is in 
 advance of the head. If the hand only 
 just appears by the side, it frequently 
 remains behind as labour advances, 
 and the head is born first. If, how- 
 ever, the arm is far in advance, there 
 is danger that the head may be deflected 
 into the iliac fossa, and the shoulder 
 descend. If the hand is at the side of 
 the pelvis, it is less likely to obstruct 
 that when it lies in front, and so 
 reduces the space in the conjugate dia- 
 meter available for the head. In the 
 Guy's Hospital Lying-in Charity, out 
 of 22,980 births, there was a presenta- 
 tion of hand with head in 54 cases, 
 or 2-2 per 1,000, or 1 in 425. 14-8 
 per cent, of the children, or 1 in 6*7, 
 were still-born. 
 
 Fig. 337. — Dorsal displacement 
 of the arm. 
 
 Treatment. — Before the rupture of 
 the membranes, an attempt may be made to push back the hand or 
 arm through the membranes, while the other hand, used externally, 
 fixes the head in the brim. The patient should lie on the side 
 opposite to that on which the hand is prolapsed, in order to counter- 
 act any tendency to deviation of the head toward the iliac fossa. 
 The attempt at reposition of the hand may be repeated on rupture 
 of the membranes, if it has not succeeded before. If it still fails, and 
 the hand merely descends by the side of the head, the case should 
 be left to nature, unless symptoms of protracted labour appear. 
 Delivery should then be accelerated by forceps, and the hand will 
 
"Labour Obstructed by Anomalies of Ovum. 679 
 
 frequently fall behind, being retarded by friction. In applying 
 forceps care must be taken not to include the hand between the 
 blades. If the arm descends much in advance of the head, and 
 the head remains high in the pelvis, it is better to perform version 
 rather than apply forceps. Version should also be performed in 
 any case in which the head is above the brim, and contraction of 
 the conjugate diameter is found to a degree which is likely to 
 render the passage of the head difficult (see Chapter XXIX.). 
 
 DoKSAL Displacement of the Akm. — Sometimes the arm becomes 
 displaced so that the forearm lies transversely across the back of 
 the neck, and forms a bar or ridge which may catch upon the 
 pelvic brim, and impede the 
 advance of the fcetus (Fig. 
 337). This condition will 
 naturally escape diagnosis 
 unless the hand is carried 
 up past the head to explore, 
 a proceeding which will gene- 
 rally require full administra- 
 tion of an anaesthetic. Such 
 an exploration will generally 
 have been indicated by failure 
 to bring down the head with 
 forceps, while there is not 
 sufficient disproportion be- 
 tween the head and pelvis to 
 account for the difficulty. 
 
 Treatment. — Extraction 
 by forceps having, by supposi- 
 tion, failed, the best treatment will generally be version. Sir J. 
 Simpson, who first described the condition, advised bringing down the 
 arm, so as to convert the case into one of hand and arm presentation. 
 
 Presentation of Hands and Feet together. — Presentation of 
 hands with feet implies that the position of the fcetus is more or 
 less oblique or transverse, and that legs or arms are extended 
 (Fig. 338). Most frequently the breech is lying lower than the 
 head, and the arms are extended. 
 
 Treatment. — Before rupture of the membranes, the axis of the 
 foetus should be brought into coincidence with that of the uterus by 
 external manipulation, if possible, so as to produce either a head or 
 breech presentation. If this fails, as soon as the os is fairly dilated, 
 
 Fig. 338. 
 
 -Presentation of a hand and foot 
 with funis. 
 
68o 
 
 The Practice of Midwifery. 
 
 one foot should be brought down, and traction made upon it until 
 the half-breech fully occupies the os, the hands have receded, and 
 the head occupies the summit of the uterus. 
 
 Presentation of Foot with Head. — Presentation of a foot, or of 
 both feet, with the head is very much rarer than that of hand with 
 head. It imj)lies a doubled-up condition of the foetus as well as 
 extension of the leg. Accordingly, it is chiefly found with pre- 
 mature and dead children. If it happens with a living child, it 
 
 Fig. 339. — Locked twins. 
 
 may be due to the foot having presented in the first instance, the 
 axis of the child being somewhat oblique, and to the head having 
 been brought down with a rush of liquor amnii escaping suddenly. 
 I have known this occur when the foot has been seized, in order to 
 bring it down artificially, but not drawn down quickly enough on 
 the rupture of the membranes. A similar condition may be 
 produced by an attempt at version, when the foot has been brought 
 down, but the head will not recede. 
 
 Treatment. ^If the membranes are unruptured, or shortly after 
 their rupture, the foot may be pushed up above the head if possible. 
 Much time should not be expended upon this attempt after rupture 
 
Labour Obstructed by Anomalies of Ovum. 68 1 
 
 of the membranes, especially if the child is living, since it is likely 
 soon to perish from pressure in its doubled-up attitude. If the 
 attempt does not succeed, traction should be made upon the foot 
 until the half -breech is brought into the os and the head recedes. 
 If this proves difficult, a noose of tape should be placed round the 
 foot for traction, so as to leave the pelvis free for counter-pressure 
 upon the head with the other hand. Traction and pressure may 
 then be tried simultaneously, or, if this does not succeed, alternately, 
 until the fcetus revolves. If this failed, perforation of the head 
 would be the only remedy, but this would hardly ever be necessary. 
 Before making traction on the foot, the physician should make sure, 
 by abdominal palpation, that head and foot belong to the same 
 child, not to twins : since, if they belonged to twins, the head 
 should be delivered first, and the other treatment might lead to the 
 twins becoming locked. 
 
 Locked Twins. — Obstruction to labour from locking of twins is 
 rare, but is apt to be serious when it does occur, and especially 
 fatal to the children. The children are in separate membranes in 
 the great majority of cases of twin pregnancy (see p. 366), and then 
 the membranes of the second child prevent its interfering with the 
 first. Even if the twins are in a common amnion the second 
 child as a rule glides out of the way as the first enters the pelvis. 
 It is only when the heads are small relatively to the pelvis 
 that they are apt both to enter the pelvis together, and so become 
 locked. 
 
 First Variety. — The first way in which twins can become locked 
 is when both present by the head. The second head may then be 
 pressed in between the head and thorax of the first child, and so 
 partially enter the pelvis with the thorax and there become arrested. 
 The first child is in greatest danger, for the funis may be compressed 
 as well as the thorax, if the two have advanced far into the j)elvis. 
 According to Eeimann,^ in six cases, five of the first children were 
 still-born, and four of the last. 
 
 Treatment. — The condition will generally only be discovered after 
 birth of the first head, or an obstruction being met with to its 
 extraction by forceps. The second head should be pushed up out 
 of the way if possible. If this cannot be done, delivery must be 
 effected by traction on the first child. Perforation of the second 
 head will rarely be necessary, and should not be carried out, unless 
 the second child is certainly dead, before a further attempt has been 
 
 1 Arcliiv. f. Gyniik., 1871, Vol. II., pp. 99—101. 
 
682 The Practice of Midwifery. 
 
 made to overcome the difficulty by perforating the head of the 
 first child. 
 
 Second Variety. — The second variety of locked twins arises 
 when the first child presents by the pelvis and the second by the 
 head. The head of the second child may then enter, or partially 
 enter, the pelvis, pressed in between the head and thorax of the 
 first (Fig. 339). The first child then quickly perishes, its funis 
 being exposed to pressure. If space is ample both children may 
 IDass the pelvis together in this position. In some cases the whole 
 of the second child has been spontaneously expelled before the 
 delivery of the first head. According to Keimann, 23 out of 26 
 of the first children, but only 10 out of 29 of the second children, 
 in such cases were still-born. 
 
 Treatment. — If the heads are still high in the pelvis, it may be 
 possible to push up the lower head out of the way while the first 
 child is delivered. If this cannot be done, the head of the first 
 child, lying uppermost, should be severed with the serrated hook 
 (see p. 674) or scissors. The body of the first child is then 
 easily delivered, next the second child, and finally the head of 
 the first. If the head cannot be severed, it may be perforated, 
 but this does not so completely overcome the difficulty. This is 
 probably better treatment than attempting to deliver the second 
 child by applying forceps to its head, since in any case the chances 
 of delivering the first child alive are very small. These expedients 
 failing, there remains the resource of perforating the lower head, 
 and extracting with the cephalotribe, or by other means, but this 
 plan involves the death of both children. When the obstruction 
 is due to the locking of the aftercoming head with the shoulder 
 and prolapsed arm of the second child the best treatment will be 
 decapitation of the first child and the delivery of the second by 
 version. 
 
 FCETAL MONSTEOSITIES. 
 
 Conjoined Twins. — Conjoined twins are extremely rare, com- 
 pared with the total number of deliveries, but a considerable 
 number of cases altogether have been recorded. Conjoined twins 
 are divided by Playfair ^ into the four following classes, including all 
 varieties likely to cause much difficulty in delivery : — 
 
 A. — Thoracopagus. Two nearly separate bodies united in front 
 to a varying extent, by the thorax or abdomen. 
 
 1 Playfair, Trans. Obst. Soc. London, 1867, Vol. VIII. p. 300. 
 
Labour Obstructed by Anomalies of Ovum. 683 
 
 B. — IscHioPAGUs. Two nearly separate bodies united back to 
 back by the sacrum and lower part of the spinal column. 
 
 C. — DicBPHALUs. The bodies being single below, but the heads 
 separate. 
 
 D. — Syncephalus. The bodies separate below, but the heads 
 fused or partially united. 
 
 Out of 31 cases collected by Play fair, spontaneous delivery took 
 place in 20. 
 
 Class A. — This is the most numerous, including 19 cases out of 
 31 (Fig. 340). Both children present by the feet in a much larger 
 proportion of cases than normal children. Playfair regards this 
 as the most favourable presentation, and recommends version in 
 the rare cases of head presentation, in which a diagnosis can be 
 made early enough to allow it. The bodies generally pass the 
 pelvis parallel to each other, without much difficulty, but obstruc- 
 tion may arise when the heads enter the brim. Owing to the 
 bodies being inclined forward toward the pelvic outlet, the posterior 
 head will enter the brim in advance. In aiding delivery it is 
 important to bring down this head as far in advance of the other 
 as possible. The bodies should therefore be carried as far forward 
 as possible, and traction made chiefly upon the body belonging 
 to the posterior head. Force23S may be applied to this head, if 
 necessary, or it might be requisite to perforate it. 
 
 "When the heads present spontaneous delivery may occur in one 
 of two ways. In the first and more common the head of the first 
 child is born first, and advances until it is arrested by tension upon 
 the band or surface of union. Then the two bodies are born 
 together by a kind of spontaneous evolution, the body of the first 
 child in advance. In this evolution, the second head remaining 
 above the brim, a rotation of the two bodies, accompanied by a 
 doubling up, takes place around the point where the neck of the 
 second child rests upon the pelvic brim. It is somewhat analogous 
 to the spontaneous evolution in shoulder presentations (see p. 670). 
 Finally, the second head is delivered. 
 
 In the second mode of delivery, both heads are in the pelvis 
 together, the second head being pressed in between the head and 
 thorax of the first child, as in the first variety of locked twins. The 
 lower head will become anterior towards the pelvic outlet. For this 
 mode of delivery it is essential that the children should be very 
 small in proportion to the pelvis. 
 
 Treatment. — In the case of head presentation a diagnosis is only 
 likely to be made when the progress of the first child is arrested 
 after birth of the head or in the pelvis, and for this purpose 
 
684 
 
 The Practice of Midwifery. 
 
 complete anaesthesia and the mtroduction of the hand will generally 
 be necessary. Evolution may be assisted by traction upon the 
 conjoined bodies, or bringing down the feet if practicable. In case 
 of necessity there need be little hesitation to divide the band of 
 union, or carry out any other form of embryotomy which appears 
 to be indicated. Cleidotomy often will be found most useful.^ If 
 the first head is still in the pelvis, version should be performed, and 
 all four feet brought down. 
 
 Class B. comprises three cases out of the 31. The children in 
 
 Fig. 340. — Thoracopagus monster. (Univ. 
 Coll. Hosp. Med. School Mus.) 
 
 Fig. 341. — Dicephalus monster. 
 (Meigs.;) 2 
 
 these were delivered spontaneously, the first head in advance, then 
 the bodies by evolution, then the second head. Delivery in this way 
 is easier than in Class A., because the junction is generally lower 
 down, allowing the bodies to be more separated, and more of the 
 body of the first child to be born, before traction comes upon the 
 surface of the union, and evolution commences. 
 
 Class C. comprises seven cases out of the 31 (E'ig. 341). In two 
 the children were delivered spontaneously. The usual mechanism 
 is the delivery of first the first head, then the body by evolution, 
 then the second head. If the presentation is a breech, then the 
 
 1 Ballantyne, Munro Kerr's Operative Midwifery, 1908, p. 121. 
 
 2 Meigs, The Science and Art of Obstetrics. 1868. 
 
Labour Obstructed by Anomalies of Ovum. 685 
 
 single body is usually born without much difficulty, followed by 
 the posterior and then by the anterior head. 
 
 Treatment. — Evolution should be assisted by traction upon the 
 body, or by bringing down the feet, if possible, after the birth of 
 the first head. If this cannot be effected, some extra space may 
 be gained by evisceration. If the first head is arrested within the 
 vagina, its removal by decapitation, or perforation, may be necessary 
 before the feet can be brought down. 
 
 Class D. is the rarest, comprising only two cases out of the 31 
 
 Fig. 342. — Syncephalus monster. (Univ. 
 Coll. Hosp. Med. School Mus.) 
 
 Fig. 34.S. — Anencephalus monster. (Univ. 
 Coll. Hosp. Med. School Mus.) 
 
 (Fig. 342). The enlarged monstrous head is the part most likely to 
 cause difficulty. It must be delivered, if necessary, by craniotomy. 
 In all these classes the prognosis to the children is very bad, 
 since they are often premature, and subjected to pressure in a 
 doubled position. The results to the mothers have been favourable. 
 
 Other Forms of Monstrosity. — There is another variety of 
 double monster, which does not usually cause much difficulty in 
 delivery, namely, tliat in which there is partial or complete doubling 
 of upper or lower limbs, generally of the latter. 
 
 Acardiac Monsters. — The production of an acardiac ace 
 phalic monster out of one of twins, when the umbilical arteries 
 
686 The Practice of Midwifery. 
 
 communicate, by reversal of the current of blood in the weaker child, 
 has already been described (see p. 369). There may be a large 
 sha]3eless mass, replacing the head and thorax, formed by hyper- 
 trophy of a low form of cellular tissue and oedema, but it rarely 
 causes difficulty in delivery. The monster generally presents by 
 the feet. The amorphous variety of acardiac monster, in which 
 there is merely a shapeless mass, without either head or limbs, has 
 to be extracted like a detached head after the birth of the first 
 twin. 
 
 Anencephalic Monsters. — -In these there is absence of the 
 brain and vault of the skull, the eyes are prominent, and the face 
 looks upward. The neck is short, the shoulders relatively broad 
 and large. This form of monstrosity has been supposed to originate 
 from hydrocephalus at a very early stage of development, followed 
 by rupture and disappearance of the brain substance. Other 
 authorities deny this explanation. If the head presents, it generally 
 does so by the face. Pelvic and transverse presentations are 
 common, while i^rolapse of the cord or limbs may occur. If the 
 head presents it may cause difficulty in diagnosis. The nature of 
 the case will be discovered by recognising the features of the face, 
 not surmounted by any cranium, and feeling the sella turcica and 
 other projections of the base of the skull. The broad shoulders 
 may cause delay in delivery, especially when these follow the head, 
 too small to dilate a passage for them. If labour is protracted from 
 this cause, while the head is yet high in the pelvis, version should 
 be performed, and delivery accelerated by traction, or cleidotomy 
 may be practised. 
 
 Extroversion of Viscera. — In some cases a large portion of the 
 viscera, especially the liver and the small intestines, lies outside 
 the abdomen, uncovered by skin, and covered only by the amnion. 
 This condition is sometimes associated with shortness of the funis, 
 which is attached to the extroverted mass. The deformity more 
 often causes difficulty in diagnosis of the presentation than difficulty 
 in labour. The fcetus is often in a position of extension or 
 opisthotonos, and the liver, or other part of the extroverted mass, 
 may then present. The liver frequently ruptures during delivery. 
 It may at first be mistaken for a placenta prgevia, but is dis- 
 tinguished from it by the absence of haemorrhage. If the extroverted 
 mass presents, version should be performed, as in other cases of 
 transverse presentation. 
 
Labour Obstructed by Anomalies of Ovum. 687 
 
 Excessive Development of the Fcetus. — Excessive size of the 
 foetus is rarely so extreme as to cause much difficulty in a perfectly 
 normal or wide pelvis. Combined, however, with slight degrees 
 of narrowness in the maternal passages, a large size of the foetus is 
 one of the commonest causes of difficulty. Thus the greater size of 
 male children, and firmer ossification of their cranial bones, are the 
 reasons why a greater proportion of males is still-born. Excessive 
 size of the foetus may depend in part upon the size of the parents, 
 and is likely to be most marked in relation to the pelvis, when the 
 father is very large in proportion to the mother. The size of the 
 children also increases, up to a certain point, with the age of the 
 mother and the frequency of pregnancies (see p. 120). In some 
 cases excessive size of the foetus is due to post-maturity, up to one 
 month or even more. In such cases very serious difficulty may 
 arise, even with a full-size pelvis. 
 
 Excessive ossification of the cranial bones is recognised by 
 unusual smallness of the anterior fontanelle, and the unyielding 
 feel of the bones, even near their edges. Combined with a moderate 
 disproportion of the head to the pelvis, it very greatly increases 
 the difficulty of delivery, since the diminution of the cranial 
 diameters by moulding is rendered difficult. 
 
 Treatment. — Protracted labour from excessive size of the foetus 
 is to be treated in the same way as when due to equable contraction 
 of the pelvis. The size of the head cannot be exactly measured, 
 but can only be estimated generally from the comparatively slight 
 curvature of the cranial bones, the length of the sagittal suture, 
 and the degree to which the head fills up the pelvic space, or its 
 failure to enter the brim. Bimanual examination may assist the 
 diagnosis when part of the head can be felt above the brim. In 
 general, extraction by forceps will be sufficient to meet the case. 
 In rare cases after delivery of the head, detention of the thorax 
 takes place at the outlet from its excessive size, and may even 
 lead to the sacrifice of the child's life. If moderate and cautious 
 traction on the neck, in conjunction with a pain, does not effect 
 delivery, the finger should be passed into the vagina, and hooked 
 into the posterior axilla. Traction is then made upon the axilla 
 in conjunction with that upon the neck. If necessary the rotation 
 of the shoulders into the antero-posterior diameter of the pelvis 
 should be aided. If the finger does not suffice, the small blunt 
 hook used in version (see Cliapter XXXIV.) may be passed round 
 the axilla, and traction made with that. Care must be taken that 
 its point is clear of the axilla on the other side. In an extreme 
 
688 The Practice of Midwifery. 
 
 case, the posterior arm, and then, if necessary, the anterior arm, 
 may be drawn down over the chest, so as practically to reduce the 
 dimensions of the thorax. 
 
 The shoulders may also be arrested higher in the pelvis, but this 
 very rarely happens except in cases where there is pelvic contraction, 
 and the head has been brought through the brim after craniotomy. 
 In such a case, space having been gained by the lessening of the 
 head, the small blunt hook may be fixed in the posterior axilla. If 
 this does not succeed the arms may be brought down by the aid of 
 the same instrument. Afterwards extraction may be aided by 
 seizing the body, either the thorax or the abdomen, with the 
 cephalotribe. If, with an after-coming head, extraction of the 
 body gives great trouble, the small blunt hook may be used to 
 bring down the arms. The child being dead, space may be gained, 
 if necessary, by cleidotomy or by evisceration. 
 
 General Dropsy of the F(etus. — General dropsy may result 
 from a variety of different causes. No doubt in the later months 
 it may arise from certain maternal diseases which increase the 
 blood pressure in the placenta by causing structural changes in the 
 maternal and secondarily in the fcetal parts. It may also arise 
 from structural anomalies in the organs of the foetus (liver, kidneys, 
 heart, blood) which directly produce the dropsy.^ In a few cases 
 there is not merely infiltration with serum, but a hyperplastic 
 condition of the subcutaneous cellular tissue and skin (congenital 
 cystic elephantiasis). Otherwise the skin and subcutaneous tissues 
 as well as the muscular and osseous are more friable than usual. 
 The condition is frequently associated with a large and dropsical 
 placenta. 
 
 Treatment. — The child is generally incapable of surviving long. 
 In case of difficulty, therefore, there need be little hesitation 
 about performing craniotomy ; delivery may then be assisted by 
 fixing the small blunt hook into any convenient parts of the body. 
 The swelling may also be diminished by making incisions or 
 punctures through the skin, or perforating the abdomen. 
 
 Emphysema of the Fcetus. — Emphysema is the result of 
 decomposition of the foetus following its death either before or 
 during labour, and the access of air to it. The effusion of gas 
 may take place both into the serous. cavities and into the cellular 
 tissue. In the latter case there is crackling under pressure by 
 the finger. At the same time the tissues become friable. The 
 
 1 Ballantyne, Antenatal Pathology : The Foetus, 1902, p. 288. 
 
Labour Obstructed by Anomalies of Ovum. 689 
 
 abdomen is the part most likely to cause difficulty in delivery by 
 its distension, but even the breech and limbs may become con- 
 siderably swollen. 
 
 Treatment. — If labour is obstructed, the accumulated gas 
 should be let out, especially from the abdomen, by puncture with 
 the perforator or any other convenient instrument. If necessary, 
 the skin of the breech or other parts may be incised with scissors. 
 In extraction, it is to be remembered that the limbs are liable to 
 tear away. 
 
 Congenital Hydkocephalus. — In congenital hydrocephalus there 
 is a fluid accumulation within the ventricles of the brain, or 
 (Fig. 344) rarely between the membranes. The dimensions of the 
 child's head are often enormously increased, the brain being spread 
 out as a thin layer over the serous fluid. The average diameter of 
 the head is thus not very rarely increased to as much as 7 or 8 
 inches (17'5 to 20 cm.), with a diameter of upwards of 30 inches 
 (75 cm.). In general the cranial bones are thin, soft, and spread 
 out, but not so much so as completely to cover the whole surface. 
 Thus not only the fontanelles, but the sutures, are very wide, and 
 the bones easily movable upon each other. In rare cases, esjDeeially 
 when the effusion is moderate, the bones are more firmly ossified 
 and more completely cover the enlarged head. The face is small 
 relatively to the head, the forehead projecting over it at an angle, 
 the frontal suture gaping. The body may be of normal develop- 
 ment, or wasted. Hydrocephalus is sometimes associated with 
 spina bifida, club feet, encej)halocele, or hydrops amnii. The 
 frequency of hydrocephalus is estimated by Lachapelle as 1 in 
 about 2,900 deliveries. In the Guy's Hospital Charity, however, 
 perforation or puncture on account of hydrocephalus was called for 
 only once in 23,591 deliveries. In general, interference is called 
 for in about three-fourths of the cases. Pelvic presentations are 
 about ten times commoner than in normal cases (29 per cent.), 
 especially when the distension of the head is very great, for then 
 the adaptation of the child to the uterus takes place best when the 
 head is uppermost (see Fig. 100, p. 142). 
 
 Course and Terminations. — When the amount of fluid is 
 moderate, the head not tense, and the bones soft, the head may be 
 compressed and squeezed through the pelvis by the natural powers. 
 More frequently labour becomes arrested, the head not entering the 
 brim, and symptoms of protracted labour arise. The difficulty in 
 delivery depends not only upon the size of the head, but upon the 
 
 M. ' 44 
 
690 
 
 The Practice of Midwifery. 
 
 tension of the fluid in it, and the degree of ossification of the bones. 
 Sometimes it is overcome by spontaneous rupture and escape of the 
 fluid, especially when the child is dead and decomposition com- 
 mencing. Spontaneous delivery occurs more easily with an after- 
 coming head, because the head then enters the pelvis with the 
 narrower end of the wedge foremost. Compression of the bones 
 may then also be assisted by traction. Kupture of the uterus is 
 
 Fig. 344. — Labour impeded by hydrocephalus. 
 
 relatively frequent. It occurred in 30 cases out of 143 collected 
 by Keith and Schuchard.^ This is probably to be explained not 
 only by the obstruction to labour and a failure to recognise the 
 condition, but by the large size of the head, which in head presenta- 
 tions is forced down into the lower distensible segment of the 
 uterus, as the upjDer contractile portion retracts. This produces 
 great transverse stretching, and thereby a tendency to longitudinal 
 rupture. 
 
 1 Schuchard, Inaug. Diss., Berlin, 1884. 
 
Labour Obstructed by Anomalies of Ovum. 691 
 
 Prognosis. — The mortality to the mothers is high, 46 deaths 
 occurring in 246 cases, or 18 per cent. There is, however, Kttle 
 danger if the case is early recognised and treated. The risk lies in 
 its nature being overlooked. The child generally perishes, and, in 
 any case, it is not capable of prolonged life ; of 70 cases recorded 
 by V. Winckel,^ with 17 living children, 7 died within a few days, 
 and the remainder lived for a varying time. 
 
 Diagnosis. — In head presentations, the head will be high up, 
 not entering the brim, and the presenting j)art may be made out 
 as less convex than usual, forming part of a larger spheroid. The 
 wide fontanelles and sutures, soft bones, and comj)ressible character 
 of the head generally render the diagnosis easy. The head is 
 distinguished from the bag of membranes or cystic tumours of the 
 foetus by the presence of hair, and of the cranial bones. If the 
 bones are much ossified, diagnosis is more difficult, and the whole 
 hand should be introduced into the vagina for exploration if neces- 
 sary. The brow may then perhaps be reached, and the overhang- 
 ing forehead and open frontal suture made out. Another most 
 valuable means of diagnosis is the estimation of the size of the 
 head bimanually, since from its magnitude and high position it can 
 usually be defined quite easily from the abdomen. In general there 
 will be urgent pains, combined with failure of the head to descend, 
 and the absence of any pelvic contraction to account for this. The 
 urgency of pains is not, however, always noted, if the head fails to 
 enter the brim at all. If forceps are applied, they often slip off, in 
 consequence of the collapsible character of the head. If the bones 
 are firmly ossified, the handles may remain widely separated when 
 the forceps are locked. When the pelvis presents, the presence of 
 hydrocephalus is generally only discovered when the head cannot 
 be brought into the brim. The unusual size of the uterine tumour 
 and bimanual estimation of the size of head will then generally 
 reveal the true state of the case. 
 
 Treatment. — Forceps will generally slip off the head, and it is 
 not usually worth while to attempt delivery by version, since the 
 child is seldom capable of prolonged life. For the same reason 
 there is little object in puncturing with a small trocar, in order to 
 secure a living child, unless it should be of legal importance to 
 secure the birth of a child, even though it lives for only a short 
 time. The distended head may be punctured with the perforator, 
 by preference in an interval between bones, near the most prominent 
 
 1 v. Winckel, Lehrbuch der Geburtshiilfe, 1893, p. 394. 
 
 44—2 
 
692 The Practice of Midwifery. 
 
 part. If it does not quickly descend, it is then extracted by 
 craniotomy forceps or cephalotribe. If an after-coming head 
 cannot be drawn through the brim, it should be perforated in the 
 manner described in the chapter on craniotomy. A possible alter- 
 native is to let off the fluid by a catheter passed through the spinal 
 canal into the cranial cavity. 
 
 Ascites, Hydrothoeax, Distension of Abdomen. — Ascites and 
 hydrothorax may arise from chronic intra-uterine inflammation of 
 the fcetus, due to syphilis or other causes, or to malformation or 
 obstruction of veins. Hydrothorax is very rare, except in associa- 
 tion with ascites. The abdominal distension is most likely to be 
 the cause of difficulty in labour, but, on account of the yielding 
 nature of the abdominal walls, this is only the case when distension 
 is considerable. Another cause of abdominal distension is occlusion 
 of the urethra or ureters from malformation or inflammation. The 
 foetal urine secreted then accumulates, and produces distension of 
 the bladder, ureters, or kidneys, according to circumstances. I have 
 found it necessary, in order to effect delivery, in a case of jDelvic 
 presentation, to perforate first the bladder, and then two cystic 
 tumours formed by the ureters. Here there was occlusion both of 
 the urethra and of the lower part of the ureters, the latter probably 
 being of later date. The abdomen may also be distended by other 
 causes, which less frequently lead to enlargement great enough to 
 call for interference. Among such cases recorded are enlargements 
 or tumours of the liver, kidneys, spleen, or pancreas, and an 
 included foetus situated in the abdomen. In the latter case one 
 ovum appears to be included within another, and to undergo partial 
 development, deriving its nourishment by its attachment to the other. 
 
 Diagnosis. — The morbid condition is generally first discovered 
 when the foetus will not advance after the head has passed through 
 the pelvis. The hand being then passed up to ascertain the cause, 
 enlargement of the abdomen or thorax is detected. A complete 
 diagnosis is generally impossible till after delivery. 
 
 Treatment. — In minor degrees of enlargement, delivery may 
 be effected by traction upon the head with forceps, or after its 
 delivery, or by traction on the legs in pelvic presentations. If this 
 does not succeed, the abdomen, or if necessary the thorax, should 
 be pierced with a trocar and cannula. In the absence of a trocar, 
 the perforator may be used to pierce the abdomen, unless there is 
 legal importance in securing a child to live, if only for a short 
 time. If the perforator is used in a cranial presentation it is 
 
Labour Obstructed by Anomalies of Ovum. 693 
 
 better to perforate also the head, and destroy the medulla (see 
 Chapter XXXV.)? lest a living child be born with a lacerated 
 abdomen. If the cause of obstruction proves to be solid, it may 
 be necessary to perform complete evisceration, and perhaps to 
 apply the cephalotribe over the abdomen for extraction. 
 
 Congenital Encephalocele. — In congenital encephalocele a 
 serous sac is applied to the head by a base or pedicle of varying 
 breadth. It is filled with cerebro-spinal fluid, originally continuous 
 with that in the head. Generally the communication still exists at 
 birth, but the pedicle may be found impervious when of small size. 
 Cerebral substance may or may not be spread out more or less over 
 the surface of the sac. Encephaloceles are most frequently situated 
 
 Fig. 345.— Encephalocele. (Meigs.i) 
 
 in the middle line. The commonest seat is the occiput (Fig. 345), 
 next to that the frontal region. They may be of any size 
 up to one considerably larger than the head itself. Difficulty in 
 parturition is generally produced only when the sac is of large size, 
 since from its position it generally passes through the pelvis in 
 front of or behind the head, and is compressible. In the case 
 figured, one recorded by Dr. Meigs, the head was born first, and 
 then, the sac remaining above the pubes, the rest of the body was 
 born by spontaneous evolution. The sac was then delivered intact 
 by powerful traction. The sac may be mistaken for a second bag 
 of membranes. In case of delay the diagnosis must be made by 
 passing the hand high up into the pelvis. 
 
 Treatment. — If traction is not sufficient to effect delivery, the 
 sac should be punctured by trocar. 
 
 1 The Science and Art of Obstetrics, 1863, p. 409. 
 
694 The Practice of Midwifery. 
 
 Spina Bifida.^ — In spina bifida a similar serous sac, its contents 
 generally continuous with the cerebro-spinal fluid, is situated over 
 the lumbo-sacral region. Its size may be as large as that of a foetal 
 head. In this case also the sac has to be distinguished from a bag 
 of membranes, especially if it presents alone at the os. 
 
 Treatment. — If delivery cannot be effected by traction, the sac 
 must be j)unctured. 
 
 Othek External Tumours. — Tumours growing externally, of 
 cystic, fatty, cancerous, or other structure, are a rare cause of 
 difficulty in parturition. They may be situated on the neck, chest, 
 axillae, and other parts, but especially about the sacral region. The 
 most common tumour in this situation is a cysto-hygroma, which 
 may attain considerable size. 
 
 Treatment. — Puncture should first be tried, if delivery cannot 
 be effected with the tumour intact. If this does not succeed, it 
 may be necessary to incise or crush it. 
 
 Anomalies of the Membranes. — Undue friability of the mem- 
 branes leads to their premature rupture, and consequent prolonga- 
 tion of the first stage of labour. The effects of undue toughness 
 are generally obviated by artificial rupture. If not, the membranes 
 may remain intact in the second stage, as they have done in the 
 case shown in the frozen section (Fig. 131, p. 220). The second 
 stage is then prolonged, both from the less vigorous action of the 
 uterus, and from the larger size of the body to be expelled. Some- 
 times the child, when small, is even expelled with the membranes 
 intact. It then quickly perishes from asphyxia, unless the sac is 
 artificially ruptured. A child born with the membranes over its 
 head is j)opularly said to be born with a " caul." ^ 
 
 When the child is born with a caul, or even when the bag of 
 membranes descends far in advance of the presenting part, special 
 care should be taken to see that none of the chorion is left behind 
 in the uterus. For the amnion usually presents alone in such 
 cases, separated from the chorion (see p. 223) ; and the aid to the 
 separation of the chorion, afforded by its attachment to the amnion, 
 thereby fails. 
 
 Undue Shortness of the Funis. — Obstruction to labour may 
 arise from either actual or relative shortness of the funis, but much 
 more commonly from the latter. Eelative shortness arises from 
 
 1 From calea, a helmet. 
 
Labour Obstructed by Anomalies of Ovum. 695 
 
 the funis being wound round some part of the foetus, generally- 
 round the neck. Thus an actually long funis, when wound two or 
 three times round the neck, may become a relatively short one. 
 Moreover, since the neck is as much as three inches further from 
 the placental insertion than the umbilicus, the available length has 
 to be so much the greater when the funis is round the neck, if no 
 obstruction is to arise. According to Matthews Duncan's experi- 
 ments,^ the average length of a normal funis was found to be 
 17| inches, and the average stretching under tension before 
 breakage amounted to one-sixth of the original length. The 
 average breaking strain was 8 J lb., the weakest funis requiring 
 51 lb., the strongest 15 lb., to break it. The breaking strain 
 gives the limit to the force obstructing labour which a funis 
 can exert. 
 
 Extreme actual shortness, such as a length of four inches or less, 
 is excessively rare. Monsters occur, however, in which there is no 
 funis, the extroverted viscera being in direct contact with the 
 placenta. In such cases even the earlier part of the expulsive 
 stage of labour might be affected. In general the placental as well 
 as the foetal attachment descends to some extent in the earlier part 
 of labour, and the funis is therefore less likely to be put early upon 
 the stretch. It is very rare for the funis to cause obstruction before 
 the birth of the head, or that of the breech in pelvic presentations. 
 More commonly obstruction arises after birth of the head, and still 
 more commonly after that of the shoulders, the cause being generally 
 the winding of the funis round the neck. 
 
 Results and Terminations. — The result may be rupture of the 
 funis, separation of the placenta before delivery, or inversion or 
 partial inversion of the uterus. Inversion has been recorded as 
 due to this cause, but is very rare, since the funis is only put on 
 the stretch when the uterus is acting, and therefore not prone to 
 become inverted. Probably it could only occur through artificial 
 traction. The most common result, if the funis is wound round the 
 neck, and no artificial relief is given, is that birth takes place by a 
 kind of spontaneous evolution. The neck is fixed under the pubic 
 arch by the tight funis. The tension causes a partial undoing of 
 the twist round the neck, and so rotates the foetus with its abdomen 
 forward. Then evolution takes place by a rotation of the body 
 round the point where the neck is fixed by the funis as a centre, 
 accompanied by a doubling up, the body coming down posteriorly. 
 
 1 " On S?iortncsH of tfie Cord as a CauHC of Obstruction to the Natural I'rogress of 
 Labour," Trans. Obst. Soc. London, 1881, Vol. XXIIL, p. 248. 
 
696 The Practice of Midwifery. 
 
 It is somewhat analogous to spontaneous evolution in shoulder pre- 
 sentation, where the rotation is round the point where the neck is 
 fixed against the pelvic brim. The fcetus may be asphyxiated 
 meantime by the pressure of the funis round its neck, together with 
 the retention of the chest within the vagina. 
 
 Diagnosis. — In the rare case of obstruction caused by the funis 
 before delivery of the head, diagnosis is difficult. Shortness of the 
 funis may be suspected if the head is arrested, though not tightly 
 grasped in the genital passages, and recedes in a marked way in 
 the interval of pains, still more if, in addition, ante-par turn 
 haemorrhage occurs when the head is in the vagina, not accounted 
 for by vaginal or cervical laceration. A coil of the funis round the 
 neck may possibly be detected on rectal examination. In general, 
 the head would have to be delivered by forceps without exact 
 diagnosis of the cause of delay. In pelvic presentation, tension of 
 the funis would be more easily detected, the hand being passed up 
 to ascertain the cause of difficulty. One of the symptoms given 
 is special pain at the placental site during a uterine contraction, 
 or when traction is made on the foetus. There may possibly be a 
 recognisable depression at the placental site, if traction is made on 
 the fcetus when the uterus is lax. Dr. Braxton Hicks ^ has recorded 
 a case in which a funis only four inches long had to be divided 
 within the uterus. 
 
 Treatment. — As soon as the head appears, if a coil of the funis 
 round the neck is discovered, the funis should be drawn down as 
 much as possible so as to slacken the looj), and the loop or loops 
 passed over the head, or, if this is impossible, over the shoulders. 
 If it is too late thus to release the coil, or if the pains are too rapid 
 and violent to allow it, and the funis is drawn tight, or impedes the 
 advance of the child, the funis should be divided with scissors. 
 The fcetal end may be compressed between the finger and thumb 
 until after the delivery of the child, accelerated, if necessary, by 
 traction, and then it should be tied in the usual way. Impediment 
 due to absolute shortness of the funis should be treated in the 
 same way by division. 
 
 1 Trans. Obst. Soc. London, 1881, Vol. XXIII., p. 253, 
 
Chapter XXIX- 
 ANOMALIES OF THE PELVIS. 
 
 Enla7'ged Pelves. 
 
 A PELVIS larger than the normal may occur simply as a part of 
 the general large size of the body. In general, however, it is not 
 specially tall women who have large pelves, but rather those who 
 are broad, and have the feminine characteristics well marked, 
 sometimes even though they may be below the average height. 
 Tall muscular women often have a pelvis rather small in propor- 
 tion to their size. A large pelvis is generally normal in its 
 proportions, and is then called the Pelvis ALquabiliter Justo Major. 
 In some cases there may be an exaggerated development of the 
 special characteristics of the female pelvis, particularly of the 
 relatively wide transverse diameter. In cases of double uterus, a 
 marked increase in the transverse diameter has been noted. 
 
 An enlarged pelvis cannot be regarded as a pathological con- 
 dition. The only disadvantages likely to arise from it are the 
 inconveniences which may result from precipitate labour. On the 
 whole it may be considered an advantage to have a pelvis above 
 the average size. It has been stated that labour is not necessarily 
 easy in large pelves, because from want of close adaptation the 
 head may fail to undergo the usual rotations. These rotations, 
 however, depend to a considerable extent on the soft parts, and it 
 appears that the head does undergo them, so far as is necessary for 
 its easy delivery. 
 
 Contracted Pelves. 
 General Forces concerned in the Production of Pelvic 
 Deformities. — The forces upon which the shape of the pelvis 
 chiefly depends are the vital forces of growth and development, 
 the effect of the body-weight and the resistances which it calls out, 
 and the pressure and traction of muscles and ligaments. The 
 results of these may be seen in all forms of deformed pelves as 
 well as in the development of the normal pelvis. When the bones 
 are softened, the effects of the mechanical forces are exaggerated. 
 In many forms of distortion the shape of the pelvis depends 
 upon the alteration of the points of application of the mechanical 
 
698 The Practice of Midwifery. 
 
 forces owing to some local want of development or disease, or to 
 deformities or injuries of the spine or limbs. 
 
 In relation to the views, already mentioned, of Breus and Kolisko,^ 
 in regard to the development of the pelvis and the large part 
 played by the normal forces of the growth of the bones, it is 
 necessary to see what effect their views will have in elucidating 
 the etiology of contracted pelves. They maintain that a very 
 important factor is the maldevelopment of certain portions of the 
 bones composing the pelvis, especially the ilium and the sacrum. 
 They consider that the shortening of the conjugate diameter of the 
 brim is rather to be explained by an imperfect development of the 
 iliac portion of the innominate bone than by any displacement or 
 rotation, the result of mechanical causes, of the sacrum. At the 
 same time they hold that there is not that marked rotation of 
 the sacrum which has been described, but that the alteration in 
 the position of this bone is due rather to a want of the displace- 
 ment backwards of the sacro-iliac joint which should occur in the 
 normal development of the pelvis. 
 
 No doubt the imperfect development of different portions of the 
 component bones of the pelvis plays an important part in the pro- 
 duction of various kinds of deformed pelves, but at the same time 
 it is impossible to ignore the effect of various mechanical causes 
 acting on the bones. 
 
 The mechanical forces which influence the shape of the normal 
 pelvis in growth from infancy to adult life, and the exaggerated or 
 uncounteracted or one-sided influence of which is concerned in the 
 production of many pelvic deformities, have already been described 
 (see pp. 25 — 33). The reader is recommended to refer back to 
 that description before reading the account of the mode of pro- 
 duction of the varieties of deformed pelvis. Certain influences 
 which are in action in the formation of all varieties of pelvis will 
 here be briefly recapitulated. 
 
 (1.) Effect of the Pelvic Inclination. — If pelvic inclination 
 is increased beyond the normal angle, the sacrum tends to sink 
 more towards the centre of the pelvic brim, and the effect, both of 
 the body- weight and of the traction of the abdominal muscles, in 
 widening the pelvis transversely and flattening it antero-posteriorly, 
 is increased. If pelvic inclination is diminished, the contrary effects 
 are produced, and the tendency is to increase the antero-posterior 
 and diminish the transverse diameter of the pelvis. At the same 
 
 ^ Breus and Kolisko, Pathologischen Beckenformen, 1900. 
 
Anomalies of the Pelvis. 699 
 
 time the sacrum tends to sink down more deeply between the ilia 
 in the direction of the coccyx. 
 
 (2.) Effect of Standing, Walking, etc. — The effect of standing, 
 walking, or running is to call into play the inward pressure of the 
 heads of the femora upon the acetabula due to muscular action 
 (see p. 28), as well as the reaction to the body- weight. Hence the 
 tendency of the body-weight to widen the pelvis through the 
 leverage exerted upon the innominate bones (see p. 27) is resisted 
 by the inward pressure at the acetabula more in children who 
 stand, walk, and run much than in those who are constantly sitting. 
 This principle is especially illustrated by the form of almost 
 uniformly contracted, not flattened, pelvis, occasionally met with 
 as the result of rachitis, as contrasted with the usual flattened 
 rachitic pelvis. Such a form of pelvis is attributed to the occur- 
 rence of rachitis at rather a later age than usual, so that the 
 child is not constantly sitting, but standing and moving about. 
 
 If one or both acetabula are for any cause displaced inwards 
 towards the middle line, the effect of the reaction to the body- 
 weight is altered. It has been already explained that this reaction 
 is directed vertically upwards (see p. 28). Its effect upon the shape 
 of the pelvic brim depends upon that of its component resolved in 
 a plane parallel to the brim (see Fig. 25, p. 27). If the acetabulum 
 is nearer the middle line than the sacro-iliac joint the line of this 
 force will fall inside the fulcrum of the lever instead of outside, 
 and the force will therefore tend to thrust the lower end of the 
 lever inwards instead of outwards. Hence, if an acetabulum is 
 displaced inwards nearer to the middle line than the sacro-iliac 
 joint, the reaction to the body- weight assists the inward thrust of 
 the muscular force acting on the femur instead of tending to 
 counteract it. If the acetabulum is displaced inwards in any degree 
 at all, the counteracting force to the inward thrust is diminished. An 
 instance of this effect occurs, as will shortly be described, on both 
 sides in the triradiate pelvis, whether of the malacosteon or 
 pseudo-malacosteon form, on one side in the various forms of 
 oblique pelvis. 
 
 Effect of Sitting. — It has already been explained (see p. 30) 
 that, in sitting, the body-weight tends to widen the whole pelvis 
 by the leverage it exerts on the innominate bones, and also that 
 the reactions to the body-weight through the tubera ischii tend to 
 rotate the lower part of each innominate bone outwards on an axis 
 
700 The Practice of Midwifery. 
 
 joining the centres of the symphysis pubis and sacro-iliac synchon- 
 drosis, and so specially to widen the pelvic outlet, increasing the 
 distance between the tubera ischii, and widening the pubic arch. 
 In the case of congenital absence of the legs, where the woman 
 can sit, but not stand, the pelvis, both at brim and outlet, has 
 been found wider than normal, the inward thrust at the acetabula 
 being wanting. 
 
 As in the case of the acetabula, the action of the force is 
 diminished, and eventually reversed, if the tuber ischii is displaced 
 inwards. If the tuber ischii lies nearer the middle line than the 
 sacro-iliac joint, the tendency will be to thrust the anterior end of 
 the innominate bone inwards instead of outwards ; if it lies inside 
 the line joining the centres of the symphysis pubis and sacro-iliac 
 synchondrosis, the tendency will be to rotate the lower part of 
 the innominate bone inwards instead of outwards. If the usual 
 widening effect is merely diminished owing to partial displacement 
 inward of the tuber ischii, the inward tension of the sacro-sciatic 
 ligaments may be sufficient to overcome it. On the contrary, if 
 the pelvis is wider than normal, the tendency of sitting to widen 
 the outlet is yet further increased. Hence the general rule is that 
 a pelvis relatively wide at the brim is still wider at the outlet, and 
 a pelvis transversely contracted at the brim is still more contracted 
 at the outlet. The principle is also illustrated both in the triradiate 
 pelvis, and in oblique pelves. 
 
 Diagnosis of Pelvic Contraction. — The general diagnosis of 
 pelvic contraction will be considered before the special varieties of 
 pelvis are described. General indications, such as may be obtained 
 from a person's aj)pearance, denote usually simply the probability 
 that some pelvic deformity may exist rather than its nature or 
 degree. They are chiefly of use in showing, in the case of a 
 woman pregnant for the first time, when it is desirable to make a 
 local examination as to the capacity of the pelvis before the full 
 term arrives, and so possibly avoid a very difficult and dangerous 
 delivery by the induction of premature labour or other means. 
 Such indications consist in smallness of the whole figure, especially 
 if accompanied by slenderness, relative shortness of limbs, pointing 
 to the probability of rachitis, spinal curvatures, lameness, especially 
 if due to shortness of one leg, undue hollowness of the back, 
 pointing to the probability of excessive pelvic inclination, any 
 other deformity affecting the back or legs, and in a primipara a 
 pendulous abdomen and non-fixation of the head in the brim in 
 the last few weeks of pregnancy. Attention should be paid to any 
 
Anomalies of the Pelvis. 
 
 701 
 
 history of rickets, or other disease of bones, or of any disease or 
 injury affecting the back, pelvis, or legs. Rickets may also be 
 revealed by curvature and thickening of the tibiae. If previous 
 deliveries have occurred, the history of the course of parturition 
 is the most important guide of all. 
 
 Pelvimetry. — For the exact diagnosis of pelvic deformity, it is 
 necessary to take certain external and internal measurements. 
 The external measurements are obtained with ease, but do not 
 allow any exact inferences to be made as to the size of the pelvic 
 canal, which is the only point of real importance. They are of 
 value, because they not only give evidence, in many cases, of the 
 existence of deformity in the canal, although not of its precise 
 degree, but often indicate the general character of the pelvic 
 distortion, as, for instance, that it is due to rickets, or that oblique 
 
 Fig. 346. — Pelvimeter. 
 
 distortion exists. The form of pelvimeter used for external 
 measurements is shown in Fig. 346. It is simply a modifica- 
 tion of the ordinary callipers used by carpenters, having an 
 index near the hinge, from which the distance separating the 
 points can be read off. One arm may be made straight, if it is 
 desired to have an instrument which may be used for measuring 
 the thickness of the bones, with one arm in the vagina and one 
 outside. The internal measurements are of most direct import- 
 ance, but are more difficult to obtain with exactness. Various 
 pelvimeters have been invented for taking them, but on the whole 
 the fingers are to be preferred to any, and therefore no description 
 of these special forms will be given. The fingers can be used with 
 less pain to the patient, and being sentient, are less likely to lead to 
 the fallacy which may arise, if the points of the pelvimeter are 
 not in reality exactly where they are supposed to l)e. 
 
 External Measurements, — The most important of the external 
 
702 The Practice of Midwifery. 
 
 measurements are two, the distance between the anterior superior 
 spines of the ihum (Dist. Sp. II,), and the maximum distance 
 between the outsides of the iliac crest (Dist. Cr. II.) . These distances 
 are normally about 10 inches (25 cm.) and lOf inches (26*8 cm.) 
 respectively. For the measurement the patient is placed on her 
 back, and may be covered with a thin garment. For the first 
 measurement the tips of the callipers are placed outside the spines. 
 For the second the callipers are set at the smallest width which 
 will allow them to pass over the widest part of the crests, or over 
 their centres about 2^ inches (6 cm.) posterior to the spines, 
 if the spines are wider apart than any other portion of the crests. 
 
 Contraction of the pelvis may be indicated by one of two 
 things. (1.) The distances may both be less than normal. 
 (2.) The relation between them may be altered in such way 
 that either the distance between the spines is greater than the 
 distance between the crests at any other point, or at any rate is 
 not exceeded in the usual proportion by the maximum distance 
 between the crests. If the spines are wider apart than any other 
 part of the crests, the pelvis is flattened and rachitic, with a 
 greatly contracted conjugate diameter. If even the excess of the 
 maximum distance over that between the spines is less than in 
 due proportion, the pelvis is probably flattened and rachitic. 
 One exception to this rule, however, occurs in some cases of the 
 rachitic generally contracted pelvis, in which the relation between 
 the two distances is altered in this way, but the pelvis is not 
 flattened. If not only the relation of the two distances is altered, 
 but the mean of the two is too small, there is a generally con- 
 tracted pelvis, which is also probably flattened. If, on the other 
 hand, the due relation between the two distances is preserved, 
 but both are smaller than the normal, there is jDrobably a generally 
 contracted pelvis, without flattening. There may also be one of 
 the rarer forms of pelvis, contracted in the transverse diameter ; 
 but in this case the external conjugate diameter will be above 
 rather than below the average ; while, in the generally contracted 
 pelvis, it is below the average. 
 
 The transverse diameter of the brim may be roughly calculated 
 from the transverse diameter of the false pelvis. If the measure- 
 ment is taken, not as usual from the outside, but from the summit 
 of the iliac crests, half its magnitude will give the transverse 
 diameter of the pelvic brim, with only a slight margin of error. 
 
 The external measurement next in importance, but of inferior 
 value to these transverse diameters, is the external conjugate 
 diameter (C. Ext.). In measuring this, the patient is placed 
 
Anomalies of the Pelvis. 703 
 
 upon her side ; one point of the callipers is placed in front of the 
 top of the symphysis pubis, the other just below the spinous process 
 of the last lumbar vertebra. The external conjugate is on the average 
 about 7^ inches (18'7 cm.). The object of measuring this distance 
 is to calculate from it the probable size of the internal true conjugate 
 diameter. It does not, however, lie exactly in the pelvic brim, 
 for the plane of the brim passes above the spinous process of the 
 last lumbar vertebra, as may be seen from the frozen section. 
 Fig. 131, p. 220. Moreover, the amount to be deducted from the 
 thickness of the bones and soft parts varies very widely in different 
 cases, the difference being as much as an inch, or even more. 
 Especially in the rachitic pelvis, the thickness of the sacrum, where 
 the projecting promontory is formed, is apt to be greater than 
 usual. The thickness of the external soft parts is also variable. 
 Hence moderate values of the external conjugate, such as those 
 between 7 (17-5 cm.) and 7 J inches (18-7 cm.), give little information 
 about the state of the pelvis. It is only from more extreme values 
 that any positive conclusions can be drawn, and even then only as 
 to the fact of contraction or its absence, and not as to the degree. 
 Thus if the external conjugate measures over 7^ inches (18'7 cm.), 
 it is pretty certain that there is no flattening ; if it is under 7 inches 
 (17'5cm.), a contracted conjugate may be inferred. 
 
 It is indeed possible to measure separately the portions to be 
 deducted from the external conjugate at its anterior and posterior 
 parts by placing one arm of the callipers inside the vagina, and 
 the other outside the body, and then get the true internal conju- 
 gate by deducting these from the external conjugate. This can 
 be done tolerably well in some cases to obtain the thickness of 
 the sacrum and soft parts covering it. But it is scarcely possible 
 to get the internal arm of the callipers sufficiently high on the 
 internal surface of the symphysis pubis to measure the thickness 
 of the anterior pelvic wall with accuracy. This method, therefore, 
 probably does not give the true conjugate with so great accuracy 
 as. that of deducting it from the diagonal conjugate, measured 
 internally. If the method is used, the callipers should have one 
 arm curved, as in Fig. 346, p. 701, the other straight or nearly 
 straight. The curved arm should be introduced into the vagina 
 to place against the promontory of the sacrum, the straight arm 
 to measure the thickness of the pubes. 
 
 When a transverse contraction or asymmetry of the pelvis from 
 want of development of both or of one wing of the sacrum is 
 suspected, the transverse distance between the posterior superior 
 spines of tlie ilia is a measurement of some value, since it gives 
 
704 The Practice of Midwifery. 
 
 some indication whether or not the sacrum is narrower than 
 usual. Its average magnitude is about 5 inches (12*5 cm.). 
 
 Certain oblique external diameters should also be measured 
 when an oblique pelvis is suspected. These will be mentioned in 
 the account of the diagnosis of the oblique pelvis. In the com- 
 paratively rare case of contraction of the pelvic outlet, the antero- 
 posterior diameter of the outlet is obtained by measurement with 
 the index finger, introduced into the vagina, the radial border 
 pressed against the apex of the pubic arch. It is measured from 
 the apex of the pubic arch, at its internal surface, to the tip of 
 the sacrum, not to the tip of the coccyx, unless that bone is 
 anchylosed to the sacrum. It may also be measured by callipers, 
 one point being placed on the apex of the pubic arch and the other 
 on the posterior surface of the lower extremity of the sacrum ; the 
 deduction of 1'5 cm. will give the true measurement. More 
 important than this is the so-called posterior sagittal diameter of 
 the outlet, which is measured from the centre of the transverse line 
 joining the two ischial tuberosities to the lower end of the sacrum 
 (see p. 784). The transverse diameter is measured between 
 the internal margins of the tubera ischii. It may be measured 
 either by callipers or by a straight rule, the patient being placed on 
 her back or on her side. The average normal magnitude of the 
 former diameter is about 4| inches (10'7 cm.), of the latter about 
 4J inches (10*35 cm.). 
 
 External examination also reveals, apart from the measure- 
 ments, certain general facts about the pelvis, such as the 
 massiveness of the bones, development of prominences for 
 attachment of muscles, direction of iliac fossae, whether the whole 
 pelvis is symmetrical, whether the spine is straight and the legs 
 equal, and whether there is any deviation from the usual position 
 of the great trochanters, or of the sacrum in relation to the 
 innominate bones. 
 
 Internal Measurements. — ^The most important object in internal 
 measurement is to obtain an estimate of the true conjugate 
 diameter, since this is the diameter of the pelvic brim which is 
 most frequently contracted, and the contraction of which has the 
 greatest obstetric importance. By the term true conjugate will 
 be here understood what is sometimes called the obstetric true 
 conjugate, namely, the line drawn from the promontory of the 
 sacrum to the nearest point on the inner surface near the top 
 of the symphysis pubis (e f. Fig. 22, p. 21), not the line from 
 the promontory of the sacrum to the centre of the top of the 
 
Anomalies of the Pelvis. 
 
 705 
 
 symphysis pubis. It is the former distance alone which has any 
 practical significance. 
 
 The distance actually measured is the diagonal conjugate (b n, 
 Fig. 22, p. 21), or sacro-subpubic diameter. From this the true 
 conjugate has to be inferred. For measurement of the diagonal 
 conjugate the patient may be placed on the left side, or on the 
 back, the hips raised on a folded blanket. Two fingers, or four 
 fingers, if the vagina is capacious enough to allow it, as in the 
 
 Fig, 347, — Measurement of diagonal conjugate. 
 
 first stage of labour, are introduced into the vagina and directed 
 upwards behind the cervix, depressing the posterior vaginal cul-de- 
 sac until the tip of the finger touches the sacrum (see Fig. 347). 
 The fingers are then still raised until the angle formed by the 
 promontory of the sacrum is recognised and the tip of the middle 
 finger rested upon it. For this the fingers have to be directed 
 nearly vertically upward in the axis of the trunk. The left 
 hand is often used internally, as it is easier to mark ofi^ with 
 the index finger of the right hand the exact spot in the radial 
 border of the left hand corresponding to the lower border of the 
 M. 45 
 
7o6 The Practice of Midwifery. 
 
 symphysis pubis. The angle the diagonal conjugate makes with 
 the vertical axis of the body is about 20° in the normal pelvis, the 
 pelvic inclination to the horizon being taken as 55°. If the pelvic 
 inclination is greater, and the promontory of the sacrum therefore 
 higher, as it sometimes is in a flattened pelvis, the fingers must be 
 directed still more vertically upwards. Care must be taken not to 
 mistake for the promontory of the sacrum a slightly projecting 
 angle which sometimes exists between the first and second sacral 
 vertebrae. The tip of the middle finger resting then upon the 
 promontory, the hand is slightly raised, so as to press the radial 
 side of the index finger, or the side of the hand, against the apex 
 of the pubic arch. The point of contact is then marked with the 
 finger-nail of the disengaged hand, the hand is removed from the 
 vagina, the finger-nail being kept upon it, and the distance from 
 the marked point diagonally to the tip of the middle finger measured 
 with a rule. This gives the diagonal conjugate. It is rather 
 difficult to mark the exact point with the nail while the finger is 
 closely pressed against the pubic arch. It is still better, therefore, 
 if the perceptive faculty of the radial side of the finger can be so 
 educated that it retains the impression of the exact spot cut by the 
 apex of the pubic arch until the hand is removed from the vagina, 
 and the finger-nail is then placed upon this spot. If there is any 
 doubt of the exact point, the mean should be taken of the estimates 
 derived from several trials. 
 
 In the normal dry pelvis the promontory of the sacrum can 
 always be reached in this way with two fingers, but in the 
 living woman the soft parts generally prevent it, in the absence 
 of contraction, unless an angesthetic is given. As a general rule, 
 however, if the fingers can be introduced a fair distance, and 
 the promontory cannot be reached, it may be inferred that there is 
 no great contraction of the conjugate diameter. The length of the 
 fingers must of course be taken into consideration. In a flattened 
 pelvis, the promontory of the sacrum can often be felt by the 
 index finger alone, and it is then better to measure the diagonal 
 conjugate by introducing that finger only. If the promontory 
 can be easily reached in this way, it may generally be inferred 
 that considerable contraction exists. 
 
 The diagonal conjugate (e n, Fig. 22, p. 21) being known, the 
 true conjugate, or the side e f of the triangle e f n, has to be 
 deduced from the two sides e n, n f. The angle e f n, between 
 the symphysis pubis and the plane of the brim, is almost always 
 an obtuse angle. It is evident that the difference between the sides 
 E N and E F will be greater, the greater is the side f n, or the 
 
Anomalies of the Pelvis. 707 
 
 height of the symphysis pubis, and the greater also is the angle 
 E F N, or the inclination of the symphysis to the plane of the 
 brim. The average amount to be deducted from the diagonal 
 conjugate to get the obstetric true conjugate is about two-thirds 
 of an inch. Corrections for individual cases cannot be made with 
 absolute exactness, but a general estimate may be formed. The 
 height of the symphysis may be directly measured. If it 
 amounts to, or exceeds, an inch and a half, the inclination of 
 the symphysis being assumed normal, the deduction may be 
 estimated at f inch at least, instead of § inch. Some increase in 
 the deduction must also be made if it is judged that the pro- 
 montory stands higher than usual, or that the direction of the 
 symphysis pubis is more vertical than usual. In the reverse cases 
 
 B 
 
 Fig. 348. — Diagram for calculation of true conjugate diameter. 
 
 a deduction of f inch may be rather too much, the difference 
 being sometimes under J inch. The difference is likely to 
 be greatest in the case of a very greatly flattened pelvis with 
 excessive pelvic inclination. It may then reach and even exceed 
 1 inch.^ 
 
 Direct Measurement of True Conjugate. — The true conjugate 
 itself can be directly measured by two methods, which are of great 
 value, but can only be applied under exceptional circumstances. 
 
 1 The following construction gives a more exact result (see Fig. 348). Draw 
 a line A B equal to the height of the symphysis pubis. From the point A draw A c, 
 making an angle of 110'' with A B. From the centre B, draw a circle having a radius 
 equal to the length of the diagonal conjugate, cutting the line A C in the point F. The 
 length A p will be the true conjugate. For this construction, a graduated circle is 
 required ; or the angle BAG may be traced from Fig. 348. The only element of 
 uncertainty is the magnitude of the angle BAG, which varies somewhat in different 
 cases, bat its average magnitude is about 110°. In the rachitic pelvis, it is often rather 
 less, owing to the diminished pelvic inclination, and may be taken as 100° on an 
 average. 
 
 45—2 
 
7o8 The Practice of Midwifery. 
 
 The first method (Hardie's) is, just after deHvery, to pass the whole 
 hand mto the pelvis within the cervix, and see how far the four 
 fingers side by side, or the breadth of the hand, will pass up in the 
 conjugate diameter. The point at which they are arrested is noted, 
 the hand withdrawn, and its breadth at that point measured with 
 a rule. In case of slight contraction only, the thumb may be 
 added, but diameters up to 3J inches can generally be measured 
 without it. It is not so well to measure the diameter by separating 
 the fingers, for it is difficult then to keep them in exactly the 
 same position during withdrawal. This method gives precisely 
 the conjugate diameter available for the passage of the foetus ; 
 and this may be recorded for use in future pregnancies. 
 
 External Measurement of True Conjugate. — Another method 
 (Johnson's^) is by measurement from outside ; and this can be used 
 only when the patient is not pregnant, the abdominal walls not too 
 thick, and the abdomen not very tense. The index finger is pressed 
 in above the pubes, and the abdominal wall carried before it, until 
 it rests on the promontory of the sacrum (at e. Fig. 22, p. 21). 
 The wrist is then depressed, and the point noted where the top of 
 the symphysis cuts the finger. This gives the distance from the 
 promontory to the centre of the top of the symphysis. Something 
 has to be added to the distance measured for the thickness of the 
 soft parts pushed before the finger, and something subtracted for 
 the thickness of the pubes, to get the obstetric true conjugate e f. 
 The addition and subtraction will nearly balance when the 
 abdominal walls are thin. 
 
 Other Results of Internal Measurement. — The true conjugate 
 diameter is the only dimension of the brim which can be estimated 
 at all accurately from internal examination. A general estimate, 
 however, can be obtained of the characters of the pelvis in many 
 other respects ; and it is in forming this estimate that the 
 experience and judgment of the observer are of most value. The 
 student, therefore, in every case of labour, as well as in vaginal 
 examinations apart from labour, should take the opportunity of 
 gaining practice in judging the usual pelvic dimensions. The 
 chief points to be noted are the following : — Whether the promon- 
 tory of the sacrum is exactly opi^osite the symphysis pubis ; 
 whether it forms a jDrojection encroaching on the space of the 
 pelvic brim, with hollows at each side of it, as in the reniform 
 pelvis, or only forms a part of a concave or flattened wall ; whether 
 there is ample space in the hollow of the sacrum, or whether the 
 
 1 R. W. Johnson, A System of Midwifery, London, 1769. 
 
Anomalies of the Pelvis. 709 
 
 sacrum is so flattened, without being divergent from the symphysis 
 pubis, that lower diameters, as well as the conjugate of the brim, 
 are likely to cause obstruction ; whether the lateral space in the 
 pelvis appears to be as large as usual ; and whether the space is 
 equal on the two sides of the promontory of the sacrum. 
 
 The measurement of the diagonal conjugate can be made in 
 pregnancy, or even in labour, if the head is still high in the pelvis, 
 or if it is so movable that it can be pushed up. If the head 
 has descended considerably into the brim, and is fixed there, even 
 though its largest diameters may not yet have entered the brim, 
 it may be impossible to measure the diagonal conjugate. It may 
 still be possible, however, to ascertain whether the promontory 
 of the sacrum encroaches upon the space of the brim or not, and 
 to form an estimate as to the symmetry of the pelvis, and the 
 lateral space in it. 
 
 It must always be borne in mind, especially in considering the 
 treatment of contracted pelves, that even more important than the 
 exact measurement of the diameters of the pelvis is the estimation 
 of the relation the size of the fcetal head bears to the size of the 
 pelvis. 
 
 Numerous methods and instruments have been devised from 
 time to time for the purpose of measuring the foetal head in utero. 
 None of them have, however, come into general use, as the results 
 obtained are either too inaccurate or their employment too difficult 
 or too painful to render them of practical value. The best clinical 
 method of determining the relation between the size of the foetal head, 
 and that of the pelvis is the one introduced by Miiller^ in 1885. In 
 this procedure the foetal head is pressed into the pelvic brim either 
 by the examiner himself or with the aid of an assistant, while, 
 with the fingers of the other hand introduced into the vagina, the 
 degree to which the head descends into the pelvic brim is estimated, 
 and also the amount of space which is available in relation to the 
 size of the head. In an intolerant patient it may be necessary to 
 administer an ansesthetic, and if the slight modification suggested 
 by Munro Kerr^ be adopted, and while the index finger is introduced 
 into the vagina the thumb is placed externally over the symphysis 
 pubis, it is possible to determine with great accuracy the amount 
 of overlapping of the pelvic brim by the head in cases where it 
 does not descend into the cavity of the pelvis. This method is of 
 the greatest possible value not only in determining the correct 
 time at which to induce premature labour, but in coming to a 
 
 1 i'. Miiller, Sairimlung Klin. Vortrage, 1885, No. 264. 
 
 ■-' .Muiiro Kerr, Jouni. (Jbst. and Gyn. Brit. Emp., I'JOiJ, Vol. 111., iNo. 4, p 341. 
 
7IO The Practice of Midwifery. 
 
 decision as to the best method of treating a case of contracted 
 pelvis, since the relation of the size of the head to that of the pelvis 
 is the most important factor in forming a correct judgment upon 
 this point. 
 
 The X-rays in the Diagnosis of Contracted Pelves. — Obstetricians 
 have attempted from time to time to make use of the X-rays in 
 determining the shape and size of the pelvis, but unfortunately 
 with little success. There are several difficulties, the chief of which 
 are that it is impossible to place the plate parallel to the plane of 
 the pelvic brim, or always at the same distance from it. For these 
 two reasons the results obtained, although they give a very fair idea of 
 the shape of the pelvis, yet are of no value for determining its exact 
 measurements. Various ingenious methods have been devised for 
 overcoming these drawbacks, but none of them are sufficiently 
 simple or accurate to render them of clinical value. 
 
 Varieties of Contracted Pelves. 
 
 Classification. — Most writers on the subject have formulated 
 some scheme of classification of contracted pelves. One of the best 
 and simplest is that of Schauta,^ who divides deformed pelves into 
 five main classes, dej)ending upon their causation. 
 
 Class 1. — Pelves abnormal as the result of faults of development. 
 
 Generally contracted pelvis, including the infantile, the masculine, 
 
 and the dwarf. 
 Simple flat, non-rickety pelvis. 
 Generally contracted, flat, non-rickety pelvis. 
 Narrow, funnel-shaj)ed pelvis. 
 Naegele oblique pelvis. 
 Eobert pelvis. 
 Justo major pelvis. 
 Split pelvis. 
 
 Class 2. — Pelves abnormal as the result of disease of the ijelvic bones. 
 Eickety. 
 Osteomalacic. 
 New growths. 
 Fracture. 
 Atrophy caries. 
 
 1 Schauta, Die Beckenanomalien ; P. Miiller, Handbucli der Gebuitshlilfe, 1889 
 Bd. 2. 
 
Anomalies of the Pelvis. 711 
 
 Class 3. — Pelves abnormal as the result of disease of the 
 sjnnal column. 
 Spondylolisthesis. 
 Kyphosis. 
 Scoliosis. 
 Kypho-scoliosis. 
 Assimilation. 
 
 Class 4. — Ahnoriiialities of the articulations of the hones of the pelvis. 
 
 Synostosis — 
 
 Of the symphysis pubis ; 
 
 Of the sacro-ihac articulations ; 
 
 Of the sacrum with the coccyx. 
 Imperfect union or separation — 
 
 Of the pelvic articulations ; 
 
 Of the sacrum with the coccyx. 
 
 Class 5. — Pelves abnormal as tJte result of disease of the lotver limbs. 
 
 Coxitis. 
 
 Dislocation of one or both hip joints. 
 
 Single or double club-foot. 
 
 Absence or curvature of one or both lower extremities. 
 
 The different forms of contracted pelvis, however, will here be 
 classified primarily according to their shape rather than according 
 to their causation, since it is the shape which is of main obstetric 
 importance. It is true that each of the characteristic shapes has a 
 special cause to which it is most frequently due, but the two methods 
 of classification do not give exactly parallel results. 
 
 There are three forms of contracted pelvis, which are met with 
 more frequently than the others, and are those which most usually 
 demand operative interference. These are the generally contracted 
 pelvis, including the allied varieties of the infantile, the dwarf, and 
 the masculine pelvis, the pelvis flattened without general contraction 
 and the generally contracted flattened pelvis. 
 
 The Generally Contracted Pelvis. 
 
 The generally contracted pelvis, or pelvis (equahiliter justo minor, 
 is the rarest of the three principal forms mentioned above. It is 
 characterized by a general diminution of all the diameters, but no 
 deviation, or but little deviation, from their relative proportion in 
 the normal pelvis. In its most perfect form it is seen in the pelvis 
 of women who are very small, or actual dwarfs, but not otherwise 
 
712 
 
 The Practice of Midwifery. 
 
 deformed. The pelvis may then have the perfect female type, but 
 in the case of true dwarfs, the parts of the pelvis may be found 
 
 Fig. 349. — Sagittal section of a normal pelvis. 
 
 united, not by bone, but by cartilage only, as in childhood. In 
 most cases, hoAvever, a pelvis which, from its general appearance, 
 is classed as a generally contracted pelvis is found, on minute 
 
 Fig. 350. — Sagittal section of a small round pelvis. 
 
 examination, to deviate slightly from the normal shape. Sometimes 
 the conjugate diameter is contracted in rather greater proportion 
 
Anomalies of the Pelvis. 
 
 713 
 
 than the rest, especially when rickets has existed as a cause. This 
 kind of pelvis forms a transition towards the generally contracted 
 flattened pelvis, and all grades between the two may exist. 
 
 The Infantile Pelvis.— In the majority of pelves approximating 
 to the type of the generally contracted pelvis, the characters point 
 to a partial arrest of development, the changes which take place in 
 the advance from the foetal to the adult pelvis not having taken 
 place to the full extent. Thus the sacrum is relatively narrow, its 
 curvature on transverse section is too great, on antero-posterior 
 section too little, its face does not look enough downward, its 
 posterior surface is not sufficiently sunk between the ilia, nor the 
 whole bone in the direction of the coccyx ; the pubic arch is not 
 fully expanded; the transverse diameter of the brim does not 
 exceed the conjugate in the 
 due proportion. When these 
 peculiarities are well marked, 
 the pelvis is called infantile. 
 The general size of the out- 
 let is apt to be small, funnel- 
 shaped, compared with that 
 of the inlet, as it is in the 
 fcetal or child's pelvis. But, 
 as already explained (see 
 p. 26), as regards the shaj)e 
 of the brim at any rate, the 
 pelvis would be more pro- 
 perly called childish than 
 
 infantile. Fig. 351 should be compared with the infant's pelvis 
 Fig. 23, p. 24. 
 
 The generally contracted or infantile pelvis may arise from any 
 disease or other condition which interferes with nutrition in child- 
 hood. Thus it may be the result of scrofula, cretinism, premature 
 hard work, or bad feeding. It is interesting to note that this variety 
 of pelvis was found by Whitridge Williams to occur in two-thirds of 
 the cases of contracted pelves in black women in Baltimore, as com- 
 pared with its occurrence in one-third of the cases of contracted 
 pelves in white women. He regards it as a result of the imperfect 
 physical development of the negroes living in large cities. It may 
 also arise from a form of rickets, protracted in time but not severe 
 in degree, so that it has the effect of interfering with bone growth, 
 without causing actual softening of the pelvic bones. A marked 
 form of infantile pelvis, with narrow pubic arch, and relatively 
 
 Fig. 351. — Infantile pelvis. 
 
714 The Practice of Midwifery. 
 
 small transverse diameter, is associated with congenital absence of 
 the uterus, or uterus and ovaries, but this is not of obstetric 
 interest. It appears, however, that an infantile pelvis, though 
 not so marked, may also be associated with that minor degree of 
 imperfect development of uterus and ovaries, in which menstrua- 
 tion is scanty, and begins late in life, the cervix uteri is conical 
 and narrow, the uterus often more anteflexed than usual, and the 
 woman often sterile. Dr. Eoper has related such a case, in which 
 pregnancy followed incision of the cervix uteri, but delivery could 
 only be effected with much difficulty. It has been supposed that in 
 some cases a generally contracted pelvis is due to premature bony 
 union of the parts of the pelvis, possibly the result of excessive 
 muscular work in early life. In other cases no cause for the 
 infantile form of pelvis can be discovered, and it must be ascribed 
 to some unknown congenital tendency, hereditary or otherwise. 
 In some cases an infantile shape of pelvis is associated with a size 
 not below normal, growth having gone on, though development has 
 failed. 
 
 The Rachitic generally Contracted Pelvis. — It has been 
 already mentioned that a simj)ly infantile pelvis may result from 
 a form of rickets which only impedes bony growth without 
 causing softening of the pelvis. There is also another form of 
 generally contracted pelvis due to rickets, in which some of the 
 changes in shaj)e of bones due to that disease are manifested. 
 The iliac fossae look forward, the relation between the Dist. Sp. II. 
 and Dist. Cr. II. is altered, the latter not exceeding the former by 
 the usual proportion, and there are signs of rickets in other bones, 
 as in the tibite, but the pelvis is not flattened. This form of pelvis 
 is generally described as due to the disease occurring compara- 
 tively late in childhood, after the child has begun to walk, the 
 tendency to widening and flattening being in consequence counter- 
 acted by the inward thrust at the acetabula. It must, however, 
 be also true that the disease has been so far mild in degree, that 
 neither the sacrum nor the iliac beams are sufiiciently softened 
 to bend. This form of pelvis is therefore to be contrasted with 
 the triradiate or pseudomalacosteon form of rachitic pelvis (see 
 Chapter XXX.), in which also the disease produces its effects after 
 the child has learned to walk, but in which the degree of softening 
 is greater instead of less than that which leads to the usual flattened 
 rachitic pelvis. 
 
 The Masculine Pelvis. — In strong muscular women, rather 
 tall in proportion to their breadth, especially those who have a 
 
Anomalies of the Pelvis. 715 
 
 somewhat masculine appearance from the growth of hah- on the 
 face, a variety of uniformly contracted pelvis is sometimes found, 
 showing some approximation toward the male type. The bones 
 are thick, the pelvis deep, prominences for muscles well marked, 
 the transverse diameter too small in proportion, and the outlet 
 comparatively narrow. 
 
 The Dwarf Pelvis. — Besides the true dwarf pelvis characterised 
 by the presence of cartilage uniting the bones, Breus and Kolisko 
 recognise the cretin dwarf pelvis and the hypoplastic dwarf pelvis. 
 The first, with its poorly developed bones, is the result of faulty 
 growth throughout early life, while the second is a normal pelvis 
 in miniature, but is completely ossified. 
 
 In the marked cases of general pelvic contraction all the internal 
 diameters of the pelvis may be reduced by as much as one-fourth 
 of their normal value. The difficulty in delivery may then be very 
 considerable, even after the performance of craniotomy. 
 
 Mechanism of Labour. — In minor degrees of contraction the 
 mechanism of labour is not altered, except that the flexion of the 
 head is apt to be extreme while it is passing through the brim, after 
 it has entered the cavity of the pelvis, owing to the want of space 
 for its longest diameter, and that the natural rotations may be 
 impeded by excessive friction. 
 
 Diagnosis. — All the external diameters are diminished in about 
 equal proportions, and the diagonal conjugate is also diminished. 
 On internal examination there is found to be diminution of lateral 
 space, but no encroachment by the promontory of the sacrum into 
 the area of the brim. The normal relation between the Dist. Sp. II. 
 and Dist. Cr. II. is unaltered, except in the rachitic form of the 
 generally contracted pelvis. 
 
 The Flattened Pelvis and the Generally Contracted 
 Flattened Pelvis. 
 
 In the former class of pelvis there is contraction of the conjugate 
 diameter, but no notable contraction of the remaining internal 
 diameters. In the latter, combined with the relative contraction 
 of the conjugate, there is general smallness of the whole pelvis 
 from failure of development. It is evident that if a full-sized 
 pelvis were flattened, its transverse diameter would be rendered 
 greater than normal. In point of fact, however, it is hardly ever 
 found that the transverse diameter is greater than normal in a 
 
7i6 
 
 The Practice of Midwifery. 
 
 flattened pelvis, and frequently it is, if anything, rather diminished. 
 Therefore, even in pelves reckoned merely as flattened, because 
 there is no notable contraction in the transverse diameter, there is 
 almost always, in reality, some lack of full development. 
 
 The flattened pelvis, whether generally contracted or not, may 
 be divided into two varieties, according to the shape of the brim, 
 the elliptic flattened pelvis, and the reniform or kidney -shaped 
 flattened pelvis. In the former the shape of the brim resembles 
 an ellipse flattened on the posterior side. The concavity of the 
 sacrum on transverse section is almost or entirely lost, but is not 
 
 Fig. 352. — Section of a normal pelvis parallel to and just below the inlet.^ 
 
 converted into a projection. In the latter the brim is kidney- 
 shaped (see Fig. 356, p. 719). The promontory of the sacrum 
 has sunk so far inward toward the brim as to form a rounded 
 prominence encroaching upon its area. This is the commoner 
 variety of the two. 
 
 By German authors a different division of flattened pelves is 
 made, namely, into the rachitic and non-rachitic flattened pelves. 
 It is admitted, however, that the form called non-rachitic, because 
 other characteristic peculiarities of rickets are absent, is often due 
 
 ^ Breus and Kolisl-vO, Die Pathologischen Beckenformen, 1904, Bd. 1, Th. 2, Fig. 143. 
 
Anomalies of the Pelvis. 
 
 717 
 
 to slight rickets. Moreover the division given above corresponds 
 to a difference in the mechanism of labour, while that into rachitic 
 and non-rachitic forms does not. 
 
 Causation, — The flattened pelvis without general contraction is 
 
 Fig. 353. — Section of flattened rachitic pelvis parallel to and just below the inlet.i 
 
 probably often due to slight rickets, causing some softening of the 
 sacrum, but not marked enough to produce the general peculiarities 
 
 Fig. 3.54. — Sagittal section of a rickety flat pelvis. 
 
 due to the disease. The fact that some slight failure of develop- 
 ment almost always exists is in favour of this view. The 
 dofoDuity is also ascribed to lifting or carrying heavy weights, 
 
 I Breus and Kolisko, he. cit., Bd. 1, Th. 2, Fig. 144. 
 
7i8 
 
 The Practice of Midwifery. 
 
 such as babies, in childhood, either with or without the slight 
 rachitic tendency. Flattening is also produced by excess in the 
 pelvic inclination, for then the component of the body- weight 
 which acts in the plane of the pelvic brim is increased. The 
 excess of inclination may be due to an exaggeration of the normal 
 curves of the spine, a condition itself often the consequence either 
 of slight rickets, or of carrying weights in childhood, or of both 
 causes combined. Whether or not general contraction is present, 
 the elliptic flattened shape of the brim must be ascribed to the 
 effect of the body-weight, without marked softening of the sacrum ; 
 
 Fig. 355. — Upper half of a section parallel to the plane of the pelvic inlet, through a 
 normal and a rachitic innominate bone, showing the marked shortening and the 
 increased curvature of the iliac portion (1 — 2).i 
 
 when the sacrum is much softened the reniform shape is produced. 
 Hence, as a general rule, the greater part rickets has in the 
 causation, the more marked is the reniform shape. Sometimes, 
 however, a distinctly rachitic pelvis, with general contraction, has 
 the simply flattened shape either because the softening has not 
 specially picked out the sacrum, or because the disease has shown 
 itself more in arrest of development than in softening. The simple 
 flattening in such a case may have been produced by carrying 
 weights. The degree of contraction is seldom extreme in those 
 
 1 Breus and Kolisko, loc. cit., Bd. 1, Th. 2, Fig. 128. 
 
Anomalies of the Pelvis. 
 
 719 
 
 cases where its rachitic origin is not manifested by the peculiarities 
 in the pelvis generally produced by that disease, the conjugate 
 diameter being rarely less than 3 inches. 
 
 Breus and Kolisko^ lay great stress upon want of development 
 of the bones in the production of the flat pelvis. They maintain 
 that the shortening of the iliac portion of the innominate bone ^ is 
 one of the most characteristic signs of rickets, and that it is the 
 most important factor in the production of the flattening of the 
 rickety pelvis. In such a pelvis the shortening of this portion of 
 the bone is in striking contrast to the slight shortening of the sacral 
 portion, and to the practically normal length of the pubic portion. 
 
 The Rachitic Flattened Pelvis. — This is the most typical form of 
 rachitic pelvis. Usually there is general contraction as well as 
 
 Fig. 356. — Reniform rachitic pelvis. 
 
 flattening, in consequence of the retardation of development pro- 
 duced by the disease, and, in the higher degrees of contraction, 
 this is always the case. The bones are usually small and thin, 
 but there may be compensatory hypertrophy in parts. Thus the 
 thickness of the sacrum may be increased, and the difference 
 between the external conjugate and true conjugate diameters 
 therefore greater than usual. The brim has the reniform more 
 frequently than the elliptic shape, owing to the softening of 
 the sacrum itself (Fig. 356). In the rachitic pelvis, most of 
 the changes in shape which occur in the advance from the fcetal 
 to the adult pelvis from mechanical influences are exaggerated. 
 
 1 Breus and Kolisko, loc. ait., Bd. J, Th. 2, p. 45.5. 
 
 2 The iliac portion of the os innominatum corresponds in extent to the iliac portion 
 of the ilio-pectineal line extending from the anterior margin of the auricular surface to 
 the ilio-pectineal eminence. 
 
720 
 
 The Practice of Midwifery. 
 
 The pubic arch is more widened, the relative size of the transverse 
 diameter of the brim, and of the distance between the tubera 
 ischii, is more increased. The sacrum sinks more deeply between 
 the ilia both toward the brim and in the direction of the coccyx, 
 and as a result of its displacement downwards and forwards there 
 
 is a deep depression over the 
 sacral spines. The promontory 
 is more rotated forwards, so that 
 the anterior surface looks more 
 downwards, and the curvature 
 on antero-posterior section is 
 usually increased, but in some 
 cases the bone is almost straight 
 on vertical section (Fig. 360, 
 p. 722). The curvature on trans- 
 verse section is diminished and 
 generally converted into a con- 
 vexity toward the brim. 
 
 These effects are due to the 
 fact that the bones are softened, 
 but not so much so as to prevent 
 their acting as beams or levers. 
 The softening affects chiefly the 
 growing extremities and the car- 
 tilage about to form bone, so that 
 the yielding takes place mainly 
 at certain points, as between the 
 centre and wings of the sacrum. 
 If the softening is more extreme, 
 affecting the whole of the bones, 
 so that they can no longer act as 
 levers, a totally different form of 
 pelvis, resembling that of mala- 
 costeon, is produced (see Chap- 
 ter XXX.), the acetabula being 
 pushed inwards. 
 
 The relative widenina; of the 
 
 Fig. 357. — Skeleton of a rachitic dwarf 
 with contracted pelvis. 
 
 pelvis, especially at the outlet, is explained by the fact that the 
 effects of the disease on the pelvis are mainly produced before the 
 child can walk or stand much, and that therefore the counter- 
 pressure at the acetabula has little influence. The widening then 
 is chiefly due to the effect of the body-weight in the sitting position 
 calling out the leverage of the innominate bones (see pp. 23 — 26), 
 
Anomalies of the Pelvis. 721 
 
 and to that of the counter-pressure on the tubera ischii in rotating 
 outward the lower part of the innominate bones (see p. 26). The 
 bending inward of the lower end of the sacrum so as to increase 
 the curvature of the bone on antero-posterior section is partly due 
 to the resistance of the sacro-sciatic ligaments to the rotation for- 
 wards of the promontory, and to muscular action, but is assisted 
 also by the effect of the pressure on the lower end of the bone in 
 sitting (Fig. 26). 
 
 The shape of the iliac fossae is characteristic, and has been 
 already referred to as valuable in diagnosis. They are flatter 
 than usual, and look more forward, so that the maximum distance 
 between the crests does not much exceed that between the spines. 
 
 Fig. 358. — The outlet of a rickety flat pelvis. 
 
 In cases of marked deformity, the distance between the spines 
 is the widest diameter. This shape of the ilia appears to be 
 partly due to arrested development, but partly also to the action 
 of the gluteal muscles. There are other minor points by which 
 the effect of rickets is shown, such as eversion of the edges 
 of bone to which muscles are attached, especially those of the pubic 
 arch, and of the ischia, and sharpness of the ilio-pectineal line. 
 Bony projections are sometimes present, forming the so-called pelvis 
 spinosa. 
 
 The general effect is to produce a shallow pelvis, the transverse 
 diameter of the brim relatively wide, but in most cases absolutely 
 more or less below the normal, the outlet less contracted than the 
 inlet in all its dimensions, and sometimes even actually expanded. 
 This wideness of the outlet and shallowness of the pelvis facilitates 
 
 M. 46 
 
722 
 
 The Practice of Midwifery. 
 
 the access to the foetus in the case of difficult delivery after 
 craniotomy. The promontory of the sacrum is not uncommonly 
 displaced somewhat to one side in consequence of a scoliosis 
 (lateral curvature) of the spine. The pelvis then partakes of the 
 characters of the oblique pelvis, hereafter to be described (see 
 Chapter XXX.). 
 
 In some instances the body of the first sacral vertebra is dis- 
 placed forwards to a very marked degree, and its lower border forms 
 a projection, the so-called false promontor3^ It is important to 
 recognise such a condition clinically, as the distance from it to the 
 
 Fig. 359. — Median section through a flat rachitic pelvis. ^ 
 
 upper border of the symphysis pubis may be the shortest antero- 
 posterior diameter of the brim. 
 
 In the rachitic pelvis the inclination of the brim to the horizon 
 is generally somewhat diminished. This may be explained on 
 two grounds. First, on account of the sinking of the sacrum 
 deeper toward the coccyx. Secondly, owing to the sinking 
 of the sacrum into the brim, the line of action of the body- 
 weight falls anteriorly to the sacro-iliac joints. The counter- 
 pressures to the body-weight therefore at the acetabula or the 
 tubera ischii, which must necessarily act in the same transverse 
 vertical plane as the body-weight to produce equilibrium, tend to 
 rotate the anterior part of the pelvis upward on a transverse axis 
 passing through the sacro-iliac joints. Thus, while an increase of 
 the pelvic inclination in any pelvis tends to cause the sacrum to 
 
 1 Breus and Kolisko, loo. cit., Bd. 1, Th, 2, Fig. 135. 
 
Anomalies of the Pelvis. 
 
 723 
 
 sink forwards into the brim, such sinking forwards has a secondary- 
 effect, tending to diminish the pelvic inclination. There is often 
 a counterbalancing influence, tending to increase the pelvic 
 inclination in the rachitic pelvis, namely, an exaggeration of the 
 normal curves of the spine. But the influence of the first two 
 causes usually preponderates. 
 
 Figure-of-eight Rachitic Pelvis. — In very rare cases there is a 
 depression inwards of the symphysis pubis of a rachitic pelvis. 
 
 ^ 
 
 !^ f 
 
 Fig. 
 
 360. — Median section through a fiat rachitic pelvis with marked 
 bending of the sacrum. 1 
 
 This is ascribed to the traction of the recti muscles (see Fig. 361, 
 p. 724). In this case the brim has the shape of a figure of eight, 
 or hour-glass, but not a uniform figure of eight, for the projection 
 inwards of the sacrum is greater than that of the symphysis pubis, 
 and the hollows at each side of it deeper. More frequently the 
 symphysis pubis is not drawn in, but the curvature near that 
 point is more acute, in consequence of a slight flattening opposite 
 the acetabula, due to the inward thrust of the femora. The pelvis 
 thus approximates to a heart shape (see Fig. 357, p. 720). Such a 
 
 1 Breus and Kolislio, loo. cit^ Bd. 1, Th, 2, Fig. 136. 
 
 46—2 
 
724 The Practice of Midwifery. 
 
 pelvis may be regarded as intermediate between the ordinary 
 reniform shape and the generally contracted rachitic pelvis, and it 
 implies an intermediate influence of standing, walking, etc. 
 
 Chondrodystrophic Pelvis. — The pelvis due to chondrodystwphia 
 fa'talis or enchondroplasia (Fig. 362) is somewhat allied to the 
 reniform type of rachitic pelvis. The disease as it occurs in foetal 
 life has already been described (see p. 544). If the subjects of it 
 survive to maturity, they are dwarfs of a peculiar appearance. 
 The trunk may be of not much less than normal size, but the 
 limbs are extremely stunted ; the shortening affecting the humerus 
 and femur more than the forearm and lower leg. There is some 
 evidence of softening of bones allied to that which occurs in 
 rickets, for the lumbar curve is generally greater than normal, 
 and the promontor}^ of the sacrum projects more than usual into 
 
 Fig. 361. — Figure-of-eight rachitic pelvis. 
 
 the brim (Fig. 362). The iliac fossfe are also everted as in rickets. 
 The pelvis diflers from that of rickets, in that its contraction is 
 chiefly due to shortening of that part of the ilium which forms a 
 part of the ilio-pectineal line. Thus the acetabulum is much 
 apj)roximated to the sacro-iliac synchondrosis, and, in consequence, 
 the pubes to the sacrum. The conjugate diameter is therefore 
 much more shortened than in any rachitic pelvis, except the most 
 extreme forms. In six chondrodystrophic pelves described by 
 Breus and Kolisko,^ the conjugate varied from If to 2| inches 
 (4 to 7 cm.). In most cases, therefore, Caesarean section is necessary 
 for delivery. 
 
 Mechanism of Labour in the Flattened Pelvis. — The 
 flattened pelvis has certain peculiar efl'ects of its own upon the 
 mechanism of labour. In accordance with the three dimensions 
 of the foetal head, there are modifications of the mode in which the 
 
 1 Loc. cif., 1900, Bd, 1, Th. 1, pp. 313—349. 
 
Anomalies of the Pelvis. 725 
 
 head passes through the pelvis in three respects : (1) as to its 
 rotation ; (2) as to its flexion or extension ; (3) as to its lateral 
 obliquity or lateral flexion. 
 
 (1.) Rotation. — In pregnancy the head will generally lie with 
 the occijiut somewhat forward, on account of the adaptation of the 
 whole foetus to the shape of the uterus and of the abdominal cavity. 
 But, on the rupture of the membranes, the head will enter or 
 attempt to enter the brim with its antero- posterior diameter in the 
 longest diameter of the brim, that is to say, in nearly a transverse 
 position, whenever the space is not sufficient to allow it to enter 
 freely in an oblique position. In the elliptic flattened pelvis, the 
 
 Fig. 362. — Chondrodystrophic pelvis of a woman twenty-seven years of age. i 
 
 antero-posterior diameter of the head will be almost exactly trans- 
 verse. In the reniform flattened pelvis, the main part of the space 
 at the sides of the pelvis is posterior to a transverse line bisecting 
 the conjugate diameter. Hence the broader or occipital end of the 
 head will find most space by turning somewhat backward (see 
 Fig. 363, p. 726). If there is sufficient transverse space in the 
 pelvis, and the shape is reniform, the head generally deviates 
 bodily somewhat toward that side of the pelvis toward which the 
 occiput is directed, so as to bring the broad biparietal diameter 
 into the freer lateral space, and get a smaller diameter of the head, 
 one as near as possible to the bitemporal, into opposition to the 
 contracted conjugate diameter (Fig. 363). It is only when the 
 head is very small relatively to the transverse diameter of the pelvis 
 tliat it can deviate so far to one side as to allow the bitemporal 
 diameter itself to enter the conjugate. Thus at the early stage of 
 
 > Brcus and Kolisko, h.c. rit., V,<\. \, Th. 1, Fig. 89, p. ■'Jl.'S. 
 
726 
 
 The Practice of Midwifery. 
 
 labour there is often some rotation of the occiput hackivards. The 
 antero-posterior diameter remains in the same direction until the 
 superior strait is passed. Then, if flexion occurs, the occiput is 
 rotated forwards as usual by the inclined plane of soft parts. 
 
 (2.) Flexion and Extension. — Before labour the head is Ijdng 
 above the brim, if contraction is at all considerable. The head 
 not entering the brim easily, both occiput and forehead are 
 detained above its level, and therefore the usual flexion cannot 
 take place. Owing to the shape of the head, the anterior fon- 
 tanelle will be more within reach than the posterior. The head 
 at this stage is therefore more extended than usual. The further 
 course of affairs depends upon the exact shape and size of the 
 pelvis, and the relation of these to the size and shape of the head, 
 especially as regards the prominence of the parietal tubera. In 
 
 Fig. 363. — Engagement of head in brim of flattened pelvis viewed from below 
 in the axis of the brim : — a, anterior fontanelle ; h, sagittal suture ; c, pos- 
 terior fontanelle ; d, promontory of sacrum ; e, symphysis pubis. 
 
 the reniform pelvis, when the lateral spaces are large, as in the 
 case of the flattened pelvis \Yithout any, or with only a slight 
 degree of, general contraction, it generally happens that when the 
 head is beginning to engage in the brim, the diameter most 
 tightly grijjped is that opposed to the contracted conjugate. The 
 biparietal diameter in the free sjjace at the side meets with less 
 resistance. The greatest resistance is then anterior to the occipital 
 condyles, and therefore produces flexion, the head rotating in 
 some measure around the diameter gripped in the conjugate until 
 the occiput is well engaged in the pelvis. In this case, therefore, 
 the head passes the brim, if able to pass it at all, by a movement 
 of flexion. 
 
 The mechanism is different in the case of the elliptic flattened 
 pelvis, and also in some cases of the reniform pelvis, when the 
 reniform shape is slightly marked, and the hollows at each side of 
 the promontory not large. The diameter which meets with most 
 
Anomalies of the Pelvis. 727 
 
 resistance is then frequently the biparietal, that which is engaged 
 in the conjugate not fitting so tightly. The points of greatest 
 resistance are then behind the line of propelling force passing 
 through the condyles, and therefore the resistance produces 
 extension. The head then passes through the brim, if able to 
 pass, in a position of somewhat greater extension than it had 
 while resting above the brim. There is sometimes evidence of 
 this in a groove of depression on the parietal bone caused by the 
 pressure of the promontory as the head passes. When the passage 
 takes place in the position of extension, this groove runs nearly 
 parallel to the coronal suture and posterior to it. Otherwise it 
 is obliquely inclined towards, or crosses, the coronal suture. It 
 is obvious that it must depend greatly upon the relative size of 
 the biparietal diameter, and the degree to which it can be 
 diminished by moulding, whether the biparietal diameter or that 
 engaged in the conjugate meets the most obstruction. These vary 
 greatly in different heads. -"^ 
 
 The extension of the head is generally limited by the capacity of 
 the transverse diameter of the pelvis to admit the long diameter of 
 the head when increased by extension. In a generally contracted 
 flattened pelvis, which is not wide enough to admit the long 
 diameter unless the head is flexed, the head must either pass by 
 the movement of flexion, or else remain arrested. 
 
 After the head has passed the brim, flexion is usually produced 
 by the resistance of the soft parts, and the occiput rotates forwards 
 in the usual way. 
 
 (3.) Lateral or Biparietal Obliquity. — In a fcetal head before 
 moulding, the biparietal diameter is generally greater than adjacent 
 oblique diameters drawn from a point a little above the parietal 
 tuber on one side to a point a little below it on the other (which 
 may be called subparieto-superparietal diameters). The same is 
 true, though to a less degree, of the maximum transverse diameter 
 in other parallel sections of the head. Hence the head will pass 
 through a smaller space if tilted a little sideways, so that one 
 parietal tuber passes in advance of the other. Now, if a body is 
 pushed through a narrow passage by its posterior pole, and is so 
 shaped that a tilting one way or other will facilitate its passage, the 
 resistances are certain to effect that tilting. The body is in unstable 
 equilibrium until the tilting is produced, and the slightest variation 
 in the direction of the propelling force or the amount of friction 
 
 1 By Litzmann, Playfair, Spiegelberg, and Lusk only the former of these modes of 
 transit, by Schrrider and Ooodcll only the latter, is described as being the usual one 
 in the flattened pelvis. 
 
728 The Practice of Midwifery. 
 
 will bring it about. The principle may be illustrated by the experi- 
 ment of trying to push an egg through an elastic tube with its long 
 diameter exactly across the axis of the tube. The egg is certain to 
 turn so as to bring its shorter diameters into coincidence with the 
 diameters of the tube. Similarly the head can never by any 
 possibility continue to advance in a position of brow presentation, 
 with its longest mento-occipital diameter thrown across the 
 parturient canal, but, if it advances at all, the presentation is 
 always converted into either a face or a vertex (see p. 339). It 
 is in the same way that lateral tilting of the head is produced by 
 the resistances whenever there is pressure at the ends of lateral 
 diameters, and a mechanical advantage is thus to be gained. 
 
 It may also be shown that the shape of the head is such that, 
 if arrested above the brim, it is in a position of unstable equili- 
 brium until it has been tilted to one side or other to a greater 
 degree than that which will give the greatest mechanical advan- 
 tage when the biparietal diameter is actually engaging in the brim. 
 When the head is engaging in the pelvis, the greatest mechanical 
 advantage is gained by a tilting of not more than about 12° or 15°, 
 even before moulding. When the head is arrested above the brim, 
 the tilting may proceed to as much as 20° or 25°, though such an 
 amount of obliquity is not a mechanical advantage, but rather the 
 contrary. 
 
 In the flattened pelvis, it is found that the sagittal suture is 
 generall}^ displaced towards the promontory of the sacrum, so 
 that the anterior parietal bone enters the brim in advance of the 
 posterior, and the child's head is flexed towards its posterior 
 shoulder (Fig. 176, p. 266), {anterior parietal presentation) . 
 
 This is called Naegele-obliquity, because Naegele described it as 
 existing in normal labour. It remains to explain why the tilting 
 is generally in this direction rather than the opposite.^ 
 
 One reason may be posterior obliquity of the uterus in reference 
 to the axis of the brim. Frozen sections show such an obliquity, 
 and K. Barnes contends that it is the normal condition. In frozen 
 sections, however, it is due, in great measure, to the prolonged 
 effect of gravity on the corpse lying on its back, and to the chest 
 being in a position of exj)iration, whereas in a pain it is in one of 
 deep inspiration. It is probable, therefore, that the usual assumj)- 
 tion that the axis of the parturient uterus normally coincides with 
 that of the brim is not far from the truth. But the slightest degree 
 
 ^ See papers by the author " On the Occurrence in Normal Labour of Lateral 
 Obliquity of the Fcetal Head," Trans. Obstet. Soc, London, Vol. XVII. , 187.5, p. 283 ; 
 and by Robert Barnes " On the Mechanism of Labour with reference to Naegele's 
 Obliquity," Trans. Obstet. Soc, London, Vol. XXV., 1883, p. 2.58. 
 
Anomalies of the Pelvis. 729 
 
 of posterior obliquity is sufficient to determine the direction of the 
 tilting, which the resistances then increase. The effect is produced 
 in the following way. The component of the oblique force acting 
 perpendicularly to the axis of the brim pushes the condyles for wards ; 
 this calls out a reaction of the anterior pelvic wall directed backwards, 
 but passing through the centre of the head or nearly so. Thus is 
 produced a " coujjle " or pair of equal and oj^posite forces, not in 
 the same straight line, tending to tilt the sagittal suture backward, 
 and produce Naegele-obliquity. 
 
 Another reason is probably the effect of friction against the 
 sacral promontory. It might at first sight be supposed that friction 
 would be greater at the anterior part of the pelvis, where the surface 
 of contact is greater. A mathematical consideration of the ques- 
 tion, however, shows that exactly the contrary is the case.-^ This 
 result depends upon the fact that the curvature in the plane of the 
 brim of the head where it is in contact with the anterior j)elvic wall 
 is less than that of a circle having as its diameter the conjugate 
 diameter of the pelvis. Hence the posterior side of the head is 
 retarded most by friction against a projecting promontory. It is 
 retarded still more if the promontory makes a depression in the 
 head by its pressure. A kind of ledge is then formed, which offers 
 a greater resistance than that of friction proper.^ 
 
 There are exceptional cases, amounting, according to Litzmann, 
 to about one-fourth of the whole, in which the oj)posite of Naegele- 
 obliquity occurs, and the sagittal suture is displaced forward 
 (posterior parietal presentation) (Fig. 177, p. 267). An anterior 
 obliquity of the uterus, as from pendulous abdomen, tends to 
 produce this result when the resistances come into play. 
 
 In general, the maximum degree of Naegele-obliquity is observed, 
 as according to the above explanation it ought to be, when the 
 head is arrested above the brim. In such a case I have found the 
 sagittal suture within an inch of the promontory. If considerable 
 before, it becomes diminished as the head enters the brim, being 
 
 1 It must be remembered that friction is not increa.sed by increasing the surface of 
 contact. If the surfaces are plane, the total friction remains the same, the friction 
 being proportional to the pressure over each small element of area. 
 
 2 By Goodell it is stated that the sagittal suture is slightly displaced forwards at the 
 earlier part of its passage, before its main displacement backwards begins. Matthews 
 Duncan held the same view. This would imply that the anterior side of the head is 
 at first most retarded, as was found to be the case in the experiments of Matthews 
 Duncan with an after-coming head. No satisfactory mechanical explanation has 
 hitherto been suggested for this. It is possiVjle that, contact being wider in front, a 
 more extensive fold of skin may be pushed up there than by the sacral promontory, 
 and that this may cause the greater retardation, before the head is tightly enough 
 engaged for friction pioper to liave much effect. No other authors, however, describe 
 this primary displacement of the sagittal suture forwards, and I have generally found 
 it displaced Ijack wards when first observed. 
 
730 The Practice of Midwifery. 
 
 reduced more nearly to that degree which is mechanically advan- 
 tageous. The extra resistance, from friction, or from friction and 
 depression, caused by the sacral j)romontory, tends, however, to 
 maintain or to increase the obliquity beyond the advantageous 
 point. The obliquity may be reduced also, during a slow passage, 
 through shortening of the biparietal diameter from moulding. 
 But some degree of obliquity is generally maintained till the 
 superior strait is passed. Then when the liead meets the inclined 
 plane of the pelvic floor, its advanced part is pushed forward under 
 the pubic arch, and the opposite obliquity is so produced as in 
 normal labour. Thus the lateral flexion of the head toward the 
 IDosterior shoulder is at this stage converted into lateral flexion 
 toward the anterior shoulder (see p. 263). 
 
 When it is said that lateral or biparietal obliquity is produced by 
 a rotation of the head upon its antero-posterior axis, it is not meant 
 that the rotation takes place without a concomitant advance of the 
 head, or that one side of the head actually recedes. In general, 
 one side is merely retarded more than the other. But in some 
 cases the rotation may imply an actual recession of one side of the 
 head, as when lateral obliquity is produced when the head is 
 completely arrested above the brim. 
 
 In some cases, again, when the resistance at the promontory is 
 unusually great, in consequence of a depression being produced in 
 the head, the posterior side of the head may be actually arrested, 
 while the anterior is advancing. The movement may then be 
 regarded as a rolling upon the sacral promontory. When the 
 depression in the head is found to be round, it is a sign that such 
 an arrest of the posterior side has taken place. In the commoner 
 case, in which it forms a groove, there has been merely retardation. 
 A spoon-shaped depression indicates an intermediate condition, 
 probably complete arrest of the posterior side during a part only 
 of the passage. 
 
 It is sometimes stated that in the earlier part of the passage the 
 head rotates or revolves upon a transverse axis passing through 
 the sacrum, in the lower part upon one passing through the 
 symphysis pubis. This, however, is only a graphic and popular 
 mode of representing the most striking part of the motion of the 
 head, and is not strictly accurate, since it disregards other parts of 
 the motion, namely, all rotations except that in the antero-posterior 
 plane of the pelvis.^ 
 
 1 By Matthews Duncan a distinction was made between rotations of the head or 
 body of the foetus on its own centre, and what he called " revolutions," that is to say, 
 rotations on an external axis (" On the Revolutions of the Foetal Head," Trans. Obstet. 
 Soc, London, Vol. XX., 1878, p. 151). The word "revolution," however, is more 
 
Anomalies of the Pelvis. 731 
 
 Path of the Centre of the Head. — In the flattened pelvis, in conse- 
 quence of the displacement forward of the sacral promontory, the 
 centre of the pelvic brim is displaced forward to half the same 
 degree, also the pelvic inclination is sometimes increased, although 
 in the rachitic flattened pelvis it is generally diminished (see p. 723). 
 From both these causes the axis of the pelvic brim may be inclined 
 more forward than usual, and the axis of the uterus has then 
 usually a posterior obliquity in reference to the axis of the brim, 
 even when the fundus is thrown forward in a pain. The head 
 being then kept back by the anterior uterine wall, its centre will 
 lie at first behind the axis of the brim (a o. Fig. 22, p. 21). When 
 this is the case its centre will have to describe a curve having its 
 concavity backward at its entrance into the brim, before proceeding 
 along the nearly straight portion of the pelvic axis (a b, Fig. 22, 
 p. 21). This curve has been described by E. Barnes under the 
 title of the " curve of the false promontory," and more recently 
 under the title of " Barnes' curve," as being followed by the head 
 in normal labour as well as in the flattened pelvis. It is drawn by 
 Barnes as a semicircle, having its centre at the sacral promontory, 
 and the so-called curve of Carus as another semicircle having its 
 centre in the symphysis pubis. But it has already been shown 
 that the normal path of the head does not approximate to an arc of 
 a circle except in the lower part of its course through the soft parts 
 
 appropriately applied to the path of the centre of a body, independent of any rotations 
 that may take place around that centre, as, for example, in speaking of the revolutions 
 of a planet about the sun. In mechanics the word " rotation," and not " revolution," 
 is used, if it is intended to represent the whole motion of a body, whether the axis 
 of rotation is internal or external. If the motion is all iu one plane, it is only two 
 different ways of describing the same thing to say that a body is rotating round an 
 external centre of instantaneous rotation, or to say that it is rotating in such or such a 
 way round its centre, while its centre is moving in such or such a path. 
 
 But this is not the case when the motion is in three dimensions, like that of the 
 fcetus. The only accurate mode is then to describe the path of the centre of the body 
 (or any other convenient point within it), and the rotation or rotations about that 
 centre. The component rotations in three rectangular directions may be combined 
 into a single resultant rotation ; but this cannot be combined with the movement of 
 translation into a single rotation about an external axis, unless the two happen to lie 
 in the same plane. In the case of a body like the foetus, moving in all directions 
 under the axis of various forces, the chances are infinity to one against this being so, 
 except in the case in which the body is rolling. As already mentioned, the motion of 
 the foetal head may sometimes be a rolling motion. There is then an axis of instan- 
 taneous rotation passing through a point on its surface, and constantly changing its 
 position. Otherwise no axis of instantaneous rotation exists, and the probability is also 
 very great against its being even an approximate representation of the whole motion 
 to call it a rotation or "revolution" about an external axis. The principle hei'e 
 described is one simply of solid geometry, although it is used as a basis in the dynamics 
 of rigid bodies. (See Routh, Treatise on Rigid Dynamics, Chapter V.) The conclusion 
 here stated may thus be summarised : — (1.) No axis of instantaneous rotation (the 
 "revolution" of Matthews Duncan) exists for a moving body, unless the movement 
 is limited to one plane. (2.) The movement of the foetal head is not limited to one 
 plane, unless in the exceptional case when the movement is a rolling one ; and in this 
 latter case the axis of instantaneous rotation is not external, but passes through a 
 point, on the surface of the head. 
 
732 The Practice of Midwifery. 
 
 (see pp. 21, 22). So the " curve of the false promontory " is only- 
 followed for a short space, and ceases when the centre of the head 
 reaches the plane of the brim at a^ (Fig. 22). From that point the 
 path is for some distance nearly a straight line, as in the normal 
 pelvis. In a normal pelvis it does not appear that the centre of 
 the head lies initially behind the axis of the brim (a o, Fig. 22). 
 Even in the flattened pelvis it does not necessarily do so. It does 
 not, when the pelvic inclination is notably lessened, as it generally 
 is in rickets,^ nor when the uterus is anteverted from want of room 
 in the abdomen. In such cases no " curve of the false promontory " 
 is followed at all, but the path of the head may be, at first, nearly 
 the axis of the brim, or even a curve having its concavity forward, 
 especially when, at the commencement of labour, the head lies far 
 forward, overhanging the pubes, being pushed forward by a 
 prominent lumbar curve. 
 
 Mechanism of Labour with the after-coming Head. — The long 
 diameter of the after-coming head enters the longest diameter of 
 the pelvis in the same way as that of the fore-coming head. In 
 this case, also, the head may pass either in flexion or in extension, 
 according as the biparietal diameter, or that engaged in the con- 
 jugate, is most resisted. But the tendency to extension is generally 
 increased by the traction which has to be made in order to bring 
 the head through the brim. On account of the posterior position 
 of the condyles, the traction force tends to bring down the 
 occiput most. The occipito-mental diameter may thus be thrown 
 across the transverse diameter of the pelvis, and be unable to 
 pass, especially if the pelvis is generally contracted as well as 
 flattened. 
 
 1 It is held by R. Barnes that, even in normal labour, the centre of the head is con- 
 strained to follow " Barnes' curve " still further, and is guided backvpard into the 
 hollow of the sacrum, by what he calls the anterior or uterine valve, that is to say, by 
 the anterior lip of the os, extending lower over the head, in reference to the plane of 
 the brim, than the posterior. This implies a displacement backwards of the os uteri in 
 reference to the axis both of the brim and of the uterus, and there is no evidence that 
 this exists normally. The anterior lip of the os is indeed often more noticeable than 
 the posterior as overlapping the head, but generally only because the examining finger 
 first impinges upon it, the direction of the vagina being nearly at right angles to the 
 axis of the brim. In Braune's frozen section (Fig. 131, p. 220) the anterior lip of the 
 external os is notably higher than the posterior in reference to the plane of the brim, 
 and not lower, as represented in R. Barnes' diagrams. This is explained, as a normal 
 condition, by the drawing up in labour of the anterior pelvic triangle (see p. 223), It 
 appears that it is only when full dilatation of the os is delayed some time after the 
 rupture of the membranes, and after the descent of the head near to the pelvic 
 floor, that the anterior lip of the os may be sometimes pushed lower than the posterior, 
 in reference to the plane of the brim, by the occiput, which is descending in advance 
 of the forehead, in consequence of the flexion of the head. 
 
 2 In R. Barnes' figure showing the curve of the false promontory (Lectures on 
 Obstetric Operations, p. 71:), the inclination of the brim is represented as increased in 
 rickets, although in the sectional views of the several pelves ((.)}}. cit,, p. 286), it is 
 correctly drawn as diminished. 
 
Anomalies of the Pelvis. 
 
 733 
 
 Lateral obliquity will also occur in the passage of the after- 
 coming head. Usually the posterior side is most retarded by 
 the promontory of the sacrum for the same reason as before, 
 especially when the expulsion is effected by the natural powers. In 
 experiments made with an after-coming head and a wooden pelvic 
 brim, with various degrees of flattening, Matthews Duncan ^ found 
 
 Fig. 364. — The rhomboid of Michaelis in a, woman with a well-formed pelvis. 
 
 that there was first a deviation of the base of the skull forwards, 
 and afterwards backwards, the direction of traction being perpen- 
 dicular to the brim. This implies, first, a retardation of the anterior 
 side, then a more important retardation of the posterior.^ 
 
 Diagnosis. — With a rachitic pelvis there will usually be some 
 signs of the disease in the body generally. The stature will be 
 
 ' 'J'raiJH. Obfitet. Hoc, London, Vol. XX.., 1878, p. 1.51. 
 
 '-^ For a possible mechanical explanation of the former, see note, p. 729. 
 
734 The Practice of Midwifery. 
 
 short, especially the limbs ; the tibise perhaps bowed or thickened, 
 and there may be a rickety rosary present on the ribs. In well- 
 marked cases the rhomboid of Michaelis (Fig, 364) becomes more 
 triangular in form. As regards the pelvis, the most valuable 
 sign of rickets is the change of relation between the Dist. Sp. II. 
 and Dist. Cr. II. already described (p. 721), There is usually a 
 depression in the sacral region between the ilia, in consequence 
 of the sinking of the sacrum, and the anus looks more backward 
 than usual. General contraction will be revealed by general 
 dimiiiution of the external diameters, as well as by want of space 
 detected on internal examination. The convexity of the anterior 
 surface of the sacrum, and when present the marked bending 
 forward of its lower extremity, can be recognised. The most 
 important sign, as regards the probable difficulties of delivery, is 
 the estimate of the diagonal conjugate diameter (see p. 705), and 
 the calculation from this of the true conjugate. This is especially 
 the case when the pelvis is flattened only, with little or no general 
 contraction, whether rickets has anything to do with the causation 
 of the deformity or not. 
 
 When labour has commenced the existence of disproportion of 
 some sort is indicated by the head remaining high above the pelvis, 
 or by its not descending upon the os uteri to continue the dilata- 
 tion, when dilatation has progressed satisfactorily up to the time 
 of the rupture of the membranes. If in addition the sagittal suture 
 is found to remain in a nearly transverse position, or with the 
 occij)ut directed a little backwards, a flattened pelvis may be sus- 
 pected. A marked degree of Naegele-obliquity or displacement of 
 the sagittal suture backwards towards the promontory, also usually 
 indicates a flattened pelvis. The projecting promontory of the 
 sacrum, if one exists, may then usually be felt. 
 
 Eaee Forms op Flattened Pelvis. 
 
 The Pelvis of Double Congenital Dislocation of the Hips, 
 
 — Although this anomaly has been generally called a dislocation, 
 it is in most cases a fault of development, no acetabulum being 
 formed in the proper situation, but the head of the femur resting 
 upon the dorsum of the ilium, behind and above its natural situa- 
 tion. Some have supposed that the condition may result from 
 rupture of the ligamentum teres, through traction upon the leg in 
 pelvic presentations. 
 
 Resulting Changes in the Pelvis. — It might be suj)posed, at first 
 sight, that, the points of application of the reactions to the body- 
 
Anomalies of the Pelvis. 
 
 735 
 
 weight through the heads of the femora being displaced backward, 
 the pelvic inclination would be diminished, to maintain the balance 
 of the body. In point of fact, however, it is found that the pelvic 
 inclination is increased, and that the balance is maintained by an 
 increased lordosis of the lumbar vertebrae, by which the trunk and 
 shoulders are thrown back. The resulting figure is shown in 
 Fig. 365. The reason of the increase of the pelvic inclination is, 
 that a pressure backwards on the anterior half of the pelvic ring 
 is exercised by the ilio-femoral ligaments, 
 and the iliaco-psoas muscles, in consequence 
 of the displacement backward of their attach- 
 ment to the femora. Assuming that it is not 
 compensated for by a diminution of pelvic 
 inclination to preserve the balance, the dis- 
 placement backwards of the heads of the 
 femora itself tends to increase the pelvic 
 inclination. For the posterior half of the 
 pelvic ring is in consequence pushed up 
 more by the pressure of the femora, and the 
 anterior half less, than usual. In conse- 
 quence of the weight being transmitted more 
 than usual through the posterior half of the 
 pelvis, the anterior half is found to be lighter 
 and more slender than in the normal pelvis. 
 In consequence of the increase of the 
 pelvic inclination, a greater proportion of the 
 body-weight acts in the plane of the brim, 
 the leverage exerted on the innominate bones 
 is increased, and the inward thrust of the 
 heads of the femora acts not at the aceta- 
 bula but on the dorsa of the ilia. It there- 
 fore renders the iliac fossae more upright, but 
 has less tendency than usual to resist the 
 widening of the pelvis. The tendency to widening is also increased 
 by the traction of the ilio-femoral ligaments and the attachment 
 of the iliaco-psoas muscles, which are directed more outward than 
 usual. Hence arises a moderately flattened pelvis, enlarged trans- 
 versely at the brim and still more at the outlet, the pubic arch 
 being wide, and the tubera ischii far apart. It rarely causes 
 difficulty in parturition, there being no general contraction 
 associated with the moderate flattening. 
 
 The Split Pelvis. — The split pelvis, in which there is no bony 
 union between tlie pubes, but only a fibrous band, also generally 
 
 Fig. 365. — Pregnancy 
 with double congenital 
 dislocation of the hips. 
 (After Ahlfeld.) 
 
736 The Practice of Midwifery. 
 
 arises from a fault of development. It is usually associated with 
 ectopia vesicae and imperfect development of the sexual organs, 
 and is therefore of little practical obstetric interest. It is, however, 
 of some importance in illustrating the action of the mechanical 
 forces concerned in pelvic development. 
 
 Resulting Changes in the Pelvis. — The separation of the anterior 
 ends of the innominate bones, amounting to 10 cm. or over,^ 
 necessarily renders the pelvis relatively wide. The widening forces, 
 namely, the reactions to the body-weight at the acetabula, and at 
 the tubera ischii, therefore act at an increased advantage (see p. 28), 
 and the result is a wide slightly flattened pelvis. The tension at 
 the symphysis pubis is not abolished, but is maintained by the 
 fibrous union, as is shown by the fact that the separation does not 
 go on indefinitely increasing. 
 
 General Effects. 
 
 Since the generally contracted and the flattened pelves are those 
 which most frequently lead to practical difficulty, certain general 
 efiects of these commoner forms of contraction will here be 
 considered. 
 
 Effects of Pelvic Contraction upon Pregnancy. — In the 
 
 earlier months, if there is a projecting sacral promontory, and if 
 the uterus is retroflexed or retroverted, the pelvic contraction may 
 favour incarceration, the promontory preventing the fundus uteri 
 from readily rising out of the pelvis into the abdomen as it 
 enlarges. In the later months, the uterus, with the foetus, is 
 generally situated higher than usual in the abdomen, if the head 
 is too large to lie low within the pelvis. Hence deviations of the 
 uterus, especially anteversion, with pendulous abdomen or lateral 
 obliquity, are commoner than usual, especially when the stature is 
 short, as in rachitic patients, and the abdomen does not afl'ord room 
 enough for the uterus in its usual position. If the patient is tall 
 there may be unusual prominence of the fundus uteri. Such 
 deviations become progressively more marked in repeated preg- 
 nancies, from tbe increasing laxity of the abdominal walls. 
 Malpresentations are at least five times as common as with a 
 normal pelvis. Thus vertex presentations occur in about 84 per 
 cent, of cases of contracted pelves as contrasted with 96 to 97 per cent, 
 in normal pelves. This result depends partly upon the frequent 
 obliquity of the uterus, partly upon the high position of the head, 
 
 1 Breus and Kolisko, loo. ciL, Bd. 1, Th. 1, p. 107. 
 
Anomalies of the Pelvis. 737 
 
 the consequent readiness with which it deviates to one side, and 
 the ease with which the irregular pelvis allows the descent of a hand, 
 arm, funis, or other part. 
 
 Effects of Pelvic Contraction upon Labour. — In the early 
 stage of labour the head is generally high above the brim. The 
 bag of membranes may then protrude more deeply, in a sausage- 
 like form, through the os, and, owing to the head not engaging and 
 its ball-valve-like action being absent, the forewaters are exposed to 
 the full force of the general intrauterine pressure. As a result the 
 membranes often rupture prematurely, and their rupture is 
 accompanied not infrequently by the descent of the cord or of some 
 of the limbs of the foetus. After the rupture of the membranes, 
 dilatation of the cervix, if incomplete, ceases, if the presenting part 
 is unable to descend and continue it. The cervix may even contract 
 again to some extent. Nearly the whole of the liquor amnii 
 quickly drains away if the presenting part is unable closely to fill 
 the lower segment of the uterus. For a very short time after 
 rupture of the membranes, if the head cannot enter the brim, the 
 pains may be less vigorous than usual, from a lack of reflex 
 stimulus through pressure on the cervix. But before long the 
 uterine wall being more stimulated than usual by the pressure of 
 the foetus, the pains assume an expulsive character, even if the 
 rupture of the membranes has taken place before the dilatation of 
 the OS has proceeded far. 
 
 The further course of labour depends greatly upon the relation 
 between the size of the head and that of the pelvis, upon the 
 strength of the uterine muscles, and the character of the pains. If 
 these are vigorous they are. stimulated, up to a certain point, by the 
 resistance encountered, and labour may take place easily and 
 relatively rapidly in moderate degrees of contraction. On the other 
 hand, and especially in multipara with a pendulous abdomen, 
 exhaustion of the uterine muscle may set in quickly, and, as the 
 patient is unable to render any assistance with her abdominal 
 muscles, the labour may be delayed or even arrested. The 
 retraction of the thick muscular portion of the uterus (see p. 622), 
 and thinning of the distensible portion, especially the cervix, then 
 take place rapidly, and there is danger of rupture, if the obstacle 
 is insuperable. If this does not occur, and the patient is left 
 untreated, eventually exhaustion supervenes. The pains may die 
 away for a time, and again return, or the uterus may at once pass 
 into the state of continuous action or tetanic contraction (see p. 622), 
 and the constitutional signs of protracted labour, which have been 
 
 M. 47 
 
738 The Practice of Midwifery. 
 
 already enumerated (see pp. 619 — 623), appear. If the uterine 
 wall is initially thin, or the pains weak, the stage of exhaustion 
 comes on much earlier. 
 
 Effect of Pressure on the Soft Parts. — The long continuance 
 of labour and the pressure of the child's head lead to congestion 
 of the mucous membrane of the cervix and vagina, with extravasa- 
 tion of blood and destruction of the epithelium, which favours the 
 occurrence of infection. At the same time the liquor amnii, after 
 rupture of the membranes, is very likely to undergo decomposition, 
 and the normal vaginal discharge is replaced by a thin, blood- 
 stained secretion, which forms a very favourable nidus for the 
 growth of infective organisms. 
 
 Severe injuries to the soft parts are almost invariably caused by 
 the head, not by other parts of the foetus. They are produced 
 rather by prolonged pressure than by rapid transit, and therefore 
 occur chiefly in head presentations. 
 
 In cases of generally contracted pelves, where the head when 
 engaged in the pelvis exercises uniform pressure on the part of the 
 uterus lying between it and the pelvic brim, marked oedema and 
 congestion of the cervix occur. In cases of obstructed labour, 
 accompanied with extreme impaction, the swelling of the caput 
 succedaneum and the oedema of the soft parts may be so marked 
 that there may be great difficulty in distinguishing between them. 
 
 In the flat pelvis the uterine wall, generally the supra-vaginal 
 portion of the cervix, may be bruised and injured by pressure 
 against the promontory of the sacrum, against the pelvic wall 
 generall}^, or against any other projections which may exist. 
 Hence may follow haemorrhages in its substance, and subsequent 
 inflammation. Sometimes the injury produced may be the starting 
 point of rupture in labour. More frequently, a necrotic j)rocess 
 takes place afterwards, especially over the site of the sacral pro- 
 montory. The injury is more extensive on the surface of the 
 utero-vaginal canal where the tissue is exposed to the access of air 
 and germs, and rarely causes perforation through the peritoneum. 
 
 Injuries to the anterior wall of the genital canal, from pressure 
 against the pubes, affect the vagina much more often than the 
 cervix. Tlius vesico-vaginal fistula is much more common than 
 utero-vesical fistula. Hence it is rare that sloughing in this 
 situation results from pelvic contraction so great as to arrest the 
 head above the brim. It more commonly arises when the head 
 has partly entered the vagina, and is long detained in that position, 
 either from moderate disproportion or uterine inertia, while no 
 
Anomalies of the Pelvis. 739 
 
 artificial assistance is given. Here also the lesion is most extensive 
 on the vaginal surface. It very rarely arises from immediate 
 laceration in delivery, instrumental or otherwise, almost always 
 from a gradual process of sloughing afterwards. The fistula 
 then becomes manifest, by the escape of urine, only after the 
 lapse of some days. Sloughing may also occur after prolonged 
 pressure in other parts of the vagina. This may lead to general 
 cicatricial contraction in the end. If the slough is posterior, a 
 recto-vaginal fistula may be formed, but this is much more rare 
 than a vesico-vaginal fistula. Injuries to the perineum and 
 vaginal outlet, which may be promoted by contraction of the bony 
 outlet, especially of the pubic arch, will be considered hereafter 
 (see Chapter XXXVII).. 
 
 Effects of Pressure on the Child's Head. — The caput 
 succedaneum or scalp tumour arises from a limited portion of 
 the head being unsupported, while the rest is subject to pressure. 
 It may be produced while the head is at or above the brim in 
 contracted pelves, but, in consequence of the mechanism of its 
 production, it is not so readily produced when the obstacle lies 
 in one diameter only of a flattened pelvis, as when there is 
 uniform contraction, or when the obstacle is due to rigidity of 
 soft parts. The presence of a considerable caput succedaneum 
 indicates not only the existence of resistance, but that the pains 
 are effective, and is therefore not altogether unfavourable when 
 pelvic contraction is known to exist. 
 
 In cases of difficult labour in contracted pelves marked moulding 
 of the head usually occurs, and there may be grooved or spoon- 
 shaped depressions on the parietal bones, the result of the pressure 
 of the sacral promontory. These will be described more in the 
 chapter on injuries to the child (see Chapter XLII.). 
 
 Prognosis in Contracted Pelves. — Pelvic contraction in the 
 more extreme degrees is fatal to the child, unless delivered by 
 Csesarean section, and very dangerous to the mother. Even in 
 less extreme degrees of contraction the risk to the mother is 
 greatly increased from the exhaustion consequent upon prolonged 
 labour, from the access of air to the uterus consequent upon the 
 total escape of the liquor amnii or the performance of operations, 
 and from the injury to the soft parts from pressure between the head 
 and the pelvis, or caused by the operations necessary to effect 
 delivery. The bruised and injured soft parts become inflamed, and 
 the inflammation is liable to assume a septic form, and extend to 
 
 47—2 
 
740 The Practice of Midwifery. 
 
 the peritoneum or affect the general system. The risk is greater 
 the nearer the injured parts are to the peritoneum. The risk 
 increases to some extent with the degree of contraction, although 
 the greatest difficulties are often met with in cases of moderately 
 contracted pelvis, since in these the condition is so frequently not 
 recognised before the onset of labour. The risk also increases with 
 the number of children. This is explained by the fact that each 
 successive child is often somewhat larger than its predecessor, 
 malpresentations are more common in multiparae, and the uterine 
 contractions are liable to be less regular and less powerful. The 
 prognosis to the children is more unfavourable. Many die from 
 asphyxia in consequence of the prolongation of labour and the 
 excessive pressure. 
 
 Of 5,288 cases of contracted pelvis among 49,397 births occurring 
 in the Clinique of Schauta ^ in the years 1892 — 1906, 24 of 
 the mothers died, a mortalitj^ of '45 per cent., and 491 of the 
 children, a mortality of 9*28 per cent. These figures demonstrate 
 the dangers of labour in cases of contracted pelvis at the present 
 day when the treatment is undertaken in a lying-in hospital, and 
 may be contrasted with the figures given by Spiegelberg,^ who in 
 the Breslau Maternity had a maternal mortality of 7*9 per cent. 
 (54 in 680), and a foetal mortality of 32 per cent. (219 in 682). 
 
 Treatment of generally Contracted and Flattened Pelves. — 
 
 Contracted pelves may be divided into four classes in reference to 
 treatment : — (1) Those in which delivery of a living child at full 
 term by the natural powers, or by the aid of forceps or version, may 
 be expected. (2) Those in which delivery of a living and viable 
 child by induction of premature labour is probable, but not that of 
 a living child at full term. (3) Those in which a living child 
 cannot pass through the pelvis, but a child can be extracted after 
 embryotomy without great risk to the mother. (4) Those in which 
 dehvery through the natural passages is impossible, or involves 
 greater risk than the performance of Csesarean section. 
 
 No very positive line of demarcation can, however, be drawn 
 between these classes. Much depends upon the character of the 
 pains and the size of the child's head, and these cannot be accurately 
 measured before delivery. Moreover, there is a liability to error 
 even in the estimate of the conjugate diameter by skilled observers 
 up to a quarter of an inch or more, and other diameters can still 
 less be measured accurately. Thus it happens that, on the one 
 
 1 Schauta. Journ. Obst. and Gyn. Brit. Emp., Vol. XV., No. 5, p. 311. 
 
 2 Spiegelberg, Text-book of Midwifery, English translation, 1888, Vol. II., p. 82. 
 
Anomalies of the Pelvis. 741 
 
 hand, cases are recorded of a living child at full term passing 
 a conjugate diameter of only 2| inches, while in other cases, 
 craniotomy proves necessary with a conjugate of as much as 3| 
 inches. Again, the inferior limit of space through which delivery 
 by craniotomy should be attempted is very variously estimated by 
 different authorities, and has been much modified by recent 
 improvements in Ceesarean section. Hence it is necessary not only 
 to make careful measurements of the pelvis, but also to determine 
 as accurately as possible the relation of the size of the child's head 
 to that of the pelvis, and to consider carefully the history of former 
 deliveries, in deciding the question as to the correct method of 
 treatment to be adopted. 
 
 In cases of flattened pelvis having a conjugate of 3 J inches or 
 more, it may be expected that delivery will be effected by the 
 natural powers, provided the pains are sti'ong enough. These form 
 the majority of the whole number. Unless the head is unusually 
 large, the conjugate diameter exceeds the diameter of the head likely 
 to engage in it, and moreover some diminution of the corresponding 
 diameter of the head from moulding is to be expected. Hence, in 
 the early stage of labour, an expectant treatment should be adopted. 
 In this, as in all cases of pelvic contraction, much pains should 
 be taken to avoid rupture of the membranes before full dilatation 
 of the OS. The patient should be kept lying down, and restrained 
 from making premature bearing- down efforts. 
 
 Of the 5,288 cases recorded by Schauta, in 4,116 spontaneous 
 labour occurred, with 4 maternal deaths, or a mortality of '09 per 
 cent., and 91 foetal deaths, or a mortality of 2'2 per cent., results 
 better than those obtained by any other method of treatment with 
 the exception of Csesarean section, which gave a slightly lower 
 foetal mortality, namely, 1*7 per cent. 
 
 After rupture of the membranes, care should be taken to correct 
 any anteversion or other deviation of the uterus from the axis of 
 the brim. If pains are feeble, it is often useful to keep the patient 
 on her back, so that gravity may assist the advance of the foetus 
 and reflex stimulus be increased. Moderate external pressure may 
 also be used during the pains. A ceitain influence can be exercised 
 on the flexion or the extension of the head by the position of the 
 patient. Obliquity of the uterus tends to cause advance of that 
 part of tbe head opposite to the direction of the obliquity. Hence, 
 if the occiput is directed as usual to the left, and if it can be made 
 out that the diameter of the head engaged in the conjugate is most 
 tightly gripped, and that, therefore, the head has a better chance 
 of passing by flexion than by extension (see p. 726), the usual left 
 
742 The Practice of Midwifery. 
 
 lateral position is injurious. If the patient is placed on her right 
 side, and right obliquity of the uterus thus encouraged, the descent 
 of the occiput will be favoured. 
 
 A reasonable time should be allowed to see the effect of the 
 natural powers, especially if progress is being made, but no oxytocic, 
 as ergot, should be given. If the pains begin to fail, or symptoms 
 of exhaustion, especially considerable acceleration of pulse, appear, 
 assistance should be given. The greater is the apparent dispropor- 
 tion between the foetal head and the pelvis, the less time should be 
 allowed to elapse to exhaust the patient's powers, because it is then 
 more likely that she will have to undergo afterwards the ordeal of 
 a difficult extraction ; and the more she is exhausted beforehand, 
 the worse will her prospects be. The foetal heart should also be 
 watched. Any marked diminution of its rate, especially if accom- 
 panied by feebleness of sound, shouldbe an indication for interference 
 in the interest of the child. Comparatively early interference is 
 especially indicated when, after rupture of the membranes, the 
 head cannot descend upon the os to continue the dilatation, though 
 even then a reasonable time may be allowed to see if the head will 
 engage in the brim. If pains appear to be so violent as to threaten 
 rupture of the uterus, especially if no advance is being made, 
 interference should on no account be delayed. 
 
 "With a flattened pelvis having a conjugate between 3f and 3 
 inches, a certain time may also be allowed to nature, to see if the 
 head will engage in the pelvis, but assistance should here be given 
 earlier, since there is less likelihood of delivery being completed 
 by the natural powers with a full-term child. If the pelvis is 
 generally contracted, the same rule will apply with a conjugate 
 up to 3| inches; and even with such a conjugate, craniotomy 
 sometimes becomes necessary. 
 
 Choice betiveen Forceps and Version. — Much controversy has taken 
 place on the relative merits of the high forceps operation and 
 version in the flattened pelvis, and very diverse views are still held 
 on the subject. 
 
 For extraction through a flattened pelvis, forceps have two great 
 advantages : — (1) A much greater force can be used than can be 
 applied to the neck without risk of injuring the spinal cord.^ 
 (2) The extraction may be made gradually, while the extraction of 
 an after-coming head must be effected in a minute or two if the child 
 is to be saved. Against these are to be balanced the following 
 
 1 In the experiments on the foetus at term, Matthews Duncan found that the spinal 
 column gave way under tensions of from 90 to 122 lb., and that decapitation took 
 place under tensions of from 91 to 141 lb. (Mechanism of Natural and Morbid 
 Parturition, p. 136). A premature foetus might be expected not to endure so much. 
 
Anomalies of the Pelvis. 743 
 
 disadvantages : — (1) In the high forceps operation the blades are 
 generally applied nearly in the transverse diameter of the pelvis ; 
 and, even if any other mode of application is attempted, the blades 
 naturally tend to fall into such a position. The compression thus 
 exercised upon the head in the transverse diameter of the pelvis 
 tends to increase to some extent the other diameters, but it must 
 be remembered that, as Budin and Milne Murray have shown, the 
 main increase is in the vertical diameter, and therefore this objec- 
 tion is not one of much importance, (2) The same force of com- 
 pression tends to turn the long diameter of the head out of the 
 transverse into an oblique pelvic diameter. (3) It is generally stated 
 as another objection that the compression tends to cause flexion. 
 This, however, is not in all cases a disadvantage, if the flexion is 
 produced by rotation on the diameter engaged in the conjugate, 
 for this may be the best mode of passing the brim (see p. 726). 
 It will be a disadvantage only if the 
 bi-parietal diameter is brought nearer to ^^s^"'^^ ^^^ 
 
 the middle line, not if the bi-temporal // n^ 
 
 diameter is brought nearer to the side of "((- -]W 
 
 the pelvis where the occiput lies. The u | 
 
 latter will generally be the case, the whole ^ // 
 
 head sliding somewhat in the direction of \ Jf 
 
 the occiput, where there is most room. iBkv J^09^^ 
 
 The former effect, however, may be pro- ^ ^^^ ,:'^^ 
 
 ' . , Fig. 366. — iransverse section 
 
 duced to the extent of the thiclmess of of foetal skuU. a, a. Bi- 
 one blade of the forceps, if there is scanty parietal, b, b. BUmastoid 
 
 ■■-'.. '' diameter. 
 
 space in the transverse pelvic diameter. 
 
 The comparative advantages of version are the following : — 
 (1) The head naturally adapts itself to the pelvis in that position in 
 which it can find most room. (2) The second advantage depends 
 upon the shape of a vertical section of the head. In Fig. 366 
 a vertical section of the head through the parietal tubera is shown. 
 It will be seen that the section forms a much more tapering wedge 
 when it enters the brim by the base first than when it enters it 
 with the summit first. Now the transverse diameter of the base, 
 or bi-mastoid diameter, is practically incompressible, measuring on 
 the average about 3 inches. The bi-parietal diameter exceeds this 
 by f inch, measuring about 3f inches on an average. But the 
 bi-parietal diameter can be reduced by moulding under pressure 
 to the dimensions of the bi-mastoid without necessarily causing the 
 death of the child. 
 
 If, not the bi-parietal diameter, but some other transverse 
 diameter of the head engaged in the conjugate meets with the 
 
744 
 
 The Practice of Midwifery. 
 
 greatest resistance, the same general argument will apply, although 
 in this case the original maximum transverse diameter of the 
 section will not be quite so great in proportion to the diameter of 
 the base. 
 
 Opposed to this advantage there is one disadvantage in the 
 
 Fig. 367. — Transverse section of foetal 
 skull. The dotted line a a, b b, o c, 
 represents the normal outline. 1,2 2, 
 represents the alteration produced 
 by the compression described. 
 
 Fig. 368. — Ti-ansvcrse section of foetal 
 skull, a a, b b, normal outline. 
 1 1, 2, outline of skull as com- 
 pressed by extraction after ver- 
 sion. 
 
 passage of the after-coming head. When it is the diameter engaged 
 in the conjugate which meets with the greatest resistance, traction 
 on the body generally tends to produce extension, because the 
 condyles are generally posterior to this diameter, which is usually 
 
 Fig. 369. — Passage of after-coming head through reniform flattened pelvis. 
 A. Promontory of sacrum. B. Symphysis pubis, c. Space between fore- 
 head and ilium. D. Depression in foetal head, e, f. Anterior and pos- 
 terior fontanelles. 
 
 one only slightly behind the bi-temporal. (See Fig. 369.) The 
 extension will go on until it has reached such a point that the line 
 of traction passes through the diameter gripped in the conjugate. 
 Hence not merely the fronto-occipital, but the occipito-mental, or 
 maximum vertico-mental diameter of the head is liable to be thrown 
 nearly across the transverse diameter of the pelvis. It will probably 
 
Anomalies of the Pelvis. .745 
 
 be unable to pass in this position, especially if there is general 
 contraction, as well as flattening of the pelvis. Hence the extended 
 position of the after-coming head is often a disadvantage in com- 
 parison with its position in extraction by forceps, not an advantage 
 as is stated by some authorities. 
 
 It is sometimes stated that a fcetal head can be brought through 
 a pelvis having a conjugate diameter smaller by ^ inch by 
 means of version as compared with forceps. No such general 
 statement, however, can be proved. Budin,^ by experiments on an 
 artificial pelvis, with a sacral promontory movable to imitate 
 different degrees of contraction, found that a premature fcEtus 
 could indeed be brought through by version with a less force than 
 by forceps but that a full term fcetus could not. Much, however, 
 depends upon the exact relation of the shape of the pelvis to that 
 of the head. It is undoubted that, even at full term, sometimes a 
 living foetus, and still more frequently a dead one, may be extracted 
 by version, when forceps of an efficient pattern have been tried, and 
 have failed. 
 
 There is one condition in which version may have a special 
 advantage as compared with extraction by forceps. This is when 
 it can be made out that there is more room on one side of the pelvis 
 than the other, especially when this is due to greater breadth of 
 the wing of the sacrum, and greater depth of the depression at the 
 side of the promontory on the corresponding side. Such a pelvis 
 is shown in Fig. 369, p. 744. It will then be an advantage to 
 have the broad bi-parietal diameter of the head on the widest side 
 of the pelvis. Hence if the head should present by the vertex in 
 such a way that the occiput is turned towards the wrong side, and 
 the head is arrested at the brim, it is desirable to perform version 
 so as to bring the occiput to the widest side of the pelvis. This 
 may always be effected, if it is remembered that the leg which is 
 brought down always eventually rotates anteriorly, under the pubic 
 arch. Hence the rule is as follows : — If it is desired to bring the 
 occiput into the right side of the pelvis, bring down the right leg, 
 and conversely. 
 
 Version is also preferable to forceps where some other condition 
 is present beside a contracted pelvis, such as placenta prsevia, and 
 in cases where the head is movable above the brim of the pelvis, 
 and either the application of forceps or the performance of version 
 is indicated. 
 
 There is one condition, on the other hand, under which all 
 authorities are agreed that forceps should have the preference over 
 
 ^ La Tele du Fcjetus au Point de Vue d'Obstetrique, Paris, 187G. 
 
746 The Practice of Midwifery. 
 
 version. This is when the head is ah-eady engaged pretty deeply 
 in the pelvis, though its maximum diameters may not j^et have 
 passed the brim. If, in addition, there is such retraction of the 
 uterus that the internal os (or the retraction ring, see p. 621) 
 can be felt as a line of transverse depression from the abdomen or 
 as an internal ridge above the head on introducing the hand ; if 
 the uterus is so closely contracted round the foetus, that the head 
 cannot be elevated ; or if the head has passed out of the cervix 
 into the vagina, through the drawing up of the cervix, it should 
 be inferred that the case is too far advanced for version, and 
 craniotomy should be at once performed, if forceps fail. For, 
 under these conditions, the attempt to perform version would risk 
 the rupture of the uterus, and the interest of the mother forbids 
 such a risk to be run for the possible chance of saving the child. 
 For the same reason, if the mother's general state appears so 
 critical that rapid delivery is urgently called for, it is generally 
 better not to perform version. For, if craniotomy proves necessary 
 after all, it is sometimes a more difficult and tedious operation 
 on the after-coming head, especially if the disproportion is very 
 great. 
 
 It is when the head is arrested above the brim, in a flattened 
 pelvis, and the case not too far advanced, that authorities differ 
 most as to the course to be pursued. The best plan appears to 
 be that generally adopted in England, namely, to apply forceps, 
 and try the effect of moderate traction, and then, if this fails, to 
 perform version, unless the alternative of symphysiotomy or pubi- 
 otomy should be chosen by the operator, and the patient and her 
 husband give their consent to that operation. As to the com- 
 parative results of forceps or version as a first choice under these 
 circumstances, very much depends upon the efficiency of the 
 forceps used — axis-traction forceps should always be employed — 
 something also upon the predilection of an individual operator for 
 one operation or the other, and his consequent skill in the 
 performance of it. Version is an operation performed in the 
 interest of the child, and it should not therefore be chosen if the 
 child is dead. If the foetal heart has ceased to be heard, version 
 should generally be rejected, if forceps have failed ; for, although 
 the foetus may be still just alive, it will hardly have vitality enough 
 to survive the difficult passage of a contracted brim. If there is 
 still greater certainty of the death of the child, no prolonged or 
 very powerful effort should be made even with forceps, but early 
 resort should be had to craniotomy. 
 
 The statistics of Guy's Hospital Charity afford evidence how 
 
Anomalies of the Pelvis. 747 
 
 much depends upon the use of an efficient instrument. Thus in 
 the six years 1863—1869 deUvery was effected by forceps or 
 version in 20 cases of labour protracted in consequence of pelvic 
 contraction, in which the head was arrested high above the brim. 
 In 8 of these version was chosen as the primary operation, and 
 the children were saved in 7 out of the 8. In 12 cases forceps 
 were chosen for the primary operation. In 7 out of the 12 delivery 
 was effected by their means, and 3 of the 7 children were living. 
 In the remaining 5 delivery was effected by version after forceps 
 had failed, and 3 of the 5 children were living. During these six 
 years a pair of long curved forceps (Lever's) was in use, but these 
 were rather short in the handles, and pliant in the blades. 
 
 At the end of the six years a new pair of forceps was procured, 
 otherwise similar in shape, but having longer handles, and more 
 unyielding in the blades. During the next six years delivery was 
 effected by forceps or version in 18 similar cases, in all of which 
 forceps were chosen for the primary operation. In 17 cases out of 
 the 18 delivery was effected by them, and 15 of the children were 
 living. In the remaining case version was successful after forceps 
 had failed, but the child was still-born. Version was performed in 
 other instances after the failure of forceps, but had to be followed 
 up by craniotomy. There have, however, been a few cases since the 
 above date, in which a living child has been delivered by version 
 after even the more efficient forceps had failed. 
 
 Thus in delivery by the more efficient forceps 88-1 per cent, of 
 the children were saved, a better percentage^ than the average per- 
 centage in low forceps cases in the same charity ; in delivery by 
 version 71*4 per cent. Among the 24 mothers delivered by forceps, 
 there were no deaths ; among the 14 delivered by version, there were 
 two deaths. The 38 cases above enumerated, together with 15 only 
 of craniotomy, comprise all the cases of most considerable dispro- 
 portion between the foetus and the pelvis out of 23,591 deliveries. 
 These statistics show that the use of forceps in contracted pelves is 
 superior in safety to version, and the same conclusion is confirmed 
 by the report of the Guy's Hospital Charity for the years 1875— 
 1885. Forceps were used at the brim 92 times ; 6 of the mothers 
 died, and 18 of the children. Version was performed for various 
 reasons when the head was at the brim in 33 cases, out of which 5 
 of the mothers and 29 of the children died. It must be stated, 
 however, that, in 10 of the version cases, forceps had been previously 
 tried in vain. 
 
 1 Out of the total number of forceps cases the percentage of children saved was 
 76-9, 
 
74^ The Practice of Midwifery. 
 
 The following comparisons will further show the gain as regards 
 foetal mortality in contracted pelves from the modern improvement 
 in midwifery practice. The improvement in question probably 
 consists mainly in the employment of longer and more unyielding 
 forceps than it was formerly thought safe to use, and in a less 
 reluctance to employ them when the head is high in the pelvis. 
 In the Guy's Hospital Charity, between 1853 and 1854, craniotomy 
 cases were 3-6 per 1,000 ; between 1854 and 1863 they were 
 reduced to 1-2 per 1,000 ; between 1863 and 1875 they were further 
 reduced to 0"7 per 1,000, or more than fivefold in about forty years. 
 In the following ten years, 1875—1885, they remained about the 
 same, namely, 0-9 per 1,000, so that the minimum possible had 
 probably already been attained in 1863 — 1875. 
 
 The use of axis-traction forceps and of Walcher's position (see 
 Chapter XXXIII.) undoubtedly enlarges still somewhat further the 
 scope of extraction by forceps in contracted pelves, both in com- 
 parison with version and with craniotomy. But it, perhaps, can 
 hardly be anticipated that material advance will be gained on the 
 results of the Guy's Charity as quoted above, both as regards the 
 extreme rarity of resort to craniotomy, and the successful results, 
 both to mothers and children, of extraction by forceps in the con- 
 siderable degrees of pelvic contraction. It should be mentioned 
 that although forceps have been used very sparingly in the Guy's 
 Charity (only once in 197 deliveries from 1863 to 1875 ; once in 93 
 deliveries from 1875 to 1885), it has been the practice not long to 
 delay the operation when considerable pelvic contraction is 
 recognised. That the foetal mortality in forceps operations in con- 
 tracted pelves depends very largely upon the actual degree of 
 contraction of the pelvis- is well shown by the results given by 
 Munro Kerr.^ In 39 cases with a conjugata vera of 3 inches, the 
 foetal mortality after delivery with forceps was 46 per cent. ; in 
 52 cases with a conjugata vera of 3^ inches, 23 per cent. ; and in 
 39 cases with a conjugata vera of 3 J inches it was 15 per cent. 
 
 The average transverse diameter of the incompressible base of 
 the skull is about 3 inches. Hence, allowing a little for the soft 
 parts, it cannot be expected, as a rule, that a living child at full 
 term will be delivered with a conjugate diameter much under 
 3f (8'5 cm.) inches. In exceptional cases, no doubt, a full-term 
 child is delivered with a conjugate of 2f (7 cm.) inches by forceps, 
 version, or sometimes even by the natural powers. Thus in a case 
 in the Guy's Hospital Charity, where the patient was at term in 
 her second pregnancy at the age of 24, craniotomy had to be 
 
 1 Munro Kerr, Operative Midwifery, 1908, p. 366. 
 
Anomalies of the Pelvis. 749 
 
 performed, with the head arrested high above the brim, and the 
 conjugate diameter was estimated at not more than 2f inches. 
 But at her first confinement she had been dehvered spontaneously 
 of a living child after 24 hours' labour. 
 
 Hence version should never be performed with a conjugate under 
 2f (7 cm.) inches, nor with one under 3i (8 cm.) inches if there 
 is evidence that the head is large. No prolonged efforts to 
 extract with forceps should be made with a conjugate less than 
 3f (8'5 cm.) inches. With a conjugate under 2| (7 cm.) inches, 
 the choice will be between craniotomy and Caesarean section. 
 With a conjugate from 2f (7 cm.) inches upward, there is the 
 alternative of symphysiotomy or pubiotomy if the child cannot be 
 extracted by forceps. 
 
 In the case of the generally contracted pelvis, extraction by 
 forceps is always preferable to version. If forceps fail, recourse 
 must be had to craniotomy, symphysiotomy, or pubiotomy, and not 
 to version. The difficulty here does not lie mainly in the transverse 
 diameters of the head. Hence there are neither the disadvantages 
 in the use of forceps, nor the advantages in version, which exist in 
 the flattened pelvis. Moreover, after version, the extended head 
 would j)robably find insufficient room for its long diameter in any 
 diameter of the pelvis. The generally contracted pelvis not unfre- 
 quently gives occasion for craniotomy, even when the conjugate 
 diameter is as much as 3f (8*5 cm.) inches. In the generally 
 contracted pelvis more advantage is gained by symphysiotomy or 
 pubiotomy than in the flattened pelvis, because in this case a great 
 part of the difficulty lies in the transverse diameter, which is much 
 more increased by these operations than the antero-posterior. 
 
 Extraction of the After -coming Head. — In the extraction of- the 
 after-coming head more assistance to nature is generally required 
 than in primary pelvic presentations, with a normal pelvis. Before 
 the shoulders engage in the brim, it is well to pass the hand into 
 the vagina, and make sure that the arms do not become extended 
 in the brim, by the side of the head, drawing them down, if 
 necessary, over the chest. When the head engages in the brim, 
 extraction must be effected quickly if the child is to be saved. 
 The legs may be grasped, wrapped in a napkin, and traction made 
 nearly in the axis of the brim. At first, just as the head is entering 
 the brim, the direction of traction should be a little more forward 
 than this, in consequence of the "curve of the false promontory." 
 In case of doubt, various directions of traction may be tried in a 
 tentative way, but not to the extent of making a " pendulum move- 
 ment," which might injure the neck, or rub the head backward and 
 
750 The Practice of Midwifery. 
 
 forward against the brim. Advantage may also be gained by 
 having an assistant to press down the head from the abdomen. 
 
 If the head will not pass, it will generally be found, on passing 
 up the hand to examine, that it is too much extended. There are 
 two ways of overcoming this and promoting flexion. The first is to 
 incline the direction of traction as much as possible toward the side 
 of the pelvis to which the occiput is directed. If the line of traction 
 can thus be made to pass between the forehead and the diameter 
 most tightly grij^ped, descent of the forehead more than the occiput, 
 and therefore flexion of the head, will be promoted. The pressure 
 of the lateral pelvic wall against the occiput also forms, with the 
 lateral component of the traction, a "couple," or pair of equal and 
 o|)posite forces, which aids the same effect. 
 
 Jaw Traction. — Another still more effective expedient, and one 
 which may be combined with the former, is that of jaw traction, 
 which often ma}^ turn the scale in favour of the child in a head- 
 last case. It has the advantage that it not only promotes flexion, 
 since the maxillary joint is generall}^ slightly anterior to the 
 diameter gripped in the conjugate, but increases the force of 
 extraction without increasing the dangerous tension applied to 
 the neck. The index finger should be placed on the edge of the 
 lower maxilla, and the jaw drawn downward at the same moment 
 that traction is made upon the legs with the other hand. Care 
 must be taken that the finger is not passed too far back, so as to 
 injure the floor of the mouth or the larynx. Since a certain 
 amount of injury may be done to the jaw, and the child's power 
 of sucking thereby impaired, the expedient should not be used 
 until simple traction has been tried and failed. 
 
 In laboratory experiments on the amount of traction which 
 could be placed on the lower jaw without causing injury, 
 Matthews Duncan ^ found that, in several instances, up to a 
 weight of 56 lb., no obvious injury was produced. In one case, 
 a crack was heard at 28 lb. It thus appears that, in many cases, 
 an additional amount of force can thus be obtained without 
 serious injury to the child, equal to more than one-half of that 
 which can be safely applied through the neck (see note, p. 742). 
 The additional amount of force thus obtained is generally of more 
 importance than the flexion. It is not, indeed, an actual flexion 
 which can be expected, but only a limitation of extension ; for 
 the traction by the spine will often have greater effect in causing 
 extension than the jaw traction in causing flexion, if the diameter 
 
 1 "On Traction by the Lower Jaw in Head-last Cases," Trans. Obst. Soc, London, 
 1878, VoL XX., p. 61, 
 
Anomalies of the Pelvis. 751 
 
 engaged in the conjugate is the one most tightly gripped. The 
 jaw traction, however, will limit the amount of extension pro- 
 duced to that degree from which it results that, not the direction 
 of the spinal traction, but that of the resultant of the spinal 
 traction and jaw traction, passes through the diameter of the 
 head most tightly gripped. The result will probably be to keep 
 the head in moderate extension, so that only the fronto-occipital, 
 and not a diameter nearly approaching to the mento-occipital, or 
 maximum vertico-mental, is thrown across the transverse diameter 
 of the pelvis. The inclination of the tractile force toward the 
 side where the occiput lies, described on p. 749, may materially 
 aid in aiding the descent of the forehead. It is to be remembered 
 also that, when the transverse diameter of the pelvis is large in 
 proportion to the head, it may allow room for the long diameter 
 of the head, even in the position of maximum extension likel}^ 
 to be attained, and then the additional traction force is alone 
 of value. 
 
 The mode of extracting the head through the pelvis and vaginal 
 outlet has already been described (pp. 359 — 364). If its passage 
 is resisted by the pelvic outlet, as may be the case in the 
 uniformly contracted pelvis, jaw traction may be used in the same 
 way as at the brim. It will rarely be required to overcome the 
 resistance of soft parts only. 
 
 Choice hettveen Craniotomy and Ccssarean Section. — In the more 
 moderate degrees of contraction, craniotomy is an operation 
 involving very little risk to the mother. If bad results follow, 
 they are generally due rather to the previous prolongation of 
 labour, or the efforts to extract a living child by forceps or 
 version, than to the operation itself, provided that it has been 
 IDerformed skilfully. In the severer degrees of contraction, how- 
 ever, the case is different, especially when the disproportion is so 
 great that there is much difficulty in extracting the body as well 
 as the head of the foetus through the brim. In these severer 
 degrees of flattening, the pelvis is almost always rachitic, and 
 generally contracted as well as flattened, so that the want of space 
 in the transverse diameter seriously increases the difficulty of the 
 operation. Under these circumstances it is one of considerable 
 risk to the mother. According to Perry, craniotomy in America, 
 in 70 cases of pelves having a conjugate measuring 2 J inches and 
 under, gave a mortality of 38*5 per cent. 
 
 The recent improvements in Ceesarean section have greatly 
 enlarged its field as compared with craniotomy. The general 
 mortality is now less than 10 per cent., and some expert and 
 
752 The Practice of Midwifery. 
 
 experienced operators have obtained still more favourable results. 
 In 385 operations by ten operators, collected by Whitridge 
 Williams, there were only 23 deaths, a mortality of 6'87 per cent. 
 Deducting cases infected before operation, he arrives at a corrected 
 mortality of 4*06 per cent. 
 
 Munro Kerr has collected 172 cases operated upon by different 
 English operators, with 19 deaths, and if to these we add the 37 
 cases published by Gow^ without a death, we have a total of 209 
 cases with 19 deaths, or a maternal mortality rate of 9 per cent. 
 
 Leopold has recorded 229 cases with 16 deaths, or a mortality 
 of 7 per cent., and Schauta has recorded 158 cases, with a mortality 
 of 5 per cent. 
 
 It is sometimes stated that the mortality of embrj^otomy in all 
 but extreme degrees of contraction is or ought to be almost nil ; 
 but there do not appear to be any statistics on an extensive scale 
 to show this. 
 
 In statistics from any given institution the mortality of Caesarean 
 section is generally greater than that of embryotomy ; but statistics 
 of embryotomy do not show a greater or even so great a safety 
 to the mothers as those of Caesarean section in the hands of the 
 most successful operators. 
 
 The statistics collected by Meriwether^ show a maternal mortality 
 of 8'1 per cent, for embrj^otomy, compared with one of 5*1 per 
 cent, to the mothers (3'8 per cent, excluding cases previously 
 infected), and 4*7 per cent, to the children in Cesarean section. 
 In the Guy's Hospital Lying-in Charity, for ten years up to 1901, 
 there were 8 deaths in 33 embryotomies, or 9 per cent. At the 
 Eotunda Hospital, Dublin, from 1896 to 1900, there was 1 death 
 in 6 embryotomies, or 16'6 per cent. In 47 embryotomies recorded 
 by Gusserow ^ there were 3 deaths, or 6"3 per cent. In 63 cases 
 of craniotomy recorded by Munro Kerr there were 6 deaths, or a 
 mortality of 12*6 per cent., but nearly all these cases were infected 
 at the time of oj)eration. Even delivery by forceps or version 
 through a markedly contracted pelvis, has a mortality little if at 
 all less than the most favourable statistics of Caesarean section. 
 The statistics of the Johns Hopkins Hospital, Baltimore, showed a 
 maternal mortality of 2*8 per cent, for all operations for delivery in 
 contracted pelvis, and one of 3 per cent, for delivery by Cassarean 
 section. 
 
 It may be inferred that the field of Caesarean section may now 
 
 1 Csesarean Section, Harveian Lecture, 1907. 
 
 2 Amer. Journ. of Obst. 1901, XLIV., pp. 207—209. 
 
 3 Berl. Klin. Woch., 1902, No. 6 et secj^. 
 
Anomalies of the Pelvis. 753 
 
 be justly extended at the expense of embryotomy in cases of con- 
 tracted pelvis, and that a patient at or near the full term of 
 pregnancy may rightly be advised to undergo Caesarian section, if 
 it can be performed by an experienced operator in favourable 
 surroundings, in all cases in which it is likely that the delivery of 
 a living child through the pelvis would be impossible, or even 
 involve very serious difficulty. 
 
 Induction of premature labour, however, in cases for which it is 
 applicable, involves a less mortality to the mothers, and should 
 therefore be chosen in preference. For the maternal mortality is 
 estimated at not more than 1 per cent. The mortality to the 
 children, however, may be as much as 30 per cent., and some 
 reckon it as high as 50 — 60 per cent., including those children 
 who do not survive more than a few months. 
 
 Some writers have claimed that embryotomy must now be 
 regarded as a murderous oi)eration because it destroys the child, 
 and that Cfesarean section may displace it altogether ; but this 
 conclusion is not as yet justified, nor does it appear likely to be so. 
 For many embryotomies are performed in cases in which difficulty 
 is met with unexpectedly, in which there has been no question of 
 arranging for Caesarean section beforehand, and in which attempts 
 have been made to deliver by forceps, or the child is dead. In these 
 circumstances the mortality of Cesarean section would be far 
 greater than the minimum mortality, especially if the surroundings 
 were unfavourable. Even the interest of foetal life, therefore, may 
 demand embryotomy, that the mother may have the better chance 
 of surviving to bear more children. 
 
 It is possible to extract through the pelvis after craniotomy 
 with a conjugate diameter as small as 2^ or even 2 inches, if there 
 is a fair transverse diameter, and room at the sides of the sacral 
 promontory. But the risk of the operation is then so considerable 
 that a skilled operator should rather choose Caesarean section, even 
 after prolonged labour, if the surroundings are not too unfavourable, 
 with a conjugate less than 2| inches. In these circumstances, as 
 the patient is very likely to be infected, probably the best results 
 will be obtained by the performance of extraperitoneal Caesarean 
 section, the formation of a utero-abdominal fistula, as recom- 
 mended by Sellheim, or the removal of the uterus. 
 
 Symphysiotomy and Pubiotomy. — Tbe improvement which has 
 taken place of recent years in the results, both as regards the 
 mothers and the children, of the operations of symphysiotomy and 
 pubiotomy, and especially the introduction of the subcutaneous 
 method of performing the latter operation, renders it likely that 
 
 M. 48 
 
754 The Practice of Midwifery. 
 
 they will be practised to a much greater extent in the future in 
 this country than has been the case in the past. 
 
 In the last edition of this book the best results of symphysiotomy, 
 those of Pinard, showed a death-rate of 12 per cent, for the mothers 
 and 15 per cent, for the children, while in a recent table of 275 
 cases quoted by Munro Kerr the maternal mortality is 6*5 per cent, 
 and the foetal 10 per cent., a diminution of the maternal death-rate 
 by nearly 50 per cent. Even better results than these have been 
 obtained after pubiotomy. Thus Leopold has operated in 60 cases 
 with no maternal deaths, Bumm in 53 cases with 1 death, 
 and Burger in 30 cases with no death, or a total of 143 cases with 
 1 death, a maternal mortality of '69 per cent. In Leopold's 60 
 cases four of the children died, or 6'6 per cent., and in 225 cases 
 collected by Doederlein the foetal death was also 6*6 per cent. 
 This mortality, both maternal and fcetal, is considerably less 
 than that of symphysiotomy, and compares very favourably with 
 that of any other method of delivery in contracted pelves. 
 
 It must be remembered, however, that these results are those 
 of expert operators in good surroundings, and they represent the 
 best results which can be obtained by the operation of pubiotomy. 
 It must also be remembered that the morbidity of these cases is 
 very high. Thus more than half of Bumm's cases were feverish 
 during the puerperium. The risk of tears and lacerations is also 
 considerable : in 41 of his cases delivered artificially there were 
 7 lacerations of the bladder and urethra, and in 19 there were 
 tears of the vagina and vulva in the neighbourhood of the section 
 of the bone. On the other hand, of the 53 women 34 were seen 
 subsequently, and all were well enough to do their work. There 
 also seems to be some evidence in favour of the view that the 
 pelvis remains permanently enlarged after the operation of 
 pubiotomy, at any rate in some cases. 
 
 Pubiotomy or symi)hysiotomy is only to be carried out after full 
 dilatation of the soft parts has occurred and in cases of moderate 
 contraction of the pelvis when one or two attempts with forceps 
 in Walcher's position have failed to deliver the patient, and the 
 disproportion between the head and the brim seems too great to be 
 overcome by the natural forces. In all cases after the operation 
 has been performed labour should be allowed to terminate naturally. 
 The operation therefore may be suggested to the patient and her 
 husband as one which, at a slightly increased risk to the mother, 
 offers a much better chance of saving the child than version, forceps 
 having failed or being considered inadvisable, provided that it can 
 be performed in good surroundings, and in conditions which allow 
 
Anomalies of the Pelvis. 755 
 
 of the dangerous sequelae which may follow it being properly and 
 promptly dealt with. 
 
 It should only be practised as a general rule in pelves with a 
 conjugate diameter measuring from 3 inches (7"5 cm.) up to 3| 
 (9 cm.), and is more suitable for multiparas than primiparse.^ 
 
 Induction of Premature Labour. — By the induction of premature 
 labour, two advantages are obtained : first, the smaller size of the 
 head ; and secondly, the more yielding consistency of the bones, 
 allowing the diameter engaged in the conjugate to undergo a 
 greater reduction from pressure. Benefit is thus gained both for 
 the mother and the child. Labour is less severe for the mother, 
 and there is a greater chance of a living child being born in those 
 cases in which such a result is not probable at the full term. 
 
 In the slighter degrees of contraction, in which there is a fair 
 prospect of a living child being born alive at full term, either 
 spontaneously or with the aid of forceps or version, it is better 
 not to induce labour, for the amount of interference necessary for 
 the induction of labour does somewhat increase the risk to the 
 mother, although not to such a great degree as a severe instru- 
 mental delivery would do. In the flattened pelvis, the scope of 
 the operation lies chiefly among conjugate diameters varying 
 from 3f down to 3 inches. In the generally contracted pelvis, it 
 may be called for even with a conjugate above 3| inches. Since, 
 however, the average size of the child varies in different women, 
 and the transverse measurements of the pelvis cannot be exactly 
 estimated, the history of previous labours, when the patient is not 
 a primipara, gives even more information than the measurement 
 of the pelvis. As a general rule, when craniotomy has been 
 required in a former labour on account of disproportion between 
 the fcetus and the pelvis, or when the child has been still-born, in 
 consequence of delay within the pelvis, even though delivered 
 whole by forceps or version, premature labour should be induced 
 in subsequent pregnancies. A careful examination should be 
 made, if necessary with an anaesthetic, and the exact relation 
 between the size of the child's head and that of the pelvis deter- 
 mined, and then, if it is thought advisable, at the proper time 
 the induction should be commenced. A primipara with a con- 
 jugate of 3§ inches should be allowed to go to full term. If the 
 conjugate measures less than this or the child is unduly large, 
 premature labour should be induced. In order that the condition 
 may be recognised before the onset of labour, as a general rule all 
 pregnant women should be examined by the abdomen at about the 
 
 1 I'.lacker, Luncct, March ID, I'Jlo, p. 778. 
 
 48—2 
 
756 The Practice of Midwifery. 
 
 thirtieth week of pregnancy, in order that, if they are primiparae, 
 the external pelvic measurements may be taken, and, if necessary, 
 the internal measurements, and that, if they are multiparse with a 
 history of difficulty in their previous labours, after examination 
 a decision may be come to as to the correct treatment and as to the 
 necessity or not for the induction of premature labour. If the 
 patient is a multipara, most reliance should be placed upon the 
 history of the more recent labours, since, in contracted pelvis, the 
 difficulty is apt to increase progressively with increased size of the 
 children. If a female child only has been with difficulty extracted 
 alive at term, it may sometimes be desirable to induce premature 
 labour on a subsequent occasion, since the difficulty is likely to be 
 greater if the next child proves to be a male. 
 
 It must be remembered that the mortality among the children 
 born after the induction of premature labour in hospital practice is 
 very high, and especially so in the higher degrees of contraction of 
 the pelvis, for example with a conjugate of 3 to 3 J inches. 
 According to Bar,^ the mortality to children after induction of 
 premature labour is with a conjugate of 6 to 7 cm. (2"4 to 2"75 
 inches) 80 per cent. ; with 7 to 8 cm. (2*75 to 3'15 inches) 53 per 
 cent.; with 8 to 9 cm. (3*15 to 3-5 inches) 12 per cent. ; with 9 to 
 10 cm. (3"5 to 3'95 inches) 8*6 per cent. 
 
 Munro Kerr records a foetal mortality of 44 per cent, with a conju- 
 gate of 3 inches (7*5 cm.), 33 per cent, with a conjugate of 3J inches 
 (81 cm.), and 25 per cent, with a conjugate of 3J inches (8'7 cm.). 
 
 Of 84 cases treated by Leopold 1 mother died of septic infec- 
 tion, while 13 of the children, or 15'4 per cent., were born dead, 
 and 13 of them died before leaving the hospital, a total mortality 
 of more than 30 per cent. Of the remainder 24 died within the 
 first 3'ear, but this is not above the average mortality of infants of 
 that age. Leopold^ does not advise the induction of premature 
 labour in generally contracted pelves with a conjugate diameter of 
 less than 3 inches (7"5 cm.). 
 
 A good many obstetricians at the present day disapprove of the 
 induction of premature labour on the ground of statistics apparently 
 showing the mortality to children, as well as to mothers, to be 
 greater in cases of premature labour than in those of labour at the 
 full term in contracted pelves. Some of these statistics are 
 fallacious, because they include in the latter class the commoner 
 and slighter degrees of pelvic contraction, in which it is admitted 
 that the induction of labour is unnecessary and inexpedient. When 
 
 1 Bar, L'Ostetrique, March, 1902. 
 
 2 Leopold and Konrad, Arch. f. Gyniik., 1907, Bd. 81, p. G48. 
 
Anomalies of the Pelvis. 757 
 
 different labours are compared in the same woman, in whom pelvic 
 contraction is considerable, the advantages of the induction of 
 labour are strikingly exhibited. Thus Milne^ records 38 induced 
 premature labours in 6 women without any maternal death, in 
 which 35 children were born alive. In 12 labours at term of the 
 same 6 women, only 1 child was born alive. 
 
 Dohrn,^ too, records the case of 19 women among whom only 4 
 children, or 9"7 per cent., were born alive as the result of 41 
 deliveries at full term, while among the same women in 25 
 labours after the induction of premature labour 15, or 60 per cent., 
 of the children were born alive. 
 
 Again, Von Herff^ records 31 premature labours with a death- 
 rate of 20 per cent, among the children, while in 61 deliveries 
 at full term among the same patients 50*82 per cent, of the children 
 were born dead. 
 
 With a conjugate less than 3 inches there is practically little 
 chance of a living child being secured even by induction of labour. 
 There is, however, just a possibility of it with a conjugate a little 
 under 3 inches, provided the transverse diameter is large in pro- 
 portion, and the pelvis is reniform, with ample space at the sides 
 of the sacrum. In these circumstances a trial of the effect of 
 induction may be made. When the contraction is so great that a 
 living child cannot be hoped for, that is to say, in most pelves 
 with a conjugate less than 3 inches, it is better to let the j)atient 
 go to full term, even if Csesarean section is refused. The extra 
 disturbance and risk involved in the induction of labour are 
 thereby avoided. In extreme forms of contraction, as with a con- 
 jugate of 2i- inches or less. Cesarean section will now generally be 
 chosen, if there is an opportunity of arranging for its performance 
 by an operator skilled in abdominal surgery. 
 
 Date for Induction of Labour. — Although a child is nominally 
 regarded as viable at the end of twenty-eight weeks, there is so little 
 chance of its surviving if born before about the end of the thirty- 
 second week, that it is not worth while to induce labour before 
 that time for the sake of the child. In choosing the exact time 
 in any given case, regard should be paid, not only to the size of 
 the conjugate diameter and the size of the foetal head, but to 
 the other dimensions and shape of the pelvis, to the amount of 
 difficulty found in extraction at term, and still more to the results 
 of induction on any former occasion. Thus, if labour has been 
 
 1 " Piemature Labour and Version," Edin. Med. Journ., Vol. XXI. 
 
 •2 Dohrn, Arch. f. Gynak., ]877, Bd. 12, p. 53. 
 
 8 Von Hcrff, Volkmann's Samml. Klin. Vortrage, N. F., No. 386, XIII., p. 269. 
 
758 
 
 The Practice of Midwifery. 
 
 induced before, say at the thirty-sixth week, and the child has 
 been lost through delay at the brim, it should be induced earlier 
 on the next occasion. If it has been induced, say at the thirty- 
 second week, and the child has passed very easily, the patient may 
 be allowed another time to go a little longer, especially if the 
 former child did not prove strong enough permanently to survive. 
 
 So far as the conjugate diameter can be taken as an indication, 
 the following may be given as reasonable rules : — 
 
 With a conjugate of 3J inches induce labour at the end of the 36th week. 
 
 Fig. 370.— Munro Kerr's method of determining relative size of fcetal head 
 and maternal pelvis. 
 
 A more exact determination may be obtained by measuring the 
 size of the foetal head in proportion to the brim in the particular 
 case. Two or three weeks before the date provisionally fixed for 
 the induction, the foetus should be examined by abdominal palpa- 
 tion by the fourth method described at p. 277. The examiner 
 ascertains whether the head is engaged in the brim, and, if not, 
 whether it can be pressed down into it. If he cannot determine 
 this by the two hands used externally, one or two fingers of the 
 right hand are passed into the vagina to ascertain the level of the 
 
Anomalies of the Pelvis. 759 
 
 head, while the left hand is used to press down the head from above. 
 If necessary, the aid of an assistant may be employed, to exercise 
 additional external pressure. In the case of a fat patient, or one 
 intolerant of manipulation, an ansesthetic may be required. 
 
 The modification of Miiller's ^ method introduced by Munro 
 Kerr^ is undoubtedly an improvement (see Fig. 370). He employs 
 a cephalic grip (Paivlic's grip) with the left hand to press the 
 head into the pelvis and places the thumb of the right hand 
 above the symphysis pubis so as to estimate the amount of over- 
 lapping of the head in cases where it does not descend into the 
 brim of the pelvis. 
 
 The examination is repeated at intervals of a week or rather less. 
 As soon as it becomes difficult to press the head down into the 
 brim, the time for induction has arrived. This method of examina- 
 tion should be employed in all cases of contracted pelvis to deter- 
 mine the relation of the size of the foetal head to that of the pelvic 
 inlet, and is of the utmost value not only in determining the exact 
 date on which to induce labour, but also in enabling the practitioner 
 to come to a decision as to the correct treatment to follow in any 
 case of contracted pelvis. Too much stress cannot be laid on the 
 fact that in the majority of cases the decision depends upon the 
 relation between the size of the head and that of the pelvis, and not 
 upon the pelvic dimensions alone. 
 
 Induction of Abortion. — When contraction is so great that there 
 is no hope of obtaining a viable child, and extraction after cranio- 
 tomy at full term is likely to be very difficult and dangerous, it has 
 been suggested to induce abortion at the earliest opportunity. In 
 such cases, however, it is much better for the patient to go to full 
 term and to have Ctesarean section performed, and be sterilised if 
 she demands it. Not only in such a case must the life of the child 
 be considered, but if abortion be procured pregnancy may recur 
 quickly and the operation be again required. Indeed, it is exceed- 
 ingly doubtful if the production of artificial abortion is ever justifi- 
 able in these conditions. 
 
 Treatment of Shoulder and Transverse Presentations in Contracted 
 Pelvis. — In a flattened pelvis, as a rule, no attempt should be made 
 to effect cephalic version, for delivery of the after-coming head 
 will probably be more easily effected ; and, if the head were brought 
 to present, podalic version might be called for afterwards. If, 
 however, the contraction is so great that there is no chance of 
 
 1 Miiller, " Uber das Einprcssen der Kopfes in den Beckenkanal zu Diagnostichen 
 Zwcckcn," Volkrnaiiii's Hanniil. Klin. Vortnige, 188.5, No. 204. 
 '■' iVIunro Kerr, .Jouni. Obst. and (Jyn. Brit. Emp., 1904, No. .3, p. 227. 
 
760 The Practice of Midwifery. 
 
 saving the child, then the head should be brought to present if 
 possible, unless the alternative of Cesarean section is adopted, 
 sinne in considerable contraction, craniotomy with an after-coming 
 head is a more difficult and tedious operation. In the pelvis 
 sequabiliter justo minor also the head should always be brought 
 to present if possible. 
 
 Summary of Treatment. — Now that we have discussed the various 
 methods of treating cases of contracted pelvis, we may summarise 
 the treatment appropriate for the four classes of pelvis mentioned 
 on p. 740, the foetal head being assumed to be of normal size. 
 
 We will consider, for the sake of clearness, class 4 first — namely, 
 pelves in which delivery through the natural passages is impossible or 
 involves greater risk than the performance of Caesarean section. 
 This class will include all pelves with a conjugate diameter equal 
 to or less than 2 inches (5 cm.). In these cases Cfesarean section, 
 either the classical operation or the extraperitoneal one, will give the 
 best results, and should be practised whether the child is alive or dead. 
 If the patient shows signs of infection, then the operation should be 
 followed by removal of the uterus by hysterectomy, or by Porro's 
 operation, or by the formation of a utero-abdominal fistula as 
 recommended by Sellheim. 
 
 Class 3 is that of pelves in which a living child cannot be born 
 with certainty at full term, but in which a child can be extracted 
 after embrj-otomy without undue risk to the mother. This will 
 include pelves with a conjugate diameter of 2 to 3 inches (5 to 
 7"5 cm.). 
 
 In these cases when seen during pregnancy Cesarean section at 
 full term should be advised. If the patient is in labour and the 
 conditions of the mother and the child are both good. Cesarean 
 section will give the best results. If seen for the first time late in 
 labour when the condition of the child is doubtful or it is dead, or 
 the condition of the mother is not satisfactory, delivery by 
 craniotomy or embryotomy is indicated. 
 
 Class 1 is that of pelves in which delivery of a living child at full 
 term by the natural powers may be expected. This class will 
 include pelves with a conjugate diameter of 3| inches (9 cm.) or 
 more. All such cases should be allowed to go to full term. In the 
 very great majority of them no interference will be required, and 
 none should be carried out unless strictly indicated, since spon- 
 taneous delivery gives the best results for both the mothers and 
 the children. If any assistance is required, then axis traction 
 forceps should be employed or version performed when indicated. 
 
 Class 2 is that of pelves in which delivery of a living and viable 
 
Anomalies of the Pelvis. 761 
 
 child is probable by the induction of premature labour or by other 
 means, but not that of a living child at full term by spontaneous 
 delivery. This class will include pelves with a conjugate diameter 
 between 3 and 3f inches (7"5 to 9 cm.). This class of contracted 
 pelvis is the one about which there is the greatest difference of opinion 
 among different authorities as to the treatment to be adopted. 
 
 If the patient is seen during her pregnancy, no doubt the best 
 treatment in private practice is the induction of premature labour 
 at a date to be determined by a careful estimation of the relation 
 between the size of the head and that of the pelvis. In a lying-in 
 hospital or in the best possible conditions the question of allowing 
 the patient to go to full term and then, if necessary, performing 
 pubiotomy or symphysiotomy must be considered. It is in this 
 degree of pelvic contraction that a sharp line of demarcation must 
 be made between the treatment suitable for a patient in private 
 practice and that for one in a lying-in hospital. In the former case, 
 where possible, the induction of premature labour is indicated. If 
 the patient is seen for the first time in labour and the condition of 
 the mother and child is good, then a sufficient length of time should 
 be given to see if spontaneous delivery will not occur. For this 
 purpose there need be no hesitation in allowing the second stage to 
 continue for several hours provided that a careful watch is kept on 
 the condition of the mother and the heart of the foetus. If it 
 becomes evident that spontaneous delivery will not occur, then in 
 private practice axis traction forceps should be applied to the head 
 if it is engaged in the brim, or if not a cautious attempt, with the 
 patient in Walcher's position, may be made to pull it into the brim, 
 while if this fails version may be performed, since this may succeed 
 in a small number of cases where axis traction forceps fail. If the 
 child is dead or it cannot be extracted after the application of forceps 
 or the performance of version, then there should be no hesitation in 
 performing craniotomy. It is better to kill even a living child than 
 to gravely endanger the mother's life, since there will be every 
 chance of obtaining a living child on a subsequent occasion by the 
 induction of premature labour, the performance of symphysiotomy 
 or pubiotomy, or even by Csesarean section if necessary. 
 
 In lying-in hospitals the plan of treatment already adopted with 
 marked success by many obstetricians will tend no doubt to become 
 more and more prevalent, namely the performance of pubiotomy in 
 preference to the induction of premature labour. This practice 
 will especially api)ly to pelves in this class with a conjugate from 
 3 to 3^ inches (7*5 to 8"7cm.). In such cases the patient, if she con- 
 sents, will be allowed to go to full term, and after complete dilatation 
 
762 The Practice of Midwifery. 
 
 of the cervix has occurred symphysiotomy or pubiotomy will be per- 
 formed, or, if she refuses pubiotomy, Csesarean section, as an opera- 
 tion of election, will give the best results for the mother and the 
 child. It must always be carefully borne in mind that pubiotomy 
 and symphysiotomy are operations performed in the interest of the 
 child, and therefore neither of them should ever be practised if the 
 life of the child has been at all endangered. For this reason not 
 more than one or two attempts should be made to deliver with 
 forcej)s if it is intended to practise either of these operations. 
 
 The line of treatment to be followed in the case of a contracted 
 pelvis cannot be defined in terms of the degree of pelvic contraction, 
 and due regard must always be had to the many other important 
 factors involved. Thus in coming to a decision in any particular 
 case the practitioner must carefully consider whether his patient is 
 a primipara or a multipara, and if the latter her previous obstetric 
 history, the duration of the pregnancy, the relation between the 
 size of the head and that of the pelvis, the surroundings and con- 
 ditions in which her confinement will take place, the character of 
 the pains, if she is in labour, and the kind of assistance he can, if 
 necessary, call to hishelp. 
 
Chapter XXX. 
 RARE FORMS OF PELVIC DEFORMITY. 
 
 The Triradiate or Eostrated (Beaked) Pelvis. 
 
 This form of pelvis is evidently due to the pushing inward 
 both of the sacrum with the lumbar spine and the acetabula toward 
 the centre of the brim (see Fig. 371). The bending takes place 
 
 Fig. 371. — Triradiate malacosteon pelvis in extreme deformity, viewed in the 
 axis of the brim. 
 
 earliest and most at the weakest part of the superior rami of the 
 pubes, as well as near the junction of the pubes and ischium, and 
 it is in this way that the characteristic beaked shape is produced 
 (see Fig. 373, p. 765). The shape of the brim comes to resemble a 
 three-rayed star, regular or irregular, the anterior ray being 
 generally the narrowest. 
 
 Causation. — The triradiate pelvis is most frequently the result 
 of osteo-malacia, or moUities ossium. This is a disease extremely 
 rare in Britain, and still more so in America, where insufficient 
 feeding is less common. It appears to be endemic in certain 
 districts, especially on the islands in the Danube, round the region 
 of the Po in Italy, in the valley of the Ehine, in some valleys of 
 Switzerland, and in the city of Vienna. The main cause seems to 
 be something unsuitable in food and sanitary conditions, with 
 [)rt>]);i])]y the addition of some influence of climate and locality. 
 
764 The Practice of Midwifery. 
 
 Evidence in favour of this view is to be found in the fact that in 
 some locahties the disease has disappeared as the result of 
 improvements in the sanitary and social surroundings of the 
 people. 
 
 Osteo-malacia, like rickets, softens the bones, but it differs from 
 rickets in that, almost invariably, it softens them after they have 
 attained maturity, softens them throughout instead of only at the 
 growing portions, and softens them to much higher dogree. 
 
 Osteo-malacia occurs far more frequently in women than in men 
 and is especially associated with pregnancy. This may be explained 
 in some degree by the expenditure of lime-salts for the nutriment 
 of the fcetus. It rarely occurs in a first pregnancy, more frequently 
 after repeated childbirth, is associated with a high degree of 
 
 fertility, and is generally 
 recurrent in repeated preg- 
 nancies. Usually it is pro- 
 gressive, but sometimes it is 
 arrested, and the bones 
 become hardened again in 
 their abnormal state. The 
 disease is a form of osteo- 
 myelitis. The periosteum is 
 generally thickened, soft 
 hypertrophic medullary 
 , . tissue, containing a large 
 
 Fig. 372. — Ihe same malacosteon pelvis seen . n n 7 • 
 
 from the outlet. proportion of fat, IS depo- 
 
 sited in the bones, and the 
 calcareous salts are absorbed. They are believed to be excreted 
 through the kidneys. 
 
 Microscopical examination shows absorption of lime-salts round 
 the Haversian canals and the canaliculi, with degenerative changes 
 in the animal matrix which remains ending in the formation of a 
 jelly-like mass. Numerous small haemorrhagic exudations are to 
 be seen, and the osteoclasts are increased in number. 
 
 The result is that the bones become very light, pliant, soft, and 
 friable, capable of being easily cut or indented. In some forms of 
 the disease numerous spontaneous fractures take place. The 
 disease sometimes affects the whole skeleton, but it may expend 
 itself chiefly upon certain bones. In pregnant women the spine, 
 pelvis, and ribs are generally most affected. 
 
 It has been stated that there is an excess of lactic acid in the 
 blood leading to decalcification, and the condition has been called a 
 tropho-neurosis and has been supposed to be dependent upon a 
 
Rare Forms of Pelvic Deformity. 765 
 
 pathological state of the ovaries with an altered internal secretion 
 of these organs. The fact that the disease occurs in men is a 
 strong argument against any such hypothesis. In favour of this 
 view, however, may be urged the good results and the frequent 
 arrest of the disease which follow the operation of ovariotomy. 
 
 Mechanism of Production of the Deformity. — The reason why so 
 different a state is produced from that of the usual rachitic pelvis 
 is, first, that the bones are softened more uniformly, and more 
 completely, so that they can no longer act as rigid beams or levers ; 
 secondly, that the woman is generally standing and walking, at 
 least in the early stage of the disease, not constantly sitting, like 
 young children suffering from rickets. In the early stage the centre 
 of the sacrum sinks some- 
 what into the brim, and the \ 
 acetabula are driven inward y^^^'^^'iSk.Jii 
 by the inward pressure of 
 the heads of the femora, 
 including the effects of 
 muscular force and that of 
 pressure in lying on the 
 side (see p. 28). The 
 bending takes place most 
 at the thinnest parts of the 
 bones in the anterior half 
 of the pelvic ring, that is in 
 the superior rami of the 
 pubes, and near the junction 
 of pubes and ischium (see 
 Figs. 373, 374). Thus, the 
 
 acetabula come to look more forward than usual (Fig. 374, p. 766), 
 the pelvis becomes beaked, and the shape of the brim, in the earlier 
 stages, is a pointed heart-shape (Fig. 373), transverse contraction 
 predominating. The tubera ischii are carried inward with the 
 acetabula, so contracting the outlet (Fig. 374, p. 766). 
 
 The effect of the approximation of the acetabula is that the out- 
 ward leverage upon them, due to the reaction of the body- weight in 
 standing and walking, is diminished, and eventually converted into 
 an inward leverage, if the acetabula are brought nearer to the 
 middle line than the sacro-iliac joints (see p. 28). The same 
 reaction to the body-weight, on account of the forward direction of 
 tlie acetabula, comes to have a component acting inward perpendi- 
 cular to the pelvic wall, tending more and more to bend the ilia, as 
 distortion progresses. The reaction to the body-weight in sitting, 
 
 Fig. 373. — Rostrated malacosteon pelvis, in 
 earlier stage of deformity. 
 
766 
 
 The Practice of Midwifery. 
 
 action on the tubera iscbii, also comes to exercise an inward instead 
 of an outward leverage, as soon as the tubera are nearer to the 
 middle line than the sacro-iliac joints (see p. 28). Hence all the 
 forces causing distortion act at constantly increasing advantage as 
 distortion progresses. Eventually sacrum and acetabula approach 
 nearer and nearer to the centre of the pelvis, as do the tubera ischii, 
 and the space both of inlet and outlet is almost obliterated. The 
 sides of the pubic arch are closely approximated. The crests of the 
 ilia are folded together and the Dist. Sp. II. diminished. The 
 acetabula, and with them the ilio-pectineal eminences, are also 
 forced upward by the reaction to the body-weight, so that the 
 anterior and posterior halves of the pelvic ring are no longer in the 
 
 same plane. The inclina- 
 tion of the pelvis as a whole 
 is also diminished, in con- 
 sequence of the displacement 
 forward of the sacrum into 
 the brim, for the same reason 
 as in the rachitic pelvis (see 
 p. 723). In extreme forms 
 of distortion, the spine often 
 yields irregularly, producing 
 corresponding irregularity 
 in the pelvis (Figs. 371, 
 372). 
 
 Fig. 374. — Rostrated malacosteon pelvis, seen 
 from the outlet. 
 
 The Triradiate Rachitic 
 or Pseudo - malacosteon 
 Pelvis. — In exceptional 
 cases of rickets a form of pelvis is produced closely resembling 
 the malacosteon pelvis (Fig. 375, p. 767). For its production it is 
 necessary that the softening of the bones should be greater and 
 more general than usual, and that the disease should be pro- 
 longed beyond infancy, so that the child walks and stands while 
 suffering from it. If the child walks and stands while the softening 
 is only slight, the result is the rachitic generally contracted pelvis 
 (see p. 714). The distinction from the malacosteon pelvis is made 
 by the history, by the signs of rickets in other parts, by the small 
 size of the pelvis, especially of the iliac fossfe, and by the fact that 
 the normal relation between Dist. Sp. II. and Dist. Cr. II. is 
 reversed, whereas in the malacosteon pelvis the spines are approxi- 
 mated. In other words, in the rachitic form the iliac fossfe are 
 flattened and look forward, in the malacosteon they are folded 
 
Rare Forms of Pelvic Deformity. 767 
 
 together (Fig. 373, p. 705). In the rachitic forra also the bones 
 are not so pliable, and there is not the irregularity often seen in 
 extreme degrees of osteo-malaeia. 
 
 Diagnosis. — In the early stages of osteo-malacia, attention may 
 be attracted to the disease by the occurrence of so-called rheumatic 
 pains in the pelvis and other bones, together with some paresis of 
 the flexor and adductor muscles of the thighs. The next change is 
 a sensation of weakness and debility, the patient is unable to walk 
 with any freedom, while the gait is peculiar. Bending of the spine 
 and long bones occurs, so that the stature is apparently shortened, 
 and ultimately in very severe cases the limbs become quite flaccid 
 and useless. When the deformity is established, diagnosis is easily 
 
 ¥i(i. 375. — Pseiido-malacosteon rachitic pelvis, viewed in the axis of the brim. 
 
 (Naegele.) 
 
 made, in the slighter forms from the beaked shape of the pubes 
 and narrowing of the pubic arch, in severe forms from the great 
 narrowing of the outlet and cavity of the pelvis in addition. The 
 bones may be pliant under pressure, and there may be deformities 
 also of the spine and other bones. The rachitic form is diagnosed 
 by the characters given above, and by the bones being hard and 
 not pliant. 
 
 Treatment. — In the malacosteon pelvis trial should always be 
 made whether the bones may not prove to be pliable enough to 
 allow the pelvis to be expanded by the hand passed into the 
 vagina, sufficiently to allow extraction of the foetus. Failing this, 
 the choice will generally be between embryotomy and Cesarean 
 section (see Chapter XXIX.), although in minor degrees of 
 deformity it may be possible to extract by forceps. Csesarean 
 section is preferable unless labour has been greatly prolonged, 
 since the ovaries can then be removed, and this operation has been 
 found to have a favourable effect upon the disease. 
 
768 
 
 The Practice of Midwifery. 
 
 In the iDseudo-malacosteon rachitic pelvis, with an equivalent 
 degree of deformity, it is still more likely to prove impossible to 
 
 Malacosteon 
 
 Naegele 
 
 Fig. 376. — The outline of the pelvic brim in the principal varieties of 
 contracted pelvis. (Bumm, Grundris der Geburtshilfe.) 
 
 extract through the jDelvis, since the pelvis is originally smaller, 
 and the bones are hard and not pliant. 
 
 The Oblique Pelvis. 
 
 There are three chief forms of oblique pelvis : — the scoliotic 
 oblique pelvis, due to lateral curvature of the spine ; the oblique 
 
Rare Forms of Pelvic Deformity. 769 
 
 pelvis, due to shortness or disuse of one leg ; and the oblique 
 pelvis of Naegele, due to deficiency of the wing of the sacrum 
 and anchylosis of the corresponding sacro-iliac articulation, 
 There is a similar action of certain forces in the production of 
 all these. 
 
 The Scoliotic Oblique Pelvis. — In lateral curvature (scoliosis) 
 of the spine, the bodies of the vertebrae are rotated to one side in 
 the dorsal region, to the opposite side in the lumbar region. 
 Generally the deviation is to the right in the dorsal region, being 
 due to the over-use of the right arm, and to the left in the lumbar 
 region. The result is that the line by which the body-weight is 
 transmitted to the pelvis is displaced to the same side as the 
 bodies of the vertebrae, and one leg or tuber ischii has to bear 
 more than its share of the weight. The bones and muscles of the 
 overweighted leg often become thicker. Hence the inward thrust 
 at the acetabulum, due to muscular action, is greater than on the 
 other side, and this is one cause why the acetabulum is pushed 
 inward, and the symphysis pubis is displaced toward the opposite 
 side (Fig. 377, p. 770). 
 
 Another cause is the following. When the line of body-weight 
 is displaced much to one side, it cuts the posterior sacro-iliac 
 ligament on one side (see Fig. 15, p. 13) instead of falling in the 
 middle line between the two ligaments. A consideration of the 
 equilibrium of the sacral beam itself shows that the result must 
 be that more and more strain is thrown upon those fibres of the 
 ligament close to the joint, and upon the " bite " on the bony 
 surface which exists in the Joint itself, and is pressed more strongly 
 than usual against the ilium. Otherwise the over-weighted end 
 of the sacrum would be displaced downward, away from the 
 corresponding ilium. It follows that, although the weight trans- 
 mitted to the ilium on the over-weighted side is increased, the 
 posterior arm of the lever formed by the innominate bone is 
 diminished in more than the same proportion. The leverage, 
 therefore, is diminished on the over- weighted side, and that on the 
 other side preponderates over it, and displaces the symphysis 
 pubis toward the under-weighted side. 
 
 As soon as displacement of the acetabulum inward has begun, 
 the princij^le already mentioned, by which the tendency to dis- 
 placement is thereby increased, comes into play (see p. 699), for 
 the outward leverage of the reaction to body-weight at the 
 aceiabalum is diminished, and may be eventually converted into 
 inward leverage, as in the triradiate pelvis, if one acetabulum is 
 
 M. 49 
 
770 
 
 The Practice of Midwifery. 
 
 brought nearer than the corresponding sacro-iliac jomt to the 
 middle line. 
 
 The other chief changes produced in consequence of the obliquity 
 are the following. The wing of the sacrum and the ilium on the 
 over-weighted side are thickened and shortened from the effect of 
 extra pressure acting in the axis of the bone. The pelvic brim is 
 elevated on the over-weighted side, there is some bulging inward 
 opposite the acetabulum, the crest of the ilium is higher, the iliac 
 fossa. looks more inward. 
 
 Generally there is in addition some flattening in the scoliotic 
 pelvis. This may be due simply to increased pelvic inclination in 
 consequence of the normal antero-posterior curves of the spine 
 
 Fig. 377. — Scoliotic flattened pelvis. (After A. Martin.) 
 
 being exaggerated, or it may be the result of associated rickets, 
 The characters of the flattened pelvis, rachitic or otherwise, are 
 therefore generally more or less combined with those mentioned 
 above (see Fig. 377). 
 
 The Oblique Pelvis from Shortening or Disease of one 
 Leg. — This is closely allied to the last form. Unless the legs are 
 equalised by the wearing of a high boot, the pelvis is tilted down- 
 ward on the side of the shortening. This displaces the line of the 
 body-weight toward that side, and the shortened leg becomes 
 over-weighted. Obliquity of the pelvis is produced by the same 
 forces as in the former case. There is here also an additional 
 cause, namely, that from the tilting of the pelvis the reaction to 
 the body-weight at the acetabulum on the side of the shortened leg 
 
Rare Forms of Pelvic Deformity. 771 
 
 is inclined inward toward the centre of the pelvis (which normally- 
 it is not), and therefore has a component producing an inward 
 thrust. The scoliosis of the spine, secondary to the tilting of the 
 pelvis, will still further increase the effect. 
 
 A similar effect is produced when the function of one leg is 
 destroyed, as by amputation, disease of hip-joint or other parts, 
 fracture, or unreduced dislocation, and the patient stands and 
 walks with the remaining leg and a crutch. The effects of over- 
 weight are then manifested on the side of the sound leg, and 
 the symphysis pubis is displaced toward the opposite side. In 
 Fig. 378 is shown an oblique pelvis due to the disease and 
 anchylosis of one hip-joint. The 
 atrophy of the pelvic bones, pubes 
 and ischium, on the side which 
 bears no weight, is in this - case 
 very marked. 
 
 The Oblique Pelvis of 
 Naegele. — The essential charac- 
 ters of this pelvis are that there is 
 complete absence or imperfect 
 development of one wing of the 
 sacrum and anchylosis of the cor- 
 responding sacro-iliac joint, caus- 
 ing bony union between the 
 sacrum and innominate bone. It 
 is probable that the maldevelop- fig. 378.— Oblique pelvis, from Zichj- 
 ment is primary and the anchy- ^osis of the hip-joint, and disuse of 
 
 right leg 
 
 losis is secondary, since the whole 
 
 of the ala may be absent without any bony union, and pelves have 
 
 been described in which one or more of the alse of separate sacral 
 
 vertebras have been absent while the remainder were present and 
 
 normal. 
 
 The condition may, however, be due to disease of the joint 
 in early infancy, or to caries affecting its neighbourhood; and 
 if this occurs at a very early age the ultimate effect upon the 
 pelvis is the same as that produced by the congenital mal- 
 development. 
 
 Naegele, however, himself considered that the deformity is the 
 result of an original anomaly of development, because there is 
 generally no history of disease, nor evidence of it in the appear- 
 ance of the bones, and because the bony fusion is complete. In 
 the case of anchylosis of the joint produced by inflammation later 
 
 49—2 
 
772 
 
 The Practice of Midwifery. 
 
 in childhood, a less complete form of the Naegele obliquity may 
 result 1 (Fig. 380, p. 773). 
 
 Causation.— The deformity is produced in the following way. 
 Complete bony union forms between the sacrum and the ilium at a 
 very early period, and the wing of the sacrum remains quite 
 undeveloped. The growth of the ilium is not affected because the 
 synostosis does not affect its growing extremities. The leverage of 
 the innominate bone on the affected side is entirely destroyed, and 
 the weight of the body on that side is transmitted through the bony 
 union. Hence, since the ilium is not subjected to the usual bend- 
 ing force, its inner border on the affected side, which forms a part 
 of the ilio-pectineal line, remains almost absolutely straight (see 
 
 Fig. 379. — Oblique pelvis of Naegele. 
 
 Fig. 379), instead of becoming more sharply curved than usual, as 
 in the other forms of oblique pelvis (Fig. 377, p. 770, and Fig. 378, 
 p. 771). This peculiarity is perhaps the most striking proof of the 
 truth of the theory as to the leverage action of the innominate bone. 
 The obliquity of the pelvis results from two causes : first, the 
 deficiency of the sacral wing ; secondly, the anchylosis. The first 
 calls out forces similar to those which act in the two other forms of 
 oblique pelvis. The line of body-weight falls nearer to the 
 acetabulum and tuber ischii on the affected side. Hence the leg 
 on that side is over- weighted, the muscles hypertrophied in com- 
 parison with those on the other side, and the inward pressure at 
 the acetabulum, due to muscular action, is increased. 
 
 In consequence of the anchylosis, the leverage exerted by the 
 
 1 See Champneys, " On the Obliquely Contracted Pelvis of a Child with Left Sacro- 
 liac Synostosis," Trans. Obst. Soc. London, 1882, Vol. XXIV., p. 191. 
 
Rare Forms of Pelvic Deformity. 773 
 
 posterior sacro-iliac ligaments on the innominate bone on the 
 sound side (see Fig. 25, p. 27), being unopposed, draws over the 
 symphysis pubis toward the sound side, and thus forms an additional 
 force causing obliquity. It is difficult to say which of the two 
 causes has the greatest influence in causing the oblique shape. 
 Probably the deficiency of the sacral wing has most, since an 
 obliquity as great as that of the Naegele pelvis may result without 
 any unilateral action of the leverage of the posterior sacro-iliac 
 ligaments (see Fig. 378, p. 771). But the effect of the unilateral 
 leverage is shown in the straightness of the ilio-pectineal line near 
 the anchylosed joint, as already mentioned. 
 
 The more obliquity has been already j)roduced by the action of 
 these two causes, the more the forces tend to increase the obliquity. 
 
 Fig. 380. — An oblique pelvis of Naegele, in which the distortion 
 is only slight. 
 
 according to the principle which has been already explained (see 
 pp. 698, 699). 
 
 Other resulting changes in the pelvis are that the affected side 
 is elevated, the ilium is shortened and thickened from excessive 
 pressure in the axis of the bone, the crest is elevated and the iliac 
 fossa looks more inward. The last peculiarity is more marked, 
 being partially due to failure of leverage acting on the ilium. 
 Owing to the synostosis on one side, that sinking forward of the 
 sacrum between the ilia, which normally takes place in the advance 
 from infancy to adult life, can only occur on the sound side. Thus 
 is produced a turning of the anterior face of the sacrum toward 
 the affected side, not only in reference to the distorted pelvis, but 
 in reference to the mesial plane of the body. The pubic arch is 
 narrowed, from one tuber ischii being inverted, and faces somewhat 
 toward the deformed side (see Fig. 379). 
 
 There is an important difference as regards the tuber ischii from 
 
774 
 
 The Practice of Midwifery. 
 
 other forms of oblique pelvis. In the scoliotic pelvis (see Fig. 377, 
 p. 770) this is everted in the usual way from the reaction to the 
 body- weight acting on the tuber ischii in sitting (see p. 30), 
 especially since the pelvis generally partakes of the flattened 
 character, and this side has to bear more than its share of the 
 weight. In Naegele's oblique pelvis, on the contrary, owing to the 
 absence of the sacral wing, and the straightness of the innominate 
 bone, the tuber ischii initially falls very little outside the line 
 joining the junctions of the innominate bone with the sacrum and 
 
 Fig. 381. — Oblique pelvis of Naegele seen from behind. (Naegele, Das 
 Schrag Yerengte Becken., Fig. Y.) 
 
 pubes. The tendency to rotate the lower part of the innominate 
 bone outward on an axis passing through these junctions is therefore 
 much diminished, and the tuber ischii, which is always drawn 
 inward by the tension of the great sacro-sciatic ligament, remains 
 inverted, as compared with that on the opposite side, and so con- 
 tracts the pelvic outlet (Fig. 381). The same counter-pressure 
 on the tuber ischii, since the tuber is often nearer the middle 
 line than the synostosis of sacrum and ilium, tends also to rotate 
 the anterior end of the innominate bone inward on an axis perpen- 
 dicular to the brim through that synostosis. The former of those 
 two effects depends upon the component of the counter-pressure 
 resolved perpendicularly to the plane^of the brim, the latter upon 
 
Rare Forms of Pelvic Deformity. 775 
 
 the component resolved in a direction parallel to the same plane, 
 as explained at pp. 26 — 33. Thus the effect of sitting, as well as 
 standing, tends to increase the obliquity. 
 
 In all the forms of oblique pelvis, the ilio-pectineal line on the 
 under-weighted or less contracted side has its curvature diminished 
 at the posterior part, and increased at the anterior part. Not only 
 is the ilium on the over-weighted side shortened and thickened by 
 excessive pressure in its axis, but the same effect is produced also 
 on the superior ramus of the pubes which forms the opposite 
 quadrant of the pelvic brim, for, being parallel to the oblique 
 diameter which is undergoing compression, this is also subject to 
 extra pressure in its axis. 
 
 In all forms of oblique pelvis, one oblique diameter of the brim 
 is shortened and the other, if anything, lengthened. Also the 
 greatest shortening affects the sacro-cotyloid diameter on the over- 
 weighted side. The shortening and the general contraction are 
 much the greatest in Naegele's pelvis, on account of the absence of 
 the sacral wing and the contraction of the outlet. A pelvis approxi- 
 mating in shape to Naegele's pelvis may be produced if, without 
 any anchylosis, but in consequence of caries, disease of the joint, 
 or any other cause, one wing of the sacrum is less developed than 
 the other. 
 
 Diagnosis. — Scoliosis of the spine or an affection of one leg will 
 attract attention to the probable pelvic obliquity. A Naegele's 
 pelvis may easily be overlooked unless special examination is made. 
 A difference in the distance from the last lumbar vertebra to the 
 posterior superior iliac spine, and from the tip of the sacrum to the 
 tuber ischii on the two sides, is the best sign of deficiency of one 
 wing of the sacrum. If the woman is made to stand upright and 
 a plumb-line is let fall from a sacral spine, and another from the 
 symphysis pubis, a line joining the two will deviate from the mesial 
 plane in an oblique pelvis. The best test is, however, vaginal 
 examination. If the promontory of the sacrum is reached, it will 
 be found to deviate to one side, and the diminished lateral space 
 on that side will be detected. Certain external oblique or diagonal 
 measurements may be compared on the two sides, but too much 
 reliance should not be placed upon this comparison. The following 
 characters are given by Naegele for the Naegele pelvis : — 
 
 (1) The distance from the tuber ischii of the deformed side to the 
 posterior superior spine of the opposite ilium is shorter than its 
 fellow. 
 
 (2) The distance from the anterior superior spine of the deformed 
 side to the opposite posterior superior spine is shorter than its fellow. 
 
776 The Practice of Midwifery. 
 
 (3) The distance from the spinous process of the last lumbar 
 vertebra to the anterior superior spinous process of the deformed 
 side is shorter than its fellow. 
 
 (4) The distance from the great trochanter on the deformed 
 side to the opposite posterior superior spine is shorter than its 
 fellow. 
 
 (5) The distance from the symphysis pubis to the posterior 
 superior spine on the deformed side is longer than its fellow. 
 
 In all these, except No. 3, that is to say, in all the diagonal 
 measurements, it will be seen that the posterior extremity of that 
 measurement which exceeds its fellow is on the side of the 
 anchylosis. 
 
 Mechanism of Labour. — The mode in which the head enters 
 the brim varies according to the exact size and shape of the pelvis. 
 If the deformity is slight, the long diameter of the head enters in 
 the longer oblique diameter. If one sacro-cotyloid diameter is 
 greatly contracted, the corner of the brim which it shuts off cannot 
 be utilised by the head at all. The long diameter then enters in 
 a diameter approximating to the shorter oblique (see Fig. 377, 
 p. 770, and Fig. 380, p. 773), but having its anterior end nearer to 
 the symphysis pubis. 
 
 Prognosis. — Naegele's oblique pelvis causes great difficulty in 
 delivery. According to Litzmann's statistics, out of 28 mothers 
 22 died after the first confinement, 3 after the second, and 2 after 
 the sixth. Only 6 of 41 labours ended spontaneously ; of the 
 remainder 2 were delivered by Cesarean section, 4 by premature 
 labour, 13 after perforation of the child's head, and the remainder 
 by the use of forceps or manual extraction. Five women died 
 undelivered. Of the 41 children 10 only were born alive, and of 
 these 4 were by the same mother. The scoliotic pelvis, when com- 
 bined with the rachitic type, may also cause great difficulty. While 
 Naegele's oblique pelvis is very rare, slight degrees of obliquity, in 
 combination with flattening of the pelvis, are relatively common. 
 
 Treatment — In the first two forms of oblique pelvis, if the 
 distortion is moderate, forceps may be tried, and, if they fail, 
 craniotomy performed. It is not desirable, as a rule, to perform 
 version, unless the flattening of the pelvis preponderates over its 
 obliquity. But if the long diameter of the head does not appear 
 to lie in the best available diameter of the pelvis, version may be 
 performed, the leg brought down being so chosen as to bring the 
 head into the opposite oblique diameter, but it must be remembered 
 that, in considerable obliquity, the longer oblique diameter of the 
 pelvis does not give most room for the head. If the head cannot 
 
Rare Forms of Pelvic Deformity. 777 
 
 be brought through, perforation of the after-coming head must be 
 performed. 
 
 In the oblique pelvis of Naegele the difficulty is likely to be 
 greater at the brim and still more at the outlet. Cesarean section 
 is generally preferable as a first choice, otherwise craniotomy will 
 usually be required. 
 
 Ischiopuhiotomy. — Prof. Pinard, of Paris, successfully performed 
 the operation of ischiopuhiotomy in an oblique pelvis of Naegele. 
 The two rami of the pelvis are sawn through on the diseased side 
 between pubes and ischium, and between pubes and ilium. The 
 symphysis pubis is thus allowed to rotate outward upon the sacro- 
 iliac joint of the sound side, as the two pubic bones do in symphy- 
 siotomy. The gap thus obtained is supposed to be better placed for 
 
 Fig. 382. — Transversely contracted pelvis of Robert. 
 
 allowing the head to pass than if it were at the symphysis pubis. 
 This operation should only be considered if it is desired to save 
 the child after prolonged labour or attempts to extract through the 
 pelvis. 
 
 Transversely Contracted Pelvis, 
 
 There are two most marked forms of the transversely con- 
 tracted pelvis, namely, the transversely contracted pelvis of Kobert 
 (Fig. 382), due to anchylosis of both sacro-iliac joints, and the 
 kyphotic pelvis (Fig. 384, p. 780). 
 
 Transversely Contracted Pelvis of Robert The mode of 
 
 formation of this deformity has to be considered in close connection 
 with the obliquely contracted pelvis of Naegele. The difference 
 
778 The Practice of Midwifery. 
 
 is that, in Eobert's pelvis the anchylosis affects both sacro-iliac 
 articulations, and development of both wings of the sacrum fails. 
 In this, as in the Naegele oblique pelvis, there are two possible 
 explanations of the production of the deformity, the first that 
 there is a primary maldevelopment of the alfe of the sacrum, 
 associated or not, as the case may be, with secondary anchylosis 
 of the two sacro-iliac articulations, and the second that the synos- 
 tosis of the joints is the primary condition and has as a result the 
 maldevelopment of the alse. Breus and Kolisko maintain that 
 the latter is the true explanation. As both al?e are involved, 
 there is no inequality from unilateral action, but the other 
 effects of the failure of the action of leverage on the ilia, and the 
 want of the transverse width given to the pelvis by the sacrum, 
 are apparent. Not only does the widening of the pelvis usually 
 caused by the leverage exercised by the posterior sacro-iliac liga- 
 ments fail, but the outward leverages at the acetabula, due to the 
 reactions to the body-weight (see p. 28), are diminished, the 
 acetabula being nearer to the middle than usual. On both sides 
 the inner border of the ilium which forms part of the ilio-pectineal 
 line is nearly straight, and thus the transverse narrowing, due to 
 the want of the alae of the sacrum, is increased. Both tubera ischii 
 are inverted, instead of one, as in Naegele's oblique pelvis, and 
 hence the outlet is contracted even more than the inlet (see p. 699) , 
 the pubic arch is very acute, and the pelvis somewhat funnel- 
 shaped. The distance between the tubera ischii may not be more 
 than two inches. The antero-posterior diame-ter of the brim is 
 about normal, the transverse much contracted. The iliac fossse 
 are more upright than usual, but flat and directed anteriorly. In 
 described pelves of this kind the sacrum has been deeply sunk 
 between the ilia, and the concavity, in transverse section, of the 
 anterior surface converted into a convexity. This does not seem 
 explained by the mode of production of the deformity, but may have 
 been due to a softening of the sacrum by the diseased condition 
 of the bone which produced the double anchylosis, or else to an 
 exaggerated pelvic inclination. 
 
 Eobert's pelvis is extremely rare, and only about thirteen well- 
 marked pelves of this kind have been described. The difficulty in 
 delivery which it causes is, as might be expected, much greater than 
 even in Naegele's oblique pelvis. Of eight recorded cases, the 
 women were delivered in six by Cesarean section. In two they were 
 delivered by craniotomy, but died after parturition.^ 
 
 1 Spiegelberg, Lehrbuch der Geburtshiilfe, English translation, Hurry, Vol. II., 
 p. 107. 
 
Rare Forms of Pelvic Deformity. 779 
 
 The diagnosis would be made easily by the great contraction of 
 the outlet, and the smallness of the transverse diameters (Dist. Sp. 
 II. and Dist. Cr. II.). 
 
 I have met with one instance in which a similar transverse 
 contraction of the pelvis was ]3roduced 
 apparently not so much by absence of 
 the wings of the sacrum as by extreme 
 stunting in development of the whole 
 bone, which was less than half its 
 normal length as well as very narrow, 
 while the antero-posterior diameter of 
 the pelvis was normal. The trans- 
 verse diameter of the outlet between 
 the tubera ischii was less than two 
 inches. The shortness of the sacrum, 
 however, allowed more space than 
 usual behind the tubera. Delivery 
 was effected by the cephalotribe after 
 craniotomy, without very great diffi- 
 culty, entirely through the posterior 
 half of the pelvic outlet, and the 
 patient did well. 
 
 Treatment. — Csesarean section is best 
 as a primary choice. It may be pos- 
 sible when Caesarean section is contra- 
 indicated to extract after perforation by 
 the cephalotribe, the blades being kept 
 exactly lateral, if the outlet allows 
 sufficient space to apply it. 
 
 Fig. 383.— Figure of pregnant 
 woman with kyphotic pelvis. 
 Pelvic measurements : Dist. 
 Sp. II., 9 ins. ; Dist. Cr. II., 
 9 ins. ; Ext. Con j . , 6f ins. ; 
 Diag. Conj., 4i ins. ; Dist, 
 Tub. Isch., 31 ins. First 
 pregnancy, labour induced 
 at thirty-fourth week, child 
 delivered by version and per- 
 foration of after-coming head, 
 which was obstructed at out- 
 let of pelvis. Second preg- 
 nancy, labour induced at 
 thirty-fourth week, and living 
 child delivered. 
 
 The Kyphotic Pelvis. — The 
 kyphotic pelvis is a form of transversely 
 contracted pelvis resulting from 
 kyphosis (curvature with the concavity 
 forward) of the lumbar vertebrae with 
 the sacrum (Fig. 384). This is gener- 
 ally the consequence of caries in that 
 
 situation leading to a falling together and fusing of the bodies of 
 the vertebrse. Frequently, there is a compensatory lordosis 
 (curvature with the convexity forward) in the dorsal region. When 
 this is the case the natural curves of the dorsal and lumbar region 
 are exactly reversed. If the kyphosis affects the dorsal region, as a 
 rule it produces but little effect upon the pelvis. When, however, it 
 
78o 
 
 The Practice of Midwifery. 
 
 is in the lumbar region, and more especially when it involves the 
 upper end of the sacrum, the pelvis is markedly affected. In some 
 cases the superior strait of the pelvis is so overhung by the vertebral 
 column as to produce the so-called pelvis obtecta. If not, the 
 plane of the pelvic brim is almost perpendicular to the general axis 
 of the spine, as may be seen in Fig. 384. Hence, in order to 
 preserve the balance of the body in standing or sitting, the pelvic brim 
 must be almost horizontal instead of being inclined to the horizon 
 at an angle of 55° or 60°. Even when the kyphosis is somewhat 
 compensated by a lordosis above, the pelvic inclination must be 
 greatly diminished. The vertical space in the abdomen is much 
 diminished, the ribs being approximated to the iliac crests, with 
 
 Fig. 3Si. — Kyphotic pelvis. 
 
 the result that the abdomen tends to become markedly pendulous, 
 and abnormal presentations are especially frequent. The resulting 
 figure is shown in Fig. 383. 
 
 Mechanism of Production of the Deformity. — All the peculi- 
 arities of the kyphotic pelvis are explained by the abolition or 
 diminution of the pelvic inclination. The weight of the body, 
 instead of tending to force the sacrum downward into the brim, 
 tends only to force it in the direction of the coccyx. Thus the 
 action of the leverage of the innominate bone in widening the 
 pelvis is almost or entirely abolished, and the inward thrust at 
 the acetabula due to muscular action is unopposed. Hence the 
 pelvis is flattened transversely and elongated antero-posteriorly, 
 like a monkey's pelvis (see Fig. 10, p. 7). Narrowness already 
 existing to some extent, the effect of sitting in everting the tubera 
 ischii (see p. 30) is diminished or even reversed, while that of the 
 
Rare Forms of Pelvic Deformity. 781 
 
 tension of the great sacro-sciatic ligaments in inverting them is 
 increased in consequence of the antero-posterior lengthening of 
 the pelvis. The tubera and spines of the ischium are thus 
 approximated and the pubic arch narrowed. 
 
 In standing, the weight of the body is transmitted to the pelvis 
 much further back than usual in reference to the vertical plane 
 through the heads of the femora. As a result of the destruction of 
 some of the bodies of the vertebrae by caries, the bod3'-weight tends 
 to be transmitted through the arches and the transverse processes ; 
 this results, when the kyphosis is sufficiently high up, in a marked 
 lordosis of the spine below it, and in elongation of the bodies of the 
 sacral vertebrge.^ 
 
 The body can only be balanced on the heads of the femora by a 
 general inclination of the spine forward, a position calling for more 
 muscular effort to maintain than the normal position of the spine, 
 namely, one coinciding on the whole with a vertical line, the curve 
 falling alternately in front and behind. To avoid this muscular 
 effort, in the position of " standing at ease," more strain than usual 
 is thrown upon the ilio-femoral ligaments, attached to the anterior 
 inferior spine of the ilium and the upper border of the acetabulum, 
 and the spine is thus rendered more erect.^ 
 
 The result of the over-action of the ligaments is shown by 
 increased bony prominences in these situations (see Fig. 384). 
 The effect of this increased tension tends to rotate the innominate 
 bone on an axis passing through the sacro-iliac joint and symphysis 
 pubis, inverting still more the lower part of the innominate bone, 
 the tuber and spine of the ischium, and everting the upper part 
 with the iliac fossae. As regards the sacrum itself, the results of 
 the altered direction of the body-weight are that the transverse 
 concavity is greater than in the normal adult pelvis, the antero- 
 posterior concavity less. The promontory is not rotated forward, 
 but rather the lower extremity, partly from the traction of the 
 sacro-sciatic ligaments, partly from the falling together of the 
 bodies of the vertebrae. The iliac fossae are everted, looking upward 
 and forward, and the S-shaped curve of the crest is slight. This 
 result, like the inversion of the tuber and spine of the ischium, 
 follows from the altered effect of sitting, and the traction of the ilio- 
 femoral ligaments. In some cases the sacrum is very narrow, a 
 result probably due to the disease which led to the kyphosis. 
 
 1 Breus and Kfjlisku, \)\(: I'lithologischen Beckenformcn, 1900, p. 163. 
 
 2 it is not sufficient merely to say that the rotation of the pelvis backward, to bring 
 about the diminished inclination, (tuts these ligaments on the stretch. If this were 
 all, the ligaments would doiihlless accommodate themselves to the position of the 
 pelvis. 
 
782 The Practice of Midwifery. 
 
 The final result is that at the brim there is alteration of shape 
 but no contraction of importance, while at the outlet contraction 
 may be very considerable. Unless the sacrum is narrowed, the 
 brim is actually larger than normal, from the eversion of the upper 
 part of the innominate bones. In some cases, however, the dimen- 
 sions of the brim are in reality smaller than normal owing to the 
 presence of some general contraction. 
 
 Mechanism of Labour. — It might be expected that the long 
 diameter of the head would enter the long diameter of the brim, 
 and it doubtless does so, when it fits the brim at all tightly, a result 
 which can only hapj)en when there is a considerable narrowing of 
 sacrum or general contraction, in addition to the kyphosis. But 
 it is most frequently found that the long diameter enters obliquely 
 or even transversely, since it finds room to pass easily even the 
 smaller transverse diameter, and its direction is therefore deter- 
 mined by that of the foetus in utero.. According to Klien,^ in 
 37 to 38 per cent, of all head presentations the occiput is 
 directed backwards, a result no doubt of the condition of pendulous 
 abdomen so often seen with these pelves, and the absence of the 
 normal lumbar convexity of the spine. For the spine of the child 
 will not be near enough to the spine of the mother to be repelled 
 by it and turned forwards. Brow and face presentations are also 
 relatively frequent in kyphotic pelves. The difficulty generally 
 begins when the head approaches the outlet. Here the head is 
 often unable to use the anterior part of the space, on account 
 of the approximation of the tubera ischii (see Fig. 384, p. 780). 
 It frequently descends transversely, or with the occiput rotating 
 somewhat backward, and passes through the outlet entirely 
 behind the tubera ischii. This mode of delivery resembles that 
 which is usual with the lower animals. The joints in this form of 
 pelvis have not uncommonly been found somewhat yielding, and it 
 is recorded that in some cases space between the tubera ischii has 
 been gained by widening of the pubic arch. If the head passes the 
 bony outlet in a transverse position or nearly so, the occiput may 
 afterwards rotate forwards under the pressure of the soft parts. In 
 some cases a compensatory lordosis, when situate very low down, 
 forms a projection overhanging the brim [pelvis ohtecta or spondy- 
 lizeme),^ and impedes the descent of the head into it. 
 
 Diagnosis — The diagnosis will be made by the recognition of 
 the spinal deformity, by the contraction of the outlet, especially the 
 small distance between the tubera and spines of the ischium, found 
 
 1 Klien, Archiv f. G-ynak., 1896, Bd. 1, s. 1. 
 
 * Herrgott, " Die Spondylizeme," Arch, de Tocologie, 1877, p. 65. 
 
Rare Forms of Pelvic Deformity. 783 
 
 on vaginal examination, and by the difficulty of reaching the upper 
 part of the sacrum. 
 
 Prognosis. — In the statistics collected by Champneys^ of 32 
 labours occurring to 20 mothers, the results were that 9 mothers 
 died, that is to say 45 per cent, of the mothers, or 28*1 per cent, of 
 deaths in proportion to labours ; 13 children died, or 40*6 per cent. 
 These results doubtless give a higher mortality than the average, 
 the gravest cases having been recorded. Of 200 cases collected by 
 Neugebauer^ only 44 ended spontaneously, and 24 per cent, of the 
 mothers and 48'4 per cent, of the children died. Klieh records a 
 foetal mortality of 40 i^er cent., while the maternal mortality varied 
 between 6*2 and 17 per cent., depending upon the degree of con- 
 traction of the outlet of the pelvis. 
 
 Whenever the distance between the ischial tuberosities is less 
 than 8 inches (7'5 cm.) delivery is likely to be very difficult. 
 
 Treatment. — It will very rarely happen that interference is 
 called for, in head presentations, until the head has descended far 
 into the pelvis. If in any case assistance is required while the head 
 is in the brim, or high in the cavity of the pelvis, the action of 
 forceps is more favourable than in the flattened pelvis, since the 
 compression of the head produced by them is exactly in that diameter 
 of the pelvis where compression is wanted, namely in the transverse. 
 Hence, in head presentations, version should never be performed. 
 Forceps should be tried, if there appears to be a fair prospect of 
 delivery by their means. If craniotomy is found necessary, extraction 
 by the cephalotribe has an advantage similar to that of extraction 
 by forceps. The blades of the cephalotribe being kept lateral, the 
 compression exercised is precisely in the direction most required. 
 The head flattened in the grasp of the instrument may pass in part 
 between the tubera ischii, even when the distance between these 
 is not above 2 inches. If the outlet does not give room for the 
 passage of a living child, Csesarean section should be preferred as a 
 first choice, especially if there is not a space measuring 2^ inches 
 in its smallest diameter, and at least 3^ inches in a diameter 
 bisecting the former at right angles. Symphysiotomy will afford 
 a greater relative increase of room than in a flattened pelvis. 
 Induction of premature labour will be desirable in case of any 
 considerable contraction of the outlet, if the patient comes under 
 observation before full term, and the alternative of Csesarean section 
 is not preferred. 
 
 1 See ChampncyH, "The Obstetrics of the Kyphotic Pelvis," Trans. Obst. See. 
 London, 1883, Vol. XXV., p. UiC. 
 ' Neugebauei', Monatschr. f. Geb. u. Gyn., 1805, Bd. 1, s. 347. 
 
784 
 
 The Practice of Midwifery. 
 
 The High Assimilation Pelvis. — This title has been given to 
 the pelvis resulting from a fusion of the last lumbar vertebra with 
 the sacrum, so that the sacrum is made up of six vertebrae instead 
 of five. In consequence, the sacro-vertebral angle and the inclina- 
 tion of the pelvis are diminished. The effect is a pelvis of which 
 the transverse and conjugate diameters at the brim are nearly 
 equal, or which may be slightly contracted transversely. The 
 lower parts of the innominate bone are somewhat inverted, and 
 the lower end of the sacrum tilted forward, so that the pelvis is 
 somewhat funnel-shaped, but less so than the kyphotic pelvis. 
 Thus obstruction to labour may occur at the outlet, especially if 
 
 there is some general contraction 
 in addition. 
 
 Whitridge Williams^ has drawn 
 particular attention to the not 
 infrequent occurrence of slight 
 degrees of contraction of the pelvic 
 outlet, and he maintains that three- 
 fourths of these cases are associated 
 with a high assimilation pelvis. 
 The shortening may occur in either 
 the transverse or the antero-pos- 
 terior diameters of the outlet. The 
 increased shortening of the trans- 
 verse may be associated with such 
 narrowing of the pubic arch that 
 only the posterior portion of the 
 outlet lying between the greatest 
 transverse diameter and the lower extremity of the sacrum is avail- 
 able for the passage of the child's head. To estimate this space what 
 Klien has termed the posterior sagittal diameter of the outlet should 
 be measured from the centre of a line joining the two ischial tubero- 
 sities to the posterior surface of the extremity of the sacrum. If 
 it measures less than 8*5 cm., and is associated with a contracted 
 transverse diameter, spontaneous labour is likely to be extremely 
 difficult, if not impossible. 
 
 Fig. 385. — Pelvis of a woman who had 
 been bedridden from infancy up to 
 the age of 31. (After Blittner.) 
 
 The Low Assimilation Pelvis. — In the low assimilation 
 pelvis, the first sacral vertebra is assimilated to the lumbar spine, 
 and the sacrum consists of only four vertebrae. This pelvis does 
 not lead to obstruction in labour. 
 
 1 Whitridge Williams, Obstetrics, 1908, p. 762 ; Klien, Volkmann's Saml. Klin. 
 Vortrage, 1896, N. F., No. 169. 
 
Rare Forms of Pelvic Deformity. 785 
 
 The Bed-ridden Pelvis. — The bed-ridden pelvis is analogous 
 to the kyphotic pelvis in the shape of the brim, but the outlet is 
 not contracted in the same way, as there is less approximation of 
 the tubera ischii and narrowing of the pubic arch. There is apt 
 to be some general contraction as well as alteration of shape, since 
 the disease which obliged the child to lie in bed during the years 
 of development is likely to have interfered with nutrition. The 
 explanation of the shape appears to be that in the absence of sitting, 
 
 as well as standing and walking, the 
 leverage effects of the reactions to the 
 body-weight in widening the pelvis 
 are abolished. Also, the sacrum 
 growing less rapidly than the rest of 
 the pelvis, the brim is relatively 
 narrower transversely than that of a 
 fcetus or child, and the outlet remains 
 somewhat funnel-shaped. 
 
 The Spondylolisthetic Pelvis.^ — 
 In the spondylolisthetic pelvis 
 (Fig. 387, p. 786), the body of the last 
 lumbar vertebra is dislocated forward 
 and downward over the anterior 
 surface of the sacrum. The other 
 lumbar vertebrae are carried forward 
 with it, hanging over and projecting 
 into the brim. The available conju- 
 gate diameter is thus greatly reduced, 
 and is measured, not to the promon- 
 tory of the sacrum, but to the nearest 
 of the lumbar vertebrae. 
 
 A hollow is formed in the body 
 above the sacrum. The stature is diminished, the abdomen 
 shortened, and the ribs approximated to the iliac crests. The 
 resulting figure is shown in Fig. 386. 
 
 Causation. — This dislocation of the lumbar vertebrae is produced 
 after birth by the weight of the body, and, in the majority of cases, 
 it is due to a fall or injury. The displacement is normally prevented 
 by the locking between the articulating processes of the sacrum and 
 the inferior articulating processes of the last lumbar vertebra. It 
 is rendered possible in one of two ways. (1) By a separation 
 
 Fig. 386. — Figure of a woman with 
 spondylolisthetic pelvis. (After 
 Ahlfeld.) 
 
 l'"rom (nr/)V^vK(iv , a vertchira, oAiVSr/o-is, Klidiiig or dlHlocatioii. 
 
 M. 
 
 50 
 
786 
 
 The Practice of Midwifery. 
 
 between the anterior and posterior halves of the last lumbar 
 vertebra. This may be due to a failure of development, namely, 
 a want of union between the arch and body of the vertebra, or to 
 a destruction of that union by fracture of the pedicles. The body 
 of the last lumbar vertebra is then displaced forward, leaving the 
 articulating processes behind, and the antero-posterior diameter of 
 the whole vertebra is eventually increased. (2) By a dislocation 
 forward of the whole lumbar vertebra upon the sacrum. This 
 implies a destruction of the union between the pairs of articulating 
 processes, generally through fracture of the articulating processes 
 of the sacrum.-"^ According to F. Neugebauer,^ there may be first 
 a dislocation of the whole lumbar vertebra, and later a separation 
 
 Fig. 387. — Spondylolisthetic pelvis. (After Kilian.) 
 
 of the anterior and posterior halves, owing to the displaced action 
 of the body- weight. He maintains that this is accompanied by a 
 gradual elongation of the interarticular j)ortion of the last lumbar 
 vertebra, which becomes converted into a long, thin lamina of 
 bone. The elongation of the interarticular portion he attributes to 
 imperfect development or to fracture and subsequent stretching of 
 the callus. Deficient ossification of the laminae of the fourth and 
 fifth lumbar vertebrae is not at all uncommon, and may be associated 
 with similar defects in the laminae of the upper sacral vertebrae.^ 
 
 1 Arbuthnot Lane, however, contends that the whole effect may result from pressure 
 due to carrying weights, and that this pressure alone, acting over a long period of time, 
 may cause absorption and division of the laminje (Path. Trans., Vol. XXXVI.). 
 
 2 Du Bassin vicie par le Glissement Vertebral, Paris, 1884. Also in Trans. Obst. Soc. 
 London, 1884, Vol. XXVL, p. 84. 
 
 3 Blacker, Trans. Obst. Soc. London, 1900, Vol. XLIL, p. 90 ; Lawrence, Trans. Obst. 
 Soc. London, 1900, Vol. XLIL, p. 75 ; Neugebauer, Spondylolisthesis et Spondylizfeme, 
 1892. 
 
Rare Forms of Pelvic Deformity. 787 
 
 The change in the pelvis is generally produced more or less 
 gradually by the action of the body-weight. It is usually accom- 
 panied by inflammatory changes in the bones, and the sacrum and 
 some of the lumbar vertebrse often become fused into one mass. 
 In well-marked cases the inferior articular process of the last 
 lumbar vertebra and the superior articular process of the first 
 sacral vertebra, as well as the inferior articular process of the fourth 
 lumbar vertebra and the superior of the fifth lumbar, become firmly 
 anchylosed together. 
 
 In some cases the spines of the lumbar vertebrge become greatly 
 thickened, and either fused into one mass with each other, and 
 with the spine of the first piece of the sacrum, or united by joints. 
 This proves that excessive weight has been in action, and that it 
 
 Fig. 388. — Bony growth of the sacrum. 
 
 has been transmitted, in part, by the spines instead of by the bodies 
 of the vertebrge. 
 
 Resulting Changes in the Pelvis. — As the whole spine sinks not 
 only downward but forward over the pelvis, the pelvic inclination 
 must be diminished, to preserve the balance in standing or sitting. 
 The reactions to the body-weight tend to increase the same effect 
 by pushing the anterior half of the pelvis upward, as in other 
 cases in which the line of incidence of the body-weight is displaced 
 forward, such as the rachitic and malacosteon pelves. In severe 
 cases, such as that shown in Fig. 387, the inclination is actually 
 reversed, the top of the sacrum being lower than the symphysis 
 pubis. The last lumbar vertebra pushes the top of the sacrum 
 backwards (see Fig. 387), and the lower end of the sacrum is thus 
 rotated forward, narrowing the pelvic outlet antero-posteriorly. 
 In severe cases this is increased ]jy pressure on the lower part of 
 the sacrum in sitting. Owing to the diminished pelvic inclination 
 
 50—2 
 
788 
 
 The Practice of Midwifery. 
 
 Fig. 389. — Sacral exostosis filling the 
 pelvis. 
 
 the sacrum sinks deeply, under the pressure of the body-weight, 
 in the direction of the coccyx, separating the iha. Thus the 
 
 posterior crests of the iha are 
 wide apart, and the Dist. Cr. II. is 
 increased. Increased traction on 
 the sacro-sciatic hgaments, owing 
 to the recession of the sacrum, 
 draws the tubera and spines of the 
 ischium inward. Also, in conse- 
 quence of the diminished pelvic 
 inclination, increased strain is 
 thrown upon the ilio-femoral liga- 
 ments, as in the kyphotic pelvis 
 (see p. 781), but not to so great 
 an extent, because the body-weight 
 is not transmitted to the pelvis so 
 far back as in that case. The 
 tension of the ilio-femoral liga- 
 ments increases the tendency to 
 inward rotation of the spines and 
 tubera of the ischium, as in the kyphotic pelvis. Hence the 
 pelvic outlet is contracted transversely as well as longitudinally. 
 
 The spondylolisthetic 
 pelvis, in its fully developed 
 form, is very rare, but accord- 
 ing to F. Neugebauer, minor 
 degrees of it are commoner 
 than has been supposed. 
 Since the development of the 
 deformity is largely due to 
 carrying excessive weights, 
 it is much rarer in women 
 than in men. 
 
 Diagnosis. — There may be 
 a history of injury in child- 
 hood or youth, followed by 
 pain in the body, change of 
 figure, and perhaps loss of 
 stature. Walking is affected 
 by the deformity, and is waddling in character. The buttocks 
 project much backward; the posterior crests of the ilia and top of 
 the sacrum are very prominent, while above is a deep cavity 
 corresponding to the lumbar vertebrae. The edges of the ribs are 
 
 Fig. 390. — Minor degree of deformity from 
 exostosis of the cristje of the pubis. 
 
Rare Forms of Pelvic Deformity. 789 
 
 too near to the iliac crests, the abdomen shortened and prominent. 
 On vaginal examination the prominence produced by the lumbar 
 vertebrae may be distinguished from a projecting sacrum by the 
 absence of the sacral wings. Sometimes the bifurcation of the 
 aorta and iliac arteries can be reached, being displaced much 
 downward. The contraction of the outlet will also be a point of 
 distinction from the flattened reniform pelvis. 
 
 Prognosis — Swedelin^ has collected the statistics of 19 cases. 
 In these there were 48 deliveries, 31 at full term, 10 induced 
 premature labours, 4 spontaneous premature labours, 3 abortions. 
 Of the 19 mothers 8 died, or 
 42 per cent., 1 after an abor- 
 tion, only 3 after Csesarean 
 section. Of the children 16 
 passed the genital canal alive, 
 4 were delivered by Csesarean 
 section. It is clear from this 
 that in the severer degrees of 
 deformity the obstacle to 
 delivery is very great, but in 
 slighter degrees it may be 
 overcome by the natural 
 powers, or by forceps or ver- 
 sion. In some cases increase 
 of difficulty in successive 
 labours has been noted, 
 apparently due to increase in 
 the deformity. 
 
 Treatment. — In milder 
 degrees of deformity the 
 choice between induction of premature labour or abortion, the use of 
 forceps, version, craniotomy, symphysiotomy, or Csesarean section, 
 will be similar to that in the reniform flattened pelvis, the virtual 
 conjugate, measured to the nearest point of the lumbar vertebrse, 
 being taken for the estimation instead of the true conjugate. In 
 more extreme degrees the contraction of the outlet may complicate 
 the question by rendering access with instruments difficult, as well 
 as by impeding the passage of a living child, and so may turn the 
 scale in favour of Csesarean section. 
 
 Fig. 391. — Cancerous growths from the bones 
 of the pelvis, causing deformity. 
 
 Pelvis deformed by Outgrowths. — Obstruction of the pelvis 
 caused by exostosis is rare, but may be so great as to render 
 
 1 Arch, flir Gynak., Bd, 22, Hft. 2. 
 
790 
 
 The Practice of Midwifery. 
 
 delivery through the genital canal impossible. The most common 
 situation of growth is the upper half of the sacrum. The growth 
 has then to be distinguished from a projecting promontory by its 
 shape, and by the external measurements of the pelvis. In cases 
 of multiple exostoses throughout the body, there may be multiple 
 exostoses also in the pelvis. These cause more difficulty if they 
 are on opposite sides of the pelvis, and easily cause laceration of 
 
 Fig. 392. — Enchondroma of sacrum obstructing labour. Porro's operation 
 with intraperitoneal treatment of stump. Death from uremia. (Univ. 
 Coll. Hosp. Med. School Mus.) 2 
 
 the uterus through pressure and friction even when they are 
 comparatively small. The pelvis in such cases is often found to 
 be in addition generally contracted or rachitic,^ and the difficulty 
 is thus increased. Growths may be enchondromata,^ osteo- sarcomata 
 or carcinomata as well as purely bony (see Fig. 392), In the case of 
 rheumatoid arthritis, with bony outgrowths, affecting the hip-joints, 
 osteophytes may form also on adjacent parts of the pelvis (Fig. 390, 
 
 1 Neuenzeit, Becken mit multipelen Exostosen, I. Dissert., Breslau, 1872. 
 
 2 Spencer, Trans. Obst. Soc. London, 1896, Vol. XXXVIII., p. 389. 
 
Rare Forms of Pelvic Deformity. 791 
 
 p. 788). In other cases spiculse or ridges of bone projecting 
 inwards may form at the insertion of ligaments or tendons or along 
 the natural edges of bone. These not only occupy some space, but 
 may press upon and lacerate the uterus in labour. Cases are also 
 on record in which the callus resulting from fractures of the 
 pelvis has encroached upon the pelvic cavity, and obstructed 
 labour. 
 
 Treatment. — If the growths are bony they will be incompres- 
 sible, and the treatment must be decided according to the amount 
 of space left, as in the case of pelvic deformity. If projecting 
 points or edges of bone are detected, the tendency of these to 
 cause laceration of the uterus must be remembered. Much force 
 must not be used in extraction by forceps in order to secure a 
 living child, and there must not be too great hesitation in resorting 
 to embryotomy. In the case of growths filling up the main part 
 of the pelvis, Csesarean section may be necessary. As a rule, 
 extraction after embryotomy is possible, if there is a minimum 
 diameter not less than 2 inches, and a diameter bisecting this at 
 right angles not less than 3J inches ; but unless these measures 
 are as much as 3 and 3^ inches respectively, C^esarean section is 
 generally preferable as a first choice if it can be performed under 
 the most favourable conditions. 
 
Chapter XXXI. 
 
 INDUCTION OF PREMATURE LABOUR AND 
 ARTIFICIAL ABORTION. 
 
 Induction of Prematuee Labour. 
 
 The induction of premature labour, as a conservative operation 
 both for the mother and the child, was first proposed and practised 
 in this country ; and, as a means of deUvery in cases of contracted 
 pelvis, has generally been held in higher esteem in Great Britain 
 than on the Continent. By induction of premature labour it is 
 intended to save the child, or, at any rate, to give it a chance of 
 surviving. The operation is called induction of artificial abortion 
 when performed at too early a stage of pregnancy to allow this. 
 Induction of premature labour is, therefore, generally performed 
 not earlier than about the thirtieth week, and, in most cases, 
 not earlier than the thirty-fourth week. Before that time there is 
 but little chance that the child will be reared, especially in 
 hospital practice, or when the parents are poor and the infant is 
 not likely to receive the most constant and careful attention. 
 The operation may be called for in the interest of the mother or 
 the child, or in that of both. The following are the principal 
 indications for it. 
 
 Indications for the Operation. 
 
 (1.) Pelvic Contraction. — In moderate degrees of pelvic con- 
 traction the operation is performed mainly for the sake of the 
 child, but, in some measure also, for that of the mother. The 
 conditions under which it should be undertaken, and the date of 
 pregnancy which should be chosen, have already been discussed 
 (see p. 755). Since the difficulty arises, not from the absolute 
 size of the pelvis, but from its relation to that of the child, even an 
 habitually large size of the fcetus or a continuation of the pregnancy 
 beyond the normal time (post-maturity of the foetus) may be, in 
 some cases, an adequate reason for the induction of labour, though 
 no manifest contraction of the pelvis is revealed on measurement. 
 In such cases, if a child has been stillborn after difficult forceps 
 delivery, labour may be induced three or four weeks before full term. 
 
Induction of Premature Labour, Etc, 793 
 
 (2.) Diseases endangering the Mother's Life.— In this case 
 the operation is performed mainly in the interest of the mother, 
 but it may be undertaken with much less reluctance when the 
 pregnancy is so far advanced that the child is not likely to be 
 sacrificed. It may also conduce to the preservation of the child, 
 which shares in any danger to the mother's life. In cases of 
 eclampsia or placenta prsevia there need be little hesitation about 
 proceeding to the induction of labour. Other conditions occa- 
 sionally calling for the operation are albuminuria, especially when 
 there is much oedema, grave diseases of heart or lungs, severe 
 jaundice, hydramnios, especially if early and acute, severe chorea,^ 
 pernicious anaemia, leucaemia,^ ascites, and some abdominal tumours. 
 Uncontrollable vomiting, which endangers life, may sometimes be 
 an indication, but this more frequently calls for the consideration 
 of the induction of abortion. It has been proposed by some to 
 induce labour in the interest of the child alone, when the mother's 
 condition is hopeless, or she is dying. This, however, is not 
 generally desirable, since, in most cases, it would risk a shortening 
 of the mother's life or her immediate death, and the mother's 
 welfare should always be considered paramount. 
 
 (3.) Habitual Death of the Foetus.— Habitual death of the 
 foetus at the certain period of pregnancy, within the last two 
 months, is generally stated as an indication for the induction of 
 labour. It is only, however, in very rare cases that the plan has 
 been adopted with success. Most frequently the cause is syphilis, 
 and in such cases the child would probably be already too gravely 
 affected to survive. Mercurial treatment of the mother would 
 afford a better prospect. Induction of labour may be performed 
 if the cause is probably placental degeneration or inanition, 
 especially when these result from anaemia or some condition 
 other than syphilis in the mother. The operation may be then 
 performed a little before the time at which, from the mother's 
 sensations, the death is presumed to have occurred in previous 
 pregnancies. 
 
 Methods of Operating. 
 
 Puncture of the Membranes.^ — Evacuation of the liquor 
 amnii by puncture of the membranes was the earliest method 
 
 1 French and ificks, I'lactilinncr, IDOf), Vol. LXXVL, p. 178. 
 
 2 Herman, Trans. Obst. Soc. London, 1901, Vol. XLI.IL, p. 2;i4. 
 ' Von Herff, Volkmann's Haiuml. Klin. Vortrage, No. 880. 
 
794 The Practice of Midwifery. 
 
 adopted for the induction of labour, and was the method recom- 
 mended as the result of the great consultation of obstetric 
 physicians in London on this subject in 1756, It is a perfectly 
 certain method, since it never fails to bring on labour sooner or 
 later. It has also the advantage that it can generally be carried 
 out with less inconvenience or discomfort to the patient than any 
 other method. Its disadvantage is that it does away with the 
 fluid wedge of the bag of membranes as a dilator of the cervix. 
 It follows that, although in many cases labour goes on satisfac- 
 torily, and the child is saved, yet it may happen that the first 
 stage of labour is protracted, as it is apt to be after spontaneous 
 premature rupture of the membranes. The child is then frequently 
 sacrificed from its exposure to prolonged pressure, unsupported by 
 the liquor amnii, a premature child having less power of endurance 
 than one at full term. This disadvantage has led to the method of 
 puncture of the membranes being abandoned by most obstetricians 
 as the ordinary mode of induction of labour when performed mainly 
 in the interest of the child, although its dangers have perhaps been 
 exaggerated.^ There is one condition, however, in which puncture 
 of the membranes is the best method, namely, eclampsia, in which 
 there is an advantage in relieving the tension of the uterus at once. 
 Puncture of the membranes is an uncertain method as to time, and 
 therefore, by itself, it is not adapted for those cases in which speedy 
 delivery is called for. When followed up, however, by artificial 
 dilatation of the cervix it is the most rapid of all methods. In the 
 ordinary case of induction of labour on account of pelvic contraction, 
 in the interest of the child, it should not be chosen. 
 
 Introduction of a Flexible Bougie into the Uterus. — This 
 method consists in the introduction of an elastic male catheter or 
 bougie into the uterus between the membranes and the uterine 
 wall. The mode in which it acts is by exciting reflex stimulus, 
 partly by the separation between the membranes and the uterus 
 thus effected, but mainly by the presence of the bougie itself in 
 contact with the uterine surface. Hence the special merit of this 
 method is that labour pains come on in a manner resembling as 
 closely as possible the onset of natural labour, and that the bag of 
 membranes is preserved for the dilatation of the os in the natural 
 way. There is one drawback to the operation, namely, that the 
 bougie may separate the placenta and cause haemorrhage. But it is 
 found practically that it does not often happen, especially if the 
 
 1 Reynier, Beitrage f. Geb. u. Gyn., 1905, Bd. 9. For full account see Williamson, 
 Journ. Obst. and Gyn, Brit. Emp., 1905, Vol. VIII., No, 4, p. 257. 
 
Induction of Premature Labour, Etc. 795 
 
 bougie is not passed more than about seven inches within the external 
 OS. There is generally room for this length below the placental 
 site. It is also possible that the membranes may be ruptured in 
 the attempt to introduce the bougie, especially if the operator is not 
 very practised. If this happens, the method is simply converted 
 into that of puncturing the membranes, with the difference only 
 that the presence of the bougie furnishes an additional stimulus to 
 reflex action. 
 
 The time required for the induction of labour by this method 
 varies according to the height to which the bougie is passed into 
 the uterus, as well as according to the susceptibility of the 
 individual to reflex stimulus. As a rule, provided that the 
 bougie is fairly well introduced, labour pains commence within 
 twenty-four hours, and labour is usually completed within forty- 
 eight hours. Sometimes pains commence immediately, and labour 
 is completed well within twenty-four hours. The method is not 
 adapted for cases in which very rapid delivery is called for, but 
 labour may be accelerated by artificial dilatation of the cervix, as 
 soon as labour pains have fairly commenced. 
 
 Mode of operating. — This method is one of the best for the 
 ordinary case of induction of labour in moderate pelvic contrac- 
 tion, in the interest mainly of the child. If the cervix is closed, 
 and high up, hot vaginal irrigations or injections may be employed 
 every two or three hours for twelve hours preceding. These may 
 have the effect of softening the cervix, and inducing some com- 
 mencement of dilatation. The best instrument to use is not a 
 catheter, which admits air into the uterus through the opening at 
 the end, but a hollow bougie, which can be used with a stylet, if 
 desired. Bougies made of flexible celluloid are more non-absorbent 
 than the ordinary gum-elastic bougies. The bougie should be 
 sterilised by soaking in 1 in 1,000 perchloride of mercury lotion 
 for twelve hours and softened in warm water sufficiently to make it 
 pliant, but it should not be so soft as to double up and be incapable 
 of any direction. Hands and bougie should be carefully disinfected 
 with perchloride or iodide of mercury, 1 in 1,000 ; and the vagina 
 should also be irrigated with the same solution. 
 
 For the operation the patient should be placed at first on her left 
 side, preferably under an anaesthetic. The stage at which the 
 accident of rupturing the membranes is most likely to occur is when 
 the point of the bougie is passing the internal os. The bougie may 
 generally be guided into the cervix, held between the index and 
 middle fingers. If possible, the index finger should be passed up 
 to the internal os, and guide the tip of the bougie between the 
 
79^ The Practice of Midwifery. 
 
 membranes and the uterine wall, so that rupture of the membranes 
 is avoided. The bougie will generally pass much more readily 
 along the posterior uterine wall than along the anterior, because the 
 direction of that wall is more nearly in a line with the cervix and 
 the vagina (see Fig. 114, p. 159). If, however, it can be guided to 
 one side, or somewhat toward the front, there is less likelihood that 
 it will encounter the placenta. 
 
 If the cervix is not wide enough to admit the finger, previous 
 dilatation may be carried out with Hegar's dilators, or the stylet 
 may be used to facilitate the direction of the bougie until the point 
 has passed the internal os, and reached a safe position between the 
 uterine wall and the membranes. The stylet should have a very 
 gentle curve given to it, considerably less than that of a male 
 catheter. For introduction through the cervix the bougie, made 
 firm by its stylet, is maniiDulated like the uterine sound. After the 
 point of the bougie has passed through the internal os, the stylet is 
 withdrawn, and the bougie afterwards pushed on without it, until 
 it has passed deej)ly enough. 
 
 For the further passage of the bougie, after its point has once 
 entered the uterine cavity, it is often convenient to place the 
 patient on her back. The index and middle fingers are then 
 introduced into the vagina, the bougie grasped between their tips 
 a little below the cervix, and so gradually insinuated further and 
 further into the uterus until about seven inches have passed. If it 
 is found that it can be pushed on without resistance until the lower 
 end is within the vagina, the support of the posterior vaginal wall 
 will generally keep it in position, without any further means being 
 used. But generally, there will be four or five inches outside the 
 cervix, and the lower end will be outside the vulva. Some means 
 should then be adopted to prevent its slipping out. The most con- 
 venient is the following. The length remaining outside the cervix 
 is measured by the forefinger, and an equal length is broken off with 
 a pair of pliers from the lower end of the stylet. This piece of 
 stylet is passed into the bougie, thus making rigid onl}^ that portion 
 which is outside the uterus, and tapes are fastened to the ring of 
 the stylet. Two of these are carried up in front, two behind, and 
 fastened to a belt round the waist, so keeping the bougie in position. 
 
 Bleeding to the extent of a few drops often occurs from the 
 separation of the membranes. If, however, any considerable 
 bleeding occurs, indicating that the placenta has been touched, 
 the operator should abstain from pushing the bougie any further 
 in the same direction. If bleeding continues afterwards to any 
 important extent, the membranes should be punctured. 
 
Induction of Premature Labour, Etc. 797 
 
 If labour pains do not come on satisfactorily, the reason 
 generally is that the bougie has not penetrated far enough. It 
 may then, on the following day, be reintroduced, or a second 
 bougie may be passed in a somewhat different direction. If, after 
 the commencement of pains, the first stage of labour is long pro- 
 tracted, or if a rising pulse indicates the expediency of accelerating 
 it, hydrostatic dilators should be used to expand the cervix. 
 
 Use of Hydrostatic Dilators or Bags. — If the cervix is 
 patent enough to admit one finger, as is not uncommonly the 
 
 •I 
 
 h 
 
 Fig. 393.— Horrocks' Maieutic, 
 natural size. 
 
 Fig. 394.— Maieutic, fixed 
 on catheter. 
 
 case in multiparse, dilatation may be commenced by introducing 
 one of the smaller varieties of hydrostatic dilators. The dilatation 
 sets up pains through reflex action ; labour is generally started 
 by the time that any considerable dilatation has been effected, 
 and afterwards goes on automatically. If the pains cease 
 after the smallest dilator has been expelled, larger ones must 
 be introduced afterwards. Most operators find that, when 
 the cervix is small, Barnes' bag and, still more, ChamiDetier 
 de liibes' bag, cannot be introduced without some previous 
 dilatation, either by tents or mechanical dilators, such as 
 Hegar's. Hydrostatic l>ags of a smaller size have therefore been 
 used. Thus Tarnier's dilator consists of an india-rubber tube, 
 terminating in a small ball ; and this may be used to start labour, 
 
798 
 
 The Practice of Midwifery. 
 
 being introduced by a special form of sound. Other accoucheurs 
 have adopted india-rubber toy balloons for the purpose. At 
 Guy's Hospital Horrocks' Maieutic (Figs. 393, 394), consisting of 
 small bags of various sizes, made of very thin india-rubber, has 
 been much used. The smallest bag, when unstretched, measures 
 about IJ by f inch, and, when dilated, expands into a nearly 
 spherical form. It is used in the following manner : — 
 
 The bag is tied over the end of a No. 6 gum elastic catheter, 
 by means of which it is introduced. It is then filled with some 
 weak antiseptic lotion to an extent previously determined sufficient 
 to completely distend, but not to burst, it. 
 
 This method acts rather by exciting reflex action than by 
 
 Fig. 395.— Maieutic distended hi situ. The dotted line above represents amnion. 
 The cervical canal is represented as open merely for the sake of clearness. 
 
 directly dilating, although some dilatation is effected if the bag 
 is expelled. It is probably the most perfect method of inducing 
 labour, since it has the advantage, as compared with the use of 
 the bougie, that there is no risk of separating the placenta. The 
 only difficulty is to get the rubber bags made thin enough to dilate 
 easily by hydrostatic pressure and yet strong enough not to burst. 
 
 The method is uncertain as regards the time required, like the 
 use of the bougie. In favourable circumstances labour may be 
 completed in twenty-four hours, but several days are sometimes 
 required. If the bag bursts, another should be introduced. If 
 pains are quiescent twelve hours after its introduction, it should be 
 introduced afresh, since the fluid is often found to have oozed out 
 of the bag. If it is expelled, and the pains cease, it is generally 
 
Induction of Premature Labour, Etc. 799 
 
 better to use a Barnes' or Champetier de Ribes' dilator, which the 
 cervix will now admit, since the larger bags of very thin rubber do 
 not answer so well. Frequently labour will go on automatically 
 after the bag is expelled, especially if the patient is allowed to be 
 up and about in her room. 
 
 Champetier de Ribes' dilating bag, already described (see p. 640), 
 was invented for the purpose of inducing labour. The design is 
 that the bag when placed above the internal os and dilated should 
 assume the diameter, approximately, of a foetal head, leaving the 
 maternal efforts to expel the foreign body. By this means, not only 
 is the uterus stimulated to contract, but, when the bag is expelled, 
 no further difficulty is experienced from the obstruction of the 
 soft parts. 
 
 The inventor declares that, in all his cases, multiparas and 
 primiparse alike, he has been able to pass his index finger into the 
 uterus, to strip ofi' the membrane and explore, and satisfy himself 
 as to the direction he should give the bag. Chloroform is to be 
 given, if necessary ; and, as soon as two fingers can be inserted as 
 far as their first articulation, the bag can be introduced. The 
 further manipulation has been already described (see p. 640). 
 
 Besides being used as the primary method for induction, this 
 plan may also be adopted as an adjunct, especially to the introduc- 
 tion of a flexible bougie, or smaller bag, when labour is not set 
 up, or does not progress rai3idly enough. The introduction will 
 then be generally facilitated by some dilatation of the os having 
 already taken place. This proceeding is especially desirable when 
 the membranes have been accidentally ruptured in the introduction 
 of the bougie, and is a certain and speedy method, the average 
 length of time elapsing before the onset of labour being about 
 fifteen hours. -^ 
 
 As a primary method it has the disadvantage that it does not 
 imitate so closely as the bougie the natural process of labour, and 
 involves some risk of displacement of the presenting head, prolapse 
 of the cord, and consequent danger of the death of the child. 
 
 If the bag is properly introduced, it should never burst, but its 
 use appears to involve a slightly greater risk to the mother than 
 the use of the bougie, and it certainly increases the danger to the 
 child. For these reasons it is not employed so much for the 
 induction of labour now as it was on its first introduction. 
 
 The Vaginal Douche. — The method of inducing labour by 
 repeated douches of cold or hot water directed against the cervix 
 
 J Kromer, Monatschr. f. Geb. u. (iyri., 1904, Bfl. 20, s. 903. 
 
8oo The Practice of Midwifery. 
 
 uteri was introduced by Kiwisch, of Wurzburg, in 1836. The 
 mode in which this treatment acts is mainly that of exciting the 
 uterus by reflex action, set up partly by the distension of the 
 vagina, partly by the impression of heat or cold. Hot water is 
 the most effective in stimulating the uterus, as is illustrated by 
 its efficacy in the arrest of jpost-partum hsemorrhage, and thus the 
 douche answers best if used at a temperature of 110° to 115° F. 
 Besides the reflex stimulus, some effect may also be produced by 
 the water penetrating the cervix uteri, when slightly dilated, and 
 partially separating the membranes in its vicinity. The hot water 
 also tends to soften and dilate the cervix and so assist its dilatation. 
 The injections may be made with an irrigator elevated above the 
 bed, and of sufficient size to contain about a gallon of water. 
 
 This method of induction met at first with considerable favour 
 on account of its apparent simplicity and safety. It is, however, a 
 rather tedious and somewhat uncertain method, and the repeated 
 manipulations favour the occurrence of sepsis. 
 
 The vaginal douche is, therefore, now not often practised as the 
 sole method of induction, and is generally limited to treatment 
 preparatory to the use of other means, especially to the passing 
 of an elastic bougie into the uterus. If the douche is used for 
 about twelve hours at intervals of two hours, it tends to soften 
 and slightly dilate the cervix, and sometimes sets up some 
 commencement of uterine action. 
 
 The following are other methods which have been used for the 
 induction of labour, but are not recommended for adoption : — 
 
 Oxytocic Drugs. — Labour was formerly sometimes induced 
 by oxytocic drugs, such as ergot. Their action, however, is very 
 uncertain, and frequently repeated doses have often been found 
 necessary. A graver objection is that the results to the child are 
 very unfavourable, in consequence of the tonic contraction of the 
 uterus which is apt to be excited. This method has therefore been 
 abandoned. 
 
 Intra-uterine Injections, — An effective and also a rapid 
 mode of inducing labour is the injection of a considerable quantity 
 of warm water into the uterus, especially if the injection is made 
 by means of a tube passed up a considerable distance towards the 
 fundus. The method probably acts partly by the direct stimulus 
 caused by the uterine distension, and partly by separating the 
 membranes from the uterine wall over a considerable surface, so 
 that the ovum acts as a foreign body, and excites reflex action. 
 
Induction of Premature Labour, Etc. 80 1 
 
 In some cases, however, these intra-uterine injections have been 
 followed by sudden death. This is a result so extremely unpleasant 
 for the accoucheur, that the general use of the method has been 
 given up, although it is probable that, in very skilled hands, it 
 may be as safe as others. The cause of sudden death is most likely 
 the entrance of air into opened venous sinuses at the placental 
 site. This appeared to be demonstrated in one case at least, which 
 occurred in America, where a Higginson's syringe had been used 
 in the injection of water into the uterus for the induction of 
 criminal abortion. After death, the heart was found full of froth, 
 and it was also found, on testing the syringe, that, in consequence 
 of its not being air-tight, a considerable quantity of air would be 
 injected with the water. 
 
 If, therefore, this method should ever be adopted, an ordinary 
 syringe, not a Higginson's syringe, should always be used, and 
 great care should be taken that no air remains in the tube or in 
 the syringe. Seven or eight ounces of warm water would probably 
 be sufficient to produce the effect. 
 
 Injection of Glycerine, — Pelzer has introduced the method 
 of injecting slowly from an ounce to an ounce and a half of aseptic 
 glycerine between the membranes and the uterine wall by means 
 of a catheter passed through the cervix. He considers that 
 glycerine acts as an exciter of labour in three ways : (1) by 
 mechanical separation of the membranes ; (2) by a direct irritant 
 effect on the uterine mucous membrane, which excites muscular 
 action as rectal glycerine injections excite contraction of the bowel ; 
 and (3) by the affinity of glycerine for water, the liquor amnii being 
 drawn through the membranes, causing more or less collapse. 
 This method has, however, been abandoned almost entirely, since 
 it has been found that the intra-uterine injection of glycerine may 
 be followed by toxic symptoms such as hsemoglobinuria and the 
 occurrence of acute parenchymatous nephritis.^ 
 
 Vaginal Tampons, — C.Braun, of Vienna, introduced the method 
 of inducing labour by means of a vaginal dilator of india-rubber 
 distended with water. This dilator, under the name of the 
 colyeurynter , was for some time considerably used in Germany. 
 The method is, however, uncertain as to time, and unpleasant 
 to the patient. In cases of accidental haemorrhage or placenta 
 previa tight plugging of the vagina, combined with pressure 
 
 1 Pfannenstiel, Zcritr. f. Gyniik., 1804, No. 18, p. 37. 
 M. 51 
 
802 
 
 The Practice of Midwifery. 
 
 upon the uterus, has been found an effectual means of starting 
 labour (see p. 604). 
 
 Choice of Method. — In ordinary cases, when time does not 
 press, the best method is the introduction of a bougie. If there is 
 
 Fig. 396. — Hearson's Theemostatic Nurse. 
 
 Tank of warm water interposed between upper and lower compartment (a and b) 
 D D. Slips of wood supporting cradle. S. Capsule containing a liquid which boils 
 at the temperature at which it is desired to keep the chamber A. From the centre 
 of the capsule s, a stifi wire passes out through the top of the apparatus, where it 
 comes into contact with a light lever V, which is hinged at F. From the free end 
 of this lever hangs a damper (w), which rests on the top of the chimney under 
 which the flame burns. If the temperature in the compartment A rises too high, 
 the fluid in the capsule (s) boils and expands the capsule, thus raising the wire 
 rod, which, acting on the lever v, at once lifts the damper (w) ofE the chimney, 
 allowing the heat from the flame to escape by that outlet, and preventing the 
 further heating of the water. M. Aperture for entrance of air. o. Tray contain- 
 ing water. The centre of this tray is raised in the form of a cap (p), which fits 
 over the aperture M, through which the air enters. It is perforated all round 
 its sides, so that the air jjasses through it horizontally, as shown by the arrows, 
 instead of rising vertically. Another tray (x) of very coarsely perforated zinc, 
 somewhat smaller than the first, is turned upside down within it, and over this is 
 fitted the coarse canvas (n), the edges of which are tucked into the water all 
 round. Thus the air entering is constantly moistened as well as heated. R R. Flue, 
 shaped like the letter U, through which the heated air from the flame passes, so as 
 to twice traverse the length of the water-tank, and thus keep the water heated. 
 In the top of the apparatus is a glass window, through which the infant is kept in 
 view. If a higher temperature than the boiling-point of the liquid within the 
 capsule be desired, this can be obtained by moving the weight T along the lever 
 towards the end to which the damper is attached. 
 
 urgent need to effect delivery as rapidly as possible, the membranes 
 should be ruptured, and the cervix then dilated by Champetier de 
 Eibes' bag, after preliminary use, if necessary, of mechanical 
 dilators. In case of great urgency, the cervix can be more rapidly 
 
Induction of Premature Labour, Etc. 803 
 
 dilated by Bossi's or Frommer's dilator, or vaginal Csesarean 
 section may be performed. 
 
 Care of the Child, — The rearing of a premature child is the 
 more difficult the earlier is the date of its birth, and often is only 
 possible when minute and unremitting care is expended upon it. 
 Protection from cold is the first essential. In winter, therefore, the 
 child should be wrapped in cotton wool immediately on its birth, 
 and kept near the fire in a warm room. 
 
 Hearson's Thermostatic Nurse (Fig. 396). — This is warmed 
 and adequately ventilated, so that the demands upon the heat- 
 producing powers of the baby are diminished as much as possible. 
 The source of heat is a gas jet or oil lamp, and the box is kept at 
 any uniform temperature that may be desired by an ingenious 
 automatic arrangement. In general, the temperature may be set 
 at 85° F., but it has been made as high as 95° without injury to 
 the infant. As time goes on, it is gradually lowered. The child 
 is kept in the box for some weeks, being taken out only for feeding 
 and washing. It is generally found that it is quiet and happy, 
 under the influence of the equable warmth. 
 
 A very feeble premature child should not be taken up more often 
 than can be helped, and should only be washed every second or 
 third day. It is quite easy to keep it clean by smearing the 
 buttocks with lanoline or pure vaseline and then wi]3ing this off 
 with cotton wool. If not strong enough to suck, it must be fed, the 
 mother's milk being drawn off for that purpose and given to the 
 infant with a spoon or special drop feeder. In most instances 
 the child will thrive best if it be fed for the first ten days or so upon 
 good nursery milk completely peptonised. After ten to fourteen 
 days unpeptonised milk is very gradually and slowly substituted 
 for the peptonised, about one teaspoonful at a time, every two or 
 three days, depending upon the manner in which the child is 
 thriving, until at length only the former is being given. In this 
 way it is usually possible to rear without undue difficulty even the 
 most premature and delicate babies. 
 
 Induction of Artificial Abortion. 
 
 Indications for Operation.— Induction of artificial abortion is 
 called for in two classes of cases. (1.) When the dehvery of a viable 
 child through the natural passages is impossible, and the induction 
 of abortion offers any advantage to the mother as compared with 
 
 51—2 
 
8o4 The Practice of Midwifery. 
 
 delivery at full term. (2.) When the mother's life is materially 
 endangered by the continuance of pregnancy, while cutting short 
 the pregnancy is likely to save it. 
 
 Hence in all cases in which the pelvis is so obstructed by deformity 
 or the presence of tumours that delivery even by craniotomy is 
 likely to be impossible, or even very difficult and dangerous, abortion 
 may be induced should the alternative of Cfesarean section at term 
 not be accepted by the mother. 
 
 The various conditions endangering the mother's life, and on 
 that account calling for the induction of abortion, have been 
 considered among the diseases of i^regnancy. That which most 
 frequently raises the question is severe vomiting in pregnancy. 
 It is only very exceptionally, however, that life is actually 
 endangered, and the physician has often to resist the desire of 
 the patient, who is wearied and exhausted by the malady. The 
 other conditions which may call for artificial abortion are albumi- 
 nuria, jaundice, eclampsia, uterine haemorrhage, hydramnios, 
 chorea, pernicious anaemia, leucaemia, and diseases of heart or 
 lungs. Induction of abortion has been performed in chronic 
 .phthisis ; but the general opinion is that, in general, the effect upon 
 the course of the disease is so doubtful that the operation is not 
 justified. The case in which there need be least hesitation in 
 inducing abortion is that of uterine haemorrhage sufficient to cause 
 serious symptoms, for there is then very little chance that the 
 ovum can ultimately be saved in any case. In threatened or 
 incipient insanity a delicate ethical question may arise, and each 
 case must be judged on its own merits. But it will generally be 
 held that the sacrifice of the child is justifiable, if there is very 
 strong ground for believing that the mother's reason will thereby 
 be saved. In most cases, however, the interference itself is as 
 likely to be injurious to the mental condition as the continuance of 
 pregnancy. 
 
 It should be an invariable rule that artificial abortion should 
 never be induced without a preliminary consultation. This is 
 necessary for the protection of the practitioner himself against any 
 possible imputation of an improper motive. 
 
 Choice of Time. — If there is a choice of time for the induction 
 of abortion, there are some advantages in undertaking the opera- 
 tion within the first eight or ten weeks of pregnancy, for then the 
 ovum may be ex^Delled unbroken, and the abortion is a less serious 
 matter. If, however, the pregnancy has passed beyond the tenth 
 week, it is better, when circumstances permit, to allow it to 
 
Induction of Premature Labour, Etc. 805 
 
 continue as far on as possible toward the twentieth week, that the 
 placenta may become more readily separable, and the membranes 
 easier to puncture. 
 
 Mode of operating. — Within the first ten weeks of pregnancy, 
 the best method is to dilate the cervix with a laminaria tent, careful 
 antiseptic precautions being taken, and the tent being anointed 
 with an antiseptic lubricant, as lanocyllin, iodoform in vaseline 
 (1 in 8), or salicylic cream. Such dilatation will generally call out 
 uterine action, but, if not, the finger may be passed up through the 
 dilated cervix, and the ovum punctured with a sound. Up to the 
 end of the third month, or even later, this will often prove difficult, 
 as the bag of membranes is lax, and does not fill the cavity of the 
 uterus. In this case, a pair of forceps may be passed up into the 
 uterus, guided by the finger, and a piece of the membranes torn 
 away, letting out the liquor amnii. If any considerable haemor- 
 rhage is thus produced, dilatation of the cervix should be comj)leted 
 with Hegar's dilators, and the uterus at once evacuated. 
 
 Another method which may be employed instead of a tent is to 
 plug the vagina and cervical canal with a strip of iodoform gauze. 
 
 In the later months it is generally better to puncture the mem- 
 branes at once, since the ovum is not likely to be expelled intact. 
 For this purpose a rather narrow-pointed uterine sound may be 
 used. The point is passed up to the internal os, and directed as 
 perpendicularly as possible to the surface of the ovum. It is then 
 pushed through the membranes by a rather sudden movement. 
 In the later months of pregnancy it is always possible to do this. 
 But up to about four months, if the membranes do not fill the 
 entire uterus, and are lax, as well as tough, it may be impossible, 
 until the cervix has been dilated. 
 
 If it is important to evacuate the uterus quickly, as in cases 
 where there is much haemorrhage, or an offensive discharge, the 
 cervix may be rapidly dilated under anaesthesia, by means of 
 Hegar's dilators or Bossi's dilator, and the contents removed with 
 the finger, aided, if necessary, by a pair of ovum forceps. The 
 artificial dilatation of the cervix and the emptying of the uterus at 
 about the fourth or fifth month of pregnancy is often a very difficult 
 matter, and for this reason some writers favour the performance 
 of vaginal Cacsarean section in all cases where there is any 
 urgency. 
 
Chapter XXXII. 
 
 EXTRACTION OF THE FOETUS IN PELVIC 
 PRESENTATIONS. 
 
 It has already been explained (see p. 359) that, in the manage- 
 ment of pelvic presentations, the most important point is to avoid 
 premature interference with nature ; and that artificial aid, beyond 
 that afforded by external pressure upon the fundus uteri, is rarely 
 required before the stage at which the arms have escaped and the 
 head alone is still retained within the vulva, lying, no longer in the 
 body of the uterus, but in the vagina and distended cervix. The 
 mode of extracting the head under these circumstances has also 
 ah'eady been described (see p. 361). 
 
 Causes of Impaction in Breech Presentation. — Undue 
 protraction of labour may, however, occur, and interference on 
 that account be called for at an earlier stage. This may result 
 in breech presentations — (1), from disproportion between the 
 foetus and the pelvis ; (2), from rigidity of the soft parts, such 
 as is common in primiparfe, associated with more or less uterine 
 inertia ; and (3), from the attitude of the foetus. In presentations 
 of a foot, or both feet, the first or second of the causes may be in 
 operation. 
 
 In general, the limbs of the foetus in breech presentations are in 
 the same general condition of flexion as in head presentations (see 
 Fig. 217, p. 3-16), and the feet are close to the breech. Sometimes, 
 however, the legs are extended upon the thighs, so that the feet are 
 above the shoulders, and the toes close to the head (see Fig. 218, 
 p. 347). In this case the whole foetus may form a wedge with its 
 base uppermost, the dimensions of that base, formed by the head 
 and feet together, being too great for the corresponding diameters 
 of the pelvis. The advance of the foetus is thereby arrested. Even 
 that part of the wedge formed by the shoulders and arms, with the 
 legs added (see Fig. 218), may be too large to enter the brim, and 
 progress is then arrested earlier. If the trunk of the foetus is 
 extended, the legs are not long enough to allow the feet to reach 
 up to the level of the head. For the formation of the obstructing 
 wedge, it is necessary that there should be flexion of the foetal 
 
Extraction of Foetus in Pelvic Presentations. 807 
 
 pelvis upon the trunk, owing to flexion of the lumbar and lower 
 dorsal spine. Hence, when one leg is descending in advance, 
 having either presented originally or been brought down artificially, 
 the obstructing wedge is never formed, and it is not necessary to 
 bring down the second leg in order to break it up. For, in this 
 case, the position of the thigh in the genital canal causes some 
 extension of the pelvis upon the trunk. 
 
 There is also another mode in which extension of the legs causes 
 impaction, or arrest of progress, in breech presentations. When 
 the extended legs lie on each side of the trunk, they form, as it 
 were, splints, keeping the trunk straight, and preventing that 
 lateral flexion of the breech which is essential to its escape under 
 the pubic arch. This cause comes into operation at an earlier stage 
 than that at which the wedge formed by the legs with shoulders 
 or head would be obstructed by the pelvis. If, however, the legs 
 lie at the front of the trunk, not at the sides, they do not altogether 
 prevent the lateral flexion, although they must somewhat impede 
 it, the lateral flexion of the breech to one side implying a deflection 
 of the feet toward the opposite side. 
 
 It is probable that the position of complete extension of the legs 
 upon the thighs is rarely an original one. The limbs of the 
 embryo, as it grows, are naturally in a position of general flexion, 
 just as the leaves are folded in a bud. But some degree of exten- 
 sion may arise through foetal movements, and the legs may remain 
 fixed in the extended position if the liquor amnii escapes at the 
 moment when extension exists. It has already been explained 
 that the comparative want of space in the lower segment of the 
 uterus favours a partial extension of the legs during pregnancy. 
 Assuming that, at an early stage of labour, there is a partial 
 extension, like that of the left leg in Fig. 217 (p. 346), this may 
 be increased as the breech descends, the legs being retarded by 
 friction against the uterine wall, and thus the complete extension 
 may eventually be reached. 
 
 In a few cases, the extended position of the legs is inferred to 
 be primary, because the legs naturally take that position after 
 the birth of the child, and spring back into it when flexed by the 
 hand. 
 
 Allowance has to be made for the fact that, in foot or breech 
 presentations, labour is generally more lingering than in vertex 
 presentations, the half-breech or breech not causing so great reflex 
 stimulus to the pains by its pressure as the head. But interference 
 becomes necessary if the mother begins to show the constitutional 
 effects of protracted labour (see p. 620), or if there is evidence of 
 
8o8 The Practice of Midwifery. 
 
 impending asphyxia of the foetus. Such evidence may consist of 
 increased slowness and feebleness of the foetal heart, or, if the 
 breech has already passed the vulva, of attempted inspiratory 
 movements. After version, early extraction is more frequently 
 desirable or necessary than in primary presentations of the foot ; 
 first, because the life of the foetus has often already been imperilled 
 by the condition which called for version ; secondly, because the 
 version may have interfered with the natural position of flexion of 
 the arms ; and, thirdly, because some pelvic contraction often exists 
 in cases of shoulder presentation. 
 
 The delivery of the foetus in pelvic presentations consists of three 
 stages: — (1), delivery of the trunk; (2), liberation of the arms; 
 (3), extraction of the head. The various means of delivering the 
 trunk will first be considered. 
 
 Extraction by the Feet. — When one or both feet are already 
 presenting, traction on the leg is the mode of acceleration to be 
 adopted. The patient, as a rule, may be kept in the ordinary left 
 lateral position. But, for the final stage of extraction, there is a 
 certain advantage in placing the patient in the dorsal position, 
 across the bed, the buttocks overhanging the edge of the bed, and 
 the feet rested on two chairs. The operator stands between the 
 knees. This position allows an assistant to press more effectively 
 upon the fundus, and the child's trunk to be more easily carried 
 forward in front of the pubes. 
 
 It is most important that in the delivery of the foetus in pelvic 
 presentations the cervix should be fully dilated, as if any delay from 
 an undilated cervix occurs in the delivery of the after-coming head, 
 the child will almost certainly be still-born. 
 
 If the foot is still in the vagina, the operator seizes it by placing 
 the index and middle fingers in front of and behind the leg, just 
 above the foot, and draws it outside. If necessary, the thumb may 
 assist in grasping it. As soon as the foot is outside the vulva, it is 
 grasped with the aid of a napkin. As the leg descends, the grasp 
 is shifted higher, so that the leg is held as close as possible to the 
 vulva. If pains are fairly frequent, traction should be made 
 during the pains only. In the absence of sufficient pains, the 
 traction should be at intervals, like those of ordinary pains. With 
 each traction firm pressure should be made upon the fundus. The 
 object of this is not only to gain additional force, but to prevent 
 extension of the arms above the head, both by direct pressure, and 
 by stimulating the uterus to contract. 
 
 Until the half -breech is resting upon the perineum, the direction 
 
Extraction of Foetus in Pelvic Presentations. 809 
 
 of traction should be as far backward as the perineum will allow. 
 This direction of traction will nevertheless be inclined forward in 
 reference to the axis of the brim and that of the upper half of the 
 pelvic cavity. It will therefore assist in rotating the presenting 
 thigh under the pubic arch, and there is no necessity for using any 
 other means to promote this rotation. As soon as the half-breech 
 begins to distend the perineum, the direction of traction must be 
 shifted rather rapidly forward. At this stage additional force may 
 be gained, if desired, by hooking the index finger of the left hand 
 in the flexure of the other thigh. 
 
 If both feet present, they may both be brought down outside the 
 vulva, and grasped together for traction. If, however, the anterior 
 hip does not rotate readily under the pubic arch, rotation will be 
 promoted if the traction is made mainly upon the anterior leg. 
 When both legs come down, it is sometimes found that the funis 
 passes between the legs, and up the back to the placenta. The 
 child is then said to ride upon the funis. In this case an attempt 
 should be made to draw down as much as possible of the funis and 
 slip the loop over one leg. If this attempt fails, the funis should 
 be tied and divided, and the child extracted as quickly as possible. 
 
 Bringing Down the Leg in Breech Presentation. — If accelera- 
 tion of labour is called for in breech presentation, the best treat- 
 ment is to bring down one leg, and then proceed to extract by 
 that leg in the manner just described. When the child is in its 
 ordinary attitude, it is easy to accomplish this, even when the 
 breech has descended low into the vagina, for the feet will be found 
 close to the breech. In general it is better to give an anaesthetic. 
 If the patient is on her left side, the right hand may be used ; if 
 she is in the dorsal position, the hand should be chosen so that its 
 palm corresponds to the abdomen of the foetus. The foot of the 
 anterior leg should be taken if possible. If, however, the breech 
 is still high up, it is not of much consequence which is taken, for 
 the leg which is brought down will rotate forward under the pubic 
 arch as the foetus descends. 
 
 If the legs are extended upon the thighs, as shown in Fig. 218 
 (p. 347), the operation is much more difficult. In order to seize 
 the foot, the hand must ))e passed up higher into the uterus than 
 is ever necessary in version, and even when the foot is seized, 
 there may be much difficulty in flexing the leg, owing to the 
 resistance of the uterine wall. The operation is therefore often 
 more difficult tlian any ordinary case of version. 
 
 The patient should be placed under the influence of chloroform 
 
8io 
 
 The Practice of Midwifery. 
 
 to the full surgical degree, so as to secure the greatest possible 
 relaxation of the uterus. In general, as in the case of version, 
 it is preferable to place the patient on her left side, and introduce 
 the right hand and arm. The hand must be cautiously passed up 
 into the uterus, in the intervals of pains, as for performance of 
 internal version. The left hand makes counter-pressure upon 
 the fundus. Adequate counter-pressure must always be made upon 
 the fundus of the uterus during the delivery of the child in pelvic 
 
 Fig-. 397. — Pinard's manoeuvre. 
 
 presentations so as to minimise as much as possible the likelihood 
 of the head or arms becoming extended. The hand must be passed 
 on quite to the fundus to reach the instep or foot. It is guided to 
 the anterior foot by tracing up the leg from the breech. It is 
 useless to attempt to flex the leg directly forward. The foot 
 must be carried toward the opposite side of the foetus. Thus the 
 right foot should be swept across toward the left side of the chest. 
 The effect of this is to turn the knee outward and evert the thigh. 
 There is then room for the leg in a transverse position, lying flat 
 against the uterine wall. 
 
Extraction of Foetus in Pelvic Presentations. 8ii 
 
 Pinard's manoeuvre is often very useful in these cases ; it consists 
 in making pressure on the flexor aspect of the knee joint with two 
 fingers ; this will often cause some flexion of the joint, with the 
 result that the foot is brought nearer and can be more readily 
 seized (Fig. 397). 
 
 The operator is to flex the leg and draw it across, by placing 
 the index and middle fingers upon the instep. It is not generally 
 necessary to use the thumb to grasp the foot. If the thumb is 
 used, the closed hand occupies more space in the uterus. 
 
 Some eminent authorities have considered that the operation is 
 only possible before the breech has descended into the pelvis, and 
 becomes impossible or dangerous when the breech is low down. 
 There is room, however, for the leg or thigh to lie transversely 
 across the pelvis, unless there is very great general contraction, 
 and also across the dilated vagina. The chief difficulty is to pass 
 the hand past the breech, when the breech is close to the perineum. 
 Great gentleness and caution are required at this stage. 
 
 I have always found it possible to bring down a foot in the 
 manner here described, and have never had occasion to resort to 
 any of the means recommended by many eminent authorities for 
 the treatment of impacted breech presentations, such as the use of 
 the soft fillet, or blunt hook, or the application of forceps to the 
 breech ; nor were such means ever found necessary in 389 breech 
 presentations occurring in 23,591 deliveries in the Guy's Hospital 
 Charity. The operator might, however, find it impossible to secure 
 a leg, if the uterus were very closely contracted around the child 
 after long escape of the liquor amnii, especially if the breech were 
 close to the perineum, or there were great general contraction 
 of the pelvis. 
 
 Digital Traction, — The plan of digital traction in breech pre- 
 sentation is one which may be tried, if labour is arrested, when the 
 breech is close to the perineum, before recourse is had to the plan 
 of bringing down a foot. The index finger is hooked in the flexure 
 of the anterior groin and traction made therewith. It may be of 
 service to make the traction alternately on the anterior and 
 posterior groin, and so get the benefit of leverage. If the vaginal 
 space allows, the right index finger may be hooked into the anterior 
 groin, and the left into the posterior. 
 
 The Soft Fillet. — Traction by means of a soft fillet is the best 
 means to employ in the case of failure in the attempt to bring down 
 a leg. The fillet is sometimes passed over one thigh only. In 
 
8l2 
 
 The Practice of Midwifery. 
 
 such case the anterior thigh should be chosen if possible. If the 
 fillet can be passed across both thighs, the pressure is more dis- 
 tributed, and is less likely to injure the skin or soft parts of the 
 groin. It is better still, although more difficult, to pass the fillet 
 round the child's pelvis in the following way. A soft sterilised 
 handkerchief or bandage may be used for 
 the fillet ; a knot is to be tied at two 
 opposite corners or ends. By means of 
 the forejfinger the corner is to be passed 
 from without inwards over the flexure of 
 the groin till the knot can be reached 
 between the thighs and drawn down. In 
 the same way the opposite end of the fillet 
 is to be passed from within outwards over 
 the other thigh. The centre of the fillet 
 is then slipped up over the buttocks till it 
 surrounds the sacrum, and traction is made 
 by the ends. In this way the pressure is 
 distributed over both groins and the circum- 
 ference of the pelvis. If the fillet is passed 
 over one or both thighs only, care must be 
 taken, if the abdomen looks forward, that 
 it does not slip up from the groin to the 
 thigh, and so cause fracture of the femur. 
 
 In place of the handkerchief a piece of 
 thick- walled india-rubber tubing about the 
 size of the little finger may be used. A 
 strong piece of tape is passed through the 
 tube and sewn to the tube at each end, 
 the ends of the tape projecting beyond the 
 tube. The knotted ends of the tape are 
 then passed over the flexures of the groins 
 from without inward as before. 
 
 If the fillet cannot be passed over the 
 thigh by the index finger a large gum-elastic 
 catheter, with stylet, may be bent to a suit- 
 able shape, resembling that of the blunt hook, and passed from 
 without inward over the thigh, having a tape attached to its 
 extremity. By means of the tape, the fillet can then be drawn into 
 position. A special instrument, or porte-fiUet, has been made for 
 this purpose, on the principle of Bellocq's sound, used for plugging 
 the iDOsterior nares, but having a curve like the blunt hook. A 
 long piece of whalebone runs through the central canal. 
 
 Fig. 398.— The blunt hook. 
 
Extraction of Foetus in Pelvic Presentations. 813 
 
 Traction by means of the soft fillet generally so far breaks up 
 the opposing wedge as to allow the foetus to pass, unless there is 
 great disproportion between foetus and pelvis. For the traction 
 on the flexures of the groins diminishes the flexion of the foetal 
 pelvis upon the trunk, and by this means brings the feet below 
 the level of the head. 
 
 The Blunt Hook.— The blunt hook is an instrument con- 
 structed expressly for extraction in breech presentation (Fig. 398, 
 p. 812). It is not, however, desirable to use it, in the case of a 
 living child, unless all other means have failed, on account of the 
 injury which it is liable to do to the skin and soft parts of the groin. 
 The instrument is generally made of steel, and the diameter of the 
 semicircular curve forming a hook is about two inches. The 
 likelihood of injuring the groin will be less, if, at the time of use, 
 a piece of sterilised india-rubber tubing, jStting the hook closely, 
 is slipped over it. The tubing should be new for the occasion. 
 
 It is better to place the hook over the anterior thigh. It is 
 passed up, lying flat against the thigh, the point directed towards 
 the front of the foetus. When high enough the point is turned 
 inward, and passed over the flexure of the groin. Care must be 
 taken to feel the point lying clear between the thighs, before 
 traction is made. When the foetus is dead, the blunt hook is a 
 good means of traction, and will generally succeed in sufficiently 
 decomposing the obstructing wedge, by bringing the feet below 
 the level of the head. It can rarely, however, be certainly known 
 that the child is dead, unless the funis is within reach. 
 
 Forceps. — The application of forceps to the breech has been 
 recommended by some eminent authorities. Forceps specially 
 adapted for this purpose have even been devised, and have been 
 distinguished by the title of "retroceps." Forceps of any form 
 are, however, unsuitable for holding the breech. The tips of the 
 blades cannot be approximated without risk of injury to the foetus. 
 If they remain divergent, there is a very wide sjjace between the 
 centres of the blades. In consequence of this, not only are the 
 forceps apt to slip off, but injury may be done to the maternal 
 tissues. Lusk, however, speaks highly of the application of 
 Tarnier's axis-traction forceps to the breech, one blade being 
 applied over each thigh of the foetus.^ 
 
 If extraction Ijy forceps is attempted at all, it should only be 
 after the breech has descended in the pelvis. If the breech has 
 
 1 The Science and Art of Midwifery, 2nd ed., p. 380. 
 
8i4 
 
 The Practice of Midwifery. 
 
 rotated, one blade should be applied over the sacrum, the other 
 over the anterior surface of one thigh, care being taken not to 
 injure the genitals of a male. If the breech has not rotated, it is 
 recommended to apply the blades over the lateral surfaces of the 
 thighs. The mode in which they should seize the foetus is shown 
 in Fig. 399. 
 
 Bringing Down the Second Leg. — If the child is dead, and 
 extraction is difficult on account of disproportion between foetus 
 and pelvis, it is desirable to bring down the second leg, as there is 
 
 Fig. 399. — Axis-traction forceps applied to the breech. 
 
 then no object in keeping the half -breech as a dilator for the soft 
 IDarts. In such cases, the cephalotribe, applied over the pelvis ; or 
 the cranioclast, the male blade being passed into the rectum and the 
 female blade applied over the sacrum, will afford, if necessary, a very 
 powerful hold for traction. Both legs should be brought down, if 
 possible, before its application. The crochet, hooked over the 
 symphj'sis pubis, may also be used in conjunction with traction on 
 the legs. If there is any morbid distension of the abdomen 
 perforation of it may be required. 
 
Extraction of Foetus in Pelvic Presentations. 815 
 
 Liberation of the Arms. — The second stage in extraction consists 
 in the liberation of the arms. When it has been necessary to 
 accelerate labour by traction, the arms are retarded by friction 
 against the genital canal, and generally become more or less extended 
 by the side of the head, instead of lying folded across the chest as 
 shown in Fig. 217 (p. 346). They then do not slip out from the 
 vulva before the shoulders under the influence of the natural force, 
 but have to be released artificially. 
 
 Fig. 400. — The manner in which the pelvis of the child should be grasped 
 by the two hands. 
 
 When the legs of the foetus have escaj^ed, the pelvis should be 
 grasped in two hands, and used for traction. Traction should 
 still be made with the pains if possible, and should be assisted by 
 pressure upon the fundus uteri. As soon as the funis can be 
 reached, a loop of it should be drawn down, as in normal cases of 
 pelvic presentation, to prevent its being put upon the stretch, and 
 should be placed opposite one sacro-iliac articulation, where it is 
 least exposed to pressure. Traction should be continued until the 
 shoulder-blades begin to reach the vulva; then is the time for 
 releasing the arms. 
 
8i6 
 
 The Practice of Midwifery. 
 
 In easy cases, when the arms are only shghtly extended, the 
 anterior arm should be released first, but, m difficult cases, always 
 the posterior. For, if the anterior arm is below the brim, it will 
 be very close to the vulval outlet, and can be easily hooked by the 
 finger. If, however, one or both arms are partly above the brim, 
 the posterior is the easier to seize. For as the trunk descends 
 in the direction of the pelvic outlet, the posterior shoulder is 
 necessarily lower than the anterior in reference to the plane of the 
 brim. There is also more room posteriorly for the hand to be 
 
 Fig. 401. — Bringing down anterior arm when extended. 
 
 passed up to reach it. For release of the posterior arm, the body 
 of the child should be held as far forward as possible in front of the 
 pubes. The patient being in the left lateral position, the fingers of 
 the left hand should be introduced. 
 
 If the extension of the arms is only moderate, the elbows will still 
 lie in front of the chest, below the head, and the release of the arms 
 is then easy. Four fingers of the left hand are passed within the 
 vulva, lying flat against the shoulder (Fig. 401). The fingers are 
 run along the arm till the elbow is reached, and then the index and 
 middle fingers draw the elbow downward and forward across the 
 chest. Care must be taken that the fingers quite reach the elbow, 
 
Extraction of Foetus in Pelvic Presentations. 817 
 
 and do not make the pressure upon the middle of the humerus ; 
 otherwise the humerus is hkely to be broken. 
 
 For release of the anterior arm, the body of the child is held as 
 far backward as possible ; and the fingers of the right hand are 
 introduced, and release the arm in a similar way. If the patient 
 is in the dorsal position, that hand may be introduced the palm of 
 which corresponds to the abdomen of the child, for liberation of 
 each arm. 
 
 Liberation of the Arms when much Extended. — Sometimes the arms 
 are found completely extended by the side of the head. They may 
 then become jammed with the head in the pelvic brim, especially 
 if there is disproportion between the foetus and pelvis. Liberation is 
 then much more difficult, both on account of the fixation in the brim, 
 and on account of the difficulty of reaching as high as the elbow. 
 
 Sometimes one arm is not merely extended beside the head, but 
 displaced somewhat behind it, and then the difficulty is greater 
 still. This position is due to a rotation of the trunk in its descent, 
 in which the arm has been left behind. The remedy is to rotate the 
 trunk back again in the opposite direction and so bring the arm 
 across the face. The same proceeding will facilitate the liberation 
 of the arm even if only extended by the side of the head. The 
 posterior arm is to be liberated first as in the former case. The 
 trunk of the foetus is, therefore, to be grasped with two hands and 
 turned in such a way as to rotate the posterior shoulder towards the 
 back of the foetus. The fingers must then be passed quite up to the 
 elbow, and the elbow must be drawn downwards and across the face of 
 the foetus towards the opposite side. 
 
 "When the anterior arm is extended above the brim, it is difficult 
 to reach the elbow, the foetus being tightly pressed against the 
 symphysis pubis. To overcome this difficulty, the trunk of the 
 foetus should .be rotated, so as not merely to reverse the former 
 rotation, but to carry the anterior shoulder backward to the side 
 or posterior part of the pelvis, and so convert it into the posterior 
 shoulder. The arm is then drawn across the face, and is in a 
 position more easily accessible. The release of the arm, originally 
 posterior, will generally allow the foetus to descend lower. The 
 trunk should, therefore, be drawn down as much as possible. 
 The best mode of rotating the shoulders is to make use of the 
 released posterior arm and draw it forward across the chest 
 toward the symphysis pubis. Thus, in a position like that shown 
 in Fig. 401 (p. 816), the left arm should be drawn forward across 
 the chest on the left side of the mother, so as to bring the left 
 shoulder towards the symphysis pubis. 
 
 M. 52 
 
8i8 
 
 The Practice of Midwifery. 
 
 If the patient is on the left side, the right hand may be used for 
 the release of both arms, provided that the anterior shoulder is 
 thus drawn backward. If she is in a dorsal position, the hand 
 whose palm corresponds to the abdomen of the foetus should be 
 used for the posterior arm, the other hand for the anterior arm, 
 after the shoulder has been rotated backward. 
 
 If the child descends with the abdomen looking directly forward, 
 and the arms cannot be brought down between the thorax and the 
 
 Fig. 402. — Shoulder and jaw traction. (Mauriceau-Smellie-Veit Method.) 
 
 symphysis pubis, the thorax should be rotated so as to bring one 
 shoulder backward, and the corresponding arm should be brought 
 down first. 
 
 If insuperable difficulty is experienced in bringing down the arm, 
 and the child is certainly alive, it will be justifiable to deliberately 
 fracture the humerus by pressure, since this usually overcomes the 
 difficulty, and it is better to deliver a living child with a broken 
 arm than to allow it to succumb. 
 
 If the child is certainly dead, and the arms cannot be brought 
 down by the fingers, the small blunt hook, recommended for 
 securing the knee in version, or the crochet, may be used to secure 
 
Extraction of Foetus in Pelvic Presentations. 819 
 
 them. In this case it is of little consequence if the humerus is 
 fractured. 
 
 Delivery of the Head. — The third stage in the extraction of the 
 foetus consists of the delivery of the head. The delivery of the 
 head through a contracted pelvis has already been described (see 
 p. 750). The extraction of the head when detained only by the 
 soft parts of the vaginal outlet has to be carried out in the same 
 way as in a normal case of pelvic presentation, and has been 
 described at pp. 361 — 364. 
 
 If the birth of the head is delayed by the imperfectly dilated 
 soft parts, it should be pulled down, if possible, to the vulva 
 and the cervix stripped back over the head or even, if necessary, 
 incised. This should only, however, be done if the child is 
 certainly alive. 
 
 Injuries to the Foetus from Extraction in Pelvic Presenta- 
 tion. — Effusions of blood in the abdomen from damage to the liver 
 or other viscera are sometimes found, as are also effusions of blood 
 in the brain or its membranes. Effusions of blood may also take 
 place in the breech or genitals. The genitals of a male may be 
 injured by fillet, blinit hook, or forceps. From traction of the 
 neck may result hgematoma in the sternomastoid or other muscles 
 of the neck. This generally disappears without eventual ill result, 
 but sometimes cicatricial contraction leads to wry-neck. 
 
 Injuries to the cranial bones, due to the pressure of a contracted 
 pelvis, will be described hereafter (see Chapter XLII.). The 
 cervical vertebrae may be separated, and the spinal cord or medulla 
 destroyed, from the effect of traction upon the neck. Sometimes 
 even the body may be completely pulled away and separated from 
 the head, but the spinal column gives way long before the soft 
 parts. Paralysis of the arm (Duchenne's paralysis) may occur 
 as the result of pressure or tearing of the upper roots of the 
 brachial plexus. By jaw traction may be produced fracture of the 
 lower maxilla, dislocation of the maxillary joint with rupture of 
 ligaments, and also injury to the floor of the mouth. 
 
 In attempts to release the arms the humerus may be broken 
 near the middle, one of its epiphyses may be separated, or the 
 clavicle may be broken. The most likely lesion to be produced by 
 traction on the leg is separation of the lower epiphysis of the femur ; 
 but this is not common. The so-called congenital dislocation of 
 both hips has been ascribed to traction on the legs in pelvic 
 presentations, but is really a fault of development. 
 
 52—2 
 
820 The Practice of Midwifery. 
 
 A fractured humerus may be set with softly padded splints, the 
 outer splint extending the whole length of the arm. The arm 
 should be secured to the side. 
 
 If the femur is fractured, the child should be placed on its back 
 with the legs kept extended at right angles to the body by a light 
 weight. 
 
Chaptei- XXXIIL 
 THE FORCEPS AND VECTIS. 
 
 Use of the Vectis. 
 
 The vectis is one of the simplest forms of instrument which can 
 be used for the extraction of the head, but its use has been, in 
 general, abandoned in favour of that of forceps, which is found to 
 be both a safer and more effective instrument. The vectis consists 
 of a handle and single blade (Fig. 403), having 
 a cranial but no pelvic curve. It somewhat i 
 
 resembles a single blade of a pair of straight 
 forceps, except that the cranial curve is much 
 sharper, especially near the extremity of the 
 instrument, in order to enable it to take a 
 better hold of the head. 
 
 This vectis is generally said to act both as a 
 lever and a tractor. Its essential action, 
 however, is that of a tractor applied to one 
 portion only of the head. 
 
 The Vectis in Occipito-posterior Posi- 
 tions. — The vectis is now practically regarded 
 by most authorities as an obsolete instrument. 
 There is one condition, however, in which 
 precisely that power is wanted which the 
 vectis is able to exercise, namely, the power 
 of drawing one pole only of the head in any 
 required direction. This is when labour is ^la. ios.^The vectis 
 arrested or protracted in occipito-posterior 
 positions of the vertex, and the occiput fails to rotate forwards. 
 The rotation may then be effected either by a force actually direct- 
 ing the occiput forwards, or by one which causes flexion, since it is 
 through defect in flexion that the inclined plane of soft parts fails 
 to turn the occiput forward as usual (see pp. 260, 261). .Both these 
 indications are fulfilled by the use of the vectis. If the vectis is 
 applied over the occiput and traction made towards the vaginal 
 outlet, as much forwards as possible, first, flexion is promoted by 
 
822 The Practice of Midwifery. 
 
 the descent of the occiput, and, secondly, the occiput is directly 
 drawn forwards, since the vaginal outlet is directed forwards in 
 reference to the direction of the j)elvic axis at the point where the 
 centre of the head is lying (see Fig. 22, p. 21). I therefore consider 
 that the vectis has fallen into unmerited disuse, so far as regards 
 this particular case. Even when called in to perform craniotomy, 
 after vigorous efforts to extract with forceps had failed, I have 
 found that the occiput could be turned forwards by the vectis with 
 surprising ease, and that then extraction by forceps presented no 
 difficulty whatever. It is generally recommended that forceps 
 should be applied in such a case, and the head drawn down in its 
 existing position. The result almost always is that the occiput 
 remains posterior, although, if the descent of the head had been 
 effected by the natural powers, the occiput would probably have 
 rotated forwards at a late stage. Hence, although the extraction 
 may be successful, yet it requires more force than if the head had 
 been in the usual position, and there is a much greater probability 
 of laceration of the perineum. When used in this way to draw 
 down the occiput, the vectis does in fact itself form a lever as well as 
 a tractor, although the leverage should only be just what is necessary 
 to secure the tractile force. For, the blade being single, the 
 inclined plane formed b}' its distal portion pushes the head toward 
 the centre of the i^elvis, at the same time that the vectis itself is 
 pushed against the pelvic wall. To avoid this pressure on the 
 pelvic wall, a jDressure different from any produced in forceps 
 delivery, while downward traction is made by the right hand on 
 the handle of the vectis, the left hand should be placed on the 
 shank, as high up as it can reach, and press it towards the centre 
 of the pelvis, or at any rate resist the pressure away from the 
 centre of the pelvis which the traction calls into play. The fulcrum 
 of the lever here lies between the power and the resistance, and is 
 formed, as far as possible, by the left hand, and not by the pelvis or 
 soft parts. It is obvious that the pressure towards the centre of the 
 pelvis exerted upon the occiput is beneficial, since it aids in pro- 
 ducing flexion, whenever the occiput is in any degree lower than the 
 forehead (see Fig. 157, p. 249). 
 
 The vectis is introduced in the same way as one blade of the 
 forceps. The patient is placed on the left side, the left hand or 
 half-hand is introduced into the vagina, and the tips of the fingers 
 placed upon the occiput, just within the rim of the cervix, if the 
 cervix is not completely retracted. The blade is passed up with 
 its convex side under cover of the flexor surface of the fingers, and 
 is thus guided over the head. The blade will generally have to 
 
The Forceps and Vectis. 823 
 
 be directed nearly in the direction of the sacro-iliac synchondrosis, 
 or somewhat in advance of that point. It will be somewhat more 
 difficult to pass than a blade of the forceps, on account of its 
 greater cranial curvature. As soon as the occiput has been brought 
 to look somewhat forward instead of backward, the vectis may be 
 removed, and delivery completed by forceps. If, however, there 
 is no occasion for hurry, it is well to allow a short time for the 
 new moulding of the head in its changed position to take place. 
 Delivery also may sometimes be completed by the natural powers, 
 when once the position of the head has been rectified. There is 
 one condition in which the use of the vectis, as above described, 
 is not available. This is when the head is already distending the 
 perineum, and so close to the outlet of soft parts, that there is no 
 longer room for the combined movement of rotation with flexion to 
 be effected by drawing the occiput downward and forward, especially 
 when, as will usually be the case at this stage, the occiput has 
 rotated backward into the hollow of the sacrum. 
 
 The Vectis in Brow Presentation. — A much more rare con- 
 tingency, in which the vectis may sometimes be of use, is that of 
 brow presentation. By applying the vectis over the occiput, an 
 attempt may be made to convert the presentation into a vertex. If 
 this fails, the vectis may be applied over the chin, and another 
 attempt made to convert the presentation into a face. 
 
 The Foeceps. 
 
 History. — The midwifery forceps were invented by Peter 
 Chamberlen, born in 1601, who, with his three sons, long kept 
 the invention a secret for their own benefit. The existence of a 
 secret method for saving the lives of infants in difficult labour was 
 first mentioned in a pamphlet published in 1647. The invention 
 gradually became known, but it was not until 1735 that Chapman, 
 in a treatise on midwifery, published a description and plate of the 
 instrument. 
 
 The forceps of Chamberlen did not essentially differ in mechanism 
 from the instrument now known as the short straight forceps (Fig. 
 404, p. 824). Each blade is straight, viewed in profile, but has a 
 cranial curve to grasp the head, the curve starting immediately 
 from the lock. The blades are fenestrated, to lighten the instru- 
 ment and allow the head to bulge through the fenestras ; the 
 handles are of metal, and looped somewhat like the handles of 
 scissors. The lock of Chamberlen's forceps was formed by a fixed 
 
824 
 
 The Practice of Midwifery. 
 
 pivot upon one blade, which fitted into a depression or mortise on 
 the other blade. This lock had to be secured by tape tied round it, 
 to prevent the risk of the blades separating. It is, in fact, the 
 embryo of the lock still used in French, German, and some 
 American forceps (see Fig. 405), in which the pivot is sur- 
 mounted by an adjustable screw, which prevents lateral separa- 
 tion at the lock, and allows the tightness of the lock to be adjusted 
 
 Fig. 404. — Short straight forceps. 
 
 Fig. 405. — Short curved forceps, with 
 French lock. 
 
 by turning the screw. This adjustable screw was first added by 
 Levret, who published a treatise on midwifery in 1766. 
 
 The lock known as the English lock (Fig. 404), which allows the 
 blades to be joined much more easily than any other, and is 
 sufficiently firm for all purposes, was invented by Smellie, who 
 also covered the handles with wood, for greater convenience in 
 grasping. 
 
 The Pelvic Curve. — The short forceps are only capable of grasping 
 the head when near the perineum, or after its descent into the 
 cavity of the pelvis. In order to grasp the head when arrested at 
 or above the brim, a longer instrument is necessary. Length may 
 
The Forceps and Vectis. 
 
 825 
 
 be attained by making the shanks parallel for a certain distance 
 
 beyond the lock before they diverge into the cranial curve. The 
 
 instrument thus formed constitutes the long straight forceps 
 
 (Fig. 406). If, however, long straight forceps are applied to the 
 
 head at or above the brim, the blades can neither grasp the head in 
 
 the axis of the brim, nor can traction be made in the direction of 
 
 that axis. For the axis of the brim (o p, Fig. 22, p. 21) passes 
 
 behind the tip of the coccyx when that bone is in its undisplaced 
 
 position, whereas the resistance of the perineum, even when pressed 
 
 backward to the utmost, must push the 
 
 shanks of the forceps at the vaginal outlet 
 
 much further forward than this point. 
 
 Practically the inclination of the axis of the 
 
 forceps to the axis of the brim cannot be 
 
 less than about 20°. In flattened pelves, 
 
 especially when the pelvic inclination is 
 
 increased, the axis of the brim is sometimes 
 
 directed further back than usual, and the 
 
 deviation of straight forceps from the desired 
 
 direction is then still greater. The result is 
 
 that, when traction is made, the tips of the 
 
 blades, being posterior to the axis in which 
 
 the head has to move, are apt to slip off the 
 
 head posteriorly. Also the perineum is liable 
 
 to be injured from the pressure made upon 
 
 it in retracting it to the utmost extent. The 
 
 difficulty thus caused by the perineum is 
 
 overcome by giving the forceps an additional 
 
 curve, the pelvic curve (see Fig. 408, p. 828 ; 
 
 Fig. 409, p. 828 ; Fig. 410, p. 830). In this way are constituted 
 
 curved forceps, long or short, as the case may be. 
 
 The invention of the pelvic curve has generally been ascribed to 
 Levret, or to Smellie, who adopted it almost simultaneously. It 
 appears, however, to have been previously used, although not 
 published, by Benjamin Pugh, of Chelmsford. Levret's forceps, 
 introduced about 1747, were long and powerful curved forceps 
 with iron handles, and the French, or pivot and mortise, lock. 
 Benjamin Pugh, in a treatise published in 1754, gives a figure of 
 his long curved forceps, closely resembling the long curved forceps 
 now in use, and states that he had invented them upwards of 
 fourteen years before, and was accustomed to apply them to the 
 head even when detained aljove the brim of the pelvis. 
 
 The long curved forceps are able to grasp the head in the axis 
 
 Fia. 406.— Long straight 
 forceps. 
 
826 
 
 The Practice of Midwifery. 
 
 of the brim even when the head is arrested quite high up above 
 the brim (see Fig. 419, p. 844). But not only is their power of 
 prehension superior to that of straight forceps, but they are much 
 easier to apply. For each blade passes more readily along the 
 genital canal, in consequence of its having a curvature correspond- 
 ing to that canal, so that the tip of the blade always passes in 
 advance. But when a straight blade is passed along a curved canal, 
 the point which leads the way is not the tip of the blade, but a 
 point more towards one side, and the introduction is then not so 
 
 Fig. 407. — Diagram illustratiDg the defects of long curved forceps. 
 a.m.f., line of traction ; a.d.b., ideal line of axis traction ; a.n., 
 representing the component of tractile force wasted in injurious 
 pressure against anterior pelvic wall. (Tarnier, Description de deux 
 nouveaux Forceps, Fig. I.) 
 
 easy. The advantage gained by long curved forceps is strikingly 
 shown by the diminution of the proportion of craniotomy cases. In 
 the Guy's Hospital Charity, mainly owing to the introduction of 
 longer, firmer, and more effective forceps, the proportion of 
 craniotomy cases was reduced from 3"6 per 1,000 in the interval 
 1833—1854 to 1-2 per 1,000 in the interval 1854—1863, and to 
 the extremely low proportion of 0*7 per 1,000 in the interval 
 1863—1875. 
 
 Axis-traction Forceps. — The ordinary long curved forceps have 
 the disadvantage that the direction of traction is apt not to be 
 that in which the head is grasped, and in which it has to advance. 
 
The Forceps and Vectis. 827 
 
 but one inclined more anteriorly. When the handles are held in 
 one hand this is indeed inevitable, since the line of traction must 
 necessarily be a straight line from the centre of the head to the 
 point at which the handle is held. This line will make an angle 
 of from 22° to 25° with the axis of the brim, if the pelvic curve 
 of the forceps does not exceed 35° and the forceps are held near 
 the end of the handles. If the forceps are grasped at the lock, 
 the deviation is somewhat less. The deviation of the line of 
 traction from the right direction is therefore slightly greater than 
 in the case of long straight forceps. The consequence of this is 
 that rather less than one-tenth of the tractile force exercised is 
 lost as regards its effect in causing advance in the axis of the 
 brim, and a useless and injurious pressure is exercised on the 
 anterior pelvic wall, equal to more than two-fifths of the tractile 
 force.^ The latter effect seems to be of more importance than 
 the former, since the ratio to the traction exercised is more than 
 four times as great, and, moreover, the loss of one-tenth of the 
 force in ordinary cases is not of much consequence, since there 
 is usually a sufficient reserve of power which may be put into 
 action. 
 
 It will be shown, however, hereafter, that by the use of two 
 hands in traction the force exercised may be made to act accurately 
 in the axis of the brim, a fact which has been rather overlooked by 
 the advocates of axis-traction forceps. 
 
 To avoid the disadvantage of an incorrect direction of traction, 
 a third or perineal curve has been added to the forceps, so as to 
 make the shanks and handles curve backward again round the 
 perineum, until the part of the handles to which traction is 
 applied either approximates more or less to the axis of the blades 
 or lies exactly in that axis. In the latter case traction can be 
 made precisely in the axis of the brim, or of any other part of the 
 pelvis in which the head may lie. By the axis of the blades must 
 be understood the axis of the extremities of the blades, since it is 
 by this part of them that the propulsive force is mainly applied to 
 the head. 
 
 A slight inverted curve has been given to the shanks of the 
 forceps by various authorities, of whom the earliest appears to 
 have been Dr. liobert Wallace Johnston, who published a " System 
 of Midwifery" in 1769. Hubert, in 1860, bent the handles of 
 his forceps back almost at right angles till their extremities 
 nearly reached the axis of the blades. Aveling, in 18G8, 
 
 ' The exact proportion in Ihe former caKC, taking tlie angle at 25°, is 1 —cos. 
 :/', or •093()'J22, in the latter, 8in. 2'/' or •1226183. 
 
828 
 
 The Practice of Midwifery. 
 
 introduced forceps with the handles curved backward, so that 
 the whole instrument has a sigmoid shape. The inverted 
 curve is not, however, carried far enough to meet the axis 
 of the blades. Morales of Belgium, in 1871, gave an inverted 
 curve to the shanks and first part of the handles, finishing the 
 handles with a straight portion. In this case also, the inverted 
 curve was not carried far enough to meet the axis of the 
 blades. Tarnier, in 1877, introduced his now well-known axis- 
 traction forceps (Fig. 411, p. 832). In these, for the first time, the 
 cross-bar by which traction is made lies accurately in the axis of 
 
 Fig. 408. — Simpson's forceps. 
 
 Fig. 409. — Barnes' forceps. 
 
 the blades, and a new principle is also introduced, namely, to make 
 the traction, not by the handles of the prehensile blades, but by 
 traction rods jointed to them in a line with their axis. Tarnier's 
 forceps first called general attention to the principle of axis 
 traction, and various modifications of them have since been 
 introduced.^ 
 
 Mechanical Action of Forceps.— It is frequently stated that 
 the action of forceps is threefold, namely that of a tractor, a lever, 
 
 1 For historical sketches of the various forms of forceps, see Tarnier, Description de 
 Deux Nouveaux Forceps, Paris, 1877, and Aveling, " The Curves of Midwifery Forceps, 
 their Origin and Use," Trans. Obst. Soc. London, 1878, Vol. XX., p. 130. 
 
The Forceps and Vectis. 829 
 
 and a compressor. The essential action, however, is that of a 
 tractor only. To carry out this action it is essential that the 
 instrument should be so constructed as to be capable of maintaining 
 a firm hold of the head without slipping. The two blades of the 
 forceps also form a double lever like a pair of scissors, the fulcrum 
 being at the lock. The action of the double lever is to compress 
 the head. This compression of the head, however, is not one of 
 the objects aimed at in the use of forceps, but is, on the contrary, 
 generally injurious, and should only be carried so far as is 
 necessary to secure a firm hold. For the blades of the forceps 
 being generally applied at the sides of the pelvis, or nearly so, the 
 compression of the head in the transverse diameter of the pelvis 
 tends to bulge it out to a slight extent in the conjugate diameter of 
 the pelvis, where there is generally least room for it. Budin and 
 Milne Murray,^ however, have shown that the main elongation 
 of the head takes place in a vertical diameter, and not in the 
 diameter opposite to that which is compressed. Besides the double 
 leverage causing compression, another kind of leverage may be 
 exercised, not when simple traction is used with forceps, but only 
 when an oscillatory or pendulum movement is made with the 
 handles, the head being grasped tightly enough to form an immov- 
 able mass with the two blades. In this case the lever is formed, 
 not by one blade of the forceps, but by the whole mass of the head 
 with the two blades. It will be seen hereafter that the oscillatory 
 movement in traction is not generally desirable, though recom- 
 mended by many authorities. 
 
 Requirements of Good Forceps. — All patterns of forceps are 
 now made with metal handles, that they may be sterilised by 
 boiling without risk of injury. The handles should be long enough, 
 and the shanks and blades stiff enough, to maintain the hold on 
 the head even under strong traction, otherwise the blades may slip 
 off the head, and diverge at their widest part, thus causing pressure 
 on the lateral pelvic walls. At the same time the tips of the blades, 
 as they slip off, are liable to injure the head, and possibly even the 
 maternal soft parts, if they slip off anteriorly. Good forceps, 
 therefore, should have moderately long handles (not less than 
 5 inches from the lock), and should be as stiff as possible. The 
 quality of stiffness should be tested by holding the handles firmly 
 together, and trying how far the tips of the blades can be separated 
 by the finger and thumb. The advantage to be gained by stiffness 
 is only limited by the consideration that the blades must not be 
 1 Edinburgh Med. Journ., 1888, Vol. XXXI V., Part 1, p. 417. 
 
830 
 
 The Practice of Midwifery. 
 
 made so thick as to occupy too much space in the pelvis. In the 
 shanks a little extra thickness of metal may be employed without 
 any drawback. The cranial curve should be of medium sharpness, 
 so that the elongated head of average size may be grasped 
 uniformly, and not excessively compressed either at its centre or 
 at its extremities. A curve equivalent to the arc of a circle 
 9 inches in diameter is found to be generally the best. If the curve 
 is too sharp the forceps are more difficult to introduce, if it is too 
 
 flat they are more apt to slip off the 
 head, and, in both cases, the head is 
 unequally compressed. The tips of the 
 blades should be about an inch apart 
 when the handles are closed, that they 
 may not be liable to injure the head or 
 neck by their pressure. The outside 
 measurement across the blades at their 
 widest part should not be greater than 
 3f inches. The measurement is of 
 course increased somewhat beyond this 
 magnitude when the forceps are in use, 
 if either the head is too large to allow 
 the handles completely to close, or the 
 blades and shanks yield somewhat 
 under the traction exerted. 
 
 In long curved forceps, the length 
 should be sufficient to allow the head 
 to be grasped even when arrested above 
 the brim, without its being necessary to 
 introduce the lock within the soft parts 
 of the vulva, and so run the risk of 
 pinching the mucous membrane. A 
 length of about 9J inches from the lock 
 If the length is increased beyond this, 
 the quality of stiffness is impaired without any corresponding 
 advantage. The pelvic curve should not be greater than is neces- 
 sary to allow the head to be grasped above the brim in the right 
 direction, for which purpose a curve of from 30° to 35° is 
 sufficient. 
 
 If the curve is increased beyond the necessary amount, the 
 deviation of the line of traction from the correct direction is 
 increased, and then both the loss of power and the useless and 
 injurious pressure on the anterior pelvic wall are increased more 
 than in proportion to the deviation. In the forceps shown in 
 
 Long curved forceps. 
 
 is sufficient for all cases. 
 
The Forceps and Vectis. 831 
 
 Fig. 405, p. 824, the pelvic curve is too great, amounting to about 
 49° ; and the same is true of many foreign patterns of forceps. 
 
 Varieties of Long Curved Forceps. — A great variety of patterns 
 of long curved forceps has been introduced. Of these the best 
 known in this country are Simpson's forceps (Fig. 408, p. 828), 
 and Barnes'^ (Fig. 409, p. 828). Simpson's forceps have the most 
 comfortable handles, the flanges below the lock (see Fig. 410) 
 affording an excellent hold for the index and middle fingers. On the 
 other hand, they are scarcely long enough for all cases in which the 
 head is high above the brim. Barnes' forceps have a more suitable 
 length, though in some recent patterns the length is carried to 
 excess. The loop above the lock (see Fig. 409) is also a great 
 advantage. It allows the left hand to grasp the forceps high up, 
 the index finger being passed through the loop (see Fig. 420, 
 p. 848). This is a gain, as will be seen hereafter, with a view to 
 axis traction. The expansion of the shanks at this point also aids 
 in guiding the blades into conjunction, as they are being locked. 
 An excellent form of forceps is a combination of Simpson's handles 
 with the blades and shanks of Barnes' forceps, including the loop 
 above the lock for the insertion of the index finger (see Fig. 410). 
 With this instrument, when two hands are used, the index finger 
 of the left hand may be passed through the loop, or two fingers may 
 be placed upon the flanges, according to circumstances. When one 
 hand is used the index and middle fingers may be placed upon the 
 flanges, and a firmer hold thus obtained than when the handles 
 are merely grasped by their sides. 
 
 If the handles of the forceps are very short, the operator cannot 
 comj)ress the head firmly enough by grasping them to enable the 
 blades to maintain their hold. If the hold on the head is main- 
 tained at all, when the resistance is considerable, it is because 
 divergence of the blades at their widest parts is prevented by 
 pressure against the pelvic wall. Some obstetric authorities have 
 deliberately set themselves to design forceps with which the com- 
 pression of the head shall be exercised by the pelvis, and not by 
 the operator. Thus in Assalini's forceps, which at one time were 
 used by many, the blades and handles are parallel and do not 
 cross, so that practically no compression can be exercised by the 
 handles. It seems obvious, however, that the pressure thus 
 exercised on the pelvic walls )jy the wedgelike action of the diverg- 
 ing forceps-blades is entirely unnecessary and liable to be injurious. 
 
 ' The pattern of these is similar to that of Lever's forceps, except that the handles 
 are increased in length. 
 
832 
 
 The Practice of Midwifery. 
 
 It is much better that the pelvis should be subjected only to so 
 much pressure as is inevitable in the passage of the head, and that 
 the compression should be exercised by the operator, who can then 
 estimate what force he is exerting, and limit it to that amount 
 which is necessary to maintain his grasp of the head. 
 
 Disadvantages and Advantages of Straight Forceps. — It has 
 already been explained that, when the head is arrested at or above 
 the brim, it is impossible with straight forceps of any length, either 
 to grasp the head, or to make traction, in the right axis, because 
 the coccyx and perineum force the handles forward. In these con- 
 ditions, therefore, there is no question of the superiority of the 
 long curved forceps. The short straight forceps were at one time 
 recommended for the low forceps operation when the head was on 
 the perineum, but the greater facility of passing the blade of curved 
 
 Fig. 411. — Tarnier's axis-traction forceps, with the traction-handle removed. 
 
 forceps, owing to its pelvic curve corresponding to the curve of the 
 genital canal (see pp. 824, 825), is quite manifest even in the low 
 forceps operation, and even when the head is on the perineum. 
 Therefore the use of the short straight forceps presents no advan- 
 tages over that of the long curved. 
 
 Axis-traction Forceps. — It will be explained (see pp. 847 — 848) 
 how perfectly correct axis traction may be made, theoretically at 
 any rate, with the long curved forceps. In ordinary cases it is not 
 difficult to carry out the plan described, if not with perfect accuracy, 
 yet to such an extent that the disadvantage of the ordinary forceps 
 as regards the axis of traction is much less than the advocates of the 
 axis-traction forceps have contended. In difficult cases of the high 
 forceps operation, however, when the resistance is very considerable, 
 and the operator has to put out most of his strength in pulling, it 
 is almost inevitable that he should pull nearly straight towards his 
 chest with both arms, instead of pulling with each hand in the 
 direction of the corresponding forearm in the manner described 
 
The Forceps and Vectis. 
 
 833 
 
 (see p. 848). The direction of traction is then most defective when 
 the force is greatest, and therefore the pressure on the pelvic wall, 
 
 Fig. 412. — Upper or right-hand blade of Tarnier's axis-traction forceps. Traction rod 
 detached for cleansing of hinge (d). 
 
 due to the erroneous direction, most likely to be injurious. In 
 these circumstances axis-traction forceps have a great advantage. 
 In Tarnier's forceps (Figs. 411, 412, 413) the instrument, seen 
 
 Fid. 413. — Traction with Tarnier's axis-traction forceps when the head is at the brim. 
 The dotted line shows the direction of traction. 
 
 from the side, forms an S-shaped curve, so far as regards that part 
 of it which is used for traction, the perineal curve being carried 
 back so far that the end of it lies exactly on the axis of the upper 
 halves of the blades. Besides the principle of axis traction, a 
 second principle is embodied in the instrument, namely, that of 
 separating tbe " prehensile branches," or that part of it wbich 
 M. 53 
 
834 
 
 The Practice of Midwifery. 
 
 corresponds to ordinar}' forceps, from the " traction rods," at the 
 extremity of which the force is applied by means of a strong trans- 
 verse bar, which allows the utmost strength of the operator to be 
 put out by a firm grasp with both hands. The traction rods are 
 hinged near the lower part of the blades. In the original pattern 
 the prehensile branches had the same S- shaped curve as the traction 
 rods, and were to be kept close to them, the traction rods being 
 made in one piece. In the latest pattern (Figs. 411, 412, 413), the 
 prehensile branches are made in the same shape as ordinary long 
 curved forceps, so that the bandies lie forward; the traction rods 
 are divided by a joint in the middle, at which the rods belonging 
 
 Fig. 414. — Tarnier's axis-traction forceps. 
 
 to each blade are affixed to a common handle (Fig. 414). This 
 attachment is made after the prehensile branches have been intro- 
 duced separatel}^ and locked. The prehensile branches take their 
 grasp of the head and exercise compression upon it, not b}^ being 
 held by the hands, but by means of a screw which approximates the 
 handles. This screw should be tightened only just when traction is 
 made, and loosened somewhat in the intervals, that the head may 
 not be subjected to constant pressure. The whole instrument is 
 very stout and firm, so that the blades have the merit of stiffness in 
 a high degree, and are, in consequence, able to hold the head with 
 a less compressing power than would otherwise be necessary. 
 
 It is claimed that the prehensile branches form an '' indicating 
 needle," showing the direction in which to make traction at any 
 
The Forceps and Vectis. 
 
 835 
 
 moment, and that the handles turn forward as the head becomes 
 extended under the influence of the pressure of the genital canal. 
 The operator, therefore, it is said, need not trouble himself to 
 discover in what direction he ought to pull ; he has simply to keep 
 the traction rods close to the prehensile branches without actually 
 pushing against them, and to pull in the direction thus indicated. 
 
 Tarnier's axis-traction forceps have been much improved, and the 
 best model of them at the present time is that of Milne Murray (Fig. 
 422, p. 855). He has worked out the construction and use of axis- 
 traction forceps in great detail. It is important that the shanks and 
 handles should be as straight and as light as possible, so that they 
 
 ii 
 
 1 
 
 
 LjI 
 
 ) 
 
 1 
 
 
 Fig. 415. — Axis-traction forceps with screw at end of handles. 
 
 may in reality serve as indicating rods. Theoretically the traction 
 rods should be attached in the centre of the fenestra, but practically 
 it is sufficient if they are attached as near to this point as possible, 
 and for this reason there should be a good expanse of metal at the 
 base of the fenestree. The traction rods must lie parallel to the 
 shanks and handles, and their attachment to the traction handle 
 should be such that a straight line drawn through the centre of the 
 handle so as to bisect the line uniting the two attachments coincides 
 with the axis of the upper halves of the blades, when the rods are 
 touching the shanks. In one pattern of Milne Murray's forceps the 
 handle is adjustable so that the line of traction can be altered to suit 
 different pelves. It is an advantage to have the screw uniting the 
 blades at the extremity of the handles instead of near the lock, and 
 
 58—2 
 
836 The Practice of Midwifery. 
 
 to have the traction rods readily removable for cleaning purposes 
 (Fig. 415, p. 835). 
 
 Advantages and Disadvantages of Axis-traction Forceps. — The main 
 advantage of the instrument is that it allows perfect axis-traction, 
 the handle for pulling being situated accurately in the axis of the 
 ujDper halves of the blades. I have succeeded with it in extracting 
 a living child when the best efforts with the long curved forceps 
 had failed. It has some slight drawbacks. It is rather more 
 complicated and a little more difficult to adjust than ordinary 
 forceps. The hinge at the blades is difficult to keep perfectly 
 clean, whereas with ordinary forceps the part of the instrument 
 introduced into the vulva has no point which is likely to retain 
 septic material. This disadvantage is, however, to a large extent 
 got over in the most modern patterns of these forceps, in which the 
 screw is placed at the extremity of the handles instead of near the 
 hinge. The compression of the head with a screw is also a dis- 
 advantage. With ordinary forceps the operator, almost automati- 
 cally, proportions the amount of pressure to the traction force 
 exerted. With axis-traction forceps he cannot make the adjustment 
 so quickly, and he may omit to loosen the screw in the intervals of 
 traction. When the lock is placed at the end of the blades, owing 
 to the greater leverage obtained, great care must be taken not to com- 
 press unduly the head. In most cases, however, it is possible to use 
 a well-made pair of axis-traction forceps with the slightest possible 
 tightening, and indeed often without any tightening, of the screw at 
 all, and with a little practice the loosening of the screw between the 
 pains becomes almost an automatic action on the part of the operator. 
 
 The advantages of the best type of axis-traction forceps so far 
 outweigh their slight disadvantages that they should be chosen for 
 use in all cases. The importance of being able to make correct 
 axis traction with one hand alone in any position of the patient is very 
 great indeed, and the fact that the use of axis-traction forceps reduces 
 to a minimum the amount of force required to deliver a j)atient 
 reduces the risk of the use of force^Ds for both mother and child. 
 
 Application of Forceps. 
 
 The indications for the use of forceps in various circumstances 
 have been already discussed. Certain conditions are, however, 
 necessary in all cases. These are that the membranes should be 
 ruptured, that the os uteri should either be fully or two-thirds 
 dilated, the presentation should be a suitable one, there should not 
 be too great disi^roportion between the head and the pelvis, and 
 whenever possible the head should be allowed to become engaged 
 
The Forceps and Vectis. 837 
 
 in the pelvic brim before the forceps are applied. A catheter should 
 first be passed, to make sure that the bladder is emptied, and the 
 rectum should also be empty. The blades should be warmed to a 
 comfortable temperature in hot water, and great care should be 
 taken to make sure that they are perfectly clean and free from any 
 septic material. To this end the instrument should not only be 
 cleaned with scrupulous care after use, but immediately before use 
 it should be disinfected by boiling and immersed in a warm solution 
 of lysol 1 in 100, or carbolic acid 1 in 40. The hands of the operator 
 and the vulva of the patient must be cleansed with all antiseptic 
 precautions, and if there is any likelihood of the vagina having 
 been infected, a vaginal douche of some weak antiseptic lotion, such 
 as lysol 1 per cent, or cyllin one drachm to the pint, should be given. 
 
 In the high forceps operation rubber gloves should be worn, as 
 indeed they should be always if the operator has had to deal with 
 any septic cases recently. 
 
 Position of the Patient. — On the Continent, and in America, it is 
 usual to place the patient in the lithotomy position at the edge of 
 the bed ; in this country she is kept in the usual left lateral posi- 
 tion, the hips being merely brought near to the edge of the bed, the 
 knees drawn up toward the abdomen, and the head and shoulders 
 directed toward the opposite side of the bed, so that the trunk lies 
 transversely. The latter position involves much less disturbance 
 of the patient, and has a great advantage in point of delicacy. It 
 also allows the application of the forceps and the use of traction 
 quite as well, and indeed better. I or, with the lithotomy position, 
 the hips must quite overhang the edge of the bed, otherwise there 
 is not room sufficiently to depress the handles in the high forceps 
 operation, and such a position may be difficult to maintain. The 
 lithotomy position is more convenient only at the last stage of 
 extraction, when the handles of the forceps have to be carried 
 forward over the abdomen. Even this movement may be accom- 
 plished equally well with the lateral position if the knee is raised 
 by the nurse or other assistant (see Fig. 421, ]3. 851). The mode 
 of making axis traction with ordinary forceps, to be hereafter 
 described (see p. 847), is also much more difficult, if not impos- 
 sible, to carry out, when the patient is in the dorsal position. The 
 lateral position is, therefore, to be preferred. The application is 
 easier if the hips are brought quite to the edge of the bed, because 
 then there is plenty of room to dej^ress the handle while passing 
 the upper blade. This is not, however, essential, as will be seen 
 hereafter, and, if the patient is nervous, it is possiljle to apply the 
 forceps without changing her position. 
 
838 
 
 The Practice of Midwifery. 
 
 Walchefs Position. — It has already been mentioned, in the 
 description o£ the sacro-ihac joints (p. 10), that extension of the 
 pelvis on the trunk increases somewhat the conjugate diameter 
 of the pelvis and diminishes the antero-posterior diameter of the 
 outlet, while flexion has the opposite effect. The most effective 
 mode of producing such extension is Walcher's position, in which the 
 j)atient is placed on her back transversely across a rather high bed, 
 so that the thighs and legs hang down over the side and the toes 
 
 Fig. 416. — Diagram showing the increase in the conjugate diameters in 
 Walcher's position. 
 
 just touch the floor. The position has therefore some advantage in 
 forceps extraction through a contracted conjugate, when the head 
 is arrested above the brim. It may also be used to facilitate the 
 entry of the head even without the application of forceps, especially 
 if combined with external pressure, or again in the extraction of an 
 after-coming head arrested above the brim. Walcher estimated the 
 amount of gain in the conjugate as 8 to 13 mm. ; Klein at 5 to 
 6 mm. ; Fothergill at 9'3 mm. on the average, the maximum 12 mm. 
 AiKESthesia. — If the labour is being conducted without anpes- 
 thesia, there is an advantage in avoiding an ansesthetic for the 
 application of forceps. For any anaesthetic diminislies the force 
 of the pains which would otherwise act in conjunction with the 
 tractile force. Moreover, for the application of the forceps the 
 
The Forceps and Vectis. 839 
 
 anaesthesia must be either short of the stage which completely 
 abolishes self-control, or must be pushed nearly to the full surgical 
 degree. An attempt to apply forceps in the stage of rigidity and 
 spasm might cause injury. If the anaesthetic is to be given to the 
 full surgical degree, there should of course, as in any other surgical 
 operation, be a skilled administrator, who devotes himself to this 
 duty alone. Generally, the application of the blades does not 
 cause much pain in skilled hands. If, therefore, chloroform is being 
 given during the labour, it may be continued during the applica- 
 tion of the blades to the extent of deadening pain without quite 
 abolishing self-control, and may be given to somewhat greater 
 degree when traction is made. If Junker's inhaler is being used, 
 the patient may be allowed to work the pump herself, since she 
 will leave off working it before becoming deeply narcotised. If, 
 however, the patient is very nervous and difficult to control, 
 especially if she is a primipara in whom there is danger of the 
 perineum being ruptured, there is a great advantage in having an 
 assistant to administer the anaesthetic, and in having it given to a 
 pretty full extent at the final stage of extraction, since otherwise 
 a sudden movement at the height of a pain may render it impossible 
 for the operator to prevent a rupture. 
 
 Introduction of Blades. — ^With curved forceps the operator must 
 select the upper or lower blade. With the lock made as it usually 
 is made, it is better, both with straight and curved forceps, to 
 introduce the loiver or left-hand blade first. With curved forceps, 
 if an inexperienced operator feels at first any doubt which blade is 
 the lower and which is the upper, he should lock the blades 
 together, and hold them in a position similar to that which they 
 are to occupy when applied to the head, noticing that the concavity 
 of the pelvic curve of the forceps must look forwards. 
 
 In the case of the long curved forceps, it is generally taught that 
 the blades should be applied at the sides of the pelvis, without 
 regard to the position of the head. 
 
 The position of the head should, however, be exactly determined 
 in the first instance, not so much that any great difference in the 
 position of the blades should be aimed at in consequence, but 
 rather that the operator may be made aware of any unusual 
 position, such as a diagonal or nearly transverse position of the 
 long diameter near the outlet, or an occipito-posterior jjosition, 
 which involves an increased risk of rupture of the perineum. The 
 ear cannot generally be felt when the head is strongly fiexed and 
 much elongated without putting the patient to considerable pain. 
 Feeling the ear, moreover, is quite unnecessary for the diagnosis of 
 
840 The Practice of Midwifery. 
 
 the exact position. This may be made out with certainty from the 
 sutures and fontanelles, or from the sutures alone, if the fontanelle 
 within reach is lost in the caput succedaneum (see p. 279). 
 
 In the directions which follow, it will be assumed that long- 
 curved forceps are used. The mode of introduction is, however, 
 identical, except that, with axis-traction forceps, the traction rod of 
 the upper blade should be placed in front of it while this blade is 
 being introduced. 
 
 When the head is close to the outlet and the usual rotation has 
 taken place, the blades, if applied exactly at the sides of the pelvis, 
 will grasp the head nearly at its sides, or in an only slightly 
 diagonal position. The sides of the pelvis may in this case be 
 followed exactly in adjusting the blades. If, however, the head is 
 higher in the pelvis, and its long diameter diagonal, or if it has 
 descended quite to the outlet, and the long diameter remains 
 diagonal from failure of rotation, there is a slight advantage in 
 attending somewhat to the position of the head in adjusting the 
 forceps. Suppose, for instance, that the head lies in the first or 
 left occipifco-anterior position. Each blade may be passed up at 
 the side of the pelvis, in the position in which it is found to glide 
 up most readily. But, in adjusting the blades for locking, the 
 upper blade may be brought slightly anterior to the middle line, 
 and the lower blade slightly posterior (see Fig. 419, p. 844). This 
 will cause the handles (of curved forceps) to incline somewhat 
 downwards, or to the patient's left side. Then, as the head is 
 drawn down in the grasp of the forceps, and the usual internal 
 rotation takes place, the handles will first rotate to the front, and 
 then probably somewhat over toward the right side. For the 
 blades will have grasped the head somewhat diagonally, though 
 not quite so much so as if they had been adjusted at first pre- 
 cisely at the sides of the pelvis. Similarly if the head lies in the 
 second or right occipito-anterior position, the upper blade may be 
 brought slightly posterior to the middle line in adjusting the 
 forceps, and the lower blade slightly anterior. If, however, any 
 inexperienced operator feels any uncertainty in the diagnosis of the 
 position of the head, or if it is obscured by the caput succedaneum, 
 he may, without any disadvantage of consequence, regard only 
 the sides of the pelvis in adjusting the blades. 
 
 In the high forceps operation, when the head is at or above the 
 brim, it is generally taught that the blades are to be applied at 
 the sides of the pelvis, but some American authorities have advised 
 that they should be applied at the sides of the head. Such a 
 recommendation is not easy to carry out. For in the flattened 
 
The Forceps and Vectis. 
 
 841 
 
 pelvis the long diameter of the head is generally almost transverse, 
 and the sacral promontory forms a great obstacle to passing the 
 blade of the forceps over the side of the head which lies posteriorly. 
 Moreover, if the blades could be applied anteriorly and jDosteriorly, 
 or nearly so, the advantage of the pelvic curve of the forceps would 
 be lost, and this curve would become an absolute inconvenience, 
 being directed toward the lateral pelvic wall. 
 
 The best plan is to follow the same rule as when the head is 
 lower down in the cavity, pro- 
 viclecl that the long diameter of 
 the head lies obliquely, namely, 
 so far as possible to adjust the 
 blade corresponding to the 
 anterior side of the head some- 
 what anterior to the middle 
 line, and the other somewhat 
 posterior. The head will then 
 not be quite so much bulged 
 out in the diameter engaged 
 in the conjugate diameter of 
 the pelvis, as if the blades 
 were exactly lateral, and, as the 
 head descends in the pelvis, 
 the pelvic curve of the forceps 
 will be more nearly in accord- 
 ance with that of the genital 
 canal, after the internal rota- 
 tion of the head has taken place. 
 
 When, however, the pelvis is 
 so decidedly flattened that the 
 long diameter of the head lies 
 almost exactly transversely, it 
 is better to adjust one blade 
 over the forehead and the 
 other over the occiput, that is 
 to say, to place the blades at the sides of the pelvis. The 
 pressure of the forceps will then not be so likely to displace the 
 long diameter of the head out of the most favourable position 
 as it would be if the blades caught the head obliquely. The 
 head will probably be drawn through the contracted brim in 
 its original transverse position. After the head has passed the 
 brim, and internal rotation commences, the forceps may be taken 
 off and reajjplied, or they may be loosened sufficiently to allow 
 
 Fift. 417. — Introduction of first or lower 
 blade of axis-traction forceps. 
 
842 
 
 The Practice of Midwifery. 
 
 the head to rotate within the hlades under the influence of the 
 pelvic pressure. 
 
 Introduction of Lower Blade. — The operator takes up his position 
 opposite the patient's hips. The left hand or half-hand is intro- 
 duced into the vagina, the back of the hand directed towards the 
 patient's left side. If the margin of the cervix can still be felt, the 
 
 Fig. 418. — Introduction of second or upper blade of axis-traction forceps. 
 
 tips of the fingers are placed upon the head just within the cervix, 
 so as to make sure that the blade of the forceps passes within the 
 cervix and not outside it. If the cervix has retracted quite out of 
 reach, the passage of the blade in the right direction is easily 
 secured, simply by keeping the tip of the blade in close contact 
 with the head. The lower blade of the forceps, sterilised and 
 warmed, is taken in the right hand, and the end of the handle held 
 very lightly between the tips of the thumb and two or three fingers. 
 The blade is guided up along the flexor surface of the hand till the 
 
The Forceps and Vectis. 843 
 
 point of the blade rests on the head, just under the tips of the 
 fingers (see Fig. 417, p. 841). The handle is at first somewhat 
 raised and directed rather forward, so as to allow the tip of 
 the blade to lead the way along the curve of the genital canal. 
 As the blade passes up, the handle is carried somewhat backward. 
 As soon as the tip of the blade rests on the head, the curvature of 
 the blade must be made to correspond with that of the head, to 
 secure easy progress ; for if the tip of the blade impinges upon the 
 head at an angle, it will push the skin of the head up in a fold, and 
 will be thereby arrested. For this purpose it is generally necessary 
 to raise the handle somewhat further. In pushing on the blade 
 into position over the head, the essential point is to hold the handle 
 very lightly, and overcome any resistance by change of direction, 
 and not by the use of force. As the blade passes on, the handle is 
 lowered and carried backward, until the shank rests against the 
 perineum. The flat inner surface of the handle should look nearly 
 downwards (see Fig. 419, p. 844). The easy passage of the blade 
 in this manner is a proof that it is going in the right direction. 
 
 The lower blade having been passed, the handle should be given 
 to the nurse or other assistant, who is to hold it firmly enough to 
 prevent its rotating, keeping it backward against the perineum 
 (Fig. 418, p. 842). If no assistant is available, the handle may be 
 allowed to rest on the back of the left wrist, while the left hand is 
 passed into the vagina to guide the upper blade into position. It is 
 always preferable, however, to have an assistant to hold the handle 
 if possible. 
 
 Introduction of Upper Blade. — If the patient's hips are com- 
 pletely overhanging the edge of the bed, the upper blade may be 
 placed in exactly the same way as the lower, the handle being 
 depressed instead of raised. Frequently, however, the edge of the 
 bed interferes somewhat with the handle being fully depressed. 
 Introduction is then facilitated by the plan of carrying the handle 
 at first far forward close beneath the patient's left thigh, instead of 
 depressing it so much. The effect of this is that the blade passes 
 at first not up the side of the pelvis, but nearly opposite the right 
 sacro-iliac articulation, a direction in which there is generally more 
 free space than in any other (Fig. 418). When it has passed up to 
 the required level, it is brought round into position over the head 
 at the side of the pelvis, or somewhat anterior to the middle line if 
 the head is lying in the first position, by carrying the handle back- 
 wards and slightly depressing and rotating it. Thus, as this blade 
 passes up, the inner fiat surface of the handle looks at first nearly 
 backwards, but eventually upwards, or upwards and somewhat 
 
844 
 
 The Practice of Midwifery. 
 
 forwards (see Fig. 419). To guide the blade within the cervix, the 
 left hand is passed into the vagina in the same way as for the lower 
 blade, the back of the hand being directed to the patient's right 
 side, and somewhat backwards (Fig. 418, p. 842). 
 
 The mode of introduction of the two blades of the forceps may be 
 summarised as follows : — The lower blade should be introduced into 
 
 the vagina with the handle lying 
 parallel to the mother's thigh, and, 
 to j)ass it into position over the 
 child's head, the handle must be 
 carried upwards and backwards and 
 then downwards and backwards, 
 describing a semicircle with its 
 convexity ujDwards. In the intro- 
 duction of the upper blade the 
 handle should again be placed 
 parallel to the mother's thigh 
 while the blade is being introduced 
 into the vagina, and then it should 
 be carried downwards and back- 
 wards and upwards and backwards, 
 again describing a semicircle, when 
 the blade will slip into position 
 over the child's head. 
 
 Locking tlic Blades, — The blades 
 having been passed in this way, 
 the lock will be found in the 
 right position for adjustment. For 
 locking, the blades must be passed 
 to the same level, and the flat 
 surfaces of the handles, and 
 therefore also the blades, must be 
 exactly opposite each other. If 
 one handle is found to project more 
 outside the vulva than the other, 
 it must be passed in a little 
 further, or the other slightly withdrawn, until the two are exactly 
 equal. It happens, not uncommonly, that both blades tend to turn 
 somewhat backwards into the spaces opposite the sacro-iliac articula- 
 tions, where there is more room for them than at any other part of the 
 pelvis. This tendency is increased if there is a long rigid perineum, 
 which pushes the handles forward, and thereby tilts the upper part 
 of the blades backward. If the forceps cannot be locked, from the 
 
 Fig. 419. — Diagram to illustrate intro- 
 duction of second or upper blade 
 of long curved forceps, the head 
 being in the first position. A B, 
 lower blade already introduced, 
 adjusted somewhat posterior to the 
 left side of the pelvis, c d, position 
 of upper blade as it approaches the 
 head, c' d', its final position just 
 before locking, adjusted somewhat 
 anterior to right side of pelvis, 
 c c', D d', paths of end of handle 
 and tip of blade. The flat internal 
 surface of the handle looks at first 
 backwards and slightly upwards, 
 finally upwards and slightly for- 
 wards, in consequence of the rota- 
 tion of the blade. 
 
The Forceps and Vectis. 845 
 
 handles not being opposite to each other, this rotation of the blades 
 will be found most frequently to be the cause of difficulty ; for the 
 effect of it is that the flat interior surfaces of both handles are 
 inclined forward, instead of being exactly opposite to each other. 
 To overcome the difficulty, the lower handle should be taken in the 
 right hand and the upper handle in the left, and both handles 
 pressed backward toward the perineum. This will bring the upper 
 part of the blades forward over the head to the sides of the pelvis. 
 At the same time, both handles are to be rotated in opposite direc- 
 tions until the flat surfaces exactly face each other, and the forceps 
 will then at once lock. In making this adjustment, as has already 
 been mentioned, it is a good plan, when the long diameter of the 
 head is diagonal, to bring the blade corresponding to the anterior 
 side of the head in front of the middle line, and the other behind it. 
 The upper blade will then be somewhat anterior, when the head is 
 in the first position, the lower blade, when the head is in the second 
 position. If the handles can be easily brought together, or nearly 
 brought together, after locking, it is a sign that the blades are 
 rightly adjusted within the uterus. As the blades are locked, if the 
 lock is near to the vulva, care must be taken that no mucous mem- 
 brane or hair is caught in it. 
 
 When the force]3s are locked, the fingers should be introduced 
 to make sure that the blades are properly applied to the head and 
 within the os uteri. Not more than about one-third of the fenestras 
 of the blades should be felt lying free below the head. If the head 
 is very large and much elongated, nearly the whole of the fenestrge 
 may be in contact with the head. If, when traction is made, a 
 greater and greater proportion of the fenestra can be felt below the 
 head, this will indicate that the blades are slipping off. 
 
 There is generally a groove round the handles of the forceps, to 
 enable the handles to be tied together. Tying the handles is, how- 
 ever, quite unnecessary and bad practice. If they are held lightly 
 in the intervals of traction, the forceps will not become unlocked ; 
 and it is important that, in these intervals, the head should be entirely 
 relieved from the pressure of the blades. If, therefore, the operator 
 should desire to tie the handles together, in order to be able entirely 
 to let them go, they should be tied only quite loosely, sufficiently to 
 prevent their becoming unlocked, but not to cause any pressure 
 upon the head. 
 
 If the handles are found completely to close together with 
 moderate pressure, it is a sign that the head is small, and is not 
 grasped in one of its long diameters. If, on the other hand, they 
 remain considerably apart, it may be inferred that the head is 
 
846 The Practice of Midwifery. 
 
 large, or is seized in one of its long diameters. If the separation 
 of the handles is very great, a hydrocephalic head may be suspected. 
 
 Mode of making Traction. — If the pains are still normal in 
 character, traction should be made only during the pains, so that 
 the artificial help may be combined with the natural force. The 
 only exception to this is the case in which, at the final stage of 
 extraction, there is danger of the perineum being ruptured, 
 especially when the patient is a primipara, and difiicult to control. 
 It is then often better to extract the head in the interval of pains, 
 so that the exact degree of force may be regulated, and vasij not 
 be liable to be disturbed by a sudden expulsive effort. If the 
 pains have become inefi^ective, and occur only at long intervals, or 
 if the uterus has passed into a state of continuous action, traction 
 should be made at intervals corresponding to those of the natural 
 pains ; for discontinuous pressure is less likely to be injurious, 
 both to mother and child, than continuous pressure, the circula- 
 tion being restored in the intervals of rest. The handles should 
 be compressed during traction, and the compression should be 
 proportional to the tractile force exerted, so that a firm hold may 
 be maintained on the head. In the intervals of traction, the 
 compression should be taken oft'. 
 
 Resistance of Cervix. — In those cases in which forceps are applied 
 with a cervix not yet fully dilated, before any effort is made at 
 extraction, the operator should ascertain whether the resistance to 
 the advance of the head is due, in part or in whole, to the cervix. 
 For this purpose moderate traction may be made on the handles 
 with the right hand, while the left hand is passed into the vagina 
 to feel whether the effect of this traction is to put the cervix on 
 the stretch, and to what extent. In general, if the cervix is the 
 cause of difiiculty, it will be the external os which forms the 
 obstacle. In some cases, however, especially when labour has been 
 brought on rapidly in consequence of some condition dangerous to 
 the mother, such as eclampsia, the internal os will be found to 
 be not fully dilated, and to be forming a rigid barrier. If the 
 obstruction is due to incomplete dilatation of the cervix, much 
 longer time must be allowed for delivery with the forceps, often as 
 much as an hour or even two hours. Otherwise the cervix is likely 
 to be lacerated, and then there is an increased risk of septic 
 absorption and pelvic cellulitis, as well as of subsequent chronic 
 uterine disease set up by the ununited laceration and consequent 
 eversion of the cervix. In order to bring about gradual dilatation 
 of the cervix the traction must be gentler and more continuous 
 than when the obstruction is due to the pelvis, and the finger 
 
The Forceps and Vectis. 847 
 
 should be frequently, if not constantly, testing the degree of strain 
 which is placed upon the tissues. In some cases of contraction of 
 the brim the cervix is not fully dilated because the head is arrested 
 above the brim, and not able to descend upon it and complete the 
 dilatation after the escape of the liquor amnii. It may then be 
 necessary to make powerful traction at first, to cause the head to 
 enter the pelvis and descend upon the cervix, and then, when this 
 stage has been reached, to be very gentle, and allow ample time 
 for the cervix gradually to yield. 
 
 When no part of the resistance is due to the cervix, extraction 
 may be made more rapidly, especially if the perineum also forms 
 no obstacle. But in all cases of forceps delivery there should be 
 no hurry, and time should be allowed for moulding of the head. 
 The time required for extraction in such cases may vary from a 
 few minutes to half an hour or more, according to the resistance 
 encountered. 
 
 Direction of Traction. — The object is in general to make traction 
 in the direction of that part of the pelvic axis (see Fig. 22, p. 21) 
 in which the centre of the head lies. This is the direction in 
 which, if the forceps are correctly applied, the head is grasped by 
 the upj)er portions of the blades, that is to say, by those portions 
 which alone communicate to it the onward impulse (see Fig. 420, 
 p. 848). In a normally shaped pelvis it must be remembered 
 that the direction of the axis is practically straight as far as the 
 central plane of the pelvis, and that it is inclined at an angle of 
 55° or 60°, nearly two-thirds of a right angle, to the axis of the 
 woman's body. Traction has therefore to be made as nearly as 
 possible in the axis of the brim, downward and backward, with 
 any position of the head, from one quite above the brim to one in 
 which the advanced part of the head is beginning to press upon 
 the inclined perineal body or pelvic floor, the centre of the head 
 having reached the central plane of the pelvis. From this point 
 onward the direction of traction must be carried rather rapidly 
 forward, until at the outlet, if the perineum was previously intact, 
 the direction has been changed through an angle of as much as 
 135°, and is now almost horizontally forward, in reference to the 
 axis of the mother, the handles of the forceps being carried up 
 over the abdomen. (See Fig. 22, p. 21, and Fig. 421, p. 851.) 
 
 Direction of Traction in Flattened Pelves. — In flattened jDelves 
 there is often posterior obliquity of the uterus in reference to the 
 axis of the brim, especially if the pelvic inclination is increased. 
 Regard must then be paid to the "curve of the false promontor3^" 
 If the head is lying loose, high above the l)rira, when the forceps 
 
848 
 
 The Practice of Midwifery. 
 
 are applied over it, the centre of the head may lie behind the axis 
 of the brim, the head being held back by the anterior uterine 
 wall, in consequence of the posterior obliquity of the uterus. 
 Traction must then be made at first a little more forward than 
 the axis of the brim, in order to get the head to enter the brim. 
 A little later, when the centre of the head is passing the brim and 
 rounding the promontory of the sacrum, the backward inclination 
 of the traction should be somewhat increased, so as to bring the 
 head into the hollow of the sacrum. Then, as in the ordinary 
 case, the traction should be continued in nearly the same direction 
 
 Fig. 420. — Mode of making axis traction with ordinary long curved forceps. 
 A, centre of head, as grasped by the forceps, p, Q, forces exerted by the 
 two hands. H D, E F, directions of forces, P, Q. A X, A Y, perpendiculars 
 from A upon E F, H D. A K, axis of brim. E, resultant of P Q. 
 
 till the advanced part of the head begins to press upon the pelvic 
 floor, and afterwards shifted rather rapidly forwards. 
 
 When, however, the uterus is active, and the head is pressed 
 down upon the brim, the centre of the head will generally lie, if 
 anything, anterior to the axis of the brim from the first : for the 
 uterine force presses the head downward and forward in reference 
 to the axis of the brim, and the last lumbar vertebra pushes it 
 forward somewhat over the edge of the brim, if it is too large 
 readily to enter. Any Naegele-obliquity which may exist (see 
 pp. 262 — 267) will also bring the centre of the head more forward. 
 In this case the traction must from the first be directed well 
 backward, somewhat more posteriorly than the axis of the brim. 
 
The Forceps and Vectis. 849 
 
 Axis Traction. — The only way in which, with long curved forceps, 
 it is possible to exercise traction accurately in the direction of the 
 pelvic axis at the brim or at any other point, and, at the same 
 time, in the direction of the upper halves of the blades, is to grasp 
 the handles with two hands. The mode in which traction can, in 
 this way, be made in the axis of the brim, assuming that an equal 
 tractile force is put out by the two hands, is illustrated in Fig. 420. 
 The forceps are held by the right hand at the extremity of the 
 handles, and by the left hand near the lock, the forefinger being 
 passed through the loop above it.^ 
 
 The following is the rule for exercising axis traction with 
 ordinary forceps. Grasp the forceps in the way shown in the 
 figure. Let the right forearm be inclined slightly forwards (at an 
 angle of about 25°) in reference to the handles of the forceps, 
 and the left forearm be about at right angles to the right. Then 
 pull with each hand, not directly forwards to the chest, but in the 
 line of the corresponding forearm, and let both hands pull with 
 equal strength. 
 
 The forearms will naturally be in the position above described, 
 namely, about at right angles to each other, if the elbows are kept 
 near the sides. The inclination of the two arms to the forceps is 
 also that at which the hands can most easily and naturally grasp 
 them. In order, therefore, to make axis traction with ordinary 
 forceps, the operator has not to make any careful estimate of 
 angles. He has only to take hold of the forceps in the right way, 
 and hold them in the most natural manner, keeping his elbows 
 near his sides, and merely to remember that the traction of each 
 hand ought not to be directly towards the chest, but in the line of 
 the corresponding forearm. 
 
 It is obvious that for axis traction exercised in this way Barnes' 
 forceps have an advantage over Simpson's, since the loop above the 
 
 1 The mechanical conditions necessary to secure the required result are two. First 
 the product of the force P exercised by the left hand and the perpendicular A Y from 
 Ihe centre of the head upon its direction must be equal to the product of Q, the force 
 exercised by the right hand and the corresponding perpendicular A X upon its 
 direction. The operatfjr need not, howevei', trouble himself about this condition, for, 
 in order to fulfil it, he has only so to pull that the handles are not carried either 
 forwaifl or Vjackward. 
 
 The second condition is not quite so easy to fulfil exactlj'. It is that the lines of 
 traction with the two hands must be equally inclined to the axis of the brim. The two 
 lines of traction (x v, Y D, see Fig. 420) will then meet upon the axis of the brim A B, 
 and the direction of Jt, the resultant of the two forces, will coincide with the axis of 
 the brim. It will be seen by the figure that the inclination of the two forces to each 
 other ought to be about a light angle, with foi'ceps of the ordinary shape and length, 
 assuming that the two hands pull with equal force. The line of traction of the rigiit 
 hand should be inclined about 2'/' in advance of the direction of the handles, the line 
 of traction of the l<;f't liand about <)"/' behind it. 
 
 M. 54 
 
850 The Practice of Midwifery. 
 
 lock in the former gives a convenient hold for the left hand at a greater 
 distance from the end of the handles than the flanges of Simpson's 
 forceps. With the forceps shown in the figure (see also Fig. 420, 
 p. 848) the finger should be jDassed through the loop, not rested on 
 the flanges, if axis traction is desired. 
 
 The case given above is the niost simple one. If the hands pull 
 with unequal strength, the desired result may be attained in many 
 different ways. Thus, if the left hand pulls more strongly than 
 the right, or if the left hand grasj)s the forcej)s higher up the shanks, 
 the proper direction of traction for the left hand is not directed so 
 much backward, and the two directions of traction need not diverge 
 by so great an angle as a right angle. 
 
 By this method it is possible, with ordinary forceps, to secure 
 axis traction with considerable approximation, if not with absolute 
 exactitude ; and a slight deviation from the true direction is not 
 of much consequence. Suppose, for instance, that the deviation 
 is 10° ; tben the amount of force lost as regards the advance of the 
 head is only about one-fiftieth of the whole, and the unnecessary 
 pressure on the pelvic wall about one thirty-sixth of the force 
 employed. 
 
 The mode in which the use of two hands enables the traction to 
 be made more backward than it otherwise could be may be explained 
 by saying that the two blades of the forceps, united in one mass 
 with the head, form a lever, the fulcrum being the point grasped by 
 the left hand and fixed by the traction of that hand. The traction 
 of the right hand, ajiplied at the end of the handles and inclined 
 forwards, therefore tends to tilt the centre of the head, at the 
 opposite end of the lever, backwards. 
 
 In all cases in which the head lies at or above the brim or at 
 some height in the cavity of the pelvis it is desirable when using 
 the long curved forceps to adopt the plan of traction with two hands 
 which has been here described ; for even if the operator does not 
 trouble himself about judging exactly the correct position of the 
 arms, the resultant force is likely to be more nearly in the right 
 direction than if traction were made simply from the centre of the 
 head to the lock or end of the handles. If resistance is slight, 
 there is no harm in drawing with the right hand only, two fingers 
 being placed over the flanges, or one finger through the loop above 
 the lock, and this method allows the left hand to be passed into the 
 vagina in order to feel the tension of the cervix, or judge whether 
 the blades are keeping in position ; for the pressure on the anterior 
 pelvic wall so produced is not then likely to be great enough to do 
 any mischief. 
 
The Forceps and Vectis. 
 
 851 
 
 Traction to he steady, not oscillatory. — As a rule traction should 
 be steady in the direction judged to be the right one, without any 
 swaying of the handles of the forceps, although such a " pendulum 
 movement " has been recommended by many authorities. The 
 exceptional cases in which an exertion of leverage by oscillatory 
 movement of the handles is admissible will be considered hereafter. 
 If, however, the head is found not to advance, it is desirable some- 
 what to vary the direction of traction in a tentative way, to see if 
 some direction may not be found in which traction is more effective ; 
 for the operator may not have been quite accurate in his judgment 
 of the direction of the pelvic axis at the point where the centre of 
 
 Fig. 421. — Mode of delivering head through vulval outlet. 
 
 the head is lying, or there may be some peculiarity of the pelvis 
 which he has not been able to discover. 
 
 Amount of Force to be exerted. — Experience alone can enable the 
 practitioner to judge accurately the amount of force which may 
 be exerted with safety to the mother, and the time during which 
 it may safely be prolonged. It is to be remembered that the use 
 of forceps, as compared with craniotomy in a doubtful case, is an 
 operation for the interest of the child, and that it is not justifiable 
 seriously to endanger the mother, in order to save the child. In a 
 difficult case, the operator may find it necessary to have an assistant 
 to press against the patient's buttocks, in order to keep her in 
 position, A person not of great muscular power may sometimes 
 have to put out as much tractile force as he can exert in a steady 
 manner. 
 
 54—2 
 
852 The Practice of Midwifery. 
 
 The child's head should never be pulled through the pelvic brim 
 by brute force, a method of delivery entailing great danger both to 
 the mother and the child. As much time as can with safety be 
 given should be allowed to elapse to permit of moulding of the 
 head taking place, and no premature attempts should be made to 
 pull the unmoulded head through a contracted brim. 
 
 The amount of force which may be used legitimately with forceps 
 has been estimated as considerably exceeding 100 lb. ; but there has 
 never been any satisfactory determination of the limit of force which 
 is really safe for the mother. 
 
 Mode of 'Traction at the Vaginal Outlet. — When the head begins 
 to distend the j)erineal body, or inclined plane of soft parts forming 
 the pelvic floor (see Fig. 421, p. 851), the mode of traction with 
 long curved forceps should be altered. The resistance is now due 
 to the soft parts, and has to be overcome rather by gradual exten- 
 sion than by great force, in order to avoid laceration as far as 
 possible. The right hand alone may now be used for traction, 
 while the left hand is used to estimate the tension placed upon the 
 vaginal outlet, or to shield the perineum by pressure exercised in 
 front of the sacro-sciatic ligaments, in the manner recommended for 
 cases of ordinary labour (see p. 302), and shown in Fig. 197, p. 303. 
 The inclination of the tractile force forward in reference to the axis 
 of the genital canal is not now a disadvantage, since it is chiefly 
 the posterior wall of the genital canal which is in danger of 
 laceration, and the natural expulsive force is itself inclined back- 
 ward toward that posterior wall. In primiparge, and in all cases 
 where laceration of the perineum appears to be threatened, much 
 time should be allowed at this stage, and the vaginal outlet should 
 be very gradually stretched, in imitation of nature, by successive 
 efforts, with intervals between them. If the uterus is acting 
 vigorously, traction with the forceps should not be made with the 
 pains, but only in the intervals. During the pains the too rapid 
 advance of the head should be checked, partly, as in natural labour, 
 by pressure upon it with the left hand, partly by actually resisting 
 it with the forceps, the handles being pressed rather back instead 
 of carried forward. 
 
 Grasp of Right Hand to be shifted. — As the head first begins to 
 approach the outlet, traction may be made by the right hand 
 grasping the handles in the usual way, two fingers being rested 
 on the flanges, or one finger passed through the loop above the 
 lock. The handles have now to be swept rather rapidly forward, 
 and eventually carried up somewhat in front of the abdomen. To 
 allow this the patient's leg should be held up by the nurse or 
 
The Forceps and Vectis. 853 
 
 other assistant (Fig. 421). At the stage when the occiput is 
 beginning to emerge at the vulva, the grasp of the right hand 
 should be shifted, so that the palm of the hand is transferred from 
 the anterior to the posterior surface of the handles, and the hand 
 is now used to push rather than to pull, the left hand being spread 
 out in front of the sacro-sciatic ligaments, to keep the head forward, 
 and so relieve the strain on the perineum. Not much force can 
 thus be exercised, but only a very little is wanted. The final 
 emergence of the head should be managed with extreme slowness, 
 the tension of the edge of the perineum being estimated by the 
 left hand. It should be remembered that the maximum tension is 
 reached just at the moment when the forehead is passing the 
 perineal margin. 
 
 liemoval of Blades. — As soon as the chin is clear of the perineum 
 the blades are easily removed. In some cases, when it is not the 
 resistance of the perineum which has required the application of 
 forceps, but some obstacle at a higher level, and when there 
 appears to be danger of laceration, the uterus acting vigorously, 
 it is desirable to unlock and remove the blades before the head 
 has passed the vulva, that the tension may not be increased 
 even by the small amount of space which the blades themselves 
 occupy. 
 
 The Leverage Action of Forceps. — When the head is tightly 
 grasped by the forceps, so that the head and two blades form one 
 solid mass, and an oscillatory or pendulum movement is made with 
 the handles, a kind of leverage may be exercised which aids the 
 advance of the head. 
 
 When, therefore, the head is engaged in the pelvic canal, and 
 impacted in it by friction so that it cannot readily be pushed back 
 in the interval of a pain, and when moderate direct traction fails 
 to cause any advance of the head, oscillatory movement of the 
 handles may be cautiously tried before recourse is had to cranio- 
 tomy. The oscillation should be limited in degree, and with each 
 oscillation should be combined firm compression of the handles, 
 so as to make the head one solid mass with the blades, and the 
 maximum of traction which it is thought safe to exert. The 
 oscillation, to be of service, should also be in that diameter in 
 which the head is most tightly gripped by the pelvis. Thus in a 
 flattened pelvis it should be backward and forward, in a uniformly 
 contracted pelvis it may be in both directions, or the two may be 
 combined in a limited circular movement. Side-to-side movement, 
 in a flattened pelvis, is entirely useless, and only likely to be 
 injurious. The oscillatory movement should not be persevered 
 
854 The Practice of Midwifery. 
 
 with long, unless the head is found to advance with it, for, if the 
 leverage is successfully called into play, there must be an advance 
 at each oscillation. 
 
 The mechanism by which this movement causes advance is 
 analogous to that by which a cork is got out of a bottle by pushing 
 it from side to side, and also to that by which a tight ring is 
 removed from a finger by pulling first one side and then the other 
 instead of pulling the two sides together. Both these instances 
 show that by leverage advance can be effected by less force than 
 would otherwise be necessary. Moreover, the shape of a cork, a 
 long cylinder, is much more unfavourable for such leverage than 
 that of an ovoid body like the foetal head. 
 
 The operator may fail in his effort to exert leverage in two ways. 
 (1.) The blades may slip backward and forward over the head, 
 instead of holding it as one solid mass with themselves. The head 
 is then likely to be injured by the friction. (2.) The head may 
 simply sway backward and forward on its central axis, instead of 
 advancing. The friction is then most likely to do damage to the 
 maternal soft parts. 
 
 There is another way in which a very slight oscillatory move- 
 ment may be of advantage when the head is impacted in the pelvic 
 canal by friction. This depends upon the fact that statical friction, 
 or friction between bodies at rest, is always greater than dynamical 
 friction, or friction between bodies in motion, especially when the 
 bodies have been long in contact. When friction is a main element 
 of the resistance, a slight oscillatory movement of the head may 
 convert the statical friction into the lesser dynamical friction over 
 the greater part of its surface. For this purpose the slightest 
 possible oscillation of the handles is sufficient, provided that the 
 head is held tightly enough to take part in it. 
 
 Reason for applying the Loicer Blade first. — It has been recom- 
 mended that the lower blade of the forceps should be introduced 
 first, although some authorities give the contrary advice. The 
 reason for choosing the lower blade, with forceps made in the 
 usual way, depends upon the construction of the lock. On refer- 
 ring to Fig. 419 (p. 844), it will be seen that, if the lower blade is 
 introduced first, and the handle held backward, then the handle of 
 the second blade passes in anterior to that of the first, and the two 
 handles are at once in the right position for locking. If the upper 
 blade had been introduced first, and the handle held backward, 
 then the handles would have been in the wrong position, and the 
 lock could not have been adjusted without reversing the relative 
 position of the shanks. Some authorities teach that the upper 
 
The Forceps and Vectis. 
 
 855 
 
 blade should be introduced first, and the handle held forward 
 while the second blade is being introduced, the assistant standing, 
 not behind the patient's back, but in front of her knees. The 
 second blade is then passed up behind the handle of the first, and 
 the handles come into the right position for locking. The objection 
 to this is that, when the handle is held forward, the blade is only 
 half applied over the head — in the high forceps operation scarcely 
 so much as half applied — ^and is therefore more liable to become 
 displaced. It is also impossible to dispense with an assistant for 
 holding the first handle. This may be managed, as already 
 described (see p. 843), when the lower blade is introduced first, by 
 resting the first handle on the back of the wrist. If, therefore, it 
 is desired to introduce the upper blade first, it is better to have the 
 lock of the forceps made in the reverse way to the ordinary one 
 
 Fig. 422. — Axis-traction forceps. 
 
 The upper blade can then be passed first, and the handle held 
 backward while the second blade is introduced. 
 
 The lock of the forceps can, of course, be made equally well 
 either way. Assuming that the forceps have yet to be constructed, 
 there are some advantages each way to be considered in deciding 
 whether the lock should be fitted for the introduction of the lower 
 or of the upper blade first. If the lower blade is passed first it is 
 not 80 likely to get out of place from the effect of gravity as the 
 upper blade would be, while the second blade is being introduced. 
 On the other hand, the upper blade is the more difficult to 
 introduce. There is, therefore, a certain advantage in introducing 
 the upper blade first, so that the difficulty is not increased by 
 the vagina being already occupied, to some extent, by the first 
 blade. Individually, I prefer, on the whole, the introduction of the 
 upper blade fh-st, and have therefore had the lock of my axis-traction 
 forceps (Fig. 428) made in the reverse way to the ordinary lock. 
 
8s6 
 
 The Practice of Midwifery. 
 
 Application of Axis-traction Forceps. — For introduction of 
 the axis-traction forceps, each traction rod is held with the corre- 
 sponding prehensile branch like a single blade, the lower blade being 
 introduced first. It is most convenient in introducing the upper 
 blade to place the traction rod in front of the handle until the 
 blade has been placed in position and then to carry it back into its 
 proper position in relation to the handle. The lock can then be 
 adjusted, and the screw which approximates the handles turned 
 until the head is sufficiently grasped. The two traction rods are 
 then brought together and the common handle fitted over their 
 
 ends. 
 
 In making traction the operator should hold the handle so that 
 the traction rods come as close as possible up to the pre) i ensile 
 branches, without pushing the handles of the latter forward. 
 Fig. 407, p. 826, shows how traction is thus made accurately in the 
 axis of the brim, or of any other plane of the pelvis in which the 
 centre of the head is lying. As the handles of the prehensile 
 
 Fig. 423. — The aiithfir's axis-traction forceps. 
 
 branches move forward, the traction handle is moved forward also, 
 so that the traction rods are kept close up to the prehensile 
 branches. 
 
 In making traction with axis-traction forceps, there is no necessity 
 to alter the grasp of the hands ; the traction should always be made 
 on the traction handle, never upon the handles of the forceps 
 themselves even when the head is on the perineum. 
 
 In the original types of axis-traction forceps the prehensile 
 branches were so heavy, and their weight acted at so great a 
 mechanical advantage by leverage, that their utility as an indicator 
 of the path pursued by the head was very small. In the modern 
 instruments, as the handles are much smaller and lighter, they act 
 in this way much more certainly, and although, no doubt, they do 
 not indicate with complete accuracy the direction in which axis 
 traction should be made, yet the error is but slight and practically 
 of little importance. 
 
 In order to gain the advantage of axis traction without the draw- 
 backs to the ordinary types of axis-traction forceps, which have been 
 
The Forceps and Vectis. 857 
 
 enumerated above, I have had constructed the forceps shown in 
 Fig. 423. With these I have found that a Hving child can in some 
 eases be extracted when all efforts with the ordinary long curved 
 forceps have failed. The general shape of the instrument is similar 
 to that invented by Morales, of Belgium, but the perineal curve is 
 carried back more completely to the axis of the upper halves of the 
 blades, and the lock is the English instead of the French lock. The 
 handles lie in the axis of the upper halves of the blades. Hence 
 traction has to be made simply in the line of the handles, as with 
 straight forceps, and if it is desired to rotate the head, this can be 
 done by simply rotating the handles on their own axis. The oj)erator 
 must judge for himself the direction of the pelvic axis at the point 
 where the centre of the head is lying, as in the case of the ordinary 
 forceps, and keep the handles in that direction. The lock is made 
 in the reverse of the ordinary way, in order that the upper blade 
 may be introduced first, and the handle held backward while the 
 second blade is being passed. 
 
 It will be found that these forceps can be applied more easily 
 than ordinary axis-traction forceps. The adjustment of the lock is 
 easier even than with ordinary forceps, because the transverse 
 portion below the lock affords a considerable leverage in rotating 
 the shanks by means of the handles, so as to bring the flat surfaces 
 of the handles exactly opposite to each other, and the blades 
 therefore into the right position to lock. With this, as with the 
 long curved forceps, the operator has however to judge the correct 
 direction in which to make axis traction, and since it is more 
 difficult to determine this in a contracted pelvis, with this type, as 
 with the long curved forceps, the operator is most likely to fail in 
 the very cases in which it is most important to make correct axis 
 traction. 
 
 Forceps in Occiinto-posterior Positions of the Vertex. — So long as 
 the occiput looks in any degree backwards, the application of forceps 
 should be deferred, if possible, or the occiput should first be rotated 
 forwards manually or by the vectis, in the manner previously 
 described (see p. 821) ; for if the head descends under the influence 
 of the natural forces the occiput will probably rotate forwards, but 
 if it is grasped by forceps, this rotation will almost certainly be 
 prevented, and the danger of laceration of the perineum will 
 thereby be increased. The manreuvre recommended by Scanzoni 
 is practised by some obstetricians in these cases. The forceps are 
 applied accurately to the sides of the head. For example, in a third 
 or right occipito-posterior presentation they are thus applied in the 
 left oblique diameter of the pelvis. The head is then drawn down to 
 
858 The Practice of Midwifery. 
 
 the pelvic floor, rotation forwards of the occiput being favoured by 
 rotation of the handles of the forceps. In this way the head is 
 rotated so that the long diameter of the head turns into the trans- 
 verse diameter of the pelvis, and finally the occiput looks somewhat 
 forwards. The forceps are then taken off and again applied to the 
 sides of the head in the opposite oblique diameter. Delivery of 
 the head is then effected, the complete rotation of tlie occiput to the 
 front at the same time being induced by further rotation of the 
 handles of the forceps. If the occiput remains backwards, forceps 
 should only be applied for the purpose of extraction if the condition 
 of the mother calls for their use, or if it is judged that there i? no 
 chance of rotation taking place, from the fact that the head is already 
 low upon the perineum, and the occiput rotated backwards into the 
 hollow of the sacrum. 
 
 The blades should be applied in the same way as in occipito- 
 anterior positions, and in this case no attempt should be made to 
 rotate the head artificiall}^ but it should be extracted over the 
 perineum with extreme care and slowness, in consequence of the 
 increased risk of laceration. If any tendency of the occiput to 
 rotate forwards is noticed, the blades should be removed, so as to 
 permit rotation of the head to take place, if possible, under the 
 influence of the natural forces, and then reapplied. 
 
 Forceps in Face Presentations. — In face presentations, where the 
 chin is directed forward, forceps may be used with almost as much 
 advantage as in vertex presentations. The blades should be 
 applied as nearly as possible to the sides of the face. The handles 
 (of long curved forceps) will then be directed at first somewhat to 
 the side. As the chin rotates under the pubic arch, the handles 
 will turn forward. 
 
 Mento-posterior Positions. — In the majority of cases, the chin is 
 directed posteriorly or transversely. There is then considerable 
 risk to the child in the use of forceps ; for if one blade is applied 
 over the chin, its tip will compress the neck and trachea, and is 
 liable to do such damage that the child may be still-born, or die 
 shortly after birth. Hence in all such cases the rule is the same 
 as in occipito-posterior positions of the vertex — that the case 
 should be left to nature as long as possible, unless the condition 
 of the mother requires interference. It is to be remembered that, 
 although labour is more protracted than in vertex presentations, 
 the immense majority of cases terminate naturally if left alone. 
 
 If the head is arrested high up in face presentation, version is 
 the best treatment if the uterus is not too rigid to allow it. If 
 version is not admissible, and the chin posterior, forceps may be 
 
The Forceps and Vectis. 859 
 
 applied as nearly as possible to the sides of the head, the concavity 
 of the pelvic curve necessarily looking toward the forehead. The 
 head may be drawn down in this position until it rests completely 
 upon the j)erineum. The forceps should then be taken off, and 
 the chin will frequently rotate forwards at the last moment under 
 the pressure of the perineum. Sometimes it rotates only partially 
 forwards, and the face passes the vulva almost in a transverse 
 position. Sometimes, with a small head, the chin may be drawn 
 over the perineum with the forceps, the edge of the perineum 
 being hooked backward over the chin as soon as possible. 
 
 If the face is arrested high up in a transverse position, and 
 version is not admissible, the only chance for the child, although 
 a poor one, is ■ to apply the forceps in whatever way they will 
 seize the head. They may be taken off as before when the head 
 is drawn quite down upon the perineum. 
 
 If the face is arrested when resting low upon the perineum, 
 and the chin remains posterior, the attempt may be made to effect 
 rotation artificially, although it is dangerous to do this when the 
 head is high up. The blades are applied to the sides of the head, 
 the concavity of the pelvic curve necessarily looking toward the 
 forehead. Kotation is effected by carrying the handles more to 
 the side and in a backward direction, the head being at the same 
 time firmly grasped. 
 
 As soon as the handles begin to look somewhat posteriorly and 
 the chin somewhat anteriorly, the forceps are taken off, and 
 reapplied with the concavity of the pelvic curve toward the 
 chin. Extraction is then easily completed by drawing down- 
 ward and at the same time aiding the rotation of the handles to 
 the front. 
 
 Forceps applied to the After -coming Head. — The value of the 
 application of forceps in head-last cases has been very variously 
 estimated by different authorities. The difference may depend 
 upon the degree of dexterity with which operators have tried 
 other modes of extraction. When the resistance is due to soft 
 -parts only, forceps will rarely, if ever, be required, if the method 
 of extraction previously described (see pp. 361 — 364) is properly 
 carried out. 
 
 When the resistance is due to the pelvis, the very short space 
 within which the child must be extracted, if extracted alive, allows 
 but little time for the application of the Ijlades, somewhat impeded 
 by the presence of the child's body, and for extraction, especially if 
 time has already been occupied by attempts to extract by traction 
 on the trunk. The only advantage is that greater force may be 
 
86o The Practice of Midwifery. 
 
 exerted. Accordingly, although some authorities speak highly of 
 the application of forceps to the after-coming head, I have not 
 found it so efficacious as traction on the body, combined, if neces- 
 sary, with jaw-traction. It may be preferable, however, in the case 
 of the pelvis gequabiliter justo minor, or one contracted in its trans- 
 verse diameter. Even in the flattened pelvis, it maj^be tried if the 
 other method fails. 
 
 For application of forceps to the after-coming head, the body of 
 the child should be drawn as much forward as possible, and held 
 forward between the patient's thighs by an assistant who grasps 
 the legs. The arms should be previously released, if extended 
 above the head, and these also should be kept forward. The 
 blades of the forceps are then to be introduced posterior to the 
 child's body, and so applied to the head. If necessary, a moderate 
 degree of traction applied by an assistant to the body may be 
 combined with the force exerted by the forceps upon the head. 
 Such traction may assist in elongating the head, and so enabling it 
 to pass the brim. 
 
Chapter XXXIV* 
 
 VERSION, 
 
 By version is meant the operation for altering the position of the 
 foetus, so that the presenting part is changed, and one or other 
 pole of the foetus is brought over the os uteri. Classifying the 
 operation according to the part of the foetus which is made to 
 present, the chief varieties of version are cephalic version, in which 
 the head is made to present, and podalic version, in which one or 
 both feet are brought down. Pelvic version, in which the breech 
 is made to present without a foot being brought down, is rarely 
 performed. According to the mode of its performance, version is 
 divided into three classes — external version, effected by external 
 manipulations only ; internal version, effected by the hand intro- 
 duced within the uterus, the external hand being used only to 
 steady the uterus ; and the combined external and internal version, 
 in which one hand is used in the vagina and the other moves the 
 foetus by pressure through the abdomen. 
 
 History. — Version is a very ancient operation. Before the 
 introduction of forceps it was used more than it is at present, 
 because, in cases of contracted pelvis, it was the only possible mode 
 of saving the foetus. Cephalic version, recommended by Hippo- 
 crates, was at first alone in use, and was extensively practised, 
 being employed even in pelvic presentations. Podalic version was 
 introduced in the latter part of the sixteenth century, and taught 
 by Pare, Guillemeau, Mauriceau, and others. At first it was the 
 custom to bring down both feet ; Portal adopted the modern plan 
 of bringing down only one foot, but he did not teach this as a 
 principle, and the advantage of bringing down the half-breech 
 alone was pointed out definitely by Puzos in 1759.^ On account of 
 the greater facility of podalic version, cephalic version afterwards 
 fell almost entirely out of use, until revived, for a certain limited 
 class of cases, by recent authorities. 
 
 Cephalic Version.— For the performance of ceplialic version it 
 is essential either that the membranes should be intact, and the 
 
 ' Fasbciider, (JcHcliiclile <ler OcburLslilillV, I DOG, [>. H«l. 
 
862 
 
 The Practice of Midwifery. 
 
 fcetus movable in the liquor amnii, or at any rate, that the liquor 
 amnii should have only recently escaped, and the uterus be quite 
 lax, so as to allow ready mobility of the foetus. Cephalic version 
 should not be attempted in any case in which rapid delivery is 
 called for, or in any case of flattened pelvis in which there is any 
 considerable contraction of the conjugate diameter, for in such 
 pelves the head is likely to pass better when it enters the brim 
 with the base first. It is considered advisable by some writers to 
 perform cephalic version in cases of slight deformity of the pelvis, 
 since after the version has been carried out the relation of the size 
 
 Fig. 424. — External cephalic version with the woman in the Trendelenburg 
 
 position. 
 
 of the head to that of the pelvis is more easily determined. Other- 
 wise cephalic version is preferable to podalic in all uncomplicated 
 cases of shoulder or transverse presentation in which it can be 
 performed without much difficulty, for the risk to the child is much 
 less if it passes with the head first than if it is extracted by the 
 feet. Cephalic version, however, frequently requires more dexterity 
 on the part of the operator than the ordinary podalic version. 
 
 Cephalic Version by the External Method. — Cephalic 
 version by external manipulation only is chiefly available for those 
 cases in which a transverse or oblique position of the axis of the 
 foetus is discovered before the onset of labour. It may be employed, 
 however, even after labour has commenced, provided that the 
 liquor amnii is intact, and the uterus is completely relaxed in the 
 
Version. 863 
 
 intervals of pains. For the operation the patient is placed on her 
 back, the head rested on a low pillow, the abdomen uncovered, or 
 covered only by a thin garment. As much relaxation as possible of 
 the abdominal muscles should be secured. In cases where difficulty 
 is experienced or where the head is already engaged in the brim of 
 the pelvis Pollock^ recommends very strongly the use of the 
 Trendelenburg position, or elevating the patient by the legs until 
 the trunk is almost vertical (Fig. 424). It is essential that it should 
 be possible to make out with certainty, by external palpation, the 
 parts of the fretus, especially the head and the breech, the head 
 being distinguished by its hardness and uniform rounded form. 
 Then, at a time when the uterus is comj)letely lax, the head is 
 pushed toward the os uteri with one hand, and the breech toward 
 the fundus with the other. In many cases the- foetus rotates with 
 great facility, especially if its long axis was originally transverse. 
 It should be allowed to rotate in whichever direction it will most 
 readily, but care should be taken if possible not to cause extension 
 of the body. In cases of difficulty the help of an assistant to fix 
 one pole of the child will be found an advantage. Not un- 
 commonly, the displacement occurs again, from the same cause 
 which produced it in the first instance. There is, however, 
 no harm in making the reposition once, even if the axis of the 
 child again gets out of position. The only thing necessary, if 
 labour has not yet come on, is to take care that the foetus is again 
 restored to the right position in the early stage of labour and 
 before the rujDture of the membranes. 
 
 Supposing that labour has commenced, and that the head has 
 been brought over the os uteri, the patient should be kept quiet 
 in bed, and not allowed to walk about, lest the malposition be 
 reproduced through displacement of the fundus uteri. In general 
 it is better to keep the patient uniformly on her back, so that 
 there may be no inclination of the fundus to one side or the other. 
 If, however, there is a marked natural inclination of the fundus 
 toward one side, it may be desirable to counteract this by making 
 the patient lie on the opposite side, or with some inclination 
 toward the opposite side. As soon as dilatation of the os has 
 progressed to some extent, the fixation of the head in the pelvis 
 will be promoted by rupturing the membranes. 
 
 In pelvic presentations external version may be performed during 
 the last weeks of pregnancy, or even at the onset of labour. It is 
 best performed about the thirty-fourth to the thirty-sixth week. 
 
 ' I'ollock, 'I'ntiis. Obst. Soc. London, ]W)C>, Vol. XLVllf., p. 819. 
 
864 The Practice of Midwifery. 
 
 Cephalic Version by the Combined External and Internal 
 Method. — In former days cephalic version was performed by 
 passing the hand into the uterus, grasping the head, and drawing 
 it toward the os. As this was a more difficult operation than the 
 ordinary podalic version, and one which involved more risk of 
 injury to the mother, it rightly fell into disuse. Various methods 
 of combining the action of the two hands, one passed into the 
 vagina, and one applied externally to the abdomen, have been 
 described by Busch, Hohl, and Wright of Cincinnati. The plan, 
 however, which can be employed with least disturbance to the 
 mother is that first published by Dr. Braxton Hicks, -^ which can 
 be carried out when only one or two fingers can be passed through 
 the cervix. Whenever a shoulder presentation is discovered before 
 the rupture of the membranes, and there is no contraction of 
 moment of the conjugate diameter of the pelvis, and no other 
 reason for interference than the malposition of the foetus, it is 
 worth while to endeavour to secure a head presentation by this 
 method. Even when the liquor amnii has escaped it may be 
 possible to carry it out, provided that it has escaped only recently. 
 Even descent of the arm was not* considered by Dr. Hicks as a 
 contra-indication ; but in such case, the arm must first be returned 
 across the chest. Generally when the arm is prolapsed, the foetus 
 will not be movable enough to allow cephalic version. 
 
 Method of operating. — The bladder and rectum should be 
 empty, as in all obstetric operations. Anaesthesia is not abso- 
 lutely necessary, but it always facilitates the operation, and should 
 be employed at any rate in those cases in which the introduction 
 of the hand into the vagina is difficult or excites spasm, or in 
 which the uterus is contracting frequently, and there is a risk that 
 the membranes will be ruptured. Dr. Hicks recommended that 
 the patient should be placed on the left side, and the left hand 
 introduced into the vagina, as for podalic version. As a general 
 rule, it will be found most convenient to place the patient on the 
 right side when the left hand is used internally, and on the left 
 side when the right hand is used internally. The position of the 
 head and breech must be first made out, and these parts recognised 
 by external palpation. Then one or two fingers of the gloved hand 
 are introduced through the cervix, placed upon the apex of the 
 shoulder, and the shoulder is by their means pushed upward in 
 the direction of the breech and away from the head. As soon as 
 the shoulder begins to recede, the external band, placed uj)on the 
 
 1 "On Combined External and Internal Version," Trans. Obst. Soc. Loudon, 1864, 
 Vol. v., p. 219, 
 
Version. 865 
 
 abdomen over the head, pushes the head down into the pelvic 
 brim over the os uteri. The shoulder still rising, the head can be 
 received upon the tips of the inside fingers. The head will play 
 like a ball between the two hands, the membranes being still 
 intact, and can be adjusted at will over the os. If the breech does 
 not readily rise to the fundus after the head is fairly in the os, the 
 hand should be withdrawn from the vagina, and used to push up 
 the breech from the exterior in the direction of the fundus. It is 
 only at this last stage that the method becomes truly " bipolar," 
 the forces being applied to the opposite ends of the foetus. 
 
 Choice of Position. — When the head is displaced toward the 
 patient's left side, and the breech therefore toward the right, there 
 is no doubt that it is best to make her lie on her left side, as 
 recommended by Dr. Hicks, for then gravity assists the movement 
 of the breech toward the fundus. When, however, the head is 
 displaced to the right side and the breech to the left, I have found 
 it better, in order to get a similar assistance from the action of 
 gravity on the fundus uteri and the breech towards rectifying the 
 position of the child's axis, to place the patient on her right side. 
 The left hand may then be passed into the vagina, and the right 
 hand used externally over the abdomen. 
 
 Some have recommended the use of the knee-elbow position, 
 that the foetus may gravitate away from the pelvic brim, and so 
 the recession of the shoulder may be facilitated. When vaginal 
 space is ample and the patient tolerant, so that an anaesthetic 
 may be dispensed with, the position may be tried, if the shoulder 
 is not found easily to recede with the lateral position. In other 
 cases an approximation may be made to the effect of the knee- 
 elbow position by adopting, instead of the simple lateral position, 
 the Trendelenburg position or Sim's semi-prone position, in which 
 the lower arm is extended straight behind the back, the chest is 
 rotated so as to rest downward against the bed, and the upper knee 
 is flexed more than the lower, the knee also being in contact with 
 the bed. 
 
 Podalic Version.— Podalic version is to be performed in all 
 cases of shoulder or transverse presentation in which cephalic 
 version is contra-indicated, or cannot readily be carried out. These 
 comprise much the largest proportion of the whole. Podalic 
 version is also indicated when the head is presenting in many 
 cases of placenta praevia, in some of accidental haemorrhage, in 
 certain cases of flattened pelvis, in some of prolapse of the funis, 
 in some brow presentations and mento-posterior presentations of 
 
866 
 
 The Practice of Midwifery. 
 
 the face, and also in cases in which rapid delivery is called for on 
 account of some perilous condition of the mother, such as eclampsia. 
 The grounds for deciding on the oj)eration in any given case are 
 considered under their respective headings. Podalic version may 
 be performed either by the combined internal and external, 
 otherwise called the bipolar, or by the internal method. 
 
 The combined internal and external method for podalic as well 
 as for cephalic version, as it is now generally carried out, was first 
 
 described by Dr. Braxton 
 Hicks. Priority has been 
 claimed for Dr. Wright of 
 Cincinnati, who also recom- 
 mended the combined use of 
 two hands, but his method 
 was not precisely the same. 
 
 Bipolar Version in Head 
 Presentation. — The essential 
 principle of the method con- 
 sists in the use of the internal 
 hand to push away from the 
 OS that pole of the trunk of 
 the foetus (in shoulder presen- 
 tations), or of the whole foetus 
 (in head presentations), which 
 is occupying it, and of the 
 external hand to bring down 
 the opposite pole into the os. 
 Its great merit is that it can 
 be employed at an early stage 
 of labour, when the os is only 
 enough dilated to admit two 
 fingers, and that it avoids the risk to the mother which is incurred 
 by forcibly dilating the cervix in order to introduce the hand into 
 the uterus. For its performance, it is essential that the uterus 
 should be so relaxed as to allow the foetus to move readily, and 
 therefore that the liquor amnii shall not have drained away so 
 completely that its walls have closely clasped the foetus. When 
 the membranes are still intact, the foetus can generally be rotated 
 with surprising ease. 
 
 Ancesthesia. — In all cases of version, there is nothing which 
 facilitates the operation so much as complete anaesthesia, and a 
 comparatively inexperienced operator will find it especially valuable. 
 
 Jb'iG. 125. 
 
 -First stage of bipolar version. 
 (After R. Barnes.) 
 
Version. 867 
 
 Chloroform has some advantages over other anaesthetics, since, 
 when given fully, it relaxes the uterus more completely. There is 
 also less risk attending its use in puerperal women than in average 
 patients, as has already been explained. The angesthetic should be 
 given to the full surgical degree, so that the voluntary muscles are 
 relaxed, and the uterus is rendered as flaccid as possible. If 
 possible, there should be an assistant to administer the anesthetic. 
 If it is impossible to obtain a skilled assistant, the operator may 
 first place the patient fully under its influence, and then rapidly 
 perform the version before 
 she recovers sensation. An 
 anaesthetic is not, however, 
 absolutely essential for the 
 operation, especially if the 
 operator is dexterous, and 
 the vagina wide enough to 
 admit the hand easily. 
 
 Position of the Patient, 
 and Choice of Hand to he 
 introduced. — In this country 
 the patient is usually placed 
 on her side in. the ordinary 
 obstetric position. If the 
 left hand is used internally, 
 it will be found advantageous 
 to place the patient upon the 
 right side, and if the right 
 hand be used internally, 
 upon the left side. The hips 
 should be brought to the edge 
 of the bed, the trunk placed 
 transversely, and the thighs bent up toward the abdomen. The right 
 thigh should be held by the nurse or other assistant, so that the 
 left arm may reach the abdomen by passing above it. The right 
 hand should be introduced into the vagina as a rule, and the left 
 hand should be placed on the abdomen. If, for any reason, as, for 
 instance, on account of a cut finger, the operator prefers to intro- 
 duce his left hand, he can do so with equal advantage by placing 
 the patient on her right side instead of on her left. If the bed is 
 low, the operator will find it most convenient to sit down opposite 
 the hips. 
 
 Some may prefer to place the patient in the lithotomy position. 
 The operator then stands or sits betweeii the thighs, which are both 
 
 55—2 
 
 Fig. 426.— Second part of first stage of 
 Vjipolar version. 
 
868 
 
 The Practice of Midwifery. 
 
 supported by assistants or by a Clooer's cratch. Either hand may 
 be introduced. It is better to choose the hand so that its flexor 
 surface will correspond to the abdominal surface of the foetus when 
 it is introduced. Thus the right hand should be chosen if the 
 abdomen of the foetus is directed toward the operator's right side, 
 and vice versa. 
 
 Time for operating. — It is of great importance that the version 
 should be performed before the rupture of the membranes. If 
 the liquor amnii has escaj^ed at all, it is more difficult, and it is 
 
 rarely possible to turn by the 
 bipolar method when the 
 membranes have been rup- 
 tured long. A dilatation of 
 the cervix sufficient to admit 
 two fingers is sufficient, but 
 it is easier to bring the leg 
 through the os if a some- 
 
 what greater size than this 
 has been reached. 
 
 Method of operating. — 
 First of all, the exact 
 position of the foetus must 
 be determined. This is to 
 be done by abdominal palpa- 
 tion and by feeling the 
 sutures and fontanelles. If 
 any doubt whatever exists, 
 a final determination must 
 be made after the left hand 
 is introduced into the vagina, by feeling an ear, or by recognising 
 the orbits, nose, or face. 
 
 The vulva, and if necessary the vagina, having been cleansed and 
 disinfected, the dorsal surface of the hand and the whole of the 
 wrist, covered with a rubber glove, should be well lubricated with 
 an antiseptic lubricant, such as lanocyllin, having first been dis- 
 infected with perchloride of mercury 1 in 1,000. The hand is then 
 passed into the vagina sufficiently far to allow two fingers to be 
 passed their full length through the cervix. The operation is 
 generally easier if the whole hand is passed into the vagina, but this 
 is not always absolutely necessary. If the cervix lies low, a 
 dexterous operator may turn by passing four fingers only into the 
 vagina, keeping the thumb outside. 
 
 First Stage. — One or two fingers are passed through the cervix, 
 
 Fig. 427. — Second part of first stage of bipolar 
 version, when head becomes extended. 
 (After R. Barnes.) 
 
Version. 
 
 869 
 
 and rested upon the presenting part of the head, while the external 
 hand is placed upon the abdomen, over the breech. The fingers 
 then push the head upwards 
 and in the direction of the 
 occiput (see Fig. 425, p. 866). 
 The reason for this is that, 
 if the head were pushed in 
 any other direction, the back 
 or side of the foetus would 
 come down over the os, and 
 not the knees, which always 
 lie in front of the abdomen. 
 As the fingers push the head 
 up, the external hand pushes 
 the breech downwards and in 
 the direction of the abdomen 
 of the fcetus (see Fig. 425). 
 The pressure is to be con- 
 tinued until the head has 
 receded as far as the fingers 
 can reach to push it (see 
 Fig. 426, p. 867). 
 
 Second Stage. — As the head thus recedes, the foetus generally 
 preserves its attitude of general flexion, provided that a good deal 
 
 Fig. 428. — Second stage of bipolar version. 
 
 Fig. 429. — Commencement of tliird stage of bipolar version. 
 (After R. Barnes.) 
 
 of liquor amnii is still retained, and the limbs are the next parts 
 which the internal fingers are able to touch. In this case the 
 
870 The Practice of Midwifery. 
 
 second stage of version is that the external hand continues to press 
 down the hreech toward the brim, and so brings the knees within 
 reach of the internal finger, which secures one of them (Fig. 428, 
 p. 869). If, however, but little liquor amnii remains, and the uterus 
 envelops the foetus more closely, the head may become extended as 
 it is pushed away by the fingers, and the shoulder or chest may be 
 felt over the os by the internal fingers. In this case there is an 
 intermediate stage in which the shoulder or chest is pushed by the 
 internal fingers in the direction of the head, the external hand 
 
 Fig. 430. — Second part of third stage of bipolar version. (After R. Barnes.) 
 
 continuing to press the breech in the opposite direction and down- 
 wards (Fig. 427, p. 868). The knee is distinguished from the elbow 
 by its pointing towards the head, and not away from it (see Fig. 427). 
 As soon as a knee is felt, the membranes are to be ruptured at 
 this point, if they have not been ruptured already, and the index 
 finger hooked into the flexure of the knee. 
 
 Third Stage. — As soon as the knee is firmly secured by the 
 finger, the external hand is transferred from the breech, and 
 placed on the other side of the abdomen over the head, so as to 
 push the head up towards the fundus while the finger draws the 
 knee through the os (Fig. 429). When the knee has been brought 
 through the os into the vagina the foot should be brought down, 
 
Version. 871 
 
 so that the operator, by feeling the heel, may assure himself 
 positively that he has secured a leg and not an arm (Fig. 430). 
 
 Traction should be made upon the leg, until the greater part 
 of the thigh has passed through the os, and the half-breech is 
 beginning to enter it. This will bring the foot outside the vulva. 
 If this is not done, and the leg only passes through the os as far 
 as the knee, the breech may remain at some distance from the os, 
 the long axis of the foetus may still be diagonal or nearly trans- 
 verse, and the progress of labour is liable to be arrested. When 
 the half-breech is once brought fully into the os, the head is sure 
 to rise to the fundus. It will be observed that the action of the 
 two hands is strictly bipolar in the first and third stages, but not 
 in the second, in which the right hand presses down the breech for 
 the fingers of the left to seize the knee. 
 
 In some cases, especially when liquor amnii is abundant, the 
 foetus is so very mobile, and rotates in any direction so easily, that 
 it is difficult to catch a knee. If the foot can be touched before 
 the knee, and positively identified as a foot, by feeling the heel, it 
 may be caught between the index and middle fingers, and brought 
 through the os. Otherwise it is better to rupture the membranes, 
 and then seek the knee or foot, which will be brought nearer to 
 the OS, and will be less mobile, as the liquor amnii escapes. The 
 presence of the hand and wrist in the vagina generally prevents 
 any too sudden and complete escape of the liquor amnii. Some- 
 times the long axis of the foetus may have become completely 
 turned round, so as to produce a breech presentation, before the leg 
 is seized. 
 
 Choice of the Leg to Seize. — When version is performed in head 
 presentations, it generally makes no difference which leg is seized, 
 and therefore the knee or foot which comes first may be taken. 
 There is, however, one exception to this rule. When version is 
 performed on account of a flattened pelvis, and it has been made 
 out that there is more room on one side of the pelvis than on the 
 other, on account of greater width of the sacral wing on one side, 
 or any other reason, it is desirable to bring the occiput toward the 
 wider side. Fig. 869 (p. 744) shows a pelvis of this kind, and it 
 will be obvious from this figure how it is that the head adapts 
 itself better to the pelvis when the biparietal diameter is on the 
 wider side. Since the leg which is brought down always eventually 
 rotates forward, the ol^ject may be gained by seizing the leg which 
 it is desired to bring to the front. Thus, if the left side of the 
 pelvis is the widest (as in Fig. 369), the left leg should be seized, 
 and vice versa. 
 
872 
 
 The Practice of Midwifery. 
 
 As it is difficult to select the leg when only one or two fingers 
 are passed through the os uteri, it is better to wait, in such eases, for 
 a somewhat greater dilatation of the os before undertaking version. 
 The hand may then be passed through the os to select the leg, if 
 it cannot otherwise be made out which is right and which is left. 
 
 Bipolar Version in Shoulder Presentations. — Bipolar 
 version is not so often available in shoulder as in head presenta- 
 
 FiG. 431. — Internal version in head presentation. Introduction of left hand 
 into uterus, patient on right side. (Modified from Nagel.) 
 
 tions ; for, if the membranes are intact, it is generally right to 
 attempt cephalic version, and, after their rupture, the liquor 
 amnii quickly drains away, and the uterus grasps the foetus too 
 closely to allow it to be turned in this manner. In all cases, 
 however, in which the membranes have not been long ruptured, 
 the bipolar method may be attempted in the first instance without 
 any disadvantage ; for if the shoulder cannot be made to recede by 
 pressure with the fingers passed through the cervix, it is easy, 
 provided that the cervix is sufficiently dilated, to pass the hand on 
 into the uterus, without withdrawing it from the vagina, and seek 
 the knee or foot. 
 
Version. 873 
 
 The two poles which have now to be regarded are, in the first 
 instance, not the poles of the whole foetus, namely, the breech and 
 head, but the poles of the trunk apart from the head — that is to 
 say, the breech and shoulder. The position is similar to that in 
 the exceptional stage of bipolar version shown in Fig. 427, p. 868. 
 The fingers passed through the cervix first push the shoulder 
 upwards, in the direction of the head and somewhat toward the 
 back of the foetus, so that its abdominal surface is brought over 
 the OS. At the same time the external hand is used to press 
 down the breech in the direction of the os. If the shoulder can 
 be made to recede, the knee is sought for and hooked by the 
 finger in the same way as in head presentations. As soon as the 
 knee is thus secured, the external hand is transferred from the 
 breech to the head, and presses the head up toward the fundus, as 
 in Fig. 429, p. 869. At this stage, therefore, the two forces are 
 applied to the poles of the entire foetus. The whole proceeding is, 
 of course, comparatively easy if the liquor amnii is still intact. 
 
 If the shoulder cannot easily be made to recede by the direct 
 pressure of the fingers, and the arm is prolapsed in the vagina, it 
 is sometimes advantageous to grasp the humerus with the hand in 
 the vagina, and use it as a kind of handle to push the shoulder in 
 the required direction. 
 
 Internal Version in Head Presentations. — Internal version 
 has been employed so much more extensively than any other kind 
 of version, that it is generally regarded as version jjar excellence. 
 The object is to seize one leg, and bring it through the os into the 
 vagina. Then, by traction exerted on the breech through the 
 medium of this leg, the foetus is made to rotate ; whatever part 
 was previously presenting is thereby caused to recede, and the 
 half -breech is brought into the os. The reason for bringing down 
 one leg only and not both legs is that the half-breech forms a better 
 dilator for the cervix and other soft parts than the two thighs side 
 by side, and therefore there is less risk of the after-coming head 
 being delayed, and the child's life lost in consequence. If the child 
 is previously dead, in the case of shoulder presentation, or if the 
 operation proves difficult to perform, there is sometimes an 
 advantage in bringing down both legs. 
 
 Choice of Hand to introduce. — As a general rule, the patient may 
 be placed on the right side, and the left hand used for all cases. 
 Whatever be the position of the ffjetus, the left hand can, as a rule, 
 reach its abdominal surface, and so find the knees; for the abdomen 
 never looks directly forward, even in occipito- posterior positions of 
 
874 
 
 The Practice of Midwifery. 
 
 the vertex. By supinating the forearm, the hand may he brought 
 to reach the right side of the pelvis ; by pronating it, to reach the 
 left side. By this means the posterior leg at any rate can be 
 reached by the left hand, even in occipito-posterior positions of 
 the foetus. In occipito-anterior positions the left hand has not to 
 diverge far from the posterior wall of the genital canal. 
 
 The primary choice of the hand to introduce is not a matter of 
 great consequence, and different authorities have given different 
 
 rules on the subject. If the 
 patient is placed on her 
 back, the right hand may be 
 chosen if the abdomen of 
 the child is directed toward 
 the right of the operator (see 
 Fig. 432), and vice versa. 
 
 Preparations. — In cases 
 where internal version is 
 necessary, complete anaes- 
 thesia is even more impor- 
 tant than in those in which 
 it is possible to perform 
 bipolar version, in order to 
 facilitate the operation by 
 securing the greatest possible 
 relaxation of the uterus. 
 The patient's upper knee is 
 to be raised, as in the former 
 case, that the external hand 
 may have access to the 
 abdomen, and make counter- 
 pressure on the breech to 
 support it, even if it is not 
 able actually to bring it 
 nearer to the internal hand. 
 Not only the dorsal surface of the hand, but the whole of the 
 forearm should be thoroughly lubricated, a rubber glove being of 
 course worn. 
 
 Method of operating. — The whole hand is gently and slowly 
 passed into the vagina, the fingers being held together in the form 
 of a cone. If the cervix is not dilated enough to allow the hand 
 to pass, it must be gradually stretched by the fingers pressed into 
 it in the same conical form, until there is room for the hand to 
 pass it. The exact position of the foetus should have been previously 
 
 Fig. 432. — Internal version in head 
 presentation. Seizing the leg. (After 
 Tyler Smith.) 
 
Version. 875 
 
 made out. The operator must now verify his diagnosis, as the 
 hand passes into the uterus, by feehng the face. The direction of 
 the face will guide the hand toward the abdominal surface of the 
 foetus, up which it ought to pass. To make room for the hand to 
 pass, the head must be pushed out of the way. In doing this the 
 operator should carry out in some degree the principle of bipolar 
 version, even though it is impossible to do so fully. That is to say, 
 he should push the head in the direction of the occiput, in order to 
 bring the abdominal surface of the foetus toward the internal hand, 
 and should at the same time make counter-pressure on the breech 
 with the external hand (Fig. 431). 
 
 Seizing the Knee. — The hand and arm should be gradually passed 
 up toward the fundus in the absence of a pain, the external hand 
 still making counter-pressure over the uterus, until the hand 
 reaches the child's abdomen. If unruptured, the membranes 
 should be ruptured so that the hand may be passed into the 
 amniotic cavity and be separated from the uterine wall by the 
 membranes. If a pain comes on during the operation, the hand 
 must be allowed to lie flat against the uterine wall until it has 
 passed off. As the hand passes the head, it sometimes happens 
 that a ring projecting inwards, formed by contraction of the 
 internal os, is detected above the head. In such case, the attempt 
 to turn should be given up ; for this condition implies that the 
 cervix has undergone dangerous thinning through retraction of the 
 body of the uterus in prolonged labour, and that the uterus has 
 closed tightly round the foetus after the escape of the liquor amnii. 
 If an attempt is made to force the head back over the projecting 
 ring, there is a great risk of causing rupture. 
 
 Most of the older authors recommended that a foot should be 
 seized. The knee is preferable, for two reasons. In the first place, 
 it is nearer, and generally is reached first. Secondly, it can be 
 secured by hooking the forefinger into the flexure of the joint. 
 The foot cannot be held securely without the use of the thumb, 
 and, when the thumb is used, the closed fist occupies more space, 
 and cannot therefore be so easily withdrawn. The knees will be 
 found near the elbows, and not far from the level of the umbilicus. 
 A knee is distinguished from an elbow — first, by its being broader, 
 and not having the sharp projection of the olecranon ; secondly, 
 by its pointing toward the head, while the elbow points away from 
 it. In case of any doubt being felt, the finger should be passed up 
 the limb to feel the breech, or, better, the foot, which can be verified 
 by the heel. In general, whichever leg comes first should be taken. 
 It is only necessary to make a selection in the exceptional case 
 
876 
 
 The Practice of Midwifery. 
 
 before mentioned (see p. 871), in which it is desired to bring the 
 occiput into the wider side of an unequal pelvis. If the foot 
 happens to be reached more readily than the knee, it may be 
 taken instead. 
 
 The forefinger, having secured the knee, draws it downwards 
 through the os uteri, and thereby effects rotation of the foetus and 
 recession of the head. As soon as the leg is in the vagina, the 
 foot is brought down. Traction is then to be made upon the leg, 
 until the half-breech has fully entered the os, and the head has 
 ascended to the fundus. The ascent of the head, in the later stage, 
 
 may be assisted by pressure 
 upwards with the external 
 hand, as in Fig. 430, p. 870. 
 If the foetus cannot be 
 made to rotate by traction 
 upon the knee or foot, the 
 expedients may be tried 
 which will shortly be 
 described as available in 
 difficult versions for shoulder 
 presentation. But, if resist- 
 ance is great, it is generally 
 better not to persevere with 
 the version, since, in head 
 presentation, it is usually 
 undertaken only for the 
 sake of the foetus, which is 
 very likely to be dead. 
 
 Fig. 433. — Version by leg diagonally opposite 
 to presenting shoulder. (After Tyler 
 Smith.) 
 
 Internal Version in 
 Shoulder Presentations. 
 — The left hand may be introduced, as a rule, in all cases, as in 
 the other forms of version, the patient being placed on the right 
 side ; for since, even in dorso-posterior positions, the abdomen does 
 not look exactly forwards, but is inclined to one side, the hand can 
 always be carried far enough round one side or other of the pelvis 
 to reach the posterior or lower knee. Some authors, however, 
 recommend the use of the left hand in dorso-anterior positions, the 
 right hand in dorso-posterior positions (see Fig. 433), the patient 
 being placed upon the side opposite to the hand used. If tbe 
 patient is placed on her back, the right hand may be used if the 
 child's abdomen looks towards the mother's left, and conversely 
 (see Fig. 432, p. 874). 
 
Version. 
 
 877 
 
 Choice of Leg to seize. — In general it is preferable to seize the 
 lower leg, or that on the same side as the presenting shoulder. 
 This is always nearer and easier to reach, in some cases very much 
 easier, than the upper leg, or that diagonally opposite to the 
 presenting shoulder. If it is seized, the nearest part of the half- 
 breech is brought to the os uteri by the shortest path, and the 
 foetus is turned in the bilateral plane of its trunk — that is to say, 
 
 Fig. 434. — Internal version in transverse presentation, dorso-anterior 
 position. Introduction of right hand into uterus, patient on left side. 
 (Modified from Nagel.) 
 
 round an antero-posterior axis passing through the centre of the 
 trunk. This is the simplest kind of version which can effect 
 the desired object, since no complete rotation of the long axis 
 of the ffjetus is necessary. Its position being already oblique, it 
 is sufficient to turn it through an angle of not much more than 
 lOO'^ to bring the half-breech into the os. The back of the foetus, 
 which is generally anterior to begin with, remains anterior after 
 the version — that is to say, it remains in the most favourable 
 position. 
 
878 
 
 The Practice of Midwifery. 
 
 Some authorities recommend turning by the upper leg in dorso- 
 posterior cases, in order to convert them into dorso-anterior, and 
 so facilitate the expulsion of the fcetal pelvis through the pelvic 
 outlet. This, however, is of less importance than rendering the 
 version itself as easy as possible; since the rotation of the posterior 
 hip forward, when the posterior leg is extended, only involves a 
 slight delay.-^ 
 
 Application of Noose to Prolapsed Arm. — There is an advantage 
 
 Fig. 435. — Internal version in transverse presentation. Seizing the lower 
 foot. (Modified from Nagel.) 
 
 to be gained by placing a noose of tape round the wrist of the 
 prolapsed arm, and even in drawing the arm down for this jDurpose 
 if it is easily reached. This will give the operator complete control 
 over this arm, and he will always be able to prevent it becoming 
 extended above the head, and so delaying the passage of the foetus 
 through the brim. The advantage of the expedient is sfcill greater 
 if the version is made by the leg belonging to the same side as the 
 
 1 For a full discussion of the subject, see a paper by the author " On the Choice of 
 the Leg in Version," Trans. Obst. Soc. London, 1877, Vol. XIX., p. 239. 
 
Version. 
 
 879 
 
 presenting shoulder ; for since the leg which is brought down 
 always rotates eventually to the front, the arm which is commanded 
 will always in that case be the anterior arm. Now the posterior 
 arm is always much more easy to bring down than the anterior ; 
 for as the fcetus is drawn in the direction of the pelvic outlet, the 
 posterior shoulder, and therefore the posterior arm, are much lower 
 in reference to the pelvic brim than the anterior, and more easily 
 reached in consequence (see Fig. 401, p. 816). Also there is more 
 room posteriorly for the hand to pass up. Hence if the operator 
 has comroand of the anterior arm by means of the noose, he will 
 be able to deal with the pos- 
 terior arm without difficulty, 
 and the child's life is not 
 likely to be lost through the 
 extension of the arms. 
 
 Method of operating. — The 
 hand is introduced through 
 the OS uteri as in version per- 
 formed in head presentation. 
 The exact position of the 
 foetus should have been pre- 
 viously made out. The hand, 
 as it passes into the uterus, 
 verifies the diagnosis by 
 making out the axilla, and 
 the direction of the neck and 
 head. In pushing the 
 shoulder aside in order to 
 make room for the hand to 
 pass, the operator should push 
 it in the direction of the head 
 and toward the back of the foetus, as well as upward, so as to bring 
 the abdomen nearer to his hand. At the same time the external 
 hand makes counter-pressure upon the breech, so as to diminish the 
 strain upon the uterine attachments, and also to bring the breech, 
 if possible, somewhat nearer to the os. The hand is then passed 
 on from the shoulder to the front of the chest, and thence to the 
 abdomen, and there seeks for the lower knee, or that belonging to 
 the same side as the presenting shoulder (Fig. 436). The operator 
 distinguishes a knee from an elbow in the manner already described 
 (see p. 870), and one knee from the other l)y tracing the limb up 
 to the breech or foot. The index linger is hooked into the Hexure 
 of the knee and draws it through the os. The external hand may 
 
 Fig. 436. — Version by the nearer leg, or that 
 corresponding to the presenting shoulder. 
 Noose placed upon prolapsed arm. 
 
88o 
 
 The Practice of Midwifery. 
 
 then assist the rotation of the foetus by pushing the head up 
 toward the fundus. As. soon as the leg is in the vagina the foot 
 is brought down, and traction made upon it until the half -breech 
 has entered the os and the foot is outside the vulva. The rotation 
 of the- foetus will then be complete (Fig. 437). In dorso-posterior 
 positions, the hand, on reaching the back of the shoulder, should be 
 carried round toward the side of the pelvis opposite to that where 
 
 Fig. 437. — Internal version. Leg drawn down into the vagina, head pushed 
 up to the fundus. (Modified from Nagel.) 
 
 the head is situated. Passing along the side of the foetus, it is 
 thereby guided to the thigh and knee corresponding to the presenting 
 shoulder. If the one hand cannot reach the knee or foot in this 
 way, it should be withdrawn and the other hand introduced. 
 
 Version in Impacted Shoulder Presentation. — When the membranes 
 have long been ruptured, and the uterus is closely contracted 
 around the child, there may be difficulty in getting the child to 
 revolve after the leg has been seized. Under these circumstances 
 it is first of all important to make sure that chloroform is given to 
 the full surgical degree, to secure the greatest possible amount of 
 
Version. . 88 1 
 
 relaxation of the uterus. Next there are two exj)edients which will 
 almost always overcome the difficulty. The first is to find means 
 of applying more powerful traction to the leg than can easily be 
 exercised with the finger ; the second is so to apply this traction 
 that room is left in the vagina for the hand to push up the 
 shoulder, and thus bring two forces to bear simultaneously on 
 the opposite poles of the trunk. The best means of making traction 
 on the leg is the use of a small blunt hook, as recommended 
 by Dr. Braxton Hicks. The stem of the instrument is made of 
 sufficiently soft metal to allow it to be bent, if necessary, to suit 
 the curve of the genital canal, or the direction in which it has to be 
 passed. The diameter of the hook is about one inch. The handle 
 of the hook is held in the right hand. As the left forefinger holds 
 the knee, the hook is passed up under cover of the arm and hand, 
 with the flat side against the foetus. When the knee is reached 
 the handle is turned, so as to fix the hook across the flexure of the 
 knee, the point being directed inwards. The finger makes sure 
 that the point of tbe hook is clear of the knee on the inner side, 
 so as not to injure the popliteal space. Very powerful traction can 
 then be made upon the leg with the right hand. The left hand 
 may be used to prevent the leg becoming extended, or since the 
 stem of the hook occupies scarcely any space in the vagina, the left 
 hand may be used to push up the shoulder, while the right hand 
 draws down the knee. In this case the traction of the hook may 
 sometimes cause extension of the leg and descent of the foot. If 
 this happens, it will be necessary to remove the hook, and place a 
 noose of tape over the foot. 
 
 If a small blunt hook of the kind here described is not at hand, 
 the foot should be brought down as low as possible, a noose of 
 rather broad tape should be placed over it, and traction made 
 upon the tape with the right hand, while the left hand jDushes up 
 the shoulder. If the fcetus will not rotate when pressure and 
 traction are made simultaneously, it sometimes answers better to 
 push up the shoulder with one hand, and pull down the leg with 
 the other, alternately. A little is gained at each repetition of this 
 mancjeuvre. Various devices have been suggested to facilitate the 
 application of the noose when it is found difficult to fix it over the 
 foot with the fingers. Most instruments for this purpose consist 
 essentially of a long rod with a hole at the end of convenient size 
 for passing a loop of tape through. A convenient implement is a 
 tube of soft metal about sixteen inches long, large enough to allow 
 a loop of tape to be passed through it. The loop is made to project 
 at the end of the tube, is passed up into the uterus by the aid of 
 M. 56 
 
882 The Practice of Midwifery. 
 
 the tube, and guided over the foot by the fingers of the left hand. 
 The tape is then drawn up until the foot is held firmly enough, but 
 not too tightly, against the end of the tube. The ends of the tape 
 are then tied over a. cross piece of wood at the lower end of the 
 tube, and tube and tape together used for traction. 
 
 In the absence of such a noose-carrier, a loop of tape may be 
 carried up and passed over the foot by means of a funis repositor, 
 or a large gum-elastic catheter with stylet, used like a funis 
 repositor. When the loop is drawn up tight enough, the tape 
 and catheter are held together side by side, and traction made with 
 them. 
 
 In very difiicult cases the second leg should be brought down, 
 noosed, if necessary, and traction should be made on both legs 
 together. This is especially useful if the foetus has been dead for 
 some time, and is macerated and softened, for under such circum- 
 stances a single leg may sometimes be torn away from the trunk. 
 If the half-breech begins to enter the os, and the shoulder still 
 will not recede, the plan may be tried of making traction mainly on 
 the leg diagonally opposite to the presenting shoulder, in order to 
 elevate the shoulder by rotating the foetus on its longitudinal axis, 
 as proposed by Sir James Simpson ; for, although the half-breech 
 and shoulder of the same side cannot generally become jammed 
 together in the os, this may happen if the foetus has been long dead, 
 and has lost all tonicity. 
 
 It must be remembered that all these manoeuvres are extremely 
 dangerous when the uterus is tetanically contracted, and great care 
 and experience are required to employ them successfully. In all 
 doubtful cases it is, as a rule, better not to attempt them. 
 
 The treatment to be adopted if version is found altogether impos- 
 sible has been already considered (see pp. 674 — 677). 
 
Chapter XXXV. 
 
 CRANIOTOMY AND EMBRYOTOMY. 
 
 Undee the head of Craniotomy are generally included, not 
 merely the perforation of the head, but the means required for 
 extracting it after perforation. 
 
 Indications for the Operation. — The various conditions 
 calling for craniotomy have already been detailed. The chief of 
 them are — great disproportion between the head and the pelvis, 
 obstruction caused by tumours, or by cancer of the cervix ; in rare 
 cases obstruction due to rigidity of the cervix, inflammatory 
 deposits or cicatrices ; also dangerous conditions of the mother, 
 such as eclampsia, calling for rapid delivery, when the use of 
 forceps or version is not sufficient to meet the case, and Csesarean 
 section is contraindicated. 
 
 On the Continent practice has been influenced by the dictum of 
 the Komish Church that it is not lawful to destroy the fcetus to 
 diminish the risk, or even to save the life of the mother. In this 
 country the interest of the mother has always been considered 
 paramount. The operation, however, stands on a different footing 
 when the foetus is dead and when it is alive. If there is clear 
 evidence of the death of the fcetus, craniotomy should be per- 
 formed whenever it renders extraction in any degree easier or less 
 perilous to the mother. While the foetus is alive the operation is 
 only justifiable if delay or attempts to extract by other means 
 involve a material and undoubted increase of risk to the mother. 
 When the operation has once been decided to be desirable, it 
 should be performed without delay. To wait for the previous 
 death of the child greatly increases the danger to the mother, and 
 gains only a sentimental benefit. 
 
 Mortality. — In cases of extreme pelvic contraction, or obstruc- 
 tion by tumours, craniotomy is a dangerous operation, as already 
 explained. Thus in 70 cases of pelves having a conjugate diameter 
 under 2^ inches Perry records a mortality of 38"5 per cent, (see 
 p. 751). In the easier cases, in which it comes into competition with 
 extraction by forceps or version, it involves little risk to the mother, 
 
 56—2 
 
884 
 
 The Practice of Midwifery. 
 
 provided that it is performed early. If danger arises, it is generally- 
 due to previous delay, or to attempts to extract the undiminished 
 head. 
 
 In the Guy's Hospital Charity (1863—1875) the mortality after 
 craniotomy amounted to 6 out of 18 cases, or 33'3 per cent. But 
 the proportion of craniotomy cases, 18 in 26,591 deliveries, or 
 0"7 per 1,000, is a very low one, showing that the operation was 
 only resorted to in extreme cases. The proportion of deaths after 
 craniotomy per 1,000 deliveries is thus only 0*23. In the interval 
 
 Fig. 438. — Oldham's perforator. 
 
 Fig. 439. — Simpson's perforator. 
 
 between 1833 and 1854, in which craniotomy cases were about 
 five times as frequent in the Guy's Hospital Charity — namely 
 35 per 1,000 — the total number of deaths after delivery by forceps, 
 version for obstructed labour, or craniotomy per 1,000 deliveries 
 was 0*57 per 1,000. The corresponding proportion was 0"50 per 
 1,000 in the interval 1863 — 1875. Thus the extensive substitution 
 of extraction by forceps or version for craniotomy was associated 
 with rather a diminished than an increased mortality to the 
 mothers. In the ten years 1875 — 1884 there were 24 cases of 
 craniotomy in 25,489 deliveries. There were 4 deaths, or 16*6 per 
 cent., including one case in which the uterus was ruptured before 
 
Craniotomy and Embryotomy. 885 
 
 the craniotomy. In the ten years 1892 — 1901 there were 3 deaths 
 in 33 cases of embryotomy, or 9 per cent. 
 
 Munro Kerr^ records 83 cases operated upon in the Glasgow 
 Maternity Hospital from 1901 to 1906 with 8 deaths, a mortality 
 of 12*6 per cent. In most of the fatal cases, however, the parturient 
 canal was much injured, and the patients infected before their entry 
 into the hospital. Schauta^ records, among 49,397 births in his 
 clinique in the years 1892 — 1906, 82 cases of craniotomy on the 
 dead child with 5 deaths, or a mortality of 6 per cent., and 76 
 cases of craniotomy on the living child with 1 death, or a mortality 
 of 1*3 per cent. 
 
 Instruments for Perforation. — The perforators chiefly used 
 in this country are modifications of the original scissors of Smellie. 
 These had points like the modern perforator (Fig. 438, p. 884), but 
 handles like ordinary scissors, and the whole instrument was less 
 powerful. The best forms of perforator are Oldham's (Fig. 438) 
 and Simpson's (Fig. 439). With the former the hand, placed 
 between the handles in holding the instrument, as shown in 
 Fig. 440, p. 886, keeps the points together. With the latter the 
 palm of the hand is pressed against the spring, which joins the ends 
 of the handles and keeps the points from separating. Of the two, 
 Oldham's perforator gives the more powerful hold. The points 
 should be sufficiently sharp to penetrate the head readily, yet not 
 so sharp as easily to prick the fingers or the vagina. When the 
 points are closed, the handles should not be too far apart to allow 
 them to be brought together by the fingers of one hand. The 
 point of Simpson's perforator is sometimes made curved, to allow 
 it more easily to be placed at right angles to the head, but it is 
 preferable to have the point in the line of the handle, in which line 
 pressure has to be made. 
 
 In Germany a trephine perforator has been much used. The 
 object is to cut a clean round hole out of the skull, so that the hole 
 is not likely to close, or fragments of bone to project. It cannot, 
 however, be used so easily and quickly as the English perforator, 
 and has the great disadvantage that it cannot conveniently be used 
 to perforate the after-coming head. Moreover, it is not found 
 practically that, after the use of the ordinary perforator, the hole 
 does close up, or angles of bone do project. 
 
 Condition of Cervix. — It is not absolutely necessary for the 
 operation that the cervix should be fully dilated. There should, 
 
 ' Munro Kcir, Operative Midwifery, 1908, p. 481. 
 
 2 Schauta, Jourri. Obst. and Gyn. Brit. Emp., Vol. XV., No. .5, p. .S22. 
 
886 
 
 The Practice of Midwifery. 
 
 however, be room for the separation of the points of the perforator 
 without danger of lacerating the edges of the cervix, and also for 
 the introduction of instruments for the subsequent extraction of 
 the foetus. If the cervix is too small to allow this, it should be 
 previously dilated, either by the hydrostatic dilators, or by the hand 
 introduced in a conical form, with the aid of an anaesthetic. 
 
 Method of operating. — An anaesthetic is not absolutely 
 necessary, but it facilitates the operation, and spares the feelings 
 
 Fig. 440. — Perforation of head. 
 
 of the patient. It should be used, at any rate, in all difficult 
 cases. Bladder and rectum should first be emptied. The hips 
 should be brought quite over the edge of the bed ; the bed 
 should be protected by a mackintosh, hanging down over the 
 edge, and a footpan should be at hand to catch the evacuated 
 brain substance. 
 
 The spot on the head chosen for perforation should be near the 
 centre of the presenting part, as far away as possible from the 
 margin of the os or other soft parts. The perforation should be 
 made through the anterior parietal bone, and not through a suture 
 
Craniotomy and Embryotomy. 887 
 
 or fontanelle ; for in the latter case the bones may be simply 
 separated and not broken through, and may close together again 
 when the perforator is withdrawn, not leaving a sufficient free 
 opening for the evacuation of the brain matter. 
 
 The left hand is passed into the vagina so that the fingers rest 
 upon the spot to be perforated. An assistant should make counter- 
 pressure over the uterus, so as to press the head firmly down into 
 the brim and keep it steadily fixed there. The perforator is held 
 in the right hand, in the manner shown in Fig. 440, the palm of 
 the hand being between the handles. It is passed up to the head 
 under cover of the left hand, the point being kept close against 
 the hand. As soon as the head is reached the handle is carried 
 backward, so as to make the point impinge upon the head in as 
 perpendicular a direction as possible. The point is forced into 
 the head by a combination of pressure and boring or screwing 
 movement until the bones are felt to yield. The perforator is 
 then pushed gently on until the shoulders, which terminate the 
 cutting portion, are level with the scalj). The handles are now 
 approximated by the thumb and fingers of the right hand, so as 
 to separate the points, and make a free opening in the skull. The 
 fingers of the left hand are meanwhile kept upon the blades, at the 
 points where they enter the scalp, to make sure that the soft parts 
 are not endangered. The points are then closed again, the instru- 
 ment is rotated on its axis through a right angle, and the points 
 are again separated in a direction at right angles to the first. In 
 the case of a greatly flattened pelvis, it is better to choose for the 
 two directions the two oblique diameters of the pelvis, since these 
 afford more room than the conjugate diameter. 
 
 The skull having been thus freely opened, the perforator is 
 closed and passed on through the opening into the cavity of the 
 skull, in order to break up the brain substance in all directions. 
 It should especially be passed down to the foramen magnum, to 
 destroy the medulla oblongata. The use of any force, such as 
 might risk the point of the perforator being passed through the 
 skull on the opposite side, must of course be avoided. The object 
 of destroying the medulla is to make certain that the child will not 
 cry or breathe after being delivered with a crushed head, and so 
 distress the mother or friends. It is apt to cry if delivered quickly, 
 notwithstanding the destruction of the main part of the brain, 
 provided that the medulla oblongata is intact. Hence it is well, for 
 the same reason, to wait a few minutes after breaking up the brain 
 before beginning the extraction. 
 
 It is recommended by some to pass a tube into the cranial cavity 
 
888 
 
 The Practice of Midwifery. 
 
 and wash out the brain substance with a stream of water. This 
 is not essential in easy cases, but should be done whenever much 
 difficulty is anticipated ; for the whole of the brain substance 
 is not evacuated either by the pressure of the pelvic walls in 
 extraction, or by that of crushing instruments. That brain sub- 
 stance which remains resists the collapse of the head, or bulges it 
 
 out at each side of the tract compressed 
 between the blades of the cephalotribe. 
 
 Methods of Extraction. 
 
 After perforation of the head the 
 child may be extracted in one of 
 several ways. In an easy case, with 
 little or no contraction of the pelvis, 
 it is often sufficient to make traction 
 upon the head with a pair of modified 
 craniotomy forceps, the so-called 
 cranio-tractor (see Fig. 443). 
 
 In cases of greater disproportion or 
 higher degrees of pelvic contraction, 
 it may be necessary to crush the head 
 before extracting it with one or other 
 of the forms of cephalotribe. 
 
 In a third class of case, where very 
 
 marked contraction of the pelvis is 
 
 present, and it is necessary to deliver 
 
 the mutilated child through the natural 
 
 passages, it is best, not only to crush 
 
 the head, but to further diminish its 
 
 size by removing the vault of the skull 
 
 (the so-called operation of cranioclasm), and then to induce a face 
 
 presentation, and if necessary to crush the remainder of the skull 
 
 before extraction. 
 
 Fig. 4-1:1. — Craniotomy forceps 
 with a screw to handles. 
 
 Craniotomy Forceps. — Craniotomy forceps may be used in two 
 totally different operations, which should be carefully distinguished 
 from each other. In the one, the instrument is used simply as 
 a tractor, the diminution in the size of the head being effected by 
 the pressure of the pelvis. In the other, it is used to break off 
 and tear away pieces of the vault of the skull, and so reduce the 
 size of the head, the operation of cranioclasm. That form of 
 craniotomy forceps which has a screw to approximate the handles 
 
Craniotomy and Embryotomy. 
 
 889 
 
 may be put to yet a third use under exceptional circumstances, as 
 when a face presentation is induced after cranioclasm, namely, to 
 crush the remnant of the head. 
 
 Varieties of the Tnstiument. — The simplest form of craniotomy 
 forceps is that in which the blades 
 are hinged, as in Fig. 441. This 
 may be used as a tractor, the 
 smaller blade being passed into 
 the skull through the opening 
 made by the perforator, the larger 
 one outside the scalp, so that the 
 curvature of the blades corre- 
 sponds to the curvature of the 
 head. It may also be used to 
 break away pieces of the skull in 
 cranioclasm. The fenestra in the 
 larger blade allows a firmer hold 
 of the head to be taken when the 
 instrument is used as a tractor. 
 
 Sir James Simpson made the 
 blades separable, and united by a 
 lock similar to the French forceps 
 lock. The instrument so produced 
 he called a cranioclast, though it is 
 more adapted for use as a tractor 
 than as a crusher. Two modifica- 
 tions of this instrument are almost 
 identical with each other. One is 
 Braun's cranioclast much used 
 in Germany; the other Barnes' 
 craniotomy forceps. Both these 
 are adapted chiefly for use as 
 tractors, and in both the handles 
 are approximated by a screw. 
 This is a great improvement, 
 since it enables a very firm hold to 
 be maintained without fatigue to the hand, and also allows the 
 instrument to be used for crushing, if desired. There is still 
 further improvement in Roper's craniotomy forceps (Fig. 442). 
 The lock in these is the English lock, and is therefore easier to 
 adjust, and it is nearer to the handles. It is thus always outside 
 the vulva, and can be adjusted without any risk of nipping the 
 mucous membrane. The instrument is so made that the same 
 
 Fig. 442. — Koper's craniotomy forceps. 
 
890 
 
 The Practice of Midwifery. 
 
 screw can be used for it as for Hicks' cephalotribe. It would be 
 preferable to have the screw attached by a hinge to the handle of 
 the solid blade. 
 
 Cases suitable for Extraction by C raniotomy Forceps. — There has 
 
 been much controversy as to the 
 relative merits of extraction by 
 cephalotribe or craniotomy forceps 
 (the so-called cranioclast). On the 
 Continent, where the cephalotribes 
 chiefly in use are very large and 
 formidable instruments, the cranio- 
 tomy forceps have found favour 
 with many, being considered to 
 involve less risk of injury ; but a 
 cei^halotribe such as that of Hicks 
 will be found safer as well as easier 
 to use in all ordinary cases ; for 
 since the craniotomy forceps grasp 
 only the vault of the skull, and not 
 the whole head so completely as 
 the cephalotribe (see Fig. 445), 
 they are more likely to tear away 
 the bone, when there is much 
 resistance, and so cause dangerous 
 angles to project. 
 
 The cases specially suitable for 
 the use of craniotomy forceps are 
 those in which the space is con- 
 tracted in all its dimensions, so that 
 the head flattened out in one direc- 
 tion in the grasp of the cephalotribe 
 cannot find any diameter large 
 enough to admit its greatest dia- 
 meter. This may occur in the 
 pelvis sequabiliter justo minor, and 
 also when the w4iole circuit of the 
 cervix is involved in cancer. The 
 mechanism by which the use of craniotomy forceps is then specially 
 advantageous is the following : — The head is elongated in the 
 direction of the pelvic axis by the traction, and at the same time 
 is crushed in all other directions by the pressure of the pelvic 
 wall or cervix, so that all its other diameters are reduced in 
 almost equal proportions. This is illustrated in Fig. 443, in 
 
 Fig. 443. — Elongation of head in 
 conical form by extraction with 
 craniotomy forceps (cranio- 
 tractor). 
 
Craniotomy and Embryotomy. 891 
 
 which the dotted line indicates the original outline of the head. 
 If, however, the cephalotribe is applied in the most favourable 
 possible way, so as to tilt the base of the skull into a position 
 of flexion as in Fig. 445, p. 894, it is not found practically 
 that the diameter at right angles to the compressed one is 
 enlarged by the pressure ; and in such case the cephalotribe is equal 
 or superior to the craniotomy forceps, even for extraction through 
 a uniformly contracted opening ; the maximum diameter in either 
 case being the transverse diameter of the base. In the absence of 
 the cephalotribe, craniotomy forceps are the best instrument for 
 extraction in other cases also. 
 
 Mode of using Craniotomy Forceps as a Tractor. --^\iQ left hand 
 is passed into the vagina, and the fingers placed upon the aperture 
 in the skull. The solid blade of the craniotomy forceps is taken 
 first, and guided by the fingers of the left hand into the aperture, 
 so that it passes into the interior of the skull, underneath the 
 bones. The object should be to seize, not merely the parietal, but 
 the occipital or frontal bone, since the parietal bone more easily 
 tears away from the base of the skull. The serrated surface of the 
 blade should therefore be directed toward the side of the pelvis 
 where the occiput or forehead lies, and the blade should be pushed 
 into the skull as far as it will go, so that as much as possible 
 of the bone may be secured. Of the two bones the occipital is 
 preferable, because traction then promotes flexion of the head ; but, 
 if the occiput is directed forward, the frontal bone is easier to 
 seize, because the outside blade is more easily passed up at the 
 posterior part of the pelvis. The fenestrated or external blade 
 is next taken, and passed up outside the scalp, in such a direction 
 as to correspond to the other blade. The depth to which it 
 should be passed must be regulated by the position of the other 
 blade, so that the lock may be adjusted. The instrument is then 
 screwed up as tightly as possible, and traction made in the pelvic 
 axis. Frequent examinations must be made, to see whether 
 the instrument is slipping, or any angles of bone beginning to 
 project. Such projecting angles must be nipped off. If the force of 
 traction which can be exerted by one hand is found sufiicient, it is 
 well to keep the left hand constantly in the vagina, to watch the 
 progress. If the instrument slips, or the main portion of the 
 bone which it is holding tears away, it must be unscrewed and 
 reapplied, if possible in such a way that its grasp extends more 
 deeply. If the pelvis is flattened and the occipital bone has been 
 seized so as to secure extreme flexion of the head, it is sometimes 
 advantageous, if the head does not easily pass, to rotate the 
 
892 
 
 The Practice of Midwifery. 
 
 instrument so as to bring the transverse diameter of the head into 
 the transverse of the pelvis. Unless this is done the width of 
 the base of the skull, about 3 inches, is the limit to the size 
 of conjugate through which the head can be brought. But the 
 antero-posterior diameter of the extremely flexed skull may be 
 
 reduced by pressure of the 
 pelvic wall somewhat below 
 this. 
 
 The Cephalotribe. — The 
 
 cephalotribe is designed to 
 act both as a crusher and 
 extractor of the head. The 
 requirements of a good 
 instrument are — first, that 
 it should be sufficiently 
 strong not to yield in the 
 slightest degree under tbe 
 powerful force exerted by 
 the screw which approxi- 
 mates the handles ; secondly, 
 the width across the blades 
 should be as little as possible 
 when they are closed, that 
 the instrument may be 
 capable of dragging the 
 head through a greatly 
 flattened pelvis; thirdly, the 
 blades should be able to hold 
 the crushed head without 
 slipping ; for this purpose 
 the blades are generally 
 made with somewhat 
 incurved ends, and with transverse serrations on the inside. 
 Fourthly, the instrument should be so shaped that it can be applied 
 with ease. For this purpose, it must be as long as the long curved 
 forceps, that it may be able to seize the head when arrested quite 
 above the brim, and it should have some degree of pelvic curve, 
 like that of the long curved forceps. It is better, however, to 
 have the pelvic curve made somewhat slighter than that usual 
 with long curved forceps. The instrument can then more easily 
 be rotated through a quarter of a circle, in order to bring the 
 flattened head through the brim of a flattened pelvis. The 
 
 'BBKiiSriiifiiimnilinMTO^^^ 
 
 Fig. 44-i. — Braxton Hiclvs' cephalotribe. 
 
Craniotomy and Embryotomy. 893 
 
 instrument then becomes virtually straight, as regards its relation 
 to the curve of the genital canal. If it had a strong pelvic curve, 
 the ends of the blades would be liable to injure the lateral wall of 
 the pelvis. 
 
 A form of cephalotribe much used is that of Dr. Braxton Hicks 
 (Fig. 444). The blades are nearly parallel when the instrument is 
 closed, but incurved at the ends. The pelvic curve is not greater 
 than about 20° in all, so that, when the instrument is laid flat upon 
 a table, convex side downward, the ends of the blades are not 
 separated from the table by more than about an inch. When the 
 instrument is closed, the width across the blades is not greater than 
 If inches. The form of screw shown in Fig. 443, p. 890, is more 
 convenient for the fingers than the original pattern, as shown in 
 Fig. 444. It would be still more convenient to have the screw 
 attached by a hinge to the lower blade. The lock is of the English 
 form, and therefore more easy to adjust than that of foreign 
 instruments. 
 
 Auvard's three-bladed instrument presents some advantages over 
 that of Braxton Hicks, and is perhaps rather easier to apply, and 
 when properly applied less likely to slip (Fig. 447). 
 
 Cases suitable for the Cephalotribe. — In all ordinary cases of 
 craniotomy, extraction can be effected by the cephalotribe more easily 
 and rapidly than by any other means, and with less chance of any 
 angles of bone projecting and injuring the soft parts. It is there- 
 fore an instrument which all practitioners will find it worth while 
 to possess. When, however, the child has to pass through an 
 aperture narrowed in all directions, as in the case of the pelvis 
 sequabiliter justo minor, or a cervix contracted by cancer or by 
 cicatrices, the head, flattened in the grasp of the cephalotribe, has 
 an unsuitable shape for passing when the contraction is great. 
 Since the breadth across the blades when the instrument is closed 
 is only If inches, the head may, under the most favourable circum- 
 stances, be brought by the cephalotribe through a space measuring 
 only 1^ inches in its smallest diameier, provided that the trans- 
 verse diameter bisecting this smallest diameter measures as much 
 as somewhat over 3 inches. It follows that extraction may some- 
 times be effected by the cephalotribe in quite as high a degree of 
 contraction in flattened pelves as by any other possible means. 
 For this result, however, it is essential that, while the blades grasp 
 the head pretty centrally, the extremities of the blades should be 
 free on the other side of the head, and capable of meeting, as in 
 Fig. 445, p. 894. If the neck, or thorax, or part of the head 
 intervenes Ijetween the ends of the blades, the instrument cannot 
 
894 
 
 The Practice of Midwifery. 
 
 be closed so completely, and will not pass through so small a 
 space. 
 
 It is frequently a difficult matter to succeed in applying the 
 cephalotribe centrally over the head, in such a way that the instru- 
 ment can be completely closed. Hence, in extreme forms of pelvic 
 contraction, other modes of extraction shortly to be described come 
 
 into competition with the use of the 
 cephalotribe, and may sometimes 
 succeed when the cephalotribe has 
 failed. 
 
 The diminished pelvic inclination 
 usually found in the flattened rachitic 
 pelvis facilitates the use of the cepha- 
 lotribe ; an increased pelvic inclination 
 renders it more difficult, when con- 
 traction is extreme, especially as com- 
 pared with the method of induction of 
 face presentation after cranioclasm (see 
 p. 899). 
 
 Method of operating. — The blades are 
 to be passed at the sides of the pelvis, 
 without 4.'egard to the position of the 
 head. Generally the head is caught 
 somewhat diagonally, as by the blades 
 of forceps ; but if the head is above 
 the brim in a flattened pelvis, it is very 
 likely to be caught by the two blades 
 over forehead and occiput, as shown 
 in Fig. 445, and this is the most 
 favourable way of seizing it. As with 
 the ordinary forceps, the lower blade 
 is to be passed first. The fingers of 
 the left hand are passed into the vagina 
 and within the cervix, and the blade 
 guided up just like the blade of forceps. The second or upper blade 
 may, like the upper blade of forceps, be at first passed up opposite 
 the sacro-iliac articulation, the handle being carried forward 
 between the thighs, and the blade afterwards swept round to the 
 right of the pelvis by carrying the handle downward and backward. 
 The blade does not, however, glide laterally over the head so easily 
 as that of forceps, on account of the serrations on its inner margin, 
 and its incurved extremity. Hence, if it is found difficult, by this 
 mode of introduction, to get the blade exactly opposite to the lower 
 
 Fig. 445. — Head crushed by 
 cephalotribe. 
 
Craniotomy and Embryotomy. 895 
 
 one, it is better to pass it at once up the side of the pelvis, having 
 the patient quite at the edge of the bed, and depressing the handle 
 strongly. Both blades should be passed on until the whole of the 
 serrated portion of their inner surface is out of reach, lying against 
 the head (see Fig. 445). 
 
 In order to adjust the lock, the handles should be pressed back 
 against the perineum, somewhat more than those of forceps, so 
 that the blades, with their pelvic curve slighter than that of forceps, 
 may seize the head centrally. Tbe screw is then api^lied, and 
 before it is tightened the left band makes sure that the blades are 
 at opposite sides of the head. If they are too near together, either 
 at the back or the front of the pelvis, they will slip either backward 
 or forward off the convexity of the head as the screw is tightened. 
 The instrument is then screwed up as tightly as possible. The 
 operator should first have noticed how nearly the handles approxi- 
 mate when the instrument is completely closed, and should endeavour 
 to screw them up as nearly as possible to this position ; for if the 
 inner surfaces of the blades are divergent instead of parallel or 
 nearly so, the instrument is liable to slip off when traction is made. 
 As the screw is tightened, the brain substance will be squeezed out, 
 if it has not previously been washed out with a stream of water. 
 When the crushing is completed, the left hand should be passed up 
 again to feel whether the blades have slipped off, or are grasping 
 the head centrally. There will now be room to pass the hand 
 further into the uterus, to make out their exact position. The 
 operator should also make sure that there are no projecting angles 
 of bone at the point of perforation. If any are found the pieces of 
 bone should be pulled away with the fingers or small craniotomy 
 forceps (see Fig. 441, p. 888), or the angles should be nipped off 
 with a pair of bone-nipping forceps, which are a useful adjunct to 
 the obstetric bag. Generally it will be found that, if the head is 
 properly grasped, the angles of bone are covered by the scalp, 
 as shown in Fig. 445, or are shielded between the shanks of the 
 instrument. 
 
 If it is found that the blades have slipped more or less off the 
 head, backward or forward, the screw should be loosened, and the 
 blades reapplied more centrally. There will now be probably room 
 to i)ass the hand up into the uterus by the side of the head, in order 
 to adjust the position of the blades. The crushing is then repeated. 
 In a difficult case it may be necessary to repeat this process several 
 times in succession, l>efore a sufficiently central grasp is secured. 
 It is more dangerous to make traction when the blades are rather 
 in front of the centre of the head (in reference to the pelvis) than 
 
896 
 
 The Practice of Midwifery. 
 
 when they are rather behmd it as m Fig. 445 ; for, in the former 
 case the tips of the blades are hable to project and injure the soft 
 parts. 
 
 Supposing that a sufficiently central grasp has been secured, 
 traction is to be commenced. If the head is already in the cavity 
 
 m 
 
 Fig. 446. — Simpson's 
 splitting basilyst. 
 
 Fig. 447. — Auvard's three-bladed cephalotribe. 
 
 of the pelvis, or if the pelvis is uniformly contracted, the cephalo- 
 tribe is to be drawn down in the position in which it was applied. 
 If, however, the pelvis is flattened, and the head is still above the 
 brim, the cephalotribe should be rotated through nearly a quarter 
 of a circle. This will bring the long diameter of the flattened head 
 to correspond with the transverse diameter of the flattened brim, 
 whereas at first the head was flattened out in the direction of the 
 contracted conjugate. In extreme degrees of contraction of the con- 
 jugate, care should be taken that the instrument is so far screwed 
 
Craniotomy and Embryotonn.y. 897 
 
 up as to close it completely, or almost completely, before traction 
 is begun ; for it would be dangerous to make pressure upon the 
 symphysis pubis and promontory of the sacrum by the diverging 
 blades of the instrument itself. Traction must be made in a 
 direction as much backward as possible, until the head has passed 
 the brim. It will probably not be possible to pull accurately in the 
 axis of the brim, since the advantage of the pelvic curve of the 
 cephalotribe is now almost or entirely lost, its concavity being 
 turned to one side. If the cervix is not at first fully expanded, 
 ample time must be allowed for it to dilate. The hand should also 
 be introduced from time to time to ascertain if the blades keep in 
 position, and whether any angles of bone begin to project. Any 
 such angles should be nipped off as before. As the head descends 
 to the pelvic floor, traction is to be made more forward, and the 
 cephalotribe may be allowed to rotate in any direction to which the 
 resistances impel it. Generally it will be found that the shanks 
 tend to rotate forward under the pubic arch, like the leading portion 
 of the presenting part of the foetus, and thus the cephalotribe passes 
 the pelvic outlet with its concavity directed backward. It has thus 
 been rotated through half a circle in all. It will most commonly 
 be found that the hard base of the skull has not been broken up by 
 the cephalotribe, but tilted in the grasp of the blades, either laterally 
 or longitudinally. It is best for the base of the skull to be tilted 
 into a position of flexion, as shown in Fig. 445, because then the 
 maximum diameter of the flattened head does not much exceed the 
 transverse diameter of the base of the skull, or about 3 inches. 
 
 In general the tilting of the base of the skull is quite sufficient, 
 and there is no necessity for breaking it up. Such breaking up 
 could only be useful when transverse diameter as well as conjugate 
 is much contracted. An instrument for the purpose, the basilyst, 
 has been introduced by Prof. A. E. Simpson, of Edinburgh. It 
 is first screwed into the base of the skull, and the blades then 
 separated. The cephalotribe may be applied afterwards. 
 
 The introduction of the three-bladed cephalotribe is carried out 
 as follows : — The middle blade is first introduced as far as possible 
 into the skull through the opening made by the perforator. This 
 blade having been placed in position, one of the external blades is 
 next introduced either over the frontal or occipital region of the 
 head. It is passed in under cover of the fingers of the left hand at 
 the side of the pelvis and rotated into position over the external 
 surface of the head. The screw is now turned, and the part of the 
 head which has been seized crushed. As in the employment of 
 Braxton Hicks' cephalotribe, the ease or difficulty with which the 
 M. 57 
 
898 
 
 The Practice of Midwifery. 
 
 crushing can be carried out is a good index of the manner in which 
 the head has been seized. If there is a good deal of resistance to 
 the crushing, almost certainly a good grasp of the head has been 
 secured. One portion of head having been crushed in this way, the 
 other blade is now introduced at the opposite side of the pelvis in 
 the same manner, the screw fixed, and the head again crushed. In 
 extracting the crushed head the instrument should be allowed to 
 rotate spontaneously, or if it shows no signs of doing this, then it 
 should be rotated so that the crushed diameter 
 may occupy the smallest diameter of the pelvis. 
 
 Cranioclasm. — The operation of cranioclasm 
 is much more difficult and tedious than extraction 
 by the cephalotribe or craniotomy forceps. It 
 also involves risk of injury both to the soft parts 
 and to the operator's fingers by the angles of 
 detached bone. It should only be undertaken, 
 therefore, in those cases of extreme difiiculty in 
 which the operator cannot efl:ect extraction by 
 one of the two former methods without exerting 
 a dangerous degree of force. 
 
 Method of operating.— The best instrument 
 for removal of pieces of bone is a pair of cranio- 
 tomy forceps, such as those shown in Fig. 448, 
 or, still better, one in which both blades 
 are solid without fenestra. The instrument is 
 passed up to the head under the guidance of the 
 left hand in the vagina. One blade is passed 
 between the cranial bones and the scalp, the 
 other through the aperture into the interior of 
 the skull. If possible the instrument should be so 
 passed that its curve corresponds to that of the 
 head, for then it is likely to secure a larger piece of bone ; but if 
 it is found easier to turn it the reverse way, and pass the other 
 blade between the bone and the scalp, there is no objection to 
 doing so. The bone is then grasped, and a sudden twist, first in 
 one direction, then in the other, is given to the instrument so as 
 to break the piece of bone in its grasp away from surrounding 
 parts. The forceps are then twisted round and round till the 
 piece of bone is entirely detached, and finally the piece is drawn 
 out, covered by the left hand, and so prevented from lacerating 
 the soft parts. The piece of bone should be in the palm of the 
 hand, the fingers closed over it, so that it is brought down ivithin the 
 
 Fig. 448.— 
 Craniotomy forceps, 
 
Craniotomy and Embryotomy. 899 
 
 closed fist, and cannot possibly touch any soft parts. This process 
 is to be continued until nearly the whole of the vault of the skull 
 has been removed, including the whole of the parietal bones. The 
 student must take care to remember that in cranioclasm the outer 
 blade is passed between the scalj) and the bone, but that, when 
 craniotomy forceps are used as a tractor, it is passed outside the 
 scalp. 
 
 Induction of Face Presentation. — When the vault of the skull has 
 been broken up and in great part removed, the best way to deliver 
 the head in a greatly contracted pelvis, especially one with a very 
 small conjugate diameter, is to induce a face presentation. If the 
 chin be brought to the front, the diameter opposed to the conjugate 
 is then only the vertical diameter of the face, little more than 1 inch, 
 and that opposed to the transverse is the bi-mastoid or bi-zygomatic 
 diameter, not more than 3 inches. The face may be brought to 
 present by the small blunt hook already described as useful for 
 securing the knee in version (see p. 881). The hook is fixed first 
 into the orbit, and then, after the orbit has been brought down, 
 upon the chin, or some part of the lower jaw near it. The chin 
 having been completely drawn down, so that the face presents, 
 delivery may be completed in one of two ways. The blunt hook 
 may be transferred to the inner surface of the base of the skull, be 
 fixed into some of the projections of bone there, and so draw the 
 head down ; or the craniotomy forceps with a screw at the handle 
 (Fig. 442, p. 889) may be used. This is the only condition in 
 which this instrument can be used with advantage as a crusher as 
 well as a tractor. The solid blade is passed in front of the chin, 
 the fenestrated blade over the base of the skull, and the screw 
 tightened as much as possible. Thus the small vertical diameter 
 of the head which remains is still further compressed. This 
 method of delivery is most useful when the vault of the skull has 
 not been completely removed. In the absence of the small blunt 
 hook, the crochet (Fig. 449) may be used in its place in this 
 operation. This method of delivery is the best adapted of any to 
 overcome extreme conditions of contraction affecting transverse as 
 well as conjugate diameter ; for the base of the skull is brought 
 down in its most favourable position, which it will not always be 
 when tilted in the grasp of the cephalotribe. 
 
 Version. — Version is sometimes performed to facilitate delivery 
 after craniotomy. In the extraction of the after-coming head, the 
 skull collapses under the pressure of the pelvis, and the bones 
 generally remain covered by the scalp. Version may be performed 
 
 57—2 
 
900 
 
 The Practice of Midwifery. 
 
 with advantage in the absence of an efficient cephalotribe or cranio- 
 tomy forceps, or if the operator does not succeed with either of 
 these instruments, when the degree of contraction is not very 
 extreme, especially if it is found that angles of bone protrude. 
 The cephalotribe may be applied again to the after-coming head, 
 if it will not otherwise readily pass the brim, after liberation of 
 the arms. In very extreme contraction, the extraction of the body 
 might cause difficulty, owing to the extension of the arms. In such 
 
 cases it is preferable to perform cranioclasm, and then 
 
 induce a face i3resentation. 
 
 Secondary Symphysiotomy. — When it proves 
 impossible to extract after craniotomy without a 
 dangerous amount of traction, symphysiotomy or 
 pubiotomy has been suggested as a means of gaining 
 more room in the pelvis. The same operation may be 
 chosen in preference to the prolonged and difficult 
 operation of cranioclasm. These operations have, 
 however, a less favourable influence on the pelvic 
 diameters in extreme contraction of the conjugate than 
 they have when general contraction forms a main part 
 of the difficulty, and would very seldom be justifiable 
 in these conditions. 
 
 Fig. 449.— 
 Crochet. 
 
 The Crochet. — The crochet (Fig. 449) was the 
 instrument formerly most used for extraction after 
 craniotomy. The crochet is passed through the 
 aperture into the interior of the skull, and fixed 
 against any part of the vault of the skull where it can 
 obtain a firm hold.^ The fingers of the left hand are 
 j)laced on the outside of the scalp, opposite the point of 
 the crochet and pressing against it, and then traction is made. 
 The disadvantage of this jDroceeding is that the crochet is apt to 
 slip, or to tear away the piece of bone which it is holding, and so 
 cause laceration. This mode of extraction should not therefore be 
 adopted if any better one is available. The crochet is, however, 
 often very useful in the extraction of a dead foetus, when fixed into 
 any available part of the body, in order to secure a hold for 
 additional traction. Tbe small blunt hook may be used in the 
 same way. 
 
 ^ Studeots often say at an examination that the crochet should be fixed in the 
 foramen inagnum. This, however, is impossible, since it is much too large. The only 
 instrument which could be fixed in the foramen magnum is the vertebral hook 
 invented by Dr. Oldham for extraction of the after-coming head. 
 
Craniotomy and Embryotomy. 901 
 
 Forceps. — Forceps should never be applied to deliver the head 
 after craniotomy, because they are liable to slip off as the head 
 collapses. Foreign forceps in which the points are close together 
 when the handles are closed, may succeed in easy cases, but the 
 ordinary English forceps are of little use for this jDurpose. 
 
 Extraction of the Body. — As a rule, it is only when contraction 
 is extreme, or the child very large, that extraction of the body 
 meets with much difficulty. The cephalotribe or craniotomy forceps 
 should be kept applied to the head to furnish a good hold for traction, 
 until the thorax has passed the brim. If much resistance is met 
 with, the crochet or small blunt hook may be fixed in one axilla, 
 so as to draw down one shoulder in advance of the other. If this 
 does not answer, both arms may be drawn in front of the chest 
 by the same means, and used to afford an additional hold for 
 traction. If difficulty is still experienced, the clavicles should be 
 divided, an easy method of reducing the width of the child's 
 shoulders. The operation is simple. Under cover of the fingers of 
 the left hand, the clavicles are divided with a pair of strong straight 
 scissors.-^ 
 
 The perforator may be used to pierce the chest and abdomen, but 
 not much is gained by this, unless the abdomen had become dis- 
 tended by decomposition. If necessary, the cephalotribe may be 
 applied over the chest, and afterwards over the pelvis, especially if 
 the head should have separated and come away from the trunk 
 under traction. 
 
 Perforation of the After-coming Head. — In the case of the 
 after-coming head, the usual method of craniotomy has been to 
 perforate behind the ear in the neighbourhood of the postero- 
 lateral fontanelle, or through the occipital bone. This has the 
 disadvantage that the point of the perforator impinges on the skull 
 at a very acute angle, and is very close to the maternal soft parts. 
 An improved method has been introduced, namely, to perforate 
 through the roof of the mouth. The blades can then be separated 
 in two directions at right angles, as in the case of the fore-coming 
 head. If the head has become at all extended, care must be taken 
 to direct the point of the perforator somewhat backward toward the 
 occiput, otherwise it may only enter the orbit, and not the cavity 
 of the skull. In one respect there is an advantage in this method 
 even over perforation of the fore-coming head, namely, that the 
 
 1 Spencer, Brit. Med. Journ., April 13, 1895, p. 808 ; Ballantyne, Trans. Obst. ,Soc. 
 Edin., Vol. XXVI., p. 24. 
 
902 The Practice of Midwifery. 
 
 base of the skull is more or less broken up. For this reason 
 Donald has advocated preliminary version in all difficult cases 
 of craniotomy ; ^ but this advice has not been generally accepted. 
 
 After perforation through the roof of the mouth, the brain sub- 
 stance should be broken up with the perforator, and then washed 
 out with a stream of water. In easy cases the head can be 
 extracted by traction. In difficult ones the body of the child 
 should be held forward by an assistant, while the blades of the 
 cephalotribe are applied at the sides of the pelvis. When a central 
 hold has been obtained of the head, the instrument should be 
 rotated through a quarter of a circle, in the case of a flattened 
 pelvis, and so drawn down. 
 
 Embryotomy in Pelvic Presentations. — It is only in cases 
 of extreme disproportion that the body of the child cannot be 
 brought through the brim in pelvic presentations, or after version. 
 Sometimes, however, the pelvis of the child refuses to enter the 
 pelvis of the mother, and the difficulty is then greater than in head 
 presentations. The alternative of performing Csesarean section, 
 eymphysiotomj^ or pubiotomy, before much effort is made at trac- 
 tion, then arises. If this is rejected, both legs should be brought 
 down, and traction should be made upon them, both together and 
 separately, in order to find out the best way of bringing down the 
 child's pelvis. If the child is dead this may be aided by the 
 crochet or small blunt hook fixed over the pelvis. If the abdomen 
 of the child has become distended, after death of the fcetus, it may 
 be necessary to perforate it. 
 
 The methods of performing embryotomy in shoulder presenta- 
 tions, when version is impossible, have already been described (see 
 p. 676). 
 
 1 Trans. Obst. Soc. London, 1889, Vol. XXXI., p. 28. 
 
Chapter XXXVI, 
 
 CESAREAN SECTION, SYMPHYSIOTOMY AND 
 PUBIOTOMY. 
 
 C^SABEAN Section. 
 
 By Caesarean section is meant the removal of the fcetiis by 
 incisions through the walls of the abdomen and the uterus. In 
 the variety of the operation introduced by Porro it is completed 
 by the excision of the whole of the body of the uterus. 
 
 History — Csesarean section is a mode of delivery which would 
 naturally suggest itself at a rude period of surgical art. Tradition 
 has related of several noted men of ancient days — such as iEscula- 
 pius, Scipio Africanus, Julius Caesar — that they were delivered in 
 this way. Although the tradition is not believed to be well founded 
 as regards Julius Caesar, the derivation of the title " Caesar " from 
 " A matris utero ccesus " has been generally accepted. Such tradi- 
 tional accounts are open to the interpretation that, if true at all, 
 they refer probably in most cases only to Caesarean section performed 
 after the mother's death. But, even to the present day, Caesarean 
 section for delivery of the living woman is practised among some 
 savage tribes in a low grade of civilisation, as in the interior of 
 Africa.^ This affords some presumption in favour of the view that 
 the same operation may have been performed in ancient days. 
 During the sixteenth century Caesarean section was believed to have 
 been performed in various instances, during the life of the mother, 
 although no reliable histories of the cases have been preserved. 
 The first authentic record is that of a Caesarean section performed 
 in a case of hernia of the gravid uterus by Trautman, at Wittenberg, 
 in 1710. The patient lived twenty-five days after the operation. 
 
 In former years the mortality of Caesarean section had been so 
 high as to restrict the operation to those cases in which delivery 
 through the pelvis was either impossible or so difficult as to involve 
 very great risk to the mother. British statistics gave a mortality 
 of about 84 per cent. The first improvement was introduced in 
 
 1 "Notes on LaVjour in Central Africa," by R. W. Felkin, Trans. Obst. See. Edin. 
 1884. 
 
904 The Practice of Midwifery. 
 
 1876, by Porro of Pavia, who followed up Cfesarean section by the 
 removal of the whole uterus with the ovaries in a case of pelvic 
 contraction. Thus was introduced Porro's operation, hereafter to 
 be described. It was practised in a good many cases of pelvic 
 contraction with a success considerably exceeding that of the old 
 Cesarean section. The modern method of Caesarean section was 
 first suggested by Sanger in 1882. It was perfected and simplified 
 chiefly at Dresden and Leipzig, by Leopold and other operators, 
 and has attained such success as to displace craniotomy from a 
 considerable portion of its field. Hitherto the operation has been 
 performed most frequently and most successfully in Germany, 
 where the higher degrees of pelvic contraction are commoner than 
 in England or America. The improvements introduced by Sanger 
 consist essentially in the adaptation of Lembert's intestinal suture 
 for the superficial sutures of the uterine peritoneum ; and in the 
 use of a large number of sutures, deep and superficial, to secure 
 perfect closure of the uterine wound, so that the lochial discharge 
 is prevented from reaching the peritoneum. 
 
 Indications for the Operation. — The indications for Caesarean 
 section have already been described in the chapters dealing with 
 the various conditions which may call for it. They are chiefly 
 comprised in the following : the higher degrees of pelvic contrac- 
 tion, and some cases of obstruction of the pelvis by tumours, 
 cancer of the cervix, inflammatory deposits, or cicatrices which 
 cannot be stretched. It has also been recommended and practised 
 for cases of accidental hfemorrhage, placenta praevia, and eclampsia. 
 In Eoman Catholic countries religious scruples about destroying 
 the child to secure the safety of the mother have influenced the 
 choice between craniotomy and Csesarean section. In this country 
 the interest of the mother will still be held paramount. But in 
 cases in which, owing to the improvements in Caesarean section, the 
 risks of the two operations are nearly balanced, the interest of the 
 child is justly allowed to have much weight. And now that the 
 risk of Caesarean section has become so moderate, it is reasonable, if 
 that operation can be performed under favourable circumstances, in 
 any case in which the child is likely to be otherwise sacrificed, to 
 offer the mother the option of undergoing even a somewhat greater 
 risk, to save the life of her child. 
 
 Time for operating. — The modern success in Caesarean section 
 has been gained chiefly in cases in which the operation has been 
 decided on beforehand, and performed at the most favourable 
 
Csesarean Section, Symphysiotomy, Etc. 905 
 
 moment. If a patient has long been in labour, extraction through 
 the pelvis is safer, except in the more extreme forms of distortion, 
 as, for instance, when the conjugate diameter is less than 2f inches. 
 The operation may be undertaken before the onset of labour, or 
 labour may be allowed to commence and the operation performed 
 when partial dilatation of the cervical canal has been obtained. 
 The objection that if the operation be performed before the dilata- 
 tion of the cervix there is a difficulty in obtaining sufficient drainage 
 through the cervical canal does not appear, in view of modern 
 results, to be of much importance. If it is thought best, labour may 
 be induced and the operation commenced as soon as partial dilata- 
 tion of the cervix has been secured. For this purpose a dilator may 
 be introduced a few hours before the time fixed for the operation. 
 If, however, the cervix uteri is patent enough to admit the index 
 finger, there appears to be no objection to operating without any 
 commencement of labour. Experience appears to show that failure 
 of the uterus to retract is not to be feared when labour has not com- 
 menced, but only when the uterus is fatigued by prolonged labour. 
 
 Preparation of the Patient. — The vagina should be irrigated 
 previously with lysol, 1 per cent. The abdomen should be carefully 
 washed with soap and water, the umbilicus cleaned out if necessary 
 by liquor potassse, the pubic and vulvar hair shaved. If time allows, 
 a compress soaked in perchloride of mercury, 1 in 1,000, should be 
 kept on the skin for some hours previous to the operation. The 
 abdomen should then be washed over, first with lysol, 1 in 80, 
 then with iodide of mercury in spirit, 1 in 500, The utmost care 
 should be taken to cleanse all instruments, and the hands of all who 
 take part in the operation, including nurses, from any possibility of 
 septic contamination. Hands and arms are best disinfected first in 
 lysol, 1 in 80, and finally in solution of iodide of mercury in spirit, 
 1 in 500, and sterilised rubber gloves should always be worn. The 
 patient may be placed either in the ordinary dorsal position, or, 
 if it be preferred, the Trendelenburg position may be employed. 
 
 Anaesthetic. — Ether together with oxygen rather than chloro- 
 form should be chosen for the anaesthetic, since it does not relax the 
 uterus so completely. If the uterus fails to contract well after 
 removal of the foetus, the anaesthesia should not be maintained too 
 deeply. It must, however, be sufficient to prevent vomiting or 
 straining, by which the intestines might be forced out. 
 
 Cesarean section has often been performed, especially on the 
 Continent, by the aid of local analgesia from the injections of a 
 
9o6 The Practice of Midwifery. 
 
 solution of cocain or eucain at the site of incision. A general 
 angesthetic is regarded with less dread in this country ; but the 
 method may sometimes be advisable if the operation is ever 
 undertaken when the uterus is very inert from the fatigue of 
 prolonged labour ; and the patient is endowed with self-restraint 
 and tolerance. 
 
 The Operation. — If the operation is arranged for beforehand, 
 sterilised gauze rolls, sterilised artificial sponges, made of absorbent 
 cotton wrapped in gauze, with flat j)ads large and small, should be 
 used, or, in the absence of these, wads of cotton wool, sterilised by 
 boiling, and used wet. 
 
 The field of operation should be surrounded with towels sterilised 
 by boiling, and wrung out of lysol, 1 in 80. The bladder should 
 first be emptied. Then an incision is made in the linea alba. This 
 should be about six inches long, and from a third to half of it 
 should be above the level of the umbilicus, so that the incision ends 
 three inches above the pubes. The incision should be made 
 deliberately, and all bleeding vessels secured by pressure forceps. 
 When the more superficial tissues are divided, the division between 
 the recti muscles is sought for and the incision made through it. 
 When the peritoneum is reached, after the sub-peritoneal fat is cut 
 through, a small portion is pinched up with dissectmg forceps and 
 divided. The uterus will generally lie in contact with the surface 
 through the whole extent of the incision. In some exceptional 
 cases, however, there may be intestine lying in front at the upper 
 part of the incision. If on percussion this has been ascertained to 
 be the case, the assistant should, at this stage, place the palms of 
 his hands at each side of the uterus, and press it as much as 
 possible forward against the abdominal wall. In extending the 
 incision downward close to the lower angle of the wound, it is a good 
 plan to pass two fingers of the left hand as a director beneath the 
 peritoneum, so as to elevate it somewhat, and thus to divide it 
 between the fingers. If the bladder should be dangerously near, it 
 will then be detected by the tips of the fingers, and there will be no 
 risk of wounding it. This precaution is the more desirable if 
 CsBsarean section is performed after protracted labour, when the 
 bladder will have ascended through the stretching of the lower 
 segment of the uterus. Some ascent of the bladder must be 
 expected in all cases in which labour is at all advanced (see 
 Fig. 131, p. 220). 
 
 The uterus may be incised m situ or it may be first turned out of 
 the abdomen. The former plan has the advantage that the length 
 
Caesarean Section, Symphysiotomy, Etc. 907 
 
 of abdominal incision required is not so great ; the latter that it 
 renders it more easy to prevent the escape of liquor amnii into the 
 abdominal cavity. Such escape seems to be of little consequence if 
 the membranes are unruptured at the time of operation. If they 
 are ruptured, and there is a chance that there may have been septic 
 contamination of the interior of the uterus, it is advisable to turn 
 the uterus out first. As a general rule it is not necessary to carry 
 out any special compression or kneading of the uterus, as the bleed- 
 ing which occurs is usually moderate in amount, and the uterus 
 often contracts best when left alone. If the bleeding is at all 
 profuse it can at once be controlled until contractions can be set up 
 by compression of the vessels in the broad ligaments at either side 
 of the uterus. Two or three sutures are now passed through the 
 abdominal walls at the upper part of the wound, to be ready to 
 close temporarily that portion of it, while the uterine sutures are 
 being applied. 
 
 Up to this stage the operation is to be performed deliberately, 
 and all hsemorrhage from the abdominal wound is to be stopped 
 before the uterus is opened. During the next stage, the best check 
 upon haemorrhage is to proceed as rapidly as possible, and empty 
 the uterus. The uterus should be steadied, and brought as nearly 
 as possible into the middle line by the assistant who places his 
 hands at each side of it. It should be remembered that the uterus 
 is generally both inclined and rotated towards the right side. The 
 incision through the uterine wall is commenced about the middle 
 of the abdominal wound, and carried through to the internal 
 surface. Then, when the membranes are reached, a director, or, 
 better, the fingers are passed in, and the uterine wall slit up 
 in each direction nearly to the extent of the abdominal incision. 
 If the child is at full term, the length of the incision must be nearly 
 six inches, to give space for the head to be extracted without 
 difficulty. 
 
 Haemorrhage is generally only moderate, provided that the 
 placenta is not attached to the anterior wall, and therefore is not 
 laid open by the incision. If the first incision enters the placenta, 
 a good plan is to extend the incision rapidly to the requisite length, 
 push the placenta to one side or cut it through, remove the child, 
 and then at once detach the placenta ; or the plan, strongly recom- 
 mended by Gow, may be followed of detaching rapidly the placenta 
 all round and removing it before the child. The position of the 
 placenta cannot always be determined beforehand. If, however, 
 the limbs of the child can be plainly felt over the front of the 
 uterus, covered only by the thickness of the uterine wall, it may be 
 
9o8 The Practice of Midwifery. 
 
 inferred that the placenta is not situated there. If the limbs can- 
 not be distinctly felt, and a greater thickness appears to intervene, 
 it may be suspected that the placenta lies in front. 
 
 Fiindal Incision of Uterus. — The plan of making a fundal incision 
 from side to side of the top of the fundus instead of a sagittal 
 incision in the anterior uterine wall was first suggested by Fritsch 
 in 1897,^ and has been much practised in Germany. The advan- 
 tages claimed are that the extraction of the foetus is easier, that the 
 placenta is less likely to be incised, and that the uterus being 
 turned out of the abdomen before incision, the liquor amnii is less 
 likely to escape into the peritoneal cavity. Experience, however, 
 shows that the placenta is incised less frequently in the fundal 
 incision by only a very small percentage of cases. Other advantages 
 are that the fundal incision contracts more than the anterior 
 incision, and so requires less stitching ; and that the abdominal 
 incision is higher, and is said on this account to be less liable to 
 allow a ventral hernia. The latter point is, however, doubtful. 
 Against these advantages are to be set the disadvantages that 
 intestines are more likely to become adherent to the fundal incision, 
 and that, if the uterus becomes fixed to the abdominal wall, it does 
 so at a higher level. These disadvantages are on the whole greater 
 than the advantages obtained. If, however, it is intended to com- 
 plete the operation by removal of the uterus, the fundal incision 
 may have the advantage. 
 
 Removal of the Foetus. — As soon as the incision into the uterus 
 is completed, the assistant should hook an index finger into each 
 end of it, and, by this means, hold the uterus forward against the 
 abdominal w^all, so as to prevent liquor amnii and blood entering 
 the peritoneal cavity, as far as possible. If the membranes are 
 intact up to this point, the fcetus may be extracted by the head. 
 The membranes are ruptured, and the hand rapidly passed down 
 into the lower segment of the uterus, so as to scoop out the head. 
 This plan has the advantage of avoiding the risk of the uterine wall 
 contracting round the neck, and detaining the after-coming head. 
 If, however, the membranes have been ruptured some time, it may 
 be necessary to extract the foetus by the leg. In this case, the 
 extraction of the head is facilitated, if some jaw traction is made 
 with the index finger so as to flex the head. The funis is tied and 
 divided, and the child handed over to the assistant who is prepared 
 to attend to it. 
 
 1 Zent. f. Gynak., 1897, No. 20. See also Munro Kerr : " Fritsch's Fundal Incision," 
 Journ. of Obst. and Gyn. Brit. Emp., July, 1902, Vol. II., No. 1, p. 21 ; Gow, Harveian 
 Lectures, 1907. 
 
Csesarean Section, Symphysiotomy, Etc. 909 
 
 The next step is to turn the uterus out through the abdominal 
 wound, in order to render it more accessible for the placing of 
 sutures, and to stimulate it, if necessary, by pressure to contract. 
 A large flat pad is placed to hold back the intestines, and the upper 
 part of the abdominal wound temporarily closed by placing catch 
 forceps on the sutures already applied there. Another flat sterilised 
 pad is then placed behind the uterus, to prevent its coming into 
 contact with the skin. 
 
 The uterus is then stimulated to contract by kneading, or, if 
 necessary, by the aj)plication of a pad, dipped in hot sterilised 
 water. The placenta and membranes must then be carefully and 
 completely detached, and especial care must be taken, if labour has 
 
 Fig. 450. — Diagram of mode of applying sutures in Sanger's operation. 
 a. Peritoneum ; 1), Muscularis ; c, Mucosa ; d, Superficial suture ; e, Deep suture. 
 
 begun and the membranes have ruptured, that no portion of the 
 latter is left attached to the lower uterine segment. 
 
 Uterine Sutures. — The muscular wall of the uterus is to be 
 closed by about twelve deep sutures which approximate to, but do 
 not include the mucous membrane, and about double that number 
 of superficial sutures uniting the peritoneum in such a way as to 
 fold it into the incision, and bring flat surfaces of it into contact 
 (Fig. 450). 
 
 There appears to be no real objection to the plan, adopted by 
 some operators, of including the whole thickness of the uterine wall 
 with the mucosa in the grasp of the sutures, but on the whole the 
 plan of avoiding the mucosa is the better one. 
 
 In Sanger's original operation, in order to secure this end, the 
 peritoneum was firsb undermined and separated from the muscularis 
 by passing a scalpel under it about \ inch. Then a wedge-sbaped 
 strip of the muscularis was excised along each side of the wound, the 
 broader end of the wedge ]>eing outermost, in order to allow the 
 
9IO 
 
 The Practice of Midwifery. 
 
 detached edge of the peritoneum to overlap into the wound. It has 
 been found that both of these proceedings are unnecessary, and that 
 the peritoneum is generally loose enough to draw over the edge 
 without any separation. 
 
 Silver wire, sterilised silk, or chromic catgut, may be used for 
 
 Fig. 451. — Diagram of sutures secured in Sanger's original operation. 
 a, Peritoneum ; &, Muscularis ; c, Mucosa ; d, Superficial suture ; e, Deep suture. 
 
 the deep sutures. The two latter are more convenient for manipu- 
 lation, and do not interfere with any future Csesarean section. I 
 have found boiled silk, No. 2 Chinese twist for the deep sutures, 
 
 Fig. 452. — Application of sutures in Csesarean section. 
 
 and No. 1 for the suj)erficial, answer excellently. The sutures 
 should be ready beforehand, cut of suitable length, and care 
 should be taken that the loops to be left are not touched by the 
 fingers. 
 
 For the control of haemorrhage and for the ease of the application 
 of sutures, the edges of the wound are everted and held compressed 
 
Caesarean Section, Symphysiotomy, Etc. 911 
 
 by the assistant, as shown in Fig. 452. Curved needles, forming 
 an arc of a circle, should be used for the deep sutures, so that they 
 may be inserted not far from the edge and yet may include plenty 
 of tissue (see Fig. 451). In inserting them the peritoneum should 
 first be drawn over the edge of the wound by dissecting forceps, 
 into the position which it is to occupy. 
 
 As already mentioned, the sutures do not include the mucosa, so 
 that they may not be exposed in the uterine cavity, nor conduct 
 any septic material thence to the peritoneum. The first suture 
 bisects the incision, to make sure that the edges are not adapted 
 unevenly. Each half may be again bisected by another suture, 
 and two more sutures placed in each resulting 
 quarter. The superficial sutures should be of 
 fine silk (No. 1 Chinese twist), and may be applied 
 with a smaller curved needle. In the original 
 Sanger suture, each superficial suture pierces the 
 peritoneum tissue on each side, like a Lembert's 
 suture (Fig. 451, p. 910). It is perhaps better 
 to pierce the peritoneum twice on one side and 
 once on the other, and thus produce a sero-fibrous 
 and not a sero-serous union of the peritoneal 
 edges. In Figs. 450, 451, are shown diagram- 
 matically the sutures in section, before and after 
 tightening. It must be remembered that the 
 deep and superficial sutures do not lie really in 
 the same plane, but that, generally, two super- 
 ficial sutures intervene between each pair of deep 
 ones. All the sutures should first be placed, then 
 the deep ones twisted or tied, the ends cut rather 
 short, if silver wire is used, and turned down into 
 the line of incision, and finally the superficial sutures tied. If, how- 
 ever, bleeding from the cut surfaces is not completely controlled, 
 the deep sutures may be tied before the superficial are inserted. If 
 at any point the peritoneum does not come perfectly into apposition, 
 more superficial sutures must be applied. 
 
 Before the sutures are tightened, the finger should be passed 
 down through the cervix, to make sure that drainage into the 
 vagina is clear. Before the uterus is returned into the abdomen, 
 its peritoneal surface may be sponged over with sterile water or 
 sterile salt solution. Although this method of placing superficial 
 sutures on the plan of Lembert's intestinal suture has seemed to 
 be the most essential part of Sanger's operation, several operators 
 have now discarded it for the sake of greater rapidity in the operation. 
 
 Fig. 4.53. — Sutures 
 tied according to 
 Sanger's method 
 seen from above. 
 
912 ' The Practice of Midwifery. 
 
 They simply place numerous deep sutures, tie them up, and 
 then add superficial or half- deep sutures to unite the peritoneum 
 at any points where it does not seem to be thoroughly brought into 
 contact. The result of this appears to be equally satisfactory. As 
 many as three deep sutures to the inch should then be used. Complete 
 contraction and retraction of the uterus is now obtained, if neces- 
 sary, by kneading or the application of a hot sponge, and the uterus 
 returned into the abdominal cavity. The next step is to sponge any 
 blood or liquor amnii out of the peritoneal cavity, especially the 
 pouch of Douglas, by passing down gauze sponges, held in sponge 
 forceps, or a metal sponge holder, into its dependent parts. Care 
 is required in closing the abdominal wound to avert the risk of 
 future ventral hernia. Most operators use three tiers of sutures, 
 a buried suture for the peritoneum, a buried suture for the muscle 
 
 ===-^=.^LQ t--. --==^z? Skin. 
 
 / \ Fat. 
 
 „ ^ > < ^_ . Fascia. 
 
 " ~— Peritoneum. 
 Fig. 454. — Author's method of placing sutures to unite abdominal wall. 
 
 and fascia, and superficial sutures for the skin, or skin and fat. 
 Another method is that of employing through and through sutures, 
 as is shown in Fig. 454. Three sets of sutures are used, 
 of which one is devoted to the fascia superficial to the rectus 
 muscles. The union of this fascia is at once the most important 
 for the prevention of hernia, and the most difficult to secure, since 
 it is retracted laterally owing to its attachment to the transversalis 
 and oblique muscles. 
 
 A flat pad of suitable size is first placed under the abdominal 
 wall to keep back intestines and catch any blood which flows from 
 the punctures. A pair of catch forceps is attached to it, to 
 remind the operator that it has to be withdrawn. 
 
 The first set consists of interrupted sutures of stout fishing gut, 
 and is passed through everything, including peritoneum, muscle, 
 fascia, subcutaneous fat, and skin. Straight needles 4 inches long 
 are used. The needle is first passed from the skin inwards on one 
 side, and then from the peritoneum outwards on the other. 
 
Caesarean Section, Symphysiotomy, Etc. 913 
 
 The second consists of a continuous buried suture uniting the 
 fascia. The best material for this is gossamer fishing gut, which 
 may be obtained in lengths of 18 inches. In the absence of this 
 chromic catgut or fine silk may be used. But silk sometimes 
 becomes contaminated with pus microbes, and suppurates even 
 after a considerable interval. If it does so, the whole length of 
 suture has to come away. When the buried suture is approaching 
 completion, the pad lying beneath is removed, and the deep sutures 
 are drawn up tight, to be tied as soon as the buried suture is 
 completed. 
 
 Finally the skin is united by a continuous suture of horsehair 
 which passes beneath the loops of the deep sutures. 
 
 A dressing of sterilised or cyanide gauze is placed over the 
 wound, and secured by strapping. Over this is placed a large flat 
 pad, and then a many-tailed bandage of flannel or swansdown 
 calico, the tails being secured together by safety-pins. The 
 dressing may generally be left untouched seven days. The deep 
 sutures should be left ten days. But if a few are causing inflamma- 
 tion through tightness, these may be removed at seven or eight days. 
 The superficial suture should be left two or three days longer. 
 
 Opinions differ as to the propriety of rendering the patient 
 sterile for the future. Many cases are now on record of a patient 
 passing safely through two Csesarean sections, and a few of even three 
 or more successful operations on the same patient.^ If the line of 
 incision in the uterus becomes adherent to the abdominal wall, as 
 is sometimes the case, at a second operation the uterus may be 
 opened without any opening of the peritoneal cavity, and the risk 
 of the operation is then less than usual. I have met, however, 
 with a case in which there was no such adhesion, and in which 
 the line of union in the uterus ruptured during labour. The foetus 
 escaped into the abdomen, and the patient's life was only saved by 
 the placenta sticking in the rent and forming a plug. I removed 
 foetus, placenta, and uterus by abdominal section a week after the 
 accident with a successful result. 
 
 Now that the results of Caesarean section are so favourable, the 
 patient may be advised to face the risks of future pregnancy if 
 she is in a position to obtain the best operative skill when the 
 occasion arrives. But, even at the best, the risk is about ten 
 times that of a normal delivery ; and, if the patient prefers not to 
 run that risk, it is right, in my opinion, that the option should be 
 allowed to her. 
 
 If it is decided to render the patient sterile, there is a choice 
 
 1 Wallace, Jouni. Obstet. and Gyn. Brit. Emp., 1902, Vol. II., No. 6, p. 555. 
 M. 58 
 
914 ^ The Practice of Midwifery. 
 
 between removal of the uterus, one or both ovaries being left, and 
 other modes of procuring sterility. I have several times chosen 
 the former with a favourable result, in order to avoid the risk of 
 contamination of the peritoneum from the uterus. But the 
 operation is rather more severe, and there is not yet sufficient 
 evidence to show whether the mortality is less or greater. If, how- 
 ever, there is reason to fear that septic infection of the uterus has 
 occurred, hysterectomy should be chosen. 
 
 Pregnancy has occurred notwithstanding the tying of the 
 Fallopian tubes, and even the removing of a portion of them. But 
 it appears to be a fairly certain method to place two ligatures on 
 each tube, remove a piece of the tube between them, and then 
 cut out in conical shape the mucous membrane of the piece of 
 tube left attached to the uterus, and close the orifice by a suture, 
 the peritoneum being sewn together over the stump. 
 
 After-treatment. — The after-treatment is the same as that after 
 abdominal section in general. The patient is kept on her back, a 
 pillow being placed under the knees, and perfect quiet is main- 
 tained. Morphia should be avoided if possible, but an enema 
 containing potassium bromide 40 grains and mucilage of starch 
 four ounces may be administered and repeated two or three times, 
 at intervals of four hours, if necessary, to relieve pain and soothe 
 the patient. The catheter should be used if required, but if the 
 patient can pass urine herself it is better. 
 
 For about twenty hours after the operation nothing should be 
 given by the mouth except hot water, one or two ounces at a time. 
 At the end of this time, food may be commenced, at first only 
 about an ounce every hour. Milk and barley water, equal parts, 
 may be given at first, or, if this does not suit, Benger's or Neave's 
 food, made thin, or peptonised milk. After three days tea, custard, 
 jellies, junkets, or bread and milk may be given, and fish com- 
 menced after four or five days. If there is shock or excessive 
 haemorrhage at the operation a quart of normal saline solution 
 should be injected j)er rectum before the patient has recovered from 
 the anaesthetic. In case of thirst a pint of warm water with a 
 saltspoonful of salt may be given occasionally by enema. In case 
 of prolonged vomiting nutrient enemata should be given, and it is 
 a useful plan in such cases to wash out the stomach with a stomach 
 tube. In many cases the patient is able to suckle her infant, and 
 the lactation aids the contraction and involution of the uterus. In 
 general the patient may leave her bed at the end of three weeks. 
 Vaginal douches are not essential after the operation if the patient 
 
Caesarean Section, Symphysiotomy, Etc. 915 
 
 is doing well, especially if the vulva is kept occluded by sterilised 
 pads. In case of offensive discharge from retention of clots in the 
 uterus it may be necessary to wash out the uterus with a Budin's 
 double- action catheter. In general the lochial discharge is less 
 abundant than the average. If douches are used at all, one of 
 the least poisonous antiseptics, such as chinosol 1 in 500, cyllin 
 1 in 100, or Tr. lodi 5ij. ad Oj., should be used with boiled water, 
 and the douches should be given by means of an irrigator only 
 slightly elevated. 
 
 Suprasymphyseal or Extraperitoneal Caesarean Section. — 
 With a view to avoiding the handling of the uterus which the 
 classical operation involves and the danger of septic infection of 
 the peritoneum when the aseptic condition of the interior of the 
 uterus is doubtful, Frank ^ has devised an extraperitoneal operation 
 designed to minimise the risk of hgemorrhage and of peritonitis 
 and to allow of the performance of the operation late in the first 
 stage of labour. His method has been modified by Sellheim and 
 others, but the operation as generally performed is as follows : — 
 The skin and fat are divided by a transverse incision just above 
 the symphysis pubis, and the fascia and muscles are divided longi- 
 tudinally in the middle line. The muscles are separated and the 
 retro-pubic cellular tissue exposed. The peritoneum is then care- 
 fully strip]3ed up from the superior surface of the bladder and from 
 the anterior surface of the uterus, and is pushed up while the 
 bladder is pushed down. In this way the anterior surface of the 
 lower segment of the uterus is exposed extraperitoneally. This is 
 opened by a vertical or transverse incision, and the child's head is 
 made to present in the wound by pressure exerted upon the uterus. 
 The foetus may be extracted by traction, by forceps, or if necessary 
 by version. 
 
 By some operators the peritoneal cavity is opened, and the 
 peritoneum over the bladder, having been incised, is stripped up to 
 a sufficient extent and sutured to the parietal peritoneum at the 
 upper margin of the wound. Another modification is to cut 
 through the peritoneum and to separate the bladder from the side 
 instead of turning it down, and so expose the anterior surface of 
 the lower uterine segment. By this operation the danger of 
 infection of the peritoneum is avoided, and it is claimed that the 
 incision into the lower segment can be sutured more easily and 
 more rapidly, and that it is less likely to cause severe haemorrhage. 
 
 1 Arch. f. Gyatik., 1907, Bd. 81, lift. 1, p. 46. 
 
 58—2 
 
9i6 ' The Practice of Midwifery. 
 
 In order that the operation may be readily carried out, the first 
 stage of labour should be well advanced and the cervix fully dilated. 
 
 In cases where the uterus is definitely infected Sellheim ^ recom- 
 mends that after delivery of the child the edges of the incision in 
 the lower uterine segment should be united to the edges of the 
 abdominal incision, and that this utero-abdominal fistula, as he 
 terms it, should be left open and allowed to close spontaneously or 
 be closed finally by a plastic operation. 
 
 Doderlein ^ practises a somewhat similar operation, in which, by 
 raising the peritoneum at the pelvic brim, he obtains access to the 
 lateral extraperitoneal portions of the uterus without detaching the 
 bladder. 
 
 Post-mortem Csesarean Section. — When a pregnant patient 
 dies, and the child is living and viable, it is right for the physician, 
 with the permission of the friends, to perform Cesarean section, in 
 order to save the child. There are mythical stories of children 
 having been saved in this way hours after the mother's death. In 
 point of fact, however, the child does not remain capable of resusci- 
 tation for many minutes after her death. After more than fifteen 
 minutes it is probably useless to perform the operation. If, 
 therefore, it is to be of any avail, the practitioner must be present 
 at the time of the death, and he should obtain the consent of the 
 friends beforehand. He must also operate with whatever instru- 
 ments he has on the spot. A penknife or razor has been used in the 
 absence of more convenient implements. The incisions and mode of 
 extraction are the same as in ordinary Cesarean section. The child, 
 if alive at all, will probably have to be restored by artificial respira- 
 tion. If death takes place during labour, when the os is already 
 fairly dilated, it will be preferable to extract the child rapidly by 
 version or forceps. 
 
 PoRRo's Operation. 
 
 In Porro's operation, the main part of the uterus is removed, 
 and the danger of having a uterine wound communicating with 
 the peritoneal cavity is thus avoided. 
 
 Porro, of Pavia, having devised his method, and tested it by 
 successful experiments on animals, carried it out first in 1876 on 
 a patient having a rachitic pelvis with a conjugate diameter of 
 1^ inch. This patient recovered ; and for some time a consider- 
 able number of Porro operations were performed, especially in 
 
 1 Miinchener Med. Wochenschr., 1908, No. 42, p. 2207 ; Zentralbl. f. Gyniik., 1908, 
 No. 20, p. 641. 
 
 2 Doderlein, Zentralbl. f. Gyn., 1909, No. 4, p. 121. 
 
Caesarean Section, Symphysiotomy, Etc. 917 
 
 Italy and Germany. The term Porro's operation is now often 
 extended to the more modern variety of supra-vaginal hysterectomy, 
 in which the pedicle is dropped within the pelvis. The original 
 Porro operation will first be described. 
 
 Porro's Operation with External Fixation of Pedicle. — The 
 steps of the operation are the same as in ordinary Cesarean section 
 
 Fig. 455. — Koeberle's serre-nceud. 
 
 Fig. 456. — Guarded pin 
 for fixing stump of 
 uterus in abdominal 
 wound. 
 
 up to the incision in the uterus. It is of little consequence in 
 what direction this incision is made, since it is to be removed with 
 the uterus. If, therefore, it is concluded that the placenta is 
 situated on the anterior wall, the uterus may be first turned out, 
 and an incision on the posterior wall, or Fritsch's fundal incision, 
 made. As soon as the foetus is removed, haemorrhage from the 
 uterine wound should be temporarily checked by an elastic 
 ligature. The placenta may then be left in the uterus, and the 
 
91 8 The Practice of Midwifery. 
 
 remaining steps of the operation carried out deliberately without 
 haemorrhage. 
 
 The rest of the operation is similar to the method of hyste- 
 rectomy, which was formerly employed for the removal of the 
 uterus enlarged by fibroid tumour, the cervix being clamped as a 
 pedicle in the abdominal wall. The uterus is drawn out through 
 the abdominal wound, the intestines being kept back by an assis- 
 tant, and covered with a large flat sponge or sterilised pad. A 
 Koeberle's serre-noeud (Fig. 455), an instrument like a short 
 ecraseur, is fitted with a loop of thick soft iron wire, or what is 
 better, with a wire of "delta metal," one end of the loop fixed to 
 the moving button, the other end free. This loop is passed round 
 the lower part of the uterus and adjacent portions of the broad 
 ligaments, so that it passes below the lower end of the uterine 
 incision. It is preferable, if possible, to leave one or both ovaries. 
 In order to do this, a ligature may be placed upon the ovarian 
 artery above the ovary, and the broad ligament divided above the 
 ligature, a clamp being placed on the distal part of the vessel. The 
 free end of the loop is now seized with a pair of pliers, drawn up 
 prett}' tightly and twisted round the button. The screw of the 
 serre-noeud is then turned till the wire is tight enough to stop 
 haemorrhage, but not tight enough to cut the tissues. The uterus 
 is then cut away about an inch above the loop. If there is any 
 bleeding at this time from the stump, a little further tightening 
 of the serre-noeud will stop it. It is important for success that the 
 circulation beyond the loop should be completely cut off. 
 
 The stump of the uterus has next to be fixed as a pedicle in the 
 lower angle of the abdominal wound. Two guarded pins (Fig. 456) 
 are passed transversely through the pedicle just above the loop of 
 wire, so that the ends lie on the abdominal walls, and keep the cut 
 surface of the pedicle outside, the wire loop lying in a depression 
 just below the pins. These pins, like the wires, are now made of 
 delta metal, which does not rust or corrode. Large strong hare-lip 
 pins might be used, in the absence of pins specially constructed. 
 The abdominal sutures are then applied in the usual way above 
 the pedicle, special care being taken in the adjustment of the 
 lowest suture, so that it may bring the cut edges of the peritoneum 
 into contact with the pedicle of the uterus all round, and with 
 each other immediately above the stamp. At this spot a buried 
 suture of fine silk may be used, uniting the two edges of parietal 
 peritoneum to the pedicle on the proximal side of the wire. It is 
 well to place also one suture in the angle of the wound below the 
 pedicle, so as to infold the edges of the peritoneum there also. 
 
Caesarean Section, Symphysiotomy, Etc. 919 
 
 In the absence of the serre-noeud, the operation may be carried 
 out effectively by the permanent use of the elastic ligature. The 
 ligature is tied tightly round the lower part of the uterus, and the 
 pins are passed through immediately above the ligature. Knitting 
 needles may be used for pins, and ordinary drainage tubing for 
 elastic ligature ; and thus the operation may be performed without 
 any special appliances. 
 
 Dressing the Wound. — The short stem of the serre-noeud is 
 to be enclosed in the antiseptic dressings. The layers of gauze 
 coveiring the abdomen may be slit up to some distance from below 
 so that the stem of the ecraseur passes through the slit. Then a 
 transverse layer of gauze is laid across below the stem, and the 
 instrument itself is wrapped round with strips of gauze. The key 
 of the serre-nceud (see Fig. 455, p. 917) is kept at hand, so that 
 in case there is any haemorrhage from the stump, the nurse may 
 be able to stop it at once by giving a turn to the screw. In 
 other respects, the dressings are the same as for ordinary Csesarean 
 section. 
 
 After-treatment. — The wound should be looked at the day 
 after operation ; and the serre-noeud tightened, if there is any sign 
 of vascularity in the stump. It becomes dry and leathery on the 
 surface if circulation is properly arrested. The strangled portion 
 of the pedicle may separate about the twelfth or fourteenth day, 
 leaving a depression in the abdominal wall. Decomposition of the 
 pedicle will have begun before this. As soon as it does so, the 
 pedicle must be dressed daily or twice a day, and may be dusted 
 each time with iodoform or aristol. Any redundant portions may 
 be cut away from time to time. For the first few days a rather 
 free use of morphia may be necessary, to relieve pain caused by 
 the constriction and tension of the stump. 
 
 SUPEA-VAGINAL HySTEEECTOMY. 
 
 The operation is facilitated by the Trendelenburg position, 
 especially during the stage of stitching up the peritoneum. In the 
 absence of a special table, this may be improvised by inverting a 
 straight-legged chair on the operating table, and folding a mattress 
 over it. 
 
 After removal of the foetus, the uterus is turned out of the 
 abdomen and hsemorrhage arrested by an elastic ligature or 
 clamps to the broad ligaments compressing the vessels. Ligatures 
 are placed on the ovarian arteries, so as to preserve one or both 
 
920 The Practice of Midwifery. 
 
 ovaries, and clamps on the distal portions of the vessels. Liga- 
 tures are placed on the round ligaments, and the broad ligaments 
 are then divided on both sides, up to and including the round 
 ligaments. Next the peritoneum is divided in front from one round 
 ligament to the other, about an inch above the reflection of the 
 bladder, and stripped down with the bladder. The uterine arteries 
 are then found and ligatured, and the rest of the broad ligaments 
 and the cervix cut across. Any small vessels which bleed are tied. 
 If the cervix is expanded, and the cut surface bleeds, it may be 
 advisable to arrest bleeding by inverting and stitching together 
 the cut surfaces at the sides, but a central opening should be left 
 for drainage. The peritoneum is then stitched together over the 
 stump by a continuous suture of fine silk, so as to isolate the peri- 
 toneal cavity, and the abdominal wound is closed.^ 
 
 Panhysterectomy. 
 
 The operation is the same as the last up to the stage at which 
 the uterine arteries are tied. They are exposed by separating the 
 two layers of the broad ligament, and are tied as low down as 
 possible, the ureter, in order to avoid any risk of injuring it, being 
 exposed and if necessary dissected out. The bladder is then stripped 
 well down off the anterior wall of the cervix and off the vagina, 
 and the two utero-sacral ligaments are clamped, tied, and divided. 
 The vagina is then opened in the middle line in front or at the side 
 and separated all round from the cervix. As a rule there is some 
 bleeding from the cut angles of the lateral vaginal walls, and this is 
 arrested by ligatures passed_by means of a needle. Finally, a plug 
 of gauze may be placed in the vagina and the peritoneal edges 
 united over the plug. 
 
 The uterus may also be removed by Doyen's method of pan- 
 hysterectomy. In this operation, the uterus is drawn forward 
 over the pubes, the posterior vaginal fornix is first opened, the 
 cervix is seized with a vulsellum and pulled forcibly upwards, and 
 then the bladder is stripped from the uterus from below upwards. 
 The uterus is then separated from below upwards by incisions 
 which keep very close to the uterine wall. The cervical vessels are 
 tied separately, and the upper parts of the broad ligaments are 
 transfixed and tied as pedicles. The peritoneum is closed by a 
 purse-string suture, and the vagina can, if the operator prefer it, 
 be plugged below. 
 
 1 For a full description, with illustrations, of this and the other varieties of hysterec- 
 tomy, see Galabin's Diseases of Women. 
 
Caesarean Section, Symphysiotomy, Etc. 921 
 
 Choice of Operation. — In general the conservative Sanger 
 Caesarean section is to be preferred. The extraperitoneal operation 
 may be performed in cases where the condition of the uterine 
 contents is doubtful or where they are certainly septic and in 
 aseptic cases as an alternative to the classical operation. It has 
 also been suggested as an alternative to symphysiotomy or 
 pubiotomy in elderly primiparse where these operations are 
 contra-indicated on account of the rigidity of the soft parts. The 
 exact relation which these two varieties of Csesarean section will 
 bear to one another in the future cannot be determined at the 
 present time. Further experience of the results of the extra- 
 peritoneal operation is required to settle this question. The uterus 
 should be removed in cases of fibroid tumour or removable cancer, 
 or if it refuses to contract after exhaustion from prolonged labour, or 
 if it has been damaged in attempts to extract through the pelvis, 
 especially if it is likely that septic infection has been conveyed. 
 Panhysterectomy is only called for if the cervix is much damaged 
 or infected by sepsis, or in cases of removable cancer, or fibroid 
 tumour of the cervix. In general supra-vaginal hysterectomy is 
 preferable. The original Porro's operation has the disadvantages 
 that the sloughing of the pedicle leads to a slower convalescence, 
 and a weak point left in the abdominal wall ; and the intra-pelvic 
 treatment of the pedicle now gives a less mortality. The original 
 operation may be chosen if the operator is inexperienced in 
 abdominal surgery, since it can be performed more easily and 
 quickly. It may also be chosen in cases of irremovable cancer of 
 the cervix, in order to diminish the risk to the patient by shutting 
 off the peritoneal cavity from the uterine wound, which is apt to be 
 contaminated by septic infection from the cancer. 
 
 Vaginal Cesarean Section. 
 
 This title is given to an operation introduced by Diihrssen. The 
 patient is placed in the lithotomy position. The vulva and vagina 
 having been thoroughly cleansed, the cervix is drawn down by 
 vulsella, the posterior vaginal wall retracted, and a longitudinal 
 incision is made through the vaginal wall at the base of the 
 bladder. A transverse incision is also made across the cervix just 
 at the reflection of the bladder, and the bladder and peritoneum 
 stripped off from the front of the cervix. The cervix is then 
 divided anteriorly by a sagittal incision with scissors up to, and 
 if necessary beyond, the level of the internal os. In cases at or 
 near full term it may be necessary also to incise the posterior wall 
 
922 
 
 The Practice of Midwifery. 
 
 of the cervix. In this case Diihrssen recommends that a deep 
 incision should be made through the lateral vaginal wall into the 
 ischio-rectal fossa on one or both sides. The vaginal portion of 
 the cervix is then seized by two vulsella, drawn forward, and the 
 cervix divided in the middle line as high up as the posterior vaginal 
 fornix. The posterior vaginal fornix is then opened transversely, 
 
 Fig. 457. — Vaginal Csesarean section, showing the anterior vaginal wall, and 
 the anterior lip of the cervix divided. At the upper end of the incision 
 between the two is seen the bladder pushed up. 
 
 and the peritoneum stripped off the posterior wall of the uterus. 
 If the cervical canal or external os is undilated to begin with, the 
 two incisions together must give a length of at least 4^ inches, to 
 allow the extraction of a full-sized foetus. The incisions in the 
 anterior and posterior cervical walls are then extended as much as 
 may be necessary, the membranes ruptured, and the child extracted 
 by forceps or by version. If necessary, the placenta and membranes 
 
Caesarean Section, Symphysiotomy, Etc. 923 
 
 are extracted manually, and the incisions in the uterus are united 
 by catgut sutures. The incisions in the vaginal walls are also 
 united by sutures, a small opening being left for drainage in front 
 of the cervix. Diihrssen^ has collected 201 cases of conservative 
 vaginal Caesarean section with 28 deaths, 13*9 per cent., and 47 cases 
 of the radical operation followed by removal of the uterus, in 46 
 cases for carcinoma and in 1 case for sepsis, with 5 deaths, or 
 10'6 per cent. Of the 28 deaths in the first series 15 died of 
 eclampsia, and 10 others from causes not connected with the 
 operation. 
 
 The operation has been performed in cases of carcinoma of the 
 cervix, and in conditions calling for rapid delivery and associated 
 with the presence of tumours or with rigidity of the cervix, inter- 
 fering with its rapid dilatation. It may also be adopted if the 
 condition of the mother very urgently requires rapid delivery in 
 eclampsia or in accidental haemorrhage after rupture of the mem- 
 branes, and Bossi's or Frommer's dilator is not available. Some 
 would also choose it in preference to dilatation if the cervical canal 
 is intact and very rigid, especially if pregnancy has not reached 
 seven months. Munro Kerr considers it the best method of rapidly 
 emptying the uterus in the early months of pregnancy, but sees no 
 reason to prefer it to the abdominal operation in the later months. 
 
 Symphysiotomy. 
 
 History. — The first recorded case of symphysiotomy was per- 
 formed by Jean Claude de la Courvee in 1655 on a patient dying 
 during labour. A better-known case was one in which the operation 
 was performed by Sigault and Le Koy in 1777. The result was 
 not very satisfactory : for a vesical fistula formed, and the bones 
 did not unite. The operation did not therefore find general favour, 
 but Italian operators continued to perform it from time to time. 
 Between 1777 and 1846, 65 cases were recorded in Italy, with a 
 maternal mortality of 32"4 per cent, and a fcetal mortality of 
 64 per cent. It was taken up more actively in Italy in 1866, 
 chiefly by Morisani and Novi of Naples. From 1866 to 
 1881, 50 cases were recorded, with a maternal mortality of 20 per 
 cent, and a foetal mortality of 18 per cent. Between 1881 and 
 1885, however, the maternal mortality increased to 44 per cent. 
 Of late years the mortality has greatly diminished, probably in 
 consequence of antiseptic improvements in surgery. Fifty-two 
 
 1 Diihrssen, V. Winckel, Jlandbuch dcr Gcbuilsliiilfe, 1906, Vol. II]., Part 1, 
 p. 575. 
 
924 
 
 The Practice of Midwifery. 
 
 more recent Italian cases, up to 1893, gave a maternal mortality of 
 2 per cent, and a foetal mortality of 13"4 per cent.^ 
 
 Since 1891 the operation has been warmly advocated by Pinard 
 of Paris, and a considerable number of cases have been performed 
 in various countries. According to Harris, out of 233 operations 
 performed in various countries in 1892 — 1893, the maternal mor- 
 tality was ll'l per cent., the foetal mortality 22*7 per cent. Of 
 these, very few were performed in Britain, the majority in Italy, 
 France, and Germany. Of 275 cases collected by Munro Kerr 18 
 of the mothers died, a mortality of 6*5 per cent., and 28 of the 
 children, a mortality of 10 per cent. This mortality for the mothers 
 
 Half size 
 Fig. 458. — Separation of bones in symphysiotomy. 
 
 is about the same as that of Cfesarean section, but that of the 
 children represents a considerably higher risk, for Caesarean section 
 performed at an early stage of labour is almost certain to save the 
 child. 
 
 The disfavour with which the operation was at first received is 
 explained by the unfavourable results of the earlier cases, as 
 regards children no less than as regards mothers. It also appeared 
 theoretically that, in a flattened pelvis, but little increase of the 
 sacro-pubic diameter could be obtained by dividing the symphysis. 
 It is now recognised that the field of the operation is in moderate, 
 
 1 See Harris, American Journal of Medical Sciences, March, 1893 ; Fasbender, 
 Geschichte der Geburtshiilfe, 1906, p. 867 ; Munro Kerr, Operative Midwifery, 1908, 
 p. 394. 
 
Caesarean Section, Symphysiotomy, Etc. 925 
 
 not in extreme, contractions of the conjugate ; and that, in the 
 puerperal pelvis, owing to the relaxation of the joints, a wider 
 separation of the pubic bones can be safely obtained than appeared 
 probable d ijriori, or than would be possible apart from pregnancy. 
 Thus the central mass of the head passes in the gap between the 
 separated pubic bones, and does not enter even the enlarged sacro- 
 pubic diameters at all, as shown in Fig. 458. 
 
 Indications for the Operation. — It appears that the smallest 
 conjugate for which the operation can reasonably be recommended 
 is about 3 inches (7'5 cm.) ; although Pinard considers it available, 
 in the simple flat pelvis, down to 2| inches, and I have myself 
 performed it successfully, though with considerable laceration of 
 vagina, with a conjugate of 2J inches. In Fig. 458 is shown the 
 effect of the operation in a flattened pelvis with slight general 
 contraction, the conjugate being 2f inches. Allowing \ inch for 
 soft parts, a circle of 3| inches diameter will generally be required 
 for the passage of a full-sized foetal head. The corresponding 
 separation of the pubic bones, as shown in the figure, is fully 
 2f inches, and the bones must also be separated at the anterior 
 margins of the sacro-iliac joints to the extent of at least \ inch. 
 
 The improved results of Cgesarean section render that operation 
 preferable as a first choice, when preparations are made for opera- 
 tion before labour. Csesarean section has also the advantage that 
 it allows the patient, if she desires it, to be rendered sterile in 
 future, and free from the risks of future labours. 
 
 Symphysiotomy may be performed in the interest of the child 
 in slight or moderate pelvic contractions when labour has already 
 been prolonged, and attempts to extract by forceps have been made 
 and failed. In these circumstances the risk is likely to be less 
 than that of Caesarean section. It is essential that the child should 
 be alive and uninjured, the cervix fully dilated, and the size of the 
 pelvis such that there is a reasonable probability of a living child 
 being delivered after the performance of the operation. It should 
 not, however, be undertaken if there is reason to believe that septic 
 infection has already occurred, nor when there is any likelihood 
 that the child has been injured by repeated attempts to deliver with 
 forceps. 
 
 Some authorities recommend that it should be practised, in the 
 interests of the mother, when there is difficulty in extraction after 
 craniotomy, but at the present day most operators would prefer one 
 or other of the varieties of extraperitoneal Caesarean section. 
 
 According to Pinard, if the pubic bones are separated 6 cm. 
 
926 
 
 The Practice of Midwifery. 
 
 (2f inches), a distance which should not be exceeded, the measure- 
 ments from the sacral promontory to their ends are increased 
 15 mm, (f inch), and the total gain, by the projection of the head 
 through the gap, is 22 mm., or | inch. Biermer^ found, by 
 experiments on puerperal pelves, that separation of the pelvic bones 
 to distances varying from 7 to 9 cm. caused luxation of the sacro- 
 iliac joints. Caution must therefore be used in carrying the separa- 
 tion beyond 6 cm. Doderlein^ has calculated that the area of the 
 pelvic brim is increased from 105 to 155 qcm. when the ends of 
 the pubic bones are separated 6 cm. It must be remembered that 
 the movement of the innommate bones is one of rotation downwards 
 rather than outwards.^ Biermer gives the following table ; it will 
 be seen that he estimates the gain in the antero-posterior diameter 
 lower tha^j Pinard. It is also evident that the gain in the trans- 
 verse diameter is much more marked, and that therefore the 
 operation is specially suited for generally contracted pelves, in 
 which the transverse diameter forms a main part of the difficulty. 
 
 Separation at 
 
 symphysis. 
 
 cm. 
 
 Increase of 
 
 antero-posterior diameter, 
 
 cm. 
 
 Increase of 
 
 transverse diameter 
 
 cm. 
 
 2 
 
 •25 . 
 
 1 
 
 3 
 
 •5 
 
 1-5 
 
 4 
 
 •65 ,. 
 
 2 
 
 5 
 
 •83 . 
 
 2-25 
 
 6 
 
 . ri 
 
 3 
 
 7 
 
 . 1^4 
 
 31 
 
 The operation appears to be followed by less inconvenience in 
 multiparfe than in primiparse, on account of the rigidity of the soft 
 parts in the latter. Thus Caruso reports 22 cases, in which all 
 the mothers recovered, and 20 children were born alive. Of 12 
 multiparse all passed through a normal puerperium. Of the 10 
 primiparae, 8 suffered some pathological complication, and 3 of them 
 had vesical fistulae. 
 
 Preparations. — The os uteri should be as fully as possible 
 dilated. If the membranes have ruptured prematurely, and the 
 head cannot descend upon the os to dilate it, being arrested above 
 the brim, it is desirable to dilate the os with Champetier de Eibes' 
 or Barnes' dilators. The pubes and labia majora should be shaved, 
 and pubes and vagina disinfected with perchloride of mercury 1 in 
 
 1 Zentralbl. f. Gynak., 1892, No. 51, p. 993. 
 
 2 Zentralbl. f. Gynak., 1893, No. 23, p. 490. 
 
 3 Sandstein, Trans. Obst. Soc. Edin., 1902, p. 68. 
 
Cassarean Section, Symphysiotomy, Etc. 927 
 
 1,000. It is not a contra-indication that labour has been somewhat 
 prolonged, provided that there has been no septic infection and the 
 child's condition is good. If forceps are tried first, no great force 
 should be used with them, otherwise the child's life may be 
 endangered. 
 
 Instruments.— The instruments required are scalpels, scissors 
 dissecting forceps, pressure forceps, curved needles and needle- 
 holder, sutures of silver wire, fishing gut, and of chromicised gut 
 or fine silk, and a special symphysiotomy knife (Fig. 459), or a 
 blunt-pointed bistoury with cutting edge to the 
 end. It is desirable to have also Pinard's 
 registering separator for the pubic bones, and a 
 chain saw. There should be three assistants 
 besides the anesthetist: one to assist the 
 operator, two to stand at the sides of the patient 
 and press the innominate bones together when 
 required. 
 
 The Operation. — The operator stands 
 
 between the patient's thighs. An incision is 
 
 made about 3 inches long in the median line, 
 
 commencing 1| inch above the pubes, and 
 
 ending just above the clitoris or mclined 
 
 laterally at the side of the chtoris outside the 
 
 nympha. Bleeding points are secured by 
 
 pressure forceps. If there is much venous 
 
 oozing, as is often the case, a plug of sterilised 
 
 gauze should be packed into the wound after 
 
 the symphysis has been divided. The pyra- 
 
 midahs and recti muscles are then separated 
 
 from the top of the pubic bones, sufficiently to allow the operator 
 
 to pass his mdex finger behind the symphysis, and protect the 
 
 bladder from the tip of the knife. The operator then seeks for 
 
 the symphysis and divides it from above downwards, includina 
 
 the mferior ligament, with the curved blunt-pointed knife intro" 
 
 duced by Galbiati (Fig. 459), or with a blunt-pointed bistoury 
 
 keeping the finger between the knife and the bladder The 
 
 Italian operators, however, divide the symphysis from below 
 
 upward During the cutting through the symphysis, a bladder 
 
 sound should be held in the urethra, and should draw it somewhat 
 
 to one side, the opposite side to that to which the cutaneous incision 
 
 has been made to incline at its lower part. As soon as the division 
 
 Fig. 459.— Symphy- 
 siotomy knife. 
 
928 
 
 The Practice of Midwifery. 
 
 is complete, the bones generally spring apart suddenly to a distance 
 of f — 1 inch. 
 
 Occasionally operators have failed to divide the symphysis with 
 a knife, and have been obliged to have recourse to a chain saw. 
 This has probably been due, not to anchylosis, but to the operator 
 failing to find the symphysis, which is often not exactly in the 
 middle line. 
 
 When the symphysis has been divided, Pinard's registering 
 separator (Fig. 460) may be introduced, to aid the separation and 
 indicate its amount. By eversion of thighs, and, if necessary, 
 by traction upon the ilia, a separation of at least 4 cm, (If inch) 
 
 should be obtained before traction is com- 
 menced. The separation of the bones is 
 increased if the patient is placed in 
 Walcher's position (see p. 837), with the 
 legs hanging vertically ; and this position 
 also adds to the increase of space at the 
 pelvic brim. 
 
 Whenever possible, the labour should 
 be allowed to terminate naturally, and 
 especially in primiparfe where the soft 
 parts are rigid, or in multiparse where 
 they are still not readily dilatable. If, 
 however, there is any urgency, the foetus 
 should be extracted by forceps, axis- 
 traction forceps being the best for the 
 purpose. It is advisable to rotate the 
 head if possible, so that it is extracted 
 with its long diameter transverse, not 
 antero-posterior. If the indicator shows 
 that the separation of the pubic bones reaches 6 cm., the assis- 
 tants should support the ilia at each side. If the head descends 
 covered by the cervix, ample time should be allowed, and the rim 
 of the cervix pushed back by the fingers. After the head has 
 passed the brim, the assistants should press the ilia together, and 
 endeavour to diminish the separation. Otherwise the anterior part 
 of the vagina, unsupported by the bones, is apt to tear into the 
 wound. Care should be taken to draw well downward toward the 
 perineum, and if there is any indication of commencing tears of the 
 tissues of the anterior vaginal wall there should be no hesitation in 
 making free vulvo -perineal incisions. 
 
 Four deep sutures of silver or silkworm gut should be used to unite 
 the tissues in front of the pubes, care being taken not to nip the 
 
 Fia. 460. — Pinard's register 
 ing separator for symphy 
 siotomy. 
 
Csesarean Section, Symphysiotomy, Etc. 929 
 
 bladder between the ends of the bones, including the dense tissue 
 close to the bone. I have drilled the bones and wired them together 
 with thick silver wire, in order to secure perfectly close union 
 without further trouble, but operators have not generally adopted 
 this plan. The rest of the wound may be closed by fishing-gut 
 sutures. Any laceration of vagina, bladder, or urethra must also 
 be closed by fishing-gut or silver wire. It is often a good plan to 
 drain the wound with a piece of gauze. A firm belt, if possible a 
 canvas belt with buckles, is placed round the pelvis, the sutures 
 are removed at the end of a week, and the patient is kept in bed 
 at least three weeks. After the operation, the uterus and vagina 
 are washed out with lysol, 1 per cent. The same or a weaker 
 solution is used as a vaginal douche twice a day. Pinard places a 
 tampon of iodoform gauze in the vagina. 
 
 Prognosis. — The accidents likely to follow the operation are 
 some interference with the patient's power of walking, htemorrhage, 
 injuries to the bladder and urethra, tears of the vagina, and the 
 occurrence of septic infection. Interference with locomotion is the 
 exception. In 37 cases examined subsequently to the operation, 
 and recorded by Thies,^ there was no trace of any permanent injury, 
 although even in cases where the wound healed by first intention 
 there was some broadening of the symphysis in the majority. 
 
 Not one of Munro Kerr's 9 cases had her walking impaired in the 
 slightest degree.^ 
 
 Bleeding from the numerous veins behind the symphysis pubis 
 may be profuse and troublesome to arrest, is also difficult at times 
 to avoid, and in one case, at any rate, has led to a fatal result. 
 The most common danger is that of injuries to the bladder or the 
 urethra; some of these are caused by the operation itself, but 
 more often they occur during the extraction of the child. They 
 happen more frequently in primiparse than in multiparas, and so 
 marked is this that some operators do not perform the operation 
 in a primipara. Zweifel and Pinard, however, record 65 and 100 
 cases of symphysiotomy respectively without any injury to the 
 bladder. 
 
 If tears in the unsupported tissues of the anterior vaginal wall 
 occur, they very frequently communicate with the divided ends of 
 the bones, so that the case is really one of a compound fracture, 
 and the danger of suppuration and necrosis is considerable. It is of 
 the utmost importance, therefore, that all possible means should be 
 
 1 Arcliiv f. Gynak., 1908, Bd. 84, Hft. 1, p. 99. 
 
 2 Munro Kerr, Operative Midwifery, p. 395. 
 
 M. 59 
 
930 
 
 The Practice of Midwifery. 
 
 taken to avoid such injuries, and it is always best when possible to 
 allow the labour to be completed naturally. 
 
 Thies maintains that the contention of Zweifel and Pinard that 
 there is a permanent enlargement of the pelvis after symphysiotomy 
 is correct, and affirms that the spontaneous delivery of large children 
 occurs more frequently by 50 per cent, after symphysiotomy than 
 before it. In 14 of the cases examined by him there was a definite 
 increase in the conjugate diameter, and in 24 in the transverse 
 diameter. 
 
 Subcutaneous Symphysiotomy. — Two operations of subcu- 
 taneous symphysiotomy are described. Of these the best is the one 
 
 Fig. 461. — Bumm's subcutaneous method of performing pubiotomy, the 
 needle being introduced from below upwards under guidance of the 
 finger in the vagina. (Bumni, Grundriss der Gcburtshilfe.) 
 
 practised by Herman.^ He uses a sharp pointed tenotomy knife, 
 which he introduces through the mucous membrane opposite the 
 middle of the symphysis pubis. After cutting downwards until 
 the ligamentum arcuatum has been reached and divided, the cutting 
 edge is turned upward and the rest of the symphysis divided. The 
 only difficulty experienced as a rule is that of dividing the hga- 
 mentous fibres at the top and the bottom of the joint, and this can 
 be overcome by pressing the fibres against the edge of the knife. 
 In the second, known as Ayres' operation, a tenotomy knife is 
 introduced in front of the joint to its upper end. A blunt pointed 
 bistoury is then substituted for this and the joint divided from above 
 downwards under the guidance of a finger passed into the vagina. 
 
 1 Herman, Difficult Labour, p. 426. 
 
Caesarean Section, Symphysiotomy, Etc. 931 
 
 The first operation is a very good one, and has given excellent 
 results in the hands of Herman and Buist. Neither allows the 
 placing of sutures to unite the tissues in front of the pubic bones, 
 but there is no evidence that this is at all a serious drawback, nor 
 does it appear to have much influence in affecting the subsequent 
 healing. 
 
 Pubiotomy. — Of late years this operation, first described by 
 Stoltz in 1844, has come into prominence as an alternative to 
 symphysiotomy. It is said to be attended with less danger of 
 injury to the bladder and soft parts, and to be easier to perform. 
 It consists in dividing the pubic bone instead of the symphysis 
 pubis, and brings about the same increase in the pelvic measure- 
 ments. Originally practised by the open method after the bones 
 had been exposed by an incision, it is now almost always per- 
 formed in a manner more or less strictly subcutaneous. The 
 operation as practised by Doderlein consists in an incision 
 2 to 3 cm. long being made over the pubic spine, and through 
 this the index finger is introduced to separate off the bladder from 
 the posterior aspect of the bone. A handled needle is passed down 
 behind the j^ubis and made to emerge on the outer surface of the 
 labium majus ; it is threaded with a Gigli's saw and withdrawn. 
 The bone is readily sawn through, and when divided the ends at 
 once separate to the extent of two-thirds of an inch or so. Bumm's 
 method is even more simple. A specially curved needle is passed 
 round the pubic bone from below upwards under guidance of a finger 
 in the vagina and kept as close to the bone as possible. It is made 
 to emerge through the soft parts at the upper border of the bone, 
 and is then threaded with the saw and withdrawn. Leopold makes 
 a small puncture on to the spine of the pubes, and passes the 
 needle from above downwards instead of from below upwards. 
 
 To prevent hsemorrhage, after the bone has been divided, pressure 
 is made on the two small punctures, and a plug is placed in the 
 vagina. The cbild can be delivered with forceps if the soft parts 
 are fully dilated, but as a general rule it is best to allow delivery 
 to occur spontaneously. 
 
 It is difficult at present to judge of the merits of this operation, 
 but the dangers certainly appear to be less than those of 
 symphysiotomy. 
 
 Doderlein^ records 294 cases of which 77 were done by the open 
 
 1 Dfklei-lein, MiiiiclicMcr Med. Woclienschr., 1907, No. 24, s. 119.5 ; Leopold, 
 Miinchener Med. VVochenscbr., 1907, No. 40, s. 200(1 ; Bumm, Zentralbl. f. Gyn., 1908, 
 No. 19, p. 609. 
 
 59—2 
 
932 
 
 The Practice of Midwifery. 
 
 method. The mortality of these was 10*1 per cent., that of 21'7 
 subcutaneous operations 4-1 per cent. Of the 9 deaths 5 were due 
 to infection, 2 to thrombosis and embolism, 1 to embolism, and 1 to 
 haemorrhage. Leopold, however, records 60 cases with no maternal 
 mortality and only 4 foetal deaths ; and Bumm has practised 
 the operation in 53 cases with only 1 death, or a total of 113 cases 
 
 Fig, 462. — The Gigli's saw in position for sawing through the bones. 
 (Bumm, Grundriss der Geburtshilfe.) 
 
 with 1 maternal death (see p. 754). The dangers of the operation 
 are practically the same as those occurring after symphysiotomy, 
 but the after-treatment is simpler. The pelvis is encircled with a 
 strong bandage, the knees are tied together with the thighs 
 adducted, and Bumm recommends the introduction of a self- 
 retaining catheter for a few days. Healing of the bones usually 
 takes place at first by fibrous tissue, afterwards by callus. 
 
 Of 225 cases recorded by Doderlein 15, or 6'6 per cent., of the 
 children were born dead, but in all these cases instrumental 
 
■ Caesarean Section, Symphysiotomy, Etc. 933 
 
 delivery had been practised, and there can be no doubt that 
 whenever possible spontaneous delivery should be allowed to occur. 
 In spite of the excellent results obtained by the strictly subcutaneous 
 method of Bumm, the contention that it is more likely to be followed 
 by injuries to the bladder must be allowed.^ Undoubtedly the 
 risk of injury to the soft parts both after symphysiotomy and 
 pubiotomy is greatest in primiparse, and in this class of patient 
 delivery should never be completed artificially if it can be avoided. 
 The indications for the operation are the same as those for 
 sj'mphysiotomy, and the lowest conjugate in which it can be 
 recommended is one measuring 3 inches, or 7 '5 cm. 
 
 1 Blacker, Lancet, March 19, 1910, p. 778. 
 
Chapter XXXVII. 
 ACCIDENTS DURING AND AFTER LABOUR. 
 
 EUPTUEE AND LaCEEATION OF THE GeNITAL CaNAL. 
 
 Laceeation may take place at any part of the genital canal, but 
 the most important varieties are ruptures of the uterus and 
 adjacent portion of the vagina which involve the peritoneum, 
 lacerations of the cervix, and lacerations of the perineum and 
 vulva. 
 
 EuPTUEE OF THE UtEEUS OR VaGINA INVOLVING THE PeEITONEUM. — 
 
 Eupture of the uterus reaching the peritoneum, complete rupture, 
 is one of the most dangerous accidents of labour. Eupture of the 
 vagina into the pouch of Douglas is closely allied to it, and is 
 frequently combined with rupture of the uterus itself. 
 
 Frequency. — The frequency of rupture of the uterus has been 
 variously estimated at from 1 in 1,300 to 1 in 3,403 deliveries 
 (JolljO- Ii^ the Guy's Hospital Charity, when assistance to labour 
 was given very sparingly, forceps cases being only about 1 in 200 
 deliveries, there were seven cases of rupture of the uterus or 
 vagina in 23,591 deliveries, or 1 in 3,371, a result closely agreeing 
 with that obtained by Jolly from the statistics of 782,741 labours 
 in Paris. In the following ten years, forceps cases being 1 in 93, 
 cases of rupture of the uterus or vagina were only 1 in 5,098. 
 
 Causation. — Euptuee dueing Peegnancy.^ — Very rarely rupture 
 of the uterus has been met with during pregnancy. The majority 
 of these cases have followed either a Cesarean section,^ a 
 previous rupture of the uterus, or some injury to the uterine wall 
 during the performance of the operation of curettage or the 
 removal of an adherent placenta. Occasionally the rupture has 
 followed a fall, as in a case recorded by Phillips,^ and in other 
 instances the cause has apparently been an undeveloped condition 
 of the uterus. 
 
 1 Peham, Zentralbl. f. Gvnak., 1902, No. 4, p. 87; Couvelaire, Annales de 
 Gyndcologie et d'Obst^t., 1906, Vol. III., p. 148. 
 
 2 Taigett, Trans. Obst. Soc. London, 1900, Vol. XLII., p. 242 ; Wertheim, von 
 Winckel, Handbuch der Geburtshiilfe, Bd. 2, Hft. 1, p. 4C8. 
 
 3 Phillips, Lancet, May 8, 1909, p. 1320. 
 
Accidents during and after Labour. 935 
 
 In a case recorded by Leopold ^ the uterus probably ruptured at 
 the fourth month, the child escaping into the abdominal cavity 
 and the placenta remaining in utero, and the pregnancy continued 
 
 vter^xs 
 
 Retraction ring 
 
 esoended 
 
 Retraction 
 ring 
 
 Fig. 4C.3. — Over-distension of the lower uterine segment in transverse 
 presentation. (Bumm.) 
 
 to term, when the child died. Various conditions of the uterine 
 muscle have been described as present in these cases, viz., fatty 
 degeneration, hyaline degeneration, deficiency of the elastic fibres. 
 
 1 Leopold, Arch. f. Oynlik., ]8!)fi, Bd. 52, p. :57f;. 
 
936 The Practice of Midwifery. 
 
 and a condition of interstitial myositis. In this variety of rupture 
 the tear most commonly is situated in the upper segment of the 
 uterus, in contrast to the variety occurring during labour, when it 
 is usually situated in the lower uterine segment. When due to the 
 presence of scar tissue in the uterine wall the rupture tends to 
 occur in the later months, and when due to maldevelopment of the 
 uterus, generally within the first five months of the pregnancy. 
 
 Spontaneous Euptuee during Labour. — In this case the 
 rupture is usually caused by a violent contraction of the uterus, 
 which is unable to cause advance of the foetus, and proves too 
 strong for the resistance of the thinned portions of the uterus or 
 the vagina. Among predisposing causes are weakness from mal- 
 development, malnutrition, or possibly fatty degeneration, of the 
 part where rupture takes place. Inefficient action of the auxiliary 
 muscles also promotes rupture, because the auxiliary forces, tending 
 to depress the whole uterus at each pain, take some of the strain 
 off its attachments to the pelvis. Laxity of the abdominal walls, 
 or their being overloaded with fat, is therefore also a predisposing 
 cause. Another important cause is obliquity of the uterus. Any 
 deviation of the uterus from the axis of the genital canal at the 
 level where the head, or other presenting part, is lying, diminishes 
 the efficacy of the force in causing advance of the foetus. It is 
 therefore liable to evoke a more vigorous contraction of the uterus 
 than would otherwise be necessary to complete labour. At the 
 same time the deviation causes a certain proportion of the force to 
 be uselessly exjjended in pressure on the opposite wall of the 
 genital canal, and therefore increases the liability to rupture at that 
 part. Thus, if there is a deviation of 30°, there is a useless 
 pressure on the opposite wall of the genital canal equal to one-half 
 of the expulsive force. 
 
 In the great majority of cases rupture is preceded by an 
 excessive stretching and thinning of the lower distensible segment 
 of the uterus. In very excej)tional cases this may occur even in 
 the first stage of labour. Much more frequently it happens during 
 a second stage, jn'olonged in consequence of obstruction to the 
 advance of the foetus. As previously explained (see pp. 621, 622), 
 the strong contractile portion of the uterus gradually retracts over 
 the foetus, the retraction ring and internal os uteri become more 
 and more elevated, and the distensible part of the uterus becomes 
 stretched longitudinally as well as laterally, and thus greatly 
 thinned. This distensible portion consists of the cervix, and of 
 the lower segment of the body of the uterus immediately above 
 
Accidents during and after Labour. 937 
 
 the internal os which has to be expanded to allow the passage of 
 the foetus. The most frequent causes which lead to the over- 
 stretching are disproportion between the fcetus and the pelvis, 
 hydrocej)halus, and unrecfcified shoulder or transverse i)resentations. 
 The tissue which gives way may have been weakened by the 
 effects of prolonged pressure against the promontory of the sacrum 
 or other part of the pelvic wall. The risk of rupture is of course 
 increased if the action of the 
 uterus is excessively violent, 
 either in consequence of great 
 suscejjtibility of the patient to 
 reflex stimulus, or of the inju- 
 dicious administration of ergot 
 or other oxytocic remedy. 
 
 In comparatively rare cases 
 rupture takes place suddenly 
 and unexpectedly without any 
 protraction of labour, or great 
 disproportion between the foetus 
 and the j)elvis. It must be 
 explained in these cases by a 
 sudden and excessively violent 
 contraction of the uterus, 
 probably associated with some 
 deviation of its axis, the 
 presence of a placenta prsevia, 
 scar tissue the result of a 
 XDrevious laceration, overstretch- 
 ing of the uterine wall at a 
 previous confinement, or some 
 degenerative changes in the 
 tissues which give way. This 
 may occur even before rupture 
 of the membranes,^ and I have 
 met with two instances in which 
 
 rupture occurred not long after the escape of the liquor amnii and 
 before the head had descended into the pelvis, in women who had 
 previously borne many children without much difficulty. In one 
 the accident haj^pened when the woman was straining upon a night- 
 stool, and there was reason to believe that, in both, the uterus was 
 anteverted at the time. The rupture in each case was not through 
 any over-distended cervix, but across the vagina, at its Junction with 
 
 1 Ooldner, MoimlsHchr. f. Geburts. u. Gyn., I'JDH, P.d. IH, p. 491. 
 
 Fig. 464. — Eupture of cervix and lower 
 uterine segment. Breech presentation, 
 spontaneous delivery ; tear probably 
 caused by after-coming chin. (Univ. 
 Coll. Hosp. Med. School Mus.) 
 
938 The Practice of Midwifery. 
 
 the cervix. It is clear that, in anteversion of the uterus, when the 
 head is lying above the brim, on account of slight pelvic 
 contraction, esi^ecially when there is also a projecting sacral pro- 
 montory, the uterine force may drive the head, not downwards into 
 the pelvis, but against the promontory. Wlien rupture takes place 
 the head may be deflected uj)wards by the promontory, and the whole 
 foetus may escape into the peritoneal cavity, with the head 
 uppermost. 
 
 Traumatic Eupture.— Eupture may also be brought about by 
 efforts to deliver artificially, esj)ecially by the attempt to turn in 
 shoulder presentations long after the escape of the liquor amnii, 
 or by the performance of any obstetric operation without an 
 adequate amount of dilatation of the cervix. The rupture, in such 
 cases, may be a longitudinal rent extending from the edge of the 
 cervix into the uterus, or may take place, like a spontaneous 
 rupture, in the stretched segment of the uterus. 
 
 Euptures of the uterus are more common in multiparas than in 
 primiparge, and in women over thirty years of age than in younger 
 women. The reason is that, in multiparse, and in older women, 
 laxity of the abdominal walls, deviation of the uterus, and degene- 
 ration of tissue are more likely to exist. According to Bandl, only 
 11 per cent, of all cases of rupture occur in primiparte, while 
 Merz found in 330 cases 6 per cent, occurring in j^rimiparse. 
 
 In 160 cases of rupture of uterus collected by Merz,^ 70, or 43*6 
 per cent., were due to contracted pelvis ; 26, or 16"2 per cent., to 
 neglected transverse presentations ; 21, or 13*1 per cent., to 
 operative procedures ; 18, or ir2 per cent., to hydrocephalus. 
 
 Pathological Anatomy, — Eupture almost always commences in 
 the distended part of the uterine wall, the lower uterine segment, 
 but it may extend upwards to some extent from this into the body 
 of the uterus. In some exceptional cases rupture may commence 
 in the body of the uterus, as when there is a weakened portion of 
 the wall in association with a fibroid tumour, or when the cicatrix 
 of a former Csesarean section gives wa}'. The initial rupture is 
 necessarily transverse to the line of greatest tension. Thus, in 
 cases of hydrocephalus or shoulder presentation, when too bulky a 
 mass is forced down into the cervix, the line of rupture is fre- 
 quently longitudinal. Otherwise it is more generally transverse, or 
 partly transverse and partly longitudinal, following an oblique 
 direction. Eupture may take place at any part of the uterine 
 wall, but is more frequent posteriorly because the posterior wall 
 
 1 " Zur Behandlung der Uterus Kuptur," Arch, f. Gyn., 189i, XLV., p. 181. 
 
Accidents during and after Labour, 939 
 
 is most thinned, as shown in Fig. 132, p. 221. If anterior, it may 
 separate the uterus from the bladder, or may even involve the 
 latter.^ Generally it extends more or less to one side, involving 
 the broad ligament. Eupture is commoner toward the left side, 
 because the occiput is more often directed that way, and because 
 in shoulder presentation the head is more often to the left on 
 account of the normal right obliquity of the uterus. The rupture 
 
 Fig. 465. — Rupture of cervix, lower uterine segment and posterior vaginal 
 fornix. Shoulder presentation, dead child delivered by internal version. 
 Death forty-five minutes after delivery. (Univ. Coll. Hosp. Med. 
 School Mus.) 
 
 may involve the vagina and the cervix together. When the vagina 
 alone is implicated, the line of rupture is generally transverse, 
 near the line of union with the cervix (Fig. 465). 
 
 When rupture has taken place, the uterus may retract off the 
 foetus, expelling the foetus either partially or wholly through the 
 rupture into the peritoneal cavity, and sometimes the placenta 
 also. This is more likely to take place if the rupture occurs 
 when the head is still above the brim. The placenta may be 
 
 1 Munro Kerr, Operative Midwifery, l'J08, p. 029. 
 
940 
 
 The Practice of Midwifery. 
 
 expelled into the peritoneal cavity when the foetus is delivered 
 through the vulva, or the converse may happen. 
 
 Symptoms and Course during Pregnancy. — In cases occurring 
 during pregnancy not due to trauma, there may at first be few or 
 no symptoms. In the majority of these cases, however, and in 
 those occurring early in labour, the typical symptoms are present. 
 
 Fig. 466. — Rupture of the lower uterine segment, with large subperitoneal 
 hsematoma. Flat pelvis, conj. vera, 3J inches. High forceps, perforation 
 and delivery by cranio-tractor at full term. Death eleven hours after 
 delivery. (Univ. Coll. Hosp. Med. School Mus.) 
 
 In all cases of obstructed labour, when the symptoms of this 
 condition which have already been described (see Chapter XXVI.), 
 are present, the possibility of rupture of the uterus occurring should 
 be borne in mind. In spontaneous rupture the condition is often 
 not recognised until after the child has been born. 
 
 If an extensive rupture takes place suddenly, especially when 
 the child escapes through the tear, the patient generally feels a 
 sudden acute pain and sensation of tearing. The .pains, which 
 generally have been violent up to that time, cease suddenly and 
 completely. Gradually increasing continuous abdominal pain, often 
 
Accidents during and after Labour. 941 
 
 unilateral, is substituted for the rhythmical pains of labour. The 
 pulse becomes rapid, and the anxious face, collapse, and often 
 vomiting and extreme pallor, indicate shock and internal haemor- 
 rhage. There is haemorrhage from the vagina, and the presenting 
 part recedes. In the majority of cases, when the foetus is still 
 above the brim, it passes away out of reach through the rent into 
 the peritoneal cavity. 
 
 When the rupture is more gradual, being extended by successive 
 pains, there may not be any sign making it obvious exactly when 
 the accident has occurred, and the pains cease more gradually. In 
 all cases, however, when the rupture is complete, the pains cease, 
 there is haemorrhage from the vagina, and a rapid pulse. If the 
 presenting part is low in the pelvis, it may remain without obvious 
 recession, but merely cessation of advance. In rare cases rupture 
 has been found after spontaneous expulsion of the foetus, having 
 taken place in the final pain. 
 
 Diagnosis.— A probable diagnosis from the symptoms above 
 described is generally easy. It is to be completed by passing in 
 the hand and feeling the rent, and the empty uterus, if the foetus 
 has escaped into the abdomen. The outline of the foetus may also 
 be felt through the abdominal wall and the uterus as a separate 
 mass. If the presenthig part still occupies the vagina, the 
 diagnosis can only be made from the symptoms, until delivery has 
 been completed. In cases occurring during pregnancy a diagnosis 
 of a ruptured extra-uterine gestation is very likely to be made, 
 while those occurring early in labour may be difficult to distinguish 
 from cases of concealed accidental haemorrhage. 
 
 Prognosis. — The prognosis is extremely unfavourable. There 
 is so much shock, and generally such copious internal haemorrhage 
 from the rent, that the patient often sinks before there is any 
 opportunity for giving surgical aid. Moreover, the repair of the 
 rent is itself often very difficult. Again, unless abdominal section 
 is performed, there is blood remaining in the peritoneal cavity. 
 The mortality has been variously estimated at from 64 to 82 per 
 cent.^ The child is inevitably lost in all cases in which it escapes 
 through the rupture. 
 
 Death sometimes takes place within a few hours from haemor- 
 rhage and shock. More frequently it occurs after three or four 
 days from septic peritonitis. The danger is greater when the rent 
 
 1 Von Walla, Zentralbl. f. Gyniik., 1900, No. 19, p. .002 ; Ivanoff, Annales de Gyn. 
 et d'Obstet, August, 1904, p. 449. 
 
942 " The Practice of Midwifery. 
 
 has been enlarged by the passage of the foetus through it into the 
 abdomen. 
 
 Prophylaxis. — The most important part of prophylaxis con- 
 sists in affording timely aid by forceps or other means in all cases 
 of obstructed labour, especially when any contraction of the pelvis 
 is discovered, and in avoiding the administration of ergot in all 
 such cases. The necessity for timely interference is especially to 
 be borne in mind when the pains appear to be excessively strong, 
 without producing any advance of the foetus. The patient should 
 not, however, be checked from bearing down in such cases, since 
 the action of the auxiliary muscles tends to diminish both the 
 thinning of the lower uterine segment and the risk of rupture, 
 as already explained (see p. 936). In shoulder presentations and 
 in hydrocephalus early diagnosis and treatment are of the utmost 
 importance. A useful indication of danger is the recognition 
 through the abdominal wall in protracted labour of the transverse 
 line of depression (Bandl's ring) at some height above the pubes 
 (see p. 621). If this is well marked and elevated near to the 
 level of the umbilicus, it proves that the lower segment of the 
 uterus is dangerously thinned. If it is detected in protracted 
 labour, delivery should be effected at once with the least possible 
 danger to the mother, while in head presentations version should 
 be avoided, or only attempted with great caution. 
 
 Treatment. — If the child remains within the uterus, the 
 diagnosis of rupture can generally be made only from the 
 symptoms. Kuj)ture being suspected, the child should be extracted 
 as rapidly as possible. If extraction with forceps meets with any 
 difficulty, craniotomy should be performed without hesitation, 
 since the child is rarely saved after rupture has taken place. The 
 safest instrument for extraction afterwards is craniotomy forceps, 
 since the j)osition of the outer blade can be exactly adjusted by 
 the fingers, while the cephalotribe might possibly be passed 
 through the rupture, and injure the maternal structures. It is 
 well to keep the patient in the dorsal position throughout the 
 operation, as well as afterwards. Air is then not so likely to be 
 sucked into the peritoneal cavity in respiration, and less blood 
 will gravitate into it. 
 
 After extraction of the child, the placenta should be removed 
 quickly, the hand being introduced for the purpose if necessary, 
 lest it should escape into the peritoneal cavity. If it has already 
 done so, it may be drawn back through the rent, if this can be 
 
Accidents during and after Labour. 943 
 
 effected easily without risk of injuring the intestines. Otherwise 
 the presence of the placenta in the peritoneal cavity may deter- 
 mine the balance of advantage in favour of performing abdominal 
 section, and removing it by that means. The decision as to the 
 best means of treating this class of case must depend to a large 
 degree upon the position and the extent of the laceration and the 
 size of the opening by which it communicates with the peritoneal 
 cavity. 
 
 If the laceration is a limited one and the opening into the 
 peritoneum small, probably the best treatment is to apply a plug 
 of antiseptic gauze for the purpose of arresting haemorrhage and 
 securing drainage. If, on the other hand, the tear is large or the 
 peritoneum widely opened, abdominal section may be expected to 
 give the best results in those cases in which the condition of the 
 patient will allow of such an operative procedure being carried out. 
 Only too often the condition of the patient is such that no operative 
 interference of any kind is possible. 
 
 It is exceedingly difficult, and often indeed impossible, to jDlug a 
 large tear in the uterine wall, perhaps communicating widely with 
 the peritoneal cavity, so firmly as to secure the patient from the 
 risk of further haemorrhage. This method of treatment, however, 
 has the advantage that it can be applied by any practitioner without 
 any assistance or special appliances, but it is of little value in cases 
 of extensive laceration. 
 
 If the tear communicates freely with the abdominal cavity, the 
 latter may first be washed out with sterilised saline solution, by 
 means of a Budin's catheter passed through the rent, the patient 
 being in the dorsal position. If any bleeding arteries can be seen 
 from the vagina, where the rent enters the broad ligament, they 
 should be secured by pressure forceps. The plug is then placed so 
 that it reaches the peritoneal cavity, and arrests haemorrhage by 
 pressure on the sides of the rent, while the end is brought outside 
 the vulva to act as a drain. If iodoform or other antiseptic gauze 
 is used, it may be left untouched for from forty-eight to sixty hours, 
 if the patient is doing well, and afterwards renewed daily. The 
 vagina may be swabbed out, when the plug is changed, by solution 
 of formalin (m 20 ad Oj.); but it is better not to use douches for 
 the first five or six days. 
 
 Klien^has collected 65 cases treated by plugging with a mortality 
 of 52 per cent., and Lobenstine^ records 14 cases with a mortality 
 of 02 per cent. 
 
 1 Klien, Arclj. f. Gyniik., liXJl, lid. 62, p. H)8. 
 
 2 Lobenstine, Bulletin of Lying-in Hospital, New York, VoL III., p. 88. 
 
944 The Practice of Midwifery. 
 
 In some cases, where the rent involves chiefly the vagina and 
 broad ligaments, it may be possible to pass from the vagina deep 
 sutures to arrest haemorrhage by uniting the main part of the torn 
 surfaces, leaving a space for drainage from Douglas's pouch. 
 
 If the whole child has passed through the opening into the 
 peritoneal cavity, or even if the head has passed through, no 
 attempt should be made to draw it back again through the 
 opening. If this is attempted, the laceration and bruising are 
 likely to be increased. Moreover, the uterus, being more or less 
 emptied, will have retracted. The pelvic space will therefore be 
 j)artly occupied by the double thickness of its thickened wall, 
 instead of merely that of the attenuated wall expanded over the 
 foetus. By this circumstance the difficulty of extraction may be 
 greatly increased, if there is any disproportion between foetus and 
 pelvis, and therefore also the risk of injury. 
 
 In these cases and in the case of large tears, even when the child 
 and the placenta have remained in the uterine cavity and have been 
 removed by the vagina, the best treatment is to perform abdominal 
 section. 
 
 After opening the abdomen, removing the foetus and placenta, 
 and washing out all clots and blood from the peritoneal cavity, the 
 operator has the choice of three methods of treating the uterus. 
 He may content himself with packing the tear with gauze and 
 bringing the ends of the gauze out through the vagina and the 
 abdominal wound for drainage, he may unite the peritoneum over 
 the tear or sew the edges of the tear together, or he may remove 
 the uterus by supra-vaginal or total abdominal hysterectomy. All 
 these methods have their advocates, and the choice between them 
 must depend largely upon the circumstances of each individual case. 
 When the patient's condition is so grave that it is impossible to 
 undertake either suture of the laceration or removal of the uterus, 
 plugging of the tear may be carried out. After cleaning out the 
 abdominal cavity, the rent should be packed with iodoform gauze, 
 one end being brought out through the vagina and the other 
 through the lower angle of the abdominal wound. It is advisable to 
 pack the cavity of the uterus and vagina with another strip of gauze. 
 The gauze may be renewed at about forty-eight hours' interval, 
 or the first plug may be left up to three days, if the patient is 
 doing well. Eden^ suggests that to avoid the risk of sepsis, if the 
 patient rallies, the uterus may be removed by vaginal hysterectomy 
 twenty-four to forty-eight hours later. 
 
 1 Eden, Journ. Obst. and Gyn. Brit. Emp., Vol. XV., No. 6, p. 363. 
 
Accidents during and after Labour. 945 
 
 If the tear is readily accessible, the method recommended by Z weifel ^ 
 of uniting the peritoneum over it may be followed. He makes no 
 attempt to unite the edges of the torn muscle, but this method is 
 advocated by some operators and has the advantage that the deep 
 sutures, if they can be successfully applied, arrest the haemorrhage. 
 In this case the sutures should be applied, if possible, on the same 
 principle as in Sanger's Caesarean section, deep sutures through the 
 muscular wall of the uterus, avoiding the mucosa, or through the cellu- 
 lar tissue if the ruj)ture involves the broad ligament or vagina, and 
 suj)erficial sutures about twice as numerous uniting the peritoneum, 
 and turning in its edge either on one side or on both. The best 
 material to use for the sutures is sterilised catgut. If the tear is 
 posterior, as it usually is, the uterus should be turned out through 
 the abdominal wound, and the intestines held back by large 
 sterilised pads or flat sponges, so as to allow access to it, if possible. 
 This will be facilitated by the Trendelenburg position, which may 
 be improvised with an inverted chair, as before described (p. 919). 
 When the anterior wall is involved, it is comparatively easy to apply 
 the sutures. It is most important that free drainage either through 
 the vagina or through the abdominal wound should be provided, since 
 the risk of septic peritonitis is very great, and as the tissues are often 
 considerably bruised, union by first intention cannot be relied upon. 
 The chief objections to this method of treatment are the difficulty of 
 carrying it out, the fact that it is not always successful in arresting 
 the haemorrhage, the risk of rupture of the uterus in a subsequent 
 pregnancy, and the great risk of sejDsis. 
 
 A considerable number of cases of repeated rupture have now been 
 recorded, Varnier ^ having collected 15 such cases, 5 of which proved 
 fatal. For these reasons many operators, if the laceration is a large 
 one or difficult to reach or if it is likely that the patient already has 
 been infected, practise hysterectomy, either total or supra- vaginal, 
 provided tbat the condition of the |)atient allows of such an operation 
 being performed. This method of treatment has the great advan- 
 tages of securing certain arrest of the haemorrhage, allowing for 
 the provision of free drainage, removing a possible source of septic 
 infection in the uterus, and avoiding the risk of rupture of the uterus 
 in a subsequent pregnancy if the patient recovers. Unfortunately 
 in the majority of the cases the condition of the patient is such that 
 any such procedure is out of the question. If it is decided to piactise 
 it, the operation should be performed in the most rapid possible 
 way. After ligature of the ovarian arteries, division of the outer 
 
 ^ Zvveifel, Hegur's Beitrage, Bel. 7, p. 1. 
 
 2 Varnier, Annales de Gynecol, et d'Obstet., October, I'JOl, Vul. LVI., p. 2J5. 
 
 M GO 
 
946 ^ The Practice of Midwifery. 
 
 part of the broad ligaments, and separation of the bladder, Doyen's 
 clamps may be applied from the vagina to the lower halves of the 
 broad ligaments, and left in place forty-eight hom's, the vagina and 
 the pelvis being plugged with iodoform gauze without closure of the 
 peritoneum. 
 
 Kolomenliin ^ records among 140 cases of rupture of the uterus, of 
 which 97 were treated without operation, with a mortality of 61 per 
 cent., 33 cases in which the uterus was removed, with a mortality of 
 36*3 per cent. Vaginal hysterectomy has the advantage over the 
 abdominal operation of being attended with much less shock, and 
 may be tried in these cases. In a certain number, however, it will be 
 difficult to arrest the haemorrhage completely by this method ; and 
 as it is only applicable to the relatively small number of cases in 
 which removal of the uterus is considered necessary when the 
 foetus and the placenta have been retained in utcro, it has been per- 
 formed up to the present time in but a small number of cases. On 
 the whole it may be expected that the treatment of these cases in the 
 future will be confined to plugging in the cases of slight tears and of 
 abdominal hysterectomy when the tear is at all extensive, and the 
 patient's condition admits of it. As in most cases the tear involves 
 the cervix, total hysterectomy will usually be necessary, but in cases 
 where the cervix is not involved supra-vaginal amputation may be 
 practised. 
 
 Incomplete Rupture of the Uterus. — There are three varieties 
 of incomplete rupture of the uterus. In the first, the muscular wall 
 is torn, while the peritoneum remains intact ; in the second, the 
 peritoneum is torn, while the main portion of the muscular wall 
 does not yield ; in the third, the muscle tissue alone is torn without 
 involvement of the mucous membrane. In these cases there 
 may be a good deal of haemorrhage into the muscular tissue of 
 the uterine wall.^ 
 
 Incomplete rupture of the muscular wall takes place chiefly at the 
 sides of the uterus, where the peritoneum is not in such close 
 contact with the muscle. It is hardly possible for it to occur at the 
 front or back of the uterus, except at the lower part of the anterior 
 wall, between uterus and bladder. It is much less common than 
 complete rupture. The peritoneum becomes detached over a con- 
 siderable surface, and blood is poured out beneath it, forming a 
 hematoma, especially when the site of the rupture is between 
 uterus and bladder. In some cases of complete rupture a similar 
 
 1 Kolornenkin, Monatsschr. f. Geb. u. Gyn., 1903, Bd. 17, p. 345. 
 
 2 Kuauer, Zectralbl. f. Gjnak., 1903, No. 21, p. 647. 
 
Accidents during and after Labour. 947 
 
 detachment of peritoneum and effusion of blood are formed, showing 
 that an incomplete rupture had preceded the complete. A less 
 severe degree of internal rupture, not dividing the whole thickness 
 of the muscular wall, may be produced at the internal os by efforts 
 to deliver rapidly, before the internal os has fully expanded. 
 
 Symptoms. — The symptoms of incomplete rupture are much less 
 marked than those of complete, and the diagnosis is more difficult. 
 The pains generally continue, although they may become less 
 efficient. The chief symptoms are acceleration of pulse and 
 haemorrhage. Little or no blood, however, may escape externally, 
 if the presenting part prevents its exit. A sign which has been 
 observed in some cases is that of emphysema of the anterior wall of 
 the uterus, or extending to the iliac fossa, and even to more distant 
 parts. The air may find entry from the vagina, or there may be 
 gas arising from decomposition of the foetus, or the bacillus capsu- 
 latus aerogenes may have infected the cellular tissue. Cases in 
 which emphysema has been noted have generally ended fatally. 
 
 Prognosis. — Although the accident appears much less severe than 
 that in which the peritoneal cavity has been opened, the mortality 
 of recorded cases has been high. Death has often occurred from 
 septic peritonitis, or cellulitis spreading from the vicinity of the 
 blood-clot. 
 
 Treatment. — If the accident is suspected, delivery should be 
 effected rapidly, as in the case of complete rupture. Haemorrhage 
 can generally be arrested by securing contraction of the uterus, after 
 removal of the placenta, and packing any lacerated cavity in the 
 broad ligament with iodoform gauze. The after-treatment consists 
 chiefly in preserving the discharge from decomposition, by frequent 
 syringing with antiseptic solutions and use of iodoform pessaries. 
 
 If the abdomen has been opened under the impression that the 
 tear is a complete one, it should be closed and the laceration plugged 
 and drained from the vagina. The best plug to use in these cases 
 is antiseptic gauze enclosing a large drainage tube. 
 
 The second variety of incomplete rupture has been described in a 
 few cases in which death has occurred from haemorrhage or shock, 
 or from subsequent peritonitis. Cases not ending fatally would 
 probably escape recognition. 
 
 Perforation of the Uterus. — Localised inflammation and 
 sloughing of the uterine wall may be produced by prolonged 
 pressure between some projecting part of the pelvis and the pre- 
 senting part of the fcttus, especially when the head is presenting. 
 
 60—2 
 
948 • The Practice of Midwifery. 
 
 The bony prominence most likely to cause this effect is the pro- 
 montory of the sacrum in a flattened pelvis. In protracted labour, 
 especially when the head is arrested above the brim, the internal 
 OS may be so much elevated by retraction of the uterus, that the 
 sacral promontory corresponds to a portion of the cervix, or, at any 
 rate, of the thinned lower segment of the uterus. In the more 
 rare case in which there are projecting spines or bony prominences 
 at other parts of the pelvis, as at the symphysis pubis, these also 
 may cause a similar local lesion in the uterus. Sloughing, especially 
 at the site of the sacral promontory, is most commonly due to 
 prolonged pressure, when labour has been left too long unassisted. 
 It may also result from injury in very difiicult instrumental delivery, 
 or from the use of unsuitable instruments, or the unskilful use of 
 instruments. 
 
 The portion of the uterine wall which sloughs may give way and 
 form a rounded or funnel-shaped perforation into the peritoneal 
 cavity ; or its inner or outer portion loany alone give way, not pro- 
 ducing a complete perforation. In sloughs on the anterior wall, 
 the peritoneal cavity is not usually reached, but only the cellular 
 tissue in front of the uterus. As in the case of sloughs causing 
 vesico -vaginal fistula, the perforation generally does not take place 
 before, or at the time of, delivery, but after an interval of some 
 days. It is not so fatal as rupture of the uterus, because peritoneal 
 adhesions may have meantime formed around it. It may, however, 
 set up general peritonitis, and is one of the causes of death after 
 difficult labour. 
 
 Lacerations of the Vaginal Portion of the Cervix. — Slight 
 superficial lacerations of the mucous membrane at the edge of the os 
 are almost inevitable in labour. Deeper lacerations are of common 
 occurrence. These may extend either partially or wholly up to the 
 vaginal reflection, or may even reach the adjoining portion of the 
 vagina and subjacent cellular tissue. It is very rare for lacerations 
 commencing at the edge of the cervix to extend up to the internal 
 OS, but rents caused by forcible delivery with an undilated cervix 
 may possibly do so. They then virtually become incomplete or 
 complete ruptures of the uterus, as the case may be. 
 
 Transverse lacerations, j)arallel to the edge of the os, are much 
 more rare. Such a laceration may be produced by pressure of the 
 advancing head, when there is deviation of the os uteri to one side ; 
 or the anterior lip, compressed between the occiput and the pubes, 
 may become injured and inflamed, and may give way in the form 
 of a transverse laceration. Cases have even been recorded in which, 
 
Accidents during and after Labour, 949 
 
 when the os is very rigid, such a laceration has extended all the way 
 round, and separated the edge of the cervix in the form of a ring. 
 This constitutes an annular laceration. 
 
 Causation. — Laceration results from rigidity of the cervix, com- 
 bined either with activity of the expelling forces, or artificial extrac- 
 tion. The rigidity may either be due to a previous inflammation or 
 hyperplasia of the cervix, or to labour occurring for the first time 
 late in life. Premature rapture of the meml)ranes greatly predis- 
 poses to laceration, through the failure of the natural mechanism 
 for gradual dilatation. The lacerating force may be the natural 
 expulsive power, or that expended in delivery by forceps, or traction 
 in pelvic presentations or after version. 
 
 Symptoms and Results. — There is generally no symptom 
 which attracts notice at the time of the laceration, the pain pro- 
 duced being merged in the pain of uterine contraction. Until 
 delivery hsemorrhage is generally checked by the presence of the 
 foetus. After delivery, haemorrhage may occur, and form one of 
 the varieties of jwst-partuni hemorrhage. It is only in excep- 
 tional cases, however, that it is sufficient to call for any special 
 treatment. 
 
 The slighter lacerations generally heal more or less completely 
 during the puerperal period, but often leave the cervix irregular, 
 and marked by notches radiating from the cervix. A deep lacera- 
 tion reaching the vaginal reflection is apt to cause local cellulitis in 
 its neighbourhood, owing to absorption at the raw surface. This 
 is proved by the frequency with which, when an old ununited 
 laceration is discovered long after the labour which gave rise to it, 
 a band of thickening in the cellular tissue running from the angle 
 of the laceration can also be detected. Septic absorption of a 
 more grave character at the same site may give rise to puerperal 
 septicgemia. When laceration is deep, and especially when the 
 cervix is lacerated at both sides, the clefts are apt to remain 
 unhealed, and the anterior and posterior lips of the cervix to 
 become everted and hyperfcrophied. The lining membrane of the 
 cervix, naturally clothed with cylindrical epithelium, is thus exposed 
 to friction, and to the action of the vaginal secretion. The result 
 commonly is a chronic hypersemia and hypertrophy of the exposed 
 mucous membrane. The effect of unhealed laceration of the cervix 
 may thus be chronic uterine trouble, lasting for many years. 
 
 Diagnosis. — ^The laceration may sometimes be noticed at the 
 time of its occurrence, or suspected from the sudden yielding of a 
 
950 The Practice of Midwifery. 
 
 long-resisting cervix. In all cases, when the placenta is removed, 
 if there is any occasion for introducing the finger into the vagina, 
 the physician should examine the cervix, which hangs limp and 
 flaccid, to determine whether there are any rents in it, and their 
 degree. 
 
 Prophylaxis. — The most important point in prophylaxis is to 
 avoid increasing the number of lacerations which would occur spon- 
 taneously by using forceps unnecessarily before full retraction of the 
 OS, or by extracting too hastily in those cases in which forceps are 
 called for. When laceration is threatened by rigidity of the os in 
 association with violent pains, all means should be used to promote 
 relaxation, such as hot water irrigation, and, above all, the adminis- 
 tration of chloroform. After premature rupture of the membranes, 
 if the OS does not readily yield, laceration may sometimes be averted 
 by the judicious use of dilating bags or dilatation with the fingers 
 (see pp. 638—640). 
 
 Treatment. — Haemorrhage may be checked by hot douches, or, if 
 necessar}^ by plugging with gauze. A still better and more scientific 
 plan is to arrest the hfemorrhage by uniting the laceration by 
 sutures. For this purpose, the patient should be placed in Sims' 
 semi-prone position, lying on the side opposite to the laceration. 
 Sims' speculum should be used, or the cervix drawn down to the 
 vulva by tenaculum forceps. The best material for sutures is stout 
 silkworm gut. Two sutures are generally sufficient for one side of 
 the cervix, and these may be apj^lied with a straight needle held in 
 a needle-holder, or, still better, by Hagedorn's needle-holder 
 (Fig. 471, p. 955) and curved needles. They should be removed 
 at the end of a week. The sutures should be passed through the 
 whole thickness of the cervix, just including the edge of the lining 
 cervical mucous membrane. It is not usual to perform an imme- 
 diate operation on the laceration in those cases in which there is 
 no bleeding of consequence. For it appears that, in general, if 
 careful vaginal irrigation is employed, and all sepsis avoided, fair 
 healing of the lacerations takes place spontaneously. 
 
 If a laceration has been detected after labour, it is desirable to 
 examine the condition of the cervix some weeks after delivery, in 
 order to decide whether the operation of trachelorraphy is called for, 
 or whether any other treatment is necessary. 
 
 Laceeations of the Vagina. — Lacerations of the posterior vaginal 
 cul-de-sac reaching the peritoneum, and vaginal associated with 
 cervical lacerations, have already been described. In the middle 
 
Accidents during and after Labour. 951 
 
 portion of a normal vagina, spontaneous laceration rarely occurs, 
 since the canal is capable of stretching to the dimensions of the 
 pelvis. If, however, the vagina is contracted by old cicatrices, 
 laceration may take place, and may reach even the bladder or the 
 rectum. Vaginal lacerations may also be produced by unskilful use 
 of instruments, or by projecting angles of bone in craniotomy. 
 
 Fig. 467. — Incomplete rupture of 
 perineum. (Bumm.) 
 
 Fig. 468.— Complete rupture of perineum 
 into rectum. (Bumm.) 
 
 Treatment. — Sutures will rarely be required, unless the bladder 
 or rectum is laid open, or for the arrest of haemorrhage. Care 
 should be taken afterwards to guard against decomposition of lochia 
 in the vagina. 
 
 Lacerations of the Vaginal Outlet, Vulva, and Perineum. — 
 The vaginal outlet, formed by the insertion of the hymen, is the 
 narrowest point of the canal, and suffers inevitable rupture in 
 primipane. In coitus only the edge of the hymen becomes notched, 
 
952 
 
 The Practice of Midwifery. 
 
 PevTTVfum \ 
 
 the notches not reaching quite to its base. In parturition lacera- 
 tions extend quite to its base, and reach the ceUular tissue of the 
 vaginal wall. These lacerations are longitudinal, being perpen- 
 dicular to the direction of greatest tension. The main tear is 
 in most cases posterior, but there are usually others also. Hence, 
 
 the condition of the hymen 
 generally affords positive 
 evidence as to previous par- 
 turition. 
 
 Laceration of the perineum 
 in primiparse generally com- 
 mences by extension into the 
 substance of the perineal 
 body from the inevitable 
 tear at the vaginal outlet, 
 which is shown by the line e c 
 in Fig. 469. The term 
 perineal body is applied to 
 the lower part of the recto- 
 vaginal septum. A longitu- 
 dinal section of this forms 
 (roughly) a triangle (a h c, 
 Fig, 469), the base of which 
 {h c) is constituted by the 
 perineum proper. Up to the 
 jBrst parturition, the remnant 
 of the hymen at the vaginal 
 outlet (d, Fig, 469) forms a 
 projection forward near the 
 lower extremity of the anterior 
 or vaginal face of the triangle. 
 A considerable laceration of 
 the vaginal face of the 
 triangle, occurring by exten- 
 sion upwards and inwards of 
 the inevitable tear, e c, may 
 take place without the perineum itself, or even the fourchette, or 
 fold of slvin uniting its anterior border, being involved at all. This 
 may divide so much of the anterior fibres of the levator ani (see 
 Fig. 143, p, 237), that the action of that muscle in coitus, and the 
 value of the perineal body as a support for the vagina, are impaired 
 thenceforward, the perineum being left only as a thin septum, like 
 an artificial perineum produced by a badly-performed operation. 
 
 \ 
 
 Fig. 469. — Antero-posteriia* section of peri- 
 neal body in pvimiparfe. a, recto- 
 vaginal septum ; // c, perineum ; c, four- 
 chette ; d, vaginal outlet, formed by 
 remnant of hymen ; c d. fossa navicularis ; 
 e c, inevitable laceration in primipara? ; 
 / e, deeper laceration of vaginal surface 
 of perineal body not involving perineum 
 itself ; f cj, laceration of perineum up to 
 sphincter ani ; f h, f h, lacerations 
 dividing sphincter ani ; 1 ]', 2 2', show 
 position of sutures for uniting the 
 laceration. The section shows the shape 
 of the perineal body when slightly 
 stretched transversely, as by the advanc- 
 ing head. In its unstretched condition 
 the fourchette [c) lies posterior to the 
 vaginal outlet {d). 
 
Accidents during and after Labour. 953 
 
 In rare cases, superficial cutaneous cracks of the perineum are 
 alone produced, the skin being less distensible than the muscle 
 beneath, which remains intact. 
 
 Deep Lacerations. — More frequently, as the laceration spreads, it 
 involves the perineum proper and extends more or less from the 
 fourchette backward toward the anus. Sometimes only just the 
 anterior margin is torn through, and women who have had several 
 children rarely escape so much laceration as this. In a more 
 severe form of rupture the laceration extends backward as far as 
 the sphincter ani, as shown by the \mefg in Fig. 469. Sometimes 
 the tear forks on reaching the sphincter, going a little to each side 
 without dividing the muscle. In others the skin only may be 
 divided as far as the anus, while the muscle beneath remains intact. 
 In the severest form of all, the sphincter ani is divided, and more 
 or less of the recto-vaginal septum, as shown by the lines fh,fk, 
 in Fig. 469. The line of rent in the recto-vaginal septum generally 
 deviates somewhat to one side, avoiding the central posterior 
 column of the vagina, where the tissue is thicker and stronger. In 
 parous women, in whom the inevitable laceration at the vaginal 
 outlet must have taken place at a former delivery, rupture generally 
 commences at the anterior margin of the perineum, and extends 
 backward from that point. 
 
 Central Rupture.- — ^In rare cases, when the vulval outlet is very 
 narrow and far forward, and when the head is driven backward, 
 what is called central rupture of the perineum occurs, laceration 
 taking place from the vagina through to the perineum, leaving the 
 anterior portion of the perineum intact in front. Cases have been 
 recorded in which the rent has extended backward through the 
 sphincter into the rectum, and the child has been born through the 
 opening, a bridge of perineum in front still remaining unruptured. 
 
 Causation and Prophylaxis.— The stage of delivery at which 
 laceration is liable to occur, and the precautions to be taken for 
 avoiding it, have been described in the chapter on the management 
 of normal labour (see pp. 302 — 304). It may be added here that 
 laceration may sometimes be produced before the foetus reaches the 
 pelvic floor, when the hand and arm, or instruments, have to be 
 introduced, especially in difficult cases of craniotomy. For the 
 precautions to be used to avoid lacerating the perineum in forceps 
 delivery, see p. 852. 
 
 Diagnosis.— If a careful watch is kept upon the perineum when- 
 ever rupture is threatened, any laceration will be noted at the time 
 
954 The Practice of Midwifery. 
 
 of its occurrence. Visual examination is better than digital, and 
 can be made at the time when the placenta and membranes are 
 removed from the vagina. Care should be taken to have a sufficient 
 light, if there is any doubt about the perineum being perfectly 
 intact. Some practitioners have been known to say that they 
 never see rupture of the perineum in their practice; This state- 
 ment proves only that they are not accustomed to examine their 
 patients after delivery with sufficient care. 
 
 Symptoms and Results.— There are generally no notable 
 symptoms at the time of laceration, the pain being merged in the 
 distress of the final pains of labour. Haemorrhage is usually not 
 considerable, unless the rupture extends far up the recto-vaginal 
 septum. After delivery, there is soreness at the site of laceration. 
 If the laceration is not united b}^ sutures, a certain amount of 
 spontaneous union may take place. Generally, however, if the 
 laceration is deep, there is but little union of the separated surfaces, 
 and such apparent diminution of the size of the rent as takes place 
 is due to some contraction of the healing surface, and filling up of 
 the angle by granulation. During the puerperal period, the raw 
 surface affords a site for the absorption of any septic material 
 which may be present, and may thus form the starting-point for 
 puerperal septicaemia. If septic infection has taken place, this 
 surface may become sloughy, or may be covered by a greyish 
 exudation. If a considerable laceration has occurred and is not 
 united, the following are the subsequent results. The support 
 given by the perineal body to the anterior vaginal wall is taken 
 away. Hence there is liability to prolapse of the anterior vaginal 
 wall, which may in turn draw down the uterus. The gaping 
 vaginal outlet may also allow prolapse of the posterior vaginal 
 wall, mdependently of the uterus. The sexual power of the woman 
 is also impaired in consequence of the division of the sphincter 
 vaginse and anterior fibres of the levator ani. 
 
 Treatment. — In all cases in which rupture has occurred beyond 
 the extent of a mere notch in the mucous membrane or at the 
 fourchette, it should be closed immediately by sutures. The 
 object of this treatment is not only to avert the subsequent evils 
 arising from an ununited laceration, but to diminish the absorbent 
 surface capable of proving the starting-point of septicaemia. If 
 there is merely a slight rent affecting the vaginal mucous mem- 
 brane only, and not reaching the perineum proper, sutures are not 
 generally required. 
 
Accidents during and after Labour. 955 
 
 If, however, there is a deep rent in this situation, as shown by 
 the line /c in Fig. 469, p. 952, so that only a thin surface of 
 perineum is left, the vaginal mucous membrane may be united by 
 one or two sutures. 
 
 Lacerations not dividirig the Sphincter Ani. — A laceration not 
 dividing the sphincter ani may be closed by sutures almost imme- 
 diately after delivery. The use 
 of an anaesthetic is not essential, 
 if the patient is tolerant of pain. 
 But an anaesthetic may be given, 
 if there has been no excessive 
 haemorrhage, if the uterus is 
 well contracted, and about an 
 hour has elapsed since the 
 delivery of the foetus, the 
 placenta having been also 
 delivered. A pad of sterilised 
 or antiseptic wool may be placed in the vagina to dam back the 
 sanguineous discharge, while the stitches are being passed. The 
 best material for sutures is silkworm gut. But it is better to 
 use ordinary sewing silk than to leave the laceration ununited. 
 The sutures can be applied still more conveniently by means of 
 Hagedorn's needle-holder and curved needles (Figs. 470, 471, 
 
 Fig. 470. — Hagedorn's needles. 
 
 Fig. 471.— Hagedorn's needle-holder. 
 
 the needles being flattened at the sides. The needles being 
 larger, give somewhat more pain, but, if an anaesthetic is used, 
 they have a distinct advantage. The circular curved needles 
 should be chosen, or an ordinary curved handled perineum needle 
 may be employed. The stitches may often be inserted without 
 moving the patient from the lateral position in which she is lying. 
 But the operation is easier if she is placed on her back, the trunk 
 transverse to the bed, and if her feet are rested on a couple of 
 
956 The Practice of Midwifery. 
 
 chairs, the operator standing between them. The labia may then 
 be separated somewhat by the nm'se. The needle should be 
 passed through the whole thickness of the perineum, entering 
 about a quarter of an inch from the edge on the cutaneous 
 surface, and emerging as nearly as possible on the -edge of the 
 vaginal mucous membrane, the central part of its course being 
 the deepest. On the patient's left side the needle is passed from 
 without inward, and on the right side from within outward, and 
 the loop of suture is thus completed. In general two sutures are 
 sufficient. The mode in which tbey raaj be applied for a laceration 
 extending up to the sphincter is shown at 1 1', 2 2', in Fig. 469, 
 p. 952. An error specially to be avoided is to unite the perineum 
 too suj)erficially, not carrying the needles through to the vaginal 
 mucous membrane. A thin perineum, useless as a vaginal support, 
 is then likely to result. 
 
 If the application of sutures has been neglected at the time of 
 delivery, it is desirable to apply them later, even up to a week after 
 delivery, especially if any pyrexia has occurred. If granulations 
 have formed, the granulating surface should be scraped by a curette 
 or sharp spoon. 
 
 If sutures are thought desirable in any case of laceration affecting 
 onl}^ the vaginal side of the perineal body, as along the line / c in 
 Fig. 469, and not reaching the perineum proper, one or two may 
 be applied within the vagina by means of a curved needle, held in 
 a needle-holder. Hagedorn's needle-holder and needles are the best 
 in this case also. 
 
 Vaginal douches need not be used. The patient may be allowed 
 to pass her urine as usual, but the external genitals should be well 
 douched and washed, immediately after she has done so. After the 
 first day or two, she may pass urine raised in the sitting position on 
 the bedpan. The sutures should be removed in about a week. 
 
 Lacerations dividing the Sphincter Ani. — When the sphincter ani 
 is divided, the sutures should be applied in the same way as in the 
 gynsecological operation for ruptured perineum.^ Sufficient time 
 after delivery should be allowed to elapse to obviate the risk of 
 haemorrhage, say at least an hour, and a full dose of ergot should be 
 given. An anaesthetic should be given, and there should be an 
 assistant to administer it. Ether should be chosen rather than 
 chloroform, that the relaxing effect uj)on the uterus may be less, 
 
 A sufficient number of stitches of chromic catgut may be used 
 to unite the rectal mucous membrane, the knots being tied or 
 
 1 For full description and figure of the operation, see Galabin's Diseases of 
 Women. 
 
Accidents during and after Labour. 957 
 
 twisted on the rectal side. Then, by means of a Hagedorn's needle, 
 one suture is passed completely round from side to side, through 
 the remains of the septum, being buried throughout its course, 
 the ends being close to the anus at each side. Four or more 
 perineal sutures of silkworm gut are then applied. Care must 
 be taken that the posterior suture takes up the ends of the 
 sphincter ani. It may be buried throughout its course, and 
 completely encircle the rent, if the rent is not too deep. 
 
 If the rent extends far up the septum, a third set of sutures 
 should be used to unite the vaginal mucous membrane at the 
 upper part of the rent. The knots of these are tied in the vagina, 
 and the sutures may be of silkworm gut or chromic catgut. If the 
 former is used, the sutures should not be removed till several days 
 after the removal of the perineal sutures. Chromic catgut sutures 
 are left to dissolve. 
 
 In a rupture dividing the sphincter, it is well to keep the bowels 
 confined for three days, and to give a little opium for this purpose, 
 in order to allow time for primary union. It is a mistake, however, 
 to keep the bowels locked up for a week or ten days, for the collec- 
 tion of hard faeces is then apt to break down the union. At the 
 end of three days the bowels may be opened by a full dose of castor 
 oil, and it is a good plan to administer an oil enema of 8 oz. of 
 olive oil just before they are moved. From this time the bowels 
 should be kept acting daily by a very gentle laxative. Until the 
 bowels have acted, the diet should be sparing, and consist mainly 
 of milk. The catheter need not be used unless the patient is 
 unable to pass water naturally. After each action of the bowels or 
 act of micturition the perineum should be carefully cleansed by 
 means of a syringe, and may be dusted over with iodoform or boric 
 acid powder. The perineal sutures should be removed in about 
 seven days. It is well at first to take out alternate sutures only, 
 and to leave the long suture encircling the septum, and one or two 
 others, for two days longer. 
 
 Laceration of the Vulva. — Lacerations may take place, not 
 only at the posterior surface but at the sides of the vulva or near 
 the clitoris. They are generally parallel to the axis of the 
 vagina, that direction being perpendicular to the line of greatest 
 tension. Some haemorrhage after delivery may arise from such 
 lacerations, especially if the plexus of veins at the side of the 
 vestibule is torn. 
 
 Treatment. — Hemorrhage may be arrested by bringing together 
 the edges of the laceration with one or two sutures. 
 
958 ' The Practice of Midwifery. 
 
 EuPTURE OF THE Pelvic ARTICULATIONS.^ — The relaxation of 
 the pelvic articulations which occurs in pregnancy in very varying 
 degree has already been described. Actual sej)aration at the joints 
 sometimes occurs in labour. When preceded by excessive relaxa- 
 tion of the joints before delivery, this sometimes happens under the 
 influence of the natural expulsive forces only. More frequently it 
 is produced by efforts at artificial extraction, especially in the high 
 forceps operation. The joint may then sometimes give way with 
 an audible crack. 
 
 The joint most frequently ruptured is the symphysis pubis. 
 The separation may take place at the symphysis itself, or the 
 cartilage may be broken away from one pubic bone. For any 
 space in the pelvis to be gained by the rupture, it is inevitable 
 that some separation should take place also at another of the pelvic 
 joints. Accordingly, with rupture at the symphysis pubis there 
 is commonly combined some separation at one or both sacro-iliac 
 joints, but the experience of symphysiotomy shows that this is 
 not usually of serious consequence. Usually the anterior part of 
 the joint alone is separated, the posterior remaining intact. With 
 the rupture of the symphysis pubis may be associated laceration 
 of the anterior wall of the bladder, the anterior vaginal wall, or 
 the urethra. 
 
 The accident occurs most frequently when there is lack of 
 transverse space, as in the uniformly contracted pelvis. The effect 
 of traction is then to draw the pubic bones directly apart. In the 
 flattened pelvis this is not the case. 
 
 Diagnosis. — There is pain and tenderness in the situation of 
 the affected joints, and inability to move the legs. Pain in the 
 joints is produced by pressure on the innominate bone. On 
 bimanual examination the mobility of one pubic bone on the 
 other may be detected. According to Ahlfeld the thighs are 
 everted. 
 
 Prognosis. — In the majority of cases the result has been 
 favourable, unless septic infection has resulted in consequence 
 of other lesions due to the difficulty of labour. Generally the 
 joints have become consolidated again. In some cases, when the 
 joints have not been kept at rest, abscesses have formed at the 
 site of rupture. 
 
 ^ See Ahlfeld, Die Verletzungen der Beckengelenke, etc., Schmidt's Jahibuch, 
 1876, Bd. 169, p. 185. 
 
Accidents during and after Labour. 959 
 
 Treatment.— A firm, strong binder, should be placed round 
 the pelvis, and the patient should be kept at rest in bed longer 
 than the usual period, until the tenderness in the joints has 
 subsided. She should still wear a binder round the pelvis, when 
 beginning to get about, until freedom of locomotion is restored 
 
 If undue mobility of the bones, producing lameness, persists, it 
 may be necessary to expose the joint by incision, and bring together 
 by sutures the fibrous tissue close to the bones, or even to wire 
 together the pubic bones. 
 
 Obstetrical PARALYsis.-The nerves of the sacral plexus may 
 suffer injury from pressure, especially in cases of general contrac- 
 tion of pelvis with a large head, either from spontaneous delivery 
 or the high forceps operation. Generally one leg only is affected 
 accordmg to the diagonal diameter of the pelvis in which the long 
 diameter of the foetal head lies. The external popliteal nerve is 
 most often affected, in consequence of pressure upon the fourth 
 and fifth umbar roots which supply it as they pass over the brim 
 ot the pelvis. According to Schwenkenbecher,i in 34 recorded 
 cases, complete recovery followed in only 4, partial recovery in 15 
 no recovery in 15. Occasionally some of the other nerves of the 
 sacral plexus, such as the sciatic, are affected either by neuritis or 
 from involvement in an inflammatory exudation in the pelvis 
 Paralysis of one or more nerves (or rarely of a large number) 
 from peripheral neuritis has also occurred in the puerperal period 
 and has been ascribed to the action of a toxin 
 
 Cerebral hemorrhage leading to death or hemiplegia sometimes 
 occurs near the time of delivery, and is promoted by the changes of 
 vascular pressure caused by the efforts of labour. 
 
 Treatment.-In local paralysis early recourse should be had to 
 electrical treatment. 
 
 HEMATOMA OF THE BROAD LIGAMENT has Occasionally followed 
 version or other operative interference. It has been known to 
 rupture into the peritoneal cavity, with a fatal result (see p. 661). 
 
 Presentation, Prolapse, and Expression of the Funis. 
 
 The funis_ is said to present when, before rupture of the 
 
 membranes, it is felt in front of, or in conjunction with, any other 
 
 preseiitmg part. In such circumstances, as soon as the membranes 
 
 rupture, a loop of the funis generally descends through the os, or 
 
 ' JJoulsoh. Arch. f. Klin. Med., ]1)02, Bd. 74, ,,. .r,03. 
 
960 
 
 The Practice of Midwifery. 
 
 can be felt by the side of the head or other presenting part. The 
 funis is then said to be j)rolapsed. Prolapse of the funis may also 
 occur for the first time at the moment when the membranes rupture, 
 a loop of it coming down with the escape of the liquor amnii. 
 There is yet a third mechanism by which prolapse of the funis 
 may originate, one which is more properly called expression of the 
 funis. In this case the funis does not drop down passively, but is 
 expelled by the intra-uterine pressure through some space left 
 between the child and the lower segment of the uterus.-^ The pro- 
 lapse then usually takes place for the first time at a considerable 
 
 interval after the rupture of 
 the membranes, labour being 
 obstructed by disj^roportion 
 between the child and the pelvic 
 brim. The same mechanism 
 of expression may, however, 
 come into action after the funis 
 has been artificially returned 
 into the uterus in a case in 
 which the first prolapse was of 
 a passive character. 
 
 Causation. — The reason 
 why prolapse of the funis does 
 not take place more often is 
 that the lower segment of the 
 uterus is occujDied by the head, 
 which is closely adapted to it. 
 Hence the most important 
 cause of prolapse of the funis 
 in head presentation is deformity of the pelvis, especially flattening 
 of the brim (40 per cent, of the cases, Von Winckel). This prevents 
 the head from descending low enough into the pelvis to rest closely 
 upon the cervix during dilatation, whilst vacant space is left opposite 
 the sacro-iliac articulations through which the funis can descend. 
 (See Fig. 363, p. 726.) In pelvic and still more in transverse 
 presentations prolapse of the funis is also promoted by the fact 
 that the presenting part does not so accurately fill up the cervix as 
 the head would do, and that the umbilicus, in these cases, is nearer 
 to the OS uteri. With prolapse of the funis, Von Winckel ^ found 
 
 1 See Eoper, Trans. Obst. Soc. London, 1875, Vol. XVII, , p. 318; Matthews 
 Duncan, Trans. Obst. Soc. London, 1879, Vol. XXL, p. 302. 
 '^ Von Winckel, Klin. Beobachtungen zur Path, der Geburt, Rostock, 1869, p. 220. 
 
 Fig. 472. — Prolapse of the funis, with the 
 head in the first position. 
 
Accidents during and after Labour. 961 
 
 cephalic presentations in 56'9 per cent., pelvic in 25*2 per cent., 
 shoulder in 17*5 per cent., and face in 1 per cent, of the cases. 
 Other causes predisposing to prolapse are excessive length of the 
 funis, low insertion of the placenta, low implantation of the funis 
 in battledore placenta, fibroid tumours of the uterus, multiple preg- 
 nancies," dead and premature children, and excess of liquor amnii. 
 Prolapse is commoner in parous women than in primiparge, since 
 in the latter the greater tonicity of the abdominal walls keeps the 
 head more closely adapted to the brim. 
 
 Frequency. — The frequency varies considerably in different 
 countries, and in different lying-in institutions. The occurrence is 
 probably commoner in those places where pelvic contraction is 
 frequent. The frequency has been variously estimated at from 1 in 
 70 to 1 in 400 deliveries. In the Guy's Hospital Charity (1863 — 
 1875) it was 1 in 383 deliveries. Churchill's statistics give a 
 frequency of 1 in 245 deliveries. 
 
 Diagnosis. — There is scarcely anything which can give rise to 
 error of diagnosis except foetal intestine in a case of ectopia of 
 viscera. When the funis is felt to pulsate diagnosis is perfectly 
 easy, even before rupture of the membranes. If the funis is pulse- 
 less and flaccid, it may generally be inferred that the child is dead. 
 The child may, however, be capable of resuscitation for a short 
 time after the funis has ceased pulsating, and therefore the fcetal 
 heart should always be listened for, to complete the diagnosis. 
 Pulsation may also be arrested for the time by a pain, to reappear 
 during the interval. If the pulsation becomes progressively slower, 
 it is a sign that the child's life is becoming endangered. 
 
 Prognosis. — The prognosis is very unfavourable for the child, 
 especially in head presentations. The mortality in general is at 
 least 50 ^er cent., but it varies much according to the stage at 
 which a case first comes under observation, and the treatment 
 adopted. In pelvic presentations the danger is considerably less. 
 There is no danger to the mother, except such as may result from 
 efforts to save the life of the child. 
 
 Treatment. — Before Rupture of the Membranes. — In the first 
 stage of labour, the great object is to defer the rupture of the 
 membranes until the os is quite fully dilated. For this purpose 
 the patient should be kept recumbent, and directed to avoid any 
 bearing-down efforts. She may be placed in the semi-prone position, 
 
 M. 61 
 
962 The Practice of Midwifery. • 
 
 on the opposite side to that on which the funis has descended. No 
 attempt should be made to push back the funis through the mem- 
 branes. The attempt is not Hkely to succeed, and may possibly 
 cause rupture of the membranes. The only method of restoration 
 which may be attempted with advantage at this stage, provided 
 that the foetus is alive, is the postural method. If the woman 
 is placed upon a firm mattress in the knee-elbow position, so that 
 the thighs are exactly vertical, and the chest as close as possible to 
 the surface of the mattress, the brim of the pelvis, and therefore 
 the fundus of the uterus, will be directed almost vertically down- 
 ward. The funis will then tend to gravitate away from the os. 
 The i^atient should be kept in this position during two or three 
 pains. If recession of the funis is thus obtained, she may be turned 
 into the semi-prone position previously described. 
 
 As a rule the funis is not exposed to pressure as long as the 
 membranes are unruptured. In exceptional cases, however, it 
 may be so, when the os is so far dilated as to allow onward move- 
 ment of the presenting part through the cervix to take place, 
 even without rupture of the membranes, as in such a case as that 
 represented in Fig. 131, p. 220. The ring of close contact which 
 sometimes divides the " fore- waters " from the rest of the liquor 
 amnii may then compress the funis. In such circumstances, if 
 either the pulsation of the funis, or the rate of the foetal heart, 
 is found to be becoming slow, the membranes should be ruptured, 
 and the case treated by one of the methods shortly to be 
 described. 
 
 Reposition of the Funis. — If, after rupture of the membranes, 
 the funis is found without pulsation, and no foetal heart can be 
 heard, no treatment directed to the prolapse should be adopted. 
 If, however, the funis pulsates, if the os is sufficiently dilated, and 
 if the vagina readily allows the introduction of the hand, an 
 attempt should be made at manual reposition of the funis. 
 Advantage here also is gained by putting the patient in the knee- 
 elbow position. The hand should be passed within the cervix, 
 laid flat against the head, and the loop of funis pushed up by 
 the tips of the fingers until the whole of it is completely above 
 the head. If a limb can readily be felt, a part of the loop may 
 be hung over it. If a pain comes on, the hand should remain 
 quiescent until it has passed off. Then the other hand should be 
 used externall}^ to press the head down into the brim. At this 
 stage the patient may be turned into the semi-prone position, 
 the internal hand gradually withdrawn, and the pressure of the 
 external hand maintained until a pain comes on, and assists in 
 
Accidents during and after Labour. 963 
 
 fixing the head in the brim. This method is Hkely to SQCceed, 
 unless, through deformity of the pelvis, there is a space, by which 
 the funis may again come down. If the patient cannot readily 
 be induced to adopt the knee-elbow position, the semi-prone 
 position may be used from the first with almost as much advantage. 
 This method of reposition is useless if the case is one of expression 
 of the funis at a considerable interval after rupture of the mem- 
 branes, or if the funis is found to come down again after complete 
 reposition. The only chance for the child is then to extract as 
 quickly as possible. 
 
 Extraction by Forceps or Version. — If the funis cannot be replaced 
 by the hand, or descends again 
 after reposition, or if the hand 
 cannot readily be passed into the 
 vagina, the best plan, if the cervix 
 is sufficiently dilated, is to extract 
 by forceps or version as rapidly as 
 is possible without risking injury 
 to the mother. Forceps should be 
 preferred if the dilatation is so 
 complete that the cervix is not 
 likely to delay delivery, otherwise 
 version may be performed. After 
 the foot has been brought down, 
 the funis should be replaced, if 
 possible, within the uterus, and 
 the half-breech at once drawn 
 down into the os, so as to fill up 
 the space. If this can be effected, 
 delivery need not be hurried. If 
 a loop of funis still remains prolapsed by the side of the breech, 
 delivery must be hastened by traction upon the leg, a watch being 
 kept upon the pulsations of the funis. 
 
 Instrumental Reposition. — If the membranes rupture and the 
 cord prolapses with the cervix only partially dilated, so that 
 manual reposition or immediate delivery is impossible, an attempt 
 may be made to replace the cord with a repositor. This method 
 may also be tried, in the place of manual reposition, in primiparse 
 and others in whom a narrow vagina renders it difficult to intro- 
 duce the hand. A repositor may be improvised in the following 
 manner : — A large-sized gam-elastic catheter is taken, a slit is cut 
 near the end of it opposite the eye, and a loop of tape passed 
 through the eye and the artificial slit (Fig. 473). A loop of funis is 
 
 61—2 
 
 Fig. 473. — Gum-elastic catheter 
 adapted as funis repositor. 
 
964 The Practice of Midwifery. 
 
 then secured in the tape, but not so tightly as to compress it. The 
 stylet is introduced into the catheter, and by its aid the catheter is 
 passed nearly its whole length into the uterus, until the funis is 
 quite out of reach. The stylet is then withdrawn, and the catheter 
 left in place until after the delivery of the head. Koberton's funis 
 repositor is a rod of gutta-percha, having a hole near the end, and 
 is intended to be used in the same way. It has the advantage of 
 being longer than an ordinary catheter. A long piece of whale- 
 bone may also be used in the same manner, a hole being cut near 
 the extremity. 
 
 If the pulsations in the cord are good, and it can be completely 
 replaced within the uterus by means of the repositor, the latter 
 may be left in situ and dilatation of the cervix, hastened by the 
 introduction of a Champetier de Eibes' bag. Unless the cord can 
 be completely replaced, however, the bag is very liable to compress 
 the latter, and in any case where the cervix is only partially dilated 
 the chances of delivering a living child are very small. 
 
 Treatment in Pelvic Presentations. — In breech presentations one 
 leg should be brought down. It is useful to fasten a noose of 
 tape round the foot. The funis should then be pushed up as far 
 as possible into the uterus, and, by means of the tape, the half- 
 breech drawn down into the os, so as to fill it up, before the 
 internal hand is withdrawn. If this does not succeed, labour 
 must be accelerated by traction on the leg. 
 
 Physometra or Tympanites Uteri. 
 
 Air may gain access to the uterus during obstetric operations, 
 especially when the hand is introduced into the uterus for version 
 or to guide the application of extracting instruments in cranio- 
 tomy. In these circumstances, if the child is becoming somewhat 
 asphyxiated from prolonged pressure it may attempt to breathe, 
 and even to cry, producing the so-called vagitus uterinus. I have 
 met with a case in which such a cry was heard during version 
 performed on account of contraction of the brim. The child was 
 still-born, but, on post-mortem examination, partial distension of 
 its lungs was found, such as would generally be considered as proof 
 of live-birth. This medico-legal test of live-birth is therefore open 
 to possible fallacy in these circumstances. 
 
 Even without the performance of any operation, air may enter 
 the uterus in smaller quantity, replacing some of the liquor amnii. 
 When, after long rupture of the membranes, the greater part of 
 that fluid has drained away, and air has entered, carrying with it 
 
Accidents during and after Labour. 965 
 
 gas-producing bacteria, decomposition of the foetus is set up soon 
 after its death, and this goes on rapidly in presence of warmth 
 and moisture. It is still further promoted if free entry of air has 
 taken place in attempts at operation. From decomposition foetid 
 gas may be freely produced, and if, at the same time, the uterus 
 is inactive from exhaustion, it may become distended and tym- 
 panitic. Such a condition is always a grave one for the patient, and 
 generally indicates that interference has been too long deferred. 
 The presence of air or gas within the uterus involves the possi- 
 bility of sudden death through the 
 entrance of the air or gas into the 
 veins (see Chapter XL.). 
 
 Treatment. — The uterus should be 
 emptied as soon as possible and at 
 once washed out with an antiseptic 
 fluid. All means should be taken to 
 secure firm permanent contraction of 
 the uterus. Uterine irrigations should 
 be continued through the puerj)eral 
 period, if there are any unfavourable 
 symptoms. 
 
 Invbesion of the Uterus. 
 
 In inversion of the uterus, the 
 uterus is more or less completely 
 turned inside out, so that its peri- 
 toneal surface becomes interior. Into 
 the cavity thus formed is necessarily drawn more or less of the 
 Fallopian tubes, ovarian ligaments, broad and round ligaments ; 
 sometimes also the ovaries themselves. Inversion may exist 
 in three stages : in the first, the fundus is partially inverted, 
 but does not pass through the external os ; in the second, the 
 inverted fundus passes through the os into the vagina but the 
 inversion is still incomplete ; in the third, the inversion is complete, 
 so that there is no longer any groove round the neck of the tumour 
 formed by the inverted uterus. Either the second or third stage 
 may be complicated by prolapse of the inverted fundus through the 
 vulva. In other instances the inversion may begin, not at or near 
 the fundus, but lower down in the uterine wall, and one wall may 
 become' inverted before the other. In this case, a section of the 
 uterine wall forms an S- shaped curve, while the inversion is in 
 
 Fig. 47-1:. — Commencing inversion 
 of the uterus, from a prepara- 
 tion in the Museum of Guy's 
 Hospital. 
 
966 
 
 The Practice of Midwifery. 
 
 course of production. Inversion may be produced either before or 
 after the expulsion of the placenta. 
 
 Causation. — For the production of inversion, it is essential that 
 there should be inertia, either complete or partial, of the uterine 
 wall.^ In some cases inversion is produced, or at any rate initiated, 
 by the interference of the accoucheur. This may be done, when the 
 
 Fig. 475. — Complete inversion of uterus with prolapse, 
 attached. (Bumm. ) 
 
 The placenta still 
 
 uterus is relaxed, either by injudicious traction on the funis, the 
 placenta being adherent, or by a too localised downward pressure 
 upon the fundus employed either to expel the placenta, or to stimu- 
 late uterine contraction. In other cases inversion is entirely 
 spontaneous. Here also there must be relaxation at any rate of 
 the part of the uterine wall at which the inversion commences, 
 often the placental site. A bulging inward may be the result 
 simply of gravity, especially through the weight of a still attached 
 
 1 See Bar, Bull, de la Soc. d'Obst. de Paris, 1902, Vol. V., p. 2. 
 
Accidents during and after Labour. 967 
 
 placenta. Or it may be the effect of a bearing-down effort, 
 especially when made in an upright position, as for micturition 
 or defaecation, shortly after delivery. Such a bearing-down effort 
 may complete the inversion, if the uterus is entirely relaxed. But 
 it appears that, in spontaneous inversion, a partial contraction of 
 the uterus itself often aids in the process. The relaxed and 
 partially inverted fundus, bulging into the cavity, excites the lower 
 
 Ov. 
 
 Fig. 476. — Sagittal section of pelvis with complete inversion of the uterus. 
 Bl., bladder ; Sy., symphysis pubis ; Oc, ovary ; L.r., round ligament ; 
 O.e., OS externum ; Tu., Fallopian tube ; It.^ inversion ring. (R. v. 
 Braun Fernwald, Von Winciiel's Handbuch der GeburtshUlfe, Bd. III., 
 Th. II., p. 1.57.) 
 
 part of the uterus to contract, as a foreign body would, and by this 
 means is expelled through the os. The mechanism is the same as 
 that by which a commencing intussusception is increased by 
 intestinal contraction. The patient also feels the sensation as of a 
 foreign body which has to be expelled, and is thereby stimulated to 
 a bearing-down effort, which aids in completing the inversion. 
 
 The bulging inward of the placental site, which is the first step 
 towards inversion, may be produced even before delivery in con- 
 sequence of shortness of the funis, either absolute or due to the 
 
968 The Practice of Midwifery. 
 
 funis being twisted round the neck.^ This will happen the more 
 readily if the delivery is aided by forceps. Its spontaneous occur- 
 rence must generally imply some irregularity in the uterine con- 
 traction, since a firm contraction of the whole fundus renders 
 inversion impossible. If, however, delivery takes place in an 
 upright j)osition, inversion may be produced by the weight of the 
 child acting through the funis, while the uterus is relaxed. An 
 insertion of the placenta exactly at the fundus, instead of on the 
 anterior or posterior uterine wall, has been thought to be a pre- 
 disposing cause of inversion, since the relaxed placental site is then 
 more likely to bulge into the uterine cavity like a polypus. Inver- 
 sion generally happens very soon after delivery, and more frequently 
 before than after the expulsion of the placenta. If observed at a 
 later stage, it is more generally gradual in its production. I have 
 met with a case in which it was produced two days after delivery as 
 the patient was sitting uj) to pass urine. But in cases of this kind 
 it is probable that a partial inversion may have existed from an 
 earlier stage. Inversion has been recorded after delivery in the 
 earlier months of pregnancy, but much less frequently than at full 
 term. Apart from pregnancy, it may be produced by traction of a 
 tumour. 
 
 Frequency. — Inversion of the uterus is very rare. Only 1 
 case was observed in 190,833 deliveries at the Eotunda Hospital, 
 Dublin. Jardine^ records 3 cases among 51,290 cases in the 
 Glasgow Maternity Hospital with 2 recoveries. 
 
 Symptoms and Results. — The symptoms of inversion are shock 
 and haemorrhage. The shock is due mainly to the strangulation of 
 the uterus and the traction on the broad ligaments. It is shown by 
 pain, rapid feeble pulse, anxious expression, and often vomiting. 
 The haemorrhage is due partly to the uterine inertia, which allowed 
 the inversion, partly to the strangulation impeding the return of 
 venous blood from the fundus. If the inversion is produced gradu- 
 ally, shock is less manifest, and haemorrhage the main symptom. 
 If the inversion is left unrestored, haemorrhage is apt to persist and 
 recur, especially when menstruation recommences. I have known 
 a woman to remain free from haemorrhage or other symptoms for 
 many months as long as she was suckling, but to begin to suffer 
 from serious haemorrhage as soon as she weaned her baby. More 
 
 -1 Dyhrenfurth, Zentralbl. f. Gynak., 1885, No. 51, p. 801 ; Dighton and Collins, 
 Jouru. Obst. and Gyn. Brit. Emp., Vol. VIIL, No. 4, p. 250. 
 2 Jardine, Clinical Obstetrics, 1910, p. 494. 
 
Accidents during and after Labour. 969 
 
 or less inflammation of the surface of the inverted uterus also 
 follows. Hence arises semi-purulent discharge, and sometimes 
 sloughing and septicaemia. The presence of the tumour in the 
 vagina also sets up bearing-down efforts, with rectal and vesical 
 tenesmus. Eventually, in some cases, toleration is established to a 
 great extent, and women have lived for many years with an inverted 
 uterus. But death may result from haemorrhage even at a con- 
 siderable interval after the first occurrence of the accident. 
 
 Prognosis. — In a considerable proportion of cases, death results 
 from haemorrhage aided by shock, generally within half an hour or 
 an hour after the accident. According to Crosse,^ a fatal result 
 follows within a few hours in about 28 per cent, of the cases, 
 sooner or later in about 42 per cent. In about 7 per cent, death 
 took place after more than a year's interval. In 23 cases collected 
 by Munro Kerr, death occurred in 6, or 28 per cent. Beckmann,^ 
 however, reports a mortality of only 14 per cent, in cases treated 
 by immediate replacement. 
 
 Diagnosis. — In recent inversion diagnosis is easy. Before the 
 separation of the placenta no mistake can possibly be made. After 
 its separation, the inverted uterus could only be mistaken for a 
 fibroid tumour or fibroid polypus. It is distinguished from these 
 by the absence of the fundus uteri from its normal position in the 
 hypogastrium. The diagnosis may be made by abdominal exami- 
 nation alone if the accoucheur, on placing his hand on the abdomen 
 shortly after delivery, fails to feel any fundus uteri ; but can pass 
 his hand down deeply, and feel the promontory of the sacrum. It 
 will then be easily verified by vaginal examination. If any unusual 
 pain, or symptoms of shock, or haemorrhage are observed shortly 
 after delivery, a vaginal examination should never be omitted ; 
 otherwise an inversion of the uterus, partial or even complete, 
 may be overlooked. The diagnosis in the chronic stage belongs to 
 gynaecology. 
 
 Treatment. — If the case is recognised at once, reduction should 
 be effected as soon as possible, without more delay than is necessary 
 to give some brandy, or a subcutaneous injection of ether, if there 
 is great collapse. If the placenta is still completely attached, it 
 should be left as a protection to the uterus and to avoid further 
 haemorrhage, but if it is partly detached, it should be peeled off 
 
 1 "An Essay on [nversio Uteri," Trans, of the Provincial Med. and Surg. Assoc, 
 1847. 
 
 2 Zeitschr. f. Geb. u. Gyn., 1895, lid. :jl. p. :}71. 
 
970 
 
 The Practice of Midwifery. 
 
 first, because the size of the mass to be returned is by that means 
 considerably reduced. 
 
 In carrying out the taxis, counter-pressure is to be made with 
 the external hand, to prevent too great stretching of the uterine 
 attachments. The fundus should not be indented, for then four 
 thicknesses of the uterine wall instead of two would have to be 
 passed through the cervix. The uterus should be returned in the 
 same way as that in which it came down. For this purpose, the 
 
 fundus may be grasped in the palm 
 of the hand and pressed upwards. 
 When it has been elevated as far 
 as possible in this way, pressure 
 may be made upon the fundus 
 with the closed fist. At each 
 stage, the direction of pressure 
 must be that of the pelvic axis. 
 If resistance is met with at the 
 final stage, after the fundus has 
 been returned through the external 
 OS, advantage may be derived 
 from the method recommended 
 by Noeggerath, namely, to make 
 pressure with one or two fingers 
 near the orifice of the Fallopian 
 tube, and so restore one corner of 
 the uterus first. If the reduction 
 is prevented by contraction of 
 Bandl's ring, an anaesthetic should 
 be given, if the condition of the 
 patient will allow it, and the 
 operation will thus be greatly 
 facilitated. 
 
 If the inversion is only discovered at some interval after delivery 
 an attempt at reduction by taxis, with the assistance of an anaes- 
 thetic, may still be made, if involution has not progressed far. If the 
 attempt fails, the case must be treated as one of chronic inversion. 
 The same plan may be adopted from the outset, if more than two or 
 three days have passed since delivery, and the base of the uterine 
 tumour appears to be small and firmly contracted. Inversion is 
 regarded as chronic, when the process of involution has become 
 complete. 
 
 Elastic Pressure. — The best treatment for chronic inversion is 
 gradual elastic pressure by means of Aveling's repositor. This 
 
 Fig. 477. — Modified Aveling's I'epositor 
 for inversion of uterus. 
 
Accidents during and after Labour. 971 
 
 consists of an S-shaped stem with double curve, pelvic and perineal, 
 surmounted by a cup which receives the inverted fundus (Fig. 478). 
 By means of this repositor pressure can be made always in 
 the correct direction, along the pelvic axis, just as axis traction 
 is made by Tarnier's forceps, which it resembles in shape. The 
 pressure is exercised by four elastic rings, fastened by bands to a 
 waistbelt, which is again supported by shoulder straps. By means 
 of these, the direction and degree of the pressure can be exactly 
 regulated. The instrument is made with cups of two or three 
 sizes, which can be screwed on at the top. The largest cup is 
 
 Fig. 478. — Modified Aveling's repositor applied for reduction of inverted uterus. 
 
 used while the inverted fundus is in the vagina. It may be 
 changed for a smaller one when the fundus has passed up to the 
 level of the vaginal roof. There is one drawback to Aveling's 
 instrument, namely, that the restoration is often suddenly com- 
 pleted in the middle of the night. When the patient is visited 
 next day, the internal os has contracted beneath the shallow cup, 
 and there is much difficulty in extracting the cup out of the uterus. 
 To obviate this I have had a modification of the instrument con- 
 structed in which the smaller cup forms the summit of a cylinder 
 12 inches long. When the restoration is complete, the cylinder 
 keeps the internal os dilated, and is easily withdrawn. The external 
 OS does not contract for a few hours. The cylinder is also perforated 
 
972 The Practice of Midwifery. 
 
 by a small hole, to prevent its withdrawal being hindered by 
 atmospheric pressure. 
 
 The position in which the instrument lies, when the bands are 
 tightened up, is shown in Fig. 478, p. 971. The bands may 
 require further tightening, after a few hours, as the uterus ascends ; 
 and morphia must be given, if much pain is produced. In a con- 
 siderable number of cases the inverted uterus has been removed, 
 when reduction has been found impossible. It is probable that 
 this will hardly ever prove necessary if a fair trial is given to elastic 
 pressure with a proper repositor. I have never known restoration 
 fail to be completed within forty-eight hours. Even if reposition 
 fails it will usually be possible to re-invert the uterus by practising 
 one or other of the operations which have been devised for this 
 purpose. 
 
 In attempting reduction with an Aveling's repositor, at a stage 
 intermediate between the acute and chronic, within a week after 
 delivery, I have found even the largest cup slip aside, being too 
 small for the fundus. But success was at once attained when an 
 extra-sized cup had been made to fit the fundus. 
 
 Occasionally if attempts at replacement fail, and the patient be 
 left alone, spontaneous reinversion occurs, as in a case recorded by 
 Boxall.i 
 
 1 Trans. Obst. Soc. London, 190i, Vol. XLVI., p. 292. 
 
Chapter XXXVIIL 
 
 RETENTION OF THE PLACENTA AND POST- 
 PARTUM HEMORRHAGE. 
 
 Eetention of the Placenta. 
 
 Causation. — Eetention of the placenta may arise from inertia 
 of the uteruSj from morbid adhesion of the placenta or membranes 
 to the uterine wall, or from the so-called hour-glass contraction of 
 the uterus, a condition always associated with more or less inertia 
 of the fundus. Any of these causes existing, retention is also 
 promoted by unusually large size of the placenta, by over-distension 
 of the bladder, or by deviation of the uterine axis from that of the 
 pelvis. 
 
 Inertia. — Normally the shrinking of the uterus on the expulsion 
 of the foetus separates the placenta partially, and perhaps some- 
 times wholly (see pp. 281 — 287). If the uterus afterwards remains 
 inactive, the placenta may be retained, notwithstanding that it is 
 separated or almost entirely separated. The laxity of the uterus 
 may be sufficient to cause post-partujn hgemorrhage, or there may 
 be sufficient tonic contraction to prevent excessive bleeding, but no 
 rhythmical pain strong enough to expel the placenta and separate 
 the remaining shreds of attachment. In general, when the 
 placenta is long retained from inertia, the bleeding is greater than 
 normal. The blood is then apt to collect behind the placenta and 
 invert it in the manner shown in Fig. 195, p. 286. When this 
 occurs spontaneously, or when it is produced by traction on the 
 funis, the difficulty of the expulsion of the placenta is increased. 
 For the placenta, when in the form of an inverted umbrella, forms 
 a larger mass to pass through the os than when folded longitu- 
 dinally on itself in the natural manner as shown in Fig. 194, p. 286. 
 The degree of inertia necessary to cause retention is relative to 
 the firmness of attachment of the placenta to the uterus. A slight 
 excess of firmness at some remaining points of attachment, which 
 would be broken down by a strong contraction, will suffice to cause 
 retention if contraction is feeble. Inertia of the uterus is of course 
 more likely to exist in the absence of the stimulation by external 
 pressure and friction usually employed in the third stage of labour. 
 
974 
 
 The Practice of Midwifery 
 
 Adhesion of the Placenta. — The separation of the placenta 
 normally takes place through that layer of the decidua basalis 
 which forms an open network of areolar spaces due to the dilatation 
 of the uterine glands (see p. 76). Morbid adhesion occurs from 
 failure in the development of this areolar layer, or its replacement 
 by fibrous tissue, or from unusual firmness of the bands forming 
 the trabeculse. Any of these conditions is usually the result of 
 
 Fig. 479. — Uterus with adherent cotyledon of placenta from patient dying of 
 post-partum and ante-partum, haemorrhage. (Univ. Coll. Hosp. Med. 
 School Mus.). 
 
 previous endometritis, which may be syphilitic or not. The 
 endometritis leads to excess of fibrous tissue in the decidua basalis, 
 and this condition and the consequent adhesion of the placenta are 
 apt to be repeated in successive pregnancies. In some cases the 
 adhesion has been found to be due to complete absence of the 
 compact as well as the areolar layer of the decidua, the villi being 
 directly connected with the muscular wall of the uterus. ^ This 
 may be the consequence of degeneration, rather than inflammation, 
 
 1 Langhans, Arch. f. Gyn., 1875, Bd. 8, p. 295. 
 
Retention of the Placenta, Etc. 975 
 
 of the endometrium previous to pregnancy. It is dijfficult for the 
 great shrinking of the placental site which accompanies the 
 expulsion of the foetus to occur without some separation of the 
 placenta. Accordingly the adhesion is almost always found to be 
 partial, the tracts of firmest attachment having alone resisted the 
 effects of uterine shrinking. Haemorrhage may occur from 
 the placental site at the separated portion. Adhesion of the 
 placenta is thus one of the causes of j^ost-partitm hgemorrhage, for 
 the haemorrhage is promoted by the presence of the placenta 
 within the uterus preventing complete retraction and closure of the 
 vessels. Its resistance to expulsion is also liable to set up irregular 
 contraction, one part of the uterus remaining lax and allowing 
 haemorrhage while another is contracted. 
 
 Adhesion of the placenta at full term sufficient to make artificial 
 separation a necessity is a rare condition. It is apt to be inferred 
 when it does not really exist, if the third stage of labour is badly 
 managed, and the placenta is brought away piecemeal by the hand. 
 
 Adhesion of the Chorion. — Eetention of the placenta may also be 
 produced by undue adhesion of the chorion to the uterine wall, 
 especially when this exists around the edge of the placenta. The 
 placenta is then specially apt to be inverted by blood effused behind 
 it which does not escajDe externally. If the adhesion of the chorion 
 is at a greater distance from the edge of the placenta, the placenta 
 may be arrested when partially expelled into the vagina. Adhesion 
 of the chorion is generally due to previous endometritis affecting 
 that part of the uterus occupied by the decidua vera. 
 
 Diagnosis of Adhesion. — There are no reliable signs during preg- 
 nancy of adhesion of the placenta. It may be expected as probable 
 if it has been found more than once in previous deliveries. Some- 
 times there is during pregnancy pain referred to the fundus uteri, 
 and produced by the inflammatory condition of the uterine wall. 
 After delivery, adhesion may be suspected if good uterine con- 
 tractions appear to occur without any descent of the placenta for a 
 considerable time. In the very rare instance of complete adhesion 
 there may be an absence even of the usual sanguineous discharge. 
 This is rarely observed except in cases of abortion or premature 
 labour, where the placental site is smaller and has therefore a better 
 chance of resisting detachment through the uterine shrinking. 
 More frequently there is a gush of blood with each pain, indicating 
 a partial detachment of the placenta. If traction is made upon 
 the funis with an adherent placenta, the whole uterus descends, 
 the placenta not advancing, and pain is produced at the fundus. 
 Such traction should, however, never be made. The only positive 
 
976 
 
 The Practice of Midwifery. 
 
 mode of diagnosis is to feel the adhesion when the hand is passed 
 into the uterus for removal of the placenta. 
 
 Hour-glass Contraction of the Uterus. — The placenta may be 
 retained in consequence of spasmodic contraction of the lower part 
 of the body of the uterus associated with inertia of the upper part, 
 especially of the placental site. There are two forms of such 
 contraction. In the commoner, and that which most completely 
 
 Fig. 480. — Eetained placenta from hour-glass contraction of uterus. 
 (Bumm, Grundriss der Geburtshilfe.) 
 
 deserves the name of " hour-glass contraction," the part of the 
 uterus spasmodically contracted is the internal os, the circular 
 fibres around which form a sort of sphincter for the uterine cavity, 
 and are the most ready to contract again after dilatation. The 
 hand when introduced then feels a sharp ring of contraction. It 
 is probable that many observers describing " hour-glass con- 
 traction" have not realised to what a height the internal os is 
 raised, owing to the elongation of the cervix by stretching, and, 
 accordingly, have supposed the constriction to be at a higher level 
 
Retention of the Placenta, Etc. 977 
 
 in the body of the uterus. In other cases there really is a con- 
 traction of the part of the body of the uterus below the placenta, 
 possibly of Bandl's ring, with atony of the placental site, so that 
 the placenta becomes encysted. This condition is apt to be reached 
 if a more or less adherent placenta is allowed to remain for a 
 
 Fig. 481. — Eemoval of an adherent placenta. 
 
 considerable number of hours after delivery. There is generally 
 not such a limited sharp ring of contraction, and the term " hour- 
 glass contraction " is therefore not so fully suitable. 
 
 Causation of Spasm. — The spasmodic contraction of the uterus is 
 analogous to the spasmodic rigidity of the cervix in the first stage 
 of labour, and, like it, is always associated with an absence of active 
 expulsive pains. It may be a sequel of spasm during labour, and 
 
 M. 62 
 
978 The Practice of Midwifery. 
 
 depend upon the same constitutional conditions. It may also be set 
 up after delivery by irritation of the uterus jDroduced by traction on 
 the funis, by resistance of the placenta to exj)ulsion owing to morbid 
 adhesion, or it may be produced by the administration of ergot. In 
 both spasm of the cervix in labour and in hour-glass contraction 
 there is a disturbance of the natural nervous relations ; and, in both, 
 the so-called " polarity " of the uterus (see p. 212) has been said to 
 be modified. If an active expulsive pain occurs, the circular fibres 
 are not only distended by the advance of the placenta but undergo 
 physiological relaxation. An atony of the placental site, with con- 
 traction of other parts of the uterus, similar to that which occurs in 
 hour-glass contraction, maybe the starting-jDoint of inversion of the 
 uterus. In cases of complete encystment of the placenta by con- 
 traction of the whole of the body of the uterus below its level, I 
 have generally found that some morbid adhesion existed as a cause 
 of the spasm. 
 
 Prophylaxis. — Retention of the placenta is best avoided by the 
 judicious management of the third stage of labour, and is therefore 
 apt to be much commoner in the practice of the inexperienced than 
 in that of skilled accoucheurs. It is especially important not to 
 make jDremature attempts to deliver the placenta, not to irritate the 
 uterus by traction on the funis, and to use external pressure for 
 expulsion only when the uterus hardens with a pain, repeating it, 
 if necessary, with successive pains. 
 
 Treatment.— If there is no hfemorrhage of consequence, a fair 
 trial should be given to the method of expression described in the 
 chapter on the management of normal labour. If there is haemor- 
 rhage, the placenta should be removed at once. If the method of 
 expression fails, the hand should be introduced for removal without 
 any attempt to extract by pulling the funis. For this purpose the 
 patient should be placed upon her back, and the gloved hand passed 
 up into the uterus, the fundus being supported by the other hand 
 externally. If there is any constriction, it must be gradually 
 dilated by the fingers in the form of a cone. If the placenta is 
 found quite loose in the cavity, it has simply to be grasped and drawn 
 down. If any attachment is found, it must be separated by passing 
 the fingers side by side between the placenta and the uterine wall, 
 the dorsal surface towards the uterus. Hence, if, as is usually the 
 case, the placenta is found attached to the posterior wall, it is most 
 convenient to begin detachment at the lower margin, the fingers 
 being passed ujpwards and from side to side until the whole is 
 
Retention of the Placenta, Etc. 979 
 
 separated. The placenta is then easily grasped by the hand and 
 withdrawn. If the placenta is attached to the anterior wall, the 
 hand must be passed up to the fundus first, and separate it from 
 above downwards by the tips of the flexed fingers. 
 
 In the case of extensive and firm adhesion great care is necessary. 
 The surface of separation will then probably be not in the decidua 
 basalis but in the placental tissue itself. The main mass of placenta 
 should first be separated in the way already described. Then the 
 hand should be introduced again, and any separate pieces of 
 placental tissue broken down by the pulp of the fingers and 
 removed. It is better to leave small shreds of roughness attached 
 than to injure the uterine wall. After firm adhesion of the 
 placenta, it is generally desirable to wash out the uterine cavity 
 with a warm antiseptic douche such as lysol 1 per cent, or iodine 
 5j. to 5ij. to the pint, after its removal. 
 
 If there has been previous haemorrhage, the use of an anaesthetic 
 should be avoided if possible. In any case ether is preferable to 
 chloroform, as causing less complete and less prolonged relaxation 
 of the uterus ; and the anaesthesia should not be deeper than is 
 necessary to allow the requisite manipulation. In the case, how- 
 ever, of a tight hour-glass contraction the effect of the anaesthetic 
 in overcoming spasm may be essential, and chloroform may, in this 
 instance, have the advantage. 
 
 POST-PARTUM H^MOREHAGE. 
 
 Haemorrhage after delivery may come from various sources. 
 Haemorrhage from the placental site is, however, so much the most 
 frequent and most important, that this is regarded as post-partum 
 haemorrhage _29ar excellence. The subject is one of immense im- 
 portance, for post-partum haemorrhage is one of the most dangerous 
 complications of parturition. It may occur after the most perfectly 
 normal labour, and a household may thus be unexpectedly plunged 
 into grief by the sudden death of the patient. Nor is there any 
 emergency in which so much depends upon the care and skill of 
 the physician. The occurrence of haemorrhage at all may generally 
 be prevented by a careful and correct management of the third 
 stage of labour. When haemorrhage does occur, the life of the 
 patient will generally depend upon the promptitude and vigour of 
 the treatment. 
 
 Frequency. — The frequency of post-partum haemorrhage varies 
 so much, both according to the circumstances and social position of 
 
 62—2 
 
980 The Practice of Midwifery. 
 
 the patients and the skill of the accoucheur, that no estimate can 
 be given. In the Guy's Hospital Charity (1863 — 1875) fatal cases 
 were in the proportion of 1 in 2,040 deliveries, and formed about 
 10 per cent, of the total mortality after delivery. Deaths due to 
 post-jMrtum slightly exceeded in number those due to ante-partum 
 haemorrhage. The frequency of post-partum haemorrhage in this 
 Charity is probably much greater than the general average, for the 
 patients are often very ill-nourished and frequently are late in 
 sending for assistance, so that the child is often born before the 
 attendant arrives. 
 
 In the University College Hospital Maternity Department from 
 1893 to 1900 in 15,130 confinements 39 women, or 1 in 387, suffered 
 from considerable post-partum haemorrhage. In 8 instances the 
 patient's life was endangered, 2 of these cases ending fatally, a 
 mortality of 1 in 7,565 deliveries. Veit^ among 47,065 deliveries 
 found 5 deaths from atonic post-partum haemorrhage, a proportion 
 of 1 in 10,189. 
 
 Normal Mechanism for controlling Hsemorrhage. — The 
 numerous large arteries and veins entering the placenta are torn 
 across on separation of the placenta through the shrinking of the 
 uterus, and the blood which follows the birth of the child comes 
 from these vessels. The arrest of bleeding depends upon the 
 compression of the vessels by the contraction of the uterus. This 
 is facilitated by the anatomical arrangements already described 
 (see p. 103), namely, the spiral course of the arteries and the 
 so-called "falciform valves" in the venous sinuses. The veins, 
 however, are destitute of true valves, and thus, in the absence of 
 contraction, blood may pour in great volume from the veins as well 
 as from large arteries. Fatal haemorrhage may thus occur in a few 
 minutes. 
 
 Besides the contraction of the uterus, a part of importance is 
 also played by retraction, that is to say, by the reduction of its 
 size and thickening of its walls, not followed by relaxation and 
 expansion. The more complete is the retraction the more 
 thoroughly are the vessels closed and blood squeezed out of the 
 large venous sinuses. Hence the security against haemorrhage is 
 greater after the delivery of the placenta than before. 
 
 After delivery, as at other times, uterine contractions only take 
 place rhythmically at intervals. It is only during a contraction 
 that the well-known hard, defined, cricket-ball-like outline of the 
 uterus is felt which assures the physician of the impossibility of 
 
 1 Veit, Zeitschr. f. Geburt. u. Gyniik., 1894, Bd. 28, s. 210. 
 
Retention of the Placenta, Etc. 981 
 
 hsemorrhage from the placental site for the time being. But, even 
 during the intervals, although the uterus becomes softer, a suffi- 
 cient amount of tonic contraction normally remains to prevent the 
 vessels becoming patent again. The uterus should not become 
 larger during the intervals of contraction. A further security 
 against haemorrhage is afforded by the thrombi which form in the 
 vessels, but it is unknown how soon these are normally produced. 
 Owing to the- presence of these, even a morbid relaxation of the 
 uterus at a considerable interval after the delivery of the child is 
 not necessarily accompanied by haemorrhage. 
 
 Causation of Haemorrhage. — The one essential cause of 
 haemorrhage from the placental site is atony of the uterus, and 
 without this it can never occur. The atony does niDt necessarily 
 affect the whole uterus, but haemorrhage may occur with irregular 
 contraction, some part of the uterus being contracted and some 
 relaxed. In this case it is essential that the placental site, or part 
 of it, should be the atonic portion, as it is generally apt to be. If 
 the whole uterus is relaxed it may allow itself to be dilated again 
 to a considerable size by the blood poured out into it. Given a 
 certain amount of uterine atony, there are other causes which 
 promote haemorrhage. The first of these is imperfect uterine retrac- 
 tion. This may be due to the placenta being still within the uterus, 
 especially when partially adherent ; to the presence of clots within 
 the uterus, distending its cavity ; to a fibroid tumour in its walls ; 
 or to the presence of adhesions to some other structure which 
 prevent due retraction. In 102 cases of labour following ventrofixa- 
 tion of the uterus Negri ^ records 5 cases of post-partum haemorrhage, 
 a proportion much above the average. Other causes promoting 
 haemorrhage are excessive vascular tension, arterial or venous, excited 
 action of the heart, relaxation of the arteries supplying the uterus, 
 and any condition of the blood rendering it less prone to form 
 thrombi, as in cases of septic infection or haemophilia.^ In those 
 women who show a special proneness to flooding in successive 
 deliveries it is probable that some of these causes are often in 
 operation, as well as a tendency to uterine inertia. Too early 
 assuming the erect posture may also promote haemorrhage, by 
 increasing the statical pressure in the vessels and exciting the 
 circulation. 
 
 Causation of Uteriiie Atony. — The constitutional causes of uterine 
 atony after delivery are similar to those which produce inertia in 
 
 1 Negri, Annali di Ostelricia e Ginecologia, August, 1890. 
 
 2 Kehrer, Archiv f. Gyntik., 1876, lid. 10, s. 201. 
 
982 The Practice of Midwifery. 
 
 labour, and hence, when there has been marked mertia in labour, 
 the physician should be on his guard against post-partum hsemor- 
 rhage. Any debilitated condition or any form of malnutrition may 
 be a cause of inertia. The great danger of even a slight degree of 
 post-partum haemorrhage when ante-partum haemorrhage has 
 occurred is well known. Certain women have a constitutional 
 proclivity to flooding, not easily explained, and have been described 
 as '* flooders." This proclivity may depend upon some morbid 
 state of the nervous system, since the uterine contraction is directly 
 regulated by the nerves. A diseased state of the " ganglion cervi- 
 cale uteri " has been assigned as one possible cause.^ To these 
 constitutional causes must be added exhaustion from protracted 
 labour, frequent child-bearing, previous over-distension of the 
 uterus, as from twins or excessive liquor amnii, and the administra- 
 tion of chloroform. Westermark^ has shown that chloroform when 
 given to the obstetrical degree lengthens the intervals between the 
 pains, diminishes their frequency, and causes the individual con- 
 tractions to begin more suddenly and to pass off more rapidly. 
 Too rapid artificial delivery while the uterus is quiescent, and in 
 a condition of secondary inertia, the temporary passiveness of 
 Braxton Hicks, may also be a cause. Spontaneous precipitate 
 labour is also described as likely to be followed by haemorrhage, but 
 this tendency appears to have been exaggerated. Fritsch has called 
 attention to cases of uterine atony due to septic infection occurring 
 during labour, the paralysis of the uterine muscle being analogous 
 to that of the intestinal muscle seen so commonly in cases of 
 septicEemia. 
 
 Extreme nervous depression and shock, such as may follow the 
 birth of a still-born child, may account for the uterine inertia in some 
 cases. In a large proportion of cases the relaxation of the uterus 
 which allows the haemorrhage occurs when for some reason the 
 physician has omitted to keep a constant watch on the condition 
 of the uterus by keeping his hand upon it continuously until the 
 placenta has been delivered, and he is assured that a satisfactory 
 and permanent uterine contraction has been obtained. Some of 
 the worst cases have happened when attention has been diverted 
 by the necessity for resuscitating the child, or when the child has 
 been born before the arrival of the physician. 
 
 Symptoms and Diagnosis. — The haemorrhage may occur 
 immediately after the birth of the child, or, after remaining 
 
 1 Jastreboff, Trans. Obst. Soc. London, 1881, Vol. XXIII., p. 273. 
 
 2 Westermark, Paris Thesis, 1878. 
 
Retention of the Placenta, Etc. 983 
 
 contracted at first, the uterus may relax again and allow haemorrhage 
 either before or after the delivery of the placenta. At first the 
 blood is poured out into the flaccid uterus. After a while a con- 
 traction may occur and expel it in a copious stream ; or the same 
 effect may be produced by the patient's coughing or bearing down, 
 or the pressure of the hand upon the fundus. The quantity may be 
 so great as to drench the bed, and even pour abundantly on to the 
 floor. Even without external flow the uterus may allow itself to 
 be expanded again so much that dangerous and even fatal haemor- 
 rhage may take place into its interior, "concealed post-partum 
 haemorrhage." The physician can only be certain that no excess 
 of haemorrhage is going on by keeping his hand for a sufficient time 
 upon the uterus, making sure that it does not altogether lose its 
 definite outline or become enlarged in the interval of contractions, 
 and that no copious gush of blood from the vagina is produced by 
 a pain or by pressure upon the fundus. If haemorrhage occurs 
 without even temporary relaxation of the uterus, it must be due to 
 some other source of bleeding, such as laceration of uterus, cervix, 
 vagina, or vulva, and careful search must be made for the source. 
 It has even been known that a patient has bled to death from a 
 ruptured varicose vein in the leg, while the accoucheur was directing 
 his attention to the uterus. 
 
 A copious haemorrhage may be quickly followed by syncope, 
 which is in some cases an advantage, since it checks the flow of 
 arterial blood. Otherwise, in severe cases, the pulse becomes 
 rapid and weak, or even imperceptible ; there is extreme pallor of 
 the face, lips and gums, the patient is bathed in cold sweat, she 
 gasps for breath, for lack of sufficient blood corpuscles to carry 
 on respiration properly, and tosses her limbs about restlessly. 
 Towards the last she complains of being unable to see. Voice and 
 even muscular strength may apparently remain good almost to the 
 end. The gravest signs of impending death are absolute failure of 
 pulse, extreme restlessness, and failure of sight. 
 
 Prophylaxis. — In the great majority of cases, haemorrhage may 
 be averted by due care, although, very exceptionally, women are 
 found in whom flooding takes place notwithstanding the utmost 
 precautions. But practitioners who manage labour properly will 
 never find post-partum haemorrhage anything but a rare 
 occurrence. 
 
 If women are known to be liable to flooding they should be 
 treated if possible during pregnancy by tonics, especially iron, 
 iron and quinine, or small doses of ergot and strychnine combined 
 
984 The Practice of Midwifery. 
 
 with iron, as well as by good diet and other hygienic means. 
 Women with a history of haemophilia should be given calcium 
 chloride in ten grain doses three times a day for the last three or 
 four weeks of their pregnancy. In women with a history of 
 previous haemorrhage, a dose of ergot may be given just as the 
 head is reaching the perineum, if it is certain that no obstruction 
 exists. The same treatment may also be adopted in multiparae 
 when inertia of the uterus has been very marked throughout labour. 
 Chloroform should be avoided, as far as possible, in the case 
 of women prone to haemorrhage. When chloroform is given to 
 the full degree, as for obstetric operations, anaesthesia should not 
 be deep at the final state of delivery, and the uterus should not 
 be emptied too quickly, but allowed to expel (in head presentations) 
 the body of the child. The most important part of all in the 
 prophylaxis of haemorrhage is that the physician should manage 
 the third stage of labour correctly according to the principles 
 already described, following down the fundus uteri with his hand 
 at the expulsion of the child, and keeping a watch upon the uterus 
 until the placenta is expelled, and permanent contraction is 
 secured. While engaged in tying the funis, or resuscitating an 
 asphyxiated foetus, he should direct the nurse or other assistant to 
 keep up pressure upon the fundus. 
 
 Ergot is useful rather as a prophylactic, or to prevent recur- 
 rence, than in the presence of severe haemorrhage, for there is 
 then no time for it to act. If it is found difficult, after removal 
 of the placenta, to maintain a sufficiently firm condition of the 
 uterus, or if gushes of blood take place whenever the uterus 
 hardens, ergot should be given. The most rapid method is to 
 inject two grains or more of ergotin or 5 to 10 minims of ernutin 
 deeply into the gluteal muscles. In the absence of these prepara- 
 tions, a drachm dose of the liquid extract of ergot may be given, and 
 repeated, if necessary, or a fresh infusion may be made of sixty 
 grains of powdered ergot, and the powder and infusion administered 
 together. The liquid extract, diluted with an equal part of water, 
 may also be used hypodermically. A wineglassful of vinegar, taken 
 by the mouth, has sometimes been found to check haemorrhage 
 rapidly. It may probably cause a reflex effect upon the uterus. 
 In any case in which flooding is anticipated, a hypodermic syringe 
 should be ready, filled with a solution of ergotin or ernutin, and 
 iodoform gauze for plugging the uterus should also be prepared. 
 In all cases hot water should be at hand. 
 
 It has been observed that a probability of haemorrhage is indicated 
 if the pulse remains rapid after delivery, instead of falling to a 
 
Retention of the Placenta, Etc. 985 
 
 quiet rate. Whenever this condition is observed, therefore, the 
 condition of the uterus should be watched for a longer time than 
 usual, and a dose of ergot may be given with advantage. 
 
 Treatment.— The essential point in treatment is to secure 
 contraction of the uterus, and by far the greater part of the value 
 of all the means used for the arrest of haemorrhage consists in 
 their efficacy in producing this effect. The first expedient to be 
 tried is that of direct manual stimulation to the uterus. The 
 patient should be placed on her back, and the uterus grasped, 
 compressed, and kneaded with both hands. Care must be taken 
 not to cause inversion of the relaxed uterus by pressing downward 
 one part of the fundus. If this treatment does not quickly succeed 
 in producing hardening and contraction, one hand should be intro- 
 duced into the uterus, all clots turned out, and the placenta 
 removed, if it has no'" previously been expelled. The uterine walls 
 are then compressed between the outside hand and that in the 
 uterine cavity, the latter affording an additional stimulus to con- 
 traction. If the placenta has been exjDelled, the uterine walls 
 should be examined, while in a state of contraction, to make sure 
 that no portion of placenta or membranes remains attached. 
 "When this has been done, and fair contraction secured, the hand 
 should be slowly withdrawn into the vagina, and the fingers 
 placed in the posterior cul-de-sac, so that the cervix is received in 
 the hollow of the hand. The fundus is then drawn forward toward 
 the pubes in the grasp of the external hand, and the uterus com- 
 pressed in the direction of its axis until retraction is secured, and 
 the cavity closed. 
 
 If bimanual comiDression does not produce adequate contraction, 
 or if relaxation and haemorrhage recur, stimulation by heat should 
 be tried. 
 
 Intra-uterine injection of hot water is the most valuable means of 
 exciting uterine contraction. A large jugful of water should be 
 ready, and the temperature should be from 115° F. to 120° F., or 
 the water may be used as hot as the hand can bear. The patient's 
 hips may be brought over the edge of the bed in the lateral position, 
 and a mackintosh arranged to convey the water to a footpan below. 
 A long tube should be used which can be passed up to the fundus 
 uteri, and has a curve corresponding to that of the genital canal, 
 either a metal tube such as Budin's, or one of vulcanite or glass. 
 In the absence of a special tu)>e, the ordinary tube of an irrigator 
 can be used, but it will be necessary to pass the vaginal tul^e wholly 
 into the uterus. The water is then to be injected in considerable 
 
986 
 
 The Practice of Midwifery. 
 
 quantity, several quarts at least, until contraction is produced, great 
 care being taken to avoid the injection of air. If a Higginson's 
 syringe has to be used in the absence of an irrigator, special care 
 must be taken to avoid the entry of air. 
 
 If bimanual compression and the use of a hot douche both fail to 
 arrest the bleeding — and this will very seldom occur if they are 
 employed properly — then, as a last resource, the uterus should be 
 plugged. There are, however, two classes of cases in which this 
 method may be necessary in preference to either of the others, — 
 
 namely, when the uterus is 
 prevented from contracting 
 and retracting by the presence 
 of adhesions or the existence of 
 fibroid tumours in its walls. 
 Sohauta has suggested that, in 
 some very severe cases of post- 
 partum haemorrhage, the 
 uterine vessels may be athero- 
 matous, and in any case where 
 this condition is suspected gauze 
 plugging should be carried out. 
 Schmit ^ has recorded a case of 
 this kind in which the patient 
 died of uncontrollable hsemor- 
 rhage, although after plugging 
 had failed the uterus was ulti- 
 mately removed in an endeavour 
 to arrest the bleeding. On 
 microscopic examination well- 
 marked hyaline degeneration 
 of the vessels at the placental 
 site was found. 
 The best material for plugging is iodoform or sterilised gauze in 
 long and rather broad strips. In the absence of this, muslin, lint, 
 strips cut from a clean sheet, or any available material, may be used, 
 and should be sterilised by boiling water or wrung out of a weak 
 antiseptic lotion. Plugging the uterus may be carried out in the 
 following way. The uterus is drawn down to the vulva, a manoeuvre 
 which has the advantage of assisting to arrest the bleeding, or 
 pushed down through the abdomen. The gloved left hand is then 
 introduced up to the fundus and all blood clot or fragments of 
 
 Fig. 482. — Uterus and vagina completely 
 and properly plugged with gauze. 
 (Bumm.) 
 
 1 Schmit, Zentralbl. f. Gyniik., 1899, no. 35, s. 1089. 
 
Retention of the Placenta. Etc. 
 
 987 
 
 placenta removed. The strips of iodoform gauze or any other 
 available material are then passed up to the fundus with a pair 
 of uterine dressing forceps and the fingers of the left hand, and the 
 whole uterine cavity firmly and completely packed from above 
 down. Special care must be taken that no space in which blood 
 might accumulate is left between the fundus and the gauze. The 
 vagina should also be packed, a large pad of wool placed over the 
 vulva, and then a binder and T bandage applied with considerable 
 
 Fig. 483. — A uterus and vagina improperly plugged with gauze. The gauze 
 fills only the lower uterine segment and the vagina. A portion of 
 retained placenta is seen at the fundus. (Bumm.) 
 
 pressure. The plug should be taken out at the end of eighteen to 
 twenty-four hours, and the uterus douched out. If any hsemorrhage 
 recurs the plug must be removed, the uterus washed out with a hot 
 douche and if necessary replugged. 
 
 Diihrssen -^ records 65 cases of post-partum haemorrhage treated 
 by the uterine plug, with 6 deaths, of which 1 only was from 
 septicemia. 
 
 Treatment of resulting Ancemia. — In slight cases of haemorrhage 
 it is sufficient to give liquid nourishment as soon as possible. 
 Beef-tea or fluid meat, with plenty of salt, answers well, since it 
 
 1 Volkmann, Bammlung Klinischc Vortriige, 1890, no. 347 (Gyn. no. 100). 
 
988 The Practice of Midwifery. 
 
 allows water and saline constituents to be absorbed quickly and 
 replenish the volume of the blood. It is well also to give a dose 
 of opium or subcutaneous injection of morphia, in order to quiet the 
 circulation, and relieve the nervous irritability which results from 
 haemorrhage. 
 
 In graver cases, in which there is temporary syncope, failure of 
 pulse, extreme pallor., vomiting, or great restlessness, the chief 
 indication is to maintain the action of the heart and avert fatal 
 syncope. In the great majority of cases of j)ost-partum haemor- 
 rhage the patients recover if they do not die from syncope within 
 an hour or two. Sometimes, however, it appears that not enough 
 blood-corpuscles are left to permanently carry on respiration or 
 maintain the nutrition of the heart. Then, although the pulse 
 may improve for a time, it fails again, and the patient dies after a 
 considerable number of hours. This result is more likely if there 
 has been ante-partum haemorrhage, for then the loss is generally 
 more gradual, and a patient may be more completely drained of 
 blood without the immediate production of fatal syncope. 
 
 The first j)oint is to counteract anaemia of the brain by lowering the 
 head. All pillows should be taken away, and the head should not 
 be raised at all for any purpose, such as the giving of nourishment, 
 till it is certain that all danger has passed away. It is useful also 
 to raise the foot of the bed upon blocks, so that the head may be 
 lower than the body. Alcohol should be avoided until the haemor- 
 rhage is arrested. When that is done, brandy may be given if the 
 patient is not sick. If she is sick, or if brandy does not suffice 
 to revive the pulse, subcutaneous injections of ether, n\ 10, or 
 strychnine, ^ gr., should be given and repeated as required. In 
 the absence of ether, brandy may also be injected subcutaneously. 
 
 Auto-transfusion. — If the pulse still indicates danger, notwith- 
 standing the use of stimulants, there is a valuable resource in a 
 method which has been called auto-transfusion. This consists in 
 bandaging the limbs, so as to save a larger proportion of the 
 blood to fill the heart and vessels of the brain. The legs should be 
 bandaged from the feet to the hips. Esmarch's elastic bandage is 
 the most effective, but, in its absence, a calico bandage, firmly 
 ajDplied, may be used. The arms may also be bandaged in the same 
 way. The bandages may be allowed to remain for some hours, 
 until the patient has been able to retain nourishment and the pulse 
 has revived. 
 
 Intra-venous Injection of Saline Fluid. — The plan of injecting a 
 saline solution into the veins is the best method of treating 
 extreme cases of haemorrhage. Such injections tend to counteract 
 
Retention of the Placenta, Etc. 
 
 989 
 
 the tendency to fatal syncope resulting from emptiness of the 
 vessels, but not the failure of respiration or of the nutrition of 
 the heart from lack of blood. They are probably useless when 
 the patient fails again after being at first revived by stimulants, 
 and after being able to absorb fluid from the stomach. Even when 
 used at the early stage they have, in some cases, proved to be of 
 temporary benefit only. Intra-venous injections are now much 
 practised for the haemorrhage and collapse of ordinary surgical opera- 
 tions, and have been found to have a powerful effect in improving 
 
 Fig. 484. — Horrocks' apparatus for intra-venous injection. 
 
 the pulse and rallying the patient from the collapsed condition. The 
 modern plan is to inject in all cases a considerable quantity of the 
 fluid, as much as from four to six pints. The saline used may be 
 common salt, or two parts of salt mixed with one part of bicar- 
 bonate of soda. About 90 grains of the mixture may be dissolved 
 in each pint of hot water, which should have been sterilised by 
 boiling, if time allows. It is best, whenever possible, to use the 
 tabloids, which are now prepared for this purpose, containing 
 potassium, sodium, and calcium chloride with a small quantity of 
 bicarbonate of soda and dextrose. The solution should be strained 
 through muslin or filtered, and injected at a temperature of about 
 
990 The Practice of Midwifery. 
 
 100° F. A funnel with tube and cannula is the best apparatus to 
 use, or a large glass syringe, with the piston removed, answers very- 
 well the purpose of a funnel. 
 
 In Fig. 484 is shown the mode of using an apj)aratus devised by 
 Dr. Horrocks for intra-venous injection of fluid. In this case, the 
 cannula has a small round, not a bevelled opening ; and has to be 
 tied into the vein. 
 
 Injection of saline fluid should be practised in all cases in 
 which the pulse becomes very bad from the immediate effects of 
 hfemorrhage, as soon as the bleeding has been arrested. If the 
 collapse recurs after this, after an interval of some hours, and 
 stimulants fail, probably the only chance of saving the patient is 
 transfusion of blood. 
 
 An equally good effect has been claimed for the plan of injecting 
 a saline fluid into the cellular tissue. A special apparatus has 
 been invented for this, but one can be improvised with a piece of 
 drainage tube four or five feet long, a large funnel, and an aspirator 
 needle. The funnel is fixed at one end of the tube, and the needle 
 at the other. The tube having first been filled, the needle is 
 inserted at the edge of the breast or into the axilla, and the fluid is 
 allowed to flow by gravity, the funnel being kept filled. When 
 symptoms are urgent, this method is not so good as intra-venous 
 injection, since it does not so rapidly raise the vascular pressure. 
 
 After-treatment. — After transfusion, or in cases of haemorrhage 
 of severity just short of that demanding transfusion, great care 
 is necessary in giving fluid nourishment frequently and in very 
 small quantities, in order to secure, if possible, its retention and 
 absorption. At first, not more than a tablespoonful should be given 
 at a time. Fluid meat or beef-tea may be given at first, milk or 
 gruel a little later, brandy being added if the pulse flags. The 
 head must be kept low until all danger of syncoi3e has passed. 
 
 Secondary Puerperal Haemorrhage. — Secondary puerperal 
 haemorrhage may occur at any time within the puerperal period, 
 sometimes even several weeks after delivery. The bleeding may 
 be caused by detachment of thrombi from the vessels at the 
 placental site, or the blood may come from other parts of the 
 mucous membrane. The haemorrhage may take the form of 
 excessive lochial discharge, or a profuse loss may come on 
 unexpectedly. 
 
 Causation. — Haemorrhage may arise from any cause producing 
 active or passive congestion of the uterus. Among these are over- 
 exertion, getting up too early, mental excitement, inversion of the 
 
Retention of the Placenta, Etc. 991 
 
 uterus, laceration of the cervix, retroflexion of the uterus, retention 
 of clots within the uterus, sometimes merely a relaxed condition 
 of uterus, or softened congested state of the mucous membrane. 
 The most important cause of all is the retention of a piece of 
 adherent placenta or membranes. This cause should be suspected 
 as probable if, after a normal lochial discharge at first, a profuse 
 loss comes on after ten or fourteen days. Constitutional con- 
 ditions, such as albuminuria, may also predispose to secondary 
 haemorrhage. 
 
 Treatment. — A vaginal examination should always be made, and 
 if the cervix still admits the finger, and the loss is considerable, 
 the uterine cavity should be explored. If the cervix is found 
 closed, and the loss not excessive, the patient should be kept 
 perfectly at rest, and styptics, such as the liquid extract of ergot 
 in half-drachm or drachm doses, or tincture of cannabis indica in 
 fifteen-minim doses, should be administered. Any retroflexion of 
 the uterus should be rectified by a pessary. 
 
 If this treatment fails to arrest the loss, or if the bleeding is 
 excessive, the interior of the uterus should be explored, the cervix 
 being first dilated by Hegar's dilators or a tent if necessary. If 
 involution has proceeded to a considerable extent, it will be possible 
 to reach the fundus without introducing more than the index finger 
 into the vagina, as in the case of an abortion (see p. 582). 
 If the uterus is still large, it will be necessary to pass the half- 
 hand or whole hand into the vagina. For this purpose, an anaes- 
 thetic should be administered. If any placenta or membrane is 
 found within, it must be carefully broken down by the finger and 
 removed. This will generally suffice to arrest the haemorrhage. If 
 only a softened, congested state of mucous membrane is found, 
 the uterus should be curetted, and then swabbed out with liquor 
 iodi fort, or Churchill's tincture of iodine ^ by means of a Playfair's 
 probe or uterine sound wrapped in absorbent cotton. If only a 
 short time has elapsed since delivery, the uterine cavity may be 
 X)lugged after the curetting with iodoform gauze, without any other 
 application. 
 
 1 Iodine, 73 grains ; iodide of potassium, 90 grains ; absolute alcohol, 1 oz. 
 
Chapter XXXIX. 
 PUERPERAL FEVERS. 
 
 The nature of the disease known as puerperal fever has been 
 the subject of much controversy. The view that it is a specific 
 zymotic disease, analogous to small-pox or scarlatina, but liable 
 only to affect puerperal women, has been generally abandoned. 
 The modern view is that the affections which have been included 
 under the title of puerperal fever or metria are analogous to the 
 febrile disturbances which may follow surgical wounds, that they are 
 in reality septicaemia, or septic infection, and are due to absorption at 
 some surface, either that of the placental separation, or at lacera- 
 tions of the cervix, vagina, perineum, or vulva. The importance 
 of this subject is shown when we remember that three-fourths of 
 all the deaths occurring after delivery are due to puerperal fever, 
 and that in the year 1905 1,743 women died in England and Wales 
 from this complication of childbed.^ 
 
 That puerperal fever, in its severe forms, is a highly contagious 
 disease there can be no doubt. This is proved both by the records 
 of lying-in hospitals and by those of private practice. In conse- 
 quence of this disease the death-rate of some lying-in hospitals 
 has, over a considerable interval, been as high as 15, 20, or even 
 30 per cent. Thus in December, 1842, in the first obstetric clinique 
 in the Vienna Lying-in Hospital 75 of the 239 women who were 
 confined during the month died, a mortality of 31*38 per cent.^ 
 
 In many instances such hospitals have had to be closed in 
 consequence of the prevalence of the disease, and in some, whenthe 
 closing has been too long deferred, almost every puerperal patient has 
 died. On the other hand, recent experience in lying-in hospitals 
 has shown that, with careful use of modern antiseptic precautions 
 against the possibility of contagion being conveyed, mortality may 
 be as low, or lower, in lying-in hospitals than in private practice. 
 The contagious character of puerperal fever is equally proved in 
 private practice by the unfortunate instances in which a single 
 case of the disease is followed by a series of severe or fatal cases 
 
 1 Registrar-General's Eeport for 1905. 
 
 2 Semmelweis, Gesammelte Werke, Gyory, 1905, Table 2, p. 104. 
 
Puerperal Fevers. 993 
 
 among the patients attended by the same person, a series arrested 
 only by his entirely giving up midwifery practice for some time. 
 
 The chief arguments showing that puerperal fever is not a 
 specific zymotic disease are the following : — (1) The symptoms and 
 anatomical lesions of the disease have not a special and definite 
 character like those of a sjDecific zymotic disease, but are rather 
 analogous to those of septic8eD:iia or pysemia following surgical 
 wounds. The micro-organisms found are also generally the same 
 as in surgical septicaemia and pyaemia. (2) A similar condition 
 following abortion in the earlier months gives rise to a febrile dis- 
 turbance which resembles puerperal fever, though it generally 
 differs from it in being less fatal. (3) Puerperal fever may be 
 originated not merely by contagion conveyed from other puerperal 
 women, but by various kinds of septic material, notably by post- 
 mortem poison, or contagion from erysipelas, or suj^purating 
 wounds. The former was specially demonstrated by Semmelweis,^ 
 who showed that among the patients in the lying-in hospital at 
 Vienna attended by students who at the same time were attending 
 the dissecting and post-mortem rooms the mortality was as much 
 as 10 per cent. Among those attended by women in the same 
 institution it was only 3 per cent. In consequence of this evidence 
 a strict rule was enforced that the students should wash their 
 hands with a solution of chlorinated lime,^ and not merely with 
 soap and water, and a great reduction of mortality was thereby 
 obtained, namely, to about 1 per cent. 
 
 Organisms in Puerperal Fever. — The ordinary bacteria 
 which are the chief agents in the putrefaction of organic fluids do 
 not live and multiply in the tissues. They are present in the 
 lochial discharge as found in the vagina, and doubtless tend to 
 cause suppuration of the lacerations in the genital canal, which 
 would heal by first intention, and without inflammation, if they 
 could be kept perfectly aseptic. The lochial discharge obtained 
 from the interior of the uterus is said to be normally sterile. But 
 saprophytic organisms frequently gain access to the uterus, and 
 cause the decomposition of any portions of placenta or clots 
 retained there. In such case the toxins produced are liable to be 
 absorbed, and to produce poisonous effects. 
 
 The organisms found within the tissues in puerperal fever are 
 most frequently the micrococci of suppuration. These are found 
 mingled with pus cells in the cellular tissue and lymphatics. 
 They constitute a large proportion of the diphtheroid deposits 
 
 1 Hemraelwcis : his Life and Doctrine Sinclair, l'.)0!>. 
 M. ^3 
 
994 The Practice of Midwifery. 
 
 sometimes found upon lacerations of the genital canal. They are 
 abundant in the purulent or semi-purulent fluid found in the peri- 
 toneal cavity, and have been seen also in exudations in the pleura, 
 pericardium, and ventricles of the brain. They are with difficulty 
 discovered in the blood during life, but they form a large element 
 in thrombi in the vessels, and are found in the Malpighian bodies 
 of the kidneys. They have been observed also in the urine. ^ 
 
 Amongst the septic microbes, Streptococcus pyogenes is most 
 often found, next to that Staphylococcus pyogenes aureus, but 
 Staphylococcus albus and citreus have also been noted. Septicaemia, 
 therefore, whether puerperal or not, is not a pathological entity 
 like a zymotic disease, but is rather a group of allied diseases. 
 The Streptococcus pyogenes, however, has a greater power than 
 the other cocci of penetrating deeply into living tissues ; and it 
 is so generally found, eitber alone or associated with other cocci, 
 that it deserves to be regarded as the organism par excellence 
 of the more severe and fatal forms of puerperal septicaemia. 
 Besides the cocci, the Bacillus coli communis is capable of acting 
 as a septic microbe in certain conditions. When tbe vitality of 
 tissues is impaired, and especially when the intestines are also 
 distended from inbibition of peristalsis, it appears to be cajDable 
 of penetrating the intestinal wall, and multiplying in peritoneal 
 or other effusions, in the neighbourhood of intestine. It may 
 also readily be conveyed to the vagina, owing to the vicinity of 
 the rectum, and is frequently an agent in decomposition within 
 the uterus, causing an offensive discharge. Gebhard^ found it in 
 seven cases of tympauia uteri. When combined with Streptococcus 
 pyogenes it is thought to render that organism more virulent. The 
 gonococcus and pneumococcus appear to be also capable of acting 
 as septic organisms in certain circumstances. The gonococcus 
 generally causes a mild form of puerperal infection. Whitridge 
 Williams has repeatedly found it in cases of decidual endometritis. 
 The pneumococcus has been recorded as the agent in fatal septi- 
 caemia, sometimes secondary to pneumonia, sometimes without any 
 lung affection.^ 
 
 1 For observations on the organisms of puerperal fever and septicEemia, see Bumm, 
 Zentralbl. f. Gynak., 1889, p. 723 ; Mironow, ii'j<^., 1890, p. 679; Doderlein, ilnd., 1894, 
 p. 18 ; Menge and Kronig, Bakteriologie des Weiblichen Genitalkanales, Leipzig. 1897 : 
 JBumm, Arch. f. Gynak., 1889, Bd. 31, p. 325 : 1891, Bd. 40, p. 398 ; Zeitschr. f. Geb! 
 und Gynak., 189.5, Bd. 33, p. 126 ; Zentralbl. f. Gyn., 1897, No. 45, p. 1337; Eobinson, 
 Journ. Obst. and Gyn., June, 1902, Vol. I., p. 646 ; Foulerton, ibid., May, 1903, Vol. III., 
 p. 450 ; Whitridge Williams, Obstetrics, 1908, p. 857 ; Brieger, Charite Annalen, 1888, 
 13, p. 198 ; Kronig, Zentralbl. f. Gynak., 1893, 15, p. 157"; Welch. Boston Med. and 
 Surg. Jour., 1900, p. 73 : Von Franque, Zeitschr. f. Geb. u. Gyn., 1893, 425, p. 277. 
 
 2 Verh. d. Deutsch. Gesell. f. Gynak., 1893, p. 305. 
 
 s Foulerton and Bonney, Trans. Obst. Soc. London, 1903, Vol. XLV., p. 128. 
 
Puerperal Fevers. • 995 
 
 In a series of 324 cases recorded by Whitridge Williams, in which 
 the temperature rose to 101° F. or higher within the first ten days 
 of the puerperium, and in which microbes were found in the uterine 
 lochia, Streptococcus pyogenes was found alone in 60, or 18'5 per 
 cent., with other organisms (Bacillus coli, Bacillus aerogenes capsu- 
 latus and gonococcus) in 28, or 8"6 per cent. ; staphylococcus 
 alone in 8, or 2*4 per cent. ; Bacillus aerogenes capsulatus in 3, or 
 0"92 per cent. ; Bacillus coli alone in 18, or 5*5 per cent. ; gonococcus 
 in 29, or 8-9 per cent. ; various saprophytic organisms in 28, or 8-6 
 per cent. ; while 68, or 20"9 per cent., were sterile. In a similar 
 series of 179 cases, examined by Kronig, the infective agent was 
 the Streptococcus pyogenes in 75, or 42 per cent., the gonococcus in 
 50, or 27 per cent. ; saprophytic organisms were found in 28 
 per cent. 
 
 It is generally believed that, in the great majority of cases at 
 any rate, the septic organisms (the gonococcus excepted) are con- 
 veyed to the vagina or uterus from without in labour or the puer- 
 perium. The vaginal secretion, in the pregnant as in the non- 
 pregnant condition, is adverse to the growth of the cocci of 
 suppuration, a condition which is ascribed to its acid character, 
 resulting from the action of the bacillus of Doderlein. Observa- 
 tions have been very contradictory as to the presence of streptococci 
 and . staphylococci in the vagina of pregnant women. But the 
 observations of Kronig, Menge, and Whitridge Williams tend to 
 show that, provided vaginal secretion is obtained without any 
 contamination from that of the vulva, neither Streptococcus 
 pyogenes nor Staphylococcus aureus can be cultivated from it. 
 It must be remembered, however, that the failure to cultivate a 
 particular organism in the presence of many others is not absolute 
 proof of its absence. If present only in small numbers it may be 
 missed in the sample taken, or the incubator may be less favourable 
 for its growth than the human body in the puerperal state. Excep- 
 tions certainly occur in inflammatory conditions, and I have found 
 pus from the vagina to contain streptococci in abundance, without 
 any demonstrable gonococci. 
 
 Kronig^ considers that saprophytic microbes are capable of 
 growing in tissues damaged by traumatism, and in the lymph 
 canals, and quotes a fatal case of puerperal pyrexia in which he 
 found bacteriologically only anaerobic bacteria. In 43 cases of 
 fever during the puerperium examined by him he found organisms 
 not capable of cultivation in the ordinary media, and 32 of these 
 
 1 \eili. (I. Duutsch. Gesel). f. Gyniik., Wion, lSi).5, VI., p. 41)8. 
 
 63—2 
 
996 The Practice of Midwifery. 
 
 were pure anaerobic bacteria. Aerobic bacteria of decomposition 
 are considered to produce only a saprasmia which is generally- 
 transient. 
 
 Organisms in puerperal fever, as in other diseases, may produce 
 their effect in three ways : (1) by producing in their growth 
 some substance which has a poisonous effect; (2) by consuming 
 oxygen or other materials required by the body ; and (3) by 
 forming j^lugs which block small vessels or lymphatics, and produce 
 foci of local inflammation, in consequence of the toxin locally pro- 
 duced. It is probable that, in most cases, all the modes of action 
 are combined, the first being the most important. 
 
 Varieties of Puerperal Fevers. — Infection from decomposed 
 or septic material may occur either by absorption of chemical pro- 
 ducts of decomposition which have a poisonous effect, or by the 
 entrance of organisms into the tissues or into the blood, and their 
 multiplication there. In the first case, if the source of poison is 
 removed, the animal quickly recovers from its effects, if an almost 
 immediately fatal dose has not been absorbed. In the second case, 
 multii^lication is likely to go on notwithstanding the removal of 
 the source of infection. The body has, however, a certain power 
 of resisting the growth of parasitic organisms. In experiments on 
 animals, it has been found that the effect of sej)tic fluid containing 
 organisms injected into the blood is generally transient unless the 
 quantity injected is considerable. A smaller quantity injected 
 into the cellular tissue may j)rove ultimately fatal, since the 
 organisms multiply in the cellular tissue, and thence supply poison 
 continuously to the blood and lymphatics. 
 
 Saprcemia, or Septic Intoxication ; and SepticcEinia, or Septic Infec- 
 tion. — The most essential division therefore of puerperal fever is 
 into two main classes : (1) saprtemia, or septic intoxication, in 
 which a chemical iDoison only is absorbed ; (2) septicaemia, or septic 
 infection, in which organisms multiply in the tissues, or in the 
 blood, or in both. The slightest degree of septic intoxication is 
 seen when wounded surfaces suppurate and become inflamed in 
 consequence of the presence of the ordinary bacteria of decompo- 
 sition on the surface, not within the tissues. More severe forms 
 may arise when foul-smelling material is produced by decomposition 
 of retained placenta or clots, or of the lochial discharge. 
 
 Septic organisms capable of multiplying in the tissues may be 
 derived from other cases of puerperal septicaemia, septic discharges 
 from wounds, surgical septicemia or pyaemia, post-mortem poison 
 from autopsies of patients who have died from diffuse inflammation 
 
Puerperal Fevers. 997 
 
 such as peritonitis, and zymotic diseases. It is probable that 
 similar germs may be casually present in dust, and so may bo 
 conveyed to the genital canal. There may be also special germs 
 present in the air of certain houses or localities, as, for instance, 
 from the effect of defective drains or other insanitary conditions. 
 The septic infection may be limited to a special tract of tissue and 
 produce inflammation there, or the organisms may multiply in the 
 blood, and so constitute septicaemia proper. When the organisms 
 not only multiply in the blood and the tissues, but also form 
 abscesses in various organs and parts of the body, the condition is 
 called pyaemia. In these cases there is present not only the 
 poisoning of the tissues with the organisms which have established 
 themselves in the body, but also the occurrence of septic emboli, the 
 result of suppurative phlebitis or thrombosis. Pygemia is therefore 
 not so distinct from septicaemia as septicaemia is from saprsemia. 
 It is rather a later stage of septicaemia, when the disease is not 
 quickly fatal. 
 
 The distinction between sapraemia and septicaemia cannot be 
 absolutely made by a recognition of the microbes which produce 
 them, since the Bacillus coli may act as a septic microbe, and 
 anaerobic saprophytes are said to multiply in necrotic and damaged 
 tissues. There may be a mixture of the two conditions, while one 
 or the other preponderates ; and sapraemia may predispose to 
 sej)tic8emia by diminishing the resisting power of the body both 
 locally and generally. 
 
 Sapraemia and septicaemia cannot therefore always be practically 
 distinguished. Sometimes, indeed, when decomposed material has 
 been removed from the uterus, especially retained placenta after 
 an abortion, febrile symptoms disappear within a few hours, and 
 it may then be inferred with probability that nothing beyond 
 sapraemia existed. In general, if any decomposed material such 
 as clot or placenta is found in the genital canal, it may be hoped 
 that any febrile condition existing is due to sapraemia, and that no 
 virulent pathogenic microbes have been introduced. 
 
 Causation. — The distinction of septicaemia and sapraemia has 
 somewhat superseded the old classification of septicaemia into 
 autogenetic and heterogenetic forms, since in all cases the 
 microbes must have come originally from the outside. Yet a 
 valuable practical distinction does remain between cases in which 
 the main cause is the leaving placenta or clot to decompose, or 
 lowering the vitality of the tissues by traumatism, and those in 
 which it is the fresh introduction of septic germs. Just in the 
 
998 The Practice of Midwifery. 
 
 same way peritonitis after abdominal section may result either 
 from a quantity of blood being left in the peritoneal cavity, or 
 from virulent septic germs being conveyed by the surgeon or 
 derived from the locality. 
 
 Streptococci and staphylococci are commonly present at the 
 vulva, if not in the vagina. These are acting as saprophytes, and 
 appear to have little or no pathogenic power under normal con- 
 ditions. But the resisting power of the vaginal secretion, depending 
 upon its acid reaction, is diminished, if not abolished, in the puer- 
 perium, owing to the alkaline lochial discharge; and it may be 
 presumed that cocci from the vulva can easily spread to the vagina 
 and uterus unless the vulva has been absolutely sterilised and kept 
 sterile. These may be capable of growing in damaged, if not in healthy, 
 tissues, or of causing mild forms of streptococcic endometritis, such 
 as still occur occasionally in lying-in hospitals, notwithstanding 
 strict antiseptic precautions. 
 
 In very rare cases microbes may infect the uterus through the 
 maternal circulation, and even reach the foetus through the placenta. 
 Thus when the mother has suffered from general infection by the- 
 Bacillus coli, originating in a virulent appendicitis, the foetus has 
 been found affected also. The foetus has died within a few hours 
 after birth, and has been found to be affected by a streptococcic 
 pleurisy, or pneumonia, or endocarditis, while the mother has 
 afterwards also shown signs of sepsis. 
 
 Site of Absorption. — The site of absorption may be the uterine 
 surface, especially the placental site, or lacerations of the cervix, 
 vagina, vulva, and perineum. Probably the main reason why 
 primiparse are so much more liable to puerperal septicaemia is 
 that in them some laceration of the vaginal outlet is inevitable, 
 and more extensive laceration is common. During and even before 
 labour, infection may be conveyed to the cervix or vagina through 
 some slight abrasion made by digital examination. It is believed, 
 however, that, in general, the placental site is the commonest place 
 for septic infection. 
 
 Chemical poisons may not only be absorbed from the products 
 of bacterial growth in the genital canal, but may be formed in 
 the body itself. Owing to the rapid absorption accomj)anying the 
 involution of the uterus, associated as it is probably with a process 
 of autolysis of the muscle fibres due to the action of intra-cellular 
 ferments, a large quantity of effete material is poured into the 
 blood, to be disposed of by the excretory organs. This must be the 
 reason why, in the puerperal state, there is such a proneness to the 
 outbreak both of septicaemia and zymotic diseases. This proneness 
 
Puerperal Fevers. 999 
 
 is much more marked at the full term of pregnancy than in the 
 earlier months, the uterus then having attained a greater size. 
 Decomposition of retained placenta after an abortion, though it 
 often leads to febrile disturbance and local inflammation, yet is 
 much more rarely followed by fatal septicaemia than the same con- 
 dition after full-term delivery. Excessive muscular exertion and 
 expenditure of nervous energy also induces a peculiar state of the 
 blood and tissues, more prone than usual to decomposition, as has 
 been noticed in the cases of hunted animals and over-driven cattle. 
 It is probably due to the waste products formed. This cause will 
 operate after prolonged or difficult labour. 
 
 If there be any deficiency in the excretory organs, effete materials 
 are likely to accumulate in the blood, and probably, like saprsemia 
 caused by absorption, predispose to septicaemia by diminishing the 
 vital resistance of the body. Thus it has been observed that diseases 
 and functional disturbances of the kidneys and liver predispose 
 to puerperal septicaemia. The term " endogenetic toxaemia " has 
 been applied to the conditions resulting from poison generated 
 within the body. Some transient febrile disturbances may be 
 purely of this nature, as when pyrexia results from a toxin absorbed 
 from the intestines in consequence of constipation, but it hardly 
 exists as a separate variety of grave puerperal fever, though it may 
 be one of the predisposing causes of septicaemia. 
 
 Relation of Erysipelas to Paerperal Fever. — It was held at one time 
 that the streptococcus of erysij^elas, first described by Fehleisen, 
 was a specific microbe peculiar to that disease. Hence it was 
 thought that the origination of puerperal septicaemia by contagion 
 from erysipelas was an instance of a zymotic disease being con- 
 verted into septicemia. Since, however, the streptococcus of 
 erysipelas cannot be distinguished from Streptococcus pyogenes, 
 either microscopically or by cultivation, the prevailing opinion 
 now is that the two are either identical, or are varieties only, of 
 which one may be converted into the other. Thus cutaneous 
 erysipelas difl'ers from septic inflammations only in the fact that 
 the microbe is limited to the skin, and phlegmonous erysipelas is, 
 in all cases, a septic cellulitis. Erysipelas may commence at a 
 laceration at the outlet of the genital canal in a puerperal woman, 
 and is very apt to be followed by septic inflammation of more 
 internal parts. Thus in most cases there are symptoms of more 
 or less inflammation of the pelvic organs and peritoneum, namely, 
 tenderness of the uterus, and tenderness and distension of the 
 abdomen. The disease is a dangerous one, the mortality being 
 similar to that of severe puerperal septicasmia. 
 
lOOO 
 
 The Practice of Midwifery. 
 
 Fig. 485. — Death-rates from puerperal fever and other diseases in London, 
 with rain at Greenwich, from 1881 to 1900. KA. Rainfall at Greenwich, 
 inverted curve. P.F. Puerperal fever. ER. Erysipelas. SEP. Septicaemia 
 and pyaemia, sc. Scarlatina. EH. Rheumatic fever. Each vertical 
 division corresponds to 20 per cent. 
 
 There is considerable evidence to show that the contagion of 
 erysipelas may produce in the puerperal woman not only erysipelas, 
 but ordinary puerperal septicaemia without any erysipelatous rash. 
 
 Again, when the mother suffers from puerperal fever the child is 
 sometimes affected by erysipelas. Dissection wounds, made at the 
 
Puerperal Fevers. looi 
 
 necropsy of iDatients who died from puerperal fever, have given rise 
 to phlegmonous erysipelas. A case was recorded in Italy, in which 
 a husband had intercourse in the puerperal period with his wife, 
 who afterwards died from puerperal fever. The husband had 
 phlegmonous erysipelas of the penis, which spread to the abdomen 
 and proved fatal. The risk of infection appears to be greatest from 
 phlegmonous erysipelas in which suppuration occurs, and there is 
 a discharge by which hands or clothes may be contaminated. 
 Several cases have been recorded in which practitioners while 
 attending to wounds of this nature have had a series of cases of 
 puerperal fever in their practice. 
 
 Interesting evidence of the relation of puerperal septicaemia to 
 erysipelas and other diseases is obtained from diagrams, represent- 
 ing in the form of curves the percentage above or below the mean 
 of deaths from various diseases in successive years. The diagram 
 shown in Fig. 485 is calculated from the Eegistrar-General's 
 statistics for the period 1881 — 1900.^ It will be noticed that the 
 resemblance of the curve of puerperal fever to that of erysipelas is 
 exceedingly close, much closer than to that of septicaemia and 
 pyaemia in general. The year 1893, in which the most marked 
 maxima of both diseases, as well as maxima in scarlatina and 
 rheumatic fever, occurred, was marked by prolonged droughts from 
 March to June, and again from August to September. The periods 
 of greatest mortality occurred from two to three weeks after the 
 termination of each. 
 
 Relation of Scarlatina and other Zymotic Diseases to Puerperal 
 Fever. — Scarlatina is the zymotic disease which occurs most fre- 
 quently in the puerperal woman, and it shows in her certain 
 peculiarities. Pregnant women appear to have a special immunity 
 from, and puerperal women a special liability to, the disease. Thus 
 Olshausen^ found only 7 cases recorded of scarlatina during 
 pregnancy, as compared with 134 within one week after delivery. 
 The peculiarity in puerperal women is that the sore throat is almost 
 always slight, but yet the mortality is, or used to be, high, compared 
 with the usual mortality of scarlatina, and used to correspond 
 rather to that of severe puerperal fever. In 134 cases collected by 
 Olshausen, it was 48 per cent. ; in 34 cases observed at the Rotunda 
 Hospital, Dublin, by M'Clintock,^ it was 29-7 per cent. ; in 25 cases 
 observed by Halahan* in private practice, it was 76 per cent. ; in 
 
 1 For further details on this subject see " Collective Investigation Committee Record, 
 British Medical Association," Report on Puerperal Pyrexia, Galabin, Vol. 11. 
 
 2 "Puerperal Scarlatina," Ojstet. Journ., Vol. IV. 
 » Dub. Quart. Journ. Med., ISfU). 
 
 4 Dub. Quart. Journ. Med., 1803. 
 
I002 The Practice of Midwifery. 
 
 13 cases recorded in the Collective Investigation Eecord, it was 
 30*7 per cent. In a series of cases in Queen Charlotte's Lying-in 
 Hospital, observed by Brown, ^ the complaint was quite slight in all, 
 and there was no death. In fatal cases of puerperal scarlatina 
 some of the symptoms usual in puerperal fever, such as tenderness 
 and distension of abdomen, and scanty or offensive lochia, are not 
 uncommonly present. 
 
 More recent series of cases in lying-in hospitals, where careful 
 antisej)tic precautions were taken, have been recorded by BoxalP 
 and Meyer,^ of Copenhagen. There was no mortality ; no puerperal 
 fever resulted, and the average of pyrexia in other puerperal 
 cases was not raised. The conclusion suggested is that the chief 
 danger of puerperal scarlatina is that it predisposes to septicaemia 
 as a complication. It may be hoped that, with modern perfection 
 of antisepsis, the dangerous character of the disease may be much 
 diminished. Further exjDerience, however, is required to confirm 
 this, since the favourable result in one or two series of cases 
 may have depended upon a mild type of the disease. 
 
 Modern bacteriology has shown that in scarlatina there is often 
 a secondary streptococcal infection in local lesions, especially in a 
 sloughy throat. The most probable explanation therefore of the 
 occasional connection of puerperal fever with scarlatina is that a 
 streptococcal infection is conveyed from the scarlatinal patient to 
 the puerperal woman. 
 
 The contagion of diphtheria involves a risk to the puerperal 
 woman similar to that of scarlatina. For streptococci are 
 generally present in the di})htheritic membrane, and thus 
 septicaemia might be set up. Also it is possible for true diphtheria'* 
 to be conveyed to a wound in the genital canal. Any secondary 
 lesions due to streptococci in other zymotic diseases, such as 
 enteric fever, may also set up puerperal septicaemia. Any febrile 
 disease in the puerj)eral woman favours the occurrence of septi- 
 caemia. Thus even the slighter zymotic diseases may have this 
 effect, either through the pyrexia simply, or through some other 
 effect upon the condition of the blood. The pneumococcus may 
 cause septic inflammation in the uterus and pelvis, whether 
 associated or not with pneumonia in the lungs (see p. 994) ; but 
 this form of puerperal septicaemia is a very rare one. 
 
 1 Brit. Med. Journ., Feb. 8, 1862. 
 
 ^ "Scarlatina during Pregnancy and the Puerperal State," by Dr. Boxall, Trans. 
 Obst. Soc. London, 1888, Vol. XXX., pp. 11 and 126. 
 
 * " Ueber Scharlach bei Wocherinnen," Zeitschr. f. Geb. u. Gyn., 1888, 14, 
 p. 289. 
 
 <• Bumm, Zeitsclir. f. Geb. u. Gyn., 1895, 33, p. 136. 
 
Puerperal Fevers. 1003 
 
 Effect of Difjicult Labour. — If tissues are severely damaged, as by 
 bruising or prolonged pressure, they lose more or less their faculty 
 of resisting the multiplication of organisms within them. Hence 
 after difficult instrumental delivery, or too prolonged unassisted 
 labour, the tissues are apt to be infected even by microbes not 
 previously parasitic. In this way may be produced either sloughing 
 of the tissues with decomposition and consequent sapr^emia or even 
 some degree of septicaemia from anaerobic saprophytes (see p. 997); 
 or septicaemia, if micrococci gain access, even though not derived 
 from any virulent source of contagion. Thus difficult labour may 
 be followed by peritonitis similar to that resulting from conveyed 
 contagion. The proneness to the reception of any conveyed 
 contagion is doubtless also increased by bruising of the tissues. 
 
 Decomposition of Retained Placenta, Clots, or Lochial Discharge. — 
 From this cause sapraemia is generally produced in the first 
 instance, but septicaemia may eventually result, the decomposed 
 organic material having furnished a nidus for the multiplication 
 of cocci either previously present in the vagina or vulva or intro- 
 duced. The true nature of the case is often proved by rapid 
 improvement following the removal of expulsion of the putrid 
 material. An offensive lochial discharge results rather from the 
 action of the Bacillus coli or other saprophytes than from the 
 micrococci of suppuration. In the most virulent forms of 
 septicaemia there may be no offensive smell. 
 
 Cold, Exposure, or Over-exertion. — In a certain number of cases 
 there is a definite history of the commencement of pyrexia imme- 
 diately after over-exertion, exposure, or cold, as, for instance, 
 when a patient gets out of bed within a few days after delivery 
 and is then exposed to cold. Probably in these cases there is 
 already some infection, the course of which is unfavourably 
 influenced by the exposure or exertion. 
 
 Shock or Emotion. —It is well known that the efi"ect of mental 
 excitement, shock, or emotion in a puerperal woman is often to 
 cause a transient elevation of temperature. In a few cases a 
 much more serious effect is produced, and such an influence 
 appears to be the starting-point of severe and even fatal septicaemia. 
 I have known a case in which, so late as the fourteenth day, a 
 lady was greatly agitated by one of her children, alone in the 
 room with her, being nearly choked by a grape. Pyrexia com- 
 menced from that time and ended fatally. It is probable that in 
 these cases, as in those originating apparently from cold, exposure, 
 or exertion, there is some latent local lesion, which is unfavourably 
 influenced by the effect of the emotion. 
 
1004 The Practice of Midwifery. 
 
 Contagion from Puerperal Septicemia. — There is little doubt that 
 the most dangerous contagion to the puerperal woman is that 
 derived from some of the forms of puerperal septicaemia itself. 
 This is most strikingly shown by the series of cases which some- 
 times occur in the practice of the accoucheur or midwife, as well as 
 by the experience of lying-in hospitals. Of 354 cases reported to 
 the Collective Investigation Committee of the British Medical 
 Association, 24 were placed in this group. These show the same 
 peculiarity as cases ascribed to the contagion of erysipelas, namely 
 a mortality much above the average — 70'8 per cent. — the general 
 mortality being 47'4 per cent., and that of cases ascribed to the 
 contagion of erysipelas 70*6 per cent. 
 
 Other Sources of Contagion. — Other undoubted sources of con- 
 tagion are post-mortem poison and discharges from wounds, 
 especially if associated with diffuse cellulitis. Gonorrlioea should 
 be also included, as the gonococcus is allied to other microbes 
 of supjmration and j^romotes their growth, leading to a mixed 
 infection. I have met with a case in which a husband admitted 
 having infected his wife with gonorrhoea shortly before delivery. 
 The child's eyes were destroyed by purulent ophthalmia, and it 
 died of jDyremia. The mother suffered from puerperal septicaemia, 
 but recovered. In general it appears that, as in the non-puerperal 
 state, the gonorrhceal poison tends rather to cause either merely a 
 superficial endometritis or limited plastic peritonitis rather than 
 general septicasmia. Puerperal sepsis due to the gonococcus is 
 generally mild, and begins at a late stage, about a week after 
 delivery. Any decomposing matter may also be a source of 
 danger. In the case of post-mortem poison, it aj)pears that a 
 much more virulent infection is derived, within a short time after 
 death, from cases of septicaemia, or any diffuse inflammation, such 
 as peritonitis, than from mere products of decomposition. But 
 micrococci which have been acting as saprophytes may probably 
 cause puerperal sepsis in some conditions. 
 
 Contagion derived from any source of suppuration may cause 
 fatal infection to the puerperal woman. Thus the case has been 
 recorded in America of a medical man who had repeated series of 
 cases of puerperal septicaemia in his practice, notwithstanding 
 disinfection and long abstinence from practice ; and this has been 
 attributed to his having suffered from chronic ozaena. In a similar 
 way the discharge from a sinus at the root of a tooth, or the sputa 
 from a phthisical lung, may be a source of danger. 
 
 Insanitary Conditions. — Insanitary conditions in the house, 
 especially defective drains, and want of cleanliness, are often 
 
Puerperal Fevers. 1005 
 
 found in association with puerperal fever. Such conditions pro- 
 bably act merely as a predisposing cause, by impairing the patient's 
 health, or possibly some poison may be produced which is the 
 direct agent in contngion. In general, it is difficult to obtain 
 positive evidence of the causation ; but sometimes rapid improve- 
 ment follows the removal of the patient to another house, or the 
 repair of the defective drain. There is then evidence that some 
 continuous poisonous influence was being exercised. This, how- 
 ever, could hardly be of the nature of septicEemia, which would 
 not be likely to be cured, when once implanted, by removal of 
 the original cause. Epidemics of puerperal septicaemia in lying-in 
 hospitals have, however, been attributed to defective conditions 
 of their drains, or to collections of insanitary refuse in their 
 immediate neighbourhood. This is better evidence that defective 
 drains may originate actual septicaemia. If cocci are present as 
 saprophytes in decomposing matter, they may be introduced by 
 sewer gas; and then may be disseminated in the form of dust, 
 and reach the vulva and vagina even without being introduced by 
 hand of accoucheur or nurse. Streptococci have actually been 
 detected in dust ; and the occurrence of maxima of puerperal 
 septicaemia after dry seasons is evidence in favour of dust playing 
 some part in its dissemination. At any rate, it is certain that 
 streptococci not distinguishable microscopically from the pathogenic 
 kind do occur as saprophytes. 
 
 Contagious Character of Different Varieties. — Since puerperal 
 septicaemia includes many varieties of disease, it may be expected 
 that the contagious character would vary in different cases, and this 
 expectation is confirmed by observation. When there is septic 
 intoxication or sapraemia only, without septic infection, there can 
 be no contagion. In localised forms of inflammation, such as the 
 ordinary pelvic cellulitis, although micrococci may be present, there 
 appears to be practically no risk of contagion. Much has yet to be 
 learnt about the circumstances which render one variety more con- 
 tagious than another. But two facts are established : (1) that 
 forms of puerperal fever themselves derived from known contagion 
 are most likely to be contagious ; (2) that very severe and fatal 
 forms are more likely to be contagious than milder forms. Thus 
 of 19 cases reported to the Collective Investigation Committee of 
 the British Medical Association, which were the probable source of 
 contagion to others, all but one were fatal. There may be 
 contagion not only to other puerperal women, but to the infant or 
 attendants. The infant may die from pyciemia, sometimes from 
 
ioo6 
 
 The Practice of Midwifery. 
 
 erysipelas. Nurse or accoucheur may suffer frora sore throat or 
 poisoned hand. 
 
 Pathological Anatomy. — The local lesions in the different 
 forms of puerperal fever are very various, and de]3end upon the 
 site of absorption, and the mode in which the poison spreads. 
 Generally there are inflammatory changes in the genital canal and 
 its neighbourhood, and these may extend to the peritoneum or 
 cellular tissue. But in the most severe forms of disease the poison. 
 
 Fig. 486. — Uterus showing acute sloughing endometritis, from a patient 
 dying of puerperal septicemia. (Univ. Coll. Hosp. Med. School Mus.) 
 
 reaching the circulation either through the veins or lymphatics, 
 may set up so intense a septicemia that death results with little 
 or no production of any local lesions. The local changes will 
 be described according to the tissues in which they are found, 
 commencing with those most directly exposed to the poison. 
 
 Vaginitis ; Puerperal Ulcers. — Wounds of the vaginal mucous 
 membrane may acquire an unhealthy appearance and suppurate 
 instead of healing. Frequently the surface becomes covered with 
 a dirty-looking greyish deposit, and the edges and surrounding 
 tissue become oedematous. Thus are constituted the so-called 
 " puerperal ulcers." They are most frequently situated at the site 
 of a perineal laceration. Sometimes sloughing of the damaged 
 
Puerperal Fevers. 1007 
 
 tissue occurs, esi^ecially if extensive bruising has taken place. 
 Lacerations of the cervix may be converted into ulcers, in the same 
 way as those of the vagina. 
 
 Diphtheritic Ulcers. — Sometimes the ulcers become covered with 
 a diphtheritic or diphtheroid deposit. In this streptococci are 
 abundantly present, and it is associated with a deeper destruction 
 of tissue than is usual in the ordinary ulcers. These diphtheritic 
 ulcers are rare in isolated cases, but in some outbreaks of puerperal 
 fever, especially in lying-in hospitals, they occur in almost all cases. 
 They do not appear to be associated with the ordinary throat 
 diphtheria, nor does the membrane contain the bacillus of diph- 
 theria. True diphtheria may, however, occasionally affect the 
 genital canal. ^ In association with the ulceration of lacerations, 
 there is often general inflammation of the whole vaginal mucous 
 membrane, which becomes congested and swollen. 
 
 Endometritis, Metritis. — Changes in the uterus are the most 
 generally present of all local lesions. The uterine wall is always 
 soft and oedematous, the involution deficient. The condition of the 
 endometrium varies according to the microbes present. When the 
 active agent is the Bacillus coli or other saprophytes the surface is 
 rough and necrotic, often with ragged clehris or adherent blood clot 
 attached. In the most virulent form of streptococcic infection it 
 may be smooth and without necrosis. There is always a layer of 
 infiltration by leucocytes beneath the layer of necrotic material 
 lining the cavity of the uterus, bat this is less developed in pure 
 streptococcic infection than in the other forms. In so-called putrid 
 endometritis the layer of leucocytic infiltration is fairly thick, and 
 while saprophytes, and even the Staphylococcus pyogenes aureus, 
 are found superficial to it, beneath it the tissue may present almost 
 a normal appearance. In cases of virulent septic endometritis the 
 layer of leucocytic infiltration is poorly developed, and streptococci 
 are often found not only in this layer, but infiltrating the tissues 
 beneath and spreading along the lymphatics. 
 
 In some cases there is nothing beyond oedema of the muscular 
 wall of the uterus. But in general in fatal cases the tissue is 
 infiltrated with sero-purulent fluid. The lymphatics are specially 
 affected. Sometimes they may be seen under the peritoneal 
 surface, distended with pus, more especially where the peritoneal 
 covering of the uterus is looser, as towards the sides, near the 
 broad ligaments. Obvious affection of the veins is less frequently 
 seen, l^ut sometimes the thrombi in the sinuses become broken 
 
 1 Whitrid<<e Williams, Amer. Journ. Obslct., August, 1898; Bumni, Zeitschr. f. Geb • 
 u. (iyn,, ]8!ir,, Bd. :^3, p. 136. 
 
ioo8 
 
 The Practice of Midwifery. 
 
 down, and pus is found in the veins. Small abscesses in the 
 uterine tissue are occasionally formed. Modern bacteriological 
 researches show that many of the slighter and more transient 
 forms of jDuerperal pyrexia are really a streptococcic endometritis, 
 in which the streptococci are isolated from the deeper tissues by a 
 barrier of leucocytes, and no general sepsis results. 
 
 Pelvic Cellulitis, or Parametritis ; Lymphangitis. — The term 
 " parametritis " is used to denote inflammation of the cellular 
 tissue near the uterus, " perimetritis " to denote inflammation of 
 the peritoneum covering it and in its neighbourhood. The 
 
 Fig. 487. — Uterus from a case of acute septicasmia following criminal 
 abortion, ending fatally on the sixth day. There is a tear of the cervix 
 at the internal os, which in the recent state was covered by a diphtheritic 
 membrane. See Fig. 490 for the temperature chart. (Univ. Coll. Hosp. 
 Med. School Mus.) 
 
 cellular tissue is liable to become inflamed by extension of 
 inflammation from the uterus, especially at the sides v/here it 
 joins the broad ligaments. Lacerations of the cervix, deep enough 
 to reach the cellular tissue, are specially liable to be a starting- 
 point. This is proved by the frequency with which a laceration of 
 the cervix, examined long after the delivery which originated it, is 
 found to be associated with a band of cicatricial tissue in the broad 
 ligament, running from the angle of the laceration toward the 
 pelvic wall. 
 
 The bruising of the tissue in prolonged or difficult labour may 
 also set up inflammation, and the damaged tissue then offers less 
 resistance to the multiplication of organisms within it. In general 
 
Puerperal Fevers. 1009 
 
 the cellulifcic inflammation is unilateral, or more marked on one 
 side, usually on the left side, because the occi^Dut is commonly 
 directed that way, and tears the cervix more deeply on that side. 
 
 In the more severely septic forms of inflammation, the cellular 
 tissue is infiltrated with turbid semi-purulent fluid, containing 
 micrococci. The lymphatics are specially affected, and may be 
 filled with pus. More rarely pus is seen in the veins. If the 
 inflammation has lasted a few days, small collections of pus in the 
 cellular tissue are visible to the eye. 
 
 In the less severe form of inflammation, which constitutes the 
 ordinary pelvic cellulitis, the disease is limited, and does not lead 
 to general septic infection throughout the body. In this case, the 
 course is slower, and a greater amount of local swelling is produced. 
 The swelling is due to the effusion, first of serum, then of lymph. 
 Suppuration may eventually occur, or the lymph may be absorbed, 
 leaving generally more or less fibroid induration. No positive 
 line of distinction, however, can be drawn between the ordinary 
 pelvic cellulitis and the cellulitis accompanying the more virulent 
 forms of puerperal fever. The lymphatics and lymphatic glands 
 always take an important part in the inflammation, and the latter 
 are found to be swollen. In the milder forms of disease, the glands 
 appear sometimes to interpose a barrier to the further spread of 
 inflammation. 
 
 Parametritis may in other cases arise, generally at a later stage, 
 secondary to salpingitis, especially when this goes on to the 
 formation of a pyosalpinx. In such cases it is more frequently 
 bilateral. 
 
 Site of the Deposit in Pm'ametritis. — The development of the local 
 inflammation is greatest in those cases which do not proceed to 
 general septic infection, and which run a prolonged course. The 
 inflammation generally spreads where areolar tissue is most 
 abundant, that is, between the folds of the broad ligament, and 
 thence to the iliac fossa. From thence it may ascend along the 
 sheath of the psoas and iliacus muscles, or along the ascending or 
 descending colon, according to the side affected, to the region of 
 the kidney or the diaphragm. It may also come forward along 
 the muscular sheath to Poupart's ligament, and thence ascend 
 upwards, between the peritoneum and the abdominal wall. 
 Inflammation may also extend in the cellular tissue surrounding 
 the bladder, or in that between the pouch of Douglas and the 
 vagina, or descend upon the vaginal walls. These courses, how- 
 ever, are more frequently taken by cellulitis of non-puerperal origin. 
 When suppuration occurs, the abscess most frequently opens above 
 
 M. G4 
 
lOIO 
 
 The Practice of Midwifery. 
 
 Poupart's ligament. Sometimes, if it is formed within the sheath 
 of the psoas and iliacus muscles, it descends near the femoral vessels 
 to the inside of the thigh, and opens below Poupart's ligament. 
 At other times it opens internally into the vagina, rectum, colon, 
 or bladder. Barely, it opens beside the anus, or passes through 
 the obturator or sciatic foramen. 
 
 Remote Parametritis. — In some cases inflammation quickly sub- 
 sides in the neighbourhood of the uterus, but proceeds to suppu- 
 ration or to the formation of considerable deposit at some distant 
 
 Fig. 488. — Diagram illustrating spread of infection (shaded areas) from the 
 cervical canal through the cervix into the cellular tissue of the broad 
 ligament, and through the uterine wall at the placental site to the 
 peritoneum. 
 
 point to which it has spread. This condition has been called 
 " remote parametritis." In such cases, an abscess or cellulitic 
 swelling may be found in the abdominal wall, near the kidney, 
 near the sacro-iliac joint, or elsewhere, while little or no thickening 
 can be detected near the uterus. 
 
 Peritonitis. — General peritonitis may arise through extension of 
 septic inflammation to the peritoneum, either along the Fallopian 
 tubes, through the medium of the lymphatics, or directly by 
 continuity through the walls of uterus or the broad ligaments. The 
 peritoneal cavity is then found to contain a turbid, foul-smelling 
 fluid, containing micrococci, and more or less pus. There is 
 
Puerperal Fevers. 
 
 lOI I 
 
 tympanitic distension of the intestines from an early stage, and 
 the peritoneum becomes roughened, as well as injected or marked 
 by ecchymoses in the situations of least pressure. It is only in 
 rapidly fatal forms of septicaemia, and in those in which infection 
 takes place through the veins rather than through the lymphatics, 
 that death may occur without the development of any sign of 
 peritonitis. 
 
 Suppuration of the tubes, without closure of the ostium, is 
 
 ^e -t.v- 
 
 FlG. 489. — Diagram illustrating the spread of a septic thrombo phlebitis 
 from the placental sinuses into the ovarian veins, o. v., and from a lesion in 
 the cervix through the uterine veins into the internal iliac vein, i. i. v. 
 
 frequently the starting-point of general peritonitis. More rarely 
 a pyosalpinx of old standing ruptures during or after delivery and 
 sets up peritonitis. 
 
 In milder forms of inflammation, the exudation is less purulent. 
 More lymph is produced, and adhesions may be formed between 
 coils of intestine or other organs. In spaces limited by such 
 adhesions, collections of pus may be formed, and thus local 
 abscesses be produced. Inflammation is generally most marked 
 in the pelvic peritoneum. 
 
 64—2 
 
IOI2 The Practice of Midwifery. 
 
 Pelvic Peritonitis or Perimetritis. — When the septic infection does 
 not spread to the j)eritoneum generally, the pelvic peritoneum may 
 become inflamed through contiguity to inflamed tissues in the 
 jDelvis. Thus, in cellulitis, the peritoneum covering the broad 
 ligaments becomes inflamed ; and inflammation may also extend 
 to the pelvic peritoneum, either through the walls of the uterus 
 or Fallopian tubes, or reach it through the abdominal extremity of 
 the tubes. In the limited form of peritonitis, the inflammation is 
 generally of the adhesive kind, but localised collections of serum 
 or pus may be formed, and thus is constituted an encysted 
 perimetritis. 
 
 Ovaritis. — The ovaries are often especially affected in connec- 
 tion with septic forms of cellulitis and peritonitis. The ovary 
 becomes swollen, the stroma infiltrated with turbid serum, and 
 abscesses may be formed either in the stroma or in the Graafian 
 follicles. 
 
 Salpingitis. — The inflammation may siDread along the Fallopian 
 tubes, so that these become filled with purulent fluid. One of the 
 modes in which peritonitis may arise is by extension of this inflam- 
 mation along the tube to its fimbriated extremity, or through the 
 substance of the tube-wall. 
 
 Thrombosis and Pldehitis. — Thrombosis in the veins of the 
 placental site is a normal condition after delivery. Thrombosis 
 in uterine or pelvic veins is also not uncommon, apart from any 
 septic infection. It is promoted by the special proneness to coagu- 
 late which exists in the blood of puerperal women, and by the 
 enfeeblement of the circulation during rest in bed. If the 
 thrombus remains healthy, it eventually becomes organised, and 
 the vessel is partially or wholly obliterated. If, however, septic 
 organisms are present, the thrombus becomes softened and breaks 
 down, fragments of it are carried away in the blood stream, and 
 are apt to form emboli in the lungs, which form the starting-points 
 of metastatic abscesses. Similar abscesses in the liver or kidneys 
 may originate from emboli formed by clusters of micrococci, which 
 have passed through the pulmonary circulation, or from fragments 
 detached from thrombi formed in the heart or pulmonary veins, or 
 may be secondary to ulcerative endocarditis. 
 
 Septic thrombi may be formed in the first instance in several 
 ways. Organisms may reach the thrombi of the placental site 
 from decomposing material within the uterus. Again, the presence 
 of septic material in the blood may give rise to thrombosis in 
 various parts. Or phlebitis may be set up in consequence of septic 
 cellulitis of the tissue surrounding the vein. Thrombosis is then 
 
Puerperal Fevers. 1013 
 
 the consequence. The phlebitis may extend from the point 
 obstructed by the thrombus, and the vein may then be found filled 
 with pus. 
 
 Phlegmasia Alba Dolens. — This may arise either from the spread 
 of a septic cellulitis, giving rise to a secondary phlebitis, or from the 
 spread of a septic thrombosis from the uterine veins. 
 
 Septicemia. — In the most virulent forms of septic infection of the 
 blood, death may be produced almost before there is time for the 
 development of local lesions. Even peritonitis may in these cases 
 be sometimes absent. The only changes then found at an autopsy 
 are an altered state of the blood, in consequence of which the 
 lining membrane of the arteries becomes stained with blood pigment 
 shortly after death, and softening and swelling of glandular organs 
 such as the spleen, liver, and kidneys. The spleen and liver are 
 most affected, and the spleen especially may be almost diffluent. 
 
 Secondary Affections : Pycemia. — If the disease lasts long enough, 
 secondary affections are apt to be developed, but the more virulently 
 septic forms of it are generally so rapidly fatal that it is only in a 
 small proportion of cases that the type of pyaemia is assumed. 
 Pya^mic deposits in the viscera, and pysemic inflammation of more 
 external parts, such as the joints, are not often found associated 
 together. The former belong to those cases in which the spread of 
 the poison takes place chiefly through the vessels, producing 
 emboli, the latter to those in which it spreads through the 
 lymphatics. As might be exj)ected, pytemic deposits are commonest 
 in the lungs, since emboli originating from thrombi in the veins 
 are likely to be arrested there. Next to the lungs the organs most 
 often affected are the kidneys. General septic nephritis may also 
 occur. 
 
 Ulcerative Endocarditis is occasionally found, but is compara- 
 tively rare. Micrococci are found in the ulcerated tissue of the 
 cardiac valves, and secondary embolic foci of inflammation are apt 
 to result in various parts. 
 
 Septic Panophthalmitis is the result of embolism of the ophthalmic 
 artery. It leads to suppuration and destruction of the eye, and is 
 generally followed by death. 
 
 Pleurisy and Pericarditis may result from extension of inflamma- 
 tion through the diaphragm from the peritoneum, or may be 
 secondary to pneumonia, generally of pyaemic origin. 
 
 Pneumonia may arise from metastatic pyaemic deposit. Broncho- 
 pneumonia and lobular pneumonia, apart from pyaemia, are also 
 liable to occur in connection with septic disturbances after delivery, 
 and are probably, in most cases, streptococcic in origin. 
 
IOI4 
 
 The Practice of Midwifery. 
 
 Joints are not uncommonly affected by swelling and inflammation 
 which may go on to suppuration, as in the case of surgical pyaemia. 
 In other cases the pain and swelling are only temporary. The 
 joints of the upper extremity, shoulders and elbows, are most 
 frequently affected, next to them the knees. 
 
 Local Inflammation of Cellular Tissue, especially in the limbs, 
 also occur often accompanied by redness of the skin over the 
 
 DAYorDIS. 
 
 1 
 
 2 
 
 3 
 
 4 
 
 5 
 
 6 
 
 
 
 
 F 
 106° 
 105° 
 104° 
 103° 
 1 2° 
 101 ° 
 100° 
 99° 
 98° 
 
 M E 
 
 M E 
 
 M E 
 
 M E 
 
 M E 
 
 M E 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ^A 
 
 
 
 
 ' 1/ 
 
 1 
 
 
 
 A 
 
 / 
 
 i/^ 
 
 , > 
 
 /\ 
 
 i 
 
 "^ 1 
 II 1 
 
 Si 
 
 
 
 
 r 
 
 \i 
 
 V 
 
 V 
 
 
 ^1 
 
 
 
 
 / 
 
 V; 
 
 
 
 
 1 "^ 
 
 ^ 1 
 
 H^ 1 
 
 O 1 
 
 
 
 
 
 
 
 
 
 ! t3 
 
 ^1 
 
 
 \ 
 
 J 
 
 
 
 
 
 
 i c 
 
 1 <b 
 
 Q 1 
 
 
 
 
 
 
 
 
 
 i '^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 i _ 
 
 
 
 
 
 
 Fig-. 490. — Temperature chart of a case of acute septicfemia following criminal 
 abortion, terminating fatally on the sixth day. (See Fig. 487). 
 
 swelling. The swellings may subside, or go on to the formation 
 of abscesses. In some cases the inflammation is obviously due 
 to embolism, and may then lead to vesication and even superficial 
 sloughing. 
 
 Among the secondary affections sometimes observed are inflam- 
 mation and suppuration of parotid or thyroid, suppuration of ears, 
 and meningitis. 
 
 Of the 354 cases reported to the Collective Investigation Com- 
 mittee, there were 15 in which pysemic abscesses in the joints or 
 
Puerperal Fevers. 1015 
 
 other external parts occurred, 20 in which there were signs of 
 secondary pneumonia. 
 
 In the Nomenclature of the Eoyal College of Physicians, the 
 term " puerperal fever " is discarded for the purpose of death certifi- 
 cates; and the return is to be made as septicaemia, pyaemia, or 
 according to the local affection present. Puerperal fever has, 
 however, since been made by Parliament a notifiable disease. 
 For the purpose of notification, puerperal fever should be regarded 
 as including the contagious forms, septicaemia and pyaemia, but not 
 sapraemia. 
 
 Symptoms and Course. — In the great majority of cases, the 
 disease commences within the first five days after delivery. The 
 third day is the commonest day of onset, especially in cases arising 
 from infection conveyed from some virulent source, such as 
 puerperal fever or erysipelas. Puerperal scarlatina and erysipelas 
 also appear most frequently on the third day. In the cases of 
 puerperal pyrexia reported to the Collective Investigation Com- 
 mittee the days of onset stand in the following order of frequency : — 
 third, second, fourth, first, fifth. In some cases the pyrexia 
 commences before delivery. In these it must be presumed that 
 the infection is received at an early stage of labour, or previous to 
 labour. Cases are comparatively rare in which the first outbreak 
 is noticed after the end of a week. It is probable that, in most of 
 these, there has been, at an earlier period, some local morbid action 
 and some febrile disturbance which has escaped notice. The 
 majority of them are either instances in which the outbreak of the 
 fever is attributed to some exposure, premature exertion, or nervous 
 shock occurring at a rather late period after delivery ; or they are 
 cases in which there is a late manifestation of a localised pelvic 
 cellulitis, the early symptoms of which may have been slight in 
 degree, and may easily have passed unobserved. The thrombotic 
 form of septicaemia also begins to cause symptoms rather late, 
 sometimes as much as a week after delivery. 
 
 The symptoms vary greatly according to the forms which the local 
 manifestations of the disease assume. The most general symptom 
 is the pyrexia itself. In the milder forms of disease, limited to 
 a septic endometritis, the elevation may not rise above 101° or 
 102° F., and may be of short duration. In the more virulent forms 
 of infection the initial rise is often rather sudden, to a height such 
 as 105 F., or more (Fig. 490). In this case rigors accompany the 
 rise, and often form the first serious symptom which attracts notice. 
 When the rise of temperature is gradual, as from septic intoxication 
 
ioi6 The Practice of Midwifery. 
 
 due to the slow decomposition of something retained within the 
 uterus, rigors may be absent. In severe or fatal cases the 
 temperature quickly reaches a considerable elevation, such as 
 103° or 104° F. The pulse rises with the temperature. In mode- 
 rately severe cases the rate may be as much as 120; in the graver 
 forms of the disease it may reach 140, and before a fatal issue 
 may be as high as 160 or 170. As a rule the temperature tends to 
 rise ^progressively towards a fatal issue. But in some of the most 
 virulently septic forms of disease, especially when purulent 
 peritonitis exists, the temperature falls again, after an initial 
 rise, while the pulse continues to rise, and the general conditions 
 become aggravated. The pulse is, therefore, frequently a more 
 reliable sign of danger than the temperature. As the moribund 
 condition is approaching, the temperature may become subnormal. 
 In the more protracted forms of disease, which take the form of 
 phlebitic septicaemia or pyeemia, there are usually great oscillations 
 of temperature ; and the successive elevations are often accom- 
 panied by repeated rigors, perhaps at intervals of several days. 
 When the fever is continuous, the initial rigors are generally 
 not repeated. 
 
 Next to the pyrexia, the most general symptom is tenderness of 
 the uterus, accompanied by a deficiency of contraction and 
 involution. Usually there is, in addition, pain referred to the 
 uterine region, and indicating endometritis or metritis. Another 
 symptom common to most of the graver forms of the disease is 
 enlargement and tenderness of the spleen. 
 
 The tendency to delirium is slight in proportion to the degree of 
 pyrexia, compared with that which occurs in many other forms of 
 fever. When fever is high there is generally more or less 
 wandering at night, but the patient can usually be roused to 
 understand and answer. In grave septicaemia, the face is anxious 
 in expression, but the mind is often quite clear, and the patient 
 may be quite unaware of her grave condition. Severe headache is 
 common. The tongue may remain moist and clean in slight 
 attacks, but is generally coated, and eventually may become dry 
 and glazy or brown. Sweating is frequent, especially when 
 oscillations of temperature occur. 
 
 Among the most prominent of the graver symptoms are diminu- 
 tion or suppression of the lochia and of the milk. 
 
 In cases of acute sloughing or putrid endometritis the lochia are 
 often abundant, at any rate at first, and very offensive. Such an 
 offensive character in the discharge may either precede or follow 
 the onset of the pyrexia. In rare cases, in which the fever 
 
Puerperal Fevers. 1017 
 
 commences before, or immediately from the time of delivery, there 
 is an almost complete suppression of lochial discharge from the 
 outset. 
 
 In some cases, more especially when the condition is one of 
 acute septicaemia, due to a streptococcic infection, the lochia are but 
 little altered except in quantity, and there may be no odour. 
 Interference with lactation is not so general a symptom as some 
 alteration of the lochial discharge, but there is diminution or 
 suppression of milk in the graver cases of fever, if at all prolonged. 
 If the onset of fever is early, on the first, second, or third day, the 
 secretion of milk may be entirely prevented. In other cases, it 
 diminishes and ceases as the constitutional state becomes grave. 
 
 Vomiting and diarrhoea, but especially the latter, are symptoms 
 which generally indicate a severely septic form of fever. Vomiting 
 is especially associated with general peritonitis, but may occur 
 without evidence of peritonitis,, as a symptom of the pyrexia, 
 especially when the temperature rises to a high level. When 
 diarrhoea occurs, the motions are often very offensive, as if some 
 septic material were evacuated through the intestines. The 
 diarrhoea does not generally commence quite at the outset, but after 
 the disease has been established for a day or two. 
 
 Bashes. — A miliary eruption frequently results from the sweating 
 which is usual in any form of puerperal pyrexia, even that of a 
 slight and evanescent kind. There may be an evanescent general 
 scarlet rash, suggestive of the rash of scarlatina, but not always 
 followed by desquamation. Again, there may be limited erythematous 
 blotches resembling, and probably identical with, erysipelas. In 
 other cases a roseolous, papular, or petechial rash is observed. The 
 latter forms of rash, at any rate, are to be regarded as merely 
 symptoms of septicaemia, and generally indicate a grave and 
 dangerous form of the disease. 
 
 The remaining symptoms must be described under the headings 
 of the special varieties of fever. 
 
 SejJticcsmic Endometritis. — There is pyrexia, which may be only 
 moderate in degree ; rigors may or may not occur. The uterus is 
 tender, often painful, and its normal involution is retarded. Milk 
 is usually diminished or suppressed, if pyrexia is considerable. 
 The lochial discharge is diminished or suppressed in severe cases, 
 but may continue of normal amount in mild ones. Its continuance 
 is a favourable sign. The discharge may be offensive. According 
 to modern bacteriological researches, this variety includes by far 
 the largest proportion of all cases of puerperal sepsis. 
 
 General Peritonitis. — General peritonitis is by far the most 
 
ioi8 The Practice of Midwifery. 
 
 frequent variety of the severe and fatal forms of sepsis. In this 
 form, the rigor and rise of temperature are generally accompanied 
 or quickly followed by acute abdominal pain and tenderness, com- 
 mencing near the uterus and extending over the whole abdomen. 
 The patient hes on her back with the knees drawn up, as in ordinary 
 IDeritonitis. The abdomen becomes distended and tympanitic 
 from paralysis of the sympathetic nerves. Sometimes individual 
 coils of intestine may be seen standing out, and, before death, the 
 distension often becomes enormous. Vomiting is frequent, and 
 the contents of the upper part of the intestine are often ejected, 
 as well as those of the stomach. Vomiting of coffee-ground fluid 
 is a very unfavourable sign. The pulse is small and rapid, but 
 soon becomes feeble rather than resistant. It is usually a more 
 important indicator of danger than the temperature. At the early 
 stage, and, in the less virulent forms of disease, throughout the 
 whole course, the bowels are confined, as in ordinary peritonitis. 
 But in the more virulent septicaemia, diarrhoea soon comes on, 
 and the motions are frequent, liquid, and offensive. The skin 
 becomes sallow, or has a yellowish tint, and there is a peculiar 
 disagreeable smell about the breath. Pain and tenderness are 
 symptoms not invariably present. In some of the gravest forms 
 of septicemic peritonitis, especially when the inflammation is of 
 the suppurative kind, they are absent. The peritonitis then only 
 reveals itself by the abdominal distension, associated with the rapid, 
 feeble pulse, and frequently with vomiting and diarrhoea. Enough 
 fluid may be present to give a manifest fluid thrill, and dulness 
 in the dependent parts of the peritoneal cavity. In milder forms 
 of fever, on the other hand, the pain and tenderness may not 
 extend far beyond the neighbourhood of the uterus, or the general 
 tenderness may be evanescent. Abdominal distension does not 
 then proceed beyond a moderate degree. If a fatal termination 
 is approaching, the extremities become cold, the hands pick at 
 the bed-clothes, the pulse cannot be felt at the wrist, and the 
 patient often becomes comatose. When the disease proves fatal, 
 death usually occurs within a week, not uncommonly in four or 
 five days. 
 
 If the course of the disease is protracted, and the peritonitis is 
 of the adhesive form, tangible masses may after a while be formed 
 in the abdomen through the matting together of coils of intestine. 
 Sometimes suppuration takes place within a space limited by 
 adhesion. An abscess is then formed which may point on the 
 surface of the abdomen, or, less frequently, open into the intestine, 
 vagina, or bladder. Such an abscess may leave a sinus which long 
 
Puerperal Fevers. 
 
 1019 
 
 continues to discharge. In some cases, apart from general pyaemia, 
 a secondary abscess of the liver has been formed. 
 
 Pure Seyticamia. — In some cases the disease kills apparently by 
 the intensity of the poison without the production even of perito- 
 nitis, and before there is time for any metastatic inflammations to 
 arise. There is, however, almost invariably tenderness of the 
 uterus, as evidence of some local inflammation of that organ, and 
 there may be " puerperal ulcers " in the vagina. The abdomen 
 may become distended to some extent from the impression pro- 
 duced by the poison upon the sympathetic nerves, even though no 
 
 DAYofDIS. 
 
 1 
 
 2 
 
 3 
 
 4 
 
 5 
 
 6 
 
 7 
 
 8 
 
 9 
 
 10 
 
 II 
 
 12 
 
 
 
 F 
 105° 
 
 104° 
 
 103° 
 1 02° 
 101 ° 
 100° 
 99° 
 98° 
 
 M E 
 
 M E 
 
 M E 
 
 M E 
 
 M E 
 
 M E 
 
 M E 
 
 M E 
 
 M E 
 
 M E 
 
 M E 
 
 M E 
 
 
 
 
 
 
 1 
 
 1 
 
 
 
 
 
 
 1 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 i 
 
 
 
 
 
 
 
 
 
 
 
 
 i 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 A 
 
 
 
 
 
 
 
 \a 
 
 ! A 
 
 
 i 
 
 w 
 
 A 
 
 H, 
 
 
 
 
 
 H.. 
 
 J> 
 
 V^ 
 
 ,/\ 
 
 V >^ 
 
 J 
 
 
 \\ 
 
 I : 
 
 
 
 
 
 
 Y; 
 
 V 
 
 V^ 
 
 \ V 
 
 
 
 \u 
 
 y^ 
 
 
 
 
 
 
 Ifi 
 
 
 V ' 
 
 
 
 \y^ 
 
 s/ 
 
 \^^ 
 
 nX' 
 
 
 
 
 
 j 
 
 
 .j,., 
 
 \ 
 1 
 
 
 
 j 
 
 
 Fig. 491. — Temperature chart of a case of saprfemia clue to retained 
 membranes. Evacuation and washing out of uterus on eighth day, 
 followed by immediate fall of temperature. 
 
 evidence of peritonitis is found post mortem. There are rigors at 
 the commencement, and the pulse and temperature rise rapidly to 
 a high level. Diarrhoea is common. There is an absence of pain, 
 but a good deal of wandering of mind. Tenderness and enlarge- 
 ment of the spleen may be made out. Death generally occurs in 
 three or four days. 
 
 Sap'iemia, or Septic 77ifo.xicaiio?i.— Saprsemia produced merely by 
 the absorption of chemical products of decomposition, without the 
 multiplication of organisms in the blood or tissues, is probably 
 rarely seen in its pure form in the puerperal woman. The chief 
 examples of it are to be found in cases of decomposition of retained 
 placenta after premature labour or abortion, when the symptoms 
 
I020 The Practice of Midwifery. 
 
 subside rapidly, sometimes within a few hours, after the removal 
 of the source of mischief. I have, however, met with the case of a 
 primipara who had severe rigors little more than twelve hours 
 after delivery. Twenty-four hours after delivery, the lochia were 
 suppressed, the pulse was 160, temperature 102° F., and the patient 
 delirious. The case had all the aspect of the most virulent form 
 of puerperal septicaemia derived from contagion. Since, however, 
 careful inquiry failed to indicate any possible source of contagion, 
 it was decided to wash out the uterus, although there was no evidence 
 of decomposition. After twelve hours, the temperature had become 
 normal, the pulse had fallen to 90, and the lochia had returned. 
 The patient recovered without further disturbance (see Fig. 491). 
 
 The symptoms of sapraemia consist of the fever itself, frequently 
 with the addition of effects commonly produced by pyrexia, such as 
 vomiting, headache, pains in the back and limbs, sometimes delirium. 
 Eapid recovery after the removal of some decomposing material can 
 alone prove that the disease was solely or mainly sapraemia. But 
 it may always be hoped that such is the case, when the lochial 
 discharge is offensive, especially if it is found to contain saprophytes 
 and not streptococci, when the pyrexia has been only recently 
 developed, and when there is no evidence of local inflammation, 
 such as metritis, peritonitis, or cellulitis. 
 
 Vascular or Phlebitic Septiccsmia. — Distribution of poisonous 
 material into the blood from septic thrombi may commence within 
 two or three days after delivery, but frequently occurs only at a 
 later period. Symptoms of a slight pelvic cellulitis may have 
 preceded, or nothing abnormal may have been noticed. At the 
 commencement there is usually a marked rigor, and sudden rise 
 of pulse and temperature. The fever is not, however, continuous, 
 but interru23ted by remissions or complete intermissions. Profuse 
 jDerspiration generally accompanies the fall of temperature, and 
 thus the disease may resemble malarial fever. In the majority of 
 cases there is no iDeritonitis, and the abdomen is then usually free 
 from any general tenderness or distension. If a vaginal examina- 
 tion is made, a slight cellulitic thickening may often be felt near 
 the uterus, but not sufficient to account for the degree of fever. 
 Kigors are apt to be repeated with the successive rises of tempe- 
 rature. Eecovery may take place without the j)roduction of any 
 metastatic inflammation, or the disease maybe merged into pyemia. 
 It is in this form of disease especially that pyaemic abscesses in the 
 lungs and other viscera are apt to be formed by septic emboli. 
 The course of the disease is apt to be more protracted than 
 other forms of puerperal fever. If it is converted into pyaemia. 
 
Puerperal Fevers. 1021 
 
 the fever becomes continuous, and the general condition more 
 grave. 
 
 Pycsmia. — In all cases the course of which is protracted, metastatic 
 inflammation is apt to arise. Such inflammation chiefly occurs in 
 the cellular tissue, especially of the limbs, in the joints, and in the 
 lungs and other viscera. Both inflammation of the cellular tissue 
 and that of the joints may subside without going on to the forma- 
 tion of abscess. Out of 354 cases of puerperal pyrexia reported to 
 the Collective Investigation Committee, there were 14 in which 
 external pyemic abscesses were formed. The mortality in these was 
 28"5 per cent., the average mortality of the whole number being 
 47'4 per cent. It therefore appears that although a patient may 
 sink from exhaustion from the suppuration of external abscesses, yet 
 the cases in which these occur, being comparatively protracted, are 
 not the most dangerous. The occurrence of pneumonia or pleurisy 
 in the course of puerperal septicaemia does not necessarily imply the 
 formation of pyemic deposits in the lung, but it frequently does so, 
 and is always of serious import. Out of the same 354 cases, 
 secondary pneumonia or pleurisy was noted in 20 cases, the mortality 
 of which was 70 per cent. Pericarditis is less frequently observed. 
 It is also of serious import. Occasionally, both external and visceral 
 pyaemia are combined in the same person. 
 
 Pelvic Cellulitis (Parametritis) and Pelvic Peritonitis {Perimetritis). 
 — Pelvic cellulitis and pelvic peritonitis are diseases which occur 
 independently of pregnancy as well as in the puerperal state. By 
 many authors the description of them is separated altogether from 
 that of puerperal fever, on the ground that they do not necessarily 
 arise from any septic origin. This is so far true that they may be 
 due to a traumatic cause, such as the effects of difficult instrumental 
 delivery. Even in this case, however, though there may be no 
 virulent infection conveyed from without, yet the spreading 
 cellulitic inflammation is probably associated with the presence of 
 micrococci, especially in those cases which end in suppuration. The 
 explanation may be that, when the vitality of the tissues is lowered 
 by mechanical injury, organisms which are commonly present 
 are able to multiply in them. It is probable, therefore, that, 
 in the puerperal woman, parametritis and perimetritis never 
 occur altogether apart from some septic element, although there 
 may have been neither any conveyance of special poison, nor 
 manifest decomposition in the genital passages. Some degree of 
 parametritis is often associated with grave forms of septicaemia. 
 But, if the parametritis is extensive, and forms the main feature 
 in the case, it is usually implied that there is no general septic 
 
I022 The Practice of Midwifery. 
 
 infection ; and that, if any special infection has been received, its 
 effects are limited to the local inflammation. Parametritis is thus 
 an example of a condition which cannot be excluded from the group 
 of septic diseases, but yet the prognosis of which is generally 
 favourable. 
 
 Apart from pregnancy, primary parametritis hardly occurs, 
 unless as the result of septic absorption from some wound or 
 operation on the uterus. Some parametritis, however, is often 
 associated with perimetritis, and arises by extension of inflam- 
 mation from the salpingitis which was an antecedent to the 
 perimetritis. 
 
 In the puerperal woman either parametritis or perimetritis may 
 be primary, and the former is generally associated with some peri- 
 metritis, from extension of the inflammation from the cellular 
 tissue to the peritoneum covering it. 
 
 The symptoms of primary puerperal perimetritis resemble those 
 of general peritonitis, except that they are less severe, and pain and 
 tenderness are limited to the neighbourhood of the pelvis. 
 
 In parametritis, as in other forms of puerperal pyrexia, the 
 onset is generally within the first five days. It is not, indeed, 
 uncommon to meet with cases in which the onset is insidious, and 
 which only attract attention at a much later period, sometimes 
 several weeks after delivery, when the woman has begun to get 
 about. But, in most such cases, there has been, shortly after 
 delivery, pyrexia with slight pain, the cause of which has been 
 overlooked. 
 
 The attack generally commences with a rigor and sudden rise of 
 temperature. The temperature commonly reaches 102° F. and may 
 rise to 103° or 101° F. The pulse is not so frequent in proportion as 
 in general septicaemia, and rarely exceeds 120. With the pyrexia 
 commence pain and tenderness in the lower part of the abdomen, 
 generally on one side. The degree of pain and tenderness depends 
 much upon the extent to which the peritoneum is involved in the 
 inflammation; and in some cases they are slight. The pain fre- 
 quently subsides in a few days, while the tenderness remains. 
 When the peritoneal affection is prominent, there may be also 
 nausea and vomiting, an anxious expression of countenance, and 
 some distension of the lower abdomen. If the exudation surrounds 
 the bladder and rectum, pain on defecation and micturition comes 
 on at a later stage, and there is also vesical tenesmus. The bowels 
 are generally constipated. If a mass is formed in the broad liga- 
 ment, the patient lies with the thigh on the affected side drawn up, 
 and cannot extend it without pain. There is also pain down the 
 
Puerperal Fevers. 1023 
 
 thigh, and in the lumbar region, from pressure on the nerves. The 
 temperature generally reaches its height in two or three days. Its 
 course afterwards is irregular, and there are usually morning remis- 
 sions or intermissions, especially as the disease is subsiding. Pro- 
 fuse sweating often accompanies the remissions. While the pyrexia 
 is considerable, there is usually headache and sleeplessness, and the 
 tongue is coated. The fever may subside within a week, or may be 
 prolonged with an irregular course for several weeks. Repeated 
 rigors, with successive elevations of temperature to a high point, 
 generally indicate suppuration. 
 
 Inflammatory thickening near the uterus may be formed within 
 a few days, but it is generally not till after a week that any con- 
 siderable mass of exudation is formed. On vaginal examination a 
 swelling is then felt, usually on one side of the uterus. It may be 
 rounded or may be somewhat wedge-shaped, occupying the position 
 of the broad ligament, the broad end of the wedge spreading out 
 toward the pelvic wall, to which it is attached (see Fig. 492, 
 p. 1024). Generally a laceration of the cervix may be felt on the side 
 corresponding to the swelling. The dimensions and outline of the 
 swelling can best be estimated by bimanual examination. The 
 lateral vaginal fornix, and often, if there is accompanying perime- 
 tritis, the posterior fornix, are depressed by the exudation. The 
 thickening may extend round the back of the uterus and reach the 
 other side, or, more rarely, descend on the anterior vaginal wall, 
 surrounding the bladder. The uterus is pushed toward the 
 opposite side. Its mobility is diminished, and may be almost 
 entirely lost, if the exudation extends around it. Fixation of the 
 uterus is not, however, so marked a feature in pelvic cellulitis as 
 in pelvic peritonitis, and its mobility is more quickly restored. If 
 the exudation extends to the iliac fossa, it may form a swelling 
 reaching several inches above Poupart's ligament, which is readily 
 felt by external manipulation only, and is sometimes visible on 
 inspection of the abdomen. The tendency to spread to the iliac 
 fossa is much greater in cellulitis of puerperal origin than in that 
 which arises apart from delivery. 
 
 If suppuration does not occur, the swelling becomes gradually 
 harder and less sensitive, and then begins to diminish from absorp- 
 tion. At the height of the disease it feels rounded from the vagina ; 
 but, as it diminishes, it becomes flatter on its lower surface, and 
 sometimes concave or angular. When the mass has been absorbed, 
 the uterus becomes drawn toward the affected side by contraction 
 of fibroid tissue. The uterus may regain most of its mobility. It 
 may be many months before the utmost attainable degree of 
 
I024 
 
 The Practice of Midwifery. 
 
 absorption is reached, and some fibroid thickening may remain 
 permanently, but often, after six or eight weeks, the swelling has 
 almost entirely disappeared. Years afterwards, the relic of the 
 disease may be felt in the shape of a fibrous band, generally 
 starting from the angle of a cervical laceration outward to the 
 pelvic wall. 
 
 If suppuration takes place, the disease is protracted for many 
 weeks, hectic fever is established, and there is loss of appetite, and 
 other signs of pus formation. It is often seven or eight weeks 
 
 Fig. 492. — Section parallel to pelvic brim, a little above the level of the internal 
 OS uteri, showing the situation of induration in parametritis. B, bladder ; 
 A F P, anterior fossa of peritoneum, free from exudation; P F P, posterior 
 fossa of peritoneum, free fiom exudation; u, uterus displaced to right; 
 B L, left broad ligament infiltrated vi^ith cellulitic effusion ; E, rectum. 
 
 before the pus is discharged. Some authors have estimated that 
 suppuration takes place in more than half the cases of parametritis, 
 but probably the proportion is much less than this, if all slight cases 
 are included. Suppuration is, however, more frequent in parametritis 
 than in perimetritis. 
 
 The most characteristic local condition produced when the 
 thickening is due to perimetritis, not parametritis, is a uniform 
 board-like induration of the whole roof of the pelvis, with the uterus 
 firmly fixed in its centre or pushed very slightly forward by lymph 
 in the pouch of Douglas. This is chiefly met with in cases arising 
 apart from parturition or abortion. Peritonitis may, however, form 
 a local swelling at the back, front, or side of the uterus, from a 
 
Puerperal Fevers. 
 
 1025 
 
 matting together of coils of intestine, and especially in one or both 
 posterior quarters of the pelvis, due to matting of the tubes and 
 
 Fig. 493. — Death-rates from puerperal fever and other diseases in England and 
 Wales, with rainfall at Greenwich, from 1881 to 1899. KA. Rainfall at Green- 
 wich, inverted curve. P.F. Puerperal fever. ER. Erysipelas. SEP. Septi- 
 caemia and pyaemia. SC. Scarlatina. RH. Rheumatic fever. Each vertical 
 division corresponds to 20 per cent. 
 
 ovaries, sometimes with distension of the tubes. If such a swelling 
 extends at the same time far above the brim, not toward the iliac 
 fossa, it is likely to be the result of peritonitis. The opening of an 
 abscess at or near the uml)ilicus is also a h'v^w of peritoneal origin. 
 M. 65 
 
I026 The Practice of Midwifery. 
 
 In encysted peritonitis a fluctuating swelling is formed, which may 
 resemble a cystic tumour, and displaces the uterus by pressure. 
 It is most commonly behind the uterus, and pushes the cervix 
 forward. 
 
 After the opening of an abscess, the pain is generally quickly 
 relieved, the fever subsides, and the sinus closes in a short time. 
 Sometimes, however, if there is deep and extensive burrowing of pus, 
 the sinus remains long open, and the patient may eventually die 
 from exhaustion. This is more likely to happen with an abscess of 
 peritoneal origin. 
 
 Frequency.— It will be seen from Fig. 485, p. 1000, that in Eng- 
 land and Wales, up to 1899, puerperal sepsis, though limited to one 
 sex and a particular time of life, still caused a mortality nearly half 
 as much again as that of erysipelas in both sexes, and nearly six 
 times as great as that of all other forms of septicaemia and pysemia 
 together. But, while in the term 1855 — 1880 puerperal sepsis 
 shows no diminution, but rather an increase, there is a steady 
 diminution from 1881 to 1900, with the exception of the years of 
 special rise, 1892, 1893. In London the improvement is as great 
 as that in other septic diseases, the curve beginning at 46 per cent, 
 above the mean and ending at 45 per cent, below it (Fig. 493, 
 p. 1025). In England and Wales the improvement is not so great. 
 The curve begins at 12 per cent, above, and ends at only 20 j)er 
 cent, below, the mean ; and at a mortality of 62 per million living, 
 compared with one of 46 per million in London. In England and 
 Wales, however, there has been a steady improvement during the 
 last few years, and while in 1901 the death-rate from puerperal fever 
 was 22*3 per 10,000 births with living children, it has fallen to 14*8 
 for the year 1908. In the same way there has been even a more 
 marked improvement in the figures for London, no doubt due to the 
 fact that a larger proportion of the confinements in this city are 
 attended by medical men or properly trained midwives. 
 
 Diagnosis. — Any elevation of temperature much above 100° F. 
 in the j)uerperal woman, if not accounted for by some independent 
 condition, such as inflammation of the breasts, constipation, or 
 nervous disturbance, should raise a suspicion as to the commence- 
 ment of septic disturbance, although many such elevations prove to 
 be evanescent. The rise of temperature is more significant, if 
 accompanied by rigors and tenderness of the uterus. A pulse rapid 
 in proportion to tbe temperature, a coated or dry tongue, headache 
 and vomiting, are also signs pointing to septicaemia. If the progress 
 of involution of the uterus is recorded in the way previously 
 
Puerperal Fevers. 1027 
 
 described, a check in the rate of diminution, especially if accompanied 
 by pyrexia, is very valuable as an early sign of mischief. It may 
 occur both in saprsemia and septicaemia. The pain due to com- 
 mencing metritis or peritonitis is distinguished from after-pains by its 
 continuous character, and by its being accompanied by tenderness, 
 and a pulse more rapid than normal. Distension of the abdomen 
 is a significant symptom, even in the absence of pain and tenderness. 
 Diminution or suppression of lochia and milk generally point to 
 developed septic inflammation, especially if the lochial discharge has 
 previously been offensive. 
 
 It must be remembered that a rise of temperature during the first 
 week may be due to the onset of some acute illness independent of 
 the puerperium. The conditions most likely to lead to error in 
 diagnosis are influenza, typhoid fever, malaria in tropical climates, 
 and the onset of acute miliary tuberculosis. I have met with a case 
 in which a failure to recognise that a puerperal patient, thought to 
 be affected by septicaemia, was in reality suffering from typhoid 
 fever, led to a disastrous outbreak of that disease among the nurses 
 of the institution to which she was admitted. 
 
 In all cases a careful examination of the genital tract should be 
 carried out, and special attention paid to the appearance of any tears 
 or lesions in the vulva and vagina. A bacteriological examination 
 should be made of the contents of the uterus in the manner described 
 on p. 1036. 
 
 A cultivation should also be made from the blood in all sus- 
 pected cases of septic infection, and a differential count of the blood 
 cells undertaken. 
 
 Prognosis. — Statistics already quoted show that, if slighter and 
 transient forms of pyrexia are included, in which modern observa- 
 tions show the presence of septic organisms within the uterus, the 
 general prognosis is favourable, and the mortality not more than 
 from 4 to 8 per cent. In the 354 cases, however, reported to the 
 Collective Investigation Committee of the British Medical Associa- 
 tion (1884), which were cases of serious forms of pyrexia of some 
 duration, with temperatures over 103° or 104° F., the general 
 mortality was 47*4 per cent. This high mortality cannot have been 
 due to undue activity of treatment, for curetting of the uterus was 
 not employed. The relative mortality of some of the principal forms 
 of the disease has already been mentioned. The danger appears to 
 depend mainly upon the virulence of the particular infection 
 concerned. The mortality of 70*8 per cent, in 24 cases 
 ascribed to infection from other cases of puerperal septicaemia, 
 
 65—2 
 
I028 ' The Practice of Midwifery. 
 
 and 70*6 per cent, in 17 cases ascribed to contagion from 
 erysipelas, but not showing any erysipelatous rash, is specially 
 worthy of note. It agrees with experience as to the high mortality 
 when a series of cases of puerperal sepsis has occurred in the 
 practice of a midwife or accoucheur. When the condition is one 
 merely of retention of lochia or of putrid endometritis due to 
 portions of retained placenta or membranes the outlook is usually 
 favourable. This is also the case when the organism present is 
 the gonococcus. In cases of general streptococcic infection, if there 
 are definite local affections, the prognosis is favourable, especially 
 if the symptoms are limited to the uterus, if there is no excessive 
 elevation of temperature or pulse, no distension of abdomen or 
 diarrhoea, and if the lochial discharge is not suppressed. The 
 earlier the onset of the disease after delivery the worse is the 
 j)rognosis, and it is still worse if the fever commences before 
 delivery. When the fever commences after a week has passed, 
 tbe prognosis is more favourable. The complaint is then more likely 
 to turn out to be local parametritis without general septic infection. 
 The gravest symptoms are signs of general peritonitis, great 
 rapidity of pulse, very high temperature, dry tongue, severe vomit- 
 ing, diarrhoea, and above all great tjanpanitic distension of abdomen. 
 Diphtheritic deposit on vaginal ulcers, or in the throat, is an un- 
 favourable sign. The most serious complications are pneumonia and 
 pericarditis. With a high degree of pyrexia, it is a favourable sign 
 to find a considerable local swelling of parametritis, for the pyrexia 
 need not then be due to the more serious condition of general 
 peritonitis, or to general septic infection. If an investigation of 
 the blood shows that the number of leucocytes is 50,000 or more 
 per cubic centimetre, that the eosinophiles are absent while the 
 neutrophiles are undergoing degenerative changes, and that there 
 is a marked diminution in the number of the red discs, a very 
 unfavourable prognosis should be given.^ 
 
 Prophylaxis. The most important points in prophylaxis are — - 
 (1) to guard the puerperal woman from the access of any special 
 infection ; (2) to prevent the retention of any material liable to 
 decompose or form a nidus for septic micrococci ; and (3) to secure, 
 as far as possible, that the woman shall be in the best possible 
 condition for resisting any morbid process, and that no unnecessary 
 avenues shall be left open for absorption, and no avoidable injury 
 done to the tissues, 
 
 1 Kownatzki, Zentr.-ilbl. f. G.ynak., 1906, No. 43. 
 
Puerperal Fevers. 1029 
 
 The first thing, in point of time, is to promote the health of the 
 woman before delivery. This, however, the physician may not 
 always have the opportunity of carrying out. The sanitary con- 
 ditions of the house and lying-in room are of special importance. 
 Care should be taken that the drains are in order, and there is no 
 access of sewer gas, or ill-arranged water-closet or sink near the 
 room. Ventilation by abundant fresh air is of equal importance. 
 This is proved by the fact that the frequency of puerperal 
 septicaemia has a seasonal variation in proportion to the cold. 
 The mean curve of mortality has a maximum in January, and a 
 minimum period from the middle of May to the end of September. 
 Ventilation should be aided by an open fire whenever the weather 
 is not warm enough to allow open windows. The utmost cleanli- 
 ness should be observed in the lying-in room, and all soiled linen 
 at once removed. 
 
 In labour, the patient should not be allowed to become exhausted 
 by undue protraction, and timely aid by forceps should be given 
 when required. On the other hand, it is of at least equal import- 
 ance not to cause unnecessary lacerations by premature or hasty 
 delivery with forceps when the head is delayed by the cervix or 
 vaginal outlet. No rupture of the perineum should be allowed to 
 remain without the application of sutures. It is of importance to 
 secure a firm and permanent contraction of the uterus, that there 
 may not be gaping orifices to afford ready access for any septic 
 germs to reach the thrombi in the vessels, and that clots may not 
 bs allowed to remain and become decomposed within the uterine 
 cavity. It has been recommended to administer, as a routine 
 practice in all cases, a mixture C(mtaining quinine, ergot, and 
 digitalis, with the object of maintaining uterine contraction. 
 This does not seem necessary when the woman is strong and 
 the uterus active, but it is very useful whenever there is any 
 tendency to inertia. The plan already recommended of not 
 letting the patient remain too much in one position, and allowing 
 her to kneel up to pass water after two days, aids the escape 
 of the lochial discharge and the expulsion of any clots from the 
 uterus. 
 
 The most important safeguards consist in the use of those anti- 
 septic precautions during labour and the puerperal state which 
 have been already described (see pp. 291, 380), especially those 
 which are designed to prevent the introduction of any septic 
 micro]>es into the genital canal. 
 
 Direct precautions should also be taken against any possible 
 conveyance of contagion from any virulent source. No nurse 
 
1030 The Practice of Midwifery. 
 
 should be allowed to be in attendance who has recently attended 
 any case of zymotic disease, puerperal septicaemia, erysipelas, or '.m 
 
 even any doubtful case of pyrexia after delivery. All unnecessary • ■ 
 visitors should be excluded from tbe lying-in room during the " 
 
 first week, especially any who are likely to have been in contact 
 with any zymotic or puerperal contagion. 
 
 In family practice it is impossible, as a rule, for the practitioner 
 to give up midwifery practice whenever he has cases of erysipelas 
 or zymotic disease, or suppurating wounds, under his charge. 
 That contagion is but rarely carried appears to be proved by 
 the comparative rarity of actual scarlatina and erysipelas after 
 delivery in proportion to the whole number of cases of severe 
 puerperal pyrexia, especially when it is remembered that con- 
 tagion may be received in many other ways besides that of 
 conveyance by the accoucheur. All medical men should, how- 
 ever, take the most careful antiseptic precautions after visiting 
 cases of any zymotic aisease before attending a labour or visiting 
 puerperal patients. Not only should hands be washed in some 
 effective antiseptic solution, such as in rectified spirit and then in 
 perchloride of mercury (1 in 1,000), but clothes should be changed, 
 and the longest possible interval allowed for disinfection by 
 fresh air. 
 
 It should be remembered that, next to puerperal fever itself, the 
 most dangerous source of infection is phlegmonous erysipelas 
 with a discharging or suppurating wound. Any practitioner 
 attending to such a wound would do well to take as careful extra 
 precautions as if he were attending a case of puerperal septicaemia. 
 In all these conditions the practice should be made of wearing 
 steriHsed rubber gloves when attending a lying-in patient. 
 
 It is a still more important question what precautions are 
 necessary when a medical man has a case of puerperal pyrexia of 
 any form under his charge, and whether it is his duty, under 
 these circumstances, to give up midwifery practice. It is as 
 undesirable to impose restrictions which are not necessary as to 
 omit any which are really called for. A practitioner may be 
 tempted to omit local treatment, which is of importance for the 
 recovery of his patient, if he believes that his undertaking it 
 renders it necessary for him to give up the greater part of his 
 practice. Again, under similar circumstances, he may be reluctant 
 to admit to his own mind, when diagnosis is doubtful, that any 
 given case of puerperal pyrexia is of septicsemic character, and 
 liable to become the source of infection. 
 
 Puerperal septicaemia does, however, appear to be the most 
 
Puerperal Fevers. 1031 
 
 dangerous source of contagion of all, as is proved by those 
 unfortunate instances in which a practitioner has a series of 
 severe or fatal cases in his practice, terminated only by his giving 
 up midwifery for a considerable time. The utmost precaution is 
 therefore necessary. When contagion has been conveyed by the 
 accoucheur, it has frequently happened that the victims have 
 been women delivered within two or three days after the one who 
 was the source of the contagion, and the mischief has thus been 
 done before the physician had become aware that the disease was 
 of a nature requiring special precaution. It would be impossible 
 for every medical man to give up midwifery practice whenever a 
 patient had a rise of temjDerature after delivery. The first and 
 most essential requisite, therefore, is to regard all cases of puerperal 
 pyrexia, even of the slightest kinds, as suspicious, and to adopt 
 the most scrupulous antiseptic precautions in attending them. 
 
 It is above all important to preserve the clothes, and especially 
 the coat, from becoming contaminated. The hands may probably 
 be made safe by the thorough use of antiseptics and the wearing of 
 sterilised rubber gloves, but the clothes cannot be so unless they 
 are disinfected by heat. Fumigation may perhaps destroy germs 
 conveyed in the form of dust and settling on the surface, but cannot 
 be relied upon if there has been closer contact with infecting 
 material, or if blood or discharge has soaked into the cloth. Even 
 if the clothes are changed, it is easy to understand that, in the very 
 act of changing, contagion may be conveyed by the hands from one 
 suit to another. When physicians have given up midwifery for 
 several weeks and yet have had a recurrence of septicaemia on 
 returning to it, it is probable that, in most cases, the contagion has 
 lingered in clothes. It is obvious that gloves especially, if once 
 infected, would readily again convey contagion to the hands. Some- 
 times, indeed, there may have been something peculiar to the 
 individual, as in the case of those who have themselves any ailment 
 associated with a purulent discharge. 
 
 In any case, therefore, of puerperal pyrexia, even if regarded as 
 not serious, the physician should keep his clothes from contact with 
 the patient or the bed-clothes. If he makes any vaginal examina- 
 tion, he should take off his coat, roll up his shirt-sleeve, and put on 
 an overall kept for that particular case. After touching the patient, 
 or anything connected with her, he should constantly bear in mind 
 that his hand is contaminated, and avoid touching his own clothes, 
 bag, or instruments with it until it has been disinfected. A 
 thermometer or stethoscope should be disinfected with equal care. 
 After disinfecting his hands, he should avoid even shaking hands 
 
1032 The Practice of Midwifery. 
 
 with the patient on leaving. The only effectual mode of disinfecting 
 clothes is exposure to steam at a high pressure. If a physician has 
 to attend a confinement after recent contact with a case likely to 
 convey virulent infection, it is a safeguard, in addition to the 
 ordinary antiseptic precautions, to wear a sterilised overall, as for 
 an abdominal section, and indiarubber gloves, sterilised by boiling 
 water. 
 
 When a case of puerperal pyrexia is likely to be specially con- 
 tagious, it is desirable that the attendant should give up midwifery 
 practice for a time. Much yet has to be learnt about the differences 
 in contagious character of different forms of the disease. But it 
 appears to be clearly established, that the most contagious are 
 very severe or fatal forms of it (see p. 1005), and also those which 
 are themselves derived from virulent conveyed contagion. My own 
 belief is that antiseptic precautions carried out as described above 
 are an adequate security. But the fact remains that contagion is 
 sometimes conveyed, and the occurrence of the first case of 
 septicaemia generally implies some deficiency in antiseptic method. 
 There is also another consideration to be taken into account. 
 If it is known that a practitioner has lost a patient after delivery, 
 and any other of his patients suffers from pyrexia, he is likely to be 
 accused of carrying contagion, even though there may be, in reality, 
 no connection between the two cases. Hence if a practitioner has 
 a fatal case of puerperal septicaemia, or one likely to prove fatal, he 
 will do wisely to give up midwifery practice up to at least a week 
 after the cessation of attendance. A bath should be taken before 
 he again attends labour, the clothes disinfected, if possible, by 
 steam, and a different suit worn. If there is reason to think that 
 contagion has actually been conveyed to any other patient, it is 
 obvious that the antiseptic precautions taken have not proved 
 adequate. It is then imjDerative to give up midwifery practice, and 
 in this case it is well to make the quarantine longer — as much as 
 two or three weeks. 
 
 By the rules of the Central Midwives' Board, whenever a midwife 
 has been in attendance upon a patient suffering from j^uerperal 
 fever, or from any ihness sujjposed to be infectious, she must dis- 
 infect herself and all her instruments and other appliances to the 
 satisfaction of the local sanitary authority, and must have her 
 clothing thoroughly disinfected before going to another labour. 
 
 Prophylaxis in Lying-in Hospitals. — In former years the mor- 
 tality due to puerperal septicaemia in lying-in hospitals was so 
 great, that many authorities considered that such hosj^itals were 
 an injury, rather than an advantage, to the community. While 
 
Puerperal Fevers. i033 
 
 in such institutions as the outdoor lying-in charities of London 
 hospitals, and the Koyal Maternity Charity, the total maternal 
 mortality generally did not exceed one-half per cent., in lying-in 
 hospitals, apart from any epidemic, the mortality almost always 
 exceeded 1 per cent., and often reached or exceeded 2 per cent. 
 
 The transformation by which lying-in hospitals, not only in 
 Britain, but on the Continent, have now been changed from 
 the most dangerous into the safest places for a lying-in woman, 
 was first obtained by the introduction of the use of perchloride of 
 mercury as an antiseptic. Taking the General Lying-in Hospital 
 as an example, the death-rate was reduced from 10 or more to 
 less than 4 per 1,000 ; the death-rate from septicaemia or pelvic 
 inflammation to 1"5 per 1,000 ; and cases of septic pyrexia, includ- 
 ing slight and transient ones, from 40"0 to 2'5 per cent. In the 
 ten years ending 1904 5,227 women were delivered in this hospital 
 with only three deaths from sepsis, or a death-rate of 0*5 per 1,000 ; 
 while in the Eotunda Hospital from 1890 to 1896 the mortality from 
 sepsis was only I'l per 1,000. 
 
 These results in the General Lying-in Hospital were obtained 
 by the use of antiseptic agents. Perchloride of mercury, 1 in 
 1,000, was used to disinfect hands and non-metallic instru- 
 ments by every one who touched the patients. A douche of per- 
 chloride of mercury, 1 in 2,000, was used after labour. The same 
 antiseptic was used for washing and douching the patient regularly 
 throughout the puerpery, for the first three days of a strength of 
 1 in 2,000, afterwards 1 in 4,000. Horsehair mattresses were 
 employed, and were disinfected by heat only when an unfavourable 
 case had occurred. A separate irrigator was provided for each bed, 
 having a vaginal tube of glass. 
 
 It is possible that some of the modern non-poisonous antiseptics 
 may prove as efficacious as mercury, but they have not yet been 
 subjected to so prolonged a trial. Lysol may be used of a strength 
 of 1 in 200 for vaginal douches, chinosol 1 in 300 or 1 in 500, 
 cyllin 1 in 100. It appears to be safest to retain the mercurial 
 solution for disinfection of hands. Of late the tendency at 
 lying-in hospitals is to disuse routine douches in normal cases, 
 but, in their absence, the vulva should be protected by a sterilised 
 or antiseptic occlusion bandage after delivery, and should be 
 carefully cleansed and disinfected before labour. At the New 
 York Lying-in Hospital douches have been abandoned, without 
 impairment of results. But the vulva is kej)t covered by antisej^tic 
 pads soaked in creolin, 1 in 100, covered with oiled muslin, and 
 changed every six hours, or whenever the patient passes urine or 
 
I034 The Practice of Midwifery. 
 
 faeces. At the Eotunda Hospital, Dublin, routine douches are also 
 disused, and the results remain excellent. 
 
 Treatment. — Local Treatment. — The first question to be con- 
 sidered is that of local treatment, to prevent, if possible, the 
 entrance of any more septic germs or poisonous material into 
 the circulation or tissues. 
 
 First, a careful examination should be made of vulva, vagina and 
 cervix, with a view to determine the probable site of absorption, 
 and direct local treatment accordingly. If stitches have been 
 applied to a ruptured perineum and union has evidently failed, it 
 may be desirable to remove the stitches. On the other hand, an 
 unstitched rupture may be united with sutures with advantage, 
 even up to a week after delivery, if the surface is not too 
 unhealthy. If any " puerperal ulcers " or sloughy granulating 
 surfaces are discovered, the}^ should be painted over with equal 
 parts of tinct. ferri perchlor. and tinct. iodi, or with solution of 
 nitrate of silver (gr. xx. ad 5].), or a solution of carbolic acid 
 in glycerine (gr. x. ad 5].). If there is any diphtheritic or 
 pseudo-diphtheritic deposit, the application should be repeated 
 till it disappears. 
 
 In the absence of any other probable situation, the placental site 
 will be the most likely seat of absorption ; and this conclusion is 
 confirmed if the uterus is tender and its involution deficient. In 
 some cases there may be reason to suppose that more than one site 
 of absorption exists. 
 
 In any case of pyrexia, vaginal irrigation should be adopted, if 
 it has not previously been carried out, the irrigation being used at 
 least twice a day. One of the mo.-.t efiicacious antiseptics should 
 be used, such as perchloride or iodide of mercury, 1 in 4,000. If 
 the patient should be suffering from diarrhoea, lysol, 1 in 100, 
 chinosol, 1 in 300, or cyllin, 1 in 100, may be used instead of the 
 mercurial solution. If there has been any offensive discharge, a 
 pessary containing 15 or 20 grains of iodoform may be introduced 
 into the vagina after each irrigation.-^ 
 
 If it is diagnosed that the placental site is the seat of absorption, 
 the first question to decide is whether to explore the cavity of the 
 uterus. In cases of only moderate pyrexia, and when the medical 
 attendant from a careful examination of the placenta and mem- 
 branes after their expulsion has satisfied himself that there is no 
 
 1 At Vienna iodoform rods are used according to the following formula : — iodoform 
 gr. 100 ; gum arabic, glycerine, and starch, each 10 grains. One of these is introduced 
 into the uterine cavity after every difficult labour. 
 
Puerperal Fevers. 
 
 1035 
 
 possibility of any portion of either of these structures being 
 retained m utero, it may be sufficient first to try the effect of irrigating 
 the uterine cavity with an antiseptic such as iodide or perchloride 
 of mercury, 1 in 6,000 to 8,000. If the poisonous effect of mercury 
 is feared, lysol, 1 in 100, tinct. iod., 5ij. ad Oj., or chinosol, 1 in 300, 
 or cyllin emulsion, 1 in 200, may be used. Whitridge Williams 
 uses only normal saline solution, others recommend alcohol 50 per 
 cent. An irrigator should be used, and care should be taken to 
 avoid introducing air, by seeing that the delivery tube is filled with 
 the solution before introducing it, and by stopping the flow before 
 
 Fig. 494. — Uterus with a portion of retained placenta, from a patient dying 
 of septicEemia, who had an attack of post partum haemorrhage. (Univ. 
 Coll. Hosp. Med. School Mus.). 
 
 the reservoir is nearly empty. The vagina should first be washed 
 out, lest any septic microbes should be carried by the tube from the 
 vagina into the uterus. The best tube for irrigating the uterus is 
 Budin's double-action catheter of glass, celluloid or metal ; and 
 care should be taken that the end of the tube is passed quite up to 
 the fundus. This can generally be done most easily with the 
 patient in the lateral position, with the hips over the edge of the 
 bed, and a mackintosh to carry the fluid down into a foot-pan. 
 Before the irrigation a specimen of secretion should always be 
 obtained from within the cervix by a sterilised swab, and tested 
 both by immediate staining of a cover glass preparation and by 
 
1036 The Practice of Midwifery. 
 
 cultivation, A still better plan is to suck up the uterine secretion 
 into a sterilised glass tube having a suitable curve, by means of a 
 syringe attached to it by a piece of rubber tubing, and then close 
 the ends with sealing-wax. The patient is placed in the lateral or 
 semi-prone position, the cervix exposed by a Sim's speculum, and 
 its vaginal portion carefully cleansed by a swab of sterilised cotton. 
 The glass tube is then passed as far as possible into the uterine 
 cavity. 
 
 If after this the symptoms are not improved within twenty-four 
 hours, or in any case where there is the least possiblity of a portion 
 of the membranes or placenta having been left in utero, the interior 
 of the uterus should be explored at once with the finger. The 
 same should be done in all cases without delay or preliminary 
 treatment, if the first rise of temperature is to a high point, such 
 as 103° or more, or if there has been an adherent placenta. Within 
 the first week after delivery the cervix will generally allow the 
 finger to pass. In cases of pyrexia arising later, it might be 
 necessary to dilate first with Hegar's dilators. An anaesthetic is 
 given, the gloved finger passed to the fundus, the whole cavity of 
 the uterus, especially the placental site, explored, and any adherent 
 placental tissue or clots or shreddy decidua that may be found 
 scraped away and removed. The uterus is then washed out with 
 a weak antiseptic solution, boiled water, or normal saline solution. 
 If shreddy tissue or offensive material has been found, the irriga- 
 tion of the uterus should be repeated once a day for several days, 
 or so long as any shreds are washed away, especially if the lochial 
 discharge, by which the decidual fragments are generally washed 
 out from the uterus, is early suppressed. A rod containing iodoform 
 (see p. 1034) may be introduced after each irrigation. If the interior 
 is found quite smooth and the pyrexia is attributed to streptococcic 
 infection, it is better to leave the cavity alone after the first irriga- 
 tion, since the streptococci will be multiplying in the uterine wall 
 and cannot be reached by the lotion. Repeated irrigations are 
 more likely to be beneficial if bacteria of decomposition or staphylo- 
 cocci, not streptococci, are found in the uterine secretion. 
 
 Some authorities recommend the use of the curette instead of the 
 finger.^ The curette may be used for two different objects, either 
 as a substitute for the finger to remove adherent shreds, or with 
 the view of removing the whole of the endometrium in which the 
 streptococci are present. While general curetting of the endome- 
 trium has sometimes resulted in a striking improvement, it is 
 
 1 Knyvett Gordon, Jouin. Obst. and Gyn. Brit. Emp., 1908, Vol. XIV., No. 4, 
 p, 257. 
 
Puerperal Fevers. 1037 
 
 capable of doing great harm. There seems to be only a remote 
 possibility that the whole of the microbes could be removed, and 
 there is evidently a risk that, if a barrier of leucocytes has been 
 formed against the streptococci, fresh avenues of absorption would 
 be opened up by the curette. While opinions widely differ, the 
 prevalent view apj^ears to be that general curetting as a routine 
 treatment more often does harm than good and increases the 
 average mortality. If undertaken at all, it should be done before 
 there is any sign of sepsis extending beyond the uterus. A.fter- 
 wards the cavity of the uterus may be plugged with moist iodoform 
 gauze 10 per cent, for twenty-four hours, both for the arrest of 
 haemorrhage, and for the destruction of any microbes which may 
 remain, or it may be swabbed out at the time with pure lysol 
 or izal. 
 
 In the opinion of the author the finger is better as a rule than 
 the curette for the removal of placental tissue or shreds, unless 
 the former is very firmly adherent ; and the curette should only be 
 used in the exceptional cases in which placental tissue or shreds 
 cannot be satisfactorily removed by the finger. The best form of 
 curette is a blunt irrigating curette of rather large size attached to 
 an irrigator. By means of this a stream of hot antiseptic solution 
 at 115° F. is poured through the stem of the curette during the 
 operation, and tends to check haemorrhage as well as to wash away 
 debris. If the shreds cannot be detached witli this, a sharp curette 
 may be used with the greatest caution and the removal completed 
 by brushing out the uterus with a brush curette, the so-called 
 ecouvillonage of French authors. 
 
 Peritonitis may be treated locally by hot fomentations, covered 
 by oiled silk, or by cold. Turpentine fomentations at the outset 
 sometimes give comfort. For the relief of tympanitic distension of 
 the abdomen, when this is very extreme, the effect of passing a 
 long rectal tube, and of giving turpentine enemata, may be tried. 
 
 Diet. — Much depends upon supporting the strength by liquid 
 nourishment given in small quantities at short intervals. As a 
 rule the interval should not be more than two hours. The chief 
 reliance should be placed upon milk, but yolks of eggs beaten up 
 with milk, beef-tea, and meat jelly may also be given. Brand's 
 essence of meat is often retained when other food is vomited. If 
 milk is vomited in curds, barley-water should be mixed with it. 
 If there is diarrhcea, beef-tea should be avoided, and the milk 
 should l>e given with lime-water. Alcohol is of use, as tending to 
 lower the temperature, and having also probably, in some degree, 
 an antiseptic influence. Two or three teaspoonfnls of brandy may 
 
1038 The Practice of Midwifery. 
 
 be given every hour, beaten up with egg, and an equal quantity of 
 water. Iced champagne is sometimes found to relieve vomiting. 
 In severe cases, when the pulse becomes very rapid and feeble, the 
 quantity of brandy may be increased up to eight or twelve ounces in 
 the twenty-four hours. If there is so much vomiting as to prevent 
 the retention of a sufficient amount of nourishment, nutrient 
 enemata should be used. The formula given at p. 459 may be 
 used, with the addition of an ounce of brandy. If there is diarrhoea, 
 twenty minims of tincture of opium may be added. Forty grains 
 of oxide of bismuth may also be added. 
 
 Medicinal Treatment. — The drugs most to be relied upon are 
 quinine and strychnine. A ten-grain dose of the former may be 
 given at the outset, when pyrexia is high, and then five grains 
 every three or four hours. When the fever is continuous, and is 
 not controlled by this means, a dose of twenty grains twice a day 
 is sometimes more effectual. Large doses of quinine are often 
 better tolerated when given, not in an acid solution, but as a simple 
 powder in water or in a mucilaginous mixture with fifteen grains of 
 subnitrate of bismuth and five grains of bicarbonate of soda. 
 
 When there is peritonitis, opium or morphia should be given in 
 sufficient quantity to control the pain. When pain is severe, large 
 quantities are often well tolerated, and aj)pear to be beneficial. A 
 subcutaneous injection of a quarter or a third of a grain of acetate 
 of morphia may be given at the outset, and then some Battley's 
 liquor opii sedativus may be added to the quinine. In the case of 
 vomiting, the sedative may be injected by the rectum or subcutane- 
 ously. In prolonged cases of fever, and those which assume the 
 pyaemic form, the tincture of peichloride of iron, in addition to, or 
 in substitution for, the quinine, is often of great value. 
 
 The result of giving purgatives as evacuants has been highly 
 spoken of by some authorities, but there is a risk of setting up 
 diarrhoea, which is always an unfavourable symptom. If there is 
 constipation at the outset of pyrexia, and no very acute peritonitis, 
 or sign of severe septic affection, three or four grains of calomel 
 may be given. This is often followed by a fall of temperature. 
 Diarrhoea should not be stopped too quickly, if moderate in amount, 
 since some of the poison may be carried off in the evacuations. If 
 necessary, opium may be given by the mouth or rectum. Tincture 
 of perchloride of iron. is of use in checking diarrhoea, if tolerated by 
 the stomach. 
 
 Antistreptococcic Serum. — Anti-streptococcic serum ^ has not yet 
 
 1 Aronsohn, Berl. Klin. Wochenschr., 1902 and 1903 ; Bumm, Berl. Klin. 
 Wochenschr., 1904, No. 44 ; Bordet, Ann. de I'lnstit. Pasteur, Paris, Vols. IX. to XVIII. 
 
Puerperal Fevers. 1039 
 
 proved so successful as anti-diphtheritic serum. It has been found 
 that one variety of streptococcus does not give immunity against 
 the effects of another. Attempts have been made accordingly to 
 obtain a polyvalent serum, and it is possible that in time one more 
 effective for puerperal septicsemia may yet be procured. The 
 manner in which the anti-streptococcic serum a,cts is at present 
 unknown. There is little reliable evidence that it possesses any 
 bactericidal action, nor are there any facts to indicate that it has an 
 antitoxic action. It has been suggested that it neutralises the 
 repellent influence exercised by streptococci upon leucocytes. In 
 this connection the interesting observation has been made that 
 some hours after inoculation there occurs a sudden local increase of 
 leucocytes. It is quite certain that an active anti-streptococcic 
 serum can be obtained, and the most probable explanation of its 
 action is that which regards its effect upon leucocytes as the 
 important factor. For the present, if one variety of serum does 
 not seem to be beneficial, another should be tried. To get the full 
 effect, it appears to be necessary to inject as much as 10 c.c. at a 
 time, and to repeat the injections as much as twice a day. A first dose 
 may be given of 20 c.c, half of it intravenously ; and in severe cases, 
 or those progressing unfavourably, as much as 60 c.c. may be 
 given daily. In some cases, this treatment, when employed early 
 enough, with a fresh serum, has been quickly followed by improve- 
 ment, and recovery has resulted. In others it appears to cause 
 temporary improvement, and to prolong the course of the disease, 
 although the fatal result is not averted. When there is purulent 
 peritonitis, or any considerable formation of pus elsewhere, it can 
 hardly be expected that the serum can check the growth of the 
 micrococci, although it is possible that it may retard the spread of 
 the organisms from the point of inoculation to the body generally. 
 
 The cases in which the serum should be tried are those in which 
 the presence of streptococci has been verified in the uterus or in 
 the blood, and cases which are very severe and likely to prove fatal, 
 since in these there is a strong probability that the streptococcus 
 is the chief microbe concerned. It may also be given tentatively 
 in any case in which local treatment does not quickly lead to 
 improvement, pending the result of bacteriological examination. 
 
 A syringe with asbestos piston, holding 10 c.c, is used for 
 injection, as in the case of anti-diphtheritic serum, and syringe 
 and skin should be carefully sterilised. The injections should be 
 made in the loin or in the abdomen, not far from the pelvis, or 
 into one of the veins at the bend of the elbow. Occasionally the 
 injections are followed by urticarial or erythematous eruptions or 
 
1040 The Practice of Midwifery. 
 
 pains in the bones, and it will be necessary to var}^ the site, if 
 many injections are made. 
 
 Vaccine. — Although the conditions in most cases of pueri3eral 
 infection do not correspond to those laid down by Sir A. E. Wright, 
 as suitable for treatment by vaccines, namely, "where we have to 
 deal with localised bacterial invasions associated with inflammation 
 at the site of inoculation," yet there are some cases of infection 
 especially with the staphylococcus to which this method of treat- 
 ment may well be applied, and there seems no reason why in 
 these cases good should not result from the use of a vaccine 
 derived from the organism present. The vaccine should be freshly 
 prepared, and a dose of 2'5 to 5 millions of dead bacteria given. 
 The effect should be determined by observations on the opsonic 
 index, but for clinical purposes the temperature and pulse form a 
 sufficient guide, a high temperature and rapid palse corresponding 
 to a low opsonic index. For the purpose of assisting the elimina- 
 tion of the toxins by the kidneys and diluting them in the blood 
 and the tissues large intra-venous or subcutaneous injections of 
 normal saline fluid may be tried. It is most convenient to make the 
 injections subcutaneously under the mammte or into the tissues of 
 the flank or axilla. Half a pint of normal saline fluid may be 
 injected under each breast daily. The beneficial results obtained 
 by continuous proctoclj^sis in many cases of acute septic peritonitis 
 suggest that this method may prove of value in cases of acute 
 septicirBmia. It has the advantage over the subcutaneous injec- 
 tions of being quite painless, and it can be carried on more 
 continuously. One of the various apparatuses, which can now be 
 obtained for the purpose, should be employed, and the injection 
 continued for several hours each day. Care must be taken in cases 
 where the heart is acting feebly that the use of saline injections 
 does not lead to increase in the amount of oedema of the tissues. 
 Glucose, valuable for its nutritive properties, may be combined 
 with the rectal injections or, in a strength of 5 per cent., which is 
 isotonic with the blood, with the intra-venous injections of salt 
 solution. 
 
 In an attempt to destroy the organisms circulating in the blood 
 and at the same time to assist the body by producing a condition of 
 leucocytosis various metals have been employed. Crede's^ oint- 
 ment is an example of this kind ; it contains 15 per cent, of 
 collargol or colloid silver, and is rubbed into the thigh once or 
 twice daily in doses of 15 to 45 grains. It is said to have a 
 
 1 Crede, Arch. f. Klin. Chir , 1903, Bd. 69, p. 225. 
 
Puerperal Fevers. 1041 
 
 bactericidal action upon the organisms with which it comes into 
 contact and to produce leucocytosis. For the same purpose a 
 2 per cent, solution of collargol can be used made up with normal 
 salt solution, and 5 to 15 cc. injected into one of the veins of the 
 arm once a day. 
 
 Collargol may also be administered by the mouth in doses of 
 J to 2 grains, or combined with a saline solution for subcutaneous 
 injection in a strength of 15 grains to the pint. Nuclein,^ said to 
 represent the active principle of yeast, has been recommended for 
 its effect in producing leucocytosis, and may be administered in 
 doses of 15 grains several times daily. 
 
 At the present time the action of these remedies is as uncertain 
 as is that of anti-streptococcic serum ; but since it is certain that an 
 active serum can be obtained, and as it is j^robable that the action 
 of such a serum depends upon tlie leucocytosis it apparently sets 
 up, other remedies, so long as they are harmless, which also tend 
 to produce leucocytosis, are worthy of further employment. 
 
 Refrigeration. — If the temperature rises to a very high degree, 
 such as 105°, and is not brought down by antipyretic medicines 
 such as quinine, benefit is sometimes found from direct application 
 of cold. Baths or wet packing have been used, but the disturbance 
 to the patient which these involve is a serious disadvantage in 
 peritonitis. The simplest mode of reducing temperature is the 
 application over the head either of Thornton's ice-water cap, 
 made of india-rubber tubing, or of Leiter's temperature regulator, 
 made of metal tubing, through either of which a stream of ice-cold 
 water is kept running from a reservoir elevated above the bed, the 
 rapidity of the stream being regulated by a tap. This application 
 of cold to the head is generally found to affect appreciably the 
 temperature of the whole body. If its effect proves insufficient, the 
 body may be sponged occasionally with water at a temperature 
 between 70° and 80° F. A Leiter's temperature regulator may 
 also be applied over the abdomen if desired. It is most useful at 
 the outset of the disease, when there is tenderness of the uterus, 
 with a rise of temperature. An ice-bag may be used in the absence 
 of a coil. A thin garment should be interposed between the coil or 
 ice-bag and the skin. 
 
 Runge,^ of Dorpat, urges the treatment of puerperal septicaemia 
 by large quantities of wine and brandy, combined with the use of 
 baths, instead of quinine or other antipyretic. From one to three 
 baths are given in the day, and their duration is from five to ten 
 
 1 Hofbauer, Arch. f. (iyri., 1903, Bd. 68, p. 859. 
 
 2 Volkmann's Ramralung, Kljnischer Vortriige, No. 287, 1886. 
 
 M. 66 
 
1042 The Practice of Midwifery. 
 
 minutes. The temperature is about 85° F. at first, and is lowered 
 to about 80° by the addition of cold water. Severe abdominal pain 
 and tenderness, and violent vomiting, are contra-indications to the 
 baths ; and they are, therefore, not available in the worst cases. A 
 tendency to somnolence or delirium, high temperature, and 
 abdominal distension, without extreme tenderness, are the strongest 
 indications for them. 
 
 In America, Kibble's fever-cot, made of cotton netting, with 
 india-rubber cloth beneath, is used for the same purpose, and has 
 the advantage of involving less disturbance than baths. Affusion 
 of water at 85° or 80° to the trunk only is practised every hour 
 until the temperature is reduced. 
 
 Treatment of Pelvic Cellulitis and Pelvic Peritonitis. — In these con- 
 ditions the treatment has to be directed chiefly to the local affections 
 and to the consequent pyrexia, not to any general septicaemia. Hot 
 fomentations should be kept constantly applied over the lower part 
 of the abdomen, so long as there is pain and high temperature. 
 Glycerine of belladonna or tincture of opium may be spread over 
 the skin beneath. If it is desired at this stage to try the effect of 
 an absorbent, the skin under the poultice may be smeared with 
 equal parts of unguentum hydrargyri and unguentum belladonnae. 
 The bowels should be kept acting freely with saline aperients, if 
 constipation is present. 
 
 An essential part of the treatment is complete and prolonged 
 rest. A late outbreak of acute symptoms is often due to the earlier 
 stage having been overlooked, and the patient getting up and 
 returning to work prematurely. The patient should remani in bed 
 until the pain, tenderness, and pyrexia have subsided for some con- 
 siderable time, and the exudation is, in great part, absorbed. 
 Caution about any over-exertion or exposure to cold is necessary 
 for weeks or months longer. If there is persistent local pain long 
 after all fever has subsided, counter-irritation to the skin over the 
 painful spot may be employed. Liniment of iodine may be painted 
 over it daily until the skin becomes sore. 
 
 Irrigation or syringing with bot water at a temj)erature of from 
 110° to 115° F. appears to tend to reduce the inflammation and 
 hasten the absorption of the exudation by stimulating the lympha- 
 tics. This may be commenced as soon as it can be carried out 
 without too much disturbing the ]3atient, and employed two or 
 three times a day until the exudation has been in considerable part 
 absorbed and the patient is able to get up. Absorbent drugs are 
 not of so much avail as promoting the general nutrition and vigour 
 of the patient by good food and tonics. But in the later stage, 
 
Puerperal Fevers. 1043 
 
 after the subsidence of fever, the liquor hydrargyri perchloridi may 
 be given in eighty-minim doses three times a day. This appears 
 to be preferable, in general, to iodide of potassium, as being rather 
 tonic than depressant. It may be combined with quinine, cinchona, 
 or with tinct. ferri perchloridi. Iodide of potassium, in five-grain 
 doses, may also be combined with it. 
 
 O'perative Measures. — As soon as an abscess forms it must be 
 opened either externally or internally through the vagina. If a 
 fluctuating swelling can be felt from the vagina, it should be opened 
 through the posterior vaginal fornix. Care must be taken to avoid 
 any injury to the ureters or to the uterine arteries, and this is best 
 ensured by keeping strictly to the middle line. If the abscess is 
 pointing in Douglas' pouch, the vaginal wall may be incised, and 
 then a pair of sinus forceps pushed into the collection of pus, after 
 Hilton's method. If the swelling is placed somewhat laterally, it 
 is often possible with care to strip up the peritoneum after incising 
 the vaginal wall, and thus to reach a collection of pus in the base 
 of the broad ligament or in the utero-sacral ligaments without 
 opening the peritoneal cavity. A drainage tube should be intro- 
 duced and sewn in by a stitch passed through tlie cervix uteri. It 
 is best not to irrigate the cavity. If the constitutional symptoms 
 indicate suppuration, and a boggy feeling only can be detected in 
 the swelling, but no distinct fluctuation, the aspirator may be used 
 to search for pus. 
 
 When the major part of the swelling is situated, as it often is, in the 
 iliac fossa above Poupart's ligament, an incision should be made 
 similar to that employed in the ligature of the external iliac 
 artery parallel to and above the outer part of Poupart's ligament, 
 or with its centre over the most prominent part of the swelling. 
 In most cases the peritoneum is stripped off the anterior abdo- 
 minal wall by the abscess, so that there is little risk of opening the 
 general peritoneal cavity, but caution must be employed, and the 
 layers of the abdominal wall carefull}'' incised so as to make sure 
 of not wounding the peritoneum. It is usually possible to detach 
 the peritoneum from the iliac fossa, and in this way with a suffi- 
 ciently free incision to explore fairly thoroughly the cellular 
 tissue of one half of the pelvis, and by making a similar incision 
 on the other side to evacuate collections of pus in either broad 
 ligament. 
 
 It may be desirable to make a counter-opening into the vagina 
 under the guidance of a probe or finger passed into the abdominal 
 wound, and to pass a drainage tube right through, or to close the 
 abdominal opening and to carry out drainage by the vagina alone. 
 
 66—2 
 
I044 The Practice of Midwifery. 
 
 In these cases it is often useful to employ a drainage tube 
 surrounded by a gauze packing. 
 
 If an abscess has spontaneously opened or has been opened exter- 
 nally, and the sinus does not close, but pus continues to be poured 
 out from a large cavity, a large drainage tube should be introduced 
 to the full depth of the cavity. The cavity may be washed out 
 daily by means of a funnel with a solution of iodine (tr. iodi 5ij. ad 
 aq. Oj.), peroxide of hydrogen, chinosol 1 in 500, or sulphurous 
 acid (acid, sulphurosi 5 j.-ij. ad aq. Oj.). Such a failure to close 
 is more likely in the case of an abscess due to peritonitis than in the 
 ordinary suj)puration of pelvic cellulitis, especially when the open- 
 ing is high up in the abdomen, as, for instance, at or near the 
 umbilicus. Carefully adjusted pressure by pads of wool may assist 
 in causing the abscess to close. 
 
 When the collection of pus is localised in tlie peritoneal cavity it 
 may be feasible to open and drain it without much risk, but when 
 it is contained in a suppurating ovarian cyst or in the tubes, the 
 safest plan is to wait whenever possible until the acute symptoms 
 have passed away and then to deal wath the conditions present by 
 an abdominal section. It is, however, often desirable when the 
 patient is acutely ill and an abdominal section is contra-indicated 
 to evacuate such collections of pus by an incision through the 
 posterior vaginal fornix, and to deal with the diseased tubes or the 
 ovarian cyst on a subsequent occasion. 
 
 Abdominal section has been performed in some cases of puerperal 
 peritonitis in view of the good results obtained in other cases of 
 general septic peritonitis. After opening the abdomen the abdo- 
 minal cavity may be washed out with normal salt solution or merely 
 drained, free drainage being provided for by opening the pouch of 
 Douglas, incising the lumbar fossse and passing drainage tubes 
 through the incisions, and leaving the abdominal wound freely open. 
 On the whole, this method, especially when it is combined with 
 continuous saline proctoclysis, gives better results than any other. 
 The operation should be carried out rapidly with as little mani- 
 pulation as possible. It has very rarely, however, been successful 
 in saving life, except in cases in which it has been performed very 
 shortly after the commencement of peritonitis from the sudden 
 entrance of some septic fluid into the peritoneum, as from rupture 
 of a pyosalpinx. One reason probably is that there is generally too 
 extensive septic inflammation in the uterus and broad ligaments to 
 allow of recovery. 
 
 The logical completion of the operation is to remove the uterus 
 and thus get rid of the main septic foci, and drain the pelvis very 
 
Puerperal Fevers. 1045 
 
 freely. The difficulty about this treatment is that if the operation 
 were performed early, while the disease was limited to septic 
 endometritis, it would often be performed, and the patient mutilated, 
 unnecessarily. On the other hand, when general septic peritonitis 
 is established, it has little hope of success, and the patient might be 
 too weak to survive the operation. Vaginal hysterectomy has the 
 advantage of causing less shock ; but it may prove difficult from the 
 size of the uterus if very little involution has taken place, and it 
 does not allow effectual flushing out of the peritoneal cavity. If it 
 is performed the broad ligaments should be secured by clamp rather 
 than by ligature. 
 
 In order to avoid the possibility of infection spreading from the 
 paralysed intestines, many operators open them at one or two points 
 and evacuate the contents. 
 
 A less severe operation has been recommended strongly by Pryor^ 
 among others, namely thoroughly to wash out the uterus and to 
 plug its cavity with iodoform gauze. An opening is then made into 
 Douglas' pouch, through which the finger is introduced to break 
 down any adhesions, and the pelvic cavity filled as far as possible 
 with 5 per cent, iodoform gauze. The plug in the uterus is removed 
 after three days, and that in the peritoneal cavity is left in for a 
 week. 
 
 In cases of pyaemia due to septic venous thrombosis, ligature 
 or excision of the affected veins has been carried out.^ Seitz^ 
 has recorded 38 cases with a mortality of 6Q per cent. The 
 mortality of puerperal pyaemia is probably about the same, 
 namely 60 to 70 per cent., so that the good effects of the operation 
 are not very apparent. In chronic cases, however, some 45 per 
 cent, of the patients recover, but it must be remembered that the 
 mortality of chronic cases is not nearly so high as that of acute 
 cases. The operation may be carried out either through an abdo- 
 minal incision or by a lateral inguinal incision. The former is no 
 doubt the best. The ovarian and internal iliac veins should be tied 
 if necessary on both sides. Eemoval of theveins is, however, usually 
 unnecessary. The difficulty is, the selection of suitable cases, and 
 the proper time at which to perform the operation. In no case 
 should the operation be performed if there are severe lung compli- 
 cations or if the heart is affected, and as a general rule the case 
 
 1 W. R. Pryor, The Treatment of Pelvic Inflammations, 1899. 
 
 ' Bumm, Berl. Klin. Wochenschr., 1905, No. 27 ; Trendelenburg, Muenchen. Med. 
 Wouhenschr., 1902, No. 13 ; Michels, Lancet, 1900, Vol. I., p. 1025 ; Himpson, Lancet, 
 190:-}, Vol. L, p. 1199 ; Cuff, Journ. Obst. and (iyn. Urit. Einp., 190G, Vol. IX., No. 5, 
 p. 317. 
 
 " (Seitz, Volkniann's Sammlung, Klin. Vortriige, No. 464. 
 
1046 The Practice of Midwifery. 
 
 should be a chronic one, and, as far as can be made out, the disease 
 localised, a set of conditions which are not often met with and 
 which, when they are, usually result in the recovery of the patient. 
 Further experience is required Ijefore the ultimate position of this 
 operation in obstetric practice can be determined with certainty.^ 
 
 Although as has already been pointed out, the logical sequence of 
 opening the abdomen in cases of general peritonitis is the removal 
 of the uterus, yet it is rarely possible to perform the operation, since 
 the patient is seldom in a condition to stand it. 
 
 In a series of 116 cases of hysterectomy for puerperal sepsis 
 collected by Jewett,^ the mortality was 48 per cent., but in the great 
 majority of these there was no peritonitis ; and therefore it is very 
 doubtful if the mortality would have been greater or so great with- 
 out hysterectomy. In 12 cases where there was partial peritonitis, 
 the mortality was 83*3 per cent. There was no recovery from diffuse 
 peritonitis. 
 
 It thus appears that the field of hysterectomy is very limited, and 
 that it gives no appreciable hope of success in the virulent peri- 
 tonitis which kills within seven or at most within ten days after 
 delivery. 
 
 If the uterus has been perforated or injured, or if there is any 
 suspicion of an abscess in the uterine wall or the presence of a 
 sloughing fibromyoma, the organ should undoubtedly be removed, as 
 it should be also if the placenta is so adherent that it cannot be 
 separated, and the patient presents signs of septic infection.^ 
 
 In 137 cases of hysterectomy for septic infection following labour 
 or abortion the mortality was 63 per cent. In 80 cases there was 
 acute puerperal septicemia with a mortality of 75'6 per cent. In 
 34 cases there was retention of a portion of the ovum, and of these 
 19 died and 15 recovered.'^ Six were cases of sloughing fibroid 
 complicating the j)uerperium, and of these 3 died. These results 
 compare unfavourably with the mortality of even the worst cases 
 of puerperal infection treated without operation. 
 
 The operation should be performed by the abdominal route with 
 as free an excision of the bloodvessels as possible. After removal 
 of the uterus the abdominal wound should be left open and drained, 
 the drainage tube, surrounded by gauze, being passed through into 
 the vagina, or if it be decided to close the abdominal wound the 
 pelvis should be packed with iodoform gauze, which should be brought 
 
 1 Macan, Jouru. Obst. and Gyn. Brit. Emp., Vol. XI V., No. 4, p. 2i6. 
 
 "^ American Gynecology, February, 1903. 
 
 3 Von HerfE, Von Winckel, Handbnch. der Geburtshiilfe, 1906, Bd. 3, Th. 2, p. 950. 
 
 •* Cristeanu, Rev. de Gyn. et de Chir. Abdom., July to August, 1904, No. 4. 
 
 I 
 
Puerperal Fevers. io47 
 
 down into the vagina, and not removed until the end of five to seven 
 days. The gauze should, however, be loosened slightly at the end of 
 twenty-four hours, as, if this is done, drainage occurs more freely. 
 In all cases a large rubber drainage tube should be placed in the 
 centre of the gauze, continuous proctoclysis carried out, and the 
 patient placed in Fowler's position after the operation. 
 
 PuERPEEAL Tetanus. 
 
 Puerperal tetanus is extremely rare in this country. No instance 
 of it occurred in 46,089 deliveries in the Guy's Hospital Lying-in 
 Charity, and I have met with it only once. According to modern 
 doctrine it depends upon infection by the bacillus of tetanus, and 
 thus is really a special form of septicaemia. When it occurs in puer- 
 peral women, it is probable that the microbe has been introduced 
 into the genital canal. It resembles surgical tetanus in the fact 
 that an important exciting cause is exj)osure to cold, especially in 
 hot climates where the microbe of tetanus is comparatively common. 
 Tetanus may occur after full-term delivery, or after abortion, 
 especially if an adherent placenta has been separated from the 
 uterus. Of the 108 cases collected by Vinay 47 followed an abortion 
 and 61 a full-term confinement. 
 
 The symptoms, prognosis, and treatment are similar to those of 
 tetanus in general. Sir James Simpson collected the records of 
 27 cases, of which 22 were fatal. Of Vinay's 108 cases 95 died, or 
 a mortality of 88'8 per cent. Of late hysterectomy has been per- 
 formed with the hope of removing the focus of the disease, but not 
 hitherto with success.^ 
 
 The result of the use of tetanus antitoxin in the human subject 
 has been very disaj^pointing. 
 
 The new-born infant is also liable to tetsnana (trismus neonatoi'um), 
 especially in hot countries, the seat of absorption being the 
 umbilicus, on the falling off of the funis (see Chapter XLIL). 
 
 1 Vinay, Traite des Maladies de la Grossesse, Paris, 1894 ; Rubeska, Arch. f. Gyn. 
 1897, Vol. LIV., p. 1. 
 
Chapter XL. 
 
 PHLEGMASIA DOLENS, THROMBOSIS, EMBOLISM, 
 SUDDEN DEATH, CHORION EPITHELIOMA. 
 
 Phlegmasia Dolens, or Peripheral Venous Thrombosis. 
 
 The term phlegmasia dolens, phlegmasia alba dolens, or 
 septic thrombo-phlebitis, is applied to a swelling of one or both 
 legs, characterised by pain, tension of the skin, brawny hardness, 
 absence of pitting on pressm-e, and a shining whiteness of the 
 surface. Much controversy has taken place as to its true patho- 
 logy. In former days it was fancifully ascribed to a metastasis of 
 the milk. From this theory, and from the white appearance of the 
 skin, was derived the popular term of "milk-leg." By different 
 authorities it has been regarded as inflammation or obstruction of 
 the lymphatics, as general inflammation of all the tissues of the 
 limb, or as phlebitis. 
 
 It is now recognised that the most constant anatomical condition 
 is thrombosis of the veins ; and that phlebitis, if it occurs, is 
 generally secondar}'', either to the thrombosis or to inflammation 
 of surrounding cellular tissue. There must, however, be some- 
 thing more than obstruction of the veins to account for the brawny 
 tension of the affected limb, the tissues of which are filled with 
 coagulable lymph, not with ordinary serum. The condition is 
 totally different from the common oedema which is produced by 
 pressure on veins, or even by thrombosis of a vein under different 
 circumstances. This can only be accounted for in one of two 
 ways : either that obstruction of the lymphatics as well as of the 
 veins is an essential part of the disease, or that there is some 
 toxemic condition of the blood, in consequence of which the fluid 
 poured out is irritating to the tissues and sets up a kind of quasi- 
 inflammation, leading to the production of coagulable lymph. 
 Probably both these conditions, and especially lymphatic obstruc- 
 tion, actually play a part in the causation. The lymphatic 
 obstruction cannot, however, be so readily demonstrated anato- 
 mically as the venous thrombosis. 
 
Thrombosis, Embolism, Sudden Death. 1049 
 
 Causation. — There is strong reason for believing that the 
 presence of some toxin in the blood generally has an influence in 
 the production of the coagulation. This is shown by the fact that 
 phlegmasia dolens does sometimes occur apart from pregnancy or 
 the puerperal state, and that this hapj)ens in cases where there is 
 some source for septic absorption. It has been especially observed 
 when there is ulcerated cancer of some internal part, such as the 
 cervix uteri, but has sometimes occurred in a late stage of phthisis. 
 Pathogenic streptococci have been demonstrated in the thrombus in 
 the veins, and without doubt the majority of cases are septic in 
 origin. The organism concerned is in most cases of but feeble 
 virulence, since the thrombus rarely breaks down. In a few cases, 
 however, the condition is followed or accompanied by general 
 vascular pysemia. 
 
 Phlegmasia dolens might have been included in the chapter on 
 puerperal fevers. It has been thought more convenient to describe 
 it separately, because it generally arises at a later stage than the 
 forms of fever there described, and is only rarely associated with 
 general septic infection. It resembles parametritis in the fact that, 
 although it probably should be included within the definition of 
 septic diseases, it has a generally favourable prognosis. 
 
 The impoverished blood of the pregnant woman is already prone 
 to clot, as is shown by the tendency to thrombosis in varicose veins 
 even during pregnancy. This tendency is further increased if there 
 has been any undue hemorrhage after delivery. The local con- 
 ditions also favour thrombosis. The veins have been distended in 
 consequence of the abdominal pressure in pregnancy, and the 
 current in them is slow while the woman is lying quiet in the puer- 
 peral period. Moreover, there are always thrombi in the mouths 
 of the uterine veins. From these thrombosis may easily extend 
 deeper into the uterus, and thence into the veins of the broad 
 ligaments. If it proceeds no further than this it gives no sign of 
 its existence. But from the broad ligament thrombosis may reach 
 the iliac veins, and spread downward to the femoral veins. It has 
 long been observed that women who have suffered from haemor- 
 rhage are most prone to phlegmasia dolens. Any febrile condition 
 also increases the fibrin in the blood, and thereby the tendency to 
 thrombosis. 
 
 It is quite possible that there are two varieties of the disease, one 
 septic in origin and due to the presence of micro-organisms or the 
 products of their growth, and the second of a non-septic character 
 and occasioned by the increased coagulability of the blood existing 
 in some pregnant women. 
 
1050 The Practice of Midwifery. 
 
 Symptoms and Course. — The commencement of symptoms is 
 rarely within the first week after delivery ; more frequently it is in 
 the second week, and still more frequently in the third. Some- 
 times, but not always, there are preliminary symptoms of malaise 
 with coated tongue and slight pyrexia. The first characteristic 
 symptom is that of acute pain in the leg. The locality of this 
 depends upon the course of the local affection. More frequently 
 this commences in the thigh, near the femoral vessels, and spreads 
 downward. Less frequently, it begins in the calf of the leg, or near 
 the ankle, and extends upward and downward. Exceptionally the 
 swelling remains limited to the upper part of the thigh. 
 
 The left leg is affected more frequently than the right, probably 
 because the venous circulation of the left leg is more apt to be 
 impeded from the presence of the rectum and sigmoid flexure on 
 the left side. Not uncommonly the other leg is affected afterwards, 
 generally after an interval of about a week. Exceptionally the 
 attack is preceded by pelvic cellulitis on the affected side. In this 
 case, the thrombosis is probably secondary to inflammation of the 
 cellular tissue surrounding the iliac or femoral veins. 
 
 The onset of pain is accompanied by a rise of pulse and tempera- 
 ture, the temperature generally reaching 101° or 102°. Sometimes 
 there are also initial rigors, and attacks of pain in the chest may 
 occur due to the presence of minute emboli with infarction and the 
 production of small areas of pleurisy. Swelling follows quickly 
 upon tlie pain. At first the swelling may pit on pressure, as it 
 does also when subsiding. It gradually increases for two or three 
 days, and when it has reached its height, has the characters already 
 described. The white tense surface may be variegated by knots of 
 purple superficial veins. If the skin is pricked, the fluid which 
 exudes is not thin serum, but coagulable lymph. Special swelling 
 and tenderness may be felt along the course of the affected veins, 
 especially at the onset or decline of the affection. When the tension 
 is very great they are not so easy to detect. Motion of the leg is 
 prevented on account of the pain and pressure of the swelling on 
 the muscles. After from seven to ten days, the pyrexia generally 
 subsides, and the swelling begins to be less tense, and to allow 
 pitting on pressure. It does not completely disappear for several 
 weeks, usually as much as five or six, and often the tendency to 
 swelling remains for many months afterwards. Occasionally, 
 during the early stage, there are renewed attacks of pyrexia, with 
 extension of the thrombosis to fresh veins. 
 
 In other cases the disease runs a course similar to that of throm- 
 bosis of the femoral or popliteal vein, apart from the puerperal 
 
Thrombosis, Embolism, Sudden Death. 1051 
 
 state, and the epithet of alha is not justified. The swelling remains 
 moderate in degree, pits on pressure throughout, and never becomes 
 tense and hard. Pain and pyrexia are comparatively slight. 
 
 Nowadays these cases appear to be much commoner than the 
 classical phlegmasia alba dolens, probably from the diminished 
 frequency of puerperal septicaemia. They imply, at any rate, a 
 less degree of septic element ; and probably there are not necessarily 
 any microbes present in the vein at all. Nor is there any sign of 
 lymphatic obstruction. 
 
 In rare cases the arm becomes affected by phlegmasia dolens in 
 the same way as the leg. Phlegmasia dolens of the arm alone has 
 chiefly been observed apart from the puerperal state. But in some 
 puerperal patients the arms become affected as well as the legs, 
 and thrombosis may occur in other situations also, as in the neck. 
 These multiple thromboses are in most cases the sequelse of some 
 general septic infection, and are of a grave character. 
 
 Pathological Anatomy. — The veins most frequently affected 
 by thrombosis are the femoral, iliac, popliteal, tibial, and peroneal. 
 More rarely there is thrombosis in the saphenous veins. In the 
 later stage, the veins may be inflamed and adherent to the 
 surrounding cellular tissue, especially when the commencement 
 of the affection has been by extension from pelvic cellulitis. The 
 lymphatic glands are usually enlarged, the lymphatics matted 
 together with the vessels by inflammatory exudation. The clot 
 may be found softened down by fatty degeneration. When the 
 affection is part of general septicaemia, the clot is more disintegrated, 
 and there may be pus in the veins. 
 
 Sequelae. — As a general rule, the clot shrinks up or becomes 
 disintegrated, and the circulation through the affected vessels is 
 restored. More rarely the vessels become permanently obliterated. 
 In these cases, more or less swelling, or tendency to swell, may 
 remain in the leg for months and even years, and the use of the 
 limb is impaired for a corresponding time. In either case a vari- 
 cose condition of the veins which have been distended in consequence 
 of the obstruction is apt to remain. 
 
 liarely suppuration takes place about the affected vessels. This 
 usually ends favourably after the opening of the abscess. When, 
 however, the septic character predominates in the affection, and 
 especially in lying-in hospitals, extensive burrowing abscesses may 
 be formed, with sloughing of muscles and cellular tissue. Under 
 similar conditions, the thrombi may become disintegrated, and form 
 
1052 The Practice of Midwifery. 
 
 septic emboli which set up general pyaemia. Even a healthy clot 
 may be detached and cause embolism of the pulmonary artery. 
 The consequence may be sudden death, or serious embarrassment 
 to respiration. Fortunately, the detachment of a clot is rare, except 
 as the result of premature exertion or injudicious manipulation of 
 the affected veins. 
 
 Treatment,— The j&rst essential in treatment is absolute rest, 
 and this must be prolonged for a considerable time, with a special 
 view to the danger of embolism of the pulmonary artery. For the 
 same reason all friction should be avoided, and manipulation of the 
 affected vessels should be used only with great caution. The 
 affected leg should be somewhat elevated, and guarded from pressure 
 by a cradle. For relief of pain it may be wrapped in hot fomenta- 
 tions, or in flannel moistened with an anodyne lotion, and covered 
 with oiled silk. Opium or morphia should be given until the pain 
 is relieved. Quinine in moderate or considerable doses, according to 
 the degree of pyrexia, is of most value in the acute stage. Later, 
 the tincture of perchloride of iron may be given. In the later stage, 
 when the swelling is subsiding, the leg may be bandaged evenly 
 with a flannel bandage, and still kept elevated. Still later, after 
 six or eight weeks, when there is no longer fear of detachment of 
 clot, massage is useful. The patient should on no account be 
 allowed to leave her bed till all tenderness and swelling of the vein 
 have disappeared. In the septic forms of the disease the treatment 
 will be merged into that of puerperal septicaemia. 
 
 Embolism and Theombosis of the Pulmonary Aeteries. 
 
 Attention has long been attracted by the startling cases in which, 
 quite unexpectedly, sudden death occurs either during labour or, 
 more frequently, after delivery. It is now recognised that the 
 most frequent cause of sudden death is embolism of the pulmonary 
 arteries. This embolism is, in the majority of cases, the sequel of 
 thrombosis in the veins of the uterus or its vicinity, or in the iliac 
 or femoral veins. It may occur at any time ujj to four or five 
 weeks after delivery, but is more common after a certain interval, 
 when changes may have taken place in the clot which promote its 
 detachment. Embolism may occur, however, even before delivery, 
 and when this is the case, the clot is most likely to be derived from 
 a thrombus in a uterine sinus at the placental site. In this situa- 
 tion, ante-jMTtiim thrombosis may occur if there has been separation 
 of the placenta, and the thrombus is likely to be more bulky than 
 
Thrombosis, Embolism, Sudden Death. 1053 
 
 that which would have been formed after delivery and retraction 
 of the uterus. Then, when retraction does occur in the course of 
 labour or after delivery, the loose thrombus may be squeezed out 
 and carried to the pulmonary arteries. According to Spiegelberg,^ 
 this accident most often occurs when premature labour is induced by 
 some method which involves the risk of separating the placenta. 
 
 The predisposing causes are therefore all those which tend to 
 coagulation of the blood, especially hsemorrhage, depression of the 
 circulation from hsemorrhage or exhaustion, pyrexia due to any 
 cause, and the entrance of septic material into the circulation. It 
 is only the milder forms of septic infection, however, which are 
 likely to lead to sudden death through embolism of the main trunk 
 or largest branches of the pulmonary artery. If the clot itself has 
 a definitely septic character, and contains septic organisms, it 
 quickly becomes disintegrated. Small fragments are then apt to 
 be detached, and either plug small branches of the pulmonary 
 artery, or pass through the pulmonary capillaries and cause 
 minute emboli in other parts of the body. This condition has 
 already been described in the chapter on puerperal fevers as leading 
 to visceral pyaemia. The clot may, however, be apparently 
 healthy, even though entrance of septic material has had some- 
 thing to do with the coagulation : perhaps because the influence 
 has been that of sapraemia only, not septicaemia. In such case, if 
 detached at all, it is more likely to be detached in a considerable 
 mass, and plug a large branch or the main stem of the pulmonary 
 artery. 
 
 Considerable controversy has taken place as to whether individual 
 cases should be interpreted as embolism or as primary thrombosis 
 of the pulmonary artery. On the one hand, it is argued, and the 
 argument has much weight, that it is not likely that coagulation 
 would take place first in a situation where the current is so rapid 
 as it is in the pulmonary arteries. On the other hand, it is said 
 that the pulmonary artery breaks up at once into a number of 
 branches, which radiate from it at different angles to the several 
 parts of the lung. Consequently a large extent of surface is pre- 
 sented to the blood, and there are numerous angular projections 
 into the currents, both which conditions are calculated to induce 
 the spontaneous coagulation of the fibrin.^ This mode of bifurca- 
 tion must also cause considerable retardation of the current, which 
 may therefore become slow enough to allow coagulation when the 
 heart's action is greatly depressed. 
 
 ' Lehrbuch der Geburtshlilfe, English translation, 2nd ed., Vol. II., p. 354. 
 
 ' Humphry, On the Coagulation of the Blood in the Venous Systeni during Life. 
 
I054 The Practice of Midwifery. 
 
 Extensive coagulation may be found in the pulmonary arteries 
 and right heart after death, having the appearance of being due 
 to thrombosis. It is to be remembered, however, that an embolus 
 always causes the deposit of fresh fibrin on its surface, and thus 
 leads to secondary thrombosis, extending backward toward the 
 heart. A small primary embolus may thus escape detection. 
 Moreover, it is often difficult to say whether the extensive 
 thrombosis may not have been formed only during the death 
 agony. 
 
 Most of the best pathologists are of opinion that embolism of the 
 pulmonary arteries is much more frequent than primary thrombosis. 
 An embolus is distinguished by its being more decolorised, and 
 distinct in appearance from the thrombosis formed upon it, and 
 by its generally being situated at a point of bifurcation of the 
 artery, at which it has been arrested. Also it is not moulded in 
 shape to the vessel which contains it, and occasionally it may be 
 fitted on to the clot elsew^here from which it has been detached. 
 
 An ante - mortem arterial thrombus presents a rounded end 
 toward the heart, and is dense, consisting of layers of decolorised 
 fibrin. It may be softened in the centre from commencing 
 degeneration. It is non-adherent to the walls of the vessel, and 
 may allow a little space for the blood to circulate between. 
 
 One fact about the clinical history is in favour of the view 
 that embolism is much more frequent than primary thrombosis of 
 the pulmonary artery. This is that, in the great majority of cases, 
 the attack comes on with appalling suddenness, which forms one 
 of its most striking characteristics. It is thus allowed that there is 
 no difference in symptoms between embolism and what is inter- 
 preted as having been primary thrombosis. It might be expected, 
 however, that the onset of symptoms would be more gradual in 
 thrombosis, as it seems to have been in the case recorded above, 
 where thrombosis commenced in the right auricle. 
 
 The cases which are most likely to be due to thrombosis com- 
 mencing either in the auricle or in the pulmonary artery itself are 
 those in which the symptoms of dyspnoea come on within a few 
 days after delivery, and in which they have been preceded by great 
 depression of the circulation, owing to exhaustion from difficult 
 labour, or haemorrhage, or both. 
 
 Symptoms and Course. — The primary thrombosis in a pelvic 
 vein, if such has existed, gives, as a rule, no sign of its presence. 
 Hence the attack of dyspnoea, in the majority of cases, comes on 
 quite unexpectedly. In some cases the puerperal period has 
 
Thrombosis, Embolism, Sudden Death. 1055 
 
 apparently progressed quite normally, and the patient may be 
 beginning to get about again. Frequently, however, there has 
 either been a protracted and exhausting labour, or there has been 
 more or less pyrexia within the first week, indicating some degree 
 of septic disturbance. In other cases, again, the attack comes on 
 within the first few days, esj)ecially after hsemorrhage, or depression 
 of the heart from exhaustion. 
 
 The starting-point appears frequently to be some slight exertion. 
 The patient is then suddenly seized with the most intense dyspnoea. 
 She gasps and struggles for breath, and all the auxiliary muscles 
 of respiration are thrown into action. The face is livid and purple, 
 or sometimes pale. The heart's action at first is violent and 
 tumultuous ; soon it becomes feeble and irregular. The pulse is 
 small and also irregular. Eespiration is hurried, and air may be 
 heard to enter the lungs freely. 
 
 If the main trunk of the pulmonary artery is blocked, death 
 follows after a struggle of a few minutes. If only a main branch 
 is plugged, the symptoms after a while may become mitigated in 
 some degree, but the violence of dysj)noea is apt to be renewed 
 on any slight exertion. Less frequently, the first onset is not so 
 intense, but the attacks recur with increasing severity. This 
 probably happens chiefly in cases in which there is primary 
 thrombosis in the heart or in the pulmonary artery itself. A fair 
 number of cases has been recorded, although only a small minority 
 of the whole, in which the patient has ultimately recovered after 
 symptoms pointing to pulmonary embolism or thrombosis. 
 
 In some of the cases not very rapidly fatal a systolic bruit has 
 been observed over the pulmonary artery. It is probable that this 
 may occur in the case of embolism at the entrance of a main branch 
 of the artery, when the secondary thrombus extends towards the 
 heart. If a primary thrombus is tethered in the heart, and extends 
 through the valves into the artery, the bruit may be expected to be 
 more marked. In this case the second sound may also be affected, 
 the clot preventing the closure of the valves. If the patient 
 eventually survives, recovery is complete. The circulation is 
 restored, probably through disintegration of the clot, and any bruit 
 which may have been heard disappears. 
 
 Prophylaxis. — The most essential point in prophylaxis is to 
 enjoin complete and prolonged rest in all cases in which there is 
 evidence of venous thrombosis. This should be continued until 
 at least five or six weeks have passed, and the vein is no longer 
 tender and indurated. More prolonged rest in bed than usual is 
 
1056 The Practice of Midwifery. 
 
 also desirable in all cases in which there has been great exhaus- 
 tion from hfemorrhage, or considerable pyrexia indicating septic 
 disturbance in the first week after delivery. 
 
 Treatment. — In many cases death is too rapid to allow any 
 treatment. In the first instance the effort should be to keep the 
 patient alive, and maintain the action of the heart by stimulants 
 such as brandy and ether. Ether may be given by subcutaneous 
 injections of twenty minims at a time, if the patient cannot swallow. 
 The administration of oxygen may prove useful. Ammonia is a 
 useful stimulant, and has also been recommended on the ground 
 that it may tend chemically to promote the solution of the clot, or, 
 at any rate, to prevent further thrombosis. Twenty minims of 
 liquor ammonite, or five grains of carbonate of ammonia, may be 
 given every hour for a while, and afterwards at longer intervals. 
 If there is cyanosis of the face, and other evidence of over-disten- 
 sion of systemic veins, a small venesection, or some leeches applied 
 to the chest, may assist in the restoration of equilibrium. 
 
 If the patient survives the first attack of dyspnoea, and obtains 
 some relief, it is of the utmost importance that she should be kept 
 absolutely at rest, and not raised in bed, or allowed to make any 
 muscular exertion for any purpose. Liquid food should be given 
 frequently, and in small quantities. The same precautions should 
 be maintained for a considerable time after the severity of symptoms 
 has abated, since a renewed attack is liable to be brought on by 
 any imprudence. 
 
 Embolism of Systemic Aktbries. 
 
 Embolism of systemic arteries is rarer than that of pulmonary 
 arteries. In the majority of cases the clot is derived from the 
 left heart. The same conditions of blood as those which predispose 
 to venous thrombosis promote its formation. In some recorded 
 cases there has been antecedent rheumatism, and vegetations have 
 been detached from the valves of the heart. In others there has 
 been puerperal endocarditis, generally of septic origin. In others 
 the thrombosis probably commences in the auricular appendix, 
 or elsewhere in the auricle, the circulation having been much 
 depressed by exhaustion or haemorrhage. In some cases it 
 has been inferred that there has been primary thrombosis in 
 the arteries themselves, the symptoms having been gradual in 
 their onset, and the arterial walls having been found in a morbid 
 condition- 
 
Thrombosis, Embolism, Sudden Death. 1057 
 
 Symptoms and Course. — The arteries most frequently affected 
 are the femoral, brachial, and cerebral. When the artery of a limb 
 is plugged, there is generally intense pain in the situation of the 
 affected artery, sudden in its origin, but persistent. Pulsation in 
 the distal portion of the artery ceases, and the limb becomes cold, 
 powerless, and sometimes oedematous. There may be excessive 
 pulsation in the artery above the plug. In some cases gangrene 
 of the limb has followed. Gangrene is not usually the result of 
 obstruction of the main artery of a limb in persons who are young 
 and otherwise healthy, a collateral circulation being established. 
 Hence, in the puerperal cases, a morbid condition of the blood, or 
 some venous thrombosis in addition, is probably an element in the 
 causation. When gangrene of a limb occurs in the puerperal state, 
 the prognosis is most grave, a fatal result being very common. 
 Cases, however, are on record in which the patient has recovered 
 after formation of a line of demarcation and amputation of the 
 limb. 
 
 When embolism of an important cerebral artery occurs, softening 
 of the brain and paralysis, generally taking the form of hemiplegia, 
 are apt to follow. Embolism of the ophthalmic artery leads to 
 complete blindness of the affected eye. This occurs in septicsemic 
 cases, and is followed by destruction of the eye, and usually by 
 a fatal result. 
 
 Treatment. — The limb should be elevated and kept warm by 
 flannel and hot-water bottles. Opiates must be given until pain 
 is relieved. The strength should be supported by nourishing 
 diet. Any concomitant septic condition, must be treated in the 
 usual way. 
 
 Entrance of Air into the Veins. 
 
 Next to pulmonary embolism and thrombosis, the most notable 
 cause of sudden death during labour or shortly after delivery 
 appears to be entrance of air into the veins. It is well known that 
 the entrance of air in considerable quantity into large veins near 
 the heart is apt to prove fatal. This is sometimes seen in surgical 
 operations upon the neck. The condition of the uterine veins is 
 somewhat similar to that of the veins at the lower part of the neck. 
 They have large mouths, and are closely united with the tissue in 
 which they lie, so that they cannot collapse when not closed by 
 contraction of the uterus. They are also near enough to the chest 
 to be affected by respiratory aspiration. 
 
 M. 67 
 
1058 The Practice of Midwifery. 
 
 The cause of death in such cases is probably complex. The right 
 heart filled with air, which is compressible and has no appreciable 
 momentum as compared with blood, cannot readily empty itself. 
 The air bubbles also do not readily pass through the pulmonary 
 capillaries, and act somewhat as emboli. If the air enters a vein 
 distant from the heart, or enters in moderate quantity, so that the 
 right heart does not become filled with air, these effects are not 
 produced. 
 
 For air to enter the uterine veins three conditions are necessary. 
 There must be air or gas in the uterus, the uterus must be relaxed, 
 and the mouths of the veins must be open, or filled only by a soft 
 easily displaceable thrombus. The conditions may be fulfilled 
 either before delivery, when the placenta is separated or partially 
 separated, or after delivery, especially when delivery is only just 
 completed. Air may reach the vagina and thence the uterus 
 merely from the effect of position, when the vagina is patulous. 
 It may also still more easily gain access during obstetric operations 
 or manipulations. Aspiration into the veins may occur from the 
 variations of intra-abdominal pressure, together with relaxations of 
 the uterus alternating with contractions. Air may also be forced 
 into the veins by contraction of the abdominal muscles, occurring 
 when the exit through the vagina is impeded. 
 
 The most marked cases have occurred when water has been 
 injected into the uterus before delivery. The placenta may then 
 be separated by the pressure of the water, and air already in the 
 vagina may gain entrance, or air may be injected with the w^ater. 
 If a Higginson's syringe is used, air is almost certain to be injected. 
 The objections on this ground to the method of inducing labour 
 by injections of water into the uterus have already been explained 
 (see p. 801). The same result has sometimes followed even a 
 vaginal douche ; and it has been thought that, even if no air has 
 been injected with the water, the j)ressure of the water may have 
 forced into the uterus some air already in the vagina. Again, 
 sudden death has followed the washing out of the uterus for the 
 removal of septic material after delivery. 
 
 In other cases sudden death has occurred shortly after delivery, 
 and the entrance of air into the circulation has been verified by 
 autopsy. In some of these instances, the accident has happened 
 when the hand has been introduced into the uterus, as for the 
 removal of an adherent placenta ; in others it has been quite 
 spontaneous. Another mode of origin for the accident is the dis- 
 tension of the uterus by gas from decomposition of the foetus. 
 On delivery of the foetus and sej)aration of the placenta, some of 
 
Thrombosis, Embolism, Sudden Death. 1059 
 
 the gas may then be aspirated or forced mto the veins. It is quite 
 possible, however, that many of these cases in reality are due to the 
 presence of a gas-producing organism in the tissues, such as the 
 bacillus aerogenes capsulatus, which has been found in some of 
 the cases in which air was present in the blood. 
 
 On post-mortem examination, the left heart is found contracted, 
 the right heart distended and filled with air. There is froth in 
 the pulmonary arteries. The vena cava and pelvic and uterine 
 veins may contain air. It is, of course, necessary to distinguish 
 the case in which gas has been produced by post-mortem 
 decomposition. 
 
 Symptoms. — The symptoms indicate pulmonary obstruction, 
 and thus closely resemble those of pulmonary embolism. There 
 is a sudden intense struggle for breath ; the face is purple and 
 livid, the pulse small and irregular. Sometimes convulsions 
 occur. Soon unconsciousness and death follow. A churning 
 sound in the heart has sometimes been heard on auscultation. 
 As a rule, however, it will be impossible positively to distinguish 
 between entrance of air into the circulation and pulmonary 
 embolism. 
 
 Prophylaxis. — Induction of premature labour by injection of 
 water into the uterus should be avoided. Even for the vaginal 
 douche, an irrigator should be used, and the tube should be emptied 
 of air. If the Higginson's syringe is ever used care should be 
 taken that the outflow from the vagina is free, and the injection 
 should be gentle at first. 
 
 Syncope and Shock. 
 
 In cases of serious valvular disease of the heart, fatal syncope 
 is apt to occur during or after labour, as already described (see 
 p. 552). Apart from any valvular disease, various cases of sudden 
 death in parturition or the puerperal state are on record, in which 
 the results of post-mortem examination have excluded the possi- 
 bility of embolism or thrombosis of the pulmonary arteries, or the 
 entrance of air into the circulation. These must be attributed to 
 failure of the heart. It is a comparatively common experience that, 
 after post-j^artum hajmorrhage not sufficient in amount to kill 
 under ordinary circumstances, fatal syncope may occur, sometimes 
 from the effect of some exertion, or of the patient's head being 
 raised imprudently. Even without any excessive hemorrhage, 
 
 67—2 
 
io6o The Practice of Midwifery. 
 
 syncope may occur, and in some cases has been fatal, especially 
 when the patient has been exhausted by severe labour. Predis- 
 posing causes may be the so-called fatty degeneration of the 
 muscular fibres of the heart, or mere thinness of its muscular wall, 
 which is generally associated with deposit of adipose tissue outside. 
 Dilatation of the heart from any cause, such as Bright's disease, or 
 disease of the lungs, may also predisj)ose to syncope. Death from 
 syncope has occurred in pregnancy, as well as during or after 
 labour, but much more rarely. 
 
 Sometimes the approach of death is more gradual, and is pre- 
 ceded by symptoms resembling those of shock. The face is anxious 
 and pinched, the skin pale, the lips livid, the extremities cold, the 
 pulse rapid and almost imj)erceptible, the skin generally moist 
 with sweat. There is an absence of the violent struggle for breath 
 and tumultuous action of the heart which denote pulmonary 
 obstruction. Sometimes, as when death is impending from the 
 effect of severe haemorrhage, there is restlessness associated with 
 considerable strength of voice and muscular strength generally, but 
 with very rapid, feeble pulse. These symptoms chiefly occur after 
 severe labour in women of highly susce^Dtible neurotic temperament, 
 and the shame of parturition in an unmarried woman sometimes 
 adds to the eftect. Some excess of haemorrhage may also be con- 
 cerned in their production. The sudden lowering of abdominal 
 tension is probably an element in the causation. Combined with 
 a paralysis of the sympathetic nerves, due to the impression upon 
 the nervous system, it allows a great proportion of the blood to 
 collect in the large veins within the abdomen, while but little passes 
 through the heart. 
 
 Treatment of Shock.- — The treatment is to apply warmth to 
 the extremities, and give stimulants, such as brandy, ether, and 
 ammonia, as well as liquid nourishment, as strong beef-tea or 
 essence of meat. Ether may be administered subcutaneously. If 
 failure of the heart is threatened, the inhalation of nitrite of amyl 
 is likely to be of use, as it is in threatened syncope during the 
 administration of chloroform ; for it acts, not only by relaxing 
 the arteries, but by stimulating the heart, as may be proved by 
 sj)hygmographic tracings, and thus it relieves the circulation in a 
 double way. 
 
 Othee Causes of Suddisn Death. 
 
 Sudden deaths from rupture of an aneurism in labour, acute 
 cedema of the lungs, rupture of the heart, rupture of the spleen or 
 
Thrombosis, Embolism, Sudden Death. 1061 
 
 of one of the splenic arteries, have been recorded, but are very 
 rare. In women prone to cerebral hsemorrhage the exertion of 
 labour may precipitate the rupture of an artery. There may then 
 be convulsions at the outset, followed by coma and paralysis, 
 generally hemiplegia. Death in this case may be rapid, but is 
 not absolutely sudden, as when due to failure or obstruction of the 
 circulation. 
 
 Some causes of sudden death would not be suspected unless 
 revealed by post-mortem examination. Thus, a woman in the 
 Guy's Hospital Lying-in Charity, somewhat advanced in apparently 
 
 Fig-. 495. — Chorionepithelioma of uterus with lutein cysts in both ovaries. 
 
 normal labour, became suddenly collapsed, and died before delivery 
 could be completed with forceps. At the autopsy, it was found 
 that the omentum was adherent to the uterus. Some separation 
 had occurred, probably from the retraction of the uterus with the 
 advance of labour, and fatal hsemorrhage had taken place into the 
 peritoneal cavity. 
 
 Choeionepithelioma, or Deciduoma Malignum. 
 
 A peculiar form of malignant disease following pregnancy was 
 first described by Sanger in 1888 under the title of deciduoma 
 malignum. Chiari had previously described three cases of 
 
io62 The Practice of Midwifery. 
 
 carcinoma of the fundus uteri following the puerperium, of which 
 two occurred in young women aged 22 and 23. At the present 
 time a large number of cases have been described, some being long- 
 preserved specimens, but the disease is still to be regarded as a rare 
 one. The chief clinical features of the disease are that it both 
 spreads locally and forms metastatic deposits with extreme rapidity, 
 so that, in the greater number of cases, it has proved fatal within 
 from ten weeks to six months after the puerperium. It may occur 
 at any age from 17 to 55 ; but a large proportion of cases has been 
 in young women. Thus, about 64 per cent, of the patients have 
 been under the age of 35 ; and there are more cases between the 
 ages of 25 and 30 than in any other quinquennium. The average 
 age of the patients in recorded cases is 31 years. 
 
 Causation. — The disease may occur after labour at full term or 
 premature, after abortion, or after a vesicular mole. Premature 
 deliveries and abortions are antecedents in greater than the relative 
 proportion, 25 to 35 per cent., as compared with full-term deliveries, 
 20 to 25 per cent. But the most remarkable circumstance in the 
 causation is the relation to vesicular mole, which was the antecedent 
 in 49 cases out of the first 90. The disease is almost entirely, if not 
 entirely, confined to multiparse. In some cases metastases have 
 occurred while a vesicular mole has been still in the uterus. In 
 others vaginal metastases have been found having the structure of 
 chorionepithelioma after a pregnancy or vesicular mole without 
 any disease in the uterus. 
 
 It is now generally accepted that the disease is associated with 
 an antecedent pregnancy in practically every case, and the statistics 
 of its relation to vesicular mole prove its connection with pregnancy. 
 A vesicular mole occurs only once in about 2,000 pregnancies. 
 Not more, therefore, than about one woman in 40,000 has had a 
 vesicular mole within a year. On this assumption, the probability 
 against a vesicular mole being antecedent in as many as 49 out of 
 the 90 cases, if there is no causal relation between them, can be 
 calculated by the mathematical doctrine of probabilities. It is 
 so enormous that it amounts to a certainty that the causal 
 relation does exist. If this is true as regards vesicular mole, 
 there is a strong presumption that it extends to other forms of 
 pregnancy. 
 
 It is now almost universally agreed that the disease arises from 
 the foetal trophoblast, and that chorionepithelioma is therefore the 
 most suitable title for it. It is admitted, however, that a similar 
 structure is found apart from pregnancy and in either sex in certain 
 
Thrombosis, Embolism, Sudden Death. 1063 
 
 tumours, described as embryomata or teratomata.^ These originate 
 generally in the testis or ovum, but have occasionally been found 
 elsewhere, as in the mediastinum. There appears to be a formation 
 in them of three layers like those of the early ovum, and of certain 
 structures derived from these. Thus, not only are growths found 
 having the structure of chorionepithelioma, but secondary growths 
 have been found in the vessels resembling vesicular mole. It may 
 be suggested that they are attempts at development without 
 
 Fig. 496. — Microscopic section of chorionepithelioma showing masses of 
 syncytium and discrete cells of Langhan's layer. 
 
 impregnation of the germ plasm, which normally should be limited 
 to the testicle and ovary, but may occasionally be included in some 
 other part of the body. 
 
 A very few cases have been recorded as much as two years after 
 the menopause, or from two to four years after the pregnancy to 
 which the disease was attributed. There is ground, therefore, for 
 
 1 Chorionepithelioma in the male is intensely malignant. iSo far definite foetal 
 villi do not appear to have been met with in man, but otherwise the tumours are iden- 
 tical in structure. No doubt in this sex they take origin from ectodermal elements, 
 and it has been proposed to call them ectodermal malignant syncytioma. 
 
1064 
 
 The Practice of Midwifery. 
 
 believing that, in very exceptional cases, it may remain latent for 
 a considerable period. As a rule, the symptoms appear within a 
 few months after the pregnancy, and frequently follow uj)on it 
 almost immediately. Two cases also have been recorded, one in a 
 young girl of 8| years of age and the second in a woman of 75 
 years of age, in whom apparently all possibility of pregnancy could 
 be excluded. In such cases as these there is at present no adequate 
 explanation of the occurrence of these tumours.^ 
 
 — cl 
 
 Fig. 497. — A collection of epithelial cells lying within a blood-vessel in the 
 muscular wall of the uterus, from a case of hydatidiform mole (see 
 Fig. 286). 
 
 Pathology — The most characteristic feature of the growth is 
 the presence of syncytium. This consists of masses of protoplasm 
 containing large nuclei, but not divided into cells. It occurs 
 sometimes in the form of masses or bands (Fig. 496), but 
 frequently forms a reticulum, surrounding spaces which may 
 contain blood, like the spaces in the trophoblast of an early ovum 
 (see p. 72). The protoplasm of the syncytium stains more deeply 
 than that of the cells. With the syncytium are associated masses 
 of large cells with large nuclei. As the syncytium resembles the 
 syncytium of an early ovum, so these cells exactly resemble the 
 
 1 Eden, Journ. Obst. and Gyn. Brit. Emp., 1907, Vol. XII., No. 6, p. 424. 
 
Thrombosis, Embolism, Sudden Death. 1065 
 
 cells of the trophoblast, corresijonding to Langhan's layer of the 
 chorionic villi, or those seen forming masses in vesicular mole. 
 
 There are three varieties of structure in the growths described 
 as chorionepithelioma. 
 
 (1) In comparatively few cases, notably one described by 
 Marchand, one by Neumann, and one by Haultain,^ chorionic villi 
 with actively proliferating syncytium are embedded in the 
 malignant mass, and the syncytial masses in the tumour can be 
 traced as continuous with the proliferating syncytium of the villi. 
 These cases seem to represent the initial stage of the growth, and 
 constitute the most decisive proof of its origin from the foetal 
 epithelium. Further evidence is found in the fact that in 
 Neumann's^ case and in some others, chorionic villi have been 
 found in metastases, as well as in the original growth. In a case 
 recorded by Apfelstadt and Aschoff,^ the secondary growth in the 
 labium and paravaginal tissue consisted of a vesicular mole, with 
 the usual stalks and cysts. Metastasis of a vesicular mole to the 
 lung has also been recorded, and metastasis in the vagina from a 
 vesicular mole, not ultimately running a malignant course, and 
 without any disease remaining in the uterus. These latter cases 
 seem to indicate a malignant or semi-malignant transformation of 
 the cellular tissue stroma as well as of the epithelium of the chorion. 
 
 (2) In the majority of cases, the structure is that shown in 
 Fig. 496. It is made up, in about equal j)arts, of syncytium, 
 generally in large branching masses, and masses of discrete cells. 
 Large spaces containing blood are a marked feature of the growth, 
 and the syncytium appears to lay open the blood-vessels in a 
 manner which has been compared to the function of the syncytium 
 in the development of the normal placenta. Malignant cells have 
 been found in thrombi within the vessels. In the growing margin, 
 where the growth is infiltrating the muscular wall, cells or groups 
 of cells appear to have a special tendency to penetrate the venous 
 sinuses and engraft themselves on the interior of their walls. In 
 this way is accounted for the very rapid formation of metastatic 
 deposits, which occur generally through the vessels and not through 
 the lymphatics, and especially in the lungs. There is a marked 
 tendency to necrosis, and, in the typical part of the tumour, there 
 are no vessels among either cells or syncytium. In the infecting 
 margin, however, small groups of cells, or small masses of syncytium, 
 
 1 See Journ. of Brit. Gyn. Soc, July, 1899 ; and for figures illustrating this form of 
 growth, 'i'eaclier, 'J'ran.s. Ol)st. Soc. London, 1903, Vol. XLV., p. 25G. 
 
 2 Verh. d. Ueutsch. Gesell. f. Gyn., 1891, p. 341. 
 '■' Arch. f. Gyniik,, 1890, p. 511. 
 
io66 The Practice of Midwifery. 
 
 even as small as single cells, appear to be springing up in the 
 stroma, so that this part of the growth may approximate in character 
 to the third variety, next to be described. 
 
 (3) In comparatively rare cases, generally of an advanced kind, 
 where the patient has died from the disease without operation, 
 there is found no considerable development or branching processes 
 of syncytium, but only comparatively small masses of nucleated 
 protoplasm, combined with a large proportion of discrete cells. 
 No doubt these small protoplasmic masses, which have the staining 
 qualities of syncytium, really are syncytium, and this variety is 
 developed out of the second, the more typical portions of the growth 
 having become necrosed. 
 
 If the syncytium of the villi in retained placenta after abortion 
 (Figs. 282, 283, p. 520), and in vesicular mole (Fig. 287, p. 527), 
 is compared with Fig. 496, there appears to be a gradation 
 toward the structure seen in the so-called deciduoma malignum : 
 and an intermediate stage between Fig. 287 and Fig. 496 is 
 furnished by cases in which chorionic villi are present in the 
 malignant growth, such as that figured by Haultain. 
 
 The author met with one case, before chorionepifchelioma had 
 attracted attention, in which a woman, near the usual time of the 
 menopause, had a vesicular mole. This was followed within a few 
 weeks by an intra-uterine growth, which bled freely, and discharged 
 gelatinous masses j^er vaginum. Sections of the growth had the 
 structure of myxoma, and no chorionic villi, degenerated or other- 
 wise, were present. For some months the growth appeared to be 
 running a malignant course, but eventually, after repeated clearing 
 out and curetting the uterus, it died out, the menopause became estab- 
 lished, and the patient has remained over sixteen years free from 
 recurrence. This appears to have been probably an im23lantation 
 of myxoma from the stroma of the degenerated villi ; and it is 
 notable that it did not show the malignancy of chorionepithelioma. 
 Every possible gradation can be met with between a normal 
 placenta, a hydatidiform mole, and a chorionepithelioma, and, in 
 the present state of our knowledge, we have no certain criterion by 
 which we can distinguish between a benign and a malignant growth 
 originating in the epithelial elements. 
 
 In a few cases chorionepithelium has been described as occurring 
 in the Fallopian tube as a sequel of tubal pregnancy. In one of 
 these, recorded by Ahlfeld, the patient was aged only 17. It has 
 also been met with in the ovary. 
 
 Early metastasis is a feature in all the varieties of growth, and 
 the metastatic growths have a similar microscopic appearance to 
 
Thrombosis, Embolism, Sudden Death. 1067 
 
 the primary. Deposits have been observed in the lungs in more 
 than 70 per cent, of the cases. In over 50 per cent, there were 
 metastases in the vagina or vulva. They also occur less frequently 
 in the kidneys, spleen, ovaries, liver, and brain. Free hsemorrhage 
 takes j)lace into the growths. They also break down easily, and 
 hence septicsemic complications occur early. Death sometimes 
 takes place through thrombosis or embolism. 
 
 In a considerable number of the cases, as with hydatidiform 
 moles, there appears to be an excess of lutein tissue in the ovary. 
 
 Fig. 498. — Chorionepithelioma of uterus with secondary growths in vao-ina 
 and in perivaginal connective tissue. 
 
 and lutein cysts occur (see Fig. 495). It has been suggested that 
 this excess of lutein cells plays a part in the production of these 
 growths, but it seems more probable that both conditions, namely, 
 the excessive proliferation of the epithelial elements in the 
 chorionepithelioma and the excessive production of the lutein 
 cells, may in reality be due to a common etiological factor, the exact 
 nature of which is at present unknown. It must be remembered 
 that even in normal pregnancy there is a considerable formation 
 of lutein cells in the ovary. 
 
 Symptoms and Course. — The characteristic symptom is irre- 
 gular hsemorrhage commencing within a few weeks after delivery or 
 
io68 The Practice of Midwifery. 
 
 abortion, or vesicular mole. Later there is anaemia with pyrexia, 
 rigors, and other symptoms of saprsemia or septicaemia. Some- 
 times masses of growth are discharged. Before death there may 
 be evidence of affection of the lungs, and frequently metastatic 
 growths appear in the genital canal. 
 
 Diagnosis. — In case of haemorrhage persisting after delivery, 
 abortion, or, still more, after vesicular mole, no time should be lost 
 in exploring and curetting the cavity of the uterus. Microscopic 
 examination should be made of any masses brought away, and 
 in the examination of the sections stress must be laid upon the 
 presence of large conglomerations of cells, syncytial or ectodermal 
 in character, displacing portions of the tissues, together with the 
 destruction of blood-vessels, the occurrence of haemorrhages, and 
 widespread necrosis. 
 
 Treatment. — The only hope of cure is in very early hysterectomy, 
 which may be carried out by the vaginal method, or preferably by 
 the abdominal route. Metastatic growths in the vagina or vulva, 
 if limited, may be removed at the same time. In a certain number 
 of cases the patients have remained free apparently from recurrence 
 after such an operation.-^ Cases occurring after a normal pregnancy 
 appear to be more fatal and more rapid in their growth than those 
 following a hydatidiform mole. The prognosis is favourable if 
 hysterectomy is performed before the appearance of metastases ; 
 but in some cases these have appeared afterwards, and led to a 
 fatal result within nine months from the operation. In a few cases 
 metastases have died out, and the patient has recovered after 
 
 1 The most important cases of chorionepithelioma will be found in the following 
 papers : — Chiari, Wiener Med. Jahrb., 1877, p. 364 ; Sanger, Zentralbl. f. Gyniik., 1889, 
 p. 132 ; Arch. f. Gyn., 1893, Vol. XLIX., s. 89 ; Gottschalk, Arch. f. Gynak., 
 Vol. XLVL, p. 1 ; Marchand, Monatsschr. f. Geb., 1895, Vol. I., pp. 419 and 513 ; 
 Zeitschr. f. Geb. n. Gyn., 1898, Vol. XXXIX., p. 173; Whitridge Williams, Johns 
 Hopkins Hospital Reports, 1895, Vol. IV., No. 9 ; Neumann, Monatsschr. f. Geb., 1896, 
 Vol. IV., p. 387, 1897, Vol. VI., p. 17 ; Spencer, Morison and Malcolm, with discussion 
 on papers, Trans. Obst. Soc. London, 1896, Vol. XXXVIII., p. 125 ; Ahlfeld, 
 Monatsschr. f. Gyn., Vol. I., p. 209 ; Ghrobak, Zentralbl. f. Gyn., 1896, p. 1281 ; Kelly 
 and Teacher, Journ. Path, and Bact., October, 1898 ; Levvers, Trans. Obst. Soc. 
 London, 1897, Vol. XXXIX., p. 246 ; Veit, Handbuch f. Gyn., 1899, Vol. III., p. 535 ; 
 Zeitschr. f. Geb. u. Gyn.. 1901, Vol. XLIV., p. 466 ; Teacher, Trans. Obst. Soc. London, 
 1903, Vol. XLV., p. 256 ; Pierce, Am. Journ. Obst., 1902, p. 321 ; Ladinski, Am. Journ. 
 Obst., 1902, p. 465; Haultain, Journ. Brit. Gyn. Soc, 1899 ; Schmauch, Surgery, Gyn, 
 and Obstet., September, 1907 ; Kromer, Deut. Med. Wochenschr., 1907, Vols. XXXI.— 
 XXXIII. ; Eden, Journ. Obst. and Gyn. Brit. Emp., 1907, Vol. XII., No. 6, 
 p. 424 ; Fairbalrn, Journ. Obst. and Gyn. Brit. Emp., 1909, Vol. XVI., No. 1, p. 1 ; 
 Rlsel, IJber das Maligne Chorionepitheliome, Leipzig, 1903 ; Frank, New York Med. 
 Journ., 1906, Vol. LXXXIIL, p. 864 ; Hermann, Beit, zur Geb. u. Gyn., 1904, 
 Vol. VIIL, p. 418. 
 
Thrombosis, Embolism, Sudden Death. 1069 
 
 hysterectomy. Chrobak and Von Franque have recorded such 
 cases, in which there had been sanguineous sputa and other symp- 
 toms pointing to a metastasis in the lungs. In a case recorded 
 by Veit, a mass supposed to be a metastasis in the iHac fossa 
 eventually disappeared. Metastases having the structure of vesi- 
 cular mole have disappeared after merely scraping out. 
 
Chapter XLL 
 PUERPERAL INSANITY* 
 
 Puerperal insanity may be divided into four classes : — the 
 insanity of pregnancy, that of labour, that of the puerperal state, 
 and that of lactation. The imj)ortant influence which child-bearing 
 has in reference to mental diseases is proved by the notable pro- 
 portion of patients admitted to lunatic asylums in which the disease 
 is attributed to this cause. By various authors this proportion is 
 estimated at from 8 to 12 per cent. At Bethlem Hospital, out of 
 1,333 female patients admitted from the year 1864 to 1874 inclusive, 
 14*7 per cent, owed their insanity more or less to causes related to 
 pregnancy or childbirth.^ The report of the Lunacy Commissioners 
 for the year 1902 shows that among women of all ages the yearly 
 average number of admissions into asylums for the years 1896 to 
 1900 due to puerperal insanity bears the percentage of 6*4 in the 
 private class and of 8*1 per cent, in the poorer classes to the total 
 yearly average of admissions from all causes.^ It^ is to be remem- 
 bered, moreover, that most of the milder and more temporary forms 
 of disease are treated at home. 
 
 Puerperal insanity may assume any of the forms of insanity in 
 general. The only peculiarity about it is its relatively good prog- 
 nosis. This is another circumstance proving the veritable character 
 of the influence exercised by pregnancy; for after the effect pro- 
 duced by this exciting cause has died away, cure results in the great 
 majority of cases ; and thus, in this respect, puerperal insanity is in 
 contrast to insanity in its other forms. Not every case, however, of 
 insanity occurring during pregnancy or after delivery has those 
 conditions for its cause. 
 
 Puerperal insanity resembles other forms of the disease in that 
 hereditary tendency is of great importance as a predisposing cause. 
 From this point of view must be taken into account the occurrence 
 in relations, not only of actual insanity, but of other neuroses, such 
 as hysteria, epilepsy, chorea, and the like. Savage found distinct 
 acknowledged insanity in the family in 31*4 per cent, out of 207 
 
 1 Savage, " Observations on the Insanity of Pregnancy and Childbirth," Guy's Hosp. 
 Eep., Third Series, Vol. XX. 
 
 2 Jones, Journ. Obst. and Gyn. Brit. Emp., 190H, Vol. III., No. 2, p. 109. 
 
Tuke. 
 
 Weber. 
 
 Jones. 
 
 18 
 
 15 
 
 21*6 per cent. 
 
 47 
 
 58 
 
 46-3 „ 
 
 35 
 
 26 
 
 32-4 „ 
 
 Puerperal Insanity. 107 1 
 
 cases ; Eeed in 40*5 per cent, out of 111 ; Tuke in 31-5 per cent, out 
 of 78 ; Hellyt in 38*8 per cent, out of 131 ; Jones in nearly 50 per 
 cent, out of 259. In about as many more cases a history of some 
 other neuroses in the family may be discovered. 
 
 Of the three principal forms of puerperal insanity, namely, those 
 of pregnancy, the puerperal period, and lactation, the insanity of 
 pregnancy is the rarest, and that of the puerperal period the 
 commonest. The following are the proportions according to various 
 authors : — 
 
 Marce. 
 Insanity of pregnancy . . 8 
 Insanity of the puerperal period 58 
 Insanity of lactation . . .33 
 
 In all the forms of puerperal insanity there is generally associa- 
 tion with debility, exhaustion, or impoverishment of blood. In 
 all of them some mental impression, such as a bereavement, 
 fright, sudden bad news, anxiety about children, or quarrel with 
 relatives, may be the exciting cause of the outbreak. Thus, in 
 times of war and revolution puerperal insanity is more common 
 than usual. 
 
 In all the varieties, but especially in the insanity of pregnancy, 
 occurring in single women in 25 per cent., and that of the 
 puerperal period, the grief and shame of seduction form an 
 important predisposing cause in many cases. Another cause, 
 which may be met with in each division, is rapid child-bearing. 
 The exhaustion of repeated child-birth and lactation may be 
 sufficient to call a predisposition into activity, especially if there 
 is hereditary taint. Septic infection is also an important factor in 
 many cases. 
 
 To all the forms of insanity, but especially to those of pregnancy 
 and the puerperal state, primiparge are most liable. On the other 
 hand, increase of age increases the proclivity. Thus between the 
 ages of 20 and 30, about 70 per cent, of the births take place, 
 but only 56 per cent, of the cases of insanity occur then ; between 
 the ages of 30 and 40, 20 per cent, of the births take place, but 
 35 per cent, of the cases of insanity occur ; less than 1*5 per cent, 
 of the births take place after the age of 40, whereas 8*6 per cent, of 
 the cases of insanity occur after that age (Marce). In some cases 
 insanity has been developed in the puerperal period after a first 
 pregnancy ; while on a second occasion, it has come on during 
 pregnancy, thus apparently indicating a progressive vulnerability 
 under the influence of the disturbing cause. 
 
1072 The Practice of Midwifery. 
 
 Tyler Smith^ relates the case of a patient who, out of seven 
 deliveries, had twins three times. On each of these three occasions 
 she suffered from puerperal mania. 
 
 The Insanity of Pregnancy. — The tendency of pregnancy to 
 call into activity other neuroses, such as hysteria and chorea, has 
 already been described. It is accounted for partly by the presence 
 of a local source of reflex irritation, partly by the increase in preg- 
 nancy of the irritability of the nerve centres to prepare them for the 
 work of parturition. The influence of pregnancy with regard to 
 insanity must be explained, in part, in the same way. The well- 
 known unnatural longings of pregnancy may also be regarded as 
 having some relation to insanity ; for in some cases these proceed 
 to such a length as to amount to moral perversion, as, for instance, 
 when they take the form of dipsomania or kleptomania. 
 
 The anaemia and deterioration of blood which are not uncommon 
 in pregnancy may often have to do with the causation. In some 
 instances albuminuria, or the blood changes resulting from jaundice, 
 have been regarded as a cause. 
 
 A mental cause frequently present is the fear or conviction, so 
 commonly met with in pregnant women, especially those pregnant 
 for the first time, that the result of delivery will be fatal. In many 
 cases the development of melancholia out of this despondent frame 
 of mind can be traced. It is a further proof of the relation between 
 the two conditions that the insanity of pregnancy takes the form of 
 melancholia in the great majority of cases. Out of 28 cases 
 recorded by Tuke, there was melancholia in 20, typical mania in 
 only 2 ; out of 10 recorded by Savage, there was melancholia in 7, 
 and typical mania in only 1. 
 
 With the melancholia more or less of dementia is associated in a 
 minority of the cases. Disposition to suicide is strong. If the 
 insanity persists after delivery, there may be a homicidal tendency 
 towards the infant. There may be refusal of food, and the delusion 
 that attempts are being made to poison is not uncommon. There 
 is generally apathy and indiiference towards husband and friends. 
 Erotic manifestations are comparatively uncommon. The tendency 
 to moral perversions, such as dipsomania and kleptomania, some- 
 times without other evidence of insanity, has been already men- 
 tioned. Insanity may come on at any time during pregnancy, but 
 generally after the second or third month, the largest proportion 
 occurring after the fifth month. 
 
 Prognosis. — The great majority of patients recover, but usually 
 
 1 Manual of Obstetrics. 
 
Puerperal Insanity. i073 
 
 not till after delivery. In a few instances, however, when insanity 
 comes on in the early months, the patient recovers before delivery. 
 There is, however, a liability to relapse after delivery. According 
 to Spiegelberg, the prognosis is more favourable when the insanity 
 comes on in the early months. Of Savage's cases, 90 per cent, 
 recovered within twelve months. The average date of recovery 
 was six months after delivery. When the insanity takes a form 
 different from that usual during pregnancy — that is to say, when 
 there is mania rather than melancholia — the prognosis is less 
 favourable. 
 
 The Insanity of Labour. — In some cases of labour a kind of 
 transitory mania or delirium is produced by the intensity of the 
 pain. The patient, in her frenzy, may injure herself, or, more 
 frequently, injure the child, the excitement reaching its height 
 just at the final pains, when the head passes the vulva. As might 
 be expected, this is more common in primiparae, in whom greater 
 pain is produced in the distension of the perineum, and inevitable 
 laceration of the vaginal outlet. The mental agony resulting from 
 seduction may add to the effect. There is a medico-legal interest 
 in the question, since it has generally been held, when a woman has 
 been delivered alone, and is accused of having committed infanticide 
 immediately upon the birth of the child, that the deed may have 
 been done under the influence of transient mania. As a rule, the 
 maniacal excitement passes off as soon as the child is born, and it 
 may therefore be questioned whether this transient frenzy should 
 really be classed as insanity. There is a resemblance, however, to 
 insanity in the fact that delusions are sometimes manifested. 
 Moreover, in a few cases, though the excitement passes off for a 
 time, other mental symptoms, such as melancholia, are developed 
 a little later. The maniacal excitement must then be regarded as 
 the first symptom of the disease. Two cases of this kind are 
 recorded by Savage. 
 
 The Insanity of the Puerperal Period. — This, as already 
 explained, is the most common form of puerperal insanity. There 
 is no positive line of demarcation between it and the insanity of 
 lactation, but it is generally regarded as including all cases occur- 
 ring within two months after delivery. Of these, the great majority, 
 about 90 i^er cent., are developed within the first fortnight, and 
 extremely few after the first month. The insanity of lactation, on 
 the other hand, usually comes on when the patient has been 
 weakened by many months' nursing. 
 
 M. 68 
 
I074 The Practice of Midwifery. 
 
 Causation. — Besides the general causes already enumerated (see 
 p. 1071), the chief causes operating in the production of this variety 
 are the effect upon the nervous system produced by the shock of 
 labour and the subsequent exhaustion. The disease is therefore 
 promoted by anything which increases either of these effects, 
 especially difficult or painful labour, or excessive haemorrhage. 
 Anaemia is, indeed, almost always a marked feature in the patient. 
 Some mental impression, such as grief at the loss of a child, is 
 present in a large proportion of cases (46 out of 92, according to 
 Esquirol). The shame resulting from seduction has an important 
 influence according to some, but Savage has found insanity after 
 illegitimate childbirth to be comparatively rare. 
 
 In some cases of neurotic patients, or those predisposed to 
 insanity, the delirium accompanying some form of puerperal fever 
 takes a maniacal aspect. The delirium then varies in proportion 
 to the fever, and subsides with it. In other cases, again, the 
 puerperal fever appears to be the starting-point of the insanity, 
 just as any other kind of acute disease may be. The insanity then 
 remains after the pyrexia has subsided. Other acute disorders, 
 comjjlicating the puerperal state, which have been observed as the 
 antecedents of insanity, are rheumatic fever, scarlatina, and 
 mammary abscess. 
 
 Sir J. Simpson held that puerperal insanity was frequently the 
 result of ursemia, but other authorities have found albuminuria 
 to be very rarely present. Savage, however, records a case in 
 which slight albuminuria was present only during the period of 
 excitement, a condition not found in ordinary acute mania. Sir J. 
 Simpson, indeed, stated that the albumen disappeared from the 
 urine within a short time after the access of the malady ; but, in 
 such case, the insanity can hardly be regarded as ursemic. 
 Insanity has occasionally been a sequel of eclampsia, but only in 
 rare cases. 
 
 Puerperal insanity may occur after an abortion as well as after 
 labour, although not so frequently. Sometimes it recurs in 
 successive pregnancies. In other cases, after a first attack of 
 puerperal mania, some uterine disorder, or an ovarian tumour, may 
 cause a recurrence. I have known very acute mania, resembling 
 puerperal mania, and followed by rapid recovery, to be the sequel 
 of the operation for the incision of the cervix uteri. 
 
 Clinical Course. — In the majority of cases the form taken is that 
 of mania (in 57 out of 73 cases, according to Tuke). This is 
 especially the case when the outbreak takes place within a fort- 
 night after delivery. There "may be premonitory signs of mental 
 
Puerperal Insanity. 1075 
 
 disturbance. Generally there is sleeplessness ; the patient may take 
 an unreasonable dislike to the nurse, or alter in her manner to her 
 husband. The maniacal outbreak may be sudden. Generally it is 
 marked by extreme restlessness of motion and incoherent voluble 
 speech. Throughout the incoherence may be sometimes traced a 
 prominent delusion, or some idea which had previously occupied 
 the patient's mind. Hallucinations of vision are frequent. The 
 patient may violently resist being kept in bed, may tear off her 
 clothes, or try to throw herself out of the window. She is often 
 violent towards relations, takes a dislike to her hu'sband, and is 
 apt to try to destroy the child. The suicidal tendency is also 
 often marked. In a few cases the mania comes on very suddenly — 
 within a few days after delivery — and passes off as suddenly. 
 Patients in this state may destroy their children or injure them- 
 selves or others, and the explosion may suddenly restore the 
 balance of reason. The condition is therefore one of medico-legal 
 importance. 
 
 In other cases the onset is not so violent. The patient at first 
 may merely be incoherent, may refuse food, or may show signs of 
 delusion ; but, in all cases which occur within the first fortnight 
 after delivery, an outbreak of violence is to be apprehended. 
 
 The pulse is rapid when excitement is present, but the tempera- 
 ture is not generally elevated, unless the insanity is dependent upon, 
 or associated with, some other cause of pyrexia, such as septic 
 disturbance. The tongue is usually coated, and the bowels often 
 constipated. Evacuations may be passed involuntarily, or without 
 regard for decency. There may be filthy habits, such as eating 
 excrement. Food is often refused. The urine is scanty, and con- 
 tains excess of urea, urates and phosphates, in consequence of the 
 increased waste of tissues. The lochia and secretion of milk are 
 generally suppressed or diminished at the outset of the disease. 
 This circumstance is to be regarded, as a rule, as a consequence, 
 and not a cause of the insanity. Sometimes, however, especially 
 within the first week, it may indicate a septic disturbance, which 
 is itself exciting the insanity. It will then be associated with 
 elevation of temperature. The incessant restlessness of body and 
 mind, sleeplessness, and difficulty about feeding often lead to great 
 wasting, and increase of that ansemia which is usually present from 
 the first. 
 
 An erotic tendency is rather common, and women may use in 
 their ravings obscene and profane language with which they would 
 hardly have been thought likely to be acquainted. Delusions 
 of a sexual kind may be prominent, and the patient may falsely 
 
 68—2 
 
1076 The Practice of Midwifery. 
 
 accuse herself of unchastity. Masturbation is pretty frequent. 
 This tendency may be associated with the fact that the exciting 
 cause of the disease is an affection of the genital organs. It is apt 
 to persist throughout its whole course. 
 
 I have met with a case in which, after an early abortion, and 
 great disappointment in consequence, mania took the form of intense 
 paroxysms, lasting only a few minutes, like epileptic attacks, and 
 recurring several times in the day. In the paroxysm, the patient 
 fought furiously with those present, under the delusion that they 
 were devils carrying her to hell to prevent her having a child. It 
 passed away quite suddenly, and she lay exhausted, but quite 
 rational. The only suspicious sign in the interval was, that she 
 wished to be left alone with one of her children and a knife, in 
 order to prove that she was quite sane. This patient had to be 
 removed to an asylum, but recovered after a few weeks. 
 
 Melancholia is more common in cases commencing later than the 
 first fortnight after delivery, and the onset is commonly more 
 gradual. In this form there is often religious despondency. 
 Other moral causes, such as grief, ill-treatment, or poverty, are 
 also more frequently operative than in mania. Sleeplessness is 
 even more marked than in mania. The suicidal tendency is strong, 
 even when there is an entire absence of delusions. It is also 
 necessary to guard against infanticide. There is rarely any erotic 
 tendency or evidence of masturbation. The patients usually 
 suffer from constipation, and are averse to taking food, either 
 from simple want of appetite or from delusions. Patients who 
 show maniacal excitement at the outset of the disease may 
 afterwards pass into melancholia or dementia. 
 
 Prognosis. — The patient rarely, according to Savage, dies from 
 simple exhaustion, as sometimes happens with other forms of acute 
 mania, but this result does occasionally follow. The chief causes 
 of death were found by Savage to be pyaemia and phthisis. There 
 were 7 deaths in 78 cases of first attacks of puerperal mania 
 recorded by him. 
 
 Probably the fatal cases are often not removed to asylums. Of 
 four cases, occurring in 23,591 deliveries in the Guy's Hospital 
 Lying-in Charity, all proved fatal ; but this is an unusual result. 
 One died from septicaemia, of which the mania was a complication ; 
 one from pneumonia ; two apparently from exhaustion. In one of 
 these two cases there was albuminuria. 
 
 If the patient does not die, cure follows in the great majority of 
 cases. It may still be hoped for, even after the disease has per- 
 sisted for twelve months. Sometimes, however, the patient lapses 
 
Puerperal Insanity. 1077 
 
 into permanent melancholia or dementia. Of the above 78 cases 
 recorded by Savage, 13 patients were uncured at the end of from 
 12 to 18 months. The most frequent duration is from three to six 
 months. A larger proportion of the cases with a sudden onset 
 recover than of those in whom the onset is gradual. In recurrent 
 attacks the prognosis is less favourable, and the cure generally 
 requires longer time. In melancholia the average duration is 
 somewhat longer. The greatest number of recoveries takes place 
 from the fourth to the seventh month. 
 
 The Insanity of Lactation. — This form of insanity is com- 
 moner among the poor than among the rich, and commences in 
 general physical weakness and anaemia. It is most frequent in 
 multiparse who have been weakened by numerous or quickly- 
 repeated pregnancies. It may commence at any time, from two 
 months up to eighteen months or more after delivery. In a few 
 cases, the outbreak has followed almost immediately upon weaning. 
 The majority of patients suffer from the outset from melancholia, 
 and, even of those who are excited at the commencement, almost 
 all become melancholic afterwards. The proportion of recoveries 
 and the duration of the disease are similar to those in the insanity 
 of the puerperal period. 
 
 Prophylaxis. — Marriage should be discouraged in women who 
 have a strong hereditary disposition to insanity, and also, in most 
 cases, in those who have already had an attack of insanity. Such 
 advice, however, will generally not be followed. If pregnancy 
 occurs in such women, the utmost care should be taken to main- 
 tain the health by nutritious food and hygienic management. If a 
 patient has previously suffered from the insanity of pregnancy, and 
 has premonitory signs of mental disturbance in a subsequent preg- 
 nancy, the question of inducing abortion with the hope of averting 
 insanity may arise. In general, this proceeding is as likely to 
 precipitate the insanity as to avert it, and as the hope of benefit is 
 not enough to justify the sacrifice of the child, it is not to be 
 recommended. 
 
 Treatment. — As the disease so generally terminates in recovery, 
 it is desiral)le to avoid sending the patient to an asylum, in 
 order to avoid the consequent stigma, provided that she is in a 
 position to secure the services of skilled attendants. Since she 
 must be constantly watched, day and night, two attendants at least 
 are necessary. In cases of violent mania, four may be required. 
 
loyS The Practice of Midwifery. 
 
 With patients who are not wealthy, therefore, removal generally 
 becomes necessary, unless the attack is mild, and of brief duration. 
 If removal is likely to be necessary, it is well that it should take 
 place early, since change of scene and complete separation from 
 relations often have a beneficial effect. In the insanity of 
 pregnancy, the consideration that the duration is likely to be 
 longer than in the other forms may be an element in the decision. 
 
 The most important point in treatment is to maintain nutrition, 
 and, according to Jones, the essence of the treatment is " com- 
 pulsory superalimentation." If possible, the patient should be 
 induced by coaxing to take an ample amount of solid food. If this 
 does not succeed, liquids must be given. Forcible administration 
 of food may be necessary in melancholia, and sometimes in mania. 
 The best plan is to pass through a nostril a long thin oesophageal 
 tube surmounted by a funnel, the patient being placed on her back. 
 Gruel, or milk thickened with some farinaceous food, or eggs beaten 
 up with milk, may be poured down. In acute delirious mania the 
 free administration of alcohol is usually indicated. 
 
 Bromide of potassium is often useful in the early stages of excite- 
 ment. Hypnotics must be used freely, as it is of the utmost 
 importance to procure sleep if there are successive restless nights. 
 Chloral with bromide of potassium should be given, and sulphonal 
 is useful when there is much motor excitement. Opium and 
 morphia are contra-indicated as a general rule. In melancholia, 
 however, opiates often act better than in mania. Stimulants in 
 free doses, given in the evening, often aid sleep, and diminish the 
 necessity for hypnotics. For the headaches, which are often very 
 distressing, antipyrin and potassium bromide may be ordered. 
 
 It is desirable that the patient should not see her husband, 
 children, and relatives, especially if she has shown any dislike to 
 them. In the later stages, change of air and scene often proves 
 beneficial. In the convalescent stage. Savage considers that a 
 return to cohabitation is beneficial, but pregnancy should be 
 avoided for a considerable time. 
 
Chapter XLII. 
 INJURIES AND DISEASES OF THE FCETUS. 
 
 CBPHALHiEMATOMA. — Besides the caput succedaneum another 
 form of swelling on the head may result from difficult labour, 
 namely, cephalhsematoma, consisting of a circumscribed effusion of 
 blood. Small effusions of blood may take place in the substance of 
 the caput succedaneum, that is to say, in the cellular tissue beneath 
 the scalp. But, in the characteristic form {cephalhematoma externa), 
 the effusion takes place beneath the pericranium, separating it from 
 the bone, and is due to the rupture of a considerable vessel. In 
 some cases, blood is effused also beneath the bone {cephalh(ematoma 
 interna), between it and the dura mater. The bone beneath is very 
 congested, and not infrequently a careful examination reveals the 
 presence of a small crack or fissure. Cephalhaematoma most 
 frequently results from the pressure of the blades of forceps ; but 
 it may be produced by pressure against any projecting bone, such 
 as the promontory of the sacrum. It is also ascribed to the effect 
 of pressure produced by an unyielding os uteri. 
 
 The occurrence of a cephalhaematoma is no doubt to be ex- 
 plained in the majority of cases by the rupture during labour of 
 some of the vessels passing from the pericranium to the bones 
 of the skull. It has been suggested, however, that such an injury 
 is predisposed to by the presence of small fissures in the bones 
 due to defective ossification, or that there may be a diseased 
 condition of the vessel walls present rendering them more readily 
 torn. Fere^ has described the constant presence of small fissures 
 at the postero-superior angle of the parietal bone, the site of most 
 frequent occurrence of a cephalhaematoma, and has shown that a 
 very slight pressure on the head will cause extension of these 
 fissures and the rupture of the small blood-vessels crossing them. 
 In some such manner are to be explained the cases where such an 
 effusion of blood occurs during an easy and normal labour or in a 
 case in which the head does not present. 
 
 Diagnosis. — The swelling is limited to one bone, generally a 
 parietal bone, more frequently the right than the left, and very 
 
 1 Kcvuc mens, de Mi^d. ot do Chir., 1880, Vol. IV., p. 112. 
 
io8o The Practice of Midwifery. 
 
 rarely it occurs upon the occipital, frontal, or temporal bones. It 
 continues to increase for a time after birth, while a caput suc- 
 cedaneum diminishes progressively and rapidly from the time of 
 birth. A cephalhsematoma is generally first noticed from one to 
 four days after birth. It may increase up to seven days, then 
 remains for a few days stationary ; and generally has disappeared 
 after from four to twelve weeks. As a rule there is no discolora- 
 tion of skin over the tumour. The tumour never crosses a suture, 
 but in rare cases has occurred on both parietal bones. When this 
 occurs the two tumours are generally separated from one another 
 by a well-marked groove. The swelling is painless, and fluctuation 
 can generally be felt in it, until the serum has become absorbed. It 
 may or may not extend over the whole bone. After four or five 
 days a hard border of inflammatory material begins to be felt 
 round the edge, so that the feel somewhat resembles that of a 
 depressed fracture. This is due to the formation of bony material 
 along the edge of the detached pericranium. From this a thin 
 crust of bone, which crackles on i3ressure, may extend over the 
 swelling during the time in which the serum and clots are being 
 absorbed. Encephalocele is distinguished by the fact that it 
 always occurs in the line of a suture or at a fontanelle. There 
 is no fluctuation, but the swelling generally pulsates, and enlarges 
 when the child cries. A vascular tumour of the scalp gives 
 no fluctuation; and there is generally discoloration of the skin 
 over it. 
 
 Prognosis. — In general the effusion is absorbed in time. But 
 in a weakly or cachectic child, it may suppurate, and then may 
 endanger life, sometimes leading to pj'semia. 
 
 Treatment. — The swelling should be left alone, unless there is 
 evidence of suppuration, when it should be laid open and the sac 
 packed with gauze. 
 
 Other Injuries to the Head. — Among the rarer injuries as the 
 result of difficult forceps delivery are fractures of the bones of the 
 face, of the nose, or of the orbit, with injuries of various kinds to 
 the eyes. Occasionally from slipping of the forceps the lobe of the 
 ear may be torn partly or even completely off. Injuries to the eye, 
 a very important variety, may be produced directly by the pressure 
 of the blades of the forceps or indirectly from the compression of 
 the head or as a result of fracture of the bones of the orbit. These 
 accidents are practically limited to cephalic presentations, and are 
 never met with when the child has presented by the breech. They 
 vary in severity from slight lacerations of the eyelids to complete 
 
Injuries and Diseases of the Foetus. 1081 
 
 destruction or evulsion of the eyes. In 112 cases of this kind 
 collected by Wolff ^ in no less than 19 the eyeballs were extruded 
 
 Fig. 499. — A spoon-shaped depression from a case of forceps delivery 
 in a flattened pelvis. 
 
 Fig. 5U0. — L-shaped depression from a case of forceps delivery in a 
 flattened pelvis. 
 
 from the orbits. Such an accident is most likely to happen when 
 high forceps are applied and the head is pulled forcibly past a 
 contracted brim. 
 
 1 Beitrage z. Augcnheilkunde ; Fcstschr. f. J. Hirschbcrg. 
 
io82 The Practice of Midwifery. 
 
 Injueies to the Bones. — As a result of excessive traction on 
 the head dislocation of the cervical vertebrae may occur or separa- 
 tion of the condyloid processes of the occipital bone, a very 
 uncommon but fatal injury. Local depressions on the head are 
 generally due to the pressure of the sacral promontory. There may 
 be either a spoon-shaped depression, or a more prolonged groove. 
 In the latter case, if the head has passed in a position of flexion, 
 the groove runs downward and forward near the anterior border of 
 the parietal bone ; if in a position of moderate extension, the groove 
 is nearly parallel to the coronal suture. In some cases the groove 
 first runs parallel to the suture and then turns forward, flexion 
 having supervened upon extension at an intermediate stage. The 
 
 N 
 
 v> ( 
 
 Fig. 501. — Fracture of the anterior inferior angle of the parietal bone in a 
 case of forceps delivery. 
 
 position of the groove is similar in pelvic presentations, except that 
 it is often more parallel to the coronal suture, passage in the extended 
 position being relatively commoner. Depressions the most serious, 
 as they are often associated with fracture of the inner table, are 
 more common in pelvic presentations, since the head is generally 
 dragged quickly past the obstruction. Fissures of the bone, or 
 actual fractures, are comparatively rare, but these again occur more 
 frequently in pelvic presentations. 
 
 Fractures of the bones of the skull are occasionally met with 
 after spontaneous delivery, but usually they are the result of the 
 pressure of the blades of the forceps or of that of the sacral 
 promontory. In delivery by forceps a depression may be pro- 
 duced by the promontory of the sacrum on the frontal bone ; since 
 in the application of the forceps the long diameter of the head is apt. 
 
Injuries and Diseases of the Foetus. 1083 
 
 in a flattened pelvis, to be changed from a tranverse into an oblique 
 position. 
 
 In flattened pelves, in consequence of the Naegele-obliquity, the 
 posterior parietal and posterior half of the frontal bone are generally 
 more flattened, the anterior more rounded than in normal labour, 
 because the latter, projecting more deeply into the brim, are more 
 unsupported. In general there is a " shear " or sliding movement 
 of the anterior parietal bone upon the posterior in the direction of 
 the occiput, but this must be produced after the occiput has begun 
 to rotate forward, and is therefore more marked in the generally 
 contracted pelvis. Fractures usually result in the death of the 
 child, but in cases where furrows or depressions alone aie present 
 the child generally survives. Very frequently the depression dis- 
 appears spontaneously, in some cases it is corrected or remains 
 without symptoms, and in other cases permanently injurious 
 sequelae follow. These may take the form of paralysis, idiocy, or 
 epileptic convulsions. 
 
 Treatment. — An attempt may be made to squeeze out a 
 depression of the skull by compressing the head, not too violently, 
 in the opposite diameter to that in which the depression lies. If 
 this fails, and the depression is not beginning to disappear in a 
 day or two, an incision may be made, with careful antiseptic 
 precautions, along the nearest edge of the bone, and a blunt 
 elevator passed underneath the bone, to raise the depressed part. 
 Or the incision may be made through the bone a quarter of an 
 inch from the suture, to avoid the risk of cutting the dura mater, 
 which is adherent at the sutures. 
 
 An ingenious method is that advocated by Hastings Tweedy. ^ 
 The sharp point of a bullet forceps is bored through the bone at 
 the centre of the depression. The shank is then turned at right 
 angles to the bone and the depressed area pulled with a jerk into 
 position. 
 
 Injueies to Nerves. — Facial paralysis is generally the result of 
 pressure by one blade of the forceps upon the seventh nerve, where 
 it emerges from the stylo-mastoid foramen. There is also a central 
 form of the paralysis usually distinguishable by the fact that it is 
 not so complete as the peripheral ; for example, the infant is able 
 to close the eye, and in this variety the cause is to be found 
 in some intranatal trauma to the nucleus of the seventh nerve or 
 in some antenatal changes in the brain. In the peripheral variety, 
 sucking is usually interfered with, but the paralysis generally 
 
 ' Jlotunda Practical Midwifery, 1908, p. 'Ml. 
 
1084 The Practice of Midwifery. 
 
 disappears within from six to eight weeks. In the central variety 
 or in the rare instances in which the nerve is completely divided, 
 the paralysis usually remains permanently. 
 
 Paralysis of a limb may result from injury to a nerve produced 
 by traction upon an arm or leg, especially in association with 
 fracture of the bone. It is generally m,ore prolonged than facial 
 paralysis, and is apt to be followed by some permanent impairment 
 of power, sometimes by contraction. Paralysis of the arm from 
 injury to the fifth and sixth nerves of the brachial plexus (birth 
 paralysis or Duchenne's paralysis) is a most important variety of 
 birth injury, and is most commonly the result of traction on the 
 arm during delivery of the arms and head in breech or transverse 
 presentations, but may also be produced by forcible traction on 
 the forecoming head. The infraspinatus, deltoid, brachialis anticus, 
 and biceps muscles are all involved and the arm assumes a 
 characteristic attitude. It hangs limply by the side, cannot be 
 abducted, the forearm is extended and cannot be flexed, and the 
 hand cannot be completely supinated. The prognosis is unsatis- 
 factory. According to Bruns^ only 20 per cent, recover, whereas 
 66 per cent, of similar injuries to single nerves below the plexus 
 undergo spontaneous cure. 
 
 Treatment. — In paralysis either of the face or a limb, gentle 
 massage may be used after some weeks, if power does not quickly 
 return. Later, electricity may be tried, especially in the case of 
 a limb. In paralysis of the arm, if marked improvement does 
 not occur in two or three months, the plexus may be exposed, the 
 perineural cicatrices removed, and the nerves resected.^ 
 
 Cerebral Haemorrhages. — Besides the haemorrhage between the 
 bone and dura mater, which sometimes accompanies ce]3hal- 
 hsematoma, intra-cranial hsemorrhage may occur indej)endently. 
 Haemorrhage into the substance of the brain is uncommon and was 
 met with only once in a normal foetus and three times in anen- 
 cephalic foetuses in 130 autopsies on still-born children recorded by 
 Spencer.^ The greater part of the haemorrhages are into and 
 beneath the arachnoid and pia mater and occasionally between the 
 dura mater and the bone. Haemorrhages into the membranes 
 occurred in 53, or 40'7 per cent., of Spencer's cases. It is interest- 
 ing to note that among his cases, in every case in which forceps 
 had been used to deliver living children who died during or after 
 
 1 Neurolog. Zentralbl., November 16, 1902. 
 
 2 See Thorburn : "Obstetrical Paralysis," Journ. of Obst. and Gyn., Brit. Eaip., 
 May, 1903, p. 454. 
 
 s Trans. Obstet. See, London, 1891, Vol. XXXIII., p. 265. 
 
Injuries and Diseases of the Foetus. 1085 
 
 birth, haemorrhages were found. In the production of these 
 haemorrhages he lays great stress on softness and increased mobility 
 of the skull bones from laxity of the sutures, and more especially 
 the mobility of the lower anterior angle of the parietal bone which 
 lies over and is very liable when unduly mobile to exert injurious 
 pressure on the great anastomotic vein. In some cases the bleed- 
 ing is the direct result of injuries to the sinuses, usually with a 
 fatal issue, while in others the haemorrhages are due to pressure on 
 the skull from a difficult delivery or pressure on the neck of the 
 child. Of recent years a certain number of these cases have been 
 operated upon successfully, but there is always great difficulty in 
 determining if a haemorrhage exists and whether it is unilateral or 
 bilateral. 
 
 HEMATOMA AND MYOSITIS OF THE Sterno-Mastoid. — This iiijury is 
 relatively more common in pelvic presentations, but it occurs also 
 in vertex presentations. In the former it is especially likely to be 
 j)roduced by traction upon the legs or body ; in the latter it may be 
 due to extraction by forceps. The lump is often not observed for 
 some days after birth. It is at first soft, consisting of blood ; later 
 some inflammatory effusion occurs and the lump becomes harder, 
 and may increase for a time. As a rule the lump entirely dis- 
 appears in from four to eight weeks and leaves no j^ermanent effect ; 
 but in some instances cicatricial contraction takes place, and 
 torticollis is produced. 
 
 The other sjDocial injuries which may be produced by extraction 
 in pelvic presentations have already been described (p. 819). 
 
 Asphyxia Neonatorum, or Suspended Animation of the 
 New-born Infant. 
 
 Normally the new-born infant not only breathes freely, but cries 
 loudly, immediately after its expulsion. The deep inspirations 
 which it makes in crying are of service in fully expanding for the 
 first time the previously airless lungs. The cause of the first 
 inspiration is partly that the aeration of the blood is interrupted by 
 detachment of the placenta, which leads to an accumulation of CO2 
 in the blood, and partly that the cold external air acts as a reflex 
 stimulus upon the skin. Under certain circumstances, the child 
 is born apparently lifeless, or in a state of suspended animation, 
 and makes no attempt to breathe, although the heart is still beating 
 to some extent. In other cases, it makes ineffectual gasps at 
 intervals. 
 
io86 The Practice of Midwifery. 
 
 Causation. — There are two main causes of the state of sus- 
 pended animation : — First, interruption of, or obstruction to, the 
 aeration of the blood by the jDlacental circulation ; secondly, pressure 
 upon the head. Interference of aeration of the blood may take 
 place in various ways. The placenta (especially when praevia) may 
 be partially or wholly detached. The circulation through it may be 
 imj)eded by prolonged contraction of the uterus, especially when the 
 liquor amnii has long escaped, the uterus closely grasps the child, 
 and has passed into the state of continuous contraction. The funis 
 may be compressed when prolapsed or coiled round the neck, or in 
 pelvic presentations. When coiled round the neck it may be com- 
 pressed against the symphysis pubis during the birth of the head. 
 (See p. 305.) Circulation may also be impeded by pressure upon the 
 thorax or neck of the child, especially when the head has been 
 expelled, and the trunk is retained within the vulva. Again 
 deficient aeration of blood may be the result of preceding anaemia, 
 or profuse haemorrhage from the mother, and may be promoted also 
 by poorness of quality, or other morbid condition, of the maternal 
 blood a^Dart from haemorrhage, such as occur in eclampsia or uraemia. 
 
 The first effect of deficient aeration of blood is that the respira- 
 tory centre is stimulated, and the child makes futile efforts to 
 breathe. This is proved by the fact that, in many cases, mucus, 
 meconium and liquor amnii are found post mortem to have been 
 drawn into the bronchi and lungs, and extravasations of blood in 
 the lungs to have been j^roduced by the suction due to attempted 
 inspiration. It is under such circumstances that, in rare cases, the 
 vagitus uterinus, or intra-uterine cry, of the child has been heard, 
 when air has been admitted into the uterus in the course of turning 
 or some other obstetric operation. The child being unable to 
 obtain air, the heart's action becomes slower and gradually fails, 
 and eventually the irritability of the respiratory centre is impaired 
 or destroyed from the accumulation of CO2 and a lack of a supply of 
 suitable blood. When the child is born in this condition, the 
 stimulus of the external air fails to excite any attempt to breathe, 
 or calls forth only feeble gasps. 
 
 Prolonged pressure on the foetal head in difficult labour also 
 eventually causes impairment, and at last destruction, of the 
 irritability of the respiratory centre in the medulla. In general, 
 prolongation of the pressure appears to be the chief element in the 
 case. But it is possible that a more severe, although shorter, 
 pressure may have a similar effect. This may be the reason why a 
 frequent and early use of forcej)s appears, from reliable statistics 
 (see pp. 630 — 633), to have such a slight influence in diminishing 
 
Injuries and Diseases of the Foetus. 1087 
 
 the ratio of still-births, and one so much less than has been 
 imagined by various modern authors. Pressure on the foetal head 
 may produce its bad effects by interfering with the cerebral circula- 
 tion, by direct injury to the brain, or by causing haemorrhage into 
 or beneath the membranes or more rarely into the brain substance, 
 or into the ventricles. 
 
 In many cases the haemorrhage is set up by tearing of the venous 
 sinuses, the result of the compression and consequent overlapping 
 of the bones of the vault of the skull. In head-last deliveries, 
 when the medulla oblongata is exposed to injury, as by excessive 
 traction on the neck, the respiratory centre, or its connections with 
 the nerves, may be altogether destroyed. 
 
 Symptoms and Diagnosis.— Before delivery, if the fcetal heart 
 or pulsation of the funis is found to be becoming generally slower 
 and more feeble, it is a sign of impending asphyxia. An especially 
 loud funic soufSe and one increasing in intensity is of some value 
 as a sign of impending asphyxia. Temporary retardation of the 
 heart is generally a sign of temporary pressure on the funis, but in 
 some cases danger to the foetus is indicated by a marked increase in 
 the heart rate or by irregularity in its force or rhythm rather than 
 a slowing. In head-last deliveries asphyxia is indicated by attempted 
 inspirations, or convulsive movements of the limbs, and the escape 
 of meconium in other than breech presentations is also an 
 indication. 
 
 Asphyxia Livida. — After delivery, the symptoms vary according 
 to the degree of the asphyxia. In mild cases, the appearance of the 
 child is generally livid and cyanotic, especially that of the head, if 
 there has been pressure on the neck. The skin is dusky red and 
 the cutaneous vessels turgid. The muscle tone is not lost and the 
 pharyngeal and cutaneous reflexes are present. The heart's action 
 is slow but well marked, and pulsation can be felt in the funis. 
 There may be spontaneous attempts at breathing. These generally 
 take the form of deep inspiratory gasps, due to contraction of the 
 diaphragm, which have more effect in sucking in the ribs than in 
 drawing in air, owing to the obstruction produced by the fluid which 
 has been drawn into the air-passages. They are accompanied by 
 facial contortion. If breathing becomes established, naturally or 
 after the use of artificial means, rapid and very shallow diaphragm- 
 atic breathing generally Ijecomes continuous between the deep 
 gasps, some time before the gasps themselves cease, or the child 
 gains vigour ejiougli to cry. 
 
 If any air is inspired, the short inspiration is followed by a 
 
io88 The Practice of Midwifery. 
 
 j)rolonged expiration, the bronchi being obstructed by the fluid 
 which has been drawn in. 
 
 Asphyxia Pallida or Syncopal Asphyxia. — In the graver form of 
 asphyxia the skin is pale and white instead of livid, and its 
 sensibility is lost. The muscles of the body as a whole have lost 
 their tone entirely and the reflexes are generally absent. 
 
 The child after birth lies limp with its limbs flaccid and the 
 sjDhincters are relaxed. There is as a rule no spontaneous attempt 
 at breathing, unless artificial means are used. No pulsation is felt 
 in the funis, the vessels of which are collapsed, and the heart's 
 action may be very feeble and irregular and occurring only at long 
 intervals. In some cases the heart's rate may be somewhat 
 increased, and this is usually a sign of good prognostic omen. 
 The pulsation of the heart is always visible while any pulsation 
 continues, and should be looked for, not listened for. This form 
 of asphyxia is sj^ecially likely to arise from prolonged j)ressure on 
 the head. 
 
 Prognosis. — While there is any action of the heart, however 
 slow and feeble, there is always hope that the child may be 
 resuscitated. If the heart has ceased beating, it is useless to 
 attempt any treatment. If the child makes any spontaneous 
 gasp, either shortly after delivery or while artificial respiration is 
 being carried out, it is almost certain that treatment will be 
 successful in reviving it, if persevered with long enough. There 
 may, however, be exceptional cases, as when the larynx has been 
 injured by unskilful attempts at jaw-traction, or by compression 
 with the forcei)s in cases of face or brow presentation. If there 
 is no spontaneous attempt at inspiration, it may haj)j)en that, 
 although the heart's action may be maintained for an hour or 
 more, and even improved, by artificial respiration, yet the child 
 cannot be induced to breathe. In such cases the respiratory centre 
 has probably undergone irrej)arable injury. In some instances, 
 although breathing is established, and the child may even cry, yet 
 it remains feeble, and dies within a few days. In such cases the 
 condition called atelectasis imlmonum is often found post mortem. 
 The lungs are shown to have been only imperfectly expanded, and 
 a considerable proportion of them still remains solid and airless. 
 This is especially likely to be the case where the child is feeble 
 or premature. With feeble and premature children the same 
 condition of atelectasis may be found, if the child dies within a 
 few days, even if it has breathed spontaneously from the first. 
 
Injuries and Diseases of the Foetus. 1089 
 
 A vigorous cry is the most effectual means of fully expanding the 
 lungs. 
 
 Treatment. — In considering the treatment of cases of asphyxia 
 neonatorum we must remember that while in cases of asphyxia 
 livida the reflex excitability of the respiratory centre is still present 
 and can be roused into activity by appropriate reflex stimuli, in the 
 more severe form of asphyxia pallida the excitability of the 
 respiratory centre in the medulla is not only entirely wanting, but 
 there is present in addition a considerable degree of heart failure 
 and a condition closely resembling that of shock. 
 
 In the first class of case therefore, our main endeavours must 
 be directed towards exciting the respiratory centre to action by 
 appropriate stimuli, while in the second or more severe form of 
 asphyxia pallida our endeavours should be directed towards 
 restoring the excitability of the centre, and this can best be done 
 by strengthening the heart's action, and improving the condition 
 of the foetal blood. 
 
 The most certain method is the j)erformance of artificial respira- 
 tion, which oxygenates the blood, promotes the cerebral and pulmo- 
 nary circulations, and strengthens the heart's action. 
 
 Asphyxia Livida. — If the child does not breathe freely and 
 cry immediately after delivery, the first thing is to clear away, 
 as far as possible, any inspired mucus which may be obstructing 
 the air -passages. The child should be turned for a moment 
 with its face downward, or better inverted, and the back of the 
 mouth wij)ed out with a clean napkin. The next effort should 
 be to stimulate respiration by reflex stimulus. This may be done 
 by blowing upon the child's face ; if this fails, by flapping its 
 buttocks, back, or chest with a towel wetted in cold water, or by 
 rubbing its skin vigorously. An effectual j)lan is to have two 
 basins, one filled with hot, the other with cold water, and to dip 
 the child for a moment into each alternately, repeating this several 
 times. Artificial respiration may be performed, if necessary, while 
 the basins are being prepared. 
 
 If the child does not respond to the first attempts to excite 
 respiration, such as flapping it with a towel, the funis should be 
 tied in two places and divided, in order to allow the means for 
 resuscitation to be carried out more readily. If, however, pulsa- 
 tion can be felt in the funis, as will be the case only in the milder 
 forms of asphyxia, artificial respiration may be tried for a few 
 minutes before the child is separated. It is generally advised that, 
 if the child appears cyanotic, a little blood should be allowed to 
 
 M. 61) 
 
1090 The Practice of Midwifery. 
 
 escape from the fcetal end of the cord, before the ligature is 
 tightened. This does not appear to be good practice. The 
 cyanotic form of asphyxia is not the most serious (see p. 1087), 
 and the cyanosis very quickly passes off if the child can be induced 
 to breathe. Moreover, it is to be remembered that the early ligature 
 of the funis, which is inevitable when the child is asphyxiated and 
 no pulsation can be felt in the funis, is itself equivalent to bleeding 
 the child to a considerable extent. To allow any further loss of 
 blood appears, therefore, undesirable, since a child asphyxiated at 
 birth sometimes dies within a few days from feebleness and 
 atelectasis pulmonum. 
 
 If response does not soon take place to reflex stimulus, artificial 
 respiration should be performed by one or other of the methods to be 
 described, or rhythmical traction exerted upon the tongue according 
 to Laborde's method. This has the advantage that it can be 
 performed without the aid of an assistant and while the child is 
 immersed in a hot bath. 
 
 Asphyxia Pallida. — In this form of asphyxia no time should be 
 lost in attempts to reflexly excite the respiratory centre, but after 
 the mouth and throat have been cleared of all mucus artificial 
 respiration should at once be resorted to. At the same time means 
 should be taken to strengthen the heart's action. This can be 
 done by the application of a hot sponge to the cardiac area or by 
 immersing the child in a hot bath. 
 
 While artificial respiration is being carried out brandy may be 
 rubbed on to the gums or over the precordial area, and in the 
 worst cases a hyi^odermic injection of strychnine l/2-300th grain 
 may be given. In view of the condition of shock which is present 
 in these cases a cold bath should not be employed, nor should cold 
 water be applied to the skin. 
 
 Another method that may be resorted to is artificial inflation of 
 the lungs. 
 
 Ahlfeld recommends that the child should simply be placed in 
 a hot bath, without any artificial respiration. If no spontaneous 
 attemf)ts at respiration aj)pear, it is to be taken out, dried, and the 
 skin vigorously rubbed with a cloth. 
 
 Artificial Resjnration. — The most effectual method is a slight 
 modification of that of Silvester. To carry it out to perfection an 
 assistant is required to fix the legs of the child. As the nurse will 
 generally be wanted, to keep her hand upon the uterus while the 
 physician is attending to the child, some other person should, if 
 possible, be called into the room to assist. The child is placed on 
 its back, the head supported, but moderately extended, so that 
 
Injuries and Diseases of the Foetus. 1091 
 
 the chin is not pressed upon the sternum, the thorax being slightly 
 raised by a napkin placed underneath : the assistant holds the 
 feet firmly in a napkin. The physician stands behind the child's 
 head. 
 
 To imitate inspiration, he grasps the arms near the elbows, 
 raises them from the sides and brings them near together above 
 the head, at the same time making gentle traction upwards. It 
 is in order to make counter-traction at this time by holding the 
 feet that the assistant is required. During this movement the 
 arms should be somewhat everted, so as to put the pectoralis 
 major more upon the stretch. This movement very effectually 
 expands the ribs. The effect is indeed expended, in the new-born 
 infant, more in sucking in the abdomen, through the medium 
 of the diaphragm, than in drawing in air. But by repetition 
 of the movement more and more air gradually gains access to 
 the lungs. 
 
 To imitate expiration, the elbows are brought down and j^ressed 
 against the sides, and the arms somewhat inverted, so as to bring 
 the fore-arms across the chest. By means of the fore-arms and 
 the operator's hands pressure is made upon the chest and abdomen, 
 as well as upon the sides, so as to squeeze out any air that may 
 have been inspired, and, with it, some of the fluid which has 
 entered the air-passages. The movements should not be made 
 too rapidly. Twenty times in the minute are quite sufficient. 
 After a few movements the back of the mouth may again be 
 wiped clear of any mucus or liquor amnii which may have been 
 expressed. If the air does not aj)pear to enter the chest the child 
 may be held up for a few moments by the feet, head downward, 
 and the chest compressed, to aid the evacuation of fluid from the 
 bronchi. If any attempt at spontaneous inspiration is made, 
 great care should be taken so to time the movements as not to 
 counteract but to aid it ; for the contraction of the diaphragm is 
 of more avail than the artificial movements in drawing in air, 
 especially if it occurs while the ribs are expanded by means of 
 the arms ; and if once the lungs have become partially aerated, 
 the artificial resi)iralion becomes much more efficacious. When 
 the attempts at breathing become more frequent, recourse may be 
 had again to the plan of reflex stimulation. As soon as regular 
 breathing, however sli allow, begins to intervene between the 
 spasmodic gasps, the artificial respiration may be discontinued in 
 confidence that the natural breathing will steadily improve. 
 
 The efficacy of this method is shown, not only by the frequency 
 with which children are revived by it, and by experiments upon 
 
 G9— 2 
 
1092 
 
 The Practice of Midwifery. 
 
 still-born children/ but by the fact that the heart's action can 
 often be by this means maintained for a long time, and even 
 quickened, and the colour of the skin improved, even though the 
 irritability of the respiratory centre is lost past restoration. As a 
 rule, however, the improvement of the heart's action is a hopeful 
 sign, though not so significant as the commencement of spontaneous 
 gasps. 
 
 In the absence of an assistaijt, this method cannot be carried 
 out to the full extent. The elbows may be simply raised above the 
 head, but scarcely any upward traction upon them while in this 
 position can be made. The absence of such traction seriously 
 diminishes the efficacy as regards the expansion of the ribs. The 
 
 Fig. 502.— Schultiie's 
 method. Position 
 of expiration. 
 
 FIG. 503.— Schnltze's 
 method. Position 
 of inspiration. 
 
 movements may therefore be made more quickly, in order to 
 compensate in some measure for this. 
 
 Sclmltzes Method. — The oj)erator stands with somewhat separated 
 legs, and bends slightly forward. He grasps the child as shown in 
 Fig. 502, the thumbs lying on the anterior wall of the thorax, the 
 index fingers extending from behind the shoulders into the axillae, 
 the other three fingers of each hand lying on the posterior wall of 
 the thorax. He holds the child at arm's length, hanging perpendicu- 
 larly. He swings the child upward from this hanging position at 
 arm's length to a level somewhat above his head into the j)osition 
 shown in Fig. 502. The raising of the child as far as the hori- 
 zontal should be effected by a powerful swing of the arms, but 
 
 1 It has been shown by Champneys that in such expcsriraents Silvester's method is 
 found to be more efficacious for introduction of air than others which have been 
 employed, such as those of Marshall Hall, Howard, Schultze, etc., especially if the 
 arras are everted during the movement for inspiration (Med.-Chir. Trans., Vol. LXIV.). 
 
Injuries and Diseases of the Foetus. 1093 
 
 from that point the arms should be raised more and more slowly, 
 so that the pelvic end of the child falls gradually over. By this 
 falling of the child's pelvis over the abdomen, considerable pressure 
 is exercised on the thoracic viscera, and inspired fluids often pour 
 from the mouth and nose. The operator then again lowers his 
 arms so as to swing the child down again between his separated 
 legs into the position shown in Fig. 503. The child's body is 
 thereby extended with some impetus, and effects ins]3iration by 
 causing descent of the diaphragm. After a pause of a few seconds 
 the child is again swung upwards into the previous position, and 
 expiration is thus effected. The proceeding is rej^eated eight or 
 ten times a minute. This method has the advantage of requiring 
 no assistant, and the inverted position aids the escape of inspired 
 fluids ; but the inspiratory movement does not a23pear to be so 
 effective as in Silvester's method. It presents the further disad- 
 vantages that a considerable amount of chilling of the child's body 
 is produced, and it cannot be combined with the use of the hot 
 bath — a most important factor in the restoration of cases of 
 asphyxia pallida. 
 
 P rochoivnick' s Method. — The child is held up by the feet, head 
 downward, by an assistant, the arms extended by the side of the 
 head. This is the position for inspiration. Expiration is effected 
 by grasping the chest with both hands, the fingers over the 
 sternum, and compressing it. 
 
 Both this method and that of Schaefer,^ although physiologically 
 the most correct, since they tend to initiate insj)iratory movements 
 by emptying the lungs, a more powerful stimulus to the respiratory 
 centre than that produced by filling the lungs, are obviously of 
 little value in the asphyxiated new-born child, in whom the lungs 
 are generally quite unexpanded, 
 
 Lahorde's Method of Tongue Traction. — The tongue of the child 
 is seized in a napkin, and rhythmical tractions are made upon it 
 at the rate of twenty to thirty to the minute. This method excites 
 respiratory movement by reflex stimuli conveyed to the respiratory 
 centre through the branches of the lingual, glosso-jiharyngeal and 
 superior laryngeal nerves. No direct means of artificial respiration 
 is emj)loyed. 
 
 Tracheal Insufjiation. — The plan of direct insufflation of the 
 lungs through the trachea has been more used abroad than in 
 
 ^ Schaefer's method is of the g7'catest value in the resuscitation oi: the apparently 
 drowncfl, and consists in compression of the chest to [)roduce expiration (the subject 
 Vjeing plMC'-d in the prone position), and allDwinj^ the ex|)ansion of the chest walls to 
 prfKliwje the movement of inspiration. 
 
I094 The Practice of Midwifery. 
 
 this country. It has the disadvantage that ruiDture of the air- 
 cells and emphysema may be caused by the force used. It may, 
 however, be tried if other means fail. My own experience has 
 not been that it succeeds when Silvester's method does not. In 
 France, insufflators made for the purpose are used, having a curve 
 corresponding to the child's mouth, and a conical extremity 
 to fit closely into the larynx. With these, an indiarubber ball 
 may be used for the insufflation. In the absence of an insufflator, 
 a gum-elastic catheter. No. 6, may be used. This is guided by the 
 tip of the finger behind the epiglottis and into the trachea, care 
 being taken not to pass it into the cesophagus. First suction 
 should be made to remove some of the inspired fluid, if possible, 
 from the air-passages. With an insufflator, the suction is made 
 by first emj)tying the indiarubber ball and then allowing it to 
 refill by its own elasticity. The fluid in the trachea having been 
 sucked out, the operator takes one or two deep breaths, to remove 
 as much carbonic acid as possible from his lungs, and then blows 
 gently into the tube. The chest is then compressed, to imitate 
 expiration, and the same process is continued. Faradisation of 
 the phrenic nerves has sometimes proved effectual, and may be 
 tried as a last resort if a Faradic battery is at hand, but artificial 
 respiration is jJreferable. 
 
 The direct insufflation of oxygen into the lungs may be tried if 
 it is at hand, and the intravenous injection, through the umbilical 
 vein, of saline fluid has been employed with benefit in cases of 
 marked anaemia of the foetus. 
 
 Mastitis Neonatorum. — In the majority of young infants, both 
 male and female, slight swelling of the mammary glands occurs 
 about the third or fourth day after birth, and continues until the 
 eighth to tenth day. In some cases the breasts swell up to the 
 size' of a walnut, and usually they secrete small quantities of a 
 fluid, the Hexenmilch of the Germans, indistinguishable both in 
 appearance and on chemical analysis from ordinary human milk. 
 
 If the breasts are manipulated by mothers or nurses in an 
 attempt to break the so-called nipple strings, or even without any 
 such cause, slight mastitis not infrequently follows. 
 
 This usually runs a subacute course and undergoes resolution, 
 but in a small percentage of the cases suppuration occurs, and an 
 abscess forms. No doubt such an attack of inflammation may be 
 followed in after-life by atroj)hy of the breast tissue and inability 
 to suckle. 
 
 It is of the utmost importance that no attempt should be made 
 to disperse the swelling, as is often done by ignorant nurses. In 
 
Injuries and Diseases of the Foetus. 1095 
 
 slight cases it is sufficient to keep the swollen glands protected 
 from rubbing. In more severe cases a hot fomentation may be 
 a]3plied, while if an abscess forms it should be opened by a small 
 incision. 
 
 Ophthalmia Neonatorum. — Inflammation of the eyes of a new-born 
 child is a disease which has been known for many years, but it is 
 only since the discovery of the gonococcus by Neisser that the 
 close relationship between this disease and gonorrhoea in the mother 
 has been recognised. 
 
 In about 75 per cent, of the cases the gonococcus is found in 
 the discharge, but other organisms, such as the staphylococcus, 
 Loffler's dij^htheria bacillus, the pneumococcus, and the colon 
 bacillus, may be present and set up the inflammation. 
 
 In most instances infection occurs just after birth by the trans- 
 ference of the infectious matter from the eyelids to the conjunctiva 
 when the infant opens its eyes. 
 
 In some cases no doubt infection occurs intra ijartum, and in a 
 few instances children are rej)orted to have been born with 
 ophthalmia, indicating that the infection had occurred in utero. 
 There would appear to be some casual relationship between 
 premature rupture of the membranes and this occurrence, and in 
 face presentations, for example, the child may, and no doubt does, 
 open its eyes before birth. In cases of late infection occurring 
 some days after birth the introduction of lochial discharge or pus 
 into the eyes by the fingers of the mother or the nurse or the use 
 of dirty towels may be the cause, or the entrance of dust and dirt 
 containing one or other of the organisms found. The importance 
 of the condition will be recognised when it is remembered that in 
 the year 1876 30 per cent, of the cases of blindness in blind 
 asylums were due to this cause, and as recently as 1895 some 
 19 per cent., if late infections are included. 
 
 If the infection takes place during or immediately after birth the 
 disease begins from the second to the sixth day. If the first 
 symptoms appear later than the sixth day it may be concluded that 
 the infection has been derived from the introduction of septic 
 matter into the eyes by the mother or nurse. In the new-born 
 infant both eyes are commonly affected. 
 
 In mild cases the palpebral conjunctiva is alone involved, and 
 there is merely a small amount of sero-purulent discharge. In 
 more severe cases there is swelling and injection of both bulbar and 
 palpebral conjunctivas with chemosis, and swelling of the eyelids, 
 and the early serous discharge changes into the characteristic 
 purulent form. In a severe attack after a period usually of some 
 
1096 The Practice of Midwifery. 
 
 two to six or eight weeks, the swelling and chemosis of the eyelids 
 and conjunctivae gradually diminishes, and the discharge lessens. 
 
 The main danger of the condition is the involvement of the 
 cornea. This may lead to simple losses of the surface epithelium, 
 marked infiltration of the cornea, or the formation of ulcers with, 
 in some cases, the occurrence of perforation of the cornea. 
 
 The prevention of ophthalmia neonatorum is of the utmost 
 possible importance, especially in lying-in hospitals. As has been 
 already mentioned (see p. 306), immediately after the birth of the 
 head the eyes and their neighbourhood should be wiped clean from 
 mucus or blood with a piece of absorbent wool soaked in a saturated 
 solution of boracic acid lotion or in a 1 in 4,000 perchloride or 
 biniodide of mercury solution. If any purulent vaginal discharge 
 has been noticed or if there is any reason to suspect the presence 
 of gonorrhoea in the mother, a few drops of one or the other of the 
 following solutions should be dropped into the eyes : 1 in 2,000 
 perchloride of mercury, a 2 per cent, solution of silver nitrate, or a 
 solution of argyrol 25 to 60 per cent., or of protargol 10 to 20 per cent. 
 The irritation set up by the use of the silver nitrate solution is said 
 to be prevented by the use of the two latter, and the disadvantage 
 of all these silver solutions of undergoing decomposition and change 
 if kept for any length of time is avoided by the employment of a 
 5 per cent, solution of sophol.-^ 
 
 The local treatment of the condition consists in the washing or 
 irrigation of the eye with 1 in 10,000 permanganate of potash 
 solution or 1 in 5,000 perchloride of mercury solution. Iced 
 compresses may also be applied, and the chemosis, if excessive, 
 snij)ped with scissors. Later in the disease, when the conjunctiva 
 has become velvety and the discharge purulent, the best aj)plication 
 is a solution of silver nitrate 15 to 20 grains to the ounce, to be 
 painted on the conjunctiva of the everted lids and neutralised with 
 a solution of common salt. This may be rej^eated once every 
 twenty-four hours. In the intervals the eye should be frequently 
 washed with a 4 per cent, solution of boric acid or a 1 in 5,000 
 solution of perchloride of mercury and boric acid ointment apj)lied 
 to the margins of the lids. Any sign of congestion in the other 
 eye should be treated by the immediate application of a 2 per cent, 
 solution of silver nitrate. The involvement of the cornea necessi- 
 tates the more vigorous use of these remedies, with the instillation 
 of atropine. 
 
 Thrush is a parasitic disease due to the invasion of the mucous 
 membrane of the mouth by the bud fungus known as the Saccharo- 
 
 • Sophol contains formaldehyde, nucleinic acid, and 22 per cent, of silver. 
 
Injuries and Diseases of the Foetus. 1097 
 
 myces albicans. It is essentially a disease of new-born children. 
 It may, however, occur at other periods of life, but as a rule only in 
 the very old or in patients debilitated by an acute illness. 
 
 Besides the buccal mucous membrane it may invade the intestinal 
 mucosa, and may occur on the mucous membrane of the vagina ; in 
 the latter position it is possible that it may infect the infant during 
 its birth. 
 
 The infection is no doubt at times derived from the air, but more 
 commonly from dirty teats or feeding bottles, as it is mainly a dirt 
 disease. In lying-in hospitals it spreads occasionally from one 
 child to another and exhibits contagious properties. 
 
 Thrush appears first as snow-white masses of minute size on the 
 mucous membrane of the mouth, which coalesce with one another, 
 and which, when scraped off and examined under the microscope, 
 exhibit the typical appearances of the fungus, viz., branching and 
 anastomosing mycelial threads and spores. 
 
 By scrupulous cleanliness the occurrence of thrush can be entirely 
 prevented, and its treatment is therefore mainly prophylactic. The 
 nipple and the child's mouth after each nursing should be carefully 
 wiped with a lotion of equal parts of a saturated solution of boric 
 acid and hot water, and the nipple should then be carefully dried. 
 
 If thrush occurs a small dose of castor oil should be adminis- 
 tered at once and some preparation of boric acid applied to the 
 mouth. It may be wiped out with a clean piece of linen soaked in 
 glycerine of borax, or the plan advocated by Escherich^ may be 
 adopted. A small mass of boric acid powder is wrapped in a little 
 wool, enclosed in a layer of fine linen, and soaked in a solution of 
 syrup. This is then given to the child to suck, and in this manner 
 a sufficient amount of boric acid is absorbed to act as an excellent 
 mouth and intestinal antiseptic. 
 
 The mouth should be repeatedly cleaned, and this may be most 
 effectually done with a 5 per cent, solution of bicarbonate of soda. 
 
 In very rare instances thrush spreads from the buccal cavity to 
 the intestinal canal, and may lead to ulceration of the small 
 intestine and death from perforation or septic poisoning.^ 
 
 Tightness of Fkenum Ling-uje. — In some cases the frenum 
 lingua; extends too forward toward the tip of the tongue, so as to 
 prevent the tongue being extruded, and the child is then said to be 
 tongue-tied. This condition may make it impossible to suck ; and, 
 if not relieved, may afterwards interfere with articulation. 
 
 Treatment. — The thin part of the frenum should be snipped 
 
 ' De Forrest, Amor. Journ. Obstet., January, llilO, p. 1()2. 
 
 2 Mikulicz-Uaditzky and Kiinimel, Die Krankheiten des MundeSj .Jena, 1 !)()!). 
 
1098 The Practice of Midwifery. 
 
 through with blunt-pointed scissors, care being taken not to 
 endanger the hngual artery. 
 
 Tetanus Neonatorum is of particular interest to English 
 obstetricians on account of its extreme prevalence until recent 
 years in the island of St. Kilda, in the Hebrides. It is identical 
 with tetanus following any wound or operation, and is only peculiar 
 in that the usual site of entrance of the tetanus bacillus is the 
 umbilical wound. It is directly associated with the want of proper 
 antiseptic precautions in dressing the umbilicus, and since the 
 inhabitants of St. Kilda have been taught the importance of such 
 antiseptic dressings the disease, which at one time accounted for the 
 death of nearly 80 per cent, of the new-born babies in tbat locality, 
 has practically disappeared. It is still prevalent in some of the 
 West Indian islands, and is responsible for a large number of deaths 
 among negro infants. It is reputed to have followed the use of 
 impure fuller's earth, and has been met with as a result of the 
 operation of circumcision. The onset of the disease may be on the 
 first or even second day after birth, but more often it does not 
 commence until the end of the first week of life. 
 
 The most characteristic feature of tetanus neonatorum, and one 
 which generally persists during the whole course of the attack, is 
 the spasms of the muscles of the jaw. Later the muscles of the 
 trunk and those of the limbs become affected, and opisthotonos is 
 often present. 
 
 The diagnosis has to be made from pseudo-tetanus, and the main 
 distinction lies in the occurrence of clonic spasms, es^jecially in the 
 eye muscles, in the latter, and the ultimate development of paralysis. 
 The i^rognosis is exceedingly bad, death usually following, in some 
 93 to 95 per cent, of the cases, about the eighth day of the disease. 
 
 The treatment consists in the administration of tetanus antitoxin, 
 although unless this is begun at a very early stage in the course of 
 the disease the results are most disa^Dpointing (vide p. 1047). The 
 muscular spasms are best relieved by chloral or the inhalation of 
 chloroform. 
 
 Icterus Neonatorum. — Although simple or idiopathic icterus 
 neonatorum is interesting etiologically (see p. 400), yet clinically it 
 is of little importance and usually passes off within the first week 
 of Hfe. 
 
 The other forms of jaundice, although less frequent, are of equal 
 interest from the point of view of their causation and of far greater 
 importance clinically owing to the heavy foetal mortality with which 
 they are usually associated. 
 
Injuries and Diseases of the Foetus. 1099 
 
 The most important ^etiological factors in these forms of jaundice 
 are malformations of the bile ducts, congenital syphilis, the various 
 forms of septic infection having their starting point in the umbilicus, 
 certain diseases of doubtful nature such as Buhl's disease and 
 "Winckel's disease, and occasional attacks of jaundice of catarrhal 
 origin. 
 
 In the simple jaundice of the new-born child all the internal 
 organs show a yellow tinge. The presence of bile acids and bile 
 pigment in the pericardial fluid proves that the yellow colour is 
 really due to bile, and that most cases at any rate are not simply 
 haematogenous in origin. Its causation is no doubt associated with 
 the important changes which occur at birth in the circulation of 
 the new-born infant. An extensive destruction of red blood 
 corpuscles occurs, and according to Abramov, the backward pressure 
 in the capillaries of the liver prevents the liver cells from disposing 
 of the bile they form, which therefore passes into the blood-vessels.^ 
 
 The proportion of infants affected is very high, nearly 80 jDer 
 cent, according to some authors. The characteristic feature of this 
 form of jaundice is the fact that the skin is mainly affected. The 
 urine and faeces are normal ; and the eyes are often not at all or very 
 little discoloured, and these facts together with the absence of any 
 serious symptoms serve to distinguish it from the more severe 
 varieties. 
 
 Icterus from Congenital Obliteration of the Bile Ducts. — 
 The obliteration may affect almost any part of the ducts, and may 
 involve the gall bladder ; the liver is generally in a condition of 
 biliary cirrhosis, is enlarged and of an olive-green colour. There is 
 as a rule a good deal of fibrous thickening round the obliterated 
 structures. According to Thomson and Milne, the pathology of 
 these cases is as follows : A congenital narrowing of the bile duct 
 leads to the stagnation of bile in the liver and to the gradual 
 accumulation in that organ of the toxic products of metabolism. 
 These set up necrosis of the liver cells and resulting cirrhosis, so 
 that the functions of the liver are carried out inadequately, and the 
 child dies of toxic poisoning, as evidenced by the occurrence of 
 vomiting, haemorrhages and convulsions. 
 
 At birth the child is often of normal appearance, but within a 
 few days, occasionally not until the end of the first week, well- 
 marked jaundice sets in, which becomes more and more marked and 
 remains until death. The urine is deeply bile-stained, and the 
 faeces are colourless. Haemorrhage from the navel is a very constant 
 
 1 Thomson, Clifford Allbutt's System of Medicine, Vol. IV., I't. 1, p. 100 ; Abramov, 
 Vir( li. Archiv, 1905, clxxxi., p. 201. 
 
iioo The Practice of Midwifery. 
 
 and fatal symptom, and blood may be vomited or passed with 
 tbe motions. The result is always a fatal one, and no child with 
 this complaint has ever lived eleven months.^ Treatment is of no 
 avail. 
 
 Septic Infections of the New-boen. 
 
 Jaundice of Septic Origin may have its starting point in the 
 umbilicus or in the intestine. The former is due to the entrance 
 of pathogenic organisms, such as the strei^tococcus, by the umbilical 
 vein, and the latter probably to the bacillus coli from the bowel. In 
 the first the main synii^toms are jaundice, haemorrhages and fever, 
 and in the second there is jaundice, marked cyanosis, and diarrhoea. 
 In both the prognosis is bad and treatment of little avail. 
 
 Hcemoglohinuria Neonatorum, or WinckeVs Disease. — This, too, is 
 no doubt of septic origin, and results from infection with an organism 
 so far not identified. The children, born healthy, become affected 
 two or three days after birth, and die often within thirty-six hours 
 of the onset of the disease. They have a markedly cyanotic and 
 jaundiced tint, the urine contains a large amount of blood, the 
 stools are black-green in colour and the pulse rapid, but the 
 temperature normal. Post-mortem examination shows haemorrhages 
 into many of the organs of the body, esj^ecially into the convoluted 
 tubules of the kidneys, which also contain large numbers of 
 organisms. The disease may occur in an epidemic form, and has a 
 high mortality. 
 
 BukVs Disease, or Fatty Degeneration of the new-born, is also with- 
 out doubt of septic origin. It is characterised by increasing cyanosis 
 and pathologically by parenchymatous inflammation and fatty 
 degeneration of many of the organs of the body and multij)le 
 haemorrhages in various parts of the body, such as the pleura, the 
 pericardium, the lungs, the stomach, and the intestine, and bleeding 
 from the navel. 
 
 The children are often still-born. Those that live present a blue 
 colour, which becomes tinged with yellow, while later diarrhoea sets 
 in with the passage of blood and often haematemesis. The site of 
 entrance of the poison is undetermined, but the fact that, since 
 antisei)tic treatment of the umbilical cord has come into general 
 use, the disease has practically disappeared from lying-in hospitals 
 is suggestive. 
 
 Inflammation and Septic Infection of the Umbilicus may vary from 
 a mere local inflammatory process, leading to the development of 
 
 1 Thomson, Clifford Allbutt's System of Medicine, Vol. IV., Ft. 1, p. 108. 
 
Injuries and Diseases of the Foetus, iioi 
 
 an ulcer or a little granuloma at the site of the separated cord, 
 to a most virulent infection, spreading through the umbilical 
 vessels and rapidly ending fatally. 
 
 A mild local infection generally is evidenced by the presence of a 
 small ulcer, or if the condition persists without projDer treatment 
 a little granulomatous polypus may form, which will require 
 treatment with solid silver nitrate. In other cases the inflamma- 
 tion spreads to the surrounding skin or cellular tissue, and ery- 
 sipelas may occur, starting at the umbilicus. In a few instances 
 there may be no signs of local inflammation, but the entrance of 
 septic organisms through the arteries or veins is evidenced by the 
 occurrence of periarteritis or thrombo-phlebitis. 
 
 Associated often with these conditions is haemorrhage from the 
 umbilicus, the so-called omphalorrhagia neonatorum, which as a 
 rule begins insidiously about the end of the first week of life, and 
 not uncommonly leads to a fatal termination in a few hours. The 
 disease is luckily very rare (once in 5,000 confinements),^ and 
 appears to affect males rather than females. On inspection the 
 blood does not come from any single vessel, but is rather a general 
 oozing from the stump of the umbilical cord. Its cause is obscure, 
 undoubtedly in many cases it is merely a symj)tom ; thus it is a 
 common accompaniment of all forms of septic infection in the new- 
 born, and is frequent in Buhl's disease. Hsemophilia and con- 
 genital syphilis are said to be setiological factors, but probably only 
 when associated with septic processes. The condition has also 
 been ascribed to congenital malformations of the heart and blood- 
 vessels. Ballantyne points out that it may occur in more than one 
 member of a family.^ 
 
 The treatment consists in prolonged digital compression of the 
 bleeding area, or adrenalin, calcium chloride, plaster of Paris, or 
 the actual cautery may be applied locally. If necessary the base 
 of the bleeding area may be transfixed with a hare-lip j)in and a 
 ligature applied around it. 
 
 The prognosis as a rule is very bad, the mortality amounting to 
 65 to 84 per cent., and many cases end fatally within twenty-four 
 hours. 
 
 MelcBiia Neonatorum. — Occasionally in these cases the blood is 
 vomited, but more commonly it is passed by the bowel and is quite 
 black in colour and intimately mixed with the motions. The 
 bleeding most commonly begins on the second day of life, but 
 occasionally later. The amount varies greatly in different cases. 
 
 ' Ribemont, Des Hcmorragics chez le nouveau Nd', These, Paris, 1880. 
 2 Ballantyne, Antenatal Pathology, " The Fujtus," 1902, p. <)(>. 
 
II02 The Practice of Midwifery. 
 
 The causation of this condition is very obscure, but most 
 probably it is a manifestation of some form of septic infection of 
 the new-born child. In favour of this view is the fact that a large 
 number of different organisms have been cultivated from the blood 
 and tissues. 
 
 Cases have been published where melfena has been associated 
 with haemorrhages into the cerebral peduncles and the fourth 
 ventricle, and in other cases various local morbid conditions have 
 been described. 
 
 Landau suggests that delayed inspiration in feeble children leads 
 to clotting of the blood in the umbilical vein, and that from this 
 an embolus is carried to one of the vessels of the stomach, and 
 ulceration results. Congenital syphilis or congenital debility are 
 other supposed cause factors. The prognosis is always grave, 
 some 50 to 60 i^er cent, of the children succumbing. 
 
 In a case of this kind the vitality of the child must be carefully 
 guarded, and it should be kept warm, if possible, in an incubator. 
 Salt solution may be transfused subcutaneously or slowly injected 
 into the rectum. The best drug to give is adrenalin chloride, of 
 which a half to one minim of a 1 in 1,000 solution may be given 
 by the mouth every two hours. A sterile 2 per cent, solution of 
 gelatin may be injected subcutaneously in doses of two drachms. 
 If these fail ergot may be tried. ^ 
 
 The child should not be allowed to suck, but should be fed with 
 a spoon or dropper. 
 
 1 Thomson, ClifiEord AUbutt's System of Medicine, 1909, Vol. V., p. 876. 
 
Chapter XLIII. 
 DISEASES OF THE BREASTS, 
 
 Abnormalities in the Quantity of Milk. — The normal amount 
 of milk secreted varies within wide limits. Temesvary/ in a 
 long series of observations, found the average amount from one 
 breast to be two ounces, the variations being from one to two and 
 a half ounces. At the end of the first week the total amount 
 secreted in twenty-four hours is about fourteen ounces, at the end 
 of the first month about two pints, while at the end of the seventh 
 it has attained its maximum of about three pints, and after this it 
 gradually diminishes again in quantity. 
 
 Deficient Secretion of Milk, or Agalactia. — In the absence of 
 any febrile disturbance, a deficient secretion of milk generally 
 depends upon some constitutional state not to be remedied by drugs. 
 It is met with more especially in very feeble or fat women, in 
 elderly primiparse, and after a premature confinement. It is 
 especially common when the mother has to return to hard work 
 soon after her confinement, as so often happens among the women 
 of the poorer classes. So long as there is hope that the mother will 
 be able to suckle, even partially, the child should still be put to the 
 breast, but at longer intervals than usual. If unsatisfied, it should 
 be fed artificially immediately afterwards. The mother's diet 
 should contain a good proportion of liquid, especially of milk or 
 gruel made with milk, cocoa, and chocolate, and should be as ample 
 and nutritious as possible. Among other articles of diet which 
 have been especially recommended are fish, especially oysters, 
 leguminous foods, such as peas, beans or lentils, the latter in the 
 form of revalenta arabica, and stout in moderation. Pilocarpin 
 in small doses is sometimes of service, but as a general rule the use 
 of so-called galactagogues is disappointing. 
 
 It has been proved that the develoimient of the breasts and the 
 secretion of milk does not depend, or does not depend solely, upon 
 an influence transmitted through the nerves, but rather upon an 
 internal secretion. For the mammary gland of a young rabbit has 
 been transplanted to its ear. Later on, after parturition, the gland 
 
 ' Quoted by Non-is, American Text-Book ObKtclricfi, 1902, Vol. IF., p. 2'J7. 
 
II04 The Practice of Midwifery. 
 
 secreted milk five months after the operation.^ On the theory that 
 this internal secretion is derived from the ovary, and that it is 
 utilised during pregnancy in the foetal circulation, and after parturi- 
 tion has a more complete effect upon the breasts, the administra- 
 tion of ovarian extract, or, still better, of extract of corpus luteum, 
 appears to be indicated when the secretion of milk is deficient. 
 On the other hand, as the result of some elaborate experiments 
 Starling^ has concluded that the growth of the mammary glands 
 during pregnancy is due to the action of a specific chemical stimulus 
 produced in the body of the fcetus and carried thence into the 
 maternal circulation. The removal of this stimulus after delivery 
 leads to the breaking down of the built-up tissues, and in the case 
 of the mammary gland to the formation and secretion of the milk. 
 
 Polygalactia. — Some excess in the quantity of normal milk at 
 the commencement of lactation is not uncommon. The excess then 
 generally escapes spontaneously. An equilibrium is usually soon 
 attained through the increased appetite of the infant ; and the only 
 treatment necessary is to limit somewhat the amount of liquid taken 
 and keep the bowels acting rather freely by means of salines. 
 
 Galactorrhcea. — The term " galactorrhoea " is applied to those 
 cases in which there is not only a persistent excess of milk, but the 
 milk itself is thin and deficient in solids. This is generally a sign, 
 that the woman is in a debilitated condition, and unfit for suckling. 
 Continual escape of such a thin secretion has been observed not 
 only in nursing women, but sometimes in those who have weaned, 
 or have not suckled, or even during pregnancy. 
 
 Both breasts as a rule are at fault. The causation has been 
 ascribed to paralysis of the muscular fibres surrounding the lacteal 
 ducts or to extreme physical exhaustion on the part of the woman. 
 In some instances the condition appears to be associated with 
 atrophy of the uterus. 
 
 Results. — The strength is soon reduced by the drain upon the 
 system. There is generally loss of flesh, while shortness of breath and 
 other signs of anaemia quickly appear. Some impairment of sight 
 is common, and phthisis may supervene, and lead to a fatal result. 
 The infant also does not thrive upon the poor milk. Sometimes 
 menstruation returns in conjunction with the galactorrhoea, and 
 may be excessive in quantity. The exhausting effect is then 
 increased. 
 
 1 Eibbert, Arch. f. Entwickelungs Mechanik, 1899, vii. 688. 
 
 2 Lancet, Croonian Lectures, 1905. 
 
Diseases of the Breast. 1105 
 
 Treatment. — The child should be weaned, both for its own sake 
 and the mother's. If the flow of milk still persists after suckling 
 has been discontinued, firm continuous pressure should be made 
 upon the breasts. This may be carried out in the manner 
 described at p. 408. At the same time glycerine of atropine may 
 be applied to the breasts, or belladonna or atropia may be given 
 internally. If these means do not readily succeed, a few full doses 
 (gr. X. to XX.) of iodide of potassium may be given. In some 
 cases large doses of ergot appear to have a good effect. To recruit 
 the strength, tonics, especially iron and quinine, and change of air 
 are desirable. 
 
 Depressed Nipples. — Flat or depressed nipples may be due to 
 some extent to defective development, but are generally the result 
 of the pressure of stays. The child, not being able to suck readily, 
 may eventually refuse the breast altogether, or may cause much 
 pain, or produce excoriations or fissures by its efforts. 
 
 Treatment. — In this condition good may often be effected by 
 drawing out the nipples by means of a breast-glass attached to an 
 india-rubber tube and mouthpiece, and having a reservoir into 
 which the milk falls. If, even after this, the infant is still unable 
 to suck in the natural way, it may be able to suck through a glass 
 nipple-shield to which is attached an india-rubber nipple, like that 
 of a feeding-bottle. 
 
 Excoriations and Fissures of the Nipples. — Excoriations and 
 fissures are most common in primiparae, in whom the skin is gene- 
 rally more tender. They are also more liable to occur when the 
 nipples are dej)ressed, or when there is a deficiency of milk, so that 
 the infant has to make unusual efforts in sucking. They are pro- 
 moted by any want of cleanliness or want of care in drying the 
 nipples either in pregnancy or lactation. 
 
 Excoriations are generally situated near the apex of the nipple: 
 They may commence by elevation of the macerated epithelium in 
 a small vesicle, which bursts, leaving the underlying epithelium 
 exposed. If such an excoriation or erosion is continuously irritated, 
 it may proceed to the formation of a small ulcer or fissure, and 
 cause actual loss of substance of the nipple. Fissures are generally 
 transverse at the base of the nipple. Both excoriations and fissures 
 may bleed. Fissures at the base of the nipple are particularly 
 painful and difficult to heal, since they are liable to be pulled open 
 each time that the child is suckled. The child then swallows the 
 blood with the milk, and may vomit it again afterwards. It will 
 M. 70 
 
iio6 The Practice of Midwifery. 
 
 :also be passed per rectum, and thus constitute one of the forms of 
 melaena in the infant. 
 
 Both excoriations and fissures are apt to cause great agony in 
 suclding, and make the mother dread the application of the child 
 to the breast. Even a very minute fissure may cause this intense 
 suffering ; and hence it is necessary to make a very careful exami- 
 nation whenever pain in suckling is complained of. These conditions 
 of the nipple are among the most important causes of inflammation 
 and abscess of the breast. Among 433 women confined at the 
 Baudelocque Clinique Dluski found 181 cases, or 41 per cent., of 
 fissure of the nipple, 99 of which were but slight.^ 
 
 Propliylaxis. — During pregnancy the nipples should be washed 
 frequently with bland soap and water, and the epithelium should 
 not be allowed to accumulate, so as to leave tender spots on its 
 detachment. In primiparse, especially if the nipples are tender, it 
 is desirable to treat them on alternate days during the last month 
 of pregnancy by inunction with pure lanoline, the nipple being, if 
 necessary, drawn out between the finger and thumb ; and the 
 application of a mixture of spirit and eau de cologne or glycerine of 
 tannin. During lactation the nipples should be carefully washed 
 and dried after each time of suckling, and a little glycerine of borax 
 applied. The following ointment may also be employed for the 
 same purpose : tinct. benzoini co., gr. xv., olei olivse, gii. ; lano- 
 line, gvi. 
 
 Treatment. — The lotion recommended by Playfair, consisting of 
 half an ounce of sulphurous acid, half an ounce of glycerine of 
 tannin, and an ounce of water, often does great good, or a small 
 ^iece of lint soaked in 1 in 1,000 perchloride of mercury solution 
 may be kept applied. Compound tincture of benzoin painted on to 
 the nipple is a very useful application, or the fissures and excoria- 
 tions may be touched once a day with a solution of nitrate of silver 
 (gr. x. ad ji.). Some recommend touching with the solid stick of 
 nitrate of silver, and this is esi^ecially useful in the case of deep 
 fissures, care being taken that the silver nitrate is applied only to 
 the raw surface. It is frequently found that less pain is produced 
 if the child sucks through a glass nipple shield. This plan does 
 not, however, answer so well for fissures at the base as for excoria- 
 tions at the apex of the nipple. If the fissures or excoriations do 
 not otherwise heal, suckling with the affected breast should be 
 discontinued for a day or two. This will generally allow them to 
 heal without putting an end to lactation altogether. During this 
 time, if the breasts become distended and painful and drawing off of 
 
 1 These de Paris, 1894. 
 
. Diseases of the Breast. 1107 
 
 some of the milk with a breast-pump causes too much pain, gentle 
 massage of the breast from the periphery to the centre may be 
 carried out until the milk flows from the nipple. 
 
 Mastitis : Mammary Abscess. — At the time when the secretion 
 of the milk commences it is common, especially in primiparse, for 
 the breasts to become unequally swollen, knotty, and painful. This 
 condition arises from obstructions in the lacteal ducts, preventing a 
 free outflow of the secretion (caked breasts). When the child has 
 been lost, and the breasts are therefore not relieved by its sucking, 
 the glands may be more uniformly affected in a similar way. In 
 either case, the condition may amount to actual inflammation. 
 There may be elevation of temperature and pulse, as well as local 
 pain, swelling, and tenderness, and sometimes even rigors occur. 
 Thickened lymphatics may be traced, running to the axilla, 
 and the axillary glands may become swollen. It is very rare, 
 however, for this form of inflammation, without other cause, to 
 go on to the formation of abscess, and it almost . always ends in 
 resolution. 
 
 Abscess in the breast, in the great majority of cases, is due to 
 excoriation or fissure of the nipples. Probably in most cases the 
 lacteal ducts become affected, in consequence, by catarrhal inflam- 
 mation, and at the same time obstructed, microbes of suppuration 
 having found an entrance from without. The inflammation extends 
 backward along the ducts to the lobules of the gland ; thus a portion 
 only of the gland is affected as a rule (parenchymatous mastitis). 
 Small collections of pus are formed at first ; these unite and form 
 a larger abscess cavity. Not infrequently, after the opening of a 
 first abscess, one or more subsequent abscesses are formed in other 
 lobules, different foci of inflammation having suppurated in 
 succession. In other cases, the inflammation may extend from 
 the nipple, not along the lacteal ducts, but through the cellular 
 tissue, chiefly by the lymphatics (interstitial mastitis). 
 
 Abscess of the breast, in accordance with the view given above 
 as to its causation, rarely appears within the first few days after 
 delivery. More frequently it occurs about the third or fourth week, 
 and sometimes even at a later period. It occurs chiefly in ansemic 
 and debilitated women. Those cases which do not commence 
 within the first two months after delivery are observed chiefly in 
 women who are weakened by prolonged lactation, as, for instance, 
 when suckling is prolonged for eighteen months or more — a not 
 uncommon case among the lower classes. Sometimes an abscess 
 has followed sudden cessation of suckling, when the glands are in 
 
 70—2 
 
iio8 The Practice of Midwifery. 
 
 full activity. Occasionally it has been observed in pregnancy, or 
 in women not suckling their children. In rare cases, a blow or 
 other injury appears to be the starting-point of the inflammation. 
 In still more rare cases, abscess, or even sloughing, of the breast, 
 forms a part of a general septic infection, and occurs shortly after 
 delivery. 
 
 The organism most commonly present in the pus of a mammary 
 abscess is the Staphylococcus aureus or albus, occasionally the 
 streptococcus, while at times the infection is a mixed one. The 
 mode of entrance is usually through a crack in the nipple, and 
 the source of origin may be the child's mouth, the neighbouring 
 skin, the fingers of the patient or of the nurse, or soiled dressings 
 and nipple shields. When a fissure of the nipple is present the 
 organisms pass into the tissues by the lymphatics, while when the 
 nipple is intact their mode of entrance is through the lacteal ducts. 
 In a few rare cases they find their way to the breast from the blood, 
 as, for example, in the variety of metastatic mammary abscess. 
 
 According to Bumm,^ the organisms set up fermentative changes 
 in the milk, the sugar being converted into lactic and butyric acids 
 and the casein coagulated. Shedding of the glandular epithelium 
 takes place, and a leucocytic infiltration of the periglandular tissues 
 with the formation of localised collections of pus. 
 
 The most common form of inflammation leading to abscess is 
 that in which the glandular substance and areolar tissue of a portion 
 of the mamma are involved in inflammation together. The lacteal 
 ducts belonging to the affected acini become obstructed. Sometimes, 
 as the abscess enlarges, it may burst into a large lacteal duct. The 
 pus may then be discharged from the nipple with the milk ; or, if 
 the abscess also opens externally, a lacteal fistula may remain at 
 the point of opening, through which the milk escapes, and which 
 sometimes is found difficult to close. 
 
 Symptoms and Course. — The inflammation begins with acute pain 
 and pretty severe constitutional symptoms. There is considerable 
 elevation of pulse and temperature, general malaise, and usually 
 rigors at the commencement of suppuration. The temperature 
 often subsides somewhat after a few days, but pain usually con- 
 tinues until the pus has escaped. A hard and very tender swelling 
 is found at the site of inflammation. 
 
 As the case progresses, the skin becomes reddened, and eventually 
 glazed and cedematous, and fluctuation becomes manifest as the 
 pus apj)roaches the surface. If the abscess is left to nature, it often 
 bursts by a small opening ; the pus does not escape freely, and the 
 
 1 Sammlung Klin. Vortrage, 1886, No. 282. 
 
Diseases of the Breast. 1109 
 
 different foci of suppuration communicate also by narrow openings. 
 A large part of the mamma may thus be undermined. Openings 
 may also take place at several points, and the breast may thus 
 become riddled with fistulous tracts. In such cases suppuration 
 may continue for months, and the strength be greatly reduced. 
 When the patient is exposed to insanitary conditions, sloughing of 
 undermined tissue may take place, and haemorrhage may occur 
 from vessels laid open. 
 
 Supra-mammary Abscess. — Sometimes the inflammation affects, 
 not the gland tissue itself, but the areolar tissue over it. The 
 starting-point is the nipple, or some of the small glands surround- 
 ing it, and either the areola only may be involved, or the cellular 
 tissue over a wider surface. A superficial abscess, generally of no 
 great size, is thus formed. 
 
 Sub-mammary Abscess. — In other cases, the site of abscess forma- 
 tion is the layer of areolar tissue beneath the breast. Inflammation 
 generally spreads to this from the deeper portion of the gland 
 itself. The abscess is then usually extensive. The whole mamma 
 becomes prominent : there is deep-seated pain and tenderness, 
 but not so much superficial tenderness ; pain on movement of the 
 arm is greater than in ordinary mammary abscess. The abscess 
 generally opens at the border of the gland, toward the outer and 
 lower part, often in several places. This variety is the rarest 
 of all. 
 
 Treatment. — If there are signs of inflammation on the first 
 establishment of the secretion of milk, saline laxatives, such as 
 sulphate of magnesia, are to be given. If the child is to be suckled, 
 gentle frictions with oil in the direction of the nipple are to be 
 employed. If the child is feeble in sucking, a little milk may 
 be drawn now and then with a breast-glass, with a view to clearing 
 the ducts. If, however, the child is dead, it is better to treat with 
 belladonna or atropia, and apply firm pressure in the mode already 
 described (see p. 408). 
 
 When abscess is threatened, the first essential is to take away the 
 child from the breast — at any rate, from the side affected. If 
 necessary, some milk may be squeezed from the affected side by 
 gentle pressure or massage, or a little may be drawn off by the 
 breast-glass. Saline aperients should be given, and opiates for 
 the relief of pain. Fomentatives or poultices give much relief, 
 but they should not be used so long as there is a hope of avoiding 
 suppuration, nor after the abscess has been opened. In the latter 
 case they cause maceration of the skin and prolong the suppuration. 
 Strict rest should be maintained. The patient sliould be kept in 
 
mo The Practice of Midwifery. 
 
 bed, and the arm kept to the side. Gentle uniform pressure is also 
 useful. This may be applied by carefully strapping the breast, the 
 strapping not being warmed at the fire, but dipped in hot water, so 
 that it may become more pliable, and adapt itself more completely 
 to the shape of the breast. At this stage it is better to use cold 
 than heat. Dry cold may be applied by means of a bag of ice, or 
 a Leiter's temperature regulator, through which a stream of ice- 
 cold water is kept running. 
 
 The stage at which fomentatives are useful is when it is clear that 
 suppuration has commenced, or is inevitable, but the pus is not yet 
 near enough to the surface to be evacuated. As soon as it is obvious 
 that an abscess has formed it should be opened. In some cases, 
 when there is an unusually deep abscess and severe constitutional 
 symptoms, it may be well to explore first with an aspirator 
 needle. 
 
 The abscess should be opened with antiseptic precautions, and an 
 anaesthetic given as a general rule. The line of incision should 
 radiate from the nipple, so as not to divide the lacteal ducts. The 
 incision should be fairly deep and wide, and all the pus, with any 
 loose shreds of tissue, should be squeezed out by gentle pressure. 
 The cavity is then irrigated with a weak antiseptic solution, 
 such as peroxide of hydrogen, boracic acid, or i per cent, lysol. The 
 cavity should then be packed with antiseptic or sterile gauze and 
 covered with an antiseptic or aseptic dressing in the usual way 
 under a firm bandage. When the dressing is changed the cavity 
 should be lightly packed again and this treatment continued until 
 it has healed. Drainage tubes may be used instead of the gauze if 
 they are preferred, but closure of the cavities usually takes place 
 more rapidly with the use of gauze plugs. 
 
 A superficial supra-mammary abscess is easily opened by a free 
 incision radiating from the nipple. It is better not to include the 
 areola in the incision, if it can be avoided, lest the nipple be drawn 
 aside by a cicatrix. A sub-mammary abscess should be opened, if 
 possible, toward the outer and lower part. An exploring-needle 
 may be required, to make sure of the locality of the pus. 
 
 Tonic treatment, esjDecially quinine and iron, will be called for, 
 and the strength should be supported by nutritious diet. In general 
 it is better to wean the infant altogether. 
 
 If the abscess has been neglected in the first instance, and the 
 suppuration is prolonged, and fistulous openings remain, the open- 
 ings may be enlarged, the finger passed in to break down partitions 
 in the abscess cavity, and gauze plugs or drainage tubes introduced. 
 The cavity may be washed out at intervals with a solution of iodine 
 
Diseases of the Breast. 1 1 1 1 
 
 (tr. iodi. 5ii. ad, aq. Oi.), or chinosol (1 in 2,000). Closure of the 
 sinuses is promoted by well-adjusted pressure. 
 
 Galactocele. — In very rare cases a collection of milk is formed 
 through obstruction of one of the lacteal ducts. After a time the 
 milk generally becomes thick and cheesy, through absorption of 
 the watery portion, or it may separate itself into a thin and a 
 thicker part. The swelling is generally only of moderate size, but 
 has been known to attain enormous dimensions. The skin may 
 give way eventually, or the cyst-wall may give way, and the milk 
 become extravasated in the breast. 
 
 Treatment. — The swelling should be incised, and the further 
 secretion of milk stopped by weaning the infant. 
 
Index 
 
 Abdomen, enlargement of, in pregnancy, 
 173 ; discoloration of, in pregnancy, 170 ; 
 in puerperal state, B95 ; palpation of, 
 in pregnancy, 173, 273, 295 ; pendulous, 
 494 ; stripes upon, in pregnancy, 39o ; 
 
 ■ tumours, diagnosis of, from pregnancy, 
 191 
 
 Abdominal foetation, primary, 434 ; secon- 
 dary, 433 
 — • hysterectomy in puerperal sep- 
 ticcemia, 1046 
 
 — palpation, 273, 295 
 Abnormal pregnancy, 417 
 Abnormalities of uterus in pregnancy, 493 
 Abortion, 566 ; causation, 569 ; symptoms 
 
 and course, 572 ; diagnosis, 575 ; prog- 
 nosis, 577 ; treatment, 579 ; incomplete 
 treatment of, 585 ; missed, 521 
 
 Abortion, artificial, induction of, 803 ; in 
 vomiting of pregnancy, 459 ; in chorea, 
 464 ; in albuminuria, 473 ; in cancer of 
 cervix uteri and pelvis, 651 ; in con- 
 tracted pelvis, is, 759 ; operation for, 
 805 
 
 Abscess, mammary, 894 ; in pelvic cel- 
 lulitis, 1024 ; in phlegmasia dolens, 
 1051 ; in puerperal peritonitis, 1018 ; 
 in puerperal pysemia, 1021 
 
 Acardiac acephalic monster, 369, 685 
 
 Accidental complications of pregnancy, 
 551 
 
 — hEemorrhage, 608 ; plugging vagina 
 
 in cases of, 614 ; treatment, 613 
 Achondroplasia, 544 ; effects on pelvis, 724 
 Adaptation of foetus to uterus, 142 
 vVfter-coming head, extraction of, 361 ; in 
 contracted pelvis, 749 ; application of 
 forceps to, 859 ; perforation of, 901 
 After-pains, 393 ; treatment of, 403 
 Agalactia, 408, 1102 
 Ague, in pregnancy, 561 
 Air, entry of, into circulation, 1057 
 Albuminuria, in pregnancy, 465 ; treat- 
 ment, 472 ; in eclampsia, 477 ; in 
 accidental hemorrhage, 608 ; in con- 
 nection with puerperal insanity, 1072 
 Allantois, formation of, 89 ; function of, 
 
 89 
 Amnion, formation of, 80 ; structure, 86 ; 
 
 dropsy of, 531 
 Amniotic fluid, 87. (>See Liquor amnii.) 
 Amputation, intra-uterine, of limbs, 539 
 Anasmia, in pregnancy, 461 
 
 Ansesthesia, in normal labour, 314 ; in 
 version, 866 
 
 Anatomy of foetal head, 127 ; of ovaries, 
 39 ; of pelvis, 1 ; of placenta, 96 
 
 Anencephalic monster, 686 
 
 Anencephalus, 540 
 
 Anodynes in the first stage of labour, 315. 
 (^See Narcotics.) 
 
 Anteflexion and anteversion of gravid 
 uterus, 494 
 
 Antiseptic precautions in labour, 291 ; in 
 lying-in hospitals, 1032 
 
 Antistreptococcic serum, 1038 
 
 Anus, laceration of sphincter of, 956 
 
 Apoplexy of new-born infant, 1084 
 
 Appendicitis in pregnancy, 558 
 
 Areola, mammary, in pregnancy, 165 
 
 Arm, dorsal displacement of, 679 ; libera- 
 tion of, in pelvic presentations, 749, 815; 
 presentation of, 677 — 679 ; presenta- 
 tion of, with head, 677 
 
 Articulations, pelvic, 10 ; inflammation 
 of, 1013, 1021 ; rupture of pelvic, in 
 lalDour, 958 ; relaxation of pelvic, in 
 pregnancy, 12 
 
 Artificial human milk, 413 
 
 — feeding of infant, 410 
 
 — respiration, in asphyxia neonato- 
 
 rum, 1090 
 Ascites, foetal, 692 
 Asphyxia neonatorum, 1085 ; treatment, 
 
 1089 
 
 — of foetus, indications of, in pelvic 
 
 presentation, 361, 808 
 
 Atresia of cervix, 645 ; of vagina and 
 vulva, 646 
 
 Auscultation, in pregnancy, 184 — 190 ; in 
 twin pregnancy, 372 
 
 Autogenetic septicsemia, 997 
 
 Auxiliary forces in labour, 235 ; in- 
 efficiency of, 625 
 
 Aveling's forceps, 827 ; rcpositor for 
 inversion of uterus, 970 
 
 Axes of pelvis, 20, 22 
 
 Axis, deviation of uterine, in labour, 625 
 
 Bacteria in puerperal fever, 993, 991, 
 
 995 
 Ballottement, 181 
 I'andl, ring of, 156, 621 
 Barnes' dilator, 638 
 Basilyst, Simpson's, 897 
 Battledore placenta, 512 
 
1 1 14 
 
 Index. 
 
 Bed-ridden pelvis, 785 
 Bimanual examination, in early preg- 
 nancy, 174 
 
 — version, 864 
 
 Binder, application of abdominal, 313 
 
 Biparietal obliquity of foetal head, 262, 
 727 
 
 Bipolar version, 866 ; in shoulder pre- 
 sentation, 872 
 
 Bladder, calculus in, obstructing labour, 
 659 ; distension of, obstructing labour, 
 659 ; distension of foetal, 692 
 
 Blastocyst, 70 
 
 Blood, changes of, in pregnancy, 167 
 
 — pressure in pregnancy. 167 
 Blunt hook, in breech presentation, 813 
 Bossi's uterine dilator, 641 
 
 Bougie, use of flexible, in induction of 
 
 labour, 794 
 Brain, embolism of, 1057 
 Braxton Hicks' cephalotribe, 892 
 Breasts, areola of, 165 ; care of, in 
 
 puerperal state, 407 ; changes of, in 
 
 pregnancy, 164; diseases of, 1103; 
 
 abscess of, 1107 
 Breech presentations, 345. {See Pelvic 
 
 presentations.) 
 Bregma, 129 
 Brim of pelvis, 4 
 Bronchocele, in pregnancy, 557 
 Brow presentations, 322, 339 ; treatment 
 
 of, 343 ; use of vectis in, 823 
 Budin's catheter, 588, 1035 
 
 Cadaveric poison, in causation of puer- 
 peral septicajmia, 993, 1004 
 
 Csesarean section, 903 ; in accidental 
 h<emorrhage, 616 ; in cancer of cervix 
 uteri and pelvis, 651 ; in contracted 
 pelvis, 751 ; extraperitoneal, 915 ; 
 description of operation, 906 ; uterine 
 sutures in, 909 ; anassthetics in, 905 ; 
 post-mortem operation, 916 ; Porro's 
 operation, 916 ; Sanger's operation, 
 904 ; suprasymphyseal, 915 ; vaginal, 
 922 
 
 Calcareous degeneration of foetus, 440 
 
 Calculus, vesical, obstructing labour, 659 
 
 Canalized fibrin, 107, 510 
 
 Cancer of cervix uteri and pelvis, 648 ; 
 treatment, 649 
 
 Caput succedaneum, in cranial presenta- 
 tion, 225, 272 ; in face presentation, 
 336 ; diagnosis of, from cephalhtema- 
 toma, 1079 
 
 Carcinoma, 648. (See Cancer. J 
 
 Cardiac diseases complicating pregnancy, 
 551 
 
 Carneous mole, 519 ; treatment, 522 Qsee 
 547) 
 
 Carunculfe myrtiformes, 194 
 
 Caul, 222, 694 
 
 Cellulitis, pelvic, 1021. (^See Pelvic 
 cellulitis.) 
 
 Centres, motor, for uterine contraction, 
 
 207 
 Cephalhfematoma, 1079 
 Cephalic version, 861 
 Cephalotribe, 892 
 
 Cervix uteri, apparent shortening of, in 
 pregna«.cy, 159 
 
 — artificial dilatation of, in labour, 
 
 637 ; for induction of abortion, 
 805 ; for induction of premature 
 labour, 797 ; in vomiting of 
 pregnancy, 459 
 
 — atresia of, 646 ; cancer of, 648 
 
 changes of, in pregnancy, 155 
 180; dilatation of, 217, 223 
 ganglion of, 209 ; incision of, 644 
 652 ; in placenta prfevia, 599 
 in puerperal state, 390 ; lacera- 
 tion of, 948 ; mode of expansion 
 of, in labour, 223 ; rigidity of, 
 635 
 Chamberlen's forceps, 823 
 Champetier de Ribes' dilator, 605, 640 
 Child, new-born, 399. (&e Infant.). . 
 Cholera in pregnancy, 565 
 Chondrodystrophia foetalis, 544, 724 
 Chondrodystrophic pelvis, 724 
 Chorea, in pregnancy, 463 
 Chorion, formation of, 92 ; hydatidiform 
 degeneration of, 523 ; diseases of, as 
 a cause of abortion, 571. {See 
 Placenta.) 
 Chorionepithelioma, 530, 1061 
 Cicatrices obstructing labour, 646 
 Circulation, changes of, in pregnancy, 
 166 {see 551) ; of foetus, 121 ; change of 
 foetal, at birth, 123 
 Coccyx, 2 ; mobility of, 16, 20, 22 
 Coiling of funis, 537 ; as a cause of 
 
 obstruction to labour, 695 
 Collapse after labour, 1060 
 Colostrum, 394 
 Colpeurynter, 801 
 
 Compound presentations, 677, 678, 679 
 Conception, 61 ; in multiple pregnancy, 
 
 367 
 Conjugate diameter of pelvic brim, 16, 
 
 704 ; diagonal, 705 
 Constipation, in pregnancy, 458 
 Contracted pelves, 697. {See Pelvis.) 
 Contraction, pelvic, effects of, upon 
 pregnancy, 736 ; upon labour, 
 737 
 — • uterine, 206, 209 ; in pregnancy, 
 180 ; nerve centre for, 207 
 nervous mechanism of, 206 
 hour-glass, of uterus, 976 
 irregular, of uterus, 624 
 Convulsions, puerperal, 474. {See 
 
 Puerperal eclampsia.) 
 Cord, umbilical. 111. {See Fxxnis.) 
 Corpus luteum, 55 
 Cramps in labour, 214 
 Cranial presentations, 239 
 Cranioclasm, 898 
 
Index. 
 
 1115 
 
 Craniotomy, indications for, 883 ; de- 
 scription of operation, 886 ; 
 methodsof extraction, 888 ; with 
 after-coming head, 901 
 — forceps, 888 
 Grade's method of expressing placenta, 309 
 Crochet, 900 
 
 Crowning, stage of, in labour, 229 
 Crural phlebitis, 10i8. (^See Phlegmasia 
 
 dolens.) 
 Curette, use of, in abortion, 587 
 Cysts, in vesicular mole, 523 ; ovarian, 
 657. (See Ovarian tumours.) 
 
 Death, apparent, of new-born child, 
 1085 ; foetal, diagnosis of, 192 ; foetal, 
 causing abortion, 570 ; intra-uterine, 
 of foetus, 514 ; sudden, during or after 
 delivery, 1052, 1060 
 
 Decapitation, after failure of version, 
 674 ; mode of performing, 675 ; for 
 locked twins, 682 
 
 Decidua, development of, 70 ; diseases of, 
 510 ; disease of, as a cause of abortion, 
 571 
 
 Decidual endometritis, 510 
 
 Deciduoma malignum, 530, 1061 ; diag- 
 nosis, 1068 ; treatment, 1068 
 
 Deformities, pelvic, 697. (iSee Pelvis.) 
 
 Degeneration, of foetus, 440 ; calcareous, 
 of foetus, 440 ; of placenta, 519 ; hyda- 
 tidiform, of chorion, 523 
 
 Delivery, care of patient after, 403 ; mode 
 of calculating date of, 197 ; state of 
 patient after, 403 ; signs of recent, 395 
 
 Development, early, of ovum, 65 ; of 
 amnion, 80 ; of allantois, 89 ; of pelvis, 25 
 
 Diabetes, in pregnancy, 556 
 
 Diagonal conjugate diameter of pelvis, 705 
 
 Diameters, of normal pelvis, 16 ; of foetal 
 head, 130 
 
 Diarrhoea, in pregnancy, 460 ; in puer- 
 peral septicaemia, 1017 
 
 Diet, in pregnancy, 201 ; in puerperal 
 state, 40.3, 1037 
 
 Digestion, disorders of, in pregnancy, 460 
 
 Digital examination in labour, 273, 278 
 
 Dilatation, manual, of cervix, 641 
 
 Dilators, hydrostatic, 605, 638 ; Barnes s, 
 638 ; Champetier de Ribes', 640, 799 ; 
 Bossi's, 641 ; Frommer's, 642 ; in 
 eclampsia, 489 ; in placenta previa, 
 605 ; in rigidity of cervix, 638 ; for 
 induction of premature labour, 799 
 
 Diphtheria, relation of, to puerperal 
 fever, 1002 
 
 Diphtheritic deposits in puerperal septi- 
 C!cmia, 1007 
 
 Diseases of pregnancy, 455 ; zymotic, 
 accidentally complicating pregnancy, 
 562 ; zymotic relation of, to puerperal 
 fever, KXJl 
 
 Disinfecting clothes in cases of puerperal 
 fever, 1031 
 
 Dislocations, so-called congenital, 539, 
 734 (.see 819) 
 
 Displacements of uterus, in pregnancy, 
 494 ; as a cause of protracted labour, 
 625 ; as a cause of rupture of uterus or 
 vagina, 938 ; in puerperal state, 991 
 
 Doable uterus, 377 
 
 Douche. {See Injections.) 
 
 Drainage tube, in mammary abscess, 1110 ; 
 in pelvic abscess, 1044 
 
 Dropsy of amnion, 531 ; general, 688. 
 (>S'ee (Edema.) 
 
 Ductus arteriosus, 121 ; venosus, 121 
 
 Duration of pregnancy, 195 
 
 ECLA-MPSIA, 474. {See Puerperal 
 
 eclampsia.) 
 Ectopia of viscera, 541, 686 
 Elbow, diagnosis of, from knee, 667 
 Electricity in asphyxia neonatorum, 1094 
 Elytrotomy, in extra-uterine foetation, 
 
 454 
 Embolism of pulmonary arteries, 1052 ; 
 
 of systemic arteries, 1057 
 Embryo, development of, 115 ; circulation 
 
 of, 121 
 Embryotomy, 676 ; in shoulder presenta- 
 tions, 676 ; in pelvic presentations, 902 
 Emphysema, foetal, causing dystocia, 688 ; 
 
 maternal, in violent labour, 618 ; in 
 
 rupture of uterus, 947 
 Encephalocele, obstructing labour, 693 
 Encliondroplasia, 724 
 Endocarditis in pregnancy, 553 ; in puer- 
 peral septicemia, 1013 
 Endometritis, decidual, 510 ; in puerperal 
 
 fevers, 1007, 1017 
 Enteric fever in pregnancy, 564 
 Enterocele, vaginal, obstructing labour, 
 
 659 
 Enucleation of fibroid tumours in labour, 
 
 656 
 Epiblast, 69 
 Episeiotomy, 648 
 Epistaxis, in pregnancy, 558 
 Epithelium of Graafian follicle, 40 ; of 
 
 ovary, 35 
 Ergot, in abortion, 579 ; in hydatidiform 
 
 mole, 530 ; dangers of, in labour, 628 ; 
 
 use of, in labour, 628 ; in post-partum 
 
 hemorrhage, 984 
 Erotomania, 1075 
 
 Eruptions in pregnancy, 462 ; in puer- 
 peral fevers, 999, 1017 
 Erysipelas, in pregnancy, 564 ; relation 
 
 of, to puerperal fever, 999 ; death rates 
 
 from, 1000, 1025 
 Eustachian valve, 121 
 Evisceration in shoulder presentation, 676 
 Evolution, spontaneous, 670 ; with 
 
 doul)led body, 671 
 Examination in labour, 174 
 Exanthemata, 562. (iS'ee Zymotic diseases.) 
 Excretions in puerperal state, 382 
 
I ii6 
 
 Index. 
 
 Exhaustion in labour, 619 
 
 Esomphalos, oiO, 686 
 
 Expression, of f cetus, 628 ; in pelvic pre- 
 sentations, 361, 808 ; o£ placenta, 
 309 
 
 Extension of foetal head, in normal 
 labour, 253 ; in the flattened pelvis, 
 726 ; in face presentation, 321 ; of the 
 after-coming head, 744, 749 
 
 External rotation, in normal labour, 253 ; 
 
 , in face presentation, 332 
 
 Extraction of foetus, after craniotomy, 
 888 ; by feet, 808 ; in pelvic presenta- 
 tion, 806 ; in Caesarean section, 908 ; 
 after death of mother, 916 
 
 Extraction of head, in pelvic presenta- 
 tion, 361, 819 
 
 Extra-uterine foetation, 417. (^See Preg- 
 nancy, abnormal.) 
 
 Extroversion of viscera, 540, 686 
 
 Face presentation, 321 ; frequency of, 
 323 ; causation, 323 ; diagnosis, 337 ; 
 mechanism of labour in, 32S ; moulding 
 of head in, 336 ; prognosis, 338 ; treat- 
 ment, 340 ; varieties, 326 
 
 Fallopian tubes, position of, 43 
 
 False pains, 164 
 
 Fatty degenei'ation of foetus, 440 
 
 Fecundation, 61 
 
 Feeding, artificial, of infant, 410 
 
 Femora, effects of pressure of, on pelvis, 
 28, 699 
 
 Fever, enteric, 564 ; malarial, 561 ; puer- 
 peral {see Puerperal fevers), 992 ; re- 
 lapsing, 564 ; typhus, 564 
 
 Fibroid tumours, diagnosis of, from preg- 
 nancy, 191 ; complicating pregnancy, 
 559 ; as a canse of dystocia, 653 
 
 Fillet, soft, in breech presentations, 811 
 
 Fistula, recto-vaginal, 739 ; vesico-vaginal, 
 738 
 
 Flattened pelvis, 715 ; mechanism of 
 labour in, 725 ; treatment of protracted 
 labour in, 740 ; rare forms of, 734 
 
 Flexion of foetal head in normal labour, 
 245 ; in flattened pelvis, 726 ; in face 
 presentation, 331 
 
 Fluid, amniotic, 87. (^See Liquor amnii.) 
 
 Foetal head, anatomy of, 127 ; after-com- 
 ing, extraction of, 361, 819 ; after-com- 
 ing, perforation of, 901 ; articulation 
 of, 134 ; descent of, 245 ; diameters of, 
 130 ; effects of pressure on, 739, 1080 ; 
 extension of, 253, 321, 726 ; external 
 rotation of, 255, 332 ; flexion of, 245, 
 331, 726 ; fontanelles of, 128 ; internal 
 rotation of, 251, 329 ; influence of sex 
 and race on, 133 ; lateral obliquity of, 
 262 ; moulding of, in vertex presenta- 
 tion, 268 ; in face presentation, 336 ; 
 in brow presentation, 340 ; movements 
 of, 256 ; perforation of, 883 ; restitution 
 of, 255, 331 ; sutures of, 128 
 
 Foetal heart, 185 ; in twin pregnancy, 372 ; 
 in pelvic presentation, 188 ; variation 
 of, according to sex and size of foetus , 
 189 
 
 Foetation, extra-uterine, 417. (^See Preg- 
 nancy, abnormal.) 
 
 Foetus, abnormalities of, obstructing 
 labour, 663 ; ascites of, 692 ; at term, 
 119 ; attitude of, 137 ; circulation of, 
 121 ; dead, retention of in utero, 545 ; 
 death of, 544 ; degeneration of, 438 ; 
 development of, 115 : diagnosis of 
 death of, 192, 545 ; diseases of, 539, 1079 ; 
 emphysema of, 688 ; extraction of (.see 
 Extraction), 888 ; excessive develop- 
 ment of, 687 ; habitual death of, 793 ; 
 heart-sounds of {see Foetal heart), 185 ; 
 hydrocephalus of, 142, 689 ; injuries to, 
 739, 1079 ; maceration of, 545 ; move- 
 ments of, 183 ; mortality of, in labour, 
 319 ; mummification of, 545 ; nutrition 
 of, 125 ; oedema of, 688 ; papyraceus, 
 547 ; positions of, 239 ; presentations 
 of, 138 ; putrefaction of, 547 ; size of, 
 in successive months, 115 ; tumours of, 
 694 ; weight of, 120 
 
 Follicles, Graafian, 40 ; of areola, in 
 pregnancy, 165 
 
 Fontanelles of foetal head, 128 ; recogni- 
 tion of, in labour, 279 
 
 Foot presentations, 346 
 
 Foramen ovale, 121 
 
 Forceps, anassthetics in application of, 
 838 ; application of, 836 ; to after-com- 
 ing head, 859 ; the author's axis-traction, 
 856 ; Aveling's axis-traction, 827 ; 
 Barnes's, 828; Barnes's craniotomy, 889 ; 
 Chamberlen's, 823 ; direction of traction 
 with, 847 ; history of, 823 ; indications 
 for, 630 ; in flattened pelvis, 742 ; in 
 cancer of cervix uteri and pelvis, 653 ; 
 in congenital hydrocephalus, 691 ; in 
 face presentation, 858 ; in brow pre- 
 sentation, 343 ; in breech presentation, 
 814 ; in occipito-posterior positions, 857 ; 
 in prolapse of funis, 963 ; in placenta 
 prsevia, 606 ; in protracted labour, 629 ; 
 in rigidity of cervix, 643 ; in rupture of 
 uterus, 942 ; Levret's, 824 ; leverage 
 action of, 853 ; locking of, 844 ; long 
 curved, 826, 831 ; long straight, 825 ; 
 mechanical action of, 828 ; use of ovum, 
 in abortion, 584 ; Roper's craniotomy, 
 889 ; short straight, 824 ; short curved, 
 824 ; Simpson's, 831 ; Smellie's, 825 ; 
 Tarnier's axis-traction, 828, 856 ; 
 author's uterine vulsellum, 584 
 
 Forces in labour, 230 ; auxiliary, 235 ; 
 anomalies of expulsive, 623 ; magnitude 
 of, 237 
 
 Fossa navicularis, 952 
 
 Fourchette, laceration of, 952 
 
 Fractures, causing pelvic deformity, 791 ; 
 intra-uterine, 540 (.see 544) 
 
 Frenum linguae, tightness of, 1097 
 
Index. 
 
 1117 
 
 Frommer's dilator, 642 
 
 Funic souffle, 189 
 
 Funis, anomalies of, 536 ; arteries of, 112 ; 
 care of, in new-born infant, 537 ; coil- 
 ing of, 695 ; expression of, 959 ; knots 
 in, 536 ; laceration of, 695 ; ligature of, 
 306 ; management of, in pelvic presen- 
 tation, 360, 815 ; marginal insertion of, 
 512 ; presentation of, 959 ; prolapse of, 
 959 ; reposition of, 962 ; shortness of, 
 causing dystocia, 695 ; structure, 112 ; 
 
 • torsion of, 538 ; tying in labour, 307 ; 
 vein of, 112 
 
 Galactocelb, 1111 
 
 Galactorrhoea, 1104 
 
 Ganglion cervicale uteri, 209 ; diseased, 
 as cause of post-partum haemorrhage, 
 982^ 
 
 Gangrene, as result of embolism, 1057 
 
 Gastrotomy, 903. (&e Ctesarean section.) 
 
 Germinal spot, 42 . 
 — vesicle, 42 
 
 Germs in puerperal fevers, 993 
 
 Gestation. (^See Pregnancy.) 
 
 Ginjlvitis, 460 
 
 Glands, mammary (see Breasts) ; thyroid, 
 changes of, in pregnancy, 557 
 
 Glycerine, injection of, in induction of 
 premature labour, 801 
 
 Glycosuria, in pregnancy, 556 ; in puer- 
 peral state, 383 
 
 Gonococci, in puerperal fevers, 994 
 
 Graafian follicle, 39 ; maturation of, 52 
 
 HEMATOCELE, peritubal, 429 ; paratubal, 
 429 
 
 Hsematoma, pelvic, 428 ; of labium, 660 ; 
 of sternomastoid, 1085 ; of the broad 
 ligament, 959 
 
 Hsematometra. diagnosis of, from preg- 
 nancy, 191 
 
 Hsemoptysis, in pregnancy, 557 
 
 Haemorrhoids, in pregnancy, 492 
 
 Hemorrhage, accidental {see Accidental 
 hemorrhage), 608; concealed, 609; post- 
 partum (.yee Post-partum hsemorrhage), 
 973 ; secondary puerperal, 990 ; un- 
 avoidable (.vee Placenta prsevia), 591 
 
 Hand, choice of, in version, 867, 873 ; 
 diagnosis of, from foot, 667 
 
 Head, foetal, 127. (_See Foetal head.) 
 
 Heart, diseases of, in pregnancy, 551 ; 
 hypertrophy of, in pregnancy, 166 
 
 Heart-sounds, ffjetal, 185. {See Foetal 
 heart.) 
 
 Ilegar's dilators, 581 
 
 — sign of pregnancy, 1 77 
 
 Hemiplegia, puerperal, 1057, 1061 
 
 Hernia of gravid uterus, 509 
 
 Ileterogenetic seiiticiemia, !)97 
 
 Hook, blunt, 813 ; small blunt, for use in 
 version, 881 ; decapitating, 674 
 
 Horrocks' maieutic, 798 
 
 Hospitals, lying-in, prophylaxis of puer- 
 peral septicaemia in, 1032 
 
 Hour-glass contraction of uterus, 976 
 
 Hydatid tumours, obstructing labour, 658 
 
 Hydatidiform mole, 523 ; treatment of, 
 530 
 
 Hydramnios, 531 ; treatment of, 534 
 
 Hydrocephalus, congenital, 689 (see 142) ; 
 treatment of, 691 
 
 Hydrops amnii, 531 ; treatment, 534 
 
 Hydrorrhoea gravidarum, 511 
 
 Hydrothorax, foetal, obstructing labour, 
 692 
 
 Hygiene of pregnancy, 201 
 
 Hymen, imperforate, 646 ; in diagnosis of 
 parity, 193 
 
 Hypoblast, 81 
 
 Hysterectomy {see Cesarean section), 
 supra-vaginal, 919 ; in hernia of uterus, 
 509 ; abdominal, iu puerperal septice- 
 mia, 1046 
 
 Icterus, in pregnancy, 554 ; neonatorum, 
 
 307, 400, 1098 
 Ilium, 2 
 
 Impregnation, period of possible, 63 
 Incarceration of retroflexed gravid uterus, 
 
 497 
 Incision of cervix in cancer, 652 ; of 
 
 perineum, 648 ; of vagina, 647 
 Induction of abortion, 803 ; in contracted 
 pelvis, 759 
 — of premature labour, 792 ; in 
 contracted pelves, 755 
 Inertia of uterus in labour, 623 ;;■ after 
 
 delivery, 981 
 Inevitable laceration in primipare, 304 
 Infant, new^-born, 399 ; artificial feeding 
 of, 410 : apparent death of, 1085 ; care 
 of, 408 ; care of, when premature, 803 ; 
 treatment of apparent death of, 1089 ; 
 suckling of, 406 
 Infarcts of placenta, 515 
 Infecti.on in puerperal fevers, 1005 
 Injections, intra-uterine, in abortion, 587, 
 588 ; as a cause of sudden 
 death, 1058 ; for induction of 
 labour, 800 ; in post-partum 
 hemorrhage, 985 ; in puer- 
 peral septicemia, 1036 
 — vaginal, for induction of labour,^ 
 799 ; in the puerperal state, 
 402, 1033 ; in rigidity of 
 cervix, 637 
 Insanitary conditions, a cause of puer- 
 peral septicemia, 1004 
 Insanity in pregnancy, 1072; in labour, 
 1073 ; in the pueiperal state, 1073 ; in 
 lactation, 1077 ; treatment of, 1077 
 Insomnia, in puerperal insanity, 1075 
 Instrumental dilators, (!41 
 Insiifilation, in asphyxia neonatorum, 
 1093 
 
iii8 
 
 Index. 
 
 Internal rotation in normal labour, 251 ; 
 
 in face presentation, 329 ; in ijelvic 
 
 presentation, 354 
 Intoxication, septic, 996, 1019 
 Intra-] igamentous foetation, 430 
 Inversion of uterus, 965 ; treatment, 969 
 Involution of uterus, 383 
 Iodoform rods, 1034 
 Irrigation, 1005. {See Injections.) 
 ischiopubiotomy, 777 
 Ischium, 2 ; planes of, IS 
 
 Jaundice, in pregnancy, 554 ; in new- 
 born child, 307, 400 
 
 Javr traction in contracted pelves, 750 ; 
 in pelvic presentation, 363 
 
 Joints. i^See Articulations.) 
 
 KiBBiE's fever-cot in puerperal septi- 
 caemia, 1042 
 
 Kidneys, disease of, in pregnancy, 469 
 
 Knee, presentation of, 346 ; diagnosis of, 
 from elbow, 667 
 
 Knots in funis, 536 
 
 Kyesteine, 169 
 
 Kyphotic pelvis, 779 
 
 Laborde's method of artificial respira- 
 tion, 1093 
 
 Labour, 203 ; accidents during and after, 
 934; antesthesia in, 314 ; arrest of, 619 ; 
 antiseptic precautions, 291 ; causes of, 
 203 ; collapse after, 1060 ; duration of, 
 
 . 289 ; induction of premature, 755, 
 792 ; mauHgement of natural, 290 ; 
 mechanism of, 230 ; missed, 549 ; pains 
 {see Pains), 209 ; position of patient in, 
 294 ; precipitate, 617 ; prolonged, 619 ; 
 stages of, 216, 226, 281 ; treatment of 
 protracted, 626 
 
 Laceration, of cervix uteri, 934, 948 ; 
 of genital canal, 934 ; of perineum, 
 951 ; of uterus, 934 ; of vagina, 950 ; 
 of vulva, 951 
 
 Lactation, diet of women during, 408 ; 
 disorders of, 1103; insanity of, 1077; 
 management of, 406 
 
 Laminaria tents, in abortion, 581 
 
 Langhans' layer, 101, 1063 
 
 Lateral obliquity of foetal head, 262. {See 
 Obliquity.) 
 
 Lead poisoning as cause of abortion, 571 
 
 Leiter's temperature regulator, 1041 
 
 Leucocytes in puerperal fevers, 1007 
 
 Lever {nee Vectis) ; action of forceps as, 853 
 
 Levret's forceps, 824 
 
 Ligature of funis, 306 
 
 Liquor amnii, 87 ; deficiency of, 536 ; 
 function of, in labour, 88, 219 
 
 Litliopasdion, 440 
 
 Liver, acute atrophy of, in pregnancy, 
 554 ; functions of, in foetus, 125 
 
 Lochia, 391 ; arrest of, 1016 ; decomposi- 
 tion of, 1016 
 
 Locking, of forceps, 844 ; of twins, 681 
 
 Longings, unnatural, in pregnancy, 169, 
 1072 
 
 Lower uterine segment, 155 
 
 Lungs, diseases of, in pregnancy, 553 ; in 
 puerperal state, 1013 
 
 Lying-in hospitals, prophylaxis of puer- 
 peral septiccemia in, 1032 
 
 Lymphangitis, 1008 
 
 Lymphatics of uterus, in pregnancy, 150 ; 
 in puerperal septictemia, 1010 
 
 Maceration of foetus, 545 
 
 Maieutic, Horrocks', 798 
 
 Malacosteon pelvis, 763 
 
 Malarial fever, in pregnancy, 561 
 
 Malformations of uterus and vagina, 493 
 
 Malposition of os iiteri, 645 
 
 Mamma. {See Breast.) 
 
 Mammary abscess, 1107 ; treatment of, 
 1109 
 — changes in pregnancy, ] 65 
 
 Mania, 1070. {See Insanity.) 
 
 Marginal insertion of funis, 512 
 
 Mastitis, parenchymatous, 1107 
 
 Measles in pregnancy, 564 
 
 Mechanism of labour, 230 ; in foot or 
 knee presentation, 357; in pelvic pre- 
 sentation, 352 ; in face presentation, 
 328 ; in the flattened pelvis, 725 ; in 
 the oblique pelvis, 776 ; in dorso-pos- 
 terior positions of tlie breech, 355 ; in 
 occipito-posterior positions, 256 
 
 Meconium, 118 
 
 Melancholia, 1070. {See Insanity.) 
 
 Membrana granulosa, 40 
 
 Membranes, anomalies of, 694 ; examina- 
 tion of, 311 ; functions of, in labour, 
 216 ; rupture of {see Kupture of mem- 
 branes), 219 
 
 Meningocele, 693 
 
 Menstruation, 43 ; theory of, 48 ; com- 
 mencement and duration of, 60 ; cessa- 
 tion of, in pregnancy, 171 ; continuance 
 - of, in pregnancy, 590 
 
 Mento-posterior positions (unreduced), 
 330 ; management of, 342 
 
 Mesoblast, 80 ; cleavage of, 81 
 
 Mesoderm, formation of, 80 
 
 Metritis, in puerperal fevers, 1007 
 
 Micrococci, in puerperal fevers, 993; in 
 septic thrombi and emboli, 1012 
 
 Mikulicz' tampon, 452 
 
 Milk, 394 ; artificial human, 413 ; ass's, 
 410; composition of, 335; cow's, 410 ; de- 
 fective secretion of, 406, 1103 ; excessive 
 secretion of, 1104 ; goat's, 410; means 
 of arresting secretion of, 408, 1109 ; 
 modified, 414 ; secretion of, 394 
 
 Milk fever, 394 
 
 — laboratories, 414 
 
 — leg, 1048 
 
Index. 
 
 1 1 19 
 
 Miscarriage, 493. {See Abortion.) 
 Missed abortion, 521 
 
 — labour, .549 
 Mole, carneoiis or fleshy, 519 ; tubal, 425 ; 
 
 vesicular, 523 
 Monster, acardiac, 537 ; acardiac acepha- 
 
 lie, 369 ; anencephalic, 686 ; double, 
 
 632 
 Morning sickness in pregnancy, 172 
 Mortality of childbirth, 319, 1033 
 Moulding of foetal head in vertex pre- 
 sentation, 268 ; in face presentation, 
 
 336 ; in brow presentation, 340 
 Movements, foetal, 183: of foetal head. 
 
 214 
 Miiller, ring of, 156 
 Multiple pregnancies, 365 ; causation, 
 
 365 ; diagnosis of, 372 ; management 
 
 of labour in, 374 
 Mummification of foetus, 547 
 Muscles, action of abdominal, in labour, 
 
 235 
 Muscular action, effects of, on pelvis, 30 
 Myoma, 559. ((Sfefl Fibroid tumours.) 
 
 Naegele, lateral obliquity of, 262, 333, 
 728 ; oblique pelvis of, 771 
 
 Narcotics, in eclampsia, 487 ; in labour, 
 315 ; in post-partum haemorrhage, 988 ; 
 in phlegmasia dolens, 1052 ; in puer- 
 peral insanity, 1078 ; in threatened 
 abortion, 579 
 
 Nausea in pregnancy, 455 
 
 Nephritis in pregnancy, 470 
 
 Nerves of uterus, 150 
 
 Nervous shock after delivery, 1059 
 
 — system in the foetus, 125 ; 
 changes in pregnancy, 169 
 
 Neuralgia in pregnancy, 461 
 
 New-born child, 399. [See Infant.) 
 
 Nipples, changes of, in pregnancy, 165 ; 
 depressed, 1105 ; excoriations and fis- 
 sures of, 1105 
 
 Noose, use of, in version, to prolapsed 
 arm, 878 ; to leg, 881 
 
 Nulliparous uterus, characters of, 397 
 
 Nurse, wet, selection of, 409 
 
 Nursing, 406. (<Si?e Lactation.) 
 
 Nutrition of foetus, 125 
 
 Oblique pelvis of Naegele, 771 ; scoliotic, 
 769 : due to disease of one leg, 770 
 
 Obliquity, lateral, of foetal head, 262 ; in 
 flattened pelvis, 727 : 
 
 Obstetrical paralysis, 1084 
 
 Occipito-anterior positions, 240 ; mechan- 
 ism in, 245 
 
 Occipito-posterior positions, 240 ; manage- 
 ment of, 301 ; mechanism in, 256 ; use 
 of vectis in, 821 
 
 Uidenia, in albuminuria of pregnancy, 469 ; 
 of placenta, 532 ; in pregnancy, 491 ; of 
 foetus, 688 
 
 Oldham's perforator, 884 
 
 Oocytes, fertilisation of, 67 ; formation of, 
 3.5 ; maturation of, 65 
 
 Operations, surgical, in pregnancy, 560 
 
 Ophthalmia neonatorum, 1095 
 
 Opiates. (See Narcotics.) 
 
 Osteo-malacia, 763 
 
 Osteophytes, puerperal, 168 
 
 Os uteri {nee Cervix uteri) ; atresia of, 
 646 ; dilatation of, in labour, 217, 223 ; 
 position of internal, in pregnancy 
 and labour, 157 ; malposition of, 645 ; 
 rigidity of, 635 
 
 Ovarian foetation, 420 
 
 — • tumours, in pregnancy, 558 ; diag- 
 nosis of, from pregnancy, 191 ; 
 in labour, 657 
 
 Ovaries, anatomy of, 39 ; development of, 
 34 
 
 Ovaritis, 1012 
 
 Ovulation, 34, 53 
 Ovules, development of, 34 
 Ovum, early development of, 65 ; changes 
 in, 79; diseases of, 510 ; early human, 
 71 ; fecundation of, 63 ; premature ex- 
 pulsion of, 566 ; primordial, 35 ; seg- 
 mentation of, 67 
 
 Ovum forceps in abortion, 585 
 
 Oxytocics, for induction of labour, 571 
 {nee 800) ; in protracted labour, 629 
 
 Pain, cause of, in labour, 162 
 
 Pains, labour, 209 ; anomalies of, 624 ; 
 duration of, 289 ; effect of, on foetal and 
 maternal heart, 214 ; irregular, 624 ; 
 nervous mechanism of, 206 ; premoni- 
 tory, 215 ; spasmodic, 624 ; spurious, 
 215 
 
 Palpation, abdominal, in pregnancy, 173, 
 273, 295 
 
 Palpitation of heart in pregnancy, 462 
 
 Panhysterectomy, 651, 920, 946 
 
 Paralysis from cerebral hsemorrhage, 1061 ; 
 
 - from embolism of cerebral arteries, 1057 ; 
 in new-born infant, 1084 
 
 Parametritis (.see Pelvic cellulitis), 1008 ; 
 remote, 1010 
 
 Parity, diagnosis of, 396 
 
 Parous uterus, characters of, 398 
 
 Parturient canal, axes of, 20, 22 
 
 Parturition, 203. {See Labour). 
 
 Pelvic cellulitis, 1008; symptoms and 
 course, 1021 ; treatment, 1042 
 
 — peritonitis, 1010 ; symptoms and 
 
 course, 1021 ; treatment, 1042 
 
 — presentations, 345 ; causes of, 347 ; 
 
 blunt hook in, 813 ; bringing 
 down leg in, 809 ; extraction of 
 head in, 361 ; extraction of foetus 
 in, 806; diagnosis, 348; digital 
 traction in, 811 ; embryotomy 
 in, 902 ; extraction of trunk in, 
 80H ; forceps to after-corning 
 
II20 
 
 Index. 
 
 head in, 859 ; forceps to breech 
 in, 814 ; heart-sounds in, 188 ; 
 impaction in, 806 ; injuries 
 to foetus in, 819 ; liberation 
 of arms in, 815 ; management 
 of, 359 ; mechanism of, 352 ; 
 prognosis, 358 ; soft fillet in, 
 811 ; varieties of, 347 
 
 Pelvimeter, 701 
 
 Pelvimetry, 701 ; external, 701 ; internal, 
 704 
 
 Pelvis, asquabiliter justo major, 697 ; 
 sequabiliter justo minor, 711 ; anatomy 
 of, 1; articulations of, 10 ; axes of, 20, 
 22 ; bedridden, 785 ; brim or inlet, 4 ; 
 changes in, from double congenital dis- 
 location of hips, 734 ; chondo-dystro- 
 phic, 724 ; contracted, 697, 710 ; de- 
 velopment, 25 ; diameters of, 16 ; dif- 
 ference between male and female, 5 ; 
 dwarf, 715 ; enlarged, 697 ; flattened, 
 715 ; generally contracted, 711 ; high 
 assimilation, 784 ; inclination of, 8 ; 
 infantile, 23, 711 ; kyphotic. 779 ; mala- 
 costeon, 763 ; masculine, 714 ; male, 5 ; 
 measurements of, 15 ; osteomalacic, 763 ; 
 oblique, of Naegele, 771 ; oblique, scoli- 
 otic, 769 ; obhque from disease of one 
 leg, 770 ; outlet of, 5 ; planes of, 22 ; 
 pseudo-malacosteon, 766 ; rachitic, 714, 
 717, 766 ; Kobert's, 777 ; scoliotic, 769 ; 
 split, 735 ; spondylolisthetic, 785 ; 
 straits of, 5 ; transversely contracted, 
 777 ; tumours of, obstructing labour, 
 658, 694 ; triradiate, 763, 769 
 
 Perforation, 883. (See Craniotomy.) 
 
 Perforator, Oldham's, 884 ; Simpson's, 884 
 
 Pericarditis in puerperal septictemia, 1013 
 
 Perimetritis, 1010. QSee Pelvic perito- 
 nitis.) 
 
 Perineum, distension of, in labour, 227 
 examination of, after delivery, 312 
 laceration of, 951 ; preservation of, 302 
 rigidity of, 647 ; treatment of lacerated, 
 954 
 
 Peritonitis, pelvic, 1010. (5ee Pelvic peri- 
 tonitis.) 
 — in puerperal septicgemia, 1010, 1021; 
 in abortion, 537 ; in extra-uterine 
 foetation, 428 
 
 Pessary, in retroflexion of gravid uterus, 
 504 ; in prolapse of gravid uterus, 508 
 
 Peters' ovum, 72 
 
 Phlebitis, in puerperal septicemia, 1012, 
 1020 
 
 Phlegmasia dolens, 1048 ; treatment, 1052 
 
 Phthisis, in pregnancy, 553 ; in puerperal 
 insanity, 1076 
 
 Physometra, 964 
 
 Pigmentation in pregnancy, 170 
 
 Placenta, adhesion of, 974 ; anatomy of, 
 96; anomalies of, 512 ; artificial separa- 
 tion of, 978 ; battledore, 512; calcifica- 
 tion of. 516 ; circulation in, 103 ; cotyle- 
 dons of, 104 ; decomposition of, 998 ; 
 
 diseases of, 512 ; detachment of, 281 ; 
 development of, 99 — 103 ; examination 
 of, 311 ; expulsion of, 285 ; expression 
 of, 309 ; functions of, 107 ; infarcts of, 
 515; inflammation of, 514; in extra- 
 uterine foetation, 452 ; in multiple preg- 
 nancy, 367, 368 ; mechanism of detach- 
 ment, 281 ; CEdema of, 518 ; retention 
 of, 973 ; retention of, in abortion, 585 
 separation of, 287 ; thrombosis of, 518 
 tubercle of, 517 ; tumours of, 517 
 varieties of, in animals, 96 ; viUi of, 96 
 Placenta membranacea, 513 
 
 — prfevia, 590 ; cause of bleeding in, 
 
 598 ; cervix uteri in, 596 ; patho- 
 logical anatomy, 597 ; symptoms 
 and course, 600 ; treatment, 603 
 
 — succenturiata, 513 
 
 — velamentosa, 512 
 Placentitis, 514 
 
 Planes of ischium, 18 ; of pelvis, 21, 22 
 
 Pleurisy, 1013 
 
 Pleuroperitoneal space, 82 
 
 Plugging vagina in abortion, 580; in 
 accidental hfemorrhage, 614 ; in pla- 
 centa prsevia, 604 
 
 Plural pregnancy, 365. (^See Multiple preg- 
 nancies.) 
 
 Pneumococcus in fatal septicaemia, 994 
 
 Pneumonia in pregnancy, 554 ; relation 
 to puerperal fever, 1002 (see 994) ; as 
 complication of puerperal septiccemia, 
 1013 
 
 Podalic version, 865 
 
 I'olarity of uterus, 212 
 
 Polypus, obstructing labour, 654 
 
 Porro's operation, 916 
 
 Porte-fillet, 812 
 
 Positions of foetus in vertex presentation, 
 239 ; diagnosis of, 273 
 
 Position of patient in labour, 294 
 
 Post-partum hsemorrhage, 979 ; causation, 
 981 ; plugging uterus in, 986 ; pro- 
 phylaxis, 983 ; treatment, 985 
 
 Precipitate labour, 617 
 
 Pregnancy, abnormalities of uterus in, 
 493 ; accidental complications of, 551 ; 
 changes in the maternal organism in, 
 145; diagnosis of, 171, 190 ; Hegar's 
 sign, 177 ; diet in, 201 ; disorders of, 
 due to reflex, toxic, and mechanical 
 causes, 455 ; diseases of decidua and 
 ovum in, 510 ; duration of, 195 ; extra- 
 uterine, 417 ; haemorrhage in,' 452 ; 
 hygiene of, 201 ; in rudimentary uterine 
 horn, 436 ; management of, 201 ; 
 mechanical effects of, 162 ; multiple, 
 365 ; surgical operations in, 560 
 
 Pregnancy, abnormal, 417 ; causation, 417 ; 
 diagnosis, 442 ; hsematocele and hsema- 
 toma in, 428 ; mortality in cases, 445 ; 
 pathological anatomy, 420 ; prognosis, 
 445 ; symptoms, 440 ; treatment, 446 ; 
 varieties of, 417 
 
 Premature expulsion of ovum, 566 
 
Index. 
 
 I 121 
 
 Premature labour, induction of, 755, 792 
 Presentation, 136 ; arm, 6(56 ; breech, 
 345 ; brow, 322, 339 ; cause of head, 
 140 ; compound, 677, 678 ; face, 321 ; 
 foot, 346 ; funis, 959 ; knee, 346 ; pelvic, 
 345 ; shoulder, 345 ; transverse, 663 ; 
 vertex, 239 
 Pressure, external, use of, in protracted 
 labour, 627 ; in pelvic presenta- 
 tions, 361, 810 
 
 — general intra-uterine, 231 ; direct 
 
 uterine, 232 
 Primiparity, diagnosis of, 193 
 Primitive trace, 85 
 
 — ova, 34 
 
 Prochownick's method of artificial respira- 
 tion, 1093 
 Prolapse of funis, 959 ; treatment, 961 
 
 — of uterus and vagina in pregnancy, 
 
 505 ; treatment, 508 
 Promontory, false, 732 
 Protracted labour, 619 ; general efEectsof, 
 619 ; treatment of, in first stage, 626 ; 
 treatment, in second stage, 627 
 Pruritus in pregnancy, 462 
 Pseudocyesis, 165, 191 
 Pseudo-malacosteon pelvis. 76(5 
 Ptyalism in pregnancy, 460 
 Pubiotomy, 753, 931 
 
 Puerperal eclampsia, 474 ; causation, 477 ; 
 diagnosis of, 485 ; pathological 
 anatomy, 480 : treatment, 486 
 
 — fevers, 992 ; causation of, 997 ; 
 
 death rates from, 1000, 1025 (nee 
 1026) ; diagnosis of, 1026 ; infec- 
 tion in, 1005 ; mortality of, 1000 ; 
 organisms in, 993 — 996 ; patho- 
 logical anatomy of, 1006 ; prophy- 
 laxis, 1028 ; symptoms of, 1015 ; 
 treatment, 1034 ; varieties, 996 
 
 — osteophytes, 108 
 
 — septicaemia, organisms present in, 
 
 994 
 
 — state, body weight in, 393 ; condi- 
 
 tion of blood in, 392 ; diagnosis 
 of, 395 ; diet in, 403 ; manage- 
 ment of, 401 ; secretions and 
 excretions in, 382 ; physiology 
 of, 380 ; temperature in, 380 ; 
 treatment of, 403 
 
 — ulcers, 1019 
 
 Pulmonary arteries, embolism and throm- 
 bosis of, 1052 
 
 Puncture of membranes, for induction of 
 abortion, 805 ; for induction of prema- 
 ture labour, 793 ; in accidental haemor- 
 rhage, 613 ; in placenta prajvia, 605 
 
 Pyaemia in puerperal state, 1013, 1021 
 in puerperal insanity, 1076 
 
 Pyelonephritis of ttregnancy, 557 
 
 Pyrosis in pregnancy, 460 
 
 Quickening, 183 
 M. 
 
 Race, influence of, on fietal skull, 133 ; 
 
 on pelvis, 7 
 Rachitic pelvis, flattened, 715 ; generally 
 
 contracted, 711 ; pseudo-malacosteon, 
 
 766 ; scoliotic, 769 
 Rachitis, intra-uterine. 543 
 Rectocele, 659 
 Recto-vaginal fistula, 739 
 Refrigeration in puerperal fevers, 1041 
 Relapsing fever in ])regnancy, 564 
 Reposition of funis, 962 
 Repositor, funis, Roberton's, 964 ; catheter 
 adapted as, 964 
 
 — ■ Aveling's, for inversion of uterus, 
 971 
 Resistance of labom-, 238 
 Respiration, artificial, in asphyxia neona- 
 torum, 1090 ; changes of, in pregnancy, 
 
 167 
 Restitution of foetal head, 255 ; in face 
 
 presentation, 331 ; in unreduced 
 
 occipito-posterior, 259 
 Retention of placenta, in abortion, 586 ; 
 after delivery, 973 
 
 — in utero of blighted ovum, 521, 545 ; 
 
 of dead foetus, 545 
 
 — of urine, in labour, 659; in puer- 
 
 peral state, 211. 404 
 Retraction of uterus, 621 
 
 — ring, 156, 621 
 
 Retroflexion and retroversion of gravid 
 
 uterus, 496 ; results, 498 ; symptoms, 
 
 500 ; treatment, 502 
 Rheumatic fever death rates from, 1000. 
 
 1025 
 Rickets {see Rachitic pelvis), operation 
 
 of, in causing pelvic deformity, 719 
 Rigidity of cervix uteri, spasmodic, 634 ; 
 organic, 635 ; treatment, 637 
 
 — of perineum, 647 
 Ring of Bandl, 156, 621 
 
 Robert's transversely contracted pelvis, 
 
 777 
 Roper's craniotomy forceps, 889 
 Rotation, external, of foetal head, in 
 
 vertex presentation, 255 ; in face 
 
 presentation, 332 
 
 — internal, in vertex presentation, 
 
 251 ; in pelvic presentation, 352 ; 
 in face presentation, 329 
 
 Rotations of foetal head, in passing flat- 
 tened pelvis, 725 
 
 Rupture of membranes, artificial, in 
 labour, 300 ; for induction of 
 labour, 793 ; in accidental 
 haemorrhage, 613 ; in placenta 
 praevia, 605 
 
 — of membranes, spontaneous, 219, 236 
 
 — of genital canal, 934 ; of pelvic 
 
 articulations, 958 ; incomplete, 
 of uterus, 946 
 
 — of perineum, 951 ; central, 953 ; 
 
 treatment, 954 
 
 — of sac i n extra-uterine f cetation, 427 
 
 — of spleen in labour, 1060 
 
 71 
 
I 122 
 
 Index. 
 
 Rupture of uterus and vagina, 934 ; treat- 
 ment, 942 
 Eut, analogy of, to menstruation, 49 
 
 Sacro-ILIAC articulation, 10 ; action of. 
 as f ulci'um of lever. 29 ; movement at, 
 in labour, 10 
 
 Sacrum, 2 ; changes in. 25 ; mechanical 
 action of, 13 
 
 Salivation in pregnane}', 460 
 
 Salpingitis, 1012 
 
 Saprajmia in pueri)eral state, 996, 1019 
 
 Sanger's operation. 904 
 
 Saprophytic organisms in puerperal 
 fevers, 995 
 
 Scarlatina, in pregnancy, .564 ; in puer- 
 peral state, 10(11 ; relation of, to i>uer- 
 peral fevers, 1001 ; death rates from, 
 1000, 102.5 
 
 Scalp-tumour, 22;'.. (See Caput suc- 
 cedaneum.) 
 
 Schultze's method of artificial respira- 
 tion, 1092 
 
 Scoliotic pelvis, 769 
 
 Scopolamine morphine narcosis, 318 
 
 Secondary areola, 16") 
 
 Section, Cassarean, 9ii3. (See Ci«sarean 
 section.) 
 
 Secretion of milk, 394 
 
 Secretions, in pregnancy, 168 ; in puer- 
 peral state, 382 
 
 Segmentation of ovum, 67 
 
 Sei)tic;€mia, after abortion, r)77 ; in 
 puerperal state, 996, 1013, 1019. (_See 
 also Puerperal fevers.) 
 
 Septicemic endometritis, 840 
 
 Septic infection ami sci)tic intoxication, 
 992, 1019 
 
 Serous lochia. 391 
 
 Sex, influence of, on the foetal skull. 133 ; 
 prediction of, 189 
 
 Shield, nipple, 1106 
 
 Shock, after delivery, 10.59 
 
 Shortening, ap[)arent, of cervix in preg- 
 nancy, 159 
 
 Shoulder presentations, 663 : diagnosis, 
 666 ; varieties, 665 ; natural termina- 
 tions, 668 ; ti'eatment, 673 
 
 Shoulder, delivery of, in head presenta- 
 tion, 305 ; in pelvic presentation, 361. 
 819 
 
 "Show," in labour. 217 
 
 Sickness, 455. (Scr Yomiting.) 
 
 Signs of pregnancy. 170 ; recapitulation 
 of signs, 190 
 
 Silvester's method of artificial respira- 
 tion, 1090 
 
 Simpson's basilyst, 897 ; forceps, 831 ; 
 perforator. 8S4 
 
 Sinuses of uteru*, 149; in puerperal 
 state, 389 
 
 Sitting, effect of, on pelvis, 30, 699 
 
 Skin, pigmentation of, in pregnancy, 170 
 
 Sleeplessness. 1075. {See Insomnia.) 
 
 Small-pox, in pregnancy, 563 
 
 Smellie's forceps, 825 
 
 Somatopleure, 82 
 
 Souffle, funic, 189 ; uterine, 184 
 
 Spasmodic rigidity of cervix, 634 
 
 Spermatozoa, 61 
 
 Spina bifida obstructing labour, 694 
 
 Spinal an£esthesia, 316 
 
 — cord, function of, in labour, 207 
 Spines of iliac, distance between, 702 
 
 — of ischia, 18 
 Splanchnopleure, 82 
 
 Spleen, rupture of, in labour, 1060 
 Spondylolisthetic pelvis, 785 
 Spondylotomy, 677 
 Spontaneous evolution, 670 ; arrested, 671 
 
 — rectification, 668 
 
 — version, 669 
 Spot, germinal, 42 
 Spurious pains, 215 
 
 — pregnancy, 191 
 
 Stages of labour, 216 ; first, 216 ;, relative 
 effects of protracted labour in, 626 ; 
 second, or expulsive, 216 ; third, 226 
 Staphylococci in fatal cases of puerperal 
 
 septicaemia, 994 
 Stenosis of os uteri, 500 ; of vagina, 501 
 Streptococci in puerperal fevers, 994, 998^ 
 
 1007 
 Suckling, 306. (See Lactation.) 
 Sudden death during or after labour, 1048 
 Sugar in urine, 556. (See Gl^'cosuria 
 
 and Diabetes.) 
 Super-fecundation, 366 
 Super-fcetation, 376 
 Supra-vaginal hysterectomy, 919 
 Surgical operations in pregnancy, 560 
 Suspended animation, 1085. (See- 
 
 Asphyxia neonatorum.) 
 Sutures of foetal head, 128 
 Symphysiotomy, 753, 923 ; secondary, 90O 
 Symphysis pubis, relaxation of, in preg- 
 nancy, 12 ; rupture of, 958 
 Syphilis, in pregnancy, 561 ; affecting 
 foetus, 541 ; as a cause of abortion, 
 570 ; of placenta, 516 
 
 Tarnier's axis-traction forceps, 828, 856- 
 Tetanirs, in pregnancy, 562 ; of uterus^ 
 
 620 ; in puerperal state, 1047 
 Tetany, 562 
 
 Thermostatic nurse, Hearson's, 803 
 Thornton's ice-water cap, 1041 
 Thrombosis, of pulmonary arteries, 1052 ;. 
 
 of veins, 1048 ; in puerperal septicagmia,. 
 
 1012 ; of placenta, 515, 518 
 Thrombus of vagina and vulva, 660 
 Thyroid gland in pregnancy, 557 
 Tongue-tied infant, 1097 
 Torsion of funis, 538 
 lYansfusion of saline fluid, 988 
 Transverse piesentations, 663, 759 
 Trephine perforator, 885 
 Triradiate pelvis, 763, 766 
 Trismus uteri, 634 
 
Index. 
 
 1 123 
 
 Trunk, expulsion of, 304 ; in pelvic pre- 
 sentation, 354 ; extraction of, in pelvic 
 presentations, 808 
 
 Tubal foetation, 423 ; rupture of, 426 
 
 Tubal mole, 425 
 
 Tubercle of placenta, 517 
 
 Tubo-ovarian foetation, 429 
 
 Tubo-uterine foetation, 429 ; diagnosis 
 from tubal foetation, 480 
 
 Tumours, diagnosis of, from pregnancy, 
 171 ; ovarian, 558, 657 ; of pelvis, 
 causing dystocia, 658 ; of foetus, 694, 
 of placenta, 517 
 
 Tunica albuginea, 38 ; fibrosa, 40 ; 
 interna, 40 
 
 Turning, 861. (^See Version.) 
 
 Tussenbroeck's case of ovarian pregnancy, 
 420 
 
 Twin pregnancy, 365. {See Multiple preg- 
 nancies.) 
 
 Twins, binocular, 366 ; conjoined, 682 ; 
 locked, obstructing labour, 681 ; uni- 
 ovular, 366 
 
 Tympanites, in puerperal septicaemia, 1018; 
 uteri, 964 
 
 Typhus fever, in pregnancy, 564 
 
 Ulcers, puerperal, 1019 
 Umbilical cord, 112. {^Sec Funis.) 
 
 ■ — vesicle, 82 
 Unavoidable hiemorrhage, 590. (^See 
 
 Placenta priEvia.) 
 Unreduced positions, occipito-posterior, 
 
 259 ; mento-posterior, 330 
 Uraemia, in eclampsia, 476 ; in puerperal 
 
 insanity, 1074 
 Urea in liquor amnii, 87 
 Ureter, dilatation of foetal, 88, 692 
 Urethra, imperforate, of foetus, 88, 692 
 Urine in pregnancy, 168 ; retention of, 
 in labour, 659 ; in puerperal state, 382 
 Uterine souffle, 184 
 
 Uterus, abnormalities of, in pregnancy, 
 493 ; anterersion and anteflexion of, 
 494 ; arteries of, 149 ; atresia of, 645 ; 
 axis of, in labour, 625 ; changes in, in 
 pregnancy, 145, 173 ; continuous action 
 of, 620 ; contractions of, in pregnancy, 
 180; contractions of, in labour, 206; 
 distinctions between nulliparous and 
 parous, 397 ; evacuation of, in abor- 
 tion, 583 ; fundal incision of, in 
 Csesarean section, 908 ; hernia of, 509 ; 
 hour-glass contraction of, 976 ; inertia 
 of, 623 ; injections into [see Injections), 
 587 ; irregular contractions of, 624 ; 
 iri-igation of (see Injections), 587 ; in- 
 version of, 965 ; involution of, 383 ; 
 lymphatics of, 150 ; motor centre of, 
 207 ; muscular fibres of, 147 ; nerves 
 of, 150 ; perforation of, 947 ; polarity 
 
 of, 212 ; prolapse of, 505 ; retraction of, 
 211, 621 ; retroflexion and retroversion 
 of, 496 ; rupture of, 934 ; segments of, 
 156; sinuses of, 149, 389; size of, in 
 successive months of pregnancy, 150 ; 
 tumours of, 559, 653 ; tetanus of, 620 ; 
 tympanites of, 964 ; veins of, 149 
 
 Vagina, atresia of, 646 ; colour of, in 
 pregnancy, 180 ; in pregnancy, 161, 180, 
 390 ; in puerperal state, 390, 396 ; 
 irrigation of Q<ee Injections), 402 ; 
 laceration of, 950 ; mode of expansion 
 of, in labour, 223 ; mode of plugging, 
 580, 604, 614 ; results of plugging, 614 ; 
 prolapse of, 505, 659 ; thrombus of, 660 
 
 Vaginal Caesarean section, 645, 922 
 
 Vaginitis, 1006 
 
 Valve, Eustachian, 121 
 
 Varicose veins in pregnancy, 491 
 
 Variola, in pregnancy, 563 
 
 Vectis, 820 ; in occipito-posterior posi- 
 tions, 821 
 
 Veins, entrance of air into, 1057 ; in- 
 flammation of, 1012 ; thrombosis of, 
 1021 ; varicose, in pregnancy, 491 
 
 Venesection in eclampsia, 488 
 
 Ventral stalk, 84 
 
 Version, anfesthesia in, 866 ; after crani- 
 otomy, 899 ; bipolar, 866, 872 ; cephalic, 
 861 ; choice of hand in, 867, 873 ; 
 choice of leg in, 871, 878 ; combined 
 external and internal, 864 ; in acci- 
 dental hfemorrhage, 616 ; in cancer of 
 cervix uteri and pelvis, 653 ; in flattened 
 pelves, 742 ; in placenta prsevia, 606 ; 
 in prolapse of funis, 963 ; in shoulder 
 presentations, 865 ; internal, 878 ; 
 podalic, 865 ; spontaneous, 669 
 
 ■ Vertex presentations, cause of, 138 ; 
 positions of head in, 239 ; movements 
 of foetal head in, 244 ; moulding of 
 head in, 268 ; diagnosis in, 273 
 
 Vesicle, germinal, 42 ; umbilical, 82 
 
 Vesico-vaginal fistula, 738 
 
 Villi, chorionic, 95 
 
 Vomiting of pregnancy, 455 ; treatment, 
 458 
 
 Vulva, atresia of, 646 ; laceration of, 646 ; 
 pruritus of, 951 ; in pregnancy, 462 ; 
 thrombus of, 660 ; ulcers of, in puer- 
 peral septicasmia, 1019 
 
 Walcher's position, 11, 838 
 Weight of foetus, 120 
 Wet-nurse, selection of, 409 
 
 Zona pellucida, 42 
 
 Zymotic diseases, in pregnancy, 562 ; 
 relation of, to puerperal fevers, 1001 
 
 HRAlJHrKV, AflNKW, & UO. LD., PttlNTKRS, LONDON AND TONHUIDOK. 
 
¥- 
 

 •^ 
 
 \i 
 
 V\